肝臟動(dòng)脈期一過性強(qiáng)化灶

1、肝內(nèi)動(dòng)脈期一過性強(qiáng)化灶,徐州市腫瘤醫(yī)院影像科,工作中關(guān)注點(diǎn)：沒有明顯原因的肝內(nèi)動(dòng)脈期一過性強(qiáng)化灶。,男性，56歲楔形動(dòng)脈期一過性強(qiáng)化灶肝動(dòng)脈期CT楔形一過性強(qiáng)化灶，同期的MRI/CT和B超，沒有發(fā)現(xiàn)局部病灶：—56-year-old man with sectorial fan-shaped transient hepatic intensity difference associated with cholangiocell

2、ular carcinoma. Axial iodinated contrast-enhanced arterial phase helical CT image shows sectorial arterial phenomenon (arrowheads) apparently not associated with focal lesion.,三月后，梯度回波T1動(dòng)脈期楔形的尖部可見小的低信號(hào)病灶，膽管細(xì)胞癌，門脈分支浸潤(rùn)所致

3、門脈低灌注Axial gradient-echo T1-weighted gadolinium-enhanced arterial phase MR image (TR/TE, 216/1.5) obtained 3 months after A shows small hypointense focal lesion (arrow) at apex of fan-shaped arterial phenomeno

4、n, causing portal branch infiltration and subsequent portal hypoperfusion.,Transient Hepatic Intensity Differences: Part 1, Those Associated with Focal LesionsStefano Colagrande1, Nicoletta Centi1, Roberta Gal

5、diero2 and Alfonso Ragozzino2 Affiliations: 1Department of Clinical Physiopathology, Section of Radiodiagnostics, University of Florence, Viale Morgagni 85, Florence 50134, Italy.2Section of Radiodiagnos

6、tics, Ospedale SM Grazie Pozzuoli, Naples, Italy.Citation: American Journal of Roentgenology. 2007;188: 154-159.圖片摘自上文，,工作中一點(diǎn)體會(huì)（不是十分的嚴(yán)謹(jǐn)）上腹部CT增強(qiáng)掃描中：動(dòng)脈期發(fā)現(xiàn)肝臟楔形或三角形一過性強(qiáng)化灶（次要矛盾），如果沒有發(fā)現(xiàn)伴隨的局部病灶（主要矛盾），別忘了建議進(jìn)行MRI平掃+增強(qiáng)掃描。

7、如果B超和MRI檢查沒有發(fā)現(xiàn)病灶，并且其他資料能夠作為病因解釋的，是否可以建議：三月后進(jìn)行MRI平掃+增強(qiáng)掃描？以期發(fā)現(xiàn)潛在的轉(zhuǎn)移或原發(fā)的惡性病變。,參考文獻(xiàn),參考文獻(xiàn),定義：肝臟一過性灌注異常，THPD。又稱為一過性肝臟密度差異，或一過性肝實(shí)質(zhì)強(qiáng)化，是一種局灶性、節(jié)段性或彌漫性的肝臟血流動(dòng)力學(xué)異常，絕大部分為病理性改變。大多數(shù)的THPD不會(huì)引起臨床癥狀。,肝臟灌注異常的歷史淵藪sou    

8、    1981年，Inamoto發(fā)現(xiàn)了非腫瘤性肝段低密度區(qū)，并認(rèn)為形成原因可能為門靜脈血流減少所致；1982年Itai報(bào)道了CT增強(qiáng)掃描時(shí)動(dòng)脈期肝段一過性異常強(qiáng)化現(xiàn)象，并稱之為一過性肝密度差異，并于1988年報(bào)道了MR檢查時(shí)出現(xiàn)的肝段異常信號(hào)，表現(xiàn)為長(zhǎng)T1長(zhǎng)T2信號(hào)影，并發(fā)現(xiàn)了部分病例相應(yīng)肝區(qū)域超聲檢查為斜形低回聲區(qū)，肝動(dòng)脈造影有明確肝段染色 1984年，Matsui為肝臟腫瘤患者行DSA檢查時(shí)發(fā)現(xiàn)

