脑缺血半暗带界定及无创脑水肿监护的临床研究
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摘要
第一部分磁共振DWI、PWI和MRS量化评定超早期脑梗死缺血半暗带
目的应用磁共振弥散加权成像(DWI)、灌注加权成像(PWI)以及磁共振波谱技术(MRS)界定超早期脑梗死缺血半暗带,力求提出量化评定标准。方法13例发病时间在2-6h以内的超急性脑梗死患者行MRI检查,包括DWI、PWI及1H-MRS技术,并在2-28d内复查T2WI确定最终梗死范围。对梗死中心区,缺血半暗带及对侧镜像区,测量其扩张变化,血流灌注以及代谢改变。结果(1)梗死中心区与缺血半暗带表观弥散系数(ADC)平均值分别为7.01×10-4mm2/s及9.36×10-4mm2/s,rADC平均值分别为0.63及0.87,梗死中心区ADC及rADC均明显降低,缺血半暗带ADC及rADC轻度下降,二者之间有显著性差异(P<0.05)。(2)PWI显示11例超急性脑梗死存在灌注缺损区或灌注减低区,2例腔隙性脑梗死未见明显异常。(3)超早期脑梗死的MRS改变为乳酸(Lac)浓度升高和N-乙酰天门冬氨酸盐(NAA)水平降低。(4)PWI>DWI者,ADC值轻度降低(<22%)Lac升高且NAA正常或轻度下降(<14%)的区域可能为缺血半暗带;而ADC值明显降低(25%-53%)Lac升高且NAA明显下降的区域(16%-34%)可能为不可逆损伤区。结论DWI、PWI和MRS的综合应用可发现超早期脑梗死,并预测缺血半暗带。
第二部分脑出血患者微创血肿清除术后磁共振DWI和MRS临床研究
目的观察脑出血患者保守治疗及微创血肿清除术治疗后DWI和MRS的变化,从影像学方面探讨微创血肿清除术对脑出血患者脑水肿的影响及临床价值。方法20例高血压脑出血患者随机分为两组,微创血肿清除手术组(微创组):10例脑出血患者于发病后6-24h内接受简易立体定向微创血肿清除术治疗;对照组:10例脑出血患者接受内科保守治疗,所有病例均于发病后9-11d行常规MRI及功能性MRI(包括DWI和MRS)检查。结果对照组和微创组血肿周围ADC值与对侧对称区ADC值的差异均有显著性差异(P<0.01),且对照组血肿周围区域ADC值高于微创组(P<0.05)。对磁共振谱线进行分析,对照组血肿周围NAA/Cr与对侧相对应区域的NAA/Cr值有显著性差异(P<0.01),前者较后者降低12.6±7.4%,其中4例可见到明确的乳酸峰。微创组血肿周围NAA/Cr与对侧相对应区域的NAA/Cr值无统计学显著性差异(P>0.05),且乳酸峰显示不明显。结论微创血肿清除术能有效清除血肿,可显著性改善脑出血后脑水肿形成,脑出血患者微创血肿清除术组与对照组DWI和MRS的变化从影像学方面佐证了微创血肿清除术效果。神经影像学不仅提供了形态结构上的依据,还提出了功能上的客观指标。
第三部分急性脑卒中患者的无创脑水肿动态监护
[摘要]目的动态监测急性脑卒中患者的脑水肿变化,旨在探讨微创血肿清除术的价值及无创脑水肿动态监护仪对急性脑卒中患者治疗的指导作用。方法43例急性脑卒中患者(均为发病24h内入院者)分为4组:脑出血31例(脑出血组),其中15例内科保守治疗(保守组),16例行微创血肿清除术(微创组);大面积脑梗死患者12例(脑梗死组)。所有病例均于入院后1、3、5、7d采用无创脑水肿动态监护仪动态检测综合扰动系数。结果脑出血组:术前即发病1d内无论是保守组或微创组患侧综合扰动系数均低于健侧,随着病程推移保守组出现患侧扰动系数升高并超过健侧,3d时达到高峰,持续7d以上。微创组则呈现3d时患侧综合扰动系数高于健侧,5d时两侧接近,7d时两侧基本正常。病程第3、5、7d时两组对比有显著性差异(P<0.01)。脑梗死组:入院后即刻检查患侧综合扰动系数即高于健侧,随着病程推移5d时达到高峰,持续7d以上。结论脑出血及大面积脑梗死患者综合扰动系数呈不对称性改变,随病程推移呈现动态变化,反应了水肿形成过程,微创血肿清除术能有效清除血肿,可显著性改善脑出血后脑水肿形成,无创脑水肿动态监护可动态评估患者脑水肿演变过程,对再出血的诊断以及急性脑卒中患者的治疗有一定的指导意义。
Part I Quantitative evaluation on the ischemic penumbra of the hyperacute cerebral infarction by diffusion weighted imaging、perfusion weighted imaging and MR spectroscopy
[Abstract] Objective To explore the ischemic penumbra of the hyperacute cerebral infarction by diffusion weighted imaging (DWI)、perfusion weighted imaging (PWI) and MR spectroscopy (MRS), trying to produce the quantitative evaluation standards. Methods MRI was performed in 13 patients with clinically diagnosed hyperacute cerebral infarction from 2h to 6h after symptom onset, including DWI, PWI and MRS. All the patients were followed up by T2WI image to determine the final infarct area within 2 to 28 days. Diffusion and perfusion and metabolic changes were measured in the infarct area, ischemic penumbra and control area. Results (1) The average value of apparent diffusion coefficient (ADC) in the infarct center was 7.01×10-4mm2/s and that of rADC was 0.63, as for the ischemic penumbra, the average value of ADC was 9.36×10-4mm2/s, and that of rADC was 0.87. The difference was significan(tP<0.05). (2) PWI