呂銀章，翟恒，孔祥泉，柳曦，劉定西

磁共振神經(jīng)成像在外周神經(jīng)鞘膜瘤的應(yīng)用研究

呂銀章1，翟恒2*，孔祥泉3，柳曦3，劉定西3

作者單位：
1.華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬同濟(jì)醫(yī)院放射科， 武漢 430030
2.華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬協(xié)和醫(yī)院神經(jīng)內(nèi)科， 武漢 430022
3.華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬協(xié)和醫(yī)院放射科， 武漢 430022

目的 探討磁共振神經(jīng)成像對外周神經(jīng)鞘膜瘤診斷的臨床價值。材料與方法 回顧性分析27例經(jīng)手術(shù)和病理證實的外周神經(jīng)鞘膜瘤資料，所有病例均行MRI常規(guī)成像和結(jié)合短TI反轉(zhuǎn)恢復(fù)時間成像(3D-STIR)增強(qiáng)序列掃描。分析和評價3D-STIR增強(qiáng)掃描序列對外周神經(jīng)鞘膜瘤診斷的可行性和準(zhǔn)確性，比較常規(guī)MRI成像及3D-STIR序列增強(qiáng)掃描對外周神經(jīng)鞘膜瘤診斷的征象和價值。結(jié)果 27例外周神經(jīng)鞘膜瘤患者，磁共振常規(guī)成像可以顯示病灶的部位、數(shù)目、形態(tài)、體積、信號特征。3D-STIR增強(qiáng)掃描序列上均可清晰顯示周圍神經(jīng)走行及病變同周圍神經(jīng)關(guān)系。結(jié)論 磁共振常規(guī)序列及3D-STIR增強(qiáng)掃描序列對外周神經(jīng)鞘膜瘤的定位定性診斷有重要的臨床應(yīng)用價值。

磁共振成像；磁共振神經(jīng)成像；外周神經(jīng)；神經(jīng)鞘膜瘤

1Department of Radialogy, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology， Wuhan 430030， China

2Department of Neurology, Wuhan Union Hospital, Tongji Medical College of Huazhong University of Science & Technology， Wuhan 430022， China

3Department of Radialogy, Wuhan Union Hospital, Tongji Medical College of Huazhong University of Science & Technology， Wuhan 430022， China

*Correspondence to: Zhai H, E-mail: 270844031@qq.com

神經(jīng)鞘膜瘤是常見的外周神經(jīng)腫瘤，常呈孤立腫塊。外周神經(jīng)鞘膜瘤明確診斷后，多可經(jīng)手術(shù)剝離，保留神經(jīng)的功能。磁共振成像有多方位、多序列、良好的軟組織分辨率等多方面的優(yōu)勢，對診斷神經(jīng)鞘膜瘤和評價其與周圍組織結(jié)構(gòu)間關(guān)系有明顯優(yōu)勢。近年來日益成熟的磁共振神經(jīng)成像術(shù)(magnetic resonance neurography，MRN)配合增強(qiáng)掃描和多種后處理技術(shù)，對于外周神經(jīng)的顯示已經(jīng)達(dá)到大范圍、高分辨率、全程顯示的程度[1]，在診斷外周神經(jīng)鞘膜瘤方面有獨(dú)特的優(yōu)勢。筆者回顧分析27例經(jīng)外科手術(shù)術(shù)后病理或穿刺活檢證實的外周神經(jīng)鞘膜瘤的MRI常規(guī)成像與神經(jīng)成像表現(xiàn)，歸納其特點(diǎn)，并明確磁共振神經(jīng)成像的臨床價值。

1　材料與方法

1.1一般資料

共搜集武漢協(xié)和醫(yī)院27例資料完整的外周神經(jīng)鞘膜瘤病例，年齡18～52歲，男10例，女17例，所有病例均經(jīng)外科手術(shù)術(shù)后病理或穿刺活檢證實。其中位于臂叢及其分支的12例，位于腰叢及其分支的8例，位于骶叢及其分支的7例。

