Kamada Takashi, Tateishi Takahisa, Yamashita Tamayo, Nagata Shinji, Ohyagi Yasumasa, Kira Jun-Ichi
Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University.
Rinsho Shinkeigaku. 2013;53(5):356-61. doi: 10.5692/clinicalneurol.53.356.
We report a 58-year-old man showing spastic paraparesis due to medulla oblongata compression by tortuous vertebral arteries. He noticed weakness of both legs and gait disturbance at the age of 58 years and his symptoms progressively worsened during the following several months. General physical findings were normal. Blood pressure was normal and there were no signs of arteriosclerosis. Neurological examination on admission revealed lower-limb-dominant spasticity in all four extremities, lower-limb weakness, hyperreflexia in all extremities with positive Wartenberg's, Babinski's and Chaddock's signs, mild hypesthesia and hypopallesthesia in both lower limbs, and spastic gait. Cranial nerves were all normal. Serum was negative for antibodies against human T-cell lymphotropic virus-1 antibody. Nerve conduction and needle electromyographic studies of all four limbs revealed normal findings. Cervical, thoracic and lumbo-sacral magnetic resonance imaging (MRI) findings were all normal. Brain MRI and magnetic resonance angiography demonstrated bilateral tortuous vertebral arteries compressing the medulla oblongata. Neurovascular decompression of the right vertebral artery was performed because compression of the right side was more severe than that of the left side. Post-operative MRI revealed outward translocation of the right vertebral artery and relieved compression of the medulla oblongata on the right side. The patient's symptoms and neurological findings improved gradually after the operation. Bilateral pyramidal tract signs without cranial nerve dysfunction due to compression of the medulla oblongata by tortuous vertebral arteries are extremely rare and clinically indistinguishable from hereditary spastic paraplegia (HSP). Although we did not perform a genetic test for HSP, we consider that the spastic paraparesis and mild lower-limb hypesthesia were caused by compression of the medulla oblongata by bilateral tortuous vertebral arteries based on the post-operative improvement in symptoms. Given the favorable effects of surgery, tortuous vertebral arteries should be considered in the differential diagnosis of patients presenting with progressive spastic paraparesis.
我们报告一名58岁男性，因迂曲的椎动脉压迫延髓而出现痉挛性截瘫。他在58岁时注意到双腿无力和步态障碍，在接下来的几个月里症状逐渐加重。全身体格检查结果正常。血压正常，无动脉硬化迹象。入院时的神经系统检查显示，四肢均以下肢为主的痉挛，下肢无力，四肢腱反射亢进，伴有华滕伯格征、巴宾斯基征和查多克征阳性，双下肢轻度感觉减退和触觉减退，以及痉挛性步态。颅神经均正常。血清人类T细胞嗜淋巴细胞病毒-1抗体检测为阴性。四肢的神经传导和针极肌电图检查结果均正常。颈椎、胸椎和腰骶部磁共振成像（MRI）结果均正常。脑部MRI和磁共振血管造影显示双侧迂曲的椎动脉压迫延髓。由于右侧压迫比左侧更严重，因此对右侧椎动脉进行了神经血管减压术。术后MRI显示右侧椎动脉向外移位，右侧延髓压迫解除。术后患者的症状和神经系统检查结果逐渐改善。因迂曲的椎动脉压迫延髓导致双侧锥体束征而无颅神经功能障碍极为罕见，临床上与遗传性痉挛性截瘫（HSP）难以区分。虽然我们没有对HSP进行基因检测，但基于术后症状改善，我们认为痉挛性截瘫和双下肢轻度感觉减退是由双侧迂曲的椎动脉压迫延髓所致。鉴于手术的良好效果，对于出现进行性痉挛性截瘫的患者，在鉴别诊断时应考虑迂曲的椎动脉。
