彭經(jīng)建 劉桂梅 王金鵬 江建 劉俊 楊楓
[摘要] 目的 探討頭顱血管造影(CTA)數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型在動(dòng)脈瘤夾閉術(shù)患者中的應(yīng)用效果。方法? 選擇2018年4月至2020年2月動(dòng)脈瘤夾閉術(shù)患者86例為對(duì)象,隨機(jī)數(shù)字表法分為兩組,各43例。對(duì)照組根據(jù)普通CTA檢查結(jié)果,結(jié)合臨床經(jīng)驗(yàn)進(jìn)行手術(shù)治療,觀察組術(shù)前使用頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型,指導(dǎo)手術(shù)治療,術(shù)后7 d對(duì)患者效果進(jìn)行評(píng)估,并完成6個(gè)月隨訪,比較兩組手術(shù)效果、圍術(shù)期并發(fā)癥及隨訪結(jié)果。結(jié)果? 觀察組43例患者夾閉術(shù)成功41例,成功率95.35%,對(duì)照組43例患者夾閉成功35例,成功率81.40%(P<0.05);觀察組完全夾閉率高于對(duì)照組(P<0.05);瘤頸殘余、瘤體殘余率低于對(duì)照組(P<0.05);觀察組圍術(shù)期術(shù)后血管痙攣、血腫、靜脈血栓、肢體活動(dòng)障礙及顱內(nèi)水腫發(fā)生率6.99%,低于對(duì)照組的16.29%(P<0.05);觀察組最終隨訪40例,隨訪期間38例患者恢復(fù)良好,能自理生活;2例患者伴有輕度神經(jīng)功能障礙;對(duì)照組最終隨訪38例,隨訪期間30例患者恢復(fù)良好,8例患者伴有輕度神經(jīng)功能障礙。結(jié)論? 頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型用于動(dòng)脈瘤夾閉術(shù)患者中能獲得良好的手術(shù)效果,術(shù)后并發(fā)癥較低,能降低術(shù)后復(fù)發(fā)率。
[關(guān)鍵詞] 頭顱血管造影;三維立體重建;床突段動(dòng)脈瘤;前床突模型;動(dòng)脈瘤夾閉術(shù)
[中圖分類號(hào)] R651.1;R445? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] B? ? ? ? ? [文章編號(hào)] 1673-9701(2022)15-0100-03
Three-dimensional reconstruction and printing of clinoid process aneurysm and anterior clinoid process model with cranial CTA data in aneurysm clipping
PENG Jingjian LIU Guimei WANG Jinpeng JIANG Jian LIU Jun YANG Feng
1.Department of Neurosurgery, Jiujiang NO.1 People′s Hospital in Jiangxi Province, Jiujiang? ?332000, China;2.Department of Image, the Third People′s Hospital of Jiujiang City in Jiangxi Province, Jiujiang 332000, China
[Abstract] Objective To explore the application effect of three-dimensional reconstruction and printing of clinoid process aneurysm and anterior clinoid process model with cranial CT angiography (CTA) data in patients after aneurysm clipping. Methods A total of 86 patients underwent aneurysm clipping from April 2018 to February 2020 were selected. They were divided into two groups using random number table, with 43 patients in each group. The control group were given surgical treatment based on the results of ordinary CTA examinations combined with clinical experience. The observation group were given preoperative three-dimensionally reconstruct and printing of clinoid process aneurysm and anterior clinoid process model with cranial CTA data to guide the surgical treatment. The patients were evaluated at 7 days after the surgery and 6-month follow-up to compare the surgical effects, perioperative complications, and follow-up results between the two groups. Results A total of 41 out of 43 patients in the observation group were successfully clipped with a success rate of 95.35%, which was higher than that in the control group as 81.40%, in which 35 out of 43 patients were successfully clipped (P<0.05). The complete clipping rate in the observation group was higher than that in the control group (P<0.05). The residual rate of aneurysm neck and body in the observation group was lower than that in the control group (P<0.05). The incidence rate of perioperative and postoperative vasospasm, hematoma, venous thrombosis, limb dysfunction and intracranial edema in the observation group was 6.99%, which was lower than that in the control group as 16.29% (P<0.05). A total of 40 patients in the observation group completed follow-up, among whom 38 patients recovered well and were able to take care of themselves, and 2 patients had mild neurological dysfunction. A total of 38 patients in the control group completed follow-up, among whom 30 patients recovered well, and 8 patients had mild neurological dysfunction. Conclusion Three-dimensional reconstruction and printing of clinoid process aneurysm and anterior clinoid process model with cranial CTA data has good surgical results in patients after aneurysm clipping surgery, with low postoperative complications. It can also reduce postoperative recurrence rate.
