1、脑的血管脑的血管The blood vessel of the brain动 脉 Artery静 脉 Vein脑的动脉概述u位于颅腔内,弯曲多,无搏动u血供丰富,依赖性强,缺血5分钟,不可逆损伤u颈内动脉系和椎基底动脉系两个系统u分支:皮质支和中央支脑动脉脑动脉的两个系统的两个系统颈内动脉系颈内动脉系 端脑前端脑前2/32/3 间脑的前部间脑的前部椎基底动脉系椎基底动脉系 端脑后端脑后1/31/3 间脑后部间脑后部 脑干、小脑脑干、小脑 颈内动脉系统第四颈椎水平,体表相当第四颈椎水平,体表相当于甲状软骨上缘处,于甲状软骨上缘处,颈内动脉分段12344 前床突上段3 海 绵 窦 段2 岩 段1
2、颈 段1 颈段2 岩段3 海绵窦段4 前床突上段脑动脉造影颈内动脉分段1234虹吸部,动脉虹吸部,动脉粥样硬化好发粥样硬化好发部位部位颈内动脉分支 入入颈内动脉颈内动脉-颅底颅底-颅腔颅腔-经颈动脉管经颈动脉管 通过海绵窦通过海绵窦-分出分出 眼动脉、大脑前动脉、眼动脉、大脑前动脉、大脑中动脉、后交通动脉大脑中动脉、后交通动脉 脉络膜动脉脉络膜动脉 主要供应眼部和大脑半球前2/3的血液(即额叶、顶叶、颞叶的一部分及基底节的血液。)颈内动脉的供血部位颈内动脉的供血部位 大脑中动脉从颈内动脉发出后,中央支中央支由中动脉起始处发出,经前穿质上行分为内侧豆纹动脉和外侧豆纹动脉。供血部位:供血部位:尾状
3、核体、豆状核、内囊后肢的前3/5。大脑中大脑中A.A.中央支中央支尾状核、豆状核、尾状核、豆状核、内囊膝、后肢前内囊膝、后肢前上部上部1 1、大脑中动脉(、大脑中动脉(MCAMCA)供血范围)供血范围 皮层支:皮层支:进入大脑外侧裂后分布于大脑半球的外侧面。供血部位:供血部位:额下回、额中回、颞上回、颞中回、中央前后回的下4/5及顶叶的缘上回与角回。(1)眶额动脉(2)中央沟前动脉(3)中央沟动脉 (4)中央沟后动脉(5)顶后动脉(6)角回动脉(7)颞后动脉(8)颞中动脉(9)颞前动脉(10)颞级动脉眶额眶额动脉动脉眶部、额下回后部额中回前部中央沟中央沟前动脉前动脉额中回、额下回后部、中央前回
4、下4/5中央沟动脉中央沟动脉中央前回下4/5及中央沟后缘下4/5中央沟中央沟后动脉后动脉中央后回下4/5及顶间沟前部上下缘顶后动脉顶后动脉缘上回及顶上小叶下缘角回动脉角回动脉角回及顶上小叶后部上缘颞后动脉颞后动脉顶后、角回、颞后动脉均供应皮质内面的膝距束,故三支动脉梗塞后均可发生同侧皮质盲。颞中动脉颞中动脉颞前动脉颞前动脉颞级动脉颞级动脉2 2、大脑前动脉(、大脑前动脉(ACAACA)血液供应)血液供应从颈内动脉发出从颈内动脉发出-向前向上绕过胼胝体的膝部向前向上绕过胼胝体的膝部 在大脑半球内侧面-向后行进向后行进-止于顶枕裂附近止于顶枕裂附近沿着胼胝体干形成弓状。大脑前动脉分为大脑前动脉分为
5、中央支中央支和和皮层支。皮层支。1 1)中央支)中央支:中央支进入前穿质与大脑中动脉的中央支进入前穿质与大脑中动脉的中央支吻合。中央支吻合。供血部位:供血部位:尾状前核部、壳核前尾状前核部、壳核前2/32/3部,苍白球外部,苍白球外侧核和内囊前肢侧核和内囊前肢2 2)皮层支)皮层支 供血部位:额叶内侧面、额级、额上回、旁中央小叶、中央前回的上1/5、胼胝体膝与体部的前4/5及脑底面和眶部的内侧面(1)眶动脉(2)额级动脉(3)额前动脉(4)额中动脉(5)额后动脉(6)旁中央动脉(7)楔前动脉(8)胼胝体动脉供应额叶眶面、内侧面、额级眶动脉额级动脉供应额级内外侧面额前、中、后、动脉从胼胝体上部发
6、出,越过半球内侧面到半球外侧面旁中央动脉旁中央小旁中央小叶和中央叶和中央前后回的前后回的上上1/5楔前动脉扣带回上部、楔前叶前2/3、顶上小叶和顶下小叶上缘多数起于颈内动脉-沿视束向后-至外侧膝状体经大脑脚-侧脑室下角止于脉络丛 供血部位:起分支供应外侧膝状体的外侧半、视束的中部分、内囊后肢的后2/3、大脑脚底的中1/3、苍白球的大部分、侧脑室下角的脉络丛及丘脑。此动脉细小、行程长,易发生栓塞而导致苍白球和海马病变。3 3、脉络膜前动脉(、脉络膜前动脉(ACHAACHA)的供血范围)的供血范围左图详示:基底节区的血液供应。内侧豆纹动脉外侧豆纹动脉脉络膜前动脉 大脑后动脉穿通支 起于颈内动脉后壁
