葉景 張小軍 李軍 鐘群 洪景芳 王守森

(1廣東三九腦科醫(yī)院神經(jīng)外一科，廣東 廣州510510 ；南京軍區(qū)福州總醫(yī)院:2神經(jīng)外科；3影像科， 福建 福州 350025)

·腦血管疾病研究·

腦靜脈與靜脈竇血栓形成的MRV與DSA對(duì)照研究

葉景1張小軍2李軍2鐘群3洪景芳2王守森2*

(1廣東三九腦科醫(yī)院神經(jīng)外一科，廣東 廣州510510 ；南京軍區(qū)福州總醫(yī)院:2神經(jīng)外科；3影像科， 福建 福州 350025)

目的探討MRV對(duì)不同時(shí)期腦靜脈與靜脈竇血栓形成(CVST)的診斷價(jià)值。方法分析15例CVST患者，同期行MRV和DSA檢查，將3D CE-MRV及2D TOF-MRV 與 DSA進(jìn)行對(duì)比，探討MRV對(duì)不同時(shí)期CVST的診斷價(jià)值。結(jié)果在急性及亞急性期CVST，3D CE-MRV的診斷準(zhǔn)確性優(yōu)于2D TOF-MRV。對(duì)于慢性期CVST，兩者評(píng)價(jià)的靈敏度、特異度分別是：69.44%、98.15%和 100%、89.47%；兩者評(píng)價(jià)CVST治療后再通的靈敏度、特異度分別是：81.82%、71.88%和 60.00%、100%。結(jié)論對(duì)急性及亞急性CVST，3D CE-MRV較2D TOF-MRV的診斷準(zhǔn)確性高。對(duì)慢性期及再通后的CVST，宜同時(shí)行3D CE-MRV和2D TOF-MRV檢查，結(jié)合原始圖像及MIP圖像綜合評(píng)價(jià)，必要時(shí)行DSA檢查。

腦靜脈及靜脈竇血栓形成; 三維對(duì)比增強(qiáng)磁共振血管血流成像; 二維時(shí)間飛躍血流成像; 數(shù)字減影血管造影

腦靜脈與靜脈竇血栓形成(cerebral vein and sinus thrombosis,CVST)是腦血管疾病的一種少見(jiàn)類型，常規(guī)影像學(xué)診斷有一定難度，常出現(xiàn)漏診或誤診。磁共振靜脈血管成像(magnetic resonance venography,MRV)在診斷CVST中具有一定的優(yōu)勢(shì)[1]，雖然一些作者認(rèn)為三維對(duì)比增強(qiáng)磁共振血管血流成像(three dimensional contrast-enhanced MRV,3D CE-MRV)優(yōu)于二維時(shí)間飛躍血流成像(two dimensional time-of-flight MRV,2D TOF-MRV)[2～4]，但也有作者認(rèn)為CE法在診斷慢性CVST時(shí)易出現(xiàn)漏診，對(duì)于再通情況易出現(xiàn)誤判[1,5,6]。本文以數(shù)字減影血管造影(digital subtraction angiogram,DSA)為標(biāo)準(zhǔn)，評(píng)估 MRV對(duì)不同時(shí)期CVST的診斷價(jià)值。

資料與方法

一、一般資料

回顧2008 年8月至2011 年12月期間南京軍區(qū)福州總醫(yī)院神經(jīng)外科收治的CVST患者，共15例CVST患者同期行MRV與DSA檢查。其中男性9例，女性6例。發(fā)病年齡為13～54歲，平均31.8歲。病程為1～380 d，中位數(shù)病程11 d。隨訪時(shí)間0.5～24個(gè)月，平均5.2個(gè)月(表1)。

