#09-노병일ok

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1 KOR J CEREBROVASCULAR SURGERY December 2OO9 Vol. 11 No 4, page 가톨릭대학교부천성모병원신경외과학교실노병일 조광욱 박익성 백민우 Minimally Invasive and Tailored Surgical Approach to the Anterior Circulation Aneurysms Byoung-Il Roh, MD, Kwang-Wook Jo, MD, Ik-Seong Park, MD, Min Woo Baik,MD Department of Neurosurgery, CollegeofMedicine, The Catholic University Bucheon ST. Mary s Hospital, Bucheon, Korea ABSTRACT Objectives : Supraorbital route through eyebrow incision, mini-pterional craniotomy, and midline interhemispheric route are most generally used methods for key hole surgery on anterior circulation aneurysm. Surgical route is determined according to aneurysm architecture and patient status. The approaching route can be selected according to the findings of 3-dimensional computed tomography (CT) angiography simulation. Prospective decision-making protocol, surgical technique of key hole surgery, and the results are presented in this paper. Methods : 173 patients with anterior circulation aneurysms were treated by direct surgical neck clipping during last two years. Twenty patients of poor grade (Hunt-Hess grade IV,V) were treated by craniectomy with clipping. Decision making protocol was applied to 153 unruptured and good grade ruptured aneurysm patients. Simulation of key hole surgery was conducted by CT work station using conventional software InSpace (Siemens, Germany), and direction and shape of aneurysm was observed from the perspective of microsurgery. Results : 113 ruptured and 40 unruptured aneurysms were secured through one of the three approaching routes. Supraorbital approach had been performed in 82 cases (unruptured 24, ruptured 58) while 64 cases were treated by mini-pterional craniotomy. Midline key hole surgery were carried out in seven distal anterior circulation aneurysms (DACA) using brain navigation system. After locating the aneurysm, supraorbital approach was applied to 46 cases involving anterior cerebral artery (ACA), 16 in internal carotid artery (ICA) and 20 in middle cerebral artery (MCA). Mini-pterional craniotomy was carried out in aneurysms located in ACA (9), ICA (18), and MCA (37). In most cases, the results of clipping were good. The average follow-up time was 16.7months (ranging 2 to 32months) and the results were cosmetically excellent. Conclusion : Simulating surgical approaches with 3-D CT angiography is a highly useful method for determining various surgical routes in anterior circulation aneurysm treatment. Therefore, minimally invasive and tailored surgical approaches are recommended since optimal route can be found through simulation. Thus, minimal invasive and tailored surgical approach is available through this method. These procedures have clear advantages; shorter surgical time and hospital stay, less operative trauma, reduced costs and less pain, and better cosmetic outcomes compared to standard craniotomy. Optimal surgical results are expected from minimally invasive and tailored surgical craniotomy. (Kor J Cerebrovascular Surgery 11(4): , 2009) KEY WORDS : Minimally invasive surgery Anterior circulation aneurysm. 논문접수일 : 2009 년 18 월 29 일심사완료일 : 2009 년 10 월 19 일교신저자 : Ik-Seong Park, MD, Department of Neurosurgery, The Catholic University Bucheon ST. Mary s Hospital, 2 Sosa-dong, Wonmi-gu, Pucheon, Kyounggi-do, , Korea 전화 : (032) 전송 : (032) nbi24@nate.com 서론 앞머리쪽우묵 (anterior cranial fossa) 및안장옆 (parasellar) 부위의병변에대한미세침습적인접근법은정상구조물의파괴를최소화함으로서개두술로인한합병증을줄이고, 환자의빠른회복, 비용절감등의이점이있 193

다. 6)14)22)24)30)32) 이제는미용적측면을고려하여이러한수술을원하는환자들이늘고있다. 천막위뇌동맥류에대해관자놀이 (pterional), 안와위 (supraorbital), 반구간 (interhemispheric) 부위를통한작은구멍 (keyhole surgery) 을통한성공적인사례가많이보고되었다.

