online ML Comm 0CLINICAL ARTICLE0 J Kor Neurotraumatol Soc 2009;5:93-98 ISSN 1738-8708 노인경증두부손상의임상양상 동국대학교의과대학경주병원신경외과학교실 이영배 Clinical Features of Mild Head Injury in the Elderly Young Bae Lee, MD Department of Neurosurgery, Gyeongju Hospital, Dongguk University College of Medine, Gyeongju, Korea Objective: In the case of mild head injuries, patients are generally expected to make a full recovery; however, for seniors, the prognosis is often less favorable. Therefore, this study will investigate clinical features and prognosis of mild head injury in patients who are 65 and older. Methods: Between March 2006 to February 2008, a total of 76 elderly patients were admitted with a head injury and a Glasgow Coma Scale (GCS) score of between 13 and 15. Retrospective analysis was performed based on the patients age, gender, cause of injury, medical history, CT diagnosis, GCS score at the time of admittance and clinical outcome. Results: CT scan revealed abnormal findings in 38 cases (50%), and of those 12 cases showed acute subdural hematoma and 11 cases showed hemorrhagic contusion. When initial GCS scores and CT scans were examined, lower GCS scores were more likely to have abnormal CT scans, and this difference was statistically significant (p=0.005). When initial GCS scores and the patient outcome were examined, lower GCS scores correlated with adverse outcomes, and the difference was statistically significant (p=0.047). Conclusion: Initial CT scans revealed abnormal findings in 50% of the patients, which demonstrates the need for a mandatory CT scans and follow up observations, even for elderly patients who initially do not display loss of consciousness. In addition, aggressive therapy is especially crucial in cases with abnormal initial CT findings to minimize morbidity and mortality in elderly patients. (J Kor Neurotraumatol Soc 2009;5:93-98) KEY WORDS: Elderly Mild head injury CT scan Falling Prognosis. 서 론 한국사회는빠른속도로고령화가진행되면서전국 63 개의시, 군이유엔이분류한초고령사회 ( 인구중 65세이상노인비중이 20% 이상 ) 에진입하였으며, 2020 년에는한국사회전체가고령사회 (aged society) 에진입할것으로전망하고있다. 이렇게노인인구가증가하면서점차노인외상손상에대한관심이증대되고있다. 이유 Received: October 27, 2009 / Revised: October 27, 2009 Accepted: November 3, 2009 Address for correspondence: Young Bae Lee, MD Department of Neurosurgery, Gyeongju Hospital, Dongguk University College of Medine, 1090-1 Seokjang-dong, Gyeongju 780-350, Korea Tel: +82-54-770-8230, Fax: +82-54-770-8378 E-mail: leeyb@dongguk.ac.kr 는노인인구의증가와더불어이들연령층에서활발한사회및경제활동으로노인외상의빈도가증가하고있으며, 33) 또한비슷한정도의외상을입은젊은연령군에비하여사망률도높고, 4,14) 장기입원에따른높은사회, 경제적비용이요구되기때문이다. 7,34) 따라서최근의많은연구는노인외상의특징및치료에영향을미치는인자를찾아초기에적극적인치료를하여, 환자의삶의질을향상시켜주려고하는데있다. 16,27,34) 두부외상은노인외상의가장흔한형태이며, 특히산업화와교통수단의발달로두부외상환자가증가하고있다. 두부외상의 80% 이상을차지하는경증두부손상의경우노인환자에서젊은연령층에비해입원기간이길고, 기능적회복도떨어지며사망률도높은것으로알려져있다. 이에본교실에서는 65세이상경증두부손상환자를대상으로임 Copyright c 2009 Journal of Korean Neurotraumatology Society 93
