学术讨论—脑血管讲座.ppt

Watershed infarcts orinternal borderzone infarcts(IBI)第一页，共六十八页。Vascular territories of the cerebral arteries第二页，共六十八页。颈内动脉颈内动脉(dngmi)系统系统椎椎-基动脉基动脉(dngmi)系统系统Artery:Circle of Willis2 PCA2 后交通后交通(jiotng)支支2 ICA2 ACA1 前交通支前交通支第三页，共六十八页。$35.45$35.45$34.45$34.45$20.95$20.95第六页，共六十八页。第七页，共六十八页。梗塞可分三类梗塞可分三类(sn li)(sn li):cortical infarcts territorial梗塞梗塞：ACA,MCA,PCAACA,MCA,PCA watershed梗塞梗塞：ACA-MCA,MCA-PCAACA-MCA,MCA-PCA perforating artery infarcts(PAI)，分两部分分两部分深穿通支深穿通支：分布到基底节，内囊和丘脑等：分布到基底节，内囊和丘脑等浅浅穿通支：穿通支：位于半卵圆中心和外囊区域位于半卵圆中心和外囊区域,又称又称 “white matter medullary infarcts”“white matter medullary infarcts”internal borderzone infarcts(IBI)CLASSIFICATION第九页，共六十八页。Patterns of infarctionInternal border zone Internal border zone infarctions(deep infarctions(deep MCA-ACA)MCA-ACA)Territorial Territorial infarction infarction(PCA)(PCA)border zone border zone infarctionsinfarctionsLacunar infactionLacunar infaction皮质皮质(pzh)皮质皮质(pzh)深穿通深穿通(chun tn)支支浅穿通支未显示浅穿通支未显示第十页，共六十八页。Territorial Infarcts(ACA,MCA,PCA)第十一页，共六十八页。Anterior cerebral artery 供应额叶顶叶内侧部分和胼胝供应额叶顶叶内侧部分和胼胝(pinzh)体前部、基底节和内囊体前部、基底节和内囊第十三页，共六十八页。Anterior cerebral artery infarction第十六页，共六十八页。ACA infarction 第十八页，共六十八页。Anteriorcerebralarteryinfarction脑室(nosh)上切面：右半球旁矢状区高信号典型大脑典型大脑(dno)(dno)前动脉梗塞征前动脉梗塞征T2-第十九页，共六十八页。MCASuperimposed Maps第二十一页，共六十八页。第二十二页，共六十八页。第二十四页，共六十八页。MCA infarction.Involvement of cortical branches and deep MCA infarction.Involvement of cortical branches and deep perforating lenticulo-striate arteriesperforating lenticulo-striate arteries第二十五页，共六十八页。MCA infarction with luxury perfusion On the enhanced CT-images of a patient with an infarction in the territory of On the enhanced CT-images of a patient with an infarction in the territory of the middle cerebral artery(MCA).the middle cerebral artery(MCA).There is extensive gyral enhancement(luxury perfusion).There is extensive gyral enhancement(luxury perfusion).Sometimes this luxury perfusion may lead to confusion with tumoral Sometimes this luxury perfusion may lead to confusion with tumoral enhancement.enhancement.第二十六页，共六十八页。基底节血供：lenticulostriate arteries（LSA）第二十七页，共六十八页。Lenticulostriate arteriesLenticulostriate arteries：分为：分为(fn wi)(fn wi)(fn wi)(fn wi)内外侧支内外侧支外侧外侧(wi c)(wi c)支为水平支为水平M1M1段段分支分支内侧支为内侧支为A1A1分支分支(fnzh)(fnzh)第二十八页，共六十八页。第三十页，共六十八页。Lacunar Infarctsl l定义：脑深部定义：脑深部(基底节、丘脑，白质基底节、丘脑，白质)和脑干的小梗塞，由和脑干的小梗塞，由一条一条(y tio)(y tio)深穿支闭塞所致深穿支闭塞所致l l病因：动脉粥样硬化是最常见原因，其次为栓塞，常常为心源性第三十一页，共六十八页。