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심 O 헌 (M/42)

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

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심 O 헌 (M/42)

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  1. 심O헌 (M/42) 성균관대학교 의과대학 2007313075 손의영

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

  3. Present Illness (1) • 2011-09-15 (내원 3일 전) • 정확하게 언제인지는 모르나 어느 순간 부터 심한 머리 통증 발생 • Nausea, vomiting 동반되었으며 통증은 순식간에 심해진 것 같다고 함 • Headache • Location우측 귀 뒤쪽  이후 머리 전체로 퍼짐 • Nature머리 전반이 짓누르는 듯한 양상가끔 박동 뛰듯이 아픔

  4. 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

  5. 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

  6. Past medical history • 2009-08 • 간헐적인 Rt. Sided weakness 및 dysarthria 발생 • Local MRI에서는 정상 • 2011-08 (1MA) • Chest pain 및 general weakness로 local 동인요양병원 입원 • Isosorbide mononitrate 복용 시작

  7. Warfarin • 이소빈서방캅셀 50mg (Isosorbide mononitrate) • 흉통 있을 때 간헐적으로 복용 • Zolpidem • Amlodipine • Ciprofloxacin 250mg bid, Metoclopramide 4mg tid • 2011-09-13 부터 두통과 함께 nausea있어서 2개 약 같이 복용하고 있었음 Medication history

  8. Family Hx • 특이사항 없음 • Social Hx • Smoking no (약 3년 전 quit) • Alcohol no Other Histories

  9. 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 (-)

  10. 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 (-/-)

  11. Neurologic examination (1) • Mental status examination • Level of consciousness alert • Orientation Time/Place/Person (+/+/+) • Language fluent with well comprehension

  12. 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

  13. 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 (3)

  14. DTR • Brachioradialis (++/++) • Biceps (++/++) • Triceps (++/++) • Quadriceps (+/+) • Ankle (+/+) • Plantar extensor reflexes Babinski (-/-) Chaddock (-/-) Neurologic examination (4)

  15. Coordination and gait • Cerebellar function test • Rapid alternating movement dysdiadochokinesia (-/-) • Finger-to-nose intentional tremor (-/-) • Heel-to-shin dysmetria (-/-) Neurologic examination (5)

  16. Coordination and gait • Gait • Step mild Rt. Leg limping • Tandem gait (-) • Romberg test (-) Neurologic examination (6)

  17. Problem List (1) • #1. Headache • Severe, continuous • With nausea, vomiting • #2. Chronic neurologic deficit • Rt. arm/leg weakness with hypesthesia

  18. Problem List (2) • #3. Hypertension • #4. Angina pectoris • #5. SMV, Portal vein thrombosis, small bowel gangrene •  embolectomy, small bowel resection

  19. 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 #3. Hypertension #4. Angina pectoris #5. SMV, Portal vein thrombosis, small bowel gangrene

  20. Diagnosticplan • Brain MRI, MR venography • 병변 부위 확인 • Funduscopy, visual field check • ICP 증가 여부 확인

  21. Brain CT (2011-09-18) CONCLUSION: Suggestive of dural sinus thrombosis involving right transverse sigmoid sinus and internal jugular vein.

  22. T1 MRI

  23. T2 MRI (sagittal view)

  24. MR venography

  25. Funduscopy

  26. #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 Reassessment

  27. For CVT • Heparin + Warfarin • For IICP • Mannitol, glycerin • 1주 경과 관찰 후 두통호전 확실치 않거나 시력 저하등을 호소할 경우 thrombolysis 고려 Therapeutic plan

  28. 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

  29. Cerebral venous thrombosis • Pathophysiology • Cortical vein 막힘  뇌의 허혈 변화, 출혈, 뇌부종 동반가능 • Dural venous sinus 막힘  이 부근 정맥압 증가  arachnoid villi를 통해 CSF가 흡수되지 않으므로 두개내압이 상승한다.

  30. 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 vein의 영역에 따라 팔다리의 운동 및 감각장애, 실어증, 뇌신경마비 등이 발생 가능 • ICP 상승 : funduscopy에서 papilledema 가 발견됨

  31. Cerebral venous thrombosis • Diagnosis • Cerebral angiography • Imaging (CT, MRI…) • D-dimer는 도움 안됨 • Treatment • anticoagulation : to suppress blood clot formation • thrombolysis : 효과가 확실히 증명 된 것은 아님 • ICP가 증가된 경우 lumbar puncture나 medication으로 압력을 낮춰주면 증상의 호전을 기대할 수 있다.

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