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三种MRI灌注技术术前评估脑胶质瘤分级的价值对比
梅邹 毕俊英

Cite this article as: Mei Z, Bi JY. Comparison of value of three MRI perfusion techniques in the preoperative assessment of brain glioma grading[J]. Chin J Magn Reson Imaging, 2022, 13(2): 83-86, 95.本文引用格式:梅邹, 毕俊英. 三种MRI灌注技术术前评估脑胶质瘤分级的价值对比[J]. 磁共振成像, 2022, 13(2): 83-86, 95. DOI:10.12015/issn.1674-8034.2022.02.017.


[摘要] 目的 分析动态对比增强磁共振成像(dynamic contrast-enhanced magnetic resonance imaging,DCE-MRI)、动态磁敏感对比增强灌注加权成像(dynamic susceptibility contrast-enhanced perfusion weighted imaging,DSC-PWI)、三维动脉自旋标记(three-dimensional arterial spin labeling,3D-ASL)三种磁共振灌注技术术前评估脑胶质瘤(brain glioma,BG)分级的价值。材料与方法 回顾性分析我院48例术前经DCE-MRI检查,34例术前经DSC-PWI及3D-ASL检查的BG患者临床资料,分析DCE-MRI各参数[容积转运常数(volume transport constant,Ktrans)、速率常数(rate constant,Kep)、血管外细胞外间隙容积分数(extravascular extracellular space fraction,Ve)、血浆容积分数(plasma volume fraction,Vp)]、DSC-PWI参数[相对脑血流量(relative cerebral blood flowr,rCBF)]及3D-ASL参数(rCBF)对BG病理分级的诊断价值;并比较DSC-PWI参数rCBF与3D-ASL参数rCBF间的差异。结果 不同BG病理分级者Kep、Vp比较,差异无统计学意义(P>0.05);BG病理分级Ⅱ级者Ktrans及Ve明显低于Ⅲ级、Ⅳ级者(P<0.05),但Ⅲ级与Ⅳ级者间Ktrans、Ve比较差异无统计学意义(P>0.05)。DSC-PWI、3D-ASL检查中,不同BG病理分级者间与对侧半球、灰质及白质对比的rCBF差异均有统计学意义(P<0.05),Ⅱ级者rCBF均低于Ⅲ级、Ⅳ级者(P<0.05),Ⅲ级者低于Ⅳ级者(P<0.05)。ROC曲线分析显示,Ktrans、Ve及DSC-PWI与3D-ASL测量的rCBF均对BG病理Ⅳ级具有较高诊断价值(P<0.05)。DSC-PWI与3D-ASL测量的rCBF差异无统计学意义(P>0.05)。结论 DCE-MRI判断BG分级效果不及DSC-PWI、3D-ASL,DSC-PWI测量的参数较3D-ASL多,但安全性、无创性不及3D-ASL,3种灌注技术各具优劣,临床可结合实际选择合适的灌注技术。
[Abstract] Objective To analyze the value of three kinds of magnetic resonance imaging (MRI) perfusion techniques of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), dynamic susceptibility contrast-enhanced perfusion weighted imaging (DSC-PWI) and three-dimensional arterial spin labeling (3D-ASL) in the preoperative assessment of brain glioma (BG) grading.Materials and Methods The clinical data of patients with BG in the hospital were retrospectively analyzed, including 48 cases with preoperative DCE-MRI examination and 34 cases with preoperative DSC-PWI and 3D-ASL examinations. The diagnostic value of DCE-MRI parameters [volume transport constant (Ktrans), rate constant (Kep), extravascular extracellular space fraction (Ve), plasma volume fraction (Vp)], DSC-PWI parameter [relative cerebral blood flow (rCBF)] and 3D-ASL parameter (rCBF) on BG pathological grading was analyzed. The differences in rCBF of DSC-PWI parameter and rCBF of 3D-ASL parameter were compared.Results There were no significant differences in Kep and Vp among different BG pathological grades (P>0.05). Ktrans and Ve of BG pathological grade Ⅱ were significantly lower than those of grades Ⅲ and Ⅳ (P<0.05), but there were no statistically significant differences in Ktrans and Ve between grade Ⅲ and grade Ⅳ (P>0.05). In DSC-PWI and 3D-ASL, there were significant differences in rCBF values between patients with different BG pathological grades and the contralateral hemisphere, gray matter, and white matter (P<0.05), and the rCBF values of grade Ⅱ were lower than those of grade Ⅲ and Ⅳ (P<0.05), and the values of grade Ⅲ were lower than those of grade Ⅳ (P<0.05). ROC curve analysis showed that rCBF values measured by Ktrans, Ve, DSC-PWI and 3D-ASL had high diagnostic value on BG pathology grade Ⅳ (P<0.05). There was no significant difference in rCBF measured by DSC-PWI and 3D-ASL (P>0.05).Conclusions The effect of DCE-MRI in judging BG grading is not as good as DSC-PWI and 3D-ASL. DSC-PWI measures more parameters than 3D-ASL, but its safety and non-invasiveness are not as good as 3D-ASL. The three perfusion techniques have their own advantages and disadvantages, thus it is necessary to select the appropriate perfusion technique according to the actual situation in clincial practice.
[关键词] 脑胶质瘤;分级;动态对比增强磁共振成像;动态磁敏感对比增强灌注加权成像;三维动脉自旋标记
[Keywords] brain glioma;grading;dynamic contrast-enhanced magnetic resonance imaging;dynamic susceptibility contrast-enhanced perfusion weighted imaging;three-dimensional arterial spin labeling

