脑动脉解剖及临床脉络膜前动脉

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,11/7/2009,#,单击此处编辑母版标题样式,1,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,脑血管走行分布及临床,刘东医,脉络膜前动脉,Internal carotid artery,Anterior clinoid process superior part,颈动脉管段,海绵窦段,交叉池段,颈内动脉,颈内动脉和椎动脉的分支,脉络膜前动脉,脉络膜前动脉，1 4支，,以3支最多？,，为一组较细小而恒定的血管，在后交通动脉起始远侧2mm处由颈内动脉直接发出。,该动脉在未穿入侧脑室下脚之前，除发13个皮质支外，还发出23个穿支，1支穿视神经内侧至大脑脚，另两支即为纹状体内囊动脉。此动脉主要营养尾状核尾，行程长，管径较小，易发生栓塞。,Basal view of brain after transverse section of midbrain and partial excision of left temporal lobe to show magnified portions in Figure 2 (rectangle A) and in Figure 4 (rectangle B). The optic chiasm (1). The internal carotid artery (2). The left anterior choroidal artery (3). The middle cerebral artery (4). The optic tract (5). The hypothalamus (6). The basilar artery (7). The cerebral peduncle (8). The tegmentum (9) and the inferior colliculi (10) of the midbrain. The pulvinar (11). The lateral geniculate body (12). The choroid plexus (13) of the inferior horn of the ventricle.,大脑横断面的底面观，左侧颞叶部分被切除以显示放大的部分,(,矩形,A),和,(,矩形,B),。视神经交叉颈内动脉,(1),大脑中动脉,(2),左前脉络膜的动脉,(3),中脑动脉,(4),。视神经束,(5),(6),下丘脑。基部的动脉,(7),。大脑脚,(8),被盖,(9),和下丘,(10),丘脑结节,(11),。外侧膝状体,(12),。脉络丛,(13),。,纹状体内囊动脉，97%由脉络膜前动脉发出，以2支居多，一支穿视束斜向后外达苍白球；另一支在视束外侧向后行于囊状间隙内，经内囊后肢及豆状核下缘沿视辐射向后行，发支至苍白球。,其分支也供应视束、外侧膝状体、灰白结节、乳头体、内囊后肢腹侧部、苍白球、尾状核后部、杏仁核、丘脑腹外侧核、黑质和红核等。,脉络膜前动脉:在后交通动脉的稍上方起自颈内动脉沿视束后缘向后走行,穿过脉络进入,侧脑室下角,供应,脉络膜,和,海马,并于,侧脑室三角部,与脉络膜后动脉吻合;,1、右侧脉络膜前动脉,2、皮质穿支,3、颈内动脉,4、颈内动脉穿支,1、脉络膜前动脉,2、脉络膜前动脉穿支,3、海马旁回穿支,4、颈内动脉,5、颈内动脉穿支,6、大脑中动脉,7、大脑前动脉,Medial view of the left AChA (1). Note the common trunk (2) of the uncal branch (3) and two perforators (4). The other AChA perforators (5). The internal carotid artery (6). The posterior communicating artery (7) and its premammillary perforator (8).,Basal view of the right AChA (1), which is slightly displaced medially. Note two perforators (arrows) that penetrate the optic tract (2). The parahippocampalbranch (cut) (3). The internal carotid artery (4). The uncus (5).,知识普及,知识普及,Case report (Yyzzhh),A 9-year-old previously healthy girl was admitted to the Emergency Room with an eight-hour history of sudden onset of severe headache. The pain was pulsatile and bilateral and not accompanied by other symptoms. There is no history of migrainemaigrein 偏头疼, epilepsy or stroke. Parents reported that soon after the onset of the headache the patient became drowsy drauzi 昏昏欲睡的for about one hour. No trigger factor was identified. On the neurological examination, the patient was alert and well oriented with no other abnormalities but mild nuchalnju:kl 项的, 颈背的 rigidity. rididti 固执，坚定，僵化,D. Axial T2-weighted image(2500/80) reveals the presence of an inhomogeneous mass in the right lateral ventricle. The low signal intensity suggets the presence of calcification and hemorrhage.,Angiogram of the right internal carotid artery obtained on day 3 demonstrates a hyper vascular mass fed from the right anterior choroidal artery (arrows).,Computed tomography of the brain revealed hemorrhage in the right lateral ventricle (Fig 1) and