7、-在视束起始端的下方穿过-与大脑后动脉的前壁相连(为颈内动脉和椎基底动脉的吻合支)。供血部位:视交叉、视束、垂体、灰结节、丘脑下部、丘脑底部、丘脑外侧下核的较前部分、内囊后肢前的下部、大脑脚和脚间的一部分。4 4、后交通动脉(、后交通动脉(PCOAPCOA)的供血范围)的供血范围5 5、眼动脉的供血范围、眼动脉的供血范围 虹吸弯颈内动脉-与视神经伴行-发出 经视神经孔-入眶分出视网膜中央动脉等 供血部位:主要供应视网膜的血液。椎基底动脉系统1 1、椎动脉、椎动脉 上行 起自锁骨下动脉-到第5-6颈椎横突 从环椎横突孔穿出-穿过第5-6颈椎横突孔-经枕骨大孔绕行环椎侧块-入颅,至脑桥下缘汇成基底
8、动脉。基底动脉基底动脉basilar a.椎动脉椎动脉vertebral a.脑桥支小脑下前动脉小脑上动脉大脑后动脉迷路动脉椎基底动脉的主要分支2 2、基底动脉、基底动脉 基底动脉沿脑桥基底动脉沟前行,至脑桥上缘分出左右大脑后动脉。基底动脉分支:(1 1)脑桥动脉:)脑桥动脉:约10余条,均从基底动脉干上发出。包括 旁中央动脉 短旋动脉 长旋动脉 脑桥动脉主要供应桥脑底部、桥脑背盖腹侧的血液。脑桥动脉脑桥动脉(2 2)小脑下前动脉:)小脑下前动脉:起自基底动脉的下1/3处,供应小脑 前下面及小脑白质与齿状核等处血液。分支:桥延支桥延支 内听动脉内听动脉(3 3)小脑上动脉:)小脑上动脉:起自基
9、底动脉上段,自动眼神经根下方行向背外侧。供应小脑上部血液。基底基底A.A.小脑下小脑下 前前A.A.小脑上小脑上A.A.迷路迷路A.A.(4 4)大脑后动脉:)大脑后动脉:为基底动脉的终支,终支,跨越动眼神经的上方,绕过大脑脚向后行跨至小脑幕上,经胼胝体压部下方进入距状沟,分为距状沟动脉和顶枕动脉。主要供应颞叶下面(颞级除外)及颞下回、枕叶内侧面、下面及背外侧面一部分、部分间脑,以及内囊的部分血液。1 1)中央支:)中央支:从大脑后动脉的根部发出,约5-7小支。主要供应丘脑、下丘脑、红核、小脑上角、大脑角外侧、内囊后支的血液。大脑后大脑后动脉动脉2 2)皮层支:)皮层支:颞下前动脉颞下前动脉:
10、分布于颞下回前部及背外侧面。颞下中动脉颞下中动脉:分布于颞下回中部及梭状回。颞下后动脉颞下后动脉:分布于楔状回后部、舌回及枕叶背外侧面。距状裂动脉距状裂动脉:为大脑后动脉的终支之一,沿距状裂后行,绕至枕级面,主要供应距状裂附近枕叶皮质。顶枕动脉顶枕动脉:为大脑后动脉的终支之一,沿顶枕裂附近斜向后 上,供应楔叶以及楔前叶的后部,并绕至大脑半 球背外侧面。颞下前动脉颞下前动脉颞下中动脉颞下中动脉颞下后动脉颞下后动脉距状裂动脉距状裂动脉顶枕动脉顶枕动脉 大脑前动脉和大脑中动脉皮层支交错供血区为额上回、额中回上半、中央前后回上1/5及顶间沟上缘等。大脑后动脉的皮质支与大脑前动脉、大脑中动脉皮质支也存在
11、侧支吻合。大脑动脉环(Willis环)大脑动脉环大脑动脉环-Willis circle-Willis circle 颈内动脉系和椎颈内动脉系和椎-基基底动脉系吻合形成底动脉系吻合形成封闭的七边形血管封闭的七边形血管环。环。Willis circleWillis circle组成组成u大脑前动脉始部大脑前动脉始部u前交通动脉前交通动脉u颈内动脉颈内动脉u后交通动脉后交通动脉u大脑后动脉大脑后动脉特点特点1 1、位置、位置:位于蝶鞍上方,围绕视交叉、灰结节、乳头体形成环状周围。2 2、作用:、作用:沟通左右颈内动脉系统;沟通颈内动脉与椎基底动脉系统。大脑前动脉大脑前动脉后交通动脉后交通动脉颈内动脉
12、颈内动脉前交通前交通动脉动脉大脑后动脉大脑后动脉3 3、意义、意义 (1)组成侧枝循环。在正常情况下,动脉环左右两侧血液不沟通,在病理情况下,特别在血管闭塞时,两侧血液相互沟通,以维持脑部的血液供应。(2)调整颅内动脉压:使双侧颈内动脉系统和椎-基底动脉系统的血压维持平衡。MRAMRA案例案例左颈内左颈内/大脑中大脑中/大脑前大脑前/椎动脉椎动脉左大脑中左大脑中右大脑中右大脑中/右大脑后右大脑后 部分部分双侧大脑后双侧大脑后 多处局限性狭窄多处局限性狭窄供血分区供血分区颅底蝶鞍层面颅底蝶鞍层面额叶额叶颞叶颞叶鞍上池鞍上池脑桥脑桥第四脑室第四脑室小脑半球小脑半球额窦额窦鞍上池层面鞍上池层面第三脑
13、室层面第三脑室层面胼胝体压部层面胼胝体压部层面胼胝体干层面胼胝体干层面MCA 终末支ACA终末支PCA终末支半卵圆中心半卵圆中心层面半卵圆中心层面MCA 终末支ACA终末支PCA终末支MCA 终末支ACA终末支ACA终末支案例案例左枕叶梗死PCA终末支终末支Figure 1:(a)Normal initial CT of the patient;(b)The cranial CT two days after the incident shows signal changes consistent with simultaneous infarcts in the right MCA and
