online ML Comm 0CLINICAL ARTICLE0 J Kor Neurotraumatol Soc 2007;3:34-38 ISSN 1738-8708 순수한대뇌반구간및천막의경막하혈종과궁륭부경막하혈종의임상적비교 순천향대학교의과대학천안병원신경외과학교실 1, 순천향대학교의과대학순천향대학교병원신경외과학교실 2, 순천향대학교의과대학구미병원신경외과학교실 3 장웅재 1 박형기 2 윤석만 1 이경석 1 최원림 3 도재원 1 Clinical Comarison of the Pure and Tentorial Subdural Hemorrhage with Subdural Hemorrhage Ung-Jae Jang, MD 1, Hyung-Ki Park, MD 2, Seok-Mann Yoon, MD 1, Kyeong-Seok Lee, MD 1, Weon-Rim Choi, MD 3 and Jae-Won Doh, MD 1 1 Deartment of Neurosurgery, College of Medicine, Soonchunhyang University, Cheonan Hosital, Cheonan, Korea 2 Deartment of Neurosurgery, College of Medicine, Soonchunhyang University, Hosital, Seoul, Korea 3 Deartment of Neurosurgery, College of Medicine, Soonchunhyang University, Kumi Hosital, Gumi, Korea Objective: Acute subdural hematoma is one of the worst ost-traumatic mass lesion. It usually occurs at the cerebral convexity. The ure interhemisheric subdural hemorrhage and tentorial subdural hemorrhage (ITSDH) are relatively unusual atterns of subdural hemorrhage. The objective of this study is to evaluate and comare ITSDH with convexity subdural hemorrhage (CSDH). Methods: A retrosective review was done on 21 atients with ITSDH and 26 atients with CSDH among 890 head injured atients from January 2004 to August 2006. Clinical and radiological factors were analyzed statisitically between two grous. Results: The incidence of ITSDH and CSDH was 2.3% and 2.9%, resectively. All atients of ITSDH had mild neurological sign [glasgow coma score (GCS)>13], but in CSDH there were only 14 atients (55%). Eleven atients of CSDH (43%) underwent oeration (<0.001) and overall mortality was 27%, no atients required oeration in ITSDH and all had good recovery (100%). In radiologic findings, skull fractures in CSDH were more frequently observed than in ITSDH, estimated roortions are 31%, 8% in orderly. Also, there was significant relationshi between rimary imact site and location of ITSDH and CSDH. Cou injury is observed more redominantly in CSDH (69%) but only 6 atients (29%) hold cou injury in ITSDH (=0.01). Conclusion: It is suggested that the ITSDH may be occurred by contre cou injury and shows better outcome than CSDH. (J Kor Neurotraumatol Soc 2007;3:34-38) KEY WORDS: Tentorial Subdural hematoma. 서 론 급성경막하혈종은두개강내혈종중에서도발생빈도및사망률이높으며생존을하더라도후유장애를많이남기는예후가나쁜것으로알려져있다. 