海绵窦区病变ppt课件.ppt

Imaging Lesions of the Cavernous Sinus海绵窦区病变,白 洁2011-08-31,The cavernous sinus (CS) contains vital neurovascular structures that may be affected by vascular, neoplastic, infective, and infiltrative lesions arising in the CS proper or via extension from adjacent intra- and extracranial regions海绵窦有重要的神经血管结构， 可发生海绵窦本身固有的 或由临近的颅内外结构延伸 至海绵窦的血管、肿瘤、 感染或浸润性病变,Patients with CS syndrome usually present with paresis of 1 or more cranial nerves (III-VI), which may be associated with painful ophthalmoplegiaThe clinician needs to know the type of CS lesion, its relationship to crucial neurovascular structures, and its extension into the surrounding tissuesThese findings are essential for deciding therapeutic modalities such as microsurgery, radiation therapy, or medical treatment as well as for appropriate planning of surgery or radiation therapy有海绵窦综合征的患者常有一支或多支颅神经麻痹 （III-VI），可伴有痛性眼肌麻痹临床医生需了解海绵窦病变的类型、与重要神经血管结构的关系、有无延伸至临近组织这对于决定治疗方式是必要的，如显微外科手术、放疗或内科治疗，以及制定适当的外科或放疗计划,Imaging Protocol 影像学检查,Routine T2, FLAIR, and precontrast T1WI of the entire brainPost-contrast T1WI 3-mm-thick images of the axial and coronal planes with at least 1 plane imaged with a fat-saturation techniqueThin-section 3D heavily T2-weighted images may allow visualization of individual cranial nerves in the CS and adjacent cisterns全脑的常规T2WI、FLAIR、平扫T1WI轴位和冠状位的增强扫描，3mm层厚，至少一个切面为压脂像薄层3D重T2WI成像，可使每一根颅神经和临近的脑池显像 CT is best performed by using a multidetector scanner after intravenous administration of iodinated contrast medium.Acquisitions in axial or coronal planes by using 1-mm-thick sections may be obtained and then reformatted in other planesCT扫描最好使用多探测器仪器的增强扫描采集1mm层厚的轴位或冠状位信息，并可其他方位重建,Anatomy 解剖,The CS is composed of 2 layers of dura that split to form a septate venous channel海绵窦是有2层硬脑膜分隔形成的静脉通道Each dural wall contains an outer layer apposed to bone and an inner layer in contact with blood or CSF每层硬脑膜由靠近颅骨的外层和临近血液/脑脊液的内层组成The CS extends from the orbital apex 眶尖 and superior orbital fissure眶上裂 anteriorly to the Meckel cave and farther posteriorly to the dura and the pores that allow nerves to enter it,Transverse diameter is 57 mm 左右径57 mm Vertical diameter is 58mm 上下径58mmAnteroposterior diameter is 1015mm 前后径1015mmThe CS is composed of a network of small venous channels that may arbitrarily be divided into different compartments内有小静脉通道组成的网，能任意分成不同的间隔The main venous influx into the CS is the superior and inferior ophthalmic veins, pterygoid plexus, and Sylvian vein进入海绵窦的主要静脉是眼上静脉和眼下静脉、翼丛、侧裂静脉The outflow of the CS occurs via the superior and inferior petrosal sinuses经岩上窦、岩下窦流出海绵窦The internal carotid artery (ICA) is the most medial structure inside the CS and is contained in the so-called carotid trigone颈内动脉位于海绵窦的中间，并位于所谓的颈动脉三角内,Cranial nerves III and IV and the first and second divisions of the cranial nerve V (from superior to inferior) are located in the lateral dural wall of the CS (called the oculomotor trigone)动眼神经、滑车神经、三叉神经的第1、2分支（眼神经和上颌神经）位于海绵窦的侧壁（称为动眼神经三角）Cranial nerve V