冠状动脉粥样硬化64层螺旋CT和MR血管成像研究
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摘要
第一部分冠状动脉粥样硬化钙化斑块对管腔影响的CTA与CAG对比研究
目的：通过冠状动脉CTA和CAG对钙化斑块局部管腔狭窄程度的点对点对照研究，评价钙化斑块的大小、形态及钙化积分与冠状动脉狭窄的关系，提高冠状动脉CTA诊断钙化斑块局部管腔狭窄程度的准确性。
材料与方法：经冠状动脉CTA检查发现冠状动脉钙化斑块的患者43例(男37例，女6例，年龄36～84岁，平均66.9±11.7岁)。所有患者均于CTA检查后两周内行CAG检查。采用Siemens 64层螺旋CT行冠状动脉CTA检查，成像参数：120kV，900mAs，空间分辨率0.4×0.4×0.4mm，330ms/周，层厚0.75mm，间隔0.5mm，造影剂注射流率5ml/s(优维显370mgI/ml)。进行钙化积分、最大密度投影(MIP)，多平面重建(MPR)及提取冠脉树等图像后处理。计算每位患者冠状动脉钙化的数目和总钙化积分。共117个感兴趣钙化斑块(位于直径＞1.5mm的冠状动脉节段，并可测量其大小)行CTA和CAG点对点评价，评价钙化斑块局部管腔狭窄与患者冠心病危险因素的相关性；观察感兴趣钙化斑块的形态、分布特点；于CTA上测定钙化斑块的长径、宽径、体积、钙化积分及局部管腔狭窄程度。对应CTA上感兴趣钙化斑块的空间位置，于CAG上行点对点测定对应冠状动脉节段的管腔狭窄程度。冠状动脉管腔狭窄程度＞50％定义为显著性狭窄。采用相关分析、卡方检验和t检验进行统计学分析。
结果：CAG证实，117个钙化斑块中共有29个斑块局部管腔显著性狭窄。钙化局部管腔狭窄狭窄程度与患者是否有高胆固醇血症相关(p＜0.05)。CTA显示的钙化斑块局部管腔狭窄程度明显大于CAG(57％±23.1％vs．26％±28.9％，p＜0.05)。CTA诊断钙化斑块局部管腔显著性狭窄的敏感度、特异度、阳性预测值、阴性预测值、准确性分别为86.2％、44.3％、33.8％、90.7％、54.7％。血管横断面观察，弧形或环状钙化局部管腔显著性狭窄几率明显高于点状钙化(58.3％vs．16.1％，p＜0.05)。局部管腔显著性狭窄的钙化斑块其长径、宽径、体积明显大于狭窄程度＜50％的钙化斑块(p＜0.05)。钙化斑块局部管腔狭窄程度与斑块的分布无关。患者钙化局部管腔显著性狭窄的血管节段数与钙化斑块的数目、体积及钙化积分均无关(p＞0.05)。
结论：冠状动脉钙化斑块局部管腔狭窄程度与患者是否有高胆固醇血症呈正相关。血管横断面观察弧形或环状钙化易导致管腔显著性狭窄。钙化斑块的长径、宽径及体积越大，局部管腔显著性狭窄的几率越高。CTA高估钙化斑块局部管腔狭窄程度，诊断钙化斑块局部管腔狭窄程度的敏感度和阴性预测值较高，特异度和阳性预测值和准确性均较低。
第二部分64层螺旋CT和MR血管成像评价冠状动脉粥样硬化钙化斑块所致管腔狭窄的对比研究
目的：比较CMRA与64层CTA在评价冠状动脉粥样硬化钙化斑块所致管腔狭窄的准确性。
材料和方法：经CTA检查发现冠状动脉粥样硬化钙化斑块的患者24例，进行CMRA检查，所有患者均于CTA和CMRA检查后两周内行CAG检查。采用Siemens Sensation Cardiac 64螺旋CT行冠状动脉CTA检查，成像参数：120kV，900mAs，空间分辨率0.4×0.4×0.4mm，重建层厚0.75mm，重建间隔0.5mm，造影剂注射流率5ml/s(优维显370mgI/ml)。进行最大密度投影(MIP)，多平面重建(MPR)等图像后处理。CMRA应用GE Signa 1.5T HD成像仪采用呼吸导航三维FIASTA序列进行血管成像，采用T2 PREP准备脉冲抑制背景信号，成像参数：TR4.7ms，TE2.3ms，FOV 28×28cm，采集矩阵256×256，空间分辨率1.1×1.1mm(平面内)。冠状动脉CTA和CMRA检查患者心率范围控制在70次/分以下。主要评价直径大于≥1.5mm的冠状动脉节段管腔的狭窄程度，以管腔狭窄程度＞50％为显著性狭窄。由两名放射科医生分别评价图像。并以CAG为诊断金标准，分别计算CTA和CMRA对管腔狭窄程度诊断的敏感度、特异度、准确性，并进行统计学检验。
