背景:低体温下では低心拍出量,循環血液量の減少,多尿がみられ,著しい体液変動が予想されるが,体液量測定はほとんど行われていない。目的:軽度低体温療法下の重症頭部外傷例における体液量の推移を知ること。対象:GCS 5～8点の頭部外傷7例(男5例,女2例,平均44歳)。ブランケットを用い体表冷却により,直腸温を33.5～34.5℃まで低下させ,その体温を48時間維持したのち,24時間に1℃ずつ36.5℃まで復温した。復温後も最低2日間は,直腸温を37.5℃未満に維持した。方法:インドシアニングリーンの分布容積を循環血漿量(PV, l)とした。生体電気インピーダンス法により測定した全身抵抗値(Resis., Ω)と身長(H, cm)から求めた,H²/resis.を体水分量指標(TBWI)とした。PV/TBWI ratioを用いて,体水分に占める血管内水分の割合をみた。測定は,冷却中(C) (33.5～34.5℃),復温前期(R1) (34.5～35.5℃),復温後期(R2) (35.5～36.5℃),復温後(P) (36.5～37.5℃)の4点で行った。冷却から96時間,8時間ごとの尿量,水分バランスを測定した。結果:浸透圧利尿剤は6例に,チオペンタールは6例に用い,減圧開頭術は5例に行った。PVは,C, R1, R2の各時点でPに比して減少した。TBWIは,R2ではCよりも増加し,PではR2よりも減少した。PV/TBWI ratioは,C, R1, R2の各時点でPに比して低下した。尿量,水分バランスともに有意な変化はなかった。考察:PVの低下とTBWIの増加は血管外水分の異常増加を表し,復温完了後のPVの増加とTBWIの減少は,血管透過性の改善を反映する。結語:軽度低体温療法下の頭部外傷例では,血管内から血管外への水分の移動により血漿量が減少する。

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蘇生後脳の病態をより明らかにするため,magnetic resonance imaging (MRI,以下MRIと略す)所見を中心に,拡散強調画像(diffusion weighted image,以下DWIと略す)の有用性も含め検討した。蘇生後MRIを施行された28例を対象とし,予後良好群7例,植物状態群17例,脳死状態群4例に分け,各々の施行時期におけるMRI所見を中心にCT, SPECT所見についても検討を加えた。その結果,予後良好群のうち完全回復例では,CTおよびMRIで異常所見がみられなかった。後遺症残存例ではMRIにおいて被殻,淡蒼球,視床や後頭葉皮質に異常所見を認めた。植物状態群ではCT上,急性期では脳浮腫,慢性期では脳萎縮がみられたが,MRIでは急性期ではT2強調像で大脳皮質,被殻,淡蒼球,視床を中心として,脳室近傍,黒質,赤核において障害部位を,慢性期ではT1強調像でこれらの部位に異常所見を認めた。DWIは超急性期からの病変部位の描出がより鮮明で,高頻度に異常所見をとらえれた。また,SPECTでは急性期に比べ,慢性期では脳血流量の低下を認めた。脳死群のMRIはT2強調像で白質と灰白質の境界が明瞭で,DWIでは脳全域が高信号となっており,全例同様の所見であった。MRIは病変部の検出能においてはCTに比べ優れ,より詳細な形態学的な情報と,急性期でのT2強調像の高信号は浮腫を,慢性期でのT1強調像の高信号は出血や鉄の沈着を示すなどの,信号パターンの変化による情報を得られた。とくに,DWIではT2強調像で視覚化される以前の状態をとらえられ,早期より障害部位の描出が可能であり,MRIおよび各種画像所見を総合的に判断することによって,蘇生後脳の病態をより明らかにできた。

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Injuries of the vertebral artery due to severe craniocervical trauma have become relatively common but often go unrecognized initial trauma evaluation and are diagnosed after symptoms. We treated a patient with anterior C3 dislocation whose left vertebral artery dissection was diagnosed in 3-dimensional computed tomography (3D CT) angiography and color-coded Doppler sonography before any sign of cerebral dysfunction or ischemia. It is important to diagnose vertebral artery dissection early in patients with severe craniocervical trauma to initiate treatment and prevent serious complication. 3D CT angiography and color-coded Doppler sonography are comparatively noninvasive and very useful in diagnosing vertebral artery dissection in patients with craniofacial trauma.

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A middle-aged man was found unconscious at apartment after ingesting gamma hydroxybutyric acid (GHB) purchased via the internet sales and was admitted to our critical care center. He underwent gastric irrigation and respiratory assistance with intubation at the emergency room due to a probable drug overdose and respiratory acidosis. After fully recovering, he admitted he had taken large doses of GHB with alcohol. The US Federal Drug Administration (FDA) banned GHB sale as an OTC drug in 1991 but has not succeeded in controlling increased GHB addiction. Unconsciousness, coma, hypothermia, bradycardia, hypotention, muscle weakness, myoclonus, convulsion, respiratory distress, and vomiting are common symptoms after GHB ingestion. Treatment such as gastric irrigation, atropine for bradycardia, and respiratory assistance in hypoxia are recommended. Little attention is paid to GHB in Japan because of its rarity and its sale is not illegal, unlike the strict restrictions in the US and European countries. With GHB available over the Internet, its abuse is expected to increase.

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Descending necrotizing mediastinitis (DNM) is a rare but serious disease requiring emergency treatment that starts as trivial inflammation of the neck, spreads the deep neck, then spreads to the mediastinum. We demonstrate the usefulness of ultrasonography (US) in detecting the progression of this disease from deep cervical phlegmon to DNM. We combined US with a combex probe (3.5MHz) useds in the chest and abdomonal fields at the level of the thyroid gland or below the thyroid gland based on the method for observing thyroid disease. In the cross section, we detected low echoic space (LES) around the thyroid gland and around neck vessels. In the peeping section from the sternal notch into the upper mediastinum, we detected LES around the neck vessels spreading into the mediastinum, gaining much information about deep cervical inflammation spreading into the mediastinum. We could not distinguish the capsule around LES. In deep neck phlegmon, we must examine the chest and neck by X-ray and by computed tomography scan and repeated neck US to observe changes in inflammation.

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We present a case of pulmonary thromboembolism developing immediately after a long airplane flight -- socalled economy class syndrome. A 72-year-old woman was admitted with sudden dyspnea and disturbance of consciousness that developed soon after an airplane flight from Paris to Kansai airport (about 10 hours flight). On admission, the patient was apneaic and pulseless, requiring endotracheal intubation and mechanical ventilation. We suspected pulmonary thromboembolism and conducted pulmonary perfusion scintigraphy. A perfusion defect was seen in the right upper lung field, indicating pulmonary thromboembolization. Phlebography of the legs showed multiple defects in bilatral popliteal, femoral, and external iliac veins. The patient was treated with heparin and warfarin. To prevent the recurrence of pulmonary thromboembolism, a vena cava filter was placed in the inferior vena cava. Most thrombi of the legs disappeared in a few days. Deep venous thrombosis and pulmonary thromboembolism appear to have been caused by prolonged sitting and dehydration during flight. It is important that we include pulmonary thromboembolism in the differential diagnosis of patients with sudden dyspnea developing immediately after a long airplane flight.

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