螺旋CT血管造影和数字减影造影对颅内动脉瘤诊断及评估的比较研究

发布时间：2018-04-18 15:58

本文选题：颅内动脉瘤 + CT血管造影　；参考：《浙江大学》2016年博士论文

【摘要】：背景：据现有数据显示,蛛网膜下腔出血的发病率约为9/10万,而其中约85%是因为颅内动脉瘤破裂导致。虽然动脉瘤破裂导致蛛网膜下腔出血的发病率不高,但是一旦发生,会造成极高的致死率和致残率；因此,尽管颅内动脉瘤破裂所致的蛛网膜下腔出血的发生率只占总脑血管事件的5%,但其所造成的社会经济损失与其他更常见的脑血管事件相当。成年人中,颅内动脉瘤的患病率约为1%-6%,但在有动脉瘤家族史的人群中,其患病率可高达9.5%。.颅内动脉瘤好发于血管的分叉部,特别是脑基底的血管分又处,如Willis环或邻近的分叉处。多数的动脉瘤(80-85%)位于前循环,其中绝大部分位于颈内动脉和后交通动脉连接处、前交通动脉复合体或大脑中动脉分又部。后循环的动脉瘤一般位于基底动脉分支处或椎动脉与同侧小脑后下动脉连接处。多数的颅内动脉瘤为单发,多发颅内动脉瘤(2-3颗最为常见)约占颅内动脉瘤总数的20-30%。由于未破裂动脉瘤缺乏特异症状和体征,其诊断多为回顾性诊断。而动脉瘤破裂所致蛛网膜下腔出血,可通过CT检查进行诊断。数字减影血管造影技术(DSA).是目前诊断颅内动脉瘤的“金标准”；它最大的优势在于通过使用1024×1024的像素图像能够达到0.3mm的分辨率,获得良好的敏感度和特异度。然而由于DSA检查是一种有创操作,对操作医生要求较高,用时较长,费用较高,其临床应用受到一定限制。与DSA相比,CT血管造影(CTA)具有快速、无创、费用低的优势。同时,CTA能够显示动脉瘤、载瘤血管与颅骨的关系,对制定动脉瘤夹闭手术方案有较大帮助。随着技术的发展,CTA特别是多排CTA诊断颅内动脉瘤可以达到与DSA相近的诊断准确度。因此,CTA正被越来越多地应用到颅内动脉瘤的诊断中。目的：研究CTA检查与DSA检查相比在颅内动脉瘤诊断中的敏感度和特异度,探究是否可在临床应用中以CTA替代DSA作为颅内动脉瘤诊断的标准。方法：在PubMed, EBSCO, Scopus以及Web of Science等数据库进行全面的文献搜索,采用QUADAS量表对文献质量进行评估,共纳入58篇文献进行分析。对纳入荟萃分析的文献进行异质性检验和发表偏倚检验,从患者层面和动脉瘤层面两个角度统计文献在95%置信区间内的敏感度和特异度。回顾了我院自2015年1月至2016年1月就诊的怀疑颅内动脉瘤患者的CTA及DSA检查资料。从患者层面及动脉瘤层面分别计算CTA诊断的敏感度和特异度,从动脉瘤位置及直径两个方面分析CTA诊断的准确度。结果：纳入荟萃分析的文献表现出中等程度的异质性,采用meta回归分析造成异质性的因素。在计算总体敏感度和特异度时剔除异质性较大的文献,采用随机变量模型计算总体敏感度和特异度。纳入文献的文章质量较高。荟萃分析的总体敏感度为0.991(0.982-I.00,95%CI),特异度为0.931(0.903-0.951,95%C1)。文献的异质性主要来源于方法学特点(QUADAS评分),CTA检查方法差异(CTA排数的不同),纳入病例数量差异以及诊断金标准的选择差异。发表偏倚检验未发现显著的发表偏倚。按照不同的CTA检查方法,将文献分组,发现随CTA排数增加,诊断的敏感度和特异度也随之增加。特别是对于直径小于3mm的动脉瘤,使用64排及320排CTA获得的诊断敏感度和特异度与DSA得到的结果相仿。回顾我院自2015年1月至2016年1月,怀疑颅内动脉瘤患者的检查结果,在总共429名纳入研究的患者中,CTA共诊断出300名颅内动脉瘤患者,发现了331颗动脉瘤(真阳性和假阳性结果总和),动脉瘤的平均直径为4.14mm。我们以DSA检查结果为金标准,CTA诊断出320颗颅内动脉瘤(真阳性),而有94颗动脉瘤未能被CTA检查出；此外,有11颗动脉瘤未能被DSA发现而被判定为假阳性。从动脉瘤直径上来说,CTA对直径小于3mm的动脉瘤检出率较低；直径在3mm以下,3mm至5mm,5mm至10mm及10mm以上的动脉瘤的诊断敏感度分别为：0.548 (0.462-0.634,95%CI),0.852 (0.789-0.902,95%CI),0.912 (0.847-0.965, 95%CI),及1.00(0.990-1.00,95%CI)。整体而言,16排CTA对患者患颅内动脉瘤诊断的敏感度,特异度分别为：0.851 (0.809-0.889,95%CI),0.951 (0.909-0.977, 95%CI)。位于前交通动脉瘤和大脑中动脉的动脉瘤更容易被CTA诊断出来,其敏感度分别为0.837(0.760-0.897,95%CI),0.805(0.651-0.902,95%CI)。而位于后颅窝的动脉瘤受颅骨伪影影响,诊断敏感度较低。破裂动脉瘤的更容易被CTA诊断出,而CTA对Hunt-Hess分级4-5级的患者诊断敏感度为0.933(0.685-0.998,95%CI),而高于对低分级的患者的诊断敏感度0.857(0.801-0.902,95%CI)。此外,吸烟患者的诊断敏感度也高于非吸烟患者。结论：从荟萃分析中发现对于直径大于3mm的动脉瘤,所有排数的CTA都表现了较高的诊断准确度；同时,随着CT排数的增加CTA结果的准确度也随之提高。对于直径在3mm以下的动脉瘤,64排和320排的CTA表现出了较好的诊断准确度,但是排数较低的CT不能很好的诊断出直径较小的动脉瘤。根据我中心的数据显示,目前临床上使用的16排的CTA有较好的诊断准确度和特异度,对每名患者的敏感度为85.1%,特异度为95.1%；对每颗动脉瘤诊断的敏感度为77.3%,特异度为94.1%；同时,对破裂动脉瘤及Hunt-Hess分级4-5级的患者具有更高的诊断敏感度。但是对于直径小于3mm的动脉瘤及位于后颅窝或接近颅底的动脉瘤,CTA诊断的敏感度和特异度均有所下降。因此,在临床应用上,尚不能以CTA取代DSA作为颅内动脉瘤诊断的金标准。
[Abstract]:Background : According to the data available , the incidence of subarachnoid hemorrhage is about 9 / 100 000 , and about 85 % is due to rupture of the intracranial aneurysm . Although the incidence of subarachnoid hemorrhage is not high due to rupture of the aneurysm , it causes very high mortality and disability ;
