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Neurological Surgery No Shinkei Geka Volume 47, Issue 1 （January 2019）

Neurological Surgery 脳神経外科 47巻1号（2019年1月発行）

Japanese English

症例

くも膜下出血急性期に腹腔内出血を併発したsegmental arterial mediolysisと考えられた1例 Possible Segmental Arterial Mediolysis Associated with Intraperitoneal Hemorrhage in the Acute Stage of Subarachnoid Hemorrhage:A Case Report 小原次郎 ¹ , 山尾幸広 ¹ , 石井暁 ¹ , 清水大功 ² , 菊池隆幸 ¹ , 武信洋平 ¹ , 小松克也 ¹ , 池田宏之 ¹ , 稲田拓 ¹ , 西秀久 ¹ , 安部倉友 ¹ , 宮本享 ¹ Jiro OHARA ¹ , Yukihiro YAMAO ¹ , Akira ISHII ¹ , Hironori SHIMIZU ² , Takayuki KIKUCHI ¹ , Yohei TAKENOBU ¹ , Katsuya KOMATSU ¹ , Hiroyuki IKEDA ¹ , Taku INADA ¹ , Hidehisa NISHI ¹ , Yu ABEKURA ¹ , Susumu MIYAMOTO ¹ ¹京都大学大学院医学研究科脳神経外科 ²京都大学大学院医学研究科放射線医学講座（画像診断学・核医学） ¹Department of Neurosurgery, Kyoto University Graduate School of Medicine ²Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine キーワード： subarachnoid hemorrhage , endovascular treatment , segmental arterial mediolysis , intraperitoneal hemorrhage Keyword: subarachnoid hemorrhage , endovascular treatment , segmental arterial mediolysis , intraperitoneal hemorrhage pp.97-103

発行日 2019年1月10日 Published Date 2019/1/10

DOI https://doi.org/10.11477/mf.1436203902

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Ⅰ．はじめに

　Segmental arterial mediolysis（SAM）は，1976年にSlavinらによって提唱された，動脈に発生する非炎症性・非動脈硬化性の稀な変性疾患である．SAMは主として，腹腔内の筋性動脈に分節性に中膜融解を来すことで動脈瘤を形成し，動脈瘤破裂による突然の腹腔内出血を生じる病態であり，頭蓋内動脈瘤の合併も報告されている^20,21)．今回われわれは，くも膜下出血後急性期に右胃大網動脈破裂による腹腔内出血からショック状態となり，予後不良となった症例を経験したので文献的考察を加えて報告する．

　Segmental arterial mediolysis（SAM）is a rare non-inflammatory and non-atherosclerotic arteriopathy associated with the occurrence of multiple aneurysms such as intracranial and intraperitoneal aneurysms.

　We report a case of intraperitoneal hemorrhage that occurred during the acute stage of subarachnoid hemorrhage（SAH). An 82-year-old woman presented with a sudden onset of loss of consciousness with a diagnosis of SAH. Digital subtraction angiography demonstrated two consecutive vertebral artery-posterior inferior cerebellar artery aneurysms. The larger aneurysm, which seemed to be ruptured, was successfully treated by coil embolization. On the 9th day after the onset of SAH, she developed aphasia secondary to the cerebral vasospasm. After selective intra-arterial infusion of fasudil hydrochloride, she was observed to maintain elevated systolic blood pressure. Her aphasia improved；however, on the 14th day, she suddenly developed hemorrhagic shock. An abdominal computed tomography scan demonstrated intraperitoneal hemorrhage secondary to a ruptured fusiform aneurysm of the right gastroepiploic artery. The lesion was successfully treated by coil embolization, although she became bedridden. Although a histopathological examination was not performed, her clinical, radiological, and serological presentation met the criteria of the clinical diagnosis of SAM. Elevated systolic blood pressure and excessive release of catecholamines in the acute stage of SAH might have caused the intraperitoneal hemorrhage.

　Non-saccular ruptured intracranial aneurysms should be considered among the differential diagnoses of SAM. In such cases, identifying and monitoring intraperitoneal aneurysms might be useful for earlier diagnosis and treatment of SAM, especially in the acute stage after SAH.