结果：24个患者CTA上于85个血管节段检出感兴趣钙化斑块155个，其中CTA判断118个钙化斑块局部管腔显著性狭窄，经CAG证实仅有63处显著性狭窄，CTA诊断的敏感度、特异度、准确性分别为89％、33％、55％。感兴趣钙化斑块对应血管节段CMRA共检出62处显著性狭窄，其中52处为CAG证实，CMRA诊断的敏感度、特异度、准确性分别为83％、89％、86％。CTA和CMRA诊断冠状动脉钙化斑块所致管腔狭窄程度均具有较高的敏感度(p＞0.05)，CMRA的特异度和准确性明显高于CTA(p＜0.05)。
结论：CMRA评价粥样硬化钙化斑块所致管腔狭窄具有较高的准确性和敏感度，明显优于冠状动脉CTA；两者均具有较高的特异度；CMRA在诊断冠状动脉钙化斑块所致管腔狭窄方面对CTA具有互补作用。
第三部分对比增强与非增强MR血管成像评价冠状动脉粥样硬化斑块及管腔狭窄的对比研究
目的：通过对比增强提高CMRA的信噪比和对比噪声比，比较对比增强与非增强CMRA对冠状动脉粥样硬化斑块及管腔狭窄诊断的准确性。
材料和方法：对健康志愿者14例(男8例，女6例，平均年龄44.1岁)和冠心病患者20例(男14例，女6例，平均年龄57.3岁)分别行非增强与对比增强CMRA检查，所有患者CMRA均于CTA检查后一周内进行。应用Siemens Sensation Cardiac-64螺旋CT行冠状动脉CTA检查。应用GE Signa 1.5T MR成像仪，采用呼吸导航回波触发三维FIASTA序列，成像参数为：TR 4.7ms，TE 2.3ms(增强扫描TR 4.9ms，TE 2.1ms)，FOV 28cm×28cm，矩阵256×256(增强扫描矩阵320×256)，采样层厚2mm×16层，图像空间分辨率1.1×1.1mm(增强扫描0.9×1.1mm)，T2准备脉冲抑制心肌信号。增强扫描采用静脉注射造影剂马根维显(Gd-DTPA)30ml，注药流率1.5ml/s。所有志愿者和患者心率控制在70次/分以下。比较增强前、后健康志愿者和患者CMRA图像的SNR和CNR。感兴趣斑块为粥样硬化非钙化及以非钙化成分为主的混合型斑块。比较非增强和对比增强CMRA对粥样硬化斑块及管腔狭窄的检出率和斑块与血管周围结缔组织和血管腔的CNR。比较非增强与对比增强CMRA对粥样硬化管腔狭窄检出率，并检验两者诊断粥样硬化管腔狭窄程度的一致性。由两位心血管系统方面有诊断经验的放射科医生阅读CTA和MRA影像。采用SPSS11.5统计学软件进行统计学分析。
结果：对比增强CMRA图像的SNR和CNR明显高于非增强CMRA(p＜0.05)；非增强和对比增强CMRA上斑块检出率分别为32.3％、96.8％，后者明显高于前者(p＜0.05)；与非增强CMRA相比，对比增强CMRA明显提高粥样硬化斑块与血管周围结缔组织和血管腔的CNR(5.62±6.61 vs．9.81±4.69，8.79±6.63 vs．12.54±5.5，p＜0.05)；非增强与对比增强CMRA对管腔狭窄性病变的检出率分别为77.4％、100％；非增强与对比增强CMRA对粥样硬化斑块所致管腔狭窄诊断的符合率为0.742(P＜0.05)。
结论：对比增强CMRA明显提高冠状动脉图像的SNR和CNR，明显提高粥样硬化斑块与血管周围结缔组织和血管腔的CNR，能够提高对冠状动脉粥样硬化非钙化斑块和管腔狭窄的检出率，但并未提高对冠状动脉狭窄程度诊断的准确性。
Part One Evaluating Coronary Artery Lumen with Calcified Plaque on CTA: Comparison with Coronary Angiography
Objective: To evaluate the relationship between Coronary artery stenosis and the size, shape and the calcium score of coronary calcified plaques detected by CTA comparing with CAG lesion to lesion, to improve diagnostic accuracy for coronary stenosis caused by calcified plaque on CTA.
