실험적 동정맥단락 유형에서의 뇌혈류와 혈관자동능의 변화

김영 대한신경외과학회 1991 Journal of Korean neurosurgical society Vol.20 No.1-3

In order to investigate a hemodynamic complication associated with the resection of a large arteriovenous malformation. we planed the following experiment. We divided the left common carotid artery and the internal jugular vein for microsurgical anastomsis between the rostra1 carotid and caudal jugular vessel ends : the 2 remaining vessel stumps were ligated. This created an arteriovenous shunt with afferent flow from the contralateral carotid and the basilar artery and retrograde down to the carotid-jugular anastomosis. And then, we occluded the shunt vessels at the each stage of the first and fourth week after anteriovenous shunt. Forty adult cats weighing from 2.2 to 3.4kg were used in this study The animals were devided into 4 groups : group l(acute occlusion -1 week after shunt. n= 10). group 2(staged occlusion -1week after shunt. n= 10). group 3(acute occlusion -4 week after shunt. n= 10). group 4(staged occlusion -4 week after shunt, n = 10) respectively. The regional cerebral blood flow(rCBF). cardiopulmonary function were measured in each animal group and also observed the response of the cerebral blood flow on induced changes of the blood pressure and the arterial bicarbonate. The arteriovenous shunt patency was evaluated by serial angiography. The results were as follows 1) Considerable increases in the mean arterial blood pressure(mABP) as well as bradycardia were observed in acute occlusion groups(group 1, 3). After induced hypercarbia, the increments of mABP in acute occlusion groups were less than staged occlusion groups considerably. 2) Significant decreases in the mean pulse rate were observed in acute occlusion groups. The mean pulse rate were the highest decrease in group 3. 3) The values of rCBF of left frontal cortex in acute occlusion groups were more greater increase than those of staged occlusion groups considerably. 4) After induced hypercarbia. considerable increases of the rCBF were demonstrated in all groups and increases of the rCBF were lowest in group 3 compared with the other groups. After induced hypocarbia, considerable reductions of the rCBF were demonstrated in all groups and reductions of the rCBF were lowest in group 3 compared with the other groups. 5) After induced hypertension. considerable increases of the CBF were demonstrated in all groups. The rCBFs were the highest increase in group3 and lowest increase in group 2 compared with the other groups. After induced hypotension, considerable reductions of the rCBF were demonstrated in all groups. The rCBFs were the highest reduction in group 3 and lowest reduction in group 2 compared with the other groups. It might be inferred from these results that patients with large arteriovenous malformations, particulary those with cerebral steal symptoms, are at risk to develop neurologic defictis related to perfusion breakthrough if their malformed vessels are abruptly removed, and staged or gradual occlusion of feeding arteries may prevent this potentially devastating complication.

뇌동정맥기형의 병태생리

한대희,이무섭 대한신경외과학회 1986 Journal of Korean neurosurgical society Vol.15 No.4

We reviewed wide varieties of literatures about pathophysiology of cerebral arteriovenous malformation. With author's experiences on cerebral arteriovenous malformation, we described about clinical presentation, mechanisms of neurologic symptoms, natural history, hemodynamics, and cerebral steal phenomenon.

뇌혈관 기형에서 감마나이프 방사선시술의 치료 효과에 대한 방사선학적 평가

김익대,김일,전영섭,이종육,이영준,차성숙,은충기,김무성,심재홍,Kim, Ig Dae,Kim, Il,Jeon, Young Seup,Lee, Jong Yuk,Lee, Young Jun,Cha, Seong Suk,Eun, Choong Ki,Kim, Mu Seong,Sim, Jae Hong 대한영상의학회 1998 대한영상의학회지 Vol.39 No.5

