被殻出血急性期症例におけるdescending tentorial herniation signの検討

STUDY OF DESCENDING TENTORIAL HERNIATION SIGN IN PATIENTS WITH PUTAMINAL HEMORRHAGE AT THE ACUTE STAGE

　抄録　被殻出血急性期48症例についてCTスキャン上のdescending tentorial hermiation （DTH） signの出現を検討し，生命予後との関係について保存的療法群および手術的療法群との比較検討を行なった。CTスキャン上のDTH signの有無に従い次のごとくに分類した。すなわち，Grade 0；DTH signを認めない，Grade I；鞍上槽の外側の圧排所見を認める（impending herniation），Grade II；血腫側の迂廻槽，脚槽の拡大を呈する（actual herniation），GradeIII；テントレベルでの脳槽の消失を認めるadvancedstage of herniation）。Grade 0の21例（44％）は保存的療法および手術的療法群ともに予後は良好であった。Grade Iの6例（13％）は瞳孔不同を呈した1例を除いて予後は良好であった。Grade IIの症例は14例（29％）あり，保存的療法を施行した症例の中に初期には軽度意識障害を認めるのみであったにもかかわらず3〜4時間の経過で症状の悪化をみた症例が3例あった。病初より重篤な意識障害を認めた症例では，血腫除去施行により予後は良好であった。Grade IIIの7例（15％）は保存的および手術的療法にかかわりなく予後は不良であった。DTH signにおけるGrade IIの症例群の経験から，被殻出血急性期においては，一般には臨床的な脳ヘルニア徴候を呈する症例が緊急手術の対象とされがちであるが，臨床的に脳ヘルニアの徴候がない場合でもCTスキャン上にてDTH signを認める症例に対しては迅速なる手術が必要であることが示唆された。

A sign of descending tentorial herniation (DTH) on computed tomography (CT) in 48 patients with putaminal hemorrhage was examined in the acute stage. Correlation between the DTH sign and prognosis for survival was studied in two groups; a conservative group and an operative group.

Patients were grouped according to the presence or abscence of DTH sign on CT. Grade 0: no herniation sign ; Grade I : an encroachment upon the lateral aspect of the suprasellar cistern (impend-ing herniation); Grade II : widening of the crural and ambient cistern on the same side as hematoma (actual herniation) ; Grade III : effacement of the cisternal space at the tentorial level (advanced stage of herniation).

Twenty-one patients (44%) with Grade 0 DTH sign showed a good prognosis in both conserva-tive and operative groups. Six patients (13%) with Grade I DTH sign also showed a good prognosis in both the conservative and the operative groups except one patient with anisocoria. There were 14 patients (29%) with Grade II DTH sign. Three of them who were treated conservatively showed only mild impairment of consciousness at the ini-tial phase, but became worse 3-4 hours later. In the remaining patients who showed severe impair-ment of consciousness from the beginning of the illness, prognosis was poor except for patients with hematoma evacuation. Seven patients (15%) with Grade III DTH sign had poor prognosis both in the conservative and the operative groups.

It is suggested that, in the acute stage of patients with putaminal hemorrhage, operative procedure should rapidly be performed not only for the clinical herniation sign but also for the DTH sign on CT even if the patients showed no clinical sign and only impairment of consciousness.