Tenjin Hiroshi, Takadou Michiko, Ogawa Takahiro, Mandai Ayako, Umebayashi Daisuke, Osaka Yasuhiko, Nakahara Yoshikazu, Kubo Satoshi
Department of Neurosurgery, Kyoto Second Red Cross Hospital, Kamigyo-ku, Kyoto, Japan.
Neurol Med Chir (Tokyo). 2011;51(1):23-9. doi: 10.2176/nmc.51.23.
The International Subarachnoid Aneurysm Trial has shown that coil embolization achieves a better outcome for aneurysms treatable by either clipping or coil embolization. However, many ruptured aneurysms are hardly treatable by either clipping or coil embolization. Selection of either clipping or coil embolization will affect the treatment outcome for ruptured aneurysms. The relationship between patient selection and treatment outcome in a so-called "regional center hospital" in Japan must be clarified. This study included 113 patients with ruptured intracranial saccular aneurysms measuring less than 10 mm. Selection criteria for coil embolization were principally paraclinoid or posterior circulation aneurysm, Hunt and Hess grade IV or over, and patient age 75 years or older. Other aneurysms were principally treated by clipping. Aneurysms with a dome/neck ratio of less than 1.5, distorted aneurysms, Hunt and Hess grades I-III, patient age 74 years or younger, and middle cerebral artery aneurysm were actively treated by clipping. A few exceptional indications were considered in detail. Low invasiveness coil embolization is better than clipping to obtain good neurological outcome for patients with perforators difficult to dissect, aneurysms difficult to dissect due to previous open surgery, and aneurysms requiring bilateral open surgery, despite the slightly higher rebleeding rate in coil embolization. Overall outcomes were modified Rankin Scale (mRS) 0-2 in 82 of 113 patients (73%) and mRS 3-6 in 31 (27%). Appropriate selection of clipping or coil embolization can achieve acceptable treatment outcomes for ruptured aneurysm.
国际蛛网膜下腔动脉瘤试验表明，对于可通过夹闭或线圈栓塞治疗的动脉瘤，线圈栓塞术能取得更好的治疗效果。然而，许多破裂动脉瘤难以通过夹闭或线圈栓塞治疗。选择夹闭或线圈栓塞都会影响破裂动脉瘤的治疗结果。日本一家所谓“地区中心医院”中患者选择与治疗结果之间的关系必须予以明确。本研究纳入了113例颅内囊状破裂动脉瘤直径小于10mm的患者。线圈栓塞的选择标准主要为鞍旁或后循环动脉瘤、Hunt和Hess分级为IV级及以上以及患者年龄75岁及以上。其他动脉瘤主要采用夹闭治疗。瘤顶/瘤颈比小于1.5的动脉瘤、形态扭曲的动脉瘤、Hunt和Hess分级为I - III级、患者年龄74岁及以下以及大脑中动脉动脉瘤则积极采用夹闭治疗。对一些特殊指征进行了详细考量。对于难以解剖的穿支动脉瘤、因既往开颅手术导致难以解剖的动脉瘤以及需要双侧开颅手术的动脉瘤患者，尽管线圈栓塞的再出血率略高，但低侵袭性的线圈栓塞术在获得良好神经功能结局方面优于夹闭术。113例患者中，82例（73%）的总体结局为改良Rankin量表（mRS）0 - 2级，31例（27%）为mRS 3 - 6级。对夹闭或线圈栓塞进行恰当选择可使破裂动脉瘤获得可接受的治疗效果。
