【作者】 张燕；

【导师】 王燕；

【作者基本信息】 河北医科大学 ， 影像医学与核医学， 2008， 硕士

【摘要】 目的:探讨高频线阵探头与低频凸阵探头在脑梗塞患者颅外段颈动脉和椎动脉检查中的应用价值。比较两者在二维(B-US)、彩色多普勒(Color Doppler Flow imaging,CDFI)和能量多普勒(Color Doppler Energy,CDE)不同状态下的优缺点。并进一步应用经颅彩色双功超声(Transcranial color -coded duplex sonography,TCCD)经颞窗和枕窗观察颅内段颈内动脉和椎动脉及其主要分支:大脑中动脉(middle cere- bral artery,MCA)、大脑前动脉(anterior cerebral artery,ACA)、大脑后动脉(posterior cerebral artery,PCA)、基底动脉(basal artery,BA)、小脑后下动脉(posterior inferior cerebellar artery,PICA)等以及前交通动脉(anterior communi- cating artery,ACoA)、后交通动脉(posterior communicating artery,PCoA)。评价脑梗塞患者颈内动脉严重狭窄或闭塞时颅内侧支循环的建立情况并与磁共振血流成像(magnetic re- sonance angiography,MRA)进行比较,探讨TCCD在检测脑梗塞患者颅内主要动脉血流动力学变化的临床应用价值。同时,探讨提高脑梗塞患者颅外段颈内动脉及椎动脉中、远段显示率的方法。材料与方法:本课题研究对象为经计算机体层扫描摄影术(computer tomography,CT)或磁共振成像(magnetic resonance imaging,MRI)诊断为脑梗塞的患者56例,其中,男39例,女17例,均对其行常规颅外段颈动脉、椎动脉超声检查以及经颞窗、枕窗观察其颅内血管改变情况。将所有入选者用高、低频探头测量所得数据(颈内动脉颅外段显示长度及颈动脉、椎动脉血流速度、阻力指数)进行比较。选出其中行MRA检查的患者40例并将其结果与超声结果进行比较。结果:1. 56例脑梗塞患者共112根血管进行超声检查,发现颈动脉、椎动脉病变阳性率高达87.5%左右。2.脑梗塞患者颅外段颈内动脉探测长度在不同频率超声探头检查下其显示长度不同:低频探头的探测长度高于高频探头。本组56例患者中,分别比较高、低频超声探头对双侧颈内动脉(internal carotid artery,ICA)在二维、CDFI、CDE状态下显示长度结果均有显著性差异。高频探头不同模式对颅外段ICA探测长度无明显统计学意义:二维2.03±0.62cm, CDFI 2.08±0.60cm, CDE 2.12±0.59cm, P>0.05;低频探头不同模式对颅外段ICA探测长度也无明显统计学意义:二维3.83±0.88cm,CDFI 3.89±0.90cm,CDE3.95±0.91cm, P>0.05。而高频与低频超声探头对颅外段ICA探测长度的比较有明显统计学意义,P<0.05。3.颅外段椎动脉探测节段在不同频率超声探头检查下所得数据不同:低频探头的探测长度高于高频探头。本组56例,高频探头显示椎动脉节段2.30±0.60个;低频探头显示椎动脉节段3.63±0.52个,p<0.05。4.不同频率超声探头探测脑梗塞患者颈总动脉(common carotid artery,CCA)、颅外段颈内动脉(internalcarotid artery,ICA)、颅外段椎动脉(vertebral artery,VA)的收缩期最高流速(the peak systolic velocity (PSV),舒张末期最低流速(the end diastolic velocity (EDV)不同。本研究考虑到大部分脑梗塞患者颈部动脉都有不同程度管腔狭窄,此时其对侧相应血管会有不同程度代偿,故不能真实反应其血流速度改变情况。因此,本研究所述的CCA、ICA和VA的PSV、EDV和RI均以右侧为例进行说明。低频探头的PSV和EDV均明显高于高频探头所测数据,两者比较均有统计学意义: RCCA的PSV:高频探头为72.63±22.90cm/s,低频探头为79.74±23.70cm/s,P<0.05;RCCA的EDV:高频探头为18.31±7.65 cm/s,低频探头为20.84±7.77cm/s,P<0.05。RICA的PSV:高频探头为58.24±35.30cm/s,低频探头70.82±37.62cm/s, P<0.05;RICA的EDV:高频探头为20.50±13.65cm/s,低频探头为25.79±14.61cm/s ,P<0.05。RVA的PSV:高频探头为43.67±16.66cm/s ,低频探头为50.28±19.42cm/s, P<0.05;RVA的EDV:高频探头为14.33±6.47cm/s,低频探头为16.36±7.12cm/s,P<0.05。5.分别比较高、低频超声探头探测脑梗塞患者颅外段CCA、ICA、VA阻力指数( resistent index,RI)无显著性差异。其中,RCCA的RI高频探头为0.75±0.55,低频探头为0.74±0.06,P>0.05;RICA的RI高频探头为0.59±0.19,低频探头为0.59±0.17, P>0.05;RVA的RI高频探头为0.66±0.11,低频探头为0.64±0.15,P>0.05。6.行MRA检查的40例患者均经颞窗、枕窗超声检查观察颅内Willis环及大脑中动脉等改变情况。但颞窗、枕窗超声实际观察例数要少于40例,原因在于有些患者颞窗、枕窗不透声。经透声良好的颞窗观察37根血管中有27根发现病变,阳性率约占73% ,上述27根病变血管MRA均诊断为异常,MRA另外诊断3根血管病变,其中1根为大脑中动脉中度狭窄,2根为PCoA开放,共检出30根病变血管,阳性率占81%。经枕窗观察到17根血管,发现椎动脉分出小脑后下动脉之前有5根病变血管(RVA狭窄4根,LVA轻度狭窄1根),椎动脉分出小脑后下动脉之后仅发现1根病变血管(RVA袢部狭窄)。MRA结果显示上述5根椎动脉分出小脑后下动脉之前血管均诊断为异常,又另外诊断2根血管轻度狭窄;椎动脉分出小脑后下动脉之后发现异常血管8根。透声良好者所得结果与MRA结果的比较采用卡方检验,结果显示超声经颞窗对MCA、ACA、PCA的第一段和PCoA的病变检出率和枕窗对椎动脉分出小脑后下动脉之前的病变检出率与MRA比较无明显统计学意义(P>0.05)。而枕窗在椎动脉分出小脑后下动脉之后病变的检出率不如MRA敏感,有统计学意义(P<0.05)。结论:1.超声检查能清晰显示脑梗塞患者颈部血管内膜增厚,斑块形成、管腔狭窄等情况,有助于脑梗塞患者的病因诊断。2.低频超声探头探测颈内动脉显示长度较高频超声探头探测长度长,有助于提高颈内动脉中、远段病变的显示率。3.低频超声探头探测椎动脉显示节段数较高频超声探头多。可以看到3~4个椎间段椎动脉,明显多于高频探头的2~3个椎间段椎动脉,大大提高了椎动脉中、远段病变的显示率,有助于发现椎动脉扭曲、狭窄。4.低频超声探头探测颅外段CCA、ICA、VA时其收缩期最高流速、舒张末期最低流速较高频超声探头所探测的流速高;而对阻力指数的测量,两者却无统计学意义。5.高频超声探头显示病变血管内膜情况、斑块特征、管腔狭窄程度较低频探头清晰,但其探测长度相对较短,因此,对脑梗塞患者进行颅内外血管检查时要联合应用两种频率探头以提高病变显示率。6.在患者颞窗、枕窗透声良好的情况下,TCCD可以发现脑梗塞患者颅内段颈内动脉、椎动脉及其主要分支的病变情况,与MRA比较具有较高的一致性,可作为脑梗塞患者的首选检查,尤其是遇到年老耐受性差,体内有金属植入物不适合MRA检查的患者,颞窗、枕窗超声检查就显得更加重要了,但其本身仍具有一定局限性,当颞窗、枕窗可疑颈内动脉、椎动脉颅内段细小分支病变及颞窗、枕窗透声不良时应行MRA检查。更多还原