a lacunar infarct in the left thalamusl lThere is only a small area of There is only a small area of subtle hyperintensity subtle hyperintensity T2WFLAIROn the FLAIR image the infarct is On the FLAIR image the infarct is hardly seenhardly seen第三十二页，共六十八页。Posterior cerebral artery主干主干主干主干(zhgn)(zhgn):围绕中脑并到达幕上围绕中脑并到达幕上围绕中脑并到达幕上围绕中脑并到达幕上,供应枕叶供应枕叶供应枕叶供应枕叶(视觉视觉视觉视觉)和后下颞叶（记忆）和后下颞叶（记忆）和后下颞叶（记忆）和后下颞叶（记忆）穿通支穿通支穿通支穿通支:中脑中脑中脑中脑,丘脑丘脑丘脑丘脑,丘脑下部丘脑下部丘脑下部丘脑下部第三十三页，共六十八页。T1 Post-contrast coronalNeck MRANeck MRA：颈部大血管：颈部大血管(xugun)(xugun)无明显梗塞无明显梗塞DWI7272岁，左利，胸痛岁，左利，胸痛5 5天，不认识信用天，不认识信用卡，加油站和医生卡，加油站和医生办公室办公室 神经系统神经系统检查为失读症而没检查为失读症而没有有(mi yu)(mi yu)失写失写(症症).).Acuteinfarction(5dayold)involvingtheleftPCAterritory左后颞枕高信号左后颞枕高信号(xnho)FLAIRT1轻度增强轻度增强第三十五页，共六十八页。Posterior Cerebral Artery Infarctionl lPCAPCAPCAPCAl l主干主干主干主干:围绕中脑并到达幕上围绕中脑并到达幕上围绕中脑并到达幕上围绕中脑并到达幕上,供供供供应枕叶应枕叶应枕叶应枕叶(视觉视觉视觉视觉)和后下颞叶（记和后下颞叶（记和后下颞叶（记和后下颞叶（记忆忆忆忆(jy)(jy)(jy)(jy)）l l穿通支穿通支穿通支穿通支:中脑中脑中脑中脑,丘脑丘脑丘脑丘脑,丘脑下部丘脑下部丘脑下部丘脑下部左枕叶低密度左枕叶低密度第三十六页，共六十八页。l lT2WIT2WIT2WIT2WI：左侧：左侧：左侧：左侧PCAPCAPCAPCA区域区域区域区域梗塞，并且描绘出梗塞，并且描绘出梗塞，并且描绘出梗塞，并且描绘出WillisWillisWillisWillis环脉管系统环脉管系统环脉管系统环脉管系统(xtng)(xtng)(xtng)(xtng)，显著右后交，显著右后交，显著右后交，显著右后交通动脉（箭头通动脉（箭头通动脉（箭头通动脉（箭头）急性右大脑后动脉梗塞急性右大脑后动脉梗塞发病发病12小时小时(xiosh)(xiosh)，左侧同向偏盲，左侧同向偏盲第三十七页，共六十八页。basilar artery（BA）小脑小脑(xi(xionono)o)和脑干和脑干第三十九页，共六十八页。basilar artery（BA）l l小脑前下动脉小脑前下动脉(AICA)(AICA)l l是是BABA直径较大分支直径较大分支,由由BABA下下,中中1/31/3结合处结合处发出发出l l供应供应:l l桥脑被盖外侧桥脑被盖外侧,桥臂桥臂,中小脑脚中小脑脚l l小脑小脑:小叶小叶(xioy)(xioy),前小脑小部分前小脑小部分 l linternal auditory artery(IAA)internal auditory artery(IAA)l l常由常由AICAAICA或或BABA直接发出直接发出l lposterior cerebral artery(PCA);posterior cerebral artery(PCA);l l为为BABA终末支终末支,供应中脑供应中脑,丘脑丘脑,颞枕内颞枕内侧侧l l小脑上动脉小脑上动脉l l在左右在左右PCAPCA交叉处附近交叉处附近,由基底动脉发出由基底动脉发出l l供应供应:桥脑和中脑的外侧桥脑和中脑的外侧,小脑上面小脑上面BABA在在桥脑腹侧始于桥延结合部桥脑腹侧始于桥延结合部,由由2 2个椎动个椎动脉融合脉融合(rngh)(rngh)而成而成分别发出分支分别发出分支(median,(median,paramedian,short,and long paramedian,short,and long circumferential branches)circumferential branches)PCAPCASCASCABABA的桥支的桥支的桥支的桥支AICAAICAAICAAICAIAAIAAPICAPICAAnterior spinal arteryAnterior spinal artery第四十页，共六十八页。The three major arteries of the cerebellumThe three major arteries of the cerebellum:the SCA,AICA,and PICA.(Anterior inferior cerebellar artery is AICA.).B.Viw of the cerebellum removed from the brainstem to reveal the ventral surface第四十一页，共六十八页。UpperCerebellumlowercerebellummidcerebellumCerebellum-Parasagital第四十二页，共六十八页。