Lammy Simon, Fivey Paul, Sangra Meharpal
Neurological Surgery (Neurosurgery), Department of Neurosurgery, Institute of Neurological Sciences, 1345 Govan Road, Glasgow, G51 4TF, UK.
J Med Case Rep. 2016 Dec 20;10(1):368. doi: 10.1186/s13256-016-1145-7.
Cryptogenic stroke frequently occurs in younger patients and has a high risk of recurrence. Consequently, secondary prevention is often suboptimal as there is no known risk factor to target. This case demonstrates an unexpected finding of middle cerebral artery infarction and extensive malignant transformation in a 16-year-old boy more than a day post-admission. The lack of a proven culprit lesion makes this case even more intriguing and subsequently raises questions of cryptogenic mechanisms in the context of unrelated trauma.
A 16-year-old white boy had been stabbed in his chest but had a Glasgow Coma Scale score of 15. Over a day later he developed sudden signs and symptoms consistent with a neurological event of unknown etiology. Computed tomography demonstrated significant cerebral edema but was equivocal in its list of differentials. A computed tomography scan of his chest demonstrated no cardiac wall or vascular injury and he was transferred to our neurosurgical unit for intracranial pressure monitoring. A computed tomography angiogram revealed an unexpected finding of malignant middle cerebral artery infarction. Failure to medically manage his intracranial pressure resulted in a decompressive craniectomy less than 12-hours postictus. Despite extensive diagnostic investigations no culprit lesion was identified and no patent foramen ovale found. Since discharge he has returned to full functional status. He was the youngest patient (mean age of 43 years) out of a 10-year institutional retrospective on decompressive craniectomies for malignant middle cerebral artery infarction (n = 40) and had the singularly best Glasgow Outcome Scale score of 5.
This case highlights the preponderance of cryptogenic stroke in younger patients and its etiological elusiveness. It further demonstrates that age is predictive in terms of survival and functional outcome in the context of malignant middle cerebral artery infarction.
隐源性卒中常见于年轻患者，复发风险高。因此，二级预防往往不尽人意，因为没有已知的风险因素可供针对。本病例展示了一名16岁男孩在入院一天多后出现大脑中动脉梗死和广泛恶性转化这一意外发现。缺乏已证实的罪魁祸首病变使该病例更具吸引力，随后引发了在无关创伤背景下隐源性机制的问题。
一名16岁白人男孩胸部被刺伤，但格拉斯哥昏迷量表评分为15分。一天多后，他突然出现与病因不明的神经事件相符的体征和症状。计算机断层扫描显示有明显脑水肿，但在鉴别诊断方面不明确。他胸部的计算机断层扫描未显示心脏壁或血管损伤，随后他被转至我们的神经外科病房进行颅内压监测。计算机断层血管造影显示意外发现恶性大脑中动脉梗死。未能通过药物控制其颅内压导致在发病后不到12小时进行了减压颅骨切除术。尽管进行了广泛的诊断性检查，但未发现罪魁祸首病变，也未发现卵圆孔未闭。出院后，他已恢复到完全功能状态。在一项针对恶性大脑中动脉梗死减压颅骨切除术的10年机构回顾性研究（n = 40）中，他是最年轻的患者（平均年龄43岁），格拉斯哥预后量表评分为5分，是唯一最好的评分。
本病例突出了年轻患者中隐源性卒中的优势及其病因的难以捉摸。它进一步表明，在恶性大脑中动脉梗死的情况下，年龄对生存和功能结局具有预测性。