courses in the central part of the CS inferolateral to the ICA三叉神经走行与海绵窦的中部，位于颈内动脉的下方The CS is a multiseptate space, which shows intense contrast enhancement of the slower flowing venous blood海绵窦是一个多分隔的空间，由于慢流速的静脉血而增强后能明显强化The ICA appears as a signal-intensity void structure颈内动脉则表现为血管流空信号,Occasionally, the CS may contain fatty deposits that are normal These fatty zones may be more prominent in obese patients or those with Cushing syndrome or receiving exogenous steroid therapy偶尔，海绵窦可见脂肪沉积，这是正常表现这些脂肪沉积的区域更常见于肥胖患者、库欣综合征患者、接受外源性甾类激素治疗的患者,Normal fat deposits 正常的脂肪沉积Axial noncontrast CT scan shows normal and incidentally found deposits of fat (arrowheads) in the posterior CSsCT平扫可见海绵窦后部的脂肪沉积，少见但为正常,Meckel腔Meckel腔（Meckel cave，MC）为颅中窝中后份的硬脑膜陷窝，区域狭小、空间结构复杂并与许多重要神经、血管结构相毗邻三叉神经根由桥脑发出后,从岩上窦下方穿小脑幕的三叉神经孔至三叉神经节，在这段距离之前，三叉神经根与脑膜的关系酷似脊神经根与脊膜鞘的关系，其外覆盖着硬脑膜和蛛网膜，并形成一腔隙，称为Meckel 腔Meckel 腔为由颅后窝向颅中窝后内侧部分突入的硬脑膜陷凹，分为上、下、前、后壁及内、外侧壁前壁和上壁与海绵窦后部静脉间隙相邻；外侧壁与颅中窝内侧壁硬脑膜相邻，内侧壁前部与颈内动脉海绵窦段后升部相邻，并夹第四对颅神经，也有少量结缔组织相连；内侧壁后部与颞骨岩尖部的骨膜相贴三叉神经节位于Meckel 腔内，呈半月形或三角形，其表面覆盖蛛网膜，后者包绕三叉神经形成蛛网膜下腔的三叉池半月神经节位于中颅凹的后内侧，由关系密切的三种间隙围绕: 三叉神经池、Meckel 腔和海绵窦硬膜外间隙蛛网膜包裹三叉神经节，与三叉神经节之间有一定的间隙，松散的三叉神经节纤维之间也有一定的间隙，共同构成三叉池三叉神经池与邻近蛛网膜间隙相连，脑池造影时可被充盈海绵窦间隙位于形成中颅凹内侧壁的固有硬膜和蝶骨骨膜和岩骨尖之间,Schwannoma 神经鞘瘤Plexiform Neurofibroma 丛状神经纤维瘤Malignant Peripheral Nerve Sheath Tumor 恶性周围神经鞘瘤Cavernous Hemangioma 海绵状血管瘤Meningioma 脑膜瘤Pituitary Adenoma 垂体瘤Melanocytoma 黑色素细胞瘤Chordoma 脊索瘤Chondrosarcoma 软骨肉瘤Nasopharyngeal Carcinoma 鼻咽癌Juvenile Angiofibroma 幼年血管纤维瘤Sphenoid Sinus Carcinoma 蝶窦癌Rhabdomyosarcoma 横纹肌肉瘤Metastases 转移瘤Lymphoma and Leukemia 淋巴瘤和白血病Posttransplantation Lymphoproliferative Disorder 移植术后淋巴组织增生Epidermoid and Dermoid Cysts 表皮或皮样囊肿Disorders of Histiocyte Proliferation 组织细胞增生症,Neoplastic Lesions 肿瘤性病变,Schwannoma 神经鞘瘤A trigeminal nerve schwannoma commonly involves the CS and, in 50% of instances, has a typical dumbbell-shape with bulky tumor in the Meckel cave and the prepontine cistern with a waist at the porous trigeminus三叉神经鞘瘤在最常见，发病率约50%，典型的哑铃样形状， Meckel腔和桥前池的肿块+腰部位于三叉神经孔Conversely, it may be found only involving the Meckel cave 也可以仅仅累及Meckel腔It may be solid or have variable cystic or hemorrhagic components with occasional fluid levels肿瘤可以是实性的，也可以有多样的囊变或出血，偶见液平Small tumors tend to be homogeneous, whereas large ones are frequently heterogeneous in appearance肿瘤体积小则多质地均匀，体积大的肿瘤多为非均质性表现,Schwannomas are isointense-to-hypointense masses on T1 images, mostly T2 hyperintense, and show contrast enhancement神经鞘瘤T1WE多为等或低信号，T2WI多为高信号，增强后有强化A clue to the diagnosis is that they follow the expected course of the nerves from which they arise诊断依据：肿瘤常沿起源神经的走行生长Schwannomas may arise from other cranial nerves in the CS, particularly cranial nerve III除三叉神经外，神经鞘瘤也起源于其他颅神经，尤其是动眼神经Multiple CS schwannomas and bilateral acoustic ones are seen in patients with neurofibromatosis type 2海绵窦多发神经鞘瘤和双侧听神经瘤见于神经纤维瘤病2型的患者,SchwannomaAxial postcontrast T1-weighted image shows a well-defined enhancing mass (arrow) involving the Meckel cave on the right. Although the findings