脳血管攣縮の予防のためのnicardipine持続脳槽灌流療法の効果と灌流液のdeliveryを考慮した手術における工夫  [in Japanese] Sustained Intrathecal Administration of Nicardipine for Prevention of Cerebral Vasospasm Following Subarachnoid Hemorrhage and Operative Manipulation in Consideration of Nicardipine Delivery  [in Japanese]

雑誌掲載版クモ膜下出血で発症した破裂脳動脈瘤16例に対し直達手術後、nicardipine持続脳槽灌流療法を行い、脳血管攣縮における有用性について検討した。その結果、1)血管撮影上、軽度の血管攣縮が5例(31%)に認められたが、症候性攣縮例はみられなかった。2)主幹動脈の拡張率はそれぞれC1;115±19%、M1;113±23%、A1;117±26%であった。3)発症3ヵ月後の予後は、mRSでgrade 0が9例(56%)、grade 1が2例(13%)、grade 2が1例(6%)、grade 3が3例(19%)、grade 4が0%、grade 5が1例(6%)、grade 6が0%であった。以上、これらのことからも、nicardipine持続脳槽灌流療法はくも膜下出血後の脳血管攣縮の予防として有効な治療法になりうる可能性が示唆された。

We investigated the effect of sustained administration of intrathecal nicardipine, calcium antagonist, in 16 cases to prevent post-subarachnoid hemorrhage (SAH) vasospasm. Patients with SAH of Fisher CT Group 3 (15 cases) or Group 4 (1 case) underwent direct clipping surgery and the placement of the cisternal catheter. From 1-4 days after SAH onset, the nicardipine solution (0.09 mg/ml) was continuously injected through the cisternal catheter at the rate of 2 ml/h for 4-16 days. The vasospasm was evaluated from postoperative angiography performed 1 week after SAH onset. The ratios of diameter at internal carotid arteries (ICA) C1 portion, middle cerebral arteries (MCA) M1 portion and anterior cerebral arteries Al portion were obtained from preoperative and post-operative angiograms. Mild localized vasospasm was observed in 5 cases. The ratios of diameter at C1, M1 and A1 were 1.15 ± 0.19, 1.13 ± 0.23 and 1.17 ± 0.26, respectively. No symptomatic vasospasm was observed in any of the cases. These findings demonstrated that the vaso-dilative effect of nicardipine prevented the post SAH vasospasm of intracranial arteries at C1, M1 and A1. The mild angiographical vasospasm in the 5 cases was probably due to the insufficient delivery of nicardipine solution. Following the operative manipulation of the exposure of ICA and MCA with radical clot removal, administration of nicardipine solution through the catheter in the contralateral carotid cistern and draining from the catheter in ipsilateral sylvian cistern brought the widespread nicardipine delivery to peripheral arteries. Though further improvement of this method is required, sustained intrathecal administration of nicardipine effectively prevents vasospasm following SAH.