Neurological Surgery 脳神経外科33巻5号

2005年05月発行

総説

未破裂脳動脈瘤―UCAS前夜

著者： 大熊洋揮¹

所属機関： ¹弘前大学医学部脳神経外科

ページ範囲：P.417 - P.431

Ⅰ．はじめに

　脳動脈瘤破裂によるくも膜下出血は脳神経外科における最も重要な疾患の1つである．それは，死に至ることも少なくはない重篤な疾患であると同時に，手術を中心とした脳神経外科的治療の介在により，元の生活に復帰させることも十分に可能なためである．しかし，即死例も含め脳神経外科的管理前に瀕死状態となり手術に到らない症例が半数以上を占めるとされ^37,56,58,66)，全体的な予後には大きな進歩が得られていないことも指摘され続けている^25,62)．この事実から，くも膜下出血自体の発生の予防，つまり未破裂のうちに発見し手術的治療を行うことに目が向けられたことは必然的な流れである．

　この動きは，1980年代に入りMRIが実用化され，MRAにより脳動脈瘤の画像化が可能となったことから一気に加速した．日本では1988年より脳ドックが開始され，90年代に入ってからはスクリーニングにより未破裂のうちに発見し手術を行うことが広く普及し始めた．しかし一方で，危険性つまり脳障害による後遺症が生じる可能性の少なくはない症例もあることから，対象症例の見直しも行われてきた^36,63,71,81)．加えて1998年，ISUIA⁷⁸⁾の示した極めて低い未破裂脳動脈瘤（以下，未破裂瘤）の破裂率は，その検討法に問題が含まれてはいたものの，未破裂瘤に対する予防的手術自体の意義を再考する機会を提示したとも言える．

　当然，未破裂瘤の外科的治療の適否は，その破裂の可能性と手術の危険性のバランスのもとに判断されるものである．しかし，その判断根拠となるエビデンスの高い検討がこれまでに行われなかったことが手術基準の曖昧さの一因でもあった．これに対してUCAS - Japan（以下，UCAS）が2001年に開始され，その最終報告を間近に控えた今，日本における未破裂瘤の自然歴の詳細が明らかにされることが期待されている．一方，UCASの結果が報告されたとしても，これまで行われてきた未破裂瘤に関する報告の価値が失われる訳ではない．UCASの報告を前に，これまでの未破裂瘤に関係のある疫学的報告を整理しまとめておくことは，UCASの結果を理解するうえで意義のあることと思われる．そうした観点から，自験例を含め，未破裂瘤に関連する文献に関し集積・解析を行った．

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