椎体的局灶病变影像表现分析暨影像诊断扩展培训课件

1、 2016病例交流（18） （源自同学圈子的病例） 2016病例交流（18）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）女，62岁。腰痛，以急性腰扭伤住院。（江苏大丰赵文主任提供的腰椎正侧位：问题在哪？腰椎2椎体右侧份骨硬化腰椎正侧位：问题在哪？腰椎2椎体右侧份骨硬化CT轴位图细看CT轴位图细看再看CT矢状重组图再看CT矢状重组图CT矢状重组图CT矢状重组图看一看该病例的MRI图看一看该病例的MRI图T1WI未加压脂 矢状位T1WI未加压脂 矢状位T2WI未加压脂 矢状位T2WI未加压脂 矢状位T2WI加压脂 矢状位T2WI加压脂 矢状位T2WI未加压脂 轴位T2WI未加

2、压脂增强T1WI未加压脂 冠状位增强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 矢状位增强T1WI未加压脂 轴位增强T1WI未加压脂 轴位增强T1WI压脂增强T1WI压脂增强T1WI压脂 冠状位增强T1WI压脂 冠状位增强T1WI压脂 轴位增强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：Epithelioid hemangioma of bone Skeletal Radiol (2001

3、) 30:226229 Other relatively common features include surrounding sclerosis, and cortical expansion and cortical destruction. Significant in our case is the diffuse reactive sclerosis affecting virtually the entire vertebral body,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

4、，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）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

5、压脂T2WI压脂增强T1WI压脂（矢、冠、轴位）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T2WI压脂T1WIT2WIT1WIT2WI压脂常见典型的椎再看这例硬化性血管瘤再看这例硬化性血管瘤Epithelioid hemangioma of bone Skeletal Radiol (2001) 30:226229Fig. 1 Lateral radiograph of the thoracic spine demonstrates diffuse sclerosis o

6、f the T7 vertebral body.Fig. 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 margin. The remainder of the verte-bral body exhibits

7、 diffuse reactive sclerosis most prominent at the interface with the lesion.Fig. 3 Sagittal T2-weighted MR image demonstrates heterogeneous signal intensity in the T7 vertebral body. Also seen issubtle increased signal in the anterior aspect of the T8 vertebral body (arrow) consistent with bone marr

8、ow edema.（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。Epithelioid hemangioma of boneFig. 4 Simple and mildly complex vascular structures are seen within fibrous tissue (90)Fig. 5 At higher ma

9、gnification, there is 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 both areas, the endothelial cells are somewhat prominent with plump

10、 nuclei. A few tufted papillary projections are seen at lower left (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。Fig. 4 Simple and mildly compl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 Other relatively common features include surrounding sclerosis

11、, and cortical expansion and cortical destruction. Significant in our case is the 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 “

12、ivory” vertebral body and an initial diagnosis of lymphoma was considered. 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）本例以骨硬化为特点的上皮样椎体血管瘤的 Other relaWe present a case of epithelioid hemangioma of the

13、 spine with an unusual radiological appearance which to our knowledge has not previously been reported: diffuse sclerosis of the involved vertebral body.Hemangiomas of bone are benign tumors arising from blood vessels.Various histopathological subtypes including cavernous, capillary, arteriovenous,

14、venous and epithelioid have been described 1, 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。We present a case of epithelio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Benign vertebral hemangioma:MR-histological correlation Skeletal Radiol (2001) 30:442

15、446扩展一：再分析一下椎体血管瘤与病理的关系Benign verFig. 1 a 73-year-old 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 (arrow) is moderately increas

16、ed 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 proportion of surface area occupied by thin-walled, dilated vessels and interstitial edema isequivalent to th

17、at occupied by adipocytes.Benign vertebral hemangioma:MR-histological correlation Skeletal Radiol (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. 1 a 73-year-old T1WI shFig. 2 T1WI of a vertebral

18、body of the spine specimen from a 69-year-old subject 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 red dots (small arrow). C Photomicro

19、graph 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 vessels and interstitial edema in the area of high signal intensity on the T1WI. D Photomicrograph of marrow area wit

20、h intermediate signal intensity on the T1WI (small arrow in A). The relative proportion of surface area 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 photogra