二、影像采集與分析

MRV應(yīng)用Siemens Trio Tim 3.0T磁共振成像系統(tǒng)采集。TOF-MRV采用冠狀位/矢狀位快速小角度(FLASH)序列掃描(TR/TE,23/4.4 msec;flip angle,35°;bandwidth,110 Hz/pixel;1.1 mm×1.0 mm×3.0 mm;TA:330 seconds)。CE-MRV采用3D快速小角度(FLASH)序列掃描(TR/TE,2.6/1.1 msec;flip angle,20°;bandwidth,930 Hz/pixel;1.2 mm×1.1 mm×1.2 mm;TA:30 seconds)。DSA檢查使用GE Innova 3100平板DSA成像系統(tǒng)采集。所有患者檢查之前均被告知MRV和DSA檢查的方法、目的、意義和注意事項(xiàng)，并簽訂知情同意書。

所有患者的診斷均綜合應(yīng)用CE法和TOF法，每種序列均包括最大強(qiáng)度投影(maximum intensity projection,MIP)圖像和原始圖像。圖像分析過(guò)程均有1位放射科副主任醫(yī)師和2位腦血管病專家參與判斷與比較，可疑之處經(jīng)過(guò)討論后確定。參考Sun等[1]的做法，顱內(nèi)靜脈系統(tǒng)分成16個(gè)部分，分別是：上矢狀竇前、中、后段，左側(cè)橫竇內(nèi)、外側(cè)，左側(cè)乙狀竇，左側(cè)Labbé靜脈，左側(cè)頸內(nèi)靜脈，右側(cè)橫竇內(nèi)、外側(cè)，右側(cè)乙狀竇，右側(cè)Labbé靜脈，右側(cè)頸內(nèi)靜脈，Galen靜脈，直竇，竇匯。

三、CVST的分期

參考Rizzo L[7]對(duì)CVST的分期方法，患者主訴的第1天為CVST形成的第1天，根據(jù)患者起病與確診時(shí)間間隔將疾病分期：急性期(lt;2 d)；亞急性期(3 d～1個(gè)月)；慢性期(gt;1個(gè)月)。

四、統(tǒng)計(jì)學(xué)分析

采用SPSS 13.0 統(tǒng)計(jì)軟件，對(duì)DSA與MRV檢查結(jié)果進(jìn)行配對(duì)四格表卡方檢驗(yàn)，以Plt;0.05提示差異有顯著性。結(jié)合CE法、TOF法、DSA診斷的結(jié)果，采用卡方檢驗(yàn)，分別計(jì)算CE法、TOF法對(duì)CVST急性期、亞急性期、慢性期及其再通診斷的靈敏度、特異度、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值、KAPPA值。

結(jié) 果

一、不同序列診斷效能比較

在急性及亞急性期CVST，3D CE-MRV的診斷準(zhǔn)確性優(yōu)于2D TOF-MRV。在慢性期CVST，兩者評(píng)價(jià)的靈敏度、特異度分別是：69.44%、98.15%和 100%、89.47%。二者在評(píng)價(jià)CVST治療后再通的靈敏度、特異度分別是：81.82%、71.88%和 60.00%、100%。

二、各期CVST影像學(xué)表現(xiàn)

急性期CVST 1例，行DSA、CE法及TOF法MRV檢查，DSA和CE法都發(fā)現(xiàn)10處血栓形成；TOF法發(fā)現(xiàn)12處血栓，其中1處直竇和1處竇匯血流信號(hào)部分丟失，而DSA提示正常充盈(圖1)。

亞急性期CVST 6例，其中行DSA和CE法檢查5例，DSA和CE法共同發(fā)現(xiàn)23處血栓形成，1處上矢狀竇前段CE法提示血流不規(guī)則充盈而DSA提示無(wú)異常；其中行DSA和TOF法檢查3例，DSA和TOF法共同發(fā)現(xiàn)20處血栓形成，4處TOF-MRV提示血流信號(hào)丟失而DSA提示無(wú)異常(圖2)。

慢性期CVST 8例，均行DSA和CE法檢查， CE法和DSA共發(fā)現(xiàn)25處血栓形成，其中11處DSA提示顯影淺淡或中斷而CE法卻顯影良好(圖3)，2處CE法提示不規(guī)則充盈而DSA提示無(wú)異常。其中2例行DSA和TOF法檢查，DSA和TOF法共發(fā)現(xiàn)13處血栓形成，2處TOF法提示信號(hào)丟失而DSA提示充盈良好(圖4)。

