Research 김영서 in Vestibular 외 2인 Science. 외상뇌손상 Vol. 18, 후 No. 어지럼 3, : September 신경학적 2019 측면 Review pissn 2092-8882, eissn 2093-5501 https://doi.org/10.21790/rvs.2019.18.3.59 외상뇌손상후어지럼 : 신경학적측면 김영서, 임선재, 이학승 원광대학교병원신경과, 원광대학교의과대학신경과학교실, 원광의과학연구소 Dizziness after Traumatic Brain Injury: Neurological Aspects Young Seo Kim, Seon Jae Im, Hak Seung Lee Department of Neurology, Wonkwang University Hospital, Wonkwang University School of Medicine, Institute of Wonkwang Medical Science, Iksan, Korea Received Aug 19, 2019 Revised Aug 28, 2019 Accepted Sep 2, 2019 Corresponding Author: Hak Seung Lee Department of Neurology, Wonkwang University Hospital, 895 Muwang-ro, Iksan 54538, Korea Tel: +82-63-859-1410 Fax: +82-63-842-7379 E-mail: nmgom@wku.ac.kr ORCID code: https://orcid.org/0000-0003-2276-0679 Copyright c 2019 by The Korean Balance Society. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Vertigo, dizziness, and disequilibrium are common symptoms following concussion or traumatic brain injury. Dizziness and vertigo may be the result of trauma to the peripheral vestibular system or the central nervous system, or, in some cases, may be due to anxiety, depression, or posttraumatic stress disorder; these mechanisms are not mutually exclusive. While most peripheral vestibular disorders can be identified by testing and examination, those without inner ear causes that have persisting complaints of dizziness and motion sickness are more difficult to understand and to manage. Some of these patients exhibit features compatible with vestibular migraine and may be treated successfully with migraine preventative medications. This paper reviews the neurological causes of persisting dizziness, the possible mechanisms, and the pathophysiology, as a framework for patient management and for future research. Res Vestib Sci 2019;18(3):59-63 Keywords: Traumatic brain injury; Postconcussional syndrome; Diffuse axonal injury; Cervical vertigo; Posttraumatic migraine 서론우리몸의균형은시각계 (visual system), 체성감각계 (somatosensory system) 와전정신경계 (vestibular system) 를통해서들어온정보를통합하고분석하여유지한다 [1]. 이들정보를통합하고분석하는역할은주로뇌간의전정신경핵과소뇌가담당하며이정보는다시근골격계와안구운동계로전달되어자세유지에필요한동작과안구운동이반사적으로유발된다. 이과정에서문제가있는경우어지럼이발생하며, 두부또는경부손상후발생하는외상뇌손상 후어지럼은목통증다음으로가장흔히발생한다 [2]. 외상뇌손상후어지럼 이라는용어는다른기저전정신경계질환없이두부나경부의외상이후에발생하는말초및중추전정기능장애를표현하는용어이다 (Table 1) [3]. 외상뇌손상후어지럼은여러기전에의해발생할수있는데, 중추병변과말초병변모두가원인이될수있다. 그러나외상뇌손상후어지럼환자에서정확한진단을하기어려운경우가많다. 여러문헌고찰에서외상뇌손상후어지럼의발병률에대한다양한자료가보고된바있으며그결과에따르면, 외상뇌손상후어지럼의발병률은진단기 59
