科间会诊病例(1) « 医药家园

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15 条评论 发表在“科间会诊病例(1)”上

  1. 试着分析一下
    病例特点:
    1.青年女性,女性,急性起病,病程呈进展性,既往有急性胰腺炎病史2月,假性囊肿经皮穿刺置管引流术后3天。
    2.查体:意识障碍,嗜睡,烦躁、心动过速。昏睡,双眼闭合无力(不全),能执行简单指令,双瞳孔等大,3.0mm,光反应存在。右眼水平运动受限,左眼内收正常,外展可见水平眼震,四肢瘫,肌力2级,四肢腱反射消失,双侧Hoffmann征(-),双侧Babinski征(-)。颈强(-),Kernig征(-)。
    13.影像学检查:MRI上FLAIR相显示,侧脑室,第三脑室周围,穹隆柱,丘脑,中脑背盖部,小脑引部,高信号,病变在中线附件呈对称性.
    定位:丘脑高信号,考虑意识水平是由丘脑病变引起的,右眼水平运动受限,左眼内收正常,外展可见水平眼震显示为核间性眼肌麻痹,MLF肯定受损,结合MRI定位于中脑被盖,四肢瘫,肌力2级,四肢腱反射消失,双侧Hoffmann征(-),双侧Babinski征(-),考虑为双侧锥体束受损,脑休克期,结合MRI,定位于脑干。同时MRI显示侧脑室,第三脑室周围,穹隆柱亦有病变。
    定性:代谢性
    初步诊断:胰性脑病
    胰性脑病(pancreatic encephalopathy,PE)是急性胰腺炎(acute pancreatitis,AP)时,大量蛋白水解酶和磷脂酶A等通过血脑屏障损伤脑组织和血管,引起xxxx损伤的脑病,属于多脏器衰竭的一部分。其发病率为9%~20%,死亡率高达20%~40%。说明胰性脑病的发病率并不低,急性胰腺炎并发胰性脑病,增加了xxxx和xx的难度,其病死率明显高于同期重症胰腺炎。
    有学者将PE的临床表现分为3类:(1)神经精神症状,表现为精神错乱、幻觉、妄想、定向力障碍,进而嗜睡、昏迷,并常有多汗、心动过速和血压不稳等植物神经机能障碍等症状。(2)脑膜刺激征,表现为弥漫性xx、头晕、呕吐、畏光、眼球痛、感觉过敏、颈项强直、病理征阳性等,数合并有精神运动性兴奋。(3)脑脊髓病症候群,包括水平性眼球震颤、角膜反射迟钝、痉挛性瘫痪、肌肉疼痛、锥体束征和局灶性神经系统定位体征,有时还有去皮质状态、共济失调和xx发作。
    鉴别诊断:
    1.wernicke脑病:胰性脑病在后期可进展为wernicke脑病,从病时间上来看,该病人目前诊断为胰性脑病更合适些
    2。电解质紊乱
    3。xx中毒

  2. 本病例原发急性胰腺炎(AP)明确,因继发神经症状而会诊。专科检查可以参考的证据主要是:昏睡,眼球水平共轭运动异常,四肢软瘫;瞳孔正常,对光反射存在,无颈强及长束征;MRI:丘脑 小脑蚓部 中脑对称性异常信号。诊断鉴别主要涉及Wernicke’s encephalopathy(WE)和Pancreatic encephalopathy(PE)两种疾病,二者均可继发于AP。
    PE的特点如yujintai总结(见上),除了意识障碍,涉及包括脑膜在内的xxxx系统多个层次。
    WE的主要特点成为三连征,主要包括:意识障碍、共济失调和眼肌麻痹。
    从影像学角度看,二者在普通的MRI序列和CT扫描中均可呈现阴性表现。
    综上,根据现有病史,个人倾向于WE,可先给予大剂量维生素xx,同时观察病情变化,尚不能xx排除PE。从预后来讲,似乎xx得当的WE预后稍好一些。
    期待楼主反馈随访结果!
    参考文献:
    Pancreatic encephalopathy and Wernicke encephalopathy in association with acute pancreatitis: A clinical study
    <<世界胃肠病学杂志(英文版) >>2006年26期
    AIM: To investigate clinical characteristics and therapy of pancreatic encephalopathy (PE) and Wernicke encephalopathy (WE).METHODS: In a retrospective study of 596 patients with acute pancreatitis (AP), patients with PE were compared to those with WE in regards to history, clinical manifestation, diagnosis, treatment and outcome.RESULTS: There were 93 patients with severe acute pancreatitis (SAP). Encephalopathies were discovered in 10 patients (1.7﹪). Six patients with PE all developed in SAP (6.5﹪), and three of them died (3﹪ of SAP, 50﹪ of PE). Four patients with WE developed in AP (0.7﹪),and two of them died (0.3﹪ of AP, 50﹪ of WE). Two patients with WE were treated with parenteral thiamine and survived. Global confusions were seen in all patients with encephalopathy. Ocular abnormalities were found.Conjugate gaze palsies were seen in 1 of 6 (16.7﹪)patients with PE. Of 4 patients with WE, one (25﹪)had conjugate gaze palsies, two (50﹪) had horizontal nystagmus, three (75﹪) had diplopia, and one (25﹪)had myosis. Ataxia was not seen in all patients. None of patients with WE presented with the classic clinical triad.CSF examinations for 2 patients with WE showed lightlyincreased proteins and glucose. CT and MRI of the brain had no evidence of characteristic abnormalities.CONCLUSION: PE occurs in early or reiteration stage of SAP, and WE in restoration stage of SAP/AR Ocular abnormalities are the hallmarks of WE, and horizontal nystagmus is common. It is difficult to diagnose earlier an encephalopathy as PE or WE, as well as differentiate one from the other. Long fasting, hyperemesis and total parenteral nutrition (TPN) without thiamine are main causes of thiamine deficiency in the course of pancreatitis.

  3. 分析一下:
    1:青年女性,急性病程。术后由消化道症状而继发神经症状。
    2:查体:昏睡,双眼闭合无力(不全),右眼水平运动受限,左眼内收正常,外展可见水平眼震,四肢瘫,肌力2级,四肢腱反射消失,双侧Hoffmann征(-),双侧Babinski征(-)。
    3:辅助检查:头flair示双侧丘脑、中脑及小脑蚓部高信号(中线左右)。
    定位:昏睡,定位于网状上行xx系统或大脑皮层;右眼水平运动受限,左眼内收正常,外展可见水平眼震,定位于内侧纵束;四肢瘫,肌力2级,四肢腱反射消失,双侧Babinski征(-)定位于C5水平以上(休克期)。{zh1}按一元论定位于脑干。与影像基本相符。
    定性:有胰腺炎及手术史,出现精神症状、眼球震颤,结合病灶位于中线左右的上述部位,符合Vernicke脑病三连征,故首先考虑Vernicke脑病。
    Vernicke脑病:常见于术后、慢性酒精中毒等营养不良病人,维生素B1缺乏,TPP减少,神经纤维脱髓鞘及轴突变性,病理损害主要在丘脑和乳头体。需尽快完善维生素B1等检查,或观察维生素B1xx后效果。
    鉴别诊断:胰性脑病:见于急性胰腺炎等,大量蛋白水解酶和磷脂酶A等通过血脑屏障损伤脑组织和血管,产生一系列症状,但影像学表现似乎与之不符。

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