本文選題：磁共振成像 + 高分辨�。� 參考：《山東大學(xué)》2017年博士論文

【摘要】：第一部分高分辨磁共振成像對(duì)中青年大腦中動(dòng)脈狹窄性病變?cè)\斷價(jià)值的研究研究背景:缺血性腦卒中是全球人類致殘和致死的主要原因。在我國(guó),顱內(nèi)動(dòng)脈尤其大腦中動(dòng)脈狹窄是引起缺血性腦卒中的一個(gè)重要原因。隨著社會(huì)進(jìn)步和壓力增大,腦血管病的危險(xiǎn)因素普遍提前出現(xiàn),中青年人動(dòng)脈粥樣硬化的發(fā)病率較前增加。隨著科技進(jìn)步和醫(yī)學(xué)發(fā)展,煙霧病、動(dòng)脈夾層及血管炎也成為中青年缺血性卒中的主要病因。由于不同病因的發(fā)病機(jī)制和病理學(xué)改變不同,導(dǎo)致缺血性腦卒中的預(yù)防和治療是有區(qū)別的。早期明確中青年大腦中動(dòng)脈(middle cerebral artery,MCA)狹窄患者的病因,對(duì)合理選擇治療方法、預(yù)防卒中發(fā)生具有重要意義。目的:回顧性分析中青年MCA狹窄患者的臨床及影像學(xué)資料,探討高分辨磁共振(highresolutionMRI,HRMRI)診斷MCA狹窄病因的可行性。材料與方法:收集2012年10月至2016年12月在我院因缺血性腦卒中就診中青年患者,入組標(biāo)準(zhǔn):(1)中青年患者定義為:18歲≤患者年齡55歲。(2)MRA呈一側(cè)或雙側(cè)MCA中-重度狹窄。(3)狹窄MCA進(jìn)行了 HRMRI檢查。排除標(biāo)準(zhǔn):(1)同側(cè)頸內(nèi)動(dòng)脈狹窄50%或管壁不規(guī)整;(2)HRMRI檢查側(cè)MCA閉塞;(3)有心源性栓塞的證據(jù);(4)臨床資料及影像學(xué)資料不完整影響進(jìn)一步分析。結(jié)合分析臨床及影像學(xué)資料獲得綜合診斷為標(biāo)準(zhǔn),回顧性分析不同病因?qū)е麓竽X中動(dòng)脈狹窄時(shí)臨床及影像學(xué)特點(diǎn)。應(yīng)用SPSS 22.1 for Windows統(tǒng)計(jì)軟件包(IBM,USA)進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)數(shù)資料用頻數(shù)及百分比表示,兩組間比較采用x2檢驗(yàn)或Fisher精確檢驗(yàn)。連續(xù)型變量統(tǒng)計(jì)學(xué)分析采用單因素方差分析和獨(dú)立樣本t檢驗(yàn)。P值0.05認(rèn)為具有統(tǒng)計(jì)學(xué)意義。數(shù)值變量?jī)蓛蓵r(shí)比較采用LSD-t檢驗(yàn),均P0.05認(rèn)為具有統(tǒng)計(jì)學(xué)意義。對(duì)任兩個(gè)率均進(jìn)行兩兩比較時(shí)進(jìn)行檢驗(yàn)水準(zhǔn)調(diào)整。結(jié)果:(1)124例MCA狹窄患者,男性90例(72.6%),平均年齡41.5±9.02歲。高危危險(xiǎn)因素包括高血壓病(n =74,59.7%),高脂血癥組(n =53,42.7%),吸煙(n =50,40.3%),糖尿病(n= 19,15.3%)。124 例 MCA 狹窄病因包括動(dòng)脈粥樣硬化性狹窄(n=80,65.3%),動(dòng)脈夾層(n=16,12.9%),血管炎性病變(n=15,11.3%),煙霧病(n=13,10.5%)。高危因素?cái)?shù)與MCA狹窄患者的性別(P=0.022)及年齡(P=0.004)的差異有統(tǒng)計(jì)學(xué)意義。(2)與非動(dòng)脈粥樣硬化狹窄相比,動(dòng)脈粥樣硬化患者年齡大(43.45μ8.44比 38.05±9.10,P=0.001),男性常見(64/80[80.0%]比 26/44[55.3%];P =0.013);吸煙比例高(48/80[50%]比 10/44[21.3%];P = 0.003);局灶性狹窄常見(56/80[70%]比12/44[25.5%];P = 0.000),局灶性狹窄以累及中段最常見(30/80[37.5%]比 2/44[4.3%];P = 0.049))。動(dòng)脈粥樣硬化 MLN 管壁外徑大(4.14μ0.68 比 3.06±0.63,P=0.000)、最大管壁厚度大(2.2±0.42 比1.00±0.30,P=0.000)、偏心指數(shù)大(0.80±0.07 比 0.48±0.22,P=0.000),MLN最小管壁厚度小(0.41±0.12比0.51±0.14,P=0.000)。動(dòng)脈粥樣硬化組偏心強(qiáng)化比例最多(31/80[38.8%]),非動(dòng)脈粥樣硬化組環(huán)形強(qiáng)化最常見(28/44[59.6%]),兩組差異有統(tǒng)計(jì)學(xué)意義(P=0.000)。增厚管壁強(qiáng)化程度在兩組間的差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.853)。(3)與動(dòng)脈粥樣硬化性狹窄相比,動(dòng)脈夾層MLN管壁外徑小(3.52μ0.64 比 4.14±0.68,P=0.001)、MLN 最大管壁厚小(1.612±0.81 比 2.2μ0.42,P=0.017)、偏心指數(shù)小(0.58±0.32 比 0.80±0.07,P=0.012);16 例動(dòng)脈夾層中節(jié)段性狹窄多見(9/16,56.3%),14例(87.5%)可見內(nèi)膜瓣,10例(62.5%)可見雙腔征,7例(43.75%)可見壁內(nèi)血腫。血管炎性病變多較年輕(35.20 ±10.73 比 43.45 ±8.44,P = 0.004),非局灶性狹窄(11/15,73.3%),呈環(huán)形強(qiáng)化;MMD多為女性(7/13,P=0.009)、非局灶性狹窄(9/13,69.3%),對(duì)側(cè) MCA 多受累(9/13[69.2%]比 9/80[11.3%],P=0.000),增強(qiáng)后可呈無(wú)強(qiáng)化、或輕度、中度及明顯環(huán)形強(qiáng)化。(4)動(dòng)脈夾層與血管炎、煙霧病的MLN最大管壁厚度、MLN管壁外徑在間均存在統(tǒng)計(jì)學(xué)差異(均P0.05);動(dòng)脈夾層偏心指數(shù)(0.58±0.32)比煙霧病的(0.41 ±0.10)大(均P0.05)。