脳卒中の外科
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
37 巻, 3 号
選択された号の論文の11件中1~11を表示しています
特集 大型―巨大脳動脈瘤の外科治療
  • 氏家 弘, 上山 博康, 比嘉 隆, 加藤 宏一, 堀 智勝
    原稿種別: 特集 大型―巨大脳動脈瘤の外科治療
    2009 年 37 巻 3 号 p. 149-155
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    Giant fusiform aneurysms are characterized by tortuosity, elongation, distention, and partial thrombosis, and are most frequently found in the vertebrobasilar circulation. Surgical removal of these aneurysms is the treatment of choice for such lesions because they often develop mass signs. We report 14 surgically treated cases that were classified into so-called thrombosed aneurysms in the posterior fossa (VA involved: 9, VA-BA involved: 3, BA involved: 2). Four cases out of 9 VA-involved cases were treated with aneurysmal trapping and aneurysmectomy after OA-PICA anastomosis. The other 5 cases were trapped and aneurysmectomy was performed because of no involvement of PICA flow. Seven out of 9 cases showed very excellent surgical outcomes instead of preoperative pyramidal signs. However, 5 cases involving VA-BA or BA were treated with high flow bypass (VA-RA-PCA bypass), and Hunterian ligation showed very poor surgical outcomes. Only 1 case recovered well after surgery and resumed social activity. The unsatisfactory results were considered to be caused by high flow bypass flew up thrombus induced within the blind aneurysm sac into the perforators, resulting in catastrophic central pontine infarction. The enhanced reversed flow through the bypass caused the already thrombosed aneurysms to grow. We analyze the operative results and discuss the pathogenesis.
  • 加藤 庸子, 佐野 公俊, 渡部 剛也, 小田 淳平, 井水 秀栄, Rahul Mally, 早川 基治, 定藤 章代, 入江 恵子, 根 ...
    原稿種別: 特集 大型―巨大脳動脈瘤の外科治療
    2009 年 37 巻 3 号 p. 156-161
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    対象は過去16カ月間のクリッピングを行った大型動脈瘤45例のうち,largeタイプ40例,giant type 5例である.45例のうち8例はくも膜下出血発症,37例は脳ドックでの摘出術である.
    当教室では手術難易度の高い大型動脈瘤に対して,できる限り自然の血行動態を保ちながら親動脈血管構築を行うことを目標としてきた.今回45例のクリッピング術のうち,特に内頚動脈瘤では血管内外科とタイアップし,retrograde suction decompression法により瘤の内圧を減らし安全に親動脈構築が可能であった.呈示症例は,右large未破裂内頚動脈瘤でmultiple clips in tandem clippingの方法により親動脈の走行に沿い血管構築した.
    もう1例はくも膜下出血で発症した大型右内頚動脈瘤でクリッピングの際に破裂部と後交通動脈との癒着が強く離困難であったため部分的な内頚動脈の血管構築にとどめ残留部はただちにコイル塞栓術を行った.
    親血管内腔の狭窄や分枝,穿通枝閉塞の有無に関しては,神経内視鏡,超音波ドップラー,術中DSA,術中ICG video angiographyによる評価を行った.結果は,脳ドックで発見されたクリッピング術37例ではgood recoveryが37例であり,くも膜下出血発症の8例ではgood recoveryが6例,mild disabilityが2例であった.
    治療難易度の高い大型動脈瘤も可能な限り自然の血行動態を維持することが望まれることから血管内外科の協力のもと,根治できた例をあげその手法につき述べた.
原  著
  • 堤 正則, 相川 博, 鬼塚 正成, 伊香 稔, 児玉 智信, 新居 浩平, 濱口 周子, 江藤 輔聖, 坂本 王哉, 井上 律郎, 中右 ...
    原稿種別: 原  著
    2009 年 37 巻 3 号 p. 162-166
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    We evaluate the efficacy of the coil embolization for tiny ruptured anterior communicating artery (ACoA) aneurysms. Of 21 ruptured ACoA aneurysms with a maximum diameter of 3 mm, coil embolization was successfully carried out in 20 (95%) as the first treatment option. Complete occlusion was achieved in 17 of 20 patients and nearly complete occlusion was realized in 3. There were no treatment-related complications. Seventeen of 20 patients were followed up angiographically for a mean 39.7 months (range 6-72 months), and none of them demonstrated reopening of aneurysm that required additional treatment. Even in tiny ruptured ACoA aneurysms, coil embolization can be a safe and feasible treatment with sophisticated techniques.
