大韓放射線훌훌學會픔第 26 卷第 5 號 pp. 918-925, 1990 Journal 01 Korean Radiol ogical Society, 26(5) 918-925, 1990 한국인뇌경색증의경동맥색조도플러혈류영상 * 연세대학교의과대학진단방사선과학교실정태섭 서정호 김동익 이은주 양희철 최일생 이명식이병인 - Abstract- Carotid Color Doppler Flow Imaging of Cerebral Infarction in Korea * Tae Sub Chung, M.D., Jung Ho Suh, M.D., Dong Ik Kim, M.D., Eun Joo Lee, M.D., Hee Chul Yang, M.D., Il Saing Choi, M.D.**, Myung Sik Lee, M.D.**, Byung In Lee, M.D.** Department o[ Diagnostic Radiology, College o[ Medicine, Yonsei University Until now, there have been no reported document concerning the incidence of atheroma of th e carotid artery associated with occlusive cerebrovascular disease in Korea. We tried to identify atheroma of the carotid artery in acute cerebral infarction patients using duplex sonography and color flow imaging. Recent reports state that duplex sonography and color flow imaging were reported to be more accurate and safer non.invasive method of detecting carotid atheroma than carotid angiography Atheromas were detected in 41(56 %) out of total of 73 acute cerebral infarction patients. However, other conditions such as hypertension (37 / 73 ), cardiac problems(22/ 73), diabetes mellitus(10/ 73 ), and conditions of unknown etiologies(13/ 73) were also observed in association with acute cerebral infarction We conclude that carotid atheroma presents as the most important cause of cerebral infarction in Korea. Index Words : Carotid Arteries, Doppler 172.12984 Carotid Arteries, Stenosis 172.721 Carotid Arteries, lnfarction 172.781 서 론 뇌혈관질환 ( occl u s i ve cerebrovascul ar disease ) 의중 요한원인으로써일찌기알려져왔으나 1, 2 ) 아직까지 내, 외경동맥분지부의죽종 (a th ero m a) 이폐쇄성 본논문은 1 989 년도연세대학교교수연구비 보조로 이루어졌음. 연세대학교의과대학신경과학교실 Department of Neurology, College o[ Medicine, Yonsei University 이논문은 1990 년 7 월 27 일접수하여 1 990 년 9 월 11 일 채택되었음 국내에서는경동맥의죽종에대한정확한보고가없으며막연히죽종의빈도는낮을것이라는기록이있다 3 ) 최근비침습적인 duplex sonography, 색조도플러혈류영상 (c o l o r doppler fl ow im ag in g ) 등이개발되면서저자들의경험상국내에서도뇌경색증환자에서경동맥의죽종을많이관찰하게되었다우리나라에서평균수명의연장과식생활등의선진화추세에따라서 - 918
