| From the middle of 1990 s,the first global operation in MRI(iMRI)system has been put into clinical use in Brigham Hospital of Harvard University School of medicine,Department of neurosurgery operation towards the 3M principle that "lesion maximization,functional damage minimization,optimization of operation effect precision Department of Neurosurgery direction.As the high field intraoperative magnetic resonance imaging not only can in the preoperative further clear tumor lesion,more three-dimensional localization,showing three-dimensional relation of lesions and functional areas and important tracts clear,rational choice approach,to avoid severe complications during operation of the important structure caused by excessive damage In present,and timely but also by real time during review of MRI showed the extent of lesion resection and radical lesion resection.Guide the intraoperative real-time dynamic scanning 3.0T MRI,incision tumor and conduction bundle design basis and functional area relative.The principle is to avoid the important structure,guide the operation doctor from any angle,minimally invasive Department of neurosurgery into a new stage.IMRI can provide images in real time operation,and by updating the navigation plan and achieve the purpose of correcting the brain shift.Therefore,more and more Department of neurosurgery to install I MRI system,but because of its high cost,has not yet been widely popularized.The center in the country in 2012 third to install 3 T and high field iMRI modal navigation hybrid operation room,has completed all kinds of surgery in 1000 cases.The experience of nearly 5 years of application shows that,compared with the traditional advantages of Multimodal Preoperative intraoperative: the shortest time to provide a reference to clinical diagnosis properties,the most important is to break The fuzziness of the traditional abstract positioning provides an accurate preoperative diagnosis of the stereotactic diagnosis.Intraoperative resection of the tumor level guides the reduction of intraoperative and postoperative complications,improves prognosis,and delays the patient's life time.Brain glioma(BG)is the most common primary tumor in the brain,and BG originates from glial cells,accounting for about 30-40% of intracranial primary tumors.Because of its invasion and growth,the demarcation between the normal tissue and the normal tissue is difficult to be determined,and the operation is difficult to be completely resected.The survival rate is low and the prognosis is poor.The evaluation of tumor proliferation is regarded as an important additional prediction of tumor behavior.The clinical manifestations were more or less characteristic.Since the clinical course and treatment of BG are different in different pathological grades,it is the key to judge the pathological grade of glioma early and correctly.As is known to all,imaging examination plays an important role in the diagnosis and evaluation of intracranial glioma disease and preoperative grading,especially magnetic resonance imaging,because of its advantages of non ionizing radiation,soft tissue resolution and multi-directional,multi sequence,multi parameter imaging,plays an important role in the positioning and qualitative diagnosis of brain tumors,has gradually become the main methods of examination of brain tumors.At present,a large number of clinical practice shows that,scan and enhanced scan is used for preliminary screening and provide roughly the positioning and quantitative aspects of the information,clinical value has been fully affirmed.However,BG has high tissue heterogeneity,including tumor tissue,necrosis tissue,invasion of adjacent brain tissue,microvascular proliferation and peritumoral edema.In the past,the diagnosis was based mainly on conventional MRI features,but some BG were similar in appearance to other brain tumors,and there was a limit to discrimination even if they were enhanced.The classification of BG,the extent and boundary of the tumor and the internal condition of the tumor can not be accurately evaluated.Therefore,it is difficult to accurately assess the condition of glioma by conventional MRI data.For example,in routine MRI enhancement scans,enhancement only indicates disruption of the blood-brain barrier,rather than the high malignancy of the tumor.At present,all the modes of imaging technology,they also have their own continuous improvement phase,any single mode of medical imaging examination,cannot provide all the information of intracranial tumors,to achieve early diagnosis and timely effective treatment,must adopt different modes of image technology,multi modal image information complementary and cross validation.Multimodal