脳卒中を伴う減圧症Ⅱ型：急性期神経リハビリテーションにおける困難な状況

Decompression illness type II with stroke: challenging situation in acute neurorehabilitation.

• Harleen Uppal
• Uditha Jayatunga

抄録

プロの55歳女性経験豊富なダイバーは、2回目のダイビング後に浮上したが、グラスゴー昏睡尺度（GCS）を3/15に低下させる前に明晰な間隔を持っていた。彼女は集中治療室に入院し、高気圧酸素療法を開始した。最初の頭部CT検査は正常であったが，48時間後の脳の磁気共鳴画像検査では，両側の大脳皮質分水嶺領域の梗塞が認められた．急性呼吸窮迫症候群を発症したが，数日で消失した．彼女のGCSは3/15から6/15まで徐々に改善し、約2週間後にイギリスに送還され、彼女はミオクロニー発作を起こし、抗てんかん薬の投与を開始された第三次治療病院に入院した。その後、レスター総合病院のリハビリテーション科病棟に転院し、GCS14/15、座位バランス不良で、管理とリハビリテーションを行った。右上肢・下肢の脱力、構音障害、神経障害性両側肩痛、左踵の圧迫性潰瘍、膀胱・腸失禁、認知障害を呈していた。その後3ヶ月以内に神経学的に有意な回復を示し、独立して救急車に乗れるようになり、膀胱・腸のコンチネンタルも改善しました。Barthel index (4から17)、Montreal Cognitive Assessment Test、Adembrook Cognitive Examination、Berg Balance scale (33/56から44/56)で有意に改善した。早期診断、治療、リハビリテーションは減圧症の回復に大きな影響を与えます。

A professional 55-year-old female experienced diver, who surfaced after the second dive, had a lucid interval before dropping Glasgow Coma Scale (GCS) to 3/15. She was admitted to intensive care unit and commenced on hyperbaric oxygen therapy. Her initial computed tomography of the head was normal but her magnetic resonance imaging of the brain at 48 hours showed extensive bilateral cortical watershed territory infarcts. She developed acute respiratory distress syndrome which resolved within a few days. Her GCS gradually improved from 3/15 to 6/15, was repatriated to United Kingdom after about 2 weeks of the insult and admitted to a tertiary care hospital where she had myoclonic seizures and was started on anti-epileptics. Then she was transferred to the Rehabilitation Medicine Ward of Leicester General Hospital, with GCS 14/15 with poor sitting balance, for her management and rehabilitation. She had weakness of right upper and lower limbs, dysarthria, neuropathic bilateral shoulder pains, pressure ulcer of left heel, bladder and bowel incontinence and cognitive issues. She improved to have significant neurological recovery within next 3 months, became ambulant independently and bladder and bowel continent. Her Barthel index (from 4 to 17), Montreal Cognitive Assessment Test, Adembrook Cognitive Examination and Berg Balance scale (from 33/56 to 44/56) improved significantly. Early diagnosis, treatment and rehabilitation can have a significant impact on the recovery of decompression illness.