一例椎体的局灶病变影像表现分析暨影像诊断扩展.pptx

一例椎体的局灶病变影像表现分析暨影像诊断扩展中国石油中心医院 影像科 杨景震注：浏览时请用幻灯放映模式2016-9制作 2016病例交流（18）（源自同学圈子的病例）女，62岁。腰痛，以急性腰扭伤住院。（江苏大丰赵文主任提供的病例）腰椎正侧位：问题在哪？腰椎2椎体右侧份骨硬化CT轴位图细看再看CT矢状重组图CT矢状重组图看一看该病例的MRI图T1WI未加压脂 矢状位T2WI未加压脂 矢状位T2WI加压脂 矢状位T2WI未加压脂 轴位增强T1WI未加压脂 冠状位增强T1WI未加压脂 矢状位增强T1WI未加压脂 轴位增强T1WI压脂增强T1WI压脂 冠状位增强T1WI压脂 轴位天津医院王林森主任诊断意见：椎体硬化性血管瘤诊断意见？鉴于该病例影像学表现较特殊，且影像资料齐全，故在此将其总结并结合相关文献予以扩展和交流该诊断之所以冠以“硬化”是基于影像学的病变区骨量增多。参考文献：EpithelioidhemangiomaofboneSkeletalRadiol(2001)30:226229Otherrelativelycommonfeaturesincludesurroundingsclerosis,andcorticalexpansionandcorticaldestruction.Significantinourcaseisthediffusereactivesclerosisaffectingvirtuallytheentirevertebralbody,小结：本例椎体硬化性血管瘤的影像学表现1、病变区骨量增多，表现为平片、CT上密度增高，并在CT图上显示硬化缘。2、瘤体内含少许脂肪组织（即MRI的T1WI明显高信号；CT上的点状更低密度）3、MRI可见病变周围脂肪化（TW2及T1WI高信号，压脂低信号）即瘤周脂肪侵润4、瘤体一部分结构在T2WI压脂上呈高信号（即MR展示其瘤体之富水特征）5、增强扫描呈渐进性强化（含血窦的瘤体）该例椎体血管瘤综合影像（没有“栅栏征”）：瘤体富水并含少量脂肪、骨量增多、其血窦由对比剂充填、瘤周脂肪侵润（若瘤内含脂肪较多，也可归为脂肪侵润型血管瘤）再看这例椎体血管瘤：也没有“栅栏征”（脂肪侵润型）广州医科大学候仲军教授病例T1WIT1WI压脂T2WI压脂增强T1WI压脂（矢、冠、轴位）T2WI压脂T1WIT2WIT1WIT2WI压脂常见典型的椎体血管瘤的影像学表现（栅栏征）脂肪侵润型血管瘤再看这例硬化性血管瘤EpithelioidhemangiomaofboneSkeletalRadiol(2001)30:226229Fig.1LateralradiographofthethoracicspinedemonstratesdiffusesclerosisoftheT7vertebralbody.Fig.2CTscanofthethoracicspineshowsanexpandinglyticlesionwithpartialossificationinvolvingtherightanterolateralaspectoftheT7vertebralbody.Thelesionincludestrabecularboneandapartiallyossifiedmargin.Theremainderoftheverte-bralbodyexhibitsdiffusereactivesclerosismostprominentattheinterfacewiththelesion.Fig.3SagittalT2-weightedMRimagedemonstratesheterogeneoussignalintensityintheT7vertebralbody.AlsoseenissubtleincreasedsignalintheanterioraspectoftheT8vertebralbody(arrow)consistentwithbonemarrowedema.（病理为椎体上皮样血管瘤）女，32岁，胸背钝痛。其他无特殊。胸椎侧位显示胸椎7椎体弥漫性硬化CT检查：膨胀性溶骨性病变伴部分性骨化，侵及胸椎7的右前部。病变累及松质骨并伴部分硬化缘，余部椎体显示反应性骨硬化，以邻近病变部显著。矢状T2WI显示胸椎7不均匀信号，胸椎8（箭）前部信号轻度增高，符合骨髓水肿改变。Fig.4Simpleandmildlycomplexvascularstructuresareseenwithinfibroustissue(90)Fig.5Athighermagnification,thereismildirregularityintheshapeofthebloodvessels.Mostoftheendothelialcellsareflattened(250)Fig.6Thisfielddemonstratesbothvascularchannelsandmoresolidareaswithlessobviousvascularity.Inbothareas,theendothelialcellsaresomewhatprominentwithplumpnuclei.Afewtuftedpapillaryprojectionsareseenatlowerleft(300)图4 纤维组织内的单一和少许复合血管结构（低倍）。图5 高倍放大图：轻度不规则血管，大多数内皮细胞呈扁平状。图6 血管窦和较多含有不太明显的血管之实变区。两个区域中，内皮细胞显著并核丰满，在左下可见少数簇状乳头突起。