合并肺水平右向左分流的隐源性缺血性脑卒中患者的临床分析  

Clinical analysis of cryptogenic ischemic stroke patients with pulmonary right-to-left shunt

作　　者：彭静华[1] 张鸿日[2] 段利科[3] 沈瑞乐[1] 张栋栋 PENG Jinghua;ZHANG Hongri;DUAN like(Department of Neurology,First Affiliated Hospital of Henan University of Science and Technology,Luoyang 471003,China)

机构地区：[1]河南科技大学第一附属医院神经内科,洛阳471003 [2]河南科技大学第一附属医院神经外科,洛阳471003 [3]河南科技大学第一附属医院超声科,洛阳471003

出　　处：《临床神经病学杂志》2023年第5期347-350,共4页Journal of Clinical Neurology

基　　金：洛阳市青年医学科技创新联合基金(1503008A-15)。

摘　　要：目的 分析合并肺水平右向左分流的隐源性缺血性脑卒中患者的临床特征。方法 对2019年5月至2022年6月就诊于河南科技大学第一附属医院神经内科的经增强经食道超声心动图证实合并肺水平右向左分流的24例隐源性缺血性卒中患者的临床表现、反常性栓塞风险评分(RoPE)、头颅MRI、增强TCD、增强经胸超声心动图、增强经食道超声心动图、肺血管成像特点、治疗经过、预后进行分析。结果 入组的24例患者中男∶女为11∶13,年龄(46.04±11.52)岁,RoPE评分(6.42±1.32)分。头颅MRI提示急性梗死单累及前循环10例(41.67%)、单累及后循环10例(41.67%)、前后循环均受累1例(4.17%);单发病灶7例(29.17%)、多发病灶14例(58.33%);小病灶16例(66.67%)、中等病灶4例(16.67%),大病灶1例(4.17%)。增强经食道超声心动图1级9例(37.50%)、2级5例(20.83%)、3级10例(41.67%);在经食道彩超下可见微泡来自右下肺静脉2例(8.33%)、左上肺经脉19例(79.17%)、左上下静脉2例(8.33%)、双侧肺静脉1例(4.17%)。24例患者中经胸部CT肺血管成像证实有3例患者存在肺动静脉瘘右向左分流。其中3例就诊时间在时间窗内的患者均给予了静脉溶栓治疗,预后良好。3例确诊肺动静脉瘘患者中1例行介入栓塞治疗,另外两例行抗凝治疗,随访6~15个月均无复发。结论 合并肺水平右向左分流的隐源性缺血性脑卒中临床表现及头颅影像无特异性;肺动静脉瘘所致的脑梗死增强TCD特点为快速出现的大量、持续分流,Valsalva动作后分流特点无明显变化,其在时间窗内可行静脉溶栓治疗。Objective To investigate the clinical characteristics of cryptogenic ischemic stroke patients with pulmonary right-to-left shunt(P-RLS). Methods The clinical data of 24 cryptogenic ischemic stroke patients with P-RLS diagnosed by contrast transesophageal echocardiography(cTEE)in the first affiliated hospital of Henan university of Science and Technology from May 2019 to June 2022,including manifestations,risk of paradoxical embolism score(RoPE),brain MRI,contrast-enhanced TCD(cTCD),contrast transthoracic echocardiography(cTTE),cTEE,CT pulmonary angiography,treatment and prognosis were analyzed. Results Among the 24patients,the ratio of male ∶ female was 11∶ 13,age was(46. 04 ± 11. 52)years,RoPE score ranged(6. 42 ± 1. 32).Brain MRI showed that 10 cases(41. 67%)of acute infarction involved anterior cerebral circulation alone,10 cases(41. 67%)involved posterior cerebral circulation alone,and 1 case(4. 17%)involved anterior and posterior cerebral circulation;7 cases(29. 17%)had single focus,14 cases(58. 33%)had multiple focus;16 cases were small lesions(66. 67%),4 cases were medium lesions(16. 67%),and 1 case was large lesions(4. 17%). In all the 24 cases,a grade Ⅰ P-RLS were observed on cTEE in 9 cases(37. 50%),a grade Ⅱ and Ⅲ P-RLS were observed on cTEE in 5 cases(20. 83%)and 10 cases(41. 67%). Microbubbles were seen from the right lower pulmonary vein in 2 cases(8. 33%)on cTEE,the left upper pulmonary vein in 19 cases(79. 17%),the left upper and lower veins in 2 cases(8. 33%),and bilateral pulmonary veins in 1 case(4. 17%). Among 24 patients,3patients were diagnosed with pulmonary arteriovenous fistula(PAVF)confirmed by chest CT pulmonary angiography.Three patients combined with P-RLS who were within the time window were given intravenous thrombolytic therapy,and the prognosis were good. Transcatheter embolization was performed in one patient combined with PAVF,and the other two chose anticoagulant therapy. 3 patients had no recurrence of ischemic stroke during 6-15 months followup. Conclusions The cl

关 键 词：隐源性卒中 右向左分流 肺动静脉瘘 TCD 经胸超声心动图 经食道超声心动图 

分 类 号：R743.3[医药卫生—神经病学与精神病学]