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BEMIOLOSI-N NEU ROLOGICA

PRETATA
Probleme d,e cl,iagnosti,c topograJic pi. etiopatogenie Ln: l,eziunile nerailor cranieni,, paralizii, tulburdri d,e tonus muscul,ar,, ataaii,, migadri inoolunlare, lulburdri de sensibilitate,tindroame algiae, tulbnnd,ri troJice, agnoeii, aJazii,, apraoii, tulburd,ri de conptiittld, gi gtsihoorganice,

pa Pd,rereanoastrd, baza,td o eaperienld,6nd,elunltatd' estacd orice semiologied,i.norice domeni.umedical rute bi,nauenitd, iar d,u1td,apari,l,ia sa se {Lftee?tii cu erd,bilare aind, o akd, semiologie cu acela,siproJil. sd, Orice semiologiepoale li a4tusd, 4,tr, mriate feluri. pi. cste ind,epend,entd altarilia ao , nui a tratatalor iJe ile aul,a7i, profil. Deoarece 4n literaturt med,icald,uniwrrald, sdrtl d,estul de pwline semiologii - noi ored,em ritr sl,nt mai. d,i.ficil de sois d,eaiturl tra,tat - e bine a w scrie cl.tr rnai. rnult, cd,ci fiecare clinician, d,apd, rtttt4tcytf,ia enperi,enla3&, o Da scrie nntr-un alt mod Si d( {ltnd,ire. Nu trabuie sd, surprindd, pe nimeni, apari,tia ce uoe ci $emiologii. Neurologice, d,ugtd, dtrinele librdrii.l,or au odzut 4n acapti.ultimi d,oi.ani llratatwl nostru d,oN ettrologlienn cinci uolurne. Aceastd,carte a noaatrd pinq da.fapl, sd, umple un gol e*istent:l,n aetiaitatea th pi au pi o, nxed,ieilorneurologi,. neu,rochirurgi ',,si okiat da fl,l,tespecia,litd'li, medicind' generald, inler,niil,il o,tt,alte cuvi,nte oricd,rui' clinici'an ind'iferent d,e ptojill yeaum Fi tn a,ctiDitatea,d'in 4nad!'d,m'i'ntuluniacfd'l/j.r pi !)ostuniaersitrar'Ne-anz gtropus sd aborddm, mai practicd'., o ln pogini,l,o o,oestea, alNd'morl'al,i'tata, itre nai qfioCan'ld,, anpunere a rnatari('lul,ui serniologic, ?lrrnlnil da I,a dmptomul' iaolal, tau tn' conteatul.rnai hrg pl alungtnd La boald, In nocaato oonstd'noulalao,. ll - ortdql|n nod - nli0l6tNta odrlii nonntre, 0iti'lortt'1,

,t)u, putoa, ila lnltlni toala noilalitd,l'il'a bnbinnra n ll,nt. ila o Tttomotror,sinl,aal, ternneou lllo diagnottia, oara d,a diann,orfliad, td-l orientezainreiliat 4,ntr"o ileci,zi,e l,arapuulicd' atlcc' [nlr-o atitud'i'ne urgenld pi,,itnTtldoit, I'n tatd. XmTinim, grrin munco d'epusd' sistamatizarea praat'ied' dndalungatd' a,castui, material cara refleotd,o tra patul bolnamr,lui, 4,ntr- asid'ud, actioi,tafiaalinicdl o un d,eaidaat major, dltctatrd'e misiwnea med'isttlu'i cd' practiciatt,: ajulorarea bol,naawlui. Nd'd'd,iilui'm aom Jace wtili nobi'lei' sarai,ni' prin acea,std, carte ne med'ical,d, tn cnrene std, fald,, 4n sistemulnou d'ed'sistenld' patria noastrd,. d,i.n
AAIORII

CUPNI,NB
l. lrlr|durnto cioslonl h l, ln)lrlnmc di dloUnostlc topogrnllc tl etloPAtogonlo lezl[Dlle ncrvll'ol lr.rtologldPercchli I . :t,1. t.t, l,utologl{ Pclechil a II-a " ' " ' r " l.ll, l:robl0nlo dc diagno6tic ln exottalmii ' ' ' Itrottlor ) dc dlagnostic tn patologie sistemelor oculo otorii ' l.l. l.h, Prohlorno de dlagnostlc lr! patologia nelvului trigemen Li lrroblGt o dc diag:nostic ld patologiA nervului laeial (cochlear) ' ' ' L?. lintltlnnrc de diagnostic in patologia nervului scustic g,l, t robklrno do diagnosttc tn patotogis slctomului vestibular t,g, l1$ltonrc dc dlagnostic in patologia nervulul Slorofaringian ' ' ' ' ' l.ltl, I'robl no dc diagno8tic ln patologia nrvulul pneumogastric ' ' ' ' l,ll. lrobl' rtr de di{gnostic ln patologia nexvului spinal Lll. t|rot,l(uc dc diagnostic tn patologia nervului hipoglos paraliziilo! rnultiple ale nervlor 'J,lil, lrro}|lrnrc do diagnostic in patologia r'flrrlr!rl bulbari l, }ltrtlrtlr do dlo0trostlc In parallzti ll,l, llrDlofltrcu scnlologic{ a delicitelor motolil 11,2,ltllnrh0roo t0lsclor pareze sau Paralizll !l,il, I'rohl{ttlo do dlognostic etiologic ai topograllc ln divo$e pamli'ii ' ' '

0 t0 TO t6 g? 40 78 84 92 0tt 11r 116 t 18 [10 721 183 13S 194 19t 168 i08 170 r80 180 [81

h L Fmlhrnr dn dlo0nostle tulhurirlle tonusulul mu6euhl

a,l, llholonlllo musaulare . a,t, lllDfrtorllo mucoulqre . do dlo0trostlc h ottrxll l, litltenl$ ll,l, FrobLrrno do mctodologie seiniologica }1, PmllloDro do dlegnostic etioDatogonlc ti topogratic tEvohtlt[lr ao ilhgnorilo tn semlolo0la ml|oitllof l, ltrotlmr

' '

'

' ' '

||l, !llDrrlhrorlllc 1,9, l)lrtonlllo l.S,0onvul.tllo l, ?nltror dr dle0Do.tlo h tolburlrllc do i'rtlb lrob do t,t. nloonundlrl mctodoloSlao sandologlo ?,3. Froblomo d0 dlsgno0tlctopogtqllc $ otlopqtogenlc' ?,!1.Froblono do dlngnoltlcottologlotn dlvo!'so ilndtoamc atglco ' ' ' ' ' l trulhur do lth0Do.tl0 tn iuuurtrlllc troll0o do orhhr lirlor|' t,i, ?ulbt|rdrl trotloo alo plolll, al6 frnelclor $ ilo lo'uturllor $ol ' ' ' ' l.!. T lburirl tt0tlor orteo0rtrlcuhr! l tl. Tdb$rirl trollco nrurol|lo$

101 191 100 ,08 210 t10 ,16 It6 246 ,46 !{t t02

9 . l "o l, lonrn

dth x,^ti. 'tn 11.l. A gln)z ii l r l . r r c t i t o l ).:1 . t J noz i i i c v i z u a l c :r.;J . glloz ii L ! : r u ( i i t i \ c

I n r r 0 r ,o ztl

270 27(t 275 276 2'.19 2',7 S 275

siurbolurilor

l )..1 .A t jnoz ii l e i n l a g i n i l o r . c o r p o r a lc I0. l|rubll.|Do dc diagnostic in tulburdlite d0 vorbiro gi lD afrzil t().1. c t ls iiica r c a t u l b u r : i r i l o r d e vo r b ir c Io.:1. ' l Ulbrr f i r i r i i r ] t r c p l i c i , r, . r L.rlc

1O.2.l ulbur.;iriale rnrisiunii si arliculirii cuvintelor

co n r p r r jh cDsiu n ii,Io r Dr u tir ii

si rfxp}esici

I t. |||rttrnr(! dr,d i l , D o s l i c i t l l r pr a \ii

l l .l . I )f f i| lit i i I 1.2. l, l\ iur)cn u l l l p r a r i i i l o i . . l l .:1 . lirrJ l, l(. r l i i c c . . t 1 c a p l ,a r iir i l i: . Prrbleln( rlr { l i r l l n o r t i ( i n l u tb u r ir ile ite co n lti( a ti ( r u n o stilr i) l :1 .1. l, rir)ril) i j l f r n f i { ) l t o t o p i { r csr r r io to g ice J d e d ia g u o stic e tio lo g i c si topogr:rti c I il. l i rl b ur' t iri t )ri h o r , r r f t r i . r , . l | r t , ( l 1 r i ! ( i e l e z i u r i ir 1 n u clcii b a za li l i l .i l . s ; ndr. )u r r x , ( h t c c l r l L : ziu n i co r ticu ic I:1 ..1.SiI (lrrJ l l r c i h t f r t r j c z i rn j d ilu zu l :l .l ). l. iiudroa n r c ( t l t c ( l r l o z i ur i situ ste D .\,.r r ia tc e tr jc lll]..i . Sirx lro :1.:J :1,,,1",

282

1.INTRODUCERE

295 ;J02 J02 315 :\,17 3.19 :i51 352

,' (tiro.lr ieziunitc p,,";", *.,1r...;";.; ,tiIl *u.,,,*,,,,i., ,,""0l"i

' ,r rr i rl r,r' r l rtl l rIrv l Ii , i tr:ri l l0 r lf 1t r lt lc, isc vlt , 1: kt o t t t r t r xit r t t r , t t llit t i0 trl r i . trl r r,rrrr ci ti 0 i tr rrui srrt ir $ii, ( xi( 't t l. ( r zt . 0lir r it . iir r rlr l gr |lt ir r t , r . sl, i1xr ', t,rl rtl r' r | | III:| (,Ii | | i ru.t.l rrrr l tr' l rtrit . r r f r . r r lt I t lr . .

Penlru a veni in spdjinul rnedicului practician neurolog ll, llll llrr)plfssii scriem I en?,iologie neurologicdd,eurgenlii, itt <:lra ^ceasita rl'r rrrr .r rrrr prezenti,m in mod analitic ttiversele semne subiective ;i ,,r'r,, tr\ r.ir, numeroaselesemiologii clasice,ci sd,sugeri,m qi si, coltil_ irr '.. r rrrr rrrrrIIr1,IlIl posibilit5,ti diagnostice sindromatice qi de boa,li,,porninri ,lr lr , rrrr.lrrqirrelementarS, cu alte cuvinte Sd,potnim de ln sint|tltrnt, ,l | ,rlrr'., rr ll, boaliirla diagnosticul neurologic, care si, perrlliijti iur(r(lirLl rillrr,.r rrrrr.i rr,iil,rrdini practice,de urgentf. .Irebuie sd pornirn dc la irlrtlr, r.r ,lr,,"r', lrrrrl nelrrologic necesitd,cunoa$tereaunei semiologii prlcisr., r r I rr.,, ,r urrli discipline aproapo matematice. r, | | , lr,,, I rrrl,ua5, metodele paraclinice modeme de rrrin,cDrrrcrzrc L| ,r, clasici, $i cea inrlrogii(ilir ' rr ''rli ll[ {iaele (electloencef:}lografia , rl,, 1,"1, rrrri dc informatici, scintigrafia cereblali,, ecoenctl lonr.rr ri I.irr, rr , rl' rr\ , rligal,ii ultlasonice, angiografia celebrald,, studiul cfixrirrlrri lr,,t,t,l,', lrrr'rrrnot'ncefalografia clasici ii frac.fionatl, angiogll,{irrspi,r ,l , , l,, lrorrriogllfi:r cu rirultrplelesale adjuvante, elcctrodiagloslilrrl rlr lrrrrrrlr,r'r'ri dctec!ie si indeosebielcganta,miri{ica, spcctacuLlltsr rlo r,,r,,'j,r.,trirr,irrli rornputelizat:'iau liirgit considerabil cimpll ilc inrros ) lt1, 1,, ,,, ,i rt(,l[]gio fi in neurochir.urgie. toa,1e Cu &coste&, c)itl,it iuitr.it, ot,(,I lr,r rrr lr.rlrrr(i;i plccizie nu pot sd,,,dctrongzs', exandlul clinic, rr rli,rrti ,r,,,,,r, rr rr:rr'irilrrlri, fine{.etlebuirr si, rliri jcze al,it indic:r,{iilo nr.l,,rlolrr lniti SuS, fi iusta,it)tofpr.cltt,c cer'C0t?il,ii ciii l', ,, 1,||,.,, \ l)r'rio lt insirr.rrrr0n I lr ' 1,r i, ((( l{,{ i.rl(, rlcl(jdf, (:,t:Li;lrc,clitricianulntr ltolltc llpsi, rrl nrt rlin rll(xl(r.11, nioi |,,,r1r,lr ,,r'IrrrrirIrrL)' cinrliul rlr, ltrplli, trrtl,otlologic rlru: (xtlij{t)i')) rlr"r,iillrr nrol'odologill trr lrrrrl. lr rtlrxl0r'rrii. lr.olrrrir Nrr ',lirsrr,l,

l ' l l l tr' l i trtri i n.l l n.nrl t t tii ( r t t r lcot r lr i vir t lit 't ', t t t t t i r t lt 't i glilt it lr ') , r : it t l l " ,l I' rtrl rrr.r' rrrrvti l ,r' ol l rrc livo r t r , t t lr zit t t t i t ir t lt t cr , l: r I ilr '. llillt r t ir t , llt t o l trl rl ,r , .| | |r| | | | | r(' i I 11i l r, i tr[.r '( ii gct r ollt lo lt r r l, pt 'ot lt t r t 't ll ilr lt t t lt t t r il t t t r vtilr ' :rl r,l l ,r, l rrr 11/rrrr ruorri rrgor,r r r r r 'l: r lilr '. '1xr l, ir r lJlt r i t t t lt t it t gr t t 't t r r cf llilr ,( pt t t t t Sr l rrrl ,. l trl rr,r' rrrl rrrrsr' ,l rrtrl ilr ') , ( . 1( jr , f r r lif t \r , ir t t l'ict ', t t t ct t it t gilr r r r 1t ir I t r I I r icr '. l l l ' l ' trtttl ttl i sntr: (l ( t!l, r r t . il, ir lii t : t : lu. l, iorr:,,t t r livlr so I r t 'r t lizilr 'i r yi k' rtrrrr , l rr' l rrr rrr i rrl rrtrrl l rt r r :lr,illr t t t ir lci r ir zll( f , ( '( lt 't it ( tl, I lt t t r t r t lit u'illl zt r r r i r rl l ,r. l nr,, l l rrcl rrl i rrkr l l rtrr ci cit r t r t if ir r t , r lt noit lr t lui ( cu lt 'zilt r r t l f ikr t i'lr r l rl l r,,i rl t\ | | l r. | |(,| | r'()| | i | ()r' l xrlilit |'ici I i, ov( t r l, lliLl,ou sl|plit inr 'f l, t , ii st , ct t t t t lit lc lr osr C' PROBLEME DIAGNOSTIC DE TOPOGRAFICrt rr \ rl r. ,rIl ;rr.Ii vr' ). l Jrrcoli r urx) ntniilo po$t -i, : t um a l ioo pl) 1, t '( ! ( it t lloit I lt lr llovii, ur lr , bulllului t t lllt cl'iv r yi/ sr t , t t r1lrr l .rrrrrrl l rrrrrurrri l ctLl i , I ) lir ( 4. $I ETIOPATOGENIC iN LEZIUNILE rr Irl rrrIr'Ir.Ir,Iololluclivrr. AllcoI'i ba,ndelotcle ol1'active pot' Ii lozrr,l'oplitt NIiRVILOR CRANIENI l l r,,ru. pl rrl i ;ri Lr rni ci ul c slonojdului. Jlxist l sil, t t a{ii in t 'at t t r it t ot t t st t l it|"r Irl'.rr''r1ii rroU r'ochiru] gio c, ridicarca lobuluj frrrulal pttillo ltftrt'l,a I rrr t rrI r.Ir' I r.I r, rrllrrr,livtr, (iilro se atlal po l:a!a, inl:orioru'i, a, lobulni orbilrrr. A l l ,.,,rt, l rrrrrrurl i srrrcl c, dat li leziunilo vasculluc lot ir nt l'olr r lupl, ur N' Intlad,ucere, Fatoiogia nervilor cranieni este deosebit n'||r ,r lrrrrir 1r|rIicrrIrrIrrivnscular provcnilj diu artur:l oerobralil ruti;trl'ittit . I l't Irogu,l;ri, de rl,rial5,, atit stb proceselor morbide xesponsa ryi .aspeetul r rr r. r,r, rlr. r';i vrrscrrlrrtizeaziibulbul olfactiv (Dr*loix fi frilrtt'fla, 1l)l-;$, $t[r aslrcct,rrl contiguratiiloi ;i al contextelor patologice '.it, fi I l l ' rl l rl {, l \l rl r16r.scu, }?5) . 1l .\cr.irtrir,ir .\r:r.:r,:,t,ir, comploxitc,te patologict, de multe ori luxuriantx si, cler oomplo-xrrc,repatologrot, d.e multc luxuiianti, qi ' | ' rrrrrrrrrrIrrrrrrr' | c o-cer ebr alo pot ploduco r nosm ii, hiposnr ii, t l: r l (l(,1;{runrnatrr, dc o parte de pozilia strategic[ a nuolei]or de cl ani ,.,r1,'\ pe i rl Ir| | | | f trrr, r.rrr:ostrriS i ha luoina, lii olf aot ive. rr,u tlo 1;crminarein trunchiul cerebial ;i in iorma.tiunile l,r,l lrrrrl,. lr:rzci craniului artreneazl tlcstul ilrl frecvent hipo- srttr rulitoonto &cestora,
.l l l l rnl l rl l

porrl;o-ocrebelos, stlnca in rrtrr rorfiirnrgicalc.

2.1,PAT0L0GIA PERECHIItNERVUir t 0LFACTIV)

rrorrrolol;lo lrxt[ intogritatea neuronilor gi n ciilor ollaetivo, esto vorba dlrosrrrii rlo nnturd _rinolog,ied("Miloqescu,1925; Chusid, 19?0 ; Rir - Acestoa se caractorizoa,zd, llll"r9.;l'opoyiciu.Fi Pascu, 1.980), pril'anos

ll.l.l. tn prozonla unor disosmiila indivizi la caroun eorocr6xam

1,11111111111rr 11iN i ccol l i n i ( 1958, oit a, {, i dc }I iloqescu, 1975) a, u ar i, lt t l i,ll | | ||| i , | | I rI I t .rr r.rrlcfalopatiilor posttraumat'ico oonsecut'ivo ltziunilot'r'olt ' ItDl,,rllrl, 1rr,zrrrl:i in contextul clinic tulburlri scnzorialc, inclusiv aartsrnii 1rrr rrprti xi m at iv 10o/ o din t r aum at ism ele clllnio- cor ol) UlL' Ittul l t,rl rrrl rt, fl ' l r ' I l l i ,rl ,)ntl ttt r(l r:ul ur ( cer cbr a, Le leneazi, r ar 'eor i t ulbr t lir li r ) llir r ' ant \rrrrrrl r.i rrrrl rrrl rti ol cI ochzia pediculului vasculal pr ovollil, ( liI l l l tr, rttl r' rrr r, l l rl rl rr l rrl r,ri ol rl i , calo vascular izazi, bulbul olf llel iv ( I ) r xlloir tl l ,l l r, r, r, l l rl rH , (l i l rr{i rl e 1! liloqescu,1975) , poat e pr oduc{) r ln( , Blnjo. lll Itrh nrlo.t:iut.lii (cu atropirri,, cu rnodinX, cocainii, sulfutir, (l(' r,rrrfrrrrr,, r ) rir .!lri,.i/(rlostnarceXi,(e se pot flolda cu hipo- s:ru ltltostrtii
| | rl l l ,l l "r il

""""ir ' if r fil,.rdsT .#. H' J,T,ii ll'i; .t ;j"i'.]t-i"i#.i: iii;, intorvenfii ohirurgicalo poii.'# supeiior iazal qi pe sinii j) sl;il,r'i.dupl, rvellrr o,orruJgrcatopo etajul
nrrr.i rr) fiuli ; l() ; diverso dorssH,ri respiratorii. dorogld,ri resDiratorii.
produse prin aleetarea neuronilor ollaotivi gi a . 2:1,2, Disosmii ollnctivo. ?.1.2.1:.Dieosmia (anosmi a, hiposmia gi eaentualparovnio), ituttalowd, brutal y.i astaJi9 un ilaturAld, Jie'ile obicei bilaterald,'ie nrtgr,r:lrrlt rrill.oi r,r'rrlrr lr,tor.!iuni: ltl

pozo (t:ol rn&l &desea inJectate) : d) de;viatii de scrt: c't rinite acuto pozo (r:ol mir,i &desea infectato); cl) devialii rlo Bept i e) rinifa'c.i rdectato); deviarii do l,llzo (oot mir,i orouitlrl do divorse naturi I f). ozen*.; g) reactii alergice uazalo; h) tum

ryi hiJrosrnlirespiratorii (unilaterale sau bilatralo) provoctto ale rori,at|, e ra. impioclici accesul curentului respirator-la zona olfactivtr l,) rtonozoii sinoohiinaza,le;b) hipertrofii ale cornotolornazaloi o)

:' | 'I' l)ivt:flttiu (unosmia, hiposm,iaFi eaenlual parosmia) cu,'inut : lntt' ltrti rt prr4tnwit:d. ridicii ulrrlitoarr:lc problomo ct'io-po,togonioo lll 'l'trll'tt,trt ,l.f,rt'titt ola-ziw ,,fiaiologice" Sunescenla po&tc 6it ror,, llrr,rr, lrrlr" r'lllr( (i$, i'ot|8('(ntivirprocoselor' fllnolico alo neuronilol olfa,o" lf vf ;l rrlr lrrrrlriurrilor rru,slom. Unele std'ri, Jiziologicelo femai (graoiili.uneo porturbtrr'i ln perccplia, milosurilor'. Itlrt ttun,,ftu::tl / rrrrlleneirzii, Fh I lrrnrttri, rlr, l)il(li, hi;xrrosntiir din primul tlimostru de gravidittttrl l,tllbull lrlpruurirrrlirr rr,lrloik,ir, al l,rcilll trimcstru, cu roverBibilita,totu 1i l{tlhr| ||ur(,1lr,r ollitrrtivl dtrprinrrqtr.nr, homopnl,iilo ff) l,nr,ll luli lynualt (r, (liab(ll,ul, ur'('mia,pa,ludiBInul, r)ouxmii c{,ilor olftrcl,ivo,pl'in (liYortt(, lIlr,]llr, lr,l/r'r.rriiq,u,.)1xrl,af,r'ct{t, r,rrrr.lltrt i Bllli(.icJlicl:r iclr l,(1, lrr,r,r||rlxn||', Iil f i) '/'r,,r rrv, llnrralt tatt, lrx,c&r.'ntorlilru, $l[l,ulnifinlul, llr,bngilnrul, n.rginl,, 0lonlrfl (lo zlhat, *lIrrltlIr, i(x I Ir, lt|r,nl(]lul,r'Itrldn , ritr'l|1ul(1(] rtrllurx ilr\ r.rflrrr, llrlirirr(,rr lor'irlil rlc solutii hi;roltonictr (clt.t'u 1lir. t:11 sr', |lllr,l|lrI r lllr ollirot ir'i). ll

.11 | I t,l t ,' , r' .l ltrr' " i ' l l ruttt,tl i ttnt ( r r u, t tio- t t n'ebt 'aht lxt zr t 'lo, I t 'lr lt lllLt l, t t t t t r t t - lt ilxt )rl tttrl trr Ii | ,,| l rl ' l ' | ,r rIr(' trc| IIt t,t' ). At t r int im , - r lr ' lt ikli1, r lis1t lut in l 1 t j " , 1t,nti t,nrl r' tti .Ia k: ; i r nt t it t , ,tl r' t,, r1,rttl ,rl t" ,' rrt,' i i i sttnl c: r zil t lr , 1t r , 1icin''t lt r t '1 it : i ( r ll hiDo- - sil'llil'lloil gt ,,, ,,,,,,,,, ,, ,,t , ti z,,ttno ir lt t t t l) qi st : r nr t t lr lt r ir r t a, nf ilisr r l t t il; ill ( Alvoolr ', ' ,i ,
lll , I l \l l l l l '.r, l l l {i l )).

trilltcratil. ardtatastletlerseniqi S-a is?ej;;, degi ant in rireningiormer;.1;,rul;i in "biffi, iitactiv, ;:,i':1:] liii:.1:il .:"T-1-q'iolippr z|'r(.rx|||lrlvu,)r'it,cerStii
"iii; nesemnificrti""'iri"itiil iirofla mucc ::l::lll:,:ci'l,rl,1.l,l9"qrglocale lli rr;rzrl' r,lt:.)rrkrcit;unei leziuni cerebrale
optici,, Deci, anosrnia'prerl .tumola $i nrltir j.rr orolusivii, u _de o parte, qi coincizind cu alie'se;ne tumo :rlr' (| lt)irit vil|ra,r'e diagnostici'in meningioa-"rc (f ofircli"". A rrrrv 1l;1111111 arteri, ca?otidd intein-d,, osteomul frontal, de giotrtttl sttlltilsclitt. ijDmorilc r'la ,r.r'in;. mi.; sulrrrsr'lirr,tumorile de adpd, micd ,lj sfenoiA unele l.lr{'rr,r||l cle "i^;:ri;,;:^'^ tumori si rlf ) rrrlf l. l.l ln)L (t(,Lermina tulburdrt-unilaleraleale mirosului, cu -. deoset

:rrkrsoir bollavul se prezinti, Ia medic aor" .to""isau se il rifilr'i, cofi ce,aqi_tulburirile ocolare *sociat!;;;;ifi "i"dliur ifii*roi, , ou rk'.jrr, l)r:.rrrrrllc.ori, cin<Icstc recunoscuti, .1"
dcville sesizabili,doar atunCi cind este bilatr

,,,(r(. .i,u N,H lbu;x;i, i ti"t-iii^ t li,ii?':ri:"if ff,.f rifi T1,,T*1ilT%11

p;;i;;t]-, Ja'este atritr

poale F;;;l{";;;d;;';;;ii,fi :i:,::l1ll1l,t..lll],'l,t:i: insoliun sinaroi" ir(fr.r'rf pl t t,c cu r cu atrofia

acoroa ci, ;i it;.;,,';r;i se* l:,rtir, uv!.ritrj. (Ars.ni 5i cohb., .19?J).' ;";;;i; d]J"rlrnn,oe '

r:rlus,.t'.r'aniofaringioimele, -jt?.,1"jumoriie g[oambte;;"r"r;i-;fi1" "on gtioamaeEentrale rol"i"t "i"ontJi pragur t .r" ::)-1;li,lil,?"9"_:,-11 multd, rionnal vreme,ir" ,l"ll,Jg ri"lmin:i t, esturare Inl,iluitri,1,lnliv. .h rr,prorpc treime'din ;;;;'.;;hJta o ;-;;l;gr";;;il aripii mici rli.rroirhtlui,
r{o pl'o(Illeo tnrUrl (, crc}l,oro pragului. olfactiv, res so pt'orlucc in-itria,lo crcgtoro a prag"utul. olfacnv. resnec r i [(r(]{rrl r'l |:I r1r ir,rrlrrsr.lii .llrrr.l.ivrr rl{.st:rl I irziu sr,insbal,ltiiirrt Fi rlc iJrsilnl'rrriuhL r,urrrorii(ltisrrr, lr)fir).'Arsrni r'i ,r,riiii. ir.9i]lj-rorl,r,rrl,z{,
l"rt.. '

sibi.tatel ::,ll:il,: lgE:,1i-rrtolie.(Arseni s. p.l, irrlilrri in meningioame bffactivJ giganiq ql d" in "ri6'r" ""ii"a !i l:::: lllll,-itt t umori hilofizare expansivZ in iiO_"oc"rariic" jArsen.i iota'b,-1'erz).-iiu-u,i'i''au.i,I qi -""e ur :::i.T::lll: iillill"Jl,lie:lii I precoce cursulmeningioamelor y:: in :ll.:1.,.':' i":.i::-?lli anosmiei iltrlorior, in vreme ce aceastae-st" *ai u"ri" iffia1i oe cetre it -u1t rruruilro"iif ii nr" l:liillj,, .":emptu .neorgmaliunte "fr'

corab., isii,lsd)."-;;rmii

lll l trl l ,rrtrrri Trsi l ti t:a nt vnlzt r , llsilt r r zt r ' Anosr ni: l isl'cIioli, t lr r . pilt lii, " ' ,, i i ,,' 1,' ,r,, ,r' l rrrrri bi rt c 4in4 bolir a'r t r lt r i sil r r t ir oa's. ilr nt t t t iit 't r As1'li'1, ' ", kr r|| r,r,l,r, ,l, r 1'r |z ir rl ri Rl lt,rltl nazo-lacrirnnl (pl'in stimultrtn' trigtrtntltlttltti.t r nir osul, t lcr yi liicr it t t Irr t 'a' lkl it i ,l tr, ,rrl ,, l i rrl :, i l i ttrrri ri ), lur lecr noa, , st c l i r r rl { .trl ri (,,\r' soniqi co1ab. , : 11) 77) l .rl r' ' txtrlttrttt'l ud'i'tr(t. cura intereseazd'ratlialiile ^olf l \l lttttt t'lr l)t t)11'!)o .8tt'11' r:rrcl l tl i l e, t r aur nat ism e oi; t l') nu - sinl. inso{'it o nir r t ot lr r 'l'r i rrl l r| , i l trrrrr,rrr, irr crtzurile de kviuni llill,t'cI illo, hlttttttrtrtt-trxplitrlt'ltil tl tt rrl'' ,' ,,,,,, ,1,, 't , jiilol intracu eblale (Alscni qi colil'b', l1)?7) Itt ,,,, , ,,, ,, .rtstt t lr bilat cr alo, st l llt t llt c t lt ) r ) 's1'l[ i'irt lt t ' t t t lit t t i, i ' r,' r' r' rl :rl ,' trtl sr r , lL i i i r" , ' I lt ir l) ,,i ,,,r, ,, ' , rrrl r(rr ,,l l l roi i vtr qi, dc ur ul1, cr lr i, lcnom cnc do, t ll! {l}ozio il t\r,, rrr .r l ol rl b., 1 977) ' "lllt clplcitir,{ii olll'ctivc) sc i'r.tl'illrclkrtl|slttl l,l l. llll,'r'tl"rrri (or'o$tercil, la subcr , 1. 2. 1. 2. ' c1- oxc. . p[ ; iit 'it 'f r xr f it t t t il't tl t, r.i r,, ,t,i l rrtri l . rri rri niit e Hiper osm il por r . ' si. r cllizt 'zr '. r r lr {{'t i r ' [ or 'r r r il i l " rf,r' , ,," , r,,.' , , l ,,rrl rozr') . l , l ,1, ,,t,, tr,,' . r i "t . lodit ) t i", r r r ( ' so illLillr c: l{' lll ll( 'lllir sl. lll( l' ;' ,fr' r "ll I' t i ,,,,,, ,,, , .,r 1,,l N rt| i l ri i ' in'cur sul l1r sS, t ur ilor gr avit lit xl, l'l t r ovt r 4}t '{i llll ' r ai t,, ,,,' ,, t,' l r\r1r ..rIrItrt| | :|I i. Alt ( 'u1i, ll ipet 'ost tiit ' si' pr r r t l. llsr ) ci: t cll (.rr li. n, nlcuu r Jo hipr . r r . r t it r lr ililr t ic l r ig( 'lr r ir r r r Jir lr i ,' ,,i u,r' ,,1, ,r rr.rr.;rl r. 1\i l t Il \| tt.,, rrcrr, l l l ?Ii ). l l l Il t lt l r. trr,l Ii i rr lihr it r : qi ir r ur r elc cazur i do opil( , , psio, t t t lt olo l l l rrl rU r ,,I , ,, , r:r| | ;,, , r,tl .l )t : r lr . ,ir r I ir zr . lt ' dt . t lt br Ll. : ll' llllt , r lullll) l i ( r 'l{' | | || || | | , ,, | | in- m ig- ur t o r yiit r un. lt r slit 'r i i ,tntu, ,,, l rrl rr,rl r.,i rl i srrr,i rr piu, , lizi. gr r olalll,

1{)52)' 1$75; ll'isot'' i1)7?;l\lilorycscu, ri iiir,ili" ,,\i,,r'rrr ,,,trrir.,

lrit, lf I l, I'r||.orrrriilr. rirrl, rlisosrnii 0i|-0 cuttstittt lu irtl,erplotit,t ilrrtttlt,l,r'

t l l l r l r l l r , l l l l l l 'l vi tr i :l l r i l tr ' l tr t'i l l r l r l r l 'r l fl r ti i l {) l r ti tr t l i l u l r ' I l t , t t r I r r r | 'r t r {r 'l l ' t l r r r t p l tl i l i l t'r r r r l csl r ' r 'l i rr l :tto g t'tl i l r : ;i to p ttg t'l r l i txr ; l t l r r r l r , t ' r l , l , r ', 'r , , , ' t 'r , t 'i l i l i i 1 i ,t t I I l'rtttttntiilr lnttrtlt, nt d,otul'tt'flIrur timTtlii tt' nt'itttttrri'l,lt': l) )ll lllr,,. ll tlr' Ir,l ', , r r r | / r f t t l t 't l i t \ ': g t'r r vi tl i l :t'l c. sl i l r i r l tl l ttr ttttr ttl t'j 1 l l ( r vl o u ( '; l ) si l l o '( \; t t t t t t t t t , l t:ti h i t ll,,lt " rrrtllltrr' 1iI trltIt|ii. 1, r r n o t' tttu l i u tu tt:ttl r : ( I r t r I i 1ri t i t t i i , l l l !1 r r l 'l l l l 'i \ u l n i u i t t l ti t'i i l r t , 't t t t u l r;t rlr rrttll llt").

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ll.l.5. Ilalucinaliile ;i iluziile olfaetive paroxistiee

,,,,,,,!,:,1,,,0;o;,fl{tffi ?lffi&:"\':2i1.-peroeperea.unorcu.rodsubir

sint de e1r'eprico J;1;''.f iii';,?':gi.uJ,"'1,.y:ioz rorme crize rr.r',', , ti,,.,rtr.'r i:eu(a.te,tr*i"i r io i i,i,, :i .f"ii r-r'r:" "G'td "#rezulta[ui'uiJr-. iiH,f r:; r.otab.,t9Z6). Reprezinrd. j, . :..::ll:i"',.' ;i ior"a"",i"i ir'||:rtr.
:rt( . r , ( , t l, . x ului r rn r.i n a t (c ri z e u n c i n a te ),

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r'Iptrrlt{\ o(lol:trll,ji ln oursul

:l:lil,'lli:,,11:;l';:ii-':;ilil;,'i"'t#iT[ll1'"u0"",i11Y,;m:.yffil"il ru: ji t "iT illr tl;iil* iti,s'#,tiliibili: qilfl',,i?.fl#,# :1,i rgiliid

rura c. li:Ii: (,lll;,i i :ll,'#i; r "t 1 ::,"ff:T,'* f + Il:i'iil' :J': ,11i;il;ti,i.'i;i''I:;.fff; #.it;;'";il:';;'ffi"f,1,",iii'161i,[ii;)r

;, $::fl ;: lili*riiiii rllTf;,], '}::: :l i:,r;l: :niis {l{,!,'ffi]ji,

{t'.'rl)$rrr{,r,,,'gimioi -a" r,: r-i.". p"[,"g;,Jfi ;*; .;i:;h#","r",ryHr ;ilffi 'sT, ;tl :i,'i'

u,nainate ,.. ...,:,.!:.!!:,! . lriret,c. unor ,,:::! Wr!ir|. Crizele epilepuce de care mj 'itzil lrntt lx.l.(,(,p{,jin srrrrrdrrr':,r,,,rr'i{,r([ rr/i ,i J"-"j:"'il'.j?tS^fl*:llfot slrt iare tz- rloTo

lt r or ulr t r l r r t 'izoi t t t t t : int ll, t r t lr r t t l, t t llt t t r r lr t r xl hr,l tv l xrrrl ,o l .i i nkrorri i rl orrlr r i( r l, it r r it lot l0pt 't r xiu, t lot t , t t xit r l, t t , l, oslt , t t dot t uf or i tx r' rl rrl rr..n{ ' " rrryl ,i i nt' ti 11"Lr.' ,Ir| .rrrIrrr,r), r $rr pol, lr r so{i r yi r lo sint lt t ot no r lir t st t r r ll ot r lit r 9i , , r r , liot,r{ (lo l,otrtrt,l,ixtrto ltlt,Bl'itrlltit!, rlo sltliv:r,t'io, sitltltl,tlttttt viutlrtrttltlFltrrt." (rr,tt q*rtrlllri' r,ri/Hir,ttiscrrt'oIti, tnol,orii) ( I'rrssotttt,l 1.002; l'olxlvioit tii collr,b., v cil, l ttl rt l ,l rl o i rrrl xrhr,trLxi i rr r {, inr r t t t it t upr t t xilnt d; iv f ioJ[ t lin c1[ r lt t i o{islilt r rt r rr * nn. i ,.r,' rl rr IrrrItrci tur,t,i ilt aol, ivr r 1igt t sLlt l; ivc( [ 'r t ssou: r r t t ,11102) , llt ilnt r lo liilrl, rl,, rrrrr,rrrrrrrrrrr, rl tullgt'ott,ltilo,txrhr tttluitr t;ipuri tlo ttxprcsii otil;ico strn, it rrrrt,rl r ;r.trrrrrlH ri sr. rurtttl l lt i, ozo t oxpr csill lor ( Pr lpovir r it t qi lllt sr r t t ' 19t 10) rtd rrrr rrrl.rrrr,rl(l rslrrI{rn{ll, ri1,,,lillsl" porcopfio ol{llcl,ivir,polr,lo I'i itrso{,illi', r i hr psilt t t - sllnzot 'iit lt llr r l r ,,,1 ,1,, rrrrrru| rrr:rl ,:i;i rlo: r , lt o t ipt t t ir lo r n: r , nlit lg l'r 'i l tl r Ir,Irr' rrr:rIor (r i zrr:r1., : lur lit , ivc, Lr , t r ir inl, ico,sonr cst ozico) . I ln0lt r r 't izr r l rrl i ,r,l rr,, p,rl . rr:i , i rr i rrso{ rit ot lo , , st t nzr r t ; ii"soxt t llo, r nolgit xI pinll, llr o. lr r i!rl r t' ,ri rl i i (r\.j ttti rrgttttut l f i lt la, nc, ll) G l. ) . I 'lt ssouant ( l9t i2) N, PI '{{iizir l, rt rl rrrr ,l rl ' ri rrr rrrrrr| osi | l l t oil, ir nit osl, r ililol clinim llt r , , clizt li t llf lt cl; ivr r ": l ,rh,r l , r,, 1r(r' ol l rtcl ,i vi , ( hillt t cint 't ir t ' ol! r r r r l, ivii) st lr nt r t lo vis" sr l, t tt lr , L, r11,1' S r,,,rr,rl rzr,rr.. rr, l rvl tt t snt ipol; t zr t , ct i t t , t t lt olf : r , cl; ivii t lo Ll t lt r lt t t l, t t l rrrr' ' rrl l rl ,orr l i i d eclilnqllt il t l0, , t illencof alul olf a, cl; ivt ', t lllr t t ( r sl't r | tr.t ' r' ' l propir if onn ( ut r cus) , cl, r o t : st o lt r glt t . lt rI ct lt r lt l; or ii l ,l " ' .,,' l L' 1.rl l rror' l ,rrxrrl ( iloor r lll( il; ( tr,rtl ' rt,r ;' rrrr l rrrl l rrrl ol l rr , r . lbiv. 1[ r r cl] cr r n li ool&l) . r 1952; r I q' ,,,,rnri , tl tt;:;. l rr H ch ir nl) , r n*r lif ( ) st i, t 'ilc cor r t lt loxt r psihosor r zor ir|( i s( \ rlr,,l,rrr, r''r ,rrlrrlri,('ll propa,garotl d tlsciilcir,r'iilil ,,tinontlol'lllttl nttolllttrl,iv" | | r| ;r,l ,r,rIrr,,rrrt toprozi n t ii un vor it ilbil , , cl'oior t iut r t t cof l ir l", t r ot r slil't t ii; (cl rl l t trr r r,' rl r rrl rrl ,rrs r pa,rt c r eccpt or ic) [ i ( lir I ct t r lllr ] lui At nt r t on ( cll lllt r i'o r-l r{ ,1" lr' I t ,rrrrl rl .rrl ;rl r.rr, sorrti ologicl a t t lizoLt r t t t t t t inlt t t , r osput t , iv it t lt iclt t olr , sliillo", t t | ,I i I I | | ,, | ,| | | I | , | ( r'il,i(x) ?sihosenzorilllc cu forttttnonul de "{ll(rarny r.rr rr,rrr, r | ' :| | | r,Irl Ini ()i i ,, , ilt r ocut uluit ', ct t r ca, cliilo t t r no! , iolt t t 'loyi t lt r i, r r I r l rl r,rrl l , ;,,rr,' i rrl i cc i rl o ,,oonf lt iiDl, oit teului, st t pot inf clego f olt . t , t r lr ilt r r rlHi.it llrrr'nr r.rrtir, (lo contploxitatell func{iilor dtl intcgt':rrtl alc ,,tirttltttrtrlit Irrl l l rr, , ' | | r, I rr ' ' , rl sprrtrliv t lc r olul jucir , l; r lo I t ipoc: lr r t 1 li I or r nil( it t I t ilt t ' rr r r r rr 'rl,i rrr:rr r,irrirnrv{tlntii lirnbicc in exprcsia tnto{ion:llii, [i lrl rrttlo(l{} rl l rl trrr" rrrr.IrrrrIrrrrr.IoI rr tt t om ot ie, in 1ix: lr ca, t lalt lot r nnt r zir lt r ,in r r r gllt t!,{ nlr|| tli,r 'lr, v(.glro rii tlt: somn, procurn Di in lcgl:r,rcJ'viscorall qi soxualil, l l ' or' ,r' rr,,r' t, tl rr;' -t (l l ' )" r' , l06l; O r r , dillt t or ) i colr b. , 1962; St 'gcr qi colillt . , i l l tl tt 1 1,,1' ,' rrl i rr ri i crrl rr , ll. ,1{) ?8) . rizoll'zi' prin ' I tt ,l t't it! r lltilc\tl,ioa ilttzi,on,ulc oL.Jacti'Da clr.N,cl,e Bn o r,l l rrr' l rvrr:rl l rrntt t . Ui lt t l st t ger t r it zt l, t lt lt t t liir calt tnt lulonillf i, N,( l( , t '' l + ' rr,,,11, l rl rl rrt ,rl l rr, l rr rpr.r' i fi c nlr t t t lin vt r r inii't at t , puf , lnd t aco par t o dit l <r t izr t , tl l l fl ,l l ' rl ,l (l l rrtrtrr l , l (17i3) tt |', I tttir'lr tpiloptice o$actitse ,,telflcna" ((lnstllut, 19?ii) sinl, orizrr yttitt rt'ltlitllrotl urrui 8t'irnul rllltctiv, tjrsp(to1,iv xfll|r1ltr r, rIr.r'Irrrrrlr|,rr 1tl'in' r t; frfrr,r. rl r' rrl ,;rl rrrrrcoux ci t ilzllkr . Act r st t t olizo Blnl;r t xt r or n t lo r lo( M ot lis, l l l l l I | ' ,,Ir' r' i l rrt ri i rxrl rrl r , , ll) 70; Sct vil r yl ur llt lt . , 1002i St 'oiulr l9( ilJ Fl thl l ,l r, ,\rrrr.rrr11i (xrl l l, l) . , ll) Tu) . ibttli a't (,,r1o inflttcrrl'ri'" ' I ft h Ntrr,lrtn'ul hnl'u,oirtuhr oronio ,y'la n,l,r rqrl ,rl , ' r( (l rrr\" ) (l ti sr' ,r, l{}li9) sr c: tt 'ltr llt tr izt r t lz; I pr it t l'r - o gl, llr ot lolit 'ir t r l'ii 'sl0 r 'onsl, ilt ti l, r l r li|l olt r r r t r r nf irlt illt t oit t it l'ot 'ii l l .tl t,rl t, ri , ,r. r' rl l r,i l (,nr1r l, iorr1, t' rrl l !i r,l l rr, l rr l r,r'r' r'i l i r' , rr,xplr iiv it t r t '[ it , t :r 'pir olt t lt r Lr l lt lllt t t : it lilkr r ii, lt olt t t lvii {llll ll( {'l( 't l l rl t,utl l r' ;t l rrrr,rl rrl rrri l o$| lt ilo, lt t t t t t xl ; t r t t r : ir1i t r t t lt t olit r t t lozilt t , lo, r rrrrr l r,rrrl l ot ,,rxl 'il" t 1i t lr ' , , ; r . t gt , r r t t I it r ". Ittl tl l
I It

14

lr rrrvcl l tl rl c i trl l rrtl i r, vi rsrrhr tr r , lt t t it 't t r ,it t t t clt ', I it t ll, lit r 'I t ilt llt I t I l, lr l i( 'ilr li'll l rr.rrrl u ,i rrfi trrl ronrttl l xxl tl i olm r t r lr l, r olr t t llr ir t '( t t r r lilit o; t i'ilr i't 'r 'lr olr t t llt lt l'I ) . dr A J I\pi l i tu. (si ttrl totttrtl t r t lt r iu jr t , r t lohr t lharsuu sindr ont . r t l. po. Tt ilo (r'ttt.lrinu.rtsulnrc'u,li) (llintrr, l115!; l\'llttrolcxrrtt, ll)fil{1 rliavrrostie rdinic' lopogruric .tiopatogenic n, ttili ttl,t1||,i0/ousti, si ,,,,',,i;;;l'rli;ll$;rlt' Hilu l)illlrfr'lllt si rrrrilizcltzi't,tta,t"r lrtlbtrrtit"i, lltilr lrzitr 1u,:rlrrfi t.ttrilitt,tuirl?i rrrl " i trl l urrtatori j < l e tu,vtill, in1t , r 's1, if ial1' t xllr hullr lr r 'li, : r t ) Ar r t t ilit lt 'ir it uizuote pot exprimain urmatoarete r r:rrrrrl sr:adetotdoaruta l ap it l, lt llt al, in cil, cva zilt : , ut t ilai. t 'lr t l, slt t l lr illt ii se l.r;rl (cga,l sau jnegal), pini lr o drarnntici arntntrozil; ll) (lirrrprrl vizrrrrl '11llll{ffiJi,Jcaititlii lll .4nbliopio lepl.czjntdtlimjnuarer acuitrilii trtt , rir. rlrr ollicei ingustat concentric, dar uncori tloar sectolial 1si st ttlnltttt,' vizurle. ll\ Cecitalea silsiu amauroza reDrezintd, nicrrl,,roo rnnoti ., l,lrirrt ccntlalc), vedelea macular'[ liind mai rcspectati,; o) ilitttItll rrtrr rrr:rlic cste foarte a terat (cu moclificS,ri ale cir,rpulilor ct'ttmlftir,tr,lltt st,,r lrilatoal[ (6i in accepliuneia, l,,irrr{f pontru culori, cu discromatopsii qi chiar acronliltopsitr I'olrtli); c*orectEiinli*iX,-piiiiizt;ne' ce.nt.",u ,lr \rlrrptarea la intuneric este loarte deficitari I e) Adcscn lo1'oltsii '1i tltr ..io D) Ilemerabpia reprezinti iliminualea acuitelii , rr ll rrtilci,rile globilor cculari I f) Pronunlat edern pa,pila'r, prrpilrr,Iiittrl *, l.l spl:c Seara. r,,.rr,,,lrrlblre, tumefiat5, cu conturuli foarte qtelse, cu sll'ii (r1| I ' I I Ii t'I t l i | |r{' "irort" ,,.rrrl,ii-rozate. Manifesti,rile edematoase peripapiltlle se itrt'itttl ltrr zott, ,r;rri rrLr cimpului oftalmoscopic, r'ealizind aspectul rlc ,,ntrlttorrrtirtilri,". invizibilc ( llisr r t , l1) l': l; ' ,,rrr1i rrJl cpapi l ei deveni nd , in accst c sit ualii, .,,.itri1i, {ininelseama indeos?binc.rmai.oarete-;i.;l,iii, iiJpiltir",i \1. n()l (' s(i u, 1958; D uke E l d el $i Sco1, t ,19?1) ; g) Yelele ; i t ,II I t i IIt tr ' It ' st t r l r.rrul fundului de ochi gi pi,strarea al t,r.rri r. rl i htate qi si nuoase , ar t er ele slnt inecat e in et lcm ul lt t r t sir '1 lt ) lt r r"tf"iofui p'r!i"ar la tuminri. , i l,,:rr'('l(i papilare $i pedpapilale se obscrr''Xhemoragii si ctstttlrtlt', r'l'r'tt ... l') !):l!r"*,atoysja_peytyyalb negru fi tentru iulori reprezintri tl ,,l i rsl l ccte de trombozd velt la, s: i cu zone vast e t lc t 't lt r t t t llt 't t t t iI r r I lil t t t in-considerare,'inirucit l aceasia poaresd, :l:,1l,,,1o'1'"]T3"jlrlt-,*:.ll?1 cr,rr,rli scrio de lezinni ale chiasmei o l rrrrrl :rcr.storl ezi uni ; i ) C o af e, ct ar eavit r osult i se po: ll, o r ( r lr lizr lilr l) r r lt ilil, r ' $ rtlttl;r lrr, lrlii (,\,[anolescu,1958) ; j) fn forma de ner-r'i1,L opticil trtlt'tttrtlortsri :!./,,.1.1.Amb_Iiop.iile am.turncplo "pti"bsi a,,t,-..,]- *^ i!.2.1.1. Amblioniile "in "ail'* si, n.alra <; sul.tacute iatilnesc acute ;i, amaurozele se in rrl r:rl rrnrr.l i cul ari descri si i dc Rcnar d ( cit at t le Riscr ', . t 95! ) , ', ir r cllr r l nlr l ir r rors(| ir1(:(i1i1tni, diverse etiotogii qi cu vdriate tocatizXri de pe clitc ;,ri rrrrl i o rnasi vi , tumcfi clc, cu ilspect t 1c , , nr Lcir t cii'" lN' it t lt 'r t t lr t ct r t lr r :.4.2.l.l.1. AJecJiunile in lamatorii ale nerl)I.tlui, r I rLri,rr'il canalului op1,ic. wtic l. :!.:4. /. l. l. Perinct:ritele,optice (nearitele ii lrr lrr!r unui tablou dc papilit[ trebuio sii plecizitrrl .lut,lrtt r lio1ul,, rr.lrlczirriiio irrIllLrnl.r,t,io Drim:rri, a, tecilor nprl //ri r l )r' i n i nvesti ga.{ ,i isi si em at r iccqi r ninulioase: a. ) inlcc( ii kx, r t L' r r lt t l. r t r : ,, rlrr olrir,ci,r,xtcrrsicirrlui pr.oces inflamatrol Ae fa'r"eilinld"'Ja" .i" fa r rr,l ,ri ,i l l i te, coroi di t, pl i igi per f or at e inf cct at e alc glt t lr t t lt t i oct t i: r t ) ; ( l') rrrrzii,o (anterioare, sfenoitialc qi ctmoitlale postcrirllurr) I tr) rrlirr'littrrr :ii]'ll:1,',;.1":i:,1^'j;'l:1.'.",':'si:l_::t11i.obi$nuilisinttacteitiepiugenc r lr r r rrul l,r,rr r, i, r lc ir illlii, in nn|lrngrltaa-SUpUrJlivi cprr.bro_spin \ ul tl l o rc l i n g i it illl alriuni rrrII:rrrrrri ol i ial e urechi i me dii; t l) f ocar e dent ar e I c) ost oit t r I l) r r , lr r ii", r lr r t, i -di fuzi l(|i.|r Jr l||l|st. l ( l) r r k c ll) ldcr s r Scott, 19?1). Este v o rb a o u; 1 i rrl sr r (t,ut({r lrjl(lcr fi Scn l-tt. l 9 7 l ). E s l c li s c o t. vorba de ainzltfi in trl, ; r1) inlrc!,ii generale (scarlatinl, variol[, folrrl'i,liloirlii, rlill'r'r ir', gli;rrr. lrrl rr;rtir' :r|. rrrrr rr'.rrcningite bazaie bacierie.ne1inc1u-sii iaclarc S ,,,Lrri rl i i -un, ti fos exantema t ic et c. ) ; h) papilit c lL, ll1( r $ilt l f it ll) ir ( llll( ,I t i, l 'rniiai,ato"ti I i'.1,):.,.'.',ii,'flll sauale, lil)..1::ll::t altor p"occs" rt' :rrr,rr, i n scl eroz:l i n plici it llusr 'lu ocult t r ', it L lix: nillgo- cll( x llllil( : ,5j l.l:1,',','f,':1,1 rl:lij:_"1,"T: 1 ,il:]:l: sinuzjie sfenoidar" i,'alarc,se r1 rrrltrr{ii virotice ncurot'ropc (o{tralmonculoln itrlilrii, lrollrt lrti l)rrvirr; ; r.r. ::'l: ;:1,r, ll I r'tinicc: perinevrita jl;:1,:1: , r' , r' l rrl otni c-l i to demi el i ni za nt c; I t er pcs zost e: 'I cr r cr ialil, o; I t t t 't t iI t I '; iicr t r , t t lt ' l]l,i::,..1:llr, , , 1rlr l ri p rrr.rr t ll' 1, . llt "pii.a"".iiaJii"#c;ilr;I ,i , ,l i v| ' i so nai uri ). |)iIr11rrosl,icrrJ orientat de: contextul general trsto lil N c1)ritct, apticd, refrahulhard &clttii' :tan' stthur"utii (t;lndnntttrl 7r'slt /,,r/ / s{ , < uracteri zeaaX , i Ir plincipilr , sPt r l t lt r osclr it t r t lt l piLlt ikrt li, t 'r 'illt -irn"eor, pollrurli . r"rre cx_plic:iambliopia * $i cu la*traiua a l rrri rl rrrl b:rri l , pri n l i ps:l sa r r r I isclef ia, m or lif icii, r ilol t t ] t ir xl, ivc r r llr t lt r t t r st r r t ,rcrrllrr,|r,). cu,zlrl r.rrtr':rL.)- r,rz,rldispari,tieiqi a vecleiii centiale se lnsiJeaza * ved lrr riirprr ili"i ti-;-;.d.;ii o l ' r( | rrr i tchi mb pri n prczo nl'll ilr alilor l, t t lbut i i vizt t lt Lr lt t t it '{iot I I t hr . a-eclematui pupitr" ;"riuiloio" q, :lllj,,.ll.',11:1, consecin{d f,ln;i I !txtrioristici clinil : lt) l)cl)Ii, l)l'ujr(f, itt c,ilcvu, ziL' trrrlizitttitt tlr' ,, ('l' llr'{. I it l)j' J o . " ,l l r.r,r' r, rl l l rnati c:i a tcrti 1 t if ii vizr t lt lt r , pir r ii' l: l ct 't t ilr t 'lr t(rt t t t t r t t t t lt zii) t r ot t t pt lt 1,1l :i , cl ri l rl ctt rl i sprtri {,i ir , r tcoplit r i I t lt nilt lt it . st '; lr ) ilt r it r lr r t 'r 'lr r r t t ilir {ir r , r ri rr:rl ,rci i { ,r pt' ouxl tt,l i i si trt ir r sr l{, i1iilir lt lgii or lr ilt lr t r slt lt lt r , t iot 'lt ilir , t r ', 'sr t t ..r'rr.1;rl. neyritc optice) iealizeaa:i.tabtorii v1\ r,r' l rrl (' sl l ,l r tl t' t,l l rtql l l ri l o l t lr t i r iililo gk r ilol t t ( lt llllr i ; r i) iJ( r ai( l'll( 'r r ' lr 'r il scciiuJ "ti"i""-,iitrirJ"f"Si." por *,:.:i." up0rc: pl.rma . i Ll rl i ,r,rIl .i { (i i l rfitrtrtti l i col o t t t t t ct t lt 'i llt , t t r r t t i t lit r t t , t lsit t t li, t t t t lr lt i 31r ; 1lt t t l, t """.*. afecrdrii vu,ur ;t;;;'fr pc il.i,", I li:::f:.lll,f13"ll: t1e ".r-""l"i cl.recuprinde ptpila .rr|r ul opii(1lrirr;iI:r'zuuartc i .irrrl:llrrrllrarJ, n(.r.1 | | Jr' l ro,rl (f :rl ]ol rrrri i trl rr' { r , int llt t l vizt t lll ( lt 't t t t t t t t 't t t lc , , t t I l't ill'i t t lt r r llt r l "i l vllsclor centratc atc t"ctrncrin lcrv (10_.LZ mln), realizindri-so ( siud l )l t| i r' | ,l LIll iLi i''r : oli, ll) 71) . llt r cr r l i t it r t I I ot t t t r I I '( 'I t ||ir | r ll( \ l r rrrr :rri rr!r' i )' Nrrl(,Jiol', i*xt,abuJbar, p4lilita sau sinrlrol.ul dri lrilpil. _ ( t l : r I r , r 'I I t t r , : r t lt l, gt t lt t i t t t , tt it ,l r,:rr. l rr.rri rrl rrrtl l t,i ; rl ) 1' t r cr r zt t t ilr . Fiit r 'r 1, , rr.vrilr;.i, .domz I.rrsii,ircrr1,l'l' srrlliriltrfii; (r)r:r lx)r{rrt,r', r.rr.olrrrlrr:'ii, srru il' l \'lt t t r t t lt 't t , llt l'l"i) ,$( ' ilt lllt lllr zli ( ) illr lillll! ) zll lolll st irrl,itrsr,i I rlrr l ,,l ( vl i l i i | | i rtIri | r,Ii .i i ' '

2,!. l'l1I)lnXllA l,l,)Rlri(]llrr tr-l

(NlillvUt, ot,1,l0)

"i'#trXl:::iu^K:T:##,ffi:-ii"$:iilrTi,l":?Xr*,J ,,,'',,iJrv'ffi tlllLLi,'#'ii?'ifdi""lffi "'f"""11?Y1 i?: {?::;,;,i:!:,"'i##ii

#,l:'tiH" r: l'lr!{,?i'[]i,'i1iii."1iL,slf i'_lTi,$"",i,",1 I seseLci' oiieiene#iea ae j:311", tap ]jlj,,lltu'l]:l;.,o:11 llry:fant "':?n

"fiff, ,1.,,,ir1.,1i,!.1.,,fl"'l:.it'i, J"i,*" -l'iTl,:*gx,"ll,';ji,:l*$"1

l6

l't

l)l.lfl,,ll

r''I'l

,,,l.

irrol'L,\ir! l)'J)illt,l.ri ryi rnitl.irr,zrl (rr.v.ll,,

r.rrl,r'l'rlllnritr
, l t r r l , ,, r t r rr t , . I r i . r r r .r ';r ;:i i , r i . 'r r l ) ( ) l ,.tt.l l r l i l .i .r r l l ,i i ( i r l r r r l i ;r g tr ,si ,i . r i i l i r 'r ,l r '. t k r r ' l ', r l 'r t r t . r , . i r l l l , t'i i i r r r r r l l , .r t .i l i tr l 'r r l r .l r \,1 ,( i ( ,1 ,( r.H t,r , l l ,'i tv il llBt ' ; t , ; r , 'r l r I t r l : r t'r l r i r ':t tl r l r l i tr g r r 0 sl l r ,, ( i r r i tr r l sr .r r r tl tr{l o t,ttl i ,l n ) l tr r ,L , l l l r t ', t r pllt.lll l 'r r l r r l : r r r r I r I r o Ir i r .i r .tl r r r r ;r i l l r ,tr s,l r r i i l .r r r l l ,z:r vl ,'{\t {x,l 't,i tl t. :l . 'l , r t t r l r r . r r r , I r r r r | . r l , r l r l r . , r .|l r 'r ||u l r r fl i r i l l r l Isl o l i r a r ,l ,0 r ,r l ,i r r s, .l ,r ,r r r ,Lsi l r l l r u l l

rrr h t l , , t r t " 'l 'r , Ii r ll,,j:l]1l,,",11::l:lll.1:.fii.,":1t,,;tlri;r1;,,,1'r,",,'',Liii,,i,,li'i,rii','r,,,r,ir,,r.rmrno rr.r'rrrrliL,r.rrllr ri,",i,],iiuir,',1*i'iili;ifi'i,,i;;;',;,i;i;lllir",l"'T.llll. r\ t. frirlliitr,r rr r ', r(rrr(i..rrirvr \\r\1r.'t,,1 r r i .r ';.) l t r r .tttr x':r r t:r tt.i r r ,ttr ,ttr t un.',,,.,,,r,i,, .r 1,rr, . I t r l t *'. , r .( .r .r l |r ,r .i l ,i tl r i l :l r , v.r r r r r l i l l r i ,l r l l r l i r r i r r , . slrLl.rr rt,rLt,ir

f'enrpo.at,i. t"mporatit, it,ii.,,,;;;i' lrih rt'i ,;;,,,,,.,,, riisnraf rr,llir,ro rliscrot rrn nn ,j1lf,;' (tt.s.'-ryi.Ashrvorrh, rt,'t,it,,. rsos,'oit*U'd;"ijor.," gi Scott, iir,r"" I n71).

o | | {' { || | )| I r Dlpih'1.1,, ,,fricci . rl{'(x)lor.itr. prr (lr. li1,_ obicei rtr.

;;i^1xrs.to|io.rl.e) Oftalinoneu"rpj:llte ft;;i;'t"ib;;;;; c) ; ty no". (ruieotd, virotic(. parolirtild or.ioiil'ur,c"ira"e :]ll,l Ii:l.l-,1 \':tlrorr.it,, zonil zoster, variceld,l--bacteriene "piau-i.;,
(diverse), riclettsiene qi 'irip,a,no^*]r;r(in t,rr,l(.,,,{'irr(. special mataria, qi;;Aiiiiloza) ; s)

r.', lr,.rrr,,r'irAiil,, ilini,.llll{lr,r)itsrr Iilrr,l,rr rixl,irrsrr irril.g pr, ;ri Sll. ll:, l,:,1,, lllltl'rl r,lrrr,r,, lrrrir l:r 1x.r'rli,r'ir,, lrlrr'u.rrl v.tr.Lrr,(.rr.lrr,rrrrri t,, irrlri rl.
Fl i tl , l || t' ' t' rl rl r' )

ltt ll|'

I tltnlttlttnttlt ,

, rrlri.r.i,,. ,,,.ii(l,.11.ir ini.tlirrti ,, ,,.,r,it,i1ii uii,,,,i,. l,ll,,l r1,, | 1,r1'rt.rr,, .r1,. r l , | |lr'
l l l t ; O) .

ti o l t n l l

tl t

ttr r u l u i

o Jr ti r j l \r l ,

r u r l i zi r , ctl ctr r o ;r

'l'rrlrlrlrrikt clinice descriseanterior (vezi 2.2.1,.1.1.) fi pot rcalizate tlc t lli .lu,ckri:

I r.rlrnriloirrdirc<rlt :rk, rrerrulrri op(ic ilr Lratr I isrn ura rlt. r.tu rrio-rrrtbrrtle inehis0
I r' ' rrrrrrr' I r rr rrrrr: r r i rrrr iadilr *ir '( r r . r *r v ( u) r i( . st ' ir t t ir r t t r gait t r , r . ' 1r t . ,1, | ," ,, rl rrr l rrrr r r 'r lisr r r r . lr . r , r . lr r r i'r , r , r i. b'lr L, r . hir ir , . ir l. ) L. r l, . , , 1ii, , , . , It{t.l t' r,r,tt' ,t,rrrl r' , I I1Ij 1I1I| ;1|; ; ;1|t r si r r r r r i I *. avar r in sr , ingi. - - r i, ,ir r i; ir r r . s. l [h.l rrr. r" r' L' rr' | i r{ r rrrr' ..l 5- r 0 it li, ir r nlxr r iir l ir r r r inr i. 'l, isr r r . r . r 'r '. 'i*r r . IH rr' ' r ,r,t, rri r.rl :r rr r . r Lt *r l, l . pr lir . , r t . r , v, l pollt , . I i <xr trtllr it r 'r 1. ,lr , z; t l, l S tl r' r' ,r t,,t:rt l ,rr cir . r r [ iiir r oour i, , ilr ol, t , zi ulr r i lczir r r r r l ncr . r , r r lr r r l l fl ' ,' , ,,,1, ',rr , 1," .1,:r tl l l l l r .r.rrl urrl i r r r ir lr . ilr zlr , t r r r . l'|, i t r . , t t sglt suol oollt i( r t , vil, l, . rrrIrl ' l ,,rrrrol oi l ,' u l 0 zir r r r ilor ir r r lir '. olo , . r t r , r , vikr l 0pl, i. , i ir r l, r , r r . I r r r r lir .

inl,0nsmidriatice, iar reflexul fotomotor este atrotit. Nrur,,,u,tr1.1r,. oTtticedin .alte_into,ri,calii.(optgchin, f"iiix mas, barbitu. t ilr.,., irl (lo. bromuri, injtoform, 'aciri ialicilic, snli"itnti 'etc.) sini 'r ',.r,r.lrln, Irrr'tr' :r,u,rrri'itolrft! cu cele chininice, dal,oriti *u'""oirro"i'o. ;;;G;;i v;r.r.rrl:r.r.,. rrsrrpr.rr. cclrrlelor ionare din reiind ,i ,r"pau fiLruioa'n"uI _gangl v,r;u,r. (\frrrrrrlr.sr.t', t.Di8). N.europatid. opticd din intoiiealii iautd araenineld rmporr:)nle, cu evolufie spre amaurozi in citeva zile, ,i1]li'.,.r.,.,,r:,r..,1,,'l]],'(,1)u

chirrinii scopteiap_eltic abofiFj qi p"oauce (in sau amaul |r'r| iiir, :r,rrblir4rii, irrsolite;i de suiclitate,re_marcatd OulA ieqireatiin .trr,(';trrr'r,l,oirHli, citeva rlo Examenuloftalmologic arald,ciieva rrnrrtr.rliti,r'rrrrl,irr,lo.tu,ff're, nouropatiitoxicu , asiecf isclemic elo. de alte aI re^estemult r^r,r.l,rrr.o cu crescut[. lllll''l i'', sirrl, ,Iiliforme,. paloarea F.O.; TACR I'rrlril.hr

(jilzaro ;;'i,r,' n(i r j n{,ir,r retrobulbar6r cu scotom initial centrL,l, "Ireyrltra" rrlrrrrrIri_rlrr rrl,rnfiooptic:fi progresivi, cu intens?i, o a papileir t$2; "*ouor"u Eiiazzoni, 'lii],,i,jl:.1.,,,:11,1.s11""^o-3joas';,^{sf,annon, i6[f : ;l:,1,:l'; l)1lrq-l!|lcr fi Scott, 19?i). lil,rr{i.rlrr o1tt.icd, chininicd apare in urma ingerilii cle dozo mari . -. N tu.r.oltutitr. (cil.v;r grrrrrrc).rltr

l; [t,'r'rlrrt,rrr (|pli|t. loll,l r,lr rrrnlr t,j(t imrrtliirlc. lr)kr sirrl, hr,r.v0rrl'| -, Ir' '"rrlrr rtr rrrrrrr'.r(,;rs(f vrrIirr{iillt,it crr, gru,vilrrl{' rli (xr rrslx,r.l trii, ll,i,i,,,',"

,, rrr.lris. r'li. vitriui,ii,. fllrih r r'rrrt'' r.rrrrrIr' J)ur,ri rrur'rir1,ur ,,p,ur.i{i,,i ni,li ,,,rrl;rr.r,lc JxrlIi gnrllr,tc il crLtttolii in filllr,l,,r :

,rn,,,i'l,li'i",l,i"i,r;,iiil;;liil;llililii;lfi1'lilll;iillL l,'t,,r,r',r,,,r
l4llirt
r cllr r .,'t:'rrirr :,r,s,rrrr,,,r,'r,i :in','"i lillil,,lill;J,';i:i":i,,lii,;ii,,]::ljij'lij;l'1rNcor,"'|r'ii,, I . ip lr r . ur it , r r , , lr , , i,r r r r iI r r t clir I , , , r . iz, , t r lit l $l l l ttr rl ,' l rr,,rrrl l rrr.rI rl i r ) lr ti( . ir .r . lr 1) l, llll) : u. i t r , : r r r *vor sli. 1rr rrrrr| , I Ir ,1rrr, rrrri Hl. u lr ill, t or , ; r , lii, nir ni<lr . ir r zr i r r r lilr r ut lr r r lr scr <t ^,.,

:rrrr.rr{it.ziuirir,r' r,rr r-ri,tirit, vr;;,,;,i;ii rl..r :rs1).rr 1r,rpil, ,,,

1,,,,, ,d,,,,1'.rt rl r. 'ij,ll,,,Il,'i,,1"1i,j,ljlili,1 r,r'r, ,ill:ilill::,i'ilt zr r : r l t lr . ilxlillilii;l,ii;ili:",' rl t rl r.l t' r.i rrrtr r
l l Fri l | l | | l i | | l i .l trl t, rtrrri t t lr t

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\ | rrI I i I rrrI i Irr,Ir tlc. .lucl,ori etiopatogenici ai nevritelor optice dc t'r1r'r,ri\ r. rr lirsi sisl,rrrrur,tiz:tbi,noi (Popoviciu $i Pasou, 1980),pe :r Ir||rIr|.r'r|irs(| slrr,listicc, publictilc indeosebi Dukc-lJkler SI Sco sirtrlii de (r1rir):
ll l"ttt rt\i itt.lltuutl.ar.i. Lor:ali ,1i ai B.i[.C. .. a) Uveitc si I'etinite i l r ) lrrtrr'(i i ir r lr , r rr r llr ilr r r.c ; c ) ,\Io n i n g i te o to n i c e (i ndeosebi brci l ara gi lr , lri :r);rl l \ r ' r r lr r r oir lii,rrp l o c h i i i s rn a ,l ,i c e u e x te n .si eantori orl ti , cu reao (c lrr:rr, r,lrr:rl rlr. rlvlil(l .jrrxl,l,liullrtre ,sipapilito) ; e) Sinuzite antedoaJe fit tr.ri,.r r,, rlr' ; l) 'l'()\oplltsruozir,;g) Tubelculoza, fic prin lropagare, directi/ rlr. Lr ri lrrclrrlilr vooirrc (proceso tbo intra-ocula,re, iridociclite, osteite etc,), lr,. rlr' lrr o rrrcrrirrgil,iitbo bl,ztli,, {tretermlnii,ferromenc de ne.t-r'iti, gi rI0 t)(.rrr,vr il;r oplicir,, clrirn dc pl.pilitd, (Sverdlick, 1964, citai de l)uke-Eklof rrr ll ,ri l, l!)7l). li,ll,rl\rli ljoitte dctermina un tuberculom Solitar masiv pr, p;r.prl;roplicii, crr rolliz:lreil urrui tablou de pseudogliom optic (cn simlrlr)nri , r ;riil rrriri s{)v(lro c1t cit i,uberculomrl se extinde ;i spre apexul ,'r'l)rlru ); lr) Nlvlil:r, ol)1,ici:i sifiliticd de obicei provinc de la o meninEitf r r :rrrrrrr.rri rrllr llr r r ' lr r lili lue ti c i i l , i n s ta d i n l s e c u n d r sau terti ar al l uesul uj . '\r1,.r.rr rlrislirrrL l:l lriirttrrrcn, cr'ncomitenti, a neryilol' oculomotoli, faciall r.r r.r,lrlco yr:rlilrrrlrrli. illtrlLnrii r.iltr rl c r*cdere sint yaliabile, ,te h u$oir,l.[ _ :rrrr| I r, rI rir, ;rirr'i lt rrrrrir,unrzi 1ofltli,. flalacl,eristice sin1, strimtorii,r.ile corr ' l c r Lt lrl l rrl r lir r r lr r r lr r i v izl l l l L p c n ttrr a l b fi l x rn t ru cr ori , precunr si s0o. l o rrr'1 , ((.rllir lr , s i/ s iul l )i u i l ro l )l l a l c . l )i i L g n o s l ,i c u l se bN zcazi i ,po dl i l (!l r i r I r: | | | rI r| ,Ii i i {rr,, pr r , lc s t r ' lc sc ro i o g i c (' , l x ) ri ro (l i l i c i i .t' i . l () i rr 1r" (l .l L. (crr pkrr r:l ( rl! r zi r I|| 1(I( ) r ||iI r I r r r ilir r r l i x ri l rr| i i ,,c tr p o z i i .i v i i l rl o i i rtl r(j i i i l or l l i .ri ,r' rr l i l | s), (,IIrrri | rri i rrrstrr0l rti rr 1 rr . r rrrrrIi l i (, ir liI r r r t pilt r r r , 1 i 1 x . rro rrl i ' c l l tl rl t,.trr,r' r' i IrIt lr r r :rlr ; i ) l l o rrr lll r r I iI iI ill rrIr.| | 1r' \rIIIri rrl rl i { j s i rrl l i rrrrl r, rrrri ., l or,:rl i zi trrl rr srr
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( |\( r '||['l ItI|1 l I r r r I r '. r ,rI t t Ir I t r, t t I : r I I i l t i t t I t'I t'rr t I t i I I t' I t l l l r ' tl r 'l !l l l l l l ' l tttr to tl i ' tl tl 'tr t o tr ttl r ttr t I j ) r \l l o l r r r .l r l i r r :r ' rr r , r r r r t r r l 'r 't l l i ' i ,r 'r l r l tl l l l l l t( 'i 1 l r r i tt l :r 'l r cs, l i tt,r r .l I r i I : t I r' r': r I I r ' tr 'r tl t . l . r'.. ', r , . r r . 1 , , | | | I I | | I I I I I l1)i l)' , , 1 1r r l ( r ! l l : l t l rl l r l i l r' l r l r t' i tti tttr r r t i tr ( |) r r l i t' Ir ) Ir Ir 'r 'i "i fi r r .l 'l ' . . r , , I ', | , l tx) l l ( 1 1 \l l l l i r fl i l l tr ) * tl r fl i \''i i l ' ( fl l t) l r l l l l l l , , , r 1 't r ', 1 'r i ' ; , t r t t l ll i tttl ,,t;tr '( r l l ' *1 . r . . , ! r t r , , . l l l l rl r' l ){f l l l t rl r o ;l t) , tttso l ,'i l 'l i r l l r r r p l r 'r 'i ( 'i l r 't.tl to l " l o l o l tsi i " l =r . l ' ' l l ) 0 j t' s:r l l r l q i r r l i .tr ( l l l r l 'l r o fi ' 1 1 ) r i l l ' \'; 1 1 l {':l l l ti l l l . r r r r ', , , , . . , 'l , r r r r l r 'r t l l !l r l l ' tl l l l 'r ( r r 1 1 'r i |f i r l ( l l r sl :tl r l o r l l l r l l r l r r , r , 1 , l r , r l . , l ) l r l r r | r i i l r r o l ,l , t l r ' :l l r tr r t l r l l l :l l :l I l l l \ i l :r l l i l , ' "l ' { r rr., lll l l 'l 'i ," t r "r l l l i l i Itt'tr vr fl l l :r ' l l l 1 . , t t t t ,t t t u l t t r r r r ttL t r r ) S1 :l ( 1 1 'zr r r tr ttl l i l |l 't I l l r r r r l l .r 'v,r 'i , r r , 1 , r r r l r r r r r r l r r r r r t i ( 't'r r r r l i ;i l i r r r l 't r ', l l fi ;t'r r l l i s,.l l l {i l i i r t si l ':r s''tt, l l r s( ) ; l ) r l l i t l tl l r l ct fi St'ttl t'' , r l : r l t r l . I'r r '.r i ' l,r' lll,ir r r l r l l tl t l l r r '' l : I , r r r r i r r l i l l r ' r l r ;, l "i ttr tl :r :l ( l tl i r ; r ') N ,r 'ttt'r ttti r 'l i l ';t' Ir l,t,lr tIr 'Ir tt|' p t i tt tttr xl ttl IIttti ItItII 1 , ' l r , r r i 't . r 'r r l i l l r l c I l tl r '' r l I ttr tl l l 'r ' r tti , r l , , ', 1 i I I I i {I I I I I I I I I' ' , ', , , , , , , , r r l , l , l r r r 'r r I i Ii r IIi l i Ii ' Ir i r Ii I r .r r ' ''i p l i r .r l r 'r 'l tt( .i r r ',sr l | ' ,,,,,, l p i i r 'r ', l r 'r l r i ' r '|,ttl i l r zl t,.r ,l r sl fl ( 'l l r z:l l l l l l l , l , r L r L r r r l . r l r I l l l : t tcztttr r i l o t ,., 1,r r | ) | I Ii (' - .I 'l I ( ' '. ' Il l l i l ; r . o l r r l r . , l !) ? i l ; l ) r "i u r r r r l sl r l si .."'l r r l ', .I . ,,fi, 't , ' l l l 'r l l r r i r \p |i l \i Vl l l l so l L l l ( r l r l ) ( r tg ( l 1 l i ( i ) , ,,, ( r . r ! x 'l i r | i ,,,,,i ,,]i , ,' tr;, lr 'r ,,i i , , , . , ', , , , , , , , , , f i , , , , , r t,ti tl l r I t t I t t I I rt t t i t ' I i 1If i r 1 r 1r r i 'r 'tl r r l i p i ) tr vi l r l ) r '( r zi l r l r r ' l l ( r ( 'f'1 'o l ( l l l zl l l l r r r r ' , r ' l , l r r , r r l r o l r l r r tl cttti tr l i tti zl ttl l r r q i ti i ' r r r l r '.i o ti l l l i t'i l ' l l l i i si \'l i i l tl t'tvi l ttt o l l ti o i l ( '1 ) t( l zl l tl i l ' ', r , , r . l " t ', 1 r , l r , 1 l 1 r l i ( i l Ii o l l l ( 'zi l l l fl l ' ', 1 , , t 'L r t r r r l l t r r i r l l i tl i zi l ,l l l {r I I 1I I i I I I I t I I (| ; r l ) .l r ) tr cr ' , t r '; t l ) l i l r . l r t( ( 'i tl r i r l tr l i I , l cl l l tt r ') l r i v{ r i i ' l ' l i l tttti tl t r l r l r r z r i (l r o r l l l tti Sr l r r l 'l l r l ; t . l r r , i , , , ', ', 1 . r , . 1 , 1 ', l r l r i ' l r r ttr r o r l i s tt l l 'l t t t t t t t t t t ) | |||It |t||tt!Ii 1 "t: ttt r l r :l r tttt'i u i sttt tl tt.tttL i t: l t) ( l tr tl tl r t 'l 'r tt' Sr tl r l t'l l i i l r l t'r l g r l r tg l i o zi r l r r zr ') ; ,' lr, r 'r , , l , , , l r r l , , r r r r r ;r ttl o I'i tItI l r r tl i ttcttttt , I l ' , , 1 , | , , | , l , r 'r ( : r l t o l t rt o p t'i r r i i ' r r r r 'r l i l r r 'tl i l l l l l i Ir ( l l ) ( !t) 1 i l tl l i r l !) 'i 'r ') r r l | , 1 , '1 , , , r , l , l r 'r r r r l l l r , l ltl l {r 'tttl l i tr ( ( l t:o ttr ti 'tto t'l r tt,l l ) 7 fi 1 l 'l l r l tl l i g l i o r r t" . t t t 1rl l t 'i I I l i ( ||l ( j ( l l l l - i ( lEi g i t,Itt,r l( l tr l l tl l t l ttt | | | 1 ', 1 | | , | '| . 1 | I l | | 1 : |\| i tt i r 't'i l :t l r ' lll(1rl r r r i , r , r l r 'l r r 1 r l , r r r r l l r 'r 'i "l 'l l l ( '.'i i i i 'r 'l r l i r 'l l ,'l r '.r '1 i {) l ) i L l ( l g tr l l l ( f l l ', r , r r ', l | , (( ' t : I ( | It ' i , , , , , , 't , 'r '', ,.r u .l i i t',tl r r , r 'i l l r l i r l cl r ', "ttl tt l l r t ' i '.'t t 1l.t l i l 1 i ) |1' | I ri ,. rl 1 ,,., ( l l J7 l ) r !r t l ) l ( ..!zi r l ' r , , , , , , 1 " " . , 1 , . , , : r ll ( . r '1 .r 1 ,. Ir r r l i r , l r l 1 l .r . si i - r ( ..i | ,,i., i r {) t]{r tl i tt l r l tzttt'i ' orililill(f ill l0 r l | r 'l r r r r r { :r ;r :r r l ttl l r r tti i t'i , L , ', ' , l ' I l | . . 1 | . . | . l r . . t t , r r r l ; r I l 't '; r I r ', r ll 'r ttttl l l '( ) l 'i ( :||l Il l l tIl i l l i ( j l l l l IIl i |,1 |t.{) z( 1 ,|) t'l Il ( x'tl tl i l l 'i l l tl tt- str str tttttr r tl c r , '1 r l r r '. r r r , l r ,'tr r i ci i , Il t r ttttsl 't' ( l l l ztl Ii u , t , , 't , , 1 tl l r ttl tl l kr l t Il i l i tl ( r i ( l l l l l i l l Jl ' ( .,r,l ' r r ': r r r r t o r : li l ztr ') ',t i ttl ''tt'i ,l 1 l l j i l ; d l , l ! ', 't r l r r I) ttl i r r ci l r ( i i ;r . .''r l :r .l r ', l l r l ;:l r r f , , r r r r l , l 1 ) l t{i ; \\l r r l l i r l r l i,., r r l i r t h i l ttt l r 't t l , , 'l l , l l r i l ) ; lr ) i i 'r r l i r r' ' 1r: r I i i I r' r I i t r :r l t'r 'o sl l r .r 'r 'zi 1 i i r t , l ', ' i t t t 1I r I I I It t t I I r I'r sttr l l t'l t' I) i l 'l ) i l i i r i ! l i l xr l i p i l ' , t , 'r , 1 . , 1 , , , 1 i r r r p r ','zi l tl r t - , , , , , ', ( r l 1 :r l l l r l l l i i l zr . {r 'i r l ( r i l tl :l r i l ( ' ''1 . t , , '1 , , | | , l l t . . r 'r l l r l .r l r cr r r "r "r g i i l .l :r l r ', f , ,,. t , i ', . f l , f , . ,tu f,,,i r '.r .r 'ttl .r r :i r r l ,r :l r l r ''r 'ti l ttl t'l "r ':r tl ( i 'r i - "{si ' r r l i l r r l r t ll l l l ( ( ' Il l l r l ( r r i r i S( r o l l , l 1 ) '/l ) Al l r r tr r .l :r i l l ( l i vi zi i l l l 'r r ' l 't r . ', rl,r r' ', l l l tl l tttr l tt i tt r r , | | | I | (, | | ( I I I t i I i 1 1 i :r l r l t,t i r l l 'l l i l ,r l t't i ( ) s( i l {) t( tl i tl i , ,,,,1, p o l ' r l t'zvo l l l u l tsl i r r r r l 'r ' Ir l l ItItIto i r Ir I r r l , r r 'r r 'r r t r l ti l l r ' l r r i 't i tr cr sr ' rl,, rl ,l I,'II) i II!I1 . r i i III'|||( | I I | '| | | . | | I i | | | I I r r/, r 'r r r .r .Ir .r Ii r r 1 'r r 1 r r Ir I, I'|| |tItII|| IIL I,|,I|, ' r r r r r 'o l r '\r '" i ', r r l i r '{i r r tr i 6 i r r i ' , ; , , , r, , t . , , , , , ' , , , , r Ir tr , l r t :r l l l l i i il,,., "p l i '' ' r l "l i 'r 'l r ' : r I I i i t t r I i t t I t I r' l t l r ' l" r r r I t ', '1 , , r r r l r 'l r ', '1 . tl zr tl tl ,: t,,, tIi tt''|'t|'' """' l ( r l l r l l l r 'r ' r l l , r , , 1 . , 'l . r r I r r . r l l ) r l l l r l r r l ttr tl ttl tt'zi i '<'"tl r ;r l r 'l i r ; r l ) l r jr i til i i . cl r z rt i l t'l l l l l ' l l t'r \l l l U l ) l l ( 1 \i l r l ( '( 'l l tt' r IIIIi i 'r 'ti r tt:IIi 'IIl i i fi l l r r , , 1 , , , i . 'l l , rlr I1;(,Ilill (r rr t r rr' 1' I , , , ', , t , 1 ', r , , , , , i , , ,Ir cIi r r i Ir r '' '\r 't'tr l i ^ tIcIIcttI'ti |II'r 'IIIi I i i l l rr "l 'r l l ', , , , , r l r ' r l r vt't;tr l i l ti ttl r " l r tl r l r '[r 'r r l c ttt i tt'tr l l r l l t r l l l l r ' r r ,tl t,ti r ir ,,,,tr,,,.,,' ( l l l o l l ( l r ' l r l l l l l l l l vr ' i .r I r r r I r r r l r 'r , l r t l l r o t l tttl l tl t ; r ') 'l 'r r 'tttl r o zr 'l r ' :l tl r 'l ( 'l 1. 1 , '1 1 ', 1 , '.t.I

rrl l) . 1 r'r':rl i z ; rlr c t r r ilr L' gi; r, l | r' rl i ' ri l l l i o 0 -1 ri | l trri rl rr,l i r, r.rrr,rrrL:r l l ,l rrl ,,vi r rl rl r, |lt i.L l rn {'rl (1 1) , 1I t )i, t ' r r l rr s | rrs O c i i tz i , d j } u n (1 , rl c r| rl r,r.r,r,l i rri < r, hcrrr o pllrirr rlrr I)Nr'1olol)lrsijriJi o rrmaurozi:i, prin atrol jri opiilr'i, rlr. :r<,r,r;a6i pltr'l rr r I r'ocrrsrr istdrernir: (catc intcr.eseazii,artera ofi,lt,irrrici,). l

ll\ Ilol.i. .sistem,ica toaico-metabolice a) Diabel,ul lealizcazi, neulr : li lrrl irr,rrlrl,ici, dirbctic5,,. relatatii, destul de frecvent in evolulia diabetuh rr.r,rrtrlir,hiirr., se_ml cu, al bolii (Skillern qi lackhar"t,' 19i9 ; Duk -inilial l,llrltr si Scott, 1971)-.Nevrita optic5, diabeticl (retrobulbarl, adeiea ci:rlii ,ri crr ,,pu,pitjti,',) nu este atit toxicii, ci mai alegrabe froclusi, rrrcclrrisnro vl,soulare. Apare in diabetul zaharat cri acid6zi,. anro-a .rrri.rrsiv lrl biirbali, este dc obicei bilateratd,, cu evolu{ie cronic6; re;lizil re:'irlcrtir vr:derii (cu scotom central, inilial pentru culori, in Bpecial rrllr:rsllrr, ultorior gi pentm alb-negm). ModiJicirile 'papilare ( rrl,r' o rlccololare cu predominanll temporald,, la ilebut iuilnalu-se in '.r l, n{)monr, ('rlomatoas{'i b) AnenriiJe, in lpecial a.ne-miapernisir ;rlrxirro ndeseu novrite- (neuropatii, n.n.) retrobulbare (Oliva;ius, 1961 .r(,lH('lr, .ltrru'n, 11)61 citati de Duke-Elder $i Scott, 19?1); cj pofineur'onatiil 11,6I 1971); c) pol Si rur,r'rl,ronllro,oarenlrare-,diqmetabolice pot afecta qi' nerwii o rrrrLlil,iorlrle, oarentriale-, o'rsmetabolrce atecta qi nervii optici (: (lin pclagr5,, din beri-beri, din deficientele tle vita,rnini, B,; rrrirrozrrlo lilro|Irlvinls din su-ferinlele rligestive cu fenomen ile malabsorbliil rrlrrrr4rr,l,iile etilici). la lt) Sutcri.nlele endocrine (tireotocicoza ), l;)_ l,olin.euro?aliile paraneoplaaire pot implica qi neuropa,tii r-rrlrtrr)rli opii. lI) ln trlt,imii ani se relateazi, aparilia de tabloud clinice de p:rlii (irrclusiv.l,ablorui ,,neulomielitd, de optici,r' asem5nltoa.r,e s cu rrrr.lrrf )r'r'io) itr b<tl.ilc colagen,cc, dc ef emplu in lupusul eritema de (A.l)ril $. Vl ils(ltnenbcrg, qi co1eb., l9?2; Shephcril -19?6;-Fulford cirl:rlr..llrTl ; \-ii:t|. ;i r'ulrb., lg73). ll 'ltor:itt u:oqene fi.end,o.gene(ambliapii gi &md,uroBe to(xice S_al . ). rl.r.r'iri rr.lrrrr.rrrfi Iarl,oli toxici, care pot, sii prorluci, nevrite (nouiopatii) l.rrricr., rljrr ,clro lt)(fnliorilm pe^coi mai importanli (clupi ,\hnoGscui l{rIri 11iI)rrlc l,)klt'r qi Scott, 1971): r) N icol.irtu, delorrninii, cele mai frecvcnte amblioDii toxicc. rrrrrl rl rrnrxriirzi'r intoxiclli etilici. Arnbliopja tnbagicii este'b cu r'rr r{'oiorrrrurnhal lrr rl'oiorrr rurnlral (inilial pontTu r'o$uqi r.erdc) cale u-iterior se poat ox pontru rosu verdc) caxe I -tmporale Irrrrlr spro zonrlo_ peliferice, indoosabi superioare. Uieoli rii, rrpalri rnili multo Bcotoamecentr.alo rtrargili difuze (Duke_Elriei rrii, palri rnili mullio Bcotoame centrftle cu mareini difuze {Dr:ke-Etd
lirrr , Mi l ) . rl,l

llr ' , I N t' tttnl ,ql i l ' !,pl i tt ii lt r it t t t t l. lr t t 'iir lr t cr lf lr ( 'r rll'l) llt ( 1. t t t r ii t t t t t t t t 'iI I r I i ( , ll l l ,l l ,trtrr' l t 1rl ,i r rrrrl rl i l ti tr r ic r r r : 'llt r sr ,r,lr r cir , t lr it lc r 'l, r r . ) 1i sr r llll\ ll, lllil'lljl, r,I ri t t 'll s( 't ) lI t lll |clll I ill' ,,1,,' ,' l ' rl ttl r:rgi crt: : r.t rI I I i t ' r,r ( tt t\tutol )ttl i a opl .i , r 'iit t r t t t ': . r t inii r slo ( lo ol) i( xr i r lo lip t clr olt t t llr lt r ( r r t r '. (r r t lt r r [ l) ' {llll pol[ 1, ( rI 't r t llizlr t 1i.it 'slxNll'rttlt r plr lr ilil'li'' tIrl ,l t,,1,rr ,' ,r' ,r," ,1,,,r,' r rl i i ,,' ,,,,' ,,,r,i . Itttrl l o.r'i r r r r iir l'r r Jizii ( xlt l[ ( t I x) l'{) r ii qi t lt r I t t l, t r t lxllt {'ir " llr r t I t ivr r lt t l rl rr rr r' r rrl l c ttl t,tti frr sll-it l liilt r , t lt t t t t lsllr t l'o: r 't llill( ir $lt t t gt t it t o, llt ' I l( ) r 'vilot ' p( f I 'it or it r i ( pr llit r t : t t r r t palii) ' Ior' 1i l l r Iri vol tt l IrIl .rr' r.r, s" llr l l l ttl r:rl r,l i i l rtr.rrfu - i. lr t : "'t ' t t ivr 'lt t l lt ( r lvllllli olt t it l sint '. r ilt r ', lr t t lit r r lt t ,,, i ri l ri ol rl ' i ctr ir r t t t r opllt slt t ozit , ( Zilnt noit r r llt l, 1{) li{i; I r llt r lir 'l r yi It,ti l ,,, '| ,,,,t,,, l l tl ,u r:i l rr{,irlt I ) tI Ii I ri I')I rI trI r ii Sco1, [ ,1{) ?1) , ct r t r it r sii' I t r llizt 'r t zr t ' Ir ,,1t, rr.nrro rt,.ttrri Lt git t o( lo $llf of it lliii, ct r lilt l l'. u'tt lr) ,\r'r,rrtr,/rroltlitrt tit'r ir:a ;ilsatt i trt ttlol1irn, cu'. srttt ,lrird rrkrlil 1xr sii' ,u ,' t,' ,,' ,, tntdt.i pl i i l ,!. , 'lI ') . I "or liiir t nult o I it 'vr lilc olt i'icr o. 1' r r pr r t r iI ( sit ,rt l rr ,,,trl ,' rl ttl i tl ,,,ti ,t t t ct ^lir lt t lt t it lilt it r lt 'cl'iolr sr r ll I X) slill[ ( f ( i( ilr ll${il( 'H ( ) iuo t lollt pliclt lit r ir r t 'ir zilr lii r l llllt li lllr r r ( r lr llllllr l , 1r, l tr 1,.rr.rrrrl | (1{ i ors|) ; b) r r r( Wllslr 1i t l i , , rl t" ,' i 1,,:i t t '1, . u", , *, ,,t , t i , , i , , , , , t t , ' , r lt r l'ult t - : lgt t r sit t t1ol1r l'''I 1l?l'; ( ,,,1, rl u;r' ; ' trri hi r-tl l lir r lsi li( lir t t ' 1l) it 1'Nilioskr 'lr r ilr oll iii i t,,,,, t t i ,,,,,,ri ,,,,11l ,Lttri i i rrrl i . 1{t ?d; 1l'ot r lt cllol, r : , l! ) ?l) , clr 'r r ls'r t 't tlr t r r cizr t 'l ri "d', , i. ,, r,l ,,l rrti i urrttrol i rgico, , r l; t *izlil, llN, lI t ( nior( l( r r t lr i ( lblt r r vicir r $i l't ls( ir l' sit rrrt,, r lit t , f;,..,,,, ..1 t,, .,,.1ri r' t,,,1 s, . r 'i, . , 1, . , ( , \ r . il, 1r , l, t i, . ( , ( r r . i r r ull. l. . r lr . . jr r r r r r r l: r l, t r li'r 'ilr r r r pf icl ir t ililr lo t l) ir 'r 'olr l'izo ,,,,,,,,i ,l r,,l rrr' ' rzrii,tr' cllt h'ul ll. I l', s: r t t t lt ' llll'( sll' r l ', ntonosir npf , t t r ir i' it , r 11, , 1 s( ' illiJr '1'( iit s{il'i' r lit ) l 1,,t, rrr,l , qi colr r 'lr ', u,,| ' ,,, ,.1,,'ttrl .trl tl , $.,1- (M c Alf ir r qi g, , lr r t , . , llt ?: t ; Nilt r . 'sl<r 'lr t ilt t r t t ' r' rrrrtr.

, , ' t l rrr' 1,r., l i )7i t, t9?l ' ,; t r lr , t on'e r i coJ. r r lr .l1l?'l ; Sclr r r f cli \ j llllli) ( 'r olr st t r t lr iI r ' r 'pl'icc llll l{! lt lllr ) H( 1 tOi l rr, ,,,, i 1i r' ,,l l r' 1r., 4 ) ; t l) 1lr iLr , 1i, i{' l\'l'' ,r,, l, , r rrir*'rtttistticttr,ioilitogrlrii",r',ir, S.ll. li lrici-lllr .vrllrt(lN'zi' spnr ,p'ice ([(1.,t'tulzii Itrrpttrtrizrtlri rri,rrIilirriililr of l,rr,lriotofico :titt ttearttr:Le rfr1t

11)'il-i S.rr,l'5o.g-\\7,Llh.itn, I Srrr.llx't' r',i,i , rli;l'; i,,'tri,i-;i'tt1a5.,'J9?+; O liilr r r r r r tlll{il};

rlo iilt,'irt il'i',t," ,i i t"1., .*u,strtatc iir clr'zurilcbillo tlolittil'tr ,,,,'1",i ,"i Li,', ill i.tt cvolttlir'r,('llro (rB1'{r rlcci, o otnritili,t inrlelungatd, nil' ;t,, i,,,1,,,tt,t, opticri rii S'M' (lJrr'llrlilitrh6 rLt'vlitlr' i:t'lrr,(ii ovllnl,ua,lelt, ni 111it,r1r.i ni'rru"izirzt, ll r1, ry llirrkrr, lll?it) . o ii.il,i!. Morlitirtfirilotinlpului vizrtll oforrii, sclio (lo lno(llllil'i'l'ido trll'o
lor, rr rrru.ll,rrur,.(]i!I.(l nO p0t fUrniZA, Ctll rUli

i ii cll'tenionattt, osiovont'ru Jattt'or i',,-t.' *iii- t,iietetia i'; ,'1, ',;;;';':;;;d,,'ilii c l r r c .i D l l fe r n l l l cl l tn l n a . t l t " r l 'u n n i a i t)(. -" " r'i.,,:i:,:;;i'i,,i a prli,,ip,rit"tnodat i srm,oloui i.c alterdre otnptt.tu ittil "nt'gttrt'lrzl
(tlu![ ]\ri$Ili,rJi p.t t'l-rt,rlt!r Ttal'oktgiac o,,'., lu 'It,isir, ",,rrr1,r)ndonlela flriZ; 'etnrsiA, 19?0; t)rrke-liklor qi St:rtt'l r,,t,rlr,' lllli?, 'l{)??; lIirr (lrH. l); tuhtll'driN ,r'I).ed(tca ''' r.t.l) orhi'r'tt , c:lro rctrliztltt'zi' ,rrtirrru'mJcranlitltii" ttrtrrr (prqrilitil); lr) novt'it'r'l' jL xtrr,birllrrr,r'il' 1,11g,,t : r4 novi:itil,opfi,IL r,ir,zi'1, 1q1. r Ir llr,r ii l c) iHl'irrio,
r. rr| | t

a'tl0SOA, l)I'l{)iSO OOR'SpOnlt(llt['{!

opi,iri), din intoxicalia tabagicd, cu ovolutie oonici, Rple al,rolie oDtic{, t) Al.utolul. metdlk prodrtce mai ales ,rnevlite" (neuropatii, n.t,) opl,irlr u,rruttr cu:lmbliopio soverl, lar care BoaBo{iuii I miihiazl, parezo $l; (,xtrinscci oculari (cu diplopie, divl'se strabisme qi rrrrrrrchilor' thztr pol. prrlrllli),) gi alltr l.ulburiri ncur.o-psihice. d) N uropalii opticl ?rin dioerce alt.e mecan.i:tnteloui<urmetabolkn tnllolJttttr l-rr,u mai dercris in: auJlrril$lutinnc, tlrnoli (nour.opa,l,ia r.4lt;io6 prlrunouphzitrrl),In trrtnrr, htmoragiilol mtsivo, lrr grtll,i(lil lt,l,rf, ptrion. In r|r,lo drr la,ut,tr,l,irr olrr,
'.1.4

b) Al<nolul ?rilic produce ,,amblyopi& potal,orum;', probabit pdn I ilxrvil rrntinozil, cu tablou clinico-oftalmoltgic a.semlnd,1.or nevrito IJ, eu

tlltoi lt'zitttti tIottI1tIt'I tntilttu.tld, l0 tllt.l,oltr6to ' :1.:1.!. orhirc lal,/jld o (

tl rrrv ol rl i tr (t llr lt lxolr i lr ir 't t lt llt l'klil, l't t t t xt t 'lt lii gt t t t i t t I I I It rt tt 'rI I i r' ) '

ollir r tt ' :' .:.' ,:1, IIn ttrtol ,o'ntr t t t ln t t nil. alt ul, it lt t lr o lt t lt 't lit t t t ot tt t lt vt t lt li ,r' | | \ ' , | |' |, I t| : l. t

clM P VTZUAL

'' :' :!-4. Iln tT)|,.r'ttt' |ll'rr t tlvtrllllr0t'ptrttl,ttt unl'rdl hrttttirttto,xiahrtlttt'ttrtirtt | | l ,' rl r| | (\ l oorr,l i zl rLi1xr 0hi rr st t llt olt f it r i! - l) r r t nt t lllr r r t 'i, lt llil' lt t t t t r t t 'ilo t lt lt '1 r, , (!illl l{! | ,rrt t rI rt rrrri i, 1lt,ti,ult, 1xrsloliorttil, a, cltitstntri, tlntlo trHl,ttlocttl tlo i I Icrtl l,t hctttirrtltt lt'l $t l (x)lllnll prodtlco ttlr $(ltlt,rtttt rl liltrr'lor trrttlttllltr, 1x11, Irlrrt rrrlr o lll,oll,r'u jroi'ltcrfcri u, vtrlolii (Il,cllv, t!)(i2 I Wilsotr li lr'rJ(x)ll(!l r'il,rr,[,i lllllr{ rlo I ) ttl<c'lt]ltkrt r,{i Scotir, l.(}71.)(r ' :1.:1.lt. lln ;tu,l,onrc(lntTaLhernia'n.opsi,a hontonim oiJl 1'(\vollll'ot lxrrl' l|tr r, lIziIr(, Irxra,liza,tir, zona postolitl:rrii il chiasrnci olllitrt', 1lo ltlt'tttlr' 1xr l . l r r,l rl i c:' i , ol i 1rr l xrl uI o ccipit al.

I 12

I \3

cAt ontcE

njj*iHiili ll l;':1 i,''mliii,{i"',';;, fiiii,l lt;i'

Fasciculd(' rol! :: nlzfllt Dl'rl(n,. lr ' r I r , r . , r lt r r t ( r 't , , r ,

'.:'.i!.1;. Il nnian opsiiLe hetaro'nimeb'item'poru,le ittliltLcsc itt [r:irrttilr se t,t, tlrtrttr rrlr t irr,sm.ei oytlice, t."alizttte in special de ttl'tniii.<r:lttltr rllixt{,itttli; ' r t l i r' { i rrtri sagi l ,l ,k, i l c c ir iasm ci; b) if um oi'i schr e {in( lt r ) s( {ii hilr r r li. ,i,|,'t rorr,rtiir, ttlcrtoca'lcinoame, clrcinoarntl mel :r,sl,tlt'i(Nl) I .tr) 'l'ttrtrrttl ( lr t sir lr , 1r,rr ,l rrtrr (tttotti rgi oame par asclf t le, t nm oli alc gllglionulr r i lt li ' ' Irrrr| ' rr rrl rr osrrLui rfonoi d ( ost eoam e, ost cocondr olnm o' slu'( x) NlI l( f ) lllllr ( r u l rr, Lrr)rl l t(!, 0l t' toi noa,me, salcolm e r nct ast at ict ' li. a. ) \ si chist lll i : t lc t r t t 't t it t ,,, l,,r l,rrzr ti, lrrtrxxi (orllitale, :nazale sau nazofaringi{'tttr ct: ittvllllttr' rr l ,,r,, r ,' r' rrri rrl i ri ..si zoi i ci p am solar e) ; 11)it 'r ulor i supr '2r solir r '(olt t t io I r t t it l 'I a, t.r,,,,rr(, | l ror)i i l gi oamc S up r asellr '1, ,t ut t r or i [ i abcos, ol c lr lt t t lt li it 'r t t t llt l I,ttr,,rL rirt rre,trlrtiiuiirnoame qi nl1e trLmori nlo ventriouluhli lrl ilcilt'ir' ltitlrrr ,,,1 rl rr, l rntrrtl i opi tl cunoi do, cor doam e i c) Tu I O I 'i pt ost r llt lr ' ( lllll, i llll) ttt, trrtr.Ii ol l l tt(rr,l ti i i anl uhLi olf act i\ '; f ) Ant vlisr nt l llt r ilt t clt i t r it lt t lit lt ' it t l trrrr, ; g) Arul'r'isme ':r,1o?r,rtct'eic;municattllc ilttl;criollttr I lt) l)r'gottt'tlr ,i irl(fto. sl,u :rrtoliosclerotice, DIin sclelozti oblit,cm,ltt'ii it tltitrilttt vittt,' '|li ,r|, r'Irrrrritttrri ilttttttirtittri ltolrlt'i;1 opl,ice;' hcmi anopsio rle arlcr':i corel)rrIli'1, i) Anevrisrnui tl rrl rzl zrr rttttri ri o llit er npor all, sit not r icr ii ( FI illor r . . si llr r 11, l l rr;l ;)t ,i ) i J-i ru rol ata,t \,i cit cva caznlj. dc ancvlisr ll 'll l\ r lt r t 'r lr : r zr lr r r r t , tl,rir iiirloliol prirl sp;tiul intcrpetiuncular, ott ctttnplitnlr t eit t rI t i It r'tt tt't ,' l rl ri (1( Lr' r' ou i off , ci tat , de. Duk; - Elder $i Scot l, 1{) 71) ; , k) At 'r tht t oir lilr , d, ,'jrl,r,'liitsrnalice (poitmelingitice virotico' bactcl'ierrc, r'ickti,l'siozitro, Ittl ' t ) lf : r lr esr r l f n, ir t " 1( ': r ljzir I I( rI I I i II I I ()I )Ni i ti ,r' , l trl xrt' t,ttl tti tsttitraunr alicc) ; l ,rl r" rrl )oti [l o, rcspti ci i v l l i tuzalt i, t lr r r t 1e cclt - nt lt i r t t t lllt ' r r r i it sit t t t r lt icr '. ; 1 ( n ( olr t 'plr t cocicr ', Jr r l( 'ulr t t x x'it ( llr ( ^llilr , {( x'ri( { r, r' tIul :l l r: i t' 1) l l ttri ngi l .cl ' rr) St'letrrzrt trrrrlliplii, It'rt'lizlrtzi r'rir irl(,s); rr) lri t vrilelii r-rpio-c hia'smatir:r' I ,,rr,',rr ltiritirinopsii bit'cmpnralc pl1n lcziul)c t,1i:tstnrr,lici'i(l:rt tittit' sittt;tlrtttl i rrrr(i rrl ), i tr o116 sht neci) sar e ir r vcst igr lii l. t llt r u'lit t ir c ( ilr r lt 'ost 'bi t t t 't t t t r r liagnost lr . r llr r l r lc lt t t t t ot i lt i; xr I izr r r i r.' rIrr,l i ,ui cr' ) rIr rt:rl trt' i u clir nililii t l ,' , 1,n' fi l \i t' I.rr, l l l ?:,; l rt,bot : zky, . t C5; t j; p) 1lI t t t t t ot ik pt ir r t it ivc r t l'' t lr i: ', 1lo cltirtl rrr.i rilrlirxr (gliotrrrclo, ganglioneulorrrntlti)J r) '-llrrrn,rri*.1,11111111111 rrr,'i olllitxr (gliaa,mrr iau rirenirrgionmo do ncl'v opt,i(!' oll ittt'tttllt$lt' tLltitlx ri r rrr ). f{r'ryiitr <ri't, lozitrnikr rno(liiilo l1r rrivtrlul chitsrnt'i opl,i('(" (1ill'o il[(('l'(rrr7 lrlrr'('l(' llttzlr'lt\ (caro so i nct'uciryoazir,), . tr)ro{luc tillitlc rltlilllr ll(rltliil'Itol)$i(r lrilcrtr';xrrillo. lia,r' brobuitr ticoirlat,ii riurrrr iltctr{ it . ttt rot' irslorrt'o it'li1litn, lt t r r r , t i h ipr t f iz'r lt r '1 ,r' l r' r' :i ,l o tl tr ttttol * ,rocoso f i) r I [ [ r t t 'r 'iir . t 1'j's ( r lr r ,,,[.rr;trl 1,ptrxl rrr:rri i ri {,i rr,l t r lixr t r ldt cir r t p vizu l ir r r . v r lt 'ir t r lt , lr .Ht t llt t liot t t tl 'i1lii, (rl I(,I| | | | ol .i l | (i v(' l l l ,l l u,lttl ,t' " t t t tnit r gr t I r 'ir r r p vizt t t r l) , t lt t lt i' ot t t t l t lt t r r lt ' lt 0nt lt t l' i ,,rrtrrl rrtor.l i trl o o tl t,ttstt;lt 'itp, r i, pr , , r lr r i, ' it r i[ ir t l r lr , lr r r l vizt lt r lt r t lot t t ' it t tl , ( l l ;l tl nrttl l ' l o i ttl i rti ol l t' t,.l l i rollr r i't r 'i t t t : t i ( , it r lt t t $( 'r ll) l: r l( ' l\ r l) llll ( ! lI ' l) r ( xx'$( 'h lt l rI| l l | | [[1i (!(t, vu,gtrttl i t,to i l ll'l{r n0 i, r r l i lt lr t <llt it llr t t oir ) l) l, ilxtll( ll' ; t t r lr lt t t r t r r ) t Ii pl | r,i c | l i ,,nrftttl rrl t,r,kr rl rr| r r t r Lr t I t r ili, , t r it t t lt vlzt llll l\ lr r i lt t lt ll, lll] r '! 'li! lll0l( r t l

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I' t,' l l rrl rni n. 11,p1r 'zit t lil, ( l. olr llt vir l'r glt ) l) t llt li r ) ct llit l' ilt r r lir t r t r t t lr ilt 'i' o l frf,ff, l l rl rl l l r.rrr.l i i rrr t t lr illr ir , r r r ll iii lr or r lr rt 'r , r t liz: tlt ci . 'lt 'r lll( ': : t ) l\ t lt t t . it t t nt l frrfrrrl rrrrrr,rtl rrt' (r,rol ir r lt t t iot lolul) lr ) r , t t t . llulut ir t r t lt t r r li: t '\ t nt t hilit t r nul. f.i l .l . ,l pfr,r.i oInr r linir il $r , lr r r , r , lt t t ': t |ot '1, , t t I ozi( ir r r {r t lt i'( 'i lir t : i r lt ' r (' i rrr, r11r.11111' t r' ol r r r r ll t lr r llr : r t |'r r t lr tf lr lr t l|r 'lt oit si. . '\ lr t |r 'i|'t I lt I ot 'r 'r 'lit , l l l rtrr
Iti

in

.,. f.,r.,. . , t i t t r(ilr,:r, lrr.rrr , i , tI I t t I II t , , tI t , I t .t | \ , t l r.| tl , l rl , r,r.r.l ,rrl tri l l l rri r / : rt l ,rtl. . tt(' fr :r1 ,. liitrrl tlr . l; , lt i t 1111, , , . , ,o Lollr . r r r t r r r l ( , t j l n n r ( l i l i , l , r I I r1 ' I lrt : I lll| r1.t.

l r r ! ! ', r , i

r r r l | r | r l c l r l r 'l r ' I '

1 r:tI'r Ir r ;'t'r ', t'r i sl |'ttl l t

tl c

r 'ttl l ttti

1 t|t|t'1 r ttI|'

tl r '

out..r-era;"'ii 'llll:;:(t 1 ,5 0)ii .or2r. "A1#""riL 1jo;r1. s..ii'tiiiil 5iL,opoui,,r,r I lr N(,|liii;i,r | :

I t l.'.r,'Jlttl.ni.iproduse pri tt Iezi,r 11 ay6I1o.o"u1o,,". i ;, r |,(.ztutl1 itte lereti]or orbitari : osteoame, osteogarcoame, ma.lli ,,",,1,,,.t.i

;;'1 i:l.iiiliil,fj'iiill$"}"f,-,ff ;"x]1, ,iir' , ':":'#lilJi' Jiliill;: t,. i11,"!"ii' ot"*Jdd-o gi,r,oiiii'u.or"",1;; r,,,,,*i,, rrrr:r,r.rrr,,,,.rvd :;l;l;l r,:r. ':]::il?ly.3. onrii.. ',, i',,,lli;iill"i'j:.11r, r;{;1.1:;g;if.b"*",i"iji'i#rrl,,,i}::;t,;i'l],li (rr);; ,rrf..r:.ttri.tiL gttipe ero.ftatn;i,ri" patri dp ic sis[em:rt.jrl

l l ) - I( tl l l l i l r l l l ) i l l : 1 \ l tttl tr tl i tr ttl l l l r i l j i l 'l . r n t t t r t t t r l r r l ti l l l i l " l r ) .l l r zi {'i l r g l 0 l r l tl ttt i t'tl 'i l "tt'; r Y t 'l r ) 1 , " tl t l l .g tttttt ttl |l o t 1 "'i l ,r, r io lt "rr lrlllill s:r r r ttr t, i tr tr ttr 'i l ' l l r '. sttg tr l l l zl i sr 'r l i l tl 1 1r , l , , , , l l r l r r r r r ' ( l l l l ( r , l , r l l ,"tl l tr t'rt I 'r l , r r l l l r t r ( l l l i l l ,r,,1' l!l ,,,"l "i t'l i t' |r ) zl l r :l t'- r o l l r r l l tr i l 'i i tt Itttr r '{i r '( l t' I r r , r , , , , . . | \ | | | ( |: I i ( I ; I I I rr r l r i i l ti l i l l l l ( 'l r t'l ' ( l ( ' (x rl l l l )l t r l r ' i l l l r l r ttl tti i tr l r i tl l e ) 'i l l |rt rtrtrrr li .lt}l 'o \'o l{'1 1 1 r 'i r r l : r [ l l r l t t t l t l .l l i l l <'t ] t u 1 ', t , ' , ' 1 r , 1 '\ |i l r r ( i r r i l i i l i t l r r; r l r{' \Il r '' t ' t t t t l ""t' si ,l,, t|"rrlrrt l r t|ttl :tt'' l r l t tr r l i l r l l r rxl i ( r l l r l r ' II( II|:IIIi l i r i ttt ] l , , r t , , l l , { i t t r 1Ir rt I I t t I t 1 " i,,,,, - | | | I I: I I I i II I I I I | ' ' ' l t 'r . r l r , l r l l l l l r 'r r "l r ' t'II'tttt'ttIt : tte .i ttl tl tl ttl 'i tzi i l tsttl l tl l ttl r tl i r l o l l ttl o : t ', 1 1 , , , , i , , t t i t l i t u l i I) ,) r l l l l ) l 'l l l ( l ( 'l ( 'r l t'- r r l l 'l l i l r tti t'i ; s : r r r ttt'r r ttl l i l l i l i l l l l tl l rrrl,,, rlrrlrlll(:r lt tl t'.1 t'l tsi ttttc i r r ''l r ) l ) l l l l l i t') , r l rr LJr ' 1, t , , , , , t i r , , , , ,,,ti '"'i 1 i i t""'t ''l r tl tl t lttrr, sr r tt tL tl tr tl sr tl i l i i :t g l ttl ttr l tti o r r ttl i tt' ,l) l:rlrr l r r r l r 'r r l i lr i ; ; r ', . , ' |t'tttti l r o tl ti l r r tr i ;i 1 tIti ttr b i l u t :i tl tl tu 'r tsl i ti , | , t t t l , t t t r t r l i r r ', t ( ''l l ( r l i ( l ( ) ( 1 i l \'( 'l sttl l tt ( l tttt'l l 'i stl t sl tl l l i si tr l i t t rr 1, , , , , , , , , r, t t t t t r i , , t , , , 1 t , ,,1 llt r,| , Ii t' tt l tl ttt'zr 'i l l tl t r l r '' r l |r tzi r l t I t t t t"t', ',t,t,t,t l t t t r t t i ! i I i i !i t u l u l tttl tti tn 'ttl ttl r l .. tr r U l r 'l r tr r l ' {'r 'r l l i r l ' l ) l i l r l 'tr " r '' ,f, , i ', - t ', , . l i i ' r ttr l l ' t' r 't f "' ;ttr, llilr , il' l rl ( tl i tti tt sl Ir r ) l r l c txl r l l 'l i 4 tl r tt:,- l ) 1 I I l ': t t u t l t 't t 't r I r' l l rt I t t t ' ' I t t1 i ' ttct tttzl l r 'l i 'tti ttl r l :r r 'l l ctl tl i i i i ' l t l 1 r I I ' r r :i ;r l l r r t, .1,, t' rttt lrlltlt 'llllttr l tt'* i|s, I I l l : I I I I I i i . tl r 'tr r r 'l r ti :r - l 'r l tttl ttt I :I ' ' t, rr.,,, I II , | | I . I : I | | .: | : l r 'r r l l l l r 0 r 'l l tl . t":i t'r ti ' ( l i i r sr '|r ''r tr '"tt I't'r tt"tttt ' t"r t'' ' , '; i , '; ; , i 't , 'r r rtr r ; ;;];' rrrlt lr' 'i i i rlt l tl o tcscl t'( 1 r r 1 1 r r t l . 'l\r r t u l u i ri trtl;i ''l h i l ttt'r .i za ttzi i ' ( 'r '( 'r r l r l r tl r l tl ) i s , '', , ,r, ,r r l , , 1 r 1r ', l r r r p i i : r , ,l ti l r 'i "" ', i ;i l i 'r 'r i r i r l ,i r r r r i l .'.r ;r i r r i '' ;;,. r r sl l tzi i l r l l l t) l l l l i r Il ( ' l i |'r r tr r 'r l r . r t r l t , r t r r l i 'l c t ir,,.' '" r r l cr xr r r t i tt:ti n r l t'tttn u l ' l : I l . l 'l l a t t t i t t i i t i l r'l tr r ttr d i tr i t:r tttl i l e si 'l b so l tr l rrollrlr' (1117?): 1 t t r , , l t t t t , r r r I o s l i c t : t l 'l i izr i l c tl l Ar sl tti 1 i i i l l l l 'tl o r ' l t , , l t t t l t t t o t t t d ) 'i r t , : t l i xl ' :r ttti tl l i ( i I l r r l tr! t )I I t I | | I t t t I t 't | | r 'r l r t otr ':tzi i vl r l i l r ( i i l r ' 1 r l 'r 'si tttti i.i tr I't'Ito IIti L Ittr '' L t ' ,ro l l : r l t t t i c i , p t'r 'tl ti l i tr tl l l l l ( \ r l i t] C r L , t , l r l ) r l r 1 : r l ( . I t r r ', rIr r ,.Ii b i Ii IIr 1 r ''Ir I t '

r'xo|IItItIti. ; "1 , ,,,, rrlrrillrrl'()l(){ir') Vrrliabilillir'",1{t:ltl'11111..:.1.t' sl l tl t'i ( i tr r l to tl l tr r l i tr ,r l i l r g tr l r sl i r r r r l Ii

ale nerYului optic (glioame, lnot ,ii,r l rr.z iur r i iDt r J or bita re : .:r(,rnr(,. {,'it?,ir.ti^.,,-^ p""li.iioi.-;:'fi.ffi;;il:rl"r1*lTi",xt";lli, r,r,..,.r,rt.r.lio,,,o", -^-,.^,,1:30ri ili,;.,lj;l:11,'.'"i,lll..,ill::1,""^lll{,i l,.l;r.rrr;111., fr""';;;;" "pri.1_"in,ii,i"""oiiioiuo.,I",,r

sa,u i,li r, , ,,;,,1|:tzi,r,1 ,,,,, 'r,,, r,'ri,,"r,"'"'"",";;il"l,,Y"1'i"'H,fliliiil r,,l n::Lmdui a unuiadin p;";r.ttl;;;;ati (fonr :1:."1X,'.i:"li:i;; l r)

p"oces" io"ito'iitorii [cet,,ti i,;li']l)ii,]lll;'i'.i,*j,iJffi:"?Hff;jiilr"groa'n"'

ale ochillui : d.iversc tumori, facomatoze, glaucom, ,,,,,1i*1,,1,,1'ri,,r,i

i;;g,"'ii,i."if1i,r'ilt'Hii#j'rJi;ll rrrr){ r',,i,-i:r'r(.ti.'staze), lli l:ourn,"vi n. 1;urotiL,rofiri";;l;1 ;;; ihtfingh,,,,,

.rurr. l r,onl o-orbitare, mctistize,sarcoame. etc.) ny li"ffii""i.#irql, trrrr:,)r'r(r(dr.rlo(xic 'i"til,m"i"G lrouto-orbitare c) I,eziuni ; ; paraorhi , 1 . I r . , I I I | .I i t .| . . o.t (

jilirtr,iy?:1g!f-t$d*e{;"#^{#:#y:!;:*{i ::ttr#"i:i,l ;,l,lii

' ' ' r.ii r,. I lrc es o) .

i',r.,,l*,, ,rurrrori.tist"iui" intro""n"i"nl, ::.',:.il,l:ll::l i ti) ariri, clesfenoial, a"i"lllixT#Il"i"rrit"i , t,,,, t,rrrrr.r,i tlc
iIlrJ||r:t1,,sr r.rl ntduralt.

factori a1 -pt.otluse' :,l,r. nl rof bitc ate u,s\rlui r le liOit", '"iloii;;;r;;fi;;S.,'""Yi;,filli ::l]';l ::]:,',, tioti \.itsc.l'ro -sin i.i] rrrrli.r'; lr) , """""oor,-r"r1fr

II,l t);ntl.trntii ...,., .,

prin,

cranio-e.mefalici:

tumori-_;il;fTril;i"ii;i;;ilii 'r,.,..'tir*., grionme,siil".,i,tsi;";;;"."-kiJiit. ro""ri,n,,i ::l',;11:l;1.,1:,1:!:1,:,'1.:1l_qit,i: r'1 \r rlr,,r'rrr:rlii ,.r..r'ioce'cbrale: iii'sto"gu_w"r Ir.:rt: trrr ti,',,titirt.Lirusen: Trr"il"i;;i;;;;;^i;Jrl ir urnaiis'nr,.-.,;l,i;;;"#"'lo, hcm:rl.,l

],,':ll:1j1.]: , r L'r|,r11rirrII{, y(,s.clall\-osillrlalice r.egc[al,ivo sltn)a1ice

LL,I|'',.,',',I':'l: rIrri rt,i) .,i
I r | , ; rl ) \l )l lz ii

,1",';;i1,,,,,:l,l:: ,,1*tisrir;"r,f .u-.liiiii"iocrinr. i l,j,,ij;:i" Iroli, ;:rt.riatr 1tril .) s,r,.EJuine 1r.u".-iiit"rii#);'il';#;!ii"l;,.\l'l{ilil

; ) | )isyri,zia, Iiilu,ri',sii lui riichte;;re;iitii^'f i.s,c"rri"ii "noE"oit^l"'{oJfta,lmir, ,, cotat,.,r rrl x".c:to.f,luluzti Co-nstitufionale Sindrorrr : a) ful b) rrtrrr ; ,,,",,) 1..,,,,",i:.f:..:t

l\ t l ,).' , lt r r t t nii pt , r t 6 p D r,i tt J a rl o ri ,i s tc mi c i ;

r,1r'. r.rrrl.orrflrrrirrrri r,r.rr 1,, r . ;iit, ";,, ,, ., ; ,, , , 11 1 , , i, 1 rlr.o|iuirr| or.liilrrljirl. .,t lt,l,t,,t.irilr rtrt|,i,,|,,r1itr,. rk, irr Irrrrrr(ic lirlrlottlclirrir i,i oIlltlrtrrrlogir', 'l ttt
Ftr' iif t' 1 1 1 1r l r r r r t's p :r 1 o l 1 r g i r ' t t I I: t t I t I t I ri I l I r , , , l , r r z : r I t t r r r r r l l l 'i l r l o l r l r l r i l i l "l t' sr ' l ttr tt r r " r 'r r p , l I r I I i I i I l r 'l r ' .\r 'st'r r i 1 i l r r l r r l r ' ( tl l l i s r r ' l r 'r '' l !l "i i ) '

a) A fecgi uni r:rrl ,

f)Bol) ; f) Boii conEenitale (e\oftdlmia, |r,rrl'r o,,ir

li,"r'rrir'rl It,r'rrrr'r,rr .rof1r:t'nio t".,r,i

llr , l) { , lr ) tj l o r o r.b i i ,i rri . "*i-;

"iliiJiiitli.,tin"

porr,r.u,,,,i

i.ll.il. I,irrrrrrclrrl conrplex al llnoi crioflalinii solicilir:

" .il. ii. l. l,l.rtt tn t tt rtI t,linh: ' : . , : i.,' i. 1./. .l nltttttr:tr n t int t liot r : t ii, t iolir r r lt r . s o . r r r or I I r I i I I r I i | r , r [ i . t||s I.i rl rl rl c l ro lrr{ir' (r ' , r rr 1i 1111 q , , I,r., r : t r r . . ir : i, i rr I r.r.rr r i I r, rrI I i ) . , i , , , ,i ,, , , , 1, . f, , , f , , ir(|( tltl|r 1 '| l "ll ;

r r l l r r ti l r i l o l , I i , t rI t rt r1t rt. l i i s i t t r l t l r' tl . o t l r i l r ', :r l t' l i tttl r 'l r r t i l r' l ' r i i r l rr l r' ;i :r l l n l tt Ii |''r ' I ' r , , , i l , r l l l r t t t r t l c . l )l r ( 'i Ij r ( l r r ;q ti r l i i :'l r ' 1 '' r '' rlr .r 't'Ir i IIL ti ' Il ,: ' ''l tl l 'l i l i l ''r l r 'l 'l r ' :|"tt 'l l , l ) : r : / , r , 'l : 'l l l . t ll r .:r l r |' |"r "'i "l l l | |||| "":|"i i t r r li ttttr l r ' i tr l |i r Ir 'r r !r '' l o ttto tl t l r .l i i o tl r i l r tr " Ii IIIIi '' , , , , 1 , , , , t r , r 'i r t r i r 'l l ( ! r r r l i ( ) q l i l l i i r tl t' ;;l i tttr i l {'t l I ' t | | I |{ )! I I | | ' fi r r l t : r r i i r ', 1,,,, 1 ' I t rI I t | ,tI t | | | i | ( t t \ttl t:;l ttttl tr r l r t'tttl tr ttl : ' rt I I i I r rtI t' I t 1i r' ' l l l Ir r II1 I:tItI' t t t rro t.t t I r' 1: l l ' r , r t l , r r , . r t l r 't l o r l l : r l t r ' , , t 1, ' l rt t : t , : r t l l t i o r 'l l tl i i l r r l r r l i r l i r 'tr r ', 1 'r L ' i . t r I r i ( I | | | 'l l I i I l l r '. t,r r,, I I ) l t t l r t , r t t l , t l r t l t t rI t r r' r 'r 'o "r 'r r l i ' o tl r r l :r t'r r ' r l r r ''tt|r 'l r L l 'r i 'tl r l i r ., r r |.l tr l t ': l t r r i , r l r : 't I I l t l t 't t t t t
I r '.1i , | , r r r r , r ; , t rr I i I il\ l l l l :l ,IIII||||III rt 7 : I I : I

:i i !

,",,,,111 ,iij.i,:jl'i;l{l;ll;l',ll:l,lll;; Iilj;,, )ll?:iliiiiii,X,t,,1ll:il;llll,,,,l;l;,,il,,,li.Jl """'li''il,l,1;,;l;;,,:,'',:r;i,),';,,:),,,,,,,":;,:,i;f1i;;-.,!\-df;llll'":i

r.4. pfioBLEME DIAGNostrrc Dti INRPATOLOGIA SISTEMHL0R

rrrttN tl t,i ttl itt P rrrl rl i zl rt (Hlu ll Hr , luilt ilr , r r r r llr illr l, o r r lr , , I 1t ir r r r iI r I lt lt f cllilol. I 1 trl i r' ,l rt{i l tr fi :rzrrIi l o rl c I lr r r lr r llzii rrrrI I I,i 1 Irr) . , \ t r csl, cir r r lr t lr r r nr r lilillr lr , xr , l)olllo Ail)lt(jiit, foarto oxaal, ftt rrJtrl()t'ril pt[.irrrot1' ltr i irri l,.iilst,r,r', r'rr,rrrii rr l rr:ttr.l a l i nri i r. ti i ne[ fi z iolr gi|r , : : r ) , {r r l, ( . r . ior 45. ; [ r r t ( . t _ I,r,r.rl I.i : , r i rrl cr.i or- 50" ; d) inf i, r olr r zir l : li- , {0": t , ) nr r zr t l _ 4. - , ". Bl I.i.miloreo ctmpului d( not it0lp ;tt pt.;t)irea,bin<,t.t,la1i.:-p .1i,. , :r rrr ctzul in care ochiul sdnii,toseste fixator, del afecta,t va suicri lirrril,rrir,a, rrri;cirilor in maniera indicatd, mai sus. |n cazr in care ot,liul lxrllrrv cnI'c_fixator, o-chiul sind,tos ya prezenta o extind.ere a cimpulrri rlrr Iixrr(,io

iu,.tlircclia ,,liperacliunii', miqchiului sinergiccontrllaicrl) ,clrri lirrI i \l (Lal ,

:iff *liflri,ilffi ;,r"*.rm,m if i;$tiFrl fu",x[

,riri;r ilft{i,:}}}"{*;1$

jiilililtf t:flr.rriffi'ft;ffi ri ld'*f T-pfroq:*ffi jiri'i,r1ir,J'llidnilltl[lFt*l::r;i"ilr3rp;;1:;i*:""*r::

jinrl:ii;rril{}1l*#il}:ryfffi$il,r1if#*#r,lxrY iiil
,,,,,' jli l,iii;,n:Ttj"i,{'fiii1"fii.lx."lljy,, T\;:ii,,i "il:iliI ;l ilil:lixl

**l,-;'pg,f fi';ffi *l*fftl',i"lffi ;3Hl*T.1 jiril"lr',',","ff j$ti:p1r,ir"*:r

Cl T.imitareacfmpului rL. motilitqte oculard,coniuaatr;. ilillir'll 11,,1 volun rd sc pxpjoreazl prin in.pccla.rea-ex"curslilor gl,biLr| "'rrjuga.ld or, t3rl t0.col]lItzlle p-rivte in sus, in ios.la dreapl,a la stingrr, de r 5i Ir.t.r.rIr ,,i lil solicilarea bolnavului de a rrrmdr"iun obieci caic sc dcilnii.lzr'i ir, rlivct,se direclii: orizontal, vertical, oblic qi in plan medio-sagitlal (corrvrrr. r('nt{ ).

ir'*fl iii:ii: ;i-i|'i,::,*i#iilii$#*:#11lt t+ury$ffi*ffiffi ,,v:": ,iiiiit i,, *;,; ,, -iii

' 'i:',ii;lilr'u*l,,i ,ll1#i:i''',1fl' ll;iil;ill'lx;'' d1?"iih:,,,"',,,,,'
I. , . :;..t. l.,\ttrrl irrl uotilildlii, l0

Uii:i,ii*i**i$*,ii,;'tr'{it'1fi;,'{#:ffi{f;;i;g$

2.4.1.2. El utliul ntotilitd!ii canjuoole aulttmal ico-refletr utilizcirz:'i rlr'tli procedee: a) Deplcsareain cimpril vizual a unui obihct-1cst lumino*, ,)l'servindu-se ulmdxirea acestuia prin miqcirile globilor oculari (,,tloll's lui ") ''\,'..movements ; b) Modificarea pasiv5 a pozil.jii r.apuJui(maLrr.vi,:r. Alrjou.anine), care subiectul arelendinta ile a'-simeirline globii ucrrl:tri la Itr pozif ia ,,primard,' (,doll's bcrd fenomehon"). lisifel, ia roiarer crrprrlui rtrre dreapta, globii oculari tind sd, rd,mind,in pozitia anterioa,r,ri,, a,ll,o ori .r , trvilie, fali a .de nou_a.pozilie capului, or privi s'prcstinga. l_i rotirr.rr. ,'rr ui spre stinga, globii oc}lari r.or av"tr,o puJ rielativX': splt dr.cl;rlr,. ,,p-ozltrlc Lrr }tiperextensiacapr.rJui, globli ocrdrri vorliua ilozifia relaliv infoririirlrl, r:rr' flexiulea .apului, aceslia ror lua pozilia rcjrtiv' srrlcr ionri. Ll| llr(li l[r t[trea capului pe un um5,r sau pe celdJali, sc vor produce^miqc?ili tonjugfl,t,0 tr'llr'-tccu ca^ra_clcr ghaior, in sins orar cind calui csm aplccll spo rtir.i1l.rr. rl,r ituterior.cind eapul aplecat spre stinga.^Seva ruriri,ri qi cirmxrrr,ll,ir1, -este rl|llrre Iimrtalea ml$crr or cojrjngxl r.olullarc o 5i rr.fle:r.cu rri.t:rgllrrrst prin cscitarer labfujtriiciprix teslcl,.clnsicc(rolltor.ii,lc|rrricc). ;,r',rvocai

:,,,:iii:,:i[,i,!!i:,:ii,i,,,,:i,,ii,|inri'i:i{;*|;;,-*,1,
4t

... ?:4.1.4. Stud,iul d,erialiei paralitice a globut,ni.oautar (Strati.smul, ). slr abismrl se.exploreazS,urmdrind pozilia "globilor oc.;ula,ri privirr:l ln ia lllli.Di 14. priyirea in toate dil'ecliite. Sr.&bi sial 1sl.ratitic(tlctutirit,1tn.rutr,.,,tni,tent" ).se. ca,racterizeazl prin laptul cX sc acrentncaz:i,1xrrniitrri, r,o l,rilrr:wuliqi dirijeazd,privirea in rlircitria, mrqchiulni fl,Ileota,ti. i,ukrm lnlilli trltrLitoarIetiprr-ri de strabism a) donr:ergmt,prin llaralizil rnrr6chilor llnlrlctori; b) Diaergent, priu paraljzia, nli6chitrii: atlituctrx.i; o) iu1,ru tt ticnl. (.surcumrergent prin paralizia mrrqChilol colxrlll,orj rl) l\lrr.,)1 ; tt tttcttr (subsumaugcnl plil paralizia mu"schilorrirliciilot'i. ), I$to necesar ca strabismul (cirrd rru es1,o }r'ca cvitlcnt) sli,fi{\ rf)iilrr)inl1 rrlif.lrrin testuldruia!.iei (.1t silliil(}$), ltrimtrr (eincIurhiul-Iixl.tr11,ca{6'1,,.1 rri.lrrin lesiriZ detialiei secuntlare (cirxl ocliul rfccl,or cstc ilralor), ovtr:riul,l trf jliziniln-so Ei p arirnetrul, lu,i I' i)rst.er.

2.4J,4, Iiwmin-qrca pftilid t'ottt1t ttr i I a MInl?ti,ri rr gfirrlrr.i, tttsrt 1.irrr t t ltltta du rcguln: ,,boln:lvnl i;i thr<r'r,ltprrl trrolrrirrrrlclrt.r,ri'lrorrtir'rlit ,.ltittl pu,rolizol;tt, lncolctttr,a, rl. it t,.,nJ,(,ltHlt, ln ta Itttrrr{rilt lrtt4rlrirrltt

, \ t t llr' 1, llir( l{,lrllll rilr l) r t it lr t r ( ' lr ( il( f c il, l) ul ir lr l r , r r r r l i r r r r l r o r l r r i i l l i t tl i r t l l t l 111 1111, ltl r'rt ltolrll trtlr r r r oc lr ii. l, r r lir l, lt oz ililr qt , l l l x \ 1 1 1 q 1 t . 1 . l r ( , 1 t 1 1 11 1 . li i l r, rir rr l i r i (. (lr1 (l1 1.l,l, rl\l,rrrt t i t lr r 0lt li. i ( r s t , o ooit 1[ 1r q l q , 1 1 ; q 1 1r1 r , r . i l q l l l i , i ] ., ,rrprrl rri 11i lr gilltlu i, r.rrrrl jz , ir u[ - r uini os la oopii rrslrr.r,l,rrl clirLirr rj.e , l rr I l i I rrlis" o{,ltlltr', rllr (1 ll oit I ir ( : ' l r edlr ( t ibi- l ( pl. ill l i | i i l lrl) stnului sau

r lrrIlrrr,{ici utrrlrlrirrlrris1cll,r t.leirlo-mestoi{lian) lRiior, iOlZ ; Aneni 1i lo lrrh., 11)67 ).

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1.1.1.5. lltumenul d,iplop,iei. Diplopia (perceplia a clouL imagini alo rrrui sirrsul oltiect) apare doar in leziunile oculomotorilor cu strabism fiind absenti,jn strabiBmele,,concomitentet'.De obicei, ,rIr,or0orni1,otrt", rlisliugc cu uqur,in!d,,in majoritatea cazurilor, imaginea ,,ade'olrrrrvrrl 'rilrr,lir' (rrdicii,cea,perceptt5, d9. o_chiulnorma,l), care este n15, imobiii, Si rrir.:r.nr.rrr pozitia calului, fa!5 de ,,imaginea falsd,t', care este mai puliri fi llrilrrcii,oarc, mai pulin neti, d.ar mai ales mobiH in raport cu deplasXiile rl iv irii (Iiisur. 1952). ln diagnosticul $i tn interf)retarea d,iplopiei,trebuie si se tin?l seama lrr rrlrrrii,l,oart>loprdncipii. (Riser, 1952 I Sachsenweger, 1966, 1969) : r) Irrirginol care trpar{ine ochiului afectat (imaginea ,,fals5tt) estetotdea;una fullirrcrrlrii il dieclia_ de acliune a mlgchiului paraliza.t,, de piltl5, sprg lrrr:r,1rl,rr, strbiectului, dacd abd.uctorul drept este in cauzi, I b) Oaracteiul [r rrrobilitlto estc deosebit de important, in sensrt cd, ,,indepd,rta,r'ea" r,|,rl rkrrrii,Lna,gini este mai mare Ia dirijarea privirii in direcfia de acliuno paralizat; c) Oinat privirea este astfel diriiati, incit.cele rrrrrrichiuhri orrl irrrir,rrirri $int indepf,rtate la maximum, imaginea cea mai perifericd) ltitrc ochiului afectat. lrrr mai . I)rul,nr, sl,ud,i,u,l preais al iliplopiei se practici, testul d,ed,iltlopie (al, li(lt i t.tlotul.(). Acosta se ofectueazfi solicitlacl bolnavului s5, fixeze gi sd, rrrriirc:rsri trrr ltr.ivirea (capul fiind fixat) o sursd,lumitroasd,de mici, rlr'rr$il,ll.c(tlir,crirl uloi luminflri) rDezatd ]a o distante de 4 m. Do rlilr, i r lr.( r ,rr,hirrlrri drept de ptascrzi o sticld rosie,prin carc Sursa rrrrirrorrsii, rrltlrc coloratri.Apoi sursa luminoasS, fi aleplasati, directie va in lizorrl,rr,ll, v(x1,i(n1,1,oblici. Bolnavul va relata pozilia qi direclia depia;i prcc[m qi distanla dintre ele. Una dintr.e imagini (fib6 irii irrrrr,ginilrr., rrr r,rrsir., r'r,s|i'ctiy cca,falsf,) se indepi,rteazi de cea rea15,mai mult sau rrri pr(,irr, in l:urr(rtie direcfia privirii. Astfel, rlistalta rtintre imagini de , rrrirrrrql,rr rnrisurri ce bohavul pli'veqte in ctireclia cle acliuno a mu$1xr tirrltti lt,lircit. rt po:.,t,(',li (produsdde afeetareamuschilor ztbductori l)i1rlo1rir, ot'irontdl.d rrrIrIrrrrIoli), (prorlus[ rle a,fectareamuqchilor rialic[tori sau rertica,Id, rl,rr|il,rrIi) oblicii (ft!1. i,8,9). ,".i parte cn ochiul afectat vorbirn l)rlir inrir,gilloit {alsri i.lparede aceeaqi o d.illtltic h,ononimd, (sau, d,i,rectd, iar dacl a,ceasti,imagine fal$d, ':ln'o ), l, l,lrr.:rt:r l|rrtr'il (x.hiuluisADitos,volbim despreo d,iplopti helerorh, I ; tt,,r(s,rrr itt( rtt(iyti ).1n goncral,itiplopi* homonimilsc a5oeirlzil utr c nrlrirrrr corrvo!'!loril, diplopia hei,eronim,i(incruci$atd,) cu 'ut stritii)r ttt rr r l i t ' r rlgott l.

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Fi?. 7. lnvestigalia unei diplopii priD paraliziea nelvului aotor ocular (xlfr|l (lr('l)l' ochilLl sting fiind normal:
pc'e relr'znkli i' llnii 'ln .StiLla r6ie s-! Dllsl in fdta o.hi. ui Prrc ?d lnagnra @lorait F tufL l mJ 8 i ' e a ro ' i e s " d P p l r. e ? e rr a l l r'', n l D u l r' s a " o d i i ' l P n h o mo ri n c onti nr ,o.Se i .r s " r v a'c a eLo 'oi u s a d Fa p i r, . d i c d d F h t l ' r' O P a l i t i e d d Fl rr! i ! (h i ! h l t " n l i ' a l Li r bol nav Ll D r i v es l es D r e D ar t.a P J r' 1 e d a c @ . i t a z j t i F d i E r8 i n i l . r: i , , d ' * " t i d e n u s d r' . l . r. t l n 1 i , ' l .tr r gar a" o i i ptopi e or i ani al A j ,n" i sre , . u pLn drPrfr3: spre lEvrJ' rn l -l r. i h ' L r! : $ f i r i . . n F a f rs rt d r" . ,Ac eea.ii nv es r i r a!i e,d" r ,r i ,l a ro : n ' . c a t l a i a . ' i r " , . rri ' n i -l rI l I t r Fi s P r' o 5 2 l d FP l " /

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| Iri 0. ,. 1)i pl 0l )i c geuc tal i r tl c l l l |nrl l z Ir IIrt drol )t i rrh' r' i or d0 l )l ttl rr rl f,.i r!trt. dri l l ui s ti rl i r rr)i i r s Il rs rrl i n l x l t r,fl tl ul l rl l l rt!l l l rl 1. l rl IrU i D ( r r ol i )rx l i i l rr rol [ (ti r!||c nl i l (:rl l i ni i ) s ,. i |, I)|r|,I,:|2n\l )tf l " i ' f. I r l l l l l IIl || rl rrl l ( r (1l t)ri \i |rr :rr i l l rl l ri rl n i [,,r\ tl rl rr' , rl r, rrl rl r ((l rrl rr ,l i t$rrl , l l l l :r).

l)( liltlii,: I)i,plo7ti,(, o|izont.aldh,unzon.i,mii poato fi prodllsi, do luloz:r, rrlrlrirrltri rllrpl, r,siorrrtltr l:r 0,IJ., ilc la, 0.S. s:lu do Ia,a,lnbiiochi. l)rurjl, lt,girrrlrsc rlo;li,r'lcuzrlir rLrlrIlts:lltl,srrrsci)utrrinolse slrtr (1t{.il,l)trit, (,sjn rrrl,rrl, rlllpltrl rrr l'rr rlrrilr,()..1). sitrrattill lrr rrol(,rario, tst,cnfocl;;l{r tlrr,lrfittl ([iitll,r(,(,i IrrrrrrL, I:r (),iJ. Nli,r'irrlr rlirrllc irnrr.girri lnrlttrlrrxoir;rrli rlrr lrr

|tg.8. Diplopie priD p:uRlizir nrutchiultri d]'ept intern, carc se :lIL'i llllr-ulr u$or slri' lrisnr divergent (sprc drcnpta). Stlcln fo$i( s{ rlld plasattr 1lr fnfa oohiului palrllril t , i l 'l o p i l l r 's l , r i | | c l u c i ) u t , i |r l i r tr x,r i ,rr' r1,lr)mlI iri roflt (tnrr(r1,fi {lLr lilrii ol)ll(f) nr. {ll)llrs(:rrzil slr(j !ttltlIrt, oltlntl rlllrl l),,1_ r I d /l /sf/, l l l s:l ) . 'r r \ r l J i r i \ 'f f l o $ ! r c r l 1 l r 8 n (

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,,, riiicr aparli:re ;?d;L1'JJJ #friH ii,,ii,'i,i". t' ^;,,#ilX fr#ii:flf rkfiicicnla .l"r, u t,rrrr.i. mqchildr conoriioi,i, ia"-iaca distanta .rlrr lrr,irr.lintu.taspre in sus, este-vorbacle. p"";rt;;di;;#il;
lnr rlorri irrrrr,gini, prin inclinz

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rrr,rrr{r,lr,silnlunc ileterm,,inarea. sc ochiuluipi a mu-;ctttului aJectat. Astfat, c vollrl rlr ochiul drcpt, daci, imaginea iann lrosle)est",ma, jos sau

mare sau dreptul irfe'_ rror pp de o prr le (coborifori globnlui a.i I n. .-r, * oc.ular) dreptul superiorsi-oblicr Mu ] lq p:. p.Irtc lridicitori/. Asrlel, .:....., I | --.rl1'!, qo a.l1,i orca_drptolrr I /_ verticalflso lccenlrreazi, I ,".... | r!rs. hdh I iit".rl lO la ridicareasurseiluminoase(sau1aritti_ carea_ capului), ochi l fiinal in adrluctie, muqchiul afectat esteobticut mic (/2.q. JOjl llntry dcpistarcapdrtii paralii1,i",oi_ tarmo,ogrjDbtlizcazd"prob& lui Eottsi rnannqi Bielcho.n-sky : dacf, indepirlarer, imaginilor se mx,re$te prin inelinareacapului la d.reapta, inseamnd, oblicul ci, /i Ess pic sting este palalizat, ln sittratia in ,/--\ | ./h. carediplopianu seaccentueazi, aceastd, in o'( \ | /////An n -\ I I V/////t pozilie cleadduoliea ochiului,estre \*.. vorba Yal de paraliziadreptului superior (fig. l1). I Daci, diplopia se accentueazd cofori_ / r , l ,i l rl r, pi(i $( f n * r r I I d c p l r r a l i z ia la ' h llll ,ri l | ri( r)l)ll(:( s obllc inflrlior) lea sursei luminoase (sau la coborirea , I r . lrI rl f . I t ii, (l n r c L l n r D a l t r o r m sl capului), ochiul fiintl iu arlclucl;re, r r r rzn{l i , lrrl r)r: u l r t rl n o L r i r ' [t l h su s. rnuryI r ',rl i r r t l lrl s lt l I o l n [ c d o d ) t u lu i chiril poralizatcsteoblicul maro i,11,,g. tZ ), l l/ ll, Ilrdf l)rlf lrlr o l i n l l r ; t i l l c o lo in sohimbrlacii,diplopia nu so rcoclrtru-. r1r lt, I|l l x lI lil nlt r t r ( : l d ( l b o l u l v u l , l lr ' l I M t i irzil jn lcou,sti, pozifio, a[unci lllul1(jhiul I l i t I r ' r \ I g n ( d t r t) { r' r. , 1 1 ) 5 . t ) , /ti rrsl,o Irrrrll,lizDli rlr0llt,rrl itrl'rilior, _ 1 I I

,, I --T-----l b, I

f"?:,iff;"|;;H"Jil"f,,",1J"J;'"ffi,,f1 rerpecbi_v oblicirl

Jriq. .17.Diplopie generatd de paralizia rniEchiului drept superior de Partea dreaptA. Sti;]a coloraLl s-a plasat ln fata ochiului paralizai. Imaginea colorate se depiaseazl snrc in sus, cu atit mai mu1t, cu cit privirea spre ln sus 5i spre dreapLa' sc j e -lrii"azrie m a r c a . i o b l i ci l a te a i m a g i n i i poitc r ''oloiale spre slincu (dupi Rirer' 1952)'

m,, m,, -o1 ',o1

genrrJ Ld d. l ' rr rl j r i l Fi g. ,?. D i pl opi c . muqc hi ul ui obl i " marc (s ru onl l r s "Ir' r r(' r ' de partea c l reaptd, c nre h nl oti rror' rtl rrl j" ' depl :c eaz e gl obul oc ul ar In af' uJ s i l rr i rl i l i fnl S ti c l a c ol orati (l i ni i obl i c e) s ' i inaintea oehinlui PamliTrrt '

2./r.2. Paralizia nervului oeulomotor eomun

in situalii sen'iologice cadrul paraliziilor perechii I Ill-tt' I Existii,,srise ttrll slrlr rtlir' po$iald (inconpleld) cu alectarea uJr .'t oarali2iaertrinseed (cu rfr^r'lrrt'r completd' ertrinsecd rl,,itir." . o..tili u:.irinsi"i iil p)arat'iziit' (cu aflctlr'('r' ilr'rrr iri*""'*t*ilifi" ;'c\ Ttaraliziai rt\rinsecd""trinsi'cij ridtra rei : d) paralizia totald'(cu printl"l'rr :rlri ;, il;;"ill*ii ;; pilocor'st intrinseci); e, r) irt mllort ctt.frr.trr'i qi, &iGi".i.ii ; ;;;;;;i;ii sau bil'axatatd p6tn"nii a "*lei poate fi : wnilateraLd' rrr-a i;;;;"s;;;;;i*iiri"

ilmpliax' o-.ptond 2.4.2.1. Paralizia tctald' a nenu'lui oculomotoraomtLm glob ocular imobil in dirocliile- ilo a'o{iuno a oo*rrieta ;i un ""f""fr"aie ati, i"i"t", arupi inferior (mi;ci'rile iu jos fi ind tol'ttqi itttt tri'rr(.rirr"" -".ii*"i bbuc-mar'')|i drc'prsulx'ri'r rnuqcbiului ,:ii*]"p"!u't" "T ir";" St:rabi.imulttivirsent csbe foarte'evidenb, irr rliplopia cste orizontllfi ;r ptpita este midriabicl $i ,,fixa", nercacfiolrirnl lr lttmitrii i'"i"-ii*i,. Ir! flcomodare gi la converAoo!6.

osl'o ltlllll 2.4.2.2. Itaralizirt' parliatrd, a nerawlui ocuLomotot coT'?lzzr, 'corirplel,ri. rolinut fllrl'lll cil' tttltttrrrtxt l)iur trcbuio ,no,iireoventl ,fecit oca lrl th'btrlt incompleL (prr'rlirLll ulcc Irtin nl,rlrlitrl i,,itriitil .lir' p:Lrlrlizii prrrIirrlort Ar:r'sl:r' ",,i"ttt,ltr: .,',,,u I'ii 1r:rr:r'lizici' i,i,,..r.i""ii. ii,:'i"-i',,i*ui 1x'.'t $lrb ll),nN ;;;;;ili,t blli,i,, s,,h t'rtrtil llzitrtrii 'iinoi sing.r. rl'rtrttti, srt'tt ttrtttr!i rnttll,,t rrllllltl'i lrol'vr)lr' tl.rr rlo iiii rr ,,*,,i,,ii vrr,r,itbil. nrlr*rr* Hrlll l'lrrll tl vrrrirllriLl' ltit'tozohtt tltl ^f(nJli[,tr) irr,bl,rrrli iltl'trtrttltt'ttr il,i,',ilii'li','n,, '',',,fizol,zr1,

l r,"rrl. r rl. rrrrrrl.lrr rlr, lr l . r r lr ( l. t . r ' , r lr . r , 1r i ir I . r ' i' r ' , r l 'r , 1 r l r r r ; rtr rrrlr| trlo r' l:r Jrlr"rl r lr r . r I I t I , r ' I I r I I ||( , . : ' . ! : ' ,:.
t lt t t t t l l t I

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:'.1.:!..;.1.I'uruli.,:iilc lronculare itint ijelc tn:li lutnet,oil.se, specia! in |rrrr :rl,,,ii',i (.11t.se (lezvolt;i la nir,elul bazei craniului (J,hnsi,ori qi l'r',1I .lollriou, l1)6?i liucker, 1966; Riser, 19i2; popriviciu li l?ascu, I : lr;0). li. rrrl r'li'gc ilrt,rL]citnerYll ocu]or:rrotor cor1tunp:i}isoqte tt,unchiul 'iL, ( f'r',1'r'irll)l ir li) ila$oioulc, leziunik: ,,rad,iculare,1 accsl,rrivr:l ltaiizcazL lil :rl,. i.r'i l'lltill(' si irLcuale alo muschilol oculomotorj.il schirnb, l.rrlte It ttt,tlt. lrr ',i.t,drr[, lrttttchiului rertos prod'c o ]tt.alizie lotali'i dc pcrtcho l l l. r u (,\(1{il,1ifr i'ibrelol pentru mUsculatura ocularii intrinse0i. care ..ri. l,r( o olul'ciite protectie specialir lozirLnile in blza.le.ltrin ;i:rptrrl r':r r.lr. 'r'rirr(lc silrrLl,trintr-o pozi!ie arialir ir.r interionrl nervrrhri. doar rr, rrlli
Itrltrtlr ttsittntrr ittltut't antirttd plotlucintl 1l r , l ri ,r' liliigilr r , 1! ) 50 ). a.fectaroa pfr,(iorrr lt llce\loI[L

'' l.:.'.;;.1.1. I)u.ru.li''"i([rcnrcttlard izolutd, singu,latri a nrrvu]ui o0.rlo, ,1,,r' (l,r''r p,rric lii r.r,aliza1,ii procesc nevritice, meningitice (iriclusiv do lrrr,lrlr'), r'rrlr,ori do alie pluceBe bazale (dupii culrr rom r.etlea), ri:r, de olrrr li, lrlirr \'(rrit)iilit1c1llcestui terv cu ceilalti nervi oculon$tori fii (,n'tlti rr, r'r r r.ltrrriIrri, sc rt'lllizeazI sindrolrne tt.otLctrhrc r.-\1r.ilrre\"r,it,\in]e ale. l, rr i ,, ' r lt i; r li r lr . r r , r' \ i (.l ttri ,,r.i . :'.1.:!.:j.l.:.'_,\inrlntu,utt tronc:ttlr.r,t entraneuoJ)iale d,c It::i.tttti rnullifie r: , 1, tr, rri l nr t ir , t r i ( r u, r:o i n l e re s a re a i a m o to ta c u l arl l l tl i {:o.t,tu,n,): s \t ll itrtttrr, oIt rtl..tn oltk:aiaii- Se ltie ci, trunchiul lerr.rilui oculoritotor. i.,'||||l|r \rrr{l lrr (,l|lll,lt(,1] 1,r'ei:ulcle (:uttCra bazilar5, a;r1.era. (1lt cerelir,loaSli rrlrr.r'rrrrir ril ;uJr.r'l r,t'r,r,lrlal:j llosLcrioari). Aceste configuleirii topog.allice t , r'rrrl l l z r lr ( ' ir r r r , r ' r r rl rrij rr a rrc r-r,i s me l c i i n p ro cesel c l j ,ero- sf al teri oq
I l "1, ll, ' ll'. :l. l..t,rt i I,.l' .. n lir s( . r ,\ir li( ,1 ,t n ti,trntttr ,,:! rl rtt6ptl l i

lrlr ,,rrl r l ir r ir , r r l r r nr it .r i ri c v rj s rrti ,rrl t, e c c s tr,rr' -]a " . .-l U i gr" ti ,,c,ftai rni pl egi ci , r1'.,r'r.r|. ,lri.r'i irr rr.lriliilio sa,uadolesilcnli, (tiickerst:iff, 19{l+), lr, siiliiircti , , r',.rrrrrrr l, r , r . r jt ' t r llrilig ro tl o a s o ,l i e ta m i l i a l e , fi e p erson:rl e. I{ i gl en:r, oftal t r rr, ,| 'l I r, rr I I ) : r i( . s ii l11r ' t,l l (fz 0 s a s i r n i ' m c rz e u p i i O n i grel ti si rnpl i . Il nrerOa l rl , l, l ,,l ,l , r r , r ir 1r ' ir r r r r l i rtrl rl ,,rrr.l !:.r r,;1 c u n i l a te ra i l , cu i ol l l i i z:i r.e or1;i i i l i s ||r ;r,,rr0r I r i( I r I iiI , i r , i | l td j 0 ro N l ]l ' { rv c tte x , i l p :rrc c obi cet 1l r cri zrl . cU il, , l,rt l ',1 . ( 1 r li t , r r t . r r |irtrl ,u . i, l tu l s :ri i l , ,rrl e s r.tiu s rl rL r tl cr gr..r1,tisi r-i i r' si i tul i , 1, , "r,. rr ' r I l J u l (...\l r,-.1 , fr o ,.,.t, ,,,.,,,,,i ;1,,,. rrt,rz"tl :1,r. .,.i ' r ( t , ir . , r t , - , , , l. l ,l ;'i r., , ( , r r ) t r r lilui( ,l i r:rrtrrrru ti rl s i r0 a l i z o a z l -r, l mai fr,({ rr1:er}tati gcre .te o , r rrrrl rl lr:r-: r I r , r ' r ' r , lt iilr t rl l .rt, rc s p trc ti ri d u n c o ri i n e l vl l i i ti i :r1.r,i nseci i .l { o, , ,lf l, .:r l \ r r . i r r 1lr r , r i rrl i tL t| r.r:s ti l ,0 u l t n l i ri l l t,, ai l csi rt, i t.rl soci rti | cu rn .rlr r;,,.r'i :r 1r lr . r ' r , lr ii I l1 ri . In rrn d c c a .z rrl i p o a i .c fi i n1,(,i (,fi l l ri rrci .rul l , , 'Jl: rl rr( (\ \ ' ir lr lr r i ( ) r l) { ri r(' rl )., l 1 } (i l ); .[1 .l rr.< u 1 .. 96$). -rrLrrl t,s,ri i s l i rl Lnr:. r, S r rrr r( '" r':r'i r ( ' 1r ' r ' r z r l.r lt |rr,i p ri rr rl i Il o p i i 1 r,t:c i i i :r,tr , l .l i l i i rl rucl ' i , sl Lr [0r,i rr0 o r rrllrrtr: rrl r., r ll r r r ir lr r . r r iri rn g rJ i 6 i ri ri ;' i r.r,rri il l :rl rrroIl r,i ri ti (l l < l l L:z S ol l rai o 5i rli r, l l l ti l, ) - , , \ li' r , i, r r ll l rrrr,r,r' i Irr ,IIrrr| o rIrl rIrrl rrr.I i r[r1ori l i i rrrrri l rl rrrr:l l i r i ' . u, r ,ri o l l {r r ' \ ' i, it r Llr r ic rl rrl l o l j rrl l l r< ri rv t,r' i ro s l,c l ti i r.rr :rt.l cl r rl rrrrrl i tl l i l rrl, 'r'''r, ,,i ' r . lr ' r ' z r r r lr r lr r.r' r.ti irl i l :rl ' (i rri .rIr,rrrrrIi Irti(\\,:rl rl r rri (),l rrl ri rl r,, ll) t ; l l t. 4t l

.t l i n

oftalmicdui, reflox cornean abolit' dureri in teritoliul llorl'rrltri rtllrtltttic. Daei, sint a;fectade$i fibrele simpatice oculal'e, apare o ltiozti ltrritrIIItctrIrrIIi r1e cocainii. AceastS, tr,iozil ne indici, respectatea g^rurglionul i t'ilirtr' ;i, r'rr, Dimpotrivii, aplril,ia midrir.zli rr(' rrltrrll^ .afare, o lr:zjune exttaorbitlri. atenti:i rsllpra unei leziuni intr:rorbitarc, ct lldecta}.eafilrt't'loi' rh' Lr tl:rtr .Elionul .1iliaf. b\ Sintlromul de apen orbitd,l' al lui Jacob ti Eollcl sollmirri ('rr lrrl'('{rdentul, dar, lrin distrugerea soncomitellti, qi a giul'ii opti('t, s(' rtrltrt::;:io leziune progresivii, de nerY optic cu cecital,e Trrogl'esiYri i^rtsolili'r si rlrr r chemo$js. Dxoftalmia estc mai lrronunlatl'i, rlecit irt siiltllottrlll llt(\lrtlltrll .qi pulsltili, {prin comprimalea $i a Yonelor olliiillnicc). Iractorii etiolol\ici care irebnie dccelati sint : (peJlLllr sirrr;''ili.' iriterven-iiile chirurgiotle - L-actori traumatici: .de exernplrri ; fractruile (,ralu'cnL' care intercseazli' ii orl)itn: lt:t|Itr|ilrr .aripii mici a ,ifenoidrlui (cu afec{area ini.tialil a lel'fclililr' Ill ;i l\'. rlrlr ultelior si a tligemennlui - Rollvet' 195?r citat tle Iloger fi ('trlrrl), ll,(il)); ollrultractura crtstei supraorhitare (in aceasiin sittatie, oetit:ltcll lrlrr{,trtl{' m0piegi:l). neoplasmele orbitare i tnclliltgioanlel(' ,'ii uli,r:rrrtllr' - Iunrcrile: eryului optlo: t, Inorile osoasc (osteoamo' rnot:lsl'Nze osoils(r, llllriot'r rrrl .ostcocla"cte, chistuli osoa.se) meningoencefllocel ; clistut i tlt't tttrtirtr'; lrr'li t prolifertitiyc dt sistcdr (grilluloame eoziuofile, boala, llLi Ilittll Sr,lttrllr,r' (1 Ch'jstiari, rrieloame, boala' lui Ilodgkin) ; turnoli tle l-ecjltiti,tti (ltttttot i rrlr' tumori hipofiza.re; tumori n:tzol:ll'ilrgi{fl)c, itttlcosr'ltr r3inusuhli sfenoidal, arcinoarne rpki{.xmoide, limfoe.pitelioame, hemangiot^pili:lirrrt'tito St t tt i l'asarl si colab., 19i5), Aceste ultirne tumori rlazillc 1i tritzolrrt'ittr.1t('lr, pot lenliza ilttii si'ndronu,tr Josi Ttleriyopalnl i n i al I rri lir ht stttt siutlt,,nul. cle ,tl epl an\eu otb i. t $ d, lllt i Dejer u, in clt o se r cllizpuzr - rit t ii i r I l. zit lt t r r r tt t ct t t t lt t r ,{nlrilal superior qi a non'ulrri clnalul[i ]ierjgoi(lilr.lr (li,rxct' 1i .olrtlr., illr q. icolab. , 191ir ) ; ilm or i m {- : t asf ir {}( t r t Llr t t t t r , ir li' l) lr 'r 'ir r ! ' 1969; S ri ni vts lt 'ntitlntr sau Df[,siallc l. ; - tr-scli,ii l\usclllari: ltner'risn c]; iingiolnxr (ir spi,ciirl crrr.l ttorr'rr') ti oI icc u:.esr caro t idir . t"r'. - Ll-ip crrt,'tee, cu ale1brtilat'orlfisulii or'bilnlc sttpt't'iurt ttJ Sintlrt'tnttL in.fracltnoidian al lai I)rtwl.tl st' tltl'rlrrlotizcrtzit pt itr rci un0l o si n(h {) r }r ului do all\ ( n: l) it al, dt r cslt l}r {xlt ls ( l1r lllr / r / r ilr i! r r , < d.t.tl tt" ei , catt) lillo ilf iar r Lasil, Llllt iI l piir t ( f ir ,lt lllt r l'ir ) lllii r r sit t t t st t lt t i( '||\ r '||||) r I , r.l rl q t,r1t!:a,zr i lllr t t l'izglt tr r lit t oit iir : lr llt lt 'iolll( f ( ( l( t t lll( lc l) l( , \ 'ilr ( f I I r' | | | | | | | i I t '|| llr r:j rrh' orri rrl tri)f r i Ff r ( '1, ( r l{r l r 'r t l r t l t ut t t t t lt t lt t i oI i ir '. (l ) ,S i l //r ') / / / ?f lt lt r iislt r t t l. ir '7'1l1ttt. l7: noidr t lii t l lt r i , lr r &! l r '- r lc lcr r liz: t l, t r ri r, l ,rl Irr(| ti cu lr t t t t r I t lr r lt lt 'f lt t r ' llllr lll' lt r l] lr r r ii, llI it t zr ) lr ir r lll) l lr lr r ar lllr r , :,rrrri ,tr i ' trrri tlr r lr i. ; . islit t |r r l, 'lr llll't lt lllllli. i{t 'lt t ir t lolf iI r 'sll. r ; it t t illt I t ll r ilr lilr i) sl lll, lV r r i \ ) , lt r ' I 't r t r l rl ,,rrrrl ,, l rl rl r , 'r 'lr ilr r t ( l, r r t t t r i r r llllil) 1": 1r clllI t iI r 'll,

l i \ l l r t t t l r t ttttr r l r l r ' l tttr tt,r ,,r t'tt,ttt; \ttl ) t't i ( 'ttti t ( N tttt r l , l ,ttl r t :.1 |tt,,i i 'r l i ) rrt tl I t , rrt t t t r' , ( l l l l ) l l r r l l l r r l l l l l l l 'i l zl l ( l i r ,r ', t' l l t t . ( , l l i / r 'i t z r i . r l r ' 1 r r 1 r 1 ,r r l u r r r l l r . | o l r r l r . " l l ) ( i l l ; l i i r i ,l . l l l .,i l ) : i\) fiirult'onl1ti. t:lu,si tlt l,rttltr. x.ltttrtidulii, rtl. lui lirrhtttt I)trtir1ttrurt| :it' c a i t a {r t e r i z e a T . [ ]xi u 1 ,1 '( ] l ) l r l r l l i zi l ' l l ( l cl o l 1 ,1 |i l l ( l r vi o ( 'l l l 1 ]1 l Io i ( ni . i l l i r i L l l i r l ( ' Sc r e :i l i ztl r tzi i : l l l l Ji l l 'r i ( '\( ) l l i r l l l ) i ( ' a f e c t a r ( 'a f f ) n c o n r i te n ti r , ti o l l a h u i o u l u i ' ( u q o l r e d u c l i b il i ) ,, p to zi , p a l p e b r a l i , o l ta l m o p l e g i r ' ( r 'tr vJo l r ( ,( 'IIIi II ( I) ||II) I( '|' imobil lrin 1lalalizia le.rechilor III' lYSi YI), trxttliticitri 1)lrl)iLrl!' (lirilril:i areactir.-i la luminii Si la acomodare), hipo - silit lnestozi(r itr 1r'r'ilo|irtl

4'I

:tr,r::i,:,1:;t,;,*,ii#x;!i:x*[ffi ffir:;li#j:P"*:Trl;:3:; l' tii,;;ll,l; i" ^t"'ito"iuriliiifri".\i.ii ;t;t*:ll,*lt,ru til;,"l;l;fu".,?ftritlts#Hl;{i Ff p""uri,ia perechilor I ;;..;i'ii ']'l1l'|fili*,1:"'n'*"
Eoger 1e0e qi ,,,r,i,;j,:iill,JllI:i,,gl?j"t: qicorab., qideArseni corab.,

Lui It, Si.Ml,fomu| .It'hrhn' | tllrli) t1*.7t1 i'nauroytrtlirt ';;;l,l';,i;i;'l;;'ll;;;i;Ji,lliii:l'lil",llilllil,"Lilll,ll,il,li:i,i,ll;lll H(\tr ftrltrrirt l.irt'.''.ii' l'rlrrr),lll(il'') ^;,,i r,rirlri, lii:,;/,,1';11,,,",n l)o 1,1rr, rt,rrdloxirr. l'rr,1rl,, rrta,,rio'rtri r;i l(t ll1', lll{il.; \V( irrlt I t) N iurl.nnn.ul, ilo ,nt

irr ollr!l ln('pl(!grr,' t'rttittrlt't'iztrttz'i1',ltl

j,lilil!lT:f;it*.1i{1'jx'H',",r"1,Hffi j?rtl# J:l:l:l 1r;ll"t*;;":nf,I;i

atecteazd,:. ramurire toate j;l ,,,,,, ll;iilj;fif'l "#:mi:

tr) t|,in.d,rornulanNeriore,ste identic cu sindromul de fisurX . orbitard, ri lrr,r,r{|lrrii, coafeCtare& (cu qi nervu]ui opU"l.'^--* -a tt) N,intlromul med,,iancoafecte?zd,to.,i icuiomotorii 6i primele rloud,

,,,,,,,,',t'1,t,,"'i,l,i"'i;'i,"0!,rll.on')
Ir't <ttori tli.ol,ollici :

p :ry,,,rr,,r,1,riirrri,li;l,,1if ?*1i"-?H1fl*T*1":i'fli*i"",S1llf fml*: seadaugr' pQ'tro' d l)ariantii,:

ri:;,r;ni;,**uili::,,J,ffi #i'"'#m'Fl:,-k*#?#i ;iil;litil;'li",ll:,T,1#**,ff

r rrrp | 'r.l i l i rr( ( , r rI iic t ' im are ), |

;Hr,i"#fd i'*1116*:f1ti*_T,%trf
sindromut' gtaratrise-

conmn rorlizal,oa, (cu a" r"r,f,l'r""i ori;, nroprosii lil:jl,l,,;iililli:11;lrrlui

t8

,t,,,,ur,tr,u:ale arterai carotid,e(Jeftercol, 1958; Arseni qi colab., ,r; ,.ri,.t ,l,t.u.t.t,Dtul.i,rzr :il c/c, incleosetri cr. realizarea de fistule . carotjrlo_ca.yerr,,'iu,.! r.irrt irr.rrriolrgis rtalizrnzdL rapiO : ottalmopt"egli ?riftamli puts:"tite r,r LI||||,|||I||I\ i,r'illonirrrlc(Iioger irl colab., lgOiO)." | ) 'l,nutlnfhltitt:le sin .sului caaernos ,tealiz(,azri : exottalmie masivd,, ,,ri.rrr IrrrIIrr.IrlrrI (,xtensic rju ftuni9 qf _p"" lfre rrr,;rt rlr,rrrir.i, p.rrvii, 5i Jcziunile respective Ae ""gr""#iemporata, stare ocrriimoiori $i trigemen. !) i.lll( lr.ro.ta,ea infecJi,oase meningite t rrrtn, o.oiogite : sifr_litice. ti) ltol.i d,o sxrtarz.. mir{om. multiplu (boala iui foft.1 5.*. t,',) tlintlrr.trnn,l da hemiboad, (sindromul lu,i Garaii, tintl,rotnul lt6 , tttrttlriu yi Q rrn:itt, sutt, sind,romultui io"tu realiza, in ..Bc.rtolotti-.Gairil,"i' ..rir,xl,{rl .lirriu rkr rna,sivll, r:xtcrrsivi,utu"t""" Bi ii" o".Ji;i,'ieni, qi p',ra_

tigt!,",",Lq; i;,lll l,,ll)(;ili,'ii,1,,,,,,".,,'*i*l,'iff-:"'i;"if,fl:x;"^'ii*iiL

lol:rlr., l!t(il)) b) ll\rmori rn ;

,,,,,,,,1,1,,,'11i,11:,T,ill,;il,H11i,f,l"Jifig:'.ljx"l?,:i"tfdeosebi "'anior,rin-

l"i likx,,iwirr $i llosor' l!)(ill; {lilrlr,lr',1 ' tkr rt, ,r' de t; Bi)mtrom'u'l' ar(xutltL t'littttsu,lrti Iosl; tloslrl'is Ifisclrot'-llriiAgl tl..r'i,ltrr <,ttttttttt (x)t'l)r.('Hilrrii .crvttlui (Lgiiffili se da;torc'Uo 'cltltttttttl,,t' ,,i'castailivus'lui, ca urttt:iro , proccsclol hrloc,it'lr. t[. sltitl'itt (rxlrttr ittsl'alaro rt' 1ta'l'rtlizit'i hematorir subdulat q.a.i. Succcsiunea -de "eiebral, unilaterali - lrritf iazr'i' ;-i miozi tranziiorie ,,ste I I [-rt' ptozd palpebrali' - in final, paralizie completi a perccltii l' 'rrpili' fixd -'r'in5,toa.rea: itt Fischer:Briigi iiolo; a izolat dou5, forms clinic-e: a) lorma aau't'd', t"'ttt' i naralizia ocirloniotorrllui este urtratd, ime4iat de pierderea o111lofliilrfoi itr progresiad,, care paralizia perechii a [II-l sc.ast.rci:rzi tttrNI i,' Surn,n in lreplar cu somnolenli qi apoi cu piertlerea cunostrntol' ' H1 Bindromul Iotoia-Eunt' Olialm'oplegia (sitrtltrrtn-ttllirdureroasd" . reprezintd, entitatea nosologic-5,.incatc se-asociazii o oft;n'ltnotosa-gi*t) parte' Tolos:r (I9j41 a. tk'rctir+ de pf"ei" o ndrratgie brigeminalS aceeagi "u le'iunj peria.rteriulc :rlo ritirrrrrlrri itriimunfeeia, dur-eroasi la ul caz cu llunt gi colab. (1961) la qaso cazuri cu inflamalii gri ttrlo"r"otioini.-iut ale sinusului ealvernos' Smith qi Taxtlal (1966) alr folo$il' lente -rJomu de ,,sind.rom Tolosa-Ilultt', Ia cazurile care au lespuns tavoltltil iermenut ta tra'tamentui cu corticosteroizi. ln acest fel se pare ci' se t'intlo sit' srr fac6 o clistinclie clari, fa!d, de alte sintlroame asemdnii'toarc, diu'.citrtr tumoralo sau inflamatolii, care tttt ctrtltrltzii iini produse de'leziuni, in s1]ecial la tratamentul cu torticosteroizi (Other. 1967; '\tilslcitr ;i [lottr'. oromnt iio, ibzi; nnllf,lt". 19?3)' Lapresle qi Desi (197?) considct'ricii It'r'rttrrttttl ('!,t{) llll n(! tle'sindroin Toiosajllunt trebuie folo8it numai la caz*rile la etiologia' poate stabili cu certitudine Mai recent, I[unt (19?6) a stabilit urms,toarele criierii pclrl'm tLingttttx ticul tle sindrom fotosa-nunt : a) Criteriwl, anat'omic: deficitul tttrtttolttgitt prin leziuni la nivelul sinusului cavernos anterior qi nl fisru,ii "*i"-prio",sun,jri"are. Structurile care pot fi implicate incltd nervii rttrttlo ornitiale oftalmic, fibrele pupiloiilatatoari parasimlrilf ico tt l trrt'trt' l l i i *.io"i, ""ii"t a IIf-a, qi fibrele pupiloconstricloaresimpatice ale ple\u1Li lttlritlilttrl,irIirltt. b) Cri,t'eriut etiolioi6 qi' terapeu'tic: atingerea forrna{'iunikrr ilmittlil'rt csl'r' iiatizatA de un iirodes inflamator granuloma'tos oronicr 1i botrigtt, citto reaclioneazd, favorabil 1a corticoterapie. Cafuu,I'notologioolsindrom,nt'lui'Iolow'Huntloa[()1:irtstl'olsist'rrttt;t tiza't {I[unt, I961; 19?6; Lapreslo qi I}'''i. ll}77) : ir) rrl'rrrl itr I'trrltrrt(it 'i* ambele spxe; b) debutul mL ci'" lcciLt do ryirsl.ir (rlitr .tr1,iI:'itit' "nufl it A""ua" a VI-;), cu predominlr,rtl,l virsLtdonrii6cii; o) (l('l)lll'lrl lll rrlo; (lo-?lllllrglrl lllloi ilaie fi nroelesiv, in citcv:l zile sau in inni tntLltotti;n1to ()sto olro lllllll'1r rlc debut ce1 nai <xtnsl,rlrtt' ii,ota-itrii; ii) seninul (111 oftalmoplogici, oontx)lllil'(rrll 'Lrre're&' de obicci ct clt(rvr zilo ina,ittl,oa' br-usc, I oIl':rlttt'1llt'gi.i tItt':i itr:rlrlrtLtu' oaar*iu, *uu, iu rarc cirzurirll l,niirr lilrtlr r:tr.Irrlrt'ii' ([t'buleazi Filr :tli,,ralr'aslirii gontrraL', air'ctiunea ;i-;;r"i rnodeTAtd;f) dUrerea esLellnilAtol:llii, 'crlr.'i;itrrI rl{1t(gttlii 1r!rrlt)rl.lll g) oital*ic, raroo'i prezonLin{f i*,rliri'. ilr horrrir:rarrju; rlrrorilo pnroxitttioo. qi. u'0o U)il'""i,o,"li.i urt oxu'c"arbrtrri sin't severe, cu caracl,cr contitnru ii :r,ti.,"r,nzii, na,t ll1rI trrllrrrrilr'i tn do eurLsibilil;rr'i'. t'ori ou iii^iu ao '5icri'ivo lrrl,vltlrri ttltxiltr qi ortr.''r{illtttl iirririf n-ffii-i",1lrri, urrtrrri hr i,r,r,iI,r,irrI li h) 1xrrr10 tlo rttit,itttttll,o ir, ,*t .,1 rrurvrrlrri'lrra,lrdibul,.r; olil,n,hnollogit, ,rxtornn cornplri;ll, (liit rtirr r,rrzrrti) li,ti'g.r'. oxt,rl.n.cll, izulnl;ll, I iiprii;i I

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lr:rrlrrlir Iit loltrltr : r lr r , r , r , r . lt t | r lllt r : ( l/ il r lr r r r r . . l l l r r r | r , r . r . r , : tt i l i ) t 1 l i r i l i" r,,r' lr rr lt \ | :r { l.'., r lt r r , . : r z r r r . r ) ; ! : |l. t : t ir , I r , ||r l|l|l i r l r r . r l , , , r r r I r , I , r I rIr. .riirr,,r,r,rr r' , . rr' t tr,,t ||r.rtIr)r r ||LI I LI I I ) |. I i i) ] llil|lir . r ! . ir l| | 1 t , . l,l r]t / I I I I. I l I II(,I 1| r , i l . r \ ' ir ol| t ]:rltl.t l:l', {lil ( , ir z ||r i) Lr t ; r |jlr lr ilir : r ir , l r , , l l r j t l t t l | . r i t l l l | l l r . t j r z r l rr. : rr, lirr .liu t Jltlirr |, ( , I I r , i|\ . j. r , . l) t 1. , r l. t t f ir( [ c lr . / , : l r . . r 1 , . , r . , , , r r ,1 , , r l i , , r r l r r i , , , t,rtirz: r rrrrlrt :r rlr, l|z:t t r , r r s ir r r lr : r , iii, , r t lr r i nlr u r r illl l r l ] ( , t , , , ', , r , . 1 , r , , , 1 r | t , 1,ortl,. ll rl,, ,.lirir 'l,lr lrlollr r ur I ir . r . lr r .I I r |r , l, , t ll, ir , , , , l , l , , , l , , i i s {, l }r ) i r r {f r {, l l }l l i , t l I ilrrr!r'lt. :r.,,r'r'\ lilllj olt l, ic ( 1,. { ) ( [ ilr ,I(,,r;rtlli. U, i) Zt ' it , t g r l r r t , . r ] , , r , I t l l i i 0 , O u I n r N ; i , i i ; 1 r. : r . r l,itiiir.i rro ([ili( jir . ilor . I r r nt lr r lr r i dn oc hi ; lr) \,.S.lI. cste rirxlr,r,rrl ,

l fl ,,r l tui l S r,,i n r',.lrrr,tlrl'l ; S,rrrllr.irrL.r. ltrrlpp, 19?3); si n) sirr.pto_,ii" pritil;;;i,, -u .,rr. .:i;rr:irrrirri p(rl p.ozcnl,,-rbmisiuni spontan'e,- neori cu defit.it. .f,i rr.zrr ',: '.,,11',19,,,: rirrr.: (,) l:cnomcn.,lo pol .reapFrolr jnterval, dr. lrrrrl ' ,.i'.,; ll urn:tglr, slulrlntn:tlologie rispunde [rlorabil la ldmhistr:rrr.:r, ,,'l or){Urilr(hr-se unoo4 o remisiune complerd, ilr cil,ovrr, i,llllli::, i'll:'!il}, ,l::'.1:l:ljlll.rl ,,1 \riu'c:,ez I j: te ., ,,,rl11, r,rl'Ntrlg,.l .r. disculi :^lapr.essi Desi.reTi);r) rtinprrrrr.r ,'. ::',,i::.1 r. Iie exislenla Lmui proces i:rfllm:rlol. '.t ,|| rI rrII Ir,| |IiI |,I)fi 1rs.r.l.t,urno,l .(IIallpikc, 1g73 ;' flult, iOfOl, ti" a ii,,,,i, -Clanhy irrurrilrrrl| cil Ia clzrDile. Aeicrise Oe-Uathe* Jtr,r'r',,r' 0l. {i ri',rr,r,"rrr:rr,,r,rsi:r criuici, a sindromllui rolosa-rrnirt poate-fiilSf intilirir,ir t I t (4 t ut ttt tt't r t ttt tn ) e care:,par prin afeCtarea aceleagfzOne topOUrl,li|r, ',, ilr. r':rr,{r lrrrl'ri. sri,-ldiferenlie-m,,ieqi a" di'iiiii,,f . 'rritrlurlrl lrrrrl,r,i """orie;t;-0.#Jit sfcnoirl:ile( iloctton_Duvigueaud) b) Si"O"omut ; lrrr ,r"Iri|,:rr, (|IrII'rI,) ; c) Sindroamelesin.sului cavtrnos; "1ru*ii, cLl Sintlromrrl rt,, r:',,lrrrlrr. (Jacoti) ; e) Sindromul pereielui extern al si,,r, rrirr ,,ir,y(,rtr)s lnrix) ii) S."l,lr.uryrt paratrig6minai '.i,rrrslirlr.irlalri ; al lui Raerl,,r,; ''ti'rrrIr''trrrrrrI .( rrri rr) sinrtromirrtle dff'us aiiui-r,isoner-griilrg,,. l) lrr ;rl;r,nr,'rrrr.rrirxo; ,l.olosir,-Hunt, cirui sirrrlr.orrrrrltri a, etiopatogenie a 1it$l ri r rlrrl: rl:r rrlri srlri, o.ll alnoll( : |to^tefi produsii,'tit d. crrrzr, ..,.rl,.ril ll., ri rr. ,,^u"r,, r.rr r,rr!|]!o.t"t'eroasd

,]:l.ll:.ll'].:lril_ll,,.lt,,,t,rrlt'rlfla unete o t"coriiri,.,iii ],,,]i,l;1,,\ ' . . r . 1. o \.:r o o l ,.trrr.tj F in r.e n C icazuri uilpr""e '|| rr. t r , : r a o fl al rni ce

r l r ttItr r r r 'l l l l r l /r l r | Ir |, l r ) ( 'r r r t z r 'l r . r 't l r 'tttr r t Ir 'r i 'Ir |, ''IIIr Itttr r 1 r Ir ';1 r |r , r t t t t t l t l o t t t r t t u t r r t/r 1 1 r to r 'r 'r r ' l r .r l r ;r r r ', tttItI|'It tttIt{i i t:t r |tr l l r tr " tttl t t'l I ,, I|ir.:r|( ). r 'r r tr r r ' l r xr l r l i zt'l tzi i l i t tl i vt'l tr l i tl r l r tl l tti l 'r r x t 't r r l t r c t ;tl tttsi t, 'r tl r i l l r l ' 'l 'l tr ttr r l t:l si \ 'r r r - r l l l l i ( l ) r l I r r l I t r o i t l i t l l . s l t i t l O.i i i r ,:r t,"r 'r r 0 r r r r ,tr 'l r r l r zi l ti 'i 'tl ttl i i i , r t ' , , r l i t t l o l : t l t t l ( ' r l l l zt;i {) l l l tl l r l cl ct ttti tti t, l r l i tl l l r tr o l l r r g i i l l l l l cl o r tst" "r 't:t ''' ( l !r l ( . , , r , , l , r r l r i i . . i r r r t t l l t l ttl tr l l ti ,,\tr i i 'r r i ;i co l r l b . ( 1 f) ? ? ) . U l t 1 IItItIo II1 i t.i l ( r l i i l ";, ( ( ) l l sti i i l i l , fi o r l r - t i r L r - :ttl i l tr l t' l tl l l l i ttr xr l tl r tsl r t ttr tz't t , ', , , , r r l . l I i , x p l t t L , s ir - e csto ( iII * i ', I i c r l c r i r tta sta zc cl r e p r o vi r l d e l i l n t',o l r l l sttl ' l l r i l i I I I I | ' | ' i i t I 'r r : i : r t r , ( n l e tti n g i o l t l ttr " Itt[t ttIr Ittr r r p r i m i ti ve I r r L r ': t z i t t t t n o l i l t r i n tr a cl a n i o n i , ( 'l ( 1 ) ' l ,t'{'r l 'tl I t , , r i i r r r r r r , , c n r t t i o l i u t i n g i o a m e , '(osteoame,J tu m o r i o 0 i d e l r n o j ( l o co r d o a m e mieloame, silrcoallti) rrh' ) ('\r'rrcrri r t rrrrrolil<' ,,ru,t*,, 1,r'imitive

,.1:rl r., Il )17; lllhor nas si Yoss' 1970) . i\lrrllirlrrraiiilo \::lsctlai'e reprezintir d.upti, 'I'horla's fi \''(tss (l1l';0) ,1,r,rri trIl ri i Y fO 91,, iin cazr ui, m lar ea f r ecvenl. i a accst o}r t f iit t t l r t lit 'r t r r r lr r : A rsr,ttj q; ,,i i 'ab. ( 197?) . bint r e acesi, car r ller ir ism clt '. st t 1t t 'r t r lit r oir lict r r '' ' ' ,l , rl r:rl rl rri ri ,rl cs 1 a or ; iginea ar t er ei com llnicant c po'sbcr io: u( ',ll'lt lt {'ll{'r r zit ,,l t.rl rrrol rl t' gi i tl Lt r t r ', , , ise cu inst allr e r apidl, cu: r ; I oct al'it r r : t lr t sir ': i ili r r t 't 'r r lr r i ,,,r' rl )l (,l i i ri ' pcr' cdr ii a I I I - a si cu dur or t - : localizat L pe - t cr jf 'r t . ir ll ,,tt:ri rrri r,f[ri i si l se ir r soleasci dc r egr : lii t le t llbur iir i obit divo t lt 'sct t silr i , ,1,. .'itr.vr'istu'le inliiaclinoidjenc (intr:rcaverno:nsc) silli' reslt,trsrtlril' (,,pst'tltLrltItrtIIlItI''1, prop5resi'l' , , ,,llrrlrrropleuJi(ltllett)rt$o ctrro se inst:r'leaz5, ,, l,rrlulizic oculolnolorjo complt*il' $i o nevralgie trigtlrn-irrat'i tlttc lxrrtlr' ' ' r t lr i. r r iir ' d'' ' t, 1,:rril ,oi l ori rrl n et vului r - , f t 'llm ic qi s, : , r com paniaz'r i t r r lbr r lr 'ir i gi: isi o dolicom eg: r t ': lrrr1ir li sr r t t . I isl t t lit llar oot 'i st r p'r r r lc " ' " rrsi l l i l i l al c , | ,rl i rl o {.l l V r.r' nO ilSi. lr ( t r r r l'r 'zr ' ( ll l rrl i ' r1i i l c ol rt t it t ologit , r : ( : t r lest r l llr in int cr r n( 'lI iiI I - iI |I r t 1t r t I r t t llit r r r l, t l ulLoi ! Lr r.:t,\:{,1,t,os) sct nii, . lat c r lir r r r ir r ( , , . ] t ili [ ] t lf , ilrir L I si nl r' j i l , 11ti i ni ,ti t t t ilr t 'r t zLi it t lt t liil, , r lr lt t nt r lr r i s; l't lr r lr ' 1: r tit t lr 'lt t r ' ilL r r r r r r l : i " ,l rl r.l (' j si nttzi l r '1r ',clr t t t ojt lit elc. tl(t t tll't) tt'lttttt j ''.1.:1.:i.:1. (i.tLt.ttr'tttttrrt'r:iu'lr, I'ara,li:iile rutliL.'u,Ll;t'e lt inllla, r nLit or ii; i 1I t t t t t t t t I t I 0 t r . zI t t r r r '1: r lir 'r " rrl i i l tot(i i tt l tzit lr t i vlt st lr t lit lo, t rf Ir(' ri rri Ll ri 0r t I iblr 'lr t I lr t 'r 'r 't t lt t i i) |lllolllol, o! ( 'olI lll11( : ll t r t t ( , l{'t t l t r t r t t , rl ,r i rrl l l l l fi tgl i ; i ct t ! lt st ir ltt lt llt r s( 'llzilil'( f si t t lollir ii' slr llt ioiol'i: r L' uir t r r r : tl ' ;,, r, fl ri i rr Il l -l r so t r t r lr r |lr 'lcilzi ( 'll s( lt lllr t lit alt lilllLlr r ,t 'r i'l'lt lr it r t r r t ir lr r l"' r '( 'lt lr r 'lr r r il' sr r t t r lt r lt t llir t t iit 'i sct t zililI ii rr,rl l ,rl l r(' tl c l tttt r lclt l't lst t - 'ir / pr lt ,\l ,S i trr/t,,,r t t t i/ r i ll r lnt ( : t it t r lr r t t nt r l' t lt r t t t ult 't l) t t t ( t t l( t lit t t t t 't lt lt t t l' J t t,,,i ,t' rttrl rl t ' ti t: ir 'r lt r r lt t t r t t l, t t . t r t t r I t lt t t i1t I r ''1i, r llt t t t , il : ; t t '1t r t r or r lr t t lr t t : t , r,r u l ):l l rl l i zii' ilr silr r lr 'llr lii t lI I r I 't t I t t I t iol, t t ( lollt t lll li ( ) llr "r r r lr l11 1 1': r r r lr I ll- lt t lslc lr r llt lr r lr t t t lr r r t 1,,rrrr rl r,,:i r,) otrI 't I r , t I LI r 't 'ir IIr Lllr r lizill llt lt lt ii 'r r' r ,l r.r rro tl l tl ot' r 'llt r l( '7il llii I il) r r 'lor I lt t li|r t llt l! r ll| ll( f i\ 'lt llli I ll r r r lt r r i" lr ll ti l, l ,r ,i r rI,r,i r.r, i r r lr iciolr r l ll( . 2( , 1{, ( , lllir 1. ) iiic ir r r 1I ot '|, I t Isil sr 'l: l( i r lr jll'lr , , i 1rl t l l , l l l {l i l (' r(' l l l ,i i fl it t lt t ' t 'r ilr r hilt t l si' r ln'nt ll t lt r t , r |'r ; t 't i: i t t t lt i lr ll ' r li / r l1'r r i/ ( "lllt r i) lllilir "l r r i ,,t,l t' ,ttr l l tht lLt it t t 'r r t t t , , li; nt r t t l ! t |t lt ( lt lt t l nt r . t t t t : t . lt lit , r l I ||r 't I r I ||{I ( ||t I I r lr r r 'l'iir 'ai . li( . il t r r olr I il( I 1' ,.rl i zi ,,i ol rrl ri r r I r , r . r , r , lr ii lll|, trl rttsri . l ' ) r lt llr : r r t llr , , lr r lv : t it t r lt t t r r nt t ll t / r t l", ll|'t t ' t I t I r ' ( li ir lr I 1,,11,rr ,
t r l r , : r t l r , rr ,r |l r to i t( |, l , , r l , r 'l | : r r 'r ' r : t r t r tl , :tti ,'tIi ,,,rrrl r , , 't t I o t t t , , Ir !I ( i l r r tl r r l ,rr.rrr,. ttr l ( .t|l r . ( r l i l : ) , l l ( . r r r 'l r .l ( 'l r '( ||||||tIIt IIIIII r ,'t,l tt;r l ,' Ir o IIIt ti r IIL tr '' r ':tr r ' Ir Itr tItti tttIr l l r tr r I I rr' t I t t t t rI t t I t t I t t t ( N l cl t( l o l \l l , l !'r |) ,r l r r r 'o tttl

tl c p e l cchea l t ffl -:r,. D c l rrtrl l ,, i'. rI r,! r'r.r . r r I I r r I r r r . I r Ir,.:i rl i s .' i ^ l l i ,.' i rr re s l x tc td re :l .,.,sc* l Ituri i i rr1,r,i rr;.rr.r,r t l: rrrr.rl . r i l) r ' r i, r 1) T i ). u r* rr.i s o p o ,tr: r' i rn a ,r' cr dri :1. sri i i rrrrr Irri A l ,rl r, r i. lr,.1! ;1 111( \ l; r r r , { ir i) . i t,s 1 rl ' r,1 .r| r,rr c l j l i tu r.i i l1) l rrrrr* n l ri nre(i ,l l tt:ol rrrri l ri rrrrrl l r, , || |',.r| , , r. r| .r. r I rI r. r l tr.r.,ri rr- .i ,.r,1 :,1 r. I ' 1 l ti .,;r. I| r l .al )Ll l c:i rrr.tt i r:r L| l rr, L"'i I rr'rr( r r ' , lr r . r ' r " ir l.r I' r* 1 ,' rr.r' rrl r' ;rl i i1 r 1 ,ru n (i h i uhrir)a.vi rl ' i r,(,rJ.rrrl .t r r " il) 1' r r i' :lr ir' l (' i r ;r.r' i l i ' r' i rrri ,trrttrr,' ti i ,i l t..rrtl ti trgrrrrl ,rrl i ',' Ii l r.r,l rrr. ' I', ', i , ', , i i i , ,'.' I )l 'l :rlr r r r r lr ic gr r r r r r.ro Il :ulItr rrr:ri Io s l , rl r,s r,r,i sr rI i rr l rrrl i rl r, r,ol i $,1t,,l i ;t. ' I , rI rt t I i t tr,rrri i , I r oI ir ; r r I il rrIIrIrr,rrr,,| | ,i | | iIII(.i i | ,Ir.. i,
:,l l

, ,i Dintr 0t,l , ' l l , 1.,', ::., r. '.r,t i:lt s , . lv l l l )(l l to (,i rs , tu ,rrta ,1 ,nerviibciiornoturr, rlri . it ' :i .lf',,1i..ir',,]..1e?{)).

r r'rrr';r'r,r irli irrr.r'rii. r)rrrariziir.ocuromotoriiqi ale trig,r,i,,i, rl\,r rl r, rrlrirr.iilr lr rLrrrrrjrrrn:itirll ir, vietii, 'erv'hii la iroLnavicaro ar fol.nr, r :,r'r'rIr.rIirrIrcI , sll rrrrrlillrr,i lrrir.n1. )ff 1i1le1rtegja f sirrvinebrusssj n,, , r,,t,t, tr':rzirirr.r:i'lr.yir._ (.. i''lte orl cu ril.lerea trig"_,,"iii,,i-ii,., orc, Iir..irlivtlt,sitr1, 1.r,,r,r."'tc,. tle accea;ip:lrte,-iir: par,k,', fi,, ',,:rrl,:'li" de, '

'i'ililli1,,":!:::,i!::,,i:,:,,{,i#[":,ii,,iil*fr,1i,\iJ,"?:rlif,fJJ,,,:flj;.'i;iililli ,,t,1,:,1 i'i :, i

'.;i ;;;,;,;:r :rir;m; iriliiixt,,liilii;ilril;iri::iiii:r,li,,l,,ij11liil,'i'rl]rr11 l:llr

t') b i nl.trl ttrtlt, nucltttl

f,',i,,1',ir*rili**p,;ti*;.t,;ifiixr*ilfiit1{{;ll* 'r*ii;iliiltifi;riiifii:;#xrrn!:,;"!i,:":i',iiru#*,
5 $;*g*iiffi ;gi,hT,ii,,i

t;;: :''ili:ii,,l;iilfixr;,,iiiil[*"jlti4!ij1l{i"i1l;rlJl:,|':l'';]-:'"r I :l;r'r,i;i;lillj; ';il;i;ji:[ji],iil,1j;.",:ii{i:[]:l,ffiiJ1,J*1-i,,i'{#;i;

,:-i[t'id**,f*iir***"1,*n*i*l**rui:?',","l[ :l, :i;il,,,il-;,ii

I 'orrlrr Ii lrr.orhrs de tumori 5i aie glantlei pineale.

