实时三维超声造影诊断兔闭合性肾外伤的实验研究

发布时间：2018-03-08 06:16

本文选题：超声造影　切入点：实时三维超声　出处：《南方医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：研究背景：肾脏位于肾窝,周围受到腹腔脏器、腰肌、脊柱、膈肌、肋骨的保护,肾脏本身有一定的活动度,加上肾周脂肪囊形成的保护垫缓冲外力,肾脏通常不易受到损伤。但肾脏是一血流量非常丰富的实质性器官,质地较脆弱,包膜较薄,当受到较强的外力冲击时可造成闭合性损伤,尤其在肾脏本身已有病变时,轻微的创伤也可导致严重的自发性肾破裂。随着经济社会的发展,交通事故伤、高处坠落伤以及各种暴力事件的发生,使得肾损伤的发生率大幅上升。据统计,肾外伤发生率约占腹部损伤的8%～10%,其中80%～90%为闭合性损伤。及时、准确合理地把握手术指征显得非常重要,影像学检查可为下一步救治措施的选择提供重要的参考信息。 CT检查被认为是诊断肾创伤的重要及主要的工具,它对腹部闭合性脏器损伤的敏感性高、特异性强、准确率高,被认为是诊断外伤的首选方法。但CT检查也存在一些缺点,尤其是对患者无法避免的放射性损伤；此外,CT仪器移动不方便,对于病情不稳定的病人不宜做CT检查；其造影剂的排泄需要一定时间,短期内不能进行重复多次造影等。超声以其无创、无辐射、移动便捷、实时及检查费用低廉、允许多次检查以动态观察病情变化等优点,成为临床上诊断外伤的常用方法,但常规超声对于积液的敏感性高,而对于轻度的肾损伤敏感性则较低,多种因素对其图像的干扰也较大。超声造影技术的出现,大大提高了闭合性腹部实质脏器外伤的诊断率与准确率,使得超声在诊断闭合性腹部外伤领域发挥着越来越重要的作用。然而,二维超声造影(2D-CEUS)仅能显示单一断面的增强信息,无法显示肾损伤病灶的整体信息。实时三维超声造影(RT3D-CEUS)是一种新的超声造影技术,它可动态、实时地获得病灶造影全程的三维灌注信息,但RT3D-CEUS用于外伤方面的研究报道较少。第一章RT3D-CEUS诊断兔闭合性肾外伤活动性出血的价值目的采用自制迷你型撞击器(SMS型撞击器,专利号为：201220162205.6),对全身肝素化的实验兔进行撞击,建立闭合性肾外伤活动性出血模型,探讨实时三维超声造影对兔闭合性肾损伤活动性出血的诊断价值。材料和方法一、主要实验材料 1、实验仪器：SMS型撞击器,GE Voluson E8Expert彩色多普勒超声诊断仪,配备三维成像专用软件及编码造影软件包,RIC5-9D探头。 2、其他：声诺维(SonoVue)注射用六氟化硫微泡,3%戊巴比妥钠,生理盐水,肝素钠注射液,静脉留置针。二、实验方法 1.健康新西兰大耳白兔15只,随机分成3组,每组5只,经耳缘静脉注射3%戊巴比妥钠1ml/kg进行麻醉并备皮,取仰卧位固定于动物板,于耳缘静脉留置22G套管针。 2.采用常规超声(包括灰阶超声及CDFI)及超声造影检查于撞击前观察正常的肾脏超声表现。 3.实验兔股动脉插管接压力传感器,经耳缘静脉留置针注射200U/kg肝素钠,生理盐水冲管。调节撞击器,使3组实验兔分别接受77.2N、106.2N、135.1N的力度撞击单侧肾,建立闭合性肾外伤活动性出血模型。 4.于撞击后行常规超声、二维超声造影及实时三维超声造影检查,观察撞击后损伤肾的超声表现。 5.动态观察实验兔的血压变化。当平均动脉压降至40mmHg以下时,提示实验兔进入休克状态,处死实验动物,开腹暴露伤肾,评估伤情。结果 1、15只肾均受到损伤,共制造闭合性肾外Ⅱ伤级损伤2例,Ⅲ级损伤6例,Ⅳ级损伤5例,V级损伤2例。 2、撞击前,灰阶超声清晰显示了肾的内部结构。CDFI显示血流灌注良好。2D-CEUS显示了正常肾血流灌注,未见异常信号区。RT3D-CEUS显示了立体的肾结构及血流灌注信息,未见异常增强或缺失信号。 3、撞击后,灰阶超声：伤肾包膜下均可见液性暗区,液性暗区范围逐渐增大,肾实质可见局部异常回声区。CDFI:病灶区血流信号中断,但无法确定出血的部位。2D-CEUS:肾实质损伤区呈楔形或不规则形无增强区,与正常肾皮质形成强烈对比,可见造影剂自破口向肾外涌出的增强信号。RT3D-CEUS:实时显示肾损伤病灶,开始呈不规则凹陷的充盈缺损,之后可见造影剂自损伤病灶向肾外溢出,呈宽带状、云雾状或喷射样。 4、Ⅱ级损伤的实验兔约在230min、270min进入休克状态；Ⅲ级损伤的实验兔在90min～160min内进入休克状态；Ⅳ级损伤的实验兔在40min～100min内进入休克状态,Ⅴ级损伤的实验兔在30min、50min内进入休克状态。结论实时三维超声造影可实时、立体、逼真地显示闭合性肾外伤活动性出血,可以为下一步救治提供重要的参考信息。目的采用自制迷你型撞击器对实验兔进行撞击,建立闭合性肾外伤模型,探讨实时三维超声造影对兔闭合性肾损伤的诊断价值。材料和方法一、主要实验材料实验仪器：自制弹簧式小型撞击器,GE Voluson E8Expert彩色多普勒超声诊断仪,配备三维成像专用软件及编码造影软件包,RIC5-9D探头,Siemens SOMATOM Difinition双螺旋CT。