대한응급의학회지제 18 권제 6 호 Volume 18, Number 6, December, 2007 증 례 두부외상으로인해발생한가성뇌동맥류의진단적방법및중요성 - 증례보고 - 경희대학교부속동서신의학병원신경외과, 응급의학과 1 방재승 김명천 1 The Diagnostic Method and Importance of Intracranial Pseudoaneurysm Developed by Head trauma - Case report - Jae-Seung Bang, M.D., Myung-Chun Kim, M.D. 1 Traumatic intracranial pseudoaneurysms are rare and it is easy to overlook the evaluation of intracranial vascular injury in head trauma patients in the emergency room. If the result of missing an intracranial aneurysm however is catastrophic. I describe a case of a patient with intracranial internal carotid artery (ICA) pseudoaneurysm after head trauma and stress the importance of obtaining a three-dimensional-computed tomogram angiography (3D- CTA) in cases of patients with skull base fracture or eyeball pain. We report a case which a patient complained of severe headache and right eyeball pain after head trauma. 3D-CTA revealed carotid-cavernous fistula and pseudoaneurysm of the right ICA. After performing transfemoral carotid angiography (TFCA) and a balloon occlusion test, we carried out endovascular trapping of ICA and extracranial-intracranial (EC-IC) bypass surgery. Afterward, the patient was discharged without neurological deficit after two weeks. We recommended 3D-CTA in cases of head trauma when the patient has skull base fracture or sphenoid sinus fracture. Key Words: Head Trauma, Pseudoaneurysm, 3D-CTA Department of Neurosurgery and Emergency Medicine 1 of East-West Neo Medical Center, Kyung Hee University, School of Medicine, Seoul, Korea 서론외상으로인한두개내혈관손상 (intracranial vascular injury) 은두부손상환자의약 0.2% 정도의빈도로매우드물게보고되고있으며 1,2) 실제임상에서간과하기쉬워, 치명적인결과가초래된뒤뒤늦게진단을하는경우가있다. 두개내혈관손상의종류로는혈관내혈전증, 박리성가성동맥류 (dissecting pseudoaneurysm), 해면정맥동루 (carotid-cavernous sinus fistula : CCF) 등이있으며대부분외상후 2~3주내에발생하며, 환자가회복되는과정에서갑작스런돌발증상의출현후진단되는경우가많다 3). 이런질환들은발생빈도가낮으며또한병태특이적인 (pathognomonic) 증상이없는경우가많고, 응급실에서두부외상환자검진시대부분두개내출혈을감별하기위해단순뇌 CT(computed tomography) 를주로촬영하기때문에혈관병변에대한평가를하지못하는경우가많다 4). 뇌혈관병변에대한평가시에는원칙적으로는뇌혈관조영술 (TFCA:transfemoral carotid angiogram) 이표준 (gold standard) 검사로되어있으나응급실상황에서바로검사할수없는경우도많이있어 3차원뇌혈관촬영 CT (3 dimensional-comp-uted tomogram angiography : 3D- CTA) 가혈관손상의증상이나징후가있는환자에서는아주유용한검사이다. 저자들은두부외상후촬영한 3차원뇌혈관촬영 CT상에서외상으로인해발생한가성내경동맥동맥류및해면정맥동루를발견하고신경외과적인수술을시행하여잘회복된증례를경험하여보고하고자한다. 증 례 책임저자 : 김명천서울특별시강동구상일동 149번지경희대학교부속동서신의학병원응급의학과 Tel: 02) 440-8275, Fax: 02) 440-7799 E-mail: edkmc@chol.com 접수일 : 2007년 10월 16일, 1차교정일 : 2007년 10월 22일게재승인일 : 2007년 11월 23일 609 37세여자환자가 2층건물에서낙상한채로발견되어외부병원을거쳐본원응급실로내원하였다. 신경학적검사결과의식상태는혼미 (stupor) 하였으며심한음주상태로추정되었고, 후두부위에 11 cm 길이의깊은열상이있었다. 양측눈주위의심한부종소견이있었으며, 가벼운
