颅内结核的MRI特点及抗结核治疗动态分析

Study of MRI features of intracranial tuberculosis and its dynamic evolution during antituberculous treatment

目的 探讨颅内结核的MRI表现特点及抗结核治疗中的动态变化.方法 搜集我院2009年9月至2012年2月颅内结核患者72例,将颅内结核病灶分为单纯脑实质结核、结核性脑膜炎和同时具有脑实质结核和结核性脑膜炎的混合型3种类型,分析其MRI特点.单纯脑实质结核根据病灶大小,≤0.3 cm者称为粟粒,＞0.3 cm且＜1.0 cm者称为结节,≥1.0 cm者称为结核瘤.36例患者进行了动态随访检查,观察其抗结核治疗过程中3及6个月时的动态MRI变化,并计算病灶的消失率,统计学分析采用x2检验.结果 38例单纯脑实质结核共883个病灶,均呈多发性广泛分布,其中423个（47.9％）≤0.3 cm、330个（37.4％）在0.3～1 cm之间、130个（14.7％）≥1.0 cm.结核性脑膜炎型24例以脑基底池脑膜强化为主.10例混合型同时具有以上2种表现.36例动态MRI随访患者中,22例表现为单纯脑实质结核,粟粒病灶、结节病灶及结核瘤治疗3个月病灶消失率分别为52.2％（59/113）、33.3％（33/99）和0,治疗6个月病灶消失率分别为87.6％（99/113）、50.5％（50/99）和18.2％ （2/11）；粟粒病灶在3及6个月时的病灶消失率明显高于结节病灶,差异有统计学意义（x2值分别为7.657、34.786,P值均＜0.01）.治疗3个月后9个病灶出现反常性增大,至治疗6个月病灶消失.结核性脑膜炎10例,吸收相对缓慢,2例病变加重并合并脑积水或脑梗死.结论 按照脑实质结核病灶大小及分布分为粟粒型、多发结节型及结核瘤型较为客观,把握颅内结核抗结核治疗动态MRI表现有助于进一步提高对本病的认识.

Objective To explore MRI features of intracranial tuberculosis,and the dynamic evolution of intracranial tuberculosis during antituberculous treatment.Methods From September 2009 to February 2012,seventy-two patients with intracranial tuberculosis were reviewed retrospectively.Intracranial tuberculosis lesions were divided into 3 categories：pure parenchymal tuberculosis,tuberculous meningitis and hybrid type with both parenchymal tuberculosis and tuberculous meningitis.The MRI characteristics of these lesions were analysed.According to the lesion size,pure parenchymal tuberculosis was divided into 3 subtypes：0.3 cm or less was defined as miliary,〉 0.3 cm and 〈 1.0 cm as nodule,greater than or equal to 1.0 cm as tuberculoma.Serial follow-up scans were performed in 36 patients,and dynamic MRI changes in the process of anti-tuberculosis treatment during 3 to 6 months were observed.The disappearance rate of the lesions was calculated and statistically analysed by using Chi-square test.Results There were 883 lesions in 38 cases with parenchymal tuberculosis.Multiple lesions distributed widely,423 lesions （47.9%） ≤0.3 cm,330 lesions （37.4%） between 0.3-1.0 cm,and 130 lesions （14.7%） ≥ 1.0 cm.Twenty-four cases with tuberculous meningitis showed meningeal enhancement at basilar cistern.Ten cases with hybrid type presented both parenchymal tuberculosis and meningitis.Among 36 patients with serial MRI follow-up scans,22 cases were pure parenchymal tuberculosis.The disappearance rates of military,nodules and tuberculomas were 52.2% （59/113）,33.3% （33/99） and 0,respectively,after 3 months treatment.The disappearance rates were 87.6% （99/113）,50.5% （50/99） and 18.2% （2/11）,respectively,after 6 months treatment.Disappearance rate of miliary lesions was obviously higher than that of nodules at both 3 and 6 months,and the difference was statistically significant,（x2 =7.657,34.786,P 〈 0.01）.Nine lesions of parenchymal tuberculosis enlarged with paradoxical response to antituberculous chemotherapy at 3 months,and 8 of them disappeared after 6 months of therapy.The outcome of tuberculous meningitis was relatively poor.Conclusions It is objective to classify parenchymal tuberculosis into three types：miliary,nodules and tuberculoma.Dynamic MRI changes of intracranial tuberculosis is helpful for understanding the disease better.