A Fig. 1. This 37-year-old woman underwent neck clipping for the ruptured left posterior communicating artery aneurysm 12 years ago. The follow-up thr

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1 KISEP Clinical Article J Korean Neurosurg Soc , 2003 재발한 뇌동맥류의 치료 박종수 임만빈 김일만 이창영 손은익 김동원 Treatment for Recurrent Cerebral Aneurysm Joung-Soo Park, M.D., Man-Bin Yim, M.D., IL-Man Kim, M.D., Chang-Young Lee, M.D., Eun-Ik Son, M.D., Dong-Won Kim, M.D. Department of Neurosurgery, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea Objective:The aim of this study is to make a management strategy for the patients with recurrent cerebral aneurysm after surgery. Methods:Over a 19-year period, 1,546 patients were treated for a ruptured intracranial aneurysm surgically. Twenty-six of these patients(1.7%) were subsequently treated for regrowing aneurysm(8) or de novo aneurysm formation(26). Among them, twenty-three individuals who presented with recurrent subarachnoid hemorrhage underwent conventional angiography to detect the aneurysm recurrence. Three-dimensional computed tomographic angiography was performed in the remaining three patients who complained chronic headache. The mean age at the first surgery was 48.6 years. An interval ranging from 1 to 192 months(mean, 76.1 months) since the original treatment. Results:Total 34 recurrent aneurysms in 26 patients were treated by microsurgical clipping(29 cases), wrapping(1 case), and endovascular coiling(4 cases) as a second procedure. A satisfactory outcomes were achieved in twenty-one patients(80.8%) during a mean 69.5 months follow-up period. The most common site of the recurrence was the internal carotid-posterior communicating artery. Patients with de novo aneurysms are frequently hypertensive(61.1%) and younger in age(55.6%). Conclusion:The treatment of recurrent cerebral aneurysm could be performed effectively using direct operations and/or endovascular procedures. KEY WORDS:Cerebral aneurysm Recurrence Three dimensional computed tomographic angiography Subarachnoid hemorrhage Coil embolization Clipping. 서 론 ReceivedJanuary 22, 2003 AcceptedMarch 10, 2003 Address for reprintsman-bin Yim, M.D., Department of Neurosurgery, Keimyung University Dongsan Medcial Center, 194 Dongsan-Dong, Jung- Gu, Daegu , Korea Tel , Fax y760111@dsmc.or.kr 472 대상 및 방법 J Korean Neurosurg SocVolume 33May, 2003

management strategy for the patients with recurrent cerebral aneurysm after surgery. Methods:Over a 19-year period, 1,546 patients were treated for a ruptured intracranial aneurysm surgically.

2 A Fig. 1. This 37-year-old woman underwent neck clipping for the ruptured left posterior communicating artery aneurysm 12 years ago. The follow-up three-dimensional computed tomographic angiographya demonstrates a large recurrent aneurysmarrow head at the initial operation site and the proximally slipped cliparrow. Conventional angiography immediately after near total obliteration of the aneurysmal sac with Guglielmi Detachable CoilsB. de novo 결 과 B 고 찰 J Korean Neurosurg SocVolume 33May,

The follow-up three-dimensional computed tomographic angiographya demonstrates a large recurrent aneurysmarrow head at the

3 Table 1. Clinical summary of 26 patients with recurrent intracranial aneurysms Age/Sex Original site Hypertension Interval mo Regrowth De novo Treatment Outcome /F Lt MCA 091 C G /M Acom 001 C E /F Acom 002 C E /F Rt MCA 001 C F /F Lt Pcom 168 * Co E /F Lt MCA 002 Lt A2 C P /F Rt ICA 011 Rt P1P2 jx C D /M Lt Pcom 180 Rt MCA C F /F Rt MCA 043 Lt MCA C E /F Rt MCA 052 Acom C E /F Lt MCA 060 Lt PICA C E /F Rt Pcom 087 Lt Pcom C E /F Lt MCA/Lt Opthalmic 062 Lt A2 C G /M Lt ant.choroidal 069 Rt Pcom C E /F Acom 079 Rt Pcom C E /F Acom/Lt ant.choroidal 117 Lt PICA AcomC/ Lt ant.choroidalc G /F Rt MCA 056 Acom C E /F Acom/Lt MCA 106 Lt A2/Rt MCA* Rt Pcom* Lt A2C/Rt MCAC Rt PcomCo /F Acom 079 Lt MCA C E /F Rt MCA 023 Acom C E /F Lt Pcom 054 Rt Pcom C G /F Lt A2 128 Acom/Lt ICA* Lt MCA*/Lt M2* AcomC/Lt ICAC Lt MCAC/Lt M2:C /F Both MCA/Acom Rt cavernous/rt A2 154 Lt SCA* Co E Lt ant.choroidal /F Rt Pcom 192 * Lt Pcom Rt PcomW/Lt PcomC E /F Acom 027 BA* AcomC/BAC F /F Lt Pcom 135 * Rt Pcom* Lt PcomCo/Rt PcomC E Unruptured aneurysm, MCAMiddle cerebral artery bifurcation, ICAInternal cerebral artery bifurcation, jxjunction, BABasilar artery, AcomAnterior communicating artery, PcomPosterior communicating artery, SAHSubarachnoid hemorrhage, PICAPosterior inferior cerebellar artery, SCASuperior cerebellar artery, DSADigital subtraction angiography, 3DCTA3 dimensional computed tomographic angiography, CClipping, Co:Coiling, WWrapping, EExcellent, GGood, FFair, PPoor, DDeath G E 474 J Korean Neurosurg SocVolume 33May, 2003

51/F Rt MCA 043 Lt MCA C E 10. 35/F Rt MCA 052 Acom C E 11. 59/F Lt MCA 060 Lt PICA C E 12. 61/F Rt Pcom 087 Lt Pcom C E 13. 60/F Lt MCA/Lt Opthalmic 062 Lt A2 C G 14. 53/M Lt ant.

