前頭葉内に大型血腫を合併した破裂前交通動脈瘤の治療方法

抄録

Patients who present with a large intracerebral hematoma (ICH) associated with a ruptured aneurysm usually require urgent clot evacuation as well as aneurysm obliteration, in order to lower the intracranial pressure as early as possible. However, controversy persists regarding the optimal approach for the obliteration of an anterior communicating aneurysm (Acom AN) with massive ICH. The aim of this study was to determine a suitable approach among a variety of surgical procedures for these aneurysms.
The records of 38 patients with ruptured Acom AN with large frontal ICH treated with hematoma evacuation and aneurysm clipping between April 1996 and March 2015 were retrospectively reviewed. The adopted approaches were classified as follows: hematoma-side pterional (PT, 7 patients), contralateral hematoma-side pterional (c-PT, 19 patients), interhemispheric (IH, 9 patients), and transhematoma approach (TH, 3 patients). Preoperative patient characteristics were similar in the four approach groups.
The overall outcomes at discharge according to the Glasgow Outcome Scale (GOS) are summarized as follows: Good Recovery was obtained in 42.1%, Moderately Disabled status in 39.5%, and Severely Disabled status in 13.2%, while the mortality rate was 5.3%. Significant factors associated with poor outcome included increasing age, incomplete evacuation of hematoma, occurrence of infarction due to vasospasm, hydrocephalus, and the use of the c-PT approach.
We therefore recommend aggressive hematoma evacuation and aneurysm obliteration using appropriate approaches such as the TH technique rather than the c-PT procedure for ruptured Acom AN with massive frontal ICH.