本文選題：后鞏膜炎 + 多參數(shù)磁共振成像　； 參考：《第三軍醫(yī)大學》2017年碩士論文

【摘要】：研究背景與目的:后鞏膜炎(posterior scleritis,PS)是一種罕見的發(fā)生于眼球赤道后部及視神經周圍的鞏膜炎癥[1],嚴重時可累及鄰近脈絡膜、視網膜和視神經,導致視覺功能損害[2]。由于該病變位置較深,臨床表現(xiàn)多樣,是眼科易誤診的可治療疾病之一[3],當被誤診為眼底腫瘤如脈絡膜黑色素瘤時,常引起不必要的眼球摘除術[4],造成不可逆的嚴重后果。目前PS的診斷主要通過超聲表現(xiàn)和臨床病史[5],然而超聲的診斷穩(wěn)定性和軟組織分辨率欠佳,且部分PS患者的超聲表現(xiàn)常常未發(fā)現(xiàn)異常,因此PS尚缺乏有效的診斷方法[6]。長期、遞減、足量的糖皮質激素全身或局部應用可使多數(shù)PS患者炎癥迅速減輕和控制[7-8]。但仍小部分PS患者糖皮質激素療效不佳。而盲目使用糖皮質激素,會誘發(fā)或加重感染,引起物質代謝和水鹽代謝紊亂、骨質疏松和胃腸道出血等[9]。因此,準確預測糖皮質激素對PS的療效對于臨床制定正確的治療方案非常重要。目前針對PS的病理生理機制、臨床診治均有研究報道,但尚無有效的預后評估手段。近年來,磁共振成像(MRI)越來越多地應用于PS的研究中[10-12]。其中高分辨率擴散加權成像(Readout segmentation of long variable echo-train diffusion-weighted imaging,RESOLVE-DWI)是一項能檢測活體組織內水分子擴散運動的無創(chuàng)性方法[13],與常規(guī)擴散加權成像(diffusion-weighted imaging,DWI)相比,RESOLVE序列可提高DWI圖像質量,降低運動偽影、畸變偽影及模糊效應,目前已廣泛應用于人體多個部位及其疾病的研究,包括乳腺腫瘤、肝臟腫瘤和腦卒中等[14-15]。RESOLVE-DWI通過表觀擴散系數(shù)(apparent diffusion coefficient,ADC)值可以反映病灶組織的水分子擴散運動。同時常規(guī)MRI及增強掃描可以直觀地顯示正�；虿∽兘M織解剖結構上的變化[16-17]。多參數(shù)磁共振成像(multi-parametric MRI,Mp-MRI[18])作為一種掃描參數(shù)多、成像序列多、軟組織分辨率高且安全無輻射的檢查技術,已廣泛運用于各類疾病的病理機制、診斷、治療及預后研究中。國內外關于PS的Mp-MRI表現(xiàn)報道較少�；诖�,本研究中Mp-MRI結合了常規(guī)MRI、增強MRI和RESOLVE-DWI,本文研究目的:(1)比較分析Mp-MRI和超聲對PS的診斷價值;(2)評價Mp-MRI在預測糖皮質激素治療對后鞏膜炎的療效中的價值。材料與方法:1.病例資料本研究第一部分:招募我院2014年9月至2017年1月期間眼底占位病變患者共56名(83眼),男性24例,女性32例,年齡18~85歲,平均(52.8±19.3)歲,病程3d~2年。56例患者共檢測到病灶85個,均為單發(fā)。經PS金標準或病理證實,其中PS30例(40眼),脈絡膜黑色素瘤13例(22眼),脈絡膜血管瘤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患者中未經糖皮質激素治療且在我院眼科門診初次就診的PS患者28例(38眼),其中男12例,女16例,年齡18~83歲,平均(48.0±19.9)歲,病程5d~1年。2.設備與方法本研究第一部分:磁共振檢查采用Siemens Tim Trio 3.0T磁共振儀,超聲檢查采用法國IneScan S型眼用超聲儀。所有患者均行Mp-MRI和超聲檢查。由3名從事5年以上的診斷工作放射科醫(yī)生和超聲醫(yī)生分別觀察分析眼底病變的MRI結果(包括形態(tài)、邊界、邊緣及內部強化表現(xiàn))和超聲表現(xiàn)。用IBM SPSS Statistics Version 19.0統(tǒng)計學軟件依據(jù)PS金標準分別計算Mp-MRI和超聲診斷PS的敏感度、特異度、準確率、陽性似然比、陰性似然比;用Med Calc 16.0統(tǒng)計學軟件繪制受試者操作特性(receiver operating characteristic,ROC)曲線,計算ROC曲線下面積(area under the curve,AUC),并用Z檢驗比較兩組間AUC,P0.05為差異有統(tǒng)計學意義。本研究第二部分:磁共振檢查采用Siemens Tim Trio 3.0T磁共振儀。本研究第一部分中的30例PS患者中未經糖皮質激素治療且在我院眼科門診初次就診的PS患者28例(38眼)于糖皮質激素治療(口服潑尼松片1mg/kg,每2周減10mg,直至10mg維持至治療結束)前1天、治療后2周、治療后4周、治療后12周及治療結束后4周行Mp-MRI檢查。