多排螺旋CT血管成像技术显示脊髓Adamkiewicz动脉的临床研究
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摘要
目的：①采用多排螺旋CT血管成像技术（multi-detector-row CT angiography, MDCTA）显示脊髓的根髓动脉（the artery of Adamkiewicz，简称Adamkiewicz动脉），探讨最佳的扫描参数、强化延时时间及图像重建方法；②探讨利用上述MDCTA技术来显示胸腹主动脉瘤病人（瘤样扩张、假性动脉瘤、夹层动脉瘤或主动脉夹层分离）脊髓Adamkiewicz动脉，帮助制定恰当的手术方案以减少术中脊髓血供损害和避免术后脊髓截瘫的发生。
材料和方法：1. 收集2003年9月至2004年5月在四川大学华西医院放射科行CT增强检查而胸腹部无明显器质性病变的连续性受检者作为正常组研究对象，前瞻性探索MDCTA的最佳方法学（CT触发阈值、扫描延时时间和图像后处理方法）以及Adamkiewicz动脉的解剖细节，本组人数共计125例（男96例，女29例）。
2. 采用上述MDCTA技术，纳入同期连续性的胸腹主动脉瘤病人作为病例组研究对象进行CT增强扫描，共计23例（胸主动脉瘤7例，腹主动脉瘤10例，胸腹主动脉夹层动脉瘤3例，胸腹主动脉夹层分离3例）。
3. 对所得CT数据采用不同的二维和三维血管重建技术处理，包括最大密度投影（maximum intensity projection，MIP）、多层面重
组（multiplanar reformation，MPR）、曲面重组（curved planar reformation，CPR）、容积再现（volume rendering technique，VRT）等，分别获得主动脉、肋间动脉和脊髓动脉的各类重建和重组图像。
结果：1. 应用16层螺旋CT显示脊髓Adamkiewicz动脉的最佳成像技术为：扫描参数为扫描速度0.5s、层厚0.75mm、螺距1.5；在T7平面降主动脉区域设置兴趣监测区，扫描触发阈值170Hu； 达到该阈值后再延时18s后自动扫描；原始图像按1mm层厚、0.75mm层距、B20f算法进行重建；图像后处理重建及重组方法为VRT、MPR、CPR和MIP。
2. 采用上述MDCTA方法，均能在所有正常组和病例组研究对象清楚显示出脊髓前动脉；正常组Adamkiewicz动脉的显示率为91.1%（41/45例），病例组为91.3%（21/23例）；在正常组，CTA图像能够清楚显示从主动脉经肋间动脉到Adamkiewicz动脉的连续性走行关系者，占60%（27/45例），在病例组为60.9%（14/23例）。在正常组中有一支Adamkiewicz动脉的占75.6%（31/41例），41例中有10例（24.4%）能辨认出二支Adamkiewicz动脉，该动脉中有39支（39/51，76.5%）起源于左侧，49支（49/51，96%）位于T7~ T12之间。
结论：采用恰当的扫描和图像重建技术，MDCTA能清晰显示正常人和胸腹主动脉瘤病人脊髓Adamkiewicz动脉的解剖细节（起止关系、分支情况和走行特点），应作为Adamkiewicz动脉影像学评价的首选方法。
Objectives: 1. Using Multi-Detector-Row spiral CT angiography (MDCTA) (16-slice spiral CT) to investigate the visualization of the artery of Adamkiewicz with the optimized scanning parameters, scan delay time and reconstruction methods. 2. To assess the visualization of the artery of Adamkiewicz using MDCTA in patients with thoracoabdominal aortic aneurysms, so as to aid in surgical planning and help to reduce the incidence of intraoperative ischemic injury of the spinal cord and to prevent postoperative paraplegia.