;r,;;1iil;1;iif#l*li,r*""""**-;ii#!{;i;x$*l,4,fr*#r i;, i:;rIiiI hr*li*rtl ;.}l ij,, ii,IIri gtt'1,,ru iI st.,.ffi I I;,t,l';r:'':t, * :I ii, lj-;.;,t
*i,'illJ:?j**ffi:ii."i?:*"" "..,"."",i1{iitfli*s:;

*t+ffi$-**+*ffi ;lllliirli*':i*$*?i*ruTlfl ii i;j:lir,l",1",x'1"{lli*ii:i":"dl?:':il"J'"{"'rT; lll,ir;i;.lirl; jffi,".it';;:;;Xg

otareamuscu. jlliril;'{i,',ri,iffi l;:l:t #j:ifiT!:i{{:{il1'.::.,rj'-,:f
t l r l"; t l )rrl ri l l, i 11ipr r r r r l- r t r ,rro rrr rr

:uffi.r*?; *",+,,grf:if .ir,11;li,'lll{rii3i#i3{,,1fr{$Sl1"fu

i!4ffiiq1ll;giEil{iti iili*i* ;*lffi Irriiiil:i,l::l:l::':l?l'1,:"il'l,il,,ii,,il,il,,',il,itli,"l';,ll,,l*ii,iS;jUruifii.,*f n:ll

iiil*iff i*ili mrniil,-'lr'-*'i-ili tlrft;t*'iti,liifi
5tl

rlrorr sint : a) oftalmrplt,gic [rilrrl,elalti in glatkr (lifoli1,(r; lr) sorrrrroilo lcritri: c) ataxie; it) lis1,:i,grnus; delir in faza acul;li rii stalo arrrtrcsl e) r,oufabulatoriein fazele tardile. Pzrraliz:iile ocukimol,olilor sinl rrrrclrrirlr,, incomplete sau ctlmplete, cu prezenla la peste 50]i din cazuli r lrlozci |:rlpr'lrrale fi cu oxistenla rrneoti a t'ulburirilor pupilalo. Acrsl sinrlrorrr 1,s11' rrodus printr-un defic,it de tiamind, (etilism, tuibuliiri rnol,ulx rlilr'). B) Bintlromu,l I{estenbaum ( Bindronlul periapetlttataL rcr,lizoir,zii rrrr ) rontp\l, clinic constituit tlintr'-un sindrom Parinr"ud, la, c:ne sc rrsLrcirrzri, irisf:rqmusdisju:rctiv, mioclonii oculo-retractorii, tulburiiri pupilaro ryipnllzc rLuclea,re perechilor III ;i IY.In acest sintlrom este aiectal,ii srrlrslrur{rr, ale cem;ie pei iapcrluctala, nucleii oculomotori si barLtleletlL, longil,rrriirrrrlii, posterioarS,. Leziiutile cele mai fr"ecvente sint da natut'il infcclioasr'i s:r,rr ischernicii, (ocluzii rle arterelor plandui posterior al pediculului rotr.urnrlrniler, sari ale ilsusi pediculu.lui retromamilar (Aqgian ryi Vuil, I l)5$ ; Pop.r.icir, 1965 ; Popoviciu $i Afgian, 196E ; Aqgian li cola,l)., I l)71-i). Zona responsabili de aparilia sindromului I{estenbaum este replczcnl rrl,lr, de un sistern morfo'fu:rclional periapeductal mezercefalo-diencciir,lic, crrrtr rrrc conexiuni cu nucleii oculomotorului qi cu centrii oculogiri din tnrntlrirrl cerebral, prin comisura albii, posterioari qi prin bandcleta krngil,rrrlirrrlli, posterioarl (Bentler, 1965; Taube qi colab. 1965; Pasik, 1965 I Sh rzor,, 1965 - citaii cie Popoviciu qi A,;gian, 1968). Popoviciu $i ADgirn (l lxis) nu plopus - pontru fenomenul de ,,nistagmus retractorius" * torrrrrrrrrl de ,,mioclonie oculoretractorie", ari,tind ci aceasta are ca, substrnt rnollirlogic leziuni vasculare sau infectioase, reversibile sau irevcr.sibile, ils('til,o de multe oii de hipersomnii qi de mutisms akinetice (Popoviciu qi collb., 1980). C) Sindromrr,l Lgle (o vaiantd a sindromului Kestenbaum) Bo (litrrl(iteuzeazd, fie prin palalizie bilaterali, ile new oculomotor connnr (1n midriazS,,sonuolertri fi uneori paralizia miqcd,rilor riculare cle vcrticir,lil;rr ttr, qi {ie prin spasm de convor'gentd, mioz6,. I:eziunile rcsponsabilo dtr }rorl.rrrxrlea acestui sindrom sint de naturi, inflamatorie sau.prolifclai,ivi,. D) Leeiuni,le ttu,cleureala ocxr,lonxoton comun, tnai illos ookt rlo ,ui naturd sifilitici, duc, la teducerea tonusului in murschii oculnri, irr sprr,irr,l al ridicitorului pleoapei superioare qi, in conseciniai,, a,parilia urroi pl,ozo la lalpebrale bilaterale. fL unel) cazuri, diferenlicroa fu,lii rlo sinrlrornrrl Olaude Bernard-Ilorner este thficilS,. E) Sindlornwl arterei. nuclatr,lwi, oculornotorull,wicornu.n (ALlllolli 4i cola,b., 1952) implic5, afectarea n ucleului oculomotomlui oonrun, nn{,loii (,omisurii posterioare gi conexiunilc vestibulo-cortir:a,lo. Artoril rrrr0lorrlrti perechii a Il.I-a pare s5,tic o ramurti a artoroi sulorrsrrlui htonll, rrrxlrrrrl,iv tu a,nastomozii intro artcra cc,rebeloasi, supotionril, {i itrbolr! corrrlrrir,lrl, . s r ix.r be io i n'ir, 'Ir) $iw)romnl Lwl Aaenlald, Sohuranberggi llu,m'pol,tli(nil;rr,trlo Alsorri ilirglu,r'u lirilr,totar[, oir,r'llc1;or.iznlii uxisl,rrtrf,u plin csio o n rir,tt 6i <xlllb., 1.1)67) rlo oirltrli, (ru o (lutitii;i'i, lrrrxlio tlo 90 Noo rr(Lr,lrt r:l,r'oir,ll,ur.tr lllrillizirr, rr:tzr), rr il;rl,ou, cornplol,it, ;tolrxrhiirt,ll.l.l, cu ir,r:l,iv axngorrr,l,rl,rrrrrirorrln,t,ur.ii lr, lrrcr.(fottrrtrrrttttl tlo v:tlrfl, rrcrr:r,sl,il lrti Anllirl, ,,rriclic" :r,l ooulorrlll,or.u rronrrttr).

t r ( 'l l r l i r l r r r l r r r o r j l r zi i , i tr r r r ,l r r r l ) r 'o ( l l l so r L o l r .zl l 'o tr ti I,t'ttr r |.ttl i Ir tt'r {,r \'r Jl r {r t l l l \ '( r 't l l i l l l '. r l l i tl i z{.:r zi 'i t J i n r . l n t t u l l l u n i tl ,r I,,r .l r r l ,tl l ( Vi cl o l q i r ,o l r r l t,, l l ) i l ) , '\ . i t t r l t {r)r t n l t o l o g i r r ti .i tt i r l r r zi l r ,,l r o l i o cttctr l .a l i td , l r cttl ,r i Itr tttu r t:r ti ''i r sr p ,ti t'lt'i" (:iintlrontul Gttllrl ll rtnitlit:). Sernuele eiLrtlitrirlc it,lc :rcrrsl,ui riitt-

It8

llr,,l * i lli ii; binccontr',tr'r jn*ltt t*xxl ;t: iIrIril :in,i liitiiii*l'l;rs,,-*"'ris*iiiii''re?4;\,oiculescu ltw li",'1,,li,i.]'"ili?l;'i*t'rLitr
iJ,4.it. lhrolizia ncrvului paletie (trohlear) :!..1.;1./. n(r N de semic,Iogi,e oblicul ma,re, care Nrrr.vrrl lrrrl,ctic (trohlear) iaerveazd, mu;chiul t:Lrlrrtl ot,t lr,, produc ",,lro:r.tji

:liji;li,illrili;l-.ll$r iiilrill,ir;ii,,ri ;rillrf ri, imi:lii;iiUiU_i, jitit

rrr' r'rrrJii rr*'rrrrrri. :r1r,,r'r,.rrii lll'l\i'lll"lli',illii;l;'i:11i;;:;j1i1'1,,1::.'::lllrllll.'tLfi"

tl t' l l l ttr r t'tr l ti i tt IIl r r l r ) l 'l r l 'r t l i z i i t l l t'l '\'l l l l l l l r r r i r 'l i l l r r r r l i i tl i i r l tl r N 'l l l r ti tt l tt'txl t'sl t r r l r ttl i i r r sl r r ( [( 'l ti ]l l l tl '- l l l l ( 1 1 ( tl tti i : L c t . o r t l i l t a r l 't l si ttt tl r ' l tttt'l l l t ( [( '( l l l sl l ti ( \i l to l 'r 'tl l ti i r t l V:l t u u " i i t i o , r . l t t o efl l l i l i t't':;tttt Ittttto tItIr '' l ) i l r ci [l l zi l po sl ,cl 'l o i r t:r :t l ttl r sl 'l ttt!'t'i o o n r l fi i l ) ( 'l 'i i l p ( r l l ttr l 'l tl c' l o zi tttl Il t itr portiunea

fJSf iff*"ur?#j": ll,;ll;l;,-;li':till,:';itx",{if;i#ii#?;31[.i"_fi ('lriilr

., r prrr':r,rizicgradmed.iu muqchiurui d. a obricmareestesuficienti

ol)rrsi.' I'^r'rr oblic rirrr<' tlo lrit't'lrtrt' i'tirl,' rrrrrrl.hiulrii ;;;"i";;;;td;";.1ii Hi rr leziuno nu(l(l'l'ti1' vrr lizia bilaterald, izolalit rr ttt't'vrtlttipatt:tic inctici fhgcodr|--ll"llwrI' 1pp13pi {i-ferenrirtd rL' .itrrItDtttttI [x'rt'itrlr.ii superioarri Sindromut de ortcrd, cerebeloasd b\ ^(s.itrdronlll(I()IIj'Li1'IIiI' *,,r]oi'in-" a tesmcBtului) este un sildrom inezclcefalic all'crrr' lt.llt. a#','t".tliii. o""*"nii n-iv-u .oot"*latcralr' bemisindromcctt'lt"los olrrltlil d" pil,r'trotl lrtn"Jf- *,i 1""iirin6rom senzitiv tle tip slringomk'Iic, Ciaude Eernerd-Ilornor i It i ItI 1r'I'It I leziunii. Se loate asocra ot *-d"o"l *u. *"*Oitni"' Leziultile lntereseMi' lxxlttntrttlttl si chiar o hipoacuzie "r,,oJ"io",-1"*"iscui fibrelo prrpil r(' metliat, lemniscul latoral, i;";;;;, coliculii inferiori. ;i sirldromtr'l :ttt'h c) Nucleul perechii a pa,tra mai poate fi implicat itt .

;;I :;Illj;il;ir, il,#[Ii$:1ff:i!i".'" i;iff

vertislrd liliill,iil,,'1,,1,1,',',,1,':Ji'i'ill#3fi a imaginilo" ,!g-P.u"1':' .*'"94di; inciina'li ;j;

*n ii il*iii

ile lcziuni tt":riipia"ctati sili,sizd'rimut tectl piotlus

opifiznnr'

2.&.4. Paralizia nervului oculomotor extorn 2-4.4.7.Bum'at d'ed'atesemiologiae

P erecheaaYl- ae$t eaf ect at 5, in30- 500/ u. t lint t lat t lt lt . l'zt lr ilt llllt t . l' llXll)' implicn paralizii ale mugchilor oculomotori (!hrad31- 5i Schlczingtrr''

r;;;q1,;1;riiiiiurriLi,rhn1ir,:{lir:lrr{,rf*ir#jirilnti
afecral 5. i n

ii""tii'i.", r" ttt. li:.;f,:i#,1i:""..""'t'lTirui"?llTHHii#,f*.tiilii .""unre""t" lrAiestultim finomensc explicS' I" !(tnlirrlrr privir'u in jos ;i tit,div15t1n1;t l'.11.]ll.:: "l#Jii'r ;li i#il"ei"a l::t1:':l:r.:lll riiir'il; csle convergr.nl,iar mi$c.'.or d(' iru(tllopclr. l{l.r'rrlrrr in Susl Srrabisn?al 1,, l;1,,,:1, ;,r\{;1*?J,?*1.1ijli ll;i'11,,:,:i:1 11),lillil::;l i 1'll compcn'satll Capul esie lirnitat5." l lilil 1:' -l:ll.li1 rr ,..rr.rrl -este-rotal' t':rlrrjiziikrl r.rrrhi- in iartr s_auinstalilt ,i s""i" d"'iiipr*_ ""i""'r.ip."il" sau liporlt'opl'trltti "l", mod gr,,hat ;; echilibrii intre hipor;a'c{'iunr:u' para,iziei ,i;l;ll"i",,"lllil;ll"llll -.rtopt..r"i cto ,,ll,,i];lii':i,,:l;lilr,ii';Trlli3i*;+i*i":i"i*i"" .;;';;;iil";;i" cxtorn partoa
( t ( l lt lllgil r lr r r : r r ; l par ezel, ' dc per cchc VJ do gr ad lr r cr llll ll

il ;rliiri:l,tl;iir,;iiril:l.;lriu,*r,;'an'l*lxl*:i*#lii*#
,.,,,,,,rr ,r,, r.,,.,1,rrrrir, ,,,,,.,"o.,lXiulil""lt,ll, roilcr ;i 'u'.:n-

1tild-1#l :;ll;iili'l',1;,,11:;1i.,:l1;*gT{,i;;ff :i'TT,:'^'f

ad citiigi- Popoviciuqi Pascu' 1980; Ilatsud:r,1'q63)'

inrrgittt'.ttrt'iLrtl'rt'rJi Dinl'opia este bornolaterali 5i orizont'alii" Firlszr' jos, colror.lrL. u.gor\r s. irl)r'i.)'r. se incieb1iteazi,orizontal itr privirca in priJr

jllil,,,','l,,ii"ii]",liiilil,,,ili,/"lilnll"9""oas i"i't"i ' (rcrrers;n)i'i"-'i"a"ui""r ,rj"{X1",' si

t t t drt tl'iugnosl,icetiogtntoienic toltograf ic 6tt pa.al.iziile ,si , , ,.,,il,',",j,',,,,',',',,:'"lt i t,.,. ,',,.:,r,,,i,iilt, t,rl)rcu,l.are. inso!,esc jle-cjieni pa.rali-aiilepercchii ,.., , ii

i"t".i' iiirrp"'ritri"n"" pctrlru

carurifd ""nirliouitut dacfl teziunile initi;lo

.lllli'l Jll -::iitt.l prirnrl rlatil in :lccast'iililzi! osl'ttllr('u {tt' slirl}rlrl' au ?ost tlrcpLc satt stingi'

:lp"*1'

,lll'li,!:r:l;i;i;ii;'trltTi.t#'iT*fflti,rli!i:,r-1J*?:{'l,1'r'4 ;fil"ill,,;lli;,,tt]:",:;#;;,:;y3ilii";;;i; jii:,i['t,Hf

iii,tii'l :i:;Kili;E:f:::i#,,Jffi,/,,:i1l :n,liil lL?"li iiili,r'li,,if:i:;i!i':,,,{:i:'i 1l !\tratiziih:
) nttderr,rr: rlp IVa sinl gr'(trt (li[('r!'rrtiitl; (l(r ,trr il(\ r1(lt(\ lr,rr.rlir,rrr ;,,|i:j;li:Ji:'.rr ^,,,, t
{! r 1 i ( ! l 'l l , u l l ( ', o l 'i l ti l a ,l 't'r l tl .

ti'tt pt t'oTtogra[i'a 1to'rnli;iilrt e'ti'o'pntogen'itt 2.4.4.2. Problemade dinllnostic neruultti oculotflotor artern. A)Para|.iziilalron'tn,arc,sitttflelcventittl'ilrti|tl,r1ll1;rrril,i1|'rr;rltrlttirlit ttcrltltitttttl'tttt ou"n"fr6r-,r-iii-o'ai t, t,rrs"rrl o.l m,i lung dirrtr. 1,.fi norvii rt* rliforif. nr{uri. 1)l rxil,. trut,ivttlttrr'irltil !"pii*t rn f,,i.',i,t ;i;;;;";"r.i-j tnzonainca,rctrcotpur,,,,-*fitt""t'1'otnporl'ltlltriqiltil'trrrrrtlolttsittttxttl cavetnos. a)Pt'oaesauuS|lll'I'(t.(11t,'sittct'r'ulrtt:ttlttttlttl'ot"'rltttttn,portxlllott'tlVli"r'itii lirrttic :tIrrrlrirtli'rttt rtr ( sd lttittt:' Arlf..l' ittlol'tt' til, ( "ao.l 't r , -"-,riuiuu,i,1 l i .r i r kr i ttl .t'vi ttt'ttl o ttttl L tl r i t.r L t'l tti , t It t' i I | ' I 'I'II r :l 'r ( !t) ( \' t,,rzi l , L t ( '{r ,'l tt'i l l llitr il iiilrr,i'r,pl 4i rr,r,hr'ulrt,biritrt,itlil itttrrttt,irtrt't'I' rItr|.'Itt'||'tI {ra,rul lrn1;r*o. lrl6rrlll' tt rrfl{tr.i ('iu'ot'l(l{! s. ir,lli"tl)(r li:n'ti. Itt s!tlltslll 'llv('rlr's tttl,tt ',llt'l'(rll AiLtt'pro(t('x(ul ttl'ttudtrotlt tt lx)l llli(]l'll tlotvttl txtttlttltlttl'rtt' itl,tirrtc, I li llr i,r' l5

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gi l o,

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l r;:'r;r,:rriln l; li:ljr ir#rl*i:",ffi 1;i:{"g:#qJ#$t? i, :, ;i, ii' iii[,*31g I';IIlli1,ji rl,.;l1ii'1illl::t,,tr:,*!#itr#::*#"*{,ffi "k::rilr*11#x"ii;*t .;x?d,Ti:Tif"::,ff;:H:
Lr,,,,il,il iili it Ijii1,liiriili i'ili*i

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stincii #:;';:::,:,i",!'i:w*.,t,f3,wi. te,n. l,:,.,!,:.).!:':"r::i,'!::':i;j!:,li:",,#H::^

1,'.,,;11:r,iilir;ii.,Uil{-$1$l=qitr#,*i':iI:}{1.+l $ trigenicu':L i'tii l'.:'n**" $"'JiT,'""!

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r.Hrr* irrfr )vlrriru 4ig,,rr,ri, z.frr(\rr rrrr z.rir irrli,r,{ii rrxl'rrr,,;:ill,ll'l'lil'lJll,'r
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r.96 9). h) Paralizia percclriirr V I ir :r,llilrerle :r,scnrorcrr irt sinilrttnu,l.,liutlti Si. ^ sJewidale pi 4n, celL ,uirl\tlui or:bttar. al i).Tu.mori ale fosti 1tl,ru'ir1o-Ttalatine ptotTLa ltilroestezio qi rrcvlrlgirr . jn teritoriu-l ramu-r.ii 1r,.ll-1, l ncrvului trigcmcn, hiposecrc!,io lrr,r'irnali, si pa.ralizia ner.vului oculomoror e:lern. j) Paralizia cronici a neryului oculomotor exl,ern poate consl,itrri prinrul semn aI unei lu,mori din regiunea tli nl,rt drful stincii yi sirt.r.r,tlrt L carernt (Sakalas qi colab., 19?5). . B ) Paralizi,ile rad,iculare (intranearaniale ectranucleare) a1tlr. (rrl mai fi'ecr-ent ale porliunii ventrale a protuberan{,oi. -in,,lezitni ,\ ind;rotnul ]Iitlard-Gublei esie lrodus iie leziuni ischemicc itr l,tl.il,o riul arterclor medianeale alterei bazilare. Clinic se traduce prin tnrrirlizirr facia,li si de ncrt, oculomotor extern ipsilateral, cu herniplcgic tli. 1rrr,r.L,'rr, opusl'i_. Forma clasici a acestni sindrom are u:rele variantc, h funclic rto extinderea leziunii: a) dac5, leziunea se intinde posterolatcrrr,l ryi iirfi,rrr. seazi nucleul sru riid:icina principali, a trigemcnului, la tabloul cljrrio amiirtil se-adaugi fcnomene senzitive de tip ilgic sau parestczic pc Lcrrri, fala homohtelali ; b) dacri leziunea se intinde nurnai in diroclic 1xrsh, rioa,r:i si afecteazd,pa[glica 1ui Reil, realizeazraqi un sindroru sctrziliv alte-rn; c) dacl, leziuncase intinde in direcfie medi.rnir. cupr.ildr: trolvrrl qi oculornotor ertern de partea opusi,, apmc o parelizie si a acr.stlri nrtv ; cl) rnar::i leziunea se intinde in diledlia crlotci plotubeiantirL,, alirol,rrrz:i qi n:untleleta longiturlinald, posteriod,ri,. Q ) Pu,raliziile nuclearesint in gener,alrare ;i aprl rnri eltu irrprr,rrrril, cu al.ctarea altor sttuoturi neryoase din \-ecinr: t r.. .\stlr.l. Dlirillizirr i,ii nuclenri, de ocu-lomotor exterrt apare aproape tot(lc:runa lsocilrti t'rr 1,rr ralizie facialiL periferici.. Nucleul perechii a lrl-a sc :rfLi aproape elc rr:rrtrul porrtin l,onl,frt plivir..l ipsilateralir, la care o cale tlc asociatiecorxlticc,prirr intrrr.nrrrrl de irrl bantlt'letei lotgitudinale postelioare, la nuclirul pcltlu nrn;clrirrl rlr.rpl, oxtern de partea opusti,. Acst ccntru ponti estc Nd{rserllfccttt (lc lcziunee care inteleseazi, nucleul oculomotorului cxtcln, qa incit, po lirrgr"l paratizia de nuqchi rircpt cxtelrr, :ll):ll.e;i o paralizic rr prilir.ii lir,1,i,r'rr,lo rlo ilc|p11r.i prrt' qi tlerilfia coniugatir I globilor ocrrlitri rlc prrrtcrl,oprrsi. O rfr.clltne limitet.i h norvul facial si alxtucerlsilc rrcrct;i lrarltr {i fiiri, pararLlizja miqci,ritorconjueatc r1r,latcrialil:rt,r, sugcr,c;rzi loziirrrulcni,r.;rll, o la m:rllinca infcrioat.ri ltrrniii, lndo lctsiti rloi no'l-i lliliisr:sl lr,rrrrclrirrl ;r certl,r,rl foarle :lplr,4c lrtrul do r:itlirlrl1,.t)llnllizirr,rirrtleu,rii irilrrl,rrlrrli de ootlornotol ertenr nu txtc rlr.ii, rlacr'ii:irrcurslrrrrlr rlo lattl rrl ri, cli rkri ('oncornilr.trl; lLsoci:lzii trucleise giscsc in apr',11itrr'. s(r llrrlalizilrrrriscir.ilor rle la-crilltate ;i plr';rlizi rrrrilrrtcllliisirrrlriluict'rrli Irrri:r,lii r puiliilicri. at Sinrlromttl lui (lus?tiui (sittrlln,ntl ilot;;o-[t lu.or:a urLulftl lrqnt: . tttlui pontin) s(' lrlllit(i1(nizl'llzi (t.llIti(ji V, rlt.fioil lrl tt('l\.il()r 1rIirri,t.rrIr TI,YII qiYItrIrl, lrurl,r':r llzirrrrii,lrrl)rrrlrilir|^ scrrsilriliiirlr'l,r'r.rnoll!:.r'zill, (1('\'iil1illolrilol oirrrlltlisl)l\. 1)itt1r!ll de pi,rfor,ol)r tsii, il sililolrsli rii lirlrrgrnus {ilrc bfi1c tlr 1|rr,lr':r lr,zitrrrii(l{r,rrlr.rrlriilrl \-lrsrrlgil, lllir?: ,l,rrrrr 1i r|()rrisi .Nlonl,rrrtN,l'i, l!r(i0). lt\ Sintl.tonrt,l. ll,utturtntl Lu.[ (*irrltrnu.l urrrrltl tl lt,ilnht't'(nl(i \rl ) tliU'irrllt'fizu 1rt.itt ,zii lt lr.zirrrrri Drrrr si llrr,rrlizirr 1l(\n,('lrii \'1.:r rlr' 1Ir1l1,1q
l l t r r t rr I i t t o z i l , d ( ' l ) i ttl l i r o l r r H i i .

.a,t' i tl uroidit r ( lt ot r nr , l, llt t ) i'i l) l

lr , usir r ollr , b. ,t lXi0; lii) g( , r qi colr r , lr . ,

rt

(ollllrtropklliik' ittlortttttlt'nro) :1,4.!i. lhrnllziilrr ittlctrrur'k'rtrr' rlill I) t'r'zttll,ii, I(rza,r'olli I tII II' II' I t' i lotrgiltttli o,ltnl.n11l il.r 'iul(t't'ttt:l(xt.t't t11i ( siltt rrrrlr.jroilIcliirrrlr'.lltt'lr'1t't'olr, t'st'trfirt)r' palaliziik-rt'ittlt'lltttrrlt'itltr itlo ( sr t.lrs('l rw(,grfr', ll)(i9) : a) rrt soltiul drept illtern este para,liz.Il,]rcntr'l] (,rlrr.iugalri, lRtclr'titatr:, insi, funclioneaz5,norrnal in timpul tle |||rr1r'iri(.r| prepolgcr,,rrir llglrr{r'i ; ll) prozerrla nistagmusului tlisociai, singular sau_ orrlriul oiro privefte in afarri; c) prezerlta paralolismului glo}lilor l.rrl lrr, ,r'rrlrrli lrr plivilca, inainte, in ciuda parezei bilatelale a muqohiului drept
r ll l (.l l r.

t
il 1
I
ll

pozlina (indeosebi vasculare) se poi intilni doui forrle 1.,'.:irrn,ile i 1rrrrilrrlrrlrr rIo oltalmoplegii jnternucleare: | ) (),lltlnto1tlegiu i.nternttalrard,anlet'ioa'rd, cea tnai frt'r,r'cntil, aparl+ ,,;r ,r ,,orsr.r,itrtii leziii'ii fiblelc)l care leagii nuclcul pcrcchii t ffl-a, cu a rle partea oi:us[ (r'rlr'Il Donl,itI petttru mi;ca.r'eaoonjugat5' orizontal:"1 (lrlrlr,ll rrscrtrtlrlrtr:ale bandeletei longitudinale lostf ioare). Clittic sir |', |||rrIr';i,lrr plivil'ca lateraid, paralizia muqchiului drept irtteln (de p,rt'tca tliptopieincruciEatb, lrjstaguus ulizontal la othiul r rrrlr.sr.rrllilrrzittnca,), $i r':rr',.pr'irlsic irr lrfrrii. AJoste lenomone se explicr'i?r'iir 1ri'tnl ci, nrtcleul ;rr,rrllrr rrrrryrlriuldropt intern nu primeqte impulsrrl'i pentrt mileatea' r.orrirri:,rrIi1, rle lrrl,rtrrJi, ln centrul pontin de partca ol)trs:i.Pe de altii pnrte, rrrrr,lorl rrrrlvrrlrti rlbdncens primeqte impdsuri cerebrale qi vestibuJare r; rrri IrrI r,r'rrIrr fi r sl,lit funcl,ioneazi normal. Convergenia se produce, intrucit r r:rr lr. l)r.r1r'u rc('rstir, mifiare nu trc ?rin centrul pontin aI mi;clrii la1'erale ,'{,| | i ||ri rrI r' . I)rrrri leziurrea este bi1il,terald, apal'e o paralizie a adducl,iei l,lolrrrlui rrrrlar irt arnbelc sensu'i (dar cu conservarea convergen{ei)l | | iIi I i r:fi |rrIr.rIrr liot'alo din ochii afla{,i in abduc.tie li nistagmus lt} privircir. | rrr rr|11.\iN1irglnusul opi,olri etic qi indus prin excitalrie vestibultril cvi rlr'rrlr: list)rrsrli tliferite la cei rloi ocli (Bender,1969' cita,t de Popozir l{).B0). r rcrrrsi l'rrsr,tt, este adesea greu tle _diag_li ) | ).llrtltrtrryilrlti( internucle d, Ttoslerioard' r,rtrri. i) 1rrr,r':rlizie supranuclearl a, perechii a Vf-a este foarte dificil rll rlil!.r'r'rr(,ilr,t, tlo o afingerela nivelul nuclear sau radicula,ra' net'r-ului lil{ii, \ t (llrllrlri si rtlab.. f9;$). I{u$chiul drept intern de partea nelezai':isc r'.rrr1rrrrIii rrolrrlL),iri schimb ml;chiul dfopt exterl de partea ]cziunii rni In aceastl' formi'l sint lrrr! iionllilzi'i irr r.tu'srilInisci ilor dc late,ralil,ate. l,'zrrlr'lilrlr,lc rk,srrr,trrlentc bandeletelorlongituclinalcposterioale {ile ltr ale de {.r'rirrl porl'ilr rr1rnilciit'ilor dc }ateralitate la nucleul tr'bducens aceea';i (l)rvllg(,r11ll,srr llrotlrroc rrormal, NistagmusLrlorizontal aprlre de lrirr'lr'). olrrtsi,lcziurrii l:t ooliittl c:Lre?rjveqte in aflrii ;rirr'lr,rr intlc celr tlouli forrne se facc pf ii'l lruliza' compr,tr'tlrii l)ili,f('r1,ii^r'(,rr ( irlr, itr:ti{)llrlrzii, seng orizorLtal.Astl.el, in forma antu ioiir;lt in rrrrrrrr'IriIor' rrl rlr r,1rl r,r lc|rr il(f l)lutea leziunii funcliolleazi normirl, in tirup oe clrcptul rrlr'r'|| rlr' |rrr'l0rl oltttsli cste I)al'alizat pentru miqcareaconjugatil,de l:r,telrlilrrlr. s1rlr. l)lltetu lcziunii, insL fulc{,ioneazi, norirral in convergeltit' ia Irr lirrrrrr pos t,r'ir i'ii, rtmhii drtpli jntcrni :ru o arti'r-itate normalil, a1,it l N r:it i11timpul corn-ergen1,oi. rnai rkr rrr lirrrlrrrl rrrir;r'r'ilii l.rLclt.tlit,:tte, "ri mi;carea tl'lrtterlr'r,l)lrl('\l{,1'rr prtr' 1t,ir rLr loziunii cstc pat'alizalpcrttlr'u. tltl Ii r':rlilirir'. lfrrlrrlr lrorict'ioilt'ii 1xrrr1,o tli'lirt'ctt('ia,iir,ltalirlizil,ptr4llitt zisi
(krllrrtrl 1i I t 1 r| tt' t' lt ii rt \ lir ttttttlit i lt r ilt lt ' llr ' lI t lt l s f it t t t t lt t t ' t 'l l t 'i ) i l 'i l l f i f i t . (lllillt rrrt rrtrL llrl , : t , lt r r lt lr t t t l, ' t t t r it t r r lr t gir ' , r ' s l r ' l l l i r i l o g i r , s f i t 'r '1 i r t I l r l '' o l r rlr,

'in

(1i dc rllllrtlrllrll'ii tL' :rlxlrlr'('il"' trtt lxrslctiort'ti) 1r't'trr.ttii ,,o1lrrInto1tl,6ir' (1i tlr ,,ollt,irllrtoll ltrgic i tt 1r't' tt ttr,Ir':t t ri tltl rltltl.utrlitl" lttt ltttllrirlltl'il)' 1i tttrti lt'trtrvtrtll'ri ti(rll' l)iaqnostic etiologio:lt) 'rr'/rto;-rl pliici eslr' (1:l'llzil 'in r, l of lalmoplegiilor inicrttttclt,iu ttlti- sau bilater:lltr; lr) lczitttriltrvirs(rllilt(t se iau irLconsiderarein tjotttoxtul clinic (Ifa ingtorr si cttlab., l1)61i;\!rllHll ;i lloyt, 1969; Cogan, 19?0; tr'dtzsch, 19?1; Gonyoa' 11f74) CJ Oltalmoplegiile internucleare pot si apari' de ambth piirli,.trsr.t rtlrr ciirtrlu-seqi o oaiecare asinergiea globilor oculari, precum ,1ipitt'rr'lizii prir.irii veiticaie, 1l sus, ale globilor ocdari (prin extcnsia lozittttiltrl lrott. -iinc in paltct'| inferioarS, a rnezencefalului (Cogan gi colab., 11)5() r'iirt,l'i r L'. iiotlecht lC6j). el, 2,/r.6. Paraliziile oculogire suprarruclearc . 2.4.6.1, Sumat d,e iJ'ata semioloylice L'ezi.ltlile suptanuclt'ilt t rrrtttt afecteazij, mecanismele miqclrilor conjugate se traaluc sentiologic ltt itt : a ) Dim,imtarea *atr abolirea mi;cdrilor conju'gate oolunl,arc s(r (lirril'(t' ierizcazi, prin paralizii de tatera,litate, de ve*icalitate sau dc collv('l'gll lI r'i'. ln funcfid de iopografia leziunii, bolnavul nu poate sI'-;i dirijcze gkrbii oclllari ia comandi intr-o anumit[ clil'eclie. De asemenea, drurii rt[rrtt('itt' pacientilor este atraBrispre un obiect cale nu se afld, in fata krt',.lti.trtt 1i pot deplasaochii pentru a-l privi. Eristl $i o cresterell ,,tonicii;i'l'ii" ttlttrl chilor antagoniqti, care duc Ia o devialie a globilor ocul&ri de l)rrl(rir, ol)rr$ . \r apal fenomenc rliplopice refletelor de .fitalic st' pttxltttrrr ;ttitt Dlec&nismelor b ) Itttensifi,aareo, *,r itllil sLtlrcolr pielclereaconti'olului inhibitor. ln mod normal, iirlrtt tltpii, rLrlitr(ri. trolul r-oinfei qi ochii pot fi miqcali de la un obiect ia a[1,uI p.r''rliziile supranu-cl"are, bolnavul lu poate sri-li tr2rnslix\ror,ltii tlr' !n pe un obiect pe altul Ia comand5, insd poate uuniti i [u obiotrl; orttrr so se tjtl rni;ci. in direcl.iaparaliziei. De asemenea, pot e!'iden uicllrsji Lrilllrrfr' rolrnalo la stirnLrlarea labirinticii. Pie}derea rnisciil'ilor vollllll,iIrrr irl(' globilcr ocula,ri, cu lespectarea trtulor mi;cirilor ooulal'o r{rflo\(', $(\ Paratiziilc m\ciLrilor dc ltttttrlitrtlt', rrtr riurnegte pseudo-oftalnnplegie. pistr:.rer -conrergiltei, indicii o leziune corticdld'sar pe c(idl. tnrl,ittol'tt 11ult, inainte ca acestea si, a,tingi centrii subcorticali. In untlc cazttti, ilt rrrt'tr' contloltl voluntar se pirde, reflexele de fixalic pot dovdii t tt' i tI It i I tIrI I' , prir-irea se,,ancoreazi" de un obiect, lncit o mi;cart ultcriorl'rilIlll lxrirlr' lrt li fir.urtri decit tiupi, ce se elimili irnpulsrltile lctirticno (itrcltitlt,t rrt,tt acoperirea ochilor). :Lceste situa'!ii ar1 fost dcnul]Iil;r' ,,a'l!1t,1:it o()ttl'!ri tttolorie'1(Goldstein li Cogan' 1965). rlrr t ) Intensi.ficutearcll(.relor proprioaeptiu cillo l)or'11{ls(' Irt. lrrlrititrl' tlcilsul)lilllll(lf ilt)r gitului epa'e atunoi cincl leziunt'lrsc:rllr-t' si de la rnurschii pontini ai sistemului l'estibulal. Astfel, tle piklir la lttr clz lilcrtt'trttrilt'ritill voluntrro itL sus sau spre dreapta sint irrrfosiJ]il{',lLrltriiinsi ('rt,l)lll('sl,r' sttlr tttt tttt$lti rr{ttl br s'r (oborit sau illtori sl)rt! sl,inga, otrlrii str r.ott'it.zri sii in srrsi1islr'(f {lrolrpt,it, ct':t1xli ilt Illo(l aul,ornfl1 srrt t' i rtI'rI It t'tIii, ltt lrozililr ttt|tliltlthr<'il,rrr t't'll0xt'ltr ilt fii. Irrt'rrt'izotll; Ilsl,t'.lcnonenttl ,,oohilot Ttityttt;i'". lrt'tts<rii, rlt, crli;t't'i t trp ttl st tt i lr' icr', dlr,cil,llliri{ilrlil' crr,pllltli r^s14' LrrLrilirtl ;i
l r l o p l i o g r r p {, ivr , tl c t l l ; , r r r r u i k 'ttti i ,. l tt, tti l cl ttl IIl IIfj ( IIi I( || .'tl l ttl ti j ' r l l r r ,r i , ttti ;t:l ttt'i t, t'i tl r ttl ttt

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rl.rrrrrrrr'r':rzi r.zirrrr. r':rrr'r'li.rrrolr,,iitl"",';,r" , r'r r',,iil],,,,,,,",u 'riscririlo' ll,ii,.;.iiir...i,rili"li :i':li'i,';,',;:ill;);;:;i,l',;;l:]'ili.-:1il,i;:;,,r.ziunei,

,,,. r rr

,, ,,,:;,1,,,,1'lll"-i1:';1"','i,"'j1i:.'i,ii,'iiill;lli,il,l,l,i;-;,,l,,i," llil,li,;i,i,,,1,,:iii,;,,'l,iil;
l' l)| (.1, |lrt0 se tnis c t j, di;

ir r r J r li|l. r:

pii'r"1.te ,,,,1,,,,,,,,i,. ,i,,.;i.,,,;i,;;,;''il;';ili"Ji ",,ri,""" sint T,;:i:i:". ;|?1iil11:# tt ) t,tix:iir.itc

da .u,tmd,rire sint l,estatesofi"itilJ laci"ntuhi si1 jireze

( It )I |(I()l | | i I (' | | I sc lt t r t t lt t lr r r r r l. t r r l L, lr lr ilr l ( 'r ll. lllglllii ; l glr r lt ilr lt r x, t t lr r t t i n (l i rcl l i l l ol i r t sii llt r r lizir . r ; r rr r r lr L. l )ccrl sl r1ja libr elol or , r r louilr ' pr , t r it t t t ni; cr iit 'ilr ,( ( nl, jr lgr r l( 'I lt , i'r 'r ': t llil: r Iri l el !eduncular inf er ior ' f i lxlr r l, ilr st t pur ir t t) alr : t t n t ol i; t qt ol't 'alt l;it r : lr r bilirc:r, diagnosticului topogralic al It-'zitrnilor'.Astlcl, iIrtrclnpcrc:l Iilrl''1,,r' deasupra incruciqirii induce pitlalizia milcilii latcralo slfc ?l11crl' (il)rrfi,.

rita, 60 r,,r,, ,,,.r,ir,,,l.irl,,i;,;.,ilil|":;:ll:i^tu:!"i" la aproxirnativ t,rl irr

) 'l'rxttt!.ntet:u.n,is.mului,d.e l.ixuJie: piLcierhul csio sol;i,;tat pri\ i.:, r'rrrlr'('l)1i fat. cramirxtoruiui, rJlilmp in care .roA.airu;o,rrL uir",;. ,ii'iul ,,l,rr'.t;r l,(,rili,r'i', .imltului vizual (#i;r:arit:a ,"ii"ii, _"ii),'i_,s* dc lLi,l*il)i). tr rr,,rt rrl.trurl, st: ltroduceo rniscare privilii iplr stinlnlui r,e:jljr,!.Li\,. r 11 r'rr.r!'' rr.r'srr:irnisciiri s.gereazii -a o t,,ri*" t"ri"""ur,i cr-iiLr. ;rrir_ r( rrr'|r (''!*1r' rrc re'einrui occipital oi ","u'li i,riir" i rre rir,,:*:. '|", t \t,4t,tt( t ttttt'p) , "i""riit gen,rri.., examinatolul cr'le borr[r\'rLrui si_i rlr,rnr, .. . " .,' ('.rr. (e

,r;ri 1,,i"i,,,-ioai.i'T1il::"ffi.'i:-Jii:tfiil?"1i?llff:lif;,yui*or'i ir,,.,, ,

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rni..:j5. ir fatraochitorip,:" .,io,i,,;",,ia"iiiiii lerN

) 'l'r-'xlurau ( farei l.ente tl"stctgnustrltti ttptoltittetic. ,t Utl ect:ul tiriutcat |' ,, t)t'/t \l'rticaie de curo.i dileritc este in Ilta pacrelt,rrlr, i.r. .str soricil,atsii tiui,p'ir-irea u't 'riicat r'i" pe ceni,.lr er,-r11'r{rr ,, rlrri, ii'rt) irr salp ngeslj, "ruJ'"u"..t,,ir'i esti miscat-l;^il#;,i;;jtr.u direci,ii.ln ,.,rrriitr l{)t.lrlll(j apari: nistagmu-"ul -- ' optokinetic. ) ,. , ,, , ,., ttirttt0tnusul.ui,_;c11t!Uuia,r , rotator srLr\ tlistq(nt| ).tllu . l .. t , i t ..,.!t t t . : rt ',,.,, ( l i r 1 ( _ i r n l r ot,la l]t tttt , t ^

nucleilur nervilor, .oculoin"t""i- aral \, .1rl)rlr1 ( sI{l ilrlrft. ln_prezenfaparaUril". iril21i"r"lJali'prs,irii llri,r:rale , Ir r,r ,r| | iI I( . r| jl:rrt,rr ulechii protluce ' numai rniqciili tenie. afe ochiuhii. :'. t.( i.:.1. l, uihl tu e rIe di a ElttostictoltograJia .,si etir.tpat ogenic

i"iilI lltllli,li ;li,lLl];,Il;?:ii:;lJ,Jl;L';';,1'f,1i,'"_,ii;1;tl":l,";:lfll: rrrr,rrrr.rl'rl, (J(,llsltllrl 'r._,i..,.'.,i

; ,"nu"u,-#iiii:,:?".,?,::t;,",i,",,x"::,r11:ij:;;;illi; , -rii.,,iia-',1;;;;;," \,,,lrr,rtr' sirrt, leziu,rcltr.t J)ri_..1rate, arc,tui r.eUrur "i" ' l1iI rl,tihrrtlr (ncrvulr,,estilul _nuclcut_,.r t,,fr,l,ni iui Deitet,s

r) r, irrr,,.lr,rraliziti

,,,,,!,:,'i;,,i ,., ,,1 ,,,',;::'i',:i;li,{:i:,:,:,,;"x!;i:1,i.:,1:,^1i,,r"'1;,*;T:l:.fiH:T,,;"_,:

. l ' r.rlr' t ' lt, rlrrr lt <,r^ trlt.iloi O Lt t t lo l t ' rrrjli' r' r )lilriilo:lsii.lrr illr ir llr , , lr r r r , : r l. iz , iilr , pr , J lilii llrrrrhtst. f[(] lozil,lri in I l l l l i llul lllr,lrr,trl r,itrl r ir . r llr : r lli I t t lt i lt lt t lli' t L' r ' it r i 'l r l p r o t l t l s L r r l q l, ziLtlj r , rrN r(' rr(. r.. | ) I ',tt'lli.:iil( n tis : r r r ilt t . |, , , t |it |||, |t | , , t i. , , t t lr r lr . ( r i 4 t l ) , , ) 4 . 1 t 1 t t , l i . t , ; l l t , ) I , :r l I r I j z rr I r, rrri,r,Irr,r I r . r r ir . lt r lr . t , t r lillr lr . l , . , , r r , l, r r r i r r i I rI rr |:i i | | i I i I : I I r, .L I r r i r , , ( ' , t.r, l r,ol.il.,rtr rrll l,lolr r lr r l olr r lr l, r , lr l r , 1r r , , r l t , , : r ; , 1 :J l r fi,, . i,r,, i,,,,i,i ll t )

r1i,;iI; 1lli:liilu liix ,,;li ;1, i#]r nsft [mlri#"1*,uffi I l,i : r;, i
r , r rrl ,rrl i riI r , or r t ir lir ljr r a; rtb tl c t,

.,,,,ir,ri ;ilii d;illli"ftlrliii'iTlift:J.,,*"TT;l'Ii ',,rrr,r'.1,;; ii"i,.li,?i];

c.iilar aculolttc: I:i{/. 1 1 . L t . i u l ri i e : Ne!rc! .l : N.Eon mezo.cialnr hcDicrrltrrnrr ; .artnrl :rdliocnl:rrat.r; -B l i . ri re rn i a . c l l o n ' C : \ . r{ o n n e T. . e l a l n i x l . . ! l o n r. l . r, ] ri i . o n r: n ; 7 -' I ' . h l i z i c l.rt ll:i .\tdn : I - Pi.rli2ie n!(l.arr .onjlgali | ., - I-rerialic conjrrgai' lrnr leTirx' _- Dc;irlie tunjlgat: lrin itTnD' crnisJ'r(' )pNte'di.il 4

i n 1,i rrr1r i ri l lclu1t elca' 1ot sr b t lccusalie cat r zet zlj,plr llizir i lr t it t il ii lr r llt . r l' cc ci 1rr, rtct,ou5 ilt lr t '1r '. ' Itr fttttcl ir r t lt , lr t tt t lizlt lt 'it lt , zit r t r ii 1i r lr r pt it t t kr t 't , r tlt llot s] r 't t r rtlt t t t r ''t ' vt' r, iI r r 'i1lt I rst 't lt 'r t '; 'it l lr t i lilt t t r i t l. t 'sir t r ! t 'olt t t t t I r or illt ' ( lil. i l: i . i r: vrri rsr.rl rr l l g. I l ).

:r). , { ir r r l. r , r r it r llt ' t' ti l l t rttl r' t,i rt (tn ti l l Iri r $ i ? l .I t,nl at.)r,rrl r, . l rr..rl rtnrl 0 I' rrri l ' . r ' : iilul olr r lo ;i l r' rL .i rs u l rr,i r,l rrn l c j s j l l i i (tnl i l L,x l tr rri vr,l i rr,psul rr,r). l i ,, rrr:r r r ili. r lii 1r r ir r l ,r' -orrrri r,l i z i r, c l l rl c l l l i l a te a rl l ])fi vi ri i , rj l l ([{ fvi oi (]r\gl ol ,rl ,'r ,, r ' ul: r . r ' i,r r r r or.iq i i i r l l l )l l u i , s l )r' (,tr)a rte aezi uni i (bol l raytrl i ;i pri vi tqte r l Ii 'zrrr.:r ) , l: L r . : u' r . s (.rrs o c i l l z i -r, p a t,? l l i z i o c i a i 5 tl e ti p central () fa ,i o hemi _ lrlcgir'.rtc l)itll,(fr ollnsir lczinnii. L,eziulile cauzale sint hemoragiile, infalrct r.l r. i .i lr r r r ur r ilr c m i s fc ri e e . Nlrrriii'stiir.ilo inverse, ilitative, pleced aleviatii conjrgate alo globilor . ,,, rrlrli (rrrruor,i alc capului) sprc si lartea oprrsil (confotm legii lui pr6vost
I

( ot t S xl .rotttu l f l( r gr t t nt t l- lr Nltttt ( lillt llt ) llllll 'supct 'i( n't ll- lt 'glt t l't r lt t lt t i lt rtlr' lrovillo ttrijlocill' lrt't in conljexl,ul sorrtirrlirgir',tttt sirLrj'rotn t,in) culrirrdtr, gl'5rrli

;;;ililii';tti l,;'i;;;;;it de parlea olusl leziunii. -'

c,'i,'l,t,il's'ipsilatoralhotrliliipo.sl'r'zi' fi

It\ '{inrln,nul Fot,ille m ijlocitt, (protuberanlial superi,or cste realizat ) (1, 1,,,:rl, iilrlelor ocnlogire dup5, incruciDare astfel globii oculari sint ir $i

'll

tl( ll )llZ\').

bilalerale,iirs:i i'og^ltr' irtt ii'iiiiiii"X#"i, oil"iiriir" p"tl"e sint aclesea -irnpulsruili'rostibulale silt pierilute' risnunsulile li ' *"-.'i"o*firiifn pot irnbrlca, lirirrt

'",'is;,,air,rr1 fstiTll In.fPrioi (ptolltl)rtta!ial itll.'.itttl crlr gr'ttlt;rl ptitr p;rlirlr/r:' ii O" l"riooi ,i".ailol oculogiri-ub inciucjsarp st malrilc'\lI nl)11' coniugatira globilur o(:rllirri alevjereririi:i.iiirrt" pn,1oaleziunii, cu jnfeliol s. loir,. rsocia.$i,.rrurr siI(lr','t'l i'r,1"^i'-ii,gi SioO,omufTorlillc tl' siluirii sislemelo' tle asoci{rlio:rlr'.irlr. ijnj"tI ilin'"nua fif;iijt.r-"d i"cdmpt"te ale privirii de latiralitateorizorlh, c"."i i-pn" cintl globii oculrri silrt itttlrtrlrlrrii nistrE "tii,r,ii ln diieclia paraliziei. I'itt I'iraliaiile migcdrilor conjugo'te tle tertic:ttlilate (sintlttittrttl !) jll'rlischtrwil s' h "u'?Jrlunlt" comisulii albe posterioare, alc nucllilor lui din reglllll{'aLllrtr'lrrrrr.i .i Crial si ale iubstrn(ei cenuEiipcriapedu('lirl( I r rttrr rrl.' i aoietlo"i p.ino tibrele ocirlomor'o'i bupranucloa'r' litt ;;"r;l';t.;;;i si'-'" L;ltiur!i (ar\':r' vcrlicalp' ryivirii iiir:'riiliilTj.'i;l o pu'i-li,i"paralizia pr-ivilii i.n-'us, iar r'r'l('(:tx rr'l inri-aor"rio' (craniait prorl'uc mai posterioare (cautlal) realizeazi parallzla prwrr]r rn Jos' rt' fn cazul in care pa'ralizia migcirilol, conirgate de vertiur'lilrt'1't' se gdseqteirr lta'ttthrl.lrt purlotizia miqcAritor orizontale, teziuiica din regiuner 1ep12li 1J.5olli qi Srrlli' llrtil "*o"irn'* r"i'"ii'iur"i5paializiil,' cle veit icalitate nrr apar in leziunilc 'irt;:ttl:tt' ""tio"io"ii Si;"i,bl;;i;i .i sup'eriori, ci ntmai in leziunile care a'fecteazi' zotlil l)r{'l"r r-" Bnderl1)(i1r) i.rx"oli*fifo" . ibt}t;.rttltli colabl,tooz; Pasikqi colab 1966; prin ' imposibilitalcl oxtrltrlrrrtt Sindromul Parinaud se mani{e)t; portlr'lr rolr"Ariiol de titlicare;i1 sau dr. coborir('a globilot'ocuJari'-hlr paralizio itttrttttilrigcare de verticali{ate' lntr-o ,n"iiiA-.ti."' "";,Jf.ia" t"ri it:"cl,"nr,afcctarca priririi in sit''' rtpui rr'.|rit i"ii i,i"ti. i'iiiriitat l'ir'trk'trir i; ilb;];; ;;;! ;i "el to ti.p ce numai in jos apare foartc L asociizi rdesea cu absenla rcaclici l)ulilxl.(i lrr l1r ilr_?irir,", il--ll.s (lollv('l'g('rr1rr ' ;i; miclriazS, relativ2i li tu menlinelea ree-c{ici dtr ;;t-. It''" privire in jos, rparc ln plus tlisprtt'i{'irl Daci,'*;';ierd; si iniqcareade modirii qi a oonvergenlei. aplorpr. do uumJrlo\lllllll(l{'irf rl ReEiuncr precolic(llal'lnsle fl':.rl'lc I ..indlomul Pat inaur[ {{' 'rt(rt'iirziirr rn si, ca alal.-' lidicrilrx' itl l)l(r()tr l "",lotrrJi-Gi'ctm l" a rrilu', in special a llruscbitLlui ;;;;;;-;i;. o;;"}ii tr (x)ltvtf'gr'rrl.r ' lupilei, i'ncrioare ii tleficite in )ol,ilitatcp. -ebt{i a1erl.'omodal Sr excepl i()tlir'Li .In krzitrnilt' il" p""".hii a I\''-i A'r:oli;"ll-a' rr"t*lrl.i in ;i;cdrile t1eurmirile pot ti pristri't^e, tirtrli.l,t' trtiq|r'i.r'il' ;;;';;ljidt'tit irr ParrrliziilrL'v.r'1" t Ii 1r'oz' i"t oinitt''" DiIlopia 1'o'rt'' i.,i."i;" ttu ittrlttr'' tlirlitqttl't satt vestibttlalr't opl tiiri",- ,st,it,',rtarea orl 'irLeiic,-r lerl,ical. Sintctizincl4llpjgtlinlitr.r':l1Ltr.i,Il{'ILdcr'(]{)U|r)iLlillli(jiiil||,iu'll'llxIiI .,t91, tttltti'l'l'trittr'l'' lsi'ciit,ttttnlsntiIrrlti tttttllr,rlitt lloi,4elqrl.iculitatosir ,,ris,,,i: ltttpilltt'lrt : a,) tliirrirrrtleit s:rtt ltit'ttlctt'itr'('gt,rrrlrti t;ii;ii,,;";i,,t;irlorii (1r)rr\'('r'gt'rr{'('i sittt ; | ) (' b) i;;;;;i;i,;; i'i;; r'otr*trtgr:til,ir; sp:tritrr I l!rlrllrtl' I IIf1IIII I |)|||1 tlislrtAtttlls i,'r', vitlirrllrlt,ir riqoirilol nisl,rrgrrr ittr,lttsit,'ir't'rtlizia
r i: l

I l!1, . Sl lltoulnele Lui FoDiItre: /.l .L 'r!l l l i rrh l rl i l ./r .Ir l&l!,ui\,r r lonlnor ii( oculosnc) jr .- r ilr r ec ol ti c odr dur e lr ,) vr lt. por tjh( xr t*; Z _ Si r r tr dm r t l Lj i F ov i l ) c p.{nr nel l rd rn , l .!.h l )j i,- SLr ||,J"nl ' rh L l i,t r Ir r yn{ ; ,t -r :ir ' r ,t t!i ltvil. l) r nr l u.r nl i r t i nfc .i or , ' ' Ir t

rl ,"r i l r{, i- lor r ils l) t . r ,l) r l r' l (,i l ,.l l )l i tr1 i rtn i i . I)rrn rl i zi l ,l :tri tt,i i i r,stc rl c l i l l oq11 r,l l r,z , r,l ,r r.i ('l t l' lii,it r r ; r r ' r . r r rrl tr I rr,I rr i ; I Ir,; I i I r, rl r' l rrrr' l r.rrr1r 0 r rrsl l r' zi rrrri i (l rol i rrr vrrl i ;i l ,t rvo l lr , t lr , lr llr ( , 1r , ;rrtl rrl i z l rl ,rr). 0 :l

r||rInrirl.Firrii rrifl. vrlIrlr..( lrii. (1r'iz('l('rt'Il(,{.if.rir,|t{rr rr]n)(i(hl(1(rllll{.(', :rr(,ti.li, slttr^rl. r gil.r(t.,.irr\.rr,l,.ir. (1. r,,t.ilil,, trrlli,rr.,,,.r si rlri rrrtrrStiirr(,i, Ar'fhl" irrlrlirrrc.sivi 1lr,,v.rri{,i l.zirrri iriliac(r}l,o rlrrr "r'iz. rirrl 1r'rxlrrsr'(lr'sr criilrrl r.or.l trtrr,ltrart l lrr rrrJ;r,iirilc r.iugat iro pr'tr coi ci l,)) (rlst)ilatliru firls1ri, irr- lr;rrril,ia uror urisrr:ili (x,llrlrc r,lipidc . -in $i lr;r.li.(., rtislilg,l'irk'sntt nri,rr.l,r ri.c, specialorizc,.ialt., tllr. qi v-ortical'e srrrr .rrrlirl,r,ii,ir'etliat inairrlr,rle a fixa un obiect (u'tel de,,tremordo lrrr'lrxrrrr"'). ,\r,cste.miqciri pot fi acompaniate de tlemor il capului. ()lrr.(,k)lriir rr fos1,descrisrli,.in dir-e'se cncefalite, iiinel prod'si, de i6ziuni rrL,olivtri bulbar.e;i a,lenucleilor ditla{i din cei.ebcl(Jicnder, 1969i. l,') ,ll i.oclouiile ritmice ole globitor oculari pot upiire:l in leziuni ale rrtl l, l i rIirrr:ttrlirr.cerebel. ruclctrlui roiu. oli\-ei' lrrrllrale sau ale rrle si7 r'r'r'rrr1r.lr,r'rlrunorrrbroolir-ure. manifesti, prin contraclii riimice lr Se ale llnlrilol or,trlali ('u o flecvenld, de 50"-90 pe lfinut, clrora'Ii *" o*o"i*rii, rrr rr.r.lrrqi ri1,rn,tnioclonii ale.palalului mdale, ale f01ei,Iinlbii, faringeluij lr,'r.rrr'r('lri,irLl'r'lgn*rlui chi:rr ale membrelor. Dc 'rrrrilte' miocl6niile rl si rl|,Iri|'r'.rrrrllr'i silr1, $e'de diferenl,iatde nistag'mus, i.si. o 'ri' elaJizi, clinici rrr:rrlrllrrlli rrc alllri, cii nu eristi, fa.z[ lelti_ (i ) p|in ;lqilatiu alobiloroculuri,(,,ocular bobb:ng',) se craracterizeazii rrrrlr'rrliirrvolrrrrtrrr.c sincrone ale ochilor 1n ios,-cu reyenirea,imetliati in A lrrrzi{io rrOr.rnrlii. fost- d.escrisi, leziuni iiisiructi\-c intinse alc protu_ in lr.r:rrr(r.i(Jrishcr,19e4).ln leziuni ce,rebeloase d.e"qclis s-au mi6ciiri ini-oltnlrrrr. si Ir.IrrlrrlIrr,u ni$ciiri oriznntale ale globilor.ocdari, cu apa{iti:r in r.i r,r(,l|||i, llrriDul lirririi ur[ri obiect. ilr :i.1.7. I'roblcnre de diagnostie etiolo.{tie in palalogia sistemelor 0rtrl0|[{rI0tii ,prinriltalelorrouze ale olal no,plegi,ilor irr prezinti, .'l'r't,r.r,rt'rr lcristl tt rrrrrL'osr,bilirrlr,r,trs pr,actic,cr rltale procerld.m u"sintczit, la etiopaiogenich (rlrrpri .,\r'slrrisi r.olali., 19?? ;i Popor.iciu si Fa,scu, lgg0). l)oli. .inJec!base ;i in.feclios-ulet gtce acute si srlbttcltte: ..:!..1,.7..1. rr) || rrrrI'I irIi I Ir 'r-i.riticepr.imitir.e(t-pidernicrii, z,,siiriani, ubici, prin arbo_ .1..). b) )lncefalite necundare(rariceld, vari'olii, rrijeoli,, 'r'rrsrrr.i 'ir'o1ico infectioas:'i, |rr.rl irlili rlrirl'rnictr, n)onontl'.leozri gripi elc.). c) Encetalite rli. I''r'srr.linl*(iiilor generalo Ifebr'i, litoidri, scar.lafini, lrise 'conYulsivd,r iir,;rIirrltrrii, ttrurnii, richetis jr'ze, malar.ie ttc.) al) Nc.11ingite ltrtrrt acpte sau rrrrlrirrrrrlr.(r'cningococic5,_.}ncumococici, t uber'cuJoasii,, s#itis rr]o.niogor;rs.rrLr' rri..) tr) J.)oliradic,loneuopa,Lii (polirad.iculoirer.-ritd, Guillar-nlli'r.(t1 r,{li,i{'tk)z(: prrnneoplazice etc.). f) Nevrite interstil ir}lc secunda,re rrrrrrr irrlr'<rl,ii r'ccini"lato (sirr zitc,_o-tite, rl0 ostei1,e, abceseetc.). g) Nevritc rlir..ltrslrl .u',r' h,li . inlcc{,i.lrso.(tlifteria, botrilismul, tetriniiiul, s.a.) lr) Nr*r'il. irnr'ro,k*c,i.. (lt.slvlr.crinale: asa-ziscle rccurenic,ial6 ,,p,r'aiizii
r't I ll( J t ctallli It 01 c.) .

I) tl l r tt' ttttt l t' . r r r l r r , i r r I t r I l i | 'o t'i tl tr l tto ttttttttl l tt,,,',tr l i r zr ', i t'l tl i ttti l l i tl i l 'r r o l 'l t ) ' r ')
I r l l l l l l l l 'i i l n\Z l l .

'''1 'i '. . 1 . 1 't '''i u tti l .I|!( l t],ttl ':|||Itt|',l r ( !( 1 i h r n t.,l ',t1 ti i r ,.'t'.r Itt'i r l r 'sl r ttr Ir . u tTo l 'i r l i tw ' l r q t t c l t i r r r r l c l r r itl . i l t) tl n tn 'r i stttr '.'l \'' l r r i i o r '''!'i r r r r .tci t- u 'n r r :i "w e l t i l i i tr |'r r tr r {i " r h ' D "z i I i r t o si ttr l tl tr tr tl 'tl o g i r '' , ,t t t ,t , l i t r, , i rl i r u , t) to r l u ( ' 'l(i il 'r 'ctr i 'l l a \1 .( a ) l r r l r '1l r t'l ; r l l s|.r r l t , r ' 1 , t , . l l i r '. i r t r , l l i j i x; ( i 'g r r l t 'i N l r r tttr l . t9 6 l l ;

t'o!'i ltot'vii octtLrtttttl.ri . , i,i,'l'., lrrtri, l.9t.r, 197?) : ctkt untirioare leze:r'zil ll, pcrethii a ltt-a) ,si tlltntttlt't tI i'It I ttt it IIt lt ,,,,,1,,,sr,I'ti t,,ttiu.rl superio,uii Lok)rl l)t1\rllrrl t la trr;','rrrlrrrrItri) ; tde rniitoaiilezeai5, fet to!'i nervii,oulllulr loztt"tr'ir '1,, uieltisrnt'lc ptttteri'oaro ' ii',,'ri, it,Jtilirormu:i ale trigerncndui ; irI ;rteru (VI) $i rrel'vultrigeruetL l()lrrliltll'r.' oculomotor rrr r,lrirrilr, n('r'\'ul ,,,,,;;;;i,;-'_,; rrri sindrom claude Bernard llolner ([t'ziurLet,1rrit,$lo;tt"Zl\r _i pttl lt'zrt ttt s'upt'aclinoitlieut aarotid'i'ene Anet:rism,ele ,,,a,,'ii,",'*i,*",t'i,'rrn). tI de comtltt. Att'eurismele urterd tiont'lt it:Qrt'lt1 ,,,,,,i ir,,lal tt,', t'tLl oculomotor cloar plin plozii' pllptilt'llii' lrlr'ftirtlii s1' 11rLmanitesta atlcsea,',,,,ti,,:;,,,,r:A nrtereibazilurt poi protltce jrlr:rlizii txrtttltitrrt'l'r" rrr trrlitlr'i.. 'lnrtrisnte[,e f I-.r,-ia" d. hrrllt oLi ttlt sinrlrt,tttI'rtritt:trtrl ,t. ,,,,,i,".i,i1u,,lll-.r, .,i rr 't'r"ntt'lt ^ n.ite ie tt.iJeritcetiutuqii' t't ' ' i;;;;,:,;,';i;tl 'tt',t,u-r'iri,talirr". ',Lt A ' si r r ( t olido'( t t Dcr t t oust lni ( Llt Pr t t u^. t ) t 'isl e
tt,l ,rl r r ice itnle ctalt it,cttctful : t1 -F\'mtrrri clrrtritrlto itlt' ltrtzt't l!.1.?,5. '1't'{trunttt in. n) nlllzir r ' ,,,,,,i ,i i r,i * i l * r,i r le or bit ei. b) Coniuzii cer ebr alt '. I ) c pilt lt 'r ,

, , ; ,'l;;:;ii iiffiil;il

(x'l'1rl)rllltl ,rrt ttltlltlizii multiplc l)a,l'ttil'lc (le oculomotoli' ln coli'ttzilt gr inlr '11'\ 11( i. ( ir L r r r k r lili'r il") ,.,, 1." ,,," i ,:rl ,, i'i, 1, : , l', , i; ; i'l ct r ob'll, pot I i t.tt ," ,' ,,i 'r',;;;i;;1i,,";,;;';r.ir,t,: : r . t t t r il. c*it r it 'n. r 1c et : r 'j r t r ijlo. it t lt t t lr 't t t .,,' u t , , i, , , , 'r , i' it r I t u pc.'(1hii v I rr irl(' trururri iit oi vt, ,l-n'urteo..i i.,; ; ' tl i i , 1 l,lli'rl ttrcll'al posttlrlumal.it. d-) nlecrnirtrru hitlrr,'tlinarnico' erl('ltr 4l vr t t i: t lt ' r' ' .,' ,u,,,ai ;r," .i " pcdl, 't a le. t ') lln( o{ulopi lii l'o"t t l'r ulnal ic{' 1t 'r 'll lt t r t i

pi l"*

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i' . / , , r . ; ' . . lit . r t t , l .i t,tttl r.u t.l trrl ttl rl ,,t rl i .l ,.i l. sn.hsl .* )tl .i rrrl ,i l ;r,l rrrr str.rtl lt i . ,o || IIr |r r . ||\ : || oli, r l p rrn i l ri l rIrrl r,rr r. rr rl rrl ri l i r ,orr xrrroi r rl rl l ,i r, sl ,rrrrrrrl rri rr, si vr,A l :tl i t ( s it t r ; r r r t i. s i l l l l l n l r,i ' rl ,i rtrr.;rl r.r..r' r.:r1 Irr,{.i rrr,h.zi rrrtr.:r r,;rrr.,, l ,r,ul rl rr :rrrl l |tit t l: r ( lr . t I : ir il I(. :l I | | | , | || .|| , |.. A ..l l i .l , s I I L { | | I I |( r, l r. r.rrl i rrr.rgi | r. | ;i r.r,l n ;| Jr.r r ] r . s t r t it z r c t r l l ro d u c | o rrl t;r(l { i tr r(rr l )u l )i l c i , i n ti mp u) S l tl )sl j A l | i ,ellt, rl i " i rl i rr.r ' { ilc r ii, r ir nlrr,L i " n mi rrrr.l ,i r.r,i i l rri ;i . I)e cel e mai rnul to o i ol i , IIi rorruI| i i IIr ; r lo pup i l c l o r.s l rrL Ir' ,,,h r" (,ti c d o l czi uni rl c .i rsi l | rl ,| ' li ,,Il l rrl , l: :1 l r,r j' ll:.:Z llllu i l' , r ' .' r t p Sl m D a l ,tC L tl U i . ,\rii,s/arrlr l" cu)e ,,Jecteaad actiritatea pard,simp( ix(i si se folosoFtc .1 , rr ) r ' r r ii, 1, . r . ar ? rfT re n l ru i n g n u s [i c u ] d i l c re n i i l l al aD oLnal i i l ot,d,, D ,.,\) r d mi l ,i nto IrrrIi l : r li . . ir r l par a s i mp a f i c o m i m o l .i c e S i p trasi mpai i col i ti cc. l ri nl tc cr.l o 't)tt)u\ntputLu)ntmctrcp emmtim | physoswrnhLa (ezeina) O,Zi % Uo_ rlrrlr'lrr rrrrochi normalo contrac_ti;-madmai; pupiGlor ^) a

r l o tti i l tttl ti l c ( ) r l i f l l r r r r ti i r l r r i tttl r l l ,'l l ' r r r r r r i ttl r c r I i I t I t t t I I I r' I I I l l l o t r r r i 1 ) r r ( l i ( i i sl l tl i t'.', I,tl ' i r l r r r :r i o r r sl l i l 1 , , , t , 1 i l o r r s i r l l i l r 'l 'i r , t'r r , Ii zr ,,i ,,; '.r i l , r r r , l i : r I i i : t I r r s t r l t,tl o t'l tltto l ta l t r i r l r r r r l r r tl t r r tr l tr tr r ( i t'i sl r r t r l i l l tl r i l i i , i tt l r l r ttr i r r I ( ) l ttL i zr x:t- r l 'i c l l 1 j ( i i l r o i l i ( r Ii Ii t'r ttl ttr r l t s1 t , ', , , , r i r r i i , t : t l t l tr vi r tc Etlt t t t t i l i rr :t I t r I t p u r e L i a d ', t'tt;t'r ii t[t'l '1 t':l zl 'i r cttl tttl t l , \ , l t : . i t n t ( i t t , t ti l tttt:r r tl ,ti ,.l i r i r i l u l i tti i ,,l i e l l l L l l l l l l r r l r l fl ( 'r ) r r r 1 'l l 1 , r 1 , r , 0 t r s l , t i 0 1 ti r q i cl i ,i kr N l l l |' l l f{'l ( 'l l tr '( 'p a r a sl n l }:l '1 'l co r , p o a l 'c si ' l l l ':l l i i ':i l l tl r r i r l r ' i , 1 , , . , 1 , , , , , , 1 , ,s i n r p:r 1 ,i ci r ,.I) ( , ts( :l r I( r l ca , a n i zo co r i a l r ', , .

i , ,' ' ,,,,,r,,i i ,ri i i i r t r L inhibi! , ii a, ct r it r ului co'st r ict or , co. s{j( r ul'i'r ' lt 'zit t t r il. t ' ,,rr,,r.rrrrroL,rr[r r .Lizucor i: j calo sc accent ueazi, in t im lul diJr Lt iir ii lr t t lr il. 'i Ar ( 't 'il.{r r l( ' r l , rl l rrl ri t' r' i l rl odusi, de lt ziuli ale sir npat icului' in t ilr lp r x lezir ii par asil) r l) r 'li( 'lr lr r i" ,' ,,,,,. 1,, t,i rr,l r ir l cont r acliei est e consecinla idriaza (creFterea dium'etrultti ltttTtilo'r pesle 4'. 5 tttttt.) :',t.ti.,t. -/,I (lil'll1 il lrr r',,.rt, lr rrrt,ilniltj,si in conditii nolrnale. Astfel, pupila trstc nlai ,,' I:r l ri t l'r r li, I a m opi, ll' : r r lolescenr i' i, ' ' ,,' l l l ' .i trtti ulr ciilur t 'lt lit r ll i(t.t'i.a,f;(t Qrtaur(i,icii se nallilestri prin faptul cti ltupilrt' lrr oclr ittl ,,r l' { Hl(f irrk'sca' Inai mare decil, ]a ochiul s;nil'tos Acela6i fl]rroltlotr Ntr bilateral[', apart rt tttith'i:rzii li irr rrhiul ambiiopic. ll :rmautoza 'ui,t,,,i,,i,' ttt l tt. l ,r rrtrrl ri i

lfll''rl Ir:) rtttttcotl_na sollttie 2,5 7o.nuproduce nici o modificare ia o pupil), ror'r||irt:r. (rzII iD care inervr-ti, tlr r.pflrasimpatiel osteixtrerultd, m sihii -va'proriuco c,,rslriclr)t'i rlevin mai sonsibili astfcl hetacolinn 2,5 o/o _$! r,,rrr. ri,. lrlpilrr.ri1 rll Ceg maj loloiitd .s/rslonld rli, p,trusintpiticot.iiica esie rlt uttttt,ltt tt hldrobromi"d 5o/o. rimp de 40_60 minute de lt inslilrLre:], ln Ir| )|, |:| | | r,| , II |{' i . cr pupili normalii se dilrlr] la maximum. DacJ inervabia, :,rr.t,:rl r'.ir. irrl reruptir rlilalrrrr.resfe tnici salti)b;:eati. r|i

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lrr' rrlrrl

l.,l lll rlurlo,[.oq.i( tt.tilizd,rii probelctr colirelor este urmltoarea ; a) Dd,od, lt t.t t ltr t :tlt'.tttith i.atiLrii, ta testa in primul lincl cu metacolin i, 2,i t/o. Api_ lt se lr{r:r pr;rilrr ( r 'lsir.ic1-ieidemonstreazL o leziune parasimpatici:" Liisa i)rriirr',r n\:rtlltt puprlare ]trage atentia asupra unei Stiri de excltatiO rLrrrrIrrrIi.ii, r,r*. |.rN{r ti confirmatl printr-rin-bkrcai aI ga'gliouului iiefii rrlrrl,r:, :r.r.,t 1,11,('r{rler api-(ind ia ,co-nsirici pupilei)'; ni \icA pupUa isii r/,','./,,,,..sr..\1',sljrrL.primul rind cu homaLropixd ioo. ln clzrt in car,l rlr.v||r'.1i,:r11" mrdrirtici, rvem dc,r frce cu o slare d.ccrcilllrilitrto l)rrl'rl:r ,l' iar rtaci se md:e$te pu1i1, aflaim in fa,1aui;; l,;ll:l ll ir jri:.:: :l:icu1i, ir(,,rrr, trlrunulur simpatic. Du1ri-trecereaefectrluile r'r homatropinei,'pulenl rrr'{ r r.r (lo{liritril,.Darli pupila se dilati in mod oviclentr probibil li-ziuaca r,rrrrI rrrI irriii,sc ir,i'lir, caclrul S.N.C., iar dac[, acest fenomen nu se in Droduco, l.zrrrrr.rr grist.rjl{' s. irr:r,ftta S.N.C.,I* nivel'l f.ibrelorple- sau posl;gangliotrrrlr,( N1r:rlrtirrr, ltltif)). :.)..1.,\.,:j. ,lti:rx:urit (iuHt ,lit lt,t, ytTilard)-'ln rnod rxrr.rrn,l, pupilr.lo " *r,'l rl('r(x.'rr\ii rrriilirrrr' I0rrclirrrr.nzil rrglrll r stirntli. llacil prrlilcJr,irr 1i

rytlegie internd,)' iir ilrtr''o llttinrri' trzi jjol',sii' alrrtlii' fiorrrt(r ,t.,,,.. 1,,1:til,u (1;:rr\r li('(ri,{rrrzil a ,1, ,t,r,',"ilrrr ,",rirpii,1r'i, pereihii :r, III-n. Nu toli,e lcziurtjlt (| ( tl l ol l l t) li( l'Ioonlult poi im plicr r I ibr el'1'r r 1li1'r r ''r t r sit i|1't l: t 1. ( l''llt lt t t t r t l' r,rr\| | l ' , it rrrr,l .rr l rri l ,)rl iger - Wr : st pir a, l llult . 1cr r z. ro qlli'i1'r ll"' i''pogt r t lit r ii st '1t lt , rt lcr'itrttrt tl.ttdcfitii it, l,tt't' i ,t.1 lll .:l(lr..l rxrinpltx*lrLi nu.1ut1' 'cUlott'tol.t'tt silr llr lt lit 'i l) it t I or t l't lt ' o plt llt noof il] i colllir i r l rr, rr l l l -rl , i )oir t , o I 'oNpo{}lll' | ' rl l trr.l tl | (' tv| | | lI it lr lt t |olr t t t l; t llcont t t t t l. lt . it t t ] t lsil|ilr r 'r 'llllut t 'lt sir t t ; t ; t 1ir , t . , . llt t , '' l r' r , | ,.r| | .i l tl i ' r,llt |t l st llt lt l': t ,llt t t ir 'r 'lt t l glit t uI ilr t r t llt t ir . ililt t ,'; i ir I t r r 't . yi|. r t 't . ililr t . i pl! ir l ,rr' :rl i zi ;r lr r r lr illt r : ii, r so{i1i r k'olilr ilt t olr l'gii li( ill1( 'sr r t l( 11( 'r lit '( nlr t f ( l it lt lt r llt lillt lr 'llt t '11i, 'r , it ,t, , 1,,{,ti i:rl rr sisl, qt t r llr r i lt ot v( Js, l'( ) ll( ! sir r r l, llt : 'i, t : ii' , , ,, I.rl ol xrl i rrrt t il't illt ,lt t t t r , t it r lt 't r i,(|I I(' t' I II I i 1i I llo$1'\ 'ilc{'it Li \ 'ill l( lr l| ' zr r lr ir n: pt 't t zilt lr t llll li t t ( llr li lr r ' ,r l , t r.l c. l l t lllllll, ( ! <r lt zt t t 't t t t lr lr ilt zlt ' lllr llr lif it lil 1,,1| | i | | | | l { r)| | l ' t. r i|'llI lr |ir t l( , it t t r ilr lr . lt t t t it t lil, r '. Sji'ilisI lI lt l( |lljllg( t vlt sr lt t I lt t 'lxt lt l, t r 'l) ot t lt 'r t t t t t r lt ilt t liit 'lr tlr t 'lt lcr ilillr r.,Lrl rzr o rrri rl t'ilt zi. p11, , "11, lr ivii 0s1't lI ipit r r i' si'lr r liilo l( n l (' I I t I I I I tI I t! ' tr!r rl rl ti i l z:r lr olr ir ' I i l'( 'lll: ll'( f l ll, it r ' | l i d| ' i /l .i !( 'Tt ur t l|, i|'it . iilr r r r t l, t 'l'i, i||lilt I i1iiiI lr , r lr lr . |'lllrr lt 'l |,\iilt't ( t r ickr r ) ' t lllt \ r , , lll'|ll|1|j||( t I r r r lt lr t ( lr 11' ,,Irootrrrr' | rt I o1r it ll( r r xr r ilgi( r iiir lllr lr i( r ilt lr |, iI lf it t li't r {illr Hr r l rri ori rrtr{iilr r t r t t t t l, t opit t ii, t 't t t it t plt ci' lr t i't 't t t t t ii lllr ( 'l( ! l) r ) li l'illt lI t lt llt rl .,,trl tl | | r, l ,' l rt t t t , s 4. t 1. ) llt ( r llllr f lr llt r r lizii lr t t lr illt t '' r 'r t t t t ir lli: r zlr

Al i tfr'(l{ f r t , f r : llt i.s ilr l i l l g l t,l ,, tr. l x ri tl n r l rtl l ti tl rr q tttt,i :pt1xt,i t / 1.r,ri;rr rl :rri l , r ,,rf4 i, rtrr,r.I;r I iI r r I lir l) ir r ( ' u r l i rrrIrrl t,r,l l r,rr,l o r. ir i tvotn o /l xi :or,/)f//rr./i ri (,1 1 rrr1 ri l rrr,r,, 'l i'.

7il

r l('zirr,ilc nuclrarer oftalmollegia e..tc'riri porrle Ii completir,, i'sii..irr. ,,1 rr rL' rrftnhnoplegie.intcrnri. r\c.rLstadil rumil rplre r:rreori sillgurii. ii Ir ) l[ idriala sl/asticd, trtt co'socinta uno. lezinni iritatir-e are cr-r,ir'r e rrrrrl,rrlilr.l)upilo-dilrtatoare. Acest fenomen a,pere in contextul sirdro. rrrrrlri lrri Portrfour du Pctit,. care cuprinde: midriazi, lf,rgirca farrloi se I rrr| |rr.IrI irIrr ;i u;olr.ir. cxo1tamie._LTnc.ori asociazli ou vasdcorrstric{,io, r.rir|'r'r'rr 1.rrrpt'lltruii qi hiperhidroza lemifelei ipsilaterale. Midriazr 'rrrr r|r' rI| l)lIirrrri rna,rc,nu siltt scmne_ paraliiir., ial reflertrl fotomotor de '' ryi rlr. r,orrvr.rgcrrlir, prtrz,ente, sint sal doar uqor diminuate. ln leziuni progr.rl irir r', slrrrlirrll,.clirninrr. dc irita'fie simpaticil trece intr-un stadiu d;deii(iit, i irrrptri i. si , l)irrj1iir consecutiviia miozei paretice in conte)itul sintlrotn.u lui ('lr,tlt l, ) n.trtd-Ilornr:r, crne estc lniti stabil qi mult mai frecvent intilrril,, Sirrrlrrrrrrrl I'or.r,l u,r,rdu Petit se inLilneqte in adonopatii laterocervir:,|r,, lrri lr,r;rlrr llrll lr ctilo:,lnei cgtvicale,traumatismo ver"te6romedulnre ocrvi(xr rl.rrrrlr', irr .ilr(l{r'ul si in tubelculoza Tirfului prrlrnonrr, in ttmori mrxlirw Lirr:rIr', rilirrgorrrirlio,tnttfltlite si trtmnri cerebrl.le. llll l,i:irrtti (ltt cenlt'ihl' gi crl,ilortu:perioot a .l ,l Ilrrlr.irrzrr o)r!irr*1,i oxpe.imentalprirr inllibitia co]11.,1.i 1r.rr1,'lli ,lIi(li(,r',.ir |r,zrrll,rr.l, stirnuliirii cortoxnlui ft.oltal lrl 1rrrIrrI.r..rr !i :r,Ihip.1,rr, rrrlrr. ,\lrrl'irrzrr lrrrrrrr .sii' rrlri mruo tlc p:rrton opusil stirnuliiii ccirtiorrlrr, rrr r,lrrrrrl,r.rl. rrrrr r.i I rrrrI:i lr0r nol:rl;i,trtl stimulirr,oat in hipot:llarnusul tri.

; rl I t . r t t i o l f I t t t l to l t t t l l t i . \ l' it t i . , lr . r ir r t ( ' |, , : r , l : r r , t r z , t r r i l r . ( , i l t t ( , \ . t i J t l l ( . t l i \ 1r' l.r'ir .M)lirlir il r l( ' r ' r ll, r r r r r , r l, r r . lr . ; , r r 1r ir r r r I i r r o i r I i r ^ t r r(,r l l f ( i J l ) L l r l ) t , ( x n r 1 1 ((!l rrrrr ':rlizir' lzrlrrlii r r r ) ( ' lt f ( ' lr ir r r r r r r r r r l' is r r r r 1 . r | rr l . r 'i r , r 1 , ! r o i l s e l til\.orrolrsi\ rr' if .lrriIrrzii, rli'o lr ir : t ' i, t t lt r r r r r li lt r t lt ilut i c o n l t l t k i . o ] n i ( t r i r r , z r i p . t l r r l i i , i ( i L . it ir' ,rrrr1 r)t,i{f l),ll1 r ! i- L lr } la. , ir r r r r r : r . , r r : r _u1|Ll rr L o p l c u i r i , s r r r r p o l t t o , \ i t l t ( x t t t t . p:rrri 1, ., itrli\.ti, . ; ' r , , ' lulr . lr r r r . r r r r , r it l. r lc l , o i l e r i o l l c . cl:rlliclre 'l'r',lllrrali$rni'[{] o c:11'rz;rco'nun:.], a !fr,r'illiziirr)r' 'cr)rrzirt; 1,rilrili*i'. Slirh'iilza lloate fi con-(ecinla, lczririi dir.cte a tlunchiuhii (1ercln.rl, rrr rr .rrFirrrii, re-qp{lctiv a cornplimirii neryul r1i ocrlonrotor cor lrr.

I ' r r r rr ' r , ll. r| | |i |(' | | | ri rI r , rr, r, l rrr r,i )r rr| r,rrr(N . rri (rr.rj rz:r rr' .rl rri r..t, ' 1r \r'r,r ' t r r r t l, r r r ( , I l l l l i l )) rrrr ,1 ,. , r r ,n ,l t r tr tttti l trl .r,ntl i1.i t Itr s(fl rLui l ti (| l tl i

\'i l l r l l l :r l l I t ) l l i l n r l 't :;tu tttr t i rt I t rI r' t rr t t t rr t t rr ( I t I | | |r i I I : | , l r i r l l l tl i l l l r 'r r , '' , | | r r ( ) 1 .r(l ( . r l r . r r r o r i i l i , i r r i Itt;r i l l ttr '. \r |r ;l l l r sr tr i l r to r l ttr r t tr r r r i r r l l r r r r ' t' t ', r r r l r ' I r . r r I o l i r r Ir ' :r l r . q i l r n r r l tr i Ir i 1 r o l l r r tr 1 r ttItti ( ;\r ';r 'l r i 1 1 i ( \r r r sl :r tr l i tr r "t r r . l ! r / r l r rrr, r 'r I r . s i i t rrr { i i , tr r i t l l i l r zl i 1 r rirl r rItl r tIr i 5 1 r |o r r l tr i l r r o i i si r l r '|l r tci l , 1 , 1 , r ', r . l r i l o l l l l , I\', \'l si IIl . l 1 l r t r r i .t. tTti l r l tl i |i r l r , 1 i p g tr ttr tl I I ri I I , I ) I t I i | (' I (I Ii ttl tr ti r ,i r l r r tr ':r r 'l r r ' 1 ' r r . ': r i i , l i {, i r . i r r si r L r vi tr r r r i r |r 'i l L i r r r . r tr Il zl r l L r l ti r ,l 'i . \ f r r l l i r r z r r i r r r i r i r 'Ii i r l i l r i l i i i r tc[a u tTtti t, M '( ti ( r 4 .ttt) r tttti !. tts.l i r ;t, ttl | , , l . r l \ r l r r : r l ( ' :.tk' i ttl r t,ti ( tt!i i l o r u l t:o tl i a t, ( \1 b ( t]L i l tt) 'i t t ti l l l ( 'l l r r l l ( ' fl /r '\ r , r , , ( ) r r r i r l l i l r zi i r r r u r i tr u tl i i tl r l r r t i tt xl o 1 ttt,la r .n l i u tt ( ,l r tr l l i ttt,r t '.i l i ttl r t r r , l '1 1 , ,) l f l i i D r l rttl tr ',r 2 i r r r /i fi ( l h ( !l n tSto L r N ,l r ttl l i l i t' l l ttl tl e l ) 1 1 'zl ,r r l r r( ) r r r r r si r ':r , , , r i l r : r z r i i t r l l ,zl r r l c i r tsl r i t'r r l i c a tl i ttci i . . '. l . l i . i . , ', , r r r . r . r 'i n l i 1",tt., l,Iit ll t l ll i o .tr r ,( tl i r r ti l ttl ttIr t i I i l t - t t r' 1t t t I r t i 1 ;ttp i l l l t'sttl t i - l ttttr t) l t;tl tr | r ':r I it tt l r ';i u n i l o r i ti l a ti tt' It'cti i .l o r 'p 'u l ti l o u n :tl 'ti r :l o ttr : ( l ttr r tsi tr t ( si l ttl i ( t') . r r l t':i tr n i l o t l n r d i tl tl t ci r ,i l o r p u p i l ,o r l i l tl a l o tr tr

i n .l e r i .o a r a o ,l .t ct n l t i l o t' 1 i ci i l o t r tl c ( i {r l r tl l l l l l i co ttsl l i o l ,o r r r i l l i o . u s,p r r si cr i p l i tt Iczi u tti i ti l r tl i vt i 't ) , l , r : r r k r r s l r l c o 1 i 'r r r l l i l so l ) l ) r 1 ( ' i ttl i l l l i i r I: h e r n tl t'l g i i sa u l ,l l tM r ti l ) o l l l ,l l l r '. i r r , r l r r l i l l i r 'p i r k,tr ti r l i , r tr r r i n g i l t . i ttl i 'c1 i i :tl c si r tttsu h ti ( r i tvt'1 'tl o s. l ( 'zr r l l r l r r l r : r r r l r i l l r r r r , l cl l tto N , l ti l ) r ) \i ( ' r ,r 'tr r l r l l l '1 scvt't'i l t'1 c. ( ,Jr tttl :ttto v q i l i ttl r l r r ,

l r : i t r . r ti

t,r,, ,

('lursi(I,I ()70).

ti ) ') 'tt tt t ttt.i I t' ltr)d)t, l.r, rruri iiltrs (jcle srlratdrtOriaje, e\etcitii el:rtl,, ir vrrr', ; r ) , i1. , r r l[ ir l]rrl )j l { ri ,tl rrc o ri fr" ui n s o c i e l e a de rnodi fi ci ri a]e aaLi vi l ;i ,(,i l l r rr.rrrl, ;rrtr :rlr. r'cl'ltrrclol totornotorii. S-a flescris midriazi c6ntralat,rrl*iir rrr trr r r r or , lr , { r r l: rl( ' $ i u r i o rn p o rrro c c i p i ta l e .A rs eni ryiJl otez (19?1) au d(,srt.i } r i ,.r'.r, 1, , : r r { . 1.r r r . r l] l i i fi ri l rrrp i l a ,rc ; u ,) i n i ,rL rnol i l e rontal c: mi ozri i psi l rrl ,r, i r rl r.. : r r o, r ' l; r lr t l ti l ttts l o n rl ,i o l U tri m trl :i ; b) i n tnmOr.i l e temporui ,, (i rr r.', rlr . l. r , . ir r r r r ' : r 1 r' rrrr.h i rrl u ic c l rb ri rl s i tu de herl i o t1e l ob tcmprl nrl ) : rrrrrl r r : r z rrr[ r r lr l. t r r l i ; c ) i tr t,u l i :l r)ri l {o trc i p i t:r,l c: mj tl r.i azrirl c pl r.tei r rrprN i t. ] , trrrrr ! r r ' r ; r l) r t r ll tto fi l o i n fi l ti rl ,i rre d 0 ttu n chi cer{!brl l l : a[i z0rrrrIi r, r,rr rr,,7 r ii t r r r ir ir il tz i i p s i l l l rtftl fi (i 1 r ? 5 o 1 , (1i n 0[z]n.i ); t,) i n hrrrnl i otrrrrl ,..tr.: r r lr r r : r l: lr r ,ir r r u rl rrrlrrL i rh ,i l i z irl e p a rto :t, l czi rrni i , l l pi l i rLc pl rrl el r, rrl rr* 1, , , (l rIrrr . r r r r r l r |' pI rrs i rrrrrl i rrrrp o ri )s i i n fl z | , l l i [al l -r, rni d.rj rrzl iI r i I:rI ri r.rr|;t, o c Ir'l r lll( \ r ' r r lr ilr r r IIrIri trItri r,trIrn l l ; t) t' l t l trr ml l toi ttncl c sul xl rn,l rl ot11,{ .l l i r,: trrtrlt i: r z : riI s ilr ilr ' ; rl i I g ) i tt Itr^ tl rl o a tl c l c s r tl trl untl o rtr)tri ct. : rrri ,rai rr!.i r
l: r | , ) i l l : r .

stl r tl r r r l i r ',, p l i tr l czi tttr i r l c ( {'l l 1 r 'r i l l ti ;i ci i kr t l ' ) i l l i o : u . ? a l tl i l i ti i r ttl tsl l t :si tr L n tn ttl . ( '1 l u 'ttd l l r u tr l l r l r l i zcl zi i r ,r 'l l l r i 1 , '1 , r l , , r l i l : r i , l r l rr i r l c l l , 't t t r t : t | i o r , ^, r 'r r g ttsl i r t{'r t Ii ttr l l 'i 1 ti tI1 tt'Ir l r tIr isi l l l o l l r i i {.tto l l l l tl tr r i r '. A( ,|, r i ,r l , r r r r r r ' l i s c p ro l r r sr i ci l r : r 'tr ,sl t'tt'r t rr r l r 1rI i i t I r I i I r i i ( tt l l r x) l l tr ) ( l l l l '( ', \'l r sr ) tl i l :IIr r i r l r r r L l r l r r l i l l r l i r l i tr ci , r ,o r r .i r r i r t,lr t'i si r t r l tsr 'l o l l i tr r i l tl t', sti i tl o r t'r l r tttzi l o l r , i , 1 r , r r r r r i i i t rl t'r r o cr r l l r tr ', <.r 'r 'sl r ,r 'r 'r Ir 'ttt1 r ctr t1 tL ti i |j i st,l i t[l 'tcr t l t i l l rfi l r rr : r I rl r r l r , r r r r l ', l l i ( l c i l r ,( '( '1 t[j l r r t'l r . l tt;l i l l tl tl t tl .c t'ti i 'r ti tti i tr ti tl tr i ctr tti tti t l tti r l tr r r T:r ,l r r r r l r r . S i tttl tr r tr r n l ( 'l r r ttt[r ' Ii ct tu i l tl l l o ttl 'r ' t'si c r l l ct'l t' ttl l tr l l r l l l l , .r l , 'r I l i r l r '| 1 r i . l t \ 1 i ) t ) u : h i tl :i t'l r \tl r \ti o /,i \ ;r i ttt1 l r tIi cl ] i l l {) i .1 tl {'N tl i i r i i r r s( 'l ( tr }7 ,:r l r r l r l r ; 1 . , . r . r r r 1 . l r rIi L i i , si l i l i s, I,r r r tttl to zr t r tt'l "t't'i r ct l tl r Itr l {'r ;tl l r r r r l l t'l ( 'r {xl {l ) r ' l j :l l ) tl r i l ,l I' r i r r l t'o tttttl i . l ) r i s l ( 'r 'o i r r l i ,r 'i o i i r r ' ( si tttl l r r r r r ttl \\'r L l l cttl r o q , , i 'l i r ') . r i l r ttl l r r r t( . r i ( ' j r l r r r ) l r 'r r l \ lr l l i \ tl i tt r i i tttl tti l i tttr 'l t'l ) l t) 1 l l l ) ( 'l i l l l l ,i i r l ( f , 1 , r r o r ': r I r r r I r tIi I,i o i i ,r l c l tr u 'r ':t;i l ,l ) l r ' r r t Ir ( r '\'i i ( '!r l l i i r 'l r i l ( 'zr l l i . ( ) l ( zi l l l r t r r l si tl r ,r .'ttr l i :tt 1 tt ,,ttr r , ,i ( r l 1 o :L l { l l r r r l l l r l r ' r r r r ti ti ' " , i t r t , r t r t t i ttr l i i i .tt.l t o u r tr {'l r r r tr l r " l l l t r l r tr l Il o l ttr t'. I}( ' I ri lr ,r l rr' I l {' i r , :'i r '\l ) r i l l ( l tr tr t r l r tr 'r ' tr ', r r , 'r r r 1 . r t , t t l , r i t r l i ti tti l r tt n r l ti r l i l ttr 'l to sl t ti r tr tt r tIr ' * r tl tttr ttl tl t]t t( tr i t4 l t i n i ttt,',tt, r l i l o z;i . l r r r l r l r r i r l i r r r I ( 1 r :r r 'Ir i tr r ctr i tIr Ii L i l r r ,'l i , r r , l I , , , 't : , , r l r . \ u l ) tti t) i tt r l l r I I i I I I I I 'r ); r | ! L I l. r i l r l r r l r . , l xr r r l r r l l r l l . l t( 'l tti tto :tl l l {') . l } l l l l i ti l r r tti l l l t t r t h i u l , tr tr tr r l r i r .r i ttl t'r l r tttl t':tr Ii r r ttIl r I l r r l r l ,.i l l l i tr l i l i l r Il l r l i ( i r 'r r r ,r,,ultti l r ,l ,r ( i r r ' r 'i r tr ' l }r ttr r l I r r r l r l , r ') r ; { ' r r r i o {( vl ( l c Jr i o zr rri t r t I rrt i i t ' rr . l ,.i ttti l r tt r r r l r r l 1, I rLr rr i t r t t I I t i l j i r l o u r tl l ;r l l r tr t I ( i ';i t Ir o tr r III l 'r l I tr .:t$ i 'l l r l l i r r l ) 1 ',r 1 r r !r 'r 'l r r , r r l l r r r r r l r i r r r ;r r l i c r ,',t vi t'r r l r i .i r r r t r ttl r l r r l r t ( l tr ttto t i l r l ctr r r I | | I I | | | | )| | i | | ( , ' | | I l ( ' \ ' I Irl I I I t ^ l l r ' l | | l r - r , | l l r ) z r , L tl tr r l }|i r tt|tIi r tr 1 i Ir r Il r ' tl ti l l l r ', l l tt( l tr r l d l o |i t\t tr l t ttr tp tr l i i l r l l l r t,n tt'ti n r l t r r l i tt:l r r l r ': r ' orl r r ; x " r 'r r ( i i l o r :t{r i ( ( ) . l tt l r l r l r , IIi r ttr l t IIi tttIr l r r r tl o :ttttr ', l r o ttl :r l l ,r r l l 'l 'l tr ) r l , r . : r r l r , f l r r l r r ) n r ( 'l l r r r i l r 'l tl ttr r tttl I I r l r.r, l : l l r. i I r t r r t t I I rt t t l i i r rI i I r r I Ji I i rr' I I I I I I Ir r l tr 'r t r l ,r t ,r , r tIr r r ttrr Io t i l r r r :tl t r l r r r tr ':r ,,r l 'tl ,r l , t|I) |) It,||) t I ' i r r t t t , I ( i .tl r ':i l tl tJtl tl tl t ttl t l i tttti 'r

( r I \ lr r r lili. : i' i l . Irrp i l rU r' :r1 l rl rl rrl ri Itrr,rurt,rr,ri stttr' r' r.trtti ,nr' tr rt' { ,i o rl tl cri u 'lllri:l v i l i tir t Iczi urri l ol rrcl vo:rl r, (,\r,i r.l rl /rl rrl r' r i r it t t l r lit lr , l l s rrrri ,(,i -l rto l r ri r ()l u r . : r lr , lllil: ) . l l r l rl rtl ti l r ttl ti l l n r\' (, l r, l r ol i trl ,i l rri rl i rl l i l rzr,i l rsi l :r,l r,r.rtl tr l r rrllr lr lr . : r lr r lr r lol l r.l l l rr' Irr, Irrl ri l rrl r. (;rrtl r rl rrrl r, l i l l l rtl rrrrrrrsorrl 'i l

rtrl rilr r l. r ' rri i rrrIrr I i(i :l ;{ ,1 )r' i rr (' rrrrl r | { ()rrrr .i .i ot rl i rr i r . ' r,.r,;rl :.,r,s. r' r' i rl ( :r(', I I r|_' (IrrI | rlil r) ii -l l i ' rf\l )l i r' i r rrrrz r (l i l Iro l tl l r, l ,l uki trsotr, i !l n' r1,fi ri u\rl )zi r, . |r"r'r' J r r ' : r I rlr il) ( ' r ll l l l s i rL (j r i rrr r': rr,r'rrrrr:rrrri i, rri rl fi l urol (j fnrr,1 ,i 1i rrrri rrrrrr, r,si rr(l r'r ir r ir lr r lNlil, ic i e s tt tl tr s (,tl l l n l l t tn : ri obi $l l ui 1. '.'.'l .,\ "/). lI rd,,iJ ti r i,le d,i,nanticii,p tt il.jr c ic tr) ll 'l'ttlht.cdrile relleaului ;folomotor apar ca lezultat al leziilii oljcir.ci 1,,rr'(irrrrirlirr comlticata sa cale, fie peTea uJercliii, fic pe ccrr, c/r,ilir.lri, lr rrilrlul un etiurLilot mezeuccfalice. Existii" dozd eucnlital,i[iiti: .1.) .l'ural.i.tii 'pztpilure &sacial.ecu trulburdri de uerlere, L.l ulrriu.(, :r, rrtt)r' l(.zirrri carc afecteaz5, atit fibrele pupilare, cit qi fi].licle opti$f, l)(! I|:||(|r.L.rrIlor comun (intre retini,, rii zona d.inaintc:I coryibr g;nicril;t,i , \l,r'ri, lrr)do fibrele pupiiat:e se alespart cle cele optice) i :t\ I'u'rulilia pu?ile,rd, amaurotici, rezulti, dintr-o leziune tlistraetivii, ,r'rrl)lcl,i rr lctinci sau a nervului optic. Se pierdo rcr,ctia tlirect:-r,si corr '.rr,. : , 1: r . l: r lr Lm ir ri , l n ri m p u l s l i m u l i i ri i p a i t i i ochi ' ]ri i i rrsrr s,. ' fer.l al , lrr iir.irzii, r'.110(ilr' corLsensua,lila stinrulare; luminoasti a ochiului'si,ni'rl,r)$. rrilo. r.rniLrtorale, rlc obice:i prrpila F"stedilatati (midriaza arn:ruloticii I rr llz i.rr ), rrrl l r . llc r r r l r lr : lt c o n to d a l e e s te n o rm a l . lr) I'rrroza, pupilarl ambliopic:i apare in cazurile i]t care leziunilr rr.l irrr,i srrrr ,kr'.r'.lui optic slnt irrcompletc. Rc:r,ctia lulilar:i la I'ntirrl ..i. l..l:'i 5i p.rrlurigit.i, a'tit cea dircctri. cit 6i cea coirsensriald.ln lczirurilrr unrl;ril rrl(', (x)lll,rincfiia,consensuali oblinuti, prin si;imu1::r,rea ochirrlrri rirrrrl,s .irl. rr'r,i nrla.c rlocit r.ir,spunsuldircct la lurninii. pareza pupil .ii, i r| | | | )| i(| | ' ;r' i i rr iirs1,d.solisii iu nc-r'ritelerctrobulbarc, leuropatiile dlabd;ir*, r r rrrr r lr lir r lr ilr lr lr r r g i r,l ' r_ I llit.ir l('zil'r.rt .iiikrr a,lirro.tc se g!'tseftc Ia nivelul chiasrnoi uptirr. I r : r r r r IIi' I . I ' r ' r)rrrr(' r' ,r' r.l l tr-ro l c u p i l a re sl nt pi crdnte nunl ai Ii ! sl i r)l I p .:rrr Irrr 'r I r . r r r ir , ' I ir r r ' |' r r' ,' rr' I' ' . i , i l c o s l ,oc d rru ti i , lY cm o heni :l nopsi e i rs{)oi l rti i rtr ,'r ltttli ii ltttpiltrl h urt..iurt oltsice (rtrxti-,ia hcmialopsicir, :t_ llti 1,Vll trrr'l , l | ,r' :,rrrrri Irr ccrrl llr.lo trlo i o lr,rralirie yr,pil u,rd, in. ^clilsrnei 11roduc ,,rtttrtrl, ri ,rtlr hil(tt)?oftr,lc, i.' i,ianp co lezirlrLilelatcrale ilr'chilsrrL.i lttttrt rt lt,rttli ir 1ru,yt.i.l,a.rd, aimpurilc uizualc hinaxtl e. i.n, l: ) l'rtltli ii prtltilu,re Jd,rci tt,tlblh,dri tle uetlare, ca, Llrmitt.c ir rrrr()r. l i .| |Il ,r l, i l|r r i. r , lr l o Iu p i Iu c , rc l s p c c ti v d rrp l i ce so pl ,oduce i fus1}i ri ;i | r,r, l rr olr ir r , r ' r lr r r , ir l trl r. { ,I:l c x u l l l i p u l j l a ,r. t :t) l',rnli:.itt. i:t;kr.l.,il rellr.t uLui .lolomolor (pupila tL: tip Ar.l.t4| rr' ,,ri r . ' rIi lirr I'r'r'r ,r r I r , ' rrrrrrr i. r':ri,r' i (ri r' ri o ]rri r : r;r,.fl c x i r. I 1 t' rl i l ,i rf rr hrrri rri i (rr,ti i rl r r , , , r r ; I . r r I I r r I rIIil ). s l ,ll l j l o fl ,rc a C l ,i e i p u p i l U c pol tt;r,u1,(,(l .r)l ,ot )l ,ol ri l l i r, )i :)l ,r l )i r l' i' r . il t r . r r il, r rl ;i iv i z i u L l c ,,\Ii o z i .r, u rti ,s p uns foar.1,r,:l rl r l l r, l i ' n' ri .r (o sl I r,rt i, r ilr iz t ) ( x ll iit sj l l l , l i (fl tl n oc l i n i c o o i tr0 :tc o rnpani l l zi i i tl tl ol r,l tc i trr,l tl i rrl ri l r r,'r,l ri. r l, : r l: r ,lr r r ir r : r.rr,p u p i l l l o 1 1u t1 g c l 1l jrs o l i a l,i i -qigrr fl .cl ,i i l nrrri l l t 1rtr1ri l 1| rr., i i ,ttl r,' t t t r l lnt t ll l trl u rl " tttt i trs ,{ .;1 . ? i -.-1 00i )1, rIi ' r .i rzrrr.i l . i l ,i si l .i l i ,r tt, tr.r ir t r s lr r . r . ir r l rrl rc s s i i ;rrr' :rl i z i c g trrrc l l l i Ini g1l qsi 1,;1.' l rr sl ,rr,rl i i L,rrci r ' ' . llr \ , lr l.l: r lr rrrri rr:rrrrrrl ,o i k rrrl 5 i i rrIIo r rr1I| r,I. r,,l l rrl rl ri rrrrrl l l rrri , l 'r' l l )rr l 'rl ,r , r z , , l: r l: i : r 1 1 .l l r l l l ti l i l l Q rr)l rl 0 r 0 s l ,| l r i l l tl ,rrr;tl i i . .l rrrr rl | l | r,i r.,,;rzrtti \l l r:r':rl r / r ir l ,l l t,i rl|l. t i|t ||A |r lt ' ll I i rI I rr,r' I IIrI rr rI rri IIr I r,r.Ir| . i rr tr| r,sl ri l ,rIr{ i i , i rrrtrr i j | ri l l | | tu. l , rrrr or , lr ir t l : r lr . ri: r l rrrr o l ,(rr)(fl r ri l i rl )l l tfi rl i l c r l , l l l rrrrri ri :i ,i rr;rtr| ,i Ii rI,| | | | sIII 't It

.) tl) t t i t)tu.t. l, lll itoti t tlt ttn lttl,,r ,,tl,t :t |) tttrrz]t lr p l.,r r lr r L r r lr ,r lr !ll,L lj.lt!: (.,.1r. | r r : r lr ' l r r.r,l l i l rfrt ul tl i tl trtl tl . rl, rllir i o ! r t l r ) ( l l l ( f l l ( . S i l i ( . Il l | | l t \, r .,.1 :tlr \, r l r, ,. .. l ||l l ri kl i i (l t i I I i ( I I I r I i I ti ,l l l tS

, , , r r . , t r l t t : r I l l ri l r .. l)jr(r lr rr r l r r r r r tl r 'r r zr ,r r 'l ttttl r r r tttr l o :t, t;r r l r ttr r l ttl , l r l r l r " . l , r ' l r t r .z, tr i ,r tt l ttr r l r ,, ,,1 , o r r l ( r t r tr l tl l r .Ir ':r Ir IL tti . i i l tt{: r l l r r r r 'fr tr r r , | , : r r 'r 'l r r r i r rf i l tr r r {,i r ', r tr 1 r r tl r l r r L :r . l ,r r Ir l i l r ':i :l r tr r r tl fr ]i ,i ci t,;tl i tttttl l ttr ':t r r l r tr tl tti r , r 'l r r l t t t t l r t o tl ttr r r r .o ttl l r r r ( t,. l r r t,r t ,, l r ttl r i !r t, i tr l i r r r l r r u ' i I It i tt i t tItt l I r o r 'l tr tt , r r r l r t r : i l o s il 1 ( l l l ( f( , ( ,( |||i l i l ( r tIr r :r n r l r r 'Ir t l ttt;ti l r '. l , , r r r r t l k 'z i tttti i i tt l i i tr tl to tr r ttI r \r 'g \'l J Ii o l r t'tl so tl r l ,r l l i l l l l i i sl i l i r r r o r r l t0 , , . : r i . i i c r l i u l ( i {'l m a i p l i [u zi l 'i l :r l l r .zi ttti i i se r l l l i l a tti l t']ttl r i i i l o t tttl z, ttl r ' J , , ' i r l {' r ( 'l l cxu l u i fo to u r o to l ', ( i l t ( L ( r ) scb i l e l l r r i vcItr ] ( xr l r ti i i l l t i i Ir ) r l cr i o r r r l ' r : r l s t t l r s l , rL tL l j o ico n n $ i i p o r i l ) {) d u cti ,l c, C i tl ti r , ttto {i tti 0 i t to l l r r r ttl r r i r l r ' , r rr o t l l i t c - r o rr yo i g o n ,l i , se g i sa ,l te m a i vcn tr n l fi csti o r 'csp tct'r l i i . Il i r ) z:r , '' r , , i , \ 1 'r r 1 i r r l i l rl i l i i , fi b r o l o r l tL l p i |r - tl i l r tl 'i tl l ,:r tr ', e ste l r o d u si n d c a ti l ) g e l e l

r', r,obolitrtl de la regiunea tuberiand, trece in fatra corrjstu'ii l)osl,r'r'iorrrl'. f icr(lor{rir singulari, a reflexului lotomotor (sindrr.,n 'ltrllll litfurlst,tt i,/r, l so porutc intilni in: tumori mezencefalictr, cn(rcti[lii,i' lrrl'rttgir,ri, ,lLrlx,l za,ltultt, poU oencefaliti , sclerozi, mtltiplir,, a,lconli$nr, zrrttrl zrrrrl'r,t, r r.llrll,i,islno Oranio-ccrebrale, In acuste cilzuri fr.rlorlr(.ltl,r sirrl trrrilrrll .r1,.. Iiiril, rniozli, li?i,rica pupJla si, fie cxcentlici, fi ru)rcgltl:r1ri,i:rt r',islrLtrr rl lr liolnNl,i'opini:i )ste evident ;i rapicl. I l)'lttt [bu, iir iLe r eJlelx r *lui. [,a'intuneric liclilextrl pupilo-tlilatator la intuleric este Inult rnrli vttlttcrrrlril itr ,,,rr' l i ti i pel ol o gice c: , rccl pupilo- const r ict or I a lunf nil. - t \ t nbulosit t l r r lr olil. , ,rr l .zi trl ri l t: ciilor com ule f izuale $i pupilar e, insl pot t i ir ] t t r '{r r Jr r lr '( lilr 'r 'r l I l,.ziurLilc de trunchi cor,cbr: . pulilar'ri a lrlrui ochi osto ([ i I r] i r I rIi t I l L iiiur lrr oazril in cale ac1,ivit2r1n'.1, ,1,(,lirii, r'efiexul consensual la intuneric, pro\.onit rlu lit cclilrt'll, ollrr, l ' ,,l l l r' (l onri ria r c&t ivit at ea p1t ] r ilar : ii ( sem nt t l lni ) I ar cus ( it r nr ) . lt : t r t ,, lrrrl slir iitos este stimulat qi cdiilalt este it,oop(x'i1,pttlilrt, rir'tttrtIo:r:i:r , ,,orLI,r'r,iri,ri nolinal. DacA se ilumineazi, oohiul zrfocl,rt1,;i ccliil:rll, r'rlr, ,,,1,r' ri l i , l i {r c nr m ai o r er , ct ie m inim alil, , 11t r ] Lii, tde o ( 1illli1lr '1r lt pt it r zr r i st al ,, r, r'. Airr.sl semrl a fost doscris in neuitele t'ctrobu.l,lrur?. '1.'t r,rd,r rel'l,eltnllLi. de a,ptt'opierc (tlc ul:trnndlrc ) llll tlln il.e .\llolilL';L jzolllt:i l pupilooonstrioliei ll ltlivitt'tt aprtltltrr /sirr/torrr rti lnttll IJri*:r'!totL itn:r:rsu.l, a fos1, tiesorisii ilI olt(xfllirliirl,(,1)i([('ttri(jai itt ) r' rrrrrlisr )t|r (ilt,]iio]l{r clt intelesat'o1l ol'bitci. NV) lrlrrrliri Tnrpil.uri:lon,icc ;,i trrl rr;i r ; r t lpupilci lr olr icr :colt sLi in: t lit lt 'illziL, t clilt >. lit Lt t nur lot sllt b, ," l r' :rc{ j i i l )lli) iluil, kt r t ii, it r 1; it ir pt t l r t t llr ixt t lt t i llo lt pt r t lt it r lr ; ii lt t llr t t t 'r ir i
! | rr'()Il |()(Ii IJ r' .

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ru rl :r r . il r r lr r ?ir ll, l (.trl l rl rl r , rl r l :r o l l ri rrl :rl i .r,l :ri l i l i )tl ti tl l l :t rl r' l rL :rtt: r lol.( loI r s I t ir r (i :r l r g rrl :rr:rl r , , | | | \ r' I I ' (.| | | i I l )0:l i c Ii :tl l N i ' rIl l l tl l l t l i )l ttl l . trrrrl l r r r i|lz ilr lii, S ir rrl to rrrrrl \rl r .r l ,rrl ,l < ' rl r,r.i s i ri l l l | s l i r l l ' | | ' l i tr rl r.r:rrl l r. trl rr i l l i :r \ 1lr lr . r |( (I(,I{' I t r: I i I r| | | I I 1 i ' r' r l :r rrrro c l r i si l t l l oi l l r (,{ .l ti l i l l i . l ,r' zi rrri l r, r|rl )r)Dr r ill) ilr f ( ' |l|u s j l t(l r()n rrrl \rl rr' l ro l Ii s ituttl ( i rr: si si t' rrrrrlri l nl )rl i {, l, Iti l ro l : ilr r r r r r s , ( 1( t le \i l u ti l (' l ri l ro l l rl rrrrro D rc z c l rcefal i co, gi uri (' l t Ii t(,h (rl l l i t, I,{' ,,:rrrriI iot r r r I, iliir r . . l)u D i i ,H Iu ti ]l :l l l s i (i u rl a l d (19ti 8) k' zi uni l r, gl l rgl i r)ri ul tu ( ,rl ri rr r iI ir iji) lc s r ] ! i d e l e z i u n j i rr g i rrrg l i o n i i s p i tal j , fapl i rral c l rI r,xpl i Irr fr : rr.l l r . r . i: rI r si. ( r { ) i na l i n o a F J i c . iu rtisl.trtfia i)tltsc,ulat'd ntiotolticd, (boala lui Steinolt) lr [os1, (k'N('ri$rl urr'(,ri {) l)upili mjotir:li cu contraclie lelt5, Ei slabi,la lumini fi cotrl'('r.g-crii . r1 lt) ll,i.?,pltsul 'lLtpiiar ciJnsti'l inttlo serie de tniscriri allcrnllnl;r, r,rrlrirlr, rll' r,rrrl|rrol,ie {i dc dil:r.1atiopupilar.c clonice Si ritmice, amlli, |Ji d{'stnil rl',, r{ r'lrlirl0, cNre intol'cseazil irisul atit in lepaus, cit mai alos la ,,lrrovocln clr," rrrirrr,rrliIrrr' l)Lrpilare (de piltli,, cn ocdzia eJplorirjl reflernlui fotornolor.). \{,('ri Ji'roul'Il p{)lrio e\ista irr sta{e ,,frnstii" qi lil unii subiecti ltorlrrit,li, rl :rr' .r. r r J r s lt ' r ' i ir r t l e o s e l tii n : a ) p a l a l i z i i l e o cul omotorri l ui corrun ]l {i cl l (. ri l rr,r lr ' r ' s ilr nr , ) c o l e c , l 1 re s ,s c l c ro z i i i n l l i c i (oa un fel al e ,,ni stl gnuN 11r prrrlrilrrr'") (liis(!', l9ll2) ; c) miastenil gr.r,\-is; d) rl1]eori f:il.ii valoale scnrir) l .r' i l ri r lc lit r iir i ( 1lis tr,, 1 l )i ? ).

| )l trrl ' tt \l ri rl ri rl (l l )l r' 1r' rr l l l ' r1l l r rL rl ,rrrrl r l ,' l i 1 rl l r' l l ol r:l l l 'l' l l tl tr' 1r" I1IrrrIIItotrttI Ittl r It|rrl rtl tl rl r i tl ,tt i tt't l l r, li l (1i l t l l i i l rrI l r Irrr ' Ittrl |rrIr' |rt l l l l l l rt r l l r i l tt ttt I r ,r'l : ' :rl | {r||I|II( .|I|tI| o1o.r ' Ll rrtl r ' ttrr' ttt;tl l t : l t t r t tt l t r r i l l l l l l l ' 1( t I r ) I rl Ll /' l l l ri i rl rrr.l :l l ri t ' , r,rtl :rl rrt i ||I(),|l |I |Ii I l l t trrl r' l rrl :r1"

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( lot t t 'yt 'r 'sir t r tI, ir t t Iri rt / r ' sr ' 'lt . , ,,I. , ,, , ti , ,, , ,, ,, i i i r t r '( r . r 'i, r - v, 'r r , r r r$. r ' . )i ( i) . , r ir . . r , t igllr t it t lt l' r lr ' lt ' rx) t lll) l'{lsillllil( t t t t t t ot t llt r 't 'clliizclt ziit t lt t lllr : ii f , ,1, ' l ri r,ci , ( '\ islli sr r , t liiii iir f ar '( ' t lllolo lt lLuoli ( lir r l": 't r 't t 'lt t 't l'r 1lir t ' 1, ,' .trtttl rtt, ') ; r cr r Hliu{"r r ! - r r ir r t {i( }lr r t r (l) , 1' ) ,' | ,,;;,;;;;;; i i ' ,,i, , , , i , , yiir 'i, "', ""i0, r L( 'uLir r ur lur . . ( Ar seni ; i O l) r cst ill'. lll71) ; I ! r xlr 'r 'lr lr "l' ' ' rrIr' rr trcvtl tl g ii ( l{1 lr ip plu}r it ir ' ir ir r . l 1. . l1) 'il; , ar 1,,(;t,)-/t ) /l l ti lit ( lof ! , : a1{r lo- - , si ier iosci. r ozir cer ld; r li. r . ( rtrr'l'rr 1,,,1r' (tl i rl rt' l , ir k, , , blism 1 llncf u boli inf r : c! 'iolr c ^( glipi '. r ; ( ) lr r ( 'r r r : r r ' t 'nt x: f it lilt r ( At soui si , f i ' | i ," f," ]r 'r . 'i, t t t er , 1', 's"l, '. , , r t ir nult iplir ' ' :," ' , ll) t' r,i i i I| )(Lr' (!lr t n'lr {ii) . ) trillemittalti secuntf,ard'( sittTtkttnulir:d' :'.ti./.:!. N (:1't'rllgiu ,l t,i ui l ot('l( ,t Lt r r - r 'lilgici isr lniliill( ' s', ct lnclilTL' silli, ( [ lt l) ii' t r t t r t r sr r ; 1 ir ', Lr { t ''it lr ( I c lil' lr t r \ l ,r' r,,l r,' i ,ri ,i tl , r ct , lc lilt , nt 'r 'lr igi''i , , 1r ir ni1ile", r lt lt ''r cr t t f t t lt t Lt t l I t lt lt o i ,l i l pi rr,\i \l ,i oai, olt llllll ll( ; s coir t inr i', con^st iuf il', 1xr scur l'c t 'a' it l t t r r vt r r l'1i: r r oYr ||] gico *" r' rr(' l rt' I,,,,,,,i fi " 1" ] gt' r r f it I llt L p, , a, , iir t u" - f ie" s im pr tl'it 'l{icc lir lt 'r ' ' l ir r pr r dur it liit r 1i t I it uzc ct t ' in 'llgiilo nnclt t t l ( [ ( f la' f cnt 1i r,1' . i tt si atlii t nr t i il, vr lllslll( ' ir $isiin( 11t - so "ir t r ( 'r :tltrtt {t it r . , | | r| , .r'r ,i rsr )' . 'l'o tlltlll,ttrltl so stll l)uin(l serltltc obi{fctivo: .ltiprttrll'r'zlt" ai, t t ivr r lLr l I it r lir r r t r t l ln , i ," .i ,, rrr.rr lr u iuir , i, t ,r u, , , lt t t ilt , dc sot lsil) i1it i! 1, i', i ' t i'1t t t r '' lolxr gr : r l'i: ' : rt t : tl t ' l n '.rr , :r r . r I vlr lr r i lr r t r r r r r r l ;1,' ; ,],1'f , , , t ,' , r ",t l'illr lxt t lr t i c t l! r 'l|, n r 'iit ( r 's{'lllJir lr r l . l) l( r l( t ( 1( " lI I 'r 'r r \ t \ rrtl ' ;' ,;;' | ri l l i sr r elit ili " ,:r- i i ,,' ;;,:j r t 'l't 'lr ' r r 1': r . r r lizir ' 1i f iiuii . t i. , t ut n ; i r '. r r t r lcinr L 'r 'r tiut ir,'r l'i, . ri. l. 'zir r r r i . i : r l' : , 11, 'l , ,,, ,..| ,i i ,,,,,,., i, 1, , i, ,i, . t r r . lr r . . ir . . \ , . r . : , , , . iir zrr l, , t " t t t "lr r ui' r ' {ir "t r t t 1r r r t . z'' / r 'r ..' i. il''' ; 'l|; , ; 'i i'lt '' ;: ;,; ' ': ' ll'' I r,.rrrr:t Lr,;l t' 1x, I t ilt nkr t t t 'pt ll( x) l) t tlr-lir l( t a I ) ' r' ' ,' czi ) r t t lt l l \l rl l (' \l rl l r 'lit Lir rt t t l ( r f ii'r lt cllzi sl) f o l) ar ?: dl(tlJu: ! it t t t i t jt t ii't \ ! t st l ' l ' ,,,ttl l ttr' : ' 'l it xt 'r d'iJ{)l) ill1r ( lii r lt r t t lr li t t t t l'r l 1' ''l ' ,ttt,, r il, t lt lo: t ii t t t 'r t lt t r t liiTt r t slr t ' t t r t r vlir lgiilor 1't 'igt 't r t it t : t Lrlt l iilt r 't 'r I t t t t r I : r I I , ' ,, ,, i t I, , i i , ,, , , , t I r r I iir t , ir lclr lci ll) , \r rr.tri rri ()1 , 11'"( - r l, ?1) ): Ll ' .tl ' l ' trtttrtilt t lt ir lt t 't nr t ilt ; 1' l111r 1t lizt 'r trzli r t lr it r ci lt r t t t t qlt it t l I . , t t lo t f t '( lllr ' ( lo: lr , ,, rr' l rr.l rrsrr,tt, t t t t l, 'git lt t t 'lt . it lr llt llt t r t t ir t ) i, llt ot lt t oi; t t l r lr llllii , i l (, lll'vl, |lci( , 1r 'ig|t nit r r r li, ( 1ll l( ) ( f illizllt '(trlr , r . t llic|i ill ilt ll{ q lt 'l l ,, , , ,r , ,, , ,, i( r 'it t r lit r l lr t ir r t t t t t t t t r r t t ) ,,,,' i ,i f,i tI,' t,,L, , , f ( '\ iit r r i si ( ) 1r r cst lt , 11) 71)s1lll. ill.l) 11't 1( 'll' () l1i'il) ) ' , rLrrIrr| r' (()Ii r |i t r t t t I t , l1) 11|,( lilr r l' t lr r '\ t st "t r i f i rll
lllI l 1 t'ttl tr ^ l tzl i tttr vt'l r l l :- i i l t i r l t'l l l i l l l l l t' r ttttsl i tt l t 't \ | t t t i t t t) t||tt( I'( ' Ir l ti ctr l i vr r <l c I0 t t ' i I rt I i I I t I ( ' Ir r IIr r r l i i Ii ,r 'r l : r l , I r )I ( I i ' i I t I I I i I r 'tl Ir r t1 r o ]IIr tr Ir ' tr l r ( {) l i .,r t l r t i ttr r i tttl r i ttt 1 l 'l l i o tl '\'l 1 l ( i :l ' ,;, ', , i ', , , , 1 , i r , I r r r i l ,r ( :i 'i Isi l r r l Ir 'r r l i i ,( l i l r ( l ( r o l ti cr t tttl ti l i tzi tt, tl ttl r l t r l l o tr l t'r l ttl , r l . 'l r l r ' , \ r ', r l rr i i i i ) 1 ,1 ,'sr ',r , l l l i tl l , ( l , l r l r r ', r 1 . . | ] i I l ( | I Il ||l |||'l Il |],.||l l |l It|1 ( |r 'r 't'r .l tl 'Ir r tl ( |,||I) t'l '( 1 1 'Itl i l r l It|( l t'l ti l r tl l l r r ttr r .l r r t , , r r 'l r t l o r l I I I i I rr Ii Ir t'r ') l l l r r xr l l :L l l i tl r l ' l l l ' i l r k'l l tr 'l l ( 'i l t l l l r l l I r \ , l l t t t t t ttl t,,tr ttr r 'tr ' l r .l 'x'r | | 1:t | ( t i | |t I t t t l "l tl i zr 'l tzl t' ,r, I I r I,r.: r r ,t.\ i l ( ,r . l l a ,l l l l tr r r r r 'l r |l .,r r 'r ';tli l r ttl l r t' 1 1 tr l l r ,t ttl l l l l l r l t\ l ,l zl l t l , r l r r :r I r

l 1)?l ) ); l )l ( ' rt t t t 1t t t : ; t t r t t i t ts ' t.tl tttt (rl ttc V ti s l ttr' rl l r' l l r' { r' i ti l rrtz i l rttr' ' l l Ll i l I r:r' tt' l tr' l 0l ts rr s l l l )t t i i )i l r' (' ' l (s tl { ' (' l i \ i l l (' l l l l l ' l !' l rtt l l l l l ,i l l i l l i i

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:rl . | l l , lI r lr ' |||i||: r Lr r :1 1 1 ,1 ,1 | .I1 1 I1 ," rI c i c ri te rii : :r) si nl t l l al ' oxi sti ce; l l ) i1 1 ti D rrrt I,r. r , r . r r I r iI r ' i ( i) ri rl l l i l rtc l a l o I 1 1 )s i n t Fri ri ct l ocal i zi i tc i n teri tor.i rrl trr,'r'rr rr r : r l: r . ) r I r . i i ri i ri s o i i to d a s t' ri rn ed e s u f(l ,i rrt1iorgaui c:i (tl i n parl l ' rr Irr,'r.r, r r r r r r lr r r r r iill l ti u l s r.rL z i t,i r., i i r p a rte a a l i tor ncn' i cl .:i ni eni sai l l l l i d l ,,r r lr ' r , . lr r i r r r , r r l o l r' rq i c c ). t)i i ,{ 1 s e r} i [i O ]j rescu (19i !]), tl rrcl cr fi i r,rl I)u ,,'rr rrlr ' , . r i: rr ' r r il s jt rl rl r)l l l i u l t c ti o b o a J i ,,i tn 1xl t1,csi i exi sl e o ,ti )fi ti i l i i l , , l . u rlr ! . l, r rr r r r r. . | i l rri l i -ri " (D ri rrl rr.i ,)[i (i ..a , rj i tn])1a]r]tal i cl ' J L ncnl tl gi ci l rrr,,.r ir r ; r lr . iir : r . r ' r ' rl i l r.l rz ri i ,s l l i ' l i d c ta c i i ,,r -,$tc uta, si Lt{ ,{ ,i t,si (} i l l l ' i tt, i }} l rr rl i l ,,r r , r r lr r ir r lir l rru l :r;rr z ;i s i r,,p l i rl i i i r.i rr),1i :r,ti ,or.i i ol ogi ,.J i i i Lnttrrrrir lii ci rr, l , l r ir ior i, r r 1i< , c irl rrra i p rri .h o l i l l l ' n tc , n a i grc,Lrdtrccl al ri Lrsj (l { r l rl l l l r, s ,,rr rl rnlr ' iir r , ( ' \ r ' s c t r i s i (rl x ' c s (fu , l 9 i f)). l r l; r i: ur i' i t r c tr' :tl q i i l ,r' i 1 ]c 1 n i n a lr1 o l r,l ul i i ,,l ri tJi i ti \rfi " , 1t1,1)Ll i si l 0 1' rr. rr lrlrlr, rllt r tntlqnisnt,l, putorrcnic ii,cl,iotx'azi ll, tt.i,lt'[, t:ottltttI lt'.1,r'l rl , \ Ii l \r' ll) s : r r r i; r r lc o s r' l ri l a , rti t:c ' i , e rti ;fd i c (c-r1,r' i l rrct rd). p l l rri l ,l r lr ' por ilr il ir r s l rrrl i rrl l r,tl rri , l l t,i rr rn i .j J o itci rrol fcci i ornl rr rl r^i rri r,sl i l lr(rr', rlir s { . ( f li( l( ' lli( . 2 (f o s r,t' i i ' < l r' ./i rrl .rr? :,s l x )l sl l ri l i rl .r' IrI' orIrrrrcIr,Ir tl l rrol rl si l)rtxu |(f r lt f t lr . t t r ir ' lit ti z trl r,, r, s i rl rl rs o IrrrrIr,rrrIrI(' tl t, l i ' nrrrnr.rrcrl f l rrrl i , lrrl rrri :r lr r i rri r.l ; t \ r)rri t l i i j l l i l i \:{ ,ttr i l r' rl rl (.l tl c rrl i l rr,i rrrrrl rti rrr.rrrr i Ii rl r' rrri l rrI rrr f r' : | | | |, I rr| | rt | | lt r i { lr r l l r' . r' trrrrrrl i l c i IIII| .| ,Ir., Iri rl ti rri l l t, l rl rrzi l i r,rrl ,\r,r' rrl r 'i tl

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(.r l|| lll7 l|t) ||r'\ r . it l. , || I I r, I ,. rr r rI r r |, , r r r r r lr , lIll(,r)rr ]ii,ll, llilrr(1o (Ali r.ltl ,1rI ll|lr.ti( |l, l!l/ll). '! ) 'l'tttttttilt: t lr (.t ,t | )t t t t I t t | : . lux t t r . , t , Lt , t l, t r t t l, , r , it r l i ( l r l ) l : t i ,l ,. ,\, t,tlilIt,tI t lt ( x t . lt t r . t r t nr , t r t tt lr ) A q , n , q l . i . o t t t r l t tl.rit i . ( i t . , i , . r , : i i , , ; , r t t , tt[,. t tttltt, n n, lt,,ttt r ; 1. , t : t ir , , . |, . , . t r \ r l. . 1, , 1, , i r r r r r , . ] r l t , t l i . , r . i , r l i r . r , : l . i r l r l , . J , . t . rrilr:r r,rr |r'||lr'\l ( ' l Llr j t k , r i||ir l ( lf lr ilr oc s l. r : z i e l , t , i ( r , l r r i r r a l i j , si rl0 ptrrr.ztr rr i' i.rrr rrr.rrrrl.rri ntot or ' , . dul( ' lil. liir r L ll[ ir r ce p u t I o , L ] i z l , t . r](, (l slrgrr.rl r'llrullr it 1r'ig-crI1elului,. apoi ill l)r(xl progresiv extinzitulrl sr, p0 iLrl|r,ri

l , : r t r 'r r I I i r , t I r l r | | l| ( ( 1, l l l |r frl !( ' [ , l l n i l r ) ; r l ) l l tttr r ttt I I t t ' I I t II I : r I i I ' ( ; r ') 1 L ( l l r l l , r r r r r r r r r : t I r , | | r | | | |r ||1'r l I r , r 'Ittr r r i tIttItti ( ,\r sl tr i r ;i r o l l r l r - , l l ) , 1) ; l ) l t rr t t t r t r i rr; t rt ' L sr r '{r l r r l r ., l l l ( ;1 1 ) , r r | , r 'u r I r r r u , r 'r ':r l r . l i sl r tl r r t,r ttr r l i tl o ( i i L r l l l l o i l fi {' ( l i o :t'r ' r l t) tr tctr i tr l l i l r ' l r :r z:tl , tr r l ttr r r t"r l ' ''I I , r '. t r r I r o i | r '| r i It r r l r si ttttsr l l tti ( i I\( fl 'l l o i r I r l i {i r , c ; i ) I r ol i r l ti si sl ,tr n ( l r o l l l t, l u i l i r r l l l cr ') . r r tt r r tr l r r r r l r .i i l a l o l cl sl .l Il L tr ., N fl o ci tr ,zi o l tl i l tl l r to p l cl i l i ) ,\iitttlronul 1 | r r . r i r r r l i i d e a ce e a q i p a tte . l tstl tr i r l tr r r l tl l r ( r i 1 r ( 'vl r l l r l i l ti l f r r r r . \ ) B i . t d r o m u l [tti . Gr a d e n i g o i tr l l i ci

t) 'l'tt.tl,orile ntaligne nazo-faringiene (ittd.eoscbi carcinoilme si srrl r'rr:rrrrr.)irrr':rrlt'u zi\ b:.z^ crnni]4ui fi afcctcaz;i trjgcmlmtl in Z0;;, (litl (,ir,1ru ( \r',\('ri ;i. (\trcscu, 1979),,fic prin forarnerr oralc, i fie prin {oi.,irncrr lr.r,r',r.'1 f i. crti'zinth-se prin f-osa ptc'igo;narilari ;i/ sau prin sirrrrs'l rrli rr,irlrrJ. Lir trov. gia t'igeminalii sc asociazi, semne neu'oloiice, I.csJ,r\l Iu rrr,rrrr.r-olltlhnologice, ltrtr_cfiede top,rgrxfia invaziei tu]loialc.ia (l) ( I ll niolt ringioamek:, adenolmelc hipolizule, cu ext{,nsie sulrt,rl , rr.l rr': i, lr r r ( D' ilr f lt a ra s e l a re (me n i n g i o a mc ,S.;.), chi al , ql i oamel e rl e nri r.l r.i lr:rz;rli si tr.rrrlrltlo cu diverse loc_rlizijli pot ger)er"nnei-ralgii trigcrnirr;rJr,, rrr r,or r llr lc c linic c a d e s e a re v c l a to l l o (.\rseni si Opreseu, 1d?g). t) l.l.rtr st.ntcleba:ule, in sinrLsul crre.rnor qi rn qaigtioni! hri r {irrsslr, . r' tliy,t:tz,:.i, olrirrci siurlroamc, ,.om1llexe, cu alinge;e;Di rlc a tltor ncl,\ | , r':rr,jlt r i, t ' r I ' { r . , l' i i l r" l l l tl t9 to ti l o f. ii ) I'nn:t's. tt,n,.r.c.tlc ale felei, nle ca.ritii!,ilor orbi.t,te $i (xle sintsrtilor ,ntt.itll)t firrl rrsoI rl,t I0rIrnriicut, prin sennelc locale ii'prjn coafcctlrrr.| rrrl r r r lr r i r r ; r lic li/ srrrrl r o c rtl o n to to ri l o r. |) lit ::itttlttrrtrr.l. ttltt:t trtui i,/i,it,/), {onr:rtut tle tutnori, hematoatno si o , Irrr,r' , , ir I r r r r r r r r I i.rr, l i { ,l tl l rL o p l c g i xu o c i ti ]te x $i e\ol frl mi a vi n sri , se.s,' , .r,..r' l:r . rrr.ri.rrlt,,i.I rigor[)int],Ii; cu iocalizare pe teritorirll ottalrniorrltri. .t ) l, .\i)titt).,t.1t1 tlc,fantti sfr:naid,ald,, a,\\t*ri de drir.elel loc:rlizrlri irr l r rrl ,. r r r r l, , r l- lr r lr r i, ,rrl rri , a s o c i * z r o l l r,l m o l tl c gi a exi ;eri r:i si i ni .cr.rLi io.l ri rrl sc , I rrrrl r r r r ilr il . i r , r r rri th ,j rrz i .l l l c i J l ,.;r,. (c i t.r t rl o Ii ..r, j 052) rr suJtl i rri rrl p rr,r ',, r i. r t , : r . i r ' , , ,,r ,.i : 1 r,.\ i .rl q ;i c i n tc ri l o ri ul oftl l mi c' l i ri i rr :.i i tri .rrrrrrrl i i rrr i l .r , lr i ir r . , ' r ' : l) rl ,' rl ' ri ," s l l ' o i c -l a .l i l ,i n c a r,c 1a tl ebr* t l l 11i , (,sto | )rl ,l i r',ri I I i . I ( , , I I I I I I ( I r l r.0 rrto -p i uc ta l i , a p o i e x ti n zi i tdl _S e l l 11i l ci ul l r" .l i rrrri i , L rrrrr : r s i irr rrl o } l i l o c ' -rl a r. ' l l i rn p d 0 ci tcva si i }ti i rrri r:i r!rvr.i rl ,Li i l ' r ' l, ilr r l. .r.l rrr: r r : r s ir r r lr i|r i , 1 i i :i , tl i mi rru rrc a l c fl c x rl u i comcai r si 1l ,i irrl l rrri i i l ,r r,r' , rl , rr, ,rr rrI ri i i i Ir i i ,, pl r' ;l ri l i rrrl t-s r c l o n c rl rrl i,i c ,L, 1i p ,.1,i ,i r1i r;v).. ri J.f rr nitrrlrtyt.tt,l,|(rd(]l,i er.:kirn al sinustt[,ui <:,.t,,n,:t (si.ttrt'totnrriltri .. /",,i .i . / r lr r . r ' r ' iL, l) l\ r i r) t(' r' i 1 { )ri _ u lfta l rn i c rl rr i si l tl rnrrri r;r' rrl rri srrl r' i ,r., o rrI I rr I rrrrr; rI r 1I iI I r l' lr r rl r,l z l i p r.i n l (' z i rrn ,,1 1 rry l t,l ri i rr IJ_r,,,xi tl l l rl rrri r,,,sl ,i rrL :rrl : r r r liir r ( l) r ir . { k i l i .,r.i .,]' (' it,i tc rL l :rL i ov c rr0 rso) qi str i rrs.l .ri rr rkr rrl r.rrr l i 1 rrrI1 r lI r lr rs i r lr : c lr.,rro z i s . N c l trrl c ru g i n tl i I rr,; l r) l rrrcvl i srrrt rrl r, :rrl r,r.r,i I ,:r| o l i rlI ir r lr . r , ii, r ' i rrls i rrrrs rrl u i(,i r,\,r,rr)o s i ,l l t,r' rorr,.l l )5i i ; A t,srrrri .ol rrl r-, (,l ri l l l i l ); lr ) l. r r r r r . r ' ir rl . r' r' g i rrri i Iri ;x rIi z rrrr' ,i rrrl .. s.l i i .r' l ,ri r;frf rrgr.i rrr. (ri r,1 1 t't rli r r t llt lr . , ll) lilt)l r) { ,rrrrro Iirrl r,l i g rrI i l ,l (l l:l Zol l r,t l j l .(,l i , 11r i rr 1 11I; I I.,,,I i 1 lll)

1,,rrr o l ara lizic a per echii : l Yt r - ir '. sr' (rillrlirl('r'izcrtzit pt ttt 9 ) Si.trilntmul ?aratf i,lleminctl td I'tti .Raer.lrtr r ligl't llLi, sit t t I t 'lr t t t l'lr r r t r lr ' l] r 'r ' ,, rrtl ti t i rt 1 eli1, t t lilt l ncnr ului olt alr nic) r.rri lllnrr $i paraiizii alc fcrechii n YI-ll. enoidd,l'ii ul lrt''i''lu''ul t lrtliz' rtz:t l0 ) f i.ndrontn,l tle r,:isplnlie ?eLro-sf t, :ri r i nul l ,i plc t 'le ncr r . i cr at r icni: pcl: chilc I l, lI I , lV ; i Y, 1r r 'lr t it r r plr r r r rti rlr'irrlu-s(. felralgia o{i,ahnicri ii }irratljzia, dc pcnrlrtr l ll. rt o'r'nn ii It .trtlt t'i.t) ttltttrt 11) ,lnetrism.elc de (|'rterd. bo'zil'arti ;i. ntal,.f ! 1 l r rlrlsirl.ri dj n fosa cerebrali, po.<tet'ioalri )pot sri rilll,llzczcrt)gii t t' i g rIt rt i t rI rIr' rI r' r,y, rrrrri ' al gi c,it t sol. it cuneor iSir loheinisliasr t r f r lci: t l( , \ r sct r i; i( ) Pr l's( 1r l, llr ; 1) ) l!) Lea tn,i,leinflarnatorii lot fi l:tlctr)ri (rl,llzirli (l{r ll(rvrrrlsi; irlil, ttl i , rrrri l tti gtm it r l l, r Tif elic, r : il, f i in ce1c0nt lr 'l] ( - '\ lscni f i olt r ( lsr lr r , lllill) l rr si ui i i nul lr t llunint Ll pdiJer it i t r t ni l, im : [ ) Ar t r hw) id"iltlr lr t lt nt titxtrd, (tio tnrghi 1rottlo -ccrcl:cltts \ti jurtapolrtirr(') ; lt) 1'r'tlutoirliltlr 1'.'::it rl t,,r rrlr ; <t\ Zrtt,u postcr g8tlcria'tt(i po.'Ltedoclan$il,violt'l(ic ll('vl rllgii l t itl< rri i. ,,1r., l rxral i zate indeosr : bi lr t t cr il'oliul llcr vr lui oI 1, aJ) l) i( l) t r t t bit r t 'i r r lr : r r l --po 1.mni;t,,llo l)l(roiLl)tr' ('r)tlr,'t , , , ,lt!iil, lt()rpeticil - bittc outLtisctLtir, Irrr , , r i rl l nl qi po t . er it ot 'iul cilLlt , t r ir tlll n: L. 't ilt luht i i] lll) cli{) r . St r it sr t t r ir t zrr r t r lt t l ,Ll rrr.rl rzi t' pc t er il liul r ( r sp( xlt 'iv, 1e m t llt c or i I i li( 'lr liilli' I ll( ] ( r llr lr r iii' r r \ : r \ ' ,i i l o l )ol l )('r 'sisl: I : ] 'r t no il idclr r t r glr l, i, iur leosir bi llt , blilr 'ilt i. i\ r lI sr . r P, r ; r lr ' t ;,,.rri sl l r o ,,(l i sir si. czio ost hetp( ir jci " ( . Ar scni5i O pr csct t , 1l) ?1);) t l) t it : ; ': r t t lt t l) t r/r/i i i r,ri , (rrso ciit i, r icll o u( t r ills{ ) - 1'nlict tI it : i ) ( liisr r ', l1}5: l) <r ' it t l, ilt r . r ll , t:rri l orr| j o }ir . l. - \ nlor r '{1( 'ilii( lo,pr t ) zullt r Lst lt t lt llt lt t i lui A|gI ll llr t lr r 'tl , r t t , ; r r, i ri l r sttrtloqit ur li cilnlol, {'r Ll1dr Llt 'r 'jLt r ( r t 'lgii I It I t t1i t t t L ' , lt t t '. i: r l. t t lr ', t L , rr,ri rrrl l l rpit l 1ot t l, t iiut t ilf ilo ii it lr 'r ni'r r r r lt li)1, t lt , t t ; r 'it ziili; t alt or iilt t l l .i ) Lt:;:it t ; t i. lti) t llLt t lt t Li&)t,llt t r t pliclllt ' t llt lt r ict , t t li llr t r it r 'lr ll : t pr ': r t lr L lt r lr t ,,,,i Ir.rr i rot 'lr I <.i, ii ir t r r t r liJt t lr t ir li( o I ) ( , s1, - 11'll'lllll1i1, it xl,r 'zit r lr lr ', ir t lr l , t,,' ,rr1i r,i ri rl ti l'i) r ir r lilllii, i ( , \ r nolr i si ( ) 1t ir 't r r r t l,ll) il) ) . l .l ) l ,r::': i. unilt nuck: ilor r lr or 'i4it t r : ; i r r l. r t . lilt nI r t inlr t t , - h't t lbopr olt t lt , t t r l ri ' 1N rlIi l c: t lir , r t t r rr lt ' t it r t t r ilolii l: r r : iot i < {ioLt llir , i ( llis( 'r ', ll) i, : l) : r t ) , '; irr r r , it < , '. ,,t ,' i It i tr. Ij rr s, . 1irr r , r t t 'ltlt t 'is1 r t 'r r ir rt t lt t t 'zt 't t l, lt l,l|'lr ilr o r . lr it r ii l: t lt t t l i, zr , ' , ir ,l ,,, :ri i i r.r' t r r ( }: t l. , r 'zi( ii r t ", r , r r 'r ', r i'it r r r it , r llr i I t {'t t r illt ! 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I' rrrr t lr z. r iloI r r iir lr r :' .1;.::.1 !,'t , t li: iilr ' . lt t r ir r lr t t l! t t t lt ( st t llr t t t t t t t l't t t t ) j'r r ! i r l'r r r r l( r 'r ' rrrr(' rtfU l l )r' i t: r r ) I it r r it : r t cr t l, ilt r llizif i iir l, t 'ti{r , r ir ll lr r llil lr r ll|| l; r I ir t lr t lr t i (l trr lt t l r . t lt t , r r i, 'r t li't r lr r t 'r r t t , l't ir '( lr r t t . zii lr r . ir r lr i) ; r r ) , '\ ir , r r i. t r ': r t ' rl r' ,rrrr' ;l rl lllll , , i l r)r' i )l tr(' zollt , t lt r sir r llt t : lt t l) ir lllt ii( [ lll {i( r il, ( l( : ( 'il'si l( '; ( [ ) l'ilslt t r t r r r lilr Ii l 1' r, cl 0| 1r,0J] r i0glilli( , ( ,ir lli) ( liii( iit il( r ' I l'llt l\ ( ', ijr . nz{) f ilt lr .sr t t t llllr lr t lt l , t rr' , ; r' ) Ihr..t'i t t r : t r sr : t t llttit r t lr t r r ilt lil'st r t llit llt lt lr l'il ilollt llll ill t , t t r lilii v, lr ,,,rr:rl r., rl It:rl l r r r '{, ( lf llioi{it l r llllijclr ilor l) or i( nl1li, lll t lt i; llllt 'olt 't 't t t o{t r r t t : t I I t t rrroi l ot al riilr ill . c{robsclr ii ii. t t t t m t r it lt l invt r t 's: lt ist r lt t t 'lt ' lt r i'1"r 'r 'ii r r l "t r r,rrl {,, (l l r tl (, i'iir il;r . 0li1it lnal. O 0onlt t zir l cu lozilllli i'lll}lir nllr : lclr 'r ( lxr : r 'lr r ocI ziot it l ir r cur 's, l vilI ( l( f ai. ii l) il*r liziilo. I ir . ir , lo | ;rl ' ti i i (:1o , . ir r ( lc r t.rrrr r,l i ol ogi tr ( it ui, 't or L 1, ip I lt ll, I : iI ilct r f t i bolt r lr i, r t liur t f lr ll I lllr ( 11i( 'i 'llr N lolt lcar in: l 1llc( 'odt r1) {!c( 'iL' gr lll) ( 'l( 't ' lt llli( ll1' ,l .t' l l ttrst:ttl llr esll] ) ( 'r 'ioilt o t 1,r," i rrl i .ri rl :tt'r 'qi,ur i a1. lr e, in sl, lr r liilt 'llivlllr silt o le lclit llt 'r 't r rl'oir lr r I ) ( 'r sisiil' ( ( ] supr llllll( , 1( . lr f li)Ll|f ( ' r ll'( 'lllir ,rrrrl cl i oj t, rrrIsr , ii] ar , siinilil] ( 11.f1 ( lit i l) alr lr lizil! ,.rrrrri D N l c si ull l) ll ist ot ilr : r l lllllii polt c pl'lf Y{r lli or i( i( ' ( r ) lr lllz't '' llt l ' ;rr' :tl i zi a llet , i: lli lclt t t 'ali, ( llit olil, ii Llziur lii ijbr r lor s Lt pLlt r t tr lt r llr ', t r r ' ([ par t ialii a 1: t t lil t t lui sr llt r 'lit ] l' r r r r t l. r ,,' r:rr,tt,r' i zr" rr zii,( ] ci, ] f ir t t t sl; oolillr ( lll. !l , rrllrirrIii, jttorvalfl ttc taciatrlt supofiol avilld o l o Llt(iz( ltiilrlf trtrlirrltli r, rIIrI r,r,IrI ii . Astlel, lxtlnavuL po:11,c illor.01iIruritol 1i ltu l)rozi|l l,it lrtgoll,rtlrrtir,, r rrr ri ri sci ti l e a ulji) r nu, 1i( x) , r 'ollor(0 is, clc li1( Li) asilnclnin, , 'li''I i{'ii ( li''r iDr r ' ,r,i^ tll;tolitil ilti;cEli1:lil,iitr[ilot' rnol,ot'ii rlllt.{)rnlto, oa'lorrvollllliiiuii Iiilril rrrr' ,t,i l i ntct' .si. t ii . it 1, i, , ", du'i culn ar n lillt ir t t il' t r ut i sus, st r t 't t t t slr t 'i: ir lr r 'f pirrl,c (xt prr,ralizia,Irr,irirr'li''llrl r11r, tlir ,1,r,:r,i h.rniplcgie lr.stii'irl1ii, rt't.retrali o c.tt'lrtrrl., i'ttttrori (plin srtfori.]c 1r:rsoll]zrre ila,cirllcc.n1r'alc ' rrtrr 1'ra..r,lizii citrr4lir,,'ritl:llo, ltsitlrrrl.irt lr'{"r tt'lt 1i.,.iiilor t, l, irt .u,r'e, prirL ir rt.r't:sit ( ;r(1iontuerlzii,(,u oca,ziil' c\l-)rosiei elnotioni[lo. rii :.1.6.t.2. t.)ard.ieiile Jnt:ial,a y iJi'rice (frin l''zitiIIi rrrt(1ltriit'(' itrlr'rl ( lr ' \ 'r lt lo lopout r r lir it r : ' l .:rl r' l l r" l li {r 'ul'al' dit r l, ut r cl prirt lPniu.lli ttttt:lcure. [r]si'r' r'rrtlr:r rl'' r\) -f'oroli:rri faria!,a peri,fet'i,ce ,rr,,ri ttttt,l t: ului iLt r vuhii f icit l ii l) or '1iunolli111r 'r t 1i(irniii' lt t it t r ': t lr r r 'lo rr l, 1,,i i uri (vl ,!( 1ulilr t , l, um olale' inI lr inat or ii ot c. ) . 1ir iL( {isi, ( 'siir r r r ( it r ( \ r L,l ;,rLi i )(l o ohict i, lir r r r liziei f aei: ile, o lcziut Lt : t ,lilt , soioLilt t lt tIi I' Ii I t t i t I rrI , cr r 't , 1 lozir lir ii ( ; i t ! 't r i ir r r t r r lizr lr ,:t\i r,t' uzi t o lt t 'nLipleplicalli( t 'nii, aalicli opusi, L rrrl r.), l i l oalt - se lt ot a"r oeia qi t ulbur lif i d( ' sor lsil) ili[ 11( ]lx! <i. - h( r lr r i( ''r I l'lll t ,;,rrs(j ' i ' l i ,ziur t e: riir ilor scnzil, iYc) ; i, d. t r r 1. lt r lli r r r lr li, ( r i, Jr r z, it r r r ir r . ( jf lt llicnir or i'c collt ur eaz?i t t ivt 'r 'st 'lll . ! jlr ( [ r o: ilr x)illlt f lt l{' r ll' r 1i ,(l { j l r(' t1 'j r r rrrrl l ti cl i cl rt 'it 1. tt'it:e pritu Le2iulli iu.;lranuclcnrt l'r' lrrtzrr' ll) !'ant,li:;i'i, Juuialt: p ari,J l :,1,t,rI rrr.r i o l0ilit t r t lit r ir : r i, ilt r r t r of iziologice lj I ) e I ) l'z: 1, t t t lt t r lt r t lr lt r r r {ir r rr lt , 1,, fo Itort ; l, rsllt lr ili r / t iiyr osli. ul, lof ) olJr Q I 'i|ll, l lczjllllii t t t r t 'r 't llr t i I r r {'i: r l' r ' \,' . l (' l )rrl xf lit ll( ( ir t t |it lc sit r i': icr lt t l liiolir niilii ( s|t r l, ir slt t l lt r i S{1lt iI t r r t ") , r 'l ri l r,l i rl l | ri ]l cr0lot ir r t t , '1r 'lr r t r ltiililJ) ( i( lius ( 'iir lr gisir : ir r il o 5i r lcI i t or r |t t sl ir ') , iI si trrrl rrtl s| ttri lr ililii( ii gr r r . lt r livr ', I ) i1'( r 1r l) l lr r lt t t it 'lt t r lt 't r it r r $r t ; l'ot t t t 'l r t rrri i l rrl i rl i (( lr : lr lr cr ', ll) ii'; 'l'r r ir r t lr 'lt r i r , ollt }. , ll) {i'/ ; I 't t llr r , lll?l; I 'l1t 't \ r, r| r ri l ' i rs( lr ! lt ) 3( ) ) l, r 'zir r t r il( .ilr llll, lll( il{'lll1f 1xr l, I i gr t t lr : t lt l lr slli'l llit t l 1,rrrr, rl r, tl tl lr r ' : r l: r lr r t t r t r ' {'l'r t llr t r lt , ll) ( i{); I 'ollovir r it t 1i I 'r t lr r t t , ll}i'io) : '
u 1 n r l ,'l r t1 1 tr 'r l , l ', tti l tr t:r l t:ti r n ttt t t r I t t I i t t t I I t t t tt ' I t r l r ' tl t tr n l l h r l ttttl tt r tn Iu :l o :; ( i r r r l l o l o l ti : r ) 'l 't r t t t pttl , ' l tttttl ) t i l r r r r l ti ;r l ,i r l r ,) p l ,l , l r Ic|l ;l r' r I t t | ; ' I rr. r | | r, Ir ',:II;r l l !l D i l l i l ti l r ', f i , . r \ l t . [ ] r l i r ', I t I |. l 't t ) a t :t

:j-5.:!. llrrnrlizia norvulti. trigemen (paralizia masticatorie) so (iiu,ir(l t rt rrt rr,ii ll jlr dcli:ltil, tnatiilarul.ui inferior sple pantea pn.ftliza,tiii ((rll ,,(:rzrirrl('s(lrirlot'iigtll.ii) in caz de paralizie unilatera,li (nuclealir, silrr ],(;ri lr'r'r,.irl l,r,igcrlorului (prin aclilrrel predominatrtF :_r, ) rnuschiului ptt:r;iqoi rlrir) (.\1,(,tn (x)ntil,ltla,tetal sini,tos), prin rtrofia mugchilor na,iticirl,r,fi (|r.IrIIlr||irIsi rrLesotcr), plin diminua;reafortei de stringere a, maxil:rr.rrlrrj rrrl,,r ;i ptirr rlirnirLualcasau abolilea refterului maseteuo. ior' Sr.r[:.rlrrrrr;te ur\or'procese inl,rapontine(tumori, tuberculoame, gl)r|tr., , lrrrlrrx'rrlllllil,r, {.1.) sau :nnor lezi'Llnifdd,iculalte ale rd,d[cinii m;tol,ii l, I ti Ir' IrIr'r)|I I rI i (ptocrrseneo{olmatiye sau traumatice bazale) sau tron(rtrtu.tj ' r,'r'rrrlrri rrlrrrrlibnlar :r1,. (trauntatice, tumolale etc,), .patalizia u,niltlt r',r/a;r,rrcrlrrltri lricemcn poate.apdrea Si_incontextul unol suter.inlornll lll'l{ rl(' |r'r'\ i (J'Nlri0i. Paralizia biloterald, trigemenului se poate rcalizir a rr r:r(lr,.l rr1'l' srt{rrinte bulbo-pontine (scleroz:i, laterali1 amiotrofi.ii,, rrlr,rirr, rk. s.lrYoziillbclalii amiotrcficd,, diverseproccseintraner-ut,_r iu,L,) ,irr :rl llrot rrrli,r,irrlc llaz:rlcextinso (tle obicei tumornle).

,Ii I,III)III,I.]I\'II,] I)IA(iNOSTIC I)IJ iN PAIOLO{.I]A NER\TULUI IIACIAL :l.li.l. Irrrost,i1;atil scrniologici .,1j nervullii faciai ulnrireqte : | ) l',t.idt) ti().ur,t(ntn,elorclinice d,eTtare*i sau d,eytarali.zie.faci il, .r, rrtrr I rir. x|rt::tu .faai,all)f in probcle bine ounoscul,eale era,xrc1r i l. t,tttt ,,t rlt' t.t rr,rtt,r'n.rt,l,tr,,i di,ttr.tmit:, ,lsupra cir'ora nu ilsisti,rn irici. I: ) l,)rllt))ut'(ionutdtJ.ir:iril,or ] lnd,{odrelor reJlem (Ilist\,7 t1}i2; ll,lr r r.r'rrr.r., lt)lilt; llrpoyii,ir fi l.,asou,I9g0) : a) rcllext na,zo_lluJpdrll,l ; lr) r, l, rrl .r'Irir,rrIrr'rrIrri rxrhirLhri;o) r'{rflexull,siho-palpd)ral rl) rrrrllrrrrrl ; r'r lrlr, Prrl;x'lrlrrl lrri llcclilurcl. 1 e) roflexr corr]orr,D; rr:llc.rrrl rrl I) rrirzrr. lrrrlrr,rrl; !J r.r"ll{rxui ruu;chiuhristaporlius;h) r,cfloxclo clipil. rtc | ) ltt::lqt't:uttusluljl.i,(lllpi m{ltodelc oxluse r1c rlri irr ,,, .rrlrrirrlrlrr l\r'rrrolorlir.)' (l'{)l)r)vii,ill t,Nsru, l1i,$0). $i
l) ) l 'l ) , l;r ri c rr l lttttl rtl o t
811

'l t.\l(t.t1!.tnli.tvrliri., ' l' t x t , lt t ' lr r l rtt.l i :,i rl u rl i a:r: rr) r:x rrrrri rr i .i l r. rk, r,l .rrl ,r,,rrl i i ' drr.r l i tr lI . I t r , { iiI , r t r ll rl r,l c rrl rrrc r' tr{ i , 1 l r) r.rrrr rrrrl rrrI \l (i ; r,) rrr]i .Irrr,I1,r,Ir, I,)l r lr , llr lr ' t r { lr tr r' 0 ItrIIrr,r' t l t!fl .t,o l l ,.]r,. rt

t|tl

r,:| |1 :r i , -q l i l t r i, 1" ' 1i111 r,.s , " :i r l ,Ol j l trl i , l On ,.t.r,i l (,. ) ,u ; r., r. t ,r rI I rrrr r,.,,, .,rr.rr r,' .l rlr,lrrl. l ilt ( lr . l l | | i r d e fry rfU l r.i i n l ezj U rri l r. l rol ,\ul i l t(.;i tl l I r.r, tt.tt I Iil tl I c lrlril uhcranl i si stinca temporaluJu i, l:l semnole r r'lt di: iI l :r.rrl rr r l r r loc ir r z li tl e o l ti c r.i s i s e n l l to d e .' l e zi une a al tot ncl l r 1l,lrtltiz trl rrr,,trr (\, \'1, \ I I I ) , _ ln( , ({ rn t s i n ro d i fj c r' l r.ja l e L .C .R ., i ar i n cazul l )roc{,s(,l ol | | | I(|(. | | r1( |I r. {. tio spal:iu - scnne. dt hilx,t,telsilne jntlacr.:utjatil; (j) I l)i rri ' I i ()rrI i{' I rI (l('vilr(' irrsi rrrrri dil icil irr lari'lc sitnaifii tte ,pe:ratirii Juciut(i ltit,l It rrrtt , t,rr' 1xr1: :tIr,.i itr trnrle si Jornt de distroJie nlus;ularai,,di,prli.ntio:,iti ::t rl t , r ir t s lt , nit , ( lllt , l ,t (,_ \l )l n (,' :l tc n t s rtrp ],i ri de contextul cl i ri i c al l xrl i i rl t l rtt. : t . ll l, it t 1, , l. .trtl ri .l u ri rrt .x i ttu -tcp n ,.,i mnt ,yl 4,,1i Jol i dt qol gti o , .l 1 ' u t'tl ( " t lt t , t t ; u, t ' , t : ,t1 t1 rtrr ,i t,rl n l fi ). S r.n rrr,.l r.r.l j ni r.o.j rrti urrl l l rsC rnl i rr:r l ,:rrr,rr r . r ' 1. lr lc u,tri s i rrrl ro rrt d . tn .j g h i p o n t o_ce.ebcl os. ptl Il ftl i zi a :l l i * , l ,:rz, r r lr r i( ' l rri l u ' l i i n c l y a l i i d e i ' a c i a l , ra cl re sc asoci azi i tul brrri n l , r gil Ii r(' r' Il I r'r r(''r)' r.1rr'".rrr, si ilfccla.ca $rstului in ceb doud tleimi alteriollrr. rI r rrl ,' l i rrrlr ii. lI llt lr ll{ ' !i i z l i s c a s ri c j a z i i s i h i p o a cuzi o. l,lr rrrl i rrr'i i lo lrr[io]ogigt' alc lir z,,i (,1,J1iuluj alt.porliunji pietroe,sl lr l . fi ,, trl Ii lr , r r r |, r ' lr l 1r .l r.r' i rL ,rrl i rrL i ,l ttrrc { l c r.t.. zi l tnr., di e fl ectrtri sau ri l l ,r, f rrrll(' rlrrIri-r(' r.rr,1 I ir. .,rtrt pror:cse r,rr r'r'is sitttGtela {tce*tn.il:el: tnetringio:rrrr., l r rr"l rl, ) r r , ilr , . lr : r ll l trl i .l .l r.. ()s 1 (,i 1 (, ml o ra l c, C .:l tl j nOl ntC rtU mi l i te cl l i r i ,rr , , lt | | |l., I '( I I( | | I III I I I (' , r e ti ts l ,a z c dt h car' ci troarrrI ' l lol cni te r r r,l l r ' llr , : r liz ; u i { ,| ' Irt.r,r' rrl r.,l )(i l )). l l l I ) I t it r t ilI s i l trrrl r' ,i ttl tt: l l o l t0 l i o n u l g e ni r: Iri pi ori qi nea rutrt.tttrr ' '',rl t, t r r t t lt . ir l : t r t rrttrl i tr"(i , 1 )o tri u n . L x u .1 )1 ' ..l r1.. ar r)edi Li' rl setancl c cri ri rr. .rl , :r, r ' r lr r l llz lt r i s i n l l i l rt' 1 r' l rs g rri n i tq l rtt C rr r.gl c ). C ,S C rj se rt1' r.i qr,. l ':,r:l ri ,r ir l: r . r l: r . s 1 r. rrs ' r,i l ri i i r,rr l l l .r,:rte a e r stul ui l )o r,cl o tl oui . trci rrri :,rrl , ri ):r . , li' I ir r r lr ii, (' r ri f(.fl rrre :l s l l l i v i l l l c i , c n hi pcl aauzi c si r,.r al tcrrr.r,rr lr,tr.i l: u. r r l: r lr , r , rrrtl q .rrn g l j o n ri lg c n j c n l fl t e s te deosebi i , (l o tfect:t1. N l l '. ,, l L t r lr lr ipo : irU l l l l i rr Z j f. l .e $ D c c ti rri n l l ,. l i carc:l :ri t()],tLct.\i ri | rr]]i Irri , , r i 'i .l ) ir lr r r lr r r ril rl t. c rr l tr,:' 1 rez o s tc r..T \.0 c t,scl epal ol og,i cc | cs1ttrrrs:rl ri l . r s r'1 , || lI r r , r r l^ r . t .l (' trrr,r,l i o l l i r1 ,t, i t]Ite t,i o t,)]rt c:ut sc i dl tri ei .t l )i rrl ri l :r.r:,1 ;rlr r r ' : rr t iololic r.l i ti .i l Iu j l l c l 1 . D i tg -n ()s ti cl l l ani l i ()nl i c sri l l rrztl rzrii :ti :r 1x, i i rrl rl r l{ . r r l r l I I r cl j rrIIri .i t,il,l g rrs l ,rrl u i ,a l s a l i vl _l i ti si l t.l l l zl l l l ti . l l ) l, : ir t t t i/ r : : t ti trrrl r d .i ttrt[.,l u l i itl c rto " t:trl , f]pn1nt. tl ut(i hi 1tlrl .t!l r,l i ttr, ,1 ,'t I't,, ' nt t t l . lr , ! t i t lt ,L l tl l tl c u t)d u .l i n tl )l tl u l ri i i rn pol l i rrrrr.i ri nl i ,l rsi ;r1r,rl i rJr l l r r r r lr ir . r iit lr l i i , l l i ti tl i z i t, l :rl i ;rl :-r :l r{ j ti tzi -l i l t rl i trri rrrl u.r,lrl rrr rrl ,rr t r, l,r.r',;r r : r l, ulr rri. i r r r r r l i v rri i " i ,.l i p s t' s r l rd l I,' ,i i l i k , il r l i i r,r,i nl rrr' 4i l ri l x' r' rr.rrzrrr.. rrr I 'i rI r l rz r r lr r lir r lii iiilii l l i o l o c i (,rl c l i rri l i s i ,i o l a z r)sl { ' r. rr I ccl c rrr:ri rl ri sr ri l r,, ri i rr rl rrt l tr' lr t r c r ii t r l r l i rrrl i l r s i l rt l tl l r' N l (, rrrr,t,l ri i rrr,,rl i i , l ,l o (j c s { r: i l ti l ti i r, Ir'rl Ir,I r I oI Lr I r I 'I,I I II I | |I I I i s I rI{, IrI rri I[r,rr1 It s l l t I )l t t.t,i ti 0i i i (,l .i l \,r,f]t(,t..Mi i I r l0 ; ll rl ro r i lir t r , r i l' il. ( ' 1, l l l ti (t). l ') l, r ' ' it t nilt : , il trtl t d i tl rrl .l tl i tl t ' i rtrttl r ,or:t.tl tri ttt 1tt rtt tt | /I / (l t I l rrr Jrtrtrl l r i | | | t':r(,I || r| :r| :i ) i rr l t,o rl r' l r' z i rttrr r o trr I,l l ti rr rrrl l rl :t l l ul l i ztr, l tL,ri rl r, I t{;

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r.l rrr' r'\ l l:r, rrrl. tlrr : r lr r r r r r . . r r I r l, , , lr r , , r . ; , : r lt r l r . | r , l ; r i , r r l t r r , | l r . I I | | I I i r I I . I i I I i | . lr), lt r rr lrrtrrlr. yn n.r ; t l, i t r | , r tt t , rI , ,, | | t |t , l( , l) t ! ) ( {. - t {. I | | I I I I r . ; | r r i . r r f r || : 1 i , I Z ; l | | :ttl, ( r l! illrzrt I;rt,i: r I c I r iI I r I r , r l I r . , r r r , I , r , { li j r l l ) . , i ] r l l , r . I l ) : r J . l l i r : i i t r r t l i l r l r . rll rtclr j t,t:lli(.1 i. r \ t t t ir r lir r r 1, , , lr r r ,r li, l, . r r . l l l i r " l r " . 1r, , I r r I rI I rr, t rI I I r rr. r r . i I , . I r rlr' . lilr l,;rrrrllr (ilillr r iu lilr lr , , r r r r r r r 1r i, . l, , r h , r l i r r , r r , . L , l i r r l o ! : i i ( r i l r l r r . , , . Itrlr. r' r,1.,rr.. lrr.ii.r') , s lr r . r , ' ir l. z r , lr , ll. r ir r ilr . r , l s i I i i I , I r I r 'r I ; . , l 1 ) {i l ) . r . r r r . r r r , rrrrrloz|lI iIlillll|li\(,rli lr r z c s . : r . _\ ( . , , s 1i.lll. o( . ( , r - , ! ( , r i u \ ( {, 1 ) l i i r ,; lxrlirk,r |ii,,lor. r 1rolir.11 rli1,1 1l1 11 11, t ' r . i1( ior( ' lr ir r r il( l( , t . J pot s i nr }r o d u c u L d " r , , , , , , l ) i t r . r r l i z i t

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' :i lLllri. l vt) t) t\!.l t'r i ttl N l l I 'u . t r tl i :i i l t.l i u ti u l .t l r tr xl ttr r r tl c l tn r t) ti h tn i q ttt ( l r tr l l r t l tttr to t i g _ l tl ttti r tr , tt( 'tl ti l !o i l tr l ( ', i u r r ttt|i Il r r 'r t l r r r l r , rr r r 0 i t l r ', l r ti ^ tl i tl g i o r l l tl |, r r f i i " ; r r ') s r r r r t,tu l i q n t ( cttr t.i ,to i i r r ( ,, l r tt!r l |i l r n ^ l r sl i r l i ( 1 ( ') . r i t' i ttl i l r tcsc i r t: tl t;tl r r ,l ,, l t , 1 I 'r l n r ti :i i i r .l r r r i r r l l r l i n Iu l .i l t si xl r n ti u | | | | | ' r | | , l r . r ; I r Ir l ' rr r' I r.r' i rrI i i , r r l r .to i r i i |l l 'r ,tj ( ) st,l |t'o zi ( 1 r t'i tr l fzi ttn i \'a N |l tl l \t|' r r r 1 r 'r r r r r i r i r rl ( r .r 1 .l ,r 'r l ) , l r .ttl l tr ti i , l r r r tl r t l tti tr l r i tl g l i i tr , l ,{'fi :t1 1 r 'r i i l t r to tl o u l r t, 'r ': r r r r l o r r l r l o z:t l tti Wr .r 1 r .tt't ;.;t. ( .l r i r i i , r l i t,l t,q i r ) ( l r tn r l i :i l l tti l l l ) l t l l t t t t li .:;u .l r r ti tl i ,,i tl i q t,tl i ci i " r l o l tt Tr ti tt r '''.L ,l ttr l tttr t r , 1 , r 'r 'z i r r l i i o r r l r ,r 'l i tr tr r .tr l r ,:r l r .i r l i ;tt,tr n l i l st'si r r l i i l r 'l l l i tl|tlttllt tl i tl ) tl tt!t r r i , r ' l tt l ttr ,ttl ', 1 ",'i',, r l i tt i r r r r l t' t:tztttl l r , r L . l t o ti l 'i l i l ttl i l r . r r r r l r z i i I r r r 'r Ir Ir . r .r IIr I r tl r .l tl ,r ' ttr ,:l l ( ,r ,,o r r r r |r r r l l r l i zi i l ,r r Ii r l r i t.l i r ,l ,r g i r , 1 ttr ,<r tr l l , r l tr r l ti . , rr I ro I rrr I i l r , ' 1, r l i r r l r r 'l i r l r r :r r l tr r l :r l n l tr r ti l r tt{i ttr ' l xr i l i l r r tr si r l l r tl r r 'l ':r i ct tr l t, l 1 l {l l l ; Wo l l i ,tttr r ttt, , r I t o 1 r I r i i l r r I { ' t i r I }|.t | ,| , , l 1 ) / i : l 'i r l r l t'1 , l l l 'i Ii

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tl l t'tl ttti t ;tr 'l t' u 'ttl ttttr l r tl r 'tt l :tr r r i I t t rt I t r r t r rr t I l r tr 'ttttttl r tt r l r 'r 'r 'r 'r ',r l tl , r i , r ', : r , l r r l r l r T r r ,r r l l r i r r i ttl tl ttl i l l l . l ttl l st^ l r i tt r r l l r r l i i l t l r r tr l r r tl i i l r l r ' |r :r tr tl tzttt lri I l' l|, sl ttt l tt'l 'l ttsr tl ( l l t't';to stl l !l o l l i tr r l r tl : l . l i . l . 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r r| | | | I . Ir' { |:I zrgorrrrrliIilor, si :r, iilitioulalului buzelor., (,u drpltsar.et g1lrij). t), ( , r ' ll n ir i r rrrrl l rr ri t,i , s 1 :a s n c 4 c s i n i t l t:d:i rrsate fi {te (.rl l l t,i l ,,li j l l \ r,rrrti r ' ( r r l. r r r r r s .rrl l tl r' .i i r.i l ti r:c ,1 i ;s a ri m:rs1i rl i rl i . f." .i i ,i " ri uai ,r' , o r':rrr:r|r r , r r . : r I r I I r r i. r,i rrl a tu l u j . a l i s u l n i , rr a vorl l j l .i j si rl ut;i s1" rot1i 1,j .;i trl ,1 rtr.r't : r s ir r r P lr ' 1,{ , \ (,i l .ti i tc .trri .r,. ta c ti l r, ,l , 1,.i .,," i " i ri ,.Ii .l a:rrrr.erri rsi Li .r" i r l rrr lr . : r : r .rrr elior tl rz i s j tl i l e s c s p a s i n e l e . i _ tn t,ol i sc rcrnn,tl cazi i .q,,r,u,t,, 'r'r(' r r : r r ' (: r ir * r ' . r . r' rr l rrl i ' i l l te l t s p a s m ri i tri tr ,,;l rt. 1r;| ,r" t,,,rrj 1i o r, . ri ! | ; rI rl r Ii i

t,rlrlrri),i.' .s.r,liti rr, l.ont:rhrl,i. lle.un fontl O" ii]u,.ir,,, r('rtir. ro lrrrxlrrl slrrrli, sccuseparl,iale, cind po"oriiro"ti"'Oi*"1"tlle iill ul. ur ,.r.r"qi.fti, cr,,,i . r'r,srrlrr.ilalt,, i.tt,o rlt.car. (i. scc.se dezorrlonateri1i1 r.rr l,,i;1..,,', ,r r.irlirrr ;r ] rr.(trr.( rl tL,autr.itie,c:Lte itrtertseazii linrl inlr.eaea pe rnust:trllr Irrrrr Ir.rrrilrr.i;rrii rr, rrilrrrlcrr. ;i rco\te criz..u'r,irziL urecl.i d,nr,oit.rrr rLi.( rr(1r,, rr;r'rr:1rr'lrrlrr r.rr r.,,i'lrciiil,, tn ri.,"_ci,ro;"" sc iliiocate Oe ,lx,.i t:rlr:r .lr..l :r r.,r,r.rrlrri. .onsiatri Sc. it"i;i p"ez"n1a- siricrgirrnor.rnal,, 'ir.r'i tr.:rr.ii.r l:r r.,rr I'r,rlaiiilui,," ur,,,,iirri*",iri',i,i'"uon,r.a,,, ,,,. l,l, r:|l ||l|. D r, ||1'.t,t,. i r . l. , 1 rtl ,.,r,.1 ' rz i l o r.h i u l u i . c i rrr " l a or,l Izi t,,,.hi rrtrri .,.,. ..,i ,rzl , ' .

I '1,,1, lil:'t,.:1i,,';::';;1";,I,iilJi,Jii1",Jir:;:ili,1t,tiill;;lllil: 'll,l"lil;;,Xi -tiii ,]']l:r[,' :r,;,]rrLie,r1rrn,i t; cil,o-a o"o;.l, p""ii,o,i,i lr.ax tm,.i rt,.rr,,t )'.1.1 .,,iill ii,' i,'t,i. ,rlii li .i,i,1i"ilii*i,i!i"Ti'.i1'.;rtil,.]iiiil"il.:i.*iiili';T ii,lillxl;, -

apar' ,, rtirr J;rl::r.,r ]]rrir,r,, l] . .],. ll,.:lli].l.: llli'til]" ruuscutare irir,;ar

\ , l l r a s i ttttl .]r r t:i tl t,o r ti tu tl tttt t,stt', i tt tr r l tl i l l tl r ^ , l l l l . sl ) l l r i tl l l l r ( l i l l ' r 'l 'r 'ti :ti stttl ' l ti i l tl ttti l i '{r 't t , r , r r 'l i r t l t, o .i u l ;:tr tn i ttn i i l o tr l tl i zl tl l i l l t tr ttt- r ( l ( \( 'ti l l l l 'i l ttl r l l r :t ttr , 1 , t , , I r | | i s t iti Io tti Io tItItIi ct', cl tti l sl 'tl i l i 'ttl t( i tl 7 'i , t . . i 1 r | i i r l l r l ) i ti l ( i , i l ( ' I1 r l ;l ( {) l l l l i l ( '!i i L ttttl si 'tl i r tl 'r i st'. p tr xl tt|r ' i tt tr r r r r l 'i tt a t,l 'l l tsi ti tr tl t o <'l ttzi l t l r l co l r l x'i , ||Ii I( i II|':I ,r,r, r . , \ s l 1 L .j . tttt * ,,,,l r r ,'tr i l o l l r r t ( l r r ( t sl l { r '( r r tr l r r r ' s i ,,r l ,.i 'r r l ttl tr ca " p l i r tl 'i l l l r i i u ttl i i , t1 ','r r,] f i , r ( . i "g ' ,,t, tr tttl cl ti "1 tt'r1l 1tl l , r 'i i zl t l l tti i ttr l r r r r '' 1 r " , i , r 'r 'i r l i l oi .i i tcl i so tr i tr tl i l ,, 1 ,,' 1 l l r r r r l o t t t t 't r i ti l l r r l i r r l ttl tti i r r l i 'r 'i o r ', i i t' Ix"t't'l l r l l r Il i i r Iti Itti stl p 'i i 'r t, 'r r 1 "' l , r l r r \ 1 r 'l r s i1 ' 1 r r ' It{,r tti tIr I;IttI 1 1 'sl ) ( 'r r i i \ ;i t'l ti r tt i 'L r g ^ 1 '1 1 ( 'l l l l l z:l r t'' tl ) 4 r .n " ( h 'l i l l tr l i l l l l l ( 'r i r ) t u l l tr i ]l Ii l tr , I f ) , {T r r r .r a l r / n tIl i ttt r ) ;1 r 'o i 1 ) l !|)',1'rtt'r tl r r l i 'r ' , , , . , 1 S i r l r r r rl r i t I I rt t I t t t ' rt : t t t , l 1 ) 'i i , r 'i l r r l i tl t' Il r tl ttl l r r ttr ' tl str i l l t ; rI I ' r t I t ; I I ' I t I t , i tt ;tt t l l tr t t , l t i l r r l r t r r l i ,t'r r i r ':r 'l tr tl Itttr '1 ,i i ,',,,i ttr i ,'l r t sr ' 1 r r r 1 i r so ti i t tttt'r r ':l tr l t ttttts,'l ti l r r t l to ttl l r l i r l , , I l r r I r I t i t I Ii r t.i tl l tl i ci ,,, .r 'ttt1 r 'r tl t' l ttl l s( 'l l i l r ) l l r ttzcl o t .IttI'tIIo ttttItr i si ;r Ir r g i l ttl tti , t'r 'r ':t rl.Lvr." tl I sl tr tu tr r | ttt ttsl t|r 'l i r , l r , '. r . r l r ) r l i , tl l i r si i Ii r ' :ttti tttl t,l l i ( l ( ' l tti i ( l i l i ' ,l,l I ! l r r .i tr l l tti ,r tl l r .t,i o t, ;i r l 0 st.r .r |r r . 1 r 'l tq tr t|tr l :ttr , ( sl ttt Il tsr 'i |ttl l r l r r ) l tr l i r r l i ,r 'i r r r . { r .i zr .i r ,, rrr. i r r | | rrr, t rI i r I ( ' tl |' r 'r ti ttl l i , r 'r 'r l |l tr 'l l r l tr , r r , l L r i l i r r , i lr l Il tr .\( l t'i - l ' I'i {l l l l ) l l r l l l , , 1 , r , , , r r t I r , z i l i r , r ,ti zr r l r i r r l l t si .i ttl 0 r l r 1 r 'tl tl r 'l L '( l ) l r ) 1 1 1 , 1 , l ' , ! r r r i r o j r .r , i r r r cr i ,'ti i ,;r r o r l r i r i r i i :t I rI i t t tl I r i ; t I i r 'i Stl tvi tr l l l t i ttr i tt tztl , , , \ r ' l i r . l : r li l r ' Il l l zi l r l l ) i \l l l tl i i l i l l ttl i l i l l r ' l l ':',i tttti ttIt r o l tr r ', r l ;tt r r ' l r r r |r ' Sr ' l tr r ':ttr t\ttr \ I ' I I , I I rl . r r ' i ,I r ' r I , rrI t , 1I t t r ' r )| I ', I I I I r' : | 1 \ i l fi ( 'l l l i l l ;i ;l i L l 1r 'l l r |l :l l i i tr 'i ) :r ' l r "r l L r /i r 'l r tl i r r ': Llllr,tl\lr f r r l l l r r 'l r ' l ,r r :u , .l ,r 't,r [' 1 t,tl t n l tl tl i l i r t. ( l 'r "r 'l r r tt t l ':t i l l ' l 1 ) l 'i l l ' ' r 'r l l r i | l t l l lr c r I r : r 1rr t I r t rr t r I Ir|t ( , 1 l l 1 t , r :.tt,tr ll ,tr t,r l ,l i tt |r t:;tr l tttt"t : i ttt|||'tttt|t l 'tr l l "' l "'tti tr r ( r ;ti 1 |L tl "tr ', i r r r r r , i t r l r ', r l r t, r r l l .tr r zr r tr tr r l l r p l l r , r l r r r ; LI t t r' ' r rI I rt | | rt I ) l l r l l i r l l l ( r 'l l l r '\l l l l 1 |l

i l , , l ; l l 'i i i :,i l l

r tr It.ttrr'lrtli' lit.crtttt si setrz a l, ii , { r' ' r' r' lr' g irr, ' rs 1 . } rrr. r' 1 i

u r ) ii l) ( ,lit;r\ i ,t, ,,,,t,s,,1 {,t.tz(,t (.l utri (.t, i . i , | \ i , I | | { | ( . , . I , , | | I , i r r i| l.r . tI r .r r 1 r . 1 1 ,i ,,.l ri l t ,,rl r, Ir. r , r., .,1 t r' r \ r, r/ 1 . l r r l l o , . 1 ) i ll) ltlllr .tr l r .,r l,o s,,lr r .r : r,l l ol rrl ,,r I I \ r . , . I , I i 1| I r. ) I rl ,. lirr. rl l r : r r:|| | tll :l| | r . .1.. ,rl |,i l L lr r r r trl , lr :r ] r r tl l,,r r l,, ri ti l rl l rl 1,, rl'r n, i l , r i r l t l.,rlirl :l lr r \ i r l:,r r :,1 lr ,,;r lr. r rl ,,1.,|,.:,, 1,:r r,r|l r' , . irir

il, ( r l lr r r r lj* p l ts rrr i tr.i n ri 1 .i t rrrr s l to rrs i rrl i l i r.i rrrr l i ,l rl i r ]rr,r,.rl i zi l , rtr 'l l r:rl r r . r ' r r , iilllr il i l trl .l r I,l .r,1 ri .ri ,l I)(,r.v ,l l ti i r ri ,rr* ,,l i i 1,,, (,;11. Il l t l ' (xl r ' . \ r r , r lr r r r lr lir r,.r,r,l i i , tr, | (r. l ri p l r,r,rl i trri ri l i l rl r.). " i i ,rr l ri i i l url rr:rl i , ._1r:r_rrrul . .r)l | l l l Ii . .\l i rrq | r,r,tr t | l rr;i r . i 'l ri l rrl l ||r it t |ll||t l lt rrl i sr,;rri l ri l t Irtl , r.rl rl rr,.r r, iDrrr'rI r ' I r , . | | I I | ' I I | | I I r , | ) | l rr ,| | | | I( .( i( |

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I Ir . I r l rr | | ( | I / i ( : t l : [ ' ( ' f r i 0 t. i: irr lr! )l | | t r f l t l l r ' r ' l | l . illi\ (, lr r lr It | l | lr .ltr ( , (,|,(,I,t:II, (.u (,{) l i gl l |,i l i ,i c (l I

::.1; . 1i" ilr lr ' { r r n u l l u i } l t' l l i c rs s o rr-l l o s s rrl l rrl ronsti i rl i rrtl o ptrr.;rl i zr,, S l r.i rl i i ir lliliu( jlc lr li' , a ,d e s c l Iri Il I.r' i rIr' i , c a rc s c r)or)tcrt' l rcl rr rtrornri rti rl l r ,rr i l rr ir r l( ' r ' r - ul(d0 lu n i s a u a n i (S n l r| r' rD :rn l l e nte, 1gtj 6; ti r\-orn(,rJ l J)(i t| 1. | ;i IiIrirrrrrrrL'Irr l)ilrll,li1]iccse pot insoti do urt simplu ,,bloc de r:onrlucci,t'., r,u r rrrrlclrrlo loilrlii, dllr cu ocaztia repetiil.ilor se pot ilrstir]a yali$ile grllrrlr. {li. rli rr.r'\.r1r J)o lnUsctlatura faCia,li,,Cu pareze reziclUirl. si cu Coltsl,(ruli\(, ,1 r:rrrr r rlr r c ilr lc . A pt r e d e p re fe ri l tl l a fe me i Si ]a. Ti rsl o tl ai 1i ner,t,tl ,r,rl ' lr ;rrrr':rl iz ir r r i llell. Ro s e l th a l (1 9 3 1 , c i ta i j d e i l l a verner, 1969) a l el atat crrzrrl i r || irr,irlonlir l'utniliale. Acest sindrom se insoteste dc cele mrri nLullo rtri si ,l ,,.,l cr r r r ' n, . r llr , , lu; r s o i l (.i c t' ,i ,.i .rl r.h rrz e l o r' ,c ar.l rof l i bi l ar..r.:I,..r.r, ,tr.tl ,tl rrrrr|r'rr Ir'1oi, rftial drc:i ptlr:ilizia fuci:r1[ este Inilaterr]ri. [-rr rl lr.rril0rr rru p l o r r r , ( iille es t e i n s ti i n c o n s ta n t, e s 1 ,e l rezertat ri ,,o i rl j cnl i i i rrl c rr re l i rrrl ri i ( lit r lt t r l) lic at u ). H a l e o ri tu m c fi e re a fe te i poa:te sr' Li tei " url i L l l rrrrrl i zr:r l rr, r:rl rrt r r llt r r i s it u l n i 1 1 ez i l e , p e rn ri ti n r.l u n d i agnosl i r. rctl ospccti r l ' l ,l \, r l i r' , 11, ( i1) ) . l.li.7. Sirrlronul lui Xloobius este o rar5, afectiutrt, {.(rlgenit{ iiii 1l(, ,l rrrl o rlic ir r r , : i r r c ple c i z a ti l , c a re a s o c i t.,z i o !a l . l l l ' zi p l tLrxl a i tni - sau l )i l :r i, l .r'rrl :r. c r r llr laiiz ii o c u l o :n o to ri i (i n d c o s e b i d e abi l ucens). :l.li.l|. Sindromul lui l{eerlord leprezintii, o cor}rllicalie treulokrgir,:r :r rrrtrrirhrzci, irr cnrsrrl cr[eia poate apirea o p:],]alizic faciali peli{r,r,icrr :r rrx i rrlr i r r r y r r r lot irl i tr' is i c u u v c i ti i ,

t t ll( 't t i lr r selr iubr t . l- r ': '; " r zi( i. i r r r t ; t t t lt t t l ,,,i ,,,,r t" " ' i ntli ';;'r:l;;,;;,r o cluzi lpar cm il, : "i diYflso cliolosii si lrrrrrliziiti rr)itr i i*r'iriit" "p)'1t'iii', ill(" ilt t'tllsttl rr\r'lrtli{ r (''Taniocorcl)l (tluT)allttrntttttils-" t, ittnilt |.s.bit'1,tttic "t" ilr " ir r L zit r t 'i r r l' ,rrrl l ol unol ttr r1 e hi per t ensm nr '- it t t r . - '"n"i'"i', ir r . lllr ilir r l r ( t r . r 't il. r t . r t r r i ''r " : b) i. ie: ii', r t ae n?r t t illt i. t 101t st i( i ' , ,.i i ' i :,;r;;" ,;i , , ; c. j l l oxi ce. r r culiloam e il( llslit 'r ', lur llor i si : r llt ' lr l'r r ( 't r \ r "( ) I ||I I f |sI \I r| ,.| | r0D l rl i i
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( i l .7.i !. S crrr ir t kr llia t r t t t r lt lt 'lt r ir lr t . r r s{ir r i) r 't r lr r ir r t l{r : . . . . . l rrrl rtc i rrrr( i i l . lt ilt ct r t r t t zilt ' ' :!./.:a.1. ' \tt) t 1) iolt , r t r ', ', "''^iii't l) t 'r t "r t ill"'l'" ,rrl i l i vc qi rl (' llii) lx) lc, ol) i{) ( 11ivc"' '' sir r r lr l( t r r r lllr rr' L i | i ' cul i " i ,, f e ( t innii'us) pt ii r qr ir 'r 'r 'lr r iil . it t ot t r t t t 'r lr ll .

