Takayasu disease concurrent cobweb subcranial hemorrhage, cerebral infarction 1 case reported

!---- Takayasu disease (Takayasu arteritis, TA) is also known as veinless disease, an unexplained arteritisthis paper reports on the complications of cobweb hypoliation bleeding and cerebral infarction in 1 case of TA patients, and discusses the possible causes of various complications of TA in combination with the literature1Case data patient, female, 19 years old, was hospitalized for "dizziness and vomiting for nearly January"patients before January no obvious cause of dizziness, dizziness, nausea and vomiting, vomiting for the contents of the stomach, weak limbs, no obvious cough, coughing sputum, no fever, no panic, chest tightness, chest pain discomfortin the local hospital to check blood pressure (right upper limb) 75/40mmHg (1mmHg -0.133kPa), parallel skull CT did not see significant abnormalities, blood routine red blood cells 3.07 x 1012/L, hemoglobin 102g/L, stool latent blood analysis show edifice positive; Complementary fluid, boost, anti-shock and other supportive treatment, but blood pressure did not see a significant increase, continued norepinephrine 5mL/h pump ingest maintenance, blood pressure maintained at 90/60mmHg, review blood routine red blood cells 3.17 x 1012/L, hemoglobin 101g/L, stool routine hidden blood negative, but the above symptoms did not improvehalf a month ago patients sudden headache, dizziness and dizziness did not see aggravation, there is still nausea, no obvious vomiting, limb activity is OK, emergency check head CT show right frontal temporal lobe brain ditch, external fissure and saddle pool high density shadow, brain front high density increase, consider cobweb membrane Lower cavity bleeding, immediately to reduce cranial pressure, nutritional nerves, hemorrhage and other treatment, patients headache, dizziness, dizziness discomfort slightly alleviated, in order to seek further medical treatment in my hospital, outpatient to "cobweb cavity hemorrhage and low blood pressure causes to be checked" hospitalpatients are physically fit and deny a history of high blood pressure, kidneys and heart: body temperature 36.5 degrees C, breathing 19 times / minute, heart rate 95 times / minute, blood pressure of the limbs: left upper limb 60 / 40mmHg, right upper limb 80 / 50mmHg, double lower limb 180 / 100mmHg, double pulse disappeared, blood oxygen saturation 99%Shenqing, mental poor, memory, computational and directional force normal, fluent language, two-sided pupils and other large such circles, light reflection sensitive, two-sided eye movement, no eye tremors, two-sided forehead symmetry, tongue center, two-sided nasal lip groove symmetry, limb muscle force and normal tension, two-sided tendon reflection symmetry, feeling and co-examination normal, pathologicalneck strong 2 fingers, two-sided K.C., (-plus)heart, lung and abdominal detection of no positive signsauxiliary examination: blood routine red blood cell count 3.19 x 1012/L, hemoglobin 102g/Lurine routine, stool analysis no abnormalities; biochemical set, blood clotting set, anti-cardiophospholipid antibodies, rheumatism and rheumatoid whole set, immune set, lupus anticoagulants are no abnormal; blood sink 53mm/H, hypersensitivity C reactive protein 8.2mg/Lcheck the neck and limbs venous color over-the-top display: double-sided cervical main artery wall thickening, tube cavity stenosis (a major arteritis change possible);review the head CT show the right side of the forehead flaky density slightly reduced the lesions of the stove, accompanied by slight swelling of the right brain tissue, considering the cobweb subcavity bleeding absorption after the change, significantly better than beforeconsider the diagnosis as: TA; cobweb subcavity hemorrhage, and give discontinuation of boost treatment, hormones (Astrong dragon 40mg static droplets, qd), nutritional nerves, improve mood (Shecurin tablets 50mg, oral, qd) and other treatment treatment after 15d treatment of the above symptoms significantly improved, patients did not complain of headache, dizziness and drowsiness, limb activity is OK, did not complain of other special discomfort, check body: blood pressure of the limbs: left upper limb 60/45mmHg, right upper limb 70/55mmHg, double lower limb110/7 0mmHg, two-sided artery pulse disappear, God, memory, computational and directional force normal, language fluency, craniofacial nerve (-), limb muscle force and muscle tone normal, double-sided tendon reflection symmetry, sensory and co-check normal, pathological signs not led, neck soft, double-sided Kerch signs (-) review the head MRI show: left frontal lobe, temporal lobe, right top temporal lobe, right buckle to bring back the brain back abnormal signal, two-sided half-egg center, left base section area, left amygdala, right temporal lobe multiple spot abnormal signal, combined with medical history, more consideration for fresh infarction, consider the possible vasculitis caused by, recommended combined with clinical the skull MRI-DWI-MRA show: the front artery starting part of the left brain, the upper artery at the right side of the brain, the upper artery inthetle is less average, the tube cavity stenosis; skull PWI show: the above changes, combined with flat sweep and DWI and MRA, more consideration for the infarction changes, vasculitis caused by the possibility final diagnosis: TA disease; cobweb subcavity hemorrhage; cerebral infarction after discharge from the hospital to give hormones (aperisone 36mg, qd), improve mood, stomach protection, potassium supplementation, calcium, anti-platelet aggregation (by aspirin) and other treatments, half a month after the review of blood, hypersensitivity C reaction protein are normal after decreased the amount of athapine, follow-up for six months, the patient's life and study is normal, the inflammatory index is normal, did not relapse 2 80% to 90% of TA cases are discussed in women, usually aged 10 to 40 years TA is widely distributed around the world and has the highest prevalence in Asia the cause of it has not been clarified, possible related factors include nutritional deficiencies, tuberculosis, syphilis, collagen diseases, rheumatic fever, autoimmune diseases and nonspecific allergic reactions lesions mainly affect the aortic arch, head and arm artery, cervical