基底節(jié)區(qū)急性腦梗死M1段血管斑塊的T1W-3D-VISTA診斷研究

趙慶龍，劉天怡，楊詩琪，李露露，劉鵬飛*，李國(guó)忠，王巍，崔英哲

基底節(jié)區(qū)急性腦梗死M1段血管斑塊的T1W-3D-VISTA診斷研究

趙慶龍1，劉天怡2，楊詩琪2，李露露1，劉鵬飛1*，李國(guó)忠2，王巍1，崔英哲1

目的利用T1W 3D-VISTA磁共振成像序列對(duì)基底節(jié)區(qū)急性缺血性腦卒中患者大腦中動(dòng)脈M1段血管斑塊分布、信號(hào)以及相關(guān)臨床特點(diǎn)進(jìn)行分析。材料與方法對(duì)MR DWI診斷為大腦中動(dòng)脈供血區(qū)急性缺血性腦卒中的患者行顱內(nèi)動(dòng)脈MRA、大腦中動(dòng)脈T1W 3D-VISTA掃描，根據(jù)梗死部位將患者分為基底節(jié)組(基底節(jié)區(qū)/基底節(jié)區(qū)合并基底節(jié)區(qū)外腦梗死)和非基底節(jié)組(不包含基底節(jié)區(qū)腦梗死)，研究?jī)山M患者梗死同側(cè)斑塊在M1段血管壁的分布，斑塊與胼胝體相對(duì)信號(hào)強(qiáng)度比值(contrast ratio，CR)，以及相關(guān)臨床特點(diǎn)分析。結(jié)果52例急性大腦中動(dòng)脈供血區(qū)腦梗死伴有同側(cè)中動(dòng)脈粥樣硬化斑塊患者(基底節(jié)組：30例，非基底節(jié)組：22例)，一共1560幅圖像被研究，其中251幅圖像包含斑塊，基底節(jié)組的上側(cè)壁斑塊所占比例(37.74%)較非基底節(jié)組(10.26%)大，差異有統(tǒng)計(jì)學(xué)意義(P=0.004)，基底節(jié)組的下側(cè)(26.42%)及腹側(cè)(13.21%)斑塊所占比例較非基底節(jié)組的下側(cè)(48.72%)及腹側(cè)(33.33%)斑塊所占比例小，差異有統(tǒng)計(jì)學(xué)意義(P值分別為0.047，0.039)?；坠?jié)組斑塊相對(duì)信號(hào)強(qiáng)度(CR)較非基底節(jié)組小(均值分別為0.84，0.92)，差異有統(tǒng)計(jì)學(xué)意義(P=0.001)。兩組之間相關(guān)臨床因素(年齡、性別、高血壓、糖尿病、血脂異常、吸煙、飲酒、BMI、入院24 h NIHSS評(píng)分、卒中家族史)比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。結(jié)論T1W-3D-VISTA序列可以檢測(cè)大腦中動(dòng)脈斑塊的分布及相對(duì)信號(hào)強(qiáng)度，與非基底節(jié)區(qū)急性腦梗死患者相比，基底節(jié)區(qū)急性腦梗死患者腦中動(dòng)脈M1段斑塊更多分布于上側(cè)壁，下側(cè)及腹側(cè)壁相對(duì)較少，基底節(jié)區(qū)急性腦梗死患者中動(dòng)脈斑塊相對(duì)更穩(wěn)定。

腦梗塞；磁共振成像；大腦中動(dòng)脈；斑塊，動(dòng)脈粥樣硬化

趙慶龍, 劉天怡, 楊詩琪, 等. 基底節(jié)區(qū)急性腦梗死M1段血管斑塊的T1W-3DVISTA診斷研究. 磁共振成像, 2017, 8(1): 17-21.