610 / 대한응급의학회지 : 제 18 권제 6 호 2007 비출혈 (epistaxis) 이있었다. 응급실에서시행한말초혈액검사상혈색소치가 6.0 g/dl, 혈소판 25000/mm 3 로심한빈혈및혈소판감소증소견이관찰되었다. 수혈후환자의혈색소치와혈소판치는정상화되었으며, 타장기의 손상이없어후두부열상에의한심한실혈로인해빈혈이발생한것으로추정하였다. 응급실에서촬영한단순뇌 CT 및안면골 CT (facial bone CT) 검사에서는우측전두골기저부골절 (frontal base fracture), 접형동골절 (sphe- A Fig. 1. Facial bone CT* shows (A) right frontal base bone fracture, pneumocephalus and (B )sphenoid sinus fracture (arrow). CT* : computed tomography B A B C Fig. 2. (A) 3D-CTA* shows right internal carotid arterypseudoaneurysm (arrow). (B) This pseudoaneurysm is penetrating into the sphenoid sinus (arrow). (C) The size of this aneurysm is measured as 4.2 4.4 mm by 3D-CTA. 3D-CTA* : 3 dimensional-computed tomography angiogram A B C Fig. 3. (A) TFCA*(anteroposterior view) shows right internal carotid artery pseudoaneurysm (arrow). (B) TFCA(lateral view) shows pseudoaneurysm and CCF (arrow). (C) The size of this aneurysm is measured as 7.2 7.1 mm(upper arrow) by 3D TFCA, the size of which is increasing. Lower arrow indicates CCF. TFCA* : transfemoral carotid angiography CCF : carotid-cavernous sinus fistula
방재승외 : 두부외상으로인해발생한가성뇌동맥류의진단적방법및중요성 - 증례보고 - / 611 noid sinus fracture), 공기뇌증 (pneumocephalus) 소견이관찰되었다 (Fig. 1). 후두부열상에대해서는전신마취하에창상세척및봉합술을시행하였으며이후환자는서서히의식및전신상태가호전되었다. 수상후 1주경부터새로운양상의두통및우측안구통을호소하여수상후 10일째촬영한 3D-CTA 검사에서해면정맥동루가발견되었으며우측내경동맥침상돌기주변부위 (paraclinoid area) 에 4 4 mm 크기의가성뇌동맥류 (cerebral pseudoaneurysm) 로생각되는병변이발견되어 (Fig. 2), 4일후뇌혈관조영술을시행하였다. 뇌혈관조영술에서소량의해면정맥동루및 7 7 mm로크기가더욱증가한침상돌기주변부위가성뇌동맥류를확인하였으며외상에의해발생한박리성동맥류 (dissecting aneurysm) 로추정하였다 (Fig. 3). 바로우측내경동맥을막고풍선폐쇄검사 (balloon occlusion test) 를시행한뒤, 핵의학방사성동위원소를주입하여단일광자방출단층촬영검사를시행하였다. 풍선폐쇄검사에서는환자에게허혈증상은나타나지않았으나단일광자방출단층촬영 (single photon emission tomography : SPECT) 검사에서우측기저핵쪽에경도 (mild) 의뇌관류 (perfusion) 감소소견이보였다 (Fig. 4). 다음날다시뇌혈관조영술을촬영한결과뇌동맥류의크기가 8 7 mm로더욱증가하여 (Fig. 5), 뇌혈관우회수술 (cerebrovascular bypass surgery) 을먼저하고내경동맥을뇌혈관내코일색전술 (endovascular coil embolization) 로막을시간적여유가없다고판단되어우선뇌동맥류가있는부위의내경동맥을코일색전술로막았다 (Fig. 6). 박리성가성뇌동맥류인관계로뇌동맥류만막는것은의미가없어내경동맥전체를막았으며, 색전술동안시행한뇌파감시 (electroencephalogram (EEG) monitoring) 에서는이상변화는없었다. 색전술전후로환자상태의변화는없었고우측내경동맥폐색에대해발생할수있는허혈에대비하여다음날우측측두동맥-중대뇌동맥간접합수술 (superficial temporal artery(sta)-middle cerebral artery(mca) anastomosis) 을시행하였다 (Fig. 7). 수술 2주후환자는거의사고전평상시상태로호전되어퇴원하였으며현재까지 3개월정도외래경과관찰중에있으나새로이발생하는증상은없는상태이다. 고 찰 Fig. 4. SPECT study after balloon occlusion reveals mild decreased perfusion in the right basal ganglia. SPECT* : single photon emission computed tomography 두부외상으로인해발생하는외상성뇌혈관손상은수상후 2~3주내에가장흔히발생하는것으로되어있으며그종류로는혈관내혈전증 (intravascular thrombosis), 박리성가성뇌동맥류, 해면정맥동루등이있다 3). 이들병변은한종류만생기는경우도있으나복합되어나타나는경우도많이보고되고있다 5,6). 외상성뇌동맥류는여자보다남자에게흔하며, 자연발생뇌동맥류의발생위치와다른부위에호발한다고알려져있다 7). 전대뇌동맥이나중대뇌동맥의원위부 (distal segments of anterior and/or middle A B Fig. 5. Follow-up TFCA on the next day shows more increased size of the aneurysm (A) (B).
