探討3D-FIESTA和3D-TOF在三叉神經痛微血管減壓術中的指導意義及臨床價值

邢振義　劉善賢　李艷慧　王磊　夏鶴春　孫濤

1.河南新鄉市中心醫院神經外科　新鄉　453600; 2.寧夏醫科大學總醫院神經外科　銀川　750004

?

探討3D-FIESTA和3D-TOF在三叉神經痛微血管減壓術中的指導意義及臨床價值

邢振義1)劉善賢1)李艷慧1)王磊1)夏鶴春2)孫濤2)

1.河南新鄉市中心醫院神經外科新鄉453600; 2.寧夏醫科大學總醫院神經外科銀川750004

【摘要】目的探討三維穩態進動快速成像序列(3D-FIESTA)和三維時間飛躍法(3D-TOF)在三叉神經痛微血管減壓術中的指導意義及臨床價值。方法回顧性分析86例三叉神經痛微血管減壓術患者術前MRI及術中影像，分析3D-FIESTA 和3D-TOF-MRA序列在三叉神經痛患者與責任血管的關系以及其臨床意義。結果本組86例患者證實83例(96.5%)存在血管神經關系密切，以術中所見影像為金標準。術前均采用3D-FIESTA 和3D-TOF-MRA序列。本組78例患者至目前無明顯癥狀，2例再次手術，1例術后面部麻木無疼痛，1例術后出現顱內感染癥狀經抗感染治療后痊愈，2例面部間斷性輕度疼痛且拒絕口服藥物(患者自述不影響正常生活)，未給予特殊處理，1例遺漏輕度面癱。1例失訪。結論術前3D-FIESTA 和3D-TOF-MRA檢查能夠清晰識別三叉神經痛患者神經血管的關系，對指導微血管減壓術以及預測手術難易度有重要的臨床意義。

【關鍵詞】三叉神經痛；微血管減壓術；磁共振成像

三叉神經痛(trigemimal neuralgia，TN)是以三叉神經區域反復發作的劇烈尖銳的疼痛為主要特征。其中原發性三叉神經痛多數學者支持Jannetta提出微血管壓迫的“短路”學說[1]。目前多數患者需手術治療，術前對責任血管的分析辨別對取得手術效果意義重大，本文通過回顧性分析新鄉市中心醫院神經外科2013-01—2014-10間86例患者結合術中影像來探討FIESTA、TOF序列對微血管減壓術的指導意義及臨床價值，現報道如下。

1資料與方法

1.1一般資料本組86例患者均為原發性三叉神經痛,其中男30例，女56例；年齡33～68歲，平均50.52歲。病程：1個月～22 a, 其中<4 a 57例，4～9 a 15例，≥10 a 14例?；颊呔浛诜幬?卡馬西平)治療有效，但無法耐受者獲不斷加大劑量。

1.2研究方法(1)影像學檢查：患者術前均行FIESTA、TOF序列，(美國GE HDxt 3.0T MR 成像系統和8通道頭頸聯合線圈)(2)手術方法：患者均采用經乙狀竇后入路。

2結果

2.1責任血管類型及與三叉神經的接觸程度根據 Arbab的標準分析[2]：本組86例患者MRI檢出者83例(96.5%)，83例術中均證實責任血管類型。小腦上動脈34例(40.9%)：小腦前下動脈20例(24.0%)，小腦后下動脈1例(1．2%)。 椎動脈5例(6.0%)。巖靜脈5例(6.0%)。多支動 脈14例(16.8%)。動靜脈混合4例(4.8%)。3例MRI顯示無明顯接觸，手術未發現有血管接觸或壓迫，僅見三叉神經周圍有蛛網膜粘連。

2.2治療效果本組78例患者隨訪至目前無明顯癥狀。2例再次手術。1例術后面部麻木無疼痛。1例術后出現顱內感染癥狀經抗感染治療后痊愈。2例面部間斷性輕度疼痛且拒絕口服藥物(患者自述不影響正常生活)，未給予特殊處理，1例輕度面癱。1例失訪。

3討論

隨著MRI技術的發展，其用于微血管減壓術前行MRI檢查，不僅可在術前明確神經血管關系，同時對于取得良好手術效果具有重要指導作用。特別是高分辨率MRI，尤其是3D-FIESTA序列及3D-T0F MRA在術前檢出TN患者的責任血管、判斷癥狀側三叉神經與責任血管的相對位置以及判斷責任血管的性質等方面準確性高，對 MVD術前評價、制定手術方案及判斷預后都具有重要意義[3]。

3D-FIEST序列利用重T2WI的效果來襯托腦脊液的信號，達到相同于“腦室系統造影”的效果。動、靜脈及三叉神經都呈低信號，而腦脊液顯示為明顯高信號，其分辯率和對比度具有高空間性，再加用流動補償技術，可有效消除流動干擾偽影，對于細小靜脈也能清晰顯示[4]，但無法明顯區別神經和血管組織。而在3D-T0F MRA上，動脈顯示為高信號，靜脈不易顯示，三叉神經顯示為中等信號，腦脊液顯示為低信號。通過對3D-FIESTA序列和3D-TOF MRA序列的觀察，可以判斷責任血管類型，3D-T0F MRA圖像上顯示的血管為動脈，而在3D-FIESTA圖像上顯示卻未在3D-T0F MRA圖像上顯示的血管為靜脈。二者結合不僅可準確判斷出責任血管的性質(動脈或靜脈)，避免患者注射造影劑痛苦，并減輕患者經濟負擔。文獻報道[5]在判斷責任血管性質方面，3D-FIESTA和3D-T0F MRA[6]圖像相結合的準確率98.0%，與本文觀察結果(96.5%)相近。

本組5例出現不同程度并發癥，文獻報道[7]新生的責任血管亦是引起復發的重要原因，故臨床應不斷提高手術技巧，充分減壓，降低責任血管遺漏，避免材料的移位、脫落，預防術后蛛網膜粘連等均可降低術后并發癥，提高手術效果。同時術中應盡量較少對腦組織的損傷。

4參考文獻

[1]Jannetta PJ.Microsurgical approach to the trigeminal nerve for the douloureux[J].Prog NeuroSurg,1976(7):180-186.

[2]Arbab A S, Nishiyama Y, Aoki S, et al. Simultaneous display of MRA and MPR in detecting vascular compression for trigeminal neuralgia or hemifacial spasm:comparison with oblique sagittal views of MRI[J]. European radiology, 2000, 10(7):1056-1060.

[3]Chavhan GB,Babyn PS,Jankharia BG.Steady-state MR imaging sequences:physics,classification,and clinical applications[J].Radiographics.2008;28:1147-1160.

[4]林青，童綏君，曲紅麗，等．磁共振斷層血管成像對三叉神經痛病因的診斷價值[J]．福建醫科大學學報，2013，42(4)：341-343．

[5]Zeng Q,Zhou Q,Liu Z,Li Z,et al. Preoperative detection of the neurovascular relationship in trigeminal neuralgia using three-dimensional fast imaging employing steady-state acquisition (FIESTA) and magnetic resonance angiography (MRA)[J].J Clin Neurosci.2013;20(1):107-11.

[6]Garcia M, Naraghi R, Zumbrunn T, et al.High-resolution 3D-constructive interference in steady-state MR imaging and 3D time-of-flight MR angiography in neurovascular compression: a comparison between 3T and 1.5T[J]. Am J Neuroradiol. 2012;33(7):1251-125 6.

[7]楊德寶，王之敏，將棟毅,等.顯微血管減壓術治療三叉神經痛術后復發與再手術[J].中華神經醫學雜志，2013,12(3)：308-310.

(收稿2016-01-22)

The guiding significance and clinical value of 3D-FIESTA and 3D-TOF in microvascular decompression for trigeminal neuralgia

1)XingZhenyi,LiuShanxian,LiYanhui,WangLei,DepartmentofNeurosurgery,XinxiangCentralHospital,Xinxiang, 453600,China；2)XiaHechun,SunTao.

DepartmentofNeurosurgery，NingxiaMedicalUniversity，theAffiliatedHospital,Yinchuan750004,China

【Key words】Trigeminal neuralgia; Microvascular decompression; Magnetic resonance imaging

【Abstract】ObjectiveTo investigate the guiding significance and clinical value of 3D-FIESTA and 3D-TOF in microvascular decompression for trigeminal neuralgia. MethodsPreoperative MRI and intraoperative images on 86 patients with microvascular decompression for trigeminal neuralgia were retrospectively analyzed. Meanwhile, the roles of 3D-FIESTA and 3D-TOF-MRA on the relationship between nerves and responsible vessels in trigeminal neuralgia patients as well as the clinical significance were analyzed. ResultsA total of 86 cases in this group had confirmed that 83 cases existed a close relationship between blood vessels and nerves, regarding intraoperative images as golden standard. 3D-FIESTA and 3D-TOF-MRA were adopted before operation. All patients in this group showed efficiencies after operation and so far 78 cases had no significant symptom; 2 patients received the operation again; 1 case had facial numbness without pains; 1 case had intracranial infection after operation and cured with anti-infective therapy; 2 cases had facial intermittent mild pain and refused to take oral drugs (patients had stated those pains did not affect normal life), without special treatments; 1 case had mild facial paralysis and 1 case was lost to follow up. ConclusionPreoperative 3D-FIESTA and 3D-TOF-MRA can clearly reveal the relationship between nerves and blood vessels in trigeminal neuralgia patients, which is of vital clinical significance in guiding microvascular decompression and predicting operation difficulty.

【中圖分類號】R445.2

【文獻標識碼】B

【文章編號】1077-8991(2016)02-0005-03