脊髓髓内病变课件

急性及亚急性脊髓髓内病变急性及亚急性脊髓髓内病变MRIMRI诊断与鉴别诊断思路诊断与鉴别诊断思路（一）（一）（一）（一）急性及亚急性脊髓髓内病变MRI诊断与鉴别诊断思路（一）脊髓病变脊髓病变良性病变良性病变n n脊髓空洞症脊髓空洞症脊髓空洞症脊髓空洞症n nVentriculus Ventriculus Ventriculus Ventriculus terminalisterminalisterminalisterminalisn n挫伤挫伤挫伤挫伤n n脓肿脓肿脓肿脓肿n n梗塞梗塞梗塞梗塞n n脊髓炎脊髓炎脊髓炎脊髓炎n n多发性硬化多发性硬化多发性硬化多发性硬化n n郝郝郝郝-伯二氏病（肉样瘤伯二氏病（肉样瘤伯二氏病（肉样瘤伯二氏病（肉样瘤病）病）病）病）n n动静脉的畸形动静脉的畸形动静脉的畸形动静脉的畸形占位性病变占位性病变n n畸胎瘤畸胎瘤n n星形细胞瘤星形细胞瘤n n室管膜瘤室管膜瘤n n成血管细胞瘤成血管细胞瘤n n淋巴瘤淋巴瘤n n成神经节细胞瘤成神经节细胞瘤n n转移转移脊髓病变良性病变占位性病变脊髓髓内病变课件The typical MR imaging protocol The typical MR imaging protocol for evaluation of the spinal cord lesionsfor evaluation of the spinal cord lesionsn nunenhanced sagittal and axial T1-weighted and unenhanced sagittal and axial T1-weighted and T2-weighted imagesT2-weighted imagesn npost-gadolinium-enhanced sagittal and axial T1-post-gadolinium-enhanced sagittal and axial T1-weighted images.weighted images.n nideally with MRI of the entire spine.ideally with MRI of the entire spine.Contrast-enhanced images are helpful in Contrast-enhanced images are helpful in determining the solid portion of an intramedullary determining the solid portion of an intramedullary neoplasm,tumoral vs nontumoral cysts,other neoplasm,tumoral vs nontumoral cysts,other enhancing pathologic entities,or other features enhancing pathologic entities,or other features that may modify the differential diagnosis.that may modify the differential diagnosis.The typical MR imaging protocoWHEN IT IS AN ACUTE MYELOPATHY WHEN IT IS AN ACUTE MYELOPATHY，WHAT CAUSES SHOULD BE CONSIDERED?WHAT CAUSES SHOULD BE CONSIDERED?n nIn patients with recent onset symptoms,In patients with recent onset symptoms,particularly ones that evolve rapidly,the initial particularly ones that evolve rapidly,the initial priority is to exclude a surgical emergency such priority is to exclude a surgical emergency such as epidural metastasis or abscess.as epidural metastasis or abscess.n nimmediate imaging is required,ideally with MRI immediate imaging is required,ideally with MRI of the entire spine.of the entire spine.n nIf imaging demonstrates spinal cord If imaging demonstrates spinal cord compression due to an acute lesion such as compression due to an acute lesion such as epidural metastasis,definitiveepidural metastasis,definitive management(i.e.,surgery)should be pursued management(i.e.,surgery)should be pursued withoutwithout delay to prevent rapid and irreversible delay to prevent rapid and irreversible worsening.worsening.WHEN IT IS AN ACUTE MYELOPATHY一、与肿瘤有关一、与肿瘤有关Sagittal T1-weighted MR image(a)of the thoracic spine illustrates diffuse marrow Sagittal T1-weighted MR image(a)of the thoracic spine illustrates diffuse marrow hypointensity Gadolinium-enhanced T1-weighted MR image(b)depicts multiple hypointensity Gadolinium-enhanced T1-weighted MR image(b)depicts multiple heterogeneously enhancing lesions(yellow arrows).The STIR MR image(c)shows heterogeneously enhancing lesions(yellow arrows).The STIR MR image(c)shows abnormally increased signal in the posterior elements and the vertebral bodies.A abnormally increased signal in the posterior elements and the vertebral bodies.A compression fracture is seen in the upper thoracic spine(red arrow).compression fracture is seen in the upper thoracic spine(red arrow).Sagittal T1-weighted MR image Epidural lymphoma.Epidural lymphoma.A 62-year-old man with known history of lymphoma presents with progressive A 62-year-old man with known history of lymphoma presents with progressive back pain and lower extremity weakness and paresthesias.Sagittal and axial T2(A,back pain and lower extremity weakness and paresthesias.Sagittal and axial T2(A,C)and postcontrast T1(B,D)images demonstrate an elongated enhancing epidural C)and postcontrast T1(B,D)images demonstrate an elongated enhancing epidural mass(long arrow)at the posterior aspect of the spinal canal with extension into the mass(long arrow)at the posterior aspect of the spinal canal with extension into the neural foramina,causing compression and displacement of the thecalsac and spinal neural foramina,causing compression and displacement of the thecalsac and spinal cord anteriorly.A hypointense dura(arrowhead)is displaced anteriorly.The mass is cord anteriorly.A hypointense