경막외 및 경막내 접근법을 이용한 상상돌기주위의 크거나 거대 동맥류의 외과적 치료

황충진,김창진,권병덕 대한신경외과학회 1994 Journal of Korean neurosurgical society Vol.23 No.6

Between May, 1992 and April, 1993, four patients with paraclinoid aneurysms were treated by a direct operative approach. Two patients had large aneurysms, all of which had ruptured, presented with subarachnoid hemorrhage(SAH). The other two patients had giant aneurysms, causing visual symptoms by optic nerve compression. All patients were treated by a combined extradural and intradural approach. All the aneurysms were successfully clipped and collapsed or resected, eliminating the risk of rebleeding and decompressing the visual system immediately and effectively, while preserving the blood flow of the carotid artery and its branches. Removal of the individual bony structure including anterior clinoid process(ACP) and orbital roof at the skull base extradurally provides a better and safer exposure of the aneurysm, and of the ophthalmic segment of the carotid artery than does excessive retraction of the brain. This technique also affords exposure of the internal carotid artery proximal to the lesion and ophthalmic artery, which is important in securing safe and complete occlusion of the aneurysm. Authors present operative technique, summary of cases, and literature review.

척추의 전이암: 노발리스 방사선 수술 후의 자기공명영상소견

황윤준,손문준,황충진,이동준,허감,차순주,김용훈,김수영,서정욱,한윤희,김미영 대한영상의학회 2006 대한영상의학회지 Vol.55 No.5

Purpose: To assess the therapeutic effect of Novalis radiosurgery for metastatic spinal tumors and evaluate the changes after treatment using MR imaging. Materials and Methods: Between November 2003 and June 2005, 21 patients with metastatic spinal tumors underwent Novalis radiosurgery. Of these patients, the 7 with 13 metastatic spinal tumors who had undergone follow-up MR imaging were included in this study. The tumor locations were cervical spine in three, thoracic spine in four, lumbar spine in five and sacrum in one. During the first three months after Novalis radiosurgery, follow-up MRI was performed monthly and subsequently at 3-6-month intervals. On MR imaging, the volume of the tumors, the changes of their signal intensities and any changes in adjacent spinal cord were evaluated. Results: Among the 13 lesions, 9 were decreased in volume (69.2%), 2 were stable (15.4%) and 2 were slightly increased. Seven of 9 lesions showed decreased signal intensity on T2 weighted images and 4 had compressive deformity. Two of 9 lesions had increased T2 signal intensity and tumor necrosis were detected on contrast-enhanced MR imaging. No changes in spinal cord were noted in any of the lesions. Those changes were detected on MRI obtained 1 month after Novalis surgery and the lesion sizes were gradually changed up to 3 months. Conclusion: Novalis radiosurgery was effective for the treatment of metastatic spinal tumor and the suppression of tumor growth. The estimation of therapeutic effect and detecting complication were precisely evaluated on MR imaging. 목적: 척추의 전이암 환자에 있어서 노발리스 방사선 수술을 시행한 후 자기공명영상을 통하여 전이암의 변화를 알아보고자 한다. 대상과 방법: 노발리스 방사선 수술을 시행한 척추의 전이암 환자 21명 중 자기공명영상으로 추적 관찰이 가능하였던 7명의 환자에서 총 13개의 병변을 대상으로 하였다. 병변의 위치는 경추 3개, 흉추 4개, 요추 5개, 천추 1개였다. 노발리스 방사선 수술 후 첫 3개월간은 매달 자기공명영상으로 추적 관찰하였고 그 이후에는 3개월-6개월 마다 관찰하였다. 자기공명영상을 통하여 병변의 체적 및 신호강도의 변화를 관찰하였고 인접한 척수의 변화 유무도 관찰하였다. 결과: 총 13개의 병변 중 체적이 감소한 예가 9병소(69.2%), 변화가 없었던 예가 2병소(15.4%)였고, 2병소(15.4%)에서는 약간 증가하였다. 병변의 체적이 감소한 9병소 중 7병소에서 T2신호강도가 감소하였고 그 중 4병소에서는 압박 변형을 동반하고 있었다. 나머지 2병소에서는 T2 신호강도 증가 소견을 보였고 조영증강영상에서 병변의 괴사가 관찰되었다. 척수는 전 예에서 변화를 보이지 않았다. 이러한 변화들은 노발리스 방사선수술 후 1개월 후에 시행한 자기공명영상에서 관찰할 수 있었고 병변의 체적은 추적관찰 영상에서 더욱 감소하였다. 결론: 노발리스 방사선 수술은 척추 전이암의 치료 및 성장 억제에 유용하였고 자기공명영상을 통하여 치료 효과 판정 및 합병증 발병 유무를 정확히 관찰할 수 있었다.

