2017年 · 第51卷第04期

Clinical diagnostic requirements for coronary atherosclerotic heart disease (hereinafter referred to as coronary artery disease, CAD) include anatomical diagnosis, that is, information such as the site and extent of the lesion, the degree of lumen stenosis, and the composition of plaque on the wall, as well as functional diagnosis, that is, the presence or absence of ischemia and abnormal myocardial perfusion in the distant lesion. The combination of anatomical and functional diagnosis is the scientific basis for risk assessment and reasonable treatment plan for patients. Multi-slice CT has been used in clinical anatomical diagnosis of coronary heart disease for more than 10 years. Coronary CT angiography (CCTA) has become mature, and it is considered as the "gatekeeper" examination technique before invasive diagnosis and treatment of transcatheter coronary angiography (CAG) and percutaneous coronary intervention (PCI). It can also be simply understood as the first choice examination method before invasive examination. In recent years, CT functional imaging has gradually become a research hotspot, and it is expected to be the first to realize the clinical application of anatomy plus function.

The explosive development of science and technology has led to the great transformation of society, accompanied by the uncertainty of cognition, concept, environment and even behavior code. In the current social environment, discipline construction and personal development are facing new opportunities and challenges.

Treatment of acute ischemic stroke with novel retrievable stent bridging is effective^{[1,2,3,4,5,6]}Diseases with risk of bleeding, such as intracranial aneurysms, are generally considered to be contraindications for recanalization of acute ischemic stroke. Epidemiological survey results show that the incidence of aneurysms in the population is as high as 3% ~6%^[7]However, the incidence of aneurysm in patients with ischemic stroke may be higher, reaching 6.6% to 9.3%^[8,9]This may be due to the common risk factors of cerebral infarction and aneurysm, such as advanced age and hypertension. Although previous studies have shown that intravenous thrombolysis is relatively safe for acute occlusion of large intracranial vessels with unruptured intracranial aneurysms^[9,10]But the safety of endovascular therapy in such patients is unknown. The author analyzed the data of a patient with acute internal carotid artery "T" embolism complicated with multiple basilar artery aneurysms, and combined with literature review, aimed at exploring the safety of endovascular treatment in patients with acute intracranial vascular occlusion complicated with unruptured intracranial aneurysm.

The patient was a 38-year-old female. Amenorrhea appeared without obvious trigger 10 years ago, polydipsia, polydipsia and polyuria appeared 2 years ago, which worsened in the past 2 months, and showed lethargy, drowsiness and persistent pain in the left chest. History of rash denied. Physical examination: No rash was seen throughout the body, and no swelling of superficial lymph nodes was observed; Left lung breathing sound was low, percussion sound was turbid, left chest wall tenderness and percussion pain, liver was 3 cm subcostal, soft in texture and blunt in edge, spleen was 2 cm subcostal, and no abnormalities were found in neurological examination. Laboratory tests: pituitary follicle stimulating hormone 3.07 U/L (postmenopausal normal 16.74-113.5 U/L), luteinizing hormone 1.04 U/L (postmenopausal normal 10.87-58.64 U/L), estradiol 2.72 pmol/L (postmenopausal normal 5.45-10.90 pmol/L, 1 pmol/L =10^-9mmol/L), pituitary prolactin 65 μ g/L (postmenopausal normal 2.74~19.64 μ g/L), total bile acids 37.6 μ mol/L (normal 0~10 μ mol/L), alanine transferase 68 U/L (normal 7~40 U/L), aspartate transferase 77 U/L (normal 13~35 U/L), glutamyltransferphthalase 103 U/L (normal 7~45 U/L), direct bilirubin 6.6 μ mol/L (normal 0~6 μ mol/L), retinol binding protein 81 mg/L (normal 26.7~57.9 mg/L), urinary osmotic pressure 96 mOsm/kg (normal 600~1 000 mOsm/kg), blood routine, coagulation function, adrenocorticotropic hormone, and cortisol were all normal.

Example 1A 7-year-old female suffered from paroxysmal pain in the lower abdomen for 1 week without obvious trigger. B-ultrasound showed pelvic mass and was admitted to hospital. Laboratory tests are not special. Physical examination: Flat abdomen, obvious pelvic tenderness, mild rebound pain, no gastrointestinal pattern and peristaltic waves, and weakened intestinal sounds. Abdominal CT showed a circular mass shadow before the pelvic sacral vertebra, about 75 mm ×70 mm ×60 mm, with poor boundary and uniform internal density (Figure 1), more obvious nodular enhancement and small patch-like and strip-like enhancement were seen in the arterial phase of enhanced scanning (Figure 2）； In the portal phase, the range of lesion enhancement gradually increased and the degree of enhancement increased (Figure 3，Figure 4), considered as vascular tumor. Operation: There is a huge tumor in the pelvic cavity, which is solid and tough in texture. The lesion is mainly located in the mesenteric lining of the small intestine, which is rounded in shape, enveloped and relatively fixed. Pathological examination: Under the microscope, the tumor was mainly composed of epithelioid cells. The cells were sparsely arranged and slightly fascicular. A large number of lymphocytes and plasma cells infiltrated in the interstitium, and mucoid changes were visible. Immunohistochemistry: Vimentin (Vimentin), Actin (Actin), keratin (CK), heavy calmodulin binding protein (H-caldesmon), ALK (+), cell proliferation index Ki-67 (+5%), CD34, Desmin (Desmin, -). Pathological diagnosis: pelvic epithelioid inflammatory myofibroblastic sarcoma (epithelioid inflammatory myofibroblastic sarcoma, EIMS).

Invasive coronary angiography (CAG) and non-invasive coronary CT angiography (CCTA) are the most commonly used methods for diagnosing coronary heart disease at present, but they can only provide anatomical information of coronary arteries, but cannot evaluate the function of stenosis. The anatomical characteristics of coronary artery stenosis do not directly reflect the functional status, especially in moderate stenosis lesions, and the correlation between the two is poor. Clinically, functional assessment of coronary artery stenosis is the most important factor in determining whether a patient needs revascularization and affects clinical prognosis. At present, the commonly used methods for judging the function of coronary artery stenosis mainly include invasive fractional flow reserve (FFR) measurement and non-invasive myocardial perfusion radionuclide imaging. However, the former is an invasive examination, which is complicated and expensive to operate and increases the radiation dose of patients^[1,2]； Although the latter is non-invasive, it cannot be completed at the same time as the angiographic anatomical evaluation, which brings inconvenience to the operation and adds additional costs. In recent years, non-invasive CT function evaluation technology has emerged, and its combination with CCTA can complete the one-stop evaluation of coronary artery anatomy and function, which brings great convenience to clinical diagnosis and treatment. The author summarizes the progress in this respect as follows.

With the popularization of low-dose CT lung cancer screening, the detection rate of subsolid nodule (SSN) has increased greatly. SSN is the collective term of nonsolid nodule (NSN) and part-solid nodule (PSN). SSN with long-term persistence has a high probability of malignancy and is usually lung adenocarcinoma^[1]。 In 2011, International Association for Lung Cancer Research, American Thoracic Association and European Respiratory Association jointly announced the International Multidisciplinary Classification Standard of Lung Adenocarcinoma^[2]Among them, pre-invasive lesions include atypical adenomatous hyperplasia (AAH) and adenocarcinoma in situ (AIS), invasive lesions include minimally invasive adenocarcinoma (MIA), invasive adenocarcinoma (IAC), and the invasiveness of lung adenocarcinoma affects the stage of lung cancer and the prognosis of patients. Therefore, early diagnosis and evaluation of lung adenocarcinoma can provide reference for the choice of surgical methods and the prognosis of patients. Long-term persistence of SSN enlargement or internal appearance or increase of solid components highly indicate that the nodule is malignant^[3]。 CT quantitative measurement can objectively quantify the characteristics of nodules, so as to reflect the changes of nodules more objectively in the follow-up process. The repeatability and sensitivity are higher than the traditional macroscopic assessment, and it has broad prospects in the analysis of nodule infiltration and prediction of patient prognosis. The author mainly discusses a variety of CT quantitative measurement methods for SSN, and summarizes the value of each method for nodule assessment.