3D-TOF-MRA上大脑前动脉、后动脉偏侧优势预测大脑中动脉供血区梗死的长期功能预后

发布时间：2018-03-29 22:01

本文选题：MRA　切入点：TCD　出处：《郑州大学》2014年硕士论文

【摘要】：背景与目的脑梗死（Cerebral Infarction，CI）泛指缺血性卒中，是指由于脑部血液供应障碍，缺血、缺氧引起的局限性脑组织坏死，其临床发病率约为所有脑卒中的70％。经数字减影血管造影（Digital Subtraction Angiography，DSA）证实，80％CI首发患者伴有颅内或颈部血管狭窄，其中亚洲人、黑人与西班牙人等人种以颅内血管狭窄最常见。CI的主要发病原因是由于动脉粥样硬化，导致颈部或颅内血管严重狭窄、血栓形成或斑块脱落导致相应供血区脑组织血流量急剧下降，出现缺血缺氧而坏死软化。一般在20-30岁就会出现动脉粥样硬化所致动脉狭窄和闭塞，50-70岁是发病高峰期，发病初期表现为纤维斑块，病变晚期动脉壁会出现不规则增厚，管壁有粥样斑块形成，导致管腔狭窄，以致远端血供明显下降，最终由于反复出现血小板聚集、纤维蛋白和血细胞沉积致血栓形成或斑块脱落引起管腔闭塞。CI在全世界范围内的发病率、致残率与死亡率都较高，而且有明显的逐年升高的趋势，因此，早期诊断与预防CI的发生、发展，提高其治疗水平是世界医疗工作共同亲关注的课题。目前临床中对侧支循环的检测方法主要有DSA、磁共振血管造影（MagneticResonance Angiography，MRA）、经颅多普勒超声（Transcranial Doppler ultrasound，TCD）等，其中DSA属于有创性检查，对脑实质改变观察不完整，而且检查费用相对较高；因此临床中多选用MRA作为常规无创血管成像检测技术，可以较为完整地显示Willis环的血管解剖结构，同时还可以反映出血流方式及血流速度等功能性信息，时间飞越法（tof法）是MRA常用的检测技术，具有检查费用低、无需使用造影剂、成像时间短等优势。目前，国内外文献中普遍认为对大脑中动脉供血区梗死患者进行检测可以对患者的预后情况提供参考依据，但是绝大多数关于急性大脑中动脉区脑梗死侧支循环变化与其预后关系的研究资料来源于DSA检测，临床局限性较大，缺少评价侧支循环的详细方法。因此，本课题将着重探讨3D-TOF MRA在大脑前动脉、后动脉偏侧优势预测大脑中动脉供血区梗死患者诊断中的应用，总结其在大脑中动脉供血区梗死患者预后预测中的作用。方法选取2010年7月至2013年4月期间我院确诊的76例大脑中动脉区脑梗死患者作为本组研究的观察对象，分别行TCD与MRA检查，并对检查结果进行对比总结，比较TCD与MRA在大脑前动脉、后动脉偏侧优势预测中的作用。患者在行TCD检查后48小时内行3D-TOF MRA检查，再将经MRA检查确诊为MCA供血区梗死的患者按照梗死部位分为主干支组、皮层支组与深穿支组，并对所有患者进行NIHSS评分、MRS评分、ADL评分，并将各组预后的相关危险因素进行分析，最终将患者的检测数据进行整理，经统计学计算得出结论。 MRA检查设备选用Acmeva3.0TNovadual双梯度磁共振仪（Philips，荷兰），所有患者在接受检查前均经颅部MRI扫描，初步掌握患者的脑组织病变情况。MRA检测方法选择三维时间飞跃法（Three Dimensional Time Of Flight，3D．TOF）序列，容积采集以Willis环为中心，横轴位采集容积包括颈内动脉的末端、大脑前、中动脉及其主要分支以及基底动脉和大脑后动脉；对患者的颅底动脉环及双侧椎动脉（VertebralArtery，VA）颅内段、基底动脉（BasilarArtery，BA）进行检测。 TCD检测仪器选用DWL TCD仪（德国），通过2MHz探头对患者颅内血管情况进行探测，并用2MHz探头对颈内动脉终末端（TICA）、大脑前、中、后动脉（ACA、MCA、PCA）、基底动脉（BA）、椎动脉（VA）进行探测。 TCD、MRA检查均由相同的神经科医师、影像科医师完成。患者均于发病24h内进行先进行TCD检查，通过2MHz脉冲式探头，经颞窗分别对两侧ACA、PCA的收缩期峰值及平均血流速度进行检测。（1）经颞窗检测双侧MCA、ACA、PCA、TICA；（2）经枕窗检测双侧VA，BA，经眼窗检测眼动脉（OphthalmicArtery，OA）、颈内动脉虹吸部（Siphon CarotidArtery，SCA）。收集参数以收缩峰血流速度（Systolic Phase Blood Velocity，VS）、平均血流速度（Mean Blood Velocity，VM）、音频、频谱形态及搏动指数（Pulsate Index number，PI）等作为主要分析数据。本组研究中将分别通过TCD与MRA两种检查检测方法进行检测，并比较所有患者的MCA梗死情况，属于定性资料中的分类变量资料。选用配对四格表方法判断患者颅内大血管的结果有无显著性差异。研究中采用SPSS16.0统计软件针对所得资料进行系统的统计学分析，其中的计数资料采用卡方检验方法进行检验。当P0.05时认为两组之间所存在显著差异，具有统计学意义。结果（1）本组脑梗死患者TCD检查结果：单纯ACA代偿37例，单纯PCA代偿28例， ACA与PCA代偿并存11例；（2）3D-TOF MRA检查结果：有同侧PCA优势（DIPCA）现象64例，ACA与PCA代偿并存11例，，检测结果与TCD相符。（3）ACA与PCA代偿并发的患者在入院时及第3个月时NIHSS评分均明显低于单纯ACA代偿患者与单纯PCA代偿患者，具有统计学意义（P＜0.05）；ACA代偿患者又明显低于PCA代偿患者，具有统计学意义（P＜0.01）；有DIPCA现象的患者在入院时及3个月时NIHSS评分均显著低于无DIPCA现象的患者具有统计学意义（P＜0.05）。结论在大脑中动脉区脑梗死患者中，侧支循环状况与患者的病情与预后情况呈正相关，而且单纯前循环代偿患者预后情况明显优于单纯后循环代偿患者，有后循环代偿的病情与预后情况明显优于无后循环代偿患者。
