高分辨磁共振成像对大脑中动脉狭窄性病变诊断价值的研究

发布时间：2018-05-17 16:15

本文选题：磁共振成像 + 高分辨　；参考：《山东大学》2017年博士论文

【摘要】：第一部分高分辨磁共振成像对中青年大脑中动脉狭窄性病变诊断价值的研究研究背景:缺血性脑卒中是全球人类致残和致死的主要原因。在我国,颅内动脉尤其大脑中动脉狭窄是引起缺血性脑卒中的一个重要原因。随着社会进步和压力增大,脑血管病的危险因素普遍提前出现,中青年人动脉粥样硬化的发病率较前增加。随着科技进步和医学发展,烟雾病、动脉夹层及血管炎也成为中青年缺血性卒中的主要病因。由于不同病因的发病机制和病理学改变不同,导致缺血性脑卒中的预防和治疗是有区别的。早期明确中青年大脑中动脉(middle cerebral artery,MCA)狭窄患者的病因,对合理选择治疗方法、预防卒中发生具有重要意义。目的:回顾性分析中青年MCA狭窄患者的临床及影像学资料,探讨高分辨磁共振(highresolutionMRI,HRMRI)诊断MCA狭窄病因的可行性。材料与方法:收集2012年10月至2016年12月在我院因缺血性脑卒中就诊中青年患者,入组标准:(1)中青年患者定义为:18岁≤患者年龄55岁。(2)MRA呈一侧或双侧MCA中-重度狭窄。(3)狭窄MCA进行了 HRMRI检查。排除标准:(1)同侧颈内动脉狭窄50%或管壁不规整;(2)HRMRI检查侧MCA闭塞;(3)有心源性栓塞的证据;(4)临床资料及影像学资料不完整影响进一步分析。结合分析临床及影像学资料获得综合诊断为标准,回顾性分析不同病因导致大脑中动脉狭窄时临床及影像学特点。应用SPSS 22.1 for Windows统计软件包(IBM,USA)进行统计学分析。计数资料用频数及百分比表示,两组间比较采用x2检验或Fisher精确检验。连续型变量统计学分析采用单因素方差分析和独立样本t检验。P值0.05认为具有统计学意义。数值变量两两时比较采用LSD-t检验,均P0.05认为具有统计学意义。对任两个率均进行两两比较时进行检验水准调整。结果:(1)124例MCA狭窄患者,男性90例(72.6%),平均年龄41.5±9.02岁。高危危险因素包括高血压病(n =74,59.7%),高脂血症组(n =53,42.7%),吸烟(n =50,40.3%),糖尿病(n= 19,15.3%)。124 例 MCA 狭窄病因包括动脉粥样硬化性狭窄(n=80,65.3%),动脉夹层(n=16,12.9%),血管炎性病变(n=15,11.3%),烟雾病(n=13,10.5%)。高危因素数与MCA狭窄患者的性别(P=0.022)及年龄(P=0.004)的差异有统计学意义。(2)与非动脉粥样硬化狭窄相比,动脉粥样硬化患者年龄大(43.45μ8.44比 38.05±9.10,P=0.001),男性常见(64/80[80.0%]比 26/44[55.3%];P =0.013);吸烟比例高(48/80[50%]比 10/44[21.3%];P = 0.003);局灶性狭窄常见(56/80[70%]比12/44[25.5%];P = 0.000),局灶性狭窄以累及中段最常见(30/80[37.5%]比 2/44[4.3%];P = 0.049))。动脉粥样硬化 MLN 管壁外径大(4.14μ0.68 比 3.06±0.63,P=0.000)、最大管壁厚度大(2.2±0.42 比1.00±0.30,P=0.000)、偏心指数大(0.80±0.07 比 0.48±0.22,P=0.000),MLN最小管壁厚度小(0.41±0.12比0.51±0.14,P=0.000)。动脉粥样硬化组偏心强化比例最多(31/80[38.8%]),非动脉粥样硬化组环形强化最常见(28/44[59.6%]),两组差异有统计学意义(P=0.000)。增厚管壁强化程度在两组间的差异无统计学意义(P=0.853)。(3)与动脉粥样硬化性狭窄相比,动脉夹层MLN管壁外径小(3.52μ0.64 比 4.14±0.68,P=0.001)、MLN 最大管壁厚小(1.612±0.81 比 2.2μ0.42,P=0.017)、偏心指数小(0.58±0.32 比 0.80±0.07,P=0.012);16 例动脉夹层中节段性狭窄多见(9/16,56.3%),14例(87.5%)可见内膜瓣,10例(62.5%)可见双腔征,7例(43.75%)可见壁内血肿。血管炎性病变多较年轻(35.20 ±10.73 比 43.45 ±8.44,P = 0.004),非局灶性狭窄(11/15,73.3%),呈环形强化;MMD多为女性(7/13,P=0.009)、非局灶性狭窄(9/13,69.3%),对侧 MCA 多受累(9/13[69.2%]比 9/80[11.3%],P=0.000),增强后可呈无强化、或轻度、中度及明显环形强化。(4)动脉夹层与血管炎、烟雾病的MLN最大管壁厚度、MLN管壁外径在间均存在统计学差异(均P0.05);动脉夹层偏心指数(0.58±0.32)比烟雾病的(0.41 ±0.10)大(均P0.05)。动脉夹层与血管炎性病变相比,动脉夹层的吸烟比例高(P=0.008),血管炎多为环形强化(P=0.012)。动脉夹层与烟雾病相比,夹层多为单侧病变常累及中远段,而烟雾病以近中段多见且对侧MCA常见狭窄。血管炎性病变与烟雾病相比只有对侧MCA受累情况有差异,烟雾病对侧MCA多受累(P=0.009)。结论:(1)动脉粥样硬化性狭窄是中青年MCA狭窄最常见原因,动脉夹层、血管炎性病变及MMD是中青年MCA狭窄常见原因。(2)动脉粥样硬化性MCA狭窄多见于男性,局灶性狭窄多见,MLN管壁外径、最大管壁厚度及偏心指数均高于非动脉粥样硬化,管壁呈偏心性增厚,偏心强化较常见。(3)非动脉粥样硬化狭窄MRA多为节段性或全程性狭窄,管壁向心性轻度增厚并环形强化最常见。大脑中动脉夹层HRMRI典型征象包括内膜瓣和双腔征,壁内血肿是常见征象。血管炎性病变多较年轻,管壁多为明显环形强化。烟雾病女性多见,管壁增厚不明显,增强后可呈无强化、轻度强化、中度强化及重度强化。(4)不同MCA狭窄病变HRMRI表现有所不同,中青年MCA狭窄性病变HRMRI检查一方面有助于狭窄病因的诊断,另一方面通过描绘不同病变血管病理改变特点,提高对不同病变的认识。(5)血管炎性病变与烟雾病在HRMRI表现有重叠现象,在表现不典型时,还需要结合临床、实验室检查及随访进一步确定。第二部分年龄因素对大脑中动脉粥样硬化性狭窄血管重构及斑块负荷影响的高分辨磁共振研究研究背景:冠状动脉研究证实年龄与重建方式和斑块形态相关,而重构方式及斑块形态又会影响治疗方案的选择。但针对年龄因素与颅内动脉粥样硬化改变有无相关性的研究极少。随着磁共振技术发展,HRMRI可用于评价颅内动脉粥样硬化斑块形态和血管重构方式,而且具有良好得可重复性。目的:利用HRMRI评价年龄对中-重度MCA动脉粥样硬化性狭窄血管重构和斑块负荷的影响方法:收集2012年10月至2016年10月因缺血性脑卒中在我院就诊患者。入组标准:(1)MRA检查显示一侧MCA中-重度狭窄(MCA狭窄≥50%)。(2)具有两个或两个以上动脉粥样硬化危险因素,动脉粥样硬化危险因素包括:高血压、高血脂、糖尿病、吸烟]。(3)患者年龄≥18岁。(4)根据患者年龄分为青年组(≤45岁)和中-老年组(45岁)。