64层CT冠状动脉成像对急性胸痛病人治疗的作用:两中心的前瞻性研究

正摘要目的本项两中心的前瞻性研究是针对因低到中度危险评分到急诊科(ED)就诊的急性冠状动脉综合征(ACS)病人,评价采用64层CT冠状动脉成像(CCT)检查排除其显著冠状动脉狭窄的作用。方法175例因急性胸痛(ACP)入院且心电图未见异常,首次肌钙蛋白测量值为正常范围的病人被纳入研究     

直肠癌新辅助治疗后再分期的影像学评估及进展

影像学检查是直肠癌新辅助治疗后局部再分期的重要手段,可供选择的检查方法很多,对于再分期的价值各不相同。针对特定临床场景的影像学检查临床适用性评价工作可以提高检查的应用效能,减少不必要的检查和医疗花费。笔者从不同影像检查技术,包括直肠腔内超声、CT、MRI、PET检查入手,分别介绍不同检查手段及其新技术、新方法评估直肠癌新辅助治疗后再分期的应用价值,以期为临床选择合适检查提供依据。     

影像学在先天性心脏病患儿脑发育评估及预测模型中的应用进展

越来越多的研究结果显示,先天性心脏病（CHD）患儿会发生脑发育不良,如何基于影像学数据早期预测CHD患儿的脑发育状况是近年来研究的热点问题。超声及MRI等技术已被证实可以预测CHD患儿的脑发育状况,并在早期评估及干预中发挥了重要的作用。笔者综述了近年来基于影像学的预测模型在CHD患儿脑发育中的研究现状及进展,旨在为临床治疗及随诊提供参考。     

前庭性偏头痛的影像学研究及中医诊治进展

前庭性偏头痛（VM）的临床症状复杂,常规检查无特异性,诊断困难。近年来影像技术发展迅速,尤其是静息态脑功能成像、DTI和波谱成像等为VM的诊断及疗效评估提供了新的方法和有益视角,且上述功能成像还可进行无创的神经网络结构、基因-代谢组学研究,进而从多维度推动VM的发病机制研究。中医对VM的宏观辨证有独特的优势,VM的中医证型分布和病机特点与现代医学对VM的机制假说存在交叉重叠,融合中西医学理论与研究方法,可促进VM的临床诊治。     

影像学预测自发性脑出血血肿扩大的研究进展

【摘要】自发性脑出血具有起病急骤、病情凶险、预后不良且死亡率高的特点,血肿扩大是脑出血患者预后不良的主要因素之一,预测早期血肿扩大可以为临床制订合理的治疗决策提供支持。近年来预测血肿扩大的相关研究逐渐增多,主要涉及基于CT平扫、脑血管CTA和MRI征象、以及基于影像组学模型来进行预测。本文对血肿扩大的机制、影像特征及影像组学的研究进展进行综述。     

肺功能的影像学研究

肺功能的影像学研究主要是通过形态、密度或信号的改变来反映肺功能的变化，以揭示呼吸的生理病理机制。介绍了用CT和MRI进行肺功能研究的方法、临床意义及其优缺点，并回顾了该研究的现状与进展。     

肺癌化放疗疗效评估的影像学方法及进展

肺癌是呼吸系统常见的恶性肿瘤,也是对人群健康和生命威胁最大的恶性肿瘤之一。由于大部分患者在明确诊断时已经失去手术机会,故治疗主要以化疗和姑息性放疗为主。因此,如何准确评估其疗效具有重要的临床意义。本文主要对目前临床上肺癌化疗后疗效评估的影像学方法作一综述。     

腰椎旁肌肉退变的影像学评估及进展

<正>慢性腰痛是持续至少3个月的慢性疼痛综合征[1],患病率及致残率均较高[2]。1990～2013年全球对301种急慢性疾病负担的研究发现,腰痛排在致残率首位[3]。成人腰痛患病率达20.3%,且从生命的第三个十年开始呈线性增长[4],超过80%的人一生中至少有一段时间在经历腰痛或相关疾病[5]。腰椎旁肌肉作为人体核心肌群的重要组分,其结构与功能改变被认为与慢性腰痛有一定相关性。椎旁肌肉退变与腰椎疾病及术后并发症的产生亦相关[6],     

