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在1920年最早由Krukenberg提出主动脉壁间血肿(aortic intramural hematoma,AIH),AIH定义为主动脉壁间发生的血肿,没有游离内膜片,无明显内膜撕裂或血流交通[1]。急性期主动脉壁间血肿(acute aortic intramural hematoma,AAIH)是指2周内发病并确诊的AIH。笔者回顾性分析AAIH的多层螺旋CT血管造影(multiple slice computed tomography angiography,MSCTA)影像学特征,探讨MSCTA的应用价值,为临床个性化治疗提供参考。
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76例AAIH患者中Stanford A型27例(35.5%)(图 1),其中男性18例、女性9例,平均年龄(64.0±12.6)岁;B型49例(64.5%)(图 2),男性35例、女性14例,平均年龄(66.5±10.3)岁。Stanford A型与B型AAIH患者在性别、年龄分布上的差异的均无统计学意义(χ2=0.187,P =0.665;t=-0.964,P =0.338)。
图 1 患者男性,72岁,急性期主动脉壁间血肿Stanford A型,MSCTA平扫横断位、增强横断位和矢状位最大密度投影图像图中,A:MSCTA平扫横断位显示升主动脉和降主动脉管径增粗,外围新月形稍高密度影(白色箭头所示);B:MSCTA增强横断位显示壁间血肿,内部无对比剂充盈(白色箭头所示);C:MSCTA增强矢状位最大密度投影重建直观显示壁间血肿累及范围(白色箭头所示)。MSCTA:多层螺旋CT血管造影。
Figure 1. Male, 72-year-old, Stanford A acute aortic intramural hematoma. Multiple slice computed tomography angiography plain axial image, enhancement axial image and maximum intensity projection image
图 2 患者男性,51岁,急性期主动脉壁间血肿Stanford B型,MSCTA平扫横断位和增强横断位图像图中,A:MSCTA平扫横断位显示降主动脉外围新月形稍高密度影(白色箭头所示);B:MSCTA增强横断位显示壁间血肿无对比剂充盈,升主动脉未受累(白色箭头所示)。MSCTA:多层螺旋CT血管造影。
Figure 2. Male, 51-year-old, Stanford B acute aortic intramural hematoma. Multiple slice computed tomography angiography plain axial image and enhancement axial image
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76例患者的MSCTA均能清晰显示AAIH的累及范围和程度。CT平扫表现为主动脉管壁增厚,沿主动脉管壁纵向延伸,新月形增厚46例(60.5%),环形增厚30例(39.5%)。CT平扫壁间血肿CT值均>60 HU,内膜钙化影内移48例(63.2%)。MSCTA扫描示主动脉管腔均匀强化,壁内无假腔形成。AAIH溃疡类病变32例(42.1%),局限性强化11例(14.4%),合并心包积液15例(19.7%),胸腔积液39例(64.5%)。
Stanford A型与B型AAIH患者在壁间血肿厚度、合并溃疡类病变、局灶性强化、合并胸腔积液之间的差异均无统计学意义(P>0.05)。Stanford A型与B型AAIH患者在受累主动脉最大管径、溃疡类病变深度、合并心包积液之间的差异均有统计学意义(t=5.020、Z=-2.345、χ2=16.138,均P < 0.05)(表 1)。
Stanford分型
(例数)男/女
(例)平均年龄/岁 受累主动脉最大管径/mm 壁间血肿最大厚度/mm 溃疡类病变深度/mm 溃疡类病变/例 局灶性强化/例 心包积液/例 胸腔积液/例 A型(n=27) 18/9 64.0±12.6 45.1±9.1 10.6±3.8 2.8±2.9 10 3 12 12 B型(n=49) 35/14 66.5±10.3 35.7±4.7 10.4±3.2 2.5±3.3 22 8 3 27 检验值 χ2=0.187 t=-0.964 t=5.020 Z=-0.788 Z=-2.345 χ2=0.441 χ2=0.383 χ2=16.138 χ2=0.338 P值 0.665 0.338 < 0.001 0.431 0.019 0.507 0.536 < 0.001 0.561 注:表中,AAIH:急性期主动脉壁间血肿;MSCTA:多层螺旋CT血管造影。 表 1 Stanford A型与Stanford B型AAIH患者的临床特征和MSCTA影像学表现
