多發(fā)性急性腦梗塞病例討論

單擊此殊痛輯母醐標題鮮式-會澤縣人親蟹健膨像梱題樣式*氺1臨床資料-陳正開，男，42歲，新街老村，農(nóng)民。-突然出現(xiàn)頭昏、口舌麻木、言語不靈活、左側(cè)上、下肢乏力2天；在當?shù)匦l(wèi)生所疑“感冒”治療未見好轉(zhuǎn)，病情加重。飲酒（每天5公兩）20余年，近1年來已戒酒。門診以“慢性酒精中毒”收入住院。-查體：T、B、Bp、R在正常范圍，口唇輕度發(fā)紺，右側(cè)顏面皮膚痛覺較弱，額紋及鼻唇溝變淺，口角下斜，伸舌試驗：舌尖向右偏斜，神志清楚，定向力稍差。?i化驗：血常規(guī)、肝、腎功能各項指標在正常范圍，血糖：7.3mmol/Lo2013-6-19ct平掃yjImqNo.AAAAStudy:Thick:10加Studv^TickJ^O*IWC:33\|ww:昍Col:512Row:512IThick:W.OCICHENZHENGKAIM42YID:68919Sex:MOD:CT1CHENZHFNRKAIM47YD:68919Sex:VIOD'CTE?Et-EAccessNo.:CHENZHENGKAIM42YPosition:HFSID:68919SeriesNo.:4600Sex:AccessNo.:CHENZHENGKAIM42YPosition:HFS10:68019SeriesNo.:4600Sex:AccessNo.:Position:HFSSeriesNo.:4600AcquisNo.:4600mqNo.:4AccessNo.:Position:HFSSeriesNo.:4600AcquisNo.:4600ImgNo.:12Jate:2U13/0B/19Time:11:44:34Date:2013/06/19Time:11:45:01fWC:33>ww:昍Date:2013/06/19Col:512Time:11:44:58Row:512^^^^Studv^BjicklLOOAccessNo.:CHENZHENGKAIM42YPosition:HFSID:68919SeriesNo.:4600Sex:AcquisNo.:4B00MOD:CTImgNo.:11AccessNo.：CHENZHFNAKAIM47YPosition:HFSID:B8919SeriesNo.:4600Sex:AcquisNo.:4600MOD:CTWC:33WW:8E)3tR：2013/06/19Col:512:11:44:31Row:512StudvJJiicM^JUWC:33WW:86□ate:2013/0B/19Col:512Time:11:44:27Row:512^^^^StudvJTiickJ^JLAccessNo.：CHENZHENRKAIM47\Position:HFSID:68919SeriesNo.:4600Sex:AcquisNo.:4600MOD:CTCT報告影像所見：右額顳葉多發(fā)小片狀密度減低影，周圍未見確切占位效應(yīng)，腦室系統(tǒng)未見異常。中線結(jié)構(gòu)無偏移。診斷意見：右額顳葉多發(fā)小片狀密度減低影，腦炎?建議MRI檢查?！酢酢?0Im::16R:2DTE:98.00rype:2D)00.001.00■'aIlAcq.Type:2DTR:5000.00TE:98.00MRI報告影像所見：大腦右側(cè)額、顳、頂葉區(qū)灰、白質(zhì)界面欠清晰，見多個片狀長T1、長T2信號病灶灶，部分病灶邊緣模糊；附近腦溝、裂、池變窄。中線結(jié)構(gòu)無明顯移位。診斷意見：大腦右側(cè)額、顳、頂葉區(qū)多發(fā)大片狀病灶灶，腦梗塞與炎癥性疾病待鑒別。建議提供詳細臨床病史、相關(guān)體征、血液化驗資料作腦功能成像、腦血管成像及顱腦增強掃描檢查。::刺*S”MAoe0i2*XifS1K?2lMureM*6?ETOMESseUZASrimBMoTym20r^swoo「Ee?(?aibr>j&?t*efnSlew?JOStceThckne^603CdSI2flo*432*VC3992V**^■■■rf*■nZh?&it**yrnSim<3JSfctThtknwM603T2脂水抑制像&rh*?enSew?30SicfTbdfnewCOJCoi?12Rwr432MngkjiI^MP?W$e<M勺e042YK.?—SeeingBTt?mStKm73)SeeThdfwta600r-Spsnhgwtwwi9knSiceThrfcfW!-,1M*^4ETQMESSENI*Sr<Im158]Befwwi9cw?X&rpThckWMMr*AjMET0M_ESSEKZ*Sr4二00M*3?ETCiM_ES$EML*營B1I.WET增強掃描AAAE.EE.EE.EMAGNETOM_ESSENZASr:12Im:8MAGNETOM_ESSENZASr:12Im:10Acq.Type:2DTR:550.00TE:9.00|ETL:1SpacingBehreenSlices.:7.20355lj^Thickness.:6.00Col.:432Row:512WC:798WW1649SpacingBej4reenSlices.:7.20rKSjjlfeThickness.:6.00Col.:432Row:512WC:798WW1649AAE'J；MAGNETOM_ESSENZASr:12Im:13Acq.Type:2DTR:550.00TE:9.00|ETL:1HuizePeople'sHosptalChenZhengKaiID:MR795539494Sex:MAge:042Y2013/06/21MAGNETOM_ESSENZASr:12Im:16Acq.Type:2DTR:550.00TE:9.00IetliHuizePeople'sHosptalChenZhengKaiID:MR795539494Sex:MAge:042Y2013/06/21SpacingB^/eenSlices.:7.20^JSliceThickness.:B.OOCol.:432Row:512WC:798WW1649:ingBelweenSlices.:7.20SliceThickness.:6.00Col.:432Row:512WC:798'AAA,'1649AAAAE'E'J；J；MAGNETOM_ESSENZASr:12Im:11MAGNETOM_ESSENZASr:12Im:14Acq.Type:2DTR:550.00TE:9.00|ETL:1HuizePeople'sHosptalChenZhengKaiID:MR795539494Sex:MXAge:042Y2013/06/21selweenSlices.:7.20；liceThickness.:6.00Col.:432Acq.Type:2DRow:512TR:550.00WC:798TE:9.00WW1649ETL:1Acq.Type:2DTR:550.00TE:9.00|ETL:1Spaeir^BelweenSlices.:7.20SliceThickness.:6.00Col.:432Row:512WC:798WW1649HuizePeople'sHosptalChenZhengKaiI□:MR795539494Sex:MAge:042Y2013/06/21HuizePeople'sHosptalMAGNETOM_ESSENZAChenZhengKaiSr:12ID:MR7955Im:1239494Sex:M■XAge:042YLV\2013/06/21SpacingBaleenSlices.:7.20'■Thickness.:B.OOCol.:432Acq.Type:2DRow:512TR:550.00WC:798TE:9.00WW1649ETL:1HuizePeople'sHosptalMAGNETOM_ESSENZAChenZhengKaiSr:12ID:MR7955Im:1539494Sex:MAge:042Y2013/0B/21Spacing^^eenSlices.:7.20j^iceThickness.:B.OOCol.:432Row:512WC:798WW1649Acq.Type:2DTR:550.00TE:9.00IetliHuizePeople'sHosptalChenZhengKaiID:MR795539494Sex:MAge:042YA2013/06/21HuizePeople'sHosptalMAGNETOM_ESSENZAChenZhengKaiSr:12<ID:MR7955Im:939494AgeS042Y//v2013/06/21if■PenSlices.:7.20Thickness.:6.00Col.:432Acq.Type:2DRow:512TR:550.00WC:798TE:9.00WW1649ETL:1HuizePeople'sHosptalChenZhengKaiID:MR795539494Sex:M|Age:042YkY\2013/06/21MRI腦功能成像、增強掃描及腦動脈成像診斷報告多像所見:大腦右側(cè)額、顳、頂葉區(qū)多發(fā)大片狀病灶灶，在DWI呈高信號，ADC上呈低信號，靜脈注射對比劑后掃描未見強化，相應(yīng)供血的右側(cè)大腦中動脈主干及部分分支狹窄，其余分支閉塞。右側(cè)大腦前動脈及后動脈代償性擴張增粗。其余腦組織形態(tài)、信號正常。診斷意見：大腦右側(cè)額、顳、頂葉區(qū)多發(fā)新S鮮梗塞病灶。臨床追蹤-入院后經(jīng)上述檢查明確為“腦多發(fā)新鮮梗塞”，以1.開通靜脈、持續(xù)吸氧積極預(yù)防和減輕腦水腫；2.給以營養(yǎng)腦細胞、活血活血化瘀、維持水電解質(zhì)平衡；3.積極對癥、支持治療。2天后病人病情好轉(zhuǎn)，頭昏、口舌麻木癥狀減輕，口唇發(fā)紺、口角偏斜異常體征程度減輕。5天后病情進一步好轉(zhuǎn)。討論?本病例在門診就醫(yī)時因?qū)π哪X血管病醫(yī)學知識缺乏，提供病史表現(xiàn)混亂，致門診以“慢性酒精中毒”為主要診斷有欠準確。但以“突然出現(xiàn)頭昏、口舌麻木、言語不靈活、左側(cè)上、下肢乏力2天”病史資料及相關(guān)化驗資料，再仔細臨床檢查發(fā)現(xiàn)“口唇輕度發(fā)紺，右側(cè)顏面皮膚痛覺較弱，額紋及鼻唇溝變淺，口角下斜，伸舌試驗：舌尖向右偏斜，神志清楚，定向力稍差”的臨床體征并不難。故臨床初步診斷應(yīng)首先考慮腦血管疾病較為妥帖。必要時影像科醫(yī)生應(yīng)親自仔細詢問病人或其家屬，并進行臨床體格檢查以發(fā)現(xiàn)有鑒別診斷價值的病史和體征資料。討論2.-CT檢查影像中低密度病變雖為散在病變，侵及腦灰白質(zhì)，但病變區(qū)域限于右側(cè)大腦中動脈分支供血區(qū)域，病變邊緣稍模糊，病變周圍組織水腫不多，與典型的“腦炎”病變邊緣模糊度較大、周圍腦組織水腫范圍較廣有一定區(qū)別，應(yīng)首先考慮該動脈某些