惊险!差点掉进脑卒中的“陷阱”

2018-06-26 吴积宝(湖南郴州市第一人民医院神经内科) 林邑中枢”公众号

患者系46岁中年男性,走进可以隐约闻到少许酒味!一看就是经常在外应酬的。旁边的老婆手里拿着一堆影像片子和资料焦急地问到:“医生,快帮我老公看看,突然就左手麻木,以前从来没有过”。

和往常一样每到会诊周的晚班都很忙,各种会诊时间一下就过去了。洗漱准备休息时已经过了凌晨十二点,手机上的运动健康早已提示超过1万步了。

刚躺下不久,电话铃声再次响起,急诊科会诊!当赶到急诊室时完全看不出是凌晨1点的样子,急诊科的医务人员紧张有序的接诊各种患者。“吴医生,这里有个昏迷的,已经气管插管,那边有个头痛患者,刚做完CT,还有个头晕的... ...”

都会诊完准备走时,急诊科同事又把我叫住:“等一下,这有个左上肢麻木的病人,也麻烦你看看是不是你们神经科的问题”。我习惯的问到“发病多久了?”他答道“1个多小时”;呀!还在时间窗内。心里马上进入急诊绿色通道模式。赶紧走过去看病人。

患者系46岁中年男性,走进可以隐约闻到少许酒味!一看就是经常在外应酬的。旁边的老婆手里拿着一堆影像片子和资料焦急地问到:“医生,快帮我老公看看,突然就左手麻木,以前从来没有过”。

我:哪里不舒服?

患者:左手麻木

我:多久啦?

患者:一个多小时前

我:突然发病的吗?有没喝醉酒压迫手臂?

这时她老婆马上抢答到:是喝了酒,但没喝醉,以前有颈椎病,是不是颈椎压迫引起的呀?

我:是整个手都麻还是仅仅是手指麻木?

患者:整个手指都麻!

我:有高血压病、糖尿病没?吸烟、喝酒?

患者:没有高血压糖尿病,但是抽烟,喝酒。

我一看患者左手上有散在分布瘀斑!问是不是自己掐的?患者点头,我心里很肯定了有客观的感觉障碍!否则不会掐这么厉害都没感觉。

定位靠查体,定性靠病史。马上给患者专科查体:除了左上肢感觉障碍其他无特殊。定位:右侧顶叶?中央后回?远端皮层引起的孤立性感觉障碍?又这么年轻,肯定不是简单的脑血栓,难道是栓塞?想起以前总结过:年轻患者卒中要警惕夹层!

因此,继续追问病史:发病前颈部和脖子痛不痛?

患者:颈和脖子都不痛,但是脖子下面痛!

我:胸背部痛不痛?痛之前在干嘛?你把你发病前的整个过程描述下,我试图还原整个发病过程。

患者:晚上11点左右在解大便时突然脖子下面痛,并且出了很多汗,衣服都湿了!疼痛一直没好,就去XX医院看病,做了胸部扫描没查出什么问题,加上疼痛又有所好转,就准备回家,在回来路上左手就开始麻木了!

听完我马上意识到问题的严重性!马上梳理下整个过程:解大便是诱因,突发疼痛伴大汗,持续不缓解,然后再出现手麻木。这时觉得该病人的诊断要往后退,不能仅仅局限于神经专科,手麻可能是整个疾病当中的一个点而已。

因此初步诊断应该是:胸痛查因


首先排除胸痛三大急症:

1.急性冠脉综合征

2.主动脉夹层

3.肺栓塞

“马上给他做个心电图!联系心内科会诊”因为之前听过腹部以上部位的突发疼痛不缓解的话都要排除急性心梗!但是,床旁急查心电图不提示心梗。

“测双侧血压排除主动脉夹层”;果然双侧血压收缩压相差30,立马联系胸外科,急查CTA,结果如下:



图中可见夹层主要累及头臂干,一直撕裂延伸至右侧颈内动脉!这就很好解释了突发疼痛和缺血性脑卒中。如果当成脑卒中静脉溶栓了后果会怎样?如果晚上打一下盹没问清病史,就当简单的颈椎病,打发他回去会怎样... ... 回想起来后怕的很!睡意全无,也没在睡着了!