CE法發(fā)現(xiàn)9處再通，而DSA顯示血栓形成(圖3)；DSA發(fā)現(xiàn)2處血栓再通，而TOF法提示血流信號(hào)仍丟失(圖5)。

三、DSA在CVST診斷中的假陽(yáng)性

1例患者DSA顯示左側(cè)橫竇顯影缺失，而MRV矢狀位顯示橫竇闕如，如圖5所示。

圖1 急性期CVST的MRV與DSA診斷比較
Fig 1 The comparison between MRV and DSA in the acute phase of CVST
A:2D TOF-MRV demonstrated the normal signals of blood flow in left transverse sinus and sigmoid sinus,which disappeared in the Torcular herophili (arrow);B:Left carotid arteriography revealed the filling of blood flow signals was normal in the straight sinus and Torcular herophili (arrow);C:3D CE-MRV showed the fine image of straight sinus and Torcular herophili (arrow).

圖2 亞急性期CVST的TOF法與DSA診斷對(duì)比
Fig 2 The comparison between 2D TOF-MRV and DSA in the subacute phase of CVST
A:2D TOF-MRV demonstrated reduced blood flow in the right transverse sinus,sigmoid sinus and Labbé vein (arrow);B:Right carotid arteriography revealed a filling defect at the right transverse sinus and sigmoid sinus (thin arrow),and it showed normal blood flow in the Labbé vein (thick arrow).

圖3 慢性期CVST的MRV與DSA診斷比較
Fig 3 The comparison between MRV and DSA in the chronic-phase of CVST
A:Two months after onset,right carotid arteriography revealed a filling defect at the posterior segment of the superior sagittal sinus (arrow);B:Four months after onset,3D CE-MRV showed the superior sagittal sinus filled with normal blood flow (thick arrow);C:Four months after onset,right carotid arteriography showed the superior sagittal sinus did not obviously improve (arrow). D:Four months after onset,right carotid arteriography showed the diploe veins had linked up with the intracranial venous circulation and the scalp developed thickly (arrow).

圖4 CVST治療后再通的MRV與DSA診斷比較
Fig 4 The comparison between TOF-MRV and DSA in evaluating the recanalization of sinus
A:At onset of acute phase,right carotid arteriography showed the filling defect at the posterior segment of superior sagittal sinus (arrow);B:Six months after onset,2D TOF-MRV showed that the superior sagittal sinus thrombosis did not improve obviously (arrow);C:Six months after onset,right carotid arteriography demonstrated normal blood flow in the superior sagittal sinus and suggested the recanalization (arrow).

圖5 MRV與DSA在鑒別橫竇發(fā)育異常與血栓形成的對(duì)比
Fig 5 The comparison between MRV and DSA in distinguishing the hypoplastic transverse sinus from thrombosis
A:Left carotid arteriography showed the right transverse sinus (thin arrow) dominantly developed and the left Labbé vein (thick arrow) was refluxed through the hypoplastic sigmoid sinus;B:MIP image of 3D CE-MRV demonstrated a filling defect at the left transverse sinus (arrow);C:Sagittal original image of MRV revealed absence of the sinus structure at the location of left transverse sinus (arrow).

