不妊治療中・体外受精着床後2週間で発症した奇異性脳塞栓にrecombinant tissue plasminogen activator静注療法を施行した1例

A Case of Paradoxical Cerebral Embolism Developed during in vitro Fertilization Treatment

不妊治療中の35歳女性で，体外受精卵移植・着床後（妊娠4週）に発症した脳梗塞症例を報告する。rt-PA静注療法により後遺症を残さず改善し，経食道心エコーの結果，小型心房中隔欠損が確認された。不妊治療に併発した卵巣過剰刺激症候群に関連する深部静脈血栓が，ASDを介した奇異性脳塞栓をきたしたと考えられた。妊娠未確認時点でのt-PA投与としては本邦初の妊婦症例で，満期帝王切開により健児を得た。若干の文献的考察を加えて報告する。

Abstract

A 35-year-old woman with a history of infertility, was presented to our hospital because of impaired consciousness and cerebellar ataxia, 14 days after in vitro fertilization. She received an embryo transfer under controlled ovarian hyper-stimulation. Magnetic resonance images revealed acute infarction in the cerebellum and brainstem. Magnetic resonance angiography showed a basilar artery occlusion at the end point. Following immediate intravenous rt-PA treatment, the symptoms disappeared completely. A transesophageal echocardiography revealed an atrial septal defect with a continuous left to right shunt. In addition, a Valsalva maneuver trans-esophageal echocardiography with injected saline showed the presence of jet bubbles in the left atrium crossing via the atrial septal defect. She was diagnosed with paradoxical cerebral embolism. Anticoagulant therapy was continued and she gave birth to a healthy baby. Deep vein thrombosis was associated with the ovarian hyper-stimulation syndrome that occurred during infertility treatment. As anti-phospholipid antibodies were weakly positive, the possibility of anti-phospholipid antibody syndrome was suggested. If a woman of childbearing age is presented because of stroke, it is important to administer initial therapy by keeping fertility in mind. Thrombolytic therapy for pregnant women should be carefully considered, because of the associated hazards; however, it is a very important treatment for maternal function after birth.

(Received March25, 2015; Accepted May 27, 2015; Published October 1, 2015)