Surgical Management of Central Neuropathic Pain Using the Neuroablative Procedures of Brain

Central pain is defined as pain initiated or caused by a primary lesion or dysfunction within the central nervous system and has proved the most difficult pain to control. Many intracranial ablative procedures have been tried, including stereotactic cingulotomy, thalamotomy, and mesencephalotomy, which have been described to be effective in about 50% to 60% although the relief of pain is faded out with time. Anterior cingulotomy is effective for the relief of cancer pain and noncancer chronic pain. Although few side effects are potential benefits of cingulotomy, the effectiveness for central pain is not yet established. Mesencephalotomy is particular value in central denervation pain, cancer pain involving the head, neck but its use is limited due to significant morbidity. The value of thalamotomy for treatment of central pain is not documented. Trigeminal tractotomy and nucleotomy are beneficial for vagoglossopharyngeal neuralgia, geniculate neuralgia, and the caudalis DREZ is beneficial for atypical facial pain, postherpetic neuralgia. Recently neurostimulation is recommended for the treatment of central pain or neuropahic pain rather than neuroablation. The use of destructive central procedures for central pain and noncancer chronic pain has not yet been well defined. With the potential benefit being less certain, priority might be given to a procedure with less risk.ope

Factors Related to Occurrence of Radiation Necrosis Following Gamma Knife Radiosurgery for Metastatic Brain Tumors

Objective：Gamma Knife radiosurgery(GKS) has been used for treatment of metastatic brain tumors. Radiation necrosis is the most significant complication of GKS. Authors retrospectively reviewed the treatment parameters of GKS to determine if there were significant factors affecting the occurrence of radiation necrosis after GKS. Materials：From 1992 to 2002, 171 GKS procedures for 572 metastatic brain lesions in 150 patients were included in this study, Total 10 lesions in 10 patients were diagnosed as radiation necrosis. Their treatment parameters were analysed and compared with control group. Results：Of 10 patients with radiation necrosis after GKS, the primary sites were lung(7 patients), gastrointestinal tract(2 patients) and kidney(1 patient). Five patients had multiple brain lesions and the mean number of lesions were 2.6. Mean dose, maximal dose, integral dose, prescription isodose volume(PIV)/tumor volume(TV) and 10% normal brain volume showed significant difference between radiation necrosis group and non-radiation necrosis group. Patient`s age, marginal dose, prescription isodose line, number of isocenter, marginal dose, PIV and tumor volume were not related to the occurrence of radiation necrosis. Conclusion：For the treatment of metastatic brain tumors, radiosurgery has the advantage of whole brain radiation therapy. Because the radiation necrosis, which is the only serious complication of radiosurgery, is reversible condition, the goal of tumor control should not be affected by concern of this complication.ope

Nonpharmacological Management of Cancer Pain

It has become traditional to separate discussion on the management of intractable pain into the arbitrary categories of cancer pain and benign pain. Based on physiological considerations, this is somewhat capricious and probably not always accurate. Certainly patients with malignancy predominantly suffer form nociceptive pain due to direct tissue damage by tumor invasion or compression. However, those patients also suffer from neuropathic pain. In general, patients with terminally ill cancer patients have a somewhat limited life span. This factor is one of the most important when considering the surgical procedure. There has been a resurgence of interest in neurosurgical procedure in the management of cancer pain. Functional stereotactic procedures for cancer pain are divided into two broad categories: ablative and neuroaugmentative. Many patients with intractable pain secondary to malignancy respond better to surgical procedures than do patients without malignancy. And cancer pain is most often responding well with narcotics. However, the recent development of various oral and systemic narcotics has dramatically changed the management of pain secondary to cancer. In addition, a number of technical advances have made it much easier to deliver medication on outpatient basis. All these modalities in combination have dramatically reduced the need of nonpharmacological procedures for patients with cancer pain. However, once these measures have failed, it is appropriate to consider surgical interventionope