Table 1. Clinical characteristics and multiple slice computed tomography angiography features between Stanford A and B acute aortic intramural hematoma
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76例AAIH患者中,41例患者有短期随访。其中进展组20例,男性14例、女性6例,平均年龄(65.0±10.8)岁;稳定和缓解组21例,男性17例、女性4例,平均年龄(62.4±12.3)岁。进展组Stanford A型9例(进展为AD 4例;进展为主动脉瘤2例;死亡3例),B型11例[进展为AD 4例,进展为主动脉瘤3例,均接受主动脉腔内隔绝修补术(图 3);壁间血肿厚度增加4例]。稳定和缓解组Stanford A型5例、B型16例(图 4)。进展组受累主动脉最大管径和壁间血肿最大厚度分别为(39.6±9.7)mm和(10.7±3.0)mm;稳定组为(38.4±6.9)mm和(9.8±3.7)mm。进展组有12例合并溃疡类病变,平均溃疡深度为(3.9±4.0)mm;稳定和缓解组有3例合并溃疡类病变,平均溃疡深度为(1.3±3.5)mm。进展组及稳定和缓解组合并局灶性强化均为4例。进展组出现心包积液和胸腔积液分别为5例和13例,其中3例心包积液密度较高,提示为心包积血,短期随访死亡;稳定和缓解组分别为2例和7例。
图 3 患者男性,50岁,急性期主动脉壁间血肿Stanford B型,MSCTA增强横断位、矢状位和数字减影血管造影图像图中,A:MSCTA增强横断位显示降主动脉外围新月形稍高密度影,合并左侧胸腔积液和左肺下叶压迫性膨胀不全(白色箭头所示);B:MSCTA增强冠状位显示壁间血肿,内部多个溃疡类病变(白色箭头所示);C:两天后该患者接受主动脉腔内隔绝术。MSCTA:多层螺旋CT血管造影。
Figure 3. Male, 50-year-old, Stanford B acute aortic intramural hematoma. Multiple slice computed tomography angiography enhancement axial, saggital and digital subtraction angiography images
图 4 患者男性,45岁,急性期主动脉壁间血肿Stanford B型,首次检查和复查MSCTA增强横断位图像图中,A:MSCTA横断位显示降主动脉外围新月形稍高密度影,厚度约为8.7 mm(白色箭头所示);B:患者保守治疗3个月后复查,MSCTA横断位显示壁间血肿厚度明显缩小约为2.0 mm(白色箭头所示)。AAIH:急性主动脉壁间水肿;MSCTA:多层螺旋CT血管造影。
Figure 4. Male, 45-year-old, Stanford B acute aortic intramural hematoma. Multiple slice computed tomography angiography axial images in acute stage and follow up
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采用单因素检验方法分析,结果显示进展组、稳定和缓解组在合并溃疡类病变、溃疡类病变深度、胸腔积液间差异均有统计学意义(χ2=9.227、Z=-2.689、χ2=4.111,均P < 0.05);进展组、稳定和缓解组在性别、年龄、Stanford分型、受累主动脉管径、壁间血肿厚度、局灶性强化、心包积液方面差异均无统计学意义(χ2=0.666、t=0.723、χ2=1.453、t= -0.439、Z=-0.874、χ2=0.006、χ2=1.733,均P > 0.05)(表 2)。
组别
(例数)性别
(男/女)平均年龄/岁 Stanford分型
(A型/B型)受累主动脉最大管径/mm 壁间血肿最大厚度/mm 溃疡类病变深度/mm 溃疡类病变/例 局灶性强化/例 心包积液/例 胸腔积液/例 进展组(n=20) 14/6 65.0±10.8 9/11 39.6±9.7 10.7±3.0 3.9±4.0 12 4 5 13 稳定和缓解组(n=21) 17/4 62.4±12.3 5/16 38.4±6.9 9.8±3.7 1.3±3.5 3 4 2 7 检验值 χ2=0.666 t=0.723 χ2=1.453 t=-0.439 Z=-0.874 Z=-2.689 χ2=9.227 χ2=0.006 χ2=1.733 χ2=4.111 P值 0.414 0.474 0.228 0.663 0.387 0.007 0.002 0.939 0.188 0.043 注:表中,AAIH:急性期主动脉壁间血肿;MSCTA:多层螺旋CT血管造影。 表 2 进展组与稳定和缓解组AAIH患者的临床特征和MSCTA影像表现
Table 2. Clinical characteristics and multiple slice computed tomography angiography features between progression and stable acute aortic intramural hematoma in 41patients