Materials and Methods: 1. Between Sept 2003 and May 2004, a total of 125 consecutive subjects (96 males and 29 females) without any history of thoracic and abdominal lesions underwent contrast-enhanced MDCT angiography in Radiology Department of West China Hospital, Sichuan University, thus they were enrolled as the “Normal Group” of the study to prospectively investigate the optimization of MDCTA techniques, in terms of scan-triggering CT threshold, scan delay time and image
post-processing methodology, for the depiction of the detailed anatomy of the artery of Adamkiewicz. 2. Using the optimized MDCTA techniques, we prospectively scanned 23 consecutive patients with thoracoabdominal aortic aneurysms (aneurysmal dilatation of thoracic aorta in 7 and abdominal aorta in 10, 3 thoracoabdominal aortic dissecting aneurysms, and 3 aortic dissection) in same period of time. 3. All MDCTA data were processed by various two-dimensional and three-dimensional reconstruction techniques including maximum intensity projection (MIP), multiplanar reformation (MPR), curved planar reformation (CPR) and volume rendering technique (VRT) to delineate the artery of Adamkiewicz and other related arterial structures.
Results: 1. The best scanning parameters using 16-slice MDCTA to visualize the artery of Adamkiewicz were as follows: 0.5 seconds per rotation, 0.75mm slice thickness, 1.5 pitch; Measured with ROI placed in the descending thoracic aorta at T7 level, CT value of 170Hu was selected as the threshold to trigger data acquisition; When this CT threshold value was reached, we delayed the scanning for another 18 seconds, then helical scanning automatically began. Axial images were reconstructed with B 20f algorithm, 1mm slice thickness and 0.75mm interval. VRT, MPR, MIP and CPR were used for image post-processing. 2. Using the optimized MDCTA techniques, the anterior spinal artery was clearly visualized in all normal subjects and patients with aortic aneurysm. The
artery of Adamkiewicz was visualized in 41of 45 normal subjects (91.1%) and in 21of 23 aneurysmal patients (91.3%). The anatomic continuity of the entire course of the artery of Adamkiewicz, starting from the aorta to the intercostals artery and ending at the characteristic hairpin-like junction with the anterior spinal artery, was clearly depicted in 27 of 45 normal subjects (60%) and in 14 of 23 patients (60.9%). There were 31 in the 41 normal subjects (75.6%) who have a single artery of Adamkiewicz. Two arteries of Adamkiewicz were identified in 10 of the 41 normal subjects (24.4%). Altogether a total of 51 arteries of Adamkiewicz were visualized. There were thirty-nine arteries of Adamkiewicz (39/51, 76.5%) originated from the left side and forty-nine (49/51, 96.0%) originated between the level from T7 to T12.
Conclusions: Using the optimized scanning and reconstruction techniques, 16-slice MDCTA can clearly depict the detailed anatomy of the artery of Adamkiewicz (including the origin, the branching patterns and the entire course) both in normal subjects and in patients with thoracoabdominal aortic aneurysms. As a noninvasive and efficient imaging technique, optimized MDCTA should therefore be the method of choice for the depiction of the artery of Adamkiewicz.
