肺通气血流灌注显像、螺旋CT肺动脉造影及D-二聚体测定对诊断肺栓塞的临床价值

目的探讨放射性核素肺通气血流灌注比值(V/Q)显像和螺旋CT肺动脉造影(SCTPA)以及血浆D-二聚体(dimer)检测对肺栓塞(PE)诊断的临床价值。方法对我院2010年2月—2013年2月可疑肺栓塞的患者,行V/Q显像、SCTPA检查和血浆D-二聚体测定以及相关检查,以最终临床诊断为依据,分别评价V/Q显像、SCTPA和血浆D-二聚体测定对PE的诊断价值。结果 278例高度怀疑PE患者经上述检查确诊PE患者151例,V/Q显像、SCTPA检查和血浆D-二聚体测定诊断PE的灵敏度、特异性、阳性预测值、阴性预测值分别为93.6%(132/141)、96.0%(120/125)、96.4%(132/137)、93.0%(120/129);95.8%(137/143)、96.9%(124/128)、97.2%(137/141)、95.4%(124/130);99.3%(140/141)、43.1%(59/137)、64.2%(140/218)、98.3%(59/60)。结论血浆D-二聚体测定的价值主要用于排除PE。对PE患者的检查应力求全面,V/Q显像、SCTPA检查均有其优点和不足,只有全面掌握各项检查的特点,才能对该项检查对疾病的诊断价值做出正确评价,从而正确运用这一诊断方法更好地服务于临床。     

D-二聚体在肺栓塞疾病诊断中的应用研究

目的：探讨肺栓塞患者中血浆D-二聚体（DD）含量的变化,为肺栓塞疾病（PE）的早期诊断提供依据。方法：采用免疫比浊法检测肺栓塞住院患者和非肺栓塞患者D-二聚体的含量。结果：肺栓塞患者血浆D-二聚体（DD）含量均值为（3.01±2.81）μg/ml,非肺栓塞患者为（1.11±0.90）μg/ml,前者显著高于后者（P〈0.01）。结论：血浆D-二聚体测定可作为诊断肺栓塞疾病的重要指标之一,特别对于临床低概率肺栓塞疾病的排查具有非常重要的临床价值。     

多排螺旋CT肺血管成像结合血浆D-二聚体测定对肺动脉栓塞的诊断价值

目的探讨多排螺旋CT肺血管成像(MSCTPA)结合血浆D-二聚体(D-dimer,DD)测定在肺动脉栓塞(pulmonaryem-bolism,PE)诊断中的应用价值方法对48例临床可疑PE患者进行MSCTPA检查和血浆DD检测以临床诊断为依据,分别评价MSCTPA、DD测定及MSCTPA结合血浆DD测定对PE的诊断价值其中22例病人于MSCTPA检查结果阳性后即进行溶栓治疗,并于治疗后第2天、第3天、第7天及2周分别复查DD值,于治疗后2周内分别复查了1次MSCTPA结果DD测定值全部阳性(48例),阳性率100%;MSCTPA共检出PE45例,3例无明显栓塞征象(2例肺内见片状炎性浸润影,1例两肺见散在纤维束条影),45例PE中1例MSCTPA首诊结果可疑,在DD阳性的提示下行0.625mm薄层重建肯定了PE的诊断溶栓治疗后复查的22例中,13例于1周内DD测定值升高,1周后DD测定值下降,9例DD值变化不明显;MSCTPA复查中DD值先升高后下降的13例充盈缺损征象明显改善,9例DD值变化不明显者充盈缺损征象亦无明显变化结论MSCTPA和血浆DD测定结合可提高PE的检出率,对诊断PE具有重要的临床应用价值     

