破裂内頸動脈kissing aneurysmsの1手術例―症例報告と文献的考察

A Case of Ruptured Internal Carotid Artery “Kissing Aneurysms”：Case Report and Review of the Literature

Ⅰ．は じ め に

　独自の頸部を有し，隣接する動脈瘤の体部に癒着がみられる場合，Yasargil²¹⁾はこれをkissing aneurysmsと称した．Kissing aneurysmsは，その剝離の困難さ故に，時に重篤な手術合併症を起こすことが知られ^6,7,9,15,21)，単に多発性脳動脈瘤の中の一型という分類に止まらず，手術難易度の高い動脈瘤という臨床的意味があると考えられる．そこでわれわれの経験した破裂内頸動脈kissing aneurysmsの1手術例を呈示し，そのclipping術の困難さ，および治療法の選択に関し，若干の文献的考察を加えて報告する．

Objective A rare case of ruptured kissing aneurysms on the right internal carotid-posterior communicating artery (ICPCA) and -anterior choroidal artery (ICAchA) is reported.

　Case A 47-year-old female was transferred to our hospital because of subarachnoid hemorrhage (SAH). Cerebral angiography revealed two aneurysms on the right ICPCA and ICAchA. Right frontotemporal craniotomy was performed to obliterate them on the day of admission. Despite the presence of angiographical cleavage,these two aneurysms were attached to each other tightly,and it was extremely difficult to dissect the space between them and premature rupture occurred. A Sugita long straight clip was inserted parallel to internal carotid artery to obliterate the body of ICAchA aneurysm and the neck of ICPCA aneurysm. Another straight clip was applied to the neck of the former aneurysm. Both PCA and AchA could be secured successfully. Postoperatively,although she developed symptomatic vasospasm on the 10th day,she discharged without any neurological deficits 40 days later.

　Conclusions Because of the difficulty in dissection of aneurysms,the operation for kissing aneurysms has been recognized as hazardous and challenging since Jefferson. We emphasize that a clipping technique described above should be kept in mind as a safe value,though meticulous dissection of each aneurysmal neck followed by independent neck clipping is reasonable.