臺灣博碩士論文加值系統

目的:以16切面電腦斷層搭配回顧式心電圖偵測分析患者冠狀動脈重組影像在心週期的最佳影像相位並探討此參數的輻射劑量不高於其他研究設計。
材料與方法:171位病患(男性103位，女性68位;平均年齡55.38 ±11.43歲;年齡範圍由28歲至83歲; 平均心跳數為65.86bpm，標準差為11.07bpm，心跳範圍自34bpm至101bpm。)。在接受16切面電腦斷層冠狀動脈檢查，其影像重組由心週期35% 至85%，間隔10%。重組影像分段依美國心臟協會分段標準評估右冠狀動脈(第1~3段)、左主冠狀動脈(第5段) 、左前降枝(第6~8段)及左迴旋枝(第11~12段)。重組完之影像品質評分標準由很好到很差分別由1分到5分分佈。1分表示很好，5分表示很差，影像由兩位心臟放射線專科醫師判讀評分。輻射劑量暴露則依此檢查參數，以100型熱發光劑量計植入假體偵測有效劑量。
結果:171位接受電腦斷層冠狀動脈血管檢查病患之三維重組影像以SPSS ANOVA軟體分析出各冠狀動脈皆在75%相位心週期有最佳影像品質(p < 0.05)。輻射劑量為3.05~5.5msv，相較其它在多切面電腦斷層冠狀動脈檢查的暴露來得為低。
結論:電腦斷層冠狀動脈重組影像最佳品質在心舒張期中末段有最佳品質。在此研究中，75%心週期為重組最佳影像，輻射劑量亦不高於其他研究結果。

Objective: To investigate and analyze the optimal reconstructed images of retrospective ECG gating 16-detector row computed tomography (MDCT) for each of the major coronary arteries during the cardiac cycle and measure the radiation dose under the scan parameters.
Materials and Methods: 16-detector row coronary artery CT angiographies obtained in 171 patients (103 men, 68 women; mean age, 55.38 years ±11.43; age range, 28-83 years; mean heart rate, 65.86bpm; standard deviation, 11.07bpm; heart rate range, 34-101bpm) were reconstructed at 35%-85% of the cardiac cycle in increments of 10%. Two independent reviewers who specialize in cardiac radiology assessed the image quality, obtained with three-dimensional post-processing for segments 1-3 (right coronary artery), segments 5-8 (left main and left anterior descending coronary arteries), and segments 11 and 12 (left circumflex artery). Segments were defined according to American Heart Association (AHA) guidelines. The 5-point system was introduced to meet the agreement among reviewers. 1,2,3,4 and 5 represent excellent, good, fair, poor and very poor, respectively. The radiation dose measurement of this study was carried out by using TLD-100.
Results: The three-dimensional reconstructed image data were statistically analyzed with SPSS software version 10.0. The authors analyzed 171 patients' data with 2-way ANOVA and found the left anterior descending artery; left circumflex artery and right coronary artery all were best visualized at 75% of the cardiac cycle (p < .05). The radiation dose is between 3.05msv and 5.5msv.
Conclusion: The results demonstrated that the reconstructed images of coronary arteries usually performed optimally during mid-to-late diastole phase. 75% of the cardiac phase was the best visualization phase for all coronary arteries in this study. This result of radiation dose is also lower than other researches.