CT阻塞指数对肺栓塞的评价及其与D-二聚体相关性分析

目的：探讨肺动脉CT阻塞指数对肺栓塞(PE)高危性的评价及其与D-二聚体之间的关系。方法收集经 CT肺动脉成像(CTPA)及D-二聚体检查的125例PE病例。将其分为高危PE组和非高危PE组,比较分析2组在 CT阻塞指数、D-二聚体、主肺动脉直径间的差异,以及肺动脉 CT 阻塞指数与 D-二聚体、主肺动脉直径之间的相关性(Spearman相关性评价)。结果高危PE组的CT阻塞指数明显高于非高危PE组(P=0.000),高危PE组主肺动脉直径较非高危PE组增粗,差异有统计学意义(P=0.000),而高危PE组和非高危PE组D-二聚体差异无统计学意义(P=0.103)。CT阻塞指数与D-二聚体无相关性(P=0.71)。结论血浆D-二聚体指标可以提示PE,不能评价PE的高危性;肺动脉CT阻塞指数在一定程度上可以反映PE的严重性,其与 D-二聚体间无相关性。     

D-二聚体测定联合临床评分对急性肺栓塞的诊断价值

目的评价D-二聚体测定联合临床评分对急性肺栓塞的诊断价值。方法以经过CT肺动脉造影确诊的急性肺栓塞（APE）患者为观察组（74例）,以排除APE的患者为对照组（74例）,两组患者均行D-二聚体测定及临床评分（改良Geneva评分）。结果观察组中,23例大面积APE患者经积极治疗后,21例痊愈,死亡2例,病死率为8.69%;51例非大面积APE的患者全部治愈,无一例死亡。74例APE患者的Geneva评分：0～3分4例（5.40%）;4～10分50例（67.57%）;≥11分20例（27.03%）。观察组的Geneva评分和血浆D-二聚体浓度均明显高于对照组（P〈0.01）。结论 D-二聚体测定联合改良Geneva评分对APE疑似患者的确诊有极大的临床意义,值得临床推广应用。     

螺旋CT肺动脉造影对肺栓塞的诊断

目的：评价螺旋CT及其肺动脉造影诊断肺动脉栓塞（PE）的价值。方法：回顾性分析12例PE患,均行螺旋CT容积扫描,并在工作站进行图像后处理,获得肺动脉多平面重建图像及三维立体图像。结果：对12例196支肺动脉分支进行分析,受累率为46.4%;栓子发生在主肺动脉、左右肺动脉干及叶段肺动脉。多平面重建图像上表现为充盈对比剂血管内有充盈缺损区,或其远侧方无对比剂充填区。肺动脉成像示,主干血管内可见充盈缺损影,或呈截断状影;叶栓塞或段栓塞亦呈突然“截断状”,其远侧方肺动脉分支不显影或呈纤维状。结论：螺旋CT肺动脉造影不仅可以获得轴位图像,而且可以获得立体图像,可多轴向旋转观察PE部位,是诊断叶或段以上PE可靠而直观的检查方法。     

肺通气/灌注显像结合血浆D-二聚体分析对肺栓塞的诊断价值

目的　探讨肺通气 灌注 (V Q)显像结合血浆D 二聚体 (dimer)分析在肺栓塞 (PE)诊断中的临床价值。方法　疑有PE的患者 10 4例进行肺V Q显像和血浆D dimer分析。以临床诊断为依据 ,分别评价肺V Q显像、D dimer分析及V Q显像结合D dimer分析对PE的诊断价值。结果　 4 4例确诊为PE ,6 0例排除PE。肺V Q显像对 86例 (82 .7% )明确诊断 ,另 18例 (17. 3% )为非确定性诊断。V Q显像诊断PE的灵敏度、特异性和准确性分别为 84. 1%、75 .0 %和 78. 8%。血浆D dimer分析诊断PE的灵敏度、特异性和准确性分别为 93. 2 %、6 0 . 0 %和 74 . 0 %。以D dimer <5 0 .0mg L作为V Q显像中非确定性诊断病例排除PE的依据 ,则诊断的特异性和准确性分别提高到 85. 0 %和 84 . 6 %。结论　在V Q显像中出现非确定性诊断结果时 ,血浆D dimer测定可作为排除PE的依据 ;V Q显像结合血浆D dimer测定可提高诊断的特异性和准确性。     

CT肺动脉成像在儿童急性肺栓塞中的应用与进展

儿童急性肺栓塞（PE）罕见,好发于新生儿期和青春期。主要的危险因素是制动、恶性肿瘤、雌激素过量、中心静脉导管置入、感染、先天性心脏病、高凝状态及静脉血栓病史。临床表现不典型常被基础疾病所掩盖易被漏诊,因此检测方法尤为重要。影像学检查,尤其是CT肺动脉成像（CTPA）越来越多地用于儿童PE的诊断。本文综述儿童PE的流行病学、危险因素、临床表现、CT血管成像技术和应用以及辐射剂量问题。     

