32. 高齢者破裂脳動脈瘤の手術中の問題点

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33 surgical cases of aged patients exceeding 65 with ruptured cerebral aneurysm were studied in terms of operative procedures and prognosis. Of these 33 cases, 6 cases showed aggravations of clinical signs and CT findings. The pitfalls for operative procedures in aged patients are summarized in the following points.<BR>1) Injury to the veins leads to impairment of venous return which provokes cerebral contusion, ischemic infarction or intracerebral hematoma. At the time of dissection and separation of the Sylvian fissure or interhemispheric fissure, unnecessary cutting of the veins should be avoided.<BR>2) Pointing procedure at the time of premature rupture or use of a temporary clip lead not only brain edema due to decreased blood flow, but also impairment of the vital structures due to injury to the perforators once in a while.<BR>3) Removal of clots with a suction tube or bipolar forceps are prone to avulsion or kinking of perforators which lead to small infarcts in the vital structures. And further, retraction with a spatula makes the brain prone to contusion or infarction in aged patients. Consequently, extensive clot removal should be avoided in aged patients.<BR>4) Arteriosclerotic changes of the artery are so severe that the parent artery adjacent to the aneurysm easily become flexuous, stenotic or occluded by clipping procedures. Consequently, intentional incomplete clipping combined with wrapping should be done as necessary.
The Japanese Society on Surgery for Cerebral Strokeの論文

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