Kanama ile ilişkili anevrizma/AVM işaretleri

Özet

Lober, sisternal ya da ventriküle açılan kanamada altta yatan anevrizma, arteriyovenöz malformasyon (AVM) veya travma sonrası psödoanevrizma araştırılır. Kontrastsız BT kanın yerini ve dağılımını gösterir; BT anjiyografi (BTA) kanama odağındaki damar ilişkisini ve makrovasküler lezyonu hızla ortaya koyabilir. Küçük, tromboze veya kanla örtülmüş lezyon ilk BTA'da görünmeyebilir; negatif tarama anjiyografisi, kanama örüntüsü kuvvetle düşündürücüyse damar kaynağını kesin dışlamaz. Kaynağın atlanması yeniden kanama riski taşıyan lezyonun tanınmasını ve uygun ileri damar incelemesini geciktirir.

Faz ve pencere

Kontrastsız tanısal

Akut kan, sulkus ve sisternlerde ya da parankimde çevre beyin dokusundan yüksek atenüasyonlu görünür; kanın bazal sistern, Sylvian fissür, interhemisferik fissür veya lober hematom içindeki dağılımı olası kaynak damar için ipucu verir. Damar lümeni opaklaştırılmaz; bu seri tek başına anevrizma boynunu veya AVM nidusunu göstermez.

BTA tanısal

Arteriyel fazda sakküler kontrast çıkıntısı damar bifurkasyonunda anevrizmayı; düzensiz kese ve bitişik kemik kırığı/arter seyri travmatik psödoanevrizmayı düşündürür. Serpijinöz besleyici arterler, damar yumağı ve genişlemiş drenaj venleri AVM şüphesini oluşturur; erken venöz opaklaşma zaman çözünürlüklü anjiyografide değerlendirilir. Hematom içindeki kontrast odağı spot sign olarak aktif ekstravazasyonu gösterebilir.

Önerilen pencereler: Beyin (G 80 / M 40), Anjiyo (G 600 / M 150), Kemik (G 1800 / M 400).

BT bulguları

• Sakküler anevrizma — BT anjiyografide damar bifurkasyonu veya dallanma noktasında izlenen, damar yolundan çıkan sınırlı sakküler genişleme; komşu kan dağılımıyla birlikte değerlendirilir.
• AVM nidusu — birbirine dolanmış, normal kalibrasyon ve seyir düzenini kaybetmiş damarların kompakt odağı.
• Besleyici arter ve drenaj veni — nidusa giren geniş arterler ve genişlemiş drenaj venleri AVM şüphesini destekler; erken venöz opaklaşma zaman çözünürlüklü anjiyografide değerlendirilir.
• Psödoanevrizma — damar duvarı bütünlüğü bozulduktan sonra oluşan, damar dışı sınırlı kontrast cebi; travma veya komşu hematomla anatomik ilişkisi aranır.
• Spot sign — parankimal hematom içinde damar lümeniyle devamlılığı seçilemeyen fokal kontrast birikimi genellikle aktif kan ekstravazasyonunu düşündürür ancak psödoanevrizma veya anevrizma ile karışabileceğinden ayırıcı tanı dikkate alınmalıdır.
• Anevrizmal kan dağılımı — suprasellar/bazal sistern, interhemisferik fissür veya Sylvian fissürde yoğun kan, ilgili arter çevresinde kaynak aramayı yönlendirir.
• Komşu parankim hematomu ve intraventriküler uzanım — kanamanın hacmini ve olası ruptür yönünü açıklar; damar malformasyonunu tek başına kanıtlamaz.

Normalde

Aynı düzeyde normal BTA'da internal karotid, orta serebral ve anterior serebral arter dalları düzgün konturlu, beklenen çapta ve birbirinden ayırt edilebilir; damar dışı sakküler opaklaşma ya da kompakt damar yumağı bulunmaz. Kanama tarafını karşı hemisferle kıyaslayıp arter bifurkasyonlarını, hematom kenarını ve genişlemiş kortikal venleri izleyin; normal varyant damar kıvrımını kese boynu veya AVM nidusu sanmayın.

Ayırıcı tanı

İntraparenkimal spot sign

hematom içindeki kontrast odağıdır; damar ağzı ve kese boynu izlenmiyorsa anevrizma olarak adlandırılmaz.

İnfundibüler arter çıkışı

damar bifurkasyonlarında görülen, iyi huylu doğası tartışmalı olan ve sakküler anevrizmayla karışabilen yapısal bir varyasyondur.

Gelişimsel venöz anomali

medusa başı biçiminde merkezî toplayıcı vene açılan ince venler görülür; belirgin arteriyel besleyici ve erken venöz drenaj tipik değildir.

Kavernöz malformasyon

arteriyovenöz şant içermeyen, düşük akımlı bir lezyon olup MRI'da 'yosun başı' benzeri görünümde ve çevresinde hemosiderin haliyle izlenen, mikrokanserizmaya yatkın bir yapıdır.

Arteriyel diseksiyon

damar duvarı yaralanması sonucu gerçek ve yanlış lümen oluşumu, segmenter daralma veya oklüzyonla seyreden, sakküler anevrizmadan farklı morfolojideki lezyondur.

Tuzaklar

• Hematom içindeki aktif kontrast sızıntısını kese anevrizması sayma; kaynak damarla süreklilik ve opaklaşma biçimi farklıdır.
• Küçük ya da kısmen tromboze anevrizma, hematom komşuluğunda seçilemeyebilir; kanama paterni ile BTA uyuşmuyorsa negatif sonucu mutlak dışlama kabul etme.
• AVM’de erken venöz doluş, geç faz görüntüsü veya venöz varyantla karışabilir; zaman çözünürlüklü seriyi/DSA fazlarını ve çok düzlemli kesitleri birlikte değerlendir.
• Travma sonrası psödoanevrizma ilk incelemede belirgin olmayabilir; kafa tabanı kırığı boyunca komşu arter segmentini ve fokal dışa taşmayı ayrıca tara.

Kendini dene

1. Lober hematomun kenarında BTA'da arter dalından çıkan opak kese görülüyor. En olası kaynak nedir?

   • Rüptüre sakküler anevrizma
   • Kavernöz malformasyon
   • Gelişimsel venöz anomali
   • Hipertansif mikroanjiyopati
   Cevabı göster

   Rüptüre sakküler anevrizma. Arter dalıyla devamlı opak kese anevrizma morfolojisidir. Kavernöz malformasyon düşük akımlıdır; venöz anomali toplayıcı venlere açılan ince kanallar yapar; mikroanjiyopati damar dışı fokal kese oluşturmaz.

2. Çok fazlı BTA’da kompakt damar yumağına besleyici arterler giriyor ve arteriyel fazda bir drenaj veni erken opaklaşıyor. En olası lezyon hangisidir?

   • Arteriyovenöz malformasyon
   • Dural sinüs trombozu
   • Serebral venöz anomali
   • Sakküler anevrizma
   Cevabı göster

   Arteriyovenöz malformasyon. Kompakt nidusa giren besleyici arterler ve çok fazlı incelemede arteriyel fazda erken opaklaşan drenaj veni AVM şantını destekler. Sinüs trombozunda dolum kusuru beklenir; gelişimsel venöz anomali tipik olarak kompakt yüksek akımlı nidus oluşturmaz; tek anevrizma serpijinöz damar yatağı değildir.

İlgili konular

• İzole travmatik sulkal kanama

Kaynaklar

Bu sayfadaki 41 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 5 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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