#02-여석곤

KOR J CEREBROVASCULAR SURGERY June 2OO8 Vol. 10 No 2, page 358-363 후하소뇌동맥동맥류의치료결과 : 단일기관후향적분석 (1989-2007) 울산대학교의과대학신경외과학교실, 서울아산병원신경외과여석곤 권도훈 안재성 진성철 김현정 권병덕 Management of Posterior Inferior Cerebellar Artery Aneurysms : A Single Institution Retrospective Analysis (1989-2007) Seok-Kon Yeo, MD, Do-Hoon Kwon, MD, Jae-Sung Ahn, MD Sung-Chul Jin, MD, Hyun-Jung Kim, RN, Byung-Duk Kwun, MD Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea ABSTRACT Objective : The incidence of posterior inferior cerebellar artery (PICA) aneurysms is rare, and neurosurgeons have found that the direct open surgical approach for PICA aneurysms is challenging. [0]We analyzed the results of treating posterior inferior cerebellar artery (PICA) aneurysms by embolization or by open surgery. Methods : 41 patients (1% of all the aneurysms treated; 13 (32%) men, 18 (68%) women; mean age: 55.5 yr) with ruptured or unruptured PICA aneurysms underwent treatment at our hospital. The clinical outcomes of these patients were studied retrospectively by using the medical records and the neuroimaging studies. Results : The sites of PICA aneurysms were at the junction of the vertebral artery and PICA (63%), the lateral medullary segment (7%), the tosillomedullary segment (10%), the telovelotonsillar segment (13%) and the cortical segment (7%). The shapes of the PICA aneurysm were either the saccular type (85%) or the fusiform type (15%). 25 patients with PICA aneurysm underwent surgical treatment and 16 patients with PICA aneurysms underwent endovascular treatment. Open surgery was used more often to treat a distal PICA than an endovascular procedure. Within the open surgery group, 24% of the patients received the Hunt and Hess (HH) grades IV and V, whereas among the endovascular-treated patients, 37.5% of the patient had HH IV and V grades. Twenty eight percent of the patients In the surgery group achieved a Glasgow Outcome Scale (GOS) score of I through III, and 72% patients had gained a GOS score IV or V. For the endovascular-treated patients, 37% of these patients achieved a GOS score of I through