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Neurological Surgery No Shinkei Geka Volume 37, Issue 1 （January 2009）

Neurological Surgery 脳神経外科 37巻1号（2009年1月発行）

Japanese English

症例

脳内出血を繰り返した進行性脳静脈血栓症の1例 A Case of Cerebral Venous Thrombosis Causing Refractory Intracerebral Hemorrhage 加藤直樹 ¹ , 森良介 ¹ , 関厚二朗 ¹ , 野田靖人 ¹ , 諸岡暁 ¹ , 森田昌代 ² , 田中俊英 ³ , 阿部俊昭 ⁴ Naoki KATO ¹ , Ryousuke MORI ¹ , Koujirou SEKI ¹ , Yasuto NODA ¹ , Satoru MOROOKA ¹ , Masayo MORITA ² , Toshihide TANAKA ³ , Toshiaki ABE ⁴ ¹富士市立中央病院脳神経外科 ²富士市立中央病院神経内科 ³東京慈恵会医科大学附属柏病院脳神経外科 ⁴東京慈恵会医科大学脳神経外科 ¹Department of Neurosurgery,Fuji City General Hospital ²Department of Neurology,Fuji City General Hospital ³Department of Neurosurgery,Jikei University School of Medicine,Kashiwa Hospital ⁴Department of Neurosurgery,Jikei University School of Medicine キーワード： cerebral venous thrombosis , surgical treatment , intracerebral hemorrhage , pulmonary embolism , thrombolytic therapy Keyword: cerebral venous thrombosis , surgical treatment , intracerebral hemorrhage , pulmonary embolism , thrombolytic therapy pp.51-55

発行日 2009年1月10日 Published Date 2009/1/10

DOI https://doi.org/10.11477/mf.1436100872

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Ⅰ．はじめに

　脳静脈血栓症は脳静脈および静脈洞の閉塞に伴って脳浮腫や静脈性梗塞を呈する疾患である．従来稀な病態と考えられてきたが，MRIなどの普及により報告例が増えてきている^11,12)．また静脈閉塞による循環障害から血管が破綻し，脳内血腫が合併することも少なくない．このため，閉塞病変に対する抗凝固療法と出血病変に対する治療を同時に行う必要があり，治療法は複雑である^1,2)．

　今回われわれは，表在静脈の進行性閉塞により脳内出血を繰り返した1例を報告する．また本疾患における手術報告は少ないが，再出血時に行った開頭血腫除去術が神経症状の改善に有効であった．病態機序や手術適応，周術期管理について考察を加える．

　Cerebral venous thrombosis is an uncommon disease characterized by expansive cerebral edema, venous infarction and massive intracerebral hemorrhage. Magnetic resonance imaging and angiography are useful for diagnosis of cerebral venous thrombosis.

　A 54-year-old man was admitted with headache, vomiting and right hemiparesis. Computed tomography (CT) revealed subcortical hematoma in the left parietal lobe. Digital subtraction angiography (DSA) demonstrated occlusion of the left Labbé vein with dilation of cortical veins and deep cerebral veins. He also suffered from pulmonary embolization and deep vein thrombosis in the lower extremities. Anticoagulant and thrombolytic agents were administered, then respiratory condition and hemiparesis were improved. However, his condition deteriolated 7 months after the initial attack. CT revealed huge subcortical hematoma in the same site. He underwent craniotomy and intracerebral hematoma was evacuated during treatment with vitamin K. His symptom gradually improved and he was discharged with moderate disability 2 months after operation.

　Dicision of surgical treatment is difficult because there is a risk of rebleeding due to thrombolytic therapy and progressive venous congestion. Since anticoagulant and thrombolytic therapy are inevitable, surgical indication for refractory intracerebral hemorrhage associated with cerebral venous thrombosis should be considered carefully.