過去５年間の破裂脳動脈りゅうによるクモ膜下出血の治療成績―５０３例の分析から―

Background: Management strategies for aneurysmal subarachnoid hemorrhage (SAH) have undergone radical changes following the development of Guglielmi detachable coils (GDC). However, which treatment option, direct surgical clipping or endovascular coiling, should be the treatment of choice remains debetable. Here, we evaluated and compared the recent outcomes of SAH cases that were treated using these methods. Material & Method: Data on 503 patients who underwent treatment for SAH at the Department of Neurosurgery, Fujita Health University, Japan between 1998 and 2002 were analysed. Out of the 503 patients, 279 patients underwent direct surgery and 95 underwent endovascular coiling. One-hundred and twenty-nine patients received conservative treatment. Results: The pretreatment Hunt & Hess grading scores of the patients who underwent direct surgery was as follows: grade I, 22 (8%); grade II, 57 (20%); grade III, 98 (35%); grade IV, 50 (18%); and grade V, 52 (19%). The scores of the patients who received an endovascular coil were as follows: grade I, 12 (13%); grade II, 19 (20%); grade III, 21 (22%); grade IV, 19 (20%); and grade V, 24 (25%). No statistically significant difference were observed between the two groups (p>0.15). The final treatment outcome was assessed using the Glasgow outcome scale (GOS). In the surgical group, 182 patients (65%) exhibited a good recovery (GR), 24 patients (9%) exhibited moderate disability (MD), 15 patients (5%) exhibited severe disability (SD), and 58 patients (21%) died. In the endovascular coil group, on the other hand 39 patients (41%) exhibited GR, 15 patients (16%) exhibited MD, 18 patients (19%) exhibited SD, and 23 patients (24%) died. These differences were statistically significant (p<0.001). Thus, the outcome was better in the surgical group. Out of the 129 cases treated conservatively, 100 cases had experienced cardiopulmonary arrest on admission and eventually died. The remaining 29 cases with angiographically occult aneurysms, however, exhibited a good recovery. Conclusion: Direct surgery should be considered as the treatment of choice for Grade I-IV SAH patients, while endovascular coiling should be adopted for Grade V SAH patients.