橋出血に対する治療とその機能的予後—保存的療法と手術的療法の比較

Functional Outcome of Primary Pontine Hemorrhage : Conservative Treatment or Stereotaxic Surgery

I．はじめに

　高血圧性橋出血に対する手術的治療はいまだ論議の域を出ない．直達手術としては1932年のDandyの報告以来成功例がいくつか報告されているが，元来橋出血自体が他の脳内出血に比べ重篤であり，血腫がうまく除去できても多大な後遺症を残しうること，手術自体が侵襲の大きいものでまた橋という場所がら手術によって症状を悪化させる可能性のあることから，ほとんど行われていないのが実状である^{4,6,8,10,11,13）}），しかし，こうした深部脳内出血に対する侵襲の少ない手術法としてわが国では1978年に駒井らがCT下定位血腫吸引術を施行し良好な成績をおさめており^5），この定位血腫吸引術が現在橋出血に対する唯一の手術的な治療法といえるかもしれない．ただし，この手術の有用性つまり機能的な予後に関する報告例は少なく^1,3,9），特に保存的療法と比較検討したものは数えるほどである^5,14,15）．今回われわれは1988年から1996年の8年間にわたり橋出血に対して手術した年度と保存的加療のみとした年度に分け，その機能的予後を発症後3カ月の段階で評価し，両群で比較検討したのでこれを報告する．

In this study we compared the outcome of patients with primary pontine hemorrhage (PPH) in those who underwent stereotaxic aspiration and those treated non-surgically. Out of 75 PPHs, 37 patients were selected. Their consciousness on admission was somnolent to semicoma (alert and deeply comatose cases were excluded). Patients admitted between 1988 and 1990, and between 1995 and 1996 underwent CT guided sterotaxic aspiration (18cases : Surgical Group), and those admitted between 1991 and 1994 were treated conservatively (19 cases : Conservative Group). The outcome was analyzed three months after the onset from the viewpoint of level of consciousness and severity of paresis, according to the location of the hemorrhage. With regard to consciousness, 13 of 18 cases in the Surgical Group showed remarkable im-provement, while only 8 of 19 cases in the Conservative Group did. The severity of paresis was evaluated only among the patients who could obey commands three months after the onset. Paresis improved in 7 of 13 patients in the Surgical Group, vs. in 3 of 8 patients in the Conservative Group (p＜0.05). According to the location of hemorrhage (CT classification), in the Unilateral tegmental type and the Massive type, the Surgical Group and the Conservative Group showed no difference. On the other hand, in the Bilateral teg-mental type and the Basal tegmental type, surgery seemed to be more effective than conservative treat-ment. In conclusion, CT guided stereotaxic aspiration may improve not only the consciousness level but also the functional outcome.