online ML Comm 0CLINICAL ARTICLE0 J Kor Neurotraumatol Soc 2007;3:13-18 ISSN 1738-8708 미만성축삭손상과장애평가 부산대학교의과대학신경외과학교실 김정호 성순기 조원호 최창화 Disability Estimation in the Diffuse Axonal Injury Jeong Ho Kim, MD, Soon Ki Sung, MD, Won Ho Cho, MD and Chang Hwa Choi, MD Department of Neurosurgery, School of Medicine, Pusan National University, Busan, Korea Objective: Diffuse axonal injury (DAI) is one of the most important types of brain damage that can occur as a result of acceleration-deceleration head injury. This type of injury can be classified as 3 types according to the lesion site and severity of damage by MRI findings. This study was undertaken to estimate the neurobehavioral impairment and disability according to DAI degree. Methods: Total 50 patients from 1998 to 2003 with DAI cases were analyzed according to MRI finding, psychometry results and locomotor dysfunction retrospectively. Main analyses of psychometry were about intelligence quotient (IQ) (K-WAIS test) and memory (Rey-Kim test). Disability was estimated by single doctor (author) according to neurocognitive dysfunction in psychometry and the severity of locomotor ataxia comparing the degree of DAI. Results: 1) There was no significant difference in intelligence and memory according to DAI grade. But memory quotient (MQ) was decreased in grade III vs grade I+II with significance. 2) There was high incidence of locomotor a- taxia and increasing McBride disability due to locomotor ataxia (category III) as increasing DAI grade with significance. 3) There was significant difference of verbal IQ and decreasing tendency of memory quotient (MQ) in case of positive temporal lobe lesion, excluding the effect of corpus callosum and brain stem injury. Conclusion: In diffuse axonal injury, estimations of main disability were cognitive dysfunction, especially intelligence and memory and locomotor ataxia. As increasing the grade of DAI, there were decreasing memory quotient, increasing locomotor ataxia, and McBride disability. The Significant difference of verbal IQ and decreasing tendency of MQ were presented in positive temporal lesion. (J Kor Neurotraumatol Soc 2007;3:13-18) KEY WORDS: Diffuse axonal injury Neurobehavioral impairment Psychometry Disability. 