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Neurological Surgery No Shinkei Geka Volume 46, Issue 8 （August 2018）

Neurological Surgery 脳神経外科 46巻8号（2018年8月発行）

Japanese English

症例

破格側副血管起始部（A1）の破裂脳動脈瘤で初発し，twig-like network内に新生した微小脳動脈瘤の破裂により再発した中大脳動脈M1低形成の1例 A Rare Case of a Ruptured De Novo Aneurysm Arising from the Twig-like Networks of an Anomalous Collateral Artery Associated with Hypoplasia of the M1 Segment of the Middle Cerebral Artery 4 Years after the Rupture of an A1 Aneurysm at the Origin of the Collateral Artery 酒井洸典 ¹ , 日宇健 ² , 福田雄高 ^2,4 , 大園恵介 ² , 本田和也 ³ , 川原一郎 ² , 小野智憲 ² , 牛島隆二郎 ² , 戸田啓介 ^2,5 , 堤圭介 ² Kosuke SAKAI ¹ , Takeshi HIU ² , Yutaka FUKUDA ^2,4 , Keisuke OZONO ² , Kazuya HONDA ³ , Ichiro KAWAHARA ² , Tomonori ONO ² , Ryujiro USHIJIMA ² , Keisuke TODA ^2,5 , Keisuke TSUTSUMI ² ¹独立行政法人国立病院機構長崎医療センター脳神経外科初期研修プログラム ²独立行政法人国立病院機構長崎医療センター脳神経外科 ³独立行政法人国立病院機構長崎医療センター ⁴福田脳神経外科病院 ⁵独立行政法人国立病院機構長崎川棚医療センター脳神経外科 ¹Residency Program, Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center ²Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center ³National Hospital Organization Nagasaki Medical Center ⁴Fukuda Neurosurgical Hospital ⁵Department of Neurosurgery, National Hospital Organization Nagasaki Kawatana Medical Center キーワード： twig-like middle cerebral artery , M1 hypoplasia , twig-like networks of anomalous collateral artery , de novo aneurysm , ruptured aneurysm Keyword: twig-like middle cerebral artery , M1 hypoplasia , twig-like networks of anomalous collateral artery , de novo aneurysm , ruptured aneurysm pp.713-722

発行日 2018年8月10日 Published Date 2018/8/10

DOI https://doi.org/10.11477/mf.1436203799

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Ⅰ．はじめに

　Twig-like networks（TLN）を伴う中大脳動脈（middle cerebral artery：MCA）M1形成不全（aplastic or twig-like MCA¹⁰⁾：Ap/T-MCA）は頭蓋内出血での発症が多く，出血源の1つとして脳動脈瘤の破裂がある^1,5,10)．今回われわれは，破格側副血管起始部（A1）の破裂脳動脈瘤で初発した4年後，TLN内の新生微小脳動脈瘤破裂で再発した稀な症例を経験したため，臨床上の留意点について考察する．

　We report a rare case of a de novo ruptured aneurysm arising from the twig-like networks（TLN）of an anomalous collateral artery associated with an aplastic or twig-like middle cerebral artery（Ap/T-MCA). A 65-year-old woman with a decreased level of consciousness, who had been diagnosed with a right Ap/T-MCA and was treated with coil embolization for a ruptured A1 aneurysm at the origin of the anomalous collateral artery 4 years ago, was transferred to our hospital. Head CT revealed an intracerebral hematoma extending from the right frontal lobe to the caudate nucleus with intraventricular hemorrhage. Subsequent 3D-rotational angiograms revealed a ruptured de novo aneurysm arising from the TLN and regrowth of the residual neck of the coiled aneurysm. The two aneurysms were successfully treated by surgical clipping combined with superficial temporal artery middle cerebral artery anastomosis in the subacute phase. To our knowledge, only 11 cases of this type of aneurysm have been reported, including our case, and this is the first report of a de novo aneurysm within the TLN so far. Although all previously reported aneurysms were small（＜5-6mm), 10 of them（91%）ruptured. These data may indicate the vulnerability of this type of aneurysm to rupture despite their small size, probably due to hemodynamic stress and the fragile nature of their immature walls. To prevent recurrence of hemorrhage in these cases, revascularization may be necessary in addition to surgical clipping. Whether this concept is correct is an open question. Further studies are necessary to examine this issue.