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

Medication history• Warfarin

• 이소빈서방캅셀 50mg (Isosorbide mononitrate)• 흉통 있을 때 간헐적으로 복용

• Zolpidem

• Amlodipine

• Ciprofloxacin 250mg bid, Metoclopramide 4mg tid• 2011-09-13 부터 두통과 함께 nausea 있어서 2 개 약 같이 복용하고 있었음

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

• Tandem gait (-)

• 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 hematomar/o aneurysmr/o pituitary apoplexy

#2. r/o Chronic ischemic stroke

#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 .