脳動脈瘤の手術適応と手術手技 3

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This review is based upon 424 cases with the anterior communicating artery aneurysm (Acoma.) directly attended by the author between June 1961 and September 1975. 350 cases of these had single aneurysm, at this site, 74 cases had multiple aneurysms including one at this site.1,000 cases of intracranial saccular aneurysm have been attended directly during this period, the ratio of Acoma. was 42.5% of the total cases. As the result, mortality rate during hospitalization was 5.4% in single cases and 6.7%. in multiple cases. Result of the follow-up study during the period of 6 months to 14 years and 6 months after surgery were as follows: 32 cases died, 15 of which died of other diseases. 10 could not walk. 18 had at least one psychic disturbances, aphasia or disability of walking without assistance. 312 were healthy or in good condition. 38 could not be followed and consequently the follow-up rate was 90%. The technical specialities in direct attack of Acoma. were given according to author's experiences: 1. Acoma. is always approached through bifrontal incision. 2. Bilateral frontal Robes must be dissected only by blunt technique interhemispherically. 3. Before exposuring of aneurysm, if possible, bilateral anterior cerebral arteries at proximal and distal portion of the aneurysm must be exposed for the temporary clipping. 4. Bilateral olfactory nerves must be dissected from the frontal lobes carefully, to prevent falling out of their attachment to the olfactory grooves. 5. Blood clot in subarachnoid spaces must be aspirated as completely as possible to prevent postoperative vasospasm. 6. Brain, arteries and veins must not be injured artificially during the surgery. 7. Of course the growth direction of the aneurysm, the grade of adhesion with four export and import arteries and neighboring tissues, the size of aneurysm and the deformity of anterior communicating artery may have influences upon the difficulty of the procedures. 8. Anyhow, certification of the four arteries and complete dissetion of aneurysm itself are the fundamental points of the operation. 9. Aneurysm must be ligated then clipped exactly at its neck, and if necessary, muscle wrapping is added to these procedures. 10. The time of temporary occlusion of the feeding arteries is approved as long as 40 minutes at one time, if 1,000 cc of 20% manittol is given intravenously just before the craniotomy. The author's policy for preare and postoperative management for ruptured Acoma. as follows: 1. The most favorable time for surgery is before 40 hours from the onset of the first rupture of aneurysm. 2. As for the decision of surgical indication, the consciousness level is the most important factor. The patient must be in the state of up-hill course of consciousness. If not, he must be brought to up-hill course by some way. 3. When the infarctic sign due to vasospasm appears before or after surgery, immediate superior cervical ganglionectomy will be effective to release the vasospasm. 4. The continuous ventricular drainage is very useful to control the intracranial pressure in acute stage of subarachnoid hemorrhage.
日本脳神経外科学会の論文

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鈴木二郎
東北大学脳疾患研究施設脳神経外科

脳動脈瘤の手術適応と手術手技 3

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