III and 63% patients gained a GOS score IV or V. Conclusion : We found that the open surgery patients had better clinical outcomes than the endovascular treated patients and they especially achieved higher HH grades. However, Fisher s exact test and Chi-square tests did not show any statistically significant difference between the two groups (p=0.49, which is explained by the selection bias). In the previous literature, the predictors of the outcome for intracranial aneurysms, such as age, the size of the aneurysms, the HH grade and the Fisher grade showed statistical significance for the GOS grade. Yet in our study, we showed that there was no statistical significance between the above mentioned predictors and the GOS grade, while a strong correlation existed between the HH grade and the GOS grade. (Kor J Cerebrovascular Surgery 10(2):358-363, 2008) KEY WORDS : Posterior inferior cerebellar artery Aneurysm Outcome Endovascular Surgery 서 론 논문접수일 : 2008 년 4 월 27 일심사완료일 : 2008 년 6 월 20 일교신저자 : Byung-Duk Kwun, MD, Asan Medical Center, Pungnap-2 dong, Songpa-gu, Seoul 138-736, Korea 전화 : (02) 3010-3550 전송 : (02) 476-6738 E-mail : bdkwun@amc.seoul.kr 후하소뇌동맥동맥류는전체뇌동맥류의 0.5~3% 정도로드물게발생한다. 11)6)13)-15) 후하소뇌동맥은근위부에서원위부까지일반적으로 5개의분절로이루어지며후하소뇌동맥동맥류는후하소뇌동맥의기시부인대뇌척추동맥과후하소뇌동 358

여석곤 권도훈 안재성 진성철 김현정 권병덕 맥이접하는부위에서가장많이발생하는것으로보고되고있다. 6)11)14)15) 후하소뇌동맥동맥류는천막상부에서발생하는동맥류에비해깊은위치에있고뇌간이나뇌신경과의인접하고있어서수술적접근이어려운경우가있다. 이렇게수술적치료가힘든경우또는전신상태가좋지않아마취가힘든경우, 고령인경우에혈관내치료가추천되었었다. 4)9) 그러나최근에는혈관내치료에있어혈관내치료의재료나기술의발달로적응증이넓어지고있는추세이다. 이전에발표된연구들은연구대상이적었던것에비해이번연구는 1989년부터 2007년까지후하소뇌동맥동맥류에대해치료받은 41명을대상으로임상적그리고방사선학적분석을통해수술적치료와혈관내치료에대한수술후결과를분석하는데의의가있겠다. 대상및방법 1989년 5월부터 2007년 12월까지본원에내원하여뇌동맥류로치료받은 3774명의환자중에후하소뇌동맥동맥류에대해수술적치료또는혈관내치료를시행했던 41명을연구대상으로하였다. 의무기록과전산화단층촬영또는뇌혈관촬영등의방사선학적영상을바탕으로연령및성별분포, 내원시헌트-헤스분류 (Hunt and Hess classification), 동맥류의위치, 모양과크기, 수술방법및치료후퇴원시글라스고우결과등급 (Glasgow Outcome Scale : GOS) 의변수등을후향적연구방법으로분석하였다. 수술적치료는 1989년 부터시행하였고혈관내치료는 1995년부터시행하였다. 통계학적분석은피셔의정확한검정 (Fisher s exact test) 과피어슨카이제곱 (Chi-square test) 을이용하여 (P 값이 0.05보다작을경우통계학적으로의의가있는것으로간주 ) 수술적치료를받은환자집단과혈관내치료를받은집단간에차이가있는지에대한분석과수술적치료를받은환자집단과혈관내치료를받은집단간에임상적치료결과를분석하였다. 