4 결 론 References 1. Andrews RJ, Spiegel PK:Intracranial aneurysms. Age, sex, blood pressure, and multiplicity in an unselected series of patients. J Neurosurg 51:27-32, Boet R, Poon WS, Yu SC:The management of residual and recurrent intracranial aneurysms after previous endovascular or surgical treatment-a report of eighteen cases. Acta Neurochir(Wien) 143: , Dietrich W, Reinprecht A, Gruber A, Czech T:De novo formation and rupture of an azygos pericallosal artery aneurysm. Case report. J Neurosurg 93: , Drake CG, Allcock JM:Postoperative angiography and the slipped clip. J Neurosurg 39: , Drake CG, Friedman AH, Peerless SJ:Failed aneurysm surgery. Reoperation in 115 cases. J Neurosurg 61: , Drake CG, Vanderlinden RG:The late consequences of incomplete surgical treatment of cerebral aneurysms. J Neurosurg 27: , Drapkin AJ, Rose WS:Serial development of de Novo aneurysms after carotid ligation:case report. Surg Neurol 38: , Dujovny M, Osgood CP, Barrionuevo PJ, Perlin A, Kossovsky N: SEM evaluation of endothelial damage following temporary middle cerebral artery occlusion in dogs. J Neurosurg 48:42-48, Dyste GN, Beck DW:De novo aneurysm formation following carotid ligation:case report and review of the literature. Neurosurgery 24: 88-92, Feuerberg I, Lindquist C, Lindqvist M, Steiner L:Natural history of postoperative aneurysm rests. J Neurosurg 66:30-34, Giannotta SL, Litofsky NS:Reoperation management of intracranial aneurysms. J Neurosurg 83: , Graf CJ, Hamby WB:Report of a case of cerebral aneurysm in an adult developing apparently de novo. J Neurol Neurosurg Psychiatry 27: , Kato Y, Sano H, Kanaoka N, Hayakawa M, Iritani K, Katada K, et al: Mechanism and prevention of enlargement or new development of aneurysm following treatment by clipping or coiling. Neurol Res 22: , Kwon TH, Chung HS, Park YK, Cho TH, Lim DJ, Park JY, et al: Treatment results of intracranial aneurysms by wrapping and coating. J Korean Neurosurg Soc 30: , Miller CA, Hill SA, Hunt WE: De novo aneurysms. A clinical review. Surg Neurol 24: , Nakase H, Kamada Y, Aoki H, Goda K, Morimoto T, Sakaki T:Clinical study on recurrent intracranial aneurysms. Cerebrovasc Dis 10: , Rinne JK, Hernesniemi JA:De novo aneurysms:special multiple intracranial aneurysms. Neurosurgery 33: , Sacco RL, Wolf PA, Bharucha NE, Meeks SL, Kannel WB, Charette LJ, et al:subarachnoid and intracerebral hemorrhage:natural history, prognosis, and precursive factors in the Framingham study. Neurology 34: , Sakaki T, Takeshima T, Tominaga M, Hashimoto H, Kawaguchi S: Recurrence of ICA-PCoA aneurysms after neck clipping. J Neurosurg 80:58-63, Seppo J:Risk of subarachnoid hemorhage from a de novo aneurysm. Stroke 32: , Sim JH, Kim SC, Jung YT, Lee SI, Kim MS:Surgical experience of 2178 cases of intracranial aneurysms. J Korean Neurosurg Soc 31: , Thornton J, Bashir Q, Aletich VA, Debrun GM, Ausman JI, Charbel FT:What percentage of surgically clipped intracranial aneurysms have residual necks? Neurosurgery 46: , Tonn JC, Hoffmann O, Hofmann E, Schlake HP, Sorensen N, Roosen J Korean Neurosurg SocVolume 33May,

Acta Neurochir(Wien) 143:1093-1101, 2001 3. Dietrich W, Reinprecht A, Gruber A, Czech T:De novo formation and rupture of an azygos pericallosal artery aneurysm. Case report.

5 K: De novo formation of intracranial aneurysms:who is at risk? Neuroradiology 41: , Tsutsumi K, Ueki K, Morita A, Usui M, Kirino T:Risk of aneurysm recurrence in patients with clipped cerebral aneurysms. Results of long-term follow-up angiography. Stroke 32: , Tsutsumi K, Ueki K, Usui M, Kwak S:Risk of recurrent subarachnoid hemorrhage after complete obliteration of cerebral aneurysms. Stroke 29: , Yamakawa H, Sakai N, Takenaka K, Himura S, Andoh T, Yamada H, et al:clinical analysis of recurrent subarachnoid hemorrhage after neck clipping surgery. Neurol Med Chir(Tokyo) 37: , J Korean Neurosurg SocVolume 33May, 2003

Stroke 32:1191-1194, 2001 25. Tsutsumi K, Ueki K, Usui M, Kwak S:Risk of recurrent subarachnoid hemorrhage after complete obliteration of cerebral aneurysms.

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding