比较神经影像学-各种影像学检查方式的临床应用课件

1、比较神经影像学各种影像学检查方式的临床应用比较神经影像学为例这是什么影像学检查方法？快速自旋回波序列（1）短ETL的FSE-T2WI序列的临床应用左枕叶脑脓肿 ETL=8脑内多发急性血肿 ETL=7T1WIT2WIPDSE-T1WISE-T1WI增强扫描什么叫现代医学影像学？利用现代系统设备收集生活人体的正常解剖和病理变化产生的信息，并经过处理和计算，将数字化的信息转变为体外影像以进行医学临床工作和医学研究的临床学科。医学影像学是现代医学中发展最快的学科之一，已经形成传统放射诊断、计算机辅助X线断层扫描（CT）、磁共振成像（MRI）、超声医学、核医学、介入放射学、放疗等于一体的综合性学科。 广

2、义：一切采集与医学有关的影像，并运用于临床和医学研究的技术，包括最简单的光学或者相机摄影、各种内窥镜技术（包括腹腔镜等）、脑电图、心电图、肌电图、热敏成像，等等。狭义：三要素： 1、信息搜集系统系统的影像设备； 2、信息来源活体人的解剖、病理、生理代谢变化； 3、信息的体外影像再现系统计算机数模转换、解析软件。现代医学影像学在临床中的意义某种意义上说，代表着未来医学的发展和前进方向！改变了传统医学以主观经验为主导的诊断、治疗模式！介入放射学成为与内科治疗、外科治疗并列的临床治疗方式！The role of radiologistserving the patient and clinician

3、 with optimal images fordiagnosis, treatment adjustment of iatrogenic intervention assessment for prognosis.现代医学影像学分类1按影像设备分类X-线，X-Ray，CR，DR超声波扫描,USG同位素，核素显像ISOTOP，磁共振，MRI普通X-线摄影X-CT特殊造影：脊髓造影，脑室、脑池造影，血管造影，包括DSA经颅多普勒超声，TCDECT单光子发射计算机断层摄影，SPECT正电子发射体层摄影，PCTMRI，MRA，MRV，MRS，fMRI现代医学影像学分类2按活体人信息来源分类呼吸系统医

4、学影像学运动系统医学影像学消化系统医学影像学神经系统医学影像学内分泌系统医学影像学泌尿生殖系统医学影像学循环系统医学影像学颅脑医学影像学五官医学影像学胸部医学影像学肿瘤医学影像学脊柱医学影像学甲状腺医学影像学 等等现代医学影像学分类3按临床应用领域分类影像诊断学介入放射学放射治疗学2007“五一”长假的色达现代医学影像学分类4医学影像诊断学医学影像治疗学医学影像技术学（工程技术、成像技术，等）医学影像诊断学的目标形态学改变功能学改变代谢水平改变从而达到定位、定性、定量诊断的目的，为临床治疗和预后评估提供依据。 进一步参与临床治疗介入放射学。目前，神经系统的疾病的诊断和鉴别诊断已经主要依赖于影像

5、学的检查。影像学检查的影像质量评估解像力分辨率空间分辨率，Spatial resolution,高对比分辨率密度分辨率，对比度分辨率，contrast resolution，低对比度分辨率组织分辨率时间分辨率医学影像学发展方向提高分辨率代谢、功能成像介入放射学，从单纯的医学诊断学工具向临床治疗发展。分子影像学血管造影尤其是DSA各种体层检查：X-CT，USG，MR介入性放射学PACS，picture archive and communication system，与计算机网络相关的图像存储和传输系统临床影像学检查方式X-线，X-Ray检查（一）普通检查传统的X线技术也已经实现全面的数字化，即

6、计算X线摄影（computed radiography，简称CR）、数字X线摄影（digital radiography，简称DR）。目前，X线检查作为传统放射学技术，组成了现代医学影像学的重要基础部分 临床影像学检查方式X-线，X-Ray检查（一）普通检查可以用于人体各个系统疾病的诊断。对于骨骼（颅骨）病变，包括创伤性骨折、骨瘤、骨髓炎等，可以作出明确诊断，但是对于早期骨病的诊断较为困难。对于颅内病变，除外含有钙化者外，单凭头颅平片一般不能达到诊断目的。人工对比法，如脑血管造影、脑池、脑室造影，目前已经基本淘汰。X-线，X-Ray检查在神经系统影像学诊断中具有一定的价值，是诊断颅骨疾病的基本

