대한신경집중치료학회 2015 추계학술대회 황교준방재승김택균한정호김영훈김재용권오기오창완한문구배희준김범준 Indication and Technique of Surgical Management for Increased Intracranial Pressure 분당서울대학교병원신경외과, 신경과 광역심뇌혈관질환센터 IICP 를유발하는질환 Trauma Tumor Intracerebral hemorrhage Subarachnoid hemorrhage Hydrocephalus Infarction Abscess 1
수술적치료의적응증 질환이광범위하기때문에각질환의특성을고려해야한다. Space occupying lesion 질환의진행속도 환자의상태 이후예상되는질환의경과 수술의용이성 수술로얻을수있는효과 수술적치료 - 고려사항 질환의진행속도 2
수술적치료 - 고려사항 환자의상태 수술적치료 - 고려사항 예상되는질환의경과 3
수술적치료 - 고려사항 수술의용의성 수술적치료 - 고려사항 수술의용의성 4
수술적치료 - 고려사항 수술의용의성 수술적치료 - 고려사항 수술의용의성 5
수술적치료 - 고려사항 수술로얻을수있는효과 수술방법 Drainage Evacuation Craniectomy 6
수술방법의선택 제거할 target 이무엇인가? 제거할 target 의성상이무엇인가? 얼마나빨리제거해주어야하나? Target 제거후예상되는경과는? 수술방법의선택 제거할 target 이무엇인가? 명백한 mass effect 를유발한 focal lesion: hematoma 이차적인변화로생긴 IICP: hydrocephalus 미만성병변 : malignant infarction 7
수술방법의선택 제거할 target 의성상이무엇인가? 액체 고체 뇌조직 수술방법의선택 얼마나빨리제거해주어야하나? Basal ganglia ICH를가진환자로 Herniation 이임박한환자 vs 그렇지않은환자 8
수술방법의선택 Target 제거후예상되는경과는? Focal lesion 이주된 IICP 의원인이며주변 edema 가심하지않은경우 : 대부분의 spontaneous ICH Diffuse lesion 혹은주변 edema 가심한경우 : traumatic ICH 많은경우수술중에결정된다. Catheterization and Drainage 9
대표적인예 External ventricular drainage (EVD) Spontaneous ICH drainage Chronic SDH drainage Entry point Kocher s point: frontal horn 10
Entry point Supraorbital point: frontal horn Entry point Orbital point: frontal horn Keen s point: temporal horn Occipital parietal point: occipital horn frontal horn Dandy s point: occipital horn 11
EVD 빠른강압효과. 치료와모니터링이동시에가능하다. 적응증만된다면다른방법에비해우선적으로고려할수있음. ICH catheter insertion Rigid frame Navigation system CTF Angio machine 12
ICH catheter insertion ICH catheter insertion Urokinase irrigation ICH: 3000 5000U, q4-6hrs IVH: 1500 3000U, q6 12hrs 30분정도 clamping 후natural drainage 간간히 squeezing 13
Burrhole drainage for chronic SDH Single vs two burrholes Catheter 로drainage 하는게이득 재발률 10-15% Craniotomy and Evacuation 14
대표적인예 Urgent decompression 이필요한 hematoma Traumatic ICH, EDH, SDH Spontaneous ICH Aneurysm 혹은 AVM rupture 대부분의 tumor Craniotomy site 결정 Brain surface 위에위치하는경우 Traumatic EDH, SDH Brain tumor (meningioma) 병변 margin 보다크게 Intra-axial lesion 직선 route 하지만 cortisectomy 는최소화할수있도록 일반적으로 deficit 을유발하지않거나적은 route 가경험적으로존재한다. 15
Craniotomy site 결정 Craniotomy site 결정 16
Craniotomy site 결정 Craniotomy site 결정 17
Craniotomy site 결정 Craniotomy site 결정 18
Craniotomy site 결정 Craniotomy site 결정 19
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Craniectomy 언제 bone flap 을덮지않나? 수술중결정 IICP 의원인을제거해도 diffuse swelling 이남아있는경우 IICP 의원인이 focal lesion 이아닌경우 21