材料和方法：1. 收集2003年9月至2004年5月在四川大学华西医院放射科行CT增强检查而胸腹部无明显器质性病变的连续性受检者作为正常组研究对象，前瞻性探索MDCTA的最佳方法学（CT触发阈值、扫描延时时间和图像后处理方法）以及Adamkiewicz动脉的解剖细节，本组人数共计125例（男96例，女29例）。
2. 采用上述MDCTA技术，纳入同期连续性的胸腹主动脉瘤病人作为病例组研究对象进行CT增强扫描，共计23例（胸主动脉瘤7例，腹主动脉瘤10例，胸腹主动脉夹层动脉瘤3例，胸腹主动脉夹层分离3例）。
3. 对所得CT数据采用不同的二维和三维血管重建技术处理，包括最大密度投影（maximum intensity projection，MIP）、多层面重
组（multiplanar reformation，MPR）、曲面重组（curved planar reformation，CPR）、容积再现（volume rendering technique，VRT）等，分别获得主动脉、肋间动脉和脊髓动脉的各类重建和重组图像。
结果：1. 应用16层螺旋CT显示脊髓Adamkiewicz动脉的最佳成像技术为：扫描参数为扫描速度0.5s、层厚0.75mm、螺距1.5；在T7平面降主动脉区域设置兴趣监测区，扫描触发阈值170Hu； 达到该阈值后再延时18s后自动扫描；原始图像按1mm层厚、0.75mm层距、B20f算法进行重建；图像后处理重建及重组方法为VRT、MPR、CPR和MIP。
2. 采用上述MDCTA方法，均能在所有正常组和病例组研究对象清楚显示出脊髓前动脉；正常组Adamkiewicz动脉的显示率为91.1%（41/45例），病例组为91.3%（21/23例）；在正常组，CTA图像能够清楚显示从主动脉经肋间动脉到Adamkiewicz动脉的连续性走行关系者，占60%（27/45例），在病例组为60.9%（14/23例）。在正常组中有一支Adamkiewicz动脉的占75.6%（31/41例），41例中有10例（24.4%）能辨认出二支Adamkiewicz动脉，该动脉中有39支（39/51，76.5%）起源于左侧，49支（49/51，96%）位于T7~ T12之间。
结论：采用恰当的扫描和图像重建技术，MDCTA能清晰显示正常人和胸腹主动脉瘤病人脊髓Adamkiewicz动脉的解剖细节（起止关系、分支情况和走行特点），应作为Adamkiewicz动脉影像学评价的首选方法。
Objectives: 1. Using Multi-Detector-Row spiral CT angiography (MDCTA) (16-slice spiral CT) to investigate the visualization of the artery of Adamkiewicz with the optimized scanning parameters, scan delay time and reconstruction methods. 2. To assess the visualization of the artery of Adamkiewicz using MDCTA in patients with thoracoabdominal aortic aneurysms, so as to aid in surgical planning and help to reduce the incidence of intraoperative ischemic injury of the spinal cord and to prevent postoperative paraplegia.
Materials and Methods: 1. Between Sept 2003 and May 2004, a total of 125 consecutive subjects (96 males and 29 females) without any history of thoracic and abdominal lesions underwent contrast-enhanced MDCT angiography in Radiology Department of West China Hospital, Sichuan University, thus they were enrolled as the “Normal Group” of the study to prospectively investigate the optimization of MDCTA techniques, in terms of scan-triggering CT threshold, scan delay time and image
post-processing methodology, for the depiction of the detailed anatomy of the artery of Adamkiewicz. 2. Using the optimized MDCTA techniques, we prospectively scanned 23 consecutive patients with thoracoabdominal aortic aneurysms (aneurysmal dilatation of thoracic aorta in 7 and abdominal aorta in 10, 3 thoracoabdominal aortic dissecting aneurysms, and 3 aortic dissection) in same period of time. 3. All MDCTA data were processed by various two-dimensional and three-dimensional reconstruction techniques including maximum intensity projection (MIP), multiplanar reformation (MPR), curved planar reformation (CPR) and volume rendering technique (VRT) to delineate the artery of Adamkiewicz and other related arterial structures.
Results: 1. The best scanning parameters using 16-slice MDCTA to visualize the artery of Adamkiewicz were as follows: 0.5 seconds per rotation, 0.75mm slice thickness, 1.5 pitch; Measured with ROI placed in the descending thoracic aorta at T7 level, CT value of 170Hu was selected as the threshold to trigger data acquisition; When this CT threshold value was reached, we delayed the scanning for another 18 seconds, then helical scanning automatically began. Axial images were reconstructed with B 20f algorithm, 1mm slice thickness and 0.75mm interval. VRT, MPR, MIP and CPR were used for image post-processing. 2. Using the optimized MDCTA techniques, the anterior spinal artery was clearly visualized in all normal subjects and patients with aortic aneurysm. The
artery of Adamkiewicz was visualized in 41of 45 normal subjects (91.1%) and in 21of 23 aneurysmal patients (91.3%). The anatomic continuity of the entire course of the artery of Adamkiewicz, starting from the aorta to the intercostals artery and ending at the characteristic hairpin-like junction with the anterior spinal artery, was clearly depicted in 27 of 45 normal subjects (60%) and in 14 of 23 patients (60.9%). There were 31 in the 41 normal subjects (75.6%) who have a single artery of Adamkiewicz. Two arteries of Adamkiewicz were identified in 10 of the 41 normal subjects (24.4%). Altogether a total of 51 arteries of Adamkiewicz were visualized. There were thirty-nine arteries of Adamkiewicz (39/51, 76.5%) originated from the left side and forty-nine (49/51, 96.0%) originated between the level from T7 to T12.
Conclusions: Using the optimized scanning and reconstruction techniques, 16-slice MDCTA can clearly depict the detailed anatomy of the artery of Adamkiewicz (including the origin, the branching patterns and the entire course) both in normal subjects and in patients with thoracoabdominal aortic aneurysms. As a noninvasive and efficient imaging technique, optimized MDCTA should therefore be the method of choice for the depiction of the artery of Adamkiewicz.
引文
Adamkiewicz A. Die Blutgefasse des Menschlichen Ruckernmarkes. I. Die Gefasse der Ruckenmarksubstanz. Sitz Akad Wiss Wien Math Natur Klass 1882; 84:469-502
Savader SJ, Williams GM, Trerotola SO, et al. Preoperative spinal artery localization and its relationship to postoperative neurologic complications. Radiology 1993; 189: 165-171
Williams GM, Perler BA, Burdick JF, et al. Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia. J Vasc Surg 1991, Jan; 13(1): 23-33
Yoshioka K, Niinuma H, Ohira A, et al. MR angiography and CT angiography of the artery of Adamkiewicz: noninvasive preoperative assessment of thoracoabdominal aortic aneurysm. Radiographics 2003; 23(5): 1215-1225
Kawaharada N, Morishita K, Fukada J, et al. Thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography. Eur J Cardiothorac Surg 2002; 21(6): 970-974
Yamada N, Takamiya M, Kuribayashi S, et al. MRA of the Adamkiewicz artery: a preoperative study for thoracic aortic aneurysm. J Comput Assist Tomogr 2000; 24(3): 362-368
Maruyama R, Kamishima T, Shiiya N, et al. MDCT scan visualizes the Adamkiewicz artery. Ann Thorac Surg 2003; 76(4): 1308.
Kudo K, Terae S, Asano T, et al. Anterior spinal artery and artery of Adamkiewicz detected by using multi-detector row CT.AJNR Am J Neuroradiol 2003; 24(1): 13-17.
Takase K, Sawamura Y, Igarashi K, et al. Demonstration of the artery of Adamkiewicz at multidetector row helical CT. Radiology 2002; 223:39-45
Cargill H, Alleyne Jr, Cawley CM, et al. Microsurgical anatomy of the artery of Adamkiewicz and its segmental artery. J Neurosurg 1998; 89(5): 791-795
刘正津，陈尔瑜.临床解剖学丛书，胸部和脊柱分册。北京：人民卫生出版社，1996；380-382。
潘之清。实用脊柱病学。山东：科学技术出版社，1992；38-40。
Koshino T, Murakami G, Morishita K, et al. Does the Adamkiewicz artery originate from the larger segmental arteries? J Thorac Cardiovasc Surg 1999;117(5):898-905
吴沛宏，卢丽霞，黄毅。螺旋CT诊断学。广东：广东科技出版社，2000；26-69
顾恺时. 顾恺时胸心外科手术学。上海：上海科学技术出版社，2003；1117-1137
兰锡纯，冯卓荣. 心脏血管外科学。北京：人民卫生出版社，2002；757-771
孙衍庆。现代胸心外科学。北京：人民军医出版社，2000；1442-1443
Bachet J, Guilmet D, Rosier J, et al. Protection of the spinal cord during surgery of thoraco-abdominal aortic aneurysms. Eur J Cardiothorac Surg 1996; 10(10): 817-825
Grabitz K, Sandmann W, Stuhmeiner K. The risk of ischemic spinal cord injury in patients undergoing graft replacement for thoracoabdominal aortic aneurysms. J Vasc Surg 1996; 23:230-240
Griepp RB, Ergin MA, Galla JD. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg 1996; 112:1202-1215.
Fereshetian A, Kadir S, Kaufman SL, et al. Digital subtraction spinal cord angiography in patients undergoing thoracic aneurysm surgery. Cardiovasc Intervent Radiol 1989; 12 (1):7-9
Safi HJ, Miller CC III, Carr C, Iliopoulos DC, et al. Importance of intercostals artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998; 27:58-68
Svenson LG, Crawford ES, Hess KR, et al. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993; 17:357
Savader SJ, Williams GM, Trerotola SO, et al. Preoperative spinal artery localization and its relationship to postoperative neurologic complications. Radiology 1993; 189: 165-171
Williams GM, Perler BA, Burdick JF, et al. Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia. J Vasc Surg 1991, Jan; 13(1): 23-33
Yoshioka K, Niinuma H, Ohira A, et al. MR angiography and CT angiography of the artery of Adamkiewicz: noninvasive preoperative assessment of thoracoabdominal aortic aneurysm. Radiographics 2003; 23(5): 1215-1225
Kawaharada N, Morishita K, Fukada J, et al. Thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography. Eur J Cardiothorac Surg 2002; 21(6): 970-974
Yamada N, Takamiya M, Kuribayashi S, et al. MRA of the Adamkiewicz artery: a preoperative study for thoracic aortic aneurysm. J Comput Assist Tomogr 2000; 24(3): 362-368
Maruyama R, Kamishima T, Shiiya N, et al. MDCT scan visualizes the Adamkiewicz artery. Ann Thorac Surg 2003; 76(4): 1308.
Kudo K, Terae S, Asano T, et al. Anterior spinal artery and artery of Adamkiewicz detected by using multi-detector row CT.AJNR Am J Neuroradiol 2003; 24(1): 13-17.
Takase K, Sawamura Y, Igarashi K, et al. Demonstration of the artery of Adamkiewicz at multidetector row helical CT. Radiology 2002; 223:39-45
Cargill H, Alleyne Jr, Cawley CM, et al. Microsurgical anatomy of the artery of Adamkiewicz and its segmental artery. J Neurosurg 1998; 89(5): 791-795
刘正津，陈尔瑜.临床解剖学丛书，胸部和脊柱分册。北京：人民卫生出版社，1996；380-382。
潘之清。实用脊柱病学。山东：科学技术出版社，1992；38-40。
Koshino T, Murakami G, Morishita K, et al. Does the Adamkiewicz artery originate from the larger segmental arteries? J Thorac Cardiovasc Surg 1999;117(5):898-905
吴沛宏，卢丽霞，黄毅。螺旋CT诊断学。广东：广东科技出版社，2000；26-69
顾恺时. 顾恺时胸心外科手术学。上海：上海科学技术出版社，2003；1117-1137
兰锡纯，冯卓荣. 心脏血管外科学。北京：人民卫生出版社，2002；757-771
孙衍庆。现代胸心外科学。北京：人民军医出版社，2000；1442-1443
Bachet J, Guilmet D, Rosier J, et al. Protection of the spinal cord during surgery of thoraco-abdominal aortic aneurysms. Eur J Cardiothorac Surg 1996; 10(10): 817-825
Grabitz K, Sandmann W, Stuhmeiner K. The risk of ischemic spinal cord injury in patients undergoing graft replacement for thoracoabdominal aortic aneurysms. J Vasc Surg 1996; 23:230-240
Griepp RB, Ergin MA, Galla JD. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg 1996; 112:1202-1215.
Fereshetian A, Kadir S, Kaufman SL, et al. Digital subtraction spinal cord angiography in patients undergoing thoracic aneurysm surgery. Cardiovasc Intervent Radiol 1989; 12 (1):7-9
Safi HJ, Miller CC III, Carr C, Iliopoulos DC, et al. Importance of intercostals artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998; 27:58-68
Svenson LG, Crawford ES, Hess KR, et al. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993; 17:357