Discussion of Case

1. Discussion of Case

2. 疑难病例讨论 神经内科 魏微 2006.12.20

3. Case Characteristic • This patient is a female with age 79 • Acute onset • Initail symptom was headache and fever • The situation aggravated rapidly, dead after two weeks • She had congenital heart disease, cardiac inadequacy occurred gradually

4. 病历特点 • 患者79岁，高龄女性; • 急性起病; • 首发症状为头痛、发热； • 病情进展迅速，发病到死亡2周； • 既往有先心病病史，逐渐出现心功能不全；

5. Medical examination • Breathing sound of lungs was coarse, moist rale could be found. • Heart bouncary expanded, heart rate was irregular, double phase noise was found in cardiac apex • Liver was under costa 3CM • Two sides Babinski was positive by nervous system check

6. 体格检查 • 双肺呼吸音粗，可闻及湿性罗音; • 心界扩大，心律不齐，心尖部可闻及双期杂音; • 肝脏肋下3CM; • 神经系统检查双侧Babinski征阳性。

7. Auxiliary examination • Lab examinaion: BUN10.5mmmol/l, WBC was normal, neutrality classificatin was a little high. • Imageology examinaion: • Lung CT :There was double-lung lump shadow, the shadow of heart expanded • Brain MRI was normal

8. 辅助检查 • 实验室检查：BUN10.5mmol/l，白细胞正常，中性分类高。 • 影像学检查： • 1）胸部CT双肺团块影、心影增大；符合心力衰竭。 • 2）头颅MRI平扫未见异常；

9. Auxiliary examination • Heart ultrasonic inspection: atrial septal defect(ASD), tricuspid incompetence, arteria pulmonalis expandation, pulmonary valve backstreaming, mitral regurgitation(MR), composite congenital heart disease. • ECG: atrial fibrillation with conduction block (CB) on right bundle branch(RBB)

10. 心脏超声检查：房间隔缺损、三尖瓣关闭不全、肺动脉扩张、肺动脉瓣返流、二尖瓣返流；符合先心病。心脏超声检查：房间隔缺损、三尖瓣关闭不全、肺动脉扩张、肺动脉瓣返流、二尖瓣返流；符合先心病。 心电图提示：房颤伴右束支传导阻滞 辅助检查

11. Diagnosis Analysis

12. 诊断分析

13. Location Analysis • Double-side pyramidal tract damage based on double-side pathology were positive.

14. 定位分析 • 根据双侧病理征阳性定位于双侧锥体束损害。

15. Qualitative Analysis:

16. 定性分析及诊断：

17. Diagnosis 1: menigeal canceration support: • The sufferer is senile. • Acute/subac onste • Heavy headache • No physical sign for cerebrum parenchyma damage • Brain MRI is normal • Suspectable focus of infection on lungs • Possibility of menigeal canceration cannot be excluded

18. 诊断1.脑膜癌病 支持点： • 患者高龄 • 急性/亚急性起病 • 头痛剧烈 • 无脑实质损害的定位体征 • 头颅MRI检查未见异常 • 可疑的肺部占位病灶 • 不能除外脑膜癌病的可能

19. nonsupport: • No cancer cell found by cerebrospinal fluid cytological examination. • No abnormal found by enhanced MRI

20. 不支持点： • 1.无脑脊液细胞学检查发现癌细胞的证据 • 2.无增强MRI检查结果

21. Menigeal Canceration • Menigeal Canceration is meninges diffuse infiltrating by cancer cell. • It can be classified as primarily and metastatic, the later is more popular and of which lung cancer metastasis is more common. • Symptom of brain is headache,emesis, obvious meningeal irritation sign. Its main characteristic is severe headache, gradual aggravation. Sometimes behaved as epileptic attack, awareness and mental aberration

22. 脑膜癌病是脑脊膜弥漫性癌细胞浸润。 • 分原发性、转移性，以后者多见，其中肺癌脑转移最常见。 • 脑部症状以头痛、呕吐、脑膜刺激征突出，剧烈头痛、渐进性发展、不缓解为特点。部分可表现癫痫发作、意识及精神障碍。

23. This disease can also has fever, but usually low-grade fever, which is caused by metabolic product of tumor diffused into blood and this is different from fever caused by infection. • Examination of cerebrospinal fluid is important to diagnose this disease. Its criteria is high pression of skull, high WBC in cerebrospinal fluid, high proteinum and low carbohydrates.

24. 本病也可出现发热，但一般低热，系肿瘤代谢产物进入血液引起，与感染性发热不同。本病也可出现发热，但一般低热，系肿瘤代谢产物进入血液引起，与感染性发热不同。 • 脑脊液检查对本病诊断有重要意义。颅压高、脑脊液白细胞高、蛋白高、糖低。

25. It cannot exclude possibility of this disease if no malignant cell found in cerebrospinal fluid. Multiple examination of cerebrospinal fluid can improve the detection rate of malignant cell. • Using CEA/EMA immunocytology examination can also improve the detection rate.

26. 脑脊液细胞学检查未找到癌细胞不能排除本病，反复多次查脑脊液可提高癌细胞的检出率。脑脊液细胞学检查未找到癌细胞不能排除本病，反复多次查脑脊液可提高癌细胞的检出率。 • 用CEA/EMA免疫细胞学检查可提高检出率。

27. This disease behaved as complication and diversification. And it is difficult to to make a definite diagnosis. Especially primary lesion is usually masked. Damage of nervous system simply reflects as headache, which make diagnosis more difficult.

