高压电损伤肢体256层螺旋CT灌注成像的应用研究
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摘要
目的探索256层螺旋CT灌注成像技术对于高压电后四肢损伤的应用价值。
材料与方法选择高压电损伤患者53例,其中接受四肢灌注检查者48例,常规四肢CTA检查者5例。按照手术后截肢与否,将48例接受四肢灌注检查者分为截肢组14例及未截肢组34例。将MSCTP检查结果(肌肉微循环灌注信息及相应部位血管CTA图像)与手术、病理对照,以及进行自身、双侧对照。将灌注所得图像传入Phillips公司专属EBW工作站,用Functional CT-general模式行灌注图像处理。(1)从灌注扫描结果中,选择最佳时相提取CTA图像,采用MPR、 CPR、VR、MIP及高级血管分析(advantage vessel analysis, AVA)软件进行分析,获得相应部位的血管图像；(2)截肢组及未截肢组中选定兴趣区即得到包含血流灌注(BF),峰值增强(PEI),达峰时间(TTP),血容量(BV)的伪彩图、具体量化数值及时间密度曲线(TDC)。53例均进行血管等形态学分析,截肢组、未截肢组48例进行t检验,其中对截肢组另外进行判别分析,以比较各组肢体各部位灌注参数的差异。
结果1、高压电损伤后肌肉、皮肤及骨骼CT表现患者肌肉损伤在CT平扫、增强图像上一般表现为低密度影；皮肤损伤表现为皮肤局部缺损、皱褶；骨骼破坏后表现为骨皮质不连续、错位。2、高压电损伤后CTA表现CTA对血管显示较为清晰,损伤血管表现为节段性狭窄或血管远端的鼠尾状闭塞、中断。3、高压电损伤后CT灌注表现高灌注、低灌注及无血流灌注表现。各组参数分析如下：(1)截肢组：a、患侧与健侧各部位灌注参数的比较。患侧截肢平面下份与健侧相对应下份层面比较,BF值：前者<后者,差异有统计学意义；PEI值：前者<后者,差异有统计学意义；TTP、BV值：前者均<后者,差异无统计学意义。患侧截肢平面上份与健侧相对应上份层面比较,BF、PEI、BV值：前者均<后者,TTP值：前者>后者,差异均无统计学意义。患侧截肢平面与患侧相对应平面比较,BF、PEI、TTP、BV值：前者均<后者,差异均无统计学意义。截肢组的患侧各部位灌注参数的比较。b、患侧截肢平面上份与截肢平面比较,BF值：前者>后者,差异有统计学意义。PEI、TTP、BV值：前者均>后者,差异均无统计学意义。c、患侧截肢平面下份与截肢平面参数比较,BF值：前者<后者,差异有统计学意义；PEI值：前者<后者,差异有统计学意义；BV值：前者<后者,差异有统计学意义。TTP值：前者>后者,差异无统计学意义。通过判别分析得出,以上三组的kappa值均>0.6,一致性比较好。BF、PEI、 TTP、BV值对测量肢体是否需截肢的判定具有实际意义。(2)未截肢组：患者上肢BF、PEI、BV值患侧<健侧,TTP值：患侧>健侧,差异均无统计学意义。未截肢患者下肢BF、PEI、BV:患侧>健侧,未截肢患者下肢TTP值：患侧<健侧,差异均无统计学意义。
结论应用256层螺旋CT灌注诊断四肢高电压损伤,能够获得清晰的血管CTA图像及不同损伤部位灌注参数值,并且这些灌注参数对肢体是否需要截肢的判定具有实际意义；MSCTP对区别高压电损伤和电弧损伤有一定的帮助作用。MSCTP是临床诊断、治疗高压电损伤的方便、安全、定性、定量的理想检查方法。
Objectives:To explore the application value of256-slice spiral CT perfusion technology for high voltage electrical injury of limb.
Materials and Methods:To select high voltage electrical injury patients in53cases, which underwent limb perfusion scan in48cases, underwent CTA scan in5cases. According to accept amputation or not, which divided into amputation group in14cases and no amputation group in34cases. The results of MSCTP(muscle microcirculation perfusion information and the corresponding CTA image of vascular) compared with operation, pathology, as well as their self, bilateral control. The perfusion images derived into Phillips company excusive EBW workstation, and used the Functional CT-general pattern to process images.(1) From the results of perfusion scan chose the best phase extraction from CTA image, used MPR, CPR, VR, MIP and advantage vessel analysis (AVA) software for analysis, obtained the corresponding parts of the vascular images;(2) Selecting region of interest from amputation group and no amputation group to obtain blood perfusion (BF). peak enhancement(PEI), time to peak (TTP), blood volume (BV), pseudo color, specific quantity and time density curve (TDC).53patients underwent vascular morphology analysis, and amputation group, no amputation group of48cases were analyzed by t test, the amputation group in addition to discriminant analysis, in order to compare all parts of limbs perfusion parameter differences.