髋臼前柱髓内螺钉固定的解剖影像学研究及临床意义

目的 探讨髋臼前柱髓内螺钉治疗髋臼前柱骨折的解剖影像学参数,为临床应用提供参考.方法 取30具国人尸体(男18具,女12具)完整骨盆标本.直视下分别置入右侧顺行和左侧逆行双侧髋臼前柱空心拉力螺钉,通过肉眼观测和多排螺旋CT二维重建,测量螺钉的进钉点、角度、钉道长度、螺钉与髋臼和盆腔的关系,确定最佳进钉点和安全角度.结果 髋臼前柱逆行置钉点在耻骨结节处,距耻骨联合中线垂直距离为(17.15±1.82)mm,距耻骨上缘垂直距离为(20.51±2.19)mm;顺行置钉点距坐骨大切迹顶点的水平距离为(33.25±2.35)mm.逆行进钉的安全角度在矢状面头倾(32.1±2.7)°,冠状面外倾角度为(46.5±3.6)°,顺行置钉角度与逆行置钉角度相同,在矢状面和冠状面呈相反方向,左右侧略有不同(P>0.05).螺钉钉道长度为(119.5±2.2)mm,左右侧比较差异无统计学意义(P>0.05).螺钉的最大直径为7.2 mm.结论 髋臼前柱髓内螺钉固定有较高的准确性,可作为髋臼前柱钢板固定的一种有益的补充.     

自身免疫性胰腺炎的临床进展及影像学评价

自身免疫性胰腺炎(AIP)是慢性胰腺炎中的一种特殊类型,是与IgG4相关的系统硬化性疾病,其主要影像学检查手段包括B超检查、超声内镜、CT、MRI、磁共振胆胰管成像、经内镜逆行胰胆管造影等。AIP在影像学上表现为胰腺弥漫性或局灶性肿大,伴不同程度胰管或胆管的狭窄,但经超声引导下的细针穿刺活检诊断的敏感性与特异性均不高,正确的诊断对其治疗方案的选择和预后具有重要意义,现就AIP的临床进展及影像学表现予以综述。     

Cost analysis of diagnostic testing for coronary artery disease in women with stable chest pain

BACKGROUND: Seven clinical sites compiled data from 4638 women who were referred directly to coronary angiography (catheterization-first strategy; n = 3375) or who underwent stress myocardial perfusion imaging (MPI) first (n = 1263) followed by coronary angiography if at least one reversible myocardial perfusion abnormality was detected. The study examines the cost minimization potential of these available invasive and noninvasive diagnostic strategies in women with chest pain. METHODS AND RESULTS: Women in both groups were subclassified by the core laboratory as being at low (<0.15), intermediate (0.15 to 0.60), or high (>0.60) pretest likelihood for coronary artery disease (CAD). Among the catheterization-first patients, at least one coronary stenosis >70% was present in 13% of low likelihood patients, 29% of intermediate likelihood patients, and 52% of patients with high CAD likelihood. Perfusion abnormality rates in the MPI-first group were 23% in low likelihood patients, 27% in intermediate likelihood patients, and 34% in high CAD likelihood patients. Of the MPI-first subset, 50%, 55%, and 76%, respectively, underwent catheterization in at least one coronary stenosis >70%. Cardiac death rates ranged from 0.5% to 2.2% in patients with CAD and did not differ from the 2 testing strategies (P = not significant). The composite cost per patient of diagnostic testing plus follow-up medical care over a period of 2.5 +/- 1.5 years (calculated for both strategies from inflation-corrected Medicare charges, adjusted for institutional cost-charge ratios) ranged from $2490 for patients with low likelihood to $3687 for patients with high likelihood with the catheterization-first strategy and from $1587 to $2585 for patients undergoing MPI first (P < .01 between risk subsets and strategies). CONCLUSIONS: In women referred for diagnostic evaluation of stable chest pain, MPI followed by selective coronary angiography in patients with at least 1 perfusion abnormality minimizes the near-term composite cost per patient compared with a direct catheterization-first strategy, regardless of pretest CAD likelihood.     

Clinical assessment of chest pain and guidelines for imaging

For many emergency facilities, risk assessment of patients with diffuse chest pain still poses a major challenge. In their currently valid recommendations, the international cardiological societies have defined a standardized assessment of the prognostically relevant cardiac risk criteria. Here the classic sequence of basic cardiac diagnostics including case history (cardiac risk factors), physical examination (haemodynamic and respiratory vital parameters), ECG (ST segment analysis) and laboratory risk markers (troponin levels) is paramount. The focus is, on the one hand, on timely indication for percutaneous catheterization, especially in patients at high cardiac risk with or without ST-segment elevation in the ECG, and, on the other hand, on the possibility of safely discharging patients with intermediate or low cardiac risk after non-invasive exclusion of a coronary syndrome. For patients in the intermediate or low risk group, physical or pharmacological stress testing in combination with scintigraphy, echocardiography or magnetic resonance imaging is recommended in addition to basic diagnostics. Moreover, the importance of non-invasive coronary imaging, primarily cardiac CT angiography (CCTA), is increasing. Current data show that in intermediate or low risk patients this method is suitable to reliably rule out coronary heart disease. In addition, attention is paid to the major differential diagnoses of acute coronary syndrome, particularly pulmonary embolism and aortic dissection. Here the diagnostic method of choice is thoracic CT, possibly also in combination with CCTA aiming at a triple rule-out.     

