醫(yī)看一例椎體的局灶病變影像表現(xiàn)分析暨影像診斷擴展

1、一例椎體的局灶病變影像表現(xiàn)分析暨影像診斷擴展,中國石油中心醫(yī)院 影像科 楊景震,注：瀏覽時請用幻燈放映模式,2016-9制作,2016病例交流（18） （源自同學(xué)圈子的病例）,女，62歲。腰痛，以急性腰扭傷住院。,（江蘇大豐趙文主任提供的病例）,腰椎正側(cè)位：問題在哪？,腰椎2椎體右側(cè)份骨硬化,CT軸位圖細(xì)看,再看CT矢狀重組圖,CT矢狀重組圖,看一看該病例的MRI圖,T1WI未加壓脂 矢狀位,T2WI未加壓脂 矢狀位,T2WI

2、加壓脂 矢狀位,T2WI未加壓脂 軸位,增強T1WI未加壓脂 冠狀位,增強T1WI未加壓脂 矢狀位,增強T1WI未加壓脂 軸位,增強T1WI壓脂,增強T1WI壓脂 冠狀位,增強T1WI壓脂 軸位,天津醫(yī)院王林森主任診斷意見：椎體硬化性血管瘤,診斷意見？,鑒于該病例影像學(xué)表現(xiàn)較特殊，且影像資料齊全，故在此將其總結(jié)并結(jié)合相關(guān)文獻(xiàn)予以擴展和交流該診斷之所以冠以“硬化”是基于影像學(xué)的病變區(qū)骨量增多。參考文獻(xiàn)：Epithelioid

3、hemangioma of bone Skeletal Radiol (2001) 30:226–229…… Other relatively common features include surrounding sclerosis, and cortical expansion and cortical destruction. Significant in our case is the diffuse reacti

4、ve sclerosis affecting virtually the entire vertebral body,……,小結(jié)：本例椎體硬化性血管瘤的影像學(xué)表現(xiàn),1、病變區(qū)骨量增多，表現(xiàn)為平片、CT上密度增高，并在CT圖上顯示硬化緣。2、瘤體內(nèi)含少許脂肪組織（即MRI的T1WI明顯高信號；CT上的點狀更低密度）3、MRI可見病變周圍脂肪化（TW2及T1WI高信號，壓脂低信號）即瘤周脂肪侵潤4、瘤體一部分結(jié)構(gòu)在T2WI壓脂上呈高信

5、號（即MR展示其瘤體之富水特征）5、增強掃描呈漸進(jìn)性強化（含血竇的瘤體）,該例椎體血管瘤綜合影像（沒有“柵欄征”）：瘤體富水并含少量脂肪、骨量增多、其血竇由對比劑充填、瘤周脂肪侵潤,（若瘤內(nèi)含脂肪較多，也可歸為脂肪侵潤型血管瘤）,再看這例椎體血管瘤：也沒有“柵欄征”,（脂肪侵潤型）,廣州醫(yī)科大學(xué)候仲軍教授病例,T1WI,T1WI壓脂,T2WI壓脂,增強T1WI壓脂（矢、冠、軸位）,T2WI壓脂,T1WI,T2WI,T1WI,T2WI

6、壓脂,常見典型的椎體血管瘤的影像學(xué)表現(xiàn),（柵欄征）,脂肪侵潤型血管瘤,再看這例硬化性血管瘤,Epithelioid hemangioma of bone Skeletal Radiol (2001) 30:226–229,Fig. 1 Lateral radiograph of the thoracic spine demonstrates diffuse sclerosis of the T7 vertebral body.Fi

7、g. 2 CT scan of the thoracic spine shows an expanding lytic lesion with partial ossification involving the right anterolateral aspect of the T7 vertebral body. The lesion includes trabecular bone and a partially ossified

8、 margin. The remainder of the verte-bral body exhibits diffuse reactive sclerosis most prominent at the interface with the lesion.Fig. 3 Sagittal T2-weighted MR image demonstrates heterogeneous signal intensity in the

9、T7 vertebral body. Also seen issubtle increased signal in the anterior aspect of the T8 vertebral body (arrow) consistent with bone marrow edema.,（病理為椎體上皮樣血管瘤）,女，32歲，胸背鈍痛。其他無特殊。,胸椎側(cè)位顯示胸椎7椎體彌漫性硬化,CT檢查：膨脹性溶骨性病變伴部分性骨化，侵及胸椎

