KISEP Clinical Article J Korean Neurosurg Soc , 2003 광범위낭종제거술및개창술에의한중두개와지주막낭종의수술적치료 최현철 전신수 이관성 김문찬 강준기 Surgical Treatment of Middle Cranial F

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1 KISEP Clinical Article J Korean Neurosurg Soc , 2003 광범위낭종제거술및개창술에의한중두개와지주막낭종의수술적치료 최현철 전신수 이관성 김문찬 강준기 Surgical Treatment of Middle Cranial Fossa Arachnoid Cyst by Wide Excision and Fenestration Hyun-Chul Choi, M.D., Sin-Soo Jeun, M.D., Kwan-Sung Lee, M.D., Moon-Chan Kim, M.D., Joon-Ki Kang, M.D. Department of Neurosurgery, College of Medicine, The Catholic University of Korea, Seoul, Korea Objective:The results of the excision of both outer and inner membranes with fenestration to the basal and parasellar cisterns for symptomatic primary middle cranial fossa arachnoid cysts are presented. Methods:Twenty-three symptomatic cases of middle cranial fossa arachnoid cyst treated by excision with fenestration from 1993 to 2001 at our hospital were analyzed retrospectively. Results:There was no significant morbidity and mortality after surgery and no recurrence of cyst during the follow-up period(mean 40.8 months). We observed reduction of the cyst with expansion of the surrounding brain and clinical improvement in most of the patients. All cases of type III by Galassi classification, 83% of type II cases and half of type I cases were belonged to the excellent group(reduction of the cyst size over 50% during follow-up period). Seventeen cases(74%) were belonged to the excellent group and 6 cases(26%) were the good group(reduction of the cyst size under 50% during follow-up period). Conclusion:The results of this study suggest that the excision and fenestration procedure may be considered as the primary shunt-independent procedure in patients with symptomatic middle cranial fossa arachnoid cyst. KEY WORDS:Arachnoid cyst Middle cranial fossa Excision Fenestration. 서 론 ReceivedJuly 22, 2002 AcceptedAugust 16, 2002 Address for reprintssin-soo Jeun, M.D., Department of Neurosurgery, College of Medicine, The Catholic University of Korea, 505 Banpodong, Socho-gu, Seoul Korea Tel , Fax ssjeun@cmc.cuk.ac.kr 대상및방법 56 J Korean Neurosurg Soc/Volume 33/January, 2003

HC Choi, et al. 넷째, 낭종에 의한 뇌경막하 출혈이 있는 경우가 2례(Fig. 우측이 13 10으로 좌측이 많았다.

수술 방법은, 전측두골 성 소견을 살펴보면, 두통이 14례, 간질 발작이 6례, 국소 신경 형적 개두술(frontotemporal

외막(outer membrane)뿐 아니라 내막 정신 지체가 3례, 행동 변화가 3례, 시각 장애가 4례에서 관 (inner membrane)도

기저조를 열어 낭종과 뇌지주막하 공간을 서로 교통하게 만 추적 기간은 8개월에서 84개월로 평균 40.8개월이었다. 들었다(Fig. 4).

변화를 측정하였고, 이들 변화와 임상 증상을 수술 전과 수 하고 있었다(Table 1). 뇌지주막하 낭종의 위치는 좌측과 술 후에 비교하였다.

1. The arachnoid cyst shows various mass effects.

Note that collapsed right lateral ventricle by the cyst and the expansion of

B Computed tomography shows an arachnoid cyst in the left middle cranial fossa

전체적으로 볼 때에는 23례중에서 17례가 낭 종의 크기가 50%이상 감소하였고, F Fig. 2. The case of the engrowing pattern.

middle cranial fossa at the time of initial diagnosis(a, B).

Five years after initial diagnosis, the size of cyst was markedly increased(c, D).