Materials and Methods: 43 consecutive patients (37 men; age 66.9±11.7 years) with coronary calcified plaques detected on CTA were included in the study. CTA was performed on Siemens sensation cardiac 64 spiral CT scanner with 0.33s/r, 120kV, eff.900 mAs, slice collimation 64×0.6mm, pitch 0.2, thickness 0.75mm, increment 0.5mm. Contrast media (Ultruvist 370mgI/ml) was injected with 5.0ml/s rate. The image postprocessing included MIP, MPR, coronary tree VR and calcium score. The numbers and the total calcium score of coronary calcified plaques of every patient were calculated. 117 calcified plaques (located in the coronary segment > 1.5mm in diameter and the size can be measured) were studied comparing with CAG lesion to lesion. To evaluate the correlation between the coronary stenosis with calcified plaque and the risk factors of coronary artery disease. To evaluate the shape and the distribution of calcified plaques. The length, width, volume, calcium score and the coronary stenosis with calcified plaque were measured on CTA. The diagnostic accuracy for coronary stenosis with calcified plaque on CTA was calculated. All the patients were performed CAG within two weeks after CTA. The stenosis (>50 % was defined significant stenosis) was also evaluated on CAG lesion to lesion. Statistic analysis included correlation analysis,
chi-square test and t test.
Results: 29 (of 117) calcified plaques caused significant coronary stenosis on CAG. There was correlation between coronary stenosis with calcified plaque and hypercholesteremia (p<0.05). The coronary stenosis with calcified plaque on CTA was more severe than that on CAG (57%±23.1% vs. 26%±28.9%, p<0.05). The sensitivity, specificity, positive predictive value, negative predictive value and the accuracy of diagnosis of significant coronary stenosis with calcified plaque on CTA was 86.2 % 、 44.3 % 、 33.8 % 、 90.7 % and 54.7% respectively. The frequency of coronary significant stenosis in group of arch or circular calcified plaques was higher than that in group of spotted plaques from cross section image on CTA (58.3% vs. 16.1%, p<0.05). The length, width and the volume of calcified plaque in group of significant stenosis were more than that in group of <50% stenosis (p<0.05). There was no correlation between coronary stenosis with calcified plaque and the distribution of calcified plaque. There was no correlation between The numbers of significant coronary stenosis with calcified plaques and the numbers, volume and total calcium score of the calcified plaques ( p>0.05).
Conclusions: There was correlation between coronary stenosis with calcified plaque and hypercholesteremia. The frequency of coronary significant stenosis in group of arch or circular calcified plaques was higher than that in group of spotted plaques from cross section image on CTA. Significant coronary artery stenosis is more frequent in those patients with multiple lesions, large volume and high calcium score of coronary calcified plaque. Calcified plaque with large size may cause significant coronary artery stenosis. CTA overestimates the coronary stenosis with calcified plaque. CTA showed high sensitivity and negative predictive value and low specificity, positive predictive value and accuracy of diagnosis of significant coronary stenosis with calcified plaque.
Part Two Evaluating Coronary Artery stenosis with Calcified Plaque on
64-slice Spiral CT and Coronary MR Angiography
Objective: To compare the diagnostic accuracy of CMRA with 64-slice spiral CT for coronary stenosis with calcified plaque.
Materials and Methods: Consecutive 24 patients with various extent calcified atherosclerotic plaques on CTA were included in the CMRA study. CAG was performed within 1 week after CTA and CMRA. Siemens Sensation Cardiac 64 CT scanner was used with 120kV, 900mAs, 0.4 × 0.4 × 0.4mm spatial resolution, 0.75mm thickness and 0.5mm increment. The contrast media was injected at a rate of 5ml/s (Ultravist 370mgl/ml). The image post processing included MIP, MPR and coronary tree VR. The CMRA was acquired with GE Signa 1.5T HD scanner using navigator-gated 3D-SSFP sequence with a slab of 16-partition and a resolution of 1.1 × 1.1 × 2mm. T2-preparation was applied to suppress the myocardium. The coronary tree was visualized in multiple target slabs. During CTA and CMRA, the heart rate was controlled to be <70bpm. The CTA and CMRA data were graded for the presence of greater than 50% stenosis in vessels larger than 1.5 mm in diameter, and the images were reviewed by two radiologists. The diagnostic accuracies of the two modalities were evaluated with reference to quantitative CAG using the chi square test.
