多发性急性脑梗塞病例讨论

单击此殊痛辑母醐标题鮮式-会泽县人親蟹健膨像梱题样式*氺1临床资料-陈正开，男，42岁，新街老村，农民。-突然出现头昏、口舌麻木、言语不灵活、左侧上、下肢乏力2天；在当地卫生所疑“感冒”治疗未见好转，病情加重。饮酒（每天5公两）20余年，近1年来已戒酒。门诊以“慢性酒精中毒”收入住院。-查体：T、B、Bp、R在正常范围，口唇轻度发紺，右侧颜面皮肤痛觉较弱，额纹及鼻唇沟变浅，口角下斜，伸舌试验：舌尖向右偏斜，神志清楚，定向力稍差。•i化验：血常规、肝、肾功能各项指标在正常范围，血糖：7.3mmol/Lo2013-6-19ct平扫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报告影像所见：右额颞叶多发小片状密度减低影，周围未见确切占位效应，脑室系统未见异常。中线结构无偏移。诊断意见：右额颞叶多发小片状密度减低影，脑炎?建议MRI检查。□□□20Im::16R:2DTE:98.00rype:2D)00.001.00■'aIlAcq.Type:2DTR:5000.00TE:98.00MRI报告影像所见：大脑右侧额、颞、顶叶区灰、白质界面欠清晰，见多个片状长T1、长T2信号病灶灶，部分病灶边缘模糊；附近脑沟、裂、池变窄。中线结构无明显移位。诊断意见：大脑右侧额、颞、顶叶区多发大片状病灶灶，脑梗塞与炎症性疾病待鉴别。建议提供详细临床病史、相关体征、血液化验资料作脑功能成像、脑血管成像及颅脑增强扫描检查。::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*营B1I.WET增强扫描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脑功能成像、增强扫描及脑动脉成像诊断报告多像所见:大脑右侧额、颞、顶叶区多发大片状病灶灶，在DWI呈高信号，ADC上呈低信号，静脉注射对比剂后扫描未见强化，相应供血的右侧大脑中动脉主干及部分分支狭窄，其余分支闭塞。右侧大脑前动脉及后动脉代偿性扩张增粗。其余脑组织形态、信号正常。诊断意见：大脑右侧额、颞、顶叶区多发新S鲜梗塞病灶。临床追踪-入院后经上述检查明确为“脑多发新鲜梗塞”，以1.开通静脉、持续吸氧积极预防和减轻脑水肿；2.给以营养脑细胞、活血活血化瘀、维持水电解质平衡；3.积极对症、支持治疗。2天后病人病情好转，头昏、口舌麻木症状减轻，口唇发紺、口角偏斜异常体征程度减轻。5天后病情进一步好转。讨论•本病例在门诊就医时因对心脑血管病医学知识缺乏，提供病史表现混乱，致门诊以“慢性酒精中毒”为主要诊断有欠准确。但以“突然出现头昏、口舌麻木、言语不灵活、左侧上、下肢乏力2天”病史资料及相关化验资料，再仔细临床检查发现“口唇轻度发紺，右侧颜面皮肤痛觉较弱，额纹及鼻唇沟变浅，口角下斜，伸舌试验：舌尖向右偏斜，神志清楚，定向力稍差”的临床体征并不难。故临床初步诊断应首先考虑脑血管疾病较为妥帖。必要时影像科医生应亲自仔细询问病人或其家属，并进行临床体格检查以发现有鉴别诊断价值的病史和体征资料。讨论2.-CT检查影像中低密度病变虽为散在病变，侵及脑灰白质，但病变区域限于右侧大脑中动脉分支供血区域，病变边缘稍模糊，病变周围组织水肿不多，与典型的“脑炎”病变边缘模糊度较大、周围脑组织水肿范围较广有一定区别，应首先考虑该动脉某些