【头颈】图解脑疝课件

圖解腦疝腦疝是指在顱內壓增高的情況下，腦組織通過某些腦池向壓力相對較低的部位移位的結果，即腦組織由其原來正常的位置而進入了一個異常的位置。腦疝的類型：a.大腦鐮疝：一側大腦半球占位病變可使同側扣帶回經大腦鐮下緣疝入對側，胼胝體受壓下移。

小腦幕切跡疝b.前疝：也稱顳葉溝回疝，是顳葉溝回疝於腳間池及環池的前部；②後疝：顳葉內側部疝於四疊體池及環池的後部；f.小腦幕切跡上疝：後顱凹占位病變時，小腦上蚓部可向上疝入小腦幕切跡的四疊體池。c.中心疝：幕上壓力增高，致使大腦深部結構及腦幹縱軸牽張移位。

d.顱外疝：腦組織通過顱外缺損疝出。e.枕骨大孔疝：後顱凹占位病變時，可致小腦扁桃體疝入枕骨大孔。g.蝶骨脊疝：顱前凹和顱中凹的占位病變，由於病變部壓力相對高一些，則額眶回可越過蝶骨脊進入顱中凹，可顳葉前部擠向顱前凹。示意圖a)subfalcial(cingulate)herniation;鐮下疝b)uncalherniation;鉤疝c)downward(central,transtentorial)herniation;下行性小腦幕疝d)externalherniation;顱外疝e)tonsillarherniation.扁桃體疝f)ascendingtranstentorialherniation(reversedtentorial)上行性小腦幕疝g)sphenoidherniation蝶骨脊疝類型腦疝部位命名別名疝入腦組織命名1．大腦鐮下疝扣帶回疝2．小腦天幕疝前疝後疝小腦幕切跡疝、小腦幕下降疝腳間池疝環池疝，四疊體疝顳葉鉤回疝海馬回疝3．小腦幕孔中心疝間腦4．小腦幕孔上疝小腦幕上疝小腦蚓部疝5．枕骨大孔疝小腦扁桃體疝示意圖解剖關係解剖關係FQcMb3vTOSyCClvFPOSpCClvss解剖關係FTCesPd4thVFTMbCesThesuprasellarcistern&thequadrigeminalcisternTheleftandcenterimagesshowthesuprasellarcistern.Itsanteriorbordersareformedbythefrontallobes(F).Itslateralbordersareformedbytheuncus(U)ofthetemporallobes.Theleftimageshowsthe5-pointedstarappearanceofthesuprasellarcisternwheretheposteriorborderisformedbythepons(Po).Theblackarrowpointstothefourthventricle.Thecenterimageshowsahighercutwherethesuprasellarcisternhasa6-pointedstarappearancesincetheposteriorborderisformedbythecerebralpeduncles(P)whichhaveacentralcleft.Therightimageshowsthequadrigeminalcistern(blackarrow).Notethe"baby'sbottom"appearanceofitsanteriorborder.WhenICPisincreased,thequadrigeminalcisternspaceiscompressedorobliterated.Thesuprasellarcistern

&thequadrigeminalcistern.ThemidlinesagittalMRIscanshowsthelevelsoftheaxialdiagrams.Thequadrigeminalcisternislocatedabove(anteriorto)the"Q"inthehighestcutshown(number9).Theanteriorborderofthequadrigeminalcisternisformedbythesuperiorcolliculi(c).Image8(lowercut)alsoshowsthequadrigeminalcistern.Inthiscase,itsanteriorborderisformedbytheinferiorcolliculi(c).Thisgivestheanteriorborderofthequadrigeminalcisterntheappearanceofa"baby'sbottom".Thequadrigeminalplateiscomprisedofthesuperiorandinferiorcolliculi.Thequadrigeminalcisternisposteriortothisquadrigeminalplate,thusitsanteriorbordermaybeformedbytheinferiororsuperiorcolliculi.鐮下疝臨床表現影像所見併發症頭痛對側下肢無力同側額角截斷大腦鐮前份不對稱同側側腦室腔消失透明隔移位因大腦前動脈卡壓到大腦鐮上引起同側ACA供血區梗塞伴有其他疝Subfalcineherniation(cingulateherniation)

