腦梗死的血管定位5/9/20241《腦梗死的血管定位》課件內容腦供血動脈解剖腦梗死的血管定位5/9/20242《腦梗死的血管定位》課件人腦動脈解剖5/9/20243《腦梗死的血管定位》課件腦動脈兩大體系頸內動脈系：大腦前部＋部分間腦

椎基底動脈系：

大腦后部＋部分間腦＋腦干＋小腦小腦幕為界頂枕溝為界（3/2)5/9/20244《腦梗死的血管定位》課件腦動脈供血系統(tǒng)模式圖5/9/20245《腦梗死的血管定位》課件腦的主要供血動脈。(A)腦腹側觀。方塊區(qū)域放大圖顯示W(wǎng)illis動脈環(huán)。(B)腦外側面觀和(C)中間矢狀面顯示大腦中/前/后動脈。(D)冠狀切面顯示大腦中動脈行程。5/9/20246《腦梗死的血管定位》課件頸內動脈系統(tǒng)MCA＋ACA＋脈絡叢前動脈5/9/20247《腦梗死的血管定位》課件大腦中動脈（MCA）供血范圍MCAACAPCAMCA皮質支供應：半球外側面（額中回以下、中央前后回下3/4、頂下小葉、枕葉月狀溝或枕外側溝以前、顳下回上緣或上半以上的部分）；島葉；顳極內外側；額葉眶面一部分。5/9/20248《腦梗死的血管定位》課件MCA中央支供應：殼核、尾狀核、內囊前肢、內囊膝的背外側和內囊后肢的背部區(qū)域。立體看，供應內囊上3/55/9/20249《腦梗死的血管定位》課件5/9/202410《腦梗死的血管定位》課件大腦中動脈（MCA）供血范圍5/9/202411《腦梗死的血管定位》課件大腦前動脈（ACA）血液供應ACA皮質支供應：半球內側面為頂枕裂以前皮質和胼胝體；在背外側面達額中回上緣或上半、額上回、中央前后回上1/4、頂上小葉及眶部內側半等區(qū)域。ACA中央支供應：部分額葉眶面皮質、外囊、尾狀核和豆狀核前部、內囊前肢和內囊膝部和后肢前邊部分。5/9/202412《腦梗死的血管定位》課件5/9/202413《腦梗死的血管定位》課件脈絡叢前動脈：→側腦室下角的脈絡叢，并供應外側膝狀體、內囊后肢的后下部、大腦腳底的中1/3、蒼白球等，易形成血栓阻塞。脈絡膜前動脈的供血范圍左圖詳示：基底節(jié)區(qū)的血液供應。5/9/202414《腦梗死的血管定位》課件5/9/202415《腦梗死的血管定位》課件脈絡膜前動脈脈絡膜前動脈，1～4支，以3支最多，為一組較細小而恒定的血管，在后交通動脈起始遠側2mm處由頸內動脈脈直接發(fā)出。該動脈在未穿入側腦室下腳之前，除發(fā)1～3個皮質支外，還發(fā)出2～3個穿支，1支穿視神經(jīng)內側至大腦腳，另兩支即為紋狀體內囊動脈。此動脈主要營養(yǎng)尾狀核尾，行程長，管徑較小，易發(fā)生栓塞。5/9/202416《腦梗死的血管定位》課件D.AxialT2-weightedimage(2500/80)revealsthepresenceofaninhomogeneousmassintherightlateralventricle.Thelowsignalintensitysuggetsthepresenceofcalcificationandhemorrhage.E.Angiogramoftherightinternalcarotidarteryobtainedonday3demonstratesahypervascularmassfedfromtherightanteriorchoroidalartery(arrows).5/9/202417《腦梗死的血管定位》課件WhichoneistheAnteriorChoroidalArtery?5/9/202418《腦梗死的血管定位》課件5/9/202419《腦梗死的血管定位》課件脈絡膜前動脈閉塞常引起三偏癥狀群，特點為偏身感覺障礙重于偏癱，而對側同向偏盲又重于偏身感覺障礙，有的尚有感覺過度、丘腦手、患肢水腫等。5/9/202420《腦梗死的血管定位》課件內囊額狀斷面腦后片圖顯示各部位血液供應來源。5/9/202421《腦梗死的血管定位》課件中央前回及中央后回的血液供應圖5/9/202422《腦梗死的血管定位》課件椎基底動脈系統(tǒng)VA＋BA5/9/202423《腦梗死的血管定位》課件椎動脈（VA）①V1（骨外）段：向上進C6橫突孔。②V2（椎間孔段③V3（脊椎外）段：④V4（硬膜內段）：過枕骨大孔，在腦橋及延髓交界處合成基底動脈。近側椎動脈段解剖（A側位；B前后位；C頦頂位）：骨外段（V1）橫突孔段（V2）椎外段（V3）4.硬膜內段（V4）5.