症例報告 Managing Subdural Hematomas associated with Intracranial Hypotension with Intra subdural Hematoma Cavity Pressure Monitoring A Case Report Nobusu

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1 症例報告 Managing Subdural Hematomas associated with Intracranial Hypotension with Intra subdural Hematoma Cavity Pressure Monitoring A Case Report Nobusuke Tsuzuki, M.D. 1, Terushige Toyooka, M.D. 2, and Hiroshi Kageyama, M.D. 1 Key words Jpn J Neurosurg Tokyo , 2016 はじめに intracranial hypotension IH IH epidural blood patch EBP Address reprint requests to Nobusuke Tsuzuki, M.D., Department of Neurosurgery, Shin Kuki General Hospital, Kamihayami, Kuki shi, Saitama , Japan Jpn J Neurosurg VOL. 25 NO

the pons, engorgement of the venous sinuses A, and diffuse meningeal

2 R Fig. 1 Head CT on admission showing bilateral subdural hematomas SDHs and partial effacement of the basal cisterns. A B Fig. 2 Gadolinium enhanced brain magnetic resonance imaging showing flattening of the pons, engorgement of the venous sinuses A, and diffuse meningeal enhancement with bilateral SDHs B IH 症例提示患者 60 主訴現病歴 1 CT scan Fig. 1 入院後経過 MRI T1 Fig. 2 MR myelography data not shown MRI IH 1 治療経過第 1 病日 ( 入院初日 ) 2,000 ml day

R Fig. 3 Head CT 20 days after admission showing enlargement of the bilateral SDHs and complete effacement of the basal cisterns. 第 20 病日 20 CT scan Fig.

3 R Fig. 3 Head CT 20 days after admission showing enlargement of the bilateral SDHs and complete effacement of the basal cisterns. 第 20 病日 20 CT scan Fig. 3 第 21 病日 ( 穿頭術施行 ) IH mass effect Codman MicroSensor ICP Transducer, Codman & Shurtleff Fig mmhg 2 10 mmhg 第 22 病日 ( 穿頭術翌日 ) CT scan 4 2 mmhg 第 24 病日 ( 穿頭術後 4 日目,EBP 施行 ) IH CT scan data not shown EBP EBP Franzini theory EBP EBP 4 20 mmhg 第 25 病日 EBP CT scan 90 data not shown 25 mmhg 14 mmhg 第 29 病日 CT scan Fig. 5 CT scan 考察 IH 1 EBP IH Jpn J Neurosurg VOL. 25 NO

30 25 20 15 10 5 Burr hole surgery Hematoma cavity pressure mmhg EBP Drainage tube declamp 0 12 00 14 00 18 00 22 00 2 00 8 00 14 00 20 00 6 00 16 00 2 00 6 00 14 00 16 00 18 00 10 00 16 00 2 00 8 00

4 Burr hole surgery Hematoma cavity pressure mmhg EBP Drainage tube declamp Burr hole surgery Day 1 Day 2 Day 3 Day 4 EBP Day 5 Day 6 Day 7 Day 9 Hematoma cavity pressure mmhg Fig. 4 Intra SDH cavity pressure ISCP trend throughout the therapeutic period. The patient's ISCP dropped to 2 mmhg 2 days after burr hole surgery arrow despite bed rest and intravenous hydration. A few hours after the application of EBP arrowhead, the ISCP rapidly increased to more than 20 mmhg at which point hematoma drainage was begun arrow. The ISCP rose slightly to 23 to 25 mmhg, and then decreased to the normal range during the next few days. R Fig. 5 Head CT 5 days after the application of EBP showing complete remission of the bilateral SDHs and the reappearance of the basal cisterns. Schievink 18 IH IH mass effect IH 2 IH EBP IH IH IH

5 IH IH absorbable type IH mass effect IH IH IH 8 16 IH acute type mass effect IH acute on chronic 8 chronic type Amorim 1 1 De Noronha 2 IH 4 1 IH mass effect IH IH EBP mass effect mass effect EBP mass effect EBP EBP IH absorbable type acute type chronic type Loya 8 IH Trendelenburg IH IH EBP IH 1 20 mass effect Jpn J Neurosurg VOL. 25 NO

6 EBP mass effect 3 EBP EBP IH EBP IH strategy 結語 1. IH absorbable type acute type chronic type 3 2. Chronic type IH 3. IH 1 COI COI 文 1 Amorim JA, Remígio DS, Damázio Filho O, de Barros MA, Carvalho VN, Valença MM Intracranial subdural hematoma post spinal anesthesia report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol , De Noronha RJ, Sharrack B, Hadjivassiliou M, Romanowski CAJ Subdural haematoma a potentionally serious consequence of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry , Ferrante E, Savino A, Sances G, Nappi G Spontaneous intracranial hypotension syndrome report of twelve cases. Headache , Franzini A, Messina G, Nazzi V, Mea E, Leone M, Chiapparini L, Broggi G, Bussone G Spontaneous intracranial hypotension syndrome a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients. J Neurosurg , Fujimaki H, Saito N, Tosaka M, Tanaka Y, Horiguchi K, Sasaki T Cerebrospinal fluid leak demonstrated by three dimentional computed tomographic myelography in patients with spontaneous intracranial hypotension. Surg Neurol , Lin WC, Lirng JF, Fuh JL, Wang SJ, Chang FC, Ho CF, Teng MM, Chang CY MR findings of spontaneous intracranial hypotension. Acta Radiol , Loya JJ, Mindea SA, Yu H, Venkatasubramanian C, Chang SD, Burns TC Intracranial hypotension producing reversible coma a systematic review, including three new cases. J Neurosurg , Messori A, Simonetti BF, Regnicolo L, Di Bella P, Logullo F, Salvolini U Spontaneous intracranial hypotension the value of brain measurements in diagnosis by MRI. Neuroradiology , No Shinkei Geka Miyazawa K, Shiga Y, Hasegawa T, Endoh M, Okita N, Higano S, Takahashi S, Itoyama Y CSF hypovolemia vs intracranial hypotension in spontaneous intracranial hypotension syndrome. Neurology , Brain Nerve Mokri B, Piepgras DG, Miller GM Syndrome of orthostatic headaches and diffuse pachymeningeal gadolinium enhancement. Mayo Clin Proc , Mokri B The Monro Kellie hypothesis applications in CSF volume depletion. Neurology , Sayer FT, Bodelsson M, Larsson EM, Romner B Spontaneous intracranial hypotension resulting in coma case report. Neurosurgery 59 E204, Schievink WI, Meyer FB, Atkinson JL, Mokri B Spontaneous spinal cerebrospinal fluid leaks and intracranial hypoten- 献

7 sion. J Neurosurg , Schievink WI, Maya MM, Moser FG, Tourje J Spectrum of subdural fluid collections in spontaneous intracranial hypotension. J Neurosurg , Schievink WI Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA , Sperry RJ, Gartrell A, Johnson JO Epidural blood patch can cause acute neurologic deterioration. Anesthesiology , Sipe JC, Zyroff J, Waltz TA Primary intracranial hypotension and bilateral isodense subdural hematomas. Neurology , No Shinkei Geka 要旨 1 脳外誌 25: ,2016 Jpn J Neurosurg VOL. 25 NO

8 慢性硬膜下血腫を合併した低髄液圧症候群の診断と治療 1 文献

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ml ml ~ml : ml , ) RI CT MRI( MRI (T2T1 MRI MR Mokri Mokri Mokri ICHD-II) Schievink post-lumbar puncture headache) 1938 Schaltenbrand spontaneous aliquorrhea( 1958 Shenkinlow cerebral spinal fluid pressure