자발성 대뇌 피질하 출혈의 치료 방침

Abstract

[한글]

자발성 대뇌 피질하 출혈은 자발성 두개강내 출혈의 약 10-44% 차지하는 것으로 보고되고 있다. 근자에 이르러 이의 원인에 내과적 질환의 합병증에 의한 경우가 점차 증가하고 있는 추세이며, 이에 따른 치료방침의 선택은 환자의 예후에 중요하다. 최근의 자발성 대뇌 피질하 출혈의 원인 변화 추세와 이에 따른 치료 결과를 분석하여 올바른 치료 방침을 세우고자 한다.

1998년 1월부터 2000년 12월까지 3년간 파열성 뇌동맥류에 의한 뇌출혈을 제외한 179명의 자발성 대뇌 피질하 출혈 환자를 대상으로 하였다. 환자는 성별, 연령, 의식, 신경학적 상태, 과거력, 과거 전신 질환, 현재 출혈과 연관된 전신 질환, 출혈의 위치, 원인 진단, 치료 방법, 환자의 예후를 분석하였다. 환자의 상태는 Glasgow Coma Sale(GCS)에서 eye response와 motor response를 합한 것(Glasgow Coma Eye Motor Scale, GCEMS)으로 평가하고, 점수를 그룹화 하여, Group 1 (10점), Group 2 (8, 9점), Group 3 (5-7점), 그리고 Group 4 (2-4점)로 하였다. 환자의 예후는 Glasgow Outcome Scale(GOS)에 따라 평가하였다. 환자의 상태에 따라 진단적 검사의 진행에 차이가 있어 최종 검사를 기준으로 출혈의 원인을 진단하였고, 정확한 진단이 어려운 경우는 가장 가능성이 높은 것을 택하였다.

환자는 Group 1이 79명(44.1%), Group 2가 35명(19.6%), Group 3은 27명(15.1%), 그리고 Group 4가 38명(21.2%)이었다. 고혈압성 출혈이 55명(30.7%)으로 가장 많았으며, 이어서 전신질환에 의한 혈소판감소증 및 항 응고제 투여 등에 의한 출혈성 요인이 45명(25.1%), 전이성을 포함한 뇌종양이 23예(12.8%), 모야모야병을 포함한 뇌혈관기형 24예(13.4%), 뇌경색 후 치료 중 출혈 20예(11.2%), 심내막염 5예(2.8%), 뇌혈관염 2예(1.1%) 등

이다. 혈종에 대한 치료는 보존적 치료 115예(64.2%), 개두술에 의한 혈종 제거술 31예(17.3%), 도관삽입술 33예(18.4)이었다. Group 1은 주로 보존적 치료(58예, 73.4%)를 하였으며, Group 2와 3에서는 각각 13예(37.1%), 16예(59.3%)에서 수술적 치료를 하였다. Group 4에서는 24예(63.2%)에서 보존적 치료를 하였고 14예의 수술적 치료 중 1예에서만 개두술을 시행하였다. 전체적인 치료결과는 GOS 5이 77예(43.0%), 4가 21예(11.7%), 3이 14예(7.8%), 2는 11예(6.1%), 1(사망)은 56예 (31.3%)이었으며, 입원 당시 GCEMS가 낮을수록

사망률이 높았다(Group 1;7.6%, 2;22.9%, 3;44.4%, 4;78.9%).

자발성 대뇌 피질하 출혈의 주요 원인은 고혈압, 뇌혈관기형 등의 뇌혈관질환 이외의 전신 질환으로 인한 출혈성 소인, 항암제, 항 응고제, 혈전용해제 투여 등의 합병증이었다. GCEMS가 10인 경우에는 보존적 치료, GCEMS 5~9의 환자에서는 전신상태가 양호하면 개두

술에 의한 혈종 제거술을, 전신상태가 양호하지 못하면 도관삽입술을, GCEMS 2~4인 경우에는 전신상태가 양호하면 도관삽입술을, 그렇지 못하면 적극적 치료를 유보하는 것이 자발성 대뇌 피질하 출혈의 치료방침으로 생각된다.