are nonspecific, the most common mass in this location is a schwannoma. T1增强扫描可见边界清晰的强化肿块，累及右侧Meckel腔；尽管表现没有特征性，但是该位置最常见的肿瘤是神经鞘瘤,Plexiform Neurofibroma 丛状神经纤维瘤Plexiform neurofibromas most commonly involve the trigeminal nerve, especially its first and second branches最常累及三叉神经，尤其是三叉神经的第1支、第2支A suggestive imaging feature is a tortuous or fusi form enlargement of the nerves that exhibit heterogeneous signal intensity有提示作用的影像表现是扭曲或梭形增大的神经、信号不均匀Unlike schwannomas, neurofibromas are less likely to extend to the Meckel cave与神经鞘瘤不同，神经纤维瘤很少累及Meckel腔They are seen in 30% of patients with neurofibromatosis type 1 but are extremely rare outside this disease约30%的神经纤维瘤病1型患者可发生丛状神经纤维瘤，此外很少发生,Malignant Peripheral Nerve Sheath Tumor 恶性周围神经鞘瘤High-grade sarcoma that may infiltrate the CS高级别肉瘤、可侵润海绵窦Large tumor size (5 cm), ill-defined infiltrative margins, rapid growth, tumor signalintensity heterogeneity, and erosion of the skull base foramina out of proportion to tumor size suggest its underlying malignant nature 肿瘤体积较大（5 cm），边界不清，侵润性生长，生长迅速，信号不均，对颅底孔的骨质侵蚀与肿瘤体积不成比例，提示其潜在恶性特性Its imaging findings are nonspecific, and the diagnosis is made by histology影像学表现没有特征性，确诊需要组织学,Malignant peripheral nerve sheath tumorCoronal postcontrast T1-weighted image shows a large aggressive-appearing mass that involves the left CS, surrounds the ICA (arrow), erodes the middle cranial fossa floor, and extends into the infratemporal region.恶性周围神经鞘瘤：冠状T1增强扫描，累及左侧海绵窦的巨大侵袭性肿块，包绕左侧颈内动脉，侵蚀中颅窝底并延伸至颞下区,Cavernous Hemangioma 海绵状血管瘤More commonly seen during the fifth decade of life in female patients最常见于约50岁的女性It is among the most common primary CS tumors along with schwannoma and meningioma与神经鞘瘤、脑膜瘤是最常见的海绵窦肿瘤This tumor is formed by sinusoidal spaces with endothelial lining that contain slow-flowing or stagnant blood肿瘤由内衬上皮的窦腔组成，腔内是慢流血或淤血A preoperative diagnosis is important because of its propensity to bleed at the time of resection术前确诊很重要，尤其肿瘤切除时易出血These tumors are nearly hyperintense on T1- and T2-weighted images and are attached to the outer wall of the CS, and their diagnosis may be suggested when they show progressive “filling in” after contrast administration肿瘤多表现为T1和T2WI高信号，附着于海绵窦外壁，增强后渐进性强化是诊断依据Other times, they show nonspecific intense homogeneous or heterogeneous contrast enhancement 增强后也可表现为无特征性的均匀或不均匀强化,Cavernous hemangiomasA, Axial postcontrast T1-weighted image shows a large and homogeneously enhanc-ing mass arising from the lateral wall of the left CS. B, Axial postcontrast T1-weighted image in a different cavernoma, which shows inhomogeneous contrast enhancement but also arises from the lateral wall of the CS, pushing the ICA (arrow) medially. When a mass arises in the lateral wall of a CS, themost important differential diagnosis is that of meningioma versus cavernoma.海绵状血管瘤：轴位T1增强-左侧海绵窦侧壁局部均匀强化肿瘤轴位T1增强-另一例，海绵窦侧壁不均匀强化肿块，推移颈内动脉内移起源于海绵窦侧壁的肿块，主要鉴别诊断是脑膜瘤和海绵状血管瘤,Cavernous hemangiomaA, Coronal T1-weighted image demonstrates a hypointense left parasellar extraaxial lesion. 