Research in Vestibular Science Vol., No., June 0 riginal Article pssn 09888, essn 090 어지럼으로응급실에내원한환자의중추성원인에대한예측인자들 : ABCD 스코어의유용성 서남대학교의과대학예수병원 응급의학과학교실, 신경과학교실, 순천향대학교의과대학순천향대학교부천병원신경과학교실 김형준, 김수익, 강지훈, 성기범, 이태경, 박지윤 Predictors of Cerebrovascular Causes in the Emergency Department Patients with Dizziness: Application of the ABCD Score HyungJun Kim, Suk Kim, JiHun Kang, KiBum Sung, TaeKyeong Lee, JiYun Park Department of Emergency Medicine; Department of Neurology, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju; and Department of Neurology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea Received Sep 7, 0 Revised M D, 0 Accepted M D, 0 Corresponding Author: JiYun Park Department of Neurology, Presbyterian Medical Center, 6 Seowonro, Wansangu, Jeonju 6070, Korea Tel: +8607 Fax: +86078 Email: truejy@jesushospital.com Copyright c 0 by The Korean Balance Society. All rights reserved. Background and bjectives: Dizziness is a common presenting complaint in the emergency department (ED) that had various pathologic causes. Most of dizziness can be caused by benign origin but identifying cerebrovascular causes among ED patients with dizziness is a diagnostic challenge. ABCD score is clinical prediction tool for assessing the risk of stroke after a transient ischemic attack (TA). We evaluated predictors of cerebrovascular causes and whether ABCD score would identify cerebrovascular events among ED patients with dizziness. Materials and Methods: We analyzed 80 patients ( 0 years old) with dizziness in ED, Presbyterian Medical Center (singlecenter prospective observational study) for months. Type of dizziness, associated symptoms, past medical history, ABCD score (0 7), neurootologic examination, diagnosis were recorded. Results: The incidence of dizziness is.6% (9/,7). After excluding patients, 80 patients (6% female, mean 9 years) met our eligibility criteria and were included in the final analysis. Cerebrovascular causes of dizziness were found in 0% (8/80): vertebrobasilar insufficiency, 9 cerebellar infarction, right middle cerebral artery (MCA) infarction, right MCA giant aneurysm, lateral medullary infarction, posterior limb of internal capsule infarction, intracerebral hemorrhage of cerebellum. Patients with cerebrovascular cause were males and had more hypertension, diabetes mellitus, imbalance, abnormal neurootologic findings and ABCD score. Conclusion: Several clinical factors (hypertension, diabetes, abnormal neurootologic findings ABCD scores) favored a diagnosis of central neurological causes of dizziness. ABCD score is a simple and easily applied tool for distinguishing cerebrovascular from peripheral causes of dizziness in ED. Research in Vestibular Science 0;():0 Keywords: Dizziness; Cerebrovascular accident; Emergency medicine
