磁敏感加权成像在脑胶质瘤诊疗中的应用进展.pdf

国际医学放射学杂志 23 Jul鸦46穴4雪磁敏感加权成像在脑胶质瘤诊疗中的应用进展涂佳琪1，朱凤平2，李郁欣1*【摘要】脑胶质瘤是中枢神经系统发病率最高的恶性肿瘤，预后极差。磁敏感加权成像（SWI）可用于了解脑胶质瘤周围的静脉分布和走行，对于胶质瘤的准确诊断和治疗方案的制定具有重要意义。综述SWI在脑胶质瘤鉴别诊断、预测分级和分子分型、术前规划及术中指导中的研究进展。【关键词】磁敏感加权成像；胶质瘤；脑静脉；脑静脉成像；磁共振成像中图分类号：R739.41；R445.2文献标志码：AAdvances in the application of susceptibility-weighted imaging in the diagnosis and treatment of brain gliomasTU Jiaqi1,ZHU Fengping2,LI Yuxin1.1 Department of Radiology,Huashan Hospital,Fudan University,Shanghai 200040,China;2 Department of Neurosurgery,Huashan Hospital,Fudan University.Corresponding author:LI Yuxin,E-mail:【Abstract】Glioma is the most common malignant tumor of the central nervous system and is associated withextremely poor prognosis.In the management of glioma,susceptibility-weighted imaging(SWI)can be used to observe veindistribution and orientation surrounding gliomas.This information is crucial for accurate diagnosis and treatment planning.Inthis article,we review the progress made in the application of SWI in various aspects of glioma management,includingdifferential diagnosis,predictive grading and molecular staging,preoperative planning,and intraoperative guidance.【Keywords】Susceptibility-weighted imaging;Glioma;Cerebral veins;Cerebral venography;Magnetic resonanceimaging ，23，46（4）：414-416作者单位：1复旦大学附属华山医院放射科，上海200040；2复旦大学附属华山医院神经外科通信作者：李郁欣，E-mail：*审校者基金项目：上海市科技计划项目（20511101100）DOI:10.19300/j.2023.Z20320综述神经放射学脑胶质瘤是中枢神经系统（central nervoussystem,CNS）发病率最高的恶性肿瘤，约占CNS恶性肿瘤总数的80%，预后极差，手术切除是其首选治疗方式1-2。损伤重要的静脉结构是发生术后并发症最常见的原因之一3。高分辨静脉成像技术可用于脑胶质瘤的诊断、分级及分子分型预测，从而改善脑胶质瘤病人临床管理。本文简要介绍磁敏感加权成像（susceptibility-weighted imaging,SWI）技术，综述SWI在脑胶质瘤诊断和治疗中的临床应用。1基于 SWI 的大脑静脉影像SWI是一种以T2*加权梯度回波序列为基础的三维高分辨MRI技术，于1997年首次提出4。SWI由4组图像组成，包括磁矩图、滤波相位图、SWI图和最小强度投影（minimumintensityprojection,MinIP）图像，其中MinIP是SWI对颅内静脉实现可视化成像的主要图像5。SWI利用脱氧血红蛋白磁敏感效应，能够在不使用对比剂的情况下对颅内静脉进行高敏感成像，具有极好的对比度和分辨率6-7。由SWI衍生的定量磁化率成像（quantitative susceptibility mapping,QSM）还能定量分析静脉血氧饱和度8，其应用范围较SWI更为广泛。随着SWI技术的发展，研究者开始将其用于大脑静脉成像9。Cai等10发现SWI可清晰观察到脑干周围的静脉网络，提示SWI可以有效检测后颅窝静脉，为颅内胶质瘤的术前规划与术中导航提供了可靠的技术保障。Zhang等11采用SWI技术对丘脑纹状体静脉（thalamostriate vein,TSV）与尾状核前静脉（anterior caudate vein,ACV）的变异类型进行成像，发现TSV具有丰富的侧支循环，该结果不仅为解剖学研究提供了证据，还对神经外科术中静脉的安全闭塞提供了：414-416414国际医学放射学杂志 23 Jul鸦46穴4雪解剖依据。综上所述，对于无MRI禁忌证的人群，采用SWI对颅内静脉成像是一种较好的选择。2SWI 在脑胶质瘤诊断中的价值2.1鉴别诊断高级别胶质瘤（high-grade gliomas,HGG）、脑转移瘤（brain metastases,BM）和原发性中枢神经系统淋巴瘤（primary central nervous systemlymphoma,PCNSL）是大脑深部结构常见的3种脑恶性肿瘤，三者的鉴别诊断具有挑战性。