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1 원저접수번호 :09-029(2 차 -0710) 뇌졸중홍보캠페인에사용된대표적인다섯가지대표적뇌졸중증상의타당도조사 울산대학교의과대학울산대학교병원신경과, 을지대학교의과대학대전을지대학교신경과 a, 동국대학교의과대학경주병원신경과 b, 분당서울대학교병원뇌졸중센터신경과 c, 인제대학교의과대학일산백병원신경과 d 김욱주고영채 a 박정현 b 반별님 c 한문구 c 조용진 d 배희준 c Validation of Five Cardinal Symptoms Used for Stroke Awareness Campaign Wook-Joo Kim, MD, Youngchai Ko, MD a, Jung Hyun Park, MD b, Byeolnim Ban, MD c, Moon-Ku Han, MD c, Yong-Jin Cho, MD d, Hee-Joon Bae, MD c Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea Department of Neurology a, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea Department of Neurology b, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea Department of Neurology c, Stroke Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang, Korea Department of Neurology d, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Ilsan, Korea Background: For the improvement in stroke care, we have campaigned for stroke warning signs and its symptoms. However, few reports on the validation of symptom selection in the campaign have been published till now. Methods: Based on the prospective stroke registry, patients were identified, who were hospitalized with stroke within 7 days from the stroke onset and had relevant lesions on their brain images. One presenting symptom was selected in each patient through review of electronic medical records by an investigator, and those collected symptoms were classified into 5 symptom categories or the unclassified. Those 5 symptom categories were developed and are being used in the stroke awareness campaign in 2009 by the Korean Stroke Society (KSS). Results: A total of 3027 patients (age, 66.57±12.6 years; male, 58.2%) were enrolled in our study. The rate of frequency of each categorized symptom was 54.9% for unilateral numbness or weakness, 27.5% for confusion or speech disturbance, 2.8% for visual disturbance, 10.5% for dizziness or gait disturbance, 2.3% for severe headache, and 2.0% for the unclassified. Ninety-eight percent of stroke patients were classified into one of the 5 symptom categories. Confusion or speech disturbance was associated with the shorter pre-hospital delay, whereas dizziness or gait disturbance with the longer delay. Dizziness was the most frequent symptom in TIA, and so was severe headache in hemorrhagic stroke. Conclusions: Our study shows that the 5 stroke warning symptoms of the KSS campaign represent well the presenting symptoms of Korean patients with acute stroke or TIA. J Korean Neurol Assoc 31(1):15-20, 2013 Key Words: Campaign, Presenting symptom, Stroke awareness Received August 13, 2012 Revised October 4, 2012 Accepted October 4, 2012 *Hee-Joon Bae, MD Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seoul National University College of Medicin, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam , Korea Tel: Fax: braindoc@snu.ac.kr * 본연구는보건복지부보건의료연구개발사업의지원에의하여이루어진것임 ( 과제고유번호 : A102065). 서론 뇌졸중은우리나라에서악성신생물다음으로많은사망원인이며, 단일장기로는가장흔한사망원인이고, 1 심각한장애를남기는경우가많아개인과사회적손실이큰질환이다. 따라서뇌졸중에대한적극적인일차예방과질병발생시적절한치료를통해장애를최소화하는것이중요하다. 특히최근 J Korean Neurol Assoc Volume 31 No. 1,

김욱주고영채박정현반별님한문구조용진배희준 호소하는증상에대한체계적인대규모연구는아직없었다. 저자들은 뇌졸중갑자기 5 (Five) 캠페인에사용된다섯가지증상군에따라서급성뇌졸중과일과성허혈발작으로병원에온환자가호소한증상을분류하고그분포를평가하여, 캠페인에서사용된증상체계가우리나라에서적절한지를알아내고, 다섯가지주증상과내원시간과의관계와임상특성을조사해보고자하였다.