김형준외 인. 어지럼으로응급실에내원한환자의중추성원인에대한예측인자들 : ABCD 스코어의유용성 서론어지럼은응급실을방문하는환자들이흔하게호소하는증상중하나이지만, 어지럽다는표현이같아도실제환자들이경험하는증상은서로다른경우가많고, 여러가지원인질환들에의해유발될수있어감별진단과치료에어려움을겪는다. 어지럼의대부분은말초전정질환에의한양성의경과를취하지만,, 때로는심각한상황을초래하는뇌혈관질환이나심장질환을원인으로가질수있으므로진료시어지럼을일으키는다양한질환의발현양상을숙지하여이들을감별하는것은매우중요하다. 이를위해서는어지럼의양상, 증상지속시간과발생상황, 어지럼의유발요인, 동반증상, 과거병력등자세한문진및신경이학적검사를시행한후필요에따라청력및전정기능검사와뇌영상등을시행하게된다. 이중어지럼의양상은진단에도움을줄수있으나, 환자들은때때로본인이경험한어지럼을정확하게설명하지못하고, 의사또한병력만으로어지럼양상을구분하는데어려움을겪기도한다. 또한응급실에서어지럼환자를진찰하는경우병력청취나검사에한계가있으며어지럼진찰에경험이적고숙련되지못한경우신경이학적진찰이나진단하는데어려움을겪어불필요한영상의학적검사를시행하거나잠재된위험성을인지하는못하는경우가있다. 응급실에내원시구음장애, 사지실조증, 감각이상, 운동마비등국소적신경학적증상을동반한경우뇌병변을강력히시사하므로뇌영상을바로시행해야하지만, 소뇌경색이나척추뇌기저혈류부전 (vertebrobasilar insufficiency, VB) 의경우때때로현훈이나균형장애만단독으로호소하므로내재된위험성이간과될수있어임상에서이들을정확히진단하는것은매우중요하다. 6,7 전형적인말초성어지럼어지럼을보이지않거나뇌졸중의위험인자를가지고있는경우안진의양상, 두부충동검사 (head impulse test), 머리도리질검사 (head shaking test), 균형장애등에서중추성어지럼을시사하는의심스런징후를보인다면뇌영상검사를고려하고주의깊은관찰이필요하다. 8,9 그러나이러한검사는숙련된신경과, 이비인후과의사들에의해시행되며, 응급실에서숙련되지않은의사가어지럼환자를진찰시이러한검사를정확하게시행하는것은어렵다. 일과성뇌허혈후에발생하는뇌졸중의위험도를예측할수있는지표로사용되는 ABCD 스코어는쉽고간단하게측정할수있으며그유용성과타당성이이미검증되었다 (Table ). 0 최근 ABCD 스코어를응급실어지럼환자에게적용하여뇌졸중환자를감별하는데도움을줄수있다는보고가있었으나, 후향적으로의무기록분석을통해최종진단을내렸다는한계를가지고있으며, 국내에서연구되었던적은없었다. 본연구는응급실이라는제한된상황에서뇌혈관질환과연관된어지럼을비교적간단하고효율적으로예측하기위해전향적으로어지럼의양상, 동반증상, 과거력, ABCD 스코어, 신경이학적검사등을기술하고 ABCD 의유용성및응급실어지럼환자에게적용하는경우 ABCD 스코어의문제점을분석해보고자하였다. Table. ABCD and modified score. ABCD score is clinical prediction tool for assessing the risk of stroke after a transient ischemic attack (TA). We modified the ABCD score because if the patient present unilateral weakness or speech disturbance, physician can make the diagnosis of central origin of vertigo and exclude this study. Because the duration of symptoms was not readily available, all patients were scored points Risk factor Points Modified points Total A B C D D Age 60 years or older BP elevation on first assessment after TA (sbp 0 mmhg or dbp 90 mmhg) Clinical features Unilateral weakness Speech impairment without weakness Duration of TA 60 minutes 0 9 minutes <0 minutes Diabetes 0 0 7 0 (all) (all)
