CTA对不同部位急性颈内动脉闭塞特征的诊断效果评价
|
摘要
目的 :评估CT血管造影(CT angiography,CTA)的影像学特征对不同部位急性颈内动脉(Internal carotid artery,ICA)闭塞的诊断效果。方法 :回顾性分析2012年1月—2016年12月在我院就诊的不同部位急性ICA闭塞患者的临床特征和影像学特点,并进行比较。利用受试者工作特征(Receiver operating characteristic,ROC)曲线来评价CTA对不同部位ICA闭塞的诊断效果,共探讨了五种诊断方式,分别为:(1)根据CTA确定的颈动脉闭塞残端形状诊断;(2)根据CTA确定的颈动脉钙化情况诊断;(3)根据CTA确定的Willis环闭塞形状诊断;(4)根据CTA确定的软脑膜侧支循环(Leptomeningeal collaterals,LMC)状态诊断;(5)综合前四种诊断方式的联合诊断。利用多因素Logistic回归分析急性ICA闭塞患者短期预后不良的危险因素。结果:本研究共纳入161例患者,分为三组:C_1颈段闭塞患者56例,C_4海绵窦段闭塞患者72例,C_6眼段或C_7交通段闭塞患者33例。各组相比,越远端的闭塞部位,发病时神经功能缺损的程度越严重,梗死体积越大,比较差异具有统计学意义(P<0.05);闭塞部位与脑梗死发生的病因、脑梗死后并发症的发生以及患者的预后有关(P<0.05)。不同ICA闭塞部位患者的CTA成像特征也不同(P<0.05)。ROC曲线显示,结合了颈动脉闭塞残端的形状、颈动脉钙化情况、Willis环的闭塞形状和LMC状态特征的联合诊断取得了最优的诊断效果,对C_1颈段闭塞、C_4海绵窦段闭塞、C_6眼段或C_7交通段闭塞诊断的ROC曲线下面积分别为0.966,0.878,0.902。年龄较大和ICA远端闭塞是预后不良的危险因素。结论 :ICA闭塞的临床表现和CTA影像学表现均与闭塞部位有关,利用CTA提示的颈动脉闭塞残端的形状、颈动脉钙化情况、Willis环的闭塞形状和LMC状态特征的联合诊断方法可有效地对不同部位的急性ICA闭塞进行诊断,值得在临床上广泛推广。
Objective: To evaluate the diagnostic effect of characteristic CT angiography(CTA) patterns on the internal carotid artery(ICA) occlusion in different parts. Methods: The clinical characteristics and imaging characteristics of patients with acute ICA occlusion were analyzed retrospectively from January 2012 to December 2016 in our hospital. Diagnostic effect of characteristic CTA patterns on the ICA occlusion in different parts was evaluated using receiver operating characteristic(ROC) curve. The five diagnostic methods were:(1)The carotid occlusion stump shape based on CTA;(2)Carotid artery calcification based on CTA;(3)The occlusion shape of Willis ring based on CTA;(4)The leptomeningeal collaterals(LMC) based on CTA;(5)The combined diagnosis of the above four diagnostic methods. Multivariate Logistic regression analysis of risk factors was also performed in patients with acute ICA occlusion with short-term poor prognosis. Results: A total of 161 patients were enrolled in this study, which were divided into three groups: 56 patients with C_1 cervical segment occlusion, 72 patients with C_4 cavernous segment occlusion, and 33 patients with C_6 ophthalmic segment or C_7 communicating segment occlusion. In the three groups of patients, the more distant the occlusion site was, the greater the degree of neurological deficit and the infarct volume were(P<0.05). The etiology of cerebral infarction, post-infarction complications and the prognosis of patients were related with the occlusion site(P<0.05). The imaging characteristics of CTA in patients with various parts of ICA occlusion were also different(P<0.05). ROC curve showed that the combined diagnosis of carotid artery occlusion stump shape, carotid artery calcification, the occlusion shape of Willis ring and LMC status was the best. The area under curve(AUC) for C_1 cervical segment occlusion, C_4 cavernous segment occlusion, C_6 ophthalmic segment or C_7 communicating segment occlusion were 0.966,0.878, and 0.902, respectively. Older age and ICA distal occlusion were risk factors for poor prognosis. Conclusion: The clinical manifestations and CTA imaging findings of ICA occlusion are associated with occlusion location. The CTA-based combined diagnostic method can effectively differentiate the part of acute ICA occlusion, which is worthy to be widely promoted in the clinic.
Objective: To evaluate the diagnostic effect of characteristic CT angiography(CTA) patterns on the internal carotid artery(ICA) occlusion in different parts. Methods: The clinical characteristics and imaging characteristics of patients with acute ICA occlusion were analyzed retrospectively from January 2012 to December 2016 in our hospital. Diagnostic effect of characteristic CTA patterns on the ICA occlusion in different parts was evaluated using receiver operating characteristic(ROC) curve. The five diagnostic methods were:(1)The carotid occlusion stump shape based on CTA;(2)Carotid artery calcification based on CTA;(3)The occlusion shape of Willis ring based on CTA;(4)The leptomeningeal collaterals(LMC) based on CTA;(5)The combined diagnosis of the above four diagnostic methods. Multivariate Logistic regression analysis of risk factors was also performed in patients with acute ICA occlusion with short-term poor prognosis. Results: A total of 161 patients were enrolled in this study, which were divided into three groups: 56 patients with C_1 cervical segment occlusion, 72 patients with C_4 cavernous segment occlusion, and 33 patients with C_6 ophthalmic segment or C_7 communicating segment occlusion. In the three groups of patients, the more distant the occlusion site was, the greater the degree of neurological deficit and the infarct volume were(P<0.05). The etiology of cerebral infarction, post-infarction complications and the prognosis of patients were related with the occlusion site(P<0.05). The imaging characteristics of CTA in patients with various parts of ICA occlusion were also different(P<0.05). ROC curve showed that the combined diagnosis of carotid artery occlusion stump shape, carotid artery calcification, the occlusion shape of Willis ring and LMC status was the best. The area under curve(AUC) for C_1 cervical segment occlusion, C_4 cavernous segment occlusion, C_6 ophthalmic segment or C_7 communicating segment occlusion were 0.966,0.878, and 0.902, respectively. Older age and ICA distal occlusion were risk factors for poor prognosis. Conclusion: The clinical manifestations and CTA imaging findings of ICA occlusion are associated with occlusion location. The CTA-based combined diagnostic method can effectively differentiate the part of acute ICA occlusion, which is worthy to be widely promoted in the clinic.
引文
[1]Hasegawa H,Inoue T,Tamura A,et al.Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture[J].J Neurosurg,2015,122(4):1-9.
[2]Li W,Yin Q,Xu G,et al.Treatment Strategies for Acute Ischemic Stroke Caused by Carotid Artery Occlusion[J].Interv Neurol,2016,5(3-4):148.
[3]Paciaroni M,Inzitari D,Aanelli G,et al.Intravenous thrombolysis or endovascular therapy for acute ischemic stroke associated with cervical internal carotid artery occlusion:the ICARO-3 study[J].J Neurol,2015,262(2):459-468.
[4]Appireddy RM,Demchuk AM,Goyal M,et al.Endovascular therapy for ischemic stroke[J].N Engl J Med,2015,372(24):2363.
[5]Berkhemer OA,Fransen PS,Beumer D,et al.A randomized trial of intraarterial treatment for acute ischemic stroke[J].N Engl J Med,2015,372(1):11.
[6]Campbell BC,Mitchell PJ,Kleinig TJ,et al.Endovascular therapy for ischemic stroke with perfusion-imaging selection[J].N Engl J Med,2015,372(11):1009.
[7]Jovin TG,Chamorro A,Cobo E,et al.Thrombectomy within 8hours after symptom onset in ischemic stroke[J].N Engl J Med,2015,372(24):2296-2306.
[8]Saver JL,Goyal M,Bonafe A,et al.Stent-retriever thrombectomy after intravenous t-PA vs.t-PA alone in stroke[J].N Engl J Med,2015,372(24):2285-2295.
[9]翟争峯,蒲立新,曲建明,等.CTA三维重建的研究与展望[J].中国数字医学,2014,9(5):64-67.
[10]Marquering HA,Nederkoorn PJ,Beenen LF,et al.Carotid pseudo-occlusion on CTA in patients with acute ischemic stroke:a concerning observation[J].Clin Neurol Neurosurg,2013,115(9):1591-1594.
[11]Powers WJ,Derdeyn CP,Biller J,et al.2015 American Heart Association/American Stroke Association Focused Update of the2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment:A Guideline for Healthcare Professionals From the American[J].Stroke,2015,46(10):3020-3035.
[12]Zaidat OO,Yoo AJ,Khatri P,et al.Recommendations on angiographic revascularization grading standards for acute ischemic stroke:a consensus statement[J].Stroke,2013,44(9):2650.
[13]Pessin MS,Duncan GW,Davis KR,et al.Angiographic appearance of carotid occlusion in acute stroke[J].Stroke,1980,11(5):485.
[14]De Weert TT,Cakir H,Rozie S,et al.Intracranial internal carotid artery calcifications:association with vascular risk factors and ischemic cerebrovascular disease[J].Am J Neuroradiol,2009,30(1):177-184.
[15]Liebeskind DS,Flint AC,Budzik RF,et al.Carotid I’s,L’s and T’s:collaterals shape the outcome of intracranial carotid occlusion in acute ischemic stroke[J].J Neurointerv Surg,2014,7(6):402.
[16]Bouthilier A,Van Loveren HR,Keller JT.Segments of the internal carotid artery:a new classification[J].Neurosurgery,1996,38(3):432-433.
[17]覃浩强,曾光.症状性颈内动脉闭塞临床特征及诊治进展[J].广西医科大学学报,2014,31(1):156-158.
[18]Lee JS,Hong JM,Kim EJ,et al.Comparison of the Incidence of parenchymal hematoma and poor outcome in patients with carotid terminus occlusion treated with intra-arterial urokinase alone or with combined IV rt PA and intra-arterial urokinase[J].Am J Neuroradiol,2012,33(1):175-179.
[19]Sun-uk L,Man HJ,Yong KS,et al.Differentiating Carotid Terminus Occlusions into Two Distinct Populations Based on Willisian Collateral Status[J].J Stroke,2016,18(2):179-186.
[20]Hademenos GJ,Massound TF.Biophysical mechanisms of stroke[J].Stroke,1997,28(10):2067-2077.
[2]Li W,Yin Q,Xu G,et al.Treatment Strategies for Acute Ischemic Stroke Caused by Carotid Artery Occlusion[J].Interv Neurol,2016,5(3-4):148.
[3]Paciaroni M,Inzitari D,Aanelli G,et al.Intravenous thrombolysis or endovascular therapy for acute ischemic stroke associated with cervical internal carotid artery occlusion:the ICARO-3 study[J].J Neurol,2015,262(2):459-468.
[4]Appireddy RM,Demchuk AM,Goyal M,et al.Endovascular therapy for ischemic stroke[J].N Engl J Med,2015,372(24):2363.
[5]Berkhemer OA,Fransen PS,Beumer D,et al.A randomized trial of intraarterial treatment for acute ischemic stroke[J].N Engl J Med,2015,372(1):11.
[6]Campbell BC,Mitchell PJ,Kleinig TJ,et al.Endovascular therapy for ischemic stroke with perfusion-imaging selection[J].N Engl J Med,2015,372(11):1009.
[7]Jovin TG,Chamorro A,Cobo E,et al.Thrombectomy within 8hours after symptom onset in ischemic stroke[J].N Engl J Med,2015,372(24):2296-2306.
[8]Saver JL,Goyal M,Bonafe A,et al.Stent-retriever thrombectomy after intravenous t-PA vs.t-PA alone in stroke[J].N Engl J Med,2015,372(24):2285-2295.
[9]翟争峯,蒲立新,曲建明,等.CTA三维重建的研究与展望[J].中国数字医学,2014,9(5):64-67.
[10]Marquering HA,Nederkoorn PJ,Beenen LF,et al.Carotid pseudo-occlusion on CTA in patients with acute ischemic stroke:a concerning observation[J].Clin Neurol Neurosurg,2013,115(9):1591-1594.
[11]Powers WJ,Derdeyn CP,Biller J,et al.2015 American Heart Association/American Stroke Association Focused Update of the2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment:A Guideline for Healthcare Professionals From the American[J].Stroke,2015,46(10):3020-3035.
[12]Zaidat OO,Yoo AJ,Khatri P,et al.Recommendations on angiographic revascularization grading standards for acute ischemic stroke:a consensus statement[J].Stroke,2013,44(9):2650.
[13]Pessin MS,Duncan GW,Davis KR,et al.Angiographic appearance of carotid occlusion in acute stroke[J].Stroke,1980,11(5):485.
[14]De Weert TT,Cakir H,Rozie S,et al.Intracranial internal carotid artery calcifications:association with vascular risk factors and ischemic cerebrovascular disease[J].Am J Neuroradiol,2009,30(1):177-184.
[15]Liebeskind DS,Flint AC,Budzik RF,et al.Carotid I’s,L’s and T’s:collaterals shape the outcome of intracranial carotid occlusion in acute ischemic stroke[J].J Neurointerv Surg,2014,7(6):402.
[16]Bouthilier A,Van Loveren HR,Keller JT.Segments of the internal carotid artery:a new classification[J].Neurosurgery,1996,38(3):432-433.
[17]覃浩强,曾光.症状性颈内动脉闭塞临床特征及诊治进展[J].广西医科大学学报,2014,31(1):156-158.
[18]Lee JS,Hong JM,Kim EJ,et al.Comparison of the Incidence of parenchymal hematoma and poor outcome in patients with carotid terminus occlusion treated with intra-arterial urokinase alone or with combined IV rt PA and intra-arterial urokinase[J].Am J Neuroradiol,2012,33(1):175-179.
[19]Sun-uk L,Man HJ,Yong KS,et al.Differentiating Carotid Terminus Occlusions into Two Distinct Populations Based on Willisian Collateral Status[J].J Stroke,2016,18(2):179-186.
[20]Hademenos GJ,Massound TF.Biophysical mechanisms of stroke[J].Stroke,1997,28(10):2067-2077.