颅脑外伤CT诊断改课件

颅脑外外伤的的CT诊断改断改颅脑外伤的CT诊断改颅脑外伤的CT诊断改颅脑外伤的CT诊断改一、头皮一、头皮（一）解剖层次 颞部 穹窿部 皮肤 皮肤 皮下 皮下 颞浅筋膜 颞深筋膜 颈肌 颅顶肌和帽状腱膜 帽状腱膜下脂肪组织 骨膜 骨膜2020/11/32一、头皮（一）解剖层次2020/11/32（二）头皮外伤血肿 皮下 头皮血管 帽状腱膜下 由于 硬膜血管 破裂 骨膜下 板障静脉擦伤挫伤裂伤挫裂伤 2020/11/33（二）头皮外伤2020/11/332020/11/342020/11/34二、颅骨骨折二、颅骨骨折（一）分类发生部位 颅盖 颅底骨折线形态 线样 凹陷样 粉碎性 穿透性与外界关系 闭合性 开放性 2020/11/35二、颅骨骨折（一）分类2020/11/35（二）表现1、颅盖骨折颅缝分离：2mm；不对称线样：并血肿凹陷性：并颅板内陷（儿童：乒乓球）；并血肿粉碎性：并血肿-大的暴力穿通、开放性（硬膜）、穿孔（一次、二次）：为锐器伤，并：头皮破裂、头皮血肿 硬膜外、硬膜下血肿、蛛网膜下腔出血、气颅 脑挫裂伤，脑内血肿 颅内外异物 2020/11/36（二）表现2020/11/36鉴别 板障静脉 不规则 对侧可见 终于静脉湖 血管沟 渐细 硬化边 颅骨内板 骨缝 走行部位固定 两侧对称 2020/11/372020/11/372、颅底骨折（1）特点常合并颅盖骨折多呈线形常通过薄弱处在前后颅凹，纵行；在中颅凹，横行不常合并颅内血肿 2020/11/382020/11/38（2）征象1）直接：骨折线颅缝分离2）间接：气颅鼻窦可见液气、混浊脑脊液鼻漏（筛骨）2020/11/39（2）征象2020/11/392020/11/3102020/11/310Skull FracturesLinear fractures：CT is not good for linear fractures，always need bone window to evaluateDepression fracture.CT is important for the depression of fracture and other associated interacranial lesions.2020/11/311Skull Fractures2020/11/311Head injury with fractures，scalp hemorrhage，countre-coup acute subdural hematoma，uncal/tentorial herniation 2020/11/312Head injury with fractures，sca三、颅内脑外积聚物三、颅内脑外积聚物-血肿、积液、积气血肿、积液、积气 包括硬膜外腔 硬膜下腔 蛛网膜下腔 主要相关于硬脑膜软脑膜蛛网膜 2020/11/313三、颅内脑外积聚物-血肿、积液、积气 包括2020/11/3二、Epidural lesionsEpidural hematomasubdural hematomasubdural effusion2020/11/314二、Epidural lesions2020/11/314（一）硬膜外血肿（一）硬膜外血肿1、特点急范围局限脑组织可受压；中线结构移位不明显并发骨折位于脑膜动脉区颞区多见 2020/11/315（一）硬膜外血肿2020/11/3152.CT表现梭形高密度急性：密度均匀；慢性：密度不均-活动性出血或再出血内缘光滑范围局限，不越颅缝但可越中线或小脑幕占位效应小，中线移位轻并骨折包膜钙化或骨化2020/11/3162.CT表现2020/11/3162020/11/3172020/11/3172020/11/3182020/11/318Acute Epidural Hematoma Fusiform shape（纺锤体）of hyperdense lesion.Always causing strong mass effect.2020/11/319Acute Epidural Hematoma FusiAcute Epidural Hematoma The hematoma still contains uncoagualated blood,or still has active bleeding.Round,stream-like filling defects may be seen in the hematoma.2020/11/320Acute Epidural Hematoma The male/16,delayed EDH,and sportaneous resorption88,3,28 Head injurypatient was irritable88,4,15 A subacuteepidural hematoma88,5,18 No surgeryThe EDH is small2020/11/321male/16,delayed EDH,and sporta1、急性硬膜下血肿（1）分型单纯型-矢状窦旁顶部桥静脉 静脉窦 皮层静脉 动脉复合型-脑挫裂伤引起 皮层静脉或动脉出血破入硬膜下腔 与冲击部位有关 2020/11/3221、急性硬膜下血肿2020/11/322（2）典型 CT表现高密度密度均匀范围广颅骨内板下方-新月形或“3”形（侧裂处）位于大脑镰旁、小脑幕旁-带状范围局限，不越颅缝但可越中线或小脑幕占位效应-同侧侧脑室变窄 中线移位明显复合型-与脑内血肿联接2020/11/323（2）典型 CT表现2020/11/323（3）非典型 CT表现 表现 原因密度不均 未凝、血清外溢 脑脊液漏入梭形 活动性出血 没有及时散开同侧侧脑室扩张 室间孔受压受阻2020/11/324（3）非典型 CT表现2020/11/324 Sickle-shape（镰刀型）or new lunar shape（新月形）of hyperdense lesion over large portion hemisphereAcute Subdural Hematoma2020/11/325 Sickle-shapeAcute Subdural Acute Subdural Hematoma with mass effect A.Acute subdural hematoma with mass effect B.Post-craniotomy,the SDH was removed,the mass effect2020/11/326Acute Subdural Hematoma with mThe hematoma may extending