多層螺旋CT冠狀動脈檢查課件

1、多排螺旋CT冠狀動脈成像影響CT冠狀動脈成像質(zhì)量的主要因素 因 素 設(shè)備參數(shù) 空間分辨力 探測器層厚度 時間分辨力 球管選擇速度 Z軸時間分辨力 探測器寬度 后處理功能 簡便、實用的后處理 軟件 冠狀動脈管腔大于50%狹窄者， 16排CT與64排CT的比較 Sep Spe PPV NPV16MSCT 95% 69% 79% 92%64MSCT 97% 90% 93% 96%Hamon M, Radiology,2007,Dec,245(3):720-731.64-slice CT with z-Sharp technology0.6 x 32 x 2 = 64Spartial resoluti

2、on:0.4mm x 0.4mm x 0.4mmTemporal resolution: 0.33s/r 165 msCourtesy of Siemens medical solution China = 83 msrotation time 0.33s4Temp. Resolution =Dual Source CTCourtesy of Siemens medical solution China TOSHIBAZ-軸時間分辨力：16 cm coverage per rotation空間分辨力： 320 x 0.5 mm detector elements時間分辨力： 350 msec

3、rotation time (數(shù)據(jù)由東芝公司提供)one aquilion256-iCT Z-軸時間分辨力：8cm納米探測器空間分辨力： 0.625x128(256Slices)時間分辨力： 270 msec rotation time （數(shù)據(jù)由Philips公司提供）心臟、冠狀動脈CT檢查：更高的時間分辨力更高的空間分辨力最小的輻射劑量更寬的探測器（Z軸時間分辨力）簡便易行的后處理軟件推薦選擇設(shè)備：使用64排以上CT設(shè)備空間分辨力為毫米級0.4x0.4x0.4 mmYZ X 螺旋CT三維重建技術(shù)冠、矢狀位重建Co. Sa. Reconstruction多層面重建- MPR最大密度投影重建-M

4、IP最小密度投影重建-Mip容積編碼重建Volume Rendering冠脈檢查注意要點技術(shù)簡介和心理溝通呼吸訓(xùn)練心律和心率的干預(yù)硝酸甘油的使用五、心臟CT成像適應(yīng)癥簡介美國多學(xué)科學(xué)會聯(lián)合推薦心臟（包括心胸部）CT成像適應(yīng)征：ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIRJournal of American college of Cardiology 2006,48:1475-149719分法CT心臟檢查分級（79分）1，有癥狀者、中等以上冠心病風(fēng)險、ECG不 確切、不能進(jìn)行運動試驗，無癥狀者不推 薦CT檢查（篩查）2，急性胸痛者，中等以上冠心病風(fēng)險、ECG無改

5、 變、酶學(xué)正常者3，各種檢查結(jié)果均不能明確診斷者4，冠狀動脈、大血管、心腔和瓣膜等的形態(tài)學(xué)檢查5，腫瘤、血栓、心包病變、肺靜脈、冠狀動脈內(nèi) 乳動脈、主動脈夾層動脈瘤、肺栓塞正常冠狀動脈正常冠狀動脈正常冠狀動脈左冠狀動脈狹窄CTA與DSA對照前降支狹窄明確診斷后介入治療CT檢測冠脈狹窄準(zhǔn)確性MDCT vs. ANGIOGRAPHY作者 例數(shù) 旋轉(zhuǎn)時間/周 敏感度 特異度 陰性期望值 不能評價Leschka 53 370 ms 94% 97% 99% - Raff 70 330 ms 86% 95% 98% 12%Leber 59 330 ms 73% 97% 99% -Mollet 52 330

6、 ms 99% 95% 99% 2%Ropers 82 330 ms 95% 93% 99% 4%楊立等 61 330 ms 90% 94% 93% - 冠脈粥樣硬化斑塊鈣化（混合性）斑塊 纖維斑塊 軟斑塊（脂池） Agatston Score 90 + 20HU 30 + 20HU管壁偏心性斑塊管壁偏心性斑塊管壁偏心性斑塊管壁環(huán)周性斑塊粥樣硬化斑塊導(dǎo)致管腔狹窄冠脈血管造影冠脈支架治療The progress of coronary atherosclerosisPlaque rupture resulting myocardium infarctionCourtesy of Dr. Wei