magnetic resonance imaging provides more alternative tools for preoperative evaluation and accurate classification of gliomas.Therefore,in addition to the current clinical operation of gliomas with various magnetic resonance imaging evaluation before illness,many researchers focused on a combination of 2 or more than 2 kinds of modal technique for intracranial glioma were evaluated more perfect.The purpose of this study was to assess the value of preoperative MRI scan,enhanced scan,DWI,ASL,DTI,and MRS in the diagnosis and evaluation of preoperative pathological grading in BG patients.Then based on the above research conclusion,ASL,DTI and MRS three MRI examination technology of multi-modal imaging technology,the surgery and pathology in patients with BG diagnosis and correlation with pathological grading,thus further elaborates the multimodal MRI examination in pathological grading of BG before operation,in order to optimize the BG the patient's imaging scheme,provide reliable imaging data for disease assessment and treatment options for clinicians more accurate.Object:To explore the application of magnetic resonance and multimodality image fusion technique in the diagnosis of brain gliomas in ultrahigh field surgery,summarize the experience and clarify the advantages and disadvantages.To investigate the correlation between conventional MRI scan and enhanced scan combined with DWI imaging in the diagnosis and pathology of brain gliomas.To investigate the correlation between functional MRI,ASL,DTI and MRS imaging in the diagnosis and pathology of gliomas.To investigate the correlation between MRI-ASL and DTI and MRS imaging in the preoperative diagnosis and pathology of gliomas.The first chapter: The value of conventional MRI scan and contrast enhanced scan and DWI examination in the diagnosis and correlation of brain gliomaMethod:Collectting our hospital from January 2015 to January 2017 with complete clinical data and confirmed by pathology in 55 cases of brain glioma,all patients had not received radiation and chemotherapy and other anti-tumor therapy,all patients underwent preoperative conventional MRI scan and enhanced DWI examination.The lesion location,number,size,shape,signal intensity,peritumoral edema and enhancement were observed in routine MRI scan and enhanced image.On the basis of ADC respectively in the tumor parenchyma,strengthen the non enhanced tumor,cystic necrosis,edema area,away from the adjacent edema and contralateral normal brain parenchyma from each of the 5 regions of interest,each ROI area is 0.16cm2,ADC value were measured,the average values.Tissue samples of brain glioma were obtained by operation or puncture.Paraffin embedded tissue blocks were inserted into 2 slices of continuous slices with a thickness of 4 um.Then HE staining was used to observe the pathological grading diagnosis.Results:Brain gliomas in conventional MRI image is not uniform long T1 and long T2 signal mass or nodule boundary,edema disease,classification depends on the lesion,I grade of glioma,the lesion with clear boundary,peritumoral edema or mild edema,space occupying signs are relatively the lighter;grade III-IV gliomas boundary less clear,surrounding the lesion showed obvious peritumoral edema and space occupying signs is relatively serious,midline structures can be found in ectopic.In addition,the signal in the lesions less uniform,can appear necrosis,cystic degeneration,calcification,hemorrhage and other signals,enhanced scan showed a patchy lesions,line shape,rosette like or nodular enhancement,necrosis or hemorrhage area without enhancement.DWI images showed that the tumor parenchyma showed equal,slightly higher or higher signal,and peritumoral edema was high signal.The tumor parenchyma and peritumoral edema were often difficult to distinguish.The ADC images showed that the ADC values of different tumor tissues were different,which were easy to distinguish.The ADC values ranged from low to highest: enhanced tumor parenchyma,non enhanced tumor parenchyma,peritumoral edema,and cystic necrosis.By t test,different tumor tissue and contralateral normal brain ADC value had significant difference(P<0.01);tumor and adjacent edema ADC non enhanced value of the difference was not statistically significant(P>0.05);near the area of edema and edema area away from the ADC value difference was statistically significant(P<0.01).HE staining of 55 cases of glioma was performed to evaluate the pathological grading,and to analyze the correlation between the ADC value of the tumor and the parenchyma.In 55 cases of glioma,the parenchymal ADC of the tumor was from 0..6 * 10-3mm2/s to 1.46 * 10-3mm2/s.To compare the difference in tumor