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두개강내 뇌실질, 혈액, 뇌척수액으로 구성되어 있고 이 두개강내의 부피와 압력은 Monro-Kellle doctrien에 의해 일정하게 유지되고 있다. 뇌압은 두개강내의 여러 생리병리학적 상황에 의해 영향을 받고 특히 뇌내 병변의 발생으로 변동된다. 저자들은 1985년 4월부터 1986년 9월까지 영남대학교 의과대학 부속병원에 입원한 뇌실질내 출혈환자 33례와 두부손상환자 10례등 총 43례에서 지속적인 뇌압측정을 실시하여 뇌압측정, 논압변동인자추적, 예후와의 관계등을 관찰하여 다음과 같은 결과를 얻었다. GCS이 높을수록, 혈종량이 적을수록, 뇌압의 amplitude가 낮을수록, A-wave의 빈도가 낮을 수록, 탄성치가 낮을수록 뇌압이 낮았고, 좋은 예후를 보였다. 환자의 예후와의 관계를 보면 GCS이 12이상인 경우 ADL Ⅰ 및 ADL Ⅱ에 속한 경우가90%, 7이하인 경우는 19%이었으며, 내측피막이 손상된 경우에 서 ADL Ⅰ에 속한 경우는 없었고, 내측피막이 손상되지 않은 경우에서는 48%가 ADL Ⅰ에 속하였다. 또한 혈종의 량이 10㎖이하인 경우는 50%가 ADL Ⅰ에 속하였고 20㎖이상인 경우는 ADL Ⅰ에 속한 경우가 없었다. PCO₂가 25∼29㎜Hg인 경우는 ADL Ⅰ 및 ADL Ⅱ에 속한 경우가 없었다. 뇌압의 amplitude, A-wave의 출현빈도, 뇌탄성치, 뇌압의 변동추이를 알게되어 환자의 예후 를 짐작할 수 있었다. 즉 뇌압의 amplitude가 높을수록, A-wave의 출현횟수가 빈발할수록, 뇌탄성치가 높을수록 환자의 ADL이 불량했다. 또한 뇌압이 점차 상승되었던 군에서 ADL이 불량했다. 이상의 결과로 보아 내원당시의 GCS, 내측피막의 손상여부, 혈종량, PCO₂등이 환자의 예후에 영향을 미쳤고 또한 지속적인 뇌압 측정으로 뇌압의 amplitude, A-wave의 출현빈도, 뇌탄성치, 뇌압의 변동추이를 측정함으로써 환자의 예후를 짐작할 수 있었다. The cranium can be thought of a as shallow, rigid sphere of constant volume. There are three main components within the intracranial space: brain, cerebrospinal fluid and blood. Intracranial volume and pressure are maintained constantly by Monroe-Kellie doctrine. Also intracranial pressure is influenced by a number of physiologic factors and it will be changed with intracranial lesion. Now we were look for the possible factors that influence the intracranial pressure with continuous intracranial pressure monitoring. At the same time we studied the possibility of the relationship, between factors that influence ICP and ADL (Ability of Daily Life) in 43 severe brain lesions (33 cases; intracerebral hematoma, 10 cases ; head injury). In cases of higher GCS, smaller hematoma, lower amplitude of ICP, lesser frequency of A-wave and lower elastance, the ICP were lowed. Ninety percent of cases that GCS is over 12 was belong to ADL Ⅰ and Ⅱ. but only nineteen percent of cases that GCS is under 7 was belong to ADL Ⅰ and Ⅱ. No case of internal capsule involved group was belong to ADL I but forty-eight percent of cases whose hematoma volum is under 10ml was belong to ADL Ⅰ. Fifty percent of cases whose hematoma volume is under 10 ml was belong to ADL Ⅰ and no case that hematoma volume is over 20㎖ was belong to ADL Ⅰ. Cases that PC02 is in the range of 25㎜Hg-29㎜Hg were not belong to ADL Ⅰ. In cases of higher amplitude of ICP, higher frequency of A-wave and higher elastance, the patient's ADL was grave. And in cases of ICP was progressively increased, the prognosis was also grave. Consequently we are able to guess that patient's prognosis will be influenced by initial GCS, internal capsule involvement, hematoma volume, PCO2, amplitude of ICP, frequency of A-wave, brain elastance and curve of ICP.
