甲状腺动脉栓塞治疗Graves病的不良反应与并发症分析

目的 回顾分析甲状腺动脉栓塞术治疗Graves病的不良反应与并发症。方法 41例Graves病患者接受了双侧甲状腺上动脉或加一侧下动脉的栓塞治疗，栓塞剂选用白芨微球或聚乙烯醇微球(PVA)和羊毛微钢圈，对所有患者进行了术中及术后不良反应和并发症的分析。结果 所有病例均出现不同程度的咽喉部疼痛和颈前区不适，栓塞术后3d至1周T3、T4可有一过性增高，随后逐步下降至正常水平。大多数患者(30／41)术后出现发热。1例(1／41)出现左侧视力部分缺失。1例由于栓塞甲状腺上动脉主干的钢圈脱落异位至大脑中动脉顶后小分支，但未引起血管堵塞，没有出现任何临床症状。1例术后出现一过性甲状旁腺功能低下。1例选用白芨微球栓塞剂的患者术后出现肝功能损害。所有患者术后眼症均无变化，未出现声音嘶哑或发音困难，无并发甲状腺功能低下和甲亢危象等并发症。结论 甲状腺动脉栓塞治疗Graves病可出现一些可逆的不良反应和严重并发症，但通过细心操作，经验积累，并发症是可以预防的。     

介入治疗Graves病的中远期疗效分析

目的 探讨甲状腺动脉栓塞术治疗Graves病的中远期疗效。方法 对25例因Graves病行介入治疗的患者进行了24－57个月的中长期随访，分别于术前及术后6个月和1，2，3，4年观察血清总三碘甲状腺原氨酸9T3），血清总甲状腺素（T4）水平，同时观察心率，甲状腺体积。结果 25例患者均接受了双侧甲状腺上动脉栓塞治疗，其中有11例甲状腺2度以上肿大者的尚栓塞了一侧甲状腺下动脉。栓塞剂选用白芨微球＋钢圈得6例，聚乙烯醇微球＋钢圈者19例。随访24－57个月。随访时间达到2年者有25例，达到3年者有17例，达到4年者有8例。介入方法治疗Graves病的中远期治愈率达88％（22／25），2例术后尚需服用抗甲状腺药物，另1例术后12个月复发，所有患者均未发现甲状腺或甲状旁腺功能低下。结论 介入治疗Graves病具有较好的中远期疗效，是临床治疗难治性Graves病的有效方法。     

弥漫性毒性甲状腺肿（Graves病）的介入治疗

目的：探讨采用甲状腺动脉栓塞方法治疗弥漫性毒性甲状腺肿（ Graves病）的疗效及临床意义。方法筛选30例Graves病患者,经动脉造影明确甲状腺动脉的位置及血供情况,超选入甲状腺上动脉或下动脉内用聚乙烯醇微球进行栓塞治疗,并观察其疗效。结果30例全部栓塞成功,16例栓塞双侧甲状腺上动脉,11例栓塞双侧甲状腺上动脉加单侧下动脉,3例栓塞一侧甲状腺上动脉。栓塞前后测定血清甲状腺激素,30例患者T3由3.4～41.2 nmol/L降至0.9～8.1 nmol/L;T4由79.1～436.3 nmol/L降至62.2～236.9 nmol/L;栓塞后颈部血管杂音完全消失,颈围于术后1天开始缩小,2周左右达到稳定状态。随访6个月～2年,20例完全停药,6例间断服药6个月,症状消失,未出现复发;4例随访1年,间断服用抗甲状腺药物,症状得到有效控制。所有病例未见发生甲状腺功能低下。结论甲状腺动脉栓塞术是治疗甲亢引起的Graves病有效的微创治疗方法。     

