未破裂脳動脈瘤根治術の問題点とtailor-made medicine

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  • Tailor-made Strategy for Treating Patients with Unruptured Cerebral Aneurysm

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The indications for radical surgery to treat unruptured cerebral aneurysms (uAN) remain unclear. Most investigations of evidence-based medicine have focused on prognostic factors such as the natural history, surgical outcome, risk-benefit analysis, and socioeconomic effects, and not on patient factors such as decision-making, anxiety, or satisfaction. This study undertook a survey of these factors in 172 patients who underwent radical surgery during the last 7 years, using a mail questionnaire sent to a third person. The total response rate was 53.5%. Almost 90% of patients could understand the explanation of their condition including the presence of uAN and risk of bleeding, and the proposed treatment. About 70 percent of patients (70.9%) selected the type of treatment from among observation, clipping, or coiling, and 72.8% decided on the same day as the explanation. Patient decision-making was affected by anxiety about bleeding (49.3%) and recommendation by the attending physician (43.2%). The delay from the decision to the operation was 1 month or less in half of the patients, but more than 6 months in about 20%. Sixty-nine patients with asymptomatic aneurysms found on brain examination were treated by clipping, and 10 with asymptomatic aneurysms by coil embolization. Eighty-one patients with aneurysms causing SAH or neurological symptoms were treated by clipping, and 12 with giant aneurysms underwent other surgery. Visual analogue scale analysis found that 75% of all patients were satisfied, but 91.6% of patients who underwent coil embolization were highly satisfied. The most common factor causing dissatisfaction was anxiety during the delay from the explanation to the surgical treatment (44%). Almost half of the patients complained of several problems other than neurological symptoms such as the surgical wound. This study indicates that patient decision-making was highly affected by the explanation of the physician, especially the recommendation for treatment and the sense of anxiety about the possibility of aneurysm rupture. Patient anxiety should be minimized by collecting better evidence about the natural history, surgical risk, and recurrence of uAN. The reaction of individual patients to the potential risks and possibilities of surgical intervention differed enormously, so a tailor-made approach to individuals to support patient decision-making should be formulated.

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