動(dòng)脈夾層與血管炎性病變相比,動(dòng)脈夾層的吸煙比例高(P=0.008),血管炎多為環(huán)形強(qiáng)化(P=0.012)。動(dòng)脈夾層與煙霧病相比,夾層多為單側(cè)病變常累及中遠(yuǎn)段,而煙霧病以近中段多見且對(duì)側(cè)MCA常見狹窄。血管炎性病變與煙霧病相比只有對(duì)側(cè)MCA受累情況有差異,煙霧病對(duì)側(cè)MCA多受累(P=0.009)。結(jié)論:(1)動(dòng)脈粥樣硬化性狹窄是中青年MCA狹窄最常見原因,動(dòng)脈夾層、血管炎性病變及MMD是中青年MCA狹窄常見原因。(2)動(dòng)脈粥樣硬化性MCA狹窄多見于男性,局灶性狹窄多見,MLN管壁外徑、最大管壁厚度及偏心指數(shù)均高于非動(dòng)脈粥樣硬化,管壁呈偏心性增厚,偏心強(qiáng)化較常見。(3)非動(dòng)脈粥樣硬化狹窄MRA多為節(jié)段性或全程性狹窄,管壁向心性輕度增厚并環(huán)形強(qiáng)化最常見。大腦中動(dòng)脈夾層HRMRI典型征象包括內(nèi)膜瓣和雙腔征,壁內(nèi)血腫是常見征象。血管炎性病變多較年輕,管壁多為明顯環(huán)形強(qiáng)化。煙霧病女性多見,管壁增厚不明顯,增強(qiáng)后可呈無(wú)強(qiáng)化、輕度強(qiáng)化、中度強(qiáng)化及重度強(qiáng)化。(4)不同MCA狹窄病變HRMRI表現(xiàn)有所不同,中青年MCA狹窄性病變HRMRI檢查一方面有助于狹窄病因的診斷,另一方面通過(guò)描繪不同病變血管病理改變特點(diǎn),提高對(duì)不同病變的認(rèn)識(shí)。(5)血管炎性病變與煙霧病在HRMRI表現(xiàn)有重疊現(xiàn)象,在表現(xiàn)不典型時(shí),還需要結(jié)合臨床、實(shí)驗(yàn)室檢查及隨訪進(jìn)一步確定。第二部分年齡因素對(duì)大腦中動(dòng)脈粥樣硬化性狹窄血管重構(gòu)及斑塊負(fù)荷影響的高分辨磁共振研究研究背景:冠狀動(dòng)脈研究證實(shí)年齡與重建方式和斑塊形態(tài)相關(guān),而重構(gòu)方式及斑塊形態(tài)又會(huì)影響治療方案的選擇。但針對(duì)年齡因素與顱內(nèi)動(dòng)脈粥樣硬化改變有無(wú)相關(guān)性的研究極少。隨著磁共振技術(shù)發(fā)展,HRMRI可用于評(píng)價(jià)顱內(nèi)動(dòng)脈粥樣硬化斑塊形態(tài)和血管重構(gòu)方式,而且具有良好得可重復(fù)性。目的:利用HRMRI評(píng)價(jià)年齡對(duì)中-重度MCA動(dòng)脈粥樣硬化性狹窄血管重構(gòu)和斑塊負(fù)荷的影響方法:收集2012年10月至2016年10月因缺血性腦卒中在我院就診患者。入組標(biāo)準(zhǔn):(1)MRA檢查顯示一側(cè)MCA中-重度狹窄(MCA狹窄≥50%)。(2)具有兩個(gè)或兩個(gè)以上動(dòng)脈粥樣硬化危險(xiǎn)因素,動(dòng)脈粥樣硬化危險(xiǎn)因素包括:高血壓、高血脂、糖尿病、吸煙]。(3)患者年齡≥18歲。(4)根據(jù)患者年齡分為青年組(≤45歲)和中-老年組(45歲)。如果患者具有以下任何一個(gè)條件將被排除:(1)同側(cè)頸內(nèi)動(dòng)脈狹窄50%或管壁不規(guī)整;(2)MCA閉塞;(3)有心源性栓塞的證據(jù),包括房顫、風(fēng)心病及先心病等;(4)動(dòng)脈夾層、煙霧病和血管炎等非動(dòng)脈粥樣硬化性血管病變;(5)圖像質(zhì)量不能滿足血管壁和血管腔的進(jìn)一步分析;(6)由于MCA走向迂曲或分叉導(dǎo)致未能獲得最狹窄處(maximal lumen narrowing,MLN))與參考位置的軸位圖像。在HR-T1WI測(cè)量MLN和參考位置的血管面積(vessel area,VA)管腔面積(lumen area,LA)。根據(jù)公式計(jì)算狹窄程度,斑塊負(fù)荷百分比和重構(gòu)指數(shù)。重構(gòu)指數(shù)≥1.0為陽(yáng)性重構(gòu),1.0為陰性重構(gòu)。應(yīng)用SPSS 22.1 for Windows統(tǒng)計(jì)軟件包(IBM,USA)進(jìn)行統(tǒng)計(jì)學(xué)分析。符合正態(tài)分布的計(jì)量資料,以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示;。計(jì)量資料兩組間比較使用采用t檢驗(yàn)進(jìn)行兩組間的比較。計(jì)數(shù)資料兩組間比較采用x2檢驗(yàn)或Fisher精確檢驗(yàn)相關(guān)系數(shù)及95%可信區(qū)間評(píng)估測(cè)量的可重復(fù)性。結(jié)果:(1)共71例MCA動(dòng)脈粥樣硬化狹窄患者納入分析。其中青年組24人,平均年齡36.54 ±5.72歲;中老年組47人,平均年齡57.49 ±7.76歲。性別比例、DWI陽(yáng)性率和癥狀性狹窄比例在兩組的差異無(wú)統(tǒng)計(jì)學(xué)意義。最常見危險(xiǎn)因素均為高血壓(青年組79.17%,中老年組78.72%,P=0.965)。青年組吸煙明顯高于中老年組(54.17%比29.79%,P=0.045)。青年組糖尿病發(fā)病率明顯低于中老年組(30.83%比55.32%,P=0.006)。(2)青年組、中老年組陰性重構(gòu)比例分別為80.83%、44.68%(p=0.037),青年組、中老年組的斑塊負(fù)荷百分比分別為 0.314±0.183、0.405±0.126(p=0.017)。結(jié)論:顱內(nèi)大動(dòng)脈粥樣硬化的重構(gòu)方式和斑塊負(fù)荷與年齡相關(guān)。動(dòng)脈粥樣硬化性MCA狹窄的青年組患者NR比例較高,可能與吸煙、腦血管壁的獨(dú)特結(jié)構(gòu)特點(diǎn)和腦血流動(dòng)力學(xué)特點(diǎn)有關(guān)。在進(jìn)行動(dòng)脈粥樣硬化性顱內(nèi)動(dòng)脈狹窄治療時(shí),除了解決血管狹窄、穩(wěn)定易損斑塊外,延緩血管狹窄速度為側(cè)枝循環(huán)建立提供時(shí)間尤其對(duì)年輕患者可能會(huì)是一個(gè)新治療方向。
