quarta-feira, 20 de junho de 2007

Tomografia Computadorizada Helicoidal (Noções)

A Tomografia Computadorizada Helicoidal é um avanço técnico que permite imagens mais rápidas e precisas do que a Tomografia Computadorizada padrão.


A Tomografia Computadorizada Helicoidal permite realização da imagem e injeção do meio de contraste simultaneamente, de modo que as imagens possam ser adquiridas durante fases específicas do realce pelo meio de contraste.

As aplicações clínicas da Tomografia Computadorizada Helicoidal incluem todas as aplicações da Tomografia Computadorizada convencional no tórax, abdome e sistema músculo-esquelético, além de uma variedade de novas aplicações como Angiotomografia e imagem tridimensional.

A Tomografia Computadorizada Helicoidal é o estudo de escolha na avaliação de patologias pulmonares; tem numerosas aplicações no fígado, pâncreas, rins e outros órgãos abdominais; e é de grande valor na avaliação do trauma.

A Tomografia Computadorizada Helicoidal foi uma mudança estratégica introduzida em 1990. Na Tomografia Computadorizada convencional, cada corte é adquirido separadamente e a mesa move o paciente através “gantry” em incremento entre os cortes. Na TC helicoidal, o paciente é movido através do “gantry” continuamente, enquanto o exame também é realizado ininterruptamente, então o feixe de raios X atravessa o paciente formando uma hélice. Depois de toda a região anatômica ser examinada, os dados podem ser reconstruídos em cortes individuais. A aquisição de um “conjunto de dados de volume” do volume anatômico examinado permite excelentes reconstruções de imagem bi e tridimensionais.

Além disso, a TC helicoidal introduziu uma variedade de novas aplicações que não eram possíveis com a TC convencional. Todo o campo da angiotomografia, que fornece imagens detalhadas das estruturas vasculares, é baseado no exame helicoidal.

A TC helicoidal fornece um estudo simples, rápido e menos invasivo para o paciente. Os tempos de exames estão entre 40 e 80 segundos, com o paciente no aparelho por no máximo 5 a 10 minutos. Isto reduz o tempo necessário de colaboração do paciente pela metade. A habilidade de adquirir um conjunto de dados durante uma única respiração, tem significado numa variedade de aplicações no tórax, pulmão e fígado. Os conjuntos de dados numa única respiração eliminam os problemas como movimentação durante ou entre os cortes, que poderia levar à perda de lesões.

TÓRAX:

A TC helicoidal é o estudo de escolha na avaliação das patologias pulmonares. A única indicação específica para TC convencional está nos casos em que a TC de alta resolução é necessária para avaliar doença do parênquima pulmonar, onde a TC helicoidal oferece poucas vantagens.

Três fatores são responsáveis pela superioridade em geral da TC helicoidal:

habilidade de realizar a imagem de todo pulmão numa única respiração.

habilidade de adquirir o volume de amostra com qualquer incremento (geralmente 4 mm).

habilidade de coordenar a aquisição de dados com tempo de administração de contraste iodado.

Numa paciente com potencial metástase pulmonar, uma TC convencional seria

realizada com cortes de 8 a 10 mm de incremento. Um estudo helicoidal de rotina, ao contrário, teria cortes sobrepostos de 8 a 10 mm reconstruídos a cada 4 a 5 mm ou, em sistemas novos, cortes de 5 mm reconstruídos a cada 5 mm. Em um estudo, o aumento dos dados de amostra com a TC helicoidal, resultou num aumento da detecção das lesões pulmonares de 9%, com aumento de 30% na certeza do usuário sobre a presença ou ausência de doença.

Sem surpresas, a utilização de uma única respiração também aumentou a detecção de lesões. Em casos indeterminados, os dados da TC helicoidal podem ser examinados a intervalos de 1 mm através de lesão. A habilidade em se coordenar o tempo de injeção de contraste e a obtenção de dados é um fator crítico nas aplicações oncológicas e vasculares.

Procedimentos de rotina para determinação do tempo de início na obtenção de dados após a injeção do contraste, resulta na opacificação de todas as estruturas vasculares mediastinais, tornando a detecção de nódulos mediastinais e/ou hilares, os quais tipicamente não realçam, muito mais fácil. A classificação das massas mediastinais é também otimizada com estes protocolos. A invasão do mediastino, estruturas cardíacas mediastinais mais facilmente em estudos com contraste revistos com incrementos pequenos, permitindo a classificação mais precisa destas neoplasias.

Diversos estudos demonstraram bons resultados usando a angioTC helicoidal para a avaliação da suspeita de embolia pulmonar. Apesar da angiografia convencional permanecer o padrão-ouro, muitas instituições usam a angioTC como o primeiro estudo em pacientes com exames indeterminados de ventilação-perfusão.

