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1、單擊此處編輯母版標(biāo)題樣式,編輯母版文本樣式,第二級,第三級,第四級,第五級,Cerebral Venous Thrombosis,Barbara Simons,Geert Lycklama a Nijeholt and Robin Smithuis,Radiology department of the Medical Centre Haaglanden in the Hague and the Rijnland hospital in Leiderdorp,the Netherlands,腦靜脈性栓塞形成,Introduction,When to think of venous thromb

2、osis,Dense clot sign,Empty delta sign,Absence of normal flow void on MR,Venous infarction,Imaging in suspected thrombosis,CT-venography,MR-venography,DSA,Pitfalls in CT,Arachnoid Granulations,Mimick of dense clot sign,Pseudo empty delta sign,Wrong bolus timing,Pitfalls in MRI,Hypoplastic transverse

3、sinus,Low signal intensity in thrombus,Flow void on contrast-enhanced MR,Chronic dural sinus thrombosis and related syndromes,DAVF,Thrombosis and increased CSF pressure,Venous territories,Publicationdate October 21,2010 Cerebral venous thrombosis is an important cause of stroke especially in childre

4、n and young adults.It is more common than previously thought and frequently missed on initial imaging.,It is a difficult diagnosis because of its nonspecific clinical presentation and subtle imaging findings.In this article we will focus on:,Findings on routine imaging that should make you think of

5、unsuspected venous thrombosis.,How to image patients in suspected venous thrombosis.,Pitfalls.,此時應(yīng)想到靜脈栓塞可能,致密斑塊征,空三角征,MR,上正常流空征消失,靜脈性腦梗塞,疑似此病的成像方法,CT,靜脈成像,MR,靜脈成像,DSA,CT,陷阱,蛛網(wǎng)膜顆粒,酷似致密凝塊征,假性空三角征,錯誤的團注時間,MRI,陷阱,橫竇發(fā)育不良,血栓內(nèi)低信號強度,MR,對比增強時的流空,硬膜竇栓塞臨床與相關(guān)綜合征,DAWF,（硬膜動靜脈瘺）,栓塞和腦脊液壓力增高,靜脈分布圖,靜脈性腦梗塞是中風(fēng)的重要原因，尤其是

6、在兒童或年輕人。,它比以前更常見而且常常在最初的成像中漏診,由于臨床上缺少特征而且影像所見微妙，因而診斷困難,這里主要討論的內(nèi)容：,*提示可疑靜脈性腦梗塞的常規(guī)影像學(xué)表現(xiàn),*疑為靜脈性腦梗塞如何進一步進行影像學(xué)檢查,*陷阱,Cerebral venous thrombosis is located in descending order in the following venous structures:,Major dural sinuses:,Superior sagittal sinus,transverse,straight and sigmoid sinuses.,Cortical

7、 veins:,Vein of Labbe,which drains the temporal lobe.,Vein of Trolard,which is the largest cortical vein that drains into the superior sagittal sinus.,Deep veins:,Internal cerebral and thalamostriate veins.,Cavernous sinus.,Clinically patients with cerebral venous thrombosis present with variable sy

8、mptoms ranging from headache to seizure and coma in severe cases.In neonates shock and dehydration is a common cause of venous thrombosis.In older children it is often local infection,such as mastoiditis,or coagulopathy.In adults,coagulopathies is the cause in 70%and infection is the cause in 10%of

9、cases.In women,oral contraceptive use and pregnancy are strong risk factors.,重要的解剖與臨床,腦靜脈性栓塞多位于以下的靜脈結(jié)構(gòu),*主要靜脈竇：上矢狀竇、橫竇、直竇和乙狀竇。,*皮質(zhì)靜脈：,Labbe,靜脈，顳葉的引流靜脈；,Trolard,靜脈，為最大的皮質(zhì)靜脈，匯入上矢狀竇。,*深靜脈：大腦內(nèi)靜脈和丘腦紋狀體靜脈。,*海綿竇。,*臨床上，腦靜脈栓塞可有多種癥狀，嚴重病例如頭痛,、癲癇、昏迷。,*,新生兒休克或脫水是腦靜脈栓塞常見的原因。,*,在兒童，局灶性的感染如中耳炎或凝血障礙。,*,成人中，,70%,的病因為凝

