肺炎支原体感染合并颅内静脉窦血栓1例并文献复习

A Case of Mycoplasma Pneumoniae Infection Complicated by Cerebral Venous Sinus Thrombosis with Literature Review

摘要: 目的：讨论儿童颅内静脉窦血栓(CVST)的病因机制，提高对该病临床特点的认识，及早识别、干预和治疗，以降低相关死亡及后遗症风险。方法：回顾性分析2023年11月青岛大学附属医院儿童医学中心收治的一例肺炎支原体(MP)感染合并CVST患儿临床资料，并以“颅内静脉血栓”、“颅内静脉窦血栓”、“脑静脉窦血栓”、“儿童”、“child”“pediatric”“cerebral venous sinus thrombosis”、“intracranial venous thrombosis”为关键词，对中国知网、万方数据库、中国生物医学文献数据库、Pubmed相关文献进行检索，结合文献分析，对儿童CVST的临床特点及预后进行总结。结果：本例患儿早期出现轻微呼吸道症状，后逐渐出现神经系统症状，出现意识障碍后就诊。经检查发现血清MP抗体IgM滴度高，D-二聚体及C反应蛋白高。脑血管DSA提示上矢状窦、双侧横窦、右侧乙状窦血栓形成。入院后逐渐出现呼吸节律不规则，血压升高，瞳孔不等大，颅脑CT示颅内出血，脑中线偏移，脑疝形成。经呼吸机辅助呼吸、抗感染、抗凝治疗后，患儿意识恢复，可独立行走。检索文献共检索到97例儿童CVST病例，结合本组病例共纳入98例，男59例(60.2%)，女39例(39.8%)，发病中位年龄9岁。起病方式以亚急性为主(59.2%)，其次为急性(25.5%)和慢性(15.3%)。多数患儿存在继发性危险因素，常见为感染(28.6%)、急性淋巴细胞白血病应用培门冬酶(16.3%)及肾病综合征(12.2%)。血栓多累及多条脑静脉窦，常累及上矢状窦、横窦及乙状窦。所有患儿均出现神经系统症状，35.7%伴癫痫发作。87.8%患儿接受抗凝治疗，经治疗后，85.7%血管再通、症状缓解，4.1%遗留神经系统后遗症，3.1%因原发病死亡，治疗过程中未见严重出血事件。结论：CVST神经系统症状异质性大，且非特异性，病因多样，机制复杂。MP感染为儿童常见病因。在MP流行季节，应关注患儿凝血状态，一旦出现神经系统症状，应警惕脑静脉血栓形成。本病预后良好，应积极治疗原发病及抗凝治疗。一旦脑静脉血栓形成，溶栓并不是首选治疗方案。

Abstract: Objective: To explore the etiological mechanisms of Cerebral Venous Sinus Thrombosis (CVST) in children, improve recognition of its clinical characteristics, and facilitate early identification, intervention, and treatment so as to reduce the risks of mortality and long-term sequelae. Methods: The clinical data of a pediatric patient with Mycoplasma Pneumoniae (MP) infection complicated by CVST admitted to the Children’s Medical Center of the Affiliated Hospital of Qingdao University in November 2023 were retrospectively analyzed. Using the keywords “intracranial venous thrombosis”, “cerebral venous sinus thrombosis”, “brain venous sinus thrombosis”, “children”, “child”, “pediatric”, “cerebral venous sinus thrombosis” and “intracranial venous thrombosis” relevant literature was searched in the China National Knowledge Infrastructure (CNKI), Wanfang Data, Chinese Biomedical Literature Database, and PubMed. The clinical characteristics and prognosis of pediatric CVST were summarized based on the retrieved literature. Results: The patient initially presented with mild respiratory symptoms, followed by progressive neurological manifestations, and sought medical care after developing impaired consciousness. Laboratory tests showed a high serum MP IgM antibody titer, elevated D-dimer levels, and increased C-reactive protein. Cerebral Digital Subtraction Angiography (DSA) revealed thrombosis of the superior sagittal sinus, bilateral transverse sinuses, and the right sigmoid sinus. After admission, the patient gradually developed irregular respiratory rhythm, elevated blood pressure, and anisocoria. Cranial computed tomography demonstrated intracranial hemorrhage, midline shift, and cerebral herniation. Following treatment with mechanical ventilation, anti-infective therapy, and anticoagulation, the patient regained consciousness and was able to walk independently. A total of 97 pediatric CVST cases were identified from the literature; together with the present case, 98 cases were included. There were 59 males (60.2%) and 39 females (39.8%), with a median age of onset of 9 years. Subacute onset was most common (59.2%), followed by acute (25.5%) and chronic (15.3%) onset. Most patients had secondary risk factors, most commonly infection (28.6%), followed by the use of pegaspargase for acute lymphoblastic leukemia (16.3%) and nephrotic syndrome (12.2%). Thrombosis frequently involved multiple cerebral venous sinuses, most commonly the superior sagittal sinus, transverse sinus, and sigmoid sinus. All patients presented with neurological symptoms, and 35.7% experienced seizures. Anticoagulation therapy was administered in 87.8% of patients. After treatment, 85.7% achieved vascular recanalization with symptom improvement, 4.1% had residual neurological sequelae, and 3.1% died due to underlying diseases. No serious hemorrhagic events were observed during treatment. Conclusion: The neurological manifestations of CVST are highly heterogeneous and nonspecific, with diverse etiologies and complex mechanisms. MP infection is a common cause of CVST in children. During MP epidemic seasons, attention should be paid to the coagulation status of affected children, and prophylactic anticoagulation may be considered when necessary. Once neurological symptoms occur, cerebral venous thrombosis should be suspected. Overall, the prognosis of CVST is favorable with timely management. Active treatment of the underlying disease combined with anticoagulation therapy is recommended, and thrombolysis is not considered the first-line treatment once cerebral venous thrombosis has developed.