<30322DC0CCC7D0BCB12DC0D3BBF32DBFCF2D E687770>

Size: px

Start display at page:

Download "<30322DC0CCC7D0BCB12DC0D3BBF32DBFCF2D E687770>"

해인 탄
5 years ago
Views:

1 CLINICAL ARTICLE J Kor Neurotraumatol Soc 2(2):00, 200 뇌농양 27 례의임상분석 고려대학교의과대학구로병원신경외과학교실 이학선ㆍ권택현ㆍ김종현ㆍ김주한ㆍ박윤관ㆍ정흥섭 Hack Sun Lee,.D., Taek Hyun Kwon,.D., Jong Hyun Kim,.D., Joo Han Kim,.D., Youn Kwan Park,.D., and Hung Seob Chung,.D. Department of Neuro, Korea University College of edicine, Guro Hospital, Seoul, Korea Objective: This study was undertaken to evaluate the clinical presentation, sources of infection, outcome and microorganisms involved in the brain abscess in our locality. ethods: The case notes, radiological results and laboratory records of all 27 patients who were diagnosed as a brain abscess in our institution between 0 and 200, were reviewed retrospectively. Results: The mean age of the 27 patients was 7.7 years and the ratio of male to female was 2:. The common presenting symptoms were, pyrexia, and changed mental status. The temporal lobe was the commonest site () and the frontal lobe () was followed. The primary sources of infection were found in cases (%), and those were bacterial (), prior (), otic infection (2) and trauma (2). Surgical intervention was performed in of 27 patients. Culture of material drained from abscess isolated microorganism from cases of the patients. The isolates were Staphylococcus aureus, Streptococcus mitis, Pseudomonas auresinosa and Proteus mirabilis. Three patients were died (%) and the causes of death were medullary failure and septicemia (one patient was discharged hopelessly). Conclusion: There was a relatively high incidence of negative culture rate (7%) compared with other studies and the reason would might administration of antibiotics prior to. Key Words: Brain abscess Clinical analysis Culture Antibiotics 서 론 뇌농양은국소적인뇌내감염으로피막으로둘러싸인고름덩어리로보통감염원과근접한병소, 혈행성전파또는두개외상, 뇌수술에의해발생한다,,2). 뇌농양에서배양된세균류는 20세기후반부터변화하였으며, 이러한병원균의변화로인하여진단및치료방법에많은변화가초래되었다 ). 뇌농양으로인한사망률은 70년대까지 0~0% 정도였으 교신저자 : 권택현 270, 서울특별시구로구구로동 0 번지고려대학교구로병원신경외과전화 : 220, ax: 22 ns0@kumc.or.kr 나효과적인항생제의사용, 새로운수술적치료및 CT (compu ted tomography) 의개발등으로최근에는 0% 이하로보고되고있다,2). 저자들은최근 년동안본원에서치료한뇌농양환자들의임상양상, 감염원, 감염균및치료결과등에대하여분석하여그결과에대하여문헌고찰과함께보고하고자한다. 대상및방법 0년부터 200년까지본원에서치료한뇌농양환자 27 명을대상으로후향적분석을시행하였고, 경막하및경막외뇌농양환자들은이연구에서제외하였다. 수술을통하여확진된경우가총 례였고, 임상적특징및 CT 소견으로진단된경우가 례였다. CT로진단된경우는 조영제투여후 J Kor Neurotraumatol Soc

HS Lee, et al. 주변의환형조영증가를보이는중앙의저신호강도를보이는병변 (ig. ); 2 뇌부종의다양한저신호강도나결절형조영증가를보이는병변또는조영증가없는저신호강도를보이는병변 7,2,2) 을보이는경우에뇌농양으로진단하였다. 환자각각의임상증상, 감염원, 발생위치, 치료및그결과를포함한임상적특징을조사하였다.

Precontrast brain CT (computed tomography) (A) shows masslike isodensity with peripheral low density on left frontal lobe. Contrastenhanced CT (B) shows well enhanced peripheral rim. ig. 2.