28. 该病临床表现复杂化、多样化，生前诊断很困难，常易漏诊、误诊。特别是原发病灶隐蔽、神经系统损害单纯表现为头痛诊断更加困难。该病临床表现复杂化、多样化，生前诊断很困难，常易漏诊、误诊。特别是原发病灶隐蔽、神经系统损害单纯表现为头痛诊断更加困难。

29. Summary1: • This sufferer should have done further lumbar puncture cerebrospinal fluid cytology examination if condition allowed. • If cortical sulci nodus focus of infection or irregular thickening of meninges can be found by Enhanced Skull MRI examination, this assumption can be furthersupported. • Meningeal carcinomatosis has two types: diffuse and focal. And can occur diffuse linetype intensification or nodus intensification

30. 回顾总结1 • 该患者如有条件应进一步腰穿脑脊液细胞学检查。 • 头颅增强MRI检查如发现脑沟池内结节病灶或脑膜不规则的增厚强化进一步支持诊断。 • 脑膜癌病肿瘤生长以弥漫性和局灶性两种，可出现弥漫性线型强化、结节型强化。

31. 脑脊液细胞学检查

32. 头颅MRI平扫未见明显异常 增强扫描可见脑膜明显强化

33. 头颅MRI平扫未见异常 增强扫描可见脑膜明显强化

34. 图1.矢状位ＴＷＩ扫描脑膜未见异常图2.水平增强ＴＷＩ扫描,见硬脑膜 蛛网膜沿颅骨内侧面呈线型、弯曲状增强,该增强不伸入脑沟

35. 图3. 冠状位增强Ｔ1ＷＩ扫描,见小脑幕、大脑镰增强(箭头)图4.横轴位增强扫描显示主要为软脑膜 蛛网膜下腔弥漫性增强,该增强伸入脑沟　

36. 图5　横轴位Ｔ1ＷＩ扫描脑膜未见异常　图6　增强Ｔ1ＷＩ扫描,见硬脑膜 蛛网膜增强(箭头)同时伴有软脑膜、 蛛网膜下腔弥漫性增强　

37. Currently, mixed intensification found by enhanced skull MRI is an important symbol for meningeal carcinomatosis diagnosis. • If primary lesion in lung could be confirmed, it might be meninges carcinomatosis complicated by lung cancer. • But the patient's family refuse further examination, so we couldn't find related evidence.

38. 目前认为头颅MRI增强扫描混合型强化是脑膜癌病与其他鉴别的重要标志。目前认为头颅MRI增强扫描混合型强化是脑膜癌病与其他鉴别的重要标志。 • 如能确定肺部原发病灶可考虑肺癌并发脑膜转移。 • 但患者家属拒绝进一步检查，无法寻找诊断证据。

39. Diagnosis 2: Brain metastases tumor support: • old age • heavy headache • had doubtful primary lesion in lung nonsupport: • No abnormal found by brain MRI

40. 诊断2.脑转移瘤 支持点： • 患者高龄 • 头痛剧烈 • 有可疑的肺部原发占位病灶 • 应考虑肺癌脑转移瘤 不支持点： • 头颅MRI平扫未见异常

41. Brain has rich blood suply,and its blood flow accouns for 20% in the body. The possibility of lung cancer embolus transferred to brain is high. • Moreover, lung cancer has the characteristic of addict to nerve tissue, expecially for central nerve. So it is easy for lung cancer embolus transfer. • Intracranial metastasis focus has four types: 1.brain essence transfer,2 skull metastasis focus 3. scleromeninx metastasis focus 4. meninges metastasis focus.

42. 脑具有丰富的血液供应，血流量占全身血流量20%，肺癌栓子转移到脑组织的机会高，另外肺癌具有嗜神经组织的特性，对中枢神经组织具有特别的亲和力，肺癌脑转移发生机率大。 • 颅内转移灶有四种形式：1）脑实质转移2）颅骨转移灶3）硬膜下转移灶4）脑膜转移灶。

43. As for this patient, no abnormal found by skull MRI, while most brain metastases tumor can be confirmed by MRI • But a very few cases in early phase, MRI cannot find abnormal symbol. • Enhanced MRI should be used if highly suspect brain metastases tumor. Sometimes even dosis of constrast medium can be added.

44. 患者头颅MRI检查未见异常，绝大多数脑转移瘤MRI即可诊断。患者头颅MRI检查未见异常，绝大多数脑转移瘤MRI即可诊断。 • 但极少数病例在转移的早期，或者病灶位于皮层，MRI平扫不能发现异常信号。 • 当临床高度怀疑脑转移瘤时应增强扫描，甚至造影剂可加大剂量。

45. 肺癌脑转移,ＭＲＩ增强可显示平扫未显示的转移灶肺癌脑转移,ＭＲＩ增强可显示平扫未显示的转移灶

46. 左图为左颞叶单发转移右图为ＭＲＩ增强显示为多发转移左图为左颞叶单发转移右图为ＭＲＩ增强显示为多发转移

47. when brain metastases tumor happens, part of blood brain barrier (B.B.B.) will be damaged. Newly born micrangium of tumor develops badly.So permeability is high. Enhanced CM Gd-DTPA easilly permeates into interstitial fluid.Enhanced scan can discover focus of infection, which cannot be found by plain scan.

48. 脑转移瘤时局部血脑屏障破坏，肿瘤新生毛细血管发育差，通透性增加，增强对比剂 Gd-DTPA极易渗透到局部组织间液中，出现显著强化，平扫时不能显示的病灶增强时可显示。

49. Summary 2: • Enhanced scan can find more ealier focus of infection, and improve detection rate. Especially for little focus without peripheral edema, it has more importance. • This patient didn't do enhanced skull MRI, so brain metastases tumor cannot be excluded.

50. 回顾总结2 • 增强扫描可以发现更多更早的病灶，从而提高病灶的检出率，特别是对于没有周围水肿的小病灶诊断意义更大。 • 本患者未能进行增强头颅MRI检查因此不能完全除外脑转移瘤。