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Neurological Surgery No Shinkei Geka Volume 22, Issue 9 （September 1994）

Neurological Surgery 脳神経外科 22巻9号（1994年9月発行）

Japanese English

研究

虚血性脳血管障害に合併した未破裂脳動脈瘤の外科治療 Surgical Indication for Unruptured Cerebral Aneurysm in Patients with Ischemic Cerebrovascular Disease 小松洋治 ^1,4 , 兵頭明夫 ¹ , 能勢忠男 ¹ , 小林栄喜 ² , 目黒琴生 ³ , 小野幸雄 ⁴ , 杉本耕一 ⁵ , 石井完治 ⁶ Yoji KOMATSU ^1,4 , Akio HYODO ¹ , Tadao NOSE ¹ , Eiki KOBAYASHI ² , Kotoo MEGURO ³ , Yukio ONO ⁴ , Koichi SUGIMOTO ⁵ , Kanji ISHII ⁶ ¹筑波大学脳神経外科 ²筑波記念病院脳神経外科 ³筑波メディカルセンター脳神経外科 ⁴県西総合病院脳神経外科 ⁵小張病院脳神経外科 ⁶北茨城市立総合病院脳神経外科 ¹Department of Neurosurgery, University of Tsukuba ²Department of Neurosurgery, Tsukuba Memorial Hospital ³Department of Neurosurgery, Tsukuba Medical Center ⁴Department of Neurosurgery, Kensei General Hospital ⁵Department of Neurosurgery, Kobari Hospital ⁶Department of Neurosurgery, Kita-Ibaraki General Hospital キーワード： Unrutured aneurysm , Ischemic cerebrovascular disease , Surgical treatment Keyword: Unrutured aneurysm , Ischemic cerebrovascular disease , Surgical treatment pp.811-818

発行日 1994年9月10日 Published Date 1994/9/10

DOI https://doi.org/10.11477/mf.1436900898

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Abstract 文献概要
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I．はじめに

　未破裂動脈瘤の外科治療については，その安全性を強調した積極的な報告が多い^{3,11,12,14,26）}．しかし，虚血性脳血管障害を伴なう症例では，術後合併症が多くみられることが指摘され，より慎重な手術適応の判断や手術操作が要求されている^{1,3,4,16,17,22,26）}．最近のmagnetic re—sonance angiographyの普及により^19,21）頻度の低下が予測されるが，未破裂瘤のかなりの部分は，虚血性脳血管障害の精査を目的とした血管撮影で診断されることを考慮すると，このような症例での治療方針については詳細な検討が必要である．

　また，未破裂瘤の自然歴についての青木らや浅利らの検討^3,5）では，虚血性脳血管障害の精査で診断された瘤は，他と比較して出血を来す危険が高く，このような症例での外科治療についての検討の必要性が示されている．

　われわれは，自験例の検討から，未破裂瘤の外科治療の危険因子のひとつに，虚血性脳血管障害の合併および，それを示唆する神経放射線所見の存在があることを，以前に報告した^17）．今回，虚血性脳血管障害合併症例について直達手術の成績を解析し，その治療方針および転帰改善のための対策などについて検討したので報告する．

A series of 44 cases is presented of patients who re-ceived surgical treatment for unruptured aneurysms in the anterior circulation, and which were associated with ischemic cerebrovascular disese (CVD). The age of pa-tients varied from 34 to 76 (mean 62.8) years old. The associated ischemic CVD was transient ischmic attack (TIA) in ten, minor completed stroke in 23, and major completed stroke in 11 cases.

Thirty five patients recovered fully. However, there were three deaths due to new cerebral infarction or de-layed intracranial hemorrhage within 30 days after surgery (mortality 6.8%). Transient morbidity occurred in four patients (9.1%), and permanent morbidity in two patients (4.5%). In six cases, new ischemic events occurred after the surgery. In contrast, all 40 patients whose unruptured aneurysms were not associated with CVD fully recovered from the surgery they underwent. The authors indicate three risk factors which might lead to complication; diabetes mellitus, aneurysms lo-cated in the middle cerebral artery, and those larger than 6mm in diameter. Another three life-threatening factors are; elderly patients (＞65 year-old), male, aneurysms larger than 7mm in diameter. Direct surgery for unruptured aneurysms in ischemic CVD patients should be considered in cases free of risk factors indi-cated above.

Eight cases in this series had extracranial carotid artery stenosis on the same side as the aneurysm. Caro-tid endoarterectomy (CEA) was performed prior to aneurysmal clipping in six patients, and their postopera-tive courses were excellent. In two patients, clipping was performed prior to CEA, and transient morbidity occurred in one of them. These results suggest that management of cerebral blood flow in cases of ischemia of the brain may improve surgical prognosis of patients with ischemic CVD.