Usually cases of brain stem hemorrhage reveal high mortality and poor prognosis in spite of meticulous medical or surgical treatment. Recently we experienced stereotaxic evacuation of brain stemhemorrhage with Brown-Robert-Wells(B.R.W.) system in four cases. If there were residual hemorrhage after initial aspiraion, those were evacuated with Urokinase irrigation via stereotaxically placed catheter in the hematoma. The entry point of our operation get on the crossing point of midpupillary line and 1㎝ behind coronal suture. Preliminary results: 1) Volume of removed hematoma :5㎖(average) 2) Dates of urokinase irrigation: 2 to 4 days after operation 3) No hydrocephalus, no surgical mortality 4) Average Glasgow coma scale was improved from 6 in preoperative state to 12 in postoperative state. 5) Operation was performed within 24 hours. 6) Advantages of our procedure: (1) Accurate, simple and safe. (2) Under local anesthesia. (3) Less traumatic procedure. (4) Could remove hematoma completely with Urokinase.
영남대학교 의과대학 신경외과학 교실에서는 향후 뇌동정맥 기형환자의 치료에 도움을 얻고자 최근 경험한 37례의 임상적, 방사선학적 소견 등을 후향성 조사 분석하여 아래와 같은 결과를 얻었다. 생산성이 높은 20-49세에 간질을 주소로 내원한 경우가 많았고, AVM의 크기가 작거나 유출정맥이 심부로 향할 때 출혈을, mixed type일때 간질을 주소로 내원한 경우가 않았다. 중간 크기일 경우 주로 eloquence 위치에 있고 유출정맥이 심부로 향했으며, 심부에 위치하거나 크기가 큰 경우 뇌동맥류의 동반이 많았으며, 수술후 치료 결과가 호전된 경우는 Grade가 낮은 경우가 많았고, 수술후 합병증은 low flow나 표재부에 위치한 경우에 간질이 많았고, 표재부에 있는 경우에 수술후 출혈이 많이 발생했다. Clinical and cerebral angiographic findings were reviewed retrospectively in thirty-seven patients with intracranial arterio-venous malformation(AVM). The results were as follow. Many patients who were in reproductive age had visited due to seizure(27%) and its angiographic findings were mixed Type(80%). Bleeding was predominant in the patients who had small sized nidus than medium or large one, and deep draining vein than superficial one. Medium sized AVM was located mainly in the anatomically deep portion(71%) and drained to deep portion also(71%). Associated aneurysm was more prevalent in deep seated or large sized AVM. Low grade AVM according to Spetzler's grading system showed good results of treatment. Postoperative hemorrhage or sizure were frequently found in patients who had superfically located AVM.
We analyzed 66 posterior fossa hemorrhage for evaluation of contributing factors to the patient prognosis. Among them 41 patients were cerebellar hemorrhage and 25 were pontine hemorrhages. We analyzed the effect of 7 contributing variables to the patient prognosis with multiple logistic regression methods for eliminating the compound effect of mutiple factors. In cerebellar hemorrhages, we found that the significant contributing factors toward positive prognosis were a good initial mentality, the location of the hemorrhages in the hemisphere, an absence of intraventricular hemorrhages, an absence of midline shifting and an absence of quadrigeminal cistern obliteration. In the treatment methods, the prognosis of stereotaxically treated cases were better than other methods. In pontine hemorrhages, a small sized hemorrhage or an absence of intraventricular hemorrhage were significant factors in determining a posivitive prognosis although the number of theses cases was small.
