㈸−5

一次性雷鳴頭痛はどのように診断し治療するか

 

1) Linn FH, Rinkel GJ, Algra A, van Gijn J. Follow-up of idiopathic
  thunderclap headache in general practice. J Neurol. 1999
  Oct;246(10):946-8.
論文抄録
Follow-up studies of idiopathic thunderclap headache (ITH) have found no subsequent subarachnoid hemorrhage (SAH) or other serious neurological disease, but the effect on life-style has not been studied. To assess the long-term outcome of patients with ITH in general practice we prospectively followed 93 patients with an episode of ITH during 1988-1993, of whom 77 were referred to hospital. ITH was defined as a sudden, unusually severe headache that started within 1 min, lasted at least 1 h, and for which no underlying cause was found. These patients were treated in 252 general practices. Outcome measures were subsequent SAH, subsequent headaches, absence from work, and diminished daily functioning. Patients were followed up by their general practitioner for a median of 5 years (range 1-10). Three patients died, all from non-neurological diseases. No subsequent SAH was diagnosed in any of the 93 patients. Recurrent attacks of ITH occurred in 8 patients, and 13 developed new tension headache or migraine. Absence from work because of headache was recorded in 11 patients, and in the overall group 6 patients were dependent on welfare. In only one-half of patients (n=52) did the general practitioner judge the level of daily functioning to be similar to that before the index episode of ITH. Thus, although no episodes of SAH occurred after ITH during long-term follow-up, one-half of patients with ITH had a lower level of daily functioning, and one-eighth had reduced working capacity, specifically because of headache.
文献 PubMed−ID

PMID: 10552244

エビデンスレベル

IV

文献タイトル (日本語)

一般的診察における特発性雷鳴頭痛の追跡

目的
一般診療における雷鳴頭痛を伴った患者を長期追跡し,更に評価する事.
研究デザイン
追跡研究
研究施設
オランダの University Department of Neurology, Heidelberglaan
研究期間
1988 年から 1993 年
対象患者
開業医から紹介された患者で,激しい頭痛が 1 分以内に発症し,少なくとも 1 時間持続した患者 93 名.
介入
CT にてくも膜下出血,器質性頭蓋内病変を認めたものは除外した.
主要評価項目とそれに用いた
統計学的手法

追跡期間中のくも膜下出血,雷鳴頭痛の再発,緊張性頭痛あるいは片頭痛に引き続いて起こった雷鳴頭痛,雷鳴頭痛再発にあたり専門医への相談,欠勤の有無,また経過中快適な生活が送れたか,雷鳴頭痛発症前の状態に戻ったか否かを評価した.
結果

経過中,くも膜下出血をきたしたものは無かった.雷鳴頭痛の再発は91人中8人に認められた( 2 名脱落).,緊張性頭痛あるいは片頭痛に引き続いて起こった雷鳴頭痛は,89人中13人に認められた( 4 名脱落).雷鳴頭痛再発にあたり他専門医への相談は,89人中16人に認められた(神経科医,精神科医,耳鼻科医,その他).雷鳴頭痛による欠勤は,71人中11人に認められた.経過中に快適な生活を送ることが出来たのは,90人中6人であった.雷鳴頭痛発症前の状態に戻れたのは,85人中52人であった.

結論
雷鳴頭痛は緊張性頭痛あるいは片頭痛を患っている人に引き続いて発症することが多い.雷鳴頭痛は,発症後に労務遂行や社会生活にまで支障を来す.
コメント
雷鳴頭痛患者を長期にわたりフォローアップし,雷鳴頭痛が日常生活,社会生活にまで影響を及ぼすと報告しており,重要な研究である.
作成者
久保慶高

 

2) Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC,
  Sternau LL, Torner J, Adams HP Jr, Feinberg W, et al. Guidelines for
  the management of aneurysmal subarachnoid hemorrhage. A statement
  for healthcare professionals from a special writing group of the Stroke
  Council, American Heart Association. Stroke. 1994 Nov;25(11):2315-28.

文献 PubMed ID

PMID: 7974568

エビデンスレベル

I

文献タイトル ( 日本語 )

脳動脈瘤破裂によるくも膜下出血ガイドライン

目的

脳動脈瘤破裂によるくも膜下出血診療の円滑化と成績向上

研究デザイン

系統レビュー,診療ガイドライン

研究施設

米国の American Heart Association

結論

初発症状:突然の頭痛で,意識消失・嘔吐・神経脱落症状,頚部の張りなどを随伴することがある.診断: CT でのくも膜下出血の24時間以内の検出率は92%である. CT でくも膜下出血が否定されても,臨床的にくも膜下出血が疑われば,腰椎穿刺を行うべきである.

