椎骨動脈の術後血栓症—血栓溶解剤・低分子デキストラン・抗凝血剤の三者併用により効果を認めた症例

POST-OPERATIVE THROMBOSIS OF THE VERTEBRAL ARTERY:REPORT OF A CASE SUCCESSFULLY RESOLVED BY COMBINED TREATMENT OF THE INTRAVENOUS INFUSION OF UROKINASE PLUS LOW MOLECULAR DEXTRAN AND THE ORAL ADMINSTRATION OF WARFARIN POTASSIUM

　外傷後に生ずる，頸動脈の血栓については，古くからよく知られ^10），多くの報告があるが，一方，椎骨動脈の血栓は，その頻度も少なく，かつ，予後も悪い^{2）17）19）30）}。たとえば，Murray^19）（1957）の集計では，閉鎖性頸部外傷に続発した頸動脈の血栓と椎骨動脈の血栓との割合は10：1であり，報告例の大部分は脳幹・小脳の軟化，出血をともなつて死亡している。すなわち，Carpenter^2）（1961）の例の血栓は，左椎骨動脈のC6横突孔から前脊髄動脈のレベルに及び左後下小脳動脈を充満し左小脳半球の軟化・膨大を示し，さらにMurray^19）の例では，右椎骨動脈の血栓は上方に進展して左椎骨動脈との合流点をこえて，右小脳にむかう血管群を閉塞し，右小脳半球の大きな軟化巣と延髄出血を生じている。

　ここに報告する症例は，椎骨動脈第1区分のCoilingに対して行なつた矯正手術^36）のあとに血栓を発生し，失神発作，右片麻痺などの急性発症をみた。発症5時間後から全身的に血栓溶解剤・抗凝血剤・低分子デキストランの三者併用療法を行ない，血栓溶解の過程を血管写によって追跡することができた症例である。

A patient, 41 year-old female, with chief complaitsof oscillopsia on rotating head to the right, unsteady gait, right tinnitus and fainting attacks was examined. Etiology was considered to be due to coiling of the right vertebral artery which became more marked on rotating head. With scalenotomy, freeing and straightening of the coiled segment of the artery was accomplished with wrapping a prothesis of a devided Teflon tube around the coiled segment. Measurement of blood flow through the vertebral artery was also done utilizing probes of the square wave electromagnetic flowmeter. The probe had a narrow slit of 1-2 mm in width. Through the slit, the vertebral artery was repeatedly passed into the probe. It was thought, in retrospect, this procedure was a cause of the post-operative thrombosis. Post-operatively, no oscillopsia, no unsteady gait, no tin-nitus was noted on rotating head until 9 clays post-op, when, fainting attack and right hemiparesis developed suddenly. Emergency vertebral angiogramthrough the brachial artery showed irregular nar-rowing of the straightened segment of the artery which indicated fairly extensive mural thrombosis. Thrombolytic therapy was instituted 5 hours after the onset with intravenous infusion of Urokinase (10,000 units) in 1000 cc of low melecular dextran. Anticoagulant therapy with Warfarin Potassium was started at the same time. This combined therapy was intended by this author with a purpose to prevent new formation of microembolism in the brain stem or cerebellum delivered from resolving mural throm-bosis.

The patint responded well and angiogram taken at 8, 22 clays, 3 months after the onset showed gradual but complete disappearance of the mural thrombus. With follow-up of 3 months, the patient showed no recurrence of symptoms without neuro-logical deficit.