J-STAGE rt-pa , 20 15, 21, 22 AAD AAD に合併する脳梗塞の臨床的特徴 AAD ±12 16 Table 1 AAD AAD rt-pa 1 AAD rt-pa 18

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1 J-STAGE 第 42 回日本脳卒中学会講演シンポジウム総説 , 要旨 Stanford A rt-pa Xp CT D-dimer CT Key words: intravenous rt-pa therapy, chest or back pain, blood pressure laterality, carotid ultrasonography, D-dimer はじめに rt-pa rt-pa doi: /jstroke rt-pa Stanford A 型大動脈解離 (AAD) と脳梗塞 Stanford A , 14 AAD AAD 1

2 J-STAGE rt-pa , 20 15, 21, 22 AAD AAD に合併する脳梗塞の臨床的特徴 AAD ±12 16 Table 1 AAD AAD rt-pa 1 AAD rt-pa intimal flap D-dimer 6.9 μg/ml SBP 20 mmhg AAD AAD SBP 110 mmhg 4 intimal flap AAD 24 AAD 814 AAD D-dimer 4.1 μg/ ml Table 1 Stanford A Table 2 90 intimal flap 50 intimal flap SBP 17 mmhg 0.32 Table 2 全国アンケート調査 N=23 20/TIA3 ±SD 74±12 n n n n n n n n 0 2 n n n n n n rt-pa / / rt-pa 16 rt-pa 2

3 J-STAGE Table 2 Stanford A PPV NPV AUC 17 mmhg D-dimer 4.1 μg/ml AUC NPV PPV 1517 WEB AAD AAD AAD AAD rt-pa AAD CT D-dimer 救急隊へのアンケート調査 AAD ± AAD AAD AAD に合併する脳梗塞を見逃さないために rt-pa 10 rt-pa Fig. 1 AAD 1 AAD SBP 20 mmhg SBP 110 mmhg AAD AAD AAD WEB 3

4 脳卒中 J-STAGE 早期公開 2017 年 12 月 28 日 Fig. 1 Stanford A 型急性大動脈解離に合併する脳梗塞の診療指針案脳卒中診療において医師は常に大動脈解離の存在を疑う監視役を担う必要がある脈拍触知で左右差がある場合には血圧両側測定を行い左右差 20 mmhg もしくは右上肢血圧 110 mmhg で大動脈解離を疑う救急車内でこの条件を満たす測定結果を得た場合も医療施設での血圧再評価が必須である # 意識障害や失語症で胸痛背部痛の確認ができない場合や意識レベル変動など症候変動がある場合などを大動脈解離が否定できない場合とする大動脈弓部を含む CTA を施行している場合には不要であるがいまだ少なくこれまでプレホスピタルの活動がこのるその他の侵襲性が低い検査法として MRA 検査や造病態の検出に有用であるか調べた検討はないしかし影 CT 検査がある脳梗塞や一過性脳虚血発作を起こし可及的早期の診断が転帰に大きく影響する本病態では救ている症例では大動脈解離が頭頸部動脈への血流を阻害急隊の積極的な関与により適切な病院選定や搬送後救急する原因になっているためエコー検査で動脈解離の総頸診療につながる可能性がある動脈への直接波及右側に多いや血流障害多くは閉塞第 2 段階受入医療施設の初療医脳卒中診療医が約パターン血流を検出できることが多いただし経験が半数が脳卒中疑いを診療する場合には必ず AAD の存ない検査士や医師による頸部血管エコー検査診断の正確在を念頭に置き胸痛背部痛の確認両側上肢血圧同度は必ずしも高くないため頸動脈病変評価経験のある時測定胸部レントゲン検査を必須として AAD の疑い検査士もしくは医師が行うことが望ましいまた頭部がないかを評価する初療医はこの病態が発症 4 時間以 CT や MRI を行う時点で CTA や MRA による頭蓋内血内に搬送されてくる脳梗塞患者 60 例に 1 例程度 1.7 管を含めた評価を行うことが望ましい造影 CT 検査でに存在することを念頭に基本的な検査と観察を行う病は 1 回の撮影で大動脈弓部から頸部頭部まで含めた評歴と診察所見から AAD を疑う場合には速やかに頭部価が可能である測定が可能な施設では D-dimer 評価を CT もしくは MRI/MRA に加えて胸部造影 CT 検査を行行う病歴と診察所見に加えて頭頸部の動脈を含めた画う症例により胸部造影 CT 検査を優先するショック像診断結果や D-dimer 4.1 μg/ml より AAD を疑う場合状態など全身状態が不安定な場合には全身状態の安定をには速やかに胸部造影 CT 検査を追加する第 4 段階 AAD を診断したら速やかに心臓血管外科優先するや循環器内科などの専門診療科に相談して適切な治療方第 3 段階初療医が意識障害健忘や失語症などに針を決定するより胸痛背部痛の確認ができない場合緊急診療時に意識レベル変動など神経症候変動がある場合片麻痺おわりに意識障害失神痙攣健忘脊髄虚血末梢神経障害など様々な神経症状の組み合わせを呈する場合など緊急を要する急性期脳卒中診療では治療開始まで一刻 AAD が否定できない場合には必ず総頸動脈の評価を行を争うことが多いこのような中でも脳卒中疑い患者のう各施設の特性や利用可能性により画像診断法を選択初期対応をする医師は約 1.7 に AAD が含まれることするが頸部血管エコー検査が最も迅速かつ簡便であを常に念頭に置く必要がある不適切な rt-pa 静注療法 4

