Transcript (1) 2011-09-15 (내원 3일 전)

심O헌 (M/42)
성균관대학교 의과대학
2007313075 손의영
Chief complaint (11.7.10)
• Headache
• Onset
(about) 1WA
Present Illness (1)
• 2011-09-15 (내원 3일 전)
• 정확하게 언제인지는 모르나 어느 순간 부터 심한 머리 통증 발생
• Nausea, vomiting 동반되었으며 통증은 순식간에 심해진 것 같다고 함
• Headache
• Location
우측 귀 뒤쪽  이후 머리 전체로 퍼짐
• Nature
머리 전반이 짓누르는 듯한 양상
가끔 박동 뛰듯이 아픔
Present Illness (2)
• Headache
• Severity
10/10
• Associated Sx
N/V (+/+)
photophobia/phonophobia (–/–)
autonomic Sx (–)
febrile sensation/chill/myalgia (–/–/–)
URI Sx (–)
trauma (–)
• 2011-09-18
• 상기 두통 증상 지속되어 내원함
Past medical history
• HTN / DM / TB / hepatitis / allergy (+/-/-/-/-)
• 2007-09-26
• SMV, portal vein thrombosis, small bowel gangrene
•  SMC : thrombectomy c Fogarty catheter, small bowel resection & anastomosis
• 2008-05
• Anticoagulation 시작
Past medical history
• 2009-08
• 간헐적인 Rt. Sided weakness 및 dysarthria 발생
• Local MRI에서는 정상
• 2011-08 (1MA)
• Chest pain 및 general weakness로 local 동인요양병원 입원
 Isosorbide mononitrate 복용 시작
• 갑자기 말발음이 더 어둔해지면서 입이 돌아감 (방향은 모름, general
weakness 동반)
• 당시 머리가 아프지는 않았으며, 약간의 nausea(+)
• 1~2일만에 증상 호전되어 말발음도 이전과 비슷함.
Medication history
• Warfarin
• 이소빈서방캅셀 50mg (Isosorbide mononitrate)
• 흉통 있을 때 간헐적으로 복용
• Zolpidem
• Amlodipine
• Metoclopramide 4mg tid
Other Histories
• Family Hx
• 특이사항 없음
• Social Hx
• Smoking
no (약 3년 전 quit)
• Alcohol
no
Review of system
• General weakness/fatigue (+/-)
• Anorexia/nausea/vomiting (-/-/-)
• Weight loss (-)
• Abdominal discomfort/pain (-/-)
• Fever/chill (-/-)
• Constipation/diarrhea (-/-)
• Hematemesis/melena/hematochezia (-/-/-)
• Visual disturbance/ocular pain/discharge
(-/-/-)
• Dysuria/oliguria/frequent voiding (-/-/-)
• Foamy urine/red urine (-/-)
• Sore throat/rhinorrhea/sneezing (-/-/-)
• Arthralgia (-)
• Cough/sputum/hemotpysis (-/-/-)
• Myalgia (-)
• Dyspnea/orthopnea (-/-)
• Tingling sense (-)
• Chest pain/ palpitation (-/-)
• Morning stiffness (-)
Physical examination
• Vital sign
• Chest
• 135/88 mmHg – 65 /min – 20 /min – 36℃
• General appearance
• Chronic ill-looking appearance
• Head & neck
• Conjunctiva
• Sclera
pinkish
clear
• Pupil size
symmetric, no myosis on both pupil
•
•
•
•
• Regular heart beat without murmur
• Supraclavicular node
(-/-)
• Axillary node
(-/-)
• Percussion
resonance, symmetric
• Vesicular breath sound without crackle,
wheezing, rhonchi
prompt response on both pupil • Abdomen
• Flat abdomen, soft on palpation
Tongue
not dehydrated
• Normoactive bowel sound
Tonsilar enlargement
no
• Hepatomegaly/splenomegaly/shifting dullness (-/-/-)
Gingival hypertrophy
no
• Pain/tenderness/rebound tenderness (-/-/-)
Gum bleeding
no
• Palpable abdominal mass (-/-)
Palpable neck mass
no
• Light reflex
•
• Symmetric expansion
Neurologic examination (1)
• Mental status examination
• Level of consciousness
alert
• Orientation
Time/Place/Person (+/+/+)
• Language
fluent with well comprehension
Neurologic examination (2)
• Cranial nerve examination
• Visual acuity
normal (no glasses)
• Visual field defect
(-)
• EOM
full
• Pupil
Isocoric
• Light reflex
(＋＋/ ＋＋)
• Nystagmus
None
• Mastication
Symmetrically intact
• Facial motor
Symmetrically intact
• Facial sensory
Symmetrically intact
• Uvular/Tongue deviation (-)
