만성 경뇌막하 혈종에 대한 임상적 고찰

Abstract

[영문]

[한글]

1976년 1월부터 1983년 9월까지 연세의대 신경외과학 교실에서 치험한 만성경뇌막하혈

종 103예에 대한 임상적 고찰, 특히 각 수술방법에 대한 결과를 서로 비교하여 다음과 같

은 결과를 얻었다.

1. 연령분포는 41세부터 60세까지가 49명 (47.5%)으로 가장 많았고 40대 이상에서는 74

명 (71.8%)이었다. 남녀비는 남자가 87명(84.5%), 여자가 16명(15.5%) 이었다.

2. 유발인자에서는 두부외상력이 있는 경우는 72명(79.6%)이었고 알콜중독자는 13명(12

.6%)이었으며 지주막낭종 1예, 지주막낭종 및 뇌수종으로 낭종복강간도관술후 상태 1예

및 만성골수성백혈병 1예가 있었다.

3. 임상증세 및 신경학적 소견을 보면 두통이 82예 (77.6%)로서 가장 많았으며 마비증

상이 46예 (44.7%), 의식장애 및 안저소견상 유두부종 같은 유두부 변화가 각각 45예(43.

7%) 및 44예(42.7%)였다. 그 외 구토, 동공부동증, 경련, 언어장애 및 시각증상이 있었다

.

4. 뇌전산화단층촬영이 진단 및 수술방법의 결정과 예후판정에 중요한 역할을 하며 혈

종의 밀도를 볼 때 저밀도혈종이 32예(43.3%), 동밀도혈종 28예(37.8%), 고밀도혈종 10예

(13.5%)였고 그외 혼합밀도는 4예 (5.4%)의 혈종에서 볼 수 있었다. 수술후 3주내에 시행

한 뇌전산화단층촬영에서의 뇌팽창율은 나이가 들수록 감소하여 40대 이상에서는 80% 이

하로 감소했다.

5. 혈종의 발생부위는 좌측이 47예 (45.6%), 우측이 43예(41.8%)로서 큰 차이는 없었고

양측성은 13예 (12.6%)가 있었다. 단순폐쇄배출술시 혈종의 배출량은 수술 당일날 가장

많아 49%에 달했고 수술 다음날 33%로서 수술후 제 2일까지 전체의 95%가 배출되었다.

6. 치료방법으로 102예에서는 수술적 방법으로 치료했고 나머지 1예에서는 steroid와 L

asix를 사용하여 비수술적으로 치료했다. 수술방법으로는 32예에서는 단순폐쇄배출술을,

31예에서는 두개천공술및 개방배출술을, 1차 수술후 다시 혈종이 형성된 2예를 포함한 31

예에서는 성형적 개두술 및 혈종막 제거술을 시행했고 나머지 10예에서는 두개골 제거술

후 혈종막을 제거했다. 수술법을 서로 비교한 결과 단순페쇄배출술이 일차적인 치료법으

로 생각된다. 그러나 일차 수술후 혈종이 다시 고인 경우, 고형성 혈종인 경우 및 뇌팽창

이 잘 안되어 경막하강이 오랫동안 막히지 않는 경우에는 개두술 후 혈종막 제거술을 시

행해야 한다.

CLINICAL OBSERVATION OF THE CHRONIC SUBDURAL HEMATOMAS

Se Hyuck Park

Department of Medical Science The Graduate School Yonsei University

(Directed by Prof. Kyu Chang Lee, M.D.)

One hundred three chronic subdural hematomas were treated from January, 1976 to

September, 1983, of which 102 cases were operated and 1 case was treated with

medication. The clinical analysis and surgical results were summerized as follows.

1. The chronic subdural hematomas were the most common in the 5th and 6th decade

(47.5%) and prominent over 5th decade(71.8%). The proportion of males(84.5%) was

much greater than females (15.5%)

2. 79.6% of crises had previous head injuries and 12.6% were chronic alcholics.

One case was associated with the arachnoid cyst in the middle cranial fossa and

another one case in the postoperative state of cystoperitoneal shunt due to

hydrocephalus and arachnoid cyst in the supratentorial and infratentorial area. One

case was under management of chronic myelocytic leukemia .

3. The common symptoms were headache(79.6%), motor weakness(44.7%), alternation

of consciousness(43.7%), change of fundus such as papilledema (42.7%) and vomiting

(35.0%). In addition there were pupillary inequality, seizure, speech disturbance

and visual symptoms.

4. Brain CT scan was the most effective and noninvasive diagnostic tool for

detecting chronic subdural hematoma and important in planning operative

intervention and evaluation of prognosis. Chronic subdural hematomas presented in 4

different forms in CT scans: hypodense subdural hematoma(43.3%), isodense subdural

hematoma(37.8%), hyperdense subdural hematoma(13.5%)and mixed density subdural

hematoma(5.4%). CT scanning was the most accurate method of determining the age of

a chronic subdural hematoma. The cerebral expansion rate (reduction in diameter of

the subdural space) decreased with aging and it was less than 80% in average over

5th decade within postoperative 3 weeks.

5. The right sided chronic subdural hematomas were 45.6%and the left were 41.8%

with bilaterality in 12.6%. Average amount of chronic subdural hematomas drained

daily in 32 patients treated with simple burr-hole and closed-system drainage were

as follows: 49% on the duty of operation, 33% on POD 1 and 13% on POD 2, and almost

all of the hematoma was drained out within two days doter surgery.

6. In 103 patients, operation were performed in 102 patients, and the other one

patient was treated conservatively. thirtytwo patients were underwent simple

burr-hole and closed-system drainage and in 1 patient craniotomy and and

membranectomy was necessary. The blood bags were used in 31 patients and Hemovac in

1 patient. Four patients were operated under local anesthesia. thirtyone patients

were treated with burr holes and open drainage and one patient required craniotomy

and membranectomy. In 31 patients underwent craniotomy and membranectomy.

Craniectomy and membranectomy were performed in 10 patients. One patient died of

hypertensive intracerebral hematoma 1 developed during operation under local

anesthesia and another 1 patient was unchanged following simple burr-hole and

closed-system drainage. Three patients were unchanged or deteriorted after burr

holes and open drainage and 8 patients following craniotomy and membranectomy. The

results of simple burr-hole and closed-system drainage were better than other

methods. Simple burr-hole and closed-system drainage is today's most rational

approach to the chronic subdural hematoma in children beyond the infant period and

in adults. Craniotomy, membranectomy and craniectomy should be reserved for

instances :the subdural recollection, failure of the brain to expands solid

hematoma and extensive swelling of white matter subjacent to the hematoma.