1.2檢查方法

掃描設(shè)備使用Siemens公司的Magnetom Trio 型 3.0 T超高場超導(dǎo)型核磁共振掃描儀，線圈選擇脊柱矩陣線圈和頸部矩陣線圈或體部矩陣線圈。患者仰臥頭先進(jìn)，頸部呈常規(guī)體位，不需要墊高。囑患者平靜呼吸。每位患者均先行病灶局部常規(guī)磁共振掃描，包括：T1WI快速自旋回波序列，TR：600 ms，TE：20 ms，層厚：5 mm，層間距：1 mm，視野FOV：320，矩陣：320；T2WI快速自旋回波序列，TR：4000 ms，TE：39 ms，層厚：5 mm，層間距：1 mm，視野FOV：320，矩陣：320，脂肪抑制采用IR法；3D-STIR磁共振神經(jīng)成像序列，TR：4000 ms，TE：286 ms，層厚：1mm，層間距：0，層數(shù)：80～120，視野FOV：448或320，矩陣：448或320，采用短TI時間技術(shù)進(jìn)行壓脂，TI：220 ms，采用iPAT并行采集技術(shù)，行冠狀面掃描；掃描完成后，經(jīng)靜脈注射Gd-DTPA(按0.2 ml/kg體重計量)后，再次進(jìn)行同參數(shù)同方位3D-STIR磁共振神經(jīng)成像序列掃描，再進(jìn)行常規(guī)增強(qiáng)掃描。

1.3圖像后處理技術(shù)

3D-STIR磁共振神經(jīng)成像序列平掃及增強(qiáng)掃描完成后，所得到的原始圖像依次行最大信號強(qiáng)度投影(maximum intensity projection，MIP)、曲面重建(multi-planner reformation，MPR)等圖像后處理進(jìn)行，再由兩個高年資放射科醫(yī)師對所得原始圖像和后處理圖像進(jìn)行分析研究，分析常規(guī)掃描序列、3D-STIR序列平掃及增強(qiáng)掃描三者所得圖像，對病灶的顯示情況和病灶與神經(jīng)的關(guān)系進(jìn)行綜合評價。

2　結(jié)果

圖1　女，47歲，右側(cè)腰大肌內(nèi)L3神經(jīng)鞘膜瘤。A：冠狀位平掃T1WI圖像上呈等T1信號，邊界不清；B：冠狀位T2WI-FS圖像上呈高信號，邊緣清楚；C和D：T1WI增強(qiáng)掃描冠狀位和橫斷位，病灶呈不均勻明顯強(qiáng)化；E和F：3D-STIR序列增強(qiáng)掃描圖像MPR后處理圖像，MRN可見其起源于右側(cè)L3神經(jīng)，載瘤神經(jīng)(L3)較對側(cè)增粗，遠(yuǎn)端為著Fig. 1 A 47-year-old female patient with peripheral nerve sheath tumors in the right psoas major. A: On coronary position T1 weighted imaging (T1WI), the tumor appeared isointensity without sharply edge; B: On coronary position T2 weighted imaging suppression sequence (T2WI-FS), the tumor appeared hyperintensity with sharply defined edge； C and D: The tumor appeared obvious inhomogeneous enhanced on coronal and axial enhanced T1WI; E and F: Contrast-enhanced 3D-STIR scanning MPR image showed that the tumor originated in the right L3 spinal nerve. The width of the right L3 spinal nerve was greater than the left, especially at its proximal ends.

2.1磁共振常規(guī)成像表現(xiàn)（圖1A～D）

發(fā)病部位：其中位于臂叢及其分支的12例，位于腰叢及其分支的8例，位于骶叢及其分支的7例。病灶數(shù)目：除1例為沿左下肢一長串病灶外，其余均為單發(fā)。病灶形態(tài)：多為類橢圓形、梭形、串珠樣，類橢圓形、梭形或串珠樣者長軸方向與神經(jīng)方向一致。病灶體積：大小不一，較大者長徑可達(dá)數(shù)十厘米，較小者直徑僅兩三厘米。信號特征：在T1WI圖像上多呈等或稍低信號，信號基本均勻，邊界欠清楚；在T2WI圖像上多呈高信號或稍高信號，邊界清楚，信號欠均勻；增強(qiáng)掃描可見不均勻明顯強(qiáng)化，邊緣部分多為明顯強(qiáng)化，中心部分各種程度強(qiáng)化成分并存。信號特征：可見“靶征”、“神經(jīng)出入征”、“脂肪尾征”等。

