2015年 · 第49卷第11期

Current transjugular intrahepatic portosystemic shunt (transjugular intrahepatic portosystemic shunts, TIPS). It has been widely used in the treatment of complications of decompensated portal hypertension in liver cirrhosis. In patients with cirrhosis, blood coagulation disorder also increased significantly as the degree of liver function damage increased^[1]This is one of the reasons why surgery is not suitable for such patients. Although TIPS surgery is less invasive than surgical shunt surgery, the author found in clinical work that the coagulation function of patients after TIPS surgery is significantly lower than that before surgery, especially the decrease of fibrinogen (FB). There are no reports of direct relationship between abnormal coagulation function and abdominal hemorrhage after TIPS. The classical TIPS is divided into three steps: intrahepatic puncture of the portal vein through the jugular vein, vascular embolization of esophagogastric varices, and establishment of intrahepatic shunt. The first two steps are similar to percutaneous transhepatic varicral embolization (PTVE), both of which are intrahepatic puncture of the portal vein and varicose vein embolization. The establishment of intrahepatic shunt, the key step of TIPS, will inevitably change the distribution of liver blood flow and affect liver synthetic function. Therefore, the author speculates that the decrease of FB is not only related to the consumption of coagulation factors during puncture and hemostasis, but also may be related to the change of liver blood flow distribution by this procedure. Therefore, the author conducted a retrospective comparative analysis of the changes of FB in 147 patients treated with TIPS, PTVE and conservative medical treatment to explore the mechanism of FB reduction.

A 55-year-old male was seen in the Department of Neurology of our hospital in November 2014 due to numbness and weakness in his limbs, which gradually aggravated for 1 month. In the past 1 month, the patient has experienced numbness and weakness in the limbs without obvious trigger, accompanied by soreness and pain in the front of the chest, numbness in the flat skin below the abdomen, accompanied by unstable walking, and feeling of inability to step on cotton when walking. There were no symptoms such as fever, parotid gland enlargement, abdominal pain and diarrhea, dry mouth and eyes. The above symptoms of the patient gradually worsened, the strength of both lower limbs was obviously weakened, he could not walk normally, and his urine and stool control was poor.

Female, 61 years old, was admitted to hospital on 29 November 2011 due to frequent headache, nausea and vomiting for half a month. MRI plain scan showed that the sella turcica was slightly enlarged, the base of the sella was slightly sunken, and an irregular short T was seen on the right posterior side of the sella₁, etc. T₂Lesions, borders still clear (Figure 1,Figure 2), with a size of 0.9 cm ×0.8 cm ×0.9 cm. The boundary between the lesion and the anterior pituitary gland is slightly unclear, and it partially surrounds the cavernous sinus segment of the internal carotid artery, and no clear posterior pituitary gland is seen. MRI enhancement: the lesion showed hyperintensity, the boundary with the pituitary gland was clear, the pituitary stem showed uniform enhancement, and no clear abnormalities were found in the optic chiasm (Figure 3), imaging diagnosis: consider the possibility of microadenoma with hemorrhage. Surgery and pathology: Transnasal sphenoidal approach was used for tumor resection. Pathological diagnosis: pituitary cell tumor (WHO grade I). Immunohistochemical results showed: glial fibrillary acidic protein (GFAP), vimentin (vinmentin), acidic calcium binding protein (S-100) (+). Postoperative pathology: The tumor tissue was pale brown and pale yellow, with some mucus visible, and the nucleus was oval, layered and interwoven.

A 26-year-old male patient. Appeared on November 26, 2014 due to priapism for 20 d. The patient fell while walking 20 days ago, resulting in perineal riding injury, perineal swelling and pain, thinning of urine flow, no dysuria and macroscopic hematuria, no frequent urination, urgency, painful urination, no fever and chills. After the injury, the penis is in a continuous semi-erect state and can ejaculate. Physical examination: There was no deformity of the external genitalia, the penis was semi-erect, there was no ecchymosis in the penis and scrotum, and an induration with a diameter of 1 cm was seen at the junction of the penis and scrotum. The local compression induration was observed for 3 to 5 s, and the penis was gradually weakened. Laboratory tests: There were no abnormalities in blood routine and urine routine.

Male, 9 years old. Due to car accident injury, the right elbow was crushed for 11 h, the right upper limb was painful, there was no obvious deformity, and the movement was limited. He was admitted to our hospital on September 26, 2014. Physical examination: Skin abrasions at the back and outside of the right elbow, no active bleeding, no coma or vomiting. X-ray examination of the right upper limb on the day of admission revealed a fracture of the right proximal ulna and a fracture of the medial epicondyle of the humerus. MRI examination of right elbow joint: swelling of soft tissue of right elbow joint, poor continuity of distal biceps and tendon, abnormal signal shadow in subcutaneous fat space behind and outside right elbow joint, irregular edge, uneven internal signal of lateral mass of elbow joint, sagittal T₁WI showed an irregular hyposignal shadow at the back of the elbow, 8.3 cm ×2.5 cm ×3.1 cm in size, with fissure-like changes in the adjacent adipose tissue (Figure 1)； Axial plane, coronal plane T₂WI revealed an ellipsoid hyposignal "false space" on the lateral side of the biceps brachii, with hypersignal nodules in it (Figure 2,Figure 3)； Coronal plane T₂The WI lipid suppression sequence showed an ellipsoid slightly high signal "false space", and the internal nodules showed low signal (Figure 4)。 Diagnosis: Morel-Lavallée injury type IV posterior right elbow, lateral Morel-Lavallée injury type I, small nodule in "false space" suggesting fat globule, distal biceps brachii and tendon tear. Two days after admission, closed fracture reduction and Kirschner wire internal fixation, right forearm decompression and drainage were performed. During the operation, huge hematoma at the posterior and lateral side of the elbow joint was observed, and the adjacent fat layer was sneakily stripped. Postoperatively, he was plastered and discharged from hospital on 9 October 2014. After 9 months, the right elbow moved freely without complaining of obvious discomfort. X-ray reexamination showed no obvious swelling of the surrounding soft tissue after right elbow operation (Figure 5)。

Glioma is the most common neuroepithelial tissue-derived tumor, which is highly invasive, has a high mortality rate and is prone to recurrence. Surgical resection is the first choice for treatment. In recent years, postoperative temozolomide (TMZ) concurrent radiotherapy + adjuvant chemotherapy has significantly improved the survival time of patients. Monoclonal antibody bevacizumab (BV) is widely used in the treatment of glioma^[1,2]。 In addition, after Phase I clinical trials, gene drug therapy has shown great clinical application potential and is expected to become a reliable choice for glioma treatment^[3]。 However, in some patients, the MRI reexamination after treatment will show signs of false progression, that is, the enhancement range around the lesion increases, but in the follow-up without additional treatment, it is confirmed that the condition is improved or stable, the enhancement range gradually decreases, or the postoperative pathology confirms that it is non-tumor tissue component. The appearance of false progression can interfere with clinical treatment decision-making, and the traditional method of efficacy evaluation-fluid attenuation reversal recovery (FLAIR) sequence T₂WI and enhanced T₁WI cannot objectively reflect the anti-tumor effect, and it is difficult to distinguish from the enhanced range of tumor recurrence. The latest imaging technology of MRI can observe the treatment response and predict the prognosis of patients in the early non-invasive stage, and has great clinical application potential. Therefore, the author introduces the research progress of MRI imaging technology in the evaluation of glioma efficacy in recent years.