急性脑梗死的320排动态容积CT脑灌注成像研究

目的研究320排动态容积CT全脑灌注成像(CTP)在脑梗死患者中的价值。方法对2014-01—2016-01驻马店市中心医院收治的33例脑梗死患者采取CT全脑灌注成像检查,测量梗死核心区、缺血半暗带(IP)与健侧镜像区的脑血流量(CBF)、脑血容量(CBV)、达峰时间(TTP)及平均通过时间(MTT)值,计算梗死核心区及IP的相对脑血流量(rCBF)、相对脑血容量(rCBV)、相对达峰时间(rTTP)、相对平均通过时间(rMTT),并进行对比分析。结果 33例患者中,头颅平扫发现9例早期脑梗死征象,其余24例未发现异常。33例患者行CTP成像均发现异常灌注区,其中25例存在IP;与健侧镜像区对比,CBV无显著差异(P0.05),而TTP、MTT值明显延长,CBF显著降低,差异有统计学意义(P0.05);与梗死核心区对比,CBF、CBV升高,TTP缩短,MTT延长,差异均有统计学意义(P0.05)。IP区与梗死核心区rCBF、rCBV、rTTP、rMTT对比,差异有统计学意义(P0.05)。10例超急性期(发病6h以内)、15例急性期(发病6~72h)中11例、8例亚急性期(发病72h~14d)中4例存在IP。缺血半暗带分期:Ⅰ2期6例,Ⅱ1期12例,Ⅱ2期7例。结论 320排动态容积CT全脑灌注成像可通过注射一次对比剂获得常规CT、CTP、CTA数据,对脑梗死患者的病变部位、范围及有无IP等提供明确的影像学依据,且可对IP进行分期,为临床实现对患者的个体化治疗提供了可能,且显著降低了患者所受的辐射剂量,安全性高。     

640层螺旋CT脑灌注成像与CT血管成像在超早期脑梗死中的应用

目的探讨东芝Aquilion ONE 640层CT脑灌注成像(CTP)与CT血管成像(CTA)在超早期脑梗死患者中的应用价值。方法我院2014-06—2015-12收治的28例超早期脑梗死患者,均在发病后6h内实施CT平扫、CTP与CTA检查,分析平扫及灌注CT表现,计算CTP的达峰时间(TTP)、脑血流量(CBF)、脑血容量(CBV)各参数值,并与对侧及半暗带周边相应区灌注参数相对比;重建颈段和脑内动脉CTA图像,采用图像后处理技术显示病变血管情况,对动脉狭窄程度进行分级评价。所有患者3~7d内行多层螺旋CT复查,评估CTP与CTA在超早期脑梗死诊断中的临床价值。结果 28例患者经头颅CT平扫发现,11例有可疑脑缺血区,其余17例未见明显异常。行CT脑血管灌注成像发现,患者感兴趣区内rCBF、rCBV、rTTP(病变侧与对照侧灌注参数的相对比值)明显改变,脑梗死区较边缘区TTP更高,CBF、CBV更低,差异均有统计学意义(P0.01);半暗带区CBF、TTP与对侧比较差异有统计学意义(P0.01),而CBV对比差异无统计学意义(P0.05)。CTA检查发现,10例患者大脑中动脉闭塞,7例大脑中动脉狭窄,11例一侧颈内动脉狭窄或闭塞。结论 CTP早期发现脑梗死患者脑组织中的缺血半暗带,CTA检查可准确判断狭窄或闭塞血管,在脑梗死患者的早期诊断和指导溶栓治疗中有重要临床价值。     