9、，腫瘤區(qū)以外的正常肝包膜下肝組織中出現(xiàn)染色缺失區(qū)，發(fā)現(xiàn)肝段染色區(qū)就是CT增強(qiáng)動(dòng)脈期異常強(qiáng)化區(qū)；1996年國(guó)內(nèi)學(xué)者周康榮明確提出了肝臟一過性異常灌注[1]；1997年Gryspeerdt等首次提出了肝臟灌注異常（hepatic perfusion disorders）的概念，他根據(jù)肝臟在多排螺旋CT增強(qiáng)掃描時(shí)出現(xiàn)的肝臟密度差異，進(jìn)行了系統(tǒng)的研究和綜述，并提出與HPD形成相關(guān)的疾病，較Itai及Matsui提出觀點(diǎn)更全面、更具體，更能全

10、面反映其影像檢查所見的本質(zhì)特征；2006年文星回顧性分析了128例肝一過性異常灌注的CT表現(xiàn)。目前大多數(shù)學(xué)者主張使用肝臟灌注異常來進(jìn)行命名。,THPD的影像學(xué)表現(xiàn)--CT表現(xiàn)     高密度灌注異常CT表現(xiàn)：增強(qiáng)掃描時(shí)表現(xiàn)為動(dòng)脈期一過性肝實(shí)質(zhì)楔形、三角形、類圓形以及不規(guī)則高密度影，密度均勻，邊緣清晰，與周邊肝組織之間有清楚的窄移行帶，脈管系統(tǒng)無移位，在高密度灌注異常影中可見血管影

11、，門靜脈期恢復(fù)等密度，可單發(fā)或多發(fā)。異常高灌注多出現(xiàn)在肝包膜下以及肝淺表部、肝病變組織周圍，也可累及肝段、亞段以及肝葉。      低密度灌注異常CT表現(xiàn)：增強(qiáng)掃描時(shí)表現(xiàn)為動(dòng)脈期一過性肝實(shí)質(zhì)內(nèi)楔形、三角形低密度影，密度均勻，邊界銳利或與周圍組織之間無明確邊界，門靜脈期恢復(fù)等密度；異常低灌注多出現(xiàn)于鐮狀韌帶、靜脈韌帶、膽囊窩附近以及肝淺表部位等。 肝臟灌注異常CT平

12、掃表現(xiàn)：CT平掃大多數(shù)表現(xiàn)為等密度，少數(shù)表現(xiàn)為楔形或三角形低密度區(qū)。,視角：形態(tài)（與具體的病因相關(guān)）,肝葉、肝段型：異常靜脈引流，楔形或者三角形：肝惡性病變，血管瘤；活檢彌漫型：布-加氏綜合征；肝硬化結(jié)節(jié)型？多形態(tài)型？膽管炎，膽道梗阻，布-加,THPD產(chǎn)生的原因和及機(jī)理,肝臟的血供是基礎(chǔ)：門靜脈75~80% ，肝動(dòng)脈20%~25% 動(dòng)-門（肝）靜脈異常溝通；盜血—虹吸外壓；異常靜脈引流；（異常動(dòng)脈供血？）,肝臟異常灌注的

13、病因,創(chuàng)傷及各種經(jīng)過肝實(shí)質(zhì)的介入性操作；腫瘤：良性腫瘤：血管瘤，炎性假瘤，F(xiàn)NH,嗜酸性肉芽腫； 惡性腫瘤：肝癌、膽管細(xì)胞癌、轉(zhuǎn)移癌（富血供？）炎癥：膽管炎，肝膿腫，門靜脈、肝靜脈梗阻（癌栓、布-加），主要膽道梗阻；先天性的：動(dòng)靜（門）脈畸形，異常靜脈引流肝臟內(nèi)血管受擠壓或阻塞 ：肝周腫瘤、包膜下積液、巨脾、大量胸腔積液及外傷致肋骨壓迫等,①創(chuàng)傷及各種介入性操作：肝實(shí)質(zhì)的挫裂及肝內(nèi)血管的斷裂；各種介入性操作：包