【Abstract】 Objective:To assess the extracranial and intracranial cerebral vessels of patients who subjected cerebral infarction with L12~5MHz linear array scanner,C5~2MHz convex array probe and P4~2MHz probes. And find the merits and shortcomings among B―mode (B-US), color Doppler flow imaging (CDFI) and color Doppler energy (CDE). Middle cerebral artery(MCA) and Willis circles:anterior cerebral artery(ACA),posterior cerebral artery(PCA),anterior communicating artery(ACoA),posterior communicating artery(PCoA), and basal artery(BA),posterior inferior cerebellar artery(PICA)and other arteries were detected by transcranial color-coded duplex sonography (TCCD).Extracranial cerebral vessels with unilateral severe stenosis or obstructive led to the changes of intracerebral collateral circulation were be evaluated by transcranial color-coded duplex sonography. At the same time, how to improve the display of distal extracranial internal carotid artery(ICA) and vertebral artery(VA)was investigated,too.Methods and materials:56 patients(39 males,17 females) with cerebral infarction were included in this study. The diseases were diagnosed by computer tomography(CT)or magnetic resonance imaging(MRI). Common carotid artery(CCA), extracranial internal carotid artery ,the length of the distal visualized ICA and vertebral artery were observed by conventional probe .The intracranial internal carotid artery and the bifurcation of ICA were measured through temporal window, and the intracranial V-BA were scanned through sub-occipital window by means of TCCD. Then the results were compared with MRA. All of them in the group,the peak systolic velocity (PSV) ,the end diastolic velocity (EDV) and resistent index(RI) of common carotid artery ,extracranial internal carotid artery and vertebral artery were detected by high frequency linear-array probe(HFLP)and lower frequency convex probe(LFCP);And the length of the extracranial ICA and VA were observed by the same probes. The difference between HFLP and LFCP were compared by statistics software through these results. Parts of this 40 patients’MRA can compared with its’TCCD.Results:1. The rate of display diseases in CCA,ICA and VA were 87.5% detected by ultrasonograph among 56 cases (112 blood vessels )with cerebral infarction.2. The detected length of extracranial internal carotid artery was various in different frequency ultrasonic probe: The length by lower frequency convex probe was significantly greater than that by high frequency linear-array probe. Color Doppler energy compare with CDFI and CDE had no statistical significance. There are 56 patients to be selected in the