추체사대 수막종의 수술과 관련하여 뇌 정맥조영상의 의미

황승균,곽호신,백선하,오창완,이상형,김동규,김현집,정희원,Hwang, Sung-Kyun,Gwak, Ho-Shin,Paek, Sun Ha,Oh, Chang-Wan,Lee, Sang Hyung,Kim, Dong Gyu,Kim, Hyun Jib,Jung, Hee-Won 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.10

Objective : A thorough understanding of the related venous structure is mandatory for successful removal of the petroclival meningiomas. This study was planned to investigate the guideline for safe ligation and incision of transverse or sigmoid sinuses and the importance of drainage pattern of vein of $Labb{\acute{e}}$ in surgical removal of petroclival meningiomas. Patients and Methods : The authors reviewed the venogram of the consecutive 37 cases of petroclival meningiomas and retrospectively analyzed their surgical findings. The drainage pattern of confluence of Herophili was classified as Type A(confluent & equal on both sides), Type B(confluent & non-dominant on tumor side), Type C(confluent & dominant on tumor side) and Type D(unilateral drainage only) as these findings gave the information on safe ligation and resection of the sinus. Usefulness of intraoperative test clamping of sinus for safe ligation was also reviewed. The vein of $Labb{\acute{e}}$ was analyzed with respect to its draining point and its collaterals to other superficial veins. Results : Contraindications of the sinus ligation and resection according to the drainage pattern at the confluence of Herophili were Type C(n=10, 27%)and Type D(n=4, 11%). Patients with Type A(n=12, 32%)and Type B(n=11, 30%) were tolerable to sinus ligation ipsilateral to tumor, if the test clamping proved to be safe. Identification of no brain swelling, after intraoperative test clamping of the sinus for more than 30 minutes performed in 7 out of 11 cases, was a reliable indicator of safe sinus ligation. The drainage pattern of the vein of $Labb{\acute{e}}$, especially low-lying type, could predict the possibility of postoperative hemorrhage and infarction. Its drainage into tentorium or superior petrosal sinus, however, made the transtentorial approach impossible, leading to restricted operative field. Conclusion : For a successful removal of the petroclival meningiomas preoperative venogram should be examined carefully. The extent of exposure in a planned approach can be estimated by analyzing the variation of sinuses and the drainage pattern of vein of $Labb{\acute{e}}$.

뇌반구에 위치한 양성신경교종의 악성전환에 대한 임상적 연구

조근태,곽호신,정희원,백선하,정영섭,김동규,조병규,Cho, Keun-Tae,Gwak, Ho-Shin,Jung, Hee-Won,Paek, Sun-Ha,Chung, Young Seob,Kim, Dong Gyu,Cho, Byung Kyu 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.7

Introduction : It has been reported that the survival of low-grade glioma patients depends upon the time of malignant transformation. The authors presents the clinical analysis of histologically proven trasformed gliomas. Materials and Method : A total 92 patients who were consecutively treated and histologically confirmed hemispheric low-grade gliomas between 1980 and 1998 were analyzed and followed. All cases meet the criteria of WHO glioma classification of grade II. Results : The mean follow-up period was 73 months. Twenty two among 92 cases(24%) were histologically proven to be transformed into malignant ones. The mean time to transformation was 56 months. The 5-year and 10-year survival rates of the transformed group were 66% and 30% respectively and significantly different from the survival rates of the non-transformed group(p=0.0018). Among clinical factors at presentation, the initial tumor volume had a tendency to be larger in the transformed group than that of the non-transformed group and became significant when it was divided into more than $30cm^3$ or not(p=0.02). Among therapeutic factors, the extent of removal had no influence on the rate of malignant transformation. But postoperative radiation therapy were more frequently given to the pre-transformed group than the non-transformed group and the frequency was significantly different(p=0.02). Conclusions : The authors had found that the initial tumor volume and radiation therapy could be clinical prognostic factors for the malignant transformation of low-grade gliomas.

