邢振义　刘善贤　李艳慧　王磊　夏鹤春　孙涛

1.河南新乡市中心医院神经外科　新乡　453600; 2.宁夏医科大学总医院神经外科　银川　750004



探讨3D-FIESTA和3D-TOF在三叉神经痛微血管减压术中的指导意义及临床价值

邢振义1)刘善贤1)李艳慧1)王磊1)夏鹤春2)孙涛2)

1.河南新乡市中心医院神经外科新乡453600; 2.宁夏医科大学总医院神经外科银川750004

【摘要】目的探讨三维稳态进动快速成像序列(3D-FIESTA)和三维时间飞跃法(3D-TOF)在三叉神经痛微血管减压术中的指导意义及临床价值。方法回顾性分析86例三叉神经痛微血管减压术患者术前MRI及术中影像，分析3D-FIESTA 和3D-TOF-MRA序列在三叉神经痛患者与责任血管的关系以及其临床意义。结果本组86例患者证实83例(96.5%)存在血管神经关系密切，以术中所见影像为金标准。术前均采用3D-FIESTA 和3D-TOF-MRA序列。本组78例患者至目前无明显症状，2例再次手术，1例术后面部麻木无疼痛，1例术后出现颅内感染症状经抗感染治疗后痊愈，2例面部间断性轻度疼痛且拒绝口服药物(患者自述不影响正常生活)，未给予特殊处理，1例遗漏轻度面瘫。1例失访。结论术前3D-FIESTA 和3D-TOF-MRA检查能够清晰识别三叉神经痛患者神经血管的关系，对指导微血管减压术以及预测手术难易度有重要的临床意义。

【关键词】三叉神经痛；微血管减压术；磁共振成像

三叉神经痛(trigemimal neuralgia，TN)是以三叉神经区域反复发作的剧烈尖锐的疼痛为主要特征。其中原发性三叉神经痛多数学者支持Jannetta提出微血管压迫的“短路”学说[1]。目前多数患者需手术治疗，术前对责任血管的分析辨别对取得手术效果意义重大，本文通过回顾性分析新乡市中心医院神经外科2013-01—2014-10间86例患者结合术中影像来探讨FIESTA、TOF序列对微血管减压术的指导意义及临床价值，现报道如下。

1资料与方法

1.1一般资料本组86例患者均为原发性三叉神经痛,其中男30例，女56例；年龄33～68岁，平均50.52岁。病程：1个月～22 a, 其中<4 a 57例，4～9 a 15例，≥10 a 14例。患者均曾经口服药物(卡马西平)治疗有效，但无法耐受者获不断加大剂量。

1.2研究方法(1)影像学检查：患者术前均行FIESTA、TOF序列，(美国GE HDxt 3.0T MR 成像系统和8通道头颈联合线圈)(2)手术方法：患者均采用经乙状窦后入路。

2结果

2.1责任血管类型及与三叉神经的接触程度根据 Arbab的标准分析[2]：本组86例患者MRI检出者83例(96.5%)，83例术中均证实责任血管类型。小脑上动脉34例(40.9%)：小脑前下动脉20例(24.0%)，小脑后下动脉1例(1．2%)。 椎动脉5例(6.0%)。岩静脉5例(6.0%)。多支动 脉14例(16.8%)。动静脉混合4例(4.8%)。3例MRI显示无明显接触，手术未发现有血管接触或压迫，仅见三叉神经周围有蛛网膜粘连。

2.2治疗效果本组78例患者随访至目前无明显症状。2例再次手术。1例术后面部麻木无疼痛。1例术后出现颅内感染症状经抗感染治疗后痊愈。2例面部间断性轻度疼痛且拒绝口服药物(患者自述不影响正常生活)，未给予特殊处理，1例轻度面瘫。1例失访。

3讨论

随着MRI技术的发展，其用于微血管减压术前行MRI检查，不仅可在术前明确神经血管关系，同时对于取得良好手术效果具有重要指导作用。特别是高分辨率MRI，尤其是3D-FIESTA序列及3D-T0F MRA在术前检出TN患者的责任血管、判断症状侧三叉神经与责任血管的相对位置以及判断责任血管的性质等方面准确性高，对 MVD术前评价、制定手术方案及判断预后都具有重要意义[3]。