5 J-STAGE CT D-dimer AAD CT AAD 謝 COI COI 辞参考文献 1 30: , takamoto_h.pdf 3 Doroghazi RM, Slater EE, DeSanctis RW, et al: Long-term survival of patients with treated aortic dissection. J Am Coll Cardiol 3: , Mehta RH, Suzuki T, Hagan PG, et al: Predicting death in patients with acute type a aortic dissection. Circulation 105: , Kawahito K, Adachi H, Yamaguchi A, et al: Early and late surgical outcomes of acute type A aortic dissection in patients aged 75 years and older. Ann Thorac Surg 70: , Miller DC, Mitchell RS, Oyer PE, et al: Independent determinants of operative mortality for patients with aortic dissections. Circulation 70(3 Pt 2): I , Haverich A, Miller DC, Scott WC, et al: Acute and chronic aortic dissections-determinants of long-term outcome for operative survivors. Circulation 72(3 Pt 2): II22 34, Pansini S, Gagliardotto PV, Pompei E, et al: Early and late risk factors in surgical treatment of acute type A aortic dissection. Ann Thorac Surg 66: , Sabik JF, Lytle BW, Blackstone EH, et al: Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg 119: , Nienaber CA, Eagle KA: Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies. Circulation 108: , Kawahito K, Adachi H, Yamaguchi A, et al: Preoperative risk factors for hospital mortality in acute type A aortic dissection. Ann Thorac Surg 71: , Lai DT, Robbins RC, Mitchell RS, et al: Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection? Circulation 106(12 Suppl 1):I , Hagan PG, Nienaber CA, Isselbacher EM, et al: The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 283: , Bossone E, Corteville DC, Harris KM, et al: Stroke and outcomes in patients with acute type A aortic dissection. Circulation 128(11 Suppl 1): S , Gaul C, Dietrich W, Friedrich I, et al: Neurological symptoms in type A aortic dissections. Stroke 38: , Ohara T, Koga M, Tokuda N, et al: Rapid identification of type A aortic dissection as a cause of acute ischemic stroke. J Stroke Cerebrovasc Dis 25: , Sakamoto Y, Koga M, Ohara T, et al. Frequency and detection of stanford type A aortic dissection in hyperacute stroke management. Cerebrovasc Dis 42(1 2): , Hama Y, Koga M, Tokunaga K, et al: Carotid ultrasonography can identify stroke patients ineligible for intravenous thrombolysis therapy due to acute aortic dissection. J Neuroimaging 25: , Iguchi Y, Kimura K, Sakai K, et al: Hyper-acute stroke patients associated with aortic dissection. Intern Med 49: , Ehrlich MP, Ergin MA, McCullough JN, et al: Results of immediate surgical treatment of all acute type A dissections. Circulation 102(19 Suppl 3): III , Trimarchi S, Nienaber CA, Rampoldi V, et al: Contemporary results of surgery in acute type A aortic dissection: The international registry of acute aortic dissection experience. J Thorac Cardiovasc Surg 129: , Chiappini B, Schepens M, Tan E, et al: Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J 26: , Gaul C, Dietrich W, Erbguth FJ: Neurological symptoms in aortic dissection: a challenge for neurologists. Cerebrovasc Dis 26: 1 8, Yoshimuta T, Yokoyama H, Okajima T, et al: Impact of elevated D-dimer on diagnosis of acute aortic dissection with isolated neurological symptoms in ischemic stroke. Circ J 79: ,

6 J-STAGE Abstract Acute ischemic stroke caused by Stanford type A acute aortic dissection Masatoshi Koga, M.D., Ph.D., 1) Yasuyuki Iguchi, M.D., Ph.D., 2) Tomoyuki Ohara, M.D., Ph.D., 3) Yoshio Tahara, M.D., Ph.D., 4) Yousuke Inoue, M.D., 5) Tetsuya Fukuda, M.D., Ph.D., 6) Katsufumi Kajimoto, M.D., Ph.D., 7) Yuki Sakamoto, M.D., 8) Naoki Tokuda, M.D., 9) Soichiro Matsubara, M.D., 9) Naoki Makita, M.D., 9) Teruo Noguchi, M.D., Ph.D., 4) Hitoshi Matsuda, M.D., Ph.D., 5) Kenji Minatoya, M.D., Ph.D., Kazuyuki Nagatsuka, M.D., Ph.D., 7) and Kazunori Toyoda, M.D., Ph.D. 9) 1) Department of Stroke Care Unit, National Cerebral and Cardiovascular Center 2) Department of Neurology, The Jikei University School of Medicine 3) Department of Neurology, Kyoto Prefectural University of Medicine 4) Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center 5) Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center 6) Department of Radiology, National Cerebral and Cardiovascular Center 7) Department of Neurology, National Cerebral and Cardiovascular Center 8) Department of Neurological Science, Nippon Medical School 9) Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center 10) Department of Cardiovascular Surgery, Kyoto University 5, 10) Stanford type A acute aortic dissection is a disease requiring emergency surgery. Because patients with Stanford type A acute aortic dissection and ischemic stroke do not often complain chest or back pain probably due to consciousness disturbance, amnesia or aphasia, fatal course following inappropriate intravenous rt-pa therapy and delay of appropriate surgical treatment sometimes occur. When treating stroke-suspected patients, emergency services and initial urgent care doctors should always have suspicion of aortic dissection. Even in the absence of chest or back pain, the initial urgent care doctor need to immediately perform chest contrast CT examination if suspecting aortic dissection from the blood pressure laterality or the upper mediastinal widening on the X-ray. Whenever aortic dissection cannot be denied from initial clinical information, the initial urgent care doctor should evaluate the common carotid artery (CCA). Dissection extension to CCA or flow abnormality of CCA is often detected if aortic dissection is a cause of ischemic stroke or transient ischemic attack. Head CT or MRI including vascular imaging is preferable. D-dimer should be measured in the available hospitals. As soon as aortic dissection is detected, the initial urgent care doctor needs to consult with cardiovascular surgeons or cardiologists for appropriate treatment. Key words: intravenous rt-pa therapy, chest or back pain, blood pressure laterality, carotid ultrasonography, D-dimer 6

36:378 第 38 回日本脳卒中学会講演シンポジウム原著 36: , 要旨 TIA 2 t-pa Key words: stroke registry, stroke subtype, onset-visi

36:378 第 38 回日本脳卒中学会講演シンポジウム原著 36: , 要旨 TIA 2 t-pa Key words: stroke registry, stroke subtype, onset-visi 36:378 第 38 回日本脳卒中学会講演シンポジウム原著 36: 378 384, 2014 1 2 要旨 1999 2012 10 31 29 26 80 30 TIA 2 t-pa Key words: stroke registry, stroke subtype, onset-visit time, chronological change はじめに 4 12 23 27 1 Japan