수술 후 재발한 라스케열 낭 - 증례보고 -

홍석호,곽호신,정희원,Hong, Seokho,Gwak, Ho-Shin,Jung, Hee-Won 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.2

A case of symptomatic Rathke's cleft cyst, which recurred five months after drainage of the cyst using transs-phenoidal approach, is presented. Symptomatic recurrence after surgery of Rathke's cleft cyst is very rare and nine cases have been reported in the literatures. The radiological and pathologic features and clinical course of this unusual case are described. Recent concepts about embryological pathogenesis and clinical behavior mimicking craniopharyngioma are discussed with the review of literature.

두개강내 척삭종 및 연골육종 : 수술 및 방사선 치료의 효능

정영섭,곽호신,정희원,박홍준,백선하,김동규,김현집,Chung, Young-Seob,Gwak, Ho-Shin,Jung, Hee-Won,Park, Hong-Jun,Paek, Sun Ha,Kim, Dong Gyu,Kim, Hyun Jib 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.7

Introduction : The management of chordomas and chondrosarcomas in the skull base is difficult due to the critical location, locally aggressive nature, and high recurrence rate. The authors present the effectiveness of surgical removal and radiation therapy on survival and tumor recurrence. Material and Methods : Thirty cranial base chordomas and chondrosarcomas from 23 patients(14 patients with chordomas and 9 patients with chondrosarcomas) were operated in our institution between 1985 and 1998. There were 15 men and 8 women, with a mean age of 40.7 years. The largest diameter of tumors ranged from 15 to 70mm (mean 41.5). The extent of surgical removal was subtotal or total in a half(15 operations). In nineteen operations, tumors were removed by conventional approaches and skull base approaches were applied in 11 operations. Postoperative radiation therapy was performed in 16(70%) patients. The mean duration of follow up is 50 months(1- 156 months). Results : The 3- and 5-year survival rates(YSR) of overall patient are 75% and 67%, respectively. The analysis showed that 1) skull base approach to chordomas and chondrosarcomas showed a tendency to remove more portion of the tumors(p=0.058) but leave more frequent incidence of new deficits(p=0.047) : 2) larger tumor diameter af-fected the extent of removal(p=0.028) : 3) the extent of removal seemed to be the determining factor for overall survival and recurrence-free survival(the 5-YSR and RFSR of subtotal or total removal group are 92% and 80% vs. 40% of partial removal or biopsy group) : 4) conventional radiation therapy improved patient survival(5-YSR of patients who received RT is 76% whereas 5-YSR of those who didn't receive RT is 43%) but failed to prolong long-term recurrence-free survival. Conclusion : The extent of removal and postoperative radiation therapy are determining factors of patients' survival in skull base chordomas and chondrosarcomas. However, none of these factors significantly influenced the survival in multivariate analysis. Aggressive surgical removal of more than subtotal resection combined with postoperative radiation therapy seems to be the choice of therapy in the management of these tumors.

비정형성 및 악성 뇌수막종의 임상분석 : 52례 연구

박홍준,곽호신,황승균,김정은,이상형,정희원,김동규,조병규,Park, Hong-Jun,Gwak, Ho-Shin,Hwang, Sung-Kyun,Kim, Jeong Eun,Lee, Sang Hyung,Jung, Hee-Won,Kim, Dong Gyu,Cho, Byung-Kyu 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.9

