血栓回収中にマイクロカテーテルで血管損傷し，遅発性くも膜下出血の発症にて脳動脈瘤の穿孔と判明した脳主幹動脈急性閉塞の1例
78歳女性．左片麻痺，意識障害で搬送され，右M1閉塞の診断でrt-PA静注療法および血栓回収療法の方針とした．術中，マイクロカテーテル（micro catheter: MC）が血管外に穿孔したが，ガイディングカテーテルから造影すると中大脳動脈は閉塞した状態で造影剤の血管外漏出はなく，Thrombolysis in Cerebral Infarction 0で終了した．術後8日目にくも膜下出血を発症し，右M1の再開通，M1分岐部の動脈瘤を認めた．脳動脈瘤破裂と判断し，開頭クリッピング術を施行した．動脈瘤は真性動脈瘤で血餅の付着を認め，M1やM2にMCによる穿孔の痕跡は認めず，MCは動脈瘤を穿孔し...
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| Published in | 脳卒中 Vol. 47; no. 4; pp. 241 - 247 |
|---|---|
| Main Authors | , , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本脳卒中学会
2025
The Japan Stroke Society |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0912-0726 1883-1923 |
| DOI | 10.3995/jstroke.11300 |
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| Abstract | 78歳女性．左片麻痺，意識障害で搬送され，右M1閉塞の診断でrt-PA静注療法および血栓回収療法の方針とした．術中，マイクロカテーテル（micro catheter: MC）が血管外に穿孔したが，ガイディングカテーテルから造影すると中大脳動脈は閉塞した状態で造影剤の血管外漏出はなく，Thrombolysis in Cerebral Infarction 0で終了した．術後8日目にくも膜下出血を発症し，右M1の再開通，M1分岐部の動脈瘤を認めた．脳動脈瘤破裂と判断し，開頭クリッピング術を施行した．動脈瘤は真性動脈瘤で血餅の付着を認め，M1やM2にMCによる穿孔の痕跡は認めず，MCは動脈瘤を穿孔したと考えられた．血栓回収術中に血管穿孔を来したが再開通が得られず造影剤の血管外漏出を認めなかった場合でも，脳動脈瘤の穿孔も念頭に置いて術後も再出血に注意し血圧管理や血管評価を継続することが重要である． |
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| AbstractList | A 78-year-old woman was transferred to our hospital due to the sudden onset of left hemiparesis and altered consciousness. CTangiography (CTA) revealed occlusion of the right distal M1 segment of the middle cerebral artery (MCA). Consequently, we administered intravenous rt-PA and performed mechanical thrombectomy (MT). During the procedure, a microcatheter (MC) perforated the vessel wall. Upon injecting the contrast medium through the guiding catheter, we observed MCA occlusion without any extravasation of the contrast medium. As a result, we concluded the MT with a Thrombolysis in Cerebral Infarction score of 0. On postoperative day 8, the patient exhibited a decreased level of consciousness, and a subsequent CT scan revealed a subarachnoid hemorrhage. CTA showed recanalization of the right MCA and the presence of a cerebral aneurysm at the M1–M2 bifurcation. We determined that the subarachnoid hemorrhage had resulted from a ruptured cerebral aneurysm and proceeded with surgical clipping via open craniotomy. The aneurysm was identified as a true aneurysm with a blood clot on its surface. Furthermore, no vessel damage was noted at the right M1–M2 segment, leading us to suspect that the aneurysm was perforated by the MC during the MT procedure. In cases where vessel perforation occurs during MT without recanalization or extravasation, it is important to keep in mind the possibility of a cerebral aneurysm perforation and to continue blood pressure control and ongoing evaluation of blood vessels using vascular imaging after MT.
