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1、图解脑疝,1,图解脑疝1,脑疝,是指在颅内压增高的情况下，脑组织通过某些脑池向压力相对较低的部位移位的结果，即脑组织由其原来正常的位置而进入了一个异常的位置。,2,脑疝是指在颅内压增高的情况下，脑组织通过某些脑池向压力相对较,脑疝的类型：,a.大脑镰疝 ： 一侧大脑半球占位病变可使同侧扣带回经大脑镰下缘疝入对侧，胼胝体受压下移。 小脑幕切迹疝 b.前疝：也称颞叶沟回疝，是颞叶沟回疝于脚间池及环池的前部；后疝：颞叶内侧部疝于四叠体池及环池的后部；f.小脑幕切迹上疝：后颅凹占位病变时，小脑上蚓部可向上疝入小脑幕切迹的四叠体池。c.中心疝：幕上压力增高，致使大脑深部结构及脑干纵轴牵张移位。 d.颅外
2、疝： 脑组织通过颅外缺损疝出。e.枕骨大孔疝 ： 后颅凹占位病变时，可致小脑扁桃体疝入枕骨大孔。g.蝶骨嵴疝：颅前凹和颅中凹的占位病变，由于病变部压力相对高一些，则额眶回可越过蝶骨嵴进入颅中凹，可颞叶前部挤向颅前凹。,3,脑疝的类型：a.大脑镰疝 ： 一侧大脑半球占位病变可使同侧扣,示意图,a) subfalcial (cingulate) herniation ;镰下疝b) uncal herniation ; 钩疝c) downward (central, transtentorial) herniation ; 下行性小脑幕疝d) external herniation ; 颅外疝e)
3、tonsillar herniation.扁桃体疝f) ascending transtentorial herniation (reversed tentorial)上行性小脑幕疝g) sphenoid herniation蝶骨嵴疝,4,示意图a) subfalcial (cingulate) h,类型,5,类型5,示意图,6,示意图6,解剖关系,7,解剖关系7,解剖关系,8,解剖关系FQcMb3vTOSyCClvFPOSpCClvss,解剖关系,9,解剖关系FTCesPd4th VFTMbCes9,The suprasellar cistern & the quadrigeminal ci
4、stern,The left and center images show the suprasellar cistern. Its anterior borders are formed by the frontal lobes (F). Its lateral borders are formed by the uncus (U) of the temporal lobes. The left image shows the 5-pointed star appearance of the suprasellar cistern where the posterior border is
5、formed by the pons (Po). The black arrow points to the fourth ventricle. The center image shows a higher cut where the suprasellar cistern has a 6-pointed star appearance since the posterior border is formed by the cerebral peduncles (P) which have a central cleft. The right image shows the quadrige
6、minal cistern (black arrow). Note the babys bottom appearance of its anterior border. When ICP is increased, the quadrigeminal cistern space is compressed or obliterated.,10,The suprasellar cistern & the,The suprasellar cistern& the quadrigeminal cistern.,The midline sagittal MRI scan shows the leve
7、ls of the axial diagrams. The quadrigeminal cistern is located above (anterior to) the Q in the highest cut shown (number 9). The anterior border of the quadrigeminal cistern is formed by the superior colliculi (c). Image 8 (lower cut) also shows the quadrigeminal cistern. In this case, its anterior
8、 border is formed by the inferior colliculi (c). This gives the anterior border of the quadrigeminal cistern the appearance of a babys bottom. The quadrigeminal plate is comprised of the superior and inferior colliculi. The quadrigeminal cistern is posterior to this quadrigeminal plate, thus its ant
9、erior border may be formed by the inferior or superior colliculi.,11,The suprasellar cistern& the,镰下疝,12,镰下疝12,Subfalcine herniation (cingulate herniation)Transtentorial herniation,The suprasellar cistern (left image) is obliterated. The quadrigeminal cistern is very compressed and pushed posteriorl
10、y (center image). A subdural hematoma with a midline shift is noted. There is central transtentorial and subfalcine herniation.,13,Subfalcine herniation (cingula,ACA供血区梗塞,14,ACA供血区梗塞14,Uncal herniation,15,Uncal herniation15,鞍上池缺角,16,鞍上池缺角16,冠状位CT与MRI,17,冠状位CT与MRI17,海马旁回褶皱,18,海马旁回褶皱18,对侧颞角增宽,19,对侧颞角增
11、宽19,同侧桥前池增宽,20,同侧桥前池增宽20,同侧环池增宽,21,同侧环池增宽21,Uncal herniation,22,Uncal herniation22,Uncal herniation,obliteration of the suprasellar cistern (red arrow) and the quadrigeminal cistern (green arrow),23,Uncal herniationobliteration o,Uncal herniation,The ipsilateral ventricle, sulci, fissures are compre
12、ssed and obliterated, isappeared.,obliteration of the suprasellar cistern(s) and quadrigeminal cistern(q),24,Uncal herniationThe ipsilatera,Uncal herniation,Acute infarction1st day,Acute infarction 4th day,25,Uncal herniationAcute infarcti,Uncal herniation,Before surgery, a big GBM in the left tempo
13、ral lobe with uncal herniation.After surgery, the GBM was removed, the suprasellar cistern and quadrigeminal cisterns are normal.,26,Uncal herniationBefore surgery,Uncal herniation,Acute infarction of right posterior artery (PCA), this is a complication of uncal/transtentorial herniation, because th
14、e PCA was compressed by brain herniation.,27,Uncal herniationAcute infarcti,双侧大脑后动脉梗塞,28,双侧大脑后动脉梗塞28,双侧大脑后动脉梗塞,29,双侧大脑后动脉梗塞29,Durette hemorrhage,30,Durette hemorrhage 30,Durette hemorrhage,31,Durette hemorrhage31,Kernohans notch颞叶疝压迹,32,Kernohans notch颞叶疝压迹32,Uncal herniation,When mass effects withi
