後頭蓋窩脳動脈瘤の治療 : 直達手術と塞栓術の選択  [in Japanese] Management Strategies for Vertebro-basilar Artery Aneurysms : Selection of the Treatment, Clipping or Coil  [in Japanese]

We retrospectively analyzed 73 patients of vertebro-basilar artery aneurysms experienced over the last six years to demonstrate the selection of the treatment modality and its efficacy in our department. Forty-eight cases presented subarachnoid hemorrhage (SAH), and half of them were in grade IV and V at admission. The locations of the aneurysm were 24 basilar tip, 15 basilar-superior cerebellar (BA-SCA), 4 basilar trunk, 2 vertebral union, 13 vertebro-posterior inferior cerebellar and 15 vertebral dissecting aneurysms. Surgical obliteration or endovascular embolization with GDC were determined considering patient condition, age, angio-architecture and shape of the aneurysm. Direct neck clipping was performed 73% of SAH and 63% of non-ruptured cases. Coil embolization was more frequently selected than for supratentorial aneurysms. Favorable outcomes were obtained 49% of SAH and 90% of non-ruptured patients. Microsurgical clipping is superior to coil embolization in mainly the following aspects: confirmed permanent obliteration, reduced intracranial pressure, controllable intraoperative bleeding and clean-up of SAH for preventing vasospasm. Endovascular treatment can be the treatment of choice in cases when patients are aged or in poor condition, having superiorly or posteriorly protruding BA-tip aneurysms. Recently developed skullbase surgical technique and intraoperative collaboration with endovascular technique can minimize the draw-back of open surgical treatment such as excess brain retraction and perforator occlusion.