7、方法，也是检查颅内疾病的重要步骤。临床影像学检查方式(二）X-ray angiography X-线血管造影传统血管造影血管性疾病的“金标准”优点缺点DSA，digital subtraction angiography高空间分辨率理论上，所有医学影像学中最高！血管的选择性/超选择性诊断+治疗有创性使用碘造影剂辐射损伤临床影像学检查方式(二）X-ray angiography X-线血管造影-1970s以前1970s以后神经系统疾病的直接或者间接诊断、鉴别诊断CT或者MRI取代其在神经系统疾病的诊断和鉴别诊断中的地位在血管性疾病的诊断、鉴别诊断、介入神经放射学、经血管进行治疗中，地位不可取代。

8、Updately, there are a lot of radiological methods available in the hospital that can be employed, including conventional x-rays which is always available in all trauma related hospitals today, containing plain x-rays and fluoroscopy, they are still playing key roles or are baseline methods employed

9、on some special system e.g., musculoskeletal system and thoracic region,临床影像学检查方式 （二） X-线CT，X-CT检查1名称不同于其它计算机断层影像，如： USG-CT，MR-CT, ECT, etal.Computed Tomography，CTX-ray Computed Tomography, X-CTComputed aided Tomography, CATComputed axial Tomography, CATComputed Trans-axial Tomography, CTATComputed

10、Transverse Tomography, CTT临床影像学检查方式 （二） X-线CT，X-CT检查2History1895年后，German，物理学家，W.C.Roentgen发现X-线，并创立X-线诊断学以来，划时代意义的突破，并为现代医学影像学技术的发展开创了先河，并奠定了坚实的基础。1972(1973?), England, G.N.Hounsfield, Head CT Scanner1973, America, Ledley, whole-body CT Scanner1976，G.L.Brownell, 根据扫描方式和探测器数目，5代的划分方式。80年代后期以来，滑环技术螺旋

11、CT（Helical-CT; Spiral-CT)；超高速CT(UFCT, ultrafast-CT)；电子束CT (EBCT, electron beam CT)技术；锥形束CT (Cone-beam CT）等。临床影像学检查方式 （二） X-线CT，X-CT检查3优点缺点2D无重叠影像空间分辨率高（图象清晰）检查快捷检查准确检查安全无创伤性检查辐射损伤剂量大一次胸部螺旋CT扫描的放射剂量相当于400-800次胸部平片检查国人的辐射剂量来源：85%来源于医源性，90%来源于医源性诊断。什么是现代医学影像学？定义三要素理解了吗临床影像学检查方式 （二） X-线CT，X-CT检查4现状发展各向同

12、性, iso-orientationCTA, CT angiographyCTE, CT endoscopy (virtual reality )扫描速度更快扫描范围更大层厚更薄对图像质量无影响临床影像学检查方式 （二） X-线CT，X-CT检查5X-线CT成像原理：X-线经过人体吸收衰减后，探测器接收并转换为光电信号，数字化（ADC）后传输给计算机，经过数模转换（DAC）成为数字化图像。断层图像，2D数字化图像间接成像临床影像学检查方式 （二） X-线CT，X-CT检查6 plain CT scanning, 平扫Axial CT scanning, 轴位扫描、横断扫描Coronal CT

13、scanning, 冠状扫描CECT, contrast enhancement CT, 增强扫描including CTA，CT血管造影；SCTA，重建CT血管造影；Angio-CT, 介入性CT动脉造影Thin cut scanning, 薄层扫描Overlapping scanning，重叠扫描Stop-to-shot scanning，逐层扫描（传统扫描）Helical or spiral scanning，螺旋扫描；3D-CT，3D扫描CTM (CT myelography)，CT脊髓造影；CTV (CT ventriculography), CT脑室造影； CTC (CT cist

14、ernography)， CT脑池造影。临床影像学检查方式 （二） X-线CT，X-CT检查7重建算法, ReconstructionEg. HRCT： plain CT scanning +Axial CT scanning +Thin cut scanning +Stop-to-shot scanning +Bone reconstruction （target?)GE-Light speedSoft reconstructionStandard reconstructionLung reconstructionDetail reconstructionBone reconstructio

15、nEdge reconstructionBone -plus reconstruction临床影像学检查方式 （二） X-线CT，X-CT检查8后处理技术2D3DFunction CTDynamic optimal viewMPR，multiplannar reformation多平面重建VR, volume viewer, volume render: 容积再现MIP最大密度投影, including CTA ( CT angiography) CT血管造影; Min-IP最小密度投影, including CTE (CT endoscopy, CT内窥镜，VR, virtual reali

