血管内治療で救命し得たビニル傘による両側頚動脈穿通損傷の1例

A Case of Bilateral Carotid Injury Caused by Vinyl Umbrella Penetration Successfully Treated with Endovascular Therapy

Ⅰ．はじめに

　外傷性頚動脈損傷（traumatic carotid injury：TCI）は本邦では極めて稀な外傷である．TCIは外傷機転により穿通性頚動脈損傷（penetrating TCI：PTCI）と非穿通性頚動脈損傷（Non-PTCI）に分類され，Non-PTCIでは仮性動脈瘤や動静脈瘻，動脈解離等の多様な臨床像が知られている^7）．PTCIでは頚動脈断裂に伴う出血が一般的な病態であるが，仮性動脈瘤や動静脈瘻を呈する症例も報告されている^{34, 37）}．頚動脈断裂は，大量出血，血腫による気道圧排，脳虚血など極めて重篤な病状を引き起こす．特に複数損傷部位による大量出血例の救命，治療は最も困難である^37）．これらの結果，PTCIの致死率は10〜22%と高く^{3, 8, 18, 23, 25, 34）}，救命例でも10〜19%で何らかの神経脱落症状を来す予後不良の疾患である^{8, 23, 34）}．特に両側PTCIによる活動性出血例で救命された症例報告は筆者らが文献的に渉猟し得た範囲（PubMed，医中誌）では1例であった^33）．

　今回，搬入時頚部より活動性出血を来していたビニル傘による両側PTCI症例を血管内治療により救命し得たので文献的考察を加えて報告する．

　Here, we have reported a case pertaining to a 59-year-old man with bilateral traumatic carotid artery injury caused by vinyl umbrella penetration who was successfully treated. The patient fell from the stairs while holding an umbrella, which penetrated his neck. On admission, the patient was in a comatose state and the umbrella had been removed. Active bleeding was observed on the left side of the neck. Hence, tracheal intubation was performed to support respiration. Neck and head contrast-enhanced CT revealed bilateral extravasations from the carotid arteries and right middle cerebral artery（MCA）occlusion. Left carotid angiography showed extravasation from the external carotid artery（ECA）, which was treated with coil embolization. Right carotid angiography revealed bleeding from the ECA and internal carotid artery（ICA）and occlusion of the MCA. The ECA and ICA were occluded by coil and n-butyl-2-cyanoacrylate embolization. After the procedures, the patient developed a large right cerebral infarction with massive brain swelling；therefore, external decompression was performed. Subsequently, the patient became alert and was able to walk with support within a month.

　Bilateral carotid injury is severe and difficult to treat. Endovascular therapy may be effective for the management of bilateral carotid injuries.