또한연령, 성별, 헌트-헤스분류그리고뇌동맥류의크기가글라스고우결과에통계학적으로영향을미치는지분석하였다. 결과 1. 치료환자군의분석 1989년 5월부터 2007년 12월까지 3774명의뇌동맥류환자가치료를받았으며, 이환자들중후하소뇌동맥동맥류로수술적치료또는혈관내치료를시행받은환자는 41(1%) 명이였다. 41명환자의연령분포는 26세부터 80세까지였으며평균연령은 55.5세였다. 성별은남자 13(32%), 여자 28(68%) 로여자에서주로많이발생하였다. 입원당시헌트- 헤스분류는 0~3등급은 29(71%) 명, 4~5등급이 12(29%) 명이였다.(Table 1,2) 방사선학적분석을했을때후하소뇌동맥동맥류의발생부위는오른쪽이 16명 (39%) 왼쪽이 25명 (61%) 으로오른쪽에더많이분포하였으며척추동맥과후하소뇌동맥연접부위 (junction of vertebral artery and posterior inferior Table 1. Characteristics of the patients with PICA aneurysms treated by embolization. Case Age Sex Presentation H-H Fisher Size GOS at grade grade Site Shape (mm) Operation discharge 1 39 F Dizziness/HA 2 3 Lt. lateral medullar segment Saccular 6 Coil embolization 5 2 80 F Drowsy/HA 3 4 Lt.VA-PICA Jx. Saccular 4 Coil embolization 5 3 80 F Drowsy/HA/N/V 3 4 Lt.VA-PICA Jx. Saccular 8 Coil embolization 5 4 52 M Stupor 4 3 Lt.VA-PICA Jx. Saccular 3 Coil embolization 1 5 52 M Drowsy/HA/N/V 3 3 Lt.VA-PICA Jx. Saccular 4 Coil embolization 2 6 62 F Incidental 0 1 Lt.VA-PICA Jx. Saccular 3 Coil embolization 5 7 62 F Drowsy,HA 3 4 Lt.VA-PICA Jx. Saccular 3 Coil embolization 4 8 27 M HA 2 4 Lt. lateral medullar segment Saccular 2.5 Coil embolization 5 9 37 M Dizziness/HA 2 4 Rt.VA-PICA Jx. Saccular 4 Coil embolization 1 10 57 F HA 0 1 Lt.VA-PICA Jx. Saccular 4 Coil embolization 5 11 75 M Deep drowsy 4 4 Rt. tosillomeullary segment Saccular 5 Glue embolization 3 12 45 F Drowsy/HA/N/V 3 4 Rt.VA-PICA Jx. Saccular 3 Coil embolization 5 13 68 F Semicoma 5 4 Lt.VA-PICA Jx. Saccular 2.5 Coil embolization 2 14 46 F Deep drowsy 4 4 Rt.VA-PICA Jx. Saccular 3.5 Coil embolization 5 15 76 F Semicoma 5 4 Lt.cortical segment(vermian branch) Fusiform 3 Coil embolization 2 16 28 F Stupor 4 4 Lt.VA-PICA Jx. Saccular 4 Coil embolization 5 GOS : Glasgow outcome scale, HA : headache, H-H : Hunt-Hess, Jx : junction, Lt : left, N : nausea, PICA : posterior inferior cerebellar artery, Rt : right, V : vomiting, VA: vertebral artery Kor J Cerebrovascular Surgery 10(2):358-363, 2008 359