急性缺血性脑血管病76例多模式CT影像学分析

目的探讨76例急性缺血性脑血管病(AICVD)的多模式CT影像学特点。方法采用320排多层螺旋CT对76例AICVD(发病时间24h)患者急诊进行CT平扫(NCCT)+CT灌注成像(CTP)+CT血管成像(CTA)一站式扫描检查,分析灌注区脑血流量(CBF)、脑血容量(CBV)、平均通过时间(MTT)、达峰时间(TTP)等灌注参数变化及CT血管成像(CTA),并于入院后3d内行头颅MRI,评估其脑灌注特点及血管影像。结果在获取的76例CTP数据中,通过感兴趣区识别划分筛查,有59例患者有明确的异常CTP,有17例患者未发现明确感兴趣区。59例异常CTP中包括急性脑梗死47例,短暂性脑缺血发作(TIA)12例。急性脑梗死患者异常CTP特点:发病在4.5h以内的4例患者CTP表现为患侧CBF均较健侧下降,CBV正常或者轻度增高,MTT、TTP延长;发病时间在4.5~6h内的4例:其中2例CTP表现为CBF降低,CBV正常,MTT、TTP延长,2例表现为CBF降低,CBV轻度降低,MTT、TTP延长;发病时间在6~24h内的39例:其中30例梗死区与CTP异常脑灌注区部位一致,均表现CBF明显降低,CBV明显降低,MTT、TTP延长;12例TIA患者CTP均发现与临床症状相对应的灌注异常:MTT、TTP延长,CBF正常或减低,CBV升高。CTA发现责任动脉重度狭窄5例,血管闭塞10例,7例可见血流缓慢,排空延迟及侧支血管形成。结论多模式CT能够对AICVD提供血流灌注参数的变化及血管情况、供血区的血流动力学变化,对临床诊治具有一定参考价值,主要用于评估大脑半球卒中,多模式CT有临床价值。     

动脉瘤性蛛网膜下腔出血后脑血管痉挛和脑低灌注的相关性分析

目的分析动脉瘤性蛛网膜下腔出血(aSAH)后脑血管痉挛及脑灌注异常的相关性。方法回顾性分析52例aSAH病人的临床资料。在出血后3～15d内均接受CT血管造影(CTA)和CT灌注成像(CTP)检查,了解大脑前动脉(ACA)和大脑中动脉(MCA)血管痉挛的严重程度,以及相关供血区域的脑灌注情况,对获取的参数进行统计学分析和比较。结果无脑血管痉挛23例,其中发生脑低灌注5例(21%)(位于脑分水岭区4例,在脑沟积血附近1例)。轻中度脑血管痉挛18例,其中存在相关供血区域脑低灌注7例(38%)。重度脑血管痉挛11例,其中发生相关供血区域脑低灌注9例(81%)。比较无脑血管痉挛与重度脑血管痉挛血管节段的血流灌注区域,在局部脑血流量(rCBF)和平均通过时间(MTT)两方面,差异均存在统计学意义(P0.05)。结论重度脑血管痉挛是相关供血区域发生脑低灌注的高危因素。无明显脑血管痉挛的病人,在脑分水岭区和脑沟积血附近也可发生脑低灌注,可能与脑微血管痉挛有关。     

CT血管造影联合CT灌注在缺血性脑卒中的临床应用

目的探讨血管造影联合CT灌注在缺血性脑卒中的临床价值。方法选择2012-03—2014-03在我院诊治的缺血性脑卒中患者42例,采用东芝320排CT行头部CTA及CTP检查。观察两种检查方法对缺血性脑卒中的诊断情况,探讨颅内及颈部血管的狭窄与脑组织灌注异常区的关系。结果 CTP检查发现与临床症状相符的异常灌注区36例,感兴趣区的脑血容量及脑血流量较镜像区显著降低(P0.05);感兴趣区的平均通过时间显著延长(P0.05)。CTA检查发现颈部及颅内血管狭窄32例,10例未发现有血管狭窄。CTA有责任血管狭窄患者CTP阳性率(71.43%)显著高于CTA无责任血管狭窄者(14.29%)。结论缺血性脑卒中行CT血管造影联合CT灌注能准确反映脑组织血流动力学变化,有效判定颈部及颅内责任血管是否存在狭窄,为临床诊断提供依据。     

多层螺旋CT脑灌注成像与平扫CT值差值的测量对诊断急性脑梗死的价值

目的探讨多层螺旋CT(MSCT)脑灌注成像与测量CT值的差值(△Hu)在急性脑梗死早期诊断中的价值。方法对34例临床拟诊为急性脑梗死的患者行头部CT平扫和脑CT灌注成像。评价脑CT灌注成像的达峰时间(TTP),脑血流量(CBF),脑血容量(CBV),测量两侧对称部位CT值的差值(△Hu)。全部病例3⁷ d内复查头部CT及临床随访。另选取34例无脑部疾病、神经系统功能正常的为对照组。结果 34例病例中,头部CT平扫肉眼观察发现可疑病灶15例,测量对称部位CT值差值发现可疑病灶21例;脑CTP显示:32例脑CTP灌注异常,2例脑CTP灌注正常,脑CTP显示患者感兴趣区内脑血流量(rCBF)、脑血容量(rCBV)、对比剂达峰时间(rTTP)明显改变,病灶侧与对照侧、病灶中心区与周边区比较,差异有显著意义(P<0.01)。头部CT平扫肉眼观察发现病灶的敏感度44.11%,脑CTP发现病灶的敏感度94.11%。结论脑CTP检查能够早期诊断急性脑梗死,定量分析可区分中心梗死区与缺血半暗带区,有助于临床医生判断梗死病灶的存在和早期选择治疗方案。     

创伤性重型颅脑损伤早期格拉斯哥昏迷量表评分动态变化与CTP的相关性

目的通过CT灌注成像(CTP)观察创伤性重型颅脑损伤患者血流动力学的变化;探讨创伤性重型颅脑损伤早期格拉斯哥昏迷量表(Glasgow coma scale,GCS)评分变化与CTP的相关性。方法动态评定20例创伤性重型颅脑损伤患者GCS评分,行CT检查明确重型颅脑损伤诊断;并分别在外伤后或术后第2 d、7 d及14 d行CTP检查。分析创伤性重型颅脑损伤早期GCS评分与脑局部脑血流量(region cerebral blood flow,rCBF)、局部脑血容量(region cerebral blood volume,rCBV)及血液通过组织的平均通过时间(mean transit time,MTT)之间的关系。结果创伤性重型颅脑损伤患者早期GCS评分与CBF、CBV呈正相关,与MTT呈负相关。表明患者伤后GCS评分越高,脑组织缺血的程度越低。结论 CTP技术有助于了解颅脑损伤后局部脑组织血流灌注状况,rCBF、rCBV和MTT与创伤性重型颅脑损伤早期GCS评分存在相关性。     

颈内动脉和大脑中动脉狭窄与闭塞患者的64排螺旋CT脑容积灌注成像

目的探讨64排螺旋CT脑容积灌注成像（CT perfusion imaging,CTP）与头颈CT血管成像（CT angiography,CTA）联合应用在颈内动脉（internal carotid artery,ICA）或大脑中动脉（middlecerebral artery,MCA）狭窄与闭塞患者中的应用价值.方法对5名健康人及17例患者（ICA狭窄11例、MCA狭窄6例）行CT平扫、CTP和CTA检查,分析灌注延迟表现与病变动脉及其狭窄程度的关系.结果17例患者8例CT平扫未见异常,9例有腔隙性脑梗死和（或）陈旧脑梗死.平均通过时间（mean transit time,MTT）和达峰时间（time to peak,TTP）图灌注延迟表现分为3型：Ⅰ型病变仅累及MCA区,Ⅱ型病变仅累及分水岭区,Ⅲ型病变累及MCA和分水岭区.ICA重度狭窄或闭塞患者Ⅲ型7例,MCA重度狭窄或闭塞患者Ⅰ型4例.64排CT可同时获得容积CTP和颅底动脉环动态CTA,其动态CTA图像质量与常规CTA近似.结论MTT、TTP能够敏感显示灌注损伤,对ICA或MCA重度狭窄或闭塞诊断、治疗及脑梗死发病机制研究有重要价值.64排CT可得到包括基底节在内的上下8个层面的图像,可以更多地显示16层以下螺旋CT显示不到的病变,如脑干、小脑的梗死等.CTP联合CTA能够早期诊断脑梗死,并同时从功能和形态学上综合分析脑缺血的程度和原因,获得更详细的信息,为临床医师尽早进行合理治疗提供客观的影像学依据.     