甲状腺动脉栓塞治疗Graves病与外科切除术长期疗效比较

目的比较甲状腺动脉栓塞与传统外科甲状腺切除术治疗Graves病的长期(5年)疗效。方法选取2003年1月-2010年12月因Graves病入院行经甲状腺动脉栓塞治疗患者54例作为介入治疗组,选取同期接受外科甲状腺次全手术切除术者40例作为外科治疗组,回顾性分析两组1、3、5年治愈率、有效率(好转及治愈),并进行比较。结果1、3、5年治愈率在介入治疗组分别为68.52%、61.18%和47.88%,在外科治疗组分别为97.50%、78.54%,69.48%;有效率在介入治疗组分别为98.15%、80.48%和60.90%,在外科治疗组分别为97.50%、76.42%和67.60%经Ridit分析,两组间1、3、5年疗效差异有统计学意义(P<0.05);而甲状腺功能减退发生率两组间差异无统计学意义(P>0.05)。结论甲状腺动脉栓塞治疗Graves病后近中期疗效满意,远期效果逊于外科切除术     

介入栓塞与^131I治疗Graves病近期疗效的对比分析

目的对比分析甲状腺动脉介入栓塞和131I治疗Graves病近期疗效的差异。方法对接受131I和甲状腺动脉栓塞治疗的各42例Graves病患者,行造影、SPECT/CT显像检查治疗前后甲状腺形态、大小,放射免疫法检测治疗前后3、6和12个月血清中FT3、FT4、TSH浓度及促甲状腺受体抗体(TRAb)活度和治疗后并发症出现的关系,并对以上数据进行统计学分析。结果两种治疗方法近期疗效无显著差异,介入治疗组治疗后早期严重并发症的发生率明显高于131I治疗组,而131I治疗组有更高的甲状腺功能减退(甲减)发生率。结论甲状腺动脉介入栓塞和131I治疗Graves病患者疗效肯定,131I可用于初诊及其他方法疗效不佳的患者,介入栓塞治疗可用于抗甲状腺药物疗效不佳、无法手术及甲状腺摄131I率低不能行131I治疗者,特别对一些难治性、顽固性甲状腺功能亢进有效。介入疗法可作为Graves病可选择的手段。     

介入栓塞治疗Graves病的应用解剖研究

目的 探讨甲状腺动脉的解剖及影像学表现,以提高介入栓塞治疗Graves病的疗效,降低并发症.方法 对16具成人尸体(尸体组)甲状腺动脉进行解剖研究,并对8例甲状腺功能正常(正常组)及17例Graves病患者(甲亢组)的甲状腺动脉造影片进行影像学研究.结果 甲状腺动脉发出较多非腺体支.尸体组与正常组各指标差异无统计学意义,但甲亢组甲状腺动脉延长,主干及腺体干支内径明显增粗,甲状腺动脉与颈动脉的角度增大,与前两组比较差异有统计学意义.腺体支之间的吻合和腺体内外的危险吻合支丰富.结论 Graves病甲状腺动脉改变有利于进行介入栓塞.避开非腺体支和危险吻合支是降低介入栓塞并发症的关键.     

1003例Graves病131I治疗临床分析

目的探讨个体化131I剂量治疗Graves病的效果.方法根据经验结合国内外文献,给予Graves病患者个体化的每克甲状腺组织剂量,范围为1.48～4.07 MBq/g.对治疗后甲状腺毒症、甲状腺肿(简称甲肿)、Graves眼病、甲状腺功能亢进(简称甲亢)性心脏病(简称甲心病)和周期性麻痹的转归进行临床随访,成功随访1003例(76.9%).131I使用剂量平均(329.3±307.1,44.4～3700)MBq,随访(16.4±10.0,3.0～44.7)个月.结果1次131I治疗后甲状腺功能(简称甲功)恢复正常593例(59.1%),甲状腺功能减退(简称甲低)200例(19.9%),甲亢部分缓解190例(18.9%),治疗无效20例(2.0%).259例(25.8%)发生了早发甲低,其中88例为一过性甲低,Logistic逐步回归分析示甲肿质硬者易发生早发甲低,而甲肿体积较大者早发甲低易转归为甲功正常或甲亢.等级偏相关分析示甲肿较大、病程较长和使用过抗甲状腺药物者对131I治疗反应较差.131I治疗后Graves眼病痊愈195例(41.7%),好转155例(33.1%),无效105例(22.4%),加重13例(2.8%).131I治疗后甲心病痊愈56例(77.8%),好转10例(13.9%),无效6例(8.3%).131I治疗后周期性麻痹痊愈60例(85.7%),好转2例(2.9%),无效8例(11.4%).131I治疗后249例巨大甲肿(≥90g)患者中88.0%(219例)甲状腺基本恢复正常.结论个体化131I剂量治疗Graves病疗效良好.131I对Graves眼病、甲心病和巨大甲肿性Graves病的治疗有效、安全.     