Results:1. high voltage electrical injury of muscle, skin and skeletal CT performance Patients with muscle injury in CT plain scan, image enhancing general performance show low density; skin lesions manifested as skin defect, wrinkles:skeletal damage showed cortical bone discontinuity, dislocation.2. high voltage electrical injury of vascular CT performance CTA showed more clear for blood vessels, injury of the vascular showed segmental narrow or occlusion, interrupt like rat caudate of distal vessel.3. high voltage electrical injury of CT perfusion have there different performance:high perfusion, low perfusion, no perfusion. Each set of parameters was analyzed as follows:(1) amputation group:a. The comparison of perfusion parameters between the affected side and the healthy side. The comparison between the level below the limb-amputation plane of the affected side and the corresponding level of the healthy side, BF value:the formerthe latter, the difference were no statistically significant; The comparison between the amputation level of the affected side and the corresponding level of the healthy side, BF, PEI,TTP, BV value:the formerthe latter, the difference was statistically significant; PEI, TTP, BV value: the former>the latter, the difference were no statistically significant; c. The comparison between the limb-amputation level and the level below of the affected side, BF value:the formerthe latter, the difference were no statistically significant; Through discriminant analysis, the above three groups of kappa value>0.6, the consistency is good. The value of BF, PEI, TTP, BV have the practical significance on judging whether the limb need amputation.(2). No amputation group:BF, PEI, BV value of the upper limb:affected side healthy side, the difference were no statistically significant;BF, PEI, BV value of the lower limb: affected side> healthy side, TTP value:affected side Conclusion:To use256slice spiral CT perfusion can diagnosis high voltage injury of limb, and obtain clear images of CTA vascular and perfusion parameter values of different sites of injury limbs, and has the practical significance for the judgment on whether the limb need the amputation or not; MSCTP has the certain help on making a distinguish between high voltage electrical injury and arc damage. MSCTP is a convenience, safety, qualitative, quantitative check method of clinical diagnosis, treatment for the high voltage electrical injury.
材料与方法选择高压电损伤患者53例,其中接受四肢灌注检查者48例,常规四肢CTA检查者5例。按照手术后截肢与否,将48例接受四肢灌注检查者分为截肢组14例及未截肢组34例。将MSCTP检查结果(肌肉微循环灌注信息及相应部位血管CTA图像)与手术、病理对照,以及进行自身、双侧对照。将灌注所得图像传入Phillips公司专属EBW工作站,用Functional CT-general模式行灌注图像处理。(1)从灌注扫描结果中,选择最佳时相提取CTA图像,采用MPR、 CPR、VR、MIP及高级血管分析(advantage vessel analysis, AVA)软件进行分析,获得相应部位的血管图像；(2)截肢组及未截肢组中选定兴趣区即得到包含血流灌注(BF),峰值增强(PEI),达峰时间(TTP),血容量(BV)的伪彩图、具体量化数值及时间密度曲线(TDC)。53例均进行血管等形态学分析,截肢组、未截肢组48例进行t检验,其中对截肢组另外进行判别分析,以比较各组肢体各部位灌注参数的差异。
结果1、高压电损伤后肌肉、皮肤及骨骼CT表现患者肌肉损伤在CT平扫、增强图像上一般表现为低密度影；皮肤损伤表现为皮肤局部缺损、皱褶；骨骼破坏后表现为骨皮质不连续、错位。2、高压电损伤后CTA表现CTA对血管显示较为清晰,损伤血管表现为节段性狭窄或血管远端的鼠尾状闭塞、中断。3、高压电损伤后CT灌注表现高灌注、低灌注及无血流灌注表现。各组参数分析如下：(1)截肢组：a、患侧与健侧各部位灌注参数的比较。患侧截肢平面下份与健侧相对应下份层面比较,BF值：前者<后者,差异有统计学意义；PEI值：前者<后者,差异有统计学意义；TTP、BV值：前者均<后者,差异无统计学意义。患侧截肢平面上份与健侧相对应上份层面比较,BF、PEI、BV值：前者均<后者,TTP值：前者>后者,差异均无统计学意义。患侧截肢平面与患侧相对应平面比较,BF、PEI、TTP、BV值：前者均<后者,差异均无统计学意义。截肢组的患侧各部位灌注参数的比较。b、患侧截肢平面上份与截肢平面比较,BF值：前者>后者,差异有统计学意义。PEI、TTP、BV值：前者均>后者,差异均无统计学意义。c、患侧截肢平面下份与截肢平面参数比较,BF值：前者<后者,差异有统计学意义；PEI值：前者<后者,差异有统计学意义；BV值：前者<后者,差异有统计学意义。TTP值：前者>后者,差异无统计学意义。通过判别分析得出,以上三组的kappa值均>0.6,一致性比较好。BF、PEI、 TTP、BV值对测量肢体是否需截肢的判定具有实际意义。(2)未截肢组：患者上肢BF、PEI、BV值患侧<健侧,TTP值：患侧>健侧,差异均无统计学意义。未截肢患者下肢BF、PEI、BV:患侧>健侧,未截肢患者下肢TTP值：患侧<健侧,差异均无统计学意义。
