脳卒中の外科
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
35 巻, 5 号
選択された号の論文の11件中1~11を表示しています
特別寄稿
  • 寺坂 俊介, 黒田 敏, 牛越 聡, 中村 雅則, 数又 研, 柏崎 大奈, 岡本 史之, 中西 克彦, 岩崎 喜信
    2007 年 35 巻 5 号 p. 335-341
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    We report the outcomes of prophylactic cerebral reconstructive surgery aimed at reducing the incidence of perioperative cerebral infarction in patients with intracranial or extracranial occlusive cerebrovascular disease who were scheduled to undergo cardiac surgery. Before the surgery, carotid artery ultrasonography, magnetic resonance angiography (MRA) of the carotid artery, and magnetic resonance imaging (MRI) and MRA of the brain were performed on 875 patients. The high-risk group was defined as: patients with cervical carotid artery stenosis of at least 90%, those with a reduced cerebral perfusion reserve because of occlusion of the internal carotid or middle cerebral artery, and those with a reduced cerebral perfusion reserve because of major intracranial artery stenosis of at least 75%. According to the degree of cardiac reserve, patients in the high-risk group underwent carotid artery stenting (CAS), carotid endarterectomy (CEA), superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis, or percutaneous transluminal angioplasty (PTA). Of the 875 patients, 29 (3.3%) were classified in the high-risk group, and 16 underwent prophylactic revascularization and cardiac surgery. Prophylactic revascularization included CAS in 7 patients (including stenting of the intracranial internal carotid artery in 1 patient), CEA in 4, STA-MCA in 4 and PTA in 1. Cardiac surgery was performed on 870 of the 875 patients, and perioperative cerebral infarction occurred in 11 (1.3%). It is uncertain whether our treatment strategy significantly reduced the incidence of perioperative cerebral infarction because of the lack of accurate information on the number of patients with this condition before the present study. However, 73% of patients had a score of 1 or 2 on the modified Rankin Scale 1 month after the onset of cerebral infarction, suggesting that our strategy improved the outcome.
特集 脳動脈瘤の前向き調査
  • ―「破裂脳動脈瘤治療についての前向き集計」短期成績より―
    加納 恒男, 平山 晃康, 片山 容一
    2007 年 35 巻 5 号 p. 342-346
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    We evaluated the selection of surgical treatment and short-term outcome in severe subarachnoid hemorrhage (SAH) patients enrolled in a prospective analysis of treatment of ruptured intracranial aneurysms. Among 84 SAH patients with WFNS Grade 5 at pre-treatment, 51 were treated by surgical clipping and the remaining 33 were treated by endovascular coiling. In the patients treated by clipping, a favorable outcome of GOS GR or MD was obtained in 28% of the patients 2 months after surgery. On the other hand, in the patients treated by coiling, favorable outcomes were obtained in 37% of the patients. Outcome in patients of Fisher Group 4 and of advanced age of 70 years and over was not favorable.
  • ―山口大学の経験―
    中山 尚登, 加藤 祥一, 石原 秀行, 原田 啓, 黒川 徹, 藤澤 博亮, 藤井 正美, 梶原 浩司, 野村 貞宏, 小泉 博靖, 秋村 ...
    2007 年 35 巻 5 号 p. 347-353
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    Aneurysmal subarachnoid hemorrhage (SAH) poses an immediate threat to life. The accepted paradigm of treatment generally involves surgical intervention requiring craniotomy to allow neck clipping of the ruptured cerebral aneurysm, with the alternative approach of embolization of the aneurysm sac by the deposition of detachable coils delivered through the endovascular route. The selection of the treatment method depends on the establishment of clear guidelines for the attending neurosurgeon, but unfortunately no such definitive guidelines leading to a definitive treatment policy have been developed in Japan. Controlled comparison of the alternative treatment approaches of clipping and coil embolization is rendered difficult by the lack of reported series of interventions in patients using either clipping or coil embolization, and the methodological difficulties inherent in the retrospective comparison of the specific results achieved by unrelated institutes or individual surgeons. We describe our 5 years of experience of clipping and coil embolization to promote a consensus of decision-making for acute SAH.