最终诊断

主动脉夹层(I型)

体会

该患者不是典型的主动脉夹患者那样胸背部疼痛,更不是典型的脑梗死!因此,我们在临床中需要时刻保持清醒头脑,逐步积累经验,对于脑血管病,病史的采集非常重要;另外,对于脑卒中患者,除了初步要完成心电图、随机血糖、头颅CT外,还要测双上肢血压和脉搏以及听诊双颈动脉血管杂音。

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1026086, encodeId=254b102608618, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Jun 26 14:59:00 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327171, encodeId=a37832e1714b, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Tue Jun 26 13:37:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327164, encodeId=094a32e16435, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=56, 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=Tue Jun 26 13:22:22 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327157, encodeId=abb832e157aa, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Jun 26 13:15:57 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327145, encodeId=32f132e1450d, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2ac82155377, createdName=1201e5c5m39暂无昵称, createdTime=Tue Jun 26 13:02:18 CST 2018, time=2018-06-26, status=1, ipAttribution=)]
    2018-06-26 健健

    卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1026086, encodeId=254b102608618, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Jun 26 14:59:00 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327171, encodeId=a37832e1714b, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Tue Jun 26 13:37:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327164, encodeId=094a32e16435, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=56, 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=Tue Jun 26 13:22:22 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327157, encodeId=abb832e157aa, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Jun 26 13:15:57 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327145, encodeId=32f132e1450d, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2ac82155377, createdName=1201e5c5m39暂无昵称, createdTime=Tue Jun 26 13:02:18 CST 2018, time=2018-06-26, status=1, ipAttribution=)]
    2018-06-26 wzb521zf

    一起学习学习

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1026086, encodeId=254b102608618, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Jun 26 14:59:00 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327171, encodeId=a37832e1714b, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Tue Jun 26 13:37:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327164, encodeId=094a32e16435, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=56, 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=Tue Jun 26 13:22:22 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327157, encodeId=abb832e157aa, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Jun 26 13:15:57 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327145, encodeId=32f132e1450d, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2ac82155377, createdName=1201e5c5m39暂无昵称, createdTime=Tue Jun 26 13:02:18 CST 2018, time=2018-06-26, status=1, ipAttribution=)]
    2018-06-26 惠映实验室

    学习了.谢谢分享.

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1026086, encodeId=254b102608618, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Jun 26 14:59:00 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327171, encodeId=a37832e1714b, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Tue Jun 26 13:37:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327164, encodeId=094a32e16435, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=56, 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=Tue Jun 26 13:22:22 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327157, encodeId=abb832e157aa, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Jun 26 13:15:57 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327145, encodeId=32f132e1450d, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2ac82155377, createdName=1201e5c5m39暂无昵称, createdTime=Tue Jun 26 13:02:18 CST 2018, time=2018-06-26, status=1, ipAttribution=)]
    2018-06-26 医者仁心5538

    学习了

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1026086, encodeId=254b102608618, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Jun 26 14:59:00 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327171, encodeId=a37832e1714b, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Tue Jun 26 13:37:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327164, encodeId=094a32e16435, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=56, 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=Tue Jun 26 13:22:22 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327157, encodeId=abb832e157aa, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Jun 26 13:15:57 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327145, encodeId=32f132e1450d, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2ac82155377, createdName=1201e5c5m39暂无昵称, createdTime=Tue Jun 26 13:02:18 CST 2018, time=2018-06-26, status=1, ipAttribution=)]
    2018-06-26 1201e5c5m39暂无昵称

    学习了

    0

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脑卒中,神经科最常见的疾病,没有之一。据了解,全国大多数医院的神经内科都是以看脑血管病为主的,门诊主要是脑梗、头痛、头晕、肢体麻木等各类患者为主,病房也是以收治脑血管患者为主,可就在这最常见的疾病中,也有陷阱,稍有不慎,就掉进去了……

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尽管分析受到小样本和异质性研究人群的限制,本文认为需氧革兰阴性杆菌和革兰阳性球菌常与肺炎合并卒中有关。这支持需要设计适当的研究来确定微生物病因和抗生素治疗方法。

JAHA:糖化血红蛋白与脑卒中风险!

由此可见,升高的HbA1c水平与糖尿病患者首次卒中增加的风险相关,并增加非糖尿病队列首次缺血性卒中的风险。这些结果表明可能需要更强化的HbA1c血糖控制目标来优化缺血性卒中预防。

脑卒中合并稳定性冠心病运动康复专家共识

脑卒中后多数患者存在不同程度的肢体运动功能障碍,61.9%的非致死性卒中后患者冠脉造影有冠脉斑块,卒中后心肌梗死发病率为2.2%,由于偏瘫患者大部分倾向于坐位生活方式,其运动耐量(包括心肺耐力和肌耐力)下降,同时肢体肌力、肌张力、运动模式、运动灵活性、技巧性异常,故其步行活动的能量消耗大于肢体功能正常的人,因此心脏负荷增加,从而可能增加运动相关的心血管事件的发生。运动康复是心血管康复的核心措施之一

脐带血有助于脑卒中后恢复

一项小规模临床试验显示,在脑卒中发生后几天内注射脐带血,有助于缓解脑损伤、恢复认知和行动能力。据英国《新科学家》杂志最近报道,美国杜克大学等机构的研究人员招募了10名年龄在45岁至79岁之间的志愿者参加试验,他们在发生大脑中动脉缺血性脑卒中后3天到10天间接受一次新生儿脐带血注射。研究人员在国际期刊《干细胞转化医学杂志》上发表报告说,注射三个月后,所有患者的语言能力、视力和运动能力都有改善,日常生