감마 나이프

黃忠鎭 대한의학협회 1992 대한의학협회지 Vol.35 No.2

Large Paraclinoid Aneurysms Treated By Combined Extradural and Intradural Approach

Whang, C. Jin,Kim, Chang Jin 울산대학교 의과대학 1992 울산의대학술지 Vol.1 No.1

1992년 5월부터 1992년 6월까지 상상돌기주위 경동맥에 생긴 큰 뇌동맥류 환자 3명을 치료하였다. 3명의 환자 모두에서 경막외 및 경막내 접근법으로 뇌동맥류를 성공적으로 결찰하였다. 2명은 여자였고, 1명은 남자였다. 3명중 1명에서는 입원당시 지주막하출혈이 있었고 2명에서는 국부종괴 병변에 의한 시신경 압박증상이 있었다. 수술후 환자들은 잘 회복되었고, 한명에서는 시력장애가 발생되었으나 점차 회복되었다. 수술전 시력장애는 수술후 호전되었다.

체외충격파를 이용한 두부손상 모델에서 ¹H 자기공명 영상의 변화와 ^(31)P 자기공명분광법으로 관찰한 뇌의 고에너지 인 대사에 관한 실험적 연구

권양,황충진,최길수 대한신경외과학회 1992 Journal of Korean neurosurgical society Vol.21 No.12

The purpose of this study is to describe the ¹H MR imaging findings of focal brain injury by ESWL(Extracoporal Shock Wave Lithotripsy) and to evaluate the changes of high energy phosphate metabolism of the injury using ^(31)P MR spectroscopy. Spectral changes of high energy phosphate metabolites. including Pi(inorganic phosphate). PCr(phosphocreatine). and Adenosine Triphosphate(ATP) were monitored in both trauma(n=5) and control(n=5) groups over 8 hour period following injury. And 'H MR imagings were obtained to evaluate the focal cerebral lesions(n= 10) and compared with the gross and histologic findings of the specimen. The results were as follows : 1) In proton density-weighted MR images. focal areas of high signal intensity were seen in the cerebral hemispheres in S out of 8 traumatized cats(24KV. 500x shock wave). There were corresponding edematous changes in the white and gray matter and petechial hemorrhage in the cortex on gross and histopathologic studies. In 2 traumatized cats(24KV. 1000x shock wave). there were large hematomas in the cerebrum. 2) The decrease of brain pH was maximum in 30 minutes after ESWL injury in the trauma group(n=5) when compared with the control group, but statistical difference between two groups was insignificant. 3) In the trauma group. initial decrease of PCr/Pi was found in 30 to 60 minutes with return to control levels by 2 hour after injury(p<0.05). followed by a second decline in 4 hour that persisted for the remaining 5 hour observation period(p<0.05). 4) No significant changes in ATP concentration were observed during the experimental period. In conclusion, the changes seen above after focal brain injury using ESWL may be indicative of altered energy production, which may account for the reduced capacity of the cell to recover from traumatic injury.

Vasospasm as Severe Complication Following Transcranial Removal of Large Pituitary Adenoma : Clinical Review and Analysis

Lee, Chae Heuck,Whang, Choong Jin 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.11

최근까지 뇌하수체종양 수술 후 혈관연축의 합병증을 보고한 예는 드문 편이며 또한 그 기전에 대해서도 여러 가지 이론이 많다. 저자들은 뇌하수체 종양으로 진단받고 transcranial subfrontal approach로 수술 후 혈관연축을 Transcranial doppler 및 혈관조영술로 진단받은 4례를 분석하였다. 이와 함께 문헌 고찰하여 개두술로 뇌하수체종양 수술 후 혈관연축의 합병증이 있었다고 보고 된 4례와 비교분석 하였다. 저자들이 경험한 4례 중에서, 환자의 나이는 23세에서 59세까지 다양하였고 남녀 각각 2명이었다. 1례를 제외한 모두에서 의식저하 또는 신경학적 결손이 어느 정도의 기간이 지난 후에 나타났고, 2례는 완전히 회복되었으나 2례는 bedridden 상태가 되었다. 혈관연축은 혈관조영술 및 Transcranial Doppler Ultrasonogram(TCI)로 확진했으며, 가능성 있는 기전에 대하여 문헌고찰 및 논의하였다. 혈관이 수술 시 물리적자극이나 뇌저조(basal cystern)으로 흘러 들어간 피는 노출되었다가 혈관수축물질이 놔하수체간 또는 수술 시 손상받은 시상하부에서 유리되어 뇌기저부 수조(cysternal space)로 확산되어 이미 어느 정도 노출된 혈관과 반응하여 혈관연축을 일으키는 것으로 생각된다. Very few cases of arterial spasm after pituitary surgery have been reported to date. The author analysed 4 patients with vasospasm following transcranial subfrontal removal of pituitary adenoma. which were adimitted to our department and 4 cases were reviewed in the literature^(6)7)). In our 4 cases, the age of the patients varied between 23 to 59 years. There were 2 men and 2 women. Delayed deterioration of consciousness or neurologic deficit was observed in all cases. Two patients recovered completely and two were bed-ridden. Vasospasm was documented by angiogram or transcranial doppler ultrasonography(TCD. EME Co.). Possible mechanisms underlying this unusual complication are reviewed and discussed. Vessels were primed to spasm during operation due to blood in the cistern or mechanical injury. Vasoactive materials are liberated from the pituitary stalk or injured hypothalamus, either at the time of surgery, or later, after portions of tumor have undergone necrosis. These agents might then diffuse into the basal cisternal space and interact with blood vessel walls in such a way as to produce vascular spasm.

