Neurological Surgery 脳神経外科44巻5号

2016年05月発行

総説

急性期脳梗塞に対する血管内治療のエビデンス確立—ホノルルショックからナッシュビルホープへ

著者： 吉村紳一¹

所属機関： ¹兵庫医科大学脳神経外科学講座

ページ範囲：P.359 - P.369

Ⅰ．はじめに
　急性期脳梗塞に対する血管内治療は，マイクロカテーテルを用いたウロキナーゼ動注療法（局所線溶療法）から始まり，中大脳動脈（middle cerebral artery：MCA）閉塞症において一部有効性が示されたが^6,17)，より質の高いエビデンス²⁸⁾を有する遺伝子組み換え組織プラスミノゲン・アクティベータ（recombinant tissue-plasminogen activator：rt-PA）静注療法の承認によって一時行われなくなった．しかし，2010年に血栓回収機器であるメルシーリトリーバー²⁴⁾が承認され，rt-PA静注療法の無効例・非適応例に用いられるようになった．翌年には血栓を局所で吸引するペナンブラシステム¹⁸⁾も承認されたが，2013年にホノルルで開催された国際脳卒中会議（International Stroke Conference：ISC）において，3つのランダム化比較試験（randomized controlled trial：RCT)^2,4,11)でその有効性が否定され，“ホノルルショック”と呼ばれた³¹⁾．しかしその後，ステント型血栓回収デバイス（以下，ステントリトリーバー．Solitaire FR, Trevo ProVue）が承認され，2014年末にオランダのRCTであるMR CLEANにおいて初めてその有効性が示された¹⁾．これを受け，当時進行中であった多くのRCTが登録を中止して解析を行い，2015年2月に米国ナッシュビルで開催されたISC 2015にて，さらに3つのRCTで有効性が示された^3,7,21)．われわれはこの結果を，本治療の普及への期待を込めて“ナッシュビルホープ”と呼んでいる．その後，さらにもう1つのRCTでその有効性が証明され¹⁰⁾，2015年末までに合計5つのRCTが発表されたこととなる．
　本稿では血栓回収デバイスを用いた治療に焦点を絞り，そのエビデンスの詳細と実施における工夫，さらには今後の展開について考察する．

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