脳卒中の外科
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
37 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
特集 もやもや病
  • 森岡 基浩, 濱田 潤一郎, 甲斐 豊, 矢野 茂敏, 河野 隆幸, 大森 雄樹, 倉津 純一
    原稿種別: 特集 もやもや病
    2009 年 37 巻 5 号 p. 338-344
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    To clarify the important factors contributing to outcome of moyamoya disease patients showing ischemia onset, we analyzed the long-term outcomes of 59 (24 males, 35 females) young moyamoya patients. The mean follow-up period and mean age was 11.1±7.8 years and 7.0±3.9 years old, respectively. Forty-three cases received bypass operations and 4 cases refused. The distribution of Glasgow Outcome Scale of all cases at onset and at follow-up showed no statistical difference. Eight cases (2 females, 6 males) showed neurological deterioration during the follow-up period, and the causes of worsened outcomes were 4 infarctions, 1 hemorrhage and 3 other complications. No cerebral hemisphere that received bypass surgery suffered infarction. Thus, it is concluded that the most important factor contributing to poor neurological outcome is infarction and that bypass surgery (direct or indirect bypass) can effectively prevent infarction over long terms.
    To clarify the important angiographic findings contributing to infarction occurrence, we analyzed the relationship between angiographical findings and cerebral infarction. In 143 bilateral hemispheres, we identified the presence of infarction (n=57) and transient ischemic attack (TIA, n=43). Forty-three hemispheres were asymptomatic. We analyzed the relationship between the occurrence of infarction and the status of stenosis/occlusion in the internal carotid artery (ICA) and PCA in each hemisphere of moyamoya disease patients. The incidence of PCA stenotic/occlusive lesions was significantly higher in infarcted (78.9%) than non-infarcted hemispheres (TIA: 14.0%; asymptomatic: 9.4%; p<0.01). No other factors exhibited a statistical correlation.
    Our data suggest that stenotic/occlusive PCA lesions were the most important independent factor contributing to the occurrence of cerebral infarction and that inhibition of the progression of PCA stenosis/occlusion may help to avoid broad cerebral infarction in moyamoya disease patients.
  • 黒田 敏, 川堀 真人, 宮本 倫行, 笹森 徹, 遠藤 将吾, 中山 若樹, 石川 達哉, 宝金 清博, 岩﨑 喜信
    原稿種別: 特集 もやもや病
    2009 年 37 巻 5 号 p. 345-349
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    We report a novel surgical technique for patients with profound cerebral ischemia in the temporo-occipital lobes due to significant stenosis of the ipsilateral posterior cerebral artery (PCA) in moyamoya disease. The technique includes STA-MCA anastomosis targeted to the angular artery and indirect bypass through large craniotomy extended towards the temporo-parietal area. Over the past 10 years, we applied the surgical technique for 4 patients who exhibited transient ischemic attacks or ischemic stroke involving the temporo-occipital lobes. Following surgery, none of them developed any cerebrovascular events during follow-up periods of up to 8 years. Cerebral angiography revealed that surgical collaterals widely supplied blood flow to the operated hemispheres, including the posterior temporal and parietal lobes. Postoperative SPECT and/or PET studies also demonstrated marked improvement of cerebral hemodynamics and metabolism in the operated hemispheres, including the occipital lobe.
    The presented surgical technique can effectively improve cerebral hemodynamics and metabolism in the frontal, temporal, and occipital lobes at once in patients with cerebral ischemia in the temporo-occipital lobes due to PCA stenosis in moyamoya disease.
特集 未破裂脳動脈瘤
  • ―慢性硬膜下血腫および後頭蓋窩出血の発生予防―
    西村 真実, 藤田 智昭, 坂田 洋之, 堀 恵美子, 三野 正樹, 西嶌 美知春
    原稿種別: 特集 未破裂脳動脈瘤
    2009 年 37 巻 5 号 p. 350-356
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    Postoperative chronic subdural hematoma (CSH) and remote cerebellar hemorrhage (RCH) is one of the important complications for treatment of unruptured intracranial aneurysm. The purpose of this study was to determine how to prevent CSH and RCH following the treatment of unruptured intracranial aneurysms.
    Between January 2000 and December 2007, 290 patients underwent clipping for unruptured intracranial aneurysms at our institution. We studied the patient's age and sex, location, size and multiplicity of aneurysm, the craniotomy site, the operative time required, operator and the procedure and the methods of anesthesia. We also reviewed the findings and outcomes of CSH and RCH.
    The incidence was 4.4% (males, 9.5%; females, 2.9%) and the mean age was 65 years with CSH. The incidence of RCH was 6.0% (males, 6.8%; females, 5.8%) and the mean age was 59.5 years. There was no statical significance in the occurrence of CSH or RCH in location, size and multiplicity of aneurysm or the operative time required. RCH occurred in 4.4% of cases using inhalation anesthesia, and 7.2% in total intravenous anesthesia, respectively. There was no evidence of associated morbidity in any of the cases.
