慢性硬膜下血肿脑膜中动脉管径差异的DSA测量分析

谭雨豪,  尹鲁刚,  张仁坤,  张永巍,  赵瑞,  李强,  许奕,  杨鹏飞,  左乔,  刘建民

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引用本文: 谭雨豪，尹鲁刚，张仁坤，等．慢性硬膜下血肿脑膜中动脉管径差异的DSA测量分析［J］. 海军军医大学学报，2025，46 （12）：1553-1557. DOI: 10.16781/j.CN31-2187/R.20250140.
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Citation: TAN Y, YIN L, ZHANG R, et al. DSA measurement and analysis of diameter difference of middle meningeal artery in chronic subdural hematoma［J］. Acad J Naval Med Univ, 2025, 46(12): 1553-1557. DOI: 10.16781/j.CN31-2187/R.20250140.
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慢性硬膜下血肿脑膜中动脉管径差异的DSA测量分析

doi: 10.16781/j.CN31-2187/R.20250140

  • 海军军医大学(第二军医大学)第一附属医院脑血管病中心, 上海 200433

基金项目: 

上海市“医苑新星”青年医学人才培养资助计划 2023-62;

海军军医大学第一附属医院“长风”人才培养计划 .

详细信息

DSA measurement and analysis of diameter difference of middle meningeal artery in chronic subdural hematoma

  • Neurovascular Center, The First Affiliated Hospital of Naval Medical University (Second Military Medical University), Shanghai 200433, China

Funds: 

Shanghai Youth Medical Talent Training Support Project for New Stars in Medical Circle 2023-62;

"Changfeng" Talent Program of The First Affiliated Hospital of Naval Medical University .

    摘要
  • 摘要:  目的 通过数字减影血管造影(DSA)量化分析慢性硬膜下血肿(CSDH)患者脑膜中动脉(MMA)的管径差异。 方法 回顾性纳入2018年5月至2023年5月收治于我科并接受MMA栓塞治疗的32例CSDH患者，其中男28例、女4例，年龄为(66.38±10.54)岁。通过DSA正侧位图像测量MMA主干颅内段管径，采用Wilcoxon符号秩检验分析双侧MMA的差异。 结果 在29例单侧CSDH患者中，患侧MMA直径大于健侧[2.10(2.00，2.25)mm vs 1.95(1.80，2.05)mm，P < 0.001]。在3例双侧血肿患者中，双侧MMA直径差异无统计学意义(P=0.724)。 结论 CSDH患者患侧MMA管径较健侧增粗，提示MMA增粗可能与CSDH的发病有关。

     

    Abstract:  Objective To quantitatively evaluate the difference in the diameter of the middle meningeal artery(MMA) in patients with chronic subdural hematoma(CSDH) using digital subtraction angiography(DSA). Methods We retrospectively enrolled 32 patients with CSDH who underwent MMA embolization at our department between May 2018 and May 2023. The cohort included 28 males and 4 females, with a mean age of(66.38±10.54) years. The diameter of the intracranial segment of the MMA trunk was measured on anteroposterior and lateral DSA images. The Wilcoxon signed-rank test was used to analyze the diameter difference of bilateral MMA. Results In the 29 patients with unilateral CSDH, the mean diameter of the affected MMA was significantly greater than that of the healthy MMA(2.10 [2.00, 2.25] mm vs 1.95 [1.80, 2.05] mm, P < 0.001). In the 3 patients with bilateral hematomas, no significant difference in MMA diameter was observed between the 2 sides(P=0.724). Conclusion MMA is significantly enlarged on the side of the hematoma in patients with CSDH, suggesting that MMA enlargement may be related to the pathogenesis of CSDH.

