以核间性眼肌麻痹为主要表现的脑干梗死临床与影像特点

Clinical features and imaging study of brainstem infarction dominantly presented as internuclear ophthalmoplegia

目的分析因脑干梗死导致核间性眼肌麻痹(INO)患者的临床与影像特点。方法连续收集2010年1月至2016年10月该院神经内科经临床和影像学诊断证实的9例以INO为主要表现的脑干梗死住院患者的临床资料,分析其临床及影像特点,同时结合文献简述该病的发病机制。结果 9例患者年龄中位数为56岁,其中中青年(年龄小于60岁)患者5例,占55.6%。8例(88.9%)患者以水平性复视为主要表现,伴随症状以头晕最为多见(55.6%),单侧受累多见(77.8%)。前核间性眼肌麻痹6例,前核间性合并后核间性眼肌麻痹3例,5例(55.6%)保留会聚运动。头颅磁共振成像(MRI)显示中脑导水管腹侧病变1例,脑桥被盖背侧中线附近病变8例。头颅磁共振血管成像(MRA)显示与梗死灶相关的血管狭窄或闭塞6例,常见为大脑后动脉狭窄(5例)。患者住院时间为13~23d,中位数为14d。6例(66.7%)患者住院期间眼部症状消失,1例随访患者在发病后3个月内眼部症状消失。结论表现为INO的脑梗死主要由脑干背侧中线附近的小灶梗死引起,多数伴后循环血管动脉粥样硬化性病变,发病机制各异,临床预后良好,临床上遇到中青年以复视为首发症状患者应重视鉴别诊断。

Objective To describe the clinical features and magnetic resonance imaging（MRl）findings of brainstem infarction producing internuclear ophthalmoplegia（INO）as an predominant clinical manifestation.Methods The clinical data of 9 patients diagnosed with brainstem infarction presenting with INO by angiography and MRI diagnosis in our hospital were collected from January 2010 to October 2016.The clinical features and imaging findings of these patients were analysed,and the pathogenesis mechanisms was analysed by literature research.Results The median age of the 9 patients was 56 years old,and there were 5 young and middle-aged cases（under 60 years old）,accounted for 55.6%.Among them,8 cases（88.9%）with INO typically presenting with horizontal diplopia,the most common accompanied symptom was dizzness（accounted for55.6%）,and most of them（accounted for 77.8%）were unilateral.A total of 6 cases were anterior INO,3 cases were both anterior and posterior INO.Five cases（55.6%）retained converging movement.The MRI showed that paramedian ventral infarcts located in the the cerebral aqueduct were responsible for INO in 1 case,and paramedian dorsal infarcts located in the pons were responsible for INO in 8 cases.The magnetic resonance angiography（MRA）indicated that vascular occlusion or stenosis was found in posterior circulation in 6 patients,there were 5 cases with stenosis of the posterior cerebral artery which was the most common.The ocular symptoms,including diplopia and blurred vision,of 6 cases（66.7%）disappeared during their hospital stay（range：13-23 d,median：14 d）.During following up,ocular symptoms of 1 case finally disappeared within 3 months.Conclusion Brainstem infarction presenting with INO is mainly caused by paramedian dorsal infarcts located in the pons,and most of the patients complicated with posterior circulation atherosclerotic lesions.The pathogenesis varies,and the patients have a good clinical prognosis.For the young and middle-aged patients presenting with diplopia as an initial symptom,it should pay more attention to differential diagnosis.