产后大出血急诊栓塞治疗的不良反应及并发症探讨

目的:探讨动脉栓塞法治疗急诊产后大出血的不良反应及并发症及其防治。方法:对57例急诊产后大出血患者的双侧子宫动脉或和髂内动脉以及部分患者的卵巢动脉用明胶海绵颗粒进行栓塞。结果:所有病例均出现有栓塞术后综合征;1例患者出现血尿(1.8%);13例患者出现髋部及下肢疼痛、麻木(22.8%);19例患者出现臀部疼痛、红肿、硬结(33.3%);1例患者出现子宫性闭经(1.8%);全组病例未出现子宫坏死或卵巢功能减退等其它严重并发症。结论:产后大出血急诊栓塞治疗会出现一定的不良反应及并发症,在治疗过程中进行超选择性栓塞,不进行过度栓塞,严防栓塞剂返流,可避免大部分严重并发症的发生。     

彩色多普勒超声监测Graves病甲状腺动脉栓塞后血流变化的临床研究

目的 研究彩色多普勒超声在监测甲状腺动脉栓塞治疗Grayes病后甲状腺血流变化，以及对临床疗效的评估作用。方法 31例确诊Graves病的患者行甲状腺动脉栓塞治疗，其中11例用彩色多普勒超声监测治疗前后甲状腺的血流变化，观察指标有甲状腺内部血流信号、甲状腺上动脉舒张期内径、收缩期最大血流速度(Vmax)、舒张期最小血流速度(Vmin)、阻力指数(RI)和甲状腺大小。同时观察临床症状和相关的实验室检查指标的变化情况。结果 Graves病甲状腺动脉栓塞治疗后，甲状腺上动脉舒张期内径、Vmax和Vmin明显降低，甲状腺内部血流明显减少，甲状腺体积缩小。临床症状好转或消失，相关的实验室检查指标恢复正常。结论 彩色多普勒超声可用于评估甲状腺动脉栓塞治疗Grayes病的疗效，是一种较好的无创性动态监测方法。     

甲状腺动脉栓塞术的并发症及其防治

目的 研究甲状腺动脉栓塞术的并发症及其防治方法。方法 回顾性分析61例甲状腺动脉栓塞术患者术中、术后发生的并发症及处理方法。结果 术中发生对比剂反应1例、动脉损伤2例，术后发生甲状腺危象1例，其余均为非靶动脉栓塞所致，包括头痛(23例)、牙痛(11例)、颈痛(13例)、声音嘶哑(37例)。最严重者为脑梗死1例和眼睑下垂、眼裂变小1例。脑梗死者行抗凝、扩血管治疗后好转，眼睑下垂者未作特殊处理，其余病例均对症处理后完全缓解。结论 甲状腺动脉栓塞术有一定的危险，操作要仔细，出现并发症时处理要及时、恰当。     

Thyroid arterial embolization to treat Graves' disease

Purpose: To prospectively investigate the effect of thyroid arterial embolization on hyperthyroid Graves' disease in selected patients.

Material and Methods: Twenty-eight patients with hyperthyroidism caused by Graves' disease were enrolled to undergo thyroid arterial embolization and followed up for 12-22 months. Twenty-two patients had three thyroid arteries embolized and six patients two arteries. Serum thyroid hormone, thyroid-stimulating hormone (TSH), and autoimmune function were tested before and after embolization in all patients.

Results: Of 28 patients, 22 (78.6%) became euthyroid, five improved (17.8%), and one had temporary improvement followed by recurrence (3.6%). No serious complications occurred. Compared with the pre-embolization values, serum concentrations of thyroid hormone increased temporarily on day 3 post-embolization, dropped substantially after 1 and 2 months, and returned to nearly normal at 6 and 12 months post-embolization. TSH dropped on day 3, increased after 1 and 2 months, and returned to normal after 6 and 12 months. Thyroid antibodies TGAb and TMAb declined on day 3 to normal range, rose after 1 month, dropped to normal again after 2 months, and were slightly increased at 6 and 12 months follow-up.