Transtentorialherniation

Thesuprasellarcistern(leftimage)isobliterated.Thequadrigeminalcisternisverycompressedandpushedposteriorly(centerimage).Asubduralhematomawithamidlineshiftisnoted.Thereiscentraltranstentorialandsubfalcineherniation.ACA供血區梗塞Uncalherniation臨床表現影像所見併發症同側瞳孔散大、眼動受限（動眼神經受壓）對側偏癱（同側大腦腳受壓）有時顳葉疝壓跡會導致同側偏癱（對側大腦腳受壓。假定位體征）對側顳角增寬同側環池增寬同側橋前池增寬鉤回進入鞍上池大腦後動脈受壓導致枕葉梗塞鞍上池缺角冠狀位CT與MRI海馬旁回褶皺對側顳角增寬同側橋前池增寬同側環池增寬UncalherniationUncalherniationobliterationofthesuprasellarcistern(redarrow)andthequadrigeminalcistern(greenarrow)UncalherniationTheipsilateralventricle,sulci,fissuresarecompressedandobliterated,isappeared.obliterationofthe

suprasellar

cistern(s)andquadrigeminal

cistern(q)UncalherniationAcuteinfarction1stdayAcuteinfarction4thdaysqUncalherniationBeforesurgery,abigGBMinthelefttemporallobewithuncal

herniation.Aftersurgery,theGBMwasremoved,thesuprasellarcisternandquadrigeminalcisternsarenormal.UncalherniationAcuteinfarctionofrightposteriorartery(PCA),thisisacomplicationofuncal/transtentorial

herniation,becausethePCAwascompressedbybrainherniation.雙側大腦後動脈梗塞雙側大腦後動脈梗塞DurettehemorrhageDurettehemorrhageKernohan’snotch顳葉疝壓跡UncalherniationWhenmasseffectswithinoradjacenttothetemporallobeoccur,themedialportionofthetemporallobe(uncus)isforcedmediallyanddownwardoverthetentorium.Thereisipsilateralpupillarydilation.Theuncusispushedmediallyintothesuprasellarcistern.Thereisbilateraluncalherniation.Thesuprasellarcisternisobliterated.earlyuncalherniation

Therightuncusispushingintothesuprasellarcistern;earlyrightuncalherniation.中心疝臨床表現影像所見併發症意識改變呼吸模式改變去皮層、去腦小瞳孔因脈絡膜前動脈受壓引起蒼白球和視束梗塞中心疝Superiorvermianherniation(ascendingtranstentorialherniation)由於後顱凹的占位效應，小腦蚓和小腦半球通過小腦幕切跡向上移動臨床表現影像所見併發症噁心嘔吐意識障礙中腦外觀呈陀螺狀雙側環池變窄四疊體池充滿因小腦上動脈受壓引起梗塞Galen靜脈移位腦積水意識障礙迅速出現，並可能死亡陀螺狀外觀雙側環池變窄四疊體池充滿不露齒的微笑皺眉第一天的四疊體池和環池第二天，四疊體池和環池消失腦積水ascendingtranstentorialherniation枕大孔疝臨床表現影像所見併發症雙側上肢感覺減退意識障礙軸位像見到小腦扁桃體位於齒狀突水準矢狀位見到小腦扁桃體低於枕大孔5mm（成人）或7mm（兒童）小腦扁桃體出血性壞死意識障礙和死亡枕大孔疝Tonsillarherniation

Intonsillarherniation(rare),amasseffectintheposteriorfossacausesthecerebellartonsilstoherniateinferiorlythroughtheforamenmagnumcompressingthemedullaanduppercervicalspinalcord.Consciouspatientscomplainofneckpainandvomiting.Theymayhavenystagmus,pupillarydilatation,bradycardia,hypertensionandrespiratorydepression.Earlytonsillarherniationisdifficulttorecognizeinanunconsciouspatient.ItmaynotbeevidentonCTscansinceaxialviewscannotseethepathologywell.ItisbestseenonsagittalMRI.Clinicallychangesinvitalsignsmaybetheonlyclinicalclueinanunconsciouspatient.Tonsillarherniationamalepatientinhis30'swhodiedofbrainstemherniationaftercompletingamarathon.

TheCTshows(A)lossoftherostralcerebralsulcisuggestingincreaseinICP,(B)and(C)alargehydrocephaluswithwideningofbothtemporalhorns.Thegreymattercanstillbedifferentiatedfromthewhitematter,butallsulciarelost.Thissuggeststhatthebrainoedemaisofrelativerecentonsetandmassivetissueischaemiahasnotyetoccurred.(D)Compressionofthefourthventriclewithdilatationofthethirdventricleandthecaudalaspectofbothtemporalhorns.Thisisobservedwithconsiderablebrainoedemaandobstructivehydrocephalus.(E)Herniationofthemedullaandponsintotheforamenmagnum.(F)Thetonsilsarelocatedatthelevelofthedenswhichisagoodindicatorforforamenmagnumherniation.(A)Thediscshowsfloridhemorrhageswithrelativelylittleswelling,indicatingarapid,dramaticincreaseinCSFpressure.Progressivechangesofopticdiscoedemaareseeninapatientwithanintracranialtumourwhodeclinedtreatment(B-D).(B)Earlynervefiberdilatationisseenparticularlysuperiorly,inferiorlyandnasally.(C)Thisincreasesandvenousengorgementdevelops.(D)Temporalnervefiberdilatationandswellingofthediscincreasesandhemorrhagesappear.(E)Ingrosschronicdiscoedemathenormalretinalvasculatureismaske