颅内静脉窦血栓形成临床特征及抗凝治疗联合血管内溶栓治疗  

Clinical analysis of cerebral venous sinus thrombosis and its combined treatment of anticoagulation and endovascular thrombolysis

作　　者：蒋云[1,2] 褚新宇 陈鲲鹏 陈涓[5,2] 王大明[4,2] JIANG Yun;CHU Xin-yu;CHEN Kun-peng;CHEN Juan;WANG Da-ming(Department of Neurology, 3Department of Neurosurgery, 4Department of Radiology, Beijing Hospital;National Center of Gerontology, Beijing 100730, Chin;2Department of Neurology, Anqiu People＇s Hospital, Anqiu 262100, Shandong, Chin)

机构地区：[1]北京医院神经内科,100730 [2]北京医院国家老年医学中心,100730 [3]山东省安丘市人民医院神经内科,262100 [4]北京医院神经外科,100730 [5]北京医院放射科,100730

出　　处：《中国现代神经疾病杂志》2017年第12期891-897,共7页Chinese Journal of Contemporary Neurology and Neurosurgery

摘　　要：目的总结颅内静脉窦血栓形成的临床和影像学表现以及抗凝治疗联合溶栓治疗的临床效果。方法与结果22例颅内静脉窦血栓形成患者,临床表现多样,主要表现为头痛(90.91%,20/22),亦可见意识障碍、癫发作和中枢神经系统局灶性体征。12例(54.55%)血浆D-二聚体水平升高。14例行腰椎穿刺脑脊液检查,9例(9/14)颅内压升高,常规和生化无特征性变化。头部CT和(或)MRI、CTV和(或)MRV显示,22例均有静脉窦血栓直接征象(上矢状窦、横窦、乙状窦、直窦、皮质静脉扩张),13例(59.09%)存在脑实质损害(脑出血、脑梗死、脑白质异常),2例(9.10%)发生蛛网膜下隙出血,1例(4.55%)发生硬膜下血肿。DSA显示颅内静脉窦血栓形成部位为上矢状窦13例(59.09%)、横窦17例(77.27%)、乙状窦14例(63.64%)、下矢状窦2例(9.10%)、直窦4例(18.18%)、大脑大静脉1例(4.55%)、颈内静脉1例(4.55%),其中9例(40.91%)存在2个静脉窦血栓、8例(36.36%)存在3个或以上静脉窦血栓。予肝素钠静脉滴注或低分子量肝素皮下注射以及华法林口服抗凝治疗数天,症状未见缓解或进行性加重,21例(95.45%)再予尿激酶静脉窦内或动脉溶栓治疗。共住院13~59 d,平均(25.70±12.18)d,改良Rankin量表评分0~1分13例(59.09%)、2分4例(18.18%)、3~4分5例(22.73%),治疗总有效率为77.27%(17/22)。结论颅内静脉窦血栓形成患者常存在多个静脉窦血栓或深静脉血栓及脑实质损害,对于抗凝治疗效果不明显的患者,联合溶栓治疗有助于改善预后。Objective To investigate the clinical and imaging manifestations of cerebral venous sinus thrombosis （CVST）, and the clinical effect of combined treatment of anticoagnlation and endovasenlar thrombolysis. Methods and Results The clinical manifestations of 22 CVST patients were highly variable. Headache （90.91%, 20/22） was the most frequent symptom, and conscious disturbance, seizure and focal neurological deficits were commonly present. Plasma D-dimer level was elevated in 12 patients （54.55%）. Lumbar puncture was performed in 14 patients, in whom intracranial hypertension was present in 9 patients （9/14） with no characteristic changes in routine and biochemical examination of eerebrospinal fluid （CSF）. Brain CT/MRI and CTV/MRV showed direct signs of CVST in all 22 patients, involving superior sagittal sinus, transverse sinus, sigmoid sinus, straight sinus and cortex veins, parenchymal lesions （infarction, hemorrhage and white matter abnormalities） in 13 patients （59.09%）, subaraehnoid hemorrhage （SAH） in 2 patients （9.10%） and subdural hematoma in one patient （4.55%）. The involved cerebral sinuses revealed by DSA were superior sagittal sinus in 13 patients （59.09%）, transverse sinus in 17 patients （77.27%）, sigmoid sinus in 14 patients （63.64%）, inferior sagittal sinus in 2 patients （9.10%）, straight sinus in 4 patients （18.18%）, vein of Galen in one patient （4.55%） and jugular vein in one patient （4.55%）. Two thrombosed sinuses were found in 9 patients （40.91%） and 3 or more thrombosed sinuses in 8 patients （36.36%）. As no clinical improvements and progressive exacerbation were observed several days after heparin sodium intravenous drip or lower molecular weight heparin （LMWH） hypodermic injection with oral warfarin anticoagulant therapy, urokinase thrombolysis in venous sinus or artery was applied in 21 patients （95.45%）. After （25.70 ＋ 12.18） d treatment with antieoagulation, the modified Rankin Seale （mRS） score of

关 键 词：窦血栓形成 颅内 抗凝药 血栓溶解疗法 

分 类 号：R743[医药卫生—神经病学与精神病学]