정대섭외 : 한국인뇌경색증의경동맥색조도플러혈류영상- 실제적으로는발생빈도가높은것으로생각되었으며, 이에저자들은종래의국내뇌졸증의병인분석에경통맥죽종의항목을추가하여발생빈도와침범양상을확인하기위하여본연구를시행하였다. 대상및방법 급성뇌경색증으로 1 988 년 9 월부터 1 989 년 3 월까지영동세브란스병원에내원한 3 1 명의환자에서경동맥 duplex so n og r ap h y 를, 1 989 년 6 월부터 1990 년 4 월까지신촌세브란스병원에내원한 4 2 명의환자에서경동맥 duplex so n ogra p h y 를포함한색조도플러혈류영상술을시행하였다. 임상증상과전산화단층촬영상뇌경색증으로진단된환자중, 사망하거나위독한상태로인해김사가곤란한경우를제외한, 급성기에서회복기로접어든환자를대상으로하였다. 이들중임상 증상, 전산화단충촬영소견과경동맥색조도플러혈류영상술소견과잘일치하지않는 4 명에서는경동맥및추체동맥조영술을시행하여 Willie s c ir cle 의측부순환기능동을확인하였다. 기계는영동세브란스병원의 Ac u$o n 128 Computed So n ograp h y 를이용하여 duplex so n og raph y 를, 신촌세브란스뱅원의 ATL Ultramark 9 을이용하여 du pl ex so n og r aphy 를포함한색조도플러혈류영상을환자의양측총경동맥, 내경동맥및추체통맥에서시행하였다. 환자의어깨밑에앓은메개를바친후바로누운상태에서목이젖혀지도록하였으며검사시턱을반대편으로돌리게하므로써경동맥이일직선이되도록유도하였다. 도플러검사는 sampl e volum e size 를 2-3 mm 로하여 sample volume axi s 가혈관방향과평행이되도록 45-60 범위에서유지하였으며경우에따라서 7 0 는넘지않도록하여 aliasing 현상과잡신호가생기지않도록속도상한조정과감쇄보정 을하였다. 죽종동으로인한협착이있으면색조혈류영상을이용하여주혈류방향을확인하여도플러측정을협착의협착부위와그상하에서측정하였으며협착의후면에서나타나는와류를확인하여측정하도록유도하였다. 경동맥죽종의분류는 B lu t h 4 ) 의방식에따라서경동맥 duplex so n ograp h y 상궤양의존재유무에따른표띤궤양 (s urfa ce character) ( Fig 1 ), 음영도차이에따른내부구조의음영도 ( p l aq ue texture ) (F ig. 2 ), 침범정도에따른침범부위 ( pla- Fig. 1. a. Smooth plaque: Intimal surface(arrows) is continuous without irregula rities b. Irregular plalque: The surface margin of the plaque(arrows) is discontinuous and highly irregular. que extent ), 심수축기와이완기의혈류속도변화측 정과종, 횡단면영상의협착정도 ( p e r ce n t stenosis ) (Fig3, 4, 5 ) 를분석하였으며 ( Tabl e 1 ) 색조도플러 혈류영상을이용하여주혈류방향의변화, 발생동혈류역학적변화 ( Fig 6 ) 를관찰하였다. 와류의 외고혈압, 심질환, 당뇨병등의원인을같이분석하 였다. 걸 원인별분석에서보면잔치 1 73 례의환자중 4 1 례 ( 56 % ) 에서경동맥부위에축종이관찰되었으며이외에 고혈압이 37 례 ( 5 1 % ), 심전도상심질환이 22 례 ( 30 %) 딩뇨병이 1 0 례 (1 4 % ) 그외획실힌원인을찾기가 힘든경우가 13 례 ( 1 8 % ) 기있어서부분적으로여러 과 원인이복합된경우도있었으나죽종의 빈도가가장 - 919 -
- 大韓放射線훌훌學會註第 26 卷第 5 號 1990 - Table 1. Oiagnostic Ooppler Criteria for Carotid Artery OiseasdQuoted from Bluth 4 J) Peak Peak Systolic Oiastolic Spectral Oiameter Systolic Oiastolic Veloci얀 Velocity Broadening Stenosis Velocity Velocity Ratio Ratio (Bandwidth) (CategoIγ) (cm/ sec) (cm/ sec) (VICAlVCCA) (VICA / VCCA) (cm/ sec) 0% <1 10 ( 40 < 1.8 ( 2.4 <30 (Normal) 1-39 % < 110 ( 40 <1.8 <2.4 <40 (Mild) 40--59 % <1 30 40 ( 1.8 <2.4 ( 40 (Moderate) 60--79 % > 130 >40 >1.8 >2.4 >40 (Severe) 80--99 % >250 >100 >3.7 >5.5 >80 (Critical) 100% N/ A N/ A N/ A N/ A N/ A Measured distal to maximum stenosis N/ A= Not applicable b F ig. 2. Fig. 3. a. Homogeneous plaque: A large plague has uni. a. Percent diameter stenosis on a longitudinal scan form acoustic texture with smooth intimal sur- of carotid bifurcation: lntima to intima measureface(arrows). ment = arrow to arrow, Residual lumen diameter 二 X b. Heterogeneous plaque: A localized plaque(arrows) to x. b. Percent area stenosis on a transverse has a mixed echo pattern with a prominent sonolu- scan of carotid bifurcation: Arrow= vessel lumen, cent area suggestive of intraplaque hemorrhage. Oot Iines= Residual lumen. - 920 -
- 정태섭외 : 한국인뇌경색증의경동맥색조도플러혈류영상 - d Fig. 4. a. A mild degree stenosis due to smooth and homogeneous athe. roma (arrow) at Rt. lower internaj carotid artery. b. A moderate degree stenosis due to irregular and heterogeneous atheroma(arrow) at Lt. lower intern aj carotid artery. c. A severe degree stenosis due to irregular and homogeneous ather ma(arrow) at Lt. common carotid artery. d. A criticaj degree stenosis due to smooth and heterogeneous atheroma(arrow) a t Lt. common carotid arteηr. c d Fig. 5. Four sampling points and spectra of the severe degree stenosis from irregular and homogeneous atheroma at Lt. common carotid artery. a) Doppler measurement obtained at prestenotic area is a reference value which is used in the calculation. b) Doppler measurement obtained at stenotic area s hows highest peak systolic velocities(psv) and peak end diastolic velocities(pedv) c) Doppler measurement obta ined at just distal to th e maximum stenosis shows slightly lower PSV and PEDV. d) Doppler measurement obtained atjust behind to t he stenosis sh ows the lower PSV and PEDV, some reversed flow a nd broader bandwidth n 3 이μ
- 大韓放射線醫學會誌 : 第 26 卷第 5 號 1990 - 지 1 례는 duplex sonography 및경통맥촬영술로확인한바뇌경색동측에죽종으로인한완전폐쇄가있었으며반대측에서표면궤양을통반한죽종으로인한 moderate 정도의협착이있음을확인할수있었다 (Fig.7 ) 표면의형태는궤양이없이매끄러운경우가 23 례 (56 %) 표면궤양이동반된경우가 18 례 ( 44 %) 에서관찰되었다 (T abl e 5 ). 또한내부구조의음영도상균일한경우가 25 례 ( 61 %) 였으며불균일하며내부고음영도가있는경우가 16 례 ( 39 % ) 이었다 ( Tabl e 6). 고 안 Fig. 6. Color flow imaging at Lt. carotid bifurcation shows moderate degree stenosis from heterogeneous atheroma (white arrow). bended main blood stream just distal to the stenotic area (black arrows). and reversed flow just behind the stenotic area(blue col. or: open white arrow). 한국인의뇌경색중에대한많은문헌보고가있었으나그원인분석상죽종의빈도가포함되어있지않아서 5, 6. 7 ) 국내의정확한원인분석을확인할수없었으며단순히국내에서는죽종의빈도가낮을것이라는 Table 3. Plaque Extent 높았다 (Tab l e 2 ). 죽종을보인 41 례의환자에서 pla. que 의침범정도에서보아경동맥분지부위를포함한부위에 38 례 ( 78 % ) 로가장많이관찰되었으며그외국소적으로총경동맥에 7 례 (1 7 %), 내경동맥에 2 례 (5 % ) 가관찰되었다 (T able 3). 41 례의환자를심수축기, 이완기속도변화의분석과종, 횡단면상죽종으로인한협착정도로보아서 mild 한경우가 22 례 (54 %). mod e r a t e 한경우가 7 례 (1 7 %), seve re 한경우가 7 례 (1 7 %). c riti ca l 한경우가 2 례 ( 5 %) 완전히폐쇄된경우가 3 례 (7 % ) 에서관찰되었다 ( Table 4 ). 