[Abstract]:The first part is the study of the value of high resolution magnetic resonance imaging in the diagnosis of middle cerebral artery stenosis in young and middle-aged people: ischemic stroke is the main cause of human disability and death in the world. In China, the intracranial artery especially middle cerebral artery stenosis is an important cause of ischemic stroke. With social progress and pressure, the cerebral artery stenosis is an important cause. The risk factors of cerebrovascular disease occur in advance, and the incidence of atherosclerosis in young and middle-aged people is increasing. With the progress of science and technology and medical development, moyamoya disease, interlayer and vasculitis are also the main causes of ischemic stroke in young and middle-aged. The prevention and treatment of sexual apoplexy is different. Early identification of the causes of middle cerebral artery (MCA) stenosis in middle-aged and young people is of great significance for the rational choice of treatment and prevention of stroke. Objective: To review the clinical and imaging data of the middle and young people with MCA stenosis and to explore the high resolution magnetic resonance (hig). HresolutionMRI, HRMRI) to diagnose the cause of MCA stenosis. Materials and methods: to collect young patients from October 2012 to December 2016 in our hospital for ischemic stroke, the standard of entry group: (1) the young and middle-aged patients were defined as: 18 years old and less than 55 years old. (2) MRA was one side or bilateral MCA moderate severe stenosis. (3) narrow MCA performed HRMRI examination. Exclusion criteria: (1) ipsilateral internal carotid artery stenosis 50% or tube wall irregular; (2) HRMRI examination side MCA occlusion; (3) evidence of cardiogenic embolism; (4) incomplete effect of clinical data and imaging data on further analysis. Combined analysis of clinical and imaging data to obtain comprehensive diagnostic criteria and retrospective analysis of different causes leading to middle brain motion Clinical and imaging characteristics of pulse stenosis. Statistical analysis was performed with SPSS 22.1 for Windows statistical software package (IBM, USA). The count data were expressed in frequency and percentage. The two groups were compared with x2 test or Fisher precision test. The continuous variable statistical analysis adopted the single factor analysis of variance and the independent sample t test.P value 0.05. There was a statistical significance. The LSD-t test was used when the numerical variable was 22. P0.05 was considered statistically significant. The results were adjusted when all two rates were compared. Results: (1) 124 cases of MCA stenosis, 90 men (72.6%) and average age 41.5 + 9.02 years. High risk risk factors including hypertension (n =74,59.7%), high fat N =53,42.7%, smoking (n =50,40.3%), and diabetes (n= 19,15.3%).124 cases of MCA stenosis include atherosclerotic stenosis (n=80,65.3%), arterial dissection (n=16,12.9%), vasculitis (n=15,11.3%), and