Res Vestib Sci Vol. 18, No. 3, Sep. 2019 Table 1. Definitions of terms Concussion: transient altered brain function due to mechanical trauma to the head from which it is anticipated that the individual will recover in no more than 3 months. Mild traumatic brain injury: a description of the severity of a mechanical injury to the brain that is characterized by no loss of consciousness (LOC) or LOC lasting <30 min and an initial Glasgow Coma Scale of 13 15. Postconcussional syndrome: a constellation of clinical symptoms (headache, dizziness, irritability, impaired concentration, insomnia, etc.) persisting <3 months following mechanical trauma to the brain. Persistent postconcussion dizziness: persistence of dizziness >3 months following a mechanical trauma to the brain that cannot be attributed to a primary labyrinthine disorder (e.g., benign paroxysmal positional vertigo) or to any discernable structural injury to the brain. Descriptions of dizziness may include periodic spinning, spatial disorientation, unsteadiness, rocking or floating sensation, or motion sensitivity. 준에따라외래를방문하는어지럼환자의 14% 에서 90% 까지매우다양하다 [4,5]. 그에반해이러한환자에서시행한전정기능검사에서이상소견의발생률은 32% 61% 였다 [5,6]. 따라서외상뇌손상후어지럼환자를진찰할때는자세하고체계적인병력청취와신체진찰이필수적이며뇌영상검사, 청력검사및전정기능평가검사도정확한진단을위해필요하다. 외상후어지럼증상이지속하는기간은다양하다. 두부손상후어지럼또는현훈이일주일에서몇년까지지속할수있다는보고가있었다 [7-9]. 경도외상뇌손상 (mild traumatic brain injury) 에서, 전정신경계의증상을포함한뇌진탕후증후군 (post-concussional syndrome) 의증상은환자의 10% 15% 에서 1년이상지속할수있으며, 이비율은중등도외상뇌손상 (moderate traumatic brain injury) 에서 28% 로증가한다 [10]. 또한외상뇌손상후어지럼은외상환자의장기예후에있어위험요소로작용할수있다 [11]. 이번종설에서는외상뇌손상후어지럼중중추성어지럼에해당하는뇌진탕증후군, 광범위축삭손상, 경추성현훈, 외상후편두통에대하여문헌을고찰하고, 환자진료에도움이될만한내용을정리하였다. 뇌진탕후증후군 (Postconcussional Syndrome) 뇌진탕후증후군은일반적으로증상표현에중점을둔 Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) 또는 International Classification of Diseases-10 (ICD-10) 기준에따라정의한다 [12]. 뇌진탕후증후군으로인한어지럼은흔히나타나는증상이며내이진탕 (labyrinthine concussion), 외상후편두통, 지속적체위- 지각어지럼 (persistent postural-perceptual dizziness) 등의다양한형태로발생할수있고, 전정신경계이상과안구운동 장애를반영한다 [13]. 뇌진탕후증후군으로인한어지럼양상은체위동요 (postural sway), 붕뜬느낌 (floating sensation), 또는술에취한느낌등이흔하며두부움직임에의해악화하는특징이있다. 이러한특징은과거편두통병력이있는환자에서발생하는전정편두통이나머리속이빙도는느낌, 주변환경에서고립된느낌, 공황발작, 집중력저하와광장공포증과같은증상을호소하는만성주관적어지럼 (chronic subjective dizziness) 과는다른임상양상으로나타난다 (Table 2). 흐려보임 (blurred vision), 복시및감광도 (light sensitivity) 와같은시각증상도뇌진탕후일반적으로나타날수있고, 이는안구운동조절에문제가있음을의미한다 [14]. 불안이어지럼발생과지속에영향을미치며, 불안감정이나그에대한대처능력부족으로인하여어지럼이악화될수있다. 많은환자에서어지럼은지속적이거나거의하루종일지속한다고알려져있다. 뇌진탕후증후군에의한어지럼과두부외상의심각성간에는유의한연관관계가있는것으로밝혀졌다 [15]. 또한뇌진탕후증후군에의한어지럼은주로뇌간또는소뇌의타박상또는뇌출혈에의해이차적으로발생하는경우가많다. 뇌진탕후증후군에의한어지럼은여러분류기준이있으나일반적으로는글래스고혼수척도 (Glasgow coma scale), 초기의식소실의여부또는외상후기억상실여부에따라경증, 중등또는중증으로분류된다 [16]. 환자의증상은많은경우몇주안에개선되지만, 몇개월또는몇년동안어지럼을계속호소하는경우도종종있다. 이경우에는환자가직장등일상생활로복귀하는데어려움이있으며뇌진탕후증후군이발생한후 3개월이지나도증상이남아있는환자는 12개월후에도증상이남아있을가능성이높다 [17]. 서로다른문화및언어적배경이어지럼환자의증상과예후에영향을줄수있다 [18]. 일부에서는뇌진탕후증후군에의한만성적인어지럼이서유럽과미국에국한된현상 60
