【作者】 亓恒涛；

【导师】 王锡明；

【作者基本信息】 山东大学 ， 影像医学与核医学（专业学位）， 2014， 博士

【摘要】 目的：探讨非创伤性上肢神经束扭转的高频超声诊断价值。材料与方法：收集15例上肢神经扭转的患者进行检查,所有患者均行高频超声检查,5例患者同时行磁共振检查。其中,男11例,女4例,年龄18-42岁,15例患者均无明显外伤史,均为单侧上肢发病。将高频探头(9-14MHz)置于上肢体表由近心侧向远心侧直接扫查,二维超声连续扫查臂丛神经、上肢的桡神经、正中神经及尺神经,着重观察上臂中段以远及肘关节水平神经束的走行,特别是桡神经主干及桡神经深支的近心段,观察神经的内径及其回声改变,双侧对比观察,测量并记录患侧神经束及对侧相应位置正常神经束的内径。同时注意神经周围的解剖结构,神经有无卡压等。当发现神经病变,均准确定位病变的位置及病变累及的范围,并体表标记扭转的位置,用“×”表示。其中5例患者行3.0T磁共振检查,对患者主要采用T1加权成像、T2加权成像、T1压脂成像、T2压脂成像及弥散背景抑制成像等序列进行检查,观察神经束的走行、内径及其信号的改变,并观察神经束周围有无异常解剖结构。分析非创伤性上肢神经扭转的高频超声声像图及磁共振影像特征,并与临床外科手术所见进行对照。对扭转神经束的内径与对侧正常肢体相应位置神经束内径进行配对t检验,应用SPSS13.0软件进行统计分析,以p<0.05认为有统计学意义。结果：高频超声均可清晰显示各神经束的走行及其内部的束膜结构。本组15例神经束扭转患者高频超声及5例磁共振神经检查均做出准确诊断,诊断符合率为100%。15例非创伤性神经束扭转的患者中,13例为单纯桡神经扭转,1例尺神经扭转,另1例为正中神经合并桡神经扭转。13例单纯桡神经扭转中仅累及桡神经深支的有2例,余11例均累及上臂桡神经主干。15例神经束扭转中单发神经扭转5例,多发神经扭转10例。上肢非创伤性神经束扭转声像图表现为单发或者多节段性沙漏样改变,沙漏样改变两端神经束增粗,回声减低,内部筛网状束膜结构显示不清。扭转的神经束内径约0.284±0.05cm,而对侧健康肢体相应位置神经束宽约0.23+0.04cm,行配对t检验得出t值为9.542(p<0.01)。结论：高频超声可作为诊断上肢外周神经非创伤性扭转的首选影像学检查方法,可对临床外周神经手术术前评估及术式的选择具有重要的意义。目的：探讨高频超声对外周神经肿瘤的诊断价值。方法：收集46例外周神经肿瘤患者进行高频超声检查,其中男性28例,女性18例,年龄2-76岁,平均年龄37.8岁。46例患者中36例因单一肿物就诊,另10例为多发肿物。对肿物采用高频探头(9～14MHz)连续扫查,注意与病变部位相连的神经形态、回声及其内部结构等,并与血管、肌腱、韧带等的回声相鉴别。发现病变后,均准确定位病变的位置及病变累及的范围,并作体表标记。其中11例患者行磁共振检查,对患肢主要采用T1加权成像、T2加权成像、T1压脂成像、T2压脂成像等序列进行检查,观察肿瘤的形态、内部信号改变及其与周围的解剖关系等。结果：46例外周神经肿瘤患者中,超声及磁共振检查均发现肿物并准确定位,其中神经鞘瘤29例,神经纤维瘤8例,脂肪纤维错构瘤9例。其中10例多发肿物,均为神经鞘瘤。46例患者中,肿瘤位于正中神经17例,尺神经13例,桡神经5例,腓总神经6例,胫神经5例,皮神经4例,臂丛神经2例。正常外周神经声像图在其长轴表现为条索状相互平行的低回声束,短轴表现为筛网状结构。实时观察外周神经位置相对恒定,不随肌肉、肌腱和韧带而运动。神经鞘瘤纵切面表现为低回声实性肿块,边界清晰,形态规则,呈纺锤形,其两端与神经相连,呈鼠尾样改变,内部回声欠均匀,内部多见囊变及出血等无回声区,彩色多普勒显像显示其内可见较丰富的血流信号显示,部分多发神经鞘瘤声像图为沿神经分布的串珠样结节,边界清晰。神经纤维瘤声像图表现分为三型：结节型、丛状及弥漫型,其中结节型神经纤维瘤瘤最为常见,其声像图与神经鞘瘤类似；丛状及弥漫型神经纤维瘤较为少见,其中丛状表现为皮下多发低回声结节,呈串珠样改变,无明显边界；弥漫型可见皮下浅筋膜层弥漫型增厚,结构紊乱,弥漫分布丛状及类圆形的低回声结节,呈类淋巴水肿样改变。脂肪纤维错构瘤声像图表现为：神经明显增粗,呈膨胀性生长,纵切面神经内可见分布不均的条状低回声神经纤维和高回声脂肪组织相间的结构,呈“电缆状”；横断面表现为点状低回声和强回声相间,呈“莲藕状”。彩色多普勒显示,增粗的神经内未见血流信号显示。结论：高频超声可作为诊断外周神经肿瘤首选的影像学检查方法,可对临床外周神经肿瘤术前评估及术式的选择具有重要的意义。更多还原

