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1 증례 대구가톨릭대학교의과대학신경과학교실 A Follow up Study of Cognitive Dysfunction after High Voltage Electric Injury: a F-18 FDG-PET Study Oh Dae kwon, M.D., Jae Hyuk Kwak, M.D., Jae Han Park, M.D. Department of Neurology, School of Medicine, Catholic University of Daegu, Daegu, Korea We report a 43-year-old male who suffered cognitive dysfunction after an electric injury. He underwent evaluation for cognitive dysfunction and cerebral glucose hypometabolism at 1 week and 6 months. In contrast to the progressive decline of frontal lobe functions and visuospatial functions, memory and depressive mood were improved. SPM99 showed hypometabolic areas in the frontal and occipital lobes which were widened. Moreover new cingulate lesions appeared. This illustrates that the progression of derangement of cerebral glucose metabolism is correlated with neuropsychological impairment. J Korean Neurol Assoc 25(4): , 2007 Key Words: Electric injuries, Neuropsychology, Positron-emission tomography 고압전기는전기에의한사망을일으킬수있는요인중하나이며이로인한신경학적손상은대뇌손상, 척수손상및말초신경손상등으로분류할수있다. 1 대뇌손상으로인한후유증으로는의식소실, 경련, 기억력저하, 감정변화및두통등이있다. 그러나고압전기에의한인지기능의저하와관련된연구는많지않고 2 F-18 FDG-PET 을이용한연구는아직보고된바가없다. 저자들은고압전기손상을받은환자에서인지기능저하를신경심리검사와 F-18 FDG-PET 으로검사하고추적검사를시행하여그변화를관찰하였다. 증례 Received May 7, 2007 Accepted July 3, 2007 *Oh-Dae Kwon, M.D. Department of Neurology, School of Medicine, Catholic University of Daegu, Daemyung 4-dong, Nam-gu, Daegu, , Korea Tel: Fax: dolbaeke@cu.ac.kr 43세남자가고압전선에발생한화재를진압하다가 22,900 V의전압선에감전되었다. 전류가왼쪽손을통해오른쪽무릎으로빠져나간후수분정도의의식소실이있었다. 깨어난후가까운사람들을잘못알아보고들은말을금방잊어버리며공장일에대한결정을하기어렵게되어본원응급실로이송되었다. 부인과환자는고등학교를졸업하였고사고가나기전까지공장을경영하였으며사장으로서의업무수행과운전, 일상생활에는아무문제가없었다. 응급실내원시활력징후는정상이었고이학적검사에서왼쪽중지와팔꿈치, 오른쪽무릎에화상이있었다. 감전 7일째뇌 MRI 와 F-18 FDG-PET, 신경심리검사인서울신경심리선별검사 (Seoul Neuropsychological Screening Battery; SNSB) 를시행하였다. 환자는부인과함께외래를다니면서기억력과우울한기분은약간호전이된다고하였으나공장을경영하는데필요한계획을잘세울수가없었고예전보다판단할때시간이많이걸렸다. 거래처와계약을할때실수를하는경우가있어부인이거래를할때동행하여야하였다. 게다가운전을할때정지신호인데도지나치는경우가종종있었고조금씩증상이더심해졌다. 부인이조수석에 544

2 FIgure 1. SPM analysis of the brain F-18 FDG PET at 7 days after electric injury. This shows low metabolic area in anterior corpus callosum, left primary motor area and left secondary visual cortex. 앉아있다가왜신호를무시하느냐고물으면그제서야 아빨간불이지 하고반응하였다. 이러한증상이지속되어추적신경심리검사와 F-18 FDG PET 검사를시행하게되었다. 감전사고후 7일째시행한최초신경심리검사에서는 K- MMSE 27점, CDR 0.5 점이었다. 또한이름대기능력과계산능력의저하가있었고복합도형베끼기 (Rey complex figure copy) 는정상범위였다. 언어기억과시각기억이감소되었는데그중지연회상이재인능력보다더심하게저하되었다. 도형번갈아그리기 (Alternating square & triangle) 에서도형의모양이변형되었고단어유창성은정상소견이었다. 우울증척도 (Geriatric depression scale) 는 19점으로가벼운우울증을시사하였다. F-18 FDG PET 결과는 SPM99 으로정상대조군과비교 분석하였고우측뇌량 (corpus callosum) 의앞부분과좌측일차성운동피질 (primary motor cortex), 좌측후두엽의이차성시각피질 (secondary visual cortex) 에대사감소소견이보였다 (Fig. 1). 감전된지 6개월후에신경심리검사와, F-18 FDG PET 을다시시행하였다. 추적신경심리검사에서 K-MMSE 는 30점으로호전되었고 CDR은 0.5점이었다. 주의집중력은변화가없었으며이름대기능력은호전되었다. 계산능력은거의변화가없었고복합도형베끼기 (Rey complex figure copy) 는증상이더악화되었다. 언어기억과시각기억검사는정상수준으로호전되었으며도형번갈아그리기도정상으로회복되었다. 그러나단어유창성검사는매우악화되었고 stroop 검사는더호전 J Korean Neurol Assoc Volume 25 No. 4,

