대한방사선의학회지 1994: 31(6) : 1121-1125 자기공명간문맥촬영술 1 김은아 최철순 배상훈 김인재 조소연 김호철 윤구섭 목적 : 자기공명혈관촬영술 (magne tic resonance angiography)oi 비침습적인혈관촬영방법으로 관심을끌고있으나아직까지간혈관에대한연구는드물다. 저자들은정상및비정상간문맥과간정 맥의영상진단에있어서 MRA 으 유용성과한계점을알아보고자본연구를시행하였다. 대상및방법 : 정상자원자 5 명과간질환환자 11 명에게 MRA 를시행하였다. 간질환은간암 7 예, Budd-Chiari 증후군 2 예, 간경변 1 예, 간전이암 1 여 이었다. MRA 는 1.5T Magnetom( Siemens. Erlangen. Germany) 을이용하여 spoiled gradient echo 로 2 차원 time-of-flight( 01 하 TOF 로약함 ) 방법으로촬영 하였고. 2 개의사전포화대를이용하여간문맥과간정맥을선택적으로촬영하여 MIP ( maximum inten sity pr 이 ection) 프로그램으로재구성하여입체영상을 360 도회전시키어관찰하였다. 간질환환자의 MRA 소견을전예에서초음파소견과비교하였고, 그중 4 예는고식적인혈관조영술소견과비교분석하 였다. 결 과 ; 정상자원자에서는모두비잠정맥, 간외및간내중심부간문맥, 하대정맥으로유입되는간 정맥이잘보였다. 간질환환자에게시행한 MRA 상간문맥혈전 2 예, 정맥류 4 예, 비신정맥소통 2 예, 재소통된제정맥 1 예등이관잘되었고. Budd -Chiari 증후군에서는간정맥이안보였고하대정맥의폐 쇄및측부순환혈관이잘보였다. 결 론 :MRA 는정확도에있어서는고식적인혈관조영술에못미치지만비침습적인혈관촬영술로서 간문맥과간정맥병변의진단에있어안전한선별검사로서유응하다고볼수있다. 서론자기공명혈관촬영솔 ( 이하 MRA로약함 ) 이비침습적인혈관촬영방법으로관심을끌고있으나간혈관에대한연구로는외국에일부보고들이 (1-5) 있을뿐우리나라에서는아직도시도된바없다. 이에저자들은정상인과간질환을가진환자들에있어서의간문맥과간정맥의영상진단에있어서 MRA의유용성과한계점을알아보고자자기공명간문맥촬영술 ( 이하 MRP로약함 ) 을시행하였다. 대상및방법정상자원자 5명및 11명의간질환환자를대상으로자기공명간문맥촬영술 (magnetic resonance portography) 을시행하였다. 연령분포는 22세에서 68세로평균연령은 42세였으며, 남자가 13명, 여자가 3명이였다. 깐질환은간암 7예. Budd-Chiari 증후군 2 예, 간경변 1 예, 간전이암 1 1 한립대학교의과대학방사선과학교실이논문은 1994 년 8월 25일접수하여 1994 년 11 월 25일에채택되었음 예이었다. 검사기기는 1.5 Tesla 초전도자기공명영상기기 (Magne tom 63 SP; Siemens, Er langen, Germany) 를이용하였고, circularly polarized body coil을사용했다. Siemens 사의 spoiled gradient echo 인 FLASH(fast low angle shot) 기법으로 2차원 TOF (time - of - flight) 방법으로스캔하였고, 2개의사전포화대를흉부와신통맥기시부이하의복부에설정하여원하는혈관인간문맥과간정맥을선택적으로촬영하였다. 이러한촬영데이타를 MIP(maximum intensity projection) 소프트웨어프로그램을이용하여재구성해서업체영상을 360도회전시키어관찰하였다. 스캔 parameter는 one excitation( =acquisition) 으로 TR 34 msec, TE 8msec, 숙임각 40도, 192 x 256 acquisition matrix, 5mm의절편두께, 그리고관심영역 (FOV) 은 38cm를취했다. 한번의호흡정지때마다 17초간숨을참고두절편씩을얻었다. 간질환환자의 MRA 소견을전예에서초음파소견과비교하였고, 그중 4예는혈관조영술 ( 경상장간동맥문맥조영술혹은하대정맥조영술 ) 소견과비교분석하였다 (Table 1). 1121 -
대한방사선의학회지 1994 : 31 (6) : 1121-1125 결 정상인의 MRP 영상에서는 5 명모두비장정맥, 간외및 간내중심부간문맥, 하대정맥으로유입되는간정맥이잘 보였다 (Fig. 과 1). 간질환환자 11 명중에서혈관조영술 ( 경 상장간동맥문맥조영술혹은하대정맥조영솔 ) 을시행했던 4 명에대해서는 MRP 를초음파, 혈관조영술소견과비교 분석하였다 (Table 1). 간질환환자의 MRP 상각각한명의간전이암과간암 환자에서간문맥혈전 (Fig. 2) 이보였고, 간암환자중두 명에서비신정맥소통 (Fig. 3 ) 이관찰되었다. 간경변환자 1 예에서는재소통된제정맥 (Fig. 4) 을볼수있었고, 간경 Fig. 1. Normal MRP of portal and hepatic veins. Coronal an giogram created by postprocessing with breath-hold, twodimensional flow-sensitive image, shows very high signal in tensity in the hepatic (white arrow) and portal (black arrow) velns 변으로추적검사를하던도중 Budd - Chiari 증후군이발생된한예에서는간정맥은안보이고, 하대정액의폐쇄및측부순환혈관이잘보였다. 