dura(arrowhead)is displaced anteriorly.The mass is in the same posterior epidural space as in the same posterior epidural space as the epidural fat(short arrow).the epidural fat(short arrow).Epidural lymphoma.A 62-year-脊髓髓内病变课件n nIntradural-extramedullary schwannoma.Intradural-extramedullary schwannoma.n nA 55-year-old patient with right lower extremity A 55-year-old patient with right lower extremity weakness.Sagittal and axial T2(A,D)and pre-weakness.Sagittal and axial T2(A,D)and pre-(B,E)and postcontrast T1(C,F)images(B,E)and postcontrast T1(C,F)images demonstrate a relatively homogeneously demonstrate a relatively homogeneously enhancing lesion of isointense T1 and enhancing lesion of isointense T1 and hyperintense T2 signal within lower thoracic hyperintense T2 signal within lower thoracic spine causing displacement and compression of spine causing displacement and compression of the spinal cord.Identification of the dura the spinal cord.Identification of the dura(arrows),which has low signal on all sequences,(arrows),which has low signal on all sequences,confirms the intradural location of the lesion.The confirms the intradural location of the lesion.The contour and eccentric location of the lesion with contour and eccentric location of the lesion with mass effect on the spinal cord also confirm its mass effect on the spinal cord also confirm its extramedullary origin.extramedullary origin.Intradural-extramedullary schwEpidural spinal cord compressionn nMRI T2(A)and postcontrast T1(B)of a 61-MRI T2(A)and postcontrast T1(B)of a 61-yearold male with hormone-refractory prostate yearold male with hormone-refractory prostate cancer who presented with 1 month of neck and cancer who presented with 1 month of neck and mid back pain.mid back pain.n nHe was treated with 3000 cGy in 10 fractions to He was treated with 3000 cGy in 10 fractions to C1C5 and T1T6 with improvement in his C1C5 and T1T6 with improvement in his symptoms.symptoms.n nNeuroimaging demonstrated epidural disease at Neuroimaging demonstrated epidural disease at C2 and C3 and T4 and T5 with cord compression.C2 and C3 and T4 and T5 with cord compression.Neurologic exam was normal except for mild Neurologic exam was normal except for mild hyperreflexia in the lower extremities.hyperreflexia in the lower extremities.Epidural spinal cord compressiEpidural spinal cord compressionEpidural spinal cord compressiLeptomeningeal metastases This 34 year old had a 3-year This 34 year old had a 3-year history of melanomahistory of melanoma黑素瘤黑素瘤黑素瘤黑素瘤and an and an 18-month history of brain 18-month history of brain metastases.She then presented with metastases.She then presented with sciatic-type leg pain followed by sciatic-type leg pain followed by constipation and patchy sensory loss constipation and patchy sensory loss from her chest to her thighs.She from her chest to her thighs.She manifested a markedly positive manifested a markedly positive straight leg raise,mild leg weakness,straight leg raise,mild leg weakness,and diminished deep tendon reflexes and diminished deep tendon reflexes in her legs.in her legs.The postgadolinium MR scan The postgadolinium MR scan demonstrates numerous small demonstrates numerous small leptomeningeal enhancing nodules.leptomeningeal enhancing nodules.Leptomeningeal metastases 二、与感染或免疫有关二、与感染或免疫有关二、与感染或免疫有关脊髓髓内病变课件脊髓髓内病变课件Tuberculous spondylitis.结核性的脊椎炎Tuberculous spondylitis.结核性的脊 Tuberculous spondylitis of Tuberculous spondylitis of Th 4 and epidural abscess Th 4 and epidural abscess with right laterovertebral with right laterovertebral spread.a Sagittal T2,b spread.a Sagittal T2,b T1,and c T2 spectroscopic T1,and c T2 spectroscopic inversion recovery(SPIR)inversion recovery(SPIR)showing tuberculous showing tuberculous spondylitis.d Axial Gd T1-spondylitis.d Axial Gd T1-weighted image weighted image demonstrates best the demonstrates best the extradural abscess as well extradural abscess as well as the perivertebral as the perivertebral extensionextension Tuberculous spondylitis ofn nTuberculous Tuberculous spondylitis:role of spondylitis:role of SPIR pulse sequence.SPIR pulse sequence.n nSagittal T2 SPIR Sagittal T2 SPIR image of the lumbo-image of the lumbo-sacral region shows sacral region