Urokinase의 뇌정위적 혈종내 주입에 의한 자발성 두개강내 혈종의 치료 효과

박춘근,정철구,백민우,김문찬,김달수,하영수,강준기,송진언 대한신경외과학회 1985 Journal of Korean neurosurgical society Vol.14 No.2

Authors describe methods for evacuation of intracerebral and/or intrventricular hematomas with CT-aided stereotaxic infusion of urokinase into the hematoma and controlled drainage. In the past 6 months we performed the procedures in 21 cases during acute (within 3 days) or subacute (between 4 and 14 days) stage after the apoplectic attack. Three dimensional CT images were used to locate the hematoma sites, to assess its volume and to determine stereotaxic coordinates. Under local anesthesia a silicon tube was inserted into the hematoma through a burr hole and the hematoma was aspirated with syringe. And then urokinase (6,000 IU/5㎖ saline) was infused into the hematoma and the drain was clipped. Thereafter aspiration and administration were performed repeatedly every 6 hours until the hematoma was completely removed. In cases of intraventricular hematoma a drain was inserted into the ventricle having the main hematoma. As a first trial of hematoma removal, the ventricle was irrigated with urokinase (6,000 IU/100㎖ saline), and the drain was clipped after administration of urokinase (6,000 IU/5㎖ saline). Subequentry clipping of the drain for 4 hours and drainage of the CSF with the hematoma for 2 hours were repeated under the monitoring of intracranial pressure. Now we review serial changes of CT findings and results of 10 cases which were followed up for at least 4 months' and priliminarily conclude that this procedure may be as good as conventional cranitomy, and safer and less traumatic than any other management especially in cases of intraventricular or deep seated hematomas and elderly or high-risk patients.

급성 뇌내 혈종의 자기공명영상에 관한 실험적 연구

이문규 대한영상의학회 1991 대한영상의학회지 Vol.27 No.1

To evaluate the difference of MR signal intensity of acute intracerebral hematoma(ICH) between 2.0 T and 0.5 T field strengths and the capability of the lesion depiction at each field strength, brain MR imaging of 15 cats with experimentally-produced acute ICH was performed at both 2.0 T and 0.5 T units. Hematomas were formed in the right parietal lobes by injecting 1.5ml of autologous femoral arterial blood. MR images were obtained with TI-(TIWI), proten density-(PDWI), and T2-weighted(T2WI) spin-echo(SE)sequences and T2*-weighted gradient echo(GE) techniquie, immediately after formation of the hematoma(usually within two hours(n=6), six hours(n-5), one day(n=6), three days(n=6), five days(n=5), and seven days(n=5) at both 2.0 and 0.5 T. The signal intensities of the ICHs were also objectively compared by measuring the signal intensities of the lesion and the contralateral white matter using cursor. In addition, depoction rate of ICH was assessed on each pulse sequence at both 2.0T and 0.5 T field strengths. The results were as follows: 1.In immediate hematoma group, the signal intensities of hematomas were generally iso-or slightly hypointense on all SE sequences and markedly hypointense on GE images at both 2.0T and 0.5T.There was no significant difference in signal intensities between 2.0 T and 0.5 T on all pulse sequences. 2. In all other groups of hematoma older than six hours, the signal intensities of the hematomas tended to be hypointense on SE PDWI and T2WI at 2.0T, while hyperintense on SE PDWI and T2WI at 0.5T. OnGe images, hematomas appeared markedly hypointense and larger than those on SE images regardless of field strngth difference. 3.On TIWI, there was no significant difference in the signal intensities of hematomas between 2.0T and 0.5 T throughout whole groups. Hematomas generally appeared hyperintense on SE TIWI in all other groups of hematoma older than 3 days. 4.Depiction rate of hematomas on SE sequences was 97% (on T2WI) at 2.0 T, while 73%(on PDWI and T2WI) at 0.5T.On GE sequence, it increased up to 100% at 2.0 T and 97% at 0.5 T. In conclusion, 2.0 T MR imaging appears superior to 0.5 T MR imaging in the evaluation of acute intracerebral hematoma. Routine SE pulse sequences are considered to be satisfactory for detecting acute hematoma at 2.0 T, but not at 0.5 T.GE technique is useful as a complementary sequence at both 2.0T and 0.5 T MR imaging, and particularly helpful 0.5 T MR imaging.

자발성 뇌출혈에 대한 뇌정위적 Urokinase 치료

조경근,이일우,조태훈,김문찬,강준기,송진언 대한신경외과학회 1987 Journal of Korean neurosurgical society Vol.16 No.2

According to the general principle that a surgical procedure should be as atraumatic as possible, several authors proposed stereotaxic urokinase treatment in spontaneous intraoerebral hematomas. Authors presented 29 cases of spontaneous intracerebral hematomas which were managed wit stereotaxic urokinase treatment including 10 cases of preliminary report on Journal of Korean Neurosurgical Society June 1986. 19 cases were basal ganglia hematomas with or without ventricular rupture, 4 cases were thalamic hematomas with ventricular rupture, 3 cases were subcortical hematomas and 3 eases were intraventricular hematomas. The outcome of the treatment was analysed by the location and amount of hematomas, and the degree of disability of patient on admission and discharge. The outcome was worst in thalamic hematoms than putaminal or subcortical hematomas, and poorer as the amount of hem atom a increased. The outcome was bad also in the patient who showed poor neurologic condition on admission. Time requiring hematoma dissapperance with urokinase treatment was estimated by the short term follow up CT scanning. All of the patient except moribund cases showed complete dissappearance of hematomas within 10 days after treatment, and mean period was 6.7 days. Rebleeding after the urokinase treatment was noted in 4 cases, which was 2 putaminal, one thalamic and one ventricular hematoma. The cause of rebleeding might be mechanical injury of catheter insertion or too strong negative pressure on aspiration. But in 1 case of intraventricular hematoma, the possible causative factor should be anticoagulant effect of urokinase on the injured vessel. With above result, we concluded that this procedure may be better and safer than conventional craniotomy especially in cases of high risky or elderly patient with deep seated intracerebral hematomas. But the efficacy and safety must be studied further with the exact experimental model of spontaneous intracerebral hematomas.

자발성 뇌실질 출혈 후 혈종 증대 요인에 대한 분석

표세영,심홍보,정영균,이선일,정용태,김수천,심재홍 인제대학교 백병원 2002 仁濟醫學 Vol.23 No.1

■ Objectives Spontaneous intracerebral hemorrhage(ICH) was generally considered to be a monophasic event. Most of these hemorrhage stop and are stabilized within 6 hours of onset of ICH. But, in contrast. hemorrhage continued over 6 hours in some cases. Many treatment methods of ICH were disputed whether the decision is right or not in cases of hematoma enlargement. Author analysed factors of hematoma enlargement to pursue adequate treatment, to improve the outcome, and to prevent enlargement of hematoma. ■ Methods and Materials This retrospective comparative analysis involved 855 ICH patients admitted to Neurosurgery Department, Inje University Busan Paik Hospital between January 1996 and February 2000. In 55 patients(6.4%), the follow up computerized tomography(CT) scan showed an enlarged hematoma. ■ Results The clinical risk factors u·ere defined and analyzed. In the enlarged hematoma group, male to female ratio was 1.75:1 and the most frequent developmental site of hematoma was putamen(23.6%). In the shape of hematoma, 38 cases(69.1%) showed irregular shape. Preictal hypertension history was there in 30 cases. Contrast enhancement of initial hematoma was found in 14 cases. The mean time interval between initial hemorrhage and hematoma enlargement was 33.3 hours, and the time interval of 22 cases(40%) was 11 to 14 hours. ■ Conclusions The clinical risk factors in hematoma enlargement were found to be the shape of inital hematoma, time interval after hemorrhagic ictus to enlargement (16 hours), and contrast enhancement in the initial hematoma. For the patients having these risk factors in hematoma enlargement, more close observation should be needed.

