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Neurological Surgery No Shinkei Geka Volume 45, Issue 8 （August 2017）

Neurological Surgery 脳神経外科 45巻8号（2017年8月発行）

Japanese English

症例

Twig-like middle cerebral arteryに合併した末梢性破裂前脈絡叢動脈瘤に対し急性期にクリッピング術と血行再建術を一期的に行った1例 A Case of Ruptured Distal Anterior Choroidal Artery Aneurysm Associated with a Twig-Like Middle Cerebral Artery, Treated with Single-Stage Aneurysm Clipping and STA-MCA Double Anastomoses in the Acute Phase 瀬野利太 ¹ , 河野兼久 ¹ , 田中英夫 ² , 岩田真治 ¹ , 福本真也 ¹ , 市川晴久 ¹ , 麓憲行 ² , 井上明宏 ¹ , 尾崎沙耶 ¹ , 中村和 ¹ , 高野昌平 ³ , 大上史朗 ¹ Toshimoto SENO ¹ , Kanehisa KOHNO ¹ , Hideo TANAKA ² , Shinji IWATA ¹ , Shinya FUKUMOTO ¹ , Haruhisa ICHIKAWA ¹ , Noriyuki FUMOTO ² , Akihiro INOUE ¹ , Saya OZAKI ¹ , Yawara NAKAMURA ¹ , Shohei KOHNO ³ , Shiro OHUE ¹ ¹愛媛県立中央病院脳卒中センター脳神経外科 ²愛媛県立新居浜病院脳神経外科 ³愛媛大学医学部脳神経外科 ¹Department of Neurosurgery, Stroke Center, Ehime Prefectural Central Hospital ²Department of Neurosurgery, Ehime Prefectural Niihama Hospital ³Department of Neurosurgery, Ehime University School of Medicine キーワード： twig-like MCA , distal anterior choroidal artery aneurysm , aneurysm clipping , STA-MCA double anastomoses , intraventricular hemorrhage Keyword: twig-like MCA , distal anterior choroidal artery aneurysm , aneurysm clipping , STA-MCA double anastomoses , intraventricular hemorrhage pp.691-697

発行日 2017年8月10日 Published Date 2017/8/10

DOI https://doi.org/10.11477/mf.1436203576

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Ⅰ．はじめに

　もやもや病の診断基準は満たさないが，もやもや様異常血管網を伴った中大脳動脈（middle cerebral artery：MCA）閉塞が存在する病態があり，aplastic or twig-like MCAとして報告されてきた．病態はいまだ不明な点が多いが，成人での出血発症が指摘されており，再出血予防が大きな課題となっている^1,6,12,16)．今回われわれは，twig-like MCAに合併した前脈絡叢動脈（anterior choroidal artery：AChA）末梢部の破裂動脈瘤に対し，急性期にclipping術と浅側頭動脈（superficial temporal artery：STA）-MCA吻合術を一期的に施行し，術後5年を経過した現在も良好な経過を辿っている1例を経験したので報告する．

　We report the case of a patient who has progressed well over 5 years following single-stage aneurysm clipping and superficial temporal artery-middle cerebral artery（STA-MCA）double anastomoses in the acute phase, for a ruptured distal anterior choroidal artery（AChA）aneurysm accompanied by a twig-like MCA.

　The patient was a 49-year-old female who developed a sudden severe headache and disturbance of consciousness due to subarachnoid hemorrhage and intraventricular hemorrhage（IVH). Cerebral angiography showed a right twig-like MCA associated with an abnormal vascular network and a ruptured aneurysm in the distal AChA. A day after emergency ventricular drainage for acute hydrocephalus, right frontotemporal craniotomy enabled distal AChA aneurysm clipping, together with removal of the IVH via transchoroidal fissure approach, in addition to STA-MCA double anastomoses to prevent recurrence of hemorrhage. The IVH resolved after surgery and no new infarct area was observed. Cerebral angiography revealed the disappearance of the aneurysm, good patency of the double bypass, and reduction of the abnormal vascular network. The patient gradually recovered without any neurological deficits, except for mild memory disturbance. Five years after the surgery, the patient has experienced no recurrence.

　The single-stage operation of aneurysm clipping and STA-MCA double anastomoses was made possible by devising an approach for a ruptured cerebral aneurysm, even in the acute stage. The successful improvement of cerebral circulation and prevention of cerebral hemorrhage from an early stage could serve as a reference for the treatment of similar hemorrhagic cases.