#08-김희중

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1 KOR J CEREBROVASCULAR SURGERY June 2OO8 Vol. 10 No 2, page 가톨릭대학교의과대학의정부성모병원신경외과김희중 장동규 허필우 김달수 유도성 조경석 강석구 박진규 Evaluation of Surgery for Aneurysms that arise from a Non-Branching Site of the Intracranial Internal Carotid Artery (ICA) Hee- Jung Kim, MD, Dong-Kyu Jang, MD, Pil-Woo Huh, MD, Dal-Soo Kim, MD Do- Sung Yoo, MD, Kyoung- Seok Cho, MD, Seok-Gu Kang, MD, Jin-Kyu Park, MD Department of Neurosurgery, Uijeongbu St. Mary s Hospital, The Catholic University of Korea College of Medicine, UIjeongbu, Korea ABSTRACT Object : Surgery for aneurysms at non-branching sites of an internal carotid artery (ICA) is considered based on the size, shape, direction and site of the aneurysm. In this study, we analyzed characteristics of aneurysms that have arisen from non-branching sites of an ICA from the viewpoint of surgery. Methods : From 2003 to 2007, 346 intracranial aneurysms were treated at our institute. 19 (5.5%) aneurysms were non-branching site aneurysms of an ICA. Surgery for these aneurysms was retrospectively analyzed in view of the treatment strategy according to the site, size, and configuration of the aneurysms in videos obtained during surgery. Results : There were 13 cases of a ruptured aneurysm (68.4%) and six cases of an unruptured aneurysm (31.6%). There were ten cases of a saccular type of aneurysm (52.6%) and nine cases of a blood blister-like aneurysm (47.4%). There were seven aneurysms that arose from the dorsal wall of an ICA (36.8%), six aneurysms that arose from the ventral wall (31.6%), four aneurysms that arose from the lateral wall (21.1%) two aneurysms that arose from the medial wall (10.5%). Three patients with unruptured blood blister-like aneurysms underwent simple wrapping and wrapping with the use of clip. Three unruptured saccular aneurysms could be clipped perpendicular to an ICA or at a slant to an ICA. Three out of six (50%) ruptured blood blister-like aneurysms were ruptured during surgery. These aneurysms were clipped with the partial wall of an ICA, resulting in ICA stenosis. We treated 15 (84%) of 19 cases by only clipping, one case (5.2%) was treated by clipping with bypass surgery and three cases (15%) were treated by wrapping. Conclusion : Ruptured aneurysms of nonbranching sites of an ICA such as blister-like