切迫脳ヘルニアを伴う破裂脳動脈瘤・脳動静脈奇形の手術 : 脳血管撮影なしでいかに対処するか  [in Japanese] Surgery for Ruptured Aneurysms or Arteriovenous Malformations Associated with Impending Herniation Due to Intracerebral Hematoma Necessitating Emergency Surgery Without Preoperative Angiography  [in Japanese]

Preoperative angiography is basically essential for a patient of intracerebral hematoma, so as to check any underlying vascular anomaly such as a ruptured aneurysm or an arteriovenous malformation (AVM). When the hematoma causes impending herniation, however, we omit preoperative angiography to save time and perform emergency surgery even if a ruptured aneurysm or an AVM is highly suspected. We experienced 8 such cases during 2.5 years: 6 cases of ruptured aneurysm and 2 of AVM. Three of them achieved good recovery and none died. Some special considerations and tactics are required before and during surgery to ensure safety. When a ruptured aneurysm is suspected, a microscope, a self-retractor and clips should be ready prior to surgery. The superficial temporal artery should be preserved just in case. After the craniotomy, the hematoma is evacuated partially for decompression away from the suspected aneurysm. Then, in case of premature rupture, the dissection is performed directly toward the bleeding site; otherwise sylvian fissure is dissected for aneurysm exploration. When an AVM is suspected, care must be taken not to injure the draining veins. It is safer to finish the emergency surgery after evacuating the hematoma and to go on to cerebral angiography. The resection of an AVM should then be performed in the chronic period. In our experiences, we were able to perform emergency surgery safely for a ruptured aneurysm or an AVM, even when we had to omit preoperative angiography because of impending herniation.