Neurological Surgery 脳神経外科41巻6号

2013年06月発行

連載 脳神経血管内治療医に必要な知識

（10）急性期再開通療法

著者： 榎本由貴子¹ 吉村紳一¹

所属機関： ¹岐阜大学医学部脳神経外科

ページ範囲：P.541 - P.551

Ⅰ．はじめに

　急性脳主幹動脈閉塞症に対する血管内治療（急性期再開通療法）は，以前はウロキナーゼなどを用いた経動脈的血栓溶解療法や，バルーンを用いた機械的血栓破砕療法が主流であったが，血栓量の多い近位部血管閉塞では十分な効果が得られない傾向にあった．

　しかし，新たな機械的血栓回収デバイスであるMerci^®リトリーバー（Stryker, USA）が2010年に，Penumbraシステム^®（Penumbra, USA）が2011年に承認され，特に近位部血管閉塞に対する有効性が期待されている．本稿では，急性期再開通療法の歴史と，現在における適応基準，遭遇し得る合併症，そして上述の新たな機械的血栓回収デバイスを紹介する．

参考文献

1) Bambauer KZ, Johnston SC, Bambauer DE, Zivin JA：Reasons why few patients with acute stroke receive tissue plasminogen activator. Arch Neurol 63：661-664, 2006

2) Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM：Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology 56：1015-1020, 2001

3) Berger C, Fiorelli M, Steiner T, Schäbitz WR, Bozzao L, Bluhmki E, Hacke W, von Kummer R：Hemorrhagic transformation of ischemic brain tissue：asymptomatic or symptomatic? Stroke 32：1330-1335, 2001

4) Cho AH, Sohn SI, Han MK, Lee DH, Kim JS, Choi CG, Sohn CH, Kwon SU, Suh DC, Kim SJ, Bae HJ, Kang DW：Safety and efficacy of MRI-based thrombolysis in unclear-onset stroke. A preliminary report. Cerebrovasc Dis 25：572-579, 2008

5) Demchuk AM, Hill MD, Barber PA, Silver B, Patel SC, Levine SR；NINDS rtPA Stroke Study Group, NIH：Importance of early ischemic computed tomography changes using ASPECTS in NINDS rtPA Stroke Study. Stroke 36：2110-2115, 2005

6) Dzialowski I, Hill MD, Coutts SB, Demchuk AM, Kent DM, Wunderlich O, von Kummer R：Extent of early ischemic changes on computed tomography（CT）before thromobolysis：prognostic value of the Alberta Stroke Program Early CT Score in ECASS II. Stroke 37：973-978, 2006

7) Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F：Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study：a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 282：2003-2011, 1999

8) Goyal M, Menon BK, Coutts SB, Hill MD, Demchuk AM；Penumbra Pivotal Stroke Trial Investigators, Calgary Stroke Program, and the Seaman MR Research Center：Effect of baseline CT scan appearance and time to recanalization on clinical outcomes in endovascular thrombectomy of acute ischemic strokes. Stroke 42：93-97, 2011

9) Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Höxter G, Mahagne MH, Hennerici M：Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study（ECASS). JAMA 274：1017-1025, 1995

10) Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D；ECASS Investigators：Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359：1317-1329, 2008

11) Hirano T, Sasaki M, Mori E, Minematsu K, Nakagawara J, Yamaguchi T；Japan Alteplase Clinical Trial II Group：Residual vessel length on magnetic resonance angiography identifies poor responders to alteplase in acute middle cerebral artery occlusion patients：exploratory analysis of the Japan Alteplase Clinical Trial II. Stroke 41：2828-2833, 2010

12) Katzan IL, Furlan AJ, Lloyd LE, Frank JI, Harper DL, Hinchey JA, Hammel JP, Qu A, Sila CA：Use of tissue-type plasminogen activator for acute ischemic stroke：the Cleveland area experience. JAMA 283：1151-1158, 2000

13) Levy EI, Siddiqui AH, Crumlish A, Snyder KV, Hauck EF, Fiorella DJ, Hopkins LN, Mocco J：First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke：SARIS（stent-assisted recanalization in acute ischemic stroke). Stroke 40：3552-3556, 2009

