脳卒中の外科
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
41 巻 , 6 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 脳動脈瘤の手術の工夫
原  著
  • 芝 真人, 村松 正俊, 毛利 元信, 倉石 慶太, 佐野 貴則, 石垣 共基, 宮 史卓, 田中 克浩, 鈴木 秀謙
    2013 年 41 巻 6 号 p. 411-415
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    The role of endoscopic surgery for intraventricular hemorrhage remains controversial. We compared the surgical results and outcomes of intraventricular hematoma associated with hypertensive intracerebral hemorrhage between patients who underwent external ventricular drainage (n=6) and those who received both endoscopic surgery and external ventricular drainage (n=6). The period of external ventricular drainage was significantly shorter in the endoscopic surgery group (4.7 days vs. 10.5 days), leading to prevention of meningitis and cerebrospinal fluid leakage. However, there was no significant difference in the rate of patients who required cerebrospinal fluid shunt surgery and the hospitalization period between the two groups. The functional outcome at one and three months tended to be more favorable in the endoscopic surgery group, but the differences were not significant.
    Endoscopic surgery may be an effective treatment for intraventricular hemorrhage, but a larger study is needed to prove it.
  • 宮原 宏輔, 市川 輝夫, 向原 茂雄, 岡田 富, 郭 樟吾, 谷野 慎, 瓜生 康浩, 坂本 雄大, 畑岡 峻介, 藤津 和彦
    2013 年 41 巻 6 号 p. 416-421
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    The surgical procedure for a brainstem lesion must be carefully considered because of the critical neurological functions of the brainstem. We have surgically treated brainstem cavernous angioma after bleeding without significant postoperative morbidity, because the boundary between the angioma and normal brain tissue is generally well demarcated by preceding hemorrhages. However, because the angioma tissues are often destroyed by hemorrhage, care must be taken not to leave any pieces of the angioma tissue. To reduce the risk of morbidity, surgeons must investigate carefully when performing the operation.
    We analyze the surgical results and pathological findings of nine cases of symptomatic brainstem cavernous angiomas, and discuss the various surgical strategies especially based on the timing of surgery.
  • 持木 かなえ, 河本 俊介, 金谷 英明, 金 彪
    2013 年 41 巻 6 号 p. 422-427
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    Patients with posterior circulation insufficiency often have a poor prognosis despite aggressive medical treatment. We performed nine superficial temporal artery to superior cerebellar artery (STA-SCA) anastomosis for such unstable patients between December 2008 and December 2012. Surgery was performed using the subtemporal approach. The floor of the middle fossa was shaved flat and the tentorium was incised to obtain sufficient working space. The vein of Labbé and other temporal bridging veins were detached from the brain to facilitate retraction of the temporal lobe. The patency of the anastomosis was confirmed using indocyanine-green (ICG) videoangiography and Doppler ultrasonography. Postoperatively, all the patients showed clinical and radiological improvement of vertebrobasilar insufficiency. Temporal contusion was not observed on the postoperative MRI’s in the present series. Transient trochlear nerve palsy was observed in five patients.
    STA-SCA anastomosis is effective in selected patients with refractory vertebrobasilar insufficiency, and the procedure is safe when performed by expert neurosurgeons.
  • 津浦 光晴, 宮武 伸行, 中井 康雄, 松田 芳和, 中西 陽子, 山中 宏孝, 垣下 浩二, 中 大輔
    2013 年 41 巻 6 号 p. 428-434
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    Recently, endovascular technology such as mechanical thrombectomy has been used for carotid recanalization as a potentially effective treatment option in the acute phase. However, to date, angiographical results and clinical outcome remain unsatisfactory. We report our experience on ten patients treated with endovascular techniques for acute internal carotid artery occlusion. Three patients were given intravenous tissue plasminogen activator therapy before the intervention. The endovascular procedure was carried out under local anesthesia. PTA/stenting was performed in eight patients, suction thrombectomy in four and mechanical thrombectomy using Merci retriever in two. Recanalization was successful (TICI grade 2B–3) in four of the 10 patients (40%). In four of six patients (60%) with the occlusion caused by atherosclerotic stenosis, recanalization was achieved. Only two patients (20%) had a favorable outcome (modified Rankin Scale score 0–2) at discharge, and the mortality rate was 40%. There were three procedure-related complications, two distal embolisms and one hematoma at the puncture site. Patients with internal carotid artery occlusion caused by atherosclerosis benefitted more from the endovascular treatment than those whose occlusion was caused by cardiac embolism. Our case series suggest that in patients with an acute internal carotid artery occlusion, particularly caused by atherosclerotic stenosis, endovascular treatment may be associated with recanalization and neurological improvement.