2 다. 6)14)22)24)30)32) 이제는미용적측면을고려하여이러한수술을원하는환자들이늘고있다. 천막위뇌동맥류에대해관자놀이 (pterional), 안와위 (supraorbital), 반구간 (interhemispheric) 부위를통한작은구멍 (keyhole surgery) 을통한성공적인사례가많이보고되었다. 22)32) 미세침습적개두술을통한접근법에는신경내시경 (neuroendoscopy), 수술중영상 (intraoperative imagrao) 과항법장치 (navigation system) 등특별한수술장비가종종사용되는데이런기계장치의발전도미세침습적인접근법을가능하게하였다. 22)30)32) 우리는이런미세침습적인접근법을전방순환동맥류의치료에응용하였다. 이전에소개된안와위접근법 (supraorbital) 은안와상연 (supraorbital rim) 을제거하면서시행하였기때문에수술후안검부종및안와주변의얼룩출혈소견을자주보였으나안와상연을보존함으로써이러한합병증을최소화하였다. 미세침습적관자놀이접근개두술은기존의관자놀이접근법에비해측두근의박리범위와개두술크기를줄이는접근법이다. 저자들은전방순환뇌동맥류의치료를위해시행한미세침습접근법에대한경험과결과를논의하고자한다. 두개골절제술을받은 20명은본연구에서제외하였다. 환자의연령은 14세에서 86세까지분포를하였고평균연령은 52.4세였다. 성별분표는여자가 102명, 남자가 51명이었다. 동맥류의크기는뇌혈관조영술 (catheter angiography) 과 Brain Computed Tomographic Angiography(CTA) 로측정했다. 평균뇌동맥의크기는 6.67mm(range 2~35mm) 이었다. 수술후평균경과관찰시간은 16.7개월 (range 2~32 months) 이었다. 저자들은전방순환계의뇌동맥류의치료에대해알고리즘을만들었으며내용은다음과같다. 우선파열된뇌동맥류를 Hunt-Hess(H-H) 등급에따라서 good grade(grade I-III) 와 poor grade(grade IV-V) 로나누었다. 동맥류의돌출방향, 위치, 모양의 3-Dimensional Computed Tomographic Angiography(3D-CTA) 소견에따라접근경로를결정하였다. Poor grade(h-h IV,V) 인경우와뇌부종이심한환자는감압적인광범위두개골절제술과뇌동맥류경부결찰술을받았다 (Fig. 1). 비파열성뇌동맥류와 good grade인파열성뇌동맥류환자 대상및방법 대상 2007년 1월부터 2008년 12월까지본원에서전방순환뇌동맥류를가진 173명환자가뇌동맥류경부결찰술을받았다. Table 1, 2는환자들의자료와, 동맥류의위치및경과관찰기간, 동맥류의크기를보여준다. 뇌부종이심하여감압적인 Table 1. Demographic charateristic of 153 patients with anterior circulation aneurysm. Age range 52.4 years mean 14~86 years Gender male 51 patient female 102 patient Aneurysm size range 2~35 mm mean 6.67 mm Follow up duration range 2~32 months mean 16.7 months Aneurysm location ACA 62 patient MCA 57 patient ICA 34 patient Fig. 1. Algorithm for approaches to anterior circulation aneurysm - If the condition of the patient is good grade(h-h grade 0,1,2), evaluations are made before surgery using 3- Dimensional Computed Tomographic Angiography to select a suitable approach. Table 2. Initial Hunt-Hess grade at admission of patients. Initial H-H grade ACA MCA ICA I II III IV V Total Kor J Cerebrovascular Surgery 11(4): , 2009

노병일 조광욱 박익성 백민우 는이러한프로토콜에따라 CT검사실에있는 work station 에서시뮬레이션 (simulation) 3차원영상재구성프로그램 (InSpace,Siemens,

수술시야관점에서뇌동맥류의방향이나크기를볼수있으며이에따른결과로최적의미세침습적인접근로를결정하였다.

CT검사실에시행한시뮬레이션결과안와위접근법보다관자놀이접근법이더뇌동맥류의경부를잘보여줬다. 관자놀이접근법으로뇌동맥류경부결찰을시행하였으며합병증없이입원 16일만에퇴원하였다 (Fig. 3).

환자는안와위접근법을통하여뇌동맥류경부결찰술을시행받았으며합병증없이 5 일만에퇴원하였다 (Fig. 2). 증례 2 38세여자환자로갑작스러운터질듯한두통으로본원응급실내원하였다.

Fisher II, H-H 등급 III 이었으며두부 3D-CTA상지주막하출혈과전뇌동맥원위부에 3.8mm 크기의뇌동맥류가발견되었다.