梅邹 1   毕俊英 2*  

1 江汉大学附属湖北省第三人民医院放射科,武汉 430000

2 江汉大学附属湖北省第三人民医院医学影像介入和磁共振影像科,武汉 430000

毕俊英,E-mail:bijunying123@163.com

作者利益冲突声明:全体作者均声明无利益冲突。


收稿日期:2021-05-21
接受日期:2021-12-28
中图分类号:R445.2  R739.41 
文献标识码:A
DOI: 10.12015/issn.1674-8034.2022.02.017
本文引用格式:梅邹, 毕俊英. 三种MRI灌注技术术前评估脑胶质瘤分级的价值对比[J]. 磁共振成像, 2022, 13(2): 83-86, 95. DOI:10.12015/issn.1674-8034.2022.02.017

       脑胶质瘤(brain glioma,BG)为常见颅内原发性肿瘤,发病率可占颅内肿瘤的35%~60%,并呈逐年上升趋势[1]。外科手术为BG的主要治疗手段,但BG生物行为复杂,选择合适的手术方案方可达到理想疗效,而术前准确评估其病理分级是确定手术方案的关键[2]。常规磁共振成像可显示肿瘤的形态及信号特征,常规增强检查还能评估部分血脑屏障信息,辅助判断肿瘤的良恶性,但难以准确评估恶性肿瘤的分级[3]。影响纵向弛豫的T1加权动态对比增强磁共振成像(dynamic contrast-enhanced magnetic resonance imaging,DCE-MRI),影响横向弛豫的T2动态磁敏感对比增强灌注加权成像(dynamic susceptibility contrast-enhanced perfusion weighted imaging,DSC-PWI),以水质子为自身内源性示踪剂的三维动脉自旋标记(three-dimensional arterial spin labeling,3D-ASL),上述3种灌注技术均可用于判断BG病理分级,但各具优势与不足[4]。基于此,本研究分析上述3种灌注技术在术前评估BG分级中的应用价值,为BG诊疗提供临床依据。