肺动脉增强MRA及其对肺栓塞的诊断价值

本文从动态增强的原理，对比剂注射时间、剂量以及扫描序列、方法等方面介绍了胸部增强MRA的现状和应用，并回顾了该技术在肺栓塞诊断中的应用价值和潜力。     

多层螺旋CT肺动脉造影在肺栓塞诊断中的应用价值

目的：探讨多层螺旋CT肺动脉造影薄层扫描及三维重建技术在肺栓塞（PE）诊断中的应用阶值。方法：对35例临床确诊为肺栓塞的患者进行多层螺旋CT肺动脉造影薄层扫描结合三维重建后处理技术（曲面重建（CPR）、容积显示重建（VR））作影像后处理。结果：中央型PE20例．周围型PE8例，混合型PE7例。结合多层螺旋CT肺动脉造影轴位图像和三维重建图像都得到了诊断。结论：多层螺旋CT肺动脉造影薄层扫描结合三维重建后处理技术对肺栓塞可以做出可靠的诊断，     

CT和MR血管成像诊断急性肺栓塞的Meta分析

目的：应用 Meta 分析法,以 DSA 为金标准,探讨 CT 肺动脉成像（CTPA）和磁共振肺血管成像（MRPA）对肺动脉栓塞（PE）的诊断价值。方法：检索 Cochrane 图书馆、Medline 数据库、Springerlink 数据库及 Ovid 循证医学数据库中1994～2013年发表的英文文献以及知网数据库和万方医学数据库中1994～2013年发表的中文文献,按照 Cochrane 协作网推荐的诊断性实验的纳入标准,严格筛选与“CTPA 和／或 MRPA 诊断急性 PE”相关的文献。在符合条件的文献中提取诊断信息（包括真阳性值、假阳性值、真阴性值、假阴性值）和其它相关数据。采用 Stata 12软件和 Meta-disc 1．4软件对纳入文献行统计学处理,包括异质性检验,计算敏感度和特异度及其95％可信区间,选择相应的效应模型予以加权定量合并,绘制汇总的工作特征曲线（SROC）,最后进行敏感性分析。结果：按照纳入标准共获取有效文献17篇,其中与 CTPA相关的文献10篇,与 MRPA 相关的文献7篇。17篇文献均满足诊断性研究质量评价工具（QUADAS）中提出的14项标准中的10项以上。CTPA 及 MRPA 两组中的相关研究均有异质性,按照随机效应模型对纳入文献进行汇总分析。结果显示,CTPA 诊断肺栓塞的敏感度、特异度及各自的95％可信区间分别为0．78（0．74～0．82）和0．90（0．87～0．92）,MR-PA 为0．86（0．79～0．92）和0．97（0．94～0．99）,SROC 下面积分别为94％和98％。结论：CTPA 和 MRPA 对急性肺栓塞的诊断均具有很高的价值,两种方法的诊断特异度均很高,作为诊断肺栓塞的无创性检查方法可基本替代 DSA 检查。     

CT angiography of pulmonary embolism in patients with underlying respiratory disease: impact of multislice CT on image quality and negative predictive value

Our objective was to evaluate the impact of multislice CT (MSCT) on image quality and diagnostic value of spiral CT angiograms. Over an 8-month period (January 2000 to August 2000), 134 consecutive patients, including 55 patients with underlying lung disease, underwent MSCT (group 1). Image quality and diagnostic results of CT angiograms were compared with those obtained in 125 consecutive patients, including 58 patients with underlying lung disease, evaluated with thin-collimation single slice CT (SSCT; group 2) over a similar period of time (January 1999 to August 1999). A 3-month clinical follow-up was systematically obtained in all patients who were not anticoagulated in the two groups. For a significantly longer mean z-axis coverage, the mean duration of data acquisition was significantly shorter with MSCT. The frequency of examinations devoid of motion artifacts was significantly higher in group 1 than in group 2. In the absence of significant difference in the quality of vascular enhancement, mainly coded as good or excellent, the proportion of examinations interpretable down to the subsegmental arteries was higher in group 1 (57.5%) than in group 2 (13%) ( p<0.0001). The benefits of MSCT were more marked for patients with underlying respiratory disease and did not lead to a higher detection rate of peripheral pulmonary embolism. The negative predictive values of single-slice and multislice CT were 100 and 99%, respectively. Improvement in image quality on MSCT scans accounts for the improved diagnostic accuracy of CT angiography, in particular for patients with impaired respiratory function.     