SWI可用于鉴别HGG、BM和PCNSL，Yang等12分析HGG、BM和PCNSL病人的SWI影像发现，病灶周边的髓静脉常终止于BM的边缘，而HGG和PCNSL病人瘤周的髓静脉则会穿过肿瘤实体，据此鉴别3种肿瘤具有较高的敏感度（76.9%）和特异度（100%）。Ozturk等13采用SWI与扩散加权成像（DWI）鉴别PCNSL和不典型胶质母细胞瘤，具有较高的敏感度（100）及特异度（87.1）。Bozda g等14使用表观扩散系数（ADC）与从SWI中所获取的瘤内磁敏感信号（intra-tumoral susceptibility signal，ITSS）等级也能够鉴别HGG和BM。由此可见，SWI与常规MRI序列结合可以提高对胶质瘤与其他肿瘤的鉴别诊断能力。SWI不仅能对以上3种肿瘤进行鉴别诊断，还可用于区分HGG复发和颅内放射性坏死。Qin等15通过半定量分析SWI上的低信号强度比率发现，SWI鉴别HGG复发和放射性坏死具有较高的诊断效能（AUC=0.87）。2.2预测分级肿瘤形成血管的能力被认为是肿瘤进展、维持生长和改变侵袭力的关键特征之一。随着肿瘤分级的增加，胶质瘤中的平均血管密度也会增加16。SWI是描述脑肿瘤血管结构以及微出血的有效工具，可利用ITSS作为量化评估指标，能够反映与肿瘤微出血、钙化和肿瘤新生血管相关的大量顺磁性物质的存在，其检测这些物质的敏感度优于常规MRI序列（T1WI、T2WI、增强扫描和扩散成像等）17。根据ITSS评分能够对肿瘤内部细微线状或点状的低信号进行分级，与脑胶质瘤分级相关。Saini等16比较级、级和级脑胶质瘤的ITSS评分发现，和级胶质瘤间、和级胶质瘤间的ITSS评分差异均有统计学意义。此外，Bhattacharjee等18在原有ITSS定量方法上进行了更新，更新后的方法可以特异性寻找并过滤ITSS中的出血及钙化信号，并最终以肿瘤内的血管体积作为ITSS评分的内容。结果表明该方法在区分和级（敏感度87.44，特异度98.41）、和级（敏感度97.15，特异度94.12）、和级（敏感度98.72，特异度92.31）胶质瘤时均具有很好的分级诊断效能。2.3预测分子分型分子标志物在胶质瘤的诊疗过程中发挥重要作用19。若能在术前精准预判分子标志物信息，有助于临床医师做出恰当的诊断结论和选择适宜的治疗方案。Kong等20回顾性搜集脑胶质瘤病人的SWI影像，分析其影像学特征与IDH1、MGMT等分子标志物之间的相关性。结果发现IDH1突变型胶质瘤ITSS评分显著低于IDH1野生型，MGMT甲基化的胶质瘤的ITSS评分显著低于非甲基化MGMT的胶质瘤；但1p19q缺失状态与ITSS评分未见明显关联。为了评估不同成像方法对胶质瘤病人1p19q缺失状态的预测价值，Yang等21将SWI与常规MRI、DWI、动态磁敏感对比灌注加权成像数据结合，获得区分1p19q缺失状态的最大受试者操作特征曲线下面积为0.88，敏感度和特异度分别为80.36%和78.57%。3SWI 在胶质瘤治疗中的价值3.1术前规划术前决定手术入路与术区范围是脑胶质瘤手术切除不可或缺的环节。手术入路与靶区的选择与切除范围和病灶周围复杂血管解剖密切相关22，术前采用高分辨颅内静脉成像有助于为病人的手术提供更多丰富的信息。SWI对于颅内静脉具有成像对比度高的优势，有利于为神经外科医师提供病人详细的大脑静脉解剖信息10-11。将SWI与功能MRI结合可以为临床医师及病人提供一个更为完善的术前规划方案。此外，借助SWI观察静脉的侧支循环体系，也有利于辨别可能引起神经功能障碍的闭塞小静脉23-24。对于不适合立即手术切除的胶质瘤病人，SWI能为立体定向活检术提供术前参考信息。Tanji等25研究发现，术前ITSS分级较高是立体定向活检术后出血的高危风险因素，提示对于位于功能区旁的脑胶质瘤，尤其是ITSS 3级的病人，应首先考虑通过内镜或开颅术进行开放活检而非立体定向活检术，这样有利于降低术后出血的风险。因此，对于脑胶质瘤病人来说，术前行SWI十分必要。3.2术中指导对于大脑深部组织的胶质瘤，稳定且易识别的解剖定位可以有效地降低手术操作难度。术前在SWI影像上发现的可被识别的大脑深部静脉能够作为特定的解剖定位标志，利于医生开展术中导航26。Opoku-Darko等27在手术切除位于胼胝415国际医学放射学杂志 23 Jul鸦46穴4雪体的胶质母细胞瘤时，根据大脑大静脉及其汇入支等标准的解剖学标志来界定强化的肿瘤，并通过合理的术中操作能够延长病人的生存时间。4小结脑胶质瘤预后极差，严重影响病人生存质量。SWI技术作为脑静脉成像之一，不仅可以清晰显示肿瘤与周围静脉的关系，还可获得肿瘤内部丰富的微环境信息，从而提升诊断效能，帮助细化分级，指导手术方案。同时，SWI与其他序列的联合使用，也将在胶质瘤的诊疗过程中发挥更大的作用。参考文献：1LI T,LI J,CHEN Z,et al.Glioma diagnosis and therapy:currentchallenges and nanomaterial-based solutionsJ.J ControlledRelease,2022,352:338-370.DOI:10.1016/j.jconrel.2022.09.065.2MOLINARO A M,HERVEY-JUMPER S,MORSHED R A,et 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