artery and carotid artery, causing the arteries and branches of the tube cavity stenosis or blocking and the resulting brain dysfunction lesions are plaque-like or strip-like artery linings thickening, causing irregular stenosis and dilation of the arterial cavity, thrombosis may occur in different parts, and some have been re-opened TA diagnostic criteria established by the American Rheumatology Association (ACR) in 1990: (1) age at the time of onset and on the onset of symptoms or signs ( this case is a juvenile female) ;(2) limb with intermittent lameness, increased symptoms during activity; Side or double-sided large motor pulse reduction (in this case patient's double-sided artery pulse disappears) ;(4) double-sided limb systolic pressure difference of 10mmHg (left upper limb 60/40mmHg, right upper limb 80/50mmHg, double lower limb 180/100mmHg) ;(5) smell and murmur (two-sided collarbone artery smelland murmur) ;(6) aorta, one branch or upper and lower limb near end large Arterial angiography indicates arterial stenosis or blockage, which cannot be explained by arteriosclerosis, fibromyality, or other causes (about 90% stenosis of the near end of the artery in the left neck in this case); 3 of which meet this standard can be diagnosed, and this case meets 5 of the diagnostic criteria the team at Sun Yat-sen Hospital, affiliated with Fudan University, proposed TA diagnostic criteria in 2015: female (3 points), age of 40 (4 points), chest tightness or chest pain (2 points), black (3 points), vascular murmurs (2 points), pulse loss or Weakened (5 points), aortic arch and its branches were affected (4 points), abdominal aorta and its branches were affected (3 pointsChinese); the case score of 19 points, can be diagnosed with TA disease angiography is the gold standard for its diagnosis, and vascular color super can provide a change in vascular wall characteristics 1977 Lupi-Herrera, based on Ueno's TA classification, proposed four classifications: head arm artery type, which affects aorta and its branches; thoracic aortic type, cumulative degeneration of aorta and abdominal aorta; broad type, with the above two lesions; pulmonary artery type had the highest incidence of head arm artery type, followed by thoracic aorta type case is a head arm artery type cobweb subcavity bleeding is mostly found in patients with aneurysm or vascular malformation, TA disease causes cerebrovascular disease is mostly ischemic stroke, in a few cases hemorrhagic stroke including cobweb subcavity bleeding caused by the combined aneurysm, but this case patient DSA examination shows the left cervical artery near the near end of about 90% stenosis, no aneurysis and vascular malformation, no cobmesh alges analysis of the reasons may be: patients after the onset of the continuous use of norepinephrine, admission to the double lower extremities blood pressure reached 180/100mmHg, can be speculated in the patient appeared in the subcavity of the cobweb cavity bleeding, still continued to norepinephrine treatment, although not measured double lower extrem blood pressure, but can be speculated that the patient's original central artery pressure may have been very high, may be long-term hypertension state is not detected, leading to combined intracranial hemorrhage the cause may be related to the combination of hypertension or damage to the artery itself based on TA disease altered intracranial arterial hemodynamics , there is no evidence of TA disease suing or intracranial artery pathological changes in intracranial blood vessels or aneurysm formation the pathogenesis of TA disease leading to cerebral infarction may be TA disease and neck blood vessels, the lesions of arterial wall fibrosis, diffuse or irregular thickening, hardening, causing different degrees of vascular stenosis or occlusion, while combining thrombosis, hydrant shedding blocking the far end of the blood vessels to form cerebral infarction when the neck artery stenosis or blocking causes the intracranial far end of the blood vessels low perfusion, when the side branch cycle is not good, easy to form a watershed brain infarction , vasculitis and intracranial artery or arterial embolism can lead to intracranial arterial stenosis if there is critical stenosis at the beginning of the two-sided artery, the blood flow of the brain will be significantly reduced when the patient is upright and the symptoms are repeated dizziness, dizziness and even fainting case was misdiagnosed as low-capacity shock, mainly combined with medical history analysis of the cause of misdiagnosis in the upper limb blood pressure can not be measured and low, pulse can not be touched, did not measure lower extremities blood pressure comparison, medical staff on the observation of the disease is not careful, the analysis of the disease is not careful enough, the diagnosis is too limited, in the anti-shock treatment process, blood pressure has not changed significantly, and the appearance of irritability and other symptoms, not timely alert suggestthat for young women to have unexplained upper limb blood pressure can not be measured or sustained low blood pressure, upper limbve veinless or weak pulse, should be alert to the possibility of aortitis, should be timely measurement of the blood pressure of the limbs to assist in diagnosis if highly suspectted TA, should promptly carry out vascular color super or angiography and other examinations to clear diagnosis, guide treatment TA includes active treatment and vascular occlusion active treatment is dominated by corticosteroids such as pernisone oral, and relapses during ineffective or pennicosone reduction can be treated with immunosuppressants such as cyclophosphamide or thiopental vascular occlusion treatment, the lesions of blood vessels are more limited feasible surgical excision or bypass surgery, intracranial vascular bypass surgery is beneficial to relieve the symptoms of cervical artery or vertebral artery ischemia the efficacy of angioding agent, anticoagulant and antiplatelet aggregation is uncertain the prognosis of TA mainly depends on the persistence of inflammation and the progression of complications TA is slow, most patients have a good prognosis, 5 to 10 years survival rate of about 80% to 97%, cerebral infarction, heart failure, kidney failure and hypertension patients with poor prognosis