中樞腦腫瘤教材講義

CentralNervousSystem

南京醫(yī)科大學一附院放射科洪汛寧hongxunning@2/3/20231IntracranialtumorsInthediagnosticwork-upofintracranialtumors,theprimarygoalsoftheimagingstudiesaretodetecttheabnormality,localizeanddetermineitsextent,characterizethelesion,andprovidealistofdifferentialdiagnosesor,ifpossible,thespecificdiagnosis.2/3/20232Imagingdiagnosis1.Isthereatumor?2.Ifyes,whereisitlocatedandwhatisitsfunctionaltopography?3.Whatdoesthetumorlooklikeandhowdoesitaffectthebrain?4.Coulditbesomethingelse,i.e.,anon-neoplasticlesion?5.Whatarethetherapeuticoptionsandwhatmightbetheprognosis?6.Canadvancedimagingmethodscontributetoimprovetherapyandoutcome?2/3/20233基本流程basicflowsheet核對資料checkdata臨床資料clinicaldata

影像資料imagingdata綜合分析得出診斷Analysistogetthediagnosis2/3/20234臨床資料clinicaldata姓名、性別、年齡

name、sex、age2/3/20235不同腫瘤有特定的好發(fā)年齡段新生兒最好發(fā)的腫瘤為畸胎瘤、原始神經(jīng)上皮腫瘤等2-10歲的兒童原發(fā)性腦腫瘤以后顱凹多見，多為良性。最常見的有毛細胞型星形細胞瘤、髓母細胞瘤、腦干膠質(zhì)瘤和第四腦室室管膜瘤年輕人，低度惡性星形細胞瘤多見中年人，間變型星形細胞瘤多見老年人，多形性膠母細胞瘤多見2/3/20236臨床資料clinicaldata病程course發(fā)病特點theonsetofillness既往病史history實驗室資料laboratorydata

治療情況treatment返回2/3/20237影像資料imagingdata定位Localization占位效應masseffect病灶形態(tài)theform病灶質(zhì)地（成分）Internaltexture影像診斷2/3/20238定位Localization部位location：大腦半球、鞍區(qū)、中線和幕下（腦干、橋小腦角、小腦半球、蚓部）位置position：腦內(nèi)、腦外、腦室內(nèi)2/3/20239腫瘤發(fā)病部位有其特征性腦內(nèi)腫瘤可顯示局部腦回腫脹、鄰近蛛網(wǎng)膜下腔變窄或閉塞、瘤周腦血管受壓移位等占位征象腦外腫瘤:腫塊區(qū)腦灰白質(zhì)向中央移位、局部腦血管和硬腦膜向內(nèi)移位、同側(cè)局部蛛網(wǎng)膜下腔增寬和腦膜尾征等腦膜瘤累及腦組織，腦轉(zhuǎn)移瘤合并腦膜和顱骨轉(zhuǎn)移時，鑒別較為困難2/3/202310發(fā)病部位最常見的幕上腦內(nèi)腫瘤為多形性膠母細胞瘤、轉(zhuǎn)移瘤；腦外腫瘤則為腦膜瘤最常見的幕下腦內(nèi)腫瘤為血管母細胞瘤和轉(zhuǎn)移瘤；腦外腫瘤則為神經(jīng)鞘瘤2/3/202311返回2/3/202312有或無要考慮兩類不同病變占位效應masseffect返回2/3/202313病灶形態(tài)theform大小dimension形狀shape輪廓contour數(shù)目number邊緣margin周圍結(jié)構Peripheralstructure返回2/3/202314病灶質(zhì)地（成分）

