先天性心臓病兒之腦卒中

Cerebrovascular Accidents in Children with Congenital Heart Disease

林季珍(Ghi-Jen Lin) ； 呂鴻基(Hung-Chi Lue) ； 沈友仁(Yu-Zen Shen)

《Acta Paediatrica Sinica》 20卷3期 (1979/09) Pp. 160-169

摘要

腦卒中是一個最常見，也是最嚴重的發生於先天性心臟病人之中樞神經系統併發症。以往認爲發生這種常會致死的腦卒中，對於先天性心臟病人而言是一種解脫。但近年來，由於抗生素治療及開心手術的進步，大部分的心臟病兒，經過開心手術治療，可能完全恢復正常，因而先天性心臟病已不再是不治之症。其腦卒中併發症之早期診斷與治療亦應予以重視與研究。本文論及20例先天性心臓病併發腦卒中症例，分爲三組：腦膿瘍11例，所謂的腦血管炎或大腦炎5例，腦血管栓塞或腦梗塞4例。分別佔同時期先天性心臟病兒之1.9%、0.9%、及0.8%。前二者又合稱顱內炎症。全部症例具有心臓內右至左血液短路。其中以法洛氏四重症最多佔70%，大血管轉位次之佔15%。顱內炎症好發於2歲以上，腦血管栓塞却常見於4歲以下的先天性心臟病兒。腦波、腦部掃描攝形及腦血管攝影檢查對於病灶之定位及三者之鑑別診斷幫助最大，但有些病例甚至要靠開刀或病理檢查結果才能確定診斷。
腦膿瘍之藥物及外科手術治療之死亡率很高。反之，膿瘍形成的前期（即腦血管炎或大腦炎），卽不需開刀，用抗生素治療卽可能痊癒。故著者等強調對於顱內炎症，必須做到早期診斷及治療，如果能在化膿前期給予適當且足量的抗生素治療，則有可能扼止膿瘍之形成而痊癒。但是一旦發現有膿瘍形成，則應立卽予以開刀治療。此外，對於腦卒中之治療，還要矯正然血球增多症及相對性貧血。而要預防此種腦卒中之發生，則需適時做開心矯正手術，以除去其危險因素。

並列摘要

Cerebrovascular accidents (CVA) remain a serious complication of congenital heart disease (CHD). Twenty cases of this disease were admitted to the Department of Pediatrics of the National Taiwan University Hospital between 1968 and 1977. Among them, 11 had brain abscess; 5 cerebral vasculitis or cerebritis; and 4 cerebral thrombosis or infarction. The former two categories were designated as intracranial suppurative disease. The overall frequency of CVA among our patients with CHD during the past 10year period was 3.6%, and that of abscess, cerebral vasculitis or cerebritis, and cerebral thrombosis or infarction was 1.9%, 0.9% and 0.8% respectively. All cases had an intracardiac right-to-left shunt. Tetralogy of Fallot represented 70% and transposition of the great arteries represented 15% of the entire cases.
Most patients presented with convulsion, focal neurologic abnormalities, and signs and symptoms of increased intracranial pressure with or without evidences of infection. High index of suspicion was indispensable for the early diagnosis, and the differential diagnosis of abscess formation, cerebritis, and cerebral thrombosis or infarction was not always infallible even after comprehensive neurological studies. In 2 of our cases with cerebral infarction, the diagnosis was made at surgery or even by biopsy.
Of the 11 cases with abscess, 7 received a surgical intervention with a surgical mortality of 43%, and 4 succumbed before the surgery was attempted, making up to overall mortality of 64%. In the 5 cases with cerebral vasculitis or cerebritis in whom prompt and appropriate antibiotic therapy was given, the abscess formation was aborted and a complete recovery without neurological sequel was achieved, indicating that the outlook of the patients with intracranial suppurative disease can be altered by making an early presumptive diagnosis and the prompt administration of appropriate antibiotics. Correction of polycythemia and relative anemia also played an important role in tile management of the patients with CVA, and corrective open heart surgery must be resorted to prevent the occurrence of this complication.

並列關鍵字

cerebral vasculitis ； cerebritis ； brain abscess ； cerebral thrombosis ； infarction ； congenital heart disease