    Our therapeutic protocol emphasizes clipping, with coil embolization mainly considered for patients with poor neurological condition (Hunt & Kosnik Grades IV-V without hematoma), paraclinoid or basilar aneurysm, or serious systemic complications, and for elderly patients over 74 years old or older. We treated 198 patients, 55 males and 143 females aged from 31 to 91 years old (mean 61.3 years) with aneurysmal SAH between 2000 and 2005. Surgical clipping was performed in 164 cases, endovascular treatment in 25 cases, and conservative therapy for ruptured aneurysms in 9 cases. Overall, 95% of patients underwent radical treatment. On admission, 26% of patients were in poor neurological condition (Hunt & Kosnik Grades IV-V). Aneurysms arose from the anterior circle of Willis in 87% of cases. Eighty-seven percent of patients were treated with surgical clipping within 3 days of onset, and 84% were treated with coiling within 3 days.
    Favorable outcome was defined as good recovery or moderately disabled classified by Glasgow Outcome Scale at discharge, which was achieved in 71% of all patients, 76% of patients treated by clipping, and 60% of patients treated by coil embolization. Symptomatic vasospasm occurred in 21% of patients after clipping but only in 3% after coil embolization (p<0.05). Computed tomography showed a low density area in 14% of patients after clipping but only in 3% after coil embolization. Administration of eicosapentaenoic acid significantly reduced the low density area in patients after clipping from 13.5% to 3.3% (p=0.035). Shunt surgery was required in 25% of patients after clipping, but only in 8% after coil embolization. Poor outcome occurred in patients with better preoperative neurological condition (Hunt & Kosnik Grades I-III) in 12% after clipping and in 14% after coil embolization, and preventable causes accounted for 75% and 50% of these cases, respectively.
    Recently, the Ministry of Health, Labour and Welfare has required the collection and submission of accurate and complete information about treatment options, indications, and expected results for ruptured cerebral aneurysms. The availability of such an extensive database enabling rigorous analytical correlations will provide the required foundation to establish specific indications for the selection of the optimal methodology of clipping or coil embolization treatment for patients with acute SAH.
特集 AVMの手術
  • 宇野 昌明, 鈴江 淳彦, 松原 俊二, 佐藤 浩一, 永廣 信治
    2007 年 35 巻 5 号 p. 354-360
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    Multimodal treatment for AVM has been established, improving the outcome of patients with AVM. Preoperative embolization with microsurgical resection was an important multimodal management approach. In this paper, we retrospectively analyzed the outcome and benefit of this treatment. In 20 of 97 patients with microsurgical resection of AVM, perioperative embolization was performed between 1974 and 2005 in our department. There were no complications of perioperative embolization. Surgery was performed 1 to 3 days after perioperative embolization. In these patients, feeders that had been embolized were often easier to be coagulated. In addition, intraluminal embolic agents can help the operator identify feeders that require occlusion, as distinguished from normal arteries en passage that require be preservation. Moreover, reduction of blood loss and operation time was another merit.
    Perioperative embolization is beneficial especially for patients with Spetzler & Martin Grade II and III.
特集 手術教育
  • ―初心者指導の経験から―
    堤 一生
    2007 年 35 巻 5 号 p. 361-363
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    Recently, better direct surgery for cerebrovascular disease has come to be required, while less invasive treatment (gamma knife and intravascular surgery) has played an alternative role. To improve the quality of surgery, one of the most important issues is the surgical education of young neurosurgeons. They must learn traditional surgical skills and achieve more sophisticated techniques than those of their seniors. In this paper, I present my experience and discuss the education of neurosurgeons.
    My teaching method was based on suturing training with 10-0 nylon using a microscope and hands-on practice under my supervision. This training was useful to improve dexterity and maneuverability with a limited number of clinical cases. The hands-on practice of microsurgery was inevitable to learn surgical skills and judgment. Moreover, the experience of real surgery was an incentive to train harder. My residents trained in suturing for 1 to 3 years with a total of 10,000 to 20,000 stitches each. During the same period, they operated on 150-250 cases, including aneurysmal clipping (20-50 cases), STA-MCA anastomosis (5-20) and carotid endarterectomy (5-30). Surgical complication was 1-2% of all, although the time of surgery was prolonged in the early stage.
    Differences of resident's grades at the start of training were not related to the results. Satisfactory results were not achieved in less than 2 years. In my subjective judgment, the result of education depended on the individual passion for surgery, the continuous training and a positive attitude about learning from others. Even young neurosurgeons should be given a chance to perform microsurgery if they continue the training. Under a senior's supervision, the results of surgery can be acceptable.
    Early experience and education may be promising for improving microsurgery for cerebrovascular disease.