or dorsal saccular aneurysms have a high risk of rupture and can be difficult to clip. If clipping of the aneurysms is possible, preoperative balloon test occlusion should be performed to avoid ICA stenosis after clipping of the aneurysm neck with the arterial wall. Clipping after bypass or trapping can vary the treatment strategy and improve patient outcome. For small-unruptured aneurysms from nonbranching sties of an ICA, wrapping with the use of clip may be a useful method for treatment regardless of the clipping direction. (Kor J Cerebrovascular Surgery 10(2): , 2008) KEY WORDS : Aneurysm Internal carotid artery Blood Blister-Like Aneurysm Wrapping 논문접수일 : 2008 년 6 월 16 일심사완료일 : 2008 년 6 월 25 일교신저자 : 장동규, 경기도의정부시금오동 65-1 가톨릭대학교의정부성모병원신경외과전화 : (031) 전송 : (031) argus@catholic.ac.kr 서론 대다수의주머니모양동맥류 (saccular aneurysm) 는동맥의분지부에서발생하며분지가없는위치에서생기는동맥류는매우드물다. 1979년 Ohara외다수는 1) 동맥의분지부와관계없는동맥류의발병기전으로동맥경화를보고하였고그 391

2 들은또한이러한동맥류의유병률을대뇌동맥류중 1% (1116명중 11명 ) 로기술하였다. 1996년 Yoshimoto외다수는 2) 11년간치료받은전체동맥류 557명가운데동맥류분지와관련이없는곳에서발생한동맥류환자 29명 (5.7%) 을분석하여보고하였다. 이들의보고따르면 5예 (17%) 가혈액수포모양동맥류 (blood blister-like aneurysms) 였으며, 14 예 (48%) 에서동맥경화가관찰되었다고보고하였다. 분지와관련없는곳에서발생한동맥류의대부분은동맥경화와관련이있음을보여주었으며이곳에생긴뇌동맥류수술의어려움과합병증을지적하였다. 수술중상돌기상내경동맥부위의분지가없는곳에서발생하는동맥류는내경동맥의등쪽벽으로부터돌출하는동맥류로서이들은주로혈액수포모양동맥류 (blood blisterlike aneurysms) 로알려져있다. 3-5) 그러나발생위치가실제로는내경동맥의등쪽벽이라기보다는내경동맥앞벽에서생긴동맥류 (ICA anterior wall aneurysms) 로도알려져있다. 이들동맥류는모든내경동맥동맥류의 0.9% 에서 6.5% 빈도로드물게보고되고있다. 6)7) 분지가없는부위에서발생하는상돌기상내경동맥동맥류는흔하지않아이에대한정의는확실히정립되어있지않았으나 2000년에 Ogawa등의보고에의하면 1993년부터 1997년까지전체뇌거미막하출혈환자 7408명중 48명 (0.6%) 의분지가없는내경동맥동맥류를수술적시야에서확인하였고이들동맥류들을내경동맥줄기동맥류 (ICA trunk aneurysms) 로정의하였으며동맥류의모양과동맥류벽과목의구조에따른후향적연구결과에의하면혈액수포모양동맥류가주머니모양동맥류에비해훨씬더나쁜예후를보였다고보고하였다. 8) 저자들은최근 5년간경험한내경동맥내분지부위가아닌곳에서발생한동맥류의임상적, 방사선학적특징을분석하고, 이미녹화된이들의수술비디오를통하여그특징에따른수술방법을분석하여미래의좀더나은성공적인치료결과를얻고자한다. 대상및방법 2003년부터 2007년까지본원에서 346개의동맥류 ( 파열성및비파열성 ) 환자를치료하였으며이환자들중 109명 (31.5%) 이내경동맥동맥류환자였다. 두개강내내경동맥의분지부위와관련없는곳에서발생한뇌동맥류를가진환자 19명 (5.5%) 을분석하였다. 수술전뇌전산화혈관촬영과혈관조영술을통하여뇌동맥류의발생부위와모양에따른수술방법을이미녹화된수술비디오를통하여관찰하였다. Kyoshima등이제시한분류법 14) 과마찬가지로수술중확인된내경동맥의축을따라기시하는동맥벽의위치별로부 위가없는곳에서발생한내경동맥동맥류는등쪽동맥류 (dorsal aneurysm), 배쪽동맥류 (ventral aneurysm), 안쪽동맥류 (medial aneurysm) 및가쪽동맥류 (lateral aneurysm) 의네가지형태로나누었다. 또, Bouthillier등이소개한내경동맥류의분류법 11) 에따라동맥류를분류하였다. 19명중수술전뇌혈관조영술은 8명에서시행했으며한명에서두개강내외혈관문합술의준비가필요한지알아보기위한풍선폐쇄검사및 Tc 99m 을이용한뇌혈류검사 (SPECT) 를시행하였다. 