대한응급의학회지제 23 권제 5 호 Volume 23, Number 5, October, 2012 증 례 벼락두통으로발현된우측중대뇌동맥경색 1 례 건국대학교의과대학신경과학교실, 건국대학교의과대학재활의학교실 1, 건국대학교의과대학응급의학교실 2 한상돈 조윤식 최진영 김신경 1 김진용 2 Case of Right Middle Cerebral rtery Infarction Presenting as Thunderclap Headache Sang Don Han, M.D., Yoon Sik Jo, M.D., Jin Yong Choi, M.D., Shin Kyoung Kim, M.D. 1, Jin Yong Kim, M.D. 2 Thunderclap headache refers to a sudden and severe headache that comes unexpectedly, reminding one of a clap of thunder. The initial description of this type of headache was in association with an unruptured intracranial aneurysm. It is known to be a presenting feature of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, and hypertensive reversible posterior leukoencephalopathy. formula for diagnostic assessment of thunderclap headache, such as brain computed tomographic scan and spinal tap, should be established. We experienced a case of cerebral infarction presented with thunderclap headache, diagnosed using diffusion weighted magnetic resonance imaging. We suggest that, even when these patients have shown non-specific findings on neurological examination, brain computed tomography, and cerebrospinal fluid analysis, diffusion MRI should be considered for differential diagnosis of thunderclap headache in emergency medical services. Key Words: Thunderclap headache, Cerebral infarction, Diffusion magnetic resonance imaging, Emergency medical services Department of Neurology, Konkuk University School of Medicine, Chungju, Korea, Department of Rehabilitation Medicine, Konkuk University School of Medicine, Chungju, Korea 1, Department of Emergency Medicine, Konkuk University School of Medicine, Chungju, Korea 2 서론두통은응급실에내원하는주요증상중하나이다. 벼락두통은현재까지국내에서정확한유병율이보고된바없으나 Landtblom 등 1) 의보고에따르면 18세이상성인의경우연간 10만명당 43명정도로보고하였다. 대개이러한극심한두통의경우, 환자는응급실로내원할가능성이많다. 벼락두통이뿐아니라응급실로내원하는비외상성두통환자중 13.3% 는심각한두개내병변을동반한다고보고되었다 2). 미국응급의사협회는 2008년벼락두통이나신경학적진찰에이상이있는두통, 후천성면역결핍증후군환자에게응급뇌촬영을, 50세이상의새로운두통환자는신속한뇌촬영을권장하였다 3). 국내에서도통상적으로벼락두통환자에게응급뇌전산화단층촬영 (computed tomography, 이하 CT) 과요추천자검사를권하고있다 4). 이는벼락두통의원인이주로뇌혈관, 염증그리고뇌압에대한인자를고려해야하기때문으로사료된다. 이러한응급실을내원하게되는응급두통중임상양상이특이적인벼락두통에서뇌경색으로발현한증례는지금까지국내논문에기술된바없어문헌고찰과함께보고하는바이다. 증례 책임저자 : 김진용충청북도충주시교현2동 620-5 건국대학교의과대학응급의학교실 Tel: 043) 840-8332, Fax: 043) 840-8962 E-mail: palenova@naver.com 접수일 : 2012년 7월 15일, 1차교정일 : 2012년 7월 30일게재승인일 : 2012년 10월 23일 745 50세남자가내원 30분전부터갑자기시작된심한두통을주소로본원응급의료센터에내원하였다. 내원당시통증의양상은처음에는후두부에서시작되어수분이내에전체두부로확장되었으며강도는 1분이내지금까지경험해보지못한최고강도로발생했다가이후점차호전되는양상이었다. 과거력상당뇨와고혈압으로약물치료를받고