78歳女性．左片麻痺，意識障害で搬送され，右M1閉塞の診断でrt-PA静注療法および血栓回収療法の方針とした．術中，マイクロカテーテル（micro catheter: MC）が血管外に穿孔したが，ガイディングカテーテルから造影すると中大脳動脈は閉塞した状態で造影剤の血管外漏出はなく，Thrombolysis in Cerebral Infarction 0で終了した．術後8日目にくも膜下出血を発症し，右M1の再開通，M1分岐部の動脈瘤を認めた．脳動脈瘤破裂と判断し，開頭クリッピング術を施行した．動脈瘤は真性動脈瘤で血餅の付着を認め，M1やM2にMCによる穿孔の痕跡は認めず，MCは動脈瘤を穿孔したと考えられた．血栓回収術中に血管穿孔を来したが再開通が得られず造影剤の血管外漏出を認めなかった場合でも，脳動脈瘤の穿孔も念頭に置いて術後も再出血に注意し血圧管理や血管評価を継続することが重要である． 78歳女性．左片麻痺，意識障害で搬送され，右M1閉塞の診断でrt-PA静注療法および血栓回収療法の方針とした．術中，マイクロカテーテル（micro catheter: MC）が血管外に穿孔したが，ガイディングカテーテルから造影すると中大脳動脈は閉塞した状態で造影剤の血管外漏出はなく，Thrombolysis in Cerebral Infarction 0で終了した．術後8日目にくも膜下出血を発症し，右M1の再開通，M1分岐部の動脈瘤を認めた．脳動脈瘤破裂と判断し，開頭クリッピング術を施行した．動脈瘤は真性動脈瘤で血餅の付着を認め，M1やM2にMCによる穿孔の痕跡は認めず，MCは動脈瘤を穿孔したと考えられた．血栓回収術中に血管穿孔を来したが再開通が得られず造影剤の血管外漏出を認めなかった場合でも，脳動脈瘤の穿孔も念頭に置いて術後も再出血に注意し血圧管理や血管評価を継続することが重要である． |
| Author | 山中 拓也 市川 智教 小林 和人 種村 浩 佐野 貴則 宮 史卓 石垣 共基 矢合 哲士 |
| Author_FL | Kobayashi Kazuto Yago Tetsushi Miya Fumitaka Ichikawa Tomonori Tanemura Hiroshi Sano Takanori Yamanaka Takuya Ishigaki Tomoki |
| Author_FL_xml | – sequence: 1 fullname: Yago Tetsushi – sequence: 2 fullname: Tanemura Hiroshi – sequence: 3 fullname: Yamanaka Takuya – sequence: 4 fullname: Ichikawa Tomonori – sequence: 5 fullname: Sano Takanori – sequence: 6 fullname: Ishigaki Tomoki – sequence: 7 fullname: Kobayashi Kazuto – sequence: 8 fullname: Miya Fumitaka |
| Author_xml | – sequence: 1 fullname: 宮 史卓 organization: 伊勢赤十字病院脳卒中センター脳神経外科 – sequence: 1 fullname: 石垣 共基 organization: 伊勢赤十字病院脳卒中センター脳神経外科 – sequence: 1 fullname: 種村 浩 organization: 伊勢赤十字病院脳卒中センター脳神経外科 – sequence: 1 fullname: 小林 和人 organization: 伊勢赤十字病院脳卒中センター脳神経内科 – sequence: 1 orcidid: 0000-0002-3813-9847 fullname: 矢合 哲士 organization: 伊勢赤十字病院脳卒中センター脳神経外科 – sequence: 1 fullname: 市川 智教 organization: 伊勢赤十字病院脳卒中センター脳神経外科 – sequence: 1 fullname: 山中 拓也 organization: 伊勢赤十字病院脳卒中センター脳神経外科 – sequence: 1 fullname: 佐野 貴則 organization: 伊勢赤十字病院脳卒中センター脳神経外科 |
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| DocumentTitleAlternate | A case of delayed subarachnoid hemorrhage after mechanical thrombectomy, which turned out to be a rupture of an unruptured cerebral aneurysm perforated by a microcatheter during the operation |
| DocumentTitle_FL | A case of delayed subarachnoid hemorrhage after mechanical thrombectomy, which turned out to be a rupture of an unruptured cerebral aneurysm perforated by a microcatheter during the operation |
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| PublicationTitle_FL | Jpn. J. Stroke 脳卒中 Japanese Journal of Stroke Nosotchu |
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| Publisher | 一般社団法人 日本脳卒中学会 The Japan Stroke Society |
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| References | 5） 大塚俊宏，熊井潤一郎：後交通動脈分岐部と前脈絡叢動脈分岐部に未破裂脳動脈瘤を合併した内頚動脈急性閉塞に対して機械的血栓回収術を施行した1例．