shows the tuberculous the tuberculous involvement of L5 with involvement of L5 with extension to the L4extension to the L4 L5 L5 intervertebral discintervertebral discTuberculous spondylitis:role Spondylitis and spondylodiscitisPyogenic spondylitis is uncommon and represents only 24%Pyogenic spondylitis is uncommon and represents only 24%of pyogenic osteomyelitisof pyogenic osteomyelitis骨髓炎骨髓炎骨髓炎骨髓炎.Mainly adults in the sixth to seventh decades are affected.Mainly adults in the sixth to seventh decades are affected.The rule of 50%should be remembered:The rule of 50%should be remembered:50%of the patients are older than 50 years,50%of the patients are older than 50 years,fever is present in only 50%of the cases;fever is present in only 50%of the cases;genitourinary tract is the primary source of infection in genitourinary tract is the primary source of infection in 50%of cases,50%of cases,Staphylococcus aureus Staphylococcus aureus is the causative agent in almost is the causative agent in almost 50%;50%;the lumbar spine is affected in 50%;the lumbar spine is affected in 50%;patients present with a history of more than 3 months of patients present with a history of more than 3 months of symptoms in 50%of casessymptoms in 50%of casesSpondylitis and spondylodiscit脊髓髓内病变课件n nC6C7 cervical spondylitis and spondylodiscitis.C6C7 cervical spondylitis and spondylodiscitis.Associated large epidural abscess.Associated large epidural abscess.n na Sagittal T1-weighted image,b sagittal T2-a Sagittal T1-weighted image,b sagittal T2-weighted image,and c sagittal fat-suppression T2 weighted image,and c sagittal fat-suppression T2 images.The vertebral bodies of C6 and C7 are images.The vertebral bodies of C6 and C7 are hypointense on T1-weighted image,hyperintense hypointense on T1-weighted image,hyperintense on T2 and fat-suppressed T2-weighted on T2 and fat-suppressed T2-weighted image.Partial collapse of C6.The epidural abscess image.Partial collapse of C6.The epidural abscess is best seen on T2-weighted image as a is best seen on T2-weighted image as a hyperintense fluid collection.hyperintense fluid collection.d Sagittal d Sagittal Gdenhanced T1-weighted image better shows the Gdenhanced T1-weighted image better shows the epidural abscess due to enhancement of the duraepidural abscess due to enhancement of the dura.e Axial T2-weighted image shows well the epidural e Axial T2-weighted image shows well the epidural left postero-lateral pus collectionleft postero-lateral pus collectionC6C7 cervical spondylitis and 三、与正常结构有关三、与正常结构有关椎间盘突出椎间盘突出黄韧带肥厚黄韧带肥厚脂脂(肪肪)过多症过多症 三、与正常结构有关Spinal epidural lipomatosisn nSpinal epidural lipomatosis(SEL)is a rare but well-Spinal epidural lipomatosis(SEL)is a rare but well-recognized condition.recognized condition.n nIt is defined as a pathological overgrowth of normal fat It is defined as a pathological overgrowth of normal fat tissue in the extradural space.tissue in the extradural space.n nSteroid production(exogenous or endogenous)is the main Steroid production(exogenous or endogenous)is the main aetiological factor associated with SEL;the first case of aetiological factor associated with SEL;the first case of steroid-induced lipomatosis was reported by Lee et steroid-induced lipomatosis was reported by Lee et al.al.（19751975）Other reported secondary causes include Other reported secondary causes include adrenal tumors,hypothyroidism,hyperprolactinemia and adrenal tumors,hypothyroidism,hyperprolactinemia and other endocrinopathies.other endocrinopathies.n nMany cases have emerged without evidence of any clear Many cases have emerged without evidence of any clear predisposing factors.Badami et al.reported the first case predisposing factors.Badami et al.reported the first case in 1982 but Haddad in 1991 coined the term idiopathic in 1982 but Haddad in 1991 coined the term idiopathic SEL.SEL.Spinal epidural lipomatosisSpiTI-weighted axial MRI showing epidural lipomatosis compressing the spinal cord.TI-weighted axial MRI showing T1-weighted sagittal MRI showing the epiduralT1-weighted sagittal MRI showing the epidurallipomatosis compressing the upper thoracic spinal cord.lipomatosis compressing the upper thoracic spinal cord.T1-weighted sagittal MRI