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[NEJM临床医学影像]:移动的主动脉血栓
2017年07月26日 临床影像, 临床话题 暂无评论

IMAGES IN CLINICAL MEDICINE

Mobile Aortic Thrombi

Ville Sallinen, M.D., Ph.D., and Pirkka Vikatmaa, M.D., Ph.D.

N Engl J Med 2017; 377:e2 July 13, 2017

DOI: 10.1056/NEJMicm1702263

An 85-year-old woman with essential thrombocytosis, coronary artery disease, and a remote history of venous thromboembolism presented with abdominal pain, fever, vomiting, and diarrhea. Physical examination revealed tenderness and guarding in the lower abdomen. Laboratory results showed a white-cell count of 11,800 per cubic millimeter (reference range, 3400 to 8200), a d-dimer level of 6.7 mg per liter (reference range, <0.5), a platelet count of 562,000 per cubic millimeter (reference range, 150,000 to 360,000), and a lactate level of 0.8 mmol per liter (reference range, 0.5 to 2.2). Computed tomography of the abdomen and gated aortic magnetic resonance imaging revealed four intraaortic thrombi (arrows) attached to the wall of the descending aorta that moved in synchrony with the cardiac cycle (see video). Edema of the small-bowel mesentery and multiple infarctions of the spleen could also be seen. An exploratory laparotomy was performed owing to the possibility of mesenteric ischemia, but no ischemic bowel was found. The development of mobile thrombi in the aorta is rare; a possible mechanism is thrombus formation on top of atherosclerotic plaques. The patient began anticoagulation therapy, and repeat imaging showed decreases in the size of the thrombi. Unfortunately, candidemia developed, and the patient died approximately 1 month after the initial presentation.

一名85岁女性患者既往罹患血小板增多,冠心病及多年前静脉血栓栓塞史。患者因腹痛、发热、呕吐和腹泻就诊。体格检查发现下腹部压痛及肌卫。实验室检查显示白细胞计数11,800/mm3(正常值3400 - 8200)d-二聚体 6.7 mg/L(正常值<0.5),血小板计数562,000/mm3(正常值150,000 - 360,000),乳酸水平0.8 mmol/L(正常值0.5 - 2.2)。腹部CT及主动脉MRI显示降主动脉血管壁附着4个主动脉内血栓(箭头),与心动周期同步移动(参见 视频)。此外,还可见小肠系膜水肿和脾脏多发梗死。由于怀疑可能有肠系膜缺血,进行了剖腹探查手术,但未发现肠道缺血表现。主动脉内发生移动性血栓非常罕见;可能机制为在动脉粥样硬化斑块表面形成血栓。患者接受抗凝治疗,复查影像学检查显示血栓缩小。遗憾的是,患者发生了念珠菌血症,就诊后大约1个月死亡。

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