1,6) 이런급성경막 Address for corresondence: Hyung-Ki Park, MD Deartment of Neurosurgery, College of Medicine, Soonchunhyang University, 657 Hannam-dong, Yongsan-gu, Seoul 140-743, Korea Tel: +82-2-709-9268, Fax: +82-2-792-5976 E-mail: hk007@hos.sch.ac.kr 하혈종은대부분대뇌반구의궁륭부 (convexity) 에발생하며적극적인치료가필요하다. 그러나최근에두부전산화단층촬영 (comuted tomograhy: CT) 의발달로궁륭부이외에다른뇌심부에발생한경막하혈종의진단이증가하고있으나지금까지순수한대뇌반구간및천막의경막하혈종 ( 반구간천막혈종 ) 에대한연구는미흡한것으로조사되었다. 본연구는본원에서진단된반구간천막혈종과지금까지그경과및치료가잘알려진순수한궁륭부의경막하혈 34 c 2007 Journal of Korean Neurotraumatology Society
Ung-Jae Jang, et al 종 ( 궁륭부혈종 ) 에대한임상적및영상의학적요인들을비교분석하여반구간천막혈종의임상및방사선학적특징을분석하고결과를문헌고찰과함께보고하고자한다. 대상및방법 2004년 1월부터 2006년 8월까지 2년 8개월동안본원신경외과에서입원하여치료를받았던두부외상환자 890명중내원당시시행한두부 CT 결과순수하게대뇌반구간이나천막부위에서만급성경막하혈종이발견되었던 21명과궁륭부에국한된급성경막하혈종을가진 26명의두환자군을대상으로하였다. 대상환자의임상소견으로외상의원인, 내원당시의식상태 (glasgow coma score: GCS), 동반손상여부, 수술여부, 퇴원할때환자의상태 (glasgow outcome score: GOS) 와방사선소견으로두개골골절여부, 출혈정도, 출혈의진행여부및손상기전 ( 충 / 반충손상 ) 를분석하였다. 진단은모두 CT에근거하였다. 두부를안와외이도선을중심으로 5 mm 두께로 26~28 개의단편을얻은사진에서뇌실질내동반손상없이대뇌반구간과천막부위를따라고음영소견을보인환자군과궁륭부에국한된고음영를소견을보인환자군을대상으로하였으며두개의병변이동시에있는경우는제외하였다. 혈종이명확하지않은경우는관상면 (coronal section) 촬영을이용하거나외상후 2일째추적 CT 촬영을하여병변의진행여부를확인하여진단을내렸다. 대뇌반구간의경막하혈종은지주막하출혈과구별이어려운경우가있는데, 전방대뇌반구간열에지그재그형상으로머리덮개뼈 (calvarium) 에서뇌량 (corus callosum) 의부리 (rostrum) 또는무릎 (genu) 까지연결되어나타나는고음영은지주막하출혈로간주하고 25) 제외하였다. 출혈정도는두정부골두께의정도와비교하여판단하였으며손상기전의분류는진찰소견, 두개골골절의위치그리고 CT상에서의연부조직종창의위치를파악하여 FIGIURE 1. CT scan showing ure tentorial subdural hematoma by contre cou injury. A: Soft tissue swelling is seen right temoral area. B: High density lesions are seen in left tentorial area. A B FIGIURE 2. CT scan showing ure acute arietal subdural hematoma by cou injury. A: Focal soft tissue swelling is seen on right frontal area. B: In above level, there are high density lesions on right arietal area. A B www.neurotrauma.or.kr 35
Pure and Tentorial Subdural Hemorrhage 충손상 (cou injury) 과반충손상 (contre cou injury) 으로분류하였다 (Figure 1, 2). 통계적유의성은 T 검사와 χ 2 검사를이용하여두군의차이를분석하였으며 가 0.05 보다작은경우를유의한것으로판단하였다. 한발병률를보였다 (Table 1). 성별과연령은반구간천막혈종이남자가 13명, 여자가 8명, 평균연령은 48.7 세였고, 궁륭부혈종은남자가 16 명, 여자가 10명, 평균연령은 58.8 세로두군에서통계적차이는없었다 (Table 1). 결 과 발생빈도전체두부외상환자 890명가운데반구간천막혈종환자는 21명 (2.3%), 궁륭부혈종은 26명 (2.9%) 으로비슷 TABLE 1. Demograhic data Location of SDH Number of cases 21/890 (2.3%) 26/890 (2.9%) Male:Female 13:8 16:10 1.00 Age (mean±sd, year) 48.8±11.0 58.8±7.8 0.07 SDH: subdural hematoma TABLE 2. Summary of clinical characteristics Number of atients with SDH (%) Etiology TA Direct trauma Sli down Rolling down Fall down Bicycle TA Association injury