1、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,
2、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)30:226229 Other relatively common features include surrounding sclerosis,and cortical expansion and cortical destruction.Significant
3、 in our case is the diffuse reactive sclerosis affecting virtually the entire vertebral body,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“
4、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,T1WI,T1WI压脂,T2WI压脂,增强T1WI压脂（矢、冠、轴位）,T2WI压脂,T1WI,T2WI,T1WI,T2WI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,Epithelioid hemangioma of bone Skeletal Radiol(2001)30:226229,Fig.1 Lateral radiograph o
5、f the thoracic spine demonstrates diffuse sclerosis of 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 ma
6、rgin.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 T7 vertebral body.Also seen issubtle increased signal in the anterior aspect of the T8
7、vertebral body(arrow)consistent with bone marrow 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。,Fig.4 Simple and mildly complex vascular structures are seen within fibrous tissue(90
8、)Fig.5 At higher magnification,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 promine
9、nt with plump 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。,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,and cortical exp
10、ansion 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“ivory”vertebral body a
11、nd 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）,We present a case of epithelioid hemangioma of the spine with an unusual radiological appearance which
12、 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,venous and epithelioid have been described 1,2.,骨血管瘤属于起
13、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,Benign vertebral hemangioma:MR-histological correlation Skeletal Radiol(2001)30:442446,Fig.1 a 73-year-old T1WI shows an area of intermediate signal intensity(arrow)wit
14、h 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 increased in comparison with adjacent normal marrow.C Photomicrograph of the lesion shows thin-walled,dilated vessels(star),adipo
15、cytes(arrow)and interstitial edema(small arrow).The relative 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)30:442446,图A，T1WI长箭示病变区中等信号
16、；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.2 T1WI of a vertebral 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 Photomicrograph of marrow area with high signal intensity on the T1WI(large a