三维容积超声在新生儿颅内出血定性和定量诊断中的价值

发布时间：2017-12-27 15:32

本文关键词：三维容积超声在新生儿颅内出血定性和定量诊断中的价值　出处：《泰山医学院》2014年硕士论文　论文类型：学位论文

【摘要】：研究背景新生儿颅内出血是在新生儿时期最常见和最重要的发生于神经系统的疾病,大范围的出血可引起严重后果,特别对于早产儿,是造成新生儿神经系统死亡与发育障碍的重要原因之一。所以对新生儿颅内出血的早期诊断显得尤其重要。不仅可以给临床医师的诊断及治疗提供有效的资料,指导其有效及合理的治疗,对于取得良好预后打下基础,从而可以提高该病的治愈率,对于神经系统后遗症发生的减少起到了尤为重要的作用。因此深入研究及认识这些问题,将非常有益于提高临床的诊治技术及水平。超声是利用其声波的特性来了解人体组织结构和其对应病变过程的一项技术,B型超声是以灰阶形式在荧屏上实时地显示的二维显像。20世纪70年代末超声诊断技术开始在新生儿领域应用于新生儿颅内疾病的诊断,随着显像技术的进一步提高,开阔了超声诊断的视野,脑室、各种腔隙结构及脑实质的变化可清晰显示。随着20世纪80年代电子计算机技术的飞速发展及三维超声成像技术的成熟,Nagdyman自1999年首次利用三维超声探查新生儿颅脑解剖结构,开辟了三维超声应用的的新领域。可利用三维超声精确定位显示脑内实质性的病灶与周围组织的关系,立体显示病变大小并进行体积测量。新生儿因为出生时囟门尚未闭合,以前囟为好的透声窗,不仅可以取得较好的显像效果,而且为我们诊断新生儿颅内病变提供了非常有利的条件。通过颅脑超声检查可以及时发现颅内出血,而且能显示出血的确切部位,并较准确地了解颅内出血的病程进展情况以及严重程度,尤其对不能搬动、抢救中的危重患儿,不能离开暖箱的新生儿、需使用特殊器械比如呼吸机的新生儿不方便进行CT、MRI检查,由于CT、M RI需搬动患儿,CT具有放射性,MRI价格昂贵、噪音大以及检查耗时较长,不适合反复复查,而且CT与MRI检查的断层厚度常难以发现室管膜下和脑室内较小的出血团等缺点,超声检查具有价格便宜、无X线损伤、无创伤、简便快捷、实时、安全、成像速度快、可重复床边检查及随时动态观察患儿病情进展情况等独特的优势,可广泛用于新生儿颅内出血连续的动态监测,对新生儿颅内出血的早期诊断和治疗、减少可能遗留的后遗症、降低新生儿病死率等具有非常重要的临床指导价值。如果能早期对新生儿颅内出血进行定性和定量诊断,就能更准确、及时地为临床提供科学有效的诊断依据。但既往研究主要集中于对颅内血肿的定性诊断,对定量研究较少,更少见定量分析与患儿预后关系的研究。目的(1)探讨超声定性诊断新生儿颅内出血的价值;(2)研究二维超声定量分析颅内出血量的准确性;(3)探讨三维超声定量分析颅内出血量的可行性和准确性、以及出血量定量分析对患儿预后的影响。方法病例来自泰安市妇幼保健医院自2013年1月至2013年12在我院新生儿科住院,同时接受超声与CT检查,诊断为颅内出血的新生儿200例,胎龄(26-41周),年龄0~31d,平均8d,男110例,女90例,其中早产儿80例。所用超声仪器为PHILS-超凡、Philipsiu22彩色超声诊断仪,频率5~7.5MHz,高频凸阵小型探头,扇形扫描。对临床上怀疑神经系统疾病或颅内出血的患儿采用二维超声经前囟作冠状及矢状扫查,对颅内结构进行初步筛查,并同时进行颅脑CT进行确定诊断,筛查出颅内出血的病例,进行不同方法的对比研究。二维超声主要观察了解颅内脑中线、脑室大小、脉络丛回声强度及脑实质回声等结构,并对出血量进行半定量评价。采用三维容积探头对出血部位进行三维数据采集,使用三维超声定量分析出血量容积。并用颅脑CT检查检测颅内出血情况,以CT定量分析颅内出血量为标准对照,分析二维超声和三维超声定量出血量的准确性。对所有患者进行随访,分析出血部位、出血量与患儿预后的关系。结果1、二维超声可清晰诊断室管膜下出血、脑室内出血、部分脑实质出血以及大的硬脑膜下出血。对颅脑中央部位的出血分辨率最高。对小的硬膜下出血、蛛网膜下腔出血及小脑内出血、后颅窝等颅脑边缘部位的出血诊断较为困难。超声对颅内出血尤其室管膜下出血(SEH)和脑室内出血(IVH)的分辨率明显强于CT。2、二维超声定量颅内出血量的方法甚多,当前,在临床上应用最广泛的是1/2abc法和1/3abc。本研究采用公式2/3Sh进行计算。通过对采用105例数据的T检验和相关性分析结果显示公式2/3Sh和CT计算机辅助的体积分析法(金标准)计算的颅内出血量存在较好的相关性。Pearson相关分析表明2/3Sh法测定的出血容积和金标准估测数值具有良好的一致性。3、三维超声对不规则容积具有更准确的测定价值,本研究采用三维容积超声测量颅内出血量,结果表明,三维超声测定颅内出血量与CT计算机辅助的体积分析法(金标准)计算的颅内出血量具有更高的相关性和一致性。Pearson相关分析表表明3D法测定的出血容积和金标准估测数值具有更好的一致性。4、对研究对象进行随访观察,脑室内室管膜下少量出血、硬膜下血肿以及蛛网膜下出血吸收迅速,一般2~3周基本完全吸收;脑实质团块状出血、脑室内片状出血吸收缓慢,一般在治疗1个月左右出血开始吸收,本组仅2例出血灶在2周内吸收正常,大部分病灶在1~3个月完全吸收。5、临床随访表明,超声诊断颅内出血157例患儿中,Ⅰ级、Ⅱ级93例无明显临床症状或神经精神症状轻,预后良好;Ⅲ级37例、Ⅳ级26例表现为不同程度的神经精神症状,可留下后遗症,预后较差,需要进行神经系统干预治疗等。室管膜下出血约80例,出血量0.03~1.15 ml,出血主要位于室管膜下;脑室内出血不伴脑室扩张13例,出血量0.73~1.86 ml;单纯脑室扩张约14例,出血量2.97~9.68 ml,脑积水11例,出血量约7.3ml~15.8ml,脑室空洞性囊肿12例,出血量约8.2~17.4ml,出血位于脑室内;脑软化灶26例,出血量约11.21~26.4 ml,出血主要位于侧脑室周围及脑实质。硬脑膜下出血1例,出血量约8.65 ml。将实际随访145例颅内出血患儿按预后情况将其分为无后遗症、轻度后遗症、中度后遗症、重度后遗症五组。其中无后遗症组87例,主要为Ⅰ级、Ⅱ级出血、硬膜下出血;轻度后遗症15例,主要为Ⅱ级、少量Ⅲ级出血;中度后遗症27例,主要为Ⅲ级、Ⅳ级,重度后遗症16例,主要为Ⅳ级及脑实质内出血。结论1、超声具有无放射线损害、安全、价廉、方便、无创伤、可进行床旁检查及动态追踪观察等优点,尤其对于早产儿,可作为常规筛查和随访的首选影像学诊断方法。2、与二维超声相比,三维容积超声能全面反映颅内出血形状和周边脑组织的空间立体关系,其定量出血量的准确性高于二维超声法。3、对新生儿颅内出血进行早期定性和定量诊断,对新生儿颅内出血的预后判断具有较大的临床价值。
