TIPSS术后肝性脊髓病(附5例报告)

Hepatic Myelopathy after Transjugular Intrahepatic Portosystemic Stent Shunt: Report of 5 Cases

目的:报告5例经颈静脉途径肝内分流术(TIPSS)后肝性脊髓病(HM)的临床表现。资料和方法:5例均有乙型肝炎和静脉曲张破裂出血病史。TIPSS术前影像学检查显示肝萎缩明显,术后分流道通畅。曾做脊髓MR14例,1例做脊柱CT和脊髓造影。5例均行腰椎穿刺。结果:5例于TIPSS后4周～4个月出现进行性下肢痉挛性瘫痪,1例伴上肢无力,1例伴有尿失禁。5例术后有1次以上(1～6次)HE发作史。体检发现患者腱反射亢进,踝阵挛阳性,浅感觉正常,1例深感觉减退,除1例外,其余无明显肌萎缩表现。受累节段椎管影像学检查及腰椎穿刺脑脊液检查均无异常。5例均有术后持续高血氨及低蛋白血症。结论:TIPSS术后出现进行性下肢痉挛性瘫痪、不伴有感觉障碍者应考虑HM。与TIPSS相关HM的高危因素有术前明显肝萎缩、术后持续高血氨及肝性脑病。

Purpose: To describe the clinical manifestations of hepatic myelopathy (HM) after transjugular intrahepatic portosystemic stent shunts (TIPSS)in five patients. Materials and Methods: Four men and one woman, age ranging from 41 to 54 years, had history of hepatitis B and recurrent bleeding from gastroesophageal varices. Obvious liver atrophy was found in the five patients before TIPSS procedure and shunt patency was by color Doppler US after TIPSS. Spinal cord MRI was performed in 4, CT and myelography were performed in lcase. Lumbar puncture was done in 5 patients. Results: Spastic paralysis in the lower extremities occurred progressively during 4 weeks to 4 months after TIPSS in the five patients. Weakness of the upper extremities presented in one patient, and urinary incontinence was in another one. HE following TIPSS occurred more than once (1~6 times) in these patients. Physical ex- amination revealed that hyperreflexia of tendons and positive reaction of ankle clonus were seen in all patients. Superficial sensation was normal in 5, decreasing in deep sesation in 1. Muscular atrophy in the paralytic lower extremities was not obvious in all but one patient. No mass effect or other abnormalities were found in the suspected spinal cords on the imaging studies. Lumbar puncture and cerebrospinal fluid examination were normal. The abnormalities of laboratory tests included hyperammonemia and hypoal- buminemia. Conclusion: Spastic paralysis with intact of superficial sensation in the lower extremity fol- lowing TIPSS should be considered as HM. The potential risk factors of TIPSS related HM were obvious liver atrophy, refractory hyperammonemia and HE follwing TIPSS.