Summary: Ruptured vertebral artery dissecting aneurysm (VADA) requires urgent treatment because of the high incidence of re-bleeding, especially during the first 24 hours. Among such cases lesions involving the origin of the posterior inferior cerebellar artery (PICA) are formidable because it is difficult to prevent rebleeding and preserve blood flow of the PICA in the acute stage.We report a representative case in which we tried a simple and effective therapeutic method for these cases. A 38-year-old man was admitted to our hospital suffering severe headache, vomiting, and loss of consciousness. CT scan revealed subarachnoid hemorrhage, but soon after, rebleeding occurred and he fell into a deep coma. After waiting until the chronic stage when he recovered, we performed cerebral angiography. A left vertebral angiogram demonstrated a dissecting aneurysm involving the origin of the PICA. We occluded the affected vertebral artery (VA) near its root with platinum coils, intending to introduce collateral blood flow from the deep cervical artery into the VA trunk. We thought the controlled antegrade VA flow and retrograde flow from the contralateral VA would make a watershed at the dissecting aneurysm, which promotes thrombosis of the pseudolumen while preserving the antegrade flow of the PICA. After treatment, the dissecting aneurysm disappeared on angiogram and the patient recovered without rebleeding or ischemic complication.This method should be considered as the treatment of choice in cases with VADA involving PICA.
要旨他院で肺癌術後に発症したembolic stroke of undetermined source(ESUS)に対して,血栓回収療法を行った1例を経験した。その塞栓源と急性期脳梗塞診療における医療連携に関して文献的考察を含め報告する。症例は76歳の男性。他院において左肺癌に対して下葉切除術が施行され,術翌日に突然の左半身不全麻痺となった。頭部CT血管撮影で右中大脳動脈閉塞症と診断された。発症から103分で来院し,急性期血行再建術の適応と判断した。アルテプラーゼ静注療法は開胸術の翌日であり適応外と判断し,右M1,M2の閉塞に対して,ステント型デバイスを用いた血栓回収療法を行い,発症から170分で完全再開通した。2か所とも,フィブリン血栓による閉塞であった。再開通後のMRIでは右尾状核頭と被殻に小梗塞が出現したが,神経脱落症状はなく,癌治療を継続し得た。本症例は,明らかな塞栓源が不明であり,ESUSと診断される。発症時のD–dimer値は軽度高値であったが,臨床経過や術前後の心臓超音波検査より心疾患に伴う疾患群は否定的であった。発症時の胸部造影CTでは,既に血栓を示唆する所見はなかったが,過去の報告例との類似点から,切離した左肺静脈断端部に発生した肺静脈内血栓が塞栓源として最も疑われた。左肺葉切除の既往がある脳梗塞患者には,脳塞栓症を念頭に置く必要がある。
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