서 론 미만성뇌축삭손상은교통사고와같은가속및감속두부손상의결과로발생할수있는뇌손상의가장흔한형태중의하나이다. 7,10) 이러한치명적인비탄두성 (nonmissile) 두부손상치험의증가로이러한미만성축삭손상은세가지형태로분류할수있게되었다. 1) 그러나미만성축삭손상의정도에따른신경행동학적인장애 Address for correspondence: Chang Hwa Choi, MD Department of Neurosurgery, School of Medicine, Pusan National University, 10 Ami-dong 1-ga, Seo-gu, Busan 602-739, Korea Tel: +82-51-240-7257, Fax: +82-51-244-0282 E-mail: chwachoi@pusan.ac.kr 본연구는부산대학교병원의학연구소연구비지원으로이루어졌음. 는미만성축삭손상환자의사회적응에있어서매우중요한요소로작용하고있음에도불구하고미만성축삭손상의신경행동인지장애에대한연구는그리많지않다. 3-6,19) 이에이연구에서는미만성축삭손상의신경행동장애를확인하기위해다음의주가설을설정하고미만성축삭손상의정도에따른신경행동장애, 기능적회복및장애정도등을임상심리검사와보행활동력등을중심으로평가하였다. 이러한가설은첫째, 미만성축삭손상의정도에따른신경인지기능회복 ( 주로지능및기억 ) 의차이가있는지, 둘째, 미만성축삭손상의정도에따라운동성보행장애의정도에차이가있는지, 셋째, 미만성축삭손상에따라맥브라이드식의장애율의평가에있어서어떠한차이가있 c 2007 Journal of Korean Neurotraumatology Society 13
Disability Estimation in the Diffuse Axonal Injury 는지를후향적으로분석하였다. 대상및방법 III 에서는 70% 를차지하였다. 수상원인은탑승자교통사고및보행자교통사고가대부분이었고추락사고환자 1명이 Grade I에포함되었다 (Table 1). 1998~2003년사이의 MRI 사진상명확한미만성축삭손상병변이확인되었고, 두개강내병변으로인해수술을시행하지않았던환자중임상심리검사를시행한 16세이상의환자 50명을대상으로하였다. 임상심리검사의분석은주로 K-WAIS 검사를이용한지능지수 (intelligence quotient: IQ) 검사와 REY-KIM 검사를이용한기억검사등을분석하였으며모든자료는후향적으로분석하였다. 12,21) K-WAIS 검사는언어성 IQ와동작성 IQ로나누어분석하였고언어성검사에서는기본지식문제와숫자외우기, 어휘문제, 산수문제, 이해문제, 공통성문제등을평가하여점수화하였고동작성검사에서는빠진곳찾기, 차례맞추기, 토막짜기, 모양맞추기, 바꿔쓰기등의 5항목의점수를평가하였으며언어성검사의동작성검사전체의평균환산 IQ를평가다. 기억검사는 REY-KIM 기억검사방법을사용하였고언어성기억과시각적기억을분석평가하였으며이러한심리검사는동일한단일전문임상심리사에의해시행되었다. 미만성축삭손상의정도는 Gradient-Echo MR 영상 (Hemorrhagic Sequence) 에서명확한뇌병변이확인되는경우로, 17) Grade I은대뇌반구의백질부위에만축삭손상의흔적이있는경우, Grade II는뇌량체에국소적병변이있는경우, Grade III 은뇌간부위에국소적병변이있는경우로분류하였다. 1) 장애정도의평가는한사람의평가자 ( 연구자 ) 에의해맥브라이드의장애평가기준에의해평가되었고주된적용항목은신경인지장애부분인기질적뇌증후군 IX 항목과보행장애가있는경우에는운동실조항목인 III 항목에따라평가하였고통계학적인유의성은 SPSS 10.5를이용하여분석하였다. 결과 나이, 성별및원인미만성축삭손상환자의분포는주로 20~50 대의활동기연령에서주로발생하였고평균연령은 Grade I에서는 36세, Grade II에서는 35세, Grade III에서는 36세로별다른차이를나타내고있지않았으며, Grade I 18예, Grade II 22예, Grade III 10예였다. 남성에서훨씬호발하여 Grade I에서는남성의비율이 83%, II에서는 91%, 최초의식상태최초의식상태는 Grade I의경우기면상태에서부터혼수상태까지다양하였으나대부분 (82%) 이혼미상태의의식을나타내었고 Grade II에있어서는혼미상태가 95% (21 예 ), 기면상태가 5% (1예 ) 를차지하였으며 Grade III 에있어서는혼미상태가 90% (9예), 혼수상태가 10% (1예 ) 를차지하였다 (Table 2). 