14、括經(jīng)皮肝穿刺活檢術(shù)、取石術(shù)、膽道引流術(shù)、腫瘤的物理消融術(shù)等；各種損傷的共同機(jī)制是---導(dǎo)致肝動(dòng)脈與門靜脈之間的直接交通，引起動(dòng)脈-門靜脈分流，導(dǎo)致肝動(dòng)脈血流進(jìn)入門靜脈系統(tǒng)，而出現(xiàn)肝動(dòng)脈血流的重新分配，它是產(chǎn)生肝臟異常高灌注的主要原因。,創(chuàng)傷：活檢,經(jīng)皮肝穿刺活檢一月后三角：扇形動(dòng)脈期一過性強(qiáng)化灶箭頭：肝動(dòng)脈-門靜脈瘺—42-year-old woman with sectorial transient hepatic inten

15、sity differences in right hepatic lobe caused by posttraumatic arterioportal shunt. Axial gradient-echo T1-weighted gadolinium-enhanced arterial phase MR image (TR/TE, 146/2) shows wedge-shaped arterial phenomenon (arrow

16、heads) caused by arterioportal shunt (arrow) due to percutaneous hepatic biopsy performed 1 month earlier.,②腫瘤：包括肝臟良性腫瘤與惡性腫瘤。肝臟良性腫瘤主要有血管瘤、炎性假瘤及肝局灶性結(jié)節(jié)增生(focal nodular hyperplasia,FNH)；肝臟惡性腫瘤主要是指肝細(xì)胞癌、膽管細(xì)胞癌、肝肉瘤及各種富血供轉(zhuǎn)移瘤等

17、。惡性病變侵蝕血管,造成動(dòng)-靜脈瘺；當(dāng)腫瘤較大伴有門靜脈及肝靜脈瘤栓形成時(shí),可通過肝竇、脈管等多種途徑引起動(dòng)脈-門靜脈、肝動(dòng)靜脈分流。肝臟富血供腫瘤的“盜血”作用,也是產(chǎn)生肝臟病理性灌注異常常見原因。,65歲男性，肝細(xì)胞肝癌；肝硬化。癌灶和子灶。門靜脈分支癌栓（白色箭頭）導(dǎo)致楔形動(dòng)脈期一過性強(qiáng)化灶，癌栓并在T2圖像上得到證實(shí)。,65歲男性患者，肝細(xì)胞肝癌；肝硬化。癌灶和子灶。門靜脈分支癌栓（白色箭頭）導(dǎo)致楔形動(dòng)脈期一過性

18、強(qiáng)化灶，并在T2圖像上得到證實(shí)。65-year-old man with liver cirrhosis and hepatocellular carcinoma causing sectorial wedge-shaped transient hepatic intensity difference induced by portal thrombosis secondary to tumor. Axial T2-weighted

19、 MR image (12,000/82) confirms portal thrombosis (arrowhead) and shows slight signal intensity changes in triangular area of arterial phenomenon due to small increase in amount of free water.,59歲男性患者，結(jié)腸癌肝轉(zhuǎn)移門靜脈受壓；不是原發(fā)的肝動(dòng)

20、脈血流增加。腫瘤外側(cè)的楔形動(dòng)脈期一過性強(qiáng)化灶；Fig. 10C —59-year-old man with large hepatic intraparenchymal metastasis from colon carcinoma and correlated sectorial fan-shaped transient hepatic intensity difference. Axial gradient-echo

21、fat-suppressed T1-weighted unenhanced (146/2) (B) and axial gradient-echo fat-suppressed T1-weighted gadolinium-enhanced arterial phase (146/2) (C) MR images show wide fan-shaped arterial phenomenon with straight border

