DSA 及 CT 灌注成像在单侧烟雾病脑血管重建术中的应用

Application of DSA and CT perfusion imaging for cerebral revascularization in treatment of unilateral moyamoya disease

目的:探讨DSA及CT灌注成像(CTPI)在单侧烟雾病(MMD)脑血管重建术中的临床应用价值。方法:回顾性分析单侧MMD行脑血管重建术的51例患者的病例资料,其中49例行术前DSA检查,13例行术后DSA检查,51例行术前CTPI检查,分别有33例和13例行颞浅动脉-大脑中动脉(STA-MCA)搭桥术的患者行术后近期和远期CTPI检查。根据DSA图像分析血管狭窄程度、侧支循环分型和颈内动脉(ICA)分期;在CTPI参数图(包括CBF、CBV、MTT和TTP)上对5个兴趣区进行定量分析,并进行脑梗死前期的术前分期及评估手术后脑灌注的改善情况。采用配对t检验或配对秩和检验进行统计学分析。结果:1术前DSA显示所有患者均有大脑中动脉(MCA)病变,单一MCA受累占71.4%(35/49)。40.8%(20/49)的患者ICA分期处于Ⅳ期。49例均可见颅底烟雾状血管,31例可见来自大脑后动脉(PCA)的侧支循环。术后评估中,21例行STA-MCA搭桥术的患者中吻合血管再通率为95.2%(20/21),其中13例术后DSA复查示69.2%(9/13)的患者颅底烟雾状血管减少或消失;251例的术前CTPI显示患侧的MCA供血区、基底节和PCA供血区的CBV升高,MTT及TTP延长,MCA供血区的CBF降低,ACA供血区的MTT延长,且与对侧比较差异均有统计学意义(P<0.05)。定性评估中,66.7%(34/51)患侧MCA供血区梗死前期分期为Ⅰb期。搭桥术后近期复查CTPI显示患侧MCA和PCA供血区、基底节及丘脑的灌注参数绝对值及相对值较术前明显改善(P<0.05),搭桥术后远期CTPI示MCA、PCA和ACA供血区及基底节的灌注状态较术后近期明显改善(P<0.05)。结论:DSA及CTPI能有效地评估单侧MMD的血管情况及脑灌注状态,能对了解病情、筛查手术适应证及评估血管重建术的效果提供可靠的依据。

Objectire：To explore the clinical value of DSA and CT perfusion imaging （CTPI）for cerebral revascula-rization of unilateral moyamoya disease.Methods：The clinical and imaging data of 51 patients with unilateral moyamoya di-sease undergone cerebral revascularization were analyzed restrospectively.Of 51 cases,49 and 13 cases with superficial tem-poral artery to middle cerebral artery （STA-MCA）bypass underwent pre-and post-surgery DSA respectively,all cases un-derwent CTPI before operation,33 and 13 cases underwent short-or long-term postoperative CTPI respectively.According to the DSA data,degree of cerebrovascular stenosis,classification of collateral vessel and stage of internal carotid artery （ICA）disease were analyzed.On the CTPI parameter maps （including CBF,CBV,MTT and TTP）quantitative measure-ment of five ROIs was performed,and pre-infarction stage and perfusion state after operation were evaluated.Paired t test or signed rank sum test was used for statistic analysis.Results：①Preoperative DSA showed that MCA was involved in all ca-ses,71.4% （35/49 ）of which were single MCA involvement;ICA stages of 40.8% （20/49 ）patients were in stage Ⅳ;moyamoya vessels at the base of the brain were existed in 49 cases,and collateral vessels originated from PCA were existed in 31 cases.In the postoperative evaluation,21 cases underwent cerebrovascular examinations after STA-MCA bypass and the patency rate of bypasses was 95.2% （20/21 ）;Of 21 cases,13 cases underwent DSA before and after STA-MCA by-pass,and 9 cases showed that net-like vessels at the base of brain decreased or disappeared after operation （69.2%）.②pre-operative CTPI of 51 cases showed that the ipsilateral value of CBV,MTT and TTP in the MCA territory,basal ganglia and PCA territory and MTT in the ACA territory all increased,CBF in the MCA territory decreased,with statistic difference all when compared with those of the contralateral side （P〈0.05 ）.In addition,a qualitative evaluation showed that 66.7%（34/51）were in pre-infarction stage Ⅰb .In the evaluation of short-term CTPI of 33 cases after bypass,there was significant improvement （P〈0.05）in the absolute values and relative values of perfusion parameters in MCA,basal ganglia,PCA and thalamus territory when compared with those of pre-operation.In 13 cases with long-term CTPI after bypass,perfusion sta-tus of basal ganglia,and MCA,PCA and ACA territory improved,with statistic difference （P〈0.05）when compared with those of short term after bypass.Conclusion：DSA and CTPI can effectively evaluate vascular conditions and cerebral perfu-sion status in unilateral moyamoya disease,and can provide reliable evidence for understanding patient＆#39;s conditions,selection of operative indications and evaluation of surgical effects.