クモ膜下出血後6時間以内の破裂脳動脈瘤根治術

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The efficacy of the operation for the ruptured cerebral aneurysm within 6 hours after subarachnoid hemorrhage is compared with the operation performed between 6 and 24 hours after subarachnoid hemorrhage in terms of the surgical outcome, the normalization of cerebrospinal fluid (CSF) myelin basic protein(MBP), the degree of the removal of the subarachnoid blood clots (SABC) in cisterns, and the incidence of the intraoperative rupture of the aneurysm. CSF was taken from the ventricle at the operation and from the ventricular drainage 14 days after operation. And the assay of the CSF MBP was done according to Cohen et al. MBP under 4 ng/ml is reported as negative. 30 patients (27-74 years, mean 52 years) were operated on within 6 hours after subarachnoid hemorrhage (ultra early operation group), and 18 patients (26-72 years, mean 51 years) were operated between 6 and 24 hours after subarachnoid hemorrhage (early operation group). The former included 2 patients in Grade I, 6 in Grade II, 12 in Grade III, and 10 in Grade IV. The latter included 2, 3, 7, and 6 patients respectively. CSF MBP was measured in 3 patients in Grade I, 3 in Grade II, 15 in Grade III, and 14 in Grade IV. MBP was negative in the patients in Grade I or Grade II except for one with 5ng/ml. In Grade III, however, MBP ranged from 8 to 120 ng/ml, and in Grade IV it ranged from 28 to 650ng/ml. The incidence of MBP over 100 ng/ml was 20% and 79% respectively (P<0.01), by X2 corrected for small number, which showed a fairly good correlation of the elevation of MBP with the severity of subarachnoid hemorrhage. Normalization of MBP on the 14th day after subarachnoid hemorrhage was found in 15 of 18 patients (83%) in Grade III or IV in the ultra early operation group, and 4 of 11 patients (36%) in Grade III or IV in the early operation group (P<0.05), which means early normalization could be brought about by theultra early operation. 28 of 30 patients by the ultra early operation had no neurological deficit or need no help in a daily life, and 15 of 18 patients did the same by the early operation. All of three dead cases exceeded 70 years of age. Subarachnoid blood clots (SABC) were classified on CT according to Fisher et al. Removal of SABC was evaluated as effective when ++ became + or -, or + became-. SABC was removed in almost all sylvian cisterns on the operation side and prepontine cisterns in the both group. The incidence of the removal of SABC in the interhemispheric fissure was 17 of 22(77%) by the ultra early operation and 5 of 15 (33%) by the early operation (P<0.02). As for the sylvian cistern contralateral to the operation side, the incidence was 11 of 16 and 5 of 11 respectively with no statistical significance. The incidence of the intraoperative rupture of the cerebral aneurysm was 4 of 12 middle cerebral artery aneurysm and 3 of 8 anterior communicating artery aneurysm in the ultra early operation group, and in the early operation group the incidence was 3 of 7 and 2 of 5 respectively. Intra operative rupture of the internal carotid artery aneurysm was not encountered in the both group.
The Japanese Society on Surgery for Cerebral Strokeの論文

クモ膜下出血後6時間以内の破裂脳動脈瘤根治術

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