612 / 대한응급의학회지 : 제 18 권제 6 호 2007 cerebral artery) 에잘생기는것으로보고되고있으나 7,8) 본증례에서는내경동맥의해면정맥동-안동맥부분 (cavernous-ophthalmic segment) 에발생하여, 자연발생하는상뇌하수체동맥뇌동맥류 (superior hypophyseal artery aneurysm) 와감별이어려웠으나, 뇌동맥류가접형골 (sphenoid bone) 을뚫고접형동안으로돌출된소견으로박리성가성뇌동맥류로판단하였다. 가성뇌동맥류를만드는외상기전으로는주로관통성손상 (penetrating injury) 이주를이룬다고되어있으나 9) 이환자의경우는비관통성손상 (non-penetrating injury) 이었으며, 비관통성손상은주로폐쇄성뇌손상 (closed brain injury) 로인해오는뇌변위 (brain shift) 때대뇌낫 Fig. 6. Endovascular trapping with detachable coils was performed in the right carotid artery. (falx), 소뇌천막 (tentoritum), 골융기 (bony prominence) 에혈관손상이가해져서오는것으로되어있다 10). 외상성혈관손상의종류중가성동맥류는주로두개내 (intracranial) 동맥에잘발생하고, 동맥박리 (arterial dissection) 는두개강외 (extracranial) 동맥에호발하는것으로보고되고있으며 11) 이는두개강내-외동맥의조직학적인구조상의차이에기인한다. 두개강내동맥은내탄성층 (internal elastic lamina) 이두껍고외막 (adventitia) 이얇은반면에두개강외동맥은반대의구조를가지고있기때문이다 12). 임상적으로는두개내혈관손상으로인한증상이외상직후보다외상후어느정도시간이경과한뒤에발생하는경우가많기때문에응급실에서초기에진단을하기가어려운경우가많다. 하지만, Chen 등 13) 은외상후수시간부터 10년이지난시점까지도외상으로인한두개내가성뇌동맥류가발생할수있다고주장하여응급실에서두개내혈관손상이의심되는환자의경우는반드시초기에뇌혈관에대한평가 (evaluation) 검사가필요하다고주장하였다. 하지만, 외상초기에두개내혈관손상이발생하더라도의식이안좋은환자의경우는증상표현을하지못하기때문에더더욱발견하기가어렵다. Uzan 등 5) 은외상성두개내혈관손상 12례를보고하면서 10례에서접형골골절이나뇌기저부골절이있었으며 6례에서는비출혈 (epistaxis) 이동반되었다고보고하였다. 또, Lo 등 6) 도외상성내경동맥손상환자 18례를보고하면서이중14례 (78%) 에서뇌기저골골절이있었으며, 3례 (17%) 에서안면골및경추골절 (facial and cervical fracture) 이동반되었다고보고하였다. Shirai 등 14) 은반복적인비출혈, 편측시각장애 (unilateral visual disturbance), 안구잡음 (ocular bruit), 전두골기저골절등이외상성두개내가성뇌동맥류의가장중요한징후 (sign) 라고하였다. 본증례에서도비출혈이약하게있었고, 접형골골절및우측전두골기저골 A B Fig. 7. (A) Right STA-MCA* anastomosis surgery was performed to prevent possible right hemispheric ischemia. (B) Postopearive 3D-CTA shows good patency of STA-MCA anastomosis site (arrow). STA-MCA* : superficial temporal artery-middle cerebral artery
방재승외 : 두부외상으로인해발생한가성뇌동맥류의진단적방법및중요성 - 증례보고 - / 613 절이동반되었으나응급실에서안구잡음은평가를하지못했다. Fontela 등 15) 은가성뇌동맥류의발생시점이매우다양하기때문에목동맥관 (carotid canal) 을침범한뇌기저부골절이있는환자모두에서일상적으로 (routinely) 3D-CTA나자기공명영상혈관촬영 (magnetic resonance angiography : MRA) 을입원시에시행하고, 외상 3~4주후에 3D-CTA 나 MRA를재시행하여야한다고주장하였다. 따라서, 응급실로내원한두부외상환자에서접형골및뇌기저부골절 ( 특히전두부나목동맥관포함된경우 ), 비출혈, 편측시각장애, 안구잡음등이동반된소견이있는환자는외상성혈관손상의가능성을염두에두고응급실에서뇌혈관에대한평가 (evaluation) 를하는것이필요하겠다. 뇌혈관에대한평가적검사로는물론뇌혈관조영술이가장좋은검사로되어있지만, 초기두부외상환자에서바로시행하기에어려운여러가지여건도존재하는관계로 3D-CTA검사가제일좋은검사로생각된다. 3D- CTA검사는금식상태및 BUN/Cr 수치만괜찮으면바로시행할수있으며, 검사로인한합병증발생할위험성도조영제부작용외에는거의없는점등뇌혈관조영술에비해여러가지장점이있으며, 뇌혈관 3차원합성사진도해상도가기술적으로점점향상되고있어향후점차적으로두부외상환자에서필수적인검사로자리잡을가능성이있어보인다. 