10、7的右前部。病變累及松質(zhì)骨并伴部分硬化緣，余部椎體顯示反應(yīng)性骨硬化，以鄰近病變部顯著。,矢狀T2WI顯示胸椎7不均勻信號，胸椎8（箭）前部信號輕度增高，符合骨髓水腫改變。,Fig. 4 Simple and mildly complex vascular structures are seen within fibrous tissue (×90)Fig. 5 At higher magnification, there i

11、s mild irregularity in the shape of the blood vessels. Most of the endothelial cells are flattened (×250)Fig. 6 This field demonstrates both vascular channels and more solid areas with less obvious vascularity. In

12、both areas, the endothelial cells are somewhat prominent with plump nuclei. A few tufted papillary projections are seen at lower left (×300),圖4 纖維組織內(nèi)的單一和少許復(fù)合血管結(jié)構(gòu)（低倍）。圖5 高倍放大圖：輕度不規(guī)則血管，大多數(shù)內(nèi)皮細(xì)胞呈扁平狀。圖6 血管竇和較多含有不太明顯的血管

13、之實變區(qū)。兩個區(qū)域中，內(nèi)皮細(xì)胞顯著并核豐滿，在左下可見少數(shù)簇狀乳頭突起。,本例以骨硬化為特點的上皮樣椎體血管瘤的 影像學(xué)表現(xiàn)提示,Other relatively common features include surrounding sclerosis, and cortical expansion and cortical destruction. Significant in our case is th

14、e diffuse reactive sclerosis affecting virtually the entire vertebral body, a finding which to our knowledge has not previously been reported. The diffuse sclerosis resulted in the radiographic appearance of a dense or “

15、ivory” vertebral body and an initial diagnosis of lymphoma was considered.,椎體上皮樣血管瘤另外比較常見特征包括：病灶周圍骨硬化，骨皮質(zhì)膨脹、骨皮質(zhì)破壞。本例表現(xiàn)為彌漫性反應(yīng)性骨硬化幾乎累及整個椎體，作者沒有發(fā)現(xiàn)以往有過此類的報道。這種彌漫性硬化致使放射學(xué)高密度表現(xiàn)或呈“象牙質(zhì)樣”的椎體，以至于最初診斷曾考慮骨淋巴瘤。（注：椎骨硬化改變需要依賴X線平片或CT

16、檢查）,We present a case of epithelioid hemangioma of the spine with an unusual radiological appearance which to our knowledge has not previously been reported: diffuse sclerosis of the involved vertebral body.,Hemangiomas

17、of bone are benign tumors arising from blood vessels.Various histopathological subtypes including cavernous, capillary, arteriovenous, venous and epithelioid have been described [1, 2].,骨血管瘤屬于起自于血管的良性腫瘤。病理上有多種亞型包括：海綿狀、毛細(xì)

18、血管狀、動靜脈型、靜脈型以及上皮樣。,該文獻(xiàn)報告的脊椎上皮樣血管瘤病例，其影像學(xué)不常見的表現(xiàn)且以前的文獻(xiàn)也不曾報告：受侵的椎體彌漫性硬化。,擴展一：再分析一下椎體血管瘤與病理的關(guān)系 有助于認(rèn)識血管瘤的影像表現(xiàn),Benign vertebral hemangioma:MR-histological correlation Skeletal Radiol (2001) 30:442–446,Fig. 1 a 73-year-old

19、 T1WI shows an area of intermediate signal intensity (arrow) with linear and vertical areas of very low signal intensity (small arrow) in the posterior part of the middle vertebral body. B T2WI，intensity of the lesion (

20、arrow) is moderately increased in comparison with adjacent normal marrow. C Photomicrograph of the lesion shows thin-walled, dilated vessels (star), adipocytes (arrow) and interstitial edema (small arrow). The relative

21、proportion of surface area occupied by thin-walled, dilated vessels and interstitial edema isequivalent to that occupied by adipocytes.,Benign vertebral hemangioma:MR-histological correlation Skeletal Radiol (2001) 30:

22、442–446,,圖A，T1WI長箭示病變區(qū)中等信號；其中小箭示線樣縱行極低信號；圖B，T2WI箭指病變區(qū)與正常椎體相比呈略高的中等信號；圖C，病變鏡下圖示薄壁、擴張的血管（星）、脂肪（箭）及間質(zhì)水腫（小箭）。由薄壁擴張的血管、間質(zhì)水腫相應(yīng)的表面區(qū)域比例與脂肪細(xì)胞分布的區(qū)域相當(dāng)。,Fig. 2 T1WI of a vertebral body of the spine specimen from a 69-year-old s

23、ubject shows a heterogeneous area that consists of high (arrow) and intermediate signal intensity (small arrow). B Photograph of the corresponding macroscopic section shows a yellow lesion (arrow) that contains small r