超薄多层螺旋CT与脑灌注成像在颅脑损伤早期诊断中的对比研究

目的探讨超薄多层螺旋CT和脑灌注成像在急性颅脑外伤(TBI)早期诊断中的临床应用价值。方法收集2010年12月~2012年10月我院收治的200例急性颅脑外伤患者检查资料,均于伤后6 h内行超薄多层螺旋CT(MSCT)和CT脑灌注成像(CTP)检查,全部病例于伤后2~3 d动态复查MSCT明确诊断,将数据进行回顾性分析,采用卡方检验评价。结果在MSCT与CTP这两种检测方法中,CTP在脑挫裂伤、硬膜下血肿和脑内血肿的诊断中优于超薄MSCT(P0.05),并且病灶周围低灌注区域大于超薄MSCT。结论 CTP对于急性颅脑外伤早期和微小损伤的诊断优于超薄MSCT,同时可以反映脑组织的灌注情况,具有可靠的临床价值。     

多模式CT在评估急性缺血性卒中脑侧支循环中的应用

多模式计算机断层扫描(computed tomography,CT)包括CT平扫(non-contrast CT,NCCT)、CT灌注成像(CT perfusion,CTP)、CT血管成像(CT angiography,CTA),可以对急性缺血性卒中后侧支循环进行全面评估,评估脑灌注状态,了解脑侧支循环建立或开放情况,判断临床预后,在急性缺血性卒中的诊疗过程中发挥重要的作用。本文就多模式CT在缺血性卒中中的应用进行综述,以期使患者获益更多。     

Whole brain CT perfusion combined with CT angiography in patients with subarachnoid hemorrhage and cerebral vasospasm

Objective

To assess cerebral vasospasm (CVS) and monitor cerebral microcirculatory changes in patients with acute subarachnoid hemorrhage (SAH) via CT angiography (CTA) combined with whole-brain CT perfusion (CTP) techniques.

Methods

Sixty patients with SAH (SAH group) and 10 patients without SAH (control group) were selected for a prospective study. CTP combined with CTA and digital subtraction angiography (DSA) studies were performed on patients with initial onset of SAH less than three days. CTA and DSA as well as the CTP parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time-to-peak (TTP) were acquired and analyzed. The relationship of CTA and CTP measurements was assessed in these acute SAH patients.

Results

CTP techniques were used to achieve the perfusion maps of the whole brain in patients with acute SAH. Compared to the control group, mean CBF value was significantly lower while both MTT and TTP values were significantly higher in SAH group (all p < 0.05). Further analysis revealed that mean CBF in patients with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V significantly decreased when compared to patients with nCVS, asCVS, Fisher I–II and Hunt–Hess I–II (p < 0.05). Furthermore both MTT and TTP values were also significantly reduced in patient with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V (p < 0.05).

Conclusion

The study demonstrated that changes of microcirculation in patients with SAH could be assessed by whole-brain CTP. CTP combined with CTA could detect both macroscopic evident vasospasm on CTA and alterations of microcirculation on CTP. Mean CBF was significantly lower in patients with SAH.     

CT血管造影对重型颅脑创伤的早期监测及预后判定

目的 探讨CT血管造影(CTA)对重型颅脑创伤早期监测及预后判定的作用.方法 对58例重型颅脑创伤患者术前及术后使用128层螺旋CT行头颅CTA动态检查.结果 重型颅脑创伤后CTA显示脑血管主要发生五种变化:血管移位、动脉痉挛或闭塞、动脉穿支减少、脑深静脉狭窄或闭塞、大脑浅静脉狭窄或闭塞.大动脉痉挛或闭塞者预后差,大脑深静脉如大脑内静脉和基底静脉同时闭塞者预后极差,大脑浅静脉的狭窄或闭塞反映了颅内压的变化.结论 CTA可用于重型颅脑创伤的早期监测及预后判定.     

