【双语病例学习】血管周围间隙扩大

病例来源：American College of Radiology

Case Authors

Albert Lu, MD

Anna Nidecker, MD

Anoop Nundkumar, MD

Peter Yi Shen, MD

Arthur Dublin, MD, MBA

History 病史

A 77-year-old man presents after abdominal surgery to be evaluatedfor stroke.

77岁男性，腹部术后检查，评价有无中风。

Question问题

1.1  Which of the following describethe finding in the axial noncontrast CT image?
(Check all that apply)

下述哪些描述为此CT平扫轴位像的表现？（选择所有正确选项）

A. It is suspicious for ischemicinfarction in the left posterior cerebral vascular territory.

应怀疑为左后部脑血管供血区缺血性梗塞。

B. Hypodensity in the area of theright globus pallidus and adjacent internal capsule may represent recentischemic injury.

右侧苍白球及相邻内囊低密度，可能为近期缺血性损伤的征象。
C. It could represent hypoxic ischemicinjury.

可能为缺血缺氧性损伤的征象。

D. It is highly suspicious for anembolic phenomenon.

应高度怀疑为栓塞。

注释：

Based on this image, there is no evidenceof a posterior cerebral artery infarction.

据此图像，无证据表明大脑后动脉梗塞。

Hypodensity in the right globus palliduscan represent a recent infarct.

右侧苍白球低密度，可为近期梗塞表现。

Hypoxic injury may result in basal gangliahypodensity, although such hypodensity tends to be more diffuse and symmetric.

缺氧性损伤可致基底节低密度影，尽管此低密度倾向于更弥漫和对称。

Only one potentially suspicious hypodensefocus is shown on this single CT image. Nevertheless, noncontrast CT is notablyinsensitive to acute ischemic injury, and MRI may demonstrate additionalischemic sites in this case.

此单幅CT像仅见一处可疑低密度区，然而CT平扫对急性缺血性损伤很不敏感，此情况下，MRI可能会显示更多的缺血性区域。

答案：BC

2.1  Which of the following statements are true regarding the findingswithin the bilateral globus pallidi seen on these MR images? (Check allthat apply)

根据此MR图像上双侧苍白球的表现，下列哪些表述是正确的？（选择所有正确选项）

A. They are sequelae of diffusehypoxic ischemic injury.

此为弥漫性缺血缺氧性损伤的结果。

B. They demonstrate signalsuppression on FLAIR imaging.

FLAIR像信号被抑制。

C. They require further evaluation with postcontrast imaging.

需要增强扫描进一步评估。

D. They can, in rare cases, cause mass effect and evenhydrocephalus.

罕见情况下，此病变可导致占位效应甚至脑积水

注释

No abnormality is seen ondiffusion-weighted imaging (DWI).

DWI未见异常。

The findings of interest show signalproperties similar to CSF.

此表现的信号特征与脑脊液相似。

Since the appearance of these findings istypical for dilated perivascular spaces, no further imaging is necessary.

因为此为血管周围间隙扩大的典型表现，所以无需进一步影像学检查。

Large, tumefactive perivascular(Virchow-Robin) spaces have been reported to cause obstructive hydrocephalus,particularly when situated at the level of the midbrain.

据报道，大的、肿胀的血管周围间隙可导致梗阻性脑积水，特别是当位于中脑水平时。

答案：B、D

3.1 Which of the following should be included in the differentialdiagnosis for T2 hyperintensities in the globus pallidi?(Check all that apply)

下述哪些应作为苍白球T2高信号改变的鉴别诊断？

A.   Carbonmonoxide poisoning  CO中毒

B.   Cyanidepoisoning 氰化物中毒

C.   Hepatic encephalopathy 肝性脑病

D.   Hyperalimentation 营养过盛

The classic findings of carbon monoxidepoisoning are ischemia/infarction of the globus pallidi.

CO中毒的典型表现为双侧苍白球缺血/梗塞。

Cyanide poisoning may present as increasedT2 signal in the basal ganglia.

