1000例螺旋CT胸部扫描方法与扫描技术分析

目的 分析螺旋CT胸部扫描方法及扫描技术对疾病的诊断价值,以便减少病人X线照射量及经济负担,且不影响诊断要求。方法 随机分析1000例胸部螺旋CT扫描的病例。常规扫描927例,其中单纯平扫155例,直接增强扫描747例,平扫加增强25例。血管造影73例。常规扫描中加做高分辨CT105例、薄层扫描86例、动态扫描6例、支气管成像40例。结果 不同的扫描方法和扫描技术适用于不同的疾病。选择适当的扫描方法及扫描技术,可减少病人X线照射,并能提高诊断的准确率。结论 在工作中应根据临床要求和病人的具体情况来确定扫描方法及扫描技术。     

Significance of acute pulmonary embolism for the exacerbation of chronic obstructive pulmonary disease

The clinical diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease is often difficult because there is no characteristics sign of acute pulmonary embolic event. The presentation of an acute embolic event may mimic the symptoms of acute airway obstruction which is caused by different reasons. The presence of chronic obstructive pulmonary disease was recorded on a clinical history, physical examination, chest roentgenogram, and the result of pulmonary function studies. Among the 178 patients with chronic obstructive pulmonary disease in 49 patients (27.5 percent) were suspected of having pulmonary embolism. Pulmonary embolism was excluded by normal or low probability V/Q scan in 19 patients. Among 23 patients who demonstrated a high probability lung scan there was a high positive predictive value for pulmonary embolism effectively avoiding the need for further studies. Among the 7 patients with nondiagnostic or intermediate probability lung scan contrast-enhanced helical computed tomography was detected the pulmonary embolism in 3 patients. The present study was undertaken to better define the noninvasive clinical, laboratory, roentgenographic, lung scan, and computed tomography characteristics of acute pulmonary embolism in patients with chronic obstructive pulmonary disease.     

The diagnosis of pulmonary embolism: the best strategies according to the results of a large Dutch multicentre study

The Dutch national guidelines for the diagnosis of patients with clinically suspected pulmonary embolism (from 1992 en 1998) are poorly followed in clinical practice, due especially to practical objections. A large multicentre trial to investigate the diagnostic accuracy of the available modalities and of recently developed techniques such as D-dimer determination, (99m)Tc-gas-scintigraphy and spiral CT scanning was started in I997. In the first phase, the diagnostic value was assessed of: spiral CT (sensitivity 69%, specificity 84%; sensitivity for segmental and larger pulmonary embolisms (PE) 86% and for subsegmental PE 21%), (99m)Tc-gas-ventilation scintigraphy (no improvement compared to conventional ventilation scintigraphy), D-dimer determination (sensitivity for segmental PE 93% and for subsegmental PE 53%, specificity 63%), clinical decision rules (in combination with D-dimer determination; sensitivity 100%, specificity 11%) and echography of the deep venous system (sensitivity 26% for segmental PE and 7% for subsegmental PE, specificity 97%). In the second phase, the feasibility of two new potentially cost-effective diagnostic algorithms was evaluated on the basis of the results obtained in the first phase and data in the literature. In 631 patients, a clinical risk estimate was made and D-dimer determination was done, followed by a ventilation-perfusion scan and serial compression echography of the leg veins. An apparent recurrence of PE occurred in 6 of 466 patients in whom no PE had been found originally (1.3%; 95% CI: 0.5-2.8). The average costs were 812 Euro,--per patient. In 510 patients, a spiral CT followed by compression echography was performed. Recurrent PE occurred in 3 of 378 patients with initial normal tests (0.8%; 95% CI: 0.2-2.3). The average costs were 883 Euro,--per patient. A combination of both strategies can be cost-effective with a cost 674 Euro,--per patient (recurrence rate: 1.9%). Both the strategy starting with a clinical-risk estimate and a D-dimer determination as well as the strategy consisting of spiral CT and serial echography were safe and cost-effective. According to the results of a survey of hospital directors, internists and pulmonologists, both are well accepted in clinical practice.     

