선형가속기 방사선 수술을 이용한 뇌동정맥기형의 치료

이성열,손은익,김옥배,최태진,김동원,임만빈,김인홍,Lee, Sung Yeal,Son, Eun Ik,Kim, Ok Bae,Choi, Tae Jin,Kim, Dong Won,Yim, Man Bin,Kim, In Hong 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.8

본 논문에서 뇌동정맥기형에 대해 포톤나이프로 정위적 방사선 수술을 시행한 후 방사선학적으로 10명의 환자중 6례에서 완전 폐색, 4례에서 부분적 폐색을 보였으며, 특히 3cm이하의 작은 뇌동정맥기형 7례중 6례에서 완전 폐색을 보였다(완전 폐색율 : 85.7%). 모든 환자에서 방사선 수술로 인한 방사선학적 합병증의 발병은 없었다. 신경학적으로도 모든 환자에서 방사선 수술 전에 보이던 증상들이 호전을 보였다. 포톤나이프 방사선 수술 시스템은 이미 실험적으로 안정성이 검증된 것으로 이 논문에서 임상적으로 방사선 수술의 안정성 및 정확성을 다시 확인할 수 있었다. 정위적 방사선 수술은 지금까지 치료 불가능했던 부위에 생긴 병소, 수술이나 다른 치료방법으로 완전 제거에 실패한 경우, 노인환자나 다른 내과적 질환으로 수술이 어렵거나 수술적 치료를 거부하는 환자에서도 좋은 치료 방법으로 사용되어지며, 특히 뇌 중요부위나 심부병변에 위치한 경우 또는 최대직경이 3cm 이하의 소 동정맥기형으로 발견 당시 출혈량이 많지 않고 신경학적 결손이 경미한 환자에서 좋은 적응증이 되리라 사료된다. Objective : The aim of this study was to retrospectively analyze the safety and effect of Linac based Photon Knife Radiosugery System(PKRS) for treatment of cerebral arteriovenous malformation. Patients and Methods : The authors analyzed the clinical method and results of ten patients who were followed up more than two years, among the 18 patients who had radiosurgery on arteriovenous malformation from June, 1992, to Dec. 1997, with Linac based Photon knife radiosurgery system(PKRS) which was developed in our hospital. Results : The average age of the patients was 30.4(with the range of 13-49), and the sex was seven males and three females. For the initial clinical symptoms, there were five patients with headache, three with seizure, one with hemiparesis, and one with vomiting. Before the radiosurgery, computed tomography, MRI, and cerebral angiogram were done. For the location of arteriovenous malformation, it was found on six patients of cerebral hemisphere, two of thalamus, one of brainstem, and one of corpus callosum. Regarding the size of nidus, there were seven patients of smaller than 3cm, and three patients of larger than 3cm. Computed tomography, MRI, and cerebral angiogram were done periodically for sixth months, first year, and second year after the radiosurgery of PKRS for the completeness of obliteration. Six cases showed complete obliteration, and four partial obliterations were observed among ten cases, and interestingly, six cases of complete obliteration were observed among seven cases of small AVM of smaller than 3cm(the rate of complete obliteration : 85.7%). All patients tolerated the treatment and no significant complication were seen. Conclusion : In this study, linac based radiosurgery using PKRS onto arteriovenous malformation showed excellent effects, therefore authors believe that it is an ideal method for small sized or deep seated AVM.

자발성 뇌내혈종의 음압배액술

김일만,손은익,김동원,임만빈,Kim, Il-Man,Son, Eun Ik,Kim, Dong Won,Yim, Man Bin 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.6

