Temporary clippingを極力使用しない立場での脳動脈瘤手術

Abstract

We operated on 267 (87.8%) out of 304 patients with ruptured aneurysms and all of the 33 patients with unruptured aneurysms between April 1983 and December 1989. In this period patients with ruptured aneurysms were managed under lower blood pressure preoperatively, with no antifibrinolytics, and we used infrequent temporary occlusion of the parent vessels to avoid the risk of cerebral ischemia. Two hundred and seventeen patients (81.2%) were operated on in the early stage to prevent preoperative rerupture.Intraoperative rupture occurred in 32(12.0%) of 267 ruptured aneurysms and in 1 (1.2%) of 83 unruptured aneurysms. To complete permanent neck clipping after intraoperative rupture, temporary clipping of the parent vessels was required in 13 cases (39.4%), point suction “bursting” bleeding in 8, and tentative dome or neck clipping in 6. Bleeding from the rent of the neck ceased spontaneously in 4 and Oxycel cotton was effective on 1 case. Temporary clipping was also used in 4 patients with large and giant aneurysms, 3 with fragile and blister aneurysms, and 1 with a complex fenestrated Acom aneurysms without occurrence of intraoperative rupture. Occlusion times ranged from 3.5 to 24.0 minutes. Of the 21 cases (7.0%) where temporary clipping was used, only one patient had new neurological deficits in the immediate postoperative period, but made a good recover.To minimize the risk of cerebral ischemia, it is important to use temporary clipping in only selected cases and to avoid early placement of temporary clips. In particular, reduction of intraoperative rupture results in low frequency of temporary clip application. The tight clot and adhesion surrounding an aneurysm make dissection of an aneurysm-artery complex more difficult and lead to intraoperative rupture. In our experience of management of patients with ruptured aneurysms without antifibrinolytics, removal of the clot was easier in most cases because the clot was gelatinous and soft.