Neurological Surgery 脳神経外科42巻9号

2014年09月発行

総説

難治性てんかんのパラダイムシフト―緩和的治療の存在意義と迷走神経刺激療法

著者： 川合謙介¹

所属機関： ¹NTT東日本関東病院脳神経外科

ページ範囲：P.807 - P.816

Ⅰ．はじめに

　最近，世界的に「難治性てんかん」の概念や外科治療の位置づけについてパラダイムシフトが起きつつある．2013年12月の北米てんかん学会の会長シンポジウムは「The changing landscape of epilepsy surgery：てんかん外科の変貌」と題し，90年代と比較して，側頭葉てんかんの手術が減少し，小児やMRI無病変のてんかん手術が増加していることが取り上げられた．

　2000年頃までの欧米や日本のてんかんセンターにおけるてんかん外科は，効果の確実な患者を慎重に選択し，外科治療の良好な成績を蓄積して，その有用性を広く知らしめるというスタンスであった．それ以前に存在した，てんかん外科治療に対する誤解や偏見を解くためにはこのような慎重で確実なアプローチが必要だったのだと思われる．

　しかしその後，このようなアプローチでは切り捨てられていた，より難治性のてんかんにも目が向けられるようになってきた．抗てんかん薬でも定型的手術でも発作消失に至らない患者，いわば「真の難治性てんかん」の患者は，実際には相当数存在する．このような患者では，それ以上の治療は諦められ，漫然と抗てんかん薬の継続処方が行われがちだった．しかし，発作消失には至らずとも，少しでも発作回数を減少させ，発作症状を軽減することで，患者や家族の日常生活は著明に改善する可能性がある．

　てんかん治療，特に外科治療の有効性については，これまでその根治性，すなわち発作消失率をもって語られることが多かったが，根治の困難な難治性てんかんでは，緩和的治療の意義は無視できないものがある．そこで，本稿では，てんかん治療における緩和的治療の存在意義について検討し，緩和的治療の代表として迷走神経刺激療法（vagus nerve stimulation：VNS）について最近の知見を紹介する．

参考文献

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