moyamoya disease (n=13,10.5%). (2) compared with non atherosclerotic stenosis, atherosclerotic patients were older (43.45 Mu 8.44 than 38.05 + 9.10, P=0.001), males were common (64/80[80.0%] 26/44[55.3%]; P =0.013); smoking was higher (48/80[50%] than 10/44[21.3%]; P = 0.003); focal stenosis was common (56/80[70%] ratio 12/44[25.5%]; P = 0), and focal lesion The stenosis was the most common in the middle segment (30/80[37.5%] ratio 2/44[4.3%]; P = 0.049)). The outer diameter of the atherosclerotic MLN tube wall was large (4.14 Mu 0.68 to 3.06 + 0.63, P=0.000), the maximum wall thickness (2.2 + 0.42, 1 + 0.30, P=0.000), the eccentricity index (0.80 + 0.07 ratio 0.48 + 0.22, P=0.000), and the smallest thickness of MLN (P=0.000) P=0.000). The proportion of eccentricity enhancement in the atherosclerotic group was most (31/80[38.8%]), and the most common (28/44[59.6%]) was in the non atherosclerotic group (28/44[59.6%]). The difference between the two groups was statistically significant (P=0.000). The thickness of the thickening tube wall was not statistically significant between the two groups (P= 0.853). (3) compared with atherosclerotic stenosis, the artery dissection MLN The outer diameter of the tube was small (3.52 Mu 0.64 than 4.14 + 0.68, P=0.001), the maximum wall thickness of MLN was smaller (1.612 + 0.81 than 2.2 u 0.42, P=0.017), the eccentricity index was small (0.58 + 0.32 than 0.80 + 0.07, P=0.012). Inflammatory lesions were more young (35.20 + 10.73 than 43.45 + 8.44, P = 0.004), non focal stenosis (11/15,73.3%) and circular intensification; MMD was mostly female (7/13, P=0.009), non focal stenosis (9/13,69.3%), and contralateral MCA multi involvement (9/13[69.2%] than 9/80[11.3%], P=0.000), enhanced, or mild, moderate, and obvious ring (4) there was a statistical difference between the arterial dissection and vasculitis, the MLN maximum wall thickness of the moyamoya disease and the outer diameter of the MLN tube (all P0.05); the eccentricity index (0.58 + 0.32) of the arterial dissection was (0.41 + 0.10) larger than that of the moyamoy (all P0.05). The proportion of the arterial dissection and the vasculitis was higher (P=0.008), and the vasculitis was mostly Annular enhancement (P=0.012). Compared with moyamoya disease, interlayer is mostly unilateral lesion often involving the middle and far segment, and moyamoya disease is common in the middle of the middle segment and the contralateral MCA is common. Compared with the smoke disease, only the contralateral MCA involvement is different, and the moyamoya's contralateral MCA is more involved (P=0.009). Conclusion: (1) atherosclerotic stenosis It is the most common cause of MCA stenosis in middle and young people. Arterial dissection, vasculitis and MMD are common causes of MCA stenosis in young and middle-aged people. (2) atherosclerotic MCA stenosis is mostly seen in men, most of which are localized