전이성 척추 종양의 척추 전 절제술 후 발생한 급성 및 지연성 경막외 혈종 - 증례 보고 -

김영규,김정훈 대한척추외과학회 2019 대한척추외과학회지 Vol.26 No.3

연구 계획: 증례 보고목적: 전 척추 절제술 시행 후 두 차례 발생한 수술 후 경막 외 혈종 증례를 보고하고자 한다. 선행 연구 문헌의 요약: 척추 수술 후 경막 외 혈종은 드물며 혈종 제거술을 시행한 뒤 지연성 경막 외 혈종이 다시 나타난 예는 보고된 적이 없었다. 대상 및 방법: 74세 여환에서 제 9흉추(T9)의 전이성 척추 종양에 의한 병적 골절이 발생하여 전 척추 절제술을 시행하였으며 수술 직후 발생한 경막 외혈종으로 신경학적 증상이 악화되어 혈종 제거술을 시행하여 증상이 호전되었으나 수술 10일 후 신경학적 증상이 다시 악화되어 촬영한 자기 공명 영상검사상 지연성 경막 외 혈종이 또 다시 발견되어 혈종 제거술을 다시 시행하였다. 결과: 지연성 혈종 제거술 재 시행 후 신경학적 증상이 호전되었다. 결론: 일차적인 혈종 제거술 후에도 증상을 일으키는 지연된 혈종이 나타날 수 있으며, 혈종 제거술 후에도 신경학적 증상의 악화가 보인다면 혈종의 재발 가능성을 고려해야 한다. 또한 전 척추 절제술을 시행하기 전에 예방적 색전술을 시행할 것을 추천한다. 약칭 제목: 척추 수술 후 재발한 척수 경막 외 혈종 Study Design: Case report. Objectives: We report a case of recurrent spinal epidural hematoma after total spondylectomy for a metastatic spinal tumor. Summary of Literature Review: Postoperative epidural hematoma is rare, and no case of delayed epidural hematoma after hematoma removal has been reported. Materials and Methods: A 74-year-old woman experienced a ninth thoracic vertebral (T9) pathologic fracture caused by a metastatic spinal tumor and underwent total spondylectomy. Immediate postoperative epidural hematoma occurred and neurological symptoms appeared. After hematoma removal, the symptom improved. Ten days after surgery, the neurological symptoms worsened again. Spine magnetic resonance imaging showed delayed epidural hematoma. Hematoma removal was done again. Results: The patient’s neurological symptoms improved after delayed hematoma removal. Conclusions: Delayed hematoma that cause neurological symptoms may occur after primary hematoma removal. If neurological symptoms recur after hematoma removal, the surgeon should consider the possibility of hematoma recurrence. Before total spondylectomy surgery, preoperative embolization is recommended. Key Words: Delayed epidural hematoma, Metastatic spinal tumor, total spondylectomy

Role of ‘Spot sign’ on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

Soo Yong Park,Jung Hee Kim,Dong Soo Kang,Kwan Young Song,Seung Kon Huh, 대한신경외과학회 2010 Journal of Korean neurosurgical society Vol.48 No.11

Objective : Patients with spontaneous intracerebral hemorrhage (ICH) presenting within 24 hours of symptom onset are known to be increased risk of hematoma expansion which is closely correlated with morbidity and mortality. We investigated whether tiny enhancing foci (‘Spot sign’)on axial view of 3-dimensional computed tomography angiography(3D-CTA) source images can predict subsequent hematoma expansion in spontaneous ICH. Methods : During a 2-year period (March 2007 - March 2009), we prospectively evaluated 3D-CTA of 110 patients with spontaneous ICH. Based on source images of 3D-CTA, patients were classified according to presence or absence of ‘Spot sign’; ‘Spot sign’ (+) group, ‘Spot sign’ (-) group. Radiological factors and clinical outcomes were compared between two groups. Results : Hematoma expansion occurred in 16 patients (15%). Mean Glasgow Coma Scale (GCS) score of patients with hematoma expansion was significantly different compared to score of patients without hematoma expansion (5 vs. 9, p < 0.001). Nineteen patients (16%) of 110 ICH patients demonstrated ‘spot sign’ on 3D-CTA. Among the ‘spot sign’ (+) group, 53% of patients developed hematoma expansion. Conversely 7%of patients without ‘spot sign’ demonstrated the hematoma expansion (p < 0.001). Initial volume and location of hematoma were significantly not associated with hematoma expansion except shape of hematoma. Conclusion : Our study showed that patients with hematoma expansion of spontaneous ICH had significant clinical deterioration. And the fact that ‘spot sign’ (+) group have higher risk of hematoma expansion suggests the presence of ‘spot sign’ on source images of 3D-CTA can give a clue to predict hematoma expansion in spontaneous ICH.