Internaltexture脂肪fat囊腫cyst骨骼skeleton鈣化calcification液化Liquefaction壞死necrosis囊變cysticdegeneration出血hemorrhage2/3/2023152/3/2023162/3/2023172/3/202318返回2/3/202319常見腦腫瘤影像診斷神經(jīng)膠質(zhì)瘤glioma腦膜瘤meningioma垂體腺瘤pituitaryadenoma顱咽管瘤craniopharyngioma聽神經(jīng)瘤acousticneuroma腦轉(zhuǎn)移瘤metastasis2/3/202320膠質(zhì)瘤（星形細胞腫瘤）最常見的腦腫瘤占顱內(nèi)腫瘤17%，占神經(jīng)上皮源性腫瘤40%幕上多見主要癥狀為癲癇2/3/202321幕上Ⅰ-Ⅱ星形細胞瘤CT：好發(fā)于額葉，其次顳葉、頂葉、小腦和腦干。平掃多表現(xiàn)為腦內(nèi)均勻的低密度病灶，邊界不清，增強多數(shù)不明顯。MR：T1WI略低信號，T2WI明顯高信號，輪廓規(guī)則或略不規(guī)則。一般無瘤周水腫，位于白質(zhì)。增強后常不增強或輕微增強。2/3/202322Astrocytoma2/3/202323Astrocytoma2/3/2023242/3/2023252/3/2023262/3/2023272/3/202328星形細胞瘤2/3/202329Anaplastic

astrocytomas(Grade3)Anaplastic

astrocytomas(Grade3)areveryaggressivetumors,readilyinfiltrateadjacentbrainstructures,andhaveauniformlypoorprognosis.2/3/202330Glioblastomamulti-formeGlioblastomamulti-forme

(Grade4)hastheaddedhistologicfeaturesofendothelialproliferationandnecrosis.Multicentricfocioftumormaybeseenin4to6%ofglioblastomas.Gliomatosis

cerebriisanunusualconditionwithdiffusecontiguousinvolvementofmultiplelobesofthebrain.2/3/202331幕上Ⅲ-Ⅳ級星形細胞瘤CT平掃密度多不均勻,以低密度或等密度為主的混合密度多見多有腦水腫增強掃描多有強化各級腫瘤均有占位征象2/3/202332幕上Ⅲ-Ⅳ級星形細胞瘤T1WI略低信號，T2WI略高信號信號可均勻或不均勻壞死、囊變、出血、鈣化、血管多有強化瘤周水腫2/3/202333glioblastoma2/3/202334glioblastoma2/3/202335ABLowvsHighGradeGlioma2/3/202336LowvsHighGradeGliomaCho/NAA2.60HighGraderCBV7.72A2/3/202337LowvsHighGradeGliomaCho/NAA2.60Cho/NAA0.90BLowGraderCBV1.70HighGraderCBV7.72A2/3/202338鑒別診斷低度惡性星形細胞瘤——乏血供。腦膜瘤——腦外占位征象。單發(fā)轉(zhuǎn)移瘤——環(huán)樣強化，周圍白質(zhì)大量水腫（指樣水腫），多有原發(fā)灶。淋巴瘤——較少見，多位于腦室周圍，明顯強化，水腫多較輕，大腦半球單發(fā)與本例難以鑒別。其他：腦血管病，腦膿腫。2/3/202339髓母細胞瘤MedulloblastomaThemostcommonpediatriccentralnervoussystemmalignancyandthemostcommonprimarytumoroftheposteriorfossainchildren.Occursmorefrequentlyinmalesandusuallybefore10yearsofage.Clinicalsymptomsandsignsaregenerallybrief,typicallylessthan3monthsinduration,andreflectthestrongpredilectionofthistumortoarisewithinthecerebellum,mostofteninthevermis.2/3/202340

Medulloblastoma.Photographofanautopsyspecimensectionedinthemidlineshowsafairlywell-circumscribedmass(m)ofthesuperiorcerebellar

vermis.2/3/202341medulloblastoma.Photomicrograph(hematoxylin-eosinstain)ofaclassicmedulloblastomarevealsmonomorphicsheetsofcloselyapposedsmallcellswithahighnuclear-cytoplasmicratio,occasionallyinterruptedbyneuroblasticrosettes(arrows).2/3/202342case1Medulloblastomaina6-year-oldgirlwitha10-dayhistoryofnauseaandvomiting.2/3/202343

AxialCTimageshowsaheterogeneoushyperattenuatedmassintherightcerebellarhemisphere.

