破裂脳動脈瘤の治療 クリッピング第一選択による破裂脳動脈瘤の治療成績―瘤内塞栓術の導入で転帰は改善したか―

Abstract

We compare outcomes of ruptured aneurysmal subarachnoid hemorrhage mainly treated by surgical clipping between 2000 and 2004 (early term) with outcomes of patients mainly treated by surgical clipping between 2005 and 2007 (late term) with first selection of endovascular coiling to poor-grade, posterior circulation, or elderly patients. Between January 2000 and September 2007, 287 patients were treated and 147 and 140 patients belonged to early and late terms, respectively. Poor grade patients (Hunt and Kosnik Grade IV, V) comprised 24.5% and 34.5% (NS), posterior circulation patients comprised 14.3% and 10.7% (NS), and, elderly patients (over 70 year-old) comprised 23.1% and 35.0% in early and late terms, respectively. The rate of elderly was significantly higher in late term than in early (p＜0.05). Endovascular coiling was performed on 10.9% and 29.8% of patients in early and late terms, respectively, and the rate was significantly higher in late term than in early (p＜0.01). Good outcomes were assessed with modified Rankin Scale of 0－2 at 6 months. Good outcomes were 61.2% and 62.1% in early and late terms, respectively (NS). In poor-grade patients, good outcomes were 13.9% and 27.7% (NS), in posterior circulation, 47.6% and 53.3% (NS), and in elderly, 26.5% and 53.5% in early and late terms, respectively, and the rate of good outcomes in elderly was significantly higher in late term than in early (p＜0.05). Outcomes of ruptured aneurysmal patients were significantly improved in elderly patients, but not in poor grade, nor in posterior circulation, due to first selection of endovascular coiling. Despite the significant increase of elderly patients, total outcomes of ruptured subarachnoid hemorrhage in late term were not inferior to those of early term.