蜘蛛网膜下腔出血.ppt

1Neuroradiology of CVA--------Subarachnoid Hemorrhage, SAH(蜘蛛網膜下腔出血)2Subarachnoid Hemorrhage (SAH)Classification of SAH:u1. Primary SAH (spontaneous SAH)u2. Secondary SAH (ICH with ruptures into the ventricles, subarachnoid spaces)u3. Traumatic SAH1233SAHSymptoms:• headache• vomiting• neck stiffness• conscious changeSpontaneous SAH caused by rupture of aneurysmCT偵測SAH，就是在腦溝、腦池、腦裂甚至於腦室等蜘蛛網膜下腔看到CSF由暗變白，有時合併輕微腦室擴張4Circle of WillisBilateral A1 portion of ACAAnterior communicating artery (ACoA)Bilateral PCoABilateral proximal PCA5Osborn AG85% of aneurysms locate in the circle of Willis45% in PCoA40% in ACoA5% in tip of basilar artery10% in other areasAneurysms 好發順序：ICA/PCoAACoABifurcation of MCATip of basilar arteryICA, ACA, MCAPCA, Vertebral artery6• CTA：CT-angiography、CT-血管攝影， SAH患者第一線診斷工具• DSA：CTA看不清楚時，就要做DSA， 煩躁不安者須予麻醉• MRA：MR- angiography，只能用於意識 清醒可充分合作的患者診斷工具CT: SAH7F/79, SAH caused by an aneurysm in the ICA-PCoAICAPCoAACAMCAaneurysmCTADSA8M/49 SAH & IVH andICH in Rt. temporal lobecaused by an aneurysm in the ICA/PCoAICAPCoAA、B、CT：大量的SAH及IVH右側顳葉內有一小血塊，令人懷疑出血點就在右側1CA/PCoAC CTA：證實右側1CA/PCoA有一動脈瘤CTA9F/54ySAH due to aneurysm in Rt. ICA/PCoA.CTADSA10M/52Aneurysm in Rt. ICA/PCoA,with SAH and ICHCT：大量SAH，看不出出血點CTA之來源影像：相隔四小時，可見右側攝葉內有出血，這表示ICA/PCoA aneurysm，事實上已可看到(箭)CTA：右側ICA/PCoA有一巨大aneurysm4 hrs laterCTA11Intracerebral hematoma arising from asaccular aneurysm of ICA/PCoA,2 days survival.12F/45SAH due to rupture of an aneurysm in the ACoACT：少量SAH及輕微hydrocephalusCTA：發現ACoA有一aneurysmDSA：證實ACoA有一aneurysmCTADSA13F/65Massive SAH due to ruptureof an aneurysm in the ACoACT:SAHCTA: aneurysm in ACoABird eye viewBasal view14M/29, SAH caused by an aneurysm in the ACoAA：CT：SAH由於蝶鞍上腦池前中央有較多血塊，因此推測動脈瘤應在ACoAB：CTA：可見一個小動脈瘤位於ACoAC：DSA證實一個小動脈瘤位於ACoA15M/53SAH, due to rupture of an aneurysm in the ACoA16 M/29, Young stroke with ICH in Rt. frontallobe and IVH, due to rupture of an aneurysm in the distal of A1A1A,B、CT：IVH而且右側額葉內有一血塊，因此推測ACoA有一動脈瘤C、DSA：證實此動脈瘤在A1遠端，並不在ACoA裡DSA17Aneurysm in ACoA with little bleedingCT：蝶鞍上腦池有一小白點。

MRI,T2WI: CT所見的白點在MRI是暗的， 表示有血流，極似動脈瘤MRA：ACoA有一動脈瘤(箭)DSA：斜位有一動脈瘤(箭)MRAMRIDSA18M/44C：CTA的來源影像就可看到此動脈瘤(箭)D、E：CTA證實右側MCA有一動脈瘤A、B：CT大量SAH，因為右側Sylvian fissure血特別集中，懷疑右側MCA bifurcation之動脈瘤破裂所引起19CT: 大量蜘蛛網膜下腔出血，尤以左側Sylvian fissure 為多，因此懷疑 aneurysm是在左 側MCA內，CTA: 可見左側MCA bifurcation內有二個 aneurysms，一個是saccular型，一個是 fusiform形F/4820M/38Liver cirrhosis, severe headache for 7 days肝硬化患者，嚴重頭痛，CT可見輕微腦室積水，右側Sylvian fissure內有些SAH，因此懷疑右側MCA有aneurysmCTA可見右側MCA之bifurcation內有一個大的aneurysm21F/81Active bleedingfrom a big aneurysmof bifurcation of Rt. MCA22F/62Aneurysm in the bifurcation of Rt. MCA with SAH and ICH of Rt. F-T lobes.CT: SAH及右側額-顳葉間有腦內出血，因此懷疑右側MCA有aneurysm 。

DSA: 証實右側MCA bifurcation內有aneurysm23Intracerebral hematoma arising from a saccular aneurysm of bifurcation of MCA.18 hours survival.(the hematoma is partially SAH, partial ICH)24F/27An aneurysm in the transverse portion of Rt. MCA, caused ICH and IVHCT：大量IVH及右側額葉有出血DSA：右側中腦動脈之M1部份有一aneurysm25M/54y SAH due to rupture of an aneurysm in the left PCACT: SAH看不出出血點CTA可見在左側PCA近端有一aneurysm2638歲男性，SBE患者，最近發燒並有劇烈頭痛，CT可見SAH，看不出出血點CTA可見左側PCA近端有一aneurysmDSA證實左側PCA近端有一aneurysmThis is a “ mycotic aneurysm” due to SBE27CT：大量SAH，看不出出血點CTA：右側Vertebral artery 有一aneurysmDSA：證實Vertebral artery 有一aneurysm28F/55Communicating hydrocephalus due to previous SAH; a saccular aneurysm in Lt. ICA/ PCoACT：交通性腦窒積水，可能因曾有SAH造成，因此須做CTA或DSACTA：左側ICA/PCoA內有一aneurysm29F/59SAH, due to rupture of aneurysm in Lt. ICA/PCoA; a giant aneurysm in the bifurcation of Rt. MCACT：大量SAH，看不出出血點，但意外發現右側顳葉內有一圓形病灶CTA：右側MCA有一巨大aneurysm，但它並沒有破裂，SAH是左側ICA/PCoA的aneurysm所引起的DSA：證實CTA所見的這兩個aneurysmDSARt. Carotid angioLt. Carotid angio30女性77歲，左側眼皮下垂，表示第三對動眼神經麻痺。

因此須做CTA來源影像就可見到左側ICA/PCoA有一動脈瘤CTA證實之3rd N31Diagnosis Protocol of Aneurysms•For spontaneous SAH–CT-angiography–Conventional angiography (DSA--- digital subtraction angiography)•For unusual location of intracerebral hemorrhage–CT-angiography–Conventional angiography (DSA--- digital subtraction angiography)•For oculomotor nerve palsy or other suspicion of aneurysm–CTA, MRA, DSA。