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1 Brain & Neuroehabilitation Vol. 3, No., arch, 급성뇌졸중환자에서뇌병변의위치와상지기능의관계 : 예비연구 가톨릭대학교의과대학인천성모병원재활의학교실 정지영ㆍ김재민ㆍ김민욱 The elationship between Hand unction and Brain esion at Acute Stroke Patients: A Pilot Study Ji Young Jeong,.D., Jae in Kim,.D. and in-wook Kim,.D. Department of ehabilitation edicine, College of edicine, The Catholic University of Korea, Incheon St. ary s Hospital Objective: To determine the relationship of hand motor function recovery and Tatu s vascular territory classification of brain lesion in acute stroke. ethod: Thirty one patients with acute cerebral infarct were included. We divided them into two groups. One had cerebral lesions supplied by the leptomeningeal branches of cerebral artery and the other by the perforating branches of cerebral artery. The leptomeningeal group was subdivided into middle cerebral artery group (CA) and posterior cerebral artery group (PCA). The perforating group was again divided by perforating branch of the middle cerebral artery group (PCA) and anterior choroidal artery group (PACoA). The diffusion weighted magnetic resonance image was used as a reference image. The hand motor recovery was scored by physical examination at admission and discharge. Score was for no motion, was for synergy movement, and was for isolated hand movement. esults: Eight patients were in CA group, while 3 were in PCA group. Eight were in PCA group, and twelve patients were in PACoA group. The distribution of the hand motor recovery at admission was score (3,,5,8, for CA, PCA, PCA, PACoA), (,,,4) and (3,,,), while at discharge, score (3,,4,4), (,,,5) and (5,3,3,3). Hand functions significantly improved at discharge compared with those at admission in all groups. Especially in PACoA group, the significant better recovery at discharge was achieved.(p<.5) Isolated hand movement at discharge was significantly better at the leptomeningeal group than perforating group.(p<.5) Conclusion: Tatu s atlas may be helpful to predict the recovery of hand function for initial assessment of stroke rehabilitation. (Brain & Neuroehabilitation ; 3: 4-49) Key Words: hand motor function, stroke, tatu s atlas, vascular territory 서론 뇌졸중환자에서운동기능의회복을예측하는지표가명확하게확립되어있는것은아니지만, 일반적으로발병후수일내의초기운동마비의정도는운동기능의회복을예측할수있는가장중요한임상적지표이다. -3 뿐만아니라뇌졸중환자에서뇌병변의크기는운동기능의회복정도와직접적인연관성이없으며, 대뇌피질의병변을가진경우에대뇌피질하병변을가진경우보다예후가더 접수일 : 9 년 8 월 일, 심사일 : 년 월 일게재승인일 : 년 3 월 일교신저자 : 김민욱, 인천시부평구부평 6 동 43-7, 가톨릭대학교인천성모병원재활의학과 Tel: , ax: msdykim@hanafos.com 좋은것으로알려져있다. 3-5 Shelton 등 5 은뇌병변의위치에따른상지기능의회복관계에대해연구를시행하였는데, 뇌병변을일차운동피질, 전운동영역, 보조운동영역, 대뇌부챗살 (corona radiate) 삼등분중심중앞절반, 대뇌부챗살삼등분중심중뒤절반, 속섬유막무릎 (genu of internal capsule), 속섬유막앞다리및뒷다리 (anterior and posterior limbs of the internal capsule), 기저핵 (basal ganglia) 및시상 (thalamus) 으로나누어상지운동기능의회복정도를측정하여그결과를비교하였다. 순수하게대뇌피질을침범한경우에서상지의운동기능회복이가장좋았으며, 피질및피질하병변이혼재되어있는경우에서그다음으로상지운동기능회복이좋았고, 피질하병변을가진군에서가장좋지않은결과를나타내었다. 하지만대뇌피질및피질하병변뿐만아니라혼재되어병변이존재하는경우에도속섬유막뒷다리 (posterior limb of the internal 4

2 정지영외 인 : 급성뇌졸중환자에서뇌병변의위치와상지기능의관계 : 예비연구 capsule, PIC) 가보존된경우에서는상지의운동기능회복이좋았으며, 속섬유막뒷다리및인접한대뇌부챗살, 기저핵또는시상을침범한경우에는예후가매우좋지않았다. 따라서상지운동기능의회복은대뇌의속섬유막뒷다리및대뇌부챗살, 기저핵또는시상부위와매우밀접한관계가있음을예측할수있다. 그러나실제임상적으로속섬유막뒷다리의침범여부를확인하는것이어려우며, 인접해있는기저핵나시상의침범과명확하게구별하기어려울때가많다. 한편, Tatu 등 6 은뇌자기공명영상을이용하여대뇌반구의동맥혈관지배영역 (arterial territory) 을구별하였는데, 이를임상적으로이용하면뇌졸중환자에서뇌자기공명영상을이용하여병변의위치를보다명확하게구분하고, 어떤혈관의이상이있는지쉽게알수있게되었다. 임상적으로흔히보는피질하병변의뇌졸중의경우, 전맥락총동맥 (anterior choroidal artery) 및중대뇌동맥관통가지 (perforating branches) 를침범한경우가많다. 속섬유막의뒷다리는전맥락총동맥의병변시중대뇌동맥관통가지를침범한경우보다더손상될가능성이높아두군간의상지운동기능회복에차이를보일것으로예상된다. 6 본연구에서는급성뇌졸중환자에서뇌자기공명영상을이용하여뇌병변의위치를확인하고, Tatu 등의도해를이용하여 (Appendix ) 뇌병변을뇌혈관의지배영역에따라분류한후, 상지운동기능을관찰하고그회복정도를확인하여임상적으로뇌병변의위치와상지운동기능의회복과의관계를확인하고자하였다. 연구대상및방법 본연구는급성뇌경색으로 4년 6월부터 7년 6 월까지본원재활의학과에입원한환자의병력기록검토를통해자료를수집하였다. 대상으로는발병후 3개월이내의대뇌경색환자로, 뇌줄기및소뇌병변을가진환자 는제외하였다. 사지마비환자는본연구에서제외되었으며, 상지를포함한편마비환자를그대상으로하였다. 최종적으로남자 명, 여자 9명의급성뇌졸중환자가선택되었으며, 평균연령은 6.4세였다. 뇌병변은내원하여촬영한뇌확산강조자기공명영상 (brain diffusion weighted magnetic resonance imaging, brain, DWI) 을기준으로 Tatu 등의도해를이용하여대뇌병변을지배하는혈관에따라분류하였으며, 크게표면혈관인연수막가지 (leptomeningeal branch) 와심부혈관인관통가지 (perforating branch) 로분류하고, 각각을다시세분하였다. 표면혈관은다시중대뇌동맥 (CA) 및후대뇌동맥 (PCA) 의연수막가지로분류하였으며, 심부혈관은중대뇌동맥 (PCA) 및전맥락총동맥 (PACoA) 관통가지로분류하였다 (Table ). 총 3명의환자는지배하는혈관영역에따라중대뇌동맥연수막가지 (CA) 8명, 후대뇌동맥연수막가지 (PCA) 3명, 중대뇌동맥관통가지 (PCA) 8명및전맥락총동맥 (PACoA) 병변 명으로분류할수있었다. 상지운동기능의평가는이학적검사를통하여, 손의움직임이없는경우와협동작용으로인한움직임및개별적인손가락의움직임이나타나는지에대해평가하여단계별로 점, 점, 점으로점수를부여하고, 전과및퇴원시각각평가하여비교하였다. 통계분석은 SPSS 프로그램 (version 5., SPSS Inc, Chicago, Illinois, USA) 을이용하였다. 각군간의나이및재원기간을비모수방법인 Kruskal-Wallis test를통하여분석하였다. 전과와퇴원시의상지운동기능의호전여부를 repeated measured ANOVA 를이용하여기간에따라기간 x 군간으로분석하였으며, 각군에서전과시와퇴원시의상지운동기능의호전여부를비모수방법인 Wilcoxonsigned rank test를이용하여다시분석하였다. 전과시및퇴원시의각군끼리의상지운동기능의차이를비연속변수의분석인 two-by-k 교차분석을이용하였다. 통계적유의수준은 p<.5로하였다. Table. General Characteristics of Subjects Vascular territory Number Sex (ale/emale) Brain lesion (right/left) Hospital days (days)* Age (years)* CA PCA PCA PACoA Total / / 3/5 / /9 4/4 / 3/5 8/4 6/5 3.3 (3 7) 44 ( 65) 34.5 (9 54) 8.7 (8 58) 3.3 (8 7) 57.4 (44 68) 57.7 (46 65) 68.4 (47 84) 63 (4 79) 6.4 (4 84) CA: leptomeningeal branch of middle cerebral artery, PCA: leptomeningeal branch of posterior cerebral artery, PCA: perforating branch of middle cerebral artery, PACoA: perforating branch of anterior choroidal artery. *No significant difference between each vascular territory group for hospital days and age (p=.68 by Kruskal-Wallis test for hospital days, p=.56 by Kruskal-Wallis test for age). 43

3 Brain& Neuroehabilitation:; 3: 4 49 결과 총 3명의환자들의상지운동기능을평가한결과, 전과시상지운동기능은 점이 7명, 점이 8명, 점이 6명이었고퇴원시상지운동기능은 점이 명, 점이 6명, 점이 4명으로호전된소견을보였다 (Table ). 각군간의나이및재원기간을분석하였을때통계학적인차이는보이지않았다 (p=.56 by Kruskal-Willis test for age, p=.68 by Kruskal-Willis test for hospital day, Table ). 전과와퇴원시의상지운동기능은전과시보다퇴원시에통계학적으로의미있는상지기능향상을보였으나 (p=. by repeated measured ANOVA), 4군간에는통계적인차이를보이지않았다 (p=.37 by repeated Table. Hand otor unctions of Subjects Pt. Number Sex Age Hospital days esion side Admission score Discharge score eptomeningeal branch of the cerebral artery eptomeningeal branch of the middle cerebral artery Pt. Pt. Pt. 3 Pt. 4 Pt. 5 Pt. 6 Pt. 7 Pt eptomeningeal branch of the posterior cerebral artery Pt. 9 Pt. Pt Perforating branch of the cerebral artery iddle cerebral artery perforating branch Pt. Pt. 3 Pt. 4 Pt. 5 Pt. 6 Pt. 7 Pt. 8 Pt Anterior choroidal artery Pt. Pt. Pt. Pt. 3 Pt. 4 Pt. 5 Pt. 6 Pt, 7 Pt. 8 Pt. 9 Pt. 3 Pt Pt: patient, : male, : female, : right, : left, Score : no minor hand movement, : synergic hand movement but no isolation movement, : isolated hand movement. 44

4 정지영외 인 : 급성뇌졸중환자에서뇌병변의위치와상지기능의관계 : 예비연구 measured ANOVA, 시기 x군 ). 연수막가지군 (CA+ PCA) 과관통가지군 (PCA+PACoA) 인두개의군으로비교하였을때는시기에따라서는통계적인차이를보였으나, 두군간에는통계적인차이를보이지않았다 (p=.98 by repeated measured ANOVA, 시기 x군 ). 중대뇌동맥군 (CA+PCA) 과비중대뇌동맥군 (PCA+PACoA) 으로두군을나누어비교하면두군간에도통계적인차이를보였다 (p=.39 by repeated measured ANOVA, 시기 x군 ). 즉중대뇌동맥군에비해비중대뇌동맥군에서는통 계학적으로의미있게호전되었다 (ig. ). 전과시와퇴원시의상지기능을비교하였을때, 전맥락총동맥군 (PACoA) 에서만통계적으로의미있는호전을보였다 (p=.8 by Wilcoxon-signed rank test, ig. ). 중뇌동맥관통가지군 (PCA) 과전맥락총동맥군 (PACoA) 을직접적으로비교한결과통계적으로의미있는차이는보이지않았으나 PCA 에서는 8명중 명만이전과시와비교퇴원시호전된반면 PACoA군에서는 명중 7명에서호전된소견을 ig.. Hand motor functions at discharge improved compared with those at admission (p=. by repeated measured ANOVA, time). However, there was no difference between four groups (p=.37 by repeated measured ANOVA, time x 4 groups). CA: leptomeningeal branch of middle cerebral artery, PCA: leptomeningeal branch of posterior cerebral artery, PCA: perforating branch of middle cerebral artery, PACoA: perforating branch of anterior choroidal artery. *If hand function at discharge was compared with that at admissionby Wilcoxon- signed