其他：声诺维(SonoVue)注射用六氟化硫微泡,3%戊巴比妥钠,生理盐水,碘帕醇非离子型对比剂,静脉留置针。二、实验方法 1.健康新西兰大耳白兔25只,其中21只随机分成3组,每组7只,经耳缘静脉注射3%戊巴比妥钠1ml/kg进行麻醉并备皮,取仰卧位固定于动物板,于耳缘静脉留置22G套管针。另外4只作为正常对照。 2.采用常规超声(包括灰阶超声及彩色多普勒超声)及超声造影检查于撞击前观察正常的肾脏超声表现。 3.调节撞击器,使3组实验兔分别接受77.2N、106.2N、135.1N的力度撞击单侧肾,建立闭合性肾外伤模型。正常对照组不作撞击处理。 4.于撞击后30min内完成常规超声、二维超声造影、实时三维超声造影和增强CT检查,观察撞击后损伤肾的不同影像学表现。 5.检查结束后处死实验动物,开腹暴露伤肾,观察肾表面损伤情况。取出伤肾,沿长轴剖开,观察内部损伤情况。参照美国创伤外科协会分级标准评估伤情。 6.以大体病理结果为准,比较常规超声、二维超声造影、实时三维超声造影、增强CT对肾外伤诊断的敏感性与特异性。结果 1、撞击前,灰阶超声清晰显示了肾的内部结构。彩色多普勒显示血流灌注良好。二维超声造影显示了正常肾血流灌注,未见异常信号区。实时三维超声造影显示了立体的肾结构及血流灌注信息,未见异常增强或缺失信号。增强CT未见明显异常。 2、21只肾均受到损伤,撞击力度越大,损伤级别越高。A组2例为Ⅰ级,4例为Ⅱ级,1例为Ⅲ级；B组1例为Ⅰ级,1例为Ⅱ级,4例为Ⅲ级,1例为Ⅳ级；C组1例为Ⅲ级,4例为Ⅳ级,2例为Ⅴ级。 3、撞伤后,灰阶超声：6例肾实质未见明显异常,余肾包膜下可见不同程度液性暗区,肾轮廓不完整,肾皮质不连续,肾实质见边界模糊的低回声区,回声有逐渐增高趋势。彩色多普勒超声：血肿区可见血流信号缺失,其中6例血流灌注良好,1例未见明显血流信号。二维超声造影：4例未见明显异常,1例全程无增强,余肾实质内可见楔形或不规则形无增强区。实时三维超声造影：3例未见明显异常,1例全程无增强,其余伤肾通过调整不同角度可立体、逼真地显示出肾损伤病灶的部位、范围、深度及形态,表现为凹陷型灌注缺失区。增强CT：实验组2例行增强扫描失败,1例未发现明显损伤,余伤肾实质内可见不同程度、不规则的充盈缺损区。 4、常规超声、二维超声造影、实时三维超声造影、增强CT对闭合性肾外伤诊断的敏感性分别为71.4%、80.9%、85.7%、94.7%,准确性分别为76.0%、84.0%、88.0%、95.7%。结论 1、我们自制的迷你型撞击器可建立较稳定的、不同损伤级别的兔闭合性肾外伤,该撞击器具有撞击部位准确、操作简便、重复性好等优点,可为闭合性肾外伤的研究提供良好的动物模型。 2、实时三维超声造影能实时、立体、逼真地显示闭合性肾损伤的部位、范围和形态,有望为临床提供更丰富的诊断信息。
[Abstract]:Research background:
The kidney is located in the renal fossa, surrounded by abdominal viscera, muscle, spine, diaphragm, rib protection, kidney itself has a certain activity, external buffer pad to protect the formation of perirenal fat and the kidneys are not easy to damage. But renal parenchymatous organ blood flow is very rich, texture the envelope is fragile, thin, when subjected to strong external shock caused by blunt trauma, especially in the kidney itself has lesions, minor trauma can cause serious spontaneous renal rupture. With the development of social economy, traffic accident, falling injury and violence, the incidence of renal the injury increased significantly. According to statistics, the incidence of renal trauma accounted for abdominal injury 8% ~ 10%, 80% ~ 90% for closed injury. Timely, accurately grasp the indication of operation is very important, imaging can be saved for the next step The choice of treatment measures provides important reference information.
