未破裂脳動脈瘤に対する血管内治療を含めた治療方針
未破裂動脈瘤の治療については, きわめて低い破裂率であるとしたISUIAの第一報5)以来, 慎重な適応決定をする施設が増えている. また, メディアを通した医療情報の氾濫と合併症の恐怖により, 患者サイドでも希望が少なくなっているのが現状である. しかしながら, わが国での成績調査では中間報告ながら, やはり1%近い破裂率があるとされ21), 脳ドックの普及による発見率の増加と相まってその治療の需要は少なくない. また, 30年以上の歴史がある観血的治療の結果から得た経験的な合併症のリスクと, 無症状の患者の開頭術への恐怖などから血管内治療に対する期待は大きい. われわれは動脈瘤塞栓術の適応を...
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| Published in | 脳卒中の外科 Vol. 33; no. 6; pp. 442 - 447 |
|---|---|
| Main Authors | , , , , , , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本脳卒中の外科学会
30.11.2005
日本脳卒中の外科学会 |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0914-5508 1880-4683 |
| DOI | 10.2335/scs.33.442 |
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| Abstract | 未破裂動脈瘤の治療については, きわめて低い破裂率であるとしたISUIAの第一報5)以来, 慎重な適応決定をする施設が増えている. また, メディアを通した医療情報の氾濫と合併症の恐怖により, 患者サイドでも希望が少なくなっているのが現状である. しかしながら, わが国での成績調査では中間報告ながら, やはり1%近い破裂率があるとされ21), 脳ドックの普及による発見率の増加と相まってその治療の需要は少なくない. また, 30年以上の歴史がある観血的治療の結果から得た経験的な合併症のリスクと, 無症状の患者の開頭術への恐怖などから血管内治療に対する期待は大きい. われわれは動脈瘤塞栓術の適応を含めたエビデンスを明らかにするために, 過去7年間の未破裂動脈瘤に対する血管内治療例における急性期, 慢性期合併症をレビューして, 従来の治療方針の妥当性について検討した. |
|---|---|
| AbstractList | We investigated the indications for endovascular treatment of unruptured cerebral aneurysms based on the natural history reported in ISUIA and our treatment results. At Nagoya University hospital and affiliated hospitals over 7 years we treated or attempted embolization for 383 unruptured aneurysms, including 301 asymptomatic and 82 symptomatic ones. Among them, 326 were treated with embolization and 57 were left untreated due to the high risks involved. Ruptures during the follow-up occurred in 2 symptomatic cases without treatment. We experienced 28 technical complications including 9 hemorrhagic, 14 ischemic and 4 others at the intra- and perioperative stage, in addition to 14 recanalizations at the delayed stage. The rate of morbidity associated with procedure was 4.0%. There was a high risk of hemorrhagic complications from a tiny anterior communicating artery aneurysm and ischemic complications in the middle cerebral, basilar-tip, and vertebral dissecting aneurysms with a hypoplastic posterior inferior cerebellar artery. As for the symptomatic aneurysms, although 72 patients had a good outcome, symptoms due to mass effects did not improve in 19 cases and worsened in 7. Particularly large paraclinoid aneurysms with visual symptoms showed a reduced possibility of symptom improvement. Although embolization has proved highly effective for the treatment of unruptured aneurysms, the treatment decision should take into account the relevant guidelines, including those for surgical option and observation. Abbreviations : ISUIA : International Study of Unruptured Intracranial Aneurysms 未破裂動脈瘤の治療については, きわめて低い破裂率であるとしたISUIAの第一報5)以来, 慎重な適応決定をする施設が増えている. また, メディアを通した医療情報の氾濫と合併症の恐怖により, 患者サイドでも希望が少なくなっているのが現状である. しかしながら, わが国での成績調査では中間報告ながら, やはり1%近い破裂率があるとされ21), 脳ドックの普及による発見率の増加と相まってその治療の需要は少なくない. また, 30年以上の歴史がある観血的治療の結果から得た経験的な合併症のリスクと, 無症状の患者の開頭術への恐怖などから血管内治療に対する期待は大きい. われわれは動脈瘤塞栓術の適応を含めたエビデンスを明らかにするために, 過去7年間の未破裂動脈瘤に対する血管内治療例における急性期, 慢性期合併症をレビューして, 従来の治療方針の妥当性について検討した. |
| Author | 小島, 隆生 鈴木, 宰 佐原, 佳之 小林, 望 吉田, 純 岩越, 孝恭 岡本, 剛 中井, 完治 福井, 一裕 根来, 真 文堂, 昌彦 大塚, 吾郎 半田, 隆 服部, 光爾 高橋, 郁夫 服部, 健一 服部, 智司 中林, 規容 宮地, 茂 |
| Author_FL | IWAKOSHI Takayasu BUNDO Masahiko SAHARA Yoshiyujki KOBAYASHI Nozomu HATTORI Ken-ichi NAKAI Kanji OTSUKA Goro HANDA Takashi TAKAHASHI Ikuo MIYACHI Shigeru HATTORI Kouji NEGORO Makoto KOJIMA Takao NAKABAYASHI Kiyo OKAMOTO Takeshi FUKUI Kazuhiro YOSHIDA Jun SUZUKI Osamu HATTORI Tomoji |
