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中华医学超声杂志(电子版) ›› 2023, Vol. 20 ›› Issue (10) : 1040 -1045. doi: 10.3877/cma.j.issn.1672-6448.2023.10.007

头颈部超声影像学

颈动脉斑块易损性的超声造影评估及与缺血性卒中的相关性研究
吕琦, 惠品晶(), 丁亚芳, 颜燕红   
  1. 215006 苏州大学附属第一医院卒中中心颈脑血管超声科
  • 收稿日期:2022-07-11 出版日期:2023-10-01
  • 通信作者: 惠品晶
  • 基金资助:
    苏州市民生科技项目(SS202061); 苏州大学技术合作项目(H211064)

Carotid contrast-enhanced ultrasound assessment of plaque vulnerability and its correlation with ischemic stroke

Qi Lyu, Pinjing Hui(), Yafang Ding, Yanhong Yan   

  1. Department of Carotid and Cerebrovascular Ultrasonography, the First Affiliated Hospital of Soochow University, Suzhou, 215006, China
  • Received:2022-07-11 Published:2023-10-01
  • Corresponding author: Pinjing Hui
引用本文:

吕琦, 惠品晶, 丁亚芳, 颜燕红. 颈动脉斑块易损性的超声造影评估及与缺血性卒中的相关性研究[J/OL]. 中华医学超声杂志(电子版), 2023, 20(10): 1040-1045.

Qi Lyu, Pinjing Hui, Yafang Ding, Yanhong Yan. Carotid contrast-enhanced ultrasound assessment of plaque vulnerability and its correlation with ischemic stroke[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2023, 20(10): 1040-1045.

目的

应用超声造影评估颈动脉斑块易损特征及与缺血性卒中的相关性,以明确与缺血性卒中发生密切相关的“高危”斑块易损特征。

方法

连续纳入2019年1月至2019年12月在苏州大学附属第一医院卒中中心进行颈动脉内膜切除术(CEA)的患者51例。患者于术前行超声造影评估斑块易损性。根据造影剂在斑块内的不同扩散方式,分为“由内向外”灌注模式(造影剂从颈动脉管腔向斑块内扩散)和“由外向内”灌注模式(造影剂从颈动脉外膜向斑块内扩散)。根据斑块内造影增强程度分为无增强、中等增强以及广泛增强。根据是否发生缺血性卒中分为有症状组及无症状组。根据斑块的组织病理学结果,对不同造影灌注模式斑块的病理特征及斑块纤维帽破裂的独立危险因素进行分析,并对有症状患者与无症状患者的斑块造影灌注模式及造影增强程度进行比较分析。

结果

51个斑块中,超声造影“由内向外”灌注模式23个(23/51,45.1%),其中18个为典型溃疡型,5个斑块为裂隙型。超声造影“由内向外”灌注模式的斑块中,纤维帽破裂的发生率高于“由外向内”灌注模式(73.9% vs 25.0%,P<0.001)。多因素回归分析显示,造影剂“由内向外”灌注模式是斑块纤维帽破裂的独立危险因素(OR值:8.5,95% CI:2.4~30.1,P=0.001)。51例患者中,有症状患者42例,无症状患者9例。缺血性卒中有症状的患者中斑块造影剂 “由内向外”灌注模式的发生率高于无症状患者(52.4% vs 11.1%,P = 0.024)。缺血性卒中有症状患者与无症状患者在超声造影增强级别程度上差异无统计学意义(P = 0.649)。

结论

造影剂在颈动脉斑块内“由内向外”的灌注模式可为诊断斑块纤维帽破裂提供重要的形态学标志,是与缺血性卒中发生密切相关的“高危”斑块易损特征。

Objective

To evaluate the correlation between plaque vulnerability assessed by contrast-enhanced ultrasound (CEUS) and ischemic stroke so as to identify "high-risk" vulnerability characteristics that are closely related to the occurrence of ischemic stroke.

Methods

Fifty-one patients who underwent carotid endarterectomy (CEA) at the Stroke Center of the First Affiliated Hospital of Suzhou University from January 2019 to December 2019 were evaluated for plaque vulnerability by CEUS before operation. Based on the direction of the contrast agent that diffused within the plaques, the plaques were divided into "inside-outside" direction (contrast agent diffused from the artery lumen towards the inside of the plaque) and "outside-inside" direction (contrast agent diffused from the adventitia towards the inside of the plaque). Plaque enhancement degree were divided into no enhancement, moderate enhancement, and extensive enhancement. According to the occurrence of ischemic stroke, the patients were divided into a symptomatic group and an asymptomatic group. The correlation between CEUS perfusion pattern and enhancement degree and ischemic stroke symptoms was analyzed according to histopathological gold standard.

Results

Among the 51 plaques, 23 (23/51, 45.1%) had "inside-out" perfusion mode, of which 18 were typical ulcerative and 5 were fissured plaques. The incidence of cap rupture was significantly higher in plaques with the "inside to outside" direction perfusion pattern than in those with the "outside to inside" direction perfusion pattern (neovascularization) (73.9% vs 25.0%, P<0.001). Multivariate analysis showed that the "inside to outside" perfusion pattern was an independent risk factor for plaque fibrous cap rupture (odds ratio=8.5, 95% confidence interval: 2.4-30.1). Among the 51 patients, 42 were symptomatic and 9 were asymptomatic. The incidence of "inside to outside" perfusion pattern plaques was significantly higher in patients with ischemic stroke symptoms than in asymptomatic patients (52.4% vs 11.1%, P=0.024). There was no significant difference in plaque enhancement grades between symptomatic and asymptomatic patients (P=0.649).

Conclusion

Plaque "inside to outside" perfusion pattern can provide an essential morphological marker for diagnosing plaque fibrous cap rupture. It is a "high risk" vulnerability feature closely related to the occurrence of ischemic stroke.

图1 颈动脉斑块超声造影典型溃疡型图像。图a为常规二维超声可见右侧颈内动脉起始部斑块形成,斑块纤维帽可见缺口,呈“火山口”样(箭头所示);图b为彩色多普勒血流显像可见血流向斑块内灌注(箭头所示);图c为造影剂由管腔流入斑块凹陷处并充填斑块凹陷(箭头所示);图d为组织病理学显示颈动脉斑块表面纤维帽连续性中断,并伴有斑块大面积的局灶性缺损延伸至斑块深部(箭头所示)(HE ×10)
图2 颈动脉斑块超声造影裂隙型图像。图a为颈动脉管腔增强后2 s,超声造影显示斑块内无微气泡(圆圈所示);图b为颈动脉管腔增强后3 s,显示造影剂微泡以线条状进入斑块肩部(圆圈所示);图c为颈动脉管腔增强后4 s,造影剂微泡以线条状进入斑块核心部(圆圈所示);图d为组织病理学显示颈动脉斑块表面纤维帽线性撕裂继而造成纤维帽连续性中断(箭头所示)(HE ×10)
表1 患者基线特征分析(n=51)
表2 超声造影灌注模式与病理结果对照
表3 不同超声造影灌注模式斑块的病理特征分析[例(%)]
表4 有症状患者与无症状患者的CEUS灌注模式及造影级别比较[例(%)]
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