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*It is only for medical professionals to read for reference.
I am a little disappointed by the imaging results of head CT.
Shouldn't it be bleeding in the brain parenchyma? That day, during the night shift consultation, he encountered a 64-year-old male patient with a history of hypertension in the emergency room.
He was sent to the emergency department of our hospital by his family because of "headache and weakness of the right limb for more than 20 hours".
The chief complaint of headache is one of the most common symptoms in neurology.
It is mainly divided into primary headache (such as migraine, tension-type headache, etc.
) and secondary headache (such as cerebrovascular disease, intracranial space occupation, brain trauma, and cranial Internal infection, etc.
).
Timely diagnosis/exclusion of secondary lesions is the primary task.
Case analysis The patient had an acute onset and usually had a history of hypertension (the most important risk factor for cerebrovascular disease).
In addition to headaches, this patient also had weakness of the right limbs (hemiplegia), which was highly indicative of organic lesions in the cranium involving the pyramidal tract.
Nervous system physical examination: clear mind, no obvious pain, slight neck resistance, cranial nerve (-), muscle strength of the right limb 4, involuntary movement of the right lower limb, positive pathological signs on the right.
For such patients, my first impression is that it is not difficult to diagnose.
The sword refers to a common and frequently-occurring disease-"cerebral hemorrhage", so I issued relevant medical orders and arranged relevant personnel to complete the necessary examinations.
After a while, the results of routine emergency examinations continued to return: blood tests showed that white blood cells were 5.
98x109/L, neutrophil percentage was 75.
7%, platelets were 205x109/L, CRP was 11.
60mg/L, and emergency biochemistry showed that albumin was 43.
8g/L.
, Alanine aminotransferase 11U/L, glucose 8.
67mmol/L, potassium 3.
31mmol/L; plain CT scan of the lungs reveals changes in both lungs; CT plain scan of the head reveals a cord-like height in the longitudinal fissure cistern and top cerebral sulcus Density shadow, venous sinus wall is suspected of high-density triangular sides. The imaging results of the head CT are somewhat disappointing to me.
Shouldn’t it be bleeding in the brain parenchyma? Could it be subarachnoid hemorrhage? The medical history was repeatedly asked, and the patient clearly denied the recent history of trauma.
Is that also spontaneous subarachnoid hemorrhage? The diagnosis of subarachnoid hemorrhage seems to be insufficient based on the degree of headache and the damage of the pyramidal tract.
Is it intracranial venous sinus thrombosis? ★★★★★★★For a patient with an unclear diagnosis of acute headache, and in view of the hemorrhage and thrombosis, the medical staff present agreed that further craniocerebral CTV examination is very necessary because it involves the follow-up treatment.
Hemostasis or anticoagulation? Explained the patient's condition and the necessity of craniocerebral CTV examination in detail with the family members.
The family members expressed their understanding and actively cooperated.
But the results of CTV imaging results disappointed us-no clear imaging signs of venous sinus thrombosis! However, due to the comprehensive clinical manifestations, the receiving doctor considered that venous sinus thrombosis was not ruled out, and he was admitted to the hospital that night.
During the period, the right limb developed epileptic seizures, so he was treated with anti-epileptic, potassium supplement and other symptomatic treatments.
Diagnosis and treatment In order to further confirm the diagnosis, a lumbar puncture was performed in the morning of the next day.
The clear cerebrospinal fluid flowed out.
The pressure of the cerebrospinal fluid was measured to be 300mmH2O.
The specimens were collected and sent for routine, biochemical, culture, liquid-based smear and ink staining.
The results There were no obvious abnormalities in the returns.
Color Doppler ultrasound prompts of the veins of both lower extremities: from the middle of the right lower extremity vein to the popliteal vein cavity, there is a long strip of high echo, 0.
3cm thicker, and local lumen narrowing.
Consider old venous thrombosis.
After obtaining the patient’s consent, DSA was performed again.
During the operation, the bilateral internal carotid arteries and bilateral vertebral arteries were not significantly thickened, dilated, or aneurysm.
The bilateral parietal return veins partially disappeared, and the sagittal sinuses , The left transverse sinus and sigmoid sinus disappeared and thinned, and the left internal jugular vein was not displayed.
Considering the thrombosis of the sagittal sinus, left transverse sinus and sigmoid sinus, the right lower extremity seizure occurred again during the operation, and midazole was given Relief after intravenous injection of 10 mg.
★★★★★★★ At this point, based on the above-mentioned medical history, physical examination and auxiliary examinations, the diagnosis of intracranial venous sinus thrombosis is basically established, but the specific cause is not very clear (according to literature reports, intracranial venous sinus thrombosis is approximately The cause of 20~35% of patients is unknown [1]).