후하소뇌동맥동맥류의치료결과 : 단일기관후향적분석 (1989-2007) cerebellar artery) 가 26명 (63%) 으로가장많았고외측연수부위 (lateral medullary segment) 에서 3명 (7%), 편도연수부위 (tosillomeullary segment) 에서 3명 (7%), 종말범편도부위 (telovelotonsillar segment) 에서 4명 (10%), 그리고피질부위 (cortical segment) 에서 5명 (13%) 으로분포하고있었다. 후하소뇌동맥동맥류의모양은낭형이 35명 (85%) 이고방추형은 6명 (15%) 으로낭형이많았고크기는 2.5mm부터 12mm까지분포하였다. 2. 수술적치료를한경우후하소뇌동맥동맥류로수술적치료를받은그룹은 25명이였고연령분포는 26세부터 75세까지분포하고평균 56세였다. 성별은남자 8명 (32%), 여자 25(68%) 로여자가많았다. 입원당시헌트-헤스분류는 0~3등급이 18명 (72%) 그리고 4~5등급이 6명 (18%) 이였다. 후하소뇌동맥동맥류의모양은낭형이 20명 (80%) 이고방추형 5명 (20%) 으로낭형이많았고크기는 2.5mm부터 12mm까지분포하였다. 수술방법은후하소뇌동맥동맥류의위치와방향에따라수술접근법을정중후두하개두술 (midline suboccipital craniotomy)(8명 ; 32%), 유양돌기하후두개두술 (retromastoid suboccipital craniotomy)(8명 ; 32%), 원외측박하후두-경과 (far lateral transcodylar)(8명 ; 32%), 또는두개의접근방법을혼합한방법 (1명; 4%) 을이용하였다. 수술적치료를받은 25명의환자중에는 21명 (84%) 은결찰술 (clipping) 을시행하였고 3명 (16%) 은포착 (trapping) 을시행하였다. 나머지 1명 (4%) 은결찰술이나포착술을시행못한경우인데이환자는헌트-헤스분류 3등급으로내원하였고동맥류는우측척추동맥과후하소뇌동맥연접부위 (junction of vertebral artery and posterior inferior cerebellar artery) 에 8mm 크기의동맥류가있었고수술하는동안척추동맥 (vertebral artery) 의원위부 (distal portion) 를관찰못하였고. 동맥류의앞쪽은사대 (clivus) 에뒤쪽부위는척추동맥과뇌간 (brain stem) 에붙어있어동맥류를박리하지못하여결찰술이나포착을하지못하였고 7일후재출혈로인해사 Table 2. Characteristics of the patients with PICA treated by open surgery. Case Age Sex Presentation H-H Fisher Size GOS at grade grade Site Shape (mm) Operation discharge 1 M 47 Dizziness/HA 2 4 Lt.telovelotonsillar segment Fusiform 6 Midline SOC+ clip 4 2 F 36 Deep drowsy 4 4 Lt. cortical segment(vermian branch) Saccular 4 Midline SOC+ clip 5 3 M 26 Stupor 4 3 Rt tosillomeullary segment Saccular 3 Midline SOC+ clip 5 4 F 62 Drowsy/HA 3 4 Rt.telovelotonsillar segment Saccular 5 Rt.retromastoid SOC+clip 2 5 F 36 HA 2 4 Lt.telovelotonsillar segment Saccular 6 Lt.retromastoid SOC+clip 5 6 F 57 HA/N/V 2 1 Rt.telovelotonsillar segment Fusiform 5 Lt.retromastoid SOC+clip 5 7 F 56 HA 0 1 Rt.VA-PICA Jx. Saccular 3 Rt.retromastoid SOC+clip 5 8 F 60 HA 2 4 Lt.VA-PICA Jx. Saccular 9 Lt.retromastoid SOC+clip 5 9 M 69 Stupor 4 4 Lt.cortical segment (vermian Saccular 3 and Midline SOC+ vermian br. branch & hemispheric branch) & Saccular 3 An.:trapping & hemispheric An.:clip 3 10 F 65 HA/N 3 4 Rt.cortical segment(vermian branch) Saccular 4 Midline SOC+ trapping 5 11 F 71 HA 2 3 Lt.VA-PICA Jx. Saccular 6 Lt.retromastoid SOC+clip 5 12 F 55 Drowsy/HA/N/V 3 3 Rt.VA-PICA Jx. Saccular 8 Rt.retromastoid SOC+exploration 1 13 M 57 HA/N/V 2 4 Rt.VA-PICA Jx. Saccular 5 Rt.retromastoid SOC+clip 5 14 M 33 Semicoma 5 4 Lt.VA-PICA Jx. Saccular 5 Lt far lateral app + trapping+exicion 3 15 F 55 HA 2 3 Lt.VA-PICA Jx. Saccular 5 Midline SOC + clip 5 16 M 46 Semicoma 4 4 Lt.VA-PICA Jx. Saccular 5 Lt far lateral app + clip 1 17 F 62 HA 2 3 Lt.VA-PICA Jx. Saccular 6 Lt far lateral app + clip 4 18 M 72 Drowsy/HA 3 4 Rt.VA-PICA Jx. Fusiform 8 Rt far lateral transcodylar app + clip 2 19 F 62 HA/Neck stiffness 2 4 Rt.cortical segment(hemispheric branch) Saccular 6 Midline SOC, excision+ trap, excision 5 20 F 68 Stupor 4 4 Rt.VA-PICA Jx. Saccular 2.5 Rt far lateral approach and Rt SOC+ clip 5 21 F 54 HA 0 1 Rt tosillomeullary segment Saccular 4 Midline SOC+ clip 5 22 M 50 HA 2 3 Rt lateral medullar segment Fusiform 12 Rt far lateral transcodylar + clip 5 23 F 55 HA/V 2 4 Lt.VA-PICA Jx. Saccular 5 Lt paramedian SOC + clip 5 24 F 61 HA 0 1 Lt.VA-PICA Jx. Fusiform 4 Lt far lateral app + clip 5 25 F 75 HA/N/V 3 4 Lt.VA-PICA Jx. Saccular 2 Lt far lateral app + clip 3 App : approach, Clip : clipping, GOS : Glasgow outcome scale, HA : headache, H-H : Hunt-Hess, Jx : junction, Lt : left, N : nausea, PICA: posterior inferior cerebellar artery, Rt : right, SOC : suboccipital craniotomy, V : vomiting, VA : vertebral artery 360 Kor J Cerebrovascular Surgery 10(2):358-363, 2008

여석곤 권도훈 안재성 진성철 김현정 권병덕 망한경우였다. 글라스고우결과등급은 4~5등급이 18명 (72%), 그리고 1~3등급이 7명 (28%) 이였다. 수술적치료후에사망한또다른한명은입원당시헌트-헤스분류 4등급으로좋지않았고수술후경막외출혈이발생하였고이를제거하는수술을시행하였으나뇌압상승으로사망한경우이다. 3. 혈관내치료를한경우후하소뇌동맥동맥류로혈관내치료를받은환자는 16명이였고연령분포는 27세부터 80세까지있었고평균 55세였다. 성별은남자 5(31%), 여자 11(69%) 로여자에서주로많이발생하였다. 입원당시헌트-헤스분류는 0~3등급이 10명 (63%) 그리고 4~5등급이 6명 (37%) 으로분포하였다. 후하소뇌동맥동맥류의모양은낭형이 15명 (94%) 이고방추형 1명 (6%) 으로낭형이많았고크기는 2.5mm부터 8mm까지분포하였다. 색전술에서방추형동맥류를갖고있었던 1명의환자는아교 (Glue) 를이용하여색전술을시행하였고나머지 15명은지디시 (GDC; Guglielmi Detachable Coil) 를이용하여치료를하였다. 