Assessment of local microcirculatory status and infarct type in patients with severe stenosis or occlusion of the middle cerebral artery via cerebral perfusion imaging
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摘要:
目的 利用双源CT脑灌注成像（CTP）技术，探讨大脑中动脉重度狭窄或闭塞的所致脑梗死灶分布类型与侧支循环建立相关性，并进一步探索不同侧支血管建立缺血区域微循环状态。 方法 收集经CT血管造影证实单侧大脑中动脉狭窄率 > 70%、症状性猝中的患者80例。在弥散加权成像上，将脑梗死类型分为穿支动脉梗死、大面积梗死、皮质供血区梗死、分水岭梗死、多发脑梗塞及无梗死灶。经CTP成像，将所有患者分为侧支循环良好组（n=48）与不良组（n=32），分析两组灌注参数差异及相关危险因素，并用半影计算软件分析缺血半暗带区与核心梗死区，对比弥散加权成像高信号区与核心梗死区是否差异及脑梗死类型分布与侧支循环相关性。 结果 侧支循环不良组男性比例及高血压患者比例高于侧支循环良好组（P < 0.05）。所有患者CTP结果均为阳性，核心梗死区阳性66例，弥散加权成像阳性为68例，两种方法对急性脑梗死诊断具有一致性，侧支循环良好组脑梗死类型以穿支动脉梗死为著，侧支循环不良组以分水岭梗死为著。对于两组间缺血半暗带区灌注参数进行比较，脑血流量值的差异无统计学意义（P > 0.05），侧支循环良好组脑血容量增加，平均通过时间和达峰时间缩短，差异有统计学意义（P < 0.05）。 结论 大脑中动脉重度狭窄或闭塞的所致脑梗死灶分布类型与侧支循环建立有关，CTP成像可较早发现缺血区域，精准评估责任血管的狭窄程度及局部血流动力学信息，半影计算模式可更快捷地评估缺血核心梗死区及缺血半暗带区。 Abstract:Objective To explore the correlation between the distribution of cerebral infarction caused by severe stenosis or occlusion of the middle cerebral artery and the establishment of collateral circulation using dual-source CT cerebral perfusion imaging (CTP), and further explore the state of microcirculation in the area of ischemia established by different collateral vessels. Methods 80 patients with unilateral middle cerebral artery stenosis > 70% and symptomatic sudden stroke confirmed by CT angiography were collected. On the diffusion-weighted image, the types of cerebral infarction were divided into perforating artery infarction, large area infarction, cortical blood supply area infarction, watershed infarction and multiple cerebral infarction and no infarcts. After CTP imaging, all patients were divided into two groups with good collateral circulation and poor circulation, and differences in perfusion parameters and related risk factors between the two groups were analyzed. Penumbra calculation software was used to analyze the ischemic penumbra area and core infarct area, and to compare whether the diffusion-weighted image high signal area was different from the core infarct area and whether distribution of cerebral infarction correlates with collateral circulation. Results The proportion of males and the proportion of hypertension patients were significantly higher in the group with poor collateral circulation than that in the group with good collateral circulation (P < 0.05). CTP results of all patients were positive, 66 cases were positive for core infarct area in 68 cases in diffusion weighted image. Two methods were consistent in the diagnosis of acute cerebral infarction. The type of cerebral infarction in the group with good collateral circulation being predominantly penetrating artery infarction, and the group with poor collateral circulation being predominantly watershed infarction. For the comparison of the perfusion parameters of the ischemic penumbra area between the two groups, the difference in cerebral blood flow value was not significant (P > 0.05), while the increase in cerebral blood volume, and the decrease in mean transit time and time to peak in the group with good collateral circulation were statistically significant (P < 0.05). Conclusion The distribution type of cerebral infarction caused by severe stenosis or occlusion of the middle cerebral artery is related to the establishment of collateral circulation. CTP imaging can detect the ischemic areas earlier, accurately assess the degree of stenosis of the responsible blood vessel and local hemodynamic information. The shadow calculation mode allows faster assessment of the ischemic core infarct area and the ischemic penumbra area. -
图 1 多时相CTA图
患者男, 56岁, 突发左侧肢体无力5 h; A~B: 多时相CTA MIP重建图, 箭头所示右侧大脑中动脉闭塞及周边多支侧支血管影; C: 动脉峰值VR重建图.
Figure 1. Multi-phase CTA diagram.
图 2 脑灌注参数图
A~D: 灌注伪彩图TTP、MTT、CVF、CBV; E: 半影计算图; F: MRI-DWI图. 该患者侧支循环建立良好，图A示右侧大脑半球见大面积灌注减低区, 但图E显示核心梗死区（红色区域）较小, 周边存在大范围缺血半暗带区（黄色区域）, 经DWI成像（F）证实示右侧基底节区小斑片状高信号影与图E红色区域位置相符.
Figure 2. Diagram of cerebral perfusion parameters.
表 1 侧支循环良好组和侧支循环不良组基线资料比较
Table 1. Comparison of baseline data between good collateral circulation group and poor collateral circulation group [n(%)]
项目 侧支循环良好组 侧支循环不良组 检验值 P 年龄(岁, Mean±SD) 63.47±7.61 64.13±5.82 0.143 0.089 男性 16 (62.72) 23 (76.51) 4.890 0.023 高血脂 20 (80.61) 24 (83.13) 0.157 0.679 糖尿病 9 (35.78) 8 (26.45) 0.878 0.357 高血压 10 (37.67) 18 (60.00) 0.373 0.033 冠心病 2 (10.00) 4 (13.89) 0.067 0.829 吸烟史 6 (23.47) 8 (26.45) 3.749 0.127 
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表 2 核心梗死区与DWI诊断脑梗死一致性
Table 2. The consistency of the diagnosis of cerebral infarction between NVT area and DWI (n)
DWI 核心梗死区 合计 阳性 阴性 阳性 66 2 68 阴性 0 12 12 合计 66 14 80 注: 经筛选80例患者, 由2位观察者采用核心梗死区诊断脑梗死66例, DWI诊断脑梗死68例; DWI: 弥散加权成像.
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表 3 侧支循环良好组和不良组脑梗死灶类型分布
Table 3. Distribution of cerebral infarction focus in the good collateral circulation group and poor collateral circulation group[n(%)]
组别 穿支动脉梗死 皮质支动脉梗死 大面积梗死 分水岭梗死 多发性脑梗死 无脑梗死灶 侧支循环良好组(n=48) 17 (35.4) 9 (18.3) 3 (6.3) 6 (12.6) 5 (10.4) 9 (18.3) 侧支循环不良组(n=32) 4 (12.5) 4 (12.5) 8 (25.0) 9 (28.1) 4 (12.5) 3 (9.3)
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表 4 侧支循环良好组和不良组缺血半暗带区血流动力学值比较结果
Table 4. Comparison results of hemodynamic values in the TAR area between the good collateral circulation group and the poor collateral circulation group (Mean±SD)
组别 CBF (mL·100g-1) CBV[mL·100/ (g·min)] MTT (s) TTP (s) 侧支循环良好组(n=48) 47.32±41.35 5.46±2.27 7.98±9.26 16.73±1.62 侧支循环不良组(n=32) 41.05±24.33 3.18±1.99 12.01±8.76 25.09±0.63 t 6.126 2.364 0.018 -0.021 P 0.071 0.042 0.028 0.031 CBF：脑血流量; CBV: 脑血容量; MTT: 平均通过时间; TTP: 达峰时间.
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