急性缺血性腦卒中是一種好發(fā)于中老年患者的具有高致死率和致殘率的疾病。研究顯示，與歐美國(guó)家的常由顱外血管疾病引起腦卒中不同，亞洲人群由于人種、環(huán)境、飲食等多種原因，致使顱內(nèi)動(dòng)脈粥樣硬化引起的缺血性腦卒中占有更大的比重[1]。醫(yī)學(xué)影像技術(shù)的進(jìn)步，特別是磁共振血管高分辨技術(shù)的快速發(fā)展[2]，使從病因?qū)W角度評(píng)估顱內(nèi)動(dòng)脈粥樣硬化的各種特征成為可能。筆者利用T1W 3D-VISTA磁共振成像序列來研究基底節(jié)區(qū)急性腦梗死患者大腦中動(dòng)脈M1段斑塊的具體分布、信號(hào)特點(diǎn)以及對(duì)相關(guān)臨床特點(diǎn)進(jìn)行分析。

1 材料與方法

1.1 研究對(duì)象

連續(xù)搜集哈爾濱醫(yī)科大學(xué)附屬第一醫(yī)院神經(jīng)內(nèi)科2015年10月至2016年9月間52例經(jīng)DWI診斷為急性大腦中動(dòng)脈供血區(qū)腦梗死，且經(jīng)MRA及T1W 3D-VISTA證實(shí)梗死同側(cè)伴有大腦中動(dòng)脈M1段動(dòng)脈硬化斑塊存在的患者，其中男性37例，女性15例，平均年齡(59.21±10.96)歲。52例患者中，包含基底節(jié)區(qū)組30例(基底節(jié)區(qū)/基底節(jié)區(qū)合并基底節(jié)區(qū)外腦梗死)，非基底節(jié)區(qū)組22例(不包含基底節(jié)區(qū)梗死)，共有1560幅圖像被研究，其中251幅圖像包含斑塊(基底節(jié)組147幅，非基底節(jié)組104幅)，相關(guān)臨床特征信息被采集分析(表1)，斑塊以分布在中動(dòng)脈M1段的上側(cè)壁，下側(cè)壁，腹側(cè)壁及背側(cè)壁在兩組中分別被對(duì)比分析，每個(gè)斑塊以在各象限分布情況分別計(jì)入上、下、腹、背各組，當(dāng)斑塊分布在兩個(gè)或兩個(gè)以上象限時(shí)，則該斑塊所在的每個(gè)象限計(jì)數(shù)均加一(圖1)；因?yàn)殡蓦阵w組織結(jié)構(gòu)相對(duì)穩(wěn)定，斑塊的信號(hào)強(qiáng)度按其與同次檢查中同一患者胼胝體信號(hào)間的比值(CR)來表示。所有患者都進(jìn)行了頭部DWI、MRA、T1W-3D-VISTA及頸內(nèi)動(dòng)脈超聲掃描。所有患者都簽署了知情同意書。

1.2 入組條件

(1) DWI確診為急性大腦中動(dòng)脈供血區(qū)腦梗死；(2)梗死同側(cè)頸內(nèi)動(dòng)脈經(jīng)超聲檢查狹窄率＜50%；(3)排除心臟疾病患者；(4)圖像質(zhì)量能夠滿足斑塊診斷要求。

1.3 檢查方法

所有患者均使用Philips公司生產(chǎn)的Achieva 3.0 T磁共振掃描儀，16通道標(biāo)準(zhǔn)頭部正交線圈。所有患者均在入院3 d內(nèi)進(jìn)行了DWI掃描，然后先行3D-TOF MRA掃描，之后利用MRA圖像定位進(jìn)行大腦中動(dòng)脈T1W 3D-VISTA掃描。DWI參數(shù)如下：TR 2170 ms，TE 45 ms，F(xiàn)OV 230 mm× 230 mm×119 mm，層厚4 mm，矩陣112×89；3D-TOF MRA參數(shù)：TR 25 ms，TE 3.5 ms，F(xiàn)OV 180 mm×180 mm×85 mm，層厚 1.4 mm，矩陣256×256；T1W 3D-VISTA參數(shù)：TR 800 ms，TE 18 ms，F(xiàn)OV 130 mm×130 mm×40 mm，層厚0.6 mm，矩陣330×300。