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DC 후 ICP 변화 TimofeevI, et al. Effect of decompressivecraniectomyon intracranial pressure and cerebrospinal compensation following traumatic brain injury. JNS 2008 Jan 66-73 23
DC 후 ICP 변화 TimofeevI, et al. Effect of decompressivecraniectomyon intracranial pressure and cerebrospinal compensation following traumatic brain injury. JNS 2008 Jan 66-73 Traumatic brain injury Primary decompressive craniectomy 이와관련하여 Non-randomized cohort study 가있음. CRASH head injury prediction model 를이용 DC group: 0.75 (95% CI 0.51 1.07) CR group: 0.90 (95% CI 0.57 1.35) Li ML, et al. Outcome following evacuation of acute subdural hematomas: a comparison of craniotomy with decompressivecraniectomy. ActaNeurochir2012 1555-1561 24
Traumatic brain injury Secondary decompressive craniectomy DECRA trial Unfavorable outcome: DC vs control = 70% vs 51% (OR 2.21, 95% CI 1.14 4.26; p=0.02) Post-hoc analysis: adjusted OR 1.90, 95% CI 0.95 3.79 (adjusted for pupil reactivity at admission) Ongoing trial: RESCUEicp Cooper DJ, et al. Decompressivecraniectomyin diffuse traumatic brain injury. N. Engl. J. Med. 364, 1493 1502 (2011). Ischemic stroke Pooled analysis of DECIMAL, DESTINY, and HAMLET 93 patients (18 60 years) Favorable outcome (mrs 0-4): DC vs control = 75% vs 24% (ARR 51%, 95% CI 34 69%) DC group 에서 mrs 4 로생존할가능성은 10 배증가하지만 mrs 5 로생존할가능성은증가하지않았다. mrs 0 3: DC vs control = 43% vs 21% (ARR 23%, 95% CI 5 41%) 25
Ischemic stroke Meta-analysis published in 2012 Up to 96 hours after stroke 대체로결과는비슷 Poor outcome (mrs 4-6): DC vs control, OR 0.56, 95% CI 0.27 1.15 Ischemic stroke 3 year-outcomes in HAMLET trial Surgery had no effect on the risk of poor functional outcome at 3 years (absolute risk reduction, 1%; 95% confidence interval, -21 to 22), but it reduced case fatality (absolute risk reduction, 37%; 95% confidence interval, 14-60). 26
Ischemic stroke DESTINY II trial 112 older patients (ages 61 to 82 years, median 70 years) within 48 hours of stroke onset 6 개월 mrs score 0-4: DC vs control = 38% vs 18%, OR 2.9, 95% CI 1.1-7.9 Good outcome (mrs score 0-2): none Pooled analysis of patients 60 years of age: mrs 0-2 after DC vs control = 14% vs 2% Aneurysmal SAH Large case series 가 2 개정도존재함. DC 가필요한경우 7 8% 로대부분 poor grade SAH 다량의 ICH 나 delayed ischemia 로하게됨. ICH 로하게된경우가 delayed ischemia 로하게된경우보다예후는좋았음 (34.8% vs 10%; p=0.038). 27
Spontaneous ICH Surgical treatment 의필요성이명확하지않은상태. 대부분의경우 ICH evacuation 만으로도 ICP control 이가능한경우가많음. 정리 28
수술의종류 Drainage Craniotomy Craniectomy 적응증과방법의선택 국소적원인 : 제거가용이하다면수술을먼저고려 Craniotomy vs. craniectomy Infarction 처럼미만성부종이며 evidence 가있는경우 -> craniectomy 그외 : 일률적으로 bone flap 제거보다는상황에맞게선택 29