gadolinium-enhanced magnetic resonance imaging study of the brain disclosed a heterogeneous lesion in the mesialmi:zil 中央的, 中间的 portion of the right temporal lobe, above and inside the temporal horn of the lateral ventricle. The lesion extended until the subependimary area of the trigono of the right ventricle. The lesion was hypointense on T1 and T2-weighted images and enhanced with the contrast. Other hyperintense T1 and T2-weighted images lesions were seen in the right lateral ventricle suggesting bleeding. Magnetic resonance angiography and cerebral angiography disclosed an arteriovenous malformation in part of the choroid plexus, supplied by the anterior choroidal artery (Figs 2 and 3). The AVM was classified according to Spetzler grading system as grade 3 (deep venous drainage: 1; eloquence area: 0 and size: 2).,A,：左侧内囊后肢梗死,;B:,动脉瘤样扩张,;C,：动脉瘤样扩张,;D,：静脉期造影剂滞留,;E,：发病,118,天时，,DSA,提示夹层消失,;F,：静脉期没有发现造影剂滞留,;G,：,1,年后，没有发现动脉瘤。,椎基底动脉,椎基底动脉是脑血液供应的重要来源之一，左右椎动脉在脑桥下缘汇合成基底动脉。其分支分布于间脑后半部、枕叶内侧面、颞叶下部、脑干和小脑。脑干内有许多上下行的神经传导束、脑神经核及维持觉醒和调节机体内环境稳定的中枢，所以椎基底动脉的血液供应是否良好极为重要！,颅内段的三个生理狭窄：,穿过硬脑膜入颅处,分出脊髓前动脉起点上方,二者之间,常见病变,锁骨下动脉盗血综合征,椎动脉主要分支,1、脑膜支,2、脊髓后动脉：颅内位置最低的一对动脉,支配范围：脊髓后角、后索,延髓背外侧（薄楔束和核）,（如缺如，可由小脑后下动脉代偿）,绳状体尾端、背侧部,常见病变：深感觉障碍为主，损伤平面以下腱反射消失以及患侧肢体感觉性共济失调,四、基底动脉的分支脑桥支,1、脑桥旁正中动脉：分布于脑桥旁正中区，包括桥核、皮质脑桥束、皮质脊髓束和皮质脑干束，一些细的穿支也穿向背部，供应脑桥被盖的腹侧部，包括一部分内侧丘系。,2、脑桥短旋动脉：分布于脑桥前外侧区，包括皮质脊髓束和内侧丘系的一部分纤维、桥核和脑桥小脑束、一部分三叉、面神经核及三叉、面神经根等结构，此外还有大脑脚的一部分。,3、脑桥长旋动脉：与小脑上动脉一起供应脑桥被盖尾端大部分；与小脑上动脉一起，供应被盖头端。主要分布于第五、六、七、八对脑神经核、三叉神经脊束、内侧纵束、内侧丘系、脊髓丘脑束、脊髓小脑束、结合臂和脑干网状结构,中脑的血供,脑干的血管造影,（层厚,4mm,）,大脑脚底综合征peduncular syndrome或动眼神经交叉性偏瘫alternting oculomotor hemiplegia或Weber综合征,本尼迪克特综合征,benedikt syndrome,脑桥的供血,1、脑桥旁正中动脉：分布于脑桥旁正中区，包括桥核、皮质脑桥束、皮质脊髓束和皮质脑干束，一些细的穿支也穿向背部，供应脑桥被盖的腹侧部，包括一部分内侧丘系。,2、脑桥短旋动脉：分布于脑桥前外侧区，包括皮质脊髓束和内侧丘系的一部分纤维、桥核和脑桥小脑束、一部分三叉、面神经核及三叉、面神经根等结构，此外还有大脑脚的一部分。,3、脑桥长旋动脉：与小脑上动脉一起供应脑桥被盖尾端大部分；与小脑上动脉一起，供应被盖头端。主要分布于第五、六、七、八对脑神经核、三叉神经脊束、内侧纵束、内侧丘系、脊髓丘脑束、脊髓小脑束、结合臂和脑干网状结构,脑桥的血供,脑干的血管造影,（层厚,4mm,）,脑桥背侧综合征dorsal pons syndrome,脑桥基底部综合征basal pontine syndrome 或展神经交叉性偏瘫alternating abducens hemiplegia,脑桥旁正中动脉闭塞综合征 （Foville综合征）,1、展神经交叉瘫。表现为病变同侧展神经麻痹及病变对侧舌下神经及上下肢中枢性瘫痪；,2、注视麻痹：注视瘫痪侧；,3、对侧偏身感觉障碍：极轻；,4、单瘫不伴注视麻痹；,5、小脑性共济失调：对侧；,脑桥短旋动脉闭塞综合征,1、脑桥基底外侧综合征（Millard-Gubler综合征）：面（展）神经交叉瘫，即同侧面神经展神经周围性麻痹，病变对侧舌下神经及肢体中枢性偏瘫；,2、病变同侧小脑性共济失调；,3、偏身感觉障碍：较少；,4、Horner征；,脑桥长旋动脉闭塞综合征,1、脑桥被盖综合征（Raymond-Gestan综合征）：由于累及结合臂、内侧丘系和脊髓丘脑系，出现同侧小脑性共济失调，对侧偏身浅深感觉障碍，如累及三叉神经根和核还有同侧面部感觉障碍，表现为交叉性；2、其他：V咀嚼肌瘫痪，被盖中央束肢体肌阵挛，内侧纵束眼震，网状结构意识障碍。,延髓的血供,脑干的血管造影,（层厚,4mm,）,延髓内侧综合征medial medullary syndrome或舌下神经交叉性偏瘫alternating hypogossal hemiplegia 延髓外侧综合征lateral medullary syndrome亦称Wallenberg综合征,二、脑的静脉,大脑内静脉,大脑大静脉,脑的深静脉,脑的深静脉,多发生于皮质下区，在皮质表面可见不规则粗大迂曲血管。,CT,平扫表现为边界不清等或高密度的点状，线状血管影，可有钙化，血管间为等密度的脑质，周围可有低密度的软化灶。增强后呈点状和弧线状强化，无占位表现。,颅内动静脉畸形,三、脑的横断层面,五角形鞍上池,大脑纵裂池,大脑外侧窝池,桥池,脑桥小脑角池,47,第四脑室中部,小脑延髓池,垂体柄,45,杏仁体,46,脑桥,32,面神经与前庭蜗神经,43,颞骨岩部,17,鞍上池的横断层,鞍上池的横断层,延池,小脑溪,小脑延髓池,蝶窦,16,耳蜗,25,延髓,46,小脑扁桃体,37,椎动脉,47,四、脑的冠状断层面,大脑前动脉7、视神经32、颈内动脉34、钩31、大脑中动脉27,视交叉25、钩39、杏仁体38、颈内动脉41,第三脑室22、尾状核17、背侧丘脑21、红核24、颞横回25、黑质35、海马旁回、椎动脉52,穹隆20、大脑内静脉31,第四脑室52、大脑大静脉53,五、脑的矢状断层面,