1.4 圖像分析

圖像采集完成后傳輸?shù)紸chieva副臺(tái)后處理工作站進(jìn)行處理，T1W 3D-VISTA圖像沿大腦中動(dòng)脈M1段短軸方向進(jìn)行重建。每一名患者的圖像均由2名從事MRI診斷工作10年以上的影像診斷醫(yī)師進(jìn)行盲法評(píng)片，兩個(gè)人都不知道患者的臨床信息，觀測(cè)梗死位置，斑塊在血管壁上側(cè)、下側(cè)、腹側(cè)及背側(cè)的具體分布。在斑塊信號(hào)最高處選取0.1 mm2感興趣區(qū)，每處測(cè)三次取均值，沿胼胝體輪廓選取感興趣區(qū)(圖2)，計(jì)算斑塊與胼胝體信號(hào)的比值(contrast ratio，CR)。意見不一致時(shí)協(xié)商解決。T1W 3D-VISTA圖像質(zhì)量分為4級(jí)：1級(jí)，圖像不能顯示血管壁；2級(jí)，血管壁可見，但管壁結(jié)構(gòu)和管壁、管腔輪廓模糊；3級(jí)，管壁結(jié)構(gòu)顯示清楚，僅局部略模糊；4級(jí)，管壁結(jié)構(gòu)及管腔、管壁輪廓均顯示清晰。圖像質(zhì)量分級(jí)≤2級(jí)的患者予以排除。排除2例圖像質(zhì)量分級(jí)≤2級(jí)患者；排除一例梗死同側(cè)伴有大腦中動(dòng)脈夾層患者。

1.5 統(tǒng)計(jì)分析

計(jì)數(shù)資料采用百分比的表達(dá)形式，計(jì)量資料采用平均值±標(biāo)準(zhǔn)差的形式，計(jì)數(shù)資料組間比較采用卡方檢驗(yàn)，計(jì)量資料組間比較采用獨(dú)立樣本t檢驗(yàn)，P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。應(yīng)用SPSS 19.0統(tǒng)計(jì)軟件進(jìn)行數(shù)據(jù)處理。

2 結(jié)果

最終符合標(biāo)準(zhǔn)的患者共52例，基底節(jié)組患者有30例，非基底節(jié)組有22例，本研究中僅有1例大腦中動(dòng)脈狹窄率大于50%。所有52例患者一共1560幅圖像被研究，其中251幅圖像包含斑塊(基底節(jié)組：147幅，非基底節(jié)組：104幅)，基底節(jié)組的上側(cè)壁斑塊所占比例(37.74%)較非基底節(jié)組(10.26%)大，差異有統(tǒng)計(jì)學(xué)意義(P=0.004)，基底節(jié)組的下側(cè)(26.42%)及腹側(cè)(13.21%)斑塊所占比例較非基底節(jié)組的下側(cè)(48.72%)及腹側(cè)(33.33%)斑塊所占比例小，差異有統(tǒng)計(jì)學(xué)意義(P值分別為0.047，0.039)，基底節(jié)組及非基底節(jié)組背側(cè)壁斑塊所占比例分別為22.64%及7.69%，差異無統(tǒng)計(jì)學(xué)意義(P=0.085)?；坠?jié)組及非基底節(jié)組斑塊相對(duì)信號(hào)強(qiáng)度(CR)均值分別為0.84 (0.76～0.99)，0.92 (0.81～1.06)，基底節(jié)組斑塊相對(duì)信號(hào)強(qiáng)度低于非基底節(jié)組，差異有統(tǒng)計(jì)學(xué)意義(P=0.001；圖3)。所有52例患者中，男性(37例，71.2%)及高血壓患者(32例，61.5%)所占比例較大，其余臨床相關(guān)因素(糖尿病14例，26.9%；血脂異常21例，40.4%；吸煙19例，36.5%；飲酒18例，34.6%；卒中家族史13例，25.0%)所占比例較小，基底節(jié)組與非基底節(jié)組之間相關(guān)臨床因素(年齡、性別、高血壓、糖尿病、血脂異常、吸煙、飲酒、BMI、入院24 h NIHSS評(píng)分、卒中家族史)比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)(表1)。