  • 綾部 純一, 久保 篤彦, 渡辺 正英, 前田 昌宏, 田中 悠介, 田中 良英
    2013 年 41 巻 6 号 p. 435-439
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    Balloon protection effectively prevents distal embolism during carotid artery stenting (CAS). However, some patients have occlusion intolerance to transient balloon-induced ischemia and can develop secondary perioperative ischemic complications. We conducted this study to identify factors that can predict ischemic intolerance. We analyzed 58 patients undergoing CAS in which double balloon protection was used. Seven patients (12.1%) had ischemic intolerance. These patients had a significantly lower stenosis rate (p=0.0255), poor collateral flow (p=0.0001), and pooling appearance of the contrast medium in the ipsilateral internal carotid artery during test proximal balloon occlusion (P=0.0086).
    We conclude that preoperative assessment of collateral flow and intraoperative assessment of flow pattern during the proximal test occlusion are useful predictors of ischemic intolerance. These findings may be useful when choosing the protection devices during CAS or determining whether a shunt system should be used during carotid endarterectomy.
  • 池田 剛, 園部 眞, 加藤 徳之, 山崎 友郷, 粕谷 泰道, 中居 康展, 松村 明
    2013 年 41 巻 6 号 p. 440-446
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    It is difficult to completely prevent rupture or the need for retreatment after coil embolization for saccular aneurysms.
    We retrospectively analyzed the correlation between rupture or retreatment and the volume embolization ratio (VER) after coil embolization, and used a receiver operating characteristic (ROC) curve analysis to determine the optimal cut-off value of the volume embolization ratio.
    Of the 289 embolized aneurysms, rupture and retreatment occurred in 23 (8.0%) and in nine (3.1%) aneurysms, respectively, during a follow-up period of 22.7 months. Rupture or retreatment tended to occur more frequently in ruptured aneurysms with a low VER (<25%). An ROC curve based on the VER in ruptured aneurysms showed an AUC (area under the ROC curve) of 0.68 (95% confidence interval=0.58–0.79). A VER cut-off value of 25% yielded optimal sensitivity and specificity (78.9%, 54.7%).
    There is a correlation between the rupture or retreatment and the VER after coil embolization in ruptured aneurysms. The optimal cut-off value of the VER for ruptured aneurysms is 25%.
  • 周藤 高, 成生 松永, 猪森 茂雄, 藤野 英世
    2013 年 41 巻 6 号 p. 447-451
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    We retrospectively studied the mechanisms of development and enlargement of cyst following gamma knife surgery (GKS) for arteriovenous malformation (AVM) in 25 (15 males and 10 females) patients who developed cysts at 1.1–16 years after GKS. Cysts contained a nodular lesion enhanced with gadolinium-DTPA in 12 patients, and were associated with so-called expanding hematoma with severe surrounding brain edema in 10 patients. Magnetic resonance imaging with gadolinium-DTPA was not performed in three patients. Fourteen patients were treated with craniotomy, and two with placement of the Ommaya reservoir. One patient underwent both placement of the Ommaya reservoir and craniotomy. Spontaneous regression of the cyst was observed in one patient, and nine patients were treated conservatively. Two patients were lost to follow up. Histological examination showed proliferation of dilated vessels with fibrinoid degeneration associated with exudation of protein and bleeding. These findings were compatible with late radiation change. Increased vascular permeability at the vessel wall may be important in cyst formation and enlargement. Histological findings of nodular enhancement and expanding hematoma were essentially similar in terms of late radiation change.
    Our study suggests the optimum treatment for cyst formation following GKS for AVM is cyst opening and removal of late radiation change lesion through craniotomy.
症  例
  • 和田 健太郎, 野田 智之, 槇 英樹, 雄山 博文, 鬼頭 晃
    2013 年 41 巻 6 号 p. 452-457
    発行日: 2013年
    公開日: 2014/01/29
    ジャーナル フリー
    A 49-year-old woman presented with a sudden onset of right hemiparesis and motor aphasia. Computed tomography (CT) and magnetic resonance imaging (MRI) showed subarachnoid hemorrhage (SAH) localized in the interhemispheric fissure and cerebral infarction in the territory of the left anterior cerebral artery (ACA). Digital subtraction angiography (DSA) demonstrated segmental narrowing and dilatation at the left A2 segment, leading to a diagnosis of ACA dissection.
    The day after the onset, we planed trapping of the dissecting portion and A3–A3 side-to-side anastomosis. As a result, we performed only the wrapping of the dissection portion, because the dissection was longer than we expected. Neither aneurysmal dilatation nor narrowing progressed almost six months after the operation.
    This case indicates wrapping is also effective as a treatment of dissecting aneurysms, and it is important to consider longer-than-expected ACA dissections.
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