颅脑外伤的CT诊断改.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,颅脑外伤的CT诊断 改,一、头皮,（一）解剖层次,颞部,穹窿部,皮肤,皮肤,皮下,皮下,颞浅筋膜,颞深筋膜,颈肌,颅顶肌和帽状腱膜,帽状腱膜下脂肪组织,骨膜,骨膜,2,3,（二）头皮外伤,血肿 皮下 头皮血管,帽状腱膜下 由于 硬膜血管 破裂,骨膜下 板障静脉,擦伤,挫伤裂伤,挫裂伤,4,二、颅骨骨折,5,（一）分类,发生部位 颅盖,颅底,骨折线形态 线样,凹陷样,粉碎性,穿透性,与外界关系 闭合性,开放性,6,（二）表现,1,、颅盖骨折,颅缝分离：,2mm,；不对称,线样：并血肿,凹陷性：并颅板内陷（儿童：乒乓球）；并血肿,粉碎性：并血肿,-,大的暴力,穿通、开放性（硬膜）、穿孔（一次、二次）：,为锐器伤，并：,头皮破裂、头皮血肿,硬膜外、硬膜下血肿、蛛网膜下腔出血、气颅,脑挫裂伤，脑内血肿,颅内外异物,7,鉴别,板障静脉 不规则,对侧可见,终于静脉湖,血管沟 渐细,硬化边,颅骨内板,骨缝 走行部位固定,两侧对称,8,2,、颅底骨折,（,1,）特点,常合并颅盖骨折,多呈线形,常通过薄弱处,在前后颅凹，纵行；在中颅凹，横行,不常合并颅内血肿,9,（,2,）征象,1,）直接：,骨折线,颅缝分离,2,）间接：,气颅,鼻窦可见液气、混浊,脑脊液鼻漏（筛骨）,10,11,Skull Fractures,Linear fractures,：,CT is not good for linear,fractures,，,always need bone,window to evaluate,Depression fracture.,CT is important for the,depression of fracture and,other associated interacranial,lesions.,12,Head injury with,fractures,，,scalp hemorrhage,，,countre-coup acute subdural hematoma,，,uncal/tentorial herniation,三、颅内脑外积聚物,-,血肿、积液、积气,13,包括,硬膜外腔,硬膜下腔,蛛网膜下腔,主要相关于,硬脑膜,软脑膜,蛛网膜,14,二、,Epidural lesions,Epidural hematoma,subdural hematoma,subdural effusion,（一）硬膜外血肿,15,1,、特点,急,范围局限,脑组织可受压；中线结构移位不明显,并发骨折,位于脑膜动脉区,颞区多见,16,2.CT,表现,梭形,高密度,急性：密度均匀；,慢性：密度不均,-,活动性出血或再出血,内缘光滑,范围局限，不越颅缝但可越中线或小脑幕,占位效应小，,中线移位轻,并骨折,包膜钙化或骨化,17,18,19,Acute Epidural Hematoma,Fusiform shape,（纺锤体）,of hyperdense lesion.,Always causing strong,mass effect.,20,Acute Epidural Hematoma,The hematoma still,contains,uncoagualated blood,or still has active,bleeding.,Round,stream-like,filling,defects may be seen,in the,hematoma.,21,male/16,delayed EDH,and sportaneous resorption,88,3,28 Head injury,patient was irritable,88,4,15 A subacute,epidural hematoma,88,5,18 No surgery,The EDH is small,1,、急性硬膜下血肿,22,（,1,）分型,单纯型,-,矢状窦旁顶部桥静脉,静脉窦,皮层静脉,动脉,复合型,-,脑挫裂伤引起,皮层静脉或动脉出血破入,硬膜下腔,与冲击部位有关,23,（,2,）典型,CT,表现,高密度,密度均匀,范围广,颅骨内板下方,-,新月形或,“3”,形（侧裂处）,位于大脑镰旁、小脑幕旁,-,带状,范围局限，不越颅缝但可越中线或小脑幕,占位效应,-,同侧侧脑室变窄,中线移位明显,复合型,-,与脑内血肿联接,24,（,3,）非典型,CT,表现,表现 原因,密度不均 未凝、血清外溢,脑脊液漏入,梭形 活动性出血,没有及时散开,同侧侧脑室扩张 室间孔受压受阻,25,Sickle-shape,（镰刀型）,or new,lunar shape,（新月形）,of,hyperdense,lesion,over large portion,hemisphere,Acute Subdural Hematoma,26,Acute Subdural Hematoma with mass effect,A.Acute subdural hematoma with mass,effect,B.Post-craniotomy,the SDH