目錄
中文摘要 I
Abstract II
目錄 III
圖目錄 VI
表目錄 X
第一章 前言 1
1.1 研究背景 1
1.2 電腦斷層簡介 2
1.2.1 傳統電腦斷層(Conventional CT) 2
1.2.2 螺旋式電腦斷層(spiral CT) 3
1.2.3 電子射束電腦斷層(Electron Beam CT) 3
1.2.4 多切面電腦斷層(Multi-detector Row CT) 4
1.2.4.1 偵檢器及資料擷取系統(Detector and Data Acquisition 4
System, DAS) 4
1.2.4.2 操作模式(operational mode) 10
1.2.4.3 資料後處理(Data for post-processing) 13
1.3 心臟冠狀動脈解剖及疾病 14
1.3.1 心臟冠狀動脈解剖 14
1.3.2 心臟冠狀動脈鈣化及狹窄 18
1.4 研究目的 20
第二章 文獻回顧 21
2.1 冠狀動脈影像技術 21
2.1.1 介入性冠狀動脈攝影技術(Invasive coronary angiography) 22
2.1.2 介入性冠狀動脈超音波技術(Intra-vascular ultrasound,IVUS) 23
2.1.3 非介入性冠狀動脈影像技術(Non-invasive imaging techniques) 24
2.1.3.1 磁振掃描(Magnetic resonance imaging) 24
2.1.3.2 電腦斷層(Computed tomography) 25
2.1.3.3 電子射束電腦斷層(Electron Beam CT) 26
2.2 影響多切面電腦斷層冠狀動脈影像之因素 26
2.2.1 心跳因素 27
2.2.2 閉氣時間及掃描時間 28
2.2.3 空間解析度 29
2.2.4 時間解析度 29
2.3 心電圖延遲時間設定重組方式 32
2.4 輻射劑量比較回顧 36
2.5 最佳顯影濃度探討 40
第三章 材料與方法 41
3.1 研究流程與架構 41
3.1.1 心週期中最佳化重組時間點 43
3.1.2 掃描輻射劑量偵測流程 49
3.1.3 最佳顯影濃度流程 52
3.2 實驗設備與設計 54
3.2.1 心週期最佳化重組設備與設計 54
3.2.2 輻射劑量偵測設備及設計 58
3.2.3 最佳顯影濃度設備與設計 60
3.3 劑量偵測 61
3.4 最佳顯影濃度實驗 68
第四章 結果與討論 69
4.1 冠狀動脈影像判讀計分及分析結果 69
4.2 劑量偵測 74
4.3 影像最佳顯影濃度分析 77
第五章 結論 83
第六章 本研究限制性及未來研究方向 85

圖目錄
圖1.單切面及多切面電腦斷層偵檢器的排列 5
圖2.準直儀開的大小及偵檢器元件 6
圖3. 16列偵檢器(N)及4個資料擷取系統頻道 8
圖4.為4切面電腦斷層掃描器偵檢器的可調整式排列 9
圖5.電腦斷層掃描器得到病患資料的模式分為: 10
圖6.偵檢器的運算依偵檢器數列的不同而有不同組合的切片厚度 11
圖7. 多切面電腦斷層pitch的運算 13
圖8A-D.顯影劑注射下電腦斷層冠狀動脈正常解剖結構 16
圖9E-H.顯影劑注射下電腦斷層冠狀動脈正常解剖結構 17
圖10I-J.顯影劑注射下電腦斷層冠狀動脈正常解剖結構 18
圖11.冠狀動脈的鈣化 19
圖12.左前降枝冠狀動脈呈現狹窄 22
圖13.以支架治療左前降枝狹窄 23
圖14.心臟的掃描區域涵蓋自主動脈根部至心尖 28
圖15.單一部分重組的資料運算 30
圖16.使用2個週期的資料運算 31
圖17.使用4個週期的資料運算 31
圖18.心電圖P.QRS.T波 33
圖19.相對延遲方式 34
圖20.絕對延遲方式 34
圖21.反向絕對延遲方式 35
圖22.前顧式心電圖驅動掃描 37
圖23.回顧式驅動掃描 37
圖24. Peter Hunold等人的劑量研究結果 39
圖25.輻射劑量研究用人型假體 39
圖26.最高顯影濃度與尖峰濃度對照的時間 40
圖27.心週期中最佳化影像品質重組時間點的設計流程……43
圖28.多切面電腦斷層擷取之橫切面影像 45
圖29.電腦斷層擷取之橫切面影像以1.25mm做後重組三維心臟影像 46
圖30.將電腦斷層擷取之橫切面影像以1.25mm做另一方向之後重組三維心臟影像 46
圖31.二維多面向重組檢視動脈管腔內部 47
圖32.美國心臟學會之冠狀動脈分段 48
圖33.多切面電腦斷層冠狀動脈掃描輻射劑量偵測流程……50
圖34.最佳顯影濃度研究流程 53
圖35.心電圖貼片所貼位置 54
圖36.心電圖監視器 55
圖37.16切面電腦斷層掃描儀 56
圖38.輻射劑量偵測於檢查過程中的偵測流程點 63
圖39.100型熱發光劑量計 64
圖40.以6Mev直線加速器為篩選100型熱發光劑量計射源 64