3 Table 1. Results of neuropsychological tests performed at seven days and six months after electrical injury Neuropsychological test Raw score/ Raw score/ (7days) (6months) K-MMSE CDR 27/ / 30/ / Attention Digit span Forward 5/28.1 5/28.1 Backward 4/59.8 4/59.8 Letter cancellation normal normal Language and related Function K-BNT 38/8.0 44/30.1 Finger naming normal normal Rt-Lt Orientation normal normal Body part Identification normal normal Praxis normal normal Calculation 9 /<16 10/<16 Visuospatial Function RCFT: Copy 33/ /1.8 Memory SVLT Immediate recalls 18/ /41.6 Delayed recall 4/11.7 5/25.4 Recognition 17/1.3 22/86.6 RCFT Immediate recalls 11/ /56.7 Delayed recall 10.5/ /46.0 Recognition 23/ /92.2 Frontal/Executive Function Contrasting program 20/ 16 20/ 16 Go-No-Go 18/ 16 19/ 16 Fist-Edge-Palm normal normal Alternating Hand Movement normal normal Alternating Square & Triangle deformed normal Luria Loop normal normal COWAT Animal 10/0.6 15/50 Supermarket 18/ /14.2 Phonemic fluency 18/ /11.7 K-CWST (color reading) number of correct response 99/ /90.8 GDS (Geriatric depression scale) 19 9 되었다. 우울증척도는 9점으로정상으로호전되었다 (Table 1). 추적 FDG PET 에서는우측대상회 (cingulate gyrus) 까지대사감소가발생하였고좌측의이차성시각피질영역은대사가감소된영역이더넓어졌다 (Fig. 2). 환자의증상을호전시키기위하여 memantine, gingko biloba 를 6개월간사용하다가중지하였다. 고찰 고압전기에의해손상을받는기전으로는감전당시발생하 는전류자체의손상과전류가흐를때저항에의해발생하는열로인한손상이다. 3 전기감전후에올수있는신경학적손상은초기 (immediate), 손상후 5일이내에나타나는중기 (secondary) 그리고일정기간지난후발생하는후기 (late) 로구분된다. 4 후기손상을일으키는기전으로는손상을입은작은혈관들이지연된변성을일으킬것으로생각되며이로인한탈수초증상과축색돌기의변성이관여할것이다. 척수의전기감전에의해후기손상을받는기전이작은혈관들의지연된변성으로알려졌고전기에너지가열로바뀌어손상을준경우가증례와동물실험에서보고되었다. 5,6 고압전기감전에의한인지기능변화에대한연구는일부증례보고수준의연구가있을뿐이다. 뇌영상연구로는뇌 MRI 에서천막상 (Supratentorial) 의백질변화에대한보고가있었고뇌 SPECT 에서 7명의신경학적손상이있는환자중 2명이각각측두엽과미상핵 (Caudate nucleus) 에혈류가떨어진보고가있다. 7 이환자는감전후 7일에시행한뇌 MRI 에서저산소성뇌병증이나탈수초성뇌질환에서볼수있는광범위한백질변화나회백질이상이보이지않아서경과가좋으리라예상하였다. 그러나부인이느끼는환자의인지기능은큰호전이없고판단할때시간이많이걸리고계획수립과운전에장애가보였으며부부간의대화장애가점점더심해졌다. 신경심리검사에서전두엽기능과연관이있는의미유창성이악화된것은기능적 MRI 연구에서대상회의기능과관계가있다. 8 후대상회는외부의자극을종합하여처리하는중요한부위이며정상적으로후대상회의대사는대뇌에서가장높게나타나며알쯔하이머병의초기에후대상회의당대사가감소하기때문에본증례의환자도외부의감각자극을종합하여처리하는기능이저하된것으로생각되며대상회의당대사감소와의미유창성저하는연관되었다고생각한다. 시공간능력이악화된것은뇌량과후두엽의당대사감소부위가더넓어진것과연관이있을것이다. 환자의운전에장애를주었던시공간능력장애가잘회복되지않은이유는긴시각경로가원인이었을수있다. 시각경로가안구와시신경을통해뇌의가장뒤쪽인후두부를지나다시측두엽과두정엽으로정보가이동되면서처리되기때문에손상을쉽게받을수있을것이다. 이러한긴경로의어느부분이라도탈수초증이나축색돌기등의손상이발생할수있고, 이차적으로 Wallerian 변성은시각정보처리의이상을점차악화시킬것이다. 뇌량은신피질 (neocortex) 의정보가반대쪽대뇌반구로전달되는중요한구조물이다. 대뇌반구의초기감각정보와후기의고차원적정보를반대쪽으로보내는데손상을받으면관념운 546

