Neurological Surgery 脳神経外科35巻9号

2007年09月発行

症例

Rheolytic catheterとballoonを用いた機械的血栓破砕術が有用であった重症脳静脈洞血栓症の1例

著者： 中澤和智¹ 藤本基秋¹ 安藤充重¹ 橋本信夫¹

所属機関： ¹京都大学医学研究科脳神経外科

ページ範囲：P.907 - P.912

Ⅰ．はじめに

　脳静脈洞血栓症は全脳卒中のうち1％以下の比較的稀な疾患である．また，特徴的な症状がない場合が多く，しばしば診断治療に難渋することがある⁹⁾．未分画または低分子ヘパリンの全身投与とそれに引き続き3～6カ月の経口抗凝固薬投与が標準的治療になっているが^8,16），重症例の予後は極めて不良でありその対策には未だ議論が尽きない⁶⁾．近年，脳神経血管内治療の応用により局所線溶療法^3,12,15)や機械的血栓破砕療法^{1,2,5,7,8,13,14,18)}が適用され，重症例においても比較的良好な結果が報告されるようになってきた⁴⁾．しかし，大きな脳内出血が合併している場合にはurokinaseやtissue plasminogen activator（t-PA）などの線溶剤使用による出血性合併症はしばしば致命的となる^11,18,19)．われわれは，増大する脳内出血を伴った重症硬膜静脈洞血栓症にrheolytic catheterという水圧でベンチュリー効果を発生させ，陰圧を誘導し血管壁に損傷を来すことなく血栓を破砕除去するカテーテルとpercutaneous transluminal angioplasty（PTA）balloonによる機械的血栓破砕術を行い，経過が良好であった1例を経験したので報告する．

参考文献

1）Agner C, Deshaies EM, Bernardini GL, Popp AJ, Boulos AS：Coronary angiojet catheterization for the management of dural venous sinus thrombosis. Technical note. J Neurosurg 103：368-371, 2005

2）Bagley LJ, Hurst RW, Galetta S, Teener J, Sinson GP：Use of a microsnare to aid direct thrombolytic therapy of dural sinus thrombosis. AJR Am J Roentgenol 170：784-786, 1998

3）Barnwell SL, Higashida RT, Halbach VV, Dowd CF, Hieshima GB：Direct endovascular thrombolytic therapy for dural sinus thrombosis. Neurosurgery 28：135-142, 1991

4）Canhao P, Falcao F, Ferro JM：Thrombolytics for cerebral sinus thrombosis：a systematic review. Cerebrovasc Dis 15：159-166, 2003

5）Chaloupka JC, Mangla S, Huddle DC：Use of mechanical thrombolysis via microballoon percutaneous transluminal angioplasty for the treatment of acute dural sinus thrombosis：case presentation and technical report. Neurosurgery 45：650-656, 1999

6）Dentali F, Gianni M, Crowther MA, Ageno W：Natural history of cerebral vein thrombosis：a systematic review. Blood 108：1129-1134, 2006

7）Dowd CF, Malek AM, Phatouros CC, Hemphill JC 3rd：Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis：a new technique. AJNR Am J Neuroradiol 20：568-570, 1999

8）Einhaupl KM, Villringer A, Meister W, Mehraein S, Garner C, Pellkofer M, Haberl RL, Pfister HW, Schmiedek P：Heparin treatment in venous sinus thrombosis. Lancet 338：597-600, 1991

9）Einhaupl K, Bousser MG, de Bruijn SF, Ferro JM, Martinelli I, Masuhr F, Stam J：EFNS guideline on the treatment of cerebral venous and sinus thrombosis. Eur J Neurol 13：553-559, 2006

10）Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F：ISCVT Investigators：prognosis of cerebral vein and dural sinus thrombosis：results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 35：664-670, 2004

11）Frey JL, Muro GJ, McDougall CG, Dean BL, Jahnke HK：Cerebral venous thrombosis：combined intrathrombus rtPA and intravenous heparin. Stroke 30：489-494, 1999

12）Higashida RT, Helmer E, Halbach VV, Hieshima GB：Direct thrombolytic therapy for superior sagittal sinus thrombosis. AJNR Am J Neuroradiol 10 Suppl 5：S4-6, 1989

13）Murphy KJ, Gailloud P, Venbrux A, Deramond H, Hanley D, Rigamonti D：Endovascular treatment of a grade IV transverse sinus dural arteriovenous fistula by sinus recanalization, angioplasty, and stent placement：technical case report. Neurosurgery 46：497-500, 2000

14）Philips MF, Bagley LJ, Sinson GP, Raps EC, Galetta SL, Zager EL, Hurst RW：Endovascular thrombolysis for symptomatic cerebral venous thrombosis. J Neurosurg 90：65-71, 1999

15）Rael JR, Orrison WW Jr, Baldwin N, Sell J：Direct thrombolysis of superior sagittal sinus thrombosis with coexistingintracranial hemorrhage. AJNR Am J Neuroradiol 18：1238-1242,1997

16）Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T/American Heart Association/ American Stroke Association Council on Stroke；Council on Cardiovascular Radiology and Intervention；American Academy of Neurology：Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack：a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke：co-sponsored by the Council on Cardiovascular Radiology and Intervention：the American Academy of Neurology affirms the value of this guideline. Stroke 37：577-617, 2006

17）Scarrow AM, Williams RL, Jungreis CA, Yonas H, Scarrow MR：Removal of a thrombus from the sigmoid and transverse sinuses with a rheolytic thrombectomy catheter. AJNR Am J Neuroradiol 20：1467-1469, 1999

18）Soleau SW, Schmidt R, Stevens S, Osborn A, MacDonald JD：Extensive experience with dural sinus thrombosis. Neurosurgery 52：534-544, 2003

19）Wasay M, Bakshi R, Kojan S, Bobustuc G, Dubey N, Unwin H：Nonrandomized comparison of local urokinase thrombolysis versus systemic heparin anticoagulation for superior sagittal thrombosis. Stroke 32：2310-2317, 2001