多参数磁共振成像对后巩膜炎临床诊断的应用研究

发布时间：2018-07-12 19:32

本文选题：后巩膜炎 + 多参数磁共振成像　；参考：《第三军医大学》2017年硕士论文

【摘要】：研究背景与目的:后巩膜炎(posterior scleritis,PS)是一种罕见的发生于眼球赤道后部及视神经周围的巩膜炎症[1],严重时可累及邻近脉络膜、视网膜和视神经,导致视觉功能损害[2]。由于该病变位置较深,临床表现多样,是眼科易误诊的可治疗疾病之一[3],当被误诊为眼底肿瘤如脉络膜黑色素瘤时,常引起不必要的眼球摘除术[4],造成不可逆的严重后果。目前PS的诊断主要通过超声表现和临床病史[5],然而超声的诊断稳定性和软组织分辨率欠佳,且部分PS患者的超声表现常常未发现异常,因此PS尚缺乏有效的诊断方法[6]。长期、递减、足量的糖皮质激素全身或局部应用可使多数PS患者炎症迅速减轻和控制[7-8]。但仍小部分PS患者糖皮质激素疗效不佳。而盲目使用糖皮质激素,会诱发或加重感染,引起物质代谢和水盐代谢紊乱、骨质疏松和胃肠道出血等[9]。因此,准确预测糖皮质激素对PS的疗效对于临床制定正确的治疗方案非常重要。目前针对PS的病理生理机制、临床诊治均有研究报道,但尚无有效的预后评估手段。近年来,磁共振成像(MRI)越来越多地应用于PS的研究中[10-12]。其中高分辨率扩散加权成像(Readout segmentation of long variable echo-train diffusion-weighted imaging,RESOLVE-DWI)是一项能检测活体组织内水分子扩散运动的无创性方法[13],与常规扩散加权成像(diffusion-weighted imaging,DWI)相比,RESOLVE序列可提高DWI图像质量,降低运动伪影、畸变伪影及模糊效应,目前已广泛应用于人体多个部位及其疾病的研究,包括乳腺肿瘤、肝脏肿瘤和脑卒中等[14-15]。RESOLVE-DWI通过表观扩散系数(apparent diffusion coefficient,ADC)值可以反映病灶组织的水分子扩散运动。同时常规MRI及增强扫描可以直观地显示正常或病变组织解剖结构上的变化[16-17]。多参数磁共振成像(multi-parametric MRI,Mp-MRI[18])作为一种扫描参数多、成像序列多、软组织分辨率高且安全无辐射的检查技术,已广泛运用于各类疾病的病理机制、诊断、治疗及预后研究中。国内外关于PS的Mp-MRI表现报道较少。基于此,本研究中Mp-MRI结合了常规MRI、增强MRI和RESOLVE-DWI,本文研究目的:(1)比较分析Mp-MRI和超声对PS的诊断价值;(2)评价Mp-MRI在预测糖皮质激素治疗对后巩膜炎的疗效中的价值。材料与方法:1.病例资料本研究第一部分:招募我院2014年9月至2017年1月期间眼底占位病变患者共56名(83眼),男性24例,女性32例,年龄18~85岁,平均(52.8±19.3)岁,病程3d~2年。56例患者共检测到病灶85个,均为单发。经PS金标准或病理证实,其中PS30例(40眼),脉络膜黑色素瘤13例(22眼),脉络膜血管瘤5例(8眼)和眼眶炎性假瘤8例(13眼)。本研究第二部分:本研究第一部分中的30例PS患者中未经糖皮质激素治疗且在我院眼科门诊初次就诊的PS患者28例(38眼),其中男12例,女16例,年龄18~83岁,平均(48.0±19.9)岁,病程5d~1年。2.设备与方法本研究第一部分:磁共振检查采用Siemens Tim Trio 3.0T磁共振仪,超声检查采用法国IneScan S型眼用超声仪。所有患者均行Mp-MRI和超声检查。由3名从事5年以上的诊断工作放射科医生和超声医生分别观察分析眼底病变的MRI结果(包括形态、边界、边缘及内部强化表现)和超声表现。用IBM SPSS Statistics Version 19.0统计学软件依据PS金标准分别计算Mp-MRI和超声诊断PS的敏感度、特异度、准确率、阳性似然比、阴性似然比;用Med Calc 16.0统计学软件绘制受试者操作特性(receiver operating characteristic,ROC)曲线,计算ROC曲线下面积(area under the curve,AUC),并用Z检验比较两组间AUC,P0.05为差异有统计学意义。本研究第二部分:磁共振检查采用Siemens Tim Trio 3.0T磁共振仪。本研究第一部分中的30例PS患者中未经糖皮质激素治疗且在我院眼科门诊初次就诊的PS患者28例(38眼)于糖皮质激素治疗(口服泼尼松片1mg/kg,每2周减10mg,直至10mg维持至治疗结束)前1天、治疗后2周、治疗后4周、治疗后12周及治疗结束后4周行Mp-MRI检查。由3名从事5年以上的诊断工作放射科医生于前1天、治疗后2周、治疗后4周、治疗后12周及治疗结束后4周,在不知道患者分组的情况下于ADC图避开囊变、坏死出血区,手工勾画出病灶感兴趣区(region of interest,ROI),测3次ADC值,结果取平均值。病灶边界参考常规MRI和增强MRI图像,手动勾画出病灶边界。测量糖皮质激素治疗前1天、治疗后2周、治疗4周、治疗后12周和治疗结束后4周测量PS病灶的轴位最大径,测3次求平均值,计算最大径退缩率,公式为:最大径减少率=[(治疗前最大径-治疗后最大径)/治疗前最大径]×100%。计算糖皮质激素治疗前后ADC值的变化率(?ADC),公式为:?ADC=[(治疗后ADC值-治疗前ADC值)/治疗前ADC值]×100%。采用IBM SPSS Statistics Version 19.0软件进行统计学分析,计量资料以“均数±标准差”((?)±s)形式表示,P0.05为差异有统计学意义。对糖皮质激素治疗前、后有效组和无效组的PS病灶最大径、ADC值的组间比较采用两独立样本t检验;对糖皮质激素治疗前、后有效组和无效组的PS病灶最大径、ADC值的组内比较采用配对样本t检验;对糖皮质激素治疗前PS病灶ADC值与治疗前最大径、治疗前PS病灶ADC值与最大径退缩率、治疗后PS病灶ADC值与治疗后最大径及治疗后?ADC与最大径退缩率采用Spearman相关性分析;用MedCalc 16.0统计学软件绘制ROC曲线分析糖皮质激素治疗前ADC值预测糖皮质激素疗效的价值,确定其阈值,P0.05为差异有统计学意义。结果:本研究第一部分:MP-MRI检查结果显示,PS病灶呈结节型(13例18眼)和弥漫型(10例15眼)。31个PS病灶T1WI呈等信号,T2WI呈低信号,RESOLVE-DWI扩散稍受限,ADC呈等信号,增强时明显均匀强化;其余2个PS病灶T1WI呈等信号,T2WI呈高信号,RESOLVE-DWI扩散稍受限,ADC呈低信号,增强时明显均匀强化。“T”形征(由于视神经和后巩膜周围的筋膜囊炎性水肿形成T形)可见于15例(24眼),占72.7%。超声检查结果显示,PS病灶呈结节型(6例7眼)和弥漫型(10例12眼),所有病灶成均匀中等或强回声,血流信号少,声衰减不明显。“T”形征见于9例(12眼),占70.6%。Mp-MRI与超声检查结果差异有统计学意义(χ2=4.364,P=0.037)。