Case Presentation 신경과 PK 6 조 박경선, 정택영

Identifying Data Name : 김 O O Sex : Male Age : 71

Chief Complaint Non-vertiginous dizziness for 10 days

Present Illness 2006 년 5 월부터 Lt. side headache (dull nature, continuous, 호전되기도 악 화되기도하며 지속적으로 아픔 ) 있어 LMC 에서 medication 하였으나 호전 없 었음 년 12 월경 LMC 에서 시행한 MRI 상에서 Lt. PCA 가 20% 정도 좁아진 소 견 듣고 medication 하였으나 호전 보이지 않았음 년 7 월 1 일 오전 9 시경 자전거 타고 논에 물주러 가던 중 갑자기 어지러 운 증상 발생함. 주변이 돌아가는 양상은 아니었으나 어지리한 기분이 들었 음. 사물이 흐릿하게 보이고, 상기 증상은 호전이나 악화없이 지속됨 년 7 월 5 일경 원래 어지러운 증상으로 LMC 방문하여 중풍 가능성 듣고 medication 하였으나,Lt. side headache and nonvertiginous dizziness 지속되어, 2007 년 7 월 11 일 본원 NE OPD 방문.

Personal History Alcohol(-) stop smoking: 1/2 pack * 50 years = 25pack years Rt.handedness Height : cm Weight : 50 kg EKG : inverted T in v2,v3,v4 CXR : unremarkable abdominal girth; 80 cm hip girth; 84.5 cm

Past History Hypertension (+) : 2006 년 5 월. LMC 에서 regular medication 중 Diabetes mellitus (-) Pulmonary tuberculosis (-) Previous cerebraovascular accident history (-) Previous illness Hx (-) Previous headache history (-) COM history(-)

Family History Hypertension (-) Diabetes mellitus (-) Pulmonary tuberculosis (-) Cerebrovascular accident history (-)

Physical Examination Vital Sign BP140/80 mmHg PR 70/min RR 20 /min BT 36.0 C General appearance ill developed

System review Eyes Not pale conjunctiva Anicteric sclera Throat No throat injection Carotid bruit (-/-) Respiratory Symmetrical expansion on respiration Clear breathing sound s rale Cardiovascular Irregular heart beat s murmur Gastrointestinal Soft and flat Normoactive bowel sound Musculoskeletal No muscular atrophy No pitting edema No cyanosis

Neurologic Examination 1. Mental Status Consciousness level : alert Speech : intact Memory : Remote, recent,immediate : intact Orientation : Time, place, person : intact

Neurologic Examination 2. Cranial Nerve I. Olfactory : intact II. V/A : (0.5, 0.4) V/F : Lt.sup.quadrantanopsia Fundus : no papilledema & retinal change (-) III.IV.VI EOM : medial gaze limitation of Rt. eyeball(2/3 까지는 motion 있음 ) upward gaze mild palsy Pupil : RRERL c 3mm Nystagmus : no spontaneous or gaze evoked nystagmus

Neurologic Examination V. Facial sensation Pain, temperature Touch Vibration decresed all sensory modalities on Lt. hemiface VII. NLFF (-/+) Forehead wrinkling (+/+) -> Lt. central type 7th nerve palsy VIII. Hearing difficulty :(-/-) Weber test : no lateralization Rinne test : (AC>BC, AC>BC)

Neurologic Examination IX.X Gag reflex : (+/+) Uvular deviation : (-) XI. SCM & Trapezius muscle - intact XII. No tongue deviation on protrusion

Neurologic Examination 3. Motor 1) Tone : normal 2) Power : Pronator sign (-/-) hand grip (5/5) Finger abduction (5/5) finger adduction (5/5) Finger flexion (5/5) finger extension (5/5) Wrist flexion (5/5) extension (5/5) Elbow flexion(5/5) extension (5/5) Arm abduction(5/5) adduction (5/5) Hip flexion (5/5) extension (5/5) Knee flexion (5/5) extension (5/5) Ankle dorsiflexion (5/5) plantarflexion (5/5) 3) Muscle bulk : no muscular atrophy

