척수원추(脊髓圓錐)에 발생한 척수내 농양(脊髓內膿瘍)1례 보고

강준기,이영근,송진언 최신의학사 1970 最新醫學 Vol.13 No.11

A case of intramedullary abscess on the conus medullaris was reported and the literature was reviewed. This 25-year-old Korean male who suffered from paraparesis and urinary difficulty following back pain and spastic weakness in the lower limbs of 7 year's duration, was admitted to the Catholic Medical Center on Dec. 18, 1969. On admission, neurological examination revealed spastic paresis of the left leg, sensory loss below the Til level, urinary difficulty and positive ankle clonus & Babinski sign. Plain X-ray of the spine showed widening of the interpedicular distance of the 1st and 2nd lumbar vertebrae with sclerotic change of the pedicle of the 1st lumbar vertebra on A-P view. Pantopaque myelogram revealed round partial obstruction with expanding cord shadow at the lower border of the 1st lumbar vertebra. Total laminectomy extending from T12 to L3 was performed and a dorsal median incision into conus medullaris was made and evacuated caseous necrotic discharge 30cc in amount so conus medullaris was seen to be surrounded with thin external membrane as if it is hollow tubular appearance. Following operation, neurological deficits did not improved.

신경외과 영역에 있어서 Hyperosmolar Hyperglycemic Nonketotic Coma : HHNC 6예 보고 Report of Six HHNC

강준기,이용길,김문찬,허춘웅,송진언 대한신경외과학회 1980 Journal of Korean neurosurgical society Vol.9 No.2

In 1957 Sament and Schwartz reported patient with profound coma and hyperglycemia but without ketonemia or acidosis. This syndrome in usually termed hyperosmolar hyperglycemic nonketotic coma(HHNC). Six critically ill patients while on the neurosurgical service were studied to establish the diagnosis of HHNC. Criteria for the diagnosis of HHNC included 1) serum glucose over than 220㎎/dl with glucosuria 2) absence of significant acetonuria 3) serum Na over than 150mEq/ℓ 4) serum osmolarity over than 310 m0sm/㎏ 5) neurological dysfunction. The production of the characteristic stupor and diminution of mental acuity appears to result from a decrease in intracellular water content within the brain due to the osmotic effects of those predominately extracellular substances. Factors documented to be significant in it's development include nonspecific stress to primary illness, hyperosmolar tube feeding, dehydration, and mannitol, dilantin and steroid administration. The treatment of HHNC recommended the division of replacement into two stages: 1) rapid repair of water deficits which was calculated by described formula and correct the Na abnormality 2) insulin replacement according to the degree of glucosuria. During the replacement therapy of water deficit and insulin, it should be necessary to repeat plasma electrolytes and blood glucose at 4 hour intervals until normal levels are approached. One among the 6 cases of HHNC became good recovery 'and 5 cases were expired on treatment. Fatal complications of this syndrome, such as acute renal failure, terminal arrhythmias and cardiopulmonary dysfunction, both cerebral and systemic, were common in these cases.

고혈압성 뇌실질내 출혈에 대한 치료 결과 분석

강준기,박기용,하영수,송진언 대한신경외과학회 1976 Journal of Korean neurosurgical society Vol.5 No.2

We have experienced 109 cases of hypertensive intracerebral hemorrhage admitted to the Department of Neurosurgery of Catholic Medical Center from January 1973 to August 1976. We analized the result of treatment of hypertensive intracerebral hemorrhage and assessed prognostic factors affecting the results of surgical treatment of hypertensive intracerebral hemorrhage. 1. The age of the patients did not significantly influence on the mortality of operative or non-operative cases provided the age is below sixty. 2. The amount of hematoma did not directly related to the outcome of operated cases if The hematoma is less than 50㎖, while the mortality was considerably increased if the clot was more than 50㎖. 3. There was no specific difference in operative mortality between total evacuation and partial evacuation of hematoma in surgery of the hypertensive intracerebral hemorrhage, but total evacuation had better result than that of partial evacuation in the functional recovery. 4. The operative mortality of the hypertensive intracerebral hemorrhage was 43.6% and 55.7% in non-operative cases. Thalamic hemorrhage carried the highest mortality either operated or conservatively treated. 5. The surgical treatment carried better result than non-operative treatment in the case showing progressive change in consciousness following intracerebral hemorrhage. Conservative treatment obtained good result in the cases showed progressive improvement of conscious level following intracerebral hemorrhage. 6. The interval from the ictus to surgical intervention did not constantly influence on the result of surgery and it might be wise to decide the time of surgical intervention according to the progressive changes in conscious level and neurological status after bleeding. 7. The operative result was favorable in the patients who has shown progressive worsening of conscious level and neurologic status following clear conscious at hemorrhage (class Ⅱ). We also noted that the patients were unconscious at ictus then became progressively stupor with increasing neurologic deficit showed better result with surgical treatment than non-operative care.

