病例分享:剧烈头痛后晕厥,这是一生中严重的头痛

2017-10-27 文烈心 医学界神经病学频道

120指挥中心转来电话,患者,女,46岁,剧烈头痛后晕厥20分钟,已在路上,预计8分钟后到达急诊抢救室。突发剧烈头痛后意识改变,首先考虑脑动脉瘤破裂导致蛛网膜下腔出血。

1. 急诊!患者剧烈头痛后晕厥

120指挥中心转来电话,患者,女,46岁,剧烈头痛后晕厥20分钟,已在路上,预计8分钟后到达急诊抢救室。突发剧烈头痛后意识改变,首先考虑脑动脉瘤破裂导致蛛网膜下腔出血。这种头痛具有两大特点:

一为剧烈,很多患者描述这是一生中最严重的头痛;

二是突发性;

如果加上其他神经症状体征,如意识改变、呕吐、癫痫发作、脑膜刺激征、偏瘫,那基本上就比较典型了。意识改变的原因为颅内压突然升高导致脑部短暂灌注压急剧下降导致。

接诊这样的危重病例,我院有预案,流程已经很顺畅了。院前急救通知后,急诊室当班主诊医师即开始协调,CT室做好迅速检查准备,通知脑外科准备会诊,必要时请介入科急诊栓塞脑动脉瘤,ICU安排接收床位。

2. 这个脑动脉瘤有点奇怪

120呼啸而至,接诊急诊医师迅速完成病史采集和体格检查,符合蛛网膜下腔出血,立即陪同转送至CT室行急诊颅脑CT检查。扫描时即在CT控制室初步读片。
确实是蛛网膜下腔出血,但出血灶图像有些奇怪。这要是动脉瘤,还真是不小,感觉腔内有血块,瘤壁怎么这么不规整?不管怎么样,按照常规,在确认有蛛网膜下腔出血后,特别是已经看到疑似动脉瘤体后,迅速加行颅脑CTA。
瘤体确实有些奇怪。调整窗宽窗位后,形态迥异与一般脑动脉瘤。

3. 家属说这次发病前,已发烧一周余

脑外科会诊医师到达。共同再去询问病史、查体。患者丈夫补充,这次发病前,已发烧一周余,已使用抗生素

发烧、脑动脉瘤,这种形态的CT图像,难道是感染性心内膜炎相关脑动脉瘤破裂?

感染性心内膜炎,可分为急性和亚急性,急性者常由金黄色葡萄球菌导致,毒力大,较容易导致脑动脉瘤,但现在已少见。亚急性者常在基础心脏结构性病变的基础上发生,也可导致脑动脉瘤,另脑部可造成栓塞和出血。虽然心力衰竭是感染性心内膜炎首位死因,但脑部并发症也不容小觑。诊断依据的最主要两点是,心超发现赘生物,血培养发现致病菌。

心脏一听诊,心尖区收缩期杂音。马上请心超协助诊断二尖瓣后瓣上可见赘生物飘动,基础病变为二尖瓣后瓣脱垂致返流。立即留取血培养。


4. 最后,脑外科急诊开颅

这样的动脉瘤破裂,首选脑外科急诊开颅。术中见瘤体周围粘连水肿严重,瘤体内血栓形成,符合细菌性脑动脉瘤,予送培养。细菌培养阴性,考虑前抗生素使用相关。感染性心内膜国内血培养阳性率相对低,与抗生素的广泛应用相关,给后续治疗带来了一定麻烦。所幸,该病人在万古霉素长程抗感染治疗后,控制良好。

