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女患，75岁，因“右侧肢体瘫3小时”入院。甲亢5年，无高血压糖尿病病史。入院查体：BP：130/80mmhg,运动性失语，右侧中枢性面舌瘫，右侧肌力2-3级，右巴氏征（+），NIHSS:9分。入院头MRI示双侧大脑半球及右侧颞枕叶多发新发梗死，化验检查发现病人的D-二聚体：7.21，因此进行了肿瘤筛查，发现支气管肺癌并有纵膈淋巴结转移，诊断为特鲁索综合征，予低分子肝素抗凝治疗症状平稳后转肿瘤科进一步治疗。临床资料如下： 1865年ArmandTrousseau报道了第一例以游走性血栓性静脉炎（ migratory thrombosis，MT）为首发表现的隐性胃癌患者，当时把这种肿瘤所致MT称为特鲁索综合征，目前Trousseau综合征指所有恶性肿瘤相关的高凝状态 ,如：缺血性脑血管病，心肌梗死,外周动脉、静脉血栓栓塞，特发性深静脉血栓，DIC等。流行病学以及尸检证实15%的恶性肿瘤患者在生存期会发生缺血性脑血管病（IS）【1】，随着恶性肿瘤治疗手段的进步肿瘤患者生存期延长其发病率可能会更高。目前认为其主要发病机制是非细菌感染性血栓性心内膜炎（NBTE）和高凝状态【2，3，4】，有的患者以急性IS为肿瘤的首发表现，容易误诊，这种脑梗死主要特点是实验室检查D二聚体水平明显升高以及多血管分布区多发DWI高信号表现，国外有研究发现病灶累及3个或3个以上血管分布区的脑梗死患者中大约20%为恶性肿瘤相关性脑梗死【5】。这是由于NBTE的心脏赘生物小且易碎的原因，因此确诊NBTE通常需要尸检或经食道超声【6】。特鲁索综合征主要原因是肿瘤高凝所致，因此抗凝治疗是主要手段，现有研究证实普通肝素和低分子肝素能有效预防这种高凝状态所致血栓栓塞事件，而华法令无效【7，8】。 参考文献： 1 Cestari DM, Weine DM,Panageas KS, Segal AZ, DeAngelis LM. Stroke in patients with cancer: incidenceand etiology. Neurology.2004;62:2025–2030. 2 el-Shami K, Griffiths E, Streiff M. Nonbacterialthrombotic endocarditis in cancer patients: pathogenesis, diagnosis, andtreatment. Oncologist. 2007;12:518–523. 3 Kim SG, Hong JM, Kim HY, Lee J, Chung PW, Park KY, et al.Ischemic stroke in cancer patients with and without conventional mechanisms:amulticenter study in Korea. Stroke. 2010;41:798–801. 4 Schwarzbach CJ, Schaefer A,et al. Stroke and cancer: theimportance of cancer-associated hypercoagulation as a possible stroke etiology.Stroke. 2012;43:3029–3034. 5 P.F. Finelli.Three-Territory DWI Acute Infarcts:Diagnostic Value in Cancer-Associated Hypercoagulation Stroke (TrousseauSyndrome).AJNR Am J Neuroradiol. 2016 Jun 30. 6 Dutta T, Karas MG, Segal AZ, Kizer JR. Yield oftransesophageal echo cardiography for nonbacterial thrombotic endocarditis andother cardiac sources of embolism in cancer patients with cerebral ischemia. AmJ Cardiol.2006;97:894–898. 7 Rogers LR, Cho ES, Kempin S, et al. Cerebral infarctionfrom non-bacterial thrombotic endocarditis: Clinical and pathological studyincluding the effects of anticoagulation.Am J Med 1987; 83: 746-756. 8 Lee AY, Levine MN, Baker RI, et al; Randomized Comparisonof Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for thePrevention of Recurrent Venous Throm-boembolism in Patients with Cancer (CLOT)Investigators. Lowmolecular-weight heparin versus a coumarin for the preventionof recurrent venous thromboembolism in patients with cancer. N Engl JMed.2003;349:146–153 |
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