stenosis, the outer diameter of MLN tube wall, the maximum wall thickness and eccentricity index are higher than that of non atherosclerosis, the wall of the tube is eccentric thickening and eccentric strengthening. Common. (3) the non atherosclerotic stenosis MRA is mostly segmental or full narrow, the wall of the tube wall is mild thickening and the ring intensification is the most common. The typical signs of the middle cerebral artery dissection HRMRI include the intima valve and the double cavity sign, the intramural hematoma is the common sign. The vasculitis disease is more than the year light, the tube wall is more obvious ring intensification. Moyamoya disease female The thickening of the wall of the tube was not obvious. After the enhancement, there was no strengthening, mild strengthening, moderate strengthening and severe strengthening. (4) the HRMRI manifestations of different MCA stenosis lesions were different. The HRMRI examination of MCA stenosis in middle and young people was helpful to the diagnosis of the cause of stenosis. On the other hand, the characteristics of different pathological changes of vascular pathology were improved. (5) there is an overlap between the HRMRI manifestations of angiitis and moyamoya disease. In the case of atypical manifestations, it is necessary to combine clinical, laboratory and follow-up to further determine the background of high resolution magnetic resonance (MRI) research on the effects of age factors on vascular remodeling and plaque load in the middle cerebral atherosclerotic stenosis. Coronary artery studies have confirmed that age is related to the pattern of reconstruction and plaque morphology, and the pattern of reconstruction and plaque shape may affect the choice of treatment. However, there are few studies on the correlation between age and changes in intracranial atherosclerosis. With the development of MRI, HRMRI can be used to evaluate the shape of atherosclerotic plaque in the intracranial. State and vascular remodeling, and have good reproducibility. Objective: To evaluate the influence of age on vascular remodeling and plaque load of atherosclerotic stenosis of moderate to severe MCA: to collect the patients in our hospital from October 2012 to October 2016 with ischemic stroke. (1) MRA examination showed the medium weight of one side of MCA. Degree stenosis (MCA stricture is more than 50%). (2) there are two or more risk factors for atherosclerosis, and the risk factors for atherosclerosis include hypertension, hyperlipidemia, diabetes, smoking. (3) patients are older than 18 years old. (4) the patients are divided into young group (less than 45 years old) and middle aged group (45 years old) according to the age of the patients. If the patient has any of the following conditions Will be excluded: (1) ipsilateral internal carotid artery stenosis 50% or tube wall irregular; (2) MCA occlusion; (3) evidence