3D-FIEST序列利用重T2WI的效果来衬托脑脊液的信号，达到相同于“脑室系统造影”的效果。动、静脉及三叉神经都呈低信号，而脑脊液显示为明显高信号，其分辩率和对比度具有高空间性，再加用流动补偿技术，可有效消除流动干扰伪影，对于细小静脉也能清晰显示[4]，但无法明显区别神经和血管组织。而在3D-T0F MRA上，动脉显示为高信号，静脉不易显示，三叉神经显示为中等信号，脑脊液显示为低信号。通过对3D-FIESTA序列和3D-TOF MRA序列的观察，可以判断责任血管类型，3D-T0F MRA图像上显示的血管为动脉，而在3D-FIESTA图像上显示却未在3D-T0F MRA图像上显示的血管为静脉。二者结合不仅可准确判断出责任血管的性质(动脉或静脉)，避免患者注射造影剂痛苦，并减轻患者经济负担。文献报道[5]在判断责任血管性质方面，3D-FIESTA和3D-T0F MRA[6]图像相结合的准确率98.0%，与本文观察结果(96.5%)相近。

本组5例出现不同程度并发症，文献报道[7]新生的责任血管亦是引起复发的重要原因，故临床应不断提高手术技巧，充分减压，降低责任血管遗漏，避免材料的移位、脱落，预防术后蛛网膜粘连等均可降低术后并发症，提高手术效果。同时术中应尽量较少对脑组织的损伤。

4参考文献

[1]Jannetta PJ.Microsurgical approach to the trigeminal nerve for the douloureux[J].Prog NeuroSurg,1976(7):180-186.

[2]Arbab A S, Nishiyama Y, Aoki S, et al. Simultaneous display of MRA and MPR in detecting vascular compression for trigeminal neuralgia or hemifacial spasm:comparison with oblique sagittal views of MRI[J]. European radiology, 2000, 10(7):1056-1060.

[3]Chavhan GB,Babyn PS,Jankharia BG.Steady-state MR imaging sequences:physics,classification,and clinical applications[J].Radiographics.2008;28:1147-1160.

[4]林青，童绥君，曲红丽，等．磁共振断层血管成像对三叉神经痛病因的诊断价值[J]．福建医科大学学报，2013，42(4)：341-343．

[5]Zeng Q,Zhou Q,Liu Z,Li Z,et al. Preoperative detection of the neurovascular relationship in trigeminal neuralgia using three-dimensional fast imaging employing steady-state acquisition (FIESTA) and magnetic resonance angiography (MRA)[J].J Clin Neurosci.2013;20(1):107-11.

[6]Garcia M, Naraghi R, Zumbrunn T, et al.High-resolution 3D-constructive interference in steady-state MR imaging and 3D time-of-flight MR angiography in neurovascular compression: a comparison between 3T and 1.5T[J]. Am J Neuroradiol. 2012;33(7):1251-125 6.

[7]杨德宝，王之敏，将栋毅,等.显微血管减压术治疗三叉神经痛术后复发与再手术[J].中华神经医学杂志，2013,12(3)：308-310.

(收稿2016-01-22)

The guiding significance and clinical value of 3D-FIESTA and 3D-TOF in microvascular decompression for trigeminal neuralgia

1)XingZhenyi,LiuShanxian,LiYanhui,WangLei,DepartmentofNeurosurgery,XinxiangCentralHospital,Xinxiang, 453600,China；2)XiaHechun,SunTao.

DepartmentofNeurosurgery，NingxiaMedicalUniversity，theAffiliatedHospital,Yinchuan750004,China

【Key words】Trigeminal neuralgia; Microvascular decompression; Magnetic resonance imaging

【Abstract】ObjectiveTo investigate the guiding significance and clinical value of 3D-FIESTA and 3D-TOF in microvascular decompression for trigeminal neuralgia. MethodsPreoperative MRI and intraoperative images on 86 patients with microvascular decompression for trigeminal neuralgia were retrospectively analyzed. Meanwhile, the roles of 3D-FIESTA and 3D-TOF-MRA on the relationship between nerves and responsible vessels in trigeminal neuralgia patients as well as the clinical significance were analyzed. ResultsA total of 86 cases in this group had confirmed that 83 cases existed a close relationship between blood vessels and nerves, regarding intraoperative images as golden standard. 3D-FIESTA and 3D-TOF-MRA were adopted before operation. All patients in this group showed efficiencies after operation and so far 78 cases had no significant symptom; 2 patients received the operation again; 1 case had facial numbness without pains; 1 case had intracranial infection after operation and cured with anti-infective therapy; 2 cases had facial intermittent mild pain and refused to take oral drugs (patients had stated those pains did not affect normal life), without special treatments; 1 case had mild facial paralysis and 1 case was lost to follow up. ConclusionPreoperative 3D-FIESTA and 3D-TOF-MRA can clearly reveal the relationship between nerves and blood vessels in trigeminal neuralgia patients, which is of vital clinical significance in guiding microvascular decompression and predicting operation difficulty.

【中图分类号】R445.2

【文献标识码】B

【文章编号】1077-8991(2016)02-0005-03