외상후임상심리검사까지의기간최초수상후임상심리검사까지의기간은최소 6개월이상경과한시점에서시행하였으며 Grade I에서는 16.1 개 TABLE 1. Age, sex and causes according to diffuse axonal Injury Grade Age (years) TABLE 3. Time interval between trauma and psychometry Grade 1 Grade 2 Grade 3 T: trauma, P: psychometry Grade 1 (18 cases) Grade 2 (22 cases) Time interval between T-P (months) 16.1 (6-46 months) 14.7 (6-78 months) 14.9 (6-27 months) Grade 3 (10 cases) <19 03 (17%) 02 (09%) 4 (40%) 20-40 06 (33%) 12 (55%) 4 (40%) 40-60 08 (44%) 08 (36%) 1 (10%) >61 01 (06%) 00 (00%) 1 (10%) Mean 36 35 36 Range 17-67 16-58 17-73 Sex (No. of cases) Male 15 (83%) 20 (91%) 7 (70%) Female 03 (17%) 02 (09%) 3 (30%) Cause Pedestrian 07 (39%) 11 (50%) 6 (60%) Traffic accident 10 (56%) 11 (50%) 4 (40%) Fall down 01 (05%) 00 (00%) 0 (00%) TABLE 2. Initial level of consciousness Initial LOC Drowsy Stupor Semicoma Coma Grade 1 (18 cases) 1 (6%) 15 (82%) 1 (6%) 1 (06%) Grade 2 (22 cases) 1 (5%) 21 (95%) Grade 3 (10 cases) 09 (90%) 1 (10%) LOC: level of consciousness 14 J Kor Neurotraumatol Soc 2007;3:13-18
Jeong Ho Kim, et al 월 (6~46 개월 ), Grade II 에서는 14.7 개월 (6~78 개월 ), Grade III 에서는 14.9 개월 (6~27 개월 ) 로검사시기의의미있는차이는없었다 (Table 3). 차도 Grade III 에서 Grade I과 II에비해현저히편차가증가하는결과를나타내었으나통계학적의미는나타내지않았다 (p=0.087)(table 6, 7). 지능검사결과 K-WAIS 지능검사결과는 Grade I, II, III 에따른언어성 IQ는의미있는차이를나타내지않았고동작성 IQ 또한의미있는차이를나타내지는않았다. 그러나 IQ 편차 (difference; 병전 IQ와검사상 IQ의차이 ) 는미만성축삭손상의 Grade 가증가함에따라다소증가하는경향을나타내었지만통계학적의미있는차이는보이지않았다 (Table 4). 그러나뇌간손상이있는 Grade III 와그렇지않은 Grade I+II 를따로비교하였을때 (Grade I과 Ⅱ를한군으로분류 ) 언어성 IQ에서는의미있는차이를나타내지않았고, 동작성 IQ에서도의미있는차이를나타내지않았지만 IQ 편차에있어서는 Grade III 에서 Grade I+Ⅱ 군에비해편차가증가하는결과를나타내었으나통계학적의미는없었다 (Table 5). 따라서 K-WAIS 검사를통한 IQ 검사상에있어서미만성축삭손상 Grade 증가에따른의미있는차이는없었다. 기억검사결과 REY-KIM 검사를이용한기억검사에있어서기억지수는미만성축삭손상의 Grade 증가에따른감소경향을나타내었고 IQ와기억지수 (memory quotient: MQ) 편차또한 Grade 가증가함에따라편차가증가하는결과를나타내었으나통계학적으로의미있는결과는아니었다. 또한이러한기억검사의차이를 Grade III와 Grade I+II 의두군으로비교하였을때기억지수는 Grade III 군에서 Grade I+II군에비해감소되는결과를나타내었고통계학적으로의미있는소견이었다. 또한 IQ-MQ 편 TABLE 4. Intelligence difference by K-WAIS Verbal IQ Performance IQ IQ difference Grade 1 85.50±11.29 81.67±13.13 11.94±4.09 Grade 2 86.73±18.08 78.91±18.34 13.72±6.77 Grade 3 82.20±14.72 78.40±13.05 15.67±4.44 p value 0.741 0.817 0.239 IQ difference: premorbid IQ-test IQ. By one-way ANOVA TABLE 5. Brain stem lesion; intelligence difference Verbal IQ Performance IQ IQ difference Grade 1+2 86.18±15.23 