1. Case Presentation
신경과 PK 11조
서익권, 최은성

2. Identifying Date
Name : 손 O O
Sex : Male
Age : 73

3. Chief Complaint
Drowsy mentality

4. Present Illness 2007년 6월 2일 오전 6시 30분경까지 평소처럼 말이 어눌했지만, 대화 가능하고,
2007년 6월 2일 오전 6시 30분경까지
평소처럼  말이 어눌했지만, 
대화 가능하고, 
left power 감소한  증상만 있었음.
오전 7시경 환자 서서 벽 짚은 상태에서 
목욕 시키고 있는 중,
옆으로 움직일 수 없고, 
알아 들을 수 없는 이상한 소리, 
대화 불능 증상 보여,
  LMC 방문후 본원 응급실로 내원함

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

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

7. Previous cerebrovascular accident history
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 

8. Previous illness history
2004년경 fall down 으로 에서 Rt. wrist and Lt. tibia fracture 로 집에서만 생활하며 지팡이로 화장실 거실만 걸어다님
2006년경 기저귀 입고 방에서만 생활함.

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

10. Physical Examination Vital sign -BP 180/100mmHg PR 84/min
-RR 20/min BT 36.8℃
G/A : ill appearance
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

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

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

13. 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 3mm
nystagmus : no spontaneous
V. Facial sensation
Pain, temperature
Touch Vibration
; unable to check due to poor coorperation

14. 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 

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

16. 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 (-/+)

17. 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

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

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

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

21. Impression
Stroke
# intracranial hemorrhage
# cerebral infarction

22. Diagnostic Plan
Brain CTA,  MRI   

23. Brain CTA (07/06/02)

24. Brain MRI DWI (07/06/02)

25. Brain MRI T2 (07/06/02)

26. Assessment Drowsy mentality Rt. Sided weakness dysarthria 등의 증상과
CTA상 Lt. temporal lobe에 high intensity 의
hemorrhagic lesion이 보이고,
MRI DWI, T2상 Lt. temporal lobe 에
low signal의 출혈 소견
상기 이미지가 correlation을 보인다.

27. Diagnosis
Intracranial hemorrhage

28. Therapeutic Plan Airway, Breathing, circulation IICP =>구토, 두통 유발
1)controlled hyperventilation
(PaCO mmHg)
2)osmotherapy: mannitol(300mOsm/kg)
Hypertonic saline(Na mmol/L)
3. Seizure - phenytoin

29. Follow up CT(07/06/04)

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

31. - Intracerebral hemorrhage -
Disease Review
- Intracerebral hemorrhage -

32. Pathogenesis & Pathophysiology
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

33. Pathogenesis & Pathophysiology

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

35. Location

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

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

38. Clinical Features (2)

39. Diagnosis - CT

40. Diagnosis - CT

41. Diagnosis - CTA

42. Diagnosis - MR

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

44. Control of Blood Pressure

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

46. Coagulopathy
Warfarin-related
Fresh frozen plasma & Vitamin K

47. Treatment of Complication
Elevated Intracranial Pressure
- controlled hyperventilation (PaCO2 27~30mmHg)
- osmotherapy : mannitol (300mOsm/kg)
hypertonic saline (Na
145~155mmol/L)
Seizure
- phenytoin

48. Surgical Intervention

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