高齢者の破裂脳動脈瘤に対する，単一施設における治療成績の検討

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The incidence of aneurysmal subarachnoid hemorrhage (SAH) increases with age. Aged patients of SAH are thought to have higher risk for complications and poorer prognosis. We retrospectively reviewed the consecutive medical records of ruptured intracranial aneurysm patients over 75 years old (y/o), who were admitted to our hospital, where endovascular treatment was adopted as the first option between April 2004 and July 2010. Thirty-eight patients (6 males and 32 females) ranging from 75 to 90 (average 82.1) y/o were enrolled. They were divided into a course observation (CO) group (n=7), clipping (CL) group (n=13) and coil embolization (CE) group (n=18). Among these 3 groups, we evaluated the clinical characteristics, Hunt & Kosnik (H) grade on admission, and modified Rankin Scale (mRS) and Glasgow Outcome Scale (GOS) 3 months after ictus as the outcomes. Furthermore, we analyzed the main cause leading to unfavorable outcomes. According to the location of radically treated aneurysms, all MCA aneurysms were clipped and all VBA aneurysms were coil embolized, while ACoA aneurysms were more likely to be treated with coil embolization. Although it was necessary in some cases to alter the approach route from trans-femoral to trans-brachial or trans-carotid due to atherosclerotic tortuosity, every coil embolization was successful without procedure-related complications. Moreover, neither re-rupture nor re-growth requiring further treatment occurred during follow-up period (range, 6 months–6 years).Among the CL group and CE group, 20 (64.5%) of 31 resulted in mRS 3–6 despite aggressive treatment. However, the results of the CO group were much worse than those of the CL group and CE group. All 7 patients in the CO group died of primary brain damage (PBD) 3, re-rupture 3, pneumonia 1, respectively. There was no significant difference between the CL group and CE group in age distribution or H grade. Nevertheless, the proportion of mRS 0 and 1 in the CE group was larger than that in the CL group (44.4% vs. 23.1%), although there was no statistical difference. No vegetative survival (V) was found in this study, so we regarded severely disabled (SD) and dead (D) as unfavorable outcomes. There were 6 SD and 3 D of 13 in the CL group, whereas there were 7 SD and 3 D of 18 in the CE group. As the main cause of unfavorable outcomes, PBD, systematic complications such as pneumonia, pre-existing comorbidities etc. were named, but above all, vasospasm was strongly correlated with SD in the CL group (4 of 6) compared with the CE group (2 of 7). Though there were inherent limitations and biases in this study and the overall results were unsatisfactory, we validated the usefulness of coil embolization for ruptured aneurysm in elderly patients. Because coil embolization was effective against re-rupture, it might be a preferred alternative for aneurysms not amenable to clipping.Optimum treatment should be considered individually when both microsurgical and endovascular treatment modalities are available. Furthermore, intensive peri-procedural management of patients' clinical conditions especially focused on preventing vasospasm as well as greater skill in both treatments are important to improve outcomes.
一般社団法人日本脳卒中の外科学会の論文

一般社団法人日本脳卒中の外科学会 | 論文

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