Treatment: 4000U enoxaparin needle, subcutaneous injection, 1 time/day anticoagulant treatment; dehydration to lower intracranial pressure and continue to strengthen vital signs monitoring; prevention and treatment of epilepsy and supportive treatment.
After the treatment, the patient's condition improved and he was discharged from the hospital recently and ordered regular outpatient follow-up.
Intracranial venous system thrombosis (cerebral venous sinus thrombosis, CVST) refers to cerebral venous system vascular disease caused by various causes of intracranial vein and venous sinus thrombosis [2].
The disease occurs in people of any age, and the most common is young and middle-aged women.
Clinically, the onset is mostly subacute.
Headache is the most common symptom.
About 80% of patients have headache.
Other common symptoms and signs include fundus papilledema, focal neurological signs, epilepsy, and changes in consciousness.
Of course, the clinical manifestations of CSVT in different parts are also different, combined with CTV, MRV, especially DSA examination can help confirm the diagnosis.
Due to individual differences in age and general conditions, different locations of involved veins or venous sinuses, different thrombus ranges, and variations in venous structure, the clinical symptoms of cerebral venous system thrombosis are diverse, and the clinical missed diagnosis rate and misdiagnosis rate are relatively high, half of which The above CVT patients were missed in the early stage of the disease, and 2/5 patients had an average diagnosis time of more than 10 days [4].
However, with the continuous improvement of imaging examination techniques and the rich experience of clinicians in diagnosis and treatment, the detection rate has increased year by year.
According to the latest research report, the annual incidence rate can be as high as 15.
7/100 million [3].
The treatment principles of this disease are etiological treatment (mainly anti-infection and fluid replacement), symptomatic treatment (dehydration, lowering intracranial pressure, anti-epileptic and cooling, etc.
), specific treatment (anticoagulation, thrombolysis) and long-term treatment (treatment of primary Diseases and risk factors, continue to take anticoagulant for 3-6 months) [1].
Although many studies have reported that the mortality and prognosis of the disease are significantly better than those of arterial cerebrovascular disease, 68% of survivors still suffer from headaches, limb dysfunction, epilepsy, and neuropsychiatric diseases, and 2.
36% of them per year The patient relapsed [5]. Therefore, early diagnosis and timely anticoagulation treatment can not only improve the symptoms of patients, but also save the lives of patients.
The author has something to say: In clinical practice, especially for neurologists, due to the short reception time, the difficulty of comprehensive physical examination, and the difficulty of performing laboratory tests and auxiliary examinations in the first time, for patients who may have complicated conditions, they want to It is indeed difficult to obtain fast and accurate clinical judgments.
This not only requires doctors to have a solid basic clinical skills and rich clinical experience, but also a strong logical clinical thinking ability.
When this case was first diagnosed, the doctor first thought that it might be a stroke or intracranial infection.
In the emergency department, corresponding auxiliary examinations were also performed.
However, a clear diagnosis requires further hospitalization.
For people with hemiplegia, if the infarction is accompanied by headaches, there are often cases of increased intracranial pressure, such as cerebral edema caused by infarction, hemorrhage in the infarct focus, etc.
At the same time, attention should be paid to distinguishing from intracranial space occupation, meningitis, etc.
, especially Venous sinus thrombosis. Reference materials: [1] Wu Jiang.
Neurology.
Beijing: People's Medical Publishing House, 2010.
[2] Bousser MG, Ferro JM.
Cerebral venous thrombosis: an update.
Lancet Neurol, 2007, 6(2): 162-70.
[3]Devasagayam S,Wyatt B,Leyden J,et al.
Cerebral Venous Sinus Thrombosis Incidence Is Higher Than Previously Thought:A Retrospective Population-Based Study.
Stroke,2016,47(9):2180-2182.
[4]Saposnik G,Barinagarrementeria F,Brown Jr RD,et al.
Diagnosis and management of cerebral venous thrombosis:a statement for healthcare professionals from the American Heart Association/America Stroke Association.
Stroke,2011,42:1158–1192.
[5]Hiltunen S , Putaala J, Haapaniemi E, et al.
Long-term outcome after cerebral venous thrombosis: analysis of functional and vocational outcome, residual symptoms, and adverse events in 161 patients.
J Neurol, 2016, 263(3): 477-484.
Note : Special thanks to the attending physician Shao Huaping from the Department of Vascular Intervention, Department of Radiology, Chun'an First People's Hospital for providing relevant image materials.