22、(arrowhead, C) due to hypointense neoplastic lesion at its apex (arrow), causing portal compression. Note how segment III is also slightly enhanced. Although this transient hepatic intensity difference could look li

23、ke lobar type because of distribution, this arterial phenomenon is undoubtedly sectorial because lesion, being hypodense and hypoenhancing, causes portal compression and not a primary increase in arterial flow.,,50歲男性患者

24、肝包膜下血管瘤楔形動(dòng)脈期一過性強(qiáng)化灶B超見楔形區(qū)域—低回聲，彩色多普勒可見肝動(dòng)脈-門靜脈分流6B —50-year-old man with small round hemangioma beneath Glisson's capsule in right hepatic lobe and intralesional arterioportal shunt producing sectorial wedge-

25、shaped arterial phenomenon. Axial T2-weighted (TR/TE, 830/80) (A) and axial gradient-echo unenhanced T1-weighted (216/1.5) (B) MR images show right hepatic lobe nodule (arrow) that is strongly hyperintense in A 

26、;and hypointense in B.,肝包膜下的血管瘤楔形動(dòng)脈期一過性強(qiáng)化灶,B超見楔形區(qū)域—低回聲，彩色多普勒可見病灶內(nèi)肝動(dòng)脈-門靜脈分流,34歲女性患者FNH虹吸-盜血1A —34-year-old woman with fibronodular hyperplasia in left hepatic lobe determining homolateral lobar transient h

27、epatic intensity difference (lobar siphoning effect). Axial T2-weighted MR image (TR/TE, 830/80) shows slightly hyperintense nodule (arrow) in left hepatic lobe.,34歲女性患者FNH虹吸-盜血病灶周圍的強(qiáng)化灶肝段型實(shí)質(zhì)強(qiáng)化 parenchyma in segments

28、II-IV.,34歲女性患者FNH虹吸-盜血病灶周圍的強(qiáng)化灶肝段型實(shí)質(zhì)強(qiáng)化 parenchyma in segments II-IV.門靜脈期病灶周圍未見強(qiáng)化灶,血管瘤虹吸-盜血病灶周圍的強(qiáng)化灶肝段性的強(qiáng)化灶 segment II.,膽管炎多形性炎性刺激動(dòng)脈擴(kuò)張、盜血,T2見擴(kuò)張的單管，肝周滲出（圖1）（圖2）管周動(dòng)脈強(qiáng)化供血，一過性強(qiáng)化（圖3）分布在擴(kuò)張的膽管旁，假球狀強(qiáng)化灶，容易誤診為局部病灶。

29、5C —57-year-old woman with cholangitis and nonsectorial transient hepatic intensity differences in hepatic dome. Axial gradient-echo T1-weighted gadolinium-enhanced arterial phase MR images (146/2) show further appe

30、arance of arterializations with biliary vessel disease: peribiliary (arrows, B), distributed along dilated biliary vessels, and pseudoglobular, mimicking a focal lesion (arrowhead, C).,先天性的肝動(dòng)脈門靜脈瘺,先天性肝動(dòng)脈-門靜脈分流

31、congenital arterioportal shunt.,—63-year-old man with sectorial transient hepatic intensity difference in right hepatic lobe caused by congenital arterioportal shunt. Axial gradient-echo T1-weighted gadolinium-enhanced a

32、rterial phase MR images (TR/TE, 146/2) show arterial phenomenon (arrowheads) caused by arterioportal shunt (arrow, A).,segment VIII 男性65患者，活檢后持續(xù)存在局部楔形灌注改變。局部脂肪變性是灌注異常的終末期表現(xiàn)T1平掃信號(hào)稍高T1動(dòng)脈期稍顯低灌注CT平掃低密度超聲較周圍肝實(shí)質(zhì)強(qiáng)回聲