この１例から学ぶ 塞栓療法後に再増大，再治療を繰り返した破裂脳底動脈りゅうの１例

Abstract

A 58-year-old male suffered from diffuse and symmetric subarachnoid hemorrhage with Hunt and Kosnik Grade II. Angiography demonstrated 3 aneurysms. The largest was located at the basilar artery (BA) tip with a size of 18 mm ×15 mm ×14 mm and thought to have a small bleb. The 2nd largest was located at the left middle cerebral artery (MCA) bifurcation and showed an irregular shape with a maximum diameter of 5 mm. The smallest was at the right MCA bifurcation and showed a round shape with a maximum diameter of 3 mm. One of first 2 was thought to be ruptured, and we first treated the left MCA aneurysm by surgical clipping and confirmed it was unruptured. Immediately after clipping, we performed intraaneurysmal embolization of BA tip aneurysm using GDC.The result of embolization was a neck remnant with a volume embolization rate of 19.3%. The patient was discharged without any neurological deficit and continued oral anti-platelet drug for 6 months. Follow-up angiography 6 months later demonstrated enlargement of the remnant neck. Re-embolization was performed 8 months after initial embolization. At that time we planned the embolization with the help of neck plasty technique using two the balloons, but we could introduce the balloon microcatheter only into the right posterior cerebral artery (PCA). The result was again a neck remnant. Follow-up angiography was performed 6 months, 12 months, and 24 months after re-embolization, and the neck remnant was enlarged every time. Because re-embolization was technically difficult, we hesitated to perform a third embolization. Follow-up angiography at 36 months, however, showed large ballooning of the aneurysmal body, which made us decide to perform the third embolization. At the third embolization, immediately after introduction of balloon microcatheter into the left PCA, the BA was suddenly occluded. The BA was not recanalized any more in spite of fibrinolysis using tissue-type plasminogen activator. The patient died 5 days later.Appropriate case selection, including size of aneurysm, timing of embolization and probability of complete obliteration is essential for coil embolization. Performing embolization on inappropriate patients may result in poor control of the aneurysm complicate further treatment.