閉塞脳主幹動脈の再開通後にdiffusion-perfusion mismatchの遷延が認められた1例
症例は67歳男性．発症35分で救急搬送され，JCS 3，左共同偏視，全失語，右上下肢完全麻痺を認めた．心電図で心房細動を認めた．MRIでは左前大脳動脈（ACA）領域および左中大脳動脈（MCA）と左後大脳動脈の境界域に脳梗塞を認めた．MRAおよびCTAで左ACA閉塞を認めた．左MCAに閉塞性病変は認められなかった．CT perfusionでは左ACA領域のみならず左MCA領域でもMTTが延長していた．t-PA静注療法を計画したが，PT-INR 1.88が禁忌項目に該当したため，ヘパリン，ワーファリンで加療した．入院翌日には症状は軽快し，MRAで左ACAの再開通を認めた．発症早期にみられるdiff...
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| Published in | 脳卒中 Vol. 34; no. 4; pp. 243 - 248 |
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| Main Authors | , , , , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本脳卒中学会
2012
日本脳卒中学会 |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0912-0726 1883-1923 |
| DOI | 10.3995/jstroke.34.243 |
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| Abstract | 症例は67歳男性．発症35分で救急搬送され，JCS 3，左共同偏視，全失語，右上下肢完全麻痺を認めた．心電図で心房細動を認めた．MRIでは左前大脳動脈（ACA）領域および左中大脳動脈（MCA）と左後大脳動脈の境界域に脳梗塞を認めた．MRAおよびCTAで左ACA閉塞を認めた．左MCAに閉塞性病変は認められなかった．CT perfusionでは左ACA領域のみならず左MCA領域でもMTTが延長していた．t-PA静注療法を計画したが，PT-INR 1.88が禁忌項目に該当したため，ヘパリン，ワーファリンで加療した．入院翌日には症状は軽快し，MRAで左ACAの再開通を認めた．発症早期にみられるdiffusion-perfusion mismatchは脳主幹動脈の閉塞を必ずしも意味しないことを示唆しており，常に脳血管画像所見を加味して，どのような脳虚血病態であるかを総合的に判定する必要がある． |
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| AbstractList | 要旨：症例は67歳男性. 発症35分で救急搬送され, JCS3, 左共同偏視, 全失語, 右上下肢完全麻痺を認めた. 心電図で心房細動を認めた. MRIでは左前大脳動脈(ACA)領域および左中大脳動脈(MCA)と左後大脳動脈の境界域に脳梗塞を認めた. MRAおよびCTAで左ACA閉塞を認めた. 左MCAに閉塞性病変は認められなかった. CT perhsionでは左ACA領域のみならず左MCA領域でもMTTが延長していた. t-PA静注療法を計画したが, PT-INR 1.88が禁忌項目に該当したため, ヘパリン, ワーファリンで加療した. 入院翌日には症状は軽快し, MRAで左ACAの再開通を認めた. 発症早期にみられるdiffusion-perfusion mismatchは脳主幹動脈の閉塞を必ずしも意味しないことを示唆しており, 常に脳血管画像所見を加味して, どのような脳虚血病態であるかを総合的に判定する必要がある. 「はじめに」脳主幹動脈が急性閉塞した場合, 灌流画像では閉塞血管の灌流領域に脳血流の低下所見がみられるが, MRI拡散強調画像(diffusion-weighted image;DWI)で脳梗塞領域が限局してみられることがあり, これらの領域の解離をdiffusion-perfusion mismatch(DPM)と呼ぶ. 症例は67歳男性．発症35分で救急搬送され，JCS 3，左共同偏視，全失語，右上下肢完全麻痺を認めた．心電図で心房細動を認めた．MRIでは左前大脳動脈（ACA）領域および左中大脳動脈（MCA）と左後大脳動脈の境界域に脳梗塞を認めた．MRAおよびCTAで左ACA閉塞を認めた．左MCAに閉塞性病変は認められなかった．CT perfusionでは左ACA領域のみならず左MCA領域でもMTTが延長していた．t-PA静注療法を計画したが，PT-INR 1.88が禁忌項目に該当したため，ヘパリン，ワーファリンで加療した．入院翌日には症状は軽快し，MRAで左ACAの再開通を認めた．発症早期にみられるdiffusion-perfusion mismatchは脳主幹動脈の閉塞を必ずしも意味しないことを示唆しており，常に脳血管画像所見を加味して，どのような脳虚血病態であるかを総合的に判定する必要がある． |
| Author | 中川原, 譲二 遠藤, 英樹 前田, 理名 渡邉, 健太郎 本庄, 華織 中村, 博彦 浅野目, 卓 山口, 陽平 杉尾, 啓徳 上山, 憲司 |
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| References | 5.Kane I, Sandercock P, Wardlaw J: Magnetic resonance perfusion diffusion mismatch and thrombolysis in acute ischaemic stroke: a systematic review of the evidence to date. J Neurol Neurosurg Psychiatr 78: 485-491, 2007 8.増田 敦，三木貴徳，松本洋明ら：緊急血行再建術適応決定のためのdiffusion-perfusion mismatch評価の有用性．脳卒中32: 441-446, 2010 7.出口一郎，武田英孝，古屋大典ら：脳梗塞超急性期症例のt-PA静注療法適応選択におけるCT perfusionの有用性について．脳卒中31: 86-95, 2009 15.Prosser J, Butcher K, Allport L, et al: Clinical-diffusion mismatch predicts the putative penumbra with high specificity. Stroke 36: 1700-1704, 2005 6.Schellinger PD, Thomalla G, Fiehler J, et al: MRI-based and CT-based thrombolytic therapy in acute stroke within and beyond established time windows: an analysis of 1210 patients. Stroke 38: 2640-2645, 2007 9.Heiss WD: The concept of the penumbra: can it be translated to stroke management?Int J Stroke 5: 290-295, 2010 13.Toyoda K, Ida M, Fukuda K: Fluid-attenuated inversion recovery intraarterial signal: an early sign of hyperacute cerebral ischemia. AJNR Am J Neuroradiol 22: 1021-1029, 2001 12.Kamran S, Bates V, Bakshi R, et al: Significance of hyperintense vessels on FLAIR MRI in acute stroke. Neurology 55: 265-269, 2000 3.Hacke W, Albers G, Al-Rawi Y, et al: The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke 36: 66-73, 2005 4.Kohrmann M, Juttler E, Fiebach JB, et al: MRI versus CT-based thrombolysis treatment within and beyond the 3h time window after stroke onset: a cohort study. Lancet Neurol 5: 661-667, 2006 1.Wu O, Koroshetz WJ, Ostergaard L, et al: Predicting tissue outcome in acute human cerebral ischemia using combined diffusion- and perfusion-weighted MR imaging. Stroke 32: 933-942, 2001 11.