急性期破裂脳動脈瘤に対する血管内手術の治療成績

Abstract

ISAT findings and the improvement of the endovascular devices have led to increased use of endovascular surgery (endosaccular coil embolization) in the treatment of ruptured cerebral aneurysms. Since April 2003, Juntendo University and some affiliated hospitals have adopted an endovascular surgery as the first treatment of choice for ruptured cerebral aneurysms. Furthermore, a few affiliated hospitals adopted endovascular surgery when it was thought to be superior to surgical clipping. As a result, 205 patients (127 females, 78 males) with a mean age of 59.3 years (range 22-91) underwent endovascular surgery for a ruptured cerebral aneurysm within 72 hours from onset between April 2003 and March 2007. We report in this study our experiences of endovascular surgery in the acute stage for subarachnoid hemorrhage due to rupture of a cerebral aneurysm. The frequent locations of the aneurysms were of the anterior communicating artery (36.1%), internal carotid artery (31.2%) and the middle cerebral artery (17.1%). The rate of the aneurysms in the posterior circulation was 12.2%. The mean aneurysmal dimensions were 5.6±2.5 mm for the long axis, 4.0±2.0 mm for the short axis, and 2.9±1.2 mm for the neck width. The aneurysms with 10 mm or larger size comprised 7.8% of all aneurysms. The immediate angiographic results showed complete occlusion at 69.8%, neck remnant at 15.1%, body filling at 12.2% and attempted cases at 2.9%. Clinical outcome excluding attempted cases, according to the Glasgow outcome scale, at discharge or transfer to another hospital shows that the favorable outcome consisted of either good recovery or moderate disability (81.4%), and the unfavorable outcome consisted of either severe disability, persistent vegetative state or death (18.6%). The overall permanent morbidity and mortality rate directly related to the procedure was 1.5%. We had only 1 case of bleeding from the coiled aneurysm leading to death. Symptomatic cerebral vasospasm developed in 17.6% of all patients. Radiological evaluations after 3 months by either cerebral angiography or brain magnetic resonance angiography showed the following anatomical changes of the coiled aneurysms: unchanged, 51.9%; minor recurrence, 25.5%; major recurrence, 16.0% and progressive thrombosis, 6.6%. All aneurysms with major recurrences were retreated endovascularly. Endovascular surgery in the acute stage of ruptured cerebral aneurysms was safe and improved the clinical outcome. The problem of treated aneurysm recurrence, however, still remains to be resolved. Therefore, patients who have undergone endovascular surgery for a ruptured cerebral aneurysm, should be closely followed up with clinical and radiological evaluations.