Mp-MRI和超声诊断PS的敏感度、特异度、准确率、阳性似然比、阴性似然比分别为82.5%、90.7%、83.1%、8.87、0.19和47.5%,88.4%,35.9%,4.08,0.59,两者AUC分别为0.883、0.726,差异具有显著的统计学意义(Z=2.542,P=0.011)。本研究第二部分:依据糖皮质激素疗效评价标准,将28例(38眼)患者分为有效组17例(24眼)和无效组11例(14眼)。有效组与无效组的PS患者在性别、年龄及病程差异无统计学意义(P0.05)。糖皮质激素治疗前PS病灶有效组ADC值(1.36±0.11)×10-3 mm2/s明显高于无效组(1.12±0.41)×10-3 mm2/s,差异有统计学意义(P=0.036);治疗后2周,有效组ADC值(1.45±0.14)×10-3 mm2/s,比治疗前ADC值明显升高(P0.01)。此时无效组ADC值(1.14±0.37)×10-3 mm2/s,比治疗前稍升高,差异无统计学意义(P=0.285);治疗后4周、12周及结束后4周,PS病灶有效组ADC值分别为(1.53±0.13)×10-3 mm2/s,(1.60±0.13)×10-3 mm2/s和(2.01±0.14)×10-3 mm2/s较治疗前明显增高,差异均有统计学意义(P0.01),而无效组未见明显变化。糖皮质激素治疗前ADC值的ROC曲线的AUC为0.747,ADC值=1.33×10-3 mm2/s作为糖皮质激素治疗有效的阈值,预测治疗有效的敏感性和特异性分别为87.5%和75.0%。结论:本研究第一部分,通过比较分析Mp-MRI与超声对PS的诊断价值得出:Mp-MRI对PS的诊断价值高于超声,Mp-MRI不仅可以早期明确诊断,还能准确判断炎症渗出累及范围。当临床高度怀疑PS时,Mp-MRI可以作为重要的检查手段。本研究第二部分,通过评价Mp-MRI在预测糖皮质激素治疗对PS患者的疗效中的价值得出:糖皮质激素治疗中PS病灶ADC值变化早于最大径的改变。MP-MRI通过监测糖皮质激素治疗前PS病灶ADC值和治疗后2周ADC值,有助于早期预测糖皮质激素治疗的疗效。
[Abstract]:Background and purpose: posterior scleritis (PS) is a rare [1] that occurs in the posterior portion of the equator and around the optic nerve. It can be involved in the adjacent choroid, retina, and optic nerve, causing visual impairment. [2]. is a difficult to be misdiagnosed in the Department of Ophthalmology because of the deep location of the lesion and the variety of clinical manifestations. [3], one of the medical diseases, is often misdiagnosed as a fundus tumor such as choroidal melanoma, which often causes unwanted enucleation of [4] and causes irreversible serious consequences. The current diagnosis of PS is mainly through ultrasound and clinical history of [5]. However, the diagnostic stability and soft tissue resolution of ultrasound are poor, and the ultrasonic manifestations of some PS patients are frequent. No abnormalities are often found, so PS still lacks an effective diagnostic method, [6]. long-term, diminishing, full or local application of sufficient glucocorticoids can reduce and control [7-8]. in most PS patients, but the effect of glucocorticoids in small part of PS patients is not good. It is very important to predict the effect of glucocorticoid on PS for [9]., so it is very important to predict the curative effect of glucocorticoid to the clinic. At present, the pathophysiological mechanism and clinical diagnosis and treatment of PS have been reported, but there is no effective method of pre evaluation. In recent years, magnetic resonance imaging (MRI) has become more and more important. The more applied to the research of PS, [10-12]. in which high resolution diffusion weighted imaging (Readout segmentation of long variable echo-train diffusion-weighted imaging, RESOLVE-DWI) is a non invasive method to detect the diffusion motion of water molecules in the living tissue. I) compared, the RESOLVE sequence can improve the quality of DWI image, reduce motion artifact, distortion artifact and fuzzy effect. It has been widely used in the study of many parts of human body and its diseases, including breast tumors, liver tumors and cerebral pawns with the value of apparent diffusion coefficient (apparent diffusion coefficient, ADC). The diffusion movement of water