Gamma Knife Radiosurgery for Remnant or Recurred Craniopharyngiomas

Objective：The authors assess the long term effectiveness of gamma knife radiosurgery(GKS) for remnant or recurred craniopharyngiomas on tumor control and possibly set proper radiation dose for tumor control with utmost preservation of the adjacent structures. Methods : Sixteen GKS were done in 14 patients with recurred or remnant craniopharyngiomas after surgery. Mean follow up duration was 44.2 months (range 11.3~123.6 months). Follow up MR imagings were analyzed. Results : Mean tumor volume was 3.6cm3 (range 0.6~18cm3) and mean margin dose was 12.2Gy (range 8~22.4Gy). Tumor control was achieved in 87.5% (14 of 16 tumors) which were either solid or cystic in nature. Dose to optic apparatus was mean 7.9Gy and no radiation related complications were observed. Conclusion : GKS seems to be effective treatment modality for craniopharyngiomas regardless of nature of tumor whether it is cystic or solid. Dose of 8 to 8.5Gy may be sufficient to achieve long term tumor control for remnant or recurred craniopharyngiomas.ope

Giant Cell Tumor of the Occipital Bone

Giant cell tumors of the skull are very rare. They seldom involve the skull and more often tend to involve the temporal and sphenoid bone. We present here the case of a 25 year-old female with giant cell tumor of the occipital bone who visited the hospital with headache and posterior neck pain. Magnetic resonance(MR) imaging revealed a well defined extra-axial mass of 3×3cm in the posterior fossa with changes of the overlying calvarium. The lesion showed isosignal intensity on the T2 weighted image and homogeneous strong enhancement on the T1 enhanced image. The patient underwent total resection of the lesion and giant cell tumor was made as a final diagnosis. A brief review of the literature is also presented.ope

The Course of Brainstem Cavernous Malformations according to Management Strategies

The outcome and the rate of rebleeding of brainstem cavernous malformationss were analyzed following conservative treatment, microsurgical excision and Gamma Knife radiosurgery (GKS). We especially concentrated on the role of radiosurgery. We treated 39 patients with brainstem cavernous malformations using conservative treatment, microsurgical removal or GKS from April 1993 to November 2003. Follow up duration was 7 to 132 months (mean 45.8, median 30.6). The lesion location included pons, midbrain, medulla oblongata and cerebellarpeduncle. Conservative management was performed in 14 patients, GKS in 18 patients and microsurgical removal in 7 patients. The annual rate of rebleeding was 22.2% in conservative group and 22.7% in GKS group. Good and moderate outcome were obtained in 70% of conservative group, 75% of GKS group and 85.6% of surgical group. Overall mortality rate was 5.1%. Microsurgical excision tended to be resulted in good outcome. GKS and conservative managements were accompanied by a risk of recurrent bleeding, even death. There was no statistical difference in outcome and the rate of rebleeding between conservatively managed group and GKS treated group.ope

Effects of Hydroxychloroquine Co-administered with Chemotherapeutic Agents on Malignant Glioma Cell Lines: in vitro Study

Objective：Anti-malaria drugs may modulate tumor resistance to chemotherapeutic agents, but it has not been proven effective in the treatment of malignant gliomas. The aim of this study was to determine whether adequate pre-clinical data on co-administration of chemotherapeutic agents with anti-malaria drugs on malignant cell lines could be obtained that would warrant its further potential consideration for use in a clinical trial for malignant gliomas. Methods : Two malignant glioma cell lines (U87MG, T98G) were treated with chemotherapeutic agents alone or with anti-malaria drugs. Cells were incubated with drugs for 4 days. Following the 4-day incubation, drug sensitivity assays were performed using 3-(4,5-dimethyl-2-thiazol-2-yl) 2,5-diphenyltetrazolium bromide (MTT) assay following optimization of experimental conditions for each cell lines and cell viability was calculated. Results : In all of four chemotherapeutic agents(doxorubicin, vincrisitne, nimustine, and cisplatin), the cell viability was found to be markedly decreased when hydroxychloroquine was co-administered on both U87MG and T98G cell lines. The two way analysis of variance(ANOVA) yielded a statistically significant two-sided p-value of 0.0033(doxorubicin), 0.0005(vincrisitne), 0.0007(nimustine), and 0.0003(cisplatin) on U87MG cell lines and 0.0006(doxorubicin), 0.0421(vincrisitne), 0.0317(nimustine), and 0.0001(cisplatin) on T98G cell lines, respectively. However, treatment with chloroquine and primaquine did not induce a decrease in cell viability on both U87MG and T98G cell lines. Conclusion : Our data support further consideration of the use of hydroxychloroquine prior to systemic chemotherapy to maximize its tumoricidal effect for patients with malignant gliomas.ope

