静脉窦血栓的比较影像学诊断及介入治疗

Comparative Imaging Diagnosis and Interventional Therapy for Cerebral Venous and Sinus Thrombosis

目的 分析静脉窦血栓(CVST)的CT、MRI及数字减影血管造影(DSA)表现,并探讨低剂量尿激酶(起始剂量10万U/24h)行静脉窦内经导管接触性溶栓的疗效。资料与方法 18例CVST患者行CT平扫、MR平扫、MR静脉成像(MRV)及DSA检查,明确诊断后,行静脉窦内机械性碎栓、静脉窦内留置微导管接触性溶栓术。若颅内没有出血,以1万U/min流率总量25万U尿激酶冲击溶栓,然后以10万U/24h起始剂量用药2天;对于合并颅内出血的患者,直接以10万U/24h起始剂量用药2天。2天后造影复查,根据结果撤管或增加剂量至25万U/24h,然后继续留置微导管,同时积极治疗原发病。结果 CT平扫显示颅内血肿5例(右额叶3例,右顶叶1例,左顶叶合并右颞叶1例),上矢状窦或(和)直窦内高密度影3例。MR平扫显示静脉窦内异常信号,部分伴有脑回肿胀;MR显示血栓累及上矢状窦15例,横窦9例,直窦6例,乙状窦6例,窦汇3例,累及颈内静脉2例。MRV表现为受累静脉窦血流信号消失或不连续。DSA表现为受累及的静脉窦内充盈缺损,动静脉循环时间均明显延长,侧支循环形成。12例患者以10万U/24h尿激酶溶栓效果良好,6例溶栓2天后复查药量增至25万U/24h。静脉窦完全再通临床症状消失9例,大部分再通临床症状消失5例,部分再通临床症状明显缓解4例。术中1例出现导丝穿透静脉窦,造成硬膜下少量出血,2天后复查出血吸收,预后良好。所有患者溶栓过程中未出现出血加重或新发出血,预后良好。结论 CT平扫能显示CVST的部分阳性征象,MR平扫、MRV及DSA能明确CVST的诊断。用低剂量尿激酶行静脉窦接触性溶栓安全有效,并能预防大剂量尿激酶带来的并发症。

Objective To analyze the imaging manifestations of cerebral venous and sinus thrombosis（CVST）on CT,MR and DSA,and to explore the clinical efficacy of catheter-directed thrombolysis for CVST with smaller dose of urokinase（UK,initial dose 100,000u/24h）.Materials and Methods Eighteen patients with CVST were examined by plain scan of CT,conventional MR（CMR,T1WI,T2WI）,MRV and DSA.Mechanical disruption of the thrombus was applied and catheter-directed local thrombolysis therapy with the microcatheter was performed after the final diagnosis of CVST.For cases without intracranial hematoma,stoss thrombolysis therapy（the UK dose of 10,000 u/min,total dose 250,000u）was used first,then unremitting pump infusion of UK with the dose of 100,000 u/24 h was utilized for 2 days.For patients combined with intracal hematoma,stoss thrombolysis was not used,and the local thrombolysis with the UK dose of 100,000 u/24 h was applied directly.According to the imaging outcomes rechecked after 2 days unremitting pump infusion,the catheter was withdrawed or the pump infusion was continued with the UK dose increased to 250,000u/24h.In the procedure of thrombolysis,the primary disease was treated actively at the same time.Results Plain scan of CT revealed intracranial hematoma in 5 cases（3 haematoma located in the right frontal lobe,1 in the right parietal lobe,1 in the left parietal lobe accompanying with right temporal lobe hematoma）.The sign of high-density in the superior sagittal sinus and（or）straight sinus was discovered in 3 cases.Disappearance of ＂flowing void effect ＂and abnormal signal in the sinus was demonstrated on CMR,swelling of gyri was also manifested in several patients.Thrombus was detected in superior sagittal sinus in 15 cases,lateral sinus in 9,tentorial sinus in 6,sigmoid sinus in 6,confluens sinus in 3,internal jugular vein in 2 cases.Disappearance of blood signal in the sinus and（or）discontinuation of sinus was showed on MRV.The features of CVST on DSA included filling defect in sinus,prolongation of the arteriovenous circulation time and formation of compensatory circulation.Satisfacted efficacy was gained in 12 cases with UK dose of 100,000u/24h,the UK dose was increased to 250,000u/24h after 2 days unremitting pump infusion in 6 cases.Complete recanalization with clinical symptoms elimination were gained in 9 cases,most partial recanalization and elimination of the clinical symptoms were gained in 5 cases,partial recanalization with obvious relief of the clinical symptoms was gained in 4 cases.Perforation of the sinus induced by gidewire was occurred in 1 case,small amounts bleeding of the inferior tentorium was absorbed after 2 days observation.No haemorrhage aggravation and（or）new bleeding was detected in all 18 cases in the procedure of thrombolysis.All the 18 cases had satisfied clinical efficacy.Conclusion Plain scan of CT can demonstrate partial valuable signs of CVST.CVST can be diagnosed accurately by CMR,MRV and DSA.Local catheter-directed thrombolysis with the UK dose of 100,000u/24h is a safety and effective therapy for CVST,with its advantage of prophylaxis of hemorrhage induced by utilizing large dose of UK.