주산기 허혈 뇌경색의 조기 진단을 위한 임상적 및 영상의학적 특징에 관한 연구
Early Diagnosis of Perinatal Ischemic Stroke Based on Clinical and Radiological Characteristics
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목적:주산기 허혈 뇌경색은 신생아기에 발생하는 주요 질환이지만 약 40%의 환자는 뚜렷한 증상을 보이지 않아 진단이 지연되는 것으로 알려져 있다. 이에 저자들은 주산기 허혈 뇌경색 환자를 대상으로 조기진단을 위한 임상적 및 영상의학적 특징을 확인하고자 하였다. 방법:2002년 1월부터 2010년 10월까지 삼성서울병원에서 뇌 MRI로 확진된 주산기 허혈 뇌경색 환자 24명을 대상으로 하였다. 후향적으로 환자들의 의무기록을 검토하여 주산기 병력 및 임상 증상을 확인하였고, 혈액 검사, 심장초음파 검사, 태반조직검사 등을 통해 주산기 뇌경색의 위험인자를 조사하였으며 추적관찰기간 동안 환자의 발달과 신경학적 진찰소견을 통해 신경학적 예후를 확인하였다. 결과:전체 24례 중 남자가 16례(66.7%), 여자가 8례였고 만삭아는 19례(79.2%), 미숙아가 5례(20.8%)였다. 12례에서 초기 증상으로 무호흡이 있었으며 10례에서 발작이 확인되었다. 뇌 영상검사에서 중 대뇌동맥을 침범한 경우가 16례(66.7%)로 가장 많았으며 좌 반구의 뇌경색이 있었던 경우는 15례였다. 뇌 MRI에서 국소 병변을 보인 11례 중 3례는 확산강조영상에 의해 진단되었다. 증상 발생 후 24시간 이내에 진단된 환자군에서 첫 증상이 발작인 경우가 많았으나 진단이 지연된 환자군은 무호흡이 더 흔하였다. 약 50%의 환자에서 발달 지연과 뇌성 마비 등의 신경학적 후유증이 확인되었으며 뇌 MRI상 병변의 범위가 넓거나 기저핵이 동시에 침범된 경우 불량한 예후를 보였다. 결론:생후 수 일 내 원인이 뚜렷하지 않은 무호흡이나 기면 등의 비특이적인 증상을 보이는 경우나 증상이 경미하더라도 발작이 있었던 경우는 반드시 뇌경색을 감별해야 한다. 조기진단 및 확진을 위해 뇌 MRI가 중요하고 특히 확산강조영상은 질병초기에 국소 경색의 진단에 매우 유용하며 짧은 시간에 검사가 가능하여 상태가 불안정한 신생아에서도 유용하게 사용될 수 있다. 침범 부위가 넓은 경우, 특히 대뇌 반구, 기저핵을 동시에 침범하는 경우 신경학적 장애를 보였다.
Abstract
Purpose:Perinatal ischemic stroke (PIS) has been increasingly recognized and regarded as one of the major causes of neurological disability occurring in the neonatal period. Due to its vague presenting symptoms, the clinical diagnosis of PIS can be delayed. The aim of this study was to delineate the clinical and radiological characteristics of PIS in order to establish its early diagnosis. Methods:From January 2002 to October 2010, 24 neonates with evidence of ischemic cerebral infarction on brain magnetic resonance imaging (MRI) were enrolled. Perinatal and neonatal clinical characteristics, electroencephalogram (EEG), and brain MRI findings were retrospectively reviewed. Using those data, analysis was done to elicit clues for early diagnosis and prognostic factors of PIS. Results:Sixteen males and eight females were diagnosed with PIS. Twelve cases presented with apnea and ten patients with seizures. The diagnosis of PIS was confirmed by brain MRI. Sixteen patients (66.7%) had infarction in the territory of the middle cerebral artery, and fifteen neonates had infarction in the left hemisphere. Of 11 infants who presented with a focal lesion on brain MRI, three patients were diagnosed by diffusion weighted images (DWI). Their T2- and FLAIR sequences showed subtle signal changes, whereas DWI revealed bright signal intensity. Thirteen patients were included in the delayed diagnostic group (diagnostic interval >24 hours). In those patients, apnea (69.2%) was more likely than seizures (15.4%) to be the initial symptom. The extent of the lesion on brain MRI was likely to be a better predictor of the neurologic outcome. Hemiplegia or hemiparesis was found in seven patients who had extensive lesions involving the gray and white matter, internal capsule, and basal ganglia. Conclusion:PIS should be considered as a differential diagnosis for neonates who present with apnea, lethargy or subtle seizures. DWI of brain MRI is very useful for early diagnosis of PIS. The extent of the lesion was also found to be significantly associated with poor outcome.
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