Orbit Fx Rib/Fx Extremity fx None GCS at admission GCS 14 GCS6-13 GCS 5 06 (029) 05 (024) 04 (019) 03 (014) 03 (014) 14 (067) Trearment Oeration Observation 21 (100) GOS GR MD SD VS Dead 10 (38) 02 (09) 19 (73) 21 (100) 14 (55) 08 (30) 11 (43) 15 (57) 21 (100) 10 (38) 07 (27) SDH: subdural hematoma, TA: traffic accident, Fx: fracture, GCS: glasgow coma scale, GOS: glasgow outcome scale, GR: good recovery, MD: mod-erate disability, SD: severe disability, VS: vegitative state 1.0 임상소견내원당시의의식상태는반구간천막혈종인경우모든환자에서 GCS 14점이상으로대부분임상경과가경미한것에비해궁륭부혈종인경우 GCS 6~3점이 8명 (30%), 5점이하가 4명 (15%) 으로중증의비율이높은양상을보였다 (Table 2). 외상의원인으로는반구간천막혈종에서는교통사고가 29% 로가장많았으며, 궁륭부혈종인경우는넘어진경우가 38% 였으며동반손상의경우두군에서각각 33% 와 27% 로통계적차이는없었다 (Table 2). 치료는반구간천막혈종에서모두보존적인치료가이루어진반면궁륭부혈종인경우 57% (11 명 ) 에서수술적치료가필요하였으며이는유의한차이를보였다 (Table 2). 치료결과는반구천막혈종에서는퇴원할때는신경학적결손없이모두건강한상태로회복되었고궁륭부혈종인경우 38% (10 명 ) 에서만양호하였으며 27% (7명 ) 에서는사망하여중한예후를보여두군간에큰차이를보였다 (Table 2). 방사선학적소견과충격부위와경막하혈종의관계두개골골절유무는반구간천막혈종인경우 8% (2명) 에서각각측두골과후두골골절이있었으며궁륭부혈종인경우 31% (8 명 ) 에서동반되었으나통계적유의성은없 TABLE 3. Summary of radiologic findings Skull fx Temoral Occiital None Amount of hemorrhage <Bone thickness >Bone thickness Number of atients (%) 19 (092) 17 (081) 04 (019) Progression of hemorrhage Yes No 21 (100) Injury mechanism Cou Contre cou 06 (029) 15 (071) 07 (27) 18 (69) 16 (62) 10 (38) 09 (35) 17 (65) 18 (69) 08 (31) 0.10 0.20 0.01 36 J Kor Neurotraumatol Soc 2007;3:34-38
Ung-Jae Jang, et al 었다 (=0.10). 경막하혈종의진행여부는반구천막혈종인경우모두변화가없었던반면궁륭부혈종인경우 65% (17 명 ) 에서혈종의크기가커지는진행소견을보여궁륭부혈종에서혈종의진행가능성이높은것으로조사되었다. 진찰소견과방사선학적소견을바탕으로충격부위와경막하출혈의위치사이의연관성을분석하였는데, 반구간천막혈종인경우충손상이 6예 (29%), 반충손상이 15 예 (71%) 로반충손상이높은반면, 궁륭부혈종인경우각각 18 예 (69%) 와 8예 (31%) 로충손상이많은것으로조사되었으며이는통계적으로유의하였다 (=0.01)(Table 3). 고찰 두부외상에의한두개강내출혈중뇌경막하혈종은가장흔한두개강내병변으로다양한발생기전이혼합되어상천막두개부에흔하게발생하며대뇌겸부위나천막부위의경막하강또는뇌실질에복합적으로출혈을동반하는경우가대부분으로예후는불량한것으로잘알려져있다. 1,5,6,23) 본교실에서는이런다양한발생기전과다양한부위의출혈양상중연구가미흡한대뇌반구간및천막에국한된경막하혈종에대하여궁륭부에국한된경막하혈종과비교분석하여임상양상및발생기전을알아보고자이연구를계획하였다. 급성뇌경막하혈종은복합손상이대부분으로순수한대뇌겸부위나천막부위의경막하강또는궁륭부위에국한된출혈은드물며정상대뇌겸, 경막의석회화, 지주막하출혈, 소아, 미만성뇌부종등과감별을해야하는것으로보고되어있으며, 4,8,10,11,21,24) 저자들의경우두부외상환자에서반구간천막혈종은 2.3%, 궁륭부혈종은 2.9% 로드문발생률로조사되었다. 궁륭부혈종의발생기전은뇌피질동맥손상, 접촉력 (contact force) 에의한뇌실질의좌상이나열상, 뇌표면에서상시상정맥동으로가는교정맥의파열에의해생성되는것으로대부분상기세가지발생기전이혼합되어발생되는것으로보고되어있으며, 8,12,22,23) 반구간천막혈종은궁륭부혈종과는달리전두부혹은후두부의외상에의한뒤틀림장력 (tension force) 이중요한발생기전이며 2,13-15,19) Fruin 등 7) 에의하면시상면에서후두부혈류가대뇌겸부위의출혈을유발하는데대뇌피질에서중앙부정맥동으로앞쪽 -중앙으로주행하는동맥의해부학적구조가주요출혈발생부위로보고하였으나힘의방향량 (vector of force) 및출혈구조물은논쟁의여지가많다. 