如果患者具有以下任何一个条件将被排除:(1)同侧颈内动脉狭窄50%或管壁不规整;(2)MCA闭塞;(3)有心源性栓塞的证据,包括房颤、风心病及先心病等;(4)动脉夹层、烟雾病和血管炎等非动脉粥样硬化性血管病变;(5)图像质量不能满足血管壁和血管腔的进一步分析;(6)由于MCA走向迂曲或分叉导致未能获得最狭窄处(maximal lumen narrowing,MLN))与参考位置的轴位图像。在HR-T1WI测量MLN和参考位置的血管面积(vessel area,VA)管腔面积(lumen area,LA)。根据公式计算狭窄程度,斑块负荷百分比和重构指数。重构指数≥1.0为阳性重构,1.0为阴性重构。应用SPSS 22.1 for Windows统计软件包(IBM,USA)进行统计学分析。符合正态分布的计量资料,以均数±标准差(x±s)表示;。计量资料两组间比较使用采用t检验进行两组间的比较。计数资料两组间比较采用x2检验或Fisher精确检验相关系数及95%可信区间评估测量的可重复性。结果:(1)共71例MCA动脉粥样硬化狭窄患者纳入分析。其中青年组24人,平均年龄36.54 ±5.72岁;中老年组47人,平均年龄57.49 ±7.76岁。性别比例、DWI阳性率和症状性狭窄比例在两组的差异无统计学意义。最常见危险因素均为高血压(青年组79.17%,中老年组78.72%,P=0.965)。青年组吸烟明显高于中老年组(54.17%比29.79%,P=0.045)。青年组糖尿病发病率明显低于中老年组(30.83%比55.32%,P=0.006)。(2)青年组、中老年组阴性重构比例分别为80.83%、44.68%(p=0.037),青年组、中老年组的斑块负荷百分比分别为 0.314±0.183、0.405±0.126(p=0.017)。结论:颅内大动脉粥样硬化的重构方式和斑块负荷与年龄相关。动脉粥样硬化性MCA狭窄的青年组患者NR比例较高,可能与吸烟、脑血管壁的独特结构特点和脑血流动力学特点有关。在进行动脉粥样硬化性颅内动脉狭窄治疗时,除了解决血管狭窄、稳定易损斑块外,延缓血管狭窄速度为侧枝循环建立提供时间尤其对年轻患者可能会是一个新治疗方向。
[Abstract]:The first part is the study of the value of high resolution magnetic resonance imaging in the diagnosis of middle cerebral artery stenosis in young and middle-aged people: ischemic stroke is the main cause of human disability and death in the world. In China, the intracranial artery especially middle cerebral artery stenosis is an important cause of ischemic stroke. With social progress and pressure, the cerebral artery stenosis is an important cause. The risk factors of cerebrovascular disease occur in advance, and the incidence of atherosclerosis in young and middle-aged people is increasing. With the progress of science and technology and medical development, moyamoya disease, interlayer and vasculitis are also the main causes of ischemic stroke in young and middle-aged. The prevention and treatment of sexual apoplexy is different. Early identification of the causes of middle cerebral artery (MCA) stenosis in middle-aged and young people is of great significance for the rational choice of treatment and prevention of stroke. Objective: To review the clinical and imaging data of the middle and young people with MCA stenosis and to explore the high resolution magnetic resonance (hig). HresolutionMRI, HRMRI) to diagnose the cause of MCA stenosis. Materials and methods: to collect young patients from October 2012 to December 2016 in our hospital for ischemic stroke, the standard of entry group: (1) the young and middle-aged patients were defined as: 18 years old and less than 55 years old. (2) MRA was one side or bilateral MCA moderate severe stenosis. (3) narrow MCA performed HRMRI examination. Exclusion criteria: (1) ipsilateral internal carotid artery stenosis 50% or tube wall irregular; (2) HRMRI examination side MCA occlusion; (3) evidence of cardiogenic embolism; (4) incomplete effect of clinical data and imaging data on further analysis. Combined analysis of clinical and imaging data to obtain comprehensive diagnostic criteria and retrospective analysis of different causes leading to middle brain motion Clinical and imaging characteristics of pulse stenosis. Statistical analysis was performed with SPSS 22.1 for Windows statistical software package (IBM, USA). The count data were expressed in frequency and percentage. The two groups