Neurological Surgery 脳神経外科37巻4号

2009年04月発行

総説

MRI firstによる頭痛診断

著者： 下田雅美¹

所属機関： ¹

ページ範囲：P.325 - P.341

Ⅰ．はじめに

　急性発症の頭痛患者における画像診断は，くも膜下出血（subarachnoid hemorrhage：SAH）などの出血性病変と頭蓋内占拠性病変の診断を目的に，従来からCT検査を第一選択としてきた．しかし，最近，CTでは検出困難な頭痛の原因病態が解明され，頭痛の初期診療の段階で，magnetic resonance imaging（MRI）が必要な場合も少なからず経験する．また，既にtissue plasminogen activatorなどの超急性期の脳梗塞治療が広く普及し，特に脳卒中センターにおける診療体制では，急性期脳梗塞の診断を優先するために，MRIを画像診断の第一選択とする施設が多くなりつつある．したがって，臨床医は「とりあえずのCT」を経由せずに，MRI所見により少なくとも一般的な頭蓋内病変を的確に診断する必要がある．

　今回，日常の頭痛診療の中でMRI firstで検査したがゆえに異常所見と混同しやすい正常変異（normal variation），最も危険な頭痛として見逃してはいけないSAHとMRI上鑑別すべき疾患など，日常的な頭痛疾患を中心としてMRI所見を解説する．なお，MRI上，比較的容易に存在診断が可能な脳腫瘍・外傷性病変，さらに低髄液圧症候群の記載は他稿に譲った．

参考文献

1）Araki Y, Ashikaga R, Takahashi S, Ueda J, Ishida O：High signal intensity of the infundibular stalk on fluid-attenuated inversion recovery MR. AJNR Am J Neuroradiol 18：89-93, 1997

2）Arita K, Kurisu K, Tominaga A, Sugiyama K, Ikawa F, Yoshioka H, Sumida M, Kanou Y, Yajin K, Ogawa R：Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy. J Neurosurg 95：897-901, 2001

3）Atlas SW, DuBois P, Singer MB, Lu D：Diffusion measurements in intracranial hematomas：implications for MR imaging of acute stroke. AJNR Am J Neuroradiol 21：1190-1194, 2000

4）Bonneville F, Cattin F, Marsot-Dupuch K, Dormont D, Bonneville JF, Chiras J：T1 signal hyperintensity in the sellar region：spectrum of findings. Radiographics 26：93-113, 2006

5）Byun WM, Kim OL, Kim D：MR imaging findings of Rathke's cleft cysts：significance of intracystic nodules. AJNR Am J Neuroradiol 21：485-488, 2000

6）Calabrese LH, Dodick DW, Schwedt TJ, Singhal AB：Narrative review：reversible cerebral vasoconstriction syndromes. Ann Intern Med 146：34-44, 2007

7）Casey SO, Sampaio RC, Michel E, Truwit CL：Posterior reversible encephalopathy syndrome：utility of fluid-attenuated inversion recovery MR imaging in the detection of cortical and subcortical lesions. AJNR Am J Neuroradiol 21：1199-1206, 2000

8）Crombe D, Haven F, Gille M：Isolated deep cerebral venous thrombosis diagnosed on CT and MR imaging. A case study and literature review. JBR-BTR 86：257-261, 2003

9）Day JW, Raskin NH：Thunderclap headache：symptom of unruptured cerebral aneurysm. Lancet 2：1247-1248, 1986

10）Dodick DW：Thunderclap headache. Headache 42：309-315, 2002

11）Dodick DW：Thunderclap headache. J Neurol Neurosurg Psychiatry 72：6-11, 2002

12）Dodick DW, Brown RD Jr, Britton JW, Huston J 3rd：Nonaneurysmal thunderclap headache with diffuse, multifocal, segmental, and reversible vasospasm. Cephalalgia 19：118-123, 1999

13）Dodick DW, Eross EJ：A not so uncommon cause of thunderclap headache. Headache 42：555, 2002

14）Dodick DW, Eross EJ, Drazkowski JF, Ingall TJ：Thunderclap headache associated with reversible vasospasm and posterior leukoencephalopathy syndrome. Cephalalgia 23：994-997, 2003

15）Ducros A, Boukobza M, Porcher R, Sarov M, Valade D, Bousser MG：The clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome. A prospective series of 67 patients. Brain 130：3091-3101, 2007

