破裂脳動脈瘤最重症例の外科治療

Abstract

One hundred fourteen serious cases of ruptured intracranial aneurysms were studied clinically with special reference to prognosis and surgical indication. In this series, 57 cases underwent radical surgery in the acute stage and 57 cases were treated conservatively (including cases only treated with continuous ventricular drainage). The criterion for these serious cases was designated as semicoma or coma state just before operation in the radically treated group, and at admission in the conservative group. CT findings were divided into the following four types based on the cause of the severe disturbance of consciousness: 1) subarachnoid hemorrhage (SAH) type having only severe subarachnoid clot, 2) intraventricular hemorrhage (IVH) type having packed intraventricular hematoma, 3) intracerebral hematoma (ICH) type which showed massive ICH, and 4) subdural hematoma (SDH) type which showed massive SDH. All patients in the conservatively treated group died except for one vegetative case. On the other hand, the outcome in 57 surgically treated cases was as follows: four (7.0%) fully recovered; 10 (17.5%) were capable of self management; 22 (38.6%) were partially of fully dependent, and 21 (36.8%) died. In the radically treated cases, we investigated preoperative factors that might predict clinical outcome, such as neurological grade, brain stem response, CT findings, response after injection of 20% Mannitol (300-900ml), and time from the last bleeding episode to the operation. It was recognized that there is no relationship between the neurological grade just before radical operation and the outcome in these serious cases. Results were good in patients in each of the following sub-groups: 1) Neurological symptom improved after rapid administration of 20% Mannitol even though the patient was still comatose. 2) Cases in which brain stem responses such as the ciliospinal reflex and oculocephalic reflex were preserved. 3) Surgery could be performed within six hours of the last bleeding episode. If surgery is performed when any of the above conditions prevail, we feel that completely successful early surgery can be expected. It is important to emphasize, in addition, that our experience shows that a great deal of unfavorable outcome can be eliminated by the evacuation of clots at the time of clipping of the neck of the ruptured aneurysms. Thus, evacuation of the following four types of clots should be included in the surgical procedure: ICH, SDH, IVH and SAH.