80.15±16.07 12.83±5.59 Grade 3 82.20±14.72 78.40±13.05 15.57±4.44 p value 0.461 0.762 0.166 IQ difference: premorbid IQ-test IQ. By t-test McBride 장애평가표에의한장애정도운동실조즉보행장애부분의발생빈도는미만성축삭손상 Grade 가증가함에따라의미있는증가를나타내었고 (p=0.016), 신경인지장애등을나타내는기질적뇌증 후군의 IX항목의장애정도는미만성축삭손상의 Grade 증가에따라특별한의미있는장애율의증가를나타내지는않았으며장애율의평가에있어서는신경인지장애를나타내는 McBride IX항목의장애평가에서 Grade I+II 는평균 22%, Grade III 에서는평균 27% 로의미있는장애율의차이는나타내지않았다. 운동장애항목을나타내는보행장애 ( 운동실조증 ) 즉맥브라이드 III 항목의장애평가에있어서는 Grade I에있어서는보행장애부분의노동능력상실로평가된증례는한명도없었고 Grade II에서평균 32%, Grade III 에서평균 52% 의노동능력상 TABLE 6. Memory difference by Rey-Kim Memory quotient IQ-MQ difference Grade 1 75.20±12.12 07.5 (-06-23) Grade 2 74.57±19.05 09.5 (-10-24) Grade 3 62.06±14.28 17.5 (-03-30) p value 0.109 0.126 By one-way ANOVA, By Kruskal Wallis test TABLE 7. Brain stem lesion; memory difference Memory quotient IQ-MQ difference Grade 1+2 74.90±15.56 09 0 (-10-24) Grade 3 62.60±14.28 17.5 (-03-30) p value 0.034 0.087 By t test, By Mann-Whitney test TABLE 8. Assessment of disability by McBride disability table Locomotor Disability (%) ataxia IX category III category Grade 1 4 (22.2%) 22 (12-40) 0 Grade 2 5 (22.7%) 22 (10-76) 32 (32) Grade 3 7 (70.0%) 27 (12-58) 52 (27-88) p value 0.016 0.230 0.373 By chi-square, By Kruskal Wallis test TABLE 9. Bran stem lesion; assessment of disability Locomotor Disability (%) ataxia IX category III category Grade 1+2 9 (22.5%) 22 (10-76) 32 (32) Grade 3 7 (700.%) 27 (22-58) 52 (27-88) p value 0.007 0.032 0.667 Fisher s exact test. By Mann-Whitney test www.neurotrauma.or.kr 15
Disability Estimation in the Diffuse Axonal Injury 실이평가되어 Grade I에서는보행장애의노동능력상실이발생하지않음을알수있었고 Grade II와 III에있어서는뇌간손상이동반된 Grade III에서현저한보행장애의노동능력상실이발생함을알수있었다. 그러나이러한장애율의차이는통계학적인의미는없었다 (p= 0.373). 또한 Grade III 군과 Grade I+II 군을비교분석한결과운동장애가발생한빈도는 Grade I+II 군에서 22.5% (9예), Grade III군에서는 70% (7예) 였고역시뇌간손상이동반된 Grade III 에서의미있는운동장애가발생함을알수있었다 (p=0.007). 그러나보행장애부분인 McBride III 항목에있어서는 Grade I+II군에있어서는평균 32%, Grade III 군에있어서는평균 52% 로뇌간손상이동반된 Grade III에서현저한운동장애의노동능력상실률이증가하는경향을나타내고있음을알수있었다. 그러나통계학적인의미는없었다 (p=0.667)(table 8, 9). 