Purpose : To evaluate the therapeutic effect of gamma knife radiosurgery in cerebral vascular malformation using a radiologic imaging method such as MRI or angiography. Materials and Methods : We retrospectively reviewed MRIs, CT scans and angiograms of 29 cases of arteriovenous malformation and 15 of cavernous malformation before and after gamma knife radiosurgery. The patients underwent follow-up radiologic studies for between 6 and 35months after radiosurgery. No patient underwent other surgery of embolization. Radiological imaging analysis focused on changes in the volume of the nidus or central core. Other findings of edema, cystic change, hemorrhage, signal intensity, enhancement and distributional vascular markings were also studied. The volume of the AVM nidus was measured and assigned ot one of four groups : <1cc, 1-4cc,> 4-10cc and> 10cc. Results : In arteriovenous malformation cases, the volume of the nidus decreased by mean 60.2%; reduction was greatest(68.1%) in the 1-4ccgroup. Three cases showed complete loss of the nidus at 9, 12 and 25 months after radiosurgery, respectively. In nine cases, decreased caliber or loss of draining vein was noted. High signal intensity on T2-weighted MR images, suggesting either edema or demyelination, was observed in four cases. In cavernous angioma cases, core volume was reduced by 36.8%. Transient cerebral edema and presumed radiation necrosis were observed in two cases and one, respectively. Conclusion : Gamma knife surgery was effective in nearly all cases of arteriovenous malformation and some cases of cavernous malformation. More than two years follow-up involving radiologic imaging such as MRI is needed for the evaluation of therapeutic effect and diagnosis of complications.

선형가속기를 이용한 Photon Knife 방사선수술에 의한 뇌동정맥기형의 치료

김진희(Jin Hee Kim),최태진(Tae Jin Choi) 대한방사선종양학회 2003 Radiation Oncology Journal Vol.21 No.1

