11-19 조호준

eissn 2287-1683 pissn 1738-8767 Journal of Trauma and Injury Vol. 28, No. 3, September, 2015 Original Article 소아두부외상환자에서의반복적인두부 CT 검사의유용성 가천대학교길병원응급의학과 조호준, 임용수, 김진주, 조진성, 현성열, 양혁준, 이 근 - Abstract - Value of Repeat Brain Computed Tomography in Children with Traumatic Brain Injury Ho jun Jo, M.D., Yong Su Lim, M.D., Jin Joo Kim, M.D., Jin Seong Cho, M.D., Sung Youl Hyun, M.D., Hyuk Jun Yang, M.D., Gun Lee, M.D. Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea Purpose: Traumatic brain injury (TBI) is the most common cause of pediatric trauma patients came to the emergency department. Without guidelines, many of these children underwent repeat brain computed tomography (CT). The purpose of this study was to evaluate the value of repeat brain CT in children with TBI. Methods: We conducted a retrospective study of TBI in children younger than 19 years of age who visited the emergency department (ED) from January 2011 to December 2012. According to the Glasgow Coma Scale (GCS) and Pediatric Glasgow Coma Scale score of the patients, study population divided in three groups. Clinical data collected included age, mechanism of injury, type of TBI, and outcome. Results: A Total 83 children with TBI received repeat brain CT. There were no need for neurosurgical intervention in mild TBI (GCS score 13-15) group who underwent routine repeat CT. 4 patients of mild TBI group, received repeat brain CT due to neurological deterioration, and one patient underwent neurosurgical intervention. Routine repeat CT identified 12 patients with radiographic progression. One patient underwent neurosurgical intervention based on the second brain CT finding, who belonged to the moderate TBI (GCS score 9-12) group. Conclusion: Our study showed that children with mild TBI can be observed without repeat brain CT when there is no evidence of neurologic deterioration. Further study is needed for establish indication for repetition of CT scan in order to avoid unnecessary radiation exposure of children. [ J Trauma Inj 2015; 28: 149-157 ] Key Words: Traumatic brain injury, Pediatric, Repeat brain CT, Neurosurgical intervention, Glasgow Coma Scale Address for Correspondence : Yong Su Lim, M.D., Ph.D. Department of Emergency Medicine, Gachon University Gil Medical Center, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Korea Tel : 82-32-460-3015, Fax : 82-32-460-3019, E-mail : yongem@gilhospital.com Submitted : August 13, 2015 Revised : August 24, 2015 Accepted : October 4, 2015 149