또한한명을제외한모든파열성동맥류의경우에 24시간이내수술을시행했다. 수술방법은관자놀이점-실비우스틈새접근법 (pterional transsylvian approach) 으로실비우스틈새를크게열고내경동맥에접근하였고앞침대돌기주변의내경동맥동맥류의경우미리경부내경동맥을노출하거나앞침대돌기절제술 (anterior clionidectomy) 을경막내또는경막외로시행하였다. Clip 종류는 Yasargil clip과 Sugita clip을사용했으며, 포장재질 (wrapping material) 은 LyoplantR와 teflon및 glue를이용하였다. 예후는 3개월째글라스고우회복등급 (Glasgow out-come scale) 을사용하였다. 10) 결과 두개강내내경동맥의분지부위와관련없는곳에서발생한뇌동맥류를가진환자 19명 (5.5%) 을분석한결과, 이환자들의평균연령은 56.9(39~79) 세였고여자가 14명 (73.7%), 남자가 5명 (26.3%) 으로여자에서월등히많았다. 항고혈압약을복용중인환자는 5명 (26.3%) 이있었으나고지혈증으로치료중인환자는없었다. 13명이파열성 (ruptured) 이었고, 6명이비파열성 (unruptured) 이었으며비파열성중 2명은동반동맥류의파열에의해우연히발견되었다. 우측내경동맥에서동맥류가발생한경우가 12명 (63.1%) 이었고좌측은 7명 (36.9%) 이었다. 다발성동맥류 (multiple aneurysm) 는 5명 (26.3%) 에서있었다. 형태에따라주머니모양동맥류는 10명 (52.6%) 이었고혈액수포모양동맥류는 9명 (47.4%) 이었다. Kyoshima등이제시한분류법에따른동맥류발생부위별조사결과는내경동맥의축을따라등쪽에생긴동맥류가 7명 (36.8%) 으로가장많았고이어서배쪽동맥류가 6명 (31.5%), 가쪽동맥류가 4명 (21.0%), 내측동맥류가 2명 (10.5%) 이었다. 등쪽동맥류는안동맥분절에 5명 (71.4%) 이발생했고배쪽동맥류는 5명 (83.3%) 이교통동맥분절 (communicating segment) 에발생하였다. Bouthillier등이소개한내경동맥류의분류법에따라동맥류를분류한결과교통동맥분절에서 12명 (63.2%), 안동맥분절 (ophthalmic segment) 에서 7명 (36.8%) 로내경동맥원위부에서더많은 392 Kor J Cerebrovascular Surgery 10(2): , 2008

3 김희중 장동규 허필우 김달수 유도성 조경석등 Table1. Summary of unruptured aneurysms arisen from non-branching site of ICA: anatomy and surgical management No Age(yrs), Sex Type Origin segment Origin wall Athero-sclerosis Size(mm) IOR Treatment Clipping direction Outcome 1 46,M BBA Oph. Dorsal N 3.0~4.9 N Wrapping - GR 2 49,F BBA Oph. Dorsal Y <3.0 N Wrapping and clipping - GR 3 62,F BBA Com. Ventral Y <3.0 N Wrapping and clipping - MD 4 45,F Sac. Oph. Dorsal N 3.0~4.9 N Clipping Perpendicular GR 5 57,F Sac. Oph. Ventral Y 5.0~9.9 N Clipping Forward slanting GR 6 62,F Sac. Com. Ventral N 3.0~9.9 N Clipping Forward slanting GR : along with ruptured other aneurysm, BBA : Blood blister like aneurysm, Sac. : Saccular, Oph. : Ophthalmic, Com. : Communicating, IOR : Intraoperative Rupture, GR : Good Recovery, MD : Moderate Disabled Table 2. Summary of ruptured aneurysms arising from nonbranching-site of ICA: anatomy and surgical management No Age(yrs), Sex Type Origin segment Origin wall Size(mm) IOR Treatment Outcome 17 50,M BBA Oph. Dorsal 3.0~4.9 Y Clipping with partial wall, antiplatelet agent PV S 18 49,F BBA Oph. Dorsal 3.0~4.9 Y Clipping with partial wall # GR 19 