FÍGADO:

A avaliação do fígado foi muito beneficiada a partir da TC helicoidal.

A TC padrão do fígado, por muito tempo controversa, tem a precisão de cerca de 70% para a detecção de lesões de 1 a 2 cm. A principal dificuldade era que o período ótimo para examinar o fígado, cerca de 40 a 60 segundos após a injeção do contraste, ainda se prolongava de três a cinco minutos para a finalização do estudo.

Com a TC helicoidal, as imagens podem ser obtidas durante a fase predominantemente arterial ou fase venosa portal, a depender dos problemas clínicos. Por exemplo, o exame durante a fase arterial, ajuda a detectar metástases hepáticas altamente vasculares em pacientes com tumor carcinóide ou tumor de células da ilhota pancreática. Como alternativa, um paciente com câncer de cólon é melhor estudado durante a fase venosa portal, para detectar lesões metastáticas hipovasculares.

A união de dados obtidos em uma fase arterial como o exame da fase portal, aumenta a detecção de lesões em 9%. E mais, o estudo da fase arterial é útil na identificação de tipos específicos de lesões baseado em padrões de realce. A TC helicoidal, com imagens obtidas em ambas as fases venosa e arterial, é crítica na detecção de lesões como hepatoma ou tumores infiltrantes.

A TC helicoidal é também valiosa para avaliação de doença parenquimatosa não neoplásica do fígado. A síndrome de Budd-Chiari, a trombose da veia portal, o infarto hepático, o aneurisma ou pseudo aneurisma da artéria hepática, e outras patologias podem ser perfeitamente avaliadas na TC helicoidal

PÂNCREAS:

O rastreamento por TC foi sempre o estudo escolhido para avaliação de pacientes com pancreatite ou neoplasias pancreáticas.

A TC helicoidal possui vantagens adicionais de detectar as patologias mais cedo e classificar mais precisamente do que a TC padrão.

A avaliação do pâncreas é normalmente feita com estreita colimação e pequeno intervalo entre os cortes. A TC helicoidal com uma única inspiração e parada realiza este exame em 30 segundos ou menos.

Na pancreatite, o papel principal da TC é o de detectar complicações, tais como necrose pancreática, formação de pseudocisto, abscesso ou complicações vasculares. A TC helicoidal com realce por contraste particularmente com exame em fase arterial precoce, permite a detecção de alterações no tecido pancreático afetado. Nos casos de necrose pancreática e formação de abscesso, a fina colimação e estreito intervalo entre os cortes melhoram a detecção de alterações precoces. O realce vascular é particularmente valioso na demonstração de complicações, tais como pseudo-aneurisma das artérias esplênicas e hepáticas, trombose da veia portal com transformação cavernosa e trombose da veia esplênica.

Câncer pancreático permanece como um doença sombria, com uma taxa de sobrevida de menos que 5%. No entanto, em pacientes que possuem tumores definidos sem disseminação local, adenopatia, ou envolvimento vascular, um procedimento de Whupple seguido por terapia adjuvante pode fornecer uma taxa de 40% de sobrevida de cinco anos.

A TC helicoidal fornece classificação mais precisa da doença do que qualquer outra técnica. A imagem tridimensional pode ser especialmente valiosa nestes pacientes para a definição de suprimento vascular e invasão precoce.

Uma vantagem adicional da TC helicoidal nos pacientes com câncer pancreático, é a detecção de metástases no fígado. A metástase no fígado nestes pacientes é normalmente pequena (cerca de 1 cm) e pode ser desprezada no rastreamento pela TC padrão. A TC helicoidal pode fornecer uma abordagem com precisão de 90% para estas lesões.

RINS:

A TC helicoidal oferece várias vantagens significativas na avaliação de patologia renal, se colocando à frente das técnicas de exame por imagem dos rins. Como em outras aplicações, as vantagens principais são a obtenção de conjuntos de dados volumétricos e a possibilidade de ter a imagem durante várias fases do realce por contraste. A imagem pode ser realizada nas fases arterial, medular cortical, ou de equilíbrio do realce renal.

Nos pacientes com doença inflamatória renal, o diagnóstico por imagem normalmente não é realizado a menos que o diagnóstico seja duvidoso ou se suspeite de complicações. Nestes casos, a imagem da fase medular cortical é normalmente valiosa na detecção de alterações sutis da pielonefrite aguda. Em alguns casos, no entanto, as mudanças são apenas vistas em imagens de fases tardias. O exame de ambas as fases é recomendado nos pacientes com doença inflamatória ou com suspeita.

Uma combinação de imagens de fases arterial, medular cortical e tardia, é ideal para a detecção e avaliação de massas renais e classificação de tumores renais.