또다른 1 예의 Budd - Chiari 증후군환자에서 MRP상에서는복부의표재성측부혈관 (Fig. 5a) 이잘보였지만혈관조영술 (Fig. 5b) 과초음파상에서는볼수없었다. 간암환자로초음파상에서는간문맥혈전이잘보였던 1예의경우전산화단층촬영에서는잘안보였지만 MRA에서는잘보였고그범위를쉽게알수있었다. 정맥류 (Fig. 6), 혈관소통등측부혈관이초음파검사보다 MRP에서잘보였다. 고찰현재보편적으로사용하고있는 MRA에는 time - offlight(tof) 방법과 phase contrast 방법이었다. TOF 방법은스캔단면의수직방향에서일어나는혈류로인한증강 (flow related enhancement 혹은 paradoxical enhancement) 때문에혈관이밝은음영으로보이는원리를이용한방법으로, 불필요한혈관을스캔면에스핀이진입하기전에사전포화시키면원하는혈관만선택하여조영시킬수있다 ( 6). 또 phase contrast는혈류에따른 phase 의차이를이용하여 gradient 의방향으로흐르는혈류의신호를주변신호와감산하여혈관영상을얻는방법이다. TOF 방볍은 3D(3 dimension) 와 2D(2 dimension) 가있다, 3D는절편두께의범위에제한이있고호흡운동에 의해해상도가떨어지는 (7, 8) 반면, 2D 는빠른영상획득 으로호흡운동에거의영향을받지않는다. 또한 2D 절편은재구성하면 3D 에못지않은 MIP(maximum intensity projection) 를얻을수있다. 특히 2D TOF는관섬영역을넓힐수있어서정맥계, 특히문맥고혈압이나 Budd Chiari 증후군의경우와같이많은수의확장된측부혈관을보기위해서는 2D TOF가필수적인방법이라하겠다. Table 1. MRP compared with US and Conventional Angiography Diagnosis Findings US MRP Conventηt i onal Angiography Hepatoma Left gastric vein invisible fair good Splenic vein invisible fair good Thrombosis good invisible invisible Budd-Chiari IVC thrombosis good good fair syndrome Collateral veins Peritoneal poor fair good Superficial poor good poor Retroperitoneal poor fair good Li ver Cirrhosis Paraumbilical vein fair good poor Hepatoma Portal vein fair good good Note. - good = informative and good image quality, - Splenic vein fair good good poor = no informative, fair = informative but poor image quality, = study not done
김은아외 : 자기공명간문맥촬영술 Journal of the Korean Radiological Society, 1994 ; 31 (6) : 1121-1125 MR Portography' Eun Ah Kim, M.D., Chul Soon Choi. M.D., Sang Hoon Bae, M.D., In Jae Kim, M.D., So Yeon Cho, M.D., Ho Chul Kim, M.D., Ku Sup Yun, M.D. 1 Department o( Radiology, Hallym University, College o( Medicine Purpose: We performed this study to evaluate the usefulness and the limitation of magnetic resonance angiography in imaging portal vein and hepatic vein. Materials and Methods: Magnetic resonance portography was perlormed in live normal subjects and seven patients with hepatomas, two patients with Budd-Chiari syndromes, one patient with liver cirrhosis and one patient with hepatic metastasis from stomach cancer. Magnetic resonance angiography was done with a 1.5-T Scanner. Breath-hold two-dimensional time-ol flight images with spoiled gradient echo technique were acquired. Scan parameters were 34/8/40 0 (TR ms/te ms/llip angle). The portal vein and the hepatic vein were selectively imaged by applying two presaturation bands. These images were then pα,tprocessed by a maximum intensity pr이 ection algorithm. MRA lindings were compared with ultrasonography in all cases 01 