was removed,the mass effect,27,The hematoma may,extending into the,subdural space of,tentorial region,Acute Subdural Hematoma,28,29,30,31,The hematoma may,extending into the,interhemispheric,fissure,or,An acute SDH,locates,in the,inter,hemispheric,fissure,Acute Subdural Hematoma,32,The hematoma may,extending into the,subdural space of,tentorial region,Acute Subdural Hematoma,33,34,The lesion is in the,opposite side of impact site.,30,incidence.,Counter-coup Injury,fracture,Scalp,35,Contusion hemorrhage with some SAH,Head injury with delayed SDH,EDH,The same day,12 hours later:,acute,SDH and EDH,36,A.Brain atrophy with mild hydrocephalus,B.VP shunt,acute SDHs,both sides,C.The acute SDH enlarged in right side,VP shunting induces acute subdural hematoma,2,、亚急性硬膜下血肿,-4,天,3,周,37,（,1,）早期：高与低密度液面或混杂密度,-,细胞沉淀,上浮血清,-,蛋白,沉淀细胞,-,继续出血、再出血、凝血异常,（,2,）晚期：等或低密度,等密度硬膜下血肿：,白质受压内移，灰白质结合部远离颅骨内板,皮层静脉移位,中线移位,脑室变形,增强扫描：皮层染色内移,38,3,、慢性硬膜下血肿,-3,周以上,39,（,1,）病理：,包膜形成,包膜血管,血浆渗入 高渗,蛛网膜下腔血肿增大梭形,血肿液化,蛋白分解 脑脊液渗入,血肿壁玻璃样变性、钙化,血肿包裹粘连机化,多腔,（,2,）,CT,表现,梭形、新月形、,“3”,字形,低密度或混杂密度,-,有否再次出血，血肿大小、溶解吸收,程度 脑脊液、血浆渗入多少,40,Shape:,Semilunar,Fusiform,Over shape,Density:,Hyperdense,Isodense,Hypodense,Mixed density,Chronic Subdural Hematoma,41,Chronic subdural hematoma,with mixed densities,(isodense and hyperdense),Chronic Subdural Hematoma,Chronic subdural hematoma,with,fluid-blood level,(rebleeding),42,Chronic Subdural Hematoma,43,44,45,（三）蛛网膜下腔出血,46,（,1,）病理,多为对冲伤,皮层静脉破裂,血进入脑沟、脑池内,脑室内出血,蛛网膜下腔,合并脑内血肿,软脑膜破裂,合并硬膜下血肿,蛛网膜,破裂,（,2,）表现,CT,高密度，与出血量有关,多见于脚间池、外侧裂池,常在一周内消失,47,（四）脑室内出血,48,1,、病理,多数,脑内出血破入,脑室穿通伤,四脑室逆行的,蛛网膜下腔出血,少数 室管膜下静脉破裂,-,单纯,脑室,出血,凝结成块，侵入脑室后部、溶解,2,、表现,CT,1-2,周呈高密度,并发其它脑外伤改变,继发脑积水,49,Often associated with other,intracerebral or,extracerebral lesions,CT,：,Blood in the ventricles,May cause acute,obstructive or chronic,communicating,hydroceohalus,Traumatic IVH(Intraventricular Hemorrhage),（五）颅内积气,50,气颅,-,颅内外交通,硬膜外腔,气体,硬膜下腔,蛛网膜下腔,密度,脑室内,脑内,影像,51,CT,：,Multiple air bubbles in the,subarachnoid spaces,Sources of air:,1.Open fracture of the,cranium,2.Skull base,fracture,air,from the paranasal sinuses,or mastoid,Traumatic Pneumoencephalus,四、原发脑损伤,52,脑挫伤,/,脑裂伤,/,脑挫裂伤,/,脑内血肿,穿通伤,脑白质剪切伤,脑干损伤,脑肿胀、脑水肿,（一）,脑挫伤,/,脑裂伤,/,脑挫裂伤,/,脑内血肿,53,1,、,脑挫伤,/,脑裂伤,/,脑挫裂伤,（,1,）病理,脑挫伤 