16、ty 虚拟现实) ; navigation 巡航, et al.CT perfusion CT灌注Comparison 对比Sub- & add- traction 减影和增影X-CT检查的优缺点优点缺点2D无重叠影像空间分辨率高（图象清晰）检查快捷检查准确检查安全无创伤性检查成像参数单一：X-线衰减系数（主要取决于密度）容积效应影响密度差异过大的区域，如后颅凹、椎管内结构。辐射损伤剂量大X-CT检查（总结）神经影像学头颅部除颅底部因为有股指、气体、脑脊液和脑实质等多种高反差组织成分相互重叠、造成数据采集和重建算法困难、产生较多伪影导致部分干扰外，其余部位均能显示清晰地图像，可以基本满足临床诊

17、断的需要。椎管骨性结构显示的最佳影像学工具。椎管内结构因为伪影干扰，显示较差。周围神经丛病变因为密度近似于软组织，除非具备相应骨骼改变，不能很好显示（诊断能力有限）conventional tomography which has been almost completely replaced by computerized tomography (CT) , especially by updated helical CT or spiral CT, which has multiplanes reformation(MPR) / 3 Dimension (3D) i.e. VR, and

18、other software has brought revolution to radiology, especially in MTC (multi-traumatized condition) assessment, owning to high resolution of time, space, density, broad covering extent, short time for completion and providing accurate information临床影像学检查方式isotopscan同位素扫描实验核医学临床核医学诊断核医学 -体内检查法：放射性核素显像

19、+非显像体内检查 -体外检查法：放射免疫分析治疗核医学 -内照射疗法 -间质疗法 -腔内照射神经核医学利用放射性药物、核医学设备和各种核医学技术对人体神经系统疾病进行诊断、治疗和研究的科学。检查局限于中枢神经（包括脑实质和脑池），主要用于多种神经系统疾病的诊断和鉴别诊断，部分用于治疗和估价预后。现代神经核医学主要应用于脑血流、脑功能、脑受体和脑代谢的分析与评价。主要检查手段是放射性核素显像神经核医学放射性核素显像获得脑内放射性示踪分布图像不在于精细地显示脑内解剖结构更重要的是脑内结构的血流分布、受体数量、功能状态以及代谢水平的显示。计算机处理，得到多项半定量或定量分析指标间质疗法注射32P-磷

20、酸铬胶体治疗星形细胞瘤囊变、垂体瘤、颅咽管瘤，等。放射性核素示踪技术的科研意义：功能、代谢、免疫、药物代谢、细菌学，等。神经核医学放射性核素显像诊断与鉴别诊断协助治疗判断复发估价预后早期诊断准确诊断全面诊断选择治疗方案监测治疗反应评价治疗效果神经核医学放射性核素显像应用遵循的原则以疾病为中心，综合应用各种核素显像方法，并与其它医学影像学技术相比较，在诊断与鉴别诊断、协助治疗、判断复发、估价预后等几个方面致力于更好的解决临床实际问题。神经核医学优点缺点功能学代谢水平免疫定向生物致导空间分辨率低USG超声波扫描TCD-USG，transcranial Doppler s Ultrasonograp

21、hy, 经颅多普勒超声成像原理适应症超声波扫描TCD-USG，transcranial Doppler s Ultrasonography, 经颅多普勒超声成像优点缺点临床影像学检查方式MRI名称原理MR产生的长波成分，如无线电波对人体的穿透性。核子的自旋运动影像学检查方式MRI优点缺点multiplanes and multiparameters characters with highest soft tissue resolution is hopefully to be one of the most developing modality in medial imaging syst

22、em, even though it is still limited totally because of a lot of metallic resuscitation equipment that can not be allowed in the MR suite.影像学检查方式MRI适应症禁忌症影像学检查方式MRI检查技术比较放射学比较神经放射学contrast series, for example, alimentary tract contrast study for gut injury, eosophageal foreign body, urological contra

23、st study for urology system injury, the radiologist should suggest urethragraphy prior to catheterization and perform this study, expeditiously, especially when the patient presents with pelvic injury and hematuria. Similarly, angiography is performed for arterial injury and venograpahy for venous t

24、hrombosis; the latter has been replaced by Doppler Ultrasonography (Doppler USG) on lower limb already.Currently arthrography has been replaced by nuclear magnetic resonance (NMR) or magnetic resonance (MR) in most cases. Other modalities like USG is especially important because of its portable, eas

25、y, fast, directly patient conduction as well as harmless advantage, it may be the only choice in some severe trauma cases for timely assessment and in some special injury e.g. patients who is not hemodynamic stable in resuscitation room (R.R.) or scrotum problem. Nuclear medicine (NM) images e.g., c

26、an be used for suspected fracture in osteoporosis patient or fracture on special anatomic region or on a physically abused child快速自旋回波序列的衍生序列（5） HASTE用于颅脑T2WITSE-T2WIHASTE-T2WI二维扰相GRE T2*WI序列对出血灶比FSE T2WI敏感梯度回波序列扰相GRE-T2*WI用于脊柱颈椎间盘横断面显示较好胸、腰椎间盘显示不如TSE-T2WI序列椎管内结构显示不如TSE-T2WI序列，特别是矢状面梯度回波序列弥漫性轴索损伤常规G

27、RE T2*WI三维扰相GRE T2*WI梯度回波序列3D HR CE MRASense NV Coil-8Sense 3CENTRAPixel Size 0.45X0.45X0.45mmSlice Nr 180TR 5.4msTE 2.1msST 142”High Spatial Resolution梯度回波序列3D-TOF HR-MRA脑血管畸形（A-VM）梯度回波序列B. 扰相GRE序列MRA梯度回波序列快速反转恢复序列双反转FIR序列进行脑灰白质分离成像脑白质图成像参数: TR=14450ms，TI1=3700ms，TI2=525ms，TE20ms；脑灰质图成像参数: TR=10500

28、ms，TI1=3400ms，TI2=325ms，TE20ms。 飞利浦3.0T扫描机快速反转恢复序列T2WI与T2 FLAIR序列的比较FSE-T2WIFLAIRSE-T1WI增强大脑胶质瘤病快速反转恢复序列STIR-TSE-T2WISTIR频率选择脂肪饱和法反转恢复序列IR-T1WI, 冠状面Philips公司IR-T1WI，横断面Siemens公司SE-T1WI横断面Siemens公司Which modality or how many modalities should be constituted in the investigation? This is the primary qu

29、estion that comes in the mind of any radiologist who works in medical practice in whole life.The principle of imaging modality selection in MTC 1Easy: The selected radiological modality should be readily and quickly employed. If one modality can confirm the diagnosis and solve the special clinical p

30、roblem, I will not try the second one or more. This is very important consideration practically e.g. for unstable patient in R.R some times USG may be the only choice.The principle of imaging modality selection in MTC 2Less side effect: basically my opinion regarding any medical intervention either

31、examination or treatment that it is both useful and harmful. Based on most beneficial but least harmful we will go ahead, but if it is contrary to this point we should stop. e.g., x-ray radiation is very much harmful for the baby in early pregnancy, routinely we will not consider x-rays here, but if

32、 the mother suffers from arterial injury with unstable hemodynamic condition, arterography with embolization is the only choice to save her, should we perform it?The principle of imaging modality selection in MTC 3Cheap: it is commercial or financial consideration, when a cheap modality can reach a

33、similar diagnostic level, we should not use an expensive one. In China, either in government hospital or in private hospital, almost in every case, this is something we have to always keep it in our mind. The principle of imaging modality selection in MTC 4Effective: it is a comment for diagnostic c

34、apacity for accuracy. Helical CT scan plays a key role in MTC investigation currently, this is one most important reason.The principle of imaging modality selection in MTC 5Specific: The method of my choice is highly dependable upon special clinical condition and upon particular unit e.g. either usi

35、ng oral radiopaque contrast or not in abdominal CT scan on MTC case, depends mainly on clinical suspicious of bowel loop injury. Even CT scan is most useful tool for combined trauma on chest and abdomen but if there is no CT scanner available in your unit, USG and plain x-rays may be the only images

36、 which can be obtained, we should not hesitate to perform them as the initial investigation modalities.The principle of imaging modality selection in MTC 6(1)Individuality: The point emphasized here means two aspects, one is the individual condition of the victims, even if they are involved in the s

37、ame accident, it is different from one to another, and therefore radiological work-up should not be the same. Another aspect is the individual knowledge, experience and opinion of the referent radiologist who responses to the radiological work-up, will work according to his judgment rather than the

38、judgment from some one else i.e., neither from referred clinician nor from other radiologist. Regarding to the radiological side this aspect is very important in our practice. The principle of imaging modality selection in MTC 6(2)E.g., she or he is more confident in some special modality farther than the one which the clinician thinks is more suitable, or even if the one which is more reasonable on theory, she or he has the right to select the way according to her or his decision, but should take full caution against the limitation of the modality which she or he comma