     

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  • 慢性硬膜下血肿（chronic subdural hematoma，CSDH）是神经外科常见疾病之一，多见于中老年人群。随着全球人口老龄化进程的加速，抗凝、抗血小板药物使用日益频繁，CSDH在全球范围内的发病率呈上升趋势[1]。流行病学数据显示，芬兰1990－2015年CSDH年发病率从8.2/10万增高至17.6/10万[2]；美国2015年退伍军人队列研究表明，CSDH年发病率高达79.4/10万，预测至2030年退伍军人与普通人群的CSDH年发病率将分别攀升至121.4/10万和17.4/10万，或将成为神经外科领域最高发的疾病类型[3]。

    传统观点认为颅脑外伤导致的桥静脉撕裂是CSDH的主要原因，尤其是在脑萎缩患者中，轻微外力即可导致硬脑膜下腔增宽，桥静脉因张力增加而破裂[4]。然而，研究发现，仅有部分CSDH患者存在明确外伤史，且血肿常呈现“反复渗出-扩大”的动态过程，提示单纯机械性损伤理论不足以解释其病理生理机制[5-6]。同时，组织病理学显示，血肿外膜层存在大量薄壁新生血管，其内皮细胞连接松散且基底膜不完整，导致血浆成分和红细胞持续外渗；影像学研究证实这些新生血管的血供主要来源于脑膜中动脉（middle meningeal artery，MMA）的分支[7]。最新临床研究表明，脑膜中动脉栓塞（middle meningeal artery embolization，MMAE）治疗CSDH更具优势。相较于传统钻孔引流联合药物治疗，MMAE可更有效地降低血肿复发/进展风险及治疗失败率，同时减少患者死亡率、致残性卒中发生率和严重不良事件风险[8-10]。

    既往研究提示CSDH患者MMA管径较健康人群增粗，但因磁共振血管成像（magnetic resonance angiography，MRA）技术局限及个体差异，患侧与健侧对比证据不足。本研究采用数字减影血管造影（digital subtraction angiography，DSA）精准测量单侧CSDH患者的MMA管径，探讨CSDH患者患侧MMA管径的变化特征，为揭示CSDH的病理机制及探索介入治疗方案提供影像学依据。

    1   资料和方法

    1.1   病例资料

    回顾性分析2018年5月至2023年5月收治于我科并接受MMAE治疗的179例CSDH患者的病例资料。纳入标准：（1）经头颅CT/MRI检查证实为CSDH；（2）伴有占位效应的症状性CSDH，其中占位效应是指由于CSDH导致中线结构移位或大脑局部皮质变形，症状性CSDH是指出现神经系统症状（如头痛、短期认知功能障碍、语言障碍或失语、步态不稳、肌力下降、感觉障碍、癫痫发作等）的CSDH；（3）年龄≥18岁。排除标准：（1）既往有脑血管意外或中重度颅内动脉粥样硬化；（2）DSA检查过程中造影剂充盈不充分，成像质量较差；（3）缺少健侧MMA造影。

    1.2   MMA管径测量方法

    将所有DSA正侧位图像传输到影像工作站进行分析（图 1）。（1）测量段选择：由于MMA主干颅内段血管走行相对平直，能够减少因血管弯曲干扰导致的测量误差，所以选择该段。（2）测量时机：在动脉中期，当造影剂充分充盈且血流稳定时进行测量，此时血管显影清晰，运动伪影较少。（3）测量方式：由2名神经外科医师采用盲法分别测量双侧MMA直径（单位：mm），取2人测量平均值进行统计分析；若测量差值＞0.2 mm，由第3位高年资医师复核，经讨论达成一致意见。

    图  1  基于DSA图像测量CSDH患者的MMA直径
    Fig.  1  Measurement of MMA diameter in CSDH patients based on DSA images
    The long triangles indicate the MMA, the arrow indicated the measurement site, and the line segment represents the measured MMA diameter. DSA: Digital subtraction angiography; CSDH: Chronic subdural hematoma; MMA: Middle meningeal artery.
    下载: 全尺寸图片

    1.3   统计学处理

    使用R 4.4.2软件进行数据分析。计量资料若符合正态分布以x±s表示，若不符合正态分布则以M (Q1, Q3)表示，计数资料以例数和百分数表示。采用Wilcoxon符号秩检验分析双侧MMA直径的差异。检验水准（α）为0.05。

    2   结果

    依据纳入与排除标准逐层筛选，最终纳入符合条件的CSDH患者32例，患者一般资料见表 1、2。22例有明确外伤史；男28例（87.5%），女4例（12.5%）；年龄37~85（66.38±10.54）岁。左侧血肿13例，右侧血肿16例，双侧血肿3例。26例采取钻孔引流结合MMAE治疗，6例采取单纯MMAE治疗，其中1例复发。共测量64条MMA管径。在29例单侧CSDH患者中，患侧MMA直径大于健侧[2.10（2.00，2.25）mm] vs 1.95（1.80，2.05）mm]，差异有统计学意义（P＜0.001）。3例双侧CSDH患者的左、右侧MMA直径分别为2.46、2.52，2.50、2.40，2.18、2.02 mm，双侧MMA直径差异无统计学意义（P＝0.724）。

    表  1  29例单侧CSDH患者的一般资料
    Table  1  General data of 29 unilateral CSDH patients
    Patient No. Gender Age/year Diameter of MMA/mm Hematoma location Symptom Drill hole drainage Trauma
    Affected Healthy
    1 Male 83 2.65 2.30 Right Limb weakness Yes Yes
    2 Male 69 2.59 2.40 Right Limb weakness Yes Yes
    3 Female 62 2.48 1.69 Left Headache, limb weakness Yes Yes
    4 Male 69 2.42 1.77 Left Limb weakness Yes Yes
    5 Male 71 2.20 2.30 Left Dizziness, limb weakness Yes Yes
    6 Male 66 2.20 2.13 Left Headache No No
    7 Male 51 2.18 2.10 Left Headache, limb weakness No Yes
    8 Male 74 2.16 1.81 Left Dizziness Yes Yes
    9 Female 50 2.15 2.00 Right Dizziness, headache Yes Yes
    10 Male 71 2.15 1.94 Right Headache, limb weakness Yes No
    11 Male 41 2.12 1.56 Right Headache Yes Yes
    12 Male 74 2.11 2.00 Right Limb weakness No No
    13 Male 80 2.09 2.10 Right Headache Yes No
    14 Male 68 2.05 2.00 Right Limb weakness Yes No
    15 Male 85 2.04 1.92 Right Limb weakness Yes Yes
    16 Male 62 2.02 2.05 Right Dizziness, limb weakness Yes Yes
    17 Male 70 1.99 1.58 Right Limb weakness Yes No
    18 Male 71 1.99 2.00 Left Limb weakness Yes No
    19 Female 65 1.98 1.98 Left Headache, dizziness Yes Yes
    20 Male 72 1.98 1.63 Left Limb weakness Yes No
    21 Male 69 1.93 1.96 Right Limb weakness Yes Yes
    22 Male 72 1.93 1.70 Right Headache No No
    23 Male 63 1.91 1.94 Left Limb weakness Yes Yes
    24 Male 75 1.90 1.87 Right Limb weakness Yes Yes
    25 Male 65 1.88 1.82 Left Aphasia Yes Yes
    26 Male 67 1.86 1.80 Right Headache No Yes
    27 Male 69 1.80 1.60 Right Dizziness Yes Yes
    28 Male 74 2.19 2.00 Left Dizziness, limb weakness Yes Yes
    29 Female 62 2.19 1.96 Left Limb weakness Yes Yes
    CSDH: Chronic subdural hematoma; MMA: Middle meningeal artery.
    表  2  3例双侧CSDH患者的一般资料
    Table  2  General data of 3 bilateral CSDH patients
    Patient No. Gender Age/year Diameter of MMA/mm Symptom Drill hole drainage Trauma
    Left Right
    30 Male 57 2.46 2.52 Dizziness, limb weakness Yes Yes
    31 Male 37 2.50 2.40 Headache No No
    32 Male 60 2.18 2.02 Limb weakness Yes Yes
    CSDH: Chronic subdural hematoma; MMA: Middle meningeal artery.

    3   讨论

    本研究通过DSA测量发现CSDH患者患侧MMA平均管径较健侧增粗，而既往MRA研究或许受限于成像原理和测量方法，MMA管径测量值低于DSA测量结果20%~30%[11]。本研究在DSA上进行CSDH患者MMA管径的测量和比较，与其他成像方式不同，DSA通过实时减影技术消除了骨骼和软组织干扰，其空间分辨率可达0.1 mm，能够辅助术者制定栓塞治疗策略，减少术后复发率，进而减轻患者再治疗风险。

    目前认为，CSDH的病理机制与脑血管疾病特征一致，其病程大致可分为3个阶段。最初，硬脑膜边界细胞层损伤导致脑脊液和血液渗入硬脑膜下腔，引发炎症反应并释放IL等炎症介质，招募炎症细胞及成纤维细胞[12]。随后，血管内皮生长因子、TGF-β1等刺激新生血管生成，但这些血管结构不完善，导致持续渗血并加重炎症，形成高纤维蛋白溶解和反复出血的恶性循环[13]。最后，随着血肿逐渐增大开始出现神经系统症状[14-15]。

    MMA是新生血管的主要供血来源，其管径的变化可能反映血肿活动性及复发风险。CSDH患者的血肿外膜血管密度和毛细血管直径显著增加[16]，这导致内皮细胞间隙扩大，进一步加重渗血。炎症因子通过增加血管通透性和促进血管生成，加剧了这一过程[17]。Takizawa等[11]研究表明，CSDH患者的MMA直径较健康对照组显著增粗。这种病理性增粗可能源于新生血管化进程，不成熟的新生血管壁结构脆弱，易发生反复微出血，进而促进血肿扩大。从分子机制看，血管内皮生长因子、TGF-β1等促血管生成因子过度表达可驱动MMA代偿性扩张，以适应异常血供需求。在局部血流动力学改变的情况下，血管为维持恒定剪切力会通过重塑机制促使MMA管径适应性增大。值得注意的是，部分MMAE治疗失败病例中出现MMA直径偏小的现象，这提示此类血肿的供血可能依赖于其他侧支循环[18]。此外，CSDH的机械压迫效应也可能刺激MMA发生代偿性扩张。然而，这种扩张是作为原发性病理启动因素，还是继发于血肿形成的适应性改变？其具体调控机制如何？这种管径变化呈现阶段性特征还是持续性过程？这些问题均有待通过纵向影像学研究验证。

    MMAE通过阻断血肿包膜的血供、降低血管内皮生长因子表达并抑制新生血管生成，减少血肿渗漏和复发。同时，明显增粗的MMA可能提示MMAE疗效更优。MMA直径＜1.5 mm是临床治疗失败的独立预测因子[18]，小管径可能导致栓塞材料（如单纯颗粒栓塞）无法充分渗透至远端新生血管，从而残留血肿供血血管。未来可尝试将MMA管径参数作为复发预测指标，指导手术/介入联合治疗。液体栓塞剂Onyx胶因可视性佳、渗透性强，在MMA直径＜1.5 mm时仍能有效渗透，成为当前MMAE的主流材料选择[19]。对于管径较小的MMA，采用超选导管联合液体栓塞技术可显著提升MMAE治疗成功率。若术中发现额外侧支参与供血，需根据血管解剖特征扩大栓塞范围以确保疗效。在MMAE中，危险吻合的识别与处理是技术难点，其本质是处理颅内外血管间的异常交通支。液体栓塞材料一旦经吻合支逆流至颅内动脉可能引发失明、偏瘫甚至死亡等严重并发症，术前通过超选造影精准评估吻合支走行可有效降低材料误栓风险。

    在评估MMA及CSDH相关血管病变时，不同影像学技术各具特点。MRA能显示MMA主干，但受限于空间分辨率和运动伪影，难以识别微小新生血管，多用于筛查或随访[20]。CT血管成像凭借快速三维重建优势，可立体呈现MMA与颅骨的解剖关系，但对低速血流灵敏性低且存在造影剂肾病风险，适用于急诊初评或术后复查[16]。DSA可动态评估血流并清晰显示MMA分支及新生血管，但其因有创性、辐射暴露和高成本，主要用于术前精准解剖评估及栓塞路径规划。尽管DSA在栓塞治疗中不可替代，MRA和CTA仍可作为筛查或随访的重要补充，通过多模态联合应用实现诊疗全程的精准评估。

    本研究存在一定局限性，作为回顾性研究，且样本量较小，MMA管径变化与CSDH预后的相关性仍需通过更大样本量的前瞻性随机对照试验进一步明确；此外，缺乏健康人群MMA管径作为对照，未来需前瞻性纳入年龄匹配的健康队列，以明确CSDH患者MMA增粗的特异性。

  • 图  1   基于DSA图像测量CSDH患者的MMA直径

    Fig.  1   Measurement of MMA diameter in CSDH patients based on DSA images

    The long triangles indicate the MMA, the arrow indicated the measurement site, and the line segment represents the measured MMA diameter. DSA: Digital subtraction angiography; CSDH: Chronic subdural hematoma; MMA: Middle meningeal artery.

    下载: 全尺寸图片

    表  1   29例单侧CSDH患者的一般资料

    Table  1   General data of 29 unilateral CSDH patients

    Patient No. Gender Age/year Diameter of MMA/mm Hematoma location Symptom Drill hole drainage Trauma
    Affected Healthy
    1 Male 83 2.65 2.30 Right Limb weakness Yes Yes
    2 Male 69 2.59 2.40 Right Limb weakness Yes Yes
    3 Female 62 2.48 1.69 Left Headache, limb weakness Yes Yes
    4 Male 69 2.42 1.77 Left Limb weakness Yes Yes
    5 Male 71 2.20 2.30 Left Dizziness, limb weakness Yes Yes
    6 Male 66 2.20 2.13 Left Headache No No
    7 Male 51 2.18 2.10 Left Headache, limb weakness No Yes
    8 Male 74 2.16 1.81 Left Dizziness Yes Yes
    9 Female 50 2.15 2.00 Right Dizziness, headache Yes Yes
    10 Male 71 2.15 1.94 Right Headache, limb weakness Yes No
    11 Male 41 2.12 1.56 Right Headache Yes Yes
    12 Male 74 2.11 2.00 Right Limb weakness No No
    13 Male 80 2.09 2.10 Right Headache Yes No
    14 Male 68 2.05 2.00 Right Limb weakness Yes No
    15 Male 85 2.04 1.92 Right Limb weakness Yes Yes
    16 Male 62 2.02 2.05 Right Dizziness, limb weakness Yes Yes
    17 Male 70 1.99 1.58 Right Limb weakness Yes No
    18 Male 71 1.99 2.00 Left Limb weakness Yes No
    19 Female 65 1.98 1.98 Left Headache, dizziness Yes Yes
    20 Male 72 1.98 1.63 Left Limb weakness Yes No
    21 Male 69 1.93 1.96 Right Limb weakness Yes Yes
    22 Male 72 1.93 1.70 Right Headache No No
    23 Male 63 1.91 1.94 Left Limb weakness Yes Yes
    24 Male 75 1.90 1.87 Right Limb weakness Yes Yes
    25 Male 65 1.88 1.82 Left Aphasia Yes Yes
    26 Male 67 1.86 1.80 Right Headache No Yes
    27 Male 69 1.80 1.60 Right Dizziness Yes Yes
    28 Male 74 2.19 2.00 Left Dizziness, limb weakness Yes Yes
    29 Female 62 2.19 1.96 Left Limb weakness Yes Yes
    CSDH: Chronic subdural hematoma; MMA: Middle meningeal artery.

    表  2   3例双侧CSDH患者的一般资料

    Table  2   General data of 3 bilateral CSDH patients

    Patient No. Gender Age/year Diameter of MMA/mm Symptom Drill hole drainage Trauma
    Left Right
    30 Male 57 2.46 2.52 Dizziness, limb weakness Yes Yes
    31 Male 37 2.50 2.40 Headache No No
    32 Male 60 2.18 2.02 Limb weakness Yes Yes
    CSDH: Chronic subdural hematoma; MMA: Middle meningeal artery.
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  • 收稿日期:  2025-03-10
  • 接受日期:  2025-08-25

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