into the subdural space of tentorial regionAcute Subdural Hematoma2020/11/327The hematoma mayAcute Subdural2020/11/3282020/11/3282020/11/3292020/11/3292020/11/3302020/11/330The hematoma may extending into the interhemispheric fissure orAn acute SDHlocatesin theinterhemisphericfissureAcute Subdural Hematoma2020/11/331The hematoma mayAcute SubduralThe hematoma may extending into the subdural space of tentorial regionAcute Subdural Hematoma2020/11/332The hematoma mayAcute Subdural2020/11/3332020/11/333 The lesion is in the opposite side of impact site.30 incidence.Counter-coup Injury fractureScalp2020/11/334 The lesion is in theCounterContusion hemorrhage with some SAHHead injury with delayed SDH,EDHThe same day,12 hours later:acute SDH and EDH2020/11/335Contusion hemorrhage with someA.Brain atrophy with mild hydrocephalusB.VP shunt,acute SDHs,both sidesC.The acute SDH enlarged in right sideVP shunting induces acute subdural hematoma2020/11/336A.Brain atrophy with mild hydr2、亚急性硬膜下血肿-4天3周（1）早期：高与低密度液面或混杂密度-细胞沉淀 上浮血清-蛋白 沉淀细胞-继续出血、再出血、凝血异常（2）晚期：等或低密度等密度硬膜下血肿：白质受压内移，灰白质结合部远离颅骨内板皮层静脉移位中线移位脑室变形增强扫描：皮层染色内移 2020/11/3372、亚急性硬膜下血肿-4天3周（1）早期：高与低密度液面或2020/11/3382020/11/3383、慢性硬膜下血肿-3周以上（1）病理：包膜形成包膜血管血浆渗入 高渗蛛网膜下腔血肿增大梭形血肿液化蛋白分解 脑脊液渗入血肿壁玻璃样变性、钙化血肿包裹粘连机化多腔（2）CT表现梭形、新月形、“3”字形低密度或混杂密度-有否再次出血，血肿大小、溶解吸收 程度 脑脊液、血浆渗入多少 2020/11/3393、慢性硬膜下血肿-3周以上（1）病理：2020/11/33Shape:Semilunar,Fusiform Over shapeDensity:Hyperdense Isodense Hypodense Mixed densityChronic Subdural Hematoma2020/11/340Shape:Chronic Subdural Hematom Chronic subdural hematoma with mixed densities (isodense and hyperdense)Chronic Subdural HematomaChronic subdural hematoma withfluid-blood level(rebleeding)2020/11/341 Chronic subdural hematomaChChronic Subdural Hematoma2020/11/342Chronic Subdural Hematoma2020/2020/11/3432020/11/3432020/11/3442020/11/3442020/11/3452020/11/345（三）蛛网膜下腔出血（三）蛛网膜下腔出血（1）病理多为对冲伤皮层静脉破裂血进入脑沟、脑池内 脑室内出血蛛网膜下腔 合并脑内血肿 软脑膜破裂 合并硬膜下血肿蛛网膜破裂（2）表现CT高密度，与出血量有关多见于脚间池、外侧裂池常在一周内消失 2020/11/346（三）蛛网膜下腔出血（1）病理2020/11/3462020/11/3472020/11/347（四）脑室内出血（四）脑室内出血1、病理多数 脑内出血破入 脑室穿通伤 四脑室逆行的蛛网膜下腔出血 少数 室管膜下静脉破裂-单纯脑室出血凝结成块，侵入脑室后部、溶解2、表现CT1-2周呈高密度并发其它脑外伤改变继发脑积水 2020/11/348（四）脑室内出血1、病理2020/11/348 Often associated with other intracerebral or extracerebral lesions CT：Blood in the ventricles May cause acute obstructive or chronic communicating hydroceohalusTraumatic IVH(Intraventricular Hemorrhage)2020/11/349 Often associated with other（五）颅内积气（五）颅内积气气颅-颅内外交通硬膜外腔 气体气体 硬膜下腔 蛛网膜下腔 密度密度 脑室内 脑内 影像影像 2020/11/350（五）颅内积气2020/11/350 CT：Multiple air bubbles in the subarachnoid spaces Sources of air:1.Open fracture of the cranium 2.Skull base fracture,air from the paranasal sinuses or mastoidTraumatic Pneumoencephalus2020/11/351 CT：Traumatic Pneumoencephal四、原发脑损伤四、原发脑损伤脑挫伤/脑裂伤/脑挫裂伤/脑内血肿 穿通伤脑白质剪切伤脑干损伤脑肿胀、脑水肿 2020/11/352四、原发脑损伤2020/11/352（一）（一）脑挫伤/脑裂伤/脑挫裂伤/脑内血肿1、脑挫伤/脑裂伤/脑挫裂伤（1）病理脑挫伤 