55,F BBA Com. Dorsal 3.0~4.9 N Clipping with partial wall, antiplatelet agent SD 10 62,M BBA Com. Medial 5.0~9.9 N Clipping with partial wall and Bypass, antiplatelet agent MD 11 64,F BBA Oph. Medial 3.0~4.9 N Clipping with partial wall, antiplatelet agent GR 12 53,F BBA Com. Lateral 3.0~4.9 Y Clipping with partial wall Death 13 55,F Sac. Com. Dorsal 5.0~9.9 N Clipping with partial wall Death 14 70,F Sac. Com. Ventral 5.0~9.9 N Clipping SD 15 75,F Sac. Com. Ventral 10.0~24.9 N Clipping SD 16 79,F Sac. Com. Ventral 3.0~4.9 N Clipping SD 17 67,F Sac. Com. Lateral 5.0~9.9 N Clipping SD 18 39,M Sac. Com. Lateral 3.0~4.9 N Clipping GR 19 42,M Sac. Com. Lateral 5.0~9.9 N Clipping GR BBA : Blood bristlier like aneurysm, Com. : Communicating, Oph. : Ophthalmic, Sac. : Saccular, IOR. : Intra Operative Rupture. : Poor due to ischemic infarction, : Poor due to ischemic infarction and vasospasm, : Expired due to Intraoperative rupture and increased intracranial pressure, : Expired due to vasospasm, : Poor due to hydrocephalus, : Poor due to hydrocephalus and contusion by brain retraction, # : no stenosis of ICA, GR : Good Recovery, MD : Mild Disabled, SD : Severe Disabled, PVS : Persistent Vegetative State Kor J Cerebrovascular Surgery 10(2): ,

4 빈도를보였으며모든환자의분석결과를표로제시하였다. (Table, 1,2) 19명의분지가없는내경동맥동맥류중에서 6명이비파열성이었으며이들은모두크기가 10mm이하였다. 그중에서특히혈액수포모양동맥류 3개중 2개는 3mm이하로매우작았으며둘다 LyoplantR로포장한뒤이를 titanium clip으로결찰하였다.(table 1, case 2,3) 나머지 1 례는 5mm의크기로결찰시파열의위험성이높아부분적노출후 Teflon 과 Glue로포장술을시행하였다.(Table 1, case 1) 비파열성주머니모양동맥류는모두모동맥에대한클립각도가수직또는경사각으로도안전하게완전결찰이가능했다.(Table. 1, case 4,5,6) 파열성내경동맥동맥류의경우는혈액수포모양이 6명, 주머니모양이 7명으로비슷한빈도를보였으며혈액수포모양의경우등쪽동맥류가 3명, 내쪽동맥류가 2명, 배쪽동맥류가 1명이었고전체파열성혈액수포모양동맥류의수술중파열은 6명중 3명 (50%) 이파열되었다. 이들의치료는모두내경동맥의일부벽을포함한결찰술을시행했으며이들의예후는 6명중 3명 (50%) 이나쁜예후를보였는데한명은등쪽에서유래한동맥류로서내경동맥의부분적협착과결찰후허혈에의한뇌경색이원인이었으며 (Table 2, case 7) 또다른한명도등쪽내경동맥의동맥류로허혈에의한뇌경색과수술후혈관연축에의해나쁜예후를보였고 (Table 2, 9) 나머지한명은가쪽내경동맥동맥류로수술중파열과뇌부종으로인해사망하였다.(Table 2, case 12) 이에반해안쪽내경동맥류를가지고있는한환자의경우수술전풍선폐쇄검사를시행하여내경동맥의폐쇄가뇌혈류를심각하게차단하는결과를초래할수있음을예측하여수술전우회술을시행하고나서동맥류의결찰술을하였다. 수술후내경동맥이폐쇄되었음에도불구하고우회로를통하여좋은혈류가유지되고있음을확인할수있었다.(Table 2, case 10) 또다른안쪽내경동맥동맥류는동맥류결찰후내경동맥의부분적협착이보였으나우회술을시행하지는않고수술후항혈소판제제만복용하였지만더이상의협착은진행하지않아좋은예후를보였다.(Table 2, case 11) 파열성주머니모양동맥류의 7명모두수술중파열없이결찰하였다. 이들의 GOS는예후는 7명중 1명이사망하고 (Table 2, case 13), 4명은예후가불량하였다.(Table 2, case 14,15,16,17) 그외에나머지 2명은가쪽벽에서유래한주머니모양동맥류로서결찰후모두좋은예후를보였다.