demonstrated the regional cerebral blood reduction or absence in 11 patients. However, in two patients with lacunar cerebral infarction, PWI is normal. (3) MRS changes in hyperacute cerebral infarction included elevated Lac peak and decreased NAA peak. (4) If PWI>DWI, the area with slightly decreased ADC value(<22%), elevated Lac and slightly decreased NAA(<14%) might be the ischemic penumbra; while the area with obviously decreased ADC(25%-53%), elevated Lac and obviously decreased NAA (16%-34%)is irreversible infarct area. Conclusion DWI combined with PWI and MRS can diagnose the hyperacute cerebral infarction and evaluate the change of ischemic penumbra.
Part II The clinical research on the intracerebral hemorrhage with micro-damage puncture by diffusion weighted imaging and magnetic resonance spectroscopy
Objective To observe the changes of the intracerebral hemorrhage (ICH) patient with conservative therapy and micro-damage puncture by diffusion weighted imaging (DWI) and magnetic resonance spectroscopy (MRS), trying to explore the effect of brain edema and clinical value of the ICH patients with micro-damage puncture from the neuroimaging aspect. Methods Twenty patients with ICH were divided into two groups randomly. Micro-damage puncture group (micro-damage puncture group): ten patients accepted the stereo-orientation micro-damage puncture during 6 to 24 hours after symptom onset; control group: ten patients accepted the conservative therapy. All patients did the MRI and functional MRI including DWI and MRS in the 9 to 11 days after the symptom onset. Results The difference of the perihematomal apparent diffusion coefficient (ADC) value between the micro-damage puncture and the control group was significant (P<0.01), and the perihematomal ADC value of the control group was higher than the micro-damage puncture group (P<0.05). The result was analyzed by magnetic resonance spectroscopy. The difference of the perihematomal NAA/Cr value between the focus side and the contralateral corresponding side was significant in the control group(P<0.01), and the focus side decreased 12.6±7.4% as compared with the contralateral corresponding side, four could be seen the obvious Lac peak among all patients. There was no statistically significant difference in the perihematomal NAA/Cr value between the focus side and the contralateral corresponding side in the micro-damage puncture group (P>0.05), no patient showed the Lac peak. Conclusion The micro-damage puncture can clear the hematoma effectively and reduce the formation of brain edema significantly after ICH, the changes of DWI and MRS between the micro-damage puncture group and the control group proved the effect of the micro-damage puncture from the neuroimaging aspect. The neuroimaging not only provided the evidence of the morphostructure but also the objective index of the function.
