소공뇌경색증의 임상적 연구

Abstract

[한글]

소공뇌경색중(lacunar infaction)은 대뇌 혹은 뇌간의 심부에 발생하는 작은 뇌경색증으로서 병인, 임상양상, 예후 및 치료등에 있어서 일반적인 큰 혈관 폐쇄에 의한 뇌경색증과는 차이가 있기때문에 이의 감별은 임상적으로 매우 중요하다고 알려져왔다. 그러나 아직 우리나라에서는 이 방면에 대한 연구가 부족한 실정이며, 이에 연구자는 최근 5년간 연세대학교 의과대학부속 세브란스병원에 소공뇌경색증으로 입원하였던 367명의 환자들을 대상으로 임상기록과 뇌전산화단층촬영 소견을 분석하여 다음과 같은 결과를 얻었다.

1. 소공뇌경색증은 전체 뇌경색증의 33.2 %였다.

2. 소공뇌경색증 환자의 평균연령은 60.1세로 50대 (30,5%)와 60대(32.4%)에 호발하였으며, 남녀비는 약3 : 2였다.

3. 증상은 pure motor hemiparesis 가 50.7%로 가장 많았고 sensorimotor stroke 14.2%, pseudobulbar palsy 8.2%, dysarthria-clumsy hand syndrome 7.1% , ataxic hemipares is 4.9%, pure sensory stroke 4.1%의 순서였다.

4. 소공뇌경색증의 원인으로 추정되는 위험인자로는 고혈압이 77.4%로 가장 많았고, 고지질헐증 25.6%, 당뇨병23.2%, 심장질환9.5%의 순위였다. 특별한 위험인자를 발견할 수

없었던 경우는 26예(7.1%)였다.

5. 소공의 발생부위는 방선관 및 측뇌실주위의 백질이 20.3 %로 가장 많았고 다발성 17.1%, 렌즈핵 및 외낭 15.5%, 미상핵 및 내낭 전각 13.4%, 내낭 후각 12.8%, 내낭 슬 8.0%, 시상 8.0%, 뇌간4.8 %의 순서였고 뇌전산화단층촬영상 병소를 밭견할 수 없었던 경우는 28.1%였다.

6. 병변의 위치에 따른 임상증상은 superior형에서는 pure motor hemiparesis가 가장 많았고 그외에 sensorimotor stroke . ataxic hemiparesis, dysarthria-clumsy hand syndrome등의 순서로 증상이 나타났으며, anterior형에서는 pure motor hemiparesis, dysarthria-clumsy hand syndrome, sensorimotor stroke 및 ataxic hemiparesis 의 순서였다. Genu형에서는 pure motor hemiparesis. sensorimotor stroke, dysarthria-clumsy hand syndrome, lateral형에서는 pure motor hemiparesis, sensorimotor stroke. dysarthria-clumsy hand syndrome, pseudobulbar palsy, posterior형에서는 pure motor hemiparesis, sensorimotor stroke, dysaria-clumsy hand syndrome의 순서로 나타났다. Thalamic형에서는 pure sensory stroke, sensorimotor stroke, pure motor hemiparesis , ataxic hemiparesi

s, brainstem형에서는 pure motor hemiparesis, dysarthria-clumsy hand syndrome, sensorimotor stroke, ataxic hemiparesis의 순서로 나타났다. Multiple형에서는 pseudobulbar palsy가 가장 많았고 그외에 pure metor hemiparesis, ataxic hemiparesis, dysaria-clu

msy hand syndrome , sensorimotor stroke의 순서로 나타났다. 이상의 결과에서 소공뇌경색증의 위치에 따른 임상증상은 많은 중복을 보였으며 신경해부학적 이론에 의한 손상시 기대되는 증상과는 일치되지 않는 경우가 많았다.

7. 병변의 크기는 각 증후군에 따라 유의한 차이를 보였는데 ataxic hemiparesis, dysarthria-clumsy hand syndrome, pure sensory stroke등은 각각 평균부피가 0.45m1, 0.62m1, 0.78m1로 크기가 작은 반면, pure motor hemiparesis 는 1.55 ml. sensorimotor stroke는 2.70 ml로 크기가 컸다. 병변의 위치에 따라서도 병변의 크기에 차이를 보였는데 thalamic, brainstem, genu형에서는 0.39 ml. 0.47 ml, 0.64 ml로 작았고, superior 및 posterior형에서는 1.16 ml. 1.17 ml로 중간정도의 크기였으며, lateral과 anterior형에서는 2.47 ml와 3.34 ml로 컸다.

8. 마비의 정도는 병변의 크기에 비례하는 경향을 보였는데 경도의 마비인 경우에는 병변의 평균부피가 0.99ml, 중등도의 마비인 경우는 1.97 ml였고 중증의 마비인 경우는 3.77 ml였다. 병변의 위치에 따른 마비의 정도도 유의한 차이를 보였는데, superior형 과 thalamic 형에서는 마비가 경한 반면 brainstem, genu, anterior, later-al 및 posterior형에서는 비교적 심한 양상을 보였다.