Therefore , although the incidence of subarachnoid hemorrhage due to rupture of the intracranial aneurysm is only 5 % of the total cerebral vascular event , the socio - economic loss associated with it is comparable to the other more common cerebrovascular events . Among adults , the incidence of intracranial aneurysms is about 1 % to 6 % , but in the population with aneurysm family history , the prevalence can be as high as 9.5 % . Most aneurysms ( 80 - 85 % ) are located in the anterior circulation , most of which are located at the junction of the internal carotid artery and the posterior communicating artery , the anterior communicating artery complex or the middle cerebral artery division . Most intracranial aneurysms are single , multiple intracranial aneurysms ( 2 - 3 most common ) are about 20 - 30 % of the total number of intracranial aneurysms . Most intracranial aneurysms are single , multiple intracranial aneurysms ( 2 - 3 most common ) are diagnosed by CT examination . Digital subtraction angiography ( DSA ) is the " gold standard " for the diagnosis of intracranial aneurysms .
The sensitivity and specificity of CTA in the diagnosis of intracranial aneurysms were analyzed . The sensitivity and specificity of CTA in the diagnosis of intracranial aneurysms were analyzed .
In addition , 11 aneurysms were unable to be identified as false positives by DSA . From the diameter of the aneurysm , CTA had a lower detection rate for aneurysms of less than 3 mm in diameter ;
The diagnostic sensitivity of aneurysms with a diameter of less than 3 mm , 3 mm to 5 mm , 5 mm to 10 mm and 10 mm or more was 0.548 ( 0.462 - 0.634 , 95 % CI ) , 0.852 ( 0.789 - 0.902 , 95 % CI ) , 0.912 ( 0.847 - 0.965 , 95 % CI ) , and 1.00 ( 0.990 - 1.00 , 95 % CI ) . Overall , 16 - row CTA had a sensitivity to the diagnosis of intracranial aneurysms , with a specificity of 0.851 ( 0.809 - 0.889 , 95 % CI ) , 0.951 ( 0.909 - 0.977 , 95 % CI ) , respectively . The aneurysms of anterior communicating aneurysm and middle cerebral artery were more likely to be diagnosed by CTA with a sensitivity of 0.837 ( 0.760 - 0.897 , 95 % CI ) , 0.805 ( 0.651 - 0.902 , 95 % CI ) , while the diagnostic sensitivity of CTA to patients with Hunt - Hess grade 4 - 5 was 0.933 ( 0.801 - 0.902 , 95 % CI ) . In addition , the diagnostic sensitivity of CTA to Hunt - Hess grade 4 - 5 was 0.933 ( 0.801 - 0.902 , 95 % CI ) .
At the same time , with the increase of CT number , the accuracy of CTA was improved . The CTA of 64 rows and 320 rows showed better diagnostic accuracy for aneurysms with diameters less than 3mm . However , CT with low number of rows could not be well diagnosed with smaller diameter aneurysms . According to the data from the center , there were better diagnostic accuracy and specificity for the currently used 16 - row CTA . The sensitivity to each patient was 85.1 % and the specificity was 95.1 % .
The sensitivity to the diagnosis of each aneurysm was 77.3 % and the specificity was 94.1 % .
At the same time , patients with ruptured aneurysms and Hunt - Hess grade 4 - 5 had higher diagnostic sensitivity . However , the sensitivity and specificity of CTA were reduced for aneurysms with diameters less than 3 mm and aneurysms located at or near the skull base . Therefore , in clinical applications , CTA could not be substituted for DSA as the gold standard for diagnosis of intracranial aneurysms .

【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R743.3;R816.1

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