脳動脈りゅう手術におけるｄｏｍｅ ｐｕｎｃｔｕｒｅの重要性 特に前交通動脈りゅう手術における穿通枝温存のために

Abstract

In cerebral aneurysm surgeries, preservation of the perforating arteries is essential. In the case of anterior communicating artery (Acom) aneurysms, confirmation and dissection of the perforating arteries are sometimes difficult due to the complexity of the Acom complex and relatively deep and narrow operative fields. Moreover, necks of the Acom aneurysms are occasionally broad and/or fragile and easy to be torn by dissection procedures. When the dissection of the neck and/or the perforating arteries is difficult because of some of the above-mentioned reasons, we have used dome puncture techniques to reduce tension and volume of the aneurysms under temporary parent artery clipping or tentative dome/neck clipping. In a recent series of 48 consecutive aneurysms of the anterior circulation of the Willis ring, including 11 Acom aneurysms, dome puncture technique was used in 7 aneurysm cases (3 Acom, 3 middle cerebral artery (MCA) and 1 internal carotid artery (ICA) aneurysms). Sizes of these 3 Acom aneurysms were 10 mm, 10 mm and 8 mm each. In contrast to the Acom aneurysms, all MCA/ICA aneurysms were “large” (12 mm or larger) except 1 MCA aneurysm located at the junction of the M1 and the striate artery. Of these 7 cases, there were neither perforator injuries nor neck injuries. We stress the usefulness of dome puncture techniques for safe and reliable neck clipping in the case of “large” or complicated aneurysms. Especially in the case of Acom aneurysm, this technique efficiently prevents injuries of the perforating arteries and the necks, even if the aneurysmal size is relatively small.