CT examination is considered to be an important diagnosis of renal trauma and the main tool, its sensitivity to abdominal closed injury with high specificity, high accuracy, is believed to be the first choice for the diagnosis of trauma. But CT also has some shortcomings, especially for patients with radiation injury can not be avoided; in addition, CT the instrument is not convenient to move, for the unstable condition of the patient should not do CT inspection; its excretion of contrast agents need a certain time, the short term can not be repeated angiography.
Ultrasound with its non-invasive, no radiation, mobile and convenient, real-time and cheap, allowing multiple advantages to check the dynamic observation of changes, has become a common method for clinical diagnosis of trauma, but conventional ultrasound for effusion and high sensitivity, and the sensitivity of mild renal injury is low, many disturbing factors on the the image is larger.
Ultrasonic imaging, greatly improving the diagnosis of blunt abdominal trauma and the rate of accuracy, the ultrasound plays an increasingly important role in the diagnosis of blunt abdominal trauma. However, two-dimensional contrast-enhanced ultrasound (2D-CEUS) enhanced information can only display a single section, unable to display the overall information of renal injury lesions.
Real time three dimensional contrast-enhanced ultrasound (RT3D-CEUS) is a new technology of ultrasound contrast. It can dynamically and realtime obtain the whole three-dimensional perfusion information of focal angiography. However, there are few reports on RT3D-CEUS for trauma.
The value of RT3D-CEUS in the diagnosis of closed renal traumatic active bleeding in rabbits
objective
Using the self-made miniature impactor (SMS type impactor, patent number: 201220162205.6), the rabbits of heparinizing the impact, establishment of blunt renal trauma hemorrhage model, to investigate the fault value of real-time three-dimensional contrast-enhanced ultrasound on rabbit closed renal injury diagnosis of active bleeding.