冠状T1-低信号左侧鞍旁轴外病变B, Axial T2 image demonstrates a homogeneous markedly hyperintense lesion.轴位T2-均匀明显高信号C, Initial coronal gadolinum-enhancedT1-weighted image demonstrates patchyperipheral lesion enhancement. 增强后早期边缘强化D, Subsequent axial gadolinum-enhanced T1-weighted image now demonstrates homogeneous lesion enhancement with centripetal “filling in.” 逐渐向心性填充强化,Meningioma脑膜瘤Most CS meningiomas arise from the lateral dural wall, but sometimes they may be exclusively inside the CS绝大多数脑膜瘤起源于硬脑膜侧壁，但有时可位于海绵窦内A meningioma is usually hypo- to isointense with respect to gray matter in all MR imaging sequences and enhances intensely 典型者在MR各序列上，与脑灰质相比呈等或低信号，增强后明显强化A dural tail frequently can be seen extending away from the edge of the tumor and often into the ipsilateral tentorium常见从肿瘤边缘向外延伸的脑膜尾征，并常进入同侧的小脑幕Meningiomas constrict the lumen of the ICA脑膜瘤常压迫颈内动脉至管腔压缩Meningiomas may extend inside the CS and the Meckel cave and via the porous trigeminus into the prepontine cistern脑膜瘤可延伸入海绵窦和Meckel腔内，经疏松的三叉神经进入桥前池They may have an appearance very similar to schwannomas脑膜瘤的表现可与神经鞘瘤很相似,MeningiomasA, Axial T2-weighted image shows a meningioma (arrow) that is isoattenuated to white matter involving the right CS and extending from the Meckel cave into the superior orbital fissure. B, Axial postcontrast T1-weighted image in a different patient shows the bulk of ahomogeneously enhancing mass in the Meckel cave but extending through the porous trigeminus into the prepontine cistern. A schwannoma needs to be considered in the differential diagnosis.脑膜瘤 轴位T2WI-箭头所指的脑膜瘤，与脑白质信号一致，位于右侧海绵窦并从Meckel腔延伸至眶上裂轴位T1增强-另一例可见Meckel腔的明显均匀强化的肿块，但延伸至桥前池。鉴别诊断应想到神经鞘瘤,Cavernous and paracavernous meningiomaA, The enhancing meningioma on the T1-weighted postgadolinium contrast study involves the right CS, the right paracavernous region, and spills into the prepontine cistern. 增强后强化的脑膜瘤，累及右侧海绵窦及海绵窦旁，并累及桥前池B, On the coronal T1-weighted sequence, note the spiculated enhancement pattern. Nerve sheath tumors generally have a more homogeneous pattern of enhancement. Also note the dural tail (arrow), a nonspecific finding, but one that supports the diagnosis of meningioma. 请注意1.针状增强方式，神经鞘瘤多为均匀强化。2.脑膜尾征，非特异性，但常提示脑膜瘤,MeningiomaA, Coronal T1-weighted image demonstrates a hypointense left extraaxial parasellar lesion.冠状T1左侧海绵窦旁的轴外低信号病变B, Initial coronal gadolinum-enhanced T1-weighted image demonstrates intense uniform enhancement of the lesion. 增强后早期均匀明显强化C, Subsequent axial gadolinum-enhanced T1-weighted image demonstrates similar uniform enhancement characteristics in contrast to the heterogeneous centripetally “filling-in” enhancement pattern exhibited by the cavernous hemangioma.