송과선 종양 세포주의 세로토닌 유도 세포자멸사에 대한 멜라토닌의 보호작용

황금철,황충진 인제대학교 백병원 2002 仁濟醫學 Vol.23 No.2

Objective : Although the pathophysiology of neurodegenerative diseases and serotonin syndrome has been reported, its mechanism has not been elucidated. In this study, the cytotoxicity of serotonin and protective effect of melatonin is examined by using the pineal gland tumor cell line, which is known to secrete serotonin. Methods : The cell cytotoxicity concentration measurement was performed by 3-(4.5-dimethylthiazol-2-yl)-2.5-diphenyltetrazolium bromide(MTT) assay method. In order to judge the protective effect of melatonin, morphological study and 4.6-diamdi-no-2-phenylindole(DAPI) staining, flow cytometry, and RT-PCR was performed. Results : Serotonin showed about 50% cytotoxicity at a concentration 1mM in the pineal gland tumor cells(PGT-beta). Studies of the morphological changes induced by serotonin revealed cell shrinkage and cytoplasmic condensation and that the affected cells were scattered from the floor of the culture dish. "Rounding up" of the affected cells and morphological features consistent with the morphological definition of apoptosis were observed. Morphological and 4.6-diamdino-2-phenylindole(DAPI) staining analyses of cells pretreated with melatonin revealed that these cells were similar patterns compared to the control. These results showed that melatonin protects apoptosis by serotonin toxicity. Flow cytometric analysis of cells treated with 1mM serotonin showed that these cells had lower G1 peaks compared with cells grown in controls. RT-PCR analyses of apoptotic genes of cells pretreated with 100nM meiatonin showed that expressions of bclx and bax genes in these cells were slightly lower and p53 was similar pattern compared to the serotonin-treated group. Conclusion : This study would provide important basic data on the possibility of the clinical treatment of melatonin in the pathogenesis of not only the serotonin-related neuropsychiatric disorders but also serotonin syndrome.

Analysis of Inconclusive Diagnostic Lesions in Stereotactic Biopsy : Review of Cases in 5 Years

Lee, Chae Hyuk,Whang, C Jin 대한신경외과학회 1995 Journal of Korean neurosurgical society Vol.24 No.8

정위뇌조직검사에 의하여 대부분 정확한 진단을 내릴 수 있으나 때로는 진단이 불확실한 경우가 있다. 저자들은 1989년 6월부터 1994년 6월까지 지난 5년간 정위뇌조직검사 후 진단이 확실치 않았던 43례를 대상으로 rebiopsy 및 임상추적결과등을 분석하였다. 진단이 확실치 않은 43례(17.9%)의 병리조직검사소견은 다음과 같았다 : reactive gliosis 22례, foam cell infiltration with necrosis, fibrosis 6례, no evidence of tumor 5례, 그리고 ganglioglial lesion 2례이었다. 최종진단은 rebiopsy 또는 open surgery에 의한 조직검사소견, CT/MRI 등의 방사선학적 추적관찰소견, 임상양상 및 병력, 그리고 혈청학적 소견을 근걸 하였으며 그 결과는 다음과 같았다 : neoplasm 16례, infarction/leukodystrophy 8례, infection/inflammation 4례, granuloma 1례, no confirmative diagnosis 14례이었다. 처음 정위뇌조직검사 후 진단이 확실하지 않은 병변이 종양으로 의심되는 경우 rebiopsy 또는 open surgery를 다시 시행하여 확진을 고려할 수 있으며, 양성병변으로 추측되는 경우 반복되는 방사선학적 검사와 함께 집중관찰이 요구되면 병리조직학적 입장에서 볼 때, 때로 정위뇌조직검사 후 진단이 확실하게 내릴 수 없는 경우를 접할 수 있으며 이때 확진을 위하여 다른 여러 가지 검사들이 필요하게 된다. While stereotactic biopsy increases the accuracy of obtaining appropriate tissue for precise diagnosis, inconclusive diagnostic lesions can still be observed frequently. We present a review of 43 patients with inconclusive diagnostic samples in stereotactic biopsy between June 1989 and June 1994, inconclusive diagnostic lesions were found in 43 patients(17.9%); the biopsy of these patients showed reactive gliosis in 22, foam cell infiltration and/or demyelination with coagulation necrosis in 8, chronic inflammatory cell infiltration with necrosis, fibrosis in 6,no evidence of tumor in 5, and ganglioglial lesion in 2. The final diagnosis was based on histological findings of permanent paraffin sections after rebiopsy or open surgery, close follow-up CT/MRl scan findings, clinical features and/or history, and serological studies; neoplasm 16, infarction/leukodystrophy 8, infection/inflammation 4, granuloma 1, and no confirmative diagnosis 14. In conclusion, rebiopsy or open surgery is recommended if the lesion is suspected to be a neoplasm, and the patient is closely observed with repeated radiological studies if the lesion is suspected to be benign. This study provides evidence that in some cases an accurate histopathological diagnosis can not be made with stereotactic biopsy and therefore, further investigations are needed in such inconclusive cases.