Treatment Strategy of Multiple Hemangioblastomas

Objective：Hemangioblastomas are highly vascular and benign neoplasm of the central nervous system(CNS). They can often be found as multiple lesions, as is commonly observed in von Hippel-Lindau(VHL) disease. The aim of this study is to determine the proper management for multiple hemangioblastomas. Methods：Since 1990, 78cases of hemangioblastoma have been encountered. Among these, 9cases were multiple hemangioblastomas that were treated with surgical resection with or without radiosurgery. The medical, radiological, surgical and histological records were reviewed retrospectively and analyzed statistically. Results：Nine patients presented with multiple hemangioblastomas and were diagnosed as VHL disease. The mean follow-up duration was 75.7months (6.6~159.2months) after the first surgical treatment. Three patients were treated with surgical resection alone and six patients were treated by both surgical resection and radiosurgery. Twenty-one surgical procedures (13 surgical resections and 8 radiosurgery) were performed. One patient required ventriculoperitoneal shunt and a posterior fossa decompressive craniectomy because of post-radiation brain swelling. Another patient refused additional treatment for the newly developed lesions after the successful treatment of initial lesions. The other patient who presented with numerous lesions in the whole brain and spine underwent cranio-spinal irradiation. Remaining patients showed good results. Conclusion：The surgical outcomes for the patients with a single lesion of the CNS hemangioblastoma are favorable. However, the treatment of multiple hemangioblastoma is more difficult, and should be treated by surgical resection and radiosurgery with careful consideration.ope