作成者

久保慶高

 

3) Mayer PL, Awad IA, Todor R, Harbaugh K, Varnavas G, Lansen TA,
  Dickey P, Harbaugh R, Hopkins LN. Misdiagnosis of symptomatic
  cerebral aneurysm. Prevalence and correlation with outcome at four
  institutions. Stroke. 1996 Sep;27(9):1558-63.

論文抄録

BACKGROUND AND PURPOSE: It is not known what fraction of patients with symptomatic cerebral aneurysms are misdiagnosed at initial medical presentation. It is also not clear whether misdiagnosed patients more frequently deteriorate before definitive aneurysm diagnosis and therapy or achieve a poorer outcome than correctly diagnosed patients. METHODS: We reviewed records of consecutive patients with symptomatic cerebral aneurysms managed by four tertiary-care neurosurgical services during a recent 19-month period. Clinical course and outcome were analyzed according to misdiagnosis or correct diagnosis at initial medical evaluation. RESULTS: Fifty-four of 217 patients (25%) were misdiagnosed at initial medical evaluation, including 46 of 121 patients (38%) initially in good clinical condition (clinical grade 1 or 2). Forty-six of 54 patients (85%) in the misdiagnosis group were initially grade 1 or 2 compared with 75 of 163 patients (46%) with correct initial diagnosis (P < .01). Twenty-six of 54 misdiagnosed patients (48%) deteriorated or rebled before definitive aneurysm treatment compared with 4 of 165 correctly diagnosed patients (2%) (P < .001). Among patients initially presenting as clinical grade 1 or 2, overall good or excellent outcome was achieved in 91% of those with correct initial diagnosis and 53% of patients with initial misdiagnosis (P < .001). Deterioration before correct diagnosis accounted for 16 of 67 patients (24%) with poor or worse final outcome in this series. CONCLUSIONS: Patients in good clinical condition with symptomatic cerebral aneurysms were commonly misdiagnosed. Misdiagnosed patients were more likely than correctly diagnosed patients to deteriorate clinically and had a worse overall outcome. Misdiagnosed cases accounted for a significant fraction of overall poor outcomes among consecutive cases of symptomatic aneurysms.

文献 PubMed ID

PMID: 8784130

エビデンスレベル

IV

文献タイトル ( 日本語 )

症候性脳動脈瘤の誤診 4施設における予後との関連

目的

症候性脳動脈瘤患者の初診時において正診と誤診で,予後がどのように違うか検討した

研究デザイン

独立した適切な患者スペクトラムについての客観的な比較

研究施設

米国の Yale University School of Medicine ,他3施設

研究期間

19ヶ月間の retrospective study

対象患者

症候性脳動脈瘤患者217人

介入

初診時誤診例54人,初診時正診例163人

主要評価項目とそれに用いた統計学的手法

誤診グループと正診グループにおいて, Hunt and Hess grade ,性別,年齢,症候性の原因 ( 出血,圧迫症状,けいれん ) ,頭痛の特徴,誤診時の診断名,再出血率,予後をそれぞれ調べた.

結果

217人中54人(25%)が誤診されていた.誤診グループの初診時の症状は頭痛が93% ( 髄膜刺激症状を伴う突然の頭痛:57%,突然の頭痛のみ:17%,片側または眼窩の奥の痛み:11% ) ,視機能異常:13%,けいれん:7%,意識の変化:7%であった.誤診時の診断名は髄膜炎(15%),片頭痛(13%),病因不明の頭痛(13%),脳梗塞(9%),高血圧性頭痛(7%),緊張性頭痛(7%)などであった. CT でくも膜下出血を認めたのは誤診グループ:74%,正診グループ:93%で両群間に有意差を認めた.誤診グループが最初に受診した医療機関は内科:43%,救急病院:41%,神経内科:19%が多かった.誤診例54人中46人(85%)は初診時の臨床的グレードが良かった.誤診グループのうち26人(48%)が正診までに再出血または神経学的症状の増悪を認め,正診グループが治療開始まで163人中4人(2%)の再出血を認めたのに比較して有意に高かった(P < 0.001).予後不良な患者67人のうち,誤診例は23人中16人(70%),正診例は44人中2人(5%)であり,両群に有意差を認めた.

結論

症候性脳動脈瘤(出血,圧迫症状,けいれん)を最初に誤診すると再出血をきたし,予後不良になる.このような患者は頭痛を主訴に来院することが圧倒的に多く,「突然の」,「髄膜刺激症状を伴う」,「片側または眼窩の奥の痛み」を有する場合は気を付けなければならない.また, CT で異常がないこともあるので,くも膜下出血を疑ったのであれば,腰椎穿刺や MRI 撮像を行い総合的に診断しなければならない.

作成者

久保慶高

 

4) Linn FH, Rinkel GJ, Algra A, van Gijn J. Headache characteristics in
  subarachnoid haemorrhage and benign thunderclap headache. J Neurol
  Neurosurg Psychiatry. 1998 Nov;65(5):791-3.

