破裂急性期にstent-assisted coilingを行った内頚動脈large aneurysmの1例

Stent-assisted Coiling of an Acutely Ruptured Large Aneurysm of the Internal Carotid Artery : Case Report

Ⅰ．は じ め に

　内頸動脈が瘤壁の一部を形成する広頸かつ大型の動脈瘤の場合，親動脈を温存した瘤内塞栓術は容易ではなく，瘤内再開通の頻度が高い¹⁰⁾．広頸の動脈瘤にはバルーンを動脈瘤の頸部に留置して，親動脈を温存しながら瘤内塞栓するballoon-assisted coiling（remodeling technique⁹⁾），あるいは冠動脈用ステントや脳血管用ステントNeuroform (Boston Scientific) を親動脈に留置して瘤内塞栓を行うstent-assisted coiling^{1,3,4,6,7,11)}が報告されている．しかし，頸部が存在しないような大型の動脈瘤ではballoon-assisted coilingでの治療は困難であり，また脳血管用ステントNeuroformはいまだ日本には導入されていない．今回われわれはコイル型の新しい冠動脈ステントであるDRIVER ステント（Medtronic，Inc.）を使用して，破裂急性期にstent-assisted coilingを行い，治療し得た1例を経験したので，この治療法の有用性ならびに問題点について報告する．

A 48-year-old female was referred to our hospital for the management of a ruptured 22-mm-diameter internal carotid aneurysm,located immediately distal to the ophthalmic artery. The right internal carotid artery was completely involved in the aneurysm. Because the right carotid siphon was relatively nontortuous stent-assisted coiling of the aneurysm was attempted 4 days after subarachnoid hemorrhage. A new coil-type coronary stent,a DRIVER stent,was deployed after microcatheter insertion into the aneurysm dome under systemic heparinization,followed by dome packing using Guglielmi detachable coils. Systemic heparinization was continued for 18 hours postoperatively,and aspirin (100 mg/day) was administered orally immediately after the embolization. However,4 hours after heparin administration cessation,left hemiparesis became apparent. Immediate magnetic resonance angiography revealed a right internal carotid artery occlusion. Diffusion-weighted images demonstrated ischemic spots in the watershed zones of the right cerebral hemisphere. Following an immediate thrombolysis of the right internal carotid artery,systemic heparinization was continued for 5 days,and aspirin and ticlopidine were administrated orally. The patient was discharged on day 37,following the recovery from left hemiparesis within ten days. A DRIVER stent is a low profile coil-type coronary stent,which can be used for the stent-assisted coiling of large internal carotid aneurysms,located distal to the carotid siphon. It seems necessary to continue systemic heparinization for more than 2 days and to administer increased dose or two types of antiplatelet after the stent-assisted coiling of large cerebral aneurysms.