21、phs, five lesions were 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.Histological analysis of the lesions demonstrated thin-walled, large blo

22、od-filled vessels set in a stroma of adipocytes with interstitial edema in all nine lesions that indicated cavernous hemangioma. No vessel thrombosis,hemosiderin deposition or hematopoietic cells were found.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

23、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rad dots（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？Fig. 2 At macroscopic examinat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？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“

24、栅栏Hemangioma is one of the most common benign tumors 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 hemangiomas become symptomatic causing neur

25、al arch expansion, vertebral body enlargement or direct compression of the thecal sac or nerve roots 2, 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Hemangioma is one of the most 73-year-old man presented with the inability to walk, numbness in the legs and trunk, and urinary retention. Three years previously, h

26、e had noticed numbness in his knees that progressed slowly to involve the lower trunk and limbs. He also developed weakness in his lower limbs.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。Vertebral haemangioma causing cord compression: MRI findingsAustralasian Radiology (2003

27、) 47, 190193 73-year-old man presented withFig. 1. Axial (a) and sagittal (b) 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 foci

28、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.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. 1. Axial

29、(a) and sagittalFig. 3.Axial (a) and sagittal (b) sequences demonstrate enhancement of both the intraosseous and extraosseous component of the vertebral haemangioma.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Fig. 3.轴位及矢状位MR增强扫描显示椎骨内、椎骨外的血At surgery, an extremely vascular, plum-coloured extradural tumour was i

30、ncompletely excised. There was vigorous bleeding from the T7 vertebra that was involved and the patient required blood transfusion intraoperatively. Histopathological diagnosis of the extradural tumour and vertebral fragment was consistent with a haemangioma. The specimen consisted of fibro-fatty co

31、nnective tissue with small fragments 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 no evidence of malignancy.Extradural haemangiomas a

32、re rare lesions. The majority of these represent extension from a vertebral haemangioma into the spinal canal with purely extradural haemangiomas only representing 12% of spinal haemangiomas. Both primary extradural haemangiomas and extradural extension of a vertebral haemangioma can be complicated

33、by cord compression. Most cases are confined to the thoracic spine.Vertebral haemangioma causing cord compression: MRI findingsAustralasian Radiology (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

34、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。At surgery, an extremely vascu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。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J Med Case Rep. 2014; 8: 207.An aggressive vertebral hemangioma in pregnancy: a case report 19-year-old

35、 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 showed compression of her spinal cord in front of the fourth thoracic vertebra for suspected tubercul

36、ous spondylitis. A Caesarean section was done followed by corpectomy with a bone graft because we intraoperatively discovered a vertebral hemangioma. Pathology showed an aggressive hemangioma.图T2WI （A） and. （B） T1WI of the thoracic spine demonstrating the lesion in theT4vertebra (fourth thoracic ver

37、tebra).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J Med Case Rep. 2014; 8: 207.APhysiologic changes during pregnancy may induce rapid onset symptoms from these normally asymptomatic lesions. By the seventh month of gesta

38、tion, the gravid uterus begins to compress the vena cava causing obstruction or functional closure 5. Venous obstruction and increased intra-abdominal pressure cause redistribution and increased blood flow volume through the vertebral venous plexus, resulting in the expansion and growth of previousl

39、y existing vertebral hemangiomas. This is the most important contributing factor in the clinical manifestation 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,

40、mainly through structural 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 hemangioma. 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

41、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Physiologic changes during pre扩展三：这例椎体溶骨性改变 术前误诊Osseous hemangioma of the seventh cervic

42、al vertebra with osteoid formation mimicking metastasis: a case report Journal of Medical Case Reports 2009 3:92扩展三：这例椎体溶骨性改变Osseous hemangiomWe present the case of a 44-year-old, otherwise healthy, Caucasian German woman who had been experiencing paresthesia in both forearms and hands for 3 months.

43、 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 spine was almost free but painful at the end of the motion range. X-ray showed osteolysis of C7.

44、MRI indicated increased signal intensity on T2WI. The osteolysis was diagnosed as a metastatic osteolysis of C7 . The CT scan showed 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

45、an arteriovenous malformation around 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