746 / 대한응급의학회지 : 제 23 권제 5 호 2012 있는중이었으며내원당시의활력징후는혈압 170/90 mmhg, 맥박 92회 / 분, 호흡수 18회 / 분이었으며체온은 36.7 C 로관찰되었다. 신체검사상청진에서비정상호흡음이나심잡음은청취되지않았고경정맥팽대나하지부부종등의소견은보이지않았다. 신경학적검사에서환자의의식은명료하였고양쪽동공의크기는 3 mm 크기로동일하였고대광반사도정상이었다. 사지근력이나감각검사에서편측마비나감각저하의소견은없었으며바빈스키징후등의병적반사소견도보이지않았다. 그외경부강직, 브루진스키징후그리고커니그징후도관찰되지않았으며실어증, 실인증과같은신경학적피질징후도관찰되지않았다. 일반혈액검사, 혈액응고검사, 일반화학검사 Fig. 1. Initial brain computed tomography shows no hemorrhage and no hypodense lesion. 및전해질검사상특이소견은없었다. 심전도에서동성리듬과좌측심비대소견외다른이상소견은보이지않았다. 응급으로시행한뇌 CT (Fig. 1) 에서출혈등의급성출혈양상은보이지않았으며뒤이어시행한삼차원위상대조혈관조영술 (three dimensional cerebral computed tomographic angiography, 이하 3D-CT; Fig. 2,, C) 에서뇌동맥류는확인되지않았으나우측속목동맥의협착이관찰되었다. 이후지주막하출혈, 자발성두개내저압증및뇌수막염등의감별진단을위해요추천자검사를시행하였고, 개방압은 100 mmh 2O, 백혈구및적혈구는검출되지않아특이소견보이지않았다. 환자는마약성진통제투여후증상이호전되는양상을보였으나두통이소실되지는않았다. 단시간에촬영가능한자기공명영상촬영 (magnetic resonance imaging, 이하 MRI) 인확산강조영상 (diffusion weighted imaging, 이하 DWI; Fig. 3) 을추가촬영하여확인한결과, 우측중대뇌동맥영역에급성뇌병변을시사하는고신호강도의영역관찰되었으며겉보기확산계수영상 (apparent diffusion coefficient imaging; Fig. 3) 과비교할때허혈성뇌경색의심되었다. MRI 촬영후, 환자는좌측편마비와의식저하양상이관찰되었다. 신경학적검사상기면상태의식수준과우측안구편위및근력검사상좌측상 하지 MRC (Medical Research Council) grade 2 로확인되었다. 당시환자는혈전용해술의금기사항이없어조직플라스미노겐활성제를투여하였다. 투여후좌측상 하지의근력은 MRC grade 4로호전되었고기면상태의의식및혼란된지남력은차차회복되었고, 조직플라스미노겐활성제투여 24시간경과후의료진과대화가가능할정도로회복되었다. 이후지속적인재활치료시행하였고, 환자의근력은꾸준히회복되어입원 5일째보행이가능할정도로회복되었다. 내원 Fig. 2. Three dimensional cerebral computed tomographic angiography (3D-CT) shows severe obstruction of right proximal internal carotid artery and no aneurysmal lesion, vascular malformation. C
한상돈외 : 벼락두통으로발현된우측중대뇌동맥경색 1 례 / 747 당시시행한 3D-CT에서속목동맥근위부에혈전으로인한폐색소견및죽상판관찰되어디지털감산혈관조영술 (digital subtraction angiography; Fig. 4, ) 시행후경동맥내스텐트삽입하였으며, 스텐트삽입후속목동맥내경증가하는양상관찰되었다. 그후로별다른이상증상보이지않아신경학적후유증없는상태로퇴원하였다. 고찰 두통은응급실내원환자의 1~3% 를차지하는매우흔한질병이다 5). 두통은매우흔한증상이지만응급실에서는인적자원및시간의제약으로진단과치료가간과되기쉬우며, 국내보고도미흡한상태이다. 두통의종류중벼락두통은임상양상이다른두통에비해매우특이적이며, 원인이될수있는기저질환의감별이반드시필요한경우로, 응급실진료에서이러한두통의진단은중요하다. 벼락두통은환자가 터질듯이, 내려치듯이 아프다고 Fig. 3. rain magnetic resonance imaging shows high singal in right middle cerebral artery territory area (: arrow) and brain apparent diffusion coefficient imaging shows low signal in the corresponding area (: arrow). Fig. 4. Digital subtraction angiography shows near total obstruction of right proximal internal carotid artery (: arrow), and dilatation intraluminal diameter after carotid artery stent placement (: arrow).