Role of 'Spot Sign' on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

Park, Soo-Yong,Kong, Min-Ho,Kim, Jung-Hee,Kang, Dong-Soo,Song, Kwan-Young,Huh, Seung-Kon The Korean Neurosurgical Society 2010 Journal of Korean neurosurgical society Vol.48 No.5

Objective : Patients with spontaneous intracerebral hemorrhage (ICH) presenting within 24 hours of symptom onset are known to be increased risk of hematoma expansion which is closely correlated with morbidity and mortality. We investigated whether tiny enhancing foci ('Spot sign') on axial view of 3-dimensional computed tomography angiography (3D-CTA) source images can predict subsequent hematoma expansion in spontaneous ICH. Methods : During a 2-year period (March 2007-March 2009), we prospectively evaluated 3D-CTA of 110 patients with spontaneous ICH. Based on source images of 3D-CTA, patients were classified according to presence or absence of 'Spot sign'; 'Spot sign' (+) group, 'Spot sign' (-) group. Radiological factors and clinical outcomes were compared between two groups. Results : Hematoma expansion occurred in 16 patients (15%). Mean Glasgow Coma Scale (GCS) score of patients with hematoma expansion was significantly different compared to score of patients without hematoma expansion (5 vs. 9, P < 0.001). Nineteen patients (16%) of 110 ICH patients demonstrated 'spot sign' on 3D-CTA. Among the 'spot sign' (+) group, 53% of patients developed hematoma expansion. Conversely 7% of patients without 'spot sign' demonstrated the hematoma expansion (p < 0.001). Initial volume and location of hematoma were significantly not associated with hematoma expansion except shape of hematoma. Conclusion : Our study showed that patients with hematoma expansion of spontaneous ICH had significant clinical deterioration. And the fact that 'spot sign' (+) group have higher risk of hematoma expansion suggests the presence of 'spot sign' on source images of 3D-CTA can give a clue to predict hematoma expansion in spontaneous ICH.

자발성 뇌내혈종의 음압배액술

김일만,손은익,김동원,임만빈,Kim, Il-Man,Son, Eun Ik,Kim, Dong Won,Yim, Man Bin 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.6

Objectives : The less invasive stereotactic surgery of hypertensive intracerebral hematoma has been preferred. Many techniques were developed to facilitate aspiration of a dense blood clot in acute stage. Authors describe a method for evacuation of putaminal hematoma via computerized tomography(CT)-aided free-hand stereotactic infusion of urokinase and frequent negative pressure aspiration. Patients and Methods : A total of ten patients with spontaneous putaminal hematoma underwent surgery with negative pressure aspiration in the three-year period. All procedures were performed within 12 hours of insult. A silicone ventricular catheter was inserted into the center of hematoma through a burr hole at the Kocher's point under local anesthesia. In a typical case of putaminal hematoma, the trajectory of catheter was pointed the center of hematoma parallel to sagittal plane vertically and the external auditory meatus posteriorly. Immediately after the first trial of hematoma aspiration low-dose urokinase solution(2,000IU/5ml saline) was administrated through the catheter and drain was clipped for 30 minutes. Subsequently, the partially liquified hematoma was manually aspirated using a 10ml syringe with a negative pressure of less than 2 to 3ml. The procedure was carefully repeated every 1 hour until the hematoma was near totally evacuated. Results : The patients population consisted composed of 4 men and 6 women with a mean age of 61.6 years. All had major neurological deficits preoperatively. The mean hematoma volume was 44.3 ml and hematoma was drained for 20 to 48 hours. No complications such as rebleeding, meningitis, or malplaced catheter were noted. Outcome was moderately disabled in four patients and good recovery in three patients. Conclusion : Although the frequent negative pressure aspiration and low-dose urokinase infusion has the disadvantage of possbility of rebleeding and infection, it is consisdered to be an effective method because it allows a simple, safe, and complete removal of hematoma.

