多发性硬化的MRI诊断

Multiple Sclerosis MR Diagnosis 多发性硬化的MRI诊断,Overview,Multiple sclerosis (MS) is a central nervous system demyelinating diseases .多发性硬化（multiple sclerosis,MS）是一种中枢神经系统脱髓鞘疾病 Young, middle-aged common .青、中年多见Widely disseminated lesions of clinical features, course of disease recurrence often alleviate symptoms of nervous system damage .临床特点是病灶播散广泛，病程中常有缓解复发的神经系统损害症状Disease lesions in the brain or spinal cord .该病的病变位于脑部或脊髓,Generated in the central nervous system because the sizes of the symptoms caused massive loss of myelin sheath因为在中枢神经系统中产生大小不一的块状髓鞘脱失而产生症状The so-called hardenedrefers to the area because of these demyelination produced during tissue repair scar tissue and hardened所谓“硬化”指的是这些髓鞘脱失的区域因为组织修复的过程中产生的疤痕组织而变硬These lumps may be several, as time progressed, new lumps may also appear, so called multiple . 这些硬块可能会有好几个，随着时间的进展，新的硬块也可能出现，所以称 “多发性”。,Cause of disease,Virus infection: such as herpes virus (chickenpox, simple, simple chicken pox), measles virus,病毒感染：如疱疹病毒（水痘、单纯、水痘单纯）、麻疹病毒等 Autoimmune response: that is mediated by T cells in autoimmune diseases.自身免疫反应：认为是由T细胞所介导的自身免疫性疾病。 Genetic factors: There is a certain degree of familial aggregation tendency遗传因素：有一定程度的家族聚集倾向 Environmental factors: climate is cold-related环境因素：与气候是否寒冷有关,Clinical classification,relapsing-remitting : The most common 复发缓解型：最常见prinmary-progressive ： Advances in remission after the onset of increased 复发渐进型 ：发病后病情缓解进展加重seconday-progressive ： Progressive worsening of symptoms in patients 继发进展性：患者出现渐进性症状恶化progressive-relapsing ： Rare 进展复发型：少见,Clinical manifestations,Common symptoms of a certain parts of the muscle stiffness, fatigue, loss of control, limbs abnormal fatigue, difficulty walking常见的症状有一定部位的肌肉僵硬，乏力、丧失控制能力，四肢异常疲劳、行走困难Each will disappear after the onset of symptoms. In this way one after another, or continue to deteriorate, and finally make swallowing difficult. Disabled and bedridden每个症状出现后又会消失。就这样一个接一个的相继发生，或继续恶化，最后可使患者吞咽困难，致残及卧床不起,Treatment,No specific drug treatment of this disease没有治疗这种疾病的特效药物Corticosteroids or immunosuppressive drugs can relieve symptoms皮质激素或免疫抑制剂可缓解症状 Neurotrophic drugs神经营养药物Symptomatic treatment对症治疗,Multiple sclerosis( MS ) 多发性硬化,The role of MRI MRI所扮演的角色,Multiple white matter lesions（WMLs）. MS or vascular disease?多发脑白质病变是MS还是血管性病变？,Most incidentally found WMLs will have a vascular origin. 大多数脑白质病变都起源于血管病变。The list of possible diagnoses of WMLs is long. 引起白质病变的疾病很多。,According to the McDonald criteria for MS, the diagnosis requires objective evidence of lesions disseminated in time and space.根据MS的McDonald标准，诊断本病需要在时间和空间上发现病变播散的客观证据。MS has a typical distribution of WMLs(see Table).多发性硬化有典型的分布区(如表).,Multiple sclerosis多发性硬化,Typical for MS is involvement of corpus callosum胼胝体, U fibers U型纤维, temporal lobes颞叶, brainstem脑干, cerebellum小脑and spinal cord脊髓.,In small vessel disease there sometimes is involvement of the brainstem, but it is usually symmetrical and central, while in MS it is peripheral.小血管疾病有时也涉及脑干，但通常是对称性和中央性病变，而在MS病变在周边。,The lesions in the deep white matter (yellow arrow) are non specific and can be seen in many diseases.在深白质（黄色箭头）的非特异性病变，可在多种疾病出现。,Typical for MS in this case is: Involvement of the temporal lobe颞叶(red arrow) Juxtacortical lesions (green arrow) - touching the cortex皮层 Involvement of the corpus callosum胼胝体(blue arrow) Periventricular室周 lesions - touching the ventricles,involvement of U-fibers U型纤维in MS (green arrow). U-fibers are not involved in patient with hypertension高血压患者( yellow arrow).,The patient on the left not only has multiple periventricular室周 lesions of which some have the typical Dawson finger aspect (blue arrow), but there also is a juxtacortical皮层 lesion.The involvement of the U-fibers U型纤维is best seen on the magnification放大 view.,Temporal lobe颞叶involvement is also specific for MS.颞叶的累及也是MS的特异性病变In hypertensive encephalopathy, the WMLs are located in the frontal and parietal lobes, uncommonly in the occipital lobes and not in the temporal lobes.在高血压脑病，脑白质病变位于额叶和顶叶，枕叶罕见的，而不是在颞叶,Typical findings for MS as seen in this case are:Multiple lesions adjacent to the ventricles (red arrow). Ovoid卵形 lesions perpendicular垂直 to the ventricles (yellow arrow). Multiple lesions in brainstem脑干 and cerebellum小脑.,These ovoid lesions are also called Dawson fingers.这些卵形病变也被称为Dawson 指征。