重症頭部外傷14年後に髄膜炎にて明らかとなった潜在性髄液漏の1例

A Case with Surgical Repair for Delayed Occult Cerebrospinal Fluid Rhinorrhea Presented as Meningitis Fourteen Years After Blunt Head Trauma

　Ⅰ．はじめに

外傷性髄液漏に，頭蓋骨骨折と硬膜損傷の存在が，強く関与しているといわれている^{3,7,14,15,20,22)}．正中側前頭蓋底骨折に多く，また，受傷早期，とりわけ24時間以内の出現が多いが，比較的稀ながら，数年以上経過後に明らかとなる例も知られている^7,26)．一方で，意識障害ゆえに，髄液漏に気づかれないことも，しばしば経験される⁶⁾．

　今回われわれは，受傷当時，高度意識障害，内頸動脈損傷，水頭症などに対し手術加療後に自立生活に復帰し，14年以上後に明らかとなった，潜在性髄液漏の1例を経験した．水頭症術後で，髄膜炎を合併し気づかれた，潜在性髄液漏に対する治療方針について考察する．

　We describe a case of a 34-year-old woman in whom delayed occult cerebrospinal fluid rhinorrhea presented as meningitis. Removal of an implanted shunt system and surgical repair of the fistula were required. The cerebrospinal fluid fistula was located in the left frontoethmoidal region. Fourteen years previously,the patient had been treated successfully for injury to the left internal carotid artery in a motor vehicle collision,by clipping and by implantation of ventriculoperitoneal and subduralperitoneal shunts to reverse the associated hydrocephalus. To prevent the spread of intracranial infection,we immediately removed the implanted shunt system and followed this by placement of lumbar drainage. After complete resolution of meningitis in response to antimicrobial agents,we performed surgical repair of the fistula. Shunt reconstruction was not required. The patient was discharged with good performance status. This case illustrates the point that effective treatment of meningitis is greatly facilitated by timely removal of associated foreign material.