Figure 2. SPM analysis of the brain F-18 FDG PET at 6months after electric injury. This shows new hypometabolic area in right cingulate gyrus and increased hypometabolic area in left secondary visual.

4 Figure 2. SPM analysis of the brain F-18 FDG PET at 6months after electric injury. This shows new hypometabolic area in right cingulate gyrus and increased hypometabolic area in left secondary visual. 동성실행증 (ideomotor apraxia) 과실독증 (alexia without agraphia) 이발생할수있다. 9 본증례에서는뚜렷한실행증이나실독증이보이지않았기때문에뇌량손상이심하지않을것으로생각되며운전장애등의시각공간능력저하발생한것은뇌량손상과일부관계가있을것으로생각된다. 환자의인지기능증상은심장이상에의한저산소성뇌병증과감별하여야한다. 저산소성뇌병증에의한인지장애는주로집행기능 (executive function) 장애, 행동장애, 기억력장애를보이며기억력장애는지연회상이저하되고재인능력은비교적잘보존된다. 10 이는본증례의증상과유사한점이있으나뇌 MRI 에서저산소성뇌병증때잘보이는백질변성이보이지않았고행동장애가심하지않은점은주된뇌손상기전이전기 감전임을시사한다. 당시에발생했던화재는환기가잘되는건물바깥에서있었고발생한연기가매우미미하였다. 환자의호흡곤란이나흉부 X선검사에서정상이었으므로영향을미쳤을가능성이적다. 이연구는몇가지제한점을가지고있다. 첫째는 SNSB 가국내에서많이쓰이고있는검사이고전두엽기능까지볼수있는좋은신경심리검사도구이지만 55세미만에서규준이확립되지않은상태이기때문에본환자는 55세로가정하고결과치를냈다는점이다. 따라서정상으로나타난부분도실제이상이있는부분일가능성이있고이상으로나타난부분은실제이상보다약하게나타났을수있다. 두번째는환자의의식소실이있는동안일시적인심정지나심실부정맥이발생하여저산소성 J Korean Neurol Assoc Volume 25 No. 4,

5 뇌손상이같이왔을가능성이있다는점이다. 본증례는전기감전에의한인지기능의저하가초기는물론지연되어서발생할수있다는것을뇌당대사의이상영역의확대와신경심리검사에서집행기능과시공간기능장애의악화를통해밝혀주었고향후더많은증례를통한연구가필요할것으로생각된다. REFERENCES 1. Farrell DF, Star A. Delayed neurological sequelae of electrical injuries. Neurology 1968;18: Jain S, Bandi V. Electrical and lighting injuries. Crit Care clin 1999; 15: Minn YK, Cho SJ, Kwon KH, Park HS, Sung YH, YU KH, et al. Features of the peripheral nerve injury in patients with high voltage electrical burn. J Korean neurol assoc 2004;22: Silversides J. The neurological sequelae of electric injury. Can Med Assoc J 1964;91: Ko SH, Chun WC, Kim HC. Delayed spinal cord injury following electrical burns: a 7-year experience. Burns 2004;30: Bailcy SL. Electrical injuries. Considerations for the perioperative nurse. AORN J 1989;49: , , Deveci M, Bozkurt M, Arslan N, Sengezer M. Nuclear imaging of the brain in electrical burn patients. Burns 2002;28: Gaillard WD, Hertz-Pannier L, Mott SH, Barnett AS, LeBihan D, Theodore WH. Functional anatomy of cognitive development: fmri of verbal fluency in children and adults. Neurology 2000;54: Devinsky O, Laff R. Callosal lesions and behavior: history and modern concepts. Epilepsy Behav 2003;4: Peskine A, Picq C, Pradat-Diehl P. Cerebral anoxia and disability. Brain Inj 2004;18:

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