김영서외 2 인. 외상뇌손상후어지럼 : 신경학적측면 Table 2. Comparison of persistent postconcussion dizziness, vestibular migraine, and chronic subjective dizziness Persistent postconcussion dizziness Vestibular migraine Chronic subjective dizziness >3 months of periodic floating, rocking, spinning, tilting, head-motion intolerance, visual vertigo, imbalance, and feelings of unsteadiness that vary in severity day to day Ofen combined with poor ability to multitask, reduced concentration and mental focus, irritability, general headaches, disturbances of sleep Presence of nausea is variable; intolerance of stress, poor ability to organize, and easily fatigued Symptom onset within 7 days of a trauma to the head or brain At least five episodes with vertigo, visual vertigo, head-motion intolerance of moderate or severe intensity lasting 5 minutes to 72 hours Current or previous history of migraine with or without aura, according to the International Classification of Headache Disorders (ICHD) One or more migraine features with at least 50% of the vestibular episodes: (1) headache with at least 2 of the following: one-sided location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity; (2) photophobia and phonophobia, visual aura Not better accounted for by another vestibular or ICHD diagnosis >3 months of lightheadedness, heavy headedness, imbalance, feeling of spinning inside the head, perceptions of movement, disassociation from environment Anxiety, feeling as though one may lose control, panic attacks, difficulty concentrating, agoraphobia Absence of nausea and lack of worsening of symptoms with head motion Not better accounted for by another vestibular diagnosis or migraine 이라고주장했지만, 비슷한증상이지속되고 1년이지난후에도직장으로복귀하지못하는증례가다른국가에서도발생했고, 따라서지리적영향은없는것으로밝혀졌다 [18]. 뇌진탕후증후군에의한만성어지럼을유발하는요인으로는실제외상보다외상전우울증의존재, 불안, 외상후스트레스장애 (posttraumatic stress disorder), 만성통증및여성으로알려져있다 [19]. 정확한기전은아직밝혀지지않았지만불안자체가만성어지럼에기여할수있다. 연구에따르면, 가벼운두부외상이어지럼이시작하는요인이될수있지만, 기존의심리적상태가만성뇌진탕후증후군에의한어지럼을유발한다고한다 [20]. 치료의목적은어지럼, 두통및집중력장애에기여하는요인을감소시키고, 스트레스를최소화하는것이다. 불안관리는어지럼감소에도움이될수있으며사회경제적요인과가족관련스트레스요인을감소시키는것또한어지럼개선에중요하다. 광범위축삭손상 (Diffuse Axonal Injury) 광범위축삭손상은축삭의세포골격을변화시키고나트륨-칼륨채널기능과축삭형질흐름 (axoplasmic flow) 을손상시키는갑작스러운견인으로인한백질 (white matter) 의축삭손상으로정의한다 [21]. 일반적으로외상뇌손상으로인하여이차적으로발생하며, 감수성가중영상 (susceptibilityweighted image) 및 T2 기울기에코영상 (T2 gradient echo image) 을통해병터를확인할수있다 [22,23]. 