3D-CTA在急性破裂颅内动脉瘤诊断和治疗中的应用

Application of three dimensional computed tomographic angiography to acutely ruptured intracranial aneurysms associated with clinical diagnosis and treatment

目的探讨三维CT血管造影(3D-CTA)在颅内动脉瘤破裂急性期的临床诊断价值。方法148例疑为颅内动脉瘤破裂的自发性蛛网膜下腔出血患者,进行3D-CTA检查,时间分别在发病后2h到4d;其中6例在3D-CTA之前行数字减影脑血管造影(2D-DSA)检查,142例在3D-CTA之后行DSA检查,扫描图像后经计算机工作站处理。原始图像三维后处理技术采用容积重建(VR)和最大密度投影(MIP),以VR为主。后处理图像与DSA图像分别由两位放射科医生和神经外科医生用双盲法进行分析。对动脉瘤治疗采用夹闭和血管内栓塞两种技术。结果经3D-CTA、DSA和手术或栓塞证实共发现112例130个动脉瘤,大小自1.1～28mm,其中单发动脉瘤97例,多发15例33个动脉瘤。在112例动脉瘤中,3D-CTA发现112例128个动脉瘤,漏诊多发动脉瘤中的2个,敏感度为98.5%,特异度94.7%,准确度97.6%,阳性预测值98.5%,阴性预测值94.7%;而DSA发现动脉瘤109例127个动脉瘤,漏诊3例3个动脉瘤,敏感度为97.7%,特异度100%,准确度98.2%,阳性预测值100%,阴性预测值为92.3%。在3D-CTA上均可清晰或较清晰显示出瘤颈与载瘤动脉的关系,占98.4%;而DSA能清晰显示瘤颈与载瘤动脉关系仅占40.9%,两者有统计学意义(x2= 5.545,P<0.05)。结论3D-CTA对颅内动脉瘤具有极高的敏感性和特异性,并具有快捷、经济和相对无创等优点,对颅内动脉瘤破裂急性期的诊断优于2D-DSA。

Objective To evaluate the value of clinical application of three-dimensional computed tomographic angiography （3D-CTA） in acutely ruptured intracranial aneurysms. Methods 148 consecutive patients with acute subarachnoid hemorrhage and clinical highly suspected ruptured intracranial aneurysms underwent 3D-CTA by GE Lightspeed pro scanner in 2h to 4d after attack. 6 patients were performed digital subtraction angiography （DSA） before 3D-CTA scan, and 142 patients were had DSA after scan. All of the source images were processing into volume rendering （VR） and some of them have maximal intensity projection （MIP）. Results were blindly reviewed by two independent radiologist and neurosurgon. Intracranial aneurysms were treated by surgery clipping or coil embolization. Results 130 intracranial aneurysms were found in 112 cases by examination and clinic treatment, dimensions from 1.1 - 28mm. 97 cases were a single aneurysm, 15 cases were found total 33 multiple intracranial aneurysms （ MIA）, including 12 patients had two aneurysms and 3 had three aneurysms. 128 aneurysms were detected by 3D-CTA in all 112 patients. DSA demonstrated 127 aneurysms in 109 patients. The sensitivity of CTA for the detection of all aneurysms was 98. 5%, the specificity 94.7%, the accuracy 97.6%, the positive predictive value （PPV） 98.5%, the negative predictive value （NPV） 94.7%. The sensitivity of DSA was 97.6%, the specificity 100%, the PPV 100%, the NPV 92.3% and the accuracy 92.3%. Besides 2 ophthalimic aneurysms, Image of 128 aneurysms found by 3D-CTA showed more clear detail of the neck and the feeding artery of aneurysm （98.4%） than DSA（40.9% ）, X^2 test were significance different （X2 = 5. 545, P 〈 0.05）. Conclusions 3D-CTA is a quick, economical and relative noninvasive method for the diagnosis of intracranial aneurysms and has highly sensitivity and specificity, which can be used to diagnose acutely ruptured intracranial aneurysms as good as DSA.