结论应用256层螺旋CT灌注诊断四肢高电压损伤,能够获得清晰的血管CTA图像及不同损伤部位灌注参数值,并且这些灌注参数对肢体是否需要截肢的判定具有实际意义；MSCTP对区别高压电损伤和电弧损伤有一定的帮助作用。MSCTP是临床诊断、治疗高压电损伤的方便、安全、定性、定量的理想检查方法。
Objectives:To explore the application value of256-slice spiral CT perfusion technology for high voltage electrical injury of limb.
Materials and Methods:To select high voltage electrical injury patients in53cases, which underwent limb perfusion scan in48cases, underwent CTA scan in5cases. According to accept amputation or not, which divided into amputation group in14cases and no amputation group in34cases. The results of MSCTP(muscle microcirculation perfusion information and the corresponding CTA image of vascular) compared with operation, pathology, as well as their self, bilateral control. The perfusion images derived into Phillips company excusive EBW workstation, and used the Functional CT-general pattern to process images.(1) From the results of perfusion scan chose the best phase extraction from CTA image, used MPR, CPR, VR, MIP and advantage vessel analysis (AVA) software for analysis, obtained the corresponding parts of the vascular images;(2) Selecting region of interest from amputation group and no amputation group to obtain blood perfusion (BF). peak enhancement(PEI), time to peak (TTP), blood volume (BV), pseudo color, specific quantity and time density curve (TDC).53patients underwent vascular morphology analysis, and amputation group, no amputation group of48cases were analyzed by t test, the amputation group in addition to discriminant analysis, in order to compare all parts of limbs perfusion parameter differences.
Results:1. high voltage electrical injury of muscle, skin and skeletal CT performance Patients with muscle injury in CT plain scan, image enhancing general performance show low density; skin lesions manifested as skin defect, wrinkles:skeletal damage showed cortical bone discontinuity, dislocation.2. high voltage electrical injury of vascular CT performance CTA showed more clear for blood vessels, injury of the vascular showed segmental narrow or occlusion, interrupt like rat caudate of distal vessel.3. high voltage electrical injury of CT perfusion have there different performance:high perfusion, low perfusion, no perfusion. Each set of parameters was analyzed as follows:(1) amputation group:a. The comparison of perfusion parameters between the affected side and the healthy side. The comparison between the level below the limb-amputation plane of the affected side and the corresponding level of the healthy side, BF value:the former
引文
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[1]杨家斐,马林肢体高压电损伤MRI影像学的临床及实验研究.军医进修学院博十学位论文,2009年.
[2]黎鳌等.黎鳌烧伤学.上海科学技术出版社,2001,186-191.
[3]Bingham H-Electrical bums. Clin Plast Surg 1986; 13:75-85.
[4]Robson MC, Murphy RC, Hegger JP. A new explanation for the progressive tissue loss in electrical injuris. Plast reconstr Surg,1984; 73:431-437.
[5]Lee RC, Canady DJ, Hammer SM. Transient and stable ionic permeabilization of isloated skeletal muscle cells after electrical shock. J Bum Care Rehabil,1993; 14:528-540.