[Key words] Cranial CT angiography; Three-dimensional reconstruction; Clinoid process aneurysm; Anterior clinoid process model; Aneurysm clipping
動(dòng)脈瘤夾閉術(shù)是一種傳統(tǒng)的手術(shù),具有直觀、穩(wěn)妥、可靠等優(yōu)點(diǎn),能獲得良好治療效果,預(yù)后較好[1]。但傳統(tǒng)治療時(shí)多以DSA檢查及指導(dǎo)為主(診斷顱內(nèi)動(dòng)脈瘤金標(biāo)準(zhǔn)),雖能保證患者順利完成手術(shù),但創(chuàng)傷較大,風(fēng)險(xiǎn)性較高,導(dǎo)致患者遠(yuǎn)期預(yù)后較差,且DSA檢查難以顯示瘤壁及瘤內(nèi)是否存在血栓,導(dǎo)致臨床誤診率、漏診率較高[2]。目前隨著多層螺旋CT(MSCT)的出現(xiàn),CT腦血管造影技術(shù)廣泛癥用于臨床,并逐步取代DSA檢查。該方法圖像的采集和后處理均相對(duì)較快(完成掃描大約平均僅需10 min),可根據(jù)獲得的數(shù)據(jù)進(jìn)行三維立體重建,借助圖像后處理軟件構(gòu)建模型[3]。同時(shí),醫(yī)生借助該模型于術(shù)前能清晰地顯示病灶部位、病灶大小等,可指導(dǎo)手術(shù)治療[4]。因此,本研究以動(dòng)脈瘤夾閉術(shù)患者為對(duì)象,探討頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型在動(dòng)脈瘤夾閉術(shù)患者中的應(yīng)用效果,現(xiàn)報(bào)道如下。
1 資料與方法
1.1 臨床資料
選擇2018年4月至2020年2月江西省九江市第一人民醫(yī)院收治的動(dòng)脈瘤夾閉術(shù)患者86例,使用隨機(jī)數(shù)字表法將患者分為兩組。對(duì)照組43例,男25例,女18例,年齡36~80歲,平均(54.38±7.31)歲;病程1~6周,平均(3.42±0.51)周;體質(zhì)量指數(shù)(BMI)18~25 kg/m,平均(22.18±2.63)kg/m;臨床表現(xiàn):突發(fā)頭痛4例、腦膜刺激征3例、不同程度肢體運(yùn)動(dòng)障礙6例;觀察組43例,男23例,女20例,年齡35~81歲,平均(54.42±7.36)歲;病程1~7周,平均(3.48±0.57)周;BMI 19~26 kg/m,平均(22.25±2.67)kg/m;臨床表現(xiàn):突發(fā)頭痛5例、腦膜刺激征4例、不同程度肢體運(yùn)動(dòng)障礙5例。納入標(biāo)準(zhǔn)[5]:①符合動(dòng)脈瘤夾閉術(shù)治療適應(yīng)證,且患者均可耐受;②具有完整的基線資料與隨訪資料;③患者臨床癥狀多以突發(fā)性頭痛、惡心嘔吐、不同程度肢體運(yùn)動(dòng)障礙為主。排除標(biāo)準(zhǔn)[6]:①合并精神異常、凝血功能異?;驉盒阅[瘤者;②認(rèn)知功能異常和嚴(yán)重肝腎功能異常者或器質(zhì)性疾病者。本研究經(jīng)醫(yī)院醫(yī)學(xué)倫理委員會(huì)審批通過。
1.2 方法
對(duì)照組:根據(jù)普通CTA檢查結(jié)果,結(jié)合臨床經(jīng)驗(yàn)進(jìn)行手術(shù)治療。術(shù)前完成相關(guān)檢查,詳細(xì)詢問患者的病史、藥物過敏史等,了解患者的身體狀態(tài),制訂詳細(xì)的治療方案。術(shù)前對(duì)患者行普通CTA檢查,進(jìn)一步確定動(dòng)脈瘤的準(zhǔn)確信息,包括大小、位置及與周圍組織的關(guān)系等,并行動(dòng)脈瘤夾閉手術(shù)[7]。