748 / 대한응급의학회지 : 제 23 권제 5 호 2012 Table. 1. Characteristics of patients with cerebral infarction presenting as thunderclap headache Etiology Stroke localization ge Relation between headache and stroke localization YS Jo et al. 7) Cardioembolic Cerebellum 60 Yes Schwedt and dodick 8) Cardioembolic Cerebellum 66 Yes Edvarsson and persson 9) Cardioembolic Right centrum semiovale 73 Yes Gossrau et al. 10) Cryptogenic Cerebellum 44 Yes nnic and lucas 11) Cardioembolic Left centrum semiovale 80 No Lopes zevedo L et al. case 1 12) Cardioembolic Right MC territory 68 Yes Lopes zevedo L et al. case 2 12) Cardioembolic Left paramedian thalamus 26 Yes Present case Cryptogenic Right MC territory 50 Yes MC: middle cerebral artery 호소하는것이일반적이다. 이에대한정확한진단기준은뇌동맥류의파열과유사한돌발적인극심한두통으로갑자기발생하여 1분미만에최대강도에도달하며, 1시간내지는 10일간지속되고, 이후수주혹은수개월간규칙적인재발이보이지않아야한다는것이다 4). 벼락두통의원인으로는가장흔한지주막하출혈, 동맥류의보초두통부터뇌정맥동혈전증, 자발성두개내저압증, 뇌하수체출혈까지다양하다 6). 이러한많은원인에도불구하고뇌경색에서다른신경학적이상소견없이벼락두통으로발현한경우는매우드물고, 현재까지 7례가보고되어있다 (Table. 1) 7-12). 벼락두통의기전으로는아직까지정확히알려져있지는않지만두개내에있는통증에민감한구조에대한자극이원인이라추정된다 6). 본증례의경우, 우측경동맥협착부위의죽상판으로인한색전증이우측중대뇌동맥경색의원인이라사료된다. 이러한뇌경색으로인한두통의기전으로는뇌경색시에증가한내인성카테콜아민과자율신경계의항진으로인한삼차신경-혈관계의활성화가관여할것으로추정되며증가된통각자극이벼락두통을발생에중요한요인이라고생각된다 7). 뇌경색의빠른시간의진단에유용했던 DWI는뇌경색뿐아니라뇌지방색전증이나미만성축삭손상시에도응급실에서뇌 CT에서특이적인소견이없을경우고려할수있는영상의학적진단방법이다 8). 이전연구에의하면, 급성허혈성뇌경색에서 DWI는세포독성부종으로인한확산차이로고음영의균질한병변을나타내며, DWI는빠른시간내에환자의뇌손상을뇌 CT 보다예민하게반영한다 9). 그럼에도불구하고응급실에서의 DWI는비용적인측면및제한된유용성등의문제로인하여통상적인사용에는제약이있으며자기장의영향으로접근적모니터링에도제한점이있는것이현실이다. 그러나활력징후나신경학적징후가비교적안정적인본증례와같은벼락두통환자들에게는반드시고려해보아야할영상의학적진단검사라고생각한다. 본증례는임상양상, 방사선학적검사상벼락두통으로 발현된우측중대뇌동맥경색이라고진단했다. 증례환자와이전보고된증례를근거하여볼때, 응급실로내원한벼락두통환자경우정확한신경학적검사, 뇌 CT 및요추천자검사에서특이소견이관찰되지않을시, 뇌 DWI 및면밀한상태관찰을고려해보아야할것으로사료된다. 본저자들은뇌 CT 및요추천자검사결과에서특이소견을보이지않았으나 DWI를이용하여진단한벼락두통으로발현된우측중대뇌동맥경색 1례를보고하는바이다. 참고문헌 01. Landtblom M, Fridriksson S, oivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: a prospective study of features, incidence and causes. Cephalgia 2002;22:354-60. 02. Grimaldi D, Cevoli S, Cortelli P. Headache in the emergency department. How to handle the problem. Neurol Sci 2008;29:S103-6. 03. Edlow J, Panagos PD, Godwin S, Thomas TL, Decker WW. merican College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. nn Emerg Med 2008; 52:407-36. 04. Cho SJ. Emergency Headache, including thunderclap headache. Korean Journal of Headache 2009;10:66-71. 05. Chang WJ, Hwang TS, Shim HS, Lee HS, Kim SJ. The patients with headache in emergency department. J of Korean Soc Emerg Med 1997;8:380-4. 06. Schwedt TJ, Matharu MS, Dodick DW. Thunderclap headache. Lancet Neurol 2006;5:621-31. 07. Jo YS, Choi JY, Han SD, Kim YD, Na SJ.. case of cerebellar infarction presenting as thunderclap headache. Neurol Sci 2012;33:321-3. 08. Schwedt TJ, Dodick DW. Thunderclap stroke: embolic cerebellar infarcts presenting as thunderclap headache.
한상돈외 : 벼락두통으로발현된우측중대뇌동맥경색 1 례 / 749 Headache 2006;46:520-2. 09. Edvardsson, Persson S. Cerebral infarct presenting with thunderclap headache. J Headache Pain 2009;10: 207-9. 10. Gossrau G, Dannenberg C, Reichmann H, Sabatowski R. Thunderclap headache caused by cerebellar infarction. Schmerz 2008;22:82-6. 11. nnic, Lucas C. Ischemic stroke revealed by a thunderclap headache: contribution of diffusion-weighted mri sequences. Rev Neurol 2007;163:599-601. 12. Lopes zevedo L, reder R, de Santos DP, de Freitas. Ischemic stroke presenting as thunderclap headache: report of two cases and review of the literature. Eur Neurol. 2011;66:133-5. 13. You JS, Kim SW, Lee HS, Chung SP. Use of diffusionweighted MRI in the emergency department for unconscious trauma patients with negative brain CT. Emerg Med J 2010;27:131-2. 14. Chung SP, Ha YR, Kim SW, Yoo IS. Diffusion-weighted MRI of intracerebral hemorrhage clinically undifferentiated from ischemic stroke. m J Emerg Med 2003;21:236-40.