圖41.輻射劑量偵測用人型假體，每一切面為2.5公分 67
圖42.將36顆熱發光劑量計避開肺臟範圍植入假體心臟所在，偵測輻射劑量 67
圖43.171位有效樣本各段冠狀動脈的平均影像判讀分數及標準差，各冠狀動脈在心週期75%相位有最佳影像分數 70
圖44.各段冠狀動脈經ANOVA分析後呈現在心週期75% 相位有最佳影像品質 72
圖45.第一組及第二組的最高顯影濃度統計數據 79
圖46.第一組及第二組的最高顯影濃度所對應的時間 80
圖47.最高顯影濃度時間對照曲線明顯的尖峰及難以判斷的雙峰 81
圖48.最高顯影濃度時間對照曲線明顯的尖峰及在尖峰後呈現一平原,較難以判斷正確時間點 82
圖49.最高顯影濃度時間對照曲線明顯的尖峰及多個上升曲線 82

表目錄
表1.進度甘梯圖：（Gantt Chart） 42
表2.心臟冠狀動脈各段分數表 48
表3.16切面電腦斷層的重組運算 57
表4.擷取模式、心跳及pitch之相互關係 57
表5.校正因子 65
表6.將100型熱發光劑量計,依數值接近者分組,植入假體偵測輻射劑量 66
表7.三維影像所得平均分數表及標準差 71
表8.輻射劑量偵測實驗中,最後測得總和吸收劑量約為61~111mGy 75
表9.ICRP-60之組織加權因子，心臟為0.05 76
表10.最佳顯影濃度實驗數據 78
表11.第一組及第二組最高顯影濃度及對應時間的平均值及標準差 80

參考文獻
1.Kalender WA, Polacin A. Physical performance characteristics of spiral CT scanning. Med Phys 1991;18:910-915.
2.Crawford CR, King CF. Computed tomography scanning with simultaneous patient translation. Med Phys 1990;17:967-982.
3.Napel S. Principles and techniques of 3D spiral CT angiography. In: Fishman EK, Jeffery RB Jr, eds. Spiral CT. 2 ed. New York: Lippincott-Raven Press, 1998:339-360.
4.Kalender, W. A., Seissler, W., Klotz, E., Vock, P.: Spiral volumetric
CT with single-breath-hold technique, continuous transport and
continuous scanner rotation. Radiology 1990; 176:181-3.
5. Kalender, W. A.: Thin-section threee-dimensional spiral CT: is
isotropic imaging possible? Radiology 1995; 197:578-80.
6.Hu H, He HD, Foly WD, et al. Four multidetector-row helical CT: image quality and volume coverage speed. Radiology 2000;215:55-62.
7.Flohr T, Prokop M, Becker C, et al. A retrospectively ECG-gated multislice spiral CT scan and reconstruction technique with suppression of heart pulsation artifacts for cardio-thoracic imaging with extended volume coverage. Eur Radiol 2002;12:1497-1503.
8.Napel S, Marks MP, Rubin GD, et al. CT angiography with spiral CT and maximum intensity projection. Radiology 1992;185:607-610.
9.Rubin GD, Shiau MC, Schmidt AJ, et al. Computed tomographic angiography: historical perspective and new state-of-the-art using multi-detector-row helical computed tomography. J Comput Assist Tomogr 1999;23[suppl 1]:s83-s90.