3 討論

大腦中動(dòng)脈供血區(qū)缺血性腦梗死病因復(fù)雜，而腦血管病在其發(fā)病的病因中占有越來越大的比重[3]。驗(yàn)尸報(bào)告表 明 ，90% 的 動(dòng)脈粥樣硬化性腦梗死患者都伴有顱內(nèi)血管的粥樣硬化斑塊存在，43.2%的腦梗死患者伴有動(dòng)脈粥樣硬化所致管腔狹窄[4]，這說明腦動(dòng)脈粥樣硬化斑塊的形成、發(fā)展和破裂很可能是誘發(fā)其相應(yīng)供血區(qū)缺血性腦卒中的重要原因之一[5]。

以現(xiàn)有的影像診斷技術(shù)來研究腦卒中患者顱內(nèi)血管動(dòng)脈粥樣硬化性改變，有MRA、CTA、DSA、超聲等檢查手段，在這些檢查中，超聲由于顱骨的存在，所以在顱內(nèi)血管檢測(cè)上受到了極大的限制；MRA及CTA只能根據(jù)血流的流動(dòng)變化來檢測(cè)管腔內(nèi)情況，對(duì)血管腔狹窄程度較輕的或者斑塊正性重構(gòu)較好[6]的血管壁病變則難以發(fā)現(xiàn)；CTA對(duì)于斑塊的鈣化及新鮮出血敏感[7]，而對(duì)不含鈣化或新鮮出血的斑塊則難以分辨，而且顱內(nèi)動(dòng)脈管徑較細(xì)，斑塊較小，以CTA的分辨率往往難以做出明確診斷。DSA在判斷是否狹窄及小血管顯示上更加精確[8]，而無法從病因?qū)W上診斷狹窄處的具體變化，如斑塊在血管壁橫斷面的具體分布、偏心性還是向心性、斑塊的穩(wěn)定性以及與附近穿支血管的關(guān)系等，這些因素與腦梗死發(fā)生之間都存在關(guān)聯(lián)，對(duì)臨床診斷與治療具有指導(dǎo)性的意義。T1W 3D-VISTA序列由于自身特性，能夠抑制血流信號(hào)，對(duì)斑塊及血管壁輪廓顯示清晰，同時(shí)易于發(fā)現(xiàn)動(dòng)脈夾層及動(dòng)脈瘤等其他病因[9-10]，相對(duì)于傳統(tǒng)的MRA、CTA及DSA等檢查手段，能夠從病因角度更好地對(duì)腦血管病作出診斷。顯微解剖學(xué)研究表明，大腦中動(dòng)脈穿支動(dòng)脈多呈直角自大腦中動(dòng)脈M1段的上壁和后側(cè)壁發(fā)出，從主干發(fā)出后呈梳齒狀平行排列進(jìn)入前穿質(zhì)[11]。本研究結(jié)果顯示斑塊主要位于下側(cè)管壁，即腦穿支開口的對(duì)側(cè)，這與以往的文獻(xiàn)報(bào)道接近[12]，且這種分布與身體中其他大血管動(dòng)脈斑塊分布情況類似，如頸動(dòng)脈分叉處，由于血流動(dòng)力學(xué)變化，擾流和低壁面切應(yīng)力形成等因素更容易形成斑塊及促進(jìn)斑塊的進(jìn)展[13]。本研究中，基底節(jié)組腦梗死患者上側(cè)壁斑塊比例明顯多于非基底節(jié)組，這可能是由于這些斑塊離穿支動(dòng)脈口近，而位于穿支動(dòng)脈開口附近的斑塊無論引起血流異?；蛘呃^續(xù)生長(zhǎng)、破裂都更易造成穿支的血流變化，繼而造成基底節(jié)區(qū)腦梗死。Zhao等[14]也報(bào)道與非癥狀患者相比，出現(xiàn)癥狀患者的斑塊會(huì)更多地位于大腦中動(dòng)脈管壁的上側(cè)。