색전술을시행받은환자중에사망한환자는 2명이였다. 이중 1명은색전술을시행한후색전술로인해합병증이발생한경우로우측척추동맥과후하소뇌동맥연접부위 (junction of vertebral artery and posterior inferior cerebellar artery) 에 4mm 크기의동맥류파열로인해헌트-헤스분류 2등급으로내원하였고색전술을시행한당일오른쪽후대뇌동맥 (posterior cerebral artery) 에뇌경색이발생하였고이에대해감압적두개절제술 (decompresive craniectomy) 을시행하였음에도불구하고환자가사망한경우이다. 또다른 1 명은색전술을시행후 7일째재출혈로인해환자가급격하게의식이저하되어사망한경우이다. 글라스고우결과등급은 4~5등급이 10명 (63%) 이고 1~3등급이 6명 (37%) 이였다. 4. 치료결과분석첫째, 후하소뇌동맥동맥류에대해수술적치료를받은집단과혈관내치료를한집단간에나이, 입원당시헌트-헤스분류그리고글라스고우결과등급에차이가있는지를분석하였으나각각 p값이 0.99, 0.49, 0.49로통계학적으로의의가없어두집단간의집단자체의차이와치료결과의차이가없는것으로나타났으나수술적치료를받은집단의성적이통계학적의의가없었으나좀더좋게나왔다. 이는혈관내치료를받은집단이수술적치료를받은집단보다입원당시헌트-헤스분류가좋지않았고그로인해글라스고우결과등급 이좋지않았을것으로생각이된다. 둘째, 입원당시헌트-헤스분류가 0~3인집단에서수술적치료를받은집단과혈관내치료를한집단간에글라스고우결과등급에차이가있는지를분석한 p값은 1.00으로차이가없는것으로나타났고입원당시헌트-헤스분류가 4~5 집단에서수술적치료를받은집단과혈관내치료를한집단간에글라스고우결과등급에차이가있는지를분석한 p값은 0.57 로통계학적으로차이가없는것으로나타났으나헌트-헤스분류가나쁜경우 (4, 5등급 ) 는수술적치료를한집단에서혈관내치료를한집단보다치료성적이좀더좋게분석되었다. 이는출혈량이많은경우수술적치료로출혈을제거해줘서좀더좋은결과가나타났다고판단된다. 셋째, 후하소뇌동맥동맥류에대해치료를받은 41명을대상으로나이 (60세이상을고연령으로간주하고 60세이하를저연령으로간주 ), 동맥류의크기 (5mm이상인집단과 5mm 이하집단으로분류 ), 입원당시헌트-헤스분류 (0~3등급을환자상태가좋은집단으로간주하고 4, 5등급을환자상태가좋지않은집단으로간주 ) 그리고피셔단계 (Fisher grade) 가글라스고우결과등급 (4~5등급을치료성적이좋은집단으로분류 ) 에영향을미치는지에대해분석하였는데각각 p값이 0.53, 0.88, 0.06, 0.48로통계학적으로의의가있지는않았으나대체적으로고연령, 입원당시헌트-헤스분류상환자상태가좋은않은경우 (4~5등급) 그리고피셔단계가좋지않은경우 (4등급) 는대체적으로치료결과 ( 글라스고우등급 ) 가좋지않은것으로분석되었다. 특히통계학적의의는없었으나헌트-헤스분류가치료성적과밀접한상관관계를나타냈다. 고찰 후하소뇌동맥은뇌간과소뇌에혈류를공급하며매우복잡하고회전이나뒤틀림이많은주행경로를갖고있다. 20)24) 발생학단계에서기저혈관과척추혈관은뇌간주위에서얼기모양을하고있다가형성되기때문에해부학적으로많은변이를갖게된다. 17) 이러한발달형태는후하소뇌동맥의직선부위가위약한부위로작용하여뇌동맥류를형성하는데중요한선천적요인으로작용하는것으로알려지고있다. 12) 또한이러한발달형태는천막상부에있는동맥류보다후하소뇌동맥동맥류가다른동정맥기형이나다른곳에동맥류를같이동반되는경우가많은것을설명한다. 19) 이런동반된병변을발견하기위하여후하소뇌동맥동맥류를가진환자에있어서는고식적뇌혈관촬영을통한양측척추동맥혈관촬영을촬영하는것을추천하고있다. 3) 이번연구에서후하소뇌동맥동맥류에대해색전술을시행받은방추형동맥류를갖고있었던한명의환자는초기에고 Kor J Cerebrovascular Surgery 10(2):358-363, 2008 361