Res Vestib Sci Vol., No., Jun. 0 대상및방법 0년 월부터 6월까지예수병원응급실에내원한,7명의환자중어지럼을주증상으로내원한만 0세이상의환자 9명 (.6%) 을대상으로전향적으로연구하였다. 검사를진행하기어려울정도의전신질환 ( 암, 장기부전, 근골격계질환등 ) 을가지고있는경우, 외상으로인한뇌손상이동반된경우, 검사및치료를거부한경우는연구에서제외하였다. 또한발음장애나일측마비등객관적인국소적신경학적증상이관찰되는경우명백한중추성현훈을시사하므로연구에서제외하였다. 또한최종적으로뇌혈관성질환이아닌다른원인에의해중추성현훈이발생한경우도연구에서제외하였다. 어지럼환자에대한임상경험이적고신경이학적검사에숙련되지않은의사에의해어지럼의형태, 동반증상, 과거력, ABCD 스코어등을초진시에기술하였으며, 진료및신경이학적검사에숙련된응급의학과, 신경과의사에의해재차진찰및신경이학적검사시행후필요시뇌영상검사, 전정기능검사를시행한후임상적진단등을기록하였다. ABCD 스코어는나이 (age) 가 60세이상인경우 점, 혈압 (blood pressure) 은내원시수축기혈압이 0 mmhg 혹은이완기혈압이 90 mmhg 이상인경우 점, 임상증상 (clinical features) 은일측성마비의경우 점, 마비없는언어장애의경우 점, 증상의기간 (duration of symptoms) 은 60분이상인경우 점, 0 9분의경우 점, 당뇨 (diabetes) 는 점으로총 0 7점으로분포되어있다. 그러나본연구에서앞서언급한대로마비및언어장애등국소적인신경학적증상이있다면중추성현훈을강력하게시사하므로본연구에서제외하였고, 임상증상은모두 0점으로처리하였다. 또한어지럼의기간은일과성뇌허혈과달리혈관성과비혈관성을구분하는데큰도움을주지못하고 ( 말초성현훈의경우에도수초에서수개월까지다양하게호소 ), 또한많은환자들이어지럼을느낀기간을비교적정확하게기술하기어렵기때문에증상의기간은 Navi 등 의연구에서와같이모두 점을적용하였다. 따라서본연구에서 ABCD 스코어는 0 7점이아닌 점으로분포하였다. 최종진단은응급실에서진찰하였던숙련된의사를포함한두명의신경과의사와응급의학과의사가응급실, 입원실혹은외래에서추가적으로시행한뇌영상검사, 전정기능검사, 청력검사등을토대로결정하였다. VB는자기공명혈관조영 (magnetic resonance angiography, MRA) 혹은컴 퓨터단층혈관조영 (computed tomography angiography, CTA) 상기저동맥의 0% 이상의협착이관찰되고말초성현훈에합당하지않는임상증상을보이는경우로정하였다. 급성뇌경색은확산강조영상 (diffusion weighted image, DW) 상이상소견이관찰되고이에합당하는신경이학적검사및증상이관찰되는경우로진단하였다. 말초성원인의어지럼은임상양상, 전정기능검사, 뇌영상을종합하여양성발작성두위현훈 (benign paroxysmal positional vertigo), 전정신경염 (vestibular neuritis), 간헐적현훈 (episodic vertigo; 편두통성현훈 [vestibular migraine], 메니에르병 [Meniere s disease], 양성반복현훈 [benign recurrent vertigo]), 실신성현훈 (presyncopal dizziness), 심인성현훈 (psychogenic dizziness) 등으로진단하였다. 증상이나검사결과가불분명하거나검사를충분히시행하지못해진단을내리지못한경우불분명 (unknown origin) 으로진단하였다. 분석은 SPSS ver. 9.0 (SPSS nc., Chicago, L, USA) 프로그램을이용하여카이제곱검증 (chisquare test), 로지스틱회귀분석 (logistic regression) 을이용하였고 p값이 0.0 미만인경우를통계학적으로유의한것으로판정하였다. 또한 ABCD 스코어의유의성을평가하기위해 receiveroperator curve (RC) 곡선을작성하였다. 결과응급실에내원한전체,0명중 9명 (.6%) 이어지럼을주증상으로호소하였다. 이중 명은일측성마비나발음장애등뚜렷한국소적신경학적결손이관찰되어본연구에서제외하였다. 검사를진행하기어려울정도의전신질환 ( 암, 장기부전, 근골격계질환등 ) 을가지고있는경우, 외상으로인한뇌손상이동반된경우, 검사및치료를거부한 8명도본연구에서제외되었다. 최종적으로뇌혈관성질환이아니폐암으로소뇌전이로균형장애를호소하였던 명의환자도본연구에서제외되어총 80명을분석하였다. 남자는 80명 (%), 여자는 00명 (6%) 으로여성이약간더많은비율을차지하였다. 평균연령은 9세 ( 9 세 ) 였고, 남성은 6세 (0 8세), 여성은 6세 ( 9세) 였다 (Table ). 질환별분포를살펴보면전정신경염 명 (%), 양성발작성두위현훈 명 (8%), 간헐적현훈 0명 (%), 실신성어지럼 명 (%), 심인성어지럼 6명 (%), 원인불명 8 명 (0%), 뇌혈관질환 8명 (0%) 이었다 (Figure ). 6
