経眼窩的穿通性損傷後に生じた遅発性脳膿瘍の1例

Delayed Brain Abscess after Penetrating Transorbital Injury

Ⅰ．はじめに

　小児脳膿瘍は，右左短絡を有するチアノーゼ性心疾患¹³⁾，中耳炎・副鼻腔炎といった耳鼻科的疾患，化膿性髄膜炎，頭部外傷などが原因となり¹⁾，高率に神経学的後遺症を合併する予後不良の疾患として知られている．今回，幼少期の穿通性頭部外傷が原因で遅発性に脳膿瘍を発症した症例を経験したので，若干の文献的考察を加え報告する．

　We report a case of brain abscess caused by a penetrating head injury that occurred 9 years earlier. A 14-year-old girl presenting with fever, headache, and stiff neck was admitted to our hospital. She was diagnosed with aseptic meningitis and treated conservatively. Seven days after admission she became stuporous and showed left hemiparesis. Computed tomography (CT) revealed two ring-enhancing masses with perifocal edema in the right frontal lobe. We diagnosed brain abscess and performed right fronto-temporal decompressive craniectomy and stereotactic aspiration, followed by systemic antibiotic therapy. Post-surgery bone window CT revealed a well-defined, low-density foreign body passing from the left orbita to the right frontal lobe through the ethmoid sinus. We learned that the patient had been struck with a plastic chopstick in the left medial eyelid at the age of 5 years. No particular symptoms developed during the following 9 years. After the cerebral edema had diminished over the next 10 days, a second surgery was performed to remove the residual chopstick, repair the fistula at the base of the skull, and perform cranioplasty. The patient was discharged with only slight hyposmia after a 4-week course of antibiotics. This case showed that it is necessary to remove a residual foreign body and to close the dural fistula if there is a possibility of recurrent central nervous system infection. When a child presents with brain abscess, previous penetrating head injury should be considered.