以急性脑梗死为首发表现的躯体恶性肿瘤34例分析

Analysis of 34 cases of somatic malignancies with acute cerebral infarction as the presenting symptom

目的探讨以急性脑梗死为首发表现的躯体恶性肿瘤患者的临床特点和可能的发病机制。方法回顾性分析2007-01-01—2016-12-31第二军医大学附属长海医院和上海市杨浦区市东医院确诊的以急性脑梗死为首发表现的34例隐匿性躯体恶性肿瘤患者的临床资料。结果 34例患者中男29例,女5例,平均年龄(66.94±10.09)岁。无传统脑卒中危险因素者6例(17.65%)。所有患者以局灶性神经功能缺损为主要表现,其中3例出现昏迷。24例患者(70.59%)外周血D-二聚体水平升高。14例(41.18%)患者头颅DWI检查示急性多动脉供血区梗死灶。首次因急性脑梗死入院MRI检查发现有陈旧性无症状脑梗死者18例(52.94%)。肿瘤类型以肺癌(11例,32.35%)最多见,其次是肾癌(7例,20.59%)、结直肠癌(4例,11.76%)、胰腺癌(4例,11.76%)。诊断癌症时即有远处转移者9例(26.47%)。病程中出现脑梗死复发者5例(14.70%)。多数患者预后不良。入院后30d改良Rankin量表评分3~5分9例(26.47%),6分(死亡)6例(17.65%)。高血浆D-二聚体水平(P=0.000)与恶性肿瘤有远处转移(P=0.025)是患者30d神经功能预后差的相关危险因素。结论对于不符合单支动脉供血区的急性多发性脑梗死且D-二聚体明显升高的患者,特别是脑梗死再发者需要考虑合并隐匿性躯体恶性肿瘤的可能;高D-二聚体水平及恶性肿瘤有远处转移的患者一旦发生脑梗死,其神经功能预后更差。

Objective To investigate the clinical features and possible pathogenesis of patients with somatic malignancies with cerebral infarction as the presenting symptom.Methods Retrospectively investigation was performed on 34 patients diagnosed with somatic malignancies with acute cerebral infarction as the first symptom who were hospitalized in Changhai Hospital Affiliated to the Second Military Medical University and East City Hospital of Shanghai Yangpu District from January 1,2007 to December 31,2016.Results Thirtyfour patients met the inclusion criteria with 29 males and 5 females,an average age of（66.94±10.09）years.There were no traditional stroke risk factors in 6 patients（17.65%）.The Clinical manifestations presented as localized neurological dysfunction.Three of 34 cases progressed to consciousness disturbance.Blood D-dimer was elevated in 24 patients（70.59%）.DWI revealed acute infarction in≥2 vascular territories such as the bilateral anterior or anterior plus posterior cerebral circulations in 14 patients（41.18%）.Evidence for previous,potentially a symptomatic infarctions was found in 18 patients（52.94%）,and demonstrated by the additional presence of subacute or chronic ischemic lesions.The most common cancer type was lung cancer（11 cases,32.35%）,followed by renal cell carcinoma（7 cases,20.59%）,colorectal cancer（4 cases,11.76%）,pancreatic carcinoma（4 cases,11.76%）.There were 9 cases with distant metastasis at diagnosis（26.47%）.In the course of cerebral infarction,recurrence appeared in 5 cases（14.70%）.Most patients had a poor prognosis,and the 30 dMRS score was 3-5：9（26.47%）,6：6（17.65%）.High plasma D-dimer level（P=0.000）and distant metastasis（P=0.025）were risk factors for poor prognosis of neurologic function in 30 days.Conclusions Ischemic stroke patients with high level of D-dimer,multiple acute infarctions in≥2 vascular territories,and recurrent infarction dominate the phenotype of cancer-related stroke.Furthermore,patients with advanced malignant tumors with high D-dimer level and distant metastasis have worse prognosis once cerebral infarction occurred.