10.Rubin GD, Beaulieu CF, Argiro V, et al. Perspective volume rendering of CT and MR images: applications for endoscopic viewing. Radiology 1996;199:321-330.
11.Vining DJ. Virtual endoscopy: Is it reality? [Editorial; comment]. Radiology 1996;200:30-31.
12.Kalender W. Computer-tomographie.Publics MCD Verlag, 1. Edition.2000.
13. Ohnesorge B, Becker CR, Flohr T, Reiser M. Multi-slice CT in Cardiac Imaging.Springer-Verlag, Berlin, Heidelberg, New York, 1. Edition.2002.
14. Prokop M, Schaefer C, Kalender WA, Polacin A, Galanski M. Vascular imaging with spiral-CT. The path to CT-angiography. Radiologe, 33, 694-704.1993.
15. Rankin SC. Spiral CT: vascular applications.Eur J Radiol 1998;28, 18-29.
16. Achenbach S, Ropers D, Holle J, Muschiol G, Daniel WG, Moshage W. In-plane coronary arterial motion velocity: measurement with electron beam CT. Radiology 2000;216, 457-463.
17. Georg C, Kopp A, Schroder S, Kuttner A, Ohnesorge B, Martensen J,
Clausen CD. Optimizing image reconstruction timing for the RR interval in imaging coronary arteries with multi-slice computerized tomography. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2001;173, 536-541.
18. IEC: International Electrotechnical Commission: Medical Electrical Equipment-60601 Part 2-44. Particular requirements for the safety of X-ray equipment for computed tomography. Geneva, Switzerland, 1999.
19. Lawler LP, Fishman EK. Multi-detector row CT of thoracic disease with emphasis on 3D volume rendering and CT angiography. RadioGraphics 2001; 21:1257-1273.
20. American Heart Association: Heart and Stroke facts: 1996, Statistical Supplement. Dallas: American Heart Association, 2003.
21.Blankenhorn DH, Stern D. Calcification of the coronary arteries. Am J Roentgenol 81:772-777,1959.
22.Rifkin RD, Parisi AF, Folland E. Coronary calcification in the diagnosis of coronary artery disease. Am J Cardiol 44:141-147,1979.
23.Masuda Y, Naito S, Aoyagi, et al. Coronary artery calcification detected by CT: clinical significance and angiographic correlates. Angiology 41:1037-1047,1990.
24.Agaston AS, Janowitz WR, Hildner FJ, et al: Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 15:827-832,1990.
25.Budoff MJ, Achenbach S, Duerinckx A. Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography. J Am Coll Cardiol 2003;42:1867-1878.
26.Berry C, Kelly J, Cobbe SM et al. Comparison of femoral bleeding complications after coronary angiography versus percutaneous coronary intervention. Am J Cardiol 2004;94:361-363.
27.Windecker S, Maier-Rudolph W, Bonzel T, et al. Interventional cardiology in Europe 1995. Eur Heart J 1999; 20:484-495.
28.Knez A, Becker CR, Leber A, et al. Usefulness of multislice spiral computed tomography angiography for determination of coronary artery stenoses. Am J Cardiol 2001;88 : 1191-1194.
29.Hoffmann MH, Shi H, Schmid FT, Gelman H, Brambs HJ, Aschoff AJ. Noninvasive coronary imaging with MDCT in comparison to invasive conventional coronary angiography: a fast-developing technology. AJR 2004; 182:601 -608.
30.Ricciardi MJ, Meyers, Choi K et al. Angiographically silent left main disease detected by intravascular ultrasound: a marker for future adverse cardiac events. Am Heart J 2003; 146:507-512.
31.Horiguchi J, Yamamoto H, Akiyama Y et al. Coronary artery calcium scoring using 16-MDCT and a retrospective ECG-gating reconstruction algorithm. AJR Am J Roentgenol 2004;183:103-108.
32.Schoenhagen P, Halliburton SS, Stillman AE et al. Noninvasive imaging of coronary arteries: current and future role of multi-detector row CT. Radiology 2004;232:7-17.
