脳 卒 中 J-STGE 早期公開 2015 年 11 月 13 日 Fig. 1 左総頸動脈撮影では起始部から狭窄を認めており 遠位端でも狭窄が強く NSCET 50 狭窄であった MRI plaque imaging sagittal view では T1WI で高信号であり soft plaq

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1 J-STGE 症 例 報 告 CS plaque protrusion 要 旨 CS 11 CS plaque protrusion 71 NSCET 50 NSCET 80 CS plaque protrusion soft plaque Key words: radiation-induced carotid artery stenosis, carotid artery stenting, repeated plaque protrusion, in-stent restenosis 緒 1 11 plaque protrusion 症 71 Hb1c MMT 4/5 MRI 言 例 doi: /jstroke MR NSCET 50 MRI plaque imaging soft plaque Fig. 1 NSCET 85 hard plaque Fig. 2 2 soft plaque CS spirin Clopidogrel 2 plaque strong statin Soft plaque protection FilterWire EZ NSCET 50 balloon protection Filter device 3.9 mm 7.7 mm Ikazuchi 2.5 mm 20 mm 8 atm/30 sec Preciese 9 mm 40 mm non-flow FliterWireEZ flow Fig. 3 spirin Clopidogrel rgatoban 48 1

2 脳 卒 中 J-STGE 早期公開 2015 年 11 月 13 日 Fig. 1 左総頸動脈撮影では起始部から狭窄を認めており 遠位端でも狭窄が強く NSCET 50 狭窄であった MRI plaque imaging sagittal view では T1WI で高信号であり soft plaque の所見であった C Fig. 2 右総頸動脈撮影では狭窄部位は第 2 頸椎から第 4 頸椎上縁にわたり 遠位端で最も 狭窄が強く NSCET 85 狭窄であった MRI plaque imaging axial view で は低信号であり hard plaque の所見であった C C C C Fig. 3 Stent 留置前 Stent 留置直後 右上下肢麻痺が 出 現 し た 造 影 で non-flow を 認 め filterwire を回収した 回収後 麻痺症状は速やかに消失し flow も改善した C Pre-stenting Non-flow Post-stenting 2

3 J-STGE CS 1 MRI plaque protrusion lt.central sulcus artery plaque protrusion Fig. 4 Distal protection FilterWire EZ wire Stent-instent Carotid Wallstent 10 mm 31 mm Fig. 5 Cilostazol 3 1 distal protection PT Rx-Genity 5.5 mm 20 mm Fig. 6 1 plaque protrusion distal protection PT Rx-Genity 5.5 mm 30 mm Fig. 7 1 Heparin U/day hard plaque FilterWire EZ distal protection Protégé 9 mm 60 mm 2 FilterWire EZ distal protection stent-in-stent Precise 7 mm 30 mm 3 Fig. 4 protrusion central sulcus artery C C Pre-stenting Post-stenting Pre-PT Post-PT Fig. 5 Wallstent 10 mm 31 mm stent-in-stent Fig. 6 PT 3

4 J-STGE Pre-PT Post-PT Fig. 7 PT 1 PT Fig Fig. 8 考 察 2 Greco prospective controlled study vs 62 P< CIMT Carotid intimal-medial thickness Dorothy plaque 7 CIMT soft plaque SPPHIRE study 8 CS 9 case CS plaque protrusion case 10 plaque soft plaque 4 hard plaque 2 plaque 4

5 J-STGE soft plaque soft plaque merican Heart ssociation guideline plaque CIMT CIMT 0.1 mm CIMT CIMT 結 語 soft plaque CIMT 利 益 相 反 COI COI 参 考 文 献 1 l-mubarak N, Roubin GS, Iyer SS, et al: Carotid stenting for severe radiation-induced extracranial carotid artery occlusive disease: J Endovasc Ther 7: 36 40, Xu J, Cao Y, et al: Radiation-induced carotid artery stenosis a comprehensive review of the literature. Intervent Neurol 2: , Greco,., Gallo,., De Virgilio,.et al: Carotid stenosis after adjuvant cervical radiotherapy in patients with head and neck cancers a prospective controlled study. Otolaryngol. 2012, 37, Shichita T, Ogata T, Yasaka M, et al: ngiographic characteristics of radiation-induced carotid arterial stenosis. ngiology 60: , Fokkema M, den Hartog G, van Lammeren GW, et al: Radiation-induced carotid stenotic lesions have a more stable phenotype than de novo atherosclerotic plaques. Eur J Vasc Endovasc Surg 43: , Dorresteijn LD, Kappelle C, oogerd W, et al: Increased risk of ischemic stroke after radiotherapy on the neck in patients younger than 60 years. J Clin Oncol 20: 282 8, Gujral DM, Chahal N, Senior R, et al: Radiation-induced carotid artery atherosclerosis. Radiother Oncol 110: 31 38, Yadav JS, Wholey MH, Kuntz RE, et al: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351: , Fokkema M, Hartog G, ots ML, et al: Stenting versus surgery in patients with carotid stenosis after previous cervical radiation therapy: systematic review and meta-analysis. Stroke 43: , Huang MP, Fang HY, Chen CY, et al: Long-term Outcomes of Carotid rtery Stenting for Radiation-ssociated Stenosis. iomed J 36: , Gujral DM, Shah N, Chahal NS, et al: Clinical features of radiation-induced carotid atherosclerosis. Clin Oncol (R Coll Radiol) 26: , Lorenz MW, Markus HS, ots ML, et al: Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation 115: ,

6 J-STGE bstract Radiation-induced carotid artery stenosis: a case report of repeated plaque protrusion after carotid artery stenting Sadaharu Torikoshi, M.D., 1) and Yoshinori kiyama, M.D., Ph.D. 1) 1) Department of Neurosurgery, Tenri Hospital Many articles report that the incidents of in-stent restenosis after carotid artery stenting (CS) were higher in radiation-induced carotid stenosis. We report a case of repeated plaque protrusion after CS for radiation-induced carotid stenosis, in a patient who received surgical treatment and adjuvant radiotherapy for neck cancer 11 years previously. The patient was a 71-year-old man who received treatment for diabetes mellitus, hypertension, and hyperlipidemia. He was diagnosed with cerebral infarction that caused right hemiplegia. Diffusion-weighted magnetic resonance imaging (MRI) revealed infarction at the frontal operculum, and cerebral angiography revealed bilateral internal carotid artery stenosis; the left side, symptomatic, showed 50% stenosis with soft plaque seen on MRI plaque imaging and the right side, asymptomatic, showed 80% stenosis with hard plaque. We chose carotid stenting instead of carotid endarterectomy for both carotid arteries because of the risks of surgery and radiation therapy. However, repeated carotid stenting and angioplasty were needed on both sides due to repeated in-stent restenosis. The incidence of ischemic stroke is significantly increased in patients receiving radiotherapy to the neck, especially in patients with risks of atherosclerotic disease. In such cases, strict observation and early intervention are thought to be important before accumulation of soft plaque due to atherosclerotic change, which may result in difficulty of treatment for carotid stenosis. Key words: radiation-induced carotid artery stenosis, carotid artery stenting, repeated plaque protrusion, in-stent restenosis 6

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