molecules in the tissue of the lesion and the conventional MRI and enhanced scan can directly display the changes in the anatomical structure of the normal or diseased tissue. [16-17]. multi parameter magnetic resonance imaging (multi-parametric MRI, Mp-MRI[18]) is used as a scanning technique with many scanning parameters, multiple imaging sequences, high resolution of soft tissue and safe and free radiation. It has been widely used in the pathological mechanism, diagnosis, treatment and prognosis of various diseases. There are few reports on the Mp-MRI performance of PS at home and abroad. Based on this, Mp-MRI combined with conventional MRI, enhanced MRI and RESOLVE-DWI. The purpose of this study is: (1) compare and analyze the diagnostic value of Mp-MRI and ultrasound to PS; (2) evaluate Mp-MRI in predicting sugar cortex. The value of hormone therapy in the treatment of posterior scleral inflammation. Materials and methods: 1. case data: Part 1: 56 cases (83 eyes), 24 men, 32 women, average age (52.8 + 19.3) years old, and 85 cases of.56 in the course of disease, and 85 of the lesions were detected in our hospital from September 2014 to January 2017. By PS gold standard or pathology, PS30 cases (40 eyes), choroidal melanoma in 13 cases (22 eyes), choroidal hemangioma 5 cases (8 eyes) and orbital inflammatory pseudotumor 8 cases (13 eyes). The second part of this study: 30 cases of PS patients in the first part of this study, without glucocorticoid treatment and the first treatment of PS patients in our ophthalmology clinic 28 Cases (38 eyes), of which 12 men and 16 women, age 18~83 years, average (48 + 19.9) years old, the course of disease 5d~1.2. equipment and methods of the first part of the study: magnetic resonance imaging using Siemens Tim Trio 3.0T magnetic resonance apparatus, ultrasound examination using the French S type ophthalmic sonography. All patients were performed Mp-MRI and ultrasound examination. 3 persons engaged for more than 5 years. Diagnostic work radiologists and ultrasound doctors observed the MRI results of fundus lesions (including morphology, boundary, edge and internal enhancement) and ultrasonography respectively. The sensitivity, specificity, accuracy, and positive likelihood ratio of Mp-MRI and ultrasound diagnosed PS were calculated by the IBM SPSS Statistics Version 19 statistical software based on the PS gold standard. The negative likelihood ratio, Med Calc 16 statistical software was used to plot the receiver operating characteristic (ROC) curve, calculate the area under the ROC curve (area under the curve, AUC), and compare the two groups with statistical meaning. The second part of this study: magnetic resonance examination 3. 