뇌간 신경교종의 증식형태, 병리 및 예후 : Growth Patterns, Pathology, and Prognosis

나영신,황충진 대한신경외과학회 1995 Journal of Korean neurosurgical society Vol.24 No.12

A retrospective study of 29 cases of brain-stem gliomas(BSG's) from 1989 to 1993, was performed to determine prognostic factors. Our study also analyzed clinical features, growth patterns, pathologic findings and modalities of treatment in patients with brain-stem gliomas. The patients ranged in age from 6 to 65 years, most commonly in the first decade. The symptom duration prior to diagnosis was ½ to 36 months (mean 1½ months). The most common symptom and sign were cranial nerve palsies, especially 6th or 7th cranial nerve. The growth patterns of BSG's were classified into diffuse tumors(17 patients), exophytic(9 patients), focal(2 patients) and cervicomedullary (1 patient). Twenty three of 29 patients were diagnosed pathologically by means of stereotactic biopsy (13 patients) and open surgery(10 patients). The Pathologic findings were low grade astrocytoma in 9 patients, oligodendroglioma (3 patients), malignant astrocytoma (7 patients), and glioblastoma multiforme (4 patients). A significant correlation between diffuse growth pattern and malignant pathologic finding could be obtained (P=0.05). The methods of radiation therapy for BSG's were conventional (10 patients), hyperfractionated (13 patients), and Gamma knife radiosurgery (6 patients). The median survival time was 12 months. The Poor prognostic factors determined in our study were 1) short symptom duration prior to diagnosis(≤2 months), 2) diffuse growth pattern, 3) malignant pathologic finding, 4) tumor without cystic portion, and 5) tumor without hydrocephalus.

뇌하수체 선종의 치료에서 감마나이프의 역할

권양,황충진 대한신경외과학회 1995 Journal of Korean neurosurgical society Vol.24 No.9

The treatment of choice for symptomatic pituitary adenomas varies according to the hormone secreting types of the adenoma and can include pharmacology surgery, or radiotherapy. The recent development of radiological imaging and microsurgery has made surgery the treatment of choice for most pituitary tumors. However, the long-term tumor control rate after microsurgery varies from 50% to as high as 80%. During the last 38 months (1990.5-1990.9, 1991.5-1994.2), 34 cases of pituitary adenomas were treated by gamma knife at Asan Medical Center. There were 11 cases of prolactinomas, 9 cases of acromegaly, 8 cases of ACTH-secreting tumors and 6 cases of non-functioning tumors. Seventeen patients underwent gamma knife radiosurgery for recurrent or remaining tumors after resective surgery. Another 17 patients were treated primarily with gamma knife. In microadenomas, the mean tumor volume was 221 cumm and the mean marginal dose was 33.1 Gy. In microadenomas, the mean tumor volume was 2690 cumm and the mean marginal dose was 22.6 Gy. Twenty-seven patients have had an average follow-up period of 26 months with a range from 3 to 48 months. As a result, five out of eight prolactinoma patients had normalization of prolactin hypersecretion and seven patients showed clinical cure. On follow-up imaging studies, five out of seven tumors showed no changes in their size, while two showed marked reduction. Two out of for ACTH-producing tumor patients showed normalization of 24 hour urine cortisol levels. On follow-up imaging studies of the two cases, the tumor of one patient disappeared and the other one showed no change. Three out of six acromegalic patients showed clinical responses. Two out of five non-functioning tumors showed reduction in size and three showed no changes. In conclusion, gamma knife radiosurgery seems to be effective as adjuvant therapy for the treatment of remaining or recurrent pituitary adenomas after surgery and primary treatment modality in selective patients.