論文抄録

One third of patients with aneurysmal subarachnoid haemorrhage (ASAH) present with headache only. A prompt diagnosis is crucial, but these patients must be distinguished from patients with non-haemorrhagic benign thunderclap headache (BTH). The headache characteristics and associated features at onset in subarachnoid haemorrhage and benign thunderclap headache were studied to delineate the range of early features in these conditions. In this prospective study, one of two observers interviewed 102 patients with acute severe headache by means of a standard questionnaire. The patients were alert on admission and had no focal deficits. ASAH was subsequently diagnosed in 42 patients, non-aneurysmal perimesencephalic haemorrhage (PMH) in 23 patients, and BTH in 37 patients. Headache developed almost instantaneously in 50% of patients with ASAH, 35% of patients with PMH, and 68% of patients with BTH and within 1 to 5 minutes in 19%, 35%, and 19%, respectively. Loss of consciousness was reported in 26% of patients with ASAH, 4% of patients with PMH and 16% of patients with BTH, and transient focal symptoms in 33%, 9%, and 22% respectively. Seizures and double vision had occurred only in ASAH. Vomiting and physical exertion preceding the onset of headache were more frequent in patients with ASAH (69% and 50%) and those with PMH (83% and 39%) than in those with BTH (43% and 22%). Headache developed almost instantaneously in only half the patients with aneurysmal rupture and in two thirds of patients with benign thunderclap headache. In patients with acute severe headache, female sex, the presence of seizures, a history of loss of consciousness or focal symptoms, vomiting, or exertion increases the probability of ASAH, but these characteristics are of limited value in distinguishing ASAH from BTH. Aneurysmal rupture should be considered even if focal signs are absent and the headache starts within minutes.

文献 PubMed ID

PMID: 9810961

エビデンスレベル

IV

文献タイトル ( 日本語 )

くも膜下出血と良性雷鳴頭痛の頭痛の特徴

目的

脳動脈瘤破裂患者,中脳周囲限局型くも膜下出血患者,良性雷鳴頭痛 患者における頭痛の特徴を調べる

研究デザイン

適切な患者スペクトラムについての客観的な比較

研究施設

オランダの Utrecht University Hospital

研究期間

1992 年 1 月から 1994 年 10 月

対象患者

脳動脈瘤破裂によるくも膜下出血を暗示させるような突然の頭痛を呈し,救急外来を受診した102人

介入

全員に CT を行い,その所見でくも膜下出血を認めない場合は腰椎穿刺を行った

主要評価項目とそれに用いた統計学的手法

脳動脈瘤破裂,中脳周囲限局型くも膜下出血,良性雷鳴頭痛患者( CT scan ,腰椎穿刺でくも膜下出血が否定)において,頭痛の性状,程度,発症形式,持続時間,以前の頭痛の既往,随伴症状などを調べた

結果

102人中,脳動脈瘤破裂患者が42人(41%),予後良好といわれる中脳周囲限局型くも膜下出血患者が23人(23%),良性雷鳴頭痛患者が37人(36%)認めた.良性雷鳴頭痛患者に比べて,脳動脈瘤破裂によるくも膜下出血患者は女性 (relative risk [RR]=1.6) ,重労働 / 力み時の発症 (RR=2.3) ,嘔吐 (RR=1.6) ,意識消失 (RR=1.6) ,神経脱落症状 (RR=1.5) が多かった.てんかん発作と複視は脳動脈瘤破裂によるくも膜下出血患者でのみ認められた.

結論

雷鳴頭痛患者が受診した際,女性,てんかん発作,意識消失の既往,神経脱落症状,嘔吐,重労働 / 力み時の発症なら脳動脈瘤破裂によるくも膜下出血を鑑別しなければならない. CT または腰椎穿刺が必要である.

コメント -1

予後良好といわれる中脳周囲限局型くも膜下出血患者の割合が多すぎる.

コメント -2

MRI の FLAIR 画像も有用である

作成者

久保慶高

 

5) Wijdicks EF, Kerkhoff H, van Gijn J. Long-term follow-up of 71 patients
  with thunderclap headache mimicking subarachnoid haemorrhage.
  Lancet. 1988 Jul 9;2(8602):68-70.

論文抄録

Seventy-one patients with sudden, severe, and unusual headache, but with normal computerised tomographic scan and cerebrospinal fluid, were followed for an average of 3.3 years. Twelve patients (17%) had identical recurrences, but again without evidence of subarachnoid haemorrhage. Findings on cerebral angiography, performed in four patients after the first attack and in two patients after recurrent episodes, were normal. Thirty-one (44%) of the seventy-one patients subsequently had regular episodes of tension headache or common migraine. If the computerised tomographic scan and cerebrospinal fluid findings are normal, this type of headache can be regarded as a benign symptom, and cerebral angiography is not indicated.