1 资料与方法

1.1 一般资料

       回顾性分析2017年2月至2020年12月我院48例术前经DCE-MRI检查,34例术前经DSC-PWI及3D-ASL检查的BG患者临床资料。纳入标准:(1)术前接受相应影像学检查,术前未接受抗肿瘤治疗;(2)经手术病理诊断为BG且首次诊疗;(3)年龄≥18岁;(4)临床资料完整。排除标准:(1)因头部伪影未获得有效的MRI扫描图像;(2)既往脑部手术史。82例BG患者男43例,女39例;年龄18~71 (50.96±11.28)岁;临床症状以头痛头晕、局灶性或全身性癫痫发作、运动障碍、颅内压增高为主。所有患者术后根据世界卫生组织2007年制定的中枢神经系统肿瘤分级标准分级[5],其中Ⅱ级32例,Ⅲ级24例,Ⅳ级26例。本研究经江汉大学附属湖北省第三人民医院医学伦理委员会批准(批准文号:2021伦审科第19号),免除受试者知情同意。

1.2 扫描方法

       MRI扫描采用西门子超导型磁共振成像系统MAGNETOM Verio 3.0 T,常规扫描T1加权矢状位、T1加权横断位、T2加权横断位及FLAIR成像;T1加权动态对比增强MR先行T1梯度回波容积插值屏息扫描(volume interpolated breath-hold examination sequence,VIBE)序列,TR 5.08 ms,TE 1.74 ms,FOV 260 mm×260 mm,矩阵138×192,层厚5 mm,翻转角2°及15°;DCE-MRI扫描采用T1时间分辨交叉随机轨迹成像(time-resolved angiography with interleaved stochastic trajectories,TWIST)序列,TR 4.82 ms,TE 1.88 ms,FOV 260 mm×260 mm,矩阵138×192,层厚3.2 mm,翻转角12°,共采集75次,间隔5.3 s,在采集第6次前,经肘静脉注入钆喷葡胺(批准文号:H20080146,规格:0.5 mmol/mL,德国拜耳医药保健有限公司) 0.1 mmol/kg,注射速率4 mL/s。

       DSC-PWI扫描则采用平面回波序列(spin echo echo-planar image,SE-EPI),TR 1500 ms,TE 30 ms,FOV 230 mm×230 mm,矩阵128×128,层厚4 mm,翻转角90°,扫描时间约为1 min 50 s,共50期,每期20帧图,在扫描第6期前注射钆喷葡胺对比剂,使用方法同上述DCE-MRI扫描。

       3D-ASL扫描前嘱患者绝对制动,使用伪连续脉冲标记及交错的螺旋快速自旋回波序列背景抑制,达到全脑三维容积采集效果,TR 5000 ms,TE 36 ms,FOV 192 mm×192 mm,矩阵256×256,42层,层厚3 mm,标记后延迟时间1800 ms,采集时长约为4 min 29 s。

1.3 图像处理方法

       DCE-MRI数据导入动态对比增强定量分析软件(mini Kinetics tool),应用extended Tofts model模型,输入函数,获得脑组织时间-信号强度曲线,经药代动力学计算并选择感兴趣区自动匹配相应图像(感兴趣区避开坏死、囊变及出血区,下同),得到后处理图及灌注参数——容积转运常数(volume transport constant,Ktrans)、速率常数(rate constant,Kep)、血管外细胞外间隙容积分数(extravascular extracellular space fraction,Ve)、血浆容积分数(plasma volume fraction,Vp);由两名医师分别在DCE-MRI后处理图上采用“热点法”手动放置感兴趣区,面积为25~40 mm2,得到各参数测量值,该方法在异质性肿瘤中选取侵袭性最高的实性部分分析,并结合专业医师的经验,具有良好准确性,两名医师分别取3个感兴趣区,取平均值为各参数的最终测量结果。

       DSC-PWI数据传输至后处理工作站(西门子Syngo.via),行头动校正调整阈值后,生成彩色脑血流量(cerebral blood flow,CBF)图,采用“最大层面法”手动调节感兴趣区,面积为25~40 mm2,取肿瘤最大血流量(tumour blood flow values of max,TBFmax)区,以对侧正常半球、灰质、白质作参考,得到相对CBF (relative of CBF,rCBF),两名医师分别取3个感兴趣区,取平均值为各参数的最终测量结果。

