Delayed Cerebral Abscess Formation After Posterior Cerebral Artery Stroke in a Patient With Opioid Use Disorder.
Delayed Cerebral Abscess Formation After Posterior Cerebral Artery Stroke in a Patient With Opioid Use Disorder.
复制标题
阿片类药物使用障碍患者后脑动脉中风后脑脓肿延迟。
DOI：
10.1161/strokeaha.120.031081
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发表时间：
2021-03
期刊：
影响因子：
8.3
通讯作者：
Fehnel CR
中科院分区：
文献类型：
--
作者：
Zuflacht JP;Fehnel CR
一名患有阿片类药物使用障碍的33岁右利手男子，出现右臂无力和意识模糊。他发热，心动过速，嗜睡，但能够睁开眼睛重复的语言刺激。有最低限度的自发言语输出。注意力不集中限制了全面的精神状态测试。检查的其他相关特征包括右侧同向性偏盲、左侧凝视偏好、右侧鼻唇沟扁平和右侧轻偏瘫。国立卫生研究院卒中量表评分为15。头部计算机断层扫描（CT）显示左颞叶和枕叶低密度。CT血管造影显示左侧大脑后动脉（PCA）在顶枕动脉和距状动脉分叉处突然切断，与PCA远端闭塞一致。考虑到这些影像学结果（CT显示完全梗死，CT血管造影显示远端闭塞），以及最后一次已知情况未知，他不是再灌注治疗的候选者。出于对感染性心内膜炎（IE）的担忧，他开始使用经验性广谱抗生素。经胸超声心动图显示一个中等大小的移动的肿块附着在主动脉瓣上，疑似赘生物，支持基于杜克标准的IE诊断。1系列血培养均为甲氧西林敏感金黄色葡萄球菌阳性。一个巨大的纵隔脓肿需要多次清创。患者被转换为萘夫西林给予多重阳性培养物与相同的生物体从血液和manuely.The患者进行磁共振成像（MRI）的大脑2天后（图1），证实了一个大的左PCA区域梗死。考虑到梗死的范围--累及丘脑和内侧颞叶--假设脓毒性血栓最初阻塞了近端PCA（导致左侧大面积PCA梗死），随后远端栓塞（如血管成像所示）。
A 33-year-old right-handed man with opioid use disorder presented with right arm weakness and confusion. He was febrile, tachycardic, and somnolent but able to open his eyes to repeated verbal stimulation. There was minimal spontaneous speech output. Inattention limited full mental status testing. Other pertinent features of the examination included a right homonymous hemianopia, left gaze preference, right nasolabial fold flattening, and right hemiparesis. National Institutes of Health stroke scale score was 15. Head computed tomography (CT) demonstrated a hypodensity in the left temporal and occipital lobes. CT angiography revealed an abrupt cutoff of the left posterior cerebral artery (PCA) at the bifurcation of the parieto-occipital and calcarine arteries, consistent with a distal occlusion of the PCA. Given these imaging findings (completed infarction on CT, distal occlusion on CT angiography), and unknown last known well, he was not a candidate for reperfusion therapy. He was started on empirical, broad-spectrum antibiotics out of concern for infective endocarditis (IE). Transthoracic echocardiogram revealed a moderately sized mobile mass attached to the aortic valve suspicious for a vegetation, supporting the diagnosis of IE based on the Duke criteria. 1 Serial blood cultures were positive for methicillin-susceptible Staphylococcus aureus. A large mediastinal abscess required multiple debridements. The patient was transitioned to nafcillin given multiple positive cultures with the same organism from both the blood and manubrium.The patient underwent magnetic resonance imaging (MRI) of the brain 2 days later (Figure 1), confirming a large left PCA territory infarct. Given the extent of the infarct—involving both the thalamus and medial temporal lobes—it was hypothesized that a septic thrombus had initially occluded the proximal PCA (causing the large left PCA infarct) and subsequently embolized distally (as seen on vessel imaging).