脳血管攣縮に対する塩酸パパベリン動注療法

Endovascular Treatment of Cerebral Vasospasm with Intra-arterial Papaverine Infusion

I．はじめに

　くも膜下出血後の脳血管攣縮に対する治療は，早期手術による血腫除去，術中術後の脳槽洗浄^5），Ca拮抗剤の投与^25），hypervolemic hypertensive therapyc^27）が一般的である．上記の治療で対処できない症候性脳血管攣縮に対して当施設では1989年以来percutaneous translu—minal angioplasty（以下PTAと略す）を行い良好な結果を得てきた^22,29）．しかし前大脳動脈領域や中大脳動脈末梢の血管攣縮ではバルーン挿入が困難であったり，血管破裂の危険性^9,16）のためPTA困難な例も多い．この問題を解決する治療法として最近，塩酸パパベリンの選択的動注療法（以下パパベリン動注と略す）が報告され^11,12），簡便な治療法でもあり，われわれも第一選択で施行してきた．本稿ではわれわれのパパベリン動注の結果を報告し，従来のPTAとの比較からその効果と問題点について考察した．

Thirty-one cases of cerebral vasospasm following subarachnoid hemorrhage were treated with intra-arterial papaverine infusion. Symptomatic cases were nineteen, and asymptomatic cases were twelve. Papaverine (120mg/saline 50ml, 30 min) was injected superselectively to vasospastic vessels through a micro-catheter. The rate of symptomatically improved cases was 63% initially, but about two thirds of those cases had recurrence within a day. The 63% of symptomatic cases showed infarction in spite of papaverine infusion.Three cases of recurrent vasospasm after intra-arterial papaverine underwent PTA and showed good dilata-tion of vasospastic vessels. The complications of our in-tra-arterial papaverine were hypotension in two cases, convulsion in one case and transient disturbed con-sciousness in one case. We experienced no fatal com-plications. Overall outcome was ADL1 (19%), ADL2 (25%), ADL3 (44%), ADL4 (0%), ADL5 (6%), and death(6%). Since the effect of intra-arterial papaverine infusion is of short duration and weak, combination of PTA and papaverine may be necessary. It is recom-mended to use papaverine for vasospasm in distal arte-ries such as M2, A1, A2, and to carry out PTA for prox-imal arteries such as ICA and M1.