開散麻痺で発症した両側慢性硬膜下血腫

A case of Divergence Palsy Associated with Bilateral Chronic Subdural Hematoma

　開散麻痺を唯一の主訴とした両側慢性硬膜下血腫の1例を若干の文献的考察を加え報告する。

　症例は，75歳女性で2週間前からの遠方視時の複視を訴え眼科を受診した。瞳孔，対光反射，外眼筋運動に異常はなく，調節反射も正常であった。主訴の複視は，近見時には消失し，Hess赤緑試験の結果より開散麻痺と診断され，頭蓋内病変検索目的にCTスキャンを撮影したところ両側慢性硬膜下血腫を認め，手術目的に当科に紹介された。手術は，両側穿頭血腫除去を行い，血腫量は左右等しく計220mlであった。術後，開散麻痺は消失し，現在まで再発をみていない。術後の経過より，本例での開散麻痺の原因は両側慢性硬膜下血腫と考えられた。

　開散麻痺は，調節麻痺に比べ不明な点が多く，報告は少ない。これまで，原疾患として脳腫瘍や頭部外傷など様々な頭蓋内疾患が報告されているが，CT導入後の報告例では，慢性硬膜下血腫は本例が第一例であった。

A surgical case of bilateral chronic subdural hematoma presenting with divergence palsy is re-ported.

A 75-year-old female was admitted to hospital for investigation of 2-week history of diplopia. The initial neurological examination demonstrated no abnormal findings except Hess chart suggesting bilateral concomitant strabismus or paresis of lat-eral rectus on both eyes. Because of the homony-mous diplopia disappeared when the object of fixa-tion in brought closer and the patient showed no impairment of gaze movements and following move-ments, the patient was diagnosed as divergence palsy and referred to the Neurosurgical Service.

The physical examination revealed a 75-year-old, alert, fully oriented with diplopia at distant gaze. A computerized tomographic (CT) scan showed bilat-eral subdural hematoma. Emergency burrhole evac-uation was performed and total amount bilateral hematoma was 220ml. Diplopia disappeared pos-toperatively. Hess chart cxamined two months after the operation shows no impairment of diver-gence function.

This is the first reported case of divergence palsy associated with bilateral chronic subdural hematoma in CT era.