(Table 2, case 18,19) 고찰 분지부위가없는곳에서발생하는내경동맥동맥류의모양은동맥류의벽및목의성상에따라혈액수포모양과주머니모양으로나뉘는데, 대개는수술전혈관조영사진상으로도두모양의감별이가능하나항상분명하게감별되는것은아니다. 5-7)9)17) 분지부위가없는곳에서발생한내경동맥류의 30~40% 는혈액수포모양동맥류로결찰이어렵고수술시파열되면내경동맥을폐쇄시킬수밖에없는경우도있기때문에동맥류모양의수술전감별은매우중요하다. 4) 본저자가경험한분지가없는내경동맥에서발생한동맥류는 19명으로그중 9(47.4%) 명의환자가혈액수포모양동맥류로매우높은분포를보이고있다. 이혈액수포모양동맥류는주로배쪽 (5예, 55%) 에서발생하였고결찰을할수없었던경우가 3 예 (33%) 에서나있었다. 따라서완전하고안전한수술을위해서분지가없는내경동맥에서발생한동맥류의모양과성상의진단은매우중요하다. 이곳에서발생하는동맥류의성상이혈액수포모양에서주머니모양으로진행하는경우도보고되고있다. 6)8)12) 또, 혈액수포모양동맥류와비슷한얇은벽을가지고있으나박리할때와결찰시에도잘터지지않는동맥벽에생긴작은돌출을수술중에자주볼수있는데, 6) 이런작은혈관병변은딸기동맥류 (berry aneurysm) 라고한다. 즉주머니모양동맥류의초기단계일수있다. 7)10)11)13)21) 혈액수포모양동맥류는분지부위가없는곳에서발생하지만이곳에서생기는원인에대하여는분명하게기술되어지지않고있다. 8)4)7)8)17) 단지혈액수포모양동맥류가있는모든환자는내경동맥의동맥경화가동반되어동맥경화성동맥류 (atherosclerotic aneurysm) 의모양을하고있다는것이저자들의환자들에게서발견되었다. 임상적특징또한혈액수포모양의동맥류는주머니모양의동맥류보다고혈압과유의하게관련이있다고보고하였다. 8) 증례의숫자는비록적지만우측내경동맥과여자에서많은빈도를보이는것에대한여러논문의보고가있지만, 3)6)14-16) Ogawa 등의보고에의하면통계학적으로유의하게차이는없었다. 17) 저자들의경우에도여자와우측내경동맥에서많이발생되는경향을보였다동맥류의빈도와병태생리대부분의주머니모양동맥류는두개강내동맥의분지부에서일어난다. Rhoton 등은이들병변들의대다수에적용되는기본적인해부학적원칙에대해언급했다. 모동맥으로부터동맥의분지부에서발생한다고했으며동맥류의천장이나바닥은모동맥의동맥류전분절에서최대혈역학적압박이있는 394 Kor J Cerebrovascular Surgery 10(2): , 2008

5 김희중 장동규 허필우 김달수 유도성 조경석등 방향으로돌출한다. 17) 동맥류의분지부가없는부위에서발생한뇌동맥류는대부분내경동맥에서주로기술되어있다. 18) 내경동맥의상돌기상분절이가장흔하게발생되는위치이다. 이곳에서는주로혈액수포모양뇌동맥류가호발되는곳이다. 16) 상돌기상내경동맥의분지가없는부위에서발생하는동맥류의두개강내동맥류에대한빈도는 0.9~1.7% 로보고되고있고, 내경동맥동맥류에대한빈도는 0.9~6.5% 로드물게보고되고있다. 주머니동맥류또한내경동맥의상돌기분절의등쪽부위에서발생할수있다는보고또한있다. 17) 저자들이보고한경우에따르면전체두개강내동맥류에대한분지가없는부위에서발생하는내경동맥의동맥류는 5.5% 였으며내경동맥동맥류에대한빈도는 17.4% 로다른보고들에비해높게나왔으나 Kyoshima 등은전체내경동맥동맥류중분지부위와관계없는동맥류에대해전체 156명중 43명으로 28% 의빈도까지보고한바가있다. 9) 방추성, 박리성, 감염성또는외상성과같은여러형태의동맥류들은일반적으로선천적또는후천적이상을포함한다양한원인적인자들의명백한증거를나타내지만동맥의분지부와분지부가아닌곳에서발생하는주머니모양동맥류의병인은여러원인이있다고한다. 동맥벽에선행하는선천적혈관중간막의결손과혈관벽의후천적퇴행성변화그리고국소적혈역학이잠재적인자들로서 Jellinger등에의해제안된바있고 Stehbens 은병리학적으로동맥의분지부와관계없는주머니모양동맥류들이병리학적으로동맥경화에의해발생될수있다고보고하였다. 3) Ohara 등도또한내경동맥의이런변화를경화성 (sclerotic) 이라고해석하였다. 1)5-10) 고혈압은주머니모양동맥류의형성과성장을촉진할수있으며높은엇갈림힘 (shear stress) 은주머니모양이나방추상동맥류형성을시작하게하는혈관내막층의퇴행성변화를유발할수있다고하였다. 18) 혈액수포모양의동맥류의조직학적특징은혈괴 (clot) 와섬유성조직으로덮여있는국소적혈관벽의결손이다. 5) 국소적혈관벽장애는동맥경화로부터기인하며속탄력막 (internal elastic lamina) 으로궤양 (ulceration) 과관통 (penetration) 에의해유발되는내경동맥벽의열상의결과일수있다. 4) 저자들이경험한분지가없는부위에서발생하는내경동맥동맥류들은 19명중 16명에서동맥경화증이보고되었고파열성의경우모든경우에서발견되었으며이들은동맥류의기시부위에존재하고있는것으로보아분지부위가없는곳에서발생하는동맥류의병인에아주중요한역할을하는것으로여겨진다. 