本文選題：MRA　切入點：TCD　出處：《鄭州大學》2014年碩士論文

【摘要】：背景與目的 腦梗死（Cerebral Infarction，CI）泛指缺血性卒中，是指由于腦部血液供應障礙，缺血、缺氧引起的局限性腦組織壞死，其臨床發(fā)病率約為所有腦卒中的70％。經(jīng)數(shù)字減影血管造影（Digital Subtraction Angiography，DSA）證實，80％CI首發(fā)患者伴有顱內(nèi)或頸部血管狹窄，其中亞洲人、黑人與西班牙人等人種以顱內(nèi)血管狹窄最常見。CI的主要發(fā)病原因是由于動脈粥樣硬化，導致頸部或顱內(nèi)血管嚴重狹窄、血栓形成或斑塊脫落導致相應供血區(qū)腦組織血流量急劇下降，出現(xiàn)缺血缺氧而壞死軟化。一般在20-30歲就會出現(xiàn)動脈粥樣硬化所致動脈狹窄和閉塞，50-70歲是發(fā)病高峰期，發(fā)病初期表現(xiàn)為纖維斑塊，病變晚期動脈壁會出現(xiàn)不規(guī)則增厚，管壁有粥樣斑塊形成，導致管腔狹窄，以致遠端血供明顯下降，最終由于反復出現(xiàn)血小板聚集、纖維蛋白和血細胞沉積致血栓形成或斑塊脫落引起管腔閉塞。CI在全世界范圍內(nèi)的發(fā)病率、致殘率與死亡率都較高，而且有明顯的逐年升高的趨勢，因此，早期診斷與預防CI的發(fā)生、發(fā)展，提高其治療水平是世界醫(yī)療工作共同親關(guān)注的課題。 目前臨床中對側(cè)支循環(huán)的檢測方法主要有DSA、磁共振血管造影（MagneticResonance Angiography，MRA）、經(jīng)顱多普勒超聲（Transcranial Doppler ultrasound，TCD）等，其中DSA屬于有創(chuàng)性檢查，對腦實質(zhì)改變觀察不完整，而且檢查費用相對較高；因此臨床中多選用MRA作為常規(guī)無創(chuàng)血管成像檢測技術(shù)，可以較為完整地顯示W(wǎng)illis環(huán)的血管解剖結(jié)構(gòu)，同時還可以反映出血流方式及血流速度等功能性信息，時間飛越法（tof法）是MRA常用的檢測技術(shù)，具有檢查費用低、無需使用造影劑、成像時間短等優(yōu)勢。 目前，國內(nèi)外文獻中普遍認為對大腦中動脈供血區(qū)梗死患者進行檢測可以對患者的預后情況提供參考依據(jù)，但是絕大多數(shù)關(guān)于急性大腦中動脈區(qū)腦梗死側(cè)支循環(huán)變化與其預后關(guān)系的研究資料來源于DSA檢測，臨床局限性較大，缺少評價側(cè)支循環(huán)的詳細方法。因此，本課題將著重探討3D-TOF MRA在大腦前動脈、后動脈偏側(cè)優(yōu)勢預測大腦中動脈供血區(qū)梗死患者診斷中的應用，總結(jié)其在大腦中動脈供血區(qū)梗死患者預后預測中的作用。 方法 選取2010年7月至2013年4月期間我院確診的76例大腦中動脈區(qū)腦梗死患者作為本組研究的觀察對象，分別行TCD與MRA檢查，并對檢查結(jié)果進行對比總結(jié)，比較TCD與MRA在大腦前動脈、后動脈偏側(cè)優(yōu)勢預測中的作用。患者在行TCD檢查后48小時內(nèi)行3D-TOF MRA檢查，再將經(jīng)MRA檢查確診為MCA供血區(qū)梗死的患者按照梗死部位分為主干支組、皮層支組與深穿支組，并對所有患者進行NIHSS評分、MRS評分、ADL評分，并將各組預后的相關(guān)危險因素進行分析，最終將患者的檢測數(shù)據(jù)進行整理，經(jīng)統(tǒng)計學計算得出結(jié)論。 MRA檢查設(shè)備選用Acmeva3.0TNovadual雙梯度磁共振儀（Philips，荷蘭），所有患者在接受檢查前均經(jīng)顱部MRI掃描，初步掌握患者的腦組織病變情況。MRA檢測方法選擇三維時間飛躍法（Three Dimensional Time Of Flight，3D．TOF）序列，容積采集以Willis環(huán)為中心，橫軸位采集容積包括頸內(nèi)動脈的末端、大腦前、中動脈及其主要分支以及基底動脈和大腦后動脈；對患者的顱底動脈環(huán)及雙側(cè)椎動脈（VertebralArtery，VA）顱內(nèi)段、基底動脈（BasilarArtery，BA）進行檢測。 TCD檢測儀器選用DWL TCD儀（德國），通過2MHz探頭對患者顱內(nèi)血管情況進行探測，并用2MHz探頭對頸內(nèi)動脈終末端（TICA）、大腦前、中、后動脈（ACA、MCA、PCA）、基底動脈（BA）、椎動脈（VA）進行探測。 TCD、MRA檢查均由相同的神經(jīng)科醫(yī)師、影像科醫(yī)師完成�；颊呔诎l(fā)病24h內(nèi)進行先進行TCD檢查，通過2MHz脈沖式探頭，經(jīng)顳窗分別對兩側(cè)ACA、PCA的收縮期峰值及平均血流速度進行檢測。（1）經(jīng)顳窗檢測雙側(cè)MCA、ACA、PCA、TICA；（2）經(jīng)枕窗檢測雙側(cè)VA，BA，經(jīng)眼窗檢測眼動脈（OphthalmicArtery，OA）、頸內(nèi)動脈虹吸部（Siphon CarotidArtery，SCA）。