Purpose : The purpose of this study was to analyze the effect of a Linear accelerator based Photon Knife Radiosurgery System developed by the staff of Keimyung University Dongsan Medical Center for the treat-ment of cerebral arteriovenous malformation. Material and Methods : Between December 1993 and October 2000, 30 patients with cerebral arteriove-nous malformation (AVM) were treated with the Linac based Photon Knife Radiosurgery System in the Department of Therapeutic Radiology at Keimyung University Dongsan Medical Center. The median age was 34, ranging from 7 to 63 years, with a 2:1 male to famale ratio. The locations of the AVM nidi were the frontal lobe (motor cortex), parietal lobe, and the thalamus, in that order. The diameters of the AVM nidi ranged 1.2 to 5.5 cm with a mean of 2.9 cm, and target volumes of between 0.5 and 20.6 cc, with a mean of 6.8 cc. The majority of patients received radiation doses of between 1,500 and 2,500 cGy, with a mean of 2,000 cGy, at 80% the isodose line. Twenty-five patients were treated with one isocenter, 4 with two, and 1 with four. The follow-up radiogical evaluations were performed with cranial computed tomogram (CT) or MRI between 6 month and one year interval, and if the AVM nidus had completely disappeared in the CT or MRI, we confirmed this was a complete obliteration, with a cerebral or magnetic resonance angiogram (MRA). The median follow-up period was 39 months with a range of 10 to 103 months. Results : Twenty patients were radiologically followed up for over 20 minths, with complete obliteration ob-served in 14 (70%). According to the maximal diameter, all four of the small AVM (<2 cm) completely obliterated, 8 of the 10 patients with a medium AVM (2~3 cm) showed a complete obliteration, and two showed partial obliteration. Among the patients with a large AVM (>3 cm), only one showed complete obliteration, and 5 showed partial obliteration, but 3 of these underwent further radiosurgery 3 years later. One who followed up for 20 months following further radiosurgery eventually showed complete obliteration. Ten patients with seizure symptoms had no recurrent seizure due to radiosurgery and medication. One of the eleven patients who suffered intracranial bleeding developed further bleeding at 9 and 61 months following the radiosurgery although complete obliteration was eventually observed and the patient was managed in hospital then recovered. No patient suffered severe complications following the radiosurgery. Conclusion : The radiosurgery with Linac-based Photon Knife radio surgery system, developed by the staff at our hospital is a safe and effective treatment for AVM patients having diameters or volumes of less than 3 cm or 10 ㎤, respectively, located in inoperable areas or who refused neurosugery. We suggest that staged AVM radiosurgery may initially be considered, if the AVM target volume is above 10 ㎤ 목적 : 계명대학교 의과대학 치료방사선과학교실의 의료진들이 개발하여 사용하고 있는 방사설수술 시스템인 Photon Knife를 이용하여 뇌동정맥기형을 치료하고 그 효과를 보고자 하였다. 대상 및 방법 : 1993년 12월부터 2000년 10월까지 뇌동정맥기형으로 계명대학교 동산의료원 치료방사선과를 방문하여 Photon Knife로 방사선수술을 받은 환자는 30명이었다. 성별분포는 남자 20명, 여자 10명이며 연령분포는 7세부터 63세로 평균 34세이었다. 뇌동정맥기형(AVM nidus)의 위치는 전두부, 두정부, 시상부 순이었고 병소의 장경은 1.2 cm에서 5.5 cm으로 평균 2.9 cm이었으며 표적용적은 0.5 cc에서 20.6 cc로 평균 6.8 cc이었다. 대부분에서 회전 중심선량의 80% 등선량곡선(isodose line)에 1,500~2,500 cGy (중앙값 2,000 cGy)를 조사하였다. 1개의 회전중심점을 사용한 환자는 25명이었고 2개의 회전중심점을 사용한 환자는 4명이었으며 1명은 4개의 회전중심점을 사용하였다. 추적검사는 방사선수술 후 6개월에서 1년 간격으로 전산화단층촬영이나 자기공명영상을 시행하여 병소(nidus)의 완전소실이 관찰되면 뇌혈관조영술이나 자기공명영상 혈관조영촬영술로 확인하였다. 추적관찰기간은 10개월에서 103개월로 중앙추적기간은 39개월이었다. 결과 : 전체환자 중 영상학적으로 20개월 이상 추적 관찰된 환자는 20명이었으며 그 중 70% (14/20)에서 완전폐색을 관찰하였다. 병소의 장경이 따라 작은 뇌동정맥기형(<2 cm) 환자 4명은 모두 환전폐색이 되었고 중간크기 뇌동정맥기형(2~3 cm)은 80% (8/10)에서 완전폐색이 되었으며 2명은 부분폐색이 되었다. 큰 뇌동정맥기형(>3 cm)에서는 환자 6명 중 1명만 완전폐색을 보였고 5명에서는 부분폐색은 되었으나 3년째에도 남아 있는 환자 3명은 재 방사선수술을 하였고 이 중 20개월 이상 추적검사를 받은 1명은 재 방사선수술 후 완전폐색이 되었다. 방사선 수술 전 신경발작(seizure)을 주소로 내원한 환자 10명은 방사선수술과 약물투여로 신경발작의 재발은 없었다. 뇌출혈이 있었던 11명 중 1명에서 방사선수술 후 19개월, 61개월에 다시 출혈하였으나, 입원 치료 후 회복되었다. 방사선수술에 의한 심각한 부작용은 관찰되지 않았다. 결론 : 이상으로 볼 때 저자들에 의해 개발된 Photon Knife를 이용한 방사선수술은 뇌동정맥기형에서 수술이 불가능한 위치에 있거나 수술을 거부하는 환자 중 병소의 장경이 3 cm 이하이거나 병소의 용적이 10 ㎤ 이하인 뇌동정맥기형의 치료에 안전하고 효과적인 방법으로 사료된다. 또한 10 ㎤ 이상의 용적이 큰 뇌동정맥기형에서는 순차적(staged) 방사선수술을 처음부터 고려할 필요가 있을 것으로 사료된다.

선형가속기를 이용한 뇌동정맥기형의 뇌정위적 방사선 수술 치료결과

손병철,김문찬,강준기,서태석,윤세철 대한신경외과학회 1999 Journal of Korean neurosurgical society Vol.28 No.1

잠재성 뇌 동·정맥 기형

박향권,김성학,박동빈,신규만 대한신경외과학회 1986 Journal of Korean neurosurgical society Vol.15 No.3

Five cases presenting with hemiparesis, disturbed consciousness, and visual dimness gave no history suggestive of subarachnoid or intracerebral hemorrhage. Carotid angiograms were performed, and in each case failed to demonstrate a vascular malformation. The CT scans in five cases showed intracerebral hematoma that could suggest vascular malformation as a diagnostic possibility. Surgical exploration was done in each case and pathological features revealed a arteriovenous malformation in each specimen.