15、n or adjacent to the temporal lobe occur, the medial portion of the temporal lobe (uncus) is forced medially and downward over the tentorium. There is ipsilateral pupillary dilation. The uncus is pushed medially into the suprasellar cistern. There is bilateral uncal herniation. The suprasellar ciste
16、rn is obliterated.,33,Uncal herniationWhen mass effe,early uncal herniation,The right uncus is pushing into the suprasellar cistern; early right uncal herniation.,34,early uncal herniation The rig,中心疝,35,中心疝35,中心疝,36,中心疝36,Superior vermian herniation ( ascending transtentorial herniation ),由于后颅凹的占位效
17、应，小脑蚓和小脑半球通过小脑幕切迹向上移动,37,Superior vermian herniation (,陀螺状外观,38,陀螺状外观38,双侧环池变窄,39,双侧环池变窄39,四叠体池充满,40,四叠体池充满40,不露齿的微笑,41,不露齿的微笑41,皱眉,42,皱眉42,第一天的四叠体池和环池,43,第一天的四叠体池和环池43,第二天，四叠体池和环池消失,44,第二天，四叠体池和环池消失44,脑积水,45,脑积水45,ascending transtentorial herniation,46,ascending transtentorial herni,枕大孔疝,47,枕大孔疝47,
18、枕大孔疝,48,枕大孔疝48,Tonsillar herniation,In tonsillar herniation (rare), a mass effect in the posterior fossa causes the cerebellar tonsils to herniate inferiorly through the foramen magnum compressing the medulla and upper cervical spinal cord. Conscious patients complain of neck pain and vomiting. They
19、 may have nystagmus, pupillary dilatation, bradycardia, hypertension and respiratory depression. Early tonsillar herniation is difficult to recognize in an unconscious patient. It may not be evident on CT scan since axial views cannot see the pathology well. It is best seen on sagittal MRI. Clinical
20、ly changes in vital signs may be the only clinical clue in an unconscious patient.,49,Tonsillar herniation In tonsil,Tonsillar herniation,50,Tonsillar herniation50,a male patient in his 30s who died of brain stem herniation after completing a marathon.,The CT shows (A) loss of the rostral cerebral s
21、ulci suggesting increase in ICP, (B) and (C) a large hydrocephalus with widening of both temporal horns. The grey matter can still be differentiated from the white matter, but all sulci are lost. This suggests that the brain oedema is of relative recent onset and massive tissue ischaemia has not yet
22、 occurred. (D) Compression of the fourth ventricle with dilatation of the third ventricle and the caudal aspect of both temporal horns. This is observed with considerable brain oedema and obstructive hydrocephalus. (E) Herniation of the medulla and pons into the foramen magnum. (F) The tonsils are l
23、ocated at the level of the dens which is a good indicator for foramen magnum herniation.,51,a male patient in his 30s who,(A) The disc shows florid hemorrhages with relatively little swelling, indicating a rapid, dramatic increase in CSF pressure. Progressive changes of optic disc oedema are seen in
24、 a patient with an intracranial tumour who declined treatment (B-D). (B) Early nerve fiber dilatation is seen particularly superiorly, inferiorly and nasally. (C) This increases and venous engorgement develops. (D) Temporal nerve fiber dilatation and swelling of the disc increases and hemorrhages ap
25、pear. (E) In gross chronic disc oedema the normal retinal vasculature is masked and dilated superficial capillaries are observed. (F) In atrophic optic disc oedema nerve fibers are eventually destroyed and the optic disc without viable nerve fibers does not swell. This patient had longstanding benig
26、n intracranial hypertension. Retinochoroidal venous collaterals are present (black arrowhead).,52,(A) The disc shows florid hemo,颅外疝,53,颅外疝53,核磁选择,1. Subfalcine herniation. This is best seen on coronal MR images.2. Descending transtentorial herniation (uncal herniation, hippocampal herniation). best
27、 seen on coronal images, but the compression of the brainstem is best observed on axial T2-WI.3. Ascending transtentorial herniation. The sagittal imaging plane is preferred.4. Cerebellar tonsillar herniation. Sagittal and coronal imaging planes are preferred.,54,核磁选择1. Subfalcine herniation.,55,55,56,56,小结,占位效应引起的脑组织移位影像上识别脑疝的关键是看脑池的变化,57,小结占位效应引起的脑组织移位57,
