孤立性延髓脓肿的临床诊治分析

目的:分析孤立性延髓脓肿的临床表现、诊治及预后。方法:对2014—2017年海军军医大学附属长海医院神经内科确诊的2例孤立性延髓脓肿患者的临床资料进行回顾分析。结果:患者分别为48岁女性、39岁男性,均以急性头晕起病,病程6~10 d,可伴有饮水呛咳(2/2)、声音嘶哑(2/2)、视物成双(1/2),查体可见患侧咽反射迟钝或消失(2/2)、对侧浅感觉障碍、肌力减退(1/2)、闭目难立征阳性(1/2)。病程中曾有低热。头MRI平扫+增强示左侧延髓小片状(或结节状)稍长T1、稍长T2信号,磁共振成像液体衰减反转恢复序列(fluid attenuated inversion recovery,FLAIR)呈高信号,扩散加权成像(diffusion-weighted imaging,DWI)呈高信号,增强后边缘呈环形强化。感染源不明。给予2种以上能透过血脑屏障的广谱抗生素联合抗感染治疗后,患者临床表现及影像学均较前明显好转。出院后随访,恢复良好,未复发。结论:延髓脓肿极罕见,部分病因不明,细菌培养可能阴性,较典型的影像表现为囊壁光滑的环形强化占位灶。对于脓肿位置深或位于功能区、直径较小、薄壁者首选单纯药物治疗,静脉应用血-脑屏障渗透性好的广谱抗生素,并根据患者临床症状及脓腔变化进行调整。

Clinical diagnosis and treatment of solitary medulla oblongata abscess

Objective: To analyze the clinical features, diagnosis, treatment, and prognosis of solitary medulla oblongata abscess. Methods: From 2014 to 2017, clinical data of 2 patients diagnosed as solitary medulla oblongata abscess were retrospectively analyzed. Results: One patient was female aged 48 years, and the other patient was male aged 39 years. The disease duration of 2 cases ranged from 6 to 10 days. The first symptom was acute dizziness, which may be accompanied by choking (2/2), hoarseness (2/2), or diplopia (1/2). Nervous system examination showed slow or disappeared gag reflex at the affected side (2/2), disorders of shallow sensation disturbances and limb paralysis at the contralateral side (1/2), and positive Romberg''s sign (1/2). Low fever occurred during the course of the disease. Computed tomography and magnetic resonance angiography showed no obvious abnormality. Abnormal signal was found in the left medulla oblongata on magnetic resonance imaging, and the edges showed ring reinforcement after enhancement. Cerebrospinal fluid examination showed no significant abnormality. The source of infection was unknown. Given two or more broad-spectrum antibiotic that readily penetrate the blood-brain-barrier, the clinical manifestations and imaging were significantly improved. The patients were followed up with good outcomes. Conclusions: The medulla oblongata is extremely rare with some unknown etiology. Negative bacterial cultures may be associated with limited lesions. The typical images show cystic space-occupying lesions with a smooth inner wall and ring-enhancement. For abscess which is deep or in functional areas, and with smaller diameter or thin wall, intravenous administration of antibiotics is the first choice. Broad-spectrum antibiotics that easily penetrate the blood-brain-barrier should be adjusted according to the changes of patient''s clinical symptoms and abscess cavity.