- 學位論文
使用多模式非造影核磁共振技術評估急性主動脈症候群和下肢週邊血管疾病的先導研究
A Pilot Study Using Multi-Mode Non-Contrast Nuclear Magnetic Resonance Technologies to Evaluate Acute Aortic Syndrome and Lower Extremity Peripheral Vascular Disease
摘要
周邊血管疾病［Peripheral Vascular Disease（PVD），是指心臟、主動脈、頸動脈和顱內血管以外的任何循環障礙，主要是以周邊動脈疾病（Peripheral Artery Disease）和慢性靜脈疾病（Chronic Venous Disease）為主要表現方式，皆在下肢最為常見］和急性主動脈症候群［Acute Aortic Syndrome（AAS），是一個現代術語，包括主動脈剝離（Aortic Dissection）、壁內血腫（Intramural Hematoma）、穿透性粥狀動脈硬化潰瘍（Penetrating Atherosclerotic Ulcer）和破裂的主動脈瘤（Ruptured Aortic Aneurysm）］會引起一系列健康問題，並衍生巨大的醫療費用支出。臨床上通常利用超音波和橫截面醫療影像工具(如顯影劑核磁共振血管造影術或電腦斷層血管造影術)作為第一線的標準診斷工具。然而，有血管疾病的患者也有很高的機率合併慢性腎臟疾病。這種合併症引起人們對在血管疾病患者中使用顯影劑可能引起併發症的擔憂。而非造影核磁共振技術（Non-Contrast Magnetic Resonance Angiography，NC-MRA）是一種無需顯影劑即能用於診斷的血管圖像的一門新穎技術。而這門技術相關的研究大都於神經系統疾病和動脈疾病的應用。本論文則著重於下肢靜脈疾病和主動脈疾病的應用。此論文在檢驗一個虛無假說，即由於形成的偽影導致成像品質差以及需要花費大量的成像時間，使得NC-MRA難以成為PVD和AAS的常規評估。 本論文為橫斷面設計，於2017年4月至2020年5月在嘉義長庚紀念醫院招募AAS患者和PVD患者。所有受試者皆接受了多模式NC-MRA評估。AAS的患者接受四維相差核磁共振成像（Four-Dimensional Phase-Contrast Magnetic Resonance Imaging，4D PC-MRI）評估主動脈的形態和渦流。並以定量相差流量測量（Quantitative Phase-Contrast Flow Measurement；Q-Flow）分析血液動力學變化。並與電腦斷層血管攝影術（AAS的標準診斷工具）比較，評估4D PC-MRI診斷AAS中的信效度。另一方面，下肢血管疾病患者接受了觸發血管造影非對比增強核磁共振成像（TRiggered Angiography Non-Contrast Enhanced Magnetic Resonance Imaging，TRANCE-MRI），以評估骨盆和腿部血管的形態。然後使用Q-Flow測量，來分析血液動力學變化。並與雙工超音波（Duplex Ultrasound）檢查（PVD的標準診斷工具）比較，評估TRANCE-MRI診斷下肢血管疾病的信效度。 研究顯示，在AAS和PVD患者身上，多模式NC-MRA各自與該疾病的標準診斷工具具有相近的診斷表現（通過Cohen's Kappa Statistic測量評分者間信度）。應用NC-MRA作為介入治療前的影像評估工具和金屬支架植入後的影像追蹤工具，皆具有臨床有效性和可靠性。 NC-MRA在主動脈疾病患者中的臨床應用，在介入治療前的影像評估和金屬支架植入後的影像追蹤都具明顯的效度。此外，NC-MRA在評估下肢靜脈病理方面具有許多優勢。NC-MRA確認血管病理的臨床實用性非常寶貴，尤其是在腎功能不全的患者中。未來的進一步相關研究將能促此技術有更多的討論和臨床的應用。
並列摘要
Peripheral vascular disease [aka PVD, refers to any circulatory disorder other than the heart, aorta, carotid artery, and intracranial blood vessels. Mainly are peripheral artery disease and chronic venous as the primary manifestations, both of which are most common in the lower extremity] and acute aortic syndrome [aka AAS, is a modern term that includes aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and ruptured aortic aneurysm] could cause a series of health problems, leading to a huge cost in relevant medical care. Ultrasound and cross-sectional imaging modalities (such as contrast-enhanced magnetic resonance (MR) angiography or computed tomography (CT) angiography) using contrast agents (gadolinium-based MR contrast medium or Iodine-based CT contrast medium) are usually used as the standard diagnostic tools. However, chronic kidney disease was prevalent in patients with vascular diseases. This comorbidity had increased the concern of side effects of the use of contrast agents for diagnostic aims. Non-contrast magnetic resonance angiography (NC-MRA) can be performed without contrast agents to generate vascular images for diagnosis use. Regarding clinical applications of NC-MRA, previous studies focused on neurological diseases and arterial diseases. By contrast, the application of NC-MRA herein focuses on lower extremity venous disease and acute aortic disease. Our studies aim to evaluate a null hypothesis that due to artifacts, poor imaging quality, and much time for acquiring imaging, NC-MRA is too insufficient to be a routine study procedure for PVD and AAS. This thesis