parenchyma ADC values between the high and low tumor groups,and the higher the tumor grade,the smaller the ADC value of the tumor parenchyma.Spearman rank correlation analysis was used to analyze the relationship with tumor grade enhanced tumor parenchyma ADC values showed that intensive tumor ADC value was negatively correlated with glioma grade(r =-0.743,P<0.01),which shows that the higher the degree of malignancy of the tumor,the real part of the lower ADC value is,the more significant diffusion.The second chapter: Application value and pathological correlation analysis of functional MRI examination in brain gliomaMethod:In our hospital from January 2015 to January 2017 with complete clinical data and confirmed by pathology in 43 patients with brain glioma,including 17 cases of MRI-ASL patients;24 patients underwent MRI-DTI examination;11 patients underwent MRI-MRS examination.ASL after processing the data,combined with conventional scan and enhanced scan images,select the solid part of the tumor level as the level of analysis,and in the solid part of the tumor region of interest has been drawn,the blood flow of normal white matter(BFWM)value.TBF and BFWM values were measured 3 times,and their mean values were calculated.In order to eliminate the influence of the patient's individual and age on the cerebral blood flow,the relative blood flow(r TBF)of the tumor in this group was calculated,and rTBF-TBF/BFWM.DTI images are processed to obtain FA,MD,lambda,1,lambda,2,lambda,3 graphs.The measurement of FA,MD,lambda 1,lambda 2,lambda 3,repeated measurements 3 times the average,and the calculated AD and RD value;calculation of tumor parenchyma(rFAt,rMDt,rADt,rRDt),peritumoral edema region relative value(rFAe,rMDe,rADe,rRDe),the parameters of tumor area or peritumoral value / health parameters of brain area value,and record the tumor region(1t,2T,lambda lambda lambda 3T),peritumoral edema region(1E,2e,lambda lambda lambda 3e)eigenvalue.After MRS images were processed,the 1H-MRS metabolite profiles,metabolite ratio maps,and metabolic and anatomical maps were obtained.Voxel designated area of focus for the solid part of the tumor(the most enhanced or unenhanced T2 WI signal or tumor periphery,while making voxel)in the contralateral,metabolism observed as the ratio of Cho,NAA,Cr,MI,Lac,Lip,Cho/Cr and Cho/NAA.Tissue samples of brain glioma were obtained by operation or puncture.Paraffin embedded tissue blocks were inserted into 2 slices of continuous slices with a thickness of 4 um.Then HE staining was used to observe the pathological grading diagnosis.Results:Low grade glioma tumor region with high signal on ADC map,FA map mainly in low signal,rCBF and rCBV on the map with low signal;high grade glioma tumor parenchyma on ADC map to equal or slightly high signal on FA map,dominated by low signal,rCBF and on the rCBV map to high signal.In the tumor parenchyma,low grade glioma group rFAt was lower than that of high grade glioma group,but the difference was not statistically significant(P>0.05),rMDt,r ADt,r RDt,1t,2T,lambda lambda lambda 3T higher than that of high grade glioma group,the difference was statistically significant(P<0.05),see table 3;in peritumoral edema area of low grade glioma group rFAe was higher than that of high grade glioma group,rMDe,rADe,rRDe,1e,2e,lambda lambda lambda 3E lower than that of high grade glioma group,of which only a 1E in low and high grade gliomas were statistically significant(P<0.05).the parenchymal part of NAA decreased and Cho increased,and the lower grade NAA of high-grade gliomas decreased significantly,Cr decreased,and MI increased.The diagnostic accuracy was 72.73%(8/11).There were significant differences in the Cho/NAA and Cho/Cr between the affected side and the healthy side and the high and low grade side of the high and low grade gliomas(P<0.05).In high-grade gliomas,MI was significantly higher than the uninjured side,the difference was statistically significant(P<0.05),but there was no significant difference between the high and low grade gliomas(P>0.05).Analysis of the inspection technology between the diagnostic rate of the differences found: MRI-MRS examination technique in preoperative diagnosis of gliomas in the highest coincidence rate with ASL and DTI examination technique between diagnostic coincidence rate difference was statistically significant(P<0.05);DTI and ASL the difference was no significant(P>0.05).The third chapter: The value and pathological correlation analysis of multimodality MRI examination in brain gliomaMethod:In our hospital from January 2015 to January 2017 with complete clinical data and confirmed by pathology in 27 cases of brain glioma,all patients underwent preoperative