  • 石川 達哉, 数又 研, 中山 若樹, 安田 宏
    2007 年 35 巻 5 号 p. 364-369
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    Successful clipping surgery for cerebral aneurysms requires us to have a theory and an image, as well as experience and surgical skills. An expert neurosurgeon for cerebral aneurysms must possess these 3 factors. An efficient training system is necessary to train neurosurgeons to become expert at clipping surgery. Trainees can obtain a part of theory and image, which are necessary for clipping surgery, from textbooks, papers, and videotapes without on-the-job training. However, they must participate in a substantial number of clipping surgeries, maybe around 100, as the operator or assistant to brush up their theory and images as well as to develop the required surgical skills. The experience of 50 operations as the main operator followed by 50 operations teaching junior surgeons may be sufficient as a first step in becoming an expert clipping surgeon. More successors can be trained by this roof-tile system than in a one-on-one training system. However, this training system is not always open for all junior neurosurgeons.
原  著
  • ―脳動脈瘤手術初心者の経験―
    中村 一仁, 石黒 友也, 池田 英敏, 宇田 武弘, 村田 敬二, 阪口 正和, 小宮山 雅樹, 安井 敏裕
    2007 年 35 巻 5 号 p. 370-375
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    Recently, endovascular coil embolization is more often used than surgical clipping in the treatment of cerebral aneurysms. However, young neurosurgeons, who have less opportunity to perform and learn surgical clipping than senior surgeons did, must be able to achieve a good outcome when using it. The training in surgical clipping for young neurosurgeons consists of not only knowledge, but also microsurgical skills and experience. A lot of opinions by expert surgeons in surgical clipping are reported, and young neurosurgeons must learn surgical clipping to comprehend them. However, there are no reports from a beginner's point of view on surgical clipping. This paper aims at training in surgical clipping from a beginner's point of view. From 2002 to 2004, among 13 unruptured cerebral aneurysm clipping cases, 14 aneurysms (male 4, female 9 cases), there were 8 middle cerebral artery aneurysms, 3 anterior communicating artery aneurysms and 3 internal carotid artery aneurysms. We analyze operation time, postoperative complications, asymptomatic brain injury and intraoperative rupture. The mean size of the aneurysms and the mean operation time were 5 (4-9) mm and 335 minutes, respectively. There were no postoperative complications, but 3 asymptomatic brain injuries and 2 intraoperative ruptures had occurred. Retrospectively, we know that such surgical complications are avoided by expert neurosurgeons with deep knowledge based on experience. We elucidate the concept of training in surgical clipping for unruptured cerebral aneurysms from the point of view of a beginner learning microsurgery. Beginners, as members of a surgical team, should reflect on every aspect of the surgery to obtain a deep knowledge in surgical clipping.
  • ―有用性と問題点について―
    奥村 浩隆, 寺田 友昭, 中村 善也, 新谷 亜紀, 松田 芳和, 長久 功, 松本 博之, 増尾 修, 津本 智幸, 山家 弘雄, 大浦 ...
    2007 年 35 巻 5 号 p. 376-381
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    We evaluated the advantages and disadvantages of wire braided stent (Wallstent RP) in 17 patients with carotid stenosis with soft to intermediate plaque.
    The average age of the patients was 70.6 year-old and 13 of the 17 (76.5%) patients were symptomatic. Carotid arterial stenting was performed using various protection devices, such as PercuSurge, MintCatch or Parodi Anti Emboli System. In 15 of the 17 cases (88.2%) post dilatation was added and was usually performed after nitinol stents were used. Carotid plaques were evaluated by carotid ultrasounds. A diffusion weighted image was performed within 3 days after the procedure.
    All patients were successfully treated except for 1 who suffered transient ischemic attack after CAS. The morbidity and mortality rates of our series are 0%. The sealing effect of Wallstent RP for carotid plaque was observed with intravascular ultrasound. In 1 patient, carotid artery kinking of the distal side of stent occurred due to the straightening effect of Wallstent RP for the tortuous internal carotid artery. Hyper-intense lesions on DWI were observed only in 33.3% of patients, although 80% of patients had echolucent plaques or ulcerations in carotid ultrasound findings.
    CAS using Wallstent RP may be effective for carotid artery stenosis with soft plaque.