觀察組:術(shù)前使用頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型,指導(dǎo)手術(shù)治療。術(shù)前常規(guī)完成碘過敏試驗(yàn),指導(dǎo)患者進(jìn)行一系列的呼吸訓(xùn)練,采用64層GE light Speed CT掃描儀對(duì)患者進(jìn)行掃描。上述操作完畢后,行仰臥位,指導(dǎo)患者平躺于攝影床上,借助高壓注射液經(jīng)肘靜脈以3.5~4.0 m/s的速度注入碘佛醇對(duì)比劑[江蘇恒瑞醫(yī)藥股份有限公司,國藥準(zhǔn)字H20067895,規(guī)格:20 ml∶13.56 g(每1 ml含320 mg碘)]100~120 ml。患者進(jìn)行CT掃描時(shí)控制掃描范圍為顱底到顱頂,并順著血流方向?qū)颊哌M(jìn)行檢查,檢查時(shí)開啟智能追蹤觸發(fā)掃描,設(shè)定閾值為80 HU;感興趣區(qū)域ROI達(dá)到閾值后手動(dòng)觸發(fā)啟動(dòng)。將CTA所有的原始數(shù)據(jù)傳入mimics軟件中,借助最大密度投影(MIP)、多平面重建(MPR)及容積重現(xiàn)(VR)等多種方法對(duì)獲得的原始圖像進(jìn)行后處理,重建后打印床突段動(dòng)脈瘤及前床突模型,并在該模型的指導(dǎo)下完成動(dòng)脈瘤夾閉手術(shù),術(shù)后7 d對(duì)患者效果進(jìn)行評(píng)估。
1.3 觀察指標(biāo)
①手術(shù)效果。兩組術(shù)后分別從完全夾閉、瘤頸殘余、瘤體殘余角度對(duì)患者手術(shù)效果進(jìn)行評(píng)估。②圍術(shù)期并發(fā)癥。記錄兩組圍術(shù)期血管痙攣、血腫、靜脈血栓、肢體活動(dòng)障礙及顱內(nèi)水腫的發(fā)生率。③隨訪結(jié)果。兩組術(shù)后均進(jìn)行6個(gè)月隨訪,了解患者術(shù)后恢復(fù)情況。
1.4 統(tǒng)計(jì)學(xué)方法
采用SPSS 24.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,組間比較采用t檢驗(yàn),計(jì)數(shù)資料以[n(%)]表示,組間比較采用χ檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組的手術(shù)效果比較
觀察組43例患者夾閉術(shù)成功41例,成功率為95.35%,高于對(duì)照組的81.40%(P<0.05);觀察組的完全夾閉率高于對(duì)照組(P<0.05);瘤頸殘余、瘤體殘余率低于對(duì)照組(P<0.05)。見表1。
2.2 兩組的圍術(shù)期并發(fā)癥比較
觀察組圍術(shù)期術(shù)后血管痙攣、血腫、靜脈血栓、肢體活動(dòng)障礙及顱內(nèi)水腫發(fā)生率為6.99%,低于對(duì)照組的16.29%(P<0.05)。見表2。
2.3 兩組術(shù)后隨訪結(jié)果
兩組患者術(shù)后均完成6個(gè)月的隨訪,觀察組最終隨訪40例,隨訪期間38例患者恢復(fù)良好,能自理生活;2例患者伴有輕度神經(jīng)功能障礙,未出現(xiàn)死亡病例;對(duì)照組最終隨訪38例,隨訪期間30例患者恢復(fù)良好,8例患者伴有輕度神經(jīng)功能障礙,未出現(xiàn)死亡病例。封三見圖2。
3 討論