the hepatic disease, and conventional angiography (SMA portography) in lour cases Results: In normal subjects, the splenic vein, intrahepatic and extrahepatic portions 01 the portal vein, and the hepatic veins were well visualized. In the patients with hepatic diseases, the varices (4 cases), the splenorenal shunts (2 cases), and the recanalized umbilical vein (1 case) were demonstrated. There were portal vein thrombosis in the cases 01 hepatomas and hepatic metastasis. In the cases 01 Budd-Chiari syndrome, the hepatic veins were not visualized and there were inlerior vena cava obstructions with multiple collateral vessels Conclusion: Compared with ultrasonography, MRP may be uselul in evaluation 01 varices, splenorenal shunts, and other collaterals, though less accurate than conventional angiography. MRP can be uselul as a noninvasive screening alternative in the evaluation 01 portal vein and hepatic veins Index Words: Li ver, MR Magnetic resonance(mr), vascular studies Address reprint requests to : Eun Ah Kim, D epartment of Radiology, Hallym Uni versity, College of Medicine, # 445 Gil-dong, Kangdong-ku, Seoul, 134-701 Korea. Tel. 82-2-224-2312 Fax.82-2-488-0114 m
1126 1994 년도 50 차학술대회증례퀴즈 ( ill) a b c Case 5. F/3 C.C. ;trismus D Dx ; since 12 months of age ; Infantile aggressive fibromatosis infratemporal fossa (Juvenile fibromatosis) b c Case 6. F/53 C.C. ;fever, leukocytosis hemifacial pain D ; trigeminal neuritis
씨김은아외 자기공명간문맥촬영술 저자들은 spoiled gradient echo 기법으로간문맥과간정맥을고신호강도로보이게하고 cr ani ocaudal 방향으로흐르는동맥혈류에사전포화펄스를주어 caudocranial로흐르는간문맥이나하대정맥의신호강도에잡음이없도록하였다 (4, 5, 9). MRP상에서정상적으로보이는것은간문맥, 간정액, 그리고상장간정맥이다 (Fig. 1). 초음파검사에서는보이지않거나범위가불명확하였으나 MRP에서는잘보였던예를들면, 비신청맥소통이초음파검사에서는의심할정도일뿐직접적으로보이지않았으나 MRP상에서는직접적 으로보였고 (Fig. 3), 문맥혈전의경우는 MRP에서상하단부가병확히보이는반면초음파검사에서는볼수없였으며, 제부정맥이열린환자의예 (Fig.4) 는초음파검사로일일히추적해서발견될수도있으나 MRP에서는단순히스캔면만맞추면쉽게볼수있었다. Budd - Chiari 증후군 1예에서간우엽의간정액이보이지않았는데이와같은양상은아마도 MRP에서의특정적인소견일수있다. 이에대해서는더욱연구가필요하다. Budd- Chiari 증후군의또다른예 (Fig. 5) 에서혈전의간내범위는잘안보이나비침습적으로하대정맥에서의상하 a b Fig. 2. Patients with hepatocellular carcinoma and portal thrombosis. Thrombosis of main portal vein is demonstrated on abdominal CT and MR portogram a. CT shows main portal vein thrombosis(arrow) b. MR portography well depicts thrombus(arrow) with clear upper and lower margins Fig. 3. Splenorenal shunt in patients with hepatocellular carcinoma and portal hypertension. Coronal MR angiogram clearly shows splenorenal shunt (arrow) that could not be well visualized with any 이ther imaging modalities. Fig. 4. Dilated paraumbilical vein in a patient with liver cirrhosis and portal hypertension. A patent and enlarged umbilical vein(arrow) is noted on sagittal projection 3 4 m
