妊娠期及产褥期合并颅内静脉窦血栓患者的临床特点及结局

Clinical characteristics and outcomes of cerebral venous sinus thrombosis during pregnancy and puerperium

目的 探讨妊娠期及产褥期合并颅内静脉窦血栓的临床特点及结局.方法 选择2002年1月-2009年10月首都医科大学宣武医院住院并分娩的孕产妇共15 652 例,发生颅内静脉窦血栓24例,其中发生于妊娠期7例,产褥期17例.对24例妊娠期及产褥期合并颅内静脉窦血栓患者的临床资料进行回顾性分析,分析患者的发病原因、临床表现、影像学检查及其他辅助检查、治疗及结局等.结果 （1）发生率及发病原因：妊娠期及产褥期合并颅内静脉窦血栓发生率为0.15%（24/15 652）,其中,发生于产褥期17例（71%,17/24）,妊娠期7例（29%,7/24）.24例患者中,合并重度子痫前期5例,妊娠剧吐5例,贫血1例;自然分娩后发生9例,剖宫产术分娩后发生8例.（2）临床表现：24例患者中,22例（92%,22/24）出现头痛,16例（67%,16/24）出现恶心呕吐,15例（63%,15/24）出现抽搐,6例（25%,6/24）出现视物不清.入院时意识不清8例（33%,8/24）,一侧肢体活动障碍3例（13%,3/24）,合并发热8例（33%,8/24）.（3）影像学检查及其他辅助检查：行数字减影血管造影（DSA）检查12例,磁共振成像（MRI）及磁共振静脉血管造影（MRV）检查23例;显示上矢状窦血栓形成15例;眼底检查示视神经乳头水肿4例,13例患者的脑脊液常规及生化检测结果基本正常;高脂血症6例,部分活化凝血活酶时间（AFTT）异常7例,国际标准化比值（INR）异常5例,血小板计数异常升高3例,D二聚体阳性4例,血红蛋白〈10 g/L 1例,红细胞压积（HCT）异常4例,10例血纤维蛋白原（Fib）结果〉4 g/L,,（4）治疗经过及妊娠结局：7例妊娠期颅内静脉窦血栓患者中,2例孕晚期合并重度子痫前期患者立即行剖宫产术结束妊娠,术后积极降压、解痉、脱水、抗凝治疗后,母子痊愈出院.5例妊娠早期合并颅内静脉窦血栓患者中,1例行钳刮术后抗凝治疗,痊愈出院;2例行血管内溶栓治疗后病情好转,痊愈出院1例,存留功能障碍1例（右侧肢体偏瘫）;2例死亡.17例产褥期发生颅内静脉窦血栓患者,予以抗凝等综合治疗10例,其中痊愈4例.存留功能障碍5例（肢体偏瘫3例,肢体偏瘫＋不完全运动性失语1例,视物模糊1例）,死亡1例;予以血管内溶栓治疗7例,痊愈3例,存留功能障碍3例（失明＋头痛1例,偏瘫2例）,死亡1例.24例患者中,采用全身抗凝治疗14例,其中痊愈7例,存留功能障碍5例,死亡2例;血管内溶栓治疗10例,其中痊愈4例,存留功能障碍4例,死亡2例.结论 孕产妇合并颅内静脉窦血栓多发生于产褥期,以上矢状窦血栓多见,DSA诊断本病准确率高.全身抗凝治疗及血管内溶栓治疗均有较好的疗效,但容易存留不同程度的功能障碍及高病死率.及时诊断治疗妊娠期及产褥期合并颅内静脉窦血栓可改善其结局.

Objective To explore the clinical features and outcomes of patients with cerebral venous sinus thrombosis （CVT） during pregnancy and puerperium. Methods A retrospective study was performed in 24 cases of pregnant women with CVT among 15 625 deliveries in Xuanwu Hospital from January 2002 to October 2009, including 7 cases happened during pregnancy and 17 during puerperium. The etiology, clinical presentations, imaging examination results, other relevant examinations, and pregnant outcomes of these patients were analyzed. Results （ 1 ） Incidence and etiology： the incidence of CVT during pregnancy and puerperium was 0. 15% （24/15 652 ） and 29% （7/24） of the patients fell ill during pregnancy and 71% （17/24） during puerperium. Five were complicated with severe preeclampsia, while another 5 complicated with hyperemesis. One woman was complicated with anemia. CVT was identified after spontaneous delivery in 9 cases and 8 after cesarean section. （2）Clinical presentations： Among the 24 CVT cases, 22 （92%） suffered from headache, 16 （67%） reported nausea and vomiting, 15 （63%） experienced hyperspasmia and 6 （25%） complained of blurred vision. On admission, 8 （33%） patients were unconscious, 5 （ 13% ） with hemiplegia, and 8 （ 33% ） were febrile. （ 3 ） Imaging and laboratory examinations： twelve patients underwent digital subtraction arteriography （DSA） and were diagnosed. Fifteen women showed superior sagittal sinus thrombosis in MRI and magnetic resonance intravenous angiograph（MRV）. Examination of the fundus found papilledema in 4 cases. Normal cerebral sinus fluid and laboratory routine tests were reported in 13 cases, but 6 cases of hyperlipidemia, 7 cases of abnormal activated partial thromboplastin time （ APTT）, 5 cases of abnormal international normalized ratio （ INR ）, 3 cases elevated platelet count, 4 cases of positive D-dipolymer, 1 cases of low hemoglobulin level （ 〈 10 g/L）, 4 cases with abnormal hematocrit, and 10 cases of elevated fibrinogen （ 〉 4 g/L） were identified. （4） Management and pregnancy outcomes： among the 7 cases happened during pregnancy, 2 were complicated with severe preeclampsia and delivered through cesarean section immediately and discharged after proper management including depressurization, spasmolysis, dehydration and anticoagulant therapy. Five of the 7 cases presented with CVT during early pregnancy, among which 1 was discharged after dilation and curettage followed by anticoagulant therapy, 2 received endovascular thrombolysis after which one was discharged and the other one left with right hemiparesis and 2 patients died. Among the 17 patients presented with CVT during puerperium, 10 received anticoagulant therapy after which 4 were fully recovered, 5 left with functional disturbance （3 with hemiplegia, 1 with incomplete motor aphasia and hemiparesis and 1 with blurred vision） and one died. Among the rest 7 cases who underwent endovascular thrombolysis, 3 were fully recovered, 3 left with functional impairment （1 with blind and headache and 2 with hemiplegia）, and one died. Altogether, there were 14 patients underwent systemic anticoagulant therapy after which 7 were fully recovered, 5 left with dysfunction and 2 died. Among the 10 cases received endovascular thrombolysis, 4 were fully recovered, 4 remained some dysfunction and 2 died. Conclusions CVT, mostly presented as superior sagittal sinus thrombosis, are more common in puerperium than during pregnancy and DSA is the golden standard for the diagnosis of CVT. Anticoagulant therapy and endovascular thrombolysis are effective in the treatment of CVT, but may left the patients with functional disturbance or even death. Prompt diagnosis and treatment ensure a better outcome for pregnant women complicated with CVT.