24、ed dots (small arrow). C Photomicrograph of marrow area with high signal intensity on the T1WI (large arrow in A). The relative proportion of surface area occupied by adipocytes (arrow) is larger than that occupied by

25、vessels and interstitial edema in the area of high signal intensity on the T1WI. D Photomicrograph of marrow area with intermediate signal intensity on the T1WI (small arrow in A). The relative proportion of surface ar

26、ea occupied by adipocytes (arrow) is similar to that occupied by vessels and interstitial edema in the area of intermediate signal intensity on the T1WI.,At macroscopic examination of section photographs, five lesions we

27、re homogeneous, with multiple red dots homogeneously interspersed in a background of yellow or red color. Four lesions were heterogeneous with variable amounts of red dots clustered in different lesion areas.Histologica

28、l analysis of the lesions demonstrated thin-walled, large blood-filled vessels set in a stroma of adipocytes with interstitial edema in all nine lesions that indicated cavernous hemangioma. No vessel thrombosis,hemosider

29、in deposition or hematopoietic cells were found.,所有9例海綿狀血管瘤組織學(xué)分析： red dots 病變，是在脂肪基質(zhì)上的薄壁、擴張充盈的血管伴間質(zhì)水腫。無血栓及含鐵血黃素沉積或造血細(xì)胞。,圖A：T1WI示均勻高信號區(qū)（長箭）、中等信號區(qū)（小箭），,圖B：相應(yīng)的標(biāo)本切片圖片：黃色病變（長箭），其內(nèi)含多發(fā)小紅點rad dots（小箭）,圖C：圖A長箭指的高信號骨髓區(qū)鏡下圖片：脂肪細(xì)胞分布的

30、相對表面的區(qū)域明顯多于血管和間質(zhì)水腫區(qū)。,圖D：圖A小箭指的中等信號骨髓區(qū)鏡下圖片：脂肪細(xì)胞（箭）分布相對表面區(qū)域類似于由血管及間質(zhì)水腫區(qū)。即二者分布比例相當(dāng)。,如果這個病人做增強掃描，強化的部分是？,影像學(xué)檢查發(fā)現(xiàn)，椎體血管瘤很常見，但不是都具備其典型的“柵欄征”，且多數(shù)是沒有癥狀的。擴展二：試問什么情況下血管瘤出現(xiàn)病理性的相關(guān)癥狀呢？,Hemangioma is one of the most common benign tum

31、ors of the spine with a reported prevalence of 10% to 12% in the general population [1]. The vast majority of patients with vertebral hemangioma stay asymptomatic. Occasionally, in about 1% of cases, vertebral hemangioma

32、s become symptomatic causing neural arch expansion, vertebral body enlargement or direct compression of the thecal sac or nerve roots [2, 3].,注：由無癥狀血管瘤演變?yōu)橛邪Y狀性者，外傷性除外，這里指自發(fā)性,73-year-old man presented with the inability to

33、 walk, numbness in the legs and trunk, and urinary retention. Three years previously, he had noticed numbness in his knees that progressed slowly to involve the lower trunk and limbs. He also developed weakness in his lo

34、wer limbs.,病例一,男，73歲。主訴行走無力、下肢及軀干麻木，尿潴留。3年前即有膝部麻木，并逐漸加重且累及下部軀干和肢體。病人的雙側(cè)下肢無力也呈進(jìn)展性。,Vertebral haemangioma causing cord compression: MRI findings,Australasian Radiology (2003) 47, 190–193,Fig. 1. Axial (a) and sagittal (b)

35、T1WI demonstrate mottled high-signal intensity within the T7 vertebral body. The extraosseous dumbbell-shaped left extradural and paravertebral component is predominantly of intermediate signal intensity with several foc

36、i of high-signal intensity. The left intervertebral foramen is not enlarged.,Fig. 2. T2WI demonstrating a high-signal intensity extradural mass with marked compression and displacement of the spinal cord.,軸位及矢狀T1WI顯示胸椎7

37、局灶混雜信號；骨外之左側(cè)硬膜外及椎旁啞鈴形中等信號腫塊，其中伴少數(shù)高信號灶；左側(cè)椎間孔無增大。,T2WI硬膜外腫塊為高信號伴脊髓明顯受壓及移位。,Fig. 3.Axial (a) and sagittal (b) sequences demonstrate enhancement of both the intraosseous and extraosseous component of the vertebral haemangio

38、ma.,軸位及矢狀位MR增強掃描顯示椎骨內(nèi)、椎骨外的血管瘤組織強化。,打藥前,At surgery, an extremely vascular, plum-coloured extradural tumour was incompletely excised. There was vigorous bleeding from the T7 vertebra that was involved and the patient requi