a left-sided PICA-infarction一侧梗塞：上蚓支为矢状分布一侧梗塞：上蚓支为矢状分布一侧梗塞：上蚓支为矢状分布一侧梗塞：上蚓支为矢状分布(fnb)(fnb)(fnb)(fnb)，不越过中线，故，不越过中线，故，不越过中线，故，不越过中线，故病灶中线轮廓病灶中线轮廓病灶中线轮廓病灶中线轮廓清晰，注意早期清晰，注意早期清晰，注意早期清晰，注意早期水肿可越过中线，水肿可越过中线，水肿可越过中线，水肿可越过中线，使诊断困难使诊断困难使诊断困难使诊断困难基底动脉的分支不越过基底动脉的分支不越过基底动脉的分支不越过基底动脉的分支不越过中线，故脑桥梗塞常位中线，故脑桥梗塞常位中线，故脑桥梗塞常位中线，故脑桥梗塞常位于旁正中于旁正中于旁正中于旁正中(zhngzhng)(zhngzhng)(zhngzhng)(zhngzhng)，边，边，边，边界清晰界清晰界清晰界清晰双边梗塞：难以双边梗塞：难以双边梗塞：难以双边梗塞：难以(nny)(nny)存活而罕见，有存活而罕见，有存活而罕见，有存活而罕见，有时可见侧小梗死时可见侧小梗死时可见侧小梗死时可见侧小梗死病灶中线病灶中线病灶中线病灶中线轮廓清晰轮廓清晰轮廓清晰轮廓清晰第四十三页，共六十八页。a left-sided PICA-infarctionNotice the posterior extention.The infarction was the result of a dissection(blue arrow).第四十四页，共六十八页。74747474岁，男，突发头晕，构音障碍，耳鸣，听力障碍，恶岁，男，突发头晕，构音障碍，耳鸣，听力障碍，恶岁，男，突发头晕，构音障碍，耳鸣，听力障碍，恶岁，男，突发头晕，构音障碍，耳鸣，听力障碍，恶心和呕吐：心和呕吐：心和呕吐：心和呕吐：VAVAVAVA闭塞闭塞闭塞闭塞(bs)(bs)(bs)(bs)导致导致导致导致AICAAICA梗塞梗塞入院入院(r(r yun)yun)CT CT 小脑半球前小脑半球前表面低密度表面低密度区区高信号高信号(xnho)(xnho)灶灶外下脑桥，中小脑脚及小脑半球前表外下脑桥，中小脑脚及小脑半球前表面（包括小叶）高信号面（包括小叶）高信号右椎动脉右椎动脉闭塞闭塞延髓前右延髓前右椎动脉高椎动脉高信号，为信号，为新鲜血栓新鲜血栓T1WIT1WIMRAMRADWIDWIT2WI-T2WI-第四十五页，共六十八页。MRI findings in a patient with MRI findings in a patient with anterior inferior cerebellar anterior inferior cerebellar artery territoryartery territory infarction infarctionl lPossible borderzone Possible borderzone infarct between PICA and infarct between PICA and AICA is also seenAICA is also seenDWIDWIT2WIT2WI左小脑左小脑(xiono)(xiono)中脚和背外侧桥脑高信号中脚和背外侧桥脑高信号第四十六页，共六十八页。小脑上动脉小脑上动脉(dngmi)(dngmi)(dngmi)(dngmi)梗塞梗塞,基底动脉基底动脉(dngmi)(dngmi)(dngmi)(dngmi)狭窄狭窄左小脑左小脑(xiono)(xiono)中部高信号中部高信号,累及小脑累及小脑(xiono)(xiono)蚓部和小脑蚓部和小脑(xiono)(xiono)上脚和中脚上脚和中脚,4,4脑室轻度受压脑室轻度受压第四十七页，共六十八页。Basilar artery infarction左中脑梗死右桥脑梗死左延髓左延髓(yn(yn su)su)梗死梗死右丘脑梗死右丘脑梗死第四十八页，共六十八页。Watershed Infarcts第四十九页，共六十八页。Internal border zone infarctionsInternal border zone infarctions位置：半卵圆中心和放射冠位置：半卵圆中心和放射冠,有两型：有两型：l lMCAMCA皮质和白质皮质和白质支之间（深浅支之间）支之间（深浅支之间）l lMCAMCA豆纹穿通豆纹穿通(chun tn)(chun tn)支支-MCA-MCA深穿通深穿通(chun tn)(chun tn)皮质支皮质支l l两条主要两条主要血管的血管的白质之间白质之间l lMCAMCA深白质分支深白质分支-ACA-ACA深白质分支深白质分支第五十一页，共六十八页。Frster A et al.(2008)Mechanisms of Disease:pathophysiological concepts of stroke in hemodynamic risk zonesdo hypoperfusion and embolism interact?Nat Clin Pract Neurol 10.1038/ncpneuro0752Examples of borderzone infarcts on diffusion-weighted MRI(A)Anterior cortical borderzone infarct(CBI).(B)Posterior CBI.(C)Combined anterior and posterior CBI(D)(D,E)Internal borderzone infarcts.