收集參數(shù)以收縮峰血流速度（Systolic Phase Blood Velocity，VS）、平均血流速度（Mean Blood Velocity，VM）、音頻、頻譜形態(tài)及搏動指數(shù)（Pulsate Index number，PI）等作為主要分析數(shù)據(jù)。 本組研究中將分別通過TCD與MRA兩種檢查檢測方法進行檢測，并比較所有患者的MCA梗死情況，屬于定性資料中的分類變量資料。選用配對四格表方法判斷患者顱內(nèi)大血管的結(jié)果有無顯著性差異。研究中采用SPSS16.0統(tǒng)計軟件針對所得資料進行系統(tǒng)的統(tǒng)計學分析，其中的計數(shù)資料采用卡方檢驗方法進行檢驗。當P0.05時認為兩組之間所存在顯著差異，具有統(tǒng)計學意義。 結(jié)果 （1）本組腦梗死患者TCD檢查結(jié)果：單純ACA代償37例，單純PCA代償28例， ACA與PCA代償并存11例；（2）3D-TOF MRA檢查結(jié)果：有同側(cè)PCA優(yōu)勢（DIPCA）現(xiàn)象64例，ACA與PCA代償并存11例，，檢測結(jié)果與TCD相符。（3）ACA與PCA代償并發(fā)的患者在入院時及第3個月時NIHSS評分均明顯低于單純ACA代償患者與單純PCA代償患者，具有統(tǒng)計學意義（P＜0.05）；ACA代償患者又明顯低于PCA代償患者，具有統(tǒng)計學意義（P＜0.01）；有DIPCA現(xiàn)象的患者在入院時及3個月時NIHSS評分均顯著低于無DIPCA現(xiàn)象的患者具有統(tǒng)計學意義（P＜0.05）。 結(jié)論 在大腦中動脈區(qū)腦梗死患者中，側(cè)支循環(huán)狀況與患者的病情與預后情況呈正相關(guān)，而且單純前循環(huán)代償患者預后情況明顯優(yōu)于單純后循環(huán)代償患者，有后循環(huán)代償?shù)牟∏榕c預后情況明顯優(yōu)于無后循環(huán)代償患者。
[Abstract]:Background and purpose
Cerebral infarction (Cerebral Infarction CI) refers to ischemic stroke, is due to brain blood supply disorder, ischemia, hypoxia induced focal cerebral necrosis, the clinical incidence about all stroke 70%. by digital subtraction angiography (Digital Subtraction Angiography, DSA 80%CI) confirmed that the first patient with intracranial or neck vascular stenosis among them, Asian, black and Hispanic race with intracranial vascular stenosis.CI the most common cause is mainly due to atherosclerosis, leading to severe stenosis of neck or intracranial vascular thrombosis, or plaque shedding leads to cerebral blood flow and the corresponding blood supply area decreased rapidly, and hypoxia ischemia necrosis and softening. There are generally 20-30 years will appear atherosclerotic artery the 50-70 year old is stenosis and occlusion, the peak incidence, early onset showed fibrous plaque lesions, late arterial wall There will be irregular thickening and wall plaque formation, resulting in stenosis, as far end blood supply decrease, eventually due to repeated platelet aggregation, fibrinogen and blood cell deposition caused by thrombosis caused by occlusion of the lumen.CI incidence in the world within the scope of the rate of formation or plaque, disability rate and mortality are high. But there are obvious increasing trend, therefore, early diagnosis and prevention of CI development, improve the level of medical treatment is the world work Pro concern.