【Abstract】 Objective:To evaluate the role of high frequency ultrasonography in the diagnosis of non-traumatic nerve fascicle torsion of the upper extremity.Materials and Methods:15patients (age range18-42years,4female,11male) who underwent surgical treatment for nerve fascicle torsion were included in the study. There were no traumatic histories in all patients, who were affected unilaterally. Nerve fascicles of the upper extremity (brachial plexus, radial nerve, median nerve and ulnar nerve) were examined from shoulder joint to wrist joint, focusing on the distal segment of the upper arm and elbow joint. The radial nerve trunk and the proximal segment of deep branch of radial nerve were observed intensively. The location, diameter, echoic change, and peripheral anatomy structures of the nerve fascicles were observed. The location of the nerve torsion was marked by cross "x". The contralateral upper extremity was also observed as control, when necessary. In addition, five patients were examined using a commercially available clinical3.0T MRI system. The T1-weighted imaging and T2-weighted imaging, fat suppressed T1-weighted imaging, fat suppressed T2-weighted imaging and diffusion weighted MR neurography (DW-MRN) were performed. The location, diameter, signal change, and peripheral anatomy structures of the nerve fascicles were observed. The imaging characterization of non-traumatic nerve fascicle torsion in high frequency ultrasonography and MR were analyzed, and was compared with the surgical findings. The SPSS program (version13.0, SPSS, Chicago, IL, USA) was used for statistical analysis. Analysis of the paired t-test was adopted. There were significant differences between the nerve fascicle torsion and the normal nerve fascicle of contralateral upper extremity (p<0.05).Results:Both high frequency ultrasonography and MRI clearly showed nerve fascicles and peripheral soft-tissue structures.15patients were accurately diagnosed as nerve fascicle torsion preoperatively using ultrasonography and MRI. Among15 patients, there were13patients of radial nerve torsion,1patient of ulnar nerve torsion,1patient of radial nerve and median nerve torsion. In13patients of radial nerve torsion, there were deep branch of radial nerve torsion in2patients and the radial nerve trunk torsion in11patients. In15patients, there were single-segmental torsion in5patients and multi-segmental torsion in10patients.The hourglass-shaped appearance was a characteristic feature of nerve fascicle torsion, the affected segmental nerve fascicles were hypoechoic with increased diameters at ultrasonography, and had long T1and long T2signals at MRI. The mean diameter of nerve fascicle torsion at ultrasonography was0.28±0.05cm in15patients, and the mean diameter of that of the contralateral upper extremity was0.23±0.04cm. The SPSS program (version13.0, SPSS, Chicago, IL, USA) was used for statistical analysis. Analysis of the paired t-test was adopted. There were significant differences between the nerve fascicle torsion and the normal nerve fascicle of contralateral upper extremity (t=9.698,p<0.05).Conclusion:High frequency ultrasonography may be valuable in the diagnosis of non-traumatic nerve fascicle torsion of the upper extremity, there was important value in clinical preoperative evaluation and surgical intervention. Objective:To evaluate the role of high frequency ultrasonography in the diagnosis of peripheral nerve tumor.Materials and Methods:46patients (age range2-76years, mean age37.8years) of peripheral nerve were retrospectively studied, including18females and28males. There were single tumor in36patients and multiple tumors in10patients. The tumors were examined by high frequency ultrasonography. The tumor location, diameter, echoic change, and peripheral anatomy structures of the tumors were observed. The contralateral extremity was also observed as control, when necessary. In addition,11patients were examined using a commercially available clinical3.0T MRI system. The T1-weighted imaging and T2-weighted imaging, fat suppressed T1-weighted imaging and fat suppressed T2-weighted imaging were performed. The location, diameter, signal change, and peripheral anatomy structures of tumors were observed.Results:Both high frequency ultrasonography and MRI clearly showed tumors and peripheral soft-tissue structures. There were29schwannomas,8neurofibromas and9fibrolipomatous hamartomas. In10cases of multiple tumors, they were all schwannoma. Concerning tumor location, there were17cases of median nerve,13cases ulnar nerve,6cases common peroneal nerve,5cases tibial nerve,4cases cutaneous nerve and2cases brachial plexus.Normal peripheral nerves on ultrasonography appeared as hypoechoic nerve fascicles and hyperechoic connective tissue. In the transverse plane, the peripheral nerve was relatively hyperechoic compared with surrounding muscle tissue. In the longitudinal plane, the peripheral nerve had a linear fascicular appearance. The peripheral nerve location was relative constant by real-time observation, not with muscles, tendons and ligaments movement.Schwannoma on ultrasonography appeared as low echo mass with clear boundary, the tumors of the upper edge and lower edge were associated with nerve, like a rat-tail appearance. There were multiple cystic and hemorrhagic no-echo area in tumors, there were rich blood flow signals in Schwannoma. The sonography of multiple schwannomas appeared as beaded nodular along the nerve.The features of neurofibroma sonography were divided into three types: localized type, plexiform type and diffuse type. The localized type was the most common, which sonography was similar to Schwannoma. The plexiform type and diffuse type was relatively rare. The plexiform type of neurofibroma appeared as multiple hypoechoic nodules, which was bead-like change and without obvious boundary. The diffuse type appeared as subcutaneous fascia layer diffuse thickening, structure disorder, diffuse distribution of plexiform hypoechoic nodules, which was similar to lymphedema.The fibrolipomatous hamartoma of peripheral nerve was showed expansive growth. The hyperechoic fat tissue and hypoechoic nerve fibers were alternated with one and another, the peripheral nerve was lotus-like appearance in the transverse plane, and cable-like appearance in the longitudinal plane. There were no blood flow signals in nerves.Conclusions:High frequency ultrasonography may be valuable in the diagnosis of peripheral nerve tumors, thus helpful in clinical preoperative evaluation and surgical intervention.更多还原