脳動脈瘤手術の工夫 安全かつ確実なクリッピングをめざして
「はじめに」脳動脈瘤ネッククリッピングの目的は, 脳神経組織を損傷しないで, 親動脈および周囲穿通枝の血流を温存しつつ, 瘤への血流を確実に遮断することである. ことに無症候性の未破裂脳動脈瘤手術に際しては, 安全かつ確実なクリッピングが望まれる. 通常の動脈瘤でも, 開頭やアプローチ法を工夫し顕微鏡下に十分な術野を確保しても, 死角が生じる場合がある. また, 視覚的には親血管や穿通枝が温存されたと判断しても, 循環障害をきたす可能性は否定できない. さらに, 末梢性動脈瘤のように慣れない部位では, 不必要な剥離操作を加えることもありうる. これらの欠点を補い手術成績を向上させる目的で, 顕...
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| Published in | 脳卒中の外科 Vol. 35; no. 6; pp. 417 - 422 |
|---|---|
| Main Authors | , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本脳卒中の外科学会
2007
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.35.417 |
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| Abstract | 「はじめに」脳動脈瘤ネッククリッピングの目的は, 脳神経組織を損傷しないで, 親動脈および周囲穿通枝の血流を温存しつつ, 瘤への血流を確実に遮断することである. ことに無症候性の未破裂脳動脈瘤手術に際しては, 安全かつ確実なクリッピングが望まれる. 通常の動脈瘤でも, 開頭やアプローチ法を工夫し顕微鏡下に十分な術野を確保しても, 死角が生じる場合がある. また, 視覚的には親血管や穿通枝が温存されたと判断しても, 循環障害をきたす可能性は否定できない. さらに, 末梢性動脈瘤のように慣れない部位では, 不必要な剥離操作を加えることもありうる. これらの欠点を補い手術成績を向上させる目的で, 顕微鏡手術の際に, 術中の脳血管撮影5), 内視鏡1-4)10)11), 電気生理学的モニタリング7)9), 術中ナビゲーション6)8)などの手術支援システム併用の有用性が報告されている. われわれも, 安全かつ確実な脳動脈瘤クリッピングを行うために, 必要に応じてそれら支援システムを使用してきた. |
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| AbstractList | 「はじめに」脳動脈瘤ネッククリッピングの目的は, 脳神経組織を損傷しないで, 親動脈および周囲穿通枝の血流を温存しつつ, 瘤への血流を確実に遮断することである. ことに無症候性の未破裂脳動脈瘤手術に際しては, 安全かつ確実なクリッピングが望まれる. 通常の動脈瘤でも, 開頭やアプローチ法を工夫し顕微鏡下に十分な術野を確保しても, 死角が生じる場合がある. また, 視覚的には親血管や穿通枝が温存されたと判断しても, 循環障害をきたす可能性は否定できない. さらに, 末梢性動脈瘤のように慣れない部位では, 不必要な剥離操作を加えることもありうる. これらの欠点を補い手術成績を向上させる目的で, 顕微鏡手術の際に, 術中の脳血管撮影5), 内視鏡1-4)10)11), 電気生理学的モニタリング7)9), 術中ナビゲーション6)8)などの手術支援システム併用の有用性が報告されている. われわれも, 安全かつ確実な脳動脈瘤クリッピングを行うために, 必要に応じてそれら支援システムを使用してきた. We evaluated the usefulness of endoscopy, motor evoked potential (MEP) monitoring, and navigation for safe and accurate clipping of cerebral aneurysms. Of 116 patients (ruptured, 50; unruptured, 66) who underwent surgical procedures from January 2000 to September 2005 at our hospital, endoscope-assisted surgery was performed in 50 operations (ruptured, 17; unruptured, 33), MEP monitoring was done in 6 operations (unruptured, 6), and a navigation system was used in 6 operations (ruptured, 1; unruptured, 5). Endoscope-assisted surgery was performed using a 2.7-or 4-mm-diameter endoscope with a tip angle of 30°or 70°. The Stealth Station was used as the navigation system. MEP monitoring was performed using electrical stimulation of the motor cortex and EMG recording of the face, trunk, and the upper and lower extremities contralateral to the stimulated side. During endoscope-assisted surgery, the anatomical relationship between the aneurysm neck and the parent artery or perforating artery could be observed before clipping, and the location of the clip tip, occlusion of the perforating artery, or stenosis of the parent artery could be evaluated after clipping. Among the 28 patients whose perforating artery was observed endoscopically, 3 were re-clipped due to suspicion of perforating artery occlusion or stenosis. On postoperative MR and/or CT images, perforating artery infarctions were observed in 4 patients, although none were symptomatic. Although MEP monitoring was expected to predict the postoperative motor function, fortunately, no patients showed abnormal MEP findings after aneurismal neck clipping. Navigation allowed the prediction of the site of aneurysm and parent artery before dissection, resulting in an accurate approach to these structures. Endoscopy, MEP monitoring, and navigation are considered useful for performing safe and accurate clipping of cerebral aneurysms. |
| Author | 長戸, 重幸 久門, 良明 大西, 丘倫 渡邉, 英昭 岩田, 真治 伊賀瀬, 圭二 大上, 史朗 |
| Author_FL | KUMON Yoshiaki OHUE Shiro WATANABE Hideaki IGASE Keiji IWATA Shinji OHNISHI Takanori NAGATO Shigeyuki |
| Author_FL_xml | – sequence: 1 fullname: KUMON Yoshiaki – sequence: 2 fullname: IWATA Shinji – sequence: 3 fullname: NAGATO Shigeyuki – sequence: 4 fullname: WATANABE Hideaki – sequence: 5 fullname: IGASE Keiji – sequence: 6 fullname: OHUE Shiro – sequence: 7 fullname: OHNISHI Takanori |
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| DocumentTitleAlternate | Usefulness of Endoscopy, Motor Evoked Potential Monitoring, and Navigation for Safe and Accurate Clipping of Cerebral Aneurysms |