多层螺旋CT扫描诊断肺动脉栓塞的应用价值

目的：探讨肺动脉栓塞患者的CT影像诊断价值。方法：回顾性分析22例临床怀疑为肺动脉栓塞的患者利用16排螺旋CT行肺动脉成像检查的影像学资料。结果：22例患者的肺动脉栓塞部位及范围均能显示,其中肺动脉栓塞10例,肺叶动脉栓塞7例,肺段及段以下动脉栓塞5例。22例患者中只有4例为单支动脉栓塞。结论：多层螺旋CT肺动脉成像作为一种无创性检查方法,能为肺动脉栓塞诊断提供直接、丰富的影像诊断细节,并能在治疗后较好地评价溶栓效果。     

老年肺栓塞临床诊治体会

目的提高老年肺栓塞临床诊断的准确率，为减少误诊误治提供依据。方法对天津市第三医院2000年1月-2006年12月确诊的资料完整的16例老年肺栓塞病例进行回顾性分析并文献复习。结果16例患者除行基本检查外，全部行胸部螺旋CT及超声心动图检查，无一例行肺动脉造影及肺核素扫描，其中6例被误诊，误诊率达37．5％，2例进展为慢性肺栓塞。老年肺栓塞的高危因素依次为：心血管疾病、制动或卧床、恶性肿瘤、手术、慢性肺部疾病等。治疗原则以溶栓、抗凝为主，2例行下腔静脉置网术。16例中3例治愈，4例显效，4例好转，5例死亡。结论肺栓塞是呼吸科的急危重症，当医院不能即刻提供肺动脉造影或肺核素扫描或重症患者不允许行以上检查，掌握老年肺栓塞的易患因素，密切观察临床症状和体征，通过简单的临床手段（包括血气分析、D-二聚体、心电图、X线胸片和胸部CT、心脏及血管超声检查等）也能临床诊断肺栓塞，及时的溶栓和抗凝治疗可治愈本病或缓解临床症状。     

D-二聚体在高危胸痛病因诊断中的价值

目的分析D-二聚体在高危性胸痛病因诊断中的应用价值。 方法回顾性分析2018年1月至2020年5月在扬州大学医学院附属泰兴市人民医院急诊科并明确诊断为高危性胸痛患者120例的临床资料，其中男性75例，女性45例；年龄44～78岁，平均(62.43±5.28)岁；体重指数(18.26～24.37)kg/m²，平均(21.34±0.98)kg/m²。统计高危性胸痛中急性心肌梗死、主动脉夹层、肺栓塞的发生占比情况，测定急性心肌梗死、主动脉夹层、肺栓塞患者的D-二聚体水平，并进行比较。 结果120例高危性胸痛患者中，急性心肌梗死共53例(44.17%)，主动脉夹层共38例(31.67%)，肺栓塞共29例(24.16%)。肺栓塞患者血清D-二聚体水平高于主动脉夹层与急性心肌梗死，且主动脉夹层患者血清D-二聚体水平高于急性心肌梗死，差异有统计学意义(P<0.05)。 结论血清D-二聚体在不同病因所致的高危性胸痛中的水平表达存在明显差异，其在急性心肌梗死患者中表达较低，呈轻度升高，在肺栓塞患者中升高趋势最为显著，故临床上可通过检测高危性胸痛患者的D-二聚体水平，来鉴别诊断急性心肌梗死、主动脉夹层、肺栓塞。     

Diagnostic workup for indicating the presence of pulmonary embolism: still not optimal

Despite numerous studies, which have documented that only 25-30% of patients presenting with suspected pulmonary embolism actually have emboli, the tendency to overdiagnose and overtreat this disease remains. Findings from the study by Kamphuisen et al. (2002:2083-7) in consecutive patients with suspected pulmonary embolism (non-diagnostic ventilation perfusion scan) in a general training hospital, confirm that with an optimal collaboration between pulmonologists, internists, radiologists and nuclear specialists, who follow a previously agreed diagnostic work-up, the proportion of patients without a proper confirmation or exclusion of pulmonary embolism can be minimized. However, a more promising solution to the problem might be the implementation of a strategy consisting of anamnestic features, measurement of the D-dimer concentration in plasma, and spiral CT.     

