内頚動脈前壁破裂脳動脈瘤の手術戦略

─クリッピング可能症例を中心に─

抄録

We experienced four cases of ruptured aneurysms arising from the anterior wall of the internal carotid artery (ICA) in the past 12 years. Preoperative 3D-CTA and cerebral angiography showed irregular shaped saccular aneurysms in two cases and small protrusion in the ICA in another two cases. In three of the four cases the tough aneurysmal neck was observed and neck clipping was performed. In one case, a blood blister-like aneurysm was observed and the aneurysm neck and ICA wall were clipped by the root of a fenestrated clip blade. Anterior wall aneurysms of the ICA are classified into the blister type with a blood blister-like configuration or the saccular type (non-blister type) with a relatively tough neck. Saccular type aneurysms can be safely treated by clipping. But it is impossible to distinguish correctly the blood blister-type or saccular type by preoperative 3D-CTA and cerebral angiography. Recently, trapping with an EC-IC bypass has been recommended for ruptured aneurysms arising from the anterior wall of the ICA.
However, we consider that trapping with bypass should not be selected primarily in all cases. Premature rupture should be avoided by gentle maneuvers, minimum brain retraction and subpial dissection of the aneurysm while observing the aneurysm neck in detail. It is important to determine the best treatment: neck clipping, clipping on wrapping, or trapping with EC-IC bypass after careful observation of the aneurysm.