中英译文主动脉夹层脊髓梗死

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CaseDescription病例介绍

A63-year-oldmanwithahistoryofhypertension,paroxysmalatrialfibrillation,anddyslipidemiahadasuddenintensechestpainradiatingtohisleftarm,andhelostcontrolofhislegs.Hewasnotonanticoagulanttherapyandhadnohistoryofbacktrauma.Duringtransport,hewashypotensive(bloodpressure88/51),hisrightarmwaspale,andhewasnotabletomovehislegs.ECGshowedinferolateralST-segmentdepressions.Hewasgivenmgaspirinandmorphineforpain.Withintravenousfluid-replacementtherapy,hisbloodpressureroseandtheactivityofhislegsimproved.Aorticdissectionwassuspected,andthepatientwasurgentlyadmittedtothesurgicalemergencyroomwithintheuniversityhospital.Intheemergencyroom,hisbloodpressurewas/62.Cardiacandpulmonaryauscultationandabdominalpalpationwerenormal,andperipheralpulsesweresymmetrical.Computedtomographyoftheaortarevealedahematomanexttotheascendingaorta,raisingasuspicionoftypeAaorticdissectionreachingfromtheascendingaortatothebeginningoftheleftrenalartery.Theaorticvalvewasintact.

一位63岁男性患者，既往有高血压病、阵发性房颤、高脂血症史，突然出现剧烈胸痛并放射至左侧上肢，伴双下肢无力。未曾接受抗凝治疗，否认背部外伤史。往医院转送过程中，患者出现低血压（血压88/51mmHg），右侧上肢苍白，双下肢不能平移。心电图显示下侧壁ST段压低，给予口服阿司匹林肠溶片mg和吗啡止痛。给予静脉补液后，患者血压逐渐上升，双下肢运动障碍改善。怀疑主动脉夹层，患医院的外科急诊室。在急诊室，患者血压/62mmHg。心肺听诊及腹部触诊正常，外周动脉搏动对称。主动脉CT显示升主动脉旁有一血肿，高度怀疑从升主动脉到左侧肾动脉起始段的A型主动脉夹层，主动脉瓣完整。

Duringanemergencyoperation,theascendingaortaandapartoftheaorticarchwerereplacedwithaprostheticgraft.Thearresttimewas24minutes,andclosureoftheaortatookminutes.Inthebeginning,thepatientneededvasoactivesupportbecauseofhypotensionbutlateronhishemodynamicwasstable.However,thenextday,thepatienthadtoundergoaresternotomybecauseofpostoperativebleeding.Aftertheoperation,hewashypertensiveandwastreatedwithantihypertensivemedication.

急诊手术中，升主动脉和部分主动脉弓用人工移植物代替。停搏时间为24分钟，主动脉夹闭时间为分钟。因为血压过低，患者一开始需要血管活性药物维持血压，但后来血流动力学平稳。然而第2天，患者因为术后出血，不得不行开胸手术治疗。术后血压高，给予降压药物治疗。

Thepatientwasextubatedonthesecondpostoperativedayandmobilizationwasstartedthenextday,whenitwasnoticedthatthepatientcouldnotstandonhisfeetandcoordinationofhislowerlimbswasimpaired.Onthefourthpostoperativeday,aneurologistwasconsulted.Thepatientwassomnolentbutoriented,anddeniedanybackorlimbpain.Hiscranialnerveswereintact,andhisupperlimbshadnormalstrengthandsensation.Hecouldholdhisleftlegupfor5andhisrightlegfor3sinaproneposition.Hecouldnotpress/pushagainstresistanceneitherdistallynorproximally,therightlegbeingsomewhatweaker,andtonusofhislowerlimbswasweak-ened.Thepatientreportedimpairedsensationforpainandlighttouchonhisfeet.Reflexeswerenormal,andBabinskisignwasnegative.Therewasnoimpairedsensationinupperbody.Diuresiswasmonitoredbymeansofurinarycatheter.

术后第2天拔除气管插管，第3天患者下床活动时发现双下肢站立不能，伴共济失调。术后第4天请神经科医生会诊。患者呈嗜睡状态，但定向力正常，否认背部或者四肢痛。颅神经检查正常，双上肢运动及感觉未见异常。患者仰卧位时，左下肢抬起能坚持5秒，右下肢3秒，肢体近端及远端均不能抵抗阻力，右侧下肢比左侧肌力更差，肌张力低。双下肢痛觉和轻触觉减退，腱反射正常存在，巴宾斯基征阴性。上半身感觉正常。通过留置导尿管监测到多尿。

Next,MagneticResonanceImagingoftheSpinalCordWasPerformed.WhatWouldYouExpecttoFind?

下一步行脊髓MRI检查，你希望能发现什么呢？

MagneticresonanceimagingshowedincreasedsignalintensityoftheanteriorspinalcordbetweenT11andconusinT2-weightedimageswithedemaandrestricteddiffusionindiffusion-weightedimages.Thefindingsuggestedanischemiclesion.

磁共振显示胸11至脊髓圆锥段脊髓前部T2加权像高信号，伴有水肿，弥散加权像受限，结果提示脊髓缺血性病变。

Onthe19thpostoperativeday,sensorydeficitswerenolongerfound.Thepatientwasabletowalkwithassistanceofawalker,butdistalandmotorweaknesswasstilldetected,therightsidebeingweaker.Proprioceptiveandtemperaturesensewasnormal.Vibrationsensewasimpairedinbothupperandlowerlimbs,probablyunrelatedtotheacutesituation.Bowelfunctionwasnormalbutthepatientwasstillcatheter-bound,partiallybecauseofthepostoperative