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('lr' (('/?'-/ir' r) il. 1c;iir,i1t '|t.t'4.t.tti ;;1";;;;;r:o *" ill tirllr parult:ii lttitlt ltrtt ,lLrclsr ei iologii, lltcnl,ron e:interluj;11) it' inrl'rtrmlrri,t trspt'.1 ')i sf irIir( r' : /,,:; ;"it';ir;1i;;iilrir iii.r;"rtlnt torsori ai f (l'ilrltli( (t\tt't'tI niQrr'nout7;rl) in cursul unor' tt'( , i',, crizclor "i,r'rui , r.olirb.,19?3' 1li?S; (iastaut', l9?3)' ."ili r'li'rrtt'ttlrtt (irlrrclr'r'\ {zrlt' ?lir,:i""i"t ,i,,ii"l :rrxlitiie l'r"zinli.rr,rr
, t , t t n r , l t n l 'o t 'i t t l t ( tr l l n o r 'l [e m p n ;ttl t, l r l c t r u i l ci l r r r l ,:r zr r l i l ( Ar ''n n i 'r r " ,'iti , r 'i lttiili'";t'": tu n "'r i - :r ]r ' 'i ( 'l r l r '' vt'i tl r 'i r r tl r tl tti l :r ' t' l :r r /J' rrl lll l 'r t'

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si irrti(rtro ir lrrl ts Lii ,l,;i;;;;,,'i,,i,,i,,t"],:',i,,rt irr absc i a hiperltrr irtr illinri(x r tle rll'c strttrttrtlo strl('r'irl :l ;i , i;;;i;;;'1-ii :'i-: qi, ile obicrri,so acompiir i:'t'zii ';; ,l, lolr 1,r,tuporal. ' ' ")';;;;;;;;ie sirtl' reprezcntatc rltr zgornrtltrtttl't'itctrtttr..tr' i:\ ,,oltiectit'e" urehro',t srttt tl. /ir/rrir r'rrt't ,,,,.,:;L,i;'ail,"htl,rlllii'ii,rtt-''ito.i <lt i'rLllittatttt:
1|ltt t't['t\tr' oQtic. )t r tl c ttl t'r 'ttItti tIo .ItIl Itt' ') . i , 2 . 2 . 8i ttt7 :tl o n tt( t tl t: th tl i t:i l ' l 't'zi ttt.L i l tl txl i ft'r 'i cc rt i" d'c li1t lllrlcrlrlitr' t'tt sittt Iirit li'ttotttt 1,r,,tlru' tttrd.i:ltt.le Tttrrliulri xtttr'ttlotnT (1(|IIrIIII|||'

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l l rl Ir ; l{ lilir " r ' r 1r ' l [i i l . l i l rrl a rl l tl L l i . I) ) 'l'rsltlt rlc ltplttxtc a, (,rttilrj:!ii tludititc, care iiprecia,zi, colrLl)lt.r'l ii i l r,'r.rrl r r l, . r r r lr or r , r rl ,c l o l.o n rl trc l i l i i fi p c l ' c e p l i v.1 (ni :ural i i ) :i l c stnrcl u. r rl l r' :rr r r lr iv r ' : l :rr ' l\ r s lc lc { [ { r ll l l (L i ti o ri r-o r:i i c x rrn ri n l l to l u hl i . I't ' l' r . s ir , lr ' |r r ' ir rr i i rrl r:t o r,. z r') I lr ' l< x lr ' lc r lo i n r< l i o rrri rl ,r' i o n a l ri ((tr) (,ol l l )(,((.1.ti irt { rl ,o[)gj .i ti l or.], r rr1 ,. r,, . 1r r ir r r i r ( ilr ilil i (' l t l u rl i l i l i i i rL s c i ri o l o g lrri l rl rj cc rLr rl ,,r,j l rcl i . rl ) ' l\ . ! lr ' lc lr r i S r,l r$ rrl rrrr,l r, i j I (i s i \V o l )(,1.. l l J ' l' r ' r r it r l lr r j lr rrrrl rrr (rl c ,,rt' rrt' u 1 ,rrr.c i rrl r.rr:ri l i ti i sol r()r' r,rJ). rr (') llt l, t it r lt r ry tt,ti l tt u .l t ti i x l ttrtts u ti l rt t' t,.l l (:t(,| r,r.l l l rr,l rr or.l rl r" o l Ir'l , ttl rLr , r ' , r rlr l|o lrl rl p rrl rt . fO r,l rIx r l rl ri l l rr' , r.r.l l r.trrl l rrrl i l i t, 0r:trtrrgi r,t rl It ) lr t r r ' , liq, r ! iil t rrrtIi r,| ,trJ i l r r,l rl t,l i II,| !.I ir.| 1,IrrrrorIi i i .rrr.i Ior, rrr i l r,l ,l l ir'trrIrl r I r I i " ; r lI r r r . I I ' r i rl Ir. rl r r' i tl r:rl trl u ii l rl ti i \ rrrl (. r] IIIr. III| | ,\| IIIIi i I Ir.i l , rrl r, r rr' lr lr lr r r 1, . , rrrr:rl ,.l l l rr.rrri l i rr rrl trrr,

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l l 'ttl i .i r tt' * 1 r :'i tti l r l o tr ;r r i " : 1 . '\ . 1 . 1 . . lIt]t:.ti o e u si 'n tTtl tttttt[o r s h i tt:l i tt' tL ' t[i 'l l l r tsi ttr ' l ttzo ti r '' 'l 'r . r i t r t l , r t l l t t t t ,. r 'l l tr ttl l t'l 'i z:r 1 , l ) l j l l tl '( J s( l l i zi tl i ( ' ', l ) r ) l tr 1 r \tl l l l i \r 'l l l l , ! , r r . : r . . r ( , l r i r't'1 t h r t' j n t;r l r {'l i ( 1 l r sl l l ) i i \'1 u l si l l l l i i Ii l l l r | , , . ! l r l I r l l r s{ l t$ r l r 'l r l 'l tl i tt:ti , tl l tr sl ' i r \i l ( '( 'l l ) l 'i !zi r ]i l l l s{ r r r l l |l tr i :l i :r rrio(lrll , , r r r r r l i t ( l ( l l ) t) zi l i i l ( l l l ) l l l l l i j l l sp tr .l i tl . \'( 'r l i j r d l l l l i 'r l ( ', i l l l l r 'l r ( l i r l ' ( 1 " o i r ( "tr l l r ( ' ttc r l t'cr th i l r tl tIr l sl i l '\tl o st'r i tsl r ' \'r 'l l ) r i ' . , 1 , l , , r i r 'l t t z i r t o ch i l o l ;i , , 'l I r l r 'i t t c t l c zct'l tj l j Jtr tr , l ) L l i i i l l ( 1 tl l r 'l 'u ( ' l ) i l l i ' l i r ( l i l r l ( 't1 " tl :tt l 'i i ti Ii .tr l r t':t ( ( ,1 ( ,t'( ,,1 t,i .r 1 i :tl r l t. ([ i i I i I l I ( )i rt i ( I l ]l tl i i t1 ' Ittr i tti l r 'si :tL r l , ,1 'r , ! , ( . , ', r i l i l r l i i I l , 1 , 1 r , , r .s i s i i u ' o p l l r ' \r l so vN g i l l {') ( l l l p o r - i tl i r r fi l 'l l fl ( 'tt.,1 1 1 1 {l ; l 'r r ;r o t'r r :r r ri tti , . , l r r l r . , l l | ? $ ) . ( 'i 'l ttl l ti l r L o st,a vl 'l 'tj ,i r l l s( ' i ttstti t'sl i ' tl t' ttl l t' st.t 'tt * r .r l ) r r i ' l 'sl r r vttti ti t r l r '( r !i o l r .r r l r l r . , , l r r | 1 , i i i l n i l r rIi ;i l l r l l r tr r i t'i l 'r :tso i i l ( |i o l i i fi r ' t'i ( l r 'l r l Ir l r r l r ,i i t'str r tl o i L l ttl L l l r ttl i tl , t i i tt l l t' tr tl tl r "" , r L , ' , , 1 , , l i 1 , I lr ,tti i i r t', l l i tr l' ( [( f r o l l ]l i ( ' l t r tIti I'r '1 r '|o t , , r , t i r r l c s i c tttt l i 'l to l tttl tt ,r l ) si l ) i ( l ^ J: s{'l l zl i i l ' t'l tl 'tt :tt t' ( 'i l f!l l tl ( I ' ' l t l tttci 1 :l tl l l ttl i t'i r r L r i l | 1 . . f {'l ) ] r 'z cl i l r tl 0 r t tcl 0 l ti l l i t ( l r z:r \r r l l a N l ) l l l l tl u l tl i r l c cr 'h j l i l l tr t ( l l i s( 'l ' l 1 ) i ;2 ) 1 , 1 , , : i l l l l r u l t tt'l r l tl i , ( r s1 ( 'o l r l ) l i l l s i l r r r r o ( l i r 'L r ' j ' , , , , , , s ; r r l , l 1 i 1r 1 \l r l r r i i l r r ti si t tl l tsi ci i : 1 ) o l n 'i 1 'l l l l ]l {\i ( '( l i l i i l i l l l l l ( l tl l ) r l r r :r l , 1 , t r r r . t r . t i . i Yi Ol e l l tr ( i tt ( 1 .( ]tl n .i si Ii i l xl i 1 l tr i , r l r ','r sttr r l i i l r i r ' r l ' i ( 'l l l i l r r h r l l :r ':r 'r r 1i , l ( z r i o r r ( | l ( ' ll l tl 'i r 'ttl l tr c i ttl cr ts', .'i ,l .ttl b u r i i r i l r r l t tr l ti l i L ttt si tL i ttr l ti r r ]l l l l L i t( l l l l l l l l r l ( r r l , , l , l i . r ', i , l f , r n r z i1 o r ,i c. tl r ' si i l r i tti l " , , . , , , , , i {, . . 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l l )',:i ; \ t i! , x f Nc lt . I i)? 8 ). 7-, I t tlil_r'lt wltIi.t'.iJorwr., cnrat;l,efizate pri'tr_o mrre srmililu(li,rj .' :rl,, , jr' \r.r'tr!: rrr:rserlilL lrr,r,r,lu ll.jnidre, se datot,.sc ltt\or ceulc Lrnultt sar. , \ s llel, r lc i i ,l c (N l ,e rn x n j fe s l i ri v c rl i gi ttoti st tttttttl t. si rLi , rL, rnul l ,c ol r p rr| rr"is ljc r ' , r ' 10 nu a u _l tu i i i rrl i n c i ta rl ,e a c ri zel l ur di rL bui l l l r,.N [i rrri r)rrr, I)rr i Iri r'Ir.' r r ( |irlr is t lulnlls u l , L rrl l [rri rti ]c tl c c c l i i l i ]rr:u l ani ffsl i ri hr J vogol :tl ,i vI ryi ri rtl i ) r lll' r r r i r lir c ..r.' ,\s r,rr,' rri ' r,rn u ,rri l b s tr i rii nrr' i r)ri ri rrrrr. s. i rr,i rrr,s. t.tl.,'itrl,, tttrlt:,,,ti rrr.ntit,:r,itr |ttl,4,t\tl.t,tLbl,, i\ lt,ou) ,el,t) rrdirslir;r,, tttroltr itr .,,i .!,',., , ! I , . l. \ |w' 1l||ll ' | ' | ' ,\| l tl l ,1 ' ' l t' l | ' ' | 1 1 l t.rrl rttttt1i i l tttl tt' l t' dtrt4| ' dri | l | :l !l ' | ,.l ,(| | | | Il ' | .| | |l i r\\ l tr( , t . 1, , i |lt irt, , l l )ti !); l i ,i rt(fr, l { } ri :.1 l \l i l i ,fcsri rt, l l )?S ). ; I r r li. jt lt , . t lr u t.u rtti l o j ;d x (ttl tn l th i t,i ttl i h,l t, l oni tt .l l ). N l rrl pl :rl ri r.i rr. I t I r'l r, I rrr t l r, t r . r l: rlot t.,k . l rr, trtro r.trtr.rl i l trrl (\1 l ,r, 1l l (. I,rr,,' .,, r.1trl l trt)l ' r.l lt I t).t rt!

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a \-aU x... l ,lr : r r r r ir r . ir r lcv n s ti b u l l re i n te l rc ri ti c e a-\l ptl i o l i 1trl cxci tabi l !tl tc l .a l rrl ri Il|r.l,r( i 1,r|0ba0rlrlricir,, jirr prezen!a'Inui firr riistn,q.rrrrr,, ,.lir Li, | ,uleo|i chiar , rr'I, rr{ i: r l: r l l ,l i tc rl e ,,:,p l l u i . pr" num .r ,r " .:r un,.r rLj rcr.r,tr. |l ", .'| |, ir r r |ir r i. l'r r i.,.ri rilL . rrC l ri u l u i ,l e p rrl ,.r :L ;, rri l op11roil s5;,., i nsol i tr-r si rl t. ' t' " ' ri r r,tri lit : r t r . s i r r , . s i g rrr,,rn f i r ti l n p u l me rs u l ui i .ri (r,t : r t , r { l j. r ' r l l i i r a fc c l i rtrL i i , " i r.l i " l i -." ' " ' cul l ro rr, " h i p o a c l z i a si zeornote.l 0l uri r'r.',, r 2. r . { . r r r it I L rrI L o mc tri c i i :t1 ri l tg e .q i frccventei c i aC nte, i l l l prol x,l r. rr,r trr r t : r lr . ir r r lic ii o n e ti , h i p o e x c i ti ,b i l i t:rte . li ",\ i t rl.ro u u [,. ht i, C ogan,, prin'siuilitur]inea sa cochlro_r_estibulrr lii, .. .r' r'i l)r{.2(,rt,r), , .lbt'rnii.p:rrticular:ri de vertij Mdniirc, irr crlr,e r'rzrh rL.

fie I{enidrebilarcratri, fic rr ir]i. | t,il].,ljl ,,,:.:"",". ,lt,resupnno rrlo,riboa.ti, r'1 ,,l 1 r t r . . l l, . r ,l ,.l .l rrl ,.,rti rrri c i

ir I , , | l t, I{IrIIIIIrIII,I r |:|L1\ l I I i( 'i | |i | . ( 1lt it r i|llr rt i( i ir t : r ' r . t il'lr r t r t r t , it t il' r t t I r t Lt t r , 'r 'I t '' | ' ,,,r,l rrl tkr | l tt l to lt , lr r ollt t qii llt 't r zt 't t ir r i) ,I it r t lt t ot r lll( l\ lt r illlt ( 'f r llllt { ' I llr ! ' vr . siilr t t lr r t . si I t I t 'r 'r 'I t t I . I , t ' ;,r,rrl rr.Ir,zi rrrri r l. g. it . r . lr li'r . lr l. I ilt , 'r 'l. r 'r ( ir v( , ils. : r,ql i ornr.r,. l )c iiqr t vlr l, i. iit l diu ir r liixicr r iilt ll, ilit 'ii r r cLt la r '( 'r r slilllr . r '' l ' rr:ri I i l ri c c\cnp lu. ( '"ir ': r ' r S l rr:i ottti ciia llr o( hlce ( j( lo r n2t i f r {l( '\ - r 'll1( vt 't 1i. lc t lo r r t i'lit r r ' 1 illo nr oleilor ' |i : r lr : t iilr r t ' r 'r 'r : ilt t r lr t t r " \ r 'r ''r lr ' 1,ri rr l ,' zi tttti l e l a bir lint ico, sjnt dooscbjl; r lt ' ir ll, t lnst ' [ l t I r llt it r ll i t r1rrr i I rI il i ' r rri l i ,sl i l i l ttrt ig; inolse Il i Zi i 0).i rtsotj tr : r |cnlil] 'jt lll}) 111'ijr i( |( '}}}lJ's'( l|, 'lljsillI lllll|] |}l'I Zi''I ljlI ( t lc ol) i( 'ci bi. iat r elal) ,glcr r '{: l si vr ) r r ir ir t t ( 't r i( "l: t . r t t . sr ' ' ,r ,,r' i ,r,,ti l l t,' gir : i1( ) l' si i ! r: , r 1i1: , . 1i t jnit i1 lr r {'chi. il'ulbu. iI 'il. r 1r t , r 'lt ili}r . r rir i t ll t r r . t r i t,,,:rl c:rsr){,i i I () 1rs(,l l ri soiizr it iai f lo r - cr 1, ij lxr l, pt Ts, ist : r nlli r iiult ; ii Vr l'l! r r " I ) r r {r 'lr lil t,,l l rl (1,i l i i ,i 1i i l e zjr r ir ilor si u . 't r ilxr r r i, 't . ir il- . t 't i1t ilir , . , s*. t xilr 'ilr t lii r t lt t . t i , r I' r,r:r i l c si sl ,erl lLl t 'c l, r iLsllt lst r iilol'la pr obt lc \ '( sl, jhlllillt ' lr t 'lt 't r ''t r r l ''' izlt ( ,,l ,rrUfi r, l ti po- - <lt i it Lcr r t ii: r ir ilii: t t t l. t 1n'ollr , iirlel( ] r i{r i t olir l{'r i( ', lJI rr 'r r r r l - si {llt ulif ouisli, llln( llir alil'r l( lllir r ll'zit llr i : r iil ( r 'lr 1r 'r r lt " ,, rrl rl l rl ;i zl l ri 'il llr iue( t ( ) f r it l , rl si i rcri j i Itt,i ,) . I iq, t u. nt it in, o. . . int : r t t it iit o ir I ( , 01n, i12i{ 1r r t r lilr . r , {ir , . r r 1r r r I r lr r l tl ,,, i rl ,1rrr'ri orl tt t , it Lr llr c lr t it . t rplilr l iii1- 'oillLt zii, t lo. pt 'r ir r '1. rt1iccr r r lt 'lLr ' lr t ' i, r r i' lczsaziLr i l, ljr it r t r t l 1{') $1 I ) ( , r 'r r {'sir ', , 1 lr . , ,,,,i i i rrtr' ,i l l i l r,sr , s( r r , i1r ! "ii) , r' r.,' ,, { i i i l tl tl t : Llr r u't . lt onlt rr l r olt r lr ', l1}( il) ) ' '( ; l l t i .tti ,,)ut.'- a: r ar ljlr lr i iiir 'lr ilt t il( lilr il ( 111 t r t plt lt t t it : it t lL' 1I ir I t I t t cit I I I r t t r,r' .i crrrri i l t' ir i l. q: nilr liI t 'lr ' lit r r Lvell'l.liliLnillosliir , j1: 1'1'l'ilj11111r t : r 'lr t t r lr t lr " , ri i, r oi i l i ' tl r gfl 't , r lli, 1'l- ir ) r iii, 1irhilr olt , nzir '; i zilr t noir l It I I t i t I t t I It I I ' , 1lI I t t r r i: l ' I ,,,r.,,,,,:i zt' ,,i r,', r iicvli. zil. . i. i. l: llr ilr 'r . : l slilr iiilr r ili. lt r sr , llir nlt ,it t i t t1rI I it 'rI rrIr ( lo( lill( '1lI r r ; ilt f it 'r 'r - l'r 'silt t lt " i ,rl ri (rr (i l r r:l ;it Lilt i. llziililil{l l t)" ol ost,{t'o't . Li}i, lt l( ' : ili\ l1l si lr r }iit it r t t t l r |sf ilr r r llt t ' III rtrI t r' ' i t r' I r 1 r t 'r (: , r' li qi ttrl a.srr r ini r l( ) ( lt 'ill11'.r 1, r ; I 't r ir jr I i] r 'r t ill t r ' n'r zit ir r rrl r' 1r l ' l rl l l i ' l tl ili, tt,,i i i i n rl r:r:csrt,h^ 1, ip t r x'nii. |l 'i'ir l, : r r s'r ( ilr -; j 'Lr ''r ''r lll'r ' si I t iI t o|t r I t 'r r ' it r r 't t t le lt ili . gt nt t 'Lt 'lt : t t r lir linr : o. : t e N f.t" i l r:ni. f r : *li', t it t ( r) Il i [tarl t : r t : 'it , t t a( t jit lit : ! d ] llu( hr ( 1o lil ut t ii lt olt t r ll i r r t t r t liiit , r t r r l' I I ,1,,ti i ,i Jl rbi r;liillr r i r I , Slilnr lr r r ', in: r t r jloglai. l- . r ill 1r r '1, i, j( ', rt I I 1 I i l i r' :r i r' l: r ( \ 'r r t lir l .i :r ;i cr-l cit silt clllr t t lt li iii ii; sol, ir , r 'qi t kr r ir r sillt llr t t r li, llt ln( '! 'i , '' Sr lr o' ir r : r r r '''( ': r { Lt lt ilr t r t 'r 'r liir r lr ilil'r r lr ' ,' rrl l i l i r cotl si clt 't 'ii , 1elsr ''or lr 'i' ' , \ ll , ri i l rrrl l i | i , t,tr lt ilr olr r r zj0 r l, 'r r ' r ', r . Jr lr "l, illr 1"l: lji f i ( 'll . "- l( llr l{il{r l l l ,rl l l l i l rl
r ! L ( . r 'o n r !t l l l I ) l l l sl l l , ( l ( '( 'L l r l i i l l t'r 'r tr r ( i i l :tl r r t'i I t ) . II : r '1 t , ti ttt r u r a tti ( r i a l '( i ( L c l l sl l ) t1 '1 l o 1 l l ) ( r r r i c i $ 0 sj l 'u cl tzi i '- sl t t l t l l l t t L t'L \'i '1 "( 'l i l l l \:( r , , , 1 i l r r , , i r r '1 1 1 ' 1 1 1 '1 1 i1 r ':r 1 ) ( ,l r i r u l r l l tr r Si to ' r :3 r r l ttti ' vi l si l 'tl l i ) , 1 , , , 1 , , r r r r , ,l l r r r t sp i t'l L i r i i , l i .r r ttL i r l 'r l i l t ' i i ItIi ti i I'IIr I q i 1 tItt'It1 i Ir ti r Ii .tr r ') l r ' 1 r "l t , \ " 4 , / a , : t itti i t( r ttd u :r i Jtt'( h r r l tr .s.l l i tl tt tt t r rt ri l i r i rl i i t i r ,'t'ti i g i tt'l tsr ' , , , , . , 1 i ', i r , 'l r i l r . r r,x.i i l l ti l i l l r i 'r "l l tJr i r i r l l r i .i l ' [. \i tr \Jti l xr t si l tl l l tl l i ' r l t'i zt' v<'t l i r l ttr r r :r '.l ' i 1 1 '1 1 l ,tt.l ,a ttl ttttt i \ I t r t l , l i o l tt , , , , . , r 1 , i , i t , n r | t,s, cv0 l r ti r r r I i tr l r l U 'e l tr l 0 tt va Jr tl i l t. l ti p t:r :Il i r r |r r r i r .r '. l l r :l r 'r ']l r \ , , r z r r t i . c l r r i , t 'r ttti sl i l g l tt{}l tt'i l l l l l l ,- |o l tl 'r r tl vi tl cr tl i l t o l ti l tr n tl 'l l l 'l i r i l r ti o l r l l r r , , r r l i c i i I t i I rr I t ' t I t I i i , tl tr tr l ti r ,t'i si t r tl l t i r r i i' :tt l tttl t ) l t r t t T u txttto j i l i r 1 i i tt si i tr r l t'r 'a r l l 8 l ItN ttto .l i l .i tt. .1 t( l tto |ttt( l i i - l i ttIr :ttII', i tr s,Ii i r r tl tr i t'sl l r l r i l i l r r i r r l l r r ) tl '.i i l :r t,,,,i i i l i '* 1 i i l i ittl.srirt ', , i r l t r i ( r ( 'l i I1 1 !', l ) l l r ( 'r i l ( 'zl l l r l 'r 't t l i r r r i i t t t l t l i , l r r l l r r l l i i l i r L ' r 'r 'I t i I i I I l t t , l r i l r ti l i l to i i r l l i t'r ', ( l 'r r l N r vi tr i r t 1 i r r o l l l l l , l l l ? ti I ( r r t l xtp l r l :r l r ' r r ( , l r t l r t {. , l t t l n 'l l l tf f! r i l tl l fi tl l ( r l \ l r l , 'r , g ( 1 ', t 1) i sl ) - l i l i l .r .i ,ti ( ,' ( l l l i l - i ) r ,<,l r r l r ';r z:rr.'r r , r 1 r ..r 'i l r ,r l r .l r , .:r l .ti .r r ', , u i , t , ', r , 1 1 ,, r 'r r 'r 'to si r r r i l :r Ir 'i IIr tIr IIi Ii , l r i p ctl ,,r r .r l r r l r i l i l r r i r .tr .sl ,i l r r tl :r l r i , 1,,,i r |i 'r 'I:tL i r Ir tl i ( i r l l r f'l ) ( l l , tl i l t tr i tzttti ' r 'l l .r r 1 . , r , ; ', : r 'i i r i i t , i , ,,t ,,'l t,'r ',' r cr l r l r tr l o r l l l i l r l r l l i l l tl r ' 1 , . , , r , r I L , J I r r , , 'IIr ,'r r r r :r , o r r l r , :r r .i r l r r l l r r r ,.r . l r i Pcl l o l l l r l l Jr

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I)'l'ulhuritril.unaurot)ollnl l) il\t,lburrfu ih po0 irrrlrlir:t ln ooutontt{ l,lM olinntolar,ioc rrlitrif 1i rrultrilosl,r'1,r.i vtrr'ligirrorr,xr,r, lrrsrr(il,rr rrrullo ori rLt zgornol,rl t.[o r[rrzgurrurl,o rr,rrriou. rrrrti1111. Lrr.c 5i rkl i,ul[rulrit'i do ocltililrrrr, (11,llnnitro iL ltrror Iti pot'c.soitrtbilitil fl
lirlri li t t lictr (ovitlcn!itt bile l:l prrrlrir,ur lolioii,).

(rl'(i.), tti, t[o ll'(r1 lrtrirurrur'l(ltlitt 1u'oot'lio vtlcittilhrlo: t,ttttt lrtrrgitl citrltlritrtr tlo rol,rol:tltit'ittlitrt'. tirr(\il, Jl('t'vlrlui vcx(,ibt.tlar liorrll,ri tlotittrtrit'ca, ,,sitttlttllrt ryi I 'ur liaul ar il,d!,i stmiologice: ( Vtti jul aestibulatr denumit Si.rel'rolaltirinti.c oste tnai lttl{itt ittlltts, J rrrri puliri zgomotos fi rnai putin calactclistio drxrit crrl laltirittfic. I'ort1r' ifolmr oll (!\lc('t'Jrilrilrl rrrsii, aib5 un caracter pa,roxistic,de 1;iprndni<)l si, r,rilcririlccapului. I)urata accstui vcltij vestibultlr (qi a sitrpl,otttclotrrsrr ,rirrlc) cste variabilX, in functiet de natula fa'cl,orulrtiet'ittlttglic, crtt tlrr antrcneazi, o hipoexcitabilil,ato sau chittr o irtcxciiabililltlrr vcsli 'rlricci il ',r.lrrt tle parlor lqzali. J! osibili.t d,!i 7tal,ol ogiee : (luessecundar$i ttrl,iar, IrrtloI,irIiLii infaJioctse A ) N etritelaaestibularc , lridcmicii,, herpes zostcr, febr5. tifoidri, tifos cx:urtomal,ic, In(rtilrgili lolt#rospinali microbian[, meuingiljc virotice, mcniugitc tultt'tcttiortsr', ; ripii, difterie, malarie, rujeoli, brucelozli etc.), I)etalicm rloltr cil'r,r'rr (satt neurolabirinl,itu l'uetiad' I'tl, nni Neurita ustibulard si.filiticd' ), ,rli ^) ultimii ani, cste produs:i prin mecanismcdc rrre jugo-virsoull l'ilfi in rrr stadiile secundare$i tor'liruc ale bolii Si oste car:lctorizattipritr vt,r'l,iil ,1,,lrlare Yiolen{5,,crr eri&ccrblri la miEci'r'ileoapului, olr hipo:l( uzic f i ',ll q,rrriluri urechi. Pe lingil lista-gmus qi rlcvialia bralclor, se ovi(l(,lrir z.ri in l ,' ltipoe:citabilit al c vcslib lari. u,rliditd' sc pro{luce llr ll)roxil}nli\ I:) Meningoneurifut oestibulard, l, -10 zile cle la a,par:itiapa.rot,itliteicpidcmictt, asociinrltt'sr'rn,\rli ri (l tcziune concomitenl,i, a facialului, e\'cntual si :r' itltor' lrcr.vi cll|rri{rtli. doclinn$al,e vestibuJaa'e, uncori bruta.le,sin1, lrirt lczirtttirrrrvli ' trr,nifestirils precum Di plin r:dtlm consccut,ivtlot'cgliirilol cirrrrrlrrlolii l, co, rneningeale, lrrriferice intraiabilintice. Se realizcazzi astifel utl sintlronr tlirl coclrlco prin acufeno, hipoa'cuzic gi rna ifost,ili \,('sli' r'sl,ibular,care debuteazil lrrrlnre, Ilipoacuzia poate li uni- sau bilateralii, de tip percelllie,cu ovolu{,i,. lrrlrirlii,, orlrrli uneori pini la sulditate (uneori definitivl, all;oorit'oversibili, (.r vindecarea infecliei urliene). Scmnele vesl,ibulare se tr:ltluc pritt ulizc r rutiginoase (uneori foarte violente), nistag lxs, tulburri,ri rlo cchilibru 6i hipoexcitabiliiate vestibulard. c) N earita cockleo-aestibul0ii zonatoasd, (hcrpes zostcr) csto [oir,r1,(' r':r,rii ln forma acutii, veltijuJ apa,re brusc, ltr crize, oda,1,[cu il,1)l,t'it,ir, rrr[ptiei, in contextul scmiologic al unui Findrom vestibular aru)()]rioH, rrrr duratii de 3*8 zile. Se poate asocia o hipoacuzie do pcrccpl,io, rldrli{cir, ,,r'olutiv5,rpinii la suralitate totali, $i definitivS. Unoori, instr, sinrlronrrrl moderate,pc prinl plan sil,utudrr-sc vrlstibular estefoalttl discret, cu ame.feli rllt]o simptomc ale herpcsului zost'er cefalic' dJ Sdndromul l,ui, V ogt-I{oy unagi, vorosimil dc originr: virol,icri, tsrrr,ilr,z6, ncvritl'i, oochlco-vostibularli, (cu sualitate qi crizc verl,igiJlol,so), I uvoit[ l)ilatoreltr, vitiligo' rrloleoio 5i polioztr. l,u,t Il arada, fourtc ril,r, tot tle la,tuni virol;icl, ol[.rr a\ Sind,romuL t,Bomlun[totcu I)t'$ft{loltl,ul,rntxliittd ilt plus qi dt)t{lillirr:(lo r(11,i}rI. .lr'ritlll (l(! l'rt't:vtrttl.o rrnck' f[ri, sn irr I\ Ilteninllo-net.nt-hrtrcnlrnalt, llltr, ttxttcirtl lczhrrri tr.rrrltr0 ou TLin Slnthom ooohloo-vrtt'l,il)l ct'l ttttt'itttlt'uoll, rlrlltinlo do rrorvi ofttolortl El ou Sotnllotlc polirmlicttlotrcvlil[ 1,tloroa, orr sinrlrrirrr liolridiuu do lln Oullll,ln'ltu'r'r{.

vcrl,i.iul onlcl)t,i:rl, vertijul ino vertiiul inotitor.ilor.Ultimele slni, in roalituio. ol,c,), vcrl,i.iul rrl,c,), onlcl)1,i:rl, rlitrrlo, l',rlru.r,rrrl,i.ic. lil. ,,1,'ttlsol,o wrtija't sint amefeli in infelesul cei mai trannl gl

rlrllrrrrinnl; unornaliilc retraclie(astigmatism, rlo rle hipcrmetropie, miopio mioflo

cronica (trtritr rkrzrxrhililrrele hidro-clcctrolitico ou rc.pc[. s). N e,fritele_. cnsiulti cFl Dra lichidelor orralolilnfl,iooqi prin hemoragiilolabirirrtice)lxlt rri rlrrl,trllrine crize vertiginoase, urroori de tip rndnidriforrn. lt) llt,iirile. alergice.prodttc, adesea $i leziuni ale urechii intcrno, cU rtislrtrol,ii labirirrtice qi m:r,nifesti,rivertiginoase (Williams, 1056, oilnt rL' 1!likr;oscu, 1978). ll) It'orme particulara d,eaertij labirintic. Este bine cunoscut faptul ol ir rrlirltl, do procescle patologice amintite anterior, mai existl o selie tlo rrorrrlifii specia,le,caro favodzeaz5, aparilia ulor crize vertiginoase I t\') l'ertijul _f,&roMsticd,in ,,rdul d,ema,re1' traduce printr-o simpto. se rrrrl okrgio complex5,,dominatii, tle vertij cu alur5,paroxisticd qi tle feno one rlrrrrovcgctative (grea!i,, . vd,rsd,turi,- paloare, lipotimii, midriazii eto.). " Yr,r.1;i.jrr1 eorrstii, in senzalii de instabilitate, sau d.e riisturnare (rotatiol lorrsr'r'tt.ivc tangajului produs pe marea rgilaLi.. Aparjtia crizelor'rlo lrrll,i,j rlirr ri,ul de mare a fost cxplicatii prin fenomene hidrodirramicodo rlr'lrlrrsrutrlrruta,Li a lichidului eldolimfiltic, aare tuctiolteazi,asupra ftl)fl. nrt,rrlrri otolitic. Yertijul din riul t1c mare se insole;te qi de hipotonsiur0 rr.r'lrrlirr,li, grelruli, vtirsiituri, hipersalivahie,._diaree transpirafii rcci gi 6l rir, oJricoi oodeazil, dupii, inceiarea excita!iilox de cilLtorie. b) ll utij,al. d,!,n,,rd,u] de at:ionl'apare ca ;i riiul rle mare, la acoloir,rll lrrl,r,grliirlo indivizi $ensibili,traducindu-seprin vertij pr,roxistic sill.glrlr, (,tl sir,tr lriooill,i; itlte semnevestibulare.In cazul zborului cu ayionul mai DotJ rrll'rrt,rrurrrroli scnza&ii bru$te de vertij, insolite de durere :r,uriculu,t rl, irrl,r,rr|ri rlLrsrr|tlitato uni- sau bilateralS,, prin rl,ero-otit5, indivizii cu la ryi (l?iquet qi Piquet, 1965, citati de Stoica, 19?B). rrrirrl lllrirr IInilit1,('ral I'J.. ,4tkt..lo'tna d.e.. Dertij ,.labirintic:. vertijul de ascensor, vert,ijrrl .

rrpiloltsio I o) llrlsolo vcrtijo ds origine psihici, (indeosebi din std,rile fobice): r[)..1)r.r,l,solo vertij_e do carzd, oculnrl din tllburii,rile do rofraofie, in unolo grulrrJizii rnuqchilor'oculari, la, indivizii cale poartl lontilo ncC0l0l. u,lo prrrrzrl l,orlruviciului ds rcfrlc{,ie q,a.); vortijo dupii hiperventilalie ; c) I'u,lstrkr f) tu,lsrrlevorti;ic prin tulburriri de statici, (a,st,ilzo-a,bnz - ln tftboa, ice ttr l,ulbtrrll,rilctlo <:oordonaro de natur5, cersboloa,sii):

l u yi ttl ,t t lt t i : rr,) fir,lttr:lo (boala Arla,ln-Stokotr, _voltije de. origine c:i,rdio-vasculari, I rn tl i u tt ' t liilo sinuzale, aritmiile, tahicardiile, stenozcloaortict, eic.): b) l'llst*r vr*tije din unele sti,ri prodrornalcale anumitor crizo d0

g) faholo vortijo (lin st5,rilo hipoglicemico{i din hipomeflocbivitatol (l'opovioiutii colab,,1.978; Popoviciugi Pasou, sinocrrrotidifl,nli, 1081). rt ila 2.8,i,2, Munfeak\riIt oarl,'i 11iru'a'x orillina wstibulatlt (d,in tind,roq, molo rotrolahrinlin| ) B\nl:'pro(luse (lc sufsrin|iaugfvIlrrl yostibul&r,rl0 (thoot[, (prlntr-un prooottdo norritifi stlu do notuolr&tlo), .lioilrlI root{, [06

107

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,sice,r,er,er,j'. :ll:,,;,',:i'l","t"""lli,rti;_r,i1i,".9*tbul;Lr ,r"',1'i"i,itin ,iiiri;,l,\

rxr ;.li.r'r l' rir;ii';illi'lrt*i,ll,,i*-r:,iirllriri''iiri tilf,"li''j.

r ( : t lil

z,:rri,, i*p"t d"*,1.i.11;::li:"[Jill:,;illi:l;,;l,n:l. rrr, r,,rj^:, iit;l

din unhrtoiditrtr unohi n.,,,t,(tt,i),t,,\ ttr ,t,tl , ,,,,1,,i,,,"1i,1",,0''r':t',:,'ii,:i:

*t'i.ifr.lllJ pie'os,,.oar iz,, , l;i, llllllruj'*i ;,f;#4;:.,*ri"''# ,,,r,,i,, ii,,,i,jii'";,;,:;;i;.'r;;';i',lfr'H;,ii:,";li.iti::.1ll,1.iJj"::-'iogic:1,,r

,,ebtibt,t.,,,,, '!',,f ,ii.y:.'yy1';,i i;iii,lil',11,,'ff:;:{f;iii',,ii*i,i u;i !lil,l,!:,0{;,,,"u', (I tlDt()r'i, llrt)(,(,s.,rL |glr ngj, ai; 1. ,
.j r

fii-{ r ;;;rr r,;rl',l,lll', #"r#hfif:f r Jil#3;[*i i:.#'tl#!'{i11ifu """"i;'i'li;i;;l;i:l';llfj:,ili*",precizateci,rai.lliiii,f larse'ri;: illi,ii: #":ft ;,,'lil',lii llt;;,;;*;lll;;;,irij#t#l,i#il""ii'l_;il","#1,ffi
,r.:rr r,,,,r,.,,,",,,,,Jtf r.,..). l'lii]j.,ii' {;j}ffi,.'i[1;i$?,#1ilili
lr\r ti,rl{)1 , I orlil > r r lai. i.

iii, ;;; ;irtii;,d;1;*:*i*|j{{,|"",iti:i,Li;ttr1 ., i,,, iii:,l i "'i,gi, ili*

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,) 11, ji(rlifolicc.

lllfiif,ril,li , ,,, ,"i,i,'l,i"ii,'i",fii,ii,:i:,iili:{L:,,!",,i{,'!,,,ii,j,i,i)1,1;1ui,,, ,,, i;;;;"-;;i iuror ,i zir,, :

l:,;,;,1'l:,',,',li,l', 3i,.1yt,.1111i,r,, ll;,,:i'i;1,,?:';,f -,Li','*..

ill rlrt ltttlu rlr, oti,:ittrrotrrtilltliistrrtzrt'l tIt' Ii'tt ttII t It IIi, prrlr1t'lii'liltsllt;;r'rr' Ioillto violclrt,. ilr". rr.isl,ii,rrr tttt rristtlgtnus lrr r'r'i rlislilrglrrrrsrtl io ,,, Drrcii itL sintlromui-vestibular lierift-T itrt'ihrirrL .ctrirltlii' ttisLrg r,rrrrla,i sau lotator, in sindromrd vestibulirl de ollgilitl -si/ ,rrs.] isi,c atlesea,,schimbltor de sens" (a'dici,bate in m:ri r'ulttr tlit'rrrl'ii) ri. i:, Irlus, aparc nlstagmusul Yertical, care nu so intilncfjlo IrirIiotiIt'iiiitr r llr iiele perifericc. i, irr sindrom'l vesl,ibularcentral, directia cilderii corptllLti[it' lrr.lrir ii{,}rrl)its rlr cste influentlti de schimbirile de pozi!,ie trlo (r:l'luLli r ?"n aceste sirrrlroiuile centra'lo se pot remarca nodilicr-lti It i IIt'I t' I'i rI i I lt')' t:r, ;,i',1iek.instrumentale ltic hipoexcitabiliiate, fio hipere\oitllbilil'rt so in ii'r trcmplt in scleroz:r' pl5'ti, in ca;reaproape con'strt'tti itti'ilrrrrlll '' ,, lripr:rc-r:citabilitate toa'te probele. lt cu doar nturile crize aerliginoase grea!'irsi vr'1'l'rii'l'ttti' 1ti Ne dentteazii, ('irr('liot li Incori intitnito qi in unete vertije centralet.ca de pild'-l'irr ritr <llolr-r:ielevasoulare bu.lbo-pnntine (Wa1lenberg, Geli, R:rynond 1k'r'jlrrrl (lt! r (:t,-.tan-Chenais in scleroza in plxci (uneori)r in lrnolc cllfi)ftllil(r ), tttlt'trr, tIrirLr,iiicerebral, in sii'ingnbulbiesi in nneLettrmori de fosit'posttrt 'serniologicapare q:io hiport'cuzitr (p|irr r,lrri ill{,s aturci'cind" in contextul lt[ situaJ,iicarc poi pf{:}te' (jr]1rl:lrzii lr.zirili ,isocialeak-.tncleilor cochleari), , ri . rdroamele vcstib'da,re periferice. i, in sindroanele veslibular:ecentrale reactiile nistilgnrki{),,itt rl'rttr' 1969; liiser, 1952)' -{stlel, itt trrtztrl qi l,rri',i:'sintraie (Oarvthornc co1ab., r,1,",'lirriituturor nucleilor r;l)stibulari, nistagmrlsnl baie in trtrti ttrttilr' mrclci lrtrrrrcrr' ,lirll:rii. c1a,r krziulea ueciom:inanti a rluia djntre :rccqNi hi pretlomine intr-o anuniti, t'li}eo!,ie' silrrrr{'irrrtr st' , ',',''il-ititirgi"iisul singrr nutdtlll vestibultlr, pui,cm intiltti llli llislirsrrrrrrl ln r'r,i,ste :r{e"ctat ttrt ,,,r Ir)rnlil p'.r;'". Astfef lezitnea lucleLrlui lui ]leit'ers 1tt'ottircu ttirl'rtt1 dteu]lill:i 11ll IllslirlllrrrrI rru.r o|izontelr ia.l o lcziune bulbo-ponl,inl \ (.ii ir:11 st.x predominant, reriical, Cintl lezirurilc irilotesc'ilzi cotttisttlrt' prt;;I t' Lr"t' I i(,i r ir-,se p-ot itttilt-ti dii.erso tipuri de nistagmus, t1:rt prcilttrtrir lol't|1r rr I rirlrnltul vortical. ;) E:{isten{,a,leziunilor t*,ltibol^t" oerltralc osl,t' lti'st:Llri fi Irlirr risiagmusului p,:ldulai, c:l.lc nn sil itLtiltrttlie tricirlrlltlli iit lczirr 1'',,tilr,1;1
)lt'0t'me eti{)'pa,logex.icetle manifcsNd"ri t:etliltittotse ae]tLrttl0: l'tt'Liir.tl' cr:rtltt.rl rerl'igittoasa tle ori,gittt: lxn n'ttlit:ti' /) I'arotisnt:h dc tlt-rsigutatriit, in trit:;tiirti'ttrll' tri .,r.r'lilr iu ttrtr;i.rl;ic constl -ssrl"ratir.t , r t r l 'l l u l r r i . {) r l tr i tr a l i ,i tr r l r l i l ,l {,t i r vo l ti j r tl L ti n r ti r l i i 't'i l i r tr t L l l r ttttttr tl i r r ( ) 1 ;i 'r 'r ( 1 l l ' l l ) 'r ':l l , , , r : i '. r i n l i l s r l scr tzl l r i i l r .l tl i r r :t l l r l i i ' .'r iti c i o tr ti i ( ''\tr r u .r i ;i tn i l tr i l l r ';t'i ti \'r ]l i 'i i l i r r o i r 'r r ' l l i r l l i {- l o t : i t : u .t [ ') to ,ti u r tt!r tr ..i ttn l i tt sr : p o l i l r l i l l ti r 'r , ) l L r ( 1 l t {x ) l i fr i l l r , vttl i ,i tr ) , tl l tti r r l .i t$ tl L l t i i r tr - o l l r ttz:tl i . l l tr i tt'si q tttr tl r l l r i l i fl 'r ) .l l i i i r r l ) r r r ''l i .i r l l r r r r r L c t s , l t s . r i i ti i i r tt .r 'l l i l r '', 1 t'IIII;ti :i i ''i 'i i l ttl tl r r , i ttl i l tti ttr l t r l l 'i l l tr i r l i r q r tl tl s {l t' !'r ) fi l i r " r , , , t i r ', t : r 't 'o ti ', , l r t'r l r r /r tti i Vl r 'l i .i tl l d t r tti r l i n t t]l t"tti i r ;l d tt, : ! ) l / r : r l i i t tl |) ||tt) ti ||i i || r , r r i r l i . t r i , ltr i i ti l i r t tr r .r 'i l l ,'l r l i i r 't1 ' r 'l l ( ) I) l i l i !r Ij r '( 'r r r l l l ,i i i tr r l i l 'r 'tst'l r r I' r i ( . i l ri i rt I i (, i i ' I , I ri l .i |r ti i ,l r ,ti t' l r "t l l 'l r t o l r l tl r i l :ttr r i ti I0 t ttti Ir 'tr IIt. , , r , ', i , , , t t r r , l l l r i r L i ,r 'i l r ,l ttt l r l l l tl i .l L l r r i :l i r r r r l r r l i {i i l l ttt r :ttc l tl r r ttr ', l r : r i i j r r l r r u r t l l l tttl l l l l l l r tl i I I ) | |( I( )| | | | I't ' I I I' r l ( r 'i l {l '/:l l l l l ( l \l l l r r i l r l t ; l r 'r t i i r r z i l r l i ttr r r t tr l l l l :r l ) L ti i l i l l l r l r l tl l r ';r l 1 i l l tl r r r l l l r r ) l r 'l i r l l l l l l l f l i ,l r tr tr l l tti i ,r l l l l ,l l r l l , 1 , , : r i , r , . , , l t r , r l ,l | t r i r 'r r r 0 l :r r '1 ,'r 'i :r l |r 'l , . r r , i r l rr rr, r, rI rI I r I , I r L tr l !r '1 ,.r \ r 'tl l ,{'1 . r 'r r l r .1 'r r r r l tl , ' '

, , ,1ll,l:.iil,l,lii,::,;i'j;i:,:li;iJlli,i;i,;;i,,i,lli,'i,;ii,l,iiiillil,li,,i,,T;;t,j,i:;1,,,1
,iroii,i, i j ,,1: ,,..{,\.. ,,,iiil..'l;-iiil;l;i,:':lJi,,i:,il;il;lillll:;,;l;j;llll;
: l l frl l tt r ' r r r r llr lr r l rrrrrri s i 4 rl trrr,i t,t.,tl i b ttl (t,t.i r.,,r,,,,r,i ;,i .'

1i;i;;i;'.;i;;ii; o(,,1,,,,rr,o,,r,\ ill l;11';ll;;,'r,:'",,1;lt;ilil,ilifl,r,iv,,srir,rri,rr1.

lrrl l rrl r\lr ( ir l 1r . ir r I r r ' ,rIrr.Ir' i rrrrI' rIrrrr.rrI:rIrr li .f,,,:,.,i i j ' r,rri rtri i rr l0 l t

,lt;;;t:r ii;;,:il,,iii,,llil,l,l,llil:li:,i,lilil,,lil,:t;i:,'lll;,:;i;,,tl,l,il;i,,tijlii'l;"1i;iil,il ,,,,,r11),,1i,,'ljli;;,'l;l;1';;ll,,lllllt',1'l',;j,ll;iiiljlili;,ilt;,,ii;ll,",Jt,lll;;1,;';ill,,i;;,liij

i rr l i rrrl .,rrr' l t{)11
,,1&,1

lr.lr'..l'r,ziLur.. (l''1r' vi.irr r,,i ..lrrtr., llt;lt, ll)??, Jl)l{0; }1r1xrvi.irr l,ir,s.rr, ri '8tl :i) )t sir'inltltbulbia )llil,l|il!,81,!iIij(ror,l,ig,irorso plitrsoirrzi! rn.! \ sc trrll " irri,r' sirrrpl,'rncloinitialc, pulirr<l ,,pii,rtlt, 1rr Jic'in crize foail,o vi'l*nlr, iri. rr r,i,lL(,ulr llur ufoalc, aproapc ioldcartrra accentuate la schirlbiirilrr dt t,dr rr' :[I, (.1]pllrur asoclat(.cu julbuliri de ec]ilibrr. $r I ) I )t lt ttconertarfte tulbu{rile vestibu,lare apar in pesi;e 90}i, rlirr ,rrzrrri, rrrilnilrlstindu-se sub forrua unor crize vertiginoasg cu ahuri'rnttrrillilirlrrril, i!.speciai in cursul.py.seulilorevojhtive -ale sclerozeiruultiplc, ,.1:"r',rrrrr.l,ri ca sjmplo.nle.inilialo. ,.Liar Crizejcviolenic. br.u1rt,., sj;,i rrLrr,. \ | ,rr,,tl l IISII | r DUitlora[,de ojJjcei olizottal;i schimbilrr1'rlo.oUs, '.Stc. rIi|| |rIrr.r)||si 1(,.t1(.,1 |otalor. inso{i1dc l ulburiri dc ocbiljbrrr.Ur:cot,j, stu rlrrl.r,itr'irruci par.eze ooulomotor citern, putern constata un cie rljrior.iit,lt rtoltriculat, 'istagrirni ,..ltgc. oetu|lelc sp_itao-eerebeloase pierra_Xlarte, L]t, boale lxti, ,,t u\t! t, rh .:t ,f.) ,l I di.', rstlcJut'nede altoJii cerebeloctsr apjrca accc,.^ puD Teiti_ ,1.n . t |.clorl-tntc.clt duraLc dc la {.itora minutc ''r):r,\{' Iini la citcr i.i,zilt., ir,rioqlriLlo ttaxie ccrebeloasii, cu nistagmus, cao", -,1" obicei, olt D-i eiito ,,trl:-1, l,ib.{r.r',ri lcnt, pctbisijnd si inrie g,izelc icrtisiuoo-i. p,otoril ii , i|l',r'r{ .,.1 { Ioirtu] li sitrl rornl{l,le,.dar mu_lic ilrala J hilrer|xcifabili_ "t,, de ot.i lrLl(1, l)ll,ild fi:u.nizaohiar unple indicat. cle diagnostic prec6aela adtli,ii -igil;i. lrr('r i r ir'('sirn],tiomai,ici familia rerfiectivi (Fh cox'si din L"i*tl ti ) .4l cr:tiurtite aentriculului at ly_tca qglio'arne'qi .[i"t*i . *ri.l.*ii r.r rlc vcrl,r'icul IV, glioame de trunchi cerebral,,alte tumorl buibo-pontiitcj iilr rrrri((i'iiri tr,pt'oape ) totdea.unade tulburi,ri cleechilibru, nirtagmu s d'izont,o: : rt;r,lot \ semneCn!.pbcloase, divcrsei*Lnnc de tlirr_rrLi ',rli(,irl, ,<i,.(r(.||] \'i.tsiiLuli, ,' rr.,)rrlr, f'ol,rlar, ]si n]alifegtet,i vertiginoaSe il] c,lize, tle obicei rL (,|ii,r|,lI|L{) acccnl,uatede sclimbiriJe de p6zilie ale si r'\ i(l('rtiii,hir,u- st:,' i'excitabiritatevestibulird t'" p""t capului. Se I;rritt rrl u rrcoli JriJxtacrtzie. "r.'i".i"""i"ilt,ir", I'rrr.rrritrlr ax1;ansive vel.Tiene qi rle ventric'l al lv-lea p'ezi'tii cel rruri lqflr;r,1, contcxtul clinic irr 6i iindrom,ut lui Bruns, arr" ,tin i. y,l1 ""osti dc crifatcc vir.Jtult, qi '1.' l::l::l.i;.1 1]l

do ,L'('li!l('{,, ir,i\ir(,11i(:, sltl}lilluil:i,rii, tlo cokr rnlli rtttl{;tlttf i, sotrttttr lltt'cllttrr Bljxlc ru rlclvilor octtlomotori, ott rliplolritr. tti c) B'inrlromut Ttseutlontti i,ri,.lorn. (aI .lui .!'iytlty ), tlr'ii td'ittlttgitr r,r..tz*tii. se c*ractdrizc:lzrr, t,r'irr inanitcit;rri ver"liginoascirrst*lrl'r' rru'irl, il,r,, :m,i nrrtin brul,al decib-in boala Mdn.idre. S1 VeitlSul paroai'sti'cepiteptia,. tr'orna cea mxi pctent:r' do vtrrli.i psihoselttoritt'l .ii lraroxlsiic epil'epnii este repr6zedtat:a de criaa tampo,ali' (Arseni ii colab" 1978; Grsl':uttl' .er :aiie lle ineleal,i 3i-rostogolire ",t, r -vd"iijo1 ri colab., 1976i Stoica' 1978; Popoviciu \siPascu' l(lii{)' r:r;r F6Joviciu

{ie '. urrrt j octr cll eploEetrtreoseuitde adtivl, fie in mod rellex, sub itrllttctt(rt 'o.siibulrtu, care realizeaza cxacerbrrea paroxislicl :r .i,'nr """it*iii l'ocaru-lui. V erri.iwl' enitepl,r'c(epiteBsi'alrestibutogatud' ) poate fi cliferen{'iat tlo rrllo 'de 'vertij - cu ' aluri paroxistici, (Sloica 1969' 1978; S:t'gt't' torruc , lilicc . ,i . uirb., f'glO; Gastaut, I973; fopoviciu ii colab" 1976.;.PrinciPrulcl'r de diattiostic diterpn!itl, sint : a) alterarca cunotIin{er i o) 1l'Fr'r'rlrrr' (lo ('l'r 'i:tite;ir rcrLiiului (Iie-independent,fie altermndcu alte siulptomc cliticc unei crize epileptice convulsiv. i,';"'";;d;rH,-tie ci si buli, in cadrul g'*o.triizat"l : it couslabareaanolraliilor EEG pr'rorist ilr',r'pi ., i ''ul* lclrtice cu* loealizars ieinporalS,. Traseele EIQ po! prezent'a' dt':Lll'lr'l' iol'rue iritative cu sediu temporal qi in perioaclele intercritice' 9. Exi.std, insX gi oerlije tenporale ne.eltileptice(in tumori, .altct'tit" l.r'rLum*iiJme de lob ternpor6,I), caie apar in crize cu durati mai ltlttgii' rlrr rliteori sint aproape lerminente qi-au ulele-caractere clinioc pit'rl'itrtt' sau t,r,rle. Astfel, bolnaivii idcedrci, senzalii .le ghalie, alorid.ica,re dc loltot il'r'' proiectie in diferitele pianuri ale spaliu1ui' inso.lite sau nu (L(! irrrllr rlu rle r,,nolCiostaut, 19?3; Popoviciu qi colab., 19?6; Popoviciu $i Pascu' l1)$o; | 9E1).

ii,,'r

.lueptic {,oatoil apgl

(in .sponran cazulcxisl'r'tr1r'i

mt.nti rrrl ,:r.1,rrl rrrr,,trit I rrrisc{ oda{I cri coipul 1in.,,-60""* 1i i"i.,,lt"i_ r r,r,lr, ). ".,lil"ii-..ii"i 7) Nut,rnnitatestibulard(Dr1 Hallpi,le, 1962 Cawthorne colftb., ; $i ( llrt;1,; I i I' |.,r'ri.I| , ISZg)cuprinde $ l\ B forme tlinice : uas,t[bulurd p^ro1triu.-.zi.sd o afecl,iuno este benignl, cri inoi" , ..,::!,.\'::::,,,:!ta , (30-5qde_ani), careinterescaidneuronifvestibular.i, lji. ".t I Ll iii!l]9 i$ulte Debureazi,brusc prin crize vertiginoasocri ::l: ('||s|| 1ll;lll.! $r i.cr-qenr4,. rr :l.ilill' t"lr,rr. in Irrogrcslvir citcva ore sauzile,ciup' carcdisparc.-Nu luting0 rri. irxIrr,r'i,irl,onsitatea crizelor Mdniire, dar qr6bek I (ir..i;;T; ( l) .virltrnli*zii, l'l,N ".*tii;6;; sindrom veslribur'ar cu-rripoexcitibitiitatede lar1,*r rtli rrrllr,l,tl. 'n

-!r,t..,,posrurat",.r-iolcLrtfinsorir i ;i I rr :L l 'i r . r ' r lr ,t.ir , j( . hlm l )j i r' l c d o p o z i i i c A l e c a p uIU i . B ol na.i ,,ul

NIIRVULUI IN DE 2.f)..PROBLtsMI] DIAGNOSTIC PATOINGIA GLOSOFARINGIAN

rertigittoasd, satt tsr.rlijulrpidentic(Cirxthurne 5i r.,rlrr,lr., _ . l,)- -ryr'i'r"a,r'ila llll;1,; N ir.ls,.rr .rrlrLb., cil.t(i rirr lVil,r;,1scu,'lC?g) ;i lt,joro t.,,s,., irrl,ir'i,ii "',i;,Ji"r:itrto$ti.?! r';rin.rl irrrir'{i's .rr rulrru'irri r','spi.ati,r.ii t(, Fi .' iili",i ,r||||rr'rrIr|(' rrrtrr( r'rIr'r'fr|Iili.r'. T'ru't.r'ific o irrfcr'{,ic vir,tic,ir,lilrill(r s,i:"ir ri rlrr lrlrri.i'1'rzrr, li.hirrilnli, rim{ooita'ri,,aqa ir,,it'in"t-.i.,"i.rr',,at ;i rr,i rrr l'rtrIrrrr.rrcr.l:uIiIr. nl, T\rnoviliu ruilrll., I{rCf llifur'tiir,sr,u (l)rrr ; .5i ryir,olllr., lrr{lir).'l!r,lrt.rl r'riri( (').hri'rrr rr:urriii'r*li.ritl.ir;li',i,,in,,,-!i,i:rullr, r;.ir.nitrrri, I t0

ilnlrlicri': 2.9.1. Invcstigaria semiologiei a nervului glosofaringian i.ei a\ Entrnenwl fwnc! motorii.: Se celcetcazti'motilitatca ptrrcLt'ltti r,,,tt.r1io" al tr,rinfetui, tlcglutilia pentru Folitle' cYcntuala plczettfi a' .r rnuLtluicoltiuci tl lui Ycrncf. It\ Itrnu'menulfitnalict sanzitiar, &nalizind scn$ibilittte:r' ltorr:ltrltti tl t,onl.rriLr flrirrg,lrri ;i ir,tlrjiLrr llnrigd:llicnc' ttr:n:nrialoconstii,irr investig&ii1l' t:,\ lil,t;urnr:rt'rt'L .glsl'ulrti.ltt .[tr'na!iei, 1o ,r,lim5ii (tltt , s,iu(riol'u.i,, lrttltr,sobi r:litrinl't)' t,,,i,nu.'i rsii'.i, li '.r,r'il nrtt't'!irri irl ltltrct'it'tr':t l)ltroi'jtlt\ ultetdirir ('(,trHl,i-t
t,t,t'[ {\\ lt){.tuLu n,llttrlu turingirvte.
ll I

i\ l': \t unul. Iunoliri grtBl,l!l,rvr. sitliv$rlrr{'K{'ilitlllr qi ,1lriIo ,r:r,rr hiIr.rrrr.ri.li''ilulivrtr';1)rr rr.llr.xttlrri

pr^ lli:rgllrsi'icrrl sIrthilc,,sl,o r'ris!.lf.i!. Novrrrllliuglosolttritrl;irrrrri. .st cLlture: itt 1(,lrf1[ ullot' l)rlr'l,iotllllritlilir ltttr,lir' (l(' {'clc /rrl Jt']'ttt( att l) Nnrrutgia glosoJu'in11i ii lt t'i.ttl,i,tirii satr, Ttrint.ard (est'rl'ilr'lii ilt I r,r'rn irr.rlogia riecbi teime,n care f'olluie abandonat) afecteazd ill go]ll'rtr,l lrrrlrrrvii peste 40 tte ani. putind insi Bli apar5' ;i la tineri. t)('l)nlnl bolii cste de cele mai mdte ori brutal, iu llini, siililtal'o rrllrrrrrlir. lntre prima crizd' durcroas5, si -urmi,to-al:ea pot trece cittvll r:itrlirrritrisau cifcva 1uni, perioacli,va'riintl mult de la caz la caz. Criztilrr rnnilorr(f rlevin din ce in ce mai flecvente. l)llr'rror debuterzd brusc, violent, la baza limbii sau intr-o zonii' ditt l,,irr rrnristhlia tii. Locnl durerii maximale se afli' in regiu:reafarirgiarl iii "inelr-ati, rle nervnl glosofaringian' I)nrexea qi zonele e tlo lrrigrrrrli "s:i ilrrrli.r'o sint sl,rict localiza;teuDilatelal (Arsenl fi Oprescu.1979; Dcptui$ stahilit klcalizalerr (1963,citat de Arseni $i Oprescu'1979).a | 1l{;8). I,l'i{rl(son lir' in rlrrr,'iii irr lrd. ,o1u?, funclie de {or:ma clinici: a) in forma tlctsir:d': spre.timpan' ruri"ljlll lrrzrr lirrrbii, in regiunea arnigda,liani, cu iraclieri^ in rrrrrrrrlilrrrlrt lggiunca submarilar5:t:J ln.forma fat'.i,ngianii: regiuncit' 6i rrliirl(l,rliirnrj,'" r) \tt fonnu ti.mpanicii satt' oti.cd: in rcgiunc'a awicrrlari' prolurr(lil, s:ru nr condlictul lutlitiv exte.rn; d) in marile ytatotisme il''trcreu' t1e ir';rrlinsj .in zotre m:ri iltinsc, respectiY rlai inferioaro fa'tlii' ccltl rr,,rrl,r' dlrroreil hel'eaz5' i,.lrrlrrlc ttrai ils (Arseni li Oprescr, 19?9)' Bolnavii '"1i( ile ,.rr j'iiirl tk'oseLtit violeirtS,'5i de ahoce, lscmuilrl-o cu o ,,lolitlr:ii clo |rrlil,". .^rtrrsoc devtlic" etc. In rare sit a;lii, durerea estc apreciatii ca o 'rlist'onfot (BoJrm qi Strang, 1962 t ,, riz,,ii,. ,[,, ; -Bues,- 196ts, ,cit'a;li dtr ili ()l)r{rsctl,l9?9). Durata unei orize csie la debttul bolii de 20*il0 '\r'rr,rii rlrlr-se nrilol1,t odat5, cu cvolntia bolii. lncetarca cltrerli cst'tr ',',,,rrr,i,l, l:t'tLft,ii si d ebul,ul ci, intel']'aleJe intelpl}loxist-icefiilcl asitriort lrrl,rrlrl.ilrr de I't'l ioliktle libcrtl intru crizeledu]eloascr-al'iez5, la uI boln:w 1rIrrrrrirIitur. zilc. Roala!o:Il() 1acitevil orc s:l* Lliteva, rhr cil,oi,rtItrirutte 1tini, irr rrll,rrl, lrr, rlttltroastl qi remisiuni variabile oa dur:ite (ca;t llttl' ,,i,rlrri itr l,ttscttt'i :I|l||,1r, t)r,r;r lrr' I -i atLi). Clizclo apaT tlc cele m:ri multe ori ziull. cltt jn clizt'ltt 2llo ,1,'t,,'i,,'itirrs:isi tton,Dtc:t fazole alvinsa,te bolii De asentenea, iit slh't,, care se relct,i la intervale de tjmp valinbil' ;r, lr.,i,r1r'ul)r "d.e neTralgie glosofaringianri presrlpinl0 corect filrthi.liIrtr ilittrtttotl'i,r:t,t.ltti' in rrrrrLrlir',':r Lri lrolr r.tjltLi timpul unei crizor anlliza facl,orilorcaxedetermjllil' (,,trigger zones") (Arrrlrrrli{irrrlizci qi locatrizareizonelor declartqatoa,r'e qi Pascu.r 1981)' r,:rri si {}lrlcsctt,19?9;Popoviciu Illrriirirol), pacieirtului in timpul crizelor-permite ollscrvarea crisptirii i Ir,tr,i. rr,rrtrr'l:it i iuloluntarc a miinii ta nivelul zonei inferioare t[ ltilei fi ,rllr. l:r,r'illr.,, sa,u sDre urcche, intrerupexea masticaliei etc' Fenomcrl:lo homifotr'i fi pritr i l'lr r I ,,, ,rr,, ,t , ,ri i i :.i.rrt r' ." se pot manift'stnpt in inroSirr':r ' grrt'ii tlc partca- dulolii. In tirnpul crizci- tlurerorlsc bohrnvji rrscirciuncrr F,l,irr.(l(! rrbicei, olisltrti, cu fncit:s imobil ,si a'plccfl1iinainl;or pclltl'u ll snlivei. ln alte (iazrlrirbolnavul iqi montinc callul a'llooatt lrr,ililrr srrrrlg,r'cr sn,rt 01 nrtts.ttlllttra h 1;r'r'txrcrvicalli, ili aptrtd, mina' urochon rrr rrr,rri :r rrrlii.r:r, lurlitllrgtr,illl 1i/slrtt r':rttltlttlllll(li1:iv r'\1'\rl)' it.r',,grrntrl, cliz|lot rcfirozinlir'o (lllpilr Atrtlizit, frtol,ot'ilot'tln,trr Irr'cipil,i! ttprtt'i{'irr glono tgiitnt'[. lilt't'it tttttli lrrrlnltv(ilt llr'vtillgi{r trL it rxrt'l,tt,rr(i cnl srrlorrtrrtitttilii ltt tl tlt'iztrlot', HJrt'tri:t'l tl|!rllllnqltttrn' itt t"",, tttlottlrltl l)r,,rrlrrlilirr iorrlil tttt '',,, :rl{i Irrolot'i ttrfii,.;'i,ttrtlrtlrr,rLrglttlifirri,r'risl'ii'rii r:ttl 1tt"'rri ii,rti i,l,'1,1" r,rl,l, Dr',',t lt:rsrtltti, ltlsrrrt' criz,'l,rl: rriitrrr:ti'ttli,Hl'riitlttl,ttl, rrttIlrtl'ttl , trr,,Ir',',ipil,t rtprrtr(irr ,16

t'tt r'i.rrrrtlir rtvrttt r'i..carr':r,il,ll."i,,;,.!;,''i1.,i:ill,";,i;1.],';.'.""' rl,.s,.hirtr.r,r.,r srr'ir.

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ll;1i,T;"#!'::ffij'l;,.'"""" " 'S:ll*:ii);*,""r1,-q,e:Ld,";';?,,:?;.i motrorii salr gusia Ye' 1,irl,cr *T*{ft'"'?l#::tii';tll*'.i:ilr:!"i:l{'rinl;i"' ill;l jlr ill :.' ll';:::'; !:' :il" u',1,." ;i ;i .;' ; ; llllll'jil:l;;;r i;rI rrl"i r"rr'' ' rl;ji::l;l ,i.1, l',,,bii .i ur pc r-: ,,r tr r r r tr i 'r ' ;,;.. ,, r r

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,,ii|ItIJlii,'r ltilll,r,. Hltt(lt.rIrIluI (1)ItI t)I(,I,it, rLt u l,tri_irritrl)tll,r,ltoilir!v:t I,sl,(! ( l, clt 1(':t,Nir' .lr s:u(ii|nl.o vior(f r,r',rsrrr,rirrrirrri, tl$urintiro novr'tlrgiL\ (lu gl(]solr!tr t:rrigirr, bo s,:rnudc tliagnost,io \i, IoNllt'oIiv, rrlir:{irrrrr, li. cst0 1,,.itfll,lli rlr|| ,'r'(.. r,. in_punclul lllrirrgrrlrri superior, adicd,intre ci}nu] car1,i.l)r'r.,vor.iitr-r, r:tjr rr' Lrn1.[ fr osul l]roi.l. lloba rlccisivd este alcoolizarea ( nrvului, cr,r,o l'l||rl|rr rltllerca,. Uneori se constal,ti asocierea sindromului laringritri rrpcliur' ou sindromul cle ganglion sfenopalatin. I I ) Neuralgia glosofuringianii secund,ard(simptomatici) g]os.ofaringir,ni,s^eoundari, d.eosebegte se ctini,c d,e aea, primari, . t rin :rL(,al'cte t'r' .. ):.1.1..:l*l elemnnte:&) fond drrreros continuu,pe cale se supropull r.[rrrcroascpr,ro\isbice: Lr) tlurolqa, nrr at idqi - intcnsitateb, dctci ' Ii.i,r:r,rlr. ,||||.r,'\ l:llglll pnm rf lr : c) dulerca so .localizeazii aproaDctorclpaunaitr ,:.,, al. g-ibul i. crr iradieri r,uricutare si frr:r,ndibul*r.e; rt.1 1'11 lj^,pro.,ly-dc,,' ,.',lr\t:Lt,i ltipo- calr tnrstozi:l lojii.amigdalienc- a rngiunii farlngie'n,.: si r') r'ris1;i 5i semne de afectare lsociatd ii trunchi.tui dotor ar neryuru i rllosofrrliirgian; f) se a,sociaza semne din partea altor nervi qi cranicni rr\ ( r,rrrlr; g) sc constati, extindelea ariei durcrolse peste limitele anato, ,. j,;1l glooof*ringiao ; h ) evoturia cs[e progrfsivi, cu agrav:]r(,rr, " ,ll:.1I"]!i . | ' \.rrl,t.r.r''":li r':lpld:i r simplomat ologioi, fdri rcmisiuni. l |l ,.rrrrtiL unor lorrnp ll.ipice.si incompletclj, dcb t, sirnptoma{ ologirr, t,, t r:rlri' i glosOlalingipnC recundar.r' eSLe cele mai *r,Lt" OIj SuJiCir.llii dc rr| , ir'l ('1 :rcl lst,lCu.l\lUIf tot me rlp nevralgie glOSOfa e r.ingiani1 S{.Cundrui. prri irrsi rlcbuta cu tablou cJinic rle ncvraigie 1l;im;r;. i;i" aceste motiv(! 11rrrl)11'r.i cii orice ,er'ralgic glosofaria-ngidnJ, tz.'t irebuic consirlerati, rlo ll rr,,''( n,rmzri jo:] 1.'rll .r drrpi efectuCrea in\.obI I.iilor paraclinit,,. 1 lnlynrlar;,ri r '||) |,t' r'r.:tUlnr l(.zUll.bc rteqaf o o vom cOnSidr.r* i\ pr.jmit,iv;, ('ttu,xclc acle mai ft ccvenJe aie rrcwalgiei gloso{aririgiene secun{larlr -pi';"; ilP t./r bazei.cto rtiulai liuai alei ,;1";" .i,' ..',::.1 .t"".':t:!j':"^:lJ .:.."\ !7lilt tll..(.'il,lr' b) cranienei c\ arahnoid,itele ,{,Un..r'rnolrflngc); tr&umdlismele cen:r)ttrt: () t(,tt,crce 7unrcti: meningioame, neurinoanie : e\ anel)tisme ulr\ |rr,r'rrIirIr,i (jl,lrunc i t) i,nfec,tiilocaie, indeosebi amigda,iie;e etc. I II ) N eualgiu glosofaringiand, ,,Junc!,ionald,, (simpatalgia) ,\r,r':r,stii, llormd, d.e ne\Tc,lgie glosofaringiani, se caracterizeazd, mirr rI rr!.r r cr rritt,totjercle arsur:i, 1.1 b:r,zalimbii si in regiulea ai, r,ir,rlr{.r,{' rll}ro trompa lui Eustachio, spre ur-echeafoedie, trUgq"ii*ei' oar Dl spre alto ( ir'o depii,qesc zrrr.r teritoriul nervuluiglosofaringian. Std,readd dii;;i;;i; -tilidi; :t,lr.ltrLvilrl r[r.viuomai prosnant:Lin-1ifrp-u] clegtilt,iliei-.. Soi;'. in l'lrr:r.rii :urrirrrprcsinunui"corp sir{in.'Din ,1;;;;;;; c,cesl,i n:}ci{!nt.i sl,lLsnlt' trltr-oglenc LUSC. ineerCxrilelor de a Climila l.co"nrit r,U Ir|'r'rrrrrir rn rri,r'riirr)'..fi.,za!ia

.l ) ' l ' utt,tt , , , t il" d, f ullulit i, 1t t t lit : 'lit l' r "'t r : 'li l rt ir' . \ r' rrrrrrrl t |l r r r 'r r t rrrrIr,,tl i tttl . l ' :r't : uljzi:r nr r . 'tiiir r lr r i lt it t r 'l t ir 'l'r t '111" ir r lr r l |; r 't it t I ''I t I i lr llr 't liL'': l i, plimrLirti f itrrli rtl-tlrrelrrii{ici 1rt'ttlltt rrolirli' llt' l,'t',lrtl5ar'lra dcsfiiquralicl"' ;ri ' ,,f',iiiii, a"id,,t.toasi poato'antr'"n1, lllil,iurr(l{ r('rt ruli.trtlttlrlttl' itr Lt'tittc'r" r,, ,l*r"t iezi'nilor b-ilaterale at nt'n t,hri glostrlu.i n gi lrr, l,ttllrtrtri''ilrr rl. t t lt t r ,1..:.l rrl i ti . si nl qr lr e. S- a sr 'm nal: ll. {Ll' asf ll! {'nc1, u lnot [ ili' it 't r ': t ' lit r t l't culio t lc t t 'zot t : ut r lr r \ ' ,,i o - . liii"r t n* aspeclului l: r 'tinqolui 1r 'r 'i ' ,i i i i ' i i ' i " B )P aruti ziat t i. uselt 'iuluicot lslt t r : t or super ior alJar it t gt t ht 'i'ilol; r 'r 't t t in: r ,r,.r' ri J' c, i al .r t l, - " a i: r , r ing't ui ] r Lt lt liz&1 si'r ' 1'alior L sJnill. r r r 'r r f i l'r llir r , A. nn\ 1. ( lnllI il) |l, l. c|\ {. I I J: '{''. |||||{'iI Z'I ' r .' us (sci l i nl ] coI t jU, i l, i ] ui \ / c] 'r clJ) . : l ilr '1' rr, r,r,tounti a {onom clor . 'o" sl] ll , r a'' 5i Ja or t it elea hr in3' lr : i . r I lr lr

jiliotic:, comlrnsatorio,, ccl'r.l,lli rrrrrsrlri aiw*e repeiie p"in r siutt cslc cljrttilttt:ti' it,lxrlil. "i,J'-ii"ii Rett-exui de partea paralizatrir faiingiain f,ri,iirgi.ti. se cal1i(rleiiz{ilz'i prrrr A) Tulburririle de scttsibilitateli senzoriale inge ;i pc Jre19c3 lonftlir'rt'ti :r litrrlrii, r'tt pe t,ipociiezie sau anesl,czie fri,r lrifr slfl aSuc;io 1'cnrttl atner, in 5l'al'l{ \'l!lul Iirrrlli'l Pa,ralizii]cunilater'alcsau bilat(j]'aleizol:lte alc nttvltlui glosolru|itrllilttt ,,irrt'exceptioaale,ele in'riininc]xse rnai {r't'cvcnt inpletttri ('tr lrrrr':lliziirrl(' rrclvilor invccinai;i.

iN patoltttit,q NliRVlll',tll 2.10.PR0BL,EI|uDu IIIAGN0STIC PNI'UilOGAS1'RIC

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2.10.1. Invcstigelia serniologici a ltrvului vag (X) i[r}litrii': tll A) Dsanterutl futtclie.i ntotoriisomalirt:constil in exattritlnt tttol'tli r ,tii vxJuilraiatufrli 6i i la:'ingelui,prcturn 5i a deglut'ilioi (pcrrlrrr lir'lrirlt')' pozi(iru Enanzeit'I sinlia : vilul palatr:Iui se elamineazii' aprcciitldtt i evcltu: a 11N1slio clcttl'ttrt' 1i r,t,,i,"i.'"u.ttu"asi sirnetri*,r'iiulti, prccum ;i llo iriqc[r' inrl'oluntare velo-palaiile. trr'rl'ir Daamenul d'inantic: r'om {ace aprecit'1i*supla trrolilil'lilii ir:ult', sir,promrnl;c allurrito lroc:rlr' (tt:r'''.'I('''')' r(J.Ltru care se cere bolna,vului licrnn, vi'luluir l[etr' ntin]irrildu,-sc l'c lil]ir)' ltr(tliit'rrii' ii."^A"t"t*lU, "i trileziuni unilaterale se remarci u asiuret.ie a *i'luTi, ttt .ttlr't irt'll' ri:t'tli plrtta sllrritoasi'. ln.1ill)lul (rxllttrillr'i'r'i cu ltctjar <1e ,fi,"iu"*, i-pr"u"I rlclt'r' ttlt rtlnatt'i l.tct','nl tla iLsimcltici Lr'zittttilcIIiI:r'i.'tItIr' s'r. "',,titlt;tii, prr'1i,accsta liind inr'r''alil sil'rrr i,iiiil'li iiirri"*" ,i nirr"tuiln ambelc
c()lI [Ta0tre. r r t : lt r lilit i. r ' , D t.Ql U ti !t Ai; e r . lam ir r t r r , zlir lr lr d lr ollt ar t t lt t i sit l) ( 11,{'ll- ijliji' . . r , l/ r ir i r. zir r ni u rr il*1, , r 'r ul'. , ( r l'Nl. ir li . r'r l l t tIr t t : r , I iclt it lr 'lr r t ,t,.,ont,." l u {l( 'lt lN( "r olr iLs l1l l{'zl ( lr 'r 'liLlr \ iLt lt t lt nt i l ': r ' t 't , ,i ,rr i ri i r u.11,'. n, rl. t llt 1t : ult r ', ', ll 'l1l {1lr ilr , ( lin r uI llll , ,,i i i t,i Jri l at * r,,nt , rliohidr do l) ii1t . u) r ( l, r t r r r ; r r I ir r lli ir - t r : uh|r . . i , , iir r , , , ll, t . , sl il, . t i, , it , r r l r lcgirrrl) i'iril lit . lr jr l. lr r '. [ ) {r it s. r l( ''( r l, lr l ,i ,,r,i 'Jr ii{i. ( 'ii. llr 'lilr gt 'lt t t r t t st t lit licii t lr r ' ,l ,,gi rl tt' i l ,i"rri f,r* ,rt , iiit 'i, t t t '1'r 'r r 'l'rl! t r r r r lt : r ' ' I r ,. I r.rr l i lrr r,rr,1xr.i, 1.ziur,r,' I rrI: r, r.'' r,i L ixnr 1nih,l,cl1tlil tL i,'u,'niir, ir,?rr,,,i r,:ir,lirr trr,tvtrl ti vl l g ( si, r r llilll , , t t t iit t r ir r i lt t i Ar lr t t r r ", r l. s. t ir t lr r 'Lt r l't t li, . il'it 'l' t lr r l ' ol rovi oi tt | ti | ! r , l| r r , l{lsl) .

i,l.9.ll.-Puralizia rrorvului glosoftringian I,,l,l'rrtizi|, nurvului uk,*"1:11_iilti,l.r= so l)rir: disfagioponNru itlitrtc[1,o ilo]irlo ; tr:lftlliziru rnr -m.r,nifesti1
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| | I . . , , t t , r t . t t t f ,tn ,.t;,; i .{ 1 , tt \,1 .| n l )i u 1,rnr,i fl r.l r. i l ,.l rrl rri rtl oLri r. t | , l ,l j ,,,,], . , ' , , , , . . 1, l, , , *' , ' 1 r.ts r' rtr: s i rr rl ro r In i l (.- \o (o,.ul or,:rrrl i ac. si l rorr,r.o ,'. , , l. ' . . 1, ' ! , " t - ; ' . 1 !i i to r u .e g e ' ,:' ;, (1,1trasi 4pn;i se). l n Iezi utti , , . l i .., te ,, ' , l . ] 1ttn , i rc n e o l ,,r..i . * i.ra g ne r r1;' 6gp . ,l j .l :,gi .,r ' ' z e .,i 1" r hi ,.:irrl i ,.. , '{,'."l , i , .j , ,, , rl " r lr { '"' :lr r1 ur i z rr. rl t( r ' p a * i l i z i a acut} , bi hter;h r l netyrrl rri " ti l l a l i ' 1 ,. , , , ; : , . 1: . o :i - i n c o _ rl p i l .i l ,i :- { .r,.i .j u r ,,. Ior rj ,l .on i u,:rrl .,.:zi .i ,.; ] , ll, ] ^

i r i n s p i ra fi c . ).ll,,n1,1,,ryt f.trnc!-iei 'se*zitite sornatice ce.ceteazti sensibilitat t,:r, ., .l| ', :| |.rr , r . lr r r , ( . t lL l r I m u (,o !.F ;u ,. a c | c s i L ri lo erpto:.l r.i . cl i ni ,.,,: z,,n;r

,,, ,.,.,,,j,i..I] ,rporrioletlrbrLriir:i i..pi""i"rii /in s1,,".i:rl :rt,, I :,'l1l :]u.i Tn parxliziile t rlo u riil: rlo ra t ,\,.,, r(. , . : l j , , l ] l ]ii,.ll; i u.r 'r r.il,o-eo.._ii-stridor.. ro Iiri. mociificirri.er.idente rcspiralie cu refltrrrl ' rr,.r'r,l [[ir, vox1r1a, de ;i prraiiziite totare b nteraG-p"o&oJ 'i1". i rs(' r)irsi,r'irt. 'ir"ind,iiri"iLri sevcrc: lrlil'rii'i rkr 1bira1lie 1a afo'ie, rips:u pir:i rctteiirtiri iii." qr dispnec.rr i l r'r(i ()1 inili a, les ,

tttrrr lr ll lr lit t r r . t r lir tr '- lr . I r iI r L'I oI r , r , I r |: L t t r , r r . t rr r r : r r , ir t r ;lr lr . I r , . r ir l 1' l ttt Li rr, l) i I l l o zr r r : r r lir r lr r r r lr r , iillr lt r l lilr r ir l ; i o: r r r l lt r oir l, lor r r r c: ur . r r , r 'vll l tl rr l rrl rl ti rrrr ;rrr|r . r 'ior , . iilllll. {"I I r t I I r I ) I , iir I I II i r,I I i rI i l r | |rI ( , ,r . zi ! iq. lt il. r \ r , r , : r r l: r slt f(rt. i l /r' pol i l r r . l'r ir lilui 0 , , 1|ig. ; i|t ' z0t r ( , ", ii iill|sl{, ziit lo|lr ir i sr r lr I r r r r r rl l tri i rrr. I)i ut r r cit l) 1) lt . l{. i ( ll\ r l; t lt iit lii sir r r lr g|it r lt l, ii 1) l, it ro|ir r | ir . il: r ( i, I rrl i i L, j rl i i rr z or t r , git t r lr ii ( t r isr ', iollr ir , r . , ( iij( : it 1, ) .Lir r r r r r ll, ilr ollr ili, r lr r llr . r . : r rrr' l n cttacl , t , t 'r 'elat ir . pct r r r ur I t ii, r ; L.r slr cclbiI i pilf l) \ iil i( x. . 'ir r iir r r lr r r l t i ' r' i zi .Iol rrti l r lor . iit r rilr r r . er . or r slii lilr Lilt iJii,lxr lr llr . r r l r l, lt Lr l, ir r llr r jl, r , r r ili r r r r r. rU l , L U rcori apiL| elt iso t lc ( l( 1. t 1s{l ilt ioilr jil, ir i slt t it r [ 0 r 'i0lr 'r r lo, r . r lr I r , r ' dt trrrl l tk' tl ccrt Jt il ( I iisr : i', 1. 91i2) .I ) ur . r 'l'it at hn t 'it zi zilc r lr r r ilr liir r r ir i. r "r r r rrri rtl i l rri ngologic nr : Lt vir k'ir ljlr zi sonur e uir it clir . c. _\ lit t li, r lr r r , r 'r 'ill c r ,:l | r. :el ' l l oY lit lgic apai'in: . lur ingilr : ir c. . r t esit u clr r r r ict , ( r J0 r llr lr r r . lrlr ilr r r l. r.ln irr lLn;.rrl urror I'rlft/:tr (gt,ipr'i clir)- lti:r ''ttill|'i), dtp.i rnl i,7r{r;/ecloz,ii " l ro:l l ti i l poz.it it 'se lt it z. lt zr 'i, r ( t ilr ': it t er ul( ]dur ci. ji. r lr t I r,t ' r I i { rtr I i rrr,I r r . . i|' lr rl rrti i l r di " ql t nr i! in accst eil it r r lr I ] a l: nest czir i loclt L'lr li, , r . ir r lr r i ir r r ir ( li: r r r
l l l ['I'l '-]I.

f . 10,3. Paralizia nervutrui ilner{mo{Jatstri(i .l ' ru' el i zi l r ic] , t - ldui ] }lcur nogasi. r ic sr , r r r illif e"r l, ir t 'i'l 1. 111] ) it r it it r ) l( ) r '||, ti I {.r!zrlir-n si t'{,gola1tir1'.l)unli:irt ttttil.airrqlit, rlr.urcJa, iu^rrtiillt|rrlizil' v|1{' r li. I' rl rrti l ri L (hcrniviil t izut , liil; ot ot r . liir , 1li t l'r r , , {iir pir lt r l, , \ ir r iior r , ir ) . \ , r r . , , r r rl r' \ i l rl ni l zoi )at , i) : iiill t ullt ur ': ili 'ir r r XcghL1ir Llir . lhir l, Jor .r,, Lrlr dlr i: ur , r rlr r r ' 1r , . it ,rrr. S t' cri trst at ii o ir em iar l: i0zir 'il r . ilullr i l) ill|1 uillt ir L ir |jir r , l iI I I r , I L|. r I , I ij'. , il r lr lr lr . r 1r;l rel i l or alicl'ior i si lt ost r "r 'ir li, t ) t 1, cluJlr i lt jiult ililii l :rIi trgcl uj . Il rlil, i. ul r r cLopllal iJl {'slo ( i; nlir lt iLl silr t air 0liL llr . I lr , t r 'r r lI r : r l. r r . i ,' : i i tttl !e bi .l t!t ; 'uI t 1t : 'cxLt t t t ] ir Lt ;iili i. ilr t rl it r r L. . girl til ir Jit lririr lr r r. l rr llr r r ': r r l: t L I l i )l ri i i !1r rl diiilolr i{) r t Lr : r lir t ir . . ll'r illlL; 'r lt ilc \ i'11 llli\ '( ' , lir r lr r r r r r l , ; l ' l ri i r' t' i tl i ri r, 1|( 't t '|l t r i {'0|; l- iiit ir }: L|: I I }|I I ii] . i|li, it i. ilr lo, , ii I t , r lr r r. r |r l , , - , '; t 1] )l r .i l ri l l .l l ri ).ri I'it s. ir t l ot ji cr r lr ior iI o1t ir , 11ic,ic r r olr :lni r r r r illr ' ( l, i r , il ir ll, . ll ,,l rl . ;l.l{}./.r" l!oain hri iloska:n { hipelroikrclilll nt tir sitrourrolirlir rrlil irr i r| i i i r1cl r' el za i in Jr r ilf iLt l I i: r il lt r . ir r nt : , n. i. lr sli! t i sit r t , , p, t l, , . r ir r ': r |r , r 'l r , U i rrtl rl !i tra1;i tloglaJt ti] ilur r i- Llo t r or t lI r , sir ir r r , lr sir t r r sr r lf i r . ir ] ( , i, ( liir ir r . l, r 'l t rrl {l i r" i rl ual i z: L lt i it r nLr ' ( ( ] ir 'f t r r . iil ; i . 11; policir r , llr i: l i ( 1) l, lr l i t r lt ) ', . . i; t I\)pr,\,i (l i l : si Pr ur Ll, 11) E1) : .l ) Ti f)u L r auul ( r nr dic; iLt lt ,if ur 'J so ( ll, r 'ir ill izoilzil lilir r lr p; r r , ilir , r r r llr il u Tr rl t,l ruttrl 0r r t r t 1llr ] : r irsir ) lr r ir r ir t J, , r 'lit 'iiii t lot r I tI t r r i, iiI r I r{, r ) r ( |iit r . r r . t r |r ' lr 0i ,i lr , ' rrrr' t11,ri tl i l rt r ioir r . r t ll1iut . cll {[ ilt . t ] ii vr r ljlr ir ilir ( l- , lf r , , 1'f ) . li iI i r llr . r r r r r , l ,t i nr,r' l r l rti u iir llr tt lir i , , r . t iolzii , 1i lit r ir t r l lr r t r n; r J sr l, r 'r lllr illiil, r '. . , \ l'. ot ) ili rrrtut, ri ctt(rt Lor r , lt li( lr t uonl, oll: li r ilt t t lLt hniir islr 'r t llr .lt r , r r r lr r , r r ir iilii 1r 1r . r 'r l vrr tr r,x,.,l .ol i ,l ro1rr , r c (1r I i I j I)i rI I ri I )i I r l : i, t . l ciir ot , it it l; , r ll{, i sc ir r r , lr ir lr . r I 'r llr . i ir i :) ' f i ;l tt. it t t : , it , t |t , I t t r r ; r tr , r , ir sir i ilr r r lliiililr , ir i; r r , ior silr r ir r r lr . r ', : r 1, . , i' rrtIrrIr,.rttIl ttI, hl i ( I j1I ir , r '{I ir . , j. ill, t lr r Jr ii, , , 'r r ill ir r lr ilr r sir r or r r r . ol, ir lit r r r : r r lr ilLlr r \rtr l l ttrrrtti li': llr 'it i lt t lit r l it r l'I t t r , I r I : r I oI r r lr li'ot r ir ii. ilr sir lir l l ,r'rrr r,rr i i r. r l , t t r,l l rr i ,ri l rrl l rr 1r llr r ) r r I r iI li r lr , r t r lllr r r lit r li. tl ) ' l ' i 1tu l,t , r t t lt , r l st , r . t ; r ll, . r ilr , r r zt r I t ir r r I ir r I r r r r r r r lr ': r l: ilii r l. r lr r r r t i r.rr' 1:i . rir' I rI r. r'r' i |, l, r ) lt t iilt lr r i I | | I Iilrrr| | i rr' 1 ) 1llr ) lr {) 1, . ir llii r lir t r , , : r r r r r '( r , li,i, r t l r .rl 1 i l rur' :rr rl rt tr.rllt L', , , i r lt ir t lot t vt t llii r ll lilr r 'pr ir , plir . . r \ r 'r . r ilr ' lllnr r . l( , :rrni , i rrl l trr,trlr lr , r lr r r ir . r r r . r 'r , : r lr 'rrrr t r r r r r lr r r cr r ', , I r r I i: r r , .

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't ,;,,t.1,"j:"^T"lFl1in n a impti,.,i .j"_iiglgsr:r, rrrrr,ttui spirratimpr I I'i|amctlut clnucserniotogici nermruispi,ral icri: ''| Jl'l;,1"\'::,::l^"*:, nentmLrannna internd, i nurvrtrii-il)i,,at est,t, trt cu cel practicat p&tru compolenta practicat cel p&tru compolenta motorie nervului r)leumomotorie ;;""Jrir,iiilll"Sli a l;li:liil ill I ilri(]. ""

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tlo urgolrt'it,.ltr etlzttt'ilo an dabltl lonl,-ptogrettt', tro(x1$il,il, ll'rrlro(rsl,outit .rlrrrc strirkrr', dispnoe qi tlisfonii pinir, ltl a'fottit'. Iltllllcxttl (lo l;uso osl 0 , iiur irrurit suu chiar abolit. D ) f'aralizia neraultti sphtal et'tern'so lllrt,llifcsLilprin ssnlno (lrll pil,ll,o. grrrtr*' mr6ohiului sternocleldomastoidian ryi tlrpez do llcocil,lsi so ruanilirulf[ I'ara,lizia unilaterald, a muschiului, sternoaleidomastoidtal, irr primul rind prin qtergerea retiefului musculat a'tit in repaus, cit.qi lrt "tirnpul miqcd,rilor de inclinare qi flectare a capului do parten lozitttrii. l)e asemenea, muqchiul prezintii o hipotonie marcatl qi atunci clnd lx:l i llllvul intoarce capul de partea sinitoas5, qi examinatorul se oputut ,l,cottt( rrriqcd,ri. Uaeori sd poatelvidenlia Di o ahofie de gtadc diforitc a' nrttqchirt ii., lLri"Ilin cauza actriunii sternocteidomastoiclianului de partea.oprrsir,l"ozitrn poate si fie'ugor inclinat ci,tre partea sinS,toasf,' Paralizia unilntclrr,lii, oapul lu,inuiciriului sternbcleidomastoiilian nu impieteazd, prea mltlt miqrrfililn ,,apului din ca.uza intelvenliei celorlalli mugchi ai gitului. In clzttl lt:rrtr' liziei bilaterale, capul se afii, in u$o&r[ extensie, iar bolnavul oxtrcttl,tl,t:t.t groutate flexia capului. Parali.aia muqchiului trupez re,alizeaziaurmS,torul tnblou cliltir: : rr,) h' rrrrrlrul rle partoa lezati estecoborit qi proiectat inainte I b) mugincir ir,tr ohl Iiuaril a portiunii superioarea trapezului este qtearsd, c) spD0iulsuJrrlt ; vicrrlar. eite hdincit, iar r:laviculaapare mai bine reliofatd,$i paro proi{joltlliri in tllai te; tl) coborirea scapulei; e) clevierea afarir,a marginii- spittrllo ir, on,uplaiului; f) diticultatea efectud,riimiqcirii de abduclio 6i .tlo t'itlicl,r'r' a briilulni; g) imposibilitatea de ridicare ,,in coa,te" dirl. pozil,irlllllllnl,; h) rlificultatea efcctuirii miqci,rilor din articulalia nm:iruluil i) 1l,r't'gctlrt, r:,lieiului qi hipotonia muqchiuln) trapez; i) a,trofia,tnu;ohittltti l,rrtlcz llurulizia sittgulatd'a neraului spiual este raril. lJfl, :lllrtto rlo ttlrltrrri i. rrlrrerLnd, paralizia ultimilor nervi bulbui (in spccial ctt port'rltilo tt, cu tn caresegd'sesc i n nli al,t I X-a ii a X-a) (vezi in continuare), 'loluli, procese magnuln ;if sau' u, regiuttii, cetuicule $tt,lcriottrr ttlrof)iere a foram,enu,Ltri (lr)carcosteomielibice, qi pahimeningita specific5, nespocificft)pttt prtttlttco nnilaterzlle sa'it ltilaterale de nerv spinal, Adesorl, oparul'iilo tn lrrlalizii lnaltd (ca, tle pildi', sec{iunea spinalului in tortiut'1i*) itqiunea cerui,aald silrt rosponsabiletle proclucereaparaliziilor nervultli sltittttl Ane,tritmttl ' rcrlebraLe calo se dezvolii) il canalul slritltll superior pott,e t:otttlrrimtl (ljor'loohl;ttl' ^rterei 10(|6)' trrrilatoral.i' norvtrl spinal qi poate si plovoace o paraliz,ie

Ftg, 77a, "Astr'{te lch,rnatice ale examenulu.d lalrjngoscopic:

NDRVUI/UI HIPOOLOS IN 9.12. PROBLI]MD DIAGNOSTIC PATOIOGIA DF] n hipolllos(XtI) lmXrllod: somiolofliolt norvrrlrri 9.1L1. lnvostigutria limbii in sboretls rolf&ultrrln I ) ( )hsurva,t,irr 1,ozi1;ici a nn;rootului ."i gitutt. oroouto I) Inrplorarso mol,illtillli Umbll, solloitlndu.ssbolnavdul rl1, ,routo mtgodrllo podblle on t Imbn.

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:.1;i.l,Itt)IJLEltuD|ll]IAGNUS,II0iN|,4'trtt,rlrit,tl,^li^1,IZll|,()|tMtl|,1.1|'|.|,: I AI.,ENIIRVIL0R 0ltANll'lN lllll'ltAlil crt itloctirri mllltii]lc tlc 3.i3.1. Atoeliuai extranelraxialo 0r:rnie i bulbari. ttorvilor

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:1.l:1.:!. llaralizia nervului hipoglos .l 1 1'o.rulizia u,nil alerald, tuiertru,lui iti.ytoglas; realizeazi\ o dtr:irtit. Irr' 1 r: r . i. ir- s iinit oas i i a ,v i rl u l u i Ii rn b i i ,,i n s i n u , ,. D aci bol n[r.rr] cf(.t.t{ r{ .i rz:r Ir',rlIrrzirr Iirniiii, wir.lul il(,csteiit est.j {let'iat spre par.trr boil}rtvii. [)l,ilr r( ttturrir lt[isd]iulrd de p:rr'lea opus:i ]eZiunii. I]c :rse:lt,,i,orr, -Eenioglos l:rl.rl .*'(l'ill] al li rbii fot]Illeazit o curbiL Lu corca\-itateit, spl,e ilrit,1,(.ir r :irrlloirfi. -\t:castii deriabie esto produsri ijrin actinneil mrifohinhti r{ii{). ,'l()ir *) ;(l ; r(,!(,:1tuea in tiinlpul cfor.tLrrilor z:i de t ducc iitnba cic 1[r,r.1rrrr irrl trrrril. Lint lx r es t c { ttro fi a l (i ti e tl a d t,* p a r' n l i z i rl l iLqi prezi nti i pl i l ' i .,Ji ,i bi l . ;r. rrrlrr':rlriri ljrnbii. 11 hernijinba rrlettal i: se poi remarc,a,.Jasci::r.lu!,,i.i tnt\t tt[/t)t: irr coridi{,ii1i:in cr.r'oieziirle:r sc:rllli lr, nivelul ntc]trdii ne}i.liiui lr1r,r,:los. l)fil irittitia {.rroliirI a ilctonelronik;t,. 1t ) N'rrroli::irl itil.atert;ld, a er,nri.ui ]ti,ito1lios praiar:e tuil.lirlrj iirrrrlr,rrri l, r'r'Ive al(.. t|r{rllliti,iii jirntrii. Acessta-nu pca.ig fi .r:ri;catr),r-ilnir"o i'ril, rrr ;rliii, rtici inirrrNr-rl 6i nir:i in aftrr.agnl,ii. Atr.ofia iidrbii este bilrt('. r:rl:r, rl. r,r,l.'.ti rr tll,{: o'i ca rnuitipJe li e\.ialette flscictlatii *tusrt irlr., \p tr si lrt tr:t'ii,ri, t!e mostica.rtie, deqlt,:ti!,;e lsi tle pranut$*re ro consou.jtt:lttr. rrt(,t afectat, !n gcnelal, tL, er:erlelrsi afcc.tiuni sa Sipeieijjlil(, . . llill(1il:r!11.1 I l',. \ sj -\ l, !l'r cr,r.rnt.o.tismele craniot:erebrc(l.e frac1,lrti rie itazli pot-1,:t,Dtlncr, cit t:tt' t\t t t!.1(\:)tit 3i't1.gukt]"rinen:ui'ui hiitogios. Attetsriti,nttl qlte;:ai 1),,1{h;(lt, ()(! $, r,rtl' r'r':tlizlrrr 1:rr:rlizic nlilat,jr1r.li. a nerr-ulai hipoglos. lez;unile reqit.tn.ii t.t) t itltlt' ;ttq[te pot aft'cta re.rvi.rl ]ripoglios in poltiunea sa extracnrria Ilj,. lrr ;rr,.,r.1r, r,orrtliiir' rr: 1,t'itrrlc si sitnpatitul l.reriiclrrr l,id,lrn si llsist:im tra rrtr irrlrlrtr r,ljlii, soltprll dia pal,lizie ir11jl:tpri.li. p" 11.,tr-uh.Li ltiljOgios ;i rin_ rI|rrrr ('lr nl<, JlerI rartl-Tfutrtrl de a,ceeasi paute (Taverneri f.-Oel;.' :iirit.tr;r,Lrrlhial)otte lcsla s1i lrodtor: o henia_trofie a lin):ii, rrr.r,r, .r l i l .IrI r ' : r r r r r r lls or irl ri c u l .u l b u ri i ri l l e rt,ti s i bi i i tate i :r regi tnea' tl ' i g. D r,,rrL r lI i,.\tl(tt)1tt lrrtt:.yui.aL anti-ttiro.ficd (q.L4.) st si,nd,roamele tle tt-.[,.A. 1xtl, , rlr'lrrrlrr ,,rr ,i. ltzitr.'ro dc iipoglos, da,r de obicei se asociazil \si sentno {lo l.zirriLc rr cr,lollu,lti rcl:vi irulbari, preonnr [i simptome piramitlale. lr' irr,uil.rtLtnrtor*l,c fi it'ur.*t1{ttice ale g6,u,rii, cont'l,il.ieneanlerioare ttrl,.s,tv rrr':rzrr rrrl.rirrrir lrcrvului hipoglos (sinclroilul lui oollet). rreziuni trmorrlo r,i I.rrrrrrr:rIi.r'rrl. glj,ruii c'lrlili.ne qi ale gd,r;rii ruptc postc.xioarerea[iz{)lr,zi, :,t,rl|o)ttul. ..tr.tlil.o-qnu,rii ru,pl.i pottefiaurd, al lui S,icu,ril,aslpra ci,ruia, l.orrr rnrri l;i|zirr, rlind vom {lllorda, ;i sindrou,m.ele bulbare ct lntofestl,olt 'r,vr,rri rrr.r'v r r i I t ilt ogk r s . rrl lu l,rrttrliil.e lt .l?b,[e].ot otrrli{'(.lt superi,()are fto lot obsor,va, l)llrlilizii rl c n l 'r' v ll il) 0gl( |s . l 'rr r t l. i: iilr lint lr i i d t o t' i ti ttr' t,tn l ,t,u ,lp l,i rr l rrzi rrrrii rl o fi tsci (xl l tl l l ti q..rri _ d r'u l :r'l rI s r ir r s o{ r , s tr:tc rrl ,r' o l i iu l ,u fi l )r' i l l ti i i rrrrrscrrl l l ,nr. Irczi rrrri l sIi l l r,i ,r,1l l 1 :rl . I rrg rl irrrrI rrI rr i r r r r |ir rrrrrrl .Irrl r,r' l rrr' 1 ' . tl i n r.t i ndttrttru[ | l rr* ?* ut& tn,Lb(,ri so l rr ,tri l 'r . , 1lir r ir , lr r , i rr | ,trIIrrr| ri Iil ' rrIrrr{ i o rtItIi r . lir i rrrJr.l l t:trrl rr,trl r,r,r.sl trrl tsl i i [t| r':r(i :r, r llj, llli( it r 6i rrl l i l rrl :rl l rr rrrv i rrl ,r,l o r' .

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ri ttrl Irttto r1i tr: r lt t l r ii lr lx) lllr , r r l r Ir'rI i ' r trI ri t t I ' i ;i | | !i I i()I I I I I I I i 1, 1r ilir I r r r ( l I 'll, l, l 1).1| i ; l i i sl t, 1l) iiLl; llr por icit t r . t l': t , ; r r t t . , lt ) ijl) [ i s{' r r r r r llt r llt izt 'r t zii1t t 'it t si l rtt' rl l i ,,,i rt, i tit ot ilt I tr,I rt i I i t rrI rri , pr nt ) izic il) $ilr li; ( f r it liiil, ( r r lt '7ii vit . illr t ( ( 'll i l rl ri ,rrri t, vi i l ul u i palz[ t ului qi r r I r r I ir r gcllt i) li ( , \ - cr ] t . uill i'ir l l] r r lr r ljzi( 'r r s( , ( r i: r lr l l) I rtttt;chi l or st er nocloit lolir ir s r it lian si t r ; lpt : 2. Ut t oor i I u1 li r r lil, llt , {i r t itcrvii simpatici celvicali, o1t sindrom Cltrtdc liol'nrlr(l lkrl'tti't (liory I I,t rol al t., 1.969). tr' actoti et icloyli. cr i : : '. ) I r aum alici, in speci: t 'l, Ll r Lir r , lr t l qil, t t lr t r ; i sint h) Fat:tori, ttt.tno"rali c,tinpresi,ti (turnori ale glaridttor ptLlrrlitlr', 1f i'ilrrtlozr', pi lrctastaze l,:.,cele,adencpatii, llmfosarcorrno s.a.) ; c) l:'utlori iilllrtutrrl0tr (par{}ii(lite) :iircese, celirlite q.a.). 3) ,\i xtl rr; m r l, de hem ibazt i ( sit t dNt nLul [ t t i G alr : in, sit ulnt nt ul lr r i( it r t ] 'Lain ;i {ioci.n sau sindromul lui Bertololti'G arain ). semiolagic este constitutt tlin po'ral,illi l:rt11i;rlr: tlt' trlt i I '1'ablott'l' {'ra}iicni, in {olmele lipicc qi completc fiintl aiccl,:rte tttrtttr c|li' Il1 l'r'r'' r'lrt tLc nenri cr:lnleni <le o p:trte, da.t cu clemsili-c s(xnioloiliot) ll.o tLrirrtl, I rr|i:r 1;i l e, i n funcl i c cle sediLr tinil; ial el leziunii. il f olt nt 'lo int 'ot r t lt lt 'lr rr lt 'r t t r r rlrotn t1o iii:nihazri. tttlii ncrvi cr:iiricni 'q1ni,cruli:i1,i (f1'{'ill rrrrlil.rtit'rt l. r inti ftecyentil), i:lr nltlrior afect*rorl l]ervilol ci'lnicl]i sc {rtrro lil'tlitt rrlr' rintcro-postfl';or, fie riin srns }ostoio-alltotjoi', oll plirxlet'i'rl iirilirll,i lir' ' rrcrviit)l; c1':1ni{,ni ijlllrl(l lrltl, lrl rlin fosa oerebralai mijlocic, fie I ultilttlol (1r r:ri ' Ti crarL ioni ( I Jlom or r t i si cr ) 1: t b. , ide. I logcr f ii i'olr r J, . ,llll; 1r r ' 195i, cit a1 lillri:illilllli n(llvi rtitlli{flIi {i,' i)irllr ir, iri lite situt,irii, ito llot :lio!:ita li unul sa'.1 ;,ontloittterali, (Arsol]i 1i col:r.b." 19?3; Iloiler iri c(trlJ-), 11){i1i) Gr;lcirt tL'-t srr sl)rrr,rl('rr' liultir ;remc, itr tvolttfiil sildrotttt'lol romni: dc ltitcltonsiun{r intracrtlltiat}li , cero iw|1rc ndosea1,xl'(!iv'{ r, \IItrl,r]' tllncit) 1r'rtl rltr lt.rrtr r'{lcruihri pi1:iht', r::u'o aIliie m:i t.lci;rtrnc. ll s i11{1ro i"lr::rirm sc ilcrrla'azii, llelltle tls ltziiute lt, triittlrilot' senzitri|rr sr'rrzrrIiirl{ r rr rotorii iltr':riier-r"ilxialr. de i'u:lo: ti et,olttgtt-:itti s iiztl toa ,tictor Cor{:i.11 h(ntib,L.ii. ::.) ' 1' t.mor ile: t t r t nor i oll] 'N sil {lt }z\ - o1t alir r ir r sii; i lr , lzr i , 't r it t it r lt t l I r i inai , j{r ss; lLlr ll{'^t lr , r t lr iI r 'i lir r , ' Lri )Irorici i l l l rI ] ct di] gr lccl|i't lin: iil'llct vol b:l de tum oli linola, r it r giclr : clt o it l lt lo: t zf i, bll: r ll t r lr lt r it t lt ii. ( lr 'lc t r r : r L l l tccventc $i i rb t r r lt lof il0 a, t t r ic: ulllt ', lli'lzit lc.r illLlr : r l( rsi r t lt ' lr t t it r lr 'lr r i ( ir t r l' " t .r,bi cpi l cl i o:rmc alc : j1) af jiloi' bazalo poslt 'r ior t lc it i r llc r iilLt ut t ilt r r ',r t t ir o: rt r r '' i i ml l sartl rl l trl o : llo l inolar ingt llli, llit r '( i ir t vllil( r lLzi'ot r lit it t l lt t ilr r liv. t r l' r :ofrrfl l l ne), 1r s cut it 1i t um or ile 1; tit nililt : lllir t t lsclot lllL, zci i lt lr ' l I I I I iI iI : , t 'I r ; sllcoim c qi osl, cosllco: t t t xr) ' }I r lir ilr csint Llilt t oliit r lt t t t r t l' ' { l i l rrosarcoatlc, lni Iitr.\taclri(), ir,lr:}nlalului s:t,l alo glandclol sllivltlt, ({lrtr;1'rriilttrr rrolrrl, , ;i I 1l )l i 5; ,\r' sttr i ; i r lollt 'b. l9?4) , llli"r t Lr r l ; i t t t r r t ot ilt t r r it r I lt slilt 'it ' r r kr lr r r zr ' t t rl l l tri l ri , r,i t lt it ui. l r lir lllr : r , alc r lit r ciu ( r it t t xt no llliil) ) llli' sllt l 1 t tI rt t t I rtit t r' . i i i tr ti tl l l rrotr,t coil'illo, I , i'( '( r t t lt tli r lin lr lt o l, Lt t t xlr i lll0llllolllllt t t t t t t lt t t ', : r lr r . rl )i r,Ii l l ,ul tti5tr ir id r , i r t igest iv ( , \ l; cni 1i cohlb. , l1) 74; jir - r gcr '1it , olr r lt . , lllt ; lt ; l ;{i r,)i n1i [.rrrtt lnir 'r ', 51 ; {llalll ; ii r olr lb. ' 10{iL) . ll] \1l ;s l rtn t gt i lllt c llt t l, t lt t l, ct 't r t it t t tsir t t lt t lillt t t l t 1o lt t r r t t ilt llzlt : lllt t t t 't 'l l, t ,1' 1,i rl ittl ri rl t' , t r t t 't Lit t git t lt t t t r , , ' t I t r I t III 't t ttI ill{r .j ()r I{1 i II I I j i slir t lt I ot 'lr ipil'lr lr ', 'r r rrrrrIIoIl l rrr.l r r zr r lr , , i, t t t r t ot i t llot t t it r t , , lr llt slt t r xr ilo: t t t t lr ,t t t ii'I oI I r r r I 't t t t lllilr lr ', lt or lt ll. ir r {. ir . ( liog( 'l 1i cr r lr t lr ', llllill; \ r r il'! r l I ' Il Ir,r' rrri trr' i ,rit r lr , r : r l: t lr r i 'i , ol ,rl r., l l l i j i ll) i 1) .
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, 11)u'lt rylrrlittrri t 'rr: :t t t . , rt r : lt r nt t r lt , t nu l lr . lr i rx r l i ( I I I I I i r| | | I i ( ( I t r i I I ; r r r r u . , | l l l ,' 1, , r' llll rlI Ii,og r't ;i r . olr r lr . , llt i; ir l; . r r . t t ir t ur ' i t t f . t " r t r , t r 'r t n t \ t t ( , 1 ( 4 i l t t 't , i t: , ' . t tlitlt illt t n t (l(is''r'. 1lJ 5: l; . \ t . f ir ' li , r lr r ilb. r 11. ) 7 , 1 ) , rlt (lixlitt tro :rlt tinliLjplr , ( , r L lo( . lliz lt ( , baz ali l , \ r s c l r i s j f ( t l l i ) . , l 1 , i , l ; lj,,,r | {,rl l).. t||ri9 . / . ct r rirr,
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ll'. isl,rr roitlrnorLte fornto partic[ia.r'e dr: polila'Jicu]orcn.ite t.ririiiglo r l, trl r (lr r ilLr ir r - i3r ule , c n a l :e c ti l ,Ie ab i l a te rn l i i ( ul eor,i predami nal l t rtl i l. l,r':rl :r1 r r r r llir |r 0] ot I J ? l 1 ,tue to o l i i (i e rre i l i e t' ani el i si a ocL1l 0tl l ol ,r j oi ,, r' i }, rr ,Ii rl rr.i: r I ir rr r llr ur lir ll -c i to J o g i c :i . ru g e n n e I,l l IG cl e ]{ ' zi ul rc trcr.,,,_.,l n 1r''rrt.l l i [:, s i I r r r r r - ol i e fa r-o | r.b i l :],(Iri s l e r. l 9 i 6 ; K e1,z si l :{ ol derror"111i 6; ul \ l rrr.,rl ,1i I lr r lr il' s , 1l|fi 5 ;l l a v t, 1 9 6 ? ; l l o p o ri c i u ti P xsr.i r"i !1,!1). Fi ri l tru , r, ,,i /:l rt fr ir lr f ( ) pllr it i: ilu tn rl rl i r ,,s i n a l l ' { } tn ullu i Iri shtr:,r,{Ii etz ;i f{{ ,1!l !ti er' , l! ,{;). l/ / I rlolr. titulrtrt t( ll( u,nqhi p ctri<,,terth ot Il{}t ilrtt.rni jn uttt!t'.':tttl el , rti r,l t,rli,s i lc z ir r ni ?r l ep c re fl ri l o l II. X , i i (rareol i ,ri al e hi pogl o; I i l i i i ), -\I rr rlr,'r r.lri |rir lt,niori (nlcnir']1^io:)rner tur] oli c}itlermrli(lc. glio:rrti ._ereI , i,r r . lrlrrrrrrrgioiln)(r arl,{rbol(}tse: tllrrri]r"i:r,lcpilrlii Lltelale ii !entrir,;lnlui r l 1 r:rt:rlc ir , ir r r r ur r i r ir .r o n l u s j u g L i l tr, tu rn o t,i mettrttrtl ce, tl ent.i noi r.i t;e l e ii !:i '|,, rrrI:rl ir r I r ' ir r r r r r I r r ag r:Iu i ,:i s p i n a l u l u i 1 .,\.1 ,& ]..i | * i (j i di .i ? i sl i cr: 1i .,:l cr ' i, r/i t )t:tn t i tlt lnint ) t i; ( de (i ' i (rC .t:( ,e b rud p ' i .l ta ti l ,rrti (A l aj ol ani l e qi r:' ;i rtl i ,. r'rl :r : l i ,r , t lr ; ir : olulr . , 1 !i 6 9 :1 rs e l l i ;i r' i i h l l .,1 9 i .i ;Po l rot' i ci Li si P ascr,l $31). l"l;1.)t[{'cttunl inlranelraxialtr cu loziu}i lr}ultiF}c dc nerri eratrirni.

| ) ,'iitrtI*ttrttrIt rIts{ti|||!t'atLt:ttu,ttclti ccrebrctl, \1 ,\i t t , t , r r nt rlr lu tl b (i .t' l / ) ' \ it t , I nt t t r t l ] nt tl n !u i i .q 1 L (l i l rri ] o i t, ,U ,i l l entoul .ti S cho{.i), tu+ l '. , tt tI t , , ,rt rt I tnit ).tl;t'tt ul ltti Dljirit.t, :ti,ttl,ro'ttt.t[ itrltfuLitrr a[ !ui, ]Le|/toklI', ttllrrl lt,:lr'tittt xrrtr.h utt i;tlr:t1itr, oltr:t,nir ittferioard) .qlrtt tiduae selri,,logic lilteta][ jn1'eriotr.t! (r'esi.x,t.lintl t,r rlr , l r rrrjrrrrlzii itrrr I ielliJr lclil.ieaoI)1r'ri i. rr, || r i, t ir Lil( ' lr , ill) i (i i o l l tl l i i l l i ta tr!i rl c i L u l l l a re, i .ri scl fi ti ilr ]neor.i :i i ' l c o ( r 'rr i rrl lr " . iL. , . 1 rI i . r )(,j II 1i { . ri e ti p ta h rffu (p l i n l ezi i rl ea }rel gi i ci i i ri l i ei l ) r ;rr fr l r r I r r liz ir r ir r r ilr rtc l l tl i a , l i tn b i ;,o u :rl i .)fi o si cu fasr:i t,ub.ti r, ai ,,,,ti ,ri ti l'. ,rrrr i i ,,' ; r lr r r r r iLr I r Li i r l ri p i i g k )rl rl u i (p ;i ri i c z i n n ca fi l l ,el or r.arl i cui i l .' ,,al o t : r, , tl r, ir r t , r r i|r . lr r l 1 r;r'i l i r,:r-h rr]J ta | i tl i r:g i l tn e a i -i rLl bar para rri trI i :rl i i ). i I rL l rrl r rl r lit liy , t : t t , it ui r ri l L l tl tr s i i x l to ttr, ]-.tj ti l tz j l t nerl attrl l ' l rt zonc j rrl r' t,olr r rr,', r'r illlr r lr lc c io 1 i 1 _ l rrrrl i z i eri b ,ttrl a l :i i i pel cl hi i IItr i pri n l r.l l tzi rr l rrrri rr'l o I r r I l, r ' l| s lr it [ t I ( :l] l i i (r' i o :i l ' c ). '' I t : ; r t lt t ) t t t ul li ti l ri ' l l .i :: (s i l i (h .o i tl l tI n u ol 0ti l Ll i l i nr]-,i g1111) i .,!rsl i r lr ,l r 'r l r ' ; - , ir r r r iz ollr i::i l t r rrc l c trl tri l rn l ri g rrri (I]i, X ). tr,l l duri r sel r;n]r,:tj r, rr g rti . so l :i . lr rrtrl rl rr lt r . r r r ipr r lr r liz i l l ' rrri rrg ol a ,ri rr o -r.r,Io p a t i r r;1 i )r tl l l l l () , r o',l ri tri rt r , r lr r z ir r t t r l ri r rtu i rl l J i s i :i fi t!c i a .u l i i l l ti n[)i r]otrrl l rni (,fl i l l l rl rr , I r'i rtrtIl l' lf lr z lr l, r r lr i | rtl i l trttc z l js i /rl l .rr () h rri i i i ] ri l rrrt,sl r,zj1t.r' rrr() l ,' i l i Ir' i o l :i t rrtL Il rr|rr I r ' r ' r r lr i, , ir lizi rrrl s i rtrl n tz trl l tr.i l )tti ,l ll ' ol .l tl ri tt (l ,otl r si l ,i r' trr., tr ll)ti )). i rr lr r z r t lilt jr r ( ,l ,rtf :r i rs o i .i ;rrl l ri f,' trl L rr l r.trrl rr.l ol t-r, l i n l r' l i t,l l { ,,r tl , , , r l ,ttl tti r lr lilir r t r r ) , t ' rttl i rtl z .;t ri r,,i r,,rttrtl i ri ) l i l i rrtt ' i .l l t trui l i ,,t:l t | 1 l ' \r'r' , I ' lt ilr ) I :1 4

l ' , E i ttl tottr t l lt i St lt nt r ll 1 t ut lt ot t ui t \ t lt ) : 11) int t l) r r t rr lr t ir t t lr lc lczt ) slt tttri i tti tcl rrttl tti 1 '; lgr v it t lt l r r l : l lill( lr 'lt llli slr illill ll( ( 't 'sol, slt t l lt lilr t 'r r lt r t () il l rl l i l rtl rrl c l t,k,ttt t r iot t lt ii v: r , 1or r lr it t ; t L Er r lr t ir t lt git 'st l t r lt t lt llt r t 'izt 'lt z; I l lllll V Itt:rrri prtr.l rl i zi c Olill', lir i, illir , lr r , i, r 'zilt , r '\ 'ocale, st {, r llo( il( 'j( l. ln, sloj( liir lr lt llli ' ri, tlaoezului. '.i -]iip{ )sl( i(') irrlr'rl ('{inthomul vag'o-s})in{} 4 )-ELnrltontrI lui Jotl;:'rttt' 's ( t it t t r t t r r r l rett{ l ; paral i zie unilat er alii a r er \ r ilor ct anioni I X, - \ , \ I helniparez'i t()lllrillirl(ll irirr le cal'c se poatc asocia o .lirlrLi ) ,si \II, ll) {i- }; I t I t(I (' (' I I I'I ' I , tLi ni l [ei rr' ' i A l rj our nir r c, ] 935, c t ai' de Loeb $i ] I e"Ye] , 196i ). lui -{r-el1is, Srhurirll iii 'lrr('lis('rr -{rn aruintit an1,eriol'cir sin(lroan}tlB l r,i rrt,cel tl l ai ad eset j de or igine l}eliiet icr l "i I l|] coli r i. c 'r t 'iililr t r '( 'ir lr r r li] . cl l.ezultinil dinir.o-leziune l]| ]}el]-il(' r.enpo.ti\ i h lr;r t.lul g]i||I]'ii |'l||)l(l (} DoBteri{}lte san al sr:rliuhli rctluntili&ll llr r'l1L'le (irl'rlli ilr r'lil'(r s'illl I)l ir: iir:r.,srt rtu.l,tttt elc rezultii dir l6i,ni iluso printr_o ati'gire br lb:_''ii, (litr l|zirrlri l }Jedsebi iu,noruitl, intrlr, SaI etitrabull-litr e, ii nttrtrtti rrll('oli fie srlli'lililtl trlll Irrlrrrrr) i,usct are,8:lre realizeaz:Llie sLrferintc pnr nulleartl, (r\l)lit'rr' pirr nllcl6,rl',1,ci li aie altor folrrr.L{iril,i tiirr r''ertl' zt,)l}c,'frel oc ',rsocie'e:r, tie alie sinptone. rlupil ll.rr ltnriltlit-:rr tc'iot'(l'ii;rrrt1;lrr': si ''xlir rgOi, !os"" ;i cohb., 1969: trir-rpor-:iritsi colttr" 1llE0; I'oltrrlilirr 'i paseri , l gsi ). fn acest e'nlf im e ( r it z1l1i se m ui lor t c lolir i t jt 'sit r {lr r ) ir r r r l n[ ,\volli.q, Scbmidt sau Jtif lisoir' ci rie fallt (le lrl irutl'(l rrl(' t)rue. ,,cla!icoil 'iio,ttu".n,, 1"llsclilalc bulbrre asindlom rctr., olir-lti \1-itllcttlrttr'. ,'. tio,,l (I'opovicirL si |trsdl, 19El; Jlrltttt i.itt 't r;espectiv sin(lr{lrr interoli'll ) .ol ab., 1f180 ). :i i 8 iti.titontr1 lrttti'cl' ctl tttttbultri. o'intlrorttrl listrt'ii [tullnrr Iultttrl" xrrrr*rtr (uL l.u,i sittt",rc,niu,l,':'et]'o-()1.i1:qr D, jt,i't' I' sit'ltuttttrl ltr'[ 11-'1[lt'ttbt:r'11 (:?rebelodse Ttotl,irinlr:rioar'' ii' c:rttr tetizr::rzi s.riri.l':ri' ,ii'ornt,til arlcrd : rurlltoaleLe llil (sau lttlntiltilrol '"" - .!.)r',tc,,r,,,Fi Parl', t:J lezitnea : e) IJemianestczie rnaj ldesea disoc,iatr: (terrno-algezic[ ) ;i Jocalizrtlii rrrrl|rr 1;ezit) fa'tiali^ cel 'I ullr r r r l i i i " .l tot" ,,l cf t alm ict ihi; bt .r-oclllc ir i r l' f our lio . 1i t lc r lr r glt r li{ir ' " " fri i ; t1 Siitdrotrrrtl Ultruil'r li('r'rrrtr'.l {i,tr.,t .',i.*,tgtti1)6i ptrraiizia cotzii coloanei sit nl, r lir c r l) Sit t , L'. r r Lve. lilr t r lr r r '.( li r r ir r r r r l i i rrt.r" , l ,ai ri t" r iuir ell . '- , i. . r r t Lr ii. . r 11rsr t r t t t r r tt' t r tli ' L,,ri .i i ,i o-l ,:iitl i l n nasc, gr et , , , r . iqii . t r ir t r : r nr t t t ', ; i ri i II I I I1I i II I I : t llt I rLttrlt llt t t l it t li't ior " t l l tul nl ' e: e) l i i mi siniir ijr n 6161s11sLrrs. I , I { (rl rrr:I oPi, sd: I t il) o^'t czi" r lisr "'i: r 1r '' t lr lr r ! r 't llr . zj( 'i' { -' f,)t Ttu, r lea i', r I r 't 'r I : L1I''' r r ilir 'it ' t r r r r l" rrrl t' rca respi t,l ,ir r t l f nll ( nu t ot t lcr Lt t lr r l. 'i li111r r 1 lr il l) 2 r : ', balr . lliU; r . j , it , t lr oDt t t lt r i lt i ' ' :r.i ii,.l ,l ,.ti" rtat'ttr ( j ,ste l ri r,o r nt sii iecnlt o : l, cir r i, r r l, r r , / / t l, , . lr uit , t i, (-,.oziPopoviciu Fi ]'r.'irltl' I llSll : ll: ol[cttbt"t'!l ' l " orntu r i' ttl tr ; t ir : r i, 1i1r icrlllt 1'lllli il t {) st r lcr r 'r isit t lc f \ ir ll1'r r lr l't l ir r l$ll " I r,l l l ri rti i ,l rti ti s1 1s. ( r l) I ( t r r lil i i i tul rotttttlt 1l'uL[ t , nlt t 'r 1't li] 1i"' it ""'l'l't ' 't t t r . lr r t xlt : ir l. r f i i. t lllil( li i, 1r it r . I it I I t I t t it 'r r l, ,rr ,,l ,rj r,l t,zi l rrr , 'r I r li( , lc1l1li lr r r r liiJl't r . i t '' \ I r Li, lr t 11r 'ILt |ir t ! I t t l( lllt t 1,,,,t1,,ti lt' {rl l l i z ill( illll sir nlt om 'i'' 1i1r '\ r c}] isl11r 1 , l ,,,i ,i t ,.i a,i t,,,t, , " i. lit , i'r ', nr r . lLii 11. lilr r r lr r r i sj r , ir r lit t . s f , it 11 I r r r ( i l) r r ( r r r l r,:,l rl i ,rrri tl i zi l l r lllr r lt st r llLr r t lt r r t sill( llt ) r r lll( 'lr lt l'lilr lt r 'it t I '( ) t t t 1t I I 'I . t I I {I ') f r i||( i|( ||t |||I l ri tl r,sl ,l rrr tl l tct t r r is, t 'r t l1r lr t lt slr ' t lit lt 'o llir t t t ilt lt t r slczit " t t t t t ilr t ll( ) r t l
( l i | r t l {\ i i t 'l l l i l l ( l r r r s r . l t i r r r l r t r r , I I i t|l rl:rrllllrr' . t i r r i,r l l o t ttr r t, ttr i ' i :i ( r l l l t) ( r l ( f l |zi tttto l t ttttt'l l ,ttl tti l tttl l r i l l tttt' r r l r t ;r r , tr tt l i r r r l to ttt r t'r i i l r tL l r tt l i ) l l l l r r i || I ( 'III||i II l ,l r r tr ;i l tr i l i rrr l rr r t t t t l l l ttt l l ;r l r tttr I'i N r r "r 'r 'l l '' ( 'fl i r " l l l ;r ( 'r 'r 'l l r ,l t

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l r, ( l rl { i l 1 r'r, tr I ( |r I ( r I I r ii,, it l l ,i i ,v i t,rl rt,l rl .r t' l l z i l l tr(' i l , l l ,l ' l ,(tt' ('iitst' l ,r' iIl ttt' ttl l l r l l ttl u irrrl rri , rir r , r '. t t 1l' t r t k rttti trrr' tr1ri i ttti ,Irrrl -i i ' Iii , l Jcl nl l (fl ol ' (l o.$fl l ori tl l i i l l rl Li rr Ii lrr,i r.* i l ii, r , lr r r ilr r ilr r i (tri g r,rrrri rtrrl rl rri rri r (l c o b i cui i udoml l l ] vl l go-i i pi nl l l tl l r r.:rl o Io l lI l, o l) u1; in& 1 ,i n s ; c o r' D ttlt,l i rl o trrL s i n l Lcl ei i vesti bul l ,ri si nt l :o{l ,r1]{\ rrrir.r'r,srr,l,i, irndc rezdltii rin ;rt:t,tr';.ittdt om vestihulo-cclebelos, ctl m&r(! r[c l czi utri i l hcmi r,.r I.i i . r r r r r r i- i, s inorg id e c h tPla trn i o !i l &l c ro pul ni c de l artca "Bo c, , t' l 9 6 i ) ; (e ; l i n droamol e bul bare nucl c:t' t r L i rz!)rI lr ( , i, ll) 07 ; in mod exceptional lezrlltir' iz,,llrk' (Avcllis, Schinidt si Jackson), care

;i;'"i;f;, :'k'*;;;' *r itl*iire

1960); rl., r'l:r,rr I.rrlbrrr':rri scncibililal" (SaradiiSvili' i SIr,!- ,\t-cvclidze. lrr lr,.rrri:r,rr,,.lr.zi(.alLerni rlgnzi('ir, fali Ii pc hornicolpul opus; pc l'rmo r.rr lrlrrriri,ttt'slczic termo-:]lgezlca! contrulaieral:i, ; cu tulburriri dc sensibilgczicS, hilatel'ale pc faJi, iar pe cxti'cmititi doar tle pa'rtctt' lrirr,lr { r'r'tmr-it \Tallenberg ii,ri, tull:urili^ dil pa'rtea cor',,trrrrii'lozitrniii 1g1Sinoro:r,me (I1liJu, 196i, ciir-r,t Popoviiiu qi Pascu, 19$0); (h) Cazut'i cle ,.rkrl r,,rr,rt,lc bilarerah llc foir'i,pre"uul 'i ''aztiri cu tulbll, rr Irrll,itlllriilt' s, nsibilitrr,t, dar r':ui sr,trzil,il'c bilate-ra1c, lucitlizate tloar perioral, inciusiv pe 1imb5, ctt :r.:rrlz ir. lr,lt ii cul{r,b.'i9G;,. tSr ' cu mai' entiinser. interesa're fi de t,,,riit srnttolc,ltice sindrom lTattenbtt'g qi (l${'l}) 19i?; Scholjt gi cohb., 1965), care.ast ciazS,. suferintrl t),rrlirri, i,rr,l,.ilor''r'r'llnicni li VII $i chiar alectarea fasciculuiui piramidal (clt VI 1r'rrilrr,rozi'1, controlal,cr:t'lii), sau forme in care coexisti' qi trulburdri vasotneori cu algii &sociater,r,rl,oi (ctr orractci' :tltein) fi llgii hcmif:lciale'ii (lsch, 19;7). S-t relat-atsinlrcm'tt'lsub-bulbal lr,,rrrir,rrr';rrl'it1c corti,ralatrale qi llpocstezie faciaii, siadrom cerebolos ClaudeBernard -,l t t i ();alrlii (crL -palte, hemi:lnestezio clisociati qi eveltuaL hemipa-rezri ll.r'rr.rl rl. rr,r,r:r:a'i I-XI)' lchol'lt 1ri lrrrrrirI rriii rtlrtrrilaieralS,,dar ldri atingerea ncrrilor , .i r',rlrr,lr. (l1ili5) qi l?0poriiciu 1i colab. (1980) au -rclatat,. qi sindroamr! {le irrslilil;c si de sintL'om Pa,rinatd' 52111 paralizia perechilt-rt' \\ rr'llr.rrlx,rlu supe'rioar(') )iittts{r.i, Icl'in l"zi:Lne;iaarl.rci |crcl'ol.Jtl'{c Ill r .rr,'il\ crt rizualc de rip uc'"ipita). hAm!anopsir', asocjr'1e s,',i ,i,..,,,i.,.-i irlllrrrtrrri alcxic (Ilcyer si col*b., 1956; tr'irchor-$icolab'' 1961)' r .r'ilrlr coli irLlii satL hemibulbttlu'i li ) flitrl.roirtu,LLui lJabinstii_Jageoltc sau' sindnmll t el i zeazit-\-ageattc sr 'rut,t,,,t. \iu,lr,t,,ul clqsi" ,l I'L; B';hinRt:i 'arac bcmiplegic nohtralatctali' plin ll('llri ,.lli,'f,',,i' ruir, tt"rniftnr.'r:is",ll ronlralale[a1- pe.llelrulafa ]l)nl' 'rrr...l,.zrr' r,r,r-iulg"zicli benricoti:ul p,' \si Icl somlrir (ipsilaterx]c), lllteropu-lsie Lhr,rrl,r, IrIi|I tlisrncltir',Il,sjnergie. -prl'n de ocglurllrt' l'elopalaLuft. (,r'jplin Lerrriparllizie t'lt'il:u'' ti ulr( .tulbur';rr iphll*1''Iali,o corzlr vocalc' .r rl. r,tt Iritc ii Jlriu l':lliLlizil-l, 7 | sittrlrotntr'l lui C estan Chenatls este asemd'n5'tor cu sindrorlltll t,', ti,,r,it,*i.i N,ignnrt,', irr labloul clinic asociind totdPauna (pe ,lin'{itr r,cestui sindrom) qi semne datorite tnei - leziuni * nuc.toullll ,'i,,rrr,.rrilkr a r rt|l)i*I , l0rlpoctrY cu o par:]i;ie. ipsilatera15, I'[]ului palatului \i 8' corzii ltt'i otnt+I,lLutJleLtIL[i Dei'tart se caractelizeazil' prin crizo vcrlri' ,\ ) Uirul,t r,ii"r"'iri,i *ii 1,t,'',ir,i"nitlc 1arl,c:rlcziunii), nislt'[inrus orizottl*[ si",,'i"1.. plin devielea braiTelor sPro i,iii',ii'i',5i ",'iti?,tlt $i/iau rotatjor)' liur:um 5i
lt t l, (' ll l(fzlllllll.

},iind pe prirn o"itnlirau ; (r) sin{l,roame

le l\) il in tht ru nt,tt Potttitrc r.r'rr I ) fiitxlrtn ,ttl ht,; "ill.it.t(t)d,-(il.bld. lizt,ilzri,, solrriologic, o lxurtlizltt (10 l )n' l ' czi l l' l {l l l pl !l ' l !l l zl l r rrl i rr,Ir i, ' I r ir t if lt ilii,ilrs i L u l r' r' rl l i ,i n s o { ' i l ,i i ' ,rk r o l l i cci , l !(l

rolrv('1'g('lrlr, llllr 11l tttuilrlrirrltri dlt,pl rrxl'rrltt, rlilrlopir';li sl,tltbisttt illl l)t'c( ltllttcrill?l. rlo o Itorttipltrcziis:lu Ltotttillt,gir, r.ottl,t l!) lli,nilrotnul, I'or:iLIc irt,lrtior sau sindromul Itr,i llot:i.llrt-llillurrl-' (irLbl,a: ca,racterizeazS, prirr prlldizia rniqcSrilor ooniugatc itltr ttt'ltilot' se illr'o palirealeziunii (,,paralizieconjugatii direct5,"),plin paralizitt,lrcrvikir' (.I'lLnicrri qi YII, iar cind leziunea depLqeqte ele dosi:tlo alo l,lrllfii' zo YI rrpilrc qi o hemiparezh contralaterali. Se poate asocia ,si o hemialr('Nl('zi(r il rlternii facio-colporald (facial5 ipsilaterali, fi corlorall, disocial lr'tlirorulgozicl, de partea opusi,). 3 ) Bi,ndlomul lui. Grenet satt ,,paralizia sen.zit'it:ri"tnutt,ci;ltir consfii rLirtl,l-o a,restezio faci:lll ipsilaterald, (de obicei termo-al61ezicii,tlirl tttrt'oti :i globali,), ;i ilintr-o anesteziepe h.ernicorpulcontrolateral.,{t[r'st'rt,sl a rusociazl paralizie ipsilateral5, rnuschi]or mastioatori ;i ttn hcntisitithottt o r'orebelos ipsilateral. 4) Bi,ndromul lui Raymand, Cestan (sau' tiptttl str'perior al sitdro' ttului lui tr'or:illb t'ealizeazia, semiologic, o paralizio a miqci,rilol corlitl$Ltt" ) rr,loochilor spre partca, leziunii, alterarea sensibilitiii,lii supelficittlc r1ilrtrri unale, semne cerebcloase (ataxie, asinergie, dismetrie) $i milcr:,lj (lo 1ilr .,rtrbric" (atetozice sau balistice) la rnembrelc contralatoralc. i ) Bi,ntlromul lui Gelli esl,e asem:inXtor cu sindromul lui i\l illr,rrl ( lubier [i cu sindron]ul hLi Raymond -Cestarl, dar reaTizeaziu1ri' 1t'itrt lrlan o leziune importa,nti' a perechii \rlII, cu snrditate ;i cll r','rt isii, plcc1111 cn lateropulsii de acceaqiparte cu leziune?)Ia cnrc se iuso('iir,z:i Ui l)l,r'ftlizia motor-ocrllarrr1ni extern qi paralizie faciali. In cazuli]c cu lt'zitttt,r irnportanti, a nucleilor cochleo-rrestibulari' se impune diagnosl,iclll. (lili" lcnlial ct rln proces tle unghi ponto-cerebelos. cerebchxr:tir" 6 ) Si,nd,ronul lui Pierre Mari,e-I'oi'n saw ,,hetni'pa'reza u lni,' Marie ,s'i Toir (,,sindromul latera|') inminunchcazS,, $cmi('|)git'' lulburii,ri de echiliblu ipsilaterale, cu clismetrie, tlisilergie $i dindill(l(x'o llrinezle, rsi, exceplional, semno piranridale conl,talateralc. ntioclonic al trunclzittlwi cerebral &l lui Gu'illain, llol.llrtt'I 7 ) Sind,rom,ul ,i ilertrand, (1933) Bau sindromul posterior aI calotei (Sohotl ' ll,6?) se cara,ctcrizeezi, lrin aparitia unor mioclonii velopalato-fal'ingi0ll('' rrtlcscalimitate tloar Ia nivclul vilului palatului (',nistftgmus a1 r':"r"hrhli"), r[lr susceptibile si, se ext'ind[ !i po mufc]rii felei qi/sari ai lncrnlx'nllli sr perior fschott, 196?; Popoviciu qi colab., 1.973' 1980; Popovitirr 6i I'rlscu, 1981). ,semiologic lrtlrNl i $ ) Sindronnr,l,lui Gasperirti, cupriticle nn con1,cx1; lrrjt riintr-un cleficit al neriilor danielli' V' VI qi \rII rle o 1:altc, rriitx'iit't r rr hemianestezic contraleter'&l:t tcrmici, si durcroasii ('I'roncorti si l\'lottl,rttr:tli, 1960). ,li !) O.ltalm,oplagiilei,nlertt'1t'clettre lost c).prlsc dc noi llnl,cliot lir sistemclol oolrlor)lotorji. 1rrr,l;ologia O) Sirulntu.trn'Lcpetl,nn<ttlure (nte;c tr,eltr,lice,): pr.',r'rr'nttt],'iatt, utrtlt'r'1, I ) iJ'intltou,u,l.ltti lfr:Jxr, si.ndrunnt['Ttr u,nr:u'lctt' sILpo'iorLrii' At\ d,( i nrl,totrtr.t,l, ?itJiat pttl,tr,naufttr (srr,tr, htrniTrlallia (Ll,(t'i1.i1' ) ' lil it iz('rr,zir, rr,t'il,ct(ff lrlitrh'"o prrtitlizir, Ir'rtt'ltii 1[ Il[-lt il)silltl,orillii, cllro no ' .tooilr,zi1, pctt'r'llii tiltllgirr ('{)lllrtthll,{rt:tlii,..l'a,t:tlizirl, o ltort ti;tit,t'ozii, ltt'tt stt,tt :r ptorltttiii, itLllzittttlit, r,it liIrt'r'krl tIttIitIrtr,stxr l,oillliilir,n plt,r'{irr,lii csl,rr llI 1i lrt lonttrl, itr {t'rtilllul lttr pt'itrltir,iot'ttl tttt'zt'ttt't'frllir'. rxltrlrr,tultti r,lc lir,rr,, rrurt,ol | :t'i

, \r'rrl l l r , r ilaI i/ , r ir r r r r l r l l r/rr' l rr.l rrrrr,rl rl rrr' n l i u l t{ r, si utl nntu.l \l thtt' l)t t)t it trnrlitntlttl itr. lt'11tnrttlu.l)| tI | | |t t ' t| | t t t . r'tt prttlllizit: 1,o1;itlii l)cr(r(:hii lIr , I r rl rrl l l rl i i r lr , lic il nr { r i, o li l l rrtc trrIrl r' Io r' IIi ' l ,i rftrtio p l rs?i .

\\ lixisiii si ,,lirlsesintlurattto r'blr'", ltlirr alcvlism localizatle iilturr' posterioare'p(r al't{ttil irlr'i,irrl,olrri, in r.eciniit:ltcil lulor'(]i crre,b]ale 'rrlol .orrrrrrrir.irrrl,i, pirsterioari,, care complimi in rnod dlect nervul IlIr pli'r rrrrrsi lrir.iotttl poduncular (Ileadorvs, 1951). ropu (sau, sindroanzeleltedu,ncu'ln'edorsule) :! ) Nirult'oameletrucleu,Itr,i rl, 1rr I i rrsI fol sistetnatizate(Loeb si lfeyer, 1965 ; Bodechtel 1965; Popoviciu ;,rr lolrrl r.. l9S0; Popol.iciuqi Pascu, 1980): qj ,\ ind rot.ntele royw: i.nferi.oare rLttaleului ule l'u,i,Claude-Laye?j ("'(u silldromul lui Xothnagel se ttt Ni'nrlronrul ) r ,rr':rr'1 priritr-o paralizie pzrrlialii ft oculomotorului comun cle rrlizrrrirz,-r de prrr'lr.rr lrrzirrrrii lrrin tulbrrr:ir'i extrapiramidale ;i cerebeloase partea ;i
r' lrlli: 1.

l{)(iliI rolnnii Ii/sr,u rrrrrlisrro (Aqgin,tr Vrriu,,11)l-rl3; 1rl(irrot,ico ,,si l.)01xrvioiu, l'rtyrviciu f i -^Dgiil,r, 19ii8; Aflgilur li cola,b., 1975 I l'opovi0itt i1i coltlt., 1980). II) Afecliun,ile inJec,lioase imunoalergice d,etntnah,i cercbral (polfur\ts'i cirfitlitels de tip inferior sau superior, rombcncefalitele, sclorozr rnull,iyrli"l, afecliunile demielinizante inmdito) produc variate tablouri srrnioqi logice, cu configuraiii variabile, complexe, de lcziune a norvilol orlrriolri, rle cele mai mult ori nesistcmatizate. III) Bolikt eredoilegeneratinte d,egenerative .:i implioS, do ascnrcll{ll, k'ziuni ale nen'ilor cra,nieni. A) S-a conturat incleosebi entitatea clinici denumitS, paral,izie lt . lr.r,rd, Ttrogresirti (P. B. P) a adultului, care realweazd,r'tn contexi Bemiologio crr:ifectarea ilegernerativi, a neuronilor motori din trunchiul cerobl'l|,l, lrl |Jpecial ultilnii{)r neryi emnieni (do Ia perechea a Y-a la perechea a XfI-rr,). ai .,\celsii, P.B.I' I'eprezintd, doar un $inahom in cadrul unor variato lxrli r)curologice. In tonrte raro cazuri, P.B.P apare in mod singular, oil oonsfituind cle cele rnai multe ori o modalitate cle debut a acestei sufcrinlo rroulologice. ln cadrul P.B.P: unii autori inclual qi aspectele serniologioo din scleroza lateral5. amiotroficd, (Norris gi Kurland, 1969). Contexl settrioluoie Cele mai multc ;azuri tlebuteazd, cu tulbuldri de vorbirc (clificu ll')l,t, i de fohalie, in special cu rinolalie), Apoi se asociazS, dificultd,l,i in doglui,i{ia lichiclelor lsi a solidelor, atrofii faciomasticatorii, faseiculalii po linrbil, ;i pe muqchii rnaseteri qi tulburi,ri ile masticalie. Iieflexul faringin,n rlisp:lr'e la multe cazuri in plimele faze ale bolii (Bonduelle, 1965 ; (iirho qi Kovarik, 1970). In alte cazuri, imediat clupi elebut, s-au inst;aluh 1,ul buriri de respiratie, uneori gr&yo (Black gi llyatt, 19?1 ; Castaigrx) {i colab., 1971). Completa paralizie a mu$culaturii masticaliei duce la dl,rlorr rr r, rnandibulei, iar afectarea orbiculaluldi buzelor pelmito scurgereasalivei rlirr gura intredeschisai,'Asocierea aproape constant5, a tulburlrilor dc doglutilie duee la acumularea salivei, alind impresia unei hipersalivalii. Palatul noale devine imobil qi aton, pemitincl regurgitarea fluirlokrr: pe nas. TulburXrile de deglutilie sint frecvente, ceeace face necesartrirrl,rorlucerea unei sonde nazogastrice. Bolul alimentar sau lichiilele Du pot fi l'c!,inute de citre buze, iar gura nu poate fi suficient de bine inchisX,. ltolrravul este, de asemenea,in imposibilitatea de a impinge cu limba alinlontcle in fariDge, motiv pentru care t^z^ reflcxS, a rleglutiliei nu poato {i rleclanFatd. Bolaavii se ineaci uqor cu alimentele. I)iza,rtria este frecyenti, $i evolueazi, rapid pinii lzu anar[rie. Ao|ul soapir,prin nas in timpul fonaliei, iar corziie vocalo sint in pozilie &nol'rnali,. Dificultii,!,ile iniliale in vorbire sint proclusede hipomobilitatoa limbii, Ll ca,r'ese atiaugii, paralizia pa,latului moalo. Bolnavii n[ pot pro]rur|,lr, rolect lingualelc, tirnblul vocii captrt5,o tona,litatc nazalX t;i dispa,rornorhth,tiu, vocii. l,ipsrr,clo inchiiloro contpletl zr,glolci, palalizia, mrrsorrlai,rr rii t'iit'iLralo tosl)irr11,io buzclor', cit;i i,ulbLr cornplotanzii tftbloul serrriuloilio tlo rr,ltulbrrrtrrilot' vot'lritr:in I.r,l!.11. Atrofiilo ttluscrrlrrlotirrl' plozrrnto rJi vizibitc. lrirrrb;r, osl,o Iltrsorl,, irrrobilil, ll,rof icit,. irrrrrrrrrrrrrr, rlin prirnolo[rr,zo lrolii, $irrtrnrrrrrltr llo irrcrl, lrlo ryi tttrtryoltilrtt tn:t,url,r,,ti, lrlclil'ot t'r,lirrl'r oxrlrttotrttl rrlrolilt, Ll sl,rr,l.io lu *l,rlngo4i
l: ! t )
| 11

It1 flitulronul hti .Ilenad,il;t, asemSnltor cu plecedentult se manifest[ 1r'ir lrrrlrrlizirrotrulotnotolulti comun de partea leziunii qi prin hemiparezi, .i rrri,'iili inrl)lrlntare (de tip coreic, parkinsoniene qi intenlionale, aclesea r'lrirrlrrrirr.lorrii tuioritrnii) de partea opusal. ;i roptt: ale l',| sinr|rorttt:I.t s1.t?erio{Lre nlr,clewlui :t1 Sittdronul lai CltiraE-7'oir-[icolercu se caractedzeazd,prin hipel' ( irrczii rl ir.r,r'st,,rigiditate extrapiramiclal5,, herniataxie, disdiaclocochinezir', prlr.r.rrrn priu hemiparezir,toate 1l hemicorpul contralateral leziunii si rrr, li.rlrri r',r1u $i {la care se poaie asociafi o leziune discrti pir"amitlald, rr;.orrr',, lullrr ri}i dc sensibilitate, respectirrult sind]om talamic, care sin1, lrrr.rrlizrrlc nsernenca partea opusi,. rlc ilc It1 triurltrtrn,ul ltti Niaolesctt,este asemiinai,tor cu precedentulr dn', rlrlorilri lrplrrlui tri leziunea est situati, inapoia nucleului rogu, poate fi rli'r'lrrlrr i,r ilrv.rrsrr hLiWclnekinli ;i, ca atarc, se produc milciili invoL[n' i ! iu'

l :r tr' l r illrI llt r lr . . il I in rlr'rr.ttt.do lctltnultQle cu]rrind mai multe grupe de sintlroamtr (l ,rrcl r ii . \ l11 r ' r ' , ll) ( ii r I l J o p o v i c i n ti c o 1 a b .] 1 9 ?2' 1973, 1976' 1980; P optl t i l i rr i: i l' r r s r lt , 19 8 0 ) : sllperioare se calacierizctzX, selniot) '\inrl'rrtnrLtlflrlerai cefebela{1se lrrllrr'. lrlirr rri;rr,ritrcctcbclorlsfl homolatcraH, $i prin hipo- sau anestezio ilitelile )t s,eqsib rlrrrr.rrrlir, lr.r'rrxr-a,lgezicil (sau un"eori pentlu toate |'r'||IlrIlrrI(,r'llit. Sc poate rsocizt lrtl sindrom Claucle Bernard-Ifsrner iDsilrrlrlirl, o pirlrllizie a, percchii a IY-.r, contralaterall, datoritd incmcild,t'ii lrlrrr,lri lriiclicLLlni qil uneori, chi&r o hi?oacuzie sau surditate (clatotil;r'i l r.zi rr li r r olir r r r lr r lu i n l e ri o r). rr lt) N iniromul,tU norinau'il tr:riluce o leziune 1a nivelul eoliculului rirr1rllirrt', rtspectil' r regiuuii a.nterioare a tuberculilor quadrigemeni l1i plil palaliZi:,t milciuilor (le ridicnre qi/sau de coborire Ill(r rrr, nrrrrrilcsi.rj, rrr'lriLrr',rrrlt,sciits,rtiialt' cu o par:llizit do colYclgenli,t cu o midriaz5, ptllttlriicri ;i orr tl u,bolite rl reflexelor ?tpilare. oJ Sirulroutul lui l{esxenbau,tl realil'earn un cont\t clinic constil,ui1, rlirrlr'.rirr siurllorn .|.'aliuilud, Ll crtrc so asociazi['; 1)islitgmug disjunotiv' rrrirx,hrrriioc rtkr- t ol,r'a,clo tii, l ttlbnlilli pupililrt ,,sipaleze izolote (lo ntlr.vi I I I ;i I V. 1,)strr sitttlurrri de suft'rinlli il substrr"n{cicenufii porirp()duot,rll(! rut Ltrt'ttlor' Iorrgit,urlitlt,loltosl,ct irtilto, ptitr protr'.te oalutir:tt ztlt',:t,t rii rr,IrrrrrtIr,Ir,Ici trttrtrrl o i tl sttl i l x{ l i orrl l l l tl i p rrrl i c ttl i rl tl i tr' ,ttr,trtl rtrti Lr,i , p l rrl trlr r i lx x lt ' t ior " r r ' t Iti p r i r,t l rrrrr r r r r iiI r r r 'r,r r r r l i i r y trtr' * r i u ,l ttl i ru rs l q i , r ' i t l tl i t' tt' , xtr IrII l tsrtt' i l t, 1x' tl :l tl

T
l ,rt rl i tt f ilor ' , r . s il r lc rrrrrl i c o ri r,l l l r . f.l l o l rro rrl ci tl orl l rsl oi rl j l l l rrl ;i l ,r' l rl l rrzrrl l ;r.rtl l o lilz li, t t t ir iiir z i rr i rr r,rrr' ' rrrl r.trrl l { i c i l ro l ii . [.]rrtroti l ]al l tl i zi i l , qi l l 1,roIi rr, :tcr,sl , ot ' t t r r r f c lr ilr u p o n rL i l l ro l rl rv i l o l s i ;i l i rli co cl rpul tl tci t cu aj ul ,ol l l l rrriirrilor'..llrrscit-rulirliilcrrpa,t Iirrrbi, }r tulseteri $i urr0or.iii pe musculatuprr
| rI llu I l ( 1 1 t .

S l,r rlescris tulburili ale motilitiiiii esofagiene li gastlointostinal(j {lirrrrlucllc, t965; Boutiin qi colab., 1971), precum qi tulburlri cardiaco i trlr Iiovrlscrrlare. Tulbut'ilile respiratorii pot fi cauzate de pareze al(l rrrrrsorrlirlurii lt:spiral,orii,de para,lizii ale corzilor vocale [i chiar de crizo lcslrilrrlolii centrale (Carala$li colab., 1966). l)(lgcneratea ciiiior corticobulbir,re, relativ rar intilnitii in P.B.P purir,, ;rrlrrugr'i t'lcrncntesemiologiccde paralizie pseudobulbad. l,.,eziunile centliLrl vr'11r,tliivi duc frec\.ent la tulburdri circulatorii gi respiratorii foartc
ul it v{' '

iladrc nozologiee 1) Paralizia bu,lbard, progresiril crotui.cdla adolescenli qi la adul{i ;xrirl,orp[rea fie ca, Jorntd sptoratlicdrlie ca Jormd,eredo-familiald. (Colmant, ll)?it ; Malkland qi DaIy, 1972). Diagnosticul cle P.B.l' puld poate f i st.rrlrilil;numai pdn examenul anatomopatologic, care va erolude leziunil{, pilir,rnidale, P.B.P apflrut5, in ailolescenld,a {ost consider.ttii ite Marklanr I li I ralv (19?2) ca o form5, particuiar5, a bolii Kugelberg-Welander. :!) Grw)ul sclermelor lateral.e amiotrofiod (S.I'.A.) cuprindo 3 tipuri lrt itrrripalo,in ca.rcP.B.P apale fie la debut, fie in cursul eyolutioi (Hirano ri rurlub.,1967; Brotly f i cota;b., 1971). .r,\ !l'i1tul sporudic al B.L,A. cuprinale cortextul clinic de P.IJ.P in cel o/o din cazuri (Nishigaki, 1970; L972; }Iiiller-Jensen Fi Be1'nhardt, 1ru lii {,irr ll)7;t). I,'r(.{,vrr1,a P.B.P in eadrul acstor forrne sporadice de S.L.A. es1;o rrrri rrrarrr biirbatj decit la lemei (Girke qi Kovarik, 1970; Rai qi Jolly, la l1)?1 .Nishigakir1972). S-a raportat o creqterein ultimii ani a, frecvn1ei ; irnnoi bulbare fa!d, de forma spinal-d, S.L.A., indeosebi in jurul qi pestc a vhslolc rlc 50 ile ani (Dazzi gi colal:. 1969; Campbell, 1965; Sahar lllrr t r , 19 69 ).

lr) f ipul ,rd,eGuamt' reprezint;, o asociere intro S.I-,.A,, parkinsorrisrrr1i rlcrncnfi,. Tipul ,,de Guam"'prezinti mai frecvent sernne bulbaro 11i riyrrrsl irrilirle<lrcit forna sporadicfide S.L.A. Tipul ,,de Guamrt are o evohr(irr rrrri k'n1t1decit celela]teformc (Ilirano qi colab., 196?). l,'ol'rn(r S.L.A. asemdn[toarecu cele ,,de.Guam"seintilnesc, se pare, dt) r1iirr l,)rrropl.Nu s-a putut insi preciza nici un factor ereditar, nici subIr':rIrrl irrfcclios plintr-un virus lent (Gibbs qi Gajctusek,1972), deqi so prrrrr uilt, multe ozuli cu sindromde S.L,.A.realmentevirotice (Popoviciu cii :r I'rrrr:u, 1.980). It,rlalil tliltre complexul parkinsotrism-demenli, si S.fl.A. s-a velilitrrl lrr l5-2io,( din cazuri (Brady ;i eo1ab.,1971), f:r,pl. ronfirmat 5i do :rllii ((lrrlrl;r;si col a,b., 1966; Bonduellc si mlalr., 196E; llla,it 6i cohb., lt?lt). c,) 'l'iytrl tril,ilar tle iS.7,...| r.lesttl rlrr lar', plczirrlii u l rarrsrnisjrrrro ., :r,ulosorrllldourinlmtl, ia,r scrnnolebulbalo sint tnai frecvenl,()((1as1;lr,igrrrr ri colirlr.,l1)70I .llilrr,tro r:oltrb., J067; Ilrrglrtrs Jol]r]m{!,11170). ;i [i il) I\tuli: itr, hnllttrni,lttolyninti, tlitt, uytr,-tisrkt ,,t |.nt,l.i rttu.xr,ttlurt i
l: l{ l .d

t) tllntlit rtttrstulurirpittuli in.lutlilii (lnxr.lrr. ll trrl.niqIlo.llurtnt) ltr.i , tt tlclt'ttniltistttgcttr,l (trlri trlrrsrrrrosivirrri,osurrurl) l)oirl,r' ic irriurli rlr, s(r llzirrrri lrtrlllllt'o( l ) t'rr,chtnlLrr Illlnli{fr, 1001I M rrrncrrl,hrr,lrrr' ,,siVrrstr,ll:r, li llli0). r\('o!li col)ii, incii rlo Lr rllstrrlc, lr\)zirLl;itl,rrlbrrri'r,r'i xrrpl 1i rlr, rlc rllglrrli(ic, alr url filcics irrtrxltlcsiv, rntrxlibulil csto ciizrrlii,lirrrllr lr,l lolilrr ,r trrflcxclc lmllta,r'e dirnimtll,c. Oclo rnai rnu]bc cazuli rlccrrlcrrziiirr lrrirrrul :rrrrle v ia!,ii,. forrrLcle ltr rua,illcniglc, cu supnrvie!uiro pirrir,irr rrrloicsr,r'rr i , I rrlbuliirilc bulbalc pol, fi intilnil,e pin5,lzr, douii,tlcitni (li rr olz u li ( Nlu l ln l 'r r colrr,b., 1969; Ilriul f i ltrnofy, 1{}71). q ltl Atrotia nyuscu,lu,rd, tpinulii juaenild ( boala l{,u11r:lltu ll:tlrrnthr) l otntctelizeazd, prir) |l,ttofii spiuale proximale pseuilomioprbiccr,iillr. rrrr ,1,,1(.nninism gonetic autosornalrecesiv (Srrith qi Patel, .l.t)65 l,'rrrlkrrrr I r,ollb., 1969; Namb* fi colah.,1969). ExistL $i cazui slor',r(li(l(,. lrrlrli ,rrrrir,Ileryilol(franieni(inclusiv bulbari) a putut fi demonsl,r'ltI, lrl :.i1,'i;, rlrrr crrzrri {,\{eadowsqi colab., 1969; Narnba li co}ab., 190{,r. a) Atrofia musculard, spinald,lo,rd,iM(boala Yulpian- llcll hrrlr l l,) ;rlr. zitrlr'i, dcterrnitism genetic de tip autosomaltlomina[1.,dlt,rsirrl ,sirrrrrllo un , r,zrrrisporadice(Cazzator 1969; tr'rieil SiDmery, 1971 l Zellrvcgrrr';i('olrrb., llr72). Doar puline cazuri plezinti ,,si lczinni bulbare (Dyck iJi I rI|| rI I ) ' r'|,, ' llrl;,q; Bobowick $i Broaly, 19?3). ,1) P,B.P in alte boli degenerati,t:e. Dintre atecliunilc degerr.rirlir',, |lr (riue poate Si apar5,P.B.P, amintim: tu) Hi.potentitnea orlostalic.d,(sindromul Shy-Drager') s(r 0r|r,olr,r I z|rtzii in plimul rind plin lipsa transpiraliei, rnanifesti,fi sirrrrPrrk,,pir.r' ,llrr.ll controlului sfiloterelor', sindrom palkinsonian, atrrrir.,ri sr.rrrrr,. lrrrlllrlt'. lt) Sirtlrotttrl Riley-Day este plotlus de o ('legcllerarc lirlrrrrr(ir,r rr t , l iculare a bulbrrlti, cu inl eresaLea a newilor bull:ar'i (Ilrtrurislcr',I l)i l ). qi c) P.B.P asociatd,ou surd,itate $i. cu abo.fie opticd. losL rlr.ro is:i rlr. rrrli mulfi autori, f6rd, a se putoa contur.a un sindrom ^apaltc (il'r'ilk'l 1i colllr., {?0; Boudin qi co1ab., 1971 ; Serr.atrice Gastaut, .11)7il). fi tf) P.B.P asociaid,corcei cronit:e Ilurttittgtol cste litrli (lrnrli rjr Vrrin, 19?3). o) P.B.P asoci,atd, sindromului Bteele-Richardson-Olsaewsk lirsl, r'r.i u, rrr:rrr,l1ii chiar tiin articolul pfinceps al acestol autori (1964)li (l()lrfilnrrlri, ,1,' l.|.hrrn:rnn si colab. (1969);i Constantinidis colab., (Jt)?{}). Astn.l, $i 1',' lirrgii selrlele cuntrsrute t1e acestui sindlom, au fost des(rriso lorrrlr. llr r,||rltl' r.uzlr|i .i tulburdri tle tlcgluli{i,.. nL altor sisterne; nucleii nrlzt'rrcr,lrlili 'iJ P.B.P d,sociatd. afectareo, t IiorrrIrrt.IIt.ri colab., 19?0l, talamusul (Van Bogaert Si oolrrl,., [Xifi), (1,t(, r"'lrl (\':rrrJJogaer't;icolab.,J965; tsrbwnellqi cotati.,tOfO;. !) I'.tj.P a*ociald bolilor paraneoplazice ale siste.ilu.lu,i turtttr. l'.1\.1, rtr tottltlitul umri sintlom tlc sclelozii lateriLlili, amiol,lrliit,ii rrirlrrr,,oltrrzr,, rr losl tlrsctiir in cillcinoa,moblonhopulnronarc ;i allr, 1itrl r.i rlt, til,r,'r'r rrnligtrr, (lllrrirr qi coLlb., 1{}(i5; (iolline qi S'rxrlst,1 ii)0?; Nor.r.irr , 1i r"olllr.. l lXi9). ll\ ,\iri qt,hrlltiu .si sr./r'lota ltrlrt(l u,tttiulto,/irrrr rr.lrlizrr, pol l(,ziuni rrrrrllilrlr..r'orrrIIirrrrIr', rrL' trllt ikrl, r,rrrrrir.rri lrrillrlrri 1i porrl,ili, ICtrlo rrrlx[lirrrl rl(.r{.1ilt l (tiiur,r', llt,':i) r.r'i lrrtzr,rr{lrrrrrri i.lIrrI r,rrI rr rlo lIrllrli irr r i

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p-iimetor segrnenrc j:i':lig $il.or9r1ial gi fald de com-prosiunile cewicale-9i {uo.r)ulDurur, cal.eartrg-neaz6 adeseatulburxri paretjee Ei atrofiee Elos<iruur)gol|,rlngee(boala I:9tt inalta, .tumori ale giurii oceipitale, iumori llrl ltmedu laro tnalte, glioze mie)o-bulbare,pachimeningiti hip'ertrofied cetljcalcinalte E.a.). afecliuredesrulde l,ar.i,cauzal de o d" , -, t') lnyJqlo1ati.a .lui-fVprnickr, tloliciant[,_ thiamina,(de obicei ]a alcoolicii eronici), asociazA, oftalfii{i. de o ic (Vicl,or qi colab., I,.lr:qio .(ldeyai I otalS), o ala.:i si demenfi, progrcsi.r.d J071; Iilank gi colab.,1975).
lniduva cor-vioaH qi bulbul), ocle tloud, cauzo mdi I|('ovonro Illnd Bclerozalaterah a,miotrofici (inclusiv sindroamele de SIA) qi niringobulbia. In. aceste-situalii se nai impune G*; sd; fa,cd, aUgl un

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3,1 EXPLORAREA SEMIOLOGICA DEFICITNLOR A MOTONII E:plorarea seiniologic5,a tleficitelor motoxii (p&rezogl I&_ nrljzii sc faoe prin : 7,) Examina,re:| a,teutd a m,otititd,lii actiue (s a voluntare) ca,roroprozint:i ansamblul tle'nrlgc[ri pe czre un individ Ie oiecutd,in motl vohtntnr, incepinalde la nivelul celulelor giganto-piramidal'o lui Setz dln cor. ale l,oxulprerolandic qi pin5, Ia nivelul muschilor striali, care Blnt axocutorll dilecli qi nemijlocilj iri miqcirii. Se procedeazS, tottleauna Ia ca:atninurt, not,ili,td,liiactit;asegmentara, adicd, invitind pacientul sd,execute tn nurd sistomatictoate miqeirile fiziologice,alin toato ar"ticulagiile, obsol'vlntlu,ro {1uatontio amplitudinea, rapiditatea qi precizia executdrii lor. 2) Tottleauna acest examen se comptleteaad, a) aag oraraa,fotlai au: nnnculare segmgnlure}. probele speciak pentru depietarua pareaalot b) (lrobele lui Band, llingazzini; .Gr4sset,Vasilescu, Ba,rr6 -Iiohuror); u\ enarnenul, (bipeda,uniperld, pe virfuri qi po c{,lciio); staliunii ortostatice rl) euam,enul mersul,ui, saltulwi, al unipeil pi al Jugii; e\ eaptlorarea molilildlii ytutiaa(a tonusulbi muscular); t) enplorareamotil,itdlii.dutomata g) ertii d,enliereaet;enlualelor mifcdli, si,ncinetioe; h) eoid,enlderea a:anhtalelor ni.ycrlrinrclunlarc, I 3 ) Semnele asoaiate sint deosebit ale importante pentul. diagn.oatlaul, lopograliaal paraliziilor: a) atrofia muscularf, importantit $i progrosivd, ilno{itX de modificfui de excitabilitate electriod, inrlicd ils obicoi o lsziuno r! Trouronulnimotor periferic i b) nmdificdrile refloxelor ostoo-teud inoos6, $uta,nats,a,rticuliro Ei dccelaroaroflexolor patologice phamida,ls il do ,,olihoraro" (sinoinezii,rofloxo ds trip16,retrac{ie otc,) contribuio ln, treD, rt ,l,oadiagnosticului diferqnliial lntrs o leziuno do neuron motor coutlel poriforio, 8o,u 4 ) lluantenul, elcol,rioolaaia, emmenul, fr,M,Q,, paameai, oto aai. (lsu rfl(rrdo alte euplordri newotiaiologioe protiodsoinrlicnlli d0 dia,tsnortlo Ei littp gra{lo: lozlnno po ncruontrl r. otor' fi0ntru,lna,u por,lforlonl lo 0o nlvol, lsliun6 muBcIlor[,,tttlbrrrnr,o funollonul{,ol,(,,,).

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)) I t t oot ' t t 1' , 1' p rt.t1 s ii.ttt ,r,uttt, n t. l ,rL l tl rti cotobrl l hr I)r' i tl i l ' i \' {r si t,tt tt.l n r rrrl rrsl i r l, ir r r ,I r ot t lt l oll tn e (s trl rrl rrl l r,lr' ' l l i rl ttta l , i n traparenchi ml tos), i tl tcoso , |'r.rr.lr Ilr hr, Lrr Ouloame, pat itzit ozt: ill1,r'it,cril,niene, bct :lJ It n.r:cfulitele, enceJalomielitele, boli ilemi,elinizan a (scleroze muliiplir, lc rrcoencefa,lite $. a.) 1) linceJaloptLtiti inJantile !;l !l\r , ,lnatistne crani,o-cerebru,le

:1.,3.1.L2.Eemiplegi.a spinald este ipsilaterali,, intereseazi' numai rrrr.rrrIrlo|o, iar'leziunea medularS, este situa't5, cleasupra intumescenlei .'r'r'iolt,lo. cele mai multe ori hemiplegia spinal5, este asociati, cu semne l)c r,lirrilo r1ohemisecliune medulal5,: sindrorn Bro'n'n'S6quard. Nu se conrrlrrLri rrir:i urr semn de paralizie supra-medulari,, nici paralizie faciald,r nici :rlirzir, nioi dizartrie. Ilemiplegia se instaleazi, f6rf, ictus $i fd,rd nici o :rll.r'rrrr a, stirii de constienli,. Se recunosc cu u$urin![ e]ementele senziLivrr lhr sindromului Brown-S6quartl : abolhea sensibilitSrilor profunde rlc prrltul hemiplegic[' gi hemianestezie termo-algezicS, ale partea opusr,. Nrr rrrrri pot fi utile in stabilirea cliagnosticului de hemiplegie spinal5, ($i rrrr plirr lcziune emisfedcd,)tulburirile sfincteriene care de obicei nu lipsesc, plrrorrrn qi prezenl,a unor mici atrofii radiculare ale muqchilor scapulari qi :rlrr I nllrozului. flrrrniplegia spinalf pouta Ji' reut'izatd'de : :r) 'l'rrurnatisme. b) Mielite (virotice, luetice). c) SclerozS,multipld,. tl) liilirrgrrnielie. e) Tumori, care de multe ori realizeazi" de fapt o tetraplegie xpirrrr,lir,, tllr cu pretlominanli pe un hemicorp. f) Discopatie cervicald, (lirrr'l,o ra,r). g) Sinilromul lui Mills, tle etiologie necunoscuti incS,(probabil progresivd,, e1ectiv5,,a fasciculului piramiclal) so tra;rlirr rlrgcrrerescen!5, rlrrur priutr-o monoplegie inferioari (crurali,), care se extinde lent gi la rrrrrrnbml superior, reallzind o hemiplegie spinalS, f5,r5,tulburS,ri de sensi lrilil,ir,1,o. :1.i1.1.2. Paraplegia poale fi realizati atit de leziuni ale neuronrrlui rrol,or' rxrrrlrftl, cit qi de afecliuni a1encuronului motor periteric. Oa atare, rlirr rrrol,ivotlirlactice, in acest capitol vom aborda pe scurt pamplegiilo lrlirr lrziurri r1o neuronului motor central (cortico-spinal), care pot fi re:llrzirl,o numai Ir nivel spinal (indeosebi),dar gi Ia orice nivel al lreYrnrrl rrrlrri, rlrcr"r,sint interesate fibrele piramitlalo (ad.eseacu realizarea de l,.lr',r,plrrgii). vom permite ca in continuare s5,abordi,m separat probloNr: rrrr,lr rkr rlitguostic topografic qi etiopatogedc ale paraplegiilor in sensul (atit piramidale, cit qi periferice). rrl lrrr';1 rlrrl'itril.iei l) I't,ntp[egl,u spinald,. Forma cetu mai caractelistici este realizatii rlrr iririrllornul de sectiune ttansvers'i,, care intruneqte o para'plegie cu insolit5, tle anesteziepentru toate modurile ale sensirrlrrrrrr, trilrr,rnirlir,Ie, lrilii,.rlo,plroLrmSi de tulbuli,ri vegetative qi trolice, cu neti, limitale snbprin apreciereamodilrrziorrrL'r,. Nivcltl leziunii me:lulare se poate preciz2r, l'iciiliIrl rrrllorolor qi l nivclttltri trrlbtrdrilor rle sensibilitate ;i, in rnrtrl olrligirl,orirr,plitt crrrrnonul l./.0.1i. tli prin rndiogr:r,fiiio $implo Ii prin rlo lrrrl,orlrr rurni;trr,sI,. (simiLt,t'o rlo spiltrr,lii srxt{iuniitt'rlnsvot'so) lli '|'ir,Irlrrrlikr lrrrrrplogio 1tol, tultnltt'rrsitttti In(nlulrlro, tnirrlil,c, lroli rlt' crrl6tnr,i vrrliitt;rt lrrrrlizrr,l,rr llt'oottsc: r lcgcttot';t'1ivr,tt,. rlrrrlirrlitrizrrttlrr, lroli 1. t: l A

vIti'rtIttIittt'(ot'Itt pt'irrstlltti.tt{rr !) J.'uxt,1tl,r'uitt lritlittri lroitlrrli plrrtlttsii llt'olol rtL' zir at'iololorplllattttttlillttc sislltttttlttivtrtttlrlrl-ltltzilitt), i)tr)(1('s(r lr' mativo care comprimL pittirit'ttlporttin, boli tlernit,linizrtn ;. rt. ' 3l Purapleeia paraunl'rald este reznlt.r,l,ullc'ziutiilot' I ti I It'I Irt It Ir' :'ll tromlrolkrhilri tlt' sittrtr lobuftui paiacintrdl (meningioameparasagita'le, lonEituclinal, sindroame bilaterale ale suferinlii a altelelot (j('l!fl)I'iIl(| itI| | ('r'i oar'6etc.). Este important de relinut faptul cd' dcficitul trtolrtt' lrtrt lr' l'i precetlat sau inso-tit de crize jaksonielle loca izate Ia nrt'rrtlt('l| ittiirtiorltr', de tulburf,,ri sfincteriene. 'lrecum $i txrt('prin leatuni nt'ultiple.In atelo- $i al'ttli{)s('li'r!tzrr 4l Parapteqtot'tt de clezintegrare ischemicS,pot a,fecta, ltrtrciirltrtrr brali,,'multiflel"e hlune fibrele corticoslinale ale membrelor inferioare la nivelul cmisli'rrrltl cllrr brale (centrii dvaii, capsuia interrri,) sau in trunchiul. ccrobtrl, Irrlt'lizlttrl t ist paraplegii sau tetraplegii (cu predominenll pl raplegiei). Pfi n t ttrrtrrt'r t ttr prin ]eziuni multiple din sclororll llr plii('i' iimil-arJse realizeazfi p:r,raplegi1le din unele encefalo-mielite, din boala lui Little q. a. lin topogralicSi eliop&Iogenia sindnnnr lo 3.3.1.3.Problemed,ediagnostic paraplegice, In diagnosticlt'l sind,romuhti parapleg'ic este necesar sL so I),rtrrrrlgr'i in mod logic $i succesiYurlf,5.toareleetape (Riser' 1952 ; -$ollcirrrr ll){i?; ' Bodechtel;1965) : a) diagnosticul tlifercn.tialintre o paraplegi(' rii {r.,11rr1,'rl doparaplegie"; b) diagnosticul de tip al paraplegiei (piramidalil ; tlrr ttltt ron motoi peiiferic; pedcadon:lla' poliradiculoncvriticd, . polittrrv.t'ili|l ; rnusculilri) ;-c) tliagnoslicul dc nivel irr crzul paraplegiei pillrttirlrrlrr (rpi rtald qi topografia acesteia; cerebralal); d) tliagnosticul etiopttl rtgclt it" Yor 1l Pseu,il.oparaplegiile fi eliminato in plima et:tpii it tlirrgttoslilrt :l) Pseutloparaplegiiieprin artrite acute sau clonicc qi tr)lirr rrlllorr\ l'r protLucfalse dAficite rnotorii plin anchilozd,;i prin imobilizrlr'('ir'rr tlAr|ri' poliarticular acut, poliartdta cronicil c\-olutili) ul)t)||(|iIiIit {rtumatismul :rrrcllilopoieiici,, artroglipoza congenitalil, rnultipif,, coxNrNlt)z"lt' :t ); f. b) Psetttoparaplegiile pril afec.tiuni carc clolucllzri cu rttitti l.tilrrrlo silttltttrrtrtt' rrii, cu ltaxie gi/sau cu tulburiri t1eechilibm (ata;ie 1'rrl-rclit'ii, rirr r{ uluirnelnice, erodoataxii spilo-cerebe}oase'sindrollntl 1,cs(ilrrll;rrrr, rllorrme cerebeloase, al,axia frontal[ a lui l]rrrns) ; plin tulburili psihice : t,pirtrrplr'g..irr " rsllt'ilrr I . tr) Pseudoparaplegiile
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+r'rrziiir(scrrrlrr'lr. r':rrlir,rr grr,lilirr.iclr 1rloIorrr.rrlrrrrrrIrri r.,i i, lr,rtllrrrrluitrtill,otl

I r r t t l r , r 'i | , i c r r ) l tti n ttr l tz{ Ir r {fr r l l l l l t' tttl r Itt|:ttr ',

i l ( , 1 1 1 ,r l r l l d 0 o b i t't'i n t' r 'o ttt'Ii Itti I i tt ( i i t'vr t zi l t', p ttl i tttl l |l r l i zi l l r i r t,l ( 'tt |,r 'o l tt( i 0 r tstIttr l Il ti r l ) i {( 'l l l ttr 'l {'tl t' l |,zl ttttI P l | g i i s r t t t l ,e t't'l t,p l 0 gii ( :r ,r l t's0 l r

t 31l

ttri(irrllritrrplcgii,lrl)oi ilr r'\{'llll'i(rt c) l\l itrrl,irtt.[ntt iltlr l' rl tr.rrlrrrr t t,t lol,r'r t lr\rzrlrlir rtrol,otii,ttrllico 1i vt,iJrrl,itlivtt, r,Ilrrgiir(1ll rrit,r'i LttIIrrrtrr,t rrrlr,lrnr cvoltLtica,st:otttlrrnlri rrlr.riir,r'cli1i rrr lji r,tr iInclvil()r'clltlli('i.iJ{)llLll(t1f ,lrr lrrzirrnotrcylaxiu,Li (irrrltrosolri pilarnidale) Iipscsc..\Ioclilii iirilo irr,rrrrLclc l.li. sirrl, cl,r'actcrisi,ico. rrr 1,.( tl) l'olk nieli,ta,&cut{i e ltri. II ei.neMetlin intli, totdeauna in cliscu{io lrr rtlr copil s:l,rtIa nn indilid ti[5r, mai ales dacai,s-an conse]l]11:r,t sclnno, 1rllrrrorri1,olii infec{ioase (febr5, manifest5,ri digesljiye $i/sau respiratot'ii 'rll,clrrrlrr, goneralc), algii poriferice, ce{alee,ytlsi,turi, radiculalgii, str:i,r'ii .rlgii rrrrcl,h:, fa lialgii, semne meningeale (subiective gi/sau obiective). | 'rrlrrlrlr{iir, loate ti dintr-odati' masivd,, hipoton:i (,,paraliz izr, dimileade irr') rlcsclisi de West), cu reflexe abolite, sau sepoate instala doar o monolrl,'{ic, cventual paralizii parcelare. De ^obiceifenomenele generale qi meninu( rl(i l)r'ecod partrliziile cu 3-5 zile. In unele situalii, pierdelea blutali,, rllrrrrrrl,icii,, fortei musculareeste impoftanti, qi ertins5,, atingind mu;chii a rr.rlurilor', i:r,i trunchiului, ai membtelot, cu extensie chiar la nivelul mugchilol irrrrlvrll,i de pericarionii bulbopontini. Atlofia rnuscularS, este precoco si irrrrortantd,. q N euromielitn optiad, ( oftalmoneuromielita, boala l,u,i Deuic) debaji, I rrrr,zrlo obicei brutal, de multe ori paraplegia precedind semnelede nevriti opl,irii,(Dri,ginescu qi colab., 1962, 1963). in l') Ilxistd gi cazuri ile scleroad, pliici acutrit care realizenzd paraplegii , (rrrrr hrtrrlplegii) dramatice, flasce sau spasmoalice, cu senrne plramidalo irnl)r)rl'lntc. Sint frecvente puseele de paraplegie acnti, in cursul evoluliei rrrrci scloloze in p15ci. Puseele evolutive de mielit5 in cursul unei gclerozo rrrrrll,iple pot sd, se declanqeze cu o ,,tragici brutalitate" (R5-":.fgP", pot realiza in contextul clinic malifest5,ri parag) A.lte encefalornielite ;rlrgicobrutale, I& care se asociazdqi semne suplaspiuale. \) Spond,ilita tuberculoasd (boala lui Pott) trebuie suspicionatii totrLrr,rrur, liulrr unei paraplegii acute la un adolescent (indeosebi) sau Ia un in rrrlull,. l)itgrrosticul este u$urat prin prezenla conira,ctudi dureroase ;i it, rlru'olii colornci, dar mai ales pdn evidenlierea ghibozitS,lii qi a altor semno rlrr plri,lrrrryilo vertebrald,. i) llr,nrtnu,I primi,tits rah,id,ian al ltti Ewing poate realiza o pa'raplegio lrrrl,rr,lj1, copii qi Lr, atlolescenli. Djagnosticul se verificS, prin imaginilo Lr, lrrrl ioglrr,[icr: plulifocale, in geocle, pludver"tebrale qi costale. tumori primiti,De se,usecurl.dare i,ntrarahid'iane,intra- sau extrn. .iI JLl,l,c rlrrlrr,lopot plorluce paraplegii acute gau cu ingtalare rapicl5,, precedato rrrlrnrrirrlo o sourtl periorLdfl tle rahialgie qi ciaudicalie spinal5,. lil l[t,n.in,go-mteli.ta sifiliti,aii a,euttiintfi, astS,ziprea puiit in discufio. l) Il telom,ataciile (rumolismen'tul, total, transaars li ranxolisrnentul ttpintl rnl,rtrior) pot realiza fie paraplegii, lie tetraplegii dramatice (Lazot' Ilrrlr. l l)?2). ill 8 intlroanzeleparaplegice ou insl,alare lant-progresiud, : t) f*:lerozn rnultipld, (S.l\[.) realizeazS,cel mai frecvent un ast)tnenolr, I'ir,lrlou sorrriologic, cu par:lparezd,-paraplegie spastic5, piramitlali evolul,ivil, (url rn:r,irl(losoi)ou puserrri). Iformele ou evolul,io lont progresivir,, liiirrl, qi. mici r1i inoorto h mombrolo Buporioa,ro fi,rll rr,ltoscttrno cu lrrrrlorrrj s{)rrrno rlo rnull,iplii lirlioii, rlosigLrr, nrrlrlrl-npirrirlo sclorrrzi, lrloblclno tlo rliul4rruslin rlilirrrr rrl,irr,l trtiolil,olo crt orotrico, cotrrplosittttilo ort tnrdttli.tt'o ou i!nrllrloi. rri 140

rll rlil,i,lrr llrr s1tit rr,lr., olrirr,i, ittnii, rrltttttt'ltt lrli,cl,it,lc;r, r.l,it.jrrlol srrlrcr,iotrro ttr ttcvlrrriltlrrlr,tr.lrirlilttziutttlr' 'itriLllitnc.lr r,rrn,,irrrrr,i ri rrrri rIIr Irr r 1 -l.zirrrrii, cltt'ltt'lrrrtso, rrsooiiti'tr llr, rrtr'rrrltrr,lc, sr,tntto r,u trlltl,rr s.ir,., r,rr.uri\nr, vcslibrtlrtlo trr S..\I. crtnlial potrlt tr i.liuglnosticu1 Itr1otrt {'iilrrrrrltrsc irrvi,sl,igrr,{,ii1, tlo r,l.r, tico scljce, I[il| rlr ,i lill|s rljrr 1,.(j.1,]. trrrlir}e1,ice imunoe ctrofole qi le rrrlrr0 rrlqrrrnerlte plus pentru diagnostictl ,l, S.II., ilsr, cltlrr cr{o ru't.rriil:r, in autoimuni rle aut9ag1gsi11l0 ;lstii,zisocotiti, ca o JJoaU, (l'clrrlro li ,lolvirr, ll):14 Ila.bat, 1957 ; Liirventhll li colah , 1960 ilrlrlsrlen 1i c'lu ir., I 15tt; ; I )nmii,qi cotab., 190-1, 1965 ; Schapira qi Palki 1961 ; Vari Surrrlr,,'I llri? ; l3r*usqi colab.,19i2, 19?9; Cojocaruli c,",Ja\,19?8;'Pop6viciu t,rrr.rr, ryi l$80; Kright, 197?; Colby qi colab.' 1977). montielila, boala lui, Dpuic) poir,t;o y()r f i b) Neuromiellta opticd'( oJtftl , o evolulie subacut-cronicii, x11 ..tlebut ?xlilllrrletic - paraplirgic, rl.5i iir acu'l saLrsr-ibacut(Driig-nncscrr coi:rlr., rn:ljoritatea situaliiior debuteazd, 1i 1962. 1963). p.oru1'1egin cJ Mielita .cro,icii, spas t,-ttlicd, r:rt:d,oti.lili. .lueticd -(Er.b), tui licd"u, lui XIarJun gi sin(lronr,ul GuiLlain ti Thion {asociotorlc s,.irrrr,, de encefaliti, cil tabes qi.cu mieiitil Erb), frqiysnls altddatir, sirl .r lr.rrr r.te rar intil.nite astizi in practic,r,.neurologici,. Nu tr.ebuio i,Ohrqi rri lrr rLiti.m, iar prezenta sgmlului hii ArgyU-fi6bsrtson, a hipclcil,oz.i, rr lripefrlbuminozei qi po^zitiviratea rr,, -reactiilorB.W. si 5 benzoi r',r1rirlrr.l diagnoslicut. plus. in pataplegia rpasmodici c1orl.-sitilit.i.r, Tn '.lrrilici rr.lui Marian apar gi : keratiti,, tulburd,ri psihise importante (ca11,c1;r'r'irr,1r qi ,1,' tip demenfiall ;i, adeser. convulsii. de J) Compresiunilemedwlare diver:e naturi (tumoralo sa,u ilrflrr.nr!r.colii, primiiive sau metastatice, subdurale, extracluraLe sau intramoriu lllr.o) |eailiz.eaad,, funclie,.de livelul acestora,_plraplegii sau tetrrrpkrgii. l,)rirr' in 1,,rnj'i mulle pobibilitili de reaLizlrea dellsi[11[16e6o,' - O compresiune realizatS, brusc sau tapid se poate manitosl,rr,rrr.irr {r'-o paraplegie flascfi, ulterior, in decurs dd citevi s[pt5,mini, 0voiirlrrrl $pro o paraplegie spasticS,senzitivomotorie. Se intelege c5,tle obic.i I'rrzr1, ' ou dureri railiculo-funiculare intr-nn^terit'olil limitat, bine prociz^,1,(rrri stu bilateral) precedd,instalmea aleficitului motor cu citeia sil,,l,i,ririrri, Irrni, sau chiar ani, fenomen cu male valoar'e diagnostici. icil. - Alteori paraplegia esto lent-progreSiva, de la incerrut sDrrrt ,lrr de mu lte ori precedald, mult timp inahte de fenumenetlo clnurlicrrllri cu $pinal5, oel mai adesea fir5, clureri. - Alteori evolutia lent-progresivl nu esls precedati, de fonorncrtrr rlo rrl:urdicaliespinali, in scbimb pot apxrea 1y15iop11i sfinctoriene plnooor.. - Dvolulia cea mai tipicS, este unndtoaroa: mai intii faztr, rodlc'. LrrL ilureroas5,, apoj perioadi, de clauclica,lie,apoi sindrom Brown-sdqnrrlrl iLr r..i, shriit, paraplegie spa8tici,, inso!itd 5i rle tulburiri tlc scusibiiit.lt.o (r'rrrc mulLe ori Pot liPsi). tle rneilulara ceruicala superioare prorluc rnono- s^,ll h.rrrl. Compresi,uni,Ie plegie, urma,to r1e tetraplegie spasticS,, cu tulburd,ri de se.sibilit;,6 ,rr
lIlvet.

