Neurological Surgery 脳神経外科39巻3号

2011年03月発行

解剖を中心とした脳神経手術手技

延髄の血管芽腫の手術

著者： 斉藤延人¹ 越智崇¹

所属機関： ¹東京大学大学院医学系研究科脳神経外科学

ページ範囲：P.245 - P.254

Ⅰ．はじめに

　血管芽腫（hemangioblastoma）はWHO grade 1の良性の腫瘍である．通常は小脳に発生する腫瘍だが，脳幹や脊髄にも発生し，脳幹では延髄のものが多い．脳幹に発生した場合の症状は，感覚鈍麻，歩行障害，嚥下困難，反射亢進，小脳症状などである．遺伝性のvon Hippel-Lindau病はVHLの遺伝子異常が原因で，中枢神経系の血管芽腫に網膜血管芽腫，腎細胞癌，褐色細胞腫，膵囊胞などを合併し，病変が多発することがある．

　画像検査では腫瘍がよく造影されるのが特徴的である．また，囊胞を伴うことが多く，腫瘍本体は壁在結節として認められる．単純CTで血管芽腫の実質部分は等吸収域，囊胞部分は低吸収域である．造影剤で強く造影される．MRIで腫瘍実質部分はT1強調画像で等～低信号，T2強調画像で等～高信号である．やはり造影剤で均一に強く造影される．囊胞部分はT1強調画像で低信号，T2強調画像で高信号である．栄養血管や流出静脈がflow voidとして認められることも多い．脳血管撮影では強い腫瘍濃染像を認めるのが特徴的である．

　治療は外科的摘出が第一選択である²¹⁾．壁在結節のみを摘出すればよく，囊胞部分は切除しなくてよい．この腫瘍は血流が豊富で腫瘍内に切り込むと出血が多くなりがちである．延髄というクリティカルな部位では周囲の脳幹へのダメージを最小限に抑える必要があり，手術摘出は必ずしも容易ではない．本稿では，まず延髄の解剖を概説し，延髄血管芽腫の手術戦略について解説する．

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