Case Presentation PK 11 Identifying Date n Name

Case Presentation 신경과 PK 11조 서익권, 최은성

Identifying Date n Name : 손 O O n Sex : Male n Age : 73

Chief Complaint n Drowsy mentality

Personal History n n n Smoking (-) Alcohol (-) : exalcoholic, 15년전 stop , 소주 1병 # 2/1 week for 20 years n n n n Occupation (-) Education : 고졸 Right handedness Height : 172 cm Weight : 82 kg EKG : CRBBB CXR : mild cardomegaly

Past History n n n Hypertension : (+) 1986/1991 Diabetes mellitus : (+) 1980/1991 Pulmonary tuberculosis : (-) Previous cerebrovascular accident history : (+) Previous illness history : (+)

Previous cerebrovascular accident history n 1991년 Rt. thalamic ICH로 입원이후 Lt. hemiparesis 있었으나 독립적 보행 가능 2001년 Lt. sided weakness 진행하여 본원 내원하여 Rt. periventricular infarction으로 입원 그 후 Lt. hemiparesis있으나 지팡이로 혼자 보행가능하였고 발음이 어눌하나 알아들을 수 있었고 Lt. central type facial palsy 증상보임 n

Family History n n Hypertension : (+) ; 아들 Diabetes mellitus : (-) Pulmonary tuberculosis : (-) Previous cerebrovascular accident history : (-)

Physical Examination n Vital sign n G/A : ill appearance n HEENT : not pale conjunctiva anicteric sclera carotid bruit(-/-) Chest : symmetrical expansion on respiration Lung : CBS s crackle Heart : RHB s murmur Abdomen : soft & flat, normoactive bowel sound Extremities : no pitting edema no cyanosis LOM on Rt. Wrist Operation scar on Lt. tibia n n n n -BP 180/100 mm. Hg PR 84/min -RR 20/min BT 36. 8℃

System review n Ears otalgia/ear discharge(-/-) n Throat sore throat(-) dysphagia(-) n Respiratory coughing/sputum/hemoptysis(-/-/-) n Cardiovascular chest discomfort(-) palpitation(-) n Gastrointestinal abdominal distension/pain (-/-) n Genitourinary urgency/frequency/nocturia/hesistancy/disuria(-/-/-)

Neurologic Examination 1. Mental Status Consciousness level : drowsy (3+5+6=14/15) Speech : severe dysarthria Memory & Orientation : unable to check due to poor coorperatio n

Neurologic Examination 2. Cranial Nerves I. Olfactory : unable to check due to poor coorperation II. V/A : (20/100, 20/100) V/F : intact by confrontation method Fundus : no papilledema & retinal change (-) III. IV. VI EOM : full range by OCR Pupil : RRERL c 3 mm nystagmus : no spontaneous V. Facial sensation Pain, temperature Touch Vibration ; unable to check due to poor coorperation

Neurologic Examination VII. NLFF (-/+) Forehead wrinkling (+/+) - Lt. central type facial palsy VIII. Hearing difficulty: unable to check due to poor coorperation Weber test : unable to check due to poor coorperation Rinne test : unable to check due to poor coorperation IX. X. Gag reflex (+/+) Uvular deviation (-) XI. SCM & Trapezius muscle : unable to check due to poor coorperation XII. Tongue deviation on protrusion: unable to check due to poor coorperation

Neurologic Examination 1) Tone : spascity on Rt. Knee 2) Power : grossly check due to poor c oorperation (2/5) (3/5) (2/5) 3) Muscle bulk : no muscular atrophy

Neurologic Examination 4)Sensory Pain, temperature Touch Vibration, position ; unable to check due to poor coorperation 5) DTR : Brachioradialis jerk (+/++) Biceps jerk(+/+) Triceps jerk (+/+) Patella jerk (+/+) Ankle jerk (+/++) Babinski''s sign (-/+)

Neurologic Examination 6) Cerebellar sign Finger to nose test & Heel to shin test ; unable to check due to poor coorperation 7) Gait unable to stand due to weakness

Formulation Lt. hemiparesis Lt. central type facial palsy Rt. side와 비교시 Left DTR 항진 Left Babinski reflex (+) >과거력상 Rt. corticospinal tract를 involve했 던 질환의 후유증의 가능성이 크며,