실험적 중대뇌동맥폐쇄후 Rheomacrodex 및 혈압변화의 영향

강준기,이춘장,성태경,조태훈,송진언,김선무 대한신경외과학회 1978 Journal of Korean neurosurgical society Vol.7 No.2

An experiment was planned to observe the histopathological alteration with administration of the Rheomacrodex and blood pressure changes in induced cerebral infarct after occlusion. Eighty well developed cats, weighing 2.3 to 3.5kg, were used in this experiment. The right MCA was exposed through temporal approach and the proximal part of the MCA was occluded with a silver clip. The animals were divided into 4 groups : The control group was comprised of 20 cats with occlusion of the right MCA alone, Rheomacrodex-treated group was comprised of 20 cats after occlusion of right MCA, induced hypotension and hypertension groups consisted in each 20 cats following occlusion, of the MCA. The animals were sacrificed at intervals of 3 hours. 6 hours, 24 hours, 1 week and 2 weeks respectively after occlusion of the MCA. The animals were studied for clinical deficits and histopathological changes of the cerebral infarct according to the time courses. The results obtained were as follows : 1) In the control group, severe contralateral hemiplegia was developed in the early stage following the MCA occlusion, however the neurological deficits were progressively improved to the state of abnormal walking in 24 hours to 2 weeks. The hemorrhagic infarct was involving the basal ganglia, internal capsule and extending to the cortex with mild brain edema in the early stage and the area of the infarct was gradually enlarged from 6 hours to 24 hours following the MCA occlusion. Although the brain edema of surrounding area of the lesion was remained unchanged, the size and distribution of the infarct were decreased in one week to 2 weeks. Extensive ischemic neuronal damage was observed in the control group. 2) In the Rheomacrodex-treated group, mild to moderate neurological deficit was developed in the early stage after MCA occlusion and the deficit was less severe than control group. The clinical deficit was improving in the time course and one case had shown completely normal activity in 2 weeks. The distribution of the infarct was well defined and it was smaller than control group. The infarct mainly involved the basal ganglia and internal capsule. The area of the infarct was gradually enlarged from 6 hours to one week after MCA occlusion, then the extent of the infart was decresed in 2 weeks. The ischemic neuronal change in this group was less severe than control group. 3) In the induced hypotension group, the early neurological deficit was worse than that of the control group and severe hemiplegia was developed in one week. There was minimal improvement of the neurological deficit in 2 weeks. The area of the infarct was ill-defined and hemorrhagic extending a large portion of the brain with severe brain edema. The infart was involving the basal ganglia, internal capsule, claustrum and the cortex from 3 hours to 24 hours after the occlusion and the area of the infarct was not changed during the observation. Severe ischemic nerve cell change or resolution of the cells was observed in this group. 4) In the induced hypertension group, the neurological deficit was mild and it was better than that of the control group. The distribution of the infarct was well localized and minimum in extent. The extent of the infarct was not changed during the observation. There was no observable gross brain edema and the ischemic nerve cell changes were not severe.

두개안면골 형성부전증(頭蓋顔面骨 形成不全症) 수술에 대한 임상경험 : 수술 치험 9예 보고 Reports of Nine Operative Cases

강준기,송진언 대한신경외과학회 1987 Journal of Korean neurosurgical society Vol.16 No.1

The craniofacial dysostoses are due to synostosis of the basal skull sutures in the anterior cranial fossa. Patients with these abnormalities potentially have normal brains that are distorted by the misshapen skull; shallow anterior fossa and reduction of the orbital volume, exophthalmos, and hypoplasia of the maxilla. The authors describe the operative repair and results of 9 cases of craniosynostosis. The craniofacial dysmorphic states are presumably caused by premature closure of basal skull sutures in combination with the coronary suture. In an effort to arrest and correct both the cranial and facial deformities as well as obviate the need for further radical surgery, the authors have treated 9 children with Crouzon's disease with linear suture craniectomy along the base of the skull, forehead advancement and unilateral canthal advancement techniques. A linear craniectomy along the synostotic sutures does not affect the synostotic process at the base of the skull. The advance of supraorbital margin and creating an artificial suture at the base of skull allowed for proper correction those craniofacial deformities. Following those procedure, deformity has regressed and ultimate cosmatic improvement has been obtained in 4 cases of grade Ⅲ and 3 cases of the grade Ⅱ and 2 cases of grade Ⅰ among the 9 patients. Early neurosurgical intervention using the procedure of the forehead advancement and lateral supraorbital ridge advancement combined with linear craniectomy along the skull base suture, yields excellent results in the majority of these children.

