主动脉急症的CT诊断.ppt

急诊室经常遇到的急性主动脉疾病 内容 急性主动脉综合征主动脉夹层 AD 壁内血肿 IMH 穿透性溃疡 PAU 主动脉瘤 胸 腹破裂和即将破裂的迹象 AcuteAorticSyndrome AorticDissection AD IntramuralHematoma IMH PenetratingAtheroscleroticUlcer PAU AorticAneurysm Thoracic AbdominalRuptureandImpendingRuptureSigns AORTICDISSECTION主动脉夹层 Mostcommoncauseofacuteaorticsyndrome 70 Anintimaltearwithseparationoftheaorticmediaintotwolayers急性主动脉综合征最常见的原因 70 主动脉壁内膜被分离成两层 Classification分类 TypeADissection TypeBDissection TypeA 90 diewithin3monthsifnottreatedurgentoperationTypeB medicationsorinterventionaltreatment A型 如不紧急手术治疗 三个月内死亡率大于90 B型 药物或介入治疗 60 70 30 40 ChestRadiographicFindings胸片表现 normalin10 40 widenedmediastinum61 1 displacementofaorticcalcification14 1 abnormalcardiaccontour25 8 正常10 40 纵隔增宽61 1 主动脉钙化14 1 心脏异常轮廓25 8 RoleofMDCTangiography动脉CTA作用 1 Sitesofprimaryentryandre entry 2 Intimomedialflap falseandtruelumen 3 Extentofthedissection 4 Evidenceofrupture 5 Involvementoftheaorticbranches 6 Abdominalaorticbranchpatencyandevidenceofend organmalperfusion 7 Morphologyanddiameteroftheaortaalongwiththepatency sizeandtortuosityoftheiliacandfemoralarteries usefulforendovasculartreatmentplanning 1 破裂入口和出口 2 内膜片 真假腔 3 夹层的程度 4 破裂的证据 5 主动脉分支受累 6 腹主动脉分支通畅和终末器官灌注不良的证据 7 沿着通畅主动脉的形态和直径 髂动脉和股动脉的大小和扭曲 有助于血管内治疗计划 UnenhancedCT平扫 UnenhancedCT internaldisplacementofintimalcalcificationsContrast enhancedCT intimalflapthatseparatesthetruelumenfromthefalselumen CT平扫 钙化内膜内移增强CT 内膜片分离出真假腔 Classification StanfordtypeA StanfordtypeB FalselumenLargercrosssectionalarea Pfalse Ptrue Delayedenhancement thrombosisBeaksign CobwebsignTruelumen itscontinuitywithanundissectedportionoftheaorta Cobwebsign Beaksign 假腔截面积大 假腔 真腔 延迟强化 血栓形成Beaksign Cobwebsign真腔 一直延续 ComplicationsofThoracicAD并发症 AcuteaorticregurgitationMajorarchvesselobstruction coronaryarteryinvolvement Aorticrupture pericardiumtamponade leftpleuralcavity mediastinum 急性主动脉瓣关闭不全主动脉弓阻塞冠状动脉受累 主动脉破裂 心包填塞 左胸腔 纵隔 ComplicationsofAbdominalAD并发症 MainabdominalarterialbranchinvolvementAorticrupture hemoperitoneum 1主腹动脉分支受累 2主动脉破裂腹腔积血 Malperfusion灌注不良 Mortality死亡率 38 50 IncidenceMaincoronaryartery4 7 7 主冠状动脉Carotid6 6 28 颈动脉Subclavianartery5 6 17 锁骨下动脉SMA2 3 11 9 肠系膜上动脉Renalartery3 2 12 4 肾动脉Intercostala forspinalcirculation1 8 6 8 肋间动脉如脊髓循环Iliofemoralartery13 2 30 髂股动脉 BranchVesselObstruction分支血管阻塞 StaticOcclusion IntimalflapentersthebranchvesseloriginThrombusformationinthefalselumenDynamicOcclusion Intimalflapcoversthevesseloriginlikeacurtain Arteryarisingfromthetruelumeniscompromised 静态闭塞 内膜片进入分支血管的起始处 血栓形成 在假腔动态闭塞 内膜片像窗帘覆盖血管起始处 起源真腔的动脉受到损害 Dynamicocclusion 动态闭塞 truelumenresemblesaC shapedenvelopethatispredominantlyconcavetowardthefalselumen treatedwithafenestrationprocedure Typesofbranch vesselocclusion分支血管闭塞的类型 Staticocclusion 静态闭塞 intimalflapintersectsorentersthebranch vesselorigin treatedlocallywithanintravascularstent Typesofbranch vesselocclusion 陷阱PitfallsofMDCT NonECG gatedCT motionartifactpericardialrecessmuralthrombusinafusiformaneurysmPeriaorticfibrosisormediastinal pulmonary orretroperitonealtumors PericardialRecess ECG gatedVs Non ECG gated Managementofacuteaorticdissection Howtowritereport ExtentofdissectionLocationofintimaltearIdentificationoftrue falselumenMalperfusion sidebranchinvolvementAssociatedfindings INTRAMURALHEMATOMA壁间血肿 SpontaneousruptureofthevasavasorumintheaorticwallAbloodcollectionwithintheaorticwallwithrestrictedflow