rank test, only PACoA group showed statistically significant improvement (p=.8). ig.. Anterior choroidal artery group showed better recovery tendency during admission compared with perforating branch group in middle cerebral artery. Table 3. Cross Tables of Hand otor unctions Vascular lesion Admission outcome Hand motor functions Discharge outcome N No minor Synergy Isolated No minor Synergy Isolated eptomeningeal branch of the cerebral artery CA PCA 3 3 Total Perforating branch of the cerebral artery PCA PACoA Total n: number, Shaded area showed better discharge outcome at leptomeningeal group than perforating group by two-by-k table analysis (p=.39). CA: leptomeningeal branch of middle cerebral artery, PCA: leptomeningeal branch of posterior cerebral artery, PCA: perforating branch of middle cerebral artery, PACoA: perforating branch of anterior choroidal artery. 45

5 Brain& Neuroehabilitation:; 3: 4 49 보였다 (ig. ). 또한상지운동기능을비연속변수의분석으로 two-by-k 교차분석을시행한결과전과시에는군간의차이를보이지않았으나, 퇴원시에는연수막가지군 (CA+PCA) 과관통가지군 (PCA+PACoA) 으로분류시연수막가지군에서관통가지군보다호전된분포를보였다 (p=,39 by two-by-k table analysis, Table 3). 고찰 뇌졸중환자에서운동기능의회복정도를예측하기위한연구는많이이루어졌지만임상적으로쉽게운동기능의회복을예측할수있는지표는아직까지확립되어있지않다. -3 특히, 상지기능은일상생활동작및미세운동을수행하는데중요한역할을하므로상지기능의회복정도는뇌졸중환자에서삶의질과밀접한관련이있으나실제임상에서상지기능의회복정도를예측하는것은쉽지않다. 최근에는컴퓨터단층촬영 (computed tomography, CT) 및자기공명영상등의진단기술의발달로인해상지기능을담당하는뇌의위치를알수있게되었다. Phan 등 7 은뇌확산자기공명영상을통해상지운동영역을중심앞마디 (precentral knob) 로정의하였으며, Gass 등 8 은기능성자기공명영상 (functional I) 을이용하여상지운동영역을중심고랑 (central sulcus) 및중심앞이랑 (precentral gyrus) 으로정의하였고, 중심앞마디 (precentral knob) 의병변은모두오메가를뒤집어놓은형태의모양을나타내었다고보고하였다. Celebisoy 등 9 은뇌경색과관련하여독립적으로손의마비가있는 8명의환자를대상으로뇌자기공명영상을통하여뇌병변을확인함으로써대뇌의 Brodmann 영역 4번인중심고랑앞쪽벽의중간부터아랫쪽 (middle to lower portion of the anterior wall of the central sulcus) 이상지운동기능과밀접한관계가있다고정의하였다. 뿐만아니라 Schiemanck 등 은 75명의중대뇌동맥뇌경색을가진환자에서운동피질 (motor cortex), 대뇌부챗살및속섬유막으로뇌병변의위치를구분하고각각의부위에따른상지운동기능의회복정도를측정함으로써그예후를관찰하고자하였는데, 병변이앞에서언급한세부분의피질원심경로 (corticofugal tract) 를따라존재하는경우와속섬유막을부분적으로침범한경우에서불량한상지운동기능의회복을보였다. 이와같이상지운동기능은뇌병변의위치와밀접한관계가있기때문에임상적으로뇌졸중환자에서상지운동영역의침범여부를구분하는것이중요하다. 따라서본저자들은뇌졸중환자에서뇌병변의위치를혈관의지배영역에따라분류하고상지기능의회복정도를관찰함으로써, 임상적으로쉽게초기의 병변에따른상지기능의회복정도를예측하기위함에이연구의목적을두었다. 또한본연구에서는병변의위치확인을위해뇌확산자기공명영상을이용함으로써뇌의부종을반영할수있는 T 강조영상 (T weighted image) 보다더욱정확하게뇌경색부위를구분하고, 이를통하여지배하는혈관영역을추정하여병변의위치를보다명확하게구분하기위하여노력하였다. 저자들은본연구를통하여이미알려져있는바와같이뇌졸중환자에서초기운동마비의정도가운동회복의정도에중요함을확인할수있었으며, 대뇌표면혈관을침범한대뇌피질병변을가진경우, 대뇌심부혈관을침범한피질하병변을가진경우보다상지기능의회복이더좋음을확인할수있었다. 이는겉질척수로 (corticospinal track) 가전운동영역에서속섬유막의뒷다리를거쳐아래운동신경세포 (lower motor neuron) 로연결되므로, 운동섬유가집약되어있는이연결통로의손상이있는경우가그렇지않은경우보다운동기능의회복에불량한예후를보이기때문인것으로생각된다. 