퇴원시 GCS는 10-13점으로호전된양상보였다 (Fig. 4). Fig. 2.

surgery with the supraorbital approach is possible using 3D-CTA (the arrow represents the aneurysm).

(C) ACA aneurysm has been well clipped with the supraorbital approach.

3 노병일 조광욱 박익성 백민우 는이러한프로토콜에따라 CT검사실에있는 work station 에서시뮬레이션 (simulation) 3차원영상재구성프로그램 (InSpace,Siemens, Germany,Si사용하여술자가직접실제수술시결찰하는것과같이동맥류의위치, 모양, 돌출모양을파악하고시뮬레이션 (simulation) 을시행하였다. 수술시야관점에서뇌동맥류의방향이나크기를볼수있으며이에따른결과로최적의미세침습적인접근로를결정하였다. 15점, H-H 등급 III이었으며뇌전산화단층촬영에서우측중대뇌동맥의분지부에 6mm 크기의뇌동맥류와 Fisher 등급 II의지주막하출혈 (Subarachnoid hemorrhage) 소견이보였다. CT검사실에시행한시뮬레이션결과안와위접근법보다관자놀이접근법이더뇌동맥류의경부를잘보여줬다. 관자놀이접근법으로뇌동맥류경부결찰을시행하였으며합병증없이입원 16일만에퇴원하였다 (Fig. 3). 증례 1 40세여자환자로 1주일전부터간헐적인두통과현훈을주소로내원하였다. 3D-CTA에서 4mm 크기의비파열성뇌동맥류가전교통동맥에서발견되었다. 환자는안와위접근법을통하여뇌동맥류경부결찰술을시행받았으며합병증없이 5 일만에퇴원하였다 (Fig. 2). 증례 2 38세여자환자로갑작스러운터질듯한두통으로본원응급실내원하였다. 내원당시 GCS(glasgow coma scale) 는 증례 3 40세남자환자로등산후샤워하던도중의식을잃고쓰러진뒤응급실로이송되었다. 내원당시 GCS 10점. Fisher II, H-H 등급 III 이었으며두부 3D-CTA상지주막하출혈과전뇌동맥원위부에 3.8mm 크기의뇌동맥류가발견되었다. 뇌반구간접근법으로뇌동맥류경부결찰술을시행하였으며수술중항법장치를사용하였으며두개골편의크기를최소화하고동맥류의위치를쉽게찾을수있었다. 수술후특별한합병증없이입원 26일후퇴원하였다. 퇴원시 GCS는 10-13점으로호전된양상보였다 (Fig. 4). Fig. 2. (A) For a patient with an anterior cerebral artery aneurysm, it was evaluated before surgery whether the surgery with the supraorbital approach is possible using 3D-CTA (the arrow represents the aneurysm). (B) 3D-CTA after conducting a surgery with the supraorbital approach. (C) ACA aneurysm has been well clipped with the supraorbital approach. (D) no finding of apparent palsy or atrophy is shown after a surgery with the supraorbital approach. Fig. 3. (A) A patient found to have middle cerebral artery aneurysm (arrow) in an angiography (B) 3D-CTA after a surgery with the minipterional approach. (C) MCA aneurysm has been well clipped with the minipterional approach. (D) no apparent temporalis muscle atrophy or depression is shown after a surgery with the minipterional approach. Kor J Cerebrovascular Surgery 11(4): ,

수술기법 안와위접근법모든환자는전신마취하에서수술을시행을하였으며환자는바로누운자세에서머리를회전시키고수술자세를잡는다. 머리를돌리는정도는수술부위및접근로에있는정상구조물에따라서달라지나일반적으로 20도에서 45도사이에서진행을한다. 일반적인개두술시사용하는두개골고정용핀은사용하지않는다.

피부절개는눈썹의중앙으로안와위신경 (supraorbital nerve) 및동맥의손상을막기위해눈썹의외측 1/2 또한안와위패임 (supraorbital notch) 으로부터외측으로약 3cm까지눈썹을따라절개를한다. 안구주위의근육을이마쪽으로박리를한다. 작은천공은전두엽의외측에만들고두개골절편은안와에붙여서 2 2.5cm 크기의타원형으로만든다.