group ,the length of ICA detected by HFLP were B-US: 2.03±0.62cm, CDFI 2.08±0.60cm, CDE 2.12±0.59cm,P>0.05;the length of ICA detected by LFCP were B-US: 3.83±0.88cm,CDFI3.89±0.90cm,CDE3.95±0.91cm,P>0.05. But the detected length detected by LFCP compare with HFLP had distinguished statistical significance,P<0.05.3. The detected length of extracranial VA was various in different frequency ultrasonic probe: The length by lower frequency convex probe was significantly greater than that by high frequency linear-array probe. There are 56 patients to be selected in the group, the displayed segments of VA detected by HFLP were VA 2.30±0.60 pieces and by LFCP were 3.63±0.52 pieces, p<0.05.4. PSV and EDV of common carotid artery,extracranial internal carotid artery and vertebral artery were distinguished distinct in different frequency probe. Allowed for the extracranial cerebral vessels of patients who subjected cerebral infarction may be exist different level stenosis,and the contralateral arteries would be compensation result in the data detected by ultrasound were untruth. For this reason,right arteries to be selected to illustrate the blood flow parameter changes in this article. PSV and EDV of extracranial cerebral vessels measured by LFCP are much higher than that by HFLP. PSV of RCCA detected by HFLP and LFCP were 72.63± 22.90cm/s and 79.74±23.70cm/s,P<0.05; EDV of RCCA detected by HFLP and LFCP were 18.31±7.65 cm/s and 20.84±7.77cm/s,P<0.05 . PSV of RICA detected by HFLP and LFCP were 58.24±35.30cm/s and 70.82±37.62cm/s,P<0.05; EDV of RICA detected by HFLP and LFCP were 20.50±13.65cm/s and 25.79±14.61cm/s,P<0.05. PSV of RVA detected by HFLP and LFCP were 43.67±16.66cm/s and 50.28±19.42cm/s, P<0.05;EDV of RVA detected by HFLP and LFCP were 14.33±6.47cm/s and 16.36±7.12cm/s,P<0.05.5. The RI of CCA ,ICA and VA of different frequency probes have no significant statistics meaning. RI of RCCA detected by HFLP and LFCP were 0.75±0.55 and 0.74±0.06,P>0.05. RI of RICA detected by HFLP and LFCP were 0.59±0.19 and 0.59±0.17, P>0.05. RI of RVA detected by HFLP and LFCP were 0.66±0.11 and 0.64±0.15,P>0.05.6. 40 cases Willis circles were observed through temporal window and sub-occipital window,and the results were compared with MRA. But the cases observed through temporal window and sub-occipital window were less than 40,the reason is that some patients have no acoustic window and sub-occipital window. The detected results through 37 temporal windows were as follow: 20 MCAs were found stenosis (RMCA: 12strips, LMCA: 8strips); 4 PCoAs were opening (RPCoA: 3 strips,LPCoA: 1strip);3ACAs were suspected stenosis(RACA:1 strip,LACA:2 strips). 