14) Mori E, Minematsu K, Nakagawara J, Yamaguchi T, Sasaki M, Hirano T；Japan Alteplase Clinical Trial II Group：Effects of 0.6mg/kg intravenous alteplase on vascular and clinical outcomes in middle cerebral artery occlusion.：Japan Alteplase Clinical Trail II（J-ACT II). Stroke 41：461-465, 2010

15) Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS；TREVO 2 Trialists：Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke（TREVO 2）：a randomised trial. Lancet 380：1231-1240, 2012

16) Ogawa A, Mori E, Minematsu K, Taki W, Takahashi A, Nemoto S, Miyamoto S, Sasaki M, Inoue T；MELT Japan Study Group：Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke：the middle cerebral artery embolism local fibrinolytic interventional trial（MELT）Japan. Stroke 38：2633-2639, 2007

17) Penumbra Pivotal Stroke Trial Investigators：The Penumbra pivotal stroke trial：safety and effectiveness of a new generation of mechanical devices for a clot removal in intracranial larger vessel occlusive disease. Stroke 40：2761-2768, 2009

18) Pexman JH, Barber PA, Hill MD, Sevick RJ, Demchuk AM, Hudon ME, Hu WY, Buchan AM：Use of the Alberta Stroke Program Early CT Score（ASPECTS）for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 22：1534-1542, 2001

19) Rha JH, Saver JL：The impact of recanalization on ischemic stroke outcome：a meta-analysis. Stroke 38：967-973, 2007

20) Saqqur M, Uchino K, Demchuk AM, Molina CA, Garami Z, Calleja S, Akhtar N, Orouk FO, Salam A, Shuaib A, Alexandrov AV；CLOTBUST Investigators：Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 38：948-954, 2007

21) Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO；SWIFT Trialists：Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke（SWIFT）：a randomised, parallel-group, non-inferiority trial. Lancet 380：1241-1249, 2012

22) Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP, Lutsep HL, Nesbit GM, Grobelny T, Rymer MM, Silverman IE, Higashida RT, Budzik RF, Marks MP；MERCI Trial Investigators：Safety and efficacy of mechanical embolectomy in acute ischemic stroke：results of the MERCI trial. Stroke 36：1432-1438, 2005

23) Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, Lutsep HL, Rymer MM, Higashida RT, Starkman S, Gobin YP；Multi MERCI Investigators, Frei D, Grobelny T, Hellinger F, Huddle D, Kidwell C, Koroshetz W, Marks M, Nesbit G, Silverman IE：Mechanical thrombectomy for acute ischemic stroke：final results of the Multi MERCI trial. Stroke 39：1205-1212, 2008

24) Tarr R, Hsu D, Kulcsar Z, Bonvin C, Rufenacht D, Alfke K, Stingele R, Jansen O, Frei D, Bellon R, Madison M, Struffert T, Dorfler A, Grunwald IQ, Reith W, Haass A：The POST trial：initial post-market experience of the Penumbra system：revascularization of the large vessel occlusion in acute ischemic stroke in the United States and Europe. J Neurointerv Surg 2：341-344, 2010

25) The IMS Study Investigators：Combined intravenous and intra-arterial recanalization for acute ischemic stroke：the Interventional Management of Stroke Study. Stroke 35：904-911, 2004

26) The IMSII Trail Investigators：The Interventional Management of Stoke（IMS）II Study. Stroke 38：2127-2135, 2007

27) Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G；SITS-MOST investigators：Thrombolysis with alteplase for acute ischemic stroke in the Safe Inplementation of Thrombolysis in Stroke-Monitoring Study（SITS-MOST）：an observational study. Lancet 369：275-282, 2007

28) Yoshimura S, Egashira Y, Sakai N, Kuwayama N；Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism（RESCUE）-Japan retrospective survey group：Retrospective nationwide survey of acute stroke due to large vessel occlusion in Japan：A review of 1,963 patients and the impact of endovascular treatment. Cerebrovasc Dis 32：219-226, 2011