急性脑梗死动脉溶栓术后脑出血与“脑染色”的鉴别诊断

Comparative of cerebral hemorrhage with cerebral potentialization after intraarterial thrombolysis in acute ischemic stroke

目的研究急性脑梗死早期(6 h之内)动脉溶栓治疗后即刻脑CT征象及脑出血危险因素.方法对82例急性脑梗死早期溶栓治疗后的患者进行头颅CT检查,观察即刻、4～6 h、24 h脑CT表现.结果即刻CT扫描出现27例高密度区,包括脑组织染色8例,其中神经核团染色5例,脑灰质染色3例;溶栓后脑出血15例;亚急性脑梗死区脑组织染色4例.CT早期缺血改变及较低的ESS评分是脑动脉溶栓术后脑出血的主要危险因素,它们的相对危险度分别为8.33和11.35.结论急性脑梗死动脉溶栓后即刻脑CT显示的脑组织染色是由于闭塞的脑血管部分或全部再通,引起缺血-再灌流损伤,进一步损伤血管内皮,使血管通透性增加,局部血脑屏障受损,含对比剂的血液内液体成分渗到脑组织间隙所致,使血管再通区受损伤的灰质或神经核团的脑组织染色,白质不染色.随着对比剂在体内的减少,染色在几小时后逐渐变淡,此种表现是闭塞的脑血管再通前局部脑组织已出现缺血性脑梗死的征象,勿误认为脑出血征象.

Objective To study the immediate CT findings of brain and the risk factor of hemorrhage after intraarterial thrombolysis in acute ischemic stroke. Methods Eighty-two patients of acute cerebral infarction were examined with CT after intra-arterial thrombolysis. The CT signs immediately after treatment, 4- 6 hours and 24 hours later were analyzed respectively. Results Twenty-seven patients were found to have high density in CT immediatey after intra-arterial thrombolysis with 8 patients with cerebral potentialization. In these 8 cases, 5 were potentialization of nuclei of cranial nerves, 3 cases were grey matter potentialization. CT diagnosed 15 patients with cerebral hemorrhage and 4 with cerebral potentialization of subacute cerebral infarct. CT early ischemic changes （EIC） and low ESS scale were the main risk factors of cerebral hemorrhage after intraarterial thrombolysis, representing a risk of 8.33 and 11.35, respectively. Conclusion The immediate CT sign of cerebral potentialization after intraarterial thrombolysis was because of the high vascular permeability and the injury of blood-brain barrier after ischemic stroke and Ischemic reperfusion injury. The contrast medium could infiltrate into the cerebral tissue space. The injuried grey matter and nuclei of cranial nerves had intensified response, but the white matter showed not enhancement. We should not interpree the CT sign cerebral potentialization incorrectly as cerebral hemorrhage improperly.