- Journal of Trauma and Injury Vol. 28, No. 3 - I. 서론두부외상은소아외상환자가응급실로내원하게되는가장흔한원인중의하나로, 미국을비롯하여전세계적으로외상으로인한소아의사망과장애의주요한원인이다.(1,2) 북미지역에서는연간소아 100,000명당 60~100명의환자가발생하며미국에서는 2002년부터 2006년까지연평균 511,257명의소아두부외상환자중 473,947명이응급실로내원하고, 35,136명이입원하며 2,174명이사망했다고보고했다.(3,4) 소아두부외상환자가내원할경우두부손상정도의정확한평가가매우중요하므로두부전산화단층촬영 (Computed tomography: CT) 검사는검사시간이짧고, 효율적이어서표준적인검사로시행하고있으며검사결과에따라치료의방향이결정될수있다.(5) 소아두부외상환자들에있어서경도의두부외상은 70~90% 를차지한다.(6) 경도의두부외상으로인해임상적으로심각한결과를초래한경우는매우적으며, 두부 CT 검사의경우방사선피폭량이높은검사로소아의경우는방사선노출에취약하기때문에반복적인두부 CT 검사의시행으로인한방사선피폭의증가는추후종양등의발생위험성과관련이있을수있다.(7,8) 현재경도의소아두부외상환자들에게두부 CT 검사의시행은 Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical prediction rule을이용하는것이가이드라인으로제시되어있다.(9) 소아의두부손상은시간이경과함에따라임상양상과병변 이변화할수있어이에따른적절한평가와처치가지연될경우비가역적인신경학적장애가남을수있으며사망에이를수도있다. 따라서임상적으로경과가악화될경우에는반복적인두부 CT 검사를통해병변의악화및신경외과적인중재술등의필요성여부를판단할수있으나소아는성인과달리신경학적인진찰과임상양상의관찰을통한상태평가및경과의악화여부등을판단하기에제한점이있다.(10-12) 이러한어려움으로인해실제로소아두부외상환자들을대상으로반복적인두부 CT 검사가흔하게시행되고있지만현재반복적인두부 CT 검사의정해진가이드라인은없다. 이에일개권역응급의료센터에내원한소아두부외상환자들을대상으로시행된반복적인두부 CT 검사의유용성에대해알아보고자본연구를시행하였다. II. 대상및방법본연구는 2011년 1월 1일부터 2012년 12월 31일까지두부외상으로일개권역응급의료센터로내원한 19세미만의환자들중 1차병원에서두부 CT 검사를시행받고두개골골절, 두개강내출혈의양성두부 CT 소견으로본원으로전원을오거나본원으로직접내원하여시행한두부 CT 검사상양성소견이있어신경외과와협진을시행한환자들중두부 CT 검사를반복적으로촬영한환자를대상으로후향적으로진행하였다. 두부 CT 검사결과는응급의학과와신경외과전공의, 전문 Fig. 1. This is a flow diagram of this study. Fig. 1. * CT: computed tomography TBI: traumatic brain injury 150

Ho jun Jo, et al.: Value of Repeat Brain Computed Tomography in Children with Traumatic Brain Injury 의에의해판독되었으며서로이견이있는경우는두과의전문의의협의하에결정되어진최종진단을채택하였고, 차후작성된영상의학과전문의의판독을참조하였다. 두부 CT 검사소견상두개골골절또는두개강내출혈이있는경우를양성검사결과로판정하였다. 환자의의무기록을통해성별, 나이, 수상기전, 내원당시의의식상태, Glasgow Coma Scale (GCS) 점수, 내원시활력징후, Revised Trauma Score (RTS), 신경학적인진찰상상태변화여부, 반복적인두번째두부 CT 검사촬영시까지의시간간격, 총병원입원기간및중환자실입원기간, 시행된신경외과적중재술, 퇴원시 GCS 점수를후향적으로조사하였다. 반복적인두부 CT 검사는 1차병원에서시행한두부 CT 검사여부와상관없이본원에내원하여 48시간이내에 2회이상의두부 CT 검사를진행한경우로정의하였다.(13) 연구기간동안본원에서시행한첫번째두부 CT 검사결과상양성소견으로신경외과당직의에게연결된 222명의환자중병력청취와두부 CT 판독소견을통해동정맥기형, 동정맥루등의외상이아닌질환에의한두개강내출혈로진단된 3명의환자와지적장애와신경정신과적인병력으로인해정확한신경학적진찰에제한이있었던 4명의환자를제외하 였다. 