将单因素分析中具有统计学意义的指标(溃疡类病变、溃疡深度、胸腔积液)纳入多因素Logistic回归分析,以AAIH是否进展Y为因变量,以溃疡类病变、溃疡类病变深度、胸腔积液为自变量,分别以X1、X2、X3表示,采用逐步向前法进行逐步回归分析,对各因素进行进一步筛选,结果显示仅溃疡类病变纳入回归方程(95% CI:0.024~0.505,P =0.004),回归方程:
$ P{\rm{ = 1/}}\left\{ {{\rm{1 + exp}}\left[{-\left( {{\rm{0}}{\rm{.811-2}}{\rm{.197X1}}} \right)} \right]} \right\} $
式中,X1表示自变量溃疡类病变,说明溃疡类病变是AAIH疾病进展的独立危险预测因学。
急性主动脉壁间血肿的多层螺旋CT血管造影影像学表现和诊断价值
Imaging findings and clinical value of multiple-slice computed tomography angiography in acute aortic intramural hematoma
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摘要:
目的探讨急性主动脉壁间血肿(AAIH)的多层螺旋CT血管造影(MSCTA)影像学特征和临床应用价值。 方法回顾性分析临床确诊76例AAIH患者的主动脉MSCTA检查资料,依据Stanford分型分为A型和B型,比较不同Stanford分型AAIH的影像学表现有无差异。根据患者随访期间的不同变化分为进展组与稳定和缓解组,分析进展的相关因素。所有结果均行统计学分析,符合正态分布的定量资料采用两独立样本t检验;不符合正态分布的定量资料采用Mann-Whitney U检验。定性资料采用χ2检验。 结果Stanford A型27例(35.5%)、B型49例(64.5%)。A型、B型壁间血肿最大厚度、溃疡类病变、局灶性强化、胸腔积液上的差异均无统计学意义(Z=-0.788、χ2=0.441、χ2=0.383、χ2=0.338,均P > 0.05)。A型、B型溃疡类病变的深度分别为(2.8±2.9)mm、(2.5±3.3)mm,差异有统计学意义(Z=-2.345,P=0.019)。心包积液15例(19.7%),A型12例多于B型3例,差异有统计学意义(χ2=16.138,P < 0.001)。41例AAIH患者短期随访,进展组20例,稳定和缓解组21例。单因素分析显示,进展组与稳定和缓解组在溃疡类病变、溃疡深度、胸腔积液间的差异均具有统计学意义(χ2=9.227、Z=-2.689、χ2=4.111,均P < 0.05);在Stanford分型、壁间血肿厚度、局灶性强化、心包积液上的差异均无统计学意义(χ2=1.453、Z=-0.874、χ2=0.006、χ2=1.733,均P > 0.05)。将单因素分析中有统计学意义的指标纳入多因素Logistic回归分析,显示溃疡类病变是影响AAIH的独立危险预测因子。 结论AAIH在MSCTA上表现为平扫密度较高、增强无强化的环形或新月形增厚主动脉管壁。MSCTA检查可以对AAIH做出快速、准确诊断。溃疡性病变是影响AAIH进展的独立危险因素。AAIH早期需要密切随访,监测有无进展。 -
关键词:
- 主动脉 /
- 体层摄影术,X线计算机 /
- 血管造影术 /
- 壁间血肿
Abstract:ObjectiveTo explore the imaging findings in and clinical value of multiple-slice computed tomography angiography (MSCTA) in acute aortic intramural hematoma (AAIH). MethodsA total of 76 AAIH cases with complete clinical information were recruited and subjected to MSCTA examinations.The patients were divided into progressive and stable groups according to the follow-up changes.Then, the clinical data and MSCTA features were compared.All outcomes were analyzed statistically.The quantitative data of normal distribution and abnormal distribution were tested by two independent samples and Mann-Whitney U test, respectively.The qualitative data were tested by chi-square test. ResultsA total of 27(35.5%) type A cases and 49(64.5%) type B cases were classified according to Stanford