中樞外傷醫(yī)學(xué)知識講座專家講座

CentralNervousSystem

1/1/20241中樞外傷醫(yī)學(xué)知識講座第1頁ClassificationofHeadInjuryExtracerebrallesions:SubduralhematomaSubduraleffusionEpiduralhematomaIntracerebrallesions:Braincontusion(edema,

hemorrhage..)Subarachnoidhemorrhage

(SAH)Intraventricularhemorrhage

(IVH)Opencranialinjury.

SkullfracturePneumoencephalus1/1/20242中樞外傷醫(yī)學(xué)知識講座第2頁顱腦外傷braintrauma硬膜外血腫(epiduralhematoma)硬膜下血腫（subduralhematoma）腦挫裂傷（lacerationandcontusionofbrain）蛛網(wǎng)膜下腔出血Subarachnoidhaemorrhage1/1/20243中樞外傷醫(yī)學(xué)知識講座第3頁硬膜外血腫

(extraduralhematoma)

Thesearisebetweentheinnertableoftheskullandthedura.Theyusuallydevelopfrominjurytothemiddlemeningealarteryoroneofitsbranches,andthereforeareusuallytemporoparietalinlocation.Atemporalbonefractureisoftenthecause,butisnotessential.Theexpandinghaematomastripsthedurafromtheskull;thisattachmentisquitestrongsuchthatthehaematomaisconfined,givingrisetoitscharacteristicbiconvexshape,withawelldefinedmargin.1/1/20244中樞外傷醫(yī)學(xué)知識講座第4頁CT征象：顱板內(nèi)側(cè)梭形(雙凸透鏡)高密度影(與腦實(shí)質(zhì)比)，CT值50~90Hu；(范圍小而厚)密度普通較均勻邊緣清楚、光滑銳利局部常見腦水腫征局部蛛網(wǎng)膜下腔常見出血征局部有顱骨骨折征含有占位征：局部腦回受壓內(nèi)移，中線結(jié)構(gòu)向?qū)?cè)移位1/1/20245中樞外傷醫(yī)學(xué)知識講座第5頁

biconvexshape,withawelldefinedmargin.1/1/20246中樞外傷醫(yī)學(xué)知識講座第6頁1/1/20247中樞外傷醫(yī)學(xué)知識講座第7頁血塊內(nèi)含較灰區(qū)(箭)，

代表正在出血中，有未凝結(jié)血塊EDH：紡垂型，高濃度血塊頭皮腫(箭)，撞擊處1/1/20248中樞外傷醫(yī)學(xué)知識講座第8頁硬膜外血腫MRI平掃、Gd-DTPA增強(qiáng)1/1/20249中樞外傷醫(yī)學(xué)知識講座第9頁硬膜下血腫

（subduralhematoma）Thesearisebetweentheduraandarachnoid,oftenfromrupturedveinscrossingthispotentialspace.Thespaceenlargesasthebrainatrophiesandsosubduralhaematomasaremorecommonintheelderly.1/1/202410中樞外傷醫(yī)學(xué)知識講座第10頁CT征象顱內(nèi)板內(nèi)側(cè)新月狀(或帶狀)高密度影(與腦實(shí)質(zhì)比)，CT值50~90Hu，范圍廣而薄密度普通較均勻邊界清楚，但不光滑銳利局部可有或無腦水腫局部可有或無蛛網(wǎng)膜下腔出血局部普通無顱骨骨折，常為對沖傷出血較多時(shí)含有占位效應(yīng)，局部腦實(shí)質(zhì)受壓內(nèi)移，中線結(jié)構(gòu)向?qū)?cè)移位1/1/202411中樞外傷醫(yī)學(xué)知識講座第11頁

thecrescentichighdensitycollectiontypicalofaacutesubduralhaematoma,withassociatedmidlineshift.

1/1/202412中樞外傷醫(yī)學(xué)知識講座第12頁急性硬膜下血腫（SDH）SDH：新月型(A.B)SDH可能在大腦鐮內(nèi)(C)。SDH也可在幕下(D)(不要誤為腦內(nèi)出血)ABCD1/1/202413中樞外傷醫(yī)學(xué)知識講座第13頁A.SDH，顯著占位效應(yīng)B.術(shù)后，占位效應(yīng)消失AcutesubduralhematomawithmasseffectAB1/1/202414中樞外傷醫(yī)學(xué)知識講座第14頁等密度PlainCTIVcontrast1/1/202415中樞外傷醫(yī)學(xué)知識講座第15頁1/1/202416中樞外傷醫(yī)學(xué)知識講座第16頁0209術(shù)后02191/1/202417中樞外傷醫(yī)學(xué)知識講座第17頁同一個(gè)病人，07281/1/202418中樞外傷醫(yī)學(xué)知識講座第18頁Notethecrescenticlowdensitycollectiontypicalofachronicsubduralhaematoma,withassociatedmidlineshift.1/1/202419中樞外傷醫(yī)學(xué)知識講座第19頁subduralhematoma1/1/202420中樞外傷醫(yī)學(xué)知識講座第20頁腦挫裂傷（lacerationandcontusionofbrain）Theseoccurduetostretchingandshearinginjury,oftenduetoimpactionofthebrainagainsttheskullonthesideoppositetotheinjury.Thustheymaybeseendirectlyoppositetheimpactsite,subcutaneoushaematoma,fracture,orextraduralhaematoma(contrecoupinjury).Theinferiorfrontallobesandanteriortemporallobesarecommonsitesafterablowtothebackofthehead.1/1/202421中樞外傷醫(yī)學(xué)知識講座第21頁

CT低密度水腫區(qū),散在高密度出血灶,伴有占位效應(yīng)。有表現(xiàn)為廣泛腦水腫或腦內(nèi)血腫MR腦水腫T1WI呈等低信號,T2WI高信號;腦血腫T1WI,T2WI均呈高信號1/1/202422中樞外傷醫(yī)學(xué)知識講座第22頁Thereisafocalareaofhaemorrhagiccontusionintherightfrontallobe,withsurroundinglowdensityduetoinfarctionoroedema.Thisisafrequentlocationforacontre-coupinjuryfollowingablowtothebackofthehead.1/1/202423中樞外傷醫(yī)學(xué)知識講座第23頁出血、異物、氣顱1/1/202424中樞外傷醫(yī)學(xué)知識講座第24頁IntracerebralHaemorrhage

1/1/202425中樞外傷醫(yī)學(xué)知識講座第25頁SubarachnoidhaemorrhageThismayoccuraloneorinassociationwithotherintracerebralorextracerebralhaematomas.IncreasedattenuationisseenintheCSFspaces,overthecerebralhemispheres(lookcloselyattheSylvianfissure),inthebasalcisternsorintheventricularsystem.SAHmaybecomplicatedbyhydrocephalus.ConfusioncansometimesarisebetweenSAHduetotraumaandduetoarupturedaneurysmorarteriovenousmalformation(AVM);thepatientmaycollapseandhittheirheadasaresultofableedandthehistory(fromthepatientorawitness)isimportant.1/1/202426中樞外傷醫(yī)學(xué)知識講座第26頁Thispatienthasanacuteextraduralhaematomaontherightside,andacutetraumaticsubarachnoidhaemorrhageontheleftside.1/1/202427中樞外傷醫(yī)學(xué)知識講座第27頁Delayedhemorrhage,severalhoursordaysafterheadinjury8小時(shí)隨訪腦外傷后1/1/202428中樞外傷醫(yī)學(xué)知識講座第28頁HeadinjurywithEDHanddelayedcontusionhemorrhages6月22日6月20日1/1/202429中樞外傷醫(yī)學(xué)知識講座第29頁ContusionhemorrhagesandSAHA.9月29日

B.9月30日延遲性出血在腦挫傷極常見。腦挫傷：小血塊及腦水腫混雜在一起

AB1/1/202430中樞外傷醫(yī)學(xué)知識講座第30頁Vaultfractures1/1/202431中樞外傷醫(yī)學(xué)知識講座第31頁顱腦外傷后遺癥1.腦萎縮2.交通性腦積水，多因?yàn)橹胙?、腦室內(nèi)出血3.腦軟化或腦穿通性囊腫，多因?yàn)槟X挫傷1/1/202432中樞外傷醫(yī)學(xué)知識講座第32頁86,5,14AcuteSDH&contusionhemorrhage86,5,16Post-craniotomy,theSDHdisappeared,delayedhemorrhage;SAHinRt.tentorium86,8,13EncephalomalaciachangewithmildhydrocephalusDecompressionhemorrhagewithencephalomalaciachange1/1/202433中樞外傷醫(yī)學(xué)知識講座第33頁86,9,10:Communicatinghydrocephalus86,2,6:TraumaticSAHinthesulci,interhemisphericfissureSAHcausedcommunicatinghydrocephalus1/1/202434中樞外傷醫(yī)學(xué)知識講座第34頁DiffuseAxonalInjury(DAI)Duetoaxonaldisruptionfromshearingforcesofacceleration/deceleration.MostcommonlyseeninsevereheadinjuryClinical:LossofconsciousnessattimeofinjuryMarkeddiscrepancybetweentheinitialCTandclinicalstatusofthepatientVerysmallDAIhaveprofoundclinicalsequelasincetheyaffectdenselypackedbundlesofaxonslocateddeepwithinthebrain1/1/202435中樞外傷醫(yī)學(xué)知識講座第35頁DiffuseAxonalInjuryRadiographicfeatures:Characteristiclocations:lobargraymatter/whitematterjunction,corpuscallosum,dorsolateralbrainstemInitialCTisoftenreadasnormalDAIlesionscanbeverysmallandprimarilynon-hemorrhagicrenderingthemquiteinconspiciousonthe1stCTscanPetechialhemorrhagedevelopslateronMultifocalT2brightlesions(MRImoresensitive)1/1/202436中樞外傷醫(yī)學(xué)知識講座第36頁DiffuseAxonalInjurySurvivorsofsevereDAIusuallyhavepoorneurologicoutcomes1/1/202437中樞外傷醫(yī)學(xué)知識講座第37頁1stday4monthslater--brainatrophy5thdayComaafterheadinjury4monthslater,semi-vegetatestageMultiplepunctatehemorrhagesDiffuseaxonalinjury(DAI)causedbraina