임상소견과영상의학적판독소견에따라임상의가뇌손상의정도가경하다고판단하거나보호자들이원하지않아반복적인두부 CT 검사를시행하지않은 102명의환자와반복적인두부 CT 검사시행전사망한 4명의환자, 반복적인두부 CT 검사시행전응급으로신경외과적중재술을시행한 6명의환자도제외하였으며 1차병원에서첫번째두부 CT 검사후내원하여본원에서는 1회의두부 CT 검사만시행한 20명의환자도제외하였다. 총 139명이제외되었으며최종적으로 83명의환자를대상으로연구를진행하였다 (Fig. 1). 반복적인두부 CT 검사는담당임상의의처방에따라정례적으로시행한경우와신경학적인진찰상경과의악화에의해시행한경우를모두포함하였으며경과의악화는응급의학과와신경외과의사의경과기록과응급실과중환자실의간호기록을조사하여 GCS 점수의감소가확인된경우로정의하였다. 두부 CT 검사소견의변화는호전, 악화, 변화없음의세가지로분류하였으며악화의경우는이전의병변이진행하거나병변의크기가증가한경우, 새로운병변이발생한경우로정의하였다. 83명의대상환자를 Pediatric Glasgow Coma Scale (PGCS) 점수와 GCS 점수를이용하여경도 (GCS 점수, Table 1. Patients demographics. Mild TBI* (n=72) Moderate TBI (n=5) Severe TBI (n=6) p-value Age, yr 9 (4.3-16). 17 (11-17)00. 16.5 (14-17.3)00. 00.025 Male, n (%) 56 (77.8) 5 (100) 5 (83.3) 0.478 Injury mechanism, n (%) 0.110 Fall 33 (45.8) 1 (20)0 0 (0) Bicycle accident 18 (25)0 2 (40)0 4 (66.7) Pedestrian TA 14 (19.4) 0 (0)00 2 (33.3) Passenger TA 2 (2.8) 1 (20)0 0 (0) Assault 3 (4.2) 1 (20)0 0 (0) Sports activity 2 (2.8) 0 (0)00 0 (0) SBP, mmhg 110 (100-130)0 140 (120-160)0. 125 (100-142.5) 00.028 DBP 70 (60-80)00 80 (75-85)00. 80 (50-82.5)0 0.121 HR 93 (82-104)0 84 (80-92)00. 86 (77-112.5) 0.486 RTS 12 (12-12)00 11 (11-11)00. 10 (9.8-10)00 <0.001 CT** interval 227.5 (118.5-283.8) 195 (187.5-245) 240.5 (173.8-495)0. 0.716 Hospital LOS 8 (3-13.8). 11 (10.5-35)0 25.5 (15.5-74.80) 00.001 ICU LOS 0 (0-3)000.3 (0.5-12.5) 10.5 (5.8-25)000. <0.001 * TBI: traumatic brain injury TA: traffic accident SBP: systolic blood pressure DBP: diastolic blood pressure HR: heart rate RTS: revised trauma score ** CT: computed tomography LOS: length of stay ICU: intensive care unit p<0.05 151

- Journal of Trauma and Injury Vol. 28, No. 3-13~15), 중등도 (GCS 점수, 9~12), 중증 (GCS 점수, 3~8) 의세그룹으로나누었다.(14) 각각의분류에따른환자들의임상적특성간의관련성을 Chi-square test와 Kruskal- Wallis test를시행하여분석하였으며 Bonferroni s method로사후검정을시행하였다. 통계프로그램은 SPSS version 18.0 (SPSS Inc, Chicago, USA) 을이용하여정리하였으며 p-value가 0.05 미만인경우를통계학적으로유의하다고정의하였다. III. 결과총 83명의환자를 GCS 점수를이용하여중증도분류를하였으며경도의뇌손상환자 72명, 중등도 5명, 중증 6명의세그룹으로나누어각분류별환자들의임상적특성을비교하였다 (Table 1). 연령은경도의뇌손상그룹에서중등도와중증의그룹과비교하여통계학적으로유의하게차이가있었으며, 손상기전중오토바이사고환자의연령대가높은것과관련이있을것으로사료된다. 내원당시의수축기혈압과 RTS, 입원기간, 중환자실입원기간도각각의그룹간에통계학적으로유의하게차이가있었다. 