• SCM & trapezius muscle Symmetrically intact
Neurologic examination (3)
• Motor examination : muscle power
• Upper extremities
IV/V
• Lower extremities
IV/V
• Motor examination : muscle contour
• No atrophy
• Sensory examination
• Touch
오른쪽에 mild hypesthesia
• Pain
오른쪽에 mild hypesthesia
• Position
symmetrically intact
Neurologic examination (4)
• DTR
• Brachioradialis
(++/++)
• Biceps
(++/++)
• Triceps
(++/++)
• Quadriceps
(+/+)
• Ankle
(+/+)
• Plantar extensor reflexes
Babinski
(-/-)
Chaddock
(-/-)
Neurologic examination (5)
• Coordination and gait
• Cerebellar function test
• Rapid alternating movement
dysdiadochokinesia (-/-)
• Finger-to-nose
intentional tremor (-/-)
• Heel-to-shin
dysmetria (-/-)
Neurologic examination (6)
• Coordination and gait
• Gait
• Step
• Romberg test
mild Rt. Leg limping
(-)
Problem List (1)
•
#1. Headache
•
Severe, continuous
•
With nausea, vomiting
•
#2. Chronic neurologic deficit
•
Rt. arm/leg weakness with hypesthesia
Problem List (2)
•
#3. Hypertension
•
#4. Angina pectoris
•
#5. SMV, Portal vein thrombosis, small bowel gangrene
•
 embolectomy, small bowel resection
Assessment
#1. r/o secondary headache
•
Etiology :
r/o Cerebral venous thrombosis
r/o Sub-dural hematoma
r/o aneurysm
r/o pituitary apoplexy
#2. r/o Chronic ischemic stroke
r/o venous infaraction, mainly Lt. hemisphere
- sequele:
Rt.sided weakness (arm, leg GIV)
Rt.sided hypesthesia (face,arm,leg)
dysarthria
mild word finding difficulty
Assessment
#3. Hypertension
#4. Angina pectoris
#5. SMV, Portal vein thrombosis, small bowel gangrene
Diagnostic plan
• Brain MRI, MR venography
• 병변 부위 확인
• Funduscopy, visual field check
• ICP 증가 여부 확인
Brain CT (2011-09-18)
CONCLUSION:
Suggestive of dural sinus thrombosis involving right transverse sigmoid sinus and
internal jugular vein.
T1 MRI
T2 MRI (sagittal view)
MR venography
Funduscopy
Reassessment
• #1. r/o cerebral venous thrombosis
• Location: superior sagittal  Rt. Transverse sinus
• Etiology:
hypercoagulability (protein C/S def, AT-3 def…)
vasculitis
• #2. Chronic ischemic stroke
• Localization : Lt. corona radiata, post. Limb of internal capsule, pons
• Etiology:
r/o embolism
Therapeutic plan
• For CVT
• Heparin + Warfarin
• For IICP
• Mannitol, glycerin
• 1주 경과 관찰 후 두통호전 확실치 않거나 시력 저하등을 호소할 경우
thrombolysis 고려
Cerebral venous thrombosis
• 역학
• 젊은 여성 > 남성
• 전체 환자의 약 6∼12%는 감염과 관련있다.
• 원인과 위험인자
• 혈전 호발상태, 감염, 염증병, 혈액조건, 약물, 기계적 원인
• Idiopathic
Cerebral venous thrombosis
• Pathophysiology
• Cortical vein 막힘  뇌의 허혈 변화, 출혈, 뇌부종 동반가능
• Dural venous sinus 막힘  이 부근 정맥압 증가  arachnoid villi를 통
해 CSF가 흡수되지 않으므로 두개내압이 상승한다.
Cerebral venous thrombosis
• Clinical manifestation
• 뇌정맥 혈전은 동시에 여러 뇌정맥을 침범할 수 있기 때문에 특징적
인 증상이 없고, 다양한 증상이 나타난다.
• 두통(75%) : 대부분 수일에 걸쳐 지속적으로 심해짐
• 경련(40%) : 이 중 12~15%는 첫 증상으로 발현되기도 함
• 의식저하(30%) : 비교적 나중에 발현
• 혈전이 발생한 cortical vein의 영역에 따라 팔다리의 운동 및 감각장애
, 실어증, 뇌신경마비 등이 발생 가능
• ICP 상승 : funduscopy에서 papilledema 가 발견됨
Cerebral venous thrombosis
• Diagnosis
• Cerebral angiography
• Imaging (CT, MRI…)
• D-dimer는 도움 안됨
• Treatment
• anticoagulation : to suppress blood clot formation
• thrombolysis : 효과가 확실히 증명 된 것은 아님
• ICP가 증가된 경우 lumbar puncture나 medication으로 압력을 낮춰주
면 증상의 호전을 기대할 수 있다.