同時多発性高血圧性脳内出血例の検討

Simultaneous Multiple Hypertensive Intracerebral Hematoma

　Ⅰ．はじめに

高血圧性脳内出血（HIH : hypertensive intra-cerebral hematoma）は近年の降圧加療の進歩により減少傾向にあるが，高齢化社会を迎えたわが国においては依然重要な疾患の一つである．CTが普及した現在ではHIHの診断は容易となり，発症から早期に診断が可能となった．CTにおける早期診断によって同時多発性に生じたと考えられる症例も時に経験されるようになったが^4,6-11)，このような症例では治療方針の決定に苦慮する場合もある．そこで今回，自験例をもとに同時多発性に生じたと考えられるHIHについてその特徴を検討し，発症機序および治療方針に関する考察を加えて報告する．

　Hypertensive intracerebral hemorrhage (HIH) occurring simultaneously in different locations is rare. We encountered 11 such cases between January 1990 and November 2002. The diagnosis of all 11 cases was established by computed tomography,and the location of the hematomas was : cerebellum and basal ganglia in 5 cases,pons and basal ganglia in 4,and subcortex and basal ganglia in 2. Our patients were analyzed with respect to clinical characteristics,pathogenesis of multiple hematomas,and indication of operation.

　These patients represented 1% of all 1,069 patients we encountered with HIH. As past history,there were no characteristic disorders except hypertension. There were no characteristic initial symptoms suggesting that hemorrhage had occurred simultaneously. Both supra- and infra-tentorial hematomas were observed in 80% of the patients,and the size of the multiple hematomas was proportional in principle. Cerebellar hematomas were often mild,and pontine hematomas were often severe. The outcome in those patients whose neurological grading was 1 to 3 was good with conservative therapy or surgical treatment. The severity,treatment methods,and outcomes in these patients were similar to those in patients with single HIH,which suggests only a slight influence of multiple lesions on outcome.

　As for the possible mechanism of simultaneous multiple hemorrhages,we speculated that bleeding occurred simultaneously in the different regions,or that the initial bleeding was followed after a short time by secondary bleeding due to high intracranial pressure and circulatory disturbance. In patients with cerebellar hematoma,initial symptoms suggested the development of secondary hemorrhage after primary hemorrhage.

　The surgical treatment for multiple hematomas should be determined by the location and maximum axis of the hematoma. We proposed that cerebellar hematomas should be removed if the supra-tentorial hematoma is small.