실비안열내 혈종을 가진 파열된 중대뇌동맥류 수술에서 혈종 제거율의 중요성

초록

PURPOSE : Ruptured middle cerebral artery (MCA) aneurysm with intrasylvian hematoma in many cases has typical clinical course from others that it shows neurological deterioration from cerebral swelling after aneurysm surgery and decompressive craniectomy may be performed within a few days. In this retrospective study, the authors analyzed whether the ratio of hematoma removal in aneurysm surgery has clinical importance in the progression of cerebral swelling, and review the characteristics of the subarachnoid hemorrhage (SAH) with intrasylvian hematoma. MATERIALS AND METHODS : From 2012 February to 2014 March, twenty four aneurysm surgeries for ruptured MCA aneurysms with intrasylvian hematoma were performed in the authors’ clinic. The patients were classified into three groups. Group A was the patients who performed decompressive craniectomy within a few days after aneurysm surgery due to progressive cerebral swelling, group B not necessary decompression because the patients persisted well, and group C was the patients who showed severe cerebral swelling on initial CT scan and prophylactic decompressive craniectomy and aneurysm surgery in a stage. RESULTS : The mean hematoma volume on admission was 28.6 mL, 25.0 mL, 66.8 mL for group A, B, and C respectively. Removal of larger amount of hematoma was observed on immediate postoperative CT scan in group B and C (63.2%, 59%) in compared with group A (33.4%). Although statistical difference was not found between group A and group B (p=0.115), group B and group C (p=0.863), or group A and group C (p=0.863), it tends to show that the lesser amount of hematoma removed, the more likely cerebral swelling progress. In three patients of group A, the extension of hematoma was observed within two days in the absence of rebleeding from clipped aneurysm. We suggest that this results from small hemorrhagic transformation of infarcted tissue that caused by small vessel coagulation injury and brain re