The authors analyzed the clinical and pathological characteristics of 66 meningioma patients operated and pathologically confirmed at the Department of Neurosurgery & Pathology, Yeungnam University Hospital from 1984 to 1992. The results are as follows: 1) Meningioma was the most common in the 6th decade(39.4s) and the overall ratio of male to female was 1 : 25. 2) The most common pathologic types were meningothelid type(30.346) and transitional type(30.3 % 1. 3) The predilection sites were convexity, parasagittal and falx in order of frequency. 4) The most common clinical features were LICP signs(57.6%). 5 ) The marginal contour of the tumor on brain cT were more ~rregular, mushrooming and fnnging pattern in the case of angioblastic and atypical type. The brain edema was more severe in the case of these types. However, these findings had no correlation with prognosis. 6 ) There were 9 atypical cases(13.6%). 7) The total removal was done in 53 cases(80.396) and the postoperative mortality rate was 7.5%. 8) The recurrence rate was 9.0% and the mean duration of recurrence was 36.5 months. The recurrence depended on grade of the surgical removal rather than the pathological type.
1990년 4월부터 1991년 2월까지 영남대학교 의과대학 부속병원 신경외과에 입원한 환자중에서 자발성 뇌 실질내 혈종 환자로 뇌정위적 제거술 및 CT 이용수술법을 한 30례의 환자를 extraventricular drainage catheter를 통해 뇌압을 연속 측정하면서 urokinase 세척을 실시하였고, 수술직후, 수술후 2일, 수술후 5일까지의 혈종양의 변화에 따른 뇌압의 상관 관계, 혈압변화와의 관계, 예후와의 상관관계, glasgow coma scale과의 관계 및 재출혈을 포함한 합병증과의 관계를 비교 분석하였다. 첫째, 혈종 크기와 뇌압의 상관 관계에서는 혈종양이 많을수록 뇌압은 높은 분포를 보였으며, 혈압변화와의 관계에 있어서는 혈종양이 많을수록 수축기 혈압은 높았다. 둘째, 예후와의 관계에서는 혈종의 크기가 클수록 ADL은 낮은 분포를 보였으며, Glasgow coma scale과의 관계에 있어서도 혈종의 크기가 클수록 점수가 낮은 분포를 보였다. 셋째, 혈종의 크기와 재출혈을 포함한 합병증에 있어서는 t-test 상에 유의성이 나타나지 않았다. The development of CT scan and sterotaxic surgery with urokinase irrigation made possible early diagnosis and improved survival in the patients of spontaneous intraparenchymal hemorrhage. We had clinically reviewed and analyzed 30 patients of stereotactically treated spontaneous intraparenchymal hemorrhage, according to the hematoma volume, ICP, vital signs, GCS and prognosis. The results were summarzed as follows : 1) As the hematoma volume increasing, ICP was also increased(p<0.05). 2) The systolic arterial pressure was increased as the hematoma volume increasing(p<0.05). 3) Mean ADL was 55±26% and ADL level were decreased in cases of large hematoma(p<0.05). 4) As the hematoma volume increasing, the level of verbal GCS and total GCS was low(p<0.1). 5) No significant correlation was noted between the hematoma volume and complications(T test).
저자들은 휘귀한 질환으로서 폐암에서 다발성으로 척추 경막내에 전이된 종양을 치험하였기에 보고하는 바 이다. Intradural extramedullary spinal metastases from systemic tumor are extremely rare. A case of intradural multiple spinal metastasis (T₃, L_(1-2), L₃ and L_(5)-S₁) from adenocarcinoma of the lung is presented. Radiological findings of the intradural metastases were mimicking a benign intradural tumor, so it was difficult to make a correct diagnosis of preoperatively.
With large CPA tumors, the goal of surgery is safe total removal of the tumors and preservation of nearby neural structures. Although the suboccipital approach can be made for large CPA tumors, combined approach is more preferable method for the wide exposure of the CPA including brain stem and the lower cranial nerves. We have recently experienced favorable results by combined approach. Total removal of large tumors were obtained by these approaches. The authors present surgical points of view and a brief review of literature.