경도의뇌손상으로분류된그룹에서는두개골골절이두부 CT 검사결과가장많은비율을차지하였으며 (55.6%) 두개강내출혈의경우는경막하출혈 (30.6%) 과경막외출혈 (30.6%), 뇌좌상 (23.6%), 지주막하출혈 (11.1%) 의순으로확인되었다. 중등도의뇌손상으로분류된그룹에서는두개골골절 (60%) 과경막외출혈 (60%) 이가장많은비율을차지하였으며뇌좌상 (40%), 경막외출혈 (20%), 지주막하출혈 (20%) 의순으로뇌손상이확인되었다. 중증의뇌손상으로분류된그룹에서는지주막하출혈 (83.3%) 이가장많은비율을차지하였으며뇌내출혈 (50%) 과뇌좌상 (50%) 이두번째로많은비율을차지하였고, 두개골골절 (33.3%) 과경막하출혈 (33.3%), 뇌실내출혈 (33.3%), 경막외출혈 (16.7%) 의순으로뇌손상이확인되었다 (Table 2). 뇌손상중지주막하출혈과뇌실내출혈, 뇌내출혈은중증의두부손상환자에서통계학적으로유의하게많았다. 반복적인두번째두부 CT 검사는 79명의환자에서정례적으로시행하였으며 4명의환자는신경학적인진찰상경과의악화로인해시행하였다 (Fig. 1). 정례적으로시행한반복적인두번째두부 CT 검사결과상경도의뇌손상환자중 7명 (10%), 중등도 3명 (60%), 중증 2명 (33%) 의총 12명 (15%) 의환자에서악화소견이확인되었다 (Table 3). 각환자들의임상적특성과두부 CT 검사상의변화여부를기술하였다 (Table 4). 이중자동차조수석에탑승중발생한교통사고로인해두통을주소로내원하여경막외출혈과두개골골절로진단된 16세남자환자의경우정례적으로시행한반복적인두부 CT 검사결과에따라응급개두술을시행하였다. 이환자 Table 2. Radiologic findings on initial brain CT* Mild TBI Moderate TBI Severe TBI (n=72) (n=5) (n=6) p-value Skull fracture, n (%) 40 (55.6) 3 (60) 2 (33.3) 0.556 Subdural hemorrhage 22 (30.6) 3 (60) 2 (33.3) 0.397 Epidural hemorrhage 22 (30.6) 1 (20) 1 (16.7) 0.696 Subarachnoid hemorrhage 08 (11.1) 1 (20) 5 (83.3) <0.001 Intraventricular hemorrhage 0 (0) 0 (0) 2 (33.3) <0.001 Hemorrhagic contusion 17 (23.6) 2 (40) 3 (50) 0.290 Intracerebral hemorrhage 0 (0) 0 (0) 3 (50) <0.001 * CT: computed tomography TBI: traumatic brain injury p<0.05 Table 3. The changes of routine repeat brain CT* Mild TBI (n=68) Moderate TBI (n=5) Severe TBI (n=6) Findings, n (%) Progress 07 (10) 3 (60) 2 (33) Improve 09 (13) 1 (20) 1 (17) No change 52 (76) 1 (20) 3 (50) Intervention 0 (0) 1 (20) 0 (0)0 * CT: computed tomography TBI: traumatic brain injury 152

Ho jun Jo, et al.: Value of Repeat Brain Computed Tomography in Children with Traumatic Brain Injury Table 4. Radiographic progression patients who underwent routine repeat brain CT* Sex Age Mechanism of Initial Findings on 2nd Findings on Discharge Intervention (yr) injury GCS core initial CT GCS core repeat CT GCS score F 13 Fall 15 6 mm SDH, skull Fx 15 7 mm SDH, New HC 15 M** 16 Bicycle accident 15 4 mm SDH, skull Fx 15 8 mm SDH 15 M 14 Sports activity 15 15 mm EDH, skull Fx, 15 18 mm EDH 15 pneumocephalus M 07 Pedestrian TA 15 2 mm EDH, skull Fx, 15 8 mm EDH 15 pneumocephalus M 18 Bicycle accident 