정신지체 여학생을 위한 상황중심 성폭력 예방프로그램의 효과

정신지체인의 성폭력 발생현황과 성폭력 피해로 인한 후유증의 심각성을 고려할 때, 정신지체학생에게 성폭력 예방프로그램을 실시하고 이를 통하여 성폭력 예방기술을 습득하게 하는 것은 매우 중요한 일이다. 그러므로 본 연구에서는 정신지체 중등부 여학생에게 성폭력 예방기술을 습득시키기 위하여 상황중심 성폭력 예방프로그램을 실시하고 그 효과를 알아보고자 하였다. 본 연구는 중등부 정신지체 여학생의 성폭력 예방기술을 교육현장에서 지도하기 위하여, 성폭력에 대한 정보 얻기, 성폭력적 행위를 구별하기, 성폭력적 상황에서 안전하게 반응하기 등을 10가지 역할극을 통하여 지도하는 상황중심의 성폭력 예방프로그램을 실시하였다. 실험설계는 대상자간 중다간헐기초선 설계이며 중재는 역할극을 중심으로 훈련하고, 평가는 대상자가 친숙한 사람에 의해 성폭력이 행하여 질 수 있는 상황은 대상자가 잘 아는 연구보조자에 의해서, 낯선 사람에 의해 성폭력이 행하여질 수 있는 상황은 대상학생이 알지 못하는 연구보조자에 의해서 자연스러운 상황에서의 평가가 실시되었다. 일반화 평가는 장소와 상황의 일반화를 위하여 대상자의 하루일과 중에서 자주 접하는 장소와 상황에서 평가를 하였으며 중재가 종료된 4주 후에 유지검사를 실시하였다. 본 연구를 통해 얻은 결과는 다음과 같다. 첫째, 상황중심 성폭력 예방프로그램을 정신지체 중등부 여학생에게 실시하였을 때 성폭력 예방기술 수행점수가 증가하였다. 둘째, 상황중심 성폭력 예방프로그램을 정신지체 중등부 여학생에게 실시하였을 때 성폭력 예방기술 수행이 대상자의 하루일과 중에서 자주 접하는 장소와 상황으로 일반화되었다. 셋째, 상황중심 성폭력 예방프로그램을 정신지체 중등부 여학생에게 실시하였을 때 성폭력 예방기술이 중재 종료 4주 후까지 유지되었다. 위와 같은 결과를 통하여 상황중심 성폭력 예방프로그램은 정신지체 중등부 여학생들에게 성폭력 예방기술을 습득하게 하는데 효과적임을 알 수 있었다. 이는 정신지체인의 성폭력 예방교육이 거의 실시되지 않고 있는 교육현장에서 성폭력 예방프로그램을 실시하고 그 효과를 확인해 볼 수 있는 계기가 되었으며 정신지체 학생들을 위한 성폭력 예방프로그램이 거의 없는 현실에서 본 연구의 프로그램을 정신지체 성폭력 예방 프로그램으로 보급할 수 있으리라 생각한다. 후속 연구에서는 보다 폭 넓은 범주의 대상학생들에게 성폭력 예방프로그램을 적용시켜보는 연구들이 필요하며 또한 정신지체 학생의 성폭력 예방기술 습득을 위해 장애 특성과 장애 정도, 성별, 생활 연령을 고려한 다양한 프로그램 개발이 요구된다.;Considering the present statistics about sexual abuse to persons with mental retardation and the seriousness of after symptoms following the sexual abuse, the practice of sexual abuse prevention program and the training of sexual abuse prevention skills are very important for the persons with mental retardation. Therefore, this study tries to assert the effect of the situation based sexual abuse prevention program for secondary female students with mental retardation. This study carried the situation based sexual abuse prevention program through which secondary school course female students with mental retardation could acquire the sexual abuse prevention skills. This program consists of ten role plays based on ten different sexual abuse situations. Through these role plays, students were expected to acquire the information about sexual behavior, the ability to discern the sexual abuse behavior and the ability to respond safely to the sexual abuse situation. The method used in this experimental study was multiple probe design across subject. It was used to examine the effects of intervention condition, generalization and maintenance. Role play was used to train students. Assessment was carried on the naturalistic situation. In order to test generalization, the assessment was carried in the place and situation with which students are very familiar. Maintenance was implemented 4 weeks after fading the intervention. The results obtained in this study are summarized as follows; First, when the situation based sexual abuse prevention program was applied to secondary female students with mental retardation, the score of performance on the skill of preventing sexual abuse increased. Second, the performance of the sexual abuse prevention skill was generalized to familiar places and situations. Third, the sexual abuse prevention skill was maintained during more than four weeks after fading the intervention. Based on the results mentioned above, it could be concluded that the situation based sexual abuse prevention program is effective. In the present school situation where the abuse prevention training for the students with metal retardation is hardly provided, this study is a significant opportunity to practice the prevention program and to assess the effects. Hopefully, this prevention program can be used and examined by other interested teachers and schools. New and subsequent studies can consider the various different categories of students according to sex, age and the degree or the characteristics of disability.논문개요 = vi I. 서론 = 1 A. 연구의 필요성 및 목적 = 1 B. 연구문제 = 5 C. 용어정의 = 6 II. 이론적 배경 = 7 A. 성폭력의 개념 및 발생현황 = 7 1. 성폭력의 개념 및 정의 = 7 2. 성폭력의 유형 = 9 3. 성폭력 발생현황 = 11 4. 성폭력 발생 및 증가원인 = 12 B. 장애인 성폭력 발생현황 및 피해의 영향 = 14 1. 장애인 성폭력 발생현황 = 14 2. 정신지체인과 관련된 성폭력 = 18 3. 정신지체인의 성폭력 발생원인 = 20 4. 성폭력 피해의 영향 = 24 C. 성폭력 예방교육 = 27 1. 성폭력 예방교육의 필요성 = 27 2. 우리 나라 성폭력 예방교육의 실태 = 28 3. 성폭력 예방교육의 방향 = 30 4. 성폭력 예방교육에 대한 선행연구들 = 32 III. 연구방법 및 절차 = 36 A. 대상학생 = 36 1. 대상학생 선정기준 = 36 2. 대상학생의 특성 = 36 B. 실험기간 및 실험장소 = 39 1. 실험기간 = 39 2. 실험장소 = 39 C. 실험자료 및 연구보조자훈련 = 40 1. 성폭력 상황 선정을 위한 기초조사 = 40 2. 실험자료 = 41 3. 연구보조자 훈련 = 43 D. 종속변인 = 44 E. 실험설계 및 절차 = 46 1. 실험설계 = 46 2. 실험절차 = 46 3. 실험에 따른 잠재적 문제점 = 50 F. 자료수집 및 관찰자간 신뢰도 = 51 1. 자료수집 = 51 2. 관찰자간 신뢰도 = 52 IV. 연구결과 = 54 A. 상황중심 성폭력 예방 프로그램이 성폭력 예방기술 습득에 미치는 효과 = 54 B. 상황중심 성폭력 예방 프로그램이 성폭력 예방기술 일반화에 미치는 효과 = 58 C. 상황중심 성폭력 예방 프로그램이 성폭력 예방기술 유지에 미치는 효과 = 59 V. 논의 및 제언 = 60 A. 논의 = 60 B. 제한점 = 70 C. 제언 = 71 참고문헌 = 72 부록 = 81 Abstract = 10

