Value of combined exploration of carotid plaque by multiple ultrasound techniques to predict recurrence of ischemic stroke
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摘要:
目的 探讨二维和三维超声、超声造影(CEUS)和剪切波弹性成像(SWE)联合探查颈动脉斑块并分析其预测缺血性脑卒中(IS)复发的价值。 方法 筛选新疆医科大学第二附属医院2021年10月—2023年1月收治的首发IS合并颈动脉粥样硬化斑块患者95例，根据是否复发分为复发组和未复发组。采用logistic回归分析研究影响IS患者复发的危险因素。采用ROC曲线分析多项超声技术联合预测IS复发的价值。 结果 失访5例，有37例患者复发，复发率为41.11%，复发组高血压占比高于未复发组，药物依从性好占比则低于未复发组(P＜0.05)。复发组CEUS-血流Ⅲ~Ⅳ级占比及二维-动脉内中膜厚度(IMT)、三维-颈动脉斑块总面积(TPA)值高于未复发组，杨氏模量平均值则低于未复发组(P＜0.05)。多因素logistic回归分析显示，CEUS-血流Ⅲ~Ⅳ级、二维-IMT高和三维-TPA大及杨氏模量平均值低是影响IS患者复发的危险因素，药物依从性好则是其保护因素(P＜0.05)。ROC曲线分析显示，二维-IMT、三维-TPA、杨氏模量平均值及CEUS-血流Ⅲ~Ⅳ级单项预测IS患者复发的AUC分别为0.674、0.717、0.729、0.746，联合预测AUC为0.908，高于单项检测(P＜0.05)。 结论 二维、三维及SWE、CEUS超声技术通过评估颈动脉斑块不稳定性，在预测IS复发方面具有一定的临床价值，四者联合价值更高。 Abstract:Objective To investigate the value of combined 2D and 3D ultrasound, contrast-enhanced ultrasonography (CEUS) and shear-wave elastography (SWE) for the detection of carotid plaques, and to analyze their value in predicting recurrence of ischaemic stroke (IS). Methods A total of 95 patients with first-ever IS and carotid atherosclerotic plaque from October, 2021 to January, 2023 in the Second Affiliated Hospital of Xinjiang Medical University were selected, and divided into a recurrence group and a non-recurrence group according to whether they had recurred or not. Risk factors for relapse in patients with IS were analyzed using logistic regression. Receiver operating characteristic (ROC) curves were used to analyze the value of different ultrasound techniques in predicting the recurrence of IS. Results Five cases were lost to follow-up. The recurrence rate was 41.11%, and there were no deaths after treatment. The proportion of hypertension in the recurrent group was higher than that in the non-recurrent group, and the proportion of good medication compliance was lower than that in the non-recurrent group (P < 0.05). The ratio of CEUS blood flow grade Ⅲ to Ⅳ, 2-D intima-media thickness (IMT) and 3-D-TPA in the recurrent group were higher than those in the non-recurrent, while the mean Young's modulus was lower than that in the non-recurrent group (P < 0.05). Multivariate logistic regression analysis showed that CEUS blood flow level Ⅲ to Ⅳ, high 2-IMT, large 3-3D total carotid plaque area (TPA) and low mean Young's modulus were risk factors for recurrence in IS patients, and good medication compliance was a protective factor (P < 0.05). ROC curve analysis showed that the AUC of 2-D IMT, 3-D TPA, mean Young's modulus and CEUS blood flow Ⅲ to Ⅳ in predicting recurrence of in IS patients were 0.674, 0.717, 0.729 and 0.746, respectively. The combined predictive AUC of 0.908 was higher than that of single detection (P < 0.05). Conclusion 2D, 3D and SWE and CEUS ultrasound techniques have some clinical value in predicting the recurrence of IS by evaluating carotid plaque instability, and the combined value of the four is higher. -
