SWI结合ASL对急性期缺血性脑卒中血流动力学评估及诊断价值.pdf

第41卷第1期-502024年1月D01:10.3969/j.issn.1005-202X.2024.01.007SWI结合ASL对急性期缺血性脑卒中血流动力学评估及诊断价值中国医学物理学杂志Chinese Journal of Medical PhysicsVol.41 No.1January 2024医学影像物理丁昭军,刘文罡,黄俊昊，曹瑞,黎枝鑫1.重庆医科大学附属永川医院放射科，重庆40 2 16 0；2.陆军军医大学大坪医院放射科，重庆40 0 0 42【摘要】目的：分析急性期缺血性脑卒中（AIS）患者经磁敏感加权成像（SWI)结合动脉自旋标记成像（ASL）的诊断效用。方法：选取2 0 2 0 年7 月至2 0 2 1年7 月于重庆医科大学附属永川医院就诊的AIS患者50 例，用3.0 TMRI进行扫描，扫描序列包括FLAIR、D W I 3D-T O F-M R A 3D-A SL和SWI，分别评估患者脑梗的灌注状态、梗死核心区周围引流静脉、侧支代偿情况、是否有出血转化以及患者的预后水平。结果：梗死核心区周围引流静脉的分级与患者NIHSS评分呈显著相关（r=0.869,P0.05）；梗死核心区周围引流静脉的分级与患者的预后呈显著相关（r=0.825,P0.05）；梗死核心区灌注状态与是否出现出血转化呈显著相关（r=0.873P0.05）；侧支循环代偿状态与患者预后呈显著相关（r=0.883,P0.05）。结论：SWI联合ASL可以对AIS患者梗死核心区周围的血流动力学情况给予准确提示，并且该技术还可以准确评估AIS患者的预后，对临床诊断以及治疗方案的选择均有重要价值。【关键词】急性期缺血性脑卒中；磁敏感加权成像；血流动力学；预后【中图分类号】R743.3Hemodynamic evaluation and diagnostic value of SWI combined with ASL in acute ischemic strokeDING Zhaojun,LIU Wengang,HUANG Junhao,CAO Rui,LI Zhixin?1.Department of Radiology,Yongchuan Hospital,Chongqing Medical University,Chongqing 402160,China;2.Department ofRadiology,Daping Hospital,Army Medical University,Chongqing 400042,ChinaAbstract:Objective To analyze the diagnostic utility of combining susceptibility-weighted imaging(SWI)with arterial spinlabeling(ASL)in patients with acute ischemic stroke(AIS).Methods Fifty AIS patients who admitted to YongchuanHospital,Chongqing Medical University from July 2020 to July 2021 were selected.Scans were performed using a 3.0T MRIscanner,including sequences such as FLAIR,DWI,3D-TOF-MRA,3D-ASL,and SWI.The perfusion status of the infarctioncore,the grading of draining veins around the infarction core,compensation by collateral circulation,the occurrence ofhemorrhagic transformation,and prognosis were assessed.Results The grading of draining veins around the infarction corewas significantly correlated with NIHSS scores(r-0.869,P0.05)and prognosis(r=0.825,P0.05).In addition,significantcorrelations were found between the perfusion status of the infarction core and the occurrence of hemorrhagic transformation(r-0.873,P0.05),compensation by collateral circulation and prognosis(r-0.883,P 3cm）小面积梗死(3cm)。经SWI-mIP图像分析梗死核心区周围引流静脉,分为3级：0 级为与健侧相比,患侧引流静脉没有增多或增粗；1级为与健侧相比,患侧引流静脉稍增多；2 级为与健侧相比，患侧引流静脉明显增多或增粗。检查后的图像，经由经验丰富的医师（副主任职称及以上,2 名）判定。患者入院时，通过美国国立卫生研究院卒中量表(NIHStrokeScale,NIHSS)6判定，依据评分分为3个等级，分级如下：重型（15分）、中型（7 14分）、轻型(1 6 分)。两周后再通过NIHSS评分表6 评估患者预后，可分为好转（功能缺损评分减少9 0%10 0%）、稳定（功能缺损评分减少46%8 9%）、进展（或死亡）（功能缺损评分减少45%以下）3个等级。通过3D-ASL扫描显示脑梗死区域的灌注状态，将50 例AIS患者根据检查结果分为高、低灌注组及无变化组。若梗死核心区周围出现条状高灌注则为侧支代偿，侧支循环高代偿是指侧支循环良好，即图像显示供血区远端侧支血管填充范围超过50%，否则为侧支循环低代偿。最后分析梗死核心灌注状态与出血转化(Hemorrhagic Transformation,HT)之间是否存在相关性。1.3统计学方法采用SPSS24.0软件对数据进行分析，相关分析用Spearman检验，系数用r表示,r0.4为低度线性相关,0.4r0.7为中度线性相关,0.7 r1为高度线性相关。P0.05为差异有统计学意义。2结果2.1入院时患者梗死核心区周围引流静脉分级与患者NIHSS评分相关性50例AIS患者中,梗死核心区周围引流静脉分级与患者NIHSS评分呈显著相关(r=0.869,P0.05）,见表1。