酒精相关性癫痫心源性猝死1例报告
范真 冯芹
四川省德阳市人民医院神经内科,四川德阳 618000
[摘要]目的 提高对酒精相关性癫痫(ARS)患者心源性猝死原因的认识。方法 对1例ARS患者突发心源性猝死的病例资料进行分析及文献复习。结果 本例有饮酒史40年,4年内曾自行反复戒酒,并因出现精神行为异常曾两次入院,诊断为酒精戒断综合征,之后复饮,因发病前1日患者家属未在家中,不清楚患者发病前1天是否再次戒酒。此次因反复出现全身阵发性抽搐、呼之不应2 h入院,按酒精中毒性脑病、癫痫全面强直阵挛发作给予相应治疗,患者癫痫控制,意识好转后突发心律失常猝死。结论 酒精依赖症患者易出现癫痫发作,而癫痫发作后可诱发心律失常,其死亡风险明显高于其他人群,对该类人群应当早期戒酒并对癫痫发作后的心功能进行严密监测,并尽早干预治疗以预防心源性猝死的发生。
[关键词]酒精相关性癫痫;心源性猝死;酒精戒断综合征
国内的一项流行病学调查显示,我国约3.7%的人口存在酒精依赖症,酒精滥用和依赖的问题呈现逐年增加的趋势[1]。酒精依赖者中5%~15%会出现癫痫发作,比普通人群患病率高10~20倍[2-3],多数酒精相关性癫痫(alcohol related seizures,ARS)发作患者预后较好,但若出现癫痫持续状态,合并酒精对其他器官功能的损害,ARS患者死亡率明显高于其他人群。我院收治1例ARS突发心源性猝死患者,经及时收治后癫痫已得到控制,且无其他器官损害情况下发生猝死,现报道如下。
1 病例资料
患者,男,65岁,饮酒史40年,每日饮散装白酒(酒精多为>45°)0.5~1斤,4年内曾自行反复戒酒,并因出现精神行为异常曾两次入院,诊断为酒精戒断综合征,之后复饮,因发病前1天患者家属未在家中,不清楚患者发病前1日是否再次戒酒。入院前2 h家属发患者反复出现全身阵发性抽搐、呼之不应,每次抽搐持续几秒到数十秒,双眼向左侧凝视,呼吸急促,伴小便失禁,期间意识未恢复。既往史:否认癫痫、颅脑外伤、脑肿瘤等病史。入院时体格检查:T 36.6℃,P 114次/min,R 28次/min,BP 152/98mmHg,氧饱和度80%,消瘦,营养中等,昏迷。右侧颧部皮下血肿,左侧眉弓破裂,右侧手腕等多处擦伤,心率114次/min,律齐,未闻及心脏杂音;桶状胸,双肺呼吸音粗,右下肺可闻及少量湿啰音。神经系统检查:昏迷,双瞳孔等大圆形,直径4 mm,光反射迟钝,眼球可见无目的水平移动,双侧鼻唇沟对称,咽反射存在,肢体无不自主活动,痛刺激肢体可回缩活动,双侧病理征阴性。辅助检查:肝功能、凝血、脑钠肽、感染性疾病测定,电解质:Na+123.1 mmol/L,Cl88.2 mmol/L,血常规:白细胞计数15.53×109/L,中性粒细胞百分比85.5%,心肌损伤标志物:血清肌红蛋白测定479.52 ng/ml。头胸部CT:未见明显异常。入院后给予安定10mg反复静推3次后,于入院2 h后抽搐停止,改用苯妥英钠0.1 g,q8 h肌注,同时给予补充维生素B1、B12,脱水降颅压、纠正电解质紊乱等对症支持治疗。经治疗后,患者呈嗜睡状,空间定向力完整,理解力基本正常,四肢活动可,未再发抽搐,因患者症状好转,未予心肌损伤标志物、脑钠肽等相关指标复查。猝死前1 h检测,窦性心律,心率92次/min,氧饱和度97%;随后1 h再次复测,心率约50次/min,氧饱和度95%,立即安置心电监护,心率呈进行性下降;随后突然出现全身不自主抖动后呼吸停止,家属立即通知值班医师,触及脉搏微弱,心率、血压测不到,停止呼吸,经积极的心肺复苏抢救之后患者自主呼吸及心跳始终未恢复,临床考虑患者为心源性猝死。从发病到死亡时间约1 d。
2 讨论
国内的一项流行病学调查显示,我国约3.7%的人口存在酒精依赖症[1]。酒精依赖者中5%~15%会出现癫痫发作,比普通人群患病率高10~20倍[2-3]。Golub等[4-5]在动物实验中发现,慢性酒精中毒大鼠模型海马质量明显减少,同时自发性癫痫发生概率增加。Wilhelm等[6]通过磁共振对52例长期酗酒者海马体积进行测量,也证实酗酒者海马体积明显减小。Wilhelm等[7]的一项研究还表明,慢性酒精中毒患者的海马萎缩程度与患者所饮用酒类相关,长期饮用白酒较啤酒所导致的海马萎缩更严重。同时,Leone等[8]一项多中心研究显示,当每日乙醇量>50 g时会明显增加首次癫痫发作的风险,且多为全面强直阵挛发作。临床资料[9-10]表明,乙醇易产生自由基,并与细胞卵磷脂结合,造成细胞膜破坏,同时因其对脑组织亲和力强,可产生直接毒性作用,导致神经细胞坏死、萎缩,尤其是对大脑海马区域的损害是其导致癫痫发病的病理基础。维生素B1在体内的吸收会因乙醇中抗硫胺素物质的影响而减少,从而引起焦磷酸硫胺素的合成量下降,脑细胞代谢异常,结构和功能受损,进而诱发脑电波异常,促发癫痫发作[9-11]。同样,酒精戒断也可导致癫痫发作,危及患者生命[2]。Lutz等[3]的研究表明约1/3的酒精依赖症患者在酒精戒断过程中可出现癫痫发作,以男性为主,与年龄没有显著相关性,以强直-阵挛发作为主要临床表现,多为单次发作,少数为反复发作甚至癫痫持续状态,且出现癫痫持续状态的可能性与戒断次数呈正相关,戒断后48 h内为癫痫发作高峰期。Samokhvalov等[12]的研究也表明长期且大量饮酒的酒精依赖症患者更易出现癫痫发作,且癫痫发作风险与酒精戒断速度呈正相关。酒精戒断后癫痫发作的机制可能与以下原因有关:①离子通道,有人认为钙离子通道在酒精戒断后癫痫发作中起重要作用。Riegle等[13]与N′gouemo等[14]在动物实验中均发现酒精戒断后癫痫发作与下丘脑L型钙通道Cav密切相关,其表达在戒断后即增加,约24 h达峰后开始下降,48 h后恢复至初始水平,这与临床上酒精戒断后癫痫发作的峰值曲线基本一致。②递质失衡,酒精戒断能解除对兴奋性递质谷氨酸的抑制作用,同时降低抑制性递质γ-氨基丁酸与其受体亲和力,导致神经细胞兴奋性增加,促发癫痫。此外,重复戒断将导致去甲肾上腺素和促肾上腺皮质素释放素的分泌增加,导致交感神经系统被激活,神经元兴奋阈值下降[15]。大多数ARS发作患者预后较好,但出现癫痫持续状态风险增加,加之酒精对其他器官功能的损害,ARS患者死亡率明显高于其他人群[16]