Results: Totally 155 calcified atherosclerotic plaques could be detected on 85 segments. 118 calcified plaques ( of 155 ) were judged as significant stenosis. But on CAG, only 63 of the 118 plaques caused significant stenosis. Compared to CAG, the sensitivity, specificity and accuracy of CTA detecting significant stenosis with calcified plaque was 89%, 33%, 55%, respectively. On CMRA, 62 (of 155) calcified plaques corresponding coronary segments were judged significant stenosis and 52 (of 62) were consistent with CAG The sensitivity, specificity and accuracy of CMRA detecting significant stenosis with calcified
plaque was 83%, 89%, 86%, respectively. On diagnosing coronary stenosis with calcified plaque, both CTA and CMRA had high sensitivities (p>0.05), the specificity of CMRA was significantly higher than that of CTA (P<0.05). The overall diagnostic accuracy of CMRA for coronary significant stenosis with calcified plaque was significantly higher than that of CTA (P<0.05).
Conclusions: CMRA had significantly higher specificity than CTA for diagnosing coronary artery stenosis with calcified plaque, and both of the two modalities had high sensitivities for detection of significant stenosis with calcified plaque. The overall diagnostic accuracy of CMRA was significantly higher than that of CTA.
Part Three
Evaluating Coronary Atherosclerotic Plaque and Stenosis on Coronary
MR Angiography with and without Contrast Application
Objective: To improve the SNR and CNR of coronary artery angiography images by contrast enhancement. To compare the diagnostic accuracy of CMRA with and without contrast enhancement for coronary atherosclerotic plaques and stenosis.
Materials and Methods: 14 healthy human volunteers(mean age 44.1, 8 males) and 20 consecutive patients (mean age 57.3, 14males) with coronary non-calcified plaque detected by CTA were enrolled in pre- and post contrast CMRA studies. CMRA was performed within one week after CTA. Pre- and post-contrast CMRA were performed with navigator-gated 3D-SSFP sequence with TR 4.7ms, TE 2.3ms(post-contrast CMRA, TR 4.9ms, TE 2.1ms), Flip angle 65, FOV 28cm×28cm, Matrix 256×256 (post-contrast CMRA, 320×256), thickness 2mm, a slab of 16-partition and a resolution in-plane of 1.1×1.1mm(post-contrast CMRA, 0.9×1.1mm). T2-preparation was applied to suppress the myocardium. Gadolinium-DTPA 20ml was intravenously injected (Magnevist, a injection rate of 1.5ml/s ) using automatic injector. The coronary tree was visualized in multiple target slabs. During CMRA, the heart rate was controlled to be <70bpm. CMRA images were graded the significant stenosis in coronary stenosis>50% in segments > 1.5mm in diameter. SNR and CNR (blood versus thoracic muscle) of pre- and post-contrast CMRA were measured and compared both in healthy human volunteers and in patients with coronary artery disease. The noncalcified plaques and the mixed type plaques with main noncalcified component were included in the study. To compare the detection rates of atherosclerotic plaques and coronary stenosis between pre- and post-contrast CMRA, and the CNRs between the plaque and the surrounding connective tissue and the coronary lumen were also compared. The coordination between the diagnostic accuracy for coronary stenosis of pre- and post-contrast CMRA was analysed with reference standard of
CTA. SPSS11.5 soft ware was used to statistic analyze. MRA data were double-blind reviewed by two radiologists.
Results: The mean SNR of blood and the CNRof post-contrast CMRA showed significantly higher than that of pre-contrast CMRA both in healthy volunteers and patients. The detection rate for atherosclerotic plaque of post-contrast CMRA was significant higher than that of pre-contrast CMRA (96.8% vs. 32.3%, p < 0.05). Comparison with pre-contrast CMRA, post-contrast CMRA improved the CNRs between the plaque and the surrounding connective tissue and the coronary lumen (9.81±4.6 vs. 95.62±6.61, 12.54±5.5 vs 8.79±6.63, p < 0.05). The detection rate for coronary stenosis of post-contrast CMRA was higher than that of pre-contrast CMRA (100%, 77.4%). The coincidence of diagnosing significant coronary stenosis on pre- and post-contrast MRA was 0.742 (P<0.05).
Conclusions: Post-contrast CMRA improving the SNR and CNR of coronary artery images, and improving the CNRs between the plaque and the surrounding connective tissue and the coronary lumen. Post-contrast CMRA improved the detection rate of atherosclerotic plaques and coronary stenosis, but didn't improve the diagnostic accuracy of coronary artery significant stenosis.