16）Ebisu T, Tanaka C, Umeda M, Kitamura M, Naruse S, Higuchi T, Ueda S, Sato H：Discrimination of brain abscess from necrotic or cystic tumors by diffusion-weighted echo planar imaging. Magn Reson Imaging 14：1113-1116, 1996

17）Favrole P, Guichard JP, Crassard I, Bousser MG, Chabriat H：Diffusion-weighted imaging of intravascular clots in cerebral venous thrombosis. Stroke 35：99-103, 2004

18）Fiebach JB, Schellinger PD, Gass A, Kucinski T, Siebler M, Villringer A, Olkers P, Hirsch JG, Heiland S, Wilde P, Jansen O, Rother J, Hacke W, Sartor K：Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage：a multicenter study on the validity of stroke imaging. Stroke 35：502-506, 2004

19）Filippi CG, Ulug AM, Lin D, Heier LA, Zimmerman RD：Hyperintense signal abnormality in subarachnoid spaces and basal cisterns on MR images of children anesthetized with propofol：new fluid-attenuated inversion recovery finding. AJNR Am J Neuroradiol 22：394-399, 2001

20）福武敏夫：頭痛のすべて．二次性頭痛の診断と治療 感染に伴う頭痛．医学のあゆみ215：1171-1174, 2005

21）Given CA 2nd, Burdette JH, Elster AD, Williams DW 3rd：Pseudo-subarachnoid hemorrhage：a potential imaging pitfall associated with diffuse cerebral edema. AJNR Am J Neuroradiol 24：254-256, 2003

22）Greenberg SM, Finklestein SP, Schaefer PW：Petechial hemorrhages accompanying lobar hemorrhage：detection by gradient-echo MRI. Neurology 46：1751-1754, 1996

23）Higgins JN, Cousins C, Owler BK, Sarkies N, Pickard JD：Idiopathic intracranial hypertension：12 cases treated by venous sinus stenting. J Neurol Neurosurg Psychiatry 74：1662-1666, 2003

24）Idbaih A, Boukobza M, Crassard I, Porcher R, Bousser MG, Chabriat H：MRI of clot in cerebral venous thrombosis：high diagnostic value of susceptibility-weighted images. Stroke 37：991-995, 2006

25）井出俊光：最新の頭痛診療 頭痛の全てが分かる．頭痛診療の現場 救急外来における頭痛の診かた．診断と治療95：547-552, 2007

26）石川達也，湯浅直樹，大友　卓，白水秀樹，松田　博，北川泰久，高木繁治：初回MRI拡散強調画像が陰性であった急性期脳梗塞症例の検討．脳卒中28：280-285, 2006

27）Jakobsson KE, Saveland H, Hillman J, Edner G, Zygmunt S, Brandt L, Pellettieri L：Warning leak and management outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 85：995-999, 1996

28）Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL：The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1：Overall management results. J Neurosurg 73：18-36, 1990

29）Kim YJ, Chang KH, Song IC, Kim HD, Seong SO, Kim YH, Han MH：Brain abscess and necrotic or cystic brain tumor：discrimination with signal intensity on diffusion-weighted MR imaging. AJR Am J Roentgenol 171：1487-1490, 1998

30）国際頭痛分類第2版（ICHD-Ⅱ）．日本頭痛学会誌31：np1, 13-188, 2004

31）Kruit MC, Launer LJ, Ferrari MD, van Buchem MA：Infarcts in the posterior circulation territory in migraine. The population-based MRI CAMERA study. Brain 128：2068-2077, 2005

32）Kruit MC, Launer LJ, Ferrari MD, van Buchem MA：Brain stem and cerebellar hyperintense lesions in migraine. Stroke 37：1109-1112, 2006

33）Kruit MC, van Buchem MA, Hofman PA, Bakkers JT, Terwindt GM, Ferrari MD, Launer LJ：Migraine as a risk factor for subclinical brain lesions. JAMA 291：427-434, 2004

34）久保慶高，小川　彰：頭痛のすべて．二次性頭痛の診断と治療 脳血管障害（外科的）による頭痛．医学のあゆみ215：1159-1161, 2005

35）Landtblom AM, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I：Sudden onset headache：a prospective study of features, incidence and causes. Cephalalgia 22：354-360, 2002

36）Leach JL, Fortuna RB, Jones BV, Gaskill-Shipley MF：Imaging of cerebral venous thrombosis：current techniques, spectrum of findings, and diagnostic pitfalls. Radiographics 26 Suppl 1：S19-41；discussion S42-13, 2006

37）Leach JL, Strub WM, Gaskill-Shipley MF：Cerebral venous thrombus signal intensity and susceptibility effects on gradient recalled-echo MR imaging. AJNR Am J Neuroradiol 28：940-945, 2007

38）Linfante I, Llinas RH, Caplan LR, Warach S：MRI features of intracerebral hemorrhage within 2 hours from symptom onset. Stroke 30：2263-2267, 1999

39）Linn J, Ertl-Wagner B, Seelos KC, Strupp M, Reiser M, Bruckmann H, Bruning R：Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses. AJNR Am J Neuroradiol 28：946-952, 2007

40）Maeda M, Tsuchida C：“Ivy sign”on fluid-attenuated inversion-recovery images in childhood moyamoya disease. AJNR Am J Neuroradiol 20：1836-1838, 1999

41）Maeda M, Yagishita A, Yamamoto T, Sakuma H, Takeda K：Abnormal hyperintensity within the subarachnoid space evaluated by fluid-attenuated inversion-recovery MR imaging：a spectrum of central nervous system diseases. Eur Radiol 13 Suppl 4：L192-201, 2003

42）前田正幸：脳血管障害の画像診断2006．FLAIR, DWI, SWI．臨床画像22：86-96, 2006

43）Mohamed M, Heasly DC, Yagmurlu B, Yousem DM：Fluid-attenuated inversion recovery MR imaging and subarachnoid hemorrhage：not a panacea. AJNR Am J Neuroradiol 25：545-550, 2004

44）Moore KR, Harnsberger HR, Shelton C, Davidson HC：‘Leave me alone’ lesions of the petrous apex. AJNR Am J Neuroradiol 19：733-738, 1998

45）Nishioka H, Haraoka J, Izawa H, Ikeda Y：Headaches associated with Rathke's cleft cyst. Headache 46：1580-1586, 2006

46）西岡　宏，池田幸穂，伊澤仁之，原岡　襄：MRIからみたラトケ囊胞の病態と治療．CI研究28：9-13, 2006

47）Noguchi K, Ogawa T, Fujita H, Inugami A, Okudera T, Uemura K, Seto H：Filling defect sign in CT diagnosis of ruptured aneurysm. Neuroradiology 39：480-482, 1997

48）Noguchi K, Ogawa T, Inugami A, Toyoshima H, Sugawara S, Hatazawa J, Fujita H, Shimosegawa E, Kanno I, Okudera T, et al.：Acute subarachnoid hemorrhage：MR imaging with fluid-attenuated inversion recovery pulse sequences. Radiology 196：773-777, 1995

49）Noguchi K, Ogawa T, Seto H, Inugami A, Hadeishi H, Fujita H, Hatazawa J, Shimosegawa E, Okudera T, Uemura K：Subacute and chronic subarachnoid hemorrhage：diagnosis with fluid-attenuated inversion-recovery MR imaging. Radiology 203：257-262, 1997

50）Noguchi K, Seto H, Kamisaki Y, Tomizawa G, Toyoshima S, Watanabe N：Comparison of fluid-attenuated inversion-recovery MR imaging with CT in a simulated model of acute subarachnoid hemorrhage. AJNR Am J Neuroradiol 21：923-927, 2000

51）Ohta T, Tanaka H, Kuroiwa T：Diffuse leptomeningeal enhancement, “ivy sign,”in magnetic resonance images of moyamoya disease in childhood：case report. Neurosurgery 37：1009-1012, 1995

52）Okawara SH：Warning signs prior to rupture of an intracranial aneurysm. J Neurosurg 38：575-580, 1973

53）Oppenheim C, Domigo V, Gauvrit JY, Lamy C, Mackowiak-Cordoliani MA, Pruvo JP, Meder JF：Subarachnoid hemorrhage as the initial presentation of dural sinus thrombosis. AJNR Am J Neuroradiol 26：614-617, 2005