[영문]

Object: It is reported that spontaneous subcortical intracerebral hemorrhage consists about 10 to 44% of spontaneous intracerebral hemorrhage. Recently, spontaneous subcortical intracerebral hemorrhage due to the complication of the systemic disease has been increasing, and the selection of management strategy according to the cause of hemorrhage closely affected the management outcome. This study was designed to analyze the cause of spontaneous subcortical intracerebral hemorrhage and the outcome in order to establish the appropriate management strategy

Subject: One hundred and seventy-nine cases of spontaneous subcortical intracerebral hemorrhage managed at Yonsei University Hospital from January 1998 to December 2000 were included in this study. Patients who suffered from subcortical intracerebral hemorrhage due to the ruptured intracranial aneurysm were exempted.

The patient''s sex, age, mental state on admission, neurologic condition, past history, systemic disease related to hemorrhage, location of hemorrhage, the diagnosis of intracranial or systemic disease, treatment methods, and clinical outcome were analyzed. Consciousness on admission was evaluated and scored based on Glasgow Coma Eye Motor Scale (GCEMS), which was the sum of eye response score and motor response score of the Glasgow Coma Scale. Patients were categorized into 4 groups according to GCEMS: Group 1 (10 points), Group 2 (8, 9 points), Group 3 (5~7 points), and Group 4 (2~4 points). The clinical outcome of the patient was evaluated based on Glasgow outcome scale (GOS). Differences in diagnostic procedure were present depending on the condition of the patients, thus the final diagnostic procedure was used to diagnose the reason behind bleeding. When accurate diagnosis was difficult to perform, the reasons with the highest likelihood were chosen.

Results: The patients corresponding to each group were as follow: 79(44.1%) in Group 1, 35(19.6%) in Group 2, 27(15.1%) in Group 3, and 38(21.2%) in Group 4. Fifty-five patients (30.7%) were hypertensive intracerebral hemorrhage, 45 patients

(25.1%) had anticoagulant therapy and thrombocytopenia due to the systemic disease and bleeding diasthesis after anticancer drug therapy, 23 patients (12.8%) had brain tumor including of the metastatic tumor, 19 patients (10.6%) had arteriovenous malformation, 18 patients (10.1%) had postinfarct hemorrhages, 5

patients (2.8%) had infective endocarditis, 2 patients (1.1%) had cerebral vasculitis. Conservative treatment was done in 115 patients (64.2%), open craniotomy in 31 patients (17.3%), and catheter insertion in 33 patients (18.4%). Group 1 mainly had conservative treatment (58 patients, 73.4%), Group 2 and 3 each

had 12 patients (37.1%) and 16 patients (59.3%) underwent open craniotomy respectively. In Group 4, conservative treatment was done for 24 patients (63.2%), and open craniotomy was done for only one patients among 14 patients treated surgically. Overall clinical outcome was: 77 patients (43.0%) in GOS 5, 21 (11.7%)

in GOS 4, 14 (7.8%) in GOS 3, 11 (6.1%) in GOS 2, and 56 patients (31.3%) died. Poor neurological state (low GCEMS) on admission was closely related to mortality (Group 1, 7.6%; Group 2, 22.8%; Group 3, 45.0%; Group 4, 78.9%).

Conclusion: The major causes of spontaneous subcortical intracerebral hemorrhage were hypertension, metastatic brain tumor, vascular malformation, and the bleeding tendency due to the systemic disease, complication of the anticancer drug,

anticoagulant, and thrombolytics therapy. Conservative treatment could be considered for the patients with GGCEMS 10, removal of hematoma by open craniotomy or catheter insertion for the patients with GCEMS 5~9, and the catheter insertion or deferring the active treatment could be considered for the patients with GCEMS 2~4.