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1 原著 Branch atheromatous disease BAD CT 要旨 branch atheromatous disease BAD CT MRI MTT Key words: branch atheromatous disease, CT perfusion, deterioration はじめに Trial of Org in Acute Stroke Treatment TOAST 1 branch atheromatous disease BAD Caplan BAD 3 2 BAD lacunar infarction: LI BAD doi: /jstroke National Institute of Health Stroke Scale NIHSS rt-pa J-BAD Registry modified Rankin Scale mrs 0 1 lenticulostriate artery: LSA 40.5 paramedian pontine artery: PPA BAD BAD retrospective CT CT perfusion: CTP 対象と方法 CT CTP CT CT angiography: CTA 1

2 CTP CTA CTP CTP CTA CT GE Healthcare Light- Speed VCT XT CTP 80 KeV 180 ma 40 ml 4 ml 5 mm 16 CTA 120 KeV 120 ma 60 ml 4 ml mm 370 mg/ml CTP standard singular-value decomposition ssvd cerebral blood flow: CBF cerebral blood volume: CBV mean transit time: MTT MRI 48 MRI MRI GE Healthcare 1.5 TMRI 5 mm MRI LI atherothrombotic brain infarction: ABI BAD cerebral embolism: CE LI BAD ABI CE BAD J-BAD Registry LSA 3 20 mm PPA BAD MRI diffusion weighted image: DWI LSA PPA BAD LSA BAD PPA CTA CTP 48 MRI DWI BAD retrospective CTP CTP map MTT map 6, 7 mean transit time: MTT map CTP MRI manual muscle testing: MMT 2 MTT map 3 MRI CTP MTT MTT map 2 3 MTT MRI DWI 3 CTP MRI DWI ABC/2 8 CTP 2 2 χ p < χ p <0.05 JMP Pro12 結果 36 LSA BAD PPA BAD LSA PPA CTP MTT map BAD retrospective LSA PPA LSA CTP PPA CTP 36 Table 1 LSA Fig. 1 CTP p= χ Pearson

3 Table 1 Clinical characteristics of patients with BAD who were examined both CTP and MRI within 48 hours of onset Total BAD LSA group PPA group Number Age (y/o) 69.8± ± ±6.9 M:F 21:15 18:10 2:6 HT DM DL Smoking history Past Never CTP laterality-positive Deterioration- positive y/o: years old, M: male, F: female, HT: hypertension, DM: diabetes mellitus, DL: dyslipidemia, LSA: lenticulostriate artery, PPA: paramedian pontine artery Fig. 1 The relationship between infarction volume deterioration of symptoms. The deterioration- positive/negative group and CTP- positive/negative group is shown. There was no significant difference in infarction volume between the deterioration-positive group and deterioration-negative group (p=0.8544). CTP MTT CTP Fig. 2 Table 2 sensitivity 100 specificity 37 ROC area under curve AUC 考察 MRI MRI 24 Nagakane 26 MRI 9 CT CT CTA CTP MRI 3

脳卒中 J-STAGE 早期公開 2017 年 7 月 11 日 a b c d Fig. 2 Representative case of BAD involving the LSA region. A 62-year-old male complained of mild right hemiparesis.

4 脳卒中 J-STAGE 早期公開 2017 年 7 月 11 日 a b c d Fig. 2 Representative case of BAD involving the LSA region. A 62-year-old male complained of mild right hemiparesis. The CTP image performed on arrival could not detect signiﬁcant hypoperfused region on CBF (a) nor CBV (b) but could detect prolonged MTT in the right LSA region (arrow) (c). At 36 hours after the onset condition, he complained severe left hemiparesis. MRI demonstrated the large infarction (arrow) (d). The volume of infarction was mm3. Table 2 Predictors of deterioration for BAD involving the LSA region Deterioration-positive Deterioration-negative p-value * ± ± HT (n) DM (n) DL (n) Past (n) Never (n) 6 9 Total CTP laterality-positive (n) 3 Volume of infarction (mm ) Smoking history HT: hypertension, DM: diabetes mellitus, DL: dyslipidemia, LSA: lenticulostriate artery *p<0.05 る CTP は 1990 年代より急速に臨床の現場で広く使用される脳梗塞の患者で迅速にこれらの患者を振るい分されており脳血管障害のみならず頭部外傷脳腫瘍なけるには撮影時間が短く簡便に判別できる CTP の定どにも広く脳神経外科の領域でも応用されている性的解析が優れていると考えられる今回の我々の 10 study において初診時症状が軽微であったがその後症急性期脳梗塞例の CTP によるパラメーターの評価にはカラーマップによるソフトウェアによる定性的解析状が増悪した例を検討すると CTP において陽性を示とワークステーションを用いた定量的解析の報告があしておりこれは CTP ペナンブラの領域が表現されてるが定量的解析は客観的に数値で測定結果を示されるいると考えられるこのことから来院後脳梗塞の病型診ものの画像撮影から解析までに時間を要し救急外来断のために CTP を行わずに直ちに MRI を行い LI と診で迅速に判断するのには適さないと考えられるこれに断された場合はペナンブラの存在の情報がなく梗塞巣の対し定性的解析の特異度はカラーマップを使用するこ拡大を予知できず治療が後手に回るケースも少なからとで 80 まで上昇しペナンブラ領域の描出が可能でずあるのではないかと考えられる脳梗塞の超急性期のあったと報告されている大半が救急患者として搬送診断においての CTP の限界について検討すると今回

