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1 SPECIAL ARTICLE Korean J Stroke 2008;10:67-71 대한뇌졸중학회의뇌졸중센터설립권고안 인하대학교의과대학신경과학교실 1, 연세대학교의과대학신경과학교실 2, 서울대학교의과대학신경과학교실 3 나정호 1 허지회 2 배희준 3 한문구 3 윤병우 3 Recommendations for the Establishment of a Stroke Center in Korea - Proposed by the Korean Stroke Society - Joung-Ho Rha, MD 1, Ji Hoe Heo, MD 2, Hee-Joon Bae, MD 3, Moon Ku Han, MD 3 and Byung-Woo Yoon, MD 3 on Behalf of the Korean Stroke Society 1 Department of Neurology, Inha University, College of Medicine, Incheon, Korea 2 Department of Neurology, Yonsei University, College of Medicine, Seoul, Korea 3 Department of Neurology, Seoul National University, College of Medicine, Seoul, Korea 서 론 뇌졸중은전세계적으로중요한사망및장애의원인으로그예방과치료를위해끊임없는연구가진행되고있다. 1 그러나 20세기후반의비약적인의학의발전에도불구하고, 현재까지허혈성뇌졸중의급성기치료제로확립된약물은혈전용해제인 rtpa 가유일하며, 그동안개발되었던수많은신경보호제중임상시험에서그효능이확립된치료제는없었다. 2 이렇게직접적인치료제개발은기대만큼의성과를거두지못한반면에뇌졸중치료실 (stroke unit) 같은효율적인치료시스템의도입및개선은예상외로큰효과를나타낸다는것이알려졌다. 즉뇌경색은그특성상발생후수시간에서수일내의초급성기및급성기치료가예후를결정하는데가장결정적인시기이므로이시기에효율적인치료를하는것이중요한데, 이에따라뇌졸중치료실의개념이생겼으며, 실제로임상시험및메타분석등으로그효과를검증한결과, 일반적인기존의치료에비해뚜렷한효과가있다는것이입증되었다. 3 이렇듯뇌졸중치료에는의학적발전외에도치료시스템의개선이중요하다는인 Received: October 14, 2008 / Revised: October 22, 2008 Accepted: October 30, 2008 Address for correspondence: Byung-Woo Yoon, MD Department of Neurology, Seoul National University, College of Medicine, 28 Yeongeon-dong, Jongno-gu, Seoul , Korea Tel: , 3880, Fax: bwyoon@snu.ac.kr 식이확산되면서뇌졸중센터의개념도도입되었다. 즉각지역에뇌졸중센터를지정하고주변병원과의유기적네트워크를갖추어환자가발생하면제한된자원안에서최대한신속히효율적인치료를받을수있도록하는것이다. 4 이러한뇌졸중센터가효과적으로운영되기위해서는가능한빠른시간내에뇌졸중치료를시작해야하므로병원전단계에서부터뇌졸중환자를판별할필요성이제기되었다. 이를위해응급구조대원도사용가능한신속하고도간편한뇌졸중진단척도가개발되었고, 응급구조시스템과지역병원과의유기적인연계구축또한중요한과제가되었다. 5 효율적인예방을위해서환자를대상으로하는교육이전에지역사회를대상으로하는교육의필요성도중요한선행과제로대두되었다. 6 뇌졸중의사회적중요성을감안할때우리나라에서도이러한뇌졸중센터의확립은시급한당면과제로, 설립을위한기본적인조건및운영지침등에대한권고안마련이시급하다고할수있다. 분류및정의 뇌졸중센터는일반적으로초급성기및급성기뇌졸중치료를수행하는일차뇌졸중센터 (primary ) 및더전문적이고복합적인기능을담당하는포괄적뇌졸중센터 (comprehensive ) 로구분할수있다. 따라서일차뇌졸중센터는초급성기에정맥내혈전용 Copyright c 2008 Korean Stroke Society ISSN

2 Stroke Center Recommendation 해술 (intravenous rtpa) 및급성기에항혈소판제투여나삼킴장애선별검사같은필수진료기능을충실히수행할수있어야한다. 포괄적뇌졸중센터는동맥내혈전용해술이나경동맥내막절제술, 재활프로그램등보다전문적이고도복합적인진료를제공한다. 따라서뇌졸중치료실의운영이필수적이며필요한장비및인력등이확보되어있어야한다. 이러한일차뇌졸중센터와포괄적뇌졸중센터는일반적으로뇌졸중을진료하는지역병원과연계하여하나의네트워크시스템을구축하는것이이상적이다 (Figure 1). 즉뇌졸중환자는가능한빨리가까운뇌졸중센터로이송하도록하고, 일반병원을찾은환자도뇌졸중센터로의신속한전원을유도하며, 전문적인치료가필요한경우는포괄적뇌졸중센터로의뢰하는체계이다. 국내외현황 미국에서는뇌졸중학회의진료지침에뇌졸중센터의설립및운영을 Class I 권고안으로강력히권장하고제3기관으로부터의인증을독려하는등뇌졸중진료의핵심적인요소로중시하고있다. 7 미국에서는 Brain Attack Coalition 에서뇌졸중센터에대한권고안을주로제시하고있는데, 기존의연구및조사결과들을토대로 2000년에일차뇌졸중센터에대한권고안을발표하였다. 8 그주요요소로서환자진료영역에서급성뇌졸중팀운영, 명문화된진료지침, 응급실및구급대, 뇌졸중치료실, 신경외과적치료등을, 진료지원영역에서뇌졸중센터장등의행정적지원, 신경영상, 진단검사, 질지표향상, 교육프로그램등을제시하였다. 