뇌견인을적게하고두개강내압을낮추기위해서는뇌척수액을충분히제거하고필요시에는만니톨을줄수있다. 뇌척수액배액방법으로는뇌실천자를하거나지주막하에서흡입을하거나종말판조 (lamina terminalis) 를조기에열어준다. 수술을마치고경막을닫고지혈을하고마치면서두개골 절편은작은판 (miniplate) 으로고정을한다.

수술반대측으로 30~60 머리를돌리고나머지머리카락들은머리핀으로수술시야바깥쪽으로고정시키고 surgidrape으로수술시야를밀폐시킨다. 피부절개는손가락으로테리온 (pterion) 을찾아확인하고이곳을중심으로반월상으로모발선 (hair line)1.5cm안에협골궁에서 1.

4 수술기법 안와위접근법모든환자는전신마취하에서수술을시행을하였으며환자는바로누운자세에서머리를회전시키고수술자세를잡는다. 머리를돌리는정도는수술부위및접근로에있는정상구조물에따라서달라지나일반적으로 20도에서 45도사이에서진행을한다. 일반적인개두술시사용하는두개골고정용핀은사용하지않는다. 수술전에피부의소독은알코올과제피란을이용하여소독을하며포비돈은색소침착의우려가있어서사용을하지않는다. 눈썹은깍지않은상태에서진행을한다. 눈주위및일부의이마는수술용비닐부착포를이용하여노출을한다. 피부절개는눈썹의중앙으로안와위신경 (supraorbital nerve) 및동맥의손상을막기위해눈썹의외측 1/2 또한안와위패임 (supraorbital notch) 으로부터외측으로약 3cm까지눈썹을따라절개를한다. 안구주위의근육을이마쪽으로박리를한다. 작은천공은전두엽의외측에만들고두개골절편은안와에붙여서 2 2.5cm 크기의타원형으로만든다. 수술후안검부종및안와주변의얼룩출혈을예방하기위하여안와상연은보존한다. 두개골절편을만들고난후경막을열기전에드릴을이용하여안와천정을평편하게만든다. 이러한과정은가능한뇌의견인을최소화하는데꼭필요하다. 이과정에서안와가열려서안구주위의지방조직이노출되는경우도있으나이로인한특별한조치는필요하지않다. 경막은반원모양으로열고안와에고정을한다. 뇌견인을적게하고두개강내압을낮추기위해서는뇌척수액을충분히제거하고필요시에는만니톨을줄수있다. 뇌척수액배액방법으로는뇌실천자를하거나지주막하에서흡입을하거나종말판조 (lamina terminalis) 를조기에열어준다. 수술을마치고경막을닫고지혈을하고마치면서두개골 절편은작은판 (miniplate) 으로고정을한다. 피부는흡수되는실로피하를봉합하고테이프로고정하며배액관의삽입은하지않는다. 미세침습관자놀이접근법만져지는전두골의상측두선 (superior temporal line) 아래쪽의측두옆에절개선 (incision line) 이지날수있는만큼만삭발을하고소독을한다. 수술반대측으로 30~60 머리를돌리고나머지머리카락들은머리핀으로수술시야바깥쪽으로고정시키고 surgidrape으로수술시야를밀폐시킨다. 피부절개는손가락으로테리온 (pterion) 을찾아확인하고이곳을중심으로반월상으로모발선 (hair line)1.5cm안에협골궁에서 1.5 2cm위에서시작, 약4 5cm 위로그리고안와위전두부주름중제일낮은곳에맞추어눈썹선까지절개하면전두부감각이나근육운동에지장없이절개할수있다. 피판 (skin flap) 은측두근에서 free flap으로박리 (dissection) 하고측두근 (temporal muscle) 은 monopolar 을이용하여협골근방에서절단, 지혈을철저히하고피판 (skin flap) 과같이견인기 (retractor) 로견인하고테리온을중심으로하고직경 3 3cm 크기의골절편 (free bone flap) 을만든다. 남은접형골은 burr로갈아 (drill out) 평편하게한후경막절개를둥글게하면곧바로시야에실비우스구 (sylvian fissure) 와실비우스정맥 (sylvian vein) 이노출된다. 경동맥조를열어뇌척수액을배액하고경동맥을노출시켜수술중동맥류파열에대비한다. 비파열중대뇌동맥류의경우노출된실비우스열 (sylvian fissure) 가장외측부터박리를해야나중에전두엽과측두엽분리가좋아뇌견인이거의필요없게되며뇌동맥류결찰시에도넓은시야를얻게된다. 만일뇌종창 (brain swelling) 이심해실비우스열의박리 (dissection) 가어려우면 Payne s point를통해전두각 (frontal horn) 의뇌척수액을배액시킨다. 필요시만니톨을 Fig. 4. (A) For a patient with distal anterior cerebral artery aneurysm, it was evaluated before surgery whether the surgery with the interhemispheric approach is possible using 3D-CTA. (B) ACA aneurysm has been well clipped with the interhemispheric approach. (C) 3D-CTA after a surgery with the interhemispheric approach. (D) no finding of apparent palsy or atrophy is shown after a surgery with the interhemispheric approach. 196 Kor J Cerebrovascular Surgery 11(4): , 2009