14、PCA areas;(c)In the digital subtraction angiography of the right ICA,PCA is seen to originate from the right ICA through PCoA i.e.fetal type PCAright MCA and PCAPICAOn the left CT-images of a left-sided PICA-infarction.Notice the posterior extention.The infarction was the result of a dissection(blue
15、 arrow).小脑后下动脉梗塞小脑后下动脉梗塞On the left CT-images of a left-sided PICA-infarction.In unilateral infarcts there is always a sharp delineation in the midline because the superior vermian branches do not cross the midline,but have a sagittal course.This sharp delineation may not be evident until the late p
16、hase of infarction.In the early phase,edema may cross the midline and create diagnostic difficulties.Infarctions at pontine level are usually paramedian and sharply defined because the branches of the basilar arery have a sagittal course and do not cross the midline.Bilateral infarcts are rarely obs
17、erved because these patients do not survive long enough to be studied,but sometimes small bilateral infarcts can be seen.左侧小脑后下动脉梗塞左侧小脑后下动脉梗塞ACA:A1 segment:from origin to anterior communicating artery and gives rise to medial lenticulostriate arteries(inferior parts of the head of the caudate and th
18、e anterior limb of the internal capsule).A2 segment:from anterior communicating artery to bifurcation of pericallosal and callosomarginal arteries.A3 segment:major branches(medial portions of frontal lobes,superior medial part of parietal lobes,anterior part of the corpus callosum).Middle cerebral a
19、rteryThe MCA has cortical branches and deep penetrating branches,which are called the lateral lenticulostriate arteries.The territory of the lateral lenticulo-striate perforating arteries of the MCA is indicated with a different color from the rest of the territory of the MCA because it is a well-de
