作者：张秋灵，刘瑶，蒋敏，周祎，殷凯，王军

单位：

210008 江苏省南京市，南京大学医学院附属鼓楼医院急诊医学科；通信作者：王军，E-mail：1969463449@qq.com

关键词：

窦血栓形成，颅内；疾病特征；体层摄影术，螺旋计算机；磁共振成像；磁共振静脉成像；治疗；预后

Keywords：

Sinus thrombosis，intracranial；Disease attributes；Tomography，spiral computed；Magneticresonance imaging；Magnetic resonance venography；Therapy；Prognosis

CLC：

R 743.33

DOI：

DOI：10.3969/j.issn.1008-5971.2020.04.009

Funds：

摘要：

背景　颅内静脉窦血栓形成（CVST）发病原因复杂多样、临床表现变化多端且缺少特异性，漏诊率及误诊率均较高，而提高临床对 CVST 的认识有利于及时诊断、治疗 CVST，改善 CVST 患者预后。目的　分析 CVST患者的临床特征。方法　选取 2010—2018 年在南京大学医学院附属鼓楼医院住院的 CVST 患者 126 例，回顾性分析其人口学特征、首诊情况及危险因素、临床表现、D- 二聚体检测结果、颅脑影像学检查结果、治疗及预后。结果　人口学特征：男 41 例（32.5%），女 85 例（67.5%），男女比例为 1:2.1；发病年龄为 16~80 岁，平均年龄（37±15）岁，以 21~35 岁者居多（48.4%）。首诊情况及危险因素：首诊于急诊者 65 例（52.6%），首诊于专科门诊者 61 例（48.4%）。排在前五位的危险因素：妊娠及产褥相关疾病 45 例（35.7%），免疫系统疾病、病因不明各 18 例（14.3%），中枢神经系统感染、鼻窦炎 / 中耳炎 / 乳突炎各 11 例（8.7%），血液系统疾病 8 例（6.3%），败血症 5 例（4.0%）。临床表现：头痛 101 例（80.2%）、恶心呕吐 57 例（45.2%）、意识障碍 37 例（29.4%）、抽搐 36 例（28.6%）、偏瘫 16 例（12.7%）、视物模糊 10 例（7.9%）、言语不清 8 例（6.3%）。D- 二聚体检测结果：D- 二聚体为 0.10~55.32 mg/L，平均 D- 二聚体为（4.15±3.07）mg/L，其中 D- 二聚体升高（≥ 0.50 mg/L）者 109 例（86.5%），另 17 例（13.5%）D- 二聚体正常。颅脑影像学检查结果：本组 126 例 CVST 患者均首选颅脑 CT 检查，怀疑 CVST 者再行颅脑磁共振成像（MRI）或静脉窦成像（MRV）及增强MRV检查确诊。血栓部位：横窦109例（86.5%）、乙状窦91例（72.2%）、上矢状窦52例（41.3%）、窦汇13例（10.3%）、直窦6例（4.8%）；累及静脉窦数量：1个31例（24.6%）、2个53例（42.1%）、3个29例（23.0%）、4 个及以上 8 例（6.3%）；脑实质病变：脑梗死 24 例（19.0%），脑出血 22 例（17.5%），无脑实质病变 80 例（63.5%）。治疗及预后：本组 126 例 CVST 患者均给予低分子量肝素皮下注射，7~10 d 后改为口服华法林治疗并使国际标准化比值（INR）维持在 2~3 至少 3 个月以上；4 例患者因脑出血量大而行开颅血肿清除术；入院时轻症 105 例（83.3%）、重症 21 例（16.7%），入院 21 d 轻症 116 例（92.1%）、重症 10 例（7.9%），其中死亡 4 例，病死率为 3.2%。结论　CVST 患者以青年女性多见，临床表现复杂多变且缺少特异性，诊断较困难；妊娠及产褥相关疾病、免疫系统疾病及感染性疾病是 CVST 的主要危险因素；颅脑 MRI、MRV 检查尤其是颅脑增强 MRV 检查是目前最佳的无创 CVST 诊断手段，抗凝治疗是 CVST 患者急性期首选治疗方案，同时也是基础治疗方案，而经治疗后 CVST 患者总体预后良好。