2 김욱주고영채박정현반별님한문구조용진배희준 호소하는증상에대한체계적인대규모연구는아직없었다. 저자들은 뇌졸중갑자기 5 (Five) 캠페인에사용된다섯가지증상군에따라서급성뇌졸중과일과성허혈발작으로병원에온환자가호소한증상을분류하고그분포를평가하여, 캠페인에서사용된증상체계가우리나라에서적절한지를알아내고, 다섯가지주증상과내원시간과의관계와임상특성을조사해보고자하였다. 대상과방법 Figure 1. The Korean stroke society used this logo for stroke awareness campaign in 뇌졸중급성기치료가많이발전하여증상발생후빨리병원에도착하는것이중요해졌다. 2 하지만우리나라에서혈전용해술을받은환자는 2002년부터 2004년까지한조사에서는 2.1%, 2005년연구에서는 4.6% 뿐이였으며, 이렇게혈전용해술치료가낮은가장큰이유는병원에늦게오기때문이다. 3,4 내원시간지연이급성기뇌졸중환자치료에서매우중요한장애요인이므로, 효과적인치료를위해서환자가빠른시간에병원에도착할수있도록하는것이중요하다. 미국노스캐롤라이나주의한병원에서한연구에의하면, 뇌졸중증상에대한홍보와교육후에발병 24시간내에병원에온환자가 39% 에서 86% 로증가하였다고하였으며, 5 국내에서한병원에서진행된뇌졸중환자를대상으로한연구에서 발병 3시간이내에병원으로와야한다 는것을알고있는것이치료시간내병원도착에영향을미친다고보고하였다. 6 이렇듯환자의지식과내원시간사이에연관성이있으므로, 7 일반인에게뇌졸중증상에대한지식을증가시키기위해선진국에서는 5 Stroke Warning Sign, 8,9 FAST, 10 Give me Five for stroke 11 같은홍보활동을하고있으며, 대한뇌졸중학회에서도 2009년 뇌졸중갑자기 5 (Five) 12 라는캠페인을통해일반대중의뇌졸중증상에대한인식을향상시키려노력하였다 (Fig. 1). 이와더불어일반인을대상으로한캠페인에서활용된뇌졸중증상이실제뇌졸중발병시환자가호소하는증상을얼마나대표할수있는지에대해보다체계적인역학조사의필요성이대두되었다. 실제우리나라에서뇌졸중발생후병원도착이늦어지는원인과일반대중의뇌졸중인식에대한연구가있었지만, 6,13-15 우리나라의뇌졸중환자가뇌졸중발생시 전향적으로변함없이수집한분당서울대병원뇌졸중센터의등록자료를기반으로, 2004년 1월부터 2009년 3월까지분당서울대병원신경과에입원한발병 7일이내의환자중뇌영상검사에서증상및징후를설명할수있는병변이보인급성뇌졸중과일과성허혈발작 (TIA) 환자를대상으로하였다. 뇌졸중은세계보건기구 (WHO) 정의에따라 혈관원인에의한 24시간이상지속되거나사망을초래하는갑자기발생하는국소또는전반적뇌기능장애가나타나는임상징후 로하였으며, 16 출혈과허혈뇌졸중모두를포함하였다. 일과성허혈발작의경우 혈관원인에의한신경계증상이발생하여 24시간이내에완전히소실되는경우 라고정의하였다. 17 뇌졸중갑자기 5 (Five) 캠페인에서사용된증상군은모두 5가지로 1) 갑작스런편측팔다리또는얼굴의위약감혹은감각이상 ( 편측마비, Paralysis), 2) 갑작스런의식장애혹은언어장애 ( 언어장애, Speech), 3) 갑작스런시야장애 ( 시각장애, Vision), 4) 갑작스런보행장애 ( 편측위약이명확하지않은 ) 혹은어지럼이나균형잡기장애 ( 어지럼, Dizziness), 5) 원인이설명되지않는갑자기심한두통 ( 심한두통, Headache) 이다. 12 한명의훈련받은연구원 (BNB) 이평상어로기술되어있는환자의내원시의무기록 ( 초진기록 ) 중주소 (chief complain) 와병력 (present illness) 을검토하여병원에온직접적인이유를위의 5가지증상을참고하여조사하였고, 분류된증상은우선순위를정하여수집하였다. 가장중요한증상이라고판단한한가지증상을주증상으로정하였으며, 주증상을하나로정의하는것이어렵거나명확하지않을때는응급실간호정보지혹은일반간호정보지의주증상과입원동기를확인하고초진기록과비교하여검토하였고, 이후연구원의판단으로응급실에오게된이유로가장근접한것을주증상으로선택하였다. 다섯가지증상군으로분류할수없는증상인경우에는기타 (unclassified) 로분류하였다. 연구원의판단에대한신뢰도를확인하기위해 50명을무작위표본추출 (random sampling) 하여뇌졸중전임의 (KWJ) 가내원시의무기록외아무정보가없는 16 대한신경과학회지제 31 권제 1 호, 2013

