主动脉急症的CT诊断ppt课件

.,1,急诊室经常遇到的急性主动脉疾病,.,2,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)AorticAneurysmThoracic,AbdominalRuptureandImpendingRuptureSigns,.,3,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,.,4,Classification分类,TypeADissection,TypeBDissection,.,5,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%,.,6,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%,.,7,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）,.,8,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,.,9,Classification：StanfordtypeA,.,10,StanfordtypeB,.,11,FalselumenLargercrosssectionalarea(PfalsePtrue)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,.,12,ComplicationsofThoracicAD并发症,AcuteaorticregurgitationMajorarchvesselobstruction,coronaryarteryinvolvement,Aorticrupturepericardiumtamponade,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,.,13,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,.,14,Malperfusion灌注不良,Mortality死亡率:3850%IncidenceMaincoronaryartery4.77%主冠状动脉Carotid6.628%颈动脉Subclavianartery5.617%锁骨下动脉SMA2.311.9%肠系膜上动脉Renalartery3.212.4%肾动脉Intercostala.forspinalcirculation1.86.8%肋间动脉如脊髓循环Iliofemoralartery13.230%髂股动脉,.,15,BranchVesselObstruction分支血管阻塞,StaticOcclusion:IntimalflapentersthebranchvesseloriginThrombusformationinthefalselumenDynamicOcclusion:IntimalflapcoversthevesseloriginlikeacurtainArteryarisingfromthetruelumeniscompromised,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,.,16,Dynamicocclusion:动态闭塞-truelumenresemblesaC-shapedenvelopethatispredominantlyconcavetowardthefalselumen-treatedwithafenestrationprocedure,Typesofbranch-vesselocclusion分支血管闭塞的类型,.,17,Staticocclusion:静态闭塞-intimalflapintersectsorentersthebranch-vesselorigin-treatedlocallywithanintravascularstent,Typesofbranch-vesselocclusion,.,18,陷阱PitfallsofMDCT,NonECG-gatedCT:motionartifactpericardialrecessmuralthrombusinafusiformaneurysmPeriaorticfibrosisormediastinal,pulmonary,orretroperitonealtumors,PericardialRecess,.,19,ECG-gatedVs.Non-ECG-gated,.,20,Managementofacuteaorticdissection,.,21,Howtowritereport,ExtentofdissectionLocationofintimaltearIdentificationoftrue/falselumenMalperfusion:sidebranchinvolvementAssociatedfindings,.,22,INTRAMURALHEMATOMA壁间血肿,SpontaneousruptureofthevasavasorumintheaorticwallAbloodcollectionwithintheaorticwallwithrestrictedflow/“dissectionwithrestrictedflow”,.,23,PrecontrastCT,narrowwindow“Hyperattenuatingcrescent”onprecontrastCTNocontrastenhancement,smoothmargin30%rateofprogressiontoovertaorticdissection,AcuteIntramuralHematoma急性壁间血肿,.,24,SubacuteIntramuralHematoma亚急性壁间血肿,SubacuteandchronicIMH(1weekaftertheonsetofsymptoms)Decreasedattenuation(identicaltothatinintraluminalblood),.,25,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,.,26,ADfalselumenthrombosis:multilayeredpatternofincreasingattenuationintimalflap(whenyouscrollupanddown.),RadioGraphics2009;29:791804,AD,.,27,NaturalhistoryofIMH,10%,16-47%,20-45%,.,28,Canresolve：followed2months.,.,29,(a)UnenhancedaxialCTimageobtainedatpresentationdepictsatypeBaorticintramuralhematoma(arrow).(b)ContrastenhancedaxialCTimageobtained1monthlatershowsanenhancingulcerlikeprojection(arrow),afindingsuggestiveofanewintimaltear.(c)ContrastenhancedaxialCTimageobtained2monthslatershowsovertdissection(arrow).,Canprogresstodissectionwithulcerlikeprojectionanddissection,.,30,Canprogresstofusiformaneurysm可进展为梭形动脉瘤,(a,b)UnenhancedaxialCTimagesobtainedatpresentationdepictatypeBhematoma.