重症小脳梗塞に対する外科的減圧術

Surgical Decompression for Massive Cerebellar Infarction

I．はじめに

　小脳梗塞急性期の治療としては，梗塞巣の進展防止および全身管理などの保存的治療が中心となる．また，梗塞に伴う脳浮腫に対してはマンニトール，ステロイド，バルビッレート等の抗浮腫剤の投与が行われている^9）．しかし，脳浮腫が広範になると，閉塞性水頭症をきたしさらには脳幹部を圧迫し，急激な意識レベルの低下をきたす場合がある．このような症例に対して，外科的減圧術が著効を示しかなりの率で救命できることが知られている^{2-4,6-8,11-13,15-19,22,23）}．しかし外科的減圧術の適応基準や治療成績，特に運動機能に関するlong-term out—comeのまとまった報告はほとんどない．今回われわれは，脳室ドレナージ術および後頭下減圧開頭術を施行した重症小脳梗塞10例の急性期の臨床経過および長期経過後の転帰について検討したので報告する．

The authors report 10 patients with progressive neurological deterioration due to massive cerebellar in-farctions. Computerized tomography scans confirmed obstructive hydrocephalus and brain stem compression. All 10 patients (seven men, three women; mean age, 59 years) were treated by external ventricular drainage and decompressive suboccipital craniectomy. After dis-charge from the hospital, they were followed up (23-101 months) and their functional independence was ev-aluated by the Barthel Index. The condition of three patients with brain-stem infarction had deteriorated de-spite decompressive surgery. Two of these died during the acute stage and one became severely disabled. The remaining seven patients showed neurological improve-ment during the postoperative period. Four patients with preoperative Japan Coma Scale of 100 returned to their previous jobs within the follow-up period and three patients with preoperative Japan Coma Scale of 200 required some assistance in daily activities. It is suggested that decompressive surgery may be beneficial for massive cerebellar infarction. The postop-erative prognosis depends mainly on the presence or absence of coexisting brain-stem infarction. It is possi-ble that, without brain-stem infarction, patients who re-mained in a “dependent” state may have recovered bet-ter if they had been operated on earlier.