Compresi:,unila aeraicd'la inletrioare rea5zeazir, o paraplegio fiptrsl,l.ft - do insol:itir, hrlbul[,r'i pftreto-atroficotlc tip *idlcriin,r' rr.rrr. Bubju,cent5, Irrelo supoliotttrr (Llr- D')' 'i Oomptroaiunila nvdulara dmtalo ttti,,Lthaa,zi'i, 1r'oooc. 4ollioit. rnol,'rlt (1lt tIIttt;t,IttIttittt|tlttlrlt),nlrnlifii,ll'iHi rrlorofloxolor. t ll. (tlrr,1,0rilil lngrrstr'rlii (jI

l{tl ,fl

||irlorl |)| | ()| |ri | |i! |(. (rrrr t,irkrrr l' rIol{r'|| trr l|zirrtrii).Axl lrrl,tlt' ltirii, l0trlt'rrsr,rlirrl piklll, itr lrolrlrtoililrttik) ttivrrlrrl Ll lrlxlotrrittttLl l)tr, lrrz, trllcxolo crr1lt,tlt,l,o rrrrprrtiolrtc i rliu rlll(l\(ll(i outanato lrbd{)rninlllc rni,ilooii r'ai,lnhlncr:r, 1trozonl,o, rii itrlirliorrro sint abolite. fu stititrtlr, irt compresiunile sub Du, r'cflt-rdo :r,|rrIlrrrirrIrlrr mcnlin pii,strate. cazul unei compresiuni sub l), r1itleaIn so rirrl, r'1, Hoglrrorrtului Dro sepoate evidenlia semnul lui Beevor (itr1, de Arsoni ,,i lolrrlr., l1)?7): la ritlicarea capului $1a trunchiului, ombiJicul se deplarrorrzir, sLuir irr datoritd, laptului cd,porliunea superioard,a muqchiului ilrept rrlrrlorrrinal primeqte impulsuri motorii, in vreme ce porliunea inferiotr,r':i ( lrnn?resiu,ni,le med,ulare lombare suptaioare realizea,zn parapareze r|r' I i;r lrilurnidal, cu Bpasticitate (neobligatorii) qi cu unele indicalii de nivel. i\ltli.l, iu complesiunile I-.,1-L,2,reflexul cutanat abdominal inledol' esto prrrlrrl, ia,r'rtflexul rotulian (cu inchiclerela ltr-ln) este eriagerrlt.In lorrrplr.sirrttile Ll :rivelul Lu- la, a,tlt reflexul cutanat abdominal infelior r.rl r1i lr,llcxul ll,nal sint prezente, in schinb reflexul rotulia,n este alrolit. (iirrrl cornplesiunca lornbali se oxtinde spro coada cle cal, tulliurflile do rrrolililrrlr,inftr'acii,un caractel flasc, cu fenortene de neuron rnotor pcriI r ' l r(,r. i rlc lrirllllizitl,i,.

liut prcsi,unile m,ed,llla,re s&ar ,te realizeaz5, paralizii fd,r',i, sprnne pirarrrirlrrlr,, schimb cu nete fenomene raaliculare.Astfel, complesinnile la itr rrir r.lul opiconului (L,b-S?) se manifestd aaleseadoar printr'o paralizie llrscii in tcritoliul sciaticului popliteu interrr, iar compresiunile conului rrrlr I rrlirr' (S, - Su)se recunosc pdn a,bolireareflexolor anale, prin tulburdrile rlrr st'rrsibilitate perianale (in qea) qi pril marile tullurd,ri sfincteriene, :rbia rrrri lirzirL pul,ind si, apali, ma.nifestS'rileparaparetice. (lonpresiu,nile la nioelul cozii de cal realizeazS"paraplegie iloar in lrrzrrl sirrrllotttnluitotal al cozii i1e cal (r5,cl5,cini1e Lr-Su), insolite totdearrrrr,rlrr lulh uri,li de sensibilitate extinse r:e dermatomerele restectiTe si de rrrrrlil,rrlbu rrrrr l,rrlhullli stincteriene.in schirnb, s]nclroarnele comliesiune narli llli tle compresiune part1c prin ttlbur'dni motolii si senzitir.e in rotolii qi senzitir.e {irr,li rr cozii dc cirl se caracterizeaz:'i llr,lir r (x,Zll (le Oitt SO CalaCleltzeaz:], prln l:tl-toUlan m0lolrr Sr Senzltrl'l.e ln Irrrciic rlrr li1ul supe.rior(L.-Ln), mijlociu (Lu-Sr) sau inferior (Sr-Su) r|r' rrirriIr'orrr corilil tle cal, timul (cel inferior) intrr'unin.l$1telburdri de intlr'unin.l , rr.lctir.trc irnportante. rLlir I'rrtrxr'lt erpansiae intramed,ulare, indcosebi cer"r''icale (glioamo ,1rlrrrIiIrrrrrrrrrrr, i nbclculoame) reakzeafld,tablouri semiologice cu totul prrr'licrrlrr,rrr, r,rrrt i.rebuie cu grij5, diferenliate cle S.I-.,.A. sau de alte sil,lrrr:rrrrrr S.1,.4., precurn 1i de siringomielie.Astfel, aceste:n manift:stii rlo se r 1r irr lr'lllrlrlcgii ploglesive cu semnepiramidale (mai exprimate 1amernblei.o ou rrrli'r'iorrrrr sllrsticitate), cu aljlofii musculale de 1,ip Aran-I)ucherrner, lrr lrrrr, firr rlsociazili, tulburi,ri de sensibilitate suspendate (irritirrl) sau subIr,ziorrrlirrlo l;ip siringomielic, cu clisocialietermoalgezici. Pot s* lpa,rl plecum qi dureri de tip radicular la metrblt'le supoli. corrlorrirle, rli rlru'r,r'i ,rrrlr, lir rlr,rosc asociaai qi fenomeneyegeiati\.e (va,somotoriigi sudollrlc) rrrr1rolIrrtrItr. Irnnginca rnielografic[, descrisl inci, cle Sicard Si l{i],guc1rilu (lltJt!, cilrr,fido ll,iscr',1952),tlesemnindaspcctul in fus almldrvei dilattt,o, riu Hculllol'orr slrbslartlei radio-oplce po pi,rtilc laterale, snb fon:n:l lr rlorrii, rtrIrirrrc lirriir,rtrlirstrinlrto,vino sii confiune tliagrxrstictl tlr trrruoli, irri,r'it. rrr.tlr l:rIii. ttoscrr ptin ilsocicrrlr, rrlr a) I irirtllom.tl'i.a, i rrslrrttlit,tiv lr;iot'tlc t'ccrr t,, l:r, (srur lrrl,ltlrr,trrzil) pirrr,rrrirlrrJrl, irrso{,ilrlc lrrlnrlili Irrlrlorlrlrr l)r,r1rl)l,rt'zii t42

rl|. ,.lrrr rll' s(llrsilrilillrlr,,rrrrI|r,trrlltl,r,(irri(irrl)sttlrlt'ziottitl li;r sit'iltgrrttlir'lir', ittlt irrltsclrtt I tt I,i IIt tI I,r' , pt'r'tlrlttI ttlr' rrltt,i lttllrrrriti i,rrrlirttr, il lItot.t)I.(ft,0|(,si lrl1r,l,t , it,irtr,li.zr.i,il. itrl It'rt lrr rrivtilirltrriirril.r'qilr1rl.961r,l'r,lr lrtrr1t,r Nlrxlilicirlik,1,.(l.ll. sittl :tlttlc tiilrr si I a1,r0liiLrr, {iD ,\r'ur),1)ur,l('rrrrr'. (cvelttttalrliscrtiit ltipcltrllttttttittozi)'l'rtltt';i' itnp,rrt:rtrit' r.rrlr. i:ru luiirr ,.rist.r, siririgomi,.liiiu evoiufib rnili r1pirlli, .. 5l.crrj lidrirlirtrr qi t'tt ilttrtgirti i' rl,, liniorlolin,,Lerrzi perime4ul*re't cr,r, tumor.ilc iltra,rcrlulirtr,, siittt{ii -d iagnoslicul ev ilc fu:rrle di [il il. ,rrr.:rrtc d (boaln luiL'riodteichlitx'tlo tlrr't'itt spi no-cerebektase tr I Deqe eresccntek-Marie) minime olorncult:ltirrtrli.tr corlrrporl;it, ,, r,L,iloasi a lui 2ie*e Int$' 'itrt' rrrirllle. ne Drim Dlan situindu-se sernnelccerebeloasc tle col'(loilll(r 1i i,.r'irart'.- lf nlusi caractelul ereclo-familial tra $eazd,tlia'grrosliortl' xt Paraiteqia spa'slicd' fatnili&Ld' a lui Btrr'iirnpell-Lorrairi', 1xr litrgri' glrtrLiologitr rrila,iiegia li"ait iAaia cu contl'actur5r asociazd,in contextul (uneori discrete),pe ling5,un caracter eredo-tilrttilirt'l' .i semnEcefubeloase itt hl Arahnoiditele sqiinale compresiae (diJuze sau local.e.);i -art'lmo'n titele iealizeazd,4e obidei paraptegii (sau tetraplegii) insolite rle lttrr'tttt,tttr {ltrrcroase cu apari.tie tardivi f tle semne intinse, etajate ryi atlosca,tlistrttl ' rll,nte (hipoest"ezii neregulate, atingeri radiculare tlezordontrl'c, itllnrt'lt'"lii ale iruronsta,ntie Ir.C.R,. (in funclie de efectuarea punciiilor etajat., .tl.5ltt cu 0rr,i ncrequlat $au Dar-t-ial, lentoaxe de intoarcere la presiullerl'iltilirrliit l'l"cljul"fiintl mai iet in pozilie aqezati decit in pozilie culcati' srtl illv{rr$)' j\lir.loeratia (.ste caracleijslic, (Arseni $i colab. t9?3)' cute i) Mielopatii.le subct Fi aronice t:ascwlarepot realiza palilpirt(^'r'- rlrr|| rrrrlallegii le-nt-lrogresive, al cdror iliagnostic este extrem tlo tlifitril 1i' pttiitttltt altor cauzerdiagnosticul lor prtNris face ,,,1r.,si,r,.-se plrin"eliminarea arteriografii selective. Se qtie cd ischemiilr t crlrrlrrr! so stnbili cloarlrin vrtrt tt. pot fi realizate prin leziuni Yasculareprimare gi prin compLt'sit.ttti ]rrrt in cadrul inor afec.tiuni ale m[duvei $i ale rneningdor ((irrrrritt r,ti 1972; Lazorthes, 1972)' Atotrt- ryirur'l'tt Iirxr(lot, L966, citali cle I-,azor"thes, r iosclo.ozavaielor lpinale este mult mai rar5, decit arterioscl:tttzit v:trr'1tr' ct'r'cblule (Jellinger, 196? ; Lazorthes, 1972). (BLA) este u$ol'lle rtlcttnoscttl' 1tt'itr i) Selerosatlateramafi,iotro.7icd' ,r.zr]nt'zl atrotiilor musculare tipice, indeosebi dista,le la mern5lrrlc sttlt.t i i,'rrt (cu sindrom Aran-Duchenne), cu fasciculalii )'li c-usomk) pitrltttirlrtlrr lrr iorite membrele (mai exprimate totuqi la membrelo infolioa't'c). tlrr pol, li lea'iiztt'1t: lirrt'tlrr lateraliiam'iolroficd de k) B inal.rcamele scleroBd' tle rrrrrlt,e compresiuni cer"vica,le tliverse naturi, pa,chirlr('rrirr!{ilt' irlectiuni: .r'r'r'vic: c liipertroficd luetice, arahnoidite., encefalomielil,c fortno .irrrlrr', v.t iterjce"). LllrunliLListrlo lt'lrt" spinale (a:a-zisc 'r'r'rl'rrrinlni colrb., 1973; l)ragilncsctt{i r{'lrrlt.,ll}li:i, i rr,., I rr|.. I.,. inr.lr()q.r. (Arscni !i ',cen1r'opt'l r1xi3, t 965). l\ Stndroatne'p&roplegi( ;i lelrupleglte ltol sii aprlrii' ill Itlllnttlttrlxo sttIr.rtltil'' ll' .rli,,,tirrrri;r lr' urol;lllui In,itut'lrclifcric.{'arovul li rrLrurrllrIr'itt rl" ltior, ill conlr,rlul tlitLir', 1l;r't':r'Il|giil' lrrl rrrrrr:rtut clle .c dilt'tou{irrzri .-i rrrIr.t,r':rrrlcuiileDilunithrle:groliotrti0lil,asnltilcLrl,iisa,usuborl)ni(iil,([i(1r politttrvl'ii'oltr lrniot,rotiil0rlpinilloplr)!{r'oi;ivrr, M'r i'hrllu,rt- r;i.,, rrrrri,,tl.rjli,i-Lri (!,(lr,fi .,\lnill Il ($i 1ll,(!1t('lilgltrrrtrlr,tii), llulir.ir'rliortlottovlil,trlu. l,o[,l l ll,(11'iol ltttlttottlirrlr nttr,ttrttt {rlis1'r'ol'ii la'rc lttr' , it,,,, rrr.,ti,r'ii I 1i'rtir,lizrrlr' dt ltd,ilt ., \i tlrr rtirl rrt .t'ltlr, lri{r'trrol)rrrr rtryot' tIiltgrtrtsli11lll, plrrrsivr,, rrti0zilr,,p0lirrriozilr.),
I t r o o t t ( r , r i t t I i i t'ttti ttl tl |j i l ,'

l.l:i

i|.il.il. I'llrrlizii plirr lozirrrrirrlo rrrrrlorrrrltri nrolitl' prl ifori(1 ;i.;1.:!.1. si Oorakt!;ii rttorfo-ttt tt,cliortrr,lt se'nioloqice lezilln' a lt(uroAn n ul.rt tttolorperileric. i l) fic 5t,ie cil, indiferent de setliul lezi:lrlii, si,nd,romuld,eneui'on molor yrri.li'rit: irrrplicii o serie de caractere generale : a) deficit motol' proportio' rrrrlcrr rrni1,i,!,ilc motorii lezatc i b) hipotonie musculari' I c) retlexe osteol(,rrlirorlsc diminnate Bau abolite; d) contraclie idiomusculari pi,strata lrrrriila rrr gr:rd al atlofiei musculare; atrofie muscllard precoce li irupor' l:rrrl,ii,irr crrzurile in care este compromisi, integritatea neurollului motor; r,) plczorr{,r, fasciculaliilor (indeosebi in leziunile pericarionale) ; l) i'eacliile rlrr rlrgruorrscon!,ir, electrici,; g) modificlri EMG caracteristice de tip neuf0lfclt.

' l A l l l .l . l Ii gl .i ri l { r rrn' ml ,|1' l ol s tl p(.rl onro

N r. i l

t,
I

Il i di carca rrmi ml ui l l i di carea bratuhri

'1'raprz
"--* I3r* C, C..

Dintat mare
Ileltoid Itomboi d IL'tghiular Pectoral ,nic J)orsahrl mitre Subscapularrl

C" Co

Irri rriiii (1(' i r, r \ | i rr S pj nnl (c I.\ i |rl i (l i N c N ul { (lilll:Ll .rrl l r{ C i rc unrfl (\i N erv ul l 0l l rho rl r l ri hoi Nen'lll llDi.jhiLr N nrl li| ri Lrl N erv ul pe{ Lorl

Coborirea umi r hri

3) ]tr-'ris&l insii' o serie de particularitii,li ale distribuliei paraliziilort qi rrlrrrrlrrrlliilor' ale activit5lii electrice musculare, precum $i ale unor simlezionale: a) la ni ale rrsrxria'te, ca'reprmit ili.ferenlieri. toltograJiei. ;rlrrrrrrr vllrrl lrcrirrrrrionului motor I b) la uivelul ridS,cinilor anterioare I cr)la nivelrrl pl,rrrlLril tl) la irivelul nervului peliferic. lf) I'onlrr aprecieraatopografiei ieziuniior nsulonului nlot'or periferic rrrlc ut,ifii,olrnoaDtreapri.ncipalelor ac!'inni molot'ii segmcnlo,re coretpon;i ,ti, t nla. i erl)etie' rad,iculo-med,ulare perifc,riaa (a. tabelele nr. I' II, III Si, Iio. l[i, 19, 20,21t @up}" Iiiser, 1952 qi Chusid, 1970 - cu moalific5,rilo
rr olrn{rtlJ. TABEL NT. I lligeirile capdui

,1

Rotalia bratulili inaiDte $i inrpci Rotatia bratului in ahri -Cdrtuclia brafului

ca cn clcl ca

cs c" cs cu ot

Nervrtl rnxr(hri Ner.JulsuIs.:tll

N erv ul s l rpf)s pi nos ul r I i N erl ul s rl s pi tl ( CircuDrflc\ N eN ul dorsa l rllr i r r r r ,, al r u N etv rl l rotLrndul r r i r r f. ndul \Iai Inul l i nc r\' l t)r,,\,.rl l l ,l c l i ]r pl c )' rrl i )rrl ri :rl )

Supraspinos Subspinos Rotund rnic

Dorsollil mare l l otund mare Peotolaiul ma].e SLrbscapularnl D el l oi d Sup!aspinos

Cr cu 0r Cu
Cn- Ct

Abduclia bralului
fi

c, cu ca-cs cl-cs C,-Cu cs-ce C" Cu

CircumUex Ncrlrl sul scl

\Irrs c nl o' ( uti r rr I l l us c tl o rLrtr rrt l

Fl exi a 4nlebratrului

Biceps Brahiai anlerior Ltrng supjnator

Tl.iceps

ce -cr ce cr
c6-c?
Co C"

ExteDsia antebratului to
l '1e\i a nri i ri i

rygrl
Ii adi rl Mcdian

Pahrafii (mare qi rnic) Cubital arrLerior

Prinrul ;i al doilea radial extcrn Extensoflrl degetcl or C ubi f{ pos tc ri or

C t* C e

crbi!1l
Cu Ce -' co- 0u
i l adi al n adi:rl Itac l i al C ubi Lrl tr{cdiaIl ilubit:rl

Dlepli antcrioli Sternocleidornosloidieni

l, l \ l ( r s i l Iill)lrlIl

cr;.C, Per. XI. crao+ c , -c t

Cr-C" Ct-C'

Pr'nii ner\.i ar.nieni n. spinalI- ramura n ccrv;cali (lolr:l

tt

Ilxtensia r:liinii

,9L9,
o? 1)1 C' D' cr l)1

Splenius (lomplexul nrare Drcpti posteriori Micii oblici

S c alcn i 'I'rtlpcz S p le n iu s

q-c" cr-c,
C,- Co Pcr. XI -l-

l{xrele rlen' {rrcipilxl Marele n.n' occipital Primul ner'\'eervica]

Marelc rLcrv P dmi i 6 n{rri ccrvi rrl i S pi nal -l - Fl i mi i d,,i i r. f,r'\'i cali Mal cl c l rerv occi pi Ltrl

t:t

Fl 0xi a p oi i c el ui (pri ma f i a (loua falangd)

Scurt il cxor' Lung

ri t

I ||flillrrrcu l r l . { ' rr l l i

cr-c,
S l c rn o clcid o r r : r sto id ia lr slln g ( l r n r Ur lr xu l Dr I| r ( ) sllug S t ) l flr h r s ( l1 1 t l) Mnr'oh (lr'll. t x r r l l' ll( n r lr ' r I) t

l l cxi a i n dex tl ui Itl ter{ )l n,s ipal mx ri $i a mcdi us ul [i fi doIS.rli (D ri ma fal angA ) l rl cxi r { l tl angc l or Fl c x or c omun (s l |perl , fi pr0f.)

c?-, T)1

l l c di arr (tr1)i tj ]l

.!,!. t

1l

It0lolijr crtl)1rhri (sr'fc drr:rl,trt)

Per, XI -F

cr"-c" or--c,

SDinal l- C, l \l rrcl o nt'r! {.i Ii Lrl

cr , (:x or -- 0N

N trl rdrf rcrv rk ( i l Jl l rl M{rr!l o tr(.rv (x ( i pi tl l

i l (),i a d c gc tc l ol Ll Lc ros l ,ti p:tl rrrri 'l [i 5 fi dors r' l i (pri rnr ftl nnl i i ) (rL (l ouu tNl tl ' rl .{ i ) r,|l t,rrl r( i rl (r' Ir'i rl l r l r tV ri )

l -(? r)r ' i

j,',,,,
],',,,,

N { c (ti x rl ( l rrl rl l :rl

t44

l4ir

cqbcllI Corllnuarc
tl

(:o|l,llllalo trnbol

z
QnAdJicep$ul crulal L'n-l't

'/ liadial
Radial Cubital Cubital
Cubital Cubital Median Cubital Cubital Cubital Cubital + Median

I /

I lxl orBl[r l){ lccrlui llxlcrrsld lrlU rrrlo r 4 rl{:grd.c (primn hlu rgll) (r (loro $i a lrchr ftrlanEtr) A{l(lrr(Lin Fi |,Pr)rllla rhgcl.olor
llJ l tl

Lung fi scurt oxtensot Extcnsor comun Plopriu al indexului qi a1 auricularului Intcrosogi Lombuicali Interosofi Palmari Opozant Adduclorul policclui

o o -o ! Cu-C"
Ct Dt

iixtcn\iA Flexia pioiorqlui

c fl rrIl popl i l eu

I I '
10

L4-r"6 Gambier antelio? (Si rotalia ineuntlu) Peronier anterior Lu- st ($i rotatia ln afardl Extensor al Lu- S. degetelor (tn mod
Gemeni si solea! Gambier postedor (qi rotatia iniunttu) Ltng peronier latelal (9i rotatta in alard) Ganbier anterior Extensor propri[ al detului mare Iixtensor comun al degetelor J-ung peronier later4 Peronier anlerior Lungul flexor propriu Lornbricali ti interoso9i Lrngul fle)ror proprm Scurt llexor proplrlr Adductor propriu
I-ombricali qi interoso$i (pt. ultihele doid falange) Extensor propriu Pedios

'fibianul antcrior Sciatic poplitcu cxtcrD fll anrenol Sciatic popliteu inlerD Tibial posterior Sciatic poplitcr exLot.n

c"- Dr C"-Dt ce D.

Extensia piciorului

Ln- s, Ln* S" Lu- S'

dductia pollcelui

cr-Dr
cr- Dt cr- Dr
ce- Dt

Abdrctta (lcgctclor

Interosoti dorsali Abductotul degetului 5

Rotatia piciorului induntru piciorului in alar{

Lr*Lu.
Sciatic poplitcu cxLerD Ti}ial antealor L._ S. Ls- Sr Ls- Q La- Sr Ln- S. Ll- Sr Ln- St L"_ S. Lu- Sr n. plantar intern n.. plantar htorn Sciatic popllLcLr exlcrn Nervii planlui cx[(,nl tdrn Iibisl posterior Sciatic poplitcu intern Musculo-cutanat Iibial anterlor

2l

Alrductia pollcelui

Scuftul abduclor al policelui

I _.1 R o t a l i a ,

TABEL NT. IIL MlgeiTile membroloi lqlodoare

liJ

Irlexia halrlcehi Prima lalangd - Celelalte falange

Tibial posterior

vl

(l(llrclln A l, (luc llu

c o l l p Hcl

Adductorii Fesierul mic ii mijlociu Abductori Fesiexi miilocii Obturator Pdtlatul crural Croitor Psoas iliac Marele fesier Drept iltern Ilicep$ cluxal Somlte$dlrros somllllenrbrtnos Poplltcu 0rollor

L"- Ln

:urator, musculo-cutanat interll, Bciatic mare. fesier superior fesier superio! fesier superior Obtumtox Obturator Nervul musculo-cutandt extern NerYul crural + ramuri colaterale ale Plexului lamba! scia!ici

IJ

Extensia halrcelui

Lo-L
L, - S Ln- St
L^_L. L s- L 4 Lo-L"

totofla IitlrnLru a (roIptcr llo[n (flrll (f r lr 'In th {

c o[ pid l, f lorlll (li)rpsci (!n$ln

t5

Fl exia celorlalte degete - Pdma falange - A doua falange

Lr-Ln

Loinbricalt $i intr06oqi Flexor comun Scurt flexor plahtar Flexot comun Extensor comun Pedios (ln afala degetulul 5) I"omhlcall ti lnterosoil (pcntr ul[hnd( doul fslun{c)

plant{r inlorn il Ln- Sr Ll- St Planl inlcln plantar int(r:t plant0r lntcfn Dlautmilntqr:1 cxl0ID ll

Lr* fr
Lo-'- Sr

'jxl

0xlu g0r bol

L^-Lo Lo- Sn I-o- sr I'o- Sr

t0
sciatic mare Sciatic mqre Sclatlc male Sclallc poplibou intd Muiculo-cutaDot cltorn

llxtensia celorlnlte dcgcte

Lr- sr Lr- L*

r40

t4r

-Ttiaeps corPr - Exlensor rodidlis lonqus

B{qrhlcte diaI is ,flexar,'.carpi ra0talts ,Pqlflchs lcnilus

pallitis. Apponens pallicis Abdua.f.or brevts flexat pollicis Drevls ,Abduclor icis Po

sibiifiis Flexarccryi Abdrc.btdigili .flixor djgilj quintibretlts

coai Exlensor 'tudiolis brcvis 'fxlensorcffpi ulnoris Exiensot digikrun potliais Abductar lon1u5 Abdwlot Pollicis brcvts

superior(drept)' si F,t, 20. Muqchiisuperflciali membrLrlui

SFt

* ciis

&
.8

Atubusntdits noxinug Gluleus ailis Gto

Senilendinosus Eiceps fenoris Voslusblerolis inenhronosu,s Sen Percueus tonquS fibiql,is

2a

Exlensor digilorun longus

Anloiot

Fastetilr

Irl0. lr, Mur4hltrtrpol'llsldl al mdmltlulrrtInlopl0r (droDt)'

.i-,i.1!.)!. l'roltlrutr dr l.itr1tt,*lrtlrt1t,tt1rulirtliol.oqiritt ltrr.t,r.l,i:iilr pritr li I, irttti rr.lt|tI t|t|)|1.t||tt,i tttrlrtt1ntilr trl l\ l., itttil" p rirrtt'iunulr : l) I'olirnn.irlilr a,nlui.ourd, (lM,l,(, l,ut IIein,c-llh:tliri). l)rliciltrl &u,u,l,(i, rroiol sc irrsiirLulzii bl'utal in decut'sdc citeva oro sau zilc, rle obicei dupii o iorrrliilirlrlili, (lo nrulte ori inso{,iti,cle fenornenedigesl,ive, I'espilatolii 1r,,r i.r rlr. rr,rrrrrrnrorringe&le), uncori Ei in plini, sfnS,tate (,,pam1iziilede dar rI rrrrrrrr.rr, i r' I ). Sc lcalizeazd, tablouri I'ariallile, cu paralizii limitate, parcc{ l:n(1, riur, rIirrLllotlir-Lfoalte oxtinse, tuteoli cu caractexeascendento(sinsht abolite in zonele 'lr,rrr l,rrt(ly). 'I'otdeaunareflexele osteo-tendinoase ll)il,r'rapi{l attlfii musculancDihipotonii remarcabile. 1r:rlrrIiiicrr, jbilitatt-,. l,ipslsc 1,rrl brrliililc de sens ')) I'rtl irtm,itl,i.tn, plin deficite motorii o,nteri,oud, cronicd se caracterizeazS, lrr rrllolii lnuscrrla,r'c rnulte ori rii cr fascicldalii), cu instalare fi evolutie (rle l{'rrl plrrgrrrgivi,, loc ,lizare bilaterali, !i simetricd sau cvasisimetric[. orr l\l:rjr)r'ii lrljol,lrcos1iol sint degeneraLive(rareori cu caractero erdo-familiale), ,r c,rk, rrrri rrnrltc iiinrl dc fapt forme atipice de S.L.A. (Ratlu, 1978; Trillet rli |olrrlr., I070), iar unele cazuri putind reprezenta forne subacut-croDice rlrr prrlirruriolile qi vilotiice (Drd,gi,nescu colab., 1962) sau sechelelounei a,nterioat'e acute (Ileine-Modirr), in care atrofiile musculale 1roIiorrrir,IiIu rrrrlrlir.iirlc rlotolii, dupi mai muui ani de la stinger.ea procesului acu[, rtrlcp ;li, so extirrclil {i si se accentucze ptogresiv. Drpi, Radu (1978) {l \ rirlrlrrlrr, ontil itli distincte a atrofiei nusculare progresiyo Aran-Duchetrcir, rrr., r.rr,rlc lal)ir fi {l pa,raliziej bulbare proglesive Duchenne este indoielr r(ir,, rt'l,i.ii1oil leplezentind mai probabil forme atipice ale altor afecliuni rr'lr,rrrrrIr'orrrrIrli lnoitor (S.Ir.A., sindroame r1e S.L,.A. el,c.). Crdem, deci, r':r lrrlnurLrrlrlc ,,lrolionrieliLiilanter.ioar.i, cronici], devine incorect in etapa, :rIlrrr,lii rr,orrrLo;Lin{elo| noastre, pentt.u cazut'ilec1l otio)ogieneprecizati" Iritrrl lrlrlirlir,bil si $e nlilizeze telmenii dc ,,sindron tle S.L.A. atipictt rrr,rrrlrr ,,sirullo])r I )(r'icalion:t anterior oronic de etiologie nepleciza;bii,'r. l 'l'ilrrrl lrl rilr,i IrccvorLtintilnit este siuchomul amiott.oficAran-Dlchenne, rrr crr,r'r, rloiir,ilrrl rroi,or qi atrofia rnuscular5, incepe la triye.lul rniinilor, rr.:rlizrrrrl, oi)ritentolor tenari, |i hipotenarii [i :r, interosoIr'irr rr,i,r'olil, ,rl,,r',,,rrririt, sirrrirr,tiii') ,,rrrila in ghear5", dupi cale progresiunea atrofiei ;i l:r rrrrclrrl rr,rLi oll|ir,l,t1or, lrzaa,z\,,m ta t1elredicator.,, $i ,,mina Si antotg lrrrr,l rrr'Irrrlrrl,icJ'.l'{rfia ss poate exti de qi Ia nivelul nusculatur ii bra,rrl -,\t I rrlrri |i r'lriitI lrl rIl so[]inturalizomelici a memltrelor Supelioare. ii:ur (lrF(,r'ir.i cazut'i de ,,poliomlelitrd rji cronich" in ctre atrolia debu1,.rrz,: nilrrlrrl utl$ct atut'ii proximaie armembrelor superioare,realizind lrr :r,r lc prorrrlolrriopa,tice (Yulpian). tr'ormole de ,,poliomielitl donicS', 1,i., r r rlr.lrrrt, rrrcrrrlrlele lir itlforjoat'e (pe glupele tnuscxlare peroniene) sint
l l l r ll l t r r'.

'l .l nirlrol'i il.t: s1ti.tt.u.le progresior (aniotro{ia progresivi, in{a,ntilii, \\r'rrlrrr;1llollrrulrur, arr)io{irofiaspinalti jnvenilii, pseudomiopaticS, Wohllrrll, li rrgirllrolg-Welanrier) fi recunoscute[i diagnosiricateprin car.:rcpot | ,'r'r I lrrl lorr ol ic olc(lo-1atrilial, prin masivitatea sjibilater.alita,taatrofiilor r It IrIrL|||IrIr'(|, irrirrl(,il,c de al1,csernne de afecijare degenera,ti\.:'i motonuror a ;i rrilol rpirrrli : rr,r'olltrxil, modifioXtilc ll.M.G. de tip lteur.oosi.cotondinoasri, rrrir,Io1rrrIir., s trrrrntrlot lipst 11r.rr trir'lnridalo a,lulbnririlor d sensibililaitc, [i grllr.rrrrr l)t'il o\'olll{il l(n,l}1n1,ictrli (.llNdl, l9?8, t971}). 'ij 1i ,i) IJrrylu. (ttjr,it,iro.li() .i (llttt,t'.n|. J/o'iI srxirrzji, corrlorllrl f(.Ilrio l irr loyJil rorrtll rll ltrzirrtrt rr0rrlrIrri|rIt oli ;rr,r,iliIlirriirIjI rrivirlrrl lr, rrroI llr |rt'r'it.lr, i0

1 rt' ioItI riottrt,l (tttt iitttrltotrt , , I )()| i(t III i{|I i I I'i ' ItttItrt ii t lottit'it),r'iI i1iI'toltrtllr rlt' i{rllltf. lirllllt lt,ltt ('ill'lllrll'f tltl tjot'tItIit'tttI prrt ir,, lrrrrluttt ;i sottttttl ilirt l)osl(n itl Ilr,rrriIilr,I, itl tjr'urlo. rlr:LrttLc:t'zir c0pilli,l sttll lit, \'il'sl{r.1,itl0l(', l,ritl rl'i,tolii rlis[alclocalizi,to1:lrnomblclt inlerioare, cuplinzir([ ittl,ii ttttlst'tllrtltt|rt' 1rr'rrr la rrior'[, apoi pe cea gambier'; post,erioarr",!, illccpul ou (lolioil lrr()lt)r lrrr plc:r,irnporta,rlt, menlinind mu1t5,vreme sta,liunca fi rnol'sul (c,,trr ilttrii rlrr lrr jlrcep[t poate lua un aspect stepat). Apoir 1en1j ]l -progrosivr ll,Ilriolr'( iil rrr Iolllizirr(l o\tinde in mod simetric qi la treimea inferioarii a co[],J)s()lor' frl,rofia caracteri,sticd, ,,in picior ale coco,i' (sau ,,in cizmii iltaJl,il,") li tulbut'iit i rlo tttoli lrozi{ie de mrus-equir a picioarelor, cu consecutiYle lilnte, insolile li do tulblrrd,ri ile sensibilitate ectromelice (strbi()(liivofii obiectivo). Xlernbrele superioare si]]t afectate mai tirziu, do l'egtllii ilri(,ilrl {n atlofie tle tip Aran-Duchenne, extinsi, ulterior pini in lr'eimca ttti.ilotrirt ?r antebratelor (atrofie ,,tn rnan$eie"). Existi qi form de tl'ecclo irrlr'(r boala Chaicot-Marie $i eredo-ataxia cerebeloas;, (boa1a lui Fritxh'tr irrlt), situatii in caro se asociazd si tulburiri de sensibilitate profundX, cu irl,l \jl' {prin"leziur ea fibrelor radicuiare lungi din coraloaneleposterioare) li, ov(rlr' t,ual cifo-scolioz5,,picior scobit cu dgete in ciocan, precum !i mioi fi lirr dive semne cerebeloaso. 4) Itt siringr.tmiel'ia constat5, lrecvent semne motorii poricariorl:rl(t, se cu sindrom Aran-l)uchenne. Amiotrofia, cel mai adesea simet'ricii, int{no' {ea,zd, membrolo suporioare cu fasciculalii' excoptional de rar apil,r'irrrl lrr, lrlembrele inferioare. Prezenta tulburd,rilor de sensibilitato di$o(lirLt(1 :iirigomielic, suspondate, a imporbantolor tulburbri trofice, a sindrolrrlrllri (li:rglxtH }iramirlal asociat, procum $i Yolulia foarte lentd, ne sugereazri liicul. 5\ Iurnori,le intramed'ulare ti traumutismele aortebro-mcdulu,rtt(:tr' pot hnnal,omi,eli,e) genera siDdroame motorii pericarionaler asociirl,c(1ll rt,ll(\ $ernne comisurale, indeosebi cu tulbur5,ri de sensibilitato de tilt si|ittgrt rnielic, de obicei inil,ial suspondaterapoi sublezionale(cu niYol (l{,5(!rr$i bilitate). ll\ Leziunila rdd,ic'LLlare .mteriodre prezintr, o serie de particllllll if i,li. I a I)istribulia topografici' segmentarS, deficitului motor $i a celol'Lrlirosorrrrri colelate a1esindr'omuhi do neuron motor periteric este identici' ctt |trit' tlitt Icziunile perica,riorului, dar fasciculaliile musculare sini exceplirtLrtl rlrr fur intilnite. Pe de alti, pafte, vocinltatsa ridS,cinilor posterioare facilil,oltzil' rlso riorea frecventi tL unui silfdron do protoneuron de tip radicnl'l't,' 1) Comprosiunile raaliculare (tumori, arahnoidile, hornii (lisrlrrl{r li s(xlllrr rli,o &fectimi vertebrale compresive, tumori vertebrale primitiYo s2l,tl rfirrt, boala lui Fott .s.a.) teallzetuz[' cele mai Yaliate sindroamotolx)gtrrli(1r (rorvicale, dorsale, lombare, sacrate) mai mult sau mai pulin o\l,irrsr!. llrrrliticilrils de reflexe (osteotendi:roasor cutanater a,rticull,re'pilolrrol(,lii, rrvsntual m[coase) $i aprecirea tulbu.rAriior de sensibilitate i],so(,iirl,(t l,r\ rlclrnatomerele respectivo tranqea,zl localizarea $i extonsia, loziunil(]I'. 2) RadicxLli,tela(respect'ia ma'rlingo-rdd'i,culi,re1c ) virc1,ieo' ltotitrtt sttlr $rr'rl rlo llto ctiologii pot fi unilalrorlllo (n&i mult sritt ]nfti l)ulin oKliins(r) l)ilr,l,(n il,lo. Jl) I'olirtdia.tl.on,(,,1n lt\tl t'ollizl irttblortrii;r{,t tltlcgitltr (trtiti tiw tlorrt ild(
( ]l l i to l l l l l {l 1 r l r , r 'l l p l 0 g i c o , |) o l 'i ci l ,o l o r r l o l ( t i i i t,JIl ,t'i tt l l tttl ,cr i 'ttl l tl l o l ' l l Il ) 1 1 ) l tl i ) ( o tt l t,ttr l l tr xi o tl sl r o ttl ,o tl tl i tl ti t,si i , tl tt l ti ;tr t . . l : r , r '1 r l 9 t L {! l tt( ,l r r r i l l o t' ;r r r ti l i r r i t 1 1 i Ir r i r ,lt0 l i i ) t1 i ( l o [t1 ) 1 o l tr \l l tl ttt sttttzi l ,i t' r r tt l o u i r ! i {i l , l t l r , i,o tr i r r tr tl tsf[|tti i

ll, l

rllrl lilrt(ir! :rl,il,piriLntirllt,lii, 11i r'il, lrrI,r.orrrrrIirrii,.rlifioii po:r,kl rrIroor.i X'la i li rlirtrlrosl,ir:rrl silrrrr,!,iilrr r.rrlrr itr rIr,Ij|iir.|,1rrll')r'ii irr lll lltr.rlrrt)rinil, r,iuli.cil trrr,trrIr lrrIoI, trtt llrlrlorr tlilic I)s(ilt(l{)ntio}{,iti(r..l)tbu1,trl bnrsc lrtrrrlrrcirtil yirsiN, do .r,pl,r'ili{) or.ioevlrstS,), a,l)olirea]rtlct{ol(r' rrrrr Ir,Ir,l,iylnrrs(1, (l|, ,rlrrrrkrrrrlirultso (rlroli cn pistrrr,rear.ellexeloridiomusculare),lipsa atr:oliilrrr rrrrrsrrrrlu,r'osi,adiulde debut si mai ales n.otlificXrile in lichidienc, cet rrrr.i rrrlosoil(xr disociatie albumino-citologicX, vin sE,para,fezecliagnosticul rIrr 1 I i lr rrI icrrlone.vriti. Gtrillain,Baud. ro I) ilind,roamele coai,i d,eaal rbaltzeazi, tablouri multiradicuJare par"lilrrlrrrrr, rr,rlcsc:l, paraplegle,4A$cd,,hilg-tp[6r ?ISflexiE[ $L s11 cu at{oJii-rnrsortkllo. 'l'rrlburzirile de sensibiljta.tg pella4aler. in ga.Si tqlb.gr'rilc sfinetelr,ro irnlx)rtitnte ttimiln diagnosticut Oe potiomiitith; tifrsa tulbur{rilor. ,l(. ,.rrlil)ilira.h. ucllorrrelicd Gubiectivc $i obicctive)elirnfiai'dl;gnbiliaril rlr. llzirrrrr. rnctlula:ii. Jt)'isl,i\trei til)uri de shdroa,rne cu coadr,de cal : n,1\8intlrom.utV6ffi.\ol aoai,i. cal realiwnzd, oteritabild; p,ar-aplegie,pet! ite Irrli*i,, 1ltr,scd,, arafloxigd,r.i1lierosird ioate $rrlelo rnusctlale.alo rnembrelorrr|rriolr'o (cu integritatea psoasului iliac) 5icu masjve tulburdri sfino_
I'rrt'jtuul.

l i i r t l t 1 i l r r r t t t ii r l i stl l l r

lt) N[rulrontr isutrter'ior\ql, cozi,i,Lle ca,l.

prrlriir,l sint abolite ixl cqle achilicne qi medio-plantare sint pishate. rt xindronuL ffirior'(sauat 1 ol razii dr aul (Io - J",). Inlegrilatea rrrrr;r'hilrira,ntriori ai coapsei collrastcazi ru imlortaiita -.pariUzie-a rrr:r.iclor rrrusculare po$teti0-4re, inclusiv a mugchilor fesieli ,;i gambieri. l'iciolul cstc balant, ou tieticit de flexie-extensie, intilnim nD impo*ant rlolicil, rlu flcxie a garnLreiqi mari tulburd,ri de se)rsibilitate perianale, 1rrlrrrrrrsi pe fala posterioard gi externS,a coapsei gi a gambei. Reflexul r')l rlilr fi rnedio-pubian sint p5,sirate, in schimb roflexele achilieno qi rrrrrrlio.planta,ro sint abolite, lt]ulbgrlrile sllgleriene r i,irin pe primul plan. li,.fllrcL. rrrrrlc (cxlern $i interrl-sint aboliie. Pot .'i apalri si es'care. I'r'olrr.k, rlo elongalie pentru sciatic pot si, fie pozitivc. Teoretic ai.Ti nlilttt irtrc leBiunilecorrului Fi ale ep,iconului meduldr.fald 1r,' rlril:r r/i/i,r'r ,lr tt ittuilr,,'^-iIL]e rtrl.Inc[ Lhermitte (1919,citat de Riser, 1952)precizase rrrr,lr,rrlil,rrlii rlo tliagrnstic diferenlial: in leziunile conului qi epiconului ,l rlllilr s'irrl n)li ])ulin vii gi mai pu-tin persistentein membrele inferioare, r \ r,nr iiorrnll lrri Babinski, asistd,m la o simetrie a tulbur'[rilor cle scnsibilrlrrirr;i rle rtotilitate, la mari tulburlri sfincteriene si genito-ur.inare, rrrrrfi lrr o paralizie atroficl importantS, si a, muqc]rilor anieriori ai I'r','r Sc irrrprrrnc;i tl,iagnosti,cu,l tliferenlial fa\d, de afec!,iunileprostatice, in rrllrrlcrr, lrolrravii simlind pasajul urinii prin canalul uretral, precum qi l:tlti, rlc, ltti.tr,tti ontinpe al,epleuului, lonzbo-sawat (ca de pilcli, in invaziile Irrrrrolrrlir micului bazin), care pot simula un sinalromde coatlS, cal. rrlc de lrr frr[a unui sindrom ele coadd, de cal se rialic5,foarte malte probleme rlt rl.it rttt.o;sl,ic tl,iologic : ne t,) .Ln,cltzttl rlnei, i.nstald,ri rapid,e, aaute sau subaautre, gindim in joa,sii(lombarir,), o rneningorrdiculil,i,infocla lrlirrrrrlrlrrrl ln o borlll I?o1;1; (iorr,sii r'ozii rlo cill, ll, o prr'i,lrtr6iro rr, vorl,clllllii pliu tunrot'il 1r'irnilir.ii rarr rrr,r,nrrrlrrtii, rr,rrolo;ttt0i vtu't,olrt'ttlo lotnltit,tr'. rr litttlirut'lttrrrlotrt;ri,ozi'i lrt ;rcrrli. t5:l

tl;tt i1irrtt soi r,itrtl irtr boltrr,v rr,rrouzrr,L lrit0vit sri,lltit,tnini ,hr,lgiilu brrsottlii,, r', t-lttittllrttliili slittrlIrt'icrt itt illrrliari l,osliaulrIr'o 1xrrinoi[lo, i]i ]rooulrl Ii i tt tlrolrlenl,ul cirr.e sui'vcnit Ei lorlo ]onololilteliotr ;i l,tLlb t iili ltt tl0 srrtrl ilt au rlirigrtosticul tlo lotttlttr in ;a, trebuie categoric sii inbi],ndorti'lm lrili[a1,c scilticri ban:rH,,,siilii xe gindirn la o compresiuno in cozii (10 (,i ' rrogittrlittt lan't-progrtsiuo sau b) In cattr,L rtrvi euolulii suba,oute cron.ica irr prirrtul rind la o campresiuna cozii de cal, in spocialprin tutrroli srtlxltt a l e primitive (neurinoame indeosebi; limfosarcoame ;.rr.) sittt ttlol,rr'" IIotl' si:ltice (subdurale sau extradutale), alte tumori extrrldttlrrlc,borula, elcirr, alahnoidite chistice pseudotumorale, sau la comptositttti rlrr rrli'r'1, rrrinrir. inclusiv rertebrale (boala Pott, metastaze !s.tr.) lll) Lezi'unileplemLrale te^lizeaz\ silldroame de neutott tttrtlttt ;rt'r'i' li)r'ic cu topoglafie palticulari', uqor de recunoscutr pri]1 ertenBla, (x)lrl'rlr l,ului semiololic in teritoriul plexului respectiv (cervical, brahia,l, lortrh;rr, siloritt,).la caie in rnorl obliga-turiu se asociaz; tulburi,ri dc seusibilil;alrr iri ta'ofice in respectir[l teritoriu tle inervalie plexurali. sanxiologicd' problem'ele{k dr(llttorlio Arnintim pe icuri colt.stela,ti0, 9'i r:liologic Ln sindladmela pleaulare : 1.) Sind,rotnul plen cemiu'l impiici : alteratea mi$clrilor tic IL'xirr, d'e roirrlie qi inclinalie lateral5 a capului qi a gitului' la cate sc pol, asttt:i:r' i,ulburi,r:i reSpiratorii prin paralizia diafragrnului, prtcum $i trtll.trrtrlri tlr', n'nsibilitato in teritoriile ratliculare Cs-Cn. E*te reahzat de multiple afecliutti I tr'aumatice (rlt colonnli tltvi malformrtive {r-r'zi Arseli ,si rrolllr., inalte), tumorale, inficlior-r,se, ra,Lr. ll)iiti. " "'1;1' g i nd.ronutdaltlel,iru.bdpoate fi reatizat lie tle leziuni t'rr,rlicrr t-mnehiuri]or l,r', 1i'u-[r,), lic,le'tr"z.iuni-ale ltrim1 re (sllln'lioI',trti.jlrxtrt t .;r i,Ui..r:iur), rlr' leziuiri rte trinchillitor sccundul -(suporiorrirrf(rri(rr Iie ptexului insuqi.Ca ataie, se pot rlistitrgepatnt, I)trrittttlt' q,iptxt|r'ior), fie '.rle

cl tr tt l r o l ' I o i tl i zl t, ttl t si tttl tr tttt tl r r t o :r l l i tl o r ,l r l ' l ) o p i kl l tt

'' "''".i]{rifl,i,o,rutde.mialiiri-tiitiio pterutr+i braltialst cirruct.rrz{trLl

intreg membml superior rb$lxr(rl,iv, lrlirrtr-n paralizie c-o4qd9-t[;-exf6d"-ta |rr anestezie gtroba}i iL teril'oriul intregului plex' sipelioi,rte plea btakial ( By'.9fu94.?q-Hrb citlrr ltrzitt b\ sintlr<.nnul ), itr rirliicinile Cr-Q, respectiv teritoriul nervilor l-nruo$lrl rLr.:r intereseazd, plirl ilt\lil'rl ,,ltir.lr&l al riicllcinii erpe.gle! med!4nulyi.se rrracterizcazr'i li blahial lnleliordtutg rtt;rrtrir ilorllelt oid,/bicrpsr/ llrrruL.i atrofin r tnrrr,.b lor';i nui pulin a muqchilor dorsal mare, pectora tnarc, diltflrl tttrt'tl iii rr,1,nir(l maie. Rellexele bicipital gi stiloretli4l sint rrbolite. Tulbltli-rIil', tlt' (.,rrcsprtozilL{)atr'((r.-("!). p|ezcntr'-[r'derma-ioFier?tr' ",.rrsibilitate "inf r'1 sindrcmrt injer.ior, plex broh;Ltl ( 4t,lrupLv'lM#t;rldJ, itt crrtr' da Co-D,, respcctiv lelilrr|iul trctVilot,li:ubilrtl .,.ziuncrL inlerclcazr.i'.,'lAciniIe il-lloJgliiltlut.fuulrrrr pliu parli:r,l sc r alsncrliauutui, cat act-erizeazrl rlr'lii, li rniinii ti ri gruputui intern el antobrat/ului' tulbutriri rlo srrtrsibili "Lilol (itt (Cr-D1), llt, trlltc sc itstxriltzri lrrlir pt tL:rrniilttrneroli cot'cspurrzir,toa,rc rttL sintlt'om Ol:urtlc Berna,rrl-IIotnct, iitt tr'lllrrtl lczirrrloariuliorr[urii') tsl,o rr,lxrl.it. l:rrlriCo-prrrntlt;ot' rrl itr rl\ ,^-intlronrtl ttri.jl,riu ir 1'lt.t:htthi'rl .( Hc.mt,tlcl {':rtr' l{ /ritrtrr'.r l,.11.s(;rrii uitlrilitr:t O' tr'.plr'liv t''l il',litll('il(lrrlrlll"\llllli;i rtlfruli:rlrtlrrr. tttrttot'1ilt'ltirliutt, lrrtt4rrltilllt/tl'itropx,r'i'xtr,rr ir.,'r!r':ri,lrlizt.irz:', rlr,licil, Pliri

i
I i

t 0il

I t i || t{ r.

|,,rrrl)rr'sl|rlrL,l|f , l,f. ill',fl.llll,,li lt a. c a d e p tl d,(ureori to ri i d e (,i Ii c. j nl (} rvent,i i r , rrl )rl sl |l l l|t il,\rla, ca il\ pil.ld,ia purthtorii de cirje, intewenfii chi nri , A l a p u rl d chimr,_de Icgluur l:r,.r(,,1)r.:rr'r't,''ts-l do mai SUS; traumalismeobstclricaje,cu L.zirrne:r rImpllt xnui bazin sirimt, rrnei .nrllerii (consecutive !f::),'],1'.'.,,'::nlrr,rn l)r'r'?r'hrirlrrrtel{'ctuo-irNc, eompresiuniexercitate tle manevrele obiitetri_ unei , :rrr.,l)r'lr,\l ptcxului intre claviculd, prima coast5, l elongafiei sau smul_ Di llr rii I'julir.irrilor') elc. I,'\'.yil,t sa.* r(:Iiculitr ftslp?t;, rudiaut,,pntii)t'intec!i()1sr...."4oxi.c ,b\. r.t:tprr,(., ,( purl\ ac.tntln. l,r':rsr.t1r1 Su.feriu,!e tlc ditsersenaturi : hpondilite (indeosebi morbul , . 1) -uertebrale r.rr r.(rr r.('r'vrcar) ,tumori Yertebr.ale, ; i.tr_ara,hidiene ;i extrarahidiene; lrrrr.lrrli;i rlisiocllii vertelrr'ah.;/herrrii tlisc cervicule. de _ coslt)nertpbrolc deJileu.tu i sralarir rr6oastri cen.icalii, ...,'.rt .l':'rr!!:i .alc :.||Inrrr|lr{, Ni.rtcnlce, rcalizalo ^si indeosebiprin tribcnrofja nru^chirrlrri scrj rr.r :r.rrl('llot, crre lxgrslcaz{ ,.defiieul scalenic',(saptiul rliltre cei doi pnnra coa-slii) care iD acesl mod r.omprimi,ple.rul br.;r_ rqi if l,li,sr irr'1(,llt Ei rrrr ll' il,,l :',, suDctaviculard, (Arseni qi Oprescu,196?; Ionescu,* popovicin rri culalr.. .1.921 Riser, 19b2). ; ,.1 rl'lrmori ale, virtulyi p.1r$g-n?T. Sinilromul paneoast_Tobias, in i . cru,. Insii p,aralizia plexuliri biafiial, inti]ninr dureri qi un siDaliorn ,lr.
lJIt t}:l ro_ liorn er .

l';rLa,liz,irr lrhrx llrlrLiill r.nla. do rlc 2r.r,r/usri tliatrtrr:,tlit,!,inni: , tl 'laniu,ni l,r& ryjeliq?Irr,rrivr.lil colorrngi/cerricrr,t,, inierioartr , li,diorr{ir,l(, lxrljr)rrre, sa,u la nivclufclu,viculei, a/riL,xilei si l-[ zonelor Nl sujpia_ si (.t irulrllrrr.ilrrllrr;; frlcturi ale rtr viculei, ,1 ldxaiii scapulo_humerale. scapu umcl1l clotrEai.ii lu.h lc. cl,irrga rii 1,,,.1,,:]i l,l,l'..],, lrir uIi,ate claviculei,.luxa.l.ii

r0r'ror r'ir,iDitill rrI uu,urii rui .. r ryi ''i,1";;;lil;l,; ,;r,,litt'r, rr 1 'l ili',,'li,lliiil:,jil

Sl qlf plerului

ctriar..r.u snrulsprea I'iitticinitorl;

. , lr t )) L' dr't . i. r it . t nr t r u, lt t , i. : ar . l: +( t tnt l( . . t l, sr ' llr t t lt lt , t ' llr it t t lolit r il, t t t olor , r'ospccliv (1lr I):lI('zl, rrl tnrrrychilor' lricops, lrrrr[rilrl iull,oriof osicot rtt,olrra,ltiit'I, Il ttxi ci l rrLelr r ir lului ( suplinit iL do hr ngul supillr r t or ') ; ; i r r ,r 'ir licli'r 'ii t t t t it t t lt t i, t irso{,itr"rde o hipol,rofic;i hipotonie a rluiiohilor lo.jii ir,nt lrt'rrl'tlltri. t',r'iorrrca, 1l'rrlburririle do strnsibilitate sint mici (vezi f ig. 22). h'uctori etiologici mai imporlanJi r pligi pl'hl at'mc albt, srttt tlo lixr I It ilcl,uli ale hurnerusului I anevrisme ale alteroi Axilttt'e I r:ottrptr'sittlti (1u'oi'csiorrale san in cursul somnului) ; nor.lile (fotrrtc rtlr).

Nervul circumflex
Muschiul dellaid Muschtul ratuhd mtc NervuI musculoaianat ,qomufl culanate

Muschiui biceps

br cnhial Circumflex Ramuri cu.onle ale antebralului

:l) I,'arlrliziile d,eple* lom,bar .(traumatiee, tumola,le, infecfioasc etc)rr'ri'rr'1r'rizi'|ilzil p.ir deficile motorii cu atrufii ale coapseigi prin dureii ,.rr iIIiIr'IL||Ir{.}n lct'iloliile nervilol,abdominogenilali,-fernurocut:r,nat,.i
, { t , l il {} {,t u t.Nl.

I'ut li,ritle_d.1 tt(lt sstat realizeand,rin context semiologic in care . ,ll I I || ' .(.r|||I r||it 1'll'uii rilc din parlea,ner"vuluiscialic, la ca-rcsec,sociaziI tro_ tr tr.sr.n., rlrrrr.r'i pet.inelle si lulburdri sfjncteriene(plin afectare:isfinc. Ir'tllrri ltrutl rrxl;eln ). l.:, i,,: i , ur periJeriri pdt. fi izolate (nevrite, neuropatii), .. l:tl : rltc lterr : iriroi.rrr., r)Irlt ,, ,t (mlllUnevi.ite) sau extinse, bilatemle gi simetrice-(poli_ rrr,r lilr', lxrlirreulopatii ). | ) I\ruli:iile i:olnle flte nptrilor pcri.tpt.;(.i : l) I'uru,lizia ,ner.uuluicircumJler se traduct lrintr- n tleficit motor al rrrr..r'lrilrrirl|llrrirl,."cr, (,r,crccazd dificultalea,5i11r.,i.i.i p;oicc[ieiirrainle I rrr':rl r t! t{'s-l,r{.ttv.ir tnentineriiacestuia urizonlt ji. Atl,otia mu)r,hiul i la | | r.|||,.|| r,r'r'r'rzi] I rr|l_rrginea ,,umi,r in epoletr) sau de ,,umir tfiiat clesecur.tr,, rle !r ||r.| |.| | ||t ||:I o relilxue a articula-tiei scapulo_umerale.paralizia muqchiuIrrr l.l,r111rl rrrir,.,impietcazii ltri;oarea de rolalie ertem5 a bralului. liulbu_ I irrr.: rtr' $('r I rNil)ili1 sr.distrihuie intr-o Ltc de ,,zonir, r:lcheti,)' pe'fala rxternl, ir llf)rit lrln' (.l,iU, 22)u,ni tts ti,ntni.ti.. fractuli ;i rlislor::iri ale cu,pului ,......,1r.::.",,,,r:1r'urunrr1ir,, ,i,:.,'l,rt.t1iri (pljn N,rmcnll)o $irn de for_) com])rcsifti lN, t'tirgr ; :lll,,,ll;,1, rr\'.r,r l'';'rrtr' (l)rr,li,si{nl'1,,, cut,snlsornntrlui, irt silrr ilr curlrul irrr.slr,_ ,||lrt ;.1|.||| 1,. Iir|| rrr.,rrr ollrlii 1(lrirlr ((l11 0xirl rlrr rlt|'lrort),r,rrrl0.t0xict, (tliir
lr' l l |r. l i r rl tIr' { .). ittlr.( tio itst,, { - lt . "r , t l) lr , t , lt Dt |r .

/rr.

.r. \"f\i i

c i i c url rU c \ \i

".' rs , u1oc r,l l l :rl ,

lrli rr cnbitalul :rnterior, lungul supinator qi fasciculele cubitale ale flox rtrtrlt I i i,ornrrrrplofund). Iilexia falangelor distale a,le{legetolor_?r[-4.{t'orli.ttt.ijkr r,irr r,sl.o imposibiki. ll\carea de opozilie u,policelrri trLt st.poal,c trlt,oltttt' Sl lealizclzl l Iiirrrl inlocdilS, prirrtr'-o rniScalc rG n[duZlli.ai fi,]iclri. <lttgcir',t rz d, policohli po ltnlali llan r:u oolela'lto 1r, i(it: in a,bduclio (f (r,mlna, rtI r:rrlr'lt olie rl eririnon riitttia4ri"), t olit,t,ttttsolx)11(' x I illllir qi prr rnrrs<rrr t'rrrrt rI r,I rt i r,{ rrI rr i ( , 1i11. 'i a) . l, r r lr , xlt t lr lc it t r lt ir lt , t r ': t pt t t t t il: llrl;rr
rrrrl ui (rr,ll rt i I 'illor r i 'l'r , sl, t t l,,,l: i. u. l! il l, ) polir , r . lr . r lcgr 'lt t l r r t 'iliil, ot r lt t xr r 1i

| fi[

ll.r'l.rrzii, irn {I(,gd,ulln i jlot,iLrs. i'lrrrl urrzii, doa,r, ptrr,f,inl, rorlizind ohiar rrrr :rH;rr.r'l,.tlrr. bucleil, (a tui Pitres qi ,I.estut) ,,gr.{ii.medianl,l'. J,:r,,,pr:oba, (.1i1.. c)r lllangeta irrdexului Du poxte si, se u,propie de cea a'policelui, .:!:i rrr;l irrcll;trici nu poal,esL string5.1n obiect inlre ]olice si extremitatei, li.l cr.lrrr'l:rllo rfrrgcte. l,a proba. ,,{g!!ilgr_-!_nsnrciqate,' (.fig. ZJ (t,), lTd,exal rir rrrrrlirrsrrl rlmin intinse ,,in sdg---e-at$1'.alt test eonsta in'iinposibiliUn

(n
m ei i i anul uj .

rtt l rrxi co (ti rtl ' , r t i izo|r lc lr nt vt 'lul t t t t r li: r t t t t lr r i; ; r l) l'zi- t t r r r ': r . t t t t 't lj: r t t t t lt t i ir r t ablot t l r lit lir 'lt lot lot r t it r it r r l * i " .i " " -ti f .fn r , ""Jcar Dia8cslccr r lclet ist it ir ,

rrli rlr.rrrrrlio qi rl,irrbu{it{' lnudj:r,D, ncr.rului io".o in t6i,iioriul *l*ii iuoe.e in .i,:l;"it;-;;i", ii .i dc atlolii muscularc terilotiultlislal (sulrr::rtlrirrtrl:'l
rt(' totali a nervului cubitl,l so(11rt de minh ,,in gllfA cu'biLrId" : ltrittt'r icuhru itr in exlensie,iar |eiilrltr' rlotti IrLlattgc Ialangi a degetelor se rlouri, r1.g.lr' ; atitudide fiind mai exprimatn h ultimele iiu"i"l-r""".ie jnicro$o'so ,.ritrl frl U"e"iJ mi" se menfine in --qbd,i;ie, iar slaLiile. primul spal iii inierosos (''a qqu"a't,+bachc'ii xllirt(r inift'ebi ,i""ri,i". *i.a,t- l"i S-i.rrd).'b" asnninneacrrrirent& hipofcnari cste i4rlrlizitiir I ii il. ot.ti'alc, iorso 1leniveluT!or:1iuil inforioarcrt :r'tl1r'ltrrrtttltri .i'io f " ';.iinii), 'd'.r,torit5, "rir" cru!5,rii fleror'lui c.o1u1 prof.ntl ;i .ttlri ;l;;;ii;J;i la o pozi{ie a nriinij cu ullimele d('ui ilogcl( rrl ,-nt".ioif ^liiltn 'rf.lri Ji P;i" piralizia intelosoiilor se compromil tnilciitilc rl'' ubrlrrr'lir' t[\;; ite degetclor; e) beficilul Ino-torinrcres"r'zi 1i tlcx irr' rtll i p'rli" "i-0" aore t"fot ",Oi*i*i"g.ie, ddeosebi a degPtuluimic' precunL.)iudduc!irr tlt' tulburaruptitr miqc:lrt':t rtlt't par[ial aceasti lui (bolnavulc6mpenseazd, ctthiLrrl l .t i' rr rrn riii". .*ilt.i;.p"iir nemrl medianl; t) ParaliziamuqchiulLri Testul ltti [rr'rtrr.trl ;;;i';;;,;;.[ un tlcficit rl adduc!iei!i d llexici rniiLrii igr ailtluctoniiui policelui, in sensul,c5' bolna'vul tttt izlrtt ;;i;;ifi;t !;irtiria cu mina un ziar siu o hirt'ie intre policele intitrs .6i irttl.r i;-t";6;i;; a rla face doar prin flectxlea ultimei fala'ng-e polictrhr i- rti i;l';i;;i;;;; prin ucrvul median) l-h';,Test'ul tlt: ,,r'ii* i; policelui, rcalizeia ;rl;-;;;;ll sint aplicale una pcstc it'lli) l'r'rrr iir',r,"'i, deEetelofi atunci cind r-niinile ti,tele lor pa*Imaro.qicu degetele_ abduel.ic e:trem6' de par,lli P:";:':i _i.n iri{ir' intre tlegol'tr

o r)istanli rnult, mri micd' ,"ie .". .iia"tiirre ina14" "fi" cu ii trlina fiind a6ez-atd, fala lrLnara pe rnas[''.rrriti ,i" o"tLo *X"Xl.asXI iar txrl, t lr' m-j ciegeiglui

cu ff iutmrrii"t" ri" Oegetului-midiint'ebOIitA ;cu mina.plasat'i Ia1* ltrtl. (scrrr'rrl u'ul tru poat'e sd zgiric"masa cq d.9gc-tul.l4jq rrr.rsd, bo"6a ;;;;;; 'piir"rt sint d! r.r Tulburi,rlle. se=qlbj-titaLQ localiTate ilSY*,f 'l:':' iri ; 4"

Fig' i, ^ lr,l !1. ,,LL,r iL :lrrru,i)lj r Pa.alizjr !

23'i

x'i#A#il ii ;';t; Iti"*g*xil],*:'*g*r**gttl'*tm*'"'11"'#

rlriltl'-t'ut'tt' m)-Tr-rlb-u i, i;,.;:;; "^."^-;""; Xi a.'.^"; i,,'r'qraat,er cauzalgic; m) riU,,eo,i se asociazd dur'cri cu-caiacter carrzalpic: Tulburirilo vul'uIi in ;rr,.rrorii t rofice se intilncsc atlobea lelitoriul nerfulul (delonntlll irlr' si o*c,i"ioi."a pielii, cianozd, pielo lucioasS' qi subliatfi, txlt'tttr.' ;;";hiii";; ovdntual chiar ulceralii a,Iedegetulqi mic). : I'rincipotii faalori elinlogiri a) Leziuni IrcunaIl( la.nivclnl coi ttlrrr raI,;'plngi ale ncrvului l& nirelul itlrlcl'ril huninrusrtni 1-di r,,,,r,o""ttiri contlrtr' liziunea :lrLeleicubit'al'';1 rniiuii (adesea o.1io41'so-;i i,ii,,ti "i "f " inaIe pc osul pisilolm (par'rliziir ir'liiiiiiii ,1" 1t'nutito. nervo:l,sc-tr'rm ',( '.{.sto,]:it'tciia1" soalenicrco:tstii'trotti g;'dle d'eJileutui ntii ljlor"'l: b iU '?bm (,:rlli; lri])( 'Jlrofiarnuschjului snllcn an[eriol, cu ingu"l:rt'ea-,,deJilottltt-i pot r r ri .rr,I .rrii . i ) 1 ,'; r)aolile rultilale ittTec!ioase ap,lclr irr/lrl(s,/lcltil'/li'lrri' (livct'seviroze, tnalurie 9. a. lii('i'lii tlo neruth,i tatl'ial se carrlcterizcaail' 1tt'inlr-rtsct'itr strttttt" :,:,),1?araLizia tlt' s{! rltr srrTi*l lt:tiutti,i, itt l\1111,{itr ('rl,l'o lr'l' i' lrrrlrrgirirrrr,,ni.r,, lirrC1io : rlis{irrgo1;t,1tuva't'irtiil,i tnyttt xt hldii l\,))ln ptrrn,l.izi.rr u ttt"trttltri in[ (purali:irr',,,ltnhirtlir" drrxit'i Ilirt'r, l9l:') ru)';\trirlr'rt{'ttlrrltirt" itru ,ur.tir," ,r,tiilurd,r'tnhtil.t "

ilu,rll,il'ir r ii";l;;,ll;fijlir,.il*:tf,',.:}"!!!iliiri'Jll'''::'ill.i5'Jll"L"'r;#:tl'Ll,i'ji1::l*ill; ,,,, tin.\, t.\t..!, . ",,ri,i.,,,k, ,.,,.,,.,;"','i,ii.;,Jf;-J'.ii"ll r 1"il :i.::.:',"jJ'"', ;:"J^fr,Ill"f..l;
" n r.I..|,.d ,-;g' dtA' r .j.' t) p' tr a:,?.\1r l) j?*t"ir o.r :_,an":Jl

rl I l ).r

lrrllrr llrxici rrltimci falange a rlegetului ariltitor', astfel ineit, atutci cind r'|rrir ,.rl(! rrrjozirlai. fala pa]marii pe masd,,boLnlr-ulgg pq_?!9_-lg-ZCil!g cu rr:rr,rrrjll urrghfu degetului aeitnlotl Unelo mis(.ii coEi.h, ri srtrcrur,j i{.,, .rlr, polir,r.lrri rr,le " celorlalte degete sint imposibile sa,uincoinplete (indeo_ 1i jlIiI(r rlo prehensiune qi t1eprindcre ir,obieclelor). Itriri( ri'.1)r Nir trebuie sri Iil,ir||r |ii rle rnulto ori apal dureri cauzalgice,r]rbotite t1s tulbur,:iri vaso_ rrrrrlolii ;i l rrrliicc,limitate ldhlvehil inAe.iiitui,.i aimerl jusului, in special
l| il rrrirl in-t ( lr. net - v UI lt i m er lial} .

I sc . 'l'u trut i}'i}:. tlp- S-eg51bili.tpl-c consl,ati dolr l)c ur.l i,-,ritoriu par{ial rrl z,rrrr'i rlr.itrllvrrlic lr,Iu'rrrrlrri mrtlir.r (.[i,t.:'.j ,^i. I'rin.ciptlii.lurhti ttidouit,i t a,\ lczilunilrautta.ltceh rrivolrrl br,:r[,ului , (Dlrtiir rttrtr,irllrrr rlrr slrrr lirr.,I,,t[l,l!rHilllri, L,ziurriprirr solu{,ii l)r'it) irr,jr,,rIIIrL| l,jrt;r\r,ni)r lrr rrirr.lrrl lrlilii lolrrlrrr); l') rrr,vlilr,itrl(,r,li,r.rA(,; r)r,rii1p11,ii r.i Ih0

1t,?

cutanat a! cubitql

Gheora cubitald

FlexoruL profund
'ol degetelor

(logcltrlor'"(a,lluilr'Iottlolll) rolol'(fxl'(,rIr.l1)lil()l'(logoi('lr)l ,,r'ilslil'iXl'ii i n)'I(rst,lll a-tltrgtrkrlrr, ll cfcctuarrrl tniqoil,riidc cxl,ensicqi indeplrtarc (r'iisl'iraro) rlc nrrter Dirralizati' nu sr: observi tcndoanelo olil,tlnsorilor' (Ji11 25 b); ,,1 destul ,,itringerii miinii (al lui tr'roment) de asemonea alatir, cL (l(r l)rrl cxlonrorilor, niri I)r'(tt'trrl li.a lc ralizi tir,nu se evid"nliazd nici tendoanele nent-a radialului extern #ig. 25 c) ; p) Testul prehensiunii uttot ttlritrt'll mici plasate pe un plan orizontal (a1 lui Pitres). Bolnavul nu pttitl'tr sir' a,pucdobiecte-,intrucit pe de o parte este imposibilS ridicalon, miinii si rr' (l(g''it'l(,r' {" nijmelor falange ale dcgetelor, pe dc altb parlc IIe-\iunoir" paraliziei llcxorilot, r'i rlrtlolit:, ilce ttificil si cu for(i rcrlusd,nu ilatoriti irpl'ului ci, ace$tia nu-qi pot exereita funclia de flexie decit dacii rnirtit sr,' :r,fii in cxtensie. In schiir.rb,flcxorii vor funcliona foarte bine tlaczi so t itlit'r'r rnina de ciltre examinator, sau daci, se plaseazi mina in ii,titutlittcir '.rlc po se lusirciune" (Pitres) ; r) fulburd,rdej.e.-.sen-s,ib,-.ilitate rer:narc5, 1r'r'il'l liu-I cutanat al nervului, dal mai ales la nivelul pr!4ulUi. gpaliu inlrtrrrtsttx li tlorsalsi ruaialcs la nivelul ta bt cherei anal orAiceff;g' 2d d). Este rf irlizrt ti.n. mgtice ttild (piin luxalii ale umirului. ftactttl i ittir'llr':rl' lezi.initJau tlr ef.'.), sau olte prcrcsParilo'e (tutnotil. brrrrierrrsuiuj

Abductcr

po{icelui

Abductor

Opozant

|^,,,*,*
Interasosidorsali Interosast palmari Lambticali iIl, IV
/ i./. 3./, NrNul cubitnl: ramuri nervoqse, distdbulia Dusculali fi crtanoti. cubitald. Crila

',': lt )

ferloriul cutand

Edial : -Fig. 2r. Nelvul r - r!ri. ,,itr Eit de lebede"; ! - Sequl ,,rasfitnni dertrelot" lF/otuettJ t , - Senntrl ,,std!8erii mlt,il" (l".ott.i,) .ulirrr rrrl.a nJrili;tl ntr se obsenl tenddN'F eteDsonlor it m.i proeminmla tadialtrhi crternj d-T.ilornrl

lr "

l,\ Iurnlizitr, rad,iata tt,Lilf,cil (aBa-zisd ,.brahialf inferioafti," a, rt'ttlo rilol rilr.ici - Riser, 1952) e;ie cea niai frecvenlir lormri de paralizirr r:rrli lit' :r,lir, rezrrllii, din leziuneanervului in partea mijlocie a.brail,ului, ttivr'ltrl .si rlc torsiunc a} liuq,ro usului, Apare in cazuli de {rntlturi aJohtttrtcltr ,"'rrn {,nlui <lo srrlui snu in diverse trnumalisntc humcra'le,la purttl,1,olii oit',ii'lu,lrtrlivl qi irr rrilcrrlrstlnfc rle coutprcsiurtc ttetvttltti (cltl$ica',,p nly$io tltlg ttltttttt a' rlo fot'ttti totrxr) dtxcuisi,rlc l)il,tts satt ,,pa,I'alizi:t, rlutnilitfi")' Itt ttt:trrtsiil' St' cnlg ottttBtrl'vil,1' plsibilfi uxIr1lliit, rtI'gIrt'rr,{'ttItt i, itrI'tttcil'1t'itttrlrsttl t,sl,9 ir irrlrr'lI),irrr'lLrril rrrtrsllll iorric ilrrrrtrr.|t'||,rIt ir,||i| | |' itttllt'irtt'(llt llt,rrrlizirt t| ill
I li! |

Itltsrrrrolzii Irrrrgrrlrri srrpirurlor'. ll'irtell (citrr,ttkr liisor, 1952)r lirrruicir, olico prrlrrliziclirrlillii, ealr: rcspcotl lungul supina,tor' al'r.r,ra (in unoi leziunijolrso, ,rrlr lri[rrrrrll'1,irrcrvului) se dato]qte unei pnlalizii radiculo-rnodulxre, , rrur,i lxrlirrcvrite satutnirrc sau unei isterii. i.,) I'oral.izia radiaki antebrctltialdtnaltd, este roalizal,X, trautnrtrisme, ale rl,. lr( lrlli infccfioqi qi toxici (indeosebide satrmism). Respectd, lungul rrlririrlor' qi permite r.idicalea pumnului, intmcit lezirmea atinge nervul rtrlr rrrrr:ichiiepicondilieni. i',t) ).'arulizia radialti antebraltiald, joasii este intllniti, indeosebi in rr.rrrrriismc (de pild:fi,in fracturile radiusului) qi in nevrite. Intereseazi, rll:rt lrrrnrrrilc radiale ale policelui (scurtul qi lungul extensor, lurrgul abducI()r') si (lxirensot'ulptopriu al indexului, cu tulburS,rile motorii Si atrofiile r',,trsrrtrrtivc. Tulburiirile rle sensibilitate sint limitate la o mic5, zon[ Ia r'ivolrrl bir,zei dorsale a policelui ,sia primului spaliu interosos. li) I?aralizi.tt,nerLr ui obtu,ra.tor recunoaqte prin constatarea unui se rlclicit; rnotor 1)l adducliei coapsei a] rotariei exteme a cu atro-acesti,a, lr,r loirlsrri fi plinbr-o ansteziepe -i fa{a internS a coapsei.In timpul mersulrti lrolrrrvrrl prezintii o deplasare in a,fard, gambei qi a piciorului. Este a rrrIusriprirr traurla,tisme qi la fcmei, in tra."-ali,w prelnngit, prit:' compresi1rt Lttrorr, oxclcitatii, tle capul fetal in timpul traversiirii bazinului. i'jo irnpune si recunoaqtem sindl'omrLl ltti HowshiTt-Rombarg,, realizat 1r'itr cornpresiunea ner/ului prin hernie obturatorie. ln acesta, pe prim lrlrrn sc l,flir, o durele care imdiazi, pe marginea intem5, a coapsei, atingincl r'r rrirnuru de iltensitate la nivelul senunchiului. i) Puraliziu nerralu,i crural (cu cele patr'u llnuri telminale ale se,le : ,,r'i vrrl musculocutarat exterr, nerl'ul musculocrta,n,.t intern, nerl'nl , \ r(llioepsului qi ne vul safen intern) se manilesti prin; a) ImposibiliIrlcir fbxioi coapsci pe bazil; b) Deficitul ertensiei gambei pe coapsi I , r 'i'rrlbuliili rie staliune qi de mers prin irnposibilitatea, ertensiei $erunr lrirtlrri- Aceste tulburi,r'i de staliune qi de mers silt mai mari irt para,lizin, Irr,rrcrrIIrlii, inalti,. situa{ie in care bolnavul est oltigat si-$i ,,trag[" ]x?tnlrrrrl irrfeliol in1,r'edoui, cirji. In schimb, in palalizir, troncularir .jo:*1, lrolrrrvrrlp(,rile merge, dar cu contlilia s[-Di mellini, genunchiul ,,hlor,,it" Ir ('\t|rrsilr. l)acli se prorluceflexia, gamba se derobeazS,; Urcntul sci,r'id) 1,,r crt,r:irrrlxrsibilsiu {oarte dificil; e) Bolrrayul nu poa-tes{, se rneniin.S, rrr ,,pozi(irr 1x'r'ino':; f) Reflexul rotulian este abolit; g) In lrtostaliune se llrrllvii o lxrz:i(ie ,jgenurecurvatum"; h) Atrofia telei antt'rionre coapcle a rli ; i) 1l\rrrllrnul rotuli:rn este flaso, depresibil; j) Tulburi,ri de sensibilitate 1,r.lrr(t rrrrltto-intelri :r coapsei si pc fala internd, a genlbei. Ir'ul tt'i,tt'itlogici: a) Atecliuni vertebra,le Di ale cozii rle cirl (traumatice, Irurrolrrlo1.t.); b) Turnori pelviene; c) Comprsiuni de alte naturi (prin rl(.r'lrl g|il,vi{l, in cursul unor inter"venlii chhurgicale, cind coapsele sint rrr rrlxlrrclir rnirximi, sau irr cazul purti,rli unor banclajeherniare compre,,rvr,); rl) Abccsc ale muqchiului psoas iiiac; e) Intervenlii clirurgicale pe ruilrrl lrilzirrl f) Irractud aJebazilului qi ale porliunii superioale a femurulrii ; g) .s!tnevro de rerlucere a luxaliei coxofemalale I h) Anevlisme a1o rrrlrloi lemulille I i) 'I'tr,untatisme directe ale nervului (de obicel cu cointerr.sirlcil,corrcouritontl qi a ri,r'tereilcmurale) ; j) nevrito ,si neuopatii (diaIrr.l icii, yrrtilinrtric[, toxicl). it) I'rr,r'llizirr, rrtrlvrrlrri lir:siol srrllorior(rc:rlizati (lc frr],ctnrri l)Mirnllui, irlo rlc irrrrroli rllrligrro llrlzirrrrlrri, lrirurrtiitislrc rlrr tkr lr,urto NI'nIr! iix, sit,tt it,lrr l)rin rltr rrllrt., corrrgrtt.r'rittrri tlrr rrrrrrrilirll' i.irllul{olll in crruttl Ilrlir,tii, sltttrlrt llrr'l0tl
1

1lO COtlUl.aCUe,

lclt;i,.1rrr1r1r{,iorlrl trr,vr,ilc rlc ioricc lrrrrtitrliro{iorrso) t,rrcrtrrolt,qillr so lrlirr: r') l) inlirrLriLlrir for'{,ci tbttrrr:liu .r,cr.riLltsei rlo cvirlerr(,ilr,Lii, tr,lt,s l;iirrIrrl rulr,i irr ,.ltl.iltrii 1i :rl trr,.r'.,rrJrri i rr,.I i rrIrr',,r lxzin rrlrririr: p;rr.lr.:r, p'irr , r{}'r:i., :rtl.,.i , ttul bulrruvrrl.1.spfiji'i pe mcmlr.rrlinf.tir.,rtllcctrrl; I'l.rlizlu [rilrrt.rrr.;rl.r ro llil(luce priu meriiul legi,nat ,,de ra!:i':. . ttt l'orali;'itt t.ei,,ul'rij,sity inleriu'(prio. fueloL.ieti,rlugili irlr.ltir,i ,.rr ,r'r r.Xl) lt tir pi,ttitltZl:t pl,,r.(,!Lcnli) prin LU,nLiit0ll.t,(.lc r S(,rocUnOtstu Ji.||ll ;r.rir.rirte,rlc_paralizj nrufchiului Jesier rnare: i,) Iicttrrc{,i1, j.krxolilol , b) a '.)rpsAi: Dimil-uurr'l furlei de a\-tr'nsic corpseipc Lttzinjq ILirIir,;rr.,.:r ,lrtr.pozilir'lczindi, ostedilicilf,; d) ln ortosbarisir uoiorn:rprczirrlir lri1rr.r. ,, LIr,lrrzi,.lo-rnhrrrri (?entm,r, componsa, a egaliza contrailil l,rri,u,goriislir, $i I,r1;\ourorcoaps-el) c) ijcolioz.i cu concavitatea spre pat.to|, siirriil,o;r,rii ; ,1,Lu{.r'sul-$i ; l) mti s,les rucatr . scirilor se face cu dificlultaie; g) Itr rkrcrrbil, i crrl;r'al, dacl se lixeazL baziul bolnavutui, acesta nu-rsi r.irlirrrr, ]oatc q|rnb:l de pe planrt1patului; h) la contraclia fesei,so remircii o itsirn(!1,ri0

. ,]0!PgratjZltlg rrLllt+j I'artant(' semioloEice :

s.ctatice in _prezintii,, funclie d.etopograJin ltziurrii, rrrri

tu$1o1 myryh1t91_ garrrb--ei ai +iciorutrii, "qr.. ',']:llt]iri"corrplct rmobil; b rUersd,eEte,.Etepatn realizincl un ;ii,ri,,,. f,_ ridicarea vi|l. tlrir.irr ) pc :,..,,,-,]],,1. bla!.1-yoe?.p: ,,:.lrli'1.' vjduri tipc ciiciiceste imposib[J r.)tr,rtir:rv l .,.,.',']l I ,)u l)r):rr' rgr ft) r'rrrrizian.rrotici : a .muqculalurii posterioaro uD,llr0j lL _ rrr ' ' ,rrr1 r. l.', i*rposibilitateafrexiei gambei(testsemiologiic tararizi .,rl,,i'iiri ; ae ) ,.r r\ lrofiile muscdare interesor;z; ri ]r_q-Eq4gt _"lSlrscriatuxfi"-_postoriol,rd, i gjmbei : tt firlB'ufir-ifede scnBibilirat,. r.\t.rl ' ',r,t'r.x,.i Inrisclrlalur', s(, tl, rrrl-elnlrntregului l.l,',,,11'll fir,lertle precum picior_(cugxceptiapirlii interrrcrt,|lrrrlr'i | .,, nri,le.'ler si pe fala laterald, a gamboi I t) J)c ci,lrr rrrr,r ),, sciaIice si,,'tpnnrolc si-sosilrri-.rzjr I,r.irlrl l,llll,: :ll'l-"lE111" .simpJome t,,.
Sr : l r |'l :r .u r ci : r lrllrtri,ri vasornotorii g,rnhieroqi atc piiorulii, tript,r, Fi -Uaf]gs "rnbritticXii _(crleme ('r,rLlozir,. l, plnntare, ale pl:lii';i pi,r,, lirrrl s.d,. . ) ^f" "iigLiifuii".rlce'.,1ii l , r : r r l l l | l . ] t r t,l ZtU I]l l e IJd ,cu l a f( . C i t, si i n ce l ,. tt"o n t1 u h r o . g)

r.ia railiculard, to.:l!'trqnoatqlrd'Lnutrli, testa realizrltii plirr , rrrnce rudacinjlor,gr,u r, ..,,_!0tl _P"qr-ol.i a neryuirii s,.iaLic bazin, la ie5irol din lrizirr .,l|r.rn.r.rerrnctlg4rlrq superioaTi a.go]apgqli]! recrtnoagte Se prirt rrr.rI r:i I rrr.rr I t!t::lu9togtr.. carc .rezulbS rlin asocioreapalatiziei sci*ticrrltri prr|ti ' 'ttt( rr,r r.Klefir, r_t ,scrr,tlculuipoplilieu intern;i a ramurilor musculare , rllttur ncr\-'lut mar.e sciatic la nirelul m.sculaturii posterioar.c al0-l;r,irrr it ooitrl)rior :

' ,rrurtn(' nl ri tl lt ir lilr t r nor vs{, i: r t iciilr i: oJr . t r ct . t oi_lst . , icst i||: t lol, r . r : r , lur l', r l] Irl l l l tl i l nl l ,l l t i ill( r sir |t r loiir ,L0r Lni1r , il; r scicl] le in disl; ilr clt . lt).,\ l)t,r.u,licitt aointiaiWTwfiitc.Ii-iitam) 1s,i ,, ,..t,t.,,1,i tiltirtl, ttost,,ior Itt trtt' , t,t l t) t t , ) t . r . , llt J t 1, : r lizr llzii, : t r ) I r a, r , lr lizia, '1, 1. \ {) t ilt }r 1i lr ddit ct . t , ll'r , \ r r l{. |ll, i lI ||lI ir . | ' r(:| | r| I| | III,( || t {( , lt il{) t .I t odl. r , l. ir r t r i ga. f r . r r . i ( llr . r ( }r . r i jt .u .tt;rr.tl i ei ;' l i .. r pr 1'lr , r / , i. ; ! . r r r r . r i. , , , r 1, . : r r g, , , r i|, i, . , , .. 1, , , , , f , r i, , if , Li ir t r r lr r r i, l rrr| |.rr' | | || r || ,,r |r lt ir . |lir i" : r r I llUt , 1, cr c( r p{, ill [ r , r lir r st t lt t i ( I r t I iI t t r r I O t , ii l) t r . i0 .r u, \(| l l t rIr.; 1r 'IIi r . llr , r , r r r r , ; r lr r lr r riolij) i lr ) it 'r ( 'r r r r r |r . inI r l, I rrrI rt rr r, rrI r r r r ' ,

iu; fuiltt:ittc ] sint ttttit.C_7og.re rnuit mai fi,eaveirtc,lrt(,11ri{rrl , r'\ rr ,rcrr-L1jrc in trcimer mijlocie a coapsei fie sub ni]Iehtl t'ru ,,|oni tle crrrorgt,lltii r lrrtirurilor dcstiniite la muschii regiulii ]ostcriouc lr,crrq)sri. 0rr,rr,j,rrri,, rlr'ri.trtrlrl srrrnhl-ipo co..psr estein pi,rte cdnservat:i, plriilizil o$tc(liH(l i,r,r r"rr')' rir sr riirL rili irL u'.tt:xfrrl cli'ic predomini fie semnelepa.r1lil,i*r rrr, iie ccle de sciaiiopopliteu int(.rn.rlrrroiitril:rptrrtrrr . ]'.,,;.1:llllliJlll, l*,l,cru.

l{r I

poil,i,(! p.cvh'firl ?ioiorrlti, (,irtor)ll ?o?t.t(r plrlsat nici hr addlc,licr-nici" 1i star rrr lol,rr,{,irr iltu ni, qi nu poatc sd-fii fle,ctezedegetele: e) },iolta plantard esl;tr csle dilicil, de alurd tal'$3ld ; ,') Atrofia.i+telesea,za lrtllrrrsilii; d1.1\lcrsrrl l''girrrrr.rr. pl:lnla}i, rnargieiJepiciorului $i moletul gainbier; f1 'Tcndoqgl 'frint abolite l,.,lrilirln .,s1,o depresibil ; g) Eellexelc achilian fi medioplantar ; lr) { l1q117xlgi- dureritre de, tip-rne-v.riiicf ' sint destul ile frecvente; i) Unegi ,rli xr, rtrriir.r'ci $i $tergerea lgheibulul retromaleolar ;i picior ,,in gheeri,", cu tlegote,,in ciocan": j) Tesiul lui Fromunt: in staliunea intr-un picior, tendonul lui Achile ri.mine flasc, depresibil, iar gemenii nu se contractfl tle parted paralizatd';- k) Testui ,,piciorului balant') : bolnavtl, plasat in decubit ventral, este solicitat s5, llecteze energic gamba pe coapsi- Ie partea bolnavS, piciorul rimine balant: l1)l TulburSrile de sensibilitate obiectivS, sin1, rjecelate pe ta1, plaiitard, * piciomlui ({iq. 26); m} Sopot eviden!idii [ulbur;ri vaso' ni ricrii qi trofici (edem aI piciorului, ,rlter.alii ale pielii !i ale unghiilor. ulcere l,rofice nalca-

rrr,lirl.lrrlilirr,. iull;,rrr:rl.r|ii rr. rlitr rrrir.rrl lr:rzirr c) l,t,:t.utnkl,iHtn(. 'f,r:{irrrri, ; rlrlr{rl('|:rl' r'tvrlri .L l;r rrivr.htlrrr:.r'ii .r'rrlrilrrr.i s.iirrii.(., [r.s.i, r.rrrr 'r'irrri. io:rtr'r, 1.l frr{:t 1rosl,'r (lezirrlri prirr rlnrre ir,lllcsrnt jrritr lr,l,lrrrr rlr, ..ir-currpsrri l'r ; lolrg.i ii' dupri i'iectrr,r'e accidentlalir, in trnuchiul sciiflic ir, rnr.r. , srrr)stu,nlc jrtlcamenl nrr uase, algog! penicitinii sau alte solnf,ii r:u rrr,{,i_ tttur destrucliyS a nervului) ; {} Nevrite virotice ; tN Noulopatii l,oxii:lr suu toxicoalerEice. sciit.ic poptittu i ntern_poate lezat prin traumatisnt f,n x:eittrtur, fi c _. _,..}:r,;,11 l.rltcturi lle oaselor gambei, prin tra rme directe (cu anlc ulirt, srrrr l1,t)pIdec, 'r,' r(x.r s, tr.oori pria lcvrile (lo:ice sau infcctiof,sc). j lezat de obicei in tlitrrIn:ll,i$ll( lir, . M-rrlril scialtcpopliteu rfrtet'r est.e ,']l '1Y, !"pr-tql peroneului,in rnumiJo condilji prof{,siolritle rr ln(1it,,ri (h ,;:rrr s l.l.)-u ml .t qhemuiti.pc !inc Ia pr,r-atrrJ strdzilor. Ir prrr.bctllIi rj.r_), rn nerrilc (rusicr.. viroiiro elc.). Trcbuie relinut Irr,pl r,:r ril :1,'.j'",,'*n!li rr rvtl p_opliteuertcrn por"ie fi lezat qi ilr rrod izolai; chiln. irr rrli,r, ,scra,lic rrrrr lrlc lruDcltiului scilri rlt u aJoplerului srcmr. ic reprezinti, constelalii clinice in care serniologir. sr, ..,.,!),-fI:r-l!,1::r,/ite|. ,'-.')l:,t, par'2tlz 5aL l)ar',zrrrlo nrai mullor. nerr i perifcrici (rrrrr,,rli :.i ,lirnrcnl).rptrute lic simrrlrun.fi,. sitccr.siv, drr c o rliql}ibuli{' lrrl,.,,.:r .xp.icioasii, qi nesistematizati, p.ezenfa r,nui trbk u semiologic 'rl. rrrrrlli ..ys.:l:32i. hrnfuicdc n.odutde instalurcpi de cv"olu(ic; (in rrr.r,r,, lli.: i]1..i: etiopolsgpn;., J) llult;npwitp rirolice (prin vii.rrsrrr : iL. ,t.t:t,t lrostbtttt,{j.li l:1' rr\s1ckre, tlerpes zoster, rareori prin arborrirusurir, Z) Mlt(tint, l.::.,.,',,,, . tt 'it terapice rlorgii medicrrr|l,.r,1,,,, 'tt.?l:ct, (pusivaccinrlc. po"l sero ., ; I otogpo:p .Stbott o [otmu a ( polineuromioz IUpUS ..,:i.r..")l ji e, clilr.rrr:rtrr., -r'lf'r'o(rr.lrnjo. i)o.rrartorilinodoa-.ir."ll .l4rtlti pLtrite n ulI ii eu poI i i ) ltx ( ro triiabelicr.;,n cvolul.iilLrnor t;tbttiae polfirii; careuqiaic; pr.irrr.r:irrgh, ;y.' lfl'fl|r,.)..,r -ttttrlt c(,uloli; ptxtnectpluziae (ta.rc1. t'),1'rltlrrrittle p oli nearopatL (metabolice, torrce, onr.olll,irtr, r.la .si ...,.i Ii,t l{.' ,za doltctlo tuuscrrh|edc ertclsie letrrplegicl sau rtrIiIr, totdelula cu localizale p-rerlornlnant .ct"om'effi, insolitc rto 1rIr|Ir. lrlt'gie,r'i,, iripo o tr t trofii de .nirr,scuiale," are{le:ie osteo-tendinoasii, prccurn si rlrr l,rrl ] 1' ,..rlp ,a lrlll:rrr s{.n'rbilitalc srLLrier.lii:i ,rbioctiv.i. ra_facl?r. ir\r.lrr,rr.:r, si cu dl. rril:,rlr.rl, sirrictlic,;i eclromeli(.. ,\bscola ori"arui scim Jn h,zirrrrr, pilrrri ,lrlr, {btr r-,coldi}ie esentiali in stabilirea diagnosticului. Maselr irLrrs,,l I r'1' .,pl'rlr.rpo lulLleatrna stnt duLr.rulse prosiunc, iar elongul.i:l ll rrr.r.vilrrr. illl]gi c.l,' adc-scl, I Lsuportaili . t',,lifpyy;6.1.'.1 polinriu.opttiilr,rrrr t,,'l i h . dc nici mudiliciri :rlc L.C.H,., ','rrr1iorLa., r.-grrld. njli t,uibru,ilisfirrr.lclir.rr,.. |,r'',i','el. I;r delrrrl pa|rliziilo jnc(? rlrrr. ii predominl la cllrenriLiil.i, 1r',r. :;t sr" \l rrdt.

,i;i='--\',',)\ --'-\:iv ttervut. dknhr ' tatirat

consfind /,J. ;,;. ti.ritoriul cuL.Luat anterioriai gamboi. tabloul seliriolugic cI ctl r',;rr,lrris,illicpnpli t(rinlcrr. a) Piciorcizul, halanL, iu va"rus-equtn din: primele falange in {lexiune I b)' Impo:ibilitatea lLrxiei dolsale a piciorulu{i a falangelor ptoximale ale degetelor I diticultal,,rL tbtluctiei piciorului; c) Imposibilitatea de a ,.bate gldsum" cu prcrorul rrli'ctrt ; rl) tlina botnafirt se spii;inL pe un singui picioi, tentloanele exten' sorilor deget?lor, ale peronierilor li tibialului an' terior sint bine proerfinente cle partca s5,]r[toasi ' (prob:' de il schimb siol $te"rse partea paralizatS, proba-. n,sral,iuoii uxipede a lui }'roment) : c) Ia de at'elali fenurnen Iipsri pingelii inapbi. qecunslald, ile ividentiere a acestor tendoane I f )Mers stepat ; q1 f mposibifit'atea sta(iulc .pe cdlcii ; b) Er len'i:t de plir'rei fahngel it I)iscrete tulburi ri senzilive,p'' oartea lat'elald,a gambei 5i pe dosul piciorultri j.Sig.ZZ.),seclelorii, r asomolorii gi trofice; jr 'llr'lieiele ichiliene Ei mediopllnlaresint coneetval''. -Factoriieliolalici rn leziunile norurlul sr'iulir pot acliona, ia nivel radicuhr (In-Su) sau Ia livtl troncular' : a) tr'actorii vertobmli sint cei mai trer:' venli (hernii diseale; morb Pott; tumori -primitive. sau metastatice ; traumal,isrne ; in ultimclr situalii, paralizia sciaticS, poate a#5rea in cadrul unui sinalrom de coadd,tle cal) ; b)' Traurnatismolo ,, j Si rtiverss afecliuni a,Ie bazinului: Iuxalii coxo' Sl drversoaleclrunr ale D&zrutrrur: ruxir,lrr uur(r' DislfibUtiesm:,,,v -'-"'-'i :tcnnrrale o$teo-artriti, s&cro-iliDol frrottlri a,l(l ; i lrrrzinrrhi lrrnrori rllo lritzinttlni {:(,rtrl)t'r'Nirrrri i 1,4f .11:.,11;'llllilf .l'lllll'.".1 ; ll rrr'r'\rrrrrrr Di'l)rrrlrr r\r'rrru( rlrt sllrt ,,..,,rcilnlrJ 0rt,l l .l'()i;lr,1 rlo llir'<,r,pstlivl)r'sr. I 16'J

maleolato qi/sau digito-pl&ntarc). neenen 'r}a]} Patdlizia neraul'wi c.ialia poplilea entern' este reaizatd in. specialprin leziune ln nivelui .qgDdui leralgd]Li qi interescazi celqgsg m.rl.!-ch]

t j( o lDiI li( . i: : sim , - t r icli,>i put si r paljzezr . r . [ ii: ir r ti. , t , r , lt 1, l, gi, , ' (' l .rl i r.. r,l ;lu lt ir . ipa r . ir ir r elr isir . a m usculat ur ii git ului, I I lunchiuiui li rtt t r.' l l i ;r r 'r '. r liuljlgr r r ului. Pulaliziile sini t t t Jear Ln: l in. u1. il, er ll r r r r r . ii ,.rt, llrlrotr)lru rrlu\(.llla,rc si cu irnportante al,rofii rnuscula,re, dilr rii0irxll,l;ti,lr,1rr, ,1. ttrrtsivt. c:r in lcziunile tiir.cte ale pcricar.i.nului moio. rtin .oiut,,(,|. 'rrrfi'iiriir,r'c( l rrrlirrrrrirI i1i si ulle silnlroa,riie pe.icarionlllc). fieflexr,ltr ,rr,r,. l i l l rl l l r():rt(.F|lr l ( l{. t r . g lii rI i t rri t rrtIr I r: st r t r : r lt r r lit e, r ilr I l, r , ll, r r , lt , t 1lll. j lLlr . , Irl (l ' . r I| l l( . or i ir r l: r lt r : st r r t r l, , l. r rI i rI t i t rt IruI i .. Nli f r , e, llBt j, t t i l.It r i Ij r: I t [ ,rt rr r rrtl l scl rl l l tt,. .Nor lilicililr t lr l cx( , il, 1l) ili1, . t , l1 r r lr . isi. i, sh, r r r llizo1, zi, r , {, ii r lr , t lalt t l t' gr"* t.ri .r' rr{ii lir . ir r I r r I r ', r 'r r r r ir t 'ilr r {, ir r pr t r r r r r r ir r : r r r r ,r xr r lr t r nr r lir r ir , , r rrrr tttvl ' l rl i gl t' fi i L'l') 'M '( I . lr I lr r t r r ,r 'rt t t t 1r k'|'r t .r t r rlr npLr lr r , r r r ir |, r , iir r zr r lr r lr 1( jr ) pr r 1( ! r 1\ l ttol n)troi ]r sr . r r zlliI il 4i t l iit r r lr r lol'r lr . lr r , lr r lr {,pt , or ir r r r r lt r ir r linlt lhl il i ti l) 01 l

lrl;l

zr (lll,o I)trrliolsolxrrrirlllslrr,lrilirrrrr rlirrgrrosticului krziunetroncularil, de lr.rpr.cliv polillotroulari, (polinortrrrpllicii). Nr lilcbuio sL uiti,m ci, polincvritcle qi polineuropatiile realizaazh r lulrrrr)Nill:forme semiologice (mixte, motorii, senzitive, pseuilomiopatice, psrrurlot,ulretioe, acrodinice, hiperalgice, parestezice, predominant trofice, prtrrlornitralt vasomotorii q.a.), care ne pot sugera posibilitS,tile etiopator1r'rrilo(Iiiscr, 1952; IIareq si Nisipeanu, 1976; Mareq $i Stamatoinr llttis; l'('rrLlofunda, I976 : fo{letea, 1067;. l) l. prezcnld unui sindram poline,ari.tric (polineuropalic) cu ilrstalare rt trli. .ti. str.bacutii gintlim ln primul rinal la urmetoatele posi,bi.li.td,li ne eti,ol)trl.t)u(tn(e: r\ Polinetu'o1tatii, toni.ce {profesionale, med,iaatnentoase,crilninale, stt i r i il u,yv, eti.lice ). - l?olincuropatia etilicd, est de obicei mixt5,, dar cu predominanla Lrrllrrrliililor senziti'r'e (sublective si obiective), apare la un ei;ilic inveteratr rrrrrurli fiind pledorninant parestezic[ qi dureroash. De obicci este leltlrrrrglrisivti. Para iziile mari sint exceplionale, 'Iulburiirile trofice ryi vosrl rri,ir-esint precoce. Se poate insoli de fenomene de nevritS, opticil $i rlrr rnrrllrr ori, do tulbuli,ri psihice care realize zh forrn psihotici subacut[ rr,lrri ](ursakov (contuzie mintald,, a,mnezie,confabulalie). Se poate realiza r1i lorrna pseurlotabeticri) cn algii fulgurante, tulbur5,ri de sensibilitate rrnd:i [i ataxie. 1rrrrl * Polineuropatia d,iabetic:d, instalare subacut5, este rarii. De obicei cu rc rr:n,lizcir,zii forma cronici,. . Polinatroltatio, arsenicalii eeutd,-sub&cutd, este cle obicei profcsiorrrrli, rlstlizi mult mai rar medicameltoasi'. Apare la murLcitorii care lucroazir rrr lrriricle arsenifere, in industria pieliriei, in industria unol vopsele, a ol,r'iivulilol raticide 6i a unor insecticitle, in industria chimicd, (hidrogen rrlsorrilt, acid arsenios, axseniali). Totdeauna apar iiemne gastmintestirrillu grave, precum qi ali;e simptome neurologice (convulsii, sinthom holelilirlrrr rr,rseuical),tulburi,ri cutanate qi ale fanerelor (stria transversa,ld r, lrri .Nloes nivelul unghiilor). TabIouI polineuropatic este mixt, dar cu la lon lrrrrr rinrln!'a tulburi,rilor senzitive ;i trofice. . PoLineuroytul,ia sutrurnind,aautd-subdc'utiieste tle asemenea deoserlr glrvrii, predomininrl in tabloal clinlc tulbudrile psihice (confuzie lril, rrrirri,r,lit rgii;atd, sau torpoare), tulburiri cardiace) hepatice qi renale, plrrcrrrr 6i tulburd,ri tligestive (clureri, virs5,turi, constipalie) ,1i hematolrrgirr (crr seinne de podirie). Se poatc realiza,Di un tablou de encefalopatie psilrolricir,de tip Korsakov. Polineuxopatia poate debnta asimetric (pe rrolvrl ndial, in dreapta) qi este predominant motorie, cu atrol:ii muscttlrrrrr lilpido. ' .\'oLineuropatiamercuiiald, acutii-sttbacutd' este tle obicei acciclcntalai. rrrr,rr volrrrlbar-suicidard,,la cei care lucreazS, in przenta toxicului: distilirlcrr, rnorcnrului, fabricarea lSmpilor de incanalescenli, qi a ampulelor' lrr,rliokrgicocu trompe cle metcur, industria termometrelorr a barometrelol ri rr rnilnornotlelot cu metclr, fabricarea sirulilor de metcut, azotat de rrrurr',ur', olorulX, qi cianurd' de mercurt intlustria farmaceuticd,(calomel,

r'\l(,t'lt)fi rtri){il)(ltt.Nr.rrrlrisl,lrrlo srrrrurc ri tlo ottcrrllt,lr 1,irt, llrr(xtt.illl 4lt ((.rrstllrtl(!rlr.r'rllrrrl0lts0Jrt,irrr llri ;rlllrr), lotr:it'o aat,l,r:-su,lta.at,l,c iuriliri, lrli,lol, (11'itt . . Alty.1nl,,inr;u,ro1xr,lii lrr.trz'rl,srrlIr';i rlc rarJr'n, trioltoclozilfostat, tclanclorel;nn) s,, 'r.,,<Irr,, ,1,, , , t.r rlc (la ou ','/rf('n1,ul aparif_ir, rmrlcitori oale lucreaz:'1, loxi(,.1. rrrsp.r,l,ivr,) ri plin asoeierea de paralizii do nervj cranieni (oculrrnolor,ii oplir.i, .fi rrtolrleo-vestibulari), tulbur.iri psihicc gi sau semne henurl,olog r. iiu / tulicd.fste rard. P.ealizeazh for.nii rlixl,ri (r,rr 1rr,r, o .- P.olineuropat.i_a , ,l''rrLirrllni,.r tulburririlol senzitive)qiseasociazricusimDtonrcr,rr':rol,rrr,isl,ir :rlopccie, o\ .altera{h uxghiiior (cu striile lui Mees),convulsii, Bi}rrl)l,ornc l,t,rI ;ii'rri.irhle (tremuriluri, miscX'i coreice),sirnptome psihicc (rlirrlrrzi'.rrl
l,r Illl0s1;]ce).

lblirlrrrrrlu,t;ill, os1,o J)r'orloninr[rt rrotori, Dutin(l (lobullt t)l'in lritltlotr tl,itttit'1 irr ncttlo-trl rurrriolrgi<l trntll,ittottroltlf (nrrlirrl, rtttt tlo , lt'iltlil lroplil'trtt l0{

oiirr[rl'l <[o m.ercur, sublimat). Totdeauna sint prezente tulbur[rilo (l igosl;ivo(sto ntite me,rcurial5, gingivild ulcerativ5 Sihilersalivalie, cu gonet'ale renale. lizolrul girgiva,l),somr:olo Fi

C l J nt {, {r . unlcXlnl {o llt clr ) T n( 't illi, L( . . viscCr ll, . . gr . r . r 'r t l, , , lr . l: r lr r , r , r Itl .ttt) 6i sol riologic ucur ologic ( r Lsr , 1'cr '[ r ir r lr r clreir llr ci, . r islicr r ilivt lr illo, ser ' t 1rol i rrorl .ropat iioxice) ( , \ I ar c5 si t r t lm ir , t oiu, 1968; gof lot ou, lt l( i?; llir lr , , tt,| :.1 l Jr> dcclr lol.196i) . ; cw"opal, iit cr . liabeli. t ir . r dlnic suspiciot r N, t c lpr r r pr ir llr r r r r r lir r :e lolr . .r' ) P -ol ,i, n l rr' l ,i (. [{1,;11'1, r lialx, lar l sr ) ( l ( r so( , lxr l, ii, r r ,ciir r l t lpr il. ${r nut ( , i{1 , polit r r . r r |o r lor r l( l rtl i cr r,rttr' ( 's1o scnzit ivo- lnolr r lio ( cr r pr r xlor r iir lr r r {r i sr , r t r ilir : i, r r r r r . r r t , r r' l ti rt' psorrrl. lr r llt . l icii) , l|ir r r r r r 'I r r ist r r nilr i t , r r r li, l, it s. r r lr r r ,( lr r , lr , r iopr r lir , ) tl l l rl ' rrrrl rrl olir '. llr r r , r r li r r r t ur lizr 't v, ii o lolr r r i lr ir r lir r r r llr r ii,slr r r r r r lr t lr i ir r lil, rl r. l f, gr.r' .fi lJ"Uilor |H( l r , t l, il. ( i r lr r lt isr r r , llt ii: r ) , ( , t r , r r lir r Er rr r r r r r : r lr , r rrrrrrr' l ri i rrIrr I r r r 'I r r lr. 'r r "r r lr s, i li . 'r li'r t x I ii gr r r r r hr , i,r r r lr r llr r r r , jr lir lr , r r r r r r , r (l trl r:rl r' F l :r r t lr 'r r lr r l r r r . ir r lr r r '1. t r , r r t igt r t r , r lizt , r t zll I ot . lt r , llt lr 8r , luolllr Jll, l, t , ,

lt) P.olineuropatii i,nfecliouse. Cele mai obifnuite sint : ''-PolttrcDritucltltrricd intereseazi,in special nervii crluielrj (rrrr 1Ir|rr liz,i;r r-r'rluluipalatului, tulbur5ri tie deglutitie qi de fonai ic, rrnrxrli'r1i r,l l.qllruri-ri l'.'sp_lratorir, adesea qi cu paralizia rle acomodalic rr ;n,ivilii lrr, rlisianli,)r iar la nivelul membrolor afecteazi, indeosebi tmnclriul,ilt, rrrr,r,, ll i,lor inferioare, realizind o formS senzitivo-motorie disocialii (crr rrlr.rlo rrri rrlnJ;a tulburirilor de sensibilitate profundd,). * Polinearitu,brucelozicd (rari ia noi) se in,coteqte (le sortrnrl t r, irr fi r3'rrleqi de a,lte sinptome (heprrticcs.a.). -- Polin.e,:ritele secunderettnor beli infeclioaseqt ltt,.tl.. sild liu,rr ri rr, r(, ttlrrq. i6 noni, 1Jl l bolii d" \az:r tfelrrrit iloitli,l illi,,.\|lrrlcr r:,1i,,.,lizr,rl | ,'r irr, laludism). - Tjolintt*,itetltoi,ulinicrideb.teazi, aproape totclen'ua (1ll (lislirl,,ir., Ir,'(i'iiillne& gurii, laralizia \-iluhi lalatului, tarlburiri rle vcrlt,r,rr iri 1i,i t,,urlizilt acomotlatiei ;i midriazi), ottalmoplegii extrjnsccj hilrllllrr|r,, l:r lrr'{r s{)1rol,lsocia tleficiie:r,le memll.elol cu p}edol}l'nit1t lizorrrr.lilir. 1ij lrr','r'rrrr tulbru{ri gfincteriene (constipalie si retenlie rtrina:,ii). 1i t.'\ J'o[. 1e1 'af]alii Ttostraccbtale :postseroterutpice I'irfr,(|osi,rrrrrr,i . Sinl li trorrl)i0ii, lostselodiitelicd s.a.) qi-de obicei nri sc ilsL:rlttrzi irlrrlrrl, rrr rr i)r,lllcsa procesului a,lergic r.ilccinal sau postserotcrapic. :!) JIL fn'eeen!& unui sindront ptlincrritic (polbeuropul,i() (u .irtskt,lrttr l, nl Uoqr$iui se pun in cliscutic toatc cauzeic posibil,. lxl (,lt.o (tt,i , tll tlno|inl succint: "r r) ,Pt,/ tnett ite.le infecli.oase intri pulirr in (liscu(ie (polincvlilrr l,prrrrrurr . \,.nlllrl. polinelr'ir:r luoticu). ' 1) Potine-uropat.ii.It to.rice(satur.lliD,;, ulscnic:lli, rlt(ll1lI,iilli, 1;tli(!il ,.. rntdiclrnentoasit) lccLrrroso lorrlor'l,rrlpr.o s{r irt ,,ttllrr',1r'bon1{fi,.hllic5, l ' l {rl l l rl ,

100

sini; r:ttrtn,!iu,[,tt urttLt'rr-tiri[t"cvctrl'o doci[ so ol'tx[('lt' i\ I'ot.trt,eurttltuliiltt ttigcslive, rirrlhbsurbliYo, dc.anacidiIiirrrl ioulizittt tle tliverse ntcc{,iutLi al(oolismul .si.rrlteluLice) ':tlc i,,1,f,.j,,-rr.i"" ;i de alli -factoii (l-nulusiv de sil,amine tlh grupul B qi d'' aniil^fr'lit ($oIlclea, titttnjrt'ttil carenlc 198[,' l l|li/ i l\lrrroi 1i Siarnarciu,1968: Popoviciu ;i col:tl-r'. oe fn dismetabolice. Iata unor tl1bloultctrorce porrr't l',,linturonatiile neolucidate prin ilvesi,ig:r'liile curontc, trebuie si' ne rr,',r r',,ilL'tii croni&, si' praciicim t',',ri'i, li fu acesd gnrp de polfoeuropatii clismetabolicu ;i la lnillvrzlt Llnerl: i rr!r'.lilrrlii si in acest sens.mai a,les - Ilolineurupatia porflricd sc poate rccunoa$te prin sirnptomatologia |r|r, rrolvo:r.sli (cLr-tlblo-uri" tle multinevrite,, uneoti l1lononerrito radiale' (sir}dr.,mulabtlominall,culatrafi' ,.v,rlrrii,rl .nt'e puhncuropatii),vis{'crald, la ,,pi,ir,,i i:ipersen.ibilitare tumina, cu pcle pigmentarecafcuii 1,rr,.,,,:i ,lr' liIrl l'tnii,lcto'',' rc{pcctiv cu lcziuni cuLan'1tc "vaccinifonoe"). gl rle t,rl,,,r'',ltrr (sinitromul uiinar'; preze$a, respectiv cleqterea uroporfirineiol qi rr coproporfirinelor). ' sint' ra,re' Amintim polileuropa-^ l'rlttirunlropatii,led,isgtobulittemice li.n ncmice (mecroglobu r'pa in rericulozele raprotei tiil, r'irrl so lof iotilni in lui Kahlcr).in une)elumor!-sarL tlisclioglobu,'r"' tV,,t,i"',*inOt;i l-,oalr ri Iirro,ri ,'(lltichorr cohb., 1959; Faqon ;i Sctrwrrtz.1963; $oflct'ea,1967; t',,i,.'viciiiii.,,Lrb., 1968). Cootexiul clin!c dc srltelintti lcrvoas5 (poli,,..,i,,,p,il,i,. 1ent-progrcsivi,l, osoasi, (aspectelc de leziuni multiplo oso-as.e -hematologice, cr alterarea sti'rii in iasole late), ,,i,,,'i"l,ii """t".Liale'si ineruicf (cu.spectr'u1 caracterisp"*ruot^ hipergamrnaglobLll 1r,""'irrl,r'll tti

1n paraproteinemicii' schiml, ili,;i ;,i;;,r'i;rrt"J; aft"osti""i ae 'eticuloza ,,tl,it'r1;a, cepricioasd',6t instalr,rea sau agra,valentrbloului clinic (cu

-mrltiin rlie tle oijicei arimeLricd) pcrioltlcle leci rr,r'r'it,'tnigrlutc .1ipolineurop tliscriola"ritiiica""a ciioglobulinelor ne o.ienteazi' spre i,t,, ' ','.riii"si *""'Titli},ii;rr, din, colallenoze sint ulor de incadrat nozologic trntiite ,t,,,,,i ,,,srx,.tivlr, iulecenoz,i, (periii"terita norloai5,, lnpusul edtemir'tost derboaltr BehqeLt'a ) se io"ita, sclerodermiar rrnlurrr.rrirrrniozila, l."oLiueuroh tipici. Eristir insii'. crzuri-care pot .delut& ti*i,iu cu simft6matologia "',,',i ,.i r.r.'lllir r^rrltiir vreine cu simptoine neryoase pc.ite.ice.. Sint totrqi citeYr' I i'r'it,,r'ii olir'ntltive: - Evohitia progresiva qi c:rpricioasi' - Prezen-ta gr,rtelalc(asienie, stiri {elril"e,algii rrlticrrlareqi rnusculare etc') I lr,rrrrrr,lot i,,,l,l,,itii [i" ,,rnultinevrite" capricioase 'fi,-rio polineulopatii asimetrice; 'ide obicei vascuiare) a1e I'.0. : Hipelten$iune :lrterialil' i\toilil'icrili ; (irr plr irlrteritn lodoasS,) - Semne de arteriopatie periferici' ;i, de.ce1e ; Sderin iu, lrLlscubri, (d tip Eiozitic) pe rrni' rrrrrlte ori qi cerebrilL; od euloiniozile); -Nl iIi'"i ri rk' V'S Fl',. ale trlrrrr trlrrtLiin tlermr,mpoli ti *i waaleriRo"e, p'ecum qi rlc testelorde dispruteir'emie i;.';i,,1,'1: A3l'o ,,ii', ii"i,r"Gt".torezei ; - Prez6n{,a rnod.ilici.rilor cutanate (in dermatoin rrri,rzil;o, sclerodermie qi in lupusul en'itematos). l,lxtltni itrile E.M.G. qi moditic5rile histopatologice mirscnlare, vas(in )riupriit' r'Ilr11', iLlcfibrelot uetvuase Si ale ].esutului(lt I nrn-cpidr'r'rni' ,t"uin. obligntoril in uc''rtc silr:i'1ii)-pol {i- rrril(' ,;;i.i, ' ',i;;;iil,;',;,t ""." (Dulnn, qi colab., 1960 ar b I Dtma tst (otaD tvttd ; rlia,grLostio |r.rrrtt'rr ' l(ft,lrtr6,rr, .L9$l ). pard rcpl(tti(:f'c lnl ilrrt'ic trttr'tLi llle ntl l')cl)uio ::l l,,,lintttt,,l,r.liit{' nt'ttto1tgi.t' l'r(xlrlsr! l)l itl r:tttttltlt'sittltr' ,iit,t .ittiri.r,,lr,trLr'' ,,,r,|,Trr,1,,.t,. ,r,, ttrrtrrti ltritrlilivtr, rttr'l'itr lrr rlirtr0l,ir t,xi,r.tjilrr,l,ii r,iillt Irot'0sttl ttci,ltl:tzlr'(1 l0(i

ttlrrz,r, tr.r'I lIrrrrIr';ri/srrrr r,r'r'r'IrlIiIr,, ir,IrrIrrIrr,, irrli)lllr{ii |r,rIrrtrrrilr,,, I rr lxrrr,lir Ilulgkltt ;,rt.), l'olilrrrrrrrrl)itliilt r'r'lrrtiv l$or', so l)iLliut{,('l)llLzictrt({l los(1 scrtzitir,i),irrll rlr lorr lttitt lthlrrrl lrr trrirl; (rlrrl crr trotti, lrtrlor n irlrrrl,i't, lr,rl rlo ,,irrrplt'gnalo" ttcttcrtrli treoplazicl, cu cvolu!,io prtrgrr.sivir. lt) I',litturuyuliilr tlcgru.cruti,rc. Aoi so inculrt'azir ir5rr,-zisir ,,1r,/ilr, .t tt it,i" hip, r(n,.1;,.,i tamitiali ,.r c,./piliti?; (buofu ly; D(jlrin, sutt,tx\ rrlulttr(ti (t;ptil, lt;dpsi tourjttrr). SiLr b4li dcgr.rr|r':rtiv| ril l' rl ',\',trrlir. Irrgt 1r csi-i'r'i care atrofiile musculare cLrdebut distal itiiing ilr rrlo(l In)A11,. , in sir', in tlectls de ciliva ani, toate cele patlu rncrnbre (rlul x,slxrclii r.orr;r stk', bra,lcle,ct'nl,urile qi fa!a). Se inso(escde mari tulbulriri rlr scrrsilrilr lrt,lc do tip ectlomelic, cu caracl,ererlisociate (cu nlaforilii hiporrslr.zir', ltini )r anestezieprofuntl[) si eu mar'e atarie. Cel rnai iiilescrilrr,rli'lrrrl,rrl lr'rlii, b,rlnrrvii acuz; si clureri fulgurante. Un simptonr pirlrierr0l 0rrir, ({'.rt'.l)crlnitu rli:lgnosticulfftti r}e ,,tabesularniotroJic',)il corrs1,i1,uir, lrrgr,,r liitile foarte ugor palpabile, strlr folni, de ,,mitrinii, r]]r, 1r'ul0hilllill r(.r'\-orse,crlc) itr intregime pot fi hipcrtrofiate. Sint prtztnlr'lrrlr.sr,rr 1i l.rs.ir'uhlii musculare, c-ares6 qtie cd,"sint,cu tolul excepiionrrlr. rr.lr,,i ir t,iile pe.riferice1ra D) Poliracliculortr:rri,tele realizeazi sindroa;me senzitir,o-rrr rir,ii lrilrr o1 lrtale . Di.sirnetriee, cu diBtributie atit pluriradiculall,, cit si (rl,rr)tl('licir, rlo obicei foarte extinse, putintl gelera tablouri paraplegice sur rrriri rll ut abi1 .tetraplegice, cu axeflexie osteo-tendinoasi,, nrlrt:lti Iripolorrirr cu trrtsctrlari,qi cu atrofii precoce gi lapide. Sindromll ile profouelrrrrr sr,rr z,iliv (cu tulbur[ri globale de sensibilita;be) ptezintii aLeasclnclr{,1 ilt,tt ,r rlistt'ibulie poliractricula,ri, clt qi ectr,omclicl. Cel m:ri iulesea sc li:(lclr,lzil ;i trlvii cranjeni (perechiie III, Itrr, VI, Y motor, VII, fX, X, -\t ;i I I I ). ill,rrlilir.r'i,rile lichitliene, cel rr..u ailesea cu disociatie albumin*r.ilol rgir.ii, i r ir r'i palafeze diagnosticul tle poliratliculoncvr,itir t.irrillain-Ila ll'r.

I +.

PROBLEME DIACNOSTTC DE Itr TULSURARILE TONUSULUI MUSCULAR

4.1. HIPOTONIILO MUSCULARI' 4.1.1. Hipotoniile t/anzitorii, paroxisticcse caracterizeazf,, ptin bruschcfca cle aparilie qi prin tlurafa scur.t5, (citeva secunde sau
| | llI l[ e) :

j'ml*:*+ i*{i-T*l,l-'*:*"*}T*l$i.*"-t B'lrH":it'il:l:$

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t',",!llr{ff'::"t:t'tilt:?{f ;'!'!t"-'ie ("rarvate" Devic col'rl)' rrxi?; $i

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L) Atacli cala,pLectia consti intr-o pierdele brusc5, drarnatici,, a iorrrrsulrri muscnlat qi a motilitd,lii voluntare qi printr-o pritbusire ,,posirrr:rlii') ca,re cortrasteaz5 - de obicei - ct perfecta csnseryare a conqtir.rr{,t,i (.Devic qi colab., 1967; Popoviciu qi colab., 1978.; Rechtschaffen qi l)crnrrnt, :1.967). De fapt, atacurile catapiectice apar in mocl ercepliona,l izolrlr', t'lc nsociindu-se, dc reg'Lrli, cu atacrrile narcoleptice (Yoss $i Da1y, lll{iO; Popovioiu qi colab., 1978). Uneori accesulca;taplectic poate fi pre.rrr|rl, rlo scmne premonitorii (senzalie dc oboseal5,, de ci1,lduri sau ile r.r,rrrI,r'ic|ir,ctc.). Inhibi!;ia tonusuhi postunl poa,te plezenta intensiti.{,i rr|Jirrliillr,ric ll o hhibilie total5,, cu clclere (mar.ileacccsocataplectico), tonicX localizati, la ta telitolin rnuscular (crizek, lrrrrrrlrr o rlirnirrua.rc r.:r rL I lrl00liIrl pirrlia,le). t) l[r.uilc urcesecataplectics su,u atacuriie crtaplectice severe (Dal.r" 1i Y oss, 1l)?it Corfariu gi Popo.'-iciu,19?3, 19?4; Popoviciu ryi colab., ; ll)il{; Irolx)r.i(fiu, 1,979)sint tipice ca rnalifestare: in rnod b|rsc, manctipleoapelese inchid, capul se ilclirri, lrrrlrrlu)rolti, gura se intretlesohirle, pr' lrir'1i1,, lungul corpllui, obiectele cacl dilt urcmbrele superiod,recacl c1e-a, rrrrirrii,gcrrLrnchiise indoaie rsi bolnavul sc pri,buqeryte. PrS"buqirea este, rllr'i. r'rrpirlii, (La,r' nu instanNanee,brutali, ca in epilepsie, ci progresivi, Irrpl lritll'inl penl,ru sttubilirea diagnosticulli. Fe de alti parte, bolnayul :lrisl;i rrrrrlt,ientla at'acul siu de ,,pr5,bus,iret'caiaplectieii, r5mine de d:rr .lrilci corrrplct irnobil fi afon, ca intr-o staro tle ,,cLuarizare" si inccarcil'l rrrlr.rir.rr o sorztl.,ie neliniqte,de anxitate. Uneori sepoatelcln:rlca : rniozti't de rl lrrlrisrrr riivclgout, mici tresi,rlri mioclonioo li, cxc0!f,i{)na1, rehxir,r'j rrf iclirnr, Sint 1i cazuli, la care inhibilia motiiiti,{'ii Dn etitetotu',li i}bsoirrr prrl,inrlLr-sr: rr,rulr,lcir,, culsul clizoi, rllioi rni6ciiri lolutttlt'r:, lititil;rtlrr Irrl,r'i. in (le posjl'jlilrlti pirrtirrl(r ll'tic,ltlrut(r pr?lrrrn 1i orLrocirlc 1r, lrr rrrr'loi,r,r'i|,rrlii, rlr, turitri;cligilrih,. lirrrlrttlt'tizci sl irttttslltlii:ltilto' [n rrtr,r'r'ttvinlo, olricrri
Irttir lf ill * rrttr,r'rrlizrtlri. r t lt olit r r t t t o1|lr r t ' k t t r t t loo l l t t r l i l t o i t s r ', r t l r o l i t t . 'l l t r 'l 'l t r -

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iiilfril;li:t il,llin;f i,r,ir[ iliiillilililifriil;i: l*-irui

r'rl,ir, rrxir.nrtllri,lrrlrtavul lrlozirrt,ii l,m'rrspiratii ;i poliulie' '1'ottleilutra oslo rrrrrsrrrrlrr,Llrli| tluretoasi|ryiin tirnpul crizei se cYidenliaz'i hipokaliemia' in sr,hirrrlr,itr palalizia perioclicd,familiali hiperkaliemicd (boala lui Garni,,i,,, ,,,r"t.,,o',r dc obicei ilrlc ..,si 10 aui (90% din crzuri;, se dcclanduph inani{ie qi dupd' iud, r,:'zi' I'r'rr,,r,, os,bi ziua, mai alcs pe nemiD.cate. paraliziile predominind pe mu$chii cranieli' ,',1,,r'r rritrsculareintense, rri r,r:izci constat[ d cre;ter" lr$oariia ionului de K+ (crr rnetlie.ite se trr I irrrtrrrL de t iizr, poal" fi piovocrfaprin adtrLinist'tarca I 3 g de CLK ', ','l;,,'ir. rliiglostic. iare insi, trebuie efectuat cu pruden!d')' rtt r, r "igrir lt\ (lri'.rr de dt,m atlacl: se mlrrifesti printr-o pierdere brusci a tonu. rrlrri rrr';iutir[, tu,ritii ,le pribuqirea,bolnavului. l)ebutul este bruscr f[r6 r-Lltr ,.','1'..' 1,r,.,,,.",sr:rle, se pro{luco de obicei in timpui rotaliei sau extenr,i r,.i ,,.irrrrlrri rtu se insulrq1ede pierdelea cuno$tintei' Auzul, vederea qi , r,rlriliir rLttiLl lerltrtlte. i'riza cle drop al,tnck este un simptom al insutilicrrli,j r,irculltl,orii vertebro'bazilare Coriariu, 1971 ; Kubaia qi Millrlirrrr.l1){il; llopoviciu si co1ab.,1968; 19?6, 1980)' Diagnosticul tliterenI ,,rr , r,zr,lt' epileptice akinetice (amiotonic-llkinetice) se imptne tot,l',' ,.r,rl',r.ir, nici rlrr crz nu se evitlcntiazi modificdri -tlEG dc tip epileplic. nt,,,fiti,,iirilelillG ale atacului de dlop uttack nu pot fi suryrinse, din c\rmeaul necesart I,rr, irririrnpli vizibiJici!ii epaliriei crizei,rlai 9lFG esl" i,,t,rr,rt nu.rl, evidentia oar"cate anom:lii clcctrograIlceca'racierislice r-ertebro-bilzitare (PopoYiciu si colab', 1968r 1976r 19?8t rrrsrrlilit'rLi.ti | 1)r'i()1, l'l lr)ristii' ft,rine dc cptlepsie in care dominf pierderile tonusului de de petit " ,,,,tit,rrilin, (cpilepsiile ,,siatice" ale lui ll,amsav -Elunt, crizele 1,,,,t ,,,,,i,rtonici-akinetice, crizeie epileptice temporale amiotonic-akineri,.,, (itstaut 1i colab., 1969; [iastau-bqi Broughton,. 1972;. Gastaut' de Cont ert ul s"miologicne orienteaz;' obicei )v l :r7;, I ','r), iciu ii colab.,i 9707. : foarle frecvenLd .,i,, i,r'rri. l,...lnrctizoi, r'tt dttrali scuuti, prin asocier,'a l,ir,r'iliri conltiinfei, de obicei cle tipul ulei obnubi]iiri sau absenle' lr, pllt LLr -pdstaccesuale, a amneziei accesului si, mai ales, ,, '*iii i'ir,,' colf uzionale IIEG qi pohgralice din aceste crize' rrrrorrrrrliilr Gt I'truLiziile dP sontl (paraliziile hipnagogice,cataplexiile hipoe' sitrt' in realitate, ,,,''r(r.iirlr ctlt.oleliile cle ,,aclormirc"sir'ude ',l,rezhe") .*,. ,r,', rr,t,'rrii musculari, prin inhibilie musculari generatS,cie structuii,.il ,iil,, .,,,nll,,ni,ofalice ale sistemului somnului REM, apirind de obicei la Eis^hikawa irolrrrrviitttlurleptici (Daly qi Yoss, 19?4; Yoss Ei D3'ly' -1-q59; .i ,,,r,,n-. lCoir:- Pompeian6,fOOZ; Nan'no ;i colab.' I970; Cor{ariu 9i i',,.,,'i,'iir. f974. 19751Popoviciu ti colab., 1978)' Trebuie d iferentiatecle ,,,'i,r,, r,,.'o" tte cpilepsie rnolfelcd, prin inYestigalii EEG qi poligrafice, in tLe ,,,,,,rlizi,l,r sodn iecxisthcl anomalii EEG, in alarX de contextul policir,tt:arlti c5,paralizia de sonl, fie in forma sa izolatd" fie la narcor:r"r,lir,, icrrl rci^ implicri aplrilia inhibiliei musculare caractedsticai somnului R'EM' (Nan'no qi colab., 1970; Cor1ul ti,'gil ,ri, fulcl tle ielativS, stare de veghe frr,r'irr lbpoviciu' 19?4' 19?5). 6i 1.t.2. IliPotoniilc durabilo : It) II iytokniil,a lqnarllisate sint raro: r,itn $o llll'ilno$l'o (rtri]lrtnkt') mn!/ ni.lald'a ltti Oppcnh L M.iul,uniu,

l', t o I' lrr,r'rrDii.r r lolr ir r ,t r t il|t ,,ttl :rl l 1 i i tttl [l tl t,rl ,trx l l ri ttrl i i ,, tl i t' l t,tf,tl t' i sl ,i tl igrttrrrrrl l i I ? {l

r.;rlri, rriisr{i,r,i rlr.;rrrrp)o (sin1; rrrsir,-rrrlrrilii 1rllrrriIirirI llrrriv, rlr',rrr.lril ,,r,oprr rlc lrrrrcirtci' liiset. 1952). :!nta;ine ( atrofi,i,le cerebelo(s(: ). l:t.lt'r i nlcl.c aerebeloase ;i. Iltt(.|c tl.is{rofii musculat e progresire. 4..'l's,besitL(forma amiotonicd,). B,l J{ipotoni.ilenzo,imulNsall mdi gtulitr,locali,zate (tle 1,iplrrtrri;rl,gir,, ale lrrla,piegie,l,etraplegicsau doar la citeva se,gmente corpulrri) rrlrrrr.irr ,rrrrrilr:,r,'lt. s;lual;; pulologice : 1. ,ln- najoxii;atea cazurilor, hipotonia se instaleaai, brasc 6i esl,c llrr liziil,ri tle Le.zittttiale aroalui refler toni.gen, respectiv ile leziutii ntrtlultn. ,.,i pti,Jerice. Aceste tulburili tonice prin atingerea arcului rcfltir lorric 'Ir.rnentar sint totdezruna iinnitate si segmentare, dispuse dup5 o topoglrrtrr. L rrliculaRi sau tlonculari,. Se constati, qi coexistenla trrlburdrilor srinzilit'r,, t otice qi paralitice iar leflexele osteo-tendinoase sint abolite (semtr li rirli l :rrportant). Ilipotonia este cu atit mai importanti,, cu cit lcziun(fl, rr,lojrl rirri bnrscl. De pildi, sectiunile miiduvei tealizeaz:acea mai masivij lllr , i(nte rausculalri, ct topografie paraplegici sau tetraplegicd,, a. [,eaiunile merlulare antrerreazl simultan hipotonie pin[ ll lllon il tttusoulari qi paralizii (de tip paraplegic, tetraplegic sau mai rar mouoll(lfli(). :l\t'&,rlrnatism?.[e medt are (cu secliuni complete sau incomplctq t,vcrr I rriiI prin comolii medulare ) qi lrcnzatamieliarealizeazd,paralizii hipoi,orrir,,, rrrr atonice imccli:rte, de tip para sau tetraplogic. Adesea debuteiuii ;rr.irr il o fazii de +oc, insolitil rle un raasiv deficit motor ni atonie crr rr,i'|,.,,,. rr ' rslco-fendinoase !i critanate abolite, cu incoltinen{.I sfincl,cr,iu ii ri r rr rrrrrt'i tulbur'dri de sensibilitate. Aceast[ atonie musculari in ]eziurrikr r rir.r rr I lrr'c masiye persistf pini, cind se instaleazd, ienomencle de aul,orlrr,i,isr rr rrrrlulirL, cu respcctivele simptome de elibera,re, sincinezii globrrlr.. lrr cu , rrlsrrl compresiunilol medulalc br.utale de diverso origini, sa,u irr lrrzrrl riror'frpctiuni spinalc incornplete,se observS, adeseoriacelagidcfirril,rrrolrrr,, rlrr trr hipotonie mai pulin marcat[, qi mai pulin clurabili,. Lc;iunile medulara a.arle nelraxnn(rttce tealtzezzd acelaiii sirrrllorrr I'rllllitic cu lripotonie. Itste vorba de m,ieliteteaar,tetransoerff $i rlrr 2,,/r,, ttitlikt acndd,, care palalizia hipotonici, qi aretlexicriltlotniiri 1:ilrlorrl in ' iirric:! 0u topografie tetra- sau paraplegici,. ln ytoliam,it:lilele subasute sau tw instalareprr.rgresi,t:ii, prirrrrrl |lrrrr pc r r srl,ueazi,paralizia atroficii, hipotonia {iind ins[ nolipsil,il. !, In compresiuttiientetlulare progresioe (prin i,umoli tle rlivei'sorr:rirrli, rltcrxe, pachimeningitii,,arahnoitlitn q.a.) hipolonia^cstc rilrtxl'i irrl,ilnil,ir, rlrr obicei constatindu-se contrlcturi musculari. ln scliimb irr tir,irrro trtirrlieqi in tumorile intramedulare, leziunea, pericrliona,lrlpoatr: llrirr,rrr rrrci, de la inceput hipotonie muscularl. 3. I'eziunile progresil)e spinala posterioarepri,n leziun i ale atnlaqntlrn. lt,tsllrioare(ale fasciculelorlui (ioll qi Burdach) sa.upr'in leBiuni r(r(li(ut(rt de lripol,onii plin inl,elfln:treil u,tt'ttlrri rrrlh'r loxtarioarerealizcazd, tsorn(lnoa, lr)nl{r Olementiu. a. ilipnl tt,<)ostor rodidllo 'm i(lite poltlffiaor,r.restc rr,prtzlrrl,rr,l rlrr lrrbrl,nlti nkrsi rr ril,rrt{;ii cu irnpoltrrrrtrrtull;ulr1l:i stqr il il,i!1,{r lrlriri,. lo r[o si]r lrrol b, H i.rul;uq,nt r t Jihrr lu,rrgi (dt. .nr(loun( Ttuslrtiourt,)?v:u.lththr d,t' ,r'r'{r intnlll('iio lul (x)ut,(fxl, rr.rrriologir t:lrrcpc 1rt'irrrrrl irr pllrn sotr,l['i, lrrllrrr lililo rlrrptol)ti()nr{{rl)( rrr ;rrr,llr.lil oslr'ol,rtrrlilo:l,.ll lriprrlorrir. i{r, i,ricrr rrrrrrr lrrfrr.rii. r.sl,r, Adctr,lr, vollr:r tlt'ni itou. tt'd( ttrlu t)tii tttuhintlli, ltr lrrrr. irr (,orir,\lul clirric:r1lrr'4ir, rrrrrr, f.{r' rrrlrrlrlir, 1rilIrrrrir|Irlrr. girrrlitrr,irr :rr.r.nlr. t7l

com'bind'td carenlit' \t s irr,rLl'ou,nte l,e n'au,ronn'ent,i,.xt,sindroamele tle salerozd, (indeosebi eredo-ataxia sau ;!'a lrr, rrtrolo d'egeneresce sp i nrt-cer,ebeloase liolri, irorrJrr, hLi I'rieaheich) (majoritatea rlegenerescenlelor spilo-cerebeloaso, irrrlrrscbi eele de tipul Piene-]farie evoluind, de fapt' cu spasticitato folTa pseudo-. care teallzeazS" Rareori existS,scleroze in p15,-ci lrilrrrrrirlnld,). de sensibilitate profri:nld, cu hipotonie $i i.rIr{'l,it,ri,, marcati tulburare cr in lrirr,rrr.Il,i.,rie osteo-tendinoas5,, cate qi semnele cerebeloaseapar ceva rrrri litziu. .1. t,a: tu'nil,e periJeriae ale orat'Iui refLen c\7 hipotonie consecutivi', Polirad,i'culo-nevdte ; b\ Polirrrrrl,irrl,ilrrite in iumbroase afectiuni | ^) capitolul precedent) ; ttt t,ri:r'.ni ttoltttcur oputii il'e diuerse origini, (ve (tlaumatice' torice' metabolice $.a.); d) Leziuni , ) V,,,,r si neu,ropatil. ift,'
, ,lt pl,.ttt1 ilt,i

pi1t15 distro{ii1eilusculare plogtein l. Alealiunile rlasculttre, ca c1o (rrLri.rzulilu in c.ne se irxtaleazi atlofii importante, degi :rrcul retlex ; ir,.
r.ilc

llrt,rL ill,

lot nbar '

o: r c r aL) .

0. It;:tutlilc ftttmaliuttllor cu acliune Jaci'Li.latoareosupta dtaxt'lui' ( prin intemediul sistemului rei;iculat facilitator tlescentlent), t t llt ,t)Lt)tLioen i siirr,r(ii iricLr,rJhipotoniamusculard se datoreqte preva,Ienle acliunii for: rrr:rt irrrrilot inhibirorii etescendente (infec-tioase,traumatice, degenerative, atrofit\ I'eziunile aerebeloo'se ilr coictreloase cu tliversele lol forrne clinice) se pot insoli de hipotonie o rrrrrscrrlat'd(uni1aterald, sau bilaterali, erentual crr predominantd' 'le p: lu), care se poaLe evidcnlia, pe linga-ptobele clasice de e:.plorare a proba pasivitdtii a' lui i 'r,,ritiiziliipasive, qi prin allc probe senriolcgice: pasivS,a tmnchiuiui bolnavului, remarcindu-se Tioriias (dd rS,sucire A rrrlr'6 rrrisciililo rnai ample ale bia-tului de paltea hemisindromului cerebelos) ; prolrrr, ,,r'ezistenlei" a tui llolrnes-Ste,ivar"t; proba reflexelor pateiare qi "'o"ttlll^rl;r*,*or, neostriate (coreile tle diverse tipuri qi etiologii, acute asooiazS, hiperkinezia caracteristicS, qi crrrnicol sindroa,rnele atetozice) lrip,rl,uttia rle iltensitS,li variabile. c) Llnale sind,roatnaaesti'bulavese pot insoli de o discret5 hipotonie rrrrr*r,rrlrrlli insilater ali leziunii' d\ It l&lunite neuron'ilor tnotori'centrali, hipotonia muscularS, poato numai in situafiile in care sindromul piramidal s-a insbalat Hriti(' irrl,ihritii, lrlrrsc.dlr si il accsle cazrrri hipotonia dureazi doar timp de citeva sdp(sindromul piramidal deficitrirrririi.in cale asist[m la o hemiplegio flascS, dupd, care se instaleazS,hipertonia piramiilald, c&racteris' i:r,r:rl iui Barr6), l,irrr'i.Nlonfioni'ni ru:rele parali.ai'i fl'a,ececentrale pseud'opariJwical -inso"litg si rlrr u,1,xrliimuscula,re, adesea cu distribulie pseuclora,tliculari (dar fd'ri rea,lizate d.e unele tumori fronto'parietale (meninii. | ). ,r,,,tlo*usculard), giorr,rno,glioame) sau de suferinle vasculare.

rllra,t,t),

4.2, HIPERTONIILEMUSOULARE 4,2,1. Iliporl.orriilo plroxistioo sint roprezentata la diversa crize de Iitr (ont,'tu,hffd,cliro inturosor.tzii, orrt'pul ln int.regilne, Iio auumito scgmonto lrr oor.Dori0 ii:ola,to u, oi"!l'ol'durlll,iir Iunofio i]o rnocllnigmulcontnlcburii' ti
t{ll,ll (l(l i)l(1. rtxl,0 <1()tl00Lttttlr.}-tttittttl,o, l't !,

4.1!,1.1 I l ipul,otti,il.upu.rotittl,itl rtutt,r'ttul,izttl,t: . |) lr'onnt:ltLort,i,r qtik4tsic q(n,arlizal,ii (glarl rn:r,l}r,irntr,r. d,r: grrrrrrr,ll'li gonot',liza,1;) zirlritl,u $ootrtr(lirl sint rcl ,tiy nryorrlo rxtnrroscrrt, prilr lrrrslr,,n. rlrrrt* bruscil rr,corr;Liorrl,ei, prirr carrlr,toruloonvulsioi i,oni(x), l)rilt {lut,t[l,n sorrrtii (minuto), prin tulburf,lilo respiratorii, vit sor]ro1;ol'ii a,rxrrrrprrrri rlo rrrnonl;, plin ernisia dc urin.i in crizi,, prirr mulscaroa lirnbii, prin prrrzrrtl(,rr, rlo ottioei a miclrirlzei qi prin surprinderoa moclificririlor lrllr)(l (Ar.sorri [i , 1978 Popoviciu .,qi colab., 1970). ; "lrb., Marca lr\ crizd piliatici poate sd, realizeze o corLtrrrcitrr,il, grrrrrrr.rr,li zt,bii, da,r, spre deosebire de criza tonicd, epilepticS,, ar.eo dulttii tnli lrrrrgrr , rru se insoleqte de apnee, nici tle emisie de urinI qi do mursclrrlr,lirrrlrri, rtioi de sernneEEG, apare intr-un context psihic revehtor., illr.sirrr;rl,rr rlr,l,ologia critic5, este ,,neulomimetic5' t, adicil, are o topogr:r,tir: cN,r.o rrrlrr. sj{)ir colespunde structulilor anatomice reale, ci ,,itleii,, 1o otlr lrolrrr, {ru vul o are dcspre ,,organizarea" Ba corporald,, creintlu-se zr,sblirlo Irr,lsrr, .,schem5,corporald,'J (Enitescu gi Popoviciu, 19?8). c) Tetani (si sind,roamelespasmoJil.ice) pot s5, realizezo (x)trl r.rrrlu ll spasmoclice ale extremitd,lilor (cu spasm carpo-pedal, minil rlo rrurrrro4 ii cu planti, excavati,, cu inclestarea pumnului), a1o trunchiului (orr rrl,trrr. ciri ale torsului), ale muqchilor felei (cu,,ris sartlonic,)), spnsrrLtr orrrrkr rrrotolii, ale limbii, a1elaringelui qi chiar crizc tonice gcnei.r,liia,0orkr lrll r.t, pscudoepileptici,(Riser, 1952; Figi,rd,qan qi Popoviciu, 19?8). I'rr,zr,rr(,rr srrrrrnclor Chwostek,Trousseaugi Erb, lipsa pierder.iicunosl,iuf(\i,:lrl,(, lui ,.rl{lontele, modi{lcd,rile EEG qi EI}IG (1a proba g:lroului), motliliici'lr'ilrr c:rl lcrrrici qi/sau als magneziemiei, clarificd, dlagnosticul (f ir,glriiqrr,n;i l.,opo virirr, 1978). de ) Crizeletronice Josiiposterioariiau fost ilescrisc inilial rlc .lrrr'lisorr (ll{?1, oitnt de Arseni qi colab., 1978) sub termenii cle ,,cercbollilr.lilrr", seizurest'$au ,,crize postedoare,t.Apar mai:llos Lr,r'rrpir ,,l,rlrrrnrs _like rr rr l:r adulli tineri, in special in tumorile mecliane cle fosri,lrosloliorilrr (1rrl,po un pulrti,.r,i Taterial de 1040 caauri de tumori cle fos[ posteriorr,i.i, rlr, Arscni gi co1ab.,1974). Aceqti bolnavi prezintii de obicci ;i |i'rrorrrr,rr," rlo Iripcrl,ensiune intracraniani,, insolit5, adesea si de o r.cclo:lrol i1(\l'(,ilr :r lrrhisului, precum qi d.e pozitsia ,,ceremonioasi," a tnpultri. . ln mod brusc, de reguld,in urma unei migciri bru;tu a ca4trrlli, col prrl se plaseazd intr-o contractqd, tonic5, in extonsie, in opistotorrris, irr,r. rllpul este.aruncat_inaloi, ochii deplasali in sus, mcmbrclo liinrl Jrlrisrr,tr, eu irr lilexieqi pronalie. Uneori se asociaz^$i trismus qi incontinorrl,rlsf irrll trrrir,nir,. devin-e foarte neregulatH, qi supcr.ficialtr, stnt (lr! i,ill ^R,espiralia t llrovne-Stokes, apare bratlicardie, pulsul este filiform, bolnrr,- I'jirrrlrlorri. lI rrrroori obnubilat . Criza dtreazra do obicei clteva minute, putind I'i nro r,l,rr,lil,. t)rr!ir, .crizd,cefaleea $i vd,rsS,turilese intensificS,. S-au deicris qi lonnrr pn.r l|ak) da $tza tonioe, caracterizato doar printr-o contracturfl ;la,rrrxinl,irrrl, l rxrfci, sau a membrelor qi a oefei, dar nu lipsesc aproa,po nioiodrt,l,it, i'trllrrr |itrile r'<lspiratorii, paloarea qi cefaleea. S-nu descrisii crizo tolrim 0rr prrrrlrr nrirrrrn(;ir, unilatcrali, cu asloct rlo torsiuno a,xirll5, (Va,n Boglorl;;i Mur'l,irr, lll'..11"t, oilrrti d.o Arseni 6i oolrr,b.,19711). Mrr,ioritatolr, ir,coslior orlzo l,lrrirr. trrmorilo rlo frrstlpostoriotli'i,(inrloosolrivollrlt,lr\) rirtI rryola,torlropontr,u. rii ;rorrl,r'u nngt.jfi,rilol;errrpor.llc, r.lrtrrlo t5i l,sl,lilldo rlrizo in ctr,to H1ill1,1rlr.i so trrrrr||;iot rl,rt 1;r'rrlluio tr.rt rIIrrrlrIrrrIr11;o 0u 0r'iz0kr rrpilopiirrrr it)llir{r(li,iHr,r', l0ltll , Atlotri qi rlrlrr,lr,, lll?lt1 Al'Horri l'opnvilirr, l{)Bt)), {!lrrt,{!,rto ,I rIr\I| |\I|, tl II il( 1i jf po;rl,o lrrliltti o fi{uttoltrfn, ltrr,tll, I,rrtrit,il, r.o ri, itrxlrtil,iL rrillrrozii, rlr' rltr 1i
t i/ ]

rrirl'iilxii. l)lr', irr.lr,llr rlr'lrrrl, rrr i'izrr r.1riIr'1rIr.ir, p|0rliic0 o rrl)lr(,(,, s. ,lrrpir. r'irrr.tr.,pir':r{iills,. -rr,r:r.rll,rtr rrrr,rJ rllsl rrl rlr.r.r,j{ul;rl, I,r,Olurrd(,i, ,{r'r'l()lrrir'slr, t(}frd (lii(i'iL(i do criz,, tonici a hri Jaaksun. -tn schirltr, (1lr .rr.r.il. r'r'izr. lunice tlc_Iosii, posterioari, cu rluratii de aBerncnea Bcurtii,, nu .,. rrrr lr..r.ttc.obit.ei pierdoread,. cuno[tlntr] si ecl rnai tdesex dispar tle rrr ;rozilicde decubit dorsal (drs.ri li cohb., 19?8).Arseni (1050) a einis i.,r'ir v.'Lricu1ari, confomo sireiir aceste crizc se produc printr-rin rueca.rrrsrr rr'1icula,i, ceea, erpliri qi_fuptul de cc lrcesiecrize-pot si, apani in ce IrrrIr: pr,ocosele patologice care iriti perelii r'e1}triculari. t,) 0.izele h,tptertonice letartostlcbtteazi, prin trismus gi ris salilonic. d,in ,lllrir r.:rr',. coultactura segencrrlizctrzi,cumpletixdu sc eu rerlua rea cefei, , rr rlivr.rsr. inllexiuriiale trrnchiului (ir:ainte.inapoi ;i Jat,.t,al), reduareJ clr rrrrrr..cl_rilor, tlrepli abdominalj si a muSchilor pectrxali, plecum si clr contrac_ irrli alt rnembrelor. Aceste hipcrtonii ttanice sint pielungitg persistenie, rtrrrl'roaso, fiind eracerbate prin paroxisme tonice vioientii initise ae c"*ij l:rI ii scnzoliirlo si psihice (zgomote, lumin5, emotii etc.). t 1 .7 urb.oe apar conrracLuri bnrslo I rringo-tarjngu-d r.aemair"e, t r iaf I .t ,t(.,,.,.hir riolente..insolirpde cri"e de apnec $i ttc blo'cajlrrin;ia;; itiI d,. l.rrlrr,tivtde deglutilie a;ntreneazi, desciirrca.ri tonico-cloni"ce ale*buzelor. -de :rl. rrur;chilor faciali qi ale constrictotilor faringieni. Ca gi in crizele-cliri t'.l, rrr)s,acoste conlnacturi tonice rabice sint, in moil caracte'istic, declan_ ,rrlrr ii .xacerbate Ia cel mai mic zgomot sau Ia eea mai micii rniscai'e aol,iv6 rrr.rr llilsivii, ,{1it crizele tonice <Iil tetanos, cit qi celc rabice, sp iusolegodc oxago_ ttilet_telor idiom, sctrla,re, ostcotendinoase mai rles i unor rofleie Si 'rr.r.ir ,lc llrrnchi cerebral (nazo-palpebnl, mtscter.in, Chwostek). t) In intonica!,ia cu stricwtnd (sau, tn su.pradotareaterapeuticd) poate :rlriirtir ti sttire de contracturi d e., tip tctatic, cu t,rrucorb[-l.i p""6rliti"e, . :',i, .,':r r,llorrrind crr convtrl;ii clunice_ 'f .i!.1.2. II ipertoniile paroristice localizate t) Crizcle epilepslice localizate (tonice sau tonico_clonice) tle tio iack_ rr'rirrr ((,u f.i1 fii,rd lierderea de cunoqtir-LlL,cu sau fi,r6 der-iatia'cilj u_ ,lrrl.rr r.rrpului$i a ochilor')se recunoscprin durala lor scurta, rr uneoriipie_ lr.rlirrrlo crizii generalizatl, precum [i pri]r contextul clinico-EEG. ' b) 'I't:tunia ;i, spasm,oJiliase poi manifesta printr-o crizd, de contr"ac_ lrrlii.lirrr.itiiti la un segrnentcorpoml. Oontextul clinic gi EMG o" pr..izr.:rz:irlirrgnosticul. () (hitete ocwlogireposl,encelalil,ice realtaeazd Im context semioloEic rrryolrlo roounoscut: {ixalea brusci,, penrbilA, coercitivd, a globilor oculi,ri rrr nrr itxoliid de,deflexiunea capului. MuIt mai rar se reaU;eazi un spasm H, hipr.r,torric latelal (cu sa} flri devialia conjugatd, a capului), Irr fpilrirn ou coborirea globilor oculari. Une6ri in cursui crize'i ""*p'*iio oolifogi"" rl, lrollu r.err)in]'&r, midriazd, sau miozd,, iar alteori bolnavul poate meniile irr cursrrl crizoi o a,titudine statuiticatd, rigid6, a intregutui c6rp. Niciodati tr Hrl(xrnst,rtd, :r,ltelarea sttrrii de conqtirn{d, in timpul crizei -(element de rllrrgrrost,iu dilorcul,ialfa{,ii, unr.lc crize opiloltice cir devi:r,6ia de, conjugaid a ;lLrlrilr. oculari itr-ilus,ou [ti1; mlli t ult, cu cit s,l|'rr escriscrizc o-cu"logi|o d ,lo ltnprrtl, ricct- rnic,,rlrtlti"l tlx ttl trnt'olo Iixrnzii in tlcvia!,io sursllnvor.gcll,:1, l{}Ii2)^(lrizu ll,isrrr', ilr., lrr g.rrtiHtl, rlrrrl,l,ilIutrgl (ri. lr, tiit.ovrr 'trulogi.i"r, , rrrrrrrr1rr ; ri rri i, llr cittrt'lrorr'), llrtlirul Ii rtrtcori rrrplirnir,tr'l rrtlrr,,tlirr. llrr volrr

ol ti tl t' i tttr6t r lt tt t t li l; t t t t |'t t t t t rio gi la,ir lt r t it t isl, r illol r lr r lllt lllr . it , lo r lo : t 1, r o1r ilr ii, t rl l tu N cr ruol: r , r it rji, . r I llrlu,nnptsrtt..nl. sltttsrnu,l.faaio,t, si ltn,i<t lirlicli, irrr.Jrorl,lrrrl(r , .rl) I)|.6I)Ir\|r||, r.lurlirugrroslic, pul,irul li explorirl urrol rnllnil'estliri spasticrr p'riprr.rrlizi. Irt,ciu,L'i,, a unnl rnrr,nifesi,Lriextrapirarnidille, s.m lunc!,iotur,lc, irrdrisiv gril,i
i r h(i {).

a) Crampa scriitorilor se caracterizeazti, plintr-o contr'tt'otuI'ii1[rsa,grrlii,, . ,,(,ora,1;ivi,, a murschilormiinii (uneori [i ai antob]'atului), cu otisplu orr, liipr,r.' irr l'kr.r a.degetelor, ie care apare in co!ciilii binc rteteuninate ;i rih,l iv irlorrtlir.r,, respectiv in mornentelein care boLnavul incepe si, sctic. ()r'runj)1, rsl,rrrlrrlr, lol,sri ,5ise extinde adeseaqi la mugchii brafului, ai umintlrri ryirr,igilrrlrrr. Do aele mai multe ori este vorba de crampe ,,funcfionalo,, irrrrlrisiorrrl,, (Lr, drctilografe,-la_funclionari,la pianiqti, la violoniqti oto.), irr llrrriti,rr l iili distonice declanqateqi/sau exacerbate de o fobie a stir,isulrri r-i:rrr :r prlctici,rli profesiunii lii de o fatigabilitate excesiv5. Unrxllj insii csl,o vollrr, rlo o diskinezie eltrapiramidali,, sugeratii, incii de Il,iser (19f2) qi vrr,it.icr tl, clectromiograflc de Aqgian gi Popovi.iu ( 1980). Astfel, se pructirli, cx i r,l rrl trrI l)lIG simxltan atiL pe rgoniiti. cit,li po i],ntagoniltifprrrt,rr,,irrr.r.v;r(.r,.r r'e,'iptocc "). crampr, ncrrolicS,, la accaslA plobl'r :r i rIr.r'v r, ic i lr.r.r In ,, 1 o lrtoce)t.se tlepisteazS, funclionalitate normlh, ln sclsul i:i ll, txrrr l,r.:rr.(irr rgoni,ltilor se constat[ decontraclia antlgoniptilor. fn schirnb, rlrrrii r.ii,, vor'lla de o ditq.kinezie extrapiramiclali,, Ia contracl,ia rgorriFi,iiol sr, r,r,rr l.r'tct[ .$i rnu$chii antagoni;ti, adici. apare o activitnte EM(i ;i 1xr l,r,rrsr,rrl rrrrr;ohiului antagonist, inregistratd in mod simultan cu cont,r.l,c r, rlrr rr,. ir 1, 1r'rr,soul EMG.al muqchlului agonist..Credemcd, aceastii, prob;i lrlozirri;r,'o lrrkrilre semiologicS,pen!ry diagnosticul diferenliat intldcrarnpirlo rrrrvlo I irrr si ccle extrapiramidale ,si pentru olientarea tratamentnhii. l)..I.n (boala Lui Steinert i boala lui Tltomsen) ln o\ir,rrr\rl -m,iotonii, ,rrr;rr'r'licial ne-ar putea duce in eroa,te,sugerindu-sein mod irr<rorrrcl, r,ri r.rilr vorba de o lripertonie. De fapt,.dupii,cums-a precizai,irr uli,irrrir:rrri, .,irr ciiLdaaparenlelor qi contrar definiliei clasice,miotonir.r, cshr o lrrl nu lrrrrrr'ode relaxare, ci o contractie prelungiti, determinatri do irclivil,rrl,r,rr, I r.ir x'lcetricS" interactiv[,_suslinut[ a sarcolemei" (Radu, 19?ll). l)i:rgrrorr Iicrrl este relatiy u$or de stabilit, gratie ulm5,toarelor elomcn{,o: Caracterul eredo-familial atit al miotouiei congenittlo hipori,r.ol.ico (lxrrla lui Thomsen), cit qi.aI distrofioi miotonice,(bo;la lui Si;oirror.i); - Prezenla hipertroiiei maselor musculare irL boa,la lui ll,horrrxoirur :r rll;rofijLor musculare in troala lui Steinert; -.Prezenf,a fenomenului miotonic, care se gtio cri nu ptozint:L torrru,rir iu lotrsitate in toato grupelo musculare.Astfel, sc poate lo-rnl,r,cir lrr.rrrlrr r, rrrirrlnll a fenomenului miotonic la musculatura <listllii a lnorrrlrr,il,,r_'1,, rriol,oni:l,conge_nitald,. (Thomson).fenomenul mioto ic aprlro gorrot,:[lizlr,l,, rr vrome cc in distrofia miotonicir, Steinert este mai limitat, alleirlirrrl r|rrr,r" cilivr,.muqchi sau grupe muscuhre (mugchii policehti, rnuqrchiilirrrlrii, rrrrrqrhiiflexori ai rlegetolor,'mu;chi orb!culali ui ploo.r,pol odukrrrrol,or.ii). i rr.ryi lrr lrrr |rlmiol;onia congonitalii t, Iui. rlult'nl; rrrg lerrr)luernrlrniol,rtrrio porrl,r, rrrlclcsil ln rnorl oxclusiv nruqchii faoiali (lilrilu, l-9?8); (l -- or)rrBi,rIlil Iil 0xir,rrr{)nIllr)l\l rr,srr,lvoirrriokrni0rrriir,r.rr,rI,r, r.i rrI rrrrr 'ol, r (rrt rlrrt'lulil, pilrr'i, !l) s), corrrl,il,uili, lrr, tlirr pot,rrrr{,ilr,lrr lrlxri,il,ivsqr!r{, r,rl,r{rr irr qi ;Irr'rllr'l' rrrlpliirrrlirro irr lrrrrrvrrrr{r'i, rr,irrrrrinrlrr rDoi irrrr'rr i,r.rr,rfH xrr
(x,n{ l (' l (' l tl , ; ... l ' t' .zr f alir , r .i r rrI r , rrr rrI rri r , r r r lr r r . r 'itit r r lill. r r lir r , r r r i, i, r r i. ir , lJi, r r ir r r r l. i. l Tft

,l.I.ll. lli;lorlorriilc ptrrrrrrrrr^rrlo (srrbtrrrlc si r,ronica) I oniil,e ruh,itliute (rtthitotaiile) clu,yproase pot intiLni .sc 'l-:!.:1.1. I .iilt.l't Ntcctiiuni: ir rrrrr rotoir,se t) ilinrlrotnul mentnge&l,realizat de meningite qi de hemola,giilo subiurlrrr)irli('no implici, in tabloul semiologico hipeltonie dureroa,s5,, ertinsii irli'${,ir lir i,u{,i muqchii cen'icali postedori qi ra;hidieni dorso-1i:mbari, insoin de Liiri (l(l rlxloarea neiii, a cefei, de pozilia cancterisl,icd, ,,cocory puqci', 1i pozil,ivil,ater bingcunoscutelor manevre Kcrnig f , Kernig trI, Lasdgue, I, llrrrrlzitrslii Rrudzinski II ry.a. pseud.o-nz,eningeu,l, al f6ei posterioara trebuic dilerenbiat lt) tlii,ttdromu,l rlc sinilrrrilmelc meninge,alepropiiu-zise. Acest sindrom pseudo-lr cningeal de cslr, rr.rrlJzat proceselocalizate in fosa postelioari,, dal' qi de altc proiese r.)il):ll)sivc supratentodale, ca,re produc fenomene de angaja,re a cercbcr trrlrri, r',.spor.tiv lobului temporal. Se poate astfel evidenlia, o ledoare rlrur.r',rrsi rahitli.tuii celvico-dorsalScu Bemnul lui Kernig prezeut, cu o lrozilio rleflectati| a capului, cu membrele inferioare in flexie, cu atitudine hiper-tonie dureroasi, a cefei qi a rahisllr ,,(xxiol de puqci'". l)ar aceastS, prezenta exacerbiri qi remisiuni, fiind va,riabili in iritensitate, ia,l Irri porrl,e rrrrrrrlirr lornbard, (periculoasi in aceste situalii) poate s5, tie urmat5, de o lr.rrlrrrlrsot:nli a, algiilor occipito-cernicale $i a semnelor meninge:lle. Un lrtont ,i sistenatic al fundului de ochi este susceptibil sd,previn6, r.rrrrrrr,n
il g('rrrclloln el'oll.

o l l i z r r l o r r r l r L , o ;r i r r tu r l l i r ,i , tr u r u r ti , t,l tr tt o ttr l tti r , l tr l r i l r r ( l i i r tt, l l l l ,l '; , \ t r r . t t i r i r , , o l r l r .. l 1 l i ,l ) . r It.l l l l i r ( , \ r , t , l r s l , j i r r ,r l o :tr tr l t ccl i r i so l l o l tl o Iu Ir r r 1 r L r |,Ir ,,l r r l r i i cr tr r l l l i : u r 1 {r i o l , 0 u o tr l l si t,i ( ,o n tl l o 1 ,n I'i 'i , l t, i tr l ttl l Ji ( x) l o i r l tcr l ) l ( r r tn t si ttt r u zl t, l o n j c c t l e s c l i so tl c Ja ckso tL q i i l e Ar scn i .si tu r l ttl t. 'l 'tr r l l tti o ;i r tr r {'i ttt'ttt t'i r .

cslo tl ttt. nurlc irnportanlii plactioii prezinli ttlplul cti turbilizrllor, cruprtltri IMI||il|iiIr I |orrs[ qi ci, se inso-teSte foarte frooYont d.o paloiil'(], q1('1ilr|j. rtri'tiginoase qi rnociifie5ri carclio-vasculale qi iespir:l'1,ot'ii. t il Jntt,stulqlu sau bi,laterale,localizate, col.outtti.1i. u'le d) Contraeturitt'nipot t:erticale, tkrrsale;i d,orso-lombare fi intilnite in cele mrti tlivr:tsr':tllr'1 uni ale coloanei (spondiloze,spondilite, puseuri de rertntalisttt t'titLrr|rtrrI trrr hr:rnii dc disc, tumori vertebrale), dar si in alte proccse(aLrccsc i, c lt rrI rr lito do diver"seetiologii, arahnoidite, meningoradiculitc lo<rtlizrrlr,,'r.:r., \u trebuie si uitim nici inqeli,torul ,,lumbago primifiv llrrlrrtrrqrh.gir ' rlesclisde Sicard (citat de liiser, L952) c semu dedebut (fazi, t rrt I i rrrrIrrr':' r rir cvolulia unor tumori extradulale satr subdurale, in snre insii sitttlt0ttrrr] { iltr uranometric qi cito-chimic lichidia,n de blocaj rahidia,n sint rr1 1r.tr r r l:r'an$areadiag:rosticului. (ernrrr.li:.trl, 4,2.2,2. Hfutertoni.il,e{ t:onlraclurile d,e origi.nece,ntraLri ) tuzt. toc,alizate) a) trIfuiertonia (contractura) piramidald prezintd, p:llticul;r,riiil {iLr lrirr, (lnnoEcute:predominanld ectromelic5,; caracter electiv sau (1r'irsir'l(\'lr\ (1troponderenl,i flexod $i pronatod la meinbrele supeljoar'(',r.rp(,rl r\ pe 1rcertensori la membrele inferioare) ; atitudinea caxactcristicii a,lnrr r lr rr,l,,r r,l,', intcresate (de tip Wcmicke Mann), consecutivi acestoi contl'i|,(,1,rrIi li1'e; prezenla sincineziilor (globale, de imitalie ;i de conjuga!,io) crrlrrl I Icrtl de cedate ,,continu5," qi elastici la probele de mobilizrlrt prrrrivl lopograiia extinsS, hemiplegici,, para,plegici', tetraplogici' sau monopk',;1icrr plczenla altot semne pirarnid.aie. Caracterele propdi ale hipertoniei (contracturii) pilanlidillc lrr p('f rrrit aprecierea topogratiei leziunii qi ca, at'are, un aieosellit itLtu(.s lt)lt)ttt'tl /ic ]rrezintd,semneleasociate ,,de etaj" (spina1e, tnnchi cctclrlrrl, rtrr de licrLle,subcorbicale),care trebuie clutate cu grij6. lt) Eiptertonia (conlracturo) entrapiram'id,alii (paLr:oslriutil din sinrlr, tttu.l,lt'i,ytntoni.co-hipakinettc porhi,nsotzim prezinl,ri, d) sau ])[ri,i{]uLr'r'il,r(il, l)ltt(jcunosoute: Ia De obicei este generalizal,i,, toli muqchii pet'ifot'ici,tllt,r'itrlorr' rrorrai indeosobimusculatiuraaxo-rizomelici n staticii [i :l echililtlrrlrri (rrrrr; r,hii cetei, ai g'utierelor vortebmle qi :r,i centulilor scapulnl'it, prrlvirrrrii l. 1i !,(' mult'e ori se poabe lealiza un homip*rkinsonisr . in l, intereseazi, rnisurii, sensibilogillii it,1i glrrlrrrl,' adic5, - Este globalir', llr,xorii, cit Si pe celo cxtonsorii, rlvind toiufi o uDolrl plulorttitlr'rr{rr 1r,' .* trlsl,e ceroa,sX" nla,sticir. ului" - Ditrimrt'r,rzii iir cnrsrrl .\otnu * Ocderzl in s (.;r,rltrr l trr(ii rlirr{rr,lr.). loa,lizirrrl scrrrtirrl i Neglo (rr,l g1; ( rlitr{lt,lrr 1111,1r11{,111rivir,,rrrlrt s0 t)rir,i Ii\ ll r()rr)(' rrrrI rrr(,ii ovirlor I'ii l,rrlfi ii lriulovr'(! trtiriuili nllivr, t'-,trrltt,l,hr irllir tlc rnrrt jrr <tttltrrl t:tr r.iircl,rrit uur)r' (lr,rrrtrtrl Itti Noicl). rI rr Irr'I,rrrrrIrLt ttrt'rttlrtr, r |IIlri't rr ltri l,'r'otttlttLvirlirrt{iltzlrrcrrrtrlrltrllr, I'rtrl)1,,,(|(||||rl| lrrlrr,t rlr'Iilrlii rrl,ttttr,i cirrrllrrrlrrlvul iortiri ln lrrrrDrrltrr,IritrrItlrtii lrlllrrr, r.rr rr.r,l
rr\ (.)ft.

dureroatii,ipolatd,,interesind doi.rrunii musch i r:) Ilt"pertonia rahi.dialxd, cofiri ;i trapezul, imprimind o atitudine vicioasX (cu torticolis) loato fi rri qi ni, irrlilrrilii in cutsul unor leaia endoaraniene 'intra-rahidienece|Dicale. iir.ril rlc;te irita,lici nervilor spinali Si cervicali. In contextul serniologic litrsirsit, (lzri,:i tle sinclroamele preceilente) contlacl,ura rahiiliand, krmbJrS, nu 1i'rr nrunblclor inferioare,de ase-menea Beevidenliazi, semnnl.lui Kernig lr|ningeale. 1n plus, contractura mt$chilol cefci rnlnir'r ,', l,Lrl1r.scrrrne De i,,;l:r L1r.turr1eii. obicej capul este plasat intr-o atitudine cle anteflexie, ll;pr.r'1 iv rlc antellexie Si u$oari, rota-fie laterali (in tor"ticolis). In plus, lr6llrrrvrrlrnen-tinecapul intr-o ,,imobilitate ceremonioasi" (Yan Boo;rcri 1952).AcesI ci.trrclerde lurt icolis .,pcr'. -r Il:rrtirr, ltr28, cjlar.i de Rise.r'. firat, pufin schimbiior" 'i dunetos il diierculirzi 'i..iorl r:rrr,rrt. nl;r1i,', t,i{u)lislllFprsmodic (vezi ln continuale, ca,p' 0: Probleme de dilg'nosl,ic involuntare). Aceasl,Satitudine vicion,sXa capului iul.rlia, lniiqod,rilox irr rrr,rrr rr'prlzirt,ii, lrn somn precoc, care apare in tumorile subtentoriale, al.efosei rrlslr rliolrlc, intl eosebiale ventriculului al fY-Iea qi mult mai ral in st:rtliile qi rrle r,rcr|,icr,I,. trrmorilol rle unghi ponto-cerobelos ale emisferelor*grobe1,,.rs,.. Acr'lsth pozilie vicioasi, de ,to$icolis ceten:onios" trebuie dif,ercnli:rl,r rl,' Dozitiile licioase ale capulul consccttivo unor leziuni ale colo*uei prin morb .Pott cervica,i$i prin traumatisme ccrvirnle). trIxist;, irrrit,.,,s,.[i si riltrttii in oare unele tumori ale {osei posterioarermigrate spre rlr,hi;u} (,.r vir.rrlt)r'jrr gaura occipii,alS,unele neoformalii extra- sau intre,dnrlle po1,tlcl,errnina nn tortioolis ilaltc si mai rlr o hernie cliscal5, 1r.t,vigrrlr,lnsolit, t1e tt ledoa,ro dureroasi a mu;chiltir ceiei, a traputului l)rnrr,nrnl;, rleci, sti rglinem faptul ci, majorilulea caztrrilrt' iri rr rrrnii,nrlui.'l'r'ebttic, lTueori rahiatgia lipstq.te, nn sinl,tlc origine rounaticii, b&nalii,. ilrr lor'1icolis jllobilizrtl'ott tliftrzi"t,, acostiol' b(]lnilvi tr'{d)ui0 Irr rlrrrv rrl arflrzlnd(lor[r o crtttrllee ilrllll(ii{;o lttiltrttvt'ii, frr lttrr lrIrtt;itlii' ,ii Iir, Ii i,(rr1ii, lrtttllii, It'rttltrrr(it, lxrlrl;rr
i iLl l l \l i t, o r , t lt lr . t , blur rl rt' rts l i i l t,i i j tttl tri tttttl u irl t' l ti l l trl l ,t,trsi ttttctrtl i r(j ri l l i l l ri , lTl r

t't't

r{r rnolllino l)n |lt] }ioior', cin([ $e lirlicii, $uu oilrLltn{.rge,respcctiv atruDci r rrrl i{i i r.lir)i'r, irr:-riote. '."r'Dul - Jl,ellloxcle <le posturd, sint exagerate. ' Uitracterele contracturii imprimd, bolnavilor o serie de aspecte prr,r'l;iculare posturS, qi de migcare : atiiudine statuificatd, qi,,in sein de cle irrl,robure", mers rigial $i_cu alur5, tle ,,fug5, dupi centrul rle groutate,,, - Diminueazl la aclministrarea de scopolamini qi de substanle do Lip r[tropillic. -- Llipeltonia parkinsoniani, antreneazX disparilia unor sincinezii ronlule gi se insoleqte de o serig de sincinezii paradoxale, ca cte pild5,: lioxiunca precoce, anticipath a lungului supinator la inilierea flexiunii rrrrt;obla,{ului. faradicii, decontraclia musculari, se prorluce mai :. l)up5, teLanizarea" . lctri; rkrcit ln mugchiul normal, iar cronaxiile tind sii, se egalizeze. - In cursul ,,kineziilor paradoxale', hipertonia dimlnui| in mod net. -. I{ipertonia pa,tkinsoniand se insofeqte qi de diminuare& auiomalisnrrrlol rnotorii, plecum gi de bradikinezie. 1r) Sii nn gitnm combinaliile tariabile de h,ipertonie ectrapi,ramiilald, ti p irn,rn [d,ald.dtn sind,romul pseud,obulbar,combinalii1e d"e conlrq,ctul.d, si ,lr'.:tltusrne d,egeneresaenlele dill lt epato-Ienfiar,lare (boala, Iui Wilson gi pseurlo;rrllrrrzn lui Westpha;I-Striimpell) qi tlin d,istonia lenticulard,progresi,oii a I u,i, inhen-Oppenliedz % (spasmul ale torsiutre qi variani;ele acesttia),' rlistorz,iila dt, u|ittttline ilin sindroamele extr.lpiramiclale cornplexc, din sindroamele din 'lcrrl'r.r'ubrir"e. disronia musculolum deformausq.a. tl) Rigitlitutea ile deaerebrare, prin leziuni ale sistemelor reticulate rJlsrrcrxlontedin ca]ota mezencefalici este caracteristici,. Este vorba ds o r,orrlrlacturi, foarte puternic;, a membrelor, a, capului qi a ceiei, care este rrrir.jola1,ii, diminuati, prin schirnb)i,rilede pozilie ale capului (fenomesau rrrrl Lui l\Iagnus qi De Klejn). Crizele de rigiditate prin decerebrare realizi,l,zi, t> hiperextensie a capului $i a coloanei, extensia membrelor infeliol,r'e, in vLeme ce pozilia membrelor superioare este variabil5, (in flexie, rlir,r'rnti ales in extensie). Se insoleqte de reflexe tonice cervicale si labirinlicc. Il,igiditi.tite prin decerebrare pot fi reatizate cle procese rliferile (tumo|rrlrr, irrfocilioase,vasculare, tra;Lrmatice)care iDtereseazd, incleosebi calota rrrczcr rccfirlicii, sau structudle vecine (epifiza, tuberculii quadrigemeni). rr) Arseni (1950) :i, d.escris crise untriculare au a,spectde rigidi,tate dwtLrelnald, tumori cerebrale cu variate localizS,ri: in -- '{umori rio fosi, posterioa,ri, (50/6,respectiv ulterior 90/6). - 'I'umori ventriculare (23%, respectiy r;Jtarior 271): turnori de glllrlir, pineali, turnori d.o yentricul al Ilf-lea, tumori de ventricul latoral orr rlivorse localiz[ri. - Tumori supratentoriale asociate cu angejd,ri do Iob temporal. ln gloamele frontale profulrde, care prind peretele ventricular, ln tumori sau hemoragii extinse pe scoarla cerebra15,, situato bila(henatoame cronice subtirrale bilaterale, tumori parieto-occipitale h,,r'rr,l lrilrri,rrlc). I)rrpir,Arseni (1950) $i Arseni qi colab. (1978) cxizele ventriculare nu rrn r!$poottipic de rigiditate decerebratd,,intrucit membrele superioare sint rlo colo rnl,i rnrrlto oli in hipedlcxie qi nu in hiperextensie. Pe de alt5, pa,rte, rlcrsl,o liu'o clizc vor)l;r'i0u itpitl bnlsc, la sohimbnfc:r, pozi!ie, petrtrn ctr, d.e sri ltrlczrr irrurlirilco lrolrrrr,vttl crrlcii.l)in obsct ptczcnl,rr,te Arsorri se vn{,iilc rlo (llllt(l) iii Alsr,rri colrIl]. (ll]?lt) rr,iirsrr i,orr1,tr cii, rrrizolri hiprrrl,rrrrirr rlo prrxllss 1i lTrl

rl r, i ,trrtotrl r. rr rl rrrri r ' l x li{ lr r l( f l" vr '||||iI I ||r t I r it t l ir lr 't r ii|r ', ilr llil, t r 't t I r lt ' vr tt r r' l ;rl l i r l ol )r,i " r 'it lr r ir r ; r u'r l, ot r t , r 'lr I iit r r l pt r r r lt iscr ll it 'ilr r ( ir r llt 't t '1( 'llt tlclr it L r ,rrl rrt, rl i tt crr t r zr rpt t lt t t lr it liiI r t lt it llr xlir lt r r r ir l t lit t lit r t lr t t i st r lt it t t lr iit ii lt ozt ) r i l r, i l rtl tttl t.ti . Aocslc r , t izc sit r l, t lr r lir , [ r {' r lizr r r '1t ilr '; ri( 'r l . . t] ' I i (I | | I i r I I r ' ( \ r 'il( 'r r t i l oLrb., l {}7ii) . l )rrpi i , A rs t ui ; i ur lr r ll. ( t {) Tl: i) r liagr r osiicit l t lt r lt t t t t r t t r 'i\ t ' t t I t i l t t I rrt rI rl l rrrrrl rr .l l l i l i pc hlzl pr t : zen! oi llt t t xf it r cr jzo ( lo l] ilnr t l, r , lt ic, it t r r li l, , r 'r r li r r r ', , Itrtttot'[:r taoe rlupit cclehlte sitrrptotntt tlrrtlltt'rt;ttlc(l(r iol](tglliIiir l)l!rIr'ill se l r,i I rU rro| rrl, t lr r llr t , ur n ur m ( , r ! zi : (lrizclc prot'luse t1e tumolile tltr liosi, posLt:r'iolrii ltttplir,rr r1i gtrrr,' irrllrrrrili caldio-r'espiratorii (brattior,rtlic, puls net'cgultlt ctr vrttirt{ii trrpirl, ,rri l rrr,crrsualeclela60 120/ m in. r espiur , l, ienet eguht r i( let ip( 'lr Yr r ( 'Slr r lilr . l nl i ,l r' o sau cianozi) , pr ecur n qi it npor t lnt c m at r ilir st lil i ( lf lr il) ( 'r lr 'lliilr lr " rrl lurrranianfi ;i fenonene cerebeloase. - f izele plotluse de l'urlolilc fiuntale ca,rc ilfc(icrizii pt'rr'lrrlt' t t'ttltt , Lrlrr sint deseori asociate cu;rierderi alo cunostilrtci 1i ctt lttllrttliiti prrr lrilc do l.ip frontal. Crizele de vtnl,r'ioul al III'Ie:t, se insolcse de li'tttittrcrrt ltiJxrlrt,lrttrtr.r' rl rlc crize convr sive cu pierderea cunoittintei. C ri ze le clc yent r icul lal, er al ss inso{csc de ir llspir ': r ( ii, t t t ir lt ir t r : r i pirrost'ezii in rflcmble. 'i) Contr&ctur'ile psihogene : ;'lindromul, catalitic (al lui, Kaltlbaun, lt K'rappdin ) Htr t'rtlrtt'lt'r'tzt:tzr lrlirrl,r.o imobilitate prelungiti, cu durate do ore sau tlc zilo rt l rrrl t rrr t t t l t t t . (':uc pirstreazd, o atitudinc catapleai,icX ,.qitegativistii. l't't irtrlit', :r,r'rrirlrr r1:rro orltatonici poate fi inlocLritl de sl,ili de agillt{io, trtt it t t I t t rlsi rt t rt ,t :r;1r'r'sivitete.i,ipsa sennelor neluologice obicctivo, pt(x,tlrtr \'i t rtIrtlIctttI trrrrr,i.ionalqi pasager elirnilS ul gindron extra,Iit iulli(lll I siur rtllrt irttl, rrlii olg:rnicd, a, sistemului nervcs. ' (lontTactx$a (hiperlonia) piliat'icd, se iirrpurie oi} tlll (r])i[r'lr(]frl, ttrlt tttL tt , r'rrt crt semiologjc crrncieristic cu ccloraturS, nevroticil. ,1.2.2.3. Contt&atur'il.e re.fLere,locale pot sit apari' itr alltilr', rt,tlttrirr'. ,lirllsu adec.tiuli viscerale, precrim ;i in unelo sittt:lrtttrxr t,rt'ttzlt,lgic,' il tji (lrttl{.rlttl ,rfir ziBul sindrom extenso-progresiv a,l lui Sic:r,rrl ;i llrurr!. ,'lirri(1 r.ste I eYela,t0r'.

fl

ir.J. l'liolr!,l,li\ll,i lrlA{iN{)s'l'l(l l,l'l'll}l'A'l'l)(il'lNl(i'l\)l'{)(illAIl(l lrl,l sl

i i rr pl rr,,l , ir llrt t t t t t ologicii t llr t gt r oslilr t ll t t t t t r i lt l, it r ii slr lt lt zr r : t zr lr r l t r lllr r ill trr r rr"r' .rtrrc| ,r' It tlt t o1t r it t lt l lcslr lclivli ir r I I r t t ll'ili t lt r t r r r ot t lot t lt t t ', 'i li p" i r, l c rl rr l Irrott t I llt I r ir r t r t t t t 1; I t ' r r t t t t t 'r lt t l t r lit lic. si i i .!.1. A l, r t {i plir r lullr r r r iir i dr , sot r sihilillt r r plopr ir N'r 'plivii ir l\ r 'l ir l ,.ri rrrri1l 1l i l i , r 'icr rsr t t t t xr t t l; t r t lt cr t t r it t t t 't t 'r 't t : t zi, lilikr st r r lsilr ililii{ii 1I t I r I t t t r t I r ' ,)rrri l i rfIl l o, it ( 1 00t '0llt t r t l it c{'sli( ) ]lt llblllili pr r t plilxllr pf iVr r . r \ t r t 'r t si: ir r i r r '' [i i ur,Il i trl l ri i r,l rlor t t egr r idclt : pr t ; liir ilt '; ir r , r lt u|ogllt i'it 'r 'lt t 'ir t lr ilii ( ut 't t llr t lt zr r lr r . sl l irlrl;r'rt;rri rti t tt t r. r I r , lr, 1)lli{ri,i rlllrtnilind la mctn}lnrl,: inferioltlc) lrt '!o ( r,' r' rrrl , 0fi vililiikr lnot or ii. [ n 0lr t t lilc t lisr , r 'el] , pr ohclr lni if r t t t lil't {'r r I r lr r l ,,i l rl totl rxtl i ti t: ust 'l; ili. l! st cir npr ) t t lr n1, ( lr t r ol, ; in t r 'i, t nilt r llt t l cslt 't " r 'r 'r "1" i ,rl .r i i rci i tl e lir incl'put nl i) cost eiil:dir coljI ge i] r llliiiiir i{l r r ll, 'r '; r lr ir r r r r ir l' l I r' r ,J!l rl rl U l rl ri )ttar vllrti't spct c'r , ir .ou im pr ) 1iil] 11olcvil{, ii ir r r iit 'ot r t 'lr rsr , r r r r t r r 'r'r l e, iI sillL in : 11f il] . lit t t 'lr 't t r t 'r t l, I I I t , ) I I I I I || i i l rrl i i :r-rk: ir cll [ t , ] , Lo int r - t ul sot ls llr ,.rrrilrlirgic {ri,t,.'laplu1 ci ve{1ereii, corcstelrzintlLlbrrllii'ilo tle crxr|riottrttrr Drirr l]| 1rr', ior':cepf is fi cir, ocluzia, oohilall' le agr|lvl::t'zii l)itt rtct'rl' ltrolir, rp; (rriil'rrr rr',rlrr lrti Hornberg cste pozitivil irl il toalo plrtbole rlo rr.l,rt''rirr ,' r.rrrrrchi , i lnl- ) ar eiicilloiir ilui pc cr ellst l! t iLlici, ?r ol) il, cor cillui, l) t ol, I i! lr lr r pl I l i ri r,.i r,)oi l uzi. l ochiir , r rr nlir elt e cvjdent ( r t r lt : oli chiat t r ot t sir lt , t r t lr il) r t llr r r rl0 c,-{rt,:i0u&tit. ,,!( i i c rn:l j it sociazi' cle obicei li bilot onic m lr soulr r iu si, r lt r t t t t r ll"'t i, cttttsrrttittl(.rrl,' sitiii (lc i]sotll{)rt(iir rr iL.lier clsi;eo tefr[iiuoe,si,, fenourene ci-!.r'c pt'oftrntle. , jri i t irii ciiilot selsibilitirtii ilsto important tle relinut c[ lipsesc amr)tolilo 1i ttisl'rtgrttttstri. trrl , o, iliit':r, e$te Iloln][1i. :j.2.!.j" ;\t.t+tLitr, ilLsolitti d,e drelleaie osteotend'inortld litiioij t I t rt r;r I , ' ,, r, I , rrrr lrlcme cli;rgnosf ice ; Si: t. Poli.rir r"iti,le {. 1.talineurol.tatiifu. insolcsc 1i rltr irrirrrsl,r'zii,rll i'rrl ,rrr':ilt titr stn$ibilittte oblcctive cu disl,ril)rti.io p1li{lorllil}ililii t rt I1t rtt rtr' I it ' I t r lc rri i i ' ).up(r' l ioiit lc,ci1,li piot ulll1o) , t le iilcf ler ie oslic( )1, ol] ( lilr r ) r r $il, r llli ,,iir. rrrotorii (i[l iicterist'ioe, ova'l]tua] isi de aiil{}1ii. []tttrlrt'i tilltsivilrtl'rrrr I'rtl ici l,Iriirilol i'ie scnsibiliti],to profund:i ;i il itLlr,x Irr:rlizr,rtzri, ,,pscrt{lo I'irl}rlrrrl pr,lilrlic". .Durerile la presiunea fira$elol ltlllscullu() iii lil lrrcsitlt tolt,1,lltrrrllrI rl ,il,,r' rrervoase sin1, consttllto. .A1bc somnc (li[ ctt)l,()\t'lll s(rrl)iologir' $rlri e1;ioktgio. r l i l(' li';rftru. stabiliroa diagnosticultli !: Po!,i,rtil'icutonet)ri,tale lrrtruncso irr trrl)lolll sotttirtlogitr, 1rl ltttl;:r trr,rtirrr r,r'rr li ,.Ir.rrr, .I i i;{i I t I gxI.lIse atr]l,oriol,pozitjivital,e& scmne]rl rlti ckrrrgrr,{,io rri nrl | otnrr l licir idi, r ,r r pl ; ognot uonic polL{t r t jt it r dr {) m lr l ( }llillir ir ] - ll: r 'r 'r 'r ') ;i l i l t,rl tl . srr il. ;Jin,thonuJ meduLu'rtlt Jibtt luugi (d, d)nl t,tt: po:tlcrio4l'1r) trrrt:trr I I'it (rrl Itt tr,t::tzi\, rxtrlttsiv pI'ilt l,uIbulilri tic sttrsriLilitrrtc pt'trluttrlii (()lI$1,i1I ' r ( pr r r llr lt r t inllt t l, l'i,lu {) x( t ur jil ii lit , t r t t t t r br l'llr it r lir t 'ir r lr , t rt')r st rrrrl rot t1trl i l , ii, l, 1xic tr t l, iI .l rr rrtr' l ' l trxiir oslr 00- kr lt t lir ur asii, . $of , ( , r lr t t r r I il0 llt I ) r c$it lil( f r , t t lt t ^ioI ot t t t t ir 't t t iI l rr| r. ;i :r, L| t t t t oI t it t t ot lr ( : lvi) it sr '' lr l'( '( t llllli1i l: t , Lr l0t r gll{ilt 'iir I I 'ir I it r iLt t llr t i ) ' l \t,lnt r . l,r ) : lliz( lir zii'col t t t : t 'i lt r r lct t l' i, r r lt lt t t r lr r r ir r lir t ilr ( ii, r lr I t r I r r I t t t r '
( j l l tr r .r l l : l l tl t\i r i r ( i l l :t,ttl l l t'r i tt ti i r :tt :r l l r r 'i tl tttl tl r tl t' l tti 'r t tr l t t"tt 116llr1;i9lt,trr, t' r r r '{t|t p l |zt'ttl l r i l r . r r r r r r r l l u i i \l g r r l l ti ,o |r r r |Ii r o tI) r l l l r f( r l l l tl l i l i !r 'l l l 'l l i l l t tt lrl olrilli i l l i l l i l i i r l ( r r zr i r i l I,'Ittt':Il t:t l t'ttl l r tr '1 i tr ';ti l , r r r , r r i r r 1 1 r . r ,lp r '( 'r l r ( r '.