외상성혈관손상의종류중혈관내혈전증은혈관협착및폐색등으로인한허혈성증상으로, 해면정맥동루에서는해면정맥동증후군으로비교적초기에발견이가능하나, 가성뇌동맥류만있는경우는특별한증상이나징후가없기때문에발견이어렵다. Burton 등 16) 은외상성가성뇌동맥류의경우적절한치료를받지않을경우 54% 의사망률을보고하였으며이후여러저자들에의해비슷한정도의사망률이보고되었다 13,17). 파열되기전에진단하여외과적으로치료를한경우에도사망률이 18~20% 정도보고될정도로 18) 이질환에대한치료는어려운경우가많다. 그이유는외상성뇌동맥류는병태생리적으로진성 (true) 뇌동맥류가아니라가성 (pseudo) 뇌동맥류이므로진성뇌동맥류에대해흔히하는신경외과적인결찰술 (clipping surgery) 로는모동맥 (parent artery) 을보존하면서가성뇌동맥류를완전히치료하기가거의불가능하기때문이다. 따라서최근에는혈관내수술방법이많이발달하면서가성뇌동맥류에대한치료법도여러가지방법이시도되고있다. 즉, 병변근위부를폐색시키거나모혈관에대한포착 (trapping) 을혈관내수술방법으로할수있다. 모혈관에대한포착의경우, 모혈관폐색전에풍선폐쇄검사 (balloon occlusion test) 를시행하여우회로수술의필요성을결정하는것이일반적으로되어있으나검사상의위험성및검사결과의가음성 (false negative) 의가능성때문에풍선폐쇄검사없이바로우회로수술을시행하는것이좋다는 보고도있다 19). 우회로수술을먼저하고모혈관을폐색시키는혈관내수술을다음으로하는것이원칙이나, 본증례에서는다음날시행한뇌혈관조영술상에서뇌동맥류의크기가급격히커져파열위험성이크다고판단하여, 먼저모혈관을폐색시키고다음으로재관류수술을하였다. 외상성뇌혈관손상중가성뇌동맥류는특별한증상이없는경우가많고, 발생시점도수상직후보다는수상후일정기간이지난후에많이발생한다는사실때문에응급실에서놓치는경우가있다고생각된다. 과거에는뇌혈관조영술로진단을하였으나요즈음은 3D-CTA로비교적간단하게검사를할수있어접형골골절, 뇌기저부골절, 비출혈등이동반된환자에서는반드시검사를시행하는것이도움이된다고판단된다. 참고문헌 01. Aarabi B. Management of traumatic aneurysms caused by high velocity missile head wounds. Neurosurg Clin N Am 1995;6(4):775-97. 02. Ahmadi J, Levy ML, Aarabi B, Giannotta. Vascular lesions resulting from head injury. In: Wilkins RH, Rengachary SS, editors. Neurosurgery, 2nd ed.new York:McGraw-Hill;1996. p.2821-40. 03. Benoit BG, Wortzman G. Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry 1973;36:127-38. 04. Simpson RK Jr, Harper RL, Bryan RN. Emergency balloon occlusion for massive epistaxis due to traumatic carotid-cavernous aneurysm. Case report. J Neurosurg 1988;68:142-4. 05. Uzan M, Cantasdemir M, Seckin MS, Hanci M, Kocer N, Sarioglu AC, et al. Traumatic intracranial carotid tree aneurysms. Neurosurgery 1998;43:1314-22. 06. Lo YL, Yang TC, Liao CC, Yang ST. Diagnosis of traumatic internal carotid artery injury: the role of craniofacial fracture. J Craniofac Surg 2007;18:361-8. 07. Britz GW, Newell DW, West GA, Winn HR. Traumatic cerebral aneurysms secondary to penetrating intracranial injuries. Youmans Neurological Surgery, 5th ed. Philadelphia:Saunders;2004.p.2131-5. 08. Dowd GG, Awasthi D. Management of infectious and traumatic intracranial aneurysms. In: Batzer HH, Loftus CM, editors. Textbook of neurological surgery. Philadelphia:Lippincott Williams & Wilkins;2002.p.2473-80. 09. Chedid MK, Vender JR, Harrison SJ, McDonnell DE. Delayed appearance of a traumatic intracranial aneurysm. Case report and review of the literature. J Neurosurg 2001;94:637-41. 10. Norris JS, Wallace MC. Pediatric intracranial aneurysms.
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