2/3/202344OnanaxialT1-weightedMRimage,themasshashomogeneoushypointensitycomparedwithnormalcerebellarsignalintensity.2/3/202345OnanaxialT2-weightedMRimage,themassisheterogeneouswithsurroundingvasogenicedema.2/3/202346Contrast-enhancedaxialT1-weightedMRimageshowsheterogeneousenhancementofthemass.2/3/202347Case2Medulloblastomaina3-year-oldboywitha1-monthhistoryofprogressivelyworseningclumsiness,ataxia,headache,nausea,andvomiting.Developmentaldelayinspeechandmotorskillswasalsopresent.Papilledemawasnotedonphysicalexamination.2/3/202348AxialCTimageshowsanearlyhomogeneoushyperattenuatedmassintheposteriorfossamidline.Athincrescentofthefourthventricle(arrowheads)isnotedalongtheanteriormarginofthemass.2/3/202349OnanaxialT1-weightedMRimage,themassishypointensecomparedwiththesurroundingnormalcerebellum.2/3/202350OnanaxialT2-weightedMRimage,themassshowsmildhyperintensitycomparedwithsurroundingnormalbraintissue.2/3/202351Contrast-enhancedaxialT1-weightedMRimageshowsintensebutmildlyheterogeneousenhancementofthemass.2/3/202352Photographoftheresectedspecimenhighlightsthesoftfriablenatureofthemass,characteristicofamedulloblastoma.2/3/202353腦膜瘤meningiomaTypicallyhard,firm,rubberytumorsAbroadbaseofduralattachment

Thecelloforiginforthemeningiomaisactuallythe

arachnoidcell,thearachnoidcapcell

2/3/202354

腦膜瘤

2/3/2023552/3/2023562/3/2023572/3/2023582/3/2023592/3/2023602/3/2023612/3/202362TheDuralTailSignTheduraltailsignisseenoncontrastmaterial–enhancedmagneticresonanceimagesasathickeningoftheenhancedduramaterthatresemblesatailextendingfromamass.2/3/202363腦膜瘤meningiomaCT平掃

于好發(fā)部位見圓、卵圓、扁平或分葉狀稍高密度腫塊密度均勻，邊緣清楚，光滑多數(shù)病灶周圍有腦水腫占位征明顯,鄰近骨質(zhì)增生或破壞CT增強明顯均勻強化（homogeneousenhancement），邊界銳利2/3/202364腦膜瘤meningiomaTypicallyglobular,sometimeslobulated

massesattachedtotheduraComparativelylittleedemaSharpmarginsEnhancehomogeneously

Hyperostosis

15%–50%

Duralthickening,abnormal

duralenhancementextendbeyondthesiteofattachment.

2/3/202365

MRIT1呈稍低信號或等信號，T2呈稍高信號或等信號。增強掃描腫瘤明顯增強（hyperintensity），常能顯示腦膜尾征（duraltail）。2/3/202366腦膜瘤纖維型2/3/202367FA：纖維受壓推移，高信號，信號強度：0.81PseudoDW：低等信號ADC：高等信號ADC值：0.772-0.853DWI：稍高信號（T2效應）腦膜瘤纖維型2/3/202368病側(cè):無NAA峰

Cho峰出現(xiàn)Ala峰

Cho/對側(cè)Cr=0.34腦膜瘤MRST1WIT1WIC+健側(cè)常規(guī)MRI見腫瘤呈良性腦膜瘤表現(xiàn)。MRS也呈良性腦膜瘤表現(xiàn)。2/3/2023692/3/202370惡性腦膜瘤AlaT1WIT1WIC+NAA峰Cho峰出現(xiàn)Ala峰Cho/對Cr=3.3腫瘤邊緣Cho峰常規(guī)MRI見腫瘤呈良性腦膜瘤表現(xiàn)。MRS呈惡性腦膜瘤表現(xiàn)。2/3/2023712/3/202372垂體腺瘤pituitaryadenomaCT