[8]Baxter CR. Present concepts in the management of major electrical injury. Surgical Clinics ofNorthAmerica,1970; 50(6):1401-1418.
[9]Fujii T. Electrical injury. Nippon Geka Gakkai Zasshi.1998,99(1):52-56.
[10]Muehlberger T, Krettek C, Voqt PM. Electric accident. New aspects regarding pahtophysiogy and treatment. Unfallchirurg,2001,104(12):1122-1128.
[6]Chen YX, Xu Y, H XJ, et al. Applied value of 2-D ultrasound with high resolution on deep electric injury. Chinese J Ultrasound Med,2002,18(1):69-71.
[7]Quiby WC. The use of microscopy as a guide to primary excision of High—tension electrical burns. J Trauma,1978,18(6):423-431.
[11]陈琳,李智贤,刘达恩.高压电击伤血管损伤的影像学研究进展[J].中国医学影像技术,2006,22(12)：1922-1924.
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[1]杨家斐,马林肢体高压电损伤MRI影像学的临床及实验研究.军医进修学院博十学位论文,2009年.
[2]黎鳌等.黎鳌烧伤学.上海科学技术出版社,2001,186-191.
[3]Bingham H-Electrical bums. Clin Plast Surg 1986; 13:75-85.
[4]Robson MC, Murphy RC, Hegger JP. A new explanation for the progressive tissue loss in electrical injuris. Plast reconstr Surg,1984; 73:431-437.
[5]Lee RC, Canady DJ, Hammer SM. Transient and stable ionic permeabilization of isloated skeletal muscle cells after electrical shock. J Bum Care Rehabil,1993; 14:528-540.
[8]Baxter CR. Present concepts in the management of major electrical injury. Surgical Clinics ofNorthAmerica,1970; 50(6):1401-1418.
[9]Fujii T. Electrical injury. Nippon Geka Gakkai Zasshi.1998,99(1):52-56.
[10]Muehlberger T, Krettek C, Voqt PM. Electric accident. New aspects regarding pahtophysiogy and treatment. Unfallchirurg,2001,104(12):1122-1128.
[6]Chen YX, Xu Y, H XJ, et al. Applied value of 2-D ultrasound with high resolution on deep electric injury. Chinese J Ultrasound Med,2002,18(1):69-71.
[7]Quiby WC. The use of microscopy as a guide to primary excision of High—tension electrical burns. J Trauma,1978,18(6):423-431.
[11]陈琳,李智贤,刘达恩.高压电击伤血管损伤的影像学研究进展[J].中国医学影像技术,2006,22(12)：1922-1924.
[12]闫东,范承经,袁曙光.肢体高压电损伤后的动脉造影改变[J].中国整形烧伤外科杂志,1999,15(5)：371-372.
[13]Li LG, Cai JK, Guo ZR, et al. Application of digital subtraction angiography and type Bultrasonography in the evaluation of vascular injury in patients with high voltage electrical injury. Chinese J Bums,2004,20(3):164-167.
[14]Qiao HQ, Deng ML, Hou YP, et al. Diagnostic value of blood pool imaging for limbs viability after elect rical injury [J]. Chin J Nucl Med,1994,11 (2):76-79.
[15]舒锦尔,仇旭光,等.前臂肌群急性高压电击伤的MRI研究[J].中华放射学杂志,2001,1(35)：63-67.
[16]Nettelblad H, Thuoma KA, Sjoberg F, et al. Magnetic resonance imagaging:a new diagnostic aid in the care of high-voltage electrical burns. Burs,1996,22(2):117-119.
[17]Fleckenstein JL, Chason DP, Bonte FJ, et al. High—voltage electric injury:assessment of muscle viability with MR imaging and Tc-99m pyrophosphate scintigraphy. Radiology,1995; 195:205-210.
[18]Ohashi M, Koizumi J, Hosoda Y et al. Correlation between magnetic resonance imaging and histopathology of an amputated forearm after an electrical injury.Burns,1998;24:362-368.
[19]Miles KA, Functional CT imaging in oncology. Eur Radiol, 2003,13(supply):3-10.
[20]曾祥柱,李选,高文清MSCTP成像结合CTA评价兔慢性骨骼肌缺血侧枝动脉生成和灌注恢复[J].中国医学影像技术,2009,25(8)1339-1342.
[21]99mTc-MDP核素显像在高压电损伤组织活性判断中的应用[J].中华烧伤杂志,2003,11(19)：56.