       3D-ASL数据传输至后处理工作站,自动得到伪彩图,采用“最大层面法”手动调节感兴趣区,面积为25~40 mm2,测得TBFmax,将TBFmax分别与对侧正常半球、灰质、白质血流值作对比,计算rCBF,由两名医师分别取3个感兴趣区,取平均值为各参数的最终测量结果。

1.4 统计学方法

       数据分析用SPSS 22.0软件处理;计量资料以均数±标准差(x¯±s)表示,多组间比较采用单因素方差分析,两两比较则用LSD-t检验;计数资料以例或百分比n (%)表示,采用χ2检验;诊断价值采用ROC曲线评估;P<0.05为差异有统计学意义。

2 结果

2.1 不同BG病理分级者DCE-MRI参数比较

       不同BG病理分级者Kep、Vp比较,差异无统计学意义(P>0.05);BG病理分级Ⅱ级者Ktrans及Ve明显低于Ⅲ级、Ⅳ级者(P<0.05),但Ⅲ级与Ⅳ级者间Ktrans、Ve比较,差异无统计学意义(P>0.05),见表1,典型病例分析见图1

图1  男性,73岁,右侧额叶胶质瘤Ⅲ级。动态对比增强磁共振成像定量Ktrans、Ve值较低,难以进一步鉴别高级别脑胶质瘤。
图2  Ktrans、Ve诊断脑胶质瘤病理Ⅳ级的ROC曲线。
表1  不同脑胶质瘤病理分级者动态对比增强磁共振成像参数比较(x¯±s)

2.2 DCE-MRI参数对BG病理Ⅳ级的诊断价值分析

       ROC曲线分析显示,Ktrans、Ve均对BG病理Ⅳ级具有一定诊断价值(P<0.05),见表2、图2。

表2  Ktrans、Ve对脑胶质瘤病理Ⅳ级的诊断价值分析

2.3 不同BG病理分级者DSC-PWI、3D-ASL参数比较

       DSC-PWI、3D-ASL检查中,不同BG病理分级者间与对侧半球、灰质及白质对比的rCBF差异均有统计学意义(P<0.05),Ⅱ级者rCBF均低于Ⅲ级、Ⅳ级者(P<0.05),Ⅲ级者低于Ⅳ级者(P<0.05),见表3,典型病例见图3、4。

图3  男,60岁,左侧颞叶胶质瘤Ⅳ级。动态磁敏感对比增强灌注加权成像测量相对脑血流量及脑血容量,能准确评估脑胶质瘤病理分级。
图4  女,42岁,左侧额叶胶质瘤Ⅱ级,三维动脉自旋标记技术测量相对脑血流量分析微循环灌注,能准确评估脑胶质瘤病理分级。
图5  DSC-PWI、3D-ASL参数诊断BG病理Ⅳ级的ROC曲线。
表3  不同脑胶质瘤病理分级者DSC-PWI、3D-ASL参数比较(x¯±s)

2.4 DSC-PWI、3D-ASL参数对BG病理Ⅳ级的诊断价值分析

       ROC曲线分析显示,DSC-PWI与3D-ASL测量的rCBF均对BG病理Ⅳ级具有较高诊断价值(P<0.05),见表4、图5。

表4  DSC-PWI、3D-ASL参数对脑胶质瘤病理Ⅳ级的诊断价值分析

2.5 DSC-PWI参数rCBF与3D-ASL参数rCBF比较

       DSC-PWI与3D-ASL测量的rCBF差异无统计学意义(P>0.05),见表5

表5  DSC-PWI参数rCBF与3D-ASL参数rCBF比较(x¯±s)

