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 of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea ABSTRACT Middle cerebral artery (MCA) aneurysms account for approximately one-fifth of aneurysmal subarachnoid hemorrhage. The preferred treatment of these aneuryms is microsurgical clipping because of their peripheral location, large neck-to-fundus ratio, incorporation of major branches into the aneurysmal wall, and high incidence of intracerebral hematoma. MCA aneurysms can be approached surgically using one or two of three basic techniques; medial transsylvian, lateral transsylvian and superior temporal gyrus approach. In this presentation, selection of surgical approaches and the surgical techniques to minimize the neurovascular structures are described. Management outcomes by using these techniques is also presented. (Kor J Cerebrovascular Surgery 5:117-22, 2003) KEY WORDS:Middle cerebral artery aneurysms Surgical approaches Surgical techniques. 서 - - 론, 135-270 서울강남구도곡동 146-92 연세대학교의과대학신경외과학교실 전화 :(02) 3497-3396 전송 :(02) 3461-9229 E-mail:JYJOO@yumc.yonsei.ac.kr 해부학 - 117
중대뇌동맥동맥류의 수술적 치료 (branch) 들로 구성된다. 여기서 중대뇌동맥의 가지들은 판 혹은 삼분지(trifurcation)가 80~85%로 가장 많고 그 다 개(operculum)를 지나 실비우스구의 표면에 도달하는데 이 음이 M1의 몸통(trunk) 및 anterior tempolar artery, poral 가지들이 M3(opercular) segment를 구성하고 있으며 M4 artery, lenticulostriate artery 등 M1의 가지들이 기원하 segment는 피질가지(cortical branch) 들로 이루어 진다. 는 부위다(10~15%).22)33) 그 외 약 4~5%는 M2, M3, M4 중대뇌동맥동맥류는 대개 분지(bifurcation)에서 기원하 등 원위중대뇌동맥(distal MCA)에서 발생되는데10) 특히 지만 천공분지(perforator)의 기시부에서도 발생하기 때문 distal MCA는 감염, 외상, 종양, 염증등과 관련하여 발생되 에 이에 대한 해부학적인 이해도 중요하다. 비록 다양성이 는 동맥류의 호발부위로 알려져 있다. 있지만 M1의 상외측(superolateral) 표면에서는 uncal 중대뇌동맥에서도 혈류방향을 따라서 동맥류가 발생 및 artery, polar tempolar artery 및 anterior temporal artery 성장하는데 그 방향은 외측(lateral, 45%)과 전측(anterior, 등이 발생하며 이들은 모두 측두엽을 공급한다. 또 M1의 38%)이 가장 많고 그 다음이 상측(superior(15%) 순이 하내측(inferomedial) 표면에서는 평균 약 10개 내외의 렌 다.22) 동맥류가 projection 되는 방향은 수술접근법을 선택 즈핵선조체동맥(lenticulostriate arteries)들이 발생하며 이 하고 특히 수술시 M2를 따라 동맥류 주위로 박리(disse- 들은 내포(internal capsule), 담창구(globus pallidus)의 측 ction)를 진행할 때 매우 중요한 기준이 된다. 부 및 미상핵(caudate nucleus) 등을 공급한다. 중대뇌동맥의 기형(anomaly)은 다른 두개강내동맥에서 보 방사선학적 검사 다 발생빈도가 상대적으로 낮아서 약 3% 정도로 보고되고 있 으며5) 이 기형에 의해 유발된 hemodynamic stress에 의하 과거에는 뇌전산화단층촬영 및 뇌혈관조영술 만으로 동 1)6)11)12)15)26)31) 여 동맥류가 발생하기도 한다(Figs. 1 and 2). 맥류를 확인하였지만 최근에는 뇌자기공명촬영 및 전산화단 내경동맥에서 두개의 중대뇌동맥이 동시에 기원하는 duplicate 층혈관촬영술(CT angiogram)이 동맥류의 치료에 많은 도 MCA, 전대뇌동맥에서 발생하는 부중대뇌동맥30)(accessory 움을 준다. 거대 동맥류의 경우 낭(sac)의 일부가 혈전으로 35) MCA) 등이 있으며 그 외 fenestrated MCA 등이 있다. 차있을 때에는 뇌혈관조영술과 더불어 뇌자기공명촬영술을 시행하면 동맥류의 크기와 윤곽 및 주위 구조물과의 관계 동맥류의 호발부위 및 성장방향 를 더 정확히 알 수 있다. 특히 동매류의 경(neck) 부위에 죽종(atheroma) 혹은 석회화(calcification)가 있는 경우 전 중대뇌동맥동맥류의 호발부위는 M1의 이분지(bifurcation) 산화단층혈관촬영사진에서 잘 나타난다(Fig. 3). 또 중대뇌 동맥파열 후 대량의 뇌실질내혈종이 발생한 환자에서는 전 산화단층혈관촬영술만 시행 후 바로 응급수술을 시행함으로 써 치료결과를 호전시킬 수 있다. Fig. 1. Intraoperative photograph shows a saccular aneurysm (white arrow) originating from the accessory middle cerebral artery (black arrow). 118 Kor J Cerebrovascular Surgery 5:117-22, 2003 Fig. 2. Digital subtraction angiography shows an aneurysm developing from the distal middle cerebral end artery (arrow).
Fig. 3. CT angiography reveals calcified atheroma on the neck of the middle cerebral artery aneurysm arrow. 수술적치료 1. 머리위치및개두술 - 2. 수술접근법 - - Kor J Cerebrovascular Surgery 5:117-22, 2003 119
- - 3. 지주막박리및동맥류결찰 - Fig. 4. For lateral or posterior projection of aneurysm, it is safe to split the sylvian fissure in a proximal-to-distal direction proximalor sylvian fissure approach. However it may be approached from distal sylvian fissure distal sylvian fissure approach by advancing dissection along the outer surface of the M2s. The M1 and neck of the aneurysm can be exposed before encountering the fundus of aneurysm Left. Anterior direction of aneurysm should be approached from distal sylvian fissure. By dissecting along the inner surface of the M2s, the M1 with neck of aneurysm may be isolated first Right. - 120 Kor J Cerebrovascular Surgery 5:117-22, 2003
- - 결 - 결 Table 1. Results of microsurgery for middle cerebral artery aneurysms Preoperative grade 과 론 Results Hunt-Hess No. Good Fair Poor Dead 03 62 61 1 0 0 4 16 15 1 0 0 5 9 3 1 1 4 Total 87 79 3 1 4 Kor J Cerebrovascular Surgery 5:117-22, 2003 121
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