Neurological Surgery 脳神経外科36巻2号

2008年02月発行

総説

くも膜下出血後の脳血管攣縮―基礎研究と治療における現在と将来の展望

著者： 西澤茂¹

所属機関： ¹産業医科大学脳神経外科 ²

ページ範囲：P.121 - P.133

Ⅰ．はじめに

“When persons in good health are suddenly seized with pains in the head, and straightway are laid down speechless, and breathe with stertor, they die in seven days―”

(Hippocrates 460-370 B.C., Aphorisms on apoplexy) ⁹⁾

　これは2,400年前にヒポクラテスが記述したものであるが，おそらくくも膜下出血で倒れた人が1週間後に亡くなった状態を克明に記載している．1週間後に死亡しているということで，おそらく脳血管攣縮で亡くなったものと思われる．

　ヒポクラテスの時代から知られていたくも膜下出血後の脳血管攣縮が重篤であり，患者の生命予後を決定づけることは現在では周知の事実であるが，残念ながらヒポクラテス時代に知られていたこうした状況は，医学がこれまで科学的に進歩した現在でも，脳神経外科医にとってはまだまだ日常臨床上の重大なテーマとして残されている．

　脳動脈瘤破裂によるくも膜下出血は毎年人口約100,000人あたり10人の頻度で発症し⁵⁾，ある統計ではその半数は発症後にすぐに死亡してしまうという報告もある²⁷⁾．幸い，発症後生存した患者は病院に搬送され，開頭術によるclippingや血管内治療による脳動脈瘤coilingによって再出血を防ぐ治療を受けることができるが，こうした初期治療にもかかわらず，次に重大な問題として残るのが，脳血管攣縮であり，症候性，無症候性を問わずほぼほとんどの患者にくも膜下出血後4～9日の間に脳血管攣縮が現れ⁷⁰⁾，この病的脳血管収縮の状態によって少なからず患者は死亡し，あるいは重篤な神経学的脱落症状を負うことになる．従来の報告では，このくも膜下出血後，ある一定の時間をおいて起こってくる脳血管収縮が患者のmortality，morbidityを決定づけるsingle most important causeと考えられていた．この遅発性虚血性神経脱落症候（delayed ischemic neurological deficits；DIND）あるいは症候性脳血管攣縮に対して，これまでさまざまな治療の試みが行われてきた．集中治療室で血圧，脳血流，脳代謝などのさまざまなモニタリング監視下にnimodipine（西欧のみ），nicardipine等を中心としたカルシウム拮抗剤，いわゆるtriple-H therapy（hypertensive，hypervolemic，and hemodilutional therapy）が行われた．またintrarterialに血管拡張物質を注入する，あるいはmechanicalにballon angioplastyを行う，といった治療が行われてきたし¹³⁾，おそらく現在の日常臨床上でも，脳血管攣縮に対する治療はこうした治療戦略がまだまだstandardになっているものと思われる．これらの治療の試み，その成果が2006年にトルコのイスタンブールで行われた第9回国際脳血管攣縮学会（9th International Conferecne on Cerebral Vasospasm, ICCV）で発表されたが，一定の治療成績をあげている反面，まだまだ解決にはほど遠い，というのがほとんどの発表の骨子であったと思われる．

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