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摘要


自發性顱內低壓(spontaneous intracranial hypotension),是一種在沒有任何外傷、手術或接受任何硬膜穿刺的病史之下,以姿勢性頭痛合併低腦脊髓液壓力表現的一種症候群。頭痛的主要特徵,是症狀會因病患保持直立的姿勢而加重,當平躺時則症狀緩解。其它臨床上症狀有:噁心、嘔吐、眩暈、部份聽覺喪失、聽覺過敏、複視、腦神經麻痺等表現。治療方式包括平躺休息、硬膜上血液注射、椎管內食鹽水注射、口服咖啡因、甚至以外科做硬膜的修補手術。本個案是一位44歲男性,因搬運重物後發生反覆性姿勢性頭痛而來本院求診,臨床上沒有其他明顯症狀,理學檢查、神經學檢查及腦部電腦斷層檢查也都正常,病患在住院接受腰椎穿刺檢查及核子醫學TC-99mDTPA腦池顯影術檢查後,確定診斷為自發性顱內低壓,經臥床平躺休息、非類固醇性止痛藥、輸液點滴給予及硬膜上血液注射後,對其病況只短暫的改善,最後產生腦疝脫合併雙側硬膜下出血而死亡。任何不適當的出力如搬運重物,有可能引起自發性顱內低壓,對於自發性顱內低壓所引起的頭痛,臨床上表現較不具特異性,容易喪失早期正確診斷及適當治療的時機。因此本文就是在提醒臨床醫師,對於此類姿勢性頭痛要提高警覺並及早發現,以避免腦疝脫等之併發症。

並列摘要


Spontaneous intracranial hypotension (SIH) is a syndrome with feature of low cerebrospinal fluid pressure (CSF) resulting from CSF leakage without any history of dural puncture, surgery, or penetrating trauma. The most characteristic feature of the syndrome is a postural headache. The headache is accentuated when the patient is in the upright position and relieved in the recumbent position. Associated symptoms include stiff neck, nausea, vomiting, tinnitus, hyperacusis, deafness, photophobia, diplopia, nystagmus, visual loss, vertigo, anorexia, malaise, and cranial nerves palsy. SIH is treated by bedrest with fluid supplementation, oral caffeine, intrathecal saline infusion or epidural blood patch. If postural headache persists or neurologic symptoms occur, surgical repair is indicated. A 44-year-old man came to our hospital for severe postural headache with exacerbation, which was relieved in the supine position. He denied other symptoms including stiff neck, nausea, vomiting, tinnitus, hyperacusis, deafness, photophobia, diplopia, nystagmus, visual loss, vertigo, anorexia, and malaise. Results of lumbar puncture studies were negative. Radionuclide cisternography showed direct evidence of a CSF leakage at the middle thoracic spinal level after 4 hours. On the basis of these findings, a diagnosis of SIH was made. He was treated with intravenous hydration, bed rest, NSAID and epidural blood patching, but his symptoms improved temporarily. Conscious changed later and the subsequent brain CT scan demonstrated bilateral subdural hematoma and tonsillar herniation. Finally, he died of central brain herniation. In general, the symptoms of SIH are not specific at early time and easily loss the timing of diagnosis and treatment. Early awareness of this disease, appropriate examination and treatment offer the chance of cure.

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