criteria.No significant difference in the maximum thickness of aortic hematoma, number of ulcer-like projections, degree of focal enhancement, and severity of pleural effusion was noted between the Stanford A and B groups (Z=-0.788, χ2=0.441, χ2=0.383, χ2=0.338, all P > 0.05).The ulcer depths in the Stanford A and B groups were (2.8±2.9) and (2.5±3.3) mm, respectively (Z=-2.345, P=0.019).Meanwhile, 15(19.7%) cases (12 type A cases and 3 type B cases) were accompanied by pericardial effusion (χ2=16.138, P < 0.001).Twenty cases belonged to the progressive group, whereas 21 cases were included in the stable group.Univariate statistical analysis showed significant differences in ulcer-like projection, ulcer depth, and pleural effusion between the progressive and stable groups (χ2=9.227, Z=-2.689, χ2=4.111, all P < 0.05).By contrast, no significant difference in Stanford subtype, maximum aortic thickness, maximum aortic hematoma thickness, focal enhancement, and pleural effusion was noted between the Stanford A and B groups (χ2=1.453, Z=-0.874, χ2=0.006, χ2=1.733, all P > 0.05).Multivariate analysis revealed that the amount of ulcer-like projections was the independent risk factor for AAIH progression. ConclusionsAAIH manifested as annular and/or crescent thickening aortic wall with higher density in plain scan and non enhancement in enhanced scan using MSCTA technique.MSCTA plays an important role in the correct diagnosis of AAIH patients.The number of ulcer-like projections is the independent risk factor for disease progression.Close follow up is hence recommended during the early stage of AAIH using MSCTA. -
Key words:
- Aorta /
- Tomography, X-ray computed /
- Angiography /
- Intramural hematoma
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图 1 患者男性,72岁,急性期主动脉壁间血肿Stanford A型,MSCTA平扫横断位、增强横断位和矢状位最大密度投影图像图中,A:MSCTA平扫横断位显示升主动脉和降主动脉管径增粗,外围新月形稍高密度影(白色箭头所示);B:MSCTA增强横断位显示壁间血肿,内部无对比剂充盈(白色箭头所示);C:MSCTA增强矢状位最大密度投影重建直观显示壁间血肿累及范围(白色箭头所示)。MSCTA:多层螺旋CT血管造影。
Figure 1. Male, 72-year-old, Stanford A acute aortic intramural hematoma. Multiple slice computed tomography angiography plain axial image, enhancement axial image and maximum intensity projection image
图 2 患者男性,51岁,急性期主动脉壁间血肿Stanford B型,MSCTA平扫横断位和增强横断位图像图中,A:MSCTA平扫横断位显示降主动脉外围新月形稍高密度影(白色箭头所示);B:MSCTA增强横断位显示壁间血肿无对比剂充盈,升主动脉未受累(白色箭头所示)。MSCTA:多层螺旋CT血管造影。
