Neurological Surgery 脳神経外科37巻8号

2009年08月発行

研究

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

著者： 西村真実¹ 藤田智昭¹ 坂田洋之¹ 堀恵美子¹ 三野正樹¹ 西嶌美知春¹ 緑川宏²

所属機関： ¹青森県立中央病院脳神経外科 ²青森県立中央病院放射線科

ページ範囲：P.757 - P.763

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．

参考文献

1）Brisman JL, Roonprapunt C, Song JK, Niimi Y, Setton A, Berenstein A, Flamm ES：Intentional partial coil occlusion followed by delayed clip application to wide-necked middle cerebral artery aneurysms in patients presenting with severe vasospasm. J Neurosurg 101：154-158, 2004

2）Civit T, Auque J, Marchal JC, Bracard S, Picard L, Hepner H：Aneurysm clipping after endovascular treatment with coils：A report of eight patients. Neurosurgery 38：955-961, 1996

3）Cockroft KM, Marks MP, Steinberg GK：Planned direct dual-modality treatment of complex broad necked intracranial aneurysms：four technical case reports. Neurosurgery 46：226-231, 2000

4）Conrad MD, Guyotat IP, Morel C, Schonauer C, Deruty R：Regrowth of residual ruptured aneurysms treated by Guglielmi's detachable coils which demanded further treatment by surgical clipping：report of 7 cases and review of the literature. Acta Neurochir (Wien) 144：419-426, 2002

5）De Keukeleire K, Vanlangenhove P, Defreyne L：Evaluation of a neck-bridge device to assist endovascular treatment of wide-neck aneurysms of the anterior circulation. AJNR Am J Neuroradiol 29：73-78, 2008

6）藤村直子，広畑　優，安陪等思，徳富孝志，重森　稔：不完全clippingおよび塞栓術後に再度Neck Clippingを行った内頚動脈瘤の1例．No Shinkei Geka 27：49-54, 1999

7）Gurian JH, Martin NA, King WA, Duckwiler GR, Guglielmi G, Vinuela F：Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization. J Neurosurg 83：843-853, 1995

8）Hassan T, Timofeev EV, Saito T, Shimizu H, Ezura M, Matsumoto Y, Takayama K, Tominaga T, Takahashi A：A proposed parent vessel geometry-based categorization of saccular intracranial aneurysms：computational flow dynamics analysis of the risk factors for lesion rupture. J Neurosurg 103：662-680, 2005

9）Hoh BL, Carter BS, Putman CM, Ogilvy CS：Important factors for a combined neurovascular team to consider in selecting a treatment modality for patients with previously clipped residual and recurrent intracranial aneurysms. Neurosurgery 52：732-738, 2003

10）Horowitz M, Purdy P, Kopitnik T, Dutton K, Samson D：Aneurysm retreatment after Guglielmi detachable coil and nondetachable coil embolization：report of nine cases and review of the literature. Neurosurgery 44：712-720, 1999

11）Kim LJ, Albuquerque FC, McDougall C, Spetzler RF：Combined surgical and endovascular treatment of a recurrent A3-A3 junction aneurysm unsuitable for standalone clip ligation or coil occlusion. Neurosurg Focus 18：1-4, 2005

12）Konig RW, Kretschmer T, Antoniadis G, Seitz K, Braun V, Richter HP, Perez de Laborda M, Scheller C, Borm W：Neurosurgical management of previously coiled recurrent intracranial aneurysms. Zentralbl Neurochir 68：8-13, 2007

13）黒田　敏，牛越　聡，新谷好生，長内俊也，石川達哉，瀧川修吾，宝金清博，岩崎喜信：不完全コイル塞栓術後の脳動脈瘤に対する外科治療．No Shinkei Geka 32：645-650, 2004

14）Lawton MT, Quinones-Hinojosa A, Sanai N, Malek JY, Dowd CF：Combined microsurgical and endovascular management of complex intracranial aneurysms. Neurosurgery 52：263-274, 2003

15）Marks MP, Steinberg GK, Lane B：Combined use of endovascular coils and surgical clipping for intracranial aneurysms. AJNR Am J Neuroradiol 16：15-18, 1995

16）Minh T, Hwang PY, Nguyen KC, Ng I：Neurosurgical management of intracranial aneurysms following unsuccessful or incomplete endovascular therapy. Br J Neurosurg 20：306-311, 2006

17）Mizoi K, Yoshimoto T, Takahashi A, Nagamine Y：A pitfall in the surgery of a recurrent aneurysm after coil embolization and its histological observation：technical case report. Neurosurgery 39：165-169. 1996

18）Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R：International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms：a randomised trial. Lancet 360：1267-1274, 2002

19）Pogady P, Mustafa H, Wies W, Lungenschmid K, Wurm G, Tomancok B, Holl K, Fischer J：Microsurgical management of a complicated aneurysmal endovascular embolisation with GDC coil：A case report. Neurosurg Rev 21：206-209, 1998

20）Quadros RS, Gallas S, Noudel R, Rousseaux P, Pierot L：Endovascular treatment of middle cerebral artery aneurysms as first option：single center experience of 92 aneurysms. AJNR Am J Neuroradiol 28：1567-1572, 2007

21）Regil L, Dehdashti AR, Uske A, de Tribolet N：Endovascular coiling compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms：an update. Acta Neurochir Suppl 82：41-46, 2002

22）Sani S, Lopes DK：Treatment of a middle cerebral artery bifurcation aneurysm using a double neuroform stent “Y” configuration and coil embolization：technical case report. Neurosurgery 57：209, 2005

23）佐野公俊，加藤庸子，Singh F.B，Abdeen K，金岡成益，片田和廣，神野哲夫：治療困難な脳動脈瘤の治療法：直達手術と血管内外科併用療法．脳卒中の外科27：177-182, 1999

24）Thornton J, Dovey Z, Alazzaz A, Misra M, Aletich VA, Debrun GM, Ausman JI, Charbel FT：Surgery following endovascular coiling of intracranial aneurysms. Surg Neurol 54：352-360, 2000

25）牛越　聡，宝金清博，黒田　敏，宮坂和男，岩㟢喜信：脳底動脈遠位部broad neck動脈瘤に対する意図的な頚部形成的不完全clippingを併用した塞栓術．No Shinkei Geka 29：1215-1220, 2001

26）Yoshida K, Wataya T, Hojo M, Doi D, Yamagata S：Surgical clipping of a recurrent small saccular aneurysm after repeated coil embolization -case report-. Neurol Med Chir (Tokyo) 45：356-359, 2005