  • 片野 広之, 谷川 元紀, 相原 徳孝, 梅村 淳, 間瀬 光人, 山田 和雄
    2007 年 35 巻 5 号 p. 382-386
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    We previously reported the usefulness of three-dimensional (3D) CT angiography for perioperative evaluation of carotid endarterectomy (CEA) to avoid several complications in conventional angiography, which was reported to be 1.2% in ACAS. We describe here the utility of 3D-CTA in follow-up at an outpatient clinic made possible by the clear and accurate view provided by 3D-CTA.
    Forty-five of 64 consecutive CEA cases were examined with 3D-CTA (mean age 67.7 y/o, male: female=12:4) and 16 consecutive CAS cases (mean age 72.6 y/o, male:female=39:6) were examined with 3D-CTA preoperatively, 1-week, 3 to 6-months and 1 to 2 years after surgical intervention, reconstructing into volume rendering (VR), maximum intensity projection (MIP) and multiplanar reconstruction (MPR) images.
    Three-dimensional CT angiography visualized subtle changes such as small dents caused by vascular tourniquets used in operation, which mostly diminished in 1 year. Dilatation of external carotid artery was shown along with amelioration of internal carotid artery, though 19.4% of external carotid arteries demonstrated transient narrowing or occlusion. Restenosis after CEA occurred in 4 cases (6.3%), 2 of which were subjected to CAS. The course of restenoses as well as the state after stenting were clearly delineated with 3D-CTA. Sagittal and axial MPR images were useful in confirmation for lumen.
    Though DSA remains the gold standard in some facilities in follow-up studies after CEA, its use is declining due to the complications it presents and to the development of other diagnostic modalities. Duplex US is a handy, non-invasive, real-time technique but is limited due to its operator dependency and low resolution. MR angiography is promising, though it is still being developed.
    Three-D CTA with a high-performance workstation provides detailed images with satisfactory information for postoperative follow-up studies in outpatient clinics, though it also presents the problems of X-ray exploration and allergic reaction to contrast media.
  • ―その原因と予後―
    村井 保夫, 寺本 明, 水成 隆之, 小林 士郎, 上山 博康
    2007 年 35 巻 5 号 p. 387-393
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    Complex giant or large internal carotid artery aneurysms present a surgical challenge because limitations and difficulty are encountered with either clipping or endovascular treatment. Our review of previous reports suggests that no current vascular assessment can accurately predict the occurrence of ischemic complications after internal carotid artery ligation. The present study concerns surgical technique, complications, and clinical outcome of radial artery grafting followed by parent artery trapping or proximal occlusion for management of these difficult lesions.
    Between September 1997 and October 2005, we performed radial artery grafting followed immediately by parent artery occlusion in 17 patients with giant or large complex intracranial carotid aneurysms (3 men, 14 women; mean follow-up duration, 62 months). All patients underwent postoperative digital subtraction angiography to assess graft patency and aneurysm obliteration.
    All 17 aneurysms were excluded from the cerebral circulation, with all radial artery grafts patent. Among 4 patients with cranial nerve disturbances, dysfunction was temporary in 5; in the others, oculomotor nerve paresis persisted. No perioperative cerebral infarction occurred. Sensory aphasia reflecting cerebral contusions caused by temporal lobe retraction resolved within 2 months, as did hemiparesis from a postoperative epidural hematoma.
    With appropriate attention to surgical technique, radial artery grafting followed by acute parent artery occlusion is a safe treatment for complex internal carotid artery aneurysms. Graft patency and aneurysm thrombosis were achieved in all patients. Cranial nerve dysfunction (III, VI) caused by altered blood flow from the internal carotid artery after occlusion was the most common complication and typically was temporary.
    In our experience with these difficult aneurysms, not only clipping but also reconstruction of the internal carotid artery was required, especially for wide-necked symptomatic cavernous internal carotid artery aneurysms. Radial artery grafting was a reliable way to bypass the parent segment just prior to its occlusion.
手術手技
  • ―Pterional approachでの諸問題とその対策―
    澤田 元史, 波出石 弘, 安井 信之, 鈴木 明文, 石川 達哉, 師井 淳太, 小林 紀方
    2007 年 35 巻 5 号 p. 394-399
    発行日: 2007年
    公開日: 2008/08/26
    ジャーナル フリー
    We provide intraoperative problems and their preventive measures during the pterional approach to the basilar top aneurysm. We focus on the surgical techniques to obtain a wider operative field through the pterional approach. The surgical difficulties depend on various factors, including the size, location, and direction of the basilar top aneurysm. In particular, the interrelationship between the location of the internal carotid artery and the basilar top aneurysm is an important factor to be fully assessed preoperatively.
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