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血小板分离术:伴有反应性血小板增多症的症状性颈动脉血栓患者的非手术治疗。

Plateletpheresis: Nonoperative Management of Symptomatic Carotid Thrombosis in a Patient with Reactive Thrombocytosis.

机构信息

Neurosciences Critical Care, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA.

Neurosciences Critical Care, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA.

出版信息

World Neurosurg. 2018 Jun;114:126-129. doi: 10.1016/j.wneu.2018.03.075. Epub 2018 Mar 16.

Abstract

BACKGROUND

The most common pathology associated with an intraluminal carotid thrombus is underlying atherosclerosis. In rare cases, it may be associated with thrombocytosis. Currently there are no clear recommendations for the treatment of ischemic stroke associated with thrombocytosis. Our present case illustrates the use of plateletpheresis for the acute management of thrombocytosis complicated by an internal carotid artery thrombus resulting in a right middle cerebral artery stroke.

CASE DESCRIPTION

A 55-year-old female who presented with symptoms of acute, transient left hemiparesis and a National Institutes of Health Stroke Scale (NIHSS) score of 1. Initial head computed tomography (CT) scan was nonrevealing. Laboratory results revealed a mild hypochromic anemia and a platelet count of 1014 × 10/mL. The patient was not a candidate for thrombolytic therapy due to the time window. Soon after admission, she experienced acute worsening of symptoms, with an NIHSS score of 18. CT angiography of the head and neck showed acute ischemic infarction involving the right middle cerebral artery territory with a nonocclusive intraluminal thrombus within the right carotid bulb. Aspirin 325 mg and intravenous heparin infusion were initiated. After a thorough workup, reactive thrombocytosis secondary to iron deficiency anemia was diagnosed. Plateletpheresis was started, and after 1 cycle the platelet count stabilized at 400 × 10/mL. Complete thrombus resolution was confirmed on follow-up CT angiography on day 10 after admission without the need for surgical revascularization.

CONCLUSIONS

The role for plateletpheresis in treating secondary thrombocytosis is not well established. In cases with extreme thrombocytosis, immediate surgical thrombectomy may be contraindicated owing to a high risk of rethrombosis. Urgent cytoreduction with correction of the putative mechanism for thrombocytosis should be undertaken to provide optimal management.

摘要

背景

与管腔内颈动脉血栓相关的最常见病理学表现是潜在的动脉粥样硬化。在极少数情况下,它可能与血小板增多症有关。目前,对于与血小板增多症相关的缺血性卒中,尚无明确的治疗建议。我们目前的病例说明了血小板分离术在伴有颈内动脉血栓形成的血小板增多症的急性治疗中的应用,该血栓导致右大脑中动脉卒中。

病例描述

一名 55 岁女性,表现为急性短暂性左侧偏瘫和 NIHSS 评分为 1 分。初始头部 CT 扫描无明显异常。实验室结果显示轻度低色素性贫血和血小板计数为 1014×10/mL。由于时间窗的原因,该患者不符合溶栓治疗的条件。入院后不久,她的症状急剧恶化,NIHSS 评分为 18 分。头颈部 CT 血管造影显示右侧大脑中动脉区域急性缺血性梗死,右侧颈动脉球内有非闭塞性管腔内血栓。给予阿司匹林 325 mg 和静脉肝素输注。经过全面检查,诊断为缺铁性贫血继发反应性血小板增多症。开始进行血小板分离术,在第 1 个周期后,血小板计数稳定在 400×10/mL。入院后第 10 天的随访 CT 血管造影显示完全血栓溶解,无需手术血管再通。

结论

血小板分离术治疗继发性血小板增多症的作用尚未得到充分确立。在血小板极度增多的情况下,由于再血栓形成的风险很高,可能会立即禁忌进行手术血栓切除术。应紧急进行细胞减少治疗,并纠正血小板增多的潜在机制,以提供最佳治疗。

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