6.

pnosr,Eurg DIAGT,{osrrc D0 IN ATAXIi

5.1. pR0EtEt{}N DE tttiT0l]Ol0clti

SEMIOL0L}I0I

Ptntru aprecierea serniologicii,;i topograficii, a unei ataxii , r',1)rrn o serio de con{lili,i, lnetodoLogice enatnen: d,e /, lu:iinfe de toate rrebnitl apleciati, sterel r,l conltiot{i,. Sc e ;tie eii, ))rr{rl{lr1irl, htntc:lrca proceselol psihice,obnub.ilareaqi dezorientaleRnu l)r.r'i||il (j Trlni ccorrlonare a rtriscririlor., ci,cirril astfcl, t|tleser, rlell1tc in I or.(.i{'tlrit,cxi).ottr a probelor cle ccortlonl-r,rc. i.l. l_)'ticitelemotorii pril tcziuni a,ie neuLonului motor periferic sau rir Irrrioiculeloi.piramidale poi co litiona rt) mcls ezitant, rlificil, 1cnt, 1rrlirr lrrrlonios, precuur qi ,,falsd,"incoorrlona,r,ernisci,rilol pril tlicctiu,ea a rrris|r'l|ilLrr lctive sr:gmentare. .'i. I'Iisciirilc involuntare pot parr.zita rlano.vrele de coorilonrre. .1. Ilrtcizi:r, unei misci,ri poatc Ii, r.Leascr:renca,pertrLrbati, printr-o rrrlr,rr'(rrrtri, tnlbura,rede tonus muscula,r,regltr,rea tonic:i a atitudinii si a rrrisr.ri'ii l'iinll unul rliatre factorii edenliali ai coortlollrii. Atil hipoto;iile rrrrrrr,rrLtrrrr ;i corLtra,ctLrlile cit (pirarnidale qi extr:.Lpilarnitlale) pot sd perIrr|lrr. r'recutalca perfeeti. a unol migcilt.i,creincl impresia _ clacii, sin_ nu l.r.rrrr l,r'tr{;i cd, este vorba qi rier r: tulburlre cle coordonare l. inlinte de a trpreci:r, tulburale do coordonaro tirebuie s:i eliminilm o (| ( vctrtullt:r, astazo-abazie (func{ion:r,lir, sau orgl,nici), plecurn rii gi un irrrir ri st'rniologicz1 unui sindrom psenilobdbar. /i, ,\tr,xi:1, tr.ebuio totdea rma si, fie diferenliati de o apraxie (indeosobi rrI|IrIrr|itr)r (iilt,cse coltuldri adcscl l2t, cu rn etianten supedicial. i. itr s1i'sii, i'l:l!:r u'eri lrlrtrii sc i'rptlne examen sistcrn,t,i.r I 1;ipttlui itftrsjc (l)r,i)r rlc l,(.|llr r l)r'o(ji(,rorr liultl[t1it,i 'n ser]siltilitli{ii :r,le pt,op|io.o1ll,ivr., srrri Dr,irrlfzitrrri t.,.Lrrrlr.l,rrsr^ ir,sl,i ll |l), ll topog|lfioi llirr,xioi ..ltr r{ili'ii, rlrrrr.r'rrlizlrtrii l:r Irr r.iirgr|l 11(iirrr lrru .,i nrclrrbltt), r:llrrlrtlrri :r, irr{r,rrrl
rriilrlri :lrr.,r.i lJllr (sl,rrl, r c r , r lir r t r r r ir li ; lr l , r r lr i, r . il: tl l I r I rI I I i i (rri i,I r ) ,

tI

IrI r' r' \ if I r'i' lir|rrrclt,trrrl,rr llririrr. (Jlizr'ltr qi rlrr viscclllc sirri, rnultu oli ul ilrr rltr ' rrr |! |\,r' IIi t (,,| |.( lt0rrLrrrrliagllosl,itr. ' h) Ato,r'ti.le priri l,,ziurri^ alc co.rluune]or posterio..rrc (rnklliLe, _aauta trrl)t1.siuni merlula:'e, cpidurifl,) sint mrc. ' , ) .4.l.tp.le:;uni Jihrelor lrragi so por iulilni in: aLe \tndrolnuI ncuroonemic poi]le rFcuouagle sc prin : arbilie Eastricf. :rrr.rrrir. lripercromi, scmn{,de c,trrluane posteliolre, *reflexie o-ri;;;:;_ rlirrorrslelil oare ins5,se adaugd, qi semne de cordoan6 Uterate lsimpioine p ilrrrnitl:llc). . - Nind,romul nauroachilic.. hipocloftirlde qi achilie, semne de cor(l,i'x.. postcrioare, de obicei cu sellne mai pulin impurl,ante tle co*loan. liri,'r'irlr'. L[e]nulle oli gi r.u scmncdp potionrroriuii". d:rr Iloala Iui F riedreiah. intrunc.le rrn minrrnr.bi ,re simptorncpcrti_ (,ulirr,(!; caracter ere.1o-familial, .fenomene-cordonale posteri6aro (itaxie Lrlbctifomi,, tulburiri de sensibilitate profurrdd, hipotoinic, a,reflexie osteo_ Lendimas5,),semne de leziune a f:mciculelor spino:cerebeioaseqi eventual rr corebelului.(cu ataxie cerebeloasi, tulburiri de echiiibru, adia,docotrrij lilil:]Jii^lll I:, tremor inlentional, t ul bu r:tti de vorb ire), semne pira,m idale. u||rrnran trotlce (cllo-scoliozd,, picior scobil-cu deg..fe In cioca:r;, uncori ,i jrlrri',llotii dc tip Aran-Ducbcnnesau C.ha lcotl:\[lrlie. Itrred,o-ataaia cerebeloasd,- lui pierre Mq,rie asociazd pe prim plnn a sr,rnrro,cereboloase pira,midale, simptomcie cortlonale posterioare {iind qi rIU (l tscrete. .,lantiliald Btrilm?elt L(rr&,in. prezintii, exceplional dc ..... ,!o:!!trSia I i|| .ir stn]pto_mecoldonale posterioare, sitir:r,lie in care *taxia este mixtii (, r,.lx'1,' coftjona15 r pe plari securrdrr' [u1iirle "alrlnoa"zi piramid:rLt. ),^.dJ pri,.rplegia ' I)lsl,azia.0rcJlettcd aongrnitald Ruusq_Lirg un sind|our , ,,lr]llli r,posrerlor. (cu ,1i rrefle-ri{] ostco-tendinoasii,), apXmt in ((tr,ollrcel)s ^li,tltxilr pube]'tiite.Oaltcte|ul e,redofa,rdlial, intintc de '.,)l,ii;rr're evo_ lrt{,ii! benigni, si asocierea uneor.i de niotrofic sitaeazf, ace,,st''atoc^ai o formd, de trecere int,r,cboeirr lui (rntc clr Fricrlreich si boaia Oharcot, l\!rrt'ir^. tt.:!.1.2. Hemiataniile rru, tulbu.r.dr de se sibil itale i Ttn,jundd, d,ar ur, rqfktn. ost,eo-te,nd,inoo.se eonseraate ridicii urrlilolrele proilcine ile'rliagnoslil iop''gr'.rIi.si eliup.riog.,nic: ' 4taria pariclald esle. produoi prin leziuui vascull,re, tumorale, trau.l. rtril,lr(,,(r rlc..:rle eircrtmcolufiei pa::ietalc asr-,endente :r pnriec[iiior pe slu (i'nl( \Lul semiologic :rr'.':rqlii iiirrrrr'. ri inrIrureitclulbrlr;fi d-escn-ibilitale rrri l r' (rlur ctr prcrlomina profunrlur, h,.mi:, x ie, nstereognUzie, de r nli-L tl dar rrrllr, ofl Fr-altcsjmptornode localizrr'. l,arjctald, j{rckdoniene scnzi_ {cl.izr. r rvt, rilllr ol il' sr[zrttvomotorii, apt&xie, hemiasom* tognozie, hemianopsie). l. Ag*ig talamind, (din talamic al .lui Ddj6rine-Roussy) -sindrornul rrlllr. continlatr'al leziunii (de obicei vasculare sau tumolale) nucleif;, lrrlunllcl luterah, insotindu-sc de hetnianestcziep}ofrurdd importrnt; fi pr.r',ristr,nti, algii de tip hipel'palic (.,overrea ctiorr" .- EIcrrI-;i Eobnei) _rle t|o ruttcIln coreo-3.col,ozl0o. ir S..l.Alnniile pedunaulo-pontu-bulbare. r)ivel'scprocesepatologice(l,umoril lilrnrrrHri\jnt:c, tlctnot.t.glt) lucitliziLh)iit ctlola truuCbinlUi cercbral pot trrr,lizll,.dilr(lr()ir.lrlrr iLlt0r'nrrr cotrt,,rtul {)ilr'orir, intilrr,'sc ryi trrllruril.rid.o itr dr d.nBlrDlrtirt(' prr,ll||r(lil rr"lirrir,. crr Ar:orrLrr ilirxlr0rutrc iIll{'ln0 pot ,rr itrrp)ice propri(n1r,lltivo, qi rlrr lilr crrrrrholos, (tlrol,ilnt:t,i)hrr rr,lll; rr,1'lrrii cil l,l ti)l)r)t82

[ nrrtrzilivii oHit!i l l l ' t l l t' i rlil l J , o*1r, ;.1nr,lio ;lrltIicttItr't:rr vl\rlrlr trtt ltt,tttiitltlriit qti plttl,trtrtl lt'zitltttrit' rrtt ltrzi (tltrttlt'r'rt,'1i rrr.trrlrr'|trtsli, tlitrrci'ii t'slo Irorrrirtl,rrrirl ltr rrriLr lrrLvilot rrtlrtritrtti), oxcrp(il sitrrrriiikrltlo llrzitttti or ;tt',tltttttrttllttr', ltti rlttltii,iturlttci;rtt'tta, Wtrl'Ittrkitth. rrirr'lul rrrrclrrtrltti ro1tL, srr,tt nl it' 5.it.P. Ataxia voltibulard cslo t'cz l,rt,ttt Iozirrnilol nclvtrltti, rrlrrtLr'iilot' t.lc plitt t,Lrlburrili rLir{,ittttrr rt rrlo ttuclcilol vesl,il)ttla,ri $o (,rl,r'rt c t olizcrlzi-"t Ii illil,inh)'illill)rri fil'll iii rlo rncls, cu oscil&tii ryiou tlcvit,tt in lcchqi scrrsr lezinttij. r'\'io rtsrxrirr.zri lrr,lolrrl, l'Lrncltic trivchtl, rlc tilrul ;i tlo rrrtsivitrltea' irL r[e rr sorllu lionrberg pozitiv (olcmont impoltant (le dilglloslic)t l)tll(lttrrriii rrislrry4rnus ame.teli. Este ul,il de lctinul, lrytu1 c:i sensibilitiitt(]a,pt'ol]l'irt $i crrplivtr, reflcxclo osteo-tendinoase, probelc de r:oordonarc qi volbit'trrr,ttittl' rrorntlllc.Ata,xia vosiibularii,nu uroclific5, mi$ci,riloizolttc alo tnctttlrtr'lrrt ryi, rir, ;r,1;N,r'or doosebirede bolnavii cerebeloqi, sindloatnclc vtrsl,iltttlrrt'r, in spre rrrr sc constati, tulburd,ri scgmentare de coordonalc. :rpiitittll lit lroltrrtti 5.9.3, Ataxifl cerebeloasise recunoaqteuqor, o1,r, ,rrrrr rLu ptezintl nici tulburi,ri obiecti\-e dr: scnsibilil,rr,to, ttici sitttltl,ottto vrsl,ibulare. 5.2.3.1, Sumar de d,ata senziologice Sindromutr oarebelos om se cari,cterizeazh prin trei gt'upo ttrtli rlrr la f lt ptomg : l!., Ata*ia asrabalaasd' traduce plin urmltoarele sorrrilo: se L Dismetuia consti, intr-o dimensionare grcqitii, n, uriqc:irilot', lxrltrrr, vrrl neliind capabil s5,ajungi, la linti, in sensul ci firi o depflqolto (ltipttr rrrotrie), fie se opreqte inaintea lintei (hipometrie). Ilsl,e itnpot tilnl, tlr,, ptl r,izrr,tcL bolnavul nu eziti, la polnilea niigci,rii, crt tttitxioul pclilirt'ic, rut,rt ol posed5,, toat; tlismetria qi tremurdtura inten.tionalii, tlirect,iu,gcttr^r'rtlrr' cu rr, rrriqcii,rii,Dismetria se examineazii, prin umttoarele plobe : a) Proba i,ndice-nas. I-.,a solicitarea de a-gi duce indexul lrr, vit l'lrl rlrsului, bolnavul so oprEte inailte de !int6,, sau trece dincolo tlo ott,, iz birrdu-qi degetele de obraz, de frunte sau de ochi. Direclia genclalit itti!inln, :r, rniqcirii nu este alteratd,, iar ocluziunea ochilor nu influonleazfi, trrlbrrnrlea, s b) Proba sti,ol,ad D. a, g6,tul/ui'slrlolBd.Cerebolo$ul nu izbutoiito sii,-tti irrt;r'oduci tlegetul in ori.ficiul unoi sticlor sau uu e in stare sX,apuco glttrl sl,iolei. el dmerind al6turi, ci Probd, iniliaa-inilioa. Bolnavul cr oshii inchiqir nu esto ca,pabil Brt, {i rr,plopioin mod corect Yirfurilo celor doud dcgete inilicatoa,ro. ' 11 frobo Linidlor paral.ele. Se traseaz6 dou6, linii Yorticalor bolrtilvttl l'iind solicitat st tragi o linio orizonta,lfi, lntro aoo$toa, Oerobolosul nu r4o iilr,rl lxnllre opri exact la nivelul liniei vortioale tlin droapta' oi o alop6qo[t,o' r{r ODrcgtoinailtoa, oi. - 'Proba prekenaiunii (eatt poharului), IJa solicitaroa do a apuctt }ltltrr, a) rrrl, po de o p rte cerebolosul tlop5gogtesau nu ajungo pahar'[l' po (lo olltl, p:r,r'to minil tui so deschidemai mul[ docit ests nocos&r. l.) Proba p notului. Solioitlnd bolua,vul s[ faol un purtot rlu ol'oiorlul' slth rxurbolosul tl oxecutS,diticit, frloiltlu-I tlin mai multo liniir introt{,i1t1,o forrnil unoi gtolo. g) Pruba lotisului', Sot'i*ul oolobolosului orl,o tlifttt'trt, tlt'ntttrlttnttl,, lit,ololo Iiinrl rnlt'i, ttutogulilltt, itrttgtrltr. lB3

ttttlun,lt,i lrr rlcrrrbjLrlor.srrl, ririscrr.r,cii ,r pllll{f,ilijl u(f ! ,,,,,tt.!..t..":.,,,,,.'::.: rr. laCoCUdCpl;ilr:a rrrrrlfr' .1( llrllr(il,i,i (,[rrrs lrrtl SltitOLl riirt,ile* t:ii,:t til]tri iA r :'lrirr rl,'r'i rii.r'rl rniqcliri de e.resaie, 'boi"""oi p"ot" olrogegenuntrriur" ,i tt i'nrtu 7tr'ir,bd'r'i,i cdrcti.*ru,i creastatibiei.-ra eri,rurarca ti. rnispe ,. {':r |.' lltco <_ru CiLractel,feStonat, oSCilatii. uu cU !. l rliutloc.ohi,neaia ( Disctiadocokinezig) 'con$,j, in tncapacrtilto.i , rr .r.r,rri.ir.t'ifcL.i rl. altel:lratiye-succ.sive. e:rploreazi,.u aJuiorul urxnat_ S6 iltr 11l9t' llrobc : t) .l?rohannrioneteloy. Bolna''i cste solicitati s.i,facii, titi$cxri :iltrer_ rrrr\'(, (1.9 pr.onalie-supimlie altel.nal,rvii _rlc irnlebralelor,,prin :rtixgel,e& rr t,or| soi cI pe mele, apoi cu dosrrl rniinrior. De p'artea bo.frraYd, rniqcl,ltlr, si, , rcrrriiu irrtr-un r.itm mai lenf, mali glloi, inteie.dinil o sc o pa,orii,,r,a,,,, , , mjsciiulor succlsive, sau notnavil-gre|e;te rniqclrc:r ' i]i.,.;:jilr-" i,n":ilca " it i'h)aa JkrtutllL ;i entensiunii clegetelor zr.dla'd. constati rrceasi Se , ,rrtrr'zr,rr. sru gJrc6ir,e miqci,rii de partla bollavi,. a r ) 1'r^br. baterii tobei ca" Bolnavul os1,e solicit&t si loyeascil .d,e.1tetele. r)rririr (iu {iegetele aubelor miini, const:r,tinA"_su ac""rr.i-luburr,.e Lo-r*iiii Itl)l,1.lo procedente, })r.abaJleriunii dorsale gi Ttlantare ct,p icioarelot. lJolnaml yl irr_ , .rl) r-ll|l.\J gloci r.rzri', miscar,.xll tnt.tDbrul pitt.u l,,zifririr. rlc ,,. .rrLnerataconstt in imposibilii;atea de a, coordona artiunea tlifc_ r il /'l{n glupi trusculare in vede-reaexecuti.rii . |{ 1, rIril(r}ilo ('rnrplerc..se tlesconpun in cornponentele cornplexc. Ast, ";"ir;,ii;j; 1or clemeul,iue. sr)&te(proha asinergigi sratioe a tui Babinski). ,,. |lr{r(|nr)r.tnal, |,, ,,'.'..!,_':,.:":::,:o:y:"!:::::!, pe spale compolti, rasl,urntret flexiunea asociat[,,conco_ rrrrl.rrl,r'1r trunchiul.ui;i a mimbi.elor infei,ioare rlin genunohi. a Cerebetosrit (lrlfrxlurl)une miqcarea qi la accasti,probi lipseqte tt&iunea ga,mbelord ir: :'r'rrrrrrclri, incit cerebelosul cade pe spatc. pe gi a ao*pseipe bazm, \probli" cnl_ fk.rtunii gaml.,ei irr ,.1,)-,['rabo -ioapsZ tir,:r) sr. erecu15, decrrbit. rlorsal. ielebel6sul -rlescompune in aceasti rrriqrr,:rro, sensul cd,intr-un prim timp va 1iace irr it"r,lo"".ni tirlicil_ peplanul fatutrri 6ihou" i" uf a-rir",ii*p rr.,:{rea,sii "ou1rrni, fle, l,il.ii 1',,1y,.!^,:lt.de
\ |l | ||('li g,at]'t bet.

( r r l 1 ' l l r j \'l r l r ' l l l r l l tl l l r l ' r r i r 'r r I r o r r : r I r r, ( l r tr l l r l ,u i r ' ,r r l r , :r l l l .tl ttt,:t l l r r j i l ttl tti , , , , r . 1 1 r r l r r ( r , r r i l .t|i l i r r l r r l tt tr t|l i r r l o ti l r r l i t' ( l i l r r r r r r l r l t|i 1 i i l t0 u l l l r r ) . , ( r !|III\ |I|||III I h l t:u l l . f i i t t t . ltl .tttr t.t tl u l u t't's ,i l t'n t'r r . Atr csl ,<'i t,:l l tr tt tl l ti r tti l l l l , , r r l i " s l , t i n i l t . r l i l l tl ctr r tr l r r r l 1 i l r l l l tl l tl ,ttL vcsl ,i l l l tl l t,t ! . t l s ! , u ,|'i qo o tti l i ,i , i ttl 'r 'o i tr si 'a b i l i ta ,i ;tl , cl n 'tl r ttt l r r r l tl ti k'tl r ( 'tl l l tr r 'r 'r 'i t r l l i l , r r , r r i i v e l 'l , i c lftl . [i o l l tl tvtt! ttsci l 0 l tzi i tt l l tl l l r r sl 'ttstttj l tr tr tt l 'tl ttr cl ti tr l , l ttl l r l ,,1,li1";i,li bitzii, tItt sLtstclll,aliiu. OsciLrt,('iiltrlttl L;oLlpt itttIrr st t'r' I t' sii,-$i l)rii,r'oru;ol"l

ului Ill na,s. "o1lrtni $i ') ,L'r'tha mrrsulu,.i-Iipsind coordonar,*r intro acl,ilnea srrmrttanii, :r . tlitn(,lt)utu1 $i .1 membrelor irifcrionre, in timpul mersului, I i.:,,11.,i11. r':,. Nr\rit(.{. i'Jzil,(,e sustcntajie lniritd,,_trunchill c* ll]nlne in urm' fali ,l( rrr1'rrl)r'c, incit, bolnavul poate chiar criit"a p" sl,ate.-- ./. I)il1,oli1iituiburii,rilor de ccordonare .^"o pot irLteresa, mu;chii si l,'lrirl,rri, t,trbirea asle rltclaii (sacadarI sarr exnlozivij. 'l'ttt i lIirrea izolt-r,1, rrSUr.r:Ila {liS_ r:rrr CU , '. ,utd.lato tpn!iotul.i..Po:rlo . : t lilii
ri' , | lr' . t,.il flr.t tllc lI: ll dt

lrr.r' irrl,ii. :r}ducfia braf'lui $i abia,apoi fiexiune:i n"i"t rrrlr.r

, , . ' , !':'.:!': ' r,| ': r:, r ir i ( . c t c t eos i u ti tp U x e to a l x i t(.ti i .i i , i n Scn.u I C ri i l l p | i rnu l I.i mn face rrr .rrrr. rr'r { ar ir l|5c r p e l l rz l rl c u n rc ml j ru l i n f| r.i o r t,xti ni qi i bi e i n rl ci oj l er" i I i ) r : l( , i r ' \ r unc a g i rm h c i p e c o tT ]J i ' i . rl1. I\.olxr, ind,ice-nas. Li a_ceasid,miD&r,re so observi, cri ce'ebelosul dii;;;;

',

o .:l,l!!'L'-n;cigrutui sasva{rJ inf ' rz it i. o t lu s t rri' i). s { ' pe

:!. llcrsuL cstc ebriosr ezita,nt qi titubant. lJolltr vji lul Pr)l l)iisl rrr lt'rrii , rrrrl{ri, in trinlul rnelsului, ci deviazti ii a,ubinza do s ustol lljill,i{r llrirtrlrr' I r, r' rl r :rnl ,t t lit elo s'lu r et r opulsia. I r oba r net sulr t i it t slt r a. r it t r it r ir l r 1r ,i rrl l oi ' u1 vt r st ibular , I oat s ?la r elalii p: lt o1, gicc, bolr t r t vt t l t l. t 'iit t r l r r ' r, ri rottstanl de partea leziunii cerebeloase' ii. lr eftijlrl ,,:i nlStugmusuL L.r, un cerebelOS intliCii lcziLLttcrt,t urt I t . r i I t t r rI 0 I , r'r*lrrlo-vcstibuliile. 4. Proba tlet:ieri'ibra,telor. Br*lele tlevia,zil dc- partcil ltrzitttrii rrrrlr'lr' l,)irri', sl,u i1e partca emislerului cerc,belosccl mai lczlt. 4t.. 't'ulbu,itiri care se ea:plicd, ?rin alter&red a,JerenleLoryropt"irtLttplirt : l .H i potoni*'m 't Lscul&/ ii. Secar act er izeaziipr inllascidii'r t 'l; t 'r t t t t r t s|t t ,lru ii. llicLtm ;i prirr aroplitudincr exirgerat[ a miqci'rilol pllsivr" lio ' ' pasbii u tttttt l't'ttlttt prin uir,ii, tr,erele plol:c: ',t').I'a mobiLizuTect ,l',r{"'2,-i, :.,t atilge cu uqurinli, umii'rul cu articulaf ia rttllo-.rltlrirrtrri I lrt 1,,'riot',"!e t,ru ltra.xiurLile prriiTe a10 membr'lui inlerior, se polltc atingc f.srt .tt .itl.r rl. i,rl flexiLLi*it coapsei pe bazln se facc c* mtlt:-"t'rrqllri1riil'! tlt' rttrr'lr '1i ,lirr* oxagcrl,ii i t ) itintei,sia mtittii Sc lacc,ostc lilnit. lizi,l,r1i.ii (1rt ,l,' ,' i ,, ,l tl Trbo p, . . t "iL: ildt , ii lui l3ar a, ng. I m plir nar ca ut r ct t t t ilt r illi : r lilr r r '' u r' , l t,ri srrrir t . , 1t L, r r t hjt r lui la un colebillos in sll! iir r it r lt r r 'f it r r t l: t r l'l'r st lr rrr,ri rl tr pi Lr : 1. t it ohar ': i excur sii r r ui am ple it lo t r r cr ut lx't t 1ui t lt t li, t r lr r r , ii rrl:r!,ii iiril irr Il o -hrtlnerillia ; e) Probu rcziutuqei' ,tt Iui lloltnts '\lt tr"rtt ll,;lrri";iil cstr: iolicil'at sil frrci-lflexjunea :mtebrallrrlui pc btrr(. lrt . L r" l'rLlttttt ' .tit 1,,',1,'r,t.lu itron ienl Ltl in c:r,re dtitn dl'utlul r":utebtLi'1titlLlir ii I l lr t l'i picpt t Ll or Lm ir lr l ( r lli't I it 'i r r t lt i lt r llit r lr r l" i ,r(l i ,r' 1,rr{ r liir iuir tl ,, i , ;. tl ri ::1ii: ! i [ r 11]t:ll11or it ii liliei- int r iir ii 1a t inr p in 1'ut t r '! ior t ' r r r r lr r r lr t r ! r , uux clt t 1e t liscr onom cl; r ') c)( '\ t t t lt r 'r 'l'lt ot t t r r ) r ' l r. rLl bLt t : r . r c r L{- '. I }oiil1iii 'e \ !' trrl t(t' t' e . f l?, r / 'lr , r t t Tt t Lar r . 1) ccllt t qit iilt t cllt r t t lt t i ir r lt t lir t t t lit t t t t ir olt r : r t pit ,, :rl i 1turi r ir siL,1r t ;git lt lbole at i. 'i'11, t l*Lt : r r r r iiii r r t t n'llt "- r t , l, t r li: t t t 1r ,t , , lr r l L.r i i ' i o si't it , t il lnilciili iuei ln4llo 1i it t r t u'lr t li lit ir lt t t r r t i t t r I t ||i I r I t L'I r r t'onift ( l)]itlltitttsrrtr ri lr"rr 1 ,r Ll,' 1;:',:'i:cir i.:,,rlttr-iiI !) Praba tisl,n,t't,rici lr i; ,,;. j c i rci't lr ir lt r . r , r 't t iL. ii f it lio( j r lil ) cl( i bt 'r t 11lri ir il lt r r t 1) t lr r t sl'r tt t t r ' r l' ,' 'si ' ,,,1,1,, ,,r, * li ; r , jr it is ir r lir izi{ir r ) l. iz( ) t lir r li. l) t r plr t i, t : ir lt 'zit t t t ii r r . t r 'I r r '|. 'r r, , ,rti rl l ' orrrsllt t ir : lii, r f s{r l'it li( jit liaislist lt x'ilt r t 'l t lt t Lt it it L t r r r it llr rllt llr r t t t r t lt I '\ rl l ri pr,i trr ir l, r 'ia t lisclr t lt ot r lt l, r 'iir ,pt it t . iI t 1r 'lilt 'I t 1'ar t li"i ill I li r r r r L si ,, .r' ,,i ti ;i , ilor , ( , iI iji liiln) t oniiI t ir t isou] illi. ::.' 1.' u,l, lr u; r r it i, inu'pr u. t it t cr t lt r t , zil'iilt t t r r ) l'l{) lllilvt llt r t r 't t {ir t t r lr r I t t t lr t 'l' /i tl r(.r.r tt,. i rr 1r t , t r r . , i, 1ir t r r c, , , , 11i- ioI cit ot lr ii t t r t , lt i, si.I iir lj<: it r r r lt r lr r r 'lLr lr / ll I ll'r , 1 .,1r,,r i .i l, ii; r r lr 'it 'l't r l sli lj I i*lr : r 'li lt r 1, r , . Nit 't r r lr t t t l lr it lt t : t v t t t t t , i r t r , s.l , ,,r,i l r poziiir ir t i( ir r lr i, ci r , iir r Lr r rl; r r r r i r r iyr , l r t t r t ir ir I illr I ; lr 1 ll, r lt t r r t t t l lr t r r ' ,,,,,,,1,,,, r 'ir iir r r i,lr r r r t izr r t r llt llt , i{r lir illit r t l ro l t t: t t ' t t l t t i r lr t : 'i I r lt llr r . r l" ', i ,.l ;rl ;ri f,Irr.r r r , Lr t li lt r lillit t t r '. lir '1'lt t lllL l"'lt t r r vlt t t r 't t llr t t t l t t ir lilr r r r r : r r t r lit r r r '' ( Lt 't t t t llr r ) ,i l ' r,,t t t r st , li, 't lt t i) . lt r t t r lit r 't t it t r r r li4r ur ilit
I l i ;i , ' r I l r' rr' rIr' l i l ' rr ' ' ,rl LrI:rIl I'i i rl rtl l tttt,l ti , ttl l r' ,l l rl rt ttl ttr I I I . | | | I t I I I I I I I i I l l r tl l l rti l l :rl l tr;, I l tr i (,(.rl tl i t l ,ol l i l tl |., l rtr rtrrl tr |'t' I r' l r' \{ ' ' Ll l r i l i l (i ' i '

rrrrl:r,i,t'lt, ccf:llici,.

liirr.titl $, 1 intorrii(,'rlltr, lrr,rii;rrr- irl,xc ul crrrsur .xrcu'lirrl'rrli. lr)iii:rr cri. lrr rrrrr rrris.ii .i.ryi ipsoryl irr ri J o r*r. s.irbs.r i.ri lrr,iii.tip utr rl ,,n,,i n, ism,irll, 'ii rlrr'rrrri rrl.'lir, srirlir'rrr 'r4irr rrri;.1)r'ii s. r'r'irr.ri(irrzri, r,'a,irt[i.r.rrr ;ri Drrrrr.iirprli11lrri i r, |! r,I r I r r
Il ,1 rr I It lr I l i l l i z o l rrl i i . l i r, rrl t,i l tl i i Irl rl i si D ,,l l .i ;r.,| ,r| ,rr ,i i | III| | r| II t.l

, s i t n; r i lr r r r lr li l J r i l l ( , o i n f C r c B t _ u u , l U C l C i l O r o

lll

,.1.r0lo fiild hemargiobla sioame. cnisrufi, abcese il: .clj:11,1,,; li (A'sr,-ni colab.._1974). r'(,t,agt*ze. ^ll.1lltci
rllolil, C(.ln 0r.lOiisa al LlDc t c io( i ln. . ooier LUl

l.srrlrri.str .'k'rrrrcrrzli, unr,.i rrislllrro ..rnpltr,. Irr scrri'rrr 1r,ctrtutiit gi trr,a .rl|upi'rrrrrirlirlil,nu.stc infhren!,i[t?i; p.'leia, pilanrida,lti, accentueazil. ia'' se It. tlrilelc auebeloase.Unii bolnlvi-pr eziniducrize tle opistotonus, crr lrilx)roxl,ousio msmblelor. Aceste c'ize- se aseamd,ni,cu i,lgiaitatJi Ae a rlr,r,r'rrrbranrroblinutir, la animale prin secliune mezcnceiatiEA d;;;;pi:; rrrrclllltii lo6u, .t-Li1..2. Prlbleme etirpatogenicp,4n sind,romul cerebelos .1. II r()rtlpcprphel4oscria.trpptezenlafeinapJ'oximaf iv60o/odiLrcazuri -\e orieol i.m spre dilguosticrrl cic tuc lini c , p e l t n . q r i s e m n e l C r , e r f l b e _

, I Ir,rrrl r| [rH ,i tttllf ot t t t ll. t t t lr 't r r t it I Ir rt Ir' I i rI i r' ; li t t t t l'oli ; lit t r lt r r t t tt l0 llllglli ll( llllll r r l trrl rt' l os' (,\t'r ir ^t t1i r r olr t lt , I 1) ?'1) ( lt 't r r rt r t r t 'xl't rt lllt lht lt l l'( 'lllt ll t liit gr lr t $l ( i t, r ir r ! r r , r r lizr r , r r r r , t r 'lr t loir siit t t t r lr r lot t t t it t i r lr ' .rl . l ' i rIt,ri l cir , i r r lr cr lulor r , r ir r r k, , ,rl ri r:ri i rrtr tl r ! . {r , t r t t lillo, il, ll gt jllt r l( lilziit lr r lt t ' liit t t pklllLt t t list lt r 'l'( )( sl'll|t r st t lt l, ,' r,rrl ;r, rrsl l trir i . . i sr 'iiilcr t it t gt r 't t llr ir ', r : ellr lt 'r ') . l ' ..l Jol i teclem 'ial'inizunLa( i, t t t lr t ost t 'st t l, at eu'm nl'LiSt li) t r r lt r t r zit t ir ir r I t r t r rirrrrihr(,lro lczeazir,ccl rrui tt'o0yorlLcetcbclul. Irrt intlivizii l,ilL(\fj' lll(12('lrt'ir rrrrri siutltorrt ccrebolos ()u oYolutie lentir, qi ml,i Dls$ ou pu$r)uli i1i totttisi ri,ti,ii, l;otrle:r,unasuspiciunoa unci leuconovruiitcr lIIiLi rrltts tlrt.rt' rt'' 'iiii si simptomele ,,iiramidale Si vesljibula'rc" I!xistii ittsri,'litltrtt' 'rxx,iu'z,ii, i,,,,,t,,jiorr'"".1c'scleroz,i inultipH, in cnre sernnolc coriireloa,so l){tL (r,ll$l,i I u i rrruliril yl'ttno singllrele manifnstd,ri ciinice . \1. Afeclittttile rasctdare a[e cerebelul,ui nu este chial asa de r:*r'ir, clllrl slt ('lr'zlll' l. llenmagio cerebeloasd' din totalul hemomgiilor ptirlrrtr'(! irrltir , ir rt.urizentin{i: de fapt 10-13% (McKissock,;i colab., 1960; (iorn'villo) l{l]';ll; ,,.n biale tltpl, uneJe slltistici \lil,diell 1i,i.ngrist, 1942). Ce]e mai multe hcmoragii ccrc'}{''lorlsctlrl |rrrl olrsorvttte ttc P"opoviciu qi collb. (1980) in zona de vasculaliztl{ irI tt' lrl't't'r't ., r' r.lrl ol se t nLer o- supelt olr ( . debutul brusc, cu grcluri fi viirsil'tttt'i lrr Sr Do&t.r recunoaste tlulft ( azur i, l caic se lsocilzS, o t r iadi' cat act cr isf iclr : : t t nr t t ' r,,.sl c 90V din i ,.' ..t ci oas" ri n, pr "r lir i, pr iYir ii ipsiht er alc ; i p: r r alizic f acilr l{ . 1x't 'if r ' *"t

crr.e do mulie or.i tle"buteaid lrrrrrul nrin ' r.l.l'.{'.vhrsalur.i(de ubir.ei!,aJinale. firA greate si fare eforiuriain i,,i. lcl, bolna,vului), tulburlri de echilibm qi ata;i& indsului (sindromul &reI'r'l)N vclrr an), staz:i papila-r5,precoce, creryterea dimensiunilor cutiei crart|(.nr'. r'll .te.h r$cenl|t suturilor pe ladiografia erania,n[ simpld,, ,rzgornot rlr,, spar1,5t,la cioc5,nirea craliului ;i adesea atitucline ,,cireinonioasf,t 'rrli, .i rr r':rp.rrhri rr gitulrrir precum si.,lize lonicc t,,cor.ebcllaL,fits;'j. n lit rn tumorilc cu localjzareemisferici iglioame: jndeosebi lstro_ .ilrtrrrrr',;,.tuberc.lo_ante; hemangioblastomul ietino_cerebelos sau boala tru r trlr Hrppel,lmtlau f .a.), cit-$i in celevermiene, Bimptomelcdin lartea rr.r viloi cmDieni, precum. si cele din partea marilor cdi senzitivo-r.riotorii r r (lls(.t|1,.. lchjtnL,.in lumot jle uug.hirrlui llr ponto_cerebelos ap:r trrre_ 'r)r,c s{,rnnccochleovestibrrlnrc {per. YIIII, precufo si dc afectare a irereihi_ l,rr'\' VII, serrruele celcbcloase apiriu,i inai tirziu. -.j ll. ,4.f ecti.tmile inf njioate ale -cerebelului: .in, erotulm enr,eJalitelor diverse origini, primitive siu secund ,re, de ,1) irc'l() $a,uct'onice, apar adesea.simptome cerebeio-ase. Dxisti *nele situalii rr (1llrc, loc:tllzalea- pro_ces3luiinfectios se face cu pre<lileclie i" c"rcb"t, rr rr.t'si. cazu.i tabloul clinic fiind dominat sau fiiirl constit*it excxus# g1'rebelos. rlr rr11 11i1;1111'11 Pentru aceste cazuri se folosegte adesea l,errncnLtl rlc urtbeli.ld,. t'elt'br.litelr. rle, fapL nemarite arule in.feclioase, rnai udesea eel -sint rounile altidalr, s b lormcnul (1,. l)t'|lrrr)rr'({lar,ft seeundare}, ?.atarii :r..rrr(."irr(, lnl r-_,eyden.( ljecourt, 1922). Se pot intilni in cele ma,i variatc irrlor'tii{{r lrrd 1iloirIii .,d ifr t.rie,ru.ico]-d , sr.&rla iini. variohi. g;.ipi, pn.r,,,noj", rlrzr.Ilr.t]r.. 3t!l-cell. \ tusc convulsiv5.dir"erqenevrarilp"irolice_cu:urbuviltrsrrli rltr pildil, encefalitXepidemici) ;.a. :!. AhceselE carebetdase relativ frocvente, ma,i ales in cazul abceselor sint r.rrlillctrlr'(otogenegi rilogene) care rlau in 34% alin caauri abcesecereber',irHr, oeleoJogene rn {Arseni si colab., I9Z4) Fi mai pulin in cazul abceselo:r nl(.rlnliltlcc. l)eDulul subacut, cu sernnegenerale hfeetioase, cu discret lirrrlrrrrn d-e hipertensiune intracraniand, lf debut, dar cir aglavareit, pro_ gt'r'sir,ii, lr,tlcsoaryi cu semne mcnilgiene nc sugereazii,djagnosticul. ii. 'l\tbereulonu,l cu, Iooali:ure enre.lalicd, aDalc mlri ales la conii si lrr rrrLrh *'r'rr(i., r.lizir lo.i lijnrl iu 1.r.r.rlih'c1ir. rrx.mrri c,ir,.t,el ;iin-tfiii,,.i,i,ii 'orr..dr. 1074). ll'rrhcrrculoa.m.lo .r'r'i!rr.irr(A.s.lii ry.i .rlrlr., cerebcl0aFc r'(,aliz(,lllzr'l rr r.rrr' ('rrzr.ir. sinrrTonr hipr.fl0nFiunointrtucrnnirmii, d$ slndrorn do frr,rr | (!ri rir, l)oH {rr irr l)ilrz,rlirr cuzrrIi rl:rl rrrrnrri irr ri!f^ rli,, r,rrzrrri Firrdrrrrrr 180

pe r,a l.:,1]l:.ii]1119.li depeltlr.bd,rile care.te.tletermiin. c6piine gtndim ru Iixrl ]-l urr mcduloblastom, lt

Iorlno,irprlt f i simptome tle hipertelsiune intrasraif:l,n[,, oi,re este insil r.aria_ D ir..cit- trrjnsrrilre_$r tnoment- de aparilie, in funolie tle rapiditatea tlez-

ttilburilri rtxpilnlot'ir' se ,i,,ii."ifltt .,.1 .otrir', rgf+), dup,i car-e instale?zi. ri ssrrclt irolll'l) tl)(illl riiplr:r'1iepeti'rtlicri(llc - -tci ' in speci iri "'rrsl'ind , oum i lt lpidi if t om ai ) . i Rogpl. l$?5) . r,l ,' ,rl ri cni
$o nut tlistinge 5 tipuri ale instahre , silllptomrl Lologirli itr ItltrIot'IrI'.iIIr' , , r,'l,r l,iise (rlup.r-Schobl gi colnb., 1965 ; !'isher ,sicolab , l{){ii I Iltlxtv.tt'ttt' -Pascu, 19801 : a) Tipul ,rtumotal", cara'otcrizrtt lttitt xttttlt l','rrtrcilntla ;i t,,rrr. t,c.ebelbrso cu'ticbuf lcrit s.i. piogresir', rtsocilte cu lirttrtttrt'tr. rlr' izirl' lttitt rtlr'r iri txrit orlsiulre intracraniand. b) Tiput rrrmingian", - c,.rril,utol st'ttrttt' sirnptomt : cr,'f:llec, vllt'tsi'!trttti, rilirr, rrcuil, ]trul,il1ir, a unnii,tuarelDr rr,.rrilge:rle. fclornene confuzionale, slnptome ccre'helotlsc sll'Ll olfll'l)r'lrraspoct dc sinelt r t m t lt ' 1t 't t t r r 'lt i ,,,ri t,ri n.si 1. . ( . 1i. sr ugbinolcnt . c) Tipuliu r 'u com i, pr uf r r ndi' l) t ipilt ' r r r ir r lic{" lir t lr it r shr , ,,.t:,' ttt* f,' i o-t t i*r t - , 1it at . tullrrt'iit'il' motoiii mlri (c-rrL,rnrrsch(rllzil, r,ii,r1,<.r'a,1, hipol,olic $i tuiburili ( r l. sr r 'isil' r l" .r' trdrol tase'; i r neniligiene) . E\ ist [ li f 't m r t , 'lr t lt t t ir t r t t r li" t'lr,,tias ;i liogerr', 1925 ;i'I(innier' \filson,-Itl5i)),-ctt ,i.u'l.r't'it' lrtttirtl't :r , orusticLrieisi i.u b rnotrle rapidtr,). (l) Tiprrl cu debut mai puf in gr!r\'' t'rl r' lri . rl nsi {. lt r int il, qlr '2Lii, vir sillll i' ccf ulco violct r t ii, l; t ' r t t t ' ' r t st t l'ir r zl ', r-tI rllr,ii,,t l,Lrliru: i tt. con;ti,l1')i. er) {ipul ln care dupd' o saurtn 1{tlioll(lrr rlo rnm[," bolnarrul igi revino, '^cuzind in conlinuatc rltttct'i itt I't'gittttt'rr vi, r 'sit . r r r 'i t t iui ules lir schir nlr ilil" r lr . . lt ozilic r r l{ r ': t lr r l ,.,,gri rLIi , g lr ] t uli lt "i llt r' rrr ' .i rumr'icli'r iul'r r t c. O bit r '1iv t r i't t tult r gir ', sr 'p( r ir l, ( '. {'\ 'i'l( 't lt iir r lli$lr r il esi,r unil:.toral, inrIi.ri sulirtl Iozillnii) fi tlll lrr'lrrl ,rrr, ,,r,iz.'.i,1 (car,c tlrr,cii, I)o lrtrtlto rlti stt pttlttc OVjdtrlItill,i1i rt. Itrt ,l|rrll itr cor?b0l0s fuOrnOIatOral. rrrrrrtrrl i i l 0rlot r , I ( , r Lt coalii, , t lr icI r lI ir nlir r lr lt , t t g[ , i: t t r lt it r lllig( llllolof ( '{r llllr ( 'lollf ir ' rt :!. I:ltmalnnnrL cerlbAljA ?rrrr0df (,,spo l,ltr itr rkrntttttit'(!il, vo{'ll(', rll li'i, ' ( losllr l r lo t 'r t t ( r t lt t t t r it t t r t lit li ,rrr' ,^r' 1rt At r . ict t i1i colr b. , lt ) ?1) cst ( t ii( ' lr lr illi lt r t lr ' lt ot t t r ll, oilt lt ( 'it t t 'lll'1t r t t 'r 't t t llit t lr t l'0it lr tlit lt r t t r ') ' l i r ' ,rrtIt' i l( ' r rl i grLrrsl ,i rr l)rt il| {lol) lt llt l br , t t lr r l ( ir r lr lr r t r , lt , it t ; Lt lr . ) r r t t ut r f it lt 't ' ot 'r , iI ilulr l, ( 'ir l. it lr r 'r lir r l gr . ur,i vi rr;;I,t , vi, r . lij, r 'i[ dcr o lil, r : r 1, it r t r lt , r ,{hr nlllt of l, it t ( ll, r lr r 'r r

I rl7

(lrrrri (irLlirrlrr.r.irrtrtrN rrupi,oitevazile (in formeresubacut.e) sil* . ir*^('ci(l.lr1' sindrornneo- sa! paleo-cerebelos,'in lrr,lrrrzr'i, r, fi;;1ri; ;;"I"'*ilj rirr'| Ir(rIri rr'| rrrrrI rri (Arseni corub.. r g;4r. s'. po, t.'^*-cra ir 5i sLaza oaD ar:i' -ir,rrllorrrul irilal,ie meningeali,. do prr.cumsi ;-"; pir"*;;;i;ili--:;1; .'
bolnavul igi"revine ,tllr :l ')r' r r.Urn:rloasii ] _ frri a pfezetrLl, inili:rlr. Scmscpret m,rri cercbeloase. (., (l,rpii r.ircvazile .A aparii iemne de nip".i"nJi,rne'in;;;;;^";;.i '"r,r'r

e\irut run.in'e rapi.t.indnoseiri-;;iJ l:ll,'i:l; .'l,.llr::'n,^"_r',:,:,11 "rf" :r|||liirirr(,rul' cercbeloase gaJ? OcCipitali,.Alteori ";;'rJ;"',

|. | |ir r.( r ,I rrI f r s o. r nD'd e tn t| rc l ti c e rc b ra l (Ars c ni , . 1i col uh., i 9Z4). E xj sti

ci

jt",*]f; H:",1,f,i",":;ff rrltlii:iffi T":rrt,il",f ;;l; :i*:F:lt-,""""Xi:?li" r',r\'(tir'.rru.ui hemal,omcerebelos. ri" ;;i;;lti-"Jrr insl e'olufia
('iri r.rr- p.og'r'si'ii,.aspectul crinic fiind asemi,ndtor cer al unei neocu | (,r' lll l I I (,cl'('r'e luJia ( . . lO f
i

:1. Eindtoamele iscltemice cerebeloase.Infarctele cerebeloase izolate. lrrrl', sint in general destul de rare, intmcr. se qtie cir, :r .r.rqbelului ests relativ bogati. Astfel, ocluzia'a,r"berei "i..rfi,tir"."f"i"ilil cerel:eloaseantero_

in: t llSCU. lut Um , J r al; ! r r ) .

inrrucft infarcrele cerebeloa,"se produse ::l,il.l:ll::,..,"1i" 3,s.imqromalied,rsi r,r rr'r'rr,rr'rut <int.mi,.i dispr,rstte(popoviciu, pendefuncl:r, ,cestal ll11erp anrero_supL,_ ,i...]'].1..]1.: ,11101:-it :9bl-lr, ocluziaarrereicexcb;rolLse
"r;rr(! ,rrrri,rr'\r, mar Rdesea (.tl numero&Sesinalroameischemice ale trunchiului (sildromul arterei cerebe_loase postero-inferioare c* r,',iantele s:rlez 'i'r'r1'll.NI lrlir'e'ran-|-b,'nais, sind|.orrrul srbin.tri'.r'rg,nrtc, tui ,.i,',"lll'.':'l'] -rndl'onrIt djudromut trri pi,.rrr, Ilarie.Foir hrr ..h<,miprr.,.z,r ].ii l:,1).]"':"ul..s1rn. .,, r"-r,,.lo;,{,1\'ezi cJp. l), intftr-ir Inlrelgd jligJli. i, ..rcl.;o!ulrii e"t,. .,\rrrr-,Ulr l,rtm u e cot.cbelo.rs| {r, l'jscuic Ltio lt"uo(biltJbazil:r,. sc nLri ' rrrr's. r'irn.rismentere cerebel0ase bilaterale trin trombozcre vertebrcr, l,rrzilirr(.(l)oloyiciu, -pende{untlasi l?ascu., fOSO; Scotif fO6T a,, b). ll.,:LtroJii.le cerebeloase /. \r' sirrdim la o otro.fieaercbploosd seaundord, s[n$)lomalicd.t] nr(. /' rrl.r. llrll lurrc.iLnrlrum cclebelos, carc s_ajnsl :tlal la un-bolnar ti care nLt rIr' 1 isI ii rrr,.rrl1.iiictul. et,iologic, dari la,care eviilenlieia r in antecerlente un r:r'l|t|-t. tocTlos. roxl c. lraumatic. r,lScular,ctc ., po.ibit gencfttor cI corr_ c.r.ouotos l:r i.i_Lrc. jnvpstigdl r.for.turfo si, prin iiJo ::,) :il] Irirl(rgtallc,tomogralie illll]"1?i-L(. 1lncn. r.rr'.( { arial{ computexizati,l s_a eviilenliat ;-trofi:} l llr' lrll
ul ui.

ponto-meze.ncefa,lice (popoviciu si cod,t.j J.9l"tt"ooit il,J:,i,fil]:.Ji,l:y"I"t urtam r:'nrJ.rfdure sanu_ t:,ptur ci, reziuniburbarecu simne cei,ebeloase

pfufluce, pe- linga, leziuni cerebel0ase la niyelul nucleukri dint-at.

iz|rtziilttitrlt rllr lrllrf'' r rlrrrrii, rl(l vh'trtrt, il{) tltrlrrri,iIrr. i ,II IIrIrr| 0lirrir s0 fltt'rltllttt tltr scrttlttr l('zilllll ir :rllrrl I iirl'1' ctt sirr,lrorntxrttrbclrtx ovoltt{iolrlogttsivll , ttctvoilN{r. llttt01'uli (u sittt; aonge'n'ila'l .ltryrtrlt' rt\'rrtrtl lt) Atro! iiLa aerebrioase detsruLin'ilm ilr rr:rr'nilt'slrrl l)rillrt l'' ,,rr1,, unui funpo*ant sindrom oelebelos lriin pr6zen!a, fiinrl L,,,i hup[tna-steie,suferinti, cere1,eloas:1 evidenl; lcg,'1i.rlL' ittl'trt (ir 't'It{iIr pzr,lotoeic su.ueniLin tinrpul vielii inlrartl.r'itrr'{:rrl It rrrrrrri ',ii,ii niin"a entitSll clinicc se,Iot lptctrirt'lttr.ltrtzrt t,.s1ll''c <liscdbriopiazic[. I)iversele lczionrtlii'ltt.p.' gi celebeloase a semnelol de indica.!'ic rrrlcnsit:itii su{eri-ntei 'cere-beloaslt'. (tl'ln i. iptazia congenitald,toiald'; - herniaplazia "i'rii":r ' a li,r, n,eocerebelitasd'lui.:Vogt i - attlaiia arhi- gi,Ttaleoceretlloasd l)ilrgtr, ' pe lirrtl osto facilitat de pneuinoencefaloglafie, rrtliografiikl I'A itt pozift' rrursiv l;lgit, rtct.rl tlitt itrr.rlr' evitlenliindu-s6spaliul subtentor'1al .r,zirrrli, tttt its,tN:i rrrt'trr. irrrr. t'ealizlnr1 irno"eunii cu ce1tlin ventriculii la;terali rl l.ristic de X. in fozilia cu capul adirnat, aelul Se ac'rnul.^zr'i ltrrlr.ii\' li'sir posl,el:ioar"l, desemnind gradul tle ap-Iazie." cuti; Atrofi,ile cerobeloasa apari'lie tard'iud sint' {:'\plesiir rrrr{'t'l)ri)('t " ,' lriotmfice,' degenetativc, cu irrjtere,sa,rocereboloasil r:leci:ii'i - l)ivtrtsllr' 6cstttl rt. rlilir,il. se taraLive pot incli'idurr.lizlt de r rr,r'i*rrte atrStii cerebeioase la care debuieazii,gi a extensiei topogralico rt lt'zittttil.'r rr,, liaza virstei ,u'rrrbeloase. Tftomns tiratrr itt itrrrrl a lui ANrofia o:Li,ao-ponto-earebeloasd, Ddjdrina^ siirdrom cerellelox, t'll trvrtl.tr(ir' i'stei cl"e50 rie -ani, realizinrl rlrr ll]Lr,r'o r 1f(nl]tl rii'l I l,lrl l)rr,gfesirr6(in cale predomin[ tu1bur5,rile de mers, ataria' 1i stttttittrttxltitlrilittttitlrtl', i ,rt;riiiliona,td,;, cire pe parcrus se avrciaz5_,1i la rtlir glolrtl"t 1,,r'cuil qi iialeze oculbrnotorii.si rrle mi;clrilor cottjrigli,l't' u' Lu'i I'ittr' ta,rd'i,td cu prellorninanld' --- Atrofia cerebeloasd, -@rticnlii r It (,ie-Ioifr:At04nrani,e apare mai tirzi' decit celelalte iti:t'fii .r.'t't'Irtr1'I . r,lrrrriivirsta d; 60-65 dd ani), are evolu-tiemai leniil, iar itt trtttrl'r'rlttl l( mod net (sau sint crclllsiYli) iit'lrtlr( ' r'iiulosic oretiomin[ in tulburitri irnportante de s1,aliune ;i tlc tttt'ts, lttlltrt'r 1',,Ir:oceiebel6ase: 'ri tutburd,ri de vorbire. a lui Lejonne'[ifunn'tlid it1l:llo ttt AtroJia olitso-rubro-aercbelousd' itt virsiei"cle 50 de ani, are evolulie lentri 9i s. uitlir{jt(.r'iztritzrj, .;rrrrrl uu 'ritttttl prin importanll ati,xie a memb.-,'lor',. r!:tli tulbr'ir'r'i itrl'rrrr(ir'' 'irrrl o'oziijonale,' la c:lre se asociazil, mioolonii (lLtrooti vr'1" gi ,,,,1,, {i 'it'tttitrir) falingolar:ingienc,diafragmltice ti ale globibl o('lllrtl'i' lr,rLr,1inei ' (l('( ' Atrofia' cerebeToatd d'ifuzd tr twi llr6utoa :l'prirolnai (l{rvt('rrr(' rl (intie 40 si f'0 lnj ), are o evolu{iemai rnpid; qi rc*liz.i,z}; lttr trlrtir y , ,,l,,lrr,ltc lrr . rrr,ltotn ccrolrclos compl''l'lirlhi, pslco- 1i lcuc''r' Liel'r'i-lril:rl''lrll' ' rr' (itrcJusir'(lurrt -rlll)llc(')' r,r' rrsrtciazi, semne extlapillmirlalo Si (rt,tlttlit sa troaica irrl,iltcsc in iltoricl(,i* trl,ilitlit, lt. Atunii,te carabeloase pt'ofesiori:r,1e crorLicccrt plgrnb '1i ttltlttttr, ptr'trtlttt ri r,runici,) itr intoxica,liilo -cronictl eu tloze rntli tlo hitlll(oitlt' (ilr sllrvrirrlt' ,i i,' ,l,tlsul tlatarncnl,elor prirnitlont, 5.,u. lr,rrobru'bi1,*1, I trawnatkle sitrl; ttqol llo tccuttosott1,ittittrl li. sinilrowtcta acrubeLouga ('r,lll Zii, llr'lrlolttgii illttt ltt'tttit rtll,l,ie, crllrl l)r'rrllt(xr rir.irrrrit fitotlrrrtltr,t,rtr do ('nt'r vrrtirltil tltt llr t,ltz lit, tl;tlr', (ltrrl,oxl,til sr,rrri.l,rgir' . lolutc oot.ol,,rtlousr,, llillulllll'i(x" lrrzittttilot' ttt Ittltofio tltt lrttrtllizttttrl t':il,ottlirt, 1i rlitl iod' Ataoitr, Ialtupinoht'z Jonili'd' ( honkt'ht'i I'r.nti+lltt) (xrrrsl'ii' ll,
: r x u r . i r , r r , n , t t r tti si tr r l t'i l tr r tt,t't,|,,'i ,,xl tt t n to l tr l i t' l tr r r g ttr si ttt, l t tl tttl l 'l t'l ttttg i t'r '
, r'l l l i tl l.

respTtil-e:-. pcta^la frri,ed.rei,ck tui. tmphcli' l;zi""i qi :.:l:.:ll f:::l-1,1:".,lglli tulbur5,ri ,jl:,111 .&pinacirebeloa,aA trofice._ Hredn_ataoi.a $i 1.,]'-1'l l?)r"froarc t t l l t.t .{ C rn n r,
rlt,ir rrt,, :riirxriirzi, oi rriiocloniit,"liizlt,, la urulrhii qi ill:,'::,'1:i, lr{ rrr)rr'k)r's,, .,1". r.r.r fr .r l":,1r rr-rr1x'r'irrir'r., 1i .u (lr.ir.r'ir,rir.rrr int.r'rrrrr.ir:rri Ir','r'rrrrr
l|l1,]{r-f.rlvif. .tf.rolta otrl,od(Vtltt ltnxd, u ltti eoft]on_tItlittr,$ rlrirttlr.rrz,i

cerebeloose pritniLile : ered.o famitiate ne sint sugerate ite intervenlia, .. ,,,.,::.).,,1,!.,f -!t!:!il*yt .!il: ' \ rr{,.rrr,ir nnot l?clori. gtnefici. As el. se surprin.le caraclrrul crerio. ,ir. (lr,Dt.ut i]r'cloc j0 cnpildrioSau In-adolescenti. ri||r||ri||, cvolutia bolii erfe |l'trl Ploglcsir'5,,iar in conteitul semirrlogieo,pal n*irf,rl.t si alte elernente,
rttr t ' e J A 41L.it s o e rz i L f i d i p i U n ti d a l e Ji , cv{.nLur.l ,i l emeul (. l rnri ,,_ lr,l r((. ( t nl r ) ( r ilf iLlur ( h u | r,r,l . . I)i s i n e rg i a o e rebel oasi mi oel oni ad i, u, l rti l.knnwy Hu,nt rk'.ltrttrlzii clt tlizc rlo r:$ik,psio ia,l .sindromul cerobclor,

:!.'ltroJiile

r8 0

180

alolosuDrerrolor. ttinjurul si l"i',i,;lliJ,ijii,.u':tili,oo"_T$'f;,lt (cu tiansmisi -famiiial _trasusu.rui

'"^iffi t;:"#3"T'fi :::tl:l'lt:f l#xtrall,#ffi li{.i:#-Hffi* fi

iii:.ilillii;i; Affi'#-1"Xt'#ignetizare"
"ul,Ti;lh,t?3t;,.Fradis

rn(. .rrt(,sorulu *t olo"-*;*ti"11?rlter 'cr.csiv*]

i:',"i.}}"x'ffiry**ili|I'; r{iti'qT#{f ei Botezi ;J[Iiugsl$',1ffi1"a,i'fl r1);)tsrsor cora).r.,, F.ff"'fi qi i r;r;,

t"*i a lui Dennv'nrowq; :"3lidl3i#5#ft F::::;,,"i,!" tix'3;Hyt3:l#ff;dnexae iijijiHil ae

F O.

lt't DE PROBLEME DIAONOsrlc spl'ttot,,otitlt INVoLUNTARE MIscARILoR

6.1. HIPERKINEZIILE Sint migcx;riinvolunta,re,rrariabils ca aopect sorniologic' r,rr, topogufie qi- ca eti6patogenie' Majoritatea aoestora sint tle orlgittt' oxtrapira,rnitlalS,. xtllt 6,1.1. Hi.nerkineziibruqte ;i clonioo, fir[ dcplasdri sesmenl'ar'('.' limilatc' r.u deplasiriiegmonlaredd obieci (li)r colllli(lllr' rrusculareinvolu-ntat'e, sint eontra,clii l. Mioctoni'ila alteo'i sittcrottr' nlttr. 1i uneorirsincrone, r,.u*ia,J" iil clonie,arirmicc5i (c.vt'ttl ttttl lr un'lascicul:nuscula.sru numai la un rnurochi rria"."ii-iiri" cu 0{)n1trt(tlllr' Sint asemlni'toare mai mulLc grupe muscutare). i,fri*t fntctt*itnlt'tr "" electticc galva .no-tarariice' ino..ri-u ptoOrie di e^xcitegiite tlo .lrt' este foarte'variatril; tle 1a individ _la intlivitl iii"ii"" mt"'J""ii 'i iiir'^iai" rr"ri;. u"ele sint discrete, cle micii, amplit.dine, f[r]l 'ir'i,rrrr fr,l r'tt pntinclu'sc oottiittttlrt corpolalelespeativcl il,, ,lellasarea segmenielor :trn1tlt" *ui-cutu"e. Altele; dimpotiivi, sint tttlgertrtoarc, ('lrirrl i;,-;i;;i;tiii; respectivo $trtr corpornle s'egmcniet' ;i;;"r,;;r.i-;;r;lor" -eiirix rnin6to# ritmiec, sfereolipc, conrinut'(ttrirr'll" -o,lu.nt) iiifii:*,ii i t'lottit'r' carepot produco (lorctl'?o!:'j ii'ril"te;; "J"p.9i mioctoiii mai a,tnple, muscularemai intense. " au il;d cum ne fune dreptrr,te remalcat Ga$ttuutfi colab" (l97J)' 'reprezentat l'ttzit' multd, vreme o. sut's[ dtt t'rt:r ,*,naaoiii d'J,ffiucro"i"" a s{ fie utilizat ltt st'ttvttl ii ,i"'!ir"tt*iirli. "*tii.l""ii-"ioei.,i"t*.oot ad ,,*ioelonio" trobuie musoularf involtttt' udi"n s[, iniptice orice contraclic nf. I ot"tilit lictr, Muskens (1928' cit{tt <lo Gastnut 4i i'iiiii,"r'."i"ti,'"J-;o* r:olab.,19?4; qi do Popoviciu 5i oolab.' 19?0). unul sartmni mulli rnu6chit iivoluntai{, poato afecta, Contraotia'sourtd o mlgcoro(ttoflnsare),otunci olntl ttcli()neftz[!(r lnn'l' ri,, no'ptoauclna-nici i,hi mlioi,lleproducindo rnirlcaro. ' ln luuctio ritt tliatribulia lor splJio-tetnpwald,pot' Il dlsiinro doutl

nlunel t n){a Jragnrenlafe, u,"roi'orfiiirioiu iiiitoiti W"orotir'ote mipolittii coqro' nlo vrriat'o'p&r!! irtttroulntu'li ;il{ ll nrjinotrlo rrlneronoil rlltlFttl(lo, 6n.f0nl0olloutn at{oolond{nncluo rnlg i "ft,ift;ti;Jnoron nrnr blla,tor|l.1o, b)
ill

.l l :::i] , 1 r r ir i r lr . l. l r. I,g i u ,r.r i ,\l i trs { j q i o h i rr ,r. rrtt.cgrrl i 0or!. A ccsto rl (,l ti -i , l" i rl rrl Ir , ( i, r r r ' ( ' r f ) r l ri ,.rL r' r' :rl i z rrll,()b u i o s i l , fi c rti sti nse g rc i c i ni ocl oni ,i l ,e un.i _ tttttt.It\'lu4 ltutlltlt I ( iLr'\) r'irni]I lOCalizateln o jUrnir,t*te at cor?UlUi, SaU h i u r s{ ' llr iI ( r } t t o; po rl l .

impi,r!fte fi in: 3) aticit, .lll::;f,l"ll]:.."-:11f9! fi nesisrematizat5 mioctoniisporadiee, I b) mioctonii,,pseuttoriknice,, I ] .,ll':.ili_,ll'-r.Tlljj^u*,, rnpi muli , , ,,1. n. p|urttrrttu,rnlFtTirll. pulirr iaU
l! .hipnict bJ carpoI fi, la rlnrlul ) :...,r.,), ,l t.t.'!,. ttttn?rotlt' i -. org.unt?e.ncppilepltcc, pol, fi dc divcrsi etiopatogenii: care rl|r.r,rr,rirsrj (encr.Illitc), to)iice, degenerative,metabolice etc. *_ m-ioc1o1 rrr olganicc epileptice. L) ,l[ iocloniile orllani@lnepileptricepotfi intilnite in nlmeroase afecliuni : di,,t enaeJtlikr epiLlem;ct,(fort,o tt,iortonicdsau, atgo, !. .I!?r,y,ij,e. ,,,,,'.,,,..,.,,,u,,ru ultp tt,ptyo V[t? eunlrope Srnr l,irpidc. rifmice, Unebri ) lt lttL segrnentare). 'r, irL||.rtormpte (nu-d{'plaseri Apur rle obicei in coDl.cstul tchra. radicrrtatgii. pare-lizii ouula!.c. bip(,rsomnie (srrr ..' :l.l:,.iir: ll-rl: i!, menirgeale. sliiiIic.ontu:zive. chiar cu evolugie slre 1.,,.1::l],"', ,,rrrrr'. . ],i::lor,n.!9 cri alte mc.nilesliriri rt.rrLn{ttf t ertra piramidal,. lparkinsonieno ...l|r *lri)snrdo IoliitrLo) ,si cernbeJoasc, (.lorcaaelectriad,a tu,i Dubiu i cste o formii, pari,ic'iari, de nevraxitii, crr ' ri'rl,trrnici. rrrlocloniiampJc.brusle si rlpitl"e.

,11-{i, r.otub... ;.popovicru colatr., r"or.r Jgz2, ;i .(ll: ;l^_.i.il (ttt.ufne ii ].1!o,:,.Gr.h,lt, ,,, ,:lo'lltcP t potologiae.

mai fixe. l)i\,pxLnct tle ,ed,ere cldnic, ruiocloniile pot f-i ciasificate tn umi,toarel

(1lltol)ol,lttrlttiicl,tlivt,tHluslttrclc, ltctrsltttrt tltrltii ittl,ottsilrrlrrrt, t1it.tilitttlrrtt':t ((lir,s{;rrrrl,, I}Irtttgltiott,ll)71JII'rtpovirritt ooltlr., llllilJ, llll;ll; (lrtrl,a,trl,,,si 6i gtrltot'rrl.izrtlt', : sit,tl nitt ll)?(i; illt$sir).rti colrb., J {Xit}) lt) MiockrtriittrLtlivo ,,si rlo clrxrt,,[lilafirt'rrk', obicoi silttol,rioo,ltlttxrli itrsii, itsittttrl'rico itt lrltsrtttlii 5i (rrli,errrind Artslcrr, d.olao crizri la alttr,,tle o p:irto srtu rtltl lttrrnioot'1xrt'lli1). rllusculat ra axo-tizornolicil lii lnu;clrii llrrrioli' it rl;clcsoilzii, plcczfidero cu yrlrxlrrcind bruscii flexie a capuhli qi o proicc{ic irulint,ttit,lr,(,llbt',,l,rtit't1r' o liorr:c, mult mai rar fiind intercsate $i membl'ele itdcrioilrtl (r.rttciitlctr'). lr) llioolonii parcelare, localizate la rnici srrgnrcntooor?orfrlorsitll clt irtr t tttt tr ri lrr, r.numitc fascicule musculare (fil,ri tleplasi,ri segneDtir,ro). :lrrrlrr'k' Aceste rnioclonii insolesc o pierdere de cunoiitinl,il,(ltbsoltl,ii,), iilri)rnene (rniocloniilc qi a'bsenla) filntl cxtrem de scultc ca rltltrt,lit (ilrr lrr' firr ril,cv:l zecirni dc seculdi, pini, la citeva secunde) $i pot sil, sur'\rirrir, Blxrll lrrtt, fie dnp5, unele stimuliri senzcriale insolite (,rrcacljtr s(tllzo"ololtirii" (l(l rr,hri llusirens). Un alt element semiologicimpoll,ant, csto trplcz(rrlLrrl, rIcscii,rcarea electroencefa;1ogra{icd,generalizati,, bilil,t{rrN,lir, Hi,)cr()111, fi
pE f tf MA L N l \4IA C LO tC

, i nt 1r,,,,:,*J1!i.tc,te-25!ygzonte t:\tt"^. / tl:: ps t t t nr , , / .1 L l _ J s /rl e L tp v a n Bo g a e r.t,rni or,l oni i l esi nl mrai tcri __ ,r,{.. I j, r r ^nr i. . unoo l rrto i rL u ri b rl i s ti e l )i m- l l rrrai orl i nre (r" bi r,r hemi g,,n,._
..1 '{.r' r r , . i'pl' , gr CS rv i l \i l u t{ l o l e \C e ntj , l Ll r_uu | Otrre:l r.l i ni n C rr .g e U e rl l e . :rrl e s ca oA fcbrj . (,u ,l {.nteol i ch,

sub,:Utp qi;n tpucoenaclat.ite. 1r,eSS7

insoiir.r, rruoori de urrciipcriinozii lipisnrt. ;i I I'll].,,',, r : ugil!l,,ili.rnl",, nrembi j , ,-' r n .t utur .r ale elo-r.. s mele ru rs iu u , . , c ru if rlio n r, , spa b ] .11 rl' |r.n .r r r ( t r r l l|c ) . A p rt L r (.Op i i
s l d ri i

c5 -r5

1 l I ll l(t'

.,. , . \ t , t ! t t t ! t tpt , t l tt)t ,( re p r' o z l o i a ,n l ' o rmJ . .L ol i go,j i rnpl oni uti ci de errccfa_ r,l) t l. t ll' l. a s : | t ({ ,, :l rJ . n ttL U i t. i n c tr re ml ,cl oni i l e di rfragl n* i i c{, ' '.I|r.r i. , l: - Lr t lr , , , 1. . s rrg l l ;t c l t d rrr2 l g 4 a z i l . S N u caD i .:tni l i . ; L I'ottl)Diu([ottusul tt,ulti,plen (al .lui tlri,etlreiclr, aparo la adu11;i si , crrlrrrl,clizr,lrz,i pril nioclonii sinctxice, frccvente '(1,12 pe s), lotali_ r.,l ' l. t r l . , . lt . i Uir p ' -2 , d c l tu i rl , h j 4 o !5 ;i c v ldri ceps. S e rcc,,Jl tl i ci l zr l i r 'r ,)l | 1 lLtr llr |: ll( 1., L l .rj j Su l u ]rri , S i rrt d e ,r bi C t.i l Or i nt,r.fi obS ,. (ni ,\ i .rr_ 'rr c), I ' l, l( ' r ) r , ir r , ir ii t.i rtrii L p s i l u rp a ti . l W) clilt1tt,itu ltoi Ii in{,ilrrilc itt ntnna,r.tasl ,. ,)li,trlrtniiIc Jot tttt: tl,r:L:lrr.,. , | |,r
(l tl l )l )l l t )tJt)t :

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Ml(i dc Pfltt Mlrl rlrioclonlcl copllul ll"NI" 4 nnl. sr !'f0. ,8, ARp(,(lt ob$(frvll dcsoilr(r'lrirlo Jxtllvlrlurlulldo bilittorlrlo,6ltlctollcfSi ,llllt0ltirlrl (drtlI l'.r/nxrl.lr $l coLrb,' 1070). trrrgfll,ivo tlo l0 o/rrrrtl., izolllto nlltt ttt'ltttt'l,tttltr ritrrrd,ti0ii,, rlo utxlrr t'rxrt'tr[:r,trl,rr I rrttir,rkluil, utI(lo lcn1,(\ ttlrgtlivrr, clr,t'rr ltt rt I t ltt t, t t I t I t t I l{)t' tu!lir(\il,zii dotttl tttt

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trt cttz r i ( r lr . , i3 rl t, It,,/n r,i ,.,rl rr { i (,,/rj (,( 1., l rl rr l 0 r.i scc.) (l \rl rovi r,i u srl rrr l o l, r lr . , l1)^r ' ir . ?li) li,., l l t r r . lr . t r i. ui s r .ru i rrl o g rli tr)j )o rta n t c B te l cptezenl rat 11o(l escei rci r,t,ct de , II| l )ri rrr r r : r h. ||I I r i\ r . I iI ' ;rl rrp l u !o .U l IG, p o te l l i l l l e oare tra(i l .t si tcus.i e mi ' _ c I l,,l',,', rrlr'u(it litr.:rlc lrrrlri I'ecrutan1,1i, I'eslectiy, fiecale ,,vlrf', t1c pt, l,ll,l{,1iir pr,intr.o d.,soaircarentuscnlrii lrioclonic5'iTassilu,i';i ,rlrr)if('stti t rl rrrr . , I ll( i1|) . '.. ('ti,:, l" cpileTt.ire tiotlonice qenerrlizate biktter(Il.e ntttsire (1|mgoclonic , /./i,\' lrl.l,'frnilirrlogilr, rrrrlu'ilor anglo-saxoni) pot sil apa,*.i itt tty.,t[rtc*rele /, r ttltlrr!i clin iut tltile.plicr:: ) in l,ncl,. t'r'lri rlp ,!.ilepsie.ltetit zral (rclatate antcrio].) in o:,.r,e ,;r :r', rri' s r n l 9 ,,,r* r' rrJ i z :rtol,tp t C a l e j U S ti fi C l i r.l etrrni i l c:.r,e,,mi o_ l tl ',,( t ' ' u r'l rrtri i t' llr s.jt{ ct) ) . ir) irr :rrullc tlin cazurilc lc tpil.c:psii t:atrLtlsi,tL 11rrLnd,-ntu[. 1tr-iuvtt, !,l t,'t,r! ; |t . |, 1, , t , i. t . , .,.| o t,.i ,, s i .j rl )..| r. i rr s p r,,.' 1,1 r1,.[1;1 fi i z, i , i r,;ri ul ,l It, 1;y J rOt r:r/1r t ( , r r , ( . , r r u, r r ' l ,rti tru s i .e , d e .o b i c e i i n fl e,ri r:, A stfel , ti upi [i l rsdaut,si l rrl rl r. ( llt 7' 1) o t t ' ei rrrcrl i rr b o h ra ri i r.r1c ti z r. tL,j l i uLr uni ce pl tzi nti l cl si nri i i _ ' l .tri r t r r ' r s ir r . I ' il; , t o r.,l , i tr ,.rrrt,.rl u l , r,i z r.l ' r. r.,!rl \' l \i \r. f,,,,,." ' .],ri ,i ," . ( 1 9 :,7 r.(,i l a ti ,l . C r.ti r.u tS i c ol ul r.. l !]71 j ,tr ,nsi .l :,t r, ,,1]t.l '1 .,,r/, , i r ll|i. t iil IIIi | \' | , ) I I I I I . || hll: r l, t . t1 ,. trs t\ts : rt trl i l i z :rt l o n| l Ii l l d{. ..i trl l ,| tl ,i \.., p;l i t -c r||,rl') l)., 1nl trriocloniili] care apftri fi. c] uni. fc1lotllrn rpilcptiic (109, din . rz.rr'il, f io p'ecotiri din c:rzuri), fie (3?f/o), I-ie siit (i;lco_ .(50.0/o rrl {,l t1 o olt 0r iz ele to n i c o -c l o n rc e . 'rmeazi, ,.) Ii.,i;.iii, qi clzuri de cpilepsii manifesl,:lte prin cri:e et:clusi.u ntio,'/,,rrr,1 ;1;.,,;1,,1"..irr . sleciLl in adolescen_ti _(dar.untori si in mica copilir.ie), l r , ri rrrir,(l,rnii1cm.rsire se produc rle obicei 1a treziic .si tiot t,i licilit-lte ', l r. ,l ',lr li. i' lr . t 1' .oc l rj l u i .. Ii c tl n d e p r i v rl o r d . o:rml . t, r rrni i Lr,,1n , mi o. .r rvi ,lorriiT,. (".jr.r'lis") p,rt fi pr ur.oc:l,tc de stirnularerr, lurninoa,sl intirrmitcnt.), i l i rr'1 f, r r r l, s i c qlf . il, , G,rs ta u t ;i c o ta b ., 1 9?4; A rseni ;i col rrb., 1O?8), : -1 9 i ; r'rr Ir rIl,,,i lrtt, lent:r,l,lC2rlzele S-o1arc, lumina de tCleYizOr, rle de ,,Urmriril r1 ,",\ izI rl.'L(J.'rerr iirg epilelsy,') s1u do stimuli irten,tionaii lpiiml.r:rrea r.rprrl i..:r rrriiriii in firf:r, u,.hilur, stimula,rea luminoesti sl,r6boscopiii,i. Foi,oir, rrrilriliilt,ieir ir,ccsl,Or desc:i'ciri este bine cuiLoscttri (Gastaui si'colab., t:);t.; \ r r . ' . r , i. r . j c uh J r.. 1 0 ;b ; N a q u e t s i W e k l rui n, 19?2). A ceste mi ocl o_ , r.rt ,t'rt,rl.r':rle'i sirlctr.jce, uneorl lilritate cloar ]a rtru.cchii periol,bitui " prrlpr.lr,;rli, da. rte'bicei sint difrue, debutintl pe rnrrschii axr,r_r:izome]ici ,rr r1rrrlrrri crl,inzinrlu se qi pe tnu;chii periterici. lliocloniile masirre pot lveil l11!,\'('rl4r r'-iililbiio (rle obicci 1-n/s1 si aprr rn ,,elisu.tde mioclonice)' l rr rl ri r' , r llr( lo 2- I 0 s , d a r u n ,rJ ri s i rn ,,s frti is mi orl bni c,.cu C nl rr,ti t1e trrirrr1r. .. Ul |hi:rt rl'- o|e, putinit cuirnina.intr-o crizii Ee]reriiliz?1ti tonic<t_ ,1 ,'r,r'.r . lr r r r iz r ' ' , nti u .l On i ,' ^ , U ,l l l :rl i r/r,i I.rLgr. pol .,i i 1l ,ri .r.i r:,," ,,.i ;i :r1,, rlrilii.ilc vigilcnfi, insolrite fi rle tulbncr-r,ri r-lgetrtir.v. l)iJgnosticul i. i 11r'r' {,r'iz. epil.ptice cit mioclDnii masive este con{irmat ,*i p.iri it*,eslirlrrliilr, lrltl(i, cu,ro c\-i{1 efri;iazl pclir.irf u;:i-Inde (s:r,u ungo'i r,!rf-ur[le si trrlrrrli, llcsoilr'liri (1o undo lentr, eelelalizetc, itil,,tr-rrall., si.rrtrrrn. ;i l ri trrl l til. c . l l li, t l, Uit r : t c r . s lo t'i rt,j z ,"rI )i i )(II ()I I j (j(| rl i ,i rn l tl i zrt.tl j i tasi \' (r eS 1r,r.l tr.i trl ri l i , l rrrl i rrrl s ii, r r llni ir r tn c q fu l .i tr, t,n r' q l l t.l o tc t,t,., l i rndogutr: si 4n utcr]i l ttl tttl i i ttti rxl tu i. t t r ' t t . t r lt t ! i. .r' .rry ' r,ri (rrri .r.l rrrrx ' D i 1 rsi rr, l l rrgrr' si vi Irrrrri l i rrl i il l ,rr li l r,rrl rr lr r i llr r v r ili< ' l rl I rI I I II I I )r)t 1 l ; rl i s i tri ,rg i rr c . I.Irr,I,IrIIl i trri .r,I' rri .i i :r l tti l i r trrr.r r l llur r l) . t!),1

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tl t l ' l ' i l t lr t t t lt ilr l, , t t ir r r lt t 'r \ lr t . t ir r r . lr t nr ilir r l, r ( lxt t lr lr r i lt r ll, n :rrtt It ,ul tr l rti l tnt, r r i, lt l l, t t ur llxt r r t )ilr . l, l|ll( '11, ( , I r r r jt sl{, ; lr , ir rr . I r |I r r . ( r 'r 'rllr r r r ili. r l, rI r l rl r' ! trr .ri l rlit r llir r r ir r clr r sir , ii: r . I ilr 'lr sir '. r r r ir r ljor r ir , i r lr . r r r ur lii, cr r r r ir lir r r r l l rttti tt:rl . l l n: r lr lr lr r r lc ir r lr r r ll) lll lt r r i ( cliillir r l r lr , vir slii ( r r r I ir r r , r r r I o: r I r . ,l trrr,rr,," ,.ri ) 1i lr ll o r lr r llt l. irr,lir ! ii llr I {l ll. li( iu o r r r cr lir . r lr . ; t r sr . t r r r i( Vr r . t r . . i , (,I ri r' I I I Il r, | | , l1) 7.) . I lilr t , litr , t 'O l olr zi ir r r r I lt ir r L llo I it zr ' : p|ir r r r I lt zr i ( 'f llr| ( 'r . ] t 1 ,r r.D rr,. si i l llt r , llili. pl, icf gor r r 'r 'r t lizr t , ir . r lit zr t r r .t lr r r t r tsr r lI l: t r r gii, 1i r r r ior 'l, r rl lt . , rtt| , r' r1l t,si llj ipilllr ioo, lLsir r t cllisc,llsir t gt lt Lq, t 'r upir lc; i vllr . iill) il( j( ir r iir r r p r ttrl ,trsi i rti r , ) . r \ ccst c r nioclit nii po1,I i1l, t I 'f ilr , lcsir , r r r r r , illiz: r lr . Slr liilr . t lr , gut , Ir' r' Ii l rtIrrtr ior , kr r r iill' sint lr pr \ r zont r l, lc r [ c r nr r 5olLiinnr t 'r ilor '1i lr i r r l, nr lr r t l L,r'Ii Ii Ii ' Ii ()II I . l) colr icr ei, r losit ilr 'cii, r 'ilcr lioclot r it t nt t soir r solcst r lr '; t ir , t r l, 't , r r {, ,ttttorl i rr{r' i si sir r l ilm plilicr r l( r alc nlis( f ir f il( r int en{ior Llr lc. l) ir r inllr rrl rl t:p u i r i r{ )r r ) t ) . - htc1r s1l uvglu1, , ioi r oliisg lr , sist ii,olr lsl, r lp lt r o r lcr r r r , r r {r l. t r' r'l )r1\qr' (,siYr i, . f iiz1Ir kt llr il, f il, Sin cnuill: ll po1.t pii|c: l li s0t t |llirr . r l|r r pit : r it r 1, ' rrrtrl rrl l ri rr r Lcor i si t ulbuvir i cer r ebelolr , sc, r'1 ))i:titrcrytirLtn' telotsri mi.oclonicii (o, LuI lltnr,su.y ,l/rrril) rr. lrrrrr 1,, r, rrt,,rrsl ;c p r ir L cr r ) bext ul ser niologio cit lg l, s0ci: r zir ir npr ) t li ll( f l|t ii) r 'lo|lil , i , u i rr(xJl l ,r [ : r n) it t l t , nliot r r Llr r , )cr ize o] ) ilt 'piiicLf cor r r . ulsir . ir gcr r . lir lizr lr , , 1 ,i,rfi lri{)cLoiricc inlsive) ;i ln sinr.lrom atolcbolos crr cr.olrrlio ploglr.rrir;r rr l l l i ri r,r' trr!i 1({, 1, t t ) i. 1) . I n r niliot it al, cit c, t zlt r ilor , S. L, . I . ir ir lr r cr , i rrr1rrrr I rr rrI , , rI r' .r,rri'r' rrt i rrior:lonice fi descriroirli llil(l t1o poliv'ilfut i- rll(l{r rlrr il 1"'r'ir r l r rl r' rri si : r r r t c do 1i li sccnndc ( I i nr lcr . m eclicr ,19?4 I lll, sir r r r li ; i lolr r l, , , l l rr' l ). ti fn t n t+:.fakryt (funlr lrtt cttiu, 'nioclotticii cu, lti.1t iL'rn. (It.1l.L.ll.) xr,r ic ll, 'i7 irrlilniirr (le lr,selnener] rnioclonii, ii{losoa rnlt,si\.1-, ("irtl,ssivo rrrr',,,l,r rrr ji rlis'r). r\ilt,lcl, 11rorzul.ile in caro sp:.ts]Ilole int0r,esolr,zli ]'llLl,oil l rrr. {"titr l rrIr t:i r,!r' i rt t i, so r cllizer zil it spcct ul do lnioclolr ii m r ) sir . . t l, r lkr r ir r or r pr r lr t t 0r {'lexit nr er r li'clor snpr r ioit lc; i cu lilc- xinnr cr r iblclol ir r li, r 'i, r : r lr . , 1,, 1r pl , i rr. L r,. 1 r1111' 11 1- 5, lr r sr r nlr ht : it it udinoa , , 1[ t , u1uiin Lr Not ] ',( xl] ] l] ilr l, ilir , rl ir r . , ,, ttrIi i rIrrtl rl unr Li bliei: r r , g')( t iasl, r , ut ; i col: lb. , 19ii- l) . lhoi, spil, sr ui. loir l, r'rr'r,,ii {lr)il,r'rnuscuLltur':l Lr'utchiului ;i a llidircirtii rrrornl)i'clor',fl(' r',,rll j :rzi 1rprrsnt ill ilr i] - l izom oji{t , c&r 'eil, 1, , sr .s! r I i1t l'f lr 1i: r zr i', r t t 'r t r lir lr r r r r . r lr . l, ' gr .r , ri zl trLi r;i rlolLicr r r iusiye ( r 'r nI 'oclonic jer ks") . ( lol nlli I ir r cr , cr r l1i r r r r i r . r Lr r l 1,rr.l i (, Li } d e spasr n ( pilt cgt t olr ior Licpcn1, r 1r oir lil lr r i \ \ r csl ) ( \ si{l f , l) ir , r r ll l) I' .' ,i ,' (T1)() /din ciizlr i t lupr i , Jcovons si i] or vcr ', ll) ?4, r i t ilr ) / , r lr r pii I 'op r r i o , rrr ,i i url rl ; . r 1li7( j) , iit r r e const ii ir r l. r 'llll sl) ilsr r ) rI riI )(|Ir)rI i (I ( J'lr \ o( lor r ( ' t, rl . / l )r' l i su, soult , f ulgcr ii|n, ', got or i[ lizl[ 1, ,r u I I o: . i r , giir r lr r i, r r . llt r t r r 'lr il l rtr .i r rttrtrt lr t 't r lolit t let 'io: t t or in yr t r nt , ct r lllit . lt kr sir r 1, lt t t r r , lr ir r r r r l, r r r r r r ir lt rrr l rl l ' , rj i r t t lt [ g r lt r tir . ir ,si t l6t t t t t nit 'r . lr , r sll r sr r t , , S: t lr r . t t r t "slu , )I I I r||{rr], r',I r lr trt1,l " , i ttl nrcil lr , nslr nblul pozil, iolr li, ls{r ilr r r illlii salut r r lor icr r lr r l , , f {r r lr r r r r r ". cu \l rrtti i i r r , r , ccsir ot lt t lt r ilosl, lil'i lil sLr gr lr( ir r lr t 'iiir ul ir , r rr lr r r it r lii) , t r . ir r t i l ul r l )si l i onr olior ic ; r i ir slt cclul I ilt ) ( i cl, r 'iit l, elisi, io ( , , lr ipsir lilnr ir r " r i; r r r ,,rl i rl i l tri r l u r r f i t nl, jot 'i" - ( iilr lls si coiu1. r . ,ll) 54; ( iaslr r r r r l, lt r , t r r ot r r l, 1i l 1l ,)i j ) 1l i l )i rlil, zi, r n{) r l ( lili' r liagt t l) sl, i( 1r t l. ill l l . tl l i ot iluiilt f opr r r zinlr i,o yr r , t iolr r r l,ro r ni0olor t ii, ( , lr t llur I r 1r ; r , r 'll l rrr lo l rrrl rl t;rrtrri rrlogit r , il sor r sr r ci sir r l r 'jllr r ir r r r1r,rrrrI rrIrr,r'r' , r , it r r t t r t r r ', lt t t , r , lr r 1, . , r l ,r r I ' ;1rI 11 I i |,1 rI i 11 r r , q. r lii, s1, r , r 'r r ol, i; ) 1. r iv( f lr l: r r r lr , s1, r r r t r sll r lili. r 'iiii r l, r lr r , , I lr l\ , , 1 ' l | 1r r' :i r, | | l l ,ll I . i lr 'r jl0 r i ll0l) ost r ilr r {ii, / r r r ir rr,l r r ', ir r g, . r r r . r 't r ,r'l,i t rt i t r , , ', rrr i rl rr I i I r r,, r 'lr r . i lr r r lt lr t , , ; t . t sir r lit t t l r r r , l t r Lr , i: r 'lr ': lr , r li ir r lLt t : t t t l $r ) r' llllll (l rr| a r,r,i rl.ti |r r l r lr . , llllif l ; Sr r lt l'r 't ir ',l1) {ii ; l'r r 1rr Viir it t 1i r r olr t , lr .11, . Ar '( , r l'\ , iil) rrri ,rr' l rl i l i Irr r ilr '( t r r ir r liI r r t ir ) it r l, r r t 'r r t lr z t lr r olr ir r r r iiil t l) r llr t t r . t t lr r t r . t r , l r l, ir ri r l115

r'(,rlrlrH(. p'efi'r'crr(i:rk,: rrrrrrychii rJlului p:rl:rlului(,.nisti)Srr 5i rur,.' ,l \iillr_ Irri)., liI;rlingt'lui, h.ring(.lui, aiplan;cului 6ucal, ai timUii 1cumisliri irllctr rrrrl,r'rlrt pr.ricclic - retractie), ai gl.oiriloroculari (cu ,,nistagmus',ocular l)r.rrtltrLr, girstor sau retractor)r_ ridicdtorii pleoapelor, rliafragrnul (cu srrglri0, rrru..r.hii inrercosbali, muicbii gitului si;usctiii diilati ri rncmbrclor j.l|l]r.r'irnrrc miiciri ale degelelorqi cu (cu_migelrialtemante rio lrronalierrrpirrir,{ie). Cele rnai frecvente miocloniilo (mioritmiile) or'ofa,rin!1o-sint_ lrlingi()nc, precun fi cele oculo-relo-faringo-laringo-cliafragmatice, care Firl l)ilaterale,.cu un I'tm de 12,0-180/minut pi care "sint revel"atoarepeltru a.[u,;!,i,wni ale_triunghiului oliao-dentorubria(&uillaln si Mollaret, 19Bb; Bon_ (luollo, 1968i Gastau-t,1968; popoviciu qi 4lajouanine qi colab., 19b6; colt,b., 1973) prin leziuni yasculare, ercefatitice, tumorale siu tiaumatici. Ill. .. .Miokinlile. s.au Jascicu,l.aliile musculare sint contraclii musculare l,rii( i(:lilirre. dc,mici arnplitudine. eare nu produc deplasiri SegmeotaJe, rrrur.se-obserni, Bub-pieLe, _sub forma ulor contraclii-clonice, ieritmicej lrrlritte, fulgerltoars ale fibrelor musculare izolato li caro so succed la inter.i vrllo qi neregulate. Aceste fasciculatii' apar uneori pe teritorii ^lirccvente pe grupo musculare intinse, chiai gc nelrallzaie. rrruffi11s1, alteori Sint net rrurrrntuatede frig, de_ohoseal5,,_cle percutia muqchiior,-de excita{ia electriei ryi do arlministrarea de ad.renalin5. Nu sint irifluenlite nici do' somn, niei rlo srupolaminl. Vulo-araa semiologicd,a miokimii,Im (fasciculaliilor muscalare) este . rluoscllitS,,reprozentintl un sernn precoce, revolator- pentru o sensibilitate rluorma S,a fibrei musculare la mediatorul chimic (aclienalini,), consecutivi, rrrxri rlc_rervii,ri (feromenul lui plnngnl prin.leziuni, subacut-cronieegteri oru.ionala (sclerozd, lateral* a,miotroficf ; poliomielite subacuts qi croiice; r.nr.cllopoliomiclito lirotice subacute 9i cronico - Dr[Elnoscu si Otteanu. M56 ; gi1ing66i6l ie)..So igpune multd atenlie in sindioamelo de pseuclonr.lcrozl lateralS,amiotroficd (Barrd gi Roger, cila!i do Eiser, 1952) prin Irrsirrni corticale (tumori parieto-fron-tale, a,rahnoidito etc.), ln care so poate r1)illiza o. monoplegio sau o paraplegio corticald, phamidald,, inso!^iffi qi . rlo ltrofii musculare cu fasciculalir, dar. prez-enfa in coltextui semiologi"e rr,r.r'iz,'lorjacktoniene odenteazi de obicei diagnosticul. _ Astfcl cls faaciculaiii muscul.are se mai pot intitni qi itj c(ffeea jibtitorf l, lu,i Moroan, care esljo o newaxiti, acuti Ei caro &soeiazi b 6ntoxtul norrriologio; f2,g6io1l2,!ii, mioc_l.onii, tuiburiri neurovegetative rlo tipul aerorlirrioi, t,rrlburd,ritrofice qi sudoralo qi eveutual tulburari do somn, . .fr'usc.iculalii_musculare. izoJate la nivelul mugchilcr felei pot fi observ rr,l;c sptasmulfacial peri.feri.cpaslp6ral,iti.c. in INncep!,ional,d,a pot ti intilnito Jasciculafiilo musculare ln potirara,r. ". rliut.l.on.earitre in unele p olin etri,te inJeclioase fi tasi.cs. qi uneori-fasciculalrii izolate_la basedowieni, la i:rdivizii surmena_ti , J,l..ri,std, musculard,intensfl la indivizii normali {miokimiile 5i rrntxrri dupd, o obosealS, lrri {'rrrt'ho1). {i,1.!. ll{igctrri involuntare alternatile, regulate, rilmiec ;i stereotipo

Irt1tlI Iotrirro lrilxrJrirrr,l,ic (;llrrliirrsorrilr,lr)rlivcrsrrrrl,ioplrlogrrrii rlrr (poslorrcr, lrrlilic, rrirI'urrrIIrl', posl,lntrrrrurlic, strrrilrrl,c.).Alrir,r'o rrrI' rr( i rIr,r'r,Il, llror ltr rzi(ii(ittrtlttsiv lrozi{ilttir:ttrltit irr us),cslc t il trritrirr Irrrr1rIiLtrtIitrrrI(,t rlo rttor rLl,i'h, lrr rll Itr'rl.r,rr(ii, rrrir:ii, l{) oscilr,{ii/sr,c.), (J r'oi,r'ornt'lit:illrt,rlrlogr.sl,rrrrli, (irrrilil, ;i rrrrrrrrrilc:rtr(,itttri lrutniirar,c ltarrilot., ; dc n tlo,,flr,r,rrr,,ir, rlrr lrilrr|.lor', llr,lrrrrr :r lolrci crr rlogel,clc ci.c.), dilritrrroluti, slnrclisplrcirrcrrlstrl .rrriqr,l'i,r.ilrrt. lrqlivr,, l irrlrursiliciila cmof,ii qi tlisparc in somrr. l)c rnllli,o ori irrlrrrrrsclzi, rri , rlrcrrrilir,t;o:r, ccfalici (rniscIli ,,tlc afinna,r'cr) sau ,,rlo rrcgrr,{irr,)). :!. 'l'ten.ulr\I,ulaintenlionalii,(d,ea<:! tn,nt) ap:rrc il sirxlrorrlrl rrr,rr,lx,krrr irr lirrrpnl nisclit.ilor acl,irjer, :r,oceritnirllu-sc'progrusiv otlairi rrrrrlczlollrrr,r,l rrrir.r'iilii (ovcrrtualtlori,rlrr,slh.qitulrniqcirii). Ilstu rnai arnlli'l dtcil, lrr,rltrr.rr lrlr Jlrr')r insonitr,n[,rrereg'ulatd,, rlisparc complet in reparrsqi Irr rrrt,rr{irrorr.ir rrrrr.i1rostuli. Se insr:festede alto sernnecorebclolse. :i.. Tr.enlurdlura optoz,l]ion este tot o trcmn.rii,turir ilc rr,o[irrrrc,rupi alii lrrrl lu sfirqitul uriqcririlor activc, da.r'esbeconstiluitl r)in osciLl(ii lirrrr.lrr rrIrl,lr, (iirniste,,biit{i,, dea,rip:i,ca?etind sii indeplidrczo rrrflu[)nll lr,nprxrtiv lrlrr obicci supcrior) dc lintii (de unde tennenul tlc ,,oyrozi nrru rlt {iortali'i," antagonistL"). Este ca,racteristiczi pentm sintlroa,lrokrrlcrrt,o ,,irc1iu1ro rrrlr.t'itro diverse etiopatogenii qi pentru degenerescctll hellll,o 0o|rr dc, elo lrlrrl' (lioala lui \lrilson qi pseutlosclroza lui Wcstphal-stliimpt,ll), rrsor,i Irr I u sc a,f)roapel,otdeauna si do miqciri de tip coreic qi de spasrirc v iololr1,r,. ,1..il'r.emurd,ttuile permanlnte 86 obscrri,;tit in rdpaus,-cil, ll (irtrprrt 6i rrrl rr{i rcrii r:nor postuii qi constau ln oscil{ii neregulatd ale ilegrt'ck.rr( ulrooli ir.r rl,, ',r :rlr. lruzelot) de mici rmplituclinc. Pot fi : .fi:-iolcrg (tle iltosr,:rl,i11i lt4t), (moli1)e (simultnil boal* lui B:r,sedow)," i pcrii r,itliene, \rt tt,ilittrtrtt. lt rlrrrric,ln intor'icaliile en mereur, cu nicotin[, cu coteinti. Nu so lrrsol,onc (lf, $('funo extrapiramidale, eu exeeplia ccTor senile. ;,. Trcntoru,l isltric ,si al sirnulan!,ilor trebuie diferonliat do vtrirurl,okr Irrt.r\trlnte do 1,remu$,tufti. Acost tremor nu are car.actelo rituri<,o qi rlu.rvr lilx', eri dimpotriv{,: apare intemitsnt, apare in prezenla epr:otu,trxllor', lrrl o 1l1yq1la, neregrrlat, heterotipie, Iiinit variabil tlela un morncnt; lrr, oll,ul\lrirlc_fio ln, repaus, fie in miqoare, are caracter net circurnstau I,ilr,l, l'iilrl rlr.pcrrrlent sil,ualiile emotionale qi/sau levenrlicativo (Soflo1,(rt,, de_ J1r0?) 'llizrr.rr.'. qi tlc .r .lr.rrrtltc ori sc.insofesto de ticrrr;i, spasmt:;i rkr curilorsiulri p;r lrrrloxulc, clownieno(Riser, 1952). {i.l.i}. Iliperkinezii bru;te, iliseonl,irmc, rapide, dc ounrolrr rdorrir, tlozor . rkrrrrlrr (ncrilmicel 1. . Ii;cd,rila coreice sint rniqciiri involunta,re gencmlizrd,r: (dc ohicr,i). ,,rr pr rrrrlominanld, fa,t5 ryila rnrrnrblcle supcrioarc, bruql,tr,dworrlr.rlllo, la, rIrfir,(,, il,$irne1;r'tiooasincr,ono, schirubintlu-se noirrccl;:r,1, lir, llrr gl'ltp do $i rrrrrslullll ll altul. Sinl; va,r'iabilcdc la un monrcnt lir,altul, so inl,rrrsilicir, ( lrrr.rrroii, lir,eforl,uri 6i ln cfcclirilrtu,rrnor acNiun rnrr$cul:llcicllmcl,or,ncrrri i rrl(,nfional) 1rlra,zi1,ind rniqcir,r.ilo vohrntalr', ca,rtrdcvin asl,lrrlilra,tlrxrvll,r,. iir. rrluLrrcl,z pinr'i, rlispari{,io loptus doplin lr pl,i, ill lrr routn rlilprr,t'. ii, lrr irr I rrr.olisirr! linritrr,l,o rrn ltt:rnirrorlt Ia, (lrcrnitnroi),irlr, }iklir, ltr r.rirrrliorr, do rrrr'lr.llrllr.rttir.rr .jttxttrllt.l:trrtitr'. qi Nfitt,ririfrrr,orlioo ,vr, inlthuso )n: q) (lol'rrrrt rt.tu,lii tl'utl.t,thtr,ttt), rtpltr lit rtrlrii,rlrr ollirrci in1,ro ( tr:[ttr fi lfl rlrr rrtri,l'iitrrl il oli nrrr,l lrocvrrtrlll, 1irl,ilo. ltr, lCrcr,pl,iorrrrl lnlllturnl,o vl r,lr|'t ro 11 rrrlrrllil. \lrrrrri ilr rrrrrlrul,rrl rlrrri lloli rlrrrrrtl,ixrr lr,lo.

ozi involuutar; rapidi, sf orcolipit, rIc irtcn. .'l'rr utor_ul.r'a1lrntir,o-m;$care silirlc viLlir rili, prc rlo Lininrl nivclui c-xtremitirlilor.Sc impune ililcrcn_ la I i(rr(rir,lrrrnll,toil,rcktt',formo semiologice fi, pa,l,ogenice : .1. lltrentlLrdlura ila posturiL. (a,ry1,-zisi1, lcp&us" -- lolmon vechi, ,,do tlrv:0trrx.llrttrzriltrr') t.ltrtltl 0sl.o t,or.iHl lxtnt,t.u sirxlrotrrtrl rrxlrlrfrjt,tr,rnirllri i(ir'1,

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r(x1r*(,s(r*(lrr i* .,rrlcxt,I scmiological rospectir-ei onc,t.riiin so ,i rrllor' (l(r irLloctic gencr:ll[. "i ""m] c) (lort:eo, itronicii a lu,i Eu,.ntington aplre la vir.sti adultti, fiild eredi_ lrrli si l'arniliilliJ.cu transmisie.dom;n:lnb,i.Atingc ir mocl'egal ambele ,,,.i'_.:",11!]i,. lr'nr-pli|gresild. biperkinrziiio sirt rnri emptc, mri ;1,)i.: rr:tt.r,cvl rnitr tcnto ,rzirrr'. decil in cureea S.rderrbam, tnr.r..uliiind ntrri .,rrrrrrricrAt";i mai ,,dansant',. Eruluetzr-r, cii tlnrnrr,iii f"o.t_pi,,,gr_esii;ii. ;i rp,rre 1lr, indivizi in r'ir.st[, pe tondul suferiniei va.sculare ::!rild :. , , ' ...,,1),..,'r.,-,,r::
r r r' : rlr c l e fo t ( o , a . oolr nd Ll_s e( , U f t , om o r uoojl , | . .em

rirll l)trlt ir ll. \ ' t nt . ut . t l11, l11, lr J . . . . r r t . . c c t t t r r l t t f : i

rtLrOiji,lrt.r.r.r.trrrlir.t,-

o l r l l tr 'l ' l tti I't1 1 :t) l r 'l r l l zi l r l i r ( ti r ttl r u n ttl : '. l l r n t i l nl i sttttl ''r tl ttr l tti l r r r r ', 'r , l | | r | l . r 'r i , Ir Ii r l :t, t l i sru t t t l i r t t l ri , IIItt II|' tIII||1 | I t t rt 1t I i I t t t I i t t r' , l l l ( l tr i i l l l , , r , r r r r r r c r r r Ir r r 'Ir 'r Ir ,o ;l ti l r .si tti r l i r r l o cr tl r ' l r ti tt tl r '1 tl i tsl tti l r l tt,i l r '1 i r r l l l t'l l tr o l tr t' t r l r '. r r t ( r t r l l l ttr ,:r zr i si i ,r 1 t,'tttl ttl tttr r l ttttl t,i t l t I I t I t t t ' I r i t I I t I i . St'l to l tl t , r r t r r r r r . r i ti ( ( ) t!,i r '( ' tl ttr l l l ( '. l ) i l u l i : t n t ul , r i Il r 'Ii tttI,' r 'tcti o l r tr r r i l i r L l i i ( tr r r i i ) r t' t r tt'r ttr l l t i zr ':r z:t l r tttt r , , , , r r r i I rr, t r ri I rri I i i ' ( ( 'i r l ) l ttl \ i tt j tt ttttxl si ttto tt i r r tl l l ttr tl tr r l r l l l r i t ( 'i l tt tr r i l r r t' 1 , , ' r 1 , . , l r l r , i r tr t r l i l i r i r tl l o cvo l tt{i o l ci ti p to l l ttr si vi ,. {i . t . i i . | | iIr 'r 'l i i r r czi i l r .r tl r ', Ii ti t t'r r l i l t'l ct cl o tti t'

l)iril,rllidille dc lacunarisin celebrel (inctusiv cLr nerrrrrcile ,rr"ol.igic-psi ;i Iricii). (',tttik ?)'on,ice s;mptomd,ticepot ap[re:t in t raurrrJt isrnole clajtio., ) (.or\.t,t'irlc rr unele clcctalopatii sr toxice (indeosei:i cLr oxid de ca|botr) .ri t.ltslula,rc. {',tt,",t rlln ptcrlr'upoliile inlunlil" r,,prr.riUl rl,ty I ult qindrum ,. ..i ) qcminlogic jl|rporl.rntr. clr ;r,rn,rL, pir...rmidaI,. r.\l,.,pi|ami:ll.ritrll||l,:9rrfe\l ,lrl{'. l)sr,)rcc ,ird.tr.c (tcl minL-llril,e\pnl ,ri si r.u ciiz,, opilepr i6...Du obicci r.sli.rrrrbatle Dc, mi;c5rile coreiceliind asciat; artesea, misciiri cu -hcmicule :|l (.]r,ltcr., toallzinrt o Coreo_eletOZj rytre'r hpnipleqiriIur est,' o bomicor{'ocrr. :lplli, rudlu.cbi in . 7). lr'ttllrl(.gllp infrni ilc ..i uneori ir horrtiplegiiiu sascrrl.rie. irr.,rfoslo Sr. dc olricti qi de rnigci,ri atetozice. h.) I{ernicarei,le d,in, leaiunile mezencefaliae (sindroanrcLe de ,n,uclezt, ) ttlt r-tllln.i.oarp snt infertoarc), talatnice ;i ju,nlatalamiu sint tle obicei \;r\('t.rre lr se .ecunoscin contextul semiologicde suferinli xrr tiilamicX. rr 'rclcncet:rlicd, istpric{irp:r_t Ia copii t1e vilsl,ri scoltrr,X, obicsi il nici r, t1r. .. i) .(.lareeu ( ||r1.r.'.rlrrr..rTrtrritLcoliTe, prin ,,contamin:lle', psihogenit, Ia un caz cu col,ee do \ r,r'rtirhrlt,Irin,rmitatic- Slilcirrile coreica au calacl,erc to:r,tlalc, apar ir1 sp |r1'r'rrf:rJ ecllr1o.Ijlor,srut mai a.mpleqi rnai d:lnsanle;i so evirlcnliazri qi ;r||(' I'ielnenle Dtihoqen e. .. .l;.t.l..,tfloc;r; i,wnlu,rtalr:iliseuntiluc, inulto, rapide, dlr rnutt mni li||rilitlf .i InHi rtcroolipe({l!.r.r., 19-,.,: . Tiaurtle , ,1,.,,-r,,lrlorrr1rN, .silt ;nisc,rli inyoluni;are intelmitenie (discontinte), c,Leslrl ,/ corrtplere,. brn;tc, repet:.te, rapide ,,litle clr:rcicr clonic, Ir.r.rr Lpc.-\cestc acio sillt inoportrlne gl absurdc, ailerea :.ealizind ,,ges_ lrti incomplt:tre'r, tloar schifate. Sint loarte cliferite ca morlalil,ate tle"ex_ jucrnntlrr, blelerospasm, grirn:rse,tuse, rtisucirea gitului Jttitrt rtr. (clipit, sr,r,r ,' LPului,rniccili :rlp_membrelor). Acela;i tic po:r,tgsi'r, lepetat timp fie ,lr..lrrrri_r'lu_ rr,ni,ri,minind absolut sterectip, pinii'cind pozrtc sti tlisp:llii, .r'rlirrrl locul altuin. Ticurile ccrleaziiin sorirl !i, la incep'ut,pot fi influonl rl(l 1r,l,{i critro voin.fri. Sc exagereaziiIa emobii. llorr,l,rr. (a tk.tttri,ktr l,ui Gtlles d,elu Ilourette) so polNe l'esunoi]lbcplill {lr. lt1.z''rrlir ii(uIi rnLrliiII,',gorreritliza1'0, pt'orlornilrrur!ri nivclul 1c{,0i la, cn .1r,;-lrlrllut,ir,N(,('ii|,t,'. s i Ulr [,rilbtrli-r,r'i psilricesi 1,uIbLLlr'i,r'ivol.l)ir'{) {10 ((]ol)r{,lrt'lic.i ciroIrr,IiIr). l)obrrtr:rr,zii copil,;iriil, rrlriccicrr ticLu.iir,r,riirlo, in tlc iritri,sir r,rlittrl lrlourtsit', po rnir,sur.rt, lutorrnl,rti,r'iirr Lrt)IIttr.riliIor, psi!to1lri,irr,. Nrr ;ii tio {,otrIrI,IrIr'i, rrrrll\rntrrlr, srtt0ritri,i trici llrrr.v0l r,si, olgrl,lli(:ii.
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r t l tJl r 't l i i ttczi c tl i 'r ti ttt'r 'i r ttl ti l ctr l i r l l r ,i l ttti ',i r l i 'i t 1 . . l l t l , t : r l r 'l r l czi ttl i t t t t t I t t I I t t t I t r, l t|r 'r l ,r tr tt , , , r , r , : i , r , r r t lr l ,i |t'i zi tttl r r sr r i r ) 'j l l In i fci i fi i l IV{}l l t]l l r l l l ' l r t tti t'r l ttl i r r i tttn i l i i l Ji l tl r r l l r sl tctr i r tl Ir t tl cg r 'l r 'l l r r r i i r r . r r r l . r i : r r r c l ll r r si t'r ' Si l tt' r n i l tl i ti i ,t'l l l 'i ttr ttl r l tr ', \'( 'l 'rl r l r 'l r l i l r l ', | | l ! , r , ( l ( ' rr t r r 1rI i I rrr I i t rr r tn o tl ct'l ti L |,r' l l l l ( 's{'r ]' l r j zr l tt', r 'tt r l t'tti tr 'l r ttl .r r | l | | l r I i l | r i ( l ( 'g ( ,1 |l o l si r n i i n i i :tl i l tr tl i l l i u r l cg t'i cl o t', ti tL tl ttttttl i ttl l tr r ,i c' t'i ti r l r tl l l tl i tt t'r l r r ttsi r ', 1 1 1 "1 r 'l r 'l r ' r,' rrrr(lllrj ''r l L r L r l r r i r . i t r tr to tl i r ttl r 'p ctttl e ttl , i ttt'i l ci l c, tl e r ti vtl ttl t' tttr r tl Ii r ( l 'i r l c l r 'l l r l l r l l , , r r r r r r r l l . r l t rl l i s( 'r i r i vi r t'i i ) l ) i l 1 r l to ttl r 'tt fi cr ,tl l c tl i n l r tr cL ', tl t' l ti 1 tItIr l .'tr r l i r ' ttti ti si l 'l tr r tl i l tt'' tl r tl tzttr r r r r l . l l t 'r i r r l i r l {i r l i . l ,i r Ii ti l r t r n i r l l 'i r l l r r si tr l 'l l tt{i l l , l r r ; r i . r r r i s c r i li r l e i r r ti cl r r i tl l r tc l tl cg r i t,l o i l i r l c tl i l 'i .i r ti t l r vi l l l l l tti l ti l i o tttl tr t , r , l r l r r r . i r r i u ttl n r , r 'i r r tl sl tl r j tt a 1 r ti i , $ l ttr l ttl r i i fcl r :i ;i r i l i tt ttto tl ( ( ,r r ,l :r r r l , r r r r r r r r t i , r 't . l r l i zj r r tl r tr n i i r r i t,i i tl i vt:tsr fxp t'( .si vi r o u g ti tti i tst,l t'( x'l ( 'ttl i l i |.i l l ( l i r l r ' i tt r t{i l ttr l tl tr r i str l r i l i Irrri r {. 1 ) r '('vi r z ttr , i l n ' ttttti i th i i Si tu l i r i l e a l i zo l l zi , , , , 1 , . p l r r i r , . i tr t'r n str l r i r i ;i r i i r i l o r , h i p ti l l i i r tl z i l t' r tl r r l o zi t'i i l ) i l l i r r r l , i r zr l r r r . L r I i I l r I l 'l r l r c1 i vl j : r ,i ttt tl ct'i tte i r n ti ccvl tl i ,. \i"lf)zl l ) {l r i ( ' l i ttn .i l u .l r ttl .i stt;r t l ti l r t.l e r ttIr i , l u 'r tIi ::u .l r i . si \tt tl tl tttttl t t!l tt r t t t r | r r t i i tr r r t'i l tl i i tr tt i tl ttr ttt:l tti l tr sti Ii st'tr ti r I l o g i 0 l ', i tttl l ',r st'l r i tl i tt r r |ttr r , I rrr;rilirrrrirlrilii. rr) ltdo::rt, dubtii' (st.:,tu.s )u Q,t ttto'a,lll* al hti lt o!ll.) t'r'lt'vi rlc rrlrtlli 'r , 1 , , ( i r n r ' ( 'o ng ( fl i tr l ,i ,, sr tl r e ste co l l str o i n l a , n tl tl l tr r ttr tr fl l l i l tr i tl tr l r tttttt'i r ',r ;r t I r r r r i u r r l l n o l se ch cl o ( l o e 1 I( i e f:l o p l l l 'i c i n fl ttr l i l i i ' ( i l r tl r ,l l stl r i l ) l i l l l l r l ) .\r l l l l l r co l i c.q i c i tso ci l r l r 'i l tt o r l i l t!'i 1 i r , I ri I'I t t t t i r I I r |: r tl r ' 'r r : r l l i I r r c l r i ti r r e o u tl a l i ) . t r l r r r l l r o l i i l u i l ,i ti .l c, r 'u l u l l ) r ':ir i l l si l l i ( '( r fi 1 l ( l ( r s{'i t {1 l r 1 'r 'i z( ' ( x,tl \ l l l r i v{'. l t ) l l o a l u. l 'u i l l r l l l r l r i l u t fl tl I: * i b tu l t. l tr i l 'o tl r i r tl r r l i 'r '( i tttr i I'tl r l l r l , ; . r r r r . t 'r r l i r c i a tn i l i r r l c ( cr r i r tst'ci r t{r t' tl tt'i l tl r td i i }r i Ir I1 r 'tr tIo I) r l l i ( l r r l r r $ i :r ( 'r ) t r ( l i r tttti t Vtr g i ) r r r r t ttr l , r r l r r i l r r i l , l l l 's) . ,\l ) l r tl n p r i r ttt;i tr t't' i l ttt l It l tr i ti tttl r ttt r 'o l l l r '\l ,,l,,lr rtlli i tl l l 'l l t N ( 'l r l i r ,l n l 't. ( ) r o l r l r r l r r i Jl r tl l t,tvo tr l ctt- Sl ) l l l 7 ) , t'o t|o tl r i 0 zr t q r r tr ctr tl i zn l i i , r t r . r r ; r o | i l t zi : t'\1 l tl l ) i l i l l l l i ( l l l l i l , l ti l x'ti r ttti 0 l , l . r 1 r , r 'r r l i i , ( i tr r ,l r r r i r 'l i r tn tr r r cl ti i i i '( r ,i ) , l i r l l l tr l i i l i tl t' t'ttl l r i tr '( tl i r l r r g i r ' "l ti r tl i ) ' r r l t( |i i r r o l tf i t'i , l !'l i l ) i 1 i i l ) i u l l l ( 'l l l r l r r r . tl i i l ' | l r , ' o ( 'u L|l l ] r .r ttti tsl i t,i tl ttl i i , r r r , r r {r r ; r r u g r tr i vl 'i r 1 i t.r i l r r s ( i r r ci l l vr t l tr tti i l l i r tttti r i l tl r r r r l i l i l i r l tti \ o ;1 1 i i l ) l tl z) . , rrr liiilrr i rr r i i tt Io tttl t,.i u vctti l i i , r t, l tti l l r tl k'tr o ttl ( 'l I , 1 , l t t L t ,l i r r p o l i r l r , l u l l ti tn i i IIt|) ti n 'u i t'i i tr . l tr i tr r tt Iktl r tr tl csl c o r r l to l tl , 1 , 1 , r r , 't r r l i r , i Il l i r i l i i r l i i ( tr tti i ) , r 'r r tt ttso l i i tzi i : Iti 1 tctIr ttti tr r 'r i tr tl ti t'r tttti tl r tl :r r , , r r l r 'l r r r l l r r Ittr "tttIr It Il , i ttl i 'ti o r tl '( ' si l ttttr l t!r 'r i ttttl ' tl s( x'l l ( l ( 'l l {i i ) , l l i |( 'l l \ l l r |z r l , r r r r l r i l l ', ( , r ) l ttIl r '\r , ( ;tl r 'l o tr i , l r i l r r ( r 'r r r l i , s;l ttttttl ' tl 0 i tttsi ttttr ', I t r ' t t t i I r: r I i ,t r t ) l tttt rl) liult /ti ( ttr tl ;l r l r l ,l r l i r tl ( l tr ,l i r tn tt'.l i r l r tl tr tl .i l l ttr ttr ti l ti n ttl tttl ttl tt r r r r .l r , Ita l;tlrl)(lil' i tl r tttt' l r t I ,{i I l '' ), I I | , ' tl r ' vi tn i i r tl t.l tttl i .l i tt ttti i ttl xr ,ttl i ) l r r , 'r r , , I r r t r r l {Ir '|{ ||tIi Il l r Ii tl r , o t ttl r 'l :tIr 1 r :r Ii l l i tr r Ir i l tt cvo l r tl i r , l ctr l l i ( ( l r t I , l r r r . l r i l r r l r r l r., |!) r 'i I, r 'i i r r ( i ( |( , l ) tl i i ,l r r tl i i i tl 1 i l 'r r .j r r l , l l ) i l ) tttt'tr r l ti r i l tt l r r r tr l r t l r r r \ l z l r r . i t r , r . :\r i r r r r r r z;i ttt l r tl r l r r ttl r tl tttr r r !r ;1 i r r : l i tl l r ttl 'i i t'r {l r ' \'r '( l ( ^ r l , ( tr l l

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pritrobtastozei . t') Ilncr,lalqtotid corsccutiDd, .fetate (i.terut ntralear) dc tUut. tnt,t.ntp((ttntt,tqk Joet0/r intrutre:te de fo:lrtc multe ori in tabloul _Eh i(\rrU,)iglc col.co.atel,ozi,bilateraLi,. geoer.alizabJ,, ,sociatd cu spasm de - ar,axiecnier"ioaJ?

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(listnnin lcnticulard,, corcea iui-Ilnntington ; .r"ao-oi"iI, cerebeloasb. 11 ),Ilamiatetozaesto rezdtatul unor leziuui localizate, care generaza jiil ].lli?l .ggt"togic cu hemipa,rezi,, silriro.ln t aramic qi'nip"rk'inezie de r rp r.riuzr(.
(Bjl.u. coreo-atel ozic). La copii tablouI a parr. dupL tr?umaf igme .i)l ,,i )srrLlr ( , J lo gr dupa c U c r.ti l l i re .(ru j e o l i c d ..s c arl aui noasj ,. L.ul reol i ci . dupJ, l rrst'. oonvulsivi,,

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accidenbelor vasculare cerebraleexceplioryi

(',!. I)IS?ONIILE (SINDEOAMELE DISTONICE DISTONIII,,E SAU KINETICE _ SPASMODICERISER.1952) ,'lirrt mirycxriinvoluntare cu caiacter tonic c:!re teurizcazia pllti':Il;tr]i, cnrc semrn!ine un timp rrariabi] (citeva *""aro,l" o atitudine *uo mlnutet. mal mult sAumai pulin durabild,pe care o induc. SpaSmrii l,r'rrrilrpcl r,irnra

lll"j:,.::--!]lli lll,.!ll, !o Tgp:t1 ||(. o Uri llutit suOrotrirottin tol cursril st,lrii de l,ogl(,(llnpol.i in sontn). .\r'r.,-trr rl.isronii,kiuciicc pot sj lie.rnaj mult s,u-urri'pr:.i; "i ;r';",:;i;;;i; i\ir,ll /ix?/,3nt.. lJe obrcerse insolesc,1i hipe.r.bonii de e.rl,rapiramidilc,precum rii rfrr-liipolliinezii, Aceste distoaii hirletice tealizeazl o'a"phr*"u'*'"g;""_ {lnruritii unei contrrcLii spasmodit,e lorens" a $nrp,,lo. .,,iuscul.:']i.ll:,Ii. rjUl'rlr.(!r'r-fi;11(r,conl.rtctie-crrrccstcprogresivi.re[r,ri1.dur;l).f-.(,aractcrul r(!l)r.r,rr,lr/ mlfcar rnroluntars realizate so datorreryle itt unor varialii nein_ rotnlr: rlc tonrrs mrsclhr', bmsc_diminuat _siapoi din nor i:msc exagerftt. n {x,stc rtcplasi,ti tr)nioe a,normale sint ritmate qi oarecurn stereotipe Ia rtrxrlrr,ri bolnav, putind ant.rena cu yreme& deformalii scoliotice qi aiiicu_ Lrtrr. Nu slnt $on,sibilela preparatrele cle tip atropinic.
(i.2.1. Distoniile kineticc localizatc L Torticolisul spasmod,ic prozinti urmitoarele c&ractelo semiologice : .. llu Bptsm musoular tonic antrencazii, o lonti, rotalie qi laclina{ie vicioasd, 1r,ol,pului, ou o contraciio a muqchilor stemocleidomastoitiian qi ttapez (ovonl;ua,l. o_piolosrrlui gitr ui do acooaqi parte, .rareori qi r murichilol qi. itrvocinrlri ,i glbulrri).uuor:r'i rxruLrac{ia, tonicrna color doi n.rry.hi ino'rrrr,t,i {lo (pinull oiri,obilltorluki,, il,r: cu,prl to flccto',zil 1,oni(r spro u.u.fI (rol.rrrcolini. 20{t

in frod_srereotip, lrlcvent qi -adesea f1;arie

\r'rrrrll'ri, rrorrl,rlclir lotrft,iiltrlrrlzi'l,lll,rrnlrlrtprl o trcrrr'1il, yrtu'irrirrlll, (notrrnrlr,), , rr!ttl litrir,irrrl rr'virrrlirr lxrzil,irr, xrt rrorrrlrli\, rltr. irrrcrlirr,l, lrt.orlttr,rr rrli, lo ttn (filrr"l lr.prrrir.ct.r,lrzii, ,lrrrltt], lrr lxrzi(,irr, vi0iolr,s:i, I11ll *i trt'llirlrrprrrhr, rrtrrli, rltr rlr,r'rrii, solirr osci[ir,{ii o rlc Iotrkr,irrcglllc, cilrc ]lol, l'i rnirilc rlrrr,fr1111,1 1u,1tt,, r rrlrri, cllt, r,on;(ir.rr{, lut, s(} ollutlt llr,rltrltLlsalclt, si!lr olrprrltri, ltlilr goHl,rrl rrrrlrrgorrirl cortl\ic, rnili rlcgrtllii,sjrrrJxrlic rlrr rlocil,olic:tco(l.i,iBrr, ll)f!: llrllrllt, lf)iri),ci1,tr,t.tlt 1$(i7).J3olr,ll ilpllrt rlo obir,r'illu lrlll(i li $oflrrlirt[, rrr.r'|Iltoh)r lrrrrgltrsiv.lr:i, trn it(lolosoorrt Vorn gi di irt f itnLrlrltrrl llr,,r tto , rrr','f;rlilri oltidcrrrioi, postcr sitn l[ o seclttrlii, rccfa,li{,i.ii, gixirrr rnlt,iilkrs rllroii, I irlllr $culno rlin selirr, rrlpirl,rrridllii qi dacr'lplr:zini;ii, r:r.izcrrcrrlogirr, exl gi r r,vrrrtur'r,l pareza c,onvcrgenfci globilol ocula,ri. f,)st,rr o dcosebil,ii, rlu irnptntln!ii, practicr-l tlil en!i?r'm ,i :llitului ,ltrrtttttotlit (tlc ori.gi.nce ra,piramlduld,) d.t: aLte J'ormadc turl,ir;olix, r.lnpfi , rrrrr lrrrrrti:r,z:i: l.lorlicoli,sttl a,\ con.geni,t&l csto perrnnncnt, irrstl{il rrtr0rlr,i r rlr. rrsimctlii trl.nnio-fa,ciale. Acest torticolis congcriital loltro I'i i:ol,vrrlrlil ttn',t nmllatrnatii crutt,icne,ocr:ipitale, (rlrr ratebrnle sau, nru,trcu,fuxt olriru,i ,,r irfcrr{iabileratliologic); b) I'orticol,isnlsimptomatic cste rnnstxrrrl,iv rrrror, ,'r izr. loc,ir'le tnimitd, localli (roumaticit, virol,icd, atc.\, red,i(rtLilii uroi.aqll : rultniot'it,s1ton.d,i,l,itd,, arahnoirli,td, ceroi.t:aki, acesto situ:t,l.,ii, ln tol.t,iooliHul r,rrlr, irrsolit tlc durcli in muqchii contractati, dlrreri cilre dc ,.rbir.ci sinl, r.r,rr , , r'b, I rrslu dcclanqatc tle tuse, de stri,nut qi de migcilrile oapul ui r ryi:llcgi t,r lr I i I rl I'rri!,ii.le aici.oase atpztlui tleterminate tle l,umoli ale losci postoliorr,rri ale '.r rl'. L.ziuui vetfehrc,lo(dc^pildii, un morb Pott cervic:r,I, ftaciurii, ru,rvi o , rrl:i,ry]11'111ip rLscaliietc.). jn acestesitunlii, de obicei tottiicoli$ulcrl.oIirrrlr tllr.r ic.irnintc, cu inclinarea, .laterali, capulli), tlacl nu drrfilitiv, ccl prr(irr a lrrrrp rlc. srlpt5.mini, firl exaccrbilri tonico, filr'L manilit'stririlespu,strrixlilo lr,rr I rrr iiil icc ;i rapid intcrmite;nte, o& in cazul vcriljabilullti torticolis slrrrn rrr,xlir... Si!u, elrerrtual,:ttitudinea vicioasii a capului (.'s1c par.oxisl,irr'l,'rlrrl ,lrrlr';rzii, citcva, orc, so ilsoleqte rle ce{aleebrrifall;i tlc vir,r,srituri (ciizr,hr ,.rIrrgxjiirr') ; rl) It'alsul torticolis spasmodiaad,re insole,ltc, 3u11, s(u . axtr(J 'li' tl.tr l .t i net:ralgii a nera occiptital al lui, Arnold,, se rccunorulo rr4r rr,, ,lr('ir I,incrtrsea,ma_m.arelu.i de ]ocalizareadurerii qi de scmnelodc a<rornpir,rrirr,rr ri,rr l, l,lituur 1i ntliologice) de lezirrne rrtliculrr,r'ii('r-('o (rr11r'rrze, rlirtrt,lcif irLl,r,i lrr|rr.lizrr1c, ]riperostoze, deform:r,]ii ale lNrlui olos ctc.) ; ri) ,I,ttt,l,itnliyLtl ,,rrrric(r'echiul torl,icoiis mental al ]ui Rrissaurl qi }krigr', ci1;rL,{,i liirrrr', dc llrl,2) $o_ccunoaqteuqor, plin car.acterulatipic (pozifionu,l), r lllin irrkrrrsi" lrrlr.,rr, ltrllluri,rii (majoratii r1eenrclii), pr.in callcl,enrl inttrlrrril,trrrl, (iru'{ill anxioasi,) qi prin depista,r'ca faoliot'ilol psilrogtrnictruzu,li. ,r (l(! rjt,luo{1, !. Spas,nulntonoplagi,c (Jiiscr, J 952) ('Iorrnt'n incorcct,,ll.ll. ,l\.rnr(\nul rrrri oorcet ar fi ,,Spasm rle 1;orsiurrc lrr,aobil,lt,). Actstn ilt.r",irr 1yrrrr,r,rl, | , ti r(1lirlo similir,r"c tor.tiurlisul spasrnorlic, cu da,r'otr loonlizilr.o urr rrrrrrrrltrrr lll rrrr1r.r'irIr'. vor,ba, 0 nriqcnrc de lorsiunc ircestui rntirnlrrrritr .irrlrrl Dsto do rrrrrlrri sIu, dc pronrl,tic ;i ilo supinl,tio {orltl,:'r,llt,rrrnativitr, urr Icl rlrr r:u, ,,rrluliu(r') illttnrrrr,tivii.Oorrira,o(,irr, spirsmfiljci[ esle lehljiv lcntil, qi plogrr,. rrvir, r,!t'(toricOvtr, rnili r:tpidii (d1Ir niciodnl,li,0u r:illilctc|ul d0 brusr;hoh, lotr,icil), llstfrl incil pozi!,ia lnorrnlllir, estc nlrrrtinul.il oitcvt, sturtrndo Jrlru'l lrr. r'itovl, rtrinrrlr,, plinl,r-o ,,hipcr.1,onio lroiti,ult),,' rlo (ltiscr, l{}I?), Allrin rrlrrrlrntl srrllrrr,iolr.r,sprcLiv rtvinrr Ll loc, llr.irr trlitrxll t(yr rrrrstrrrlrrl,trril. 'rrll'lr,Ht,i, rlooorrtlrur{io liirrrl tlo rrsrrrncrrt,rr, (in !.- Ii nlcrrrrrlrr), r1tr,6ri, ltrnl,[ rlru rrrrrorr rlltrl,t'[, t1r'ttcil rh.ol,intp xrl v irrr,ll rrlrou Hpll it lr l{|l],t,l,lr r1\l)iJl,li r,()l11,fl,(]t,illu. (1ru i(rolimtlui ttltrr.xtrrrxlh,,lrril)ul ttrrrrrllortrt,lo. ;ttttrt'tltttthr. Ii ltt trttzttll,(]rl ,{t,

201

(io(]roili\', ltr(r ilupir|it,l,iv, litrviziili ; $l).lrittttrl lttr (] rt'il,r11.r' iruril rri<,i v0irrlrr,r ri{,i l,r,st,lltir, trioi rni4clililrr irrlctL{,iorr*le aut,ornatc, s:ru trici rnlnovrr:loilo olrlirr^ll spllsrrrului(irrclusiv r.[on3a1,ii] p ltclivi r.,:in rsirir'r, nrcrnbrului re$rr, T)oll sornnul le abol,5te. 1rofiliv)rru llot suprirna spastnr:lt,. . r\ccst slastn brahial ap:r,rein sti,ri postencefalitice (de obicei), in sufelil{o \/tl,sculare, tra[maiice eti], {i.il.2. 1}istoniile kilotice gencrnlizatc sau cxlinse Ziehen *i Opytt:nhcim .. 1.. lJpasmul de [,rrt;une. (tlisbutia, lord,otit:tia, l.u.i. ; tl,i:tlotr l.entit:ulard, progresird, prezinl,il douii elt'melte somioloEice: disirt ) r,'0i;.ri luriiun(,1 (lla..li.r. 19..3._citrt Soil,.ler.lC6ir. .\.r fpl. ii, de lrnz;iir. ri{. ropll,us. decrLbil,, iI1 :rceqti bolnar i lrrr aplorrp., n(,rlDali (cu er-c,,p{ia corriil,atrilii :\lNor eyentmle semne-t1e encefalopir,tic: herniparezri, nins-ciri r,rrlcu'ltr,lozice q.a.).,1n momentul in o:l,r $o lidirii, !lin pet, t-rLrnttriirl e iniepe Lii sr,irrilbozo in lordozii, crpul se re-rroflectcazit,, eOoi, ollatil cn o:reciriar lrr\,| primilDl'pa;i, ap*re (sll] se er.rcelbei-Lzi) I lrurrrro r:le i,onusposu irrr'rl, o:u'c intereseaz5, atit trunchiul, cit si rnemblcti:. llolnavul se riiicd, lxr villirl pioioarelorprintr-o e\t,,nsit' a mombrrlor iD{criotre,a,poitrunchiul lslt inr:ulbnt in rnod ploglesiv intr-o ptternicfi lordozil qi rot:1i,. lxtr:nlr, lirrrlr in ou,r'e capul sc plaseaz:iir]tr,o pozil,ieda tolticolis.sau dc rctrocolis, irrl rncLnbrelc janpcrioarc se r'risuctrscirr pr.onalio sau in supilai:ic. Acest6 riprrsrrrc cetleazii, tot I'cla1,ir; lent- si apoi din troLl l'caplr, in mod alternativ, rrrrliziiul o lernarc.rbild, variabilitlte postuf.lliir cu rtltudini bizar.e, contorsiorrrrtorincit :icest ilspeot grotcsc a,l bolnavului :l fort fo:lrlc llastic rorrl)lrirl (Lccitre liiser (1.959) ,jIraocoon .-u inlirnt ui li,,,j,turL. (.ritrc\\iurmer (r'ilrr1rlc_liiser)cu-rn ,,clorvn mrcirbr.u'). Dil lrricinr lrcestor sla$mer mis-iar r,iililc voluntare silt inadccyat: si, apllrent, rrecc{)r{1on!,te, rnelsul cslrr r.rtlem do.cliticil. l)e f:lpi, se prodtic i.':tlialii toni{ro(in scns de hipers rrr ilt, hilxrlolie) la un grup muscular fa$ii tle alt Lrl iji dintf-un monrent irr rr,llll (lie siruultan, lie alterultir.; inert s-l qi sug?r,rt(,.i lt accastjl []oa1{, lrl rr yrn'ba rlc o ,,dismetric a r',plr turilol f i :i !rju.tifilor tonice,' (Riser, l1r'l). r lr, iji in caznl boh:Ivilor pr,rkins;rieni st p:)t rir jtfol, ;i l:r, aoe91,i lrrrlrrr,r'i, kinezii pr,ra.lox:lle.De obicli rn,rschiifetei si :r,i lirnbii nu sfnt irrlolr,riii, 11.lr rlescL.is s-::r,u cazuri eil ccintefe3,lret aceJNorl,roxlizinLlu-se : r'rL\lliirrrrlir,. l,tl'lu"ari de vor'l|lr'e lio rn yr1 .i i..,11., l)in,.puttct.d,e"leilre eti,op{rtog6??,ic, rlistinge mai nrulte tormedo sepot (lo irl)itrslrt t{)rsluno: r) I)istonia cle l,ortiltne agu-zisd,,,id,ictpr.tlicd",ialentificati do unii cu it.r, ,,rl,isl.rtrt ,masr:u,lorum. in realitate o boali, clegenerativii,, , -tleforrnans)),elte lllosirrril rne'labolicd, (Wooten qi co1ab.,19?3),de obicei cu c,.t t'a-cter eredol rrrrilirl, c'r,r'c ap.tre ir copiH,rie in (Eldridge, 19?0; Marsrlen s.r,u adolescentil rri llrr,r'r'ison 1974)si cirro poate fi recunoscutti, pr.in evolutir sa ptogresiyuctttt'. r,lizrt . tit il l)isknin de tol"r.iule sitnptomaticri est{l mult n-rai frecvent5 qi aparo . rfrrlri, srrrrin crrrsul svoluliei rl.nor {LJc.a!,i,toLi stru,cf,urilor a.la entrapiramiilalarl.(!(livolslr tntt,uti: Ancc.falitri (cel mai arlesea) - Alte enctfn, t:p,irl,enicti ; . lil,rrl - Il nrrrfrr,Io ii, toni.oa(crr oxirl d0 cl,rbotr de pikli) i - I)e11c.netrcsp tr,l, )nb lutltolo hnl i.r:t.r,l.rt(hou,lu, rc Lu,i lYil,son;i boa,ktIu,i, lVet I, htr,l,p Striint,p .) r In rt,ttr rt,1tl,l'rii ) r,li,l sotnitu (iuolrrsiu sl)it$lno trslt.r,llit.r,ttrirIrllc {j.l,ri[ol(]l.istitlo (lo lrlo irr(,rri, rr.iili,r'i ur)r'(fo .Il;01,r)zi()t\, r{Lrtrilr\ li;l ;l.r,r'liitisrrlir,rr),I I I rrr.il, |,rr r.

.rl l trrl l i r I rrrI rr,rrrrI I rri r , r r I r t rlt t i, Hr , r r r l r ll r r rli, r 'ir {ir lt r '|r rI ilii, ir r r . lr r llt r i li r r r u, r r l i l l rrr,l rr,r' rii , r r l; , lr r 'lr r , , t t t l'lu: r t r . r r lr r r t , 'lr r i", lllr r lr . r 'r 'r r lr . r , r r l, r I lr r sr r r ilr lr , , r rzl r' 1ri l r. 1r (, , . r 'lr ', I ir l ,)ttrt.l i tlr t lt r t liiit t . lir t r lilt \ lt r it r lt ilr r r ir , t t cor r r r I r r I ii,I r rr rrrrr r i i r r rrr , rrl rr l r .i r i r ,,rl r' . IrIrr1rrI r I ir r r r r si ct r cr , [ I r I iI l r r r r r r iclt t , olt ilit ir . r , lr . ) ; rr l l l ! i t' tl i d t qt , t t t t i ir , r ( ir ( , r l11'r lislor r ilrlI l rri s i rrr|(. i rrl r i, i rr r r r r r 'lr , gir rr r , r |l r l r ,rl ,r,,Lr. trIri r , ( ) llr iil( . \ ir l lr , , r 'll0t 'ir; t t r isciit i ( r olt 'r ) . lr l{, lozi( . r ,rrr lt r r ir , . r ir . r r I r r , i tl 1,rr:rrrr l l r cit . ) . 2. l l nrl c r t it : t t t lt iI t l, 'lit r r l, is]iu r l. it 'r lt ) lt lr t ) alr pol r , r lilizr r lr slr llll r i, , , rrLrrrl rrl o, Ii t r r Lt I r it t lI r i ; i lt r r r r - r t t lt icloi',r or rpliil r r{r r r , r t uillr , t ii, ( , r t r . lr l I , lt ir . . l l r t .r rrI i ti tl ttt' ir ilr ( '11) illr.rsisii ( t '|, ze ir r t lr t csilr(,ii t r 0 [ 1] iit n il) [ lt 1it I I I ||r | ( |ir i|( ||||I (l l i otsi l l rr('. , \ sl t lr l, ar r lunt r ilisr nclc 0ir cr r r ncr lsivc ( sir r or r ir lc ; ( , , ( , t iz( , 1r ,, lr l l , l ' l i (,(' r' ol rt r Jliir '1 , . r , r 'lt r f l) ikr plico t ilr r uncr r |sivt r ") ( r ot isl, it Ui lr . ( ) r t l izt t,' i r' { ' (' l f (' i l c lt lir r i, clr t lc polt t r r ut t r ir t li ct ir npkr ir irr,, l r r Llr ilut t lt t r ocolr t r i pl ,:rl r, l rol rtavr r l lc f lt r c 1n jluir l sii. r r .l) c lscm onot , I 'r isl, li lr bslr r {r , qilr r lr r iir r r ri zr: l orrlr olir kr il clue gillli: r pol, i, c 1i inlolt r il, i ct r o I ilr cllor r it r r r r ilr r ll rrrl rr ((l rrsl l r r r l ; i collr lt . , . l1174) , 0 ir lit : i Lir rlr sDer r tt lc sllisr r r r lr , lol r ilt r r . . on] Itr:' IrrosLi r: r t lr c 1r 'at r f r lr z: it t ; 0r 'ill f ilvO r t t t , t i t r r r ci clizt . r , lr ilcpt it . t , , 1i r r r r r r rrrrl r rl i sl i i ngzii t , : r lr t ] t ilar nidalcr pr in a, lt r r a cl, ilic: i, t lulr r i, r r lir ir lll r lur , lr r , (i ,||II r'i|1{IiL stii,tii dc r:rxirlicrrti si ruiolr}irliile l,11tr lrr-rl.rtorrlc.

ii.ft CONVULSIiLE (i.il.l. Aspcetesc.rniologiot'. rltrisdbilt'rlcaltc rniir,irlj irnolrrrrlrrlr,, S1r'e ,,rrrvrrlsiiklso pl\izitrtii s lt formi-t,tlc acatBe. lllo llol 1li y(uutrlt:;rrlt,,tl\t ir corliotalii fi insolindu-suct:l rirrrilrrlr.rr. rl. ;.rrrrl lotalilatc rnust:ul;ll,urn, r ,' picrrlcre tutali srrr rcl:tf,ivti:r, siiuii de constiitltti, sirrr,rIirrr1roIrirri, silul!ii in caro intercseazilun gmp rn iir:rtln,r. 7,,rr'lirll:, ttrtri irrtrll itrrI rrrlrr s. lr1r lin 0xirilt l. (lon,mtts tonir:osittl re,prczenl.iltc conlrrrc{,iirrrrrst,lltrr,prt.lrrrr i ilc tie atrtron(l:lzat, stiu\) p[,ro)iisl.ioii])0 t)lln(, 1i'i,, o i,rlr', (r1lr'o tllrI r'lrIirl lr.ri,r.ri l,rlri,rlr: iigirlital,e, (.,,r'l){rlill, crrt0antLent':rz,:i scgrnt'rrl urr srrrr, ilirrrlrol riIrr, rrrlrt,lrgtr, lnuscul ,ttilii t0tpol:rlli, JJrcrnplulr.r'lrrr:rirl rrorrsl,r'rr,liv l;rzri cilr, ,l'' r'oltla(1uri, lotricl gonu'aliznl rr, iu tliilepsiciglllnrl rnrrlturrrvrtlsir, lrrrir,rr , lorricr',itr (iu(', luzilulrll st'c11s;ololhipt'r1,rxriLr, (x)rrvlllsirr si rt't,lizcilzir, lprrir,ir rrr llrrric sl,r] irr cx1t,r'rsiu, irrso1it:i rlc o piclrleltrlolaLi,rr sliit,ii(l(f .rl!l r r1i
i tr(,i .

!. (l utt: ul. siilt clot ir l sinl r ni6r r ir i it r voluni, llu r list , or r r r r r r r r ,$lr , l{\ l , l r.l ,r' , i l rrpl ('r r o1t , li1ir . r . , r r lr , l, ltr 'r11 t( ) l) lit r ilp, t i( iit lr r *t r . r r r i; . iil, i lr r , r r qlr , , . r 'izt . l .' 1..i {' r,} i rkr . r nilr i g. u p. nr r r s<r r r lr rr', . r lur ill, rscr nl. ii ( zt x, i r l. sr r . r r ir r lr r r r ir r r r i, , l, 'Lr i , { rl i N l )l l ri ( , iir ,'r r pit ir i1i r , or r r lllclli, ir t lt , solt r l l) r , ol) illf illo ( chir r l . r r g. r r . r , r r li r t z:.| r' ) l i (l c ( , r 'lr rr r I r i r r r r r llo r r I i oI | sr r sllor r r llt r 'r sliiI ii t lr , t 'igilI r r {, i, , li, r , , r r r r , , r r 'lr [[l !)t l i l l l l lr olilt r t ir lt 't r lif icit f ( , i1, i i) t ol( ) gir I t I t , cl! r r ilr t r ilr , sllr t , c lr r 0lr ic|t t [ r' 1rk' pl ,i ci i . i r\r' ci i i r I r r t r r l'r lir r r nr r r ji,( lr r r r ir , irqi ( r llli{r ii) I n) 1. ir r r lr r , ir r rr r r , r r r illolr , r r r L, , r $i Irrhl :tu.ri ..tt r : ut it loqilr '; ) ( lr . lr . t lor r ii lir lr r r r , r lo t ur r r vr I I iiil sr , l, ( , r r ll( , 1, r . t lnf lt r.rrl i zi nrl folr r r ' l'r r i. o . lr r r i. i . ir , r , lr ilr '1r si. igr , r ( 'r r r lizr ilr , ,llzlr , lor r ilii, ( r r r r r i | ' ' rr' l i i ) l )r!'( . 'lir r r l |or r Vr r I r r ii|r.r'l0li( 'r '; [ r ) ( 1r r r r t r r l. . iiL, ] , , ir ', rr . lr r r i( , r t l( lr il f ii1 :10J

ut' roc'r,'iocisa,' r,i: r,J ri Ibcr rmi, ;:',fl i i.i l&"'"t#,#?ljlli".",ln,1"b i:llii'
(i,iJ.2.l,roblcme de diagnostic etiopatogenie topografir: gi .I. ln fal;a-rlnei crize conrrrlsive.sepune in primul rind importanta Jrroblcmla sl,abilirii dacXeste g" d".ir; 'care sau, dimpotrivE, {frc{, este rrorba de o cridd,conaalsiud, "o+? "pii.pli"; poate s, survind, neepiLelttiid,,

nr),srr pr.rxluciibilatcral-siuroirioo (,epiGpsiato"l"o'_"io"i"i generalizati,), ri.ur. ruril,tr:ral. (epilepsia tonico_itcinici ir"*igu"Lri;tey," sau numii

lrrlrlizitrrl sl,ur.cd, ril,tt rpi.lrnl,i, dtt 1{)rior} ohr)i(:; (r.rurkr'i, rirrrn. 'gr.aii .) p'r Jil cxistti ir.irtii, i.*iir[,,r''i,,irii, t'rri.ir nr,' t'r.r.* .[oni.L,,,t,pit,,,siol i il;i; ;iC;il dou[, fon'o pot

,{{rg'(r'.rul , i. lr,t.irr,I'l,r.rl itrl,(ft,vul liln'.,

qi de dezoricntare, aprtie,brirtipsihie, irclerenfi, sti,ri de ag! il:li:,1,.1,,1.:r t a t e . I i l I , li\ ( ll il { l ( ' S l V

ll. ,\tumar de d,ataetiopl,togenice uieele conaulsirse 4n, epileptice

6) centoutsiile i i n. k,r en ;o, gra uitli ad. T Cott aul s iile, rti n' i nt ) or tta! i o ;t tian ; n icd. Z1 Coo ii t xiilt din tu.tbur,iiIp pnrloarin" lr,ctrnie. pi*uJbniiop,,,f i.iOi** ;.u.j. ll\ Unele conrulsi,i febrile. .. .l)itgnosticul se orienteazi. uneori relativ ulor itt contextul semnelor .liri.. ;i de h,borator, alteori imlrlicind i"""stigalii Aeoi.",lit dc aminun(il,o 6i.,atente. Astfet, Gastaut.(19?3)._$i eop""t"i" "1i ffSZ6i;" pl"_ lrrrsd illercnllie.eaclintre ,,atac.l ckr.epilbpsie.'' A"?""r,ulsie tonico_ lresp"ctiv"rtrU. ,,'"uri"l,i,ra'- i'ouiir" u",_"o puor,"o ,lll,ll'lll[) ads !i sc repoti! propriu-zisi,, f|rzr'tlr ctret,gpilupsia o aiurd, mai mult sau dc mai pulh cronici {i care rr'zrrlti-r, rlin..dcsci,rcarahiporsincrcni, a unci populr,'tii';urotrrle. O crizi ,,rrPilo|tic:i" ,Iic[', precum l-r crizele convu]sive accidentale ("o a" priJe rrrrckr conyulsii febrile, crizele de.ecl;rmpsie p"o"pui"lif tolice, rrrcl,tbolico $_.a.) constituie o veritabili'epil"pri.,.';;p; nu "r,i"tu cum nu constijo o voritabilii epilepsie nici 1rr rcpetalea mai-muit s;u ;;i pugin frecveni.d, ir lnror crizo conyulsiye in crtrsul.unci afecliuni acute (eniefilopatia urerrri.i, rlin boola lui tsright, encefalitele acuti). CrirJ" .irii.pt,"e veritabile :rrr, tlrxri, un c&racter iterativ, crnnic, ele repetinclu_selat anumite intervale (r)rrr,i i!(jllrte sau mai lungi). I flngem atjenlia indeosebi asupra oo,nawlsi,iloy kiltoglicemtca din hiperin.. strlin.i:tnt.uL gi t u_ncftonal clin kiptirinsulinismul orginl, (i"oo sru ca,r(r|r,)nt irJtcelulelol belrapancreatice), Caro tle obicei se confuncli cu epileprrirr,. l,)xist[ insii, citeva elemento care ne pot orienta asupra ulei conmlsii li;xrqli..rnice: a) precesiunea crizei piin unele simptime revel&toare: 1rrIn,r'c, tchicardie, tremurd,turl, hidriazb,, patiitalii, anxietateI l)).ifr ist,(ilL!,a unor simptome interorilice,_ca : so-noterrali,,"concentrare ilificili,, itrrilrlrr'rru, ir,1;entiei, mernoriei qi a inlelegerii unor nogiuni abstracte, a st[ri

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A .. ()r.i.zele epilepN,ice conuu,l,s.ira la sugari.llajorita,tcLlcrizelor convulsiyo ... itrlrrrrlilrr i.r'(itrr r.r.pi*r'r1e.o cunoqtinfir, rt' itr,u cro obnubir.,rc.Nu tre. 'sirrl; rrIr'1srLlil'irr]rrr}iu|ir{,rr, rreos.llir,iicu oalo copilul mio pr.zitrLit 0 cr,izit,r.lo 204

r,pllr,pHil tr l'lrntl tttic llclor prtllrgr,tril. lir, rlr,uztLr otgrr,trir:r Vottt I'oztttrtil t:rrl6 rrlr Ilr\lv(!ll, (\ lil rtln otiztrlot' opilopl,icrr ttttgrr,t'i: I ) lll tnt,nqo. (pt'irr frr,ctori itrlrtIlrrrrl;rr,li trn,ar'.lulo1xtl,iu, ,l,ittd, l,m,ut olrnl,o. Itrlrrli) r'gl,o c:urzlr ooir rnlli 1t'rrrvontit rrcolsh'1, llr virnt'fi,,I'txlto sl'[fio orlrrr, rlr, rr *irrr.;rlii,tr,4fi.r,ir( hi,lnnit) n,aon otu,Lil sittt tlo h,nnontgi,i ottrclru,lt utu, I l t'(,hn.oidick0,Ittovocirtullritr:oircullln"utlooortlottttrt,ttitnotrulliirloculrl orrrIriIir111|, prolurrgit, munopot'o lllutalo do tlcga,ju,r'o lt'l,vr.r,liu foIirL'[, rr,lrli ,,rt,, rlr forctrps, vitlext,t'it,c{,io, cxpulzii lrtltorioilso (prczotrlt,l,ii virrirrlrHr., rltrrlrxrii, iror'{,ioutcrint'r,), opora,{iicrzilricne (prin soltimbtilo ltlrrscil rlo pro ,rtrrr,), ltjliziIr'o tlo ocitocicc, b]oo:llcit,cr'tilol rcsplriltot'ii uJo frlt,ulrri lrlirr q.a. rrrpilir(iu tlo lichid arnniotio, rlpl,urii, tlc pla,ccnt':i1, )! ) .Mani,nllitre encefa,lita : mtningito acutu ba,ctrrt'iotro nrrpl,L.r,, .lcDrile ,s,i r.r rr,I n,cnto bactcricne, viroticc, richettsiono, lucticc ntc. rllI i1,o ii ) I I em,u,toama subd,urale(fotrtc frccvente lil sugar, pinr),lt 60'/, rlrrlrr'i, \rir('ui [i colrb.), angioame (28o/sdupl Arseni 6i colab., 1071). .l ) Putapitoza(cisticercoztl,, hidatidozd), do ascrncnul l'oir,r'l,o l'rrrcvcrrl,o lrr rtrrglr'(Arsoni .1icola,b.,19?4). t),Llleence,faloptali,iTtri,nJactoriprenatrali(careaunoliouirtitrprrr.iorr,tll {l|z\ ()fiii.r'iiombrionarc 5i fctale) : a) Anomalii congerlital.a (iuolrrsivil,lroDtllii .,rl'rrr()zonLiu,lo), produc disembliophziilc {ct:r,Io:mlrlfOl'lllll{,ii: r': rrir,rrrr carc r r, (rrr'r,('rfitlic, oxiccfdie, turicefalie, scafocefillie,piatiblrzir., irrrplr,rirrrr,, lrrnil:rlii). b) Malfortna!,ii cerebrale (microgirie, polenco{alic, tnlllirlrrlr,(ir,. ( \r'rrrrlrf lltirrli). c) Anoma,lii occi,Tttto-ceraicale, Mu,Ifor,nru]iirtutturtltn' <1) (i,llAi()rriLliozir, cerebro-trigeminali,, boir,la, lui Lind.a,u d,0.). ti) AJit,l,iu.tt i _ (prin factoli gcntrtici): la.*txtd ntJiilt, i 1i tel&urfumoza 'ltrnrtlrLhol,.ice.feXale ,{rrIr')tirI fonilpirul'icii, sinrlromul lui ILutnup din por.Itirr,lrclll,liot'l, sol,rrrzir, l:rrrrilirrlii diiuzii ctc.) ; lipotlistrofiilc sauslingolipiti ozdo (irlio(iir,IrrrniIirrIIr, ,rrrlrrrlrrlic;i lui Tu,y-Sacrhs; a boala lui Niernlln-Piok gir,r,goilirrrrrrrl; lrrrrrlrr I llrl (liurolrol el,c,). f) Atte, aJeeliuni,metubolicaeraLlil&re: ftrlilrrriotrrrr,irr., lr,rrrrrrr.isiilrnliir,, zlcidernia hiperfolicii, piridoxin-tlepcrulcn{,il nou-rriiscul,rrlrri, gcnetiae tulburd,ri ale formulei, cromozomi,o,Le.' au r,l Niutlto&me rirljrrrrrrrrl lrri lt linoftltcr, silrrlromul lui Patau (trizomiu l) s:tu ttizolni:! li, lb), rt|||(||{|rIruI Erlwards ('l,rizornia sa tlizorni:r,f 6-l.fJ), itli0{,irr, lui E rrrorr60f,,l(lir(ilizorni:r,27),h) Infec!,ii materne(lat.srltoli or,rrptivo rrrrrrrrri, lr,lt. rrrrilrr, rlr,, rr,ltir paratitara uLl rnunari( rxoplrr,xrrrozrr) boli infocfiol,so).i) Afec!,i.uni. lopta,l,ii p,rin aplenlitizi,ci asu,pra norzci.' tr,trunrr,t,isrrur IIr.lrIrI rj rrrI IIr II ,11I,)rtrr,[t rl{\ lrlluurli gosl,ilntc,iradioli cu rulit{ii Iioontgt:n. k) '1'ttlltu,rdri. nu:hr,hl,irt ttlt lunttr(\ oa;'o pot prod[co oncelirllopll,iiirrla,nl,ilo (tlilr,hoi,, lirtrrl,oxir,ozi), t'lt.). L) It) ctfu,lopuli.i prin aJenl,iu'ni tt ambrionare6i,fttuk ltrit irloorn1rrr,LiIrif rlrri,rr f,rct,rrr' ou ic1,<t'rruckrilr. ALli faaktr,iu,ntennktll rlrr n) (vllirrirr rltrr -Zfli, ioo otc.). rr) l'rcrnd,tur,;l,atp.. lrr li lrilrrxrf f/ir lrol.llil,scul;vrr, lrtrhrti sii Icctrtrolril orn oonruls,i otr.,trt ilt tr tr *in,L rtt i tr..t,b.iI ep i.Lep lioe , drlr orlrolutooli pol, lilsrr, ploo rp, 'lr rzi(irrtrliklrl,irri : l-,\pttt lu,l,ltoltttl,u,Lrti pl,ti.n,s (,,sp/rsl}r,c sLnolol,lt:r,llrri Itrrlrr,tlrii de tht l,r'rvr';, l'r,rr rHil lio tlt oligino llfircl;iv-orrrofionlli, o t.oirc(io lllrrrril xtrit oit, rlrr rlr, rrrrrri,,. ll|rrsc srrrl(xilrt,n,!tiilzilrsrrrril lrlitrs,itr H|r,r,lrrlrr ittlli, rtpol s1t rlr, llt.ri ttt ltolrol,tr ott 1rI'rrftttuIr,, irgii;l(ic, gtr lril,jri rlirr piliglrrrt rii s1 1vi,ril,rrliilil, rlrau rlrrlriprl ltrrlt', cI _lrt rrxpilt(ii rlitt crr itt co rtrrti1tt'olrtngilo, irlo(lxrJ,t,tl Itrtrrlr', r'rrrtr. l'itttr,l, itt xli|lr,lrL ltI Nl)itsttt gLllrri,rl0 tttlrlrr olt rrl rlrrr,ivll,tr rlr,t'|. Ittlttlrtrt'lttt|t, irHlisi(,iclt ('lrrlrrzii, rlrr llt[r1rylrrorrvrrltii. ltttltr'1, l)i(\r'rl(rrrr ,,lIrrr\rl r,tlr,yrr, rrrirr lr,, lrrllll rt'irrlr,ri ltr,t tll, litl,rlytrttt,r[ ln r'tizr,hr| r,rlr. V l,i.rltlh..
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l rl l rr { l : r , ia. r r ' l) r r i r l :r r) rr' ri l tl ,i l i r' l :l * { l { r ' ri l r. l r)sr.rrri rrl l . l rrIi rrl ,,:.il rr r.l , r rrrrr .rrri r i I rr lr ll, l( l rrrr s c 1 rl ;r,g c rrrro rrl rl i j rrir.i t,l ri rrr i rrLrrtl i l i rl ri l ri r r rl i zi i . ; . ( t r : t r t t r . ls iil, h i l n .tt.rttti t r, (1 c l r' i l r:, l ri p rrl ri i .t:1i c.) r.i r.[i ci i , , l ' .obl ,rrr. ,I l rr,: r lr r lr . r lir r ar r , s i i r' (l ,t,rrrrri r,l i u c h 1 h a l , t9 i . j ,; pc4ruI' i ri u qi col ai r., l f)?ti ; | ' , l I )r)\ i (. i II si l'iisr,rrr 1(tT9), {hrpit .llnr vo'r r.eilea iir coirtirL.*are: tj Unele . irrl i I rrri'rI t rr .'tr''lsi.i ,,:ir,cidenl_ale', gcnerate 11e'liL:b'ii1 'r', 'olLzi'rrlh l rt \l lr . lo s il1, r lc l tp t ,,s i n ru l ;e c o 1 r.u l s i 1 .c ' ' l l su-r,rqrl e s21 cl rcl i oi ahj l ]ri l ri rii s r . r )r i rr.tu l i e l i rr.i ; ,,1 \l h .h , } ,t rzi ti un .Jpotcl l l i rtl f' e\,()l u_ tl ' , llt : i i r r'p ikr 'pt irr,.; r l) , \l tc l e s i n t e l ,i l e l ,)i i rL l i L i i l i i r. rni rt,fenl :i t0 si i ;r l rI:rr,,, res_ hillctl.ct'llicc, rll'l carc silt e\ it{ter}lil,i,e 1r.r,iiIr'Jr (,1)ilrt)1t(i0 s:l ,,pl,ccipiiate" ,i, rlii.il. Iir)r.ilt' intruLlc'te; tr) Alte colmlsii {ebrilc pot sir,intr't, irr c.nl, rlirl r,lirri. .l u.,r' rlcningitc, oncefarite sau mcuingi). c:cliLliteinf:rrrtilc, l )()rl lir r ili' ir ' oit lt t ' l L :1 , c l i n i l i i . s i l l l i { 1 , p tL , {.urr sj p\-rti i 1.i i t,pci t pl eci zi ,r, ,.:., I i' r , , : r r ' , r l' : r:.,,1 , 1 ,.\,J n r i ,rcrrl r,r. ' .rt' .g { !ti i i). 3 pu,t;ttt.of i[iu lin sugal se rnarrift st:i rmr'lt urai t,rcvc}rN tlecit ]r;, a,Jult lrrirr r,riz. t,.rr'alsi'e crL pie'dc'c 11ornnoqtirifii. Di:rqnostic*l cste dr:osrl ri l rl . r iilit , il, c u r t i l m:ri l u 1 1 ..,1 i n r' .rrj r uj i rLl cl i i l tl ' .l i i l or ci .!o rorba 'il rL . rl rrr s nr oi ilii (P o p o rl c i t q i c o l tb . , 1C 76, Igi g; Ii i gi l ,[$rn si -tr en l \rl ro 'i{ . iu, t 97E c ulro gc u o l i Po l e n r.u , 1 :ri 3 ) ij i rl r\i s,,r.rrui }rri l l i r* ' stei i i l ri i ,.rlr' lrozilir', r rr:rni{rsl ii.r'i EE(l .rnt :rrrrlriguc i.i rlpl,rrtrnl,(,. lc ll. lri:tle tpi[r:p!lce rt)ttt t.rl il:t L(L rro?il. t

i ttI) tII tIt) t|'tttIt r l , :i r 'r tn tt r l , h i 1 t, tl , tl r ttn t' : ' l 't i , 1 , , yi l ,l tl i t, i tr t'l i l , 'l tu t'ti r tttl tt,r l ,; r r i t I r I l : r i r r r |r ' l r l l l r l .l ,) t l ttl tt r tt i , ttl tttl tr l |tt I r l I r 'i r r i t l r ': r t l t ti o t,.tto :tr ,.( \tr u tti ;r i r r o l r l r ., l l ) t'.) t: r 'l l l t n ttl ,ttttttt i ttl ttr 'r r , I t 'r l t y t i t t t t r t r ( tr tttl l tr r ti r r L l r . l i r r o l ) i i r l l r l l r r tr l r tl {i \ttctr i r ,r r r ','l r r l ' l1l, xi i :l tr t r t,r tl tl i n '. {l ) l l i ,l tu :r 'l i l i i r l * l r ttl i ttl ') ; ( i t i ) " l t' ). tttr l ttr tl r ' r 'r t r r r 'l r t l tr r' rt | | t.It | )| i t.I t i n tn n ,l t',ttl tt.l ttn r tt xttIr r i tl t t ', n i t t i ( c . u i i r i i l r l r i l r r r l r l i r ,i l c r ttr r l o l i i , o tt Ir r ttr i l l sl i i ,r 'i {r \l 'r 'i r l r i r 'tr r r i r l ,r I r r r 'r l ' r , i r | r i r r r t r r r r i tL l.tl i ) t( f o i i ( fr r h !i l zi i , r |t\t 1 J tttL .l ,t,l t) l t,t,l i I r 't,,tti ,"r i t.l ,tttl tl 'r 1 , r r r r l r t r l o i 'i i r r s.l l tt'i i l r tr tcti r r r ' ( r 'czi cl i z,r l t, <r p i l cl r l i l r r tr tl tvl tl si vr ' l r , ttt'i L ttl str ) tttti l , i tr l t tn t , 'tt l.llri:tlt stn tu [,si r r ' 4 ttu 'n tl i :.:r tl r ti ( r l o tn l i a tl t t . ; , t t t i r t [ o 4 i l sti b a r ,tr l ( r :t,tc r tsr tt'i i tzr i ,t'r 'i zl r r ]ti l ( r l l f i t'tr , t t t.t rt i l l rI ; r l i l r r Ir 'r 'l .r 'l r , l i i 'r ', ( l ( 'g Jr r l l i r tc 1 r '0 g ttsi t,i i r , l 'l l n {1 1 :i i l l ) r i i t1 ,L 'l tr l i ;tl tl r ') l l ( f o !i 1 'l l , r r I r l r l r ' , ' t t ) 1 . 1 t ! l i l t i ::tth tr t:t.ttti( p ,r tu ,r L t'r ,l i r l l i l ,i s!) l ct1 r ,,,u r 1 i su l r ,r ctti i . s t,r t l l r t, ,,, tr ,, I r l L i . r r i r l t r 'o zl ti r tr 1 sr r i t.tl tl L ) . r \:i l ) 1 ) r l tl l l cl co t,r 'tX'ti 0 i r l 'i tl o q i r tIi <: ctl l r tr 'p Ittr r l Ir 'r , , , r r r 1 r l l r c k r L l tti l i l tl tr r r r o l l l t o stc tcl - o l tl o t . . , . ( l t i : r 'l r u r ttt:tr .L si t:r h r .l u ti z, so L i l r r ,r r : tl i g i tr tIl i ,i l r l r r I) I( |L |, Itr I' r l ( ( l r , t'i , r r r ,l r r l r r r r , r ; ''r r , , . i i r : l i i 'i r h i r l c i n l r i i ,l l n l i yo l tl i , r i u 'tti ttL o - cttr u 'l r l i i r 'l o l l) l , r 'l i r L r r n i i l i sl ) i i r r i :l n i r ^ n i ,;r ) r 'r 'r ',l r "l ct,r 't'Ir t'r tItr r l ) {l i l r l ti r ' .\ti th n o i tl i i c I r 'r , {'i r r r i t 1 , , , r t , 'l r f , . 'l r t) i i ,i , i x) s[,l i r i fl l i l tl l i l i i i . s( ]u tl l l i l i tr o tttti tL l tttl ttttl tfi sr tl . ', 1 ', l i . i i r n i r ll fi 'i r sr L r rr tn i ti tzi tt o l t") ; o ) ,,\ttg i i r l l n o I i ) Ir ) Itr r l Ir r Io 1 r ,r ,Ii ii r r l ,r r r r l , , l r t l i l tttsl r tr r r l r tti . / i . f r r r co l ) i i l i L r tf,r i ) l r i r ^ si i tl i l ,i i l l t t\i {tr ( tr i ;( l ,c co n r tt,l si tt tl ttr t,r i t ,tl r i . '1 1 ; 11 1 6 1 "( r l r r p i 'ir ''a cci n i ti i l cr r r ti i p o l i o ttr i cl i ti tt:, r t t i ,i i i i i r ',' 1 i ;r r r l i 'l r l i ,,r r ,,1 i 1 t 't 4 , . ( i ; [ : tIt co r e 1 .r i [e p 'l ,i o t n r ttl * i .r .t L ct"u L tt,l ,l .1 ) tl tu l r ti r tttr ,i r 'p i l r '1 r 'r i i l r r r ,l r l l i n i r i 'l l t'r i 1 i u :l fi i r [c1 r .l l i r tl ,t ( ,\tso i L i i i i cl l r r l r ., l 1 ) 7 $ ) . {1 r 'l c ttt tr Il ,r 'r 'tr l r ' 1 ', r r i i , , , r '! i l ( , tl ct+r 'i n i ;r i i tr ti z,c ci r i L ci i ti o c l r l r ttL ttl t si tL l i l ,r l l r l r r Ii |l ||| Ic r ',, r r r ,, , , , l r r '. r l r ', }n ;ci ,sci o l r l r .r i i si vc i n L 'r 'i i ,,r i i l tti o tr c si i tr l i r r ,l i i l r .. L tlriylt tl o c1 ti .!r p l i r ,: l t) t ,t't.{) t. t i ce so tt'l !'ti , l :r cti zr 'l r , c r ', l ,,r r l , , r r , r r r o l l r : nt i ti r l i l i r |r 'i r i r l , "r r r r i l n p i '1 ,L l l l tt'i t,tttL r r l l i sr tt ( i fr l i l i i ) - ( i c]l 'l ) l l l l i , 1 , . r l l t s i ,i r i r L , t[u ]) fl 1 1 fu ,,( i r n o l {) g ,Il 1 ) r ,'r l l r ci r 'l r i l r '1 r si i 1 r ,r 'rllr ',r i r r 'r ,i r , , t r , l r r i r r i i u l c p l i n i k' ( r l L r p i i \r si l r i tn l i r '. r L ti l l c co l vl i {i i r i ( ,) l r 1 ,., l 1 r ,i i ) r ) l i , r l r \ r y 1 1 l si i , n u l i i r r .L r t, i zo o p i l {r p l ,i cl r l n l l r 1 'fi {}i r ,r 'o t,r ,u r r r r l i r r r r u l r r i ; l lr) llr cl 'r r r c i i s i c o l r ,l 1 ,i il o zi r i o o ( j r '( t) t'r tl fi cl l i l o l tl ,r r g r !ti i | )| rI t rr rr I rri r,i i r l i i , ttr l l . r r r 'l r r r r | | l ] t 1 ) i l r 't {tr l ) l tl fi i v i n l l l ,( tl r tl r i r l l t l L tr ttr ttl l L r ts0 ttl ', ttt,ti t,l r 's r r r i r r r r ,r i ! r '.r r t|l l r l l o l ( l {r l ) )i ) ( i ( 's i ;i p l r ,fi r vr r ,l i tl i t,1t rrt i rt t { i r , i I,rr I rrrt, i tttcr l i r r l r i r r l tr i , i ,t r r r r r r r i r r r r r ; I , ) : i r l r t r r r i st,r o l i ,l i 'l {,i l r u r cl l i L r yr l ,o g r tti i r l t o l r l i tr r - g r r r r .r '.r ,1l, I r' r rr rr, ( rr r L , r r, , si , , l r . r ', r z r i , i t .zD i ;ctr ti o , l r i l tl g l i o t'r tti rr ) ; ( l ) 'Ir ',r ,l l i !r l l ,i sr tr ttl sr i , l i l ,|r l r r i r r 'r ,l r r l , , l , l r : r l r t t t i t : l ) {'l ) l u t cl , cl r 'o i ttI l tr zi r tu r i l r ,o t'o l r r ',tIsr i Ii r r r '1 ti l r ,Il o ;1 r r . I r r I l r l r , ,l l r r I r [i l i r c i r r tl r r r r l r r l 1 t,r r r tr r r r i i o ;i cti zl r l r r r l r i l r .l l l i c r .r r i ,. l ,r :r r l r . r : r I t r l r i l , r l o l tr fi l r r yi l r u i r ttti o l ti ttr i l r , r r i {i t,.t r i l ti . I) l tl ) r i \r 'l r ,r r r ;t r ',,l .r l r i l r r '. i 1 , r l i z l l ( , r i r r r ,p i l cl r si r r p o sl l ,ti r ,tttr r r l i ci i p o l l i :r r ) l tttr r l i r tl t ( r 'r r r .1 . r r r r ' r , L r t t t , l l t r r i l ( '\'l l sr 'f l l i r sr r t ttti r r ttl o tl ttl l i i ,r tl l r r ,l ;, r l o o l r i c|i r r r .r .r i r ':r l r r r r ,l l , r r '. r l r '; l r ) l t'tt n l t ( x,l 'r t, l ) tu t) t:t') J :r l ttr r l c r , sl l l ) si ,r 'i r i , l l r fL l ( 'r r i l l i l ,r .r l , r l t r | | r r i r i | 1 1 rr o o r r i ,r tzi o stL t tr tr i ,r l tti 1 r ( l r ,i tr l ) ( !'si L Ih l r tr o t |,i o :r ,Ir r l,i i r r ,.r r r 'l r r l ,, , , r 'p i r l r r i r r sr ,r r l l l L r i i 's ( f\l ) r ,i r i i \ .L r r tl ( |tr ',r r :r I,u tr ti tr Itr r 1 r ;r tr .r r r r Ir i r r r ,r Io L l,r r .r r r r l , r r r r i i r l r l r r , r l tr tr ,.Ii l r u r l ;. r \r i ,r l r . r ti zr . r .1 r i |r '1 r Ii i u , si tr l , r r r r r r.r,1 , r r I rr | , . , lrrrl cr i r r l l r l r '.r l l l r r 1 r |i l r r Ii i Ir . r 'r 1 r .r tr r i y, l r r ,L l l r .l r ; r , ) l tl .i t. i ,tl t,:r l r t,l r r r r l r r '. : i r r 'r r r r i ,r r r r r l sr tl r l r r r 'r l r r r ,r i ,r l r 1 r L r l r t,'|r i ttr r r 1 r r r , r l r r r "l i r r l tr r l r r l r .r r . l r l r l , r 'I r r 'r i r r l r I,. l .1 r l l r . Ir t',.r 1 1 ', r l ) r l r Ir l tr r r ;r ,r Ir tr 'IttIr tL l r tr l {,l r r r r r lrrrrr , l rr . , 1 , r , I r t r rz r i , , . r rt 1rt , ' r t rt I L r tl rl r r '.r l .r ( r r r r r r '.r r ') r' Ir' I I r' rr' r' r. : I I i r I r , |tr IL i r , r 'l {l '/

. (ri::t[t epi\eptiu i.nso!ite de Jcbrd si de samne tlo lti,perLet:sirtne intrc_ .l t ttttti,ttii r:tt,itt;;tu,lctre aurtii |a,tLsltboclit(i. orienteazi ini]eOsciri spre rrnnine Irrrrtr, lI af t ' < : f iuni : tt) il[::rtingite qoLte_])xu,1t[ent,. |onturtrL] clitric crir,li si un sindrom il rr,,rir{'r,ill asocid,, iar l:r, r:rhicerrtezir,se o}r{ilt urr J,CH trilbure sall purulr.ri1, irr cirlo st tlicien'!,iazi gc,mcnii rluz:Lli,.prin cliirrlr,.'url Sacterioiogic. n l i rrrrrl lr . r . r r . r . r . ' 1, , ,1 ip rr' l ,rrg i l a .e i n s L rl ,.v .s i rl ,.rrl l o r.oml rl i l r,l i i r,oul rl l u_ .'r, r' r l' ul llt r ir ' ttr.t.\' t .r.:| trr/,' tr. ..n l !U p n r c pi | rrnri ,l .rl r,, r l L l ;,:r.i d!.
v r, ll{ t 1 r i 1 1 ( ' .) .

tl) liut:tl^alite (rctttc si, suba,culoprinr,il,i.tse (rto obicci ;.,irot,icr!. r'1 lNnce.lu,l acutc sr:cu,nl'lare cursul urror boli cruptive (rujcoli,, itc in iurr (x)nvlllsir.i) rlup:i varxrinarr: anti,r:rliolicir), t1 llnx , l, , - t , lt nl r In ,l ,i i r (1 ,' l rU r{ 2 ,.b l u t: ,1. pr.i n cIi z| r,Iri I,.trrj | t, .i .. Iri rr :rllr . r i. llr t r | |. |I rrl ' rg i rr.rl r. Irn ,i rl i Z :1 tlrl :rI i rr D i rl r., t rI :rj , I r i t , r t , , :, r.trzri _ Ii l 0 r'u r t l|t lr ' l. r r z ii o ,,rl l l rn trrc z i rrl . s rrl r.l rl J o ' ,i :l | trr,l rl trLrl i tti c srl r,otrrpl rr .i l r';rzrrr r r pir l lr r r , r ' l:r)t,r,, IrrrtIIri IrL rtr g tc s i l i i .si ttl l rr sr,trrrrtr r, Iri Irl l i ci rl .ri o rl Irl rrrrr, i r r I r ' r r lr ' : r r r i: r r r(i trc l rtri t, l l :rz i i Pl rp i l l l l i )_ ri i :10{

lt) .illeninltite rirot[ cectt lir'.h ,.1a (rnt,lingila Lu.liruriL, i,] r' nrcningita poli, rrrri.I i i it,ii, tncDillgitelo cr rilrrs C.rs:rclie si EL,II(); corioirteniriuita, lrrrrlrx'ilrr'rii' rrirus Armstrong I mctingitcle dia bolile eu rrr linillotriop l IrrrrI'r.il.z. inf.c!;ioas,e, '.ilus rnononucrieotra infeclioasi; r.uringit.eleOin bofilti ,.r'rrpl ilr'; nroningit:r herpeticri) se manifcsti, prin. sirllrori meningr:al osi rrrrcoli r.rr olize cont'ulsivc asociltlte. tt illt:ttin.gite trtberculctase. r\ntecetlenteletuberculo:rse famili:rle sau (indco,sebi p.imointoclia reocntii), deb[tn1 insir'Lios 1r.r'srrrrrl. precedat cle lr.rNlrrr:r'rr'(rnodificareastirii gcneralc, scidc'e:r, in grcut&t11, episoadcle lrrr,rrrlog|iyrnlf_.1i. _modiliciuilc. r.6rr}ort neuta)r,;, i.mnel{j nc-u1'(,.logicr,, (rrrrrr'z.ripr'.liziidele.vi crarrienilrlc rmLltc uri c.izLrcpileptico), ev.lirlin, r,rrlrr.rrlri, sug.rcazii,etiologin r.ro l) ecisii--ptritru riiagtrosiic -tnb(.r'crrloxsi,. ,, Ii rr r t | r i { \ : r ln, . t( l r.D tn l l n r :rl L .( .1 1 .

irrI't'rr'.olclrrirlii I')pilr'1r:tt tu.rtllitii(<:tr I i) rrprr,r'i(ir (i lrrrri, lt,:r t rttrttt,.r,i.tti. Lr, | :, Nni rlrrlii' irrrrrrrrr,lisnr) r,rrrr.r'r'rrlizrr,li"r, rkr cica,1,r.iccu, irgrinuo-sr,rllrra{ii, rltr ll.Lrrrrzlr, rlilrrzrl, li rriu r':r. il,r rrr.lo conLplicl{ii taltlivc (rbr.str , r r',.1,r':rh.. r.lrislUli.l. |ir ,\l.r,.rrr {,,,1irt,. l, si ([t17,{), jorii.atela,.cslor (,rizu m ,|itr r.rrrlrlr. I.i1r llitlr'l t irl (.1!t,,/. i.rzl i/, dupi l.ure ur.meazd crizclul,ocaJe, i,u (1v('tr1,uli,l?i generalizarc (lfio/o rlin botnavi) qi alte tipuri de crize. 2.^.(lr'izale. c,pitep,liaa meningite g^iencefalite,foarte frecvente l$ copii, An .i '.'. irrlilrrr.;r. .h aduUi. eLiologil infccfjors riplasinduse prinrrc orim-elc rri.i r':ruz(. irupL,rtanlo rnanifcsllirilor: cplico (Gudrn-urLrlsson. ale cpil tC6Cr rt:rt.rlr.,{r'rnni1i cotab.,1C78;. cazul crizeloier,ileDlice ?n sur\.cnitprLlr-un lorrlcxt irifeclios acut sau subacut, v:l trebui sA ni ginaim h: a) Meningite srrpural,ol b) Meningite virotice (vezi anterior) ; c) Encefalite'de divErst: rrrrl,nri (viloticc plimitivc sau secuudare) at) Meningitd, triberculoasi,l I r,) .Abces ccrebral. lrr oadrul rnanifestii,rilor epileptiec postmeningoencefalitice clomin[, tlizclc con-vllsive generalizate, :liit iu pelioada acutl u, bo1ii, cit mai ales irr cr^rr, 1,a,r'divf.Trebuie sd,nu uitlrn faptul cL ulele accesepot si, survini, rlrrpiL,luni sau ani de la sting_erea procesului infeclios (Arieni;i cotab., l1)73; I'opoyiciu ryi colab., 1076). . ij. Orizele epileptice ca simptome de ilehut sau I,n cursul et:oluliei procesr'.lrr,r,t:pamsire intracraniene. ,sinl deosebit .de frecventc, putintt ijungo din rolalul cour-ulsiilur-lr a,dult(Arsenisi r.ulrtb..l97S). Arti;|, lirrl .l:r50o/u ,.rizr.lr. r1J)eptir.e d.in pelioarJa tlebut a proceselor de erplnsire intrlcraj rrir,lr (22o/o)reprezinti un prelios gimltornde alarmii,, cu-tleosebiti, valoarc l,r,rrljzrrto:rre. focar,putind udpsea de intlicl qi natrrraprocesului e\ptnsiv. rr |ursnl rjyolutlcr proceselor oxpansive intracraniene (360/o) reprezinti (l{r lrrulto ori coirsccinla fenomenelor de hipeitensiune intracraniand,, pirt'zirulLr-si rraloalea precisS,localizatorie (Arseni qi colab., 19?8). Cei(r mai r'pilcptogene tumori cerebrale sint cele situatc in vecinitatea zonelor moiolii .si scnzitive ale cor"terului, in specia,l astrocitoamele, oligodeldroglir'irr)r{rl{', rncningioamele si glioblastoamele, l. lrizele epileptice prorlase d,euJecli,unile aasculure neurochintrqicala lrrr lrlrxlu{l irl ungioarnele cerebrale suprateutoriale, in aneurisntele:.rterei |rrtrrl itltt irtternc si alc rarnurilor acesteia, \n boalo Bturge-Weber .si tfuai,rar I tt.ltt ttt tr,[otn, prinr,&r i.ntraparellckintdtos (netmuma,l,ic ul ). 5. (irixtle e.pilepticenn pt"ocesela inflatnatorii, tt eurochirurgicale se in.tilrrcscirr : l) Tuberculoamocerebru,le (fcrarte frecvent - 850/odn cazuri dupd ,\r'rcrii rli rrolab., 19?8); lt) Abcesecerebrale c) Ifai rar in araltnctid,ilawioI rhir*utt,l,icd,qi in go'melesifil,itice. (i. (lri.zele e,pilepticein cerebrale: a) Cisticercozacerebrald, Tsarazitozele il l1l')1, tl, sirnptome de debtit, fie focale, {ie generalizate, dupd, Arseni ryi ;i )78) 1 ls) H iilatid,ozacerebrald. lr rfrrIr., t.f ii 7. Ortzele epilaptricet:ascalure ss intilnesc indeosebi la adultii mai ln vilsli qi la biitrini, fiind realizato de: a) Ramolistnentala otuntorale Tsseu 1 It\ INnlr.fal.upa,ti.a hiputcnsid ; c) Unele hemoragii cet'ebrale. Debutul ictilirr.r)r si oonlioxtul clinic sint rcvolttoale pentru accste manifestiri r.1ri lcpl,icc. ,\. Ori::i.r api.l.e;plito in, bolikt rlrttontnlite $h1t m.ult miri lrur: tJ I)itinuqit, t:r'rrhttkn,vi rtt,ior:ltntirii It)pik'psin mior:l,onicd,proTTt*irnl, n,Iu,i i b) it0tJ

l tpnrti dtl Lut r t ll'ur q Lt . ll, r t ; c) liur lt lt i l, , r r l, it : t ou ( r 'r r r r . or i) 1 r l) , li, ar l, r I tri l l tl l r t ntr r ltu, \ 1, ( l: ; ( , ) lior r lr r lr r i ( r r r , r r lzli. lr l. lr r t , or l. !). (tri r'1. r lt ilt plit r : it t it t l. . t i. u! iilr t t t , t t t . r t ,s. l | ,tt r| |||It ,tI t / \ l'lr l. i. r l .rtrIl t' j ol rrIi ir r r r r r t lit ir r loxicr r ( ii po1 sii lr llt r ir cr izl r . r r r r r ir . r , , ulr 1xr( , ir r , ur n .rrrl .r' i trrr l o I 'or r sir lor , ii lt r r 1t 1,,rrr.i I rr I ri Irr t , I ilr , ; r sii, r , i r l. lr r , , , r , . r I yr r I r . ii r r r . r . r r r rl , rrl rtl o' ): tt,)it t , inlnl; iu! , iih e, t : t r t t t t e r , lililii, r r r r ( r illr 1r ) r r r r r f l,, 11 ; r , n, ( . u r r , r r i , rrl rl o cl rl l xl lr ou sulf ulli dr r ouliot r , r , t r lx, lllir loLr j. cr r sl lilr r ir r r , r . r t r ir r lr lr lr , ,lt liltrtl ln,ll,scori s.a,.); Ir) in irk*iur!,iilt tniortlttr.,(urr,lrir,. r,rr.r. -4.n att.[\r.t, l:rlrrllrlic poltali, cncofirlopa,li(f lrit t(r r'(,;[1 . ici )