showin四、与运动、外伤等等有关四、与运动、外伤等等有关四、与运动、外伤等等有关Sagittal T2-(Sagittal T2-(A A)and T1-weighted()and T1-weighted(B B)magnetic resonance images of an acute)magnetic resonance images of an acuteepidural hematoma with maximal compression at the C6-C7 level(arrows)inepidural hematoma with maximal compression at the C6-C7 level(arrows)ina 13-year-old girl who sustained a heavy rowing exercise injury with ana 13-year-old girl who sustained a heavy rowing exercise injury with anunderlying vascular malformation.underlying vascular malformation.Sagittal T2-(A)and T1-weightMRI Findings in Spinal Epidural HematomaPhase T1-weighted T2-weighted ImageAcute Isointense HyperintenseSubacute Heterogeneous HeterogeneousChronic Hypointense HypointenseMRI Findings in Spinal Epidura Sagittal T2-weighted Sagittal T2-weighted cervical magnetic cervical magnetic resonance image shows resonance image shows a longitudinal posterior a longitudinal posterior epidural hematoma from epidural hematoma from C4 to C5(arrow),C4 to C5(arrow),compressing the spinal compressing the spinal cord(arrowhead)cord(arrowhead)Sagittal T2-weighted cervicAxial T2-weighted cervical magnetic resonance image Axial T2-weighted cervical magnetic resonance image shows an ovoid epidural hematoma(arrow)in the right shows an ovoid epidural hematoma(arrow)in the right postero-lateral aspect and spinal cord compression postero-lateral aspect and spinal cord compression(arrowhead)(arrowhead)Axial T2-weighted cervical magSagittal T1 and T2 turbo-spin-echo sequences of the posterior spinal canal.n nA A,Sagittal T1 revealing mixed signal,Sagittal T1 revealing mixed signal intensity in the posterior spinal canal intensity in the posterior spinal canal mostmost marked from approximately the T1 marked from approximately the T1 level to the T7 level,with minimal level to the T7 level,with minimal findings extending into the lower findings extending into the lower thoracic and upper lumbar levels.thoracic and upper lumbar levels.There is an area of high signal There is an area of high signal intensity extending from the T3 to the intensity extending from the T3 to the T5 level(T5 level(arrowsarrows).).n nB B,Sagittal T2 revealing mixed signal,Sagittal T2 revealing mixed signal intensity in the posterior spinal canal intensity in the posterior spinal canal most marked from approximately the most marked from approximately the T1 level to the T7 level,with minimal T1 level to the T7 level,with minimal findings extending into the lower findings extending into the lower thoracic and upper lumbar levels.thoracic and upper lumbar levels.There is an area of low signal There is an area of low signal intensity extending from the T3 to the intensity extending from the T3 to the T5 level(T5 level(arrowsarrows).).Sagittal T1 and T2 turbo-spin-Spinal Epidural Lubricant Grease CollectionSpinal Epidural Lubricant Grease CollectionMimicking Traumatic Spinal Epidural HematomaMimicking Traumatic Spinal Epidural Hematoman nwe report an unusual presentation of a traumatic we report an unusual presentation of a traumatic spinal epidural fluid collection,caused by a high-spinal epidural fluid collection,caused by a high-pressure injection injury of lubricant grease to the pressure injection injury of lubricant grease to the upper thorax and into the thoracic spinal canal.upper thorax and into the thoracic spinal canal.The spinal epidural fluid collection mimicked the The spinal epidural fluid collection mimicked the appearance of an early subacute spinal epidural appearance of an early subacute spinal epidural hematoma on spinal MR imaging.hematoma on spinal MR imaging.n nAgain,the case of our patient illustrates the Again,the case of our patient illustrates the importance of detailed clinical information,importance of detailed clinical information,including a thorough understanding of the including a thorough understanding of the mechanism of trauma at the time of interpretation mechanism of trauma at the time of interpretation of spinal imaging studies,since cord compression of spinal imaging studies,since cord compression can rarely be caused by nonhemorrhagic fluid can rarely be caused by nonhemorrhagic fluid collection.collection.Spinal Epidural Lubricant GreaThank your attention