葉景 張小軍 李軍 鐘群 洪景芳 王守森

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

目的探討MRV對不同時期腦靜脈與靜脈竇血栓形成(CVST)的診斷價值。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進行對比，探討MRV對不同時期CVST的診斷價值。結果在急性及亞急性期CVST，3D CE-MRV的診斷準確性優(yōu)于2D TOF-MRV。對于慢性期CVST，兩者評價的靈敏度、特異度分別是：69.44%、98.15%和 100%、89.47%；兩者評價CVST治療后再通的靈敏度、特異度分別是：81.82%、71.88%和 60.00%、100%。結論對急性及亞急性CVST，3D CE-MRV較2D TOF-MRV的診斷準確性高。對慢性期及再通后的CVST，宜同時行3D CE-MRV和2D TOF-MRV檢查，結合原始圖像及MIP圖像綜合評價，必要時行DSA檢查。

腦靜脈及靜脈竇血栓形成; 三維對比增強磁共振血管血流成像; 二維時間飛躍血流成像; 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類型，常規(guī)影像學診斷有一定難度，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[1]，雖然一些作者認為三維對比增強磁共振血管血流成像(three dimensional contrast-enhanced MRV,3D CE-MRV)優(yōu)于二維時間飛躍血流成像(two dimensional time-of-flight MRV,2D TOF-MRV)[2～4]，但也有作者認為CE法在診斷慢性CVST時易出現(xiàn)漏診，對于再通情況易出現(xiàn)誤判[1,5,6]。本文以數(shù)字減影血管造影(digital subtraction angiogram,DSA)為標準，評估 MRV對不同時期CVST的診斷價值。

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。隨訪時間0.5～24個月，平均5.2個月(表1)。

二、影像采集與分析

MRV應用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，并簽訂知情同意書。

所有患者的診斷均綜合應用CE法和TOF法，每種序列均包括最大強度投影(maximum intensity projection,MIP)圖像和原始圖像。圖像分析過程均有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，可疑之處經過討論后確定。參考Sun等[1]的做法，顱內靜脈系統(tǒng)分成16個部分，分別是：上矢狀竇前、中、后段，左側橫竇內、外側，左側乙狀竇，左側Labbé靜脈，左側頸內靜脈，右側橫竇內、外側，右側乙狀竇，右側Labbé靜脈，右側頸內靜脈，Galen靜脈，直竇，竇匯。

三、CVST的分期

參考Rizzo L[7]對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)患者起病與確診時間間隔將疾病分期：急性期(lt;2 d)；亞急性期(3 d～1個月)；慢性期(gt;1個月)。

四、統(tǒng)計學分析

采用SPSS 13.0 統(tǒng)計軟件，對DSA與MRV檢查結果進行配對四格表卡方檢驗，以Plt;0.05提示差異有顯著性。結合CE法、TOF法、DSA診斷的結果，采用卡方檢驗，分別計算CE法、TOF法對CVST急性期、亞急性期、慢性期及其再通診斷的靈敏度、特異度、陽性預測值、陰性預測值、KAPPA值。

結 果

一、不同序列診斷效能比較

在急性及亞急性期CVST，3D CE-MRV的診斷準確性優(yōu)于2D TOF-MRV。在慢性期CVST，兩者評價的靈敏度、特異度分別是：69.44%、98.15%和 100%、89.47%。二者在評價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提示血流信號丟失而DSA提示無異常(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法提示血流信號仍丟失(圖5)。

三、DSA在CVST診斷中的假陽性

1例患者DSA顯示左側橫竇顯影缺失，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為標準，評價CE-MRV、TOF-MRV對CVST的診斷價值
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，關于CE-MRV評價CVST治療后再通方面，仍有爭議[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，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，但目前尚無相關報道。Klingebiel 等[2～4]認為，CE法對CVST診斷的敏感性和特異性較高。本研究結果顯示，急性及亞急性期CVST診斷中，3D CE-MRV診斷準確性優(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法對不同時期CVST診斷能力上差異較大，其診斷慢性CVST的能力受到質疑，原因可能是慢性血栓的血管增強效應。在慢性期CVST，CE法理論上可觀察到靜脈竇或皮質靜脈的周壁強化及腔內不強化，但實際上更多表現(xiàn)為竇腔完全強化。Reinaeher等[9]認為，慢性期血栓機化伴微血管形成后的自身強化現(xiàn)象，在與血栓部分再通的強化現(xiàn)象相鑒別時，應在 MIP 圖像上結合增強前后的原始圖像綜合分析。

本研究結果認為，TOF法診斷慢性CVST的敏感性高于CE法，與Sun等[1]的報道一致，但TOF法易造成信號丟失，假陽性率高[10]。TOF法常導致上矢狀竇垂直段、竇匯、橫竇與乙狀竇連接部、乙狀竇、非優(yōu)勢側或發(fā)育不良橫竇出現(xiàn)信號丟失，使得與真正的血栓形成不易鑒別，與既往報道一致[11]。TOF法對急性、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再通由許多細小的血流組成，這些血流通常較正常靜脈竇緩慢， TOF法檢測過程中不易采集到這部分慢血流信號。本研究中TOF法診斷都同時結合原始圖像和MIP圖像進行，使得本文TOF法診斷敏感性都較文獻報道的高[12,13]。