이러한권고안을토대로 2003년에 1,000명이상의신경과, 신경외과및응급의학과의사들에게일차뇌 졸중센터에관한설문조사를실시한결과 80% 에서뇌졸중센터의필요성에동의하였고, 77% 의응답자가소속병원이일차뇌졸중센터에합당하다고생각했으나, 실제로는 7% 만이모든조건을갖추고있었으며, 44% 는대부분의조건을갖추고있었으나뇌졸중치료실이나의사교육프로그램, 또는뇌졸중센터장지정등이미흡한것으로나타나, 필요성에대해전반적으로공감하고약절반정도는이미대부분의시설을갖추고있으나실제설립및운영에있어서는보완할부분이있음을보여주었다. 9 Brain Attack Coalition 에서 2005년에는포괄적뇌졸중센터에대한권고안을발표하였으며, 혈관신경과 ( 뇌졸중전공 ), 신경외과, 신경방사선과, 재활의학과, 및전문간호사등의전문인력, MRI, 뇌혈류초음파등진보된신경영상, 경동맥내막절제술이나동맥내혈전용해술같은신경외과적및내혈관적 (endovascular) 치료, 뇌졸중치료실이나집중치료실, 뇌졸중등록 (registry) 같은시설및프로그램, 교육및연구프로그램등의 30여항목을주된요소로제시하였다. 10 또한이러한요소들에대한전문가설문조사를실시한결과 80% 이상의응답자가대부분의요소가필요하다고답하였다. 미국뇌졸중학회에서는뇌졸중센터를파악하는방법에대한연구도있었는데, 스스로평가하는단계에서부터입증 (verification), 검정 (certification), 인가 (accreditation) 까지다양한단계의모델이제시되었으며, 현재미국에서는 Joint Commission 등몇몇독립적기구에서이러한인증작업을하고있다. 11 뇌졸중센터, 포괄적뇌졸중센터이렇게각단계별 100 여개의요소에대해, 50% 이상이필요하다고응답한 70 여개의항목을추려서제시하였고, 그결과는미국의경우와큰차이는없었다. 13 그러나다시이결과를토대로유 Comprehensive Comprehensive Local hospital Local hospital Local hospital Local hospital FIGURE 1. Network of. s can arrive s or hospitals either directly or by transfer. Ideally, stroke patients must visit stroke center directly. 68 Korean J Stroke 2008;10:67-71

3 Joung-Ho Rha, et al. 럽 25개국 886병원을대상으로실제적용여부를조사한결과, 단지 10% 미만의병원만이필수조건을충족하고있는것으로나타나, 제시된요건이너무이상적임을반증함과동시에아직도개선할여지가많음을보여주었다. 14 현재국내에서는일차뇌졸중센터및포괄적뇌졸중센터를명확히구분하여사용하고있지는않으며, 몇몇병원에서이미뇌졸중치료실및센터를개설운영하고있는데, 포괄적뇌졸중센터의개념에더가까운형태이다. 국내에서조만간발표될뇌졸중진료지침권고안에도뇌졸중치료실및센터의중요성및설립권고안이기술되어있으며, 국립대심뇌혈관센터지정사업이진행되는등최근뇌졸중센터에대한관심이높아지고있다. 그러나아직국내의뇌졸중센터나치료실에대한연구결과는미미한편으로세브란스병원에서운영중인뇌졸중치료실의설립및운영과관련된일련의논문이발표된바있다. 15,16 국내뇌졸중센터의설립및운영권고안 이상으로국내외뇌졸중센터에대한현황및최근대한 뇌졸중학회진료지침위원회에서논의된내용을정리하여우리나라의뇌졸중센터설립및운영에대한권고안을제시하였다 (Table 1). 17 그러나앞서밝힌바와같이우리나라에서는일차뇌졸중센터와포괄적뇌졸중센터의구분이명확하지않으므로이둘을절충한뇌졸중센터의개념으로권고안을제시하되, 아직도일반병원에서다수의급성기뇌졸중환자를진료하는실정등을감안하여일차뇌졸중센터에더가까운형태로권고안을제시하였다. 즉초급성기에정맥내혈전용해술및급성기뇌졸중환자에필수적인진료를충실히수행할수있는뇌졸중센터를설립하도록하는것이주목적이다. 첫째, 항목은인적구성에관한것으로, 신경과의사가상주하여야하며뇌졸중진료에있어서관련과들이하나의팀으로진료하는다학제간진료 (multidisciplinary team) 를필수적인조건으로하였다. 그외선택적인요소는포괄적뇌졸중센터라면갖추어야할조건이라고할수있다. 둘째, 항목은운영지침에관한것으로뇌졸중환자가입원한경우의진료지침이갖추어져있어야하며, 이는활력 TABLE 1. Recommended components of in Korea Essential Personnel Neurologist 24/7 Multidisciplinary stroke Team (Neurology, Neurosurgery, Neuroradiology, Rehabilitation, nurse) Protocols & program Stroke critical pathway /Care map Staff education Program education Program Diagnosis service Brain CT 24/7 MRI with diffusion Image CT/MR angiography Laborative service Treatment service Intravenous rtpa 24/7 Antithrombotic therapy Vital sign control intracranial pressure Control Facility Emergency Department Stroke admission ward Optional Stroke faculty Neurosurgeon & vascular surgeon Intervention radiologist Rehabilitation staff Emergency department staff Stroke fellow Stroke advanced practice nurse Stroke coordinator Community Awareness/education Program quality Improvement activity Stroke database/registry Stroke center network Research activity Anticoagulation clinic Transfemoral cerebral Angiography Perfusion study (CT, MR, SPECT, or PET) Transcranial doppler & carotid doppler Echocardiography Intra-arterial thrombolysis Carotid stent/angioplasty Cerebral aneurysm surgery Carotid endarterectomy Hemicraniectomy Hematoma evacuation Stroke unit Rehabilitation unit Intensive care unit Stroke outpatient clinic 24/7 means anytime availability (24 hours in a day, 7 days in a week). SPECT: Single photon Emission Computed Tomography, PET: Positron Emission Tomography 69

4 Stroke Center Recommendation 증후및신경학적상태의감시, 항혈소판제의투여여부, 삼킴장애선별검사, 수행할검사의종류및시기등급성뇌졸중진료에필요한모든지침을망라한다. 또한뇌졸중팀구성원및환자를대상으로교육프로그램이있어야한다. 포괄적뇌졸중센터라면지역사회를대상으로한교육프로그램및뇌졸중등록사업 (registry), 지역의료기관및구급대와의네트워크구축등의선택적요소도수행하는것이바람직할것이다. 또한질지표향상활동도권장되어야할항목이다. 셋째, 항목인진단검사에서는뇌 CT가항상가능하여야하며확산강조영상을포함한자기공명영상이필요하고, 기본적인혈액진단검사도필수적인조건으로하였으며, 그외의검사들은선택적조건으로하였다. 넷째, 치료항목에서는기본적인뇌졸중치료외에초급성기에정맥내 rtpa 정맥주사고려및수행여부가필수적인조건으로하였고, 이를위한진료지침및실적이구비되어있어야할것이다. 그외수술적치료나혈관내치료같은전문적인치료는선택조건으로하였다. 마지막시설항목에서는응급실및뇌졸중입원병동이필수조건이며, 뇌졸중치료실은선택조건으로하였으나포괄적뇌졸중센터라면반드시갖추어야할조건이라고할수있다 ( 뇌졸중치료실의설립권고안은다른논문에서제시될예정으로, 여기서는생략한다 ). 이상뇌졸중센터설립권고안을제시하였는데, 이에대해국내에서도각항목에대한전문가설문조사및분석이필요할것으로생각된다. 또한뇌졸중센터와지역병원및구급대와의네트워크구축을위한권고안, 이를위한병원전뇌졸중선별검사등의보급등도추가적으로필요한과제라고생각된다. 맺음말 높은발생률과유병률, 그로인한사망및후유장애등으로인해뇌졸중은더이상개인이나가족만의불행이아닌국민보건의개념으로다루는시각이필요하다. 따라서뇌졸중센터및응급전달체계수립등은시급한과제가아닐수없다. 본권고안에따른뇌졸중센터의확산으로, 이상적으로는모든뇌졸중환자가지체없이최상의진료를받을수있도록하는체계를구축하는것이본권고안의궁극적인목적이다. 중심단어 : 뇌졸중센터 뇌졸중치료실. REFERENCES 1. World Health Organization. Burden of disease statistics. Available at: Accessed Oct 1, Kidwell CS, Liebeskind DS, Starkman S, Saver JL. Trends in acute ischemic stroke trials through the 20th century. Stroke 2001;32: Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2007, Issue 4 Art No: CD Schwamm LH, Pancioli A, Acker JE 3rd, Goldstein LB, Zorowitz RD, Shephard TJ, Moyer P, Gorman M, Johonston SC, Duncan PW, Gorelick P, Frank J, Stranne SK, Smith R, Federspiel W, Horton KB, Magnis E, Adams RJ; American Stroke Association s Task Force on the Development of Stroke Systems. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association s Task Force on the Development of Stroke Systems. Stroke 2005;36: Nazliel B, Starkman S, Leigeskind DS, Ovbiagele B, Kim D, Sanossian N, Ali L, Buck B, Villablanca P, Vinuela F, Duckwiler G, Jahan R, Saver JL. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke 2008;39: Morgenstern LB, Gonzales NR, Maddox KE, Brown DL, Karim AP, Espinosa N, Moyé LA, Pary JK Grotta JC, Lisabeth LD, Conley KM. A randomized, controlled trial to teach middle school children to recognize stroke and call 911: the kids identifying and defeating stroke project. Stroke 2007;38: Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF; American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. 8. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, Starke RD, Todd HW, Viste KM, Girgus M, Shephard T, Emr M, Shwayder P, Walker MD. Recommendations for the establishment of primary s. Brain attack coalition. JAMA 2000;283: Kidwell CS, Shephard T, Tonn S, Lawyer B, Murdock M, Koroshetz W, Alberts M, Hademenos GJ, Saver JL. Establishment of primary s: a survey of physician attitudes and hospital resources. Neurology 2003;60: Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, Koroshetz W, Marler JR, Booss J, Zorowitz RD, Croft JB, Magnis E, Mulligan D, Jagoda A, O Connor R, Cowley CM, Connors JJ, Rose-DeRenzy JA, Emr M, Warren M, Welker MD; Brain Attack Coalition. Recommendations for comprehensive s: a consensus statement from the Brain Attack Coalition. Stroke 2005;36: Adams R, Acker J, Alberts M, Andrews L, Atkinson R, Fenelon K, Furlan A, Girgus M, Horton K, Hughes R, Koroshetz W, Latchaw R, Magnis E, Mayberg M, Pancioli A, Robertson RM, Shephard T, Smith R, Smith SC Jr, Smith S, Stranne SK, Kenton EJ 3rd, Bashe G, Chavez A, Goldstein L, Hodosh R, Keitel C, Kelly-Hayes M, Leonard A, Morgenstern L, Wood JO; advisory working group on identification options of the american stroke association. 12. Brainin M, Olsen TS, Chamorro A, Diener HC, Ferro J, Hennerici MG, Langhorne P, Sivenius J; EUSI executive committee; EUSI writing committee. Organization of stroke care: education, referral, emergency management and imaging, stroke units and rehabilitation. European Stroke Initiative. Cerebrovasc Dis 2004;17 (Suppl 2): Leys D, Ringelstein EB, Kaste M, Hacke W; european stroke initative executivecommittee. The main components of stroke unit care: results of a European expert survey. Cerebrovasc Dis 2007;23: Leys D, Ringelstein EB, Kaste M, Hacke W; executive committee of the european stroke initiative. Facilities available in european hospitals 70 Korean J Stroke 2008;10:67-71

5 Joung-Ho Rha, et al. treating stroke patients. Stroke 2007;38: Choi HY, Cho HJ, Kim SH, Han SW, Nam HS, Lee JY, Ahn SH, Heo JH. Organization and operation of stroke unit. Korean J Stroke 2006; 8: Seo JH, Choi HY, Cho HJ, Heo JH. Beneficial effect of stroke unit for detection of atrial fibrillation. Korean J Stroke 2007;9: Clinical Practice Guideline Committee of the Korean Stroke Society. Round Table Meeting: criteria of stroke unit and in Korea. Seoul,

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PowerPoint 프레젠테이션 뇌혈관질환응급대응, 치료역량및관리체계 강화방안 뇌혈관분과이수주 을지대학교병원뇌졸중학회정책이사 허혈성뇌졸중 7.2% 출혈성뇌졸중 1.8% 75% 2015 (Hong KS et al. J Stroke 2013;15:2-20) Severance Stroke Center 심뇌혈관질환의예방및관리에관한법 권역심뇌혈관질환센터지정 뇌졸중적정성평가 뇌졸중 치료시스템 뇌졸중집중치료실인증