Formulation Drowsy mentality > Ascending reticular activating system n Rt. sided weakness Dysarthria > Lt. corticospinal tract, Lt. corticobulbar tract 를 involve 할 가능성이 크겠다. n

Formulation 고령의 남자 고혈압 old CVA의 CVA risk factor sudden onset한 neurologic deficit Infarction과 hemorrhage의 과거력 > vascular origin의 stroke의 가능성 고령의 남자, 고혈압의 atherosclerotic factor Infarction과 hemorrhage의 과거력 > Artery to artery embolism , in situ thrombosis에 의한 large artery disease 가능성 고려할 수 있겠다.

Impression Stroke # intracranial hemorrhage # cerebral infarction

Diagnostic Plan n Brain CTA, MRI

Brain CTA (07/06/02)

Brain MRI DWI (07/06/02)

Brain MRI T 2 (07/06/02)

Assessment n Drowsy mentality Rt. Sided weakness dysarthria 등의 증상과 n CTA상 Lt. temporal lobe에 high intensity 의 hemorrhagic lesion이 보이고, n MRI DWI, T 2상 Lt. temporal lobe 에 low signal의 출혈 소견 상기 이미지가 correlation을 보인다.

Diagnosis n Intracranial hemorrhage

Therapeutic Plan 1. 2. Airway, Breathing, circulation IICP =>구토, 두통 유발 1)controlled hyperventilation (Pa. CO 2 27 -30 mm. Hg) 2)osmotherapy: mannitol(300 m. Osm/kg) Hypertonic saline(Na 145 -155 mmol/L) 3. Seizure - phenytoin

Follow up CT(07/06/04)

Progress note (07/06/12) n Cooperation 간간이 되며 irritability 없으며 대부분 누워서 생활하며 절대 안정 상태

Disease Review - Intracerebral hemorrhage -

Pathogenesis & Pathophysiology l l Chronic hypertension -> - penetrating and subcortical arteries에 fibrinoid necrosis - arterial wall weakening - small aneurysmal outpouching 형성 (Charcot-Bouchard microaneurysms) Acute rises in blood pressure and blood flow Ruptured vascular malformation Amyloid angiopathy

Pathogenesis & Pathophysiology

Classification Etiology 1. Primary intracerebral hemorrhage 2. Secondary intracerebral hemorrhage l Site 1. Supratentorial hemorrhage 1) Lobar hemorrhage 2) Deep hemorrhage 2. Infratentorial hemorrhage l

Location

Risk Factor Hypertension l Age l Sex : male > female l Race : black, Asian > white l Alcohol l Hyperlipidemia l Cocaine, Amphetamine, heroin l Anticoagulation l

Clinical Features (1) Headache (1/3) l IICP -> vomiting l Seizure l

Clinical Features (2)

Diagnosis - CT

Diagnosis - CT

Diagnosis - CTA

Diagnosis - MR

Acute Management Airway, Breathing, Circulation l Neurologic examination, GCS l Trauma, bed sore, compartment syndrome, rhabdomyolysis l Fluid : Normal saline l

Control of Blood Pressure

Control of Intracranial Hypertension CSF drain l Decreasing brain tissue bulk l Decreasing cerebral blood volume l Sedation and pharmacologic paralysis l

Coagulopathy Warfarin-related l Fresh frozen plasma & Vitamin K l

Treatment of Complication Elevated Intracranial Pressure - controlled hyperventilation (Pa. CO 2 27~30 mm. Hg) - osmotherapy : mannitol (300 m. Osm/kg) hypertonic saline (Na 145~155 mmol/L) l Seizure - phenytoin l

Surgical Intervention

Reference l l l Textbook of Clinical Neurology, Christopher G. Goetz, 2 nd edition 전정판 신경학, 서울대학교 의과대학 Neuroimaging, William W. , Orrison, Jr. Current Updates in Perioperative Management of Intracerebral Hemorrhage, Neurologic Clinics 2006, 745 -764 Advances in the Management of Spontaneous Intracerebral Hemorrhage, Critical Care Clinics, 2007, 607 -617