[Abstract]:Background and purpose
Cerebral infarction (Cerebral Infarction CI) refers to ischemic stroke, is due to brain blood supply disorder, ischemia, hypoxia induced focal cerebral necrosis, the clinical incidence about all stroke 70%. by digital subtraction angiography (Digital Subtraction Angiography, DSA 80%CI) confirmed that the first patient with intracranial or neck vascular stenosis among them, Asian, black and Hispanic race with intracranial vascular stenosis.CI the most common cause is mainly due to atherosclerosis, leading to severe stenosis of neck or intracranial vascular thrombosis, or plaque shedding leads to cerebral blood flow and the corresponding blood supply area decreased rapidly, and hypoxia ischemia necrosis and softening. There are generally 20-30 years will appear atherosclerotic artery the 50-70 year old is stenosis and occlusion, the peak incidence, early onset showed fibrous plaque lesions, late arterial wall There will be irregular thickening and wall plaque formation, resulting in stenosis, as far end blood supply decrease, eventually due to repeated platelet aggregation, fibrinogen and blood cell deposition caused by thrombosis caused by occlusion of the lumen.CI incidence in the world within the scope of the rate of formation or plaque, disability rate and mortality are high. But there are obvious increasing trend, therefore, early diagnosis and prevention of CI development, improve the level of medical treatment is the world work Pro concern.
The current clinical detecting method of collateral circulation is mainly DSA, magnetic resonance angiography (MagneticResonance Angiography MRA), transcranial Doppler (Transcranial Doppler ultrasound, TCD DSA), which belongs to the invasive examination of brain parenchyma changes is not complete, and the inspection cost is relatively high; therefore in clinical use MRA as routine noninvasive vascular imaging detection technology can accurately display the vascular anatomy of Willis ring structure, but also can reflect the blood flow and blood flow rate of functional information, the more time fly method (TOF method) MRA detection technology is used, with lower cost, without the use of contrast agents, such as short imaging time advantage.
