叶景 张小军 李军 钟群 洪景芳 王守森

(1广东三九脑科医院神经外一科，广东 广州510510 ；南京军区福州总医院:2神经外科；3影像科， 福建 福州 350025)

·脑血管疾病研究·

脑静脉与静脉窦血栓形成的MRV与DSA对照研究

叶景1张小军2李军2钟群3洪景芳2王守森2*

(1广东三九脑科医院神经外一科，广东 广州510510 ；南京军区福州总医院:2神经外科；3影像科， 福建 福州 350025)

目的探讨MRV对不同时期脑静脉与静脉窦血栓形成(CVST)的诊断价值。方法分析15例CVST患者，同期行MRV和DSA检查，将3D CE-MRV及2D TOF-MRV 与 DSA进行对比，探讨MRV对不同时期CVST的诊断价值。结果在急性及亚急性期CVST，3D CE-MRV的诊断准确性优于2D TOF-MRV。对于慢性期CVST，两者评价的灵敏度、特异度分别是：69.44%、98.15%和 100%、89.47%；两者评价CVST治疗后再通的灵敏度、特异度分别是：81.82%、71.88%和 60.00%、100%。结论对急性及亚急性CVST，3D CE-MRV较2D TOF-MRV的诊断准确性高。对慢性期及再通后的CVST，宜同时行3D CE-MRV和2D TOF-MRV检查，结合原始图像及MIP图像综合评价，必要时行DSA检查。

脑静脉及静脉窦血栓形成; 三维对比增强磁共振血管血流成像; 二维时间飞跃血流成像; 数字减影血管造影

脑静脉与静脉窦血栓形成(cerebral vein and sinus thrombosis,CVST)是脑血管疾病的一种少见类型，常规影像学诊断有一定难度，常出现漏诊或误诊。磁共振静脉血管成像(magnetic resonance venography,MRV)在诊断CVST中具有一定的优势[1]，虽然一些作者认为三维对比增强磁共振血管血流成像(three dimensional contrast-enhanced MRV,3D CE-MRV)优于二维时间飞跃血流成像(two dimensional time-of-flight MRV,2D TOF-MRV)[2～4]，但也有作者认为CE法在诊断慢性CVST时易出现漏诊，对于再通情况易出现误判[1,5,6]。本文以数字减影血管造影(digital subtraction angiogram,DSA)为标准，评估 MRV对不同时期CVST的诊断价值。

资料与方法

一、一般资料

回顾2008 年8月至2011 年12月期间南京军区福州总医院神经外科收治的CVST患者，共15例CVST患者同期行MRV与DSA检查。其中男性9例，女性6例。发病年龄为13～54岁，平均31.8岁。病程为1～380 d，中位数病程11 d。随访时间0.5～24个月，平均5.2个月(表1)。

二、影像采集与分析

MRV应用Siemens Trio Tim 3.0T磁共振成像系统采集。TOF-MRV采用冠状位/矢状位快速小角度(FLASH)序列扫描(TR/TE,23/4.4 msec;flip angle,35°;bandwidth,110 Hz/pixel;1.1 mm×1.0 mm×3.0 mm;TA:330 seconds)。CE-MRV采用3D快速小角度(FLASH)序列扫描(TR/TE,2.6/1.1 msec;flip angle,20°;bandwidth,930 Hz/pixel;1.2 mm×1.1 mm×1.2 mm;TA:30 seconds)。DSA检查使用GE Innova 3100平板DSA成像系统采集。所有患者检查之前均被告知MRV和DSA检查的方法、目的、意义和注意事项，并签订知情同意书。

所有患者的诊断均综合应用CE法和TOF法，每种序列均包括最大强度投影(maximum intensity projection,MIP)图像和原始图像。图像分析过程均有1位放射科副主任医师和2位脑血管病专家参与判断与比较，可疑之处经过讨论后确定。参考Sun等[1]的做法，颅内静脉系统分成16个部分，分别是：上矢状窦前、中、后段，左侧横窦内、外侧，左侧乙状窦，左侧Labbé静脉，左侧颈内静脉，右侧横窦内、外侧，右侧乙状窦，右侧Labbé静脉，右侧颈内静脉，Galen静脉，直窦，窦汇。