以冠狀位為佳，大腺瘤垂體高度大于正常值（1cm），密度均勻或不均勻，邊界清，上緣局限性隆起，垂體柄常傾斜，鞍底下陷。CT增強作用明顯，較均勻，可有邊界不清或壞死區(qū)。2/3/202373垂體大腺瘤2/3/202374PituitarymicroadenomasT1WI,usuallyhypointensecomparedwiththenormalgland.T2WI,slightlyhyperintenseThecontrastisbetteront1wi.Secondarysignsincludeasymmetricupwardconvexityoftheglandsurface,deviationoftheinfundibulum,andfocalerosionofthesellarfloor.Coronalandsagittalarethepreferredimagingplanesforpituitaryadenomas.2/3/202375Pituitary

macroadenomaIsointensetothenormalglandandbrainparenchyma,unlesscysticorhemorrhagiccomponentsarepresent.HemorrhageCentralnecrosisisnotcommonPituitaryapoplexyreferstoacutehemorrhagicnecrosisofamacroadenoma,andpatientsmaypresentwithsymptomsrelatedtomasseffectofthehematomaorassociatedsubarachnoidhemorrhage.2/3/202376垂體微腺瘤2/3/202377垂體微腺瘤動態(tài)增強2/3/202378垂體微腺瘤2/3/202379垂體腺瘤侵及海綿竇2/3/2023802/3/2023812/3/202382T1WI2/3/202383T2WI2/3/202384T1WIC+2/3/202385T1WI2/3/202386T1WI2/3/202387顱咽管瘤craniopharyngioma多見于兒童（occurmostcommonlyinpediatricagegroup）分囊性（cystic）、實性（solid）和囊實性（intermixed）三種2/3/202388Originatefromepithelialremnantsofrathke'spouch,usuallyatthejunctionoftheinfundibulumandthepituitarygland.Benignslow-growingtumorscomposedofbothsolidepithelialtissueandcysticcomponents.Thecystscontainvariableamountsofcholesterol,keratin,necroticdebris,proteinaceousfluidandhemorrhage.Calcificationispresentin75to85%ofcases.Craniopharyngioma2/3/202389

X線平片：

瘤體位于鞍上（suprasellarregion）,

顯示殼狀鈣化（curvilinearcalcificrim）,實質(zhì)性可有斑片狀鈣化（scatteredcalcification）CT平掃顯示鈣化清晰囊實性腫塊增強實質(zhì)區(qū)強化2/3/202390CraniopharyngiomaVariableappearanceonMR,dependingontheirsolidorcysticnatureandcystcontents.ThesolidlesionsarehypointenseonandhyperintenseonT2WI.ThecystsalsohavealongT2,butiftheyhaveahighcholesterolcontentormethemoglobin,shorteningofT1resultsinhighsignalintensityonT1WI.CalcificationisnotreliablydetectedwithMRI2/3/202391囊性顱咽管瘤2/3/202392囊性顱咽管瘤鈣化2/3/202393實性顱咽管瘤2/3/202394顱咽管瘤2/3/202395顱咽管瘤2/3/2023962/3/202397顱咽管瘤2/3/202398Craniopharyngioma—Cystic2/3/202399Craniopharyngioma—solid2/3/2023100Craniopharyngioma—intermixed2/3/2023101聽神經(jīng)瘤Schwannomasmostcommonlyoccurinthecerebello-

pontineanglecistern(acousticneurinomas,

>80%ofextra-axialtumorsinthisregion)2/3/2023102聽神經(jīng)瘤

（acousticneurinoma）X線平片：內(nèi)聽道擴大（enlargementoftheinternalauditorycanal）CT：內(nèi)聽道擴大，橋小腦角區(qū)腫瘤（cerebellopontineanglemass），囊實性，四腦室移位，增強明顯2/3/2023103MRI：混雜信號，增強明顯，微小腫瘤更敏感2/3/20231042/3/20231052/3/20231062/3/20231072/3/20231082/3/20231092/3/2023110聽神經(jīng)瘤2/3/2023111女性，31歲，右耳聽力