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    2017-10-29 lily1616
  2. [GetPortalCommentsPageByObjectIdResponse(id=1311624, encodeId=9e8613116249d, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Sun Oct 29 03:22:00 CST 2017, time=2017-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256431, encodeId=763725643123, content=好资料学习了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=92191944782, createdName=thlabcde, createdTime=Fri Oct 27 17:13:44 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256420, encodeId=d56a2564206f, content=脑动脉瘤破裂出血.危险!, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=60791943465, createdName=1e0f8808m18(暂无匿称), createdTime=Fri Oct 27 16:03:15 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256392, encodeId=8f302563926c, content=学习了.谢谢., beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Fri Oct 27 13:22:11 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256380, encodeId=7a0725638090, content=学习了提高了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/21/39b6a0099eb602e8ac1f7e10d5d440a9.jpg, createdBy=dee01724555, createdName=杨利洪, createdTime=Fri Oct 27 13:08:47 CST 2017, time=2017-10-27, status=1, ipAttribution=)]
    2017-10-27 thlabcde

    好资料学习了!

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1311624, encodeId=9e8613116249d, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Sun Oct 29 03:22:00 CST 2017, time=2017-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256431, encodeId=763725643123, content=好资料学习了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=92191944782, createdName=thlabcde, createdTime=Fri Oct 27 17:13:44 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256420, encodeId=d56a2564206f, content=脑动脉瘤破裂出血.危险!, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=60791943465, createdName=1e0f8808m18(暂无匿称), createdTime=Fri Oct 27 16:03:15 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256392, encodeId=8f302563926c, content=学习了.谢谢., beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Fri Oct 27 13:22:11 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256380, encodeId=7a0725638090, content=学习了提高了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/21/39b6a0099eb602e8ac1f7e10d5d440a9.jpg, createdBy=dee01724555, createdName=杨利洪, createdTime=Fri Oct 27 13:08:47 CST 2017, time=2017-10-27, status=1, ipAttribution=)]
    2017-10-27 1e0f8808m18(暂无匿称)

    脑动脉瘤破裂出血.危险!

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1311624, encodeId=9e8613116249d, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Sun Oct 29 03:22:00 CST 2017, time=2017-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256431, encodeId=763725643123, content=好资料学习了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=92191944782, createdName=thlabcde, createdTime=Fri Oct 27 17:13:44 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256420, encodeId=d56a2564206f, content=脑动脉瘤破裂出血.危险!, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=60791943465, createdName=1e0f8808m18(暂无匿称), createdTime=Fri Oct 27 16:03:15 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256392, encodeId=8f302563926c, content=学习了.谢谢., beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Fri Oct 27 13:22:11 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256380, encodeId=7a0725638090, content=学习了提高了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/21/39b6a0099eb602e8ac1f7e10d5d440a9.jpg, createdBy=dee01724555, createdName=杨利洪, createdTime=Fri Oct 27 13:08:47 CST 2017, time=2017-10-27, status=1, ipAttribution=)]
    2017-10-27 惠映实验室

    学习了.谢谢.

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1311624, encodeId=9e8613116249d, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Sun Oct 29 03:22:00 CST 2017, time=2017-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256431, encodeId=763725643123, content=好资料学习了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=92191944782, createdName=thlabcde, createdTime=Fri Oct 27 17:13:44 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256420, encodeId=d56a2564206f, content=脑动脉瘤破裂出血.危险!, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=60791943465, createdName=1e0f8808m18(暂无匿称), createdTime=Fri Oct 27 16:03:15 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256392, encodeId=8f302563926c, content=学习了.谢谢., beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Fri Oct 27 13:22:11 CST 2017, time=2017-10-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=256380, encodeId=7a0725638090, content=学习了提高了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/21/39b6a0099eb602e8ac1f7e10d5d440a9.jpg, createdBy=dee01724555, createdName=杨利洪, createdTime=Fri Oct 27 13:08:47 CST 2017, time=2017-10-27, status=1, ipAttribution=)]
    2017-10-27 杨利洪

    学习了提高了

    0

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头痛是门诊患者常见症状,病因复杂,涉及的疾病多。因此,在头痛的诊断和鉴别诊断中,除了详细询问病史,还有哪些因素对诊断有帮助?