頭蓋底骨折後の再発気脳症の治療に大網移植術を行った1症例

Successful Reconstruction of the Skull Base Fracture with Frontal Lobe Contusion by Omental Transplantation for Recurrent Posttraumatic Tension Pneumocephalus:A case report

I．はじめに

　気脳症とは頭蓋内腔に空気が進入する病態であり，その多くはクモ膜下腔，硬膜外に生じるが，時として脳実質または脳室内に空気が入ることもある^15），その原因としては頭部および顔面の外傷，頭蓋底手術，感染，頭蓋底腫瘍等が報告されているが，頭部外傷が最も多い^14）．頭部外傷の7.8-13.2％に気脳症がみられ^12,17,23），気脳症の74-90％を占めている^14,20）．緊張性気脳症は，頭蓋内に進入した空気が頭蓋内圧の亢進を来たし，様々の神経症状を示すものであり，その多くは外科的治療を必要とする^13）．

　われわれは頭蓋底骨折の後遺症として1年後に発症し，繰り返し発症した髄膜炎を伴う難治性緊張性気脳症に対して，有茎大網移植術を行って治癒せしめた症例を経験したので報告する．

In July 1983, 26 year-old male was admitted to our neurosurgical clinic after severe head injury caused by a car accident. Recovery of consciousness was delayed for months due to bilateral frontal lobe contusions with anterior skull base fractures on both sides. He was first discharged 6 months after surgery for ventriculo-perito-neal shunting. He was readmitted to our department due to an episode of urinary incontinence with gait dis-turbance 11 months after the accident. CT film of the head revealed the presence of an air shadow at the left frontal base. Utilizing lyophyllized dura mater, the first cranial surgery for closure of cerebrospinal fluid leakage was carried out in July, 1984. Pneumocephalus with menin-gitis recurred again five years later. Repeated conven-tional surgery failed including a transsphenoidal and transfrontal sinus approach to treat the recurrent pneumocephalus. In order to close the defect in the skull base, and to obliterate the dead space in the left frontal lobe, vital tissue transplantation was planned. On May 23, 1990, seven years after the accident, the skull base defect was repaired by suturing fascia taken from the temporal muscle. Then the patient's vascula-rized omentum was utilized as an autograft by micro-surgical technique. A superficial temporal artery and vein, and superficial sylvian vein were used to vascula-rize the omentum. The patient has been totally free of pneumocephalus for more than three and half years fol-lowing the radical surgery.

Clinical omental transplantation using microsurgical technique for vascularization of cerebral circulation as well as plastic surgery has been reported. We discussed the advantages of omentum as free re-vascularized grafts for the reconstruction of post-traumatic basal skull fracture with frontal lobe defects which caused recurrent aerocele with meningitis. The method of vital omental trasplantation is reliable and of importance in the future treatment of the central nervous system as well as in skull base surgery.