14 5 mm EDH, skull Fx, 15 8 mm EDH, 15 HC, pneumocephalus increased HC M 12 Fall 14 Skull Fx, 14 New 6 mm EDH 15 pneumocephalus M 18 Bicycle accident 14 5 mm SDH 14 7 mm SDH 14 M 17 Bicycle accident 12 HC 12 increased HC 14 M 06 Fall 10 4 mm SDH, skull Fx, HC 10 9 mm SDH, 11 increased HC M 17 Passenger TA 09 18 mm EDH, skull Fx 09 30 mm EDH, Craniotomy 15 midline shift M 14 Passenger TA 07 HC, skull Fx 10 New SAH, ICH 15 M 16 Bicycle accident 07 5 mm SDH, HC 07 New SAH 14 * CT: computed tomography GCS: Glasgow Coma Scale F: female SDH: subdural hemorrhage Fx: fracture HC: hemorrhagic contusion ** M: male EDH: epidural hemorrhage TA: traffic accident SAH: subarachnoid hemorrhage ICH: intracerebral hemorrhage A Fig. 2. This brain CT shows radiographic progression of epidural hemorrhage of the 16-year-old patient who came to the emergency department due to passenger traffic accident. (A) Initial brain CT. (B) Routine repeat brain CT. Fig. 2. * CT: computed tomography B 153

- Journal of Trauma and Injury Vol. 28, No. 3 - 의경우내원당시의 GCS 점수는 9점으로반복적인두부 CT 검사촬영당시신경학적인변화는관찰되지않았다 (Fig. 2). Table 5에서신경학적인진찰상경과의악화로인해반복적인두번째두부 CT 검사를시행한 4명의환자들의임상적특성과두부 CT 검사상의변화여부를기술하였다. 2명의환자에서는 CT 검사결과상악화소견이있었다. 보행중발생한교통사고로인해두통과어깨통증을주소로내원한 8세여자환자는내원하여시행한첫번째두부 CT 검사결과상경막외출혈이 3 mm 두께로있으며두개골골절이동반되어있었다. GCS 15점으로의식이명료하여경과관찰중내원 5시간후 GCS 점수가 10점으로감소되어두번째반복적인두부 CT 검사를시행하였고경막외출혈의양이 10 mm 두께로증가하였다. 하지만증상이호전되어신경외과적인 중재술을시행하지않았으며 GCS 15점으로퇴원하였다. 다른한명의환자는오토바이운전중발생한교통사고로수상하여내원한 16세남자환자로 48시간이내에세번의두부 CT 검사를시행후응급개두술을시행하였다. 경막외출혈, 두개골골절, 외상성지주막하출혈, 뇌기종진단하에중환자실로입원하였으며첫번째두부 CT 검사시행당시의 GCS 점수는 14점이었다. 뇌압조절및통증조절을하며경과관찰중 GCS 점수가 9점으로감소하여첫번째두부 CT 검사시행 205분후반복적인두번째두부 CT 검사가시행되었다. 검사결과상첫번째두부 CT 검사상 2 mm 두께의경막외출혈의양이 6 mm 두께로증가하였다. 내원 30시간후갑자기 GCS 점수가 6점으로감소하면서정상으로유지되던동공반사가좌안 6 mm, 우안 4 mm 고정된상태로변 Table 5. Radiographic findings of patients who underwent repeat brain CT* due to neurologic deterioration. Sex Age Mechanism of Initial Findings on 2 nd Findings on Intervention Discharge (yr) injury GCS core initial CT GCS core repeat CT GCS score F 08 Pedestrian TA 15 3 mm EDH, skull Fx 10 10 mm EDH 15 M** 16 Bicycle accident 14 2 mm EDH, skull Fx, 09 6 mm EDH Craniotomy 15 SAH, pneumocephalus M 18 Assault 15 5 mm EDH, skull Fx, 14 No change 15 pneumocephalus M 17 