1、脊柱CT和MRI检查偶然发现的病变,偶发病变?,与主诉无明显关系的病变,发现偶发病变重要性何在?,影响临床决策影响患者预后,认识偶发病变对影像科医生很重要!,18,860 lawsuits demonstrated that 47% of the radiology lawsuits related to missed diagnosesBerlin L, Berlin JW. Malpractice and radiologists in Cook County, IL: trends in 20 years of litigation. AJR Am J Roentgenol 1995;1
2、65:781e8,同行的关注,Lung cancer detected at cardiac CT: prevalence, clinicoradiologic features, and importance of fullfield-of-view images. Radiology 2010;255(2):369376.Unsuspected extracolonic findings at screening CT colonography: clinical and economic impact. Radiology 2008;249(1):151159.Extracolonic
3、abnormalities discovered incidentally at CT colonography in a male population. Radiology 2005;236(2):519526.,Extracardiac findings on coronary CT angiograms: limited versus complete image review. AJR Am J Roentgenol 2010;195(1):143148.Incidental findings on cardiac imaging. AJR Am J Roentgenol 2008;
4、191(3):882884.Incidental findings found in “healthy” volunteers during imaging performed for research: current legal and ethical implications. Br J Radiol 2010;83(990):456465.,3488例CT检查40%患者偶然发现病变14%进行额外检查0.8%进行积极治疗,Xiong T, Richardson M, Woodroffe R, et al. Incidental lesions found on CT colonograp
5、hy: their nature and frequency. Br J Radiol 2005;78:22e9,脊柱偶发病变?,除脊柱和椎管内病变以外的病变,一个回顾性研究分析100例腰椎CT(平均年龄68岁)均以后背疼痛来诊3例发现腹主动脉瘤,直径均大于4cm,认为腰椎扫描时,如果患者年龄大于55岁,出现后背疼痛,应推荐大FOV进行腰椎扫描Gouliamos AD, Tsiganis T, Dimakakos P, et al. Screening forabdominal aortic aneurysms during routine lumbar CT scan:modificatio
6、n of the standard technique. Clin Imaging 2004;28:353e5.,一项对2500例腰椎MRI 进行回顾性分析,183个患者发现202例偶发病变病变主要位于肾脏、肝脏、子宫、肾上腺和淋巴结5例为恶性病变,1例转移瘤,Wagner SC, Morrison WB, Carrino JA, et al. Picture archiving and communication system: effect on reporting of incidental findings. Radiology 2002;225:500e5.,一个对300例患者进行的
7、腰椎MRI检查,发现25个偶发病变Green L. PACS: effect on incidental findings. Radiol Manage 2004;26:26e9,MRI检查可能发现的偶发病变,椎旁软组织结构FOV 范围内器官结构,颈椎MRI需额外观察?,有无肿大淋巴结、肿块腮腺或甲状腺病变鼻咽部有无异常,矢状位:颅内情况、有无扁桃体下疝旁正中矢状位:评估颈动脉情况,尤其创伤患者应观察有无栓子,Thyroid lesions不论良性或恶性在T2WI 信号均不均匀MRI 很难鉴别良恶性偶发的甲状腺孤立结节需进行临床进一步检查、如超声、穿刺活检、核医学显像,胸椎观察?,胸椎胸壁胸腔
