兒童腦血管疾患病因與復健成效之探討：病例報告

Etiology and Rehabilitation Effect of Stroke in Child: A Case Report

董莉貞(Li-Chen Tung) ； 楊國德(Kwok-Tak Yeung) ； 王淳厚(Chun-Hou Wang) ； 梁文宜(Wen-I Liang) ； 畢柳鶯(Liu-Ing Bih)

《中華民國復健醫學會雜誌》 29卷4期 (2001/12) Pp. 235-242

https://doi.org/10.6315/JRMA.200112.0235

摘要

兒童時期腦血管疾患年發生率為2.5/100,000，其中梗塞型中風佔57-85%，出血型中風15-51%，梗塞型中風以先天性心臟病為首要原因，主要症狀為急性偏癱；出血型中風則以動靜脈畸形比率最高，頭痛及意識混亂為主要表現。與成人相較，兒童由於有較豐富的側枝循環及發展未完全的腦部，故臨床表現及恢復狀況異於成人。預後和復發率主要取決於根本病因和起始傷害的嚴重度，故正確診斷並加以預防其誘發病因為避免腦血管疾患再發的首要之務。
本篇探討一病前正常發育的五歲男童，因頭痛、嘔吐、意識不清、左上肢局部癲癇及右側肢體無力而送醫。經核磁共振併血管攝影掃描(magnetic resonance angiogram)，包括動靜脈掃描(MR arteriogram and venogram; MRA and MRV)，結果除了雙側中腦、左側大腦腳、左橋腦及左小腦梗塞外，並無其他血管畸形或病變。患童接受多項檢查，包括血液常規/生化檢查、紅血球沉降速率、凝血時間、抗凝血酵素III、抗核抗體、腦脊髓液檢查、腦波、心臟超音波等，皆無異常發現，尚無法診斷出腦血管疾患的病因。但經復健治療，於發病兩個月後開始步態訓練，九個月後可以獨自行走跑跳，步態也趨近正常，由於有中度嚴重扁平足故使用旋前控制足部裝具(pronation control foot orthoses)來矯正。以足底壓力步態分析儀(computer dynography)評估行走平衡，表現良好，但左側肢體仍有輕度運動失調，心理衡鑑除動作能力與其相關能力作業表現受限外，智能正常。此男童復原狀況良好，唯一遺憾是無法找出致病原因，故復發機率屬未知數。應考慮再作尿液及血液胱氨酸(homocystine)檢驗，血漿凝血脢元(prothrombin)、anticardiolipin antibody等其他可能病因之篩檢，或是正子造影(positron emission tomography, PET) 探測腦部代謝、單光子放射電腦斷層(single photon emission computed tomography, SPECT)偵測腦血流變化，或許有助於發現病因，仍建議男童定期回門診追蹤檢查，以降低復發的可能性。

關鍵字

腦血管疾患 ； 核磁共振併血管攝影 ； 足底壓力步態分析儀

並列摘要

The incidence of strokes in childhood is 2.5/100,000. Of these, occlusive stroke accounts for 57 to 85 percent, and hemorrhagic stroke accounts for 15 to 51 percent. Occlusive stroke is primarily caused by congenital heart defects, and the principal symptom is acute hemiplegia. Hemorrhagic stroke is caused mostly by abnormalities of blood vessels, and is characterized by headache and loss of consciousness. Compared to adults, children have better collateral circulation and incompletely developed brains. The clinical and recovery courses those in children are different from those of adults. The prognosis and the incidence of stroke recurrence are largely determined by the etiology of stroke and the degree of severity, so that accurate diagnosis and prevention of causative factors are very important in preventing recurrence of the cerebrovascular disease.
The present study explores a case of a five-years-old boy with normal development, presenting with headaches, vomiting, loss of consciousness, and left-side focal seizures and weakness on the right side of the body. The magnetic resonance angiogram showered occlusive stroke to both sides of midbrain, left cerebral peduncle, left pons, and left cerebellum, but no other malformations of blood vessels were noted. The patient underwent multiple tests, including CBC/DC, biochemical analyses, erythrocyte sedimentation rate, PT/APTT, antithrombin III, antinuclear antibodies, cerebrospinal fluid examination, EEG and cardiac sonography, none of which revealed any abnormalities. This patient received rehabilitation and started gait training two months after the onset of illness. He could walk, run, and jump, and gait was almost normal nine months later. Since the patient had moderately, flat feet, pronation control foot orthoses were used for correction. Computer dynography was used to assess balance in walking, with good performance indicated. However, the left limbs still showed a slight degree of uncoordination in motion. The developmental evaluation showed a slight limitation in movement and related abilities, the other mental function and intelligence were normal. The boy made a good recovery, but the cause of the stroke still unknown. Consideration should be given to do urine and blood homocystine tests, and screening for other possible causes such as prothrombin and anticardiolipin antibody tests, PET study for the brain metabolism, or SPECT study for the cerebrovascular circulation. These tests may be useful in discovering the causative factor. It was suggested that the boy return to the clinic for periodic follow-up in order to reduce the likelihood of recurrence.

並列關鍵字

stroke ； magnetic resonance angiogram ； computer dynography