7、Li-xin. PLA General Hospital, ChinaThe vulnerable plaque without lumen stenosisThe aids of coronary CT imaging:detect the vulunerable plaque before ruptureCourtesy of Dr. Wei Li-xin. PLA General Hospital, ChinaCT發(fā)現(xiàn)冠脈斑塊的敏感度PLAQUE DETECTION：MDCT VS. IVUS83 segments in 22 patients Sensitivity plaque pe

8、r segment: 94%(all)16-slice CT 53%(non-calcified)Achenbach et al: Circulation 2003 -58 vessels in 37 patients Sensitivity plaque detection: 85%(all)16-slice CT 82%(non-calcified)Laber et al. JACC 2004 -32 vessels in 18 patients Sensitivity plaque detection: 84%(all)64-slice CT Leber et al JACC 2005

9、The controversy in identification of plaque types with MSCT Soft plaque:11+/-12HU Fibrous plaque:76+/21HU Calcified plaque:516+/-198HU There were statistically highly significant differences in the densitometric characteristics among the plaques and lumen The IVUS-based coronary plaque configuration

10、 can be accurately identified by MSCT. Motoyama S. Circulation J. 2007 Mar: 71:363-366Soft plaque 14 26 HUIntermediate plaque 91 21 HUcalcified plaque 419 194 HUSchroeder et al. JACC 2001The controversy in identification of plaque types:MSCT vs. IVUSCourtesy of Dr. Lars K. HofmannThe controversy in

11、identification of plaque types with MSCT The overlap of CT value on the plaque composition: 16-slice CT results vs. IVUS mean CT value IVUS 58+/-43HU Hypo-echo. Plaque 121+/-34HU Hyper-echo. PlaqueSignificant differences and substantial overlap between the plaques types Pohal K. atherosclerosis, 200

12、7,Jan,190:174-180. LAD:soft-plaqueNo significant stenosisPLAQUE TRANSFORM A 54-y/o man with “cardiopalmus”. LAD irregular-surface plaque with lower density and lumen stenosis 50% 2005-11-09治療及生活習(xí)慣干預(yù)05-11：速降脂，40mg/日，30天 20mg/日，90天飲食控制：不吃內(nèi)臟類食物，增加蔬菜類戒煙：遠(yuǎn)動: 6 km/H，30min /日 2006-08-01 2008-12-19Cor. Diss

13、ection血管迂曲、壁冠狀動脈（肌橋）血管迂曲、壁冠狀動脈（肌橋）心肌橋-壁冠狀動脈冠狀動脈部分節(jié)段被心肌纖維覆蓋，在心肌內(nèi)走行一段距離后又淺露于心肌表面，覆蓋在該段冠狀動脈上的心肌束稱為心肌橋（Myocardial Bridge MB），位于心肌橋下的冠狀動脈稱為壁冠狀動脈（Mural Coronary Artery MCA ）。心肌橋=心肌橋-壁冠狀動脈復(fù)合體（MB-MCA）楊立 趙林芬 李穎等。中華醫(yī)學(xué)雜志， 2006，86：2858-2862心肌橋相關(guān)問題一般為良性先天發(fā)育異常可能的臨床意義： 引起心肌退變 與冠狀動脈動脈硬化、心律不齊相關(guān) 導(dǎo)致急性心肌缺血、猝死等趙林芬 楊立 中國

14、臨床醫(yī)學(xué)影像雜志 2007，18：285-287。Normal pattern of the left anterior descending artery (LAD) as seen on axial plane (A, B) and multiplanar reformation (C, D). The left anterior descending artery (arrow) is embedded through all of its length in the epicardial fat. *Interventricular septum. CCTA coronary comp