氰化物中毒可表现为基底节区T2信号增高。

Hepatic encephalopathy may lead toincreased T1 signal, not T2 signal elevation, in the basal ganglia.

肝性脑病可导致基底节T1信号增高，而非T2信号增高。

Similar to hepatic encephalopathy,hyperalimentation usually leads to increased T1 signal in the basal ganglia,thought to be secondary to manganese deposition.

与肝性脑病相似，营养过盛通常导致基底节T1信号增高，被认为是锰沉积所致。

答案：A、B

Diagnosis 诊断

Dilated perivascular(Virchow-Robin) spaces

血管周围间隙（Virchow-Robin间隙）扩大  

Case Points病例点

Dilated perivascular spaces most commonlyoccur within the basal ganglia, midbrain, thalami, and deep white matter.

血管周围间隙扩大通常发生于基底节区、中脑、丘脑和深部脑白质。

These spaces may appear as a confluentfocus of hypodensity on CT, thus mimicking an infarction.

此血管周围间隙CT表现为局灶性低密度区，与梗塞相似。

Differential considerations for T2 hyperintensities within theglobus pallidi include ischemic infarctions, hypoxic ischemic injuries, andtoxic injuries (eg, carbon monoxide or cyanide poisoning).

苍白球内T2高信号的鉴别诊断包括缺血性梗塞，缺氧缺血性损伤，以及中毒性损伤（如CO或氰化物中毒）

This axial noncontrast CT of the headdemonstrates a focus of hypodensity in the right globus pallidus (arrow).

头部CT平扫示右侧苍白球局灶性低密度影（箭）。

An axial diffusion-weighted image shows noevidence of recent ischemic injury.

轴位DWI像无证据表明为近期缺血性损伤。

This axial T2-weighted MR imagedemonstrates increased signal with a somewhat multicystic appearance in thebilateral globus pallidi (arrows).

此轴位T2 MR像示双侧苍白球信号增高（箭），类似多囊性改变。

This axial T2-weighted FLAIR MR image showssuppression of signal in the globus pallidi, consistent with CSF-like spaces(arrows).

此轴位T2加权FLAIR像示苍白球区信号抑制（箭），与脑脊液表现一致。

Discussion讨论

In this patient with a suspected ischemicinfarction, the initial noncontrast CT of the brain was potentially significantfor a focus of hypodensity in the right globus pallidus area. Consideration wasgiven to a possible ischemic infarction, hypoxic-ischemic injury, or metabolicderangement in this ill postoperative patient.

此患者怀疑为缺血性梗塞，初步脑部CT平扫的可能阳性征象为右侧苍白球局限性低密度区。对此术后患者考虑的可能诊断为缺血性梗塞，缺氧缺血性损伤或代谢异常。

MRI revealed multicystic T2hyperintensities in the bilateral globus pallidi. These cystic-like findingssuppressed on FLAIR, consistent with the presence of CSF, and supported thediagnosis of dilated perivascular spaces alone. There was no diffusionrestriction to suggest recent infarction or hypoxic-ischemic injury.

MRI 示双侧苍白球多囊性T2高信号，此囊状改变FLAIR像被抑制，与脑脊液表现一致，只支持扩大的血管周围间隙之诊断。扩散无受限示无近期梗塞或缺氧缺血性损伤。

Dilated perivascular spaces most commonlyoccur in the basal ganglia, clustering around the anterior commissure. Othercommon sites include the midbrain, thalami, and deep white matter. Whileperivascular spaces are usually small (5 mmor less), they can occasionally be larger (tumefactive) and may result in masseffect and obstructive hydrocephalus. Tumefactive dilated perivascular spacescan, at times, also mimic cystic neoplasms.

血管周围间隙扩大最常发生于基底节，围绕前联合呈簇状。其它常见部位包括中脑，丘脑和深部脑白质。尽管血管周围间隙通常较小（小于等于5mm），偶尔其可较大（肿胀）并导致占位效应和梗阻性脑积水。肿胀的扩大的血管周围间隙偶尔也与囊性肿瘤相似。

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