后期仍为均匀强化，与海绵状血管瘤的不均匀的向心性填充性强化的方式不同,Pituitary Adenoma 垂体瘤May grow laterally and invade the CS向侧方生长侵及海绵窦A sign of CS invasion is encasement of the intracavernous ICA by30% of its diameter or tumor extension lateral to the top (12 oclock) of the ICA垂体瘤侵及海绵窦的征象可为增强后海绵窦内颈内动脉直径的30%、肿瘤强化后侧向延伸至海绵窦顶（12点方向）Interposition of abnormal soft tissue between the lateral wall of the CS and the ICA is a reliable indicator of CS invasion位于海绵窦侧壁和颈内动脉之间的异常软组织肿块的插入，是海绵窦受累的可靠指征Unlike meningiomas, pituitary adenomas generally do not narrow the ICA与脑膜瘤不同，垂体瘤通常不导致颈内动脉的狭窄,垂体瘤侵犯海绵窦,临床意义提示手术过程更困难，治疗效果差手术中易损伤颈内动脉海绵窦段，可能造成术后脑脊液漏硬脑膜受侵提示肿瘤部分切除，需要术后辅助放疗和/或化疗海绵窦受侵影响垂体瘤的治疗和预后，术前评估应尽可能精确,预测海绵窦受侵最有用的统计学指征：ICA包绕30%，其敏感性92.1%、特异性93.5%、阳性预测值82.5%ICA包绕45%是海绵窦受侵最特异性和准确性的指针ICA包绕25%，可以肯定CS未受侵CS外侧部或3个以上部分未显示，可以肯定CS受侵CS内侧部保持完整或腺瘤与CS之间存在正常垂体，可以肯定CS未受侵,颈内动脉完全被包绕,垂体大腺瘤,垂体巨腺瘤（蝶窦及海绵窦）,Melanocytoma 黑色素细胞瘤Primary melanocytomas originate from the leptomeninges of the CS原发黑色素瘤起源于海绵窦的柔脑膜 The lesion is hyperintense with fine punctate areas of decreased signal intensity on T1-weighted images and of low signal intensity on T2-weighted images and shows no contrast enhancementT1WI表现为高信号的肿块伴有小点状信号减低区，T2WI为低信号，增强后无强化It may be indistinguishable by imaging from primary meningeal melanoma, melanocytic schwannoma, and cavernous angioma影像上不能与原发的脑膜黑色素瘤、黑色素神经鞘瘤、海绵状血管瘤区别,A, Unenhanced axial CT scan shows ahyperdense mass (arrow) in the medialportion of the left middle cranial fossa adjacent to the cavernous sinus.平扫CT中颅窝临近海绵窦高密度肿块B, Axial T1WI shows an extracranial mass (arrow) that has slight increased signal with punctate areas of low signal.轴位T1稍高信号颅外肿块伴有点状低信号C, Sagittal T1WI shows a speckled pattern and a well-defined margin (arrow).矢状位T1斑点状外观，边界清晰D, Coronal T2WI shows markedly decreased signal (arrow) within the lesion, consistent with a paramagnetic effect.冠状T2因顺磁性效应而肿块信号明显降低E, Low-power photomicrograph showslarge nests (arrow) of cells containing melanin (hematoxylin-eosin stain).F, After bleaching with H2O2, the neoplastic cells show moderate nuclear pleomorphism (arrow) with no mitotic figures or necrosis on high-power photomicrograph.,Chordoma 脊索瘤Chordoma is a locally invasive midline primary clival tumor that may also originate slightly more laterally from the spheno-occipital synchondrosis and may extend into the CS脊索瘤是起源于斜坡的局部侵袭性肿瘤，位于中线区；也可侧向起源于蝶骨-枕骨软骨联合，并可延伸至海绵窦On T1-weighted images, it shows intermediate signal intensity with focal high-signal-intensity areas representing hemorrhage or high proteinT1WI多为中等信号伴有局灶性出血或高蛋白的高信号The tumor is of relatively high signal intensity on T2-weighted images with hypointense areas representing residual fragments or sequestrations of boneT2WI为高信号伴有残留骨碎片或死骨的低信号CT shows bone destruction and calcificationsCT可见骨质破坏和钙化,CT scan of 34-year-old man who had surgical resection of a clivus chordoma in 1980. A large recurrent tumor in the suprasellar region is seen in the follow-up scan obtained in August 1982. He received radiotherapyCT scan of patient 48 months after original diagnosis of chordoma. The patient has stable disease by clinical and radiologic criteria.34岁男性，1980年斜坡脊索瘤外科手术切除，1982年随访中可见鞍上区肿瘤复发，患者接受放疗。48月后复查，临床和放射学表现都提示病情稳定,ChordomaAxial T2-weighted image demonstrates a hyperintense left extraaxial parasellar lesion (white arrow). 轴位T2左侧鞍旁轴外高信号病变,脊索瘤,Chondrosarcoma 软骨肉瘤Chondrosarcoma may originate from the petrocliva