Mild Head Injury in the Elderly 상적특징과예후에영향을주는위험인자들에대하여알아보고자하였다. 대상및방법 2006 년 3월부터 2008 년 2월까지두부외상으로본원응급실로내원하여입원치료하였던 65세이상환자중내원당시 Glasgow Coma Scale (GCS) 점수 13~15 점의경증두부손상환자 76명을대상으로후향적으로조사하였다. 경증두부손상의정의는의식소실유무와상관없이입원당시신경외과의사에의해진단된 GCS 점수 13~15 점으로규정하였다. 최초진단이만성경막하혈종, 두부관통상환자및입원 12시간이내퇴원한환자는본연구대상에서제외하였다. 이들에대하여성별, 과거병력및사고유형에따라분류하고, 입원당시 GCS 점수, 뇌CT 소견, 임상증상과이에따른예후에대하여조사항목을기록한후비교분석하였다. 예후는퇴원 6개월후를기준으로 Glasgow Outcome Scale (GOS) 에의하여측정하였는데, 양호한회복 (good recovery) 과중등도장애 (moderate disability) 를양호한예후 (good outcome) 로분류하였고, 중증장애 (severe disability), 식물인간상태 (vegetative state), 사망 (death) 을불량한예후 (bad outcome) 로분류하였다. 통계학적유의성은 Chi-square test, Fisher s exact test 를이용하였고, 통계에서 p값이 0.05 미만이면유의하다고정의하였다. 결과 환자의일반적특성 76명의환자중남자 42명 (55%), 여자는 34명 (45%) 으로남자에서약간많았으며, 연령분포는 65세부터 92 세까지로평균연령은 72세였다. 기왕증의여부를조사한결과 76명중 29명 (38%) 에서고혈압, 뇌혈관질환, 당뇨등의만성질환을가지고있었다. 두부손상의원인은낙상이 32명 (42%) 으로가장많았으며, 교통사고 24명 (31.5%), 보행자사고 9명 (11.8%) 등의순이었다. 내원당시의증상은두통이 54명 (71%) 으로가장많았다. 내원당시의식정도를 GCS 점수에따라분류하였을때 GCS 점수 15점이 60명 (78%), 14점이 8명 (11%) 13 점이 8명 (11%) 이었다 (Table 1). 환자의평균재원일수는 20.9±4.5 일로조사기간전체경증두부손상환자평균재원일수 15.4±2.5 일보다길었지만, 통계학적인 유의성은없었다. 내원당시뇌CT 소견내원당시뇌CT 검사에서이상소견이관찰된경우는 38명 (50%) 이었다. 이상소견은급성경막하혈종이 12명으로가장많았으며, 출혈성뇌좌상 11명, 두개골골절 7명의순이었다 (Table 2). TABLE 1. Summary of the patient s characteristics Patient characteristic Number of patients Total cases 76 Gender Male 42 Female 34 Age distribution 65-74 49 75-84 22 85 05 Intercurrent disease Hypertension 13 Cerebrovascular disease 10 Diabetes mellitus 06 Initial symptoms Headache 54 Nausea/vomiting 02 Loss of consciousness 07 Dizziness 04 Others 09 Causes of injury Fall down 32 Motor vehicles 24 Pedestrian 09 Bicycle 05 Blunt injury 02 Unknown 04 GCS score at the time of admission 13 08 14 08 15 60 GCS: Glasgow Coma Scale TABLE 2. Initial CT findings Lesions Number of cases (%) Normal 38 (50) Abnormal 38 (50) Subdural hematoma 12 (16) Hemorrhagic contusion 11 (15) Skull fracture 07 (9)0 Traumatic subarachnoid hemorrhage 04 (5)0 Traumatic intracerebral hematoma 04 (5)0 CT: computerized tomography 94 J Kor Neurotraumatol Soc 2009;5:93-98