dissectionwithrestrictedflow PrecontrastCT narrowwindow Hyperattenuatingcrescent onprecontrastCTNocontrastenhancement smoothmargin30 rateofprogressiontoovertaorticdissection AcuteIntramuralHematoma急性壁间血肿 SubacuteIntramuralHematoma亚急性壁间血肿 SubacuteandchronicIMH 1weekaftertheonsetofsymptoms Decreasedattenuation identicaltothatinintraluminalblood DifferentiationofacuteIMHfrommuralthrombusorthrombosedfalselumenseeninAD Muralthrombus moreirregularlumen non displacedintimalcalcification morecommoninabdominalaorta associatedwithaneurysm附壁血栓 更不规则腔 非移位性内膜钙化 更常见于腹主动脉 合并动脉瘤 IMH ADw thrombosedfalselumen Muralthrombus ADfalselumenthrombosis multilayeredpatternofincreasingattenuationintimalflap whenyouscrollupanddown RadioGraphics2009 29 791 804 AD NaturalhistoryofIMH 10 16 47 20 45 Canresolve followed2months a UnenhancedaxialCTimageobtainedatpresentationdepictsatypeBaorticintramuralhematoma arrow b ContrastenhancedaxialCTimageobtained1monthlatershowsanenhancingulcerlikeprojection arrow afindingsuggestiveofanewintimaltear c ContrastenhancedaxialCTimageobtained2monthslatershowsovertdissection arrow Canprogresstodissectionwithulcerlikeprojectionanddissection Canprogresstofusiformaneurysm 可进展为梭形动脉瘤 a b UnenhancedaxialCTimagesobtainedatpresentationdepictatypeBhematoma c Contrast enhancedaxialCTimageobtained2yearslatershowsafusiformaneurysmatthesiteoftheinitialaorticintramuralhematoma F 70acutechestandupperbackpain 2008 02 18CTAngiography Observationacutechestpain 2008 04 26CTAngiography DifferentialDiagnosis鉴别诊断 PericaridalrecessAortitis diffuse circumferentialinvolvementRetroperitonealfibrosisorperiaorticlymphomaThickenedaorticwallenhancesMorecommonlyinvolveabdominalaortaCircumferential Retroperitonealfibrosis PericardialRecess pericaridal隐窝主动脉炎 弥漫 环周受累腹膜后纤维化或腹主动脉旁淋巴主动脉壁增厚更常见的涉及腹主动脉环 F 23palpitation HA 2010 07 07CTAngiography 40HU 75HU Takayasu sarteritis TypeBIMHPrimarilyconservativeSurgeryorstent graftifrecurring refractorychestpain evidenceofincreasingextentanddiameterTypeAIMHEmergencyoperationifthereiscardiactamponade impendingrupture orruptureConservativetreatment Howtowritereport ExtentofIMH typeAorBPresence absenceofPAUorintimaltearIfpresent locationofPAUorintimaltearSignsofrupture progression PENETRATINGAORTICULCER穿透性溃疡 Ulcerationofatheroscleroticplaque Disruptionoftheaorticmedia Medialhematomaformation localized Potentialforrupture FalseaneurysmformationMid thoracicordistaldescendingaorta Definition ulcerationofanaorticatheroscleroticplaquepenetratingthroughtheinternalelasticlaminaintothemedia 主动脉粥样斑块溃疡穿透内弹性膜进入管腔 Plaqueulceration斑块溃疡 Adventitialpseudoaneurysm血管外膜假性动脉瘤 Transmuralrupture透壁破裂 Intimalplaqueulceration内膜斑块溃疡 Medialhematoma内侧血肿 PenetratingAtheroscleroticUlcer穿透性溃疡 NaturalhistoryofPAU Initialdiameter 20mmordepth 10mm CTFindings Focalcontrast material filledpouchcommunicatingwiththeaorticlumenbutextendingoutwardbeyonditsexpectedaorticwallboundaries M 88acuteLt chestpain underlyingAGC 2005 05 06ChestCT 42 51 DDxofAorticUlceration AtheromatousUlcerNoextensionbeyondexpectedmarginofaorticwallNohematomaPAUAcute lifethreateningSometimeswithIMH hematomaorsofttissueinfiltrationIrregularmarginIMHConcentricallylocatedcollectionofbloodwithinmediasmoothlyADIntimalflapextendsacrossaortaLengthmoreextensive AorticAneurysm