At present, the domestic and foreign literature generally think of patients with middle cerebral artery territory infarction detection can provide reference basis for the prognosis of patients, but the vast majority of acute middle cerebral artery territory infarction collateral circulation change prognostic research data for DSA detection, clinical limitations, lack of evaluation methods with collateral circulation therefore, this paper will focus on 3D-TOF MRA in patients with diagnosis of anterior cerebral artery, middle cerebral artery territory infarction after artery lateralization prediction, summarizes its in the middle cerebral artery infarction prognosis prediction effect.
Method
76 cases of cerebral artery in patients with cerebral infarction area were diagnosed in our hospital in the period from July 2010 to April 2013 as the research object of observation, underwent TCD and MRA examination, and the examination results were compared between TCD and MRA in summary, anterior cerebral artery, the artery after lateralization in prediction. In patients after TCD examination within 48 hours of 3D-TOF MRA, and then the MRA were diagnosed as MCA infarction patients with infarction were divided into the main trunk group, cortical branch group and deep perforator group, and NIHSS score of all patients, MRS score, ADL score, and the related risk factors of prognosis were analyzed, finally the detection data of patients were collected, through statistical analysis, draw the conclusion.
The Acmeva3.0TNovadual double gradient magnetic resonance instrument MRA inspection equipment (Philips, Holland), all patients received before the examination were confirmed by cranial MRI scan, brain tissue pathological changes of the preliminary master.MRA detection method of patient selection of three-dimensional time of flight (Three Dimensional Time Of Flight, 3D.TOF) series, volume acquisition in the Willis loop as the center at the end, the axial acquisition volume includes the internal carotid artery in the anterior cerebral artery and its main branches, and the basilar artery and posterior cerebral artery; in patients with basilar artery rings and bilateral vertebral arteries (VertebralArtery, VA) of intracranial segment of basilar artery (BasilarArtery, BA) were detected.
The TCD test instrument was selected by DWL TCD instrument (Germany). The intracranial blood vessels were detected by 2MHz probe, and the distal end of internal carotid artery (TICA), anterior, middle and posterior arteries (ACA, MCA, PCA), basilar artery (BA) and vertebral artery (VA) were detected by 2MHz probe.
TCD, MRA were examined by a neurologist of the same radiologists. Patients within 24h after TCD examination by 2MHz pulsed probe through temporal window respectively on both sides of ACA, PCA and the average peak systolic blood flow velocity were detected. (1) through temporal window detection of bilateral MCA ACA, PCA, TICA; (2) the occipital window detection of bilateral VA, BA, the eye window detection of ophthalmic artery (OphthalmicArtery, OA), internal carotid artery (Siphon, CarotidArtery, SCA). The collection parameters to the peak systolic velocity (Systolic Phase Blood Velocity, VS), the average blood flow velocity (Mean Blood Velocity, VM), audio, spectrum morphology and pulsatility index (Pulsate Index, number, PI) as the main data analysis.
The group will study were detected by TCD and MRA two kinds of checking method, and compare the MCA infarction in all patients, which belongs to the qualitative data in categorical data. Using four pairs of table method to judge patients with intracranial vascular results have no significant difference. In the research of analysis system for statistical data using SPSS16.0 statistical software, the count data by chi square test method. When P0.05 think that there are significant differences between the two groups, with statistical significance.
Result
(1) in this group of patients with cerebral infarction TCD examination results: ACA compensation in 37 cases, 28 cases of simple PCA ACA and PCA compensation, compensatory coexisted in 11 cases; (2) 3D-TOF MRA examination results: ipsilateral PCA advantage (DIPCA) phenomenon in 64 cases, ACA and PCA both compensatory in 11 cases, the detection results consistent with TCD. (3) ACA and PCA compensatory concurrent patients on admission and 3 months NIHSS score was significantly lower than that of simple ACA patients and PCA patients with simple compensatory compensation, with statistical significance (P < 0.05); ACA patients was significantly lower than that of PCA and compensatory compensation were statistically significant (P < 0.01); statistical significance with DIPCA of patients at admission and 3 months NIHSS score were significantly lower than those without DIPCA phenomenon in patients (P < 0.05).
conclusion
In the brain of patients with arterial cerebral infarction, and patients with collateral circulation was positively related to the severity and prognosis, and the prognosis of the patients with anterior circulation compensatory was better than patients with posterior circulation compensation, compensatory circulation condition and prognosis of patients was significantly better than the free circulation.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R743.3

【参考文献】