I am a little disappointed by the imaging results of head CT.
Shouldn't it be bleeding in the brain parenchyma? That day, during the night shift consultation, he encountered a 64-year-old male patient with a history of hypertension in the emergency room.
He was sent to the emergency department of our hospital by his family because of "headache and weakness of the right limb for more than 20 hours".
The chief complaint of headache is one of the most common symptoms in neurology.
It is mainly divided into primary headache (such as migraine, tension-type headache, etc.
) and secondary headache (such as cerebrovascular disease, intracranial space occupation, brain trauma, and cranial Internal infection, etc.
).
Timely diagnosis/exclusion of secondary lesions is the primary task.
Case analysis The patient had an acute onset and usually had a history of hypertension (the most important risk factor for cerebrovascular disease).
In addition to headaches, this patient also had weakness of the right limbs (hemiplegia), which was highly indicative of organic lesions in the cranium involving the pyramidal tract.
Nervous system physical examination: clear mind, no obvious pain, slight neck resistance, cranial nerve (-), muscle strength of the right limb 4, involuntary movement of the right lower limb, positive pathological signs on the right.
For such patients, my first impression is that it is not difficult to diagnose.
The sword refers to a common and frequently-occurring disease-"cerebral hemorrhage", so I issued relevant medical orders and arranged relevant personnel to complete the necessary examinations.
After a while, the results of routine emergency examinations continued to return: blood tests showed that white blood cells were 5.
98x109/L, neutrophil percentage was 75.
7%, platelets were 205x109/L, CRP was 11.
60mg/L, and emergency biochemistry showed that albumin was 43.
8g/L.
, Alanine aminotransferase 11U/L, glucose 8.
67mmol/L, potassium 3.
31mmol/L; plain CT scan of the lungs reveals changes in both lungs; CT plain scan of the head reveals a cord-like height in the longitudinal fissure cistern and top cerebral sulcus Density shadow, venous sinus wall is suspected of high-density triangular sides. The imaging results of the head CT are somewhat disappointing to me.
Shouldn’t it be bleeding in the brain parenchyma? Could it be subarachnoid hemorrhage? The medical history was repeatedly asked, and the patient clearly denied the recent history of trauma.
Is that also spontaneous subarachnoid hemorrhage? The diagnosis of subarachnoid hemorrhage seems to be insufficient based on the degree of headache and the damage of the pyramidal tract.
Is it intracranial venous sinus thrombosis? ★★★★★★★For a patient with an unclear diagnosis of acute headache, and in view of the hemorrhage and thrombosis, the medical staff present agreed that further craniocerebral CTV examination is very necessary because it involves the follow-up treatment.
Hemostasis or anticoagulation? Explained the patient's condition and the necessity of craniocerebral CTV examination in detail with the family members.
The family members expressed their understanding and actively cooperated.
But the results of CTV imaging results disappointed us-no clear imaging signs of venous sinus thrombosis! However, due to the comprehensive clinical manifestations, the receiving doctor considered that venous sinus thrombosis was not ruled out, and he was admitted to the hospital that night.
During the period, the right limb developed epileptic seizures, so he was treated with anti-epileptic, potassium supplement and other symptomatic treatments.
Diagnosis and treatment In order to further confirm the diagnosis, a lumbar puncture was performed in the morning of the next day.
The clear cerebrospinal fluid flowed out.
The pressure of the cerebrospinal fluid was measured to be 300mmH2O.
The specimens were collected and sent for routine, biochemical, culture, liquid-based smear and ink staining.
The results There were no obvious abnormalities in the returns.
Color Doppler ultrasound prompts of the veins of both lower extremities: from the middle of the right lower extremity vein to the popliteal vein cavity, there is a long strip of high echo, 0.
3cm thicker, and local lumen narrowing.
Consider old venous thrombosis.
After obtaining the patient’s consent, DSA was performed again.
During the operation, the bilateral internal carotid arteries and bilateral vertebral arteries were not significantly thickened, dilated, or aneurysm.
The bilateral parietal return veins partially disappeared, and the sagittal sinuses , The left transverse sinus and sigmoid sinus disappeared and thinned, and the left internal jugular vein was not displayed.
Considering the thrombosis of the sagittal sinus, left transverse sinus and sigmoid sinus, the right lower extremity seizure occurred again during the operation, and midazole was given Relief after intravenous injection of 10 mg.
★★★★★★★ At this point, based on the above-mentioned medical history, physical examination and auxiliary examinations, the diagnosis of intracranial venous sinus thrombosis is basically established, but the specific cause is not very clear (according to literature reports, intracranial venous sinus thrombosis is approximately The cause of 20~35% of patients is unknown [1]).