文献 PubMed ID

PMID: 2898698

エビデンスレベル

III

文献タイトル ( 日本語 )

くも膜下出血に似た雷鳴頭痛71症例の長期的観察

目的

CT や脳脊髄液検査の所見が正常である雷鳴頭痛の患者に,脳血管撮影が必要かどうかを明らかにする

研究デザイン

Prospective study

研究施設

オランダの University Hospitals in Rotterdam, Utrecht

研究期間

1980 年から 1986 年

対象患者

雷鳴頭痛患者71人

介入

当初89人いたが長期追跡中に18人を様々な理由から除外した.71人を平均3.3年(1?7年)追跡調査した.

主要評価項目とそれに用いた統計学的手法

雷鳴頭痛患者の臨床症状,長期的な予後を調査した

結果

雷鳴頭痛患者71人の臨床症状の特徴として前兆を有したのが10%,頭痛発作時の状況は安静・軽作業中の発症が72%,高血圧の既往が16%,片頭痛・緊張性頭痛の既往が31%,頭痛の持続期間として8?24時間が34%,随伴症状は嘔吐(38%),首の張り(14%)であった.平均3.3年(1?7年)追跡調査中にくも膜下出血をきたした患者は認めなかった.また,追跡調査中,31人(44%)で片頭痛または緊張性頭痛を認めた.

結論

CT ,脳脊髄液が正常な雷鳴頭痛患者には必ずしも脳血管撮影は必要としない.

コメント

現在は非侵襲的かつ有用な MRA や CTA があるので,脳血管病変の検索は必要と考える.

作成者

久保慶高

 

6) Raps EC, Rogers JD, Galetta SL, Solomon RA, Lennihan L, Klebanoff
  LM, Fink ME. The clinical spectrum of unruptured intracranial
  aneurysms. The clinical spectrum of unruptured intracranial aneurysms.

論文抄録

OBJECTIVE--A retrospective study was performed to delineate the clinical characteristics of symptomatic unruptured aneurysms. DESIGN--Patient histories, operative reports, and angiograms in 111 patients with 132 unruptured aneurysms were reviewed. SETTING--Tertiary care university hospital. PATIENTS--One hundred eleven patients with 132 unruptured intracranial aneurysms were studied. There were 85 women and 26 men, with a mean age of 51.2 years (age range, 11 to 77 years). Many patients were referred by community neurologists and neurosurgeons for further evaluation and neurosurgical management. RESULTS--Fifty-four symptomatic patients were identified. Group 1 (n = 19; mean aneurysm diameter, 2.1 cm) had acute symptoms: ischemia (n = 7), headache (n = 7), seizure (n = 3), and cranial neuropathy (n = 2). Group 2 (n = 35; mean aneurysm diameter, 2.2 cm) had chronic symptoms attributed to mass effect: headache (n = 18), visual loss (n = 10), pyramidal tract dysfunction (n = 4), and facial pain (n = 3). Group 3 (n = 57; mean aneurysm diameter, 1.1 cm) had asymptomatic aneurysms. CONCLUSIONS--Acute severe headache, comparable to subarachnoid hemorrhage headache, but without nuchal rigidity, was associated with the following mechanisms: aneurysm thrombosis, localized meningeal inflammation, and unexplained. Unruptured aneurysms may be misdiagnosed as optic neuritis or migraine, or serve as a nidus for cerebral thromboembolic events. Internal carotid artery and posterior circulation aneurysms were more likely to cause focal symptoms from mass effect than were anterior cerebral artery and middle cerebral artery aneurysms. Weeks to years may elapse before their diagnosis. The absence of subarachnoid blood does not exclude an aneurysm as a cause for acute or chronic neurologic symptoms.

文献 PubMed ID

PMID: 8442705

エビデンスレベル

IV

文献タイトル ( 日本語 )

未破裂脳動脈瘤の臨床的特徴

目的

未破裂脳動脈瘤の臨床症状を調べる

研究デザイン

Retrospective study

研究施設

米国の Columbia University

研究期間

1986 年 11 月から 1990 年 11 月

対象患者

未破裂脳動脈瘤(132個)を有する111人

介入

Group 1 (急性に脳虚血症状,てんかん発作,脳神経麻痺を認めた群), Group 2 (脳動脈瘤の圧迫により慢性の頭痛,視機能障害,錐体路障害,顔面痛を認めた群), Group 3 (無症状の群)

主要評価項目とそれに用いた統計学的手法

Group 1, 2, 3 間で脳動脈瘤の部位,臨床症状を解析した.
Student's t test

結果

132個の動脈瘤のうち, Group 1 は19個(14%)で平均サイズ21 mm , Group 2 は35個(27%)で平均サイズ22 mm , Group 3 は78個(59%)で平均サイズ11 mm であった. Group 1 の急性症状の内訳は脳虚血症状(37%),頭痛(37%),てんかん発作(16%),脳神経麻痺(10%), Group 2 の慢性症状の内訳は頭痛(51%),視機能異常(29%),錐体路症状(11%),顔面痛(9%)であった.頭痛の性状は Group 1 が雷鳴頭痛(100%), Group 2 が眼窩の奥または眼窩周囲を含めた片側の慢性頭痛(44%),両側またはびまん性の慢性頭痛(56%)であった.

