【关键词】 小脑出血；椎基底动脉供血不足；误诊
ABSTRACT Objective To analyze the cause of misdiagnosis of cerebellar hemorrhage as vertebro-basilar artery insufficiency so as to raise the rate of correct diagnosis of cerebellar hemorrhage. Methods A retrospective analysis was made to the hospitalized patients with cerebellar hemorrhage from March, 2003 to Jan., 2008 and found out the main causes of misdiagnosis as vertebro-basilar artery insufficiency Results 12 cases with cerebellar hemorrhage were misdiagnosed to vertebro-basilar artery insufficiency, the main causes of misdiagnosis were related to the lack of recognition, careless physical examination, the quick relief of clinical symptoms and the delay of skull CT scanning. Conclusions Careful physical examination, immediate skull CT scanning and specialized treatment are the key to decrease the misdiagnosis of cerebellar hemorrhage as vertebro-basilar artery insufficiency.
KEYWORDS cerebellar hemorrhage vertebro-basilar artery insufficiency diagnosis
1 临床资料
2 结果
3 讨论
小脑出血常见病因为高血压、脑动脉硬化症、脑肿瘤、脑血管畸形等，本组12例患者有9例患者既往有高血压病史，冠状动脉粥样硬化性心脏病史者5例，脑梗死病史者3例，9例眼底检查发现动脉硬化征象。因此，本组误诊为椎基底动脉供血不足的小脑出血的主要病因为高血压和动脉硬化。
客观因素：由于支配小脑的动脉均来源于椎基底动脉系统，因此，小脑出血和椎基底动脉供血不足的临床表现往往相似。小脑出血典型的临床表现：突发眩晕、恶心、呕吐、剧烈头痛，站立和行走不稳，肢体笨拙或取物不准，可有眼球震颤。还可因血肿及水肿压迫或破入第四脑室而出现脑干受损体征、肢体锥体束征和意识障碍。但临床所见病例的表现往往不典型且较复杂，当病灶主要影响小脑与前庭的纤维联系时，主要表现为眩晕、呕吐，部分患者有平衡障碍。当其他体征不明显时，易被误诊为椎基底动脉供血不足。本组12例患者均以眩晕、恶心、呕吐、不敢睁眼及头部转动、行走不稳为首发症状，又无典型全套小脑体征(共济失调、眼球震颤、肌张力低、强迫头位)，因此将其误诊为椎基底动脉供血不足。
主观因素：神经系统检查不够细致全面。本组12例误诊为椎基底动脉供血不足的小脑出血，症状主要表现为眩晕、呕吐；体征虽无一例出现全套小脑体征，但每例均有部分小脑受损征象(眼震4例、共济运动失调8例)，而所有病例在入院查体时均未检出神经系统阳性体征，由于忽视了这些小脑体征，而造成误诊。
其次低估小脑出血的发病率，对其危险性认识不足。本组所有误诊的病例入院时均神志清楚，仅有一例患者在入院的第二天出现意识障碍，而文献报道小脑出血出现意识障碍约占40%［1］；本组6例患者既往有类似发作史，且3例不只一次发作；而通过按椎基底动脉供血不足治疗有5例患者的临床症状在一天内得到不同程度的缓解；这些都造成医生对患者病情未能引起足够重视，而未在入院查体后及时行头颅CT检查。上述几点也是误诊的不可忽视的原因。
【参考文献】
［１］ 陈清棠.临床神经病学［Ｍ］.北京：北京科学技术出版社，2000.217.
［2］ 黄如训，苏镇培.脑卒中［Ｍ］.北京：人民卫生出版社，2001.136.