O estudo da fase arterial é ideal para a avaliação do suprimento arterial, particularmente quando uma nefrectomia parcial está por ser realizada. O estudo da fase arterial também é útil para a avaliação do fígado para metástase vascular. O estudo da fase cortical medular é útil para descrever os padrões de realce venoso do rim e a permeabilidade da veia renal e da veia inferior.

Além destas aplicações clássicas na doença inflamatória renal e doença neoplásica, a TC helicoidal permite novas aplicações vasculares. Isto inclui a avaliação de estenose arterial renal, tanto quanto a avaliação de potenciais doadores de rins.

APLICAÇÕES VASCULARES:

A angioTC helicoidal aumentou em muito o papel da TC no estudo vascular. A angioTC tem sido utilizada em muitas áreas. As aplicações para as quais a angioTC tem apresentado boa correlação com a angiografia padrão, inclui a avaliação das artérias renais, das artérias carótidas e circulação intra craniana.

Uma abordagem especialmente promissora envolve reconstrução em 3D das estruturas vasculares. A informação que estes estudos fornecem ao médico examinador pode igualar ou exceder aquela da angiografia tradicional ou venografia, a custos mais baixos, com menos desconforto para o paciente ou complicações potenciais.

A angioTC também pode ser combinada com os estudos tradicionais de TC para acentuar sua utilidade na definição da extensão da doença e no planejamento cirúrgico. Por exemplo, no planejamento pre-cirúrgico para uma resseção hepática, a angioTC em 3D pode definir a anatomia vascular específica arterial, incluindo a origem da artéria hepática. A localização específica de um tumor em relação aos segmentos hepáticos individuais, baseado na anatomia hepática venosa, é útil na determinação da ressecabilidade.

TRAUMA E APLICAÇÕES NO SISTEMA MÚSCULO-ESQUELÉTICO:
A TC é o resultado a ser escolhido para muitos pacientes com trauma considerável. A TC geralmente fornece avaliações precisas do cérebro, tórax e abdome. A TC helicoidal permite exames mais rápidos, tornando possível a obtenção de imagens mesmo com a mínima cooperação do paciente. Os exames do tórax e abdome podem ser completados totalmente em um minuto. E, para a avaliação dos ossos da pélvis, a angioTC pode ser realizada para avaliar a aorta abdominal inferior e os vasos ilíacos, normalmente sobrepujando a necessidade de angiografia padrão.

Outra aplicação potencial para a TC helicoidal no estudo músculo-esquelético envolve disfunções congênitas ou adquiridas.

Um exame rápido de 30 segundos é de longe mais eficiente do que múltiplas repetições de raios X em um paciente que provavelmente não seja capaz de cooperar.

Uma das principais vantagens da TC helicoidal no estudo músculo-esquelético, geralmente é a qualidade do conjunto de dados para reconstituição de imagens multiplanares e em 3D. Em casos de traumas complexos, as imagens multiplanares e em 3D são essenciais para o preciso mapeamento da extensão total da lesão.

A Tomografia Computadorizada Helicoidal representa a grande novidade do exame de Tomografia.

Numerosos estudos têm sido feitos para avaliar as vantagens e desvantagens da Tomografia Computadorizada comparada com outras técnicas de imagem, tais como o ultra-som, Ressonância Magnética, angiografia convencional, medicina nuclear e estudos com bário. A Tomografia Computadorizada tem provado consistentemente ser mais rápida, estudo não invasivo de alta sensibilidade e especificidade para a presença ou ausência de doença. Desenvolvimentos contínuos na Tomografia Computadorizada provavelmente aumentarão estas vantagens, levando a um cuidado melhor do paciente e uma relação custo-benefício cada vez mais baixa.

PRINCIPAIS INDICAÇÕES DA TC

TÓRAX:

Avaliação de possíveis metástases no pulmão.

Avaliação de um nódulo solitário pulmonar.

Avaliação de mediastino e hilo.

Avaliação de artérias pulmonares para suspeita de embolia pulmonar.

Avaliação da aorta.

Avaliação de trauma torácico.

Estadiamento de tumores.

ABDOME:

Avaliação do fígado para possíveis metástases.

Avaliação de doença parenquimatosa do fígado.

Avaliação do pâncreas para pancreatite ou carcinoma.

Avaliação das adrenais.

Avaliação dos rins.

Avaliação do intestino delgado e cólon.

Avaliação da pélvis, incluindo órgãos ginecológicos.

Avaliação do abdome agudo.

Avaliação do paciente traumatizado.

Estadiamento de tumores.

MÚSCULO-ESQUELÉTICO:

Avaliação de trauma.

Avaliação de partes moles, inflamação e infecção muscular.

Avaliação de suspeita de tumores do sistema músculo-esquelético..

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