結論

未破裂脳動脈瘤は血栓化,局所的な髄膜刺激などで雷鳴頭痛をきたすことがある.特に内頚動脈瘤や脳底動脈瘤は動眼神経麻痺などの視機能異常を合併していることがある.視機能異常を合併した雷鳴頭痛の鑑別として, CT や脳脊髄液所見が正常であれば,未破裂脳動脈瘤を鑑別しなければならない.

作成者

久保慶高

 

7) Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute
  cerebrovascular disease. Neurology. 1986 Nov;36(11):1445-50.

論文抄録

Headache features were compared in 51 patients with acute subarachnoid hemorrhage (SAH), 61 with intraparenchymal hemorrhage (IPH), and 160 with ischemic stroke (IS). SAH patients had more sentinel headaches, more onset headaches, and more bilateral and severe onset headaches than patients with IPH or IS. Vomiting with onset headache was more common in SAH and IPH. In stepwise logistic regression analysis, onset headache and vomiting were direct predictors of SAH, but were inversely related to IS. Sentinel headache was not a predictor of underlying stroke mechanism. The data suggest that some headache features are more frequently associated with particular stroke subtypes and that onset headache and vomiting may be important indicators of stroke mechanism.

文献 PubMed ID

PMID: 3762963

エビデンスレベル

IV

文献タイトル ( 日本語 )

急性期脳血管障害における頭痛

目的

くも膜下出血,脳内出血,脳梗塞患者における頭痛の部位,程度を調べる.また,脳卒中発症前の頭痛,発症時の頭痛,嘔吐を伴う頻度も調べる.

研究デザイン

適切な患者スペクトラムについての客観的な比較

研究施設

米国の Michael Reese Hospital, University of Illinois Hospital

研究期間

記載なし

対象患者

くも膜下腫血患者51人,脳内出血患者58人,脳梗塞患者160人(脳塞栓:58人,脳主幹動脈閉塞:52人,ラクナ梗塞:50人)

介入

Sentinel headache: 脳卒中発症前の頭痛, Onset headache: 脳卒中発症時の頭痛と定義した. TIA ,椎骨脳底動脈系脳梗塞,脳動静脈奇形,動脈硬化が原因でない脳卒中,抗凝固薬内服中の脳内出血,リウマチ熱・感染性などの心内膜炎が起因の脳塞栓は除外した.

主要評価項目とそれに用いた統計学的手法

くも膜下出血,脳内出血,脳梗塞で Sentinel headache , Onset headache ,随伴する嘔吐の頻度を調べた.

結果

くも膜下出血における Sentinel headache は31%, Onset headache は100%,随伴する嘔吐は58%であった.脳内出血における Sentinel headache は14%, Onset headache は55%,随伴する嘔吐は52%であった.脳梗塞における Sentinel headache は10%, Onset headache は17%,随伴する嘔吐は7%であった. Onset headache の頻度を分類別に見ると主幹動脈閉塞が26%で最も多く,脳塞栓14%,ラクナ梗塞6%の順であった.

結論

出血型脳卒中の方が,虚血型脳卒中より発症時における突然の頭痛の頻度が高い.

作成者

久保慶高

 

8) Silbert PL , Mokri B, Schievink WI . Headache and neck pain in
  spontaneous internal carotid and vertebral artery dissections. Neurology
  1995; 45:1517-1522

論文抄録

We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.

文献 PubMed ID

PMID: 7644051

エビデンスレベル

IV

文献タイトル ( 日本語 )

内頚動脈・椎骨動脈解離における頭痛・頚部痛

目的

内頚動脈解離と椎骨動脈解離の頭痛の程度,部位,種類ならびに頭痛に随伴する症状を調べる.

研究デザイン

追跡研究

研究施設

米国の Mayo Clinic (Neurology and Neurosurgery)

研究期間

1970 年から 1990 年

対象患者

内頚動脈解離患者135人と椎骨動脈解離26人

介入

診断はすべて脳血管撮影で行った.

