非大血管病变的大面积多发脑梗死原因是?

2019-06-27 木木先生 医学之声

对于脑梗死的诊断,看似简单,殊不知其病因复杂,它的病因目前多采用TOAST分型,分为:大动脉粥样硬化型、心源性栓塞型、小动脉闭塞型、其他病因型、不明原因型。

对于脑梗死的诊断,看似简单,殊不知其病因复杂,它的病因目前多采用TOAST分型,分为:大动脉粥样硬化型、心源性栓塞型、小动脉闭塞型、其他病因型、不明原因型。

那么如何从纷繁复杂的病因中理清思路,来看看下面这个病例,是如何层层抽丝剥茧,找出病因的:

★患者老年女性,农民,以“左侧肢体无力5小时加重伴意识障碍2小时”从下级医院转入。

★5小时前患者突然出现左侧肢体无力,左上肢可上抬,下肢可行走,无意识障碍及其他伴随症状,遂至当地医院,急查头颅CT提示多发腔隙性脑梗死,NIHSS评分5分,排除溶栓禁忌症后,给予阿替普酶45mg行静脉溶栓,溶栓过程中病情进展加重(2小时前),左侧肢体上抬不能,且出现意识障碍,复查头颅CT较前无明显改变。急转至我院。

★既往高血压病史。

★查体:血压:160/105mmHg。嗜睡状态,混合性失语,双眼向右侧凝视,右侧眼睑下垂,双侧瞳孔等大同圆,对光反射灵敏,左侧鼻唇沟变浅,示齿不配合,伸舌左偏,四肢肌张力正常,左上肢肌力0级,左下肢肌力1级。左侧Babinski征(+)。余神经系统查体未见明显异常。

患者现为静脉溶栓后,NIHSS评分:17分,再次复查CT未见出血,考虑大血管病变可能性大,与患者家属沟通后给予行全脑血管DSA检查,造影结果:右侧大脑中动脉M1段斑块形成;左侧大脑中动脉M1段斑块形成;左侧大脑后动脉P3段闭塞。并未见大血管闭塞情况。

依据患者目前情况,给予完善头颅磁共振了解梗死灶部位及范围。

  
  
   

可以看到DWI像上:桥脑、双侧小脑半球、双侧基底节区、双侧颞、枕、顶叶多发急性脑梗死。

那么,既然DSA已排除大血管病变,磁共振为什么会出现如此大面积、弥散、多发梗死呢?本例用大动脉粥样硬化型、心源性栓塞型、小动脉闭塞型均不能解释。是自身免疫性?血管炎性?血凝障碍性?

紧接着又完善这些检查,结果仍然是令人失望的:自身免疫17项+ANCA均阴性、凝血六项未见异常、抗链O及类风湿因子均正常。

再次回顾病例,患者为老年女性,排除过那么多病因后,老年患者是否考虑肿瘤呢?又给予完善胸部及腹部CT。

 

果然,找到了问题所在,胸部CT可见右肺上叶前段团片状高密度影,考虑占位性病变。

★结论:脑梗死病因复杂,对于不能解释的病变,应思维广泛,不能局限于某一系统疾病。对于本例磁共振提示多个血管支配区域均存在病变,应多向肿瘤及血管炎性疾病方向倾斜。还有随着医学的发展、检查手段的丰富,一定要考虑到疾病的罕见病因。

