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中华医学超声杂志(电子版) ›› 2025, Vol. 22 ›› Issue (11) : 1071 -1079. doi: 10.3877/cma.j.issn.1672-6448.2025.11.011

外周血管超声影像学

基于超声造影的颈动脉斑块易损性评估及卒中风险预测模型构建
曹俊杰1, 姚志超1, 曾宇琪1, 郑进1, 鄂一民1, 谭梓仪1, 周大勇1, 张丽丽2,()   
  1. 1 215000 苏州,南京医科大学姑苏学院 苏州市立医院 南京医科大学附属苏州医院血管外科
    2 215000 苏州,南京医科大学姑苏学院 苏州市立医院 南京医科大学附属苏州医院超声科
  • 收稿日期:2025-04-21 出版日期:2025-11-01
  • 通信作者: 张丽丽
  • 基金资助:
    苏州市科技计划项目(SKY2022187)

Assessment of carotid plaque vulnerability based on contrast enhanced ultrasound and construction of a stroke risk prediction model

Junjie Cao1, Zhichao Yao1, Yuqi Zeng1, Jin Zheng1, Yimin E1, Ziyi Tan1, Dayong Zhou1, Lili Zhang,2()   

  1. 1 Department of Vascular Surgery, Suzhou Municipal Hospital, Suzhou Hospital Affiliated to Nanjing Medical University, Gusu College of Nanjing Medical University, Suzhou 215000, China
    2 Department of Ultrasound, Suzhou Municipal Hospital, Suzhou Hospital Affiliated to Nanjing Medical University, Gusu College of Nanjing Medical University, Suzhou 215000, China
  • Received:2025-04-21 Published:2025-11-01
  • Corresponding author: Lili Zhang
引用本文:

曹俊杰, 姚志超, 曾宇琪, 郑进, 鄂一民, 谭梓仪, 周大勇, 张丽丽. 基于超声造影的颈动脉斑块易损性评估及卒中风险预测模型构建[J/OL]. 中华医学超声杂志(电子版), 2025, 22(11): 1071-1079.

Junjie Cao, Zhichao Yao, Yuqi Zeng, Jin Zheng, Yimin E, Ziyi Tan, Dayong Zhou, Lili Zhang. Assessment of carotid plaque vulnerability based on contrast enhanced ultrasound and construction of a stroke risk prediction model[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2025, 22(11): 1071-1079.

目的

探讨超声造影(CEUS)中斑块内造影剂扩散方向与新生血管(IPN)分级在评估颈动脉斑块易损性及预测症状性卒中风险中的价值,并构建多参数预测模型以提升高危人群的识别效能。

方法

前瞻性纳入2023年1月至2024年12月在苏州市立医院行颈动脉内膜剥脱术(CEA)的患者84例,依据是否发生症状性卒中事件将其分为症状性卒中组48例,无症状性卒中组36例。术前行常规超声及CEUS检查,记录斑块形态、造影剂扩散方向及IPN评分等影像学特征;术后采集斑块病理组织,分析微血管密度(MVD)及不成熟微血管比例(MVR)。采用 Spearman 等级相关分析方法分析CEUS特征与病理学特征的相关性;采用多因素Logistic回归分析症状性卒中的独立危险因素,绘制ROC曲线评估预测模型的判别能力。

结果

IPN评分与MVD(r=0.782,P<0.001)及MVR(r=0.508,P<0.001)均呈显著正相关。造影剂呈“内向外”扩散的斑块中,纤维帽破裂及斑块内出血发生率较“非内向外”扩散斑块显著升高(87.50% vs 55.56%,87.50% vs 66.67%,P<0.05)。Logistic回归分析显示,IPN半定量评分3级(OR=4.36,95%CI:1.50~12.67,P<0.01)与造影剂“内向外”扩散(OR=3.88,95%CI:1.43~10.57,P<0.01)为症状性卒中事件的独立风险因素。ROC曲线结果表明,联合预测模型的ROC曲线下面积(AUC)为0.806,优于IPN半定量评分3级(AUC=0.751)及造影剂“内向外”扩散(AUC=0.673)的单一预测指标。

