Neurological Surgery 脳神経外科38巻12号

2010年12月発行

総説

重症頭部外傷におけるモニタリングと集中治療：Update

著者： 中川敦寛¹²³ 冨永悌二¹

所属機関： ¹東北大学大学院医学系研究科神経外科学分野 ^{2 3}

ページ範囲：P.1081 - P.1095

Ⅰ．重症頭部外傷におけるモニタリングと集中治療の役割¹¹¹⁾

　頭部外傷の病態生理は受傷時の一次侵襲（primary insult）と，その後に起こる二次侵襲（secondary insult）に分けることができる．二次侵襲の結果として二次性脳損傷（secondary injury）が引き起こされる．二次侵襲としては全身的な要因（低血圧，低酸素血症，高／低炭酸ガス血症，感染，貧血，酸塩基異常，電解質異常，血糖値異常，発熱），頭蓋内の要因〔頭蓋内圧（intracranial pressure：ICP）亢進，脳浮腫，痙攣，脳血流量（cerebral blood flow：CBF）異常，代謝異常，興奮性神経伝達物質毒性，フリーラジカル発生，ミトコンドリア障害〕が挙げられる^7,40,118)．頭部外傷では二次侵襲は頻繁に起きていると考えられており，集中治療を要した症例の91％に認められたとする報告もある⁴⁰⁾．また，二次侵襲の程度，回数，持続時間^10,11,60,71)は頭部単独，多発外傷に関わらず⁹⁵⁾神経学的な転帰不良と関連する．これまで頭部外傷分野においても数多くの薬物（グルタミン酸受容体拮抗薬，ステロイド，フリーラジカルスカベンジャー，カルシウム受容体拮抗薬，ブラジキニン拮抗薬，成長因子など）の開発が行われてきたものの，臨床試験において転帰改善効果を示したものは存在しないのが実情である⁵⁴⁾．したがって現在の神経集中治療では二次侵襲を最小限にとどめ，生体の自己回復能力を最大限に引き出す環境をつくることに主眼が置かれている．以上より，モニタリングには二次侵襲の発生を検知，予測するとともに治療効果判定の際の指標として機能することが求められる．ICPモニタリングとそれ以外の神経モニタリング（advanced neuromonitoring）の併用により，ICPモニタリングおよびICP値から算出される脳灌流圧（cerebral perfusion pressure：CPP）のみでは検出できない二次侵襲の早期検知と，画一的な患者管理から個々の病態に応じたtargeted therapyあるいはpatient specific treatment ⁹⁰⁾への発展が期待される．

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