만성 경막하 혈종의 성장에 대한 뇌 CT 소견 및 치료 방침

이영배 ( Young Bae Lee ) 대한외상학회 2012 大韓外傷學會誌 Vol.25 No.4

Purpose: The objectives of this study are to classify chronic subdural hematomas based on brain computerized tomographic scan (CT scan) findings and to determine the mechanism of evolution and treatment methods. Methods: One hundred thirty-nine patients who were diagnosed with a chronic subdural hematoma and who available for follow up assessment 6 months post-surgery were analyzed retrospectively. The presence of trauma and past medical history were reviewed and evaluation criteria based on brain CT scan findings were examined. Results: Initial brain CT scans revealed a chronic subdural hematoma in 106 patients, a subdural hygroma in 24 patients, and an acute subdural hematoma in 9 patients. In all cases where the initial acute subdural hematoma had progressed to a chronic subdural hematoma, final was a hypo-density chronic subdural hematoma. In case where the initial subdural hygroma had progressed to a chronic subdural hematoma, the most cases of hematoma were hyper-density and mixed-density chronic subdural hematoma. In total, 173 surgeries were performed, and they consisted of 97 one burr-hole drainages, 70 two burr-hole drainages and 6 craniotomies. Conclusion: This study demonstrates that rebleeding and osmotic effects are mechanisms for enlarging of a chronic subdural hematoma. In most cases, one burr-hole drainage is a sufficient for treatment. However, in cases of mixed or acute-on-chronic subdural hematomas, other appropriate treatment strategies are required. (J Trauma Inj 2012;25:209-216)

Effectiveness of Aspiration in Treating Cardiac Implantable Electronic Device-Induced Pocket Hematoma and Characteristics of Patients with Pocket Hematoma

Lee Hye Mi,Park Jin Woo,Young Cheon Na,윤치선,Jong Hwan Kim,김남호 대한창상학회 2022 Journal of Wound Management and Research Vol.18 No.1

Background: Pocket hematoma is the most common complication after procedures involving cardiac implantable electronic devices (CIEDs). Furthermore, pocket hematomas increase the risk of device infection. Unless severe, a pocket hematoma is usually managed conservatively because specific treatment is unavailable. Aspiration is not recommended as it can cause infection. This study explored whether lowering the risk of infection by aseptically removing the hematoma at an early stage would be possible through aspiration, investigated the effectiveness of treatment with aspiration for pocket hematoma, and analyzed the characteristics of patients with pocket hematoma. Methods: Via chart review, we retrospectively analyzed 570 patients who underwent CIED implantation or replacement between January 2011 and January 2021. Aspiration was performed only on grade 2 and 3 hematomas. Results: Pocket hematomas were identified in 80 patients (14%). Of these 80 patients, 52 (65%) were treated with aspiration only; six (7.5%), with aspiration plus surgical procedure; five (6.25%), with the surgical procedure only; and 17 (21.25%), with conservative treatment. Out of 58 patients treated with aspiration only and aspiration plus surgical procedure, 52 (89.65%) were treated with aspiration only, while six (10.34%) required more procedures (e.g., hematoma evacuation, Barovac insertion, or device reposition with flap surgery). However, none of these six patients exhibited an infection symptom possibly caused by aspiration. Conclusion: Out of 80 patients with hematoma, 58 were treated with aspiration, and none showed infection symptoms that could be caused by aspiration. This suggests that aspiration can be an effective treatment if performed aseptically.