Neurological Surgery 脳神経外科42巻1号

2014年01月発行

総説

非側頭葉てんかんの外科治療

著者： 三國信啓¹

所属機関： ¹札幌医科大学脳神経外科

ページ範囲：P.5 - P.17

Ⅰ．はじめに

　本稿では側頭葉てんかん以外のてんかんに対する外科治療について，臨床上重要なポイントをまとめた．日本脳神経外科学会専門医は，てんかんを含めた「対象になる疾患に対して，予防や診断，救急治療，手術および非手術的治療，あるいはリハビリテーションにおいて，総合的かつ専門的知識と診療技術を持ち，必要に応じて他の専門医への転送判断も的確に行える能力を備えることが必要」とされる．てんかんの外科治療は発作を消失させる，あるいは緩和させる，という目的のほかに，精神的身体的負担を軽減させ，社会生活を改善させる，という重要な目的がある．そのため，てんかん外科の位置づけは単科での治療ではなく，神経内科，小児科，精神科，リハビリテーション科，看護師や社会福祉士を含んだ包括的医療の中にある．精神の変容，小児期の脳・身体発達，成人になってからの脳機能にてんかんが及ぼす影響を知ることは術者の責任と言える．

　てんかん（epilepsy）とは「種々の成因によってもたらされる慢性脳疾患であり，大脳ニューロンの過剰な発射に由来する反復性てんかん発作を主徴とし，種々の臨床症状ならびに検査所見を呈する」と定義されている（WHO, 1973）．また，疾患単位としての「てんかん」の考え方以外に「脳の疾患であり，発作をもたらす持続的な病的傾向とこれに起因する神経生物的，認知・心理・社会的な影響を特徴とし，発作が少なくとも1回は生じている」多様な疾患の集まりと定義することが提案されている（Fisher, 2005）．

　てんかんの頻度は人口の0.4～1%と推定され，うち約30%が薬剤難治性（適切な抗てんかん薬2～3種類以上の単剤あるいは多剤併用で，かつ十分量で2年以上治療しても日常生活に支障を来す発作が月平均1回以上，1年以上続く状態をさす）である．ただし，そのすべてが手術適応というわけではない．つまり，てんかんは機能的疾患であり，外科治療の適応および目的は，医療側の診断の正確さ・病態の自然歴・治療方法選択の合理性を確認し，さらに患者側の機能・合併する疾患・抗てんかん薬の副作用を総合的に判断した上で，発作が生活の質に及ぼす影響を慎重に検討して手術適応が最終決定される．

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