结论

CEUS中造影剂扩散方向与IPN评分可较为有效地反映颈动脉斑块的易损性特征,并具备一定的预测症状性卒中风险的能力。基于二者构建的多参数模型在术前风险评估及卒中高危人群筛查中表现出较好的判别能力,具有一定的临床应用潜力。

Objective

To evaluate the clinical value of intraplaque contrast agent diffusion direction and intraplaque neovascularization (IPN) grading on contrast-enhanced ultrasound (CEUS) in assessing carotid plaque vulnerability and predicting the risk of symptomatic stroke, and to construct a multiparametric predictive model to improve the identification of high-risk individuals.

Methods

A total of 84 patients who underwent carotid endarterectomy (CEA) at Suzhou Municipal Hospital between January 2023 and December 2024 were prospectively enrolled. According to the occurrence of symptomatic stroke events or not, the patients were divided into a symptomatic stroke group (n=48) and an asymptomatic group (n=36). Preoperative conventional ultrasound and CEUS were performed to assess plaque morphology, contrast agent diffusion direction, and IPN grade. Postoperative pathological specimens were collected to evaluate microvessel density (MVD) and the proportion of immature microvessels (MVR). Spearman rank correlation analysis was used to evaluate the correlation between CEUS features and pathological characteristics. Multivariate logistic regression was used to identify independent risk factors for symptomatic stroke, and receiver operating characteristic (ROC) curves were plotted to assess the discriminative performance of different predictive models.

Results

IPN grade was significantly positively correlated with both MVD (r=0.782, P<0.001) and MVR (r=0.508, P<0.001). Plaques showing an "inside-out" contrast agent diffusion pattern exhibited significantly higher incidences of fibrous cap rupture and intraplaque hemorrhage compared with non-inside-out diffusion plaques (87.50% vs 55.56% and 87.50% vs 66.67%, respectively; P<0.05). Logistic regression revealed that IPN grade 3 (odds ratio [OR]= 4.36, 95% confidence interval [CI]: 1.50-12.67, P<0.01) and "inside-out" diffusion pattern (OR=3.88, 95%CI: 1.43-10.57, P<0.01) were independent risk factors for symptomatic stroke events. The area under the ROC curve (AUC) of the combined predictive model was 0.806, which was higher than that of either IPN grade 3 (AUC=0.751) or "inside-out" diffusion pattern alone (AUC=0.673).

Conclusion

CEUS-based assessment of contrast agent diffusion direction and IPN grading can effectively reflect carotid plaque vulnerability and demonstrates an appreciated ability to predict the risk of symptomatic stroke. The multiparametric model based on these two indicators shows good discriminative performance in preoperative risk assessment and screening of high-risk stroke populations, indicating potential clinical applicability.