Part III Brain edema monitoring by non-invasive dynamic method in acute cerebral stroke
Objective To monitor the change of brain edema dynamicly in acute cerebral stroke patients, trying to find out the effect of micro-damage puncture, and the guiding role of non-invasive dynamic brain edema monitor for the treatment. Methods 43 cases with acute cerebral stroke(all admission within 24 hours after symptom onset)were divided into four groups randomly. 31 cases with intracerebral hemorrhage (ICH group): 15 cases accepted the conservative therapy(conservation group), 16 cases accepted the micro-damage puncture(micro-damage puncture group); 12 cases with cerebral infarct in large areas (infarct group). The changes of comprehensive disturbance coefficient in all cases were detected by non-invasive dynamic brain edema monitor in the 1st, 3rd, 5th, 7th day. Results ICH group: the comprehensive disturbance coefficient in the focus side was lower than the unaffected side in both groups in the first day before operation. With time going on, in the conservation group, the comprehensive disturbance coefficient in the focus side became higher than the unaffected side, which reached its peak in the 3rd day and continued for more than 7days. However, in the micro-damage puncture group, the coefficient in the focus side was higher than the unaffected side in the 3rd day, and then became approximately equal to the unaffected side in the 5th day and basically normal in the 7th day. The comprehensive disturbance coefficient was significantly different in the 3rd, 5th, 7th day (P<0.01). Infarction group: the comprehensive disturbance coefficient in the focus side was higher than the unaffected side at the time of admission, which reached its peak in the 3rd day and continued for more than 7days. Conclusion The comprehensive disturbance coefficient showed the asymmetric changes in both ICH and cerebral infarction in large areas, and took on the dynamic change, which reflects the course of edema formation. The micro-damage puncture can clear the hematoma effectively and reduce the formation of brain edema significantly after ICH. Non-invasive dynamic brain edema monitoring can evaluate the course of brain edema, and play a guiding role to the detection of recurrent hemorrhage and treatment of the patients with acute cerebral stroke to some degree.
目的应用磁共振弥散加权成像(DWI)、灌注加权成像(PWI)以及磁共振波谱技术(MRS)界定超早期脑梗死缺血半暗带,力求提出量化评定标准。方法13例发病时间在2-6h以内的超急性脑梗死患者行MRI检查,包括DWI、PWI及1H-MRS技术,并在2-28d内复查T2WI确定最终梗死范围。对梗死中心区,缺血半暗带及对侧镜像区,测量其扩张变化,血流灌注以及代谢改变。结果(1)梗死中心区与缺血半暗带表观弥散系数(ADC)平均值分别为7.01×10-4mm2/s及9.36×10-4mm2/s,rADC平均值分别为0.63及0.87,梗死中心区ADC及rADC均明显降低,缺血半暗带ADC及rADC轻度下降,二者之间有显著性差异(P<0.05)。(2)PWI显示11例超急性脑梗死存在灌注缺损区或灌注减低区,2例腔隙性脑梗死未见明显异常。(3)超早期脑梗死的MRS改变为乳酸(Lac)浓度升高和N-乙酰天门冬氨酸盐(NAA)水平降低。(4)PWI>DWI者,ADC值轻度降低(<22%)Lac升高且NAA正常或轻度下降(<14%)的区域可能为缺血半暗带;而ADC值明显降低(25%-53%)Lac升高且NAA明显下降的区域(16%-34%)可能为不可逆损伤区。结论DWI、PWI和MRS的综合应用可发现超早期脑梗死,并预测缺血半暗带。