圖1 大腦中動(dòng)脈斑塊在上、下、腹、背側(cè)的分布劃分(A)，箭所示為分別在上、背、下、腹側(cè)的典型斑塊(B～E) 圖2 典型右側(cè)基底節(jié)區(qū)急性腦梗死患者，女，51歲，DWI上右側(cè)基底節(jié)區(qū)明顯高信號(hào)(A)，3D-TOF MRA像未見異常狹窄征象(B)，梗死同側(cè)右側(cè)大腦中動(dòng)脈M1段T1W-3DVISTA掃描可見管壁上側(cè)斑塊，CR=0.91(C～E)；動(dòng)脈管壁斑塊及胼胝體信號(hào)測(cè)量：分別選取感興趣區(qū)(D～E)Fig. 1 The alignment grid demonstrates the dividing method of the distribution of middle cerebral artery plaques (A) and the arrow shows examples of plaques involving the superior, dorsal, inferior, or ventral wall, respectively (B—E). Fig. 2 A typical patient with acute cerebral infarction of right basal ganglia region, female, 51 years old. The infarction is revealed on diffusion-weighted images (A). 3D-TOF MRA shows no obvious abnormal signs of stenosis (B). A ipsilateral plaque of the superior wall whose CR is 0.91 is observed on T1W-3D-VISTA (C—E). The method of measurement of plaques and the corpus callosum: select the ROI, respectively (D—E).

圖3 基底節(jié)組與非基底節(jié)組大腦中動(dòng)脈M1段斑塊在T1WI 3D-VISTA上的相對(duì)信號(hào)強(qiáng)度(CR)。在T1WI 3D-VISTA上，基底節(jié)組斑塊相對(duì)信號(hào)強(qiáng)度(CR)均值低于非基底節(jié)組Fig. 3 The relative signal intensity of plaques of BG and N-BG on T1WI 3D-VISTA at M1. On T1WI 3D-VISTA, the mean of CRs of the plaques of BG was lower in the M1 segment than that in the N-BG.

血管壁斑塊是否穩(wěn)定決定于其組織成分，含有斑塊內(nèi)出血及脂質(zhì)核心的斑塊相對(duì)更不穩(wěn)定[15]。相對(duì)于顱外血管斑塊，顱內(nèi)血管斑塊成分分析的影像診斷過去一直是難題。近年來磁共振高分辨序列對(duì)顱內(nèi)動(dòng)脈斑塊組織成分的信號(hào)表現(xiàn)的研究發(fā)展迅速[2]， 之 前 文 獻(xiàn) 報(bào) 道 磁 共 振 高 分辨血管成像T1WI上斑塊信號(hào)強(qiáng)度越高往往更易合并斑塊內(nèi)出血或脂質(zhì)核心[16-17]，這是易損斑塊的常見特征，本研究結(jié)果顯示基底節(jié)組患者M(jìn)1段血管壁斑塊相對(duì)信號(hào)強(qiáng)度小于非基底節(jié)區(qū)組，這表明本研究中基底節(jié)組腦梗死患者斑塊相對(duì)更穩(wěn)定。

表1 基底節(jié)組和非基底節(jié)組相關(guān)臨床特點(diǎn)比較Tab.1 The comparison of clinical characteristics between BG and N-BG

本研究顯示高血壓患者所占比例較大，以往研究發(fā)現(xiàn)高血壓引起的腦血管病可引起腦卒中、腔梗及腦微出血[18-19]等多種急慢性腦組織損害，是動(dòng)脈粥樣硬化及斑塊形成的高危風(fēng)險(xiǎn)因素，而血壓的突然升高或降低可能是引起急性腦血管病的病因之一。Mia-Jeanne等[20]也指出高血壓、血脂異常及吸煙是動(dòng)脈粥樣硬化斑塊形成及心腦血管病發(fā)生的重要危險(xiǎn)因素，然而本研究中血脂異常及吸煙患者所占比例較小，這可能與樣本量較小和患者出現(xiàn)癥狀后調(diào)節(jié)自身生活習(xí)慣及用藥治療有關(guān)。本研究中男性患者占有較大比例，糖尿病、肥胖、飲酒患者比例較小，這可能是由地域、環(huán)境及生活習(xí)慣導(dǎo)致的。筆者發(fā)現(xiàn)基底節(jié)組與非基底節(jié)組兩組患者之間相關(guān)臨床因素比較無明顯差異。

