クリッピングおよびコイル塞栓術後に連続して早期再発を繰り返しhigh-flow bypass併用のtrappingを要した破裂脳動脈瘤の１例

Abstract

We report the case of a patient with a ruptured cerebral aneurysm who consecutively repeated early recurrence after clipping and coil embolization and required high-flow bypass-combined trapping. The patient was a 48-year-old female brought to our hospital by ambulance for acute headache. Subarachnoid hemorrhage and aneurysm of the right internal artery (ICA)-posterior communicating artery (PcomA) were observed on CT, and clipping was performed on the admission day. The lesion was a cerebral aneurysm with a very thin wall. Clipping was applied uneventfully, but when a clip applied deeply to the blade root was re-applied at a shallower site, the aneurysm ruptured at the neck. Re-clipping was repeated 5 times, and was finally successful on pressing a weakly curved clip to the ICA. However, recurrence of the aneurysm was observed on angiography performed after 25 days. Coiling was performed the following day, and the recurrent aneurysm was completely filled, but recurrence occurred again after about 3 months. Considering the vulnerability of the neck, high-flow bypass-combined ICA trapping was performed, and the aneurysm could be finally treated. An aneurysm with a thin neck wall requires a careful surgical technique. When aneurysm neck tissue is injured by repeated clipping, the aneurysm may recur early after treatment. For such a recurrent aneurysm, trapping should be selected, not coiling. A lesion that appears to be a common aneurysm with a thin wall may actually be a dissecting aneurysm in some cases, for which high-flow bypass-combined trapping is necessary from the beginning. Techniques and preparation to perform such surgeries at any time are necessary.