枕骨髁的大概位置椎動脈行程圖A：斜側位觀；圖B：前后位觀；圖C：俯觀。5/9/202424《腦梗死的血管定位》課件1.左椎動脈2.腦膜后動脈3.小腦后下動脈（PICA）4.基底動脈5.小腦前下動脈(AICA)6.腦橋外側支7.小腦上動脈（SCA）8.大腦后動脈9.小腦半球支大水平裂10.SCA的小腦半球分支11.小腦蚓上動脈椎基底動脈系統(tǒng)及其分支解剖（側位）：5/9/202425《腦梗死的血管定位》課件椎基底動脈系統(tǒng)及其分支解剖（正位）：1.右椎動脈2.左椎動脈3.脊髓前動脈4.小腦后下動脈（PICA）5.基底動脈6.小腦前下動脈（AICA）7.腦橋外側支8.小腦上動脈（SCA）9.大腦后動脈10.后交通動脈11.頸內動脈5/9/202426《腦梗死的血管定位》課件5/9/202427《腦梗死的血管定位》課件大腦后動脈（PCA）血液供應中央支：丘腦、下丘腦、底丘腦、膝狀體以及大部分中腦。此外，分支到側腦室及第三腦室脈絡叢。變異大。主要來自PCA（72.5-88.3%）；來自ICA（6.8-20.2%）；兩部分平均參加（4.3-11%）。5/9/202428《腦梗死的血管定位》課件PCA供血區(qū)模式圖皮質支：半球底面和內側面一部分（包括：海馬回、梭狀回、顳下回、舌回、窟窿回峽、楔葉、楔前葉后1/3及頂上小葉后部）5/9/202429《腦梗死的血管定位》課件Bloodsupplyofthethreesubdivisionsofthebrainstem.Diagramofmajorsupply.Sectionsthroughdifferentlevelsofthebrainstemindicatingtheterritorysuppliedbyeachofthemajorbrainstemarteries.5/9/202430《腦梗死的血管定位》課件腦橋的血液供應特點橋腦的血供源自椎—基底動脈，橋腦基底外側和被蓋部由短旋動脈供應；橋腦基底部內側由基底動脈中央支供應，旁正中支供應橋腦被蓋部正中部分—腦室底部、外展神經(jīng)核、內側縱束和網(wǎng)狀結構；橋腦基底部和被蓋部最外側為長旋動脈供應。由于外側區(qū)側支循環(huán)豐富，發(fā)生梗塞概率較低。而橋腦旁正中動脈、短旋動脈呈直角起自基底動脈，易受高血壓的影響而出現(xiàn)動脈粥樣硬化，易出現(xiàn)梗塞。5/9/202431《腦梗死的血管定位》課件腦橋梗死的臨床特點貌似大腦半球病變的純運動性偏癱占橋腦梗塞的60.9%。這是因為錐體束位于橋腦基底部，基底部由基底動脈的旁正中深穿支供應血流，該部位動脈易有動脈硬化性改變和透明變性，其近端閉塞時導致基底部正中梗塞，使未交叉的錐體束受損。PICA和SCA引起的梗塞通常僅累及小腦；而AICA（供應腦橋外側被蓋部和小腦中腳）不同，它引起的梗塞灶多累及腦干和小腦中腳。5/9/202432《腦梗死的血管定位》課件橋腦梗塞時交叉性癱及顱神經(jīng)麻痹并不常見，因橋腦的顱神經(jīng)核多分部于被蓋部，由較豐富的長旋動脈及小腦上動脈供應血流，后交通動脈、大腦后動脈和小腦上動脈有側枝循環(huán)，所以顱神經(jīng)可不受影響。腦橋梗死的臨床特點5/9/202433《腦梗死的血管定位》課件腦橋上/中部旁中線綜合征由基底動脈旁中央支血供障礙引起；病變對側中樞性舌癱＋對側中樞性上下肢癱瘓＋同側小腦性共濟失調Patientswithunilateralparamedianinfarctionstypicallypresentedapuremotorhemiparesisthatprogressedoverthefirst3daysandwasaccompaniedbydysarthriaandhomolateralataxia.5/9/202434《腦梗死的血管定位》課件橋腦上外側綜合征小腦上動脈閉塞引起；①眩暈、惡心、嘔吐、眼球震顫（前庭核損害）②兩眼向病灶側水平凝視不能（腦橋側視中樞損害）③同側肢體共濟失調（腦橋臂、結合臂、小腦齒狀核損害）；④同側Horner綜合征（下行交感神經(jīng)損害）⑤同側面部感覺障礙（三叉神經(jīng)感覺束損害）和對側痛覺、溫度覺障礙（脊髓丘腦束損害）；⑥對側下肢深感覺障礙（內側丘系外側部分損害）⑦雙側聽力障礙，對側較重。5/9/202435《腦梗死的血管定位》課件少見SCA綜合征出現(xiàn)病變對側感音性耳聾5/9/202436《腦梗死的血管定位》課件5/9/202437《腦梗死的血管定位》課件腦橋腹下部綜合征

（Millard-GublerSyndrome)同側外展N麻痹＋同側周圍性面癱對側中樞性舌癱一；對側肢體癱。也其它位置不同的突出癥狀可能出現(xiàn)小腦前下動脈阻塞引起。5/9/202438《腦梗死的血管定位》課件5/9/202439《腦梗死的血管定位》課件腦橋基底內側綜合征

（FovilleSyndrome)

病灶側周圍性面癱；兩眼向病灶側同向注視麻痹；病灶對側偏癱；基底動脈旁正中支閉塞引起。5/9/202440《腦梗死的血管定位》課件小腦后下動脈綜合征

（Wallenbergsyndrome)現(xiàn)證實10％由PICA引起，75％由一側椎動脈閉塞引起。余下由基底動脈閉塞引起。5/9/202441《腦梗死的血管定位》課件5/9/202442《腦梗死的血管定位》課件延髓內側綜合征

（Dejerine綜合征）

椎動脈及其分支或基底動脈后部血管阻塞，引起延髓錐體發(fā)生梗死時產生同側舌肌麻痹（XII腦神經(jīng)損害）和萎縮，對側上下肢中樞性癱瘓以及觸覺、位置覺、振動覺減退或喪失。5/9/202443《腦梗死的血管定位》課件Magneticresonanceimageofthefluidattenuatedinversionrecoverysequencefortheaxial(left)andT2weightedcoronal(right)sections.Thereisawelldemarcatedunilateralmedialmedullaryinfarctjustbelowthepontomedullaryjunction.Therightsideofeachimagecorrespondstotheleftsideofthebrain.5/9/202444《腦梗死的血管定位》課件大腦動脈血管供血分區(qū)CT解剖(圖文)5/9/202445《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支5/9/202446《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支脈胳膜前動脈5/9/202447《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支脈胳膜前動脈ACA穿支PCA穿支及PCoA5/9/202448《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支脈胳膜前動脈ACA穿支PCA穿支及PCoAMCA穿支5/9/202449《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支脈胳膜前動脈ACA穿支PCA穿支及PCoAMCA穿支5/9/202450《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支脈胳膜前動脈ACA穿支PCA穿支及PCoAMCA穿支5/9/202451《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支5/9/202452《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支5/9/202453《腦梗死的血管定位》課件MCA終末支ACA終末支PCA終末支5/9/202454《腦梗死的血管定位》課件MCA終末支ACA終末支5/9/202455《腦梗死的血管定位》課件ACA終末支5/9/202456《腦梗死的血管定位》課件5/9/202457《腦梗死的血管定位》課件5/9/202458《腦梗死的血管定位》課件5/9/202459《腦梗死的血管定位》課件腦的供血模式圖5/9/202460《腦梗死的血管定位》課件5/9/202461《腦梗死的血管定位》課件5/9/202462《腦梗死的血管定位》課件5/9/202463《腦梗死的血管定位》課件5/9/202464《腦梗死的血管定位》課件左枕葉梗死。（PCA終末支）5/9/202465《腦梗死的血管定位》課件Figure1:(a)NormalinitialCTofthepatient;(b)ThecranialCTtwodaysaftertheincidentshowssignalchangesconsistentwithsimultaneousinfarctsintherightMCAandPCAareas;(c)InthedigitalsubtractionangiographyoftherightICA,PCAisseentooriginatefromtherightICAthroughPCoAi.e.fetaltypePCA5/9/202466《腦梗死的血管定位》課件PICAOntheleftCT-imagesofaleft-sidedPICA-infarction.Noticetheposteriorextention.Theinfarctionwastheresultofadissection(bluearrow).5/9/202467《腦梗死的血管定位》課件OntheleftCT-imagesofaleft-sidedPICA-infarction.Inunilateralinfarctsthereisalwaysasharpdelineationinthemidlinebecausethesuperiorvermianbranchesdonotcrossthemidline,buthaveasagittalcourse.Thissharpdelineationmaynotbeevidentuntilthelatephaseofinfarction.Intheearlyphase,edemamaycrossthemidlineandcreatediagnosticdifficulties.Infarctionsatpontinelevelareusuallyparamedianandsharplydefinedbecausethebranchesofthebasilarareryhaveasagittalcourseanddonotcrossthemidline.Bilateralinfarctsarerarelyobservedbecausethesepatientsdonotsurvivelongenoughtobestudied,butsometimessmallbilateralinfarctscanbeseen.5/9/202468《腦梗死的血管定位》課件SCAOntheleftCT-imagesofacerebellarinfarctionintheregionofthesuperiorcerebellararteryandalsointhebrainstemintheterritoryofthePCA.Noticethelimitationtothemidline.5/9/202469《腦梗死的血管定位》課件ACA：?A1segment:fromorigintoanteriorcommunicatingarteryandgivesrisetomediallenticulostriatearteries(inferiorpartsoftheheadofthecaudateandtheanteriorlimboftheinternalcapsule).?A2segment:fromanteriorcommunicatingarterytobifurcationofpericallosalandcallosomarginalarteries.?A3segment:majorbranches(medialportionsoffrontallobes,superiormedialpartofparietallobes,anteriorpartofthecorpuscallosum).5/9/202470《腦梗死的血管定位》課件AnteriorchoroidalarteryTheterritoryoftheanteriorchoroidalarteryencompassespartofthehippocampus,theposteriorlimboftheinternalcapsuleandextendsupwardstoanarealateraltotheposteriorpartofthecellamedia.ThewholeareaisrarelyinvolvedinAChAinfarcts.Ontheleftanuncommoninfarctioninthehippocampalregion.PartoftheterritoryoftheanteriorchoroidalarteryandthePCAareinvolved.5/9/202471《腦梗死的血管定位》課件MiddlecerebralarteryTheMCAhascorticalbranchesanddeeppenetratingbranches,whicharecalledthelaterallenticulo-striatearteries.Theterritoryofthelaterallenticulo-striateperforatingarteriesoftheMCAisindicatedwithadifferentcolorfromtherestoftheterritoryoftheMCAbecauseitisawell-definedareasuppliedbypenetratingbranches,whichmaybeinvolvedorsparedininfarctsseparatelyfromthemaincorticalterritoryoftheMCA.OntheleftaT2W-imageofapatientwithaninfarctionintheterritoryofthemiddlecerebralartery(MCA).

