上顎癌術後に生じた外傷性海綿静脈洞部動脈瘤の1例

Traumatic Carotid-Cavernous Aneurysm after Removal of Cancer of the Upper Jaw:A case report

I．はじめに

　外傷性脳動脈瘤の頻度は全脳動脈瘤の0.5％以下とされ^1），日常診療において遭遇することは比較的稀である．その大部分は種々の閉鎖性あるいは開放性頭部外傷後に二次的に発生するが，なかでも手術時の脳血管損傷によるものは少ない^7）．

　最近われわれは上顎癌の術後に生じたと考えられる外傷性海綿静脈洞部動脈瘤（traumatic carotid-cavernous aneurysm，以下TCCAと略す）の破裂により反復性大量鼻出血を来した症例に対し，脳外科的処置で出血を止めたものの，メチシリン耐性黄色ぶどう球菌（MRSA）敗血症を併発し不幸な転帰をとった1例を経験したので，治療上の問題点を中心に文献的考察を加え報告する．

A case of a traumatic carotid-cavernous aneurysm af-ter removal of cancer of the upper jaw was reported.

A 63-year-old male complaining of massive epistaxis from the left nostril was admitted to our clinic. He had suffered from cancer of the left upper jaw and had been treated with radical operation. During the surgical procedure, massive bleeding which was considered to be from the left internal carotid artery, suddenly occur-red. The hemorrhage was somehow controlled by pack-ing with oxidized cellulose. He experienced recurrent massive epistaxis after admission. Cerebral angiograms revealed an anterior-medially projecting aneurysm aris-ing from the cavernous portion of the left internal caro-tid artery. He had a good cross circulation from right to left on compression of the left carotid artery. This aneurysm at the carotid-cavernous portion was pro-duced as a result of injury during an operation for can-cer of the upper jaw. To prevent disastrous bleeding from the aneurysm, the aneurysm was then successfully treated by the trapping of extra-and intracranial carotid ligation in combination with left STA-MCA anastomo-sis. There was no recurrence of epistaxis after the op-eration. However, a low-grade fever persisted before operation and a blood culture showed MRSA sepsis af-ter the operation. Intensive chemotherapy was per-formed for this MRSA sepsis, he died of the accom-panying DIC.

Although aneurysmal epistaxis following a severe closed head trauma is a well-known phenomenon, an iatrogenic carotid-cavernous aneurysm presenting with recurrent massive epistaxis is rare. Several comments were made about the iatrogenic carotid cavernous aneu-rysm, and the necessity of early diagnosis and treat-ment was emphasized.