主要評価項目とそれに用いた統計学的手法

医療記録を元に内頚動脈解離と椎骨動脈解離患者の頭痛の性状,部位,随伴症状を調べた. Student t test or χ 2 test

結果

動脈解離が発症する以前に頭痛を有した患者は,内頚動脈解離では片頭痛が18%,緊張性頭痛が51%,椎骨動脈解離では片頭痛が23%,緊張性頭痛が42%であった.動脈解離発症時における頭痛は内頚動脈解離で68% ( 頭痛の先行は47% ) ,椎骨動脈解離で69% ( 頭痛の先行は33% ) にみられた.突然に発症した頭痛 ( 雷鳴頭痛 ) は内頚動脈解離で14%,椎骨動脈解離で22%であった.内頚動脈解離の頭痛は,前頭 / 前頭側頭部に多く ( 61% ) ,持続性が73%,拍動性が25%,前外側の頚部痛が26%で認められた.椎骨動脈解離の頭痛は,後頭部が多く ( 83% ) ,持続性が56%,拍動性が44%,後頚部痛が46%に認められた.頭痛の後,神経脱落症状が出現するまでの時間は内頚動脈解離で平均4日,椎骨動脈解離で平均14.5時間であった.

結論

頭痛の鑑別とともに頚動脈の雑音,眼症状,下位脳神経麻痺,ホルネル症候群などを伴っていないか調べなければならない.

作成者

久保慶高

 

9) Ferro JM, Costa I, Melo TP, Canhao P, Oliveira V, Salgado AV, Crespo M, Pinto AN. Headache associated with transient ischemic attacks. Headache 1995; 35:544-548

論文抄録

Sixty (29%) of 205 consecutive patients with transient ischemic attacks registered in a hospital stroke data base had headache within 72 hours of onset. Headache was significantly more common in nonsmokers (odds ratio = 2.8; 95% confidence interval = 6.7 to 1.2). Headache was infrequent in patients with amaurosis fugax, and was not significantly associated with any other particular clinical presentation of transient ischemic attack. Headache was more common in vertebrobasilar (33%) than in carotid distribution (24%) episodes, and was not rare in transient ischemic attacks presenting as lacunar syndromes (29%). Headache was less frequent in patients whose computerized tomograms showed an infarct appropriate to the symptoms (odds ratio = 0.2; 95% confidence interval = 0.02 to 1.4). A diffuse headache was more common in patients with lacunar events than in patients with cortical attacks (odds ratio = 3.0; 95% confidence interval = 13 to 0.07). No other association was found between headache location and the presumed involved vascular territory. Headache in patients with transient ischemic attacks is poorly related/explained by the clinical characteristics of the ischemic e

文献 PubMed ID

PMID: 8530279

エビデンスレベル

III

文献タイトル ( 日本語 )

一過性脳虚血発作 (TIA) に伴った頭痛

目的

TIA 患者と頭痛の関連性を解析する

研究デザイン

Prospective registry

研究施設

ポルトガルの Hospital de Santa Maria (Neurology)

研究期間

1985 年 3 月から 1994 年 5 月

対象患者

7人の神経学医が診断した脳虚血発作24時間以内の患者 205 人

介入

運動・感覚障害,構語障害,顔面麻痺などの TIA 症状をはっきり認めない症例や他の脳血管障害患者は除外

主要評価項目とそれに用いた統計学的手法

TIA 患者で頭痛を有する群と有さない群で年齢,性別,臨床症状, CT 所見を比較した.頭痛を有する群ではどのような TIA 症状が多いのか,頭痛の部位と TIA 症状の相関を調べた.

結果

205人中60人(29%)で TIA 発症後72時間以内の頭痛を認めた.頭痛はびまん性 (42%) ,片側性 (18%) であり,非特異的であった.頭痛は非喫煙者に有意に多かった.頭痛は椎骨脳底動脈系が33%,内頚動脈系が29%,ラクナ梗塞が29%であった.頭痛と CT 所見,頭痛の部位と TIA の血管領域には相関は認めなかった.

結論

TIA 患者の頭痛は非特異的であるが,脳虚血性片頭痛と急性発症の aura を伴う片頭痛とは鑑別しなければならない.

作成者

久保慶高

 

10) Melo TP, Pinto AN, Ferro JM. Headache in intracerebral hematomas.
  Neurology 1996; 47:494-500