2.2磁共振神經(jīng)成像表現(xiàn)（圖1E、F，圖2～5）

起源神經(jīng)：均起源于單支神經(jīng)。起源神經(jīng)計數(shù)：右側(cè)臂叢4例，左側(cè)臂叢8例(圖2、3)，右側(cè)腰叢5例(圖1)，左側(cè)腰叢3例，右側(cè)骶叢4例(圖4)，左側(cè)骶叢3例(圖5)，其中1例起源于左側(cè)坐骨神經(jīng)，自左側(cè)坐骨神經(jīng)起始部起，沿左側(cè)坐骨神經(jīng)走行和分支向下分布，滿布左側(cè)坐骨神經(jīng)及其主要分支，直達(dá)左側(cè)踝關(guān)節(jié)水平(圖5)。

圖2　男，18歲，左側(cè)臂叢C6神經(jīng)鞘膜瘤。A和B：3D-STIR序列平掃后經(jīng)MPR后處理圖像，可見腫瘤呈類橢圓形，多角度觀察均可見起源于左側(cè)C6神經(jīng)。推擠左側(cè)C5神經(jīng)；C：3D-STIR序列增強(qiáng)掃描后經(jīng)MPR后處理圖像，背景抑制效果更好，腫瘤和神經(jīng)顯示更清楚。神經(jīng)節(jié)呈低信號，類似“充盈缺損” 圖3 女，30歲，左側(cè)臂叢C6神經(jīng)鞘膜瘤。A：3D-STIR序列增強(qiáng)掃描后經(jīng)MIP后處理圖像；B：3D-STIR序列增強(qiáng)掃描后經(jīng)MPR后處理圖像。腫瘤呈梭形，起源于左側(cè)C6神經(jīng)。體積較大，推擠左側(cè)臂叢其余各支。對側(cè)臂叢諸神經(jīng)清晰可見Fig. 2 A 18-year-old male patient with peripheral nerve sheath tumors in the left C6 spinal nerve. A and B: 3D-STIR sequence scanning MPR image. The tumor was class oval in shape. It originated in the left C6 nerve and pushed the left C5 nerve; C：Contrast-enhanced 3D-STIR scanning MPR image. After enhancing, the suppression effects of background were improved, then the tumor and nerves were clearly displayed. The ganglion showed a low singal, which looked like filling-defect. Fig. 3 A 30-year-old female patient with peripheral nerve sheath tumors in the left C6 spinal nerve. A: Contrast-enhanced 3D-STIR scanning MIP image; B: Contrast-enhanced 3D-STIR scanning MPR image. The tumor was class fusiform in shape. It originated in the left C6 nerve. The volume of this tumor was so big that it pushed the other branches of the left brachial plexus.

累及神經(jīng)的范圍：除上述1例累及左側(cè)坐骨神經(jīng)及其分支全程外，均為累及起源神經(jīng)1個節(jié)段，病灶近端及遠(yuǎn)端未累及節(jié)段神經(jīng)可見清晰顯示，鄰近腫瘤部分神經(jīng)稍顯腫脹(圖1、2)，病灶遠(yuǎn)端正常神經(jīng)可見顯示。對周圍神經(jīng)為推擠改變。如：圖2左側(cè)C6腫瘤推擠左側(cè)C5神經(jīng)；圖3左側(cè)C6腫瘤，體積較大，推擠左側(cè)臂叢余支。

對比常規(guī)成像，3D-STIR序列平掃和增強(qiáng)掃描可以直觀顯示神經(jīng)本身，對于診斷神經(jīng)鞘膜瘤的起源神經(jīng)和累及范圍有重要價值。對比3D-STIR序列平掃及增強(qiáng)圖像，平掃時背景內(nèi)淋巴結(jié)、小靜脈等含水豐富組織均呈高信號影，增強(qiáng)掃描信號降低明顯，背景抑制效果良好，神經(jīng)節(jié)也呈低信號，類似于“充盈缺損”，增強(qiáng)掃描顯示神經(jīng)更清楚，干擾更少，對于診斷幫助更大。