目前普遍認為DSA是診斷CVST的“金標準”[14,15]。但是，DSA不僅有創(chuàng)、費用高、有碘造影劑過敏的風險，難以鑒別先天性竇腔闕如和血栓形成，易出現(xiàn)“假陽性”。關于如何鑒別先天橫竇闕如和血栓形成，需仔細參照MRV的矢狀位原始圖像。一側橫竇先天闕如者，在其橫竇位置觀察不到竇腔結構，有別于血栓形成的影像學表現(xiàn)。有學者[16]認為，在診斷CVST時應警惕解剖變異，在真正的一側橫竇闕如者，至少Labbé靜脈能正?；亓鳎以搨纫覡罡]通常是存在的；而一側橫竇血栓形成時,其相連的乙狀竇和頸靜脈球、頸內靜脈上段等均可能存在血栓，而且Labbé靜脈也常無法正常引流。DSA 是有創(chuàng)檢查，雖然不少作者認為MRI和MRV 結合有望取代DSA，可成為診斷本病的金標準[17]，但本研究結果顯示，MRV在診斷慢性CVST及評價慢性CVST再通的方面，仍不足以取代DSA。

1Sun Y,Zhang DY,Ji XM,et al. Diagnostic performance of magnetic resonance venography in the detection of recanalization in patients with chronic cerebral venous sinus thrombus [J]. Chin Med J (Engl),2009,122(20):2428-2432.

2Klingebiel R,Bauknecht HC,Bohner G,et al. Comparative evaluation of 2D time-of-flight and 3D elliptic centric contrast-enhanced MR venography in patients with presumptive cerebral venous and sinus thrombosis [J]. Eur J Neurol,2007,14(2):139-143.

3Meckel S,Reisinger C,Bremerich J,et al. Cerebral venous thrombosis:diagnostic of combined,dynamic and static,contrast-enhanced 4D MR venography [J]. AJNR Am J Neuroradiol,2010,31(3):527-535.

4Fu JH,Lai PH,Hsiao CH,et al. Comparison of real-time three-dimensional gadolinium-enhanced elliptic centricordered MR venography and twodimensional time-offlight MR venography of the intracranial venous system [J]. J Chin Med Assoc,2010,73(3):131-138.

5Liang L,Korogi Y,Sugahara T,et al. Evaluation of the intracranial dural sinuses with a 3D contrast-enhanced MP-RAGE sequence:prospective comparison with 2D-TOF MR venography and digital subtraction angiography [J]. AJNR Am J Neuroradiol,2001,22(3):481-492.

6Haroun A. Utility of contrast-enhanced 3D turbo-flash MR angiography in evaluating the intracranial venous system [J]. Neuroradiogy,2005,47(5):322-327.

7Rizzo L,Crasto SG,Rudà R,et al. Cerebral venous thrombosis:role of CT,MRI and MRA in the emergency setting [J]. Radiol Med,2010,115(2):313-325.

8Leach JL,Wolujewicz M,Strub WM. Partially recanalized chronic duralsinus thrombosis:findings on MR imaging,time-of-flight MR venography,and contrast-enhanced MR venography [J]. AJNR Am J Neuroradiol,2007,28(4):782-789.

9Reinaeher P,Reinges MH,Simon VA,et al. Dynamic 3-D contrast-enhanced angiography of cerebral tumours and vascular malformations [J]. Eur Radiol,2007,17 (Suppl 6):52-62.

10Sahin N,Solak A,Genc B,et al. Cerebral venous thrombosis as a rare cause of subarachnoid hemorrhage:case report and literature review [J]. Clin Imaging,2014,38(4):373-379.

11Mermuys KP,Vanhoenacker PK,Chappel P,et al. Three dimensional venography of the brain with a volumetric interpolated sequence [J]. Radiology,2005,234(3):901-908.

12Leach JL,Fortuna RB,Jones BV,et al. Imaging of cerebral venous thrombosis:current techniques,spectrum of findings,and diagnostic pitfalls [J]. Radiographics,2006,26 (Suppl 1):19-41.

13Meckel S,Reisinger C,Bremerich J,et al. Cerebral venous thrombosis:diagnostic of combined,dynamic and static,contrast-enhanced 4D MR venography [J]. AJNR Am J Neuroradiol,2010,31(3):527-535.

14White JB,Kaufmann TJ,Kallmes DF. Venous sinus thrombosis:a misdiagnosis using MR angiography [J]. Neurocrit Care,2008,8(2):290-292.

15Linn J,Brückmann H. Cerebral venous and dural sinus thrombosis [J]. Clin Neuroradiol,2010,20(1):25-37.

16王守森,張小軍,鐘群,等. 腦靜脈與靜脈竇血栓形成的臨床診斷(附13例分析) [J]. 中華神經外科疾病研究雜志,2011,10(2):173-175.

17王建禎,凌鋒,吉訓明,等. 外傷性腦靜脈竇血栓形成 [J]. 中華神經外科雜志,2007,6(2):168-170.

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

福建省科技計劃重點項目資助項目(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，博士生導師，E-mail：wshsen@126.com

2014-09-01；

2015-01-25)