Multiple lacunar stateの臨床的検討

CLINICAL STUDIES ON MULTIPLE LACUNAR STATE

　抄録　Lacuneが多発性に存在するmultiple lacunar stateは臨床的にも特徴ある症状を呈する。6年間に経験した臨床的にmultiple lacunar stateと診断し，CT scanも施行された65例の臨床的検討を行った。臨床経過としては緩徐進行性であるため変性疾患と誤られることもある。年齢は50歳代から70歳代まで，男女比では12：1と圧倒的に男性に多い。初発症状としては歩行障害がも最も多く，ついで言語障害，動作緩慢，感情失禁，嚥下障害の順である。神経症状としては構語障害，小きざみ歩行や歩行失行などの歩行障害，腱反射の亢進や左右差，病的反射の頻度が高い。Parkinson病と異なりrigidityはparatonicで，tremorはactionやpostural tremorがほとんどである。高血圧の既往が発症の因子として重要である。CT scanでは65例中52例（80.0％）でlacuneが証明され，また高解像力CT scanの重要性が強調された。臨床経過，神経症状の正確な把握とCT scanなどの補助診断法の併用により臨床的にmultiple lacunar stateの診断は可能である。

Sixty-five cases of clinically diagnosed multiple lacunar state have been analysed.

The clinical course of multiple lacunar state is usually progressive in nature, simulating degene-rative diseases, in contrast with the mode of acute onset seen in the other vascular diseases. Average age at the initial visit was 63.8 year-old, and sex ratio showed marked male preponderance, being12 for males and 1 for females. Gait disturbance and speech disturbance are the most frequent initial symptoms, followed by slow motion, emo-tional lability and swallowing difficulty. Neurolo-gical manifestations are dysarthria, short-stepped and apraxic gait, hyperreflexia, positive Babinski and Chaddock reflexes, minimal spasticity, demen-tia, positive palmo-mental reflex, emotional labi-lity, fixed face, rigidity, bradykinesia, foot grasp-ing, dysphagia, positive Myerson's sign and tremor, in the order described. The important point is that the rigidity is paratonic and the tremor is action or postural, not the cogwheel rigidity or resting tremor like Parkinson's disease. The ap-pearance of pathological reflexes (Babinski and Chaddock reflexes) are quite important, especially Chaddock reflex, which can frequently become positive despite negative or equivocal Babinski reflex.

Hypertension, especially longstanding in nature, is the major contributing factor in this disorder. CT scan showed the presence of one or more lacunes in 52 out of 65 cases (80.0%). The detec-tion of lacune can be influenced by the quality of CT scan, and the high resolution CT scanner is greatly useful for that purpose.

It is stressed that the detailed neurological and computed tomographic evaluations will make it possible to reach the clinical diagnosis and appro-priate treatment of multiple lacunar state.