1、1,Neuroradiology of CVA-Subarachnoid Hemorrhage, SAH (蜘蛛網膜下腔出血),授課老師： 沈 戊 忠 中國醫藥學院 附設醫院 放 射 線 部,2,Subarachnoid Hemorrhage (SAH),Classification of SAH: 1. Primary SAH (spontaneous SAH) 2. Secondary SAH (ICH with ruptures into the ventricles, subarachnoid spaces) 3. Traumatic SAH,1,2,3,3,SAH,Symptoms:
2、 headache vomiting neck stiffness conscious change,Spontaneous SAH caused by rupture of aneurysm,CT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,4,Bilateral A1 portion of ACA Anterior communicating artery (ACoA) Bilateral PCoA Bilateral proximal PCA,5,Osborn AG,85% of aneurysms locate in the c
3、ircle of Willis 45% in PCoA 40% in ACoA 5% in tip of basilar artery 10% in other areas,Aneurysms 好發順序： ICA/PCoA ACoA Bifurcation of MCA Tip of basilar artery ICA, ACA, MCA PCA, 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
4、合作的患者,診斷工具,CT: SAH,7,F/79, SAH caused by an aneurysm in the ICA-PCoA,ICA,PCoA,ACA,MCA,aneurysm,CTA,DSA,8,M/49 SAH & IVH and ICH in Rt. temporal lobe caused by an aneurysm in the ICA/PCoA,ICA,PCoA,A、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/PCoA C CTA：證實右側1CA/PCoA有 一動脈瘤,CTA,9,F/54y SAH due to aneury
5、sm in Rt. ICA/PCoA.,CTA,DSA,10,M/52Aneurysm in Rt. ICA/PCoA, with SAH and ICH,CT：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aneurysm,4 hrs later,CTA,11,Intracerebral hematoma arising from a saccular aneurysm of ICA/PCoA, 2 days survival.,12,F/45 SAH due
6、 to rupture of an aneurysm in the ACoA,CT：少量SAH及輕微hydrocephalus CTA：發現ACoA有一aneurysm DSA：證實ACoA有一aneurysm,CTA,DSA,13,F/65 Massive SAH due to rupture of an aneurysm in the ACoA,CT:SAH,CTA: aneurysm in ACoA,Bird eye view,Basal view,14,M/29, SAH caused by an aneurysm in the ACoA,A：CT：SAH由於蝶鞍上腦池前中央有 較多血
7、塊，因此推測動脈瘤應在ACoA B：CTA：可見一個小動脈瘤位於ACoA C：DSA證實一個小動脈瘤位於ACoA,15,M/53 SAH, due to rupture of an aneurysm in the ACoA,16,M/29, Young stroke with ICH in Rt. frontal lobe and IVH, due to rupture of an aneurysm in the distal of A1,A,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,17,Aneury
8、sm in ACoA with little bleeding,CT：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),MRA,MRI,DSA,18,M/44,C：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,19,CT: 大量蜘蛛網膜下腔出血，尤以左側Sylvian fissure 為多，因此懷疑 aneury
9、sm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/48,20,M/38 Liver 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aneurysm。 CTA可見右側MCA之bifurcation內有一個大的aneurysm。,21,F/81 Active bleeding from a big aneurysm of bifurcation
10、 of Rt. MCA,22,F/62 Aneurysm 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,23,Intracerebral hematoma arising from a saccular aneurysm of bifurcation of MCA. 18 hours survival. (the hematoma is partially S
11、AH, partial ICH),24,F/27 An aneurysm in the transverse portion of Rt. MCA, caused ICH and IVH,CT：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,25,M/54y SAH due to rupture of an aneurysm in the left PCA,CT: SAH看不出出血點 CTA可見在左側PCA近端有一 aneurysm,26,38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aneurysm
12、 DSA證實左側PCA近端有一aneurysm This is a “ mycotic aneurysm” due to SBE,27,CT：大量SAH，看不出出血點 CTA：右側Vertebral artery 有一aneurysm DSA：證實Vertebral artery 有一aneurysm,28,F/55 Communicating hydrocephalus due to previous SAH; a saccular aneurysm in Lt. ICA/ PCoA,CT：交通性腦窒積水，可能因曾有SAH造成， 因此須做CTA或DSA CTA：左側ICA/PCoA內有一an
13、eurysm,29,F/59 SAH, due to rupture of aneurysm in Lt. ICA/PCoA; a giant aneurysm in the bifurcation of Rt. MCA,CT：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aneurysm,DSA,Rt. Carotid angio,Lt. 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
14、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,31,Diagnosis 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,
