뇌하수체선종의 수술적 가료 결과

송동식,임만빈,이장철,손은익,김동원,김인홍,이인규,김덕준 대한신경외과학회 1994 Journal of Korean neurosurgical society Vol.23 No.8

저자들은 과거 6년간 본원에서 가료하였던 74례의 뇌하수체 선종을 대상으로 술후 호르몬 수치에 의한 치료결과, 시력 혹은 시야장애의 술후 호전율 및 술후 합병증에 대한 조사를 시행한 바 프로락틴 분비선종은 치료율 50%, 호전율 80.8%였고, 성장호르몬 분비선종에서는 치료율 50%, 호전율 75%였다. 부신피질 호르몬 분비선종 3례에서는 Nelson 증후군 1례를 포함하여 2례가 치유되었고, 갑상선호르몬 분비선종 1례도 치유되었다. 수술후 시야 및 시력의 호전율은 77.1%였고 치료후 주요 향병증은 뇌하수체 기능 저하 및 일시적 뇨붕증이었다. 따라서 저자들의 예들에서 치료 성적이 만족스럽지 못한 이유는 맡은 예들이 터어키안 밖으로 신전된 후에야 수술적 가료를 시행한 예들이 많았기 때문으로 생각되고 향후 수술 수기를 향상시키고 종양을 더욱 조기에 발견하여 미세선종의 예들에서 수술적 가료를 시행하는 예들이 증가하면 치료결과도 향상되리라고 생각한다. The authors report results of surgical management in seventy-four cases of pituitary tumor who were treated in the department of neurosurgery, Keimyung University from Jan. 1987 to Dec. 1992. The composition of cases are prolactinoma in twenty-six cases, growth hormone(GH) secreting tumor in twenty, adrenocorticotropic hormone(ACTH) secreting tumor in three, thyrotropic hormone(TSH) secreting tumor in one and nonsecreting tumor in twenty-four cases Fourty cases(54.1%) showed suprasellar and/or parasellar extension in the radiological studies. The modalites of management were surgery only in fourty-seven cases and surgery with radiation therapy in twenty-seven cases. Bromocriptin was medicated in twenty-two cases postoperatively. The management results in cases of prolactinoma, thirteen(50.0%) cases were cured and eight(30.8%) cases were improved. In the cases of GH secreting tumor, ten(50%)cases were cured and five(25%) cases were improved Among three cases of ACTH secreting tumor, two cases were cured and there was one case of TSH Secreting tumor which was cured The worst management result were noticed in the cases of GH secreting tumor which extended suprasellar and/or parasellar region. Of the thirty-five cases who had preoperative visual impairment(twenty-one cases of functional tumor and fourteen cases of nonfunctional tumor), twenty-seven(77.1%) cases were improved, six(l7.19%) cases not improved and two(5.7%) cases aggravated. The common complications after surgical management were hypopituitarism (eleven cases) and transient diabetes insipidus(nine cases). Recurrence was noticed in one case during follow-up period and three cases were expired with one case during perioperative period and two during follow-up period. We conclude that an extensive effort should be made to diagnose early and advance surgical technique so as to improve the results of surgical management of the pituitary tumor.

흰쥐의 가역성과 비가역성 허혈성 뇌경색모형에서 중대뇌동맥 폐쇄후 시간경과에 따른 뇌경색 크기

송동식,임만빈,이장철,손은익,김동원,김인홍 대한신경외과학회 1995 Journal of Korean neurosurgical society Vol.24 No.9

저자들은 30마리의 흰쥐를 실험동물로 사용하여 개두술없이 두개외접근으로 비가역성 및 가역성 뇌경색 모형을 만들고 중대뇌동맥 폐쇄 후 몇 시간내에 재관류를 시킬때 뇌경색의 크기를 감소시킬 수 있는지를 알아보고저 하였다. 비가역성 뇌경색은 내경동맥을 통해 18㎜길이의 4번 나이론사를 전대뇌쪽으로 16㎜정도 진전시켜 중대뇌동맥을 폐쇄하여 만들었고, 가역성 뇌경색은 삽입된 나일론사를 빼내어 전교통동맥 및 후교통동맥을 통해 재관류를 시켜 만들었다. 뇌경색 크기를 측정하기 위하여 대뇌 적출시 확인한 바, 비가역성 뇌경색 모형에서는 전예에서 나이론사가 중대뇌동맥 분지부를 지나 전대뇌동맥의 근위부에 위치하고 있었고, 가역성 뇌경색 모형에서는 나일론사가 후교통동맥 분지부 전의 내경동맥에 위치하고 뇌혈관내 혈전형성은 없어, 전교통동맥 및 후교통동맥을 통한 재관류가 이루워짐을 확인할 수 있었다. 가역성 뇌경색군과 비가역성 뇌경생군에서의 뇌경색 크기를 비교한 바 중대동맥 폐쇄 후 4시간 및 6시간후에 재관류를 시킨 가역성 뇌경색군에서 비가역서 뇌경색군에 비해 뇌경색 크기가 감소하였고, 4시간군에서 현저하였으며 특히 기저핵부위 이외의 측부혈행이 가능한 부위의 뇌경색이 감소하였다. 그러나 12시간 후에 재관류 시킨 군에서는 그 차이가 거의 없었다. 결론적으로 저자가 이용한 가역성 및 비가역성 뇌경색 모형은 개두술없이 간편하게 만들 수 있는 방법이므로 향후 뇌경색의 연구에 많이 이용할 수 있을 모형으로 생각된다. 또한 재순환은 뇌혈관 폐쇄 후 적어도 4시간내에 이루어져야 기질적 뇌경색을 감소시킬 것으로 생각되고 이러한 재순환후 뇌경색의 감소는 뇌경색 중심부보다 측부혈행이 가능한 주변부의 뇌경색이 호전되므로 그러한 것으로 추정된다. To establish a simple recirculation model in rats without craniectomy and to determine the recirculation time necessary to benefits the infarction area with restoration of the blood flow in a series of 30 adult rats, the authors induced irreversible ischemia(group Ⅰ) in 15 rats through unilateral occlusion of middle celebral artery(MCA) by inserting a 16mm length of 4-0 nylon surgical thread through the internal carotid artery(ICA). Reversible ischemia(group Ⅱ) was induced by pulling the thread that occluded the MCA with 3 hours recirculation in 15 rats. The author again divided the rats into 4 hours(Ⅰa and Ⅱa), 6 hours(Ⅰb and Ⅱb) and 12 hours(Ⅰc and Ⅱc) groups designated as according to the sacrifice time of rats in group Ⅰ and the starting time of recirculation in group Ⅱ following the MCA oc치usion. The percentage of the iufarction area to the total brian was calculated by a computer image analysis system, and the infarction size between reversible and irreversible groups were compared. The results showed that although the total average infarction sizes of irreversible ischemic groups were larger than those of reversible ischemic groups, the difference of the infarction sizebetween each group of irreversible and reversible ischemia was not significant(group Ⅰa Vs. Ⅱa : 7.78±8.37% Vs. 3.28±1.98 ; group Ⅰb Vs. Ⅱb : 9.07±4.72% Vs. 6.61±3.19 ; group Ⅰc Vs. Ⅱc : 8.35±4.47% Vs. 6.90±6.07%. p > 0.05, one-way ANOVA test). However, the degree of difference of the infarction size between irreversible and reversible ischemia decrease along with the prolongation of ischemic duration(difference between group Ⅰa and Ⅱa : 4.5% ; group Ⅰb and Ⅱb : 2.46% ; group Ⅰc and Ⅱc : 1.45%). The author concluds that ischemic brain injury may be decreased by making a restoration of the blood flow within 4 hour after oc치usion of a blood vessel in rats, and this kind of reversible ischemic model may be useful in various studies on the focal cerebral ischcmia without manipulation of the brain tissue and blood vessel.