動(dòng)脈瘤夾閉術(shù)是臨床上常用的手術(shù)治療方法,適應(yīng)于以下情況[8]:①大腦中動(dòng)脈瘤破裂后病情較輕,屬于Hunt和Hess分級(jí)Ⅰ~Ⅲ級(jí)者;②大腦中動(dòng)脈瘤破裂后病情相對(duì)較重;③大腦中動(dòng)脈瘤破裂后發(fā)生威脅生命的顱內(nèi)血腫者;④偶然發(fā)生的未破裂的大腦中動(dòng)脈瘤。普通CTA檢查雖能滿足手術(shù)治療的需要,但具有較高的風(fēng)險(xiǎn)性、創(chuàng)傷性,導(dǎo)致患者手術(shù)風(fēng)險(xiǎn)較高,影響患者的治療耐受性、依從性[9]。
近年來,頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型在動(dòng)脈瘤夾閉術(shù)患者中得到應(yīng)用,且效果理想[10]。本研究中,觀察組夾閉術(shù)成功率為95.35%,高于對(duì)照組的81.40%(P<0.05),提示頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型用于動(dòng)脈瘤夾閉術(shù)患者中能獲得較高的成功率,利于患者恢復(fù)。頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型是一種簡便、經(jīng)濟(jì)的影像學(xué)診斷手段,經(jīng)靜脈注射造影劑,通過智能跟蹤軟件進(jìn)行監(jiān)測,當(dāng)血管內(nèi)監(jiān)測點(diǎn)(事先設(shè)定好的興趣區(qū)ROI)造影劑濃度達(dá)到峰值時(shí),利用手動(dòng)觸發(fā)技術(shù)進(jìn)行掃描的范圍進(jìn)行快速薄層容積掃描,并借助MPR、MIP及VR等多種圖像后處理功能,完成相關(guān)數(shù)據(jù)及模型的三維重建[11]。同時(shí),患者治療時(shí)借助該模型能較為精確地制訂相應(yīng)的夾閉手術(shù),不僅能降低手術(shù)并發(fā)癥的發(fā)生率,亦可獲得良好的手術(shù)預(yù)后[12-13]。本研究中,觀察組圍術(shù)期術(shù)后的血管痙攣、血腫、靜脈血栓、肢體活動(dòng)障礙及顱內(nèi)水腫發(fā)生率為6.99%,低于對(duì)照組的16.29%,進(jìn)一步說明頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型治療動(dòng)脈瘤夾閉術(shù)患者安全性較高,能降低術(shù)后并發(fā)癥發(fā)生率。既往研究表明,頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型的實(shí)施其特點(diǎn)是圖像采集與后處理均相對(duì)較快,完成掃描大約需10 min左右,能較好地顯示血管的空間關(guān)系、動(dòng)脈瘤的外形、輪廓、動(dòng)脈瘤頸與載瘤動(dòng)脈的關(guān)系,能清晰地顯示瘤內(nèi)血栓的整體情況,可指導(dǎo)臨床治療[14-15]。本研究中,觀察組隨訪期間2例伴有輕度神經(jīng)功能障礙;對(duì)照組8例患者伴有輕度神經(jīng)功能障礙,提示頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型用于動(dòng)脈瘤夾閉術(shù)患者中能獲得良好的手術(shù)預(yù)后,治療后復(fù)發(fā)率較低。
綜上所述,頭顱CTA數(shù)據(jù)三維立體重建打印床突段動(dòng)脈瘤及前床突模型用于動(dòng)脈瘤夾閉術(shù)患者中能獲得良好的手術(shù)效果,術(shù)后并發(fā)癥較低,能降低術(shù)后復(fù)發(fā)率,值得推廣應(yīng)用。
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(收稿日期:2021-08-12)