    CSH occurred predominantly in male patients over 65 years old. The risk of RCH was intraoperative draining of large volumes of CSF, total intravenous anesthesia with mannitol use and postoperative drainage of larger amounts of fluid. The results showed the importance of careful operative procedure and the effectiveness of arachnoid plasty in preventing CSH and RCH.
  • 佐々木 雄彦, 大里 俊明, 早瀬 一幸, 渡部 寿一, 高田 英和, 杉尾 啓徳, 本庄 華織, 中川原 譲二, 中村 博彦
    原稿種別: 特集 未破裂脳動脈瘤
    2009 年 37 巻 5 号 p. 357-362
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    We describe our modification of the pterional approach to reduce invasiveness of surgical clipping for unruptured cerebral aneurysms, and we assess the less invasiveness and the cosmetic results of this modification. In this modification, the scalp incision was limited to the hair line from the upper origin of auricle to the temporal line. A fascio-cutaneous flap was made, and temporal muscle fibers were divided just on the lesser wing of sphenoid bone. This provided an operative field to make a key burr hole just on the lesser wing of sphenoid bone and a small frontotemporal craniotomy around the anterior sylvian fissure. This modified pterional approach was used for 46 of 127 patients who underwent surgical clipping of unruptured cerebral aneurysms by the pterional route. Successful clipping was accomplished in all patients. This modification reduced blood loss, time required for craniotomy and closure and delayed temporal muscle atrophy.
    This modification of pterional craniotomy provides sufficient surgical exposure for clipping of unruptured cerebral aneurysms in anterior circulation with less invasiveness and satisfactory cosmetic results when candidates are selected carefully.
原  著
  • 中嶌 教夫, 松原 俊二, 花岡 真実, 里見 淳一郎, 宇野 昌明, 佐藤 浩一, 永廣 信治
    原稿種別: 原  著
    2009 年 37 巻 5 号 p. 363-368
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    We present the results and pitfalls of surgery for dural arteriovenous fistula (dAVF).
    Between 1976 and 2007, we treated 257 patients with dAVF. Among them, 19 (13 men, 6 women) underwent direct surgery including drainer ligation and sinus resection. Their ages ranged from 48 to 82 years (mean 62 years). Of 19 dAVFs, 10 were located in the anterior fossa (AF) dural arteriovenous fistula, 1 in the cavernous sinus (CS), 5 were tentorial (T) and 3 were transverse-sigmoid sinus (TS) dAVF.
    The 3 patients with TS dAVF underwent resection of an isolated sinus, and the other 16 were treated by ligation of the draining vein; in 9 of these, transarterial embolization was subsequently performed. In 18 patients (95%), there was postoperative confirmation of shunt obliteration. After direct surgery, 2 patients with T dAVF suffered cerebral hemorrhage. In 1, T dAVF retrograde flow to petrosal veins occurred after clipping of the draining vein. In 14 patients, the outcome was good, 2 each were moderately or severly disabled and 1 patient survived in a vegetative state.
    Although dAVF surgery is an effective treatment, attention must be paid to cerebral hemorrhage and the development of a new draining vein in patients with T dAVF.
  • 村井 保夫, 水成 隆之, 小林 士郎, 梅岡 克哉, 立山 幸次郎, 寺本 明
    原稿種別: 原  著
    2009 年 37 巻 5 号 p. 369-374
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    Complex internal carotid artery disease presents 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 occurrence of ischemic complications after internal carotid artery ligation. The present study concerns long-term 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 2007, we performed radial artery grafting followed immediately by parent artery occlusion in 20 sides of 19 patients with complex internal carotid arteries disease with follow-up for more than 36 months (5 men, 14 women; mean follow-up duration, 62 months). All patients underwent postoperative MRI and MRA every year to assess graft patency, ischemic complications, and de novo aneurysm. Another 20 carotid aneurysms with visual disturbance were assessed concerning outcome.
    Among 13 patients with cranial nerve (III & VI) disturbances, all dysfunctions were improved in cases treated within 8 months of onset to operation. On the other hand, patients with second cranial nerve disturbances were not improved in cases treated after 4 months of onset. No long-term complications were discovered with MRI and MRA.
    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. Long-term safety is satisfactory, with no delayed complications such as graft stenosis, ischemic complications or de novo aneurysm formations in follow-up periods of more than 3 years. Good clinical outcome of cranial nerve palsy was achieved in patients treated within 8 months of onset for CN III and VI, and 4 of CN II palsy.
