脳神経外科領域におけるDICの診断と治療—新しいDICスコアの提唱

Diagnosis and Treatment of Disseminated Intravascular Coagulation Associated with Neurosurgical Diseases—A proposal of a new scoring system for DIC

I．はじめに

　種々の脳神経外科疾患に合併して，播種性血管内凝固症候群（diSSeminated intravascular coagulation，以下DIC）を生じ，重篤な転帰をとることのあることが知られている．頭部外傷^{5,7,9,13,20,21）}やクモ膜下出血^1,6,19）に合併するDICの報告が多い．重症例に併発しやすく，感染症等の合併がその引き金になることがある．したがって，脳神経外科疾患患者の治療に際し，DICの合併に注意して，その早期診断と早期治療を心がけることが大切である．近年，DICの治療薬として，蛋白分解酵素阻害剤メシル酸ガベキサート（以下FOY）の有用性を検討した報告が脳神経外科領域でも散見される^10,16,23）．

　われわれは，DICの早期診断・早期治療の観点から，DICおよびDIC準備状態に対して，新潟大学脳神経外科関連15施設でFOYを投与し，その有効性を検討するとともに，脳神経外科疾患の重症度を最もよく反映すると思われる意識レベルを加味した，新しいDICスコアを作成し，その妥当性につき検討したので報告する．

The occurrence of disseminated intravascular coa-gulation (DIC) is not rare in neurosurgical patients. We investigated the therapeutic effects of gabexate mesilate(FOY) for DIC or DIC preparatory state in 70 cases. Underlying diseases were head injuries in 31 cases, in-tracranial hemorrhages in 19, suharachnoid hemor-rhages in 10, cerebral infarctions or embolisms in 5, brain tumors in 3 and other diseases in 2. DIC or DIC preparatory states were induced by severe brain dam-age (26 cases) , infection (26 cases) , failure of other organs (6 cases) , shock (5 cases) , and others. On the basis of the clinical coagulation studies of these pa-tients, we retrospectively established a new scoring sys-tem for DIC (neurosurgical DIC score) associated with neurosurgical diseases and evaluated whether it was useful. Because the original DIC score proposed by the Research Committee on Blood Coagulation Disorders supported by the Japanese Ministry of Health and Wel-fare was not correlated with the level of consciousness representing the primary brain damage, it was likely to be underestimated in neurosurgical patients. Therefore, we included the level of consciousness with a new DIC scoring system.

The neurosurgical DIC score was calculated from platelet count (score 0-3) , FDP (score 0-3) and the level of consciousness (score 0-2) , and was diagnosed as DIC preparatory state if it was 3, calculated from 2 of the 3 parameters, and as DIC if it was over 4. The score should he checked twice if it was 3, especially af-ter operation. The neurosurgical DIC score was signifi-cantly correlated with the original DIC score. Opera-tion or infection was not a factor which affected signifi-cantly the neurosurgical DIC score and laboratory data. After administration of FOY, the neurosurgical DIC score and laboratory data were significantly improved. It is concluded that this neurosurgical DIC scoring is useful for indicating the need for early starting of FOY therapy, which is effective for DIC and DIC prepara-tory state associated with neurosurgical diseases.