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ニューロサイエンスの旅 Vol. 48

当科の堀 恵美子先生が、頭痛で発症した椎骨動脈動脈解離症例の臨床像について「脳神経外科」誌に報告しました。本症では従来、突発する一側の項部〜後頭部痛が特徴的な症候とされてきましたが、近年、外来でのMRI・MRAの適用頻度が増えるにつれて、この症候を呈する症例は55%に過ぎず、他の症例では突発しない、鈍痛を主体とする痛みを主訴に外来を受診する患者さんが増えていることを明らかにしました。T1強調画像による壁内血栓が29例中21例で検出されている点も今後、診断の参考になると思います。

A Voyage to Depth of Neuroscience Vol. 48

Hori E, Hori S, Okamoto S, Shibata T, Umemura KO, Kubo M, Furui E, Horie Y, Kuroda S.
Characteristics of Headache and Neck Pain in Spontaneous Vertebral Artery Dissections
No Shinkei Geka. 2018 Apr;46(4):295-299.

Abstract
PURPOSE:
Sudden onset severe occipital/nuchal pain is believed to be a typical symptom of vertebral artery dissection(VAD). However, recent developments in diagnostic imaging have suggested that VAD is not always associated with such pain. This study aimed to analyze the clinical features of initial symptoms in patients with VAD.
METHODS:
In total, this study included 29 consecutive patients who were referred to our hospital because of only headache and/or nuchal pain due to VAD between 2011 and 2016. In this study, their clinical features were precisely assessed, including the pain location, onset pattern, duration, intensity, disease period, diagnosis modality, and prognosis. Both MRI and MRA were performed for all subjects. Cerebral angiography and thin-slice T1-weighted MRI were additionally performed in selected cases.
RESULTS:
Of the 29 patients, 23 presented with occipital headache and/or nuchal pain. The pain was persistent in 26/29 and ipsilateral in 29/29. However, only 16/29 reported a typical sudden onset. Only 12/29 complained of severe pain, while the other 17/29 presented with dull pain. The mean interval between onset and hospitalization was 7.4 days(0 to 30 days)and the mean interval between hospitalization and diagnosis was 3.9 days(0 to 21 days). Intramural hematoma was identified in 21/29 patients using thin-slice T1-weighted MRI.
CONCLUSION:
Only 55% of patients with VAD demonstrate typical occipital/nuchal pain with sudden onset. Both MRI and MRA should be indicated for patients who complain of persistent, unilateral pain in the occipital/nuchal regions to prevent VAD being missed during diagnosis.

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