【作者】 郑瑜；

【导师】 周晓东；

【作者基本信息】 第四军医大学 ， 影像医学与核医学， 2008， 博士

【摘要】 第一部分三维超声对胎儿颜面结构的系统评估目的:本研究旨在探讨三维超声平面及容积模式在胎儿颜面部系统评估中的临床价值。材料与方法2006年2月至5月,健康孕妇134例,孕周15～40周,年龄23-37岁,应用美国通用公司GE VOLUSONE 730 Expert超声诊断仪进行二维及三维超声检查,对比其对胎儿颜面部矢状、横向、纵向系列标准切面的显示率及所需检查时间,并分析胎儿颜面部表面容积成像与胎位及孕周的关系。结果通过平面模式脱机分析三维数据库,能够获得胎儿颜面部系统评估所需的矢状、横向、冠状系列切面,鼻骨、眼眶、上下唇、上颌牙槽突、腭突、腭骨水平板等标志性结构均能准确显示,并且明显缩短了孕妇检查时间。与二维超声相比,部分胎儿颜面冠状切面的显示率有显著性差异,包括牙槽鼻后切面(88.06 % vs. 55.97%,P<0.05)、硬腭切面(69.40% vs. 43.28%,P<0.05)及腭后切面(50.74% vs. 39.55%, P<0.05),。24-28w和28-32w组胎儿颜面部容积图像显示率分别为:84.31%及83.59%,与16-20w、36-40w组(44.44%、46.15%)相比,有显著性差异(P〈0 .05);侧枕前位及枕后位胎儿颜面容积图橡显示率分别为:87.04%、87.50%,与正枕前位及臀位相比有显著性差异(P〈0 .05)。结论:三维超声平面模式与容积图像能快速有效的完成对胎儿颜面部的产前系统评估,颜面部容积图像的显示与胎位及胎龄相关. Key words:三维超声胎儿颜面产前诊断二维超声容积成像第二部分三维超声产前诊断胎儿颜面畸形的应用研究目的:探讨应用三维超声产前诊断胎儿颜面畸形的临床价值。方法:2006.5-2008.2月,孕周16～40周单胎妊娠,具备高危因素的孕妇539例进行二维及三维超声检查。首先,应用二维超声进行胎儿颜面部矢状、横向及冠状扫查,再由同一操作者以胎儿颜面部正中矢状切面为初始切面进行3D/4D采样,采样角度40-70度,取样框应包括胎儿顶部与部分颈部。三维采样形成的容积数据库存入硬盘,由另一操作者在未知二维诊断结果的前提下,利用4DView Software version 6.0 (GE Medical Systems Kretztechnik GmbH & Co OHG)进行脱机分析,显示方法包括平面和容积模式等,存储图像并记录诊断结果,与产后结果对比并由2名医生共同回顾畸形胎儿的三维及二维超声图像,判断与二维超声相比,三维超声是否提供了更多(advantage),等价(equal)或不足(disadvantage)的诊断信息。结果:539例孕妇有正常产或引产结果者373例,已证实颜面部畸形47例共69处,包括唇裂20例,腭裂18例,眼距过宽6例,眼距过窄8例,小耳畸形2例,耳位过低8例,喙鼻2例,鼻骨缺失3例,下颌短小2例。与二维超声相比,应用三维超声诊断出更多的颜面畸形(88.41% vs. 73.91%,P<0.05),但唇裂的检出率并无显著性提高(85.0% vs. 95.0%,P>0.05)。应用三维超声为56.52%的畸形提供了与二维超声相似的诊断信息,对37.68%的畸形提供了更多的诊断信息,5.79%的颜面畸形中,三维超声提供诊断信息不及二维超声。结论:三维超声能够反映胎儿颜面畸形的表面形态、细节特征及内部结构,增加了产前诊断信心,并对胎儿颜面畸形的检出率有一定程度提高,可作为二维超声的有益补充。第三部分动态三维容积成像诊断胎儿肢体畸形的临床研究目的旨在探讨动态三维超声容积成像诊断胎儿肢体畸形的临床价值。材料与方法:2006.5-2008.2孕周16～40周具备高危因素单胎妊娠的孕妇539例进行二维及三维超声检查。首先应用二维超声,沿肢体的自然伸展方向追踪扫查胎儿四肢,然后由同一操作者进行4D-Real Time三维采样,采集角度:30-60度。由另一操作者在未知二维诊断结果的前提下,利用4D View Software version 6.0 (GE Medical Systems Kretztechnik GmbH & Co OHG)进行脱机分析,存储图像并记录诊断结果,与产后结果进行对比。结果539名孕妇中胎儿近段肢体即上臂和大腿应用三维或二维超声均能显示,三维动态容积成像对20-24W及24-28w组胎儿手部显示率分别为89.66%、88.52%,与二维超声相比均有显著性差异(P<0.05),对胎儿前臂、小腿及足部的显示与二维超声相比则无明显差异(P>0.05)。获得产后结果373例胎儿中肢体畸形者45例共56处:主要包括桡骨缺如、勾状手、短肢、缺指、多指、并指、重叠指、小指中节指骨缺如、足内(外)翻、腓骨缺如、成骨发育不全等。三维动态容积成像诊断胎儿肢体畸形的敏感度与阳性预告值与二维超声相比有统计学差异(P<0.05)。结论三维动态容积成像通过对胎儿肢体表面形态、姿势动作及内部结构的直观显示,提高了产前超声诊断胎儿肢体畸形的敏感度,减少了对操作技巧及临床经验的依赖性,是二维超声的有益补充。第四部分线断层超声成像(TUI)诊断胎儿内部结构畸形的临床研究目的本研究应用TUI(Tomographic Ultrasound Imaging)技术对胎儿中枢神经系统、腹部脏器等内部结构进行显像,探讨线断层超声成像诊断胎儿内部结构畸形的临床价值。材料与方法2006.5-2008.2孕周16～40周均为单胎妊娠具备高危因素的孕妇539例进行二维及三维超声检查。应用二维超声对胎儿颅脑、胸腔及腹部行矢状、横向及冠状扫查,由同一操作者以‘3D static’采样。由另一操作者在未知二维诊断结果的前提下,利用4D View Software version 6.0 (GE Medical Systems Kretztechnik GmbH & Co OHG)进行TUI模式脱机分析,并与产后结果对比。结果通过以线断层超声成像脱机分析胎儿内部结构的三维数据库,能够获得系统评估所需的矢状、横向、冠状系列切面,线断层超声成像对胎儿部分颅脑标准切面的显示与二维超声相比有显著性差异,包括第一冠状切面(87.36% vs78.45%,P<0.05)、正中矢状切面(78.16% vs. 35.34%,P<0.01)及旁矢状切面(70.11% vs. 34.20% ,P<0.01)。产后发现畸形49例58处(除外颜面、四肢及心脏畸形),包括颅脑部畸形25例,脊柱畸形13例,腹部畸形16例,胸部非心脏畸形4例,与二维超声相比,线断层超声成像对胎儿内部结构畸形的检出率无显著性差异((98.3% vs93.5%,P>0.05)。结论线断层超声成像同时显示多个平行断面,能快速准确的获得产前诊断所需的胎儿中枢神经系统及腹部等部位的标准切面,为诊断胎儿内部结构畸形提供了新的方法。第五部分STIC&TUI评价胎儿心脏的初步探索目的本研究旨在探索联合应用时空关联四维成像与线断层超声成像(STIC&TUI)产前评估胎儿心脏的可行性与临床价值。