Prediction of short term outcome of pulmonary embolism: Parameters at 16 multi-detector CT pulmonary angiography

Purpose

To evaluate the accuracy of computed tomography pulmonary angiography (CTPA) parameters, for predicting short-term mortality in patients with acute pulmonary embolism (PE).

Materials and methods

Thirty-two patients with proven PE had CT pulmonary angiography were included in the study. The clot burden using the Qanadli score (QS), and the right ventricular dysfunction (RVD) parameters were assessed on CT by calculating right ventricular/left ventricular (RV/LV) diameter ratios, interventricular septum abnormality, inferior vena cava contrast reflux, azygous vein and superior vena cava measures. Contrast density in pulmonary artery and descending aorta was evaluated for all patients. Patients were followed up for 30 days and then classified as survivors or non survivors.

Results

Thirty-two patients were included in the study, 23 (71.8%) of them were classified as survivors, and the other nine (28.1%) patients died within the first month (non survivors). There was a positive, but weak correlation between the Qanadli score and the short term mortality (P value = 0.05). There was a statistically significant relationship between the RV/LV ratio and PE-related mortality, with a P value < 0.001. Also, there was a good correlation between degree of IVC reflux and PE outcome (P < 0.001). The PA/AO diameter ratio, SVC diameter and azygous vein diameter showed no statistically significant difference between survivors and non survivors.

Conclusions

CTPA findings that may predict short term mortality are the high grades of inferior vena cava reflux, RV/LV diameter ratio more than 1.2, and clot burden >18 according to the Qanadli score and to a lesser degree the interventricular septum abnormality.     

MSCTPA对肺栓塞患者右心功能的诊断价值

目的以超声心动图作为诊断右心功能的标准,探讨64层CT肺血管造影(CTPA)对肺栓塞患者右心功能的诊断价值。方法前瞻性收集了临床疑诊肺栓塞的41例行CTPA检查的患者,阳性组根据右心功能、肺动脉栓塞部位及肺动脉压力指数分组,薄层数据进行最大密度投影(MIP)、多平面重建(MPR)和容积再现(VRT),分析各组数据中右心功能参数的差异。结果 41例患者中肺栓塞阳性24例,阴性17例,CTPA诊断右心功能不全13例,超声心动图诊断右心功能不全11例。以超声心动图为标准,64层CTPA诊断右心功能不全的灵敏度为76.9%,特异度为90.9%,阳性预测值90.9%,阴性预测值76.9%,Kappa值为0.669,诊断具有中度一致性。对于主肺动脉干(PA)、升主动脉(Aorta)、上腔静脉(SVC)、奇静脉(AV)、冠状静脉窦(CS)、PA/Aorta比、LVd、RVd及RVd/LVd比之间比较,第一组中差异有统计学意义的指标有PA、PA/Aorta比,LVd、RVd及RVd/LVd,CS;第二组中差异均无统计学意义;第三组中,差异有统计学意义的指标有PA/Aorta比。结论 MSCTPA及其后处理重建技术可以在诊断肺栓塞的同时对心功能作出评价。     

The use of a D-dimer assay in patients undergoing CT pulmonary angiography for suspected pulmonary embolus.