Objectives : The less invasive stereotactic surgery of hypertensive intracerebral hematoma has been preferred. Many techniques were developed to facilitate aspiration of a dense blood clot in acute stage. Authors describe a method for evacuation of putaminal hematoma via computerized tomography(CT)-aided free-hand stereotactic infusion of urokinase and frequent negative pressure aspiration. Patients and Methods : A total of ten patients with spontaneous putaminal hematoma underwent surgery with negative pressure aspiration in the three-year period. All procedures were performed within 12 hours of insult. A silicone ventricular catheter was inserted into the center of hematoma through a burr hole at the Kocher's point under local anesthesia. In a typical case of putaminal hematoma, the trajectory of catheter was pointed the center of hematoma parallel to sagittal plane vertically and the external auditory meatus posteriorly. Immediately after the first trial of hematoma aspiration low-dose urokinase solution(2,000IU/5ml saline) was administrated through the catheter and drain was clipped for 30 minutes. Subsequently, the partially liquified hematoma was manually aspirated using a 10ml syringe with a negative pressure of less than 2 to 3ml. The procedure was carefully repeated every 1 hour until the hematoma was near totally evacuated. Results : The patients population consisted composed of 4 men and 6 women with a mean age of 61.6 years. All had major neurological deficits preoperatively. The mean hematoma volume was 44.3 ml and hematoma was drained for 20 to 48 hours. No complications such as rebleeding, meningitis, or malplaced catheter were noted. Outcome was moderately disabled in four patients and good recovery in three patients. Conclusion : Although the frequent negative pressure aspiration and low-dose urokinase infusion has the disadvantage of possbility of rebleeding and infection, it is consisdered to be an effective method because it allows a simple, safe, and complete removal of hematoma.

일차 배양 해마신경세포에서 NMDA- 및 Glutamate- 유도전류의 특성

김일만,손은익,김동원,김인홍,임만빈,송대규,박원균,배재훈,최하영,Kim, Il-Man,Son, Eun-Ik,Kim, Dong-Won,Kim, In-Hong,Yim, Man-Bin,Song, Dae-Kyu,Park, Won-Kyun,Bae, Jae-Hun,Choi, Ha-Young 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.11

Objectives : This study was performed in cultured rat hippocampal neurons to investigate the acute electrophysiological features of ionotropic glutamate receptors which act as a major excitatory neurotransmitter in mammalian brain. Method : Glutamate receptor agonists were applied into the bath solution embedding in whole-cell patch-clamp recording of single hippocampal neuron. Results : In voltage-clamped at -60mV and the presence of 1mmol $Mg^{2+}$, extracellulary applied NMDA did not induce any inward current. Both the elimination of $Mg^{2+}$ and addition of glycine in bath, however, elicited a NMDAinduced inward current. $Mg^{2+}$ block current was increased gradually in more negative potentials from -30mV, showing a negative slope in I-V plot with $Mg^{2+}$. Glutamate-induced current represented an outward rectification. A non-NMDA receptor component occupied about 40% of glutamate-induced current in the voltage range of -80mV to +60mV. Conclusion : Present study suggests that glutamate activates acutely the non-NMDA receptors which induces an inward current in the level of resting membrane potential. This makes the membrane potential increase and can activate the NMDA receptors that permit calcium influx against $Mg^{2+}$ block. At the depolarized state of neuron, there may be recovery mechanisms of membrane potential to repolarize irrespective of voltage-dependent potassium channels in the hippocampal neurons.

원발성 중추신경계 림프종의 치료전략

김일만,이창영,손은익,김동원,임만빈,김상표,Kim, Il-Man,Lee, Chang Young,Son, Eun Ik,Kim, Dong Won,Yim, Man Bin,Kim, Sang Pyo 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.3

Objective : We have currently changed treatment strategies to methotrexate(MTX)-based preirradiation chemotherapy with subsequent planned radiation for the initial therapy of primary central nervous system lymphoma (PCNSL). The aim of this study was to evaluate the results of treating PCNSL with chemotherapy plus radiotherapy (CRT) or radiotherapy(RT) alone. Method and Material : This study involved 10 females and 3 males patients with a mean age of 54.2 years. All patients underwent surgery, open(8 cases) or stereotactic biopsy(5 cases) for histological diagnosis. Eleven tumors were diffuse large B-cell lymphomas. Tumor volume change in the follow-up images and survival time were evaluated in patients treated with CRT and RT alone. In the beginning, two patients received ProMACE-Cytabom chemotherapeutic regimen, but did not complete the course and died of progressive tumor 8 and 9 months after diagnosis, respectively. One patient died at 6 months before chemotherapy. These three were excluded from the survival analysis. Five patients(RT group) completed full courses of cranial irradiation with or without boost. For the current combined modality treatment, high-dose MTXbased chemotherapy(systemic and intrathecal MTX, IV vincristine, and oral procarbazine) followed by whole brain irrdiation to 45Gy to tumor was introduced in 5 patients of CRT group. Result : A complete response was achieved in three of five who received RT only and in all of five who received CRT. All patients in CRT groups are in disease free status at a mean 23 months following therapy. The RT group patients refused any additional salvage therapy at tumor relapse and survived at mean 20 months from diagnosis. The Karnofsky performance status improved in eight of ten patients with treatment. The treatment toxicity included leukoencephalopathy in RT group and severe leukopenia, transient hepatitis, avascular necrosis of femoral head, hearing loss, and amenorrhea in CRT group, respectively. Conclusion : The combined modality therapy of MTX-based chemotherapy plus radiotherapy for PCNSL may enhance tumor response and improve patient survival. The patients who received CRT should be carefully followed up because of the higher risk of treatment-induced late neurotoxicity.