천막상부 뇌수막종에서의 아밀로이드 침착 : Clinicopathological and Immunohistochemical Study

이시우,손은익,송동식,임만빈,김인홍,박관규,서유헌 대한신경외과학회 1995 Journal of Korean neurosurgical society Vol.24 No.7

본원에서 1991년에서 1993년까지 3년동안 수술을 시행한 33례의 수막종 환자를 대상으로 아밀로이드의 침착율과 경련을 중심으로 한 신경학적인 검사, Aβ 단백질에 대한 면역화학적 검사를 실시한 결과 비교적 많은 예인 7례(21%)에서 아밀로이드 침착을 보였으며 경련은 아밀로이드침착을 보인 7례 중 1례에서 볼 수 있었으며 7례 모두 Aβ단백질에 대한 항체가 혈관주위에 강하게 침착되어 있었다. 비록 신경학적인 검사상 아밀로이드의 침착이 나나타난 예에서 신경독성효과(neurotoxic effect)의 소견은 없지만, 전기생리학적 검사상 인접 뇌조직에 신경자극효과(irritative effect)의, 특히 경련을 나타낼 수 있는, 가능성은 있는 것으로 볼 수 있다. 향후 더 많은 예를 대상으로 최근의 면역전자현미경 검사와 다양한 항체를 이용한 면역조직화학적검사 방법으로 연구하여, 아밀로이드의 미세침착으로 인한 뇌혈관이상과 인접조직의 신경독성효과와 함께 subtype과의 연관성이 규명되면 삶의 질ㅇ 감안되 수막종의 수술적 가료에 도움이 될 것으로 생각된다. Amyloidosis is the definition for a group of diseases that have, in common, the infiltration of one or more tissues by an abnormal protein material-the amyloid substance. which is detected histologically by their green polarization color after Congo red staining. Despite increased interest on basic nature of amyloidosis by recent immunohistochemical or experimental study. the knowledge about the incidence and neurotoxic effect of cerebral amyloid or concomitant occurrence with brain tumor is still inchoate. We examined the incidence and clinico-pathologic characteristics of the patients with amyloid deposits in supratentorial meningiomas. particularly about their neurotoxic effect to adjacent brain is considered one of the possible cause of seizure in 33 patients who underwent resection surgery for meningioma at the Keimyung University during the past three years. The pathological review and subgrouping by histologic type were done in all 33 specimens with sufficient size of paraffin block, defined by their morphology and polarization color after Congo red staining for diagnosis of amyloid deposits localized in the tumor. Immunohistochemical studies using monoclonal antibodies for amyloid-A protein(AA) and β-amyloid(Aβ) were evaluated to identify subtypes of amyloidosis. The rate of incidence of amyloid deposit in meningioma was 21%, i.e. seven out of thirty three cases. All laboratory findings and clinical studies did not suggest a systemic ferm. Seizure occurrence was one out of seven cases(14%), which was of no statistical significance. Immuno-histochemical study for AA subtype was all negative. but showed all positive for Aβ protein around the vessels. Recent reports has also demonstrated that Amyloid precusor protein(APP) and Aβ is related in Alzheimer's disease, hereditary cerebral hemorrhage with amyloidosis-Dutch type(HCHWA-D) and amyloid angiopathy. Our research data indicates that the incidence of amyloid deposit is as high as 21 % in supratentorial meningiomas. It seems that it is one of the possible cause of seizure. Nonsystemic microdeposits of amyloid and their subtype and it's relationship to neurotoxic effect in meningiomas remain to be confirmed by immunoelectron microscopic examination or immunohistochemical methods.