Bicycle accident 15 Minimal SDH 14 No change 15 * CT: computed tomography GCS: Glasgow Coma Scale F: female TA: traffic accident EDH: epidural hemorrhage Fx: fracture ** M: male SAH: subarachnoid hemorrhage SDH: subdural hemorrhage A B C Fig. 3. This brain CT shows radiographic progression of epidural hemorrhage of the 16-year-old patient who came to the emergency department due to bicycle accident. (A) Initial brain CT. (B) 2 nd repeat brain CT due to neurologic deterioration. (C) 3 rd repeat brain CT due to neurologic deterioration. Fig. 3. * CT: computed tomography 154

Ho jun Jo, et al.: Value of Repeat Brain Computed Tomography in Children with Traumatic Brain Injury 화하여세번째두부 CT 검사를시행하였다. 검사결과상경막외출혈의양이 35 mm 두께로증가하면서출혈의크기효과에의한소뇌천막의탈출이임박해보인다는영상의학과적인판독소견이있었으며즉시응급개두술을시행하였다. 이후입원치료를지속하였으며환자는상태가호전되어 82일만에 GCS 점수 15로퇴원하였다 (Fig. 3). IV. 고찰최근의학의발전과사회의현대화로인하여과거소아사망의주요원인이었던선천성질환과감염성질환의빈도는감소하였지만도시화와차량의증가등으로인하여소아외상환자들이늘어나고있다. 고층의주거건물의증가와침대에서생활하는등의생활양식의변화가소아두부외상환자의증가와관련이있을것으로생각되며두부외상은응급실로내원하는가장흔한소아의외상중하나로 (15,16) 외상으로인해사망하는경우의 80% 이상이두부손상에의한사망이었다.(17) 소아는중추신경계의발달이진행중인상태로두부외상에대한병태생리학적인반응이성인과다르기때문에증상이나경과와예후등이성인과차이를보이며경과의변화를적절하게평가하지못할경우영구적인장애와사망을초래할수있어환자와가족들에게큰고통을안길수있다.(18) 그래서소아두부외상환자를대상으로두부 CT 검사의시행이 70% 에육박하고있다.(19) 또한소아에서 CT 검사로인한방사선노출은종양의발생과관련이있지만현재반복적인두부 CT 검사에대한명확한가이드라인은정해져있지않으며실제로경과의정확한평가를위한반복적인두부 CT 검사가흔히시행되고있는실정이다. 본연구를통해경도의소아두부손상환자에서는정례적으로시행된반복적인두부 CT 검사가신경외과적인중재술등의치료방침을결정함에있어서영향을끼치지않으며중등도이상의두부손상환자에서의미가있을수있음을확인하였다. 경도의뇌손상이있는환자들중 7명 (10%) 의환자에서정례적으로시행한반복적인두부 CT 검사상병변의악화가확인되었지만그결과에따라신경외과적인중재술이시행된경우는없었으며, 신경학적인진찰상경과의악화에의해반복적인두부 CT 검사를시행한 4명의환자중 1명의환자에서병변의악화가확인되어신경외과적인중재술이시행되었다. Hollingworth 등 (20) 은 15세미만의두부외상환자중반복적인두부 CT 검사를시행한 521명을대상으로연구를하였으며 257명이경도의뇌손상 (GCS 점수, 13-15) 으로분류되었다. 이중 207명 (81%) 은정례적으로반복적인두부 CT 검사를시행하였으며그결과에따라신경외과적인중재술이시행된경우는없었으며신경학적인진찰상경과의악화로인해반복적인두부 CT 검사를시행한 50명 (19%) 의환자중에서 3명 (1%) 이신경외과적인중재술이시행되었다. 중등도 이상의뇌손상 (GCS 점수, 3-12) 의 248명의환자중정례적으로반복적인두부 CT 검사를시행한경우는 141명 (57%) 이었고 4명 (2%) 에서신경외과적인중재술이시행되었으며신경학적인진찰상경과의악화로인해반복적인두부 CT 검사를시행한 107명 (43%) 의환자중에서 11명 (4%) 이신경외과적인중재술을시행받았다고보고하였다. Aziz 등 (21) 의보고에따르면 2세부터 18세까지의두부외상환자중반복적인두부 CT 검사를시행한 191명을대상으로연구를하였으며정례적으로시행한경우는 184명 (96%) 이었다. 이중병변의악화에따라신경외과적인중재술을시행한경우가 3명 (2%) 이있었으며모두 GCS 점수가 8이하의중증의뇌손상환자들이었으며경도와중등도의뇌손상환자에서는없었다. 