症  例
  • 都築 伸介, 大井川 秀聡, 豊岡 輝繁, 魚住 洋一, 長田 秀夫, 鈴木 隆元, 宮澤 隆仁, 苗代 弘, 島 克司
    原稿種別: 症  例
    2009 年 37 巻 5 号 p. 375-378
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    A 74-year-old man presented with subarachnoid hemorrhage (SAH) and underwent neck clipping of a left middle cerebral artery (MCA) aneurysm 10 years ago. This patient presented with SAH again due to rupture of a de novo aneurysm of the anterior communicating artery (A-com. aneurysm). The A-com. aneurysm was clipped successfully. The “old” left MCA aneurysm was then inspected. A collapsed “old” aneurysmal dome and a previously applied clip were identified. The “old” aneurysmal dome was resected for histopathological examination. The wall of this aneurysmal dome varied in thickness and consisted of a thin layer of fibrous connective tissue. Fibroblasts were scattered in the aneurysmal wall and either the muscular layer or internal elastic lamina was absent. The aneurysmal dome collapsed to a certain degree, but the lumen of the dome was completely intact. In addition, neovascularization of microcapillaries was observed both inside and outside the aneurysmal dome. Some of these microcapillaries were filled with fresh erythrocytes. Thus the aneurysmal wall was apparently “vigorous.” The previous orifice of the aneurysm did not fuse together at all and could be opened widely with ease during preparation for histopathologic examination. We speculated that the clipped aneurysmal dome survived for 10 years for the following reasons: 1) Although the mechanism of neovascularization of the microcapillaries is unclear, the clipped aneurysmal dome may have obtained nourishment from the microcapillaries. 2) The cerebrospinal fluid may have incubated the dome and provided optimal circumstances for its survival. Considering the radical cure for ruptured cerebral aneurysms by neck clipping or coil embolization, the findings described in this report will be valuable for neurosurgeons and neurointerventionists.
    Regardless of the time since treatment, ruptured aneurysms treated by either neck clipping and/or coil embolization are at risk of recurrent subarachnoid hemorrhage when the blood re-enters the aneurysms in cases such as clip slip-off or coil compaction.
  • 秋山 義典, 井坂 文章, 横井 俊浩, 時女 知生, 谷 正一, 林 直樹, 荻野 英治
    原稿種別: 症  例
    2009 年 37 巻 5 号 p. 379-383
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    Partially thrombosed basilar artery bifurcation aneurysms that are not amenable to clip application are among the most challenging lesions. We report a case with a partially thrombosed basilar artery bifurcation aneurysm successfully treated by parent artery occlusion combined with endovascular embolization. The patient, who had undergone neck clipping 12 years before, presented with conscious disturbance, tetraparesis, dysphagia, dyarthria, and diplopia. Neuroimaging examinations such as CT scan, MRI and angiography revealed that a partially thrombosed basilar artery aneurysm compressed the brain stem severely. We performed rough packing of the aneurysm by GDC. After coil embolization, we surgically obliterated the basilar artery at the proximal portion of superior cerebellar artery. An MRI study demonstrated reduction of the mass volume of aneurysm and an angiography study did not show regrowth of the aneurysm over a 5-year follow-up period. The patient’s neurological deficits caused by the compression of the brain stem disappeared.
    We consider that basilar artery occlusion combined with coil embolization is a valid procedure for partially thrombosed basilar artery aneurysms.
  • 竹内 誠, 川口 務, 中谷 充, 佐藤 耕造
    原稿種別: 症  例
    2009 年 37 巻 5 号 p. 384-389
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    We report 2 cases of tentorial dural arteriovenous fistula.
    Case 1: A 37-year-old man presented with severe headache. Neurological examination was normal. MR images demonstrated a round dilatated Galenic vein. But MR images showed no intracranial hemorrhage or congestive edema. Angiograms showed a tentorial dural arteriovenous fistula with a dilatated Galenic vein. Initially, we embolized the dural arteriovenous fistula using a transarterial approach. For residual dural arteriovenous fistula, gamma knife radiosurgery was performed. After 2 years and 5 months, angiographic cure was obtained and the postoperative course was uneventful.
    Case 2: A 70-year-old woman presented with pulsatile tinnitus and headache. Neurological examination was normal. MR images demonstrated a varix near the Galenic vein and showed no intracranial hemorrhage or congestive edema. Angiograms showed a tentorial dural arteriovenous fistula. For dural arteriovenous fistula, gamma knife radiosurgery was performed. After 4 years, angiographic cure was obtained and the postoperative course was uneventful.
    We discuss the clinical features and the management of these 2 cases.
手術手技
  • 岩間 亨, 吉村 紳一, 矢野 大仁, 大江 直行, 榎本 由貴子, 山田 清文, 高木 俊範
    原稿種別: 手術手技
    2009 年 37 巻 5 号 p. 390-394
    発行日: 2009年
    公開日: 2010/04/16
    ジャーナル フリー
    We describe basic surgical strategy and techniques for resection of cerebral arteriovenous malformations (AVMs). Understanding of the vascular structure of AVMs is important to plan surgical strategies for AVMs. The craniotomy should be large enough as to expose all the structures of the AVMs, such as nidus, feeders and drainers. In the first step of surgery, feeders are secured to control bleeding and to reduce tension of the nidus and drainers. Preoperative occlusion of the hidden feeders by endovascular surgery is a useful option. For an approach to the buried nidus, retrograde dissection of the main drainer is effective. When bleeding is difficult to control during dissection of the nidus, the dissection plane has got into the nidus and should be reset outward. Feeding arteries are coagulated and cut after they are confirmed to contribute to the AVM. The main drainer should be preserved up to the final step of the resection. Intraoperative angiography is useful to identify the feeders and to confirm the residuals of the AVM.
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