Delayed Perilesional Ischemic Stroke after Gamma-knife Radiosurgery for Unruptured Deep Arteriovenous Malformation: Two Case Reports of Radiation-induced Small Artery Injury as Possible Cause

Dong-Han Kim,강동훈,박재찬,황정현,박성현,Won-Soo Son 대한뇌혈관외과학회 2015 Journal of Cerebrovascular and Endovascular Neuros Vol.17 No.1

Radiation-induced vasculopathy is a rare occurrence, however, it is one of the most serious complications that can occur after gamma-knife radiosurgery (GKRS). The authors present two cases of incidentally found deep cerebral arteriovenous malformation (AVM), which were treated by GKRS, where subsequently there occurred delayed-onset cerebral infarction (11 and 17 months after GKRS) at an area adjacent to the AVM. In both cases, perforators of the M1 segment of the middle cerebral artery were included in the radiation field and delayed injury to these is suggested to be the mechanism of the ischemic event.

경련 발작으로 발현한 유전성 출혈성 모세혈관 확장증 1예

오기욱 대한뇌졸중학회 2007 Journal of stroke Vol.9 No.1

Hereditary haemorrhagic teleangiectasia (HHT) is characterized by vascular abnormalities in multiple organs, and therefore hasdiverse manifestations. We report a 15-year-old man who presented with seizure and embolic cerebral infarction associatedwith pulmonary arteriovenous malformation. He and his family members had history of recurrent epistaxis. The patient couldbe diagnosed as having HHT with ischemic stroke and seizure. Patients with HHT should be screened for the presence ofarteriovenous malformaition using computerized tomography (CT) or magnetic resonance imaging (MRI). (Korean Journalof Stroke 2007;9:62-65)

뇌동정맥기형의 감마나이프 방사선 수술

장건호(Geon Ho Jang),임영진(Young Jin Lim),홍성언(Seong Eon Hong),임언(Won Leem) 대한방사선종양학회 1995 Radiation Oncology Journal Vol.13 No.1

Since March 1992, total 200 patients who visited our hospital as functional or organic lesions of central nervous system were treated by gamma knife stereotactic radiosurgery for 27 months. Thirty-nine patients of total cases was diagnosed as cerebral arteriouvenous malformation. The rate of magnification on X-ray film was reduced by cutting fixation adaptor from 1.6 to below 1.45 times. In order to treat the deep- and lateral- seated cereral arteriovenous malformation, we slightly modified the angiographic indicator, the commercial Leksell system, by cutting each inner sides about 5mm. We performed the more distinction of the scales by adapting 0.5mm or 1,, copper filter to angiographic indicator. The center point of indicator (X=100mm, Y=100mm, Z=100mm) si corrected by adjusting scales of X-, Y-, Z-axis to each inner 100 and outer 100point within 1-2mm by repeated exposure of X-ray on films in trial-and-errors. We have developed the 'GKANGID' programed as the Fortran-77 in Microvax-3100, which can save treatment planning time and perform accurate pretreatment planning using the theoretical target metrix center. The theoretical description of the simplified method is presented form the reduction of experimental and numerical errors in treatment planning of radiosurgery.

뇌 동정맥기형의 혈관촬영 소견의 분석: 출혈과의 연관성을 중심으로

김재형 대한영상의학회 1993 대한영상의학회지 Vol.29 No.4

Intracerebral hemorrhage is the most serious complication of cerebral arteriovenous malformations (AVM). To identify angiographic characteristics of AVM which correlate with a history of hemorrhage, we retrospectively anlayzed angiographic findings of 25 patients with AVM. Nine characteristics were evaluated ; these include nidus size, location, arterial aneurysm, ingiomatious change, venous drainage pattern, venous stenosis, delayed drainage and venous ectasia. These characteristics were correlated with hemorrhage, which was seen in 18(72%) patients on CT or MR images. Venous stenosis (p<0.5) and delaved venous drainage (p<.05) well correlated with a history of hemorrhage. Arterial aneursm and intraidal aneurysm also had a tendency hemorrhage although they did not prove to be statistically significant. Detailed analysis of angiographic finding of AVM is important for recognition of characteristics which are related to hemorrhage and may contribute to establishing a prognosis and treatment planning.