신경학적인악화로인해반복적인두부 CT 검사를시행한환자는총 7명 (4%) 이었으며이중 3명 (2%) 의환자가신경외과적인중재술을시행받았다. 2명은경도의뇌손상으로분류된환자였으며 1명은중증의뇌손상으로분류된환자였다. 위의두연구는본연구결과와마찬가지로경도의뇌손상환자에서의정례적인반복적인두부 CT 검사보다는신경학적인진찰이신경외과적인중재술의시행여부결정에있어더나은예측인자임을확인하였으며중등도이상의뇌손상에서는정례적인반복적인두부 CT 검사가신경외과적인중재술시행에영향을끼친사례가있었다. Howe 등 (22) 은 17세이하의경도의뇌손상환자중반복적인두부 CT 검사를시행한환자들을대상으로시행한연구에서신경학적인진찰상악화가없는환자들은경과관찰하는것이가능하지않을까생각되지만경막외출혈의경우는병변이진행할가능성이크고예후가불량할수있으며연구대상이작았기때문에아직도정례적으로반복적인두부 CT 검사를시행하고있다고말하고있다. 이는반복적인두부 CT 검사에있어서정해진가이드라인이없는작금의현실을대변하고있다. 본연구에서도정례적으로시행한반복적인두부 CT 검사결과병변의악화를보인 12명의환자중 5명에서경막외출혈의악화가있었고, 신경학적인진찰상경과의악화로인해반복적인두부 CT 검사를시행한 4명의환자중 3명이경막외출혈환자였으며신경외과적인중재술을시행받은 2명의환자는모두경막외출혈의악화로기인한것이었다. 추후반복적인두부 CT 검사의적응증등을마련하는데있어서경막외출혈의경우질환의특성을고려한추가적인연구가필요할것으로사료된다. da Silva 등 (23) 은중등도와중증의두부외상을받은 14세이하의소아들에서신경학적인진찰상변화가없거나호전된경우에적절한모니터링을통하여신경외과적인중재술시행의가능성을배제할수있다고하였으며, Tabori 등 (24) 은중등도와중증의두부외상을받은 16세이하의소아를대상으로시행한연구에서정례적으로시행되는반복적인두부 CT 검사는병변의변화를이해하는데중요하지만치료의변화에는영향이있을것같지않다고말하고있다. 하지만본 155

- Journal of Trauma and Injury Vol. 28, No. 3 - 연구에서는중등도와중증의두부외상으로내원한환자들에서는모두정례적으로반복적인두부 CT 검사가시행되었고, 중등도로분류된그룹에서한명의환자는신경학적인진찰과임상소견의관찰상경과의변화는없었지만두부 CT 검사결과에따라신경외과적인중재술이시행되었으며 GCS 점수 15점으로퇴원하였다. Aziz 등 (21) 의연구에서도중증으로분류된그룹에서정례적으로시행한반복적인두부 CT 검사상그결과에따라 9% 의환자는신경외과적인중재술이시행되었다. 이는중등도이상의뇌손상을받은환자에서는정례적으로시행하는반복적인두부 CT 검사가신경외과적인중재술등의시행여부결정에있어의미가있음을주장하는본연구를뒷받침한다. 또한이는경도의뇌손상환자의경우신경학적인진찰과임상소견의관찰을통해변화하는양상에따라병변의진행유무를판별할수있었음을의미한다고할수있겠으며중등도이상의뇌손상환자에있어서는변화양상을파악하는데있어의식상태및약물의사용여부와기관삽관등으로인한제한점이있을수있고, 적절한시기에적절한치료가시행되지않을경우예후가불량할수있으므로병변의진행여부의영상의학적인판단의필요성을생각해볼수있겠다. 본연구의제한점으로는일개권역응급의료센터에서시행되어환자수가많지않았으며, 특히중등도와중증뇌손상환자수가많지않았다. 또한후향적으로연구를진행하였으며, 대상을두부외상의환자로한정하여다른동반된손상으로인한신경학적진찰상의이상소견이고려되지않았다. 또한어린소아들을대상으로는 PGCS를적용하여의사소통이가능한연령대의소아를대상으로시행한신경학적인진찰과차이가있을수있는점등이되겠다. V. 결론 경도의외상성뇌손상소아환자들의경우주기적이고세밀한신경학적인진찰을통해경과가악화되지않을시에정례적인반복적인두부 CT 검사를시행하지않고지켜보며방사선노출을최소화할수있겠고, 중등도이상의뇌손상의경우정례적인반복적인두부 CT 검사를고려해볼수있을것으로사료된다. 추후더많은환자를대상으로한연구를통하여소아두부손상환자들을대상으로반복적인두부 CT 검사의정확한적응증을제시할필요가있다. REFERENCES 01) Kraus JF, Rock A, Hemyari P. Brain injuries among infants, children, adolescents, and young adults. Am J Dis Child 1990; 144: 684-91. 02) Coronado VG, Xu L, Basavaraju SV, McGuire LC, Wald MM, Faul MD, et al. Surveillance for traumatic brain injuryrelated deaths--united States, 1997-2007. MMWR Surveill Summ 2011; 60: 1-32. 03) Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics 2009; 124: e145-54. 04) Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002-2006. [Internet]. 2010 Mar [Accessed 2013 Jan 7]. Available from: http://www.cdc.gov/traumaticbraininjury 05) Durham SR, Liu KC, Selden NR. Utility of serial computed tomography imaging in pediatric patients with head trauma. J Neurosurg 2006; 105: 365-9. 06) Brain injury statistics. [Internet]. 2010 [Accessed 2013 Jan 4]. Available from: http://www.brainandspinalcord.org. 07) Schnadower D, Vazquez H, Lee J, Dayan P, Roskind CG. Controversies in the evaluation and management of minor blunt head trauma in children. Curr Opin Pediatr 2007; 19: 258-64. 08) Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380: 499-505. 09) Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160-70. 10) Dacey RG Jr, Alves WM, Rimel RW, Winn HR, Jane JA. Neurosurgical complications after apparently minor head injury. Assessment of risk in a series of 610 patients. J Neurosurg 1986; 65: 203-10. 11) Rivara F, Tanaguchi D, Parish RA, Stimac GK, Mueller B. Poor prediction of positive computed tomographic scans by clinical criteria in symptomatic pediatric head trauma. Pediatrics 1987; 80: 579-84. 12) Patel NY, Hoyt DB, Nakaji P, Marshall L, Holbrook T, Coimbra R et al. Traumatic brain injury: patterns of failure of nonoperative management. J Trauma 2000; 48: 367-74. 13) Figg RE, Burry TS, Vander Kolk WE. Clinical efficacy of serial computed tomographic scanning in severe closed head injury patients. J Trauma 2003; 55: 1061-4. 14) Rimel RW, Giordani B, Barth JT, Jane JA. Moderate head injury: completing the clinical spectrum of brain trauma. Neurosurgery 1982; 11: 344-51. 15) Tepas JJ 3rd, DiScala C, Ramenofsky ML, Barlow B. Mortality and head injury: the pediatric perspective. J Pediatr Surg 1990; 25: 92-5. 16) Kraus JF, Fife D, Cox P, Ramstein K, Conroy C. Incidence, severity, and external causes of pediatric brain injury. Am J Dis Child. 1986;140:687-93. 17) Vane DW, Shackford SR. Epidemiology of rural traumatic death in children: a population-based study. J Trauma 1995; 38: 867-70. 18) Giza CC, Mink RB, Madikians A. Pediatric traumatic brain injury: not just little adults. Curr Opin Crit Care 2007; 13: 156

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