非出血性脳血管解離症例の病態と治療方針 : 自験68例での検討(<特集>非出血性解離性脳動脈瘤の治療方針)  [in Japanese] Clinical Manifestations and Treatment Strategy for Non Hemorrhagic Cerebral Arterial Dissection : Analysis of 68 Cases(Topics : Treatment Strategy for Unruptured Dissecting Aneurysm)  [in Japanese]

We sought to clarify the clinical features, natural history, and optimal treatment for patients suffering from non-hemorrhagic cerebral arterial dissection. Fifty-four males and 14 females were enrolled in this study, and the mean age was 55.1 years. We analyzed the clinical manifestations, angiographical findings and treatment. Fifty-two patients (76.5%) presented with cerebral ischemia, 7 (10.3%) with headache, 4 (5.9%) with neck mass, and 2 (2.9%) for routine brain check-up, and 3 (4.4%) with other disease entities. Of the 68 patients, modified Rankin Scales on admission were 0-2 in 55 (80.8%) patients. In 50 (73.5%) patients, the arterial dissection was observed in the vertebro-basilar system and in 18 (26.5%) arterial dissection was observed in the carotid systems. Initial angiography revealed the pearl and string sign (PSS) in 30 lesions, which was the most common findings, and tapered occlusion, the second most common one, was observed in 15 lesions. Follow-up angiography revealed that 15 patients (22.7%) were improving on the dissected arteries, but the other 14 patients (20.1%) were progressing. We conservatively treated all the patients in the acute stage, but 7 (10.1%) patients showed symptomatic aggravations. Six out of the 7 exhibited cerebral ischemic symptoms, and 3 of these 6 patients suffered from cerebral embolism due to dissecting aneurysm at the cervical internal carotid arteries. Among the remaining 3 patients, 2 had enlarged cerebral infarction due to progressive arterial stenosis; 1 had perforating arterial infarction. Another suffered from subarachnoid hemorrhage followed by cerebral infarction. Nine patients underwent surgeries. Of the 9 patients, we performed trapping of the dissecting aneurysms in 4 patients due to a tendency of aneurysmal enlargement after being confirmed by a follow-up angiography. To prevent further cerebral embolism, a dissecting aneurysm in 1 patient at the cervical internal carotid arterial portion was treated surgically by resection. STA-SCA bypass surgery was performed in 4 patients for hemodynamic stress due to the bilateral vertebral arterial dissection. Clinical outcomes of the 68 patients at discharge were excellent or good in 40 patients (58.8%). Although most patients suffering from non-hemorrhagic cerebral arterial dissection recover well by conservative treatments, some cases require surgical treatment if they are complicated by enlargement of the aneurysms, cerebral ischemia due to dissecting aneurysms at the cervical carotid arteries, or hemodynamic stress due to the bilateral vertebral arterial dissection.