256排CTA在自发性颈部动脉夹层中的应用价值

自发性颈部动脉夹层是青年人脑卒中的重要原因之一,其造成的临床表现多变。侵入性血管造影一直被认为是诊断颈部动脉夹层的金标准,但MR血管造影和CT血管造影(CTA)越来越多的被用作非侵入性检查的替代。256排CTA具有薄层、快速、高分辨的特点,联合全脑范围的CT灌注扫描(CTP)可以对颈部动脉夹层患者进行快速诊断,并评估脑血流灌注情况,指导临床选择合适治疗方法。现就256排CTA在自发性颈部动脉夹层中的应用价值进行综述。     

3D T_1黑血序列:颈动脉夹层诊断的得力助手

正颈部动脉夹层是青年卒中的重要病因,在45岁以下缺血性卒中患者中高达10%~25%,颈部动脉夹层引起卒中的机制主要是动脉-动脉栓塞和血流动力学受损。早期准确的诊断可帮助患者选择合适的治疗方式以预防卒中的发生和复发。一般来说,颈部动脉夹层的诊断需要结合病史、临床表现和影像学等检查结果。但颈部动脉夹层的临床表现没有特异性,既可以表现为单纯头痛、颈部疼痛、Horner综合征、颅神经麻痹等局部症状,也可以表现为短暂性     

头颈部动脉夹层18例影像和临床特点、治疗及随访

目的探讨自发性头颈部动脉夹层(包括颈动脉及椎动脉夹层)的影像学特点及其治疗随访情况。方法对18例自2009年²013年于我科住院诊断为急性脑梗死/TIA,后经检查证实自发性头颈部动脉夹层患者的影像学特点、病因、临床特点及治疗随访情况进行分析。结果 11例颈动脉夹层及7例椎动脉夹层患者的发病高危因素包括近期上呼吸道感染、颈部按摩、颈部轻微外伤、偏头痛、结缔组织疾病、长期吸烟、高血压等。DSA检查5例表现为线样征,1例可见血管内膜瓣,3例表现为双腔征,8例表现为火焰征,17例患者表现为脑梗死,1例表现为TIA,2例患者伴有头颈部疼痛,1例患者伴有Horner征。3例患者接受抗凝治疗,15例患者接受抗血小板聚集治疗,其中1例伴有明显血流动力学障碍行支架植入术。所有患者在32013年于我科住院诊断为急性脑梗死/TIA,后经检查证实自发性头颈部动脉夹层患者的影像学特点、病因、临床特点及治疗随访情况进行分析。结果 11例颈动脉夹层及7例椎动脉夹层患者的发病高危因素包括近期上呼吸道感染、颈部按摩、颈部轻微外伤、偏头痛、结缔组织疾病、长期吸烟、高血压等。DSA检查5例表现为线样征,1例可见血管内膜瓣,3例表现为双腔征,8例表现为火焰征,17例患者表现为脑梗死,1例表现为TIA,2例患者伴有头颈部疼痛,1例患者伴有Horner征。3例患者接受抗凝治疗,15例患者接受抗血小板聚集治疗,其中1例伴有明显血流动力学障碍行支架植入术。所有患者在3⁶ m的随访过程中未发生新的缺血事件。结论依据典型的临床表现及影像学表现可帮助诊断头颈部动脉夹层,口服抗凝及抗血小板聚集治疗是目前首选治疗方案,部分伴有明显血流动力学障碍的狭窄病例可尝试支架置入术。     