conventional MRI scan and enhanced scanning and ASL,DTI and MRS.Processing of ASL data,combined with routine scan and enhanced scan images,software can automatically obtain the value of cerebral blood flow.DTI raw data is processed by fiber bundle imaging package on the workstation,and then FA and MD are obtained.Based on the conventional MRI image to determine the region of interest,the range of ROI to 15~30 pixels,repeated measurements 3 times the average;the calculation of tumor parenchyma(r FAt,rMDt),peritumoral edema region relative value(r FAe,rMDe),the parameters of tumor parenchyma and peritumoral edema region / contralateral brain tissue area parameter value.In addition,DTI images were processed to reconstruct diffusion tensor tractography,which was used to observe the destruction,displacement and intraoperative navigation of the white matter before operation.After the MRS raw data were processed,a 1H-MRS metabolite profile,a metabolite ratio map,and a map of metabolism and anatomy were obtained.The voxel delineation area focused on the solid part of the tumor,while the voxel was observed at the contralateral side,and the metabolic substances observed were Cho,NAA,Cr,MI,Lac,Lip,and Cho/NAA,Cho/Cr ratios..Tissue samples of brain glioma were obtained by operation or puncture.Paraffin embedded tissue blocks were inserted into 2 slices of continuous slices with a thickness of 4 um.Then HE staining was used to observe the pathological grading diagnosis.Results:3D-ASL findings of high-grade gliomas: the value of CBF in the affected side was(90.35 + 36.14),and the ratio of affected side / healthy side was(3.24 + 1.38).MRS findings: in 15 cases,the parenchymal part of NAA decreased significantly,Cho increased significantly,Cr decreased significantly,and MI increased.Cho/NAA was(5.3 + 2.2),Cho/Cr was(3.5 + 1.5),and NAA/Cr was(0.7 + 0.4),and the affected side of MI was significantly higher than that of the uninjured side,the difference was statistically significant.DTI features: 17 cases of tumor area of white matter fibers with different degrees of damage,interrupt local push shift,of which 9 cases involving the corticospinal tract,3 cases involving the corpus callosum,5 cases showed to push the shift,with local sparse thin,the fiber bundle is relatively complete.low grade glioma 3D-ASL showed that the CBF value of the ipsilateral side was(36.55 + 14.79),and the ratio of affected side / healthy side was(0.91 + 0.35).In 6 cases of MRS,the parenchymal part of NAA also decreased,Cho increased,Cr decreased in different degrees,but not higher than high-grade gliomas,Cho/NAA was(1.6 + 0.3),Cho/Cr was(1.8 + 0.5),and NAA/Cr was(1.1 + 0.3).DTI showed that 4 cases had relatively complete bundle of fibers,only showed push and shift,accompanied by local thinning.In addition,2 cases were interrupted by pushing and shifting.the CBF value between the high and low level groups,the side of the affected side / the side of the healthy and the high and low levels,the Cho/NAA,Cho/Cr and NAA/Cr of the affected side were significantly different.Before the operation,the accuracy rate was 85.19%(23/27)according to the 3D-ASL analysis alone.If the analysis was performed by MRS alone,the accuracy rate was 66.67%(18/27).The correct rate was 74.07%(20/27)by DTI chart analysis alone.Combining 3 imaging methods: compared with a functional imaging,but the diagnostic accuracy increased to 92.59%(25/27).Conclusion:1.There is a significant correlation between the parenchymal ADC value and pathological grade of glioma,and the ADC value is helpful to evaluate the pathological grade of glioma.2.Glioma edema ADC values of invasive evaluation of tumor,adjacent edema edema area is far away from the small ADC value,adjacent edema of tumor invasion is obvious;the ADC value cannot distinguish non enhanced tumor parenchyma and adjacent edema.3.ASL,DTI and MRS examination techniques have different advantages in the diagnosis of gliomas.In clinical practice,appropriate examination methods should be chosen according to specific purposes;4.MRS can judge the pathological grading of glioma more accurately before operation,and the diagnostic efficiency is much higher than that of ASL and DTI imaging.5.Combined with three kinds of magnetic resonance functional imaging,they can complement each other,improve the accuracy of glioma grading before operation,and help to determine the clinical operation mode.Magnetic resonance multimodality imaging technique can significantly improve the accuracy of preoperative pathological grading of gliomas,and optimize the treatment of patients,and improve the prognosis of patients to some extent. |
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