10．MicroneurosurgeryとPET scan：一脳神経外科医の経験から

(10) Microneurosurgery and PET Scan: Clinical Experience of a Neurosurgeon

Ⅰ．まえおき

　筆者が脳神経外科医として主に勤務した3施設（京都大学医学部附属病院1965～1969年，1977～1985年，国立循環器病研究センター1986～1992年，Zürich大学病院1970～1976年，1993～2007年）ともにpositron emission tomography（PET）を施設内にもっていた．筆者らが新入局員の頃は存在しなかったCT，MRIの発達とともに，PET，single photon emission CT（SPECT）の発達は脳神経外科の日常活動，診断，手術適応の一助となり，follw-upにも大きく関与してきた．以下の内容は，microneurosurgeryを修得した筆者がいかにSPECT，PETと関わってきたかを述べたものである．

　During the author's clinical activity at three institutes : Kyoto University Hospital (Kyoto 1965-1969, 1977-1985), National Cardiovascular Center NCVC (Osaka 1986-1992) and Zürich University Hospital (Zürich 1970-1976, 1993-2007), He has experienced (underlined periods) working with PET scan and SPECT in relation to microsurgical treatment. The following describes how and for what the author has been engaged in this regard.

　　1. As preparation for the work with PET, SPECT with a rotating gamma camera was used to know blood distribution with the use of Kr-81m infusion from a selectively located catheter in the ICA, ECA or VA, e.g. to know the flow distribution of a newly constructed EC-IC bypass, which was quite separated from and not mixed up with that of already functioning inherent collaterals (Fig. 1).

　　2. With the use of inhalation PET scan (¹⁵O labled CO₂ and O₂ inhalation and ¹⁵O CO inhalation) basic knowledge of hemodynamics of MMD was acquired (Fig. 2)

　　3. With the use of H₂¹⁵O-PET scan with Diamox^® loading, indication for and effectiveness of EC-IC bypass surgery for occlusive cerebrovascular disease (atherosclerosis (anterior circulation (Fig. 5), posterior circulation (Fig. 6, 7)), MMD (Fig. 9), congenital disease (Fig. 8) have been settled or demonstrated.

　　4. In epileptic seizures, interictally or intraictally, the active locus has been identified by the use of FDG-PET, flumazenil-PET, H₂¹⁵O or ¹³NH₃-PET respectively (Fig. 12). In this relation, selective Wada test with the use of Tc-99 m-ECD selective infusion together with Amytal^® through a catheter inserted selectively into the anterior choroidal artery is an important preoperative test for the SAHE (Fig. 13).

　　5. FDG-PET and/or tyrosine PET supply important clues concerning appropriate surgical treatment strategy, and also for intractable glioblastoma or high grade glioma, so that in combination with radiotherapy and chemotherapy one may expect more excellent long term outcome with good quality of life (Fig. 16, 17).

Furthermore, there must be cases with dementia in which some revascularization procedure might be of help, for which FDG-and H₂¹⁵O-PET could be helpful for differential diagnosis and indication of surgery (Fig. 18).

　

　Man sollte warten damit und Sinn und Süßigkeit sammeln ein ganzes Leben lang und ein langes womöglich, und dann, ganz zum Schluß, vielleicht könnte man dann zehn Zeilen schreiben, die gut sind.

Rilke RM : Die Aufzeichnungen des Malte Laurids Brigge