Materials and methods
First, the main experimental materials
1, the experimental instrument: SMS impactor, GE Voluson E8Expert color Doppler ultrasound diagnostic instrument, equipped with 3D imaging software and coded imaging software package, RIC5-9D probe.
2 other: SonoVue (SonoVue) Sulphur Hexafluoride Microbubbles for Injection, 3% pentobarbital sodium, saline, Heparin Sodium Injection, venous indwelling needle.
Two, experimental method
1. healthy New Zealand white rabbits 15, were randomly divided into 3 groups, 5 rats in each group, intravenous injection of 3% pentobarbital sodium 1ml/kg anesthesia and skinpreparation supine fixed on animal plate from the ear vein indwelling 22G trocar.
2. ultrasonography (including gray scale ultrasound and CDFI) and contrast-enhanced ultrasonography were used to observe normal renal sonography before impact.
3., the femoral artery cannula was connected to the pressure sensor in the experimental rabbits. The 200U/kg heparin sodium was injected through the ear vein catheter, and the saline was washed into the tube. After adjusting the impactor, the 3 groups of rabbits were subjected to the impact of 77.2N, 106.2N and 135.1N on the unilateral kidney, respectively, and a closed renal trauma active bleeding pattern was established.
4. after the impact, conventional ultrasound, two-dimensional ultrasound contrast and real-time three-dimensional ultrasound examination were performed to observe the ultrasonic manifestations of the injured kidney after the impact.
5., we observed the change of blood pressure in rabbits dynamically. When the average arterial pressure drops below 40mmHg, it indicates that the experimental rabbits entered the shock state, and the experimental animals were killed, and the kidneys were exposed to expose the kidneys.
All 1,15 kidneys were injured, and 2 cases of closed renal II injury were made, 6 cases of grade III injury, 5 cases of grade IV injury and 2 cases of grade V injury.
2, before the impact, gray scale ultrasound clearly showed the internal structure of the kidney..CDFI showed good blood perfusion..2D-CEUS showed normal renal perfusion. There was no abnormal signal area..RT3D-CEUS showed three-dimensional renal structure and perfusion information, and no abnormal enhancement or deletion signal was seen.
3, after the collision, injury of renal subcapsular gray-scale ultrasound showed liquid dark area, liquid dark area gradually increased, the renal parenchymal.CDFI: visible local abnormal echo lesions blood flow signal interruption, but unable to determine the site of bleeding.2D-CEUS: renal parenchymal damage zone is wedge-shaped or irregular enhanced area, the formation of strong compared with the normal renal cortex, visible contrast to break springs from the extrarenal enhanced signal.RT3D-CEUS: real-time display of renal injury lesions, irregular depression began filling defect, visible after contrast agent damage to renal lesion overflow, a wide band, cloudy or spray.
4, rabbit II injury around 230min 270min into a state of shock; III injury of rabbits in 90min ~ 160min in shock rabbits; IV injury in 40min ~ 100min into a state of shock, V-grade injury in rabbit model of 30min, a state of shock into the 50min.
conclusion
Real time three-dimensional ultrasound imaging is a real time, three-dimensional, and realistic display of closed renal traumatic bleeding, which can provide important reference information for the next treatment.
objective
A self-made Mini impactor was used to impacted the experimental rabbits, and a closed renal trauma model was established. The diagnostic value of real-time three-dimensional contrast-enhanced ultrasound in closed renal injury in rabbits was discussed.
First, the main experimental materials
Experimental instruments: self made spring small impactor, GE Voluson E8Expert color Doppler ultrasound diagnostic instrument, equipped with 3D imaging software and coding and contrast software package, RIC5-9D probe, Siemens SOMATOM Difinition double helix CT..
Other: SonoVue (SonoVue) Sulphur Hexafluoride Microbubbles for Injection, 3% pentobarbital sodium, saline, iopamidol nonionic contrast agent, venous indwelling needle.
