脑血管讲座【可修改文字】

Watershed

infarctsorinternalborderzoneinfarcts(IBI)

Vascularterritoriesofthecerebralarteries颈内动脉系统椎-基动脉系统Artery:CircleofWillisPCA2后交通支2ICAACA1前交通支2222219条血管$35.45

$34.45$20.95Vascularterritoriesofthecerebralarteries梗塞可分三类:corticalinfarctsterritorial梗塞：ACA,MCA,PCAwatershed梗塞：ACA-MCA,MCA-PCAperforatingarteryinfarcts(PAI)，分两部分深穿通支：分布到基底节，内囊和丘脑等浅穿通支：位于半卵圆中心和外囊区域,又称"whitemattermedullaryinfarcts”internalborderzoneinfarcts(IBI)CLASSIFICATIONPatternsofinfarctionInternalborderzoneinfarctions(deepMCA-ACA)Territorialinfarction(PCA)borderzoneinfarctionsLacunarinfaction皮质皮质深穿通支浅穿通支未显示TerritorialInfarcts

(ACA,MCA,PCA)CORTICALVASCULARTERRITORIESAnteriorcerebralartery

供应额叶顶叶内侧部分和胼胝体前部、基底节和内囊49MAkinesia,abulia,andmutism

infarctofrecurrentarteryofHuebnerHeubner‘s动脉是ACA分支,起源于A1或前交通动脉，供应内囊前肢，尾状核头和前苍白球临床表现:对侧下肢无力和感觉↓，如双侧ACA梗塞:意志力丧失，截瘫和尿失禁本例:最近有前交通动脉瘤手术

AxialCTAxialCTAxialCT59yofemalewithmultiplefallsoverlastweekend低密度位于caudatehead,anteriorlimbinternalcapsuleandanteriorputamenRecurrentarteryofHeubnerAnteriorcerebralarteryinfarctionAnteriorcerebralarteryTheACAsuppliesthemedialpartofthefrontalandtheparietallobeandtheanteriorportionofthecorpuscallosum,basalgangliaandinternalcapsule.ACAinfarction

Anteriorcerebralarteryinfarction脑室上切面:右半球旁矢状区高信号典型大脑前动脉梗塞征T2-A60-year-oldmalewithahistoryofdiabetesmellitus,tobaccouse,andhypertensionpresentedwithachiefcomplaintoftransientright-handedclumsinessandslurredspeechananteriorcerebralarteryterritoryinfarct.MCASuperimposed

MapsDWI:大脑中动脉梗塞类型浅穿支一个M2分支主干或多个M2分支皮质梗塞皮质下梗塞深穿支内侧分水岭外侧分水岭MCAinfarction.Involvementofcorticalbranchesanddeepperforatinglenticulo-striatearteriesMCAinfarctionwithluxuryperfusionOntheenhancedCT-imagesofapatientwithaninfarctionintheterritoryofthemiddlecerebralartery(MCA).

Thereisextensivegyralenhancement(luxuryperfusion).

Sometimesthisluxuryperfusionmayleadtoconfusionwithtumoralenhancement.基底节血供：lenticulostriatearteries（LSA)Lenticulostriatearteries:分为内外侧支外侧支为水平M1段分支内侧支为A1分支MCA的深穿支供应基底节大部分Heubner动脉是最大分支供应尾核头前内和内囊前下外侧豆纹动脉(桔色)内侧豆纹动脉(红)基底节血供：lenticulostriatearteries（LSA)内侧豆纹动脉外侧豆纹动脉供应部分海马,内囊后肢,并且向上延伸到侧脑室中央部外后区

P1段发出,供应中脑和丘脑PCA的深穿支(红)(桔色)LacunarInfarcts定义:脑深部(基底节、丘脑，白质)和脑干的小梗塞，由一条深穿支闭塞所致病因:动脉粥样硬化是最常见原因，其次为栓塞，常常为心源性alacunarinfarctintheleftthalamusThereisonlyasmallareaofsubtlehyperintensity

T2WFLAIROntheFLAIRimagetheinfarctishardlyseenPosteriorcerebralartery主干:围绕中脑并到达幕上,供应枕叶(视觉)和后下颞叶（记忆)穿通支:中脑,丘脑,丘脑下部T1Post-contrastcoronalNeckMRA:颈部大血管无明显梗塞DWI72岁,左利,胸痛5天,不认识信用卡,加油站和医生办公室

神经系统检查为失读症而没有失写(症).Acuteinfarction(5dayold)involvingtheleftPCAterritory左后颞枕高信号FLAIRT1轻度增强PosteriorCerebralArteryInfarctionPCA主干:围绕中脑并到达幕上,供应枕叶(视觉)和后下颞叶（记忆)穿通支:中脑,丘脑,丘脑下部左枕叶低密度T2WI：左侧PCA区域梗塞，并且描绘出Willis环脉管系统，显著右后交通动脉（箭头)急性右大脑后动脉梗塞

发病12小时,左侧同向偏盲SCA+PCAcerebellarinfarction:intheregionofSCAbrainsteminfarction:intheterritoryofPCASCAPCA注意病灶均不越过中线basilarartery（BA)