3　討論

3.1外周神經(jīng)鞘膜瘤

脊神經(jīng)病變病因包括外傷[2]、產(chǎn)傷、腫瘤、局部壓迫、炎癥、感染、免疫等多種。原發(fā)性脊神經(jīng)源性腫瘤主要包括神經(jīng)鞘膜瘤、神經(jīng)纖維瘤、惡性神經(jīng)鞘膜瘤和惡性神經(jīng)纖維瘤，也可以是神經(jīng)纖維瘤病的其中一部分[3]。繼發(fā)性腫瘤包括轉(zhuǎn)移性腫瘤和神經(jīng)周圍組織腫瘤兩種。外周神經(jīng)鞘膜瘤為良性腫瘤，一般臨床癥狀較輕，就診時多數(shù)運(yùn)動功能障礙較輕微，多為感覺功能障礙，局部腫脹、酸痛，受累神經(jīng)支配區(qū)域放射痛，如上述累及左側(cè)坐骨神經(jīng)全程病例，患者活動自如，僅為左下肢麻木，偶爾有類似被電擊感。就發(fā)病部位而言，本研究病例均位于臂叢、腰叢、骶叢，推測應(yīng)與這些區(qū)域感覺障礙較為明顯有關(guān)。

圖4　男，44歲，右側(cè)L5神經(jīng)鞘膜瘤，受累神經(jīng)參與構(gòu)成右側(cè)坐骨神經(jīng) 圖5 女，52歲，左側(cè)坐骨神經(jīng)神經(jīng)鞘膜瘤，累及左側(cè)坐骨神經(jīng)全程及主要分支Fig. 4 A 44-year-old male patient with peripheral nerve sheath tumors in the right L5 spinal nerve. The affected nerve participation constituted the right sciatic nerve. Fig. 5 A 52-year-old female patient with peripheral nerve sheath tumors in the left sciatic nerve, involving the left sciatic nerve and its main branches.

3.2磁共振神經(jīng)成像技術(shù)

脊神經(jīng)解剖復(fù)雜，毗鄰結(jié)構(gòu)眾多，走行蜿蜒、迂曲。超聲、X線脊髓造影、CT及CTM、常規(guī)MRI平掃加增強(qiáng)等多種常規(guī)影像診斷技術(shù)各有其優(yōu)勢和不足之處，但均無法完全滿足臨床診斷的要求。1992年，F(xiàn)iller等首次提出了MRN，MRN發(fā)展至今，日益成熟，主要包括擴(kuò)散加權(quán)法[4]、重T2脂肪抑制法、PROSET技術(shù)等多種方法[5-8]。有學(xué)者試驗彌散張量成像(diffusion tensor imaging，DTI)技術(shù)應(yīng)用于脊神經(jīng)成像[9]，目前還不成熟。本研究采用的3D-STIR技術(shù)結(jié)合了STIR抑脂、三維高分辨成像、重T2水成像、SENSE并行采集等技術(shù)，其優(yōu)點(diǎn)主要表現(xiàn)為以下3個方面：(1)更大的成像范圍，達(dá)到448 mm×448 mm，對于臂叢可顯示到肘關(guān)節(jié)水平甚至更遠(yuǎn)，對于腰骶叢可顯示到膝關(guān)節(jié)水平甚至更遠(yuǎn)；(2)更均勻、更穩(wěn)定的脂肪抑制效果；(3)更高的空間分辨率，實現(xiàn)1 mm體素的甚至更小的空間分辨率[10]。其不足之處在于，背景抑制效果欠佳，這種重T2短TI抑脂的序列特性決定了其成像范圍內(nèi)含水豐富的組織均呈高信號，如淋巴結(jié)、血流緩慢的小血管等，影響觀察。針對這一點(diǎn)，本研究增加了3D-STIR序列Gd-DTPA增強(qiáng)掃描，發(fā)現(xiàn)增強(qiáng)掃描可以顯著改善背景抑制效果，明顯提高對比噪聲比，更突出地顯示了脊神經(jīng)的走行、連續(xù)性及形態(tài)[11]?？梢郧宄仫@示脊神經(jīng)各支及主要分支，除橈神經(jīng)、尺神經(jīng)、正中神經(jīng)、坐骨神經(jīng)、股神經(jīng)這些粗大神經(jīng)外，還可以顯示腋神經(jīng)、肌皮神經(jīng)、閉孔神經(jīng)等相對小的神經(jīng)，在部分志愿者甚至可以清楚顯示肩胛上神經(jīng)、臀上神經(jīng)等細(xì)小分支[6]。一般需采用3D-FIESTA-c或IDEAL序列來直接顯示細(xì)小神經(jīng)[12]或神經(jīng)根根絲[13-14]。對于序列的選擇，常規(guī)成像必不可少，3D-STIR序列選擇平掃還是增強(qiáng)掃描，取決于病變的位置，如果病灶距離神經(jīng)節(jié)較遠(yuǎn)，不可能累及神經(jīng)節(jié)，建議直接在常規(guī)檢查完成后行3D-STIR增強(qiáng)掃描，因為3D-STIR序列顯示的神經(jīng)節(jié)呈低信號，故當(dāng)如果可能累及神經(jīng)節(jié)，3D-STIR平掃不能省略。