뇌병변의분포와심리검사결과미만성축삭손상에있어서뇌병변의분포를분석한바, TABLE 10. Brain lesion distribution White matter injury Right hemisphere Left hemisphere Frontal 30 23 Temporal 16 14 Parietooccipital 08 11 Cerebellum 03 01 Basal ganglia 04 11 Thalamus 01 03 Corpus callosum 28 Brain stem 10 Operation cases by combined intracranial lesion was excluded 전두엽, 측두엽에호발하였으며 8,9) 다음으로뇌량체, 두정후두엽, 뇌기저핵부, 뇌간부, 소뇌및시상부순으로병변의호발빈도를나타내었다 (Table 10). 이러한병변의부위에따른 IQ 및기억지수를분석한결과는 ( 뇌량체나뇌간부위손상의영향을배재하기위해 Grade II 또는 III 에속하는환자는이평가에서제외됨 ) 전두엽병변이양성인경우와전두엽병변이음성인경우를비교분석하였을때언어성 IQ (verbal IQ: VIQ), 동작성 IQ (Performance IQ: PIQ), IQ 편차 (IQ difference: DIQ), 기억지수및 IQ 와 MQ차이 (IQ-MQ Difference: DIM) 에있어서의미있는차이를나타내지는않았다 (Table 11). 또한두정후두엽병변이있는경우와없는경우에있어서동일한방법으로평가하였을때역시 VIQ, PIQ, DIQ, MQ, DIM 에있어서의미있는차이를나타내지않았다. 그러나측두엽병변이있는경우와없는경우의두군으로 IQ 및 MQ 부분을평가하였을때측두엽병변이있는경우가없는경우에비해 VIQ 가의미있게감소되는결과를나타내었고 (p=0.016), 그외에도 PIQ 가감소되는경향 (p= 0.103) 을나타내었으며 MQ 에있어서도통계학적으로의미있는수치는아니나상당히감소하는경향을나타내었다 (p=0.088)(table 12). 이러한결과는측두엽병변이있는경우기능해부학적위치상측두엽이언어와기억에관여하고있는바 VIQ와 MQ에있어서상당한저하소견을나타내고있음을확인할수있었다. 18) 고찰 미만성뇌축삭손상과 MRI상의손상정도에따른예후분석에대한논문은다소찾아볼수있다. 특히 Oh 등 16) 은미만성축삭손상환자의자기공명영상소견과예후와의 TABLE 11. Frontal lesion; intelligence & memory difference VIQ PIQ DIQ MQ DIM Lesion (+): 13 cases 86.15±10.37 81.62±11.72 12.38±4.41 74.82±13.57 06.20±08.38 Lesion (-): 5 cases 83.80±14.65 81.80±17.89 10.80±3.27 76.25±08.340 12.75±10.66 p value 0.705 0.980 0.479 0.808 0.242 For excluded the effect of corpus callosum & brainstem, only use Grade 1 group. DIQ: IQ difference, VIQ: verbal IQ, PIQ: performance IQ, MQ: memory quotient, DIM: IQ-MQ difference TABLE 12. Temporal lesion; intelligence & memory VIQ PIQ DIQ MQ DIM Lesion (+): 10 cases 78.63±11.12 76.00±14.44 11.25±3.54 68.66±13.79 7.80±10.62 Lesion (-): 8 cases 91.00±08.31 86.20±10.58 12.50±4.60 79.56±09.20 8.22±08.97 p value 0.016 0.103 0.536 0.088 0.938 For excluded the effect of corpus callosum & brainstem, only use Grade 1 group. MQ: memory quotient, DIM: IQ-MQ difference, DIQ : IQ difference, VIQ: verbal IQ, PIQ: performance IQ 16 J Kor Neurotraumatol Soc 2007;3:13-18
Jeong Ho Kim, et al 상관관계분석에서뇌간및뇌량체손상이동반된경우예후가불량함을보고하고있으며 Kim 등 11) 은의식소실기간은 MRI Grade 가높을수록증가하는경향을보였으나 MRI Grade 와입원당시 Glasgow 혼수계 (GCS) 로분류한임상정도와의관계는통계학적의미가없음을보고하였고예후와도통계학적의미가없다고보고하였다. 또한미만성축삭손상환자의예후판정은 MRI 보다는임상양상을참조하는것이바람직하다고주장하였다. Kim 등 13) 은뇌간손상이있는미만성축삭손상의경우가다른경우에비해훨씬나쁜예후를가진다고보고하였다. 