超高齢者破裂脳動脈瘤における局所麻酔下コイル塞栓術および選択的局所動注療法の役割について―preliminary report

The Role of Coil Embolization and Arterial Injection in Elderly Subarachnoid Hemorrhage Patients: Preliminary Report

Ⅰ．はじめに

　超高齢者破裂脳動脈瘤に対する治療転帰が不良であることは多くの報告により指摘されている^{1,2,7,9,10,12)}．コイル塞栓術がクリッピング術に比較して有効だとした2002年のInternational Subarachnoid Aneurysm Trial（ISAT）のsubgroup解析報告にあっても，70歳以上の症例に対しては，コイル塞栓術のクリッピング術に対するメリットは他年齢層に比べて比較的小さいとの結果が示されている⁶⁾．一方，高齢者に対してはコイル塞栓術が優れているとの多くの報告もあり^2,4,11)，高齢者くも膜下出血症例に対しての手術方針については一定の見解が得られていない．75歳以上の破裂動脈瘤症例に対する当科の治療方針は，2005年以前はクリッピング術を第一選択としてきたが，2006年以降は局所麻酔下コイル塞栓術を第一選択とし，術翌日からの離床を試みている．また，症候性脳血管攣縮症例には積極的に緊急脳血管撮影を行い，血管拡張剤の超選択的動脈内投与を行っている．クリッピング術とコイル塞栓術の対立ではなく，両者を融合させた超高齢者破裂動脈瘤の至適治療法について検討する．

　With the recent advanced aging seen in society, the number of elderly patients with aneurismal subarachnoid hemorrhage (SAH) is increasing. We focused on current management of SAH in patients who were over 75 years old. From January 1st, 2004 to the end of June, 2007, we had treated 170 SAH patients including 39 who were over 75 years old. We divided the patients into three groups：Coiling Group, Clipping Group, and conservative treatment group (Conservative Group). We analyzed the Hunt-Kosnik grade (H-K), the rate of symptomatic vasospasm, the rate of shunting operation, the Glasgow Outcome Scale (GOS) at 30 days after the onset of SAH, bed rest periods and rate of shunt operation retrospectively. The Conservative Group included many H-K poor grade cases. Symptomatic vasospasm occurred significantly less in the Coiling Group. Rates of shunting operation did not have any significant change. GOS of the Coiling Group and Clipping Group had no significant change, due to the effectiveness of arterial injection for vasospasm. Patients in the Coiling Group started walking significantly earlier than members of other groups. Twenty-five percent of the Clipping Group needed a shunt operation but no patients of the Coiling Group needed a shunt. For elderly SAH patients, we recommend doing coil embolization or clipping and maintaining the patients’ activity in daily life. Interventional treatment is necessary to improve results for elderly SAH patients.