특히 완전히폐쇄된 3 례중 2 례는 duplex so n og raph y 상죽종의소견이없이혈전으로인한폐쇄만관찰되었으며심초음파상좌심실의혈전괴로보아서 mitral valvu. lar heart diseas e 로인한심인성으로의심되었고나머 Common Carotid A.lC.C) Blfurcation(BIF. ) Internal carotid A.(I.C.) C.C. + BIF. BIF. + I.C. C.C + BIF. + I.C. Table 4. Percent of Stenosis 1-39 %(Mild) 40-59 %(Moderate) 60-79 %(Severe) 80-99 %(Critic 외 ) 100 %(Occlusion) Table 5. Surface Character qι끼?l 1i 53.7 %(22141) 17. 1%( 7 / 41) 17. 1%( 7 / 41) 4.9 %( 2 / 41) 7.3 %( 3/41) A I RυTable 2. Etiology 1. Atheroma 2. Hypertension 3. Cardiac problem on EKG 4. Dlabetes mellitus 5. Unknown 56.0 %(41173) 50.7%(37173) 30.1 %(22173) 13.7 %(10173) 17.8 %(13173) Smooth Irregular Table 6. Plaque Texture Homogeneous Heterogeneous 56. 1 %(23/ 41) 43.9 %(1 8141) 61 %(25/ 41) 39 %(6141) - 922 -
- 정태섭외 : 한국인뇌경색증의경동맥색조도플러혈류영상 - b Fig. 7. 52-year~ld male patient with cjinical diagnosls of Lt. MCA infarction. a. Color f10w imaging at Rt. proximal internal carotid artery shows Irregular and hypoechoic. moderate degree stenotic atheroma (open arrow). And highest velocity is also noted at main stenotic area. which appears as white color (asterisk). b. Color f10w imaging of the Lt. proximal internal carotid artery shows no t10w signal. Hypoechoic smooth and moderate degree stenotlc atheroma is noted at Lt. proximal external carotid artery (open c d arrow). c. Rt. common carotid angiogram reveals irregular and moderate degree stenotic atheroma(arrows) at Rt. proximal internal carotid artery. d. Lt. common carotid angiogram reveals complete occlusion of Lt. internal carotid artery due to an atheroma (black arrow) and another moderate degree stenotic atheroma within the Lt. proxim외 external carctid arteπ (open arrow). 기록이있을뿐이다 3 ) 그러나최근식생활, 환경여건 독한경우는제외하였으므로전체뇌경색증의환자를 이선진화되는추세로보아서한국인에서도죽종이뇌 경색증의중요한원인이될가능성이많을것으로생 포괄적으로대변하는데에는문제점이있으나대상의 뇌경색증환자중 56 % 에서죽종을관찰할수있었으 각된다. 최근 duplex sonography 및색조도플러혈 므로 50-72 % 로보고한외국의통계와비슷한유병율 류영상의개발로인해죽종에대한검사법이보다정확해지며비침습적으로발전함으로종래의경동맥촬영과좋은연관관계를보이고있어앞으로침습적인경동맥촬영술을충분히대체할것으로생각된다8-12 ) 저자들의경우검사대상을뇌경색증의급성기가지난회복기의환자들을대상으로하여사망한다든지중 을보이며국내에서도죽종이뇌경색증의가장중요한원인이될것으로보인다 1 3-15 ) 그외의국내뇌경색증의원인으로민퉁이 7) 보고한고혈압 40 %, 당뇨병 19 %, 심질환 19 % 퉁과저자들의고혈압 51 %, 당뇨병 14 %, 심질환 30 % 둥과는비슷한양상을보여전체적인윤곽으로보아서외국의통계와거의비슷한분포를볼수있었다 - 923 -