BTFE与e-THRIVE序列在后颅窝微血管减压术前的应用价值

目的 探讨双激发式稳态自由进动序列(BTFE)与增强T1高分辨率各向同性容积激发序列(e-THRIVE)联合应用在原发性三叉神经痛与面肌痉挛微血管减压术前MR成像中的临床应用价值. 方法 回顾性分析自2009年4月至2011年12月广东省第二人民医院收治的121例神经微血管压迫患者(三叉神经痛74例,面肌痉挛47例)的影像资料,患者均采用PHILIPS公司ACHIEVA NOVA DUAL A-serial 1.5T磁共振扫描仪成像,成像序列除头颅常规序列外,特别进行了BTFE序列及e-THRIVE序列成像. 结果 全部患者均经微血管减压术证实.74例患者的三叉神经及47例患者的面神经全部显示清楚.121例患者中共118例(98％)找到责任微血管:74例三叉神经痛患者中有52例(70％)为小脑上动脉压迫;47例面肌痉挛患者中有29例(62％)为小脑前下动脉压迫;压迫方式多呈斜行交叉、平行及垂直交叉相贴. 结论 联合应用BTFE、e-THRIVE序列可清楚显示三叉神经、面神经及后颅窝微血管,再结合空间Link功能及多平面重建技术,可以找寻到责任微血管,为三叉神经痛及面肌痉挛患者行微血管减压术提供术前影像学指导.     

高分辨磁共振在青年卒中颅内动脉狭窄病因诊断的研究

目的回顾性分析青年卒中患者颅内动脉狭窄的临床及影像学资料,探讨高分辨MRI(HR-MRI)血管壁成像对青年卒中患者颅内动脉狭窄病因的诊断。方法收集2016年1月至2019年9月就诊于盐城市第三人民医院的缺血性青年卒中患者的临床资料,分为病程14 d内进行HR-MRI扫描的80例患者(实验组),以及同期内行CTA检查,而未行HR-MRI或DSA检查的189例患者(对照组)。对两组数据进行相关分析。结果实验组中诊断为动脉粥样硬化性狭窄52例(65.00%),动脉夹层12例(15.00%),血管炎性病变7例(8.75%),烟雾病8例(10.00%),病因不明1例(1.25%)。对照组中诊断为动脉粥样硬化性狭窄146例(77.20%),动脉夹层10例(5.30%),血管炎性病变4例(2.10%),烟雾病25例(13.20%),病因不明4例(2.10%),实验组中动脉粥样硬化性狭窄诊断率低于对照组,差异有统计学意义(P0.05);动脉夹层、血管炎性病变诊断率高于对照组,差异有统计学意义(均P0.05);烟雾病、病因不明的诊断率虽然低于对照组,但无统计学意义。结论 HR-MRI血管壁成像在青年卒中颅内动脉狭窄病因诊断中具有重要价值,能提高病因诊断的准确率。     

主动脉夹层致急性缺血性脑卒中的诊治（附1例报告及文献复习）

目的总结主动脉夹层致急性缺血性脑卒中的诊断及治疗经验。方法回顾性分析1例主动脉夹层致急性缺血性脑卒中患者的临床资料,并结合文献进行分析。结果本例患者以急性缺血性脑卒中症状起病,急诊头颅MRI弥撒加权成像检查示左侧枕叶、颞叶后部早期缺血性改变;急诊胸部CT平扫及CT血管造影检查示Stanford A型胸主动脉解离伴血栓形成,同时伴左侧颈动脉和左侧锁骨下动脉血栓形成。保守治疗1月后,行血管重建手术治疗,移植人工血管置换解离的升主动脉且与双侧腋动脉搭桥。术后颈部磁共振血管造影检查示左侧颈动脉和左侧锁骨下动脉再通;放射性碘苯丙胺单光子放射计算机断层扫描检查示局部灌注改善。结论主动脉夹层致急性缺血性脑卒中的临床诊断需仔细鉴别,为改善脑血流动力学,血管重建治疗是一种有效的方法。     