10、血障礙；,10%,源自感染,女性，口服避孕藥與妊娠也是其危險因素。,When to think of venous thrombosis,On a routine non-enhanced MR or CT you should think of the possibility of venous thrombosis when you see:,Direct signs of a thrombus,Infarction in a non-arterial location,especially if it is bilateral and hemorrhagic,Cortical or pe

11、ripheral lobar hemorrhage,Cortical edema,Venous thrombosis has a nonspecific presentation and therefore it is important to recognize subtle imaging findings and indirect signs that may indicate the presence of thrombosis.,Although these findings are often present on initial scans,they are frequently

12、 detected only in retrospect.Clinically patients with venous thrombosis often present with seizures,which is not a symptom in patients with an arterial infarction.,什么情況下考慮靜脈竇,栓塞呢？,在常規(guī)的,CT,或,MR,平掃圖像若有下面的表現(xiàn)應(yīng)該想到靜脈性腦栓塞可能：,*,靜脈血栓的直接征象,*,腦梗塞非動脈性的常見部位，尤其是為雙側(cè)性、出血性,*,皮質(zhì)或周圍腦葉的出血,*,腦皮質(zhì)水腫,腦靜脈血栓形成為非特異性的表現(xiàn)，因此，認識這

13、些微妙的影像學(xué)的表現(xiàn)以及間接征象很重要，它可以指出血栓形成之存在。,靜脈血栓形成的病人在臨床上常表現(xiàn)癲癇，但這不是動脈性腦梗塞病人出現(xiàn)的癥狀。,盡管這些表現(xiàn)經(jīng)常地出現(xiàn)在最初的掃描中，但卻經(jīng)常只是在回顧中發(fā)現(xiàn)這些異常。,11,、透明隔靜脈,12,、丘腦紋狀體靜脈,13,、大腦內(nèi)靜脈,14,、大腦大靜脈,15,、基底靜脈,24,、直竇,25,、,蝶頂竇,26,、海綿竇,27,、海綿間竇,29,、巖上竇,30,、巖下竇,1,、上矢狀竇,2,、下矢狀竇,3,、竇匯,4,、橫竇,5,、乙狀竇,6,、頸靜脈球,7,、頸內(nèi)靜脈,8,、淺表皮層靜脈,9,、靜脈,10,、大腦中淺靜脈,Trolard,靜脈,La

14、bbe,靜脈,Rosenthal,基底靜脈,附加：正常解剖圖與靜脈栓塞的病理解剖示意圖,正常腦靜脈竇示意圖,上矢狀竇及腦靜脈栓塞,伴發(fā)的腦腫脹及損傷,損傷的腦組織出血,Dense clot sign,（,1,）,Direct visualization of a clot in the cerebral veins on a non enhanced CT scan is known as the dense clot sign.,It is seen in only one third of cases.Normally veins are slightly denser than brai

15、n tissue and in some cases it is difficult to say whether the vein is normal or too dense(see pitfalls).,In these cases a contrast enhanced scan is necessary to solve this problem.,*,致密凝塊征（,1,）：,CT,平掃見到的腦靜脈血栓的直接表,現(xiàn)，出現(xiàn)率為,1/3.,*,正常的腦靜脈表現(xiàn)為密度較腦組織輕度高，但有些,病例的正常與否判斷確有困難（參見陷阱）。,*,CT,增強掃描可準確地解決該問題。,Dense clo

16、t sign(2),Visualization of a thrombosed cortical vein that is seen as a linear or cord-like density,is also known as the cord sign.,Another term that is frequently used,is the dense vessel sign.,Dense clot sign(3),On the left images of a patient with a hemorrhagic infarction in the temporal lobe(red arrow).,Notice the dense transverse sinus due to thrombosis(blue arrows).,*,致密凝塊征（,2,）：,CT,平掃見到的腦皮質(zhì)靜脈血栓的表,現(xiàn)，呈線樣或繩索樣高密度影，即所謂繩索征（上圖,紅箭）。也有稱其為致密血管征。,*,致密凝塊征（,3,）：,CT,平掃顯示顳葉出血性梗,塞（紅箭）。,*,注意因血栓導(dǎo)致的左側(cè)橫竇高密度（