論文抄録

OBJECTIVES: We sought to describe the frequency and location of headache in intracerebral hematoma (ICH) and to analyze its clinical and CT predictors by means of multivariate analysis. BACKGROUND: Headache is more common in intracerebral hemorrhage than in ischemic stroke, and its frequency varies with hematoma location, but the pathophysiologic mechanisms of headache associated with ICH are not fully known. METHODS: We examined a cohort of 289 patients with ICH during a 14-month period in a university hospital. Clinical, including the presence and location of headache, and CT features were collected by two neurologists. RESULTS: One hundred and sixty-five (57%) patients with ICH had a headache at the onset of their stroke. Headache was more common in cerebellar and lobar hemorrhages than in deep ones (thalamic, caudate, capsuloputaminal, brainstem). Headache was also more common in women, patients younger than 70 years, those who vomited, and those with meningeal signs, a Glasgow Coma Scale score < 10, a hematoma volume > 10 ml or CT evidence of intraventricular or subarachnoid bleeding, moderate to severe hydrocephalus, or transtentorial herniation or midline shift. In multiple logistic regression analysis, only meningeal signs (odds ratio [OR] = 2.3), cerebellar or lobar location (OR = 2.1), transtentorial herniation (OR = 1.8), and female gender (OR = 1.6) were significant predictors of headache at the onset of ICH. CONCLUSIONS: Hematoma location, meningeal signs, and gender are more predictive of headache than hematoma volume, suggesting that headache is more often related to the activation of an anatomically distributed system in susceptible individuals and to subarachnoid bleeding than to intracranial hypertension

文献 PubMed ID

PMID: 8757027

エビデンスレベル

III

文献タイトル ( 日本語 )

脳内出血患者の頭痛

目的

脳内出血患者の頭痛の頻度,部位,臨床症状または CT scan での予測因子を解析する

研究デザイン

Prospective study

研究施設

ポルトガルの Hospital de Santa Maria (Neurology)

研究期間

1993 年 3 月から 1994 年 4 月

対象患者

二人の神経学医によって診断された脳内出血患者289人

介入

出血性脳梗塞患者,脳腫瘍内出血患者,15歳以下の脳内出血患者は除外した

主要評価項目とそれに用いた統計学的手法

脳内出血部位別での頭痛の頻度,頭痛を有する脳内出血患者の特徴,脳内出血患者における頭痛の有無の予測 (Logistic regression analysis) を調べた. Two-tailed t test, chi-square test

結果

289人中165人(57%)が発症時に頭痛を認めた.小脳出血と脳葉出血に頭痛は有意に多かった.また,女性,70歳以下,嘔吐,髄膜刺激症状, Glasgow Coma Scale Score が10以下,血腫量が10 ml 以上, CT 所見で脳室内出血・くも膜下出血がある,水頭症,テント切痕ヘルニアの所見を認めると頭痛が有意に多かった.頭痛は出血と同側が多く,小脳出血では後頭部痛が多かった.脳内出血患者における頭痛の有無の予測因子は髄膜刺激症状 (odds ratio[OR]=2.3) ,小脳出血または脳葉出血 (OR=2.1) ,テント切痕ヘルニア (OR=1.8) ,女性 (OR=1.6) であった.

結論

出血部位,髄膜刺激症状 ( くも膜下出血によるもの ) ,性別が血腫量や頭蓋内圧亢進よりも頭痛を呈しやすい因子である.

作成者

久保慶高

 

11) de Bruijn SF, Stam J, Kappelle LJ. Thunderclap headache as first
  symptom of cerebral venous sinus thrombosis. CVST Study Group.
  Lancet 1996; 348:1623-1625

論文抄録

BACKGROUND: Thunderclap headache raises the suspicion of subarachnoid haemorrhage, and it is not generally recognised as a symptom of cerebral venous sinus thrombosis (CVST). We describe ten patients who presented with thunderclap headache mimicking subarachnoid haemorrhage, who appeared to have CVST. METHODS: Medical histories of 71 patients who had CVST between 1992 and 1996 were collected. 48 of these took part in a randomised trial of treatment for CVST. The diagnosis was confirmed by conventional angiography or magnetic resonance imaging and angiography in all patients. FINDINGS: In all ten patients who presented with thunderclap headache, characteristics of the headache and clinical signs and symptoms were clinically indistinguishable from those of subarachnoid haemorrhage. Computed tomography at admission was interpreted as normal in five patients (one with single-dose contrast), as subarachnoid haemorrhage in three, and as multiple intracranial haemorrhages in the remaining patients (one with single-dose contrast). Cerebrospinal fluid (CSF) analysis was done in six patients, and showed erythrocytes and bilirubin in one. CSF pressure was high in the only patient for whom it was measured. INTERPRETATION: The best initial investigation in patients with thunderclap headache is emergency computed tomography. If no abnormality is detected, lumbar puncture should be done after at least 12 h (to detect or exclude subarachnoid haemorrhage). CSF pressure should be measured. If the CSF pressure is high or if a headache of unknown origin persists, the diagnosis of CVST should be considered.

