破裂脳動脈瘤Clipping術後画像評価のModalityとTiming

Abstract

To evaluate the efficacy and safety of CT angiography (CTA) performed at immediate early postoperative periods in patients with ruptured intracranial aneurysm, we retrospectively analyzed the modality and timing of postoperative evaluation following clip placement for ruptured intracranial aneurysms in our institution during the last decade. Between 2001 and 2007 (Phase A: 281 cases), postoperative evaluation with digital subtraction angiography was performed on or after 14 postoperative days (POD) in the majority of the subjects, except for some postoperative imaging that was done earlier. Re-ruptures were observed in five cases (1.8% of total cases in Phase A), of which three aneurysms bled within two weeks after surgery. Since 2008, we have used the CTA for evaluation in the early postoperative period (Phase B: 102 cases). In particular, after 2009, all patients underwent immediate (POD 1) CTA to exclude aneurysm remnants as early as possible. No adverse incidence was observed during this protocol. In the Phase B period, two small remnants of anterior communicating artery aneurysms (AcomAN, 2.0% of all cases in Phase B) were detected in the CTA on POD 1. The patients in whom aneurysm remnants were found immediately underwent a second surgery to prevent re-rupture. Our findings suggest that immediate postoperative examination (POD 1) by CTA is beneficial to detect an incomplete closure of aneurysms before the postoperative vasospasmic phase. CTA was particularly useful in cases with aneurysms remnant in deeper locations such as AcomAN. Early postoperative evaluation with CTA, therefore, should be considered to reduce risk for devastating re-bleeding during the early postoperative period in patients who undergo clipping surgery for ruptured intracranial aneurysms.