蜘蛛網膜下腔出血併缺血性腦中風續發膈神經功能異常造成單側橫膈肌麻痺：病例報告

Unilateral Diaphragm Paralysis secondary to Subarachnoid Hemorrhage and Ischemic Stroke with Phrenic Nerve Dysfunction: A Case Report

黃世昕(Shih-Shin Huang) ； 陳建旻(Chien-Min Chen) ； 林家弘(Chia-Hung Lin)

《台灣復健醫學雜誌》 49卷2期 (2021/12) Pp. 193-203

https://doi.org/10.6315/TJPMR.202112_49(2).0006

摘要

背景：大腦中風可引起諸多神經功能異常及障礙，其中吞嚥困難、呼吸功能異常及行動能力受限使得肺炎成為中風後最常見的併發症之一。橫膈肌是人體的主要呼吸肌群，由膈神經（phrenic nerve）支配，當膈神經功能異常時可引發橫膈肌麻痺，並因此產生呼吸功能異常。回顧相關文獻，大腦中風是造成膈神經功能異常引發橫膈肌麻痺的原因之一，但僅有少數文獻探討此現象，本篇病例報告將討論大腦中風續發膈神經功能異常造成單側橫膈肌麻痺之可能機轉、臨床表現、診斷與治療方式及其預後。病例報告：個案為一位61歲男性，新診斷為蜘蛛網膜下腔出血併左中大腦動脈梗塞，因仍有右側肢體無力、語言理解區之失語症及吞嚥困難而至本科接受復健訓練。個案休息時呼吸功能正常，但在接受復健訓練時發生間歇性呼吸急促，血氧飽和度為88%-90%，使用鼻導管給予氧氣後可改善症狀，無體溫異常，理學檢查無明顯肢體發疳（cyanosis）或水腫，無端坐呼吸，聽診顯示右下肺呼吸音減少，有雙側底部濕囉音，無喘鳴聲，血液檢查無肝腎功能異常、無電解質異常亦無白血球增加， 靜態心電圖檢查無異常，因懷疑肺炎、橫膈肌無力及肋膜積水等病因，故安排進一步影像檢查，胸部X光及電腦斷層顯示新發生之右側橫膈肌上升，雙側微量肋膜積液，無異常腫塊或淋巴結腫大。考量右側橫膈肌上升可能為膈神經功能異常造成，故安排膈神經之神經傳導檢查，其結果顯示左側膈神經複合動作電位（compound motor action potential, CMAP）正常，右側膈神經刺激無複合動作電位訊號產生，顯示右側膈神經病變。胸腔超音波檢查顯示右側橫膈肌吸氣時無明顯收縮活動。由於個案因失語症及認知功能不佳無法配合指令，無法安排完整肌電圖及肺功能測試。診斷為蜘蛛網膜下腔出血及左中大腦動脈梗塞續發右側膈神經功能異常導致右側橫膈肌麻痺。個案在接受3週的復健訓練後，可順利完成每次的訓練並減少氧氣使用頻率。結論：大腦中風可引起膈神經功能異常而導致橫膈肌麻痺，其可能機轉為皮質脊髓路徑（corticospinal tract）之傳導異常及膈神經元受損而續發橫膈肌麻痺並引起肺功能障礙，造成運動性呼吸困難及咳痰功能下降。因此若大腦中風個案有明顯運動性呼吸困難及咳痰功能下降時，應接受進一步胸腔影像學、膈神經傳導、橫膈肌電圖及肺功能評估，確認是否有橫膈肌麻痺或膈神經功能異常，作為後續治療計畫擬定之依據。

關鍵字

蜘蛛網膜下腔出血（subarachnoid hemorrhage） ； 缺血性腦中風（ischemic stroke） ； 出血性腦中風（hemorrhage strok） ； 橫膈肌麻痺（diaphragm paralysis） ； 膈神經（phrenic nerve）

並列摘要

Background: Cerebrovascular accident may lead to neurological symptoms and functional defects. Impaired respiratory and swallowing function as well as limited mobility make pneumonia a common complication after stroke. The diaphragm is innervated by the phrenic nerve and is a major respiratory muscle. Phrenic nerve dysfunction can lead to diaphragm paralysis and result in abnormal respiratory function. Cerebrovascular accident of cerebral hemisphere is one of the etiologies of phrenic nerve dysfunction and can lead to respiratory symptoms. There are few discussions in current literature regarding secondary diaphragm paralysis after cerebrovascular accident of cerebral hemisphere. This case report presents the clinical signs of unilateral diaphragm paralysis after cerebrovascular accident of cerebral hemisphere and discusses about the possible pathophysiology, symptoms, complications, diagnosis, treatment, and prognosis. Case: The patient is a 61-year-old man diagnosed with subarachnoid hemorrhage and left middle cerebral infarction. Due to persistent right limb weakness, Wernicke's aphasia and dysphagia, he was admitted to our ward for further rehabilitation. His respiratory pattern was smooth and normal at rest. However, he suffered from intermittent exertional dyspnea during rehabilitation with a blood O_2 saturation level of 88%-90%. Dyspnea improved with supplemental oxygen by nasal cannula. His body temperature was normal. Physical examination showed no limb edema, cyanosis, or orthopnea. Auscultation of the chest showed decreased breath sounds of right lower lung and bilateral basal crackle without wheezing. Blood test showed normal renal and liver functions, no electrolyte alterations and no leukocytosis. The resting electrocardiogram was normal. Due to the suspicion of pneumonia, diaphragm paralysis, and pleural effusion, we arranged chest X-ray and Computed tomography (CT) for further information. The chest X-ray and CT showed new onset right diaphragm elevation with mild bilateral pleural effusion and no abnormal mass or lymph node enlargement. Due to the suspicion of right diaphragm paralysis, phrenic nerve conduction study was performed to evaluate phrenic nerve function. This study revealed the absence of right phrenic compound motor action potential, but intact on the left side. The patient was diagnosed with right phrenic nerve axonal neuropathy. The chest echo showed absence of right diaphragm movement during inspiration. The patient could not complete pulmonary function test because of Wernicke's aphasia and impaired cognitive function. According to previous examination, the diagnosis was subarachnoid hemorrhage and left middle cerebral artery infarction with secondary right phrenic nerve injury and right diaphragm paralysis. After receiving rehabilitation, the patient could complete the training program smoothly and less supplemental oxygen therapy was needed during rehabilitation. Conclusion: Cerebrovascular accident of cerebral hemisphere can lead to phrenic nerve dysfunction and secondary diaphragm paralysis, which may further impair pulmonary function. The possible pathophysiology after stroke is the corticospinal tract disturbance and phrenic nerve motor neuron damage. The diaphragm paralysis may lead to exertional dyspnea and impaired cough ability. If a patient with stroke has exertional dyspnea and difficulty coughing, further examination include chest image study, pulmonary function test, diaphragm electromyography and phrenic nerve conduction study are suggested to confirm diaphragm paralysis or phrenic neuropathy and arrange further rehabilitation program.

並列關鍵字

subarachnoid hemorrhage ； ischemic stroke ； hemorrhage stroke ； diaphragm paralysis ； phrenic nerve

參考文獻

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