They represent areas of demyelination along the small cerebral veins that run perpendicular to the ventricles.这些卵形病变代表脱髓鞘沿脑的小静脉分布并且垂直于脑室。,There are multipel lesions in the spinal cord脊髓. By the way did you notice the lesion in the brainstem脑干? A spinal cord lesion脊髓together with a lesion in the cerebellum小脑 or brainstem脑干is very suggestive of MS.,Spinal cord lesions are uncommon in most other CNS diseases, with exception of ADEM, Sarcoid, Lyme and SLE. 除了脑脊髓炎、结节病、莱姆病和系统性红斑狼疮，脊髓病变在中枢神经系统疾病中并不常见。,LEFT: Typical Dawson finger with enhancement on T1WIRIGHT: Multiple lesions and edema水肿 around enhancing lesion on T2WI.,Enhancement is another typical finding in MS .This enhancement will be present for about one month after the occurence of a lesion. The simultaneous demonstration of enhancing and non-enhancing lesions in MS is the radiological counterpart of the clinical dissemination in time and space . MS病变强化与否同时表明其临床时间和空间分布与影像对应。The edema水肿 will regress退化 and finaly only the center will remain as a hyperintense lesion on T2WI.,On the left a patient who was re-examined 3 months after the first clinical attack.3个月后图,Typical findings for MS as seen in this case are: Multiple enhancing lesions Many of these lesions “touch the cortex皮层” and must be located in the U-fibers. These enhancing lesions all are new lesions, since Gadolinium enhancement is only visible for about 1 month. So this finding is proof证明 of dissemination分布 in time.,LEFT: Single lesion on T2WI.RIGHT: Two new lesions at 3 month follow up.,Differential Diagnosis,Borderzone infarction交界区梗死Key finding: typically these lesions are located in only one hemisphere半球, either in deep watershed area or peripheral边缘 watershed area. Case on the left is infarction in deep watershed area.,ADEM脑脊髓炎 Key findings: Multifocal多发性 lesions in WM白质 and basal ganglia 基底节区10-14 days following infection感染 or vaccination接种疫苗.As in MS, ADEM can involve the spinal cord, U-fibers and corpus callosum胼胝体and sometimes show enhancement.Different from MS is that the lesions are often large and in a younger age group. The disease is monophasic单向的.,Lyme莱姆病2-3mm lesions simulating相似 MS in a patient with skin rash皮疹 and influenza-like illness流感样病人. Other findings are high signal in spinal cord and enhancement of CN7 (root entry zone).,Typical skin rash皮疹 caused by spirochaet transmitted by a tick蜱.Clinically Lyme presents with acute CNS symptoms and sometimes transverse myelitis横贯性脊髓炎 .,MS-like lesions in Lymes disease.莱姆病表现相似MS,Sarcoid结节病Sarcoid is the great mimicker相仿. The distribution of lesions is quite similar to MS.,The distribution of lesions is quite similar to MS.Besides lesions in the deep WM, there are some juxtaiventricular lesions and even Dawson finger-like lesions.The final diagnosis was sarcoid. Sarcoid has surpassed neurosyphilis神经梅毒 as the great mimicker.,There is punctate点状 enhancement in the basal nuclei基底节. This is seen in sarcoid and can also be seen in SLE or other vasculitis血管炎.Typical for sarcoid in this case is the leptomeningeal软脑膜 enhancement (yellow arrow). This is the result of granulomatous inflammation肉芽肿性炎 of the leptomeninges.,Another typical finding in this same case is the linear enhancement (yellow arrow). This is due to inflammation along the Virchow Robin spaces. This is also a form of leptomeningeal enhancement.,Virchow Robin spacesKey finding: Bright on T2WI and dark on FLAIR.,T2WI and FLAIR,On the T2 image there are multiple high intensity lesions in the basal ganglia基底节.On the FLAIR image these lesions are dark, so they follow the intensity of CSF on all sequences (they were hypointense in the T1WI).This signal intensity in combination with the location is typical for VR spaces.,HIVKey finding: Atrophy萎缩and symmetric对称性periventricular室周or more diffuse WMLs in AIDS patient.,vessel dieaseWMLs白质病变 in the deep white matter. Not located in corpus callosum胼胝体, juxtaventricular近脑室 or juxtacortical近皮层. Unlike in MS, they do not touch the ventricles or the cortex.,SE T2WI: multiple WMLs in a hypertensive高血压 patient.,The spinal cord in this patient was normal.,In a patient with vasculitis血管炎 or ischemia缺血 the spinal cord is usually normal, while in a MS patient in more than 90% of the cases it will be abnormal .在脑血管炎或缺血患者脊髓通常是正常的，而在超过90的MS病人脊髓会出现异常,Multiple white matter lesions（WMLs）. MS or vascular disease?多发脑白质病变是MS还是血管性病变？it is no