重症破裂脳動脈瘤の治療方針

Abstract

We have analyzed the surgical results of ruptured cerebral aneurysms classified into Grade III, IV or V of Hunt and Kosnik's classification, so as to understand the surgical indications and the points of peri-surgical management for these cases at present. We also looked back 12 cases on this criteria experienced in the year of. 1994 and compared these two results. The clinical materials for the study consists of 154 cases in Grade III, 99 in Grade IV and 14 in Grade V. Surgical outcomes at discharge were classified into excellent, good, fair, poor or dead, and the former two were regarded as favorable and later three as unfavorable outcomes. These results were correlated to the aneurysmal location, timing of the operation, patient age, use of temporary clip (TC), premature rupture (PR) or use of continuous cisternal drainage (CCD). There were 52 cases (34%) of unfavorable outcomes in Grade III, 65 (66%) in Grade IV and 14 (100%) in Grade V. Vertebro-basilar aneurysms (VBA) had a tendency to result in a greater rate of unfavorable outcome (43%) compared to the other location of aneurysms in Grade III, but it was not statistically significant. Early surgery (within 72 hours) was somewhat better in VBA in Grade III and the predominance of early surgery was significant (p<0.001) in cases of Grade IV. Patient age (younger or older than 70 years) significantly influenced (p<0.05) the outcome of Grade III patients and early surgery was better especially in the group of younger (<70 years) patients in Grade IV. There was no significant correlation between TC, PR or CCD and the outcome in any group. The main causes for unfavorable outcome were symptomatic vasospasm (VS) in 26 cases (50%), primary brain damage (PBD) in 12 cases (23%), surgical procedure (SP) in 7 cases (13%) and complication (Comp) in 7 cases (13%) out of 52 Grade III unfavorable outcomes, respectively. In Grade IV, PBD occurred in 54 cases (83%), Comp in 6 (9%), and VS in 5 (8%) out of 65 cases. In Grade V, all 14 cases were unfavorable due to PBD. These results indicate that the surgical management for these patients at present should be as follows. Grade V patients basically should not be operated on except for few cases who have special conditions such as acute hydrocephalus or ICH as a cause of poor consciousness. Early surgery is strongly recommended for rest of the cases, especially for the Grade IV cases both younger and advanced aged patients. To reduce the unfavorable outcomes, prevention of the VS is most important in Grade III. It must also be kept in mind that postoperative complications such as pneumonia are important factors of unfavorable outcomes especially for advanced aged patients. Finally the operative results of 12 cases in 1994 were a little better in Grade III but similar problems were still present in Grade IV.