1、 2016病例交流（18） （源自同學圈子的病例） 2016病例交流（18）女，62歲。腰痛，以急性腰扭傷住院。（江蘇大豐趙文主任提供的病例）女，62歲。腰痛，以急性腰扭傷住院。（江蘇大豐趙文主任提供的腰椎正側位：問題在哪？腰椎2椎體右側份骨硬化腰椎正側位：問題在哪？腰椎2椎體右側份骨硬化CT軸位圖細看CT軸位圖細看再看CT矢狀重組圖再看CT矢狀重組圖CT矢狀重組圖CT矢狀重組圖看一看該病例的MRI圖看一看該病例的MRI圖T1WI未加壓脂 矢狀位T1WI未加壓脂 矢狀位T2WI未加壓脂 矢狀位T2WI未加壓脂 矢狀位T2WI加壓脂 矢狀位T2WI加壓脂 矢狀位T2WI未加壓脂 軸位T2WI未加

2、壓脂增強T1WI未加壓脂 冠狀位增強T1WI未加壓脂 冠狀位增強T1WI未加壓脂 矢狀位增強T1WI未加壓脂 矢狀位增強T1WI未加壓脂 軸位增強T1WI未加壓脂 軸位增強T1WI壓脂增強T1WI壓脂增強T1WI壓脂 冠狀位增強T1WI壓脂 冠狀位增強T1WI壓脂 軸位增強T1WI壓脂 軸位天津醫院王林森主任診斷意見：椎體硬化性血管瘤診斷意見？鑒于該病例影像學表現較特殊，且影像資料齊全，故在此將其總結并結合相關文獻予以擴展和交流該診斷之所以冠以“硬化”是基于影像學的病變區骨量增多。參考文獻：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,天津醫院王林森主任診斷意見：椎體硬化性血管瘤診斷意見？鑒于小結：本例椎體硬化性血管瘤的影像學表現1、病變區骨量增多，表現為平片、CT上密度增高

4、，并在CT圖上顯示硬化緣。2、瘤體內含少許脂肪組織（即MRI的T1WI明顯高信號；CT上的點狀更低密度）3、MRI可見病變周圍脂肪化（TW2及T1WI高信號，壓脂低信號）即瘤周脂肪侵潤4、瘤體一部分結構在T2WI壓脂上呈高信號（即MR展示其瘤體之富水特征）5、增強掃描呈漸進性強化（含血竇的瘤體）該例椎體血管瘤綜合影像（沒有“柵欄征”）：瘤體富水并含少量脂肪、骨量增多、其血竇由對比劑充填、瘤周脂肪侵潤（若瘤內含脂肪較多，也可歸為脂肪侵潤型血管瘤）小結：本例椎體硬化性血管瘤的影像學表現1、病變區骨量增多，表再看這例椎體血管瘤：也沒有“柵欄征”（脂肪侵潤型）廣州醫科大學候仲軍教授病例T1WIT1WI

5、壓脂T2WI壓脂增強T1WI壓脂（矢、冠、軸位）再看這例椎體血管瘤：也沒有“柵欄征”（脂肪侵潤型）廣州醫科大T2WI壓脂T1WIT2WIT1WIT2WI壓脂常見典型的椎體血管瘤的影像學表現（柵欄征）脂肪侵潤型血管瘤T2WI壓脂T1WIT2WIT1WIT2WI壓脂常見典型的椎再看這例硬化性血管瘤再看這例硬化性血管瘤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.（病理為椎體上皮樣血管瘤）女，32歲，胸背鈍痛。其他無特殊。胸椎側位顯示胸椎7椎體彌漫性硬化CT檢查：膨脹性溶骨性病變伴部分性骨化，侵及胸椎7的右前部。病變累及松質骨并伴部分硬化緣，余部椎體顯示反應性骨硬化，以鄰近病變部顯著。矢狀T2WI顯示胸椎7不均勻信號，胸椎8（箭）前部信號輕度增高，符合骨髓水腫改變。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)圖4 纖維組織內的單一和少許復合血管結構（低倍）。圖5 高倍放大圖：輕度不規則血管，大多數內皮細胞呈扁平狀。圖6 血管竇和較多含有不太明顯的血管之實變區。兩個區域中，內皮細胞顯著并核豐滿，在左下可見少數簇狀乳頭突起。Fig. 4 Simple and mildly compl本例以骨硬化為特點的上皮樣椎體血管瘤的 影像學表現提示 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. 椎體上皮樣血管瘤另外比較常見特征包括：病灶周圍骨硬化，骨皮質膨脹、骨皮質破壞。本例表現為彌漫性反應性骨硬化幾乎累及整個椎體，作者沒有發現以往有過此類的報道。這種彌漫性硬化致使放射學高密度表現或呈“象牙質樣”的椎體，以至于最初診斷曾考慮骨淋巴瘤。（注：椎骨硬化改變需要依賴X線平片或CT檢查）本例以骨硬化為特點的上皮樣椎體血管瘤的 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. 骨血管瘤屬于起自于血管的良性腫瘤。病理上有多種亞型包括：海綿狀、毛細血管狀、動靜脈型、靜脈型以及上皮樣。該文獻報告的脊椎上皮樣血管瘤病例，其影像學不常見的表現且以前的文獻也不曾報告：受侵的椎體彌漫性硬化。We present a case of epithelio擴展一：再分析一下椎體血管瘤與病理的關系 有助于認識血管瘤的影像表現Benign vertebral hemangioma:MR-histological correlation Skeletal Radiol (2001) 30:442