VEGF-165基因对创伤性脑损伤脑血流动力学影响的实验研究

目的 研究外源性血管内皮细胞生长因子(VEGF)基因治疗大鼠创伤性脑损伤(TBI)后脑灌注的变化,了解其血流动力学改变.方法 创伤性脑损伤大鼠模型建立后随机分为3组:治疗组,质粒对照组,外伤组.通过RT-PCR检测脑伤后1h、6h、24h、3d、7d、14 d VEGF mRNA在损伤局部的表达改变;应用CT灌注像(CTP)研究不同时间脑血流量(CBF)、脑血容量(CBV)等参数在VEGF-165基因治疗前后的动态变化.结果 VEGF-165基因治疗创伤性脑损伤大鼠后经RT-PCR扩增的VEGF mRNA绝对积分光密度值水平显著高于外伤组和质粒对照组(P＜0.05).CTP参数和伪彩图均显示基因治疗组脑灌注在伤后24h CBF、CBV有增高趋势,伤后3d、7d脑灌注明显高于TBI 组(P＜0.05),虽然伤后14 d CBF、CBV开始降低,但和TBI组比较仍然较高.结论 本研究结果显示大鼠创伤性脑损伤后外源性VEGF基因能够提高脑损伤组织的脑灌注,改善脑损伤部位微循环,为损伤组织的恢复提供基础.     

Diffusion- and perfusion-weighted imaging in vasospasm after subarachnoid hemorrhage

BACKGROUND AND PURPOSE: Better measures of cerebral tissue perfusion and earlier detection of ischemic injury are needed to guide therapy in subarachnoid hemorrhage (SAH) patients with vasospasm. We sought to identify tissue ischemia and early ischemic injury with combined diffusion-weighted (DW) and hemodynamically weighted (HW) MRI in patients with vasospasm after SAH. METHODS: Combined DW and HW imaging was used to study 6 patients with clinical and angiographic vasospasm, 1 patient without clinical signs of vasospasm but with severe angiographic vasospasm, and 1 patient without angiographic spasm. Analysis of the passage of an intravenous contrast bolus through brain was used to construct multislice maps of relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF), and tissue mean transit time (tMTT). We hypothesize that large HW imaging (HWI) abnormalities would be present in treated patients at the time they develop neurological deficit due to vasospasm without matching DW imaging (DWI) abnormalities. RESULTS: Small, sometimes multiple, ischemic lesions on DWI were seen encircled by a large area of decreased rCBF and increased tMTT in all patients with symptomatic vasospasm. Decreases in rCBV were not prominent. MRI hemodynamic abnormalities occurred in regions supplied by vessels with angiographic vasospasm or in their watershed territories. All patients with neurological deficit showed an area of abnormal tMTT much larger than the area of DWI abnormality. MRI images were normal in the asymptomatic patient with angiographic vasospasm and the patient with normal angiogram and no clinical signs of vasospasm. CONCLUSIONS: We conclude that DW/HW MRI in symptomatic vasospasm can detect widespread changes in tissue hemodynamics that encircle early foci of ischemic injury. With additional study, the technique could become a useful tool in the clinical management of patients with SAH.     

320排CT在短暂性脑缺血发作中的应用价值初探

目的 初步探讨320排容积CT在短暂性脑缺血性发作(TIA)的应用价值. 方法 在11例TLA患者发作间隙期应用320排容积CT进行一站式CT扫描,收集患者的头颅平扫、CT血管造影(CTA)及全脑灌注的信息,对影像资料进行综合分析.观察TIA患者的脑血管及其组织单元的病变情况. 结果 11例患者头颅CT平扫均未发现明确的责任病灶,3例行MRI无阳性发现;CTA结果显示,10例患者责任病灶区域内脑血管网明显稀疏,8例发现有相对应的血管明显变细,2例血管栓塞同时存在代偿血管形成.11例全脑灌注图像显示与临床症状相对应的灌注区达峰时间、平均通过时间延迟,5例脑血流量下降,3例脑血容量轻度增加. 结论 320排容积CT灌注成像可以通过一次对比剂注射,获得常规CT扫描、全脑灌注、CTA的数据,实现对缺血性脑血管病的全面评估.