图1 颈动脉斑块内造影剂不同扩散方向的超声造影(CEUS)表现。图a为斑块纤维帽破裂的典型超声表现(左图为常规超声,右图为CEUS),可见造影剂从血管腔内进入斑块,呈“内向外”扩散(白色箭头);图b为斑块内新生血管形成的典型超声表现(左图为常规超声,右图为CEUS),可见造影剂从血管外膜流入斑块,呈“非内向外”扩散(白色箭头)
图2 颈动脉斑块内不同新生血管(IPN)分级的超声造影(CEUS)表现。图a为IPN 0级(左图为常规超声,右图为CEUS):未见明显增强灶(白色轮廓内未显示造影剂微气泡灌注),提示无新生血管形成;图b为IPN 1级(左图为常规超声,右图为CEUS):见斑块上肩部见造影剂微气泡灌注,呈点状增强(白色箭头所示),提示少量新生血管形成,分布局限;图c为IPN 2级(左图为常规超声,右图为CEUS):斑块内见数个造影剂微泡灌注(白色箭头所示),增强范围有限,未累及整个斑块;图d为IPN 3级(左图为常规超声,右图为CEUS):斑块内可见多个造影剂微泡,呈线状和片状增强(白色箭头所示),造影剂广泛分布于斑块实质,提示丰富的新生血管形成
表1 症状性卒中组与无症状性卒中组基线资料比较
基线资料 症状性卒中组(n=48) 无症状性卒中组
n=36)
统计值 P
年龄(岁,
±s
70.35±5.78 67.83±7.14 t=1.788 0.077
男性[例(%)] 35(72.92) 24(66.67) χ2=0.384 0.535
体质量指数(kg/m2
±s
23.41±2.63 23.98±3.20 t=-0.898 0.372
收缩压(mmHg,
±s
122.73±14.64 122.25±15.77 t=0.144 0.886
舒张压(mmHg,
±s
79.67±15.14 77.58±14.01 t=0.644 0.521
脉压差(mmHg,
±s
42.96±20.93 44.67±19.72 t=-0.379 0.705
空腹血糖(mmol/L,
±s
6.20±1.24 6.26±0.76 t=-0.235 0.773
高密度脂蛋白(mmol/L,
±s
1.04±0.17 1.05±0.25 t=-0.223 0.815
低密度脂蛋白(mmol/L,
±s
2.22±0.78 2.28±0.83 t=-0.314 0.754
总胆固醇(mmol/L,
±s
3.41±0.83 3.24±0.71 t=0.976 0.332
甘油三酯(mmol/L,
±s
1.40±0.73 1.21±0.36 t=1.410 0.128
白细胞(×109/L,
±s
6.19±1.91 6.43±2.10 t=-0.540 0.591
红细胞(×109/L,
±s
3.78±0.74 3.52±0.69 t=1.612 0.111
血小板(×109/L,
±s
161.10±41.47 167.89±43.30 t=-0.728 0.469
血红蛋白(g/L,
±s
120.65±20.23 117.75±23.41 t=0.607 0.546
谷丙转氨酶(U/L,
±s
23.88±11.70 21.36±8.15 t=1.103 0.273
谷草转氨酶(U/L,
±s
18.67±7.26 20.44±6.79 t=-1.142 0.257
血肌酐(mmol/L,
±s
79.55±22.57 82.20±28.41 t=-0.476 0.635
血尿素氮(mmol/L,
±s
6.92±2.17 7.19±2.14 t=-0.547 0.586
吸烟史[例(%)] 29(60.42) 18(50.00) χ2=0.906 0.341
饮酒史[例(%)] 28(58.33) 19(52.78) χ2=0.258 0.612
冠心病史[例(%)] 14(29.17) 15(41.67) χ2=1.422 0.233
他汀类药物治疗[例(%)] 15(31.25) 8(22.22) χ2=0.843 0.358
抗栓药物治疗[例(%)] 7(14.58) 6(16.67) χ2=0.068 0.794
表2 症状性卒中组与无症状性卒中组超声检查结果比较[例(%)]
图3 颈动脉内膜剥脱术后颈动脉斑块的病理组织学染色结果。图a示斑块内出血(红色箭头,HE ×40)、脂质核心(白色箭头)及钙化灶(黑色箭头);图b示斑块内出血(红色箭头,Masson ×40)、脂质核心(白色箭头)及薄弱纤维帽(黄色箭头);图c示大量新生血管生成(绿色箭头,CD34免疫组化染色 ×40)
表3 超声造影与组织病理学结果分析[例(%)]
表4 症状性卒中事件的多因素Logistic回归分析*
图4 IPN半定量评分3级、超声造影剂“内向外”扩散及联合模型预测症状性卒中事件的ROC曲线 注:IPN为新生血管
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