CTPA in suspected pulmonary embolism: diagnostic strategy

De Bruin and colleagues recently analysed the performance of the CTPA scan in patients with suspected pulmonary embolism. Their study shows that in a significant number of patients no abnormalities were found on a CTPA scan, a troubling finding given the radiation exposure. Young patients and ambulatory patients, in particular, often had a completely normal CTPA scan. Better stratification of patients with a high suspicion of pulmonary embolism is required, including evaluation of the value of clinical decision rules in ambulatory patients with suspected pulmonary embolism. In addition, the use of perfusion scanning, which involves significantly less radiation exposure, deserves further research in young people. Principally, a diagnostic strategy for pulmonary embolism comprising a clinical decision rule, followed by a D-dimer test if necessary, should be applied in clinical practice. This strategy will significantly reduce the number of CTPA scans showing no pulmonary embolism.     

支气管肺隔离症的螺旋CT诊断

目的分析支气管肺隔离症的螺旋CT征象,探讨螺旋CT增强扫描和血管重建的诊断价值。方法对21例经手术和病理证实、且影像资料完整的病例进行了回顾性分析。21例患者均做了CT平扫与增强,13例做了血管重建。结果1)21例肺隔离症中有16例为肺叶内型,5例为肺叶外型。14例位于左肺下叶,7例位于右肺下叶。2)CT示软组织密度肿块或结节12例,囊肿样病变9例,病灶周围肺气肿。3)增强CT显示了15例供血动脉,显示率71.4%(15/21);而血管重建的显示率为92.3%(12/13)。隔离肺无强化(15例)或边缘轻微强化(6例)。结论螺旋CT增强扫描和血管重建能很好地显示肺隔离症的病变特征和异常供血动脉,有利于确诊此病和制订手术治疗方案。     

Diagnostic work-up of severe diseases: simple prediction rules or just a simple test?

Diagnosing pulmonary embolism is an important problem. Several risk factors have been combined in prediction models, such as the Wells en Geneva scores. These models were prospectively validated in a large Dutch study (Prometheus study). With respect to this study, two critical issues are noted. Firstly, the discriminative ability of the models was modest, with areas under the Receiver Operating Characteristic (ROC) curve around 0.7. Secondly, the cut-offs to define low risk groups for the prediction rules were rather liberal, defining 60-70% of the included patients as 'low risk', while around 15% of these had a pulmonary embolism. In combination with a D-dimer test only 22-23% were classified as negative. This test missed only 1 patient among 186 patients identified with a pulmonary embolism. Performing a D-dimer test is hence essential in all patients in the selection for a CT scan. Improvements in the prediction rules are necessary to make these meaningful in the diagnostic work-up for pulmonary embolism.     

Negative ELISA D-dimer assay can miss pulmonary embolism

This evaluation of the use of enzyme-linked immunosorbent assay (ELISA) D-dimer test in routine clinical practice supports other evidence that the assay has a high sensitivity to exclude pulmonary embolism in patient populations in which there is clinical suspicion. Nevertheless, the assay incorrectly excluded the diagnosis of pulmonary embolism in 2 cases. Other examples of clinical decision-making exist for which the acceptable negative predictive value for screening is set at 100%--eg, the diagnosis of phenylketonuria in newborns. Physicians who do not want to miss cases of acute pulmonary embolism when they clinically suspect the diagnosis should not rely solely on negative D-dimer assay results when the value to rule out the diagnosis is set at 500 ng/mL. If a lower value is used to define normal--eg, 250 ng/mL, as used in other studies-no cases of acute pulmonary embolism would have been missed in this group of patients. Regardless of the cutoff used, the assay will yield many false-positive results.     

Screening for pulmonary embolism with a D-dimer assay: do we still need to assess clinical probability as well?

Clinical risk stratification and D-dimer assay can be of use in excluding pulmonary embolism in patients presenting to emergency departments but many D-dimer assays exist and their accuracy varies. We used clinical risk stratification combined with a quantitative latex-agglutination D-dimer assay to screen patients before arranging further imaging if required. Retrospective analysis of a sequential series of 376 patients revealed that no patient with a D-dimer of <275 ng/mL was diagnosed with pulmonary embolism, irrespective of clinical probability. We conclude that a latex-agglutination assay could be used to exclude pulmonary embolism without the necessity for clinical risk stratification. If these findings are borne out by further work, D-dimer strategies to exclude pulmonary embolism could substantially reduce imaging workload.     

肺硬化性血管瘤的影像学表现

目的探讨肺硬化性血管瘤的X线、CT表现及其诊断意义。方法回顾性分析16例经手术病理证实的肺硬化性血管瘤的资料。结果左肺9例,右肺7例,均为单发;除2例出现分叶外,其余所有病灶均表现为边界清楚的类圆形结节影。3例胸片病灶表现为边界清楚结节影,无明显分叶及毛刺;13例行CT检查均表现为边界清楚的结节影,1例见多发不规则钙化,平扫时硬化性血管瘤呈均匀等密度,11例增强扫描后病变呈明显强化。结论胸片有助于硬化性血管瘤的检出,但定性诊断困难,CT平扫及增强扫描对其诊断意义较高。     

肺硬化性血管瘤的影像学表现

目的探讨肺硬化性血管瘤的X线、CT表现及其诊断意义。方法回顾性分析16例经手术病理证实的肺硬化性血管瘤的资料。结果左肺9例,右肺7例,均为单发;除2例出现分叶外,其余所有病灶均表现为边界清楚的类圆形结节影。3例胸片病灶表现为边界清楚结节影,无明显分叶及毛刺;13例行CT检查均表现为边界清楚的结节影,1例见多发不规则钙化,平扫时硬化性血管瘤呈均匀等密度,11例增强扫描后病变呈明显强化。结论胸片有助于硬化性血管瘤的检出,但定性诊断困难,CT平扫及增强扫描对其诊断意义较高。     

Diagnostic management in suspicion of pulmonary embolism: results of a survey among Dutch internists and pulmonologists]

To gain insight into the incidence of suspected pulmonary embolism in the Netherlands and to evaluate the diagnostic strategy and therapeutic consequences in this patient population, a questionnaire was sent to all practising medical and pulmonary specialists (members of the respective associations). The number of patients admitted with suspected pulmonary embolism in the previous month and the diagnostic and therapeutic management in the last patient were requested. A reply was received from 698 internists and 272 pulmonologists (total response 73%). The management by the two specialist groups was not different. In the previous month 970 respondents treated 2245 patients for suspected pulmonary embolism. Extrapolated this means that 2.6 patients per 1000 inhabitants in the Netherlands are suspected of pulmonary embolism each year. Of the respondents, 95% had facilities to obtain a perfusion-ventilation scan. Of this group, 97% performed a perfusion scan when pulmonary embolism was suspected. A normal scan was found in 16% of the patients. A ventilation scan was performed in 71% of the patients with an abnormal perfusion scan result. Of all patients with an abnormal perfusion scan, 87% were treated with anticoagulants. The ventilation scan had little influence on this decision. The clinical suspicion of pulmonary embolism is a frequent clinical problem. The fact that of all patients with an abnormal perfusion scan 87% are treated, indicates overtreatment. The diagnosis of pulmonary embolism needs to be improved.     

The role of spiral computed tomography and D-dimer in pulmonary embolism

The first part of this study retrospectively compared the discriminatory power of spiral CT versus clinical findings in 112 consecutive patients referred with chest pain or dyspnoea. Spiral CT exhibited a sensitivity 91.9%; specificity 98.7%; PPV 97.1%; NPV 96.1%; accuracy 96.4%. No other test or clinical parameter had acceptable accuracy. The SimpliRED test is a latex method of estimating the level of D-dimer. The second part of this study determined that, in a similar consecutive series of patients referred for lung scintigrams, although SimpliRED tests had a NPV 95.5%, 59/126 (46.8%) consecutive were positive. However on the basis of clinical effectiveness and cost, imaging for suspected pulmonary embolism should be based on a combination of D-dimer estimation and spiral CT.     

The cost-effectiveness of diagnostic strategies in patients with suspected pulmonary embolism

The cost-effectiveness of various diagnostic strategies in patients with clinically suspected pulmonary embolism (PE) was analysed using a modelling approach. In 451 consecutive patients with clinically suspected PE data on the performance of diagnostic tests were collected prospectively in two large teaching hospitals in Amsterdam, The Netherlands. The ventilation-perfusion lung scan was used as the primary diagnostic test in all patients. In patients with a non-diagnostic lung scan result the performance of a clinical decision rule, a D-dimer test, and ultrasonography of the leg veins was evaluated with pulmonary angiography as the gold standard. It was estimated that the strategy recommended by a 1992 Dutch consensus meeting costs about Dfl 4400 per patient and that 97.02% of the patients can be expected to survive the first 6 months after the primary PE. The nation-wide annual costs for the diagnosis and treatment of patients by this strategy were estimated at 163 million Dutch Guilders. Subsequently, the costs and effects of alternative strategies were evaluated in a modelling approach, and compared with those of the consensus strategy. One strategy was selected that produces the best results in terms of survival and leads to considerable savings as compared with the consensus strategy. In this strategy subsequently a ventilation-perfusion scan, a clinical decision rule, a D-dimer test, a pulmonary angiography and leg ultrasonography are performed. Patients with a high probability ventilation-perfusion scan, an abnormal angiography or leg ultrasound test are treated, whereas treatment is withheld in patients with a normal ventilation-perfusion scan, a normal clinical decision rule, a negative D-dimer test, a normal angiography, or a normal leg ultrasound test. This strategy will have to prove its value and usefulness in clinical practice in a subsequent prospective validation phase.     

Value of the 'non-diagnostic' lung scan--further classification as to the risk of pulmonary embolism not reliable

OBJECTIVE: To determine to what extent the 'non-diagnostic' lung scans made because of a clinical suspicion of pulmonary embolism enable further determination of the risk of pulmonary embolism. DESIGN: Retrospective. METHOD: All non-diagnostic lung perfusion ventilation scans made in the Academic Medical Centre of Amsterdam in 1997 of 114 patients in succession (55 males and 59 females aged 27-85 years) were subjected to blind and independent re-evaluation by three observers (an experienced nuclear medicine expert, an experienced and an inexperienced intern) who, using a lung segment chart, estimated the risk of embolism as < 25%, 25-50%, 50-75% and > 75%. They did this first without and then with the chest X-ray. The findings were grouped on the basis of accordance or non-accordance with the pulmonary angiogram. The interobserver agreement was calculated by means of kappa statistics. RESULTS: Of 58 patients the lung scan could be compared with a chest X-ray and a pulmonary angiogram. In 43 patients with a normal angiogram the observers in an average of 50% of the scans estimated the risk of pulmonary embolism as < 25%, as against 25-50% in 27%, 50-75% in 9% and > 75% in 5%. In 15 patients with a deviant pulmonary angiogram, these figures were 22%, 38%, 20%, and 12%, respectively. The interobserver kappa for evaluation without chest X-ray was < or = 0.16, as against < or = 0.41% with the chest X-ray. CONCLUSIONS: A reliable classification of the risk of pulmonary embolism was not possible on the basis of non-diagnostic lung scans, regardless of whether the patient did or did not have pulmonary embolism. The interobserver variability was less when the lung scan was evaluated together with the chest X-ray, but even so it was unacceptably high.     

气钡双重造影及螺旋CT对结肠癌的临床应用价值

目的探讨气钡双重造影及螺旋CT对结肠癌的临床应用价值。方法对36例结肠癌患者术前的结肠造影及CT扫描图像进行分析,并与术后病理对照。结果X线诊断符合率94%;螺旋CT诊断符合率100%,腔外侵犯符合率60%,淋巴结转移检出符合率69%,肝脏及肺部等远处转移符合率100%。结论气钡双重造影为结肠癌筛查中的首选方法。气钡双重造影、螺旋CT各有所长,相互补充,能为临床分期、选择合适的手术方式及判断预后提供较为准确的依据。     

气钡双重造影及螺旋CT对结肠癌的临床应用价值

目的探讨气钡双重造影及螺旋CT对结肠癌的临床应用价值。方法对36例结肠癌患者术前的结肠造影及CT扫描图像进行分析,并与术后病理对照。结果X线诊断符合率94％;螺旋CT诊断符合率100％,腔外侵犯符合率60％,淋巴结转移检出符合率69％,肝脏及肺部等远处转移符合率100％。结论气钡双重造影为结肠癌筛查中的首选方法。气钡双重造影、螺旋CT各有所长,相互补充,能为临床分期、选择合适的手术方式及判断预后提供较为准确的依据。