后循环脑梗死临床误诊分析_邢海辉.pdf

后循环脑梗死临床误诊分析邢海辉，高玉华作者单位:211300 南京，南京市高淳中医院神经内科(邢海辉)，神经外科(高玉华)作者简介:邢海辉，硕士研究生，副主任中医师。主要从事中医药神经系统疾病应用方向研究通讯作者:高玉华，E-mail:21130014473865 qq com 摘要 目的分析后循环脑梗死的临床特点、鉴别诊断要点、误诊原因及防范措施。方法回顾分析 2020 年1 月2022 年 4 月收治的初诊误诊为多种疾病的后循环脑梗死 15 例临床资料。结果15 例均以头晕、眩晕为主诉就诊，4 例因主要表现为头晕、共济失调、视力障碍、头痛，听诊有颈动脉血管杂音，行颈动脉超声发现椎基底动脉轻度狭窄，初诊为椎基底动脉供血不足;4 例主要临床表现为眩晕、耳鸣、恶心呕吐、平衡障碍、听力减退及眼球震颤，初诊为梅尼埃病;7 例因主要临床表现为眩晕、耳鸣、恶心呕吐，且眩晕与体位改变有一定关系，初诊为良性阵发性位置性眩晕。15 例按误诊疾病予相应治疗后症状改善不明显，入我院后经详细询问病史，仔细神经系统查体，并予床旁头脉冲 眼震 眼偏斜试验及头颅 MI 血管成像，确诊为后循环脑梗死，梗死部位:脑桥 7 例、枕叶 4 例、小脑 3 例、延髓 1例。误诊时间 2 5 d。确诊后予对症治疗后病情好转出院，随访3 个月症状均消失，尚未发现后遗症。结论后循环解剖和生理结构复杂，导致后循环脑梗死症状体征具有复杂多样性，且早期影像学检查阴性率高，易误诊为良性阵发性位置性眩晕、梅尼埃病及椎基底动脉供血不足等多种疾病;接诊医生应加强对本病的认识，熟知头晕或眩晕性疾病的病因学诊断流程，详细询问病史，细致行神经系统查体，及时恰当地选择影像学检查项目，必要时可多次复查，以及早确诊并治疗，进而改善患者预后及降低本病早期误诊率。关键词 脑梗死;误诊;良性阵发性位置性眩晕;梅尼埃病;椎基底动脉供血不足;颈动脉超声;MI 血管成像;鉴别诊断 中国图书资料分类号 743 33 文献标志码 A 文章编号 1002-3429(2023)04-0022-05 DOI 10 3969/j issn 1002-3429 2023 04 006Analysis of Clinical Misdiagnosis of Posterior Circulation Cerebral Infarc-tionXING Haihuia，GAO Yuhuaba.Department of Neurology，b.Department of Neurosugery，Gaochun Hospital of Traditional Chinese Med-icine，Nanjing 211300，China Abstract ObjectiveTo analyze the clinical features，differential diagnosis，causes of misdiagnosis and preventivemeasures of posterior circulation cerebral infarction(PCCI)MethodsThe clinical data of 15 patients with PCCI who wereinitially misdiagnosed as multiple diseases from January 2020 to April 2022 were retrospectively analyzed esultsAll the15 cases presented with dizziness and vertigo as the main complaint Four cases were mainly presented with dizziness，ataxia，visual impairment，headache，carotid artery murmur by auscultation，minor vertebrobasilar artery stenosis was found by carotidartery ultrasound，and the initial diagnosis was vertebrobasilar artery insufficiency The main clinical manifestations of 4 pa-tients were vertigo，tinnitus，nausea and vomiting，balance disorder，hearing loss and nystagmus，and the initial diagnosis wasMenieres disease The main clinical manifestations of the 7 cases were vertigo，tinnitus，nausea and vomiting，and vertigo wasrelated to postural changes to some extent The initial diagnosis was benign paroxysmal positional vertigo Symptom improve-ment of 15 patients was not obvious after corresponding treatment according to the misdiagnosed disease After being admittedto our hospital，the patient was diagnosed with PCCI after detailed medical history inquiry，careful physical examination ofnervous system，and