重症くも膜下出血に対する治療方法と治療成績の変遷(<特集>重症くも膜下出血治療の新しい試み)

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We review current management results of patients with subarachnoid hemorrhage (SAH) in poor clinical condition and compare them with those obtained five years ago at the Kyorin University Hospital. The management protocol during July 1993 to June 1994 (Phase A) was acute surgical obliteration of the aneurysm, continuous irrigation of subarachnoid clot for several postoperative days and aggressive prophylactic systemic fluid administration and repetitive intra-arterial injection of Papaverin followed by transluminal angioplasty when vasospasm is detected by daily transcranial Doppler flowmetry. The protocol during July 1998 to June 1999 (Phase B) was similar except for application of coil embolization for selected aged cases such as having posterior fossa aneurysms and/or systemic complications. Prophylactic intra-arterial injection of Papaverin followed by transluminal angioplasty was changed to therapeutic injection of Papaverin. The patient population of Phase A/B comprised consecutive 98/115 SAH cases; their average age was 63.8/64.9; the number of cases in WFNS Grade IV and V were 52/73 and the number of dead on arrival was 12/15. Among Grade IV and V cases, obliteration of the aneurysm was performed in 14/29 cases. In 8 of the 29 treated cases in Phase B, coil embolization was performed. The death rate at three months after SAH decreased in Phase B, but the ratio of good outcomes was almost the same in both Phase A and B. Limited application of aneurysm embolization for poor-grade patients improved the death rate in both total and treated patient population, but did not contribute to an increase in good outcomes. Besides the fact that the effect of vasospasm was masked by primary brain damage, the reason of the change between the two phases might be explained by unintentional shift of treatment indication for coil embolization toward moribund cases in Phase B.
2001-07-31

重症くも膜下出血に対する治療方法と治療成績の変遷(<特集>重症くも膜下出血治療の新しい試み)

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