日本脳卒中学会医療向上・社会保険委員会，rt-PA（アルテプラーゼ）静注療法指針部会：rt-PA（アルテプラーゼ）静注療法適正治療指針．脳卒中27: 327-354, 2005 14.Rovira A, Orellana P, Alvarez-Sabin J, et al: Hyperacute ischemic stroke: middle cerebral artery susceptibility sign at echo-planar gradient-echo MR imaging. Radiology 232: 466-473, 2004 10.Lassen NA: The luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. Lancet 2: 1113-1115, 1966 2.Schellinger PD, Fiebach JB, Hacke W: Imaging-based decision making in thrombolytic therapy for ischemic stroke: present status. Stroke 34: 575-583, 2003 |
| References_xml | – reference: 6.Schellinger PD, Thomalla G, Fiehler J, et al: MRI-based and CT-based thrombolytic therapy in acute stroke within and beyond established time windows: an analysis of 1210 patients. Stroke 38: 2640-2645, 2007 – reference: 7.出口一郎，武田英孝，古屋大典ら：脳梗塞超急性期症例のt-PA静注療法適応選択におけるCT perfusionの有用性について．脳卒中31: 86-95, 2009 – reference: 11.日本脳卒中学会医療向上・社会保険委員会，rt-PA（アルテプラーゼ）静注療法指針部会：rt-PA（アルテプラーゼ）静注療法適正治療指針．脳卒中27: 327-354, 2005 – reference: 4.Kohrmann M, Juttler E, Fiebach JB, et al: MRI versus CT-based thrombolysis treatment within and beyond the 3h time window after stroke onset: a cohort study. Lancet Neurol 5: 661-667, 2006 – reference: 10.Lassen NA: The luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. Lancet 2: 1113-1115, 1966 – reference: 14.Rovira A, Orellana P, Alvarez-Sabin J, et al: Hyperacute ischemic stroke: middle cerebral artery susceptibility sign at echo-planar gradient-echo MR imaging. Radiology 232: 466-473, 2004 – reference: 1.Wu O, Koroshetz WJ, Ostergaard L, et al: Predicting tissue outcome in acute human cerebral ischemia using combined diffusion- and perfusion-weighted MR imaging. Stroke 32: 933-942, 2001 – reference: 8.増田 敦，三木貴徳，松本洋明ら：緊急血行再建術適応決定のためのdiffusion-perfusion mismatch評価の有用性．脳卒中32: 441-446, 2010 – reference: 15.Prosser J, Butcher K, Allport L, et al: Clinical-diffusion mismatch predicts the putative penumbra with high specificity. Stroke 36: 1700-1704, 2005 – reference: 3.Hacke W, Albers G, Al-Rawi Y, et al: The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke 36: 66-73, 2005 – reference: 5.Kane I, Sandercock P, Wardlaw J: Magnetic resonance perfusion diffusion mismatch and thrombolysis in acute ischaemic stroke: a systematic review of the evidence to date. J Neurol Neurosurg Psychiatr 78: 485-491, 2007 – reference: 13.Toyoda K, Ida M, Fukuda K: Fluid-attenuated inversion recovery intraarterial signal: an early sign of hyperacute cerebral ischemia. AJNR Am J Neuroradiol 22: 1021-1029, 2001 – reference: 2.Schellinger PD, Fiebach JB, Hacke W: Imaging-based decision making in thrombolytic therapy for ischemic stroke: present status. Stroke 34: 575-583, 2003 – reference: 9.Heiss WD: The concept of the penumbra: can it be translated to stroke management?Int J Stroke 5: 290-295, 2010 – reference: 12.Kamran S, Bates V, Bakshi R, et al: Significance of hyperintense vessels on FLAIR MRI in acute stroke. Neurology 55: 265-269, 2000 |
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| Snippet | 症例は67歳男性．発症35分で救急搬送され，JCS 3，左共同偏視，全失語，右上下肢完全麻痺を認めた．心電図で心房細動を認めた．MRIでは左前大脳動脈（ACA）領域および左中... 要旨：症例は67歳男性. 発症35分で救急搬送され, JCS3, 左共同偏視, 全失語, 右上下肢完全麻痺を認めた. 心電図で心房細動を認めた. MRIでは左前大脳動脈(ACA)領域および... |
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| SubjectTerms | cerebral ischemia diffusion-perfusion mismatch occlusion of major cerebral artery recanalization |
| Title | 閉塞脳主幹動脈の再開通後にdiffusion-perfusion mismatchの遷延が認められた1例 |
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