Young Bae Lee 내원당시 GCS 점수와뇌CT 소견과의비교내원당시 GCS 13점, 14점환자군에서 13명 (81.2%) 이뇌CT에이상소견을보였고, 3명 (18.7%) 이정상소견을보였으며, GCS 15점환자군은이상소견을보인경우가 25명 (41.6%) 으로, 뇌CT 검사에서이상소견은내원당시 GCS 점수가낮을수록많았으며, 이는통계학적으로유의하였다 (Table 3)( p=0.005). 추적뇌CT 소견 19명의환자에서추적뇌CT 에서지연성병변이발견되었다. 경막하수종이 14명으로가장많았으며, 수두증, 만성경막하혈종의순이었다. 지속적인두통을호소한환자들에서경막하수종이발견되었는데, 주로수상후 5~ 7일째진단되었다. 수두증및만성경막하혈종의경우는경과추적중신경학적소견이악화되어진단되었다. 경막하수종의경우는모두대증적요법을시행하였으며, 만성경막하혈종및수두증환자는수술치료를병행하였다 (Table 4). TABLE 3. Association between the CT scan findings and GCS score at the time of admission TABLE 4. Analysis of delayed lesions detected with repeat CT scans Lesions 13 14 15 Total Abnormal CT 7 6 25 38 Normal CT 1 2 35 38 p=0.005. CT: computerized tomography, GCS: Glasgow Coma Scale Number of cases Hygroma 14 Hydrocephalus 03 Chronic subdural hematoma 02 Delayed traumatic intracerebral hematoma 01 CT: computerized tomography 내원당시 GCS 와뇌CT 소견과예후와의관계내원당시 GCS 점수가낮을수록통계학적으로유의하게나쁜예후를보였으나 (p=0.047), 내원당시뇌CT 소견과예후와의관계에서는통계학적인유의성이관찰되지않았다. 그러나내원당시 GCS 점수와뇌CT 소견에따른예후의비교에서 GCS 15점의경우뇌CT에서이상소견을보인경우에는예후가좋지않은것으로평가되었으나 (p=0.004), GCS 13점, 14점의경우는통계학적유의성이관찰되지않았다 (p=0.527)(table 5). 고찰 노인에서는젊은연령층과같은손상을받더라도손상정도가중증인경우가많고사망률도높은것으로보고되고있다. 즉노인들은생리적기능이저하되어있으므로단순한경증의손상이라도중증으로악화되는경우가많고, 또한동반질환으로인하여각종약제를복용하는경우가많이있으므로이러한약제의영향으로외상에대한신체적반응이정상적으로이루어지지못하여예후가나쁜경우가많다. 21,24) 그러므로노인외상의경우에는각종손상을신속히진단하고경미한손상이라도적극적인처치를시행하는것이환자의예후를위해바람직하다고하겠다. 29) 한편의학의발전과경제적성장은인간의수명을연장시켰으며, 산업화와교통수단의발달은두부손상환자의증가를가져오게되었다. 아울러증가일로에있는두부손상환자들의예후에영향을주는인자들에대한연구도활발히진행되고있다. 한국에서도노인두부외상환자에대한관심이증가하고있으나아직그결과는미미한실정이다. 17-19,26) 이에저자는 65세이상경증두부외상환자를대상으 TABLE 5. Outcome at 6 months and GCS score in relation to the presence of CT abnormalities GCS score / CT findings Good outcome Bad outcome GR MD SD V D p-value 13 0.527 Normal 01 Abnormal 04 2 1 14 0.527 Normal 02 Abnormal 05 1 15 0.004 Normal 35 Abnormal 19 6 GCS: Glasgow Coma Scale, CT: computerized tomography, GR: good recovery, MD: moderate disability, SD: severe disability, VS: vegetative state, D: death www.neurotrauma.or.kr 95
Mild Head Injury in the Elderly 로임상적특징과예후를조사하여향후이들환자의치료에도움을얻고자이연구를시행하였다. 본연구에서성별에따른발생빈도는남자 54%, 여자 46% 로남자에서약간높게나타났다. 일반적으로두부외상은주로남자에서많이발생하는것으로알려져있는데, 그이유는위험에노출될수있는사회활동량의차이로설명하고있다. 5,17,26) 그러나본연구에서는성별에따른발생빈도의차이는없는것으로조사되었다. 이는한국의노인인구중에서여자가많은자연적성비차이와여자대비남자환자의발생비율이 65세이상의노인연령층에서상대적으로젊은연령층에비해낮기때문으로보인다. 두부외상의원인으로낙상이 32명 (41%) 으로가장많았으며, 교통사고, 보행자사고의순이었다. 낙상은노인연령에서가장흔한원인으로알려져있다. 8,30) 노인의낙상은나이와관련된자세의변화나균형감각, 운동력등의감소로인해자세나걸음이불안정해지고, 시력이나청력, 기억력의감퇴로주변환경의위험을잘인식하지못하여잘넘어지면서일어난다. 또한부정맥이나저혈당, 기립성저혈압등의질환이있는환자들에서의식상실이발생되면서낙상사고가동반될수있다. 노인의낙상사고는주로지표면가까운곳에서넘어지거나떨어진경우가대부분이다. 이런경우큰에너지전달이일어나지않아경도의외상이발생하지만, 노인은신체의반사작용이지연되어반응하게됨으로써도리어두부에직접손상을받는경우가많다고하며, 이때생각보다심한손상이발생될수도있다고한다. 22,25) Lucht 등 20) 은낙상의경우 60세이상의노인에서 45% 가실신, 치매, 뇌혈관질환등의기왕증에의한이차적인사고라고보고하였는데, 본연구에서는낙상의원인이계단, 욕실, 작업중넘어진경우로서기왕증에의한사고보다노인의인지기능및감각기능의저하와관련이있을것으로추정되었다. 교통사고는또다른노인두부외상의원인이다. 18,19,26) 교통사고의경우대체로보행자사고가많은데, 이는운동기능과속도의감소, 시력저하, 청력의이상등연령에따른신체적변화가상황판단에빠르게대처하지못하기때문이다. 13) 본연구에서는교통사고가 24명으로보행자사고보다많았다. 교통사고중본인이운전한경우는 10명이었는데, 노인운전자의경우시력과청력의변화와이에대한지연반응등이위험인자가되며, 또한운전중발생하는실신도중요한사고원인이된다고한다. 임상적예측지표를찾고자환자들이호소하는증상에대하여조사하였다. 두부외상후증상은두통, 의식소실, 어지럼증, 구토및구역등이었으나, 이중두통이가장흔한증상이었다. 두통증상의유무와 GCS 점수, 방사선학적이상소견유무및예후와의관계에서통계학적인유의성은관찰되지않았다. Duus 등 6) 과 Haydel 등 10) 은경증두부외상환자에서두통과구토등의증상은두개강내병변과밀접한관계가있다고보고하였으나, Jeret 등 15) 과 Hsiang 등 11) 은외상후발생하는두통이나구역및구토등의증상이두부손상과의연관관계를나타낼특이한지표가되지않는다는상반된연구결과들을발표하고있어두부외상후발생할수있는다양한증상들에대해서 GCS 점수, 방사선소견, 예후와관련하여지속적인연구가필요한실정이다. 더욱이두통이나어지럼의경우두부손상환자의대부분에서호소할뿐만아니라그범주를규정할만한객관적인기준도없어앞으로이루어질연구결과에높은신빙성과신뢰도를보장할수있도록증상을구체화시켜표현할수있는지표의개발이필요할것으로여겨진다. GCS 점수는환자의예후를추정하는데훌륭한지표로이용되고있다. 경증두부외상의경우 GCS 에따른예후에대한보고는매우드물지만, GCS 점수에따른두개강내병변의동반유무에대해서는많은보고가있다. 3,11,31) GCS 점수 13점, 14점의환자들이 GCS 점수 15점의환자들보다 CT에서이상소견을보이는경우가많으며, 지연성악화를보이는예가더많다고한다. 본연구에서도내원당시 GCS 점수가낮을수록통계학적으로유의하게나쁜예후를보였으며 (p=0.047), GCS 점수가낮을수록뇌CT 검사에서이상소견이많이관찰되었다. 경증두부외상환자들에서뇌CT에이상소견의빈도는 4~34% 로다양하게보고되고있는데, 특히 65세이상에서이상소견이훨씬높다고한다. 22) 저자의경우도경증두부외상환자에서뇌CT에서이상소견의빈도는 30% 였으나, 65세이상연령층만분석하였을때 50% 에서뇌CT에서이상소견이관찰되었다. 두개강내병변은급성경막하혈종, 28,29) 외상성뇌내혈종 1,35) 이흔하다고한다. 노인에서경막하혈종이잘생기는이유는뇌위축으로경막과뇌표면사이의지주막하강이넓어져있고, 교정맥이긴장된상태로있으며, 피질정맥이약하기때문이다. 한편외상성뇌내혈종및뇌좌상의경우도노인들은아스피린과항응고제를많이복용하고있으며, 뇌위축및대뇌혈관이퇴행성변화로약해져있기때문에잘생긴다고한다. 1,35) 본연구에서는급성경막하혈종이 12명, 출혈성뇌좌상 11명의순이었는데, 급성경막상혈종은한예도발견되지않았다. 내원당시뇌CT 소견과예후와 96 J Kor Neurotraumatol Soc 2009;5:93-98
Young Bae Lee 의관계를보면정상소견을보인경우 38명예에서모두좋은결과를보였으며, 이상소견이관찰된 38명의경우, 10명에서불량한예후를보였지만통계학적유의성이관찰되지않았다. 그러나내원당시 GCS 점수와뇌CT 소견에따른예후의비교에서 GCS 15점의경우뇌CT에서이상소견을보인경우에는예후가좋지않은것으로평가되었으며 (p=0.004), GCS 13점, 14점의경우는통계학적유의성이관찰되지않았다 (p=0.527). Harad 등 9) 도두부외상후 GCS 15점이면서신경학적증상이없는환자들에서방사선적이상소견이 20% 까지관찰되었으며, 그예후도불량하였다고보고하였다. 이런결과로두부외상후의식이명료한환자라도뇌CT에서이상소견이발견되면세심한주의관찰이필요하다고하겠다. 또한노인환자에서의식의악화나신경학적증상의변화가보이지않더라도반드시조기에추적뇌CT를촬영하여출혈양의증가유무를확인하는것은중요하다. 경증두부외상환자에서두개강내병변의동반가능성을예측할수있는위험인자들로나이, 성별, 사고의원인, 내원당시 GCS 점수, 국소신경학적장애, 두통, 구토, 의식소실, 경련, 두개골골절, 항응고제사용, 알코올섭취유무등이제안되고있는데, 이중나이 (65 세이상 ), 내원당시 GCS 점수 (14 점이하 ), 사고원인 ( 보행자사고및상해 ), 두개골골절, 국소신경학적결손등이두개강내병변의동반가능성이매우높은위험인자로인정되고있다. 12) 연령이증가할수록예후가불량하다는 32) 사실은널리알려져있으나연령이예후에어떻게영향을미치는가에는논란이많다. Becker 등 2) 은노인의사망률증가는호흡기감염이나심근경색과같은전신적합병증에의한다고주장하였고, Narayan 등 23) 은양호한예후와불량한경우의비율이 40세를기준으로반전된다고보고하였다. 저자의경우는 76명중 1명에서사망하였는데, 두부외상과직접관련된사망이었다. 노인의경우젊은연령의환자들보다감염증, 호흡기합병증, 순환기합병증등의발생률이높으며, 간경변, 심질환, 폐질환, 당뇨등의기왕증이있는경우가많아예후가좋지않기때문에, 환자의변화와질병의진행을조기에인지하고적극적인치료를시행하는것이매우중요하다. 결론 내원당시뇌CT 검사결과 50% 에서이상소견이관찰되어, 초기의식이명료한환자라도노인의경우뇌CT 검사가꼭필요할것으로판단된다. 아울러내원당시 GCS 15점의환자가뇌CT에서이상소견을보인경우예후가불량한것으로조사되어 (p=0.004), 노인의경우상태가양호하다고판단되어도세심한주의관찰이요구된다. 