Conclusion: Thyroid arterial embolization may be an effective approach for patients with hyperthyroidism caused by Graves' disease.     

131I治疗Graves病后暂发性甲低的临床分析

目的：探讨^131I治疗后暂发性甲低的临床特点和转归。方法：对32例^131I治疗后出现暂发性甲低的患者进行临床分析和随访。结果：暂发性甲低出现在^131I治疗后2～6个月，有甲低症状者19例(59．38％)。甲低缓解后甲状腺功能正常者20例(62．5％)，又甲亢者12例(37．5％)。甲低时，T3和T4明显降低，TSH变化不一。结论：暂发性甲低多发生在低剂量^131I治疗的患者，甲低缓解后部分患者可再次出现甲亢。     

Subacute thyroiditis: a review of 105 cases

A retrospective review of 4023 thyroid scans performed at the Royal Adelaide Hospital in the five years to February 1987 identified 105 cases of subacute thyroiditis. Subacute thyroiditis accounted for 9.9% of subjects scanned for hyperthyroidism. Eighty-four percent had painful thyroiditis, 6% postpartum thyroiditis, and 10% painless thyroiditis. Follow-up was obtained in 68% of cases, and 11% were taking thyroxine, probably indicating long-term hypothyroidism. Apart from the presence of antibodies in post-partum thyroiditis, no other factor was identified which predicted the development of long-term hypothyroidism. As subacute thyroiditis is a common cause of hyperthyroidism in our community, the authors believe all people with hyperthyroidism should have a thyroid scan unless they have distinctive features of Graves' disease.     

Radioiodine treatment of hyperthyroidism using a simplified dosimetric approach. Clinical results

PURPOSE: To evaluate the clinical effectiveness of a simplified dosimetric approach to the iodine-131 treatment of hyperthyroidism due to Graves' disease or uninodular and multinodular toxic goiter. MATERIAL AND METHODS: We enrolled 189 patients with biochemically confirmed hyperthyroidism and performed thyroid ultrasonography and scintigraphy obtaining the diagnosis of Graves' disease in 43 patients, uninodular toxic goiter in 57 patients and multinodular toxic goiter in 89 patients. In 28 patients we found cold thyroid nodules and performed fine-needle aspiration with negative cytology for thyroid malignancy in all cases. Antithyroid drugs were stopped 5 days till radioiodine administration and, if necessary, restored 15 days after the treatment. Radioiodine uptake test was performed in all patients and therapeutic activity calculated to obtain a minimal activity of 185 MBq in the thyroid 24 hours after administration. The minimal activity was adjusted based on clinical, biochemical and imaging data to obtain a maximal activity of 370 MBq after 24 hours. RESULTS: Biochemical and clinical tests were scheduled at 3 and 12 months posttreatment and thyroxine treatment was started when hypothyroidism occurred. In Graves' disease patients a mean activity of 370 MBq (distribution 259-555 MBq) was administered. Three months after treatment and at least 15 days after methimazole discontinuation 32 of 43 (74%) patients were hypothyroid, 5 of 43 (11%) euthyroid and 6 of 43 (15%) hyperthyroid. Three of the latter were immediately submitted to a new radioiodine administration while 32 hypothyroid patients received thyroxine treatment. One year after the radioiodine treatment no patient had hyperthyroidism; 38 of 43 (89%) were on a replacement treatment while 5 (11%) remained euthyroid. In uni- and multinodular toxic goiter a mean activity of 444 MBq (distribution 259-555 MBq) was administered. Three months posttreatment 134 of 146 (92%) patients were euthyroid and 12 of 146 (8%) patients hyperthyroid. Two patients were immediately submitted to a new radioiodine administration. One year posttreatment 142 of 146 (97%) patients were euthyroid while only 4 of 146 (3%) patients showed TSH levels above the normal range. Only 2 of them required thyroxine treatment. CONCLUSIONS: The simplified dosimetric method illustrated in our paper is very effective in clinical practice because it permits to avoid resorting to sophisticated but also imprecise quantitative methods. Hypothyroidism should not be considered as a major collateral effect of radioiodine treatment, particularly in Graves' disease. In fact, the pathogenesis of the disease requires an ablative treatment with both surgery and radioidine treatment and the control of hyperthyroidism and the prevention of relapse are the major clinical targets. Vice versa, hypothyroidism was very uncommon in uni- and multinodular toxic goiter when our dosimetric approach was applied.     