39、red blood transfusion intraoperatively. Histopathological diagnosis of the extradural tumour and vertebral fragment was consistent with a haemangioma. The specimen consisted of fibro-fatty connective tissue with small fr

40、agments of periosteum, cartilage and bone. Numerous thin-walled vessels filled with blood infiltrated the fatty tissue. Sections from the vertebrae showed dilated blood vessels between bony trabeculae and fat. There was

41、no evidence of malignancy.,Extradural haemangiomas are rare lesions. The majority of these represent extension from a vertebral haemangioma into the spinal canal with purely extradural haemangiomas only representing 1–2%

42、 of spinal haemangiomas. Both primary extradural haemangiomas and extradural extension of a vertebral haemangioma can be complicated by cord compression. Most cases are confined to the thoracic spine.,Vertebral haemangio

43、ma causing cord compression: MRI findings,Australasian Radiology (2003) 47, 190–193,硬膜外血管瘤罕見。多數(shù)為椎體血管瘤椎管內(nèi)侵犯，單純性硬膜外血管瘤僅占脊柱血管瘤的1–2%。硬膜外原發(fā)性血管瘤或椎體血管瘤硬膜外延伸兩者均可并發(fā)脊髓壓迫。大多見于胸椎。,術(shù)中發(fā)現(xiàn)，腫瘤血管豐富、紫紅色的硬膜外腫瘤未能完整切除。術(shù)中受侵的胸椎7發(fā)生靜脈性出血，以至于術(shù)中輸血。

44、組織學(xué)發(fā)現(xiàn)硬膜外腫瘤及其椎體碎片與血管瘤一致。切除標(biāo)本由纖維脂肪結(jié)締組織及骨膜、軟骨、骨之碎片組成。鏡下：多數(shù)薄壁且充血的血管伴脂肪組織侵潤；椎骨組織病理切片顯示為擴張的血管位于骨小梁與脂肪間，無惡性病變。,本例為原發(fā)于椎體的血管瘤延伸或侵及到椎管硬膜外及椎旁伴脊髓壓迫。,J Med Case Rep. 2014; 8: 207.,An aggressive vertebral hemangioma in pregnancy: a ca

45、se report,19-year-old North African woman in her 38th week of pregnancy presented with paraplegia that progressed within 2 days after a rapidly progressive weakness of her lower limbs. Magnetic resonance imaging studies

46、showed compression of her spinal cord in front of the fourth thoracic vertebra for suspected tuberculous spondylitis. A Caesarean section was done followed by corpectomy with a bone graft because we intraoperatively disc

47、overed a vertebral hemangioma. Pathology showed an aggressive hemangioma.,圖T2WI （A） and.  （B）  T1WI of the thoracic spine demonstrating the lesion in the T4 vertebra (fourth thoracic vertebra).,病例二,女，

48、19歲，北非人，孕38周。下肢進(jìn)行性無力2天，隨后截癱。MRI見胸椎4平面脊髓前壓迫，疑為結(jié)核性脊椎炎。行剖腹產(chǎn)手術(shù)，隨后的脊柱手術(shù)中發(fā)現(xiàn)椎體血管瘤并行椎體次全切除及植骨。,圖A：胸椎T2WI、T1WI顯示胸椎4病變，因孕期而未做增強檢查,Physiologic changes during pregnancy may induce rapid onset symptoms from these normally asymptomati

49、c lesions. By the seventh month of gestation, the gravid uterus begins to compress the vena cava causing obstruction or functional closure [5]. Venous obstruction and increased intra-abdominal pressure cause redistributi

50、on and increased blood flow volume through the vertebral venous plexus, resulting in the expansion and growth of previously existing vertebral hemangiomas. This is the most important contributing factor in the clinical m

51、anifestation of a pregnancy-induced symptom [6]. The hormonal changes taking place during pregnancy have also been implicated for a growth-promoting effect on an already existing hemangioma of the spine, mainly through s

52、tructural changes within the vessel wall [7]. Maternal progesterone may increase the venous distensibility. The endothelial growth-promoting effect of estrogen may contribute to an increase in size of a preexisting heman

53、gioma. [8].,無癥狀的椎體血管瘤可能隨妊娠期間的生理變化而發(fā)生癥狀。多在妊娠第七個月，妊娠子宮開始壓迫下腔靜脈而引起梗阻或功能性閉合。靜脈性梗阻和腹壓增高引發(fā)血流再分配，并導(dǎo)致經(jīng)由椎靜脈叢的血流容量的增加，從而使得以前存在的椎體血管瘤膨脹或生長。此為妊娠期原先椎體血管瘤出現(xiàn)臨床癥狀之最重要因素。另妊娠期發(fā)生激素變化也可能對上述病理變化有促進(jìn)作用，主要是血管壁結(jié)構(gòu)變化，黃體酮增加有助于增加靜脈的膨脹性，雌激素的血管內(nèi)皮細(xì)胞的促生