그러나 1992년 Mendelsohn 등 15) 에의하면 MRI상뇌량체손상이반드시나쁜예후를시사하는것은아니라고주장하고있으며 2001년 Wallesh 등 20) 에의하면국소적인전두엽좌상이행동이나재활의문제점을유발하여나쁜예후를나타낸다는보고도있으나실질적인신경인지장애부분을구체적인임상심리검사를통해 IQ 및기억지수부분을분석평가한논문은찾아보기어렵다. Axouvi 등 2) 에의하면외상성뇌손상의인지및행동장애는전전두엽및대상엽그물망 (Prefrontal-Cingulate Network) 의활성결손에기인된다고주장하였다. 그러나이연구에서처럼미만성축삭손상정도에따른구체적인임상심리분석결과를통한신경인지장애특히 IQ 및기억력장애를분석평가한내용은찾아보기어렵고더욱이 McBride 에의한최종후유장애상태를 Grade 정도에따라항목분석한논문은더더욱찾아보기어렵다. 또한이연구에서는뇌량체및뇌간손상의영향을배제한 Grade I의환자군에서전두엽병변의유무에따른 IQ와 MQ를비교분석하였으나의미있는차이를나타내지않았고측두엽병변의유무에따른비교분석에서측두엽병변이있는경우가없는경우에서보다의미있는 VIQ 감소와 MQ의감소경향을나타내었다. Mataro 등 14) 은미만성축삭손상 Type I의환자에서다른군의환자에비해신경정신적회복이양호함을보고하였고특히두개강내에종괴병변 ( 혈종등 ) 이존재하는경우에비해더나은예후를보고하였다. 이러한연구에서그들은미만성손상의범위정도는언어성기억과집중력, 인지기능의유연성과상관관계가있음을보고하면서특히, 뇌실확장이종괴성병변 ( 혈종등 ) 이있는환자에있어서더욱뚜렷하였고미만성손상의정도가감소할수록뇌실크기가감소하는결과를보고하였다. 실제로미만성축삭손상환자에있어서신경행동학적인결손을객관적으로평가한다는것은매우어렵다. 이연구에포함된분석대상의제한점으로는최소한임상심리검사를시행할정도의인 지기능을가지고임상심리검사를시행할때까지생존한환자를대상으로하였다는점과둘째로는신경행동학적인결손을가지지않는환자는제외되었고, 또한최소한중등도의장애를가진환자들에서평가가시행되었다는점, 셋째로는이러한평가대상의환자가보상의문제가걸려있는교통사고와관련된환자가대부분이었다는점에서의손상기전의다양성이배제되었고평가대상의보상적욕구증가등이문제점으로지적될수있다고본다. 또한최종장애를평가함은평가자에따른주관적인편차가있을수밖에없다는점을들수있겠으나동일한임상심리사와동일한평가자에의해평가된내용을분석한것이므로최소한동질성을가진다고는볼수있겠다. 또한임상심리검사의시점과장애평가의시점이통일된시점이아닌편차를가진다는점도들수있겠다. 그러나최소한수상일로부터 6개월이상경과한시점에서급성기의충분한회복이이루어진이후의평가라는점, 또한평균평가시점이 14.7~16.1 개월사이였다는점에서어느정도의평가시점의타당성은인정할수있을것으로본다. 결 론 미만성축삭손상환자에있어서신경행동학적인결손을객관적으로평가하는것은매우어렵지만이러한분석결과를바탕으로차후전향적인정밀정리된다양한분석표를작성하여더많은증례의분석평가를통한미만성축삭손상의정도와신경인지기능장애및최종장애율과의상관관계의연구를지속한다면미만성축삭손상환자의장애를평가하는보다나은지표를발견할수있을것으로기대된다. 중심단어 : 미만성축적손상 신경행동학적장애 임상심리검사 장애평가. REFERENCES 1) Adams JH, Doyle D, Ford I, Gennarelli TA, Graham DI, Mc- Lellan DR. Diffuse axonal injury in head injury: definition, dignosis and grading. Histopathology 15:49-59, 1989 2) Axouvi P. Neuroimaging correlates of cognitive and functional outcome after traumatic brain injury. Curr Opin Neurol 13:665-669, 2000 3) Blumer D, Benson DF. Psychiatric aspects of neurological disease. New York: Grune & Stratton, 1975 4) Bond MR. Assessment of the psychological outcome of severe head injury. Acta Neurochir 34:57-70, 1976 5) Bond MR, Brooks DN. Understanding the process of recovery as a basis for the investigation of rehabilitation for the brain injury. Scand J Rehabil Med 8:127-133, 1976 6) Brooks DN, Mckinlay W. Personality and behavioral change www.neurotrauma.or.kr 17
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