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| References | 1) Horiuchi K, Suzuki K, Sasaki T, et al: Intraoperative monitoring of blood flow insufficiency during surgery of middle cerebral artery aneurysms. J Neurosurg 103: 275-283, 2005 10) 種子田 護：内視鏡支援による脳動脈瘤手術．脳卒中の外科 31: 319-325, 2003 4) 近藤 礼，嘉山孝正，黄木正登，ほか：内頸動脈動脈瘤における内視鏡支援下脳動脈瘤根治術―特に近傍動脈瘤における有用性―．脳卒中の外科 26: 413-420, 1998 8) Schmid-Elsaesser R, Muacevic A, Holtmannspotter M, et al: Neuronavigation based on CT angiography for surgery of intracranial aneurysms: primary experience with unruptured aneurysms. Minim Invasive Neurosurg 46 (5) : 269- 277, 2003 9) Suzuki K, Kodama N, Sasaki T, et al: Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 98: 507-514, 2003 2) Kinouchi H, Yanagisawa T, Suzuki A, et al: Simultaneous microscopic and endoscopic monitoring during surgery for internal carotid artery aneurysms. J Neurosurg 101: 989- 995, 2004 11) Taniguchi M, Takimoto H, Yoshimine T, et al: Application of a rigid endoscope to the microsurgical management of 54 cerebral aneurysms: results in 48 patients. J Neurosurg 91: 231-237, 1999 3) 木内博之，溝井和夫：神経内視鏡支援による脳動脈瘤手術．脳神経外科 32: 1117-1130, 2004 5) Payner TD, Horner TG, Leipzig TJ, et al: Role of intraoperative angiography in the surgical treatment of cerebral aneurysms. J Neurosurg 88: 441-448, 1998 6) Pirotte B, Wikler D, David P, et al: Magnetic resonance angiography image guidance for the microsurgical clipping of intracranial aneurysms: a report of two cases. Neurol Res 26 (4) : 429-434, 2004 7) Sakuma J, Suzuki K, Sasaki T, et al: Monitoring and preventing blood flow insufficiency due to clip rotation after the treatment of internal carotid artery aneurysms. Technical note. J Neurosurg 100: 960-962, 2004 |
| References_xml | – reference: 2) Kinouchi H, Yanagisawa T, Suzuki A, et al: Simultaneous microscopic and endoscopic monitoring during surgery for internal carotid artery aneurysms. J Neurosurg 101: 989- 995, 2004 – reference: 6) Pirotte B, Wikler D, David P, et al: Magnetic resonance angiography image guidance for the microsurgical clipping of intracranial aneurysms: a report of two cases. Neurol Res 26 (4) : 429-434, 2004 – reference: 5) Payner TD, Horner TG, Leipzig TJ, et al: Role of intraoperative angiography in the surgical treatment of cerebral aneurysms. J Neurosurg 88: 441-448, 1998 – reference: 9) Suzuki K, Kodama N, Sasaki T, et al: Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 98: 507-514, 2003 – reference: 10) 種子田 護：内視鏡支援による脳動脈瘤手術．脳卒中の外科 31: 319-325, 2003 – reference: 7) Sakuma J, Suzuki K, Sasaki T, et al: Monitoring and preventing blood flow insufficiency due to clip rotation after the treatment of internal carotid artery aneurysms. Technical note. J Neurosurg 100: 960-962, 2004 – reference: 4) 近藤 礼，嘉山孝正，黄木正登，ほか：内頸動脈動脈瘤における内視鏡支援下脳動脈瘤根治術―特に近傍動脈瘤における有用性―．脳卒中の外科 26: 413-420, 1998 – reference: 1) Horiuchi K, Suzuki K, Sasaki T, et al: Intraoperative monitoring of blood flow insufficiency during surgery of middle cerebral artery aneurysms. J Neurosurg 103: 275-283, 2005 – reference: 8) Schmid-Elsaesser R, Muacevic A, Holtmannspotter M, et al: Neuronavigation based on CT angiography for surgery of intracranial aneurysms: primary experience with unruptured aneurysms. Minim Invasive Neurosurg 46 (5) : 269- 277, 2003 – reference: 11) Taniguchi M, Takimoto H, Yoshimine T, et al: Application of a rigid endoscope to the microsurgical management of 54 cerebral aneurysms: results in 48 patients. J Neurosurg 91: 231-237, 1999 – reference: 3) 木内博之，溝井和夫：神経内視鏡支援による脳動脈瘤手術．脳神経外科 32: 1117-1130, 2004 |
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| Snippet | 「はじめに」脳動脈瘤ネッククリッピングの目的は, 脳神経組織を損傷しないで, 親動脈および周囲穿通枝の血流を温存しつつ, 瘤への血流を確実に遮断することである. ことに無症候性の未破裂脳動脈瘤手術に際しては, 安全かつ確実なクリッピングが望まれる. 通常の動脈瘤でも,... We evaluated the usefulness of endoscopy, motor evoked potential (MEP) monitoring, and navigation for safe and accurate clipping of cerebral aneurysms. Of 116... |
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| StartPage | 417 |
| SubjectTerms | cerebral aneurysm clipping endoscopy MEP monitoring navigation |
| Subtitle | 安全かつ確実なクリッピングをめざして |
| Title | 脳動脈瘤手術の工夫 |
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