突发神志不清伴四肢抽搐,这位患者怎么了?

2018-05-16 文烈心 医学界神经病学频道

她,71岁,突发神志不清伴四肢抽搐半小时。倒在路边,刚好有人目击,被好心的路人送来急诊室。

她,71岁,突发神志不清伴四肢抽搐半小时。倒在路边,刚好有人目击,被好心的路人送来急诊室。

幸好身上有老年证,得益于医院的信息系统记录,很快就确认了身份信息,也找到了家属的联系方式,一个儿子,一个女儿,很奇葩,都表示一时过不来。反复告知,初步判断是中风了,病情很严重,需要家属尽快赶到医院,但都推脱,就是不来,只是提供了一些零散的病史。老伴已经过世,也找不到别的近亲属,但我们一样得救治。

数据库里调出她的医疗记录,还真是有些复杂。3年前脑栓塞一次。2年前因风湿性心脏病,接受二尖瓣机械瓣植入、三尖瓣成型,后一直服用华法林,12月前右基底节区脑出血一次,遗留左侧肢体活动障碍,5月前左侧脑栓塞,范围不大,但出现偶发癫痫,服用德巴金。

初步判断又是脑栓塞,请神经内科、心脏外科会诊。

心脏外科的医师先到,自己手术的病人,一看就认识。这个人,发了好几次心衰,也中风了一次,估计是左心耳内的小血栓脱落导致,才最终手术,术中取掉了血栓,还把左心耳缝闭了,希望能减少以后的血栓栓塞事件。

其实当时手术时就担心,这家里人很不关心,以后的抗凝随访会成为问题。69岁,一般选择生物瓣,虽然二尖瓣位,在仍有房颤、左房偏大的情况下,即使置换生物瓣也仍建议继续华法林抗凝,但家属不止拒绝术中同期房颤射频消融以进一步减少血栓栓塞风险,而且一定要换机械瓣。

了解多了才弄清,家属就是不想花钱,房颤不做,省一笔,听说生物瓣有衰败可能,坚决不换生物瓣,其实对于69岁的人,生物瓣一般也够用了,但家属就是要把这风险完全规避掉。像他们这样,这病人能撑到生物瓣衰败的那天,基本上是不可能的。

据说,手术的钱也是老人自己东拼西凑出来的,她想多活几年。可是术后门诊复诊抗凝情况,很不规律,所以才有多次的出血栓塞事件。



神经内科的医师也到了,脑部、胸部CT也出来了。一看,病人也熟悉。查体完,判断还是脑栓塞,左侧,面积应该不小,从医疗上可以考虑溶栓。

别看现在左侧脑部基本正常,那时因为栓塞时间还短,水肿不明显,过几个小时就严重水肿了,右侧基底节区可见以前中风后的液化区。

但溶栓的风险极大,本身病人在华法林抗凝,出血风险大,多次脑卒中,以前还有脑出血,这次的栓塞范围大。前几次跟她的家属打交道过,真是奇葩。



心外科的医师看了胸部CT,这机械瓣,这伪影像闪动的光芒,可惜照不亮她的生命。



心房里可以隐约看到血栓。心超也证实是血栓。风心病,要是换瓣后不好好抗凝,这血栓栓塞风险还是很大。

没有家属在场,溶栓这样的高风险医疗,尤其是对这例,风险更是极大,是没法进行的。

最后决定先收入急诊留观室,行药物治疗。

后来病人有短暂意识恢复,但不太清晰。

一天多后,女儿终于露面了。病人已深昏迷,临床判断,有脑疝表现,复查CT,左侧大脑已经是这种不堪的状态。



女儿很干脆签署了DNR,病人很快出现呼吸停止,血压下降,心脏停跳。

曾经她的大脑也是没有中风痕迹的,那是她一开始想做心脏手术时术前评估留下的CT影像。

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    2018-05-20 张新亮1853311252142e2fm

    好文献学习了

    0

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    2018-05-18 gujh
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    2018-05-17 baihao215

    多么痛的领悟

    0

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    2018-05-17 张新亮1853311252142e2fm

    好文献学习了

    0

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    2018-05-17 溜溜梅不酸

    学习了谢谢

    0

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    2018-05-16 1209e435m98(暂无昵称)

    学习了.谢谢分享

    0

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