후하소뇌동맥동맥류의치료결과 : 단일기관후향적분석 (1989-2007) 식적뇌혈관촬영술을시행하였음에도불구하고동맥류가발견되지않다가두번째고식적뇌혈관촬영술을시행하였을때발견되었는데이는초기에충분한검사를시행하였다고할지라도혈관연축, 동맥류의목부위에위치한혈전등이원인이초기에동맥류가발견되지않았을것으로생각된다. 3)22) 후하소뇌동맥은근위부에서원위부까지연수와소뇌와의관계를바탕으로 5개분절인앞쪽연수부위, 외측연수부위, 편도연수부위, 종말범편도부위, 그리고피질부위로이루진다. 14) 후하소뇌동맥에서발생하는동맥류는전체뇌동맥류의 0.5~3% 을차지할정도로드물며여자에서더많이발생하고 80% 이상이척추동맥과후하소뇌동맥인접부위에서발생하는것으로보고되고있다. 6)11)13)14) 이번연구에서도전체뇌동맥류환자중후하소뇌동맥이 1% 로드물게발생하였고여자가 68.2% 그리고남자가 31.7% 로여자에서더많이발생하는것으로조사되었고척추동맥과후하소뇌동맥인접부위에서발생하는것이 63.4% 로다른원위부보다발생률이높았다. 후하소뇌동맥동맥류는좌측척추동맥이더잘발달되어있어서그로인한혈역학적스트레스가우측보다좌측척추동맥에더많이작용하기때문에우측보다좌측에서더많이발생하는것으로보고되고있는데이번연구에서도후하소뇌동맥의동맥류의분포가우측에서 39%(16명 ) 그리고좌측에서 61%(25명 ) 으로좌측에서더많이발생하는것으로나타났다. 8) 원위부후하소뇌동맥동맥류가가장많이발생하는곳은종말폄편도분절도알려져있으나이번연구에서는종말범편도부위 (telovelotonsillar segment) 에서 4명 (10%), 그리고피질부위 (cortical segment) 에서 5명 (12%) 으로피질부위가약간많았다. 2)12) 후하소뇌동맥동맥류에대해최초의수술적치료는 1932년 Olivecrona에의해시행되었고이후많은수술방법들이개발되어사용되었다. 수술방법은주로후하소뇌동맥의이행부나근위부에위치한경우에는외측 (lateral), 원외측방하후두-경과 (far-latreal suboccipital-transcondylar) 접근법을함께사용되고있으며, 원위부에위치한경우에는정중후두하 (midline suboccipital) 접근법을사용하게된다. 후하소뇌동맥의근위부, 특히척추동맥에서후하소뇌동맥이분지하는곳에위치한동맥류의수술은깊은위치와좁은수술시야그리고뇌간으로의공급혈관과뇌신경등이주위에위치하고있기때문에수술이용의하지않다. 18)22) 이번연구에서동맥류의위치를비교해봤을때수술적치료를한경우는원위부가 44% 였고혈관내치료를한경우는원위부에서발생한동맥류가 25% 로조사되었다. 이는동맥류가후하소뇌동맥에서원위부에발생할경우는수술적접근이용의하여수술적치료를고려하였고동맥류가근위부에발생 하였을경우는수술적접근이용의하지않은경우를고려하여혈관내치료를고려한것일것으로생각된다. 최근에는뇌동맥류에대해혈관내치료의기술의발전함에따라혈관내치료를하는경우가많아지고있는데특히, 수술적치료가쉽지않거나환자전신상태가좋지않을때에는혈관내치료가추천되기도한다. 또한후하소뇌동맥동맥류에도혈관내치료를많이시도하고있다. 그러나뇌동맥류결찰술이나혈관내치료후에잔류뇌동맥류가남거나뇌동맥류가재발할수있는데뇌동맥류결찰술후잔류동맥류가발생할확률은 2.3~14% 이며혈관내색전술후잔류동맥류가발생할확률은 24.8~44% 로보고있다. 5)16)23) 이러한잔류뇌동맥류나재발한뇌동맥류는인접구조물을압박하여증상을나타내거나출혈을일으킬수있는데출혈할확률은 1.9%/ 년로보고되는것을고려할때젊은연령이고수술이용이한경우는수술적치료를고려해야할것같다. 1)7) 이번연구에서보면색전술을시행한환자중에한명이재출혈로사망한경우가있었는데이는잔류동맥류에의한재출혈이원인으로추정된다. 수술치료결과에영향을미치는인자로는내원당시신경한적상태 ( 헌트-헤스분류 ), 연령, 동맥류의위치, 동맥류의크기가영향을미치는것으로보고되고있다. 10)21) 이번연구에서는이들인자들이예후에통계학적으로유의하지는않았으나고연령, 입원당시헌트-헤스분류상환자상태가좋지않은경우그리고입원당시초기방사선학적소견에서출혈이심한경우환자의예후가대체적으로좋지않은것으로분석되었다. 결론 후하소뇌동맥동맥류는다른곳에위치한동맥류보다비교적적은크기에서도잘지주막하출혈을일으키는것으로생각된다. 따라서후하소뇌동맥동맥류는크기가작더라도적극적인치료가필요할것으로생각된다. 후하소뇌동맥동맥류의치료방법에는수술적치료와혈관내치료가있고이들치료방법간에는치료성적이비슷한것으로분석되었다. 그러나수술적치료와혈관내치료에서어떠한치료방법을선택할지는환자의연령, 동맥류의위치와모양, 출혈량의정도, 환자의상태등을고려해야할것이다. 후하소뇌동맥동맥류에있어서치료성적의예후인자로는통계학적으로유의하지는않았으나연령, 입원당시환자의식상태, 입원당시출혈의정도가환자의치료예후인자로생각해볼수있겠고특히입원당시환자의의식상태가예후를결정하는가장중요한인자로생각된다. 중심단어 : 후하소뇌동맥 치료결과 색전술 수술 362 Kor J Cerebrovascular Surgery 10(2):358-363, 2008

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