图 1 超声二维、三维及SWE、CEUS预测IS患者复发的ROC曲线
Figure 1. ROC curves of 2D ultrasound, 3D ultrasound, SWE, and CEUS for predicting IS recurrence
图 2 首发IS合并颈动脉粥样硬化斑块患者随访超声影像
注：A为超声二维模式图像提示颈动脉后壁存在低回声斑块；B为CEUS模式图像可见斑块左侧有造影剂进入，表示斑块内有新生血管形成，斑块内有星点状增强，定为Ⅱ级，稳定斑块；C为SWE模式图像提示斑块硬度偏低。
Figure 2. Follow-up ultrasound images of first IS patients with carotid atherosclerotic plaque
表 1 复发组与未复发组首发IS合并颈动脉粥样硬化斑块患者一般资料比较
Table 1. Comparison of general data between relapsed and non-relapsed groups in patients with first IS complicated with carotid atherosclerotic plaque
项目 复发组(n=37) 未复发组(n=53) 统计量 P值 性别(男/女，例) 20/17 23/30 0.992a 0.319 年龄(x±s，岁) 62.34±5.60 63.15±5.39 0.690b 0.492 BMI(x±s) 25.10±2.19 24.95±2.08 0.329b 0.743 吸烟史[例(%)] 8(21.62) 10(18.87) 0.103a 0.748 饮酒史[例(%)] 9(24.32) 11(20.75) 0.161a 0.689 合并症[例(%)] 糖尿病 9(24.32) 9(16.98) 0.734a 0.391 高血压 17(45.95) 10(18.87) 7.608a 0.006 高脂血症 12(32.43) 14(26.42) 0.384a 0.535 斑块侧别[例(%)] 1.537a 0.464 左侧 20(54.05) 25(47.17) 右侧 15(40.54) 21(39.62) 双侧 2(5.41) 7(13.21) 冠心病史[例(%)] 7(18.92) 6(11.32) 1.018a 0.313 脑卒中家族史[例(%)] 5(13.51) 5(9.43) 0.367a 0.545 药物依从性[例(%)] 12.274a ＜0.001 好 12(32.43) 37(69.81) 差 25(67.57) 16(30.19) NIHSS评分(x±s，分) 7.68±2.14 8.02±1.62 0.858b 0.393 注：a为χ2值，b为t值。 
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表 2 复发组与未复发组首发IS合并颈动脉粥样硬化斑块患者影像学参数比较
Table 2. Comparison of imaging parameters between recurrent and non-recurrent groups in patients with first IS and carotid atherosclerotic plaque
组别 例数 二维-IMT (x±s, mm) 三维-TPA (x±s, cm2) SWE(x±s, kPa) CEUS-血流分级[例(%)] 杨氏模量平均值 硬度分布标准差 Ⅰ~Ⅱ级 Ⅲ~Ⅳ级 复发组 37 1.67±0.39 22.06±3.20 42.33±9.12 21.92±5.45 9(24.32) 28(75.68) 未复发组 53 0.92±0.28 15.34±2.61 50.28±10.17 23.70±5.58 39(73.58) 14(26.42) 统计量 10.626a 10.945a 3.804a 1.503a 21.244b P值 ＜0.001 ＜0.001 ＜0.001 0.136 ＜0.001 注：a为t值，b为χ2值。
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表 3 IS患者复发的多因素logistic回归分析
Table 3. Multivariate logistic regression analysis of relapse in patients with IS
变量 B SE Waldχ2 P值 OR值 95% CI 药物依从性好 -0.526 0.409 1.654 0.004 0.591 0.371~0.859 CEUS-血流Ⅲ~Ⅳ级 0.508 0.303 2.811 ＜0.001 1.662 1.336~2.874 二维-IMT 0.447 0.285 2.460 ＜0.001 1.564 1.148~2.652 三维-TPA 0.545 0.372 2.146 ＜0.001 1.725 1.309~3.001 杨氏模量平均值 0.472 0.298 2.509 ＜0.001 1.603 1.256~2.715
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表 4 超声二维、三维及SWE、CEUS对IS患者复发的预测价值
Table 4. Predictive value of 2D, 3D ultrasound and SWE and CEUS for recurrence in patients with IS
指标 最佳截断值 灵敏度(%) 特异度(%) 约登指数 AUC 95% CI 二维-IMT 1.28 mm 81.08 56.60 0.379 0.674 0.567~0.769 三维-TPA 19.35 cm2 64.86 73.58 0.385 0.717 0.613~0.807 杨氏模量平均值 39.33 kPa 62.16 81.13 0.433 0.729 0.626~0.818 CEUS-血流Ⅲ~Ⅳ级 75.68 73.58 0.493 0.746 0.644~0.832 联合 91.89 84.91 0.768 0.908 0.828~0.959
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