閉塞性脳血管障害に合併した未破裂脳動脈瘤の外科治療

-血行再建術との重複手術の安全性の検討を中心に-

抄録

Twenty-one patients underwent surgery for unruptured cerebral aneurysms associated with ischemic cerebrovascular disease between 1980 and 1989. In five patients (group A), extracranial-intracranial (EC-IC) bypass or carotidendarterectomy (CEA) was performed at the same time as aneurysm surgery. In five patients (group B), EC-IC bypass or CEA was performed subsequent to aneurysm surgery. In eleven patients (group C), revascularization was not performed. Two patients in group A had ischemic complications (reversible ischemic neurological deficits, RIND), and one patient in group B had a hemorrhagic complication postoperatively. However no permanent deficit developed in any of these patients. Two of these patients had perioperative problems, one in group A had intraoperative hypocapnia and one in group B had been under medication with an antiplatelet drug preoperatively.
The risk of aneurysm surgery for patients who have indications for cerebral revascularization are greater than for patients without such indication. And the risk of surgical complications is greatest when aneurysm surgery is performed concomitantly with revascularization. One reason may be that the brain of these patients is hypoperfused, and is vulnerable to brain retraction, hypocapnia or hypotention. The other reason may be that the temporary arterial occlusion during revascularization or the change of blood flow after revascularization increases the risk of surgical complications.
We conclude that usually, it may better to perform aneurysm surgery without performing revascularization, and when we perform revascularization at the same time, it is more important to pay careful attention to perioperative management including tender operative manipulation of the brain tissue with proper intraoperative monitoring.