BPAS-MRI在椎-基底动脉颅内段夹层鉴别诊断中的应用

目的探讨一种新型的磁共振血管成像技术——椎-基底动脉平行解剖磁共振成像(basi-parallel anatomic scanning,BPAS)联合磁共振血管成像(magnetic resonance angiography,MRA)对椎-基底动脉颅内段夹层鉴别诊断的作用。方法参照文献BPAS的扫描条件,由西安交通大学第二附属医院影像科医师及技师探寻适合3.0-MR的扫描及图像处理参数,回顾性分析神经内科部分住院及门诊MRA显示为椎-基底动脉颅内段纤细或不显影、同期进行了BPAS检查的142例患者,其中临床疑诊为动脉夹层者20例,动脉硬化者60例,先天发育不良者62例,由两位未知患者临床资料的影像医师分别对所有患者的MRA及BPAS影像进行阅片,对20例临床疑诊夹层的病例MRA及MRA+BPAS影像诊断结果进行ROC曲线分析,并对两位影像医师的诊断结果进行一致性评估。结果两位影像医师对20例夹层患者MRA+BPAS及MRA阅片诊断结果的ROC曲线下面积分别为0.93vs 0.70和0.96 vs 0.75(P0.01),提示MRA联合BPAS比单纯MRA的ROC曲线下面积明显增加;MRA联合BPAS诊断椎-基底动脉颅内段夹层的灵敏度比单纯MRA高(100%vs 55%,100%vs 60%,P0.01);而两种诊断方法的特异度无显著差异(86.89%vs 85.25%,P=0.85;92.62%vs 90.16%,P=0.65);两位影像医师对椎-基底动脉颅内段夹层的诊断结果具有高度的一致性(Kappa=0.85)。结论 BPAS检查可通过显示血管外径与MRA联合精确评估椎-基底动脉颅内段血管状况,区分该部位血管病变为夹层、动脉硬化或先天性发育不良,为该部位血管病变临床治疗方案提供依据。     

磁共振管壁成像在颅内动脉夹层中的应用价值

颅内动脉夹层即颅内血管壁内血肿,是导致中青年缺血性或出血性卒中的重要病因,因血 管管径细小,走行迂曲,颅内动脉夹层诊断较困难。磁共振管壁成像作为一种无创性、无放射性检 查手段,可直接观察到动脉夹层所致的特征性壁内血肿信号,因而对颅内动脉夹层的诊断、鉴别诊断 及随访具有重要作用。本文将对磁共振管壁成像在颅内动脉夹层中的应用价值做一简要综述。     

脑动脉夹层的诊断及治疗

正脑动脉夹层是卒中尤其是青年卒中的重要病因,占45岁以下缺血性卒中的20.0%,且男性发病率高于女性[1]。颅内段和颅外段动脉都可导致夹层,其中颈部动脉夹层的年发生率为2.5～3/10万[2],而颅内动脉夹层的年发生率为3.6～4.4/10万[2-6]。夹层后易发生相应动脉供血区脑栓塞,行TCD超声可检出46%～59%的颈动脉夹层患者存在脑微栓塞。20%的颅内血管闭塞患者同时合并颈动脉夹层,这些患者对rt-PA静脉溶栓的血管再通率较低(仅31%),尤其位于大脑中动脉闭塞的这种串联病变患者多数预后不良。     

70例脑动脉夹层患者临床特点分析

目的分析脑动脉夹层住院患者的临床特点,促进对脑动脉夹层的早期识别、早期诊断和治疗。方法回顾性分析首都医科大学附属北京天坛医院神经内科及神经介入科2014年12月~2015年4月经全脑血管造影或高分辨磁共振成像诊断的脑动脉夹层患者的临床特点、影像学特点及治疗措施的情况。结果共纳入70例脑动脉夹层患者。平均年龄(50.0±12.8)岁,男性52例(74%),女性18例(26%)。颈动脉颅外段夹层21例(30%),椎动脉段夹层30例(43%),基底动脉夹层15例(21%),大脑中动脉水平段夹层1例(1%),侧裂段夹层1例(1%)。大脑后动脉及锁骨下动脉夹层各1例(1%)。非蛛网膜下腔出血性头痛19例(27%),头晕3例(4%),颈痛11例(16%),缺血性卒中16例(23%),蛛网膜下腔出血5例(7%),短暂性脑缺血发作4例(6%),其中3例经检查后发现缺血性卒中,无症状者19例(27%)。1例同时存在头痛和颈痛。3例患者同时存在缺血性卒中和头痛,1例患者同时存在颈痛、短暂性脑缺血发作和缺血性卒中。动脉夹层的影像学特征主要表现为动脉局部瘤样扩张、内膜瓣、动脉壁内新月形高信号征等。接受抗栓治疗者9例(13%),单纯抗凝治疗2例(3%),支架辅助弹簧圈填塞17例(24%),单纯弹簧圈填塞5例(7%),单纯支架治疗11例(16%),抗凝结合支架治疗者1例(1%),没有治疗者23例(33%),死亡2例(3%)。结论脑动脉夹层的患者临床症状表现形式不同,轻症者可无症状,或单纯头颈痛,重症者可表现为短暂性脑缺血发作、缺血性卒中或蛛网膜下腔出血,正确诊断和相应的治疗十分重要。     

HR-MRI血管壁成像在缺血性卒中病因诊断中的应用价值研究

目的 研究高分辨磁共振（high-resolution magnetic resonance imaging,HR-MRI）血管壁成像在缺血性 卒中病因诊断中的价值。 方法 选择2015年1月-2017年5月于南京鼓楼医院就诊的缺血性卒中患者,头颅数字减影血管造影 （digital subtraction angiography,DSA）未能明确病因,而HR-MRI血管壁成像确诊的典型性病例8例进行 研究分析。 结果 8例缺血性卒中患者,计算机断层扫描血管造影（computed tomography angiography,CTA）/磁 共振血管造影（magnetic resonance angiography,MRA）及DSA均未明确病因,HR-MRI血管壁成像发现 2例颅内动脉夹层（cerebral artery dissection,CAD）,2例烟雾病（Moyamoya disease,MMD）,2例动脉 粥样硬化烟雾综合征（atherosclerotic Moyamoya syndrome,AS-MMS）及2例原发性中枢神经系统血管炎 （primary angiitis of central nervous system,PACNS）。 结论 HR-MRI血管壁成像在缺血性卒中病因诊断（如CAD、MMD与AS-MMS的鉴别、PACNS等）中具有重 要价值,是CTA/MRA及DSA诊断技术的重要补充。     

颈动脉夹层影像学特点及预后分析

目的 探讨颈动脉夹层所致缺血性卒中患者的影像学特点,通过超声随访分析影响此类患者预 后的因素。 方法 连续收集因颈动脉夹层导致的急性缺血性卒中或短暂性脑缺血发作（transient ischemic attack, TIA）住院患者的临床资料,分别在入组3、6个月时对患者进行随访,6个月时采用改良Rankin量表评分 （modified Rankin scale,mRS）评估预后。 结果 共纳入42例颈动脉夹层所致缺血性卒中或TIA的患者,其中颈内动脉夹层35例（83%）,椎动 脉夹层7例（17%）。颈部血管超声确诊了全部27例（64%）最终经计算机断层扫描血管造影（computed tomography angiography,CTA）或数字减影血管造影（digital subraction angiography,DSA）证实的颈部 血管闭塞患者。CTA影像学表现中以血管闭塞时“双腔征”最常见（26例,63%）,其次为“火焰征”（7 例,17%）。预后良好组和预后不良组间血管再通等因素的比例无显著差异,预后不良组一侧肢体无 力（92.3% vs 45.8%）、基底节受累（69.2% vs 25%）、颈动脉夹层比例（100% vs 70.8%）高于预后 良好组,差异有统计学意义。 结论 颈动脉夹层预后与肢体功能障碍、脑梗死的位置、夹层的分型相关,而与血管再通率无关。     

Contrast-enhanced 3-D MRA in decision making for carotid endarterectomy: a 6-year experience

BACKGROUND: Systematic need for angiography in diagnosis of carotid artery stenosis and indication of surgical therapy is still debated. Noninvasive imaging techniques such as MR angiography (MRA) or CT angiography (CTA) offer an alternative to digital subtraction angiography (DSA) and are increasingly used in clinical practice. In this study, we present the radiological characteristics and clinical results of a series of patients operated on the basis of combined ultrasonography (US)/MRA. METHODS: This observational study included all the patients consecutively operated for a carotid stenosis in our Department from October 1998 to December 2004. The applied MRA protocol had previously been established in a large correlation study with DSA. DSA was used only in case of discordance between US and MRA. The preoperative radiological information furnished by MRA was compared with intraoperative findings. The outcome of the operation was assessed according to ECST criteria. RESULTS: Among 327 patients, preoperative MRA was performed in 278 (85%), DSA in 44 (13.5%) and CT angiography in 5 (1.5%). Most of DSA studies were performed as emergency for preparation of endovascular therapy or for reasons other than carotid stenosis. Eleven additional DSA (3.3%) complemented US/MRA, mostly because diverging diagnosis of subocclusion of ICA. No direct morbidity or intraoperative difficulty was related to preoperative MRA. Combined mortality/major morbidity rate was 0.9% (3 patients) and minor morbidity rate 5.5% (18 patients). CONCLUSIONS: This observational study describes a well-established practice of carotid surgery and supports the exclusive use of non invasive diagnostic imaging for indicating and deciding the operation.     

