High position BA-SCA aneurysmに対するcranio-orbital Dolenc's approachの有用性  [in Japanese] Cranio-orbital Dolenc's Approach for High Position BA-SCA Aneurysm  [in Japanese]

遠位脳底動脈瘤に対するアプローチとしてはDrakeらのsub-temporal approachとYasargilらのpterional approachが一般的である. しかし高位のものや大きいものに対しては対処しにくく, 頭蓋底外科を応用したさまざまなアプローチが提唱されている. 今回われわれはpterional approachではclippingしえなかった比較的大きな高位脳底動脈上小脳動脈分岐部動脈瘤(BA-SCA aneurysm)に対して, cranio-orbital craniotomyとcombined epi- and subdural direct approach(Dolenc's approach)を組み合わせることによりclipping可能となった症例を経験したので文献的考察を加え報告する. 症例 患者:48歳 女性. 主訴:頭痛, 嘔吐. 既往歴:高血圧症にて内服中. 現病歴:2002年4月22日夕方, 突然激しい頭痛と嘔吐が出現した. その後も頭痛が続くため4月25日当科外来受診. 入院時現症:意識清明, 神経学的異常所見なし.

We report a case of high-position BA-SCA aneurysm operated by 2 different approaches-pterional and cranio-orbital Dolenc's approach-. A 48-year-old woman presented with severe headache and vomiting without neurological deficit. CT scan demonstrated subarachnoid hemorrhage localized in the right, Sylvian fissure. Cerebral angiogram showed right MCA ruptured and left BA-SC,A unruptured aneurysms. After clipping of the right MCA aneurysm, a left BA-SCA aneurysm was explored by the same pterional approach. However, it was impossible to clip completely because of narrow and deep operative field. Four months later, the same left BA-SCA aneurysm was well explored and clipped successfully by left cranio-orbital Dolenc's approach. The cranio-orbital craniotomy gives a wide and shallow operative field, and Dolenc's approach gives working space around carotid artery by dissecting the distal ring and the optic canal. For the highposition distal basilar artery aneurysms, there are many reports of approaches such as zygomatic approach and extradural t.emporo-polar approach to complete clipping safely. The cranio-orbital Dolenc's approach is thought to be useful.