김형준외 인. 어지럼으로응급실에내원한환자의중추성원인에대한예측인자들 : ABCD 스코어의유용성 Table. Characteristics of ED patients with dizziness Disease Number Age HTN DM CAD mbalance (%) ABCD Central vertigo VN BPPV EV (MV, MD, BRV) Presyncope Psychogenic Unknown Total 8 (0) () (8) 0 () () 6 () 8 (0) 80 (00) 67 (., 8) 9 (.9, 8) 60 (.7, 79) (.7, 0 9) 69 (6., 9) 6 (7.7, 7 9) 70 (6.9, 8 80) 6 (.8, 9) (7.) (.7) (6.9) (.0) 8 (78.) 9 (.) (66.7) 87 (8.) 8 (.) (.0) 8 (.0) (8.7) 7 (.) (.) (7.8) (6.7) (8.7) (.) 0 (0.0) (8.7) (0.9) (.) 7 (9.) 0 (6) 7 (0) (.) () () (9) () ().8 (0.7, ). (.0, ). (., ).7 (0.786, ).0 (0.76, ).6 (.0, ). (0.686, ). (.06, ) Values are presented as number (%), median (range), or median (score). ED, 풀이 ; HTN, 풀이 ; DM, 풀이 ; CAD, 풀이 ; VN, 풀이 ; BPPV, 풀이 ; EV, 풀이 ; MV, 풀이 ; MD, 풀이 ; BRV, 풀이. Table. Demographic and clinical characteristics of ED dizziness patients with and without cerebrovascular event Age (y) Women Triage symptom Headache Risk factors Hypertension Diabetes CAD Neuroophthalmologic findings Head impulse Direction change nystagmus Skew deviation All (n=80) 6 (), 9 00 (.6) 8 (6.6) 9 (7.) 88 (8.9) (7.8) 7 (9.) (.) (.) (0.6) Values are presented as number (%) or median (range). Patients without a cerebrovascular event (n=6) 6 (), 9 9 (8.0) 0 (6.8) (6.) 7 (.7) (.8) (8.6) (.6) Patients with cerebrovascular event (n=8) 67 (), 8 6 (.) (7.) 6 (.) (77.8) 8 (.) (6.7) (.) (.6) pvalue 0. 0.06 0.0 0.9 0.00 0.00 0.69 0.09 <0.00 0.00 Figure. The distribution of final diagnosis in 80 dizziness patients emergency department. VN, 풀이 ; BPPV, 풀이 ; EV, 풀이 ; MD, 풀이 ; VM, 풀이. 뇌혈관질환외원인의경우평균연령이 6세 ( 9세), 뇌혈관질환의경우평균 67세 ( 8세) 로뇌혈관질환에서연령이높았으나통계적의미는없었다 (Table ). 동반증상으로오심및구토, 두통은양군에서큰차이를보이지않았다. 고혈압은뇌혈관질환에서 명 (77.8%) 으로뇌혈관질환외원인에비해의미있게빈도가높았고 (p=0.00), 당뇨도뇌혈관외질환 명 (.8%) 에비해뇌혈관질환에서 88명 (.%) 으로의미있게높았다. 남성또한뇌혈관질환군에서의미있게빈도가높았다 (p=0.06). 그러나심장질환은양군에서통계적인의미가없었다. 80명의환자중 8명 (0%) 이뇌혈관질환에의한현훈을호소하였고, 명은 VB, 9명은소뇌경색, 명은우뇌경색또는우뇌거대동맥류, 외측연수경색, 속섬유막 (internal capsule) 의 posterior limb 경색, 소뇌출혈각 예씩이었다 (Table ). 8명중뇌 CT 이상소견은 0명 (6%) 에서관찰 7
Res Vestib Sci Vol., No., Jun. 0 Table. Characteristics of patients with cerebrovascular cause Dz Age Sex Type Asso Sx. P. Hx TR DCN HT Balance ABCD score Brain CT Angiography DW VB VB VB Bi PCA inf Rt. Cbll. CH Rt. Cbll CH Rt MCA inf Lt. C inf Lt. LM Rt MCA giant aneurysm 6 77 70 9 6 7 6 60 80 7 8 77 8 6 66 9 7 V V V Headache, H, H, H, H, H Paresthesia N Paresthesia,,,,,,,,,,,,, Lt. VA stenosis BA occlusion BA stenosis Rt. VA occlusion Rt. VA occlusion MCA, VA stenosis BA stenosis MCA occlusion Rt. MCA giant ansrysm All (n=80) Area under RC curve(abcd ) = 0.787 (9% C, 0.69 0.88) Patients without a Cerebrovascular Event (n=6) Patients With Cerebrovascular Event (n=8) pvalue ABCD (SD). (SD.0, ). (SD 0.99, ). (SD 0.7, ) <0.00 Figure. Receiveroperator characteristic (RC) curve of the ABCD score to predict cerebrovascular diagnosis in 80 ED patients with dizziness. SD, 풀이 ; C, confidence interval. 