大脑浅静脉血栓形成伴出血性脑梗死
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摘要
研究背景大脑浅静脉血栓形成为临床少见脑血管病,病因多样、发病形式和临床表现复杂且不具有特异性,易误诊或漏诊。本文通过对1例大脑浅静脉血栓形成伴出血性脑梗死患者大脑浅静脉解剖学、浅静脉血栓形成病理生理学知识的复习及诊断与治疗要点的回顾,以提高对其诊断与鉴别诊断能力。方法与结果男性患者,18岁。进行性头痛4年伴左侧肢体无力2 d。头部MRI显示右侧额顶叶类圆形占位性病变,MRV显示上矢状窦前2/3显影不清。手术切除右侧额顶叶部分病变组织并去骨瓣减压,术中可见脑组织苍白,部分呈黄色或暗红色,浅静脉怒张;组织学形态观察,软脑膜浅静脉血栓和软脑膜下软化灶形成,大脑皮质多灶性和局部脑实质出血,周围组织大量"格子细胞",并可见"血管套袖"现象,脑实质血管明显增生。术后左手活动明显受限。结论大脑浅静脉血栓形成伴出血性脑梗死临床诊断困难,影像学和血清学检查可提供一定帮助,应重视多学科联合诊断与治疗,以减少误诊和漏诊并积累临床经验。
Background missed for its various etiological factors, and complicated and nonspecific clinical manifestations. Thispaper reported one case of superficial vein thrombosis in right fronto- parietal lobe with hemorrhagicinfarction. The anatomy of superficial vein, pathophysiological points, diagnosis and treatment of superficialvein thrombosis were reviewed to help to reduce missed diagnosis or misdiagnosis.Methods and Results A 18-year-old male patient had suffered from progressive headache for 4 years and weakness of left limbsfor 2 d. Head MRI showed circular space- occupying lesion in right fronto- parietal lobe. Magneticresonance venography(MRV) examination showed the front two-thirds of the superior sagittal sinus was notclear. The lesions were removed and decompressive craniectomy was conducted, showing the brain tissuewas pale, partly yellow or dark red, and superficial venous engorgement. Histological observation showedpial superficial vein thrombosis and subpial encephalomalacia, and multifocal hemorrhage of cerebral cortexand local parenchymal hemorrhage. A large number of "grid cells" and vascular "cuff" phenomenan werevisible in surrounding tissue, and the parenchymal blood vessel proliferation was obvious. Left handactivity of the patient was obviously limited after the operation.ConclusionsClinical diagnosis ofsuperficial vein thrombosis with hemorrhagic infarction is difficult, and brain imaging and serologicalexamination can provide certain help. Much attention should be paid to the multidisciplinary diagnosis andtreatment to reduce misdiagnosis or missed diagnosis, and gather clinical experience.
Background missed for its various etiological factors, and complicated and nonspecific clinical manifestations. Thispaper reported one case of superficial vein thrombosis in right fronto- parietal lobe with hemorrhagicinfarction. The anatomy of superficial vein, pathophysiological points, diagnosis and treatment of superficialvein thrombosis were reviewed to help to reduce missed diagnosis or misdiagnosis.Methods and Results A 18-year-old male patient had suffered from progressive headache for 4 years and weakness of left limbsfor 2 d. Head MRI showed circular space- occupying lesion in right fronto- parietal lobe. Magneticresonance venography(MRV) examination showed the front two-thirds of the superior sagittal sinus was notclear. The lesions were removed and decompressive craniectomy was conducted, showing the brain tissuewas pale, partly yellow or dark red, and superficial venous engorgement. Histological observation showedpial superficial vein thrombosis and subpial encephalomalacia, and multifocal hemorrhage of cerebral cortexand local parenchymal hemorrhage. A large number of "grid cells" and vascular "cuff" phenomenan werevisible in surrounding tissue, and the parenchymal blood vessel proliferation was obvious. Left handactivity of the patient was obviously limited after the operation.ConclusionsClinical diagnosis ofsuperficial vein thrombosis with hemorrhagic infarction is difficult, and brain imaging and serologicalexamination can provide certain help. Much attention should be paid to the multidisciplinary diagnosis andtreatment to reduce misdiagnosis or missed diagnosis, and gather clinical experience.
引文
[1]Ferro JM,Canhao P,Stam J,Bousser MG,Barinagarrementeria F,Massaro A,Ducrocq X,Kasner SE;ISCVT Investigators.Delay in the diagnosis of cerebral vein and dural sinus thrombosis:influence on outcome.Stroke,2009,40:3133-3138.
[2]Coutinho JM.Cerebral venous thrombosis.J Thromb Haemost,2015,13 Suppl 1:238-244.
[3]Borhani Haghighi A,Edgell RC,Cruz-Flores S,Feen E,Piriyawat P,Vora N,Callison RC,Alshekhlee A.Mortality of cerebral venous-sinus thrombosis in a large national sample.Stroke,2012,43:262-264.
[4]Chen L,Li JY,Zhou KL,Guan YT.Clinical analysis of 40cases of intracranial venous sinus thrombosis.Zhong Feng Yu Shen Jing Ji Bing Za Zhi,2012,29:924-925.[陈蕾,李君妍,周开林,管阳太.颅内静脉窦血栓形成40例临床分析.中风与神经疾病杂志,2012,29:924-925.]