Dual-source CT for chest pain assessment

Comprehensive CT angiography protocols offering a simultaneous evaluation of pulmonary embolism, coronary stenoses and aortic disease are gaining attractiveness with recent CT technology. The aim of this study was to assess the diagnostic accuracy of a specific dual-source CT protocol for chest pain assessment. One hundred nine patients suffering from acute chest pain were examined on a dual-source CT scanner with ECG gating at a temporal resolution of 83 ms using a body-weight-adapted contrast material injection regimen. The images were evaluated for the cause of chest pain, and the coronary findings were correlated to invasive coronary angiography in 29 patients (27%). The files of patients with negative CT examinations were reviewed for further diagnoses. Technical limitations were insufficient contrast opacification in six and artifacts from respiration in three patients. The most frequent diagnoses were coronary stenoses, valvular and myocardial disease, pulmonary embolism, aortic aneurysm and dissection. Overall sensitivity for the identification of the cause of chest pain was 98%. Correlation to invasive coronary angiography showed 100% sensitivity and negative predictive value for coronary stenoses. Dual-source CT offers a comprehensive, robust and fast chest pain assessment.     

Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease)

This was a prospective, multicenter study designed to evaluate the utility of MDCT in the diagnosis of coronary artery disease (CAD) in patients scheduled for elective coronary angiography (CA) using different MDCT systems from different manufacturers. Twenty national sites prospectively enrolled 367 patients between July 2004 and June 2006. Computed tomography (CT) was performed using a standardized/optimized scan protocol for each type of MDCT system (≥16 slices) and compared with quantitative CA performed within 2 weeks of MDCT. A total of 284 patients (81%) were studied by 16-slice MDCT systems, while 66 patients (19%) by 64-slice MDCT scanners. The primary analysis was on-site/off-site evaluation of the negative predictive value (NPV) on a per-patient basis. Secondary analyses included on-site evaluation on a per-artery and per-segment basis. On-site evaluation included 327 patients (CAD prevalence 58%). NPV, positive predictive value (PPV), sensitivity, specificity, and diagnostic accuracy (DA) were 0.91 (95% CI 0.85–0.95), 0.91 (95% CI 0.86–0.95), 0.94 (95% CI 0.89–0.97), 0.88 (95% CI 0.81–0.93), and 0.91 (95% CI 0.88–0.94), respectively. Off-site analysis included 295 patients (CAD prevalence 56%). NPV, PPV, sensitivity, specificity, and DA were 0.73 (95% CI 0.65–0.79), 0.93 (95% CI 0.87–0.97), 0.73 (95% CI 0.65–0.79), 0.93 (95% CI 0.87–0.97), and 0.82 (95% CI 0.77–0.86), respectively. The results of this study demonstrate the utility of MDCT in excluding significant CAD even when conducted by centers with varying degrees of expertise and using different MDCT machines.     

动态CT心肌灌注成像评价猪冠状动脉微循环障碍模型的实验研究

目的:探讨动态CT心肌灌注成像(CT-MPI)定量指标评价猪冠状动脉微循环障碍(CMD)模型的价值。方法:10只实验中华小型猪,麻醉后经股动脉选择性插管,通过导丝缓慢注入左前降支远段1 ml微球混合液(含微球0.5×10⁵/0.5 ml),建立CMD模型。分别于建模前60 min及建模后10 min行CT-MPI静息态和负荷态扫描。测量CT-MPI的定量指标,包括心肌血流量(MBF)、心肌血容量(MBV)。以实验猪建模前后CT-MPI指标的变化为自身参照标准,采用配对样本t检验比较建模前后静息和负荷状态下MBF、MBV的差异。之后处死动物并行病理检查证实CMD心肌节段。结果:8只猪完成实验(2只猪于建模时死亡)。CMD区静息MBF、MBV分别为(98.6±20.9)ml·100 ml^-1·min^-1、(9.0±2.8)ml/100 ml;负荷MBF、MBV分别为(87.6±14.6)ml·100 ml^-1·min^-1、(8.0±1.8)ml/100 ml。CMD区静息和负荷MBF及MBV与非CMD区比较均减低(P<0.001)。HE染色低倍镜下显示损伤心肌与正常心肌并存,高倍镜下显示心肌细胞质黏附,嗜酸性粒细胞增多,心肌细胞排列疏松,细胞核部分出现皱缩以及心肌细胞间质水肿。结论:本研究通过动态CT-MPI评价CMD动物模型,表明CMD心肌节段在静息和负荷状态下的MBF值和MBV值均较造模前明显减低,MBF、MBV变化值可作为动态CT-MPI评价CMD的定量指标。     