本例以骨硬化为特点的上皮样椎体血管瘤的 影像学表现提示 Otherrelativelycommonfeaturesincludesurroundingsclerosis,andcorticalexpansionandcorticaldestruction.Significantinourcaseisthediffusereactivesclerosisaffectingvirtuallytheentirevertebralbody,afindingwhichtoourknowledgehasnotpreviouslybeenreported.Thediffusesclerosisresultedintheradiographicappearanceofadenseor“ivory”vertebralbodyandaninitialdiagnosisoflymphomawasconsidered.椎体上皮样血管瘤另外比较常见特征包括：病灶周围骨硬化，骨皮质膨胀、骨皮质破坏。本例表现为弥漫性反应性骨硬化几乎累及整个椎体，作者没有发现以往有过此类的报道。这种弥漫性硬化致使放射学高密度表现或呈“象牙质样”的椎体，以至于最初诊断曾考虑骨淋巴瘤。（注：椎骨硬化改变需要依赖X线平片或CT检查）Wepresentacaseofepithelioidhemangiomaofthespinewithanunusualradiologicalappearancewhichtoourknowledgehasnotpreviouslybeenreported:diffusesclerosisoftheinvolvedvertebralbody.Hemangiomasofbonearebenigntumorsarisingfrombloodvessels.Varioushistopathologicalsubtypesincludingcavernous,capillary,arteriovenous,venousandepithelioidhavebeendescribed1,2.骨血管瘤属于起自于血管的良性肿瘤。病理上有多种亚型包括：海绵状、毛细血管状、动静脉型、静脉型以及上皮样。该文献报告的脊椎上皮样血管瘤病例，其影像学不常见的表现且以前的文献也不曾报告：受侵的椎体弥漫性硬化。扩展一：再分析一下椎体血管瘤与病理的关系 有助于认识血管瘤的影像表现Benignvertebralhemangioma:MR-histologicalcorrelationSkeletalRadiol(2001)30:442446Fig.1a73-year-oldT1WIshowsanareaofintermediatesignalintensity(arrow)withlinearandverticalareasofverylowsignalintensity(smallarrow)intheposteriorpartofthemiddlevertebralbody.BT2WI，intensityofthelesion(arrow)ismoderatelyincreasedincomparisonwithadjacentnormalmarrow.CPhotomicrographofthelesionshowsthin-walled,dilatedvessels(star),adipocytes(arrow)andinterstitialedema(smallarrow).Therelativeproportionofsurfaceareaoccupiedbythin-walled,dilatedvesselsandinterstitialedemaisequivalenttothatoccupiedbyadipocytes.Benignvertebralhemangioma:MR-histologicalcorrelationSkeletalRadiol(2001)30:442446图A，T1WI长箭示病变区中等信号；其中小箭示线样纵行极低信号；图B，T2WI箭指病变区与正常椎体相比呈略高的中等信号；图C，病变镜下图示薄壁、扩张的血管（星）、脂肪（箭）及间质水肿（小箭）。由薄壁扩张的血管、间质水肿相应的表面区域比例与脂肪细胞分布的区域相当。Fig.2T1WIofavertebralbodyofthespinespecimenfroma69-year-oldsubjectshowsaheterogeneousareathatconsistsofhigh(arrow)andintermediatesignalintensity(smallarrow).BPhotographofthecorrespondingmacroscopicsectionshowsayellowlesion(arrow)thatcontainssmallreddots(smallarrow).CPhotomicrographofmarrowareawithhighsignalintensityontheT1WI(largearrowinA).Therelativeproportionofsurfaceareaoccupiedbyadipocytes(arrow)islargerthanthatoccupiedbyvesselsandinterstitialedemaintheareaofhighsignalintensityontheT1WI.DPhotomicrographofmarrowareawithintermediatesignalintensityontheT1WI(smallarrowinA).Therelativeproportionofsurfaceareaoccupiedbyadipocytes(arrow)issimilartothatoccupiedbyvesselsandinterstitialedemaintheareaofintermediatesignalintensityontheT1WI.Atmacroscopicexaminationofsectionphotographs,fivelesionswerehomogeneous,withmultiplereddotshomogeneouslyinterspersedinabackgroundofyelloworredcolor.Fourlesionswereheterogeneouswithvariableamountsofreddotsclusteredindifferentlesionareas.Histologicalanalysisofthelesionsdemonstratedthin-walled,largeblood-filledvesselssetinastromaofadipocyteswithinterstitialedemainallninelesionsthatindicatedcavernoushemangioma.Novesselthrombosis,hemosiderindepositionorhematopoieticcellswerefound.