본연구에서는두개골골절을동반되는경우가궁륭부혈종 에서 31% 였으며반구간천막혈종의 8% 에비해현저히높았으며두개골골절을유발하는접촉력 (contact force) 이궁륭부혈종에서더높게나타남을알수있었으며, 9) 순수한반구간천막혈종의 71% 와순수한궁륭부혈종의 31% 에서손상기전으로반충손상을경험하였는데천막부위의경막이해부학적위치상일차충격부위보다는다른충격에의한관성력에따른음압 (negative ressure) 에취약한것으로추측되어접촉력보다는반충손상에의한음압이대뇌반구간및천막에국한된출혈을유발하는것으로생각된다. 또한천막주위구조물에충격이가해질때구조상두개골의영향이적어충손상 (cou injury) 보다는반충손상이더잘발생하는것으로미루어추측할수있다. 치료는신경학적증상이심하고전산화단층촬영상혈종양이많거나증가되는양상일때수술적치료를고려 3,20) 해야하나반구간천막혈종은임상적으로나방사선학적진행없이모든예에서보존적치료를하였으며순수한궁륭부혈종환자의 43% 는수술적치료를하였다. 또한반충손상에의한혈종이진행및임상경과가악화되는경우가충손상에비해적었으며상대적으로좋은예후를경험할수있었다. 이는충손상에비해반충손상인경우에손상정도가경하여예후가좋은것으로추측되나두부외상에있어충손상과반충손상의분류에따른혈종의진행및임상경과는좀더광범위하게연구할필요가있다. 두부외상에의한급성경막하혈종은치사율 50% 이상으로예후가불량하며, 6,22) 1940년 Aring과 Evans가보고한이래특징적인증상으로 Falx syndrome 인반대측의하지마비나하지가상지보다약한대측의상하지부전마비가나타나며두통, 구토, 전간증상이발생할수있는것으로알려져있으나, 16,17) 저자들의환자군에서이러한 Falx syndrome 에해당하는증상은없었고순수한반구천막혈종의경우한예에서 GCS 14점인경우를제외하고모두 GCS 15점으로동반신경손상은없었다. 또한관찰기간동안양호한의식상태를보였으며모두보존적치료로정상퇴원이가능하였다. 이에비해순수한궁륭부혈종은 27% 의치사율로반구천막혈종보다는상대적으로높았으나문헌보고에의한경막하혈종의치사율보다는현저히적었다. 9,18,22) 이는높은치사율을보이는일반적인경막하혈종은다발성으로두개강내출혈병변을동반하기때문이며특히반구천막혈종의예후는병변자체보다는두개강내동반된다른병변이예후를결정한다고볼수있을것으로생각된다. www.neurotrauma.or.kr 37
Pure and Tentorial Subdural Hemorrhage 결 론 순수하게대뇌반구간또는천막에발생한경막하혈종은궁륭부경막하혈종에비해양호한경과를보이며반충손상에의해발생되는것으로생각된다. 중심단어 : 반구간 천막 궁륭부 경막하혈종. REFERENCES 1) Aring CD, Evans JP. Aberrant location of subdural hematoma. Arch Eeurol Psychiatry 44:1296-1306, 1940 2) Bartels RH, Verhagen WI, Prick MJ, Dalman JE. subdural hematoma in adults: case reorts and a review of the literature. Neurosurgery 36:1210-1214, 1995 3) Brill CB, Jarath V, Black P. Occiital interhemisheric acute subdural hematoma treated by lambdoid suture ta. Neurosurgery 16:247-251, 1985 4) Cronin TG, Shiey DU. Bilateral interhemisheric subdural hematoma: a case reort. Am J Neuroradiol 8:909-910, 1987 5) Fearnside MR, Hall K, Senguta RP. subdural haematoma following head injury. Aust N Z J Surg 49: 678-680, 1979 6) Foulkes M, Eisenberg HM, Jane JA. The traumatic coma data bank: design, methods, and baseline characteristics. J Neurosurg 75(Sul): S8-S13, 1991 7) Fruin AH, Juhl GL, Taylon C. subdural hematoma. A case reort. J Neurosurg 60:1300-1302, 1984 8) Gartman JJ, Atstuenas EA, Vollmer DG, Powers SK. Traumatic laceration of ericallosal artery resulting in interhemisheric subdural hematoma: a case reort. J Emerg Med 7: 603-610, 1989 9) Gennarelli TA, Thibault LE. Biomechnics of acute subdural haematoma. J Trauma 22:680-686, 1982 