双侧延髓内侧梗死的临床分析(1例报道并文献复习)

Analyze the Clinical Characteristics of Bilateral Medullary Infarction(Literature Review and a Case Report)

目的探讨双侧延髓内侧梗死(Bilateral medullary infarction,BMI)的临床特点。方法通过计算机检索中国知网、万方数据库,收集1990年1月-2012年12月间在我国各种期刊上公开发表的关于双侧延髓内侧梗死的病例报道文献,并回顾分析本文作者诊治的1例双侧延髓内侧梗死患者的临床资料。结果从169例延髓内侧梗死的文献中筛选出符合双侧延髓内侧梗死的文献共12篇,累计病例14例。文献中14例患者病情呈阶梯样加重者7例(50%),加重持续数小时至数天(2h～7d)。首发症状以头晕起病者最常见9例(9/14,64.3%),其次为言语不清、四肢无力各为6例(42.9%)。临床表现以四肢瘫、延髓麻痹为主,部分病例伴有感觉障碍。14例患者均出现不同程度的四肢瘫痪,其后依次为构音障碍者11例(78.6%)、吞咽困难及眼震各8例(57.1%)、呼吸肌受累6例(42.9%)、舌肌瘫痪5例(35.7%,其中4例为伸舌不能)。感觉障碍分别为浅感觉异常者4例(28.6%)、深感觉减退者2例(14.3%)。意识障碍少见:嗜睡者2例(14.3%)、余12例患者意识清楚。本文报道的1例病例以发作性眩晕为首发症状,10余小时后相继出现言语不能、四肢瘫、球麻痹等,病情呈进行性加重持续数日。14例患者头部MRI均显示双侧延髓腹侧靠近中线部位有异常信号;8例行头部MRA检查:显示一侧椎动脉纤细或未显影者4例(44%)、单侧椎动脉局限性狭窄者2例(22%)、1例为基底动脉中下段及双椎动脉未显影、1例正常;1例DSA显示左椎动脉V4段严重狭窄,远端基底动脉显影不良,左侧脊前动脉未显影。本例患者MRI可见双侧延髓病变呈"Y"字型改变,以DWI为著,矢状位示病变位于桥延交界处;MRA右侧椎动脉较左侧细。结论 BMI临床表现复杂、多样,发病后早期诊断有一定困难。结合头部MRI检查,尤其是早期DWI联合T2WI、Flair成像可提高正确诊断率。

Objective To investigate the clinical characteristics of Bilateral Medullary Infarction（BMI）.Methods Searched the published Chinese case report about BMI in the database of WANFANG and CNKI by computer,during January 1991 to December 2012.In addition,the author retrospectively analyzed the clinical data of another cases of BMI.Results There were 169 articles about Medial medullary infarction（MMI）,12 cases reported accord as BMI,11 articles of them was in Chinese and 1 was in English,a total of 14 BMI cases were reported in 12 articles.All the symptoms of the 14 cases had a ladder-like exacerbations,which lasting from a few hours to several days（2h-7d）.The most common onset symptoms of all the reported was dizziness（9/14,64.3%）,the descending was alalia or myasthenia of limbs（respectively 6 cases,42.9%）.The main clinical manifestation of BMI was quadriplegia and bulbar paralysis,some patients had sensory disturbance.All patients had quadriplegia,descending was dysarthrosis（11/14,78.6%）,dysphagia（8/14,57.1%）,nystagmus（8/14,57.1%）,decompensation（6/14,42.9%） and 5 cases had lingual paralysis（35.7%,four of them were bilateral lingual paralysis）.4 cases had superficial sensory disturbance（28.6%）,2 cases had deep sensory disturbance（14.3%）.Consciousness was very rare：two of them were drowsiness（14.3%） and other 12 cases were alert.The case which the author reported had vertigo then appeared unable to speak,quadriplegia,bulbar palsy in10 hours.All the cases had taken magnetic resonance imaging（MRI） scanning,which demonstrated the midline sites of bilateral rostral ventral had abnormal signals;there were 8 patients had taken magnetic resonance angiography（MRA） scanning,which demonstrated the unilateral Vertebral artery was slender or had not been shown（4/8,44%）,the unilateral Vertebral artery was stenosis（2/8,22%）,the lower section of the Basilar artery and bilateral Vertebral artery had not been shown（1/8,11%）;there were only one patient had taken the digital subtraction angiography（DSA）,which showed the V4 section of left Vertebral artery were severe stenosis,the distal Basilar artery was poor visualized,left anterior spinal artery had not been shown.The MRI,especially the diffusion-weighted imaging（DWI）,in this cases,demonstrated ＂Y＂ type lesions in the medial medulla oblongata,sagittal imaging demonstrated the lesions were located in the pontomedullary junction,and the MRA demonstrated the right vertebral artery was more slender than left.Conclusion The clinical characteristics of BMI is very complex and diverse,it is difficult to diagnose with the early symptom.The T2-weighted MRI,especially combine with DWI,can improve the rate of diagnosis.