심 O 헌 (M/42) 성균관대학교 의과대학 2007313075 손의영. Chief complaint (11.7.10) Headache Onset(about) 1WA.

심 O 헌 (M/42)성균관대학교 의과대학

2007313075 손의영

Chief complaint (11.7.10)• Headache• Onset (about) 1WA

Present Illness (1)• 2011-09-15 ( 내원 3 일 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 양상가끔 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 MRI 에서는 정상

• 2011-08 (1MA)• Chest pain 및 general weakness 로 local 동인요양병원 입원 Isosorbide mononitrate 복용 시작

• 갑자기 말발음이 더 어둔해지면서 입이 돌아감 ( 방향은 모름 ,

general weakness 동반 )

• 당시 머리가 아프지는 않았으며 , 약간의 nausea(+)

• 1~2 일만에 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 3 년 전 quit)

• Alcohol no

Review of system• General weakness/fatigue (+/-) • Weight loss (-)• Fever/chill (-/-)

• Visual disturbance/ocular pain/discharge (-/-/-)

• Sore throat/rhinorrhea/sneezing (-/-/-)• Cough/sputum/hemotpysis (-/-/-)• Dyspnea/orthopnea (-/-)• Chest pain/ palpitation (-/-)

• Anorexia/nausea/vomiting (-/-/-) • Abdominal discomfort/pain (-/-) • Constipation/diarrhea (-/-)• Hematemesis/melena/hematochezia (-/-/-) • Dysuria/oliguria/frequent voiding (-/-/-) • Foamy urine/red urine (-/-)

• Arthralgia (-) • Myalgia (-) • Tingling sense (-) • Morning stiffness (-)

Physical examination • Vital sign

• 135/88 mmHg – 65 /min – 20 /min – 36℃

• General appearance• Chronic ill-looking appearance

• Head & neck• Conjunctiva pinkish• Sclera clear• Pupil size symmetric, no myosis on both pupil

• Light reflex prompt response on both pupil

• Tongue not dehydrated• Tonsilar enlargement no• Gingival hypertrophy no• Gum bleeding no• Palpable neck mass no

• Chest• Symmetric expansion• Regular heart beat without murmur• Supraclavicular node (-/-)• Axillary node (-/-)• Percussion resonance, symmetric• Vesicular breath sound without crackle,

wheezing, rhonchi

• Abdomen• Flat abdomen, soft on palpation• Normoactive bowel sound• Hepatomegaly/splenomegaly/shifting dullness (-/-/-)• Pain/tenderness/rebound tenderness (-/-/-)• Palpable abdominal mass (-/-)

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 mild Rt. Leg limping

• Romberg test (-)

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

• 1 주 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 villi 를 통해 CSF 가 흡수되지 않으므로 두개내압이 상승한다 .

Cerebral venous thrombosis

• Clinical manifestation• 뇌정맥 혈전은 동시에 여러 뇌정맥을 침범할 수 있기 때문에

특징적인 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 vein 의 영역에 따라 팔다리의 운동 및 감각장애 , 실어증 , 뇌신경마비 등이 발생 가능

• ICP 상승 : funduscopy 에서 papilledema 가 발견됨

Cerebral venous thrombosis

• Diagnosis• Cerebral angiography

• Imaging (CT, MRI…)

• D-dimer 는 도움 안됨

• Treatment• anticoagulation : to suppress blood clot formation

• thrombolysis : 효과가 확실히 증명 된 것은 아님

• ICP 가 증가된 경우 lumbar puncture 나 medication 으로 압력을 낮춰주면 증상의 호전을 기대할 수 있다 .