Abstract：

Background　Aetiological agent of cerebral venous sinus thrombosis（CVST）is with complexity anddiversify，and clinical manifestation of CVST is changeful and nonspecific，thus its rate of missed diagnosis and misdiagnosisrate are relatively high，however it is helpful to improve the clinical understanding of CVST for timely diagnosis and treatment aswell as improving the prognosis. Objective　To analyze the clinical features of CVST. Methods　From 2010 to 2018，a total of126 inpatients with CVST were selected in Nanjing Drum Tower Hospital，the Affiliated Hospital of Nanjing University MedicalSchool，and their clinical data was retrospectively analyzed，mainly including demographic characteristics，situation for the firsttime to see a doctor，risk factors，clinical manifestations，D-dimer examination results，craniocerebral imaging examinationresults，treatment and prognosis. Results　Demographic characteristics：there were 41 males（32.5%）and 85 females（67.5%），with the male and female ratio of 1:2.1；age of onset was from 16 to 80 years old，with average age of （37±15）years old and21 to 35 years old as the majority（48.4%）. Situation for the first time to see a doctor and risk factors：65 cases（52.6%）first saw a doctor in the Department of Emergency Medicine，the other 61 cases（48.4%）in the Specialist Clinic；the topfive risk factors：45 cases（35.7%）with pregnancy related and puerperal diseases，18 cases（14.3%）with immune systemdisease or etiology obscure，11 cases（8.7%）with central nervous system infection or nasosinusitis/otitis media/mastoiditis，8cases（6.3%）with hematological system diseases，5 cases（4.0%）with sepsis. Clinical manifestations：101 cases（80.2%）with headache，57 cases （45.2%）with nausea and vomiting，37 cases （29.4%）with disturbance of consciousness，36 cases （28.6%）with convulsion，16 cases（12.7%）with hemiplegia，10 cases（7.9%）with blurred vision，8 cases（6.3%）with alalia.D-dimer examination results：D-dimer ranged from 0.10 to 55.32 mg/L，with an average of （4.15±3.07）mg/L，including109 cases（86.5%）with elevation of D-dimer（ ≥ 0.50 mg/L）and 17 cases（13.5%）with normal D-dimer. Craniocerebralimaging examination results：craniocerebral CT examination was the first choice in all of the 126 patients，and they weresubsequently confirmed as CVST by craniocerebral MRI or MRV/CE-MRV. Thrombotic locus：109 cases（86.5%）in transversesinus，91 cases（72.2%）in sigmoid sinus，52 cases（41.3%）in superior sagittal sinus，13 cases（10.3%）in confluence ofsinus，6 cases（4.8%）in straight sinus； number of involved venous sinuses：31 cases（24.6%）with single involved venoussinus，53 cases（42.1%）with two，29 cases（23.0%）with three，8 cases（6.3%）with four or more；Brain parenchymallesions：24 cases（19.0%）with cerebral infarction， 22 cases（17.5%）with cerebral hemorrhage，80 cases（63.5%）without brain parenchymal lesions. Treatment and prognosis：all of the 126 patients first received subcutaneous injection of lowmolecular weight heparin and then oral warfarin after 7 to 10 days，which need to maintain INR in 2-3 for 3 months at least；4 cases underwent craniotomy for evacuation of hematoma due to large amount of cerebral hemorrhage；105 cases（83.3%）were mild and 21 cases（16.7%）were severe at admission，116 cases（92.1%）were mild and 10 cases（7.9%）were severe21 days after admission，thereinto 4 cases died，with an fatality rate of 3.2%. Conclusion　CVST patients are mostly youngwomen，however clinical manifestations of CVST are complicated，changeable and non-specific，which is relatively difficultto diagnose；pregnancy related and puerperal diseases，immune system disease and infectious diseases are major risk factors ofCVST；craniocerebral MRI or MRV in especial CE-MRV is the best non-invasive diagnostic method of CVST，anticoagulanttherapy is the basic and first choice for treatment in the acute phase of CVST，however the overall prognosis of CVST patients isgood after treatment.

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