3.3磁共振神經(jīng)成像技術(shù)在外周神經(jīng)鞘膜瘤的臨床價值

對于脊神經(jīng)走行區(qū)域腫瘤患者，腫瘤是否來源于神經(jīng)？來源于哪一支神經(jīng)？累及范圍如何？若非來源于神經(jīng)，腫瘤侵犯神經(jīng)還是推擠神經(jīng)，毗鄰關(guān)系怎樣？腫瘤侵犯或推擠神經(jīng)的程度和范圍如何？這些對于手術(shù)入路及方式的選擇有指導(dǎo)意義。3D-STIR序列平掃及增強(qiáng)掃描可以顯示腫瘤與脊神經(jīng)的關(guān)系，明確具體起源于某一支某一節(jié)段，是否累及其他脊神經(jīng)，推斷腫瘤良惡性。對于單純椎管外神經(jīng)源性腫瘤，由于缺乏啞鈴型表現(xiàn)，常規(guī)檢查難以判斷腫瘤來自于神經(jīng)、血管、還是肌肉，神經(jīng)成像術(shù)對于判斷是否起源于神經(jīng)，價值重大。術(shù)前進(jìn)行磁共振神經(jīng)成像，明確起源神經(jīng)和累及范圍，外科手術(shù)時可以縮小手術(shù)野，將創(chuàng)傷減小[15]。如本研究中1例右側(cè)L3神經(jīng)鞘膜瘤患者，筆者在骨科手術(shù)室參觀手術(shù)全過程，患者取俯臥位，術(shù)前已行磁共振神經(jīng)成像，明確了病灶范圍，手術(shù)切口僅僅稍大于病灶長徑，即可完整切除病灶。

綜上所述，磁共振常規(guī)序列及磁共振神經(jīng)成像清楚明確的顯示外周神經(jīng)鞘膜瘤的影像學(xué)表現(xiàn)，尤其是神經(jīng)成像可清楚顯示其起源神經(jīng)、累及范圍、與鄰近神經(jīng)關(guān)系等重要信息，對于明確診斷和指導(dǎo)外科手術(shù)治療很有價值。

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Application study of magnetic resonance neurography in imaging of peripheral nerve sheath tumor

LV Yin-zhang1, ZHAI Heng2*, KONG Xiang-quan3, LIU Xi3, LIU Ding-xi3

4 Aug 2015， Accepted 28 Oct 2015

Objective: To investigate the clinical value of magnetic resonance neurography (MRN) in diagnosis of peripheral nerve sheath tumors. Materials and Methods: Twenty-seven patients with peripheral nerve sheath tumors proved by surgery and pathology underwent MRI conventional scanning and contrast-enhanced short TI reverse recovery time sequence (3D- STIR) scanning. The accuracy and feasibility of contrast-enhanced 3D-STIR scanning in peripheral nerve sheath tumors were retrospectively analyzed and evaluated. The diagnostic signs and the value of MRI conventional scanning and contrast-enhanced 3D-STIR scanning were compared. Results: In these cases, MRI conventional images can display the location, number, shape, size and signal characteristics of lesions, and contrast-enhanced 3D-STIR images can display the relevance between lesions and spinal nerves clearly. Conclusion: MRI conventional scanning and contrast-enhanced 3D-STIR scanning have important clinical value in diagnosing peripheral nerve sheath tumors.

Magnetic resonance imaging; Magnetic resonance neurography; Peripheral nerve; Nerve sheath tumor

翟恒，E-mail：270844031@qq.com

2015-08-04

R445.2；R739.43

A

10.3969/j.issn.1674-8034.2015.12.008

接受日期：2015-10-28

呂銀章, 翟恒, 孔祥泉, 等. 磁共振神經(jīng)成像在外周神經(jīng)鞘膜瘤的應(yīng)用研究.磁共振成像, 2015, 6(12): 922-926.