Noticethatthelaterallenticulo-striateperforatingarteriesoftheMCAarealsoinvolved(orangearrow).5/9/202472《腦梗死的血管定位》課件OntheleftimagesofahemorrhagicinfarctionintheareaofthedeepperforatinglenticulostriatebranchesoftheMCA.5/9/202473《腦梗死的血管定位》課件OntheleftenhancedCT-imagesofapatientwithaninfarctionintheterritoryofthemiddlecerebralartery(MCA).Thereisextensivegyralenhancement(luxuryperfusion).Sometimesthisluxuryperfusionmayleadtoconfusionwithtumoralenhancement.5/9/202474《腦梗死的血管定位》課件Posteriorcerebralartery(PCA)DeeporproximalPCAstrokescauseischemiainthethalamusand/ormidbrain,aswellasinthecortex.SuperficialordistalPCAinfarctionsinvolveonlycorticalstructures(4).Ontheleftapatientwithacutevisionlossintherighthalfofthevisualfield.TheCTdemonstratesaninfarctioninthecontralateralvisualcortex,i.eleftoccipitallobe.5/9/202475《腦梗死的血管定位》課件Therearetwopatternsofborderzoneinfarcts:1.CorticalborderzoneinfarctionsInfarctionsofthecortexandadjacentsubcorticalwhitematterlocatedattheborderzoneofACA/MCAandMCA/PCA2.InternalborderzoneinfarctionsInfarctionsofthedeepwhitematterofthecentrumsemiovaleandcoronaradiataattheborderzonebetweenlenticulostriateperforatorsandthedeeppenetratingcorticalbranchesoftheMCAorattheborderzoneofdeepwhitematterbranchesoftheMCAandtheACA.5/9/202476《腦梗死的血管定位》課件OntheleftthreeconsecutiveCT-imagesofapatientwithanocclusionoftherightinternalcarotidartery.Thehypoperfusionintherighthemisphereresultedinmultipleinternalborderzoneinfarctions.Thispatternofdeepwatershedinfarctionisquitecommonandshouldurgeyoutoexaminethecarotids.5/9/202477《腦梗死的血管定位》課件Ontheleftimagesofapatientwhohassmallinfarctionsintherighthemisphereinthedeepborderzone(bluearrowheads)andalsointhecorticalborderzonebetweentheMCA-andPCA-territory(yellowarrows).Thereisabnormalsignalintherightcarotid(redarrow)asaresultofocclusion.Inpatientswithabnormalitiesthatmayindicateborderzoneinfarcts,alwaysstudytheimagesofthecarotidarterytolookforabnormalsignal.5/9/202478《腦梗死的血管定位》課件OntheleftanotherexampleofsmallinfarctionsinthedeepborderzoneandinthecorticalborderzonebetweentheMCA-andPCA-territoryinthelefthemisphere.5/9/202479《腦梗死的血管定位》課件OntheleftanexampleofinfarctionsinthedeepborderzoneandinthecorticalborderzonebetweentheACA-andMCA-territory.Theabnormalsignalintensityintherightcarotidistheresultofanocclusion.Thiscombinationoffindingsissocommon,thatonceyouknowthepattern,youwillseeitmanytimes.5/9/202480《腦梗死的血管定位》課件脈絡膜前動脈供血區(qū)梗死5/9/202481《腦梗死的血管定位》課件A9-year-oldpreviouslyhealthygirlwasadmittedtotheEmergencyRoomwithaneight-hourhistoryofsuddenonsetofsevereheadache.Thepainwaspulsatileandbilateralandnotaccompaniedbyothersymptoms.Thereisnohistoryofmigraine,epilepsyorstroke.Parentsreportedthatsoonaftertheonsetoftheheadachethepatientbecamedrowsyforaboutonehour.Notriggerfactorwasidentified.Ontheneurologicalexamination,thepatientwasalertandwellorientedwithnootherabnormalitiesbutmildnuchalrigidity.Computedtomographyofthebrainrevealedhemorrhageintherightlateralventricle(Fig1)andgadolinium-enhancedmagneticresonanceimagingstudyofthebraindisclosedaheterogeneouslesioninthemesialportionoftherighttemporallobe,aboveandinsidethetemporalhornofthelateralventricle.Thelesionextendeduntilthesubependimaryareaofthetrigonooftherightventricle.ThelesionwashypointenseonT1andT2-weightedimagesandenhancedwiththecontrast.OtherhyperintenseT1andT2-weightedimageslesionswereseenintherightlateralventriclesuggestingbleeding.Magneticresonanceangiographyandcerebralangiographydisclosedanarteriovenousmalformationinpartofthechoroidplexus,suppliedbytheanteriorchoroidalartery(Figs2and3).TheAVMwasclassifiedaccordingtoSpetzlergradingsystemasgrade3(deepvenousdrainage:1;eloquencearea:0andsize:2).5/9/202482《腦梗死的血管定位》課件Lacunesmaybeconfusedwithotheremptyspaces,suchasenlargedperivascularVirchow-Robinspaces(VRS).TheVRSareextensionsofthesubarachnoidspacethataccompanyvesselsenteringthebrainparenchyma.WideningofVRSoftenfirstoccursaroundpenetratingarteriesinthesubstantiaperforataandcanbeseenontransverseMRIslicesaroundtheanteriorcommisure,eveninyoungsubjects(5).OntheleftCT-andMR-imagesatthelevelof