54、長作用也會促進(jìn)原先的血管瘤的增大。,孕婦需要警惕脊柱血管瘤，特別是胸椎血管瘤,本例為原發(fā)于椎體的血管瘤，妊娠后期引起脊髓壓迫,擴展三：這例椎體溶骨性改變 術(shù)前誤診,Osseous hemangioma of the seventh cervical vertebra with osteoid formation mimicking metastasis: a case report

55、 Journal of Medical Case Reports 2009 3:92,We present the case of a 44-year-old, otherwise healthy, Caucasian German woman who had been experiencing paresthesia in both forearms and hands

56、for 3 months. Occasionally, she had pain and paresthesia in her face when moving her head. Physical examination showed normal muscle strength in both upper limbs and a discrete sensory loss. Movement of the cervical spin

57、e was almost free but painful at the end of the motion range. X-ray showed osteolysis of C7. MRI indicated increased signal intensity on T2WI. The osteolysis was diagnosed as a metastatic osteolysis of C7 . The CT scan s

58、howed that the stability of the vertebra was compromised. "Hemangioma-typical" radiological findings could not be observed either on MRI or CT scans. Angiography did not show an arteriovenous malformation aroun

59、d the lesion and no accumulation of contrast medium was found in the vertebra. The laboratory investigations, including blood count, electrolytes, renal and liver values and infection parameters, were normal.,女，44歲，高加索人。

60、雙側(cè)前臂、手感覺異常3個月。當(dāng)轉(zhuǎn)動頭部時偶爾出現(xiàn)面部疼痛及感覺異常。體檢發(fā)現(xiàn)雙側(cè)上肢肌張力正常，有不連續(xù)的感覺缺失，頸椎活動近乎自如，但活動期間及結(jié)束后不適。頸椎X線檢查顯示頸椎7溶骨性骨破壞；MRI顯示頸椎7在T2WI呈高信號。頸椎7這種溶骨性改變被診斷為轉(zhuǎn)移瘤.CT掃描顯示該受累椎體失穩(wěn)。CT及MR均沒有發(fā)現(xiàn)血管瘤典型征象。血管造影未發(fā)現(xiàn)病變周圍存在動靜脈畸形，病椎也沒有發(fā)現(xiàn)對比劑蓄積。實驗室檢查包括血細(xì)胞計數(shù)、電解質(zhì)、肝腎功能以及

61、感染參數(shù)均無異常。為避免病理性骨折，術(shù)前不再施行活檢。,During corporectomy, an intra-operative consultation was performed. The frozen sections showed a cellular lesion displaying spindle-shaped cells with predominantly small, partly elongated nucl

62、ei with moderate chromatin density interspersed with immature, partly calcified osteoid. Thus, the intra-operative diagnosis was a mesenchymal tumor.,術(shù)中冰凍切片，診斷間葉細(xì)胞腫瘤。術(shù)后病理：血管樣結(jié)構(gòu)緊鄰濃密的間葉細(xì)胞以及類骨質(zhì)且位于其間。由此考慮間葉細(xì)胞來源腫瘤伴動脈瘤樣骨囊腫。但

63、最終免疫組化診斷：椎體血管瘤伴反應(yīng)性類骨質(zhì)形成,Histological aspect of the paraffin-embedded material received for intraoperative examination. Partly calcifying osteoid is the most striking feature, interspersed are partly sinusoidal, partly sl

64、it-like, blood vessels as well as more densely arranged areas with spindle-shaped to elongated mesenchymal cells.,手術(shù)后病理圖：部分鈣化性類骨質(zhì)（B圖紅染區(qū)，A圖淡粉區(qū)為未鈣化的類骨質(zhì)）是為最顯著特征，并以部分為竇樣、或部分為裂隙樣分布；除血管（不規(guī)則性）外，其中還有更多由拉長的梭形間葉細(xì)胞密集排列的區(qū)域。,手術(shù)后,本例術(shù)前

65、影像學(xué)檢查誤診為轉(zhuǎn)移瘤，術(shù)中冰凍、術(shù)后病理也未能做出椎體血管瘤的診斷，最終靠免疫組化診斷為椎體血管瘤。,This is a rare case of a seventh cervical vertebra affected by an unusual histological type of hemangioma of the bone with reactive osteoid formation with neither typic