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?.1 RIICOX{ANDARI MIiTODO],OIiICI] SF]MIOLOGIE DI' 7.1,1,,{ltnliza {nlhirrli.ilor snbieslive do sansibilitate ,r. l,t(,c piiltl,r LLninteroSl,rtoriultonl,, cu,o pLecizt rzii prczenla rli,Lrcrilcr ,;i,'.rrur ir,ltoL senzl],ii :rnolm r,l^, topogr'a{i.i irrestor'.t,J\L)cicretr alte lr, cu ir{rrzr sirbi('ritirre, oiarul de ap-rriiie, c:u'aotcre,le drlrcrii etc. L Sint .sittutlii..1tt. cuye du,rerile ;i,fsau,pareste:iile constitLtie si,nlyut u,l 'tt t . sU ierlit al bclii, st u,s imptornuL b senzitir: ilol.t,i:tu,tut, Lllb:rri.rilc obie;tive fii,,(l ririirirnesilu lirsinil) crr, pillri rrr cefrl,i, ir ariErr:rrr:, unele n:vrite rLr; in ,i lrLrlirrtrlit: ({orn* stnzitivi ri p,rJirnvlJtci etiliccl, iiLuncle r,lrlilrlone,

vti Ir'. ?. I,lristii sittttlii in ctre ,lntpt,le si sa prr,'t,slt:irle Dneei| alte seny.e trrrrtrlrtli.ae. clcci, au t.:r,ior,.r't, si, ptonl s, mnQl : .,t rLrtlerilo mu:;culare si, ,[,, 1 rii ru 1icrrlrr'..ir pe|ioada i.le inr.-ir,zie prcp],ratitic:i a poiiol.riclitci ir,iriLrrio:lre rrrrrir_; .lr) -llgiile premonitorii cclvicale s.lu dorsrie il hern r,tornielii; r).l L rluiilr r inr r olioi. , ti .l d e c l c b u tl u n e i p a rl l i z i i fa ci al o;ri ) el gi a i rr' rugural d, a rrlri lrrllx's zostcr I e) drlrei.ili. clhiJicle c.r pr.edoninr ntil noctirrnd, in irililis l rrr'(l1ilu; f) duierile lJ Lirlrl-rre di,r r,,jrnpl|simrilu medulare. ;j. lf rirli,. siltutlii in cwe urrrtlr c;t ea, prii inpari(1jqt:L lor,, tarita_ . hilt .lltturc rl.in.ice nle u,nor afer:liuni I i,1 forrn r, ,le.ici, a crmplesiunilor rneilu_ I rlr. ;, lr ). l"r'n r tlgiui. a .mrof _poliner-rito qi polineurop:ttii ; c) forrn,l algo_ Il Ir|| {| ( ||||( . : | ; l nr . v r J \tr-l c p t:l r.tn tp p , L 'L.'ul.bn rd,tile de sensibilitete subiectiud, pot sd, aibti o ,rnure uLlo&re .neurologice t tltx'.n lt)4..rt nnor u, (Guiblrt ;i Guibert, 1g?4) ; :i) Terino_ -a.fec!,itm,i rrrrrlqczi:t,srlmnalati de ci',tre poinihe eyoc:lrea unci ,siringctnielii -boin.,w rrrrrrrr rrLti sindrorn siritgornielic; b) ll,el.ltarei1 rlc ciitre boln:,lv-* unei irrcrr;r,rrilil,i rlc lecunolstere a ohiccteltrl cu liuturul pipiitului, rre face sri rrr. qrrrrlirn 1i 1:r, agnozie t:}ctil:i, plr)Irie luui sinr1r'ornp rriet:li; c) Rela_ o liu(.:r ulr,'r'rltreti (cuntlnut-, dar cu execcrbliii in p.r.rorisrne ittloce hemi | ')r'|),,IiLIr., L.\ir{cl.rtu rlc prl}utii, precurn qi cu 0 coior:lturii afectiyl clezil, grt,'lrilii) srrsctci.uzii donri p0siitiiitrili : - l) rlur.ilr.e tzl:lrnicii oLt c..lractor Ir.i;xrr'1rr I - o IcziLLuc firsciriLlluluisliir't.'hrlic Iic r, (ltunci cintl sc colstrr,tii 8i o l,0u1l{)rr,lrrrlit0zi(r. 5 . ( lq. r t t , l. u' d: 'l tl rrtl .r:i i l o t (rl i s t,s l t,z i i i rri )t rtrj rrri r,si i l i o l ri rru r,i ,o, j tccsi ( ' [ I iit t r l t t lr r l rr,i r,ri rr l i i l rr l rri l rl i v i s rr!l ri i l i ' ;,i l ;r rrs;)r' rl r: 1l ,t,ci z ,,rni (c,r,l i ,, Irtl tri r r iiI r r li, s r , r r z t r!i i o l trl rl s trtr rl c l o ru ' r,1 r.,,\rl r" strrr rJr-rl rr,r, i l r,ri trrti rc rl r,< :i II)

i l rol trrti r ;rri r t r lr , lr 'gy' , it t r piot r r l r lili, t iir , , , \ r l1, l, t r t t r l( r lr , r lt r r r t t r r l, lr , ; . 1 r r r r r lr .rLrtot rrIrr,lr r r t r r lizir rt t t r t r i t r t , 't r t lr t t t ,I lt t 'ir r : r lir 'r 'r r t lr r r t il' i) r ( 'Dzir lr r ' l'. l|1] (r' l l i ri trr. l l rr I I i.(i' t | |r.t l (' rl ( r 'r , lrr ir . lr it t r . 1r r . r , izr r 1 r ilo'ir l ; r , r t 'l'silzi, . r llor r t , , , , . ir t t (' .l rl r,sl l i Irt ( {r izit t t 'r t lt r , r 'si i ir . t il{r t ir l ot t r , t t lr ': r zr rt lir t gnoslilt t l. l\ t r : t lr t r lt lr , tprr l trt.l tr! it r t r ilt nlt r ilot lt t 'r i. lt t ir i, it r lr ': . ir t t r ilr t t t r t lt t llr l r i loill'l' iL( l( . r lr , r l rt tut' tt):.!\ilt r r |r 'slr 'lt t lit t r t lt t r il l0lt ogiir iir i l) r r ll, sl|ziil | liilr t l t rt ' r t ;lI r,rrr,r I r ,ri ri . i tt rrl rt t t i t lc llr lilc t t i, t ul logit , r , ,lt ir t r . slt , ziilr , pul r r pllr r . irt , i t r lt r t lt r t lnt ttl ' t' i ttttl rr lor i. t lt t r i. llr [ ut ( s1r r ; lt c t r r sct t Lr lr ', it ot ir lr r t r alii: L olr lilr 'r 'r r r r l: r ,l r' .). l )t(\' u nI ; i it t dit 'r 't 'ilt ler r . lt t : iit t ui l( olt t t ot ( lot i) t lt / / r , ( 'ir r l r 'li pu: r r lr ,l crrrrtrri l l rr r lt r . , I lt r t 's1t 'zii" \ 'isc( , t lll{r ( lcr r t ior r it r r ; r r r r lr 'iu. lr . l. ) r : lu {', / r , l l ,,l ' ttl i i .l \t ll'r , r t l, ocit zLt ii, lxr lr ir t vii ect t zil s( nr zillii {l1r lt r r i'{iut r c ir ; lr ( lr . lr ' rrl i ;u(, l sl rl) ll r iif elil. t 'lot s( 'gin( r ll1( f lc lr r lr ulr r i r ligt sl ir ', pr lI r lr r lr r ir r r ir ;,rrzrr{i l t rl o r iplir r r lt . ininr ii r : t c, (i . ()an r t Lr r t l. r{ixr ?'ii r r inl a( lcscirr '( 'v( 'llI ( ) lii lxr r r lt t t slr r lr ilit r ': r r lir r i, , r rir r : ) l i ' rtl rri rrfi -'r r r r ii. I lt u'er eu,( , or r s1: ilui(o sr : it zit lio lr r , t t ilr ilr i, t r r 'lr lr r r r lr r . lr r lir i rr:uul r.:ri L t t ur r , r 'ii, t r clluie 1o1( leauoll sii pt t N, izit t t : r lr . r 'ir r r l r r r r ' lr r , lr r : r r r l rl rrtl ti k' r l ocaliziuca lol pr ccisli, r iur 'r icnir cir lot ( t r ot t I it r t lt t , 1u, r 'ior lir ', , r r r r ,' ,,rl j uutt cl t er aiccr l) ij, ) , dut 'et t t , t izt ir t r ' ( luf ( , r i) ir s( 'r l r ': r zr lc r lr r r r 'r i lr r . r o r if ,ti l r' , i rtcnsit lt ea, t ir nllr r l dc alr [ 1i1ir ', t 'r r t 'lt , r , lt , t t trl<, r t zr r lii] ot r lr r r cr r r : r , . r ', ,l rrci si rrt s r Lr r in ir ] so1, jt odt i f cr r r llr r t r o iur ilolii sinr lr , gr t ir , lir c si r r r r r lr r lr rrl l sl ol l , 1ielul de inst nl: r lc zll dulclilor ' ( lr r r 1, slr u ) lt r t sr , r '1r '. ) . llr r lr 't ilr . r , , , ,l :rsi i i cri acir alr nr : nt c in t r ei lr il) uli l] r il, . iol'o( . , \ r sor i si ( ) 1, 11'sr . r r l1r {ii; tl trl ' l ou, 19?2; Wr ilt on, . [ t ] 75): t lut 'clt : : t sul) li) r 'lr r 'i ilc i I r{, cl I Irlr i , r lr r r , r r ', r ll rrl r l i )r' rl [ tle iusr t li [ i dr len] a . , J( lur 'ol'o) ' lilopt ir r zisr i ( , , r r llr ir r q 1r : r in"1. i { ' p{ )1i (l i i ugu, : dul( ilcl, pul. qlr i, ilirdur cr r r t it r : xr ( it i ( l{f gl{'lllr , r ir r r r . r 'r 'r r r l, , :l lor ruai (lc clampai ,,qidurcrell lirneinilnli. 7. l n l a polt ou r c( , st i 1lilt ilr lt clli t lc r t t r t i st t s, dt t t , 't il, ' xr 'lt t l r li. lt t lt , r t t|: nrrralgii, tltteyi rdrlitu.Lar4 dlt|'rf i. ()t'tlt)|a.l(.j dutt't i lqldtitit't :\t ttlll ,lttttri r:entrale ,<,i tlu.reri.[iftrt'ult. [.-Il]loo ll]rLr{o ot'.u1ti tr',ltlnrr strrr rlrrttr,,r l ) tt" algin,est c dlr r er eil cn loc: izill'( 'pt r illilr t t 'it t l t t t t t t i nct r . N. t r r l r:a r:i r l )oi rrti i nur nele ncr vului in t ot 'it ilr it r l t , t ilt t ir t lt pit t r '; t t r r vut lgi: r it iil, r r r r rr:rl i , rtevl i t lgiil scir t icii ct c. [ , r ueoI 'i t t cvir t lgir t t , r t t t sl t it , t t t t ir , t t l sit r t plot r t il't rl ( sl 1fori l i ti i,: r l ncr '\ . r ilui r ospocl, i\ r . lu t 'r iic r lt lt 't t t t it lt li t lc o llzit t t r c r r t r ct r r t I l rri l rrl i fcl i c, cir le unt ) r t i uu llr i. r n'nr ir lr 'i, lllt ' r it t t plot t r ', O vr r lillr r ic r lc r ii trcvl i rl gi c o oolst iLuio cit uzalgir i, it t clr lt 'st 't t zlt lir t t lt t t t 't t r it ilt r 'f ii( ' r '$illr ( il: r , t 'lt ' rtl r Iri nri , ( . lo alsur i! , ct lt r l, ir ur i, ir t sLt pLr r 1: t lr ilii, lt t t it t t lt tr ; r ' lr r r r ; r I icr r {ir r t r t I r ' r1' rl i ,rroti v pdlt nl calr ar r csli llolr t r t vi i; i it t vr 'lt 'sc t it iit r ill it r t 'it pr , t t r lr . r , r ri ' ri ) N ,j urrg ir r (sli, a, ibr i,, , r it iir r i t ll spiililor t r t sr i"; lr r r r r r t r I iI jlr liI c r r llit llr r r , , l ir l tol l rtl l i ri gi l t r r llr r r t 'r it 'i r r ljct 'lt lr , I lt t l't t lor ', ; i it r llr r lt i'I i t r t sot t t r r lot ii. ( 'r t t t zir l t I ;1i rrstr rl l r,l o r t , st o r r zii|ii f illt clr it r . r 'gr '1lr 1. 'itill( r li( 'lYil( t l ; t |t 'ili't i( i f i ir l) r t lI r l' ,,l ri | r.i 1xr 1 r 't 'ilot iul ] |( ll'\ 'Ullli llr c( liillr r '. lt l : t l lt t 'lt , t t lt t i s|iit lir r lr r r lr lil|r r rrrLt' t' n. : l t) I)urt t i. lt r r udir t t lqr r ' t t t t t t t it zi llt ilt t t it t l t I t 't t I t I t 1r t t t t t 't cI r r Ilt,; t it ir r r l rl ' ' i t l IIrg l r r |r nlt t r 'Lt t , illr lir niv( 'llr l i t I I | |{' | | i r|| I I i lt t it t t l f it t it r . l|t r r t t t |r 't t Irrl i i " . S rrl v ir r sr r ll lir ur r i t lc siinr '1i( r t t i sr it t r lr 'lt t lgr r t 'it lt t r ii, lr t oPr gr t lil r lt r r r,l | rr l rttrl i ttllr l s; lt 'o r lislir l. St t t t it t lt t lt 's|lt it t lr lizt r t lt t t ct t lilsl', t llt t lt ol ll t , t l ol i i rl o cl t ( '\ ir qr ll) iir i llt t oxislit 'r ', I lr t r lil t r lllgiiL' lt r t ", lt t 'r 't 'lr t 'lt ziillt lt t lt r ', lr rl l r' i rl l srrr r 'lir r 'lt r t 'i I izilr . , lr 'ir lit r r l it r llt r lt t lr t ' t t r '1lr 't 'ii l) 11'r iillt r ii ( lll t n{t l l ri (l i r.i l ii lr . z: r lr . . l) t t t lt ill t : t r lit 't t lr t ll lt t t t ll r t lr it 'r 'i llt lr ir zli it t llI t t r t r r ( r t l rti r r,r,rri l i l rr(i i :1r t r lr , r r , r t st t lr : t lt t lr ' lt . lr ,t r ir I r ir r it r iI oIt rt It iI I i I ' t tr' , ililll t r illlzr\ ( li' \ r 'r I rrrrl rrl r.: l rttrt r r t i t r r lr I t t I r t I t , rr t rt I t t rrrtrI i I r' , r t t r r llr t t l lt t i llr l l, lt lt t t ri t lr , t lir t r :r 'lr '. llll

( ) rrrrrrr(, rrrrIr i rrrrrt,ilil rlrr'r',ilir lrrlgrn.rlrrkr tlbotico: ?toestoa ap,rt sul) .nprvriu,lfi lirrrrrri, .r.izo rlo silg.lllrrri s:r,rr rlrr Irrlgr,r'Lltrr.i int.usitate foarte-miro. tl. int,tliitttl Jtf tt'rt,itxll;0kr stirr,lri0rrlrri, obicoi lu :,mbele membre inferioa,ic. rLr uli nlrrsin.f impul uoplii-ryi nrxxrlinrl la tratl,mentele antinevralgiceobiql rrrriirr. Asrrsto rlureri au lu, bilzr-r,mouingoradiculita postorioarf iudtic'd. (l)lnlt,esiuneh rldiculari dir, doui tipuri distincte de durori: durere rlc tip novrulgic qi durere de tip mialgic (Alexaniler qi peritz). | )urcloa de tip ner.ralgic e o durere vic, ascutit*, pltrunzdtoare. manili.l:tlit |rt o tln,rn| 1sx1's eleclric5,$i este asociaLi-cUlarestezii. tunnicd,turi nrr,rliirrrl pe inLrclgl dislribu{ie a rddi,einii (tle ^laumir in jos, in tot .rapid rruuulx'ul superior, pini la tlegete). Ea este maximi la periferie, bine 1ocali zrrl;ir, rlistal, iar proximal e r1ifuz5,.Durerea do tip ner,T:rlgicctilrintle de la irrcrlut lotrnembrul sau se poate manifesta nrimai in reglunea-proximalX, collorirLrlulterior. [)ttrerel clp tip ncvralgic are doud aspectoprincipale. -slrpel{iciali de inlepi,tur5, cir acul in zona perifericd, .r'rrrr so ^o.senzatie intinde proxim-al. Atlesea ea este precedat* de amorleal5 -qi furni (,r'il,uli ; ca este produsi, de compresiunea iibrelor rddd,ciirii rloisale crl rl isi libu{,ie superficiall ; - o t.lurere situati, profund, constrictiv5 si limitatd,, c&re so accenLrrtu,z:'i, mlqcd,ri. Este asociatX,lrecvent cu o redoare lroiurdi ln localizatd, rlc r ricci 1a,git, umi,r, bra! I rnreori durerea se intincle pe o regiunc mai rrl,ro i ol estc provocatii, de compresiulea fibrelor rldi,cinii dorsallece inervcrr,zir, lolmaliunile profunCe: muEchi, fascie, pcrigst, capsule articulare. 'l\rritoriul durerii radicutare esto mult mni intins decit distribrrlia rkrlrrlri,otnului, deoarece clurerea iradiazd, qi in muqchii inervali de r[cl],cinil lr,ftrcta,t:i. irr extremitatea supcrioari a membrrrlui dispozi{ia fibrelor nervoaso csi,o mLrlt schimbat5,, ilatolitii aranjamentului comllicat al muqchitor, rlirL ou,rrr, c-alzii,nu e.xistd, suprapu:rere topografici, exicti, intre distiibulia o sltp(nlioia]ti gi profund5 a fibrelor rddS,cinii dorsale. .ltrxlrinderea durerii in arii ce depi,qesc dermatonmele clasice ar fi tlato_ .r'ilri,qi intcresii,rii fibrelor simpatice din rddicind,, yom putea observa astli.l rlurrrli tle tip sterno-cerwico-faeiaL (datorite compresiutii la nivelul C"). fi liipul costo axilo-brahial (datorite, compresiu:rii la nivelul Cr). (hi(x) compresiute pe o rXili,cini cerwicalii,inferioarA, poate ila dureri il rcgiunoa_ pectoraiS, fl_vom av_easimptome dc pseudo,angind,pectorali,, il rirz ('i durcrea este Iocalizaldin stLnga. precordial5, poate fi dat5, de hernia cliscului Cu-C, .. l)urcrca I acest rlisrt cornprim5, ridi,cina care formeazi, nerwul toracic anterior' 'medial (t l, 1i 'l\) sl],uner-yultoracic antero-l:,teral (Cuqi C") ; Ice$tiJ, inet"vei],2i, marelo 4i rrricLrlpeetoral gi astfel bolnr,vul poate rvca o clurete localizati Drellrt,lirtr:.

l)lrrore:i de tip mialgie este caracterizat; printr-o senzrlie profundi,, corri,inuii.,nepl5cuti,, perforr,nt5, puternicii. E.r, este bine looaliziltd, intr_o zorrlr,rlirr trlirrtea proxirnali,, sc letlecti, in.,regiune:l sclpularir, qi br.r! (C6) ; ,irr urniir', in rogiuto,r,scir,pulo-pcctorrild,, n,xilarii, br:rl!, antebr.lt,, iat:r, iirdriiii ,(()r) ; itr t;nlpoz, sc,.lpulrii,, dolLoid, blll;, cot (Us); cri se ;lsuciu,zliuu rcrlo:uo Itrrrsr:ttlrr,t'1i,. l) Lu'or'oi,I rnitlgicil rlotrrirrir, rrrltrslon Libloul clirric ryi cil trsl,. rlo obiooi
nr { i r l' r r ) lr $i. . . l)t ilrlr, lril.t.rili.$l::r

l)rt'rrrort, l,i1trrritlgio rrsl,o rll rllr,l;rrlil,L rrrrcisli,t'i rlo lrilrrrloxrril,irlrililrr,lrr lr,ut'ornllxcttllr,tii, rutt;clri, nlrtr,ro itr prin cortrprrrsirtrtoir, r.Irllrrirrii [rlorlrriti, vr,trlfrrlo. llr, tnrrlrrlri,irrrprrlsrtrilo l)il sirri;oorrrlrrsrr rlrlrlrilxrl; pr.irr ni,rlLr.irrrr, ,lrrlrrllir, crtro$llrrnzir,torr,r'o, I)rrrcftlr,trsl,o sl,rio Ioolr,lizlt,l'l,rrtrrgoltii t, irr irrrrr.v rlr, r,(,i rirlrioilrilo vorrbrtln oxcil,rrl(f uir osl,0abolil,ii ciIrl. r.tlrlir,r:irrrr, qi tlors:llrI rrorrlr I.orr,lo osl,o aucgl;oziir,l,ii, sgotioniltii,. sllu ; rrrrrzii liidii,oinile vontr':r,kl sinl cornpusndin {llltr groa,so l,rausrnil,irrrlrrrl. oo ,rlilo r[ot]oilrc Lr,muschi i1i din fibro rnl,i subtiri oaro pol pftrrlrlco o nl,rr,r'rr rrrlrrlir.i in fasoiculelclnuscuLtr(r,I)urr:rilo obscty:tttr rtnoori lrr crrrltrrr^ni rrrrr,rr ri,tltrcinii ventrale uu $lnt inso!its do corrtrrrc!ii nrusnrrlirrrr, ,1,'rirr,.,,' ,l(' iirnt, provoc[tc de exr:itareafi]rrolor radiouhro vontrilkr lino. lrr regiuncr ccrvicalL, o hernie rle disc intru,fora,rninn,lil Doll,lorrrrrrrri o irrrr, trr'orlrroo comprosiune selectivi, a r5d:li,ciniirrontrtllo, tri,siirl lrl,rlr1, ,1,'r':rli mai rnu[t s,lu mri pu{in intaotii. Acclstii, ovontlrl.t,]ilill,(\ Irr{xlu.r\ do irrl,r'r, '' rlrr'{.r'c tip nrielgic. ln astfel de cazuri nr'. cxisl;ii sullnrprrrroirr ,',rrr (lo distribuire a durerii ;i dermatom. Daci, ]rct'niu, rlisc rrorrl1r rlo r,irrrII rrrrlxrlo rridi,cini, cxistd,o combinatio ale durcre dc tip millgio iii rrovr.rr,tgic. llrrtrrnrt intereseaziio arie mai ma,rs decit cea I unui rlorurrrl;ont; rlorrr'lrr, rlr,;lrrlar distribulia durcrii corespunde dennatomului. Nllncvrele pentru proclucerea durcrilor snu acccntnrlrcrlkrl sirrl lrrlkr lrrrzi{iille capului, glttlui qi bralclor, cum ar fi: intoarcorot or,yrrrlrri sprrr rleafectatdqintoarccroa capnlui spre pr,rten afecta,l,ii I'r,r'l,r'it, rii pli0rr,rr.l, pr,sirrrrii pe veltex; hiperextensia coloanei ccrvic:r,lo floxirl coloirirrrir.r,r' I r rlrrloI cornpresiuneaexercil;a,t5, asupra gitului I prx'cuilirr, l'izrr Hpi rr,lro lor. rrr'rsosiru percu,tiaparavcrtebralS la nivclul leziunii ilpliur,rrrr,prrrsilrrii I ,lri,,ilrlr pe trunchiurile plerului brahial (durclo;t s,rLr'prrrrsl,cziikr rirrl . in 1rr.r'roptrlo aril tlerm;tom ui rospect,iv sl,u pc itlilorl,gtt, tr,r'io) Ir, rIi rrrr,r.rrI I I po t,r!'sirurii mu;chinl scalcn, Atit in leziunilo rrulicrrliLu!r ;i irr crlr, rr,lrr oil l,lr'\ului,-sint ilurcri pe trunc.hiurile plexuhri su,rrprr rnrrriclrirrl scrrlr,rr ,rrrlctior'. leziunileplexului cif&ctelistic esto llptul oii sirnlrl,orr In rrrlrrllrrl, rrrlrrrrsilicate miqciirileqi poziliile umd,rnlui brtlului. l)rr,r'qi llzirrrriL, de irr li rr rli{rLllilre mi$cii,tile membrnlui afectat ryiin speciilltr,l.o rrlui (rlrr rrrr,r 1rl rr rr bltl ,rrrrl so imbracii sau se pia,ptF,n5,) decia,lqenzi, rlur.olil purrtr.rr l,orsl rrr,ri,iv ili I'rr.iotL1,Lt1limiteazii,accstetipuri de ni;ctrri, frr,pb ci,rir so rlirl,or'rr;rlirr rrrrrri ,prsr.rr muqchilor scapulo-umerali,qi nu trrlc{iunii po t,r'rr irri.ilrr rrclr _al 1rk, ,.ttltri.Mi;clrilo urnlrului nu au nici o influcufil, ruuplrllrrrz i(,irriliirli,rirrilor. \r'r,rrsl:r, cxplici, tle ce unii pncienli pot sri nri;to tl.ourbl,rrl illtxrl,rr,l,, lolrl,rr crr ,lrr''.r'ilr' rni,ri po curo )e atr. t|pIiclt,rclr tr',.r"uLiurrii blrulrrl:rli,cl..rt., po rr.r.r.rrl.r trtrrrl a,bducfio supinaJ,io capul intors corrtr:r,lit*r'Dl iu cu (s.nrurrllui i,rlxfgrro ryi l:r gil,) (icclan;o,tzriclureri itr nemllrul suporiol. rcsprxil;ir. I rrtensificare:ldurerii so oblino prin tuso qi striinut, tkxrilurco lrr ptrr. I r{i(|o clostorobrrrsc}, pr,csiuniiintr.*ab{lomina,lo intriltoltc i.o. .Atr.ir,rl,rr, qi a ' ru' pont,r:.oxplicaplin f,r,p[ulor), pfoduco o sl,r,zii, s0 vonoiwtr furvlsolo opi. rlrlll(! Di, r.tsttol,$0 comprilnij, $itoul tlural qi rir,d.tioirr oorlplruirr rroir, ikr ; :r.t,rrr,sl,l! polfo rtlor yr:_rillis I'il,ejn,lu-so so I rnioluscopio qi so vir, vtdol cttr rrrlrr.t Iniclo#r,trrt.ri irtlj.rsl,o:r,zri. sO l\plioa,roaplr)$ilrnii po prtrrlolo ntilllgioo rlor:la,ni1cazil, tlllorj Irrrnr|r^ (.1()nll)r'()silllol, riuli0lrliirii provoitlriX hipor.rr,lgrrz rnrrgultilor', ia frr,pl, orr,rrr lrto. (l0oLrlIBlr,ltllr,rrr ttrirllgltxrttt'ulll)1, zonolr) rlrrrtriij..l'tttr<il,ol|l ll,Lr , tltlooltttttttttll(, trrilllgir:o rIulotrlr,Ho r,l,o nitrl,loo.r,liz lit, rr.iyolrrl rlrilo rlr,rrrrrlilrr lrruvoilno rrrrri. ,111,r* ,ll lirt'ir"1 B ltntlitf(u,zii, i'rr,l.luir[. l)tttrrttlur+r rrr loolrt,l,r1, 1,rr l' Hi (fN1i1x:1,'lllt,g ltt rtrirt H(tgtltollt i1, l,lr, ittl,rrrrrnll,l,; 1,t'iroo rlu rlrr1li1,rl'i I i ,r,r (, i lor,rill crt rrov,rrrri" ir r. I

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(lttlrtlii l)l'itt itrljl Vitttltx'lr(,lr irrr'r,rrr plirt src(,iottirrr.lr liirlir(rrilol tlotsrrLr. lr rlttlrrr'ii llrr(iik' lrx,rr,kr Ir ot,ociritrir prrtlr.lr'tltttt'trllxtrtltrtlrtlii' ltttttriolir r.u rrr r,iriirli'iill sLttst,lo Ititttittt,rrlc r.rlilrt{ir,i. tltrii rtuioti(ltllirn) rrrrlrrii.r,1r'i lrtll$orsur$l spirs rrclo rrrrrscLrlulc lorlrlizlrlt, r'r..1)r'r'zillii dllr'otji,!jii rcdoitt'ei ilttrolrur,, rlorlurr{ur tc c\irJtiiio des(fii1('it t,rtutintuitle poterrl,iilldin princlt'1e, Ir)rsr' rulriOlLllll'(r, t.) I)urqile r:rnlatLalesinl (.trrter]nirat'ede leztrta cordortllclor laierale ('1 ilJ l l)os1 ioa,r'ot],lcm:iduvei spiri,rii, in special ale f:rsciculelot' spino-talarrrilr,. Sin1,duleli surde, neplecise,lepal'tjzate pe un teritioriu r1ale fi sint rlr.olritci irrso{ite de tulburlri do sensibilit:rtcobiectiv:i cn l'el.}artizal'e }e ltir ll|lni(orp srlu cu nive-l la un anumit segment. rl) f)ut:orca n,eni,n,gi,alii rraractclizeazii plin dureri oel:alice difuze $e r rr rrrrloiilc tle ceafi, qi oste deti, in turnorile cerehelo:lrie ;i hemor:lgiile' suiralrllrnoid jt:ne I durerea mr:ningittlL sil,uati, spinal trstedatoritS, tunorilor rrrrrlulillo 1i hclniilor de disc ;i se calarterizea,zin priti coiltrootar'ea pilrir asoc:iatl"l dureri pe ma,i multe segmente. cu vcr{;Lrbrtrlir, L:) D,urerile Lalamice apar in leziunile cturc adecteazf grupele nucleare lirlr,r'alc I)ulerile se localize*zl pe hcrnicorpul opus talaale 1,alamnsului. rrrrrsrrlrri lt:zat,,rrai ales pe fat-i, li pe rnernbml superior, au o accentuata nepH,cutd,qi se insolesc de lulburi'ri tle sensibilitate lrrrrtliltto aiecl,ivS, oIirrrlivil,, rnti a]esproprioceptivi,. Aceste dtrcri apar indcosebi irr ll:zinnile anurne in afecliunile din teritoliul alterei virroulare ale talamusulli;i lr,rr liculo-optice I leziunile vascularc tlin tcritoriul artet elor talamo-gt*1iculrrir'i, talamo-pedol'tltii dau aSterela tulbul'5ri de sensibilil;ate obieciiYl' si cu l.opografie caracteristici, da,r nu genereaz:i durerei'l talamicl propriuzisii, slu goneleazi1doar dureri tle mai mici, intensitate. .l)urelel t:llamici poate fi conl,inuX cu exacerbiri, sau po:r,te surveni tliscorrl,inuu. Soarte acleseoriap:Lri!ia durerii sau exacerbarca ci est'erleterrrrirl ii, de survenirea unor excitalii liziologice, liminale sau unoori chiar upei reci pe o1lraz, Astlel, drircrile pot si aprrl ll rlpliczr,rel srrlrliminal.e. picptinatului, a survenirii ultui culent tle acr reoe I lrlteori irr lirnpul r t)rrritirr dril'erii cste determinrtd' de excitan!,i senzoriali (mirosuri deza' gitrllrile, zgomote sau lumini putelnice) sau chiar a unol factori t'rrolioirlrli. -,\cca,sti, integlare in durere a excitaliilor senzitiYo senzoriale sau ovel'reaction (stprarcacfie). ln i,*il,i,r', ,r I'ost denluurili, tle citre lead ilgi I ruli cu tlurerile talamice, mli trehuic emitrtite noi-iunile de hiperalgizitr 1i .lriporla,tie. Il/teral.gezin, se traduce printlo sensibilitate dureroasi, r.r r,rsivi, plintr-o scidere a pragului durerii, astfei, incit uir stimul ile inten. sir, sillt(, rr({l-rrreroa poduce^tlui'ere Hiperpatia este tot o hiperalgezie, in r.rrrrrilsir, tlurerea are o tonalitate afectiYd' nepli.'cutd fi, palalel, e\ist6, I,rrllrrrliirj. da sensibilitate obiectivi, in sensul unei hipoestezii mai rrult rrrni pu(in accentuate. Iliperpatia apare foarte adeseori in cadml sin;.rr,rr ,lrrrrrrrrlui lalcnrio, al;turi tle duret'easpontrni' 11 I)urerile [isceralc. in eazurile de lezare a dilerselor organe intcrne ecuzi, rloui, categolii de senzalii nepli,cute : pe de o parte dluerile lrohraruii l:uu,|rr ilc sufclinla nt'rnijlc citi, a forrna{iilor recept'oare de Ia nivelui orgaproiect te (re.ferite)la riivelul rrrrlni rtsDectjv, iar p.' dc alti, parte, d'ureri, acnzi' dureli in rogiunea As1{e[ bolnavii cn anginI pectomlS, lcgurrrcrrt^r,lor'. iir,lir,qii pe fr,tl intorYrd,tu brllnlu.i sting, srferinzii de ficai; acuzztr ll r'ocor'd dtlef i ploicctato in ilrrr','r'i rrrrrilt rlrcl'l, bolnavii cu ol'jzc tenalc 2louzil, irr iLl t'oritorii pon'rt:1Yrulncl(f ,zonel0 oljc. itrghitro"sctirtn,L'l, A&\$1.(} rogi {)a, 'lo Irri I latult'. 1I4

r Irr pt' rr r , llnr , t t r . t t 'olr t glt r il,cl, lit t t t t t ', llt , t lt t t t r r i r 'ir it r ct lt llrsil) li illlilnit l\ t r| l 1rr rrrrrri i l r, f rt\lit r ( l( ul. t i] ( tlr t lt dir t ', t '. t t r t( r t t t t lr l: t t it t r lt t t 't r t i vir r lr , t t l'lrit t t 't 't ll r it t so{ilr r r t lt 'st 'r lt lt r viit 'sl'llt t 'i lt ot sisl'r 'tlr ', lt t tti rcrtrl ri gi t, sl icii, it r sf ir lr llr rlr r lt lo 1i rl rrr' ,.rrl ,ti go t ir , ) r il'lllr t . t lg It I i tt t t rI t I It I i rr. A. t r slt r lt it lt r t lt t t t 'it zii t r il t '\ 'it , r r t t ' 1t .rl r ! rl (' i :r zik: , cpuizir t t l 1t c lt olt t it , v. Nt t t 't r lcilzr 'i,llt , lt 't 'it lt iil olr iqt t t t ilr i' r t ,rrl i Ii rr1r,l o: gr r . sl '. I t t lt i, , t , , ( 't 'izI l'r l' gilllli( r ' lit lr t li|'r ' i| t t t lt i t 't lt t 'r st '- 'lt liir ,rl tr ,.tt.:e t: iicar al. e: ( t 'ila . l( t r inlli e; i cso. f ur ingilnt ' ( r lt asnt t ' t llt t t 't t t it sl. lt t l rrl i tr{ r si csoit lg, ct t icnil la dcglut ili( \ ) ' oil( t l^t iat kur '( st r t t z, t t ( ii- t lr ' lt r r r ' (i rrrrr;rl rLrtrr or $ii t est iculului) , t t r iza r : lit or iilior p ( st : r r zllii it t i{ir ll Vr I I t t ; I I oI r I r r ', n ,,:rrl ri r l trn r if onnii, l r ept at in t lur cr i violcnt o) , ar ize ur inut t ( r lt t t lt 'i t t t r '.zir'.i i1i rLletril), crizc hringiene (foalte pertculottso prilt lrpl,rtl lri prrl lr ,l rrr' ,' l rL :r,siixit ') .ln t oat c lcest o cr izc, nt ss ale1list azi'l t ziuni lr lolt t iit r t '; 1r t rrrrlrri ll trivolLrl c[ruia se resirnte durerca 7,1.2. Analiz:r tulbur{r"ilor obitotivc ale tliversolor slrrrifuililirli. l)rrr rrri rri r,rcn acest ot ' cat egor ii t le scnsibilit at o poat o scof t t ( tiu ovit llt t {r i t lillt ill l'r\ rrl)('(,fo piltologico Di anurno : in unclo irnpftrjrtriiri sti pl'o{lll(1rr(, r\\lrl.lr'r'lr ,, norrsilriliti,!,ii, sbilro nurnitii hiperestazial altoori ill)itr(f tr t l i t t t i t rt t rt t , ' : r' ' rrl':r lil;ii ii rcco1ttivo, care sc nutle$1c hi,podtniet c:ll(l l)orllr(r lllltl'Alf ltllril lrL rirrt IrirrlrIr,r'oilCap:r,citi{,ii recoptivc' sta,re numilii. ansra3iP. IIil)r)(f$11',ilr, r,',t rrrrcslr,zia pot intclesa 7;e itr)tli aroncttlu,re,raditttt,lu.ra t1 ttor't'ttptt)1:ttlt4!tt| t tt)tt)tt(utna nt e m ad, ula, r e.r jLelot int oi'csit i; o: t t c r nollt t t 'ilo t lr r sr r t t sjlr ilillt lr l' ,,rrrl rrri'birn rle hiTtoesteziesau' anest'eziegl.oha,ld,s',t'ttlrttt ittlt't't'srt' rttttttrtr rrrrrrrrri to t eg0Lii ile sensihilit ; , 1ii,celel: r 1t 0f iinr l iir lir o{r r , <, ir r r lI oI lr ir r r r l, . ca h i l tor' :rt,.zie sau allet t e! ie t l'isoaiold'Exist r i t louli f t r lt t t 'i t lc il's{'lr l( 't r {'rtrlr r r l ,rrr(i i : 1.. D i s ociaJia sir it tgomielicd. , in cilt 'c br t lt r lvt t l lt ict r lr r r r r t t silt ililr t it 'r t scnsibilit lr t e: rt,act ilii ; i st nsibililr r icr r lr t ol'r r lr t liiI iit r ti it r lr r , r '1r , . i ,,rrrrl ,rLl gozicii, lc \ 1rrr iri s lrizgo iit. tt ielir: 1i \rLsintlronm,e sirtrtJlontirtlirrtr.ri st'tlrtlot|i1lr. ['zti t tt itl, lrlrlr'loL tormo:r,lgezice :llc fascioulului spitto-l,tlltt,ttt llt, ttiyt,lttl tttctttli r:i l i i tl i n co m isiir a ocnt llie : int er io: r iil, sa, u 1a' nivolt t l I r lst r it 't t lt llt t i r lr ilt o I rrl rr ri c post er ior . rr \lL :!. I;isocit1,lia l,abel,icd,, care bolnavul lriet'rltr strrtsibilititltrit' IttttltttttItt lit. i.il, ,1i t'rrrt, ri s.r^ibilitatci, tacl,ild, opicriticli, sensibilitltcrt l,otttto-lrlgrrz sit'tt it sindrottttt'lt' 1t:st'trlrlt lrll r rtL rl'r,paticit fiin,.1 irLtirctc. Apare in. trabr:s t,r'lir',;si eite dctermirutri tlc iezirc'.r, colllolln0l()l [)()sit'rioirrl'.

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rrrurirIcttIrr rlirt t1(lrt)l(ltlrl)ic(,, lrollllr, Ilr,srrirrr'.Ilocli lui Srrltllrrrrrit.trrrr lr';rlli, rlitr rlirr polfirii 1i rlirr rrrrrrltr irrhrxiclr,l,ii srtli'trnrirlrrr cu oxirl rlc clr,r'lrorr llrr. qi Iriltn icl. lr, t\in;lxtltttl rarl,iottl,arsi7tol,i,tnilitttlrtt' irrrrtiirtrrrrcltoit,zr't, tIrrloli cu rl il l,r'rlrtr(ii t l,tlicuhlro, pit,fo$tozii tuLbrrlrilirl.o si sursillilil,ir obirrcl,ir.i,, t,o l)t.c(rlrrt rr lrrllrrrliilialorcllexclolin ttr:'il,oliul rtrlir,cirrikx' irrtori:srto.l,)slo crr,r'ir,rlr, r ul icli,t Ii sl;r:ib n1,iil net tndioulilril, dot'rnltornoricii,lr,1;ulbur.ii,r'ilo su rrilr i l rlrr lrlr lr', r.lrc t,sl;o obiceigklltlli,. l)cbutrL[rlurcrilor si ll1 srrrrlnrloltr.ior.jrrlr. tlo rrr,olir,trl,u:lzri tlingnosCicrrl. rr iit l,isrrr ^{ccsl cstc blrrt,ir,l 1,r:rLurnlr o, irr r rlr,rrr qi rrll il itriiccl;ii proglcsiv in tumoli. Adcseorilcziuncrtint cttrscitzii rr, rr l ll l rrt i rrrrlr'icirii, oinrl voi'bim de polir:ldiculite, sau irrbcroscl,zii, r'iirliirrirrilr, lr,lil, rrlrirli{flc, cil, 1i norvii periferici, cind vorLrirrrde pol,irnilit:u,lorrrt,tilt.ln rrlr.sl,rsitrurl!ii,semnolemotorii sirrt irrrporbd,nto, pu'illiz ii llrxro pr,r.r cu l'r'r'ir'1,l.ccs1,c poliratliculonevrite sint dc obioci irrliccfiorlsu vilrrlirr| . .rr prr1, un clt'a,ctcl asccndent.Alteori se lealizclzii ruortirrgorrrir,lo li luil po r';rr rlolcyrito. I ir.r 5. S'i,ndrom,ul, ,,ganglionitii" so caliloterizoluir,plin srrrrurrr lr,zi d,e rlrr rtrr: rrrclusivii a ganglionului spinal ;i a lii,t1.[oirrii posl,olioir,r'o (srurzilivo; plitr ltectarea ,,pri.r'ilegiatd,)' c5,trc virusul hcrpcsului zos1,trr, rr,l'irri de crr lirlr l rcuroectoderrnicil,. localizarea clasicri, sintlrornul sorrziliy :rrrr rr In l.rll)ogr'r.t'fie radicular5, manitestintlu-so printr'-o nevralgio rlo t,ip ,,irrl,r,r' rrr,ii.rrl"unilatelald,, violenti, continuX, da,r cu exircclltiiri pilrrrrisliru', rrrr lrrt:url,ere constticlie, de impuns5,tulir, rlo arsurii, lil cu,r.o ilr1r,(1irzl, ale $o 1i :rlrtoupcobligiltoriu o enLplie critema,to-veziculaL':i irrxrrl;i hrlrrrglrrl'ir.. r-rrr lrr practicii, asist:in la varilte loca,liziili: culvicir,lo,colvico Irlir,r'lrr ;rlr,, rrrilcn,le l (,,intercosta1e"), lornbo-inghintlc, krmbollornrLlir,Lr, ri:1,(,1'{) ii{r1lri ,rlicr'. .Sr-r, uitLrn tormele craniene,cu lcziurtoilnctvilor. rrlitrIicrri, V, Vll mr \ | I lris, YIII, IX, qi X. li. S intlrom,u.I Ju,n tle iur,litd,tt,l,hti Bicartl.1i l,'ot'trsl,in'(,slo rxrrrlr{'itrlrr, lr,zittttii li,tlitcinii in por!iunea sa erittr-Incnilgcu,lii, Lr,livclul l,r'ir,rrtliiit ll ,lrirnii t1e conjugare (JtU. 29) rr) )n sinilrom.u,L iritulie funiculafi, Lulburiirikrsinl, ;rrrl lr.rrzilivr, de r1i 1utrlucprin dureli vii, a,soci:rtc lu cLto blLlrt{i, lr ilrocsllz io, rIrrrr' ri. Filrr rlc r ilc liitll cxacetbatetle mi;cririle oolounei1i tlri irn,sirrrrr,l, prrlll cr'li'lrlrr lir. ;'i, irsoci.rz:"r,trtitutlil i antllgico ou conl ra,cl trrr ilor' ll rrt'lt, rirolr 1lr,r'lrvc r.lrlir lr . ;i rroio 1t) ln sbtdromttl tla aompruiutta,fvniattlut'ri,s(tunrkf rlr lrl,itrrlr.tt. lir^sittt pc prirnul plan, iat cclo tlc altrcl;rr,nr sirtrzilivi so lliulrrc plitr ;rlgii ,;i lrlirr hipoestezii in benzi (uulicLrln,rc).

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.nulu.Inra 1. llin,tlrtnmole sanli,l,i1)e L Sinilrornt,Ll ( com.plcte) nddlu,norhl,cnuinri,rrJlr,r'ifirr, sacli,u,n'ii.l,otala u i rrtrciitnrstozii glollnlo subiocl;ivo oLricctil.crlorlcsulrtullczirrtrii (l;rrllrrr. qi trrto tlrr scttsibilitrr,{;o nivol"), ittsotitri (lo l)ir,r'itl}lcgio krl,t'rrllk,g ir', srr,rr ,,otr gi ItrllrtLtiLt tr.llrrr.r'Lrt, l i irlrt l,rrlllurritv(Hot,iIt,ivo l,ttl'ico.N ivrrlrr lu lhu t r],t i ikrt' rlrrsr,nsilt rl ililrr,l,r, opirrlo rlo rrivoluI lrrzirrrr urtxlu lu,ru, i rlokrrrrr ii irru,r'our'rri,lrui, I ry :r trivlltrlrti l,rrllrrrlr\,rilor sotrsilrilil,rr.l,r,,dr,oxolriirii, rlrr u,r'o villonrr itr nl,rr,bjll rli:rgrrorlilrrlrtilollir. rl ft,zirrtrii. tr,rr, grr,rr i!. Sindronn,l hlntirrliun.rtu, rlt rrriulrrlr'i rildrlrrrrrl llnnon Nrtquuxl, lrilrrr,lrr xotnilrilil,rLlii fiitrtI rlilr,r:1,r' 11,11. lorrnilrllilrl,l.ll 6i 1ql1r lr,t'tro. ;rtol'rrruIrr
qtt

1 rl [(zi (, f l' iir ) ( l it r ( r ' u rri [rri c , ]rt,rrri s o c l i L r rr rrri rl rrvtri vi t gencra - pe i i l gi i c j r l rrrrrl i zi; r , r r c r r r I r lr r I r rirrl i ,r' i o l s l i u l r,rn t,n rb L e l o lde accea,fipal te cu l czi ui ter, i rl rrri rrrii rI rr v c i . o rlisuci:l!itr fa,bcticri horloLll,ct,alii leziutii qri o disotinlie r irirrlorrrir,lior"l toll,r'tlatelali leziutrii. Astfelr o lcziune in legiuner ri.ir.ali (irr|rrr.rrlii) [ Irorniuriir]ur'. stilrgi r.* g;cnela i (] tnonoplcgie crula]ii Jting?:? ei sctrsjbilii.i,l,ii plofulde conDtiente in membrul infcricr sting si trr('r'rl('rt.ir, pir.rrlorr.rrslrrsibiiil,rii,ii tenrro-algtzice in partea ch.eapt5, cu nivel pi*i Ia,
Rdddcinll posferbad

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Il l l ( l r '_

,.1 \i nrl tonr t t I t ( n) ut ll. i loxl. ( , t 'iott r . r t lizr , ir zi o 1( , lnlr r llit lg( 'zit ' t t t lopr r 1i r:rl r,, trtl i r,lt l, r t i, it r sr , gnl, t t ( 'r 'kt cr t llr olit lr t col'r , slt t t t t llilt llt t t ' lI li{f loll: {r f (lr 'l' ,l r i r,r ,' , r' tr piir l ut , r l"r s|ir silr ililiiii pt of t nr t lr r ; i l, r r oi ' ( r lcf i t lc ii; r r t it it t ; 1' ilr t rrrrr' l i ,j , rl rrl rlc r r cccit yili '1c lll lczir t lt cr t . St r ir t t ilt t 'slr , ir t r lt 'olr 'lt i I ll lnt llll 1,rrrri ,l i ,' . IL Si arIntunu'lt srn.-iIi'ta o,lt' I,tttrtrrh rti ((n'bn|1. itt,l t, i rtt ' l r: l ) lb t t 't ii, pr r t ubr nr , n! it le in. , f ar iour tit t t ct t st azii t . r iiilt r r r t t r 'r ) r t lilr r {r r trrrr r.l ri Ll rri r. r j r , r lllt 'olol r f t 12r iir cr ucir lt r t c: r l{) r '. ia, r ciiilc st r r silr iliiii{ii li'{r 'r nr rr,:i ,rl , rl r' i tr I r 'r t t , i1lnt r .l) {) il( ic( r LL,t . {t slolcZiilni l. ol g{'il( f l'il Nit t t ll't it t lt t st t t it t I t 'it t t 't 'I I r jilr r t tll r t t tl i t,rtl ti ttr;l ir lllt t llilit lciicnsil) ilillr loglollir , lii, alt lt 'ici l r,,r,Ll !r' l r )i bcilt ilr r t t st czic r ror t t lt l nt ellr li , ( t t ilo ixlos( '( ) li illl' I r lt ; r i ll l' , r ,,,,i rl si t i t t glor ni( '1i0. Aceir st ir ,t ullr r lt t 'e alt t , r 'r l"t ; i r lir ocir r li t lt ' r lt t r ilr ilt .rl r' yrri c i n r : ir , ost t hi sint L'om ullui \ Yallr t nlr ct g, lllt t i llr r lr it t r lii Nr r ; : 'r 'r r ll, ' in r ri l rri ( l cst r r n- ( lh{llliir ( \ 'czi ci) p, 1) . pcr :t t.,:i rrtti lc'pr r iubct ut t ! it t le su, 1t tioat c 1'L lt r t t . t ular t t lr t t t lt t llr lt t r lli r lt t .,1r\ (' (,oi lh ii. l. c. r '|, le i alo f r , {ci, lt r r t r c}r i. t ilt t i ; i r nt 'r nlr f t r loi. I ll lc;ittrtiIt bu, tu,re intrt'oli t:nrr:,riel,ot'rrtiLrrtc llrrolrilci ltlitl rrI r I i I r' t I t t r' ;I iI f lscr ict t I Lr ht i1t it 't t t t rI iI I iii : t t t lt t r t ,rri , r' r' isl i i nl le lt t t t cl ioiu'erpt lin1; r ilcz: lr : ol. t l rrr l r,| ogl os ( r : ille genot 'oaz: i o hom iple! {ic cr ) lt i. it lii t our l; - 1,, i lr lr t r r lizir r lr t f ; , l r' ' rti r l rout ilinr ir ii ipsillt t t a, lo) sc lczliizit ; i pr lt r glir r r tlr r i llt r il ir r r ! ir r r lr ; r , , r.i i r Ii . t(l n r f ( r t l, zt i 0 lt t r nti[ ncs1r ] 2i0 oolll. lilliLt ( , 1'r Llii l't lllli st 'r t ; r ilr ililr t i|'r r l] r l ,r,rl i rrrri ri (t1m i o r lisr . r cir l! 'iirlc i: ip lnlr olit : ) r 't L lt 's; r t r i'ir t r t r t 'sr 'l| . il , i I i i : rt i I
I t ( r ', . lll. S i n i r o tL tl ttl t l u ki n i cr : i tt l tttl o l o g tu , 'tr tr tr ti tti .' si ttl IIIIII|{'Ii ) i Ii .t,l l l i l l l l , l l l r i t t t i c s t li st l i cl l l t( ]su i i L c i n r i l ti n :e l l d e ccl ti i ,.l tl i l tl i 'o l tttt i .i l i r tr r l l tttr r r ,l l ) r 'l r r i o r r \ I r z l i L . r l t t . I '1 tl e i l o i l i l h l n i ci i t co n 0 !i u l l i l {}r 'l l ( r csto r r l ,I) l ( r Il l l l l li tl r ' l r r tl r r l r r '1 r ,' ', , r r r r , , , t r l l r t cl o l r tl o r 'Io ftr n cti o l l .t ] o , a ct- 'l o t ( '\l ) ( r l i l l l ( 'tr l i r l ( 'si 1 .9 6 7 I L l r tr r r r r i l {1 r , l l ) .) i , l l l Ji l i I |,Ir ctttr i IIr ' r r r r . t r i ( S i t g tr ', 1 9 6 0 ; f,i i zo tl h cs, A,i u r i .r g r L tr r tl , L 1 ) l i {i ' ci l l <l tr l l ]r g |l ', l l l ( ;0 ; |'r tIto Ii Ii tt, . r 'l r r '1 k r s , 1 9 l i t; l 1 l , i t i l ) o l ) ( i t.i !i i r r ,i i 0 r r L l r b ., 1 l i i "i 0 ) . l 'o l l l tl t i tl l e Jl 'g t'r ,t.l r i' tt'tr sl r tl i t tr 'l r tr r r l ttr 0 ttr , , r , 'l l t r r i i i r lr o l $ tl i , ( l 'o p o vi r i tt, l {) 7 {) ) ( 1 ,'i q . i tl ) ) . g l .o l ,u l cl n si t' l q o n , tl t'scr i s tl r r l ) ( i ,i ( i l 'i tr ( ' si l i ,tt r r t ' I . s i i u l ro n n l l r .r l tr ,tr ti tt tr l ) t!r tl f r f l l s l r ( {t i t l ttl l l l i i .l {ti l t( l l ( ) sj l l l l ) l o l tt( l : i \) I]( t i a ttfttl ( '!i ( tl r l ) ( l l ttt r l l so t'i i r l c ( r r u l i tt<l ctr tl l t.tl tl l Ir i 'l l l l l l l r ( 'l l i i l r l l , i r t t t i i . t , t t o l ti ( \o l u l i r i tl i tfttl ( i l r l r r t , : r p t o l u tttl i i ) . l ,) r i sl i i , si l r r r r {i i i r L tr i l r t i 'ttl ) t ttl i t'i l ' tl t s( 'ttsi l r i l i l r r l r ' r r l r i Ir t r r l r 1 , o l i t r t l tl i i cl t i r sl tco l t' tl tr l l cttzi p s( 'l l {l o l i l ( l i ( l l l l l l l '( ! i 'l r l l l i tl i ( 'l l l l i tl l l r l l ( 'l l ( 1 r [i r r l ) ( 'l r i i i r l !{'tl ( 'zi i l r ^ 1 r r r r ( i r r l l r l r ' I r r , i . r r r l i s l ti l r r t{i r r i :r xl i r r |i i sr ttr l tr l r i l r i l i ) , ] l r r r l . | | r , ( x ) i l i( i i l i i , i tt i tst'ttto ttti t $ i l l l r l l i i , ( l j i l g l l o sl i t'r r l l l i l i 'r ? tr ( i l l i tti tr 'l t|.tr r i qi l tctr ti l tttt'sl t'zi :t t'o t1 i t'ttl l i tl tr vi ttr ' l i l ttl r r r l i l i l i l I , r r r 'r t ( , z i i l i r r l l tl ti t'r 'i l l r 'l l l l r l l ' I t 1 t l t t t t i l r r r tr :i i t,r ,yi r l r r l l r ...|i r i i ( si tttl tl ttttl ( 'i l l ( ' l l l i l r { l l l l Ir l l i l l tIl t' l l tl i tl ttttsttl tr i , r 'i r r tr ';l i tttti r , r r 1 r r r , r 'i r r zi il r r tttt ( i ttr , l ,l r l r ti l t l a i s ( l l l l zi l l l l fi t t'tl t ' tt |'i t t ' I r' t I ' rr r r r,, , i t trr i rr r r , t r r ;r ,l l r .i i n l ( 'tl tr ') ; c) l l t'tti r r l ,tr ',r i t u r ttl .ttl tl r ttl ti l \//tl xr r r i r l r . ( r 'r , t t . l r r ,l l r r n ( ,,i l i r 'tt,r i i tl r r l Iti ttl tl l l ti ttr 'r r l r to l ) t'i ( tl t'( 'l 'l r 1 i t'i ) tl l ) i t I | | I I I ( i | , t || | I Ii ) i Ittttr tttr i 1 ttt'i i tl t r ,/r tl ;i r . ( i I II I r' ( | l \I ' I t i t r t t l t r 'l , , r x t l ttl r t i r 'l l l r t t , t i {//r ,r '. r i I r 'i |,t'r || {'|( ' l p |r 'i r tl r ' ( t |zi l l tl l i ,j o l ) tl t' ;tl ttl t'i t o l tttl tti ; l l 'l ', t l t t n I n r , : i r ' ( I rl rrrI r. t r I t t I tttt l tr r l r ' l r x'ttl i l r ,l t zr r l ttt c r tr i l l r l i i , ;tr ' l tt'l r ti ctttp ttl

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Sin d r o a m cle se n zili\c pcl i fol i cc.

rrtqrrrnrlul ln({lulilr. lezl,t. frrteresalea concomitentii a r"i,cld"ciniispilale tl 1|r'r'lir,. Lr nir |lul si t)e p rrtoa leziunii, prorluce o balld5 de airt*tezie " 1 ,'l Il .r r l' . ir i l' l. r z u r,t' i d r l rre -te z i r, Iro [rrn d ri st i ng:,, ,i. Sinrlroqne.Ie tle disotialie & sctlstbilitd,lilor : t) t\irtrlrrtuu.l de cortloonep <;sle,t,io&r'e (GII,Lgi l]urdach ) sau sindyum,al rlr .lilttt lungi. oI l.u,iUijdri.ttt. Tttlhuririfu su,biectiLe constau in: plrcstezii .,i rrrri rrL's s(,llllc lcccse de tlurt:ri fulgulanter (fulgeritoale), cu scrliu lir rrrrr r:u'irrlril. I)1\)\'ociireiri.lt1 ex:rCc:,barea:rcCSiolaprirl anl,efieria i:eprLlUi rr. lirll('r{,lzi o l1,ingtr,(' ccrlicillii, in sperial plin conrl:resinrir .:ln irlin r'1,'1.'i'rii 1tl:iri. X'tttbtnci.rIicobiectil)eteilizeazii o disocia,tie ta]:etici. a rcnirl rri l ri l i i rr ( ii, lr illt er ' r lir s :u l trn i l rtr' l :ri i (d t: :rc e e a ri parto cu l tzi ul trrl . I't,t,iltilitti!t r:Ii.olrLrtite 1-lbt's, sirrrlrolrnc ]tituro-anemice sau altr] ntiaI l,rzl lrrrricir'lurc (clrrrtn1. ilo1e, {r'goncratlle etc.), scleroze oornbi rtr, })oli rlr,*r'l|r,r',ilivc (bollu, lui llriOrL.eich), r'r't:ntr:n,l ftirrnt do cor'ilon lcstc|ior ., , 1 ,'r r r z , . iir r pl: ir . i, lt) ilint{xtntu,l. dr ttntitturr"r,r:r'nusit poslctioatd (sut rcl.roeTtt'niintur ) tl rtl i zl rrz it ,o t lis olir r { ic s i l i rrg o rrri rl i r,i il , rn o -i rrr: rl uczi r,ri rl rul tzc ;i i l i rrl rk' r' ), (S ,rrl rtr l ri tsllir t lr r s r r t r r . il ri l i i ri l i i l rr.r.l i l r'1 i rr, r,r,l c i p r rrl trrul r,, ' l ' rrl l rrrri r.i l c rrr.rrzi li y,,rrtt o I oI r ollI t I ir l l i l (l i c l l l l l l rtrr;l rrttrl l rl i ii,tr l rcrri :i pttl i tk' l t i rrttl rti rrrl trr Ittr.l rrt, l) r r lii it r I it r r I r' r' l rr l rz i rrrri i , (rrIIrrtl l ' i Ii l rrs i rrl Itr]l j l ()l i l i l i rtl ,' (1, r tu(,i ,.i rl ,) r{ l t I r iI r LI r . r r r lr ,. :rl l l

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LECENDA
6r nucleilor Gr nrcleilor OM:N.l)f,Rp6r hucleilor VL(Wj:N.Veitr. CL:N. Cehtral ld. CL:N. Cq'p gedcuto, laEral CM;Ncorygenbulol +N. furdfasci:ul. l-D:N-lateral 3U: N.Sutndib t6a nucleilor

Jriq. Jr, Nucleii talamrisului $i concxiunile acestora (poporiciu, 1979, sehem$ ({'rnbinnLi dupd sislematizareatf,nucleit";"?;.r,n n" Wa tct, Sager, Le Gx)s

t r ) lt H (,.v tr,.c i l r' \l D,i "di r: l tl r t,okl ri l trl i t,l j r_ i r,\l r(,l l l ( lr ! ( l( , Z ir f it 1. r)l )l l ..i i 1 l -(.i lllIrr.lt{ ,t ,i is i rrl . r r.si rrrl i l i trrrr[1. rrri t l i i .{ .i l c t)1 tl l )U l (.t, i r. rtr.(.1 t. l nl( r ( l no it l (l l ,| rl rrl g r,z i r.). tr. s l rl r. r ,i l . l rtrrri rr:t. rr I r.I .I r i rI.i rrrrr.l t. I Ir ,

psihlu)sc,,irrt(.grcazi" durcr,.. ir.r rt,,pililii, o c\(.ittli(. -A,.1ft.t. i:ll'.iJli,il Iir(.lilii, dllr(.rl)tfiqrrrlcr'rnir.i stx.cill irigrrl att'ulri.r:e),'(,lrirr 1in srru simDLl. ItI ittgr.t'rrniclii, l)ill)i{,l.itnl, ctc.. il* Xa,r,,,, lrir:1r1rirrrl1l rl"r,larrs,.rr.zir liiri .ru' f lr r nr.\'l t {) ( |ut (l o

(ttltir't' (itullorolri rlozugrr,rrJrikr), tt'rttttLici ttttlIr' rrrirrrHrrli cttto!iiL',rrvlriLllr{,ii rrrllrxlii) 11i vii rrsti(,ir,t,iikr viHorrt:r,Lr rlrrlrr,ttt, tlttttli lirit,r'l,tr tIo ;ttttI't'rt, Jrol, tlrr lroltrrt,vr'1,. Ani,fol,ttltul dirr lrolna,viilui Iltrrrrl(<ritrrt'1, Sr!g('t! .l{l{i(l)r'r'il tt'ili rlr.orrrlrii aflxrNilt rnt:zilii,, rlo rlc lttci{,,,tttrlltrtort, rt'zislrt It, ittttttui t lrt1,r sI t't'l do sll rrr,ttzrllilkrr par'1;ort, bolnilvii,", iill rtlt lrtoirrnl, rrl ltri Ilrrrt,tlit,l'it'ttttt, gt'oiLzttirlit tlirt vtrrtltt' lltt't'trtt, IloIrtltt'i'1'', r:intl oinl,itcotul, o srrrtzlt{ir: ,,lrl'rttroi tlo iOtllt oxoosiv ltt 0ticu 0x0itit(io s0ttei leritlinl,ir, t t'tr:t,c! 'l'r'o|llil,ii],ceastii, lirl, srinzoritrllsa,upsilricr'i Ir'1rl,zin1ii, fenoructtulrlo supt'rrrcrtc{ir'lrtltr (,,ovct-teaction"-IJe:r,dsa,u o ltiylpatirt" A ccstolonottttttto t'r ltlit ii st' rrrirr'i, d ) lrlirr lrlptul (Sager, 1960) cil, in nuclcii latorali convttg c-roil,lll'iirrfi1,tlitt rrrr.rlirrl rril, itrtern (prin intermediul nuclcului dolso-mtx.lian), iii tlitt tttr'tlittl r.rl'r,r'rr, a,tit prin nucleii tjalanici de releu pc cit'iledivcrsclol ilf('r'olrlr\H|tl t'trlitrtt zil'ivrr,cit 6iprin nucleii talnmici nespecifici,in lela{'iecu fotttta,tiit, lrrlri, rcspectiv chiar stalii pe sisternul reticulat asccntlcnt (v(lzi lig. iil)). hilx't' I lqr,rl1i f161p"* (citat'i de Sager,1960), incercind sL explicc tlut'ot't'tr talamicX. au ar5tat cd,lezarea fibrelor cortico-tlllatnicu rt,t t'IiItt'trt rrrrl,it.,li, ,'r'lrtlelo senzitive talamice de snb in{luenla colt'ical5 inltibitolitr 6i rlo tttrrrrrrt' rr('r,g1,i nouloni senzitiYi ar prezenta o ,,supraleact,icr'ln olitto r'rcilrt,ttl, llrirr,r subliminal. Dup5, alli auttli (citali do Sagor, 1960), rlivcrsohr 2rolr"v (tasoalare, tumorala, i,nflamatorii, cticatricialeelc',) an cxcil,rt,txrlttlt'lt' Ir'. ion,a,le rrr,rrzibivc talamice qiar producedurelea. Incerclrile cloinl,olrotrrrtt rt tllttt' lilol talamice au dus Ia ilispute incd' incomplet elucidato. S-rltr rr'lt'iltttil tlrr rui,fol talamugului, in afard de rolul si,u ds re]eur qi unelo prtnibilit'rl,{,i rt r'nlrjbui Ia elaborarea senzaliilor tlate tle stimulii nociccpt,ivi tlo l ip pt'tr ' lolxr,tic (Mori.n, 1955; Ilead, Ilolmes, 1912r cita!,i do Sagor, I9(il))' lrltot' rt'li't' rrrill,e (1936) a ard,tat c5,alterarca nucleilor laterali exalttl, lronalil.rr'l,r,rt, livil, & senzatiilor, intruclt aceastS altelnre ,,Buprimil, un l[n:]ljj. trl,or, lrll lill,nr selectiv aI sonsibilitd,lii gsnsrale", a cd,rui func!'ie csto tlo tt,ttllri trtttt dureroagogi protopatice ale acestei sensibilit[]'i. l)uror('r\'lihltl ||rrrrcntele $onzatie, esto fd,r6 indoialS rezultal,ul uneri funclii coltionlo, lnl,ntt'il, " rlorlr la nivelul scoarfei excitatia se transform5, in senza'l,io. Desigur, dnrorile rlin sindromul talamic ritlioit, plolllornrl rtivtrlttltti lrrlrnlior al integririi senzaliei dureroase, iar o ,,soluJic irtrprrr;abill' qi rltrttl rr problemei nu existd qi mdte tlin concepliilo mai vochi 6i mtli trtotlottttr pe lrrr,zrr,to interpretd,ri $i fapte totuqi obiective, difur\' tlo lit lrutol ltl n,ttl,ot"' (Alnoni qi Operscu, 196?). Scoarta cerelrralii, rcprozint;ii lt,pll.rlll,ulsttporiot rlc porceplie a clurerii, Dar qi talamusului Ii levirrc, dcsigul rttt rrtl lttlltlt' <:il, itrrportant, atit do releu pe cd,ilesenzitive (inclusiv dunt'o?r,H{i)' qi llrr lt lill,ru seloctiv,precnm gi de a ,,moclttla" qi do n contribui ln,ttlttlxrrlut'trtt rrivolul scoar'fei a unor senzc,triiparl,icularc * tlupil, cttttt trlllillt(llllll rrttotior'- prin convcrgonla,ln nucklii latera,li n' unei lnulti[utlitti tltr ttLr' tttttrloi t'tt ittrtrst,rtr tr,tr!o extcto -,proprio-gi visooroocptivo ;i prin I'oltrl,iik) liltnal,ia, rel,icnlarit' cu sc.oa,rfa qi ccrclbrt i*l(Sllgcr,l.$60 1,\rscrti qti()l)r('H('lt' (,or(o'at(totit:t', \'1\t't\ Itl f lf(i?; IloDovioiu, 19?9); i) Mrri pot apiirtr:l rnirscrirti I'ilrrtrlot' la tlr.norlrlsitrf tliscrcl,ttiii lot:a'liz11,e nivrdu) rniinii (prin ltrzitrnrrll ti,t iltt lrrlit,ttto'8trirto, r'os1:txrtiv trucltttlrti trot rl-ttttttl t l,l Itri Lu,r-s);j) ,,J\llrrrr, t tltt i sin1, tltrrl volrll,tr trtllt o t,i't, lir,liunir{r," cu't'it ol'int,irfiltt sttttsttl drrgrdcltr ttt rrsLc , rrri6oil,r'iloltotozi<xt(utStt"zisr,lotfit,utlittitlo,,tlt'gcl,trittglttrlrtlot'prinnri4r ntnlotittkt Hitlt rtl)roz(flltnlrr lltr: lt'trttltittrt'oltttitt rt,l,ol,rrzitrr) ll'rt,l,hurllriIrt i k) cor]1tt i gcttic ttlrt'l I tt trxlr'rttuttt l)l ill I'r{rtlll)l,rlr (ll'itt hk'ntlilltont,oni'ntd lrrzlttttr,;r rr,l |,zirrrtr, Irrilolirtl rrrrt'li<'nl ttt'cll,t,i, lrr prxlrrriqtrrr, rrrt li rrn1;cin,ltl tt r1t.r,lrt.rtlcI

3r0

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, !l { r.) lli t lt t t lt i hil)ttl ttl i r l tt )tt.i to N Iti N d J ti l )o.t} (tt. /),!?}?(ft,i l t l .zi rrrrr,l t (| ic r rrtl rrt r ll lr s olilr lit . c rr l i tIl rrr.r' IIr,IttI). :.'. t\ittr,ltrrrtttt lt.lttnticr ltrttliuIt,. rt) [)a,tc irnilt ut rro-clinice (a1e lui |hor, rrrrl l r', l1) 1. r , l1) jili,l, ){ \.l ti i rs i l l c Iu i l l i rr,i te s c u fi N i cul tsc ,1925, ci tal i rl c )irll('r , I j){io j i'.j.I ) Lj.1.|I ,, 19;i{i, ci1,al de S:tg01,,1960 ?opor.iciu si coial}., ( i ( ; l1r'i llr$1)) ,lu (loilLurriilrut crist{tnlt ttr\ot s i,trtlT l'. ao,rla lalamice at luibu,rd,ri tl, :;t n:;iltil.ilrrl,t, itrsd .lrirri dureri, prin lezrrea, exclusivii :r, nucleilor ventrali
l)o: l| {'t i( | I i .

l r ,ttl tr ttl ,t 0 l tl tt ( r 'l r r r ' l l l j i I r r l tr r l i Itr l u l Ii r ) i t i n l t , , tttttl tl t r l l i l |tr r tr ,r r r r r|1 ,'i i l :r l It'r r l i ) r r r r t'r ttr r tr l t'ti z|r tzi t ;tti tt 1 r t'zr 'tt{r t l ) ( ' tr r 'l l r l l ) l r l r i r 1 u 'r 'i r r l , l r r r , i r i i ( r t t l o r l ( ' (l i r l i r(' l r' l l ' l (' l ti l l l t ;r l r l i l r ') , I r t'r tl i z:t l l t tr r r r i tl tttl l Il r tttl r r tl r tttl ( i t'l r r i i ,.r r .;i l r r r r r |tIl r tU l sttl tr .ti o t si l :t l r i .l t,:r r ttr r l r r r t . 'r . i D r '11 po si l r i l i l i i !i r l I i r r r i l r , ( }l r i r .r ,l i v| r l I r r ,"tt'r i lirl r i , , rrrr I i I rr i r , , i , l i ,,.l i I r ,r ,g cl r l i r ,i 'i r l cr |r 'i r i i .'l 'r r l l i i r i r ' l i 1 r r 1 . 1 q 1 ',ttt si ttl n ti tti ttr r '. St' l r str r ,i r tzi si o l l t'ttti l tl r t'r 'zl i co tl i t'tl ' l l l r r l :t sl l r r r r , r : , , i r l r r i i 'r l i l l i i i j i tl ( '|l ) sl l l ( 'i i l r l ( l 'l i l ' \'{'( r r l r ( ') . I'ti t .i tr i | | r i t t :t i l l tt i ') tttttti ttt \ '. r ! i t t r l tn ttttt1 r i i sl ti tr l i |i ,,h i l t,,l ,tl 'r tti tr " 'tt ' 1 1 }sl l ) :r l ':r r l r l r r r l r i 'r i i r r i r '.'r r r l "'r '' l '' rlltll, si t'r r l r r i '.r r 'i l : r {i 1 1 t, l 'r l r .i i ti tt r , i r r i 'l t 't 't ' t l i tt g r ttp ttl tl l i ( l l ( 'l {) r ' ttr si i i i l tr ti o |i l 'i t'i i l r ' ;t1 r r tl i tl l r l i l 'r 'r Io r 'r l l r r ' r ttl r l r tl ttttt, r r i , r r r r r ' ( r 'l t r r r t r l i a l o i ,o l tr }n r L ,i 1 ,') J.,l i l l 1 1 ) r i i i i ,:,i tl l i i t,r l .tt : l , t r l t i ( ) t t t c k ' si ttl cr ttr l l l l tl xc ;1 i ( 1 '1 r l i l 'r l : l r , tr r i l r i l - l i . I I ' I | | | : I I : I i (' t : I I Ii " l l i r r r l :r r l , r , 'l 1 '( 'l ( l ) ( r l l ) s t,rtn 1 ,r 'tla 'tct l l ] , h tttl i i ttr ti l l si tr ttti l o tr i ttl ;' I'o ttIIIr I:r Il .t r |:t l tt'ttt l , r r , r i c z i c c o t L l ti l l ti tcl i l l i i p l o i l o r n i n :- i r ) l U o i l l l l {l i , 1 i i tsl t'r l o q tt'r ztt" tr ' l r ttti l l ) t 'i r t 1 i l r , ['o Jxtt'i ci u ;i co 1 e 1 r . ( 1 $ ( i 9 ) tr r l l tl l ci t:r t1 r 'i i i ttl tttr i l , r r l , , r ' l ) i : l ] , i n i tl .r l e , t'\ 1 r i l p i n l l l i {l r l 1 ., {x'l \'l ) {'l o 'r L ( ', ;r 'r tzi l i vt' 'i vi Tr r r r l ' r t | ' ' r , . 1 r ' i i i I l ' g i u tl e :t h i p o tl l L a l r i " r , ,'r r l r ., i r ;r i l :,l i r i ' r .l ' 'Ir III r r l l i r l L r r r r r r L l r r . r l c t t t t t l i l t 'lt, co r 'fl l ti l l i l ttl cl l L r i si l tr l t,'ttl , sl , r i r ' .,.l tttl tr ttl l ( l ( r 'i r r Ir i l l l l rl , l r l . t n t i t , i i " .

Ir) S rrLr rlcrrrris Jitrntc heniotgice pltre sindromului tr"lamic (L,hor. rrl l (', I l) ilji ; ( lr Lr r :i rr,1 9 l i i , c i ta ,t r1 e S a ,g o r,1 960; Foerstcr, 1926 S ager, ^le I l 1 )l i (l )lliir r lt , z ir r ni u L c n u c l e i l o r 1 a tc ftr1 i . ,1. fiill(lr'{)iulolo [ulln[r:p ruscrthu, sint tot I ind,rotunepu,yli&le, Tez,li, ,i,rll l)iirl plotlsc vilscniale loca,lizate hr teritor.iul ut:ruia di-tr cei cinci pedir rl i rrr lc li: r li t lc r . c r .i q i c ..ii n 1 9 2 5 d c l l o i r, Il i l i e mand si N i cul esut: :i ,rtcrcl c in Lrlilrl){} i('ri(,rriil|1, si tallirno pe}folate (r'amlrli alc :llterei cerebralc posi( r'rorr('), |1,1()1.,r irulo- opticx (r'l]}rtrii a, rrterei siir.ienc), arteri:I,iuberol{_'lrt Irrlirrrricri,(r'lunuli a itrtcrci romunicante posterioare) .,si artcra coroidi , rrr rrrrlllionlii (r:rnnu,ii a artt:rei silr-ienc)" Cele mai iinportaute qi mai frec\,'lrlr. !ilrlrl)itrre till:llnice \.il,scu1:lt,c sinl cdle trei rarietd,li {lescrise de lherrrrrl l r.r. i r ir r r i ul{ r sdc Si tg e r s i c o l a b . (v e z i Sa g e r' ,1960) : t) ;il(l)\Dtu,l Lle.obliterare e, patlic,tLlu,llLi l(.1& xo-qeniclllat (carc irigi, |)otlirrtroii llltcrl|lii si l]oiitelio:ir;1, indeoselti nurle1rl yentral postcr'o-lal,erirl). fi1' rlrnr{,t{riizr,rrzl plin tulbur.iiri t'lc sensibiliiato obicctivi, la mernbre lttt:ti i'rplirrlLl,c Ir rncmbrul in{orior), fiirii afeciar:ea sensibititi,lii felei. I )tttr.tcr'. rJ,rr.i1 e-ristii, se tlli pc 1rltn secnndar $i este pulin explimatd,. Se trrr,r loi,ilrzi o herlialropsic homonimd,. l)irrsttosrlir,rlli]rr imllicii tiiiiicultiili atunci cind apar $i alte simptome, ttt :rlrrlrr cr,loi scnzitirt : ririrtii tl.rlamici, miqor,ri coroo-atretozice,tulburi, .r,|r.I)('I().I)j('si irrrrnilrtolts!e hurnitnim,i laleralti (cal.e insj, eslc de origine ro tl i r':r l; 1, r lr ' 1r r ' r r r lo l l i id c l c z i ttrc a c o l ti c a l i :r,i n . tel i l ,ori ul al tcrei col .cbral o tro rl r.ri oiui, r lil ( ' r r (' p rrl r i re ri i 1 l e ri i c u h l ta l a mo-geni ci rl at). Iiit innr'\. rltur'lttt t't'rolo11ic, silldxomnl talarnic gIobu,l (cn de altfel qi rrrrrJtrr:rrrrIIrr lIi.trniirtr p,li.ii'tlo) cstc re:r1iza,tLl.e !x)c6p, t:usctilare (ramolist trf l r ri ItItrr'rr.l11ii),It' ottt!1i(:e,l itla)'e,le (indeosebi glioir,me), tlegeneratiue t tu Il u t t t t r t t ii ( o1 ,(t' .fi l l i te ). , \litltitt)ltltl rl.e oitliterorc o, pddic'ul'uLai tu,l ma-perJor&t (c'r,re iligd,, l\\ exti:ttalanlicr], nucleul se.nilunar :r,llui lt'Iechsig). lr,. lrrr,tri r,ltr. l()riri.n{,irLri c trrclclizlriilii llin iullrur':ili de sersibilitate obiectiY:i ]a nivelul felei, '-lr. rr i<i lrr rrrr,rrrlilrrlslrl)ct'ior'rji :ibsente 14,merrrbrul inferior, L:l fe1 durerea, rl:rlr r.ris1ii, r<csilur::Lzli1u,rrir-e1u1 fc;lei i1i er-entlal al mcmblului superior r |i,l , l)rrl in r\pfinrir,ti;. Se pot asor:iii un homisin{lrom cerebelos, mifcd,r'i lirrr,rrrrlr,lozire 5i ,,min5, i:llarriicit,". Prcciziim c:i din date lurnizate dc I'r,r! || ', r ( , r r( 11) { i6, 19? 6 ) 6 i rb I? o p o v i c i n D i c o l a b., (1980) si nrl rol nul de obl i lr,r'rrll rLl lrrrrliculului 1r:llarlo-per'1oi'a1 poato fi rnnll rn:ii gl':tl, tnai boga,l, trr .rrrr lir r r r l, it iir t r c it, i rr l rl )ro p j t.rc i Ll i n i c i rn e tl i anc, fi ecal e di ntl e artcl cItt lrljitr,r Ir('r'li)llL{r ro iLnp,n't.trirL rlouii r':rmnli, cil}r sc dirijeazil bilatcrrl r ,i i ri g r r s l lr Lr , l r lik r ll l tn u o -s rrl rL l rl rD .]j c cs j rn e l l ico- Tn l tcest fel , l rl ,etol e pc rl i l rrl rrlr r i lllr r r r r o pi. t' l i o l l rti l i q i l ri rn l .trl i :tr.g i u tL i i l i rncefl l l i ce, l udi fcrerrt tl i tt r':rtt l ) r r ' j( f plr r v r r r . I ' o rrrl rc t n ( l !){ i (i , 1 1 )? 0 ) l >opovi ci n 1i col rtl l . (1!} l i 0), tt,l t o ;i l!l <.r l r r llr , l c r J ili|r r { i rr { i (| (rr' | ' l Irr| ()Ii } i Ii r(| tt1 tItr ttrti t,l ,c drt o)l stt' ttttl i i t tttttri rt go i rl ttrl tl ' r |r ' llr . jlJ lr ' 11, r.i rl i z r,i rz i il l rri l )r' { fil l i l ;tl ttt l i l , rl rr ,,fl tLl trtrr" , (rtt tt i ' i i l tr r' l tl 1 ri o trtr r I oI o; 1ir , ; 1t r r rr1i,. Ic z i rtttr,tl i t' ttr,t' l rrl i l i t l ri l l r l rrt' lr l i i (i tr< ' l ttsi vtrtt rrttttti). :l l :t

ill

p a r i e ti l l c p o t tl e tctl n i n r t 1 1 1 ) i l l i l i l i l l l i o l l ttl l ttttti t i tl t ' tt /) l,cziunilo r l t i l i i t t l t r t n n p l e r r i , cu l u si n l , tr r l l l u l 'i tr i kr r l c r r l l r i 'ttti 1 t ' r rt 1I rrt : t I I t . :t 'l ' " 't l r tt t , , r r , ', r i . r , l l t r - ; l oe n o zi l , tl o t'ttr 0 l ] cx i :i ( i m l l i l si ]l i l i l r l l |l r tl r ' l t ttt tttr o r r l '' rl" rti.i,ri:t' vi i u i l l S I ci fr .l cr l i tci i l l c sl l tl ( l ( 's"l l .l . l t:tstl . 1, ' r '1"r' tttr ttr lrltl ' r l tr t t , , l l u r l l t ) t , l l t do l :u r l i tl r ttl tt i , cr t r l j l l i {) l 'tl l l tr tl ti I'r t'j l i tr tl i r r 'l i l ) ( 'i l cr i l n \n ) l n i i l l r !{'i t l r r l :r i r r l ' r 'l 1 r l r tl l i,ril( l r r t;i t l l i \ l i e t ,l e cl l 'tt i tL tc: o scttt;i r t 1 '. \ . ) j i 1 'r o ir u ca a n i ,ct'i o l u 'r i r ' ci t c',ttl r - o l u ( i l t tti l ct l ) ,- l '1 , r l l r i r r {' ( ' l l l l l r r r r "r r ' . , , , r r s i i r i l i l , l i ( i i p c j n l l ti tti tca o l u si l l l co r l n l l l l i , Ittr i i It t ' I ' r' t t I t I I r I i t r '' It.tr r I It' I n r , i i l l {'s po i n ci n h i u l su p cfi o r . l l l L l JJm r i ir t'l t 1 tr tr r l r " i i u l o l r r r l r i , i r r l "r 'r r r r r 'l i , , L L ! {r 1 r ( l L r i i l c r l e se n si b i l i tl l te , s'i tl 1 .to i tl t, l l ttr l r r ttti tr r t r l .i r l l r l i r r ( 'r r i l i l 'i l r i r r l rr 1 r r l t t t t r l i r . A n i 'sttt;l i i l t' g l <tb a kr ;i n r :l si vtr r ti c ttttl i i ttl l l ti i .]tttttl l l r r l t "'t l r r r l r r r r . i t r i i t t t i 'oti l 'o i ttl l o sttsl l tcto l l l r 1 ;i ti :tl i str t- ,\!r '1 ) l t'l l i ':r l tttt'sl tzr i r l l r l r tl ' p r r r i r .l :r l :r i tr ttttttti t,:t r tr ttt I | | l r r s i \ {, i ) i }l l l p i l ( ,tr o l ) i ( x1 {i \- r l Ol tIi r r i .:l ztl tr l i .:zi r r r |( , r , r 'r r t r r r r i i i t t ttttl - tt1 1 l :.tte ti tl si n co r tsl ,l t tl ttl tt' i tl 1 l r ',i r tr r r l l t i tr tl tl i r tl |||t||i IIIII||' i l, i;irrrrii. t i t t c o t 'i lttl l r ttl 'a t'tt,t l l tr str t si I r i l i 1i r1rI l tl l 'l L c stl l l ti r t tl tl t r ri I I{ | | I | | I I I I I I i .'r l r tr tl 't t r l r t l r r t i i t 'r t l tl t'sl ti s tl t' V,'l g l r r i i l ) r i .i {r 'i r r l ', r I r' t ' r' I i t t t I t t i i r 'l r i l tr l r t' p fo l 'l l l r ( i ( 'r 'r r l l r l I( 'r r l ( ', r 'r r I' i l I r r r 'l l r l . r t i i I r . l l i l c ( 'p i ( 'l 'i 1 i r '{} si r r si i l l si }r i l i l i ti j t'i l r r r tl 'r t' tl r r l t r r r l r r l r t i l r t r r l i l III'tti o ;ttIi t'' r t t'cl tti i r r t ttl o - r tl i j ,zi ( r fi r l tl l tti r r r r l r i i 'r i t t vq 'r 'i ti r b i |i I tl i so l i r r l i ,r ' ti l i ,i 1 l l r r l r l l i c si ( l tti l tcr {, l l l i l ) :l i r l r i sl :r l Il sr l p I r r l r r r r r l r r I. | | l , 't r r l t r t ' ( r r i i tI Il r '( i tr i l r l t'l sl ttzi l i t' t) i i i ( fl l l r r ) ;tl .i tr x''r 'r 'r r r '1 r 'r 'r l t t t r t t , t t i l ) t r l ttti l i l i 'r l <'si tttl tl tttr l l r ti sr 'r fr r r l .r r l :r r I i ' rr,r i I r i I i I r ' iI i I , rr' ; t t i rI t t t I t i r ' , i ttr l i l ,r |l r i i r si l l r {ttl i r i r tl i ( l t'l i tr i l l 't . I I'l 'l ! ( .l r l i ,.! l l r IIII( 'II|| ( :r l r r ,l r r r S i r r r l r r l r r i \i l t|i l l o t ( p i r l r .l i |zi tr r r l I) |l i i ,tl l ( , l , i . l 'r i a r , i ) , r t ;tt't'r 't'1 r Ii l .i ,r Itttl 'ItIti i . r r r r t {l { r 'i r l i ti r tj ( 'Ir 'I'r 'II'Ir Ir ' ( r l r i l r 'i 'ttr ' tr t 1 r 'tr r 1 ''t r 1 Itti . l r l r Ir r 'i l l l l ') ; I ) l r l l ' lrrIiIIrIi|ol ItIo Ir 'r 'ttIi tr ' ( r ..tr ',t1 ,r i , t t tlr l ,r r !i ,r 'r i i ,l i r r r r l i l , r ' ( r r l t,1 r ,';l tto zi r r t ,i r r r I i II I i I I I | 1| I | | | | ; r i t t r ( t t l tti ( | ) r| | I i | .I I , ' r i r I r' t r I r I i l ' I r r t t t I t t t I tl Il |tr l ,tl 'ttl I't l l r l r "L tr tIi tti r ( tIt tI''r ''It ztl r ) ' r l L l , l .r Il :r r tt i .r ' lrl\ r 't|."IL I||L Ii i l l :r 'i I1 III|' ||i 'l l ( . '| 'I t I i , r r t I rti I,.i l f

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lxr or,r'o rl Inrrrrr considolarc qi o invostigilrrrin Iunc{,ic de lootlizl,r'ol cofllt'oi 6i rlo in r orrllri,r.LI clinic in c;u'o apu,to(Arsturi qi Oproscrr,1007; llrrrris ryi Wrrlll', I lrl'1, (rit,trfidc Arsoni 6i Oprosorr I]otrovi0iu rii .l.,rrscu, .19?0) : ; I ) hr t:t'fo,lal gi,it(t la t,l,ir(,l(: it) 7n regiu,nao.fronto-l,arttpora,[iisirruz i h] .' lrrrrLirlir, ilirlociclil,ii;lrrrr';x's lli sil,uotrnoidrr,lrl, lcrrii,l gllrrrurrrrl ilill'i su,u (t,crrr1xn't1I) rlivrrrso (Irrrk,o8rrItI itir, rlo irr'lclioprriio trl,1;rrIi 1J,,rrirrir,l I rr,r'tot sir,rr l,r orr,rrrltrii yitirli)1 irrxrrlicirrtrlri, irr rirttrllr1,rrtirr crrrol,irlirrtril, I Lt'rr,uttrrr,linttt r l.frlirlli lrl In rtllitttttrttu'ui1t il,t.tl./r,,' trrvlllgirr ocoipil,l,lii, I -Alttoltl ltrzitttti li't\ icir,lo ( str;xrt'iol,lt | r'rrrrt rrir,i rrrr, trrltrrir,l,icr,,r I lrot'rrio rlircrrlir,, trru lilctt,t'" tr r.t Ilrrzir)1llrrfrrrr lriprrtlr,rrNirrrrrr (rtr rltr rrrt,rrirrgit,il, vn {itrrr rr,r'l,rrrillil l,u[lr'i, ; (!\'(!n oruri1riIrrIi1 tr,,rrttir tlr, rrotrli,tlttl rrlirrirr) |ll,,Xirr 11i r,iolInll rltr rl r,l rttl , tt,t ttttt i ;

tth

lr'rtr'rllgii,-slrl)rr irl:rt.irlit,lrc bolrrlvii hip.r'tcnsivi, rrt,teliosckllrri qi (llr, ici l:r, irrrlivizii ln t,il,Nl,ii,\l/ lrr u.lekrl.yiil(1 gtnuali::a.le : a) Protc.sc i.nlt,ucranieneacute (ltenn " , I rr rr(! ; ll{rmo}'ugii iltr,:rcerebtrlc - in c*re cefaleea, instaleaai, deosebit se rlr, lrlrrl;tlr plcccrlind coma - srru extracer.el:rale turnori cerebrale cu evo. I lrr{ir, rr,rirrrpi,omiltici Bau cu alte sin4rtome pini in moment}l declalqJ,ril rrrl:rkrr:i, plin creqtere bruscit a tensiunii iniracraniene; procese infla'ma. l.'lrii, ll)ccsc celcblllc. nreningite, rneningoencefalite irdrnboze ale sinu; , rllrl lrr'r'on(,rse.-i rle \'onclor cerebralc) l->) In.fertii qenpralesud t.,crtll ; (sc vrr,ctiutil contextul clilic infecfi_os.1 Altc inJbatii; ineningite, arterito, i c) 'craniene 'n6n f lrrlritq, 1,..r'rarUebitecerebraleI Ai 1 71 .d.1 .Traunotismc lt i.lr(t lt.ttsiunp afieri^ali.I f) oaica!,ii, (cu monoxid de ci,rbon, ititri{i, .Int rrilr':r{i q.r.): g) S'rf/.iirlf riscrrale (caretrt,brrje,;rrtrio acutcsou aculizate l,rlrlliilrnr r.ind nr1 ge poatc clucida utr met,anisrn cerebral). ll) .C^efalalgiileperioilice (Amcli qi Opreecu, t|)6?; Botez qi gerbi,. rtcsr:rr,,.1965 I Br"uetman,19{4 ; Kudrow, 19?4; popoviciu Di pascil, 19?9); ,l.l,l!ig11l.o(in.situal.iilcinmr.ealgiilepre2iuliuncaractcrhernicrrnic, inso{it $i de alte simptome, indeosebioculare). Vom reveni rnai lrrrlsrrtil, li|z irr iulr-un subcrpitol seDarat. .l[ cerbrolc (angioamc. anevlisme,; se pot ,2) , a(ormo! iit.e -r-asculore ir"oli dc crize cefalalgicepscudomigroroase(dar aproape totdeauna'rlo :rcr.r'rrsr pat'te) sau nemigrenoase, putindu-se insoli in ulele accese algioo i.r rle rrllc simptome (crize epileptiee, hemipa,reze, tulburXri vizlale, fdno. rrrr.rrc:rt:tzice, eventual de paralizii periotticc de nervi oculomotori_ca do llrl'lir, in rlnevl ismcle de aateri, comunicanti, posterioard si in cele de a.rteri[ Ir'r'|'hrrLi posteIioari). .. .3) le,Jal.algia p.arocisticd, peliod,icd, tn tam,wile cerebrale este rar{,, tipul ct'l mai obi;ntit fiind de ceialee progresivii, cu orar. matinal, sa.udo ',.l:ll(.e c()ntinuii cu exacerbi.ri paroxistice (Arseni qi Opreseu, 196?). ABth'1, cefrllccfl,prroxisticl pcriodicri este car&eteristic5,pcntru fazele rie detrirt ;rk, lurrrolilor dc vcntrictli laterali qi de ventricul al treilea, tiind declanr;r.rliirlc _rnoditici,rile de pozilie ale capului, de trecerea in ortostatism, do ,'fotl ;idc slrinul (ArsenisiOprescu,l967) si oste in,lol.iti$i do al[c ,onrrro r,.tttol,'gict. (obnubil_5,ri paSagere :rle vedcrii, tulburiri din pa,rle:LLtn r rrr.r'v cl'i|,nt(.nl endoerrno), l sI ! ) Aefalceu Ttaronisticd,d,in, hipertensiunea urteri.ald,poate fi tlifuzll, *rrr locirlizrtL (fronto-tcmpora,15 sau in rertex de obicei), api,rincl brusc, rl{, rjr'loruil,i multc ori sple rliminea,ti. Se poate realiza qi o formi psettlorrrigrrirou,sf. Examenul funduiui de ochi arati modificd,ri nete vnsc:rlaro lrprrslrrc ilrteriale, edem sau clia,r hemoragii). 5) ( ofaleaaparonisticd, d,i.n hipatensiunile arteriale tecuntlu,re oltor u.ltrlir.t ti.(fcocrornocitom, aterosclerozS,sistemici, qi cerebrali,, ecla:npsit, irloricu,lii profcsionale , suferinle renale) trebuie corect gi la timp identifi: cul,ir,irr contextul clinic qi prin investigalii corespunzitoare. 6) Cefaleea parorisli.cii, di,n encefaloputi& hi?a.tensh)d, se inso[r:qto ,si rlc all,c rnanitcstd,ri cerebralc consecutive etlemului cerobral acu1, rlirr ircoa,sl;i'i, oncefa,lopatio. 7) Uttul.eaa parotisl,icri din hi,ytoNensiuneu o,rteriald, (t:sen{il.1ir,snu rrrcrrrrrlirlil, tlivorgilor frlotori) rto csto sugclalll prin survenilca accstt.iir, Iio lrt ltururlolr, dinosllt,t;innt irr (,,cclilr,klr potnil" - I )iirtrrcsctr,1)rxIotllIu, rlo l1];8), Iir', rlitrtpoh'it,rl, l,trr11'11',1 ot l6ntll,istrr (ltilxrlt'ltsitrtrrtrr, lrt, itt 6t'i1s1:rlir,:i),
it"\(l

qi trr rl rl | rr Irtrrl r r r , [ r r lr r , ,Hr rlr cr r t r t lt r t t t ilr zil, t lr r lr ur lr t it t t t r , ,vi. jiil, t r I . iit t t t t |r r lLl, lt i rrr,,l ,l r, ;rrrl lr ilr r l, ii; i rrt rrI ri li'nI i l i lr t r , sit t co; t : r ltHlt t t silt collt lt , , r: t ' ) t'rlrlu't, 1t rt, tt.t :i :tI i r:i r. d,in. r.nrh su.lrt'i.ttI.rr !rrt.ltttottrr.t 1i ltlirlirrt rrr, .l .,,r' r1r xt rrrrrrzr r lc cr ir lt r t 'llr t t : ll, t r lilioii, r r , f t t t lr t t t ct t r : lol lr t t lii 1t t t I t t t ot t it , t t r t t t i l ,r,l 1 r, r.' l r. l r t r z. li. 1t1 t', l,rlurr, prt,t'o,tisl.itii irltirllr itl r'orl rl,in,rLirvt'sd,rsttloitx!0 tli.gtsl,i.ru l , ,l rl , rrrrpl, or r lllic ir l lt . r r , sI r t st t lir linlc, | 1 t't lirlr'ilr pu,rori ,it:t:urrr su,r'pinpa ut. Iond dc ot.fu,lot tirlt<' L, ttn.l,i.nutt, ( ! rl | | | ,,'r,,rri l (.sr r spioir r r r i, r lo t r t lr i iI lr p0t l, lt , t t t e, ] |, 1'(ir t lpur l t llilslr li r lr ! lllgr , llt l! , cr
I l tr, I l nl t:tl l )i u1)l c :

i ) 'l'rrrun'ilt: cercbrule (tlo obioci sc irtsof,eso 6i rlo rr,ll,o sitttltlotttr'). ' ) l n t rolt t . lit r ,hiper t ensiu, ni. i inlr acr uniene t lit t it t t gioilt t r t r Hit ll r r lr r r
r tl Ir' | ,t , r' ( \ | ) | I I I ( | .

clrttl po ftttttlttl ctrl'rt,lrrrri '| ) ln ralu'liu, tratt matis malor cranio-cerebrale,, pr' l l r urri r(i co so llor luco o ccf alalgic Dar oxisl, icr i't lvir lonl, ; i, r r xisl, l' it r r li ( r 1rtt, I,rrrrIrrr. r r lii ui helnat or n int r a, palenchint at os t ( il11,Ar sot r i f i( ) llr ol( 'lr t lnr l rrr,, r, ri rr l r r r r r r r ilt lt c com plicat r ii coleblalo. I ) l)11N111ev7,., angajii,rilor (a nnurilor ila, 1n't:t;'i,'unr: l,ttrttoli trtrlrr ) itt l ,r rl ' ., Irrrrr oilr r r , abccse, chist ur i par azit Dr o f , a. ( l( x'liill, , oit zt '1t izo vi, t tr rrr|, r r l r,l l , rl r, r' r,l rrlcr r(,1r r r e it sint inso{, it o qi do f onom cnc dc st r f t r r it t ( , it ',|'t t t t t t r I t it t I t t i r, 1,' .rl , rl o ir cglilit at e pupilar i, or r ent iual qi do I 'o. t loxo( lo ill) t t ( r , r(r\ ( ! {r r r f i '' pl l r' l l .' \):rl otn i; cilr ipendular ealeglobilor oculr r i) dol, lt ll) llt t it 'i t 'oxlt it r t ' l r' r,r | ,1,.rrrrlt l or i( lo com i nr oAr esivr i. ,) tt,.ftlti Ttlsonistice ?e Jondul unor caJulu,llliitrrnl.itr.tr'rt pol rtltr'rtrrrt' 1l potslt't'io(t (ilt r'1iilltt, ri Itt lt' t:t'rlot,ttt.t: su,Itduralecronice, \n lTfela procese tlc JoYti, calt Be l l l l , l l l , Lr('(l of l|, loca exacer beazd, lam iosct r r ilo ult t i) ' it t t r it kr r t t ( ht t oit lilr ,',r,1,,,'/r (1rosll,r'nr ma1,ico, postmeningocncefalitico)r ltt .rldri/r' ltrt:rl trilit't' t'1,t1' tttttt t irr .lenonenelc d,e kiperterniune aenousd, (\tt lrlir(ll,illlri trrtttlitt,t'rr rll, | , |, | | |r' | |iii | (,I r sau in compresiuni pe venelo jugularo) $.t1,. t' ) ltltt'il,& tentporald' (Boala lui Tlorton) ponta ow)lllll, t'tt trollr,lrrl in ciiagnostic tlupri tabloul clittitl 1rIt t ' |,i t I tt Itt t' ||,r', r,rlirlrf. No oricntim I 1'ollI x rl'i[], (\tir('rrt ir,r,l rl,,r' trrrlsrrl,ilil uisau bilateralir, Iocaliza,tli,Irrtrd,t)l rrrl , ,l l ol i rr '1, r r li,de apleci, r iie capului $i clo olinosl, : l[ 'ist r r yi ilr xr t lilo. t lt t r i rrrl ' , , r' tr{ri p ulsnl, ili a, a; r t r elor t em polale St t lt t r l'f icit t lr1i r lr r t t t t t lloot i 5i r ( Wolll, llxi; l) . rl r, i .rrrrr r r r ccr ' rl trr l (ttlal('uLnc cbr alo ; i clt iar colona, r 'iono) tltt , ) d,in atero- ti arterioscleroza tertbrt'Li lt,1tit,t'tl ltlticrri itr ,,1,r' l l l l .,rl i rl rt ilt o ale acest or af ect iuni, dar do m ult o or i f ilnsl, r t t liilo; t t r r lolr r , rl r, rl ' ,l rrrl rro r r r : I st cnic ale at er osclor ozoi ccr obr a'lo ( l'opovir r it t 1i r r r t lr t lr . , frfr,r' l ' rrl rrrvir . ir r Pascu, 1977, 1979) . qi ltl'rrr'litltti : lt I t't'lttl(.t(i.ile continue progresit c ne srgotoivil urttrill,ort,rtdrr | ) 'ltt ot i aertbraLein primul r\T\(1,2\ Ilatnabattac (ittl,rrlctrlrrltt'rtllrrtt ,trl rrl ri rrrl ), rl o obicol sociindu- t io 1i r r , , o sim pt unt u r lu sr t ll*'inl'ii,t r ot t t lr t ; llt l, . t l r, l r,r\ :rl r\ sl, i, r 'ii<lc vigilonll gi sct uno olr ir r t ivo llt 't t t l) l( r gio( ) )il) - . f t r r r r r |nd ril,rr tlo rn||,,ttt,rIttii rtnhn t (rr,Lccsti,tiqrnbtrllebitc ct:rolrt:r,lt', 1;tuttrlxtIlol rlo rltttttt alrrr ,'ir1(,nros, l,rrrutlxrfklbil;rj,tlo sintts IIttortl, bt'otttlxrlllollitr'i, sot ,r' r1,rl rrl , ir rrrr.rrir r gil, r noningoot r ct t llr lit ; o)ir l t nili it , t lo$ot l,t t lr t t t l; t lxb t t iolr t git r o, f, $(\ I r|,I rt , || 'ii i (i 1i irrfrrol,iosrnvolill;or'. ,ll II i ltri,an itt,nrut i n,lruontnitr'ttr\' l)t)llit\ t ' . l r,1,,lI rl (r rrr,l'r r , lr r o r l, ir r t t il r r glcxivr 't li) {) r r f r r , lrt,xt t t t , it t t t ol}11) glo'{ivlr lll, t ! t ll i oor l) llr . fr fl fl rftrr l r l t i n. f u, ! ii,17n, ur , li, [ t 'hr ilt ( hr lr t r r r , t 't t ; t l, ivr r , r lr lr l lif oir |r \ ' I 'iI on olt t t t ' gt l r' rr rl l fr tl l rlI r 'i( , , , t t r r t t ot t t t lllt r t zil,it t l'r xt {, iot t t t i] , 'ilii) , ill t r r lr t r $t r I t , f t t lt r ir lit t l, t rrl rrtl r Li rl rrrli, qf i6H l! , , lr 1il, lir r r lllr lr r l r r l, r r ir r {r , r r lr( 1! il, r r tl) lI f lit , cr llt lt xr l lt l

x27

ir+r., rtl,tirtrnt' rltfctrtt{it, l)r,tlilicili alc slilii rle cLttts{:iin1,ri 6i pr'rbcltt 1i/srrtt rlr. I:rlrot lrlot t'c\'clatoi-tr(,. (eYentual cu \{rl')) (lt'[ulutqii co'ntinue curstante sau cM sicotrst{r?rr, .r'r'lriiri px,r'irxlice) apar in foarte numetoaseafeclliurriI L) Leti/ulli oso(ise ,,trr. tttrtirttlt'tn aie cotoonei.ceraicale su?erioare (fn acestia cefaleea cstc ,rr'r'ilriio-rrrrcrrli, cxacerbcaz;lla schimbirile de pozitie ale capulti $i se so irrro(cslo i,,iilc :lrnedeli.)Ilste vorba de: unco-iliscartroze cen'icale, rrrt-rlforrrrir{ii rrlo .iorrc{iuniioccipito-cervjcale,rniozite etc. 2) Insuficienle circuIr lari i rart:ltrale (earotidione qi/sau vertebro-bazilare), 3) Arah'noidit e corc' /rla1r:(lxrsi,frilumatice, postmeningoencefalitice). 4\ Ce.Jalalflii de tensittnet' (lrsilrogrrrc). Aci se irrcirrlreazi, gi unele cefalei prin coirtnctura Dlrsculalru ii r:ryLLlui;i a gitului (,,mtscle tension headache"). 5) Diverse o.f(]i1ttli sislrntirtt (ancmii, le,ucemii, afecliuni a1e sistemului rticuloendotelial). ri) (lt.lirlcur,bolnarilor cardiaci fi di'n alte stiiri' hiponice (insu{icicnlc catdio' lr,spirrtolii cronice). 7) Cefaleea posttrarmatici, (postcontuzionali post' ' t , |||' ,( i()i rrrIi ). 8t Ctfqlpeo,boltat'ilor hiperlensir. 9) CaJaleenaroniri a ' ,ti,thriiril,tr. '10; ln'direrse suferinlo hipatice., dttohenibiliare fi t'ettale, Il) i4prstuf i,l,iila d.iaerse de origitti, (endocrine, neurogenc, in diverse sufet'inlc pot prezenta in contextul clinic cefalei persistente, zdesea, rli;1r'slivr:,s.a,.) |rr rrrirr:cl'bii,riparoxistice, asocia;te cu parestezii peliorale qi iir membret (rr sDirHr[ cmpo-pedal [i uneori cu manifest5,ri conrulsive. ].2) II i;pogli' (r'rii(r se manifestd, prin cefalei cronice) de obicei cu exacerbS,rir insolite qi transpiratii $i uneori cdze conY lsiv. rl(f sr)rnr rolcntii,, sti,ri de obnubilare, e lii) nu uititrm cefalalgiile din aJealiunil octtlarc (ghucom' tulburiri.ito '\i, lcllirc{'io, iridociclite, cheratitc Di alte boli inflamatodi ocularc), din gfec.-. lirrtti. na:ale, rnastoidtene si. sinttaqle (tralrmal,ice, tumnu e prin infeclii qi rlrr frrcrr,r' kroale 5s.a.) dit:rir'fecliunilemauilo-dentare(infeclii de focar, perios' hot'monale(1* femei cu disfurclii oYat i" i ittr, l,umori q.t.). f +) Cefti,lalgii.le r,rrc, cu mcl,ritc eronice, in proclimaxr in climax etc'). c\nl,inue regr$i1i), (Arsni $i Oprescu' 1967)-sint t'epro" lt) Ceful,algii,le zr,rri'rrio ile: lj Cefaleile din encefalopatiaposttrm.malicd'' 2) Cefale;iie ltl (hr h iprrltn.si.ttii tralali . 3) CeJaleea {venl Stsihogenti lemisie). 4) Alte a.;feeliuni rr:ri sus) in curs de vindecare. 7.11.3. igrcnele nl Nligrtrrt l,r'ebuie diferen{iati, de restul cefalalgiilor 7}ritL utrs.at$el'.e paz"ticu.lare, sensul unei cefalalgii periodicer predonti" in xrlt: xrtirtiologtco rr:nrl; srrrr o)iclusiv unilaterall, pulsatilXr insolit5, tle obicei de tcttomcrttt ,rrrrlu rr (l'otopsii, hemianopsii, oltalmoplegii), de tulburiri velietiltivo (itrr'(rfi, vr'irsil,tui'i). De multe ori migrena are o incidenfi, familirtiri. Litt rrll i.k.rr'rlrrlilyoai)o decisiy de tliagnostic cste reprezcntal,{le r!.ll'i1irl ,rlriirrrrili irr lilolestenli (pind,la virsta dc 1A-25 tlc ani), astfcl incil ull riirrrlrrirrr rrriglenosapd,rut tlup5, tirsta t1e 2,5-30 de ani sugcreazirllltLi rlr.glrrbiu o lcziunc organic:i intracllniani,, cri de pikli, un tune\-r'ism' rtll :rrrgiorrr, turuolil ctc. (Arselli qi Oplcscu, 1967; I)iamond, 1974; Iilboln o r;i I)r. Iiirrc Olivrrrius,t07l). ioprtlolleirr tr I'tohk.rrtc tk' r.t
) ,,(l| izrr i t t I i i t r{ t t i I rr' , , , f lt t Hlt ' t . lt t r it , t lt t , t r lt r r ' ) ) ir it r l, t r 'l i t i i v

l , r r r r ; r t r ; r l t r ( : r , r 'r 'l o t l .tr ,i sl ,:tr l i i ( p l l r 'r .[r l r r l g i r ', r , r' I rr I rr I i i i rr r l i p o r i l cr 'l r r Ir l ;i t,') , r r r r r r r l r | r r ir r g r .r tr 'r ';r l r r l l c l r to l r l |tr r r r r ,Ii o |tl r Io t|,tr i |r . r l o l r .zi tr tr r ' 'r ti j r r r i ,,r ,,r,lrt,rl.r. l l r i i r l ; r , i t r *i Il r .i i i l r r r ti r l r tr r i g tr .l t;i , tr ttt i tttl ttr tt, r l ttp r 'i tttr i i r r tr l r r ti ( At.tl tr i | | ) l 't l 'r , , | | , l tl {i i ; l l l i 'I ; l ) i Il |l ''||{1 , l 1 }? .1; l ,]l i l ) o r r !i l ) " l i 'i n r , ( ) l i vr r |i tr s, I l l r r , ', r r , l l , i) f;) , l r u l ( ( l 1 Itl l r r ttl .i i i tt si ,r tl r i l i l cl r , r l i r r g tto si i r ttl r r i , r r r ,r r o H i i i r u l , ' , r l , r r r ', i r r v csl ,i g r r {i i i l l '.r r l '' ( i r ( ,l r r si v l u l r ,ti o g r r l i cr ', | )t I r"t rI r | ( )(' r | ( | I i | |, ,| 1r'rI ' I r 'l r , ( , i l r x'r ( fcl l r l r i g l l r l 'i l r ') , i tr l tl l i l ll,, i tt sp r tl r .l l l r tl r l o u l r r i tr r i g l r .r r o i i tr r . l r ,r r l r r
' , l l r ,,l f f, l '\t 'ulu ti4tt lttt t , r, l t t t i , , i :

' ,11 i qrr'nr r ( t . st 'nu i) t t t t u'r t lor lit r t iu: [ iu ( t t Jr t lr r t t l( l. il) t t t i|t t t|t 't || r t l dt 1,,,tl ' 1,4t(, tl lr : it , lt r nit nolt t it t *i t r lt sit t t lt lt lt t obI r t : l, it rt r lt nt loqir r ') t ir lr r '; r rrrr IIui rrr.l (' r'vcllt t t liiili : tl l l i rttt, uii t uilabild, it r silr r r r liilir it t r . : ur r sit r r I l, or r r 'lr r r r r . r r r r lr r gir , l rl rl rl l :rl r, 1r.r! , r r il, r xlillt 'r , r cr izli, lr lgicir ,sl, r r ir r r or liI r Ir,|r r pl'iclizii, r r r r r r ir . r l, ul cr rl rr, .rl )i u( r,r t t r cclr t iiicon( ir ir t t ( lo iicr ir l'( )t lr t il'1,ir r t ilvr , sl igr r f iilc cot r r plr . lr r rr,, l r r! rrrrgio; llr lir r r r r , t r bur li) t r r r ovit ler t ! ir r zr 'it r it t t ir r ot gr r r ir . , r It1 l ' :i rttrlant i. r lr t nt liu r tn. giot t , nt , eLc eLr u, ltir ) r 'lr t \ r st 'lr lt r 'lr r u{lr t 'r ) l! r ilii . t t : er , rl , ,rr,rrrrIrrrrr iir r r r r 't r t , sislr i, ; i r lupii r t ispar i( i r r cllr la, luici, 1l) lr 1,ir $( r 'r . r : Ji sr 1x'r rr , r' 1rrIr.1rI ilrir r t lr r ,it r vcsligr t l, iilc I it t liologit 'c si t t t t giogt r lir r r scr l''pixlt "r r zi, ', ' rrr rl i , ,r r r.r i ti t, r , I t Sot t lll t 'ii. | | l':r ttl.otJtiqt'()tq, tlitt, rt,tt,ttrti.sttttlr <:crtbrall: totrpot lr'i o iu,t'irrrl,' r.lr. rr rl , r.rni (,lr ) gir ut t lif ct elr ( illc 1l! it t lt : I uigt t 't r l pt r r pt ir r 'zisI ( \ t 'r r r 't r i i1t l t,r, ,( n, l l ){i 7i / \ r 's( ini ; i colr . lh. , 1974) : - Vilslr r , r r lr i i rrI ri rr|,Ir I ji, it r r . : z r r l r ,,nr \ | .| | rl ,l or' psr ru. lorIrigr t : r r r r l) Ur ': r lr r pr , r r islr , r r {r 'r ot sc ( 30- . 10 r lu r r r r i) . iDLr r lilll;r lt r lt ; i I r 'izlr ,r u'lt r lr r l, ii|'i, 0ir ' r r' | | r.1,' f rrr.r r t r r kr gicc, t c nU r ot t r lot xleir zii, , I rrr rrrrrrll (.r l f i/ sllr ilicot r ) plot . i, I no( Pt 'r ^zt 't r; r 'r , lilioiit iI r l slllii r lr r lor r lli i ,rrl .r , rr l rrl rlit t icl, t l iu ilr r evlislnr r ll) r t r pl, o. l) r r 'zct r {, ir r r r or I ilir '. r li|ot ' , | | rI|| ' II r.rl i | (. (r lcili noYizullizit r el r ] nni 11r r ev|ist r1xrungir r gr ': r liir , nlr rpr t lr ilr l t

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i l l i qn' n r , of l, unoplcylt t t i ir sociazii, r x: [ llir lgir r r r r igr r r r r or r r il, o I o ;i 'llr r l () 111,r;rl ' ;' r,,rsilr r , l, ot 'alil.f t [ lt noplcgil lr pf i, t '0 lo t llr ir r r r iir r sl, r r r lir r lr u. l: r I r r |; . 1ir ', rl r ( l{r lu, it t st llilt en t lLlt cr ii qi I at r n}r 'i lr ! | I r lr lll lll ziL'. l'lt 'r r liziil, , , ', , r r ' rt1' 1,,' r,' 1,' rrrl rrrl,I i pr t , r '{ilt lc per cclt ca,t JI [ - lt , ) slr t r lol; t Lr ( pr r t r 'r , lr il, lll, l\ / li ( \ l l , ., L.,i (' c t t rrl i, f t cl, ilt 'ell pr u't , ilt , l,lr t t ot vt r lr r i lt igot r r r t r , So f i'r ur r r I r lr r l, ir , r r i ,rrrr, rrrl rl r, r ligr t r r ii, of l, ll r r uplcgicii, sil r 'iillr ili' t r r zr r r vlr r lor r r ' lr r lr r zr r r r l, , 1 | | r, rr, | l r ri rr Dr t l, t t l, cvidr r r t {ilr 0lczir Dr o ot 'glt , t t icli, r lr r r f il, r . r illli |||I |||| r r |, I r t ir it , r.rrrr rl r. ni ,1 t no o, ll. t t . opl t , 11irlr r odt t t t r lo ut t . t t : r i: ; ut ( r lr r r r r lllii, r ': r t ulir lr i l. t n n r,, i nr rrrll i r\'{'r 'r ) oNrlc lr lr r li, t ur t r r r r r r iolt t r li oslcliollnj, jr lr r lr t l, r , r 'rlor t l'r ': r lil r i l) t.' l I' rrrl rl l l l :r t r t lc r r t lr 't i, r , r 't lr , lr l1t lii sr i r lo ( / / f l t . , lir ! ir t t t i. r t hilr r t t t r ot ) I r)l l ,rl i t r t plr qiilt il, lt t 't 'r xt : t tlit r l, , r lc I r t lt i , lr scr t r lot r r iglr r t r r r t r r l t r l lt rrrrrl rl ,,.rr,, i lr lr ir l) : ll it t . l'it lt lr r , t t r r r l. idr t ct r r rt t t on, r r i( t r r r cvt iir r r r r rtllr . I r lr , t ii r' r rr,rl l rl ,r rr . ir , i{t r r r t r ll ( , lt o lr it \ 'c|s{lr Zi, sit r t r sr r l ( l\ '( ' l{'N) , Hr , jt r illr r l|t r zr r l ' rr , r, rl l .rlr r ( , ll|gio ir |r , r {illr I I r ' I u, llt |r 'r r i|}t ilt I i( 'f lllli, l: t , r . l|r r r ir : r r r . r lr zt r , ,rl l rl rrrrr' (1r r r r i,I l r r r or 'lr il, ilr r r ) ,lr ipr r csllzio it r lr lilot ir r l Ltigr , r r r r . r r r r lrlrrr r r rtr,r,, l )r | r. r' ir r r t r t : r oll: r I t r r ir r l'i) t t t r r it r llt r sit r ct r r t t t , l I r r l r r r l lr r llllr ll , I lll qi r,l rrr l rl l | lln, , r |lr il, r r oor r lr t i. . r \ t l|r 'ir 4gt 'lt lilr r iz rrrrI iz|t rz li |. isl r llr . t l i rt,l rr i tr r i, ; i t r . llr 'r t . l'lt r lnt plt t lii 1t r 'r ir r licr ir t : r lilt ' t ( r , , . lllulgr t 1', r r ', ,, /r,, rtr i r I rr,\ ' I tri rrrr.Irr r lr r lt t llt 'lr l o t rrtt t rtr' : t t rI It lr rr t lr . tir r ir t r r ,I r 'r 'r 'lr r ijt , / / , r /

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(t r. ttltltlii, tl,tLt'rn)(LNc utr t:Llf reourehlid,I, ihrr tttmi1runoatri ln ptuc0s0 irrlIrrrrilixrIiiillo sirursului cilvcr.nosstiu alo olbitoi. ' O 0 rrrlr[o}krgio rlrrroroasii cu..caract()] recu}elli,i:r,l (in care algia, nu rrri , rr'il'( I Lr:mic.alic,. ci prezi,-Itii,o localizare ret.oorbitari sau i"n toril{}r' , . l{ i I rrfl {rrt,rltr'r(i) rLpa, $i in ldfiaft,erita cdroti.tl,i&nd, e i.ntramternoasd,(descriSii rl'. I llu, ii ,'rrlrr,Jr.,. cit:t,lid0Arsctriqi Oprescu.1962). tatrloulsemi_ 1-00t. tn r'r,,,4t(.srj us,Jciu[ scmnede lcziune a oerfului optic. l)L,[ st Sindroamcle pseudomigrenoase (sindroarne migrenoase simpto. .,1.1.3. nrrlr(xl): 1. IIem,aragiil,esubarahnoidiene din_ mafforna!iita ,t)aso,u,larc (aneuris" tttr:, rr,ttliname pot genera cefalci pseudomigrenoi,se cu caracter recuren_ ) (iirl..rrsur rlilgnoslicetprin debuful brutal-al cefalcei, rlr' pritr semnele semi_ (lr,):jrr',.rtc uoompal ament oare persisti, mai multi rreme, prin constatareiu rrnrri L.C.ll,. sanguinolent $i prjo evidentierel malformitliei. :!. lllutnortle de uentriatli laterali se poi manifesta prin 'crize cefalalgico lrllir.rrlioc, deolanqate de schimbArile de pozilie ale 6apului, cu d;bu; Si rlrr'.it lrrpi,l..ldrA frze precisepre- 9i posteefrr,lalgice cain migrenr clasicd, r:'| t|r .(jv'rturt:I, ultenoari], apar semne de hipertensiune intracranian[ (;\ r solri qi Oprescu, 1967). ii. Tt.r,m,orile aentri,clr,l de .III -pot g.exeraIa clebut crize pseudomigre. rr.rr,s.irr,sofite do fenomene vizuale similare cu c(-le diD faza frotlromal"L a rrrigrtuei. l)al aceste crize sint declanqlte si, r.especliv suprinrite la schim. lriiri l', prrzi;ier,le capulli, iar evoluf ia t ra nseaiii d iagno\ticul , pu -rl.t. in"r:.lilii.siodr.omului rle hiperuensiunc intrlcranianii ip:rr qi semne neuro-isu.* l,rgi,', obioclirre erolul,ivo (sindrom parinautl, sindrod Arllylt_Robertson, l)rllz{) ooulale, semne tliencefalice etc). ll'ttmorile occipita-le pot.genera la debui crize pseudomigrcnoase cu , ,1.. Itx'rrlizrtt,'. fr.onto-orbitari,, asociate cu manifestd,ri vizfale tranzitorii (foto" l,fir. nrnlrilrtopsl tru,pziforii),. dar p parcurs apare sintlromul rle hiporten. sr"" rIrLl,,ct'i).lant, iar hemiatopsia Be contureazd, din ce in ce mai stabil fr r. ct|,titcteL progrcsiy. 5. .Pseutktmigrena bazilard,reprezinti o formil de ischemie tranzitorio in lr'r'il,orilrl vertebro-bazilar (inclusiv in teritoriul uneia sau a ambelor rrllr.rr,rrrlrrbrale p_osterioare), oaractgrizatd, prin tulburiri vizuaie (cu sco. l,'rrrr. s.i.rrl,illnte hemianopsiee,ilceloqarea vederii li/sau halucinalii'etemsn. l.:rlr..;. crfrrlrrr.pulsatilii. (cu localizare iudeoscbi postcrioard. in regiunor, olcilrirrrlii), rrr;r,ni festi,ri vcrLig-inoase. felomene ccrebe]oase, zgomotd aurillrl.lr', rliziLrlrie, parestezii bilaterale atit la membrele suireiioare, cit rtrl -chiar lr rrr,rrrlrrr.lc inferioare si la fa!d, (peribucale$i linEuale) si alte*,rca ,rlr'rrii. r'igilentd(obnubila,re,.bipersomie). p6t asocia: nistagmus ,ii rlr. Sc lr.rr.rliziirrculomotorjitrenzitorii, Acest contcxl, scmiologictrebuieiu grij'd r.l.i.lrlttliut a mi,grenabazilard (Binkerstaff, 1961 popovi*ciu qi colab., 1".9gd ; ; llrJrr.-r.rr furn, 1977).pe care de altfel unii o coniistl, si sJ ne oricntozri .i rrr 1'rirrrrrl r.intl spre o afealiune organica in teril,oriut'uertebro-bazilar: lnsuJicien!,ir, c.irculatorie aertebro-bazilard,alercscleroticd, (forrnolo ,. .t) . clirrir.i) 1r'irnzitorii inicrmitcnlo). qi , ..lt) Mu1,Jormnliiuasuilare (anenrisme, angiodtna) ln teritoriul veltcbl.o"
l)irz I ilt f .

r tr, rrrci rl r,trlrs1x'i, ilr lr r llr r r , r r r r or r r r r r 'lr r logllr lirfr r : ( ior r lr ili, r 'r , sPlcliv llr r lli llr , rrI,r;i trtIi r' ,rr l, ilizit r t l r lr , l ri{(,t r| (,| |(|l r , it t cit I r r t t ( r , I r t iur liologir r r spr r r : ir r l. pr , t r lt 't t r l rr, r ; rosl ,oto lt ,ii,l lt t 'lct iogt t r f ir r vr ', r lr r ) llr li'i, ;sr : it r l, igt r r lir , lonr ogt r r lir , : r r ir r l1L i t l , r,rrr;rrrh' r' i z11 r , |t 'cl, t t x, t . lit glir f ic q. 1, . ) . li, r cr lr tlJ ll t,l,lutntt!ii. uIt .losti t:urln'u.lr ltttsltt ittrtrt yi tlt ;ionlirntii. rrrtnio ,,/i rr!rr' (i nr I r ( . $ir t t r o br r zilir t i, plr r libuziir , sir r r l|or r r I ilippl'l lt \ , il q. r r . ) . | | | | | | ' ' | | i .n( : l; c|'l'u. lt t . t 't t , ut t t i'u. |il. ! ilt 'n'i't t t '11t t t t it l: t lt lt : u|. t t l't ', t t t 't l. |. t lt lll|ill ' ' ,rtr ttttl .l brtnat i, t or ii r lr lci sr r t t spr r ct , [ clil, cliilc sr r gr r lt r lo r lr r llir Lclr r lr r , ll l l l rl ;l ), i n(l c osel) i aplr r if , iir st r lr vilsllt r lc ll5 r lo ir r r i r ; i nr vt r lsilr ilil, : r , lr , lolr r ll, rr ,r rLrrrrl ri onr {r lr L object ivc llr scr r r l. i, vr t 'r r : t rr lr r pii,1l( ices, lx) lt lr r $l, r r lr ilir lll s{! 1,rr" l i cl l rl t . r ligr ', r r i b: r zil; r lr i. lrr slir'qilr, rtiri tleJruic avut irr vtrlclr ftrplu). cii \i u,n.rltaritr ltipruli ,,tttttr 1xt1sit nulr r o m igleni, llazilit t ii ( slu ot icu r r lii, f ot r ni r r lir r ir . ii r lr , , trrrl l r' rri i ).O ar t at t r , s- asipr opus ( l'opcscu qikr ln, . t 9?7) ploht , r lir r gr r r r lir l cu ,rf l rrr;xrtrti cii, solulio t lg glucozii 20- 30% ( 20 - 00 nr l) , r r r nr ir r xilr r ir ( iiL' rrr ,,:rrrr ptorhce disprlrilia manifcstridlor nenlopsihiur, rrl pul(fl, oli.r'i rrrr i,rLl (li' ('onfiunLrc a originii hipogliccrLicc l urror clizl rrrigrlrro:r rr'. 7.11.4.llgiilc Alyiilo
| |rl l l l tl r)gol i l (j

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i

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rl I't'oluse l,nlocui,l,oure spnli.u r.tl,c il,c fowi ?ostarioare, S'- it'l)u', rk..i, irrvr,rl.ig,r.{,ii ltt..rrt,o tJ(,tnl}l.xi! (ol:rrrrorrr, ,lLrrhrr'l'4i

n ) 'I\ruumo,lisme aertebraletau ,rterlel)ro-marlrr,lrrrr. 'l'rr,llrrio rrrrtl itr (Arscni qi Oprescu, 196?; Alslnli qi oolrrb., l1)?:t) r'iL rlrr r rrl,.r'r. Irr,llt,rrl ll,r',.r Iltuuratismele vettebro-rnglulln eotvicukr irrcutrrlri, rlrvrsr,lrrlir, u o rl:rlc 1i cii trebrie ciiuiate cu glijri, irnirlia[ rlrrpil llrrlrrlrlirrrr, rr,rrr lrr,rr ri,'ll rlc k'zirnreu,tit ver"tebmld,, si mtiduleril,. cit irr Silrl sil,rrrrt,ii oilro grr[r,r'rrr(rr, rrrlrIrrIrrlii esto oligosimptomaticit snu inexisl;ontri,in schirrrlrrrrrxlil'ilnlrlrr r ltlr.lrt;rlohaumatlce sint importlntr:, sniclinl,alirlicrrllrr1l,trulrrrlrrrltt Ntr ,'lttrrr, tlurcri crlrvicale sau celvico-brah iirlc,lntlc,,st'lri rliskxlrliilr,rr,t' lrtiu lr,lrr:rlr,si ilrcturile-disloca{ii rletenninii simlroiuno lr li(jltlrur', il r.rr'r\ l,,lrrrrlrrllrcnzi), llgii puternice in ceafii,, ilirdioli sltrtr rtgirrttolrrr,cipi, cu lrrl.r ri sprr um5,r, insolite de contr'..rctlurnlscrrlrr,t,rrrii a rrrrrrrr!' rlrr lirrri4i lr'r'.r uifjr-riiIilorcoloarreiver"tebrale cor.vioalc. lr)sto irrlxrr'1,rr xl, srr ptr,r,i. l, (lo rllzr.rlrrrii, sirrt sau nrL;i sittptone asocial.o lrrfr,rirr(ii, rrrrlltrlrrll'1. '|;trttrltte (lili,rr\rt lt ) Ilisaryatiile Lefi&)ral.e (jirt1tr11(,ro rlut0r'i ou cerait.:ala irr {l,rl' rr lrn(jiio de sttdirl alteririi discalc.-Asl,ftJ, livrr, I (iIrlI;rir,rrI.rl, .Do 'lr' .,rlirtlirionlii,tliscnlii dur:eroasii,t'* Sdze)dltlrlrril,r'slrrrlolrl Ir'rrli, lltrttlrrlirlir rrn scgrncntvcttr'.bril,l, lijrxl da1;oli1,i, oa, ir,il,rr{ici|,r.I || i IIIr1i i |||| I rr,r\rrri(l rlirr rliscul altclat, I)rrr.elca, tltzvolt?irluobicci Iltl, prrrgr,,.rirr sc lirtrr r'lrrz"'ipltlcrrtiiovi{lcr1;i1,. uncoli lr,lgirr, r) l l)oar rlohulclrzr'i, lllrsr:, lrprrrr,rrl, ' r rIr'rIr rrrIrI r'irlo rrn 1]llr,ututl,igrn (lt\ tnirtitn,rlc () tni;ollr0llt ttsoi,glrrt (rxtr)Itt(,ftl l,t lrtl1ri rrrrrozcillil.J)uttrr,rloslclruriviolcrrl,lirlirrritrclrllr,r:u(,cltziit,oxr\lll, tii ial looulljirr,ct,lrl;rrt,irzrl ltrrrr' itlgiir,. lrtrrr'lrt rriqrili lrkt coftrinrci, pr,rr:rr{,ia tllr, rlur:r(.{litsl,l'i ltrzil, rlr, rlo cvoltrrrazii, ollicci itr lrttsclri qi rru srr itrHo{r,lc rrr,tttttr, r,litrico rrl:rlr'i, sltrsilrililrrl,r'ir, (itt rlo JoctrLi) niui rlc srrltrrrllrIi,rIrgilr, tii lr llir l rlo o 0v0trl,rrirlI r'lgitlii:r1,0 colxr,rr0i vic,ltlo, 0rit lt Itr Iirzir, rlourr, lr, (rltr ,,blrlll.j tl sr,grrrorrl, I'rr 'rlisllrlrrrl,itrJ', tri 4l ltri Altr (llnrtr, rlovitrrr Ill|l1.Ir,[, lll{17) rrrrtivi0lorrl,rI,, 0rilirrsr], rr,Aittrrr,ir lrrrti itr |r,t. l lr,irlrirJi xrr ittltrrlcql.rr tll lotrl,trrr.lrrl|r1l|,rii lrlltrlUir.ii,lrr.t'1lr1r rlrr r,i li r, rrr. tllilirrL,git.o rliNItrrltrrzlr'r, lttl'o rlilr'trt lt0zir'r,. 4i/r.rrtr ilil I

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t rrIt I rrt tt r r t I r l r tttttr tl t|r ') l tl ' l r l Ii r r l ttt l r tr r 1 , , , l l , , r : rI , ) , r l i I i i l l l Ir r l r l r ' ( t t t I I ' t ir1 l [r l r r l r 'r ;i ' r l r r ,I'Ir Ir 'r 'r tr Ir . ( r 'r t]r l |i l ) l l l tl l 'l 'r l l , , , , r l r l r r i l i r l tl l tttr l l ,i I l "l 'l :r :l ' ,rlt lrrrl r :t ttl r t " .r r 'r 'l r "tr r r tl l l l i I'i r l l r '"r 'l ' tttr t \ " ; : t n t l ) t ,r tttl ttti l ,t tr ttti r t l :;i n r l tr tn tu l l tti l "r r ::'tttr r 1 "l 'tttttr t) :;'' ( ttr r ttr tr r t l ,i r r t r r r l tr i i ;' l ttl l r ttt;ttI r ' l r i l i n ) { i t tl r r , tl r r r l tttl tr ,,Ir i Ir l t:Ih '' . , , , , l , , , , ,r 'l .r ,,i i r i r l r t r r i r r ,l r r l rr rr. r , r | , r rrI rr i i .r r 1 r Ir 'i ,r r '( r .r l r .r r r ,', l ,r r l l r r r |r i Ii Ir r r ,, i r l tr r l i i ;i l r sl 'r r o l tr i tr r zi ) l tr l rt' l ,I t' rr r rrr i : I 1 ( r r r r 'r r r 'l , , , , . , , ', i , i,f,,'l i l i i l l l i ( 'r r l i l r \', , , , '' Ir t ttttr l l r . .r, I r r l l r r i r ) l i fg i t, IIr , si IttIIr Itti ,,r r r i r l i i tr r r i i r '" 1 t'r 'l l tti r r sl i ' l tt' l l i tl r l i r r r r r l tr r tttl i l r ttl tr tzr '.r 't.t ,i .|i ;Il r I1 r :r Itt {ttr :tt , l l i i l i l ) r ) i 'j l 'l l r ;r l l ) l r l l i l l ', ', , , f i , , f,,'l i ,i : fi {) l l l !r l { l l ' l 1 l {;r ' 1 r " u r r r l il r r r , si tr r l to i r l Sr tt[tl . p 'sl l r "r r L tn r l i t:- ( '\t'r 'l l r Fi i r r 'l l o r r r r r l r tl ;1 " r 'r r r r r t'r " 1 l ) i fr ) ' Si l r l t, r i r r r i l ',r r r t,tt. l 1 ) ? 1 ) ; \\'l l i tt':;i ",.,rr, l ttr ti , r l r 'r r l r i r ci ( r l l l l r r l l r r L r l , l r , r i ,fi ,,,,,l r 'l 'o tl r L r :r l o i l cv,l ;'i 1 'l i tttr tti i r r tt r tttt r r 'r tl r r t' ' 't,i 'j ,,p tl r ,l ,i ,,.i r i cl 'i r r i s}l o j r L i r r r i ' l ) r tt' r tl r 'o l i i l .' ; i ; , '; , ';;, p o 1 ' l l tr r si sl l r .r 'r 'r 'r tr r r r r r r l .l r r r r r n ti e u l u o , , 1 , i ,,,'r ,,,,r i ,i ,i r i i ;i r cr l o l i l l tttt r "l l r r r r i " t , r l . t t ttr l t' r l l l i l 'r i q i i cn tr t't'l tl Tl :'l i l t) "l t d c t,l l g o l l i sl tr r fi l l , I r : r z i r l r r r r tr i i tr i i r tl ci cn i p ttttl tr a o csl ' sl r l ( l l ( 'l l l ' tt l o r '1 r 1 . i , . I : t n h i n l .r ti .l tt tr tn m t'u ti r ,e( i n sp tci 'r l P"i l t l l l r l l i r l l l i 'i :r l r l ttr r l i r r r {'l r r Ii i ' vr "'l .'l "r 1 r \ ' s.'r r zi l i r " c"In l r i r 'i c 1 ,rit.l l l l |i , , 1 , , , i ', f , 'i i ,r !.L i zl ,:tzi i , r l i zr i Ii ( '1 l o l r r l " , | , 1 r r '- t) r tt'cti L r l ',stp r r o sto ti i l c l o f i l Yti l r - i l 'i i l t'to $ i si ,r r r r , | , l . r i 0 i r r !l l i i o n cd xl c) .

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it |[rtrrJ,rlrli-supcrior,care pfezittti o piele rnai rtt,,, (li 'r rrr r.lui':i':)rsi, iinrrirr?,ramllituirinii lursLrhri tcnsiuo* s,iterixrii [rri r,' r .r. l.:r II,Ii'I||LI,rILs'p,.r'i,,r, ltfcciat {i __-.nror.i __ t'l Lruril,r.i trofice p.irr rr, ri, llrr,. !i\l,r rir(.rt:.v:r ttrnncureretelatortrc.:2,) B etnnu!ltti Ochner gi(|Q1r,: r'rr t,r,. rL||ri'.r. rl,qi'1rrJ tlcrr51p1r1 cl: -iculei,in zona colespunzXtoari tcnit,, :rrL1r'rrrerzii durere cu 1.]c:r,1iz:l,le o :r a,min1,itd, s|ls. irl '|'rrr 'i :r' rrrrr.'r, mai ,r'lrrrrlr, rrrrlsllzir zonci do inscr,!;ie rnusphiulni a scalen anterior supt,irl r, riimiflu5, iar ra iniinderea scir,rrr, 'ilrlr!l(il l)) lt r itritruc* utnii,ruruitruteraa lrri |rrILlu]|li si 1)l::,sa,rea rrrci greutiti i" mina p:Icieillul i, .(r,'1r,,'r'11",1 I rl lll.l.rll ttt.fiul,,rruf l)[tr.uiic a,langit) se agravelzd,. gemnx;t c) lui Als,nt 't | 'tt,x t;,, r.rvllt.ll :rl itr ._czufcu rrrrirrile lrlrsrie lejor pc gr.n trr,l.l ,.r.1),ut lrii,rilr'a-t oxl,ensic$i r.plectL; p:,rtel ilurerorii, cste soliciLrt, dc 'r .rn r ,r lrlrrr.lr.zcir rr'.r,oc1c inspiralie for!,atii. in Aceastil mr,ncvr,i decl,"tscrrz.r, I , iri,..r,l irr rrr,tLbr.ul rr'i. s'psrior dureros si o dimin'r'e a ar.pl;tu,1ii,;i1,,rt ',tltrt.tl) ll,rtrrrrt lvi I lalsteo,tl, 'Irlc,liunclr,iu jos : in axtl membrulrri srrp,, )ri)r',r'u ;irlrrl rrr ori0nsic jii fi cu c,t,pullotttt cloirt;t,alrltci,ltl, exuccl,bt,ilzii. l

rr.; rr {rr(,i,,r),i,ii,i orrostatis,u. rrr,rr.r'rrirri. irf,r'irrzii li' rpri,lrpo tottleaunao set.ie ".,".,,,f:T3r'r:tj;Hfill'#j,lilil,lill de'ttrlburijr.iy:l,scullrr,r,: |r, rrrrrt |1..t rtrrl ,ltl

r:rtfiriirrr' rll rlt tr tL' 11. /rrr /ixr iitosebit til, ottlpd sind'faDllrl' tl'o <tr'ntl ( is+r , cir r . r '! di Ar seni ii O pr oscu, I l) {iT) l') t r lt rr r 'lr r lr \ r r '"1 ,i ,,- i ,1 , , t , 't , . , ( II I I | I I :I I |' I I I | ' I i|'''i||I r r ' r \ r 'l I ic ii pr : 'il'ziilc . ' ' l ' . ' ,;' .', , , - l, l; n , lu , . i: r t t t lir 't i''t . r lt . r it r 1" r r r r r r r r 'l' , i"i'i i' . ; iii init 'i: r r iut r . llc, " , r r t t lr rt , sint r evclat or u'o: 1l) ljt ( '\ : r r '( : r 'l) ( r rrt zI r ,;: ,' l ; ; ';.., i; iioi] 't r "i. . ; l) r 'r r f ir r r '"1, 'i I I r r 'r r 'r r r l'r 'r ' p"i ir ''r 't i" piui in ir lr lt i'i"i"i'i"'l .' ., ( \ r t r t I r t . I iit t r r " \,r.rri r . i l'. uiozl' 19t ??) iii sc ir nclior cezii ilt I t |'t r t t l/ r J r t r 7r 'r , r 'l i""f ui t iLnr lului ( "r t l'iir lr ( lr I 'lir r rr ': r zir r . llr r 'r 'r 'i t; i ' , l ' , i;I,i1illt isr r t ; i ll m ^{li: ln|llui; r ') '|. t lllr t lt 'it 'i1. . ll'I l't 't I lt |( '''|} ''l| ( |||l lt ii | ,' , l i l , l L r. rl ' lir t ( : r t r t t t r r t r lr t r ,,,, l i ,, t , , t , iiir "i"'* pt it "- oir . r '"'i t t cgt 't 'u , t i l'r r r i lt t zit t '', ' i rrrrui tt l: t i : llEs l, r , nit 'i: lt 1 pDlicclui' ,Irr' lnlls{) t llilllr ( r r r 'r r : r r " l l ' i rsooiilzil, i, '-'lt lbuf i[ f i' t t 'olicc ot ti; lt 't t lt 'i't lt 'ii, ii, ii, iii t t i, ni, it , t i'{ {'soils( l llip, r 't l. zi: r . r l. t t ' l , , r' ' i it 'Li r 'lloli) ', t t, ,rr rl ri p , : t t lit r it it t l t iLLt : ut r r r lI' t r r t r ilir r t t ult t i' ( li't r r t 1't t \ ( 'r r llr ' t r r '( '( r r ! l. t , i l . ( |rr rr":i | ll i.t , : t u, r t siniJ, t r t t nu. l.r , illI t ir - ll ilclt t 'll r t r lilt t z r ' cr t l'r "i'r lizt r r lzii' pli. r r it '( l lllll'( llr ) - r ii) lr 'r r {r t ' ) ,, ,' ,r,,' ,,,, ', iii, : ir t , r , lgi, , ,st l I r lisl': lr 1i t t t 'irtit rl l lrr lf lr r r lir r 'r 1r lor ] ,, ,' r,u f i, ,l , .)rl i l i i l ii,l l (r r rlsllt 'ii, lr it r r rr ir iit rr l ( r lr r r r r r r lr ' , ' ,, I 't "', ir r r l''"'r 'lr i t t t I t r r . r t t , lr r {'I lr r , ,,,, l ,:,,i , ', 1.S, , ' iiiii, ii*it i, 'ii' l" ': ''i ' r l{\ r 'r tr lr r r r t r '' r r r r 'l r f , ,tit ii, , , 'iil t llt li lji t t t r t l. r l'l' t r t t t t 'r lt . 'r 'l: t r ll't r r r ilr ' : i ' trf r i illiii ( llr l) llzit t t r i t l" r " 'r t t lr r i , | , ,, 1' rl r r , r 'ilir tilr r ll llt r r r r lr ( r 'f i''l'"i '', ", li', ; ; "1"it 'r r r r i: t 'l( r ir r tviI r r ', ''t t lt ilr Ll t : r lr r lr ' i. ,l ;;; 'r ,i ' , ,' i ' i; 'l'r l' "'l''"'ltttl IL l i l l !r l i Y i l ..:l l l 'L l r l r l 'l lrrLr rrl (ril tr t' r 'tl r
,r 1 1 1 1 1 1 "1 r ', r t l r 't lt i l l zl l l l , r 'r r t tttt't ( l .i ,1 1 ,"1 "'. l 1 1 1 ;i ) '\l l l i r l ' r r ' i i I1 I r ;Ii Ii ' It I:r r 'l I , r r l r 'r ' Ii |r 'Ir i r I|,'i ' l' r "r 'i l r r r !i l r r ','tttl t' 1 l 1 vr "rti , 1 r , , , 'r 'i , l r r r l i r ttl tl t r r l l L l r \ 'r r l r l ,r r r r r l ' l 1

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itIt,r(r'lrr ittlr'ltil if rlrr li.llolttorr lt,gr,1:rlivrr (|ri1r|r,r,rrrirr l1111rrlii, Dirlc rrr1i11 crr (jrt oVr.nlllirl (1iln(,2i, (r{lclnlli,,i(j;t\il, si sllt1l,1 i1lr1,glll1l cll ,rrli,'r'lrirrlr', ntiinii rr.rrrlrlrr. rirr'1xrIior) {'rrrlico ort,itlsc (1,('glrurctrtrurtr, si trrrtsotrlar(i rlr\ rri l:rttrrlr'lot). ir lr(,r tnlriiLscrn(ruoll l,ablou olinic trebuie si, ne Eindim cri silr,lllrrrrrl l rrrz;rl;ii" lrollrf li gerr(rlit.rlc lirrrrle ntll.i Jnctctrictiopa,logetli (;\rsoli 1i -tg6-?) ( )t)',.r(,, l1t{i7 ,lohns(m._ii Sp.r,lding, t9?4; $o el,ea, i. : a) I,r,zirrrii Ir'rrrrrrrrrii< rr (rrLri rrlcs),il{1a,rn:rtorii sau toxice alc nenlilur periferir,l si rr|., Ir)..l)r.oct'so r:on4rlesiv-e rcgjonalesau locale cu readlii conjulciir o lrlr'...rrlui1 i.i.rl'ir:. iilrr..s. crr,r.. inglobeazi,nervd Si vasele; c) Iractnri c'rl. .Irr ir.llrrlc;. {l). l(lcfi)?:r1ii (boaln,I[odgkin, tuberculozii) e) I -4feullrrrri :rl{ rlr)r}IllIi l)l(,ttl'i[l. l)rrpi.A.r'serrirli (1962) cauzalgi,r, Otr)r.rscu pfczitti, trei grade : gri,,{l,tlI rrrr r.r zirlsirr Lrcrrli; g|ldul tl_Il-le:t, uru ca;rzalgiaregion'ab (ciirl {tri,, rrrrrrr.l...p.irul i,1r,cg rncmbrul .respcctiv); gradul al Ilf_lea sa.ucsatz,rl ,iirr, rrzii(.i,rl l.',r'cnele sl: extindpeo jurni,tatc rlil rle corp qipot chiar.srr lrl r('. ri rl. 1,'hil opusi,, cu tendinfii de gencralizar't cr6tleri cii aci.srrr ). r.lrrrili.rrrr'_rliu.ti pr.cfioase indicl{ii de diagnosl,ic cazu.ile cu srirpror..,l in t.Lrr',ir,p.li'L'rfir,, ,,ba,slard[,), cu topogiafie nesislienatizati ;i lierrrrir,, rrr |{ I,iIr'I r'(|Il ror tclrrrerri iI rrr pcrima],ic:r, f i ,,siurlr'ornizioprtic" (al lui ]Je,-hir,rlr l r,,r'|, (.\t(.r)sop|ogr,rriv', lui t,r116;. rrl] (rrl -.i ..-irrrlr','rrr 7.i|.{}. rll11iiloloraco-:rbdomilale |. h'rn\t,l0i.o.fNnicu}ui (f renalgia) esterealizati, r1oleziuni ilitatir.t r 1,, rr,r'vrrlrri irr lrrngul sii'traicct din regiurea cervicalii ((rr-Lu) pirrir ,l'r'rri. I:r,rrir.lrrl rlirrh,griLului.In prezenla unei frenalgii trebuie si, girir,lilrr t,, rrrrr,r'r'isrrrr lrlolelor invecinatc (ale arterei subclavicularri sal rrL, rrlo 'c h 1rlrIirrrrI.LIIrrJ. }Lrlrnonur'), tumori sau.infl?malij rlediasl,inale,l*, pkurilrr rrrrrrIi rrr. i rrrr,rr s[rr rliilli'rrgmatico, pcricartlite sau ]t un abces'subliirl|rg I I lil .
t | ll I t ( 1.

| )'.lr'(\it si1 locirliz.azri,l:r, Jtezrl gitul*i, il}a,poiil mJrgiDii sternrrlrri, qi tol.Icc]rri (cu.proieclie lnteliou,ri), fiinr[ i"nsolit:i arltsr',r, 1r'r'rrrrrI Lr brr'z,.' ,1,.rrryllri{ rlo i onii,rospiratorre. si ( ir)rri(.\hrl slmit ogic se complcteazi, cu prezoniia umtiiioarf lor )tt)t( I | || tt | (t't)( 8(t |e1)d&toenpentl? adeastri neVralgie : | I :r) |'r'r'rirrrrr.;r puu.lului Jrenic,situa,ti intre cele doui. inserlii iufcli.rrrr, , rrrrL:r'Ir i st'.tuoch.i(IollastoidiJn. irIIrr '1,. f)) I)r{)Hiun{tr, primele spalii intercostala, irt imediat in afara rnargirrii r l,,r'rr:rlc rts1tc01,ivc. , ) ,,\lriislrlol,. punctul- d.iaJragma,tic, in situat la incl'uciqat,ca tlirrlri, litrici parastelnalecu coasf,a X-a. 1rr,lrr;1ilr.rr, ia r11..\;r:isrr,r'rr:rregtuneatle inscr!ie trJracicia diLtJtagnului (1xtnr:t1,, pa "
trtt r,u rt, t t , r t t, 1, l[ us 4 rl ) p l o ,tu c o , rl ,. a S p l n { ,n e J, rrrc| i . !" It'routt.artlin,-descrisil.d_e clilrir'icrrii m:ti vlchi, sr: traducc prirrir o . rlr';ir'1,.:tlizir,l;ii, nivclnl virhrlni cturlirc, suir {'r'rnri tiie irr!ep:ituri, irrs,rlilrr, h, r l r,.rrrrr i. t r r 1, . , ilpilin{ l D r) rrtr fo n d n c v rtrti . c .l l osl ;r,pl tti cJrrspcci l l l rl i rl rrr, i tl Ir'i rrzrri . ' pi. lls ( 1, c ll ro i u ' d r,,i l rrn i l tl r, i l trrrrs i . g.rst,ri i :i i ,, rr rgri s,r.i 0si ,/si rr l [l i r rl trx'o l ir ' ( S ollr r ior t ,l{ X i ? ). A l g i i l c l rr.n rx rrrrl i l c rr rr r,ripot ri pi rr,rr, l rr l roi ri ;r,r,i r si . rr l r.l r: r l. ilr r r s lt l0rrtl l [t,rfrrl i r'I' 1 !] l l t l j i i rr .rr| trrl srri t,i rri i . N rt l r,,,l rIi r, , r'rrrrIrrrr r I I r I rrl r r lr t t t r t i l rl i l tj i | l ()i | l i t .rrc rr rti rt' r:rl i j i rr,| l r.r' t!rl i l l l i l . c i| :t:t l 1

tr r 'tr r l r l r ' tl tttl r L l r / r / r/r r r tttl t tt tr :.l tt!tt'r 'l r tczr ttl r i tl tl i r i tr tl r l o tr t r 'l ttr r r ' ;1 i r r tr l r l ' l ;r Il ' tr ttl t i ttl l ttr r 'r l r r l '. ,,., t , , , , , i i tl l l r r l i l r r l ,', ,,,',l i t t" '1 , , '' 'tl r l ;1 i i i ] l / / / .i ,l )l ./ l l / l .' ||l l r ||( 'l I , '. t , , r , t ''i,l 'l 1 i l Il ,l tt, ttr r r '1 ..l l i tr l ' l t't'i l l r l r i l r . n t'r tl Iq i i r ttr 'l r ':r r t i r tl l r r r o l r l ':tl i o cttl i l i l tl r tr 'l i l t , , r 'r r t l ii l ti l r ttl i r r i r cr t i i 'r t ( o tr 'l p L l l l z;l l ( r r r 1 1 ' ( l l . , , , r r r r '{r r r r r 1i'I ' ( 1 l l ' r i i I i i t I i i (i i I I i I t I ti tIti IIi cttII l l r l i tr l l r l tr tIr r l ( l i 1 r l l l ( \r ;r l r,., i l l i l r r 'l t'r l i l i ,,i ] si , f.t'l l r r o r cl r tl tstr i ' o ti ttl i cttl r tl g i tr l o l r l ( 1 i ( r l i r r ;';tt( |r lr Ittl .r l '' r , , , r | , . r I . o I I I r Ii i . '1 ,( |1 l l fl , l l l t r .i r r r r r r .tt :tl t'l tl , l l o l r l ( \ Sl 'l r l r i .l i I i I t I 1t I ' rI r t t ' l r t t r Ir r r I I : f i , ' i ; ; i I l , I i t , rrI ; i r 'i' ' ; , l ) r 'i tt ( l {1 x1 i :r 'l ( 'i t'i 'o cr i sl tr r l r :i tl tl l l 'zi tttl r r l t' tl l r l i tl ttl ;tl 'l i ( l ctr ttr l l r tl ti L t , , , r . , 1 , , , ', ', ,i l i tL tti l r l l ' tl tl i ttl i r l r r sl tl o i r '. . , r " l r il tl r ( ) so l l s{l ( 'l {1 .) lt ', l :r tt r l r ' l r I L l | r 't l l 'i r , ,,,t'cl l |l l 0 i cl tl L l .i tttr g l r i , tl t'. r r ti tttr t' 'l l . r ''r r r r i l r r 'Ii " r n i l l t l r I ( r 't1 1 l l l r , r l r '- r t l r t,tr l ttl ttr r ci l .r r ''l r " , , ; 1 1 1 , l r l i si l i l l r l i t i r r b i i r u tl L , ' 'I ( l c1 r r r |i l ttl r 'stl l t s{l ( x) n sti r l 'i i ' tl l l l ) l l l l ( 1 1 ( l l l l l r ( ) 1 l r r i r \r l r r 'r r l r i l t r l |tl tl i ,. tl ttttt':t a l l tr l p l u stcL m l l ,.l t,tl i tttr tl ;l t'si L 1 1 1 i r l xtr r l t'tl cl l ;tttr i r r 1 , , , , , 'l , l , r : , , 1 1 i , 1 , z r r r r r | r r r l sl 0 si l L r i tl i i i n tl r l :r 'i L l i i tl i i r n s^ r ,i tL g "':"tttl 'r co ttj ttg r r |r "r l ttt't"' ', r Ir ) fl ( 'r r r tr ( |'r l , , , 1 . , . , . 1 ,r r r r r i n u l l tco r i ,r l o i p o l i r l cl r l i r \i ti l i i l r l ( r l l si l r r l tr :ttttttl i ( r r r r 'l ' l r r { r r i ' r Ii l i |r 'tr Ii ItI' r r 'l tttt ttt , l , l 'r r r l ) si a l i ,u l a l r te 'l i o r i p ,tr ,l sr tL l t"l l i n tcl co su tl , tl l l r '.'tr "r I r' t t :I I ' ' t I I ' I r t I t I I t l i l tr tt"r r l t' ; i i l ; i i "r i i r "i j " ', . I ( l l l tl 'l i i ' Ir l - ( 'r 'l l l r l r 'l i r ( ( r 'r r t"i t , , , , r r r , t t t , it. r tti u tr m "* -fa l :l u l o l i b i l tr tt'r 'l l l i tl r 'l l r l l ' ( l ( l l t'l :r r l I i 'l r i r 'r 'i " l 'z'r r r r r l r l r '1 " r r {i r ' , , '. f ,i ,' l ;t l ttso ' i r i l l t!l - si ( l l l 1 1 'tr ':r Ir r l r t\ r 'r , , , 1 , , r l r | r i . l lxi sti l q i a i c i n d i cl r ,l i i tl L zi ttttr r r :l i i i t'r l l i r l ;r : \ {' I I (' I } | I I I | ' ; l ) ' l , , , , '. , r l t l tr t'si r n r cr r ' tr ';;i r ttr i i |r ';i " tl i cl a n l a ti i l r l i r l r ' t 1 1 ' 1 1 11 't r l " I r tt "' ' ', , , ',ri,,'i '1 , l :i l cl r 'to i tn p t i r i u i 'i m i tci l i l o ' ' , ' i ttl :ttt.tt ', , , , . i" ; 1 , ', ', 'r ,i - r ,,l u r e r e i , ]:t Ir i ve l L r l r ') i d i r 'ci r r i i i r r 1 cr ( 'sr tl '( " tl l t'ttl r i i tr ( l i l r '( \ l l tr i i l to l r r r t\'i tr r Ir 'l t" r ', . , i i , , , r,tr l l c o r i d u r e r i l e , l n o t'i ]' p t'l l l l l l r r r r i l r tl ' tr r l ' tl tt i t t i tl o l i n sa u i n o r '1 o o l :tti sr n l 'l tl tr 'tr 'r t tl ' l r t,r l ' 'r ,z'r '. t , l , r p l r " .'s' l ' t:r 'l r l r tl r tr r ( r ttr ti r r l ' r ' r l ' , r I , , , 1 , ' st,tiOt';vi u c r a p i tt b i l l r t''r 'l tl l ' ; ', , l l r l t'tl l i 'ci n i sr l t'r 'r 'i r \ t ; I I ' I | | | I I 1' I | | I | | | I I r l r l r "l , , " , , r . r l r ') p l i r xl {o a r te i a l i se l 2 r 'tt,' r ( , i , t , , , , , . '<l .r n ftl e tca zi i co tl te xtu l So n r i {) l o g i ' .l t fii I I I I )I r )t t I i r l . r l .l t.tl tt cu ttsti t'i ''tr '" r l r ',st ttr tr r ' 1t i t'I t t rt tr | ' r I ' r t ' , ,,' t"r i i ttti tt,,,t1 l l l i l r c, ', ', , f , , , 1 , 1 ti :'l tt l i r ttr 1 r t' :i r Itr r r ttr ;" t' 1 n l u .l r l l sr r r .i l ) i l i l r r l ( ' tr l '' l :r tr j .r "l r tl ' t r i r : , i ,1 ti l , , i t t t t r tttt * i ci te va d e ta l i i l u p o g r a Ji ca ( $ o {l r 'l ':r '.1 1 1 ( ;i ) : i r ) l r |zr r r tr r "' t

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r r :t t'r tl tl tt r 'ttztttt /, ) ;I i tl r l r r r tr r l l l tt:,ti Io Ir Ir ,r tttttl t, ;j i :ttr ,ttt ttt tr vl l tt' , r , r r a . r l c rl i r t r I tt rrr rrrr. l r l g i r r o ( sr x:i r r l ,r rr l c r r |l f tr t:tt tttttl l r r r r tr l t r r tt :r l l i ' ( 'ttIII||t|i ]||IIII l :r l l l |l l i l l l l , r l r ( 'r , r l r .\l r r l Il i tIi f) 1 t0 l ' si i i r i l r l i , ,;:ia l l t tl i o l r ttl i i . lr ( tr r r ttti r r o Ittr tr r , co l csl cr tl o l r tr tr ' r 1 .r t.) sr ttt p ti tt : t I rt I rt t r , tr I rI r' , ;,rrrr lrtrrroli , , , ', l , r r l l r r i l l r l l , ( l tl co l i tu l r ( 1 ( 'i l sl i i , l ttci tl i zr ttr r ) , l tl tttl ttl tl i sttttr vl r Il Ir Ir r |r ', , tl r r tl i vctn c ttr tl r ttt l l r ' l r , r i t l r tl i cttl r ttr ', sl i r l r tr l i L r l i si czi s, n l l i tttl i l r r ', , , I t , , r l r i l oi , i r tsi , sr i r tl 'i cl r , tr tr Ii ctt|l t'tr 'i ;tto r l ttsi l tt i r r i r si 'l r l ( l to r r r r ttl zt cr tl tr l , l l , r . r l r r i r l tr l r u l l o r i l i l l czi r r i i i 6 i tu t si tttl tr tr tt tl c tu r tr l i i r l r r r ':rI r r r ''i r r r ,tr |:r I, , rrrlr.rlrrtrlt l ,r r l l l r ti r ti stttzi l ,i vr t- r r l r i o ti i . . ) , \ r i t r l il r t, 1 tIr tttl tr i i csl 't't'r 'r tl i zttl r 'i ( l t ( l i v( r 'so J]t( xx's( ' sl l tl :r l ( r L r r r r r , r l l | , I L (Lnr\i(c, l u tr to t'i i r l c sl i ctttl tti , r tl tl t'sr r l l tt'sr ttl tl tt'( 'j I'l r l r r ) ti l ,r r ,,l .r l r r ', , , , , l . r r r r r c r r l l l i r r c si r n txi i r l r ;.r .) . I) o r tr ttl l c o t'i r tl L i i l r ', r 'i o l ctr l r ', r r r r r l l r r l r , , , 1 , r r I r I o 1 .i r r r Irscsj i l c si n r l l o :r u to i r l g i co r n l i cr l i ttst, i tt l r .r i l o l i r r l 1 r l ,,r r l ttr r l' , l ) , \ t i t ! !i t1 L l r o ttL ti tr d , cl t';i t'r L t'i , 1 t'tb tti r r l o i r tl i r tvr r l r i i r r vcr l l r r '. l l r , l r t t l v ti l .i o i i , ( i tr tl o scl l .i vi ttr l i ci ) , stl ,t.ll x) l l i ( f Ii l to r l tr r i r r l c r r l tr tr r r r 'r ' r i r r l r i s cj tl i o ( ti o r tl i n o n t) , tl c ti {:ttttr r ti tl tt vct,i r r j i l l r l r r ( o r r l co tr r . o r l l ,r , , 'r r r 1 , r l t tn i cl tl u s o so s vi ci o s^ o l tl o (I()I I I I ) t i I I Ii i l tcl Y r l l ) ( 1 !( 'l r {r r r l ( l r ' \:r r l , , \ i | | ( . l r ) r ' r r c|r 'r tl r r i sci r i ti c. Ir l r "co l tst,i , tl l .i ttr i si l ,tr t{i r r ( r :tti i ) , r l r r r l 'tr l ,' r t ' 1 , r r r r c l i ri o sl ,:tl i sr r l l i l cr p :r ,r i II o r '&) sl i r 1i str t, ci tttl st't'ttttr l r tl :t r ;i 1 r r ', r , r r {:r r ,, , tl ttt.t,r r : ,' ci t 1 i su l l Ii r tttu l tl ttr 'i l ttttr l l i l tt ', . r l r r l i l ot l l ti b su l ) cu tl l m l c, I ' i r r r l l r r r p l i fr 'L t s:tr t Ia n i ve l u l ci l ,p u h r i p ( tl o tx) l r l tr i ( l j o l l t'1 r 'r r , l l l ti ,1 . ' r" \ t t ' tl q i ft c]'t{r a l d : , , I \ r 't t a l g i tt cr u r u l d tl tt o r 'i g i ttt t'.'r f.( tb ) ttl i , tl i ::u l ,r '. ,\r r l 'l l l ' r tr ,:r i r r r l , l r , r r i i r l i scr tl o Ii i , L 1 - L 2 , sc p t( xl ttt1 , ( l o o l r i tci tl tl r :r , tttr r 'l o tl , r l r r t, r r ', , r l , , r r l r : r , r r r r i t'a tl i e l i i n l cg i u n cr r :l l tl ,cl i o l tl i i r si sttl l tt'i ,r r r tr r r t r u l tl r :r l r . l r r , r r r tl , , r l r , r 'r r i i i r ( l i scu l u i l s:l I- r u , r l u l e r i l tt i ti l tl i l i l ,r r i tt 1 1 '9 - i l l ttt'i r r tl l r \) r r r ttr r r 'l r r . : u i i i r co :l l se i , d e - n l u n g u l n o t'vttl ti i s t,i i r tt i ttl 'ct'tt, p tl ctttr t ,i i r r ;r r r r l ' ",1, ' ' , , rrr ' I r i rr I rr i . Sr : co n str ,ti i , ;i o h i p o r r :sto zi c i l t l ,cr i r ti ttl ttt ttl r L l ttl r tr . l i ,'l r r 'r , , 1 r i r , . r r l i r ) {1l l tl o se l l o o a p si t d l l r cl o i r si 'r , fl txr tr tl ,i r 1 l r l r r ,zi tt. lr r r ) n t ( f\tu 1 scm i o l o g i c se n l a i l o i r tsr xr i :t : t I i t t I i t t t t : t I (' i I l i r r l l i r l l r ) l L r r ',r l l , r r l r r i t o l u l i :l tr , n n cl e d e fi ci to tl u tto l i i ( I i t t t i I 'rt t t rrt cr l l ttr r i l i i l i r r r r l r ' r l r ,, ' , 'r 1 , . r 1 i l r Il cxi e i co r r p sci p e N ,b ( l {) l l l r {l ) , l tl tr l ttttt ;i IIi Ir ( |Itl 'l i It tr r r r i .l {'l r r r l t , , ', r . r l r i r r l t s , S i r td r o r n u l tl e cr u r i l l r tl g i i r l ) {) l tl ( 'l i l l r r 'o l i l r i l r tl ctr tl , i r r l r r :r {l l , , ' , r 1 1 1 r g i lr d i r n l i o l * o r n tsi vi l h o r tti r l tl i scl u l i i tr ttr r l i r ttr i i , l i r ' l r t o r r l l .r r tl ,, r rrr, r.thrhlllLi ( sp o n tl i l i ti , tttm tl ti i , vctl r r l tr .l l ,i ) sr r r t i r ti r r r r :r l ti r l i r r tr :r ( tr , tt , , , ', 'r r r , r 'r r l l s tcttl ;o m , r r i r h n o i d i ti i {i ( r .) . l, ] ;\ t:ontl.Qitt tittl.t(Ild prin al,to t;rt,tt':t: (tu,ntori., ultrttsr: ttt 4llr l,t ', t t:t n t t t l . l t tti n ) tsl ,c tl o o l l i l o i t I t t i I l t i r: r'rr I ri', q i tl o tttttl l .r r o ti l r r Jr :r l ;,:r t, r , l , I r i l r | l i r l i i l ttr r i tttttl i t, str ]tt) i tt0 l ) o tl xl l ) l ) ( ) tt'q i tttttt tttr l l l l l l ( r l l r :ti {r r i i l l ttr r |, t p tt r N i . r , r : r l q i r r s{) l l ) o l tl i z0 l r ,zi 't, r l f,l l .r , tr ,r r l ,0 r 'r r - i tr l ,Otttr i , c{) l l t:r r .i r r tr ? ,,l r |l . r r r , I r i r r l t t i , i tr u l i i tu l si ttc fr r l .,l r t,ttl l r tr t- i ttl r r l tr i :r ' i i l r i r r i . Al ttu r tl tc Io Ir |, Ir ItIr :r , l r l ) :i l tl r l i . , r ', , r r , z , i l r i p r r i 'l l L r r i l t.r l r l i r r r 'i , 1 i l r i p r l t r l i t, cvIl l i r t, ''1 , \ t t t il q i ( r l tl tttr r l o l s( ' Il ( tl tr ( r l l l l ( ' tt;' t ;r r i tl tl ttt'r 't i l , , 'tr ttr r |u l u i i r l ' l r ' l : r {:r , i l l l l t) i :t r r r tl r l r l i r i i l t 1: r' t t t t t t r I r i t I I t t i , l l r r ,l r l r r r ' ;r 'r r ' | ,, 'r 1 ,, Il zttttti r l i r r l r l , ( 1 , I r , . . r : r , t t t r t1 r r Ir i Io I :tItr Ir tr r Io l t. l l ) r tl o t( 'r r l i zr Il r i i r r 'Iti l t L l , 1 , . , ) , li r l r l i l r l r tt l ,r ti l r tr r tl r r i l tt:ttt i tr ttr r l ttl l r :r zi tr ( tl zr , tttr r t tt , l tt r , r r : r l l . r . r r ' l r tr ';rl tr ) ,,1 L ''.

irrlice{ii ropugrafice: l,n_ I-.,u sri '1"'j,,l, ,.ll.t].1,' .:rstfel,irr hernirj rliscalir, rrr,.,.L.rl U nlpoe\tczre.le )' ).rr1' la!r, aotorolitterd,Lignnbei,pe alosut a pici{)
rrtrr .. tr trrz:i ltrlr rcelrri, hcrui:rdiserrl,i.l.s _S,.6ipucstczi.r eflh,crl, lu st. 1:rry l;11py.,1,i grmbPi. p+ irrnr:ilaiea Lt'ter,r.[i pttllrei fi r dosu ,r ]',",'., .," IIIIIrr r,|| ||,,.,,I l,r.ecln ji po ultirneL,rieg,.lc.

.l ) L'ft:){:nld Lulbtn iirilor obiec.liued.esensibilitatc ne polte, de ilsemenolr,

1) Pn:r ntt )nalif icir ol' d,e re.flene.Reflcxul ahili*n este diminurrl r.rr ,rtrrrtrt Jrfrilil rle aliscli*Sr_. Uleori refloxul cutanat, pla,ntar po?],h\ irr Ir rr.lrrlil, sirrr..ilp:irc chiar semnul 1ui ]3abinski, ca manifeiljaie supn;iozio. r rl:i (rlrr,lolilii tulbirrririkrr vesouhre l,scji te comprcsiunii raii^icul&r,.). h ). I'r(;:(n,t{t tu,lb*riirilot de btet itata po:tie avs:i certe yalori looa,lizit,. ',,r rr. \:ii;[ol, <le.pild[, p:rrezx ilerorilor :tp-r,re ]relni:l discului Lr._S,, iri -&_,u, mu:"hilor ld_0J d\DLltrslrr h,r,lue.:lui. Ir.r.r,rli 1i, tl n.r*n=o. ',.'t:.'.' .,rr il scll o{tcn{oI l ,r,irr'r,r,r' Jt ,t,,j.Lelornc p ).[to rugur,rlrer,ni,l rIis;ulrrr L, |,,,. frr lr,.r'rriilu ,li.:-r,lop.iu coinprciiunr piurir.rdiculir'i, pcato rec,lizr, se r.Ir , i' . , r l) r.t..r llnLl , cu p-r,fJ llzie. nerv scit[ic popliteu ericrn, dc nor.r dL. ,i, r.,lr,i l)r)plitouintern s:)u cl:i,' oinrL.'m (henidifah;m) cte coadii,do orr,l, i) I'tt'.:(,njdtulbu,rd.rilor i,tt sl cterien ne poalc intlica hernii media,rr. e ,1rr tr rr':r,ur(NIi:rirre, comprimi c&rc $i I'ii,laiciniles:lcrute infet,ioare. I' n I t l,t, tlc d,itr,g ic etiopd0 genia 6n. Iotnbosci me nost atalgi,i : ,r) li,olruirrtim cir, mrre:l rn ljoritatc rt rombalgiilor, a lornboscirllrrr,l . ,] :r l,rr)1,.)cr'trr'rrl.,iiiL,,r.tlr.,t,,.s0it,lirr crz,rl.i)"srrrt ori,qincrert" i,l, ;li tl;'l tttstlttt(\.t('i[) \r Lr y pL. t r ri t4\ t , , I ls or l, r ' oz r "t hof n i i r l i s c l l e ( r \ r s o n i . ; i f a , r u r l r , Si ,L)j,r'i si.()pr*{ju, l1)iiTlAlstni si.Nirniott:su 1.9(irt rr, collh., lif:ll ( ir\tscni ryi l 1J'/ ; )l)l' rii Ii's', lt,{;ll; I'.p'vi.irr si r,rrt,lr.r l lt.ii!; l\,i)r)vi(,i*li ilir,,f,, I r)ii;).

i . \ ' r t r , r llt ir r I t' u trrto ttrl rrtrrl tr (ttrr' r,tl tti rt l ttttt tl t i i t I l ui l i rl h ) u\ r', rrrr,r : r r i, r r lot pt itt l o t,rl i z rtttrt i l tttl t i i p tr l :t,l :t :tttl ctoctl trl r)l t, rt (' (ri tprl l l , l ,r o l rrru, irrrri Irr I r' t rrIli , i trs o !i l l i , l r1 tIrl rtP rr IrtItIl rtttItIt,l t: rt Iti 1tl r' 1rrtIi ot(r1rl i i rl tl rl l tl r rrl r l r r r r r : r r r r r li s lttz rtl i i rtl g rl )i tl i ' :i l i (' z i (x ) c tl rrl ti ,i trl l itl r t' xci l ,l l ttl i l trl t' ttl tr. i, .,rrrri rr r li) . S r i r r r r r ri l i i tl t' i , rttti u rti l tr,t:rL s l itn t rt;tl E i t) l tr(fsl ozi (i i so l xrl rl r, Il l ,r,r,,rrr : iI r r n r r qlqir r,tt t) t)t.t.li u l i :i t i L o (r' IL l ' & (o i tl o pfovi l l o di rl l [oectl l i Ii i rl :l ' l , rrr:r I:, r i r uc r r r r {trri o o l , Io l t.i l t' i rp ro p i l l L c tt fotnr ro oul turi l tul i tt tl ri l ttl ,.rzrrr; r i r r r r r l. r ( , lr iu l l )s r)i [s ),s i fu i [fi (] i n c l rc s o :rsoci r.tzi lo dul ' cre po 1r1rl , rrrl cl i rr r r ir : 1,c ot |s r ,i , i ttrttl i rl , s u l l l tfc l l tl t l c ntut i l l i i . t,' r t t l' , r i t liol, t ! lic i : l ) $ p o n (l i L )z c l o u rb i i tt-' , cl i scop* ti i ; b) S potttl i l i l r,; .) 'l 'rrrr r r ir ir , ' r ' lr , bt . lt l f s i l rLi rl l t i i rri h i tl i c n o (o a rc trrebui e ci i utate tottl ci tttrri r rrr l Lz rlo 1xr',risii'rrlii,li ilgt'lyiuli i tlulerilor) ; t1) ArLhnoidite sphtrl(!; i,) I i rrrI i r. rrI i I rr, fr lr rrri)nono|li['i', r'i|oticil I f) Procese inlhntntorii siiu tunl{)] irlr! Irel ,l rrr rrr ir r r l lr r r z ir r: i1 ) I' ;o i i i ' .; h ) C o mp re s i L rn ea, rLrh.Lide cX ,tre rtl ' rrl rrl ,.r' r \ trl . :"- Nindrorn,rLL;ohJ-picior replczintii' corespontlartul slnclromului utttri't :rrirLrrrlr lrr, trrirnLrrttl supolior', fiind gencrat (foflctea, 1967) tlc faol')r'i ! rr! ir{ t.ior(,iririr, r,snpri\ liutulni ganglionar prevei'tebral s:lu asullra pl(, rIil,)r' \'(l,folir1,iv()trl)(lomino-peh'iene (afec{iuni alc por!:iunilor telmittrrlr, procese inflilltrrr .'i.. lrrlirrlrri rligcslrir', rtocl;iuni uter'o-anexitle qi .t,-ezicale, precul)l til i,rrii ,i rrrli'r'trrl,ilrlollcrito|elle Di rctropcritolrealc, psoi'lo .,q.4.), rir. lczirrrri lrr,riiculrut (sponililutloze, spinclilite ry.a.). Se poate recunorrtlr' l,r irlr o rlrrrolc lsooiirti, cu. rn:rni{est;d l.egetatiYe de tip simpatllgic t1t (rrl l rrrl iili v . r s r r ' r t r r to l i i .D u re re a s c l o c a l i z c a z i , i n arfi cul nl i a qol dul ui , r' rrr r, r'lrrrrlr sr, lir rui;cir,rile mai ampl ale acestei articnit[liir iar episodic ilrr ,lrrr,l rrltc zortcli: i.nt'ecinate (r'egiuDet inghinald,, lontbilrd,, fesierii,, Irr'lrr rrrl.r'o irrlolni ir, coirpsoi), Irecrlm li dista] (in regiunile tibio-ta,rsialtii, r1t actiYil, Si pasiYri a membrului inforiol lrr.r't" rrrr(rrhlr';irL,nii,). llobiliztre:i ,. , 'r i! r lr (.ir {ir! r(.r'{)ir') rcplusu1 o am0lioreazit) de;i de rnul0e ori se irsinlri. illl zii | ! r'.i rr r { r r l) r ili lr t r t r i i l .i l cn o c tu rn e . ,\lrlorr,pr' l,oi,rhrrnurts9 cr.itlerrliazir,m{liologic motlificiri osljeoco]lrlf. rii r.irl(, (.(,loirriri vilrli{rbrale {orso-lonlblre, mcciitici,ri ale arl,iculalici t'r'r,, tl rrrrrl r r lr 1ii r r r r t ut i ()s i c o l o ro z e tl l s o -rn e ta ta rsi ene ($ofl etetr l -96?). li. Sitrl,rr,nrul ctnaltr,hri tursiutt, iKeck, 1969, citrr,t ds Dofletea' 11)li?) . rlr., olrrrrrrrr, r)tnologul sinalromului cnrpian tle la membrul supu'jot ' l,l rlr'.rl'rrolrrl, rlrr iritrtria nervului tibial posterior in canalul lLri ll,iclrrrl' Se rr:rrr rlrrl I,ibio ir$ir-ilgirl.o-cirlcelrcan). $tie cii, in acest canal osteo-fil)rrl tibial posterior qi r-aselc cilitoresc intr-o teaci fibrorrHrl, Ir;,,'r,,.',,,,' r|(r|r.Lrl Ileror proprirt rtl rrr r.r,irrr irrl,crr, i;ocii sinovirle a tendon',rlui m[lchidui lr rlrrr.r.lrri.irr l,iicsl, cilnrl, ncrrul tibial poiterior sc bifurci, inceidoi rxrt'r'r ,rrl.rlr, r'rr rlr,stinillio notorie In lnulchii pia,trtari qi senzitiYl la plttti'ii 1,1 iirrrrIlorrrrrI rr,l;1io csLe fiivorizat de traum:}trisme locale (lractnri lnitlrr,r lir rl, rrrl r.i'r1) (l )rrlrr:,jii, ontorsc, di',-ofse intcn'erilii chirurgicale) ;sido picio prin furtlicrituri, infcpS'trLli, a'mof$eli 1i dttltrr i rrrl 1rlrl, rii rir, c,rr'.iol,ctizc:trzii ( l{ i r r ! s u l i ' r, rr, i v c l u L o .Itt.tl L L l i ri 1 n t:ttsi i tl , i n }l l )nl i i i l i i n dcgol r,, , ,.,r' r r , li, , 'r i :r1 ,,,:'r c r r ilr , lilli ; i 1 ro l rt,!l i trl ,o L ' tril t , g l ,u rl ){ r i . ll \1 , r ; iilr 1i 1r r , t ' r l l ' u i i Il s 1 rN r0 1 ,i rl t{ itzli)-t i tr trl l ori ' ri ,l i stn;i i tt l i tnl tttl l ttrrl r q rrl rri r i, r lr , r r t t t llc r t ti , ttrttl ri l i . Ii ttl ri i l i L l l tIIr rl i ItII:il,ri l torrrl l rrl rili)l rl ' l l l i l ' t(ri l l r' i rl r ' r', .I ,. r| , . I i rri | .\ r r | )r' i i i ttl ,' r' ,rri i t l l l ' r t l i i s i rtl rLl ttc' t i i r l r" 1r1 l or' . l )i r11 rn rj t, ll r , t lr r l, r ; llii rl ' i l ' t 1 r' i i r I i ( r tl tl ' i { tt rrl l rtt i i r rl l 1!' r,r| 1' rrr 11frrl :'tl

II i t Ir I t I rt rt t t I t t t l tl l l r , , L l r r r 1 1 {, l r r l : r l r l 1 r 'l l r ,r ,, l t l rr (I t r( I I i I I I i L| | i I l l i l l l ( \r l {,l l ) i l l i :l tt'l l ttttti i t't'Ito tttItI|Ir I r tr ', tr "Ir 't 1 tr , rt 1 , r r , l r " ; l i ( 1 l r r |, r cL tl i l r '',.i ,i l l r l l r l r ,l ti tl i l tttl t r , , , i r , l l i l c r i,r r l o l sr r l r r [o r 'l :r l r i , r r 1r i < i r t t t t I t t i . ' 7 . i l 'L t t t a !4 i tt Tl ttn ta ti ( h o ( ,l l u i 'l l o r l r tu ) si ^ cl l t:tr r i l 'ti zcr tv,r l l ) l r l r r l l l r 'r 'tl 1".lizrrli, l t i L i vcl u l tr r l i cL i l r l i ;i i l o f l tti r ti tl r r ttso l i tl i tl ttfi r ,l to ( tl r r r l r cti :r l l l ' l l l | | \ i i i i i t t s i )i t1 i i l o d i !{i l .tr l o i ttl ctr tr ttr tl r L l si tl ttt', tr tt i l i tr l i tr l i r p tr ' r ttl ttl r l r ';1 ' I l , 'r s i ( r i i l f s.p ]'c ci \,l o i i l i Fl ) l {r l 'r l 1 '1 r ) {) stcl i o i i l l 'i l l u r l r r r l r ( 'r , { tl i r l r r r r r l r :r r r l 1 'r i , , l , . r fi s t n s i i r r ti n p r r l r ttt- r tsttl tti , l t'ttl o l i o l 'i t,ttr i tt to l l l t;tts r r i l r r .,i r l r r :r l ct'r r , r r r i r l i l o t i ' ( $ ';Il e t:e l , 1 9 {i 7 ; L i d vl o ;i Il u ca , l !]i i O, 0 i l r r ti t l o [r r l h l tr r , l l tl i r l l , r l : r i | ) I o s f o u n * i n e r r o r t si tu fl t p o r n u l d i tt r l ci i l o i l I( :l Yi l ) l i r l l l ':r Ii . l ,r r 'r r r ( l , , r '1 . r , i t c l v i l 1 r | ti i g i ta l i p l .r n tl |i . t'$ l I l :r tr r tr zr r l ;r l ) o zvo l tl l t'cr ] l l ( l vl r ) l i l l l l l l i i 1 , r r . r r i r i . i ii n l l al r r r to r i i l o cl tl e ( o so i r so l i n e t.l ( ,i l ti ti ) , ( l i r ( ' I t I I I I )I (' r 'i I I I I i r l r tr l r :i l ttr :r i r r l r ':r l r r ' r , . , j r r c i 'r , l f i 'r , m i :L tl i ,r 1 e o ste o fi te , d c r o i l cfi i }{) fi o sl 'i l l l 'tl i vr r l sr r , t , r r r ' i . 'l \ : e l . r L ti e 1 1 i {cr cn !i a ti i d e l l te a l e o i ,i r r r L i ttr l o l tr l l i o r ' : tr ttr l :tl r r tr r r l l 1 r r r l ,' , l r r , r 's o o r 'i g i l i , 4 .1 ( lo D p o tcl o l l l l l r l i ,i l l i j i ( 'l r ( f, ttI( |:||III i i ||Ii L r ' o sl o o co n d r i tc

' rl ,,rr,i -r, (cri ct ent uala t lepist ar e t lc t olli Eu1'osilr lr t r lr r t il. 11. S i ttd''ant al , picioar elor nelini. : lit e" ( , , lit sl'[ t sx lt 11t sr lt t r lr ot t t " l"'ult t *", t 1n1511111'lt t it ir t lt r t t i( ir r , t lclr : r t r 'r llr 't lr l ,t l .i boD rt l 9 6f / est clelat iYuDor t lo , ,l rrl ' ft' i i t rt t elr br clo inf elioluc ( in giunJ) o iii colt lr ilr ', lr ilr t lr 't r t lr 11tI t r r t . ' r,r,,.1, i rI xcp t nil, in: t . i ales noilpt ea, in ciLlt . lt t r iillr t lt llt li, r 'r l 1r t lt I r r I r 't l I r r ( t, rrl , i . r\cestc p: r t 'or ism e a. lgo- p; lr cst ozioc 101, ( r l'lllilli ( ' l) ollr r r r r ': r r '\ r '( 'r t li l) ,,rr,,' :i | i :l l s l lt , r r r biclor , t 1e t , r t t e t lolivii t r lt lt t ot t t t l. I Jt t I ll. t r t I r t l t r r r lr r 'r 'l: r r r l I ,ri ri i l l osi ,ic cst e negr t ir il: it ca c- {llr lor lt llr li olt it 't r liv t t t 't t I oI r r ; 1ir('l'll'lr "t r r ' r' ri 1); sD fl stca qi cohl: . , i90L) . It, (1uu: aleii }ot f i illt , ilnit e qi lil t t t tIt rt I I t r' 1II it t I lt ir I : r t r ', t t t l. t t l"r r t t l ,,, ,rri l rti sci :r t ic, cu oar act cl'cle ilr nilt il o iinl( 'liol . 11.\,),{te t ile t l'bet ice$ r ocur t osc I clill, iv llf or , lt Lilt t I t t t t I r |. I t t . I ' '; r t r ' i i r, r i r) A l :rr . in saive ile dLr r cr i llf [ lt er lt t lt Lt ll sllllt i't r ( r r t t r lt t r ', t ll t li r r 1r 'r'r I I t I' I l I I )I (' I I' it t lct io: t t ; r rl|r r ' 'r ' r rrrl f), cu il] t ej. ] 'ale liber e I 'ar iahile i l) ) I r ll " l t '1 rrl i rrr;i 'pc tiniec|: 1c scir it icut ui; c) At r t ] r t , t I t . i: I r I ttt | 1. t t I t Ir I' r 'i I I I I I r t I r t t |, r, 'r r,, r,l rrtl Gci t cleclan, sat o de sl, im uli pf ol) lio( jol, l'ivi ( t lir l t , r it lo r r r lt it r t lt r r t t l. , l , ,rrol ogi e c, ccuRce r t neoli pollic i[ dll( xr lt t t r t r r r r t r ') r l) A; r : t t r r l ll t r r lr r l'r ' ; ', rr ,rl , r,rl ttl i v, cit gi iu t : r . bcst f , , f ixr L1r " t l) St l lr socir r 'zii, t t : r llc l. r 't t t t t r 'lr r l"' I i ,, r.; l ) S e ]i ol asocia $i Cu ll, I t c cr iz{) it lgll( ] Llt lt t r lit 't r( r' i ;iI 't' I I ' I rr, r t r I I t r I : r r 'I r r
, rl r Iti ').

B.

