类卒中:3例分析及文献回顾

Stroke Mimics:report of 3 Cases and Review of Literature

目的通过3例类卒中患者临床资料的分析及文献复习,提高临床医生对类卒中的警觉,避免错误的诊治。方法对2017年1月至2018年9月在我院初诊缺血性脑卒中而后被证实为类卒中的3个病例的病史、临床表现、影像资料、治疗等进行回顾性分析。结果病例1主诉为晨起言语不清、右侧肢体活动不灵数小时就诊,头部CT提示陈旧腔隙性脑梗死,首诊考虑脑梗死。其后出现明显发热、癫痫发作,复查头部影像及经手术证实为颅内硬膜外脓肿。早期没有识别的原因是病史询问不详细,影像学复查不及时。病例2一位突然一过性左上肢酸痛、左下肢活动不灵5 h的70岁男性来急诊,接诊考虑脑梗死。行头部MRI检查未见新发病灶。住院后详细询问病史,患者早期有数分钟背部疼痛,行颈椎核磁示提示脊髓硬膜外血肿。急性脊髓硬膜外血肿很少表现类似卒中的一侧肢体无力,但是,当患者发病时伴有疼痛症状时,一定要排除脊髓硬膜外血肿,因为不适当的溶栓治疗会加重病情。病例3患者因抽搐、言语障碍、右侧肢体完全瘫痪20 h入院。虽既往有癫痫病史,头部MRA示左侧大脑中动脉重度狭窄,初步诊断脑梗死。但2次头部MRI、核磁脑灌注成像都未见异常。脑电图检查有局部异常且患者住院5 d神经系统症状基本恢复,最终确诊为Todd’s瘫痪。癫痫发作后遗留瘫痪一般都比较短,但也有持续数日的。结论类卒中临床上用于描述类似卒中的非血管疾病。即表现为急性神经功能缺损的情况。仔细的临床评估(临床病史和神经系统检查)与实验室评估相结合对于类卒中是很重要的。脑成像对于急性缺血性脑卒中的正确诊断和排除类卒中至关重要。随着临床资料、实验室资料和磁共振成像(MRI)评估的使用,类卒中的误诊率将下降到较低的程度。

Objective In order to improve the clinicians’awareness of stroke mimics and to avoid inappropriate therapy,we described the clinical data of 3 patients with stroke mimics and reviewed the literature.Methods We retrospectively gave a description of the medical history,clinical manifestations,imaging data and treatments of three typical cases of stroke mimics from January 2017 to September 2018 in our hospital.Results Case 1 The patient complained of inability to speak in the morning and weakness of the right limbs for several hours.Head CT showed old lacunar infarctions.The primary diagnosis was acute ischemic stroke(AIS).The patient developed with fever and seizures during the following days.The diagnosis of intracranial subdural empyema was confirmed by head MRI and further surgery was performed.The reason why we didn’t make the right diagnosis was that the resident didn’t ask the medical history in detail and we didn’t check the head MRI in time.Case 2 We describe a 70-year-old man who presented to our emergency department(ED)with acute onset of left arm soreness and left leg weakness for 5 hours.The AIS was considered.The patient was admitted to the ward and we knew his first symptom was back pain which lasted about few minutes.Spinal cord MRI revealed spinal epidural hematoma.Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs,mimicking a stroke.Because inappropriate thrombolysis can lead to devastating symptoms,spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a symptom of pain who is a possible candidate for thrombolytic therapy.Case3 The patient admitted to the ward with a seizure,speech disorder and right limbs paralysis for more than 20 hours.The patient’s head MR angiography showed severe stenosis of the left middle cerebral artery.The diagnosis of AIS was made.But the two head MRI being negative for acute ischemic lesion and three dimensional arterial spin-labeled brain perfusion MRI was normal.The diagnosis of AIS was wavering.Within 5 days from the admission,there was almost a complete remission of the neurological findings.The electroencephalogram examination revealed focal abnormalities and Todd’s paralysis was finally confirmed.The neurological deficits during the postictal seizure phase are usually short lasting,but they may last up to days after the convulsion.Conclusion Stroke mimics term is applied in a clinical evaluation,describing those non-vascular conditions that simulate stroke,namely those presenting with an acute neurological deficit.Careful clinical assessment(clinical history and neurological examination)in association with laboratory evaluation is important for depicting the stroke mimics.Brain imaging is essential for the correct diagnosis of AIS and stroke mimic exclusion.With the use of the clinical,laboratory data and magnetic resonance imaging(MRI)evaluation,the misdiagnosis incidence of stroke mimics will decline to lower degree.