心原性脳塞栓症の病態と治療 Pathophysiology and Treatment of Cardioembolic Stroke

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著者

    • 矢坂 正弘 YASAKA Masahiro
    • 国立循環器病センター内科脳血管部門 Cerebrovascular Division, Department of Medicine, National Cardiovascular Center
    • 横田 千晶 YOKOTA Chiaki
    • 国立循環器病センター内科脳血管部門 Cerebrovascular Division, Department of Medicine, National Cardiovascular Center

抄録

目的: 高齢者における心原性脳塞栓症の病態を明らかにし, 適切な治療方針を探ることを目的として, 当センターに入院した心原性脳塞栓症例の年齢別解析を試みた.<br>方法: 対象は当センターに発症7日以内に入院した心原性脳塞栓症連続120例 (男性77例, 女性43例, 65±13歳) である. 対象を非老年期 (64歳以下, 57例), 老年前期 (65~74歳, 30例) および老年後期 (75歳以上, 33例) に分け, 基礎心疾患, 入院時神経脱落症候 (NIH Stroke Scale), 梗塞巣の大きさ, 抗凝血薬療法の有無と再発や出血性合併症との関連性, 入院中の合併症, 退院時ADL, 及び経過観察期間における再発や死亡の有無を調べた.<br>結果: 基礎心疾患は非老年期群ではリウマチ性弁膜症 (19例, 33.3%) が, 老年後期群では非弁膜性心房細動 (NVAF) (25例, 75.8%) が最も多かった. 老年後期群における入院時のNIH Stroke Scale (median 11点) と頭部CT上の最大径が3cm以上の梗塞を有する割合 (51.5%) は, ともに他群より高かった. 急性期 (発症14日以内) 抗凝血薬療法は非老年期群と老年前期群で7割以上に行われたが, 老年後期群では57.6%と少なかった. 急性期の再発は抗凝血薬療法非施行34例中4例 (11.8%), 施行86例中2例 (2.3%) にみられ, 非施行例で多い傾向であった (Chi square test, p=0.053). 老年期の2群で急性期抗凝血薬療法中の出血が2例, 他の合併症 (感染症や肺塞栓) が14例に見られたが, 非老年期群では見られなかった. 退院時に独歩もしくは杖歩行の症例は非老年期群 (78.9%) と比較し老年期の2群 (57.1%) では少なかった (Chi square test, p<0.01). 慢性期の抗凝血薬療法は非老年期群と老年前期群では8割以上に行われたが, 老年後期群では3割弱に行われたのみであった. 全経過観察期間中の再発もしくは死亡は, 明らかに老年後期群で多かった (Log rank test, p=0.0091).<br>結論: 高齢者における心原性脳塞栓症の特徴は, 基礎心疾患としてNVAFが多く, 再発や死亡率が高く予後不良である. その要因として, 発症時の神経脱落症状が重い, 梗塞巣が大きい, 入院中の合併症が多い, および急性期と慢性期における抗凝血薬療法施行率が低いことがあげられる. 従って, NVAFからの脳塞栓症の発症や再発の防止を目的とした抗凝血薬療法の適応や入院中の合併症への対策が必要と考えられた.

To elucidate the pathophysiologic mechanism of cardioembolic stroke in elderly people and to devise therapeutic strategies for it, was analyzed 120 consecutive patients (77 men and 43 women aged 65±13 years) with acute cardioembolic stroke who were admitted within 7 days of the stroke onset. We compared underlying heart diseases, NIH stroke scale on admission, lesion size on computed tomography (CT), the relation between anticoagulant therapy and recurrence, complications during admission, ADL at discharge, recurrence, and death during the follow up period in three groups: patients aged less than 65 years (the young group), those aged from 65 to 74 years (the"non-old"group), and those aged more than 75 years (the"old old"group).<br>In the"old old"group, non valvular atrial fibrillation (75.8%) was the most common underlying heart disease and so was rheumatic heart disease (33.3%) in the"non-old"group. NIH stroke scale score (median, 11) and the proportion of patients with a large lesion (>3cm) on CT were higher in the"old old"group than in the other two groups. Immediate anticoagulation (A/C) within 14 days of onset was performed in more than 70% of the "non-old"and the"young old" groups but in only 57.6% of the"old old"group. Stroke recurred more often in 34 patients who did not receive immediate A/C than in the 86 who did (11.8% vs. 2.3%, Chi squate test, p=0.053). Hemorrhage during immediate A/C and other complications (infection and pulmonary embolism) were seen in 2 and 14 patients, respectively, in both the"young old"groups, but not in the"non-old"group. Good outcomes (able to walk with or without cane) were more common in the"non-old" group (78.9%) than the other groups (57.1%, Chi square test, p<0.01). A/C after the acute stage was done in more than 80% of those in the"non-old"and the"young old"groups, but in less than 30% of those in the"old old"group (Chi square test, p=0.0514). Survival without recurrence during the observation period (605±550 days) was significantly lower in the "old old"group than in the other two groups (log-rank test, p=0.0091).<br>Cardioembolic atroke in the elderly may be characterized as follows: (1) non valvular atrial fibrillation is the most common, (2) severe neurologic deficits on admission and large lesions on CT are noted, (3) complications (infection and pulmonary embolism) often occur, (4) A/C in both acute and chronic stages are done infrequently. Therefore, the indication and intensity of A/C for primary and secondary prevention and prevention of complications are important in management of cardioembolic stroke in the edlerly.

収録刊行物

  • 日本老年医学会雑誌

    日本老年医学会雑誌 35(10), 735-740, 1998-10-25

    The Japan Geriatrics Society

参考文献:  22件中 1-22件 を表示

被引用文献:  1件中 1-1件 を表示

各種コード

  • NII論文ID(NAID)
    10008482987
  • NII書誌ID(NCID)
    AN00199010
  • 本文言語コード
    JPN
  • 資料種別
    REV
  • ISSN
    03009173
  • NDL 記事登録ID
    4622147
  • NDL 雑誌分類
    ZS21(科学技術--医学--内科学)
  • NDL 請求記号
    Z19-25
  • データ提供元
    CJP書誌  CJP引用  NDL  J-STAGE 
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