後頭窩類皮囊腫을 同伴한 先天性皮膚洞 1 例 報告

강준기,허춘웅,하영수,송진언 대한신경외과학회 1981 Journal of Korean neurosurgical society Vol.10 No.2

Congenital dermal sinuses are dermal tubes which extended inward from the surface for varying distances and frequently connect the central nervous system or its covering with the surface of the body. The inner end of the sinus may be expanded to form a dermoid or epidermoid cyst. They are the results of incomplete separation of the epithelial ectoderm from the neuroectoderm a t the fourth week of fetal development. As cystic expansion of a congenitad sinus which is located within the cranium or spinal canal may act as any other mass lesion to interrupt neurologic function by local compression or it may obstruct the normal circulation of spinal fluid. In addition, because of its persistent communication with the skin surface, it serves as a constant potential port of entry for infection into the central nervous system. Since the first report in 1926 by Moise of staphyloccus meningitis secondary to a congenital sacral sinus, numerous reports have appeared of infection secondary to congenital sinuses along the craniospinal axis, particularly in the suboccipital region. Authors report a case of congenital dermal sinus associated with dermoid cyst of posterior fossa which was successfully removed and discuss the pathegenesis of it in embryology, and surgical management of it's complications.

수술중 체성 지각유발전위 감시하에 척수내 사구체 동정맥기형 미세수술 제거수기

강준기,박춘근,김문찬,송진언,김영배 대한신경외과학회 1984 Journal of Korean neurosurgical society Vol.13 No.4

The surgical treatment of spinal arteriovenous malformations has been improved markedly during the last several years by use of the operating microscope and microsurgical instrumentations. The possibility of total removal has been viewed pessimistically. However, total extirpation of spinal intramedullary arteriovenous malformation (AVM) can be possible by use of intraoperative monitoring of the somatosensory evoked potentials (SEPs). Authors report a case of spinal intramedullary glomus AVM which was successfully removed with intraoperative monitoring of the SEPs and discuss surgical management. Intraoperative monitoring of the SEPs to determine the safety of removing of the spinal intramedullary AVM is stressed.

국소적 뇌손상에 따른 국소 뇌혈류 변화와 뇌부종 형성에 대한 실험적 연구 : An Experimental Gerbil Model

강준기,송진언,Crockard, Alan,Symon, Lindsay 대한신경외과학회 1980 Journal of Korean neurosurgical society Vol.9 No.1

An experimental trauma model in gerbils is described in which we have attempted to produce a focal laceration and contusion. This experimental main objective was to replicate some of the mechanisms involving in human brain injuries, and observe the effect of focal brain injury on regional cerebral blood flow and oedema formation. 80 adult gerbils weighing 40 to 60 gm, were used in this study. The components of the pathophysiological responses, systemic changes, and regional cerebral blood flow (rCBF) associated with the focal brain laceration injury were studied in groups pf animals. Three groups were studied. A mild injury (20 animals) was produced by moving the drill along a predetermined pathway through the right orbit at 50 revs per minute over 2 seconds and a severe injury (20 animals) produced in a similar fashion at 200 revs per minute for 8 seconds. An indomethacin preatreated group (20 animals) was produced in a same method of severe injury. The rCBF measurements were performed immediately after injury in each animal, at 30 minutes and the final few at 60 animal by Pasztor hydrogen clearance technique. Brain specific gravity measurements as an index of brain water was determined in each animal at 1 hour after injury by using Nelson's column gradient method. There are systemic changes associated with this injury which are neurogenically mediated and results in an immediate reduction to 50 mmHg in blood pressure, a bradycardia and a generalized reduction to 50% -60% in cerebral blood flow during the immediate post-traumatic period. During 30-60 minutes following trauma, a tendency towards slight increasing of blood flow was found in each group, however marked increasing tendency of flow except focal injury site was found in severe injury animal group. The affects of rCBF are independent of the severity of the local brain injury. These vasomotor effects may induce. Cortical cerebral ischemia and this profoundly influence post-traumatic cerebral function and cause irreversible damage. There is generalized edema as judged by a decreased brain specific gravity probably related to hypoperfusion secondary to a fall in cardiac output. But there is also superimprosed on this an oedema gradient which is maximal also to the injury. This is turn affects the local capillary flow and further decreases rCBF. In the first hoar after this injury prostaglandins do not appear to be involved in the oedema formation.