(E)(F)Combined internal borderzone infarct and territorial infarct.第五十二页，共六十八页。Cortical border zone infarctions：ACA-MCA第五十三页，共六十八页。Figure 3.High CT slice shows the location of 3 small left hemisphereborderzone infarctions,appearing as a chain.第五十四页，共六十八页。低血压低血压-内分水岭梗塞内分水岭梗塞(gngs)(gngs)Note left superior parietal lobule infarct in the expected location of the middle cerebral artery(MCA)/posterior cerebral artery(PCA)cortical border zone.centrum infarcts in a rosary configuration consistent with internal border zone infarcts in a patient with hypotension T2FLAIR第五十五页，共六十八页。Figure 1 Positive diffusion-weighted MRI scan of the brain demonstrating unilateral watershed infarction(white areas)Leary CR and Caplan LR(2007)Technology Insight:brain MRI and cardiac surgerydetection ofpostoperative brain ischemia Nat Clin Pract Cardiovasc Med 4:379388 doi:10.1038/ncpcardio0915第五十六页，共六十八页。Illustrative examples of watershed infarcts in Illustrative examples of watershed infarcts in patients with ICA diseasepatients with ICA diseasel l皮质分水岭（前部皮质分水岭（前部皮质分水岭（前部皮质分水岭（前部(qin b)(qin b)重，后部轻）重，后部轻）重，后部轻）重，后部轻）l l内分水岭梗死（内分水岭梗死（内分水岭梗死（内分水岭梗死（念珠状念珠状念珠状念珠状以及融合型）以及融合型）以及融合型）以及融合型）典型分水岭梗死：三个不同典型分水岭梗死：三个不同(b tn)病人病人右半球前分水右半球前分水岭梗塞，累及岭梗塞，累及(lij)(lij)ACAACA与与 MCAMCA皮质表层狭皮质表层狭长区域长区域CTT2右半卵园中心：右半卵园中心：内分水岭梗死内分水岭梗死（念珠状）念珠状）白质型白质型DWIDWI：同一患者不同切面：同一患者不同切面皮质型皮质型混合型混合型不同切面不同切面第五十九页，共六十八页。This young patient had prolonged hypotension as a result of a drug overdosel lMRI confirmed these MRI confirmed these changes with restricted changes with restricted diffusion and high T2 diffusion and high T2 signal seen deep to the signal seen deep to the cortexcortexThis is a characteristic appearance This is a characteristic appearance of an internal of an internal watershed infarctwatershed infarct第六十一页，共六十八页。MCA-PCA皮质(pzh)(pzh)分水岭梗塞l lOn the left On the left another example another example of small of small infarctions in the infarctions in the deep borderzone deep borderzone and in the cortical and in the cortical borderzone borderzone between the between the MCA-and PCA-MCA-and PCA-territory in the left territory in the left hemispherehemisphere第六十四页，共六十八页。diffusion weighted MRI imagesPCA territoryMCAMCA territory territoryACAACA territory territory第六十五页，共六十八页。内容(nirng)总结Watershed infarcts or。供应额叶顶叶内侧部分和胼胝(pinzh)体前部、基底节和内囊。DWI。小脑:小叶,前小脑小部分。外下脑桥，中小脑脚及小脑半球前表面（包括小叶）高信号。左小脑中部高信号,累及小脑蚓部和小脑。http:/jnm.snmjournals.org/cgi/content/figsonly/46/12/1973第六十八页，共六十八页。