脳血管内治療 2022; 7: 122–127 6） Arimura K, Imamura H, Todo K, et al.: Intracranial hemorrhage after endovascular revascularization for acute ischemic stroke. J Neuroendovasc Ther 2017; 11: 391–397 1） Oshikata S, Harada K, Ikema A, et al.: Mechanical thrombectomy for acute cerebral large vessel occlusions involving a cerebral aneurysm in the target vessel. J Neuroendovasc Ther 2021; 15: 8–13 15） Takase Y, Tanaka T, Goto H, et al.: Delayed rupture from a pseudoaneurysm after mechanical thrombectomy: a case report. Asian J Neurosurg 2024; 19: 556–562 2） Zibold F, Kleine JF, Zimmer C, et al.: Aneurysms in the target vessels of stroke patients subjected to mechanical thrombectomy: prevalence and impact on treatment. J Neurointerv Surg 2016; 8: 1016–1020 17） Parrilla G, García-Villalba B, Espinosa de Rueda M, et al.: Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance. AJNR Am J Neuroradiol 2012; 33: 1791–1796 8） Willinsky R, terBrugge K: Use of a second microcatheter in the management of a perforation during endovascular treatment of a cerebral aneurysm. AJNR Am J Neuroradiol 2000; 21: 1537–1539 3） Zhou T, Li T, Zhu L, et al.: Endovascular thrombectomy for large-vessel occlusion strokes with preexisting intracranial aneurysms. Cardiovasc Intervent Radiol 2018; 41: 1399–1403 13） Mistry EA, Hart KW, Davis LT, et al.: Blood pressure management after endovascular therapy for acute ischemic stroke: the BEST-II randomized clinical trial. JAMA 2023; 330: 821–831 16） Wang C, Shi M, Li C, et al.: Rescue strategy for hemorrhagic complication during mechanical thrombectomy and the clinical outcome. J Endovasc Ther 2023; 2023: 15266028231218880 [Epub ahead of print] 14） Abuelazm M, Khildj Y, Ibrahim AA, et al.: Intensive blood pressure control after endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis. Clin Neuroradiol 2024; 34: 563–575 12） Nam HS, Kim YD, Heo J, et al.: Intensive vs conventional blood pressure lowering after endovascular thrombectomy in acute ischemic stroke: the OPTIMAL BP randomized clinical trial. JAMA 2023; 330: 832–842 9） 岩田亮一，佐々木庸，永島宗紀ら：急性期血栓回収術におけるNBCAを用いた動脈穿孔のトラブルシューティング．脳卒中の外 2020; 48: 375–378 4） Nozaki T, Noda M, Ishibashi T, et al.: Ruptured hidden intracranial aneurysm during mechanical thrombectomy: a case report. Surg Neurol Int 2020; 11: 446 11） Yang P, Song L, Zhang Y, et al.: Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet 2022; 400: 1585–1596 18） 酒井優，小泉聡，上田雅ら：中大脳動脈閉塞症に対する血栓回収術後のくも膜下出血が亜急性期に増悪した1例．脳血管内治療 2018; 3: 35–41 7） Doerfler A, Wanke I, Egelhof T, et al.: Aneurysmal rupture during embolization with Guglielmi detachable coils: causes, management, and outcome. AJNR Am J Neuroradiol 2001; 22: 1825–1832 10） Mazighi M, Richard S, Lapergue B, et al.: Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2021; 20: 265–274 |
| References_xml | – reference: 10） Mazighi M, Richard S, Lapergue B, et al.: Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2021; 20: 265–274 – reference: 9） 岩田亮一，佐々木庸，永島宗紀ら：急性期血栓回収術におけるNBCAを用いた動脈穿孔のトラブルシューティング．脳卒中の外 2020; 48: 375–378 – reference: 8） Willinsky R, terBrugge K: Use of a second microcatheter in the management of a perforation during endovascular treatment of a cerebral aneurysm. AJNR Am J Neuroradiol 2000; 21: 1537–1539 – reference: 12） Nam HS, Kim YD, Heo J, et al.: Intensive vs conventional blood pressure lowering after endovascular thrombectomy in acute ischemic stroke: the OPTIMAL BP randomized clinical trial. JAMA 2023; 330: 832–842 – reference: 14） Abuelazm M, Khildj Y, Ibrahim AA, et al.: Intensive blood pressure control after endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis. Clin Neuroradiol 2024; 34: 563–575 – reference: 1） Oshikata S, Harada K, Ikema A, et al.: Mechanical thrombectomy for acute cerebral large vessel occlusions involving a cerebral aneurysm in the target vessel. J Neuroendovasc Ther 2021; 15: 8–13 – reference: 5） 大塚俊宏，熊井潤一郎：後交通動脈分岐部と前脈絡叢動脈分岐部に未破裂脳動脈瘤を合併した内頚動脈急性閉塞に対して機械的血栓回収術を施行した1例．