국소적 뇌병소에 대한 체성감각유발전위 반응

강준기,김문찬,조태훈,백민우,강세기,윤석훈,허춘웅,송진언 대한신경외과학회 1983 Journal of Korean neurosurgical society Vol.12 No.3

Cerebral somatosensory evoked potentials(SEPs) produced by stimulation of peripheral nerves provide a useful diagnostic index of conduction in somatosensory pathways to the cortex. Thus the integrity of both dorsal column-medial lemniscus pathway and primary sensorimotor area has been considered an essential requirement to record a nomal SEP. There are suggestions that SEPs contain several components arising from different neuronal sources, the early short latency potentials corresponding to the lemniscus-mediated responses and the late waves to the diffuse spino-thalamic projections. The present work analyses the influence on SEPs of focal brain lesions, using the computerized tomography in detecting and localizing brain lesion. Somatosensroy evoked potentials were recorded in 20 patients with focal brain lesions recognized by computerized tomography. 1) Patients with primary sensorimotor area (PSMA) damages (group Ⅰ) had a very abnormal of the early component (No, Po, N1, Pl) in 100% on the lesion side. 2) Patients presented supratentorial lesions, sparing PSMA (group Ⅱ), 87.5% showing abnormal SEPs in early components and characterized by increment of amplitude in late components. 3) Brainstem damage (group Ⅲ) produced a distortion of the early components especially N11, N20 msec latency. 4) In incomplete spinal cord injuries, the SEPs is indeed signal of functional recovery, of posterior column and incorrespondance with clinical improvement.

대뇌반구 뇌손상으로 인한 뇌혈류 및 체성감각 유발전위 변화 및 Mannitol의 효과 : An Experimental Cat Model

강준기,조병일,김문찬,조태훈,박춘근,김달수,하영수,송진언 대한신경외과학회 1984 Journal of Korean neurosurgical society Vol.13 No.1

Since every component of the evoked responses are considered to be related to topographically specific neural structures, it is possible that the location and severity of brain dysfunction could be accurately defined by careful analysis of evoked responses. The main objective of this experiment was to replicate some of the mechanisms involved in human brain injuries in cat and observe the effect of focal hemispheric brain injury on regional cerebral blood flow(rCBF) and somatosensory evoked potential (SEP) and to evaluate the effects of mannitol on them. Thirty adult cats weighing 2.5 to 4.2 ㎏, were used in this study. The animals were divided into 3 groups of 10 cats each: (1) mild injury, (2) severe injury and (3) mannitol treated severe injury group. A mild injury was produced by moving the drill along a predetermined pathway through the right parietal hole at 50 cycle per minute for 2 seconds and a severe injury was produced in a similar fashion at 200 cycle per minute for 3 seconds. A mannitol treated group was produced in a same method as the severe injury group. The rCBF and SEP measurements were performed immediately after injury in each animal, at 30 minutes, 60 minutes and the final flow at 90 minutes by pasztor(1973) hydrogen clearance technique. The results obtained were as follows. 1) After focal cerebral hemispheric injury, there were rapid rise in intracranial pressure, bradycardia, changes in blood pressure and marked alteration in respiration which are neurogenically mediated. 2) Normal control flows(rCBF, ㎖/100g/min) were 30.7±5.9 in right frontal, 35.2±6.7 in right parietal, 27.9±6.8 in left frontal, and 35.2±7.3 in left parietal lobes. 3) Sequential changes of the rCBF after focal cerebral hemispheric injury were as follows. (1) Mild focal hemispheric injury resulted in a reduction of flow to 30% of control flow(RF: 18.8±3.7, RP: 25.0±7.8㎖/100g/min) at injury resulted in a reduction of flow to 30% of control flow(RF: 18.8±3.7, RP: 25.0±7.8㎖/100g/min) at injury site after immediate injury. (2) Severe focal hemispheric injury resulted in a reduction of flow to 50% of control flow (RF: 20.4±10.9, RP: 18.8±7.6 ㎖/100 g/min) at injury site after immediate injury. (3) Mannitol-treated severe injury resulted also in a reduction of flow to 50% of control flow at the injury site after immediate injury, but at 90minutes the flow was 75% of the control flow. 4) A close correlation was found between cortical-evoked potentials and flow, suggesting a threshold relationship both on injury and non-injury areas. (1) The SEP was present shortly after injury though markedly altered in shape and the early components (No, N1) of the SEP were suppressed first. (2) It was also noted that the amplitude of the SEP was much smaller, perhaps due to direct injury on the injured area. (3) The SEP disappeared if the rCBF in either hemisphere fell below 15㎖/100gm/min. 5) It might be inferred from these results that adequate flow was vital for the preservation and return of electrical activity following brain injury.