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1、海马勾画:RTOG 0933勾画图谱,Vinai Gondi,M.D.1Wolfgang A.Tome,Ph.D.1Howard A.Rowley,M.D.2Minesh P.Mehta,M.D.3Departments of 1Human Oncology and 2Neuroradiology,University of Wisconsin Comprehensive Cancer Center3Department of Radiation Oncology,Northwestern University Feinberg School of Medicine,1,MRI-CT 融合,M
2、RI:三维扰相梯度(3D-SPGR)轴位MRI以标准轴位和冠状位 FLAIR扫描头部,获取轴位 T2加权和钆对比增强的T1加权序列。推荐采用1.25mm 层厚以准确勾画海马。小于或等于1.5mm层厚也可以。仰卧位；不需要用CT模拟和日常治疗的固定装置。CT 模拟:对全头颅行不增强的治疗计划CT。mm层厚准确勾画海马。小于或等于2.5mm层厚也可以。用面罩等装置将患者固定于仰卧位。治疗病人时也应该使用固定装置。MRI-CT Fusion:将3D-SPGR MRI 和治疗计划CT融合。,2,一般原理,请注意我们并不是勾画整个海马,而更关注的是齿状回颗粒细胞亚区(SGZ)在MRI的T1加权轴位序列上
3、勾画海马。由于海马中灰质占优势，主要在勾画颞角内侧的T1低信号区。,3,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),红色:海马,从侧脑室颞角的新月形底部作为尾侧（下）勾画的起始部位，在脑脊液低信号内侧勾画低密度的灰质，而不画又白又亮的白质。,4,颞角,红色:海马,MR Images cou
4、rtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),Fimbriae,5,继续向头侧方向（上）勾画，在侧脑室颞角的内侧勾画低密度的灰质，而不是又白又亮的白质。,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Ima
5、ges Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),6,继续向头侧方向（上）勾画，避免勾画伞部，这是一个位于海马上内侧的T1高密度结构。,伞部,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assiste
6、d Tomography 22,324-333(1998),7,继续向头侧方向（上）勾画，在侧脑室颞角的内侧勾画低密度的灰质，而不是又白又亮的白质。注意勾画是向上后方逐渐移动，保持海马的香蕉形结构曲线。避过伞部和位于侧脑室颞角尖部前方的灰质（杏仁核和钩）。,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,32
7、4-333(1998),8,在向后方、头侧勾画的过程中，以颞角的前缘作为海马的前界，以区分在T1相上同为低密度灰质的杏仁核和钩，这两个结构位于 海马的前上方。海马的内侧界是“boomerang（飞镖）形”的钩。,杏仁核,钩,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),9,Unc
8、al Recess,Uncal Recess,继续向头侧方向（上）勾画，在侧脑室颞角的内侧勾画低密度的灰质，而不是又白又亮的白质。避免勾画伞部和位于侧脑室颞角尖部前方的灰质（杏仁核和钩）。,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),颞角杏仁核窝的出现界定了海马的前缘。但它的体
9、积有限，不能在所有轴位影像上出现。海马 的内侧界是杏仁核窝的内侧缘。,10,Medial edge of Uncal Recess,钩隐窝,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),11,继续向头侧方向（上）勾画，在侧脑室颞角的内侧勾画低密度的灰质，而不是又白又亮的白质。避免
10、勾画伞部和位于侧脑室颞角尖部前方的灰质（杏仁核和钩）。,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),向后向头侧，海马的内侧界定义为四叠体池的外侧缘，四叠体池 是脑干外侧的脑脊液间隙。,12,四叠体池,红色:海马,MR Images courtesy of:Holmes CJ,H
11、oge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),13,继续向头侧（上方）勾画，应注意在这个水平，侧脑室的颞角（temporal horn）不再是每个层面都能看到，但四叠体池 cistern作为内侧标志。只勾画低密度的灰质，而不是亮的白质。,四叠体池,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,
12、et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),海马在侧脑室颞角存在时一直位于其内侧，在可以见到侧脑室的层面，把它作为一个 稳定的标志四叠体池 仍然是一个好的内侧标志。,14,侧脑室颞角,四叠体池,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Regis
13、tration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),15,四叠体池,海马在侧脑室颞角存在时一直位于其内侧，在可以见到侧脑室的层面，把它作为一个 稳定的标志四叠体池 仍然是一个好的内侧标志。,侧脑室颞角,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Co
14、mputer Assisted Tomography 22,324-333(1998),16,海马尾部仍然位于丘脑后方，它内侧弯向胼胝体。注意它的内侧仍然是侧脑室。同时也要注意丘脑、基底节和内囊在这个层面上也出现了。,丘脑,四叠体池,尾状核,豆状核,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-33
15、3(1998),17,内囊,海马尾部仍然位于丘脑后方，它内侧弯向胼胝体。注意它的内侧仍然是侧脑室。同时也要注意丘脑、基底节和内囊在这个层面上也出现了。,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),18,海马尾部向后向头侧延续正好位于侧脑室腔的前内侧。,侧脑室腔,海马尾部,红色:
16、海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),19,海马尾部向后向头侧延续正好位于侧脑室腔的前内侧。,侧脑室腔,海马尾,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Imag
17、es Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),甚至在头侧（上）方向，海马尾仍然四叠体池外侧缘的外侧.,20,四叠体池,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomograph
18、y 22,324-333(1998),21,甚至在头侧（上）方向，海马尾仍然四叠体池外侧缘的外侧.,四叠体池,红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),当T1低信号的结构不再靠近侧脑室边缘时海马的勾画结束。在这个位置的前方穹窿的十字出现，其后方可见胼胝体的压部。,22,压部,
19、红色:海马,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),23,海马的灰色信号消失，再也不用画了。,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registrati
20、on for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),海马外扩5mm，生成海马回避区.,24,红色:海马绿色:海马保护区,红色:海马绿色:海马保护区,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(
21、1998),25,Hippocampal 1)Tail 2)Body3)Head,海马外扩5mm，生成海马回避区.,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),26,Hippocampal 1)Tail 2)Body3)Head,红色:海马绿色:海马保护区,海马1)尾 2)体3)头,海马分
22、成三个解剖亚区：头、体、尾；注意头部位于下方或尾侧，体部位于上后方而尾部是最头侧的（上）而且是最后方的，在矢状位上侧脑室平面上总体呈“香蕉”形。,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),27,Hippocampal 1)Tail 2)Body3)Head,红色:海马绿色:海马保护区,海
23、马分成三个解剖亚区：头、体、尾；注意头部位于下方或尾侧，体部位于上后方而尾部是最头侧的（上）而且是最后方的，在矢状位上侧脑室平面上总体呈“香蕉”形。,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),在矢状位上确认海马与邻近结构相分离，如杏仁核。,28,Hippocampal 1)Tail 2)
24、Body3)Head,红色:海马绿色:海马保护区,杏仁核,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),29,Hippocampal 1)Tail 2)Body3)Head,红色:海马绿色:海马保护区,在矢状位上确认海马与邻近结构相分离，如杏仁核。,杏仁核,MR Images courtes
25、y of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),30,Hippocampal 1)Tail 2)Body3)Head,红色:海马绿色:海马保护区,在冠状位上确认海马与邻近结构相分离，如海马旁回，它们有不同的信号强度。,海马旁回,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,e
26、t al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),31,Hippocampal 1)Tail 2)Body3)Head,红色:海马绿色:海马保护区,在冠状位上确认海马与邻近结构相分离，如海马旁回，它们有不同的信号强度。,海马旁回,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Usi
27、ng Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),在矢状位和冠状位上确认海马尾部与穹窿脚分离，如海马旁回，它们有不同的信号强度。注意冠状位上海马位于侧脑室内侧。,32,Hippocampal 1)Tail 2)Body3)Head,红色:海马绿色:海马保护区,穹隆脚,穹隆脚,MR Images courtesy of:Holmes CJ,Hoge R,Collins L,et al.Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22,324-333(1998),33,Hippocampal 1)Tail 2)Body3)Head,红色:海马绿色:海马保护区,在矢状位和冠状位上确认海马尾部与穹窿脚分离，如海马旁回，它们有不同的信号强度。注意冠状位上海马位于侧脑室内侧。,
