37:417 症例報告 37: , 要旨 78 MRA Key words: carotid stenting, ischemic intolerance, balloon protection はじめに 症 例 CAS no/slow
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1 37:417 症例報告 37: , 要旨 78 MRA Key words: carotid stenting, ischemic intolerance, balloon protection はじめに 症 例 CAS no/slow flow 1 concentric CAS doi: /jstroke /5 165 cm 65 kg 170/66 mmhg 61 / CT MRI MRA Fig. 1 Fig. 1 MRA A to A embolism
2 37:418 脳卒中 A C B D Fig. 1 A FLAIR B MRA C MRA D MRI T1 T2 TOF lipid rich necrotic core Fig. 2 PET CBF CBF DIAMOX OEF NASCET 70 cross flow MRA fetal type P1 C3 Fig. 3A CEA CEA CAS 2 CAS PS Medtronic, Santa Rosa, CA, USA 6F PS mm 24 mm Carotid Wall Boston Scientific Natick, MA, USA Fig. 3B 8 50 JCS10 Fig. 3C CT 3 JCS3 6 7
3 一時血流遮断による虚血症状が遷延した頸部内頸動脈狭窄症 B A C D Fig. 2 頸部 T1-plaque image 矢状断 A T1-plaque 軸位断 B T2-plaque 軸位断 C ともに プラーク は高信号を呈する TOF 軸位断 D では等信号を呈し lipid rich necrotic core を有するプラーク 内出血を伴う脆弱性プラークが示唆される Fig. 3 治療前左頸部内頸動脈撮影側面像 A 治療後左頸部内頸動脈撮影側面像 B 治療後頭蓋内撮影 側面像 C 狭窄部は充分な拡張が得られており 脳動脈に明らかな末梢塞栓を認めない が出にくい程度 その後も軽度の運動性失語が続いてい たが 治療約 20 時間後に行った拡散強調画像では 左 考 A B C 察 前頭葉白質に 1 カ所のわずかな小さい高信号を認めるの 本症例では プラークイメージや頸動脈エコーを参考 みであった Fig. 4 約 48 時間後には失語を含め 完全 に脆弱なプラークと判断し バルーンプロテクションを 回復した 以後新たな神経学的脱落症状の出現はなく 選択した 高度狭窄ではなく ガードワイヤーの病変通 独歩で退院した 過時に生じるデブリス飛散の可能性は低いと判断し 近
4 37:420 脳卒中 Fig MRI CAS MES 8 MES , 9 11 Willis 12 2 Willis MRA A1 P1 3, 9, , CAS
5 37:421 PET , 17 CAS CAS COI COI 参考文献 1 :MRI distal protection device JNET 3: 3 9, du Mesnil de Rochemont R, Schneider S, Yan B, et al: Diffusion-weighted MR imaging lesions after filter-protected stenting of high-grade symptomatic carotid artery stenoses. AJNR Am J Neuroradiol 27: , Henry M, Henry I, Klonaris C, et al: Benefits of cerebral protection during carotid stenting with the PercuSurge GuardWire system: midterm results. J Endovasc Ther 9: 1 13, Ohki T, Roubin GS, Veith FJ, et al: Efficacy of a filter device in the prevention of embolic events during carotid angioplasty and stenting: An ex vivo analysis. J Vasc Surg 30: , Timaran CH, Rosero EB, Martinez AE, et al: Atherosclerotic plaque composition assessed by virtual histology intravascular ultrasound and cerebral embolization after carotid stenting. J Vasc Surg 52: , Maleux G, Demaerel P, Verbeken E, et al: Cerebral ischemia after filter-protected carotid artery stenting is common and cannot be predicted by the presence of substantial amount of debris captured by the filter device. AJNR Am J Neuroradiol 27: , Angioguard XP PercuSurge GuardWire JNET 3: 79 85, ) Rubartelli P, Brusa G, Arrigo A, et al: Transcranial Doppler monitoring during stenting of the carotid bifurcation: evaluation of two different distal protection devices in preventing embolization. J Endovasc Ther 13: , Vitek JJ, Al-Mubarak N, Iyer SS, et al: Carotid artery stent placement with distal balloon protection: technical considerations. AJNR Am J Neuroradiol 26: , Chaer RA, Trocciola S, DeRubertis B, et al: Cerebral ischemia associated with PercuSurge balloon occlusion balloon during carotid stenting: Incidence and possible mechanisms. J Vasc Surg 43: ; discussion 952, Double balloon protection intolerance 41: , Lee JH, Choi CG, Kim DK, et al: Relationship between circle of Willis morphology on 3D time-of-flight MR angiograms