表1 15例CVST患者的臨床資料
Tab 1 The clinical data of 15 cases of patients with CVST

CaseNO．Sex/Ageyears)ChiefcomplaintPossiblecontributingcauseDiagnosticdelayAvailableimaging Trackingtime(month) 1F/28 headache，seizurepuerperium2daysDSA，CE，TOF7 2M/21 headache，vomitinghomocysteinemia9daysDSA，CE，TOF7 3F/21 paresis，vomitingunknown9daysDSA，CE，TOF2 4M/44 headacherespiratorytractinfection10daysDSA，CE1．5 5F/28 dizzinesshypertension25daysDSA，CE1 6F/30 headache，Lethargypuerperium2weeksDSA，CE，TOF0．5 7F/26 headache，vomiting，aphasispuerperium，anemia22daysDSA，CE1 8M/30 headache，hypertension syndrome，feverbechet＇sdisease2monthsDSA，CE24 9F/51 headacheunknown33daysDSA，CE1．5 10M/47 headachecerebralfalxmeningioma1yearDSA，CE1 11M/19 hypertensionVenousthrombosisoflowerextremity2monthsDSA，CE2 12M/17 headache，feverpheochromocytoma1monthDSA，CE2 13M/54 headache，seizureunknown11monthsDSA，CE13 14M/48 headache，hypopsiaunknown1yearDSA，CE，TOF6 15M/13 headacheunknown3monthsDSA，CE8

Note:CE:3D CE-MRV;TOF:2D TOF-MRV

表2 以DSA為標(biāo)準(zhǔn)，評(píng)價(jià)CE-MRV、TOF-MRV對(duì)CVST的診斷價(jià)值
Tab 2 Taking DSA as the standard to evaluate the value of CE-MRV,TOF-MRV in the diagnosis of CVST

StagingAvailableimagingSensitivitySpecificityPositivepredictivevalueNegativepredictivevalueκvalues Acutephase，subacutephaseCE100%97．87%97．09%100%97．43% TOF100%85．29%85．71%100%96．68% Chronic?phaseCE69．44%98．15%92．59%90．60%73．73% TOF100%89．47%86．67%100%87．35% RecanalizationCE81．82%71．88%50．00%92．00%44．42% TOF60．00%100%100%86．67%52．63%

Note:CE:3D CE-MRV;TOF:2D TOF-MRV

討 論

目前，關(guān)于CE-MRV評(píng)價(jià)CVST治療后再通方面，仍有爭(zhēng)議[1,8]。CVST治療后是否再通、程度如何，往往與臨床癥狀改善相關(guān)，治療后是否再通和臨床癥狀是否改善可能影響下一步治療方案的制訂，但目前尚無(wú)相關(guān)報(bào)道。Klingebiel 等[2～4]認(rèn)為，CE法對(duì)CVST診斷的敏感性和特異性較高。本研究結(jié)果顯示，急性及亞急性期CVST診斷中，3D CE-MRV診斷準(zhǔn)確性優(yōu)于2D TOF-MRV，但在診斷慢性CVST的敏感性僅為69.44%，容易漏診。CE法在診斷CVST再通的特異性低，容易誤診。CE法對(duì)不同時(shí)期CVST診斷能力上差異較大，其診斷慢性CVST的能力受到質(zhì)疑，原因可能是慢性血栓的血管增強(qiáng)效應(yīng)。在慢性期CVST，CE法理論上可觀察到靜脈竇或皮質(zhì)靜脈的周壁強(qiáng)化及腔內(nèi)不強(qiáng)化，但實(shí)際上更多表現(xiàn)為竇腔完全強(qiáng)化。Reinaeher等[9]認(rèn)為，慢性期血栓機(jī)化伴微血管形成后的自身強(qiáng)化現(xiàn)象，在與血栓部分再通的強(qiáng)化現(xiàn)象相鑒別時(shí)，應(yīng)在 MIP 圖像上結(jié)合增強(qiáng)前后的原始圖像綜合分析。

本研究結(jié)果認(rèn)為，TOF法診斷慢性CVST的敏感性高于CE法，與Sun等[1]的報(bào)道一致，但TOF法易造成信號(hào)丟失，假陽(yáng)性率高[10]。TOF法常導(dǎo)致上矢狀竇垂直段、竇匯、橫竇與乙狀竇連接部、乙狀竇、非優(yōu)勢(shì)側(cè)或發(fā)育不良橫竇出現(xiàn)信號(hào)丟失，使得與真正的血栓形成不易鑒別，與既往報(bào)道一致[11]。TOF法對(duì)急性、亞急性CVST的診斷能力不如CE法，且在CVST再通的診斷方面敏感性較差，原因可能是CVST再通由許多細(xì)小的血流組成，這些血流通常較正常靜脈竇緩慢， TOF法檢測(cè)過(guò)程中不易采集到這部分慢血流信號(hào)。本研究中TOF法診斷都同時(shí)結(jié)合原始圖像和MIP圖像進(jìn)行，使得本文TOF法診斷敏感性都較文獻(xiàn)報(bào)道的高[12,13]。