2.2梗死核心区周围引流静脉分级与患者预后相关性治疗两周后，患者行MRI检查，经SWI-mIP图像分析，梗死核心区周围引流静脉分级与患者的预后呈显著相关（r=0.825,P0.05），见表2。2.3梗死核心区灌注状态与HT相关性50例AIS患者中，梗死核心区灌注状态与是否出现HT呈显著相关（r=0.873,P0.05）,见表3。-52-表1入院时患者梗死核心区周围引流静脉分级与患者NIHSS评分Table 1 Relationship between the grading of draining veins aroundthe infarction core and the NIHSS score on admission梗死核心区周围引流静脉分级轻型中型重型合计值P值查,对机体的损伤大，不能作为常规检查方法。CT对0级131级82级4合计25表2 梗死核心区周围引流静脉分级与患者预后相关性Table 2 Correlation between prognosis and the grading ofdraining veins around the infarction core梗死核心区周围引流静脉分级好转稳定进展0级181级62级2合计26表3梗死核心区灌注状态与HT相关性Table 3 Correlation between perfusion status of theinfarctioncoreandHT灌注状态有HT无HT合计值P值低灌注4无变化5高灌注8合计172.4侧支循环代偿状态与患者预后相关性在50 例AIS患者中，侧支循环代偿状态与患者预后呈显著相关（r=0.883,P0.05）,见表4。表4侧支循环代偿状态与患者预后相关性Table 4 Correlation between compensation by collateralcirculation and prognosis侧支循环NIHSS评分代偿状态好转稳定进展侧支循环高代偿16侧支循环低代偿3合计19中国医学物理学杂志3讨论的关系AIS的诊断主要依赖于CT、数字减影血管造影(DSA)和MRI,其中DSA被公认为是诊断AIS的黄金标准,其能够清晰显示血管狭窄与鼻塞的部位，便NIHSS评分于了解疾病情况，但是该操作复杂且属于创伤性检808153214NIHSS评分合计值P值治疗中,其成像技术能够提供无创性、非侵人性的成52543513112327914193350合计值P值648131417第41卷21于出血性卒中的检测具有较高的敏感性，然而却在170.8690.001125025150.8250.00210500.8730.00126240.8830.00150发病后2 4 h内,无法有效显示脑梗死的病变。相比之下,MRI是诊断AIS最为实用的影像学手段，不仅可以评估脑梗死的范围，还能确定动脉闭塞的部位，并寻找是否存在潜在的溶栓禁忌证的证据 7-8 。ASL是一种基于动脉血中水分子为内源性示踪剂的全身性、无创性成像技术，可获取组织器官的血流灌注信息。在临床实践中，该技术可广泛应用于缺血性脑卒中、颅内肿瘤、脑外伤、脑供血不足等疾病诊断和像方式，且不需要放射性物质，相比于传统的MRI成像具有更高的分辨率和更准确的血流信息，因此在临床实践中具有广泛的应用前景 9-10 。DWI能够反映水分子在组织中的扩散情况,因此被认为是对急性脑梗死最敏感的成像序列。而SWI则是一种特殊的成像技术,其依赖于不同组织的磁敏感性差异和血氧水平，它是一种三维采集、全流量补偿、高分辨率、薄层扫描梯度回波序列。凭借独特的数据采集方法和图像处理技术,SWI显示出对血液代谢物（包括脱氧血红蛋白、含铁血黄素、高铁血红蛋白和静脉血)的高度敏感性 1-12 。在本研究中,SWI-mIP图像分析梗死核心区周围引流静脉的分级与患者的预后呈显著相关，这表明SWI对急性脑梗死的血栓形成具有较高的诊断价值。在梗死动脉发生血栓或闭塞的情况下，动脉中的血流量会减少,脱氧血红蛋白含量会增加。此外,脱氧血红蛋白和氧合血红蛋白的比率改变,从而导致磁场均匀性中断 1-14。急性或超急性脑梗死以红细胞为主的血栓形成特征;SWI可特异性识别含脱氧血红蛋白的顺磁性红色血栓,在SWI-mIP图像中,表现为沿血管分布的索状低信号影L15。SW I 在强磁场下由于其具有更高的灵敏度，可以提供更精确的血栓形态评估,以及在确定闭塞部位方面，SWI比T,梯度回波或3DTOF成像具有更好的敏感性和特异性，它在识别远端血栓方面也更有效 16-18 本研究发现3D-ASL伪彩图梗死核心区灌注状态与是否出现HT呈显著相关，同时侧支循环代偿状态与患者预后呈显著相关；ASL显示脑血流灌注减少，与DWI显示的高信号相比，面积更大。ASL上具第1期有高DWI信号的不匹配低融合区域被定义为缺血半暗带（IschemicPenumbra,IP），其是AIS患者恢复的重要概念，在ASL成像中，高DWI信号表示该区域存在大量的扩散受限的细胞，这通常是由于血流中断引起的，而低融合信号则表示该区域的血流量相对较少,但仍然存在一定的血流量。因此,ASL上具有高DWI信号的不匹配低融合区域被认为是IP，对于AIS患者而言，了解IP的位置与范围十分必要,且有效识别IP能够提高对 AIS 的诊断效率 19-2 0 。HT属于AIS常见的并发症,在疾病发生后的微出血通常不会引发患者出现较明显的临床症状及体征，但随着出血量的增加，患者开始出现一些症状,且随着大脑神经、组织被压迫，症状轻重情况不同，若不及时治疗则进一步恶化,甚至增加其他不良反应 2 1;3D-ASL伪彩图以及SWI均可以较为准确地评估HT的情况，可以给临床治疗提供重要的指导意义2 2-2 3。AIS后梗死核心区出现侧支循环高代偿的患者预后比低代偿的患者好，这提示该梗死区域具有较好的血液供应,改善该区域的血液循环,保证血氧供应,可提高患者的预后水平 2 4-2 5。综上所述，SWI联合ASL可以对AIS患者梗死核心区周围的血流动力学情况给予准确提示，并且该技术还可以准确评估AIS患者的预后,对临床诊断以及治疗方案的选择均有重要价值。【参考文献】1 Tiedt S,Brandmaier S,Kollmeier H,et al.Circulating metabolitesdifferentiate acute ischemic stroke from stroke mimics 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