0T magnetic resonance imaging (0T). In the first part of this study, 28 cases (38 eyes) were treated without glucocorticoid and 28 (38 eyes) in the outpatient department of our hospital, 38 eyes were treated with Glucocorticoid (oral prednisolone 1mg/kg, 10mg every 2 weeks, until the 10mg was maintained until the end of the treatment), 2 weeks after treatment, 4 weeks after treatment, 12 weeks after treatment and treatment. Mp-MRI examination was performed 4 weeks after the end of the treatment. The first 1 days of the diagnostic radiologist for more than 5 years, 2 weeks after treatment, 4 weeks after treatment, 12 weeks after treatment and 4 weeks after the end of the treatment, to avoid cystic degeneration, necrotic bleeding area on the ADC map without knowing the patient group, and manually outline the region of interest (region of interest, ROI) by hand, and 3. 1 days before treatment of glucocorticoid, 1 days before treatment of glucocorticoid, 2 weeks after treatment, 4 weeks after treatment, 4 weeks after treatment, 12 weeks after treatment and 4 weeks after treatment at the end of treatment, the maximum diameter of PS lesion was measured at the end of treatment, and the maximum diameter reduction rate was calculated by 3 times, the formula was maximum reduction. The rate of reduction = [(the maximum diameter before treatment - the maximum diameter after treatment) / the maximum diameter before treatment] x 100%. was used to calculate the change rate of ADC (? ADC) before and after the treatment of glucocorticoid. The formula was: ADC=[(ADC value after treatment - ADC value before treatment) / ADC value before treatment) by IBM SPSS Statistics Version 19 software for statistical analysis. The standard deviation ((?) + s) form indicated that P0.05 was statistically significant. The maximum diameter of PS focus in the effective group and the ineffective group before the treatment of glucocorticoid was compared with the two independent sample t test; the maximum diameter of the PS lesion before the glucocorticoid treatment, the post effective group and the non effective group, and the paired sample in the ADC value group were compared. This t test: the ADC value of PS focus before treatment with glucocorticoid and the maximum diameter before treatment, the ADC value of the PS focus and the maximum reduction rate before treatment, the ADC value of the PS focus after treatment, the maximum diameter after treatment and the maximum reduction rate after treatment, ADC and the maximum diameter reduction rate, and the ROC curve for the analysis of glucocorticoid treatment with MedCalc 16 statistics software. The value of preoperative ADC value for predicting the curative effect of glucocorticoid was determined, and the threshold value was determined. The results of P0.05 were statistically significant. Results: the first part of this study: the results of MP-MRI examination showed that the PS focus was nodular (13 cases, 18 eyes) and diffuse type (10 cases, 15 eyes) T1WI presenting with.31, T2WI showed low signal, RESOLVE-DWI diffusion was slightly limited, ADC was equal signal, The other 2 PS lesions were T1WI, T2WI showed high signal, RESOLVE-DWI diffusion was slightly limited, ADC showed low signal, and enhanced obviously. The "T" sign (due to optic nerve and posterior scleral cystic inflammatory edema formed T) was seen in 15 cases (24 eyes), which accounted for PS focus. Nodular (6 cases, 7 eyes) and diffuse type (10 cases 12 eyes), all