회질-백질이 음부 (gray matter-white matter junction), 뇌량, 뇌간, 소뇌다리, 대뇌다리, 전두및측두백질, 기저핵과시상에서광범위축삭손상이흔히발생한다고알려져있다 [21]. 광범위축삭손상은외상뇌손상의결과로나타나지만손상받은축삭에국한하여발생하는것은아니며정상백질에서발생할수있다는보고도있다 [24]. 최근의연구에서서서히자세가불안정해진뒤천천히걷는것으로완화되는외상후공간혼란을보고한바가있다 [16]. 광범위축삭손상과관련한외상후공간혼란은회복이느리고어렵다는것을의미한다. 인지장애가동반되어있는경우에는신경심리평가가도움이될수있으며, 이러한어지럼과불안정의지속기간은몇주에서몇달또는몇년에걸쳐지속할수있고, 장기적으로증상이남을수도있다. 경추성현훈 (Cervicogenic Vertigo) 경추성현훈은아직까지진단에논란의여지가많지만동물연구에서실험동물의목에국소마취주사를주입한후, 실조와안진이관찰됨에따라경추성현훈의실존가능성이입증되었다 [25]. 인간을대상으로한최근연구에따르면경추성현훈은전정정보와고유감각정보간의불일치, 경부추간판내의염증이나근육긴장증가로인해발생할수있다 [25]. 그러나아직까지경추성현훈을진단하기위한특정검사는없는상태이다. 따라서다른질환을우선적으로감별하기위해청력검사를포함한전정기능평가가실시되어야한다. 61
Res Vestib Sci Vol. 18, No. 3, Sep. 2019 채찍질손상 (whiplash injury) 은교통사고후정면또는등쪽충격을받는경부의빠른가속-감속의기전으로발생한다. 이러한충격은꼭직접적인충격이아니어도가능하다. 채찍실손상후균형장애나어지럼으로이어지는기전은경부의감마와교감섬유의과긴장 (hypertonicity) 으로인한경부고유감각기의과도한흥분으로설명한다. 퀘벡태스크포스 (The Quebec Task Force) 에서는목통증, 골다공증징후, 신경학적징후및목뼈골절또는비틀림이렇게 5가지종류로채찍질손상을분류하였다. 임상징후는비특이적이었고, 초기의식소실은거의없었다. 증상이발생하는기전으로목통증에이어이석기관과반고리뼈관에문제가발생하는것으로생각된다. 그러나전정기능에관련된연구는거의없는상황이다. 채찍질손상과관련된어지럼진단을위해전정기능평가가이루어져야한다. 경부구심섬유병터로인한시공간지남력장애도어지럼과균형장애를유발할수있다 [26]. 자세또는시력의불안정성, 진동시각또는거리측정의문제는동적시력검사와비디오안구운동검사등을통하여평가해야하며, 안구운동의조절 (accommodation) 과이향운동 (vergence) 등도확인해야한다. 진단이늦어질수록회복이불완전해지며만성어지럼과같은문제가남을수있어조기진단은치료를위해필수적이다 [26]. 외상후편두통 (Posttraumatic Migraine) 외상후편두통도어지럼다음으로두부및경부외상이후에흔히발생하는증상이며외상뇌손상후불안정의잘알려진원인이다. 경한외상뇌손상후어지럼을경험한 58 명의퇴역군인을대상으로한연구에서 41% 가외상후편두통으로진단받은보고가있다 [27]. 외상후편두통의증상은일반적으로수초에서수시간동안지속하는간헐적인회전성어지럼과앞뒤로흔들리는느낌, 붕떠있는느낌이나술에취한것과같은느낌이흔하다. 일반적인편두통과마찬가지로오심, 구토, 두통, 빛공포증및소리공포증이흔하며외상후에발생하고, 다른내이질환이없다는특징이있다. 증상은외상뇌손상후며칠에서몇주내에시작할수있지만뇌진탕후증후군과마찬가지로두부손상의중증도가외상후편두통발생에있어중요한원인이다. 외상의중증도와편두통사이의상관관계는실제신체적뇌손상보다정서적외상으로인해발생한외상후스트레스증후군이편두통발생을예측하는 더중요한요인임이밝혀졌다 [28]. 편두통의과거력이있거나편두통가족력이있는경우혹은과거에멀미를자주않은경우에외상후편두통이발생할기능성이높다고예측할수있다 [29]. 여성이남성보다더많이발생하는경향이있고 ( 여자 : 남자, 2 3:1), 이는일반적인편두통유병률과같다. 외상후편두통의치료방법은현재까지편두통치료방법과동일한것으로알려져있다. 한무작위대조시험에서외상후편두통의치료에있어 topiramate, valproate, propranolol 이가장효과가있었다 [30]. 그밖에 verapamil, venlafaxine, escitalopram 및 tricyclic antidepressants도어느정도효과가있다고보고된바있다 [31]. 결론외상뇌손상후어지럼환자를진료할때는뇌진탕후증후군, 광범위축삭손상, 경추성현훈, 외상후편두통뿐만아니라양성돌발성체위현훈과같은말초전정장애, 자율신경불균형에의한저혈압과약물을포함한모든가능성을고려해야한다. 임상의는환자가호소하는불안과같은정신과증상이어지럼의원인이라고단정하지않도록주의해야한다. 왜냐하면이차불안이외상뇌손상후어지럼환자에게흔히나타나기때문이며만성어지럼이이차불안을유발할수있기때문에상담또는약물치료를고려해야한다. 따라서환자를진료할때는다양한원인가능성을생각하고자세한병력청취와전정기능평가를포함하는신체진찰을시행해야한다. 또한청력검사, 비디오안구운동검사와뇌영상검사를포함한다양한검사를고려해야한다. 그외에도환자가일상생활에적응할수있도록격려하고, 환자가긍정적이고낙관적인생각을할수있도록도와주는것도중요하다. 중심단어 : 외상뇌손상, 뇌진탕후증후군, 광범위축삭손상, 경추성현훈, 외상후편두통이해관계 (CONFLICT OF INTEREST) 저자들은이논문과관련하여이해관계의충돌이없음을명시합니다. 62
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