軽症頭部外傷患者の初療指針に関する検討

A Guide to Initial Management of Minor Head Injury

　Ⅰ．はじめに

脳神経外科の日常診療においては，比較的軽症の頭部外傷患者の診察に時間を費やすことが多い．現在では多くの施設にcomputed tomography（CT）が普及し，単純撮影と同様に容易かつ迅速に施行できるようになったため，頭部外傷患者にはルーチンにCTを施行する施設もある．しかしながら，受診時に意識が清明で神経学的異常所見が全くみられない場合には画像検査を行わないこともあり，CTの施行基準については議論が多い^5,11,15,16)．この背景として，本邦における軽症頭部外傷患者の初療指針に関する報告が少ないことが挙げられる．今回，受診時の意識レベルがGlasgow Coma Scale（GCS）score15の症例について主訴と画像所見をretrospectiveに調査することにより，軽症頭部外傷患者の初療に関して重要と考えられるいくつかの知見を得たので，文献的考察を加えて報告する．

　We reviewed the records of 1,335 minor head injury patients with initial Glasgow Coma Scale (GCS) scores of 15 treated by our neurosurgery service between January 1998 and December 2000. Skull X-ray was performed in 945 patients (71%),and Computed tomography (CT) was performed in 590 patients (44%). Skull fracture was shown radiographically in 24 patients (2.5%),and abnormalities on the initial CT were seen in 29 patients (4.9%). The most frequent intracranial lesion on CT was acute epidural hematoma with skull fracture.

　Significantly more intracranial lesions were found in those with a fracture than in those without by c2 analysis. Post-traumatic vomiting was significantly associated with radiographical abnormalities,but headache and nausea did not increase the risk of skull fracture and intracranial lesions on the CT. Patients required neurosurgical intervention in 4 cases,and all of those were acute epidural hematoma with skull fracture.

　In this study,the first thing we should do for asymptomatic minor head injury patients with a GCS score of 15 is to investigate the presence of a skull fracture by skull X-ray. Head trauma patients with a skull fracture and post-traumatic vomiting should undergo CT to facilitate detection of intracranial lesions,even when there are no abnormal neurological signs.