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Progressive Ischemic Myelopathy due to Painless Aortic Dissection: A Case Report

無痛性主動脈剝離引發進行性缺血性脊髓病變:病例報告

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摘要


主動脈剝離之臨床症狀包括突發性的胸痛或腹痛,肢體發冷及肢體出汗,出現如同休克般的症狀,有些病人會出現脈搏消失或不對稱的情形。假如某些特定器官的支配血管正位於剝離後所造成偽腔的位置,就會產生組織突發性的缺血性傷害,如脊髓的缺血,進而造成脊髓的傷害。在過去的文獻中顯示大約有20%主動脈剝離的病人會因血液供應的問題而合併神經學的症狀,而大部分主動脈剝離的病人都會有嚴重的急性胸痛或腹痛之症狀。在本篇文章中,我們要報告一個脊髓長期缺血並以進行性神經缺損來表現的病例,而長期缺血的原因可能來自於無痛性的主動脈剝離。這是一位66歲的男性病患,到院時以下半身輕截癱來表現,檢查後發現其雙上肢肌力為5/5而雙下肢肌力則為3-4/5,刺痛覺在兩側第六胸椎以下異常,輕觸覺在右側第九胸椎與左側第十一胸椎以下異常,震動覺與本體感覺則皆屬正常,深肌腱反射在兩下肢均有異常增強的情形,肛門的主動收縮正常且肛門反射與球體海綿體肌反射均正常,核磁共振影像顯示降主動脈在T4到T10處有剝離的情形並於偽腔內發現血栓,此外,病患之胸部脊髓則有明顯萎縮的現象,以T6到T8處最為明顯,就目前可見的文獻資料,並無類似的報告被提出。

並列摘要


The clinical appearance of aortic dissection is characterized by the sudden, acute chest or abdominal pain, accompanied by coldness in the limbs and sweating-like symptoms of shock. Absent pulse or asymmetric pulse was observed in some patients. If the feeding arteries of the specific organs are located in the false lumen, this may lead to sudden loss of blood supply to the tissue e.g. spinal cord, resulting in cord damage. In the previous reports, approximately 20% of the individuals with aortic dissection might have neurological deficit resulting from insufficiency of blood supply. Most of the patients had suffered from severe chest or abdominal pain with sudden onset. Here we report a case with progressive neurological impairment because of long-term insufficient blood supply to the spinal cord. It is probably due to a painless aortic dissection. The patient was a 66-year-old male who presented with paraparesis. On examination, strength was 5/5 in both upper extremities and 3-4/5 in both lower extremities. Pricking sensation was relatively retarded below the sixth thoracic vertebra on both sides. Fine-touch sensation was limited below the ninth thoracic vertebra on the right side and below the eleventh thoracic vertebra on the left side. Responses to vibration and joint position sense were well preserved. Deep tendon reflexes were increased in his legs. He had voluntary anal contraction and preserved anal and bulbocavernous reflexes. MRI revealed dissection of the descending aorta from T4 to T10 levels with thrombus present in the false lumen, and the thoracic cord was marked atrophy, especially from T6 to T8 levels. To the best of our knowledge, no such case had been reported so far.

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