Diagnostic accuracy of stress myocardial perfusion MRI and late gadolinium-enhanced MRI for detecting flow-limiting coronary artery disease: a multicenter study

The aim of this study was to determine the diagnostic performance of stress and rest perfusion magnetic resonance imaging (MRI) and late gadolinium-enhanced (LGE) MRI for identifying patients with obstructive coronary artery disease (CAD). A total of 50 patients with suspected CAD underwent stress-rest perfusion MRI, followed by LGE MRI with a 1.5-T system. Stress-rest perfusion MRI resulted in an area under the receiver-operating characteristic curve (AUC) of 0.92 for observer 1 and 0.84 for observer 2 with sensitivity and specificity of 89% (32/36) and 79% (11/14) by observer 1, 83% (30/36) and 71% (10/14) by observer 2, respectively, showing a moderate interobserver agreement (Cohen’s κ = 0.49). While combination of stress-rest perfusion and LGE MRI did not result in improved accuracy for the prediction of flow-limiting obstructive CAD (AUC 0.81 for observer 1 and 0.80 for observer 2), the sensitivity was increased to 92% in both observers with a substantial interobserver agreement (κ = 0.70). Stress-rest myocardial perfusion MRI is an accurate diagnostic test for identifying patients with obstructive CAD.     

幽门螺杆菌与胸痛关系探讨

目的 探讨幽门螺杆菌(H．pylori)感染时胸痛的发生与功能性消化不良(FD)、冠心病(CHD)的关系。方法 采用胃镜检查530例患者，钳取胃粘膜组织，用Giemsa染色及PCR基因扩增法检涵H.pylori，按H．pylori阳性与否比较胸痛发生率，分析FD、CHD与H．pylori之间的关系。结果 H．pylori阴性中胸痛发生率为13．0％(39／300)；H．pylori阳性中胸痛发生率为19．6％(45／230)，两组比较差异有显著性(P＜0．05)；胸痛者84人中，45例H．pylori阳性中单FD发生率11．1％(5／45)，单CHD发生率33．3％(15／45)，两者比较差异有显著性(P＜0．05)。在胸痛者H．pylori阳性中FD和CHD均有的发生率为31．1％(14／45)，与H．pylori阴性中FD和CHD均有的5．1％(2／39)相比差异有显著性(P＜0．05)。结论 H．pylori感染时，胸痛的发生可能与FD和CHD发病有关，而且二者还可能发生部分重叠。H．pylori阳性患者出现胸痛时，一定要警惕CHD可能；在治疗H．pylori阳性FD时，不能忽视CHD的治疗。     

心肌灌注显像与冠状动脉钙化积分对冠心病风险评估的研究现状及相互关系

冠心病是严重威胁人类健康的常见病和多发病.早期诊断冠心病,无创、准确地进行心脏不良事件的风险评估并及时干预,是亟待解决的临床问题.风险评估模型对于心脏风险评估的有效性虽已被众多临床试验所证实,但仍有局限性.心肌灌注显像及冠状动脉钙化积分以及两者结合,为冠心病诊断及心脏风险的评估提供了新的思路.     

Use of coronary artery calcium testing to improve coronary heart disease risk assessment in a lung cancer screening population: The Multi-Ethnic Study of Atherosclerosis (MESA)

BackgroundAssessment of coronary artery calcium (CAC) during lung cancer screening chest computed tomography (CT) represents an opportunity to identify asymptomatic individuals at increased coronary heart disease (CHD) risk. We determined the improvement in CHD risk prediction associated with the addition of CAC testing in a population recommended for lung cancer screening.MethodsWe included 484 out of 6814 Multi-Ethnic Study of Atherosclerosis (MESA) participants without baseline cardiovascular disease who met U.S. Preventive Service Task Force CT lung cancer screening criteria and underwent gated CAC testing. 10 year-predicted CHD risks with and without CAC were calculated using a validated MESA-based risk model and categorized into low (<5%), intermediate (5%–10%), and high (≥10%). The net reclassification improvement (NRI) and change in Harrell's C-statistic by adding CAC to the risk model were subsequently determined.ResultsOf 484 included participants (mean age = 65; 39% women; 32% black), 72 (15%) experienced CHD events over the course of follow-up (median = 12.5 years). Adding CAC to the MESA CHD risk model resulted in 17% more participants classified into the highest or lowest risk categories and a NRI of 0.26 (p = 0.001). The C-statistic improved from 0.538 to 0.611 (p = 0.01).ConclusionsCHD event rates were high in this lung cancer screening eligible population. These individuals represent a high-risk population who merit consideration for CHD prevention measures regardless of CAC score. Although overall discrimination remained poor with inclusion of CAC scores, determining whether those reclassified to an even higher risk would benefit from more aggressive preventive measures may be important.