Hashimoto Yuji, Horita Yoshifumi, Imaizumi Toshio, Niwa Jun
Department of Neurosurgery, Hakodate Municipal Hospital, Hokkaido, Japan.
Neurol Med Chir (Tokyo). 2005 May;45(5):249-52. doi: 10.2176/nmc.45.249.
A 58-year-old male presented with severe consciousness disturbance and left hemiparesis. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) and acute subdural hematoma caused by a ruptured right middle cerebral artery aneurysm. The aneurysm was clipped and the hematoma was evacuated. The patient had almost recovered without new neurological deficits on the next day. Arterial systolic blood pressure was postoperatively controlled within 120 to 150 mmHg. Continuous ventricular and cisternal drainage from the level 10 cm above the external auditory meatus was performed to drain bloody cerebrospinal fluid and prevent vasospasm. Three days after surgery, the patient suddenly lapsed into a coma. CT demonstrated diffuse SAH and bilateral intraventricular hemorrhage caused by rupture of an anterior communicating artery aneurysm. Neck clipping was performed immediately. Unfortunately, the patient died of primary damage due to SAH 3 days after the second surgery. In this case, cisternal drainage was probably important in the aneurysm rupture because of decreased intracranial pressure and change in the perianeurysm environment. Postoperative management of patients with residual untreated aneurysms must consider the possibility that cisternal drainage may result in higher transmural pressure, leading to rupture of the untreated aneurysms.
一名58岁男性，出现严重意识障碍及左侧偏瘫。计算机断层扫描（CT）显示蛛网膜下腔出血（SAH）及由右侧大脑中动脉动脉瘤破裂所致的急性硬膜下血肿。对动脉瘤进行了夹闭，并清除了血肿。术后第二天患者几乎完全康复，未出现新的神经功能缺损。术后动脉收缩压控制在120至150 mmHg之间。从外耳道水平上方10 cm处进行持续脑室及脑池引流，以引流血性脑脊液并预防血管痉挛。术后三天，患者突然陷入昏迷。CT显示由前交通动脉动脉瘤破裂导致的弥漫性SAH及双侧脑室内出血。立即进行了颈部夹闭术。不幸的是，患者在第二次手术后三天因SAH导致的原发性损伤死亡。在这种情况下，由于颅内压降低及动脉瘤周围环境改变，脑池引流在动脉瘤破裂中可能很重要。对残留未治疗动脉瘤患者的术后管理必须考虑到脑池引流可能导致更高的跨壁压力，从而导致未治疗动脉瘤破裂的可能性。
