妊娠期及产褥期并发脑卒中11例临床病例分析

Clinical analysis of 11 cases of stroke in pregnancy and the puerperium

目的:探讨妊娠期及产褥期并发脑卒中的病因、临床表现与诊断治疗。方法:回顾分析1993年1月至2010年6月本院收治的妊娠期及产褥期并发脑卒中11例患者的临床资料。结果:18 873例分娩孕产妇中,11例妊娠期及产褥期并发脑卒中,7例出血性脑卒中(3例颅内出血,3例蛛网膜下腔出血,1例脑室出血),4例缺血性脑卒中(1例动脉瘤血栓形成伴脑梗死,3例多发性脑梗死)。最常见的症状为头痛、恶心、呕吐、视物模糊、意识障碍,肢体活动障碍等,体格检查阳性结果多为血压增高,瞳孔改变,肌张力异常,病理征阳性等。11例孕产妇中6例重度子痫前期/子痫患者(其中1例合并血小板减少,3例合并胎盘早剥),3例动脉瘤,1例动静脉血管畸形,1例妊娠期血小板减少合并巨幼红细胞贫血。2例行血肿清除术,2例行脑室引流术,1例行DSA下介入栓塞治疗,6例行内科保守治疗。11患者中7例行剖宫产,1例经阴道分娩,1例晚期流产、1例治疗性引产,1例患者未终止妊娠死亡。2例孕产妇死亡,9例孕产妇治疗好转出院。围产儿5例足月儿,4例早产儿(均为低出生体重儿,其中1例轻度窒息,1例重度窒息,1例引产后死亡)。结论:重度子痫前期/子痫和脑血管畸形是妊娠期及产褥期并发脑卒中的最主要原因。卒中发病症状不特异,对于缺血性脑卒中,病理征多延迟出现,及时的CT、MR、血管造影有助于确诊。积极的神经外科治疗对于出血性脑卒中的孕产妇可能是有益的。对于脑卒中的孕妇终止妊娠的方式和时机需个体化、人文化对待。

Objective：To describe the causes,clinical presentations,diagnosis,treatments and outcomes of stroke in pregnancy and the puerperium,and try to find out the relationship between these factors.Method：A retrospective analysis was carried out in 11 patients with stroke in pregnancy and puerperium in our hospital from Jan.1993 to Jun.2010.Results：11 patients from a total 18873 deliveries with a diagnosis of stroke were identified,including 7 with hemorrhagic stroke（3/7 intracranial hemorrhage,3/7 subarachnoid hemorrhage,1/7 cerebroventricular hemorrhage）,4 with ischemic stroke（1/4 cerebral aneurysm thrombosis with cerebral infarction,3/4 multiple cerebral infarctions）.The common symptoms were headache,nausea,vomiting,conscious disturbance and motor disturbance.The positive findings of physical examination include increasing of blood pressure,changing of pupilla,muscular tension abnormality and neurological signs.There were 6 preeclampsia or eclampsia cases,among which 1 with thrombocytopenia,1 thrombocytopenia,3 cerebral aneurysm cases and 1 cerebral arteriovenous malformation.Out of 11 patients,2 patients underwent the surgery of hematoma cleaning,1 patient treated with surgical drainage,1 patient undertook an endovascular treatment to embolize the aneurysm.6 patients discharged with conservative management.Cesarean deliveries were performed in 7/11 women,1/11 patient underwent therapeutic induced labor,1/11 patient abortion.There were two maternal deaths,both in women who had hemorrhagic strokes.Of 10 perinatal infants,there were 5 term infants,4 premature infants,and 1 fetal death.All of 4 premature infants were low birth weight infants,among which 2 newborns had asphyxial injuries.Conclusion：Preeclampsia/eclampsia and cerebrovasular malformation are important causes of pregnancy-related stroke.The clinical presentation of pregnancy-related stroke is unspecific.The presentation of neurological sign is often delayed in ischemic stroke.CT,MR and DSA performed promptly can help to make a definite diagnosis.In hemorrhagic stroke positive surgery may be benefit to mother.The way and the time of termination of pregnancy should be individual.