[5]Ji XM.Problems of diagnosis and treatment of intracranial venous sinus thrombosis.Zhongguo Nao Xue Guan Bing Za Zhi,2012,9:617-619.[吉训明.颅内静脉窦血栓形成诊治需要明确的问题.中国脑血管病杂志,2012,9:617-619.]
[6]Liu W,Zhang BS,Ren L.Clinical study of cerebral vein and sinus thrombosis.Zhong Feng Yu Shen Jing Ji Bing Za Zhi,2012,29:353-355.[刘葳,张本恕,任丽.脑静脉及静脉窦血栓形成的临床分析.中风与神经疾病杂志,2012,29:353-355.]
[7]Meng R,Dornbos D 3rd,Meng L,Wu Y,Liu Y,Li G,Li G,Li S,Sun F,Wang X,Ding Y,Ji X.Clinical differences between acute CVST and non-thrombotic CVSS.Clin Neurol Neurosurg,2012,114:1257-1262.
[8]Meng R,Konakondla S,Wang X,Lo EH,Ding Y,Ji X.Plasma biomarker may help to distinguish acute CVST from nonthrombotic CVSS in emergency.Int J Stroke,2012,7:183-184.
[9]Kitamura Y,Hara K,Tsunematsu K.Isolated superficial sylvian vein thrombosis with long cord sign:case report and review of the literature.Neurol Med Chir(Tokyo),2014,54:253-259.
[10]Multicenter Group of Diagnosis and Treatment of Veins and Venous Sinus Thrombosis.Chinese expert consensus of the diagnosis and treatment of intracranial veins and venous sinus thrombosis.Zhonghua Nei Ke Za Zhi,2013,52:1088-1090.[静脉和静脉窦血栓形成诊治的多中心专家共识组.颅内静脉和静脉窦血栓形成诊治的中国专家共识.中华内科杂志,2013,52:1088-1090.]
[11]Saposnik G,Barinagarrementeria F,Brown RD Jr,Bushnell CD,Cucchiara B,Cushman M,deVeber G,Ferro JM,Tsai FY;American Heart Association Stroke Council and the Council on Epidemiology and Prevention.Diagnosis and management of cerebral venous thrombosis:a statement for healthcare professionals from the American Heart Association/American Stroke Association.Stroke,2011,42:1158-1192.
[2]Coutinho JM.Cerebral venous thrombosis.J Thromb Haemost,2015,13 Suppl 1:238-244.
[3]Borhani Haghighi A,Edgell RC,Cruz-Flores S,Feen E,Piriyawat P,Vora N,Callison RC,Alshekhlee A.Mortality of cerebral venous-sinus thrombosis in a large national sample.Stroke,2012,43:262-264.
[4]Chen L,Li JY,Zhou KL,Guan YT.Clinical analysis of 40cases of intracranial venous sinus thrombosis.Zhong Feng Yu Shen Jing Ji Bing Za Zhi,2012,29:924-925.[陈蕾,李君妍,周开林,管阳太.颅内静脉窦血栓形成40例临床分析.中风与神经疾病杂志,2012,29:924-925.]
[5]Ji XM.Problems of diagnosis and treatment of intracranial venous sinus thrombosis.Zhongguo Nao Xue Guan Bing Za Zhi,2012,9:617-619.[吉训明.颅内静脉窦血栓形成诊治需要明确的问题.中国脑血管病杂志,2012,9:617-619.]
[6]Liu W,Zhang BS,Ren L.Clinical study of cerebral vein and sinus thrombosis.Zhong Feng Yu Shen Jing Ji Bing Za Zhi,2012,29:353-355.[刘葳,张本恕,任丽.脑静脉及静脉窦血栓形成的临床分析.中风与神经疾病杂志,2012,29:353-355.]
[7]Meng R,Dornbos D 3rd,Meng L,Wu Y,Liu Y,Li G,Li G,Li S,Sun F,Wang X,Ding Y,Ji X.Clinical differences between acute CVST and non-thrombotic CVSS.Clin Neurol Neurosurg,2012,114:1257-1262.
[8]Meng R,Konakondla S,Wang X,Lo EH,Ding Y,Ji X.Plasma biomarker may help to distinguish acute CVST from nonthrombotic CVSS in emergency.Int J Stroke,2012,7:183-184.
[9]Kitamura Y,Hara K,Tsunematsu K.Isolated superficial sylvian vein thrombosis with long cord sign:case report and review of the literature.Neurol Med Chir(Tokyo),2014,54:253-259.
[10]Multicenter Group of Diagnosis and Treatment of Veins and Venous Sinus Thrombosis.Chinese expert consensus of the diagnosis and treatment of intracranial veins and venous sinus thrombosis.Zhonghua Nei Ke Za Zhi,2013,52:1088-1090.[静脉和静脉窦血栓形成诊治的多中心专家共识组.颅内静脉和静脉窦血栓形成诊治的中国专家共识.中华内科杂志,2013,52:1088-1090.]
[11]Saposnik G,Barinagarrementeria F,Brown RD Jr,Bushnell CD,Cucchiara B,Cushman M,deVeber G,Ferro JM,Tsai FY;American Heart Association Stroke Council and the Council on Epidemiology and Prevention.Diagnosis and management of cerebral venous thrombosis:a statement for healthcare professionals from the American Heart Association/American Stroke Association.Stroke,2011,42:1158-1192.