Two years after surgery, the size of cyst was markedly decreased(e, F)(male,

2 HC Choi, et al. 넷째, 낭종에 의한 뇌경막하 출혈이 있는 경우가 2례(Fig. 우측이 13 10으로 좌측이 많았다. 수술 전 환자들의 임상 3)에 한하여 수술을 시행하였다. 수술 방법은, 전측두골 성 소견을 살펴보면, 두통이 14례, 간질 발작이 6례, 국소 신경 형적 개두술(frontotemporal osteoplastic craniotomy)을 학적 증상이 4례, 두위 증가 소견이 3례, 발육 부전이 3례, 시행한 후에, 낭종의 외막(outer membrane)뿐 아니라 내막 정신 지체가 3례, 행동 변화가 3례, 시각 장애가 4례에서 관 (inner membrane)도 가능한한 광범위하게 제거하였고, 뇌 찰되었다(Table 2). 기저조를 열어 낭종과 뇌지주막하 공간을 서로 교통하게 만 추적 기간은 8개월에서 84개월로 평균 40.8개월이었다. 들었다(Fig. 4). 저자들은 지주막하 낭종의 형태학적인 분류, 수술 후 환 남자가 15명이었고 여자가 8명이었으며, 연령 분포는 1 자들의 임상 증상의 완화 여부, 주기적으로 실시한 뇌전산 세에서 42세까지로 평균 14.7세였다. 23중 17명이 16세 이 화단층촬영상 및 뇌자기공명영상촬영상 보이는 낭종의 크기 하의 소아 및 청소년기의 환자였고, 전체의 약 73%를 차지 변화를 측정하였고, 이들 변화와 임상 증상을 수술 전과 수 하고 있었다(Table 1). 뇌지주막하 낭종의 위치는 좌측과 술 후에 비교하였다. 결 과 지주막 낭종의 형태학적 분류에 따른 수술 결과 A 수술 후 지주막 낭종의 크기가 B 50% 이상 감소한 경우를 Excellent Fig. 1. The arachnoid cyst shows various mass effects. A Magnetic resonance image shows a large middle cranial fossa arachnoid cyst. Note that collapsed right lateral ventricle by the cyst and the expansion of temporal bone over the cyst(female, 10-year-old. chief complaint headache). B Computed tomography shows an arachnoid cyst in the left middle cranial fossa with mass effect. Note midline shifting by the cyst (male, 7-year-old. chief complaint mental retardation). A B C D E group, 50% 미만인 경우를 Good group으로 나누었다. 전체적으로 볼 때에는 23례중에서 17례가 낭 종의 크기가 50%이상 감소하였고, F Fig. 2. The case of the engrowing pattern. The size of cyst is increased during follow-up period and the size is reduced after surgery. Preoperative computed tomography revealed a small arachnoid cyst in the left middle cranial fossa at the time of initial diagnosis(a, B). This arachnoid cyst was detected incidentally. Five years after initial diagnosis, the size of cyst was markedly increased(c, D). This patient underwent operation. Two years after surgery, the size of cyst was markedly decreased(e, F)(male, 9-year-old. chief complaint seizure). A B C D E F Fig. 3. The case of the secondary insult(subdural hemorrhage). Preoperative computed tomography shows arachnoid cyst in the left middle cranial fossa at the time of initial diagnosis(a, B). The hemorrhage is seen at the site of arachnoid cyst and left frontotemporal subdural space after head traumatic insult(c, D). This patient underwent operation. Three years after surgery, the size of cyst is markedly decreased(e, F)(male, 20-year-old. chief complaint drowsy mentality). J Korean Neurosurg Soc/Volume 33/January,

3 Table 3. Surgical result of cyst size reduction according to Galassi classification Type No. of patients No. of patients Excellent* Good** I 1626% 13150% 350% II 1252% 10183% 217% III 1522% 15100% 010% Size reduction over 50% during follow-up period Size reduction under 50% during follow-up period Fig. 4. Microsurgical findings of the operative field after excision and fenestration. Note the Sylvian vein running over the cyst and exposure of the basal cistern. IIOptic nerve, III Oculomotor nerve, IVTrochlear nerve, ICAinternal carotid artery, Syl. v.sylvian veinsfemale, 9-year-old. chief complaintheadache. Table 1. Age distribution of the patientsn=23-58 No. of patients Ageyears Male Female Total Table 2. Chief complaints of the patients Symptoms and signs Headache Seizure Focal neurologic deficit Decreased visual acuity Increased head circumference Delayed development Mental retardation Behavior change No. of patients% 임상증상 수술후합병증 고찰 - J Korean Neurosurg Soc/Volume 33/January, 2003

