凸面蛛网膜下腔出血合并急性脑梗死临床特点分析

Analysis of clinical characteristics of convexal subarachnoid hemorrhage complicated with acute cerebral infarction

目的分析凸面蛛网膜下腔出血(cSAH)合并急性脑梗死的临床特点。方法从2015年7月至2018年6月郑州大学第二附属医院收治的122例蛛网膜下腔出血(SAH)患者中筛选cSAH合并急性脑梗死患者,并对其发病率、临床表现、影像学特征、发病原因、实验室检查、治疗效果和预后进行分析。结果共筛选出2例cSAH合并急性脑梗死患者,发病率为1.64%(2/122)。该病临床表现多样,缺乏特异性,可出现头痛、类似短暂性脑缺血发作症状、意识障碍和认知损害。CT上凸面脑沟线样高密度影、磁共振GRE序列上局部低信号影是cSAH的影像学特征,磁共振DWI序列高信号影提示合并急性脑梗死。小于60岁的病例1 cSAH病因为可逆性脑血管收缩综合征,大于60岁的病例2 cSAH病因是脑淀粉血管病变。急性脑梗死可因cSAH引发的脑血管痉挛所致,也能由房颤等其他原因引起。病例1进行腰穿检查,脑脊液压力轻度升高(200 mm H_2O),颜色呈均匀一致淡红色,脑脊液常规提示脑脊液浑浊,可见红细胞。病例2头颅影像学已确诊为cSAH,未进行腰穿检查。针对cSHA,给予脱水降颅压、调控血压、预防脑血管痉挛治疗;针对急性脑梗死,给予抗氧自由基、改善脑循环、改善认知等治疗。经过综合治疗,2例患者病情均明显改善。出院后随访6个月,均未再复发。结论 cSAH可合并急性脑梗死,发病率可能高于现有统计结果,应给予重视。虽然发病原因不同,临床表现多样,但依据发病年龄和临床表现有助于判断发病原因,及早进行治疗,一般可获得良好效果。

Objective To analyze the clinical characteristics of convexal subarachnoid hemorrhage (cSAH) complicated with acute cerebral infarction. Methods The patients with cSAH complicated with acute cerebral infarction were screened from 122 cases of subarachnoid hemorrhage (SAH) who admitted to the Second Affiliated Hospital of Zhengzhou University from July 2015 to June 2018. The incidence, clinical features, imaging features, etiologies, laboratory examinations, therapeutic effects and prognosis were analyzed. Results Two cases of cSAH complicated with acute cerebral infarction were screened out. The incidence was 1.64%(2/122). The clinical manifestations of the disease were diverse and lack of specificity. Headache, symptoms similar to transient ischemic attack, disturbance of consciousness and cognitive impairment could occur. The imaging features of cSAH were convex sulcus linear high-density shadow on CT and local low-signal shadow on GRE sequence. High signal intensity image on magnetic resonance DWI sequence suggested cSAH complicated with acute cerebral infarction. The cSHA etiology of case 1 who was younger than 60 years old was reversible cerebral vasoconstriction syndrome (RCVS), and the cSHA etiology of case 2 who was older than 60 years old was cerebral amyloid angiopathy (CAA). Acute cerebral infarction can be caused by cerebral vasospasm caused by cSAH, also can be caused by atrial fibrillation and other causes. Case 1 underwent lumbar puncture. The cerebrospinal fluid pressure slightly increased (200 mm H 2O). The colour was uniform and light red. The cerebrospinal fluid routine indicated that the cerebrospinal fluid was turbid and red blood cells were visible. Case 2 was diagnosed as cSAH by neurological imaging, and lumbar puncture was not performed. For cSHA, the treatments of dehydration to reduce intracranial pressure, regulating blood pressure and preventing cerebral vasospasm were given. For acute cerebral infarction, the treatments of anti-oxygen free radicals, improving brain circulation, improving cognition and so on were given. After combined therapy, the condition of 2 patients improved significantly. The patients were followed up for 6 months post-discharge, and no recurrence occurred. Conclusion cSAH could complicate with acute cerebral infarction. The incidence may be higher than current statistics, and attention should be paid to it. Although the etiologies are different and the clinical manifestations are diverse. It is helpful to judge the cause of disease according to age of onset and clinical manifestations. If treatment is early, the patients generally could obtain good efficacy.