도파민 수용체 효능제와 시상밑

Dept. of Medicine/박사[한글]파킨슨병 모델의 흰쥐에 대하여 시상밑핵에 병변을 만들고 도파민 수용체 효능제를 함께 투여하여, 상승 효과를 기대할 수 있으리라는 가정하에 흑질 망상대에서 발화율과 발화 양상을 측정하였다. 몸무게 200-250 g의 수컷 흰쥐 (Sprague-Dawley rat)를 이용하였고 6-hydroxydopamine을 뇌정위 기구를 이용하여 내측전뇌다발에 주입하여 파킨슨병 모델을 제작하였다. 시상밑핵에는 kainic acid를 뇌정위 기구를 이용하여 주입하여 치료 모델을 제작하였으며, 도파민 제1 수용체 효능제인 SKF38393과 도파민 제 2 수용체 효능제인 Quinpirole은 선조체에 주입한 후 흑질 망상대에서 단일 세포의 발화유과 발화 양상을 측정하여 비교하였다. 정상군에 비하여 파킨슨병 모델에서 발화율과 극파의 비율이 증가하였고, 시상밑핵 병변을 만든 후에 의미 있게 발화율의 감소, 극파의 비율이 감소하였다. SKF38393과 Quinpirole을 주입하였을 때 파킨슨병 모델에서는 발화율과 극파 비율의 감소를 확인 할 수 있었으며, 시상밑핵 병변에 더하여 Quinpirole을 주입하였을 경우에는 발화율이 증가하였고 극파의 비율이 증가하였다. [영문]Object. It was hypothesized that dopamine agonist administration and subthalamic nucleus (STN) lesion in the rat might have a synergistic effect on the neuronal activities of substantia nigra pars reticulata (SNpr) as observed in patients with Parkinson’s disease. The effects of SKF38393 (a D1 receptor agonist) and Quinpirole (a D2 receptor agonist) were compared in parkinsonian rat models with 6- hydroxydopamine (6-OHDA) after STN lesion. The changes of the firing rates and firing patterns of SNpr neurons were analyzed.Methods. SKF38393 and Quinpirole were consecutively injected intrastriatally. SNpr was microrecorded to ascertain the activity of the basal ganglia output structure. The effect of SKF38393 or Quinpirole injection on the firing rate and firing patterns of SNpr was investigated in medial forebrain bundle (MFB) lesioned rats and in MFB + STN lesioned rats.Results. The administration of SKF38393 decreased SNpr neuronal firing rates in the lesioned rats, but did not alter the mean neuronal firing rate in the SNpr neurons of MFB+ STN lesioned rats, nor induce significant changes in the percentage of burst neurons. In rats prepared from 6-OHDA, Quinpirole significantly decreased the spontaneous firing rate. However, after an additional STN lesion, it induced a significant change in the percentage of burst neurons.Conclusions. The results demonstrated that STN lesion decreases SNpr hyperactivity and the proportion of burst neurons among total neurons, but that dopamine receptor agonists, such as SKF38393 and Quinpirole, did not change the firing pattern.ope