方法2007-2008年253名具有高危因素的产妇进行二维及四维胎儿超声心动图检查,常规行二维胎儿超声心动图检查后,选择时空相关(STIC)模式对胎儿心脏进行四维采样,采样时间7.5-12.5s,尽量避免胎动干扰.由另一操作者在未知二维诊断结果的前提下,利用4D View Software version 6.0 (GE Medical Systems Kretztechnik GmbH & Co OHG)进行线断层超声显像,与二维超声比较胎儿心脏各标准断面的显示能力及胎儿先天心脏畸形检出率。结果(1) B-mode四腔切面、五腔切面、三血管气管切面及肺动脉切面在容积数据库中的显示率依次为91.45%, 87.53%, 83.36% and 86.72%,其中,三血管切面和肺动脉切面的显示率与二维超声相比有明显改善(P<0.05).(2)彩色血流模式中,这些切面在容积数据库中的显示率依次为93.45% ,89.72%,85.25% and 89.72 %,肺动脉切面的显示率较二维超声有所改善。(3) TUI断声显像与二维超声诊断胎儿心脏异常的敏感度无显著性差异(86.95% VS 91.31,P>0.05)。结论应用TUI技术分析由STIC采样模式中获得的胎儿心脏四维容积数据库,能迅速有效的获得胎儿心脏各标准平面,为快速诊断胎儿心脏异常提供了新的工具,可作为二维胎儿超声心动检查的有益补充。更多还原

【Abstract】 Part One Systematic analysis of the normal fetal facial anatomy in utero with three-dimensional sonographyObjectives The aim of this study was to explore the clinical value of three-dimensional ultrasonography(3DUS) in systematic and precise analysis of fetal facial features.Material and methods: From Feb.2006 to May.2006, 134 healthy pregnant women, the mean menstrual age ranged from fifteen to forty weeks, received prenatal fetal facial anatomic estimation by two-and three-dimensional ultrasonography. Their fetuses were normal in postnatal outcomings. The imaging system we used were GE VOLUSONE 730 Expert, which provides conventional two-dimensional ultrasound images and can also generate high-quality three-dimensional images in the surface and transparent mode. All volume data were analyzed in version 6.0 of the 4DView Software (GE Medical Systems Kretztechnik GmbH & Co OHG). The visualization rate of each representative sagittal, axial and coronal section planes of fetal face and the examination time were calculated using two- and three-dimensional ultrasonography separately.Results By off-line analysis of three-dimensional volume databases, the fetal facial feature could be reviewed in sagittal, axial and coronal section planes. The representative structure, such as nasal, lip, alveolus, maxillae processus palatinus, palatal horizontal plate, all could be revealed in 3DUS. The rate of visualization of coronal section planes of fetal face was statistically improved in 3DUS including the alveolus view (88.06 % vs. 55.97%,P<0.05), the palate view (69.40% vs. 43.28%,P<0.05), and the post-palate view(50.74% vs. 39.55%, P<0.05).The examination time was shortened. In rendering image of 3DUS,the profile and configuration of fetal face could gain comprehensive estimation. The visualization rate of fetal faces was 84.31% in fetuses with menstrual age of 24-28w and 83.59% in fetuses with menstrual age of 28-32w, which were statistically different from the visualization rate in fetuses with menstrual age of 16-20w and 36-40w (P<0.05). The visualization rates was 87.04% in fetuses with position of left/right occipito-anterior and 87.50% in fetuses with position of occipito-posterior, which were statistically different from fetuses with position of occipito-anterior and breech(P<0.05). Conclusions By analysis of rendering image and the three simultaneous reference planes, 3DUS allows easier, more rapid screening