5 study LSA CTP PPA CTP 0 Suzuki 7 Hana 225 CTP CTP LI 0 13 CTP CTP study BAD LSA LSA LSA BAD 16, 17 PPA BAD loading dose LSA 18 study CTP CTP 結語 CTP MTT BAD COI COI 参考文献 1 Adams HP, Bendixen BH, Kappelle LJ, et al: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org in Acute Stroke Treatment. Stroke 24: 35 41, Caplan LR: Intracranial branch atheromatous disease: a neglected, understudied, and underused concept. Neurology 39: , Branch atheromatous deisease J-BAD Registry 50: , BAD J-BAD Registry 51: 881, Branch atheromatous deisease 33: 37 44, Kudo K, Sasaki M, Yamada K, et al: Differences in CT perfusion maps generated by different commercial software: quantitative analysis by using identical source data of acute stroke patients. Radiology 254: , Suzuki Y, Nakajima M, Ikeda H, et al: Evaluation of hyperacute stroke using perfusion computed tomography. Neurol Med Chir (Tokyo) 45: ; discussion , Kothari RU, Brott T, Broderick JP, et al: The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27: , Nagakane Y, Naritomi H, Oe H, et al: Neurological and MRI findings as predictors of progressive-type lacunar infarction. Eur Neurol 60: , Hoeffner EG: Cerebral perfusion imaging. J Neuroophthalmol 25: , Ho CY, Hussain S, Alam T, et al: Accuracy of CT cerebral perfusion in predicting infarct in the emergency department: lesion characterization on CT perfusion based on commercially available software. Emerg Radiol 20: , Yamada M, Yoshimura S, Kaku Y, et al: Prediction of neurologic deterioration in patients with lacunar infarction in the territory of the lenticulostriate artery using perfusion CT. AJNR Am J Neuroradiol 25: , Hana T, Iwama J, Yokosako S, et al: Sensitivity of CT perfusion for the diagnosis of cerebral infarction. J Med Invest 61: 41 45, Akashi T, Taoka T, Ochi T, et al: Branching pattern of lenticulostriate arteries observed by MR angiography at 3.0 T. Jpn J Radiol 30: , Marinkovic S, Gibo H, Milisavljevic M, et al: Anatomic and clinical correlations of the lenticulostriate arteries. Clin Anat 14: , Branch atheromatous disease BAD Neurol Surg 39: , Nakase T, Sasaki M, Suzuki A: The effect of acute medication with cilostazol, an anti-platelet drug, on the outcome of small vessel brain infarction. J Stroke Cerebrovasc Dis 23: , Branch atheromatous disease 54: ,

6 Abstract Usefulness of computed tomography perfusion (CTP) imaging for predicting the deterioration of branch atheromatous disease (BAD) Naoyuki Arai, M.D., 1) Atsushi Sasahara, M.D., 1) Taku Yoneyama, M.D., 1) Chiaki Sekine, M.D., 2) Asami Kikuchi, M.D., 1) Yuichi Takahashi, M.D., 1) Suguru Yokosako, M.D., 1) Chika Yoshimura, M.D., 1) Hidenori Ohbuchi, M.D., 1) Kengo Hirota, M.D., 1) Shinji Hagiwara, M.D., 1) Shigeru Tani, M.D., 1) and Hidetoshi Kasuya, M.D. 1) 1) Department of Neurosurgery, Tokyo Women s Medical University Medical Center East 2) Department of Rehabilitation, Tokyo Women s Medical University Medical Center East Background and Purpose: We retrospectively examined the efficacy of computed tomography perfusion imaging (CTP) for predicting the neurological deterioration of branch atheromatous disease (BAD). Methods: We treated 36 cases of BAD from October 2010 to September The patients were examined with both CTP and magnetic resonance imaging during the super acute stage. We divided the 36 cases into two groups; the lenticurostriate artery (LSA; n=28) and paramedian pontine artery (PPA; n=8) groups. In these two groups, we investigated the correlations between neurological deterioration and CTP finding or other factors. Results: Neurological deterioration occurred in 11 cases in the LSA group and 2 cases in the PPA group. In the LSA group, unilaterality was observed on CTP in 21 cases, whereas no such laterality was seen in the PPA group. There was no significant difference in the volume of the infarction between the deterioration-positive and -negative groups. All of the patients in the LSA group presented with unilateral neurological deterioration in mean transit time maps derived from CTP. Conclusions: Clinicians should carefully monitor the patients with BAD involving the LSA region who present with mild symptoms, but exhibit unilaterality on CTP. Key words: branch atheromatous disease, CT perfusion, deterioration 6

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_02.indd 30, 11-16, 2010 Z Z score Computed tomography ROC analysis 3 CT 1,2 CT 1/3 3 5 CT CT 6 7,8 MCA ASPECTS Alberta Stroke Programme Early CT Score 4 10 CT ASPECTS 50% 9 Z 10 CT Z CT 10 Z Z Z receiver operating