巨大頭蓋内動脈瘤の血管内治療

Endovascular Treatment of Giant Intracranial Aneurysms.

• Italo Linfante
• Vincenzo Andreone
• Natalia Ravelo
• Amy K Starosciak
• Bilal Arif
• Hussain Shallwani
• Peter Tze Man Kan
• Michael W McDermott
• Guilherme Dabus

抄録

目的 巨大頭蓋内動脈瘤（GIA）は破裂のリスクが高く、破裂時の死亡率が高い（65～100％）。これらの病変を固定するための従来のマイクロサージャリーアプローチは困難であり，そのため，血管内塞栓術が治療の選択肢として選択されることが多くなってきている。方法 2008年10月から2016年4月までに3つの医療センターでGIA破裂および未破裂の連続した患者を対象にレトロスペクティブ解析を行った。カイ二乗解析を用いて、前循環動脈瘤と後循環動脈瘤の転帰の違い、および破断していないGIAにおいてパイプライン塞栓装置（PED）が良好な転帰をもたらすかどうかを検討した。結果 45名の連続した患者（平均/中央値年齢＝57/59歳、範囲：16～82歳）が含まれていた。平均/中央動脈瘤サイズは29.9/28.3mm（範囲：25～50mm）であった。28例（62％）がPEDで治療された：PEDは1例で11例（24.4％）、PED＋コイルで1例（2.2％）、2例以上で11例（24.4％）、複数のPED＋コイルで5例（13.5％）であった。全死亡率は3/45（6.7％）であった。全死亡率は3/45(6.7%)であったが、手技に起因する死亡はなかった。カイ二乗検定の結果、全体的には前循環GIAの方が後循環GIAよりも臨床的転帰（mRSスコア）とX線写真的転帰（RSスコア）が良好であった。結論 PEDまたはPED＋コイルを用いた血管内塞栓術は、GIA患者にとって適度に安全で効果的な治療法であると考えられる。

Objective Giant intracranial aneurysms (GIAs) are associated with a high risk of rupture and have a high mortality rate when they rupture (65-100%). The traditional microsurgical approach to secure these lesions is challenging, and as such endovascular embolization has been increasingly selected as a treatment option. Methods We performed a retrospective analysis of consecutive patients with ruptured and unruptured GIAs at three medical centers from October 2008 to April 2016. Clinical follow-up and digital subtraction angiography were conducted at six months post-treatment. Chi-square analysis was used to determine differences in outcomes between anterior and posterior circulation aneurysms and if a pipeline embolization device (PED) provided favorable outcomes in unruptured GIAs. Results A total of 45 consecutive patients (mean/median age = 57/59; range: 16-82 years) were included. The mean/median aneurysm size was 29.9/28.3 mm (range: 25-50 mm). Eight (18%) patients presented with aneurysmal subarachnoid hemorrhage and 37 (82%) with unruptured GIAs. Twenty-eight (62%) were treated with a PED: 11 (24.4%) with one PED, 1 (2.2%) with PED + coils, 11 (24.4%) with more than one PED, and 5 (13.5%) with multiple PED + coils. The overall mortality rate was 3/45 (6.7%). No deaths were procedure-related. Five (11.1%) patients experienced ischemic stroke but only 2 had a 90-day modified Rankin Scale (mRS) score of ≥3. Of 33 patients available for six-month angiography, Raymond scale (RS) scores were 1, 2, and 3 for 23/45 (70%), 7/45 (20.9%), and 3/45 (9.1%), respectively. Chi-square test demonstrated that overall, anterior circulation GIAs had better clinical (mRS score) and radiographic (RS score) outcomes than posterior GIAs. PED alone provided similar clinical mRS outcomes but had a higher rate of complete occlusion at six months compared with PED + coils and coils alone in unruptured GIAs (p < 0.05). Conclusions Endovascular embolization using PED or PED + coils appears to be a moderately safe and effective treatment option for patients with GIAs.

Copyright © 2020, Linfante et al.