Objective : Atypical and malignant meningiomas(AM, MM) are known to be rare and show aggressive behavior. Limited data are available concerning the clinical features, effectiveness of surgical removal and role of radiation therapy with AM, MM. The authors report our experience of AM, MM, with respect to clinical features. Methods : Twenty-four cases of AM and 28 cases of MM, who were operated between 1988 and 1999 were retro-spectively studied review of medical records and radiological findings. These were compared with control group of 24 cases of menigiomas manifestating usual clinical course, which are selected arbitrarily among operative cases between Apr. 1999 and Dec. 1999. Mean follow-up periods were 26(1-91) months for AM and 23(1-62) for MM. Authors analyzed the prognostic factors for survival, and statistical analysis were accomplished by Kaplan-Meier method and log-rank test. Results : Differences of clinical features between control groups and these atypical and malignant meningioma group were not significant. However, the location of MM was frequent in non-basal area(p<0.01). In AM, there were 4 patients of recurrence, and 3 patients of mortality. Among mortality cases, only one patient died of tumor progression, the other patients died of other causes. The survival at 2 year and 5 year in this group were 88% and 74% respectively, and in MM, 11 patients died due to tumor progression and 2 had spinal metastasis. The survival at 2 year and 5 year were 72% and 20%, respectively. For extent of resection, total removal(Simpson grade 1 or 2) was less often achieved in MM compared with AM(50% vs. 83%). Extent of resection of tumor and postoperative radiation therapy did not affect survival in both AM, MM. Conclusions : Clinical behavior of AM showed more benign than that of MM. Prognostic factor for survival is not related extent of resection of tumor and postoperative radiation therapy. However, further investigation with long-term follow-up and additional cases is mandatory.

임상 : 낭종성 전이 뇌종양의 수술 후 재발 양상 및 성장 속도의 고찰

최현호 ( Hyun Ho Choi ),신상훈 ( Sang Hoon Shin ),곽호신 ( Ho Shin Gwak ),이승훈 ( Seung Hoon Lee ),유헌 ( Heon Yoo ) 대한뇌종양학회 2011 대한뇌종양학회지 Vol.10 No.2

Objectives: The purpose of this study is to evaluate local recurrence rate after surgery for cystic brain metastasis and de-termine its growth rate. Methods: Between June 2002 and February 2009, 38 patients underwent surgery for cystic brain metastasis at our insti-tution. The median follow up period was 257 days (mean 393, range 67-1,509) after surgery. If the tumors were large and comprised of single cysts (≥3 cm in the largest diameter), surrounded by a relatively small amount of enhancing pe-ripheral tissue, the tumors were classified into the large cystic group. The largest diameter was measured on T1-gadolin-ium enhanced Magnetic resonance images and cystic volume was measured by by using V-works software. The sizes of cystic mass were measured on serial MRIs to evaluate growth rate. Growth rate was calculated as the increased volumes divided by the followed period. The primary end point of this analysis was local recurrence of metastatic brain tumors. Result: Among 38 patients, 18 (47.4%) patients experienced local recurrence. Among them, twelve patients in the large cystic brain metastasis group (66.7%) had a local recurrence, while 6 (30%) in the small cystic brain metastasis group.(p=0.024). The 6 months recurrence free survival (RFS) rate was 44.4% in the large cystic group, and 60% in the small cystic group. Cox regression analysis hazard ratio of the large cystic mass compared to the small cystic mass for local re-currence was 2.61. The growth rate of cystic metastasis was 86.42 mm3/day in nine patients with cystic brain metastasis. Conclusion: The results showed that large cystic brain metastasis frequently recurred after surgery regardless of the use of adjuvant therapy. Therefore, careful and close follow-up is necessary in patients with large cystic brain metastasis.

성장호르몬분비 뇌하수체 선종 80예의 수술성적 및 예후 인자의 분석

김정은,정희원,곽호신,백선하,김동규,최길수,Kim, Jeong Eun,Jung, Hee-Won,Gwak, Ho-Shin,Paek, Sun Ha,Kim, Dong Gyu,Choi, Kil Soo 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.6