PROBLEME DIAGNOSTIC TULI}URANIUI DE iN TftOFICEDE ORIGINE NBRVOASA

8.1. TULBURARI TROFICE ALE PIELII, ALN FANERELOR MOI $I ALE TESU?UBII-/OR l. Pielpausruld,sol2oaso, slriardprin fisuri, r.calizind uneori aspcctul .,(tecrap" sau 1{e gopirld" poate fi intihite in sirixgomielio l)rr.t', gl :tr' ln slI|(| l'oilmete

strtnqomteltce. '?. Pielea_rece, nAkdd,.sub!.ia-ld, uneori pitald,, lividd, cle aspect I,amolil, rr. prrrrlcobservl i n,poliomielite, mielite;i altc atecfiuni medulare, daL rI|rr.or't rn ncl]lrpl0grlje sr vasculrre {Arseni,i .8o1ez. 19Zl). ''1.I'rr.zcnla tle Jlirtens, de eruplii butoase1i d,6 aspcite sclerodermioo I In,rLl,c t -r'cvelatoare pentru siringomielie $i alte atectiuni medulare. .l\'lot'maled,^,:I precum ;i eJilarca degetelor Irfl!]ilit.otpd.unghiilor, ss . ,4. rrlrlrr'.jc lrccvcnf iu rlivr.rsclc alec{,iuni ale nervilor'pei.itelici,piecurn gl Irr ${ilu'ozrr pltici. in 5.^,lIipcrtroJia. i,inilor,. mergind pini, la aspectul d.e ckeirotnegati,o .n rl\ ^ l lll{.:rllo ln SlTrngOmteltel,ll l;. ltcq me lple reci, cianozalese intihese in compresiun med ularo. iie rl:rr' ,.i irr hcrrriplcgiile vasculare, in'polinevritr,, pol ir:adiculonevrit gi iri c ull,rr nouropatii. 7. Arpootul do membru rogu, dureros, se intllne$ts in sindromul eriIlorrroliulgio, d ogetul alb, ischemic este u$ol de recunoscut in faza agai:r,r zilri ,,Hiltooplltrlocal[t, din sindromul Raynaud. '\'. 'l'rofalemul crozio (sinouime: boala lui Meige i distrotia edcmaloau:'lI rrrirrrltrrurrl. localVat; edemul ,,reumatismal,- cionic al lui Desrnos .rlrnr'l H.gr'cntar aI lui Debove; pseudo-elefantiaza neuro_artritici, a luiI l\,lrrl,hirrrr lr{)rrlu, luiMilroy) repre,.lintg,o v&rietate de e.demcrorlie aib, Aur, I rr{lr)l(,r',-ou lclxurtilio segmentari, avind _cel mai adesea_ sediul la ineml l, i {,to rl lct ior,l o, uni- sau bilateral. Nu are * se pare _ nici o specificitato, Ilrrr,t,ulli congcnital, ererlitar gi 16afl.jal1 dar ddmulto ori inso^,teqte bolilo r\rorlo-{logonot&tivo,unelo boli do colagen, apd,rind chiar in rcuinatismnl clorrio crr poliartrit5. 0; lldcmul obrajilor, al gitrrlrri. al spnt(.lui ,"i al iolol .rozat ,fclcir..ul , ,r'HI|.rr. ^aI il, |lInl(rr.lillii{rLiL lrnoori fi rlo pigrn.rrl.rr{.ii tlc l()lr git,ctlzii) tri ho Irl.ilr(,!1.(, pDik x k,r'rnlll irr iL Drnir rziLll(lrirlrlt lui I'olrgorr-,1:r rrolri.1,24t

itt v 10. Ihhnl rh dirr:rtttt lipu,ri 1i h)pollt' lol' Ii itri'ilrrilrr 1olirtr, ril,r,, Jii liotl ilt lt'lrtilc, 1,r'lrlrr,rliouLrrrrvt polinotttrtpttlii,colagotroztr, tlttccl tttiolttl'rtl tl}irlotlritl" ltl lrti l)r'pt6 (irusir,-zirstrl neurrt-cdelrtal,us l,'rr.r,r'ite ,,sindlorn \l,rrrrr), unolo cornpresiunimielo-radicukr'rein silingontiolitr, itr Itritttilrlc in , (,,1ritrrr' I' rrI,, rIrrrliverseorigini (Arseni si Botcz, 1971), in sintllrttrtttI l trtt it'l,ir'l ,! |r'oriLl,or,siitt sindromnl parieta,l) $.a. din mai rnult slu rnai pitl,itr pigtttctrlllrr, rlrr IL Ar:len aarnek cuta'no,tet (de la un bob de linte pinii la o circlg:i), rril,ttitlo itt tttorl 'rrrrliririclifeli.itl r{illl, r.tr,rt'irr jlilul gurii $i al na$ului (dar gi in alte zono 1;ogrlrtl('lllrrr{r) in peni]u sclcroza tuberoasi' a lui BournoYillo, ',r',,fi[toare se l2- N tutfiibrctnato!(r lui Becltlinghausen, po&to t'trcttltttrtrslrr ltt'itt de tLunori multiplu pedicula,tecle tip ,,rnollLtsr.lultttltrrtrI tt I tt tt t ' ' ; tr 1,r,.zr.rrlu, grt'llrltto), rrepediculate), consistenli moale, pigmcntate (brttttc srt,tt de lrrrrrr I , r!, {rolmai arlesei) pete ligmentare br'[nc- oirlol ii 1i ott I'tttttori coexist5, cu rr lollni de qiraguri de mi,td,nii rotuujite sau fuziformtr, tlispusrtlrtr I'trt,irrrr 1,,1,. lroryilor leriferici. pktn hernifacial, adesca voltttnittos, sil'rrrti,ilr 13. Ang ialnul cutrd,urt liinr :lltgirttttrt'ltrzrt, ,l,r|rrrLiultrigernenului, este revelator qi nc obligir,sli oil,u i.r.l ,,rr 1rlo-trige.rninali, a iui Sturge-Weber-Krabbo. (tle itrrlivrrllo pi'gmenta,te culoareacafolci olt Lr4rl,o) 14. Preaen,ta ytete de . 1L;rps11ls, ilsolite tle novi pigmentari $i pilofii po zonolttttt'rtctt rrlttlrt 'rrrr r,rrrr:rl), un copil sau la un adolescent,ne cvocii o rncli[tl(tziillotlr(t olll!rLl ttrrttrttrr rrrr rnir,i lri, ales tlaci ln contextul clinic existl ;i crize olilopl,ico6i/srt,tl ,lu l)n)cesexparsir intracranian, la tll tti. f um{'facliilecutanqte noLlulare nivolttl trtornlrtrtlor, l,ttr:rrtrltli ,r ,rl :rlrdonelulii, insolite de crcqtereain volutn ir, $irlilot' siltt tttrrtrrrltr Lu,i I)trouttt, r rl ir.o pentlu adipoza durero&sd,din sind,ronzu,l ' I'lrrl'irrtl' tu 16. Pana,riliu,l ana,lgezi,a, earactorizat pt'ittr-o l,trllrttlrt,ttt llll'i r r|lu|ilol unuia sau mai multor degete (merginrl pinii lrl N,lIll)lll'll'r{n[ ' rrrr,il:rhngo)r in absenla durerilor spontane sau pl'ovo(ill,ortlrt't'tltt rltrtroltt tr r"rr rlo tulburii,ri de sensibilitate tle tip siringotniolio, ovcttlrtttt'l tttttli ,rrilr'{)mamiotlofie de tip Aran-I)uchenne qi:r, uuol sctttltopinltltitlttlrr, ltrr I rrrr,' si'r orientezespre diagnosticul de siringorniclio stl,t tlo nitttltttttt HilittI ne l.,rrrriclictle alti naturl, tltt l7- Panari,!iul anulgt:zic, insolit de faoics.ltxtttin, lulbtrt'flli pigttrr,tt nLtlnilifornri,tl trotv ilttt',t lo tt,ltttn I rrrrr,rlc leproame cutanate, ile hiper"trofilr, l,rrri,,1.oo"ot, " (eu protlominanli, tormoillalgczicii, ittifirtl, n4roigkrbrt,hl'), pituitare, no orionl,oil,zilnpro (l it,l{ttu$l,i(!u I '1" ,rr{}ficxie, do loziunea mucoasei ,l,r hpril, obliginalu-ne sA,ci,ut5,m bacilul lui l{ansou ln tttttounul trt,ztt,lryi r,Lr pnlcbic5,m reaolia lui Midsutla, 18, Ulcarwl perforant (mal perforant) ylunl'ur attt tlttbrri, innirlior ryi Htl(nos[v' rrrrlo!rr'. Inilial aparo o zon6 tle hiporkeratozl, apoi so dozvrtli,il,t tlo rotunjitti sau oYalrrtr cu tondilr{,i1, Ildittclrot l lirl,cni {i apoi o ulceratrio ',,rr rrrrr,r'gini ploeminentg, cu fundul acopolit tlo 'o sorozitrto giiJltttitttltltt rrrr,rrrrrr irroloni;ri. Ulooralia gi togrrmoltelo din jur sint indoloro, Siu[ $l[ul!' in irr crllo ulcoraii&, clozvolCindu-so profunzimo, atingo orliiottlnl,llltl [,ri pulfrtt'rltrl, r1irrrrrl. Ilvolufia, osbotorpidtr, cu oioD1;tizflti otomoro. Ulor:r'Lrl fio fio rr.rrr',r obicoi ln Labos,so locolizoDzfl, t.litlonnoan, [a,nivoluI rlrtlott' rl$ lrr(,rrrr rrrrrtirl;ilr$otir,ltngionot lllltrooltri, fio lrlnisolul tlrtpttltti <xtlttltlrt tll qisolloitlo itsoci:!titt (livor$o:!Tl;l'ol)tllii l,tlhttl,lcrr, r.rrroilc,r rnol'lr,ht,r'sitn ltt'tr' r![o ,rrrrr 11i lozirrtri rt,lt'DIi0u rtrtbrrrttil,ioo [r!lrtn{(!lol',MlIi pol[l,o tt,pgl'otr, ort 1i rlrrltt'[ rlrt tlo rrulicol,otttiilo irt Irr rrrrirrgorrriolio,uitult'untru.lo rtort,tlrl, crt,l, 1rt'lttttr.

t4'l

|'rt.t:rrI r i. ir r i r r r . r ' r r l r' , i rr rl i l rl x rl , i rr I.;r' i ' i , rl D tr.r' rrrr l i i l r rrtl ,i )I)i ILi i I(| r{.r' . Itrl l rl i r llr f r lil s itl l rl trrttl Il l ,ri ti l i l tl 1 l l 1 i ' l ,l tgv.otri trrl sl l t I I (,I i I rI I i I i II I ( rl ro r' : r ( li( ,lr l lr r i llru t' rr,rr-l l l rr.L i t)ro i rri l x rr.{ , (i rri )xrl i ;, .l !} ?4), ) ({ ;i I!t . liJ ( ! ' t . . t .pr t.l o n rn t,.u ,l ,l 1 l ti , trl rti i ,ttl rt xi tl nru.t,i l a,i ul tti,ti t,l t,,r, ! 1, c /,i )r' r. r l, . D' li r,i l r' .,{ p l [l rt' .l ri c r,i rrr 1 r rl ,r,s, rr si i ' S i ri ng' tl ti .Il r] ' llt ll, Irttl l rtr . :'(). ll inft sttctt.lttLii u ltti J[a ncsat, so irrtiltrcst]e in siringorri ir,lirr rr rr' ( irr]l(11{'r'iz(lirzli' p|itt1r| urL tltlrrn irl rttiirrii ;i ll rlcgeiclor, 0ir10 apinl r]rr l l . l r:, I r i. l. r r I iir r r Lr k r,l ri c .i u r)l u t' r c l rn rh tc i .l i l i . U ' ci ri i nsi , pi el ea' p.rt. li rr rr:rl : r . r u$) ilf r ii i s (,l l i u rro i l s i . U n g h i i l u ti u t rrtrufi cu qi ri ^eform:l fu, i ,rl _f rl .r'.l .l rr 1r r il,I i r l. li,' rrrrL 1 ,o i p ri i L o s tc o :u tl o l Jrti i l c coc\' j 5tcnte al e i ' Irrr" s r';,.Lrr', si pfiu resot bliilc schelctice, prin frectlrrilc sl,,)' 1r'ir.st,.,liz.kr l :rrrr.,1r . ir r r iI . , . r ' : LI i r| ,, (,rrc i i p ri n p a n i ri l i i l e l ,n g;z]ce i rsoci rLtc.,l Irrirrrr. :rl ', ttri t llr ' , 1, ' , . lr ir ' i IL tl s { l c ttl (.r,1 " :; t. llitur, irt,ttttk:it l, l,tti Lhetltitte (tlin sinrlromul tl,lamic al lui l_rii,jri Iirro lirrrrsrt.) so cilt itci:cr.izclztrr intt.un aspect ciiinotic al trriinii, cLr .pf irirr_ I.:r .rrIrIirr,Iii,;ri lcce, cn unghiile recur.bate, fisulatc si sfil,rinicio:lsc] lrr , rrtrr r. rrriocirtzir, [ulinosCUte]e pozilii denir.elate aIe rlcgettlor, car,! lti ii l, :rrrrrrrr lc r lo r lis c iir i ttt:L o z i c e rl o l l e x i e , e x te n si c gi abrl uci i c. r'1. l,)sortt cle si lrtutili:eazti i:r, livelul legiunilor in care ccmprcsirr f{ r, {r'1Ul,rrliLr}l'(siirllpLicit, ischcrlril; cs1,eurrli pronunt].r,tir,, arlicii Li niv0 lrl r,rr.r'rrlui,,.1 zri'cltr.clrloinct.Lrc ln fialfefclor itrtcr..e lle c,.r.Lpselor. lrrzir ,l..rl.lrrrl, r.sr:rLr'ir, r'nccfrcia nivelul piclii, care intl-o zonri lirnitatir, capitir, , , rlr,r|r. r'rrsi,.,rlrrlri r,t|r: li1lnlo nesroza tisularii, sub forma unci lLlcet. rr,.rIrI, r ' I i' r , i||r Illr ) $e s i I p i c l c r" , l c s u tu l c e ]u l at sul ]cutanat D i mu$cl ti i , ;rrrlirrrl rr.jrrrrqrpitrii irl, os. I)c rnulte oli se supi,a,infecteazl. Aceste eior,rr, r| ,.rIcr,r I I r iL r c iul. ilt rc s c i n : a )_ p a r.a p l e g i i d e cl i -r' erscnaturi si ol .i gi rri ; l ,r rl rr, r : , f t z ir r r , i r r r..rl rrl .r.c ; r L " n ri p l c g i i d ) pol i ncv.i tc, pol i r.uri i cul ,i rr,. c ; ( t t \ , . r ' s t , l, , ,l l ,rn It,,Irl i i \r'rr'.;., ) ; l ) l ,r, b o l n l v i i comrto{i ; g) Id, bul rr\ i l 1 ',1 , r'.r1 i., . r . r iir , ; . . ,' .. i rrrri ,rl r,rp c ,l i c .n .ru rr.u ntr.rti zrri ,' supi i } i uoci :urrl j i I rI r'r| ! | | |/ , . r i , , r r ' . r . , , 1 rrrrro Ii I ,,.,rr.l rL .tl cl , h C m iC Or!U l C oul L,A l a[crrl(Jrr,,rri )0 :t l l o l l z . ' l1) i I

l) it t lr t t r r r r lr lt r '. r l't " i l ,,r' ,.;i i i rl ,trrt I r it zr r l0 olr iot r i it t t lxt lI t llo lir r r ilr r lr '1 lr 1 r 'r 'r : r r r l r ': r lilcl( liz; ll{ plit l i I | | I ' ' II I :I I |1r' l' t t t lr lr ilt i I 'ir {iir , , t,rrt,,i ,l ,, t iu silll t . slr . r 'lii : 'lt l t i't r . i ,;,1.;r;.J;;' ; ; or . t io l- r iPt r lr r r lic. , 'il 'i ir r t r 'lir '' : t t lt ''r 'r r i'l{. t t lt r r " lllr l. ilr ll lr r ( lr ' I r r 'l Ccl'm li CSt " l r r-\' | J.C i t f i "iii, . tnt Ct i\ '( 'r r t r l . 1, ", t 'l , , , " ,.i ' u' l n pr o"i, f """ain. t ) , t lugcnic,su p. r l, '( 'ir r 'r 11. . ir r r l) ''r 'i 'simi.' tici rrr1|IrrI tIi' i t t I I't t rr.t I tI' ,ir',.,1,ir"1""""drif"r'"ng"t"tit i ,tliri ztrr..''. I r1; r.rlc si leziunile tiolice osteo-articulare' irl rrrrl r :rl' r I tr)e multe od afiropatia loatc constitui semnr.l -itrii'irrl Sr r l) : r r '' r l : r 'l" ' I al ; .,rrri oE ia". lndeose- bi t abr - ului 5i r l siling, r r nir 'li"i. r ': r ' r r r "r ' i ,, i ;tl t" u ?tiilnar i"i poat n r \ cr t o t l( oqcbit i vll( r r r r 'r 't lir ': r r "r '1 membrului slrl.r't)t'l),itl(: lr r\ \, . ,f ,]"-i-oi.trorr"iic locilizat,1 Ia nivclul r "' in vr ct nr : cc 1r Lr upat iil'r . r r t ' t t r lr 't r lt t t r r r l' r , ; ;;* ;i ;' u ili"g"- i"ii"' r lr t ' t t ncot i si p' t r 1r 't tt r t r r r '"1''r r '' ' inoit set i pcut r u lt bos, ,' , , :i ' c[,. ,l"i r l r:1i;i ;;l ;;" lr r ''lr ," . l ti osnoslict , l v[ , 1, ia: {t ) I n ?"r i'ad'' l( dr t r lsit r l r llr t i . r ' r t t r opr t iJ Sc ( lr "{cr '|r 'f ir .{ r r r x: r / r , r r r , r r r , r .. ' .I i i e tu; idioS, Silut ( ie in car e llt '{: t llr r r r r : lt ll r ': r ' I 'r r r r : 'r ' l .r .. -l l ont aneslu a llnoi dislociiiilr liculllc' t.r" .foll :rt l i('rrli .tt) ttrvtrl'-t" 't,' un sau-oiil'e 'l' . J'i*"i"ti;;;;i;"; pscuilo- I I "gt n. , noslI llllr lr llir \ r {'l' ir lr lr 'r rI r r r 'r r rr 'r '. ' r' ,, cousllt i: lspccllll (lilirlrr(t! rlt llrt' rrrr cchiilotici') qi-prczenita dtr vettti ,,,1,,,,n, r'osie. tatlese'4, ' ft:l i cril. il tr o colcclit ] s( '|r t ) lr ( r r r lr r 'r r 'r t : r l est e caldil si desf insi dc , . tt' ,, ' m bdcr at ii' r ') it r 1"t i"t '1" r 't r r li"r ' : "r r t t ' l" ' ,::;' ;;- 'l- '"im nor , 'r r t i =r ' t i s( 'ir r lr r " i'r 'r r r r r r 'r r r ( r ' : ,, i i a. . f . "Lr er r ?i t 'ini l: r dispar iI i' ' cr lct r t t t l r r r ir r ': lr r ' ,L,t,,t' ;r" l i A " li upo. " o ir ipcr t lof ie : r 'pir 'lilt r l r r r r 'i' : r : r r 'li' t t l: t {i|t r' cr lcm 'nlr '( 'r l ll) r 'r l' l' r ll " l" ir l" lllr r r r ' ' ,r r ' .r,l oso: So. S'pr ll- 'cr zii r l. ' ir t t t lr I r 'i t r r r l"l"t ' r ilm in ir lf i'L r l|sl t t l ,i , :.' 1:. rj , , t iiLit t eiii'inilc; ir it o r 'r r t zr r lr i : ir r l. lr r |" ciit tr| ,. ttct t Li: c, . t ea, e Yar i: r hilir ilr {u'r ''li' r l' lr r r 'r lr .f' : r llr 'l r lt r t lr r r : r lor r 'r 'lr ''r r ll ,,ri i .l ezi ruii sist er nulni nen'os i) N obict i sr ir l tIII I t II II ) ; :t l i *f t iiiui, git uhr i, nuilii ; i t r m iit r Llni ( l'r t r r |t r t lr t t . t l I ' ' i ,.,;;,' " i " ( l r t 'r l r r r l'.t r l ir r li r r . t ) , ,, . i ri nf"i' f lZior ut r il ; i r le colpsci "1" llir r g iI 'I cr ' I I i. 'r r 'r r r lr r r r l : r r l'r 'r r "r ' sit it qoulplir " ' . -l rt: ou, r t lit t 'lit ' r r t r ir r r t .r r 'i ', r I . l r i . l . .,:i ;;.. i, '""1: ; il'; ; . d, . i, ; "i, . r 'l. i: ir r li( . 1t , r r i. ; , lr t lr t i :r r r riL1lui, ' t t t lr r t t :." i ,,l i , ovut iiled, Lt t t alt csilt cr cscr zilot ll) lt 'r lil( '( |ilI r llir r r lr r liilr 'r t t t lr r lx {t r " lt 1'tt , r r t i' t r lat h gem r t r chiulr ii ( , , r t t r i|r 'lt '. q|t t t t t t t . l, r i I ,i ;;i 1") . r l r ir i ) , picior : ului ( , , pii: it , r r Llr . r r lr ir . " r r . lI r r r {'I r I r r . r 'r , 1 ; ,..1 . ]rt-;ii; lil, r ! ia o'" 1 l ll r ;rrl l i . ' l l l rr : r ( ( ir 'il't r l - i ( : I I I I '' ||' I 'I I I I ' rr, ,r,;ri l c in c. t r r lezlunct ' 111; rr . . ir .t ': r 'r 'l' ' r r lr "r 'lr r 'r ' 1i t r lcr liu- lur iir t r r ': r ir '111i1 , . i ful , ii" ] i: r r ir ( r r . , L , : , r r ; , L, j ,],;;l ' i; ; il*neo- cuboir lir , r r i ; i) r ur lir . |I Lr li, iir 'i. . , l: r r ( lr ' il I n li' ( r , 'if c f i''r l1! r "llizr ' 2 r I ll lllil\ llr r r r lr r ,, r,ri l l ;r-r: r i, ilr , t also- r net it Llr r r ( rl }l{' r' r rl r\ l l l r rl l( ( r l r' r rr', r' ,,,.,.,.rl i i I a, nir . elul halucclr r i; i s, 'r t r . olnsi, {l{ . , ji'lr lilt ir li ( 'sl( lill ] ( r 'r 'll) lr r lilr li r r 'r lr r l r r '' 1l | rl l rl i rl l l iar ) ; h) ar ir opilt ilr ' ( r ) \ r , t,1, I'ililltrofirl cl r,ololllto, ci rltr t'ip lr'i'trrliitr)' j .:t ttl rr nlll t Ll slllloliol, it lli'lt t Pr i i l (r i 'rt l t rrl ' i t rtl sillt ' l( r lr li{ lir l i" llr l'i ir 'LI r' , l , rrl c ( lcg( r t ( 11) r . lr l r l r r r ! lllr ' r l t i ,,it il, l, t t it lt r it t t lr , t lI 't r 1 : lll) t r illll l) r ) lli'lrl) l! ) t lll 'r ' il( l( 'r 1{'r l r lir r r t l lt t t l'i't ' t l, :rrLt, trl r{i i it r r r , r r , l, r 1i , , lt r t r ' t 0r t lizit t t l l'r lr |r lt t l lt t t lir t 't lt r r lt \1. j r' , ' l ri rr r ' ( "r l: r r , i r l, {ir r r l' r l - i t ir r ilr "r t ' llt ll) ' lt "J i . l l i r : ilr l. t |it t t I r t |ii lr r r r r lr r lir lr r ll ; r r it illr lir r '1 r r l lt r ll't lir il"t "'
iit 'tl l r tlr' "t i trtti ttr 11s 1tl rt4t' t

I:T.,. TULBURARI TR(T.IOE OST}'OABTICULABE

1, 1.,'nr,cl,ut.il,c spontaneindolora srttyit fie insidios si fd,rri o ctuzii irlr.r. r',rrlri, Iirr rlrrpr'i,.urr tr':urrnrliism rninim. Indolcnla aoestorfriacturi gcncrlr,, . r utr'|' nnlsuinla ; a,)iliind igncratc de bolnav qi rlo medic, cintl anilr,,r, rzrr, I,rrllrull,ro rr funolriolta,Li moderatd,, riscd,sii nu fie ti'atate. b) Anl;r,o n, rzr, l'rrr!o (,ltl)ul.iri osoiirtc, deforrnS,ri cu scheletice,dezxyi.ri, incrlr.h'i,r,r ,,jr',ri", IIirrL)riiiIi, i'ounlro (lc pgcudo:utroze$i do cr,lLlsuli viciol.tsr, Irr{!_ , rrrrrr,r rurrrrlrrr'sitrrri ti.qulirrc ncrvoaso (inclnsiv mc(lulare !i/sr1ulri.lllrftr, si
I ir, t r1 :tzll lr':r0 lut . ili[ Vor t ebr illc ) .

r . r . lr rf li, r ' t r r i s l x ,rrtn u i n rl o l o ro tre L ru i esl :inc sugcreze: a) l fi l l rcsrrl l , , ,.\, l') l l rrrr r ' " ' r r r ir ' lir . f r r ,c r;rs 1 ,rirrl t,i rn i l Il fe c f,i rrrri ,, l Ll tru,i l o vurl ;cbl rl l tr sl rri , ffi :.,l | rr.'r rr r r r r ir r lr r r lo r l r.l o Irn i l ,r' i l o o l o ru ;rc i(i rrrl ro sLrbirl 0 oi i i rscol i r' rzl t, r c 1r| i r.ri s. I ('rrl l J ll. ir liiL, rtro 0 r' i rl l rl $ n rM )i l i i i l l r)t)rl )rrrl, rI s0t i o rl l f t4)ttrl ttr i ' \ r lt ' o l,rttttu l t r , r . ' ir ) llr r l )u l rL l l i,l r! r' r' rl rrrrc l i rri rr, l i rrl , l rl ri rrIrr l ol rl r.,rurrr rrrrl o :I,III

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n't'ltrrltillirtl'ilrio' Ma'it'lt s{)pr'('(lllt1(r lric", compiu:ubil cu col nl.tlbosului' gcn[ncl]lulul' t,rr'iiruir,$i ccu 11,

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ate nerlbr.or,xt,lrnsiviafalangelorrametatarsienilor'apoi'si'LtN'r$ttllli'oll(lt'(ritl' t,, tiu , a unor importante detormaJ'ii'
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pt t 'zlr t r ( r ' r 'r r r l ( li) : ! r i ' ,." t,ti ,,i ,i ,ti, *', r llr t t lzlt lt ii. iir sit ulr lilt r t "lr l t lt ilt st t lt t ir r t " , Lrrrr rrri l lrt i tt it t ir ioI t r I I iiI t I I lot lt t ) ! i( '1) {) ' ir r r t t r i. 'lt "lr r l' Z. V .ri l i t r lt r cr r , r . l1'xc1r r . . slr iit lct t llit t . lisr ': ll. lllllllt r it r ||I t sllt t llt t t ll; rI i I i t i rL t It 1tI it r I t r t t ioiI oI iiI c t || I I 11I j'i ,r, ti cttttrl ttgicc, r llolilt l ir 1,r,s1l tl c ni ttllii. r '1'or r r c l l) lll'. (l ntrrr lul t lit - or sr : lt t lsr : r r silr ililili, cr t r c lliil 1i r t lilt r r f ir r t r t r ' l" r lr ll' t t lr ( '{ ' lr r 'r r r r r iot l r(' l i i l l curogcn( : ( r adicr t llr c, 1xr lir t lr . t 'il ', poliir t t lit 't t Lr t t |t l rrr ctc,), c r Lr $. C kutrr t l, cxist cnlei posibilo t t ' t lr t r cr ilot , t ': t t t r pol li lt lcz. 't t lr r l'r 'itt t t t i t l r :rrrr rrrl r rl L -.1i, l ' tnirtzil'o;i lrrli tlts, in rrrrclc amiotlo{ii n"t,.og"itc r,, nenroloEice, rrrrrr" 10. n8tar ca t livcr selor at it lt t lilt i pa t t ict r lit t 't ', t t r t clit l'or t t l l) ( 't ll! r l llctll'og'(rl(r (il s(' \ t'(l('il rlr r'')rr lr,fiil(: lilicgcner sat pcntru unt'le :rtttiotlofii i rrrrl.i i ., ' ' ' " tte). yerit icalell or . igir iii llr icgele slr U t r ilr lr gr . lr r . , r r si: r r ii . 't olr r lr r r ' . r ( l') \ l( lr i pr in ilect lot li'jgnost ic t 'i plin . lr '' it r r r r r r r t glr t lir r ,' 1 ' ' t,,gttost'l"ut u t rrrctrlt rri rt .r:' 1I. Ufcctuarea, in unele cttzul i, ll birlpsitli rmrsctlllrl,tr , rr.rrnlui histopiltologic. gt 'r illi. r ' ; i r lit lt r lr 13. ]l fe clr uar ca, unt lc est c cazul, : r unei anclr eit ' r'.r orrliotipului }rllnavului. .tr":rlttrttt' r t4. Efectuaretl t1e tletelntini'r'i biochinrir* lllo rrtrritlitlrri si rnusclrlilto (fosloct't'rtlittllirrlzrr' IIrcIi..rIi Irt i,ri,, strig;,Sl llririi)' 1 cxzilnclol lt r lif t 't t iI r r ir lr r zt i r 'lr '' ,r' ,' j j " ;;l :. t . ) , , r ll, luhzelor , a t r ansanit t r r zt r lot ,

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s.J. I'ULBUttAlil TR0IiICL. MUSCULARII. Il.il. I. l,r.irr.i,ii .c corrrlililiiscr'iol'lricir i' *uri*troiii. i. r_c.er.e.i iris ti, i r rrr r.i irrr':rrIiri'ii rr.z,losic. ,recise a .in,,i at"i oi.niii, so iir1,or, o sir,i{, {lrl -irrni"ez,i "" r r.rpii rlrr rrorlluiirr'isriinioir_.gicii, lrr ,t,rf,rl l' fll irrlirl rrr.rrL.l r.rrrrrrui rr, iirrl'.ir.rrc.;i "r"r ,,r-',ii:,,i ,r1i,,, il rirr|. Al,',',,j,.rr',r 1.01t0,1;'rrfiri.t.r,rrr:1...: r) unil.,t0r.ril,i; bri:|terai,,,rr.,r bj ,i.],

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',ll t i

tegateSi ale l.llllll l.]l,l,,l,l.l,rr,rlrir, r(,cunoir:Lc , "J|'irlrXlllrlt.:rtr...SS polfe prin crr.r,ctentl eretliiar, prin apari,:, II|,r,,II)I|:||L. rrr arlolcsccnti. prin amiotrolia rizomclicd, inso1,iU, d,r ii r-|||r.U,Irl:rlr.\r{t(..cn|npo.p|in aprrilia de sidri episorlicc conbracturi de dc clorturi pi urrnrtc de.miogtobinrrric ffanziroric(revoll,'i::.,:.1:,'j]:..,j:."1 rllrguo\t rn), prin cs?mcnul ncurologic ncg-r,tiv (in afara : |lrl,ll.olt(.i t,rr'.',.||l(.r discrelcrizouelicetl-t J0% dincrzuri,)jiprinoramenul , p'obci ischemic ii"',ii;;;;;e-p'ind de r',

rc cvidenti dupi, intreruperea toxicului, pr\)]]rrr' 'l,j.il]::':.; trrlr.,rgrosi , l,,j f r l)r'irrIn.g:utrv irl.ri!_c\umenului rt clinic neurologicqi clecele mai milt0 , 'f ,r IIl,)f l,.uti (cu exceptia polineuropatiilor etilice deja cou_ '','*' 'S i,i,;ii,,'.,1" r.icalii endogette. De piirll, amiotrofit ..4nioln[ii[c tlin tm.ele .. .ll.'1 ,.i.nto rtt.rrrr,risltrvilL. irL oursitl insuficicrLlrci renr,lecronice, ar6 o pieclominantir, pt,rr i.rrLrrlii, l,sooiazii:ldcseacu.crainpe musculare, so iar invesilgitffi" rrlr,r'ir.rlrr, *''uLi. Dilicull,lli cliagnos--tice "li#il intirnpiirnin Ooar -in'silualiiio rr rr|:rIjir.ii ulcmlce. lrolirrouropa,tiei b:,r.ata llac Ard"Ie-scttmirl-peorsol, lui poate crea .,,.l.,t .1,!,,i,!':,'Jiu,.rlin rtllguostice amiotrofiiicmiogene. frpi, eilc o amioc.u 'll r',. l)r!,',1|llr'. Do :,. I'1'r, ( ,,|l.r\' ttvrt urrui t[oficit cougenital al fosfori]rzcifruscul,rr,., car,, rrr l,' r'r.ril.{rLrilnsfo|ntjrrcJ glicogenrilui in acid lactic. Ii,eprezinta o boali,

r r lr . r r t ,. i l rr,r,{ i i , i rrIrrrl .i rr, ri l r i rrrrzi s (j i rfr,\i l ) rsl ,rr s rrrl (rrl rl i l .uzi , ,, ....'. : L,'i]::r , lt., . lr r . |ll r.tf ' '.i p .l r.r r r r |' I i l l ,.s rtl rrl rti l r,rl i p rts . I)0 r rrrtl ht ()t.i ,sol rs0(]i i tzi ,0tt t| l t , : . . : li" J ll rr, { i i r .rrrIi l )rrt,0 r' rr i { 1i , tl rl l ri r u,.i chi pl uvnu,ci r, i ]l l )1 ,,i . . r r r.rl r ,t,irrlrr . ] ,'r ,, l'.rrr.tl.t I,,l x .r' ' 1 1;1151'1'1'Sir,l, pcrsislii citovlr, st{I,'i l.,. iieflcxclo Clt0 -rnusculrre rr llr)ilrrlirolsri sirri, ctirrsclvai:cr nr]_ la,scicrihlif spou, l i rl r. i r ilu pr r ) v ( ' 0iL( ,0i , t:x i l tn c l tu l -rxistilte n ofrna,l .' rt,r' IG e s rj c f)L t,, l .e c u n o i r:te pIi n rr.l ul i r si cu cpi sor._ .,.,.,.'). . 't( '"r:,,s . ,v r .,( lr . r t rr\r,,j r1 tc ,.l ,r l { r':1 1r . : r r r l: , r . . t.ti ti ri t,,t i l i c i . p t.i n p rc d o rni nanpa,h r,i daci n.r, nbrc m.i

T
t't'ttl tl ti l c' I i l o l ', c r r p t r r l r rttr i l tl u l ti l , I) l o xi l l l l r l i 'i , l r l i tr g i tttl tttl l i r tl cs tl r r r t tttl tl tl t t t

r'-l. t:rl:tlrrl:r Su ii, ,.,i,,i,,ii;,,i,,,,,,,it,i. rrrrrrit,irrrirr.,i.ri, :r.r.:r'ri 1,,rrliz,rt. rrl. c''trlrrtil'rt,rlrrr''rr' r'\r5l:r f-r.nr.p.iip llirch"nnn ;i clt" tuttrr' lri lui fuLrurr curr.r'i, rrr'rrr:r l'li.lr,' ',,','ui:r a'i-i^r.'iro,nirl ui rr,;rrrrrler'. I'i rj:i.rY. Itr'l {'ri"l forntr Iui L\ltlloni);i cel'.o.rrl:r!i' r':rrr1 6,""s'rrdr i",,lorin,'l Guibert ;i (lrril)('r'lI |1l'i|)' ';i t,'ii""-"^ttl""ite,t'i' ii2gnosticc (Ratlt, 19?E; t tt tt Itilrrrtltoli| oi De nlulte oli' a'miotrofia plorimr J contrlstr':rz:i gxrtt['it|i {trr:riirlst' lri"l' ,,1" ;rn;';*;;;i;Lirrn':ii"tie) rr alt6r mu-'chi: r rrrrrrlrlrr':'i tttt i"ri"i,l:'d) consisrenla lnuqcrrhrr-r r''t. i;;' h';i; . ,i;;il'l;-;;;i'il.j;, a"rjrotg,rii de zonc fibroa,se;i i], urr'r' ,srurl.lri'r'r'lt'pt rr' lrr pr:ccorir". t ii r'\( 'rrlrr ' ,'r nefie,'ul idiomuscular este totdealro'l abolit I irlrttrlt'(itt r;r|r'r'r prog|osivo,irtvrtJ ost"o-a'rr'iculare i i P;il;;ilid;io.-uJii , rsiir. l rrli .r,rrl;rl| nocnlm" de Boulugne); g) iJleltrorti,rg ii,-f";; .rlr.

:',-,l",\lil"Jl' n i ;i;lt , i' ii. " " i - U , l i ' Co t r t e ui:il",llilijljl;o u . r r ;r l illi"lilllii,"'li':j; i.,liiTJ;1" n t l a s . ' ut i p i c tr,''::illiltr r l : r t " r rlt . l . t t ( t "; .g g i' i
rr.ilrrso rrrr qi 1r i,i," ?"-iirli"t" ir"torie, a c5ror<lurata lnrplitrrrlirr.sirrl,
rtti asDccl, polifazic cu componenie scultt I rldlorrlt'lrt'{lt'{trrfot'lltttltllr'lot' tr.tt

(cx transmisie autosomalL_recesivA),

la sitcnliu I irrl ttrr',.ir:rotr.yrlrtlii-bioelect|ice, '.;l].1:,I l ' :llr:.,11 paralel cu instalare:l coftracturii cluic_ ,"Lr{L(riir , ,/s' tiorvlanrl $i gglg!., 1965, citali de Radu, 197g; Sr,ior ,1rSli.lrrri, 1.0?5, r:il,Lli de Raa1d, 19?g).' .i. .l!tit'tt,,li;tr de origine eu.rlouind pot se inriini io: tltittlt'ttfia,h ipertiroid,ianiiare-o pred.lominanld, proximali, (ce1m:r,i .t .rtr .l .rir'.,, l)r\r\.r t,.rtir, ,1l rn:rlrar sc.r pulohumcrali;, sc asoci.r,zii adcsclt fas. cu , r,'ur.'l||1,.t,.rr,. Sr .m t iologjc nl ). dar cxrmenul clinic neurologio i lr r' ri.{r,r I v, lrr. ox&msnul llMG evidentiazi, semne -der.uh minore d.e tip neurog6n. t,prIn hip,ercortic-lsrru. (indeosebiilin sinch.omutti,i Cusn'i"gt .. ,..,.,), l|rirrlrtcs,.irrn3SCJlii, l,:.::.,,,r::! , r, ,r't dC obCZitate. luir t'f ii pdltnr sc , ;t ir tlr \r.vItr..\prr| op&uz;cili,_ itsetmilrd cu miop-rtia 11rogresivii r.,ltrr\,, L, femciintroi0si G0dc ani, pieclominn rhdiiIa r rr:r rr,.rllrllot. (irxloosebila rne-mbrele ilferioare) gi id asociazi,cu hipo" l,rrrrr. rrrrr.rrLrr.i-r,. I)i.lr nu existi frlscicula,lii,r,eilexele osteo_tenilinoi,so rrrl .r)rr,r'virl(!, rru sc evidenliazii,alte serin6 neurologice, iar examenul ll\l (i rrr rtllvi, rrrrxlifiq"lr.i irirportanl,e.
,\.:t.:!.':.il nioh.oli.ile miouerl,e
t , r l- {r } , rlc r .. l )l .i l l Il | 1 rri rt i ,{ .l u c ; ,:tCl ,(,t.(j l { o : :r) l ' . r lir . l( ' r ' A , ! r . l ,i t r.rr{ l o ,ti trrri l i l l (rrl ro o ri l i i nrl spotarl i ce) , ; lt) Dolirl l ,r,!. oi r ' , lr , v ir s l ,r.l o rn i r:i ;i rrv o l tri i o l rtn i , L, rl trl i l r.oxol l l bj i progtorrrl r; r,) . , \ l, r ' oii. rs i t lr rl i c i l rrl rrr,rl ,o l s i rri ;, i rr rrrti rul rnl .j ol i l tr,i ,rr (rirzu' , l[ lllr4 .Jl

iraseu DMG dcirscbit tlc-bogirl;itr lirttlrttl ;,;it#-iLtdl;liratu"t"it; rlcsittl ; care gencreazi'virfuri neidentilicabiltr i) '\spcrrl r.a"1iei lrrliirlr" tlrri : ln biopsia .muscularii' rrll'r'r'rr'{ii -iirlmite, rle tiaracteristic,in geniral, (tIrtttttItIr''lti;x t' segmentare,'ct inegaliti'ti ile tibrc'lor muscttlittt' 1,ersate, ftrscictrl,r'' Ijlrtrr t.ir'rtIr|.Irr'r' i.oiice lalr-nt.ntice), c' coelistenlii in acel:rqi rlr.ri1l(il irrrp,r'lrrrr _i ii" i ri"'r"r"i", cii intittralio grisorsl rnli mull $iru 'i.i'i-"r'i.t:i"iii p,'."o"L h'lperllazie a tesutulrri irrt'clrl'i{irrl,rlrt.t lrttrt i,r. si rrrrr'itrlrr' sirngttitt:i.;t.t'rtzittrr'h't jt-Doz:'rr't,r rr sr,r'ir,r" r,rr'rrlrrr ';,"ii";,i';ldinllaliarot'i"; impoitan a valuril,,r'rrkl,,trrz,.i ,,lr,ie.-al-irrrrd, rlili'rr,r ir o "Gierea in schinrh sci,ttt'rr. v,rl.,r'i|.,r' iiiii-lliqt";'i;iiioti"iia"og"i."rui,
ii;;i;l"r"i

pt'.ir.' l)Nll" lrrrl,rrr,l (a"" nu eJtc prtogn,_,rLronici'i ;:;;;;;";di""G&otx qi.neurogcnt l ), 1'i ;1 lrs|Krrl trt ..ttL' ii qid aite-amiotrof rnioge?Le i i;""";;16\tt a" r'r'lr rll

(in unele forme,-clt de'pilt}-r' Jorma llrtch.rtttt') I li) IIt.IrIitIItrI:r

tt) 'l il'ft n,rlparc;m) lipsesc irampt'le trrllsclllrrll'; ttt s" -"""tr"c n" stu pnrvocul''; l'i1,s' rtllc ictrttt.. ttti' spoirta rrlt'li rtrllrrrr''' ':,i.1i""rorii -riar't"t,'to"itelot foarte dvoluatc, utLtl* srt iU;;'i;;^ l'(l o)',1' lf rr$l(\rrr'rtrrl ";;;pil ; ,rieotentliloirsd si apar retraclii musculotctxlinortstr) IriIr.r|,'r,I,rz.r ;iJi"al ;;; Eilta ii'ronr" alil,udiniparlicrrl:rrtr.irr.:rrtr.r'ist.i..r.: llrtr'lr' i,,rinLl'oIfr,f o*onului'ri tali:r '.rlr' r ir'-pr"' (itr i.ttrt:t ,:'i oiili'i1f "" cu mindci' lijrrt:i, ctt rl.schirlct'':r rrrrrilirlailrr lir rrlr' ,;,i ,1;;i;"i;iopai:ic itt l:ttrsv('r's" "lrttrtl rlc H 'ttr:r' .:u'buza,le .,tlpir'''. ciL rrslrIr'1 i,,,:itifo"f,r."ia, rt lrrLrLt't:tli lrtr lr'rtrrl'rrrr\ rin t..ltnin l:tciuscal'rtl'r ,,;','';;";;;i;rlIl:; l)6j6r'ine) ,,q.4. cir' ('niottttt )' S-tr'11'io :rlil lrrirll'rrrrrrr iile E.3.2.2.2 I)istrtfiite ntiolott'ice -i,'; r..'ftntliY lrrr'rl'tltrt sc pL's'',zi ;i.iiprrl .l'. ,,,, u;;;;;l; .'itrluL "irci,t ;ili,,;',,*"ii^"f,i*i"lj,''iiistroti (srrrrb,'iLr,,lui.Sl.itr.r'l), tlirtlt'lt:r r, (J)r'irlil 'ijo!r'icL fi 1'rtl'rr'rtriulrrlriir'. rx)rrA('rrilr[ cit (congolitalrr,), ,,,i,i,ini,lii intaniilr'i, t'r.'t.zittl:i rrrrlil:i{it'lttttttt liii V'rr liul.*lrr:r'g),prtxtiirtr rr,,irrr'rrri,il,,iriile, 1i
r r r l tttzi ttti t' tl l r i tt tttt l l i l tl p l o ttt 1 i tttl r r {{'I t o i ; i o ( r ( l i sl ,i n ( 1 1 ( 'i l l t ( l i l l {) tn i o l 'r r tti l t l l ) ? fi ) l r rr r rl i r ' ( l i l r r lr l , I I'tt i tt l tti l ttr i ;tr tl l ttttt I t r i l r r p l ;, i ,o l tl tl l ttr l 'sl tr :r l i r r r ( i tr tti si ttl t r l tti t'o l 'tr l i zr j r t l ttl l r ttl r ttt' I rt r rr' I i r rI rI r I i I I I I t ' I' i t | | | i | | | | r l r n o t t t c t t t t l r tti ,,l ,,n i t, tr l tl tr tt'p ttzi tti i i ' ('l l I |1' I I I t II l iI | t r r l i r r i r ';r t i tr l t tr r l tttr tl r t :l r r o l l r r :r l ' / l i l , t r 'i I r r t t s.r r l t,r 'r ', i ,l r i .r 'l i t'l r l i r '
' .l l ' l l

, , '1.,..i,t' 1, llUr" .r r r t

l)istr:4iit, trnrsculore pyognsiac (llNt.l,1 obicci nu ct'e0il,zii rlt,

:r (I|('r'IrI|'ir(I{i.i rrrl(ilriUlri sl.irri, r.rrlizirrrl rrrr.lilr rrri'|,,rri'ii,.Asl,Itl, . rlrt,)rl Iri'{iir rurf( rlirii (,sl,clollii, si prrlrrrrgili, rlrrl irrrlolor,ii, rrcggsiLirrri | ,. r'lr,r'i\'ol nlilt rlr.rrtrlril. lcoltsiii,lnrorrrllio tlccottltir,cIiei ll pott,t,e sut,vgtti (lltl)ri o c()l]1]t,t[o1,i0. rrrtrLrii, lll. ,rt)rl.Al/r),talr,r, v oh sir[ (lo o trtitniitir,Ttronncatd, :rrlilrr rl.rr.pii (i{)lllir(i1ioiru.lusii,_: r) lic_.prinl;r.oac!iruro rncornicii'(percuf,iri rrr,l' ' l,i ;r.r'rrri rrr.rI I ,.i t(.rr)r'r.. lirnbij. srrr ll lurrgulrri r' ir $upilrrtor),iic pt,illIr ,, ;'i111111 r.l,r.lrir..r. 111. li{.rr(,rn(,rrul nriutonicpuilc fi torr.ic l]et cvidcu_ tirrl r.rr ocrrzilrrli;0itilot tlo plehonsiune. I. lirtrr.llt,Lui, Sleiu.t'rl (,niottnia atroficd, sau. clislrrf ia rni,otonicd, st ) ||a ||r|,,:|-i(r'r'lrrIiIrr.,,rr, l_,rz,l UrmiIurului conluxt Sp-miOlugif l)o : t 1 I'rt.cttlrt ,ttnl,tr,t.litlar, sub acest aspect boal& lui Sfeinert fiind lif. lill,l \rlrl,tr'.rIII,.'.tirrrrr. r|est grup CtrC re|tlizoazi, ,lirr rlrolii muSCul$TC. ,\r.rsllrr,.<,.1 t rqrogr.ir sinti faciaL 5i diitele la, membre, atilginel trmdtofitr, rr,i rrrrri;drii1cfei, rcalizind un facies inexpresiv, atoir, de aspect .rrrrr;chi.: ..llirrrulrirrlilr.'), lipsa cutclor fruntii, cu deficit;I ol6icdarilor ociilor cu .i irl lIlz,r'lr)r': r'iriir':ttoIii pleorpclor_:uperioare (cu plozir pJtpebr.nli,); , r.-( t)lrllli t 3{Ir(.Jlont (cu cvldcnta alrolic)i slernoclcidornastuidi_ ,r|'r {tl{ :r{,.) ,.rr,..r {.\'i(l{.nt:i.rll.o[ie) cu ei rniinii; ; musc]ii ,ntcb|rtulrri rrrrr., rli.iirli I,i r tLelbr{l,rT inioliolrc {mult mai taldiv}. 5i lrii l,) .1' t: ( tl Iu, ! ttt rttnenultti m,iotonio relatat anterior. t' t ) o)illi: cu Q(|t?lic(i, c\ anurnite caractere particulare: I trrrlsririsio c[r'e urrnclzli o moda]itate clomidanti,, srrb aces, aspec[ liirrrl o llrrr{irurc rlotr:nninat:ide o gen5, ploiotropr,autosomalf clominait[, r'|| |)I.rI(,I|II||tii rurrnplcti, s&u_i]pruitpe completi, ifarii sri sr,rtipeste genelaliii ..r' ,r r .,r',.\:rriir bililrlt' dc crp|r,siviilte (Crughe-y Mwienr[onoulos. li l:rr;r,i 1..'r,.,s. I:1.,7 citali rle nrrdu, tgTd); apxre Oin ce in cc 6ai dcr t.,rrr,.ii irrrl'r'rcrr, rrs.l('rtrclinice dince in ce mai graye dc-a lungul genera_ (l( 1|l1,,'r ,rll](.Jr'(l(.nLrrilc ,):rntepozitiert SAU,,anti0ipAigio, ,"rprOlreSie,, qi -de-n,adu, lir.r,, lru,l; ( 'rrugli(J' ,si lWyri:rnthopoulos, cit;!i" ,.,1icr .1966,' r:rrs); rt(.|' 1r'irz:-r olricei in arlolescen![si inainte de 30 rle ani. rle l\t':tnlo iJc tttlburd,.ri tndocrine; - alopecie precoce, ptogresivt .rl1 r rr rl, Lrrr Irrrrrlrtl: (,I)ircifier.i generaloire do catnra6ld <it, cr.isiulinicne l rp \ , r;ll s:l r rt,. 1i1rJrJeisubut * atrofie l,esticulari,, cu sci,derea activifi,_ l r.rlr r, )r,,,tr(r'r iru :rz,rosllcrntie cu scdllerea eliminlrii de 1?_cetosteroizi ,si I l:, 1(ir, i, It'r'cvcn!:rl, enol'cei, a aTorturilor iterr,ltiYe saU ft StedlitS,iii; a r rr rlrrlr,n.:r r:Llolilor oestrogonilor si a pregnantlioluiui. ' <'\ )lorl,i.Jittiri ItrtrI{}: Prezen\a tlescSlcdrilor bioelectrice musculrut.o r',rr';LIll,r'i.rl oill.oloalizeazd,,,rafa,lele,,,,,avorselot, iirrr sau,,sayele" mioto_ rr'( (lr'rrllrr rlcttlii, vozi liadu, 19?8). ". Iirnlt, l.tt,i I'hontsen clasicd replezintd, ula diltrs formele clinico rrl, rrri,lrrri.i .rilgc'iti e qi so diferenliaz5, boala lui steinerbprin urrniide l,' r, L'.I i,rirrr,.r',.:.:rrApJrili3 rnulI mri mrJ I b) Exirtcnla rue-i bipnrtloIrr l r1 1.1,1 ;1,,, r'rirl'icirrilor membrelor supcrioare qi in{crioale, a geflsnik)f II , , ' rr :r rrolr.rrlrllrli; Iieacfie miotonic[ mai marcr],tit, nivclul membrelor,, o) Ia rlrr.r'rrrrloli prrtiml intcresa intreg ansamblul muscu]aturii, cl) Absculli IrrIIrrrr;r.r'iIol lnrlrxl'ine I e) lrognostic .mai bun, felti1i1,ate,. speranli rio r rrtrr ri crrprrcil.;11c rmrncl putin alicctatc, sirnpiomltologie de obicci tkr rrlrr{iorrrui (lll,rlrr, .11)78 Caughcv qi nlyri.:r,nthopoulos, 1906, citnli tto I li rrr r, ll)?fi). Ir ,i. I' t'lltiolilil t.on,trn.il,ald (hoal,a, l.'qtt lNtl,tnbu.rl nrultii yt,crrur Lrr,i ), l rrrrI rrrrrI rrI ir rrr lrorrlir 'l'lrorrscr 1ro:r,1ctol,tr6i lrri rr fi rlilirrr,rr(irr,ll'i, rlo lrolr,lil ltti '| 'IIr|| rrrrr^tI lrtirr rrrrolo rlr,r'llolcrl lrrrlii,sirrlri irlt'slrlrrlirriorrIrrrrrrIrri ttltr nriol,ollir(i

*)'i.' (r!.*kr,r, ri,1ll1,lll],il,["i,ll.il;]11,,:i;,;;;lil''i;i,,i rri,,

|iil#{;j;4i#:"1{H"i"*:1,;irtv:{rli*i li",illii*i, itr*,#,F,"?H',:g::'*".Te;:"x"*;;t"lr'***:.i1 iilll*#*$nllt*s+:t$u""ttll{y#'i{i*ilr trapart r,',r'mer1ul al t*nr",]Tl'j.".1{'_!1['"ti,.f;"'.ltlii,il,l,, ;, ,rirrr,.rri,.r

rtrr rlupii, in deglutilie, co'sLr,r'irrgr'.t:r{:r. illlili"rixffnJ:"T,:?;,u,n",ii,ila "#

d.rr i'i'' ";;;;l*i" *4, ii l{:}lil llillJli, "n".'1L*1?.',1;?11"1?iii"TlT,li "Hf-#lXit$Jil'*ililE# ll$lL: irli,'lil"ii",i,ll$i*

#'tgdllt*"t' I T+?,l3""i'ii,gT:?Tg# l,lllitil; lllj#ii #*""qf i #t;; j*j*;,iitill, ir

.rl', aroplitudinii potenf ialelor i'i;o;"'ni"t""-ql iinioii"tt" 1972, cilati dc Ilrdrr, 1178) .ttltt irrrl s-au itleniiticat qi conl''rat i' .lf i.rii ir'tri1i 4. N eurorniatoniilla i,rei entiti,li cliliee :

lll#,*ihttn*:xl*x;'*,:xx"l"*:lig;#T'r*il'Il; llr"i.mi$*;i":,:ru1"**L*"'l*lm:i1,i[i:t; ;'l,'l,l' Tt':$tH ;ri:ii#:tT&f;***tUx,,*gt, tll'iiiliiilil''llil' iili'',1'i;l"i:llll:"1 .'"li-X"'gnl,#x,?".'ii,:,"1"i".:i:3-S"'#;;'f

.rrloalte etiopatogenn.

"'T"'lll;l';:"1' ;ll :#3Y'Hi:#i11:'i:'1y?i1t,i"'f ; ii'i ;f i;*;:'"*J,'"

*LiJo*..l8l?r)'1,? (inilamatorie i,j.n ai"cta.e ,',i:ilii;:,1;1, f.,lfli;,illllJ,illiltlll :r .rlr.';'ir'';i('ir' l,ii:ll..1;:lt-r?ffi:J136;3#;ru;;ilil;;i;;;i,r,i,rr.ii '

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('tzri' , ir r r I i' iI r r , | ,rr rrrl i rrrri rr l i l r' r' l .l rr' ,rs .rIrr,r.,rr .i ' i rr,i r.rrrrzrr ru i i l r r.i .,A r,rl rr, r Ii o iUI llUt h\ l r l rl i i Ii i rrrrrrr,o trru s (i trl l l r,(,. , \ . , 1. t 1. ?. . i.' r l i n i tri l r,l r, r.j rl i c i l rl t, c rrl trrrl ri l rrrl l o ol i rl i l i ci kr prol tl currr I tl c tlir r gt r os ic , ! ir r i rl l s rra n l r rl c l l r,I)l ttl(j i c l ( 1gl .l tl )cl ,zi l , g. l (l r, nl -L o rt,tcci i urri trttt. r ' t l: ' r i. ir l. lr lr ; l l r.' l :i ,1,, l rti rrri l i r,.. r.rr,r s r.rrri ,,l ,rgi r, (,1,i ,.,.i puti ,n,,rfl i ,,:i i lopog":riitr ot'l rrriLi trtlcsol, r'izorrrclicti, pscutlorirJopal,icti, tlc ruturri infla,,

rlr.s,.rrcr':rl iv:i nesupuihl,c, er.olugie ctL :rcutr'i, lll.]1:ll.il;1 r'11lrr(':r;i/s:tu.autoirnurili, l|'':rr.rrir {r tl. rnull.' 'irU
t,licu ilrlcrl.sirr.c:r t(,-r,rur.ilor ti]'larir[(! --iir rr ,.r ||ln rrl.:'|rjrl,.. |i rl:rr.irri l,rt si ir, lrrrochirrril,rt, nprruaso.i clrii,r.: iLltol \Irr'{11(I}||I|rirri c hb., I,Jti3, 1965' PopeSou R:i,tlu, qi 19ig; Iropor-iciu qi lolrrlr., l1)Ti]. .1.1)?5)-

I,'!iyi,',:.it'l_1,lJtiut;_tite grupul .,..1.._ _(g:rnpul.I illpti \,lralton-Ac1ams, | L,( I Ir||rI t,' ,rI('I ;I {i Ir Nlontli{lii tle Neulologie ($rFN) (\-ezi popescrl "naiu, . ' ,"i Il,7,s) Nirli trxohrsi' viLotice, ar<a.-curir crezut (priir virus Coxsn,l s_a '*rrl.i r'liir, rlirr glrrpnl.I3), de obicei fiind r,-orlba rnecanisme rle iirtoimune puse in (l{r .1rrr,.rrn|o|i di\'{,tscinfeclii Yirale-(Ohouqi colab., 19?0, citali tlc liopesoLl ri l.i.rrlu,.19?8;J)un12 colab., 1963, 1965) rlar ile mfite ;i t i.i rtc piceso lrcii rrtrr,llr,r'if ictrttr. rL) l)olin.iozilele acuf,es.i subrrctLtc pot reclnoaqtc prin debutul se lolllti\ brucr').,.u rnti,Wzti,". i"Urr.,."iai,.,,, .sc np y rpit? ]:,1.1. i:lllli r l l t t t \ . ll| r' f n l - v r r t ' j t ttsr ttt.u ' p tt t.u tL tlr u lp . lI iu,l.oi.i.k: sinlj acuzate la nivclul brale1or qi gambelor, inso!,ite do . i,tntt (rattlpr Lr.t.iltr'llil ,1i ,mt6(ulc,ra, apoi.5i de parize'interesirrifs"g;e"t"ii, l)r1,\||r,rirri.,:llr._t[rnrl)reJor, uneoli qi rnusculat0ra faringelui sia rrd,hrial r|| l),rrrUtrul, uuscnllrtur't cste.sensiltilii,la presiune ;i fermi, (indura,tl) lr l)rll) ur. I,ioilexele osteo,tendinoase sint insd, de obicei no"mri", e*J r, 1r{ir li'r'r r.lLr. rl'' pulir':rrlic "o uloneuroiliozite, ill care se constat[ si'moiiifip]e(,nrr}.sitrLlbnriri de sensibilitate dc tip pclincvritic ' |l'r {,. L.Lt1.\{,, ;r:r.r.r ryicolab.,1963,196b; popoviciu qi colab., .l)('1||rrlr{.ltoll',rtiLir'(l)rur],, l.riiif. llr;.;,).,\itrt ,,tt04,tti t.steprezenli lu i1r|orirnalir 40o1, 1,l,,tt,.rlulsqitr rrrr rirz |r (t,'. r.{(' .i ( |tie. 1974.cif rli dp pup{-sr.u Ri,lu, t9;g,, iiiriri ;i
L l 'l r ' 1, . lr llr l. r { l! . : { .i tl t{ r' . r.i o l j i c \(.l n l l o a "e. po.ki j udIl rni i ,, otl cmt .ul r_ l ttl :r t r : , 1r .ll' , ( . : r lir .rt,.rrr:ri :rl ,,sp 4 , h r1 i . p c ri o l b i trri p,,gi l , pe utnr.ri , p,,tur,:l
, '. ,t l'. t : , r I : | ( I | | I |( . m e lr llr l.F lUt,) .

l l tl tcttl lli{i t I r r r t nr . I t iIttlr r t llt l. {noll ic t r r , cTlr . r r zii, 1111,1, 11111i11r , r Hr , , r 1111 11q r r r lit ,,r, l .rl tar,r r zir lr t lr lot nir lr . r , lcr , lr r lot r r ir , kr lxr lit illior r lor cr r lor r r iozilli, : lt lr lr t ) ( lll t r t oI ot ii ir t t 1r ot I , ir r r I(rr' r r rplr , r lor r r ir r r r I r (lizor r r r , lir . r i){lt lullr uf iur . ii , ' ' Ir' | | r' II( rl , , rrrrl ' rl ilr r lr r r lr , lip [ olilir r lir uLr t r r . r 'r 'il, ir , r , r r ir r r I r or 'I . r r r r Ir r r r xliliciili r lr , r, , r,l l , .,, (rl r.u Jr ir r r .riI i t rri t rrrIri rr sr r r rI r , lr olilr . )r llr r '; i cr r t x isk'r r {, rr l( 'sct r r {'pir ; l , trrr,lrl r , rl r, l r r llr r liir i lr r r llr r r lr '1i, cr . |, r r r r , i: r r lt 'sr r ir5i r lr r I r r I I I r I lr i, rr lr r l, ilr r r r ir r r i r 'i l , r,rl rur ( | ' r)| )(| \ . i r, i rr , 5i r r ollr lr . , l97it , ll) ?ii) . iilt Irt l ttqto: r lit t r l poliut io; il. t lr n lr {\ il, , iul, . , i. t t . t t t sli. y1u!put ot liuilr , , t . t r t , l, trtl rti rr r lr rr r t r r lilolr t t r lr r r r r xlilir i, r 'i : lr ) ( lr r r llr r r r lr V. S. ll. , r r r lr , por r lr , lr 1r,,1 l rr ' ,l rl r rl r, lct r cor r ilozirr,t r llr ull) lilic; ll) O lr qlt r r r l r r it , r 'lr , lol lllr r : r ' r r . lr , si llir lr r , : 11) 78)c) [ I r xlif ici, r i ir lr , lr , slclor ', \ iil, t I ; ' t,,tttttl t' s.l , t l, it r r : : r , i( llipcscr r r \\, rl r,r' l ir r sr '( it r r , or r shir r i, rIr )r l) i\ t r xlif ict ili l\ : lut lt it t r ur l r / / rr r r / r / , , r 'u ,r, l rr' i r rrllr r 3; i r r giut lul, - glolr ulir r r ilr r , ( Wllllr r r r qi Ar lir , r r r s, i{; l! r lr r r lllir nor i ' r, rrr r l rrl rr lr . , f 1) ?: , i,t 9?5) I c) I ur poll; r L: t r i.to . li, l. irr:i. it nunu, lt r lt o. lor , lir ', , , l , l ( r' r,irl( i( l si I ( i[ I ( . t 'opoviliu qi r xr ll] r . , 197; i, l{) ?5) ; ll , lluli. lir , ut lt ' I l l 1, l rtl Ii r r . r 'r lill, olt r r r ,pulin<l sLr r plinilc r r lr r r i, lollr , lt , r . lr . t r r r , llr ' ( r lr r lr i rl rrr l r.i tr ; i Nillzbuch, 1969; ll, ar lu, . 1. 078;L, olr ovit r iu 1i colr r lr . , ll) 'r 'ii, | tr, ' r d0 r ;r r r I r r t t {ilr I u f ibr ila! ic, sur yenir r il i <xr r r r PL, li, 't r llt , r r r lfr r r r I r | l rr , 11,r' ol rr r lr il c\ pl'csio: r ,unci polineur opr it ii - , , d. yilg- l) l( . 1( t oiI polr , r r ") l rrl , l ri rl rIi r, zir rcom 1lloxc sullvnlt a, t o, O r l, l il] l] lil conI |ir t , {ill, t , oI r r r r I . I I |IIr o r | . tr\ i i i i l i t r r pet it ive ( pot cn! iale cu f r ( xjvol1, ii, r , Pi( lii : \ 0/ |j, l0 , ,l , rl r: s{, it nLr lr t r el ecat r icij, a r nuqchiului sil, u dr i lnr ) l) ilizir t r r r r . lr . clr r r m ' ,,, ,l rl rr l )rl )i i I 'opcscu qi I iadu ( 19?8) t ocm li acest c f ir r sr r r ^l, ) N'l( l , , lr r ; r r 'lr , l ' , 1,, rrr r' " ( , r I ilot ef izcnzi polim iozit ele. ,ll uli,licii,rile histopatologtce din biopsir.t, ltttsrul.rr,rir,rr(lu( ,,r'r.rlr ''1 rr, r rrl ' ri l c isiv t le polim iozit l, punif t l ln evit ion( ii ( llr r r r lr si r , {, l, r lr . ,l1}( ; ; 1, l ' rr' , l ' r,l r{r s( , u ll, adu, 1978; Popovichr si colir lt . , ll, 1iJ, lt ) 7ii) : ir r lr l 1i l , rl , rrl l rl l i L lot ii lim f o- plasr nocit ale ; i m onocit ale r r r r r scr r llr r ', . rp, . r r r : r ; L,r r ,i | !' , rir'rlctit'r'csconte :r,le tibrelor mlrsoulitre, cu lrol,iviltiti r|gi.trr'r'irl!\ r, ; | ,'{,rlr)zit festtului nocrozat; - fibrozii inlclsti {,irr lii. ' l ' ol iut io: : it cle ( t ler m ut op olin iozit ele , dt r : sr r ollr i') ( r lir r ilr ult . r I t ) ,l rl rr \\ l ,' N r . czi ?opescr si I iadu, 19?li) sir r l; nnllr , r . oir f ir i, r i pnl ; . r , 111'1. 1q f rt' rIr,,rIrrri . rr lif icult ir , f i di*gnosl, ice. Cu, : it r r , r 0,ir r I , O r r icI , llr lor r lilr r r lr r I r r r r l, r r r r l rr,l rrrr,rzi i icr , cr onioet r ebuio sil, se slu'pr in( lii hr u, lq, lr , hr : ii . . r r ) Nlr lr ur ir loz: r rrr , rl ,r' i r; lr ) I r upusul er . it em at os r liscnr inir , L c) I I t liI r , r 'I r 'I , iI r r r r r r lor r ; r r ; r I ,l r l ' ,rl .rr' lri iii loum at ici) , ; e) Sint lnlr r r . r l Sjdglcr r I l) I lr lir r r iozil, r r lr r lr r r r , u, , l )i ir gn( ) st icul se st nbilc; t c t loill t lupii, plir ( iiiulllr innt t ir lt t l. r r l, , r lll , li l 1" r1,r'trttrr' : a) hnunoeloct r olor eza ; b) . l) ivclso it lt o ilt v( , sl, igr ( ii ir r r r r r r r r lr r ,' rr , , rl l rl Lt t t inii, r ileDM ( 1 ; t l) 13iopsiiloinusot llt r o; t r ) ( 1l. r 'r r r r iI iliIrrIr , lr ir r lo , rr. rl r,,l ,rr1ir I 1i) - I nvest igaf ii ladiologioc, oncologicc r i. il. ( l, or r l, r 'r rr lr , lr r ll l rrrl r.rr r.ilii, olLr l la: I ?opcscu , li }iadu, 1{) 78, I {6hnit n, l1) ${) . ) \ '1.::.;i. I ILi,tt'oJiila n,eu,rogene \.;i.:!,,:1. ( l rr,ft.t (Ltr( s( ttt,ioLot1 glenuutt' : 1, ir:( /) l )i sl, t ilnt ( io il g{r lt ct ir l <r t t pt 'r ulort it lr , r ( ii, t lis1, r r lirlt , r ioiloI iiI r r I 'r r nr l ,r l rl rrrrtl :ri r, t lr ll, loclr lizir kr , I ir r I I i I IrI I ' r'rrIrr ( sir r r r r llico llr , r r lr gir r r t llir r r r ) . 1i i ' ,| l l tr,lr : r r r r io|, t r r f iin{llr ( }glllo r r r r ir , r r r lir r {, L lr r t r x, r , r r nir r r r r r . r .i ,/ S o ir solcsr r r lr : ir ) I I i1r oLor r ir r r r r r r cr r llr lt r r lr , i r r r lll, r : lu llt i pllit l 'i, rrrrpotl ;utl ,il,ilr r t cir f t r r lr r lt r t r llr . oli r r t t r . t , llllr r zli, ir t ; lr t ; r lr , l ( r u ljlll( lll llr ir l Itol rl i ; l r) llr lr lict t llr t ii r r r dr , llir t r ', <ur t r , ir r l r : : r lr clr . r 'illilir ir r r llr ur , lr i lx'r r lr r t t ?illl

ut

sl l,r'l sittrplonteuiscepule cardiopatie(tahica,rdie,subticui_ de , ,:t.','tt.'i:t_ \,.l.rri.r rr.rli.i.1f, blu,,rtlior-entricrlar.),. adenopatii,splenontegaiie, ulcera_

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ltl I)ol.ii i.azitele rzozice contllrerzlr in motl prl,grcsi\. 1,al.ilouri pseud0r,rr',1,.rrr,,.'. l,. t.2,('.ri r,.tr :Ir.ri,'troiiilriorimaln. pfer.x111 cU sinrprLmntlr. .1 r rlr ||rIiIs| .r| | i | ,.rr| (,totrnr, colal:..l9it; J,oporinirr nohb.. ! gtJ, I -:i lgT;), ' .ci ,,' ,, ,,. irf(lr-lirzai cpisorlic trtialgii, precum-si_Jenomene cutanate ia ;i iii ",. rll'ttrtr',4r,rlirrri,rzi1.Jr. aCrrle. io0,,ntenc tip HarnrLrtl,rrr.,ni[e"1;ir1 rl^ .,1.1,,1 Itlr' (ttllr,rrsrrlri livelul artir.uletiilor.scapul",-uiner.ale a1emiinilor.) ltr, 1i ;i ' tlrr{ r'ri{\ ||l rrI i li l[ t ilri visceralo. (rniocrirtlite, lncunonii tra,nzitorii q.i.j. (l( re{ ilxt laptul cil a.miotrofiilerizornelicesirnetiit,i'r, ,1,}-lr,.irrr1r,r'laxt rr \',1ttr',,' rlr. r-r'rr1r.tr,1n.i rl( r'ctrn,clii,creeazri cclemai multe ori t.rr., .-i (lc , ol'|r ,lr. lrIul rlirlroliilrl lJruscltltltel)rogro$ive liacio_scrapulo_hrrrnorir ltr i rii.l.,1.L'i-1,)rrlr.11(' .i rr ,rrr,r'r (ltothstoill si (trri.lson, 1f)?1,c,itrriirle I>npcs.' .,r,li ,il|1U... lllTs.i rru.:r r.olrLlr.. I9ti:'i,l!)rii: Nrrrirr, lt16l: l,,r|',rr i,,irr r;i _lJ 'i ,r,l:rlr-.l1,7il,It,7J)r.I'..1'tir. s;i litrr, rlrr,i.rl,.rrs,.lril rlr.r,l,.rrli.pr:rrit.rr Irr lr rlrrlrili rrrrrli:rgrr orlirr gr'1';il, l) I,. rlc llitl

fr,nr('loHl)illlloHul)t(1lllo crolli(xf. lllrsciorrllr,tiilo rlrrostfiit strgrrsl,ivtr tlo sirrl; fi (ll lot. noull,rrlltt rtt ;tlocls rlo tlctrot'\'l,ttrr ' ltl)srlt(,tn ntt cxclurlocllrlotLrful lr41r'rr rrriclollllic :rl nrniotrotici, nta,il,lcs cil (lo pot {i rnascatodc fcsul,urilo rrIr|)| :rI rrIii(r) irrrlcostdli cind ili rlu origin{t& In fasciculclo lnusculare profuntlo (lirrrlrr, lll?lt). 'I'rchuic sii mai;tim ci fasciculaliilc,de rcguld,, ploced amio. lloliir. c) Iltrlkrx idio-rmrsculalconservat; rI) lieflexe osteo-tendinoase col nrri irrloiJcl, dinjnuato sa,u abolite; e) Tulburili vasomotodi $i sudolrrlo rlcstrrl rlo frccventc I f) Existii, in unele cazuri semne neurologiceaso. riiri(', rjil,r'cpulmit diagnosticul topografic: tulburi,ri de reflexe qi/sau do si'rsilrilil,lto, cventual alte semne spinale. 4. INl.tatrodiagnotticul rutind, incumb5, o sedede aspectereyelatoaro : cle t) I)t:n.cn:urca completd, irexcitabilitate galvanici, qi faradici a ner.' vrrlrri I incxcitabilital,o a mu$chiului la curen_tii ile excitalie scurt;,; lenlrrr,r'ca,,si miiriren pragului contmcliilor la curentul galvanic i scidercil plrrgrrlrri rcobazic a1 muqchiului; galvanotonus muscular pa.tologicI creql0l'(rlr cron:l'xlllor,

trr" i rl i ' i ,x i lr {ii l, . r '''r {r : t it lg, . r j|r f r lr . lil sir , ir r g0t r r ir , li(,1 r , (. r sllr 1 \ Ii I I i )i | |I , l, . . , . lt , r l I' trrrA ol rllr 'lr r 'r I I lt t r r t I r r t I t ir 'I itNr t t tt t t t sit r r lt r r r r r r isr r llr l . l lor r lr , r r lll'i r 'lir ilr r r lir , : i ,r,r,r' r r' l r, - {; ) lr gr 'r r ( . t . jll, r sir r l, iI r r 1r o|I , I r r r I r r llr r r liili r i. slir r |lcr , i|r r r , . I l. .,1 ttiol.xtliilt tttit,lapulict rl, t,r,ol,r.tlir: rnlidi, 1.. ,,1ttt. rolti.tr,tli.tt, bau[u, Lui, .lI t:irrt+ id f,It:rlirt, (paliotttitlilrt. rnttt.it)tu,tl ' , rl ,t! )..n. r , : 'r t . lr . r iz. lr zi p. ir r : it , ) Jr Lsl, , hr r : r alr it li, j b) _Al, ir r g. r r , r it iir \ ir ir r r, rr' | r' rror' r r r I s', r lillr r alir r , 1 l, 0 1r ) . 1. : 0ca, lizlrriLr lt igr r llr , lo, t r r , l r r r r i : r r lr . r r r ! r , I r 'rtrtolIir0, irr grriru':ll lrt'ixln'.rir ritnt0 lil rn.|rbrtlir irrlirriorr,rrr ( i rrrI r,rrrlr, I rr 1,, !' r' ttl xrl ( ] r Tr u, alc, ; i, pclonict 'c) , ilr l la r not t r lir u'kr sI l) ct , i{r i , ( l ; ir r ; 1r , f l1, , , 1, , r,ttr,,U l i r/rr Lr r r r r Trlr llhilr , lr , l 11) ; \ r niol, l, of iit , sc llsociizij, r t,rr; pr r r |lr li, , ir ., ,: ,., i , sljr , lj'c lir r r r 'lc r r r pir Li. Lr , t r r lit .. 11'r 'r r . lizir r , r lr , rI i rrri rrr.:I 1i r r r lr r r l\L I l ' l, - llll) r '1r ) llr . loit . r l( . illpor . l: t niJ ; lr lxr lir , , , lr , t , ( . ll{. \ r . lr t , r , t , lr . r , i , rr.rl rrr.l l ,No Nu Be const at i f asciculalii, t ulLr ur r i, r , sr r nzilivc i i. c) olr ir . r . t irr , , IrrIl .,rrr' Ii liil lir n, icli( r r c ( t l: ar 1n, , ot t , 1; r ecI inir c) ,i ; i r r ici 1, r r lbr n, ii, rpr r ilr ilr r i r rr, (r' tr.l ll: t Ull, . , , r i. Si 1 pr czcnlc; i : _] t ipr . r t r . r r r r ir . . r , , . l. : r h: r : , sr . t r I . ir r l, r . r . ' rr.r ,. rj ,.| |. r 'ir lr '. ie . r ixlgji. r caci. I n( : njlr gr . r "li l: r , r ir . lr 111,, 1, 1111, , , ^r t trIr.r' Itl rI.l , i. n LCRhit lXii, ) cit ozi. apoi_ {pli. i, r si hipr r , *llr ur r r ir r ozi r r r oilr . r r r t l; ; 1'r lir.rr,.{,irr, <legcnerescenfzipc mlschii cor;spunziil,ol,i l.zirrrrii .,r,rrrrliri dc .r,1,ri or' .r: iir slr il'. r zi lr pid. ; h; pot , i 1px1, . -si |, r lt , . lr r llr r r |ir . i llr , t i{, r . r , . i ' ,l :r.l i rr:: i) I iind vor ba r lc u r f cr . qjunelir olici, , r . lr c t ) n, ilt r rr . ( 1, .r r r lt ; , ,'rr l,,j/.il*i rnai extinsc (poliocncefalomielitri) po{ sil ,,ira.i, 5i si,rIl.rrr. , | | r '(
| I| | I( | ( ) -

b) Deneruareo,incompletd,.' conservarea excitabilit;lii galvanice qi lrrlrrrlicc u,nelvilor, contracliile avind ins5, o amplitudine scflzut5 ; la nivoIrrl rrnrqchilor se remalcd o oarecare excitabilitate a unor fibre musculato lrr crrtcntul faradic, dar cu r5,spulsuri heterogene la curentul galvalic, in sctrsrrlcir,uriele fibre au o contractie 1ent5, prag mai sclzut, iar allete au la o corrl,nrc!,icdestul de vie la ul pmg mai ridicat. 5. ,Eleatromiogra araLd o sd,rS.cire ia sau o absen!5, a potenliale1or do rlrillrlo motorie, in general aceste potenliale conservindu-Si morfologin rrolrrrll'l. Iieapari.tia acestor poterlia,le reprezintS,indicalii precoce, adesor (.lrirr' l)r'(!cliliice, reinervare. de ;r) I )11t1cy1)o,ys(r cotngtleld,se caractedzeazE prin: - Existenla unci rrotivil,i,{,ispontane perrnanente a fibrei musculare, cu prezenla de potenfil,lr tlo fiblila!;ie tle scurt5, durati, de slabd, ampliturline qi de frecven!tr rlir,t' .jorr,si-r,, rrrlal,iv sl,abilii, - Absenla oricS,ruipotenlial de unitate moto; ric crr rxllziir, conl;ra,c{,iei voluntare. par,tiald, se caracteizeaz\ prin : - Prezenta in repaus )t\ I)cnart)eree, rlr. plit,rr{i:rle tle fib4lalie sau cle fasciculalie qi atlesea de potenliale ilo l ilirlr. Ir'rtoti!', - In timpul contmcllei voluntare, se inregistreazl o riiliicilrr :r,poton!,iatrelor unitate ;rrotorie, care pot prezenta uneori chiar de rrrrr1Ii I rrrI i rri cvasinormale. In cazuri extreme, un efort deosebit poate der r,lir rrllr, l,r'irsr:ul simplu (i. .l)i.opsinmusc't d,rd, ofer5, de obicei imagini histopatologice net difr:lr,rrlirrl,o l'rt,t dc amiotrofia miogend,: a) Existenla de Ieziuni in insultr, ii srrtr itr pliioi, care corespund atingerii fibrelor unei aceleiaqi unit5li motolii, i vr'ornoce fibrele unii,5,lilor motorii nelezate prezinti aspectenonnrlc I lr) ltilrrrrloiozate sint atrofiate qi inlocuite de lesut fibros sau adipos. ,\.:l.!.:1.:a.AmiotroJiile mielopatice l. (:u,ntdere sam,iologice gen,erale: 1) Amiotrofia este de obicei bilal,olrrlri, rlrrl rrl cste toldeauna simetrici,. 2) Amiotrofia debuteazi, cel rnai rrrllscl rlisl,tr,l,tll,t cxamonul electric nc irrdicii totus,i o leziunc mai tlifuzil, Jl) l,)volrr(irr, tlc os1;o obicoi progresiv ascondcntl. 4) Irasciculaliile sint do rlgrrlii lrlt,zrrrttr, dar ele cel ntai adcscll tlcpiiricrsczoncle musculart ilt,roli:rt,c.4) li,ofloxoloos1,co-1;ondino:lso abolitc (eventull rlirrrinut1o) lrr sinl; lt,trl;ctionro ln sinr'lrolrmclo tlar.,silt dc rirgttlil ;roIiorrrirrIiI,oIc 6i ,,r'ccirrtr)t, r,xrrgrrlllc'in fll,A (plin rirxlrrrnrulpirrr,lnirla,l ti) aso0il1,), Trr gr,rrllrl trrr oxixl i trrllrrrtlri sulrirrcl;iyc ulrtr olrir,cl,iyo sonlrilrililtrlr,, rlc rllrr"r,rislrrtrt,lr, ll(,0

'.). A nt,ioNroJin miel.opaticd d,in hentatomielic.. So rttnl,il,rrirr r,lrpirl, l) leziunilor cIeate prin hemolagiil,iriI.ir,rrrrrrIrIIIrr.ii li)*tri t,r,r r'()rril,riorea ; lr,) l,;'.rl:i. rlr.,,un. {lctor generator dc }ior.nir,.l,orrrirrlio (1nurirrrriIilrr; .etioiogic I r l,rr,rrrl"(, c1roFi,,T"t, sau la_chesonieri a,rxrnrirlio vlrscrrlu.ii r,lr,.)i I "q; I J t.i*ir.iL tiipcctul ateliip Alan-Duchenno Unililtot..l ga,. Iri I ,rIr.t,I i r| r lrltrrr lr' ! rr ( irzal leziunilor cervi-calecu cea mai bogal,r.i, vir,srrrrlrr,r,izrrl,ir,, r'r, l,'rrl'osl,(, r'iltii, cazul leziunilor segmeDtclor in 1,":S,; (l) $o:r,so|irizii rrrr: r,lir.i.. cu 1,rr,rr f lit,sc5,, abolirea_mpid5, i.eflexclorosico-ti,irrl r,rr,x., l,*1r.r(.rl a ii {1rr rrll)r.iiri.s()nzitivecle tip tlisociat siringornicli.,crr rlislr,zil,irr irrrrrrirrr.rir.ri, rri,Ir,rrrliLl,t-r, ln cazul unci hematoini.lii rrrrilrrl,.r.ir, $. lr,s,rriilzii, I .o) h,, rl. lozirrnii, sindromRrorvn-SCclunrrl lrr rrrrr.hr un lr:rrlcrr l.irrrrlrrlo lrr,rrrrr,l,o. ; f) rrrr,rlirr insta,lcaz[sublezionalun sindrtirr Nc lrrrrrriplogiir Hrr,rr ;lr,r,lr1llrgic, rl,rrrph'si( , h inceput.fJasc,a,poispl,stic g) $r srrlprirrrlrrroriiI'ii,iir,i rr,l,, I | | ri :,,s;ulgltlloletrtr tnccput, a!oi xantoolr)rnic, pttl,orrrir,l ta ctt lri;x,rtrllru r.rrrrr.,:r, rnoderc,t crcrsterea clcrlcntclor c.lnlirt: (u,1,il ,.ji i:i, lirrrlir.ii,zii, r,il." r rrolirrrrcltxrzil,). l',. ..lu.iutt,tlii.le-littormctajoasr olo ncuru.;ittitpidruit nIr lln,tt tttr,, t, ,t'trlt,r., rny'rlnl','nti,lilirVtin ullr uirusLtti rlitt rinL, ilrr olrilr.i,r.rrIo,.:rIi., rrr,,, rr ,rrrrr.lili.(rrr:rir'.rrilr. liP,\r'lr,n-l)uclLrrrrrr.).rrtirrs{luilrt.rrlrrIirli.,irslr,iirrrlr r,r l,r rrrrrlrl'irril; rnrrLOt flascrr ccl rrrli lrrlr.stlr, 1r)|l.,i_trrLIi;r Irgir,ii Hi, ru Irr,i,rr,;l , rrl.'rrrt1.rsr1 contrrxhrlitrli'r.],irrs, lrllr,i r.r:l ;i ptiu rr,rkrsirr, Iulr|il, prcfrrrrr1l Ir. r rrr'rIil'i.iili|rr 1ip inllilrrrir,l,or 1,.(1.11,. rrlri rfilr.s.rr rkr rlirr or'l rixislii, rrr,irrrr,r ni rlr. |r.zirrr I'rrctlillir.ir,. ro I I I " rl tttiolroliilt ntitlolurlIttr t:u.r rrol.tr!i1 [r:rtUl, l'\trtrt.tll:. d. rtt,irloptlir,ru uolttlirrlr,lrlit iIilrr,l.tr ,,1tttt'tl' ttttiolro,lii. ({ . .,\,. .r l irrilrr'tl, ll)i'l): ilrr , ,1. ,.lnt illt"li,r_rl lntliluidilt tulttilurll, r.r.r1i1rl. lrlplr\ r(f(.11q1H16 .in rl, ,ltrlrlt,rrJrrIrll ll (irr|,rrr tr,rrrit, l:rlrlrrl|ii,tirt rt, tlr, tt,r.rrIirtrr,r,lirrr,ttrrl Irrrtriliir,l.

{ il,i{ulvilo l)t.ofol'( (,ilI lu,arlul{,ii rrlr,scrrlirri g5 il (irr1,r,, ,li ,lI rlrt n,ni),o arrtio_ 1t'rtf (r:tt tlofirriI n1t;1,e1) lir, rlgbrr.l, t opog4tio' [ista lir,la inclnbrglg itt, Ar.o 1 lrrlx.r'irr:rrrr (:r,nriolrulictip Atan-Duohonuo) qi iiii,ovotuoazii, lent,_progresiv, |lr ll,lrnr\I)rally Ur.tntl,uitrciL succcsiune ]ezionalii,: rnu;chii erninen(oi Irrrrr,rrr hipotrrnir,rc. iii. (nina sirniani) ; mu;chii interusoli qi iombricali {r||ill:r.$(.lt(:li.lir' i);flcxorii drgtclor. tmina de prcdioalol.); esDensorii rlrrgr.lr.lor' (r.a,ro tlansformi, mina de predicator in r-niniiale ,,marionetX,D) I rrrrrsllrii brt{,ului (,,brrr,f,ul ineft $i btlnnt',); muqchii limbii (mai tirziri). l\lir,ilrr'fi rrrult rnai tarrliv arniotrofia atinge qi mu;chii rnembnilui inferior,, tnurs-cbii srlqrulari, murychii abdominali. Aini6troti'a se inso!e;te totdeauua rlo luscieula,i;ii ovidcnter incd, din perioada de Cebut. lroziu.ni aualoago pot cointeresa .si nucleii motot'i ai trunchiului cere. _ Irllr,l, r'o:rlizind. polioenceialita superibarii cronicd, (ct oitalmoplcgie nu, l"l,ri_ .1lrogrcsir-i.), rcspectiy polioencefalita inferioari, eronicX^(plralizia Itttllrrr,t plogrusjr .i). ii progresiud, spinald, su,bacatd. a . . .). ,IniotroJia.din ,,atruJia m,usculard 1,.r1ll:lr,Zu"rt Alajounninc', /, descrisX, Ce Stl,te Driglincscu 7i ;i $i Olteanu ( ll)l-t,";), instaleazd,destul de rapid la e,rtremitilile tiisiale ale rnembrclor so tittprlioaro, sal eventual ale membrelor inferloar:c, evoluinrl relativ rapiil r'ii l!1)gr'()siv,ducind la un sfirqit letal prin grav sindrorn bulbar terminal, il rlttlrrs_dc citeva luni pind,la u.n an. S-ar pi,rea (Drigincscu qi Olteanu, l_lrlir'j fJuhova, 1951, citatr, de DrlgLnescu ; $i Olted,nu, 1915) ci,-estl} rorba rlo o vorita,bilX poliomielitS, (ence{b,lopolioririelitX)pur5, viralil. :1. .Am,iotnJin sltinald, iu,fantild, (boala lui Werdnig, EofJ nztnn ) teprrzirrlii,,in realitate, una din cele mai fJecr'onteboli genetice'atecopilului (ittt'irltrn{,ir, 1]a 20 000 de na;teri, dup5,Kriiger dc fi-Franke, 19?4, citali rh Itrr,rlu, 1978). r,l 'l'ipuL ,racuf' malign (Radu, 19?8)prezint5 urmittoarele caractere: - I,l'rNlitl,1,u rricesivii nclegati de sox; - At.ingcrea ambelor sexe i l)ol)lri;li)rrr,[o prcrnoe (uneoii fetal, dar iri generallntre 3-6 iuni - md,xi trtrrrr I a,rr)1 -.Alioctarea musculaturii oste generalizatii, qi deosebit tlc r,rrvcrii, *-llt oarirotcr imlorl,ant al amiotrofiilor din boala lui llierdnigI Ilolltrrir,rrtr t:stc cointcresaiea, a musculatur.ii par,avertebrale,care cair,:i ./.ril./.;i {.ilrl,.r'r.:1, fa!i, a copilului in pozi{ie qeziridS,, in intr-o atitudilc iIrrr:-t'' (ll,rr,du, 1978); - Evoiulia esterapidd (3*4 ani maximum); ,,IriuItir, r\ l,i|lgrrrrril trLrrsculaturii rospiratOrii determin,i, clispnee permanenti ;i t cu;ril{,{;iorliafra,gmaticS,, p}eoum Si infeclii intercru'ente i - Aretlexia astc l,olrtli ;i gonoralizat;, ; - Eipotonia este masiv*, generalizatX, sirnetricit, (r'tt rurltloplcgie, hipcrlaxitate muscuto-ligameniar[, realizind- ,,p5,purya, rlrr rit'1ri, dozarticulatS,') Guibert qi Guibert, L974); - Iievelatoaro lx)lrl nr rla,$i! a, hipotonie sinti Si abdomenui bombat Si faciesul inexpresiv, ll lr gflr'it, tlrst:hisd, (Rariu, 1978); - Paralizia flasci, este generalizatx,, tlilttz.ii,, rilrLotriotr, rlar mai exprimatS,Ia nivelul mu$chilor gitului, ai trun" trltiultti ryiai ri'tdiicinilor; - Iiareori se constat5,fasciculalii; - Progresiv nrt ilfuc1,oa,zi:r, mu$chii limbii, masticatorii, muschii felei, ai faringelu i, $i irt,t'1,ir,nlivtnugchii distali ai membrolor I * Se adaugS, picinl cifoscoliozd,, ,ri ir vr,t'.o([uiD urroorl palaplogio in flexic; - Rcaclia de degcncresccnfii, 5i rtrlo nrrxivit; DII(i ontc alo tip naurogon (pericarional clc reguli,) ; * Nrr oxixtll, ttrlflrriiri do sursibilitato, sornno pira,midalc, trrlburh,ri psihico (t'itt'rxrt'i oligolirrrrio) (llronkol, 19?il, cit&t do lia,alu, 10?t/. (lin oil,zuriqi so rrilra,ll,orizoir,zil, lt) ll'ipu,l. clrrno l;nrirno ,,ltlttiy'nf irrclrrrlrr (iarrrstxrlp, Ili07) : -- I )rodornin&rrlitr lrr, trrolnl)l'olo (lirr,rlrr, 1.1)7t11 ltlirr !0t

rrrIl rroIr| ' rr ; I , ) r 'oI r r ( , ir r , l: r lil r r r lr , ilr r r r r il,r nlr i lr r r r gi ( ; r lr r , f i, lr r lolr slr , r r t r l) , r lir ,l ,rr rl i r' ryi ir r l . s1, . lr , . . llr f i I l) r . lr r r l r lr r Di, r , ir , r r i, lrl. I lt r r ; t, Nlr r s. r r lr r lir r r r , I rr.i rrl ri l rl c nll, i l) lt ( ilt lr f r r r , lir l, i, . l . .l ttt iolr o. lit , spir r t I d. ynr yr 'slLt i . jnwuiI d lt xr r r lot t t i, t lt t r licll ( lxt r r lt lui l l ' ,l tl l 11yll ', '11r t 7lb1't 4- ll'r lt ulr/t-' 'l) ( . 1) lllil/ . ir ir r lr r lr ilir . ii. slr r r ir r lr r lolr , l ,, rrl rr, (i 0' ) {, r lir r cir z, t r r it r , r 'ir r rur t c1r '1, slgrilir r r ilit r l ( r 'r r 1r 'lr , r r sr r r isir r . r , r . r r ir ii l r. Iri IrrIIr)| | | |r I ii, ) , slr r lI iit ul s0r loijl. 0 clr zr t r . isllot 'il, r li( r(rNt ) l) lt f ii ( , t ) lill] . , lt ] i 0 Irr i l .rrl ,rr,11o slr i lolt b. , l{) ?0 - , - r il, lii iic I il, dr r , ll}ilt ) I l, ) r 'r r lr r ( ir rlr r lr r ;i l , rrl l rl ' grrr r iir , li, r r r r 0r 'i r r r 1r t r r gi lr oliolldo r lo iil, lllr ilizir , r . r r r \ r r r i, ll, r r l'ir r , I r i |) ( . I r t I I |ir , . , i|, ' l , .r(' l .l ). r '0\ ir r r r r , lii, r lr r I ir r ir or i r r r u, st r al, iit o t r rI ilt ozil, ll c I , jl{( n. ioar o, ,l , ol ri r,r,i lt r lcr nlt lclc : llt ur , it r r l olt . ost l, {, ir r r ulr , r r r r r , r . i, r ur ; ; l i r l l r rrl c {) : \ lr ! ( , 1{r t ) ( lir r r ) it so lindcosc}r i r ot ulier xr lr : ) sili ir , llolilc l}t . ( llr ) ( , r ; l rr , i r.rrl rr{iilr r 1, inc{}t r sl, a] lt e - - l) ia, gnosl, icul r lilcr r r r ( i|l I r r {r i, lr r o I r . M . $i r i I' ur Ii rrrr p c ba, zilc- r t m er lr lui I lllG , car c it t boala,hr i Wolr lllr , r 'l lir r gr , llr lr '1. 1. \\,,11q11111'1' iL srrrirrc tlo tip rrcurogen pclic:lriclrLl,l. lrli,l .'. tllrolirt rnusau.Lard, sltitrulii sau.pulo-petnnitd (boult ltri. I)t r',itlr ttl;ttr, , r ecent sub r t u, t nel,ie br t e[ a lui Nt ut l, , ht r xt r ) $o ] ) oillr r , ( , 1 ' tt)ti t;tttl ti t nui ror rl o l rl i t r t O pogr af ia am iolr uliilur , r 'ar . o sir 1, t , ur r 1, , llr rr ir r r . r , li t r iLr , rrl ,rrl rrrrr 'r spoct iv t acio- sc: r , pular e) ir r m usr ullll, r r t it (r qi Sr I r r r I . or I iolli, r plr r r r , r r oz.olo.,.lic it,pr,r,r'|inc bolii lui \\'ohllarl-Kugclbcl,g-Wrllrirrlrrr., r.rr, r.:rlir'rrrlil o .r rrrl rl ri u, ( 1ladu, 1978) . Sii, nu se conlundo ir r st l cu hlr r r l, scr pllo lr r , r , r r r r i , t,r rr | ).l \1 [ ) . . l l . l ,' ot ut cle , , usacial, etde am iot r oJii m , iclopelic( r u er olu! it / r ir l 1( ir t r l l ' , ri ,i (l rri lr r r r '1, r 19?4) clpr inr lo selie desindr 'ot , t r r ( lir r r r iol, lr licr r r r r ioI r llr lir , r r . rrlir lr r.rr itltc sirrelroame sau conste)a,!,ii sinrll o rrlr,l,ir,tr : l . ,\i nd xt r t m el, ed, a B. L. A. I iadu ( 19?8, l{) ?l) ) , ii pr llr z: r sr r gor liihr r . rl l ol rrui oli, t 't , com ant lil ut ilizar ea t er r ncm ui r lt r , , sir r r lr , or rr lo H, 1, . , \ . , , ' r ( l ,rn ci rro i ( l dcf inef t c , , cor nplexql sim pt om at io cor r sl, il, r r il,lil lt , lt iolt . lr lil rl r,i :rl r' , Ii r,sci Lla! , ii$i sem ne pir am idalc, t lin cauzir , it r lt L( ii cilr . r r r r r r lr r r r cr vilr i 1, 1,,r' n (' rrr {)ace: r st ii sir t pt om at ologie se int ilno; t o, ir r I r o ] ir |r t r ii r r llr j r r r r r ll ,,rr trrrri pr r ( , in t ipic[ ; aceast S,vi] det at o t le cir ct r r r r slr r r r {olit , r r r r r , lt lizllt , ur t l l .r ol i P rrl fil, A r n r eclur oa, r ; t e nici un ( : it z un r nr r r r ilor ' ( , ol|||l|l ( lilt in lr ll! , 1, rl I r r,rl (| r' or di( ) iogic) '. Irr rrrlour t t r ddt ilc noaist r c da plact icit , I r ct r t r r kr gici, I or r r r t lilizr r , r 'I r , li l r, rrl r,rr rl rtr r iologicil a r . ar iant clor pr t zor r 1, al, or lc lllr . lr r ( ll) ?H, ll) ?|) , r , ll rrr,r,l i l i r,i i l ikr 5i com plct [ r ile ] r oast r o : alasidi, a S. - iI , . , 4.I ) i19r r oslicr r l r r r r r lr , Lil, , r lo .:r,) [,' o r nu, Jlencr aLizr . t ld, , l ,, l i rl i r l l r' r r ii( o1r , r 'r lor . clr act r lt tsut r iologiLi( ) : - llr iir lt i,lit lij, r , r nt r llt , r , r , r , r , r lr r l ,rrrrl i rrl (rl oci f l'i,5 uu dct clr nir r isr r r gt ^1c1, ic) . - . Alit r gr r loir , lr r r r r r r , h. ili r ; rtrrl rr' k';1' 11, , lar ct r pr ct l ot nir r an{ii r lr ) ! r lr l l\ r 'r \ ll r llr r r it nr scxr r l t r r ilsculir r . l r" trr,l i r i rl l i r r l. t r lc 20 t lc illi, I n, r . i1,ia, illc t lc l! 0 ( lo t r , lj f i r lr r ll'i,?{) r lr , r r r ii" ir Irr.rrl r| o : ir r r ir ( iv 30) {, r lin t . ir , zr r rsulvinr r ir ( r c 4( }; i {i0 ( lo ll, i' i |i( , t .' l .\ (l i ' r(,r r r '0 r r r ol, 0l t , on( I r r , lsi. r r 1,l0 obir . r , i lt r r pr ilr r , llt , r r li, , , r , r r zii r lr lir r r I ( ,rrrrrrrIr,ol ii l{l 1, il) , \ r , ilt r - l) ll( , llir r t r crr , r r ( f r l( ! lt $io I ) r ogt r t iivt i, lir lr ir r r nlt l, t , r r , t . r r r,1ror IrrIr' i rr r l ; i l}r ( lr r r llr clo jt r li'r i0ir lo, M ili r ilt ' r lollt t l, r r r iar i, t r lr t r y, lr r r Ll l rrrl , rrrl ri rr ir lor ', lr ir , c! s, lx, llr ir r l lr r r I , oliolr lt ot 'iscr r , pr t lilr i, li I \ ) i|.(I | | rr| | |' i lr i r.rrI r.I rr'; r, rr I L i ( lx, ) ( , ir r 'o ir r sl ii lilir r r lr r ir r r r r lsr r l cvolr r {ici) ( r Alixl, r lr r rlr l r r I l ' ,/rrrrl rrl ,i r lisllclii, ; i r r r lr i lr r lr lilii, t r r r r r r t lr lr i! r l cr r llir r uli, l) ( r cl, ( , f nli, llt l 1i rl rrl ur,l i ,r' or r r lr r ) izi lloir r , r r r r r , lit ziu t il\ lt lllr , l, ( \ it , zil | |I | | it(,I | |i | 1rI |,II lr t r llr r t t , r l, l i , I {i l i r rrl (i l r , r , r lr r lr 'lr r 1,'r , r r r lr ir r r r i, . ir , I ir l pr . . g|r , nivii, ,ir r r , r i. r t ulr ilr r r oli lr l lt r I r

20ll

! li lulij - I,'rwr;iotr la,(,iikr prrrzrrlir. sirr1,. 1rrl,dqlu1lI -. ,l.rrlbrLrii,L,ilo sfincfr.l'irrtrllitrl litu., iir.l'(li\'(1 rlisr.r',:i,' ;i t Duilorri, rnalignill, Ii .a.pig evolntiyii, &fcctcazil inil,iaI .u,,r)It'orn.ut, $i rrlrsiv rrrrrscula,l,uril irrorvati5,cle nucleii motori bulbopontini. Tiebui'o rni{i:rl..rlili.r't'l!i:r1,1 de polioencefalitii infcrioar:i $i, dineirlrelcs, cle o | |lt r)r'ii(to 1r.ltrleltl ? c(jlcDlut,l. udultol ncuri,tri,cii SLA (form6 lui patrihios ) pr(,do_ I tle . .t.;) I,'orntu Ttst r||Iir trr, t''x t l'ctntnin. sn caractorjzerzS, al-ingerea obiceia gr.rrpcpriu de I' i,rl rrrrI i r.[| |Ir,(. jur.rvrlc dc sciaticu] p-opliteu I nyLorn,cle scil I icrrl po.-ptiicu rrlrtr'tr, sir,u:I amhelor, de in ,insotindu-se. crampe _musculare repa-uJqi h rrr),'sfr {le all')lirea reflexului achilian, eventual si a celui rotullan. j .lt) ll'ipul uaenil de BLA .ear semlalat) apaie snb 30 de ani fi realir,,orrzii,. 1trcc,;rde,re cu amiotro{ii proxirnale pseuclomiopaticc scapulo'_humer.r1'lr.;i/,sau pclvi-lombarq sau-formc scapulo-peronieie iNclsoni5i prensky, ll|7:. (.il (i tle.Rutlu, 1978; Cioran. ICZ9). r.arc por diticultiDi diai: ",:ca r'|:ir ,r,r', 1l&nsflrte tnsa prin prezen{a [asi.iculatiilot,) lrlse,atol E-\IG,; a rro(l t (,llttol Dlopstc^sr a ovoluIlot. Q. llormu Jarnil,iald,d,eBLA lpare inlr-o proportie tle 1?o/odin totalul ,r'ir,zurikn SLA (Haberlanalt,1964), atectinclde fapt, tn paii,Iel, celulele dc t'r'r.rrrIrri, antcrior, tracturile posterioare, spino-ccrebeloasi ,si piiamidale, {tr''.r de li unelc semne ce;rebeloase, corclon posterior qipiramidald -rrrptrcin(.1 ( lil,rlu, 19?8 ; Kurlancl ;i Mulder, 195b; iTaberlandt; 1964 Cibr'an,19riij. ; d\ n'orma d,e SLA d,in cotnplerul Gtmm, ( SLA - parkinsonism * dtvtt:ttlti ) rru ridici, probleme riiagnostice la noi in 1ari, cleiit in misura it {r,rr lrrti),stjii, formd, are etiologie virotici, (virus leni) li in cazul unor sinrl'r.r:rrrrrr rlr.-Sl,A.rntilni[e .la noi in larii iu ialrloul senriologic cfrror.a 5i i]LI J)ot sir :rpilrit fr altc simptorneoarecum asemxnd,toare cele din ,,complecu r.rl, ( lrrir,rn') (fenomene ext_rapiramidnle)tulburd,r.i psihice qi altel6') qi 6aro ,i.rrI llr.l in'.xdrrbilc nozologic.dar care,probabil-rcprozinti forme .,sim_ (popoviciu ,Xil?ascn, 19?9i. S_a , ' | (' rrrrIi i,:r.' ' (yilot,ir,c Nnu_degeneratit.e) { r'r|$Ii11ir,1; plcvrr,lon{:r, crr, SLA este de 100 de ori mai marc in insulele Guam rri l rlu,,rlrlci[ in oricc altir,regiune a lumii (Iieed qi colab.,1966),o frecvenl,i, rrrr.lri5rrrrit t'arc intilnindu-se si in F,itipine si in Nour, Griinee.Ilirario rlc :ri.r' Lrlr. (ll,tj7) alr rrjLtl ci, rle frl'1, ..,"ornpli,xul Crm,rn'. tlcbrrloazi ll \ rIir|r..||rirI lll(.r'u Fr lt,lco cyolufie mai leriti, semnelepiramiilale precedintl lrrr cr'lo lrrrlllilrr. progresitd,Aran-.Duchenne, prccum fi Tsoralizin , ,..\\..lIlt\li& ]nusculard, 4trllurrl.TtrytqresiM, DucltctLne p_are nu reprezintii 6ntit;!i aiisiincte, ci se cd, r,ii,, rrrrr,,jolil,a-tctr, acestora, in realitate roprezintd, forme al,ipice dc S.L.A. ( llurlrr, 1971J). l) t,utr ,uLault.plue u,e Dr_1t (_(Irinuu,1978 ; Cioran, 19/U) OSte tmpor.tani hbrm.aLa atipice d,eB-t-4 (Raclu, -ryi6;Utofan, 19?9) este important 't Hll,,lio locrrrLoscutc plactica rreurblogici: - foima mo:roparetici, (cu in rlrrlrrrl, rurtrl.din membre, de obicei dlstat; - forma pariplegici, (iot rlrrlrrrl,. runrl din membre, cleobicei lr forma ; 'membru ptraplegice (tot
('l| (l 0 lr { , ( cu rlolrrr{, rlisl;nl,cvcntual intii

:1. N i t lt e( nt , r Nit nllt ) t lli( r ' r lr t \ . 1, . . 4. i. r r r r ylio r r ii, r r lr r r r lt lulr r r r llr r rl r' , (rrrrri r r r lt r lologi|0 ; r 01,t oillizt , lr , s|r r r r l, r r r t llot r t lt 1, ir r r lo i. {lr A, ll t , r I r . or . sir 0 r,, rrrrrl rrl, cr r rr , lililr j, c$l, r r r kr osr r jl, r lr r i r tr 1xlr ,lt , rl, i, llot r i, r r t r lin, gr r ot l, ic 11i 1 t I i , I rr| | |r.rrL ; lr ) Nr r vr l, r il, ir ,ollir lor r r icr Llb) Sindr oilr r r clo r lo l{l, A r lir r ; r lr r r r r r r ,, LrI rrri II iI r r I r r ; r r , ir rr r llxr vit r r sr r li ( l h. iigillt csou [ i ( ) ll, ( ] [ lI r , I t ll- , ; i) 11lgll (, ,r' , r' r r.Li ( ) l, r l'. , ll) ( i9r ll) {; : }1. 1) r ur r t ; i colab. , . l9( i0, l9( ; ; t , l{t ( ir '') ; r ) llt r r . r r | ,r| ,,rrrrl Ii I r 'I r r lir r r r r r clcI i, lr r e t r lr r lil, iveI d) L'o) ior nicli[ a lr r t r r r ioir lii, xr r lr r r r . r r lir r,r' orrir .I c) , 4nor r r ir Jiikrjot r cf ir r nii occilit o- c( x'vioiilo 6i lr lo I r r lr ir r r lr r r ii ' rr , r | \ r{ ;rl ( l, ( 1,I, l) {l'r r r lor ilo col'! 'icillt ir r a, lt c; g) ) ) ilchir nor r it r gil, rrr.,r , r 'r l illlr l rrp, rl l rrl i r . ii ( lr r r lilir , ; r i r lo aJlo ct iologii) ; h) Alahnoidit clo <ur r . r 'ir . I r r r r r lr r I 1i l ,' | | | osi cl'ioit ] i, 1i) , \ m iollo: l'il r ] in sclor oz- ain pLici ( linr r r ir ,ir , r r r ioI r . oI iI I r , rl , i l \1.:r,lr r i l, r , . i. r r r r r , iit , al, ( iu iber '1, G uibcr t , l9?4) . O lr r r r r iir r r r r r lr r r r r , zr i, ( do $i l rr,rrrrrr ;i t nr c- \ N, ln( int r cul, olof lio at cnt st t r pr . ilil cy{lll1, i1r ,ir r pr r r r 'r r lr , u, l ,r,,rrrrr 11ilr lr : zcn( lr , l1. olset nr t il ( cer cbeloase, t , est jbulit o, r lr vlilii oplillr , r,l l .l rrrl l l r,r 'i, r r vr r nt ull r loar cu paloale papilalii, t t , r nlxnillit ; r lir or , ir r , {r r r ,.rrrrrl l l i sl ilr 'i,I il loa, c! ir cu bonzol coloidal ct c. ) 1 i) Sir . it uorr rir r lir r , lir r r 11i rl torrrrrcl rr silir r gor liclicc pot r caliza t ablour . i dc S. lr , "A, , r llr , t 'r nr : r lr , lr l r r r t ,,r, rr rrr:ulrrlogic ltoatc stuprinde cycltualclo scrnne :lsooiill,rr rrrvrrllllotrrrr 1,Irrrrrl i rr( iI r , . scnzilir ii sir ingom iclici I t ulbulir , r 'i lasonr ol, ol. ii ; i t r r r licr r
\. .'r l t l l l 1'l |l l ' ).

,\., :!..1. 1. il.'Lm iotrofi tla r ad,ic ulonerritice

|I| l Nrlt(.Il:r1,ii mu$culare la rlebut; - forma miaSteniformi, dC debUt, ( i t l rr,llirri(,iiu ctr ull;orioari de fasciculatii Ei dc amiotrofii; - founa cu tulburtiri ptilrir,o l{, dobut (confuzionalc, dr:melr!,i incipielti) ; - forrna cu somno incipicltii)1 forma sonlno
ux l,rllliliuuit.lulo.

la un singur infirior); a foima r (rolatati, $i a,nterior)I - forma cu debut brusc; _ forma ; rlcrr l rrr iopa,l,ioil

2.. It'tn.oortyti,i amiol,ro.fii,neuro{lcn.a da (<n i,ablout'i t r S.T:.A.) pot sir, Jrl)il,r'ir, sonilil,:r,l,o, ncoplir,zii ln irr rnrligrru ryiirr rnickrp:r,tiilo isrdrcrrrigo ilil,tlrr, lTrJ). l(i'l

.1. (lqvn11[py4 genetale:1) Survin ln or.icrr semiologice lil's1,i1,. A rr, rrr !) urr r',,rr,,r':rl, rlcbut tlistal, mai ales la sxtlcmilil1,rlt, rrl,lrrlrrrrlor illi'r'irrirr.r, it l',rl,l i lri la,t t*:r,lc simetrice(in poliradiculonollil,u;i ;roIilIrrIirrtr|rrrrrrrIrr si tlar t,.rlr) r;Lrrrt,sirrrel,t'ice, qi unila,teralc,chia,t'lrcirlizlrlc.,l) l,r.r'zirrlit o , lrrrr lopogllr,fic dicular'5, lit sau troncnl&t,i,, txccp(ilr,polirrirrrrrrplrlirLrr ctt ,) li(l irNo(csc tulburlri senz,itivc rkl subiective$i/ slr,rr olrir,cl (,lt lli.r'rr]l ilrr |,'Irrri1r'||irr radicularii, troncularX, l]rultinovriticir, $i]u l)0liltovrili(,ii. ) it,I rrr ,r1i'lirrlc (Lilninualea sau ab0liroa reflexr:lorosltrr-t,crrrlirrotulrr. i) Nlrrr , lrr,rr,,ii, croluiio favorrr,bili,, o regresivS, cxccpljr ]x)ljl{rvt.ilr'lur' cu (['rlr rr,rrtoIrirLiiIor') geleticc tamilialc cronico..9) So a,socil,zfl li,l), rlrr lr,;irrlir, o , l.rrrr. lipir.ir.!.|)Ilareori s0 insolesc fascicuLt(,ii. Aplorr,;rrrrI,rIrrrrrrrrrr, de l0) Ir ;i , |' ,1 r;rI r'rrr scrrsibilit*tca la, prcsiunoa rnil,solor' r i trnrscrrlarrr lr, Ir.rlrrrIrirtlrIuI, ;i rL, r'ror,s(,, 11) illulbur:irilcsfinctclicnc rlc ol.liceilipsosc(crr (!)irx!ptii[ ]1irl rIl,rrrrrrrrLrl radicnlarelombo-sact,a1n, inclusiv ir,lcoozii (lo tflll). l:J) ,l,rrllrrr r,rrrlr,vlr sorrrol,rlrii, qi $ocrotrlI.ii tloficc sinl; ft(!(rvcni,r) iltlx)t.l,tutl(f. iii li. .l t'ioNfoJ ru,tl,icttla,rc pot rcounon$to prirr rrrrrril,lo:r,r.rrLr ii.lc so r11s1q,' l, r',,sctriologico: J.):\rniotrof:il, qi csl,o ll,ingir)(lrlr,.lr.lril 1lrc(loco rrkrc1,ivii,, !) q,i c{)[t]:aoliil(] la,scicullrrc librilrr,rrr. AiriHlirrrlrr, lt) I'rrtirlrzir,{i. Iripsos(j llusa lal() (inclr,:llrr trrxlxrcl rrll rlir ir lnr'rl,/rrilr lll,tirliziifl:tsccllltr gntpolor. r',rrIrrcirri), cllro irnllrnril, o loDoJ{r'lli()spociu,lii,,r,rldicLrLllri,", rIrr,I,or.iIii, lirlr(lit, lrrlrri lii, lirlrrrrr lftlii.oitrir, r'ilnnlli lir rnili rrrul{,irrrtrqrrlri crl, Iirr'rr,r,rr ;,i rrrrtrllricsl,rr (,$lnlo.in}ItlilttltHr 4) inrrrt'a,l; rnl,i lnlrlt{r rrjrlii,oitrj. I rlkrxolrr rlo ,r r,rrl;rrltir (| i l rri t Irri l 1() sllu i )olito pcrrrrii;tliagrrosl,it,rrl Lrcrrlizrr,r.l , tlo rr, irlrrrlillii nrrlirrtlirrrr, firr srrr'Ir'irrrlrr ltilrocxr,illrbililillo fr) gillvrrrrilil r1r o Irr,trrrIicr'l,.Il lrr,zrrl li) rr,lrcl,r'irii r[ r'ilr]iir,irri|o|'poslrrlioirrrr, i l,ullrrrrjl,rilrr rlr ,,r rtr,trtti Iri Ii 1rr, rr t'iNlitrtrlr,tii, I olirll, Jrosilrilili irr pltu rlr lor.tr,liztrro: 'l'ltllnt. lt) {i t'rttilrr rzil,ivoslll)i{rrli\{rr'('l,lizcllzii rl(! {,tizcl(! ritrlirtrli gii, r,rr,r'rt,olr,r'llrr srt Iot' it|r'hlot'it,r r'tr,ttr Il itt t,irt lrrtr(rt, Irt'jrt i.rir('r,llIrt'r'rr tltr o,illr\ Iot {r rr,r,lr,l$
r r t r l f r , t r l l l z fi o l tl r l tr t'r , l l r r l tp r ,ti i i t, l ttr tti tttr i i l ,{'l t r l i l l ttr ,, tr ,|r l t.ttl l tttl U lrr

a0$

lrzir,l,(1, ,rirrl,r'il, r'i1,(lii,i1iIilor rlrrrll r;rr,lr,zii, rlrrrrrriltr ptoior'{irrirr loIil,0r'iul frr lrrlrrtrrl lrl rrrt'sl,ot riirlicirri. l,lsl,tr Irrcvorri.il, rlc lrilillola,lil,rtlca, lntrirxrtlrr\r (fxitrr rIrrlllikrr', I\'lirncvttlrrrlo oklrrga,{,it: lli,rLicirrikrrrkrcliltr;ca,ziiJitru llc crtlrrrrzr'i rr,lgiilo b) 'Urtlbtttir,t'ilo scnsibilil*tc obicctivir,s(, 0&l'aotolizoilzr"t, do ; plirr lrilrrxrsl,ozii, l,lLcslczii,unoori 1)rin hipercstczii, cu ilspect global fi prrrlrotfiotrill,(lo ilsorncncaou topografie speciali in bcnzi ra,diculilr'c. 'i ) ,\ pr'orr,lxr t{)tdoaunr, gi.sim trtoclificilri ale ICIi : fic de tip in{eclios lu me rrirrgo-r'u,rliorrlil,olc virale, luetice sau prin alte infeclii, fic tle tipul disocia( iihrl lllrtuniuo-r,itologico in compresiunlle radicularc. (1. AtniotroJiila d,in ntonon,eurite(9i mononeuropatii de ilba'se c.,rigini) (rltrpil (.1u,ibert Quibut, 1974): Si, l, |u,racl,(/rcgenerale : r,) A riotrotia reprezintai un semn constant, alar precocitatefl, $i irrrlxrr'la,ntra acestia variaz5, tn func,tie dr natura leziunii I este precoco r;i inrportuntii in sindroamele tle secliune $i de fuitalie; tardivii $i discretl rrr sirrrllotrrulde compresiune. lr) Arrtiotrotia se insole$te de: parez6,sau paralizie flascS,cu topo. IlrrIi,r Iloncularil ncti; diminuarea $au abolirea reflexelor osteo-tendi. rrorrsc toil,oriul jneryat de nervul respecti-r; tulbur5ri de sensibilitato iri iiulrirri,ivo 5i obicctivc cu topografie periferici,, do asemeneade intensitato irr vrrlirr,lrilii, luncfie de natura leziunii I tulburi,ri trofice cutanate qi vasorrroiolii irnportante in sindromul de iritalie; L,CII,este normal. r) I)rucrilc pot fi foarte vii, spontane ira,u proyocate d.e citlo rrrirlr.irli,rrrrroli ou hiperesteziecutanati, $i durere la presiunea maselol rrrrI sr,rIirrrr11i trunchiurilor nenroase. l l, rl) ltollcxolc locale sint abolite. qi o) ll,ogr'oiiiunea, vindecarea sint posibile, cu restaurare muscularii. di.feren!'iatetn J unclie d,e natllro leziunii: l. lllor)tL(l,ascntiol.oclice tfu it,) lli.tulnn,t.r,l. secliune aompletd: - Amiotrofia este precoce, proglr.sivii,i1ilirir,t'h:cxplimati, pe tnuqchii paraliz^\i ) - Asist[m la o paralizio rurrrr;r|rrLr'i,hipo- sir,tr crr atonio; -lieflexele osteo-tendinoase sint abolite; li,rrl'lrrrrrl irlio-rnusculareste. de asemenea, abolit I - Nu sint tulbur5,ri ilir rir,rrz ll lrrrlrioctivo, nici alureri Ia presiunea maselor musculare , i a trunr'lrirrli|rl rroLv()rs{i slrb niyelul seclidnii; - Se constati, a,nesiiezie superf! r,irr gbbr li, I - 'I'ulbur'5,ri1e vasomotorii sint putin exprimate ; - So lir lrr rul,rr,l,i,). Ii. l)iasivl. I It) Sinrlrom,ul,tle iritalia: - Amiotrofia este de asemenea precoce, .r'rrprirlri Asistim do:lr la o parezi,, cu conservareatonusului muscular; I lirrllrrxrrlo ostco-tendinoase cutanate sint diminuate, rareori abolito; $i llr,l[rr rrl irlio-mnscular poate fi exageratI - Se constatii impon;ante lrrllrrrllili rrrrzil,ivc subicctive: dureri vii, Bpontane,exacerbatede frig, rlrr pllrirlrrlr rrLasclor muscularo ;i cle migchrile de elongalie; - Adesea rrrtlrlirrrlrrrrlriporcstozie cutanat'),I * Se remarci, tulburiri trofice imporlrurlr: tkr pirrlii, ostcoarticllare qi ale Janerelor. 11 r\inlxntuL da compresittne:* Amiotrofitu estc tardivri $i mai prr{irrirrlrrrrsi,; |)rr,r'illizil, poal,oii c(,rlrplol,il, tolusul rnuscularosto tl*r qi tr,litl,iv ('r)llr.rolv|,t, 1 '-.ll,ofkrxclo ostft)-1,(irxlirIor,so cttltttLill.osint clirrLi(1t)tIs(tt - 'l]rtllrrrrrr,lo rir,u l,lxrlitoI - Liol'lc.r-rrI irlio-tttttscttlar c$li(J virL; yrr,r'itbiLi, lrt tiililo solrzil,ivo Asislir,ttr tt ltipttttrsl'ozitr strlriccl,ivo r'rt,t'itr,bikr silrl, I Iilrii,i'rrlJrrrliilj sottsilrilil,lr,l.l tlo (rrilirr rlrr,lri rrrrrrsl,rrzirr) li l)rtir irlilrf,,ir,, lrlrrl0$

l rttrl i i ; -- I \ lt t 6r 'lr ii r yi n. r \ ii t , ijnr r r r r r xilr ili lll pr t Hir r r ur I Nt t so r . r r r r xlr r lr l, l rrl l rrrl i rl i l r olit , o t r vir lt r r r l, r , rl l N .l n dt t nt , uLlt ! , , t . t , lt lt r ut . ( . r tHulvilo I io $l) olt l, il, n, ior lr r ; r i1, r lr r r vr . r r ( io t , 1t l. ir tr r i r 1rrr1 |,i r,1l, r . lr r . lt lizir r r lr r .sr r r , llr Allr lil, ilt r lo r lir r ot , i Hjr or r l, lr r r r r. r r , ili ir I r , ir r : t r lr t t r lr r i, . i t k. r ir r lr . r 'i r r ll. r r vir r . r t li. lir r 1rr ,r ii rr rrt .rr .Hir t l, r . r . {.lrtl lr r :,,l | |l( rI| Irr' ||( , I]ll r t ,f; 1,.:l ] ll. l, |r |||| \ r , : r sr I r lr . it sulr l, i(lt . zir t t r ii, if t r r liir r r l t pf l. lxr lili. r ir r 1r _r , r r r t ir r l | |r| | , || . | | | r| | | ir l lUl 'l lcll; 7, r t ir , t l{' llr r r . lLczir ,li, . r . t . U. ir j- l{rpr r i r lr . , [ : t , r . r . , lr , r,r s. r r silr ilil, iilii sa 1, , r : r ir t u'r niit oa, r 'ulr or r iir r . , i. , , r r , , 1, , ; 1i,i. it , ' r'rr' ri n' r'ir r '( ir( . ' | | r| | | | | rrrr | i[ [ |r ' rr rI I |(I i r , l l) rr i ( j( , i[ I , r r , 0t ilii i ] ll dt r r ut r t r yi, ir r I ir r r r l, r , r , l lr , r ; r' rr,:r ; | (|lt llSlt l lt lt r h( . I t u. r . ( t ill) in. ( i _ Rt liof Ur il0 t t ut sct t li t r lr r r t r r lr lr i r" 1rIi rr ( 'r '( 'sr r lf (,1ir r 1, "( ) lur raf r nasir i r nuscur r t r : 1 rrr r - - . lt i, 1cilr . ilr vor r r r r r r r r l, ,l , \ | tr, i l r rnor l 1) t . ( ) gr r r xiv, r lilr coinccm a, it unllo; - - 'Snpt lilr r , , , , , 11l( , llllr , r , jr f ( , ir , I 1rrr rrrrrr,li kI t . t r k: r lt it , i. l ). .l u t . iulr , 'J. iil,, lit pr , lI r t t Dt . ; lt ( f t *peliD lt t ) lint t r , ) Ut t ii ) : :u .\rrr ir '( r '''liik snr t t r ili r llllt . it r , ri, r ai r ... 1, i1il : rr r r rrI rr:r I r, lr r r lr r t r r , ( r . | ,r, Ir,r 'ii r t ilil': r _t i) sr '1. , i, . i) ; \ r r r iut r , , f iilr i"jl1l, I ri |1 | r.r : r Ir. sir r r r . r lilr . bt ' '|, 1 , 1ilr . " r' r,1 rJ.,{ ' u - ( lr Fli ll'lr t r e r list lli, . sin1; ._t opogr , a, f ioixlicult Ll, ii, , r r|. r . ( ||r r I I I iI r ; i| f iill r sir . t I l i rl l L' xol. r islt ur- t . r ilir oa, s. aboiit ii ; d) N. s. . r 'st ir t ii lr r r . ii, r r r liij , t i i . rr,;o ciilzii t : u t ulbuliili senzit ivo r luf icot iyo f i ol) i{yr 1, i\ , o lir l: r hr , 'r , r i t l rrl l rIfri ti v r l; or r r ot olii, scc] . ct o] . iisi t r uf ict ; I ) . lt . I ) . ( slo lr t 'r r zr r r r i,lolr lr , lr i rrr,.,.I U l ,r|oslir I i, . disr r li; g) S, . it sot 'iir r I ; i r lLo b, r l r r , . 1|'r r ||r r r |I iI il|r , t r , , , , , | ' r ri rr{' ..lr llllllr , loglcoe1'1. ) ,in f unclic de nat r t r a, polir r t r r r |o; I r I ir r i ( l( 'r r . r r , Itrl .r' {i oi t;r1 , pr r r losional[ , car elLt iali, , t lisr net abolici, ir , r r ioir r r r I r r ii, , r llr r ; 1, _ r Il. .l tr.iol.roJ ii.le di,n Ttolin europatiile uonict .litntilitlr 1.. .l ttt. I dr o. f ia r ] it t polt neur it u ( t cr nen. i. nr : ur t r : |. pn, lr t r r lt il : I lr r lilyl 111, , l ,' tl t,t ) i Il tn \ li! t elii h. [ per t r oJ. icd, alui Dijir ine_got , Lt : t ut , zir t , t i, lr r r r lor r r r , I r ,.rri r( l (' 11rsct niologice i a) I ) ebut e; I zii in copilir , t , ic Hir , r r r l|, r lolr r r , r , r r t irI r ir r,' r, l ul trrt r r lr lr ) lor inf er ioa, r e b) pr eilom ir iir , lt t r ir , r r lr t l r r r lr ir r soliI r r . , r r l I t" trrtri .r' i klr '1i- : t l r r r uqchilo. plant ar i, anl, r . t iint l lnor . $ Hl{il) it , l Pr . i, l. r r r , . lr r l , r ,r,' tr' tc n I ( locan f l cu gr if a degot clor I c) . l, ozon, ziir r [ r i lr r r ( ir r r r r r r lr , lr r i I,,,,I, Ii | | r' i rr , igilm bei ( iu f Lzcle inil, iak) ) I li: t , i ( 1) 1t l) soi r l) ( lr r plilr r ll lr r r r lr r rrrrrrr' l ri j rr r 0r r r lr r : llclot supcr io: ll: , t , oalizind ( ) luir ir il, r r r li0 r lo lip , , \ r , r r r r l rr, l rl nr{r i r ) I I xlxr pl; ional so oxl, illdc f i llt lluf ( 1hii li, {r r i ; l) lir . ir lr r , r , lr i rrrrt,r' ' l rit' i 'i, r l: ir r it r ilor r r llt 'cl0r i r lcr 1i lr , it m nchit t lni I g) . ll. lkr x. r r r , r lr r ' lr , r r r lr r' r' r . rri rrl, , li1, . t h) ( lr r it cxlr r l s. r . i, r ugi. ir r plit . ir qi r r r llr r r r , r r 'i ulr ! r , r r r r r r Lr r : r' r (:l rl csr , t r , i'ulgulanlr ) , hi1r 9- sl, r r r ur ciit t izict up( r r , liciir ljlglr lr r lir , r r r 1r or . . ' l rrr, t,rrl ,, l trl l r r r t 'it li ( [ o $( llt sil) ilillt t ( , lnol) r i( ] ccl) li\ , c, llclir ) r illoilr i! r lr , r r 1; r r r r , ; rl l i trt.l .r' i s li( xr sir r l,lip. r lr ', iiil. r r . r , r , ilt it , r . lllr 1r , i, f i. x1r l. r lr ( ip. ir r ; , t r llr r . r , , , , ,,,, 1,,'Iri IroI ir oI ii llr r t ilr r l I i )(l t.(.(, )t t l-, sr r lr lur uut , lt nol, ( x) 1, ( loi1l( ! ( it r r lr r r ir lr , , l i t,; rrl rrl rl ,j) lt . l) . r 'I r r t , I lir , i'i,, slo ir r r lt or ir r llii, , so\ . clii, ; li) I lvolr r ( ir r , r r , r r lr r l ' .rl i r, I ,(|r' I I I i t ,i I r( | o hnr gli, ir r r lllilvit r l, r r ilt r . ' .' ,. ,l ntit lt r ll it . lin lnt lq lui ( t ht . x. ol l, I ut ir , l, oolh. . il) lr i, l) llr , lzi, ll r rrl rtIu' i c f, il|l iu i |{I I )|rIii ('(|I | ( ii r , r r l r r [ li lr , r lr r s|lr ,r l r r r lt ) - g0 ilr r i ( r ||r r , or , i ir r , lr iI I , trri rr rl l vl r,tr r o, I lr . l I llr r i) , lr r it , i lln. lr lt r r lll ii0 r lr r lr t r i, lt lit r plinr l r r r r r ll, |r l ,r,\r, (l l tl l i I t ot , t r , t r l, xcr r r l t r r I r t ilt r I ir r ) , t lr t lr ii o rt rrrrI Ir I i1I r I rr r lr r 1tI t . tnI rr rr rirr I . l ,r,r,' l !' ar rL, lilr r I or r r ir r I r , r r Ilr jr ir r lir t I |r ii r i ll, it t r $t iBir r r r i h, i, lir r r r ( l uir , , r ii l

:( t'/

(l(\ I'il) rrr(riliiv, {lIl)ii (iulI riofirlrr rill(llrzii iirflr{r sIrorl li0(!; l)) ,,\rri{,lnr)lii! ,' fi o rrllii 1,o1xrgr.llio rlislirli, irr ilcrrtrlirl sirrrctlicii,; I)cbrL.[orzir, Ilrrrzirrli'i, r,) la, rrrrrrrrI rrrrltr irrlirrioltril, lczirrtl irritlelr,urrl rtllr,t.ior. trrctrrlrrelc si sulcr.ioilr.o; rl) l)rrlililrrl rriol,ol uvoluclr,zit, ltat':r,lcl propol,liorlal cu aniol,rofiu; in fi .) l,lr isl,ii,o slrc.o$iullo oronologicii, dispozifictopograficil a mriotrolioi, de rlrrlrii r,'rrr u notzii: l,:l nrelnbrcle inferioarc: pcronierii, cxtensorii degclirlor',glrr,rnbiurul a,ntclior, muqchii moletului, apoi, mai tliscret qi tardiv, cvrr,rllitrpsul (mai ales vastul in1,er.n), ceea cr: realizeazi, amiotrofia .,irr .irrliirrli,)'a lLri Clarcot, cu ,,picior de coco;', sau in ,,labe dc barzX". l.,a rrrcrrrlrlclo supcrioare (dupX aploximativ 2-b ani rle evolutie) amiotrofia rr,1,i1rs1) suri{lcsiy:muqchii mici ai miinii (intcrosogii,apoi muqchii tenarieni lrilx',1,orrl,rieni),rcaliziml amioirofia aietip Aran,Duchcnne, iar m&i tir_ li zirr, rnrrschiia,nljcbtalrui (extcnsorii, apoi flexorii). pronatorii si scurtul rrr1rirrlIoI' sint pu1,inafectali (sau de]oc); f) Amiotrofia respccti, urmitorii rrrrrs< : atlrluctorii coapselot', mugchii centurii peiviene, lungul supinalri lor,.rrrrrschii brafului, muqchii centur.ii scapulare, muqchii trunchiului, rri giirrlui qi ai fel,ei; g) Amiotlofia se insotefte cle fascicula,tii totrlea(lu rrrrrr si rkt crampe musculare in perioada c,ledebut, tle tulbru.ilri senzitive, ) rri,il srrbicct.ivc (parcstezii: uneori dureri), cit qi obiective (tulblrdri tle sirrrsibjlilu,l,otactilf fi proprioceptivX cu localiza.re distali, ectromelicd) I yasomotorii sint importante (eritrocitozi,, rd.cirea extremilr) 1l'rrJburir;r'ile 1,ri(iLrl etc.) ; i) Reflexele osteo tend.inoitse, indcosebi cel achilian, sint (lirr)irllill,e sau abolite; i) ,Iotdeauna se constatl Ii.D. de jntensitato r rrr,irrlrili,rilar progresivS, trasee EMG iie tip neurogen troncular; si f ) l,lvollrlja cste lcnt:i. I,'. ,Lmict|rotiilc multiner:ritice: 1) Apar in teritoriile mai multor nervi (jorrli'cla,{,i,rxtea co confer:i o configuralic asimetricl;i asincronii, care 1o (lililrtrr{,iNziinol, de polinevrite qi rie polineuropatii. 2) ln general, esto l,li'r:1rrl, irrl,ii ln nerv, apoi, la intervale de ziie -sd,ptimini sint cointeresali ||l(i r,rvi. il) Tulbud,rile de sensibilitate sublectivr, apar mai intii, manilr'rrl irr(1.s. prin algoparestezii,iar mai tirziu apar $i tulbu'd,ri obiective, r u lrr l)lsc po tu'itoriile de ilervali6 multinewiticd afectate. 4) AmiotroIiilr sr ov ir[or!i:r,zi,, in general, mai tirziu fatii, de d.eticite]e motorii. li) Vrl{)llrot, scmiologicil a semnelol de leziune multinewiticd, constd, il oucllilt.o,t,sprc urmS,toalele afecliuni: a) Colagenozd,: periatrita nodoas[ (borrLrlrri t(iissmaul-Meier), lupusul critematos diseminit q.a.); b) Diabet z,rrlr:rlll;. rr) frrkrxicatii (cu sulfamide, barbiturice, oxid de carbon) ; rl ) li rli rLr s isttrm (boala lui Rue,rger,boala lui Besnier-Boeck-Schaumann, lr,rrl,r lrri \V;rlrk.rrsllijrn); Lcpri. r,) ,\.:J.:!.J. L. A ntialrof iile d.a origi,ne centrulri |. Alroliilc la hemipleui.imai l)ech,iau fost relatate incii, do Marinescu ( ll'ilt,ri) rk: rl{i lr,rrkrr.i cllLsiui(cil,a{i de Arscni qi Jlotez, lg7j), So intolcgo 5i {rii l)t(,2{rllll Irrrrnil,1.gioi, (xnltrtLcturii,qi ilnobil izr',ro,trrt lro 0u 1I,.rntil,o Itii, ir,r'r,riirrr rlirrgrroxli<rrrl. liirnirru rknr. sii-i ptoiztirn ul iologilr. :l{itt

illl ' ' .l l ro t iilr : r t t r t : t t : ulut t lit t lt '. , it r nilt I t t 'Nlt t t lr ( l( ' ( plt t 'it r llr lr r ) HllHlr ilr t l' r tt pr l: r r lr , l lr i r , lr r lr ol' I i t t t r r "'ti t t r r l'r r t t t t 1. r r . 1i r l' sii' lt t t lr t lt t r t t ,,,,,rr,' ,i ,,* ' t i( ii, ( llil'clr kr vr l1) ] il' , r Ir i , ,,,, i , r,' 1,rr ',ti r |',,r 'lr I t i r,I rIIt t I r ( I \ 'ir I illI ir i ll{r h( l lHolr ' lll lil ; ' lt l?l) 1i ir r . sr r it r s'r l'lr s'. 'i ( it r r r r r lr l lt lt t lt t lor : t 'l) ,rl ,rl r rl i r Allct r i 6i lir l, r '2, ( ] r ilr r r r ir rl , rr| rrrrrr'l , ) NI ( l ( [ |l ( kl|l{'r vil, l{)Ei r t ', I t t "r lili( 'it 'i r lt ilt |. lr 'l - r ' ( lir lr r z t Ji lll?l) Nlr r i t t t r t ll, Alil( r r r i f i lkt ln'z cil, r r I i t lo Als( ] lr i r ii l] ol, r '2, trrrrr, l 1l {i l l sr r t t lt r ; r 'til lt t t r i ,,,,i t ,,l t l rlii'l'r r l, ili,lllt 'olliilo t r t r ll,t t t r r i llt r cvclr t t ' ; i t t t : r i r r t r r t i : t 't r r r 't r r lr t 'l i ,l ,' ,' ,' r,' r,, 'iii, it t lo r t kr r r t t t ir lt t t t lr t i t lt 'op1, 'Ar soLi; i I nit r r z ( lll?l) I t lll'( ir , , | | , ,,l tr' ,liil, ' t lt r t t r igit t r r t lt r r Llt lt lli ir Llr ': L r r lisr 'lll'ir '. ( t r ) ll: i. llt {r ( ] lllliilt llt t l ir t lr lt . r r liilo lllill l{r zilllr i l'lllr lor lr lr \ r ir t ' 1.,f r| r, l rrrlilir tioo t t t lii ir r t lxr t 'llt t r l, |: ( lr ,, , r r r r t r lr t t ( tr ,,,,,.1,ri lr i llss ( [ o ] i1) sil, x) lr t lr lulr t i l, t r r lio t lo or igilr o t r t t t ( t 'lt li rrr iI rr )) r Li rr git 't lsuI post cor r t llr I 1,in lr cr nc ct r , iu <'r lz't ll, r I t '. ir I I i1ii r r lr r r l rrr I r'r, I irr it t t lc's. lr i r [ ( o lilr Hii'r l( \ r t l'r i'slo ir i ,,r," l ,i i i ' trt 'r r r ilit t 'giit c nsr t t r hr . ', ''r l , rr' ,,:r, rrr r ur lr t 'r r lt r ipualil, ic $i at lof iilt .'r l'ii'

r l \1 l sl tr u4nor il, lt . hio hr r nr lii ( r lt 'Hcllr ii t lo ( lr ilclt lr r y, l{}5i1, r r il, t t '|,lt r o t Il r rrrrl l r.r' ,lll??) r r r r r xlr i it r it t r 1r ot t iI t iI i1I t I r 'ItIt r t t r ot tt t t t it , , st lr t it , t t lr it 't t l't r lt t t ,,Irl IrrrrIr,"frr ! jI r '1, i{r r t t ( jll ollvil, illoi! l) ll( lilli[ . tttlcot'i ctt u,1tnt':riantiitrii irtfrtrlrl plitl l) .ltrt,:ii(, t.u,tl.il,ii, illEo((iH1'o srt l r,rrrrrrr.i rrur tllt lui r lt los ( ( lt r sr lr r vin( t 8i Kr pllur , l0( i2) '

9.

PROBLEME DIAGNOSTICAGNoZII DE IN

A III

0.1. AGNOZIILE TACTILE(astereognoziile) Constau intr-un deficit de recunoaqterea obiectelor cu a,irr1,,r'rrl .pipiii,ului de c.),treun subiect (cu ochii lnchili) ate cd,rui sensil)ilil,il,tiolducrtale sint intacte. r\ccstcl, apar in leziu,nileyasculare ramolismente,hema_ _(homoragii, l(,rnrc),lntrrorale,traumaticc. etc., lobului larietal qi ate g'lrusuiui -ale_ rrrr;l.rrrnu,r'gin:r1 tactognozicia,lui lhermittd: cimlurie Z qi iO firoa_ (aria
rrrtlrr). .. .!l.l,l. I)iagnosticnl tle agnozic taetiti !i al iliverselor sale formo r.lirricoso fl.].llilg!!" printr-o irpJorare-semioiugiciiriguroasd,: a) Se stu_ rli:rzi sursihilil,il1;ile. ck)mcntare (superficiale _;i.-profuiile) ; b) Si;"pi;_ r',',:rt.l hilu4.,t,,:i,r, irrlir.ri..idflrlilicarcr mfllpriei din r.areeslo folrnrl obieibul { l||., ||r iU(', rtr.lrt(,srtrrt rcziSfoni. leled S:ru rugos ctl.,.; JCmn,fier, stU Irrr'l rirrlii. sti|l'i or..) .\i mor.tog ir., ozitt {fol.m,L diminsjunilo oUi.cLifrii I $i .) r\r. r'r1rfor.cu,zi tttpognoz.ia(se o excit;tie cutanati, Si iridit-idili -faceI.rrlrrrir' *i i irrrlico sediul cu indxul); d) Se'exploreaze disc ,mlniiii luclili.: a) i''rr;.111i1.i1; bolnar.ulsX,facfl detmnirea etictd a obieatuizt; prtieitl jrr t|rorl (,( tl)iu.|,l;iv, ambele miini. ) cu !1.1,!. l,r.olrlcrro de diagnostie clinic: t!u!.j,l,e prin^o:e a,)Agnozia,d.eintensitatel,(ah,i,Iognozia i ..... r|||||r:I(r|(' ): 't.rI !1,,,,1t/,'!,i,iil! r't(,rncntare sinl intaclc fi tolu$i sutriectul iiicalabil r,r'r "r1e rr,r''rr.rrrr,:I nrrfcrir din cat,C eslo for"ma Obie;td: Ir'in 1ra)puro t ttt t ttnt'. t",,'tt t, lc nsittte',(a norlogno:ia : dcsi 1111 6,"1a,; rdbwiri obiecj l 1 livrr rl. s.rrsilrilil:rlo, subiectul este incapabil sL rccunoasc?i form:l qi iii_ rrrr,rrrirrrrifrr olriocl,nl (!,ig. 32). ui :J) .Agnoti.itt: t.uctilesectmdare .(asinbotia tactili )- In aces[e c&zull, rIrli qi )rilog'ozia sin[ inl,aclc, bo]nav.l nu.ccu.oaqto obiec'rin'log.ozi* Irrl. l,)'l,rr Irrlllrllrrr do rtrcrrnoa6tcrc semnitioalrici . a sirnlxrlic. a, obirrrt,uhri (vt't,i .1 :ll! ). i11. 2?t)

ltisfr' lrrl'11. taclil0 ((lrrl,h care / i,/. .rr. 'touograria lcziunilor ".;Jroii,:lriYt"rttt"
',,,, ,,1 '

;'

f,.r r\ $ rp r. d l ra i ri i s ; P . : t l i c d c l rb 2 t ; P a : P f i c t rl a a s . o . d c o l l t j , ' U ' l r' / i rn x ' i ' 1 r' 1 \ rn i l l , i l . . l L d mJ t J l e s l i z s i g c rd i n d o ! , l n o ri e . o rl i (rl J ri l ' rr! l n rl l ; -1 l l ' l rl r' r,rdkr; p(ri .4rlr rczirno L."i,'l rr.!,oN',;/i"e, L ' i l i l ; L r1 Jjno/ic

r" rt r' r"

Brncrin,r

f:'&:il':"1#.,i','jl.'

.rrr '- rn/r""'

l,) .,lsl(rmgnazia bilateralti poal,c fi roN,lizltlii ltt ittl,t tt lt'zittttrr :t .trrttr t, r, r l cnrl rr ': t lc st ingi. ti) ll ulostercoagn ozia (Ilalpern, 1945, citat tto I(tlritr(ll{n', lll?7)(l(rtrrllri i ' r l i rl rl l l cir bolnavul sim t e obiect ul, pe car e- I llr ir t r lt l ill t t t it t it , t r t t t i r r r r r t , ' ,1,,r' i tr rc nlit at e. rI

VIZUAI,I,] 9.2. AGNOZIILU

(l rrshl u in pier der ca posibilit il, t ii t lc r t t ct t r t r t it lit r lt t il ( ) l) illt iln\ lot r 'll t i r;rrl rrl rrlvct lcr ii, t le; i llolr r avr r l nt t it r t t t t it li o r nuliI icr t t 't r r r vit lt r t r l'ji lr '! lzilivr t rr'rzolirli,, irlr liacull,Ifito sa,lomirl,a,lo sittl; contlcrv:lt,tr' I\rt, fi rlr, tttrti tttttllrt l rl rr| i : l. A1;rrozia vizunl"r U)ntru obittcttt txrt'esputl(lo (xr(iil,i,t'iil)$ilritrri rr lrri l \l rrrrr' l i .l i r . t olr nt lc gr avlr , r t colli bolt t r t , vi r r lt loct t ll{) f i( ,t t ioi t t t t olr it r r r l, t t ici t: )r' r' l 1rl | | |ii ,, lili t ir ilt t ' pr opt it lr ll I igt t r i, , I 't 't r zot t i, at it ,t t llt t i olr it r t r l lr t t t t r r l, ', | olt t i, Irrrrtl l rr,rl i s lilt t l, it ',illl Nnlln'( ! lt ( lilztlolt t tt nit 't lll, ir r ll; t t lt li, lllo t r iir t t i( 1il, t 'll( f li'11\ pr i l l rl rr pot t , ol, r r 1i {io t lost r ist r , St t lr it xr lt t l f ixollzit ol) i( x1i'lllrI ) t ( 'zilllt t ' r l sil izlt rrrrrrri r' :i r '; r r ir r Flii lt lt r st 'lr cor c r t , t t lot {iit ,t lo lt I ili, it t gt r ,t lt r I l, 1t t t , llt tolr I r r ' , srr t, I lllllli ol) i( , t 'l t lr i rrl , r,r.r' l r, il, t t l, t r l, r ollzii, r t r t lt t t it t ll slt ,t ', xlt cl'li. llo( llllt r ) : l, ijl( t f oil, to t ct l rrl r. rrrrrl i ,ir r glr r t t ir r l, ii t lit , r 'iiit , r 't , slit 'xlt r lt ilt t zlli"it t t lt r ot t t r l'i, t lt llr r lt r r yi t , ll'r r l rr i rl i l , rrrr , i r liLilil, cr t lil , , r it t t lr r t l" r lo t t lt ir r r r l'ttrr sl't tt t t lt , i t t li[ t 't '. r r\l l rror ir t 1r t 't t l't 't olr it r r lr r ii ir r r r r ; lir r iligr t t r r 'livt ',Ht r t t st t t 'ilt zli, lt r t t lllt , r t i t r r lir lr , r ir , llr : r lit r lii, ' r lir t 't r , lt , t t lit xlur , lir r lr i,t t r t t lil'ir r t 1, t l r,rr rl urr,ri r, r or r sl, r t ol ivit , t

'.','ll

rhr li1q11y vizutrl ;i rlc rrrrrll,o Iliclt r) rlii(l(llt) ll, rIIr1rIrrl iIii,Ii|or, rrI r,Irrr:t rrIrIr, i Ir.ir llcr, ll)'/7). rr 1li lfrl)\!t) (11)71) (]cs(1lis i[ utno::i.n, tiztr.uliiuptrt:t'1tli.r:ii.,r.trt: r.ltprrli irr lrrl.rr rl. rlisclirrrirlrlc obit:rl'rrlrri a, r:s1o pistiliil,ii,dai' ccl, tlc rcr:ulolriiclo r.rl. lrrllru|rr,1i. lrlto citzrrl'i,s0 tnarrifes'tr:i irr o,falid,t.r:t:tt ttoalf,r:rc abiic'rtlu', a .r'r'rr..r |r'la,|rrrr,zi. lrulnlrvul ilvinrl o olrecarc irLrudiredc liolmii cu obiffhti r q ii|,lril (1tlt'lrg^noziir, optir::i a lui r.on n'Iayendorf). S&u, ctaci obiectrd a l.rl rr'(ittr1r)scrrl,, rirunelos[u este ulteriol' aplicat ;i la a,ll,e obiccte, fo:r.t,to rlili'r'ilt (,,iirloxicai;io pt,in obiect),). Ei po1 si, nu rnai rocunoasci r.rjci , rl.rilr.. (,t4t,,,:it ). .t.tt,t,tltlirn Stu diferoxl,,le dr. r.ulor.i.irrl 1ic,,ceI,rrlr,,
l: , t : i :r lr. l,|Il'.ir, ir l( . nlilic X

corti.cctld penl,nt culori, calacterizat5 prin frptul \\i . l,l\ i$l,r"r, o, ccail,(da lri l,r o crrlor,ilo sint virzute cenu$iu. Existil ,li o hem,iagttrnie yteittru lrl ,'rrlr,rri ((llonning ;i colaLr.,1966, cit:tli de l{reindlcr, l9??J. 9. lguozia pcnlru. imagirri poa1,es5, existe in mod izolat. ,lstfel, . Irolrr:r,r recnnoafte obicctele co:rcrcte,dar nu recnnoaqteaceleaqi rrl obiectri lrllzlrrllri,c_in irnagini. Aceasti formi, de agtlozie se poal,e in\rcstiga pr{) zr,rrlirrl. ]rolnarru-lyi imgsini- harsruate cu linii sau im;gini la tabfrtofoolr r,i rrrliciiintlu-1 sii, ls identriflce. il. ,trgnozia vizuali asocialivi sc ca,racte.rizezi, plin imposibilit&telt, rlo il .lf[]ri, tlo :l descrie li/ sau a indica utilizarea nnui obiect perceput, r izurL,l, schimb cu conserla.rearposibitit;,-tii de a clesenaobieciul qiritl in :r I irlcrri;ifior, prin alte ,,canalo". Diferen(a dintro agnoziavizuali, apercepli\ ir, iri t(':t u,sociaivrj, consl,i in faptul ci, in aceastiadin ur.inii, p e,r cep_t"ia lrr|rrrr.i. 1l co-nformn:tici si sint nomlale (Rro.$'n, 19?2; Nreindlei, tO-t?).. .\r';rrrizirr, r.izu:rli, asoci:rtiv5, fi ut.t fel de ,,asimbolie,,r.jzualii. ar .1. ,tlynozia viru:rli spaliali cuprinde o bog;.tie c1e manifestiri: rr) .l r1ttrt;i4, t:izu.aki locnlizare rle const[ in incapacilcnoitater,pcntru spl.lqiu) lrrir.rr. l, sosiz:l rclatiilc sp.lfiale intre obiettc, de a le localiza -'mai rlc :rllir irr Irofr.rlzirne -, de a aptceia distantele calc seDarx. obiectcle intlr r'lr"ri olrir.r,ltlo lalil de obserr-ator. Dlcd, tle excnptu, su soticit; bohavul '.r ,,r:'rr'lr' rlijlo' ul rrnei linii drgptc. cl rr grn.i. zl l' ) .ltlttrrirt,tlitu,uldsteteoscopdcd, foalte lari, constEin inposibilitate* rlc:r Iirit urosimea ulti ol:icct tridimensi onat. r ) ..111n.o::iile ttzuale topogra,;f,icc, strlius legatc de tull:urilile prece_ rl, rrlr., r,orrslrr,n inca,pacitatea a se orienta in spatiul erterior, de 1I in cle rll rlrjc si (l{) l,-Ei leprezenta tlrurnul pc care trebuie s[-l uruezc. Acc$ti i lrrrlrrrrr ir,i rl<rr'l.c <lrum*l ghidindu-sc, r1e pildi, clup[ afiqr:iede pe ziduli, rlLrlr:ir illirrr elc. Ei se lltlicesc adeseain oraf, sau in propria 1or locuin!:io irrl irr rlrilirl grclesc salonul $i nu Di gi,sescpatnt. rl,i O lrrrrnir, ," aqno:ie,i spa:lialc cstt: r'eprezentatir, d.e agto:[a ai;tLo:,1trrlinlii,trruc I cltt'czintr'i, l;ulbruaro [ ,,concetptla,liziirii), ti r'cla_tiilorirr ()lrcl,cLizali, diiicrrlta,ireil a, asambl0, sei.i(} rlrrr{irrl lxlnr,cor'1)ol'll, (lc in o rlr rrr ril,rili rrirlirrrtrrrsion:rlc, lil irrcit s.i, rr lrsl lonnozo ,,1iguri,'sl_r,u ,,r]lo{lltlo), rirrtrtlo ((Iilclrlrl', 11)5;1, lrirlitrtlrt r'il,1l;ilg .li1i'ilrllqr', lt]?7). (invitul,rrlr, :r,irrozirri izrrosplr,l I'slr, rlili lili. i\sl,lrrlr rrrrr,lc r irrlo irr t,lrzrrr.i, Irrrlrr:rvli srr
lrlrtt;1 rlo :r.t tlt'Irtlrlttl t li r r r t lr r r l r t liliz lr . r r r r ll{ r , . l r r r r l t l r , l r z r r r . l ,i r 1 . i i , l r l l r r l r y j i

( o, s in, bolip t r onu l i L . 4 ) .

:tl r ' t t t r I r' r rt i t t : r r r , 'r r r 1 r o l , r 'l r .r i r r :r tr i r .r r 'r 'l r 'r r r :r r r r r r r r ;r l r 'l .r r i . r l l tr Pl r r tr tt, ', r r l I 'r l r . r l r 1 l ( r 'r 'i r r r l l "r ', l !l i 'i ) , ,\r ,r 'r l i r t, tr tt tr l r i l r o i r ^ r r 1 r i :t,i l i ttti 1 'r 'r i tr r r l r r i r rrl,l1 , lr n r :r i tr ) 1 , r l l r ( ,l l i r r l i r r tr tr ,ttto ti r 'r l r r l ttr r ti l r r r {, tr 'l tl l tttt l r l "ttl r r i r tr l '. 1 , . l r t rr r r i 1 r o i , :r si tr r r l r l l t r r o l '1 tttl tl tttti tr ttt l l i tr Jr i r 'l r 'l tr t rr t I t t I tt t t t r' t t I r' , l ttt lrr g r , r l l o ttr r Ittti ,,i ti r Ii tr tr r ttr r i r l tt:tIJ) tr i ttr I l i ;tr t't,tr , si i , tl csr r tr cztr . {l tr i i l r o l r r :r 'i r r ' r . r r r t r r t I tr r c r l r 'r tttttl i tr tl tttr r u r l {, r tl l ,r l l l i l r i i , i l t't tr ttl ti tt, ttt i |'ttl ttr l r "l ( r r r ,r ' r r r , r r l . r 'i l ttto tl l l ttl . ,\l {i l r u l r r r r .r i ci i r cl ,ttcr u i i i tr vctsr i l i ,,i tt o r l l r tr r l r r ' ;r l , , 1 , , r r r r l r r i . l :r r r l r r r l ,o r r r l i r r l r r ,( l ( 'i [ {l ( 'si r r :r , o l l l i o ]i tti i l r ' \'r 't l i l i tl ( '. ( 'r r r l l . r 'L r ( l r tr r tr r l l , r r r l r ', r ( i .r l , si r r r l l o r r r i r r r p l i r .i i , ;r r i tl i l r r u r ttt1 r tr |tt'ItIi r l t,l tl tr i l r l ', , 1 r r , l l( ) zi l o l ) i ,i r l i i , i i I I (' r' \ rrt t i t t I I i tt l t l tu tti l r t'o tt s l tttt'l i t i i ( t l z'i ( i r l r tl l , ) l r l n r t.i r r 'r l t: si ttt,ttl l u n r i l ttl .r : ( r r ' ( .tt,i l l 'o l l tttl ) t,o l tsl i i i tr i ttt1 r r rIr Ir r Ir IIr |, r .l,r t'i l ttr l t, i I t I t I I I | | I | | I (' r i i r r l r i l p ; r i c r r , Itr r Itti L t ttItIi , tl csi ti r :L r tttl l l j l tr I I 'r ', ( r l i r .r 1 r g n r l i r l 'i ttu ti co r ttp l cr r 'r ,, tl tt i t, Il tt'tl u tl l l ) i l l ( \l t t'Il tttcttIr '|.t tz,l .r l , , , r l r L r r r l o l sl r i l ti l i cl t,l ,i r .. ,\st- tl l , cl l 1 ) '!'l l l l ( Ji l fl i o ( l ( 's( fl l ( 'l tr l l tl { l , ttr r ;,l r ' , llrrrll rlr' , I 'r , , , r 1 i r r l r r r r r i tr g ,tu o b i tto t,, tl r tt tl r l l ( l l l s{'sl ( i sl i , l r tr ':i si ttl tr zl t , , r , r r r i u l ', r r L :L i co L ttp l i c,i :i 1 r , tu t i r r i i tl i i l ( }r tzi i , o :tcl i ttttr ,. {l qtto :;i r r , t,i ::u o sp u ! i ( r !d sc i l ISo l ( l ft( r , i tt si ttr l tr ttttttl l tr tti l l o o cr l r tl :r l |) , l ' , r r r r . l i r r':i cr 'r 'o l r l r r l i , d r ta p l ,i i ( r r ;a , zi si 'i l l ( r {l o l tl i l r r l ttl i t) tl t' t,4 l i i ,r t,,r l t, ttr r t' ttttlui sl i n tl l d \', ( J,( ::0 1 'i ( tl to r c:t1 ttr !i tr .l i r l t'tu l tl u tl i n 4 r r , tl t tl tr tt ti , r l ' r ttt - i r l r , l tt"tti n l 'r ,t4 tI,;i t . ''' ', i , " , \ r pr o zi i l e l i zu a l {) alo s!tn b o l u l i l ttr r l r a Ii ctr :

t ) , l r1 n o :':i u , 1 1 t:o tttt:tti ci i se o :l t'l lI t cl i ztl i t zi l tl i r r i tr tl r o r i l r i l i l :r l cr r r l '' , q co l i l ( l 1 l r i ( t( r ( ttl t t'r 'tr ', tttt l tr r i t:ti , ttr r r l , r 'r ' ', r r r r , r : r r l o ttttt:l e r tl n 'czo n 1 i l 'i i , r , r , 'l r r r rzi tL ti u n o l .) j e {i 1 ,) b ) :l 1 1 n o t t, ( l l 1 r .r 'i r 'l{' ( I (' i I I | | | | ! r I rI |r 'r 'i i r r i r r t |t l r 'r l ' ' ; ' 1 '1 " r i j ) l ) l {r 'c, i n ci :r ,l ol i n r l l a j ttl i n t'i l tl i o t' r r sl tr i ttl r t'r 'l ' l l o l ttr r r r l l Ir 'r l .. I r r l r r l ( I t ' i ] I }I ' i t rr I r' r l i r r tl , r r l r ',:r r ,,r , L , l , r l r r : r , r 'cr r ,p o n i q l ,c d o so r o , l i i l r 'r ,i l , [) L tt{'l l l l ) ) . l l r r l r r :r r ttl ' i ' 1 , , 'r r , l ,r r ( r i ,; r r ) Oe ci ta tm m ttzi t:u ,L i i ( i l l :x:r i xi i , i tt tl p . 1 'r r r r r :r 'l ' r r , | ': r l r i l si i ( kr sti i fl 'czo tl r l tl ) ti 1 , l i r tL zi cl i l . l ) r r l r r i r tr r i i , r ',r l r r ' 1 , , , r i , . , r l r i p i i r l !:i i o {o n }r i r , ( l o a Ja ;r i ( '" r r ':r l r .,:r .' r r r r r l i . S i u( l l o n l tl l u i Ik i u l ( p r r r a l i zi r r p si l r i ci r r r p r i r i r i i ) , , '1 , \ i r r ( 'tt i ( ) i () g i o ( x) tl sti i l tl i l r l i tr l tl i 'l i r r r 1 r Io r tIl l r tt'r l i tr r r l ,' ( l i i r l r r r l . l l t( l l l l t{}? 7 ;IIti t'l tcL r si .\.j ttt i r tl 'l ttl t tr t, I l l l , l ; I \ | I | | I I | | I I l l l ,,) 'r t 't r l , , l i ii 'i r r r l l o l r :r {r 'l r l r r r r l r z k r 1 ) i l i l r i |i L i t Ii r i i i ,r 'i i Vi zr r l r l ,', l l i l r r i 0 o p l i l ,i r .r l i l l l l 'l tl r l r |i r 1, ,,,,t(.. ttl l tl l tt t | | ttttl l r i ".tr tl , :ti l ttl l ttta 'r r r t 'o t t t l i...i q l txi h i o i i r r , Ii ti i r i i , , ' r r r r l , r l i r l r si l i r l : Jxr l i l tr ttl tttt r t'r l c tl cl i l ' ttl t t;i IIL ItIt r IIIi l I I r r r l t r l r r r tr ,r r r r t r l r 'l l , 1 , 1 . r r r t l l |i r i tl l r |l i i st: l tl tl r q r r r tl cl ti i r t i tr tttr r r l i tl r i ,l i l ,tr l . r 'l l ( r r .r 'I' ''r , r r r r r r u ti t'l t,r l l i l i r tl l r r o l r i r r cl c l r tl zt'tl l l i tt l i ttt;r tl I r r .tt:'l \l r r l r r | ' r r r l tl l ctl l r i l l i l r ' .t ttr , r l , 1 r . , l r rr l r l r i tr l tr tt tr l ti l ttl c r tl tso l ttl tr i ttti r r :tl i l ctl t r tr r , . i r 'l i l r r ,r 'r , l r , r 'i l r '1 1 r '. l ) i ' i i tt'l l tl r l ( 'i l ' tl tr l i i Ii r l l tr ,l r r ttr o l r i l l i , ' l 1rc r l ) ( | r 'r '|l ) r tti l i tr tt r tl l ' r tl r i l r I tl i tt i tttl tl i l tl l t l rt rr '. i i r t i l rl l l l l :r l c r l r r i :r l ':r r l ', r I l , r . r I r i l r i r ':i l r ;r t i ti l i i si 1 III|) tIIr IIfi I l r l r 'l L l !r 'i \ l zl l l l l l i l ( f l tl i r l l l r r r l r r l r r l r r r r r r r r r Ir r tr tI l i 'tr r l ttl cl r : l t,r l tr tt'ttl tttt .i l r r t:tl r r tl Il tl l tr l l t' i tr tttr r l l t'r l tl r r l .r t 1,r,rr l r l Itr {i r 'i l r ctr l Itt Ir r l r r " 'r r r rr tr r tti l |l l i ttr l l r i l r t|) o r i l ttl :i ;l |l r r l tl r ':r t,rr\rr,:t, lrllrilllrlir l l ) tr l l l l l l tr ' ,lrlrlttl r r r t:l 1 i tr i Ir ) | r 'i r r {' l r tr ,.\t'tl l tt l t l l tr ItIt|:r , ' , ', r l r r l r i r .r zi ttl l i r r tl 'r l i r r l o l r r |r 'l ttl r l i tt Ir r i :r l .l t, r l r t, r r r r r l t l r ' r r r l l l :r l r l l l r 0 l l r r 'l tl ' , , r r ; r l o r r l i r . r 'r 'r tl l r r .l :t r r ,r tr t;r r l l ttt r r :ttl l tr ttl r l . l l r tr l r r 'l i l r ;l i l r 'l l l l l l
r, ;'r r r r 1r ,,l r r i rrrrl l rr' (' ? , r| l l r r, rt j r' , . ri r' | ri l l l t l rl l I ,:r il:r | rr ltll,l r( rr , ' l ' r, lll t ilIlll | ' . I | | | ) I | | | r ) | I,, | ' rl l ,ll Ill r' : l l r' r , r' I t I r' r' . L rrl rr. lll I lLll l )r' ' : rl , o l l l l r, l rr , rL l ,

l l Ii \ r ' lt z ii. ( it ' : t t rti ti t tt ' i t t tt t ' t t t t tl t, l i rl rrl l l rl l r,r' r,r, ol l i rr,l ,ttl tri ptrrrl trrro I l rl i tt trort s ,,Iri . r ' r I r ' r ' r . I rr r ) ' r l i ' .i rrrp rrI v i z rrtrl (r| ,1 i .s l .a I.,t,r,l . i rrqr.i ,i i l rrt, (I. I,c{,i l rul , l rr J r , r lr lr v r r l llt l ,r(!z i rrl i l rrrrrri i u rro p s i c ). , llt . t ir r . olt li( t i s t' , rrrl r,rri l i .s l i r..p l i rr1 r,-rr ror,i bi l i i l t(r (l o i I pr.i n(Io ( i rul . rrrir'r .lrirrrl, .rllr. so Ir{.?,i,tii J,.l.ir,vrrl.i (dilL }rir:inD lrrrpol,tantelor r.r'o ri r 'rr. , - : r r r .lr . ir rc r.rl :rl ,l r,{ .i { .t1 .;li s rl r1 1 1 ql sa1, el i ncrt rr d l stl acei La exccul i i rrr.r, . r lr { t ( ' : r } r r r ( .l u (,b i l ,r,_ s rrr h i ;rr.rdi m r.n r i unaI o (fi i l .,.ra ti un atacti c iir Ir'r'r 1, . H, , I l, ( ' { ' r 1 .1 ' c l o s )..Ui i b o l n a v i c u s i n drom B al i nt i l i apri trd l i gara .. rir I irlr-rrlrrl r.c(\tcin, ci la rnijlocul ei, sau manevreazn eulitu.l in failurle {rr.t)llr't{i l')(.Ll[ in c{u'e rtc trebui si taie o bucatx cle caine (Krindler, t|)? ? ) . 7. - li. r ' it r r t c a p " i l i c i re p l e z i n ri o rl l i i formX (mai gral A ) de agnozi e \ r/, : r l: , . \ s i. t . b o l n a \.u l Il tt p o a tc re c u noal te obi ectul excl usi v nri n

l rtrr;roti rl l. t lj( ! nt f nt t ir r r lllot r r r , pr r , r lot r r it r it , r r l, r o of r ir , r 'lit lt r( llt . s1, t 1|l". ll oplir l l , rrrl tl tl l r "ii, t gr t oziill ollico 11r 'ot r r r , I r 'ir . irrr i gr , r r r r ir lc r lr r lczir r r r i llillr lr , r 'lr ll r ir r rl , l ,rl ri l or' llr lici: r li ( ir r r , luzir r r l1i gilr nr r l r r r lr r . lr r r ur , r 'gir r : r ,plr llr ^: r ,pollr , r r ;i l ,,.rr.r:r,l ol rt t lt r i Plr lir lt r l sr t lt t 't ior ') lr r r r ct t t r tqi lr lr r ct r lci t lo lr r lot lr , 5i lr lr t ir r , rr, rrrrrroIr r ( ii olr , ilt il, aJr r i akr . jor r c{ir r niicr r a, t loul {'ir r lllnr v{, llt t , ir , . r r ln, 1( ; r.rl .r l l i ' .cl, r . lt 5i Ar r golclgucs ( l00lt ) llu 1ur r r . izr ll r , ii lcziur r i r r lr , r r r r r ir illllr

r crk,r'r',r,i csk) necesar si recurgi, $i la atte mijloacc senzltivo_ienzoriiiel ri I 1ri1r.iic,sit audil oyentual zgomotul pe car-e-l prodllce un obiect, sau .:i I rr.rir'rlsr.. J)ifr.rcrrtadintre cecitatea lsihici, qi-cea corticalX rezidn l; l:rl)llll rl rr Irnmir,^:el,il.rdo drra.rreprczentarea (imagioca) I izualii a r,|)r'a ,, ||.Ir,|. I'r' clLd rn crcilrtea COrl icall, se pierde comple1211p61,s 61j6,6 irlrzirlic si vizualai. Cecitatea ?.sihic.i se insole,ste,de obicei, _p(,I'ceptje rr rlc ir.ltc rrlcmentcagnozice .r-izulle (aleiie, acromatognbzie), ae Ue_ll :rrrr'1r.i.. rl. lprarir. (LrDntrucli\i. ..i ii.. X)roroPnllrrozia lagnozia pontru fizionornii) se crrrclelizeazi prit) rlll',' rL)rlrl:rlcit Uolna\trlut dc a r'.Cunuasle pcrcoatj.lcdin jurul oiu, cLiar pr, r'r'lr,rrnri:tllropiatrc. Recunoa;terel.persol.n rr.spectir-e poate r.ealiza ei se rlorrI rl pii :r"llc olorneutc carncter.istice (imbrriciniinte, talicl voce etc.). ll,rlr r.rrrri Ir\'ulrrtsle ni,.i figuru unr.ipersotncintr-ungnrpdefnlografii. nl .' l ,r,:rt ,. rIr,. r'I ir'. rirIr por:oa rr i,.lt n(.lordin fot ogrl fin. nu poir e facc d if&e;i;; t rrrci lizir.rnonrii lirjrb:lt sau de lerleie, dc om tind,r sai l,i,tritl etc. Uneoil rlo rrr,;i .ici 1r.opria sa fa_tiiin oglindi,. Unii bolnavi prezinif .r'ir.rrrrl,r1lu rlilicrrllili {lrr 1'(:1111,u,,,0r""" a r}numitot segmente faciale, ca de n^ildb iu_ rriilrr(r'ir,srrlr,ri'ari silu iirferioari a felei, iumitatea dreapti, sait stinid. lr,11irrrrtr, oolrilor', regiulea truntii etc. (Glonning gi colab., 196?, citli rll l( r'r.irrrllcr', lg7?). Stttttt.i.l itrt!i.rr, t9.lo-lyof!a(n ogae:i_ilor Agnoziile yizuale au ca , . r.i":unle. r;rrlrrl.rrl lr,zirrrLi u,le klbrrlrri rccipitll sting la drepiaci, c[ci leziuni alo r,r,izrrr.ii si .r,irlr.arino alc. regiunii_paracalcarine stingi (cuprinzina intreg ( rrr(l.rrrl) pr,rluc :r,grrozii bilatcrale. Adeseaeste volba rle l6ziuni simetricl :rl. rrrrrlril.r l'1ri occipitali (fig. t,31. T,hermitte a subdivizat aceast5zo;L irr rlorrri rrgirrni : una clestinatilformelor qi culorilor (aria 19) Si alta. mai rr,rrI,'r'i,rrrlii, rlcst,jnilhii cleserului,litelalor, cifrelor. Tulburi,rile'dg 61i.r6rr,. slr;rlia,l.)sint rlatorite unor lezi'ni profunde :rle pir_iii superioaro 1:r;'rr,ziilr. ,r irrir'r'rrrl u,r'ioi l,lr, par':l{jalcarjrrc r,r'i.r, e{ingind si mlirile fascjcule dc 18), 1: :rrrocirriirr. 'l'lll)uliu'ile memolioi ton,rgllficc depin,l insi, de obicei, do lr zrrrrrilril:rlrr':rlr. rrlr.rr,spintini {r'rrrlruro-o,.r.ipifrle. ,Agnozilr, r.izu,.snrtirrli , lr' Ir',rrlrr'.i lri ir.lr',rs, rl. l.zirrrri:,lo'i.pinri' iprrir'looccipirrlc diri "inir/i,r'rrl rlrr'l,1.Nl'i r,ru.'rlr,It,r. (11)04, citai; dc triirrin.llcr,l!,)i?) a arittat.iJ ir,li|,i )]/iiilrf,riz,flirl(r.sirrl;^l)rrrlrrso rlo rlrrconectarca,iilor sonzolirlie roo{rl)1oirr(! rlrrrrliilo I i rrrIrrr,j rrI rr i . In lrirclr'sl,i, no, l,{rroziiJrr ico so a,d i6 rlil si1l, v izirr ripl rn pilt,ilor, lr:lzl,lririlc lo btrlrr riccillil,a,l, lttrrrlrro lrlirr lczirrrriIri III I rrr';rI rr. lr,lrr i l,/r'zitrrtil('silltirl{\ trririitl)rt)il'l,rt lolrll lrriliclrrlilt'Ilrrrlrtcc sirrrlrlorrri rlrr ptr,. tItrtrtitrotri, olrlir,rr sllr{,irr,lrr, ir.r,rrrrr lirzirrtrilc irr crr ulr,i Ir1rr,o1rirr,ii, lrilrll ,lrr :n4

t t,t

i r.

(hrrs pr)ndc l c topogratl ec x gn{ )z i i l or \i z ui l e :

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,, r ,,,,r L) . a ri a r(: ! , ! $ L l J i l i ' d , L a i l i h r. a a l e ri e i .' i .r . l : , . . l" li\,', . i r. ' ^ , ( rri a l 8 s 1 n . . i i' . , l l . i c d l o rn d )j , lfl . .Lr ,,, I 'r r fr i r 1 9 , ! (s t )o rl rL , i l i L ! n 1 ! c mi s l ri rl e l f r 1 ' ' ' ,r :i de ii t.grm. lormrlor ii a .d..il.r!,

,l rr 1ri r' .pr ot luo indeoscbi agnozii pent r u ir nagini I igr r lr r I r r 1pr r , iLr , l) r t liI r 17r \ r..r , r' rrozii sllllialc unilateralc,, in vleme cc l eziutrikr cr rrjsli,rti sl rrrjl r lir.r {,rr.r j/,l , ,r pli'r,ii,tkrrtl a,gnozie pentlu culoli.

e.3.A(iNOZIILE lut)tTtvt,)
( lrrprirrd urrnii,toarele formc clilicc ; l . l l ur dit t cu, psihicii l, luLt t sau r r . r lt u*ir rt r ur lili. i. r , r t ut 1t I r . lrlt.r lr r r r r r r l r zgoit t ot t io, poit , t c. O r r r lr it t irir t l, t , nsililil, , lt r t sl. , r , lr , . i lr , pr r lr lr . l, r I t r lr zr r r ;' , r' rr' 1rrr r l 1r;r(i rrl rrllt t 'cst c. incapllbil sil r lllir l r r , , r , it r lr ,r r llr , I r l. r r I lr r ir . |r ( r r , r . r r r r r r rrrrrlr r r ir l ,' r (l r l rl 1 , o( il. r vinlc si'1, id'r r lili. r '. lr r . ll, 'r r r l lr , r . ir r 'lir ''rrrrI l i r.rrr.: rt r '; r r r .r , l lc ' rri r, r (i )ll sor\ . ii, t rlt r skl ir r r lr or '1, : t r(rlol, {ir ir r l llr I ir r l I ii lr olr ir r r , r r( . u : r ! . , r . , , r r r . ,1,:fl . t l I' r.rl l t sl l lt r t , o lr ct 'cc1lo t lc r r r t t llo oli r r lr i lr illr r or , lr il. r , r r lr . r , r l r iur t r , lr . lr . t I l yorrrol r', lot r ur i f . it . ) si lii lt gt r ozit t , l) ( , nlt . u ljllllcio r r c\ r , r . llr , lr r r r r t lr , lr . i ,rrr)l ri nl i ( 'u sur dil, r Lt cit t ( r . l) lt , lr i. ::. S u . lit r ililo lsilr ir , r . . sp*r . ializnt o. ': r i) Nt xlilt r lt t r / . r r alr i. . ir r r , r r lr r r , . r . l rri .rr rl * i r, r lili't r r r r liir ,r klr *'i ir r r r lr ir r r r l'r r : r lr . r 'r r r lisr : r r r {ir r r r i. li r r r r 'r , r . lr , ; l tt,\,1di l (l ra snt , r r gno; iu t t t t lr xli, , ,r i rrr,:r I r. rr. i I :r I r..r r l. ir ir lr . r r lt lt ( . r r l' t r . t r r l . -r, rrfrr, (.rri t r r : r . ir r r r r ) ( i . r ', r r sir l. r 'li r ': r r r lir r r r r ii r lr , lr l: r zir , ); r ) lir t lir ulr t r xau ,uttrrt i rr t' ilt t t it ii: i t trr:t 1ri rr. i I Ir I r.II r lr , lr r l, . r iizir r r r t l t r r r r . illlr ir . lr r r , i r rrlz r li r lr , , , liir r l rl trl r ( ( \ 1 r,t r.r,1r( r:r , lor r : r , lli r . r r lr . it r llr r 'lir . r

it'10

il. Srrnlil.rrl.olvrtthrrlirsirrr rllrr)lil r,orl)llit Illt.ri, .L'rlr,(x) ltt,rl,o rlirr rtlirzirt, \{rrrtttioko(ttttrlt vlt li rlirs<,r'isli y(izi Olp. 10). rlc l,rlzirntilog(llr(flitl,oar'(i irgrrozii u,LLrlil,ivc colticr,lc, cu loc:r,lizlu(r sint irr 1ror'{irrrrrrrl, a lxrst,rrlioa,r'il plirnoi cilcurnvolutii tcmporale qi a cclci de :r rlorrr, r,ir\rlltrr\'olu1,ii lorr)poralc a cmisferei doninu,nto (Nielsen, 1962), rlcri rrrrii slrsl,incai loziunilo gcncratoare de agnozii auditive sint bilateralo

, l ' , r l l r r : t l t - i r t.'l o t.l tl i zi r ,tt':t r l r , r 'i r ,l tr r l r r r l tr :tt i tt l tl ttl t'i t si i tti tl o ;tr l l i , l t l l i tttttl i r l 'r r o r z i l,i \'o r r ;r l i ( 'r r ,l r , |l r ', ;[t,t l |r r l r l 'l tr r vr i , ( l l ) l i l ) ) , l tg tto zi r t l tcr tl tl t l r r r tr ti p l cg i r r tl o ttt1 Ir tl Ii i tl r r ttr 'i lrrp;i l ftcr l l ti r 'l i l j , r 1 " , i l r l i l i 'r 'i l ,o : l r ) l l tr o zo g tto zi l t vo tl r r t'l i i ( ttcg r tttr l t, vcl l r tr l i i , r r ' ItcIIti 1 r II'I1 i l t) , , , r l r r , l o l c;l ,o l ) r 'cz( l r l ti tl c I t l t I t t I ri t t I t i i i l i i l ttr sl tr zi t'tr ( r l r r r r r i ;r r r 'i l i ) i l t 1 r r ttl t- :r ' 'r ' t'r tl r t i ttt r r . | , , r r l l i '1 l t) :tttttzo g u r tzi l t l r l i tr l tt[) r ttr i ,r i ( l ( ! ( ( ) l r tl ]o l l l u l l ( 't) 1 , 1, i r r r r r r l l r l r i , p l i r r l r '- o l ,ttl l r u l ttr r l tl ,r 'tr !i ci 1 r r ,( 'i r l tl j tttr ti l ,a ,i .( i l l , ( r o tl ) r ) ti tl i r l tr r ti l
lilr.

-Fi9, 31. Topografia lcziunilor care antreneaztr c g n o T i 3a u d i i v ; :

,). ,.lI: pljcile de trc.r tcmporo-nrsulare ald circunvoluliel iemporale tnnsvcls. a luj Heschl (zoDa slJdtllii corricale aldio-senzoriale);,,itI:zona urn.zi.i;,4?7I-zona suditeJli vcrbale (drpi ltsa/, 1052).

ilr ir | , i t i lr t l( 1( 't 'olou: n, l, t t t r t t iusont n. kt t t t t o:: i st t it 'l'li, ct t t isit r t it 't lt t lr lt lr r u. lt r ,r, rl i rrl ,o t r 'ir l; t l, gilt t st t l I ) ilr i( lr t l it liol'iol', gilt t st ll iilll) lll, lr r illiiir t ir l) . lll, l l ,r,, r rort r;l, r ) gllozirilplt t ir t lo ol. r icci ir L st ldit ll iloul lt l t t t t t r i I t t It t t i I I Ir' I1t t , tr t gr rr' 1,rr" r' l c zilu r lr r ; lii ic1, ns; i st i. t r so! , i: 1t$i ( lc r llt olt ll) ( illl'( r i[ ( l ( lr r ( '( ] llir i, 'ir l e t r,l , rl i uol i cr Lllr , t c.Lllcor i llccst ,silt ( honl ar c t t t r volt r ! , in t t lli lt t t lgii. i\ t r r r z, r'r1" rrr lr(llll l ll lrtrtuiplcgic sc iri,ilntrll'c .trrrovtrtrl lloll rrt'v tltt t rtl t t i l t t l l rt t l rt t t ll ii ,1, , rr ri l ri l i l't t o ( sulr or licialii i1i pr of undi, ) , t leci t lt l it r lt t r t lt r t , t t t kit t t 'slr r zir ': t ' , ,r, l ,rrti r nr r ir l int polt llnl, 'iii , , or glnizt r ol" slr il( it t lr r i t lt I I ; t t t t it |. l) t t lt r t , r rrrri ol i ( I lr ulcna, n, 1925, cil, : lI de Klcinr llcr ', [ 1) ??1 Nir : lst r t t , lllli'- l) , t t r ' rrr r,,,1, ( i r,zru ilo dc : lgt lozic : r , r juca uD r ol im lor '1iil, I L1; lt llr zit t t t r rir t lit r r t t r ': t , ;i , ,,, rrlri. l,oo*Iizaro:r, ltlziunil in crrrisfcrl rh ca1llii, (ll;rr,-zisii , I I ri t Irrt Ir ' ' ) ill ' , t,r, l rrrtr0;i oxist cl! a ulr or spcoiiilizir r i din or r t isf t lr irill'( r lll) lii, it t lt , gt lt lt r t ,r,,,r' I rlrl(tso vizuospzr,fiale. :,' , S i rrdr onr ul lui G cr s{m ar t n ; i SeLilt lcr se oir t it cl, t r l'izt r r t ziit it t t lt t t t it , 'r t ;r lii', t II t t t t t t t i i i t, ,,ltttjir.t ' l,r r'lr o[{)rn{)ntc: ?,) O afqzie-dgtrozi toa]'t(l sltiltriar r r r r r i' , r,' i , ' 1 : b olr r avul nu poat c disl, lnlie, al'it iilt 'r ii ( l( lt t I iI r 't iI r 'I r ' r lli'r '1" ,l , r,rri rri l ot'sr i, lcf icolo: r , lcr liit r iiobscr Yr ut ollt llli ( t t t t t t t t t t t r t it r t toclt it t t r llt t , r t , ,l rr rl ti rtt fi ot 1 ochii deschisi) t lt ) . l) c: or i. t nr ln'( . ut t Y) t t t lii t lt r t t l) lt t xlt t t t lt l t r rrrrr l rrr:r,l c i t list ingir par t ca dr cipt il a colPlllt li t lt r r l': r slit r gr i, t ii \ r t lt r \r r r r i:) . ; sr , ,t l r, rl l ttl i .c( lipsir de est im ar c a vil, ] or ii cil t olor ', it t rpor ilr ilil r rlr r r t rlr r rr ,r r l: r l, r lr rrrr l rl rnr t[t: oalcu] f i t lc a, r ezolva o pr oblollt li'r lr Lt xr t t t r r 1i , , I t cI I I ct t I r l I L; 'I t i r.rl rr" , i rr ser Nul c[ boln*r 'ul ignor S, ser r r niliot{ ilt lot r t t lr t i ot , t t lt lt l r lo lt lt " i, r,r rllx'r'rrfiilo matomal;icc) ; d)- AgraJia, itar fiirir, 1,t tI I I t t t'it't'rr rr I i rI rI rIr.i tt I t tr rrrt, r' ror' .A ceast l agr aiie se pr czint d, m 2] i r nu11, : lr o lllr t lt , xit r ( 'ot r r r lllll'lr vil t 1' ,rrl rrr i i tere Si cuvint e, io: l ,r' ::i tt, t t , ea cr cseazil,p5r l, ilo an1; ol l, l'of i l) ilzlI l{r lt 'lt t git t t st t lt t i t . t t ; t t r l int rrr,r,r' :' i rI1l l om is{er ci st ingi, pr collln , ) i T, ollilllo l, t t r t r r t r t lt lit r ii I t lr 'lr ir l lr il ,,, r' i l ri l rr,l (cir npur ile 39, 40 lsi l- 9 llr odt t t it t t t t ) . I :1. [l l totopoaqnozia so ca, r aot or izo{r , zil,lilI t lt r zt t lit r r t f it 't t 'lt 't t I I I ior 'I t t I t t t ]) rrr trr.p0tl ;ou Cor pir l sit u f i pr in ir r t posibilit lt l, r lt tt,lt t t t r t , l'ii'lrtrI it 'r 't I I {. I r rt t r r lr r r{ .,rrrj ul n) [i ost o g( ] t nr t al; ir(,io l( iziuni pal'icliir lo ( t lr l olr ir r r r i I ri I; t I r,t I r Ir' ) l . | ) i sir sor r r t o 1; r noziilt t t 'clt t t zinl, ir , i, t t llr t lr iili ct t t t t lt lt , xt , r ii vlr t ilr 'lr ilr t , t r' ,rrr:r,fi i Ixr, I 'l, ict Lllr ,doi sohir r r lir , t ( iiL ( x) t 'plt llli it r lt r r g , silt , sr r gt t t r r t t lt , lr tll: r lr ', rr rr r,. l )l ' i vo sl, o lor t t r a, , lt t t r gilt xlr t , ,gI 'ot tl, lt cit , volt t t t t t t l, llslxr ci, t ll. l; l-r, | | el ttltlsoopiit ( I t i t I rrrri rt : rI i rt s;ttt vizittttt'rt spctrttlttrl't, || | I | | | 'iI '| | | | i . I \, ir rLrr :ui r,rl ,ofizol, zii, 'it r f ct r or r r ot t r t lt r t 'r r r iilot ': Ut r ilt t lr ir t 'i, ,ir t ( f it , ?,'ollr 1 l) r ilt lt t l r' Pt l rtrrr i r [l t , r r , lt t i o it t r lgit t r r l lr t i it t st r li, l) t t r l) l'ilt l $ii't t , , r lt t lr lt t ". lr ) \ if lt r lt l\ ut l rl r.r' rr,r'lrr l, r 1oi. ll, lr i nor r ol gli, lir r t it r , , Nt t il, t lr r l) t 'r t r iit t llt lr r ) 't lo l\ lt t t t lt i, l, l rr li\ l l r,,l l ot' l l !1' t lr r J\ r lt t , t t 1t it , t lr tVrttl, .r t 't t t ltlr t lt ugllulir : i : lr r zit t t t i lt : t t 'it r l'rot 't I iI r i|, I t , I r t , t l, , t rrl ttr;1i .

$.1. AGNOZIIL]I IMAGINILOR CORPORALE.TULBURARILE INMGINII (SCHEMED CORPORALE

Irrlr,sincil, sau schema corporal[ este o noliune foarte complexi,, caro lrrzrrlii, rlin iltegrarea multlplelor mesaje senzitiYo-senzoriale $i care rurrrsl,iiin pel'ct:perca fi reprezentarea exacti', in fiecarc moment, a exisIrrrr{,ci ,,eului') rrosl,m corporal in ansamblu qi pe segmente.Integrarea lul,rrlo:: cxciLu,liilor senzitive supedicialet profunde $i Yisceraler a1e celor r izrrrlc, lrlbirinlico etc., permite in permanen!5 r,conqtiinla') eului nostru r,or'pollrl in ftnsamblu, precum ,si volumulr pozi-tia exacti, in spaliu $i (lr,r | | rorror [a diyerse]or segmente corporale. | r ,)\ isl,ir, urm5,toarele ti,puri de agnozii.ale im gi,nii (schemei, corporale: f ) l. Asornatognozia constr, intr-o nerecunoa$tere sau o ignoranli, din subitxrtului (in lipsa altor hllburdri psihice) a imaginii propriului 1r:r,r'l,r'ir,
Hli,lt (x)tl) :

(sintlromul lui Alton qi Babinski) apare 1a bolI I rntinsomutognozrla rrr,vii crr lrt:rrriplogie sting5,,manifestindu-se la nivelul acest'uihemicorp card,aterfut;iae Nerecunoaqterea : a) Ii rrr lrrlrrcl,clizoilz[ prin citeva si,nrytome rrirr|r'rrrrrLir.ii, o parte a tulburXrii morbido, a paraliziei (anozognoai'e )t 1rorlo pirralizat I b) nerecunoaftereahemicorpului stilg sau a rrrrgirrrl r,r'i,e lii, propriu-zisd, r' c) uneoli llrlli H(lg)rl(!nl, hemicorpului (asomatognozie rl ) irslo vorlrl tlo o cornpletii indifcren!5 fa!5, de acest' hemico4r, pe care il igrrrrlr'i,, liirrrl o ,,p:n'tc inuti]ir, a corpului)' (u"nozoLliaJorie d) alteori c[ ); i6i rrotttlltelo, dal lo polcoll dota\sate cotp, sau defotdc lrolrrrr,vii r'(xilllro$(, rloLtti, htttnicor(:llurrgil,o rna,i lrrrl,r r scrrr'1c) itt unolo crtzttrioi perccJl sl,u I o) sulxrtir)t),sittt lttrttop tttirytilri tttirtttlrtu ttrrttiir,l l,tttilurt, sl,irrgi(ilrrzirr, lrrrri itttollilrr (iltr:tii l;irtrs tzirrlJ; l) rrriri t itt'itr I'oltrryi itr n;xrrrl,rrrrr rrrrrtrrIltrr|o !'t t;

)'t'l

li MelrrhrlJr, hurrontll:.t.\ ,llrurltul .lurthnld ul tultutolil,r rr.pr.,.zirrr.r.l . . . ik'(.iIl.ll.I'L|||I|\.|||IIrrr1rtrirr,I lr'.rt.t.ptl:t rrrrtrrllr.rtltri lr, 1x.,rlr,,irrr I rrrlriI .rr.rll, r,ir, -\li'r.l,ntl r.slr. I,(:Ir'|,|)IIi, li,ri0rrrr,rr r,.lrl, <.u rrr,,i,folOgia rlirrr.rrsirrrrilr, .ii r.r irlu,rr',i lxr:rtc tr l)cl.(:rT.rltt i.uIirrtl ctr mi;r,iu,i suprrse voinlei ;i lrt.lr.se:l r.strr l('flr,ll rff.f{f lnlr'rts;.lt) ll[rnLreb,foh-lomA urirrtputu!i sintirxct,priurlr|,. lu rnl,/.l|u it,ti: r ct(.., r:urL, . . .lrk:yuIilot, alo }idiciuilor nervoase,gangt,eur. I t l)r'r||lir (,ttouiLl r lrlrtltbru, not an^ll,cnr, rnod jn-icrntiterrl. in p.,rr.otirr rrrrrri. rrrr.rrrlrlu lirntonli suprtiul sau fLrzionatmembrailui Daralizat..DIcm_ rr*. I:r.1r)r'i lr,L (xislil ;i la buloarii cu secliune compleli iau llti Inziurro :r nrirtuvr.l sl)I|tirnl,TlrccumFi in lcziuni talamice pal,ictale(ir.,,pi,,. t 7. 'l'ulbrrrririft.paroristice ale somatognozieireprezilLi fonne parli, , , , |,. rrLrir'rrr.i ,.pilep1icr., cursul cdiora boLr:-rrvrrl in rriicglc ,,iuilar.a, I .i I l. -l : , fl,-r rrrl.,r('sl{. t4)scDtoun henieorp, d, qi-a pierdulr rn membru siiu ull Alteod inceaici, jluzia ieplasirii corlnlni, tlctapi,rii ::'fl:t,..trt._,,.t. -1",'Tbru. urrui fautomi.i. ,,u,i ,'rcrrrbnr u sil rra,{,ii gildim lir o epiiepsiefosali, pariettld, (tumoraiii,, ,l:l]:1i.ll.:srndrm rro va,s l/a,$crlarti,, crlilrli,, lli
I r'li,rrrrur,tieii ctc.).

