重症高血圧性脳内血腫術後の頭蓋内圧

POSTOPERATIVE INTRACRANIAL PRESSURE IN SEVERE CASES WITH HYPERTENSIVE INTRACEREBRAL HEMATOMA

　抄録　高血圧性被殻出血重症例21例を対象として，開頭血腫摘出後の頭蓋内圧（以下ICP）レベルと，術前の血腫量，手術時期，治療成績について検討した。術後のICPと，術前のCTから推定した血腫量（80ml以上を大血腫，80ml未満を中血腫），発症から手術までの時間，治療成績（Glasgow OutcomeScale）との関係を検討した。なおICPは，High （40mmHg以上），Moderate （40〜20mmHg），Low（20mmHg未満）とした。血腫量と発症から手術までの時間とICPを検討したところ，中血腫では，8時間以内の手術例のICPは，5／6（83％）がLow ICPであり，8時間以降のものはLow ICPはなく，3／6（50％）がHigh ICPを示した。大血腫では，Low ICPを呈した症例はなく，8時間以内，以降手術とも各々4／6（67％），2／3（67％）がHigh ICPを示した。治療成績が，severe disability, vegetative state，　deadの症例の頻度は，High ICP 9／9（100％），Moderate ICP 4／7（57％），Low ICP 2／5（40％）であった。以上より，①治療成績は，術後のICPレベルと関連性を有していた。②血腫量80ml未満の中血腫例では，発症後8時間以内に手術を行えば，術後ICPは高度に亢進しなかった。

The relationship between the postoperative ICP and the size of hematoma on CTscan and the time of operation was studied to evaluate their influence on the therapeutic results in the severe cases with hypertensive intracerebral hematoma. Twenty one patients of putaminal hemorrhage with severe neurological deficit (semicoma) were studied. ICP was monitored continuously by the Subdural bal-loon method after craniotomy to remove the hematoma. The relationship between the post-operative ICP level (High ICP : above 40 mmHg, Moderate ICP : 40-20 mmHg, Low ICP : below 20 mmHg), the size of hematoma estimated from CTscan (Large : more than 80 ml, Medium : less than 80 ml), the time from onset to removing hematoma and the therapeutic results were evaluated. Theoutcome six months after onset was determined according to the Glasgow Outcome Scale.

Of 6 cases with Medium hematoma operated on within 8 hours, Low ICP was found in 5 cases (83%) and Moderate ICP was in one case (17%). Of 6 cases with Medium hematoma operated on after 8 hours, High and Moderate ICP were found in 3 cases (50%), respectively. In the cases with Large hematoma, Low ICP was not observed, but High ICP was found in 4 of 7 cases operated on within 8 hours (57.1%) and the other three in-dicated Moderate ICP (42.9%). High ICP was found in two cases with Large hematoma operated on after 8 hours (100%). The outcome of High ICP cases was severe disability in 4 cases, vege-tative state in one and dead in 4, and that of Moderate ICP cases was moderate disability in 3 cases and severe disability in 4. The outcome of Low ICP cases was moderate disability in 3 cases and severe disability in 2. As a result, the Low ICP cases were observed to have much better out-come as compared to the others.

The therapeutic results in the cases that showed High ICP postoperatively were poorer than those in the cases that showed Moderate and Low ICP, so the postoperative ICP level is related to the prognosis.

The postoperative ICP was easily controlable in the cases with Medium hematoma operated on within 8 hours from onset.