由3名從事5年以上的診斷工作放射科醫(yī)生于前1天、治療后2周、治療后4周、治療后12周及治療結束后4周,在不知道患者分組的情況下于ADC圖避開囊變、壞死出血區(qū),手工勾畫出病灶感興趣區(qū)(region of interest,ROI),測3次ADC值,結果取平均值。病灶邊界參考常規(guī)MRI和增強MRI圖像,手動勾畫出病灶邊界。測量糖皮質激素治療前1天、治療后2周、治療4周、治療后12周和治療結束后4周測量PS病灶的軸位最大徑,測3次求平均值,計算最大徑退縮率,公式為:最大徑減少率=[(治療前最大徑-治療后最大徑)/治療前最大徑]×100%。計算糖皮質激素治療前后ADC值的變化率(?ADC),公式為:?ADC=[(治療后ADC值-治療前ADC值)/治療前ADC值]×100%。采用IBM SPSS Statistics Version 19.0軟件進行統(tǒng)計學分析,計量資料以“均數(shù)±標準差”((?)±s)形式表示,P0.05為差異有統(tǒng)計學意義。對糖皮質激素治療前、后有效組和無效組的PS病灶最大徑、ADC值的組間比較采用兩獨立樣本t檢驗;對糖皮質激素治療前、后有效組和無效組的PS病灶最大徑、ADC值的組內比較采用配對樣本t檢驗;對糖皮質激素治療前PS病灶ADC值與治療前最大徑、治療前PS病灶ADC值與最大徑退縮率、治療后PS病灶ADC值與治療后最大徑及治療后?ADC與最大徑退縮率采用Spearman相關性分析;用MedCalc 16.0統(tǒng)計學軟件繪制ROC曲線分析糖皮質激素治療前ADC值預測糖皮質激素療效的價值,確定其閾值,P0.05為差異有統(tǒng)計學意義。結果:本研究第一部分:MP-MRI檢查結果顯示,PS病灶呈結節(jié)型(13例18眼)和彌漫型(10例15眼)。31個PS病灶T1WI呈等信號,T2WI呈低信號,RESOLVE-DWI擴散稍受限,ADC呈等信號,增強時明顯均勻強化;其余2個PS病灶T1WI呈等信號,T2WI呈高信號,RESOLVE-DWI擴散稍受限,ADC呈低信號,增強時明顯均勻強化。“T”形征(由于視神經和后鞏膜周圍的筋膜囊炎性水腫形成T形)可見于15例(24眼),占72.7%。超聲檢查結果顯示,PS病灶呈結節(jié)型(6例7眼)和彌漫型(10例12眼),所有病灶成均勻中等或強回聲,血流信號少,聲衰減不明顯。“T”形征見于9例(12眼),占70.6%。Mp-MRI與超聲檢查結果差異有統(tǒng)計學意義(χ2=4.364,P=0.037)。Mp-MRI和超聲診斷PS的敏感度、特異度、準確率、陽性似然比、陰性似然比分別為82.5%、90.7%、83.1%、8.87、0.19和47.5%,88.4%,35.9%,4.08,0.59,兩者AUC分別為0.883、0.726,差異具有顯著的統(tǒng)計學意義(Z=2.542,P=0.011)。本研究第二部分:依據(jù)糖皮質激素療效評價標準,將28例(38眼)患者分為有效組17例(24眼)和無效組11例(14眼)。有效組與無效組的PS患者在性別、年齡及病程差異無統(tǒng)計學意義(P0.05)。糖皮質激素治療前PS病灶有效組ADC值(1.36±0.11)×10-3 mm2/s明顯高于無效組(1.12±0.41)×10-3 mm2/s,差異有統(tǒng)計學意義(P=0.036);治療后2周,有效組ADC值(1.45±0.14)×10-3 mm2/s,比治療前ADC值明顯升高(P0.01)。此時無效組ADC值(1.14±0.37)×10-3 mm2/s,比治療前稍升高,差異無統(tǒng)計學意義(P=0.285);治療后4周、12周及結束后4周,PS病灶有效組ADC值分別為(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較治療前明顯增高,差異均有統(tǒng)計學意義(P0.01),而無效組未見明顯變化。糖皮質激素治療前ADC值的ROC曲線的AUC為0.747,ADC值=1.33×10-3 mm2/s作為糖皮質激素治療有效的閾值,預測治療有效的敏感性和特異性分別為87.5%和75.0%。結論:本研究第一部分,通過比較分析Mp-MRI與超聲對PS的診斷價值得出:Mp-MRI對PS的診斷價值高于超聲,Mp-MRI不僅可以早期明確診斷,還能準確判斷炎癥滲出累及范圍。當臨床高度懷疑PS時,Mp-MRI可以作為重要的檢查手段。本研究第二部分,通過評價Mp-MRI在預測糖皮質激素治療對PS患者的療效中的價值得出:糖皮質激素治療中PS病灶ADC值變化早于最大徑的改變。MP-MRI通過監(jiān)測糖皮質激素治療前PS病灶ADC值和治療后2周ADC值,有助于早期預測糖皮質激素治療的療效。
[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.
【學位授予單位】：第三軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R445.2;R772.3

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