ThoracicaorticaneurysmPermanentabnormaldilationoftheaorta1 5morethannormaldiameter 5cmindiameterNormalvalue AscTA3cmindiameter 46 65 AorticAneurysm CausesAtherosclerosisMarfan sAortitisTakayasu sBehcet sGiantcellMycoticSyphyliticTraumaticTruevs pseudoFusiformvs Saccular 47 51 AbdominalAorticAneurysm OpindicationDiameterover5 5cmRapidsizeincrease7mm 6month10mm 1yearAnnualriskofrupture8cm40 60 48 51 ImpendingRupture PainGrowing 1cm 6moPerianeurysmalhemorrhageHyperdensecresentIMHorintrathrombichemorrhageDensityheterogeneityofintramuralthrombiEccentriclumenwiththinwallFocaldiscontinuityofcal RimRecentlyabruptbreak FindingsofImpendingRupture Increasedaneurysmsize diameter 7cm acutesymptoms TAA 6cm AAA 7 2cm Thrombusandcalcifications thrombustolumenratiodecreasesasaneurysmincrease thickcircumferentialthrombusisprotectiveagainstruptureHyperattenuatingcrescentsign acuteorimpendingrupture refertoPRECONTRASTCT Drapedaortasign containedrupture FindingsofAneurysmRupture动脉瘤破裂表现 TAA Hemopericardium Hemomediastinum Hemothorax Lt 心包 纵膈 胸腔积血Aortobronchial AortoesophagealfistulaAAA Retroperitonealhematoma Periaorticbloodextendingintotheperirenal pararenalspaceorpsoasmuscles AortoentericfistulaExtravasation immediateordelayedfindingsFocaldiscontinuityincircumferentialcalcificationsunstableorrupturedaneurysm 51 51 ImpendingRupture先兆破裂 M 70 Aneurysmruptureina65 year oldman NonenhancedCTscanshowsarupturedatheroscleroticaneurysmofthedescendingthoracicaorta Notethehigh attenuationfluidintheleftpleuralspace afindingthatrepresentsacutehemothorax Aortobronchialfistula主动脉支气管瘘 Aortoesophagealfistula食管主动脉瘘 2011 11 07outsideCT M 73Hemoptysis Aortoentericfistula 59 51 InfrarenalAAA Hyperdensecrescentrimvs AcuteIMH高密度新月形边缘与急性IMH Histologically hyperdensecrescentrimseenatCTinlargeabdominalaorticaneurysmiscausedbyfreshbloodthatfirstinsinuatesitselfintothemuralthrombusandlaterpenetratesintotheaorticwallIMHiscausedbyhemorrhagewithintheaorticwallAAAismorecommonlyassociatedwithachronicIMHthanwithanacuteorsubacuteone HyperattenuatingcrescentinassociationwithfusiformaneurysmisdiscordantwithsubacuteoracuteIMH Impendingrupture IncreasedsizeofinfrarenalAAA6 5cm 7 1cm M 68abdominalpain 2008 11 27CTAngiography Impendingrupture ContainedrupturecasesIncreasedsizeofinfrarenalAAA6 5cm 7 1cm Howtowritereport ExtentofaneurysmSerialchangeofaneurysmsizeProximalnecklength fromleftrenalartery AAA FeatureofimpendingruptureAssociatedfindings Infected Mycotic Aneurysm感染 真菌 动脉瘤 mostoftenpseudoaneurysm pronetorupture 53 75 endocarditisrelatedsepticemia directpropagationfromadjacentvertebralOM renalorpsoasmuscleabscess Findingssaccularshape lobularcontours eccentricthrombusperiaorticinflammation abscess andmassperiaorticgasandadjacentvertebralbodyabnormalitiesduetothespreadofinfectionfastexpansionovertime 39067380F 73Forfeverfocusw u 2010 01 28AbdomenCT SUV3 8 2010 03 11CTAngiography 42231815M 71chestpain 2011 09 12outsideChestCT HU20 2011 10 13CTAngiography TraumaticAorticInjury TAI 外伤性主动脉损伤 SeveredecelerationHighspeedmotorvehicleaccidentFallfromagreatheightImmediatedeathin80 90 Untreated 1 perhourfor48h TwoTheory Shearbtwfixedarch mobiledescendingaorta Osseouspinchbtwspine anteriorbonycomplex RadioGraphics1997 27 TraumaticAorticInjury TraumaticAorticInjury TAI 外伤性主动脉损伤 MostcommonsitesAorticisthmus 90 Ascend