15、446擴展一：再分析一下椎體血管瘤與病理的關系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圖A，T1WI長箭示病變區中等信號；其中小箭示線樣縱行極低信號；圖B，T2WI箭指病變區與正常椎體相比呈略高的中等信號；圖C，病變鏡下圖示薄壁、擴張的血管（星）、脂肪（箭）及間質水腫（小箭）。由薄壁擴張的血管、間質水腫相應的表面區域比例與脂肪細胞分布的區域相當。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例海綿狀血管瘤組織學分析： red dots 病變，是在脂肪基質上的薄壁、擴張充盈的血管伴間質水腫。無血栓及含鐵血黃素沉積或造血細胞。圖A：T1WI示均勻高信號區（長箭）、中等信號

23、區（小箭），圖B：相應的標本切片圖片：黃色病變（長箭），其內含多發小紅點rad dots（小箭）圖C：圖A長箭指的高信號骨髓區鏡下圖片：脂肪細胞分布的相對表面的區域明顯多于血管和間質水腫區。圖D：圖A小箭指的中等信號骨髓區鏡下圖片：脂肪細胞（箭）分布相對表面區域類似于由血管及間質水腫區。即二者分布比例相當。如果這個病人做增強掃描，強化的部分是？Fig. 2 At macroscopic examinat影像學檢查發現，椎體血管瘤很常見，但不是都具備其典型的“柵欄征”，且多數是沒有癥狀的。擴展二：試問什么情況下血管瘤出現病理性的相關癥狀呢？影像學檢查發現，椎體血管瘤很常見，但不是都具備其典型的“

24、柵欄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：由無癥狀血管瘤演變為有癥狀性者，外傷性除外，這里指自發性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歲。主訴行走無力、下肢及軀干麻木，尿潴留。3年前即有膝部麻木，并逐漸加重且累及下部軀干和肢體。病人的雙側下肢無力也呈進展性。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.軸位及矢狀T1WI顯示胸椎7局灶混雜信號；骨外之左側硬膜外及椎旁啞鈴形中等信號腫塊，其中伴少數高信號灶；左側椎間孔無增大。T2WI硬膜外腫塊為高信號伴脊髓明顯受壓及移位。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.軸位及矢狀位MR增強掃描顯示椎骨內、椎骨外的血管瘤組織強化。打藥前Fig. 3.軸位及矢狀位MR增強掃描顯示椎骨內、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 硬膜外血管瘤罕見。多數為椎體血管瘤椎管內侵犯，單純性硬膜外血管瘤僅占脊柱血管瘤的12%。硬膜外原發性血管瘤或椎體血管瘤硬膜外延伸兩者均可并發脊髓壓迫。大多見于胸椎。術中發現，腫瘤血管豐富、紫紅色的硬膜外腫瘤未能完整切除。術中受侵的胸椎7發生靜脈性出血，以至于術中輸

34、血。組織學發現硬膜外腫瘤及其椎體碎片與血管瘤一致。切除標本由纖維脂肪結締組織及骨膜、軟骨、骨之碎片組成。鏡下：多數薄壁且充血的血管伴脂肪組織侵潤；椎骨組織病理切片顯示為擴張的血管位于骨小梁與脂肪間，無惡性病變。At surgery, an extremely vascu本例為原發于椎體的血管瘤延伸或侵及到椎管硬膜外及椎旁伴脊髓壓迫。本例為原發于椎體的血管瘤延伸或侵及到椎管硬膜外及椎旁伴脊髓壓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.圖T2WI （A） and. （B） T1WI of the thoracic spine demonstrating the lesion in theT4vertebra (fourth thoracic ver

37、tebra).病例二女，19歲，北非人，孕38周。下肢進行性無力2天，隨后截癱。MRI見胸椎4平面脊髓前壓迫，疑為結核性脊椎炎。行剖腹產手術，隨后的脊柱手術中發現椎體血管瘤并行椎體次全切除及植骨。圖A：胸椎T2WI、T1WI顯示胸椎4病變，因孕期而未做增強檢查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. 無癥狀的椎體血管瘤可能隨妊娠期間的生理變化而發生癥狀。多在妊娠第七個月，妊娠子宮開始壓迫下腔靜脈而引起梗阻或功能

41、性閉合。靜脈性梗阻和腹壓增高引發血流再分配，并導致經由椎靜脈叢的血流容量的增加，從而使得以前存在的椎體血管瘤膨脹或生長。此為妊娠期原先椎體血管瘤出現臨床癥狀之最重要因素。另妊娠期發生激素變化也可能對上述病理變化有促進作用，主要是血管壁結構變化，黃體酮增加有助于增加靜脈的膨脹性，雌激素的血管內皮細胞的促生長作用也會促進原先的血管瘤的增大。孕婦需要警惕脊柱血管瘤，特別是胸椎血管瘤本例為原發于椎體的血管瘤，妊娠后期引起脊髓壓迫Physiologic changes during pre擴展三：這例椎體溶骨性改變 術前誤診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擴展三：這例椎體溶骨性改變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歲，高加索人。雙側前臂、手感覺異常3個月。當轉動頭部時偶爾出現面部疼痛及感覺異常。體檢發現雙側上肢肌張力正常，有不連續的感覺缺失，頸椎活動近乎自如，但活動期間及結束后不適