所有9例海绵状血管瘤组织学分析：red dots 病变，是在脂肪基质上的薄壁、扩张充盈的血管伴间质水肿。无血栓及含铁血黄素沉积或造血细胞。图A：T1WI示均匀高信号区（长箭）、中等信号区（小箭），图B：相应的标本切片图片：黄色病变（长箭），其内含多发小红点raddots（小箭）图C：图A长箭指的高信号骨髓区镜下图片：脂肪细胞分布的相对表面的区域明显多于血管和间质水肿区。图D：图A小箭指的中等信号骨髓区镜下图片：脂肪细胞（箭）分布相对表面区域类似于由血管及间质水肿区。即二者分布比例相当。如果这个病人做增强扫描，强化的部分是？影像学检查发现，椎体血管瘤很常见，但不是都具备其典型的“栅栏征”，且多数是没有症状的。扩展二：试问什么情况下血管瘤出现病理性的相关症状呢？Hemangiomaisoneofthemostcommonbenigntumorsofthespinewithareportedprevalenceof10%to12%inthegeneralpopulation1.Thevastmajorityofpatientswithvertebralhemangiomastayasymptomatic.Occasionally,inabout1%ofcases,vertebralhemangiomasbecomesymptomaticcausingneuralarchexpansion,vertebralbodyenlargementordirectcompressionofthethecalsacornerveroots2,3.注：由无症状血管瘤演变为有症状性者，外伤性除外，这里指自发性73-year-oldmanpresentedwiththeinabilitytowalk,numbnessinthelegsandtrunk,andurinaryretention.Threeyearspreviously,hehadnoticednumbnessinhiskneesthatprogressedslowlytoinvolvethelowertrunkandlimbs.Healsodevelopedweaknessinhislowerlimbs.病例一男，73岁。主诉行走无力、下肢及躯干麻木，尿潴留。3年前即有膝部麻木，并逐渐加重且累及下部躯干和肢体。病人的双侧下肢无力也呈进展性。Vertebralhaemangiomacausingcordcompression:MRIfindingsAustralasianRadiology(2003)47,190193Fig.1.Axial(a)andsagittal(b)T1WIdemonstratemottledhigh-signalintensitywithintheT7vertebralbody.Theextraosseousdumbbell-shapedleftextraduralandparavertebralcomponentispredominantlyofintermediatesignalintensitywithseveralfociofhigh-signalintensity.Theleftintervertebralforamenisnotenlarged.Fig.2.T2WIdemonstratingahigh-signalintensityextraduralmasswithmarkedcompressionanddisplacementofthespinalcord.轴位及矢状T1WI显示胸椎7局灶混杂信号；骨外之左侧硬膜外及椎旁哑铃形中等信号肿块，其中伴少数高信号灶；左侧椎间孔无增大。T2WI硬膜外肿块为高信号伴脊髓明显受压及移位。Fig.3.Axial(a)andsagittal(b)sequencesdemonstrateenhancementofboththeintraosseousandextraosseouscomponentofthevertebralhaemangioma.轴位及矢状位MR增强扫描显示椎骨内、椎骨外的血管瘤组织强化。打药前Atsurgery,anextremelyvascular,plum-colouredextraduraltumourwasincompletelyexcised.TherewasvigorousbleedingfromtheT7vertebrathatwasinvolvedandthepatientrequiredbloodtransfusionintraoperatively.Histopathologicaldiagnosisoftheextraduraltumourandvertebralfragmentwasconsistentwithahaemangioma.Thespecimenconsistedoffibro-fattyconnectivetissuewithsmallfragmentsofperiosteum,cartilageandbone.Numerousthin-walledvesselsfilledwithbloodinfiltratedthefattytissue.Sectionsfromthevertebraeshoweddilatedbloodvesselsbetweenbonytrabeculaeandfat.Therewasnoevidenceofmalignancy.Extraduralhaemangiomasarerarelesions.Themajorityoftheserepresentextensionfromavertebralhaemangiomaintothespinalcanalwithpurelyextraduralhaemangiomasonlyrepresenting12%ofspinalhaemangiomas.Bothprimaryextraduralhaemangiomasandextraduralextensionofavertebralhaemangiomacanbecomplicatedbycordcompression.Mostcasesareconfinedtothethoracicspine.Vertebralhaemangiomacausingcordcompression:MRIfindingsAustralasianRadiology(2003)47,190193硬膜外血管瘤罕见。多数为椎体血管瘤椎管内侵犯，单纯性硬膜外血管瘤仅占脊柱血管瘤的12%。硬膜外原发性血管瘤或椎体血管瘤硬膜外延伸两者均可并发脊髓压迫。大多见于胸椎。术中发现，肿瘤血管丰富、紫红色的硬膜外肿瘤未能完整切除。术中受侵的胸椎7发生静脉性出血，以至于术中输血。组织学发现硬膜外肿瘤及其椎体碎片与血管瘤一致。切除标本由纤维脂肪结缔组织及骨膜、软骨、骨之碎片组成。镜下：多数薄壁且充血的血管伴脂肪组织侵润；椎骨组织病理切片显示为扩张的血管位于骨小梁与脂肪间，无恶性病变。本例为原发于椎体的血管瘤延伸或侵及到椎管硬膜外及椎旁伴脊髓压迫。JMedCaseRep.2014;8:207.Anaggressivevertebralhemangiomainpregnancy:acasereport19-year-oldNorthAfricanwomaninher38thweekofpregnancypresentedwithparaplegiathatprogressedwithin2daysafterarapidlyprogressiveweaknessofherlowerlimbs.Magneticresonanceimagingstudiesshowedcompressionofherspinalcordinfrontofthefourththoracicvertebraforsuspectedtuberculousspondylitis.ACaesareansectionwasdonefollowedbycorpectomywithabonegraftbecauseweintraoperativelydiscoveredavertebralhemangioma.Pathologyshowedanaggressivehemangioma.图T2WI（A）and.（B）T1WIofthethoracicspinedemonstratingthelesionintheT4vertebra(fourththoracicvertebra).病例二女，19岁，北非人，孕38周。下肢进行性无力2天，随后截瘫。MRI见胸椎4平面脊髓前压迫，疑为结核性脊椎炎。行剖腹产手术，随后的脊柱手术中发现椎体血管瘤并行椎体次全切除及植骨。图A：胸椎T2WI、T1WI显示胸椎4病变，因孕期而未做增强检查Physiologicchangesduringpregnancymayinducerapidonsetsymptomsfromthesenormallyasymptomaticlesions.Bytheseventhmonthofgestation,thegraviduterusbeginstocompressthevenacavacausingobstructionorfunctionalclosure5.Venousobstructionandincreasedintra-abdominalpressurecauseredistributionandincreasedbloodflowvolumethroughthevertebralvenousplexus,resultingintheexpansionandgrowthofpreviouslyexistingvertebralhemangiomas.Thisisthemostimportantcontributingfactorintheclinicalmanifestationofapregnancy-inducedsymptom6.Thehormonalchangestakingplaceduringpregnancyhavealsobeenimplicatedforagrowth-promotingeffectonanalreadyexistinghemangiomaofthespine,mainlythroughstructuralchangeswithinthevesselwall7.Maternalprogesteronemayincreasethevenousdistensibility.Theendothelialgrowth-promotingeffectofestrogenmaycontributetoanincreaseinsizeofapreexistinghemangioma.8.无症状的椎体血管瘤可能随妊娠期间的生理变化而发生症状。多在妊娠第七个月，妊娠子宫开始压迫下腔静脉而引起梗阻或功能性闭合。静脉性梗阻和腹压增高引发血流再分配，并导致经由椎静脉丛的血流容量的增加，从而使得以前存在的椎体血管瘤膨胀或生长。