三、CVST的分期

参考Rizzo L[7]对CVST的分期方法，患者主诉的第1天为CVST形成的第1天，根据患者起病与确诊时间间隔将疾病分期：急性期(lt;2 d)；亚急性期(3 d～1个月)；慢性期(gt;1个月)。

四、统计学分析

采用SPSS 13.0 统计软件，对DSA与MRV检查结果进行配对四格表卡方检验，以Plt;0.05提示差异有显著性。结合CE法、TOF法、DSA诊断的结果，采用卡方检验，分别计算CE法、TOF法对CVST急性期、亚急性期、慢性期及其再通诊断的灵敏度、特异度、阳性预测值、阴性预测值、KAPPA值。

结 果

一、不同序列诊断效能比较

在急性及亚急性期CVST，3D CE-MRV的诊断准确性优于2D TOF-MRV。在慢性期CVST，两者评价的灵敏度、特异度分别是：69.44%、98.15%和 100%、89.47%。二者在评价CVST治疗后再通的灵敏度、特异度分别是：81.82%、71.88%和 60.00%、100%。

二、各期CVST影像学表现

急性期CVST 1例，行DSA、CE法及TOF法MRV检查，DSA和CE法都发现10处血栓形成；TOF法发现12处血栓，其中1处直窦和1处窦汇血流信号部分丢失，而DSA提示正常充盈(图1)。

亚急性期CVST 6例，其中行DSA和CE法检查5例，DSA和CE法共同发现23处血栓形成，1处上矢状窦前段CE法提示血流不规则充盈而DSA提示无异常；其中行DSA和TOF法检查3例，DSA和TOF法共同发现20处血栓形成，4处TOF-MRV提示血流信号丢失而DSA提示无异常(图2)。

慢性期CVST 8例，均行DSA和CE法检查， CE法和DSA共发现25处血栓形成，其中11处DSA提示显影浅淡或中断而CE法却显影良好(图3)，2处CE法提示不规则充盈而DSA提示无异常。其中2例行DSA和TOF法检查，DSA和TOF法共发现13处血栓形成，2处TOF法提示信号丢失而DSA提示充盈良好(图4)。

CE法发现9处再通，而DSA显示血栓形成(图3)；DSA发现2处血栓再通，而TOF法提示血流信号仍丢失(图5)。

三、DSA在CVST诊断中的假阳性

1例患者DSA显示左侧横窦显影缺失，而MRV矢状位显示横窦阙如，如图5所示。

图1 急性期CVST的MRV与DSA诊断比较
Fig 1 The comparison between MRV and DSA in the acute phase of CVST
A:2D TOF-MRV demonstrated the normal signals of blood flow in left transverse sinus and sigmoid sinus,which disappeared in the Torcular herophili (arrow);B:Left carotid arteriography revealed the filling of blood flow signals was normal in the straight sinus and Torcular herophili (arrow);C:3D CE-MRV showed the fine image of straight sinus and Torcular herophili (arrow).

图2 亚急性期CVST的TOF法与DSA诊断对比
Fig 2 The comparison between 2D TOF-MRV and DSA in the subacute phase of CVST
A:2D TOF-MRV demonstrated reduced blood flow in the right transverse sinus,sigmoid sinus and Labbé vein (arrow);B:Right carotid arteriography revealed a filling defect at the right transverse sinus and sigmoid sinus (thin arrow),and it showed normal blood flow in the Labbé vein (thick arrow).

图3 慢性期CVST的MRV与DSA诊断比较
Fig 3 The comparison between MRV and DSA in the chronic-phase of CVST
A:Two months after onset,right carotid arteriography revealed a filling defect at the posterior segment of the superior sagittal sinus (arrow);B:Four months after onset,3D CE-MRV showed the superior sagittal sinus filled with normal blood flow (thick arrow);C:Four months after onset,right carotid arteriography showed the superior sagittal sinus did not obviously improve (arrow). D:Four months after onset,right carotid arteriography showed the diploe veins had linked up with the intracranial venous circulation and the scalp developed thickly (arrow).