마찬가지로갑자기변하는동맥벽의굽이근처에서경사각 (oblique angle) 에있는혈관벽을혈류가때리면서혈관벽 을따라진행하면혈관내피에높은강도의엇갈림힘이작용하게된다. Sano는몇몇경우에내경동맥의갑작스런굽이에동맥류가발생하는것에혈역학적인자들의중요성에대해강조하였다. 18) 저자들이경험한경우에의하면등쪽동맥류와배쪽동맥류의빈도가가장많았는데등쪽동맥류는안동맥분절에배쪽동맥류는교통동맥분절부위에더많은빈도를차지함으로써가장갑자기변하는굽이부분에서동맥류가많이발생하여이런혈역학적스트레스가이들동맥류의발생에또하나의중요한인자라고할수있겠다. 8) 이런기계적인스트레스가퇴행적인동맥경화성조직과합쳐진다면전형적인혈역학적인자들과동맥의분지부와관련된혈관중간막의결손이없다고할지라도동맥류를형성하기에충분하다고할수있겠다. 19,20) 수술중파열등내쪽벽위에원위부에서기시하는내경동맥동맥류는수술중파열의위험이아주높다. 저자들의경우에도등쪽내경동맥에서기시하는동맥류두예가수술중파열이있었으며가쪽동맥류한예의경우에수술중파열이있었다. 실비우스틈새의박리와동맥류목의노출은최소한으로전두엽의견인을적게하면서이루어져야하는데특히등쪽에있으면서위쪽으로돌출된동맥류의경우에는뇌실질에붙어있거나파 묻혀있기때문에주의해야한다. 19) 저자들의예에서는등쪽동맥류의경우아주작은견인이었는데도동맥류벽의작은혈액수포모양동맥류파열이발생하였다. 다른한명은교통동맥분절의혈액수포모양동맥류였으며내경동맥의가쪽벽에서기원한동맥류였다. 이들예모두혈액수포모양의동맥류로서실비우스틈새를박리시동맥류의천장이노출될때전두엽이나측두엽을최소한의견인을행하였음에도불구하고출혈이있었던경우다이러한수술중의출혈은주머니모양보다혈액수포모양의동맥류에많은데, 이들은바깥막 (adventitia) 이나혈괴 (blood clot) 로만덮여있기때문에동맥류벽이매우약하여동맥류결찰준비중에동맥류천장으로부터혈괴를제거하는것은큰동맥류벽의결손을유발하기쉽다. 또한주위조직과의유착또한수술중출혈의위험성을증가시키며저자들의경우에도세증례모두주위조직과의유착을보였었다. 그러므로결찰하기전에실비우스틈새를넓게열어서유착으로인한동맥류의노출을최소한의견인으로시행할수있으며 20), 동맥류와혈괴를조직으로부터분리시키는것은연약한벽이파열될수있어특히혈액수포모양동맥류의박리시에는연질막밑박리 (subpial dissection) 를할만큼주의깊은박리가추천된다. Kor J Cerebrovascular Surgery 10(2): ,

6 수술의방법이전의보고에의하면여러그룹에서내경동맥과평행하게뇌동맥류결찰을시도하거나, 포장을하거나, 그리고우회술의동반여부에상관없이뇌동맥류전후의내경동맥을포착 (trapping) 하거나, 이들두방법을혼합하는것등이보고되어왔다. 8)18)21)-25) 불행하게도등쪽및안쪽내경동맥동맥류들은일반적으로상대적으로넓은목이나넓은기저부를가진것들이며이들은중재적혈관내수술로는만족스런폐쇄를하기가쉽지않은경우가많다. 22) 그리고혈액수포모양의동맥류의벽은극도로얇고연약해서수술적치료시에동맥류의목부분에서파열될가능성이매우높다. 2) 따라서동맥류의포착법이나내경동맥의근위부폐쇄가다른치료선택법이될수있다. 우회술이추가적으로수행된다고하더라도이런방법들은허혈성합병증을유발할잠재적위험을가지고있어서, 2) 혈액수포모양의동맥류의색전술이보고되어왔지만아직은기술적어려움이있다. 13)23) Yanaka 등은평행하게동맥류를결찰하고난후에내경동맥의열상이있으면봉합법을사용하고 Heifetz 두르기클립 (encircling clip) 을사용했다. 25) 포장술자체나기저귀처럼유창 (fenestrated) 클립과함께포장술을사용하는방법, 23)24) 수술전풍선폐쇄를한후에우회술을하는방법이보고되었다. 24) 저자들의경우에는파열성동맥류의경우주머니모양동맥류는등쪽동맥류를제외하고는예후가나빴던원인이결찰술자체보다는수두증이나고령, 감염등다른요인에의한것이었고혈액수포모양동맥류의파열의경우대부분이등쪽및안쪽에서유래한동맥류였으며수술전혈관조영술시풍선폐쇄검사를통한우회술을시행한경우는이후내경동맥이폐쇄가되었더라도좋은예후를보였고나머지한명은수술후내경동맥이좁아져있는소견이있었으나항혈소판제제만복용하고도좋은예후를보였다. 이렇듯혈액수포모양이나등쪽또는안쪽에서유래하는동맥류의경우에는수술전에적극적인풍선폐쇄검사를시행하여수술후올수있는허혈성뇌경색의예방을위해우회술을실시하는것이좋겠다. 수술중파열의위험이아주높은경우에는우회술및포착법등을적극고려하는것이나쁜예후를막는선택법들중하나라할수있겠다. 또한저자들의경우에는크기가매우작은비파열성혈액수포모양동맥류의경우인공경막을이용하여포장후결찰술을이용하였고현재까지추적관찰중파열된경우는없었다. 이렇게비파열성혈액수포모양동맥류의경우크기가작은경우에는목의결찰시파열의위험이높고 encircling clip 또한직접적인압박의가능성이있어동맥류를인공경막으로포장한후동맥류크립으로고정하는것을치료방법으로서적극고려할수있겠다. 결 내경동맥의분지부위가없는곳에서생기는파열성동맥류의경우혈액수포모양인경우와등쪽에서발생하는주머니모양동맥류일때는수술중파열될가능성이높아결찰이어려운경우가생길수있다. 