Radioiodine therapy in Graves' disease based on tissue-absorbed dose calculations: effect of pre-treatment thyroid volume on clinical outcome

This study was performed with three aims. The first was to analyse the effectiveness of radioiodine therapy in Graves' disease patients with and without goitres under conditions of mild iodine deficiency using several tissue-absorbed doses. The second aim was to detect further parameters which might be predictive for treatment outcome. Finally, we wished to determine the deviation of the therapeutically achieved dose from that intended. Activities of 185-2,220 MBq radioiodine were calculated by means of Marinelli's formula to deliver doses of 150, 200 or 300 Gy to the thyroids of 224 patients with Graves' disease and goitres up to 130 ml in volume. Control of hyperthyroidism, change in thyroid volume and thyrotropin-receptor antibodies were evaluated 15+/-9 months after treatment for each dose. The results were further evaluated with respect to pre-treatment parameters which might be predictive for therapy outcome. Thyroidal radioiodine uptake was measured every day during therapy to determine the therapeutically achieved target dose and its coefficient of variation. There was a significant dose dependency in therapeutic outcome: frequency of hypothyroidism increased from 27.4% after 150 Gy to 67.7% after 300 Gy, while the frequency of persistent hyperthyroidism decreased from 27.4% after 150 Gy to 8.1% after 300 Gy. Patients who became hypothyroid had a maximum thyroid volume of 42 ml and received a target dose of 256+/-80 Gy. The coefficient of variation for the achieved target dose ranged between 27.7% for 150 Gy and 17.8% for 300 Gy. When analysing further factors which might influence therapeutic outcome, only pre-treatment thyroid volume showed a significant relationship to the result of treatment. It is concluded that a target dose of 250 Gy is essential to achieve hypothyroidism within 1 year after radioiodine therapy in Graves' disease patients with goitres up to 40 ml in volume. Patients with larger goitres might need higher doses.     

A mathematical model of optimized radioiodine-131 therapy of Graves' hyperthyroidism

BACKGROUND: The current status of radioiodine-131 (RaI) dosimetry for Graves' hyperthyroidism is not clear. Recurrent hyperthyroidism and iatrogenic hypothyroidism are two problems which interact such that trying to solve one leads to exacerbation of the other. Optimized RaI therapy has therefore begun to be defined just in terms of early hypothyroidism (ablative therapy) as physicians have given up on reducing hypothyroidism. METHODS: Optimized therapy is evaluated both in terms of the greatest separation of cure rate from hypothyroidism rate (non-ablative therapy) or in terms of early hypothyroidism (ablative therapy) by mathematical modeling of outcome after radioiodine and critically discussing the three common methods of RaI dosing for Graves' disease. RESULTS: Cure follows a logarithmic relationship to activity administered or absorbed dose, while hypothyroidism follows a linear relationship. The effect of including or omitting factors in the calculation of the administered I-131 activity such as the measured thyroid uptake and effective half-life of RaI or giving extra compensation for gland size is discussed. CONCLUSIONS: Very little benefit can be gained by employing complicated methods of RaI dose selection for non-ablative therapy since the standard activity model shows the best potential for cure and prolonged euthyroidism. For ablative therapy, a standard MBq/g dosing provides the best outcome in terms of cure and early hypothyroidism.     

甲状腺机能亢进的介入治疗

目的：探讨动脉内栓塞治疗甲状腺机能亢进 （甲亢）的临床应用。方法：对11例甲亢患者作甲状腺上动脉及下动脉的超选择性插管，并对上述血管行栓塞术。结果：11例甲状腺动脉栓塞均成功，栓塞后10例患者甲状腺机能逐渐恢复至正常水平，1例患者症状未得到满意控制，第2次行右侧甲状腺下动脉栓塞术后甲状腺机能逐渐恢复至正常水平，全部病例术后均无严重并发症发生。结论：动脉内栓塞治疗甲亢安全、简便、痛苦小、并发症少，是十分有效的治疗方法。