目的：通过冠状动脉CTA和CAG对钙化斑块局部管腔狭窄程度的点对点对照研究，评价钙化斑块的大小、形态及钙化积分与冠状动脉狭窄的关系，提高冠状动脉CTA诊断钙化斑块局部管腔狭窄程度的准确性。
材料与方法：经冠状动脉CTA检查发现冠状动脉钙化斑块的患者43例(男37例，女6例，年龄36～84岁，平均66.9±11.7岁)。所有患者均于CTA检查后两周内行CAG检查。采用Siemens 64层螺旋CT行冠状动脉CTA检查，成像参数：120kV，900mAs，空间分辨率0.4×0.4×0.4mm，330ms/周，层厚0.75mm，间隔0.5mm，造影剂注射流率5ml/s(优维显370mgI/ml)。进行钙化积分、最大密度投影(MIP)，多平面重建(MPR)及提取冠脉树等图像后处理。计算每位患者冠状动脉钙化的数目和总钙化积分。共117个感兴趣钙化斑块(位于直径＞1.5mm的冠状动脉节段，并可测量其大小)行CTA和CAG点对点评价，评价钙化斑块局部管腔狭窄与患者冠心病危险因素的相关性；观察感兴趣钙化斑块的形态、分布特点；于CTA上测定钙化斑块的长径、宽径、体积、钙化积分及局部管腔狭窄程度。对应CTA上感兴趣钙化斑块的空间位置，于CAG上行点对点测定对应冠状动脉节段的管腔狭窄程度。冠状动脉管腔狭窄程度＞50％定义为显著性狭窄。采用相关分析、卡方检验和t检验进行统计学分析。
结果：CAG证实，117个钙化斑块中共有29个斑块局部管腔显著性狭窄。钙化局部管腔狭窄狭窄程度与患者是否有高胆固醇血症相关(p＜0.05)。CTA显示的钙化斑块局部管腔狭窄程度明显大于CAG(57％±23.1％vs．26％±28.9％，p＜0.05)。CTA诊断钙化斑块局部管腔显著性狭窄的敏感度、特异度、阳性预测值、阴性预测值、准确性分别为86.2％、44.3％、33.8％、90.7％、54.7％。血管横断面观察，弧形或环状钙化局部管腔显著性狭窄几率明显高于点状钙化(58.3％vs．16.1％，p＜0.05)。局部管腔显著性狭窄的钙化斑块其长径、宽径、体积明显大于狭窄程度＜50％的钙化斑块(p＜0.05)。钙化斑块局部管腔狭窄程度与斑块的分布无关。患者钙化局部管腔显著性狭窄的血管节段数与钙化斑块的数目、体积及钙化积分均无关(p＞0.05)。
结论：冠状动脉钙化斑块局部管腔狭窄程度与患者是否有高胆固醇血症呈正相关。血管横断面观察弧形或环状钙化易导致管腔显著性狭窄。钙化斑块的长径、宽径及体积越大，局部管腔显著性狭窄的几率越高。CTA高估钙化斑块局部管腔狭窄程度，诊断钙化斑块局部管腔狭窄程度的敏感度和阴性预测值较高，特异度和阳性预测值和准确性均较低。
第二部分64层螺旋CT和MR血管成像评价冠状动脉粥样硬化钙化斑块所致管腔狭窄的对比研究
目的：比较CMRA与64层CTA在评价冠状动脉粥样硬化钙化斑块所致管腔狭窄的准确性。
材料和方法：经CTA检查发现冠状动脉粥样硬化钙化斑块的患者24例，进行CMRA检查，所有患者均于CTA和CMRA检查后两周内行CAG检查。采用Siemens Sensation Cardiac 64螺旋CT行冠状动脉CTA检查，成像参数：120kV，900mAs，空间分辨率0.4×0.4×0.4mm，重建层厚0.75mm，重建间隔0.5mm，造影剂注射流率5ml/s(优维显370mgI/ml)。进行最大密度投影(MIP)，多平面重建(MPR)等图像后处理。CMRA应用GE Signa 1.5T HD成像仪采用呼吸导航三维FIASTA序列进行血管成像，采用T2 PREP准备脉冲抑制背景信号，成像参数：TR4.7ms，TE2.3ms，FOV 28×28cm，采集矩阵256×256，空间分辨率1.1×1.1mm(平面内)。冠状动脉CTA和CMRA检查患者心率范围控制在70次/分以下。主要评价直径大于≥1.5mm的冠状动脉节段管腔的狭窄程度，以管腔狭窄程度＞50％为显著性狭窄。由两名放射科医生分别评价图像。并以CAG为诊断金标准，分别计算CTA和CMRA对管腔狭窄程度诊断的敏感度、特异度、准确性，并进行统计学检验。