Treatment: 4000U enoxaparin needle, subcutaneous injection, 1 time/day anticoagulant treatment; dehydration to lower intracranial pressure and continue to strengthen vital signs monitoring; prevention and treatment of epilepsy and supportive treatment.
After the treatment, the patient's condition improved and he was discharged from the hospital recently and ordered regular outpatient follow-up.
Intracranial venous system thrombosis (cerebral venous sinus thrombosis, CVST) refers to cerebral venous system vascular disease caused by various causes of intracranial vein and venous sinus thrombosis [2].
The disease occurs in people of any age, and the most common is young and middle-aged women.
Clinically, the onset is mostly subacute.
Headache is the most common symptom.
About 80% of patients have headache.
Other common symptoms and signs include fundus papilledema, focal neurological signs, epilepsy, and changes in consciousness.
Of course, the clinical manifestations of CSVT in different parts are also different, combined with CTV, MRV, especially DSA examination can help confirm the diagnosis.
Due to individual differences in age and general conditions, different locations of involved veins or venous sinuses, different thrombus ranges, and variations in venous structure, the clinical symptoms of cerebral venous system thrombosis are diverse, and the clinical missed diagnosis rate and misdiagnosis rate are relatively high, half of which The above CVT patients were missed in the early stage of the disease, and 2/5 patients had an average diagnosis time of more than 10 days [4].
However, with the continuous improvement of imaging examination techniques and the rich experience of clinicians in diagnosis and treatment, the detection rate has increased year by year.
According to the latest research report, the annual incidence rate can be as high as 15.
7/100 million [3].
The treatment principles of this disease are etiological treatment (mainly anti-infection and fluid replacement), symptomatic treatment (dehydration, lowering intracranial pressure, anti-epileptic and cooling, etc.
), specific treatment (anticoagulation, thrombolysis) and long-term treatment (treatment of primary Diseases and risk factors, continue to take anticoagulant for 3-6 months) [1].
Although many studies have reported that the mortality and prognosis of the disease are significantly better than those of arterial cerebrovascular disease, 68% of survivors still suffer from headaches, limb dysfunction, epilepsy, and neuropsychiatric diseases, and 2.
36% of them per year The patient relapsed [5]. Therefore, early diagnosis and timely anticoagulation treatment can not only improve the symptoms of patients, but also save the lives of patients.
The author has something to say: In clinical practice, especially for neurologists, due to the short reception time, the difficulty of comprehensive physical examination, and the difficulty of performing laboratory tests and auxiliary examinations in the first time, for patients who may have complicated conditions, they want to It is indeed difficult to obtain fast and accurate clinical judgments.
This not only requires doctors to have a solid basic clinical skills and rich clinical experience, but also a strong logical clinical thinking ability.
When this case was first diagnosed, the doctor first thought that it might be a stroke or intracranial infection.
In the emergency department, corresponding auxiliary examinations were also performed.
However, a clear diagnosis requires further hospitalization.
For people with hemiplegia, if the infarction is accompanied by headaches, there are often cases of increased intracranial pressure, such as cerebral edema caused by infarction, hemorrhage in the infarct focus, etc.
At the same time, attention should be paid to distinguishing from intracranial space occupation, meningitis, etc.
, especially Venous sinus thrombosis. Reference materials: [1] Wu Jiang.
Neurology.
Beijing: People's Medical Publishing House, 2010.
[2] Bousser MG, Ferro JM.
Cerebral venous thrombosis: an update.
Lancet Neurol, 2007, 6(2): 162-70.
[3]Devasagayam S,Wyatt B,Leyden J,et al.
Cerebral Venous Sinus Thrombosis Incidence Is Higher Than Previously Thought:A Retrospective Population-Based Study.
Stroke,2016,47(9):2180-2182.
[4]Saposnik G,Barinagarrementeria F,Brown Jr RD,et al.
Diagnosis and management of cerebral venous thrombosis:a statement for healthcare professionals from the American Heart Association/America Stroke Association.
Stroke,2011,42:1158–1192.
[5]Hiltunen S , Putaala J, Haapaniemi E, et al.
Long-term outcome after cerebral venous thrombosis: analysis of functional and vocational outcome, residual symptoms, and adverse events in 161 patients.
J Neurol, 2016, 263(3): 477-484.
Note : Special thanks to the attending physician Shao Huaping from the Department of Vascular Intervention, Department of Radiology, Chun'an First People's Hospital for providing relevant image materials.
