摘要：

目的 总结颅内静脉窦血栓形成的临床和影像学表现以及抗凝治疗联合溶栓治疗的临床效果。方法与结果 22 例颅内静脉窦血栓形成患者，临床表现多样，主要表现为头痛（90.91%，20/22），亦可见意识障碍、癫痫发作和中枢神经系统局灶性体征。12 例（54.55%）血浆D-二聚体水平升高。14 例行腰椎穿刺脑脊液检查，9例（9/14）颅内压升高，常规和生化无特征性变化。头部CT 和（或）MRI、CTV 和（或）MRV 显示，22 例均有静脉窦血栓直接征象（上矢状窦、横窦、乙状窦、直窦、皮质静脉扩张），13 例（59.09%）存在脑实质损害（脑出血、脑梗死、脑白质异常），2 例（9.10%）发生蛛网膜下隙出血，1 例（4.55%）发生硬膜下血肿。DSA 显示颅内静脉窦血栓形成部位为上矢状窦13 例（59.09%）、横窦17 例（77.27%）、乙状窦14 例（63.64%）、下矢状窦2 例（9.10%）、直窦4 例（18.18%）、大脑大静脉1 例（4.55%）、颈内静脉1 例（4.55%），其中9 例（40.91%）存在2 个静脉窦血栓、8 例（36.36%）存在3 个或以上静脉窦血栓。予肝素钠静脉滴注或低分子量肝素皮下注射以及华法林口服抗凝治疗数天，症状未见缓解或进行性加重，21 例（95.45%）再予尿激酶静脉窦内或动脉溶栓治疗。共住院13 ~ 59 d，平均（25.70 ± 12.18）d，改良Rankin 量表评分0 ~ 1 分13 例（59.09%）、2 分4 例（18.18%）、3 ~ 4 分5 例（22.73%），治疗总有效率为77.27%（17/22）。结论 颅内静脉窦血栓形成患者常存在多个静脉窦血栓或深静脉血栓及脑实质损害，对于抗凝治疗效果不明显的患者，联合溶栓治疗有助于改善预后。

关键词: 窦血栓形成, 颅内, 抗凝药, 血栓溶解疗法

Abstract:

Objective  To investigate the clinical and imaging manifestations of cerebral venous sinus thrombosis (CVST), and the clinical effect of combined treatment of anticoagulation and endovascular thrombolysis.  Methods and Results  The clinical manifestations of 22 CVST patients were highly variable. Headache (90.91%, 20/22) was the most frequent symptom, and conscious disturbance, seizure and focal neurological deficits were commonly present. Plasma D-dimer level was elevated in 12 patients (54.55%). Lumbar puncture was performed in 14 patients, in whom intracranial hypertension was present in 9 patients (9/14) with no characteristic changes in routine and biochemical examination of cerebrospinal fluid (CSF). Brain CT/MRI and CTV/MRV showed direct signs of CVST in all 22 patients, involving superior sagittal sinus, transverse sinus, sigmoid sinus, straight sinus and cortex veins, parenchymal lesions (infarction, hemorrhage and white matter abnormalities) in 13 patients (59.09%), subarachnoid hemorrhage (SAH) in 2 patients (9.10%) and subdural hematoma in one patient (4.55%). The involved cerebral sinuses revealed by DSA were superior sagittal sinus in 13 patients (59.09% ), transverse sinus in 17 patients (77.27%), sigmoid sinus in 14 patients (63.64%), inferior sagittal sinus in 2 patients (9.10%), straight sinus in 4 patients (18.18%), vein of Galen in one patient (4.55%) and jugular vein in one patient (4.55%). Two thrombosed sinuses were found in 9 patients (40.91% ) and 3 or more thrombosed sinuses in 8 patients (36.36% ). As no clinical improvements and progressive exacerbation were observed several days after heparin sodium intravenous drip or lower molecular weight heparin (LMWH) hypodermic injection with oral warfarin anticoagulant therapy, urokinase thrombolysis in venous sinus or artery was applied in 21 patients (95.45%). After (25.70 ± 12.18) d treatment with anticoagulation, the modified Rankin Scale (mRS) score of 13 patients (59.09% ) reached 0-1, 4 patients (18.18% ) 2 and 5 patients (22.73% ) 3-4, with the total effective rate reaching 77.27% (17/22).  Conclusions  The severely affected CVST usually have multiple sinus thromboses, deep venous thrombosis and parenchymal lesions. Endovascular thrombolysis together with primary anticoagulation may result in good outcomes in these patients.

Key words: Sinus thrombosis, intracranial, Anticoagulants, Thrombolytic therapy