根据影像定血管精简课件

看影像，定血管,湘雅医院,内容概要,脑的动脉 脑叶梗死 基底节区梗死 胼胝体梗死 丘脑梗死 小脑脑干梗死 分水岭梗死 静脉梗死,（一）脑的动脉,颈内动脉：供应大脑半球前23及部分间脑 椎-基底动脉：供应大脑半球后13、间脑后部、小脑和脑干,颈内动脉,椎动脉,基底动脉,颈 内 动 脉 internal carotid artery 系 统,眼动脉 optic artery 大脑前动脉 anterior cerebral artery 前交通动脉 anterior communication artery 大脑中动脉 middle cerebral artery 后交通动脉 posterior communication artery 脉络膜前动脉 anterior choroidal artery 主要供应: 眼及以下组织 额叶 frontal lobe 顶叶 parietal lobe 颞叶 temporal lobe 基底节 basal ganglion,颈内动脉供应大脑半球前35部分,椎-基底动脉vertebral-basilar artery系统,小脑后下动脉 posterior inferior cerebellar artery 小脑前下动脉 anterior inferior cerebellar artery 桥脑支 pons artery 内听动脉 internal auditory artery 小脑上动脉 superior cerebellar artery 大脑后动脉 posterior cerebral artery 主要供应：枕叶 occipital lobe 脑干 brain stem 小脑 cerebellum,基底动脉供应大脑半球后25部分,脑底动脉环（willis环）,大脑前动脉（Anterior cerebral=orange ） 皮质支:半球内侧面，额叶底面，额、顶 叶外侧面的上部。 中央支:豆状核、尾状核前部，内囊前肢。,大脑中动脉（Middle cerebral=pink ） 皮质支：半球外侧面的大部分 中央支：尾状核、豆状核、内囊膝和后肢,脉络膜前动脉： 至侧脑室脉络丛，供应外侧膝状体、内囊后肢、大脑脚底中1/3、苍白球,脉络丛前动脉,后交通动脉,大脑后动脉posterior cerebral=blue,皮质支 中央支,全部枕叶，颞叶的内侧面和底面,分布于背侧丘脑，内、外侧膝状体，下丘脑、底丘脑,小脑下后动脉：分布小脑下面后部、延髓后外侧部。 小脑下前动脉： 分布小脑下面前部。 迷路动脉：分布于内耳。 脑桥动脉：分布于脑桥基底部。 小脑上动脉： 分布小脑上部。,Surface view, showing territories supplied by the superior cerebellar artery (SCA), anterior inferior cerebellar artery (AICA), and posterior inferior cerebellar arteries (PICA). A.Dorsal view. B. Viw of the cerebellum removed from the brainstem to reveal the ventral surface.,Posterior Inferior Cerebellar Artery (PICA in blue) Superior Cerebellar Artery (SCA in grey) Anterior Choroideal artery (AchA in blue) Lenticulo-striate arteries LSA s (in orange) middle cerebral artery (MCA). Anterior cerebral artery (ACA in red) Middle cerebral artery (MCA in yellow) Posterior cerebral artery (PCA in green),脑内结构的动脉血供 深蓝色区：大脑前动脉 红色区：大脑中动脉 浅蓝色：脉络膜前动脉 绿色区：大脑后动脉,脑叶梗死,DWI in posterior, anterior and middle cerebral infarction,Right Anterior Cerebral Artery - Outlines territory of infarction,ACA,Anterior cerebral artery: A1 segment: from origin to anterior communicating artery and gives rise to medial lenticulostriate arteries (inferior parts of the head of the caudate and the anterior limb of the internal capsule). A2 segment: from anterior communicating artery to bifurcation of pericallosal and callosomarginal arteries. A3 segment: major branches (medial portions of frontal lobes, superior medial part of parietal lobes, anterior part of the corpus callosum).,大脑前动脉主干闭塞致脑梗死还包括heubner回返动脉,bilateral ACA infarct,Middle cerebral artery,The MCA has cortical branches and deep penetrating branches, which are called the lateral lenticulo-striate arteries. The territory of the lateral lenticulo-striate perforating arteries of the MCA is indicated with a different color from the rest of the territory of the MCA because it is a well-defined area supplied by penetrating branches, which may be involved or spared in infarcts separately from the main cortical territory of the MCA. On the left a T2W-image of a patient with an infarction in the territory of the middle cerebral artery (MCA). Notice that the lateral lenticulo-striate perforating arteries of the MCA are also involved (orange arrow).,大脑中动脉主干闭塞致脑梗死,right posterior cerebral artery distribution infarct,posterior cerebral artery distribution infarct,PCA infarction involving the medial temporal lobe.,Endovascular treatment of a basilar artery dissecting aneurysm,Bilateral PCA infarcts from uncal herniation,急性多发性脑梗死(右侧MCA及右侧SCA),颈内动脉支配区梗死,基底节区梗死,the vascular supply to the basal ganglia,Heubner动脉区梗死,Heubner回返动脉是大脑前动脉的较大的中央支,主要供应纹状体最前端及内囊前肢,对钩束及嗅区亦有不同程序供应,损伤后可致偏瘫,在主侧可有失语,脉络膜前动脉梗死,关于脉络膜前动脉梗死，在临床上并没有引起大家的重视，确实其解剖并不是十分明确。 根据文献介绍其供血区有梨状区皮质，部分杏仁核和钩回，部分海马和海马伞，苍白球内侧部分，外侧膝状体，视辐射初段，下丘脑区，内囊后肢的下半部，部分大脑脚和丘脑枕的后壁以及脉络膜丛。,脉络膜前动脉:,供应内囊后支, 外侧膝状体, 大脑脚等. 还供应内囊膝, 丘脑, 丘脑下部, 杏仁核, 海马回尤其海马回钩. 本图见右侧内囊后支, 丘脑, 大脑脚, 以及右侧颞叶内侧长T1长T2信号,Lenticulostriate arteries,豆纹动脉：在大脑中动脉起始部算起10mm以内发出着称为内侧豆纹动脉，在10-20mm之间发出着称为外侧豆纹动脉，又称charcot出血动脉。