1SECTION1第一部分
A21-year-oldright-handedCambodianwomanwithnohistoryofheadachepresentedwith2weeksofprogressivebifrontalheadache.Shehadnosickcontactsorrecenttravel.ShemovedtotheUnitedStatesatage3years.Shehadnofever,nuchalrigidity,photophobia,phonophobia,nausea,orvomiting.Shehadarecenthistoryofweightlossandpalpitations.Therewasnotobaccoorillicitdruguseorhigh-risksexualbehavior.Shewasnotpregnantanddeniedcontraceptionuse.
21岁女性患者，来自柬埔寨，为右利手，既往无头痛病史，近2周出现双侧前额部疼痛，进行性加重。近期无病患接触、外出旅游史。自3岁移居美国。患者无发热、颈强直、畏光、畏声或恶心呕吐。近期出现体重下降及心悸。既往无吸烟、使用非法物质及高危性行为史。患者无怀孕且否认正在避孕。
Shehadanonfocalneurologicexamination.CTheaddonetoruleoutacuteintracranialpathologyshowedanabnormalitythatwasfollowedupbyMRIbrainwithandwithoutcontrast(figure1).
患者体查无神经系统阳性定位体征。予行头颅CT检查以排除急性颅内病变，检查结果提示颅内存在一个异常病灶，遂予完善常规及增强MRI。
图1头颅CT示右侧岛叶低密度病灶；头颅MRI示右侧岛叶弥散受限，FLAIR上也可见此处异常信号。
（A）头颅CT示右侧岛叶低密度（白色箭头）。（B）DWI和（C）ADC示右侧大脑中动脉供血区从右侧岛叶下白质延伸至右侧颞角的脑室周围白质弥散受限.（D）FLAIR也可见同部位的异常征象。
Questionforconsideration：
1.Whatarethedifferentialdiagnosestoconsider?
2.Howshouldweevaluatethepatientnext?
思考问题：
1．该患者需考虑哪些鉴别诊断？
2．如何进行进一步评估？
2SECTION2第二部分Thepatient’ssymptomsofheadacheandthefindingsonCTheadledustoperformanMRIbrain.FindingsonMRIincludedrestricteddiffusionintherightsubinsularwhitematter,extendingtotheperiventricularwhitematteralongtherighttemporalhorn,inferiorparietallobe,andfrontaltemporaloperculum,inthevascularterritoryofrightmiddlecerebralartery,associatedwithminimalgyriformenhancementorleptomeningealenhancement,mostconsistentwithearlyinfarcts.Thedifferentialdiagnosesfornew-onsetheadacheinthesettingofcerebralischemiabyimagingstudiesincludesstroke,CNSvasculitis,reversiblecerebralvasoconstrictionsyndrome,andlesslikelycerebralcorticalvenousthrombosis(MRIfindingofinfarctorhemorrhagestypicallyinnonarterialdistribution),meningitis(MRIfindingofleptomeningealenhancement),orencephalitis.
结合患者头痛症状和头颅CT检查结果，予完善头颅MRI检查，结果示右侧岛叶下白质延伸至右侧颞角的脑室周围白质、顶叶下部及额颞岛盖部，即右侧大脑中动脉供血区弥散受限，伴有小的脑回样增强和软脑膜增强，高度提示早期脑梗死。结合新发头痛症状及影像学提示存在脑缺血，鉴别诊断包括：脑卒中、中枢神经系统血管炎、可逆性脑血管收缩综合征，及可能性较小的脑皮质静脉血栓形成（头颅MRI可见脑梗死或脑出血为典型的非动脉分布特征）、脑膜炎（头颅MRI可见软脑膜增强）及脑炎。
Cerebralautosomaldominantarteriopathywithsubcorticalinfarctsandleukoencephalopathy;mitochondrialencephalopathy,lacticacidosis,andstrokelikeepisodes;andMoyamoyasyndromeshouldalsobeconsideredinyoungpatients(＜45years)presentingwithstrokelikesymptoms.Septicemboliinendocarditisleadingtosepticangiitisshouldbeconsideredintheappropriateclinicalsetting.1
在有卒中样症状的年轻患者（45岁）中还应考虑以下疾病：伴有皮质下梗死和白质脑病的常染色体显性遗传性脑动脉病（CADASIL）、线粒体脑肌病伴高乳酸血症和卒中样发作（MELAS综合征）及Moyamoya综合征。当出现相关的临床证据时，还应将感染性心内膜炎脓毒栓子引起感染性血管炎纳入考虑。
Thepatientunderwentlumbarpunctureorfurtherevaluationofapossiblevasculiticprocess.CSFshowedproteinof.6mg/dL,glucoseof17mg/dL,leukocytes(62%neutrophils,32%lymphocytes,and6%monocytes),50erythrocytes,andanegativegramstain.CSFfindingsofelevatedleukocyteswithneutrophilpredominance,lowglucoselevels,andelevatedproteinledustobelieveshemighthavemeningitiswithvasculitisasa白癫风医院北京中科忽悠