and more precise evaluation of the different facial features of fetuses. Part two Prenatal evaluation of fetal facial abnormalities with three-dimensional ultrasonographyObjectives The aim of this study was to explore the clinical value and additional information provided by three-dimensional ultrasonography in evaluation of fetal facial abnormalities .Material and methods: From May.2006 to Feb.2008, 539 pregnant women with high risk factors, the mean menstrual age ranged from fifteen to forty weeks, received prenatal fetal anatomic estimation by two-and three-dimensional ultrasonography. The imaging system we used was GE VOLUSONE 730 Expert, which provides conventional two-dimensional ultrasound images and can also generate high-quality three-dimensional images in the surface ,transparent and planer mode. After the diagnosis with conventional 2DUS by series sagittal, axial and coronal scanning of fetal face, examiner preformed 3D/4DUS to acquire volume datasets of the fetal face with acquisition time ranged from 3s to 6s per volume and scan angle ranged from 40°to 70°. All volume data were analyzed in version 6.0 of the 4DView Software (GE Medical Systems Kretztechnik GmbH & Co OHG). An independent examiner blinded to the indication of 2DUS explored 3D/4DUS volume databases and gained diagnostic impression. Findings of 3D/4DUS and 2DUS were compared respectively to those of subsequent autopsy examinations. All images were stored for further estimation by two sonographists to codetermine whether 3D/4D volume provided advantageous, equal or disadvantageous diagnosis information when compared with 2DUS.Results Among 373 fetuses with postnatal outcomings, 47 fetuses were confirmed with 69 facial abnormalities, including 20 cases of cleft lip,18 cases of cleft palate,6 cases of hypertelorism,8 cases of hypotelorism,2 cases of ear hypogenesis, 8 cases of lower-set ear,2 cases of proboscis,3 cases of nasal bone absence, 2 case of micrognathia. The sensitivity of detecting anomalies by 3D/4DUS was significantly different to 2DUS(88.41% vs. 73.91% ,P<0.05). However, the sensitivity of detecting cleftlip was similar between 3D/4DUS and 2DUS(85.0% vs. 95.0%, P>0.05). Compared with 2DUS, the 3D/4D volumes provided additional diagnosis information in 26 abnormalities (37.68%), equivalent diagnosis information in 39 abnormalities (56.52%) and disadvantageous diagnosis information in 4 abnormalities (5.79%).Conclusions Three-dimensional ultrasonography volume provides a novel means of visualizing the feature of fetal face. Our observations suggested that three-dimensional ultrasonography was a powerful adjunctive tool to 2DUS, in providing more comprehensible and vivid impression of fetal facial abnormalities .It may enhance the diagnostic potential sensitivity in prenatal diagnosis of fetal facial abnormalities.Part Three Evaluation of fetal extremities abnormalities in utero using four-dimensional ultrasonographyObjectives The aim of this study was to describe normal and abnormal fetal extremities