小脑和脑干

basilarartery（BA)小脑前下动脉(AICA)是BA直径较大分支,由BA下,中1/3结合处发出供应:桥脑被盖外侧,桥臂,中小脑脚小脑:小叶,前小脑小部分

internalauditoryartery(IAA)常由AICA或BA直接发出posteriorcerebralartery(PCA);为BA终末支,供应中脑,丘脑,颞枕内侧小脑上动脉在左右PCA交叉处附近,由基底动脉发出供应:桥脑和中脑的外侧,小脑上面BA在桥脑腹侧始于桥延结合部,由2个椎动脉融合而成分别发出分支(median,paramedian,short,andlongcircumferentialbranches)PCASCABA的桥支AICAIAAPICAAnteriorspinalarteryThethreemajorarteriesofthecerebellumThethreemajorarteriesofthecerebellum:theSCA,AICA,andPICA.(AnteriorinferiorcerebellararteryisAICA.).B.ViwofthecerebellumremovedfromthebrainstemtorevealtheventralsurfaceUpperCerebellumlowercerebellummidcerebellumCerebellum-Parasagitalaleft-sidedPICA-infarction一侧梗塞:上蚓支为矢状分布，不越过中线，故病灶中线轮廓清晰，注意早期水肿可越过中线，使诊断困难基底动脉的分支不越过中线,故脑桥梗塞常位于旁正中,边界清晰双边梗塞:难以存活而罕见，有时可见侧小梗死病灶中线轮廓清晰aleft-sidedPICA-infarctionNoticetheposteriorextention.

Theinfarctionwastheresultofadissection(bluearrow).74岁，男，突发头晕，构音障碍，耳鸣，听力障碍，恶心和呕吐:VA闭塞导致AICA梗塞入院CT小脑半球前表面低密度区高信号灶外下脑桥，中小脑脚及小脑半球前表面（包括小叶)高信号右椎动脉闭塞延髓前右椎动脉高信号,为新鲜血栓T1WIMRADWIT2WI-MRIfindingsinapatientwithanteriorinferiorcerebellararteryterritoryinfarctionPossibleborderzoneinfarctbetweenPICAandAICAisalsoseenDWIT2WI左小脑中脚和背外侧桥脑高信号小脑上动脉梗塞,基底动脉狭窄左小脑中部高信号,累及小脑蚓部和小脑上脚和中脚,4脑室轻度受压Basilararteryinfarction左中脑梗死右桥脑梗死左延髓梗死右丘脑梗死WatershedInfarctsWatershedInfarcts定义：灌注不足导致大脑主要动脉边界区域梗塞可分两种类型皮质型:Corticalborderzoneinfarctions位于皮质与邻近皮质下白质之间ACA/MCAMCA/PCA深白质型：Internalborderzoneinfarctions（见下图)位于半卵圆中心和放射冠,有两型：MCA的皮质支和白质支之间MCA深白质-ACA深白质之间Internalborderzoneinfarctions位置：半卵圆中心和放射冠,有两型：MCA皮质和白质支之间（深浅支之间)MCA豆纹穿通支-MCA深穿通皮质支两条主要血管的白质之间MCA深白质分支-ACA深白质分支FörsterAetal.(2008)MechanismsofDisease:pathophysiologicalconceptsofstrokeinhemodynamicriskzones—dohypoperfusionandembolisminteract?NatClinPractNeurol

10.1038/ncpneuro0752Examplesofborderzoneinfarctsondiffusion-weightedMRIAnteriorcorticalborderzoneinfarct(CBI).PosteriorCBI.CombinedanteriorandposteriorCBI(D,E)Internalborderzoneinfarcts.(F)Combinedinternalborderzoneinfarctandterritorialinfarct.Corticalborderzoneinfarctions:ACA-MCAFigure3.HighCTsliceshowsthelocationof3smalllefthemisphereborderzoneinfarctions,appearingasachain.低血压-内分水岭梗塞Noteleftsuperiorparietallobuleinfarctintheexpectedlocationofthemiddlecerebralartery(MCA)/posteriorcerebralartery(PCA)corticalborderzone.centruminfarctsinarosaryconfigurationconsistentwithinternalborderzoneinfarctsinapatientwithhypotension

T2FLAIRFigure1Positivediffusion-weightedMRIscanofthebraindemonstratingunilateralwatershedinfarction(whiteareas)LearyCRandCaplanLR(2007)TechnologyInsight:brainMRIandcardiacsurgery—detectionofpostoperativebrainischemiaNatClinPractCardiovascMed

4:379–388doi:10.1038/ncpcardio0915a58-year-oldwomanwithnew-onsetatrialfibrillationMultiplecorticalborderzoneembolicinfarctsareseenbetweentheanteriorcerebralartery(ACA),middlecerebralartery(MCA),andposteriorcerebralartery(PCA)territories.ImagedemonstrateslaminarnecrosisofthesuperiorparietallobulecortexSagittalT1-weightedimageinPETimagesinapatientwithrightICAocclusionwhoshowedinternalborderzoneinfarctionwithcorticalextensiononcorrespondingMRI/cgi/content/figsonly/46/12/1973paralleldecreaseofFMZ-BP,CBF,CMRO2,andanincreaseofOEF2differentlevels内分水岭梗塞皮质分水岭梗塞IllustrativeexamplesofwatershedinfarctsinpatientswithICAdisease皮质分水岭（前部重，后部轻)内分水岭梗死（念珠状以及融合型)典型分水岭梗死:三个不同病人右半球前分水岭梗塞,累及ACA与MCA皮质表层狭长区域CTT2右半卵园中心：内分水岭梗死（念珠状)白质型DWI:同一患者不同切面皮质型混合型不同切面centruminfarctsinarosaryconfigurationconsistentwithinternalborderzoneinfarctsinapatientwithhypotension

Noteleftsuperiorparietallobuleinfarctintheexpectedlocationofthemiddlecerebralartery(MCA)/posteriorcerebralartery(PCA)corticalborderzone.念珠internalborderzoneinfarctsDWIThisyoungpatienthadprolongedhypotensionasaresultofadrugoverdoseMRIconfirmedthesechangeswithrestricteddiffusionandhighT2signalseendeeptothecortexThisisacharacteristicappearanceofaninternalwatershedinfarctDeepwatershedinfarctioninapatientwithanocclusionoftherightinternalcarotidartery

左侧3个连续切面On