此为妊娠期原先椎体血管瘤出现临床症状之最重要因素。另妊娠期发生激素变化也可能对上述病理变化有促进作用，主要是血管壁结构变化，黄体酮增加有助于增加静脉的膨胀性，雌激素的血管内皮细胞的促生长作用也会促进原先的血管瘤的增大。孕妇需要警惕脊柱血管瘤，特别是胸椎血管瘤本例为原发于椎体的血管瘤，妊娠后期引起脊髓压迫扩展三：这例椎体溶骨性改变 术前误诊Osseoushemangiomaoftheseventhcervicalvertebrawithosteoidformationmimickingmetastasis:acasereportJournalofMedicalCaseReports20093:92Wepresentthecaseofa44-year-old,otherwisehealthy,CaucasianGermanwomanwhohadbeenexperiencingparesthesiainbothforearmsandhandsfor3months.Occasionally,shehadpainandparesthesiainherfacewhenmovingherhead.Physicalexaminationshowednormalmusclestrengthinbothupperlimbsandadiscretesensoryloss.Movementofthecervicalspinewasalmostfreebutpainfulattheendofthemotionrange.X-rayshowedosteolysisofC7.MRIindicatedincreasedsignalintensityonT2WI.TheosteolysiswasdiagnosedasametastaticosteolysisofC7.TheCTscanshowedthatthestabilityofthevertebrawascompromised.Hemangioma-typicalradiologicalfindingscouldnotbeobservedeitheronMRIorCTscans.Angiographydidnotshowanarteriovenousmalformationaroundthelesionandnoaccumulationofcontrastmediumwasfoundinthevertebra.Thelaboratoryinvestigations,includingbloodcount,electrolytes,renalandlivervaluesandinfectionparameters,werenormal.女，44岁，高加索人。双侧前臂、手感觉异常3个月。当转动头部时偶尔出现面部疼痛及感觉异常。体检发现双侧上肢肌张力正常，有不连续的感觉缺失，颈椎活动近乎自如，但活动期间及结束后不适。颈椎X线检查显示颈椎7溶骨性骨破坏；MRI显示颈椎7在T2WI呈高信号。颈椎7这种溶骨性改变被诊断为转移瘤.CT扫描显示该受累椎体失稳。CT及MR均没有发现血管瘤典型征象。血管造影未发现病变周围存在动静脉畸形，病椎也没有发现对比剂蓄积。实验室检查包括血细胞计数、电解质、肝肾功能以及感染参数均无异常。为避免病理性骨折，术前不再施行活检。Duringcorporectomy,anintra-operativeconsultationwasperformed.Thefrozensectionsshowedacellularlesiondisplayingspindle-shapedcellswithpredominantlysmall,partlyelongatednucleiwithmoderatechromatindensityinterspersedwithimmature,partlycalcifiedosteoid.Thus,theintra-operativediagnosiswasamesenchymaltumor.术中冰冻切片，诊断间叶细胞肿瘤。术后病理：血管样结构紧邻浓密的间叶细胞以及类骨质且位于其间。由此考虑间叶细胞来源肿瘤伴动脉瘤样骨囊肿。但最终免疫组化诊断：椎体血管瘤伴反应性类骨质形成Histologicalaspectoftheparaffin-embeddedmaterialreceivedforintraoperativeexamination.Partlycalcifyingosteoidisthemoststrikingfeature,interspersedarepartlysinusoidal,partlyslit-like,bloodvesselsaswellasmoredenselyarrangedareaswithspindle-shapedtoelongatedmesenchymalcells.手术后病理图：部分钙化性类骨质（B图红染区，A图淡粉区为未钙化的类骨质）是为最显著特征，并以部分为窦样、或部分为裂隙样分布；除血管（不规则性）外，其中还有更多由拉长的梭形间叶细胞密集排列的区域。手术后本例术前影像学检查误诊为转移瘤，术中冰冻、术后病理也未能做出椎体血管瘤的诊断，最终靠免疫组化诊断为椎体血管瘤。Thisisararecaseofaseventhcervicalvertebraaffectedbyanunusualhistologicaltypeofhemangiomaofthebonewithreactiveosteoidformationwithneithertypicalradiologicalnorhistopathologicalfindings.这是一例罕见的病例：颈椎7椎骨血管瘤伴反应性类骨质形成，此为不常见的组织学类型。既没有典型的放射学表现，也没有典型的组织病理学所见。E 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