来院後早期に再破裂を来たした破裂脳動脈瘤症例の検討

Rebleeding of Ruptured Intracranial Aneurysms in the Acute Stage

I．はじめに

　破裂脳動脈瘤患者の管理上，動脈瘤の再破裂は予後に大きく影響する最も重大な問題であり，この再破裂を防ぐために，早期手術が広く行われている．著者らも，早期手術を基本としており，来院後の可及的早期にクリッピングなどにより再破裂の予防を行ってきた．しかし，手術施行前の来院後早期に再破裂を来たすことがあり，破裂後数時間という急性期に来院したクモ膜下出血患者の管理の難しさを痛感している．今回来院後早期に再破裂した症例について，その特徴を明らかにし，早期再破裂の予防方法についても検討したい．

Among the cases of ruptured aneurysms we have handled, some patients have rebled before surgery was performed. In this study, we examine the factors that contribute to the rerupture of cerebral aneurysms in the acute stage and suggest measures to prevent rerupture prior to surgery.

We have encountered 32 cases of rebleeding prior to surgery. The rebleeding occurred within six hours of the initial subarachnoid hemorrhage (SAH) in 26 pa-tients, among whom 21 rebled within three hours. Thir-teen patients rebled during bed rest, 10 patients during angiography, 4 patients during CT scan and 5 patients in various other circumstances. Nine of the 10 patients who rebled during angiography had undergone the pro-cedure within three hours of the initial SAH. Overall, the patients' condition deteriorated substantially after rebleeding.

Considering these circumstances surrounding aneu-rysmal rerupture, we suggest the following measures for the prevention of preoperative rerupture in the acute stage: 1) maintenance of lowered blood pressure during the risky period; 2) intentional delay of per-formance of angiography until at least hours after the initial rupture; and 3) performance of surgery on an emergency basis.