目前普遍認(rèn)為DSA是診斷CVST的“金標(biāo)準(zhǔn)”[14,15]。但是，DSA不僅有創(chuàng)、費(fèi)用高、有碘造影劑過(guò)敏的風(fēng)險(xiǎn)，難以鑒別先天性竇腔闕如和血栓形成，易出現(xiàn)“假陽(yáng)性”。關(guān)于如何鑒別先天橫竇闕如和血栓形成，需仔細(xì)參照MRV的矢狀位原始圖像。一側(cè)橫竇先天闕如者，在其橫竇位置觀察不到竇腔結(jié)構(gòu)，有別于血栓形成的影像學(xué)表現(xiàn)。有學(xué)者[16]認(rèn)為，在診斷CVST時(shí)應(yīng)警惕解剖變異，在真正的一側(cè)橫竇闕如者，至少Labbé靜脈能正?；亓?，且該側(cè)乙狀竇通常是存在的；而一側(cè)橫竇血栓形成時(shí),其相連的乙狀竇和頸靜脈球、頸內(nèi)靜脈上段等均可能存在血栓，而且Labbé靜脈也常無(wú)法正常引流。DSA 是有創(chuàng)檢查，雖然不少作者認(rèn)為MRI和MRV 結(jié)合有望取代DSA，可成為診斷本病的金標(biāo)準(zhǔn)[17]，但本研究結(jié)果顯示，MRV在診斷慢性CVST及評(píng)價(jià)慢性CVST再通的方面，仍不足以取代DSA。

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Case-controlstudyofcerebralvenoussinusthrombosisbetweenMRVandDSA

YEJing1,ZHANGXiaojun2,LIJun2,ZHONGQun3,HONGJingfang2,WANGShousen2*

1DepartmentofNeurosurgery,999BrainHospitalofGuangdong,Guangzhou510510;2DepartmentofNeurosurgery;3DepartmentofRadiology,FuzhouGeneralHospitalofPLA,Fuzhou350025,China

ObjectiveThe purpose of our study is to prospectively investigate the diagnostic value of MRV in the evaluation of different stages of CVST using DSA as the reference standard.MethodsA total of 15 patients with CVST were recruited into this study. Diagnostic accuracy of MRV in the detection of different stages and recanalized of thrombus was evaluated.ResultsIn the acute and subacute phase of CVST,the diagnostic accuracy of 3D CE-MRV was better than that of 2D TOF-MRV. The sensitivity and specificity of 3D CE-MRV and 2D TOF-MRV for chronic CVST were 69.44%,98.15% and 100%,89.47% respectively;the sensitivity and specificity of 3D CE-MRV and 2D TOF-MRV for the recanalized CVST were 81.82%,71.88% and 60.00%,100% respectively.ConclusionCompared with 2D TOF-MRV,3D CE-MRV provides a high sensitivity and specificity for the diagnosis of acute and subactue CVST,which almost has the same diagnostic value as DSA. In the diagnosis of chronic CVST and recanalized CVST segments,both 3D CE-MRV and 2D TOF-MRV are suggested to estimate pathogenetic condition with the reference of the original image with MIP images. DSA would be performed if necessary.

Cerebral venous sinus thrombosis; 3D CE-MRV; 2D TOF-MRV; DSA; Digital subtraction angiography

1671-2897(2016)15-485-05

R 651

A

福建省科技計(jì)劃重點(diǎn)項(xiàng)目資助項(xiàng)目(2010Y0043,2014Y0036)

葉景，碩士，主治醫(yī)師，E-mail:yejing2000@126.com

*通訊作者：王守森，教授、主任醫(yī)師，博士生導(dǎo)師，E-mail：wshsen@126.com

2014-09-01；

2015-01-25)