  • 藤本 康倫, 豊田 真吾, 岩本 文徳, 重松 朋芳, 矢野 喜寛, 星 拓, 川口 哲, 太田 富雄, 若山 暁, 吉峰 俊樹
    原稿種別: 原  著
    2009 年 37 巻 3 号 p. 167-172
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    We analyzed 22 patients with hemispheric infarction that underwent decompressive hemicraniectomy with duroplasty (DHCD) between October 2003 and September 2007. The surgery was indicated when the level of consciousness deteriorated, anisocoria appeared, or the midline shift on computed tomography worsened. These patients comprised 14 males and 10 females aged 58 to 90 years old (mean 71.5 years old). At 6 months follow-up, 6 cases (27%) had a good outcome (Barthel Index (BI)≥15), and 16 cases (73%) had a poor outcome (BI<15). The mortality rate was 31.8% (7 cases), and 3 patients (13.6%) died of cerebral herniation. The results showed that DHCD can effectively control intractable intracranial hypertension due to hemispheric infarction, even in elderly patients.
  • 森川 栄治, 大井川 秀聡, 杉山 達也, 中島 弘之, 小倉 丈司, 佐藤 章, 神山 信也, 山根 文孝, 石原 正一郎
    原稿種別: 原  著
    2009 年 37 巻 3 号 p. 173-178
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    Our institution utilizes an integrated operating room in which both microneurosurgery and endovascular neurosurgery can be performed. We report our early experience of the use of this operating room. Between April 2007 and March 2008, we performed open surgery in 8 cases for cerebrovascular pathologies, 7 of which were aneurysms and 1 of which was an AVM. Two of the aneurysms were paraclinoid large aneurysms. One was a ruptured multiple mycotic aneurysm and the other was an MC bifurcation aneurysm with severe M1 stenosis. Two cases of the aneurysms were coil embolized first, and then converted to open surgery. One AVM case was embolized first and then resected after craniotomy in 1 session.
    We discuss usefullness of this multifunctional integrated operating room.
  • 原口 浩一, 外山 賢太郎, 加藤 孝顕, 真鍋 宏, 坂本 靖男, 蓮沼 正博, 伊藤 丈雄, 野中 唯, 寶金 清博
    原稿種別: 原  著
    2009 年 37 巻 3 号 p. 179-183
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    We report 6 cases with symptomatic intracranial vertebral artery stenosis treated with percutaneous transluminal angioplasty (PTA).
    Five of 6 cases had no contralateral vertebral artery (VA) and only 1 had hypoplastic contralateral VA. PTA was urgently performed in 3 cases presenting with progressive infarction. We used a balloon-expandable coronary stent against vertebral artery dissection subsequently after PTA in 1 case. No complications occurred during the procedure in any of the cases. Five cases were discharged from our hospital and could live independently. In 1 case in which PTA was urgently performed, disturbance of consciousness and tetraparesis remained.
    The presence of a high-grade vertebral artery stenosis and a contralateral vertebral artery hypoplasia or occlusion can induce a progressive infarction in the early stage, so immediate revascularization should be considered in these cases.
  • 宮本 直子, 内藤 功, 高玉 真, 清水 立矢, 岩井 丈幸, 嶋口 英俊, 好本 裕平
    原稿種別: 原  著
    2009 年 37 巻 3 号 p. 184-191
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    目的:解離性椎骨動脈瘤の治療は,血管内手技による母血管閉塞が第一選択の治療法であるが,虚血性合併症が問題となる.今回われわれは,血管内治療を施行した71例のうち,両側解離,対側の椎骨動脈低形成,後下小脳動脈(PICA)や前脊髄動脈(ASA)の血行温存などの理由からステントを併用した血管内治療を行った13例を検討した.方法:くも膜下出血発症が6例,虚血発症が4例,incidentalが1例であった.6例で解離部にPICAまたはASAがinvolveされていた.ステント併用瘤内塞栓術11例,ステント留置のみ2例であった.結果:ステント併用瘤内塞栓術を施行した11例のうち,1例で瘤内塞栓中に動脈瘤が破裂し,結果的に母血管閉塞となった.6例で動脈瘤の完全消失が得られ,4例でdome fillingであった.PICAまたはASAがinvolveされた6例では,ステントを併用し拡張部のみにコイルを留置することにより血行を温存できた.ステント留置のみの2例はfollow-upで拡張部の血栓化を確認した.虚血性合併症を1例に認めた.治療後,くも膜下出血をきたしたものはなかった.転帰はMRS 0-1が10例,3が1例,5が2例であった.結論:母血管閉塞により虚血性合併症の危険がある症例に対しては,ステントを併用した治療が有用と考えられる.PICAまたはASAがinvolveされた症例でもステントを併用し血行を温存できる場合がある.
  • 出井 勝, 山根 冠児, 沖田 進司, 熊野 潔, 中江 竜太
    原稿種別: 原  著
    2009 年 37 巻 3 号 p. 192-196
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    Meticulous clipping techniques are essential to obtain good results. Recently, the introduction of intravascular surgery for cerebral aneurysms has decreased the number of the direct clipping surgeries. And the increasing number of the lawsuits against doctors further discourages young surgeons from attempting clipping. As a result, young neurosurgeons, have less experience performing clipping. Therefore, we must learn clipping techniques from expert neurosurgeons under the limitation of having fewer opportunities to perform clipping surgery. In this paper, I present my experiences and discuss ways to obtain techniques for clipping surgery.