图4 CVST治疗后再通的MRV与DSA诊断比较
Fig 4 The comparison between TOF-MRV and DSA in evaluating the recanalization of sinus
A:At onset of acute phase,right carotid arteriography showed the filling defect at the posterior segment of superior sagittal sinus (arrow);B:Six months after onset,2D TOF-MRV showed that the superior sagittal sinus thrombosis did not improve obviously (arrow);C:Six months after onset,right carotid arteriography demonstrated normal blood flow in the superior sagittal sinus and suggested the recanalization (arrow).

图5 MRV与DSA在鉴别横窦发育异常与血栓形成的对比
Fig 5 The comparison between MRV and DSA in distinguishing the hypoplastic transverse sinus from thrombosis
A:Left carotid arteriography showed the right transverse sinus (thin arrow) dominantly developed and the left Labbé vein (thick arrow) was refluxed through the hypoplastic sigmoid sinus;B:MIP image of 3D CE-MRV demonstrated a filling defect at the left transverse sinus (arrow);C:Sagittal original image of MRV revealed absence of the sinus structure at the location of left transverse sinus (arrow).

表1 15例CVST患者的临床资料
Tab 1 The clinical data of 15 cases of patients with CVST

CaseNO．Sex/Ageyears)ChiefcomplaintPossiblecontributingcauseDiagnosticdelayAvailableimaging Trackingtime(month) 1F/28 headache，seizurepuerperium2daysDSA，CE，TOF7 2M/21 headache，vomitinghomocysteinemia9daysDSA，CE，TOF7 3F/21 paresis，vomitingunknown9daysDSA，CE，TOF2 4M/44 headacherespiratorytractinfection10daysDSA，CE1．5 5F/28 dizzinesshypertension25daysDSA，CE1 6F/30 headache，Lethargypuerperium2weeksDSA，CE，TOF0．5 7F/26 headache，vomiting，aphasispuerperium，anemia22daysDSA，CE1 8M/30 headache，hypertension syndrome，feverbechet＇sdisease2monthsDSA，CE24 9F/51 headacheunknown33daysDSA，CE1．5 10M/47 headachecerebralfalxmeningioma1yearDSA，CE1 11M/19 hypertensionVenousthrombosisoflowerextremity2monthsDSA，CE2 12M/17 headache，feverpheochromocytoma1monthDSA，CE2 13M/54 headache，seizureunknown11monthsDSA，CE13 14M/48 headache，hypopsiaunknown1yearDSA，CE，TOF6 15M/13 headacheunknown3monthsDSA，CE8

Note:CE:3D CE-MRV;TOF:2D TOF-MRV

表2 以DSA为标准，评价CE-MRV、TOF-MRV对CVST的诊断价值
Tab 2 Taking DSA as the standard to evaluate the value of CE-MRV,TOF-MRV in the diagnosis of CVST

StagingAvailableimagingSensitivitySpecificityPositivepredictivevalueNegativepredictivevalueκvalues Acutephase，subacutephaseCE100%97．87%97．09%100%97．43% TOF100%85．29%85．71%100%96．68% Chronic⁃phaseCE69．44%98．15%92．59%90．60%73．73% TOF100%89．47%86．67%100%87．35% RecanalizationCE81．82%71．88%50．00%92．00%44．42% TOF60．00%100%100%86．67%52．63%

Note:CE:3D CE-MRV;TOF:2D TOF-MRV

讨 论

目前，关于CE-MRV评价CVST治疗后再通方面，仍有争议[1,8]。CVST治疗后是否再通、程度如何，往往与临床症状改善相关，治疗后是否再通和临床症状是否改善可能影响下一步治疗方案的制订，但目前尚无相关报道。Klingebiel 等[2～4]认为，CE法对CVST诊断的敏感性和特异性较高。本研究结果显示，急性及亚急性期CVST诊断中，3D CE-MRV诊断准确性优于2D TOF-MRV，但在诊断慢性CVST的敏感性仅为69.44%，容易漏诊。CE法在诊断CVST再通的特异性低，容易误诊。CE法对不同时期CVST诊断能力上差异较大，其诊断慢性CVST的能力受到质疑，原因可能是慢性血栓的血管增强效应。在慢性期CVST，CE法理论上可观察到静脉窦或皮质静脉的周壁强化及腔内不强化，但实际上更多表现为窦腔完全强化。Reinaeher等[9]认为，慢性期血栓机化伴微血管形成后的自身强化现象，在与血栓部分再通的强化现象相鉴别时，应在 MIP 图像上结合增强前后的原始图像综合分析。