대한방사선의학회지 1994; 31(6) 1121-1125 Fig. 5. A patient with Budd-Chiari syndrome. IVC thrombosis(arrow) is well visualized on magnetic resonance portogram(a) compared to inlerior vena cavogram(b) a 는정맥내에조영제를주입해야하므로과민반응이있거나심장기능이나쁜환자들에있어서는문제가될수있어서 (11) 이런경우에는 MRA가안전한검사로유용할것이다. 결론적으로 MRP는버침습적인혈관촬영술로서간문맥과간정맥같은정맥혈관계병변의진단에있어서도안전한선별검사로유용하다고볼수있다. 참고헌 Fig. 6. A patient with portal hypertension. Multiple intraabdominal varices including left coronary(white arrow) and lundal( black arrow) varices are well visualized 범위를아주쉽게알수있었고, 기존문맥조영술에서는잘볼수없는표재성측부혈관이잘보여 MRP의장점으로생각되나문맥조영술에서잘보이는후복막정맥류는볼수가없었는데, 이것은섬재성측부혈관의위치에따른영상절편의두께및범위가설정되지않았기때문으로생각된다. 본연구에셔는문맥고혈압의경우좌관상정맥류는잘보이나, 식도주위정맥류는잘안보였는데, 기존문헌 ( 3 ) 에서는 MRA로식도주위정맥류를볼수있다는보고가있어이런정맥류를잘보기위해서는연구가더펼요하리라본다. 자기공명간문맥촬영술의한계점은가격이비싸면서얻는정보가기대보다많지않은데, 이점은좀더증례를모아서다른방사선과적방법들의장단점과비교해본다면더나은성과가있을것으로본다. 최근 spiral CT angio graphy 의발전으로복부에서는그효용성이높다고평가되고있어 (1 0), MRA를복부혈관에적용하기위해서는기술의향상이더필요하다고본다. 그러나 CT angiography 1. Edelman RR, Zhao B, Li u C, Wentz KU, Mattle HP, Finn JP, McArdle C. MR angiography and dynamic evaluation 01 the portal venous system. AJR 1989; 153: 755-760 2. Edelman RR, Wentz KU Mattle HM, Zhao B, Li u C, Kim, DS, Laub G. Projection arteriography and venogrpahy: initial clinical results with MR. Radiology 1989 ; 172: 351-357 3. Finn JP, Edelman RR, Jenkins RL, Lewis WD, Longmaid HE, Kane RA, Stokes KR, Mattle HP, Clouse ME. Liver transplantation: MR angiography with surgical validation. Radiology 1991 ; 179 265-269 4. Otake S, Matsuo M, Kuroda Y. Distinction 01 hepatic vein Irom portal vein by MR imaging. J Comput Assist Tomogr 1990; 14: 201-204 5. Nabeshima M, Moriyasu F, Ono S, Nishikawa K, Kajimura K, Okuma M, Shimizu K. Selective MR angiography 01 the liver J Comput Assist Tomogr 1993 ; 17: 730-734 6. 배상훈, 자기공명혈관조영술선별검사로서의유용성및한계성 대한방사선의학회지 1992 ; 28 : 565-574 7. Lewin JS, Laub G, Hausmann R. Three-dimensional timeol-llight MR angiography: applications in the abdomen and thorax. Radiology 1991 ; 179 : 261-264 8. Edelman RR, Mattle HP, Atkinson DJ, Hoogewoud HM. MR angiography. AJR 1990 ;154 :937-946 9. Felmlee JP, Ehman RL. Spatial presaturation : a method lor suppressing Ilow artilacts and improving depiction 01 vascular anatomy in MR imaging. Radiology 1987 ; 164 : 559-564 10. Rubin GD, Dake MD, Napel SA, McDonnel1 Ch, Jeffrey RB Three-dimensional spiral CT angiography 01 the abdomen : initial clinical experience. Radiology 1993 ; 186 : 147-152 11. Dillon EH, Leeuwen MS, Fernandez MA, Mali WPTM. Spiral CT angiography. AJR 1993; 160: 1273-1278 1124 -