The current clinical detecting method of collateral circulation is mainly DSA, magnetic resonance angiography (MagneticResonance Angiography MRA), transcranial Doppler (Transcranial Doppler ultrasound, TCD DSA), which belongs to the invasive examination of brain parenchyma changes is not complete, and the inspection cost is relatively high; therefore in clinical use MRA as routine noninvasive vascular imaging detection technology can accurately display the vascular anatomy of Willis ring structure, but also can reflect the blood flow and blood flow rate of functional information, the more time fly method (TOF method) MRA detection technology is used, with lower cost, without the use of contrast agents, such as short imaging time advantage.
At present, the domestic and foreign literature generally think of patients with middle cerebral artery territory infarction detection can provide reference basis for the prognosis of patients, but the vast majority of acute middle cerebral artery territory infarction collateral circulation change prognostic research data for DSA detection, clinical limitations, lack of evaluation methods with collateral circulation therefore, this paper will focus on 3D-TOF MRA in patients with diagnosis of anterior cerebral artery, middle cerebral artery territory infarction after artery lateralization prediction, summarizes its in the middle cerebral artery infarction prognosis prediction effect.
Method
76 cases of cerebral artery in patients with cerebral infarction area were diagnosed in our hospital in the period from July 2010 to April 2013 as the research object of observation, underwent TCD and MRA examination, and the examination results were compared between TCD and MRA in summary, anterior cerebral artery, the artery after lateralization in prediction. In patients after TCD examination within 48 hours of 3D-TOF MRA, and then the MRA were diagnosed as MCA infarction patients with infarction were divided into the main trunk group, cortical branch group and deep perforator group, and NIHSS score of all patients, MRS score, ADL score, and the related risk factors of prognosis were analyzed, finally the detection data of patients were collected, through statistical analysis, draw the conclusion.
The Acmeva3.0TNovadual double gradient magnetic resonance instrument MRA inspection equipment (Philips, Holland), all patients received before the examination were confirmed by cranial MRI scan, brain tissue pathological changes of the preliminary master.MRA detection method of patient selection of three-dimensional time of flight (Three Dimensional Time Of Flight, 3D.TOF) series, volume acquisition in the Willis loop as the center at the end, the axial acquisition volume includes the internal carotid artery in the anterior cerebral artery and its main branches, and the basilar artery and posterior cerebral artery; in patients with basilar artery rings and bilateral vertebral arteries (VertebralArtery, VA) of intracranial segment of basilar artery (BasilarArtery, BA) were detected.
The TCD test instrument was selected by DWL TCD instrument (Germany). The intracranial blood vessels were detected by 2MHz probe, and the distal end of internal carotid artery (TICA), anterior, middle and posterior arteries (ACA, MCA, PCA), basilar artery (BA) and vertebral artery (VA) were detected by 2MHz probe.
TCD, MRA were examined by a neurologist of the same radiologists. Patients within 24h after TCD examination by 2MHz pulsed probe through temporal window respectively on both sides of ACA, PCA and the average peak systolic blood flow velocity were detected. (1) through temporal window detection of bilateral MCA ACA, PCA, TICA; (2) the occipital window detection of bilateral VA, BA, the eye window detection of ophthalmic artery (OphthalmicArtery, OA), internal carotid artery (Siphon, CarotidArtery, SCA). The collection parameters to the peak systolic velocity (Systolic Phase Blood Velocity, VS), the average blood flow velocity (Mean Blood Velocity, VM), audio, spectrum morphology and pulsatility index (Pulsate Index, number, PI) as the main data analysis.
The group will study were detected by TCD and MRA two kinds of checking method, and compare the MCA infarction in all patients, which belongs to the qualitative data in categorical data. Using four pairs of table method to judge patients with intracranial vascular results have no significant difference. In the research of analysis system for statistical data using SPSS16.0 statistical software, the count data by chi square test method. When P0.05 think that there are significant differences between the two groups, with statistical significance.
Result
(1) in this group of patients with cerebral infarction TCD examination results: ACA compensation in 37 cases, 28 cases of simple PCA ACA and PCA compensation, compensatory coexisted in 11 cases; (2) 3D-TOF MRA examination results: ipsilateral PCA advantage (DIPCA) phenomenon in 64 cases, ACA and PCA both compensatory in 11 cases, the detection results consistent with TCD. (3) ACA and PCA compensatory concurrent patients on admission and 3 months NIHSS score was significantly lower than that of simple ACA patients and PCA patients with simple compensatory compensation, with statistical significance (P < 0.05); ACA patients was significantly lower than that of PCA and compensatory compensation were statistically significant (P < 0.01); statistical significance with DIPCA of patients at admission and 3 months NIHSS score were significantly lower than those without DIPCA phenomenon in patients (P < 0.05).
conclusion
In the brain of patients with arterial cerebral infarction, and patients with collateral circulation was positively related to the severity and prognosis, and the prognosis of the patients with anterior circulation compensatory was better than patients with posterior circulation compensation, compensatory circulation condition and prognosis of patients was significantly better than the free circulation.

【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R743.3

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