版权声明:
本网站所有内容来源注明为“梅斯医学”或“MedSci原创”的文字、图片和音视频资料,版权均属于梅斯医学所有。非经授权,任何媒体、网站或个人不得转载,授权转载时须注明来源为“梅斯医学”。其它来源的文章系转载文章,或“梅斯号”自媒体发布的文章,仅系出于传递更多信息之目的,本站仅负责审核内容合规,其内容不代表本站立场,本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与我们联系,我们将立即进行删除处理。
在此留言
评论区 (5)
#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=1644760, encodeId=738e1644e60da, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Tue Apr 07 02:26:00 CST 2020, time=2020-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1706142, encodeId=a00e1e061421f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Fri Aug 16 22:26:00 CST 2019, time=2019-08-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1954517, encodeId=eb3f195451e1e, content=<a href='/topic/show?id=7a804404823' target=_blank style='color:#2F92EE;'>#大面积#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44048, encryptionId=7a804404823, topicName=大面积)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Apr 20 19:26:00 CST 2020, time=2020-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1391096, encodeId=cbfa1391096d8, content=<a href='/topic/show?id=6d0689e19f0' target=_blank style='color:#2F92EE;'>#血管病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89719, encryptionId=6d0689e19f0, topicName=血管病变)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=85152500072, createdName=124987c6m36暂无昵称, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465146, encodeId=d4a51465146a9, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ccf56689148, createdName=karmond, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1644760, encodeId=738e1644e60da, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Tue Apr 07 02:26:00 CST 2020, time=2020-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1706142, encodeId=a00e1e061421f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Fri Aug 16 22:26:00 CST 2019, time=2019-08-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1954517, encodeId=eb3f195451e1e, content=<a href='/topic/show?id=7a804404823' target=_blank style='color:#2F92EE;'>#大面积#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44048, encryptionId=7a804404823, topicName=大面积)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Apr 20 19:26:00 CST 2020, time=2020-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1391096, encodeId=cbfa1391096d8, content=<a href='/topic/show?id=6d0689e19f0' target=_blank style='color:#2F92EE;'>#血管病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89719, encryptionId=6d0689e19f0, topicName=血管病变)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=85152500072, createdName=124987c6m36暂无昵称, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465146, encodeId=d4a51465146a9, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ccf56689148, createdName=karmond, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=)]
    2019-08-16 kkunny
  3. [GetPortalCommentsPageByObjectIdResponse(id=1644760, encodeId=738e1644e60da, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Tue Apr 07 02:26:00 CST 2020, time=2020-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1706142, encodeId=a00e1e061421f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Fri Aug 16 22:26:00 CST 2019, time=2019-08-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1954517, encodeId=eb3f195451e1e, content=<a href='/topic/show?id=7a804404823' target=_blank style='color:#2F92EE;'>#大面积#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44048, encryptionId=7a804404823, topicName=大面积)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Apr 20 19:26:00 CST 2020, time=2020-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1391096, encodeId=cbfa1391096d8, content=<a href='/topic/show?id=6d0689e19f0' target=_blank style='color:#2F92EE;'>#血管病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89719, encryptionId=6d0689e19f0, topicName=血管病变)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=85152500072, createdName=124987c6m36暂无昵称, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465146, encodeId=d4a51465146a9, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ccf56689148, createdName=karmond, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=1644760, encodeId=738e1644e60da, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Tue Apr 07 02:26:00 CST 2020, time=2020-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1706142, encodeId=a00e1e061421f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Fri Aug 16 22:26:00 CST 2019, time=2019-08-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1954517, encodeId=eb3f195451e1e, content=<a href='/topic/show?id=7a804404823' target=_blank style='color:#2F92EE;'>#大面积#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44048, encryptionId=7a804404823, topicName=大面积)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Apr 20 19:26:00 CST 2020, time=2020-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1391096, encodeId=cbfa1391096d8, content=<a href='/topic/show?id=6d0689e19f0' target=_blank style='color:#2F92EE;'>#血管病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89719, encryptionId=6d0689e19f0, topicName=血管病变)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=85152500072, createdName=124987c6m36暂无昵称, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465146, encodeId=d4a51465146a9, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ccf56689148, createdName=karmond, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1644760, encodeId=738e1644e60da, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Tue Apr 07 02:26:00 CST 2020, time=2020-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1706142, encodeId=a00e1e061421f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Fri Aug 16 22:26:00 CST 2019, time=2019-08-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1954517, encodeId=eb3f195451e1e, content=<a href='/topic/show?id=7a804404823' target=_blank style='color:#2F92EE;'>#大面积#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44048, encryptionId=7a804404823, topicName=大面积)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Apr 20 19:26:00 CST 2020, time=2020-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1391096, encodeId=cbfa1391096d8, content=<a href='/topic/show?id=6d0689e19f0' target=_blank style='color:#2F92EE;'>#血管病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89719, encryptionId=6d0689e19f0, topicName=血管病变)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=85152500072, createdName=124987c6m36暂无昵称, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465146, encodeId=d4a51465146a9, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ccf56689148, createdName=karmond, createdTime=Sat Jun 29 06:26:00 CST 2019, time=2019-06-29, status=1, ipAttribution=)]
    2019-06-29 karmond

相关资讯

似脑胶质细胞瘤的脑梗死1例报告

患者女,75岁,以“头痛1个月,加重伴右下肢无力3d”为主诉入院。1个月前患者无明显诱因出现头痛,3d前症状进行性加重,伴右下肢无力、活动受限,口角向左侧偏斜,双眼视力下降,不伴意识障碍、恶心呕吐、大小便失禁等。头颅MR提示,右侧额颞叶占位(图1)。

Neuroradiology:高灌注引起的脑梗死?还是脑梗死后高灌注?

65岁,女性。既往高血压病史。因为突发表达性失语就诊,无其他神经功能缺损。

Stroke:边缘带梗死和侧枝血流受损者应该置入颅内支架?

颅内动脉粥样硬化狭窄(Intracranial atherosclerotic arterial stenosis,ICAS)是缺血性卒中的常见病因,与高复发卒中的风险有关。

Nat Med:中国慢病研究全新分析,降低坏胆固醇可预防脑梗

近日,中国慢性病前瞻性研究组在Nature医学子刊发表研究称,降低“坏胆固醇”低密度脂蛋白胆固醇(LDL-C)预防脑梗死净获益高,与年龄、高血压病史或心血管病史无关。

大脑中动脉粥样硬化形成的青年脑梗死1例报告

患者男,26岁,异地来京打工白领,主诉“反复发作右侧肢体无力3d余”于2016-08-24至北京清华长庚医院急诊神经科就诊。患者3d来无诱因反复发作4次右侧肢体无力,无法持物,尚可站立及行走,每次持续约2min自行缓解。病程中无意识不清,无言语不清、吞咽困难及饮水呛咳,无耳鸣、听力减退,无心前区不适、胸闷气短,无尿便障碍。

溶还是不溶?一次惊心动魄的溶栓!

2小时前患者无明显诱因突发左侧肢体无力,当时左侧上下肢肌力1级,家属拨打120急来我院,转运过程中左侧上下肢肌力恢复正常(5级),数分钟后左侧肢体再次下降为1级;入院急查头颅CT:未见出血;急查肌钙蛋白、凝血功能、电解质、血糖等未见异常。病人回到病床后,左侧上下肢肌力再次恢复正常。