of cardiogenic embolism, including atrial fibrillation, rheumatic heart disease and congenital heart disease, (4) arterial dissection, moyamoya and vasculitis, and other non atherosclerotic vascular lesions; (5) image quality can not meet the further analysis of vascular wall and vascular cavity; (6) because of MC A toward the tortuous or bifurcate causes the axial image of the narrowest place (maximal lumen narrowing, MLN) and the reference position. In HR-T1WI measurement of the vascular area (vessel area, VA) of the MLN and reference positions (lumen area,). According to the formula, the degree of stenosis, the percentage of patch load and the reconfiguration index are calculated. The reconfiguration index is more than 1. SPSS 22.1 for Windows statistical software package (IBM, USA) was used for statistical analysis. According to the normal distribution of measurement data, the mean number + standard deviation (x + s) was expressed. The comparison between the two groups of the two groups was compared with the comparison between the two groups using t test. The two groups were compared with x2 test or Fisher accuracy. Test correlation coefficient and the repeatability of the 95% confidence interval assessment. Results: (1) a total of 71 patients with MCA atherosclerotic stenosis were included in the analysis. Among them, the young group was 24, with an average age of 36.54 5.72 years, 47 in the middle and old age group, with an average age of 57.49 + 7.76 years. The sex ratio, the DWI positive rate and the proportion of symptomatic stenosis were not statistically significant in the two groups. The most common risk factors were hypertension (79.17% in the youth group, 78.72% in the middle and old age group, P=0.965). The young group was significantly higher than the middle aged and old age group (54.17% to 29.79%, P=0.045). The incidence of diabetes in the young group was significantly lower than that in the middle and old age group (30.83% to 55.32%, P=0.006). (2) the young group was 80.83%, 44.68% (44.68%) in the middle and old age group. P=0.037), the percentage of plaque load in young group and middle aged group was 0.314 + 0.183,0.405 + 0.126 (p=0.017). Conclusion: the remodeling mode and plaque load of intracranial large atherosclerosis are related to age. The proportion of NR in young group with atherosclerotic MCA stenosis is higher, which may be associated with the unique structural characteristics of smoking and cerebral vascular wall and brain. In the treatment of atherosclerotic intracranial artery stenosis, it may be a new treatment direction for young patients in addition to solving vascular stenosis, stabilizing vulnerable plaque, and delaying the speed of vascular stenosis to provide time for collateral circulation.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R743.3;R445.2

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本文編號(hào)：1902019