were compared with x2 test or Fisher precision test. The continuous variable statistical analysis adopted the single factor analysis of variance and the independent sample t test.P value 0.05. There was a statistical significance. The LSD-t test was used when the numerical variable was 22. P0.05 was considered statistically significant. The results were adjusted when all two rates were compared. Results: (1) 124 cases of MCA stenosis, 90 men (72.6%) and average age 41.5 + 9.02 years. High risk risk factors including hypertension (n =74,59.7%), high fat N =53,42.7%, smoking (n =50,40.3%), and diabetes (n= 19,15.3%).124 cases of MCA stenosis include atherosclerotic stenosis (n=80,65.3%), arterial dissection (n=16,12.9%), vasculitis (n=15,11.3%), and moyamoya disease (n=13,10.5%). (2) compared with non atherosclerotic stenosis, atherosclerotic patients were older (43.45 Mu 8.44 than 38.05 + 9.10, P=0.001), males were common (64/80[80.0%] 26/44[55.3%]; P =0.013); smoking was higher (48/80[50%] than 10/44[21.3%]; P = 0.003); focal stenosis was common (56/80[70%] ratio 12/44[25.5%]; P = 0), and focal lesion The stenosis was the most common in the middle segment (30/80[37.5%] ratio 2/44[4.3%]; P = 0.049)). The outer diameter of the atherosclerotic MLN tube wall was large (4.14 Mu 0.68 to 3.06 + 0.63, P=0.000), the maximum wall thickness (2.2 + 0.42, 1 + 0.30, P=0.000), the eccentricity index (0.80 + 0.07 ratio 0.48 + 0.22, P=0.000), and the smallest thickness of MLN (P=0.000) P=0.000). The proportion of eccentricity enhancement in the atherosclerotic group was most (31/80[38.8%]), and the most common (28/44[59.6%]) was in the non atherosclerotic group (28/44[59.6%]). The difference between the two groups was statistically significant (P=0.000). The thickness of the thickening tube wall was not statistically significant between the two groups (P= 0.853). (3) compared with atherosclerotic stenosis, the artery dissection MLN The outer diameter of the tube was small (3.52 Mu 0.64 than 4.14 + 0.68, P=0.001), the maximum wall thickness of MLN was smaller (1.612 + 0.81 than 2.2 u 0.42, P=0.017), the eccentricity index was small (0.58 + 0.32 than 0.80 + 0.07, P=0.012). Inflammatory lesions were more young (35.20 + 10.73 than 43.45 + 8.44, P = 0.004), non focal stenosis (11/15,73.3%) and circular intensification; MMD was mostly female (7/13, P=0.009), non focal stenosis (9/13,69.3%), and contralateral MCA multi involvement (9/13[69.2%] than 9/80[11.3%], P=0.000), enhanced, or mild, moderate, and obvious ring (4) there was a statistical difference between the arterial dissection and vasculitis, the MLN maximum wall thickness of the moyamoya disease and the outer diameter of the MLN tube (all P0.05); the eccentricity index (0.58 + 0.32) of the arterial dissection was (0.41 + 0.10) larger than that of the moyamoy (all P0.05). The proportion of the arterial dissection and the vasculitis was higher (P=0.008), and the vasculitis was mostly Annular enhancement (P=0.012). Compared with moyamoya disease, interlayer is mostly unilateral lesion often involving the middle and far segment, and moyamoya disease is common in the middle of the