결찰이된다고하여도동맥류와내경동맥이동시에크립되어이로인하여내경동맥이좁아질우려가높아예후가좋지않을수있으므로수술전풍선폐쇄검사를시행하여우회술후결찰술이나포착술등의치료적전략을한층다양하게하는것이예후를향상시키는데도움이될수있겠다. 또한비파열성혈액수포모양동맥류의경우에는직접결찰을시도하지말고포장술후결찰술이유용한방법이될수있겠다. 이곳에생기는주머니모양의동맥류는내경동맥축의방향대로결찰하지않고수직또는경사방향으로결찰하여도수술중파열되는경우는없었다. 론 중심단어 : 동맥류 내경동맥 혈액수포모양동맥류 포장술. REFERENCES 11) Abe M, Tabuchi K, Yokoyama H, Uchino As. Blood blisterlike aneurysms of the internal carotid artery. J Neurosurg 89:419-24, ) Bouthillier A, van Loveren HR, Keller JTs. Segments of the internal carotid artery: a new classification. Neurosurgery 38:425-32; discussion , ) Cantore GP, Santoro As. Treatment of aneurysms unsuitable for clipping or endovascular therapy. J Neurosurg Sci 42:71-5, ) Endo S, Takaba M, Ogiichi T, Kurimoto M, Nishijima M, Takaku As. Pathological study of intracranial artery dissection with subarachnoid hemorrhage. Surg Cereb Stroke 25:169-76, ) Ezaki Y, Takahata H, Kamada K, Baba S, Kaminogo Ms. Aneurysmal embolization of a blisterlike aneurysm of the internal carotid artery: a case report and review of the literature. Surgical Neurology 65:628-30, ) Fernandez Zubillaga As. Endovascular occlusion of intracranial aneurysms with electrically detachable coils: correlation of aneurysm neck size and treatment results. American Journal of Neuroradiology 15:815-20, ) Fox JLs. Microsurgical treatment of ventral (paraclinoid) internal carotid artery aneurysms. Neurosurgery 22:32, ) Hodes JE, Aymard A, Gobin YP, Rufenacht D, Bien S, Reizine D, et al. Endovascular occlusion of intracranial vessels for curative treatment of unclippable aneurysms: report of 16 cases. J Neurosurg 75: , ) Ishikawa T, Nakamura N, Houkin K, Nomura Ms. Pathological Consideration of a Blister-like Aneurysm at the Superior Wall of the Internal Carotid Artery: Case Report. Neurosurgery 40:403, ) Jennett B, Bond Ms. Assessment of outcome after severe brain damage. Lancet 1:480-4, ) Joo SP, Kim TS, Moon KS, Kwak HJ, Lee JK, Kim JH, et al. Arterial suturing followed by clip reinforcement with 396 Kor J Cerebrovascular Surgery 10(2): , 2008

7 김희중 장동규 허필우 김달수 유도성 조경석등 circumferential wrapping for blister-like aneurysms of the internal carotid artery. Surgical Neurology 66:424-8, ) Kobayashi S, Kyoshima K, Gibo H, Hegde SA, Takemae T, Sugita Ks. Carotid cave aneurysms of the internal carotid artery. J Neurosurg 70:216-21, ) Kurokawa Y, Wanibuchi M, Ishiguro M, Inaba Ks. New Method for Obliterative Treatment of an Anterior Wall Aneurysm in the Internal Carotid Artery: Encircling Silicone Sheet Clip Procedure- Technical Case Report. Neurosurgery 49:469, ) Kyoshima K, Kobayashi S, Nitta J, Osawa M, Shigeta H, Nakagawa Fs. Clinical Analysis of Internal Carotid Artery Aneurysms with Reference to Classification and Clipping Techniques. Acta Neurochirurgica 140:933-42, ) Miyazawa N, Nukui H, Mitsuka S, Hosaka T, Kakizawa T, Nishigaya K, et al. Treatment of intradural paraclinoidal aneurysms. Neurol Med Chir (Tokyo) 39:727-32, ) Nakagawa F, Kobayashi S, Takemae T, Sugita Ks. Aneurysms protruding from the dorsal wall of the internal carotid artery. J Neurosurg 65:303-8, ) Ogawa A, Suzuki M, Ogasawara Ks. Aneurysms at Nonbranching Sites in the Supraclinoid Portion of the Internal Carotid Artery: Internal Carotid Artery Trunk Aneurysms. Neurosurgery 47:578, ) Ohara H, Sakamoto T, Suzuki Js. Sclerotic cerebral aneurysms. Cerebral Aneurysms. Tokyo, Neuron:673-82, ) Redekop GJ, Woodhurst Bs. Unusual aneurysms of the distal internal carotid artery. Can J Neurol Sci 25:202-8, ) Rhoton Jr ALs. Anatomy of saccular aneurysms. Surg Neurol 14:59-66, ) Stehbens WEs. Pathology of the cerebral blood vessels. Saint Louis: Mosby, 1972: ; Links 22) Sundt Jr TMs: Part II: Aneurysms of the anterior circulation- Middle cerebral artery. Surgical Techniques for Saccular and Giant Intracranial Aneurysms. Baltimore, Williams & Wilkins: , ) Suzuki J, Ohara Hs. Clinicopathological study of cerebral aneurysms. Origin, rupture, repair, and growth. J Neurosurg 48:505-14, ) Watanabe S, Kato Y, Sano H, Hisano S, Nagahisa S, Kanno Ts. Surgical treatment on blister-like aneurysms using clipping with wrapping technique and Gore-Tex wrap clip. Surg Cereb Stroke 25:53-8, ) Yanaka K, Meguro K, Nose Ts. Repair of a Tear at the Base of a Blister-like Aneurysm with Suturing and an Encircling Clip: Technical Note. Neurosurgery 50:218, 2002 Kor J Cerebrovascular Surgery 10(2): ,

KISEP KOR J CEREBROVASCULAR SURGERY September 2003 Vol. 5, No 2, page 중대뇌동맥동맥류의수술적치료 연세대학교의과대학신경외과학교실 주진양 Surgical Management of Middle Cerebra

KISEP KOR J CEREBROVASCULAR SURGERY September 2003 Vol. 5, No 2, page 117-22 중대뇌동맥동맥류의수술적치료 연세대학교의과대학신경외과학교실 주진양 Surgical Management of Middle Cerebral Artery Aneurysms Jin-Yang Joo, MD, PhD Department