结果：24个患者CTA上于85个血管节段检出感兴趣钙化斑块155个，其中CTA判断118个钙化斑块局部管腔显著性狭窄，经CAG证实仅有63处显著性狭窄，CTA诊断的敏感度、特异度、准确性分别为89％、33％、55％。感兴趣钙化斑块对应血管节段CMRA共检出62处显著性狭窄，其中52处为CAG证实，CMRA诊断的敏感度、特异度、准确性分别为83％、89％、86％。CTA和CMRA诊断冠状动脉钙化斑块所致管腔狭窄程度均具有较高的敏感度(p＞0.05)，CMRA的特异度和准确性明显高于CTA(p＜0.05)。
结论：CMRA评价粥样硬化钙化斑块所致管腔狭窄具有较高的准确性和敏感度，明显优于冠状动脉CTA；两者均具有较高的特异度；CMRA在诊断冠状动脉钙化斑块所致管腔狭窄方面对CTA具有互补作用。
第三部分对比增强与非增强MR血管成像评价冠状动脉粥样硬化斑块及管腔狭窄的对比研究
目的：通过对比增强提高CMRA的信噪比和对比噪声比，比较对比增强与非增强CMRA对冠状动脉粥样硬化斑块及管腔狭窄诊断的准确性。
材料和方法：对健康志愿者14例(男8例，女6例，平均年龄44.1岁)和冠心病患者20例(男14例，女6例，平均年龄57.3岁)分别行非增强与对比增强CMRA检查，所有患者CMRA均于CTA检查后一周内进行。应用Siemens Sensation Cardiac-64螺旋CT行冠状动脉CTA检查。应用GE Signa 1.5T MR成像仪，采用呼吸导航回波触发三维FIASTA序列，成像参数为：TR 4.7ms，TE 2.3ms(增强扫描TR 4.9ms，TE 2.1ms)，FOV 28cm×28cm，矩阵256×256(增强扫描矩阵320×256)，采样层厚2mm×16层，图像空间分辨率1.1×1.1mm(增强扫描0.9×1.1mm)，T2准备脉冲抑制心肌信号。增强扫描采用静脉注射造影剂马根维显(Gd-DTPA)30ml，注药流率1.5ml/s。所有志愿者和患者心率控制在70次/分以下。比较增强前、后健康志愿者和患者CMRA图像的SNR和CNR。感兴趣斑块为粥样硬化非钙化及以非钙化成分为主的混合型斑块。比较非增强和对比增强CMRA对粥样硬化斑块及管腔狭窄的检出率和斑块与血管周围结缔组织和血管腔的CNR。比较非增强与对比增强CMRA对粥样硬化管腔狭窄检出率，并检验两者诊断粥样硬化管腔狭窄程度的一致性。由两位心血管系统方面有诊断经验的放射科医生阅读CTA和MRA影像。采用SPSS11.5统计学软件进行统计学分析。
结果：对比增强CMRA图像的SNR和CNR明显高于非增强CMRA(p＜0.05)；非增强和对比增强CMRA上斑块检出率分别为32.3％、96.8％，后者明显高于前者(p＜0.05)；与非增强CMRA相比，对比增强CMRA明显提高粥样硬化斑块与血管周围结缔组织和血管腔的CNR(5.62±6.61 vs．9.81±4.69，8.79±6.63 vs．12.54±5.5，p＜0.05)；非增强与对比增强CMRA对管腔狭窄性病变的检出率分别为77.4％、100％；非增强与对比增强CMRA对粥样硬化斑块所致管腔狭窄诊断的符合率为0.742(P＜0.05)。
结论：对比增强CMRA明显提高冠状动脉图像的SNR和CNR，明显提高粥样硬化斑块与血管周围结缔组织和血管腔的CNR，能够提高对冠状动脉粥样硬化非钙化斑块和管腔狭窄的检出率，但并未提高对冠状动脉狭窄程度诊断的准确性。
Part One Evaluating Coronary Artery Lumen with Calcified Plaque on CTA: Comparison with Coronary Angiography
Objective: To evaluate the relationship between Coronary artery stenosis and the size, shape and the calcium score of coronary calcified plaques detected by CTA comparing with CAG lesion to lesion, to improve diagnostic accuracy for coronary stenosis caused by calcified plaque on CTA.
Materials and Methods: 43 consecutive patients (37 men; age 66.9±11.7 years) with coronary calcified plaques detected on CTA were included in the study. CTA was performed on Siemens sensation cardiac 64 spiral CT scanner with 0.33s/r, 120kV, eff.900 mAs, slice collimation 64×0.6mm, pitch 0.2, thickness 0.75mm, increment 0.5mm. Contrast media (Ultruvist 370mgI/ml) was injected with 5.0ml/s rate. The image postprocessing included MIP, MPR, coronary tree VR and calcium score. The numbers and the total calcium score of coronary calcified plaques of every patient were calculated. 117 calcified plaques (located in the coronary segment > 1.5mm in diameter and the size can be measured) were studied comparing with CAG lesion to lesion. To evaluate the correlation between the coronary stenosis with calcified plaque and the risk factors of coronary artery disease. To evaluate the shape and the distribution of calcified plaques. The length, width, volume, calcium score and the coronary stenosis with calcified plaque were measured on CTA. The diagnostic accuracy for coronary stenosis with calcified plaque on CTA was calculated. All the patients were performed CAG within two weeks after CTA. The stenosis (>50 % was defined significant stenosis) was also evaluated on CAG lesion to lesion. Statistic analysis included correlation analysis,
chi-square test and t test.
Results: 29 (of 117) calcified plaques caused significant coronary stenosis on CAG. There was correlation between coronary stenosis with calcified plaque and hypercholesteremia (p<0.05). The coronary stenosis with calcified plaque on CTA was more severe than that on CAG (57%±23.1% vs. 26%±28.9%, p<0.05). The sensitivity, specificity, positive predictive value, negative predictive value and the accuracy of diagnosis of significant coronary stenosis with calcified plaque on CTA was 86.2 % 、 44.3 % 、 33.8 % 、 90.7 % and 54.7% respectively. The frequency of coronary significant stenosis in group of arch or circular calcified plaques was higher than that in group of spotted plaques from cross section image on CTA (58.3% vs. 16.1%, p<0.05). The length, width and the volume of calcified plaque in group of significant stenosis were more than that in group of <50% stenosis (p<0.05). There was no correlation between coronary stenosis with calcified plaque and the distribution of calcified plaque. There was no correlation between The numbers of significant coronary stenosis with calcified plaques and the numbers, volume and total calcium score of the calcified plaques ( p>0.05).
Conclusions: There was correlation between coronary stenosis with calcified plaque and hypercholesteremia. The frequency of coronary significant stenosis in group of arch or circular calcified plaques was higher than that in group of spotted plaques from cross section image on CTA. Significant coronary artery stenosis is more frequent in those patients with multiple lesions, large volume and high calcium score of coronary calcified plaque. Calcified plaque with large size may cause significant coronary artery stenosis. CTA overestimates the coronary stenosis with calcified plaque. CTA showed high sensitivity and negative predictive value and low specificity, positive predictive value and accuracy of diagnosis of significant coronary stenosis with calcified plaque.
Part Two Evaluating Coronary Artery stenosis with Calcified Plaque on
64-slice Spiral CT and Coronary MR Angiography
Objective: To compare the diagnostic accuracy of CMRA with 64-slice spiral CT for coronary stenosis with calcified plaque.
Materials and Methods: Consecutive 24 patients with various extent calcified atherosclerotic plaques on CTA were included in the CMRA study. CAG was performed within 1 week after CTA and CMRA. Siemens Sensation Cardiac 64 CT scanner was used with 120kV, 900mAs, 0.4 × 0.4 × 0.4mm spatial resolution, 0.75mm thickness and 0.5mm increment. The contrast media was injected at a rate of 5ml/s (Ultravist 370mgl/ml). The image post processing included MIP, MPR and coronary tree VR. The CMRA was acquired with GE Signa 1.5T HD scanner using navigator-gated 3D-SSFP sequence with a slab of 16-partition and a resolution of 1.1 × 1.1 × 2mm. T2-preparation was applied to suppress the myocardium. The coronary tree was visualized in multiple target slabs. During CTA and CMRA, the heart rate was controlled to be <70bpm. The CTA and CMRA data were graded for the presence of greater than 50% stenosis in vessels larger than 1.5 mm in diameter, and the images were reviewed by two radiologists. The diagnostic accuracies of the two modalities were evaluated with reference to quantitative CAG using the chi square test.
Results: Totally 155 calcified atherosclerotic plaques could be detected on 85 segments. 118 calcified plaques ( of 155 ) were judged as significant stenosis. But on CAG, only 63 of the 118 plaques caused significant stenosis. Compared to CAG, the sensitivity, specificity and accuracy of CTA detecting significant stenosis with calcified plaque was 89%, 33%, 55%, respectively. On CMRA, 62 (of 155) calcified plaques corresponding coronary segments were judged significant stenosis and 52 (of 62) were consistent with CAG The sensitivity, specificity and accuracy of CMRA detecting significant stenosis with calcified
plaque was 83%, 89%, 86%, respectively. On diagnosing coronary stenosis with calcified plaque, both CTA and CMRA had high sensitivities (p>0.05), the specificity of CMRA was significantly higher than that of CTA (P<0.05). The overall diagnostic accuracy of CMRA for coronary significant stenosis with calcified plaque was significantly higher than that of CTA (P<0.05).