(c)Contrast-enhancedaxialCTimageobtained2yearslatershowsafusiformaneurysmatthesiteoftheinitialaorticintramuralhematoma.,.,31,F/70acutechestandupperbackpain,2008-02-18CTAngiography,.,32,Observationacutechestpain,2008-04-26CTAngiography,.,33,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,.,34,F/23palpitation,HA,2010-07-07CTAngiography,40HU,75HU,Takayasusarteritis,.,35,TypeBIMHPrimarilyconservativeSurgeryorstent-graftifrecurring,refractorychestpain,evidenceofincreasingextentanddiameterTypeAIMHEmergencyoperationifthereiscardiactamponade,impendingrupture,orruptureConservativetreatment,.,36,Howtowritereport,ExtentofIMH:typeAorBPresence/absenceofPAUorintimaltearIfpresent,locationofPAUorintimaltearSignsofrupture/progression,.,37,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,.,38,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,.,39,NaturalhistoryofPAU,Initialdiameter20mmordepth10mm,.,40,CTFindings,Focalcontrast-material-filledpouchcommunicatingwiththeaorticlumenbutextendingoutwardbeyonditsexpectedaorticwallboundaries,.,41,M/88acuteLt.chestpain,underlyingAGC,2005-05-06ChestCT,.,42,.,43,DDxofAorticUlceration,AtheromatousUlcerNoextensionbeyondexpectedmarginofaorticwallNohematomaPAUAcute,lifethreateningSometimeswithIMH,hematomaorsofttissueinfiltrationIrregularmarginIMHConcentricallylocatedcollectionofbloodwithinmediasmoothlyADIntimalflapextendsacrossaortaLengthmoreextensive,.,44,.,45,AorticAneurysm,ThoracicaorticaneurysmPermanentabnormaldilationoftheaorta1.5morethannormaldiameter5cmindiameterNormalvalue:AscTA3cmindiameter,.,46,AorticAneurysm,CausesAtherosclerosisMarfansAortitisTakayasusBehcetsGiantcellMycoticSyphyliticTraumaticTruevs.pseudoFusiformvs.Saccular,.,47,AbdominalAorticAneurysm,OpindicationDiameterover5.5cmRapidsizeincrease7mm/6month10mm/1yearAnnualriskofrupture8cm40-60%,.,48,ImpendingRupture,PainGrowing:1cm/6moPerianeurysmalhemorrhageHyperdensecresentIMHorintrathrombichemorrhageDensityheterogeneityofintramuralthrombiEccentriclumenwiththinwallFocaldiscontinuityofcal.RimRecentlyabruptbreak,.,49,FindingsofImpendingRupture,Increasedaneurysmsize：diameter7cm+acutesymptoms（TAA6cm,AAA7.2cm）Thrombusandcalcifications:thrombustolumenratiodecreasesasaneurysmincrease；thickcircumferentialthrombusisprotectiveagainstruptureHyperattenuatingcrescentsign:acuteorimpendingrupture(refertoPRECONTRASTCT!)Drapedaortasign:containedrupture,.,50,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,ImpendingRupture先兆破裂,M/70,.,52,Aneurysmruptureina65-year-oldman.NonenhancedCTscanshowsarupturedatheroscleroticaneurysmofthedescendingthoracicaorta.Notethehigh-attenuationfluidintheleftpleuralspace,afindingthatrepresentsacutehemothorax.,.,53,Aortobronchialfistula主动脉支气管瘘,Aortoesophagealfistula食管主动脉瘘,.,54,2011-11-07outsideCT,M/73Hemoptysis,.,55,.,56,.,57,Aortoentericfistula,.,58,.,59,InfrarenalAAA,.,60,Hyperdensecrescentrimvs.AcuteIMH高密度新月形边缘与急性IMH,Histologically,hyperdensecrescentrimseenatCTinlargeabdominalaorticaneurysmiscausedbyfreshbloodthatfirstinsinuatesitselfintothemuralthrombusandlaterpenetratesintotheaorticwallIMHiscausedbyhemorrhagewithintheaorticwallAAAismorecommonlyassociatedwithachronicIMHthanwithanacuteorsubacuteoneHyperattenuatingcrescentinassociationwithfusiformaneurysmisdiscordantwithsubacuteoracuteIMH,.,61,.,62,.,63,Impendingrupture；IncreasedsizeofinfrarenalAAA6.5cm-7.1cm.,M/68abdominalpain,2008-11-27CTAngiography,Impendingrupture.ContainedrupturecasesIncreasedsizeofinfrarenalAAA6.5cm-7.1cm.,.,64,Howtowritereport,ExtentofaneurysmSerialchangeofaneurysmsizeProximalnecklength(fromleftrenalartery:AAA)FeatureofimpendingruptureAssociatedfindings,.,65,Infected(Mycotic)Aneurysm感染（真菌）动脉瘤,mostoftenpseudoaneurysm,pronetorupture(53-75%)endocarditisrelatedsepticemia/directpropagationfromadjacentvertebralOM,renalorpsoasmuscleabscess.Findingssaccularshape,lobularcontours,eccentricthrombusperiaorticinflammation,abscess,andmassperiaorticgasandadjacentvertebralbodyabnormalitiesduetothespreadofinfectionfastexpansionovertime,.,66,.,67,39067380F/73Forfeverfocusw/u,2010-01-28AbdomenCT,.,68,SUV3.8,2010-03-11CTAngiography,.,69,42231815M/71chestpain,2011-09-12outsideChestCT,.,70,HU20,2011-10-13CTAngiography,.,71,TraumaticAorticInjury(TAI)外伤性主动脉损伤,SeveredecelerationHighspeedmotorvehicleaccidentFallfromagreatheightImmediatedeathin80-90%Untreated:1%perhourfor48h,.,72,TwoTheory,Shearbtwfixedarch/mobiledescendingaorta,Osseouspinchbtwspine/anteriorbonycomplex,RadioGraphics1997;27,.,73,TraumaticAorticInjury,.,74,.,75,TraumaticAorticInjury(TAI)外伤性主动脉损伤,MostcommonsitesAorticisthmus(90%)Ascendingaorta(5-10%)Descendi