巨大な高血圧性脳出血に対する定位的血腫溶解吸引術

Stereotactic Evacuation of Massive Hypertensive Intracerebral Hemorrhage

I．はじめに

　高血圧性脳出血に対する外科的治療は，従来被殻出血や皮質下出血などを中心に開頭術による血腫除去術が行われてきたが，Backlundら^1）によりCT誘導定位脳手術法による脳内血腫除去術が始められ，その有効性と安全性が報告されてくると，視床出血など脳深部の出血も含め多くの高血圧性脳出血に対し定位的な脳内血腫除去術が行われるようになってきた．これは開頭血腫除去術に比較して手術侵襲が少なく，高齢者や重篤な合併症を有する症例に対しても手術が可能であるが^6），巨大な血腫や出血が続いている症例では，血腫の除去が不十分となったり，術中における止血が困難となるなどの欠点も見られる．

　われわれはこのような進行性の巨大な高血圧性脳出血で，重篤な合併症や高齢のため開頭術による血腫除去が困難な症例に対して，アルフォナード（trimetaphan camsilate）により積極的な降圧をはかり血腫増大の進行を抑えた後，駒井式CT定位脳手術装置を利用してtwo burr holes drainageをおき，血腫腔をウロキナーゼ溶液で灌流しながら血腫を吸引除去し良好な結果を得たので，本法を紹介すると共に手術成績についても報告する．

Six patients with massive hypertensive intracerebral hemorrhage and showing progression of consciousness-disturbance were treated by CT-guided stereotactic surgery. Serious complications or the age of these pa-tients prevented evacuation of the hematomas by cra-niotomy under general anesthesia. The increase in the size of the intracerebral hematoma suggested by the progression of the consciousness-disturbance on admis-sion was stopped by controlling the blood pressure.Stereotactic evacuation of the hematoma was per-formed using Komai's CT stereotactic apparatus 1 - 4 days after the onset. On the CT slice showing the max-imum size of the hematoma, two target points showing each center or two circles which cover the greater part of the hematoma were determined, and then two drain-age tubes were inserted into the two target points of the hematoma through two burr holes, and the hemato-ma was aspirated with a syringe. Postoperatively, every 12 hours, a solution of 60,000IU urokinase in 100m/ saline was irrigated into the hematoma cavity with aspiration of the hematoma, and finally 10ml urokinase solution was left in the hematoma cavity. By 2 - 4 re-petitions of this procedure, 83 - 91% of the estimated hematoma volume was evacuated using urokinase (120,000 - 240,000IU) for 1 - 2 days. Therefore, all of the cases showed improvement in the consciousness level without rebleeding or progression of serious com-plications.

For large hypertensive intracerebral hematomas in aged patients or patients with serious complications, this stereotactic surgery can be carried out safely and rapidly through two drainage tubes using urokinase after 24 hours from the onset