多発性脳動脈瘤に対する一期的clipping術

抄録

Background: Various options that focused on securing all aneurysms using any available technique (endovascular, 1-stage clipping using unilateral or multiple craniotomies, or second-stage clipping) have been advocated for use in the treatment of multiple intracranial aneurysms (MIA). However, surgical management of MIA is still controversial.
Objective: For patients with MIA, our policy has been to treat all aneurysms, ruptured and unruptured, in a 1-stage operation, using multiple craniotomies if necessary, but only when changing of the patient's position is not required. The purpose of this study is to evaluate the safety and effectiveness of 1-stage clipping procedures for MIA.
Patients and methods: From October 2004 to March 2016, we retrospectively identified 92 patients with MIA. Patient characteristics and surgical outcomes for MIA were compared to those of 270 cases with a single intracranial aneurysm (SIA) clipped during the same period at our hospital, as well as 38 MIA cases that underwent 1-stage coiling as reported by Solander in 1999. Data included: age, sex, aneurysmal location and size, preoperative clinical Hunt and Kosnik Grade (H & K), procedure-related complications, symptomatic spasm (SS), infarction due to spasm, and postoperative hydrocephalus. Outcome at discharge was assessed using the Glasgow Outcome Scale (GOS).
Results: Except for age, clinical characteristics of MIA and SIA patients did not differ. One-stage multiple craniotomies for radical clipping of MIA were performed in 20 patients, whereas single craniotomies were performed in 72 MIA patients. The clinical outcomes (GOS) in 92 patients with MIA were as follows: good recovery (GR) 73 (79.3%), moderate disability (MD) 17 (18.5%), severe disability (SD) 1 (1.1%), vegetative state (V) 0 (0%), and death (D) 1 (1.1%). When comparing these cases with SIA patients at our institution, as well as with MIA patients who underwent 1-stage coiling in Solander's study, no difference in overall outcome was observed. In addition, while the risk of surgical complications was significantly higher in MIA patients than in SIA patients, there was no difference in the occurrence of infarction due to spasm or hydrocephalus. Although the occurrence of infarction due to spasm did not differ between MIA and SIA patients, the occurrence of SS in preoperative H & K Grade 3 patients differed significantly between SIA patients and confined MIA patients managed with a single craniotomy rather than one-stage multiple craniotomies.
Conclusions: This study suggests that aggressive surgery, such as 1-stage clipping for MIA, is not associated with negative outcomes. Therefore, we recommend that whenever feasible, all MIA should be treated with a 1-stage operation. However, in terms of spasm, we should balance the benefits and risks of 1-stage MIA clipping using a single craniotomy with greater risk of SS versus SIA clipping in a single craniotomy and MIA clipping in multiple craniotomies, particularly for poor grade subarachnoid hemorrhage patients.