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Hemoragiaintraparenchimatoasa
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Hemoragia intraparenchimatoasa
Incidenţa: 11-23 cazuri/100 000 loc Reprezinta 20% din totalul AVC. Fiziopatologie. ruptură vasculară. diapedeză, adică trecerea eleentelor !i"urate ale s#n"elui prinperetele alterat al vasului:
$n troo!leite $n cazul trans!orării &eora"ice al AVC isc&eice.
Etiologie. icroan"iopatia
secundară '(A ai ales an"iopatia ailoidă
)AV trataente antitrootice, tulurări de coa"ulare.
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Alte cauze ale hemoragiilorintracerebrale *euceii (&roocitopenie Coa"ulare intravasculara diseinata
+oliciteia 'eo!ilia 'ipoprotroineia A!irino"eneia oala Von illerand Aneia !alci!ora (rataente antia"e"ante, anticoa"ulante, troolitice
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Clasificarea hemoragiilorintracerebrale
Profunde: a!ectează capsula internă, nucleii striai, talausul. Cea ai !recventă cauză este '(A. n cazul s#n"erărilor de ari diensiuni s#n"ele poate
pătrunde $n ventriculii laterali: inundare ventriculară. Lobare: s#n"erarea se produce la nivelul sustanei ale a
eis!erelor cererale ,+,(,. Cauzele sunt: )AV, an"iopatia ailoidă. n cazul unor cantităi ari de s#n"e, acesta se
eteriorizează $n spaiul suara&noidian.
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Aspectul clinic al hemoragiilorintracerebrale
ene de &ipertensiune intracraniană 4'5C6 ce!aleea, vărsăturile
ene de su!erină !ocala neurolo"ică.
aseănătoare celor din AVC isc&eice, dar sindroaelevasculare sunt ai puin ine conturate, teritoriile vascularene!iind stric respectate ca $n AVC isc&eic.
e conturează clar sindroul de eis!er doinant,nedoinant, cereelos, sindroae alterne, etc.
tarea "enerală a pacienilor este ai des alterată (ulurările de con7tienă sunt ai !recvente.
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Eplor!rile paraclinice
8ainările ia"istice C( 7i )R5 seutilizează ca 7i $n cazul AVC isc&eice
Acestea arată localizarea, natura 7i $ntinderea leziunii, precu si edeulperilezional, e!ectul de asă, !enoenele dean"a9are.
neori su"erează 7i evideniază prezenaunor anoalii vasculare.
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Angiopatie amiloida
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;ia"nostic:
instalarea ruscă a unor sene de su!erină !ocalăneurolo"ică $nsoite de !enoene de '5C su"ereazăo &eora"ie intracererală
;ia"nosticul treuie con!irat prin C( 8!ectuarea +* nu poate elucida dia"nosticul 7i este
c&iar contraindicată, put#nd precipita !enoenele dean"a9are din cauza '5C.
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"ratament nespecific
)ăsurile nespeci!ice sunt acelea7i ca 7i $ncazul AVC isc&eice, privind onitorizarea
(A, teperaturii, !unciilor &eodinaice,ec&ilirului &idroelectrolitic;epletive )anitol 20% iniial 1"/<" corp, apoi 2=-=0 " la
!iecare 3-> ore, $n priele =-> zile, dar trataentuldepletiv se poate prelun"i 10-1? zile e evită corticosteroizii
Antial"ice: al"ocalin, paracetaol Antieetice: etoclopraid
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"ratament nespecific
(A e scade, ca 7i $n cazul AVC isc&eice doar dacă
depă7e7te valorile de autore"lare a circulaiei cererale4 peste 220 '" aia6, iar scăderea se !ace lent
e utilizeaza: 58C, diuretice, sartani, locani ai canalelorde calciu, etalocante, (A va !i eninută su 1@0 '"
(rataentul crizelor se !ace cu ;iazepa sauenitoin 5V, urate de Caraazepin sau
*evetiraceta +
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E#olutia hemoragiilorcerebrale
'eora"iile intracererale au $n "eneralevoluie rezervata/"rava
)ortalitatea este de =0-@0%Cele ai ulte decese au loc $n priele 2?-D2
ore de la deut 7i se produc prin !enoene dean"a9are
;ecesele ai tardive se produc princoplicaii: in!ecii, troo!leite 7i prinrecidive &eora"ice.
