重症クモ膜下出血治療成績

抄録

Aggressive surgical treatment, including intracerebral and/or intraventricular hematoma evacuation, cisternal clot irrigation, external decompression, unilateral temporal lobectomy with resection of herniated uncus and aneurysmal clipping, was carried out on poor-grade aneurysmal SAH patients (Hunt and Kosnik Grade 4 or 5). A protocol consisting of a reversibility test of dilated pupils and light reflex under a rapid infusion of 900-1200ml mannitol was utilized for selection of operative candidates. The patients who showed bilateral negative light reflex with dilated pupils even after the infusion of mannitol were excluded from active treatment and given supportive care only. During the period between April 1992 and December 1994 a total of 207 SAH patients were admitted to our department, with 88 (42.5%) patients arriving in Grade 4 or 5. Urgent operations were performed on all the 41 Grade 4 patients and on 12 of the 47 Grade 5 patients. Preoperative CT scans in Grade 4 patients showed Fisher Group 2 in one case, Group 3 in 23 and Group 4 in 17. Those in Grade 5 surgical group were Fisher Group 3 in 7 cases and Group 4 in 5 cases. The outcome at 3 months of the Grade 4 patients following Glasgow Outcome Scale was GR in 9 (22.0%), MD in 10 (24.4%), SD in 13 (31.7%), V in 1 (2.4%) and D in 8 (19.5%). More favorable outcomes (GR, MD) were obtained in Fisher Group 3 (14/23, 60.9%) than in Fisher Group 4 (5/17, 29.4%). In the 12 Grade 5 patients who were selected for active treatment, 5 patients survived with moderate to severe deficits and 7 died. Mortality in the Fisher Group 3 was 85.7% (6/7) and 20% (1/5) in the Fisher Group 4. In the 4 patients who survived in Grade 5 with Fisher 4, 3 were cases having casting intraventricular hematoma. In the 35 non-surgical group, all patients had died within 2 weeks.
We conclude that Grade 4 aneurysm patients can achieve a better outcome with active treatment based on immediate intracranial pressure decrease and brain stem decompression. Even in Grade 5, patients with Fisher 4, especially the cases with casting intraventricular hematoma, can survive with urgent and aggressive surgical treatment. On the other hand, the result in Grade 5 patients presenting Fisher Group 3 CT findings are poor, and we suggest that hypoxia caused by cardio-pulmonary dysfunction would have a greater effect on brain condition than intracranial hypertension.