Delgado Montserrat G, Rodríguez Sergio, García Raquel, Sánchez Pablo, Sáiz Antonio, Calleja Sergio
Neurology Service, Hospital Universitario Central de Asturias, Oviedo, Spain.
Rheumatology Service, Hospital Universitario Central de Asturias, Oviedo, Spain.
J Stroke Cerebrovasc Dis. 2015 Aug;24(8):e209-11. doi: 10.1016/j.jstrokecerebrovasdis.2015.04.016. Epub 2015 Jun 5.
A 77-year-old woman with atrial fibrillation (AF) treated with warfarin had a cortical left middle cerebral artery (MCA) stroke (October 2009, international normalized ratio [INR], 1.6) and a cortical left frontal stroke (October 2011, INR, 1.9). Anticoagulation was adjusted. In October 2011, she had a right frontal stroke (INR, 2.3). Acetylsalicylic acid (ASA) was temporally added to the treatment. In June 2013, she had a left occipital stroke (INR, 2.3). Warfarin was changed to rivaroxaban. In August 2013, she had a right occipital stroke. ASA 100 was added to the treatment. On all occasions, repeated neurovascular studies and echocardiography were normal. Diagnoses were cardioembolic stroke. In November 2013, she was admitted because of a left MCA stroke. A complete blood analysis showed the presence of anticardiolipin, anti-b2-glycoprotein antibodies, and lupus anticoagulant. Primary antiphospholipid syndrome (APS) was later confirmed. APS should be considered in young stroke patients, however is not frequent in stroke patients older than 70 years with several cerebrovascular risk factors. The existence of AF in our patient with several embolic strokes made the cardiembolic etiology likely. Uncommon causes of stroke were not considered despite the repetition of the ischemic events. Thus, a wider etiological study should be made in all patients with a recurrent stroke regardless of age, such as a complete blood analysis including immunology study in order to exclude an APS of late onset.
一名77岁接受华法林治疗的房颤（AF）女性患者，发生了左侧大脑中动脉（MCA）皮质卒中（2009年10月，国际标准化比值[INR]为1.6）和左侧额叶皮质卒中（2011年10月，INR为1.9）。抗凝治疗进行了调整。2011年10月，她又发生了右侧额叶卒中（INR为2.3）。治疗中临时加用了乙酰水杨酸（ASA）。2013年6月，她发生了左侧枕叶卒中（INR为2.3）。华法林换用了利伐沙班。2013年8月，她发生了右侧枕叶卒中。治疗中加用了100mg的ASA。所有情况下，重复的神经血管检查和超声心动图均正常。诊断为心源性栓塞性卒中。2013年11月，她因左侧MCA卒中入院。全血细胞分析显示存在抗心磷脂、抗β2糖蛋白抗体和狼疮抗凝物。随后确诊为原发性抗磷脂综合征（APS）。APS应在年轻卒中患者中予以考虑，但在有多种脑血管危险因素的70岁以上卒中患者中并不常见。我们这位有多次栓塞性卒中且存在房颤的患者，心源性栓塞病因可能性大。尽管缺血事件反复发生，但未考虑卒中的罕见病因。因此，对于所有复发性卒中患者，无论年龄大小，都应进行更广泛的病因学研究，如包括免疫学研究的全血细胞分析，以排除迟发性APS。
