内科的治療抵抗性の虚血症例に対して発症から1日以上経過して血栓回収療法を施行した1例

A Case of Thrombectomy beyond One Day after Stroke Onset Resistant to Medical Treatment

Ⅰ．はじめに

　DAWN（DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo)⁴⁾，DEFUSE 3（Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke)¹⁾の結果を受けて，症状と梗塞巣のミスマッチがある症例に対して24時間以内の血栓回収療法の有効性が示される一方で，未発症から24時間以上経過した症例に対する血栓回収療法の有効性は未だ明らかではない．

　今回われわれは，入院時に内科的治療を選択したものの，治療抵抗性であったため，結果的に未発症から24時間以上経過して主幹動脈閉塞症（large vessel occlusion：LVO）に対して血栓回収療法を行い，効果的だった1症例を経験したので，文献的考察を加え報告する．

　We report a case of thrombectomy beyond one day of onset of right middle cerebral artery occlusion.

　An 82-year-old woman who presented with difficulty in body movements was transferred to our hospital. After admission, left-sided weakness and dysarthria worsened with an National Institutes of Health Stroke Scale of 9. The initial MRI DWI on admission revealed multiple hyper intense signals in the right cerebral hemisphere and MR angiography revealed occlusion of the right internal carotid artery. We performed medical treatment because FLAIR also revealed hyper intense signals in the same lesion as the DWI image, and more than one day had passed since the onset. However, her symptoms worsened and we performed angiography on the next day, and found contrast defects like crab claw at the top of the right internal carotid artery. Even though more than one day had passed since the onset, we assumed that thrombectomy could prevent the worsening of symptoms. The procedure was a success and it resulted in complete reperfusion to the right middle cerebral artery. She showed improvement after the procedure.

　According to this case, thrombectomy one day from onset could be considered as a treatment option for large vessel occlusion with good collateral flow in the cases resistant to medical treatment.