8、肺:SPN(Solitary pulmonary nodule)纵膈结构推荐:轴位,Figure 3 A 69-year-old male smoker presented withabnormalities of gait. Cervicothoracic MRI revealeda solitary pulmonary nodule in the right lung. This wasfurther investigated with CT,腰椎观察?,腹膜后、腹腔、盆腔器官腹壁结构应结合矢状位进行附件结构观察,Hepatic lesionsRenal lesionsPelvisUter
9、usAortaLymph nodes,冠状位可对椎旁结构进行总体评估可确定在其它序列发现的异常,Hepatic lesions肝囊肿需与血管瘤鉴别出血囊肿信号不均匀良恶性病变鉴别需进一步检查,Renal lesions肾囊肿最常见注意囊性肾癌约5-10%肾癌呈囊性病变,如果脊柱MRI表现不能解释患者临床症状 应对椎旁结构进行观察,Pelvis盆腔器官盆壁结构,F/64 后背疼伴左下肢放射性疼痛,Uterus正常子宫内膜在T2WI呈高信号增生表现为子宫内膜弥漫增厚绝经后妇女如果内膜厚度大于4mm,异常,子宫肌瘤那氏囊肿,F/65后背疼,Ovarian lesions卵巢囊肿子宫内膜异位卵巢肿瘤,
10、Aorta腹主动脉瘤胸主动脉瘤,M/85 后背疼,Lymph nodes主动脉旁肿大淋巴结,小结,脊柱的偶发病变在MRI常见的可能比脊柱本身的病变更重要放射科医生任务在于发现、定性、报告这些病变,一个系统的脊柱MRI 应包括除对脊柱本身病变的观察同时应发现尤其对临床有意义的偶发病变,脊柱CT偶然发现的病变,Extraspinal Findings at Lumbar Spine CT Examinations: Prevalence and Clinical Importance2012 march Radiology,Purpose 回顾性分析400例门诊患者进行腰椎CT检查时发现的脊柱外病
11、变的情况,Materials and Methods:年龄:平均49岁212例男性188例女性主要临床症状腰痛、根性疼痛,排除已知罹患恶性肿瘤患者观察原始图像以最大FOV重建FOV :16CM层厚和层间距:2.5mm、1.5mm,病变分级系统Colonography Reporting and Data System (C-RADS)Zalis ME, Barish MA, Choi JR, et al. CT colonography reporting and data system: a consensus proposal. Radiology 2005;236(1):39.,C-RA
12、DS E1 :正常解剖变异C-RADS E2 :无明显临床意义病变,无需进一步处理的病变,如肾脏单纯囊肿、憩室,C-RADS E3 :不典型病变,可能是良性的,需进行临床随诊或处理的病变,如复杂肾囊肿C-RADS E4 :有重要临床意义的病变,需临床处理的病变,如实性肾脏肿块、腹主动脉瘤,随访对脊柱外C-RADS E3 and E4病变进行 2436 months,Results400例患者中其中162例(40.5%)发现脊柱外的病变160例中其中127例(79.4%)采用最大FOV清楚显示脊柱外病变33例患者发现2个病变3例患者有3个病变病变总数: 201,C-RADS E1 :2例分别左侧
13、下腔静脉、双集合系统,TABLE1summarizes the data in 160 patients with C-RADS E2, E3, or E4 extraspinal findings.,C-RADS E2 :最多,101例以憩室和肾脏单纯囊肿为主,Classification of All C-RADS E2 (Benign) Extraspinal Findings according to Organ System and Frequency,C-RADS E3:42例其中1例患者发现2处E3病变最常见的病变为肾脏病变腹主动脉扩张在2.6-2.9cm之间也进行随诊,42例C
14、-RADS E3患者中39 例(92.9%)中以前不知晓其中14例患者进行进一步检查包括CT(7) MR(1) US(14)检查,,C-RADS E4: 17 (4.3%)最常见为腹主动脉瘤13例腹主动脉扩张直径大于3cm,其中8例患者以前不知晓,左侧肾癌,最常见的病变为肾脏病变腹主动脉扩张在2.6-2.9cm之间也进行随诊,总结,成人由于腰痛或根性疼痛而进行腰椎CT检查发现脊柱外病变几率约40%79.4%的脊柱外病变需扩大FOV可观察清楚其中约60%病变为良性或无需进一步处理14.8%病变需进行临床处理,可行性探讨,扩大FOV 可观察到更多病变但在绝大多数影像中心不可行对我们意义?,谢谢!,