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Neurological Surgery No Shinkei Geka Volume 38, Issue 1 （January 2010）

Neurological Surgery 脳神経外科 38巻1号（2010年1月発行）

Japanese English

研究

内頚動脈閉塞による広範囲脳梗塞に対する側頭葉前方内側切除を伴う外減圧術の治療成績 Surgical Outcome of External Decompression Associated with Anterior and Medial Temporal Lobectomy for Massive Hemispheric Infarction Due to Internal Carotid Artery Occlusion 山崎貴明 ¹ , 上山憲司 ¹ , 大里俊明 ¹ , 佐々木雄彦 ¹ , 中川原譲二 ¹ , 中村博彦 ¹ Takaaki YAMAZAKI ¹ , Kenji KAMIYAMA ¹ , Toshiaki OSATO ¹ , Takehiko SASAKI ¹ , Jyoji NAKAGAWARA ¹ , Hirohiko NAKAMURA ¹ ¹中村記念病院脳神経外科 ¹Department of Neurosurgery,Nakamura Memorial Hospital キーワード： decompressive hemicraniectomy , external decompression , anterior and medial temporal lobectomy , massive cerebral infarction , internal carotid artery occlusion Keyword: decompressive hemicraniectomy , external decompression , anterior and medial temporal lobectomy , massive cerebral infarction , internal carotid artery occlusion pp.25-32

発行日 2010年1月10日 Published Date 2010/1/10

DOI https://doi.org/10.11477/mf.1436101086

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Abstract 文献概要
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参考文献 Reference

Ⅰ．はじめに

　中大脳動脈灌流領域を含む広範囲脳梗塞のうち“malignant middle cerebral artery（MCA）infraction”は，内頚動脈もしくはMCA proximalの主に塞栓性閉塞により，急速に進行する致死的脳腫脹で，78％がuncal herniationを来すとされている⁶⁾．そのmortalityは80％に及ぶ極めて予後不良の疾患である^1,6,7,23)．特に内頚動脈閉塞は，近年行われるようになったrt-PA（アルテプラーゼ）静注療法の効果も乏しく¹⁷⁾，その梗塞の範囲は中大脳動脈の灌流領域のみならず，前大脳動脈，後大脳動脈の灌流領域といった多血管領域に渡ることもある重症脳梗塞の1つである．われわれは，内頚動脈閉塞による広範囲脳梗塞に伴う著明な脳腫張に対し，救命目的で硬膜形成を伴う外減圧術に，内減圧として側頭葉前方および内側切除（anterior and medial temporal lobectomy：AMTL）を加えた内外減圧術を行ってきたので，その治療成績につき報告する．

　Objective: Acute occlusion of the internal carotid artery (ICA) can lead the massive cerebral hemispheric infarction and cause massive cerebral edema and may result in tentorial herniation and death. The mortality rate is estimated at 80% with maximum conservative medical treatment. We have performed external decompression associated with anterior and medial temporal lobectomy (AMTL) as internal decompression for lifesaving. This study evaluated our surgical results and gives an analysis of the prognostic factors.

　Methods: Twenty one consecutive patients with massive cerebral infarction caused by internal carotid artery occlusion who underwent external decompression associated with AMTL for lifesaving between June 2000 and December 2005 were included in this retrospective analysis. Survivors were divided into two functional groups at three months after surgery: good (Barthel index; BI≧50) and poor (BI＜50). The characteristics of the two groups were compared using statistical analysis.

　Results: The patients consisted of 11 males and 10 females aged from 28 to 81 years with a mean age of 65.0±11.6 years. Eight patients had an infarction restricted to the middle cerebral artery (MCA) territory, others had additional anterior cerebral artery (ACA) or posterior cerebral artery (PCA) territory infarctions. The mean time between stroke onset and operation was 43.5±30hours and ranged from 7 to 148hours. Two patients died, so the mortality was 9.5%. Elderly patients (≧60 years) (P＝0.038), high preoperative Japan coma scale (≧3 digit) (P＝0.013), low preoperative Glasgow coma scale (GCS＜8) (P＝0.044), and multiple arterial territory (MCA＋ACA or PCA) infarction (P＝0.045) were significantly associated with poor functional outcome.

　Conclusion: External decompression associated with AMTL can immediately relieve peduncle compression and could be effective in preserving life as effectively as “early” external decompression.