脳梗塞を合併したテルソン症候群に対して硝子体手術を施行した1例

A case of Terson syndrome associated with cerebral infarction treated with vitreous surgery

要約　目的：くも膜下出血の発症後早期に，脳血管攣縮により脳梗塞を併発することがあるが，脳梗塞がテルソン症候群の視機能に影響を及ぼしたとする報告は少ない。今回，脳梗塞を併発したテルソン症候群の1例に対して硝子体手術を施行したので報告する。

症例：52歳，男性。前大脳動脈瘤破裂によるくも膜下出血を発症し，複数回のVPシャント手術を施行し，経過中に左側頭葉の梗塞をきたした。約1か月間意識不明の状態であったが，意識を回復した際に，両眼の高度の視力低下を訴え近医受診となった。両眼とも視力は手動弁で，上方の一部を除いて眼底透見困難であった。ゴールドマン動的視野検査では両眼とも左側〜下方周辺部のみイソプターを認め，出血による視野障害に加えて，脳梗塞による右同名半盲が疑われた。出血量の多い右眼から硝子体手術を施行し，術後矯正視力0.9を得た。左眼は硝子体手術後の視力が0.2にとどまった。その理由として，左眼では脳梗塞による中心視野障害が右眼よりやや大きかったこと，黄斑部近傍に線維増殖膜を認めたことなどが，視力不良の原因になった可能性が示唆された。

結論：脳梗塞を併発したテルソン症候群では，硝子体出血，網膜病変に加えて，脳梗塞によって視野障害が修飾されるため，視機能改善の予測が難しいと考えられた。

Abstract　Purpose：Early after the onset of subarachnoid hemorrhage, cerebral vasospasm may lead to cerebral infarction. However, a few reports have detailed that cerebral infarction can affect visual function in Terson syndrome. Here, we describe a case of Terson syndrome with cerebral infarction in which vitrectomy was performed.

Case：A 52-year-old man developed a subarachnoid hemorrhage due to a ruptured anterior cerebral artery aneurysm and underwent multiple drainage procedures. He was unconscious for about a month, but when he regained consciousness, he complained of severe vision loss in both eyes and was referred to an ophthalmologist. The visual acuity of both eyes was hand movement, and fundus examination was difficult except in the upper part of the eyes. The Goldmann visual field test showed isopters only in the left to lower periphery of both eyes, suggesting right-sided homonymous hemianopsia due to cerebral infarction in addition to visual field impairment caused by the hemorrhage. A vitrectomy performed on the right eye showed a large amount of bleeding, and postoperative corrected visual acuity of 0.9 was obtained. In the left eye, the visual acuity after the vitrectomy was only 0.2. These findings suggested that the central visual field impairment due to cerebral infarction was slightly larger in the left eye than in the right eye and that the fibroproliferative membrane near the macula was observed postoperatively, which may have caused poor visual acuity.

Conclusion：In addition to vitreous hemorrhage and retinal lesions, the visual field impairment caused by cerebral infarction is modifiable in Terson syndrome, making it difficult to predict achievable improvements in visual function.