以急性脑梗死为首发表现的隐匿性恶性肿瘤的临床分析

摘要

目的 通过对急性脑梗死为首发表现的隐匿性恶性肿瘤患者的临床表现、实验室检查及影像学特点进行分析,以加强对急性脑梗死患者的肿瘤筛查.方法 收集自2013年1月至2015年1月北京大学第三医院神经内科收治的1139例急性脑梗死患者,其中8例(0.7%)患者在住院期间发现躯体恶性肿瘤.回顾8例患者的临床表现、危险因素、影像学改变、D-二聚体水平等化验结果及预后,并复习相关文献进行讨论.结果 8例以脑梗死为首发表现的恶性肿瘤患者,年龄为58~78岁,平均(70±3)岁,男6例,女2例;其中5例为肺癌,肝内胆管细胞癌、结肠癌以及前列腺癌各1例;3例多次发生脑梗死患者于住院期间因呼吸衰竭死亡,其确诊卒中至死亡间隔时间分别为49、95及28 d.5例患者完善了D-二聚体检查,其中2例D-二聚体水平(分别为0.73μg/L及3.0μg/L)升高;8例完善肌酸激酶同工酶(CK-MB)检测的患者中,2例CK-MB水平(分别为31 U/L及49 U/L)升高,其中1例确诊为急性心肌梗死.所有患者完善头部MRI扩散加权成像和脑血管检查,仅1例患者脑梗死病灶与狭窄血管一致;6例患者为双侧大脑半球且前后循环同时发生多发性脑梗死,且MRI扩散加权成像提示脑梗死病灶均为多支血管供血的小点片状或大面积脑梗死.结论 对病因不明的多发性脑梗死患者,尤其是早期卒中反复的患者,需要注意躯体恶性肿瘤的可能性,且急性脑梗死早期复发提示预后不佳.%Objective To guide clinicians to strengthen tumor screening in patients with acute cerebral infarction by analyzing the clinical manifestation,laboratory examinations and imaging features of patients with acute cerebral infarction as the first manifestation of occult malignant tumors. Methods From January 2013 to January 2015,1139 patients with acute cerebral infarction admitted to the Department of Neurology,Peking University Third Hospital were collected. Eight of them (0. 7% )were found to have somatic malignancy during hospitalization. The clinical manifestations,risk factors,imaging changes,Ddimer levels and other laboratory results and prognosis were reviewed,and the related literature was reviewed and discussed. Results Eight patients with cerebral infarction as the first manifestation of malignant tumor,their ages were 58 -78 (70 ±3)years old,6 were males,2 were female. Five of them were lung cancer. Intrahepatic cholangiocarcinoma,colon cancer and prostate cancer were in 1 case respectively. Three patients who had multiple cerebral infarctions died of respiratory failure during hospitalization,and the intervals between diagnosis and death were 49,95 and 28 d,respectively. Five patients improved the Ddimer test,including 2 of them had elevated levels of D-dimer (0. 73 μg/ L and 3. 0 μg/ L respectively);in 8 patients with improved creatine kinase isoenzyme MB (CK-MB)test,the CK-MB levels were elevated in 2 patients (31 U/ L and 49 U/ L respectively),and one of the patients was diagnosed as acute myocardial infarction. All the patients improved head magnetic resonance imaging (MRI)diffusion-weighted imaging (DWI)and cerebral vascular examination,and only one patient with cerebral infarction was consistent with the stenotic vessels. Six patients had bilateral cerebral hemisphere infarctions,and multiple cerebral infarction occurred in the anterior and posterior circulation simultaneously,and MRI-DWI indicated that the cerebral infarction lesions were numerous small or large area cerebral infarctions in multiple vessels. Conclusion In patients with multiple cerebral infarction with unknown etiology,especially those with early recurrent stroke,attention should be paid to the possibility of somatic malignancy,and the early recurrence of acute cerebral infarction suggests poor prognosis.