3 뇌졸중홍보캠페인에사용된대표적인다섯가지대표적뇌졸중증상의타당도조사 상태에서주증상을분류한뒤, 이를연구원의결과와비교하였으며, 일치도 (kappa value) 는 0.85였다. 나이, 성별, 뇌졸중위험인자, 증상발생시간과내원시간, 질병력, 미국국립보건원뇌졸중척도 (National Institute of Health Stroke Scale, NIHSS), 18 Trail of Org in Acute Stroke Treatment (TOAST) 분류 19 에대한정보는뇌졸중등록체계데이터베이스나전자의무기록열람을통해서수집하였다. 본연구에서는응급실에온뇌졸중환자의다섯가지주요증상군의빈도를조사하였다. 환자의기본적인특성과내원시간, 뇌졸중위험인자는범주형인경우빈도와분율로, 연속형인경우평균과표준편차, 혹은중앙값을사용해표기하였다. 증상에따른임상특성을분석하기위해, 각증상군의빈도가성별에따라차이가있는지, 뇌졸중종류에따라차이가있는지에대하여카이제곱 (Chi-spuare) 검정을하였다. 발병후내원까지소요된시간에따라호소증상의차이가있는지를확인하기위해발병부터병원도착까지소요된시간을환자의분포와임상적유용성을고려하여 4구간으로분류하였고, 각구간에서다섯가지주증상의발생빈도를기술하였다. 나이와증상의종류에차이를보기위해나이를 55세미만부터 10년간격으로구분하여각연령군에서다섯가지주증상의빈도를기술하였다. 모든통계분석은 SPSS for Windows (version 17.0, Chicago, US) 을사용하였으며, 통계적유의수준은 0.05 미만으로정의하였다. 결과 2004년 1월부터 2009년 3월까지 7일이내의급성뇌졸중과일과성허혈발작으로분당서울대병원에입원한환자는 3,027 명이었다. 평균연령은 66.57±12.5세 ( 평균 ± 표준편차 ) 였고, 남자가조금더많았다 (Table 1). 허헐뇌졸중의비율이 79.7% 로출혈뇌졸중과일과성허혈발작보다높았다. 이들중 3시간이내에도착한환자는 29.3% 였다. 내원시호소한증상은편측마비가가장많았으며 (54.9%), 언어장애 (27.5%), 어지럼 (10.5%) 의순서로흔하게발생하였다 (Table 2). 다섯가지증상어디에도들지않는경우 (Unclassified) 는 61명 (2%) 밖에되지않았다. 이 2% 의환자중가장많은경우는일시적인기억상실 (22명) 이었으며, 비정상적인행동 (abnormal behavior), 지남력장애 (disorientation), 연하곤란 (swallowing difficulty), 청각상실 (hearing loss) 순으로발생하였다. 각증상중에서편측마비와언어장애가주증상인환자가더일찍병원에도착하는경향이있었으며, 시각장애와심한두통이주증상인환자는병원에늦게오는경향이있었다 (Fig. 2). Table 1. Baseline characteristics of subjects (N=3027) Characteritics Male 1761 (58.2) Age (years) 66.57±12.6 < (17.3) (21.9) (32.5) (22.4) (5.8) FAT to Arrival time (hours) 9.45 (2.37 to 36.38) <3 886 (29.3) (25.2) (24.2) > (21.3) NIHSS at admission 4 (1 to 8) Risk factor Hypertension 1897 (62.6) Diabetes Mellitus 812 (26.8) Hyperlipidemia 480 (15.9) Smoking 1077 (35.6) Atrial fibrillation 136 (4.5) Prior TIA 175 (5.8) Prior stroke 630 (20.8) Stroke type Ischemic stroke 2411 (79.6) Hemorrhagic stroke 320 (10.6) TIA 296 (9.8) TOAST classification (Ischemic stroke only) Small vessel occlusion 498 (20.6) Large artery atherosclerosis 937 (38.8) Cardioembolism 487 (20.2) Other cause 63 (2.6) Undetermined cause 426 (17.7) Prestroke mrs 0 to (91.0) 3 to (9.0) Value presented as number (%) or mean ± standard deviation or median (interquartile range). FAT; first abnormal time, TIA; transient ischemic attack, mrs; modified Rankin scale < 3 hours 3-12 hours hours >48 hours Paralysis Speech Vision Dizziness Headache Figure 2. The bar chart showed changes of the presenting symptoms according to arrival time. The number represented a proportion of each symptom within the set time (%). J Korean Neurol Assoc Volume 31 No. 1,

4 김욱주고영채박정현반별님한문구조용진배희준 Table 2. The frequencies of presenting symptoms in overall and by sex or stroke type Symptom Overall Sex Stroke Type Male Female p a IS HS TIA p a All patients 1761 (58.2) 1266 (41.8) < (79.6) 320 (10.6) 296 (9.8) <0.01 Paralysis 1661 (54.9) 991 (56.3) 670 (52.9) (54.8) 187 (58.4) 153 (51.7) 0.24 Speech 832 (27.5) 443 (25.2) 389 (30.7) < (28.2) 81 (25.3) 70 (23.6) 0.16 Vision 84 (2.8) 61 (3.5) 23 (1.8) < (2.8) 7 (2.2) 10 (3.4) 0.67 Dizziness 318 (10.5) 183 (10.4) 135 (10.7) (10.4) 20 (6.3) 48 (16.2) <0.01 Headache 71 (2.3) 45 (2.6) 26 (2.1) (2.0) 17 (5.3) 5 (1.7) <0.01 Unclassified 61 (2.0) 38 (2.2) 23 (1.8) (1.8) 8 (2.5) 10 (3.4) 0.15 Value presented as number (%). Each symptoms represent words in a parenthesis; Paralysis, Speech, Vision, Dizziness, Headache. IS; ischemic stroke, HS; hemorrhagic stroke. a p value is for chi-square test. 70% 60% 50% 40% 30% 20% 10% 0% < (years) Paralysis Speech Vision Dizziness Headache Figure 3. The stroke symptoms occurred differently depending on age. 