Iwamuro Y, Miyake H, Ito T, Kumai J, Kuroda T, Sugino T
Department of Neurosurgery, Hamamatsu Rosai Hospital.
No Shinkei Geka. 1996 Apr;24(4):357-61.
The patient was a 71-year-old female. On December 20, 1995, she suddenly developed a severe headache with vomiting and was transferred to our hospital. On admission, her conciousness level was 1-2 on the Japan Coma Scale, but there was no neurological deficit except for right oculomotor palsy. Computed tomography showed subarachnoid hemorrhage which had permeated the right lateral ventricle. On cerebral angiography, a giant fusiform aneurysm in the right internal carotid artery was recognized. During the emergency operation, neither neck clipping nor carotid reconstruction was possible because of the tight adhesion of the aneurysm to the peripheral tissue. On account of this, proximal clipping of the carotid artery with external carotid-middle cerebral artery anastomosis with saphenous vein graft was selected. This patient had had an episode of subarachnoid hemorrhage owing to rupture of the right internal carotid-posterior communicating artery aneurysm ten years earlier. At that time, the aneurysmal neck was clipped with a slight residual neck and she left the hospital on foot. Five days later, when the aneurysm was found to be completely thrombosed on CT scan, antiplatelet therapy was started. Although low density areas which corresponded to the regions fed by the right anterior choroidal artery were presented, re-rupture did not occur. Follow-up angiography showed that the aneurysm was completely thrombosed and that the right middle cerebral and the anterior cerebral artery blood was circulated via the vein graft. Among recurrent cases of aneurysm after neck clipping, it is unusual for a giant fusiform aneurysm to be recognized. The growth may have been caused by sclerotic change of the arterial wall. Oculomotor palsy may have delayed the detection of the recurrence of the aneurysm. When residual neck is presented on follow-up angiography, the next angiography should be carried out within at least three years. In this case, antiplatelet therapy was effective to prevent thromboembolism from the aneurysm.
患者为一名71岁女性。1995年12月20日，她突然出现剧烈头痛并伴有呕吐，随后被转送至我院。入院时，其日本昏迷量表意识水平为1 - 2级，但除右侧动眼神经麻痹外无神经功能缺损。计算机断层扫描显示蛛网膜下腔出血已蔓延至右侧脑室。脑血管造影显示右侧颈内动脉有一个巨大的梭形动脉瘤。在急诊手术中，由于动脉瘤与周围组织紧密粘连，无法进行颈部夹闭或颈动脉重建。因此，选择了颈动脉近端夹闭并采用大隐静脉移植进行颈外动脉 - 大脑中动脉吻合术。该患者十年前曾因右侧颈内动脉 - 后交通动脉瘤破裂发生过一次蛛网膜下腔出血。当时，动脉瘤颈部被夹闭，仍有轻微残余颈部，她步行出院。五天后，当CT扫描发现动脉瘤完全血栓形成时，开始进行抗血小板治疗。尽管出现了与右侧脉络膜前动脉供血区域相对应的低密度区，但未发生再破裂。随访血管造影显示动脉瘤完全血栓形成，右侧大脑中动脉和大脑前动脉血液通过静脉移植循环。在动脉瘤颈部夹闭后的复发病例中，发现巨大梭形动脉瘤并不常见。其生长可能是由动脉壁的硬化改变引起的。动眼神经麻痹可能延迟了动脉瘤复发的发现。当随访血管造影显示有残余颈部时，下次血管造影应至少在三年内进行。在这种情况下，抗血小板治疗对于预防动脉瘤的血栓栓塞有效。