2 HS Lee, et al. 주변의환형조영증가를보이는중앙의저신호강도를보이는병변 (ig. ); 2 뇌부종의다양한저신호강도나결절형조영증가를보이는병변또는조영증가없는저신호강도를보이는병변 7,2,2) 을보이는경우에뇌농양으로진단하였다. 환자각각의임상증상, 감염원, 발생위치, 치료및그결과를포함한임상적특징을조사하였다. 치료결과는신경학적검사및치료후방사선학검사를통한병변의변화로결정하였다. 결 과 총 27명의환자의기록을분석하였다. 내원당시 27명중에서 0명이두통을호소하였고, 명이발열증상을, 명이의식변화를주소로내원하였으며, 그밖에언어장애, 이통, ig.. Computed tomography scans of brain abscess. Precontrast brain CT (computed tomography) (A) shows masslike isodensity with peripheral low density on left frontal lobe. Contrastenhanced CT (B) shows well enhanced peripheral rim. ig. 2. Age distribution of brain abscess in 27 patients. 간질, 구토등의증상을보였다. 의식변화를보인 명중 명은기면상태였고, 나머지 명은혼미한의식상태를보였다. 2명이남성이었고 명이여성이었으며, 나이는 2개월에서 7세까지분포되었으며, 평균나이는 세였다 (ig. 2). 본원에서의뇌농양환자의치료방침으로뇌농양이 cm 보다크거나, 종괴효과를보이는경우수술을시행하였으며, 이보다작거나수술적접근이용이하지않은경우내과적치료만시행하였으며, 그결과전체 27명의환자중 명이수술적치료를받았으며, 다른 명은내과적치료를받았다 (Table ). 주감염원은세균성심내막염, 두개수술, 내이감염및두개외상으로나타났으며, 뇌농양의발생위치는측두엽 (례), 전두엽 (례), 두정엽 (7례) 순이었고, 다수의병변을보이는경우도 례에서관찰되었다. 수술적치료를시행한 명의환자중에서균배양양성을보인경우는단지 명 (22%) 뿐이었고, 그경우동정된세균은 Staphylococcus aureus, Streptococcus mitis, Pseudomonas auresinosa and Proteus mirabilis이었다. 그밖에 grampositive cocci 와 gramnegative rod가각각 례씩배양되었으나, 균이동정되지는않았다. 나머지 2명의환자의세균배양에서는음성을보였으나, 조직병리학적검사상급성염증세포및급성농양에합당한괴사조직을관찰할수있었다. 치료성적으로전체 27례의환자중 명의환자가사망하여약 % 의사망률을보였으며, 사망원인은연수기능마비, 패혈증등이었다. 고찰뇌농양은주로 0대에발생하며, 20대이하에서도높은발생률을보인다고보고되며,,,), 본연구에서는 0대와 0 대에서주로높은발생률을보였다. 보통남성에서여성보다두배이상높은발생률을보인다고하는데,20), 저자들의결과는남성에서여성보다.배높은발생률을보였다. 두통은가장흔한뇌농양의증상으로 2,,7,), 본연구에서는 0례 (7%) 에서환자들이두통을호소하였다. 일반적으로뇌농양의 0~0% 에서간질을보인다고하나,), 본연구에서는단지 2례에서주증상으로간질을보였다. 또한발열은뇌농양의 0% 가까이에서보고되는데 ), 본연구에서는 20% 미만 (27례중 례 ) 에서발열증상이확인되었다. 뇌농양은외상, 이염및부비동염, 차병변의혈행성전파등다양한감염경로가알려져있으며, 일반적으로 차병변이확인되는경우는전체뇌농양의 0~7% 정도로보고 Volume 2, No 2 December, 200 7

3 Table. Characteristics of 27 patients with brain abscesses Age (yr) Sex Symptom/Sign Origin Lesion OP Culture x (weeks) Outcome pus N/V otalgia seizure dysarthria seizure otalgia dysarthria CO trauma CO trauma LtP Rt LtT RtP Rt Rt LtP RtP LtT LtT RtT LtP LtP Rt LtT LtT LtT LtT LtBG RtT RtT Rt LtP Lt Lt multiple Rt Staphylococcys aureus Streptococcus mitis Pseudomonas auresinosa Proteus mirailis G()cocci G()rod yr: years, N/V: nausea/vomiting, CO: chronic otitis media, Rt: right, Lt: left, : frontal, T: temporal, P: parietal, BG: basal ganglia, OP: operation, G: gram, x: medication 되고있다 2,). 본연구에서는 0례 (7%) 에서 차병소가확인되었으며, 이는감염성심내막염, 두개수술, 이염및외상등이었다. 일반적으로 staphylococci와 streptococci는세균성뇌농양의가장흔한미생물이며 20), S. aureus와 Enterobacteriaceae는두부외상및수술후감염에서발생한뇌농양에서가장잘동정되는것으로알려져있다 0,,). 본연구에서도수술후발생한뇌농양의배양검사에서 S. aureus가동정되었고, Gramnegative rod도 례에서확인되었다. 이성뇌농양의보고에서가장흔한세균은 Proteus spp인데 22), 본연구에서도 P. mirabilis 가이성뇌농양에서 례동정되었으며, 이성감염의또다른예에서는 Pseudomonas auresinosa가동정되었다. 또한저자들의환자중심내막염에의해발생한뇌농양에서 Streptococcus mitis가동정되었는데, 이는다른연구에서보고된것과유사하였다 2). 다른연구와의비교에서상대적으로낮은세균동 정률 (%) 을보였으며, 이의원인으로배양과정의문제또는수술이전에경험적으로항생제를오남용했을가능성이있다고추정된다. 뇌농양의발생위치와동정된세균은감염원과밀접한관련이있다 0,,,2). 이성감염에의한대부분의뇌농양은측두엽과두정엽또는소뇌에서주로발견되는데, 본연구에서는이성뇌농양의 2례가측두엽에서발생하였다. 뇌농양의치료는항생제투여, 외과적배액및 차감염원의박멸로요약된다 7,2). 외과적배액술은세균동정을위한유일한방법이며, 가능한초기에시행되어야한다,2). 본연구에서는외과적배액술이병변의위치보다깊이에의존하여그방법을결정하였는데, 적출술은표면에가깝고피막에싸여있을경우시행하였고, 정위적흡입술및배액술은심부병변의경우에서시행되었다,2). 뇌농양에대한적절한항생제치료기간은불명확하나, 전통적으로 ~주간감수성 J Kor Neurotraumatol Soc