脑内散在出血灶,静脉淤血,脑水肿,和,脑肿胀,脑裂伤 上述改变伴脑膜、脑或血管断裂,两者常合并存在，同称,54,（,2,）,CT,表现,脑水肿,-,低密度，可局限性或广泛性,脑出血,-,高密度，可散在点状分布或广泛性,可合并蛛网膜下腔出血或硬膜下血肿,55,2,、,脑内血肿,（,1,）病理,多发于额颞叶,位于受力点或对冲部位脑表面,演变：急性期,吸收期,囊变期,（,2,）,CT,表现,密度：高低,囊,水肿：轻重无,皮层下区,占位效应：正负,56,（二）穿通伤,异物,出血,肿胀,（三）,脑白质剪切伤,灰白质受剪切力作用,轴突损伤,伴行血管破裂出血,中央、周边灰白交界、胼胝体、大脑脚,多发少量出血,57,（四）脑干损伤,剪切伤,脑肿胀,/,脑水肿,（五）,脑白质剪切伤,脑室小,脑沟脑池消失,灰白质界限消失,中线移位,脑组织密度减低,脑疝,58,1.Circumscribed area of brain,edema,2.Brain edema mixed with,multiple small hemorrhages,3.A solitary hematoma,4.Diffuse brain edema,5.,Diffuse axonal injury,(shearing injury),Brain Contusion,59,Delayed hemorrhage,several hours or days after,head injury,Delayed Hemorrhage,soon after head injury,8 hours later,60,Head injury with EDH and delayed contusion hemorrhages,june 22,june 20,61,62,63,64,65,同侧撞击,同侧出血,66,When clinical symptom is grave,but the CTfinds,no serious injury,DAI shuold be considered,CT findings:(positive under 20,),Punctate hemorrhages or edema in the,carpus callosum,centrum semiovale,basal,ganglion brainstem,Diffuse Axonal Injury(DAI)(Shearing Injury),67,Coma after head injury,4 months later,semi-vegetate stage,4 months later-brain atrophy,5th day,Multiple punctate hemorrhages,Diffuse Axonal Injury(DAI),1st day,68,Punctate hemorrhages and edemas in the subcortical white matter of,left frontal lobe(A),and carpus callosum(B,C),Head injury,GCS:3,Diffuse Axonal Injury(DAI),五、脑血管损伤,69,脑梗塞 压迫,痉挛,脂肪栓塞,血管壁剥离,低氧血症,假性动脉瘤,动静脉瘘,静脉栓塞,五、脑血管损伤,70,（一）正常颅腔,颅骨 多个腔 承托 脑组织,硬膜 压力平衡 固定、保护,（二）占位病变,一腔脑组织,压力失衡,某一孔道 脑疝,另一腔中,71,（三）表现,脑池被脑组织填充,正常结构移位,（四）各部疝的形成,名称 疝出脑组织 通过孔道,大脑镰下疝,额叶、颞叶 大脑镰下切迹,海马沟回,颞叶（海马）小脑幕切迹,小脑幕下,小脑扁桃体 枕大孔,脑外疝,大脑 颅骨缺损区,72,Acute subdural henmatoma with strong mass effect,uncle/transtentorial hemitation,（,disappearance ofsurpras ellar and the,quadrigeminal cistern,）,and,subfalcial hemitation.,Acute subdural henmatoma due to a minor head injury,73,七、脑外伤后遗改变,74,1.,脑积水,即脑室系统扩大,梗阻性 内通道受阻 多见于疾病急性期,交通性 外通道受阻 脑脊液回流不足,常为后遗性改变,2,、脑萎缩,3,、脑软化或脑穿通囊肿,75,76,Coma after head injury,4 months later,semi-vegetate stage,4 months later-brain atrophy,5th day,Multiple punctate hemorrhages,Diffuse Axonal Injury(DAI),1st day,八、颅脑外伤阴性表现,77,1,、真阴性,2,、不典型,弥漫性轴突损伤,脑干损伤,3,、迟发型血肿,建议密切观察和复查,谢谢！,78,