54）Ostrov SG, Quencer RM, Hoffman JC, Davis PC, Hasso AN, David NJ：Hemorrhage within pituitary adenomas：how often associated with pituitary apoplexy syndrome? AJR Am J Roentgenol 153：153-160, 1989

55）Port JD, Beauchamp NJ Jr：Reversible intracerebral pathologic entities mediated by vascular autoregulatory dysfunction. Radiographics 18：353-367, 1998

56）Rogg JM, Tung GA, Anderson G, Cortez S：Pituitary apoplexy：early detection with diffusion-weighted MR imaging. AJNR Am J Neuroradiol 23：1240-1245, 2002

57）Rottger C, Trittmacher S, Gerriets T, Blaes F, Kaps M, Stolz E：Reversible MR imaging abnormalities following cerebral venous thrombosis. AJNR Am J Neuroradiol 26：607-613, 2005

58）Sames TA, Storrow AB, Finkelstein JA, Magoon MR：Sensitivity of new-generation computed tomography in subarachnoid hemorrhage. Acad Emerg Med 3：16-20, 1996

59）佐々木泰志：パターンから進める頭部MRIの読影．T1強調像で高信号を含む病変．臨床画像15：146-154, 1999

60）Schievink WI, Maya MM, Tourje J, Moser FG：Pseudo-subarachnoid hemorrhage：a CT-finding in spontaneous intracranial hypotension. Neurology 65：135-137, 2005

61）Schwartz RB, Jones KM, Kalina P, Bajakian RL, Mantello MT, Garada B, Holman BL：Hypertensive encephalopathy：findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol 159：379-383, 1992

62）Shimono T, Miki Y, Toyoda H, Egawa H, Uemoto S, Tanaka K, Hattori H, Kanagaki M, Itoh K, Konishi J：MR imaging with quantitative diffusion mapping of tacrolimus-induced neurotoxicity in organ transplant patients. Eur Radiol 13：986-993, 2003

63）鈴木一郎：頭痛のすべて．慢性連日性頭痛，頭痛救急診療，女性・小児・高齢者の頭痛，その他の話題 救急室（ER）での頭痛診療．医学のあゆみ215：1203-1206, 2005

64）鈴木則宏：最新の頭痛診療 頭痛の全てが分かる．頭痛診療をめぐる最近のトピックス．片頭痛と脳梗塞．診断と治療95：601-606, 2007

65）泰地秀信：頭痛のすべて．二次性頭痛の診断と治療．耳鼻科領域の頭痛．医学のあゆみ215：1193-1196, 2005

66）Takeda S, Yamazaki K, Miyakawa T, Onda K, Hinokuma K, Ikuta F, Arai H：Subcortical hematoma caused by cerebral amyloid angiopathy：does the first evidence of hemorrhage occur in the subarachnoid space? Neuropathology 23：254-261, 2003

67）The International Classification of Headache Disorders：2nd edition. Cephalalgia 24 Suppl 1：9-160, 2004

68）Tsuchiya K, Inaoka S, Mizutani Y, Hachiya J：Fast fluid-attenuated inversion-recovery MR of intracranial infections. AJNR Am J Neuroradiol 18：909-913, 1997

69）Tsuchiya K, Osawa A, Katase S, Fujikawa A, Hachiya J, Aoki S：Diffusion-weighted MRI of subdural and epidural empyemas. Neuroradiology 45：220-223, 2003

70）佃　守：頭痛診療の実際．各科における診療の実際．耳鼻咽喉科の頭痛診療．綜合臨牀56：759-763, 2007

71）Uchihara T, Tsukagoshi H：Jolt accentuation of headache：the most sensitive sign of CSF pleocytosis. Headache 31：167-171, 1991

72）内野　誠：頭痛のすべて．二次性頭痛の診断と治療．脳血管障害（内科的）による頭痛．医学のあゆみ215：1162-1165, 2005

73）矢野貴徳，小玉隆男：画像診断のkey words　Jugular bulb pseudolesion. 画像診断28：448-451, 2008

74）Yuzawa H, Higano S, Mugikura S, Umetsu A, Murata T, Nakagawa A, Koyama A, Takahashi S：Pseudo-subarachnoid hemorrhage found in patients with postresuscitation encephalopathy：characteristics of CT findings and clinical importance. AJNR Am J Neuroradiol 29：1544-1549, 2008