5 본연구에서는전과시보다퇴원시에앞에서분류한모든군에서상지운동기능의호전을보였으며, 중대뇌동맥을침범한군에비하여비중대뇌동맥을침범한군에서상지운동기능의회복이뚜렷하였다. 특히전맥락총동맥군에서전과시와퇴원시의상지운동기능을비교할때의미있는호전을보였다. 이는전맥락총동맥군을중대뇌동맥군으로부터분리해서생각할필요가있음을제시한다. 전맥락총동맥은일반적으로속목동맥 (internal carotid artery) 의상돌기의윗부분 (supraclinoid portion) 에서기원하여표면지배영역 (superficial territory) 으로갈고리이랑 (uncus), 해마두부 (head of the hippocampus), 편도핵 (amygdaloid nucleus) 및외측무릎체의바깥쪽 (lateral part of the lateral geniculate body) 을포함하며, 관통지배영역 (perforating territory) 으로는속섬유막의뒤쪽 /3의아랫부분및렌즈핵부분 (lower part of posterior two-thirds and the retrolenticular part of the internal capsule), 인접한시각로부챗살 (optic radiation), 청각부챗살 (acoustic radiation), 안쪽창백핵 (medial globus pallidus) 과꼬리핵의꼬리부분 (tail of the caudate nucleus) 이포함된다. -4 중대뇌동맥관통가지는일반적으로중대뇌동맥의 부분에서기원하며, 꼬리핵의머리와몸통의윗부분 (superior part of the head and the body of the caudate nucleus), 창백핵의바깥부분 (lateral segment of the globus pallidus), 조가비핵 (putamen), 속섬유막의윗쪽반절 (dorsal half of the internal capsule) 및앞맞교차의바깥쪽반절 (lateral half of the anterior commissure) 을지배한다. 5,5-9 따라서이두개의혈관만을비교한다면, 속섬유막의뒷다리를현저 46

6 정지영외 인 : 급성뇌졸중환자에서뇌병변의위치와상지기능의관계 : 예비연구 히침범하는전맥락총동맥에병변이있을경우, 중대뇌동맥관통가지를침범했을때보다운동기능의회복에대한예후가나쁠것으로예측되었다. 그러나본연구결과에의하면전맥락총동맥의병변이있는경우전과시보다퇴원시에보다양호한결과를보이는것으로보아침범된속섬유막의병변이불완전하게침범되는것을시사한다고생각한다. 그러므로환자에게보다향후호전될것에대한지지적인도움말을줄수있을것으로생각한다. 본연구의제한점으로는연구의표본수가충분하지않아더욱다양한혈관의지배영역에해당하는환자에대한비교가어려웠으며, 환자의재원기간도 8일에서 7일로그변화가다양하여상지기능의회복정도를확인하기에충분하지않았던점들이영향을미쳤을것으로사료된다. 또한, 상지기능의평가를시행하는방법에대해서도병력기록검토를통하여자료수집을하게되어자세하고신뢰도가인정된평가방법을완벽하게이용하지못한것도본연구의제한점이라고할수있겠다. 따라서추후에는전향적연구를통하여표본수의확대및추적관찰기간의조절이필요할것으로사료되며, 신뢰도가인정된 ugel- eyer otor Assesment Scale 과같이상지의기능을평가할수있는도구를이용하여상지기능을자세하게평가하여그차이를확인하는것이보다정확하게뇌병변의위치에따른상지기능의회복정도를예측하는데도움이될것으로생각되며본연구를바탕으로추가적인연구가시행되어야할것으로생각된다. 결론 급성기뇌경색환자를대상으로 Tatu 의뇌혈관분포에따른병변부위와상지기능의회복정도의연관성을알아본바, 상지운동기능은전과시보다퇴원시의미있게호전되었으며, 특히전맥락총동맥경색환자군에서호전되는정도가높았다. 표면혈관을침범한경우심부혈관을침범한경우보다양호한회복을보였다. 그러므로 Tatu의도해서 (atlas) 를참고로뇌경색환자의병변부위를분석하는것이상지운동기능의예후예측에도움을줄것으로생각한다. 참고문헌 ) Hendricks HT, van imbeek J, Geurts AC, Zwarts J. otor recovery after stroke: a systematic review of the literature. Arch Phys ed ehabil. ;83: ) acciocchi SN, Diamond PT, Alves W, ertz T. Ischemic stroke: relation of age, lesion location, and initial neurologic deficit to functional outcome. Arch Phys ed ehabil. 998; 79: ) Binkofski, Seitz J, Hackländer T, Pawelec D, au J, reund HJ. ecovery of motor functions following hemiparetic stroke: a clinical and magnetic resonance-morphometric study. Cerebrovasc Dis. ;:73-8 4) Noskin O, Krakauer JW, azar, esta J, Handy C, O'Brien KA, arshall S. Ipsilateral motor dysfunction from unilateral stroke: implications for the functional neuroanatomy of hemiparesis. J Neurol Neurosurg Psychiatry. 8; 79:4-46 5) Shelton N, eding J. Effect of lesion location on upper limb motor recovery after stroke. Stroke. ;3:7-6) Tatu, oulin T, Bogousslavsky J, Duvernoy H. Arterial territories of the human brain: cerebral hemispheres. Neurology. 998;5: ) Phan TG, Evans BA, Huston J. Pseudoulnar palsy from a small infarct of the precentral knob. Neurology. ;54:85 8) Gass A, Szabo K, Behrens S, ossmanith C, Hennerici. A diffusion-weighted I study of acute ischemic distal arm paresis. Neurology. ;57: ) Celebisoy, Ozdemirkiran T, Tokucoglu, Kaplangi DN, Arici S. Isolated hand palsy due to cortical infarction: localization of the motor hand area. Neurologist. 7;3: ) Schiemanck SK, Kwakkel G, Post W, Kappelle J, Prevo AJ. Impact of internal capsule lesions on outcome of motor hand function at one year post-stroke. J ehabil ed. 8; 4:96- ) Gibo H, enkey C, hoton A Jr. icrosurgical anatomy of the supraclinoid portion of the internal carotid artery. J Neurosurg. 98;55: ) Saeki N, hoton A Jr. icrosurgical anatomy of the upper basilar artery and the posterior circle of Willis. J Neurosurg. 97;46: ) ujii K, enkey C, hoton A Jr. icrosurgical anatomy of the choroidal arteries: lateral and third ventricles. J Neurosurg. 98;5: ) arinković S, ilisavljević, Puskas. icrovascular anatomy of the hippocampal formation. Surg Neurol. 99;37: ) Gibo H, Carver CC, hoton A Jr, enkey C, itchell J. icrosurgical anatomy of the middle cerebral artery. J Neurosurg. 98;54:5-69 6) osner SS, hoton A Jr, Ono, Barry. icrosurgical anatomy of the anterior perforating arteries. J Neurosurg. 984;6: ) arinkovic SV, ilisavljevic, Kovacevic S, Stevic ZD. Perforating branches of the middle cerebral artery. icroanatomy and clinical significance of their intracerebral segments. Stroke. 985;6:-9 8) arinković SV, Kovacević S, arinković J. Perforating branches of the middle cerebral artery. icrosurgical anatomy of their extracerebral segments. J Neurosurg. 985;63:66-7 9) Umansky, Gomes B, Dujovny, Diaz G, Ausman JI, irchandani HG, Berman SK. The perforating branches of the middle cerebral artery. A microanatomical study. J Neurosurg. 985;6:

7 Brain& Neuroehabilitation:; 3: 4 49 Appendix. Tatu s Atlas. 6 48

8 정지영외 인 : 급성뇌졸중환자에서뇌병변의위치와상지기능의관계 : 예비연구 Appendix. Tatu s Atlas. 6 (continued) 49

2-1

2-1 Part Brain, Head & Neck PART Brain, Head & Neck Overview of brain Caudate nucleus Nucleus accumbens Globus pallidus Subthalamic nucleus Putamen Substantia nigra Cerebral corter Thalamus Nucleus subthalamicus