lesions were homogeneous medium or strong echo, the blood flow signal was less, the sound attenuation was not obvious. The "T" sign was found in 9 cases (12 eyes), accounting for the difference between the results of 70.6%.Mp-MRI and ultrasound (x 2=4.364, P=0.037).Mp-MRI and ultrasonic diagnosis of PS sensitivity, specificity, accuracy, positive The negative likelihood ratio was 82.5%, 90.7%, 83.1%, 8.87,0.19 and 47.5%, 88.4%, 35.9%, and 4.08,0.59, respectively, and AUC were 0.883,0.726 respectively. The difference was statistically significant (Z=2.542, P=0.011). The second part of this study: 28 cases (38 eyes) were divided into 17 cases (24 eyes) and invalid group 11 (38 eyes) according to the evaluation criteria of glucocorticoid efficacy. 14 eyes (14 eyes). There was no significant difference in sex, age and course of disease between the effective group and the invalid group (P0.05). The effective group ADC value (1.36 + 0.11) x 10-3 mm2/s before the treatment of glucocorticoid was significantly higher than that of the ineffective group (1.12 + 0.41) x 10-3 mm2/s, the difference was statistically significant (P=0.036), and the effective group ADC (1.45 + 0.14) x 10-3 after the treatment. The value of mm2/s was significantly higher than that before the treatment (P0.01). At this time, the ADC value of the ineffective group was (1.14 + 0.37) x 10-3 mm2/s, and the difference was slightly higher than that before the treatment. The difference was not statistically significant (P=0.285). 4 weeks, 12 weeks and 4 weeks after the treatment, the ADC value of the effective group of PS foci was (1.53 + 0.13) x 10-3 mm2/s, (1.60 + 0.13) x 10-3 mm2/s and (2.01 + 0.14) * mm2/s than the treatment. The difference was statistically significant (P0.01), but no significant change was found in the ineffective group. The AUC of the ROC curve of the ADC value before glucocorticoid treatment was 0.747, and the ADC value =1.33 x mm2/s was the effective threshold for the treatment of glucocorticoid. The sensitivity and specificity of the predictive treatment were 87.5% and 75.0%., respectively: the first part of this study, Through comparison and analysis of the diagnostic value of Mp-MRI and ultrasound to PS, the diagnostic value of Mp-MRI to PS is higher than ultrasound. Mp-MRI can not only make a clear diagnosis early, but also can accurately determine the range of inflammatory exudation. When the clinical highly suspected PS, Mp-MRI can be used as an important means of examination. The second part of this study is to evaluate Mp-MRI in predicting sugar by evaluating Mp-MRI. The value of corticosteroid therapy for PS patients: the change of the ADC value of PS focus in glucocorticoid therapy is earlier than the change of the maximum diameter..MP-MRI can be used to predict the effect of glucocorticoid therapy at early stage by monitoring the ADC value of the PS focus before the treatment of glucocorticoid and the 2 weeks' ADC value after treatment.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R445.2;R772.3

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