PURPOSE: To assess the ability of a semi-quantitative latex agglutination D-dimer test Accuclot with bedside measurements of arterial oxygen saturation, respiratory and cardiac rates to exclude pulmonary embolism (PE) on computed tomographic pulmonary angiography (CTPA). MATERIALS AND METHODS: All patients referred to our CT unit for investigation of suspected acute pulmonary embolism were enrolled. Pulse oximetery, respiratory rate, heart rate and blood sampling for D-dimer testing were carried out just before CT. A high resolution CT (HRCT) of the chest was followed by a CT pulmonary angiogram (CTPA). The images were independently interpreted at a workstation with cine-paging and 2D reformation facilities by three consultant radiologists blinded to the clinical and laboratory data. If positive, the level of the most proximal embolus was recorded. Discordant imaging results were re-read collectively and consensus achieved. RESULTS: A total of 101 patients were enrolled. The CTPA was positive for PE in 28/101 (28%). The D-dimer was positive in 65/101 (65%). Twenty-six patients had a positive CT and positive D-dimer, two a positive CT but negative D-dimer, 39 a negative CT and positive D-dimer, and 34 a negative CT and negative D-dimer. The negative predictive value of the Accuclot D-dimer test for excluding a pulmonary embolus on spiral CT was 0.94. Combining the D-dimer result with pulse oximetry (normal SaO2 > or = 90%) improved the negative predictive value to 0.97. CONCLUSION: A negative Accuclot D-dimer assay proved highly predictive for a negative CT pulmonary angiogram in suspected acute pulmonary embolus. If this D-dimer assay were included in the diagnostic algorithm of these patients a negative D-dimer would have unnecessary CTPA rendered in 36% of patients.     

CTPA对肺动脉栓塞的诊断及临床应用价值

目的:探讨多层螺旋CTPA及后处理技术对肺动脉栓塞的诊断及临床应用价值。方法:回顾性分析40例经多层螺旋CTPA确诊为肺动脉栓塞的影像资料,并应用MPR、MIP、VR等后处理方法不同角度显示肺动脉及其栓子情况,观察肺动脉栓塞的征象,10例经临床治疗后行CTPA复查并与临床结果对照指导治疗。结果:40例肺动脉栓塞(PE)病例中,中央型PE32例,周围型PE8例。肺动脉内栓子表现为中心型、偏心型及闭塞型的充盈缺损。经治疗复查CTPA显示栓子变小或消失。结论:MSCTPA已成为诊断肺动脉栓塞的可靠方法,并为肺动脉栓塞的治疗提供必要的指导。     

Comparison of doses for pulmonary embolism detection with helical CT and pulmonary angiography

The objective of this study was to compare the radiation exposure delivered by helical CT and pulmonary angiography (PA) for the detection of pulmonary embolism (PE), with an anthropomorphic phantom. A preliminary survey defined a representative standard procedure for helical CT and PA (n=148) by choosing the exposure settings most frequently used. Then, radiation doses were measured with thermoluminescent dosimeters TLD 100 (Lif) introduced into the depth of an anthropomorphic phantom. Average doses were approximately five times smaller with helical CT than with PA (6.4±1.5 and 28±7.6 mGy, respectively). The most important doses were abreast the pulmonary apex for CT, and abreast the pulmonary arteries for PA. Compared with PA, helical CT dose distribution was relatively uniform (10–13 mGy). Finally, concerning abdomen and pelvis, doses were more important for PA than for CT scan (0.06–2.86 and 0.2–11.5 mGy, respectively). For the diagnostics of PE, radiation exposure is five times smaller with helical CT than with pulmonary angiography.     

Imaging of acute pulmonary embolism using multi-detector CT angiography: An update on imaging technique and interpretation

Computed tomography angiography (CTA) of the pulmonary arteries has become the main diagnostic test for the evaluation of pulmonary embolism (PE). Not only due to the good availability, low cost and minimal invasiveness of this technique, but mainly because of the introduction of multi-detector CT techniques resulting in significant improvement in resolution, speed and image quality. This continuous gain in image acquisition speed went along with the introduction of new techniques of image acquisition, such as the dual-source CT scanning and novel concepts of image interpretation beyond morphological findings including the definition of the resulting perfusion defects and assessment of the cardiopulmonary circulation as a functional unit.This article will focus on technical and practical aspects to optimize CTPA examinations with modern multi-detector CT scanners, discusses aspects to be considered in specific patient groups (e.g., during pregnancy, young patients) and outlines new advents such as dual-source lung perfusion and automatic detection of pulmonary emboli.