성별차이는언어장애가여성에서더많았고, 시각장애는남자에서더자주발생하였다. 뇌졸중종류에따른증상의차이에서어지럼이일과성허혈발작에서빈번하게나타났으며, 출혈뇌졸중에서는적게나타났다. 하지만, 심한두통은출혈뇌졸중에서가장흔하였다 (Table 2). 연령으로분류하면편측마비와두통은 55세이하에서 57.6% 와 4.4% 발생하였고 85세이상에서는 48.9% 와 1.3% 로나이가많아질수록줄어드는양상을보였다. 반대로언어장애는 55세이하에서는 24.1% 의빈도였으나 85세이상에서는 40.9% 로나이가많아지면급격히증가하였다 (Fig. 3). 고 찰 이연구는대한뇌졸중학회의 2009년 뇌졸중갑자기 5 (Five) 캠페인에서사용된뇌졸중의다섯가지대표증상을이용하여실제국내뇌졸중환자의내원시주된호소증상의발생빈도와그역학적특성을조사한첫대규모조사이다. 전체환자의 98% 가다섯가지증상중한가지를주호소로응급실에왔고, 가장많은것이편측위약과감각이상이였다. 1990년대대전의 한대학병원에서발표한자료에의하면주호소가운동장애인경우가 28%, 의식장애와어지럼이각각 25%, 23% 로빈도의차이가없었다. 20 이는본연구와비교할때운동증상이적은편이며, 의식장애와어지럼이많은양상이다. 하지만미국에서 2009년발표된한연구에서는편측마비가 52%, 언어장애 / 의식장애가 28%, 시각장애가 4.8%, 어지럼이 13.7%, 두통 8.3% 로본연구와비슷한분포를보였다. 21 또한증상의정의가조금씩다르기는하지만외국의몇몇대규모연구에서도편측마비증상이가장빈번하고, 의식장애 / 구음장애가그다음으로많이발생하여, 본연구와비슷하였다 내원시간에따른분포를보면편측마비와의식장애의경우빨리병원에오는경향이있으며, 두통과어지럼환자는늦게오는경향이있었다. 이결과는편측마비와의식장애환자가내원까지걸리는시간이짧다는이전연구와일치한다. 20,21,25 다만, 본연구에서다섯가지증상군에속한환자들의미국국립보건원뇌졸중척도중앙값 (median) 은편측마비와의식장애의경우 4였고, 시각장애는 2, 어지럼과심한두통은 1로나타났는데, 이는미국국립보건원뇌졸중척도점수가높을수록병원에더빨리온다는 2009년전남지역의보고를고려할때주증상의종류못지않게뇌졸중중증도도내원시간에영향을줄수있을것으로생각한다. 6 편측마비와의식장애가전체뇌졸중증상의 80% 를넘게차지하여, 이두증상을집중적으로홍보하는것이효과적일수있지만, 이증상군은이미일반대중이잘인식하고있어서빨리병원에온다는점을감안한다면, 향후뇌졸중홍보전략에서는어지럼과심한두통환자가병원에빨리오도록하는교육이필요하다고생각한다. 특히약 10% 의어지럼이주증상인환자에서병원도착이지연되는데이를개선하기위한대책이꼭필요하다. 최근뇌졸중치료의성별차이에대한연구에따르면여성이남성에비해급성기혈전용해술을받을확률이 30% 이상낮 18 대한신경과학회지제 31 권제 1 호, 2013

5 뇌졸중홍보캠페인에사용된대표적인다섯가지대표적뇌졸중증상의타당도조사 고, 26 증상발생부터내원까지의시간도늦어지는경우가많았다 이러한차이는남녀간에뇌졸중주증상의차이때문일것으로추정된다. 여성에서편측위약혹은마비, 시각장애와같은전형적인증상 (traditional symptom) 보다는통증이나의식변화와같은비전형적인증상 (non-traditional symptom) 이더많다는보고에서, 30 통계적으로유의하지는않았지만편측마비와시야증상이남성에서더많이발생하였고, 의식장애는여성에서통계적으로유의하게많았으며, 언어장애는비슷하게발생하였다. 또다른연구에서는의식장애가여성에서 1.4 배많다는보고도있다. 31 본연구에서도남성에게편측마비와시각장애증상이많았고, 의식장애가포함된언어장애는여성에서더많이발생하였다 (Table 2). 