33.Fayad ZA, Sirol M, Nikolaou K et al. Magnetic resonance imaging and computed tomography in assessment of atherosclerotic plaque. Curr Atheroscler Rep 2004;6:232-242.
34.Hatsukami TS, Ross R, Polissar NL et al. Visualization of fibrous cap thickness and rupture in human atherosclerotic carotid plaque in vivo with high-resolution magnetic resonance imaging. Circulation 2000;102:959-964.
35.Nikolaou K, Becker CR, Muders M et al. Multidetector-row computed tomography and magnetic resonance imaging of atherosclerotic lesions in human ex vivo coronary arteries. Atherosclerosis 2004;174:243-252.
36. Fishman E. A brief overview of CT angiography. Suppl Appl Radiol 2003;32:9-11.
37. Schoepf UJ, Becker CR, Ohnesorge BM et al. CT of coronary artery disease. Radiology 2004;232:18-37.
38. Moshage WEL, Achenbach S, Seese B, Bachmann K, Kirchgeorge M. Coronary artery stenoses: three-dimensional imaging with electrocardiographically triggered, contrast agent-enhanced, electron-beam CT. Radiology 1995; 196:707-714.
39.Budoff MJ, Qudiz RJ, Zalace CP, et al. Intravenous three-dimensional coronary angiography using contrast enhanced electron beam computed tomography. Am J Cardiol 1999; 83:840-845.
40.Rensing BJ, Bongaerts A, van Geuns RJ, et al. Intravenous coronary angiography by electron beam computed tomography: a clinical evaluation. Circulation 1998; 98:2509-2512.
41. Schmermund A, Rensing B, Sheedy P, Bell M, Rumberger J. Intravenous electron beam computed tomographic coronary angiography for segmental analysis of coronary stenosis. J Am Coll Cardiol 1998; 31:1547-1554.
42. Boudoulas H, Rittgers SE, Lewis RP, Leier CV, Weissler AM. Changes in diastolic time with various pharmacologic agents: implication for myocardial perfusion. Circulation 1979; 60:164-169.
43. Hong C, Becker CR, Huber A, et al. ECG-gated reconstructed multi-detector row CT coronary angiography: effect of varying trigger delay on image quality. Radiology 2001; 220:712-717.
44. Giesler T, Baum U, Ropers D, et al. Noninvasive visualization of coronary arteries using contrast-enhanced multidetector CT: influence of heart rate on image quality and stenosis detection. AJR Am J Roentgenol 2002; 179:911-916.
45. Nieman K, Cademartiri F, Lemos PA, Raaijmakers R, Pattynama PM, de Feyter PJ. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography. Circulation 2002; 106:2051-2054.
46. Schroeder S, Kopp AF, Kuettner A, et al. Influence of heart rate on vessel visibility in noninvasive coronary angiography using new multislice computed tomography: experience in 94 patients. Clin Imaging 2002; 26:106-111.
47. Nieman K, Rensing BJ, van Geuns RJ, et al. Non-invasive coronary angiography with multislice spiral computed tomography: impact of heart rate. Heart 2002; 88:470-474.
48. Nieman K, Oudkerk M, Rensing BJ, et al. Coronary angiography with multi-slice computed tomography. Lancet 2001; 357:599-603.
49. Gerber TC, Kuzo RS, Karstaedt N, et al. Current results and new developments of coronary angiography with use of contrast-enhanced computed tomography of the heart. Mayo Clin Proc 2002; 77:55-71.
50. de Feyter PJ, Nieman K. New coronary imaging techniques: what to expect? Heart 2002; 87:195-197.
51. Kopp AF, Schroeder S, Kuettner A, et al. Non-invasive coronary angiography with high resolution multidetector-row computed tomography: results in 102 patients. Eur Heart J 2002; 23:1714-1725.
52. Morgan-Hughes GJ, Marshall AJ, Roobottom CA. Multislice computed tomography cardiac imaging: current status. Clin Radiol 2002; 57:872-882.
53. Ohnesorge B, Becker C, Flohr T, Reiser MF. Multi-slice CT in cardiac imaging: technical principles, clinical application and future developments Berlin, Germany: Springer-Verlag, 2002; 3-109.
54. Flohr T, Stierstorfer K, Bruder H, Simon J, Schaller S. New technical developments in multislice CT-Part 1: Approaching isotropic resolution with sub-millimeter 16-slice scanning. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2002; 174:839-845.
55. Flohr T, Bruder H, Stierstorfer K, Simon J, Schaller S, Ohnesorge B. New technical developments in multislice CT, part 2: sub-millimeter 16-slice scanning and increased gantry rotation speed for cardiac imaging. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2002; 174:1022-1027.
56. Ohnesorge B, Flohr T, Becker C, et al. Cardiac imaging by means of electrocardiographically gated multisection spiral CT: initial experience. Radiology 2000; 217:564-571.
57. Becker CR. Assessment of coronary arteries with CT. Radiol Clin North Am 2002; 40:773-782.
58. Flohr T, Ohnesorge B. Heart rate adaptive optimization of spatial and temporal resolution for electrocardiogram-gated multislice spiral CT of the heart. J Comput Assist Tomogr 2001; 25:907-923.
59. Schroeder S, Kopp AF, Baumbach A, et al. Noninvasive detection and evaluation of atherosclerotic coronary plaques with multislice computed tomography. J Am Coll Cardiol 2001; 37:1430-1435.
60. Achenbach S, Ulzheimer S, Baum U, et al. Noninvasive coronary angiography by retrospectively ECG-gated multislice spiral CT. Circulation 2000; 102:2823-2828.
61. Achenbach S, Ropers D, Holle J, Muschiol G, Daniel WG, Moshage W. In-plane coronary arterial motion velocity: measurement with electron-beam CT. Radiology 2000; 216:457-463.
62. Stephan Achenbach et al. Detection of Coronary Artery Stenoses by Contrast-Enhanced, Retrospectively
Electrocardiographically-Gated, Multislice Spiral Computed Tomography. Circulation. 2001;103:2535
63. Andreas F. Kopp et al. Coronary Arteries: Retrospectively ECG-gated Multi-Detector Row CT Angiography with Selective Optimization of the Image Reconstruction Window. Radiology. 2001;221:683-688.
64. Paul Schoenhagen et al. Noninvasive Imaging of Coronary Arteries: Current and Future Role of Multi-Detector Row CT. Radiology 2004;232:7-17.
65. Peter Hunold et al. Radiation Exposure during Cardiac CT: Effective Doses at Multi-Detector Row CT and Electron-Beam CT. Radiology 2003;226:145-152.
66. Cademartiri F, Nieman K, van der Lugt A, et al. Intravenous contrast material administration at 16-detector row helical CT coronary angiography: test bolus versus bolus-tracking technique. Radiology 2004; 233:817-823.
67. Elliot K. Fishman. Multidetector-row computed tomography to detect coronary artery disease: the importance of heart rate. The European Society of Cardiology 2005.
68. Benoit Desjardins, Ella A. Kazerooni. ECG-gated Cardiac CT. AJR 2004;182:993-1010.
69. Christopher Herzog, Nasreddin Abolmaali. Heart-rate-adapted image reconstruction in multidetector-row cardiac CT: influence of physiological and technical prerequisite on image quality. Eur Radiol 2002;12:2670-2678.
70. Thomas J. Vogl,MD, Nasreddin D. Abolmaali,MD. Techniques for Detection of Coronary Atherosclerosis : Multi-detector Row CT Coronary Angiography. Radiology 2002;223:212-220.
71. Martin Heuschmid, Axel Kuettner, Stephen Schroeder, Tobias Trabold, et al. ECG-Gated 16-MDCT of the Coronary Arteries: Assessment of Image Quality and Accuracy in Detecting Stenoses. AJR 2005; 184:1413-1419.