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首页> 外文期刊>The Internet Journal of Emergency and Intensive Care Medicine >Acute Ischemic Strokes after Central Line Placement
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Acute Ischemic Strokes after Central Line Placement

机译：中线放置后的急性缺血性中风

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Objective: To describe an uncommon complication of cervical central venous catheter insertion. Design: Case report. Setting: A major academic medical center. Patient: A 53-year-old female transferred to our institution with several acute cerebral infarcts in the anterior and posterior cerebral circulations after inadvertent central line placement into her right vertebral artery, with the length of the catheter in the aortic arch. Interventions: Surgical removal of intravascular catheter.Measurements and Main Results: Good clinical outcome. Conclusions: A complication of cervical venous catheter insertion can be inadvertent vertebral artery cannulation with subsequent ischemic strokes. Institutional Review Board: approved as case report IRB040265 Case Report A 53-year-old female was admitted to an outside hospital for cachexia and gastroparesis following partial gastrectomy for severe gastric ulcerative disease. Management required placement of a triple-lumen central line (TLC) for total parenteral nutrition (TPN). Initial attempts at placing a right subclavian vein were unsuccessful. Subsequently, a right cervical TLC was placed and TPN was initiated. Few minutes thereafter, the patient developed weakness in her left upper extremity, which quickly progressed to complete left hemiparesis and hypesthesia. Over the next several hours, her weakness improved, but she continued to have numbness in the left hand. A non-contrasted head CT showed no evidence of intracranial hemorrhage. She was started on clopidogrel and transferred to our hospital for further evaluation. Upon arrival, magnetic resonance imaging (MRI) and angiography (MRA) of the head were obtained which showed multiple areas of acute infarctions in the right cerebellar hemisphere, right and left occipital lobes, throughout the right middle cerebral artery territory, and a small infarct in a distal left middle cerebral artery branch. There was no evidence of hemorrhage. The intracranial MRA was normal. A transthoracic echocardiogram (TTE) demonstrated no cardioembolic source of emboli. However, no color Doppler or microbubble study to evaluate for the presence of a right-to-left shunt was performed. As a right-to-left shunt was in consideration as a source of the strokes, microbubble-contrasted TCD was done. Due to her poor peripheral venous access, the microbubble solution (9 cc normal saline and 1 cc air mixed via a 3-way stopcock) was injected into the right cervical TLC. The left MCA was interrogated without difficulty via the left middle temporal ultrasound window. The study was markedly positive immediately (<3 cardiac cycles) after injection (Figure 1), leading to the suspicion of an arterial location of the TLC. A blood gas sample confirmed arterial blood. TPN was stopped. A chest x-ray (Figure 2) was obtained that showed an unusual course of the TLC. A CT angiogram of the neck demonstrated that the TLC tracked lateral and posterior to the right internal jugular vein without puncturing it, and went on to enter the right vertebral artery, the tip was positioned in the aortic arch. The patient underwent right neck exploration with direct removal of the TLC and proximal thrombectomy with right vertebral artery primary repair. Following surgery, the patient's neurological status continued to improve. No other clinical evidence of ischemia or embolism was found.
机译：目的：描述颈中央静脉导管插入的罕见并发症。设计：病例报告。地点：主要的​​学术医疗中心。病人：一名53岁的女性因无意中线置入其右椎动脉，导管长度在主动脉弓内而转移到我们的机构，在前，后脑循环中发生了几次急性脑梗塞。干预措施：手术切除血管内导管。测量和主要结果：良好的临床结果。结论：颈静脉导管插入的并发症可能是椎管插管不慎和随后的缺血性卒中。机构审查委员会：作为病例报告获得批准IRB040265病例报告一名53岁的女性因严重胃溃疡性疾病部分胃切除术后因恶病质和胃轻瘫而入院。管理层要求为总肠胃外营养（TPN）放置三腔中线（TLC）。最初放置右锁骨下静脉的尝试未成功。随后，放置右颈TLC并开始TPN。此后几分钟，患者左上肢无力，迅速发展为完全左偏瘫和感觉异常。在接下来的几个小时中，她的虚弱程度有所改善，但左手仍然麻木。头颅CT无异常，无颅内出血迹象。她开始接受氯吡格雷治疗，并被转移到我们医院接受进一步评估。到达后，获得头部的磁共振成像（MRI）和血管造影（MRA），显示右小脑半球，右枕骨和左枕叶，整个右中脑动脉区域以及多个小梗塞区域有多个急性梗塞区域在左中脑动脉远端分支中。没有出血的迹象。颅内MRA正常。经胸超声心动图（TTE）显示没有栓塞的心脏栓塞来源。但是，没有进行彩色多普勒或微泡研究来评估从右到左分流的存在。由于考虑了从右至左的分流作为中风的来源，因此进行了微泡对比的TCD。由于她的外周静脉通畅不畅，因此将微泡溶液（9毫升生理盐水和1毫升空气通过三通旋塞混合）注入了右颈TLC。经由左中颞部超声窗口对左MCA进行了无障碍询问。注射后该研究立即显着阳性（<3个心动周期）（图1），导致怀疑TLC的动脉位置。血气样本证实了动脉血。 TPN已停止。获得的胸部X光照片（图2）显示了TLC的异常进程。颈部的CT血管造影照片显示，TLC在未穿刺的情况下跟踪了右颈内静脉的外侧和后方，并继续进入右椎动脉，其尖端位于主动脉弓内。该患者接受了直接切除TLC的右颈部探查，并进行了右椎动脉一级修复的近端血栓切除术。手术后，患者的神经系统状况持续改善。未发现缺血或栓塞的其他临床证据。

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