본연구와동일한증상분류를사용했던미국의연구 21 에서도비슷한양상을보였고, 독일의인구집단기반연구 (population-based study) 에서도남성에서안면위약, 편측위약, 감각장애와같은편측마비와연관된증상이통계적으로유의하게많이발생한다고보고하였다. 22 본연구와동일한증상분류는아니지만, 서울에있는한지역응급의료센터에 2년동안병원에온환자를조사한결과편측마비와어지럼, 시각장애같은증상은모두남성에서많이나타났으나, 이전연구와는상이하게의식장애도남성에서많이나타났다. 27 하지만한지역응급의료센터에서비교적적은 325 명의환자를대상으로한연구임을고려해야하겠다. 본연구와대부분의이전연구결과를종합할때편측마비와연관된증상은남성에서더많이발생하였고, 의식장애와연관된증상은여성에서더많이발생하였다. 하지만본연구에서는비전형적인증상에대한조사가자세하게이루어지지않아여성에게더많이발생한다고알려진비전형적인증상빈도가상대적으로낮게측정되었을가능성이있다. 본연구의한계점으로첫째, 본연구는단일병원신경과에온환자를대상으로하였다. 지역과병원의특성은뇌졸중환자의임상특성에영향을미칠수있기때문에 32,33 본연구결과를한국인전체로확대해석하는데주의가필요하다. 다만, 본연구의주요결과가이미발표된외국의대규모연구결과와큰차이가없고, 약 5년동안 3,000명이상의환자를대상으로한대규모연구이므로어느정도일반화가가능할것으로생각한다. 둘째, 본연구는후향연구로환자의말을의료진이다시의무기록에작성한것을기반으로하였다. 이상적으로는환자가한말을그대로적는것이질병에대한의사의편견없이환자의호소증상을알수있는가장좋은방법이지만, 응급실사정상진단이이루어진후기록이작성되는일이빈번하기때문에의사가최종진단에맞추어주증상을기록하였을가능성이있다. 따라서실제보다다섯가지주증상을호소한 환자의비율이높게나타났을가능성이있다. 미시간주의연구에서는다섯가지주증상을호소한사람이약 80% 라고보고하였으나 21 우리는이보다도더높았다. 또한명의연구원이기록을분류하였기때문에연구원의편견으로오류가발생했을가능성도고려하여야할것이다. 다만, 연구원과뇌졸중전임의사이에무작위표본추출분석결과를비교하였을때비교적높은일치도를보였으므로연구원의해석오류가크지는않을것으로생각한다. 셋째, 우리연구는주증상군에따라환자특성을비교하기위해증상을주증상하나로제한하였다. 하지만실제환자가호소하는주증상이두개이상인경우가 80% 이상이라는국내보고가있었으며, 27 외국에서도환자의 58% 가두가지이상의증상을호소한다고보고하였다. 31 본연구에서주증상을하나로제한하였기때문에실제많은비전형적인증상이드러나지않았을것이다. 다만, 이조사의목적이캠페인에서사용했던다섯가지주요뇌졸중증상에대한타당도검증과향후연구방향설정을위한것이고, 실제환자가병원에왔을때가장중요하게호소한증상한가지를선택하도록연구를설계하였으므로, 이결과를뇌졸중증상에대한홍보와응급실에오기까지의소요시간을줄이기위한캠페인개발에사용할수있다고생각한다. 넷째, 환자군의사회-경제적상태, 교육정도에대한정보를얻지못하여위특성과뇌졸중증상과의연관성을조사하지못한것도본연구의제한점이다. 2009년대한뇌졸중학회는 뇌졸중갑자기 5 (Five) 캠페인 을통하여다섯가지주요뇌졸중증상을집중적으로홍보하였다. 2004년부터약 5년간의환자를대상으로한본연구에서이다섯가지주증상이뇌졸중환자가처음병원에와서호소하는주된증상의대부분을차지하고있음을확인할수있었다. 따라서이들다섯가지증상에대한집중적인홍보는적절하다고생각하며, 이번연구의결과가뇌졸중환자의내원지연을감소시킬수있는적절한뇌졸중캠페인의설계와홍보에도움이될것으로생각한다. REFERENCES 1. Office KNS. Annual Report on the Cause of Death Statistics Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38: J Korean Neurol Assoc Volume 31 No. 1,

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Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical