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Treatment Choice for Ruptured Intracranial Aneurysm in the Hybrid Era

Point

・当施設では，中大脳動脈瘤分岐部動脈瘤以外の破裂脳動脈瘤に対しては，原則として血管内治療を第一選択としている．

・3 mm未満の小型の脳動脈瘤，大きな血腫を伴う症例，バイパス術併用が必要な症例では，現在でも直達術を選択している．

・前交通動脈瘤や後交通動脈瘤などでも，くも膜下出血急性期に安全に治療できると判断すれば，クリッピング術を選択することがある．

　Long-term follow-up results from the International Subarachnoid Aneurysm Trial suggest that coiling is preferable for ruptured aneurysms treatable with both modalities. This finding has led to a growing trend towards coiling for these patients. At our institute, coiling is now the first-line treatment for ruptured aneurysms, with exceptions for middle cerebral artery aneurysms. We also favor direct surgery for small ruptured aneurysms（＜3 mm）, cases with massive intracerebral hematoma, or situations requiring bypass surgery. While early rebleeding after coiling is uncommon, it carries a certain risk. Therefore, we sometimes choose clipping for ruptured anterior communicating artery or posterior communicating artery aneurysms if clipping poses minimal technical difficulty. To achieve optimal outcomes for ruptured aneurysms, a combined approach is crucial. This involves safe and effective endovascular treatment alongside necessary direct surgical interventions.