[영문]

Lacunar infarctions are small ischemic lesions in the deep subcortical portions of the brain or the brainstem, resulting from occlusion of penetrating branches of the large cerebral arteries. Several studies have suggested that lacunar infarcts

may consitute 10 to 23 percent of all symptomatic cerebral infarctions. The pathogenesis of lacunar infarctions is different to other types of ischemic lesions with unique clinical manifestations and better prognosis.

Several studies investigating cerebrovascular disease in Korea have reported that 6 to 40 percent of all cerebral infarctions were lacunar infarctions. However, they collected too small number of cases to evaluate the general clinical aspects of

lacunar infarctions. The objective of this study is to demonstrate clinical characteristics of lacunar infarctions in Korea, therefore to establish a way to help the diagnosis, treatment and predicting prognosis in the disease . Subjects.

were 367 patients who had been admitted under diagnosis of lacunar infarction to severance hospital, Yonsei university medical center from January 1, 1983 to December 31, 1987. Analyzing clinical manifestations and brain computed tomographic

findings following results were obtained.

1. Lacunar infarctions accounted for 33.2 percent of all cerebral infarctions.

2. The ratio between male and female was about 3:2. The mean age was 60.1 years old and the most common age groups were the 6th and 7th decade.

3. Clinical syndromes of lacunar infarctions were pure motor hemiparesis (50.7%), sensorimotor stroke(14.2%), pseudobulbar palsy(8.2%), dysarthria-clumsy hand syndrome(7.1%), ataxic hemiparesis(4.9%), pure sensory stroke(4.1%), and others(1O.9%).

4. The most common underlying disease of lacunar infarctions was hypertension as present in 77.4% of all subjects. Other underlying diseases were hyperlipidemia 25.6%, diabetes mellitus 23.2% and heart disease with possible embolic sources 9.5%. In 14.7%, no underlying diseases were found.

5. Lacunar infarctions were documented on brain computed tomographic scans in 71.9% of subjects. Locations of the lesions were corona radiata and white matters around the body of lateral ventricle (superior type: 20.3%), lenticular nucleus and external capsule (lateral type; 15.5%), the head of caudate neucLeus and the anterior limb of internal capsule (anterior type; 13.4%), the posterior limb of internal capsule(posterior type: 12.8%), the genu of internal capsule (genu thpe; 8.0%), thalamus (thalamic type: 8.0%), brainstem(brainstem type; 4.8%), and multiple areas (multiple type: 17.1%).

6. Categorization of the clinical syndromes was variable according to the locations of lacunar infarctions . In superior type, pure motor hemiparesis accounted 63.2%, sensorimotor stroke 13.2%. ataxic hemiparesis 5.3% and dysarthria-clumsy hand syndrome 5.3%. In anterior type, pure motor hemiparesis 44.%, dysarthria-clumsy hand syndrome 20.O%, sensorimotor stroke 12.0%. and ataxic hemiparesis 4.0%. In genu type, pure motor hemiparesis 46.7%, dysarthria-clumsy hand syndrome 13.3% and sensorimotor stroke 13.3%. In lateral typed pure motor hemiparesis 79.3%, sensorimotor stroke 13.8%, dysarthria-clumsy hand syndrome 3.4%

and pseudobulbar palsy 3.4%. In posterior, pure motor hemiparesis 62.5%, sensorimotor stroke 33.3% and dysarthria-clumsy hand syndrome 4.2%. In thalamic type, pure sensory stroke 33.3%, pure motor hemiparesis 20.O%, sensorimotor stroke 20.0%, ataxic hemiparesais 13.3%. In brainstem, pure motor hemiparesis 44.4%,

dysarthria-clumsy hand syndrome 22.2%, sensorimotor stroke 11.1%, and ataxic hemiparesis 11.1%. In multiple type, pseudobulbar palsy 53.1%, pure motor hemiparesis 9.4%, ataxic hemiparesis 6.3%, dysarthria-clumsy hand syndrome 6.3%, and sensorimotor stroke 3.1%. These clinical syndromes showed a great degree of

overlapping without specific functional neuroanatomicaL basis.

7. The size of lacunar infarctions were significantly different among the types of clinical syndromes. The mean volume of the lacunar infarctions with ataxic hemiparesis asccounted 0.45ml, dysarthria-clumsy hand syndrome 0.62ml, pure sensory stroke 0.78ml, pure motor hemiparesis 1.55m1, and sensorimotor stroke 2.70m1. The size of lacunar infarctions were also significantly different among its locations, small in thalamic(0.39m1), brainstem(0.47ml) and genu type(0.64ml), moderate in superior(1.16ml) and posterior type(1.17ml), and large in lateral (2.47m1) and anterior type(3.34ml).

8. The severity of motor weakness showed direct correlation to the size of lacunes. The mean volume of lacunes with severe weakness was 3.77m1, moderate 1.97m1, and mild 0.99ml. The severity of motor weakness also showed significant differences according to its locations, that isle the weakness was mild in thalamic and superior type, and severe in posterior, lateral ,anterior, genu and brainstem type.