by four-dimensional ultrasonography and to explore its clinical diagnosis value in prenatal evaluation of fetal extremities anomalies.Material and methods From May.2006 to Feb.2008, 539 high risk pregnancies with the mean menstrual age ranged from sixteen to forty weeks, received prenatal fetal anatomic estimation by 2DUS and 3DUS. The volume datasets of fetal extremities were acquired with the‘4D real-time’option with acquisition time less than 20s per volume cine and scan angle ranging from 30 to 60°. All volume data were analyzed in version 6.0 of the 4DView Software (GE Medical Systems Kretztechnik GmbH & Co OHG). Volume data were reviewed in‘plane’and‘render’option. Findings of 3D/4DUS and 2DUS were compared respectively to subsequent autopsy examinations.Results The ability to visualize fetal hand was better with 4DUS than with 2DUS in fetuses with gestational ages of 20-24w (89.66% vs. 74.71%,P<0.05) and 24-28w (88.52% vs. 73.77% ,P<0.05). Among 373 fetuses with postnatal outcomings, 56 extremities anomalies of 45 fetuses were confirmed, including club foot, clenched hand, polydactyly, overlapping finger, absent antebrachium, osteogenesis inperfecta, absent middle phalanx of 5th finger, absent fibula ,et al. The sensitivity(78.57% vs. 55.35% ,P<0.05) and positive prospective value (84.61% vs. 65.95%, P<0.05) of detecting extremities anomalies by 4DUS was significantly different to 2DUS,Conclusions The enhanced display of external profile and internal structural of fetal extremities by 4DUS increased the confidence and veracity of the abnormality. The novel technology offers the potential to provide greater information in prenatal evaluation for both normal and abnormal extremities. Part four Three-dimensional Tomographic Ultrasound Imaging for evaluation of normal and abnormal fetal internal structure.Objectives The purpose of this study was to investigate the use and potential of Tomographic Ultrasound Imaging(TUI) in describing the fetal internal structure (mainly involving fetal central nervous system and abdomen) and to assess the clinical value and the feasibility in diagnosis of fetal internal anomalies.Material and methods From May.2006 to Feb.2008, 539 high risk pregnancies with the mean menstrual age ranged from sixteen to forty weeks, received prenatal fetal anatomic estimation by two-and three-dimensional ultrasonography. After the diagnosis with conventional 2DUS by series sagittal, axial and coronal scanning, examiner preformed‘3D static’to acquire representative volume datasets of the fetal head , thorax and abdomen. All volume data were analyzed with TUI mode in version 6.0 of the 4DView Software (GE Medical Systems Kretztechnik GmbH & Co OHG) by an independent examiner blinded to the indication of 2DUS. Findings of TUI and 2DUS were compared respectively to subsequent autopsy examinations.Result By TUI display of three-dimensional volume databases, the fetal internal structure could be reviewed in sagittal, axial and coronal section planes. The rate of