脑内散在出血灶 静脉淤血 脑水肿和脑肿胀 脑裂伤 上述改变伴脑膜、脑或血管断裂两者常合并存在，同称 2020/11/353（一）脑挫伤/脑裂伤/脑挫裂伤/脑内血肿1、脑挫伤/脑裂伤/（2）CT表现脑水肿-低密度，可局限性或广泛性脑出血-高密度，可散在点状分布或广泛性可合并蛛网膜下腔出血或硬膜下血肿 2020/11/3542020/11/3542、脑内血肿（1）病理多发于额颞叶位于受力点或对冲部位脑表面演变：急性期吸收期囊变期（2）CT表现密度：高低囊水肿：轻重无皮层下区占位效应：正负 2020/11/3552、脑内血肿2020/11/355（二）穿通伤异物出血肿胀（三）脑白质剪切伤灰白质受剪切力作用轴突损伤 伴行血管破裂出血中央、周边灰白交界、胼胝体、大脑脚 多发少量出血 2020/11/356（二）穿通伤2020/11/356（四）脑干损伤剪切伤脑肿胀/脑水肿（五）脑白质剪切伤脑室小 脑沟脑池消失 灰白质界限消失中线移位脑组织密度减低脑疝 2020/11/357（四）脑干损伤2020/11/3571.Circumscribed area of brain edema2.Brain edema mixed with multiple small hemorrhages3.A solitary hematoma4.Diffuse brain edema5.Diffuse axonal injury (shearing injury)Brain Contusion2020/11/3581.Circumscribed area of brainBDelayed hemorrhage,several hours or days afterhead injuryDelayed Hemorrhagesoon after head injury8 hours later2020/11/359Delayed hemorrhage,several houHead injury with EDH and delayed contusion hemorrhagesjune 22june 202020/11/360Head injury with EDH and delay2020/11/3612020/11/3612020/11/3622020/11/3622020/11/3632020/11/3632020/11/3642020/11/364同侧撞击同侧撞击同侧出血同侧出血2020/11/365同侧撞击2020/11/365 When clinical symptom is grave,but the CTfinds no serious injury,DAI shuold be considered CT findings:(positive under 20)Punctate hemorrhages or edema in the carpus callosum,centrum semiovale,basal ganglion brainstemDiffuse Axonal Injury(DAI)(Shearing Injury)2020/11/366 When clinical symptom is grComa after head injury4 months later,semi-vegetate stage4 months later-brain atrophy5th dayMultiple punctate hemorrhagesDiffuse Axonal Injury(DAI)1st day2020/11/367Coma after head injury4 months Punctate hemorrhages and edemas in the subcortical white matter of left frontal lobe(A)and carpus callosum(B,C)Head injury,GCS:3Diffuse Axonal Injury(DAI)2020/11/368 Punctate hemorrhages and ede五、脑血管损伤五、脑血管损伤脑梗塞 压迫 痉挛 脂肪栓塞 血管壁剥离 低氧血症假性动脉瘤动静脉瘘静脉栓塞 2020/11/369五、脑血管损伤2020/11/369五、脑血管损伤五、脑血管损伤（一）正常颅腔颅骨 多个腔 承托 脑组织 硬膜 压力平衡 固定、保护 （二）占位病变 一腔脑组织 压力失衡某一孔道 脑疝 另一腔中2020/11/370五、脑血管损伤2020/11/370（三）表现脑池被脑组织填充正常结构移位（四）各部疝的形成 名称 疝出脑组织 通过孔道大脑镰下疝 额叶、颞叶 大脑镰下切迹海马沟回 颞叶（海马）小脑幕切迹小脑幕下 小脑扁桃体 枕大孔脑外疝 大脑 颅骨缺损区2020/11/3712020/11/371 Acute subdural henmatoma with strong mass effect,uncle/transtentorial hemitation（disappearance ofsurpras ellar and the quadrigeminal cistern）and subfalcial hemitation.Acute subdural henmatoma due to a minor head injury2020/11/372 Acute subdural henmatoma wit2020/11/3732020/11/373七、脑外伤后遗改变七、脑外伤后遗改变1.脑积水即脑室系统扩大 梗阻性 内通道受阻 多见于疾病急性期 交通性 外通道受阻 脑脊液回流不足 常为后遗性改变2、脑萎缩3、脑软化或脑穿通囊肿 2020/11/374七、脑外伤后遗改变2020/11/3742020/11/3752020/11/375Coma after head injury4 months later,semi-vegetate stage4 months later-brain atrophy5th dayMultiple punctate hemorrhagesDiffuse Axonal Injury(DAI)1st day2020/11/376Coma after head injury4 months八、颅脑外伤阴性表现八、颅脑外伤阴性表现1、真阴性2、不典型弥漫性轴突损伤脑干损伤3、迟发型血肿建议密切观察和复查 2020/11/377八、颅脑外伤阴性表现2020/11/377谢谢！2020/11/378谢谢！2020/11/378谢谢观赏谢谢观赏谢谢观赏