目的分析颅内结核核磁共振影像表现与患者预后的关系。
方法回顾性分析2012年1月1日至2016年12月31日本院收治的420例颅内结核患者的MRI资料并随访患者的预后。420例颅内结核患者中，男220例，女200例，年龄8~83岁，中位年龄28.5岁。根据MRI影像表现分型，420例中脑膜结核93例，脑实质结核192例，混合型颅内结核82例。头颅MRI无异常31例，表现为小片状脑白质脱髓鞘改变22例。本研究结果的计量资料采用单因素方差分析，2组间比较采用 t检验；计数资料采用卡方检验或Fisher精确检验，采用logistic回归分析方法分析预后相关因素。
结果脑膜结核的MRI表现为脑膜渗出增厚强化，继发性改变包括脑积水、脑血管炎、脑梗死和颅神经受累。脑实质结核包括脑实质结核瘤、结核脓肿和结核性脑炎，脑实质结核瘤表现为实性结节影，在T 1WI为等或稍低信号，在T 2WI上为高信号，中心出现干酪坏死后表现为T 2WI低信号，干酪坏死液化时在T 2WI为高信号，增强扫描无干酪坏死时表现为均匀强化结节，伴干酪坏死时为环形强化结节；结核脓肿表现为环形强化的脓肿壁伴扩散受限加重的脓液；结核性脑炎表现为脑回样T 2WI高信号，T 1WI低信号，增强扫描可见不均匀强化。混合型颅内结核同时具有脑膜结核和脑实质结核的影像学表现。脑膜结核型入院及出院时的Barthel评分分别为（53±30）和（61±28）分，脑实质结核型分别为（77±29）和（81±26）分，混合型颅内结核分别为（58±29）和（66±28）分，脑膜结核型及混合型颅内结核入院及出院时的Barthel评分均明显低于脑实质结核型（ P<0.001）。近期（出院时）预后不良（Barthel评分≤60分）的患者151例，远期（随访至少12个月）预后不良的患者71例中死亡35例，遗留功能障碍者36例。脑膜结核型近期预后不良的患者占50.5%（47/93），远期预后不良的患者占25.8%（24/93），病死率为15.1%（14/93）；脑实质结核型近期预后不良的患者占23.4%（45/192），远期预后不良的患者占12.5%（24/192），病死率为5.7%（11/192）；混合型颅内结核近期预后不良的患者占47.6%（39/82），远期预后不良的患者占20.7%（17/82），病死率为7.3%（6/82）。脑膜结核型及混合型颅内结核患者近期预后及远期预后不良的发生率均高于脑实质结核型（均 P<0.001），脑膜结核型的病死率明显高于脑实质结核型（ P=0.009）。环池脑膜受累82例，脑积水59例，脑梗死45例，多因素logistic回归分析结果显示，环池脑膜受累（ OR=2.339，95 %CI为1.355~4.037， P=0.002）、脑积水（ OR=3.896，95 %CI为2.077~7.308， P<0.001）、脑梗死（ OR=3.282，95 %CI为1.615~6.670， P=0.001）是近期预后不良的独立危险因素；脑积水（ OR=4.458，95 %CI为2.341~8.492， P<0.001）和脑梗死（ OR=2.456，95% CI为1.179~5.114， P=0.016）是远期预后不良的独立危险因素。
结论颅内结核影像学分型与患者临床表现及预后相关。脑实质结核患者较脑膜结核或混合型颅内结核患者临床症状轻，预后好；脑积水和脑梗死是远期预后不良的独立危险因素，脑积水是患者死亡的独立危险因素。
ObjectiveTo study the association of magnetic resonance imaging (MRI) characteristics with prognosis of patients with intracranial tuberculosis.
MethodsFrom January 2012 to December 2016, the MR images and case records of 420 patients with intracranial tuberculosis in our hospital were retrospectively analyzed. There were 220 males and 200 females, aging 8 to 83 years, with a median age of 28.5 years. According to MRI, 93 patients were classified as meningeal tuberculosis, 192 patients as parenchymal tuberculosis, 82 patients as mixed intracranial tuberculosis, and another 31 patients showing no obvious abnormalities while 22 patients had only leukoencephalopathy. The measurement data were analyzed by t test. Chi square test was used to count data analysis. The prognosis related factors were retrospectively analyzed by Logistic regression. P<0.05 was regarded as statistically significant.
ResultsThe direct signs of MR imaging of meningeal tuberculosis were meningeal exudation, thickening and enhancement. Secondary changes included hydrocephalus, cerebrovascular inflammation, cerebral infarction and cranial nerve involvement. Brain parenchymal tuberculosis included brain parenchymal tuberculoma, tuberculous abscess and tuberculous encephalitis. Brain parenchymal tuberculoma showed solid nodules, with equal or slightly low signal on T 1WI, high signal on T 2WI, low signal on T 2WI after central necrosis, high signal on T 2WI during liquefaction of necrosis, homogeneous enhancement nodules on enhanced scan without necrosis, and ring enhancement nodules with necrosis. Tuberculous abscess manifested as a ring-shaped enhancement of the abscess wall with aggravated pus with limited diffusion. Tuberculous encephalitis manifested as gyrus-like high signal on T 2WI, low signal on T 1WI, and uneven enhancement on enhanced scan. Mixed intracranial tuberculosis had features of both meningeal tuberculosis and parenchymal tuberculosis. The Barthel scores at admission and discharge of the meningeal tuberculosis group were (53±30) and (61±28), while those of the parenchymal tuberculosis group were (77±29) and (81±26), and those of the mixed intracranial tuberculosis group were (58±29) and (66±28). The Barthel scores at admission and discharge of the meningeal tuberculosis group and mixed intracranial tuberculosis group were significantly lower than those of the parenchymal tuberculosis group ( P<0.001). There were 151 patients with poor prognosis at discharge (Barthel score ≤60 points) and 71 patients with poor long-term prognosis (death or dysfunction after follow-up for at least 12 months). There were 35 patients who died. The poor prognosis rate at discharge, at long-term and the mortality rate of meningeal tuberculosis group were 50.5%(47/93), 25.8%(24/93) and 15.1%(14/93), respectively, while those of the cerebral parenchymal tuberculosis group were 23.4%(45/192), 12.5%(24/192), 5.7%(11/192), respectively, and those of the mixed intracranial tuberculosis group were 47.6%(39/82), 20.7%(17/82) and 7.3%(6/82), respectively. The poor prognosis rate at discharge and at long-term were higher than the cerebral parenchymal tuberculosis group(all P<0.05). The mortality rate of meningeal tuberculosis group was higher than the cerebral parenchymal tuberculosis group ( P=0.009). Logistic regression showed that peri-mesencephalic cisterns involvement( OR=2.339, 95 %CI 1.355-4.037, P=0.002), hydrocephalus( OR=3.896, 95 %CI 2.077-7.308, P<0.001), cerebral infarction ( OR=3.282, 95 %CI 1.615-6.670, P=0.001) were independent risk factors for poor prognosis at discharge. While hydrocephalus ( OR=4.458, 95 %CI 2.341-8.492, P<0.001) and cerebral infarction ( OR=2.456, 95% CI 1.179-5.114, P=0.016) were independent risk factors for long-term prognosis. Hydrocephalus ( OR=6.803, 95% CI 3.119-14.839, P<0.001) was the only independent risk factor for death.
ConclusionsMR imaging classification of intracranial tuberculosis was correlated with clinical manifestations and prognosis of the patients. The prognosis of patients with meningeal exudation was worse than that of patients with parenchymal tuberculoma. Hydrocephalus was independently associated with the risk of death in patients with intracranial tuberculosis.
李多,吕岩,王岳,等. 颅内结核核磁共振影像分型与患者预后的关系[J]. 中华结核和呼吸杂志,2020,43(1)：27-34.
DOI:10.3760/cma.j.issn.1001-0939.2020.01.008版权归中华医学会所有。
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除非特别声明，本刊刊出的所有文章不代表中华医学会和本刊编委会的观点。
李多：图像分析，数据整理，统计分析，论文撰写；吕岩：图像分析；王岳：数据整理；马大庆：研究指导，论文修改；侯代伦，吕平欣：研究设计，论文修改
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