Outcome,observer reliability,and patient preferences if CTA,MRA, or Doppler ultrasound were used,individually or together,instead of digital subtraction angiography before carotid endarterectomy

OBJECTIVES: To evaluate the accuracy of routinely available non-invasive tests (spiral computed tomographic angiography (CTA), time of flight magnetic resonance angiography (MRA), and colour Doppler ultrasound (DUS)), individually and together, compared with intra-arterial digital subtraction angiography (DSA) in patients with symptomatic tight carotid stenosis; and to assess the effect of substituting non-invasive tests for DSA on outcome, interobserver variability, and patient preference. METHODS: Patients referred from a neurovascular clinic were subjected prospectively to DUS imaging. The operator was blind to symptoms. Patients with a tight carotid stenosis on the symptomatic side were admitted for DSA. CTA and MRA were performed during the admission. The CTA, MRA, and DSA films were each read independently by two of six experienced radiologists, blind to all other data. RESULTS: 67 patients were included (34 had all four imaging procedures). DUS, CTA, and MRA all agreed with DSA in the diagnosis of operable v non-operable disease in about 80% of patients. CTA tended to underestimate (sensitivity 0.65, specificity 1.0), MRA to overestimate (sensitivity 1.0, specificity 0.57), and DUS to agree most closely with (sensitivity 0.85, specificity 0.71) the degree of stenosis as shown by DSA. When using any two of the three non-invasive tests in combination, adding the third if the first two disagreed would result in very few misdiagnoses (about 6%). MRA had similar interobserver variability to CTA (both worse than DSA). Patients preferred CTA over MRA and DSA. CONCLUSIONS: DUS, CTA, and MRA all show similar accuracy in the diagnosis of symptomatic carotid stenosis. No technique on its own is accurate enough to replace DSA. Two non-invasive techniques in combination, and adding a third if the first two disagree, appears more accurate, but may still result in diagnostic errors.     

脑动脉狭窄的CTA、MRA临床应用比较

目的评价及比较128排螺旋CT血管造影和3.0T磁共振血管成像(MRA)诊断脑动脉狭窄的可靠性。方法通过对脑动脉狭窄支架成形术患者的CTA、MRA检查结果与DSA结果进行回顾性对比分析。结果CTA诊断脑动脉狭窄较MRA诊断脑动脉狭窄的正确率高,误诊率、漏诊率低,但差异无统计学意义。结论 CTA及MRA诊断脑动脉狭窄可靠性均很高,可视情况选择应用。     

Three-dimensional computed tomography angiography and magnetic resonance angiography of carotid bifurcation stenosis.

PURPOSE: To evaluate the role of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) in the quantification of atherosclerotic stenosis of carotid artery bifurcation in comparison with digital substraction angiography (DSA) and Doppler sonography (DS). MATERIALS AND METHODS: Twenty-five patients with atherosclerotic disease of the carotid arteries with proven stenosis by DSA, had spiral CTA, MRA using two- and three-dimensional time-of-flight gradient echo techniques, and DS using Doppler flow signal recording (total 47 carotid artery bifurcations). The degree of stenosis was measured according to the North American Symptomatic Carotid Endarterectomy Trial criteria: total occlusion (100%), severe (70-99%), moderate (30-69%) and mild (0-29%). The degree of stenosis measured by CTA, MRA and DS was compared to DSA, used as the gold standard. RESULTS: Ninety-seven percent of MRA measures were equivalent to DSA, and 3% were underestimated; 96% of CTA measures were equivalent to DSA, and 4% were underestimated; 77% of DS measures were equivalent to DSA, 21% were overestimated and 2% were underestimated. CONCLUSIONS: CTA and MRA are equally accurate methods in quantifying the degree of carotid bifurcation stenosis.     

Intraplaque Microvascular Flow Signal in Superb Microvascular Imaging and Magnetic Resonance Imaging Carotid Plaque Imaging in Patients with Atheromatous Carotid Artery Stenosis

Carotid artery atherosclerosis is one of the major risk factors for ischemic stroke. Intraplaque neovascularization (IPN) is one of the steps toward the development of vulnerable plaque. Superb microvascular imaging (SMI) is a new ultrasonographic technique for visualizing low-velocity and microvascular flow by clutter suppression to extract flow signals from large to small vessels and enables visualization of intraplaque microvascular flow (IMVF) without echo contrast media. We aimed to investigate the association between IMVF signal in SMI and MRI plaque imaging among patients with atherosclerotic carotid stenosis.We prospectively enrolled patients (>18 years old) with mild to severe carotid stenosis (more than 50% in cross-sectional area) diagnosed by carotid ultrasonography between August 2017 and April 2018, irrespective of sex and history of stroke.A total of 40 patients (31 men, 9 women; mean age, 75.1 ± 10.0 years) were enrolled. SMI revealed IPN findings in 21 patients. SMI clearly visualized the direction of pulsatile flow movement in microvessels and IPN was easily classified into the two types of Type V (n=2) and Type E (n=19). Multivariate logistic regression analysis presented that microvascular flow signal in carotid plaque on SMI was identified as a significant predictor of intraplaque hemorrhage as evaluated by MRI (OR, 8.46; 95%CI, 1.44?49.9; p=0.018).This study demonstrated a significant association between the presence of IMVF signal in SMI and intraplaque hemorrhage characterized by high-intensity lesions on MRI T1-FFE images     

责任动脉闭塞与夹层相关缺血性卒中复发的相关性分析

目的 寻找脑动脉夹层相关卒中复发的高风险影像学特征,探讨责任动脉闭塞与其复发的关系。方法 前瞻性连续性纳入2018年1月-2022年2月在郑州大学第一附属医院住院的首发脑动脉夹层相关卒中患者,通过MRI、MRA、CTA、HR-MRI及DSA等影像学方法评估血管闭塞、长节段夹层等影像学特征,长期随访其复发情况。通过单因素、多因素COX回归分析其复发的影响因素,构建Kaplan-Meier生存曲线评估血管闭塞与脑动脉夹层相关卒中复发的关系。结果 共纳入107例脑动脉夹层相关卒中患者,有10例（9.3%）患者复发。单因素及多因素COX回归分析提示,责任动脉闭塞是脑动脉夹层相关卒中复发患者预后不良的独立预测因子（HR 6.150,95%CI 1.227～30.810,P=0.027）,出血转化也与脑动脉夹层相关卒中复发显著相关（HR 12.605,95%CI 2.373～66.949,P=0.003）。Kaplan-Meier生存曲线提示,闭塞组与非闭塞组卒中复发率差异具有统计学意义（Log-rank P=0.001）。结论 责任动脉闭塞是脑动脉夹层相关卒中复发的危险因素,需要大样本研究进一步验证本研究结果,为二级预防提供更精准的帮助。     

椎动脉夹层六例临床诊断和预后

目的 探讨椎动脉夹层的临床特点、诊断、治疗和预后.方法 6例表现为急性后循环障碍导致脑缺血的患者,经询问病史、体检、常规检查及DSA、MRI、MRA及颈部血管超声等检查,总结临床上椎动脉夹层的诊疗过程.结果 起病时有突发颈、枕痛者4例,发病时全部伴有眩晕或头晕,临床上2例表现为Wallenberg综合征;3例有明确颈部外伤史;影像学特点:DSA示椎动脉闭塞或狭窄,MRI示壁内血肿,颈部血管超声示残端样血流信号或线样血流,未发现有血管内膜增厚及动脉粥样硬化斑块;6例椎动脉夹层中5例发生在颅外段;平均随诊26个月,经过抗凝治疗,改良的Rankin Scale评分分别由病初的4、4、4.2、2,2分提高到随诊时的4、3、2、1、0、1分,经配对秩和检验,差异有统计学意义(Z=-2.07,P=0.038).结论 椎动脉夹层动脉瘤有特殊的临床表现,诊断并不困难,经长期抗凝治疗,血管可以再通,临床预后较好.