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Neurological Surgery No Shinkei Geka Volume 47, Issue 4 （April 2019）

Neurological Surgery 脳神経外科 47巻4号（2019年4月発行）

Japanese English

症例

ワルファリン拮抗後に硬膜外自家血注入療法を繰り返すことで救命し得た重症低髄液圧症候群の1例 A Case of Spontaneous Intracranial Hypotension Successfully Treated with Repetitive Epidural Blood Patch after Warfarin Reversal 松田拓 ¹ , 松崎和仁 ¹ , 佐藤浩一 ¹ , 石原学 ² , 花岡真実 ¹ , 仁木均 ³ , 三宅一 ¹ Taku MATSUDA ¹ , Kazuhito MATSUZAKI ¹ , Koichi SATOH ¹ , Manabu ISHIHARA ² , Mami HANAOKA ¹ , Hitoshi NIKI ³ , Hajimu MIYAKE ¹ ¹徳島赤十字病院脳神経外科 ²川崎医科大学脳神経外科 ³徳島赤十字病院神経内科 ¹Department of Neurosurgery, Tokushima Red Cross Hospital ²Department of Neurosurgery, Kawasaki Medical School ³Department of Neurology, Tokushima Red Cross Hospital キーワード： spontaneous intracranial hypotension , epidural blood patch , warfarin reversal Keyword: spontaneous intracranial hypotension , epidural blood patch , warfarin reversal pp.441-447

発行日 2019年4月10日 Published Date 2019/4/10

DOI https://doi.org/10.11477/mf.1436203959

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Ⅰ．はじめに

　特発性低髄液圧症候群に対する治療は，「脳脊髄液減少症ガイドライン2007」では安静臥床と水分摂取での保存的治療が優先され，保存的治療で症状の改善が得られない場合に硬膜外自家血注入（epidural blood patch：EBP）が推奨されている⁷⁾．しかし，EBPを複数回施行することが必要な症例や，複数回行っても脳幹の下垂が進行し，重篤化する症例が報告されている^11,12)．今回われわれは，ワルファリン内服中に発症し，ワルファリン拮抗後にEBPを行うことにより治療し得た重症低髄液圧症候群の1例を経験したので報告する．

　We report a case of spontaneous intracranial hypotension successfully treated with repetitive epidural blood patch after warfarin reversal. A 75-year-old man presented with a 2-week history of headache. He was being treated with warfarin for atrial fibrillation. Neurological examination on admission showed mild disorientation. Prothrombin time-international normalized ratio（PT-INR）was elevated to 2.43. Initial magnetic resonance images of the brain demonstrated bilateral subdural hematomas, distortion of midbrain and diffuse pachymeningeal enhancement. Conservative treatments with bed rest and hydration were administered. On the third posthospital day, he became lethargic and emergently underwent epidural blood patch（EBP）at lumbar level. Consciousness disturbance improved immediately but reappeared 12 hours after the EBP. The second EBP was performed but consciousness level decreased again 12 hours later. The effect of warfarin was reversed by administration of vitamin K and fresh frozen plasma before the third EBP. After the procedure, he became alert. The findings of neurological examination did not change but a CT on day 12 revealed increase in volume of left-sided subdural hematoma. He underwent EBP and evacuation of hematoma. The neurological findings remained unchanged. A CT on the 17th posthospital day showed increase of right-sided subdural hematoma, and EBP and evacuation of hematoma were then performed. After the 5th EBP, the clinical course was uneventful.

　Predictors for successful EBP are not fully clarified. In patients who undergo anticoagulation therapy, EBP may be ineffective and normalization of coagulability required.