Neurological Surgery 脳神経外科43巻4号

2015年04月発行

症例

後下小脳動脈を含んだ破裂椎骨動脈解離に対し，ステントを用いた二期的コイル塞栓術により後下小脳動脈を温存した1例

著者： 福田健治¹ 東登志夫¹ 吉岡努¹ 重森裕¹ 岩朝光利¹ 三木浩一¹ 井上亨¹

所属機関： ¹福岡大学医学部脳神経外科

ページ範囲：P.331 - P.337

Ⅰ．はじめに
　後下小脳動脈（posterior inferior cerebellar artery：PICA）起始部を含んだ破裂椎骨動脈解離（PICA involved ruptured vertebral artery dissection：Pi-rVAD）の治療法には直達手術と血管内治療があり，その中でもいくつものバリエーションが存在する．また最近ではステントを用いた血管内治療の報告がなされている．今回われわれは，発達したPICA起始部を含んだ破裂VADに対して，初回治療でPICA分岐後のより不整に拡張し，破裂部と考えられた椎骨動脈（vertebral artery：VA）遠位部に対してコイルによるinternal trapping（IT）を行い，破裂急性期を脱した後に十分な抗血栓療法下にPICAから近位VAにかけてEnterprise vascular reconstruction device（Enterprise VRD；Codman Neuroendovascular, Johnson ＆ Johnson, Miami, FL, USA）を用いて近位VA拡張部を塞栓し，PICAを温存できた症例を経験したので報告する．

参考文献

1) Ahn JY, Han IB, Kim TG, Yoon PH, Lee YJ, Lee BH, Seo SH, Kim DI, Hong CK, Joo JY：Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling. AJNR Am J Neuroradiol 27：1514-1520, 2006

2) Bodily KD, Cloft HJ, Lanzino G, Fiorella DJ, White PM, Kallmes DF：Stent-assisted coiling in acutely ruptured intracranial aneurysms：a qualitative, systematic review of the literature. AJNR Am J Neuroradiol 32：1232-1236, 2011

3) Chung J, Kim BS, Lee D, Kim TH, Shin YS：Vertebral artery occlusion with vertebral artery-to-posterior inferior cerebellar artery stenting for preservation of the PICA in treating ruptured vertebral artery dissection. Acta neurochir（Wien）152：1489-1492, 2010

4) Endo H, Matsumoto Y, Kondo R, Sato K, Fujimura M, Inoue T, Shimizu H, Takahashi A, Tominaga T：Medullary infarction as a poor prognostic factor after internal coil trapping of a ruptured vertebral artery dissection. J Neurosurg 118：131-139, 2013

5) He M, Zhang H, Lei D, Mao BY, You C, Xie XD, Sun H, Ju Y, Zhang JM：Application of covered stent grafts for intracranial vertebral artery dissecting. J Neurosurg 110：418-426, 2009

6) Iihara K, Sakai N, Murao K, Sakai H, Higashi T, Kogure S, Takahashi JC, Nagata I：Dissecting aneurysms of the vertebral artery：a management strategy. J Neurosurg 97：259-267, 2002

7) Kim BM, Shin YS, Kim SH, Suh SH, Ihn YK, Kim DI, Kim DJ, Park SI：Incidence and risk factors of recurrence after endovascular treatment of intracranial vertebrobasilar dissecting aneurysms. Stroke 42：2425-2430, 2011

8) Kim MJ, Chung J, Kim SL, Roh HG, Kwon BJ, Kim BS, Kim TH, Kim BM, Shin YS：Stenting from the vertebral artery to the posterior inferior cerebellar artery. AJNR Am J Neuroradiol 33：348-352, 2012

9) Kitanaka C, Morimoto T, Sasaki T, Takakura K：Rebleeding from vertebral artery dissection after proximal clipping. Case report. J Neurosurg 77：466-468, 1992

10) Lv X, Jiang C, Li Y, Wu Z：Clinical outcomes of ruptured and unruptured vertebral artery-posterior inferior cerebellar artery complex dissecting aneurysms after endovascular embolization. AJNR Am J Neuroradiol 31：1232-1235, 2010

11) Mizutani T, Aruga T, Kirino T, Miki Y, Saito I, Tsuchida T：Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 36：905-911；discussion 912-913, 1995

12) 毛利正直，内山尚之，見崎孝一，林　康彦，林　裕，濱田潤一郎：後下小脳動脈（PICA）分岐部を含んだ破裂椎骨動脈解離性動脈瘤に対する治療—PICAの灌流領域と治療後動脈瘤のサイズ変化—．脳卒中の外科41：358-362, 2013

13) Park SI, Kim BM, Kim DI, Shin YS, Suh SH, Chung EC, Kim SY, Kim SH, Won YS：Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 30：1351-1356, 2009

14) Prabhakaran S, Wells KR, Lee VH, Flaherty CA, Lopes DK：Prevalence and risk factors for aspirin and clopidogrel resistance in cerebrovascular stenting. AJNR Am J Neuroradiol 29：281-285, 2008

15) Sasaki O, Ogawa H, Koike T, Koizumi T, Tanaka R：A clinicopathological study of dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 75：874-882, 1991

16) Shin YS, Kim BM, Kim SH, Suh SH, Ryu CW, Koh JS, Kim DI, Kim DJ：Endovascular treatment of bilateral intracranial vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage. Neurosurgery 70：75-81；discussion 81, 2012

17) Takai N, Ezuka I, Sorimachi T, Kumagai T, Sano K：Vertebral artery dissecting aneurysm rebleeding after proximal occlusion--case report. Neurol Med Chir（Tokyo）33：765-768, 1993

18) Turk AS, Niemann DB, Ahmed A, Aagaard-Kienitz B：Use of self-expanding stents in distal small cerebral vessels. AJNR Am J Neuroradiol 28：533-536, 2007

19) Yasui T, Komiyama M, Nishikawa M, Nakajima H：Subarachnoid hemorrhage from vertebral artery dissecting aneurysms involving the origin of the posteroinferior cerebellar artery：report of two cases and review of the literature. Neurosurgery 46：196-200；discussion 200-291, 2000

20) Yeung TW, Lai V, Lau HY, Poon WL, Tan CB, Wong YC：Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 116：882-887, 2012

21) Zhang J, Lv X, Jiang C, Li Y, Yang X, Wu Z：Endovascular treatment of cerebral aneurysms with the use of stents in small cerebral vessels. Neurol Res 32：119-122, 2010