第二部分脑出血患者微创血肿清除术后磁共振DWI和MRS临床研究
目的观察脑出血患者保守治疗及微创血肿清除术治疗后DWI和MRS的变化,从影像学方面探讨微创血肿清除术对脑出血患者脑水肿的影响及临床价值。方法20例高血压脑出血患者随机分为两组,微创血肿清除手术组(微创组):10例脑出血患者于发病后6-24h内接受简易立体定向微创血肿清除术治疗;对照组:10例脑出血患者接受内科保守治疗,所有病例均于发病后9-11d行常规MRI及功能性MRI(包括DWI和MRS)检查。结果对照组和微创组血肿周围ADC值与对侧对称区ADC值的差异均有显著性差异(P<0.01),且对照组血肿周围区域ADC值高于微创组(P<0.05)。对磁共振谱线进行分析,对照组血肿周围NAA/Cr与对侧相对应区域的NAA/Cr值有显著性差异(P<0.01),前者较后者降低12.6±7.4%,其中4例可见到明确的乳酸峰。微创组血肿周围NAA/Cr与对侧相对应区域的NAA/Cr值无统计学显著性差异(P>0.05),且乳酸峰显示不明显。结论微创血肿清除术能有效清除血肿,可显著性改善脑出血后脑水肿形成,脑出血患者微创血肿清除术组与对照组DWI和MRS的变化从影像学方面佐证了微创血肿清除术效果。神经影像学不仅提供了形态结构上的依据,还提出了功能上的客观指标。
第三部分急性脑卒中患者的无创脑水肿动态监护
[摘要]目的动态监测急性脑卒中患者的脑水肿变化,旨在探讨微创血肿清除术的价值及无创脑水肿动态监护仪对急性脑卒中患者治疗的指导作用。方法43例急性脑卒中患者(均为发病24h内入院者)分为4组:脑出血31例(脑出血组),其中15例内科保守治疗(保守组),16例行微创血肿清除术(微创组);大面积脑梗死患者12例(脑梗死组)。所有病例均于入院后1、3、5、7d采用无创脑水肿动态监护仪动态检测综合扰动系数。结果脑出血组:术前即发病1d内无论是保守组或微创组患侧综合扰动系数均低于健侧,随着病程推移保守组出现患侧扰动系数升高并超过健侧,3d时达到高峰,持续7d以上。微创组则呈现3d时患侧综合扰动系数高于健侧,5d时两侧接近,7d时两侧基本正常。病程第3、5、7d时两组对比有显著性差异(P<0.01)。脑梗死组:入院后即刻检查患侧综合扰动系数即高于健侧,随着病程推移5d时达到高峰,持续7d以上。结论脑出血及大面积脑梗死患者综合扰动系数呈不对称性改变,随病程推移呈现动态变化,反应了水肿形成过程,微创血肿清除术能有效清除血肿,可显著性改善脑出血后脑水肿形成,无创脑水肿动态监护可动态评估患者脑水肿演变过程,对再出血的诊断以及急性脑卒中患者的治疗有一定的指导意义。
Part I Quantitative evaluation on the ischemic penumbra of the hyperacute cerebral infarction by diffusion weighted imaging、perfusion weighted imaging and MR spectroscopy
[Abstract] Objective To explore the ischemic penumbra of the hyperacute cerebral infarction by diffusion weighted imaging (DWI)、perfusion weighted imaging (PWI) and MR spectroscopy (MRS), trying to produce the quantitative evaluation standards. Methods MRI was performed in 13 patients with clinically diagnosed hyperacute cerebral infarction from 2h to 6h after symptom onset, including DWI, PWI and MRS. All the patients were followed up by T2WI image to determine the final infarct area within 2 to 28 days. Diffusion and perfusion and metabolic changes were measured in the infarct area, ischemic penumbra and control area. Results (1) The average value of apparent diffusion coefficient (ADC) in the infarct center was 7.01×10-4mm2/s and that of rADC was 0.63, as for the ischemic penumbra, the average value of ADC was 9.36×10-4mm2/s, and that of rADC was 0.87. The difference was significan(tP<0.05). (2) PWI demonstrated the regional cerebral blood reduction or absence in 11 patients. However, in two patients with lacunar cerebral infarction, PWI is normal. (3) MRS changes in hyperacute cerebral infarction included elevated Lac peak and decreased NAA peak. (4) If PWI>DWI, the area with slightly decreased ADC value(<22%), elevated Lac and slightly decreased NAA(<14%) might be the ischemic penumbra; while the area with obviously decreased ADC(25%-53%), elevated Lac and obviously decreased NAA (16%-34%)is irreversible infarct area. Conclusion DWI combined with PWI and MRS can diagnose the hyperacute cerebral infarction and evaluate the change of ischemic penumbra.