Figure 2. Male, 51-year-old, Stanford B acute aortic intramural hematoma. Multiple slice computed tomography angiography plain axial image and enhancement axial image
图 3 患者男性,50岁,急性期主动脉壁间血肿Stanford B型,MSCTA增强横断位、矢状位和数字减影血管造影图像图中,A:MSCTA增强横断位显示降主动脉外围新月形稍高密度影,合并左侧胸腔积液和左肺下叶压迫性膨胀不全(白色箭头所示);B:MSCTA增强冠状位显示壁间血肿,内部多个溃疡类病变(白色箭头所示);C:两天后该患者接受主动脉腔内隔绝术。MSCTA:多层螺旋CT血管造影。
Figure 3. Male, 50-year-old, Stanford B acute aortic intramural hematoma. Multiple slice computed tomography angiography enhancement axial, saggital and digital subtraction angiography images
图 4 患者男性,45岁,急性期主动脉壁间血肿Stanford B型,首次检查和复查MSCTA增强横断位图像图中,A:MSCTA横断位显示降主动脉外围新月形稍高密度影,厚度约为8.7 mm(白色箭头所示);B:患者保守治疗3个月后复查,MSCTA横断位显示壁间血肿厚度明显缩小约为2.0 mm(白色箭头所示)。AAIH:急性主动脉壁间水肿;MSCTA:多层螺旋CT血管造影。
Figure 4. Male, 45-year-old, Stanford B acute aortic intramural hematoma. Multiple slice computed tomography angiography axial images in acute stage and follow up
表 1 Stanford A型与Stanford B型AAIH患者的临床特征和MSCTA影像学表现
Table 1. Clinical characteristics and multiple slice computed tomography angiography features between Stanford A and B acute aortic intramural hematoma
Stanford分型
(例数)男/女
(例)平均年龄/岁 受累主动脉最大管径/mm 壁间血肿最大厚度/mm 溃疡类病变深度/mm 溃疡类病变/例 局灶性强化/例 心包积液/例 胸腔积液/例 A型(n=27) 18/9 64.0±12.6 45.1±9.1 10.6±3.8 2.8±2.9 10 3 12 12 B型(n=49) 35/14 66.5±10.3 35.7±4.7 10.4±3.2 2.5±3.3 22 8 3 27 检验值 χ2=0.187 t=-0.964 t=5.020 Z=-0.788 Z=-2.345 χ2=0.441 χ2=0.383 χ2=16.138 χ2=0.338 P值 0.665 0.338 < 0.001 0.431 0.019 0.507 0.536 < 0.001 0.561 注:表中,AAIH:急性期主动脉壁间血肿;MSCTA:多层螺旋CT血管造影。 表 2 进展组与稳定和缓解组AAIH患者的临床特征和MSCTA影像表现
Table 2. Clinical characteristics and multiple slice computed tomography angiography features between progression and stable acute aortic intramural hematoma in 41patients
组别
(例数)性别
(男/女)平均年龄/岁 Stanford分型
(A型/B型)受累主动脉最大管径/mm 壁间血肿最大厚度/mm 溃疡类病变深度/mm 溃疡类病变/例 局灶性强化/例 心包积液/例 胸腔积液/例 进展组(n=20) 14/6 65.0±10.8 9/11 39.6±9.7 10.7±3.0 3.9±4.0 12 4 5 13 稳定和缓解组(n=21) 17/4 62.4±12.3 5/16 38.4±6.9 9.8±3.7 1.3±3.5 3 4 2 7 检验值 χ2=0.666 t=0.723 χ2=1.453 t=-0.439 Z=-0.874 Z=-2.689 χ2=9.227 χ2=0.006 χ2=1.733 χ2=4.111 P值 0.414 0.474 0.228 0.663 0.387 0.007 0.002 0.939 0.188 0.043 注:表中,AAIH:急性期主动脉壁间血肿;MSCTA:多层螺旋CT血管造影。 -
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