第202课 病例探析（50）—（右侧基底节区）弥漫性大B细胞淋巴瘤

患者，男，34岁，头晕、痛10余天，患者入院10余天前无明显诱因出现头晕、头痛，疼痛为间断性胀痛，呕吐1次，呕吐物为胃内容物，偶有肢体麻木感，近两日偶有行走不稳感。

Patients, male, 34, dizziness, pain more than 10 days, the patient was hospitalized more than 10 days ago has no obvious cause dizziness, headache, pain for intermittent pain, vomiting, vomit for gastric contents, occasionally limb numbness, nearly two days I have to walk unsteadily feeling.

（右侧基底节区）B淋巴细胞瘤，符合弥漫性大B细胞淋巴瘤

(right basal ganglia) B lymphoma, consistent with diffuse large B cell lymphoma

右基底节区可见一类椭圆形占位性病变，呈稍长T1稍长T2信号改变，其内信号不均匀，可见长T1长T2信号区，FLAIR序列呈稍高信号，DWI序列呈稍高信号，中央见片状低信号，灶周水肿较明显，向下累及右侧大脑脚，右侧脑室明显受压移位，中线结构左偏。增强后病灶大部分呈明显半环状强化。

Right basal ganglia region is a class of elliptic space-occupying lesions, a slightly long T1 long T2 signal change, its signal is uneven, visible long T1 long T2 signal, FLAIR sequence was slightly higher signal, DWI sequence can show slightly high signal, the central see flake low signal, focal weeks edema is obvious, drag down the right side of the cerebral peduncle, right ventricular pressure shift obviously, left the midline structure. After enhancement, most of the lesions showed obvious semi-circular enhancement.

颅内淋巴瘤的起源尚有争议，主要因为颅内无淋巴结构。目前较公认的是病变起源于血管周围间隙的多能干细胞或单核巨噬细胞系统。淋巴瘤发病部位具有一定的特征性，即主要发生于颅内的中线区，幕上较幕下多见，如丘脑、基底核、胼胝体、侧脑室旁脑白质；此区的血管周围间隙比较明显，因此肿瘤好发于上述部位。临床上，颅脑原发性淋巴瘤多发生于中老年人，但近年来本病有年轻化趋势。患者多以头晕、头痛、恶心、呕吐、偏侧肢体乏力、抽搐等症状为主，主要表现为颅内压增高及神经损害的症状;MR表现：扫时T1WI呈等或稍低信号，T2WI呈等或稍高信号，轻、中等度水肿甚至无明显水肿，与肿块体积相比占位效应并不严重，少有出血；DWI呈现高信号是淋巴瘤的特征性表现之一，脑淋巴瘤强化方式分为三种类型：均匀型、不均匀型及环型，部分强化病灶可有局限性内凹，使整个病灶似马鞍状改变。MRS具有一定的特征性表现，呈Cho峰明显升高，Cr峰及NAA峰消失或明显降低，出现高耸的Lip峰，有时可见Lac峰，为脑外恶性肿瘤的表现，PWI显示淋巴瘤呈低灌注，说明其明显强化不是由肿瘤血管的增生，而是由于肿瘤细胞侵犯血管周围间隙破坏血-脑屏障所致。

The origin of intracranial lymphoma is controversial, mainly because there is no lymphoid structure in the skull. At present, it is generally accepted that the lesions originated from pluripotent stem cells or mononuclear macrophages in the peripheral space of blood vessels. The location of lymphoma has certain characteristics, that is, it mainly occurs in the midline area of the skull, and is more common on the upper part of the curtain than under the curtain, such as thalamus, basal nucleus, corpus callosum and paraventricular white matter. The perivascular space in this area is obvious, so the tumor is more likely to occur in the above areas. In clinical practice, the primary lymphoma of the brain is mostly in the middle aged, but in recent years, this disease has a younger trend. The main symptoms of the patients are dizziness, headache, nausea, vomiting, weakness of the limbs on the left side and convulsion. MR performance: T1WI showed equal or slightly lower signal when scanning, T2WI showed equal or slightly higher signal, and the edema was mild and moderate without even obvious edema. Compared with the mass volume, T1WI had no significant space-occupying effect and little bleeding. DWI presents high signal can is one of the characteristic performance of lymphoma, brain lymphoma strengthening way is divided into three types: the uniform type, uneven type and ring type, partial reinforcement lesions can be limited within concave, make whole lesions like a saddle shape change. Have certain characteristic, MRS Cho peak increased significantly, and NAA Cr peak disappear or decrease, a towering Lip peak, peak, sometimes visible Lac for outside the brain tumor, PWI showed lymphoma is low perfusion, explain the obvious reinforcement is not by the proliferation of tumor blood vessels, but because of the tumor cell invasion gap caused by destruction of blood-brain barrier.

鉴别诊断The differential diagnosis

1、高级别星形细胞瘤：高级别星形细胞瘤占位效应明显，伴有坏死时囊壁常厚薄不均，强化不均匀，周围可伴有中重度水肿。脑淋巴瘤坏死较少见，往往不伴有钙化，增强扫描多表现为均匀强化，边界清楚，往往伴有轻度水肿，或者边界清楚，呈握拳征。

1. High grade astrocytoma: high grade astrocytoma has obvious space-occupying effect. When accompanied by necrosis, the capsule wall is often uneven in thickness and thickness, and the enhancement is uneven. Brain lymphoma necrosis is relatively rare, usually not accompanied by calcification, enhanced scanning mostly presents uniform enhancement, clear boundary, often accompanied by mild edema, or clear boundary, presenting clench sign.

2、脑膜瘤：发生于脑表面的淋巴瘤，需与脑膜瘤相鉴别，脑膜瘤来源于蛛网膜颗粒，属于脑外肿瘤，表现为宽基底，密度均匀，增强扫描可见脑膜尾征，强化均匀，不伴水肿。

2, meningioma, occurs in the surface of the brain lymphoma, need to identify with meningiomas, meningiomas from arachnoid granulations, belongs to a brain tumor, is characterized by wide base, uniform density, enhanced scanning visible meningeal tail, strengthen the uniform, not with edema.

3、脑转移瘤：发生于皮髓交界处时需与脑转移瘤相鉴别，其鉴别点是转移瘤除了具有原发病史之外，往往发生于皮质髓质交界处，病灶较小但水肿较重，坏死液化多见，增强扫描表现为环形强化。

3, brain metastases: happens on the skin is required for a pulp junction with brain metastases, that differentiates the differential points are metastases in addition to the primary disease, often occur in the cortex medulla junction, small but edema, liquefaction necrosis, enhanced scanning performance for circular reinforcement.

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