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Neurological Surgery No Shinkei Geka Volume 40, Issue 7 （July 2012）

Neurological Surgery 脳神経外科 40巻7号（2012年7月発行）

Japanese English

症例

脳梗塞とくも膜下出血を同時期に発症した前大脳動脈解離の1例 Spontaneous Dissection of the Anterior Cerebral Artery that Simultaneously Presented with Cerebral Infarction and Subarachnoid Hemorrhage,Successfully Treated with Conservative Management: A Case Report 南原翔 ¹ , 堤圭介 ² , 高畠英昭 ² , 藤本隆史 ¹ , 川原一郎 ² , 小野智憲 ² , 戸田啓介 ² , 馬場啓至 ² , 米倉正大 ² Sho NANBARA ¹ , Keisuke TSUTSUMI ² , Hideaki TAKAHATA ² , Takashi FUJIMOTO ¹ , Ichiro KAWAHARA ² , Tomonori ONO ² , Keisuke TODA ² , Hiroshi BABA ² , Masahiro YONEKURA ² ¹独立行政法人国立病院機構長崎医療センター初期研修プログラム ²独立行政法人国立病院機構長崎医療センター脳神経外科 ¹Residency Program,National Hospital Organization Nagasaki Medical Center ²Department of Neurosurgery,National Hospital Organization Nagasaki Medical Center キーワード： spontaneous arterial dissection , anterior cerebral artery , cerebral infarction , subarachnoid hemorrhage , simultaneous occurrence Keyword: spontaneous arterial dissection , anterior cerebral artery , cerebral infarction , subarachnoid hemorrhage , simultaneous occurrence pp.635-642

発行日 2012年7月10日 Published Date 2012/7/10

DOI https://doi.org/10.11477/mf.1436101774

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Ⅰ．はじめに

　従来，前大脳動脈解離（anterior cerebral artery dissection：ACAD）は比較的稀な疾患とされていたが，画像診断機器の進歩に伴い報告例は近年増加傾向にあり，虚血発症例が多いとされている¹¹⁾．脳梗塞とくも膜下出血（subarachnoid hemorrhage：SAH）を併発する症例は稀であり¹¹⁾，その治療方針にも未だ定説はない⁵⁾．最近，この2病態を同時期に発症し保存的治療により良好な経過を辿った症例を経験した．文献的考察とともに報告する．

　We recently encountered a rare case of anterior cerebral artery dissection (ACAD) that accompanied fresh cerebral infarction (CI) and subarachnoid hemorrhage (SAH). An initial head CT showed a thin SAH in the interhemispheric cistern and cortical sulcus of the left frontal surface. Subsequent MRI performed 10 min after head CT scan revealed a fresh infarction in the left ACA region. MR-and digital subtraction angiograms demonstrated a dissection in the A2 portion of the left ACA with a leak of contrast media around the left A3 portion,suggesting that the bleeding occurred in a distal portion of the main dilation. Without anti-thrombotic therapy,the patient recovered without complications by blood pressure control and administration of brain-function protection therapies.

　We found 11 cases similar to the present case in the literature. All cases presented with lower-extremity dominant hemiparesis; however,sudden onset headache was rare. Blood pressure was not well-controlled in 4 out of the 6 known hypertensive cases. Main sites of dissection were located at the A2 portion in all cases except one A3 lesion,and extended to A3 in 2 cases. Conservative therapy led to favorable outcome in 8 cases,while 4 cases underwent surgical interventions for increasing risk of aneurysm rupture after initial observational therapies. Re-bleeding did not occur in any of the 12 cases reviewed. These data suggest that conservative treatment can be considered for an initial management of ACAD with simultaneous CI and SAH. More evidence needs to be accumulated to establish the optimal therapeutic approach for ACAD associated with CI and SAH.