3 讨论

       DCE-MRI的定量参数Ktrans、Ve是评估血管通透性的重要参数,正常血脑屏障完整时,对比剂不能由血管渗透至血管外,Ktrans、Ve值近乎为0[6, 7]。在出现恶性肿瘤时,新生血管基底膜不完整,通透性升高,对比剂可渗透至血管外,Ktrans、Ve值随之增加[8, 9]。本研究中,BG病理分级Ⅱ级者Ktrans及Ve明显低于Ⅲ级、Ⅳ级者,BG病理分级与Ktrans、Ve也呈显著正相关,提示Ktrans及Ve值可随BG病理分级的升高而增加,能辅助术前诊断,与既往报道一致[10]。然而,近年有研究发现[11, 12],Ⅲ级与Ⅳ级BG的肿瘤新生血管基底膜均不完整,血管通透性相近,对比剂渗透至血管外情况相同,DCE-MRI参数难以鉴别Ⅲ级与Ⅳ级BG。本研究结果显示,Ktrans、Ve虽然对BG病理Ⅳ级具有一定诊断价值,但BG Ⅲ级与Ⅳ级者间Ktrans、Ve比较,差异无统计学意义。这也说明,DCE-MRI参数在术前评估BG病理分级方面存在一定缺陷,只能初步分辨低级别与高级别BG,难以进一步鉴别高级别BG的具体分级[13, 14]

       与DCE-MRI不同,DSC-PWI是测量CBF及脑血容量的标准方法,可评估肿瘤组织血管密度,能反映BG血流动力学及新生血管具体数量,与血脑屏障破坏程度、血管通透性变化无相关性[15, 16]。本研究中,DSC-PWI测量的rCBF在Ⅲ级与Ⅳ级BG间差异有统计学意义,且对BG病理Ⅳ级具有较高诊断价值,提示DSC-PWI参数能准确评估BG病理分级。考虑该结果与随着BG病理分级的升高,肿瘤体积增大、新生血管增生,使rCBF逐渐增加有关[17, 18]

       3D-ASL则是一种无创灌注技术,可利用自身循环动脉血中水质子,行射频脉冲磁化标记,具有安全无创、可重复等优点[19]。近年国外研究还发现[20],3D-ASL技术能利用rCBF参数分析肿瘤微循环灌注情况,对BG病理分级诊断有利。本研究中,BG病理分级随3D-ASL对侧半球rCBF、对侧灰质rCBF、对侧白质rCBF的升高而升高,且3D-ASL测量的rCBF均对BG病理Ⅳ级具有较高诊断价值,提示3D-ASL也能准确评估BG病理分级,与上述国外报道相似。本研究还发现,3D-ASL与DSC-PWI测量的rCBF数值相近,均能用于术前BG分级评估。然而,两种技术具有各自特点,3D-ASL虽然具有安全无创的优点,但仅能获得rCBF一种参数,还易受脑脊液污染,影响诊断[21];DSC-PWI需要使用对比剂,肾功能不全、对比剂过敏等患者限制应用,但图像分辨率较3D-ASL高,还能测量血流通过的时间特点,通过多种参数综合判断BG分级[22]。因此,DSC-PWI、3D-ASL均能辅助判断BG病理分级,但各具优势,临床可结合实际情况选择合适的灌注技术。另外,DCE-MRI作为临床广泛应用的灌注技术,应用范围广,可辅助鉴别低级与高级BG,若临床要进一步明确高级BG的分级,则需联合DSC-PWI或3D-ASL技术观察,具体联合方案应结合二者优缺点选择个性化的灌注方案。此外,本研究作为回顾性分析,样本量较小,结果可能存在一定偏倚,为保证本结论的科学性与严谨性,还需后续大样本量前瞻性研究的论证。

       综上所述,DCE-MRI及DSC-PWI、3D-ASL均能通过参数判断BG病理分级,但DCE-MRI在鉴别BG Ⅲ级与Ⅳ级时存在欠缺,DSC-PWI能测量多种参数准确判断BG分级,3D-ASL能无创、准确判断BG分级,各有其优劣性。

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