visualization of fetal head was better by TUI mode than 2DUS in the first coronal view (87.36% vs78.45% ,P<0.05) , the mid-sagittal plane(78.16% vs. 35.34% ,P<0.01) and the parasagittal plane (70.11% vs. 34.20%, P<0.01). Other representative views of fetal head and abdomen were gained similar visualization rate in 2DUS and TUI . A total of 58 anomalies, excluding facial ,extremities and heart anomalies, were confirmed postnatally. The sensitivity of detecting internal structure anomalies showed no significant difference between TUI and 2DUS (98.3% vs93.5%, P>0.05). Conclusions Three-dimensional TUI display can deliver informative images of the region of interest regardless of fetal position. It may be particularly helpful for evaluation of fetal normal and abnormal internal structure.Part five Prenatal assessment of the fetal heart using Tomographic Ultrasound Imaging display of four-dimensional volume datasets acquired with spatiotemporal image correlation (STIC).Objective The objective of this study was to investigate the feasibility of examining the fetal heart with Tomographic Ultrasound Imaging (TUI) using four-dimensional(4D) volume datasets acquired with spatiotemporal image correlation (STIC).Material and methods 253 pregnant women underwent two-dimensional and four-dimensional fetal echocardiography. After the diagnosis with conventional 2DUS fetal echocardiography, volume datasets were acquired with spatiotemporal image correlation in B-mode and Color Doppler Image. Volume acquisition time was between 7.5 and 12.5 seconds and, whenever possible, the procedure was performed in the absence of fetal movements or breathing. In version 6.0 of the 4DView Software (GE Medical Systems Kretztechnik GmbH & Co OHG), volume datasets were reviewed offline using TUI, a new display modality that automatically slices 3D/4D volume datasets, providing simultaneous visualization of up to eight parallel planes in a single screen. Visualization rates for standard transverse planes used to examine the fetal heart were calculated and compared between TUI and 2DUS. Diagnoses by TUI were compared to postnatal diagnoses.Results (1) The Four-chamber view, five-chamber view, pulmonary artery view and three-vessel view were visualized in 91.45%, 87.53%, 83.36% and 86.72% respectively, of the volume datasets acquired with B-mode. The visualization rates of the pulmonary artery view and the three-vessel view were improved(P<0.05). (2) These views were visualized in 93.45% ,89.72%,85.25% and 89.72 % respectively of the volume datasets acquired with Color Doppler Image. The visualization rates of the pulmonary artery view were improved(P<0.05). (3) The sensitivity of TUI to diagnose congenital heart disease was similar to 2DUS (86.95% VS 91.31%, P>0.05) Conclusions Standard transverse planes commonly used to examine the fetal heart can be automatically displayed with TUI in the majority of fetuses undergoing 4DUS with STIC. It may be particularly helpful for evaluation of fetal congenital heart disease.更多还原