rt-PA（alteplase）静注療法後，急性期に頚動脈ステント留置術を施行した頚部内頚動脈高度狭窄症の1例

Emergency Carotid Artery Stenting within 24 Hours after Intravenous Thrombolysis for Acute Ischemic Stroke: A Case Report

Ⅰ．はじめに

　Recombinant tissue plasminogen activator（rt-PA：alteplase）静注療法は，発症から4.5時間以内の虚血性脳血管障害患者に対し強く推奨される治療方法であり，適応基準を満たせばすべての脳梗塞病型に適応がある^11,12,17)．本治療法は，脳梗塞の病型別に検討すると，塞栓性脳梗塞については血栓溶解に伴い末梢側の脳血流の急激な改善が得られるため，極めて効果的な治療法と言えるが，頚動脈狭窄症などが原因の場合，治療後に血流改善が得られたとしても狭窄病変は残存するため，再閉塞により神経症状の再増悪を来す危険性がある¹²⁾．さらに，原則として治療開始後24時間以内の抗血栓療法が禁止されているため，その間に再閉塞を来した場合の明確な治療方針が存在しておらず，その後の治療に苦慮する場合も多い^3,12,16)．今回われわれは，rt-PA静注療法後に血流改善が得られたものの，高度の狭窄病変が残存した頚部内頚動脈狭窄症に対し，rt-PA静注後24時間以内の超急性期に頚動脈ステント留置術（carotid artery stenting：CAS）を施行し良好な経過を得た症例を経験したので報告する．

　We report a case treated successfully by emergency carotid artery stenting（CAS）within 24 h after intravenous thrombolysis for acute ischemic stroke. An 80-year-old man was admitted to our hospital with disturbance of consciousness. Neurological examination on admission revealed severe right-sided motor weakness and motor aphasia. Magnetic resonance（MR）imaging showed cerebral infarction in the territory of the perforating artery and cortical branch of the left middle cerebral artery（MCA). MR angiography（MRA）revealed occlusion of the bilateral cervical internal carotid arteries（ICAs). Systemic intravenous injection of recombinant tissue plasminogen activator（iv rt-PA）was therefore performed 2.5h after onset. Following iv rt-PA therapy, neurological symptoms improved for 1h, but MRA and cerebral angiography revealed severe stenosis of the left cervical ICA, complete occlusion of the right cervical ICA and left MCA occlusion. Revascularization of the left cervical ICA was then performed using endovascular surgery（percutaneous transluminal angioplasty and CAS）3.5h after iv rt-PA therapy. Postoperative course was uneventful except for mild restlessness, and hyperperfusion syndrome（HPS）did not develop. Strict control of blood pressure under dexmedetomidine anesthesia allowed effective prevention of HPS. After 1 week, recanalization of the left MCA was recognized on MRA and ¹²³I-IMP-single photon emission computed tomography. The patient was discharged with no neurological deficit after 2 weeks.