Objectives : The surgical results of 80 patients with growth hormone(GH)-producing pituitary adenoma were analyzed retrospectively to evaluate the clinical manifestations and to determine which preoperative factors significantly influenced the surgical outcome. Patients and Methods : The patients consisted of 39 men and 41 women and the age of patients at the time of initial operation ranged from 17 to 67 years(mean age, 40.5 years) Between January 1990 and June 1996, 77 patients underwent transsphenoidal surgery and 3 patients underwent craniotomy for GH-producing pituitary adenoma at our institution. Preoperative administration of octreotide was performed in 18 patients. Surgical control was defined as a postoperative serum basal level of GH less than 5ng/ml. A logistic regression model was used for univariate and multivariate analysis. Probability value of less than 0.05 was considered as statistically significant. Results : The most common presenting symptom was acromegaly, followed by headache, visual disturbance, and fatigability. Visual symptoms were present in 39% of the patients. Diabetes mellitus was associated in 24 patients and hypertension in 12. Preoperative mean basal level of GH was 93.2ng/ml(range 72-500ng/ml) which was closely related with tumor size(p<0.05). Grade II by Hardy's classification was the most common radiological type. Preoperative octreotide treatment significantly reduced the level of GH(p<0.05), but not enough to induce endocrinological remission. One patient died of cerebral infarction after craniotomy. The most common surgical complication was transient diabetes insipidus. The symptom of the earliest improvement after surgery was paresthesia and tightness of the hand and foot, followed by headache and easy fatigability. The preoperative visual symptom was improved in all patients. The patients who had hypertension or DM experienced alleviated symptoms in 67% and 92%, respectively. The overall rate of endocrinological remission was 44%. By multivariate logistic regression analysis, the size of tumor, extrasellar extension, and extent of removal were significant prognostic factors for endocrinologial remission. Conclusion : Early detection of a small tumor without extrasellar extension followed by a complete resection is highly recommended in order to achieve endocrinological cure of GH-producing pituitary adenomas.

성인 쿠싱병의 치료성적과 예후인자

박철기,황승균,곽호신,유헌,정영섭,백선하,김동규,정희원,김성연,홍승관,Park, Chul-Kee,Hwang, Sung Kyun,Gwak, Ho-Shin,Yoo, Heon,Chung, Young Seob,Paek, Sun Ha,Kim, Dong Gyu,Jung, Hee-Won,Kim, Seong Yeon,Hong, Seung Kuan 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.10

Objectives : The authors analyzed the surgical series of Cushing's disease to evaluate the proper treatment policy and to verify the possible prognostic factors. Material and Methods : Of 50 patients diagnosed as Cushing's disease and operated at Department of Neurosurgery of our institute between 1988 and 1999, 48 patients with available medical records were analyzed retrospectively. Mean follow-up period was 48 months(3 to 109 months). Preoperative diagnosis was made after evaluating the patients with multiple-stage endocrinological studies and 31 selective patients were evaluated with inferior petrosal sinus sampling(IPSS). Magnetic resonance imaging(MRI) and/or high resolution computerized tomography(CT) was done in all patients. A total of 51 transsphenoidal adenomectomy(TSA) were performed including 3 revision for initial surgical failure cases. Remission was decided on the basis of both endocrinological criteria and clinical status. Radiation and/or ketoconazole therapy were applied to failed cases. For the verification of prognostic factors, the authors evaluated the statistical significance of multiple variables over remission rate by chi-square test. Result : Sensitivity of IPSS for central localization was 93.5% which was better than that of MRI(87.5%). But for lateralization, it was 72.4% for IPSS versus MRI 90.5%. Success rate of TSA was 82%(42/51) and recurrence rate was 9%(4/48). When including adjuvant treatments for surgically failed cases, overall success rate was 89.6% and all of 3 reoperated cases(TSA) due to recurrence were successful. Significant complication occurred in 7.8%(4/51) after TSA including hypopituitarism, diabetes insipidus, and visual loss. Non-existence of tumor in MRI and prolonged symptom duration(>3 years) were significant prognostic factors. Conclusion : TSA can be considered as initial treatment for Cushing's disease. In surgically failed cases, multiple treatment modality may improve the overall outcome and repeated TSA for recurrent cases seem to provide similar success.