4 HS Lee, et al. 이있는항생제의투여가추천되며,), 저자들의경우도평균 주간정맥내항생제를투여하였다. 최근 CT, RI 등과같은진단방법의발전및새로운항생제및배양기술의발달에힘입어뇌농양의치료성적은많은향상을보이고있다. Alderson 등이발표한뇌농양치료결과에서는 년부터 년까지 2% 의사망률을보였으나, 0 년후에는 0% 로감소하였다고보고하였으며 ), ampalam과 Rosenblum는 70년과 7년사이의 22례중 % 의사망률을보였으나, 7년과 0년사이의 례중 % 의사망률을보고하였다 ). 저자들의결과에서도총 27례중 례에서사망하여 % 로최근의다른연구결과들과유사하였다 ). 몇몇보고에따르면사망률이초기신경학적의식상태와높은관련을보인다고하였으나,2), 저자들의연구에서는내원시의식상태와사망률과의관련성은보이지않았다. 결론본연구는뇌농양환자 27명을대상으로임상양상, 감염원, 감염균및치료결과등에대하여분석하였으며, 세균동정률 (%) 은다른연구에비해낮은결과를보였으며, 치료후사망률 (%) 은유사한결과를보였다. 저자들은본연구를통하여수술전초기항생제투여가세균동정에서음성결과를가져올위험성을증가시키기때문에외과적배액술을진단후즉시시행해야함을알수있었다. 참고문헌. Alderson D, Strong AJ, Ingham HR, Selkon JB: ifteenyear review of the mortality of brain abscess. Neuro :, 7 2. Beller AJ, Sahar A, Praiss I: Brain abscess: Review of cases over a period of 0 years. J Neurol Neurosurg Psychiatry :777, 7. Bhatia R, Tandon PN, Banerji AK: Brain abscess; An analysis of cases. Int Surg :, 7. Brewer NS, accarty CS, Wellman WE: Brain abscess: A review of recent experience. Ann Intern ed 2:77, 7. Buonaguro A, Colangelo, Daniele B, Cantone G, Ambrosio A: Neurological and behavioral sequelae in children operated on for brain abscess. Childs Nerv Syst :,. Carey E, Chou SN, rench LA: Experience with brain abscesses. J Neurosurg :, Chun CH, Johnson JD, Hofstetter, Raff J: Brain abscess: A study of consecutive cases. edicine :,. Cochrane DD: Brain abscess. Pediatri Rev 20:202,. Corson A, Postlethwaite KP, Seymour RA: Are dental infections a cause of brain abscess? Case report and review of the literature. Oral Dis 7:, de Louvois J, Gortavai P, Hurley R: Bacteriology of abscesses of the central nervous system: A multicentre prospective study. Br ed J 2:, 77. Garfield J: anagement of supratentorial intracranial abscess: A review of 200 cases. Br ed J 2:7, 2. Habib AA, ozaffar T: Brain abscess. Arch Neurol :02 0, 200. Lee SH, Choi BK, Choi KS: Experience with 2 cases of brain abscess. J Korean Neurosurg Soc 0:77,. amelak AN, ampalam TJ, Obana WG, Rosenblum L: Improved management of multiple brain abscesses: A combined surgical and medical approach. Neuro :7,. ampalam TJ, Rosenblum L: Trends in the management of bacterial brain abscesses: A review of 02 cases over 7 years. Neuro 2:,. athisen GE, Johnson Jp: Brain abscess. Clin Infect Dis 2: 777, 7 7. iller ES, Dias PS, Uttley D: CT scanning in the management of intracranial abscess: A review of 00 cases. Br J Neurosurg 2:,. organ H, Wood W, urphey : Experience with consecutive cases of brain abscess. J Neurosurg :70, 7. Park SC, Neches WH: The neurologic complications of congenital heart disease. Neurol Clin :0, 20. Samson DS, Clark K: A current review of brain abscess. A J ed :2020, 7 2. Schliamser SE, Backman K, Norrby SR: Intracranial abscesses in adults: An analysis of consecutive cases. Scand J Infect Dis 20:, 22. Sennarglu L, Sozeri B: Otogenic brain abscess: Review of Volume 2, No 2 December, 200

5 cases. Otolaryngol Head Neck Surg 2:77, Seydoux C, randioli P: Bacterial brain abscesses: actors influencing mortality and sequelae. Clin Infect Dis : 0, 2 2. Tunkel AR, Kaye D: Neurologic complications of infective. Neurol Clin :0, 2. Tunkel AR, Wispelwey B, Scheld W: Brain abscess. In: andell GL, Bennett JE, Dolin R, eds. andell, Douglas and Bennett's Pronciples and Practice of Infectious diseases. Philadelphia: Churchill Livingstone 002, Yang SY: Brain abscess: A review of 00 cases. J Neurosurg :77, 00 J Kor Neurotraumatol Soc

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical