IRM Pelvis Pt Colegiu
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Transcript of IRM Pelvis Pt Colegiu
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Dr. Vasile Morar
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o Indicatii – Contraindicatiio Anatomie pelvis feminin si masculino Tehnica examinariio Semiologie IRMo Patologie
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INDICATII
Principalele indicatii ale IRM pelvin la femeie:- Patologia uterina: bilant de extensie a neoplaziilor
caracterizarea endometrului
bilant pre-embolizare a fibroamelor
malformatii uterine- Patologie anexiala (torsiune)- Dureri pelvine (endometrioza, infectii)- Prolaps genital- Patologie obstetricala
Nu este indicat IRM de prima intentie in meno/metroragii, caracterizarea maselor anexiale, bilantul sistematic de infertilitate, urmarirea postterapeutica a unei neoplazii
ROL Ecografia endovaginala si EchoDoppler
se realizeaza in prealabil
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INDICATIIPrincipalele indicatii ale IRM pelvin la barbat:
- Patologia prostatei si a veziculelor seminale
- Explorarea vezicii urinare
Patologia rectala : bilant de extensie al CANCERULUI RECTAL
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CONTRAINDICATII
ABSOLUTE:
Stimulatoare cardiace (pacemaker)
Defibrilatoare cardiace implantabile
Neurostimulatoare, implanturi cohleare
Clips-uri vasculare cerebrale
Corpi starini metalici (intraoculari, zone de risc)
RELATIVE
Sarcina (primele 3 luni)
Alte implante non feromagnetice
Claustrofobie
Dispozitive transdermice
Tatuaje
IR severa : Cl creat <30ml/min (Omniscan, Magnevist)
Piercing
Aparate auditive externe (ext+implant intern)
Anumite valve de derivatie ventriculara
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ANATOMIE pelvis feminin
Ovar drept Ovar stang
Vezica
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ANATOMIE pelvis feminin
Cap femural
Vezica
Uter
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ANATOMIE pelvis feminin
Sigmoid
Uter
Vezica
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ANATOMIE pelvis feminin
Sacru
Rect
Vagin
Vezica
Simfiza pubiana
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ANATOMIE pelvis masculin
Simfiza pubiana Prostata
ProstataRect cu gel
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ANATOMIE pelvis masculin
Vezicule seminaleVezicule seminale
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ANATOMIE pelvis masculin
Vezica
Simfiza pubiana Prostata Prostata
Simfiza pubianaRect
Rect
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PROTOCOL IRM de pelvisPregatirea pacientului: Post relativ Vezica in semirepletie Abord venos plica cotului Ne asiguram de ABSENTA CONTRAINDICATIILOR ABSOLUTE LA
IRM Antena pt pelvis Contentie abdominala ; Antiperistaltice ; Secvente de reperaj - totalitatea bazinului, servind la pozitionarea
sectiunilor Abord venos cu injectare chelat de Gadolinium Opacifierea cu gel de eco a vaginului endometrioza
cancer de col uterin
malformatii uterine
prolaps
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PROTOCOL IRM de pelvisSecvente de baza:- Sectiuni sagitale T2 FSE ; grosime 4-5mm (spt 1mm), de la un cap
femural la celalalt.- Sectiuni axiale T2 FSE ABDOMINO-PELVIENE de la simfiza pubiana
pana la pediculi renali; grosime 4-5mm (spt 1mm)- Sectiuni axiale T1 FSE de la simfiza pubiana pana la pediculi renali;
grosime 4-5mm (spt 1mm)
Justificarea secventelor de baza:• T2 : Ofera cele mai bune informatii anatomice
Ofera cel mai bun contrast• T1 si FatSat: cauta zone de hipersemnal T1; diferentierea tes grasos de
hemoragie• Plan sagital patologie uterina• Plan axial patologie anexiala
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PROTOCOL IRM de pelvis Secvente postinjectare Gd: - IRM postGd : studiul structurilor parenchimatoase (dgn dif al diferitelor
leziuni): injectare IV 0.1mmol/kg sau 0.2 mmol/kg chelat Gd cu achizitie la 3 – 4 min de la injectare. Indicatii: endometrioza;
dgn dif ovar vs. hidrosalpinx
- Angio-IRM secvente 2D sau 3D curbe de captare ce permit caracterizarea diferitelor mase pelvine
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Secventa T2 coronal
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Secventa T2 sagital
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PROTOCOL IRM de pelvisSecvente optionale: Sectiuni axiale T1 (SE sau GR) cu supresie de grasime Sectiuni coronale T2 Secvente de difuzie Secvente T2 dupa opacifiere (vagin, rect)
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Structuri lichidiene:Lichid pur: apa chisteLichide impure: sange, grasime, coloid, myxoid
NOTIUNI DE SEMIOLOGIE
LICHID Aspect in T2 Aspect in T1 Aspect in T1 FatSat
Postcontrast Gadoliniu
Apa Hipersemnal Hiposemnal hiposemnal Fara
Sange Izo/Hipersemnal
Hipersemnal Hipersemnal Fara
Grasimea izosemnal Hipersemnal Hiposemnal Fara
Coloid hiposemnal izosemnal Izo/hipersemnal Fara
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Structuri solide:Tisulare: fibroza, neoplazia, miomNon-tisulare: fanere, cheaguri
NOTIUNI DE SEMIOLOGIE
Injectarea de chelat de Gd este necesara pentru a recunoaste o structura tisulara in IRM pelvin
Absenta unei structuri tisulare este sinonima cu benignitatea
Prezenta unei structuri tisulare pelvine nu inseamna neaparat malignitate
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PATOLOGIE GINECOLOGICA
SEMIOLOGIE IRM-leziune la nivelul colului in Hiper T2; in cazul leziunilor incipiente , IRM poate fi normal.
- Caracter intracervical pur: banda de hiposemnal intre Tu si parametre (H T2).-Infiltrarea paramentrelor: aspect neregulat sau infiltrat al grasimii -Infiltrarea vaginala: leziune in Hipersemnal fata de hiposemnalul normal vaginal-- Adenopatii: hiposemnal T2 clasic --Fibroza postradioterapie
CANCER DE COL UTERIN
IRM dimensiunile tumorale
extensia la parametre
diseminarea ganglionara
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PATOLOGIE GINECOLOGICA
SEMIOLOGIE IRM-Hipersemnal T2, uneori dificil de diferentiat fata de continutul cavitatii uterine-Infiltratia miometriala: disparitia liniei in hiposemnal dintre endometru si miometru-- Postcontrast, masa tumorala se opacifiaza
CANCER DE ENDOMETRU
IRM extensia miometriala
Extensia cervicala
Invazia ganglionara
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PATOLOGIE GINECOLOGICA
Diferite forme de malformatii uterine
MALFORMATII UTERINE
IRM Tipul malformatiei
Septe vascularizate
Uter didelf
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PATOLOGIE GINECOLOGICA
CANCERUL DE OVAR:
Dimensiuni>4cm
Perete neregulat
Captarea contrastului dupa inj. Gd
Raport solid/lichid
Continut hemoragic/necrotic
Caracter multilocular, bilateralTumora ovariana aspect heterogen T1
MASA PELVINA
IRM originea masei?
continut grasos? endometriozic?
contingent tisular? caracterizare
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PATOLOGIE GINECOLOGICA
Masa anexiala – 4 intrebari: - este de origine ovariana? secv T2 - are componenta endometriozica? T1+/- Fat Sat - are o portiune tisulara? T1+Gado - structura tisulara este maligna? PWI +DWI
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PATOLOGIE GINECOLOGICA
ADENOMIOZA: prezenta ectopica a mucoasei endometriale la nivelul miometrului-Hipertrofie musculara reactionala-IRM: T2 hipertrofia musc >12mm
- Hipersemnal T2 mucoasa ectopica endometriala
ENDOMETRIOZA PERITONEALA SI SUBPERITONEALA
ENDOMETRIOZA PELVINA : migratia endometrului in afara corpului uterin ovar (80%), peritoneu, reg. subperitoneala
IRM Atingere ligam. utero-sacrate
Afectarea rect
Afectare vezica
Afectare vaginala
ENDOMETRIOM OVARIAN
Pseudochist hemoragic :
secundar microhemoragiilor
semnal hemoragic : hiperT1
hipo T2
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PATOLOGIE GINECOLOGICA
Endometriom – Hiposemnal T2 Endometriom – hipersemnal T1 bilateral
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PATOLOGIE UROLOGICA
SECVENTE
-axiale si coronale T1 SE; T2 FSE; T1+Gd GR 2D sau 3D
-axiale T2 pt arii ganglionare
CANCERUL DE VEZICA
IRM Bilant de extensie al cancerelor vezicale
Evaluarea extensiei in profunzime si extravezical
Extensia adenopatiilor – lanturi ilio-obturatorii
Secventa T2 axial SE – masa tumorala in hiposemnal ce ocupa toata fata laterala dreapta si trigonul cu extensie in grasimea vezicala si vezicule seminale.
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PATOLOGIE UROLOGICA
SEMIOLOGIE IRM-Hiposemnal T1 si hipo semnal T2-Captare contrast Gd postinjectare
CANCERUL DE VEZICA
IRM analiza peretelui vezical
analiza spatiilor grasoase pelvine, perivezicale
analiza lanturi ganglionare iliace
alte organe pelvine
T1 coronal SE fara contrast – leziune parietala in hiposemnal cu invazie a grasimii perivezicale
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PATOLOGIE UROLOGICA
SEMIOLOGIE IRM-Hiposemnal T2 intr-o zona periferica a prostatei-- intreruperea capsulara cu infiltrarea grasimii periprostatice
Hiposemnal T1 tumoral cu efractie capsulara
CANCERUL DE PROSTATA
IRM dgn pozitiv; bilant extensie
adenopatii satelite
Antena endorectala permite cele mai bune rezultate mai ales in ceea ce priveste efractia capsulara
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PATOLOGIE UROLOGICACANCERUL DE PROSTATA
Hiposemnal T2 intr-o zona periferica a prostatei
Intreruperea capsulara
Secventa T2 sagital- nodul in hiposemnal T2
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PATOLOGIE RECTALA
Secventa T2 axial – ingrosare parietala tumorala rectala
Prezenta de ganglioni perirectali
CANCERUL DE RECT
IRM bilant local al cancerului rectal;
opacifiere rectala cu gel de ecografie.
T2 sagital ; T2 axial perpendicular pe “rectul tumoral” ; T2 coronal.
T1 axial Fat Sat + Gd
Difuzie axial
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PATOLOGIE RECTALA
Secventa T2 axial – tumora parietala rectala cu interesarea grasimii perirectale si a fasciei mezorectale
CANCERUL DE RECT
IRM rezultat:
-localizarea masei tumorale si masurarea ei in 3 dimensiuni
-distanta pol infer Tu – pol super sfincter anal intern
-extensia Tu la diferitele straturi parietale ale rectului
-distanta Tu – fascie perirectala
-adenopatii pelvine inafara mezorectului
- Evaluarea extensiei la organele vecine