되었고, CTA 혹은 MRA 상이상소견은 9명 (0%), DW 상이상소견은 6명 (89%) 에서관찰되었다. 뇌혈관질환과연관된현훈의평균 ABCD 스코어는.8로비뇌혈관질환군의평균 ABCD 스코어.과의미있는차이를보였다 (p<0.00). 예외적으로뇌혈관질환과연관되지않은중추성현훈은폐암의뇌전이를보인한명에서관찰되었으며 ABCD 스코어는 점이었다. ABCD 스코어의 RC curve 아래면적 (area under the RC, AUC) 은 0.7 (9% confidence interval, 0.70 0.88) 로혈관성과비혈관성을구분하는데증등도의정확도를가진검사로판단된다 (Figure ). 8
김형준외 인. 어지럼으로응급실에내원한환자의중추성원인에대한예측인자들 : ABCD 스코어의유용성 고찰급성어지럼또는현훈을호소하는환자의대부분은별다른후유증없이회복되는양성경과를보이지만, 뇌줄기 (brainstem) 또는소뇌를침범하는경색이나 VB에의한중추전정성질환은심각한후유증이나생명을위협할수있으므로임상에서잘감별할수있어야한다. 이를위해서는각각의질환의전형적인임상양상과신경이과학적특징을숙지하고있어야하며뇌졸중의위험인자를가지고있거나국소적신경학적이상을동반하는경우반드시뇌혈관질환과연관된중추성현훈을감별해야한다. 최근혈관위험인자를가지고있는급성전정증후군 (acute vestibular syndrome) 환자에서 Head mpulsenystagmustest of Skew (HNTS) 로표현되는두부충동검사, 안진의관찰, 스큐편위검사를통해뇌영상검사보다더정확하게중추성원인을감별할수있다는보고가있지만, 9 이러한검사는검사자의숙련도에따라다양한결과를보일수있고, 급성전정증후군에서만적용할수있는임상적인제한점이있다. 반면에 ABCD 스코어는신경이학적검사에숙련된의사가아니더라도비교적쉽고간단하게측정할수있으며급성전정증후군외에도응급실에내원하는모든어지럼환자들에게적용할수있다는점에서보다유리한점이있다. ABCD 스코어는이전 Navi 등 의연구에서응급실을방문하는어지럼환자들에서중추성원인을감별하는데유용한정보를제공할것으로보고되었으나, 이연구는후향적으로의무기록분석을통해시행된연구로임상연구의한계점을가지고있다. 그러나본연구는전향적으로응급실에내원하는모든어지럼환자를대상으로시행하였고, 처음으로국내에서 ABCD 스코어가응급실방문어지럼환자의혈관성질환을감별하는데임상적으로유용할수있음을밝혔다는데의의가있다. 본연구의한계점은첫째, ABCD 스코어는본래 transient ischemic attack (TA) 환자에서뇌졸중의위험도를예측하는인자로서이들항목중 C항목 ( 임상증상 ; 일측성마비혹은언어장애 ), D항목 ( 증상지속기간 ) 은 TA에적용할때와달리어지럼환자를대상으로한본연구에서는불필요하거나의미가축소되는항목으로서, 향후이러한항목들의변형을통해뇌혈관성원인에의한어지럼을구분하는데좀더유용할수있도록해야한다. 예를들어균형장애는비교적쉽게측정할수있고, 중추성어지럼을구분하는데유용하다고알려져있으므로, 이를체계적으로점수화 한다면 C항목을대체하기에용의할것으로기대된다. 실제로본연구에서사용한 ABCD 스코어는 C, D (duration) 가빠진 ABD (diabetes) 에해당하여나이와혈관위험인자에해당하는고혈압, 당뇨유무에해당하여임상적인소견을반영하는 C와 D (duration) 의의미는축소되어있어, 변형된 ABCD 스코어를통해어지럼의감별진단에도움이되는객관적인신경학적검사를추가할경우더유용할것으로판단된다. 둘째, 본연구는한기관에서적은환자를대상으로한연구로아직일반화하여적용하기는어려우며향후다기관에서많은환자수를대상으로본연구를적용하여유효함을검증 (validation) 할필요가있다. 셋째, 본연구는뇌혈관성원인에의해발생하는중추성어지럼을예측하는데유용하게적용할수있으나소수의종양성, 염증성, 감염성질환등에의한중추성현훈등을감별하는데는용의하지못하므로모든중추성어지럼을진단하는데유용하게사용할수없다는한계점을가지고있다. 따라서비혈관성또는혈관위험인자를가지고있지않은혈관성중추성현훈을진단하기위해서는중추성현훈에서관찰될수있는임상양상및신경이학적소견들 ( 심한불균형, HNTS) 또한잘알고있어야한다. 비교적쉽고간단하게측정할수있으며뇌혈관성어지럼을감별하는데유용한 ABCD 스코어를임상에일반적으로적용하기위해서는향후변형이필요하며다수의기관에서많은환자수를대상으로연구를진행해보아야한다. 중심단어 : 결 론 CNFLCT F NTEREST No potential conflict of interest relevant to this article was reported. REFERENCES. Baloh RW. The dizzy patient. Postgrad Med 999;0:66, 677.. Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol 00;6:066. 9
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