5 노병일 조광욱 박익성 백민우 줄수도있다. 수술을마치고경막을닫고지혈을하고마치면서두개골절편은작은판 (miniplate) 으로고정을한다. 뇌반구간접근법전신마취하에고정핀과항법장치를사용하며환자는대부분앙와위자세를유지한다. 전두부분을면도하며항법장치로뇌동맥류의위치를측정한후동맥류를확인할수있는최단거리에골절편을만들도록계획한다. 피부절개는양측관상절개로필요한만큼만한다. 시상봉합에 2개의천공을만들고약 3 4cm 크기의두개골절편을만들고경막을선형으로박리한후뇌반구간접근법으로수술을마친후두개골절편을닫는다. 저자들은한쪽경막을열고대뇌겸 (falx) 을절개하지않으며열성반구인우측접근을선호하였다. 결과 전방순환뇌동맥류를가진총 153명환자에미세침습적접근법으로개두술을시행하였다. 내원당시평균 GCS는평균 13.8점이었으며퇴원시 GCS는평균14.6점이였으며파열성뇌동맥류인경우 mrs(modified Rankin scale)0, 1은 110 명, 11명이었으며나머지 2명이 mrs 2였다 (Table 3). 안와위접근법을이용한 82명의환자중창상감염, 뇌척수액누출, 경막하혹은경막외출혈등으로재수술을한경우는없었다. 비파열성뇌동맥류인경우수술후 1병일부터거동을허락하였고 5병일부터 10병일사이에퇴원이가능하였다. 눈썹절개를시작하여동맥류에도달하기까지시간은 15분에서 25분으로고식적개두술보다훨씬짧았으며뇌동맥류결찰을하는시간은차이가없었다. 경막을닫고뼈를고정한후피부봉합을마치는시간은 20분에서 25분으로수술시간도의미있게단축되었다. 82명의환자는잘결찰되었다. 평균추적관찰의기간은 14.1개월 (range 4-22) 이었고미용적으로우수하였다. 수술상처는대부분이눈썹으로인하여가려지고있으며함몰등의안면의변형은보이지않았다. 수술후합병증으로는 1명의환자에서 15cc정도로미세한대뇌출혈 (intracerebral hemorrhage) 이전두엽에관찰되었으나신 경학적인결손없이입원 16일후퇴원하였다. 또한파열된뇌동맥류를가진 59명의환자중에서 3명에환자에서혈관연축이발생하여혈관성형술 (angioplasty) 을시행했으며증상은호전되었다 (Table 4). Minipterional 접근법을이용한 64명의환자중수술로인한합병증감염, 뇌척수액누출, 경막하, 경막외출혈등으로재수술을한경우는없었으며, 비파열성뇌동맥류경우수술후 1병일부터거동이가능하였고 7병일이후퇴원이가능하였다. 피부절개를시작하여동맥류에도달하기까지시간은 25분에서 30분으로고식적인관자놀이접근법보다훨씬짧았으며뇌동맥류결찰을하는시간은차이가없었다. 경막을닫고뼈를고정한후피부봉합을마치는시간은 20분에서 25 분으로수술시간도의미있게단축되었다. 64명의환자는잘결찰되었다. 평균추적관찰의기간은 17.1개월 (range 4-32) 개월이었고미용적으로우수하였다. 수술상처는대부분이머리카락으로인하여가려지고있으며측두근이거의보존되어함몰등의안면의변형은보이지않았다. 수술후합병증으로는 1명의환자에서 5cc정도로소량의경막외출혈 (epidural hemorrhage) 이관찰되었으나신경학적인결손없이입원 21일후퇴원하였다. 2명의환자에게서수술후관통동맥경색 (perforating artery infarction) 소견이보였으며이중 1명은경미한신경학적인후유증 (modified rankin scale 2) 을남겼다. 또한파열된뇌동맥류환자의 51명의환자중 4명에환자에서혈관연축이발생하여혈관성형술 Table 3. Outcome of patients when discharge. mrs* Ruptured an. patient Unruptured an. patient Total *mrs: modified Rankin Scale Table 4. Complication of supraorbital approach in anterior circulation aneurysm. Complication none ICH* vasospasm Perforation a. infarction ICA ACA MCA Total * ICH: Intracerebral hemorrhage Kor J Cerebrovascular Surgery 11(4): ,