또한환자의상태를악화시킬수있는위험인자를조기에확인하고이에대한적극적인조치를취하는것은매우중요하다고하겠다. 중심단어 : 노인 경증두부외상 뇌전산화단층촬영 낙상 예후. REFERENCES 1) Amacher AL, Bybee DF. Toleration of head injury by the elderly. Neurosurgery 20:954-958, 1987 2) Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:491-502, 1977 3) Culotta VP, Sementilli ME, Gerold K, Watts CC. Clinicopathological heterogeneity in the classification of mild head injury. Neurosurgery 38:245-250, 1996 4) Demarest GB, Osler TM. Injuries in the elderly. Geriatrics 45:36-42, 1990 5) DeMaria EJ, Kenny PR, Merrian MA, Casanova LA, Gann DS. Aggressive trauma care benefits the elderly. J Trauma 27:1200-1206, 1987 6) Duus BG, Boesen T, Kruse KV, Nielsen KB. Prognostic signs in the evaluation of patients with minor head injury. Br J Surg 80: 988-991, 1993 7) Flanagan SR, Hibbard MR, Riordan B, Gordon WA. Traumatic brain injury in the elderly: diagnostic and treatment challenges. Clin Geriatr Med 22:449-468, 2006 8) Grisso JA, Schwarz DF, Wishner AR, Weene B, Holmes JH, Sutton RL. Injuries in an elderly inner-city population. J Am Geriatr Soc 38:1326-1331, 1990 9) Harad FT, Kerstein MD. Inadequacy of bedside clinical indicators in identifying significant intracrnial injury in trauma paatients. J Trauma 32:359-361, 1992 10) Haydel MJ, Preston CA, Millis TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 343:100-105, 2000 11) Hsiang JNK, Yeung T, Yu AL, Poon WS. High-risk mild head injury. J Neurosurg 87:234-238, 1997 12) Ibañez J, Arikan F, Pedraza S, Sáchez E, Poca MA, Rodriguez D, et al. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg 100:825-834, 2004 13) Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care 9:535-539, 2003 14) Jacoby SF, Ackerson TH, Richmond TS. Outcome from serious injury in older adults. J Nurs Scholarsh 38:133-140, 2006 15) Jeret JS, Mandell M, Anziska B, Lipitz M, Vilceus AP, Wave JA, et al. Clinical predictors of abnormality disclosed by computed tomography after mild head trauma. Neurosurgery 32:9-15,1993 16) Kilaru S, Grab J, Emhoff T, Fiallo V, Simon B, Sweiencicki T, et al. Long-term functional status and mortality of elderly patients with severe closed head injuries. J Trauma 41: 957-963, 1996 17) Kim WH, Lee KS, Bae HG, Yun IG, Lee IS. A clinical analysis on 1,000 consecutive head injuries. J Korean Neurosurg Soc 18: 290-300, 1989 18) Lee K, Lee KS, Bae HG, Yun IG, Lee IS. Characteristics of head injury in the aged. J Korean Neurosurg Soc 19:1001-1008, 1990 www.neurotrauma.or.kr 97
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