Conclusions: CMRA had significantly higher specificity than CTA for diagnosing coronary artery stenosis with calcified plaque, and both of the two modalities had high sensitivities for detection of significant stenosis with calcified plaque. The overall diagnostic accuracy of CMRA was significantly higher than that of CTA.
Part Three
Evaluating Coronary Atherosclerotic Plaque and Stenosis on Coronary
MR Angiography with and without Contrast Application
Objective: To improve the SNR and CNR of coronary artery angiography images by contrast enhancement. To compare the diagnostic accuracy of CMRA with and without contrast enhancement for coronary atherosclerotic plaques and stenosis.
Materials and Methods: 14 healthy human volunteers(mean age 44.1, 8 males) and 20 consecutive patients (mean age 57.3, 14males) with coronary non-calcified plaque detected by CTA were enrolled in pre- and post contrast CMRA studies. CMRA was performed within one week after CTA. Pre- and post-contrast CMRA were performed with navigator-gated 3D-SSFP sequence with TR 4.7ms, TE 2.3ms(post-contrast CMRA, TR 4.9ms, TE 2.1ms), Flip angle 65, FOV 28cm×28cm, Matrix 256×256 (post-contrast CMRA, 320×256), thickness 2mm, a slab of 16-partition and a resolution in-plane of 1.1×1.1mm(post-contrast CMRA, 0.9×1.1mm). T2-preparation was applied to suppress the myocardium. Gadolinium-DTPA 20ml was intravenously injected (Magnevist, a injection rate of 1.5ml/s ) using automatic injector. The coronary tree was visualized in multiple target slabs. During CMRA, the heart rate was controlled to be <70bpm. CMRA images were graded the significant stenosis in coronary stenosis>50% in segments > 1.5mm in diameter. SNR and CNR (blood versus thoracic muscle) of pre- and post-contrast CMRA were measured and compared both in healthy human volunteers and in patients with coronary artery disease. The noncalcified plaques and the mixed type plaques with main noncalcified component were included in the study. To compare the detection rates of atherosclerotic plaques and coronary stenosis between pre- and post-contrast CMRA, and the CNRs between the plaque and the surrounding connective tissue and the coronary lumen were also compared. The coordination between the diagnostic accuracy for coronary stenosis of pre- and post-contrast CMRA was analysed with reference standard of
CTA. SPSS11.5 soft ware was used to statistic analyze. MRA data were double-blind reviewed by two radiologists.
Results: The mean SNR of blood and the CNRof post-contrast CMRA showed significantly higher than that of pre-contrast CMRA both in healthy volunteers and patients. The detection rate for atherosclerotic plaque of post-contrast CMRA was significant higher than that of pre-contrast CMRA (96.8% vs. 32.3%, p < 0.05). Comparison with pre-contrast CMRA, post-contrast CMRA improved the CNRs between the plaque and the surrounding connective tissue and the coronary lumen (9.81±4.6 vs. 95.62±6.61, 12.54±5.5 vs 8.79±6.63, p < 0.05). The detection rate for coronary stenosis of post-contrast CMRA was higher than that of pre-contrast CMRA (100%, 77.4%). The coincidence of diagnosing significant coronary stenosis on pre- and post-contrast MRA was 0.742 (P<0.05).
Conclusions: Post-contrast CMRA improving the SNR and CNR of coronary artery images, and improving the CNRs between the plaque and the surrounding connective tissue and the coronary lumen. Post-contrast CMRA improved the detection rate of atherosclerotic plaques and coronary stenosis, but didn't improve the diagnostic accuracy of coronary artery significant stenosis.
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1. Mollet NR, Cademartiri F, Van Mieghem CA, et al. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation, 2005, 112(15): 2318-2323
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1．赵锡海，蔡祖龙．冠状动脉粥样硬化斑块磁共振成像研究进展．中国医学影像技术，2007，23(3)：460-462
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3．赵锡海，程流泉，蔡祖龙．心脏磁共振分子影像学研究进展．国外医学临床放射学分册，已修回待发表
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1．赵锡海，蔡祖龙．冠状动脉粥样硬化斑块磁共振成像研究进展．中国医学影像技术，2007，23(3)：460-462
2．赵锡海，蔡祖龙．64层螺旋CT心脏检查应用进展．解放军保健医学杂志，2005，7(4)：241-244
3．赵锡海，程流泉，蔡祖龙．心脏磁共振分子影像学研究进展．国外医学临床放射学分册，已修回待发表