2 cases’RVA may be seen indistinctly and one case existed higher flow rate and RI though sub-occipital window.There are 27 blood vessels were pathological changes through 37 transaudient temporal window and the rate of masculine was 73%. The 27 disease vessels above-mentioned were diagnosed abnormity by MRA; in addition, there are 2 PCOAs were opening and 1 MCA was midrange stenosis. So MRA found 30 vessels were pathological changes, and the rate of masculine was 81%. There are 17 blood vessels were observed by sub-occipital window,and found 5 blood vessels with pathological changes(stenosis of RVA were 4strips and LVA was 1 strip),and these diseases were all located in pro- bifurcation(PICA) in VA;But there are only one blood vessel with pathological changes were found,and it located in post- bifurcation(PICA) in VA(stenosis of RVA’s fillet). MRA’s results revealed all the 5 blood vessels above-mentioned with disease,otherwise ,it also found another 2 blood vessels with lower grade stenosis and 8 blood vessels were abnormal,the former were located in pro- bifurcation(PICA) in VA,and the latter were located in post- bifurcation(PICA) in VA.The results of sub-occipital window were used to compare with MRA through paired chi square test. The result displayed: the rate of disease detection by temporal window (to detected MCA-M1 , ACA-A1 , PCA-P1 and PCoA) and sub-occipital window(to detected pro-bifurcation(PICA) in VA )have no significant statistics meaning,the former P> 0.05,the latter P>0.05. But the rate of disease detection by sub-occipital window to detected post-bifurcation(PICA) in VA compared with MRA have significant statistics meaning and the data’s P<0.05.Conclusions:1. Ultrasonogram can display thickening of inner memb- rane,plaque and stenosis of blood vessel and other changes among patients who subjectd cerebral infarction. It can contribute to diagnose the cause of cerebral infarction.2. The imaging length of extracranial internal carotid artery showed by LFCP was significantly greater than that of HFLP,which contributes to higher display of the distal extracranial internal carotid artery’s diseases.3. LFCP displayed the segment of vertebral artery were much longer than that of HFLP: 3~4 segments can be seen by LFCP,while only 2~3 segments can be seen by HFLP. LFCP can increase the rate of the sighting of distal vertebral artery, and contributes to higher display twist and stegnosis of VA.4. PSV and EDV of CCA, extracranial ICA and VA measured by LFCP had obvious statistical significance than that by HFLP;However RI had no difference.5. The displayed inner membrane, plaque’s character and the degree of lumina’s stenosis were clear by HFLP than that by LFCP. So apply both HFLP and LFCP to detected intracranial and extracranial vessels can make for higher displayed rate of unhealthy vessels. 6. TCCD can found the changes of intracranial internal carotid artery and vertebral artery as well as the main branches of them,the patients with cerebral infarction are also applied and the precondition was the bone windows were clear. TCCD compared with MRA was consistent in basic. But temporal window and sub-occipital window themselves prossess limitations.So it is essential to diagnose diseases by MRA when temporal window and sub-occipital window were vague, ramulus of intracranial ICA and VA with disease were suspected.更多还原