4 - - J Korean Neurosurg Soc/Volume 33/January,

5 결론 References 1. Arai H, Sato K, Wachi A, Okuda O, Takeda N:Arachnoid cysts of the middle cranial fossa:experience with 77 patients who were treated with cystoperitoneal shunting. Neurosurgery 39: ;discussion , Callaway MP, Renowden SA, Lewis TT, Bradshaw J, Malcolm G, Coakham H:Middle cranial fossa arachnoid cysts:not always a benign entity. Br J Radiol 71: , Choi JU, Kim DS:Pathogenesis of arachnoid cyst:congenital or traumatic? Pediatr Neurosurg 29: , Daneyemez M, Gezen F, Akboru M, Sirin S, Ocal E:Presentation and management of supratentorial and infratentorial arachnoid cysts. Review of 25 cases. J Neurosurg Sci 43: ;discussion , Di Rocco C:Arachnoid cysts, in Youmans JR(ed):Neurological Surgery, ed 4. Philadelphia:WB Saunders Co., 1996, Vol 2, pp Donaldson JW, Edwards-Brown M, Luerssen TG:Arachnoid cyst rupture with concurrent subdural hygroma. Pediatr Neurosurg 32: , Fewel ME, Levy ML, McComb JG:Surgical treatment of 95 children with 102 intracranial arachnoid cysts. Pediatr Neurosurg 25: , Galassi E, Gaist G, Giuliani G:Arachnoid cysts of middle cranial fossa: experience with 77 cases treated surgically. Acta Neurochir(Suppl) 42: , Galassi E, Piazza G, Gaist G, et al:arachnoid cysts of middle cranial fossa:a clinical and radiological study of 25 cases treated surgically. Surg Neurol 14: , Kang JK, Lee KS, Lee IW, Jeun SS, Son BC, Jung CK, et al:shuntindependent surgical treatment of middle cranial fossa arachnoid cysts in children. Childs Nerv Syst 16: , Kawamura T, Morioka T, Nishio S, Fukui K, Yamasaki R, Matsuo M:Temporal lobe epilepsy associated with hippocampal sclerosis and a contralateral middle fossa arachnoid cyst. Seizure 11:60-62, Kuntzer T, Assal G, de Tribolet N:Supratentorial intracranial arachnoid cyst. Neurochirurgia 32: , Martinez-Lage JF, Ruiz-Macia D, Valenti JA, Poza M:Development of a middle fossa arachnoid cyst. A theory on its pathogenesis. Childs Nerv Cyst 15:94-97, McDonald PJ, Rutka JT:Middle cranial fossa arachnoid cysts that come and go. Report of two cases and review of the literature. Pediatr Neurosurg 26:48-52, Parsch CS, Krauss J, Hofmann E, Meixensberger J, Roosen K: Arachnoid cysts associated with subdural hematomas and hygromas: analysis of 16 cases, long-term follow-up, and review of the literature. Neurosurgery 40: , Punzo A, Conforti R, Martiniello D:Surgical indications for intracranial arachnoid cyst. Neurochirurgia 35:35-42, Rengachary SS, Watanabe I:Ultrastructure and pathogenesis of intracranial arachnoid cyst. J Neuropathol Exp Neurol 40:61-83, Robinson RG:Congenital cysts of the brain:arachnoid malformations. Progr Neurol Surg 4: , Samii M, Carvalho GA, Schuhmann MU, Matthies C:Arachnoid cysts of the posterior fossa. Surg Neurol 51: , Sato K, Shimoji T, Yaguchi K, Sumie H, Kuru Y, Ishii S:Middle fossa arachnoid cyst:clinical, neuroradiological, and surgical features. Childs Brain 10: , Sato H, Sato N, Katayama S, Tamaki N, Matsumoto S:Effective shuntindependent treatment for primary middle fossa arachnoid cyst. 60 J Korean Neurosurg Soc/Volume 33/January, 2003

6 Childs Nerv Syst 7: , Sgouros S, Chapman S:Congenital middle fossa arachnoid cysts may cause global brain ischaemia:a study with 99Tc-hexamethylpropyleneamineoxime single photon emission computerised tomography scans. Pediatr Neurosurg 35: , Shigemori M, Okura A, Takahashi Y, Tokutomi T:New surgical treatment of middle fossa arachnoid cyst. Surg Neurol 45: , Starkman SP, Brown TC, Linell EAL:Cerebral arachnoid cysts. J Neuropathol Exp Neurol 17: , Wester K:Peculiarities of intracranial arachnoid cysts:location, sidedness, and sex distribution in 126 consecutive patients. Neurosurgery 45: , Wester K, Gilhus NE, Hugdahl K:Spontaneous disappearance of an arachnoid cyst in the middle intracranial fossa. Neurology 28: , 1991 J Korean Neurosurg Soc/Volume 33/January,

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