びまん性軸索損傷(diffuse axonal injury; DAI)はCT所見に乏しい割に,転帰不良の症例が存在する。急性期の脳血流量(cerebral blood flow; CBF)測定とMRI (magnetic resonance imaging)撮像を積極的に行い,その所見によりDAIの予後を予測し得るか検討した。対象は来院時指示動作に応じず,CT上頭蓋内占拠性病変を有しない症例のうち意識障害が24時間以上遷延した症例とした。CT所見は外傷性クモ膜下出血,実質内小出血,脳室内出血,異常所見なしなどの症例が含まれた。それらは1995年7月から1999年12月までの期間に当院に入院したDAI症例のうち急性期にCBF測定およびMRIを施行し,転帰を確認し得た21例で,内訳は男性15例,女性6例。年齢は17歳から86歳,平均37.5歳。来院時Glasgow Coma Scale (GCS)は3から12,平均6.7。CBFはXe(キセノン)CTにて測定し大脳半球平均値を算出し,MRIはT1, T2 axial像とT2 sagittal像を撮像した。いずれも受傷7日以内に施行した。受傷6か月後のGlasgow Outcome Scaleがgood recovery(症例数10,以下同じ)とmoderate disability (4)の転帰良好群(14)とsevere disability (4), vegetative state (2), death (1)の転帰不良群(7)に分け,それぞれの年齢,来院時GCS, CBF値,MR所見を比較した。年齢は転帰良好群の平均が31.4歳,転帰不良群の平均が50.0歳で,転帰良好群で有意に低かった。来院時のGCSは,両群間で有意差はなかった。転帰良好群のCBF平均値は43.2ml/100g/min,転帰不良群では33.6ml/100g/minと,転帰良好群で高かったが統計学的有意差はなかった。MRI上の脳梁と深部白質病変の有無は転帰とまったく相関せず,一方視床と脳幹部病変は転帰不良との相関が高く,とくに脳幹病変の有無と転帰との間には統計学的有意差がみられた。DAIの転帰に影響する因子は年齢とMRI上の脳幹部病変の存在であった。脳血流量と転帰との間には統計学的な有意差は認められなかった。高齢者やMRI上脳幹部病変を有する症例では日常生活自立が難しいといえる。

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A 56-year-old woman hospitalized for severe upper abdominal pain and nausea 1 hour after eating dinner was found in abdominal ultrasonography (US) to have abnormal fluid collection. Enhanced abdominal computed tomography (CT) showed an irregular stain around the pancreatic head, suggesting retroperitoneal bleeding in that area. Emergency angiography suggested an aneurysma of the variational artery on the pancreaticoduodenal arcade, but we could not find the obvious bleeding point because of no extravasation was obvious. Emergency surgery was conducted with a diagnosis of retroperitoneal hemorrhage because the patient developed circulatory shock. During surgery, only venous bleeding was identified on the anterior side of the pancreatic head and on the retroperitoneum. A second emergency laparotomy was conducted 14 hours later after the first laparotomy because the patient suddenly developed hemorrhagic shock. During the second laparotomy, arterial bleeding on the posterior side of the pancreatic head and in the hepatoduodenal ligament was observed. The intraperitoneal hematoma was evacuated and the bleeding point ligated. This bleeding point differed from the previous one. No aneurysm was found in resected material, but imaging and operative findings showed the rupture of a variational blood vessel.

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Plasma exchange (PE) is considered to be essential for the treatment of fulminant hepatic failure. However, small or middle-sized abnormal molecular weight substances are suspected to be a cause of hepatic encephalopathy. We report three patients with fulminant hepatic failure who were treated without PE and discuss the role of PE in the treatment of fulminant hepatic failure. We performed continuous hemofiltration (CHF) in these three patients, using large quantities of filtration and fresh frozen plasma (FFP) transfusion. PE was not performed in any of these cases. All patients were conscious after the completion of their treatments. CHF is useful for treating encephalopathy caused by fulminant hepatic failure and may be an effective means of replacing the liver's normal antidotal functions. The method can be used to remove small and middlesize molecular weight substances that are suspected of being hepatic toxins. FFP transfusion is a viable alternative to the normal liver's synthetic functions. The outcome of the three patients presented here suggests that PE may not be needed for the treatment of fulminant hepatic failure. Instead, CHF and FFP transfusion may be critical for the treatment of fulminant hepatic failure.

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