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| References | 21) UCAS Japan事務局：日本未破裂動脈瘤悉皆調査（UCAS Japan）の現況―中間報告II. 脳外誌 12: 166-172, 2003 3) Hayakawa M, Murayama Y, Duckwiler GR, et al: Natural history of the neck remnant of a cerebral aneurysm treated with the Guglielmi detachable coil system. J Neurosurg 93: 561-568, 2000 9) Johnston SC, Higashida RT, Barrow DL, et al: Recommendations for the endovascular treatment of intracranial aneurysms—A statement for healthcare professionals from the committee on cerebrovascular imaging of the American Heart Association Council on Cardiovascular Radiology—. Stroke 33: 2536-2544, 2002 17) Nagahiro S, Takada A, Goto S, et al: Thrombosed growing giant aneurysms of the vertebral artery: growth mechanism and management. J Neurosurg 82: 796-801, 1995 8) Johnston SC, Zhao S, Dudley RA, et al: Treatment of unruptured cerebral aneurysms in California. Stroke 32: 597-605, 2001 14) 宮地 茂，野田 篤，根来 真，ほか：未破裂動脈瘤の治療―観血的治療と血管内治療の比較―．脳卒中の外科 27: 162-169, 1999 23) Weir B: Unruptured intracranial aneurysms: a review. J Neurosurg 96: 3-42, 2002 6) International Study of Unruptured Intracranial Aneurysms Investigators (ISUIA) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362: 103-110, 2003 15) Miyachi S, Negoro M, Sahara Y, et al: Treatment strategy for cerebral aneurysms based on the evidence of the efficacy of GDC embolization. Interventional Neuroradiology 9 (Suppl 1) : 51-55, 2003 22) Wardlaw JM, White PM: The detection and management of unruptured intracranial aneurysms. Brain 123: 205-221, 2000 7) Johnston JC, Wilson CB, Halbach VV, et al: Endovascular and surgical treatment of unruptured cerebral aneurysms: comparison of risks. Ann Neurol 48: 11-19, 2000 10) Katayama Y, Tsubokawa T, Miyazaki S, et al: Growth of totally thrombosed giant aneurysm within the posterior cranial fossa. Diagnostic and therapeutic considerations. Neuroradiology 33: 168-170, 1991 20) Tsutsumi K, Ueki K, Morita A, et al: Risk of rupture from incidental cerebral aneurysms. J Neurosurg 93: 550-553, 2000 1) Bederson JB, Awad IA, Wiebers DO, et al: Recommendations for the management of patients with unruptured intracranial aneurysms. A statement for healthcare professionals from the stroke council of the American Heart Association. Stroke 31: 2742-2750, 2000 12) Malisch TW, Guglielmi G, Vinuela F, et al: Unruptured aneurysms presenting with mass effect symptoms: response to endosaccular treatment with Guglielmi detachable coils. Part I. Symptoms of cranial nerve dysfunction. J Neurosurg 89: 956-961, 1998 13) Miyachi S, Negoro M, Okamoto T, et al: Endovascular treatment of unruptured vertebro-basilar aneurysms. Interventional Neuroradiology 5 (Suppl 1) : 83-88, 1999 16) Murayama Y, Vinuela F, Duckwiler GR, et al: Embolization of incidental cerebral aneurysms by using the Guglielmi detachable coil system. J Neurosurg 90: 207-214, 1999 2) Brennan JW, Schwartz ML: Unruptured intracranial aneurysms: Appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria. Neurosurgery 47: 1359-1372, 2000 5) International Study of Unruptured Intracranial Aneurysms Investigators: Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med 339: 1725-1733 1998 11) Lebranc R, Worsley KJ: Surgery of unruptured, asymptomatic aneurysms: a decision analysis. Can J Neurol Sci 22: 30-35, 1995 4) Iihara K. Murao K. Sakai N, et al: Continuing growth of vertebral giant thrombosed aneurysm after endovascular trapping. J Neurosurg 98: 407-413, 2003 19) Thornton J: Endovascular treatment of paraclinoid aneurysms. Surg Neurol 54: 288-299, 2000 18) Proust F, Debono B, Hannequin D, et al: Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures. J Neurosurg 99: 3-14, 2003 |
| References_xml | – reference: 10) Katayama Y, Tsubokawa T, Miyazaki S, et al: Growth of totally thrombosed giant aneurysm within the posterior cranial fossa. Diagnostic and therapeutic considerations. Neuroradiology 33: 168-170, 1991 – reference: 7) Johnston JC, Wilson CB, Halbach VV, et al: Endovascular and surgical treatment of unruptured cerebral aneurysms: comparison of risks. Ann Neurol 48: 11-19, 2000 – reference: 6) International Study of Unruptured Intracranial Aneurysms Investigators (ISUIA) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362: 103-110, 2003 – reference: 11) Lebranc R, Worsley KJ: Surgery of unruptured, asymptomatic