血栓溶解療法後にたこつぼ型心筋症および神経原性肺水腫を来した急性期脳梗塞の1例

Takotsubo Cardiomyopathy and Neurogenic Pulmonary Edema Following Fibrinolytic Therapy for Embolic Stroke:A Case Report

Ⅰ．はじめに

　急性期破裂脳動脈瘤患者において，たこつぼ型心筋症や神経原性肺水腫などの急性呼吸循環障害を合併することは比較的よく知られているが⁶⁾，虚血性脳血管障害患者においても同様の合併をみることが稀ながら報告されている^10,11)．アルテプラーゼを用いた血栓溶解療法は，2005年に発症3時間以内に治療可能な虚血性脳血管障害患者を対象に保険承認され，2012年には発症4.5時間以内へと対象が拡大した．現在，虚血性脳血管障害に対する急性期治療は急速に変遷しており，血栓溶解療法に加えて血管内治療による血栓回収療法も積極的に行われている．一方，転帰の改善には急性期の内科的治療および管理が重要である．今回われわれは，血栓溶解療法後にたこつぼ型心筋症および神経原性肺水腫の合併を認めた非常に稀な症例を経験したため，文献的考察を加え報告する．

　A 79-year-old man presented with left hemiparesis and disturbance of consciousness. Brain magnetic resonance（MR）imaging revealed an infarction in the right insular cortex. MR angiography showed a defect in the inferior trunk of the right middle cerebral artery. The patient was treated with alteplase about 2.5 h after onset. Immediately after the intravenous alteplase administration, the hemiparesis improved. However, his respiratory condition unexpectedly worsened 10 h after onset. Chest radiography demonstrated an infiltrative shadow in both lung fields. Transthoracic echocardiogram showed a dysfunction in the left ventricle and no contraction at the apex of the heart, consistent with a type of cardiomyopathy, known as takotsubo cardiomyopathy（TCM). Gradually, the patient's respiratory and cardiac function improved. Here, we describe a very rare case of TCM and neurogenic pulmonary edema（NPE）following an acute cerebral infarction, which was treated with alteplase intravenous administration. TCM and NPE have a poor prognosis, therefore diagnosis, management, and treatment in the acute phase is required.