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실비우스수조에서 중대뇌동맥을 압박하는 결핵육아종

Tuberculous Granuloma Compressing the Middle Cerebral Artery in the Sylvian Cistern

Article information

J Korean Neurol Assoc. 2017;35(3):185-186
Publication date (electronic) : August 1, 2017
doi : http://dx.doi.org/10.17340/jkna.2017.3.17
Sook Young Roh, MD, Young Ik Jung, MD, Junghee Seo, MD, Eun Mee Han, MDa, Jeong Yeon Kim, MD,b
Department of Neurology, Bundang Jesaeng General Hospital, Seongnam, Korea
aDepartment of Pathology, Bundang Jesaeng General Hospital, Seongnam, Korea
bDepartment of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
노숙영, 정영익, 서정희, 한은미a, 김정연,b
분당제생병원 신경과
a분당제생병원 병리과
b인제대학교 의과대학 상계백병원 신경과
Address for correspondence: Jeong Yeon Kim, MD  Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea  Tel: +82-2-950-1090 Fax: +82-2-950-1955 E-mail: jykimmd@paik.ac.kr
received : March 8, 2017 , rev-recd : March 31, 2017 , accepted : March 31, 2017 .

약 8개월 전부터 결핵수막염으로 항결핵제를 투약해온 77세 여자가 졸음상태가 지속되어 내원하였다. 확산강조영상에서 양측 대뇌반구의 다발뇌경색이 관찰되었고(Fig. A), 뇌자기공명영상에서 대뇌혈관의 혈관염을 시사하는 광범위한 조영제 증강과 좌측 중대뇌동맥 M2-분절의 협착이 보였다(Fig. B). 혈관벽-뇌자기공명영상을 시행하였으며, 실비우스수조에서 조영제 증강되는 결절이 중대뇌동맥을 둘러싸며 압박하였다(Fig. C). 결절의 현미경소견은 상피모양의 조직구와 림프구로 둘러싸인 중심괴사가 관찰되어 결핵육아종에 합당한 소견이었다(Fig. D). 기존 항결핵제와 병용하여 스테로이드 경구요법을 하였고, 9개월 후에 추적관찰한 혈관벽-뇌자기공명영상에서 좌측 중대뇌동맥 M2-분절협착이 호전되고 결절의 크기가 현저히 줄었다(Fig. E, F).

Figure.

Brain images and biopsy findings of the patient. (A) Diffusion weighted image showed multiple cerebral infarct lesions in bilateral frontal white matter. (B) Brain CE MRA showed left MCA M2 stenosis (white arrow). (C) Vessel wall brain CE MRI revealed 1.2 cm-sized enhancing nodule at left sylvian cistern (black arrow). (D) The microscopic finding of enhancing nodule around left MCA revealed central necrosis surrounded by epithelioid histiocytes and lymphocytes (H&E stain, ×200). (E, F) Follow up vessel wall brain CE MRI showed slight improvement of luminal stenosis of left MCA M2 division (white arrow) and further decreased size of the enhancing mass-like lesion (black arrow). CE; contrast enhanced, MRA; magnetic resonance angiography, MCA; middle cerebral artery, MRI; magnetic resonance imaging, H&E; hematoxylin and eosin.

결핵육아종은 밀집한 수막삼출물이 대뇌의 기저부에서 자라는 세포군으로 주로 뇌실질에 생기고 감염균의 성장을 봉쇄하는 조직으로 알려져 있다[1,2]. 실비우스수조에서 발생되어 대뇌혈관을 둘러 싸 압박하는 결핵육아종은 매우 드물며, 혈관벽뇌자기공명영상과 생검으로 병소를 진단하는데 도움이 되었다.

References

1. Küker W, Gaertner S, Nägele T, Dopfer C, Schoning M, Fiehler J, et al. Vessel wall contrast enhancement: a diagnostic sign of cerebral vasculitis. Cerebrovasc Dis 2008;26:23–29.
2. Rubin EJ. The granuloma in tuberculosis – friend or foe? N Engl J Med 2009;360:23.

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Copyright © 2017 Korean Neurological Association

Figure.

Figure.

Brain images and biopsy findings of the patient. (A) Diffusion weighted image showed multiple cerebral infarct lesions in bilateral frontal white matter. (B) Brain CE MRA showed left MCA M2 stenosis (white arrow). (C) Vessel wall brain CE MRI revealed 1.2 cm-sized enhancing nodule at left sylvian cistern (black arrow). (D) The microscopic finding of enhancing nodule around left MCA revealed central necrosis surrounded by epithelioid histiocytes and lymphocytes (H&E stain, ×200). (E, F) Follow up vessel wall brain CE MRI showed slight improvement of luminal stenosis of left MCA M2 division (white arrow) and further decreased size of the enhancing mass-like lesion (black arrow). CE; contrast enhanced, MRA; magnetic resonance angiography, MCA; middle cerebral artery, MRI; magnetic resonance imaging, H&E; hematoxylin and eosin.