    I performed surgical clipping in 19 cases, 12 unruptured and 7 ruptured aneurysms, 7 males and 12 females aged from 36 to 79 years old (mean 61.9 years). Postoperatively, there were no symptomatic complications, but there were 2 asymptomatic infarctions that were revealed on CT scan. Intraoperative premature rupture occurred in 1 patient with a ruptured aneurysm.
    Techniques of manipulation with micro-forceps, suction and spatula are required for successful clipping. Off-the-job training of dissecting chicken wing arteries and rat abdominal aortas and vena cavas is useful. Moreover, actual experiences of surgical operations are essential. Surgical experiences raise the motivation of young neurosurgeons and encourage them to train more. We believe that this benign cycle contributes to meticulous surgical skills.
  • 若林 和樹, 黒崎 みのり, 甲賀 英明, 田村 勝
    原稿種別: 原  著
    2009 年 37 巻 3 号 p. 197-202
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    We experienced 5 cases of nonbranching site aneurysms arising from the internal carotid artery system in the past 5 years. Two cases were successfully treated with neck clipping and 2 cases were treated with trapping. Wrapping by gauze and fibrin glue was used in 1 unruptured case. The outcome was good in all cases (mRS 0-2).
    However, non-branching site aneurysms have fragile walls, the neck is not clearly defined and postoperative rebleeding can easily occur. We believe the sacrifice of a normal parent artery is necessary to prevent re-bleeding. For this reason, we believe interception of the parent artery should always be considered to prevent postoperative rebleeding.
    When parent artery interception is of concern regarding postoperative ischemic events, a high-flow EC-IC bypass may be needed. On the other hand, the issue of separation of the neck is possible at all sides and the possibility of clipping strangling part of the parent artery also exists.
症  例
  • 小畑 仁司, 杉江 亮, 田中 秀一, 黒岩 輝壮
    原稿種別: 症  例
    2009 年 37 巻 3 号 p. 203-208
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    We present 2 patients in whom basal interhemispheric (BIH) approaches were applied to surgically address anterior communicating artery aneurysms (AcomAn) after initial surgery via pterional approaches that resulted in incomplete clipping. In both patients, the initial clips were successfully removed with use of vario clip appliers followed by complete neck clipping. The first case was a 55-year-old man with subarachnoid hemorrhage (SAH) who arrived in poor cardiopulmonary condition. Angiographic evidence of extravasation of the contrast media led us to immediately surgically intervene via the dominant side of the anterior cerebral artery. However, complete neck clipping was abandoned due to marked brain swelling, and only aneurysm dome clipping was achieved. Thirty-eight days later, a second surgery was performed using the BIH approach. The second case was a 66-year-old woman with SAH caused by ruptured AcomAn associated with the median artery of the corpus callosum (MACC). A residual neck remnant grew gradually. After failed coil embolization, she had a second surgical intervention via the BIH approach 18 months after the initial surgery. Previous clips were removed in both patients and the coil was also removed in the second one. The BIH approach provides a wider surgical view and working space. We report technical tips to remove previously placed clips via different surgical approaches.
  • 布施 孝久, 渡辺 賢一, 市橋 鋭一, 大野 正弘, 神谷 健, 小山 英樹
    原稿種別: 症  例
    2009 年 37 巻 3 号 p. 209-214
    発行日: 2009年
    公開日: 2009/09/29
    ジャーナル フリー
    We successfully performed carotid artery stent placement (CAS) in 3 patients with cervical carotid artery stenosis presenting with progressing stroke. In our presented cases, we used intravascular ultrasonographic virtual histology (IVUS-VH) to evaluate carotid plaque and continuous monitoring of regional cerebral oxygenation by near-infrared spectroscopy to detect early hemodynamic complications. These techniques significantly helped to improve neurological outcome after CAS in patients with progressing stroke. In Case 1, an 80-year-old female presented with progressing right hemiparesis due to severe stenosis of the cervical portion of the left carotid artery. IVUS-VH revealed the plaque as mainly fibrous and partially necrotic and fibrolipidic, and under distal protection, CAS was successfully performed. In Case 2, a 70-year-old male presented with repeated transient loss of consciousness. 3D-CT angiography demonstrated severe stenosis of the cervical portion of the right carotid artery, and under the distal protection, CAS was conducted. During placement of the carotid stent, near infrared spectroscopy revealed a marked change in cerebral oximetry. His blood pressure was carefully controlled for 3 days to avoid hyperperfusion syndrome. In Case 3, a comatose 76-year-old male was admitted to our hospital with right-sided hemiparesis. He had suffered several transient ischemic attacks 6 months previously. Intravenous rt-PA therapy was performed, and his symptoms improved rapidly. 3D-CT angiography demonstrated severe stenosis of the right cervical carotid artery with dense calcified plaque. However, IVUS-VH revealed the plaque as mainly fibrous with partial calcification, and CAS was successfully performed.
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