bedside oculomotor examination head impulse test，nystagmus，test of skew(HINTS)and cranial MIangiography The infarct sites included pontine in 7 cases，occipital lobe in 4 cases，cerebellum in 3 cases，and medulla ob-longata in 1 case Misdiagnosis lasted from 2 to 5 d After diagnosis and targeted treatment，the condition was improved andthe patients were discharged from the hospital At 3 months after follow-up，the symptoms disappeared and no sequelae werefound ConclusionThe complex anatomy and physiological structure of posterior circulation lead to the complex diversity ofsymptoms and signs of PCCI，and the early negative rate of imaging examination is high，which is，therefore，more likely to22lead to misdiagnosis as benign paroxysmal positional vertigo，Menieres disease，vertebrobasilar insufficiency and other disea-ses The receiving doctor should strengthen the understanding of this disease，be familiar with the etiological diagnosis processof dizziness or vertigo，inquire about the detailed medical history，conduct careful examination of the nervous system，selecttimely and appropriate imaging examination items，perform repeated review if necessary，and conduct early diagnosis and treat-ment，so as to improve the prognosis of patients and reduce the early misdiagnosis rate of this disease Key wordsCerebral infarction;Misdiagnosis;Benign paroxysmal positional vertigo;Menieres disease;Verte-brobasilar artery insufficiency;Carotid artery ultrasound;MI angiography后循环缺血是由颈动脉系统短暂性缺血引发，按程度和持续时间可分为短暂性脑缺血发作和脑梗死，约占脑缺血性血管病的 20%1。后循环脑梗死临床表现复杂多样，主要表现为头晕或眩晕、步态不稳、视觉功能障碍、肢体或头面部麻木、瞳孔异常、意识模糊、恶心呕吐、头痛、声音嘶哑、一侧或双侧肢体麻痹无力、构音障碍及吞咽障碍，多发生于中老年人，常伴高血压病、糖尿病、高脂血症和颈椎病等2。后循环脑梗死梗死部位以脑桥最为常见，因后循环部位特殊，发病后意识障碍及生命体征异常发生率高，严重威胁患者生命健康，故及早诊断并予有效治疗是挽救患者生命的关键3。本病患者常以眩晕为首发或主要症状就诊于耳鼻喉科、神经内科及急诊科等多个科室，因早期临床表现多样、影像学无特异性表现、神经系统查体不细致、问诊不详细、鉴别诊断不认真等原因，常首诊为良性阵发性位置性眩晕、梅尼埃病、椎基底动脉供血不足等疾病4，错失最佳溶栓治疗时间而致治疗效果不理想。故此，本研究将我院2020 年1 月2022 年4 月收治的初诊曾误诊为其他疾病的后循环脑梗死 15例作为研究对象，回顾分析其临床资料，根据相关文献探讨其临床特点、诊治方法、误诊原因及防范措施，以提高后循环脑梗死首诊确诊率，进而及时有效治疗、改善患者预后。1临床资料1.1一般资料本组 15 例 中 男 11 例(73 33%)，女 4 例(26.67%);年龄 39 72(61 32 6 75)岁，其中60 岁 者 4 例(26 67%);发 病 至 就 诊 时 间20 min 15 h，10 例(66 67%)在发病 6 h 内就诊我院;均急性起病;有高血压病史 7 例(46 67%)，高脂血症史、眩晕发作史各 5 例(33 33%)，糖尿病史、慢性化脓性中耳炎史各 4 例(26 67%)，心房颤动史及颈椎病史各 2 例(13 33%)，白内障史、脑梗死史各 1 例(6 67%);有饮酒史 7 例(46 67%)，有吸烟 史 5 例(33 33%)，饮 酒 后 发 作 3 例(20.00%);肥胖 2 例(13.33%)。文化程度:小学 2例(13.33%)，初中 3 例(20.00%)，高中及以上 10例(66.67%);职业:公司文员、退休人员各 4 例(26.67%)，教 师、农 民、自 由 职 业 者 各 2 例(13.33%)，警察 1 例(6.67%);首诊科室:急诊科 7例(46.67%)，耳鼻喉科 5 例(33.33%)，神经内科 3例(20.