Neurological Surgery 脳神経外科51巻6号

2023年11月発行

特集 神経救急—初期診療から集中治療までエキスパートの暗黙知に迫る Ⅲ 疾患別の初期診療

くも膜下出血の初期診療

著者： 中江竜太¹

所属機関： ¹日本医科大学付属病院高度救命救急センター

ページ範囲：P.1062 - P.1068

Point
・くも膜下出血（SAH）は再破裂が予後に大きく影響するため，再破裂を起こさないように初期診療を進めることが重要である．
・SAHを疑った場合，降圧や鎮静，鎮痛などにより，根治手術を終えるまで再破裂予防を行う．
・脳動脈瘤に対するクリッピング術とコイル塞栓術の治療選択は，患者背景や動脈瘤の部位，大きさ，形状，術者の技術などから総合的に判断することが重要である．

参考文献

1）Broderick JP, et al：Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke 25：1342-1347, 1994

2）Starke RM, Connolly ES Jr；Participants in the International Multi-Disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage：rebleeding after aneurysmal subarachnoid hemorrhage. Neurocrit Care 15：241-246, 2011

3）片岡大治，他：くも膜下出血に対する初期治療の現状と問題点．脳神外ジャーナル28：542-551, 2019

4）日本脳卒中学会脳卒中ガイドライン委員会（編）：脳卒中治療ガイドライン2021．協和企画，東京，2021, pp. 149-173

5）Hoh BL, et al：2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage：a guideline from the American Heart Association/American Stroke Association. Stroke 54：e314-e370, 2023　doi:10.1161/STR.0000000000000436

6）Tang C, et al：Risk factors for rebleeding of aneurysmal subarachnoid hemorrhage：a meta-analysis. PLoS One 9：e99536, 2014　doi:10.1371/journal.pone.0099536

7）Tanno Y, et al：Rebleeding from ruptured intracranial aneurysms in north eastern province of Japan. A cooperative study. J Neurol Sci 258：11-16, 2007

8）Kaneko J, et al：Ultra-early induction of general anesthesia for reducing rebleeding rates in patients with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 30：105926, 2021　doi:10.1016/j.jstrokecerebrovasdis.2021.105926

9）Bederson JB, et al；American Heart Association：Guidelines for the management of aneurysmal subarachnoid hemorrhage：a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 40：994-1025, 2009

10）Perry JJ, et al：Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA 310：1248-1255, 2013

11）Post R, et al；ULTRA Investigators：Ultra-early tranexamic acid after subarachnoid haemorrhage（ULTRA）：a randomised controlled trial. Lancet 397：112-118, 2021

12）Hashiguchi A, et al：Rebleeding of ruptured cerebral aneurysms during three-dimensional computed tomographic angiography：report of two cases and literature review. Neurosurg Rev 30：151-154, 2007

13）John AM, Yadav S：Effect of bolus administration of non-ionic radiopaque contrast media on blood pressure variation. Radiography（Lond）25：346-348, 2019

14）Hellingman CA, et al：Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke 38：96-99, 2007

15）Molyneux A, et al；International Subarachnoid Aneurysm Trial（ISAT）Collaborative Group：International Subarachnoid Aneurysm Trial（ISAT）of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms：a randomised trial. Lancet 360：1267-1274, 2002

16）Molyneux AJ, et al：The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms：18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial（ISAT）. Lancet 385：691-697, 2015

17）CARAT Investigators：Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke 37：1437-1442, 2006

18）McDougall CG, et al：The Barrow Ruptured Aneurysm Trial. J Neurosurg 116：135-144, 2012

19）Spetzler RF, et al：Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg 132：771-776, 2019

20）Spetzler RF, et al：The Barrow Ruptured Aneurysm Trial：6-year results. J Neurosurg 123：609-617, 2015

21）Spetzler RF, et al：The Barrow Ruptured Aneurysm Trial：3-year results. J Neurosurg 119：146-157, 2013

22）日本脳卒中データバンク：「脳卒中レジストリを用いた我が国の脳卒中診療実態の把握」報告書2022年．2022　https://strokedatabank.ncvc.go.jp/f12kQnRl/wp-content/uploads/%E6%97%A5%E6%9C%AC%E8%84%B3%E5%8D%92%E4%B8%AD%E3%83%87%E3%83%BC%E3%82%BF%E3%83%90%E3%83%B3%E3%82%AF%E5%A0%B1%E5%91%8A%E6%9B%B82022%E5%B9%B4_FIX.pdf（2023年6月17日アクセス）