수막 혈관주위세포종의 임상상, 치료 및 장기 추적 결과

이준호,황승균,곽호신,백선하,김동규,김현집,정희원,Lee, June-Ho,Hwang, Sung-Kyun,Gwak, Ho-Shin,Paek, Sun Ha,Kim, Dong Gyu,Kim, Hyun Jib,Jung, Hee-Won 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.7

Objectives : Meningeal hemangiopericytoma is a rare tumor. Clinical and radiological features are similar to those of an ordinary meningioma. But its biological behavior is quite different from those of a meningioma as it brings profuse bleeding in the operation field, frequent recurrence and metastasis to other systemic organs even in the case of gross total resection. In order to find out the prognostic factors and to compare longterm outcome after various treatment modalities, the authors reviewed consecutive 20 operated cases of meningeal hemangiopericytoma to characterize their clinical features, surgical outcomes and effectiveness of the radiation therapy. Methods : Twenty patients with a hemangiopericytoma were treated between 1982 and 1999 in our department. They are composed of 13 patients of hemangiopericytoma and 7 patients who were initially diagnosed as angioblastic type meningioma and then confirmed as a hemangiopericytoma after review of their previous histopathology slides. The mean follow-up period was 99 months(1-256 months). The long-term outcomes after various treatment modalities were evaluated according to recurrence-free survival and image follow-up. Recurrence-free survival curves are compared between the patient groups according to the extent of removal and radiation therapy. Results : There were 10 cases of recurrence and 4 cases of distant metastases ; lung, liver and femur(2 cases) respectively. The 5-year recurrence rate was 37%, while the 10-year recurrence rose to 77%. There was also statistically significant difference of median recurrence-free survival between the completely-resected group(Simpson grade 1 or 2) and partially-resected group(Simpson grade 3 or 4 or 5) ; 137 months compared to 47 months, respectively(p=0.009). The median recurrence-free period after subtotal resection of tumor and postoperative radiotherapy was 47 months compared to 117 months of the patients who underwent gross total resection of tumor and did not receive radiotherapy. But radiation therapy alone did not show significant difference in recurrence-free survival. Marked tumor volume reduction and easy removal of tumors without bleeding were found in 2 recurred cases. Conclusion : The extent of tumor resection and presence of metastasis are the most important factors related to long-term outcome of the patients with hemangiopericytoma. Radiation therapy after the first operation did not have a role in extending the recurrence-free survival, but it affected favorably to decrease the size of residual mass and intraoperative bleeding during the second operation.

성인 두개인두종 연속 100예의 장기 치료 성적

방재승,정희원,김동규,곽호신,백선하,정영섭,홍승관,Bang, Jae Seung,Jung, Hee-Won,Kim, Dong Gyu,Gwak, Ho-Shin,Paek, Sun Ha,Chung, Young Seob,Hong, Seung-Koan 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.4

Objectives : The authors present a retrospective analysis of 100 consecutive adult patients harboring craniopharyngiomas who underwent microsurgical resection between 1981 and 1999 to assess the long-term outcome of surgical treatment and to determine the most optimal management strategy. Methods : The extent of surgical removal was divided into four categories ; GTR(gross total removal), RSTR(radical subtotal removal), STR(subtotal removal),and PR(partial removal). The median follow-up period was 50 months(4-198). CT scan and/or MR imaging and hormonal status were evaluated to the last follow-up. Results : Visual disturbance was the most common presentation, which was improved in 42 cases and aggravated in 19 cases following the operation. Hypopituitarism was detected in 56 patients preoperatively, 82 during the immediate postoperative period, and 76 at the last follow-up. Improvement of pituitary function was not observed in any of these patients. Twenty of 100 patients showed recurrence at the mean of 27 months(3 to 196). The median progression-free survival(PFS) time of all patients was 145 months and 5-year PFS rate was 74%. Five-year PFS rate of GTR or RSTR group(71%) was significantly higher than that of STR or PR group(30%)(p=0.01). Postoperative radiation therapy significantly prolonged the PFS from 94 months in non-radiation group to 182 months(p=0.002). However, there was no statistical difference in number of patients who required hormonal replacement therapy between radiation and non-radiation group. Conclusion : Visual disturbance can be improved by early diagnosis and surgical decompression. GTR or RSTR in selected patients is considered a proper surgical strategy. Post-operative radiation therapy for residual tumors must be considered, although the ideal timing of radiation therapy is to be determined.