Part II The clinical research on the intracerebral hemorrhage with micro-damage puncture by diffusion weighted imaging and magnetic resonance spectroscopy
Objective To observe the changes of the intracerebral hemorrhage (ICH) patient with conservative therapy and micro-damage puncture by diffusion weighted imaging (DWI) and magnetic resonance spectroscopy (MRS), trying to explore the effect of brain edema and clinical value of the ICH patients with micro-damage puncture from the neuroimaging aspect. Methods Twenty patients with ICH were divided into two groups randomly. Micro-damage puncture group (micro-damage puncture group): ten patients accepted the stereo-orientation micro-damage puncture during 6 to 24 hours after symptom onset; control group: ten patients accepted the conservative therapy. All patients did the MRI and functional MRI including DWI and MRS in the 9 to 11 days after the symptom onset. Results The difference of the perihematomal apparent diffusion coefficient (ADC) value between the micro-damage puncture and the control group was significant (P<0.01), and the perihematomal ADC value of the control group was higher than the micro-damage puncture group (P<0.05). The result was analyzed by magnetic resonance spectroscopy. The difference of the perihematomal NAA/Cr value between the focus side and the contralateral corresponding side was significant in the control group(P<0.01), and the focus side decreased 12.6±7.4% as compared with the contralateral corresponding side, four could be seen the obvious Lac peak among all patients. There was no statistically significant difference in the perihematomal NAA/Cr value between the focus side and the contralateral corresponding side in the micro-damage puncture group (P>0.05), no patient showed the Lac peak. Conclusion The micro-damage puncture can clear the hematoma effectively and reduce the formation of brain edema significantly after ICH, the changes of DWI and MRS between the micro-damage puncture group and the control group proved the effect of the micro-damage puncture from the neuroimaging aspect. The neuroimaging not only provided the evidence of the morphostructure but also the objective index of the function.
Part III Brain edema monitoring by non-invasive dynamic method in acute cerebral stroke
Objective To monitor the change of brain edema dynamicly in acute cerebral stroke patients, trying to find out the effect of micro-damage puncture, and the guiding role of non-invasive dynamic brain edema monitor for the treatment. Methods 43 cases with acute cerebral stroke(all admission within 24 hours after symptom onset)were divided into four groups randomly. 31 cases with intracerebral hemorrhage (ICH group): 15 cases accepted the conservative therapy(conservation group), 16 cases accepted the micro-damage puncture(micro-damage puncture group); 12 cases with cerebral infarct in large areas (infarct group). The changes of comprehensive disturbance coefficient in all cases were detected by non-invasive dynamic brain edema monitor in the 1st, 3rd, 5th, 7th day. Results ICH group: the comprehensive disturbance coefficient in the focus side was lower than the unaffected side in both groups in the first day before operation. With time going on, in the conservation group, the comprehensive disturbance coefficient in the focus side became higher than the unaffected side, which reached its peak in the 3rd day and continued for more than 7days. However, in the micro-damage puncture group, the coefficient in the focus side was higher than the unaffected side in the 3rd day, and then became approximately equal to the unaffected side in the 5th day and basically normal in the 7th day. The comprehensive disturbance coefficient was significantly different in the 3rd, 5th, 7th day (P<0.01). Infarction group: the comprehensive disturbance coefficient in the focus side was higher than the unaffected side at the time of admission, which reached its peak in the 3rd day and continued for more than 7days. Conclusion The comprehensive disturbance coefficient showed the asymmetric changes in both ICH and cerebral infarction in large areas, and took on the dynamic change, which reflects the course of edema formation. The micro-damage puncture can clear the hematoma effectively and reduce the formation of brain edema significantly after ICH. Non-invasive dynamic brain edema monitoring can evaluate the course of brain edema, and play a guiding role to the detection of recurrent hemorrhage and treatment of the patients with acute cerebral stroke to some degree.
引文
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