术中CT在脑血管疾病手术中的临床研究

发布时间：2018-06-16 11:25

本文选题：脑血管障碍 + 外科手术　；参考：《中国人民解放军医学院》2013年硕士论文

【摘要】：目的：评价颈动脉内膜切除术（CEA）中CT灌注成像（PCT）灌注参数的变化，分析大脑中动脉及大脑前动脉供血区的脑血流动力学变化，探讨术中CT在CEA和颅内动脉瘤手术中的应用价值。方法：收集2012年3月至2013年3月解放军总医院神经外科收治的脑血管疾病44例，其中颈动脉狭窄16例、颅内动脉瘤28例。所有病例均在术中CT手术室完成手术，在术前及术中分别行PCT及CTA扫描。在CEA术中，选取大脑中动脉供血区及大脑前动脉供血区作为感兴趣区，获得脑血流量（CBF）、脑血容量（CBV）及达峰时间（TTP）伪彩图及定量数据，计算术侧与对侧的相对值rCBF、rCBV及rTTP。分别比较术侧和对侧各灌注参数、术前和术中各相对灌注参数。在颅内动脉瘤手术中，根据动脉瘤所在部位选取感兴趣区，获得CBF、CBV及TTP伪彩图及各灌注参数。根据两次PCT及CTA情况，指导手术操作。结果：1、CEA术中：（1）大脑前动脉供血区：各参数比较差异无统计学意义（P＞0.05）。（2）大脑中动脉供血区：CEA术前，术侧与对侧CBF及CBV比较差异无统计学意义（P＞0.05），TTP延长（P＜0.05）；CEA术中，，术侧与对侧比较，CBF及CBV明显增加（P＜0.05），TTP明显缩短（P＜0.05）。CEA术前及术中，rCBF及rCBV增加，rTTP缩短，差异有统计学意义（P＜0.05）。（3）术中PCT未见脑过度灌注。（4）术中CTA显示病变部位狭窄程度明显改善。（5）16例CEA预后良好。2、颅内动脉瘤手术中：（1）25例术中PCT未见脑灌注明显变化；1例后交通动脉瘤夹闭术中，术中PCT发现术侧脑灌注明显变差，调整动脉瘤夹后，再次行PCT提示术侧脑灌注明显好转。（2）术中CTA提示无动脉瘤残颈、载瘤动脉狭窄或闭塞。（3）手术共处理31个动脉瘤，恢复良好27例（96.43%）、中残1例（3.57%）。3、共行PCT89次，CTA42次，图像质量良好127次（96.95%），差4次（3.05%）。4、术中PCT及CTA扫描平均耗时（19.87±0.64）min。5、术中CT平扫均未见颅内出血，其中2例蛛网膜下腔出血伴血肿者，术中CT平扫显示血肿清除满意。结论：1、术中CT是一种安全、操作简单、成像时间短、能提供高质量图像的技术，能及时、准确提供脑组织灌注及颅内外血管解剖情况。2、rCBF、rCBV及rTTP是反映CEA术后早期脑血流动力学变化的敏感指标。3、CEA术中MCA供血区脑血流动力学变化更明显。4、术中CT有助于在颅内动脉瘤手术中及时发现动脉瘤残留、载瘤动脉及穿支动脉闭塞，可以作为脑血管疾病手术中一种新型辅助评估方法，尤其在颅内复杂动脉瘤及颅内血管重建术中作用更明显。
[Abstract]:Objective: to evaluate the changes of perfusion parameters of CT perfusion imaging (PCT) in carotid endarterectomy (CEA), to analyze the cerebral hemodynamic changes in the middle cerebral artery and anterior cerebral artery, and to evaluate the value of CT in the operation of CEA and intracranial aneurysms. Methods: from March 2012 to March 2013, 44 cases of cerebrovascular diseases in neurosurgery department of PLA General Hospital were collected, including 16 cases of carotid stenosis and 28 cases of intracranial aneurysms. All cases were operated in CT operating room, and PCT and CTA were performed before and during operation respectively. During CEA operation, the middle cerebral artery (MCA) and the anterior cerebral artery (ACA) were selected as the regions of interest, and the pseudochromograms and quantitative data of CBFV, CBV and TTPwere obtained, and the relative values of rCBFV rCBV and rTTPwere calculated between the operative side and the contralateral side. The perfusion parameters of operative side and contralateral side, preoperative and intraoperative perfusion parameters were compared respectively. In intracranial aneurysm surgery, CBF CBV and TTP pseudochromatic images and perfusion parameters were obtained according to the location of the aneurysm. According to twice PCT and CTA, guide the operation. Results there was no significant difference in the blood supply area of anterior cerebral artery (P > 0.05) (P > 0.05). There was no significant difference in CBF and CBV between the operative side and the contralateral side (P > 0.05), and there was no significant difference between the operative side and the contralateral side (P > 0.05) in the extension of TTP during the operation (P < 0.05), and there was no significant difference between the operative side and the contralateral side (P > 0.05). Compared with the contralateral side, CBF and CBV increased significantly (P < 0.05) and TTP shortened significantly (P < 0.05). CEA increased rCBF and rCBV shortening before and during operation. The difference was statistically significant (P < 0.05) there was no cerebral hyperperfusion during PCT. (4) CTA showed significant improvement in stenosis degree of lesions in 16 cases. CEA prognosis was good in 16 cases. In 25 cases of intracranial aneurysm, no significant changes of cerebral perfusion were observed in 25 cases. In 1 case of posterior communicating aneurysm clipping, the intraoperative PCT found that the cerebral perfusion of the operative side became worse obviously. After adjusting the aneurysm clip, another PCT was performed to indicate that the lateral cerebral perfusion was obviously improved. 2) CTA showed that there was no aneurysm residual neck during the operation. 31 aneurysms were treated with aneurysm stenosis or occlusion. Among them, 27 cases recovered well, 1 case had middle disability (3.57%) and 42 times PCT 89 times (CTA42 times). The average time of PCT and CTA scan during operation was 19.87 卤0.64 min. 5. There was no intracranial hemorrhage on plain CT scan. In 2 cases of subarachnoid hemorrhage with hematoma, CT plain scan showed satisfactory hematoma clearance. Conclusion: 1, CT is a safe, easy to operate, short imaging time, can provide high quality image technology, can be timely, Providing accurate cerebral tissue perfusion and anatomy of intracranial and extracranial vessels .2rCBFFrCBV and rTTP are sensitive indexes to reflect the early changes of cerebral hemodynamics after CEA .3The changes of cerebral hemodynamics in MCA feeding area during CEA operation are more obvious. Ct during operation is helpful in cranium. The residual aneurysm was found in time during the internal aneurysm operation. The occlusion of aneurysm carrying artery and perforating artery can be used as a new assistant evaluation method in cerebrovascular disease surgery, especially in complex intracranial aneurysm and intracranial vascular reconstruction.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R651.12;R816.1

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