グリセロールが奏効した重症上矢状静脈洞血栓症の1例

A CASE OF SEVERE SAGITTAL SINUS THROMBOSIS, AND THE THERAPEURIC EFFECT OF GLYCEROL

I．はじめに

　頭蓋内静脈，静脈洞血栓症の概念は古くから知られているが，確定診断を剖検に頼つていたため，非常に稀な疾患とされていた。しかし，近年，脳血管写の発達に伴つて生前診断が可能となり，その報告例も増えつつある。脳静脈洞血栓症は感染性と非感染性（原発性）とに分類されるが，抗生物質の発達によつて，前者は減少しており，最近はその症状の多彩さとあいまつて，原発性上矢状静脈洞血栓症が注目されている。

　我々は，虫垂炎の術後に発症し，一時は，鉤ヘルニアまでおこし昏睡に陥つたが，グリセロールの使用により，全治せしめ得た本症の1例を経験したので，その治につき若干の文献的考察を加え報告する。

A 15-year-old boy had been admitted to this hospital with fever, headache and left hemiconvul-sion. He had been well untill one week before, when he was operated for appendicitis. Two days later, he experienced febril sensation, headache and vomitting. Five days later, he became drowsy with progressing left hemiparesis. Since a day before admission, left hemiconvulsion had been continu-ously observed. At the admission, his temperature was 38℃. He was in drowsy state and left hemi-convulsion was observed. Optic fundi, eye move-ments and pupils were normal. On the second hospital day, right hemiparesis was also developed.A spinal tap revealed colorless clear cerebrospial fluid with the initial pressure of 320 mm H₂O. Protein content was 64 mg/dl. The white blood cell count was 8600/mm3 with 77% neutrophils, the hematocrit was 41.4% and platelet count was no-rmal. The erythrocyte sedimentation rate was 43 mm/hour, and CRP was 3+. The blood coagula-tion time, blood chemistry, and other serological examinations were all within the normal ranges. (Table 1). No marked abnormality was seen on X-ray films of the skull and chest. Right carotid angiography revealed marked delay of cerebral circulation time with non-filling of the superior sagittal sinus and cortical veins. (Fig.2). EEG showed occasional slow wave bursts of 2.5 Hz in the right fronto-parietal area, (Fig.1) and an abnormal accumulation of radioactivity was observed in the corresponding area by ⁹⁹Tc brain scanning. A diagnosis of sagittal sinus thrombosis was made at this stage. On the sixth hospital day, he became unresponsive and mydriasis with no light reaction was seen in the right pupil. Supposing the development of right-sided uncal herniation into the tentorial incisure, 500 ml of 10% glycerol solution was given by DIV. A remarkable im-provemement of consciousness was seen immediately after the DIV, and anisocoria was also disappeared. (Fig.3). The right carotid angiography at that time showed a marked right-to-left shift of the anterior cerebral artery. (Fig.4). From these findings, secondary hemorrhagic infarction of the right hemisphere was suspected. The same condition was appeared intermittently during the following five days and glycerol was repeatedly given. He was gradually improved thereafter, and discharged without any neurological deficits at all two months after the onset. In this case, the cause of sinus thrombosis was unknown ; no evidence of migrating thrombophlebitis, blood diseases and other systemic disorders such as col-lagen diseases could be found.

Anticoagulants and control of intracranial hyper-tension have been proposed as emergency treat-ments for primary sinus thrombosis in the acute stage. Krayenbuhl et al. have reported a good result of anticoagulant therapy with minimam side effects. However, in the severe case as this, control of intracranial hypertension is most im-portant. This is the first report of glycerol solu-tion which was utilized for this purpose with a quite favorable result.