10) Houtteville JP, Toumi K, Theron J, Derlon JM, Benazza A, Hubert P. subdural haematomas: seven cases and review of literature. Br J Neurosurg 2:357-367, 1988 11) Ishikawa E, Sugimoto K, Yanaka K, Ayuzawa S, Iguchi M, Moritake T, et al. subdural hematoma caused by a rutured internal carotid artery aneurysm: case reort. Surg Neurol 54:82-86, 2000 12) Jamieson K, Yelland J. Surgically treated traumatic subdural hematomas. J Neurosurg 37:137-149, 1972 13) Kasdon DL, Magruder MR, Stevens EA, Paullus WS. Bilateral interhemisheric subdural hematomas. Neurosurgery 5:57-59, 1979 14) Kim YS, Lim HY, Nah JH, Doh JO, Chang KS. Traumatic tentorial hemorrhage. J Korean Neurosurg Soc 15:439-444, 1986 15) Koyama S, Nishimura T. A case of bilateral interhemisheric subdural hematoma. No Shinkei Geka 18:289-294, 1990 16) List CF. Diagnosis and treatment of acute subdural emyema. Neurology 5:663-665, 1955 17) Ogsbury JS, Schneck SA, Lehman RA. Asects of interhemisheric subdural haematoma, including the falx syndrome. J Neurol Neurosurg Psychiatry 41:72-75, 1978 18) Raana A, Lamaida E, Pizza V, Leore P, Cauti F. fissure, a rare location for a traumatic subdural hematoma, case reort and review of the literature. Clin Neurol Neurosurg 99:124-129, 1997 19) Sadrolhefazi A, Bloomfield SM. and bilateral chronic subdural hematoma. Neurosurg Clin N Am 11: 455-463, 2000 20) Sibayan RQ, Gurdjian ES, Thomas LM. Interhemiheric chronic subdural hematoma. Reort of a case. Neurology 20:1215-1218, 1970 21) Taveras JM, Morello F. Normal neuroradiology and Atlas of the skull and facial Bones. Chicago, Year book Medical, 1-37, 1979 22) Wilberger JE, Harris M, Diamond DL. Acute subdural hematoma: mortality, morbidity and oerative timing. J Neurosurg 74:212-218, 1991 23) Yoo JS, Hu C, Hong SK, Kim HJ, Han YP. Clinical analysis of interhemisheric subdural hemorrhage and tentorial hemorrhage. J Korean Neurosurg Soc 20:13-19, 1991 24) Zimmerman RD, Russel EJ, Yurberg E, Leeds NE. Falx and interhemisheric fissure on axial CT. Part II: interhemisheric subdural collections and alterations in falx aearance. In roceedings of the Annual Meeting of the American Society of Neuroradiology, Los Angels, 1980 25) Zimmerman RD, Russel EJ, Yurberg E, Leeds NE. Falx and interhemisheric fissure on axial CT: recognition and differentiation of interhemisheric subarachnoid and subdural hemorrhage. AJNR 3:635-642, 1982 38 J Kor Neurotraumatol Soc 2007;3:34-38