文献 PubMed ID

PMID: 8961993

エビデンスレベル

II

文献タイトル ( 日本語 )

脳静脈洞血栓症における雷鳴頭痛

目的

脳静脈洞血栓症患者における雷鳴頭痛の特徴を調べる

研究デザイン

Prospective registry

研究施設

オランダ  アムステルダム大学( Neurology )

研究期間

1992 年から 1996 年

対象患者

脳血管撮影または MRA で診断された脳静脈洞血栓症患者71人

介入

48人は低用量のヘパリンを3週間投与した

主要評価項目とそれに用いた統計学的手法

雷鳴頭痛を認めた患者の頭痛の特徴,随伴症状,神経学的症状, CT の所見,脳脊髄液の所見を調べた

結果

71人中10人(14.1%)で雷鳴頭痛を認めた.雷鳴頭痛に随伴する症状は嘔吐 ( 60% ) ,運動障害(30%),意識障害30%,顔面神経麻痺(10%),てんかん発作(10%)であった. CT 所見は正常(50%),くも膜下出血(30%),脳内出血(20%)であった.脳脊髄液所見は血性(20%),正常(20%),髄液圧高値(10%),不明(50%)であった.

結論

脳静脈洞血栓症患者の頭痛を有する頻度は文献的に80%といわれるが雷鳴頭痛は14.1%でみられた.CTで異常が認められない場合は腰椎穿刺を行い,髄液の性状,圧を調べるべきである.原因不明の雷鳴頭痛で,髄液圧が高い場合は脳静脈洞血栓症を鑑別しなければならない.

作成者

久保慶高

 

12) da Motta LA, de Mello PA, de Lacerda CM, Neto AP, da Motta LD,
  Filho MF. Pituitary apoplexy. Clinical course, endocrine evaluations and
  treatment analysis. J Neurosurg Sci 1999; 43:25-36

論文抄録

BACKGROUND: The purpose was to analyze clinical manifestations, hormonal changes, diagnosis difficulties and treatment of pituitary apoplexy (PA). EXPERIMENTAL DESIGN: A retrospective study of clinical records from patients with pituitary adenomas admitted from January 1980 to June 1996; the purpose was to identify the patients with clinical evidence compatible with PA. Setting: Neurosurgery unit of an institutional hospital. Patients: Sixteen (12.8%) of 125 patients with pituitary adenomas were analyzed because they had pituitary apoplexy. Interventions: Surgical treatment by the trans-sphenoidal or transcranial route or both routes; dexamethasone (DXM) treatment with 16 mg/day i.v. Measures: Hormone assays were performed either by radioimmunoassay or by chemical luminescence. RESULTS: Tumors were nonfunctioning in nine patients and functioning in seven. TSH and prolactin basal serum levels were impaired in 55.5% and 10%, respectively; after exogenous TRH 80% of the patients did not show stimulation of TSH and prolactin secretions. LH and FSH levels were low in 63.6% and 54.6% of the patients, respectively; gonadotrophin-releasing hormone (GnRH) testing was abnormal in 75% of the patients evaluated. Cortisol levels were low in 50% of the patients. After insulin-induced hypoglycemia, cortisol and GH failed to rise in 25% and 40% of cases, respectively. Ten patients were submitted to surgical treatment, but none during PA. The average time from the onset of apoplectic symptoms and surgery was 70+/-50 days. Only one patient died two months after surgery. Five patients were treated with dexamethasone (DXM) during the apoplectic symptoms: three patients died; one patient had good quality of life; the other patient was treated initially with DXM with improvement of vision, but after surgery he developed panhypopituirarism. Two other patients did not receive specific treatment for PA. CONCLUSIONS: PA is not a rare pituitary adenoma complication and its prognosis may be poor; baseline hormone levels showed a wide range of abnormalities of pituitary function; surgical treatment was required in the majority of patients and the prognosis was relatively good; on the contrary, the treatment with DXM only had high levels of mortality.

文献 PubMed ID

PMID: 10494663

エビデンスレベル

IV

文献タイトル ( 日本語 )

下垂体卒中 - 臨床経過,下垂体ホルモンの評価,治療法の解析 -

目的

下垂体卒中の診断,臨床症状,下垂体ホルモン検査を解析する

研究デザイン

Retrospective study

研究施設

ブラジルの Hospital de Base do Distrito Federal

研究期間

1980 年 1 月から 1996 年 6 月

対象患者

下垂体腺腫125人

介入

Cardoso and Peterson の診断基準に従い,下垂体卒中を診断した

主要評価項目とそれに用いた統計学的手法

下垂体卒中患者の臨床症状,治療方法,下垂体ホルモン値などを解析した. Macintosh program により ANOVA by Student's t test

結果

下垂体腺腫125人中16人(12.8%)で下垂体卒中を認めた.下垂体卒中患者の症状として,突然の頭痛が12人(75%),突然の視野障害(62%),動眼・滑車・外転神経麻痺9人(56.2%),嘔吐8人(50%),複視3人(18.7%),発熱3人が認められた.

結論

突然の頭痛とともに視野障害や外眼筋麻痺が随伴する場合には下垂体卒中を考えなければならない.文献的に CT での診断率は50%で低いので MRI 撮像も必要である.

作成者

久保慶高