高度脳浮腫を伴う脳梗塞症例に対する広範外減圧術について

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Two cases of cerebral infarction associated with massive cerebral edema leading to progressive deterioration within short period after the onset which was sufficiently reverted with decompressive hemicraniectomy were reported. The first case was 57 year old man with an acute onset of left hemiparesis and disturbance of consciousness on August 17, 1977. On admission three days after the onset, marked stenosis of M1 portion of the middle cerebral artery and poor filling of the major branches with shift of the anterior cerebral artery indicating mass effect were demonstrated on carotid angiography. CT scan showed diffuse low density areas over the right hemisphere, collapsed lateral ventricle on the right side and subfalcial herniation. The patient was semicomatous, with spastic hemiparesis and dilated pupils on the right side. The downhill course of the neurological signs was noted following two days in spite of conventional conservative treatment when repeated CT scan demonstrated more marked mass effect of brain edema and downward transtentorial herniation. He became deep semicomatous, dilated pupils with decerebrate posture.Emergency decompressive hemicraniectomy was performed on August 22 when ICP measured via burr hole on the epidural space before craniectomy showed 1200 mmH2O which declined to 250mm H2O following dural incision. The pressure was gradually declined to a range of 400 to 500 mmH2O within three days following the operation. The neurological signs were also gradually improved within three months when consciousness level was returned to 3 to 10 (3-3-9 classification) with residual left hemiparesis. The second case of 67 year old man with hypertension and previous several attacks of TIA who had an acute onset of speech disturbance followed by left hemiparesis on September 8, 1978 was admitted because he became stuporous. Carotid angiography demonstrated complete occlusion of the right internal carotid artery at the bifurcation of the neck. Massive cerebral edema was also noted on CT scan. Since the neurological signs were progressively aggravated and mass effect due to brain edema on the right side was significant on angiography, similar surgical decompression was carried out on September 11, 1978. The clinical signs were remarkably improved within two to three weeks when consciousness level was returned to an range of 1 to 2. The benefits of decompressive hemicraniectomy for the cases with cerebral infarction associated with massive cerebral edema showing downhill course due to intracranial hypertension and importance of ICP monitoring inter and postoperation as anestimation of the treatments were discussed.
The Japanese Society on Surgery for Cerebral Strokeの論文

高度脳浮腫を伴う脳梗塞症例に対する広範外減圧術について

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