대 뇌동맥류 및 거대 뇌동맥류의 수술적 가료

임만빈,이창영,김일만,손은익,김동원,Yim, Man-Bin,Lee, Chang-Young,Kim, Ill-Man,Son, Eun-Ik,Kim, Dong-Won 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.6

Objectives : The goal of the surgical management of large and giant aneurysm is complete extirpation of the aneurysms with preservation or reconstruction of the parent artery. To improve the surgical management results of those aneurysms in the future, we review our experience and discuss technical maneuvers and strategies used to avoid potential complications of those aneurysm surgery. Material and Methods : During the past 12 years, thirty six cases of large and giant aneurysms(diameter>19mm) were managed by surgery. The clinical characteristics, treatment methods, surgical complications and outcome of those cases were analyzed and, based on the review of the literatures, the preventive methods of surgical complication related to the clipping of those aneurysms were discussed. Results : The locations of those aneurysms were anterior circulation in 34 cases and posterior circulation in 2 cases. The most frequent site of aneurysmal location was a paraclinoidal region of the anterior circulation. The aneurysms were managed surgically by direct clipping of aneurysmal neck in 31 cases, aneurysmal trapping followed by extracranial-intracranial bypass in 2 cases, proximal clipping of parent artery, aneurysmorrhaphy, and excision of aneurysm followed by end to end anastomosis of parent artery in each one case. Surgical complications occurred in 13 cases. A parent vessel occlusion by thrombus formation and parent vessel stenosis after clipping of aneurysm were the main complications. We obtained good outcome in 27, fair 5, poor 1 and dead in 3 case(s). Conclusion : We conclude that selection of suitable management method for each case, high quality of surgical technique and prevention of complication during operation are important key points for the successful treatment of large and giant aneurysm. The heparinization prior to application of temporary clip on parent vessels, aneurysmal decompression during dissection and clipping of aneurysm, complete closing of the aneurysmal neck and avoiding the narrowing of parent vessel after clipping of aneurysm were the main technical maneuvers used to avoid complications of those aneurysm surgery.

소아 시교차-시상하부 신경교종의 치료

도홍직,김일만,이창영,손은익,김동원,임만빈,김상표,Doh, Hong-Jik,Kim, Il-Man,Lee, Chang Young,Son, Eun Ik,Kim, Dong Won,Yim, Man Bin,Kim, Sang Pyo 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.9

Objective : Management strategies for pediatric chiasmatic-hypothalamic gliomas(CHG) include surgery, irradiation, chemotherapy and a combination of these modalities. This study was performed in order to compare the efficacy of various methods of treatment and to describe its optimal management. Material and Method : We have reviewed the results of management of 6 children with a diagnosis of CHG, who were observed closely during the last 8 years. The patients were aged 7 months to 15 years. Our patients presented with diencephalic syndrome, endocrine dysfunction, and progressive visual loss. None of these had evidence of neurofibromatosis-1. Treatment consisted of surgery alone(2), surgry and irradiation(2), surgery, irradiation and chemotherapy(1), and surgery and chemotherapy(1). Results : Four children had large exophytic suprasellar tumors and two showed diffuse midline lesions. Obstructive hydrocephalus was present in all patients. Pathologic examination revealed anaplastic astrocytoma in 1 and lowgrade astrocytoma in 5. Two patients, recently treated with radiation therapy following radical subtotal resection, showed significant tumor reductions and good clinical status. Four patients had partial tumor resection. Of these patients, two developed disease stabilization during follow-up period of 7 and 8 years, respectively. Life-threatening complications were noted in remaining two patients. Conclusion : CHG may follow an unpredicatable course and show a various reponse to each treatment modality. Further studies are indicated to define the optimal method of treatment of CHG in childhood.

수근관증후군의 수술방법에 따른 성적 - 내시경수술과 개방절개술 -

이한영,김일만,이장철,이창영,손은익,김동원,임만빈,Lee, Han Young,Kim, Il-Man,Lee, Jang Chull,Lee, Chang Young,Son, Eun Ik,Kim, Dong Won,Yim, Man Bin 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.11

Objective : The goal of this study is to present whether endoscopic release(ER) is superior to open release(OR) for the treatment of carpal tunnel syndrome(CTS). Method and Material : Fifty-nine wrists in 43 patients who had clnical signs and symptoms consistent with CTS, not responded to non-operative management, were entered into the study. Authors retrospectively compared 27 wrists treated with ER(February 1999-June 1999) with 32 wrists treated with OR(October 1997-March 1999). We performed conventional open surgery in 25 patients(mean age ; 46 years) and Brown's two-portal technique in 18 patients(mean age ; 53 years) under intravenous regional block or general anesthesia. Results : Sixteen patients had CTS on both hands and left hands were affected more frequently than right hand, 34 and 25 respectively. Successful and poor results of ER were similar to those of OR. For patients in OR group, mean duration of symptoms was 5 years(range 1 month-30 years), and postoperative outcome was good in 27(84.4%) of wrists and poor in 5(15.6%). For patients in ER group, mean duration of symptoms was 7 months (range 2 months-25 years), outcome was good in 23(85.2%) of wrists and poor in 4(14.8%). The average time for complete relief of pain was 1.3 weeks and 7.6 weeks, respectively for OR and ER groups. No complication was noted in either group. Conclusion : This preliminary analysis suggests that faster relief of pain was achieved when the endoscopic method was used, although there were no significant differences in their efficacies regarding the improvement of symptoms.

뇌동맥류의 조기수술 전 재출혈 방지를 위한 항섬유소용해제 투여의 효과

이창영,임만빈,이장철,손은익,김동원,김인홍,Lee, Chang Young,Yim, Man Bin,Lee, Jang Chull,Son, Eun Ik,Kim, Dong Won,Kim, In Hong 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.9

파열된 뇌동맥류의 조기수술이 계획된 환자에서 수술전까지 단기간에 걸친 항섬유소용해제 투여의 효과를 알아보기 위해 뇌동맥류성 지주막하출혈 환자 137례에 대하여 60례를 AMCA 투여군으로, 77례를 비 투여군으로 분류하여 재출혈, 증상적 혈관연축, 뇌수두증의 발생빈도 및 전체적인 치료성적을 비교, 분석하였다. 재출혈의 발생빈도는 AMCA 비 투여군에 비해 투여군에서 통계학적으로 유의하게 낮게 나타났고 AMCA의 장기투여에서 증가를 보인 증상적 혈관연축과 뇌수두증의 발생빈도는 양군에서 유의한 차이를 보이지 않았으며 전체적인 치료성적은 AMCA 투여군에서 비 투여군에 비해 보다 양호한 결과를 보였다. 따라서 조기수술이 계획된 뇌동맥류성 지주막하출혈 환자에서 AMCA의 단기간 투여는 재출혈율을 감소시켜 전체적인 치료결과를 향상시키는데 도움이 될 것으로 생각된다. Object : This study was conducted to evaluate whether short-term intravenous infusion of tranexamic acid (AMCA) was able to improve the management outcome by preventing rebleeding without increasing vasospasm and hydrocephalus associated with the long-term administration of this agent in the patients with aneurysmal subarachnoid hemorrhage(SAH) who were planned for the early surgery. Methods : During the period from June, 1996 to May, 1998, 137 patients admitted within 3 days of their SAH and planned for early surgical intervention were subject to study population. Of these, 60 patients who had been treated with AMCA were classified as AMCA treated group and 77 patients without AMCA treatment as AMCA untreated group. Initially, prognostic factors for rebleeding, vasospasm, hydrocephalus and outcome following SAH including age, sex, clinical grade, CT grade, site of ruptured aneurysms, admission day after SAH, surgery day after SAH, number of aneurysms and hypertension history, were analyzed and compared between AMCA treated group and untreated group. Secondly, the incidence of rebleeding, symptomatic vasospasm and hydrocephalus were compared between the two groups. Also, the management outcome of the patients was compared between the two groups. Results : There were no significant differences in prognostic factors between the two groups. The rebleeding rate was 0% in the AMCA treated group whereas the rate was 7.8% in the untreated group. This difference was statistically significant. The incidences of symptomatic vasospasm and hydrocephalus were found not to be significantly different between the two groups. Of the treated group, 31.7% of patients developed hydrocephalus compared to 32.5% of those at the untreated group. Fourteen(23.3%) patients in treated group developed symptomatic vasospasm and 6 of them(10%) suffered stroke whereas incidences of these in untreated group were 25.9% and 11.7%, respectively. The AMCA treated group showed more favorable outcome than that of untreated group. There was no case of death by rebleeding in the AMCA treated group while one of the main causes of death in the untreated group was rebleeding. Conclusion : Short-term high-dose AMCA administration is considered beneficial in improving outcome and diminishing the risk of rebleeding in the patients who suffer from an aneurysmal SAH prior to early surgical intervention.