[Abstract]:Background neonatal intracranial hemorrhage is the most common and most important neurological disease in neonates. Massive bleeding can cause serious consequences, especially for premature infants, which is one of the important causes of neonatal nervous system death and developmental disorders. Therefore, the early diagnosis of intracranial hemorrhage in the newborn appears to be particularly important. Not only to the diagnosis and treatment of clinicians to provide effective information to guide the effective and reasonable treatment, to lay the foundation for good prognosis, which can improve the cure rate, to reduce the sequela of the nervous system plays a particularly important role. Therefore, the in-depth study and understanding of these problems will be very beneficial to improve the clinical diagnosis and treatment technology and level. Ultrasound is a technology to understand human tissue structure and its corresponding pathological process by using its acoustic characteristics. B ultrasound is a two-dimensional imaging displayed in gray scale on the screen in real time. In the late 1970s, the diagnostic technology of ultrasound began to be applied in the diagnosis of neonatal intracranial diseases in the neonatal field. With the further improvement of imaging technology, the field of vision of ultrasound diagnosis was broadened, and the changes of ventricles, lacunar structures and brain parenchyma could be clearly displayed. With the rapid development of computer technology in 1980s and the maturity of three-dimensional ultrasound imaging technology, Nagdyman used the three-dimensional ultrasound to detect neonatal brain anatomy structure for the first time since 1999, and opened up a new field of three-dimensional ultrasound application. Three-dimensional ultrasound can be used to accurately locate the relationship between the lesions of the brain and the surrounding tissues, the size of the lesions and the volume measurement. The newborn was born because the fontanels have not yet closed, fontanelle through the window of good, not only can obtain good imaging effect, and provide favorable conditions for the diagnosis of neonatal intracranial diseases. The ultrasound can detect intracranial hemorrhage, and can show the exact position of hemorrhage, and accurately understand the progression of intracranial hemorrhage and severity, especially to be moved, the rescue of critically ill children, can not leave the warm box, such as the neonatal neonatal ventilator is not convenient for CT, use MRI to check special equipment, CT M RI, because the need to move with CT radioactive, MRI is expensive, big noise and check the time-consuming, not suitable for repeated review, and the thickness of the fault CT and MRI examination is often difficult to find the subependymal and intraventricular hemorrhage group and smaller defects, ultrasound has the advantages of low price and no X-ray damage, non-invasive, convenient, real-time, safe and fast imaging speed and repeatable bedside examination and any dynamic observation in children with the disease progress and other unique advantages, It can be widely used in continuous dynamic monitoring of neonatal intracranial hemorrhage. It has a very important clinical guiding value for early diagnosis and treatment of neonatal intracranial hemorrhage, reducing sequelae that may be left behind, and reducing neonatal mortality. If the qualitative and quantitative diagnosis of intracranial hemorrhage in the newborn can be carried out early, the scientific and effective diagnostic basis can be provided more accurately and timely. However, previous studies focused on the qualitative diagnosis of intracranial hematoma, less quantitative study, and more rare quantitative analysis of the relationship with the prognosis of children. Objective to investigate the value of ultrasound (1) qualitative diagnosis of neonatal intracranial hemorrhage; intracranial hemorrhage (2) accuracy analysis of two-dimensional ultrasound quantitative; (3) to investigate the quantitative analysis of the impact on the children with three-dimensional ultrasound pre analysis after the feasibility and accuracy, and the amount of bleeding quantitative intracranial hemorrhage. Methods a case from Tai'an maternal and child health hospital from January 2013 to 2013 12, was hospitalized in the neonatal department of our hospital. Meanwhile, 200 neonates diagnosed with intracranial hemorrhage were diagnosed by ultrasound and CT examination. The gestational age (26-41 weeks) was 0~31d, with an average age of 8D. There were 110 males and 90 females, including 80 premature infants. The ultrasonic instruments used were PHILS- super, Philipsiu22 color ultrasonic diagnostic apparatus, frequency 5~7.5MHz, small probe of high frequency convex array and fan-shaped scanning. The clinical suspicion of nervous system disease or intracranial hemorrhage patients by two-dimensional ultrasound after anterior coronary and sagittal scanning, preliminary screening of intracranial structures, and brain CT to confirm the diagnosis and screening of intracranial hemorrhage cases, comparative study of different methods. Two dimensional ultrasound mainly observed the structure of the intracranial midline, ventricle size, choroid plexus echo intensity, and the echo of the parenchyma of the brain. Three dimensional volume probe was used to collect the three dimensional data of the bleeding site, and the volume of blood volume was analyzed by three-dimensional ultrasound. The intracranial hemorrhage was detected by cranial CT examination. The accuracy of quantitative bleeding was analyzed by CT quantitative analysis of intracranial hemorrhage volume as standard control. All patients were followed up to analyze the relationship between the site of bleeding, the amount of bleeding and the prognosis of the children. Results 1 and two dimensional ultrasound could clear the hemorrhage of the subdural hemorrhage, intraventricular hemorrhage, partial cerebral hemorrhage and large subdural hemorrhage in the diagnosis room. The highest resolution of the central craniocerebral hemorrhage. It is difficult to diagnose the bleeding of small subdural hemorrhage, subarachnoid hemorrhage, intraderebellar hemorrhage, posterior cranial fossa and other craniocerebral hemorrhage. The resolution of intracerebral hemorrhage (SEH) and intracerebral hemorrhage (IVH) was better than that of CT by ultrasound. 2, two dimensional ultrasound quantitative method of quantitative quantitative intracranial hemorrhage, the most widely used in the clinic is the 1/2abc method and 1/3abc. In this study, formula 2/3Sh is used to calculate. The results of T test and correlation analysis of 105 cases showed that there was a good correlation between the formula 2/3Sh and CT computer aided volume analysis (gold standard) for calculating the amount of intracranial hemorrhage. Pearson correlation analysis shows that 2/3Sh method
【学位授予单位】：泰山医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R743.34;R445.1

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