15、uted tomographic angiography.K0NEN，JACC, 2007,49(5): 587-693.Coronary morphologyThe normal morphology of RCAThe normal LADIntramuscula LAD, superficial type, as seen on axial plane (A, B) and multiplanar reformation (C, D). The mid LAD (arrow) shows a typical deviation and straitening and is only pa

16、rtially surrounded by myocardium. Of note, an atheroscleroticplaque in the proximal LAD, whereas the intramuscular segment is free of disease. Konen，JACC, 2007,49(5): 587-693.Intramuscular LAD, right ventricular type (arrow). In this variant it is frequently difficult to follow the LAD on sequential

17、 axial images (A, B) because it disappears between the right ventricular trabeculae, whereas the multiplanar reformationimages easily show its intraventricular course (C, D). Konen，JACC, 2007,49(5): 587-693.Intramuscular LAD, right ventricular type (arrow). In this variant it is frequentlydifficult

18、to follow the LAD on sequential axial images (A, B) because it disappearsbetween the right ventricular trabeculae, whereas the multiplanar reformationimages easily show its intraventricular course (C, D). Konen，JACC, 2007,49(5): 587-693.SUPERFICIAL TYPEVENTRICULAR TYPE(深在型）MB-MCA ON RCAAtheroscleros

19、is on MCARight ventricular type Right ventricular typeRight ventricular typeMCA on diastolic and systolic phase diastolic phase systolic phase MCA: Mural Coronary ArteryMCA on Diastolic phase MCA on systolic phaseMB-MCAMB: Myocardial Bridge, MCA: Mural Coronary ArteryMCA on diastolic and systolic ph

20、ase Diastolic phase Systolic phase M，42y，AMI 4 years (at 38 years old)RCA: NO SIGNIFICANT STENOSIS LCX: NO SIGNIFICANT STENOSISMB: Myocardial BridgeMCA: Mural Coronary Artery LAD: MB-MCAF，67y，EFFORT ANGINA，3MMyocardial infarction F，67y，EFFORT ANGINA，3M M, 53 y, Chest Malaise 3 yearsMyocardial ischem

21、ia女63歲，冠心病17年，高血壓2年擴(kuò)張性心肌病肥厚性心肌病術(shù)前 術(shù)后瓣膜病變左房黏液瘤心臟腫瘤心房腫瘤？“胸痛三聯(lián)”檢查-PE“胸痛三聯(lián)”檢查主動脈壁內(nèi)血腫CABG復(fù)查ANASTOMOSIS STENOSIS支架通暢冠脈支架評價M/58支架鄰近再發(fā)狹窄支架內(nèi)膜增生In-Stent Restenosis74 cases 16 MDCT(n=27), 64 MDCT(N=43)Demonstration ISR: Accuracy 93% (10/70) Sen 100% PPV 67% Spe 91% NPV 100%MDCTIVUS stent diameter and area : R=

22、0.78, R=0.73Van Mieghem CA, et al, Circulation, 2006,114(7):616-61937個冠脈內(nèi)支架CTA與DSA評價再狹窄 劉新，楊立 等， 中華放射學(xué)雜志，2006，40（8）：808 sen spe ppv npv肉眼觀察法（） 18 69 20 67 CT值測量法（） 27 81 38 72冠狀動脈起源和分布變異LAD、LCX單獨在左冠竇開口：LCX異位起源RCA、D1RCA、LAD共干LADRCA回旋支缺如冠狀動脈間交通RCA起源主動脈LAD、LCX共同起源左冠竇 LCX起自D1并纖細(xì)左、右冠脈共干冠脈畸形并左右交通左冠經(jīng)交通支與右冠相連LCX 起源RCALCX 起源RCA心臟CT和其他檢查心臟CT應(yīng)用 替代檢查心臟鈣化 超聲冠脈鈣化 參照其他風(fēng)險因素評估冠脈解剖異常 MRI冠脈狹窄篩選