Abstract：

Objective To explore the application value of 320-slice volume CT in detecting the cerebral transient ischemic attack (TIA). Methods One-stop CT scan was performed at intermission of onset on 11 patients with cerebral TIA; the data of plain CT scans, CT angiography (CTA) and whole brain perfusion on these patients were collected. Analysis by synthesis was performed on these imaging data. Results No lesions responsible for the attack were found in the brains of 11 patients with TIA under plain CT scan; 3 of them performed MRI did not have positive results. CTA indicated that the vascular networks in 10 patients were obviously sparse in the region of lesions responsible for the attack;the corresponding vessels in 8 of them became thin; both vascular thrombosis and compensatory angiogenesis occurred in 2 patients. The cerebral perfusion indicated that perfusion areas corresponding to clinical symptoms displayed delayed mean transit time and time to peak level in these 11 patients.Decreased regional cerebral blood flow was noted in 5 patients and regional cerebral volume increased mildly in 3 patients. Conclusion The 320-slice-volume CT perfusion imaging can obtain the information about whole brain perfusion, routine CT scan and CTA by injecting a kind of contrast medicament for only one time, thus can assess the ischemic cerebrovascular disease comprehensively.     

Differential approach to the application of hyperventilation in acute period of severe brain injury in relation to cerebral circulation

Seventeen patients with severe brain injury (Glasgow-8 Coma Scale 3-8 scores) complicated by traumatic subarachnoidal hemorrhage and severe cerebral hemodynamic disorders (hyperemia, vasospasm) were examined. Hyperventilation was performed in different phases of cerebral circulation under multiparametrical monitoring (intracranial pressure, cerebral perfusion pressure, jugular oximetry, Doppler study using the carotid compression test). The use of hyperventilation to eliminate intracranial hypertension in victims with brain hyperemia was shown to make cerebral circulation consistent with brain tissue oxygen demands and to improve the autoregulatory reserve of cerebral vessels. The application of hyperventilation to eliminate intracranial hypertension in vasospasm leads to a temporary reduction in intracranial pressure, but simultaneously causes cerebral circulatory changes that do not correspond to cerebral oxygen demands, as well as lowered cerebral perfusion pressure, which increases a risk for ischemic brain tissue lesion. This requires a strict rationale for the use of hyperventilation and for multiparametrical monitoring of cerebral functions, which includes jugular oximetry, Doppler transcranial study, and measurement of intracranial pressure throughout the hyperventilation period in order to prevent secondary brain lesion.     

Temporal averaging angiographic reconstructions from whole-brain CT perfusion for the detection of vasospasm

PurposeThe aim of this study is to evaluate the image quality and diagnostic performance of angiographic images reconstructed from whole-brain CT perfusion (CTP) using temporal averaging compared to CT angiography (CTA) for the detection of vasospasm.Materials and methods39 CT studies in 28 consecutive patients who underwent brain CTA with CTP for suspected vasospasm between September 2020 and May 2021 were retrospectively evaluated. The image quality of these two vascular imaging techniques was assessed either quantitatively (image noise, vascular enhancement, signal-to-noise (SNR) and contrast-to-noise (CNR) ratios,) and qualitatively (4 criteria assessed on a 5-point scale).Intra and interobserver agreements and a diagnostic confidence score on the diagnosis of vasospasm were measured. Radiation dose parameters (volume CT dose index (CTDI_vol) and dose-length product (DLP)) were recorded.ResultsBoth SNR and CNR were significantly higher with temporal averaging compared to CTA, increasing by 104% and 113%, respectively (p<0.001).The qualitative assessment found no significant difference in overall image quality between temporal averaging (4.33 ± 0.48) and brain CTA (4.19 ± 0.52) (p = 0.12).There was a significant improvement in intravascular noise and arterial contrast enhancement with temporal averaging.The evaluation of intra and interobserver agreements showed a robust concordance in the diagnosis of vasospasm between the two techniques.ConclusionsTemporal averaging appeared as a feasible and reliable imaging technique for the detection of vasospasm. The use of temporal averaging, replacing brain CTA, could represent a new strategy of radiation and contrast material doses reduction in these patients.     

多模式CT在后循环缺血性孤立性眩晕中的应用价值

目的 探讨多模式计算机断层扫描（computed tomography，CT）在后循环缺血性孤立性眩晕中的应用价值。