破裂脳動脈瘤に対する慢性期クリッピング術を前提にした急性期意図的部分塞栓術

Choice of Intentional Partial Coiling for a Ruptured Intracranial Aneurysm in the Acute Stage Followed by Clipping in the Chronic Stage

Ⅰ．はじめに

　近年，人口の高齢化とともにデバイスの改良，治療技術の進歩とあいまって破裂脳動脈瘤に対する血管内治療の果たす役割が重要になってきている．さらにInternational Subarachnoid Aneurysm Trial（ISAT）の報告¹⁸⁾以降，血管内治療の適応は拡大している．当院においては局所麻酔（局麻）下で破裂脳動脈瘤に対するcoiling治療を施行しており，その治療数は年々増加しつつある．

　しかしながら，動脈瘤の形状からcoilingのみで根治不能な症例では，最終的にclippingにて根治術を施行する必要がある．以前より，意図的に初回coiling，追加治療clippingの方針を立てて破裂脳動脈瘤の根治にあたる方法については，種々の報告例がある^1,3,11,15)．

　当科において慢性期clippingを前提に，急性期意図的部分coilingを行い，最終的にclippingによって根治し経過良好であった6症例について報告する．

　The inpact of the International Subarachnoid Aneurysm Trial (ISAT) trial publication in 2002 and major technical advances in neuroimaging, endovascular devices and techniques have resulted in increasing numbers of patients with ruptured aneurysms undergoing endovascular coiling, as first-line treatment for aneurysm occlusion.

　We treated six cases of ruptured aneurysms with this strategy, with choice of clipping as additional treatment following intentional partial coiling. In this series, patients ranged in age from 36 to74 years and included one man and five women. Three aneurysms were located in AcomA, 1 in ACA, and 2 in MCA. The reasons for the choice of this strategy were clinical and angiographical spasm in 2, high general surgical risk in 2, and other reasons in 2 cases, respectively. The mean interval between the first partial coiling and final clipping was 33 days. All cases were successfully clipped without difficulties and coil removal were performed in 3 cases for follow up examination.

　It is proposed that the choice of this strategy contributes to progresses in overall outcomes in cases of aneurysmal subarachnoid hemorrhage.