is a cross-sectional design, recruited participants in Chang Gung Memorial Hospital, Chiayi branch, from April 2017 to May 2020. Patients with PVD or with AAS were recruited and underwent multimodal NC- MRA. Patients with AAS underwent four-dimensional phase-contrast magnetic resonance imaging (4D PC-MRI) to assess the morphology and eddy current of the aorta. Quantitative phase-contrast flow (Q-Flow) measurement was also used for analyzing the hemodynamic changes. The diagnostic performance of 4D PC-MRI in evaluating AAS was assessed compared to computed tomography angiography (standard diagnostic tool of AAS). On the other hand, patients with lower extremity vascular disease underwent TRiggered Angiography Non-Contrast Enhanced Magnetic Resonance Imaging (TRANCE-MRI) to assess the morphology of vessels of the pelvis and legs. Q-Flow measurement was then used for analyzing the hemodynamic changes. The diagnostic performance of TRANCE-MRI was assessed compared to duplex ultrasound (standard diagnostic tool of PVD). Using multimodal MR sequences, NC-MRA demonstrated reliable diagnostic performance in diagnosing AAS and PVD. In patients with AAS and PVD, the diagnostic power of multimodal NC-MRA is similar to that of standard diagnostic tools (measured by Cohen's kappa statistic to measure inter-rater reliability). Our research results show that the application of NC-MRA for image evaluation before intervention and image follow-up after metal stent implantation has high clinical validity and reliability. The application of NC-MRA to AAS is efficient in pre-intervention evaluation and follow-up after metal stent implantation. Besides, the application of NC-MRA has many advantages in evaluating low extremity venous pathology, despite a minor role in evaluating low extremity arterial disease. The clinical utility of NC-MRA to confirm vascular pathology is promising, particularly in patients with renal insufficiency. Further relevant researches in the future are needed to prompt more discussion and application of such technologies.
參考文獻
延伸閱讀
- Lien, C. H., Hwang, B., Tiu, C. M., Chen, J. D., Lee, P. C., & Meng, L. C. C. (2004). 比較核磁共振影像及血管攝影對主動脈弓縮窄之評估. Acta Cardiologica Sinica, 20(3), 154-159. https://www.airitilibrary.com/Article/Detail?DocID=10116842-200409-20-3-154-159-a
- Lu, C. C., Yen, R. F., Wu, Y. W., Huang, P. J., & Lee, W. J. (2008). 左主冠狀動脈瘤：核子醫學心肌血流造影與X光電腦斷層冠狀動脈血管造影的表現. 核子醫學雜誌, 21(3), 191-195. https://doi.org/10.6332/ANMS.2103.009
- 邱芳瑜、楊志明、陳良光、蘇誠道、羅偉業、李正輝、李易濰、呂坤木（2014）。探討256切電腦斷層血管攝影於冠狀動脈繞道術後評估之輻射劑量與影像品質研究：比較前瞻性與回顧性心電閘控掃描技術。中華放射線技術學雜誌，38(2)，77-86。https://www.airitilibrary.com/Article/Detail?DocID=16849418-201406-201406200020-201406200020-77-86
- Huang, J. Y. (2022). Attenuation Corrected Myocardial Perfusion Imaging as the Diagnostic and Prognostic Tool in Patients with Suspected Coronary Artery Disease [doctoral dissertation, National Taiwan University]. Airiti Library. https://doi.org/10.6342/NTU202200054
- Cui, Y., Huang, T., Wang, Z., Zhao, G., Zheng, M., & Cheng, Z. (2019). Intravenous Thrombolytic Therapy Using Low-Dose rt-PA in a Broadened Therapeutic Window for Ischemic Stroke Treatment Under Multimode Magnetic Resonance Imaging Monitoring. International Journal of Gerontology, 13(3), 231-234. https://doi.org/10.6890/IJGE.201909_13(3).0010