本研究结果认为，TOF法诊断慢性CVST的敏感性高于CE法，与Sun等[1]的报道一致，但TOF法易造成信号丢失，假阳性率高[10]。TOF法常导致上矢状窦垂直段、窦汇、横窦与乙状窦连接部、乙状窦、非优势侧或发育不良横窦出现信号丢失，使得与真正的血栓形成不易鉴别，与既往报道一致[11]。TOF法对急性、亚急性CVST的诊断能力不如CE法，且在CVST再通的诊断方面敏感性较差，原因可能是CVST再通由许多细小的血流组成，这些血流通常较正常静脉窦缓慢， TOF法检测过程中不易采集到这部分慢血流信号。本研究中TOF法诊断都同时结合原始图像和MIP图像进行，使得本文TOF法诊断敏感性都较文献报道的高[12,13]。

目前普遍认为DSA是诊断CVST的“金标准”[14,15]。但是，DSA不仅有创、费用高、有碘造影剂过敏的风险，难以鉴别先天性窦腔阙如和血栓形成，易出现“假阳性”。关于如何鉴别先天横窦阙如和血栓形成，需仔细参照MRV的矢状位原始图像。一侧横窦先天阙如者，在其横窦位置观察不到窦腔结构，有别于血栓形成的影像学表现。有学者[16]认为，在诊断CVST时应警惕解剖变异，在真正的一侧横窦阙如者，至少Labbé静脉能正常回流，且该侧乙状窦通常是存在的；而一侧横窦血栓形成时,其相连的乙状窦和颈静脉球、颈内静脉上段等均可能存在血栓，而且Labbé静脉也常无法正常引流。DSA 是有创检查，虽然不少作者认为MRI和MRV 结合有望取代DSA，可成为诊断本病的金标准[17]，但本研究结果显示，MRV在诊断慢性CVST及评价慢性CVST再通的方面，仍不足以取代DSA。

1Sun Y,Zhang DY,Ji XM,et al. Diagnostic performance of magnetic resonance venography in the detection of recanalization in patients with chronic cerebral venous sinus thrombus [J]. Chin Med J (Engl),2009,122(20):2428-2432.

2Klingebiel R,Bauknecht HC,Bohner G,et al. Comparative evaluation of 2D time-of-flight and 3D elliptic centric contrast-enhanced MR venography in patients with presumptive cerebral venous and sinus thrombosis [J]. Eur J Neurol,2007,14(2):139-143.

3Meckel S,Reisinger C,Bremerich J,et al. Cerebral venous thrombosis:diagnostic of combined,dynamic and static,contrast-enhanced 4D MR venography [J]. AJNR Am J Neuroradiol,2010,31(3):527-535.

4Fu JH,Lai PH,Hsiao CH,et al. Comparison of real-time three-dimensional gadolinium-enhanced elliptic centricordered MR venography and twodimensional time-offlight MR venography of the intracranial venous system [J]. J Chin Med Assoc,2010,73(3):131-138.

5Liang L,Korogi Y,Sugahara T,et al. Evaluation of the intracranial dural sinuses with a 3D contrast-enhanced MP-RAGE sequence:prospective comparison with 2D-TOF MR venography and digital subtraction angiography [J]. AJNR Am J Neuroradiol,2001,22(3):481-492.

6Haroun A. Utility of contrast-enhanced 3D turbo-flash MR angiography in evaluating the intracranial venous system [J]. Neuroradiogy,2005,47(5):322-327.

7Rizzo L,Crasto SG,Rudà R,et al. Cerebral venous thrombosis:role of CT,MRI and MRA in the emergency setting [J]. Radiol Med,2010,115(2):313-325.

