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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)30:226–229……Otherrelativelycommonfeaturesincludesurroundingsclerosis,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)30:226–229Fig.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,venousandepithelioidhavebeendescribed[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。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)30:442–446Fig.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)30:442–446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,withmultiplered