Two, experimental method
1. healthy New Zealand white rabbits 25, of which 21 were randomly divided into 3 groups, 7 rats in each group, intravenous injection of 3% pentobarbital sodium 1ml/kg anesthesia and skinpreparation supine fixed on animal plate from the ear vein indwelling trocar. The other 4 22G rats as normal control.
2. conventional ultrasound (including gray scale and color Doppler ultrasound) and contrast-enhanced ultrasonography were used to observe normal renal sonographic findings before impact.
3., adjusting the impactor, the 3 groups of rabbits were subjected to the impact of 77.2N, 106.2N and 135.1N on the unilateral kidney respectively, and a closed renal trauma model was established.
4., we performed routine ultrasound, two-dimensional ultrasound, real-time three-dimensional contrast-enhanced ultrasound and enhanced CT scan after 30min, and observed the different imaging findings of renal injury after impact.
5. after the end of the examination, the experimental animals were sacrificed, and the kidneys were exposed to expose the kidneys. The surface damage of the kidneys was observed. The injured kidneys were removed, and the internal injuries were observed along the long axis.
6. the sensitivity and specificity of CT in the diagnosis of renal trauma were enhanced with general pathological results, compared with conventional ultrasound, two-dimensional ultrasound contrast, and real-time three-dimensional ultrasound contrast.
Result
1, before the impact, gray scale ultrasound clearly showed the internal structure of the kidney. Color Doppler showed good blood perfusion. 2D ultrasound angiography showed normal renal perfusion, no abnormal signal area. Real time three-dimensional ultrasound angiography showed that the renal structure and blood perfusion information of three-dimensional, no abnormal enhancement or lack of enhanced CT no obvious signal. Abnormal.
2,21 kidneys were all injured. The greater the impact force was, the higher the injury level was. The higher the injury level was, the higher the injury level was, the 2 cases in group.A were grade I, 4 cases were grade II, 1 cases were grade III, 1 cases in group B were grade I, 1 cases were grade I, 1 cases were grade II, 4 cases were grade III, 1 cases were grade IV, 1 cases in group C were grade III, 4 cases were grade IV, 2 cases were grade V.
3, injured, ultrasound: 6 cases of renal parenchyma had no obvious abnormalities, residual renal subcapsular showed different degrees of liquid dark area, the outline of the kidney is not complete, renal cortical discontinuity, renal parenchyma see fuzzy boundaries hypoechoic echo has increased gradually. The color Doppler ultrasound: hematoma area blood flow signal loss among them, 6 cases of good blood perfusion, 1 cases had no obvious blood flow signal. Two dimensional ultrasound angiography: 4 cases had no obvious abnormalities, 1 cases of the whole no enhancement, more than renal parenchyma wedge or irregular area. No enhancement of real-time three-dimensional contrast-enhanced ultrasound: 3 cases had no obvious abnormalities, 1 cases of the whole no enhancement, rest renal injury by adjusting the different angle of stereo, vividly shows the renal injury lesion site, scope, depth and shape, is concave. The deletion region of enhanced CT perfusion: experimental group 2 cases underwent enhanced scan failed, 1 cases without obvious damage, residual renal parenchyma injury There are different, irregular filling defects.
4, the sensitivity of conventional ultrasound, two-dimensional ultrasound and real-time three-dimensional contrast-enhanced ultrasound to enhance the diagnostic value of CT for closed renal trauma is 71.4%, 80.9%, 85.7%, 94.7%, respectively, and the accuracy is 76%, 84%, 88%, 95.7%. respectively.
1, our self-made Mini impactor can establish a relatively stable and different injury level of closed renal trauma in rabbits. The impactor has the advantages of accurate location, simple operation and good repeatability. It can provide a good animal model for closed renal trauma research.
2, real time three-dimensional ultrasound imaging can show the location, range and shape of closed renal injury in real time, stereoscopic and realistic. It is expected to provide more informations for clinical diagnosis.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692;R445.1

【参考文献】