8Leach JL,Wolujewicz M,Strub WM. Partially recanalized chronic duralsinus thrombosis:findings on MR imaging,time-of-flight MR venography,and contrast-enhanced MR venography [J]. AJNR Am J Neuroradiol,2007,28(4):782-789.

9Reinaeher P,Reinges MH,Simon VA,et al. Dynamic 3-D contrast-enhanced angiography of cerebral tumours and vascular malformations [J]. Eur Radiol,2007,17 (Suppl 6):52-62.

10Sahin N,Solak A,Genc B,et al. Cerebral venous thrombosis as a rare cause of subarachnoid hemorrhage:case report and literature review [J]. Clin Imaging,2014,38(4):373-379.

11Mermuys KP,Vanhoenacker PK,Chappel P,et al. Three dimensional venography of the brain with a volumetric interpolated sequence [J]. Radiology,2005,234(3):901-908.

12Leach JL,Fortuna RB,Jones BV,et al. Imaging of cerebral venous thrombosis:current techniques,spectrum of findings,and diagnostic pitfalls [J]. Radiographics,2006,26 (Suppl 1):19-41.

13Meckel S,Reisinger C,Bremerich J,et al. Cerebral venous thrombosis:diagnostic of combined,dynamic and static,contrast-enhanced 4D MR venography [J]. AJNR Am J Neuroradiol,2010,31(3):527-535.

14White JB,Kaufmann TJ,Kallmes DF. Venous sinus thrombosis:a misdiagnosis using MR angiography [J]. Neurocrit Care,2008,8(2):290-292.

15Linn J,Brückmann H. Cerebral venous and dural sinus thrombosis [J]. Clin Neuroradiol,2010,20(1):25-37.

16王守森,张小军,钟群,等. 脑静脉与静脉窦血栓形成的临床诊断(附13例分析) [J]. 中华神经外科疾病研究杂志,2011,10(2):173-175.

17王建祯,凌锋,吉训明,等. 外伤性脑静脉窦血栓形成 [J]. 中华神经外科杂志,2007,6(2):168-170.

Case-controlstudyofcerebralvenoussinusthrombosisbetweenMRVandDSA

YEJing1,ZHANGXiaojun2,LIJun2,ZHONGQun3,HONGJingfang2,WANGShousen2*

1DepartmentofNeurosurgery,999BrainHospitalofGuangdong,Guangzhou510510;2DepartmentofNeurosurgery;3DepartmentofRadiology,FuzhouGeneralHospitalofPLA,Fuzhou350025,China

ObjectiveThe purpose of our study is to prospectively investigate the diagnostic value of MRV in the evaluation of different stages of CVST using DSA as the reference standard.MethodsA total of 15 patients with CVST were recruited into this study. Diagnostic accuracy of MRV in the detection of different stages and recanalized of thrombus was evaluated.ResultsIn the acute and subacute phase of CVST,the diagnostic accuracy of 3D CE-MRV was better than that of 2D TOF-MRV. The sensitivity and specificity of 3D CE-MRV and 2D TOF-MRV for chronic CVST were 69.44%,98.15% and 100%,89.47% respectively;the sensitivity and specificity of 3D CE-MRV and 2D TOF-MRV for the recanalized CVST were 81.82%,71.88% and 60.00%,100% respectively.ConclusionCompared with 2D TOF-MRV,3D CE-MRV provides a high sensitivity and specificity for the diagnosis of acute and subactue CVST,which almost has the same diagnostic value as DSA. In the diagnosis of chronic CVST and recanalized CVST segments,both 3D CE-MRV and 2D TOF-MRV are suggested to estimate pathogenetic condition with the reference of the original image with MIP images. DSA would be performed if necessary.

Cerebral venous sinus thrombosis; 3D CE-MRV; 2D TOF-MRV; DSA; Digital subtraction angiography

1671-2897(2016)15-485-05

R 651

A

福建省科技计划重点项目资助项目(2010Y0043,2014Y0036)

叶景，硕士，主治医师，E-mail:yejing2000@126.com

*通讯作者：王守森，教授、主任医师，博士生导师，E-mail：wshsen@126.com

2014-09-01；

2015-01-25)