and transient ischemia during vascular clamping of the internal carotid artery during carotid endarterectomy. AJNR Am J Neuroradiol 25: , Montisci R, Sanfilippo R, Bura R, et al: Status of the circle of Willis and intolerance to carotid cross-clamping during carotid endarterectomy. Eur J Vasc Endovasc Surg 45: , Wei H, Inan S: Dual effects of neuroprotection and neurotoxicity by general anesthetics: role of intracellular calcium homeostasis. Prog Neuropsychopharmacol Biol Psychiatry 47: , Backhaus R, Boy S, Fuchs K, et al: Hyperperfusion syndrome after MCA embolectomy a rare complication? Am J Case Rep 14: , Chung JM: Seizures in the acute stroke setting. Neurol Res 36: , Alberti A, Paciaroni M, Caso V, et al: Early seizures in patients with acute stroke: frequency, predictive factors, and effect on clinical outcome. Vasc Health Risk Manag 4: , 2008
6 37:422 脳卒中 Abstract A case of carotid stenting with prolonged ischemic symptoms by transient distal balloon protection Suguru Yamaguchi, M.D., Ph.D., 1) and Katsuhiro Nishino, M.D., Ph.D. 1) 1) Department of Neurosurgery, Kakunodate Municipal Hospital A 78-year-old man was admitted to our hospital because of right hand weakness due to small cortical infarction at left precentral gyrus. Neck MR angiography revealed left neck internal carotid artery stenosis. The stenotic part was fragile plaque with intra-plaque hemorrhages. We performed carotid artery stenting (CAS) approximately 2 months after the onset. Because fragile plaque was suggested, we chose the distal protection using the Carotid Guard- Wire PS (Medtronic, Santa Rosa, CA, USA), not a filter. Immediately after the distal balloon was inflated on trial, the patient presented right side hemiparesis, aphasia, and consciousness disturbance. Carotid Wall stent (Boston Scientific Natick, MA, USA) was placed in a rapid manner under sedation. Total occlusion time was 8 minutes 50 seconds. After the distal balloon became deflated, his symptoms did not disappear regardless of any distal embolisms in the final angiography. Three hours later, his right hemiparesis was recovered almost fully, but his aphasia continued. At last, his neurological deficits disappeared completely after 2 days. The CAS procedure using balloon protection has problems about the ischemic intolerance. Commonly, the symptoms of intolerance are improved rapidly after restore patency of blood flow. In this case, ischemic symptoms prolonged for 2 days in spite of cerebral infarction not being seen. It was thought that the ischemic intolerance purely caused this symptom. Key words: carotid stenting, ischemic intolerance, balloon protection (Jpn J Stroke 37: , 2015)
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2005 IVR 1 Carotid endarterectomy CEA Carotid stenting CAS CEA CEA Percusurge Guardwire distal protection CAS CAS CEA CEA CAS CAS CEA 50 70 60 80 1 2 70 CAS variation type B variation 1 0.1 debris dangerous
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19 83 7 18 628 1 19 8 3 7 18 6 28 30 MI 31 360 21700BZY00247000 5mm CEA 59 mm 2 50% 80 1. 2. 3 19 8 3 [ ] 7 [ ] [ ] [ ] [ ] 18 6 28 [ ] CEA 49mm 50 80 2 4 carotid endarterectomy CEA 1,2 CEA ECST 3 NASCET
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