脳血管内治療 2022; 7: 122–127 – reference: 6） Arimura K, Imamura H, Todo K, et al.: Intracranial hemorrhage after endovascular revascularization for acute ischemic stroke. J Neuroendovasc Ther 2017; 11: 391–397 – reference: 2） Zibold F, Kleine JF, Zimmer C, et al.: Aneurysms in the target vessels of stroke patients subjected to mechanical thrombectomy: prevalence and impact on treatment. J Neurointerv Surg 2016; 8: 1016–1020 – reference: 11） Yang P, Song L, Zhang Y, et al.: Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet 2022; 400: 1585–1596 – reference: 15） Takase Y, Tanaka T, Goto H, et al.: Delayed rupture from a pseudoaneurysm after mechanical thrombectomy: a case report. Asian J Neurosurg 2024; 19: 556–562 – reference: 7） Doerfler A, Wanke I, Egelhof T, et al.: Aneurysmal rupture during embolization with Guglielmi detachable coils: causes, management, and outcome. AJNR Am J Neuroradiol 2001; 22: 1825–1832 – reference: 4） Nozaki T, Noda M, Ishibashi T, et al.: Ruptured hidden intracranial aneurysm during mechanical thrombectomy: a case report. Surg Neurol Int 2020; 11: 446 – reference: 3） Zhou T, Li T, Zhu L, et al.: Endovascular thrombectomy for large-vessel occlusion strokes with preexisting intracranial aneurysms. Cardiovasc Intervent Radiol 2018; 41: 1399–1403 – reference: 13） Mistry EA, Hart KW, Davis LT, et al.: Blood pressure management after endovascular therapy for acute ischemic stroke: the BEST-II randomized clinical trial. JAMA 2023; 330: 821–831 – reference: 18） 酒井優，小泉聡，上田雅ら：中大脳動脈閉塞症に対する血栓回収術後のくも膜下出血が亜急性期に増悪した1例．脳血管内治療 2018; 3: 35–41 – reference: 16） Wang C, Shi M, Li C, et al.: Rescue strategy for hemorrhagic complication during mechanical thrombectomy and the clinical outcome. J Endovasc Ther 2023; 2023: 15266028231218880 [Epub ahead of print] – reference: 17） Parrilla G, García-Villalba B, Espinosa de Rueda M, et al.: Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance. AJNR Am J Neuroradiol 2012; 33: 1791–1796 |
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| Snippet | 78歳女性．左片麻痺，意識障害で搬送され，右M1閉塞の診断でrt-PA静注療法および血栓回収療法の方針とした．術中，マイクロカテーテル（micro catheter: MC）が血管外に穿孔したが，ガイディングカテーテルから造影すると中大脳動脈は閉塞した状態で造影剤の血管外漏出はなく，Thrombolysis in... A 78-year-old woman was transferred to our hospital due to the sudden onset of left hemiparesis and altered consciousness. CTangiography (CTA) revealed... |
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| StartPage | 241 |
| SubjectTerms | aneurysm rupture cerebral aneurysm ischemic stroke mechanical thrombectomy subarachnoid hemorrhage |
| Title | 血栓回収中にマイクロカテーテルで血管損傷し，遅発性くも膜下出血の発症にて脳動脈瘤の穿孔と判明した脳主幹動脈急性閉塞の1例 |
| URI | https://www.jstage.jst.go.jp/article/jstroke/47/4/47_11300/_article/-char/ja https://cir.nii.ac.jp/crid/1390022167032834560 |
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| ispartofPNX | 脳卒中, 2025, Vol.47(4), pp.241-247 |
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