モヤモヤ病の経硬膜供給血管の破綻による非外傷性急性硬膜下血腫の1例

Nontraumatic Acute Subdural Hematoma Caused by the Rupture of Transdural Anastomotic Vessels in Moyamoya Disease

I．はじめに

　急性硬膜下血腫のほとんどは外傷に起因するものであるが，非外傷性に発症した症例も少なからず報告されている^5,8-10）．その原因として，脳動脈瘤，脳血管奇形や皮質動脈からの出血，硬膜の転移癌からの出血，出血性素因などがあげられ，外科的治療の対象となるものが多い．しかし，非外傷性硬膜下血腫の場合，いうまでもなく基礎疾患の病態を充分把握したうえでの治療が必要となる．

　われわれは，モヤモヤ病の経硬膜供給血管から出血した重篤な急性硬膜下血腫の1例を経験し，硬膜下血腫の発生機序と治療上におけるいくつかの問題点について考察したので報告する．

A case of nontraumatic acute subdural hematoma caused by the rupture of transdural anastomotic vessels in a patient with Moyamoya disease is reported. The patient was a 55-year-old woman who was admitted to our hospital in a comatose state. A diagnosis of acute subdural hematoma associated with Moyamoya disease was made on the basis of CT and angiographic find-ings. No lesions suggestive of trauma, such as cerebral contusion, could be detected during surgery. Although total evacuation of the hematoma was performed, she developed the apallic syndrome and did not recover consciousness. Judging from the angiographic and op-erative findings, it appears that subarachnoid hemor-rhage occurred first and stretched the transdural anas-tomotic vessels which supplied the collateral circula-tion. This led to tearing of some of the vessels, and their proximal ends were consequently exposed in the subdural space.

The surgical treatment of acute subdural hematoma associated with Moyamoya disease requires the closest attention to avoid damage to the collateral circulation. Although we carefully arrested the bleeding without using a coagulator in order to spare the collateral ves-sels, the transdural anastomosis was no longer visible on postoperative angiograms. Our experience suggests that hematoma irrigation with trephination therapy, which may minimize the damage to the collateral cir-culation, may be the most appropriate treatment for acute subdural hematoma associated with Moyamoya disease. Furthermore, cerebral revascularization should be performed for the treatment of the circulatory dis-turbance intercepted by the hematoma itself or by op-erative manipulation.