這項(xiàng)研究還有一些不足：(1)研究患者例數(shù)少；(2)沒有病理學(xué)結(jié)果的支持；(3)沒有專業(yè)的后處理軟件對(duì)圖像進(jìn)行處理分析。將來我們將繼續(xù)入組新的患者，爭(zhēng)取取得相關(guān)病理學(xué)結(jié)果，并計(jì)劃引進(jìn)專業(yè)的血管處理軟件，不斷完善研究，這將是我們進(jìn)一步研究的方向。

總之，T1W 3D-VISTA可以檢測(cè)急性中動(dòng)脈供血區(qū)腦卒中患者大腦中動(dòng)脈的斑塊分布特點(diǎn)與相對(duì)信號(hào)強(qiáng)度。與非基底節(jié)區(qū)急性腦梗死患者相比，基底節(jié)區(qū)急性腦梗死患者腦中動(dòng)脈M1段斑塊更多分布于上側(cè)壁，下側(cè)及腹側(cè)壁相對(duì)較少，基底節(jié)區(qū)急性腦梗死患者中動(dòng)脈斑塊相對(duì)更穩(wěn)定。

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The diagnostic study of T1-weighted 3D volumetric isotropic TSE acquisition in evaluating characteristics of plaques of middle cerebral artery in acute ischemic stroke of basal ganglia

ZHAO Qing-long1, LIU Tian-yi2, YANG Shi-qi2, LI Lu-lu1, LIU Peng-fei1*, LI Guozhong2, WANG Wei1, CUI Ying-zhe11Department of Magnetic Resonance, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
2Department of Neurology, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
*

Liu PF, E-mail: liup.fei@163.com
Received 12 Nov 2016, Accepted 10 Dec 2016

Objective:To evaluate the characteristics of plaques of middle cerebral artery (MCA) in acute ischemic stroke of basal ganglia using T1-weighted 3D Volumetric Isotropic TSE Acquisition (T1W 3D-VISTA) and its clinical relevance.Materials and Methods:Patients with acute ischemic stroke of middle cerebral artery territory, which were diagnosed by DWI, underwent both MRA and T1W 3D-VISTA examinations. Patients were divided into two groups according to the distribution of infarction, one contained basal ganglia (BG, basal ganglia/ basal ganglia as well as the area outside of it) and the other did not contain basal ganglia (N-BG). Distribution of blood vessel walls and the contrast ratio (CR) of signal intensity of the plaques to that of the corpus callosum were compared between BG and N-BG and their clinical characteristics were evaluated.Results:Among 52 patients with cerebral infarction and ipsilateral plaques in M1 (BG 30 and N-BG 22), a total of 1560 image slices were studied. Overall, of the 251 slices with identified plaques, the plaques located at superior wall of BG (37.74%) accounted for a higher proportion as compared with N-BG (10.26%)(P=0.004), and the plaques located at inferior wall (26.42%) and ventral wall (13.21%) of BG accounted for a lower proportion as compared with the plaques located at inferior wall (48.72%) and ventral wall (33.33%) of N-BG (P=0.047 and 0.039,respectively). The average signal intensity (CRs) of plaques of BG was lower as compared with plaques of N-BG (mean, 0.84 and 0.92, respectively, P=0.001). The clinical characteristics (including age, gender, hypertension, diabetes, dyslipidemia, smoking, drinking, BMI, NIHSS score within 24 hours after admission, family history of stroke) had no significant difference between BG and N-BG (P＞0.05).Conclusion:T1W-3D-VISTA can detect the distribution of arterial atherosclerotic plaques and the relative signal intensity. As compared with plaques of N-BG, the plaques of BG are relatively more stable and account for a higher proportion at superior wall and a lower proportion at inferior wall and ventral wall of MCA M1 segment.

Brain Infarction; Magnetic resonance imaging; Middle cerebral artery; Plaque, atherosclerotic

1. 哈爾濱醫(yī)科大學(xué)附屬第一臨床醫(yī)學(xué)院磁共振科，哈爾濱 150001

劉鵬飛，E-mail：liup.fei@163.com

2016-11-12

R445.2；R743.33

A

10.12015/issn.1674-8034.2017.01.005

2. 哈爾濱醫(yī)科大學(xué)附屬第一臨床醫(yī)學(xué)院神經(jīng)內(nèi)科，哈爾濱 150001

接受日期：2016-12-10