急性期破裂脳動脈瘤の脳室鋳型血腫およびクモ膜下血腫除去に関する工夫

抄録

Casting hematoma and subarachnoid hemorrhage in acute subarachnoid hemorrhage causes serious consciousness disturbance and can be fatal. Severe subarachnoid hemorrhage with Fisher Group 3 or more causes symptomatic cerebral vasospasm, which greatly affects the prognosis in such serious cases. Here we report our procedure to remove intraventricular casting hematoma and subarachnoid clots to improve the prognosis in such serious cases.
Intraventricular casting hematoma: Intraventricular casting hematoma is often found in ruptured anterior communicating artery aneurysm, and anterior interhemispheric approach (AIH) is used to clip the aneurysm. Intraventricular casting hematoma complicated with anterior communicating artery aneurysm, in many cases, ranges from the anterior horn of the lateral ventricle, to the body, posterior horn, inferior horn, and third ventricle. Removal of casting hematoma is possible from the anterior horn of the lateral ventricle by frontal corticotomy after AIH. The contralateral intraventricular casting hematoma can be treated by breaking the septum pellucidum, and the third ventricle can be treated via the foramen of Monro. After removal of the hematoma, drainage tubes are placed in the trigone and third ventricle to control the intracranial pressure.
Subarachnoid clot: For subarachnoid hemorrhage in the acute stage, the irrigation suction system is applied with irrigation water, that is 500ml of saline mixed with 60,000 units of urokinase compressed to 400mmHg, to remove the subarachnoid clots as much as possible. In severe subarachnoid hemorrhage with Fisher Group 3 or more, the sylvian fissure is opened widely from the distal part to remove clots. In addition, clots are removed from the carotid cistern and prechiasmatic cistern, then the liequist membrane is opened, and clots are removed from the ambient cistern, interpeduncular cistern, and prepontine cistern not only in case of internal carotid aneurysm but also in case of middle cerebral aneurysm. Finally, the tip of the drainage tube should be placed in the opposite inlet of the ambient cistern. In case of anterior communicating aneurysm, removal of subarachnoid clots is basically limited to those in the anterior interhemispheric fissure and prechiasmatic cistern because the approach is made by AIH. Therefore, the frontal base should be opened with the bifrontobasal approach first, to allow the sylvian fissure to be easily opened by the frontobasal approach. Subarachnoid clots in the sylvian fissure can be removed by the frontobasal approach, and also from the interpeduncular cistern and prepontine cistern.
By this method, consciousness disturbance was improved in early postoperative stages in intraventricular casting hematoma cases. In addition, extensive removal of subarachnoid clots significantly reduced the occurrences of symptomatic vasospasm.