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"romboflebitele cerebrale
u!erinte severe)or!opatolo"ic: in!arcte cu tran!orare
&eora"ica)ult ai rare decat in!arctele arterialeraportul in!arcte venoase/arterialeE1/>2
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$orbiditate% mortalitate
)ortalitate 13,@-?@% in cazurile netratate D% or in !aza acuta
1% or in cursul priului an dupa (C =F% dezvolta eveniente trootice
ulterioare
10% au crize 11% au ce!alee severa
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Etape
aza de trooza venoasa aza de in!arct venos
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&emne clinice
Ce!aleeene de su!erinta !ocala neurolo"ica
Alterarea starii de constientaCrize epileptice !ocalizate sau "eneralizate
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Cefaleea
8ste un sipto a9or Caractere: 5n od oisnuit apare cu cateva zile/saptaani
inainte de alte sene neurolo"ice Apare ca sipto in '5C +oate !i sin"urul sipto
neori poate !i rutal instalata, ieaza 'A
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&emne de suferinta focalaneurologica
enele neurolo"ice staileene neurolo"ice cu caracter !luctuant,
ieaza A5(
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Alte semne clinice
Alterarea starii de constienta : sonolenta-coa
Crize epileptice !ocalizate sau "eneralizate4!recvete in troo!leitele venelorsuper!iciale si ale sinusurilor venoasecererale6
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Cauze
(roo!ilii con"enitaletari protrootice doandite: sarcina,
des&idratare, tuori ali"nr, etc 5n!ectii: otita, enin"ita, in!ectii sisteiceoli in!laatorii: sarcoidoza, *8;, e&cet, etcoli &eatolo"ice: leuceii, policiteia,
aneii, troociteii (rauatise: trauatise cererale, +*,
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Analize
8ainari ia"istice: C( 5n!arctul nu respecta teritoriul arterial cunoscut
)R5 *ipeste !luul venos noral 8videntiaza !oarte ine sinusurile venose
Analize de laorator: ;-dier, coa"ulo"raa,sdr. AA+*, proteina , proteina C, etc
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C"
5n!arctul nu corespunde unui teritoriu arterial 5n asenta trans!orarii &eora"ice este
di!icil de sustinut d" Arata alte conditii patolo"ice su9acente:
epie sudural, tuorienul delta la eainarea cu contrast
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"ratament
Anticoa"ulare, c&iar daca eiste trans!orare&eora"ica: 'eparina urata de antivitaine cel putin > luni
(rataent depletiv: )anitol (rataent antiepileptic: Caraaazepin,
;iazepa
(rataent antiiotic (rataentul eventualelor conditii patolo"ice
su9acente
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Hemoragii posttraumatice
'A'eatoul sudural
'eatoul epidural
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Hematomul subdural
'eora"ie in spatiul dintre dura ater siara&noida
Cauze: trauatise G se rup vase venoase;oi tipi: )oentul (CC cu ruptura vasculara )oentul senelor clinice
ituatii clinice: 'eato sudural acut: 'eatoul sudural cronic
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Hematomul subdural acut
(CC severe Acuulare rapida, asiva a san"elui in
spatiul suara&noidian;eteriorare rapida a starii neurolo"ice
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Hematomul subdural cronic
8ste aspectul clasic (rauatise inie, adeseori neluate in seaa, uitate recvente la atrani, alcoolici
Acuulare lenta a san"elui, iiitie ene clinice: (ulurari de coportaent Alterarea starii de constienta, stare con!uzionale Ce!alee ene de su!erinta !ocala neurolo"ica Crize de epilepsie
Hematomul subdural
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Hematomul subdural'diagnostic
H ;ia"nostic la care treuie sa te "andestiHHH Aspect clinic
+ersoane susceptiile Alcoolici +ersoane in varsta +acienti in trataent anticoa"ulant sau cu
tulurari de coa"ulare8aen C(: aspect de lentila plan-convea
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Hematom subdural
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Hematom subdural
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Hematoame subdurale
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Hematomul epidural
an"ele este prezent in spatiul dintre dura atersi periost
Apare si la nivelul coloanei verteraleCauze: (rauatice G cel ai !recvent pontane: tulurari de coa"ulare, oli &eatolo"ice
e rup vase arteriale cel ai !recvent, dar sivenoaseC(: aspect de lentila iconvea
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Hematom epidural
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"ratament
C&irur"ical (rataentul crizelor
(rataent siptoatic
