[논문]급성 뇌경색에서 자화율강조영상에서 보이는 현저한 유출정맥 저신호 강도의 임상적 유용성: Penumbra 및 예후 예측인자로서 가능성

이현실; 안국진; 최현석; 장진희; 정소령; 김범수; 양동원

doi:10.13104/jksmrm.2014.18.4.332

[국내논문] 급성 뇌경색에서 자화율강조영상에서 보이는 현저한 유출정맥 저신호 강도의 임상적 유용성: Penumbra 및 예후 예측인자로서 가능성
Clinical Utility of Prominent Hypointense Signals in the Draining Veins on Susceptibility-Weighted Imaging in Acute Cerebral Infarct: As a Marker of Penumbra and a Predictor of Prognosis 원문보기

대한자기공명의과학회지 = Journal of the Korean society of magnetic resonance in medicine, v.18 no.4, 2014년, pp.332 - 340

이현실 (가톨릭의과대학 서울성모병원 영상의학과) , 안국진 (가톨릭의과대학 서울성모병원 영상의학과) , 최현석 (가톨릭의과대학 서울성모병원 영상의학과) , 장진희 (가톨릭의과대학 서울성모병원 영상의학과) , 정소령 (가톨릭의과대학 서울성모병원 영상의학과) , 김범수 (가톨릭의과대학 서울성모병원 영상의학과) , 양동원 (가톨릭의과대학 서울성모병원 신경과)

초록
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목적: 급성 뇌경색 환자의 자화율강조영상에서 보이는 관류 손상 부위의 현저한 유출정맥 저신호 강도 (PHSV)의 임상적 유용성을 평가하고자 하였다. 대상과 방법: 확산강조영상과 자화율강조영상을 포함한 뇌 자기공명영상을 시행한 급성 뇌경색 환자에서 추적 단면영상검사가 있는 환자 18명을 대상으로 뇌경색 및 주변부에서 PHSV 유무와 위치를 정성적으로 확인하였다. 자화율강조영상에서 PHSV와 정상 뇌피질 정맥의 신호강도차이 비율을 측정하였고, 주변 PHSV 유무와 추적검사에서 뇌경색 크기 변화의 상관관계를 분석하였다. 결과: 18명의 환자 중 10명의 환자가 추적검사에서 뇌경색이 진행하였고, 8명은 변화가 없었다. 뇌경색이 진행한 10명의 환자 중 9명에서 뇌경색 주변 PHSV가 관찰되었고, 새로 생긴 경색 부위는 초기 자화율강조영상에서 보였던 주변 PHSV 부위와 잘 일치하였다. 경색의 크기가 변화 없는 환자군과 비교하여 경색이 진행한 환자군에서 뇌경색 주변 PHSV의 빈도가 통계적으로 유의하게 높았고 (p=0.0001), 신호강도차이 비율도 유의하게 높았다 (p=0.006). 결론: 자화율강조영상에서 보이는 주변 PHSV는 반음영부 (penumbra)의 지표가 될수 있으며 급성 뇌경색 예후 예측에 이용될 수 있다.

Abstract ▼ AI-Helper

Purpose : A relative increase in deoxyhemoglobin levels in hypoperfused tissue can cause prominent hypointense signals in the draining veins (PHSV) within areas of impaired perfusion in susceptibility-weighted imaging (SWI). The purpose of this study is to evaluate the usefulness of SWI in patients with acute cerebral infarction by evaluating PHSV within areas of impaired perfusion and to investigate the usefulness of PHSV in predicting prognosis of cerebral infarction. Materials and Methods: In 18 patients with acute cerebral infarction who underwent brain MRI with diffusion-weighted imaging and SWI and follow-up brain MRI or CT, we reviewed the presence and location of the PHSV within and adjacent to areas of cerebral infarction qualitatively and measured the signal intensity difference ratio of PHSVs to contralateral normal appearing cortical veins quantitatively on SWI. The relationship between the presence of the PHSV and the change in the extent of infarction in follow-up images was analyzed. Results: Of the 18 patients, 10 patients showed progression of the infarction, and 8 patients showed little change on follow- up imaging. On SWI, of the 10 patients with progression 9 patients showed peripheral PHSV and the newly developed infarctions corresponded well to area with peripheral PHSV on initial SWI. Only one patient without peripheral PHSV showed progression of the infarct. The patients with infarction progression revealed significantly higher presence of peripheral PHSV (p=0.0001) and higher mean signal intensity difference ratio (p=0.006) comparing to the patients with little change. Conclusion: SWI can demonstrate a peripheral PHSV as a marker of penumbra and with this finding we can predict the prognosis of acute infarction. The signal intensity difference of PHSV to brain tissue on SWI can be used in predicting prognosis of acute cerebral infarction.