Neurologic Examination 4. Sensory Pain, temperature Touch Vibration, position - decresed all sensory modalities on Lt. hemibody 5. DTR : bilateral symmetrical DTR

Neurologic Examination 6. Cerebellar sign Finger to nose test : intact Heel to shin test : intact Romberg test : (-) Tandem gait : tilt to left side Past point test : No finger deviation to Lt. side Dysdiadochokinesia (-/-) Rebound phenomenon (-/-) Hypotonia (-/-) 7. Gait : intact

Formulation Medial gaze limitation of Rt. eye, upward gaze limitation  Rt. midbrain or pons 의 MLF lesion 가능성 Left Sup. Quadrantanopsia  calcarine fissure 의 아랫쪽 Rt. Side lesion 가능성 Lt. central type 7th nerve palsy  corticobulbar tract lesion 가능성 Decresed all sensory modalities on Lt. hemiface and Lt.hemibody  Rt. medulla 상방의 spinothalamic tract, med. lemniscus 가 지나가는 pons 의 paramedian lesion 또는 Thalamus 의 VPL, VPM 이 이 지나는 lesion 가능성 상기소견을 종합해보았을때, occipitotemporal lobe,brain stem, internal capsule 을 침범하는 광범위한 lesion 이 의심된다.

Formulation History 상 Non-vertiginous dizziness for 10 days 를 주소로 내원한 71 세 남자 환자로 old age, HTN 의 CVA risk factor 지니며 Sudden onset neurologic deficit  vascular origin 가능성 old age, HTN artherosclerosis risk factor 지님  large artery artherosclerosis 에 의한 A to A 가능성 여러가지 증상 동시에 보이는 점  Cardioembolic embolism 에 의한 multiple infarction 의 가능성

Impression R/O Unspecified Cerebral Infarction

Diagnostic Plan Brain MRI & MRA & Carotid TTE, TEE, Holter monitoring & TCD

Brain MRI DWI ( )

Brain MRI T2 FLAIR ( )

Brain MRA ( )

Assessment Brain MRI& MRA& carotid Subacute infarction of right PCA territory 소견과 함께 hemorrhagic transformation 소견보임 ---  antiplatelet agent 사용 하지 않고 conservtie manage 시행하여야함.

Diagnosis #Rt. PCA territory infarction --- Right thalamus, right midbrain tegmentum right occipitotemporal parahippocampal gyri.

Therapeutic Plan Bed rest and conservative manage

Thalamic infarction

Thalamus The way-station of the brain's networks. Function Motor Control Receives Auditory, Somatosensory and Visual Sensory Signals Relays Sensory Signals to the cerebral cortex

Arterial supply of the thalamus

Territory of thalamogeniculate artery Ventrolateral thalamus( VPM, VPL) Most common thalamic infarction Findings occur on the side of contralateral lesioned thalamus Pure sensory; Mixed motor & sensory Ataxic hemiparesis Thalamic syndrome Dystonic hand

Territory of paramedian artery Posteromedial thalamus (Rostral interstitial Nu. Of MLF, DM ) Transient loss of consciousness or somnolence. Behavioral changes recent memory loss (with anterograde & retrograde) vertical gaze and convergence disorders contralateral hemiataxia, asterixis, or motor weakness. delayed action tremor in contralateral limbs

Territory of polar artery Anterolateral regions ( Reticular Nu, mammillothalamic tr. VL, DM) Apathy Anterograde memory loss Facial paresis for emotional movement Dysphasia with left-sided lesions Hemineglect and impaired visuospatial processing with right-sided lesion

Territory of post. choroidal arteries Dorsal region (Pulvinar, LG, MG, Ant.Nu) Visual field defects (eg, quadrantanopsia, sectoranopia) Visual hallucinosis Hemisensory loss with mild hemiparesis Transcortical aphasia Delayed contralateral abnormal movements ** isolated med. post. choroidal artery territory infarction has not been reliably documented