aneurysms: a decision analysis. Can J Neurol Sci 22: 30-35, 1995 – reference: 5) International Study of Unruptured Intracranial Aneurysms Investigators: Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med 339: 1725-1733 1998 – reference: 12) Malisch TW, Guglielmi G, Vinuela F, et al: Unruptured aneurysms presenting with mass effect symptoms: response to endosaccular treatment with Guglielmi detachable coils. Part I. Symptoms of cranial nerve dysfunction. J Neurosurg 89: 956-961, 1998 – reference: 13) Miyachi S, Negoro M, Okamoto T, et al: Endovascular treatment of unruptured vertebro-basilar aneurysms. Interventional Neuroradiology 5 (Suppl 1) : 83-88, 1999 – reference: 16) Murayama Y, Vinuela F, Duckwiler GR, et al: Embolization of incidental cerebral aneurysms by using the Guglielmi detachable coil system. J Neurosurg 90: 207-214, 1999 – reference: 4) Iihara K. Murao K. Sakai N, et al: Continuing growth of vertebral giant thrombosed aneurysm after endovascular trapping. J Neurosurg 98: 407-413, 2003 – reference: 3) Hayakawa M, Murayama Y, Duckwiler GR, et al: Natural history of the neck remnant of a cerebral aneurysm treated with the Guglielmi detachable coil system. J Neurosurg 93: 561-568, 2000 – reference: 20) Tsutsumi K, Ueki K, Morita A, et al: Risk of rupture from incidental cerebral aneurysms. J Neurosurg 93: 550-553, 2000 – reference: 9) Johnston SC, Higashida RT, Barrow DL, et al: Recommendations for the endovascular treatment of intracranial aneurysms—A statement for healthcare professionals from the committee on cerebrovascular imaging of the American Heart Association Council on Cardiovascular Radiology—. Stroke 33: 2536-2544, 2002 – reference: 17) Nagahiro S, Takada A, Goto S, et al: Thrombosed growing giant aneurysms of the vertebral artery: growth mechanism and management. J Neurosurg 82: 796-801, 1995 – reference: 14) 宮地 茂，野田 篤，根来 真，ほか：未破裂動脈瘤の治療―観血的治療と血管内治療の比較―．脳卒中の外科 27: 162-169, 1999 – reference: 23) Weir B: Unruptured intracranial aneurysms: a review. J Neurosurg 96: 3-42, 2002 – reference: 1) Bederson JB, Awad IA, Wiebers DO, et al: Recommendations for the management of patients with unruptured intracranial aneurysms. A statement for healthcare professionals from the stroke council of the American Heart Association. Stroke 31: 2742-2750, 2000 – reference: 8) Johnston SC, Zhao S, Dudley RA, et al: Treatment of unruptured cerebral aneurysms in California. Stroke 32: 597-605, 2001 – reference: 19) Thornton J: Endovascular treatment of paraclinoid aneurysms. Surg Neurol 54: 288-299, 2000 – reference: 15) Miyachi S, Negoro M, Sahara Y, et al: Treatment strategy for cerebral aneurysms based on the evidence of the efficacy of GDC embolization. Interventional Neuroradiology 9 (Suppl 1) : 51-55, 2003 – reference: 21) UCAS Japan事務局：日本未破裂動脈瘤悉皆調査（UCAS Japan）の現況―中間報告II. 脳外誌 12: 166-172, 2003 – reference: 2) Brennan JW, Schwartz ML: Unruptured intracranial aneurysms: Appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria. Neurosurgery 47: 1359-1372, 2000 – reference: 22) Wardlaw JM, White PM: The detection and management of unruptured intracranial aneurysms. Brain 123: 205-221, 2000 – reference: 18) Proust F, Debono B, Hannequin D, et al: Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures. J Neurosurg 99: 3-14, 2003 |
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| Snippet | 未破裂動脈瘤の治療については, きわめて低い破裂率であるとしたISUIAの第一報5)以来, 慎重な適応決定をする施設が増えている. また, メディアを通した医療情報の氾濫と合... We investigated the indications for endovascular treatment of unruptured cerebral aneurysms based on the natural history reported in ISUIA and our treatment... |
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| SubjectTerms | complication embolization endovascular treatment indication unruptured aneurysm |
| Title | 未破裂脳動脈瘤に対する血管内治療を含めた治療方針 |
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| ispartofPNX | 脳卒中の外科, 2005, Vol.33(6), pp.442-447 |
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