豆纹动脉供应尾状核头和体（前下部除外），壳核的大部，苍白球的外侧部和内囊的上3/5。,大脑中动脉穿支支配区(基底节)梗死伴出血,纹状体梗死,外侧豆纹动脉累及的确切部位,left lenticulostriate artery,Brain MRI revealed a small hyper intense area in left putamen and internal capsule (T2, FLAIR, and proton density); that was iso-intense in T1, and was correlated with an infarction in territory of left lenticulostriate artery,腔隙性脑梗死,Lacunar infarcts are small infarcts in the deeper parts of the brain (basal ganglia, thalamus, white matter) and in the brain stem. Lacunar infarcts are caused by occlusion of a single deep penetrating artery. Atherosclerosis is the most common cause of lacunar infarcts followed by emboli.,Common sites of intracerebral hemorrhage.,(A) cerebral lobes, originating from penetrating cortical branches of the anterior, middle, or posterior cerebral arteries; (B) basal ganglia, originating from ascending lenticulostriate branches of the middle cerebral artery; (C) the thalamus, originating from ascending thalamogeniculate branches of the posterior cerebral artery; (D) the pons, originating from paramedian branches of the basilar artery; (E) the cerebellum, originating from penetrating branches of the posterior inferior, anterior inferior, or superior cerebellar arteries,胼胝体梗塞:,blood supply from three main arterial systems,the anterior communicating artery the pericallosal artery the posterior pericallosal artery (branch of the posterior cerebral artery, supplies the splenium. ),Postcontrast axial T1-weighted image (A) (500/20/1) shows subtle enhancement with surrounding hypointensity within the genu of the corpus callosum (arrows). FLAIR images (B, C) (8900/140/1) show abnormal increased signal within both sides of the genu and body of the corpus callosum. Axial FLAIR images (D, E) (8900/140/1) from follow-up MR imaging performed 3 weeks later showed almost complete resolution of the abnormal signal within the corpus callosum,Sagittal precontrast T1-weighted image (A) (400/12/2) shows a hypointense ovoid mass (arrow) within the body of the corpus callosum, depressing the roof of the lateral ventricle. After administration of contrast material (B) (400/12/2), it enhances homogeneously. A small infarct (white arrow) is noted within the right thalamus on the axial T2-weighted image (C) (2560/90/1). Subsequent biopsy confirmed an infarct,infarct in the splenium of the corpus callosum : “Boomerang sign”,Strokes involving the splenium of the corpus callosum are associated with hypoperfusion, and can be seen in association with metabolic changes such as hypoglycaemia, hyponatraemia, hypernatraemia, and renal failure.,Corpus callosum infarct in a 57-year-old woman. a, b Diffusion-weighted fluid-attenuated inversion recovery (FLAIR) axial images obtained 9 days afteronset show hyperintense lesions in the left side of the splenium of the corpus callosum and left occipital lobe, indicative of acute infarction of the left posterior cerebral artery territory,丘脑梗死,丘脑解剖,丘脑本身血供就比较复杂，加上小血管变异就更扑朔迷离,位置：位于脑干和端脑之间，大部分被高度发达的大脑半球所掩盖。,分部:背侧丘脑 上丘脑 下丘脑 后丘脑 底丘脑 间脑的内腔称第三脑室。,Up,down,背侧丘脑,形状：是一对卵圆形的灰质团块。 分部：“Y”形纤维板-内髓板，将背侧丘脑分为3部分：前核、内侧核群、外侧核群。 功能：是皮质下感 觉的最后中继站。,Up,down,Schematic view of the arterial supply to the thalamus.,1 = carotid artery; 2 = posterior communicating artery; 3 = basilar artery; 4 = thalamogeniculate arteries; 5 = tuberothalamic artery; 6 = posterior choroidal artery; 7 = paramedian pedicle; 8 = posterior cerebral artery.,T2-weighted MRI of bilateral paramedian thalamic infarction in a patient with a top of the basilar embolus involving midbrain and hypothalamus. Horizontal sections from ventral (A) to dorsal (D).,thalamogeniculate arteries infarct,thalamic perforating arteries,Digital subraction angiographic images show (a) ruptured basilar tip aneurysm and normal filling of thalamic perforating arteries (arrowheads); (b) after