난천성 측두엽간질의 발작간 뇌혈류 SPECT , MRI 와 수술성과 비교

전석길,주양구,이상도,손은익,이영환 ( Seok Kil Zeon,Yang Goo Joo,Sang Doe Lee,Eun Ik Son,Young Hwan Lee ) 대한핵의학회 1994 핵의학 분자영상 Vol.28 No.3

Interictal single photon emission computed tomography of regional cerebral blood flow (rCBF SPECT) in 18 intractable temporal lobe epilepsy patient,s(8 male and 10 female patients : average 23.5 years old) were eompared with 2.0 T magnetic resanance imaging (MRI). And surgical outcome was analysed with the findings, symptom duration and lateralization of temporal lobe. Preoperatively rCRF SPKCT was done in all 18 patients with intravenous injection of 740 MRq 99mTc HMPAO. MRI was also done preoperatively in 13 patients, Surgical outcome was classified by Engels outcome classification (four part classification recommended at the first Palm Desert conference). rCRF SPECT detected correctly lateralising abnormality of temporal lobe hypoperfusion in 13/ 18(72.2%), contralateral temporal lobe hypoperfusion in 2/18(11.1%) and showed no definite abnormality in 3/18(16.7%). The positive predictive value of unilateral temporal lobe hypoperfusion was 87%. MRI detected correct localising abnormality in 8/13(61.5%), such as hippocampal atrophy(7/13), asymmetric temporal horn(6/13), anterior t,emporal lobe atrophy(1/13), increased signal intensity from hippocampus(1/13) and ealcific density(3/13), and no abnormal finding was noted in 5/13(38.5%), There was no false positive findings and the positive predictive value of MRI was 100%, Only 2 cases showed same lateralization findings in rCBF SPECT and MRI. There was no significant correlation between symptom duration and no abnormal findings on SPECT or MRI. Surgical outcome showed elass 1 in 15/18(83.3%), and class II in 2/18(11.1%). One case of no abnormal finding in both SPECT and MRI showed elass I1I surgical outcome. No class IV surgical out.come was noted. Surgical outcome, lat.eralization of epileptic focus in temporal lobe and abnormal findings in rCBR SPECT or MRI were not significantly correlated.

측뇌실 삼각부의 거대 상의하 세포종 1례

정성훈 ( Sung Hoon Jung ),손은익 ( Eun Ik Son ),김인수 ( In Soo Kim ),김상표 ( Sang Pyo Kim ) 대한뇌종양학회·대한신경종양학회·대한소아뇌종양학회 2005 대한뇌종양학회지 Vol.4 No.2

Symptomatic lateral ventricular subependymomas are rare. A 34-year-old man presented with a 3-year history of progressive headache and seizure. Computed tomography and magnetic resonance imaging demonstrated inhomogenous well-enhancing, mass with calcification and chronic hemorrhagic component. A gross total resecton was performed via inferior temporal approach and the patient did well postoperatively. This report presents an introduction of subependyma and surgical strategy for lateral trigonal tumor.