6 (angioplasty) 를시행했으며증상은호전되었다 (Table 5). 전대뇌동맥원위부에동맥류를가진 7명의환자의경우항해장치를이용한뇌반구간접근법으로하였으며모든환자는뇌동맥류는잘결찰되었다. 평균추적관찰의기간은 12개월이었고수술후합병증이나재수술한경우는없었다. 40명의환자가비파열성뇌동맥류를가졌으며 39명의환자는잘결찰되었으나 1명의환자에서안와위접근법을하고난뒤관통동맥경색인한합병증으로 mrs 1의후유증을가지게되었다 (Table 3). 고찰 19세기말에 Krause가처음으로관자놀이개수술에대해기술했다. 18) 1918년에 Heuer와 Dandy가시신경교차 (optic chiasm) 와뇌하수체 (hypophysis) 에처음으로관자놀이혹은측전두엽 (frontolateral) 접근법을시행했다. 4)5)22)33) 1944 년 Dandy는전방순환뇌동맥류치료로측전두엽개두술에대하여서술하였다. 이접근법은관자놀이개두술의기본을두고있으며이후에 Kempe, Shepard. and Swain에의하여더욱발전되었다. 4)20)21)33) 관자놀이개두술은주로 Yarsargil에의하여다듬어졌고보편화되었다. 35)36)37)38) 그러나필요한수술적시야에비해서많은대뇌피질이노출되어우발적인위험이크다. 게다가측두근의위축을막기위한몇몇변형된방법에도불구하고미용적으로좋지않은결과를보였다. 1-4)7)16)20)22)34)38) 그러나미세침습적방법은일반적인개두술에비하여수술시간및입원기간을단축시키며수술중외상과비용, 통증을줄일뿐만아니라더좋은미용적효과가있다. 일반적인관자놀이개두술의수술범위와그에관계된합병증을줄이기위하여몇몇다른기술들이제시되었다. 1-3)5)7)12)16)17)19)21)22)35)38) 일반적으로넓은수술시야을가진기존의관자놀이접근법이더큰표출각도 (Angular Exposure) 를제공하지만 Eberval는관자놀이접근법과와미세침습관자놀이접근법에서제공하는각 (angle) 들의통계학적차이가없다고발표하였다. 10) 뼈를제거함으로써시야가변화시킬수있는두개저 (Cranial base) 접근법과다르게실비우스를통한작업 (Trans-sylvian working) 각은뇌의수축력과실비우스열 (sylvian fissure) 의벌어짐의정도에따라좌우된다. 그러므로실비우스를통하는 (trans-sylvian) 각이이두가지접근법에따라달라질해부학적근거는없다는것이다. 10) 그러나관자놀이접근법은측두엽의수축력을배가시켜서각를증가시키게되는장점이있다. 이러한수축력은미세침습관자놀이접근법의경우에는제한적이어서측두엽의노출이적게나타난다. 미세침습관자놀이접근법의또다른단점은전방에서수술부위로의접근이어렵다는것인데, 이는개두술에서의전두엽쪽으로의확장 (extension) 이관자놀이접근법보다감소하기때문이다. 그러나실비우스경로를사용하게되는경우에는어떠한해부학적제한이없게된다. 10) 앞머리쪽우묵및안장옆부위의병변에대한수술적인접근법은일반적으로관자놀이접근법이이용된다. 9)13) 최근에는내시경및내비게이션을비롯한미세현미경의발달로보다두개골절개술을작게하는수술이가능하게하였다. 16) 이러한미세침습적인두개골절개의장점은뇌피질의손상을줄이고, 정상조직을최대한보존한다는점이다. 이러한작은두개골절개의수술법중에대표적인것이바로안와위이마밑접근법 (supraorbital subfrontal approach) 이며미용적으로도우수한수술법이다. 1908년 Fedor Krause가처음으로보고를하였고 Jane과그의동료들은안구종양, 앞교통동맥의동맥류, 뇌하수체종양, 안장옆의수막종등의치료에이방법을사용하여보고하였다. 13) 그러나당시에는미세현미경수술기구의발달이현재와같지않아많은제한점이있었기때문에널리시행되지못했다. 최근에들어서여러가지문헌에서안와위접근법을이용한뇌동맥류, 안장옆의종양, 앞기저부병변의치료를보고하고있다. 15)16)33) 저자들은수술시에눈썹을제거하지않고수술을시행하였다. 그러나감염은없었으며눈썹으로인하여오히려수술상처가가려지는효과가있었다. 또한저자들은안와상연을보존하였기때문에, 안검부종및안와주변의얼룩출혈을예방할수있었다. 비록안와상연을보존하더라도수술시야에방해되지않으며시야의한계는안와천장에의해이루어지므로안와천장을편평하게 drilling하는것이중요하고충분히확 Table 5. Complication of minipterional approach in anterior circulation aneurysm. Complication none EDH* vasoapsm Perforation a. infarction ICA ACA MCA Total * EDH: Epidural hemorrhage 198 Kor J Cerebrovascular Surgery 11(4): , 2009

7 노병일 조광욱 박익성 백민우 보할수있다. 또다른장점은두개골의절개가작아서수술시간이줄고뇌척수액의누출, 경막하, 경막외출혈의위험도없었다. 또한배액관을넣지않아서환자의일상으로의복귀또한빠른장점이있었다. 이접근법에대해서비판을하는사람들은두개골절개가너무작아서수술시야가좁다는점을지적하고있다. 그러나이러한문제는현미경의발달로해결되고있다. Spetzler는전통적인관자놀이점접근법 (pterional approach) 과안와위접근법의수술시야를비교한결과큰차이가없음을주장을하였다. 11) 실제로저자들도수술시야가좁아서문제가되지는않았으며, 수술전에 3차원컴퓨터단층촬영 (3D-CTA) 을통하여적절할접근경로를결정하였기때문에이러한문제는해결할수있었다. 그러나안와위접근법에도단점은있다. 먼저작은두개골절개술로도수술을진행할수있는특수고안된기구가필요하다. 기구의크기가맞지않을경우오히려기구가수술시야를가릴수있기때문이다. 또한대부분의신경외과의사들이익숙한관자놀이접근법에비하여일정기간의수련이필요하다. 그리고전두동이큰경우에는두개골절개시에전두동이열릴수있고이럴경우감염의위험이높아지기때문에전두동을막기위한추가적인조작이필요하다. 안와위접근법의적응증은뇌하수체종양을비롯한안장옆부위의종양, 안구신경감압술을포함한안와병변, 앞교통동맥의동맥류에적용할수있다. 그러나이러한수술에있어서모두적용할수있는것은아니다. 안와위접근법으로수술시야확보가가능한지에대해서수술전에 3차원컴퓨터촬영을통하여미리평가가꼭필요하다. 27) 반구간 (intehemispheric) 접근은항법장치를사용함으로써뇌동맥류의위치를쉽게찾을수있으며절개부위를선택할수있다. 이로인해두피절개부위또한최소화하므로미용상좋은결과를얻는다. 또한뇌척수액배액에도불구하고뇌의이동 (brain shifting) 이적어항법장치사용에따른오차가적게발생한다. 결론 현재대부분의병원에서사용중인삼차원영상재구성프로그램은전방순환뇌동맥류치료를위한수술적접근방법을결정하는데있어매우유용하다. 따라서수술적 simulation을통한최적의접근경로를결정할수있으므로미세침습적수술이가능하며, 일반적인개두술에비하여수술시간및입원기간을단축시키며수술중외상과비용, 통증을줄일뿐만아니라더좋은미용적효과가있다. 저자는미세침습적수술적개두술을통해전방순환계동맥류치료에좋은결과를얻었다. 중심단어 : 최소침습적수술, 전방순환계뇌동맥류. REFERENCES 11) Ammirati M, Spallone A, Ma J, Cheatham M, Becker D: Preservation of the temporal branch of the facial nerve in pterional-transzygomatic craniotomy. Acta Neurochir (Wien) 128:163-5, ) Aydin IH, Takci E, Kadioglu HH, Kayaoglu CR, Tuzun Y: Pitfalls in the pterional approach to the parasellar area. Minim Invasive Neurosurg 38:146-52, ) Badie B: Cosmetic reconstruction of temporal defect following pterional [corrected] craniotomy. Surg Neurol 45:383-4, ) Brock M, Dietz H: The small frontolateral approach for the microsurgical treatment of intracranial aneurysms. Neurochirurgia (Stuttg) 21:185-91, ) Chehrazi BB: A temporal transsylvian approach to anterior circulation aneurysms. Neurosurgery 30:957-61, ) Cohen AR, Perneczky A, Rodziewicz GS, Gingold SI: Endoscopeassisted craniotomy: approach to the rostral brain stem. Neurosurgery 36: , ) Coscarella E, Vishteh AG, Spetzler RF, Seoane E, Zabramski JM: Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontal branch of the facial nerve. Technical note. J Neurosurg 92:877-80, ) Delashaw JB Jr, Jane JA, Kassell NF, Luce C: Supraorbital craniotomy by fracture of the anterior orbital roof. Technical note. J Neurosurg 79:615-8, ) DH Wilson: Limited exposure in cerebral surgery; technical note. J Neurosurg 34 : , ) Figueiredo EG, Deshmukh P, Nakaji P, Crusius MU, Crawford N, Spetzler RF, Preul MC : The minipterional craniotomy : technical description and anatomy assessment : surgical anatomy and technique. Neurosurgery 61 :256-65, ) Figueiredo EG, Deshmukh V, Nakaji P, Deshmukh P, Crusius MU, Spetzler RF, et al: An anatomical evaluation of the minisupraorbital approach and comparison with standard craniotomies. Neurosurgery Oct;59(4 suppl 2) : ONS212-20, ) Harland SP, Hussein A, Gullan RW: Modification of the standard pterional approach for aneurysms of the anterior circle of Willis. Br J Neurosurg 10: , ) Jane JA, Park TS, Pobereskin LH, Winn HR, Butler AB: The supraorbital approach: technical note. Neurosurgery 11:537-42, ) JB Delashaw, H Tedeschi, AL Rhoton : Modified supraorbital craniotomy ; technical note. Neurosurgery 30 : , ) Jho HD : Orbital roof craniotomy via an eyebrow incision ; A simplified anterior skull base approach. Minim Invasive Neurosurg 40 : 91-7, ) Kang SD: Pterional craniotomy without keyhole to supratentorial cerebral aneurysms: Technical note. Surg Neurol 60:457-61, ) Kiya N, Dureza C, Fukushima T : Computer navigational microscope for minimally invasive neurosurgery. Minim Invasive Neurosurg 40:110-5, ) Krause F: Chirurgiedes Gehirnsund Rückenmarks: NacheigenenErfahrungen. I Band. Berlin, Urbanand Schwarzenberg, 1908, pp ) Lim LL, Seubsman SA, Sleigh A: Thai SF-36 health survey; tests of data quality, scaling assumptions, reliability and validity in healthy men and women. Health Qual Life outcomes Jul 18;6:52, 2008 Kor J Cerebrovascular Surgery 11(4): ,

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KISEP KOR J CEREBROVASCULAR DISEASE September 2000 Vo. 2, No 2, page 뇌동맥류수술을위한측두하접근법 이재환 허승곤 Subtemporal Approach for Cerebral Aneurysm Jae-Wha

KISEP KOR J CEREBROVASCULAR DISEASE September 2000 Vo. 2, No 2, page 163-70 뇌동맥류수술을위한측두하접근법 이재환 허승곤 Subtemporal Approach for Cerebral Aneurysm Jae-Whan Lee, MD and Seung-Kon Huh, MD Department of Neurosurgery,