surgery, residual aneurysm and bilateral thalamoperforator occlusions were detected (not shown). Residual aneurysm was treated with additional embolization. (c) Transverse T2-weighted MR image (2625/98) shows bilateral thalamic infarctions (arrowheads) 1 year after aSAH.,This image is from Lateral posterior choroidal infarct,脉络膜后动脉区梗死 Posterior choroidal artery occlusion uncomonly present as an isolated stroke syndrome, usually coexisting with posterior cerebral artery and often superior cerebellar artery involvement. When seen in isolation damage was characteristically limited to: lateral geniculate body pulvinar posterior thalamus hippocampus parahippocampal gyrus The lateral posterior choroidal artery may be a singular structure or exist as multiple lateral posterior choroidal arteries. In both cases, they arise from the P2 segment of the PCA, just distal (and lateral) to the medial posterior choroidal arteries. In some cases, they may arise from one of the PCA branches (parieto-occiptal). They pass from the ambient cistern (cisternal segment) into the choroidal fissure and supply the choroid plexus (plexal segment) of the lateral ventricle. Anteriorly they anatamose with the distal branches of the medial posterior choroidal artery, which ascend through the foramen of Munroe. When just the lateral posterior choroidal artery territory is infarcted, the most common clinical manifestations included: homonymous quadrantanopsia +/- hemisensory loss neuropsychological dysfunction (trans-cortical aphasia, memory disturbances). homonymous horizontal sectoranopsia (uncommon by highly suggestive of the involvement of the lateral geniculate body The medial posterior choroidal artery is a small branch (often multiple - 40% of hemispheres) usually arising from the P2 segment of the PCA. It may also arise from one of the PCA branches, e.g. parieto-occiptal, calcarine, splenial artery. It ascends deep to the rest of the PCA and supplies small branches to the tegmentum, midbrain, posterior thalamus and pineal gland as the cisternal segment. It then penetrates the velum interpositum, becoming the plexal segment. It then runs in the roof of the third ventricle supplying the ipsilateral choroid plexus. As it reaches the foramen of Munroe it passes through it to anastamose with branches of the lateral posterior choroidal artery. Medial posterior choroidal artery territory infarct is less frequent with Its neurologic presentation dominated by eye movement disorders. 脉络膜后动脉区梗死 Posterior choroidal artery occlusion uncomonly present as an isolated stroke syndrome, usually coexisting with posterior cerebral artery and often superior cerebellar artery involvement. When seen in isolation damage was characteristically limited to: lateral geniculate body pulvinar posterior thalamus hippocampus parahippocampal gyrus The lateral posterior choroidal artery may be a singular structure or exist as multiple lateral posterior choroidal arteries. In both cases, they arise from the P2 segment of the PCA, just distal (and lateral) to the medial posterior choroidal arteries. In some cases, they may arise from one of the PCA branches (parieto-occiptal). They pass from the ambient cistern (cisternal segment) into the choroidal fissure and supply the choroid plexus (plexal segment) of the lateral ventricle. Anteriorly they anatamose with the distal branches of the medial posterior choroidal artery, which ascend through the foramen of Munroe. When just the lateral posterior choroidal artery territory is infarcted, the most common clinical manifestations included: homonymous quadrantanopsia +/- hemisensory loss neuropsychological dysfunction (trans-cortical aphasia, memory disturbances). homonymous horizontal sectoranopsia (uncommon by highly suggestive of the involvement of the lateral geniculate body The medial posterior choroidal artery is a small branch (often multiple - 40% of hemispheres) usually arising from the P2 segment of the PCA. It may also arise from one of the PCA branches, e.g. parieto-occiptal, calcarine, splenial artery. It ascends deep to the rest of the PCA and supplies small branches to the tegmentum, midbrain, posterior thalamus and pineal gland as the cisternal segment. It then penetrates the velum interpositum, becoming the plexal segment. It then runs in the roof of the third ventricle supplying the ipsilateral choroid plexus. As it reaches the foramen of Munroe it passes through it to anastamose with branches of the lateral posterior choroidal artery. Medial posterior choroidal artery territory infarct is less frequent with Its neurologic presentation dominated by eye movement disorders.,Templates used to determine vascular territories of the perforating arteries supplying the thalamus and striatocapsular area. a, Artery; ACA:anterior cerebral artery; AComA: anterior communicating artery; ant: anterior; post: posterior.,The artery of Percheron is a rare variant of the posterior cerebral circulation. The term is used to refer to a solitary arterial trunk that branches from one of the proximal segments of either posterior cerebral artery (PCA). It supplies blood to the paramedian thalami and the rostral midbrain bilaterally. Percheron infarct: bilateral thalamic and mesencephalic infarctions; clinically, often obtunded, comatose, or agitated, with associated hemiplegia or hemisensory loss.,Variations of the paramedian thalamic-mesencephalic arterial supply according to Percheron. A, In the most common variation, there are many small perforating arteries arising from the P1 segments of the PCA. B, The artery of Percheron is a single perforating blood vessel arising from one P1 segment. C, The third type of variation is that of an arcade of perforating branches arising from an artery bridging the P1 segments of both PCAs.,Percheron动脉梗死,Symmetric Bilateral Thalamic Infarcts: A Rare Complication of Cardiac Catheterization,脑干、小脑梗死,Kataoka将旁正中梗死分三型： 旁正中基底部梗死； 旁正中背盖部梗死； 旁正中基底-背盖部梗死。 本图为前内侧组脑桥穿通支（主要是短、长前内侧动脉）受累引起的旁正中基底-背盖部梗死。,Paramedian tegmental infarct 旁正中基底-背盖部梗死,infarct of pons artery,Posterior Cerebellar Artery Infact from thrombosed Basilar Artery,基底动脉血栓形成,椎动脉起源的栓子，可以造成多发病灶，对于脑干、小脑、丘脑、颞叶的一些多发病灶病例，应该考虑探测椎动脉，核磁MRA和CTA应该最好，彩超也不很好，因为VA起始段和入颅段并不属于其敏感探测区。,locked-in syndrome,Wallenbergs syndrome,It is the clinical manifestation resulting from occlusion of the posterior inferior cerebellar artery (PICA) or one of its branches or of the vertebral artery,PICA,On the left CT-images of a left-sided PICA-infarction. In unilateral infarcts there is always a sharp delineation in the midline because the superior vermian branches do not cross the midline, but have a sagittal course. This sharp delineation may not be evident until the late phase of infarction. In the early phase, edema may cross the midline and create diagnostic difficulties. Infarctions at pontine level are usually paramedian and sharply defined because the branches of the basilar arery have a sagittal course and do not cross the midline. Bilateral infarcts are rarely observed because these patients do not survive long enough to be studied, but sometimes small bilateral infarcts can be seen.,SCA,SCA,On the left CT-images of a cerebellar infarction in the region of the superior cerebellar artery and also in the brainstem in the territory of the PCA. Notice the limitation to the midline.,双侧SCA,符合SCA支配区,Webers syndrome,It is caused by midbrain infarction as a result of occlusion of the paramedian branches of the posterior cerebral artery or of basilar bifurcation perforating arteries,分水岭梗死,Watershed Infarcts,皮层型: 皮层前型:是大脑前、中动脉交界区的梗塞。 皮层后型:位于大脑中、后动脉交界区。 皮层上型 皮层下型:位于大脑中动脉皮层支与深穿支间的分水岭区。,Watershed Infarcts,Cortical border zone infarctions Internal border zone infarctions,1