脳動脈瘤直接手術不十分例の検討

A CONSIDERATION FOR THE INCOMPLETE CASES OF INTRACRANIAL ANEURYSM AFTER DIRECT OPERATION

緒言

　脳動脈瘤の破裂はクモ膜下出血の主要原因であり^1），現在のところその予防および治療には頭蓋内直接手術が最もよい手段であることは，次第に信じられつつある現状である。その直接手術の原理は極めて簡単である。すなわち，脳動脈瘤柄を明らかにし，それを糸で結紮あるいは銀クリップでクリッピングする方法，または摘出し柄部を縫縮する方法，流入流出動脈を遮断してしまう方法，流入動脈だけを遮断してしまう方法，あるいは重合接着剤による壁補強法，筋肉片によるwrappingの方法がある^2）。

　われわれは，1969年12月末までに，316例，369動脈瘤の症例を経験し，そのうち274例315個の動脈瘤に直接手術を行なつて来た^3）4）。これらの中で壁補強を用いたものは12動脈瘤だけであり，しかもそのうちの9個は泡状のものであり，2個は止むを得ず行なつたもので，残りの1個だけがどうしても柄部の処置ができなかつたものである。従つてそれ以外の303個は全て柄部の結紮，クリッピング，あるいは摘出，縫縮などの確実な手段を主操作として用いたものである。

1) The total number of the intracranial aneurysm experienced in our clinic is 369 (316 cases) until the end of December, 1969. Direct operation were performed in 315 aneurysms (274 cases), in which 303 aneurysms were handled by the methods of ligation and/or clipping of the neck of aneurysm, another 12 aneurysms were treated with adhesive coating or muscle wrapping.

2) Although the aneurysmal neck seemed to be completely ligated or clipped during operation, post-operative angiography revealed the remaining aneurysm in 11 cases. The body of aneurysm re-mained in 4 cases after neck ligation, in 4 cases after neck clipping, and in one case, the early case of our series, muscle pad was packed into the bleed-ing portion of the aneurysm which suddenly rup-tured during operation before exposure of it. The small portion of the base of the neck remained after clipping in 2 cases.

3) The remined aneurysm after direct operation seems to disappear early after operation, if the aneurysmal neck is ligated correctly but not so completely at the time of surgery, or if the residual neck is so narrow by the clip. Reoperation need not be considered in such cases. On the other hand, the cases, in which the residual portion of the aneurysm is growing progressively after the clip-ping or the clip is slipping off with pulsations from the aneurysm, must be reoperated in an early stage. The postoperative angiography is necessary in evry case to know whether there is the residual portion of aneurysm or not.

4) The best management for the direct opera-tion of intracranial aneurysm is careful neck dis-section at first, neck ligation and then neck clip-ping.