middle segment and the contralateral MCA is common. Compared with the smoke disease, only the contralateral MCA involvement is different, and the moyamoya's contralateral MCA is more involved (P=0.009). Conclusion: (1) atherosclerotic stenosis It is the most common cause of MCA stenosis in middle and young people. Arterial dissection, vasculitis and MMD are common causes of MCA stenosis in young and middle-aged people. (2) atherosclerotic MCA stenosis is mostly seen in men, most of which are localized stenosis, the outer diameter of MLN tube wall, the maximum wall thickness and eccentricity index are higher than that of non atherosclerosis, the wall of the tube is eccentric thickening and eccentric strengthening. Common. (3) the non atherosclerotic stenosis MRA is mostly segmental or full narrow, the wall of the tube wall is mild thickening and the ring intensification is the most common. The typical signs of the middle cerebral artery dissection HRMRI include the intima valve and the double cavity sign, the intramural hematoma is the common sign. The vasculitis disease is more than the year light, the tube wall is more obvious ring intensification. Moyamoya disease female The thickening of the wall of the tube was not obvious. After the enhancement, there was no strengthening, mild strengthening, moderate strengthening and severe strengthening. (4) the HRMRI manifestations of different MCA stenosis lesions were different. The HRMRI examination of MCA stenosis in middle and young people was helpful to the diagnosis of the cause of stenosis. On the other hand, the characteristics of different pathological changes of vascular pathology were improved. (5) there is an overlap between the HRMRI manifestations of angiitis and moyamoya disease. In the case of atypical manifestations, it is necessary to combine clinical, laboratory and follow-up to further determine the background of high resolution magnetic resonance (MRI) research on the effects of age factors on vascular remodeling and plaque load in the middle cerebral atherosclerotic stenosis. Coronary artery studies have confirmed that age is related to the pattern of reconstruction and plaque morphology, and the pattern of reconstruction and plaque shape may affect the choice of treatment. However, there are few studies on the correlation between age and changes in intracranial atherosclerosis. With the development of MRI, HRMRI can be used to evaluate the shape of atherosclerotic plaque in the intracranial. State and vascular remodeling, and have good reproducibility. Objective: To evaluate the influence of age on vascular remodeling and plaque load of atherosclerotic stenosis of moderate to severe MCA: to collect the patients in our hospital from October 2012 to October 2016 with ischemic stroke. (1) MRA examination showed the medium weight of one side of MCA. Degree stenosis (MCA stricture is more than 50%). (2) there are two or more risk factors for atherosclerosis, and the risk factors for atherosclerosis include hypertension, hyperlipidemia, diabetes, smoking. (3) patients are older than 18 years old. (4) the patients are divided into young group (less than 