주제어

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문제 정의

The purpose of this study is to evaluate the usefulness of SWI in patients with acute cerebral infarction by evaluating PHSV within areas of impaired perfusion and to investigate the usefulness of PHSV in predicting prognosis of cerebral infarction.

가설 설정

a. Initial DWI shows an acute infarct in the right middle cerebral artery territory. b.
Initial DWI shows an acute infarct in the right middle cerebral artery territory. b. SWI obtained on the same day shows peripheral PHSV in the posterior aspect of infarction. c.
DWI shows a large acute infarct in the left frontoparietal lobe. b. Core PHSV is detected in the initial SWI. c.
Although multifocal hemorrhagic foci are noted, PHSV is not detected in the infarction area on SWI. c. Follow-up T2 weighted-imaging 9 days after the attack shows no progression of the extent of infarction.
And the possibility of measuring error such as partial volume effect can make the measurements inaccurate. Second, the vessels used in comparison of the signal intensity difference on SWI in both cerebral hemispheres were not identical veins. Although the vessels used in calculation of this parameter were selected segmental traversing veins on same axial plane in order to minimize the angle difference to main magnetic field, these veins in contralateral hemisphere did not have same vessel course in reality.

제안 방법

The follow-up brain MRI or CT examinations, ranging from one day to 27 days after initial brain MRI were available in 18 (seven men and eleven women; age range, 51 to 90 years; mean age, 72.4 ± 11.6 years) of the 37 patients, and these patients were finally included in the study to assess the change in the extent of cerebral infarction on follow-up brain imaging.
All patients underwent MR imaging on a 3-Tesla superconducting MRI system (Verio; Siemens, Erlangen, Germany). The MR imaging protocol included an SWI sequence in addition to routine sequences such as T1, T2, FLAIR, and DWI sequences.
All patients underwent MR imaging on a 3-Tesla superconducting MRI system (Verio; Siemens, Erlangen, Germany). The MR imaging protocol included an SWI sequence in addition to routine sequences such as T1, T2, FLAIR, and DWI sequences. The MRI parameters were as follows: T1-weighted image (TR/TE, 477/9.
Second, the PHSV was assessed semi-quantitatively using signal intensity difference on SWI. According to Yuri Zaitsu et al.
In this study, by using SWI, we measured the signal intensity difference ratio of PHSVs to contralateral normal appearing cortical veins quantitatively. In the progression group, signal intensity difference of peripheral PHSVs was 2.

대상 데이터

Patients with territorial lobar infarctions in the anterior and/or middle cerebral artery territories based on DWI were included in the study, but those with lacunar infarction less than 1 cm in diameter were excluded. A total of 37 patients fulfilled the eligibility criteria and were selected for the study. The follow-up brain MRI or CT examinations, ranging from one day to 27 days after initial brain MRI were available in 18 (seven men and eleven women; age range, 51 to 90 years; mean age, 72.

데이터처리

For statistical analysis, a Fisher’s exact test was employed to evaluate the correlation between the presence of peripheral PHSV and various evaluating items (i.e., the progression of the extent of cerebral infarction, the presence of hemorrhagic transformation, and the cause and size of cerebral infarction).

성능/효과

Of the 18 patients, there was no statistical difference between the infarction progression group and the group of little change in the distribution of sex (p=0.204) or patient age (p=0.454). Imaging time from the onset of symptoms varied from 1 hr 20 m to 7 days (Table 1).
Core PHSV is detected in the initial SWI. c. Follow-up T2 weighted-imaging 3 days after the attack shows no discernable change in the extent of infarction without further progression when compared to (a).
Because the core of the infarct consists of tissue that has undergone irreversible injury, the core PHSV only cases may not be associated with an increase in the infarction area in follow-up imaging. From our results, we can hypothesize that significant peripheral PHSV represents the penumbra in acute cerebral infarction, and there is no relevant penumbra when the initial SWI shows only core PHSV or no significant peripheral PHSV.
In conclusion, noninvasive and quantitative measurement of hypoxic condition of acute cerebral infarction is possible using SWI, reflecting deoxyhemoglobin level in the draining veins. By evaluating PHSVs within areas of impaired perfusion, this can be a prognostic indicator of acute cerebral infarction and important for planning therapeutic strategies.

후속연구

Several investigators have recently shown that disruption of the bloodbrain barrier is associated with a high risk of HT (17, 18), and permeability MR imaging can be useful in predicting HT in patients who have received thrombolysis. However, because the number of patients in this study was too small, further investigations including larger numbers of patients are needed to obtain more concrete results for relation between HT and PHSV.

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저자의 다른 논문 :

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용어 설명: PCR은 세균 특이성이 있는 primer를 이용하여 적은 수의 세균이 있을지라도 쉽게 검출할 수 있는 유용한 방법이며, 이를 이용하여 구강 내 치면세균막이나 타액에서 직접 세균을 검출할 수 있게 되었다[8].

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