本例报告中患者长达40年酗酒史,4年内曾自行反复戒酒,多次被诊断为酒精戒断综合征,之后复饮,因发病前1天患者家属未在家中,不清楚患者发病前1天是否再次戒酒。此次以反复抽搐发作为主要表现,头颅CT无明显异常病灶,既往无脑炎及颅脑外伤史,通过对文献复习,考虑为慢性酒精中毒及酒精戒断所致癫痫可能性均存在,患者反复癫痫发作呈癫痫持续状态,通过积极对症治疗,患者抽搐症状得到控制,意识好转,无明显心肺功能损害,无明显肝肾功能异常、电解质紊乱,突发进行性心动减缓猝死。目前大量的研究表明,癫痫引发心律失常十分常见,其常表现为心动过速、心动过缓/发作性心脏停搏、传导障碍等[17-18],癫痫持续状态后高碳酸血症、低氧血症均可改变离子通道的去极、复极,降低心律失常发生的阈值[19-20]。此外,Lathers等[21]研究发现,癫痫发作期及发作间期的棘波与心脏迷走神经与交感神经的异常放电存在同步现象,从而引起心律变化或传导异常等。研究表明,颞叶癫痫可能会导致自主神经功能紊乱[22],而全面性癫痫发作比颞叶癫痫对自主神经的影响更大[23]。综上,考虑本例报告中患者在无其他器官损害证据的情况下,可能为癫痫发作后诱发了心律失常,最终导致心源性猝死。若能对患者的心功能进行严密监测,并早期处理,则可能会挽救患者生命。
酒精依赖症患者易出现癫痫发作,而癫痫发作后可诱发心律失常,其死亡风险明显高于其他人群。对该类人群应当早期戒酒,戒酒可以减少癫痫发作的风险[8]。当癫痫发作时,应当明确是否为酒精引起,并完善脑电图检查给予合理的抗癫痫药物治疗,当癫痫得到控制后,还应当对患者的心功能进行严密监测,发现心力衰竭、心律失常等心功能异常时,应当进行及时的药物治疗,必要时进行起搏器的安置,以预防心源性猝死发生,有效提高患者的生活质量并延长生命。
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Report of sudden cardiac death of one case with alcohol related seizures
FAN Zhen FENGQin
Departmentof Neurology,People′s Hospital of Deyang in Sichuan Province,Deyang 618000,China
[Abstract]Objective To enhance awareness of causes of sudden cardiac death in patientwith alcohol related seizures (ARS).Methods Case data of sudden cardiac death in a patientwith ARSwas analyzed and reviewed.Results The patients had 40 years of drinking history and repeated quit drinking in 4 years bymyself,admitted to hospital because of mental and behavioral abnormalities for two times,he been diagnosed as alcohol withdrawal syndrome and then drank again.Because nobody was at home one day before the patient was ill,so it was not clear whether the patient quited drinking again.The patientwas admitted to hospital due to repeated systemic paroxysmal convulsions and calling without any answers for 2 hours.Corresponding treatmentswere according to alcoholic encephalopathy and generalized tonic clonic seizures.The patient was dead with sudden cardiac after epilepsy controlling and conscious improvement.Conclusion Patients with alcohol dependence are prone to epileptic seizure,then can induce arrhythmia.The risk of death was significantly higher than that of other crowd.For these Patients,early quit drinking,closemonitoring cardiac function after epileptic seizure and early intervention treatment should be done to prevent the occur of sudden cardiac death.
[Key words]Alcohol related seizures;Sudden cardiac death;Alcoholwithdrawal syndrome
[中图分类号]R742.1
[文献标识码]A
[文章编号]1674-4721(2016)08(c)-0040-03
(收稿日期:2016-06-24本文编辑:方菊花)
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