20、fined area supplied by penetrating branches,which may be involved or spared in infarcts separately from the main cortical territory of the MCA.On the left a T2W-image of a patient with an infarction in the territory of the middle cerebral artery(MCA).Notice that the lateral lenticulo-striate perfora
21、ting arteries of the MCA are also involved(orange arrow).On the left images of a hemorrhagic infarction in the area of the deep perforating lenticulostriate branches of the MCA.大脑中动脉豆纹动脉深穿支大脑中动脉豆纹动脉深穿支On the left enhanced CT-images of a patient with an infarction in the territory of the middle cereb
22、ral artery(MCA).There is extensive gyral enhancement(luxury perfusion).Sometimes this luxury perfusion may lead to confusion with tumoral enhancement.大脑中动脉大脑中动脉Posterior cerebral artery(PCA)Deep or proximal PCA strokes cause ischemia in the thalamus and/or midbrain,as well as in the cortex.Superfici
23、al or distal PCA infarctions involve only cortical structures(4).On the left a patient with acute vision loss in the right half of the visual field.The CT demonstrates an infarction in the contralateral visual cortex,i.e left occipital lobe.左枕叶梗塞左枕叶梗塞大脑后动脉大脑后动脉On the left three consecutive CT-images
24、 of a patient with an occlusion of the right internal carotid artery.The hypoperfusion in the right hemisphere resulted in multiple internal border zone infarctions.This pattern of deep watershed infarction is quite common and should urge you to examine the carotids.多发脑梗塞多发脑梗塞右侧颈内动脉闭塞右侧颈内动脉闭塞On the
25、left another example of small infarctions in the deep borderzone and in the cortical borderzone between the MCA-and PCA-territory in the left hemisphere.介于大脑中、介于大脑中、后动脉交界后动脉交界On the left an example of infarctions in the deep borderzone and in the cortical borderzone between the ACA-and MCA-territory.The abnormal signal intensity in the right carotid is the result of an occlusion.This combination of findings is so common,that once you know the pattern,you will see it many times.介于大脑前、介于大脑前、中动脉交界中动脉交界颈动脉闭塞颈动脉闭塞异常信号异常信号脉络膜前动脉供血区梗死脉络膜前动脉供血区梗死脉络膜前动脉 ACA