APE的影像学检查.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,肺栓塞的影像学表现,十堰市太和医院心内科,詹中群,超声心动图,排除威胁生命的其他疾病，如室间隔破裂、夹层主动脉、心包填塞等,对中央型肺动脉栓塞诊断有一定价值，经食道超声可探察到主肺动脉和左、右肺动脉，敏感性和特异性可达,80,90%,主肺动脉或肺动脉分叉处可见栓子属少见情况。,栓子来源于心脏的肺栓塞，可直接观察到右心系统的血栓,超声心动图,右心室壁局部运动幅度降低,右心室和（或）右心房扩大,室间隔左移和运动异常,近端肺动脉扩张,三尖瓣反流速度增快,下腔静脉扩张,经食管超声心动图,对大块,PE,病例有,92,的敏感性和接近,100,特异性。,有三分之一的肺栓塞患者表现为正常,异常表现为,右心室扩大，肺动脉高压、下腔静脉扩张、室间隔向左心室移位,超声心动图：心腔大小形态、心肌结构、瓣膜运动。,超声心动图观察心脏解剖结构,短轴切面：右室扩大，左室呈,“,D,”,形,三尖瓣反流速度峰值,4.8m/s,，计算跨瓣压差为,92mmHg,提示重度肺动脉高压,超声心动图测三尖瓣反流速度,McConnells sign,下肢静脉超声,胸部,X,线平片,异常率约占,84%,。,肺血管纹理变细、稀疏或消失,肺野局部浸润影,以胸膜为基底的实变影,(Hamptons,隆起,),患侧膈肌抬高,胸腔积液,右下肺动脉干增宽或伴截断征,肺动脉段膨隆,右心室增大,上腔静脉增宽,CT,平扫,肺缺血性改变（肺窗），即肺纹理稀疏和肺透亮度升高,“马赛克”征（无特异性）,但如与肺动脉高压改变（中心肺动脉扩张及右心室增大）同时存在，则属于,PE,表现。,CTA,表现,直接征象：,充盈缺损；,管腔突然狭窄；,充盈缺损,管腔突然狭窄,CTA,直接征象,腔内网格状改变和栓子钙化,实时,3D,成像显示肺动脉虫咬状完全闭塞和虫咬状不规则充盈缺损,腔内网格状改变,本例为,2D,成像,CTA,间接征象,1.,肺少血征；,2.“,马赛克”征；,3.,胸腔积液；,4.,右室增大伴,/,不伴室间隔偏移；,5.,主肺动脉和,/,或右侧叶间肺动脉扩张；6.,支气管动脉扩张；,7.,心包积液；,8.,肺梗死。,马赛克征,肺少血征,下肢血管,CT,明确有无下肢静脉血栓及血栓范围。,CT,胸痛三联征一站式检查,embolism,胸痛三联征之一,心梗,胸痛三联征之二,肺栓塞,胸痛三联症之三,主动脉夹层,(A)In a 77-year-old woman with acute pulmonary embolism,a 4-chamber(4-CH)view reconstruction of a chest computed tomography scan shows,septal,flattening(arrows).(B)There is also grade 4 reflux of contrast medium into the inferior vena cava(long arrow)and proximal hepatic veins(short arrows).Measurements of(C)maximal right ventricular diameter(RVD)and(D)left ventricular diameter(LVD)on axial sections show RVD axial/LVD axial ratio of 0.98.Measurements of(E)maximal RVD andF)LVD on 4-CH views show RVD4-CH/LVD4-CH ratio of 1.12.,Semiautomated,right ventricle,volumetry,(RVV)(purple)and left ventricle,volumetry,(LVV)(orange)displayed(G)on axial section and(H)on,sagittal,reformation shows RVV/LVV ratio of 1.62.The patient required mechanical ventilation on the first day of her hospital stay and died on day 28.,(A)In a 69-year-old man with acute pulmonary embolism,a 4-chamber(4-CH)view reconstruction of a chest computed tomography,scan shows,septal,bowing(arrows),convex toward the left ventricle.(B)There is no contrast reflux into the inferior vena cava.Measurements of(C)maximal right ventricular diameter(RVD)and(D)left ventricular diameter(LVD)on axial sections show,RVDaxial/LVDaxial,ratio of 0.97.Measurements of maximal(E)RVD and(F)LVD on 4-CH views show RVD4-CH/LVD4-CH ratio of 1.4.,Semiautomated,right ventricle,volumetry,(RVV)(purple)and left ventricle,volumetry,(LVV)(orange)displayed(G)on transverse section and(H)on coronal reformation show an RVV/LVV ratio of 1.54.The patient died on hospital day 4.,肺部放射性核素扫描,放射性核素扫描（通气,-,灌注显像）：单纯的肺灌注扫描对诊断肺栓塞相当敏感，如果正常可排除明显的肺栓塞。内径大于,3.0mm,的肺动脉栓塞时，肺扫描结果全部异常,;,内径,2.1-3.0mm,者,92%,异常；,内径,2.0mm,者是否异常不确定,肺栓塞患者肺灌注显像影（异常）,肺栓塞患者肺通气显像影（正常）,肺栓塞灌注显像与通气显像图,肺通气显像与肺灌注显像不匹配（,mismatch,）,灌注显像正常可排除肺栓塞,肺动脉造影,敏感性,98%,，特异性,95-98%,主要征象,血管内不规则充盈缺损,血管树修剪征,造影剂排空延迟,间接征象,造影剂流动缓慢，局部低灌注，静脉回流延迟,肺栓塞介入治疗,溶栓球囊扩张术后,右侧肺动脉栓塞治疗前,肺栓塞介入治疗,右下肺动脉栓塞治疗前,溶栓治疗后,谢谢,