大韓放射線짧學會誌 : 第 26 卷第 5 號 1990 죽종의특정파이로인한혈액혈류역학적변화의로보고되고있다 11, 1 7) 분석은 Bluth 동의 4 ) 분석자료를참고하여 1 ) 침범범최근에색조도플러혈류영상시스템이개발이용되 위 2 ) 협착정도 3) 표면궤양 4) 내구구조의음영도등 고있으나아직은그유용도에대해서명쾌하게확립 을분석하였다. 죽종의발생은주로경동맥분지부위은되어있지않다. 일부저자들은정상적인경동맥에서, 외경통맥의반대측, 정상의경우에심수축기때분지부위에서생길수있는심수축기의역류현상을확혈액의역류가생길수있어서잘발생하는것으로보인할수있으며여러가지해부학적변화를쉽게관찰고가되고있다 16 ) 저자들의경우 78 % 의환자에서할수있다고보고하고있다 1 6, 1 8) 저자들의경험으로 경동맥분지부위를포함하는부위에발생하였으며그 외총경동맥에서 17 % 내경동맥에서 5% 가보이고있 는데이들은아마도광범위한동맥경화증의일부로사 보아죽종으로인해서주혈류의방향이휠수있는것과 저음영도로인해잘보이지않는죽종을쉽게찾을수 있는장점을더추가할수있으리라보며앞으로이용 료된다. 에따라서보다많은유용성이파악될것으로생각된 죽종으로인한협착의정도는단면적의계산, 혈류다. 학적속도변화동의여러가지측정방법이있으나대 략적이긴하지만 Bluth 퉁이권장한 Peak Systolic Ve locity(psv), P eak End Diastolic Ve locity(ped V), P eak Systolic Ve locity Ratio(SVR =VICA / V CCA) 및 Spectral Bro ade ni ng을이용하여협착의비율이 1-39 % 를 mild, 40-59 % 를 moderate, 60-79 % 를 severe, 80-99 % 를 critical, 100 % 를 cclus i o n으로구별하였다 4 ) 저자들의경우 mild 와 m o d erate 가 71% 결론한국인의뇌경색증에있어서죽종이가장중요한발병요인이될것으로사료되며비침습적인 duplex s onography를포항한색조도플러혈류영상만으로도죽종을포항한경통맥병변을검사함에충분한것을확인하였다. 그이상이 29 % 이어서 Hames 퉁의보고와비슷한소 견을보였다 l 이. 죽종의표면특정상궤양이있는것과없는것으로 나눌수있는데 Bartynski 동은 2 ) enda rt e r ecto m y 후조 직검사상큰궤양 (g ross ulcerat i o n ) 이 50 % 미세궤양 ( m icro ul cerat i on ) 이 33 % 이었으며이중 15 % 는큰 궤양과혼합되어있었다고하였으며궤양이없는것이 32 % 에서보였다고하여저자들의의견상큰궤양과 미세궤양의일부가 duplex sonography 검사상관찰될 것으로보여저자들의성적도이범주에해당될것으 로사료되었다. 궤양자체가혈전의발생을유도하기 때문에존재유무의확인이중요시된다 1 7) 죽종의궤 양을진단하는데있어서초음파검사가겸통맥촬영술 보다도보다높은성적을보이고있으므로앞으로유용 할것으로생각된다 6 ) 저자들의경우표면궤양을보 이는 At h eroma 의 l 례에서내경통맥촬영상다발성색 전이관찰되어이들의 이론과잘부합될것으로생각 된다. 죽종의내부구조읍영도는주로균일 ( h omog e n eous) 한것과불균일 ( h eteroge n eous ) 한것으로나눌 수있으며특히 내부출혈이불균얼음영도의원인이 되며 lll tj m a 의파열을유발하므로보다더색전현상 (emboli c phen o m e n on ) 을일으킬위험도가높은것으 REFERENCES 1. Fisher M. Occlusion of the carotid arteries. Arch Neurol Psychiatr 1954;72 187-204 2. Bartynski WS, Darbouze P, Nemir P J r. Significance of ulcerated plaque in transient cerebral ischemia. The American Journal of Surgery 1981; 141:353-357 3 대한신경외과학회. 신경외과학 1st Ed 서울특별시. 중앙문화사. 1989; 138, 303-307 4. Bluth EI, Wetzner SM, Stavos AT et 외, Carotid duplex sonography: A multicenter recommandation for standardized imaging and doppler criteria. RadioGraphics 1988;8:487-505 5 양인명, 김봉희, 송정상외. 뇌졸증의임상적고찰. 대한내과학회잡지 1982; 25:174-181 6 배효근, 전영준, 이정규외. 뇌졸중의신경학적병변부위에대한고찰. 대한내과학회잡지 1981 ; 24: 510-151 7 민광기, 변동일, 김성근외. 뇌졸중의임상적고찰. 대한의학협회지 1988;3 1 :409-419 8. Erickson SJ, Mewissen MW, Foley WD et 외. - 924 -
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