45 years old) and middle aged group (45 years old) according to the age of the patients. If the patient has any of the following conditions Will be excluded: (1) ipsilateral internal carotid artery stenosis 50% or tube wall irregular; (2) MCA occlusion; (3) evidence of cardiogenic embolism, including atrial fibrillation, rheumatic heart disease and congenital heart disease, (4) arterial dissection, moyamoya and vasculitis, and other non atherosclerotic vascular lesions; (5) image quality can not meet the further analysis of vascular wall and vascular cavity; (6) because of MC A toward the tortuous or bifurcate causes the axial image of the narrowest place (maximal lumen narrowing, MLN) and the reference position. In HR-T1WI measurement of the vascular area (vessel area, VA) of the MLN and reference positions (lumen area,). According to the formula, the degree of stenosis, the percentage of patch load and the reconfiguration index are calculated. The reconfiguration index is more than 1. SPSS 22.1 for Windows statistical software package (IBM, USA) was used for statistical analysis. According to the normal distribution of measurement data, the mean number + standard deviation (x + s) was expressed. The comparison between the two groups of the two groups was compared with the comparison between the two groups using t test. The two groups were compared with x2 test or Fisher accuracy. Test correlation coefficient and the repeatability of the 95% confidence interval assessment. Results: (1) a total of 71 patients with MCA atherosclerotic stenosis were included in the analysis. Among them, the young group was 24, with an average age of 36.54 5.72 years, 47 in the middle and old age group, with an average age of 57.49 + 7.76 years. The sex ratio, the DWI positive rate and the proportion of symptomatic stenosis were not statistically significant in the two groups. The most common risk factors were hypertension (79.17% in the youth group, 78.72% in the middle and old age group, P=0.965). The young group was significantly higher than the middle aged and old age group (54.17% to 29.79%, P=0.045). The incidence of diabetes in the young group was significantly lower than that in the middle and old age group (30.83% to 55.32%, P=0.006). (2) the young group was 80.83%, 44.68% (44.68%) in the middle and old age group. P=0.037), the percentage of plaque load in young group and middle aged group was 0.314 + 0.183,0.405 + 0.126 (p=0.017). Conclusion: the remodeling mode and plaque load of intracranial large atherosclerosis are related to age. The proportion of NR in young group with atherosclerotic MCA stenosis is higher, which may be associated with the unique structural characteristics of smoking and cerebral vascular wall and brain. In the treatment of atherosclerotic intracranial artery stenosis, it may be a new treatment direction for young patients in addition to solving vascular stenosis, stabilizing vulnerable plaque, and delaying the speed of vascular stenosis to provide time for collateral circulation.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R743.3;R445.2

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