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Neurological Surgery No Shinkei Geka Volume 43, Issue 3 （March 2015）

Neurological Surgery 脳神経外科 43巻3号（2015年3月発行）

Japanese English

症例

重症くも膜下出血による意識障害と痙縮が改善してバクロフェン髄注療法から離脱し得た1例 Complete Remission of Consciousness Disturbances and Spasticity due to a Severe Subarachnoid Hemorrhage after Intrathecal Baclofen Therapy:A Case Report 旭雄士 ¹ , 柏崎大奈 ¹ , 高正圭 ¹ , 松村内久 ¹ , 黒田敏 ¹ Takashi ASAHI ¹ , Daina KASHIWAZAKI ¹ , Masaki KOH ¹ , Nobuhisa MATSUMURA ¹ , Satoshi KURODA ¹ ¹富山大学大学院医学薬学研究部脳神経外科 ¹Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama キーワード： intrathecal baclofen therapy , subarachnoid hemorrhage , consciousness disturbance , spasticity Keyword: intrathecal baclofen therapy , subarachnoid hemorrhage , consciousness disturbance , spasticity pp.253-257

発行日 2015年3月10日 Published Date 2015/3/10

DOI https://doi.org/10.11477/mf.1436202997

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Abstract 文献概要
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参考文献 Reference

Ⅰ．はじめに

　バクロフェン髄注療法（intrathecal baclofen therapy：ITB）は，さまざまな脳・脊髄疾患による重度痙縮に対する手術治療として行われている．GABA_B受容体のアゴニストであるバクロフェンは，血液脳関門を通過しにくいため，脊髄腔内に直接注入することで微量でも劇的な効果をもたらす．ITBは1992年に米国食品医薬品局（FDA）で認可され，本邦では2006年に保険収載となっている．バクロフェンが充塡されたポンプを体内に埋め込み，バクロフェンを髄腔内に留置したカテーテルを通して持続注入する．

　ITBは，通常一度埋め込まれると永続的に埋め込まれることが多く，ポンプ埋め込み後に症状が改善し，ITBから離脱できた症例の報告は少ない³⁾．今回，われわれは，重症くも膜下出血によって痙縮を来した患者に対してITBを施行したところ，痙縮および意識障害が劇的に改善したためITBが一切不要となった稀な1例を経験したので報告する．

　Typically, intrathecal baclofen therapy（ITB）for spasticity is continuously required because the spasticity can recur if the ITB is stopped. Thus, an infusion pump for the ITB is permanently implanted. Some sporadic cases exhibiting remarkable improvements in their spasticity and consciousness disturbances have been reported after implanting the ITB pump. We experienced a rare case involving removal of the ITB pump after the spasticity resolved and the consciousness disturbances markedly improved. A 15-year-old girl developed a subarachnoid hemorrhage due to rupture of an aneurysm in the right anterior cerebral artery. Her initial Glasgow Coma Scale score was 4（E1V1M2). Trapping of the aneurysm and decompression craniotomy were performed. Subsequently, she underwent a tracheotomy, and a percutaneous gastrostomy（PEG）tube was implanted because of persistent consciousness disturbances. Cranioplasty and lumbar-peritoneal shunt for normal pressure hydrocephalus were performed after 1 month. An ITB pump was implanted to improve the spasticity observed mainly in the lower extremities 61 days after hemorrhage onset. Right hemiparesis remained due to Kernohan's notch. After transfer to the rehabilitation hospital, her consciousness disturbances and spasticity remarkably improved（1.9 to 1.0 and 3.5 to 1.0 on the Ashworth scale for the upper and lower extremities, respectively). The tracheostomy and PEG tubes were removed, and the baclofen dose was gradually reduced. She was completely off baclofen after 7 months, and she was discharged with a short leg brace and a cane for walking. The baclofen pump was then removed. In this case, temporary ITB improved the spasticity and consciousness disturbances.