I n

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votuutuJ lNAt'AZtl DD iu rtrr,uuR,4nu,D $t

DE r)lt()trLEME DTAGNOSTIC

:illllilll::',,b1y..ll,L1zjra -l u c i n a ti e l rrl l rlr : r . r ' , . au tliie\tee o h llir i ,.{ l o haiucina,lie h o a u l oi copi ci . in tn1, .,rro" *irro heautosco;iricir,, fa(a rrnor ai al o in .Fau ' ii']].'.,.1:,"_l

,.mernbru

sirfla-

l)li volllll ltli r0.1.cLASIIrICAltl.lA'l'ULttURARIL0lt

Dxist il dour Ygr t t pil iLnpor t a, ut t r t lo 1t t I I t t t t 'I it i t lt ' t r t t lr t lr ': l . ' l ' rrlbt t r ii, r i alo cr t isiunii qi : r , r t icr Lli, t iicuvir t lt , lt t t ' ( lt lr ) I I I ( ! ( I l I ||I I t I |||||I l ,rrr.rl rrr' (lo at t ioular e a ct r yint olor ) . ;i l l .' l ' ul i ) ur it r i ilL) r coepliei, cor npt ohcllsit lr I ii, li) nlr ll lij'r 'ii lt i r , r I r 'r 'r ir 't ,r" rl ,,,l rrl i l i r vcr : bale. Aces|t a cor ut it uie af llziit , , t r lt t r t lt r r , i t t t t lt lr t lt t 't : t t lr , r 't l lor Lilii. ' , 1,.rt, rl i r r lulbulit ilc

)lt 10.:.TULltuttARI ALII EMISIUNII ARlrOULAltll(itlVI N't'l{l,r $I PR0PRIU-ZIS I)l'] All'l'l(llll,Alll'lA MI,ICANISMULUI IT0NATOB tAl,lt '5[ CUVINTDI,OR)
l i i ri , rrI innif os iili pnl, ologioe {r il, t 'o pol' r t lit t gr r I io sl, lll'llt r l' t 't t viI t I r 'I ot , l, l rrl l l ut 'iu'i f ona, t or ii ] ) r o?I 'iu- ziso ( t lu r r ut isit t t r o ; i t lr t plr r t t t t t t lr t t r , r t , ;,rrrr l orrr:rrrcl ol5 i n silabelor ) , f io alt t r or t ia, , lil, r r t t t l, r lollil't t l f i r ', t {lr ) r t f ltt' or 'lt t lit . f' r' rrl l r 1r)ilt ioaccst oa s0 t ozt r l'vil,t t t t t t ur t lul gr r t t cnll t V' t li*r t t lr ii, lt t lt ult 't t l r rrol rr, i rrl ,t '1"i, t 't o r t t ult c t nlbr r r iir i: loit l . ' l ' rrI bt t r ir r ilc t lo t t nisiunt t si ( l( t l) r onut t lit r t rrr rrrrr rr rrrrkr gnr po r lo l) lt , r lilif sf iiI 'i ( r illi( x) : 1 t t t ()t l || || ||' | | | t ( 't t l) l r r r l

, l . l )i xlul. it , r r r r r sl, liir r ir r r posilr ilill, lclr ,r lo lr lr t t r t r r r t llt ir , t r t t t r t ilr ; t t r r , ln gt ( r,rrr ,' or,LIr it r r r , l, ii iit r t lr 1, t r t lot t iillc, lit , bit t 'lc, t lt t t llt r i1. lt . ) . t \ t r t it t lir r t t lor r t r lo l rl rrr l r l ortt lr r lt t r lisllt , lir; r ,t ) I)i .- l t i( , , p( 'nh't , su, nt 'lt 'lr r lr t r lt lr , . r 'ot r sl, li ir t it t t Posilt ililr r llr l r ll () , tt ;rrrrrrrrrr(rr , r 'c,ir , I pt ot t t nr ( it , r r , lr r lllir t 'l, t t oit lil, r u i. it t t t r lr , lot r l, 1, ,H, z, r i, , i, t t t ir t t t lr r t t lr t lt t , r liHl; llii r , slr rt illnr r . lisnt , n.rl: t Lt r ir iir ulr t , l rrl rrr:r l rrrrr vr r t r liir r ,r r , r . r r slr r i lt l rl r Il rnl l {, ilt '{\ il r lr lr r r l't r r r ir , sir,,t it t t t r r lr lloln, z, t l, . j. At x) r l,Niijlr lI liHr t lr oillt t lit l l Irrrrl ur rl r ' r , ir , t zr r li\ r l, r , lo ( lt t lr r t t r lii ir t it r t I r lit , t r I lt , r ',r'r r ,r ( ilot , t ir , t t t t t lir t t r r t t , , 11lr I rrr; rrrr,i ( i l r , t t r ir r ilir t t , lr r t i l, t ! , jt lll! , lir ll, lr lo; ir t r io) r yi r lr r clt 't t zt rlt r r r lt 't t l, t t I r

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i i { ||I|I|II|I II i r 'l ( r l ,l l :l r I r I rI r I ' t I r i Ir I rI r o tr 'l r l r t r l t|I |||I |II|II r II':ttIIr o tttr "' l :ttl t 1 'l tt':tl t,,tr ' 1 tt"ttttr ' tl ttt I : t l r ll r ',l 1 l l l i r 'l l l l . \r r ':tl l l l t r l ' l l r ItI ItIItr i ' r :r tl r ' ,'1 r , l l ' r r L r {: l , ,1 ,,r l ,,,1 ,,, r 'o o tr l r t t r '' l ' r .r l r ' .r r i 'I:r It':r t'. It l ' l r r r r l r 'r l ttl \r l ',l r r r r r ri r l : r I , , 'l l r t t r t Ii zi ttr ti l ,' r ,, Io Ir ttIr r ;r ''i ,i t r l l ; r 1rr t : ' rr r ttl '.ttr l ', 1 'r l .t.l r t l l r l r i r ", l' i , , , i 1 . i tr t t t I t t ' I:1t t t r' ,,',, 'r 'l r r t "'ti ' "t 'l lrrllrrl r r r '( 'r 'l r r i '1 ,'u r l i ,,,',,,,' l ) l i zi r .r 'l r i r l ) 1 r tr r :r r r .'!i r 'r tr r \i r l ' r :r l l r l l ; ; i ', 'l 'r , ( ttti tt , ' , . '. , r i : r |i ';i l r r r l i ;l l r zi i ,

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ttl r i ti t r r tt , , ' , l r, r l i r l i i l ; "\o }u ttl ,c :l stttl i l t ;i o IttIJIItIi Iti I l t' l ttl i r l ""l ' Ir r i ' :l ) :r |i r r r r l r r r : l r l r r i \\i l "r r ' r r r I t ; , t ,tt;i 1 , l r tf "l tt,tt I "r r :r t' "zr r l ttl r l l r r i \r '1 t ,i ' f""l r i ,'',f'.ff.'i r ', i ', ' 'r ':r i ttvtl l L ttl l l r ttr , ttti i r t'l o tti i : t I r' . t rr t r I r' I r t I ' r t l "tt t t i l r l i i ( l o l o tIL ts, sl l l t,sl i ttr \l ' l ( fl '!l ( i i i i l t'i L r l i r l , tl l l r 'o l r ( 'l r l r ''1 ' , , , '. t , r r r l r l l I,^ r l .i l l i i r r i \{}l i ) i l i i l 'r "r ' Ittti r r tr r r ': ttr r l 'r l r r r l r ' tl i ' , , i t , i ,,r i t'i i t,,'r a :ti ,'tl l i l l ( r ( :'III) Ii IIIi i I'j ( 'i l r ( f l r r ,r r r r l l r l r r l r 'l tr r r 'r r ' 1 ;o tl i tttr i ' ' , r l l " r -r ,,i ttl t^ si tti .,,i l l l l l ttr i r tL l l tl tr ) 'i l t' r i t I l r r r r 'r r l r 'l r i , r , , l , r r 'l l l l r '. i tl l t ttl l sl 'l l tl i tL l l ttl i l L r l l r tsr l i , i IItt IL tIIr t Il i It:'o r Ii l tr i ' r , , i l j ttt tr ti l i l ) l o l l u l l l i i l i ( r ti l 'r 'i l 1 l t 1 r Ir If I ,' r l r ', l r 'l l 'r r r - L ttl 'r r ' {l i l t) r r r r l ! ) i : : i ttr ti i ( tt ( tti s.l t i i l t ) r '''; 'i t 'l r 1 'r ,r 'r "r ' I L l r r l l '"l r r t i 'r r r :r l ',r ti ',. " ( :r l :r r l .r . , i , , r ' i'o l l i i l r ', i 'l i i i , i Ii t,'I' ''''/I1 , r' r L :r tl " l r 1 ;l r r tl ttr r l , r r r ' r l l l l l {l \t) i 1 ) r ,l \'r l tti tl o tr ti r i tttti l r 'r 't'r r r tr l r ' 1 1 1 1 t,i, rl I :r " r r r l l tl r r l ':r , , , , , , 1 r ,r ,l i l i i r tt'l ) l l ,l l zc. i '( 'l i o l l r i {l i i \r Jl l l i l '( r l tr ttttl r tl l t , , 1 , , t : it,l ttl t, tl r r l r l l 't'ti l l t: I0 l l l l t'l i ',tr, ( l 'r r tr r r r l I' t 1 I ) i ::Itttti i Ir : ( d i s,l t:i i l t ) tr ) t'l tr l r tr r sr , tl r r 'l o l i l r r i r r i l r l l r i r r '' (| I i i I ( )I l 0 r Ir l o r i , r ,f ( l l r 'l r 'l , r 'r , i r r '']r l r r r r , l , , , , , , ! , i r;r ,.,.i ( ,i r 1 i IIi i r o Ir r r r i r .i I I I I I i . Iti I t t I ' rr I : I t ri I r I r r 'l ' ,, ,,, , , , .l :,,,l rl,,i , stttt st'l ttttl l i l i i , i ) fi r l l l ( 'i l 'r t tr l r L r zi i :i , \ tr l l ) i l l l ' ( l r 'i r l r 'r r r r 'r l |r l , , , ', 1 , , r' It ' It t I t rI I I t I r' ' ' l i i l l l 1 I) IIII) I i IIII|1 ( I l l .l {'l l i r l l l l , l r 'l ) r l r ' l l l ', , ', , , . l r ttr tl o t"( 'i , f i ' ; ,', ftr 'si l l r r r r r i ci l l r r r i i r l i ti 1 t;r t'l r zi l r r r r l r r ,,, (lr' llllrl" rt r "l l t( ' l r r r l Ii l i l r :i ' ( 'l r 'l l |'tsl ttl t' ( r l ;r l l ( i l i r l 1 r ,i l l l l ) i t , , . , , r I l l \i l r l ( I r : r l , i . r 1 , l 1 l 'i l ) . ] | , t t | | lttl ttti ItItl l ,Ij l '!) l l ||ttl ,ttr ttIi ti t.i i tl .ttt'r d tttttl tt) 1 l l |||||\|'|. l l l 'l ) l r l l l i r l ''l "1 l . , , r | , | | . |. , .1r' t:tttIr IIi IIi r l r ' l r r t:r z l l t tr ti ;tl t l ) l |l l l ( 'l l ' I' i r l r r)ll r r 'r l r l 'r r i tl t' i ( l ttl r l l l l l ' l tr 'l 'ttl l r t \l r l r r '.") , l ', 1 1, 'l r l t "l l i r l r l l l ( i I l r 'l r l |tl l {f l r t'l r l l ;i l i l "l i r l ( r l l l '' ' r r , , l r l L r l l ', r 'r r i l 'r r l r r l l l tl l l i t'l l \ l l l l l r :l i r r '{ r t r t l r l 'r l tr "l l r l r '1 tt'" , " r . , ) r '1 r , , 1 ,,',,, ,,, Ir r 'l ,r tl t"tr l r ' r l r l l 'ttr l r 'l ' r l l l i ':l l' l l ! t r' r' ; 'l I I

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r r r r r Ir l i l t sl ttttr "l 'r t t i l r l . r t r l r r 1 r ', Ii i i xi l l ttl m ti t r '- :tl tl i t't'|' st'tttl r ti ti l i 'r',,r,r.sr'1,. ', , 1 l t,zi tl ttl tl s| l l l l r i l ttz,,tt:t ' tt'1 "' r , , , , , : r s i v r l Ol tl cl t l o l l r tr r ct.i t.i l . su l ) stl l r .ttl l tl i ttn i tttL ttl t'' ( , 1 , , g r , r s i o t'i u i t,t'r 'rr tr i & i l 9 ) l l ci tr i l [cr ci ' te r b r t[r i : - '\l t'r i r r ' r tr l l tr tl i i Ir tcr Io ttr i tr I l .l l t l . l l r .t:i L r , ctl l ttt.tzi ci i sr r r 1. I t , t , ', , , ', , t : , i 1i i tl t :i l cr i l l L i ttr l l l r i ; ' J'cl tttl r t,.t'i tttl .t'sl r ' ;to r i i l ti l r t' ' l '' i fl ) i r l r r r l r r ; r l r ' r 'r r l i r ;r l r r r l i :' r l cp i tl r l ( l o n i u zi i l e l i l e tcl o r 1 , 1, . r ; ,l r .r r ' r l |g ,'l Pl o I si r r l r ' ,r r .l r i l r r r , t'r tr f III||I IIt i I L r L r r , r , l c tr r ci l i tl l l i i i l e r n i st'i L ti l r , i tr l tr r l tr r si l r i l i i r i l r l " r l .' co tcsp r .r n r h 'l r l i i sl Ii Ii i i , , '; i , , , , ; I i ti ',r e i ; - - l l xi sl ,i l 'o r 'tti i tr i t l o r ' 'i l r 'l 't r r l r ' I , ,f,,,ii.,,,,i"i - ,i ., .,i i ,.p ".,1 .,r r si rr tr g 1 .l l r r l o ttr l l r tr 'l i r t, t"" o s1 ,tll o tttl r i l , tl r tt t'ti l ti tttr l t l r l t i tr r 1 r o Ii Ir i IIr ' l i ' , l, lrorilrilii; - Scl i sr i l r r l :tzi r '' l tr ':r l l l r 'l , r , , , . ', 'i i , r i i i i ,i ,r t,r l - tn l i x'l ,ttl i i csl r r tl t'o tr l i tt p o i l r 'p 1 i r '1 i ttL t r t I tl r r , , , , i , l , . r r {il r zi |i i l l i 0 si r tr U l ( t r l 0 l t,g ttttzi r '( l t l ,r tr r tt'l ( ,r '( t'r tt.l ti 'l t i r ',, .r 1 1 1 '1 1 1 i ;;l .r .t r i 'r tr r r r :l l l l . so ttl ttt' tl tr l cr 'i l ttttr l l tr l i l r i {l l i | 1 " r 1 . l r t t c tttr t |i l t'l 1 r l r tl tr ,) r l r , r r r r r i r l l t s i tr I I t t t I t t I I t i t t I l - l tl tl r tl ti i ttttt'l t' t'l tzttti ' l tti tt l r "r r i tr tr . r tl tl l t'ttt r ) . l l , L :i l r tl l tto :i r r i si a ,l u :i ti .l tt r 'i l fi o t'l l i l r i l r r l i i , sc l 'r 'r r l i zcr r z'i ir ttttl x'l r ' l i 'r 'tr tl r r ( 'l r r r r l i r l 'r r ( r , ' , , 1 , , t " , s l l ti ,r tti l i , \r t I'ttl r tr '' l i , , i ; 't '" ' ( i r i si ,t',,i i 'l p ,,:i ,, 1 ,,,,,','''' i tttttr r tItIr ', r l r r r '5 i l t.i tr l 'r .r '( ''i ( ' "i r l i cr l i r r .i l :r i l ,tl l t'l t tl 'tt'l ttl tl :t l to l l l l t tr r l ttl r ) , . , . r r l r f t , ; ,s{,l r ;i i l tl i l - r i l l i r r tti , l t tr l r i r tl tt l t t t t r I i t t t I c t t I I t I r I ( si tttl to ttttl l l ttl l r tttl i ti . '1 . i t t r tl r ttl t, l ttl l i r tt t tl l r I r i tr l ;r i tt l tl :r l r i :t \\r r r tti i l 'l i l l l l l r l r l ") , r , , 1 , , , i , '" i si tttl to l ttttl l l l i i l 'i ( r i r t i ttr r i sl :r 'i i r r r i i f i r r ttt' i \l r tti .' : l r l ttr tt tt t t r l l , t r t r r t i l t o ti i tt 2 si ,l ti r ', l tr l ttl r t l r ci r tr tt l t I tl r tl r 'l tr t Ir 'tr t, ttIItt,' i , , , , , , , , , , , i i t , , ,,,i i ,,.i r i I r, , t r i z. 1i i I r l .r . r l . r ''l l r r .r i . r r r r r r 'r i l l i tr i I I I | | | I t I i l t i I I (' | ' I | | I I I I l r r l , 'r i L l r t t i r ', g co ;.1 t':r l i l r 'l r '.,r i r l i r r l r to l i 'l i r t' l r tt r i l l l t I I I I I l r tt i tr l r 'l |t l ttr tl i '

liciirs...,i i, uicrirr rllrzir.iL i l,,t,"i"ag.,i.

:It /

lr .ll. l,ltr:irr, orolir corrsr:jir irrlrrsirriJitlrtclrlu t,-rplirnar,c vor.bil,rii,, ,4,r'rrllsllll st,r.isii. l.iolrr:tvii illr4eg cr.el_ce se spune, jar nu ptit, cvoca li rni..narile corenpLUzrjloald ].,'1.,.\l'tUnir trr \'utbrl'' ),:,-,rll. fcnilu :r.s(, 1t:.1]..: O.rlii. .inrrr.rrrrru;,.Liimiinii, pentrU a ScCipriml rrr vorlriro scrisi. Afazia, rnotolie cuprinde 2 forme- principale: i,fazia rrrol,olurprlrpriu-zis?i, (alemia) qi agrafia. .1..Ll.,fcntkt {.a;faziamotorie propriu,_zisii, (mu,tria lui ptene Marie ) lrrrrsl,ii,. imposibiiitatea dc exlximare oralii. Este produsi, il ae feriri"i af," ..r)11111'_i. yorbir.if:lrtioul:lte, localizat' in piciorul ,,irnaginilor.t) trontatei ,i;r. rI i rr .tilr{l r.nnl ru I lui Bluca;. r,u r t t, roI in eLaborared-iscililor mus_ m , . ,'r' . {r l,)rrirl,rftrn llrnpul !orbirii :r.rticulrln.Spr" dcosebire de muLism, i rrll ul irro(lurnrlecolo lutr inasi\.e,boltayiiflot pronunla ci.te,uncuvint, o,\i1.,l)ii(ta-ta,_ti-ti,rnil-ma, da,._nu etc.). 6i fa; efo"iui, urrror_,e p"'tru 'rr rrrrlr.i. r :rrrL.dr'zola{i i'a.cihili rlio-r.anza nerou.itci Lenttlivci -lur ;i de .r ri,)lr'r. lolu-rocltdoiol gl.slU.l ila|gi. ln lULmele mai Ufuaro,boitraViipo0
r' \ lrl llrl;b ''llo r:l .'U\ r Ulp "aU I I AZe Sr - Ut 1o. \ d c s e t Ci SpUt: . , s l i U , d a f 'n U

l::illl,lll

,:,'l:l

crpriinlre,cu al1,c ll'ill,'rL1r'rr i,ii fon;rturi. cuvinti ci s'"oru,in ii"posiiriii_ ru rnl.r,

indicind prin moiliiic,ri ale fclei nasl plin gesluri, ooea ce estc incapabil si, cxprim6 prin grai. uLr.r Exprimarca r u loirrrlrri (lurniratul, denllrir.ea zilelor tlii si,pfdmin? sau a lunilor rrrrrrlui,cintatul, recitarea ulei poezii etc.) este inai line conseryata. .irr rf:rzi:r^rnotor.ie}Julorn intilni urmiiorrele grupc dc tulbur.iri ( ., .1963). \rir.t,';l|rIlrn.(Jmtlredaoeli J)urrnd, j939; llolalli Lhct,rnj e. ;t) il'tr,lburdri artrice. Dez,integrarea foneticd,. fntensitatea tulburiirilor {t(l (,\l)i ll1il,rc..(:inartlia,duprii,unii autori) este variabili,, de ta sr"Lpresiunea

Alreori t"t"'avii uiiiizui"x p""i rlroruntii, ll:il.^.,ll:l.9iflii1loc d_e substa,ntivele. tjl ,,qutri"sptn :.,,[staestecn caresetaie',). Deieori l], i:']il::-I. r",llrir\.ut r{r rcrzi nrilrri,.a.crpros.i\.ir,

1r' | ll| r.]rii itt{.r ttt.

:l,l.,,flli:.].1:1ll.l,i r.\l4r, l|ol1iJ (in(,la osle nocc_'l,t,i rttilizlrcr dc lcste spenialn. -tA;;;1;; Din'prtnof r.lr v1'11911lorLcticr estc net tletorrnnti. r-i"earizareava-torilo' cirrc\e, 'orbi.ea rompLrre limba,jul necesiti,o a ',1:1.]'l::' , lllrrUl llll lr.Llre[[, a tensirmii corzilor vocale, gi a "oor,loo^l" Ierfectii, lrrrr'. r'r'l r-lilringiene' caro sint proprii, adec.iiatle ,,forrnuleloi, rnotorii tietliirlii-ton"m. s,presirir (,, si/ riiL. deteriorareafoncmeloi crpr.inrl: elizi.ni, asimiliiri (ex.';;ii ,ll l,'r ii. Fnniiiruri-. pri,{rcl rnluc,lc,.eslcl ctc.). orrbrririiili 11,ci. l],11"'j (bel.rilou iuc dc [ribelour.npc||inzo mel:1rozo iu iilll'lr,rrrI I "l' i ll"'l'11'i'9t,t, ll: r.ir rLlu( ( |)||, de tliblioteci,). Se mai prodrlc unelo modific5,rif6netice, r rr : rrlrzir,lizl,r.cilunor vocale dcschise,_ diiiongarea unor r,-ocale,asurzired r'r'|)r'{'r)rso:rlre sonorc' o red,clie g10bal[ a varia.fiilor mel0diceaie vorbirii, rr r,,Lt:r,lizir,r.. a, accL'ntului tonic asupra fieci'ei silabe enuntate etc., merEitld lirrii lrr rlislorsiuni fonetice complexe. A):i,joualirre qi .,;trlr. iig3g, -i?.6ti rrrr r.rrrril, i.i[lic aceste tulburi,ri an:rtrice qi foneiice *.,b in";;;;i d; ..;rrrrlrr'rrr rl,',rlozinlcgrlre font.lici.'. _!nsi"lirid1i arupra apra.:iei buco_ r:rr'ri|lr.,tr lrrt ,rr r ntlJZtrcflar.oSt0t, i Itdllut,-ri aie eSpreSiei oi.ale. lrr .urlrul turb,rEr or de articrrare are afazicirormotori se situeazi ..lr) (4l.iitc(Alajouanine colab., 1939, 1964; Iloriad_Krohn, itt ii.\ltt(.': ;i tS+Z : I i, )rr,z, | :r(iz). Ao(,rtrt,l touic,. ritmul, tonalitatea,,timbrul si intensitated, r,r':rliz,.rrzrr.rrr|'lorli:r,.siru.l,rozo(lin I).jn pro.oai, oe ;t,teteE rorbirii. variatiiLc
li, l( lDt o l, r t lAlr - t . : j do r it m , cai,o cOnfOrij t.Orbirii tliVCrSe

p0sibiLif de,crprirnare, ititor pinilla tulilurii,ri

r'.) fltt,prt:iitt tttrt. lintlttjttlrtt. t\lrtttliIirt.. I|\|| | I)|| r'I| |rIrI lo:r rrr:r,iit rlror' iirltl'L lr, un(,f lr,lit,zirri rroruljr irrll o lrrrlrlr{,ic rtrlrrrxirri lr, olrr,lc.lrlrlrlrlrilr, r cllrillli 1xtn,lc lii-- rlrrpii, clln jt,ln llrrrirrl,il, 1,ulir,l suplitrrir,l,i, lr,rlrrti slr,rr iil ( itcva lottc,rno: stolcol,illiilo r.'ct ltillc. So inlrelcgcptin stttrol,iltirtn'rlnlt o t eductie a limbajului I'olbit, lir, o e-rpresie i s1,oreo1,ipir slrr ir'1,r'ii crr sr,,rrrrr lirltic lingl'istici, ca un fel dc .Loit-motir., caro Jacksor)il colIrIrIr,r'Ir, pe r'rr tttLteflen de org5. Aceasti, expresie stereotipX poato fi corrsl,il,rril,ii, rlirr lrrrorne,tlin cuvinte sat dintr,un fragment de frazir. Io }itr(llrrsul r.orlrl lrilirii, afazicul i$i poate recuper& unele formule &utomalrizitt,(), pol, r,rr,r.rr rlot'eni,in mod pasager, noi sterootipil. Se intilnerytclroovenl; irr lrrrrrlr, lornncle intra.er.ebrale (temporale; Arseni, 1980). d\ Agramutismul se manifestl prin imposibilitatea rlo I rrlilizrr lrrr' rrttrile (modurile de a$ezaTe cuyinbclo{ in Im,zi,), cuyinl,cl0rlri logiil,rrlli, a rrrotilurile qi formele grama,tic e ale verbelor. In cltlrnl lt,gnt,rnir(i,rnllu! irlliilnim sirnltomnl denumit ,,stihr,[neorilor", carc conslir il rrlilizrr,rr,rr lirtlrnlui la ilfinitiv, procurn qi simptom[l ,rstilul teLqr&Jid), r,it,rc r.orrslri irr omisiunea ile cuvinte (in special de legi,turii) rlin frazir,. c) ParaJo;iilr, j arou a;f n a,zi,ik:,tlisinteniile. Oa ;i in a{a,zirr, sorrzolill:i, rll iitilziir nrotorie scpol,intihrj celcmai lariate tipuri tlepm.tlittii ,,ti;jtnlrttt rr/,r:i;. lsupra, r.irola nu mai insistiim. La acesteaso Ldlrrgii rrrrrlilrrrlo rint.;xit, (d,isinlari.ile care constau in aceea c5, irnbiutr,r't.: :rr':r,rr.|rrr, r, rr ), l l lzelDr comportir, confuzii. Disintaniile, numito qi lrt il,-l{l rrll,isr rr lr rl il .,rlslarnatismeimpresive') se diferenliazi, de aglam;ltisrno l)r'ir l,(,(\.r,r'r, rlrrc tleosebirede agramatismul adevdrat sau exprcsil', irr r,lrrrr cslr, r'rrllrr rl(rritil.izareaunui limbaj simplificat, in disintaxii cslo volllr rlrr o ;rir,r'rlr,r'r' rr r-i:tloriielenentelor gramaticii si ale sintaxei, cr,l'orlrrlr, lrr,rrlilizrrlr,;r, l,,r' rrfoorentii, la conluzii in orrlonan_ta cuvintelor'. l) $i in afazia motorie se intilnesc p erseue il.( fi inlt).1 t'ii.r ituliilt' ltttt
t'u 11) |1,,

l, (i l s (,,..u l l x l l trtv rtl rri , fo i n ,t. atl esoi t, vorl l i rti ;l fi i nrl ' tyni si , ('t Il t i I ri (.| {,]rI I I I I lL( ' (' 01 (l(' l i rrrb rLs l l L i rri i . , |, :.| t

oslo I)r1,2(,rlrc altoratir, afaziilcmotorii, incit irL ].1.,.,:1ll!,..../.1'f',,*t1, ,u l grosolan ( i l l .rs''r. ' , ' . 1r , (r , lr l

g) Unii descriu in afazia motorie o anosognozia ult:.ir.trlrri, r'tlt u. rtinst*,in aceeacd,,clemulte ori, ca,racterul patologic al l)r'rr(l(,tiiIrr r r,r'lIr,lr' lrtl este perceput de bolnavi, car so comporti, ca qi cLrrrr vorlri rro|rrrrl. :r| Accgti afazici anosognozicisint intr-o staro do oxcilrr,!iop),ilrorrrolorrr,, iin cruberanlX, qi logoree. grr,rrrii t,iiLi: Pentru enamenula.faziei, ,l, m<tlorii se ulilizc:lzir,o lrr,r'gii 1r)Teste care apreciaziibilanlu1 posibilitiifilor lrlir,rrlilkrlii: irrliirrrr,rr, rlrr a se exprim& liber asupra diverselor subieoi,o;soli|iirr,r'orr,,;,r.1,;'r,Ir,lrr, li)l}eme, cuvinte qi fraze din lis1,eintocrnite de nr-riirr lfl, li'I, in( rl, lr, luprindd, cele mai diversevariet[,!i qi ansarnbluli<lclirnrrrrrrr, r,rvirrlo ilrr glirrrrirlrlrrlr'. solrir,rrlir.rr;i fi de fraze. b) Teste care apreciazS, ,,va,1orile" ,\stfa'l, vor studia sistematic: -l)osibilili,tilcalcov{x'itlr)rrlrrfrrrirrlrrlor'; se :ltomaliiLeYalorilor fonenri, eiprirnrl,r (rlcfo}rrrriIi:rlo I|lvirrlr,lor', e itiltrcuiri dc cuvinte) ; - natura lingvisli.lil il cnviulolrrr crrIrIrrllIIIrr ir,l 1rl)sl'nte (substantive, a,rller'be, olvinl,c rlc lcgii,1,rrlri,) r r|,Irri r,r'r.rr, rlrr ; irlitmalie :l limb:ljLrluioxplinrirtl - slllJfosil.lrrilo llolilo irr rllrr.l,rrlrr, sarr .*rrrrrfiicnlii, rL I razolol,. lnc:ir,.llrill:rlg0r'1i ,lirrlis()rr (cilrr{,i r.ir rlo'l'issot, l1)i;(i) 1r|olrrrri lirrrrrrr llt,jttl sri Iic si tttlilr,l Itttrc(,il corrlrrr{,rrl irrIrrlor,(,rrlrI irr rlrr rrlllr,l silrr ryilr,lirr,lil, litr|i1^ trrrrlftr itr t,r,rrlrrr llrrrlirr rr,lill:r:rir.i rrliliz;r'ltzii slurlirrlricrrrirrl,' rl0 irr so rlic: - litrrlrrr,jrtlrilll\1lttl rrrrlorrlr{iztrl (,,girl:r Iitrrri") ; lirlrrrtr|rr|rr tll rlo rlrr r,rrlltz lilrrlr;r.irrl il lporrlrr.rr rrrlir,l lrttlii,'{r,, lrrtcttlir', lrtr,, :rcr.r'1riIrrr', I
il l 'l r l ) i r l '1 .r 'tt i l ttl r i cl i r , l xr r 'l o l u tl r \ ( l r r r r r i l i r ., l r r r r l i 'l i u r r r '. r .i r l i r l i r l r , r '1 r .,) , r 'r r ,r ,, :ll il,

l rrr:r lr , r lr r r r ulr i o l rl tt(' l i l rc t l .l tl r. i l l rl r,L r,tr ,rru\ i l l l cl rl t i i r l l l ol gi l l rr,rrl (' i r l i 1 r':rz liI lir r r lr lr , j rrll rri rr p l rrl x r ,,< o l rIIIrIr.' ' (r! i l l i ti l (' l r[c{ ,l i \ r' . i *r \ ' orbi l c:t H p()nti nl i i si rl -i r ,i l r,l 'rr ' f \ lr l r . r r r r r ; l, o rr, l o J t .rrtu ti n rt l t) i tt : l, r o rrl o |r r r i|s lc l0t (l o rn i ti s l l s , (l i l l c o l l \ (r ' sl l ,,l .i l (rrl onl i !; I)s ul i l j | i ,ri o l ri l rlr ' lol s l, r L r r ,in tl g i u i k rt' l l l e z c u l i tto l l rw ri u rrLttl ui ; Ll oscri cl e;-u o tl i l tl tl lrolrr:r,r lr, rn{ri $(iori) lLriLlc siuLlligut inl,o })o u}r tabl{)lr I .- l?or-estiltit, rlr, i .rrlll lrrr:icrrl,N rrl{ji isiolioar'o (are i-a iost e-\}rrsi i - C'onstrutca tlt i.r'rtzrr r. (lolii, l|oi sjt,rrrll:ri lmrlte c[\.inte inpuse ; - Solicitirli tlc lcperrll e ri,, r rr(.1( f J ( ilr \ ir r 1, c; i 1 r' a z c . '!. ilgru.l irr (x)rstil,lrio o a,11;. forDri. t1e afazie r-notorie, caic eor;siir il Irlrrrrlrrlr.r, lrosibilitir.t,ilol unui indiyid dtl :l se cxprima c[ rjutoml sti'isu]ri. I,lrr, rlrrlurc\tc ur)ol loziuni la nivehil centrului ,,imaginiior" graiirt ll{' rc r orlrilii, lolrrlizat, iir piciorul circumvoluliei fuontale, a doutl din cnisfcr':r,
rl | l]i t .

greu de :lprcci:lt la bolnalii afazici, dcoareceii{aziilrr ,\glllir csle trra,i lrr rllclrt,lci sc irrso{:esc de htlmillegii dlcpte. In acestecazuri, se l'ecul'sil 1i ili llr prrlrc speailllcde exarni ale a,scrisului,prin folosireade litele con{trr i irrrrr I c si plin solicitarea bolna.r.ului dc a, sclie cu rlina stingii. Se poill o ,orrsi:rirr cli, bolnar.ii tru pot sct'ic nici spont:r,r:l, nici dicta1,,nici copilll. jzlrrrteso jMgonajrlzie li. l,r (,('i r.lnr'(! totuqi sir scrie, se consiali, ?oralJrafie, r!:rt\.t'&re (fonrirircno ascm[niitoare cu cclo descrise anterior). l)t I'toltel.ctttiliztttein so'tsttl sponlan, tltctat pi aopiat sint foarte variairr rii .onsl,ltr irr : - Scrici'ea de lilcre, cuvinte fi propozilii (eventriir,l,irr lrr.zrrlilc lllrrver in consNruireade cuvinte tlin litere con{ectionatq s,rl rulisrr po (iilr'loarrrc), Denumirea prin seris a unor obieci,ecare s pr'c lrrrlii lrolrrrir.rrlui. Solioitarea de a rd,spundein scris Ia intrebi,ri puso, rlrrr rlcsnio in sclis anumite scene,de a povosti (in seris) scurte istol'iat:ir(', rl0 lr rurrrrlllct:r, anumite cuyilte o serie de ftaze scrise,in care lipJos{: ou rrrrrlrriic crrvinto. Se apreciaz[ astfel defectelede evocare scrisi ale c .i11 ir,lor' (\ri ur:r,rlrrle rlcslJora))deformarea, cuvintelorr tulburirile ortogfifi( o si rIlrrrrrlrIir,lrIrr dr sintrl,-.i:i, etc., despre care anr amintit. l',. tl.lt:iu ntirtd, (totalii satl tle tip Broca, constd in a,socielea r:elit ) ill|r:r lir|r)r' r,lirrit'c dcscrisc:Scrizorial[ motolie. In contextu] clinir: lxrl [i rirrrlrlonrcle celei senzbriale, s:m ale celei motolii. ;rlr,rIorrrirr:r, ll. tlllt.lo) ta iliniae de aJuzie. S-zru]rlai desclis o sei:iede :fulrrrt rlr, :rlrr,T rrrri rrrrrllstLrr prliin binc in r.lir-it'lu irr, luaj alizaie ,,\i acccpiNte elrtiilili ca
rl rrl i rr lir : l" l lt:itr t,nncsticii (t1tlsr:r:is:i iniljnl de Pitres qi de Wilsol): ronf tii rrr rrr r I r or r r I r iI iI lI t r rt c a p rrrri u n !r,, (l c a e l o ca anumi tc onl i nte, mi l i i l l { ' l tl rrrrIrr Lr r r I r r r ' I r ' ,lr ol rrry rL l i r.t i tu r$ u l I o rb i ri i d i srursi l c l rti l i zi ni l ' nul t,' , i l { | |r|| i) |r t iI r I r i s i 1 rc i:frl z e (c u i n rl i c a l c a u til i ti i l ri i obi ectel or) fi E r' ,ri ur' l r' '. 1rI i, :r I rr r' . l lfrlo rin f(d r'lc i,nllltllro cltl.tili, a alenllnril'ii) cu rncrrfirrcrr.rr, rrl rrII llr r I ii, r r lr . pc li ,r' i i 1 i rr,i n 1 ;c l c g c l i i \' o l l )i l i i . [Il l 11i (l i r]tro :r,cel i bcl rr\ i ,l rrrr ir r r I r llr r ir r r lc o rrtu trtri ri i s i ,r' i r1 ril u r l ri l l l (r i . l J(i ovi tl crrl i rtzI l a, I:ol rr' 1,' , s rrr,rcllr o v ot llr lr t r tl c tl c rrtttrri trra , o l ti rrtrl o t . l l vo< ,l utl t, r' tn,i ni ttl ni ri r,t i rrr, rrrrrr r , olilr ilii, r lr u' i , i r,rl rrrrr c l l c l r,j trl l r,lrl r c\ri l i ri l l ,or' . l )r' r)l rrr)l i l rl Ll i xl trl , lr l rl i rrrr r illt lr ii, r t rrrrv i rI i rrI rt i , rl rL r rl rtr' i i i r.rtrIrl orr_rrrrIio srri l l i rl tr l i i i i rri r' , L p ttrrlt r r r . : t t r t r r . r ' ,1 1 ;rr' ;lri i r' ttr,i tri ttl trrs l rr.rr l i i . Itt tttrr.l r' l ottttt tl rr r' r,ztr' o ,rr,rtr llii, : r ( r r t r rr , r i r tc tl rrrl i i rl tt1 tri rttri i rttl o l i ) l rol r:tt rl ru l r,rrl r' ,t.r Ll rrrrrrrir r l , r r ' l, ljr ' , i rr.rl r.l i rrl l l c o ,' l tr,ri , rl ,' ,rl r i l r' 1r' l rl :rr,rfrrrl ). rrr rl , ,i l rl rt :,l l r)

l l :''r t lloli ;r l ,'r ':r tl r r , l :l i o ) : i l i r ,l o l l l i i , Il Itttr IIIItt, l l tl r ':t ' 1,, l,t,itrlllt r ', , l : i r , r l r |r r i tr r l l r .t r r r l ,'r ':tr l i t, l 1 ) r {) ) i l i ti l r r i l l l ' g r r r tt {'{}tt( tIt,ti i Ir I Ii r ItttIt,ttIt|r ' : l tt r t|l ti tr tl r , L i i l r r l l r r l tt:ti l tr r r t |r r ttItItti i ItI l l l l tl i :l l l .i |r 'l l \ : l r l L l ' r 'r r l i ,, 1 t,,ilr.{ r r u ,i l r .{ ;.:r . t ' J , , 1 f i i i r l r r r ,r 'lIttl l tti i tl t' l tl l tzi tr l r r r ttti 'sl i r r i i ' ( l sl {r l l ( 'tf( fi r i tt t'i ttr r tttt l "l r 1 'l o l i o . i - j o ( 'l ( r ( fl l zl l :l r i l l r 'l ,, r r l , o r r l I v,r t l r i i tt l i r ttl r l t, sl r i i tti l ) o ( '? l l o l t' i l l \i i ,l l l ' , i ! . r t t t r l i r tl r tttl r zi i ( tl r l tl tttl i l vi r tl l ;i tl o r tttr tti r 'tl i t r t,tr cs]tr il i tttttr ' r l r r :tl r tzt' ) , L ', i i r l |r i l t,t'l r l tsi i i l u l L ttttl t,ttr 1 .,i l ttrtl o i r l i o t'i l ,tr r l r l {'l r l ,{i i l ( r l r l i r r l |r r r r '1 " L , r r l I l r r r r i r , r i 0 r r tl l t,l i z:l r r r ,si i r r sl l tl ( i l l l tl tl Ii l r l l l l tl l t l ti l l l sl l l l l n r tr ! l l l r l r l r r L l , , r r 1 r ti t ti r tl i tr l tl r l tl i l ctr si sl tr tr L tl tl stl tttl t:t,l i zl u r r r l 'i i ,t'i i tt tttr r r l tr r 'ttr t:r l t, ,,,, ,r' r. ,rplilii tttt ttvo r ti i i tr i a g i ti c:t' l tti si tttl r o l i ci i , r cr l r :r l :r l r , o l ti u ttttl tti , r r r r ' r i l r i i ,1 r 'o i u ti i , cl i l tctl l tsi i ' :L l i tzi o l u l l l l o ;i l i ( 'i ) ( 1 l l l l ( ti r 'l l l l l i r r i r r l l ) ( .l l t'r t,tl ) l l t l r r l r 'r r r :r l r ':l ,, , l , L l i , ,r t'l 'r tzi trr u tttti ti t'l i t", sl tl l ',str r :l liil1 :i trl i i )d i tt i 'i tti sl ctl t ( I ( | | | I | | | | I | | | I I , r r r , i tl tl i ttn i o cci l ) 'i !l ( ' l ta l i cto - te m p o l o , r r t l l l l {i . ( 'i l i l l ( l o l ) cl J,y ,.si Jr l ttr r tn i tte , l l ) ( i ;i ) r r r l ( r r r l l r tl r l ' :r |r 'i r 1 l:l ', ( , , , , . 1 : i t r q l l tr l {0 l i r ttn l l ]:i ti o r r :i ]e A,1 ) , 1 l 1 IO l ,I( 1 ( i 1 .i tr r , tl tr ,ti l r , , I t I t t t t i I t ; t i t r r r Ir 1 l , r r f r r trr ,i 1 ,r o il ttzi u n e tl i i a ccl sti vo tb i l e si tt'r ttr i i ',i ItItr |l tt;IIIi , l r l tr r :r r l " . rlrjrl{, r,rt1'oiniliriz:r,te lilrii conlimll, cL1 i'(til,ir'i, I r I t t I t t t I rI t t ! I t rr lr:r'rr'rrlil r . , r i r , . l fr tttcl ,i r t, u u D i n :r ,ti Yr i ( ,'r e p r e zo r r tr ,i ,i vi r ) ) ) r t t'o t b i ti i , ( l ( r l r r r r r r :r l r r r , , i LL r Ii r r , ( 1 1 1 1 i 6 ,( i i 1 ,a t,d o []]r o l m i 1 ,t,o $ i l ]i i r ( ) l l r l sl r {i , l l J/{;) , ( .r r l l r l ' cu i , r l i i r 'i r I i ( ) ti i "l ,r 'L ti ]'i l l i , i l ) ti l - l l l ,t u In i t, o b i t) ( i I ;i l t0 t tl ttl r t r Jl ( fl tl t'z|.t!|l l Ir 'i r ', ,r 1 , L 'r ' i r , j l l L r u '"'i n te l e e o l csl l l m zi r ,to r c. L l to tr tti i ,l r r fi l ) ( !r '') r r ' r r r r i l l l l '{;) r : 1 t ii t'L r l L i n r [r 'i l c r l e l j m ]a i d i n :r 'j i t'zi l t' l r 'tr tttr r zi r r i 'r r l l n tl r { r '.r 't l i r l . ,, i n L cl cl ttu a l i i , n i si ci t o t,L tl b ttr l i ,tr l ,) g r l l ) ( 'l 1 r l r i ":r r r r r 'r r r 'r r r r ' '1 , 'l i ri o tr l r i ]' \Il r r l l r r ( ,,i tp l ttr r tt{i sl r tr i l r , , i t tl b l ti i l r c a , r 1 1 1 1 .[1 i [r i l o r vi zn a i c" , i , r l r ri l l cu u n d o l i o i l i a ,Lm 0 l r L tl f i o i \'o l i ) tl o . /\l l l ti i l r :ttttttl ztct tttr l 'l t :' , , l L l r r t' sttti su l tti u n i ti i i /i l o r l i u * l i sl i tr tl , ( 1 i i r '{!r 'r 'zr l l l i i r l r tr l r ''r ..tr '1 i t'' . 11 i {1 ,o r g o to t 1 1 III1 1 I|1Ir r r tr r riI|o |l ||r , r r ,, i r l i , i r , l o | j l 0 r 's.r l n a l r ti o o g i ( l i n tt',o i , r '" ( l ,l r {r n i i ,tr : q i l ) 6 r o u e sn i ' L 9 i tl ) . I) r l l ti i :r ( 'r 'i r i r l r r r l r tt r ' l ( 'r r r r r r l r ' , l r 'r r rl ) t) l a l c st'i l l g i l r n tl cn e a zi i o tl i si r r tr cl i r r tr r ttl i l r r l r i , r :r r ''\ r r l r r r "r :tl ,r ':r r l :r :tl r t;t' . ' | | ) r r r l j r tctL l i a ,l u }l n tl c D xl e zi ce l l o ci r vi l l i ( :l r ) r '. i ) :r t lr, r cillr r l u p i r , |,1 !i :l u i ,o r i - - a l i ) l l l $ l i l l ( i i l ' s( r 'l r ( 'l i r r ':i ;r r l r r |'r r r l 'r ' r r i ,r r l 'r :r 'l t ,,' l , 1 r o t.r tkr t.l o r cg r e si tu r c ( l l i cr r c - i \L l r i o I l l r i r I l i tl i ttr l l l r , | , r L i l tt l l l l ;i i , :u r ;p l e ze tl L i \ tt l i l t'l n i , tl tr l tl r tzi tr tttr r i o t i r r . r r r ttt r l r ' :r l r tr "tl i, l. 1, Itr zi tttttr i tt l r o r l tr tr r l r t I'r r r '1 r 'r r o ;r .l 'r l r r r r l r i , r l l t Or i g j n t, i ,ctn l tOl l u l i ,, l tr i tt , , , r : rl r .i l r , l t e l r . ' ( ]$ to \ , , 1 / 1 :1 1 1 [1 1 , o [( ]l ttl i tl o l t,l 'r tzi rirl t l l tte l l o l ttl t,r tl l !r fi l l l r r r r r l ( 'l l t'l r " , l r r l r i r r l i r ,l tr ,l ;, i l i l t'tl s1 ,c i l i r ,:tl tr tl r i l si i , r r l i o l tzr '( 'r l r r ( 1 r l :r l tI r l l tl \l ' r r l r , t l 'l t o t ttl tl l tti ( l tr t's ,tn l l t t t t ( t i tr l r r zi r l ttr r l tl tttcl r t l 't'tr tl t'r t. o ( l l ) L l r r l L , . , t r , r r sr ti r i l t,zi ,r l r l tl t:ttl i t, l t,u l r tl i t', ttq l tttzi tr r l i r l i i l r l :i ;r l ttl l ' r r 'r r r r l i r ', , r 'p o tr l i i ( t I i I i rrI r I t, i ( i tl r r i ti tr ttl ,i l i l r ttc tl i r ':t1 r 1 r r ,i l Ir ttl r r l r

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r l r , r tl r tzl r '. r 'l l l l t,( l r 'l i 'i l l i r l r l r r r l / / / r / i .t i 'i r l c o fr tt tr ti i , l ) i r l l i ( 'l l l l l l i i , . r r , , ol r t,l l r l r , l i l tti l r tr l i tr i l ,r r ' l r l r l zi ( fr r l r r . l l c l :r l r l . r r l r l r ) :r ,l r r ' l {r ( l i r l r r i 'r r r r t r , r r r t r l .tr tttt;r i ttttq tr ttl l l l :l 'i r l l l l l l l l t r t rt l r i 1rt t 1i. t t rrr l rI i rr r:r l r l r' : t t r t t t r I i I L r ,'( 'l r ( L i t l i tttr r 'i |l r 't ttr ,t.;r 'l tl ( ' l l r , r tl l :t i tr l i l i l l l l l i I1 1 ||III\I||IIi I|' r l r r r l rl r tj i i r r ,ri r r l i S) , i :r r ', l r r l l r r l l ttti i tto l r 'l o t'ttr ttzi r ';tl r ':r r 'l l l o r .r 1 t.'l I r ' , ' I I | | r)| I .( i tl tttti l t) tl t1 1 r /r tr tr ', r r t'r tt I ', , I r l ,:r p l r l i i ' tl r l r r '. \tr tl l ti :r l , r t t t,r :,, tt |t i tr l ,r .l :r tr r r r l tr l t:ttt i tl tl t) tttt /;) /r r r ,. i I|IIt||I:||i I| r r r 1 r ,I ' l , r | , , rr |,r |r i r r 1 r ':t r l | i r r r' (' I I I l ( || | .I r ( ' i l r 'l | tl r l l l ? .I( r l :r l tttr ,r l l r ) r r r r l ,l ' . L r I l r tr r l r :r ;tr l r l l t i r l tl ttt.'r ':r l t, 1 l r r r l l l r ,l l r l r l r l r r .l r l r <1 , :l l r ', l r l r o :l ,l r ' l r i r r r 'r r r r l r l r "r d | , t t . t.t't,'t r , I | | | I ), rr I rI I r | : r I r . r r l , r ,r r l i .r ,, r r r r , '

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,,,,,,,,111;';";,,li,J;illiiii'il''ii lil},,lii'ii,tix'#ili;"il:il,ff1:_imporra,,i,o i l $ lllr lill r r r r 1, I . o Iri c i tl rc rl s

.) 'l' u ntot i cerebraleale lobului.ternporal. ;i alc regiu rLii lxr,r'icLo-lr.rrrp.r'rr rrr, rtrlrrlrr stingi. Caractrfrul afaziei oste c:i, ca cvoluo:lzir, lont lrtogrr'.rrr, r!| l ' ,,rIr (l i rl ' lr t ear ziibr usc, cind in t ut nnr ii, sc llaco ut r I his1; sir , t rlr or r , r 'r r , gr i, . |. 'l'nun&lbma cr ankt -cerebrale. ., it atroJiite corticale din dcmclfcle prcsonilo (bou,lr lrri i\lzlrr.irrrt), ,rl rr.r l l rrl i zcl, z- i,t le obicei L- rinceput o af azic anr m r sI icil, .Ar r r sl: r , sr , r r r o, r , rr,r rrl i l ti or cu a, lt e t [ lbur il, r i cle t ip af lzic, cu alt . t i sit t t lr lr r t t t r r lr r r r lr . t it r lr i, r'r,,lrr;r,lri ;i cl l,ulburiili de tip derncnlial. f){,sigrlr, I,n d,iagnosticul,topograJic pi eNiol,oJlia irirrii, ,ti lulhtltlttlt lc tr,ru"lt4it:1: asr.tciate: a) Ilemianopsia lateral[ hotrrorrirrri,, rllu,r'r,lr,/rrl(.1, Irl r,' r' rrl xr t' r r , r lialiilcopt ics in subst anla aibii par iet o- t or t r polillir ,I lr ) lt r r r , t ' ri li, rrtl)1orll(i parietalc, tcrnporale ,si/ sau occipil,alo l)l'r'z.ilrl,i], rrrr irrl,,r'(1r rlr rr L,lrrl, irr sta,bililea exa,cti, a t,opografiei; (t Acrrlo ljn,, a,grroziir,rli'z t.rr,rr l rrrr' .r rl rrri l l r 1; a- st ingtqi t ulbur ilr ile bilat er ale r lo sor t t ir , l, ogt t ozior r gr r , zir r ( ,l r1.ri ;rl rr, trttut opoagr xr zie $. a. ) cocr ist t i at unoi oilt ( l lczilr r c: r , lt it r gr r lr lr liu I rr l ri r rj i l l i tr t cf t post cr 'o- it f cr ior u'il a lobr . r luipar iolal; r l) Apl't xir r , ( xr r r $l 'ur l r l \ r, rrl col n ot olic f i nneoli ideat or ie sc ilsocia, z: "r , lczir nr ilo piu'ii, lr lr , r ur l in , rr) llot t t iplcgia ( cu sat r f t ir ii t ulbur ilr i r lt : scnsilr ilil, a, lr r r , lr r f r il ) ' 1,1,11,1 | ' rrrrl (i l l ,l {0r 'io*r 'e, inso}int [ lf r t ziih lr olol'ii, r ] ar r lr r lr t ull, o oli 1i : r , lr r , zt t lr r trr' . l ,' ri l l ti a r ', ii colc sollzoli, r , lo( 1r ljn cxl, cnsia lozir r niLlr r or 'l, ir , osr r lr r r r tl. r r ozir , r rrI rrrrrrrrr, .I r', .rr,zrr, lt ' rrl , t; l ) | ' (rt '1, r r llt ir , r ih llxioc, dc cr ) ct r l r ii sor t i|, 1, ogl I | | | I , , | ( i LIr1i t, ur git t nii Din ict o- t ct t I puli c it L cllbr l: r , t r r il llr lir iliililot 'r 'r , lr r t ' ' rrl r rl i l i rt' ctr{ir u1, c.r liir r gr r , l, o r r llr r t lij, r ilolir J'u, zir c, ilu f lir r cir , zi ; i r r r ir i r nr r ll, ,\ r {, got r r1'r.,r1:i l ,i l r r lr t '; t lo t Lr ct t ir r lr r lt Li qi r ir licli, llr t r blcr r lr , I 'I t p( |r '|, I I r iI r Ir|' / ili l'ir , | | ,r.' rl ,zi i r, si r r r r , pr ilxilt ,( , \ l*. iour t , r ino si r nlilb, , I l) ( i'1 | | i t rI rt r' I rt t r, I r rrr, t , I trr/l )_

,j, irriilr;:,, jilr*rlir, ;ti,:i;,,,:,: iil lirlilir{rjlrilr ijl in: :,

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:ltlll

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ttr l tti i l r r l t'tcl o l p tr tl r t' :

\ , ' , l i r ' s ( r l l tt'r " I tl l tj tl l tttttl |

D0 iN 11. pBoBl,EME DrAcNosrrc ApRAXrr

r l r r r r ) ti r r r r l r r ) : r r ') {l l i : L c i il i i r tl r l tr tzi l i r r ' ( l 'r r f( r l l tl i r ttl l l i r r i t' tr IIt'tti 1 r ttIi Il i ti ' r i tl tt ;i tL r r scl l i tl tr tr r l t'o o l ti l r tt' r t t l t r r tt',i l i t't. ( l t) n I( :l tl t.L t( t: i 1 n 'Ii l l l r l i r l r,r,,",tt i i tr g ttto tl l . l tl t' r r r l 'tl ttsi l l tl i [o ti i cl ttt r l r r ' r 'r t t i i , $ r r ttl l l 'r l ttr l t,l i r r l l r i i , l l tl xi i L ;i i gi tl r l .tti i n cl - tl tt l tr r l i r l tl I r r i t r l Ii .r 'l o t r , ' r ,r | , r . l 't , s I t i ttttj t i 'l l 1 trt t t t r t t t l i l i , t',t"'t'l 't't'l t l t\ r tt'i 1 r :i i r t i r ! r tl tt':i l i t'tt l tr t ttt tt't' r f , ' , r r , r . r t , , ' t , ,ti ,,,'r 't,l ti vi l l 'r r l p i i r i o r r r l tr i "ti 'c' i (I I (\ g r r sl ttl tl I l l ,l II( r 1 Ii n 1 1 r r o ,i n tl t tL r i 'l l tr r a '. cl 'tr '' I i l \ I ' I I l 'ir 1 , , , ', ' , , r , ) : stl l i h L l l r i n l r tn ti l 'i ttr : r l r sttti l tl i ,,t : , 1 , , 1 ', , , , , 1 , ', r l 'tl r i tl sr l i t l l r i tl i r r r i l 'l r '( ;i o I r N r r r i l r ;r i r ti p ti tttl c o l i r l l 'so 'l ' r l ( j r l ' ]i l l l l i l ' p , , 1 , , 't , t , , : r s r : l r i tl r i o r i , tl tr l t, b :r to tttr ctL i , tl l r t' tl o l t',.l tr i tL tl a ' tl tr i r l r tt i ' l l , l , '1 r , l r '1 , ( lr l l , sl l l ) i l l N ' so n cl i t\) t.kl t' si t sr l i l r p i n a , r .tt , f , , ', ', , , , , t ', , i , , rr r i i r r r i r ti g i r ,ctc.;d ) i n i ;t'i i r i 'i n l r a "zi l i ':ct"t'ttl ttr ttr 'Tte l l tsi r ttl r 'l 2 l t\p l i l l l ( l i ) ' i ) \( r ( 1 1 l i l l 'l '( 'i |;l r 'fl l l l l r l l *n , , t t l t , , t t r t l i i: sl i ,l tL l ti l tl i i l i ta r , g o stu l d ( r cu n l i n &, !s i n ' l r r r ', r r r r r r l r r l t t i , i I' g o stu h l i d e l l r l i o r l ( r /l ) f:i ' ( ctn o i tr i l l l i cl ' l n a n i p []a r ( xt' r l r r o l r i tr tl tr ) : I l l i s c r i l i l r i ttr zi l i l e l r p ttl t l a cr a vr 'ti ', stl 'i n g {) ] ( r N l i ttl 'ttl tti ' r , , r r , , , l | r l r 1 1 i fi t'to a , l i n ccL {i i l r L ,r tl u l r r i

1.11. DUFINITII

Pnntlu cxecutareaunor acte mai cornplexe, estesuliciun0 nu ,'ri r,ri,r'il,r cr olcrn:nLatosi {il nor'nale tloar c} for!:a$i cooidonare. ci sc iutqi ExecLrfit , so ;rrrrr ,r r,oir s:r, desfir,loare inlir-o &numiti, forinS,si succegiuno. ,r,rr,,rrrLii,iniSc-"urilor, geslrurilor, ittr-o formi qi succesiunoadecval,itr a l, iat aLLpra.ritT, aprania este o tulburare a gesiualiljfl,ilt xrrrrllrlrri,crrrrstil,uie pcntru un subiect caro nu estenici paralizlr,trt r,rrr,oorrstir, irnposibilibl,taa, in efoctuft corect gesturile. Cu 4,11,(t nici rriri rr,l,rr,ctio, coroic, nici doment, t1e:1, csl,o incapl,cit:ttea de a orecuta mitrc5,riailecvate unrtl \.|\ i\1,\',, nproixitt, rlr;i lrolnavul nu prezintl parozi, tulburii,ri de sensibilitate, ataxio, uoo1r, rrri,r,r li i rrvoIttnta,l'ouou tnlburilri psihice. r Srr sl,irroii roalizrlrcl unei acliuni voluntare in vederea indopliniril rrrrrrist,rp lrlrr,vrt su rlestiiqonriiin mcd grailai;, la trei nivelo succcgivo (f(r,,irrrf lrr', l1)77; Zl,urvill, 1960) : Primul esre nitselulclnceptwul,\L atrL\ irrrliri,lrrl i1i pr:opunrii-li stttbilelto un aoumit scop al acliunii motorll i1i o r,,lrrrrlrrrc, rrlrrlrolcn,zrischilii,,o schem;ianiicipatoare a actului. Al rlrrr1,. l il,rrn i atl.ul, nzul,iirii r lrinaticea actului) a gestului, in caro indivit] ul ,[or lr rlcrloerr,r'ou,, cadrul stosul[i innozical foimule]or kinotiotr din Irr',r,,',1,'r,zri irrr. Lll,c, rr,rr,cokrT lirnnLrlocntir sint colo ma,l aalccyaterealiz'irii ac{,iunii, A1 n otori,i, ccntrillu 6l rr, rl,rirrlrri 1r,,r1rrt,r. i;rr;iloacsto ni,uelali,neruw!,i,ei if|r'ir!r (f |l inllrLr'{Ji, joc * sistolnclorrnotorii piramitl',llc,extra,pir'&mi" in lItl si rlrlr, rrr'r'clrrllr,so spitlrlo), ilalo conourii lll rolllizlurol ac!iunii vrtluntllt'o, lo I'r'rlrirl roztrlt;i't, lr,cl,i doci, rIit irnllirr,llrlit, v it ir,fi r: oolor l,t'rrl l rrcsl,rrlilrt,
r,rirl t,I Irrr,'l,r l rrtrrt,iorrr r rl) t "lr t iz r ll, lr ) t I ir ' i N|lJ , I , r lr s I r t r r r I r f , r r L l l i $ t r u , t l t t p t l t l g t . l l t r t i ! t t t rlrslo crr,r'r, in lr iLt r f , , lln r z ir t , ; ] os l, ulli, J ' t ', r 1 l t 'r r z i l l , i , o t o t t t ; t r i t l r t l t l i u t l r t t t " tr.lril rll i,lt I irtrprrt lrr t t lii.

tt;ii, I t i rr; r|'I i t rI r'|' tt | , ,1,.,, , ,,,,,,i r,ltillrit, tpr.indcrcr, til]ci ligir,ri, incuirr,l,nl pt r t r ir {' {lr r t l rr,:r i cl clir t t t t lr Li, ar t t ncilr t t l ningii, punt lr cll ocllclr lt iLr t 1r,1,' lt t i r r l'r " r l ri ,t, r,:r rtri i cLl ohciar pllner cil unei hir t ii in plic ; i li; r it r r r t lil't t t t I 'r 't r ,t. l ' r' i rri r r ( 'ot lsl. I t r oli\ il : descuul din nlcnt ot ic, l'olt ilt ' t t t t t r i din ohibrituri o1'(r' nnoi tiguli ir, rr r, , , { r)rrs{r'lrtll,irl gr r slt t : t lilt t l" r 't t l l ,l r\ (l r' of ic] ) it d0 lr npolLaut ca t oat e acest c pr olxr t lo t m nzit 'iv( i) sr 'iI ir r ir r slllr r it r r r r or l ( r cs}ect iv int r anzit ive $i ,rl l rr.r *t t it ' l ri l tl ' pent t u nr in: l dr cn'pt d, cit qi pcr r ir r r t r t 'r tt't i'it t ll: i l') r r lr r l r, l ,l rl ri r i r,;r r r ; r r t , it t lr 'r r r . il' si, , rrr l rl ' i r ir lt por '1. t lnt ne : I sjgul; m cL bolr r llvt t l t t o ilt {r r lr '4o' rl , lt l) o &s( 'lt l( r t lr . il',t r r t t it r lt illt t t it l rrrr, ' l ,Lr\i (' i r in- t ir t a, r claqit inlpi; i af : lzici t pt t lzeli{, t lit t t lot t lr r . t icillr t r r t lolii r t i'it r r t t l' 1,,' ,t,1,,1,l rc t r lt lt : t ,nu gr '( lgi,a, sr llt ll, l lt r nt t r t l, t lt r a'( rt r {ir r 1i t lr r it r ilir rlr r r r ' i , ,, ,,,,, ,, t' ,* i i, lI ult r ] r 'i. ulbr u llj t l t : cor i'lr n r t l. ( ' a'r r ( 1t l i'oilll lr llr r sr r t t r t r ilr 'r r 'l'r t rr 1,r,,1 :rl l ot lr , lir o! 'iuuin( rut 'o- Dsihi( l( l'1i 1,' ,,,1,,;,r' r ;i I ollogt r , f ico.

( l l l " ; t .t , I ) l l M l t l , l , ]t , l N I ( r l ,A l , l ' lA l ' l l l x l l ' l l

tttl tt tttl tt r l l l ( fl ( r g ( r l 't'tt,.l o t ttt,tl o r r tl "i n i u t u 'l tt d 'l l 'tt' t i i l o r I'tr tl i i ttt l ', f l l l l l tl o l i l r r i tttl l r r ', l 1 }7 7 ) t cr t'ttt tr ttttttttt - , l , , t t 'r , l , , s i t ' i r , t l tr i l ,i .r p n tu r u ( l !|0 1 i , {'i 1 l l l r .r '' r IIr '|'i t' : , , r l 'r l r r l r r , , r l r ,r tl l r :,r il.) ttPi t l ,i r ';tttr l t r r tt,0 l i cl r I'r i r yttl t't0r 'o l tr .ll.t t t i i tr tl l tr Ir t ( r l l l l r o I t i r 'l l l ' i r l t,l r l o r r 'l r r "r tl l r | sr t ,1, l , l t , r r 1.i r .r t|IIr IIItr Ii i i 1 tIt,Io t, tl r r o ,,n r r l r i fi , 'r , , i tItr tIttto Iu t'' l 'r 'l l ttttttti t'tt,,r r r ttl tttl tti 1 , , l , i r l l r r r,r i r 'l r r l sl i r r g ( r r ,ti l r '1 0 ) i ti trr 'u ' I'r 'l r l l l l l I ,rlr,rl r r I o lr ttl l to ttl l t,l l l r r l i l ( r r l i r r ' {i ) , i l l t' rri 'll l l l rr l r' I I I | !t | | | )1| )| ' i t l l l | , 1 ,{'||II|:It||I ||1 l l l ,l l l l i r i l l tr l r f t rrl rt ' r' z ' ' t t l i i t' i l r r l r r r tl o t i i t rI r' t t I I ' t rI i |' | l r i ', , r r r r r l o t :'l tl l

| .i ttrr LiI I t r ' I . . . r ' : t t rr:t,tl i tt rl i ti .i r1 ,trrl 1 o c i rrl r.orrl ri l c(,i rLrr,rrrrtgrrtrtrr1tl l rl l rr,ri ii 1q(xfS l htal i Il o (lll( x \ r ii r r r ilc i i ,tl o r.. A (.t\ri 1 (\),rl g ti r,l r)o Ii i | || |i ,i {r(\1) $o l ,nl ,nsunt, s(,l l t,tl i !l rrrrrl" ' r ' ii, . r ' ' I : r r r r Iir1 ..:r' r' r' ;.rJ i i (r (l { r.l ,l l rt(' l .1rrrsi i(| r,i rr..r1l rrl rl r,l ,rs;, ;rt .r. , l fi .l l l | '.l l ||r I rI i :r' | {| i Lr'(:: ! rrL rs l ' l i Ii i . | )o l t l l ,o r)o l lIrz i rtni l t 0ttri srb| (} i rna,j 0r' tr (sl i i rl .gt; , \1or rt(jru)rir,rr,plrt,rio bi lli,l,olrt llr. i,ulrl lczjrrrrjlu corlrrlrLi ctlos srr,u rr,lri lir,, .rrri rl.r'.i ririrrr.o (rlropto) relLizurr,zir, rp.*lie_ urriJll,cr.al.i stirrgri. ijupt ,,;i,r; 11,y1,,11 rr,1lrliio o lozirrn(] a, rrnuii.r, 1l1r 0rr slln :t alhtia alin acclti cdntli, ;si$irt'l

)'r

la llifcritc l,ipuri dc apraxic: ideatorie (lozirr nea centrului ideator parietal), apraxiLl rrrrr lori,'sau melokiueti,d, llcziu'nca conI.r,rrI I ld{'L,nlolol $i irl,.omulorie (lcziunoc ciilirt' ) .tro uu{.scr.ei dei c,.nlri) [fig.36i. uxi*trr, ' binointplr':. .i u,Ltn forme - clc apr.rr,ri,,, seiniologiit crirora o \rom exp lre in (xll l,lnuale,

, , , 1 , r , r l l r , rr ,l r l ttl r r u l r r r :r l r tr ,;r ti ttr l ,r Ittttr i tr l ttI l |) l ) tl l r i r t r t'ttl tr :t,l t ttl i l r , r l l , l r r l , r , l r r r r l ) , ,1 r . l r r tr r i tr i ttr r t;t r ,o ttttl r r t'r 'l r t tr tr ti t ttl i o l tn r r fi i t tI t, I rrt rr : t I rr r tr l r r . t , r t r , t , r . r t l r . r 'r i i l i ( ,r l l r l r ,l l l r r ,r ,Ir r r l r ,i l r l l r r r tr l o l r r ,( i r r tr i , r l r : l ti l r l i i , i tr l ttr r l r r l l r r ':r , , 1 , , I ' r | , r r ': r , l r r ,u i ttl r 'r 'r 'r ttl i t, q l r r 1 1;i r r , , 1r i t r1r I l t t I I |,) I r r tt tttt l tt i l t'l tg , l l l t,tt r l r r ;t, , ', r r , , r r r l r r i r ,r 'r r g sr r ,r rctr o !ttttti i , si i sttg i t r l i tt ttti ttl ttr l tttto i r ':r tti , t:r tr ti :r , r r r , r , r , , , 1 , r r r r l I:r ti tttttti |r r tr l r '. l l t g ctr r r l tl , l i o l ttl tr tr l r l i i i tttPtl si r r tl r r o tr t r l i l i tIcr IIttr tIo t, r 'r r r tttl l t \ | 'r r r " . r r r r l i r l fr r ,l o r ', sl r tr r r l r r r t;r l l ti ttr tl o r tp ti !r i t,ttl tr,l l , r L 'r r . I 1 , , ir r r r l r r l ) r i l i u r i i l l l r i , r l l l i l , l l l o tr l i tt. l ,'i i tr l vo t'l l l l tl r ,o k zi tr tr r , l l r , 1 1 , ' l r l r l r t r i r r r l r l i r ,n l r tg l i tr r ,l c r i i ttg i l r t,ti r t 'l ( ) ) , tr t'r ';i i l to l tr r r ,vi si ttl l ,i :t,l i tzr r . ' \ ; r r ; r r i r r i r Io r tr r r o Io r i r , :r , l tti L i r l r ttl l r r t l r o l t,l c Ii ttl i l l ti t'r 'r r l i r l r r r r r l r r l ;r r , r , ' i r | l r r : r l r ,l i ) , I rr I I r t r t l r r t ' rt, i t;r ti tr i t'i r , l ) l j \ i l r l l l l l i i i l tr l l r l tr t r Ittt Ir Ii |i r Ir '. r tl . I l , ' , 1 , . r 'r ; rr si r r r l r l r ', r l l l t tr r r ttr i r ,i 1 l c tr r l c r tr ct'L tl l t,1 o l l u tr ttl i tt, tr tt ti i ;r r ' ,,,l r r . ; r o r r i l n i .r r r ,ri r tl o ttr i l l ,. Al ( l i '1 , b o l l l l r L tl n l to l r i t, ( l i :r i \( r n Il r , r r ,r i l ' ",l.il' 1,, 1,,, I r r r : rr ,Ir l r cl i r r r I o l :t,r ,ci t,r tlo r tl l r l ,l l l u tttt tt'tr st'sl r l l t tttr l i tt. l r r r r r ',r r 'l r r t,,r, rl,r:r n r s|r ,'i :r l tr r i ;ci i l i !r i r tl t'l u tz,i l i r r '. .l ) l tt'i t'r 'tcttt l r r l tr r ,r r r l tl , r1. :r l r r l r r l r r r i l i l :r r ', s:'l ,tL , l l ) l l ( {r l l tr l ) N .l l i r ,l t:l tr tr r l l l ,r l r 'i r l l ( r J si , r , , r , , , . , , r r : 'i l i n r l r r ;1 i r r r i r r :t, i r r i l {i l , i Jl ,l r , tl c l r i l r l i l , tl i t<'i i ' so l i t'i l i i r r r l to l tr r r r tr l I i , ( U r i r i l i i r r r l l i l tr i tstr l , o l t[t tr 'tt;r 'sl 0 si t't( ( |l i o ]l t r r ttl i tr :r ,, r I i , l r r r l l r l r r i r l r , l \'l tl i ztl n l i i ( l l i o t i tttl r ccr l l ti l , f( ) t( '( 'i \l i f.;to ttl r t,tr , r r tr r l r, t'i r r ;r l r , ', r . r ' r '. Sp r c r l co scL i j r t d c i ,tl t r l xi e u l i tl t'r t,1 t- tt', l tr r s( \l l r l l r r r r , , r r l i , r r r r r r , r r r r r l i sl 1 .1 u t,l t,Pti txi IttI i tl o o ttt0 '1 ttt'sti l i s|l r Itl ti l l i i tr l t,i tl cr l r r ) r r r r r t r i l : r,r i r u u r r ( 'o l r j ( i si '1 r 'cl ;u i c n i ttl l i r i tl ctr ( i o l r t'tti l tt l r , r l i i l t, r r tr ;l w, ,i l , l r r ':r \i o ( l o l L 1 ,r ) ,\i l f;l r ( l o l o l e ( '. , 1 1,1 1 1 1 1r1 o l cstc se ttti o l u g i tu r p o tl tr l l l l r ,i c i ttl tl tttr r i r t, i r Ir 'r r tr L r r i .r r r . l1 M ? ? ) : l r ,ct,sl i b o l n l tr i n tt tl l i l ,i l ) o l L '\r 'l r l r t i t r rl t t rt rrr ' rr l r. ', 1 , , 1 , , l , r , r ! l l r . r', r r r r r , r l , r r r r so 1 xtl , s( tIi d o N ti l o l r l x|]) i l l I i ) , s( 'l i l r ( l tL i l l |l '\ ti tttl tt I tt r r l | .r |, | , I L r l r ol ttl r l i zi t {l ,c1 l ( l o l l ttl cL c ,,1 r i t'i o t l r t'l 1 c p i l i o r '", tr tt 1 ,,r 1 l ,'r r r , r r r t ' ' , r r l l i ( .i o r l , tr r t Io i i tL ci l fa , co to ct, tttt l .) l [l i o l r |l I l ) o l ( l ' , r .r ' r l i tIr 'ttttr o Io t i c i r \ r 'i r || .' r,rr, | l 'r r l r i r ,i t) tr r l l i i u u Ii g co r n e l ,r i c{i g .i t,. r \l r l l xi i l , 'r r r,i,, . ' t ( l ul r i , Kr 'o i r xl l r r r ', 1 9 7 7 ) i l r tl tr o so l ti 1 ) l 'i 1 1( 'o l r Il l zi r t, i ttl tr , tttt,r ,r tr l ,' ', , r 'r 1 , , , r r rr r l r r l l l r r r tr tci i r ,c{i n i , l l r i n r ,( l ( i l i l ,i ( fr o i ttr l t,t'r 'sl r i t tn i i r 'l r .t i i ,;r r , r r l tl t.,it,,lr | | r rrri r t t I : r,r' rt l tcN ,tl ccl 'l l ) sl ]i l p l i tt , ) sl l l ) l '{r si tl t r{'i tl ' r r tr r l ( ( ,tl ||,r ,r |, r IIr r \ll,
,r l r '

I. Apraxia idcatorie. ln aceasti lrrrrrfl este perturbat insuqi planul general, lrpl'rr. zertilrea generalir, a, executiei actului, r,tl / i, r. . r / i . S c h r i n a d t sici a lu i f"i(,pma[n: incapacitatea de a utiliza, corect obiorlr,lrr i! , 1 i , | ! r i ) r r i e h l t s i hg A; B:Ce n .l uzuale. Clasicii inl,erpreta,u acest feno||r{,tl rL, .,' ) !lil slingi; C-- Ccltrji moldi rlir dreatta, cil,o ,,uil,are" a formulei kinelice, ca o ,,uitllrrllr a identificirii simbolice utilil,are a obirrr,. irrlrri. ,\r. fi vor'l:a de o n,gnozie_ utilizare a obiecteior. Apltxln cle rilr':rl,rli'rr.ni,ci,llroa,p,j tol"dorr,irna bilateralzi ;i se caracterizeazH, prii rr,ll,rr r'1,r,.1 plorrr.hrr cato implicd, utilizaTa de obiecte (migcX,rile tr-anzitivrr), It,,l r.trrl l, .l,L;,.uIecul I acte rirnplo,dlr nu poato ln6nplini x,ctccomll(,\r,. ,\si,li,l, :litt,clcparrialc, elementare (hrnte iiotat) pot fi execuraro col,or,tl rl:ll .,sr.oy1.11f;1 lo]]ici'r,, Ior a,rmonioac;)' estc tullruraLi (Zaurwill. I tttlo i Iil, irrrlL,r', ll,7/). Urrlll.i lrtrlnavulscoprc<tulr primuI acbeleinenlarctlri i:r,":l):Ll rlirr c'r'p,rzifiir,{(.ltul i o'ilou}t. Altei'i. el nu r.ospect:i,0r,rlitrr,rl l,. rrtt'rrrrt.r, gi.sl,rrutor. :r, I)ezordinoa,este cu atit mai exprinatt cu cit {[(1l,lll (;1rr:rl,rrl) s'licitlr,i,ostc mai complex. pacientul nrr cste-capabiL nici sL irrrll,it r, rriricrrl!, l)o (rirrLr dclatureazi- prin bulversa,reasecienlior gesLrrlrri, o I,'r'rr :r,r',..-ir' r.l iculr,r.itir,!i, apl.,,&ia idcatoare (ideatorie) de difei.cn ri 1r: I,irr,r ,1i , ,, r i,l(.,,rir.r.Llrir,, clrt. qi gcstuite simplo sint tulbural,e, datirlil,lt in (lefcctuoilse a Comenzilor li centrii motori. r r,'i Jrir,nsnrisii I ) . ) t i , s r r L i ) [ t ) i t llpr.lricul idoator pottc sL irnite mi$cili nu Droa (x, li j,l'o norur nu po,r,r.,r'ca,lizl , i t t v t ' r ) l n i r , ';r,l)r.i,\;r.ltl I l, , rrcerqlri pr.r.lirt
rttrr ilri, Io ririnrriascii, r r r nc nr . i r nf , ir ' "i ] " i, I() titin r r il, s oi, . da, uneoli actiilnile o i . t ^ creoaz5iirnprisia,, . n '- ^ . i " ; , , dar si,le " " ^ , , . " ; rr1 , \r. , ; r r t |l i. r : t 11 ,(i ,rtl ' g ra lrl e _ :rg l ]Oti C .D n pl [, l A ll,

, t , ( l l . ( ll l r r l l vl r , i t'ci vl u 'i cl i i ],i tl o 1 tt,tstr t:tt'ti t'i ,r 'l r tc tl r r t,l l l i 'l l r o l Ii r tr l r l r r r r : r , l rl r r ,xi l r i r kl l l ,o r i o : tt) 1 tt:r se t:cr u ,r , /r ) r i i ( '/i ( g ( ,sl ' ,,1 i g n ") ; l r ) 1 r ,r r r . i,rl' ta , , , ', , t , l , t n i r :i l . t'0 i l ,r i r i u ( ,i i r ,l r l i l l ,o {tl r i i l i {i g r r sl ,) ; c) I) ( tsttl l ti tttt'( ( i u l tn !i i r ttl .l u ' r , r r i r . l , r l , r i r r kr xi r r r ,{,i t l ) r i n i r ,( i l i ) , cl ,l {i ( 'o l sl i l , i tr l u ,}ttr I ti r IIo Ittr t,t'ttI, r tl tt,.r tr tl , , ! 1 , I r r , r l 0 r 'si i n vi l l r ,l , Ii i r r r l Si l cx{|ctr l ,( ) tr l l , i l r ,l r r 1 l l t,r 'yr r 'l i j r r r fr ,,r r r r |i r r l

'.

l r ttttt.

Irr :r,1rlrr,r idol,l,oric ii! bolnavul lccirno&$le)irr gcnet.&l, obiectolc D0 (,lr1r

l rrOU fti pri rrrl r.t.l t ' ,\ct I 'rr", { i, 1. ' r ' i. l: r r . ' ,rt.j t r.rr r.h i rrl i trrr.i fri ri s ii , sr.,r rr ,,l ri bi i tul , sau rl rr.r,i , irrr.,rlr., sl,i. ,. sir,fac.i cu ol sau fi'clr,cir, grosit chibrilnll, clc pari,ctr,l.il,rlt '' r irrllrr,rrlr,ltilir, tr lOl; I sr.rrinc,.,r,r.ri, ': rrinrlii, r, u l"ri'll,rr,i 1, a u , r t rr r r r i r J r r r ,0 r r lr i! l,r cLrticiI St.ll r l]O^ l!l' Cu ir Uu

{,ii, S l tr:trl r sir, r,l n([i r] l,igira tiu clrilrlii,rrl O11 cl tj l )t,i l ,ul 1,rgi _tI,a rrrrrr,1rIirr|, irr finlll, lnl stin{r. <.hiIrIi|,rrI. lr,tt, srt,l., llri l,csi,"rocot tulrt,l rln na,

orrri, r r

(lr),{l.ilt1,i, 1ilr,r,l:rtil, gtrrrrii,, lllci,l,crr o clulirr; lrrlrril:lr.rr ri 0 l,),rll,r rrrt o rrrr o 1i lul,, rlrrolrilrr.il,rrri.. Alloi.srr solicil,iilrolrrir,vrrl irt irr nrirrr'i, r.irrrltlrisl,rr sii, lrtr
rjt lI, r l|ltflt t l, 0 lir g|Sl, t t r i Sli,r lr r Dr or r s l , r '| z l \ ( 1 r t t r r L r t r i i l i z r l t , z i i , , j {r t , l l |

l rl l i rr r lllr ' ( - l: ) ji) rrs l l rrl rn i i l o l rrl : s o l s l tr,z i i,rr f,i r,!l l rol rrl ,vrrl rriurr t,i or,rr,l rr i

i tto t'r i tl tl ti t r r l r r i l i l l i st. l tr , | \ u r : r 'ri r r ttttl ttl ti l ttl i r ,;i si r r i tl r tr xi l , 1 , , , r r r r r r l r r l ll l l l i i ,:r ,cl i l s1 ,i i , l t,p l i r r i r sr 1 to :t,1 oi ttti l r t. ti ti i u l :l ttl t I t ' ; trt t I rt t t t , tr I l 1 , , , 'r r l r r ti l ttt tl t, r i tttl i r tr l l r , l l r ,r '\r 'n r l ) l r t,n tr l r i o cl u l tr tr r :t l r ttl ci t si - ;i l l l l l l zl , l , r , 1 , , n r l ll r ,i i , r sr r <r ,o ti i r r r r cr r , 'o tr Itr r r r ( ,i i |o t r ';1 o ti r tt o l g r r tti r tl i t, i i ttt, r l ,' lrr, p r r tr r i r l i i , ttr i Sr 'i i ti r l r i l tr i l r tttr :l l r tr i r tl ttl r r l l , r l , l I , r r 1 r o r r ,l ,o l i cr r r r l i r r L | , , r I r | | r l r 'r l j r .sl n l si i r r ,;r |sr Jr o u r t l r ttl o tt. N Ii ;r 'l i t'i l c r l l l o l r l i r l i , l ]l l r l l i r l,i r ' | , 1 , r l , , l : r ,l r ., r 'l r , i r i r r r 'l c r o l tr tr l r r ,ttr . ( 'i tttr :t, r tt'r 'sl ci l r r ttttr r tl r ' :1 1 't:r ,\r i . 1 1 |l , , l , r r r r r . r l . r ,l r u i r t, r 'r l l r r r ttl r r i tr r r r l o t l r l i l tr r l ttl r r tl r l . \ 1 , r . r . r r ; r, ttr r ,Io |'i ttr .|,i r r i 1 r tr .r i ttIi i , o l r r 1 to g l tl l l i I l o :ttl r ' Ir t|r t,Ii :zr tIi t, ttr l , t, | , , 'l , 1 , , L r l | t||r i 'r o r r |:r ,r i r tr r r 'r r l rr r rt rrr' t I I I r r' , ;r r 'rr l i l Ir i r r r :t I|Ji i r 'tl r l tttL tl l r r ,:t l l '. r l ttr ./r ) r i r , Ir r 'r tl r 'i ,,r 'r , r l r , , r l r r ,l r , r,, r r rI r' rr I rr I r. r' ; r | ; r r r r r r 'i l r .r r tttr i

, .i { | ,I l t' l r|, ,I | |I ; (i ) . r \ l i ,r' t rz tr Ii trrrl .l r ,,.i ' r,rrl rri rrrr,l ,rri rr.,' :rl rrrrrfr.l ri krr.trl r,r,.r:rrr.tt[i i i (' Nl, ' r ' i. |r. . 1. r r ri l ,i i l i l i rl rrrr(,i rr,1 r.. tr' i .rq l ,,r.t.:r l l ,1.l ,i )l L, l {l (i t). (.l osl ,u;:l l ; (,\.j si
rlrv Jrr Ii1rsi1,0rlo t t t r t r r r ( r ' r El. lr s r r lir , r iU, r , it r r l, r l r r i l j , 1 , l i r , r . , l c n i t r c 1 1 l i z i t t o " , r r I ,,r r,;Lo cu,.;li0r11, (,ii, .,l] 1,. lrirt1,r. ,,1,.r,1,1r,r, ,li, u |'r,cul o u:oit,t,o. |,:r,r'Ir'IrLrII srr,U

(,1,r alu[(]ii pc lriltic la hazard lrngmeltelc fclei, iil,r'u \- alu[(]ii pc lri|tic la hazardlrngmeltelcfclei, fir5 a ril,r'll(,1,r tlS line seamil,
{, (,irJrr.iir/ r,T,u. t.od analug-, Lronsl,luc{,ia figuri geometricc Sau de lil,old tr do | r { ' r r l( . din br ' 1 r.l ,t.rL i L ,r:i t A}rl}\lil' constructivil poirl'rl ',:r , ir 1i .r,rr r^-i.,-i ^-,.1:,:,"- it:il9:1')rld' Ii ,.,..,ri.,,.1rtit rle Lcziuniemisfericc.stlngi, qiire?tc. AsttA, in teriuiiiiii lizr.L,l,il, .,r.. cii, -+i{.

l,r'irrrrgLri, .1,c.). ..r'c f.i.ii;lt si desc..zco fafl o'reneaJoX,, up.^"i",ii'iriiii

'1. rlpra,ria colstrrrclilii a iui l(leist consl; in imposibilitatea do I (.)r'rl{',,, sprr,ri*[actolo'rotol.ii rcce,s:]Jru crci!,tieiutei ,,foime,,, Ita se lrrlrri. l{ r$1 rnlti al(jrjin ir,otulde a dosenlt,, tomanclri, o Itrmiii getrrrretricii,(p,Ltt,ltt,, ri }il Iornrai, geotDetr'icii, {pLtt,lll,,

t',:,.]l].-1.]J,l.1l,t jlir afir.rir,ror,,rL. La fel, crnd-i se ieri) si, deseneze cu,xttr, o

ir, ri r! , ,rJL I ) r'I I | ) | I I rrr' ' iuc os l, t r it t lt r r : n ls r r I r ' r ir , liz :r . j i I r r |r,r, l -J,,i i r l r u l r , L [ r l i r r or l . t l ; r , ti t l , i v o

|rnislcrci stingi, apra,xiacorrstructiriise.manrfesti, .rrislcr.i stingi, apra,xia corrstructirii se.manlf n'in im,osihilit,,r,r'rr, rl, :, r'r.;uli:rir, cr l. mri simplu ,rbir(.le tjgut.i r.hj:'r' dreDlunslll, $i tpAlr,at,, ttrrrrrslri. r1.,i..,.r'lr..c clc.r. ln leziuLril. t.rnist;.r,,.i.lrnpi". l6r;,;;;;-;J;r;;: tr r i(rr, irrl,rlrcscazlrlrai alcs dcsunelc compluxe, cvidi.ntiindu_se tulbulil,r.l rlrr rrliutLtr,r'r_r spatriali, a-,,cle-mentelor'-constructivc,,, rlisproporlii qi r:l1xrr," 1rr i gr,rjsiln) diversolor lenf.ute dc cunstructie,'irnposiEititato de i.r,l, :r,k: lirrrrr. rr,lrorspeclivei spalirle si, dc multc ori, neglil#ea pd,rlii stirqaiiu Iirrrii lcsortctivel'r,olrtilc tlo dingriostic seilioJugic sint reprezunt:lte do probcle rln . r|l's.rr ;i d* .o'sl,rur{ic rlin cuburi,.diu belc dd chibrituri g.a.-Se solicilrl, il;il,lirlrL)sc|larcila dir.erse obicclu, iroagini figuri. tr-,a piobele rle urtr. ;i ,irrrr'1,i.s. snlicitii pr,cio,tur si' culstruiasci, din;hibrrturi'un triunghi, riit pl I r';r rrrrrltt4rl,ulghi eto., sii,construiascd, 1,, din cuburi un scaun, ui girrl, , ,'rriir, ur) l rLurJsi lc_cofirpun;i orlr d.]n pnrlile lui componeirte un tIial,,i ,irrr .r11.rr, sr-r,,kragi1 din1,r-'n 11'I Xr dc be.te-p6 celc cu dhiensiuni cg.lrr, r;rr, rrrrrl.lrrzrr rlirL plastilini. construcl,,i,r, tridirnensionald, testeazri'irli, se ,,r] $rr. r'(.pr.odu{,,X buci,li rle lemn de diverse foruur din :.lli.ll:1.,t','1,1, rlrlcrjte, 4{ 'll rr:lrru. rrl,,tr.t(1. sau sJ, transpul_rd, iruaginc bid nelsiorlr,lil o (r,tiilirll.lie tridimension:r,Iir rr t,r!, (Kreindler, 19?Z). Testul lui Abcls,tt (rl.lr;r l(r'(1i')([lr)i, 1.97?) co'st;, i' solicitarea bolnavuiui de a marca pilr.l,uu ,orrrrr :r, l,rci tig.trli goorrrotrice suprapuse. llrrl.rrrr,vii.crr rt,praxieconstructivi, comit urmX,toarelctilturi tle arttstr,ll , (rlrrlr;r t977):-a) Conturul.clcsenului ap&re nerel'lat qi'irrt,rrr, ,lir..irrrllrr', I lr) I'rir'(ili rlt:sc'urui sint- grcgit asamblatc,-putirrtl Ii izolalc lrrt,r.rr 'rrIr, r'1. t,,' 1;1l,r7i;1, rl,:\,.1r'l'i.".J I)"soUUl (.it,. 11.irl mir,isirrrplifiulf,sr:t'," ir:r,t; C) rrr:rl.r/:r.t, rrl.r_rrrl rr,r'ii r.rtliuii irtrr rslul.c,ri r,,t;riirnrti'rnici rrr, rI ;.i irr slrtt rr tl dJ t)ctirulr rI.rrricrrtrili.rlin,r.1iuirrr,lu,ut,,,f".ui,,,i,ri flr'liI(i| |.III||tIi ,') Ift ln) lr I . lt r t I :1,,l .rrro'.1,'IrrII ll r,i :| ' I i' r l. , r ClO Silt g- iUt t , t l . S r r t 'i S t l . l \ , l . l r V r U . _o S S ( l l l i l l i , Of .il;r,1il. l(r'r:irrrllr',r, ll)7'l) c,rrsl,ii, i,rrrulin!,rr, irr rl'Ir,,,irrI,r,ir,'t rrrJrtol'ryi irr rlri rlr,rirrrril, ,,l.i.ri,rl. s|:r,(.i, si llirrr'rrr.rr .) ;1,r1',);
rrtt f r lf :Lli rr:r,p lr,lrilrilr ,r , |pr r ) llt t t , li, t t ir , i lir |r r I t , r . r .: t r r t l r , i , l i r r r I l : r , r . , , , t , r 1 1 i r 1 1 1 111,,11

t rr t L l |) , lr r r poI r ilr ilillr 'l'lr r r ll t t ' l ri ,i ,rl rrr :rrrr r r r lir ,liili. i, t t ili o I ' 1' :I I rt t :r' . 1t t I r r 'l r l. : l'l lll t r ': r li'/ lr 'r r lr lllllii" r,l rr,,rl rr,r' rrr r t lr r i( f t t lt l 1, t 't t - ; t , "'i li, 'r llt : I t t r 'lr t t \ t lt lt t lr t t r lt t ''r ''i. r r I ,rr rrl: r , f r ilr l t t t t t lr r r r li. / r 't r ''ont . lt , u, t lit lil' (r tii t d't r . t t it t 'r t t . lil lr r r '11lr 1 t t r r r 'i lr r r r r r t t r lii) t , ,t " ,,,,,' t,, i ,, i1ii, t , , , , ', : , lr ' , : it t 'ir . 1t : t 11l{; l) ; l) r r ( r lsilr g f i r , . lr r lr '' ,' ,f,,,,,,' :,' r;I il v", , jl', , t , , lll{i2; I 'i( 'r ( v si r ''r lr r 'lr 'r r r r t lr t 'lt ll) {i{}1 i ;,' , - ,,,,u: '11,t , ; t , , t iV: t t 'ii, gllll', lll{ilr ; - A. ilr r i: r t lt r . r r ': L'- isi ' r 'iir r '{i r . lo lit . 'it r r lI r ', . l! ) i7) : r r ) / l] ) t t t 'I t t l ,' ,,,,' l ;' ,l rril r 1i , ", 1r , li. , t 1l( i! lr t llr t r t r r t i 1.,, t,,,, t,,,, , 1, t : nr is. loiilolt it r , t t t l. ir ( siir r gi, ) Hr -r 'alr , '1r 'r iztu, zi,1lt it r t lr r lr ir ! r " t t t ,, ,l r - r, r r r |, I : r 't t i't I t t i; lt t t t t lr t t t 1i ilt r lr ii' lir ot lt r l, t t t ''t "'t 11t lt r ] ilt . trr st 'lt t 't lla'i'ic . ollit r t 'lclor lit t r ; r lr r ' iiir ,,,u, ,, 1,,, , , , , , , 1, 1, , 'sl , ii, 1r r t lr r sr it r r ll r l, ( li ii{ l lt r r r l) 0r 'r , . llr ir ii ( 10 r ': ur r I silt r lr lilit ii) ' l) f ilt l'r 'r 'ir t r lr r r rri , ! , ,, l l't t lr it lt llr r t t t t t l lt r r 1,,,,,, ,,,' r,,' , l, , , , , it , , r i', , : 'ilr "'f i lt ill iisot 'it t ll'l' adosr or i it ( 1ll it t lt zt lt , lr , it t t t t lsl'it" ill ult r u't ir t t t t u: t lt t t t lit 'ii 1'tt t t fr, I l r l l tl r r l/ t ll, ll r . 'ir r 'zi' lr it r r r li1'r r r r 'r i, . ;,' ; ,i , ;,i, ii'r 1: , r :,:,ii it , , iiiL"uir i ( t lr c: r '1r li) , 1'. cit 'ir 1r . r l ( '; l{' ?, r r r 1i' t li'lr : " r lir r t 'r r r t r r r r ll'' t ,,' , t , i. 'i, i'r , : i, , 'r i l, 't ' l, r r r r lr t r r il'( 1 li"t t t l"r r,, ,",r'r r l ir , 1', r ',1x, r 'lir ir ' t 't t r sl' lr osibil' I r r '. lr 'l t 'r r 'lizr r r r ': r ' :, I llr r llr r r t t t r r ': '1i. 1: ' I I ' I I I i r | ' I' I i :I I i | ''t it t : lr r - ll' r 't r t t lt t t r 't .' , lr ' , l, sl r ' i .. l t l l r l rl t ' l{ t t 'r r 'l lr lr 'l r \ '' ,r". lr i 'r 't : 'lizi r r zr t i( 'r r ll( ll( i( r lur r '' I r t t li ' l ( i1 l( . zir t ni ilLr it nisf ot t t i ll{f ( l{illlillllt llr ' : r l ll ,,,,, ,r, r , rl :r r lr ,*1i lr r lnlvilol lt t l, , i lllt r liit iI t ' g( 'r lt l'alo I i7'uopt ''t '( '( 'l) it llo ( lt t it t I t t llr t t t r r lt ,, ,,' ,, ' ,' ,i, , , 't , ,ti, i it t ct lTt t pot t it Lt er le agr r ozi| lizlr oslr r l1, 'ilt lit ')l) r 'ilr 'r r . lr \ !,,, t.l r,rIr slt t Pt I t,,,r, ,' ,t,,, , , r r lr . zir ir r i ill( i ( , t r iislil. i ledut uir n nl{ sit t i r r t r r i llir gr r r r 'lr lir lr ' lr r' ,,, ,1 l ,, rilr , i( r ( r lovr , t lillt l {l }it lr dolc a r claljik) r sl) l! 1, ilt 'lr ) ) ' llr l lr r r t l t;,,l rrrtii r . t l lr r zit t r ii t lc t . liiisl( r lil donlillanlr l lnr r r liol( r r 7t i llr r ) r l( ( lcziuni d( ) ( r t liFli'lii I |I I | |)| | | I | |i I t | | i I r r r r I ' ..t,1, , t,r lir r r l llr , boht alii lr r nr ot l' l si r l'r ''t r t t l Lt t r olilil: t t ' ,' ' l r r l', i, it : ilt t r r colt it t t r t ' t ilt pir ' r 'it l' t r lilr 'zi ilr t lr r r ; r 'lr i r r . l lr lllt r lllt r l r 1'lr " lr i ' r,," ,1, , rr r ir t li't it iilor r r illr r t l sr " llt r i l't r 'i | || | I| |I | | | | |' t' | | | i I r, Ll L l t,lr r ir r i t 'olt slt Lt ct ivt , lt ' r 'it t 11iI t r clr ' : ull 1r . t 'r I lr r lr lr ll''' lt "t ' ,,," ,' ,, , , , , ', 1, , , 1, u1,r,ili: Ll'- I lllllir lllilit r "t t olt r t 'lit " ' r1 I t r I lr '{lllr I l( r l/ \ ,,rr r,' ||, r 't il. . l{lt 4) lll lt z, it lnilil om i$f cr ( li n( 'dolll illil t l lt ') ' 0}i l. r r , t ,r t . , 1ll1l11'] Jir t ic elt lir t ir l, t lalr n'iili t t t r t 'i , , t I r lr t r t l, . t t t t . , , . r.'r " lot t t r lt t t r 'lr t r r l' )' , , , ri ' ,, t i, ii Np; ! il, lo" ( Zlngv'i11,. l lJG ( ) lr r : t lt t lt r , ir r ir lc lr r ', l) ( r r lr r l'r r ' lr t lr "'|lr |t r ' r r ''r ' , r i't , r : r lr 'r isi ill') 'nclilit i ,," r., i l r'l, t 'i, ', , , , , , , r lr 'f i. it r r in , , s'r 'ilt l""'i r lit . r 'l"r 1'r 'r t {ir r lt lr "r r t r r '," ,.,,' ' i ' ,,: ,, 'i iUt r ''t t t r I t i' t I r |'' r i" r: i ,' , ,lt i'*r t , ii't ; , ', , . 1, , t r t t r isilil r lr opt Fit t l' rIrt I tt It Ii II 1 t ; i. ', r ', ilt t l't 'llt r : I 'r r lllr llt r iilr r { ollh1I lt r 'lr \ r ' , ,t,' ,,,1,.,,,,r ii, : i1,lt t lt r t r pl; ivt l spl, i, il r lo ; r rr . , .r . . , in ,i , ,, i ,.,. , iii, , ll ir , lr lalsr , : lzii cur r l, , . , r l lt t r llr r r |ir il, r r t . ' I ir r r lr r r .riii lll{; ii; lir '( r r r r ll|r ' r,1,,1,,r. r r i/ slr r r ir l, t ut r ol r . 'r it r ( 'Air t liir 'gu0t Tll osi ll'issol' r , t )t lt t l) t l : ; t ] t t l't 'l l , rl , lllir r lir r i, t l, t qlt [ dii\ t . in. diuSr t oslir t r l.st nit , louir ( r niisl( ii( r i I tI ItI t tt t t i t tIt t t I I r ir l|r lr lr ') : L|r ' l: t ' , ,' ,, , , i, , l, 'i lr i t ' , , it 'r t it t ' {1ll ill) l'll\ ill' t lt l it LI r t ir r : t t r '' t t t t t r ; ill1: 't 'r '' , ' ,,, ' ( ot r llllt l( 'ilvlt , st r it sr r l'ilt zi' ( t li( r t r r lr r l f li r . u lullr r r r iili illiir r r r , r r r r lici 1o|oqlr licr | ,,, , i, i , , r i, r r r l, r l rrtrt i t r' t t ' t t ' ir l't : r '\ i; r ' 'r 'r ' ; lr ) ir r l' zir r r r il"111i I r I . 'i ; ' ': 1, iili, i; r lo: r 1r t t 't " r t , i', i, , , 'i, u'" r t t r ; '1ot r r r '. t I I r t I r t zi" t 'r t t r . t ir t lr t ' ,,,,' r,, i, , , , it n', ', ,ir l'r , ot t r oI ot ir :t,'t t llit 't lt ''t l' ( l (' t 1: l l ri l l l l r l' i lt t it ; lt lt lir '( r llli lt t lr r l ,,1, i ,,' ' , , r l , , ,' r rl , lr r r r lr r r . j) .
\r, r. ti :r IrttI rI-l :rr,i Ir|:r (5i |ItII It-[rrt"i o' Ii IrIIrIi I|:i ] ttl tti ' i t' 1' l l l i l t' l Il r"r' i r/l l l rIl l
t , i l

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tttt l rt)l l ' l rr rl l r rl r L rrrl ttrti tt:l l ot i r l ttttl rrl l l t IIoIi I i IIutl Ir' ' \i l l t' t,ttl " ru 11\u1rl ol i i rrr:rl orl i rrl i i ,rrr ,t,,,r,,,r,i j ,rrrrr, Irr r.Ir1ri l rl r., l r' l '

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1 , l{ l l . l, . s ,l.I1 : u i , ' I , , i .\ (i,! ',r l, :]ri,l r ) s l .lll; lilu:tn:L;I.r iul i ril:rtulrriintr,o lurnintrc. i. ,t,
lI r]::-t|llrl:, lt oL , . \ r jpUl u ir - , , . iLC O r , aliU . .

,,, , , ,,1,',. nir/ nrx,ir , , it i, I r ll, , I lSl, lr lt t |I l) , [ . N l l p O i t , L O t t i C i S i r , i t t o l L i t l i l i t r rrr,rl r.,.,rlrll,.iLr.riu _, . lr i, . s r "r , - ; i ur nllt . Lr r . , r , . ii i , s i r ,i . r t . , ir, l,i(,irtir , l] ', , , , , ' , , r r , . r r 'i rrrl r.,rrr ;i /su ,u ,,,r clc , c i t 't itil;;;;i't _l'ri,'sLi,il,. ! rtrrrri i i rur u;",r ; c i i r i ,,. ., ... rrrl' grrst[ 1, lil,ului,a.[ r ; r r r u r l l , l l 'l respir.ll!;ioi r | u , r r str;-r,nu1,ului, t \ l ) I . i l , l l r . t prol|.r | lrr i, al r . p r u l t ru r , | l ;1,...1,1.,, ,1 ]'.,,,.1 ',.1;, i

l 1 rIc s rrri rrIrri rl i rrrbi it, ;ir|rI i{|r'rr|,,rI I rri , l'i' lli"l;;l,ilii rr l'J','1";',;,,.,il" ;; |;:";;i'l,lliill,'r ,i L'i,,,llli i . N rr ,,ll:i'l; ill,,,llii;,,,lll { Ic nri r,sl ,i (,i rl i r! l i ri l u l

Uuiuairii,,r [:].uL'rrr,'rliL, izbutrse si"r, 1"'l r.r::lLi1,i drl,l inghitii,lnrnoJrenex. ".,..f,i bol'*vil l]ac:i, , r rr1 ,:l

,, , , . r1 ,ri r.ir b , L rri. d iu n;Ls. r r cor r iu r u tu I' i 1r ,,:r r ,r

pot fi cxe'utulr' la -u rt linp o 1I i irrrlc p liu it rr ,

l r r 'r , I I r, t r I i | | i t r' (r,,ri , r l tr r r l Il l r i ,,l ;tl :r /l r r r l r ' l i p l i t o |l t. i \tr ':tl l 'i i ' Io ttl tr i ' l r l r tl r ,.rlir r l ', r tl r tl r r i | r ';l o to r tl i zl tl l t r l r r l o zi tttti l l l r r t'tl tl ttl l tti t'l l l r tr ( i l tr l |r r l r 'l r t t , ', , , , l r t z t i l c l t,t'l 'o to i tr r r ttr l tttl l r r I I I t I t rt i t t I t, rI ;i i tt Ittttto t i l 'r It'ttttl 'r r tr l tIr l r l r ') i i ' . ' l r u r r ( l r i l ( l [l ) l r tr t, I1 ) l i :]) . l l l - l l r rtr i :l :tttttl zi t:i ( a tl ttttzi a vo e tl i i sl ttt:tvo l a l i a l tti l l r r ttse h r r r r ) r ';tl 'r llrrittl';rrlttr r,, .i ' ti. il,lltlt,xirl t.trlooltirLtri.;ic,i, lollllizltl,i 1xr ttttt;.ltii 'rr:r 'ii,

rrr . . , r\: ,:\ .i: t :':'mod itutolrru,l l||,|| ) .1;'l 'i']i ) -rn i:9lt'nu . I)c IO: ,te rnUlLe apr*sir bUCuf*r,i;Lll ori ,',rr . . rri,r,.rr,,r,',,,\l*irnl,[urnJ,tiC,I,SOCi :],1 in a[rrzi:lmO1'o.e a lrri lrr(){.ir,. Si rr inr', r'rrr, r{"/.ra'r r','r:'rrr"lr fior,riia e'ir.i pr+ceutrare (Dcrlv-si Lber,rrir.r.,,. r:'r'.,; \r:1..1,)'iutltn{r 1960: K'oind.lcr.,tgll; Ar.seni IJ.l,rz, :l LUe.nt1,lc, ;i ltt0{)). P..tru rr,sr: prod*cc accaiti, apraxie, trebJie si, exiite rlrrrrl, ,ll)l)!,, r'lrrli rul,! rr r,cgnrnen ilterio]tii a, ariei preccntrale gi a iloua lezirrtrrr |Ir)rrrt,lr lr) iurrlu.r)t cmrst,lrj sau in ernisfetaopusi, (Arscni, 1959. lg7g).
l;, ,\l)raKi' l.ru'chiul'i se.caracterizeazir, prin dificulti,lile bolnavulrri , ,.,.llc:t, rn pr1. do a q" r,irlica ctin piur,tlc,, aj-loio*."n si de a urirl 'l{..r rl)) r,r,'\iu r:r,p'rr. J5o(.iiul,i lic unnori ii c,t iemnc dc lpraric a' rncmbr,lt,,r,. lrlsl,,1 rrsir,toarte g_rerde rlitelenliat dc nra\ia t""ncnii f"i ryi Ae asincigi". .\ p.rltr irL krziuni dc rlivcrse ulturi (_intlcosebi tunori) lr,iebrrpof"i-rii* j lr u I l,,llt;ilk),prccum gi il bo.r,l:t pick (la nge 1930, lui cita,t A"' X"oiriai,,ii , I l); ;
i.

l{fruLOGIC 11.4. I)IA(iNOSTI0

lrr lrlruclir,ii,,:tplilxiile api:l,tde celc mil,i llullto tlti itr lt:'iurtr t'.tt(ttlttt' , ,t ,, Lrl i i scit t , t uict t i r llm olisnelr t u, het nor r r , gii, Lct r ulor t r t Lr ') \ i it t . l. t r nt "tt l' ,,i ,r,r/r.srr r r r aiir t lilr t escinal't o. liit e( Uebr alclt r t sct t ilL ( lt t nl4lt r i ll hr int t t , t't,1,), it\ I {d,Itrnat'i's ar&nio-urebw,Ia l'1.,. ne

al.mcmbrelor interioar" Aeiol, cliiru,. fali l;].,1r,,: rr ,,r's tr: rrfe p.rctroOtalc ,'. r,.r ,r l,.lll.rl.'tj'ir.,ra,or:r,iion) popovir.iu (Kleinrl_lfl,,
1977; tr)ri; \t,,y{.r. ttrrrrunl 1900, citaii a" XrcinUier,' pi fOi?;". qi'Aggirlrr, ll. \pr.rrxia rlr imbrieare (descrisi, de Ildeaen) se caracterizeazil pr.irr rrrrprrrrlrilil,rr,lrt,nar.uluidc,a.seimbr5oa,. lxrl de-a se A"rn"i.o, Oe a qiirgii I r.r,\.rl:r ;i|rr1.rrril,.rle panloli, dc a maDipula, si la ilr mod adecvat div|r,lolrr ,', (il,Lr1, spontan, cit qi la coma,nrli).Se asocirr,zr-L r:t1 llli,, r'r,,,r"'t ''r'iL('.'r.'rlrr itrcapta.sl,ingJ,J tulburir.i vizrtor LJ'||1IIIi||rI cu urrsl ruclivo ti/ ,l',. .,r,,r rll)ut.:u.r:r.t,: lu s,.tl0mci corporalo5i alto trtlburiiri grruzir,c (lc-li,j:rrirrl lrrrrrris'rr(irlrri sri.g.t,c.), evont-ualqi un rrurnirlniipir,"rr,rrxr'irnistirrgitr lrlrrr. loziruri prrr.i ctllo,lospcotir ptrioto_ocoipil;tlorllopto (llCclon 4i ,\ jrtlirr,urrrrlr':r, ll)51), l). ,1;rrrrxi:r irnpll,ol.ir:ii(,,sirrrp:r,l,icil,r) ,.s " -lclluol lo(r,rc(j1,, rr.rr,)rnl,rr Itt tlllilrtic rrtrsitrllorrrtrtlt,i corrrIlcl, r,tr,l, rt,srroiit,zli o tr,Illr,lirr rrIorrrI rfrrlrrt. lr, ;t0{)

tncrsului pirioarele se inciur.iSolzl, 'r||rir.r ,r,,||,.,\ lll,.Tgc|| l,Jil rnici. pr. virfurilo piciOarelor, bat, nasul Oe toc tlri r'||)!,;r,,/r,.]. rl,,.pr *t,rr rnrl grcrr picioarelc pe sol, iar lrunchiul iimin,r.irr tlc rr'rr,:.., t,r\:r.il1ru .\i il,l)rir\iu mursul.,i u,pat,e Ieziuni liniloosebi ln tumorllrr) 'u car,' irnp-lic; 111,rrkI,p rtlon1;rt, $i.pllrtca arrlerioari.a corprrlrri ',,',]1,,,1 :111 ,.rrr, .,ii. ,'(:r1...r'rrllin ttenlie discrnii,mintin iclentific,area acestei fbr'rrr -$i r'.|| ,r" :rIr'ir\ , lr{:n1 rLt.l'urr li cou[unda cu lipsade iniliativl ld, " 1i dn,torrrr,r p,.trlrrl, .rr rr,1;lr,xiN trunchiului a lui'Brun.qsau-cufenornind d";,;;g,ni;i;-

(d{,n.risa cersrrnann Schitdcr, dc qi t926, cit.,r,l.r .. ,.: ltlJ|:tllrrr{|lluic,r ctcrizcazir, / )"s,e. q l]1,l),ij,,,ll1l.r: t. A$1lel. in timpul prin piuderr.* ini[,iariici ;i I ilrtl l11/ |l. t|l.r.ittt

{ l rtl l i l r' rt' l rl i t' l | | I I t | i III t i I ' Ii | | | | | | I I t I I I i I i l r' , r r. r, t rr' i r ,: i rr ) l l l l ,fl l l l r' l l rrl l ' ' ttr ' rl ' r"r' l (l i l (i l l l ti l ' pt ttt l rrrr' trr' l i :rrrIroI:r' Ii i ,l ,t l ,ttttrr' l l i L' , ,', ',' rtrl rri l rl trl ri ' ' rl rr' l "rl i i i fi " trrttttrt, l t' r:r' 1 I r!\ or! { ' trv rtl ttl ' ' i rr l rr I t,.: rt, i tLi l ,i l r,l ri , ,

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1I. I. PRINCIPIILE M]ITODOIOGICE SEIIIOLOGICI, 1)B DIAL.INOSTIC IITIOTOGICSI TOPOGRAI,'IC 12.I.1, Prceiziri de {tr.meqi Qi alc Droblerxati*i. in:r,r.t,rrl .rr,lril,rrlvorir abtirtla succilt problcrnctc de diienosfic doan itt std,ri.te t:attrr lr.,a*r qi.in.alte su,spnd.d.I'i con$tienli, de scurtj, tlurati, ca dt, de }illii irr rrlurrifcstilrile silcepale. I) irrruno51 iu15salr cunriienti Se1n lifatca clea fi i.rl-r.rr.r , t lolegcposibi rtrl :r,:r,v(.iri a ltu crrrro;lirrlii cer&, de a sii in ruor] iust de obi(.,.i,,1,. siru de '-i lr.rr,r|lrr.nole inconjurltoal.e 1dc rcalitatea inconjuldtbarcl. J pir.rrl,. .rrr,rsl,ir4,ir, inseamnii it,nu Dti de sine (Dicfionarul lirnbii romf ne tnc,il"r,,,,, r1,l'7). il'rrlburdlile care survin in sfera cunoqtintei constau nu in rnoriijir,rlrr rl,r rliloril,c gr':r,rL., cum.se.s1une, liinrl vorba-numai dcspre pr,czen{rr rrir,l

;Ji ,;.';"; rr.ttLttrr' ' r ;,, .i,,1 rie t'uilur:r,riv";ciativc, niti rlr ln'rrlili.i'ti rlrr .rtrr l,\r',1 ',:,",t",r";,rrrl, iicurologlc tlir,i r'r. . ,l ',,i,iii 'rzirrrr. "" "i'*iriJ"or,, r';tr i.n cuvirrlttl..gttr' ' irsi c1e l',,,r,r,,ont com5, arc ori$irel "litttttrr"''"rt ,

l;,J"l:li'J;:l''",' ,i,ii'illllll,u'l"i';";ll.1,,Xin"."s'',iil ,,i:1.';llll rrri ,,ri't,i,. l)e rr'suti i1i,,r',:t..'1" i llll" ';i:"T;; r"rr.rrrrrl' tr" ,,

Es: Leo clct r se, bir t i ' t, .rl r rl i | o il st ilr ii de conlt , eili' r lr r r'. ' ir O o" t " lunct 'ii vir sol; r ll t t t r r t lt t t r [ . ' L r' , I rl i r o{) nLr , cllcu m adiul t . ii't ir lir r llr r r r i lr r ' co- 1, unAe exlst ii' o leziunc r r ' Slt 'A'\ ' , , ' ,,,"i"f , r r iici li s,rrrrrrrl.irlr' " prr , i;i,i;6f ;;1;.'co** 6siu-ostareprtologicr-r'' <'irttl

iirl'i'rr ,;ti';,;il-;-t""0.'1"p'r'r'ot'isi"ttlli'::.::l-.l',lll:1.rt'rIrltl'rt'r'(rrr illt r o. iolt r lI ' t r r t Trtr|r lr I '

r r. lizioLogici,. NL1.2, Problcms rte diagnostic in s{irrile tolnlloilt(l Y ; '-1.2.1.As7e?te niotogiac

i' r ' ' ,rrtn icl) loz; nli, o slt r ': p'l't oloqicii, r n *r ' r : r t : r ' lr 'r 'iz' 'r "! r r r r lt , 11 lt r . t ! t l . r ' l: r ' l. r r r r ' a con, . ricuici cu 4ispar i, . ir i, . . nit r r , ,,1 "", nilni* lt r t r t ": t ' {\ lr lr r r 'r r '' l t,,i ,,,' ,t' .. ir or , t l"cval', : r r eacliilor la slilnulii 'lit t r(rr r cu supr im nr cr ' ( sir 'r . lit r r ilr r r ll: t ) t r r 'r lt lr i l ,; : i"t i"i"". "lcd; i. i , i it t t t c{t i vt r qr 'llr lr vr " r t lr ' ,,,l Lr rl rrl ) . ou m o{lt r calr u, i"iut 'it o i'lo t livot sclt " ,,,',, r,,,,i',in" hidro-etectlolitico qi umor:llo'

:r,I| {| | lllL {1r n ilrU L, ons llt ut e c Um a.

Oorna csto un sindrom care, prin definilie, Se traduce prin abolirrr[ * lrrlrr,Li, conrytion{ci element constant;i dorninani * asociatii, rr, frecl,t,rrt, r:' :r,lhr'ii,r.ialc luncliilor tulburi,ri biochimice ryi, evcntuill .rr ^ve,getativo, irrrrrrrrrr r.urr)lr)gico de diferite grade, dup6 intinrlerea laterali, a bziurril rrr Llrrrrr:IrirtI urrebral. du fiziopatolugic, ncuropaiuJogie clinicXau dus la cot,.lr,,irl qi ,l)rrlulu i:, :.r),'rrro slant de cunolllnlti, csle expresiaunei L.ziuni sau u lcrtu|lri||,1 rr.rr l lrr ri,rn'a f-orma,liulii roJiculare ascondcnte de pe linia median-d, tr.rlrr" din ,lrrrrl lcr.rrbral.Porturbi,rile legetati-ve, care insolesc fi.ecr.cnt $tal,orl(ll implic5rii stlucl,urilor vegetative din trunchiul ccnrlrrrrl ''r,rrir, f{) {lirl,oroBc :r,lr,r.irrlc.rIraccoali leziunc, prin intindcro:l ei laterali,, caro dtlpitfr,ltl.(, :r'r'iil. :r'rirrlr ryi_pcriariialo formaf,iurii roticularc. Nuriai o.xporirr,irri:r,r *le , r',rrri p,rut,o[i dctcrmilati, printr-o l.ziurLopurii fu SIiAA rtin 1,r,rrrrr.lri, Irr r lirrifir,lrzirrui puro .il trunclri sc irrtilncsc r;ir,r'; rna,i iL,4os11, ccl 1rz,irrr1'rr, r, l. rliluzii, crrflinzind,,si<ltrriclrrrl. l)oci irr corri, o.xisliidc Irrlrt o Lrzirrrrr, ,, lr rrrr.lri llsooia,l cu lrzirrri ir lrx rl <rr.irrrrrlrri, lr,rrl,ori lnr {l.ir(.r'ri ;5 slrLl, r.:li. r,trrl. itr lozittttisttlD'itl,r!rlorilrLl, itrl,r.ti|i 1,lrl,o:l ftt Ilrrtrr,IrirrIrri .rrr'r'IrllrI. lrr ;r'rirrr'rrfrIr, zrt|i Ir|rrl)ir'lril rr';r,rr rrllrrrr]i,i,i rrorrrr'l,iirr(r'i, rii i rl0 (olrrrtrlril; r,r,, r'otrlttzir',rrorrrrrlrl'trt,i'i,) {,r)rrii IirI rr, rIi I r,:| ,,,.,,,,.ur,,, rr;lrl:r, rrrlr,r 5i rrtrIr:r'ii;ilrilii ;
Ir;.i rrr r ilr :lllut lc r r ioli ;l l r :t(| 1 l r,rrrI rrI r,r.rrri rrI ri , r.r,l Lrr, l rrl l i rrri r.r.it!l t t i r)l l Ll r. ((l l l

cottstil'ttio sitttltl'rrtrttrl l t t t rrI I t't tt ' ' t r | :.1.2.1.1. 'l'ttlba'area ite t:ons'tienlii' itit"* diagnosticului dc cotrrii' ,,, ,,, 'lt^t trrlr'l:r l'rrr ' Ii rulrlilrtir' , I i )'.tL'rt.lsl altlele d"e inst(llare n std'rii d'e aotnii 1xt|' l'r r r r ' r,,nr' Itl l i lgnosil", ^t r o""'o'^iiit xI t locolt lt na'it r t it llor r t iI I I ) I 'i|||IrIr r |'I'r I r r r l'r r r lr . r r ' r r l |: 'r I r r l ri , it il iic cbnqr ; i. *t 1";la t n int livit l in r t 'plt . t t lr i li ( \ \ l, r r , r r r ! , r ,, ';,.;.,ri . ; ; i- t ; o; i{icni'vasc, ul1, r : r cr g6r 1l ; i r r r ult r ^r lr ilir , r 'r r t r I r 'r '( , \ ) r :,t,r',,t,r:,1

irr *n.t ,;r ,.,,,., i,ii;,;:"ii;; i.:.ir,r-,,nu crnnio-oirlobnrl rrrrl,r,r,r,rlrrrrt,.L)r 'r 'l r r r i r l t l l 'l fi l ' l

( r r xi 'r l r 'tl ttt:tl 1 q , 1 r o : t 'lo ti l tq {) ti n o l to r n o tl l 'g i tl sl t'tt ttl t l ttl ttti l l o tr l Ittt l l r tl t'l 'tl i tttl i r r r l l r r r vr r tr l 'tr :tl r t' r ''r r r r r r ( ) l ttti l tn n o zl t, ,,p t ttl i t* i 0 r l l l i '" r r l , r l t r | r l l) . I

lil,.,,',rr(r , , , . , ' , , , r i i l i : i , r ' , r , r i a , , r , , - , r i , l r i i J , , , r . L r l t r r '(iliitriit 'orrtr' ,tr t' t ,i r r r : r_ lrrr'lr l: rrl" r rt'l"i , r i , h r . t l ' , 't oir r i r
1 "'l l l l t'tt l o r i l 'o tr l r 'tti " 1 l , r , r r t , t t l r' r l i t l : l 't t t l tl t l ' l )l l 'i 'il' ' A ttl r r l r r l l r l ttl l ' l tr l i l ti tr tl ( l ' r l r "" IItti t Ir IIt'tIi ' r l ttt i tl 'tL r o l 'o tttl i l r ti r r r j l l l ) l i l r l .'i r r tr ttttti i , , , , , , , 'l , t tr r Io l r r i r r r r r r l r "r "r ' , i , , r : , , i , , , i ',i ;,';tr t ttl i i ,r cl t'r 'r .r l r r tttr ttr tl r t tr r Ii 'l tl r .r i tt,ItIt'tr ':t' i ttl r r t l 'l r r l ttl tl r '' l l l 'ftl i l l i l tl r i r l l 'tt ' r tt l r tr r , r 'r , , l r r l l t,l , tr l tl r , i l ,l l tl ) tl t l r l l r r l Ir l t'tt't'r ';1 i i rrr ( ' r l i r r tr r ;r ' rl" l r i r i ( r r l r l r r r r t'r 'r r r r r r l l I , ; ; , , , ; , , ; ', ;;. ( ',,.r ,,,'L ' p i "r '"r l :r l ' ""l r r 'l r r i

ir r r r , 'l'r '1" r 'li'r sr r 'i'r t t 'r r ir r ii) ' 1i' I r 'r r r r ' ' ; ' .;' ' ' i ;, ; i, ; , i, i I r r t l t t t l t t i lr ( r r ': r 'r r r {lr { r r r ,' .,i ,,, | J"', , , 'i, , i, i t , , i; t , t 'it tn'i" it l r t Dt 'olt ir r t r r Jrt't l tl ' t r rr' r

i \ \ I,| | | | IIIl||(r ]l( t 'r'r.fi rlr r r iit t ! o lir l, ( t li : i {tl

, t, 1,,rrri Iri I r I I r I r r,r r ,iiiI r 'r r i, r r r r u| | | (, | | | :|,i | | | | | r ll plt t i, t lot r r r oi lr , lr rr t t lr r t lr r r . rr . I r : ;t " ' rr, l i ,rl rr | |I Lr r jIr , I I lt , lit r t lr r r ; t o1,lr lc<lr r , r r r t lt t t o t , ot t t r ir '1r iI r , I t iicli. 'r t , t , 'rt t I ,' 11 r.: rrLr r', r lr lczir r liro r r r r t r riI it 'lr , ( , irllr r cilicii, I lr t lt t l; i st r it t lilt t r , ; i l t r r : r , r , tt r t' 1, , I ur l trr r r r olllgir r , r r t r r I llllt ii, t r , ot t lt ,c( ilir r ii ; i t t r t t r oli it t r lr t t t r t ,lr r t ) r t it t it r ,r, , ( ri r,l ozl ! t r c st t gllclt zii, t lc olt ir , r t io cr t t t t i,ilL clt , t or r xlslr 'i( , sl'ir , zlr( 't r ) : r i: l \' , 1,,rtrrl l ri i t : i ir r I r r r r liiilct cspir t , {r nii ( r , ot t t clt ipr t t 'cr ult t t it 'c) . ( lt llr t lt , tttlzr r l; r r lr rlrrrrrrriirrsir'. sr)r(), ilf..(irr*r v'sclilirr:1, irit',it.rjtui i,..ilt.br.,r ,,,,' r,, (ci rrsir ) lt 'pir lii t t c 1t ot t 1,ot ior r l' sl) l'( ) t r t t nij, l, r r jr i'r ,or it ': t t lr ot r r r l: r ' o bazil,r,r,. tr l'r.rlrr'rrfr.lrl .clir..,ritt:poi 1i rorr:latoalc p(rlltr. r Li l ,, ,,:r, i rl ct ilr r , li, t cgr r r r r ur t cln'( c\ 'olr i, ur t l Ei pr ozct t lr t ,t lc , , ; ( clulc" r : r r r.melc a]crr.lir,,,, rr,'Jrrrir.r...rii,Ll,crjr ' !l ,' r rrc ol i r r r r lor z, i'i. c o t ot t r ii, helt : t t icr i, .l l. ipor 'pigt lt r {, 1r , ( 'iltr r t t t r t r lt t l, r.. rlonrice,,ii,",u:ii,pr.rli1r,, it 1t slir \, i,, r,r1, :ii: .il. l:ll ll l1,]r. ( r . r I { , , . t iI I iL. , ||||''{ |||,:|.,,. I| , rrr( r) r n{}lol r t c por lil ir r dr t , l- r t lt 1, cI t i, , iii, 't rt t t lt lt t r i' pt it t i t rs t r I i . i . rri rr ljr oJ r i. Ur . t . : , o., , , . D i t r p , , , , r r i . i , j l r r r , , u, sllt ' , , rr, r' r ,,.,,t r, ' ll.r. |||(|l|||(|I)1rrrrIrIr|)rrii,slrt)l,iocrnii).(.t.lu,lllgiilnvit,,:nt.ii;rsufirct1e,hip,.1,*rrrri,,, ,,t' ,r, rrrl rr. [ 'r 'r 'zcr Lir l,ut ui hcr pcs pot ll, c f i LLLilr i, L t lit lqt t or lilt t l t t t r , r it r .rr 1,.11r.r'r,r,rlrl .i1<'ri rnt su,ri.zilc ,, ' ,' r' rl .' r' r'r t lr r r r spir r t lo slt t r al t t noi pnout r t or t ii. I 't l1, t r ; iih ll{i ( ) |iI r t I I i i| | institarlca cum"iir. ..ii"r*rit",, or"riu.,lir,,, r,r'lrrrr'$r.r'r'('I)r'ir|(^, l.rrrLlro{r.Lritc rl rtrr r r suli, r 'int li hep: li, it : i, , sllo o scpliuNt r ie sit , t L r r o lr r r r r l: rr l. spt cc*rbrare.o ar*ri i,."""a".1,ii, cor,r,rrirr dc ,,,,,,.1i1r ,' r l l t.,r,t ir iLlr t cit , guur clt clor ' ; i it , t im cillt sclol r sl, r t [ cst , t t l t lr : r 'r r r , r lll tkrauna j ':,,;,,11:::l ll"ll,lLi ,sprto arecliunei"tntiacramanri iLt ,,,,,,,1 1u ,|||,){ Iir'r,{r,' rr .i:l.ll:,. i\lr1|,r 'lurrrot,i lcmatorrr in plirrrnl rind _, i situ ' ,. ' l rr' rrl t 'r Lt ollt , r liu, bct 'ict i $i pont r u cot t r li, t lo i II r 'i)III I i (|, it t r , r 'lr r r r r lr clritrrlilrr, rr, lrrl,pirli. lrigr.r'1.rrsi'ii. ,, encrlrlopirtie,ir " l ,rr.ri i i l rr t , bt t r ir lt ulc pot f i r cr . clilt ot lc pct t lt 't t cot t ll I I ipo, lli, r 't r t r , : , , i rl,,"rirt'i"biti (rcr.ci'irrir), ' ,,r. rrirr|J lri1r.;llirrtrrrio ,,r ,,)rrr! r liir int or icai, iilo cu iDSe{1{, iaii(tl(t},l, it t t t lit t t r sit r t r t , zir:rir r lt r llr t strr'al1,d, r lr tulbrlra,r.,: "rri";', l, t t ruetaboiicd,. f,a,o temeieg}a,i,irlri, ' ,,l r,. ,,rrrrr i lillilo, j"r\lIi)l j:II:IIIj. .li:.lll:.I:..tt"t,l oricnr,eazi, o .o,ria,'.*t"irp1ici.ulr spr" De i.,r,r i I:I r ll{ u, I I I I : . l. |,,. { . l ,l, 1 l ' , i rl rr , ccit inr ozclor , a, cseor ialiilol I i il, 1r n{) r pliui I 'r t pir i, r r L,r '' I' l r. i tJ p l .c r n l J t,e t .rl OA l ,odi f 1n0S J i . rJ,tt.trr.rl :, .,, ,1 ,. r lt ' ' l 1, r , . , ' 11:r ,,.In rr' ;ri rl i rl r.s c l n r(. i 1 schi mfi , ,_,1r,,i .,,,1 ' ,' r,rr i l rrrrr r ir , iic: l sim 1l{) st cr il, ioilla, Lin t lr ilr lbic, l) r t z( 'r 1r t ( |( I r 'I r I r '|( ||r , ' rl .,l i p lir *r l lr r : l' r i. s i i r1 o (' r' i c l ri ' ,2 { r tp .,, " i -t . ,,,:r,.:r i l ) r i) r ) couii"Lr r cr nicr i, ccllm pt icii, ,i .,ii "z" i n i r.,c.i i ,ri ,rrr,, t f i ult {r ( }r 'islt t ir t t t t r r l, 't r r , ', t , ' (lr'r)r'ii, (ii ' r'{rl ) r'ir 1 ,. abc.s cc'e),r'r,1,truuirottit1 ".o.,.r" ri " ^r" rl rte, eu""}uiital. \,iir.sri1rrr,ir. r,r,uno1o ,rrl t.:tsculal'c, rnerrilgifiec, p"i" into:;ic,1i,l r,rr ' r rrr1rr.r.i, orirl rlc c:r,ibon al1t, crr 'r'...r1,, (sl ' lt tit.pt|u,llti"a tori,:e;, """r"i"a, corn"le r'11 Gidi.;. t;;;il;ii urpor*\d,. Ilipotorflriil, poi}to sii t,rritttrirl:i' tl ,,) ,r.l ,' rli:r,lr,t poril,o ic iltra in rliscuiiLr o curni i.ip"ig1i"or"ia r,ii1, r,, r, r)\ if i! r Jt {}nat ii, hipot ir oit li*t r il sm lt ilr r pii, uilr t lr i. p1,ir1rlt r,t,r,l), ' rL ' lrlr ,r , . ' . : : l: 1tt;r,.2gp.,11 i, l ttl ' ttl t' t.i( , h debut 1ioalc f i t evolat olt t 'c lt t , t t l'tt t r r lt t t r t lr r ir r li r 'li, r : r l 1 ,,:l ':,l l j ln'.Jlinr.r,r.in,, l lccrctcnt vascular ,, r."i* n i. ri-oiii, oia b " r r, 1 , , : . . , , , , , i) i ':r "rrir/ J'r'|l11r' cercbral (arteriopatia atolonrairrir rrr , l rr r t rrc t t it t go- encef illit li, abces cel'cbr it Ls: r . t tl, t t t t r t lr o llr 'lr ilr r r , r ', 1'r ': r lr r t rr rli:rlrrrti*'i) sir,rr chi*r' o corrrir, hiperosmot";i".i."-i;;;ili; .siitiii.r :rl,.r,ri ,i ,1r rrrl r, l tilxr lt er t r dla *pr ir ut ir , pe par ct t lsul t t t t r r i r ', t t t t l r r t l lr r r '/ ir r i r l'r , I I lrr lrr1rl .i, . r,,.ri, la rrrrbolnr,r. dpileptic rrl ioiO"*"l*-" ."ir,; ,1,i' ' ,, ,ri (l r!l s, ilr t r uclir int cr vinc in conlicr t ul t iLt t llol t r r t t t c: r t l) nlr l, , | , . , l, ;rl,i,:r, ,,'r'r' s.", r'i 1;1p,,;r,tc rlaforif,i;";l"., h.,;il;;:i;i*anio_ctr.r,tr.rr,t "*t" {i , ,rr .rl i ri i ,, i rL st at [ s cpilcpt ic, t um or i ccl: br r r lc lu lt t r gr r '. ir ili, t lor r , r ( r , it Irr,,\r)(i:, llt r.rt|lrut Il lt ll{.{,(]s conr,_ulsir,, unei suferinte ccrcbrale Jrrr,,,,. I' ,I' l r| i (i i i i lr , t r opir r ici ct c. ) . ,li :r, s,,r..r',r.1 ,.r',,'sr.lo.r.pit,.l,1icu _.i (iumor.-' rbcns, Lenr:r:,,r,r. l , rrrpct'l ur a, pr ezint r i per t ur blir i st t t t t t t iI it llt it 'o lt t lt r r ili ilr t r lr r ti , , 'r r r r r r: |lil,l: , r :L l.lr1,\:rsr,rrtjr , l; l, . . r il|| l] i i|ll' nlinli | r. rr' .i..]li ir v : t "c r t l l r i , s&u chiAr u A1, , Ii,ut, r, ,, t,r' r)l un ilc - - in cor nelc do gr aalclo li iji'l | \ | r:r' r' 11 .,D:l,rr,. :l rlr. pt l, li u t l , , r lr r r r iilr ( r l'7llli ( , r r lr '; r t r t t t t dnt r uln in< u I u r 1r a n r . t , c a 1 i c g o o r . r t t u r l l l l i r . l r,r,l , r) l )1 1, r inf er ioar i, lt , pll) ijii ; i ir t bt t llr . llr iir lii, r lr r lr , l1r t lir , lr ilr , 'r o (|rrI Ir Iri1r,ulit*nrii lcil, |' |1,r|\ rri| d*cl*tU*tornede con'vulsii) s",i 1Voft"fe qi ii,,i,,r, 1,,' ,1,, ,.rr pl ilt ou", cu. car act or pr oglt si\ '. i\ sllcl, t r lt t Lt t t t t iitr lo zilr r cr ir r l. r ' lirr;i; Arl,llli.. ti .colNb.,tg?3;- popoyiciu lt .fhi,.,"-ibzg; Arstli ,,,i ,1,,1,, r1(.rrrj o r not lcr at ii, ( il jul do i] 8') ; i t r r I I r f it r r r ii, t '1t t tit r I t lt t r iil, r : r t , 1, , r i I'r)lro\ 11,il llll"j0). /\ rrtcccdontr;lr'hepatice, pohlo^rc, a<lclisorrilrrl zi ""o"t", , o,,.n n . ," p o r i .i; iJt.;,' i;." n a rh i1 ,, ' l , | l r{ l i rl l vjr r c 0 noui clclt ct c ( 0u o( 'lr l") soi 'ur ; l! t lr t t t r l, l, r ; lr ,] : r ,: r t , l: r ; . r h .;' i :,,.::i j'] ':.till. , lli l l i l l " ; 'l: ,:,t,rr,r tr,lr:rcrtrs,lliln:t, i(), rr,orrrii :tpiruti r, , | 1,,i rr pl rr t our ') , pent r u cir , st t llr il iilr si, st : I it li<r , , , ilt zit t : t r t t r r r r r l, , : r r , l :r un b6lnl,r hipor.tr.i,.,rr' lr t t ; t l, r:r,lrrl i g.rrr'rr,t,iirl. bou,r, .o b*zii,1r' ' 1,, ..l l r pl i li( ) u) '( Alsoni 1072) 5i r Lql,si sc r olt t ll, t t Pit t ii l: u r r lr t r lt t t l icnccfatop*l,ia frip""i"osrvii,),dir,' r.l -*ii ,l i u\i r(1 r i lt illcli, clt nio r io 11" siLt t lllli t i1ul1" r'li ;r..irl.rrr, vr,s.rrla. c,rub'*l' 1'r'rrr iltac ischerrri,,1, 1r,"irr,rr.'gi. l|r i l l | || r , irl|f f r r i|i, J rl ! ttrt i t,l c rru l i c1 ,f,,b u i es ..,l l i ern i rr rtrri cl ,c rtrai , rrrrl l ,r : l l ta.rt lt t l, t 6- lt it f t lor ; i cr ut lio'nat t r : t t lt t t :t ) ll, t lt t r r t I t oI I t r I r t r I t I i 1r , r ; r l" r 1rrr, rI rrI rI rr { r : . r.'rrrir, *lrr,,li.ii pr,lxiu_zisii, , ,rrurit, tr,,"iii, 11,rcil (rrrril , o t ,r r rl rr,gr r osl t t l, t 'r ^t t <l ct t t t sllllil t , i, r r r lllii ( t li lt t ili, s t lo : t llr t ol lr lr r r . , it sc ,,,), intoxiorlic ic,ii,nltr,r,a, o ,,,,r,,,r il:l:.1;:.,1 :.:::,.t1,:li]i o coriiri.prin ,ll::,:: tl ,' r). rl c rr r lr lot t ii, sllt r t lt t t t r . t 'r '( r f ( t ( ic ( r t r t r t : t ,I I i: r , I r r , I icii) ,lr , lr r l lr r '1': r lr , ' r t' r' i | | ,,i r|l,,r.,rir,|| I l. t r , . t , r r r r r r r i r . 1r il. Dt i, . i. r . r r . r r l r . : r l ( t : r . i I , l t , t , ), , ( . , r r , r i l , ' ,r l rr' l rrrl, ir i) $ u lr t t t r t t t ir t t lt 'l( t 'r r r t r lrt,t lr , t r r i, r ; i) 1lt ) linr iilt t t t |r r 11'1, o; r lr ' l(r 'l:rl,,lj:rli(,,.1 ili, , r r l ' r rr, 1r i1r , y , . l. \ \ , I , r iir L, . l. ,' Lr,l r,r rr r' ,rr t t r 'LrI t r t r lt llt r r lit it t oI ilr , t 'r 'r rir i ill llll{r lr r t 't t t t t t l I t I t , t I t t I t t tr ', , , ) t ;' r,rti rr. l trolt nt t l'i,r lt t ilt h iixst t t r t , t iir t t t t t t I t t t 'it , t t lr r r iclt t r 'or r r : rr lr , r l) li , I r it tl l :.1.;!.1.:i, l u,l,out dtld.or tr,rrrt ttnttltr.i, qtttrru.l. crr, li p( (l)(t.(rla Jllr t , , ' Ii , r' orrr r r : r r r ir |, I ; , . ir 'r ',lr ii r r r lr lr ic r 'r r t t t r , lr t v{r ,( 'Lt t llllr 'r r r {; rlr t r ll'. r t . , r lr r | | : l nti l i tt pr r it r li, ii. t lr lt lt ( 'hr t lt t r t , \ r / / , r r r lr lr lll'r illr r I r ; l r r ir r t l, t t r r l L lr t r l I . l'tUu t()tld r: f i, t t t t t r ' , t r ut r , l. r 'Nr r r r r l olt t r r r t r , , I rIrl .ri I r rr, r r I rrIr r l t r p r r l r r r , i ,,Ii ,rl l )" l )t , ). ' l l () t l trl ilt : , t ' t t r t t rIt |, , r' i I Ir I r'rr <r r t r r r r |, r t t t t t t r t , ir lr 'r r l r r , t r l; r . r I r { , liln r rr{\o Irirrrr|,ir:I lt r 6ilr ilil; q, lr , 1r r r r nr iI , r , : r r r r r r : r l i ; i r r r . , ,
, r : r r , i l , ,rr. l i , , \ r ) 1 ,l l r l L j i , ; r t , ir r r r : |1, r r r i r r . I r i ; r : r r r r i I r : r . , _ r , \ . r , r . r , t .
r . i ';.,l ,l r , rrttr: ttr' , ttttr' :t l tr' tl l r i ' l l ri l l r' \ l r' l l t l l r ) l l r l r l r ' 1 ; l rrrtr,,t:i r ' r ' t , I r r'r r | ; I j r' ' ,r' ,,; :rl rrrrrl l ol i '. :l tttrrl t,r rl t |i 1t l )tt,l . ri , t,l r!:rr' r rr rrr l trrl rtrl i .l l l rrl l l l l :i l |,

(,i.r,rl irix.r,!(. l:l:ii ( lri L l,t |.t, : | / .I I,irrrli(:r li) ( : it liliir i ,t.t., : r I rr r r r ) ( n, ( r l) r , l I h rI , l t n t o ] , i ( x r ; , i r l ) f : t 1 . , l t *l l t l r | r .iLII I rrrI r , lo:r,nr! ( rrrI | )I | | | I i lulc t r ) , r u. or r tic , r lir r , lr r r l, r l i i , , l l n r r i r r i r l r r c l r , l , i i , srtlllt,l l r' r' r)llrr f ({lt o rirl rlc c lt , t lt r ir r , plr t r r t ll, r lr r r , iv lll; i r l o l t , t , s c r t c l ; o . ) . ' | ' rrIIrrr.ii,I.iIrrrlri v . r k r r c ( lr , r ir bli' pii, r : lr lips o r . i z r r i l l * . .r \ r . i t , . ) i ) r . l r r {r '*i i , t , r) i l , r r t (x)J r(! rt0 0r'i0 rrr , 0r r , z li,r [ il0s o] r i rr" i[ s r ) r . 0 lui pf o 0 c s i l r l , r , ; [ ( j r r r , r i r r , ri I r [ r l 0 r r i r , r r ] r

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i I I n,utnarat,lipu,Luiraspirator' (ijoiaoic lrr,blrba'li qi abdominal la femei) rtrlicii, rr ulrvilirto rrraxirnil a comeii g) Bradiaard,iaeste caracteristici, rrrrlirlirr{,rltr in bulba,ro ca,drulsindlori,melor hipertensiunoiDtracranian[ de plirr lrorrror:rgiecelcbralX, hematoame intracranieno, tumoni si abcese cf |ob|r,lrr ntrningite , ineningo-encefalite. IIai apare ln comsle din nixerlr,rrr qi in rxrle pril hipopituitarisrn ; h\ Ta,hieard,iaapare in multe come, irrrlrroscbiil cele infeclioase, in comele in care apar complicatii pulmonare i i1 NotntLc|a l.e:iune aaloul,ard, d,a ca,rd,iacd, olienteaz;, spre o embolie cerene irlrr,lir, j) ,lritnii.le card,inceFi,alte mod,ificd,ri card,iaceie pot sugera meca; rrisnrc oxtraccrebra,lo ale unci come (embolie, infarct, iusuficientd circulalrrlic lrermodinarnicS, etc.) ; k) Eipertensi,unea d,rterid,ld, intXrirea zgomocu lrrtui a1 doilea la nivelul orificiului aortic $i cu hiportlofia ventriculului sl inq ne poate orienta sprc o hemolagie cerebralS,,encefalopatie hipertenr'ir.ii sau urcrnie; l) Eitrtotensiuneaatteri&ld, Ia debut poate sugcra o insuricrrLil saptatenali,, o comX cliabeticS,,o com5, prin tleshiilratarc, o com5, l.oxiu"r,, sau rnctabolicii, (prin oxitl de carbon, barbiturice, alcool, suferinle lLop*ticc, boala lui Addison), o com5,hemoiiina:nicii prin hemoragie masiyS, r;rlrr prin infatct mioca,rdic etc. 4. iligesti.ts, Vd,rsd,turile sint ncaracteri$tice, putintl st -A.paratul :rprlrii, in nuureroase come de origine neuroiogicr, toxici sa,umetabolic5,. Ilepatosplenonegaiia ne poate sugera o comd, hepatici,, leucemic5, malarir:L, in boli de colagen sau a,1teatecl;iuni d.e sistem. Dagluti,li.aeste perturbati, in leziuni caudale ale trunchiului cerebral qi este un elemcnt de prim ordin in tirrrlinl nucleilor :rervilor IX*XI) rrprrrcicrea grtulului de profunzime a comoi. Deglutilia are aloi timpi. 'l'iurpul I (lzr,bial): bolnavuiui inconrstiont i se apropie o liugurili, cu apd rlo )ruzorel intinde buzele, o suge gi o inghiie normal sau nu intintle buze]o - iltunci vom spune c5, timpul I (labial) este prezent sau abolit. Timpul )rrbi:rl are o reprezentale cort,ical5,qi una la limita superioard a trunchiului lur:olrral. Timpul II (degiutifia propriu-zisd,) zicem c5, este bun atunci rrirrrl tirnpul labial este absent (pacientul nu intinele buzele sH,sug5,aprd,), rlrr,r'cind, introducinal apa intro dinli, eI o inghite bine. Timpul II al tlotlrri'i{,ioi csto intirziat atunci cind o introd.uccm in guri,, paoientul lino rr,pl,irr gurii, rn timp gi apoi o inghite, Leziunea eslo Ia nivelul nervilor crrr,nioniIX I inl,roducem a,pii,in gura holnavului, pacientul trine a,pa, cars lrolboloseqte, dar nu o inghlte, are un refler c1otuse, o parte tlin ap[ irrllri in ci,ile rospiratorii $i se ineacS. Spunem c5, timpul II al d.oglutijiei osl,r a,bsent, cu sau f[IH, reflex de tuse. Ireziunea este la niyelu] nueleilor rror'r, ilot cranieni X-XI. I udoral,io este semnificativi, numai in cazurile f5,r5,hipertensiune. lioziurrol, csto in ium;,tatea in{erioard, a bulbului. 'lluto tulburirile vegotative (afari ile deglntilie) au valoare daod in nirrl, lrrl,1;o ansamblu (tabeiul IV); izolat, elo nu au y&loare. menului neurol,og I 2. 1.2. 1.3, Y al,oarea d,atelorefro, ic 1.. Il;ri.ttcn;la harniplegioi,l,robrLie vcrilical,i, din capul locului. Constal,ir,r'oir, r nci ho,niplogii irrstalir,tobLusc sugottnzii -a,ploilpc totrlcauna un ylrii0rtljr,r Itr mrobral $ll,I lln(x)ri {] r,11.q?}jilro. sohirnb, su]prirriloron) rlr.rcirlr:rtl; ir itr.l;rr,lll,ri trrorIlotrl t1uporr,1;o lrorniplogii ri;r'-o cotrtrt in rrrrrri $ugoni] u,l1;c' Fi (1;utttrrr,r'o r!b00$oot'ullt'1tr1, rrii,rloqirlrr itrr,lr hrttttrt,li0rn Nlrlxl|rnrl, Jrosilrilil,r"r,l,i ;10 0

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rrroningitS,tuberculoas[', parazitozd, cerebrald,, mai ra1' cncolil,lil't'I, ltsrrtttl,r 'hrrnorald,): a) ln comele superficiale, deficitele motorii silt uryor do I'0orllrorrrrl'r rl,r prin probele motilitS,lii active gi pasive, cit $i prin inogtll if ir,l,r,rr' rr,1,it roactie a membrelor la Dracticarea stimul5,rilor dur'otoitsa. 'b) ln comeie profu,udo Be ror practica o serie de pr'obo : . lrlf ul;(tnlt[ rrrcmbrelorparalizate, care cad mai rapid pe planul Jxll,tthtilrr ttttt,tttrvrl|r (lc ddicare qi d Hsare brusc5,; -,,semnul piciorului totilr In nlh,rfi)'nl prt,tlirii, lrri Bogolepov (citat de Yoiculeseu qi Stoica, 1907): - trrl:tt;irt, rrrir,ximI, ln afar5, a membrelor evidenliazl' lipsa do lovolliro itr lozi{irl irridial5, mernbrului paralizat, plin hipotonia rotatorilol intrrtrti I . lrtl a t,x 1rit.i t}lt parezei faciale dc tip centlal (eviden{,i:r,bilir, ft1cs ttrritzjlt ltt" z.rr{,a rlr, prin ,,semnulpilr'i" sau ztl ,,pinztrido cutitbiottI lll plrtlrrrlr, lrr,{iilur', ii illttla't srltt 1rr lltt trlltlttl rrpir,t pe globii oculati, lxJ rtlillgirroi!rrrl,r'ortrarrtl illo prr,ra lizlll rl')I - ltntzrtttl:t,t tIi IrrI r' I'tr,tl I t l:rlirrlrrhri,rn lipsl grittr:rsti tlo 1r*rl,tlit, tilt,tt It' tr^lh, ltri rr llt,rrrrrrhri ltiulritrtlii;- tlitttittttirtt'lt' lllxrlinlil ttlrill'1,r',rilli'1, rclltrxrrlot' r)$t,(r(t hrll(luroirrltt. t;ii rllot' ctt1,ir,ttir,1,r.r it,lxlrtrrirriikr Iriritrtrl;t'iit, trNr).u(rt't'{lltuHpilU{ 1111v,i 1'rrl'lrt't'd( roJlox) rtrrtt it" I'rn( l,t.tuttilu.l'ttt'tl<L,, rriittii, rr'l;rit Ilt ttIrti,ltl gtlt'ii,lrttzllor (,lr,,l'iljl tr'l|r,;i):r,l rlrrlrlrrrcrrfr. lr)rll!1ii,
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ri :t'l litttlrir' ptt,ztrtt(it, ttttiIiutrrlrlIit liislllnslllrri Iorric lll uirrior,rrIrri ]rri ir ill h rrll (l.lrlsl.irr ll rrrrlrolrr;r,r, rblrrrbilill srr,Lr corrLill,os iroatoiugcra o loznllx) trrrri,r,rrl[1.r.r.r,I/u. gr(]spiugrotlox bil;1,el'tt,l LIrr IrtrrIr.rrl,rr,lii, .]ru il,t,cIaloa,t,o lrrr.rlizrr,lolio, lLrcsLusrrgctiltl o su:tilinli, dc lrunclri cet,ebr,il. :';. .4ho[.it.'ctlre!l.et;ektr o1teoleniliuoase sc poal,e constata in diabr:tr , . rr lrcrrLor.ilgiiic subiuahnoidiole, irr unelc mcningil,c blcilare, in situali:i, 1r,{l\isL{)lrl,ci urror polincvrite (polineuropa,tij) inteitiorsr', etihde,cliabeticc, r:o.lirgritrozicc, lxccurn fi in hts. hr stntlii ar arisr,tl alc'coneloi, abolirea lolIrxr,lul ost(]o-tondinoaso prezinti somnificalie patologici, (ce1mult nu prrrgr rsl,icii). rr de pi de . L L'rczerrla sem,.nelctr rigitlitate prin decerebrare a cel,rtr ri,oiditate prin lcc,o.rlir:are a.)poato fi constata,tii rnulte corne(vasculare,'toxice, (y. irr rrlri rr,l,rolicc, tunoralc, cncefa,litice) qi pot indica sediul leziunii (Jouvet, I l)0{)) |ii scnrrifica,Iiilc prognostice. 5. [trezo]]t& temnelor meningeale intr-o comX, instalatir, ictiform no irrrlicir,in prirnul rinrl o hemorlgie subtrahnoialiax,i,, dar si o hemoragio ,r'(,rcl)r'o-rnellingoc s:l,u o inundalie ventriculard,. jDtr-o coni, fcbrild,, semrrr:lcnctir4leale sint lerela,toare puntm o meningil,i (urruilles) sau pentru 'absen?e rnr lbces ccrcbral. Recloareacefei (cl atte s,,rnn6merringeale sau rLrr,r'schi!,:r,te) poate intilni in proceselc expansile intralcraniene (tumori, se tlrctrscr Lernatoame) cu fenomene de angajare. 6. _Prezerrla unr_ rnipcdri au,tomatico-rejlerech co;r&ctar stereolip, o":dtLu.1,,if,cle_miFcltri caqfologice (readocerea cuverturii ori cle citc ori desc-ofeiim Irolrull'ul1 miscd,ri do apucare qi de frecare a organelor geriitale, a na;ului, lnr r'r,ltcrni,sciri ges1,ua1e storcotipe) se intilnesc irrrloosebi in comele mai ,,ul,,r'ti,.illo din irrtcclii, in[o:ic-r,1ii unclc mo n iugo-cnccflli ,ii re. '/. 1't nurdturi ole e.ttrenitd!ilot tu a*p.(t ttc ,,biitdi de oripi', (,,Jtappinl lrrmoi" 1 apr in cornr.lehepatice. 8. Mod,iJicd,rilepuptil.are. .Pnpileie se prozinti miotice in intoxicalia , rr o;rinrr.c. in.conLa uro-nrice;i unclc l,.ziuniprotu bcra,ntialrl in (benloragio l bazilar'ri, unrorj puni inc). pupilele midrirLticesugerca*zi, t 1,,,rrl.ini.,rornbozii. ,r rrrr,'rrc:trtre al,roplmcAstu o comd,gravd,vascularS,O midriazx unilaterrrlrt (ipsilai;er-ali, sc intilncqte iu heruatoame epiclurale, Nubd.uralo -lezirnii) r,;ru irrtr;lcercbr ale, in tumori cerebrale cu anga,jare a tonutui temporal ryiirr anovlisrnele de arterd, cerebralil mijlocie sau postrrioard (asociaid cu lrt,oziipllpebralil), 9. Pre:renld.anai oftalmoplegit (ptozh, strabism gi rnidriazd,) asociatd, ('r.ri.crrnc rnenrngrale ne sugereazl o meningitd, s&u o hemoragie subarah_ ruritlia,nd prorlusi^ prin rupturi de anevrfum. O oftalmopl6gie masivd, ilrl,r'-rnr corrtext infcclios ne poate indr.uma sprc o tromboflibi[i, de sinus , iivr.r'r',r. socieroa, oftnlmoplcgicicu bcmnc piramiclalc.caro realizeazd ,r lr'.rripL'gio:rlLernfi,, sugfroazii, leziunerle tnlnr:hi ocrcbral (tunrori, nc u i,rrr.r'Irr,Ii1,o, tt ombozll dc afieri, bazilar[ s.a.). tU. n,flr.ru| Iolo.n?,otar ti abolir, in conrele protundc, in unelo -poi\I " |'' ro irr ciLr.(f &Nociazi afcctarea motorocularnlui coinun qi/ Sau nervul srj ol)1ic, pr'ocunl qi in comele vascularo prin a, jeriti lueticA. a , ,I1.. .l)euialiaconjugatd globiior oculari constituio un semn important rll lt.zirrnn.el,ir focar._I)eria_!ia,. eonjugati, a globilor oculari spre-partoa oprrsi, Ircmiplegioi indicil o lezirLnc eniisfcricil 1l_,olnavul,,iqi privegf,e lezi*spre'partoa rtrirr,", conf{rrrn.Icgii Jui IlrCv,'sh f i L:r,nilouz.y).Ilcvii,lil, h.rrriplugitii, inilicir, ilo obicr,i . l(,zitnlc nlr,i ji,risr'i, lrLrnchiiLl <drcbt.li,l in (ri rrrl l rnr ltovil lo [t11,rlrrrr,lr,rrl,irII r i nlor:ior), :i{)tl

-1

l:!, Nln:rrl)t!ltl ttl pl:rll rrrr,:r. rrrrrllrplc llrrrrrilir,lrtii l)11,(x'.r : r,\l,lt,liltv r| | t rr(1 ir,Irii r,t , lr!rlrl)ollrlllir r r,r'r'IrI;IIII, I I r,rrcr'lltlii,rj r'rrlr,ltr,lrsottrloirrlror.lrlii, iolrirl'ilrII i I)r' r'I r.rr ri r Ii , r.Irlr.IrrIo1rrr,I r.cclllrrr!tioi, lrotrollt,gicsrrllrr,lllrrrrrr Itrr,t rii. 13. Alrof iu opLioiiutlilolet&l,ri, un bolnav couli)los porrl,csr'i rro irr la, Ilrrrrrsgp16 o hcmor.agit subarahnoidianirprin anelrisnL lupl, (rlilcii rirrl, ri scrrLlemcniageale), sple o tronbozii, de alterri carotirl"L (rllrci, r,sl,rri rr lr(:rriplegic contralaterali) s&u spre un sindrorn l.ostel .Kcrrrrcrlr' lilirr rrrrrnli bazrlii {lo claj rnterio). 14. Motli.;f icitrile reJlernlui cornean, si, ofcre inrlict,lii rlo prrrlrrrrzirrrrr pot, r,rortteiriat uneori prezinli, ,sit-aloarelocalizatorie. Asl,fcl, tbolilclr, rrrrilrr, it'raiinne sugcle:lzilo leziunc pontind,, iar o abolirc llilftLcl.itlil(rrrrrrrlrliorlrr, irtiu gradul de profunzime al comei) ne sugelea,zlo lcziunrrrrxlirrsii rrr tlttl chiLrl cerebrul. Prezenla rutlexului corrrcu-pteligoir_liu,n (ur, ,si :r rr,llor, r',.llcxearhaice) lre poato intliel o suferinl,i f trun]chiului ircrtir,rrt, ,lrr,r. lr'rflLilte oli nu are valoa,re ]ocalizatorie (reflexo clc clibor.lr.c). 1i. Abolirea reJlerelorJaringi,an ,si 1)elo-p&latin, rr:prczilti'i, irrrIir:rr,Ior,i 1,. l)rol[nziur(' i.i,comei, dlr uncori qi semnc cle srLfclilfii brrll)lr,r'iI rr:r|| i,rtcuilobulbin'ir,. 12.1.2,2. Clinica sintl,ro mu,lui comatos Olinic, siridromul comatos,ue uriniitoarele co[1pouc]11,o : 1. Abolirea, total[, a stS,riidu cuno;tinld (cou;iienfn;. fir corrrii,rrrr rrrr ' otte vorbi de eristen_ta altor tipuri do porturbiiri ale $1rii,rii crrrrollnrlrr,. d.o alr)ua $9 poa,te agrava, ducind. la exitus, san so poate a,tnclioll, Irr,rirrrrI rrI I r rrr'ozertinalin a,ccst caz simptome de trezire. !. Tulbur:lri vujjetativc.
.J. -LtL.DUraIl OCUm,IC.

4. Tulbur5ri neurologice, 12,L2.;i, Gradarea Si clasiJicurea comeilor

llator-itir,clracterului evolutiy al leziunilor, c:r, fi Ltltilil,ii,(ii lx\fi,ll i)r'lrilory&sornotorii existi o variabilitate a aspeoteloi r,linioo rii rlc i1t",,,,r, ,, sl,riutl cl$siiici]rcrru cste posibili practic. nst:e ins[ }osil)ilL (; grrrlrrrrrl i Ii t'.r'',turzimiicomci $i aceastaesteindispensabilsi fie reaLizl,tir,irr rlooo*I,ri, d clinice qi practice, adicfl ds rS,spuns tratamcnt (lc apr'c(Jiol,o la pr.r,;jr'r,t I rc,l,. 'i rls profunzime a comei nu poate fi cert stabilil, rlrrril, 1;11f i1, ,G,raclul rrivelnl gi intindsrea leziunii majore din trunchiul oerobrtl, (lol,orrtitxrt rlrrpri criterii clinice Si paraclinico. Dup5, acest criteriu al lcziunii clominante, noi am propu$ siiitorlrl i zrr,r'ea 5 grado de comi,, cu urm5,tora,le caractorc (tabcltrl V) : in Grailul I. Bolnavul este inconltient, functiiis vogota,tivosinl; ln linritrr rrorinalc sau_,uqor modifricatc, toli timpii ds aleglutitio slnl; plczorrli, rlo rri{rrrruc&Iel'lexolc rlo apirr,r.o $i autom&to plozonto. _tictloxrrlrkr rr,[11,r'rr,r,' lrlo prozcnt, boln*yul so apillri la, cxcitaliilo oxtorocoplivo (srr:r,l)iI,r"d, o rlrr rrLrLsoii,). .Il,oflorclo rr,ul,urnlll;o plrrzonto, sirrl; bolrllvul so apilrii,h oxoil,rr,l,irll (Li.!rjiir rnirll il rlollro,so:lcopor,i'l o lriil,rrlrr, 1rt'opriorotxrlrt,ivr,(rlrrcrr lll,oit.U crr rlrr,oii oirl,ollig). l,rt;rilolohilti norrnlln $ll rtfr)t.ruirli.ilttirui, lrrllux ii r,rr Irlllltr(rl,i)r rlitrtitrttrr,l nlrulil,.Irrr, s:t,u so lrtolr.lrlIrr.icli, voil,ilrttllr.ji, rrotr.tlillii,
:()tl

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rlttrttrltttttir' r-:stc iii'y,t'i i it.tri,,tll,l rltrglrrfilici abulit,'1'fJ:'),1'1"t'rtIrti.lt' ,', ,,"'':rl,'i,i,, vt:slilittlit'til'

I.rir'Ilobii r,olti tlo ,r,irir,r;,r,itiT i, ,,, ,",iLst','r'vrrti., 'boiitt'' llr gr r r ir ' ,. ,l i i o dovi|lc ler it cor l. iugr ll, ira globilor ocula'r 'i spr '( j ] ) r r lliil , 1,,,.,l| lci} este lnedin-pontini. l)il'l'i .i!l(! rttqd,ul LII. Bolnalul este inconqtient, exist':i- gravo lnn'trll ' I l it r lit zir r 'l , ,l f,o u" u"iur j'e, i ilr t ul f nf J"gr r iit i, . i, lor cabolil. t ir r r lr r t l

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git'1 a r, r'rr,iri'i, (Ii'l1'role glrbilor oculari, frecvent .discorrjtt u ' oscilarLl'i',ou 1(\lr(lilrlri' ,l, r illii ocliilor'. Hipertcrmle qi i"tt"iooo "t"riali' lr .r,ltut'r'. Lezitrncl cbl,c in parlca' in[r'tioati c p nlll' ii.ltt t tt4tt" {i rud,u.I I{. Bolnar-ui este inconqticnt, 1'otll areactit', liuno! cu limiirr, curnl"atil''ilitrr'.tii stll)Ill'vr{rlllrrtrir" ,rlr,, iiiiii"te gr:aypertltrbate' kr, 's.au abolil;' Nli'ltirr'zo ',r, .r,,tlr.'ia-aliiiii,, 'reilexul ae iuse p"c,ent,*intirziat i,bolit"' rit'tl"t"ltr ttottlotrtrrrt'lt i .'',';,,il"il;;,l"'r;i;;;;;t-$i;iii-o;pi"r'l .r t'trttrirr , r,.. r)r{llo-l.tr,iibulare sint *froiii".'ff*t"iAita,te muscula'ii, a' 'i ;s!" io patteaquperioar[ bulbultri' i, i,"''ii,',l" l.i;;;.-i";il;

i* pr'ba rt' jurrlrr'ri i':r tt" ''rtl'tt i srt'ttlt'ttstttrl'u

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crr circullr'{'irr' t1i t irrttlLrl | (eoma tlepir,qitd,) Bcrlnav total inconglicnt, ' zit t t r f r r '. r "'lt t r, r,,r' :LI rl l ilic; al sust r nule- 'piin m et or lc de r csus, cit ut '" l" ;rr ct ] l{ \ l) llllt lr \ ( 'r 'r r r rr r r rr,r.rt.r trr sc! r nenl0le bulbar c inier ioar e. Sindr ot nt r l ll .r,rr,:rc i i cr eielului". (lo$otr$ trr' lllr,;iic. tailloul tle comd' depnqiti' - a,,& cuin t' li)sl ( l( r sit r r l'lt ) r r r r r : r' . ti r,,i l u,tl ei it . G odon, in 1959- - bupr inct e t r ci oit 'logor ii li

,r) ,\br:lirca totalii a tuncl,iilor vielii do relal'ic' l,) ,\bo1irea, marilor f unc!,ii vegcttltive ' (,) llEG cu traseu izoelectric persistent' t'rt'tt' ttton'r1'ttu' lliD(rl,oniacor]leeicu lipsa cletransparenld'a ei tlonot?1' denoti, cd,Ieziunet , cttlt'itts l'rrrilrrtirtl i."i*'."t""e t, ,';:il;"".i.i;iii. t r t,l,rrit,nuhti tli:f zona bulbo-medularS'' I :l . I .2.4. Probtame d'e d'id,gn\stic etiololia N Oont epibpticd. Ctiz:r,cpilepticri,grant-lmal $'r ill\olr1iln)l:i:l,],1:,,1:l . itnrrrrt,i' ,t, t,.r,,.t{, .r prolunhi, tulburar,. a, ('on$titulci, cftr"o tn , rr l" o t iro idtt'a- si poetaccosuate. rnoclbrusc, sau r lu 1ti'r'i' rir,sll,I);l(ll,',,;;,ll;i:i:

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,L L nr r o o sorioasa tlt .l)ltt .si o catarmxlzi', caro rto lii'ttrut'ttq[tr'

,lill;lll: .,;lll,'il;li**lr;h";:;*;,tl*t';*'*rr*qLll;t'" 'lili;i.i"p#ffi;;il. rrrrrrlir" ari lost asistrtir rfi't't'. b;A;"r,-'" , :l il

aroactiv la- sfirnnlt'i'rila ;,,,;'';'i,,,ri;; i;;lu"uuf iiii"itt,t incirnrytiont, in S,tpoi rtrtnnrca' cLrlllul sbcrtorolsir,, ,rrrr',,, ttrsltit'rt,llia, r'rt it'll:i l::::ilit'11:l] l r 'l i 'l '
n l ) l l l t) r r l l si t, l l tl r r sr ':t l sl l t,tl {l l l l l ( r l ( !l l l i r t , , , ', . , . r r ', . 1 r l i r r r l r i i , r ( 'r 'r r '{i :r J l i Il i \ 'I'r i "t , , , , r ', 1 l . i r , tr ,r l tr ,l i i o tl ,r r i tt',r ,r r * 1 ,i r "r ['i 'ip 'o l r r z:'t',.r 'v'ttr l 'ttr u l tr l tt l ( r zi l l l r i .l l l l r l l l l l l l ' r r r l r r r r r r t r l , 'ti 'zci .t,'l r ttt,,l ,',t,','i t'i '1 "'ttti i tt:u l i ,r i tl l t'xt'l t'r 'tl l l ttt:Il r tIIIIr Ir ttr r i ttttIt' 'l'l,i,ii;t':

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2. Oonxele d,in accid,entela aasaalnre cerebra\e

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lilcrrlrlltllii cotoJ.rralo lrin me

1i.:.,1'#1"i3;i,*",""'sf,f ,,i llir:.,i:lt{*jijrlJ h un.tind,r po^t"iji tl ffi1""i"f;Tli !] cii,,,pari1,iD fifi i irr v..rl.r.. unei corne porinifit"ioii "" "".1"0" iti ;;il,iitiitfil*Ji"v,lliih*11,1?"ilfiliiti*t"Ji i""i:tt*il.i*,*"i#il

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r,r.r'r't,lrtirl rrir rr lrtitttii,it'tttrI'IIt,ttttritLit', r,Lrr.,rI rI rrrrtIt, 0x ilkltr (tri ltrrr lrr,r l,o I itrI.r't Ir I Llt tr, tt ittt'ttltrrl' ,\r'ltlrtti (xrllll)., lll? l) $tlll ll' tii r,' ., ,,.it ..Ltr,,tti,It,tr'' ij (trrrrrI t i rtt ' It, iI tlrr trt,t.t ttttt r,',zrr.i r.ii, Hrr ,,,,,; ,,,',ii,,iirrrrrrlrr':Ltrr.rll.irr llr rrrrrrlr ttrrttttrlrr tlivt'ts| tlrr[itriltr (itrsttttLitr'l i( ltii,tirr:i, rL:r r rrztli,) sitnll{,0tltlti,olrtgilt, (! (1.(, rti:iliz.lr,l,i' (, t,Ltru(,i!l .trt .5r'lllt' (1tt'ittlttrttt'rrt';1it r.i r1',',, coirrir,) lioato fi '"'t"'irrrnoralir'!i l.tlrrttlii' ctloln,prirLl'rrgl j i'ri lle unor tutnori ltt .r'ttltl{'irr IlrPitli'r' rrtt cu r-rvolLtfio 1i ,,rr,r li'!rlr r oirient tlai;, prin mlt, staze cereLrrnlo i,',' . l,o1ont edemaio=s bcmolagic intt lt ttmr'r'll;' itl ;i orl r"ijdentintna unei hemiplegii la un boln:rv colnftloJ (srr'll r'\t'lrrtir' itr un r.rr,.,i ;nro tom5) reprezinti-in-general bot;,rilor atgutttr.ttl. frrt,,:ttr';r' l(rr':r'trll irr ,, ] ,.,,'iident o aicuia" cercbrali TotuSi, in unelc sixufl'tii' ('rl'r'(r fa!5, de cd'jlonrultlii l)inrltI i(lrr|1' I r i,rrr,r,l vascular s-a constituit la ttistan!5, poato lipsi, dar putem constaiaalliesemneneurologi.. l't(\21\lr(r! r,,."'ifttcgia jttsl'rrlitirr l,rl,rit,tr,l-La unor- semno neurologice (indeosebi pirlq'1i{alg)' It ' tt trrt :t ;ii rr mai .,' .,, :iLitent sau in tloi t,impi, suger-eazd, multe posibiliti (i : ' procis ocluziv bazilar, hcmatolrr (lr' 1r'tllrr'lrl , u ri tt(latie vcutriculard',tl() ,, r, :,r.Ll. h'".atom emisJeiiccercbral (ctt marc cdcm lii sau irl)grr"iitIt\ tr{rr' l',1,,, ,,r|oral, cu c,rlrenareain suferinl1 ;i a enristmului optts)' l'r'r'z' l splo ('{rlrrii l{lrt:r la ,rr',r lr,,mipl"giiinr"omplote un paciont cate cvolu-cnzd. ittlt't' expansiv: hcmatom subdural,htrlttrt'lotrt , ,, Licirineaunui Drbces ,,' tumoale cirebraiS.(Lrseni qi colab., 1974 ; Yoicultstltt ryiNloit'rt'' ',r,,),,1. ||r(;;). ne i'r':lcticaneurologicS, mai invali' ci, tol'deauna, i'aitrtt: tlrr rt'rt'littttrt' isrrlttrttrir'), Fr,ltill,rt,t: vascul:lr cerebral (hemor:agit, rlr,r.l|,rsticljll accid"ent de i'lirri(''r ||itlrr''lirri"': ;i . r, ',l,lit:l1o|irlrd,climini,m, prin cxatniniti tlr'nlo l iti l 1,,,' trrrr, ilcleraumaticecxlraduml $i subdulat (iL('uL slll)ll'('lll)'lrlrrrrlrr(' r'l{ ,, ", t ,.,lo, r'rcningitcle mcn illgoce{aUl rl1uilrslitlitlcrrr;lirli li tttr'ltr{t" fi ( r|ir' hipertcnsivi si crrllLrul)]l{'l'l l Irr ,,'rnil, encr'[alopalir, tttltlt. ]'ol:L1,iV tlrr ir|,lllliIt|, osi,e hi.pcftensinii lti|r,grrt,s|icul mcefaloptt,tie de rrtt ; a) n6 afl6,r in falil urui crt'z' It'tt1tttItrt II ' tt|'rr ' r, , ,r i. nl toarelor eleircnie lirr cstrnl'irrlii', tir" tttt i,,,,,,1,,r,si..e {fie cu hipertensiune a'terialii, a.sa-zisir' lrrlr'l ,t,ir.r:lrcfr.Se;Amaial6s,irrcadr"ulunuifeocromocitotrsil,llrr,rrlrlli r,rrl ,,,unla-rnoal, cadrul unei coarctalii rll i-1lrLltorli(, rrl ttlr'i tttt'trttr, in ,,,',' trlllir;i trtt ittt'rrl' t , ,.lrrri,tsii'sau unui Satu'risrn),cu masir-r' r]1't! lr.ttsi. al 'lirodific[ri ale Il.O. (pini la maro edcrnprr,liLtt 1. b) Ootttittttt t'rtl" ) tr rli tt tltr cste lrr.ofunr15,, de obicelitranzitorio I c) O'trta,trs1,t: tttttllrr rtl'i ;rlttt 'r,,rr asotriit' :rll'tt rtrtttttrr 1i lr,,r,l iiui I il) Cefaleeaesteintensii; e) Se 1lr-tt' "oo""i*ii ,i,i r,,,,,.,"(uriu importantul etlem cerobra,l) f) J)c .bicci I rtttItrl rt,IrIIrIt I tIt' ; 'lrccetlatS, ittlrrttttil, ltt rle fenor*ene protlrottti.t (trtrlrlltrtr t, ,,,,l,,,ir"iaid, este rrr'r,'rnii, episoacle-deconfuzic qi obnubilare)' rr de t ilamoriaia subayahnoid,iand, obic.i nu crccuzi, rI i I i r,rr| |,ii, i rlirr,ifrr, 'r : , i, ,,. ,,, inilr"iiot *amiologicliind cel mai adcseare't'lil1,ot' s.rttttrrttt.ttitt*rrtrlrr tu cefalee inf,erLsit, vii,rsl,t'ltri,rrrotliticili :r'Lr'lr''O (itrrlxrrlirttl' 'rrrrr,tiri,ntc" 1 i f ,d^o.*gii ret irri,n,'), rnici tulbrrrlri d{! oonltiinli, (t || I II I| / |' ,,, I ,,1, ( '( '1, , r ir r lr r r lllr ' lt
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,i'lii,,oiirri-i?nii""q#a ':l'lli l' : sing' tttt i::r'rl ' rr sau microscopjci) r'r' r' | ' i'lcntieroa (macruscopicA -io hernoragii' Da. lipslr'.. atxrsl'o'ir rrrr I'l:r l" .,',, f,,,- *""o"t i"d io f,,Cn (Voiculcs"rr $l'i.ru' llrr;' ; l':r 'rr focar l:emoragic ,. . tl"iff;;uu-i irrr'(lr' I ir r'| cfecl i i " i i .' 'i ' , ',' ,.. l;:;1i iCft J,tarc, r ,ti iuarcaunei rrbiccntczr'( u lrl(rlt:\ ' ;r lC?7). i .- 11," '" 'r r i r oti c n c c i {l 'uL\:r 's .r tl r.r r ''1'r 'r r ' r:rrrl rrrlr"r' . carriiLor cu S"lnnc dc hiptlr'l''trl;irttr' , rrti:t rielrloPtii a ';,;.";;i;.", qi/ siu I L'lrtrlrr' t' r"1"'r''l t"'"bnlot"" . I opi$1'o1('rrrrr rril ' rr-'r'illtoaro: midriazil Lrnilatrali'' ,' ', ,,,t" iiifiouse "'"ic;.i"l"i udem pttpilar) qi a stazci l)lrDilit11" ,. , ,,., i''li"'a"i.tii..r"r, ' rr( {lrrri:rr'r' (\ I'rr rl p-(llr1'lll .llrtdi.f icdrite EllG ut pot fi hot':'iritoi],re t. 19R0I 'tr'1rir'r''ll)(i'iI lirrlttrtr r't ,. i l;ri,iin. id67 ; l'opoviiio Ii co]3,L., irrl'rl' r l1r{;l; \ rrrr(l.r t9i9; Fir"\'rjr'r ,l . iil,z'i"illtcmi:la'li colrr'b', ' ir dbPupr" irL;i r'"r'r'rr.,,. ,, ilol 1' r ' ll r 'r r r r r r r r ( l"Lr ' "l')' lli' lll:iill. ' r" " ., . ), c: r l, "p: llXl nt l t t C pt 't t nil' 'i l" ' \ l) t lr ' : r ', 1 | - I I 1 I rrr: ' r 1' ; ' ' 1 ' 1 11 ' t 'r 'r l' pl'''duc nr uclir i': ' i , , , r , , ; . "l, . r t n*ii' isr lt t r t t t ir r r ( t t t r r i lr li I I t t t t l r ce f ouillr lt o , t ri a, ', ". - Uiot Jit air a, it , ( lr r . r I ) r ' r r oot n" .,,r,,,*it i: ut ") genor eazi. r-lor lif icii'r i lt ll( ; r r lr 'i lit t iilit 'l'r r ' , r "., I ,i cn car:l'cLel i'egrcsrY. ( 1jt i{l r nl I 'r ) it l" r ll" lr r 'r ' , ti o. : ioivq{la cst ; cont r aindicaf it ' in <'lr lii it r t r t t t I t or . ' r r r 'lt t "'ir '' 1t ' t r lt t t i': r : r r 'lu'lr i1' llr .,, ' ,l t' ii el, : ineir t e t liagnosf
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lirr rrIrt,i,oIr,r'rI tlili;clo r.r-lbrtrrlrlluigonctrll, p(. irrpli,t.l.Itc, sirrl, ]lcurol(\lil ;,i rl. IrIIr'r,ii,lo} ' llsltcct tltshi,l|ltlut it t,t,tnrri-tLtui, tegurn(x]i.lr\ r cu .ii*r I.. I'(l(li ciurLotict:.1 gl.bii ocul.L,ri h.iytrtori la p:ll1:lrc - itratiilrrrr,, Ii (llJ Irl,irrriri),crr iuspiralie pr.'ihngiti, apoi pauz{ tt-upi,I bare cxpii;l(,itr, {,ilr) irrlurli) rilrrtlr,ii,rlr.o:r,ltir p:r,trzr'r lunE:t,(r,espirllic ascnri,niit, i l, rn:],i o r'rr (r.rrr i,ip li.iissnnrrl); {l{r ,-- in haloni, se pcrCepclniroslrl de acetoni,; lrilrolr'lrsiurur l,t{ct il,lij,, l)uls slab si r.rWidl - hipotrrrnic,i _ nalcati; lri 'ostco-ien(Linoas[, hipo- sau arefletiu lrrrl.rri* rrL'srrrrlrr,r,i,; I * nidriazii : , jrl'otir.irnu n)ici hemortqii h l'.O.; _ pt.nz,.lrl:i r',,1 , 'r.rr,'rlr: inu|rtir. d ,,lLrrrrzr.i rr,r.oll)il{rr(etnnici in urin5,1 - gliccrnia rnult cresenti,i si rezcr.r;rr, rrr,lirrii :r,lr sciizutli. t ) Ct)ntq tlre ricd Nste relativ usor de rccunoscut : _ antececlcnl,rr rr|lloprrlicel - arproalc totd{ aun:t r.str. Irr.:cet1rr,1,ii Drotltoarne ca,r0 tlc rrrrrlurrrrrrlrcezii oboseal5,cefalee, anorciie, glealri, v:.irs[turi, diarr:o, : (liril)rcr',n).iodozopsii (,,,rnuqte z}uritoara,,), eclipsevi2uate (pini, la amlrr r',,r...1,r'rrrrz,ltririi), rnioclonii,,sitresiriri fnscicll:lre mlscuhre, ufteorl ortl i rrlsiiI - l'rillonii, lu.c rriros a.mouitcll; respirrr,{i:r, r:s1,e in[lte ori rlr, de lrlr (rirr1'11s Stokes; - bolnar-ul Ostc palirl, hilotelmic, cu pleoapol(l r,rlrrrrr,l iir,lc fi lrozinlii, sughit; - pulsul este f,,irtc binc bi,ttti Ourl l.rr.irrrrrrr, rr,r,tclia,lil este cr.cscut5, - cordul estc rnirii,, cu zgomote dlllr .i lr lrlrriii.uli pcuicardiacc * la examenul nelrologic'sc cons1,atrX, semlr{, i rrr.rrrrgitrlri,rniozir,. hiperr.eflexicosteo-ten(1inoasii,, ilneori seinne pitatrri ,lrL, ii c x I rrlpi r:lrnidillc (inclusiv flapping tremorj ; - la exaucail F.(). ,r, r.irirslrrl;iL: ncur.orci,irritil albnminurici, cu nLorlificiri evidente vas(ilr i;rr',',r.rrirr.srrrllll,rr stca,,',. cdern sau s,lazX cu papilar[ cl hemoragii I ,,il ,. r,orrrirlii oliguri(i, :r,lbruninurio, azotemie ma,siv6,acicLozJ, tl ) ('ort.tt,.ttotrnir:ti sc irst&lcazit trpta,ij I,r,un bolnav carc a prezentu,t, , rr;r:rlrrii*rlrirl,ltc (pri1ra{ociiuni gas.iiro-intcsitinale vi.r,situricentra,l.) salr r,i , :i,r',, t)it,r:i[1,11 rnr rles]ridratat. Se,rllne1e proclrornrlloSint asemxni,toitr\\ .rr r.r'1.riirr (,o riL ltr01)t.icil, fi,tar.e ca diaglosticul difcrenlial va Ltrre scanlr, lr, ( rl,:\ir r,lcirrcnl.c t.cr.olatoare:, bolnav tleshidratat; * TA scizLrtrl; r,rrrlrirr,zii l)l.ozon1:n i :lzotemiei, a alcalozel qi a cloiopeniei. , ) il,ttttrr, tr:itr,ny|ioi este u,sol.de recunosou.t:- ilsoleqtc o toxicozi rlirr:r,rlorutimniil_rte:i, 'r'rrrrlrr':i sa,rcinii in crrsul nastariii _ prczirll,i, san | | r, ;rlii Ii 1r|,lli orlr!,lc ovelatoare(r:elaiee, I v5rsi,tori, cdlme , ilbuilimrr ir,, 'r:r lrlrr.ri,.rr.irrrrr', oligillitr pin:"lla arulie) I -- coma debtteazf,'cu mioclonii, lrrrr rr i rrIri rrI r.rriIII .,ir.,,.lsii l,onico,clonice(:rdescasubiriIante) qi chirrr; r,r rl.r rrr, Ior.:r crrlclrrir,lo lo (parcze,mftniiestiiri alazice etc.)" l (itttrttt. ltrrLirii ut ridicir lu |) , lroblemc cliagnosticedir,ci,_tiflomSca,rI| rl. rr.rrrrri.rrr.Irr .l.rrrcrri(::-- antooetlctrte ]ropatil-ro gr:il\'e1i{)xio{r thcp:i,tite rrl rrr|r'r'irorlrc, irtzc, nctiltlitsrrL r liep:tlic), eltrnluil etilism cloniol rrrrrilr.sliililrr,r rrltuttlt,ltrorta,r,r.r.rrlnlrcltinslcsjrll;r,tllrlrr,,N,l)atiorx,Ni(\ni(r rrr:r.rrrlrt,suiilri(,yirsil,lri,nl{'i,'i,r,is r.,,iirr;1i1,rr{i,.,s.rrrrr,,l,,rr(,r.i,progrosiViI,, r'lrirrr:r'1. r'orrlrrz'iorrirlo, rlrr rrqir'rrriir. sl,iili Illscicttlrrlii sprr,srnc si rrllrsrirrrtrlr, rrrr,,olr r',rrrvrlsiirl r lilr o;rilrr!lir,; ,\rpr.cl ,rrlrrIIrrrrt,rrI rri r:liirrlrrlrr|rrl,ol,: I
r 1 1r | 11, I 1 1 1 I I I r' ri i. or r . irrrt.,lr' l i\ :t It l ,i .l ( t.t{ ,r,. Ir' | :rr, l rr rl ri 1,.,i ,fl i i ri rl o l rr,rrrol .l rgi i r.rr

tr r ' l ' tr l r ' l r tr r l t:' Ir ' r tl l r l ' tttl r l t' r lrr l r I l l r ,l l l l tt r tl 1 'r ' ' r r r l I r r r 'q r r : r 1 ,1 i 'r ' r 'r ) r 1 r l l :r l :l r r r l l r r 1 r r Io Ir tl I'IIItr '; , l , r t r ': r l : r , 1 ,* ,1 1 1 1 l r l r 1 r l tl l r ', r tl r "r l r r ' l r ' l r i l r r l Il l r l ' r r r , l t o r t t t t r, t t t t I I t II i I t I , 1 ,,tIr r Ir ,,r I ' l "r r r L r r 'r l r l r ' r 'tl l r l { l tr tr r tr r r r l : i r r tl ) ( r 7 .l l l o l l i r l ' lrrlrlr' lrrlllrrl , , , 'r r , , ' r l t l t l ,i i l t l r l i rl l 1 , t' i l l l l " .l ) r ) r l l l l l i l l i l l :\l ( ' r i l l i l r sl r i i r l ) '.r r \( l l l l l r r l r l r 'l ;r i r l tl o r ',',, r r l r 'l 'r r r ', i , r r l r i l i ( l {'l i p ci tr l i r l i r r l i i i Sl r tr 'l o r 'l ' r t r' : r i ' I r 1 r t'r g r l r i t '.i tl t ', , r r r l l l ri i p l tl i ,'i i r r c t t r I I : r r r |r 'Ittr r l Ii l r r l i r l r ' |'ti 1 ) r tvi t'i tt' l l l i fi ) ' l i ( ,r 'l ( r r r , l !'( ;r i 'r , l ; ( i I l o i l , , i l l i i ? ; Jl r l l r r r l l l ) tr ) l l l l .l l l l l Ir l t l l tti tL 'l l r i tr 'i , r r l r t l t 's c g r i tl l tl r i ,, l ti l tr :tso tr r r r t" i 'i n tl r 'l L r ''vti . i j l .r 'l r ''l ( r i ( r l r l ) i i tl n n l r r r u l r ttstti .i i t,r i i ', , , , , ''l i , i " i *i',, ,n l :i t) tr ';r ttzi ttl " e i ce fu l .o p u ti ,t l tr 1 t':tl "'l ttttl u l t l xttu l t- t't.t' , , i b , i , , r i ,i i i j r t r ttr r r r l o ttr ,,r r 'l ' , , , , ': i 'i , , i , r a i j ti ,,,tr .i ,u cl ti ,,to r r r i i l r tp r L 'i i '''r " 1 1 'r i r r l r cIu L r r 'l r r r r i

; i,; ,.,,i; ,iiltiilui,oili"i.r,19?d),c,ll,elnrnltrLur-,herzio_sirrrlrrorrrrlolrf'r, ltr'prtltr ' htpalic qi neuiopsihict'\pll s in cadllrl t(il)r(ri , ,''1,,ii, taLrioul ,,i tlll lr(rlrr('lt'\lr'l in | ,rro so aclarlgil'J sladiul precornntos;i subr'otnalos' elcnLuiib ,'ll.lllils ti'' root)) (Slr.r'l,r'l' ,;' i'.1;r: ;,i;; ,apffii'at"pr., a rrriirrilor', l!)?!i; iiir : cii,it,1i T'rrpuvjcirL, 19il{1 Iropxrr-ii'irt, tle ijilieJ, 19iiT iiii;ri.'i"EIII'diagriosticul"'':"r'rLileqtcliplinlrrulrtrlctIt'IItIt.tItIIIt ' |,L";. ie). )r.r'rluronient I :r Spa!,iulnu ne permitc decit clumtTlttrr'fslli( trrlir lo,riee. 7. Ootnele jrrljltrilr": in citeva come to)'icc mai tlt:s ,,,,,r'rr,criterii tlc diagnoitic rr''trl oste precodat'; de citeYa serrne dc rtltrottlisttt ,r ) Cotn,r,alroolicci l s(' rlupJ {-rr11' Irr'"tlrr{ rliznrilie, ulr\i' ' \ilri'lllii' , r ,',i,i'r:,.L,1rtzic, ',f iii, laLicardi( 5i lr''Iit:r'{it 'l' t. ilolot' tnidrirzS. , ,'i.', t.1ni ,.i i ' on.itrrrcr ,,',,,,;il.Apoi aoar lenomenede colups:palut'rertransltjrltiiit ;ttll:rt:r;rrrl ilor ''$io ( {'rrr'r ,i,,t, tr:iiiri, iipotensiune, cianozir, r'lcirea cxtr emitr'il , CI(r).r(i filr)li('r(, Ll tlltutil rellcxelol, cLl respira.lie ,,,,,i,,,*fii-"ii-Oiula'ri1ia de rigitlitalc de tlt(crthlrrrr' (rrcDr ,,,,,r rrlsii f,.rr"o"i) si'clria" cu tenourene ,t, l,roundstic gtli- ). Coma dureazi pini' la 20 de orc' tltirrrrl'. rlrrlril se It ) Ooma mc'titicd, instaleazi| brusc (chiar 1& ('ii;tlYr'r' rrl metilio)' realizfutl ulmXtoalc'le silllptt)rnc: Irtri. r I ,,,, ,.,,ri,r, ,i,,uufiiliti pulilt ,r..!Ilb t.rr|irrrrrIir,.lrr' , , , |',,,r""r* ccf"i, ,.onIul.ii. areUcrie tltt ie) aloi paralizie respfuatol ;i txitrrs lrt' Jttrslt lrlr"" 1,,rri f1r1ripnec,
, ,r 7l l t' i l t. ' ' i

r loll' r r t r r iir r ilr r r r r l C ,r, no bar bilur icd, . in c: r 'zu'i r D'lllc sr ' I caliz. ir l; r conlvie lninlt r 'li' 5j cr r l"t i' ) ' 'lf r t tt t r r 'lr ' gt : t r ' , ,' ,,' ,r' t,' u d izalt l'je, at axie, lr , ,,sl ri tal l zi,r,alid, c. , Som n lr ogr esit - J p, of und, t , r r pulc'r r lr ',r r r iozii, r lit hiliut el: ir r nc' I I t I t r I iI r t r lt lt il"'l' t r r ' ' .r, * 1,' i l ilot lt "ulail, blldi''lr ''lic' | \ ilr '' l: r t l. z' lt t l' ' L , Li ' ; tl i i, , 't r cnnin) . ar cll( - xi{'' t li: r 't r ii: r ' iir t r "zr r 'i r t{ t u_ IrIrr, r ,l i c,rtnt at t lpinicil dcbuLor zil cll 0 st , li, r o {0 er t ilr r lir ' I r I r iI r r r r r r \ ,l i r' .1i halucin'r f ii. Se I t r m alcil; cr it om t xpr inlllt ' lll , l( 11( 'r|' ( ' 1I I | |I I | | I t' ,,r , r lll r I r li'r '" I ri Lr(' or:.or ls{llr lc,t ulbur i, r j t io deglulilit r qi dt r lt l] lalir r , lt r l}r r r r iiI i I 't t t r lt not ot li ( l( r ( t I I |\ I I I I ( '||\ iI i , r nrl si yi t t r r it lr iizir ) , disl}lll'ilia 1'0f i( 'r t 'lor ( : r r "il ( 'olI r, r' rri ti l l ttl i, r o|or r t it l't t t it r lit i {) r ilr , ii I r r it r sl: r lilr ( '11' I cj' ijt f r ) l'l( '(lr \ r '( l( 'r t rI r llr r r r r f" , ,,fi ,' , pr , l, sf ilif , , lr t r , ll ipoi ct t silt r t t r ,lt llt r lr liir it t r sllit lt l'olii' llt I I ,,| | r,' l | 1 fi inollllr , ( r l, r zli lt 'ir r lii r lo: l{t r r lr it t r i i lt io; r 'i: t t r r it t iiI iit r t l r lr '( l t r t or 'lit r il) t li'lr t t lt lt r r r lr t r t t lt " r ) (| or t t r r lJt it t t t lt it t t Nt '( ir r r lllr sllr i r lt t |ii' ' ,1,, l ,,r' , l rt r r ii'llr ir ', I lr t 't t ll, , it t r r r iit it t r ot it ii lt t lr r r llt t t ir ii t lt i. zr t ll'r t I r l'' ii ( t t t lr : lt t z'r t r r r r t r it lr lor t lt t t il' t t t 1' rrrrr' l i l i rt t t t t r ") rlrrtr r t lil'; llt li. , ' ) r r I t r I i; r t r |r ' 'r , r lr r lr , , I I I |, i|||'I i( ' 1r t t ir r I I ir ': i'') 'l""t t lr , ', t r 1ir ', , 'r r r r ir I r 'l ,,: rr,,rrl rrrrglilli r llr t lr r r lr r rr' l l { rl r' !j tr l t t t lt r 't l( f ,I 'I I |' |||: I it 'I t t I ' , i r : r llir ', ir lr r r i r lr 't ' t r it t r l t 'r 'i I liI olr r r r r : r ' llr llilt 'r lllll 11ilt t r t r , 'lr , , . I l r r r l: r lllr ": r llr lit lr llil t.,1,,, ri l ,,trll

tr, I I i I I I I | { | | rI i I lt :rlr ' lilr lt . llr f \ t . lt f lr f llr ollit ( , lr i l ; r r l o z t r r l t . {) , l 0 tl (lr(,t.of) , r ll. llJ ri' (nr()llrn ir ir r . ilt lt r , lr illr ) ir c I I rI )I Lr,i (.i r , . ll! liu( . ( f lt s ( , lul) iinli i r r l i r r i i r r l r , r . i ( . l l r o l r i r , .l ) tlt)tttt l)nt) t lt ut ulioll( 4i( ?' s c llin

r :r'rrl.li.. r^ilr.rrr,1r'i. si.rL rra,rrroirrarii. obicat,ili ir ,,.0irsi,ipar.r''ilrrrr, 'i rr .irrrrrlr i. lrr,( Iir.vrllu|r:r'r.((l:l'liir.r,hi i,i,lrrl)., .ll)66): rrri'l_ .rl...s.l*llopo1, lrr,lrrrir',...trrirl.irr,zii,i.a,rrl (,r'iic'r .,1 fc!oi, h,anipirrr,!ii,h\re.icnsirr i,*lr i.,. ir,, :rrl.r.r'irrIii, lriIrr.t.r.riri..I)oslul ila .r,pir1se insialclzi, cu'.a, aio0iatin.' : I,:r1,,.'r-,. l,'|ll.. li]ilor' l. lpslrirllit.ncrcglrlul:i.tr.lt" I'rrli spirurii r.eci,slrr,r.,.
| | r' I t:ll).r. 1,,'zjt t, t t il r t r . r , s r . 111g; r . . ln l_2 g I 'o r o t , , l *: u . 2 u u r j t {} A rrr rrrI r rr in islL lr,t,o l)i[r c n1, oi' a] i, . ). (,','t' tlit.itr , l". t . i, ' , t lia hidt a. : i. , lic g c lebu l c r z J r . u i a g i r l t i o p i i L o r r r , r " . , 1, r"ri . i. t)',r, t . t lll I t , r , n1 , , 1a' ' 1oni. o_r . l u n i n o , : r l c o s n j , , r . o n , u l " s i 'r , .'tL'lt rll: .ij trn r . ir r inr . lnr > UbinL|ant . O ( l t t : - r C U a n r O l J n d t t . o a l, | | r rrl tr SlliIii

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L 'I r I r i | | | l t r ) ? :i |:I r l l .l i l r .,j 1 , r 1 ,, l r tr i r i r I r, r ,r, I r , t rr; Li r r r tr l l r o r i 1 ,,.n l l u r,li |ori r l r i i , l cr I,r r r r ,:r . r { l , I l L l ,r r r .r r r r , Ir r r i o r 'r i r r r r l i , r .r l ,,l r Ir r r Itr r r r r r l l l L l r l l r t t i L 'i tl i '1 'l ( r i ,r r ' I'r ,',r ||r r ,L 'r , l l r ( i 'r ') r 'r r l . 1 r r l r r l . r l r ' fj ,l l .l .r r , ' t : r . l r , r 'i r r l i . r i :r r Ii i r r l r r r r r r l r r .,r . r l r , I r l ,.l r :r ,t 1 r r 'l l i i r r r l r r r r l :r ,r ,r r l .r .:r ,l r . r " r r '. r i L \ r i 'r r r I r 'r 'Ir i .i r i L r r :r r l . r r r ,', r l , l :r r r r i r r r l i l j r l si i ,r r i [r r r ]i i o ( r l ,:r r .r " [ ) ( l t t t r r , L l i tt i ttl o tt,i .tr r l i r t r tr ,ttr l ,r i ,.i r l cb i L l .o i r ,zi i 1 n ]t,( l {j l r u i t1 r , r i r r l ,r .r r r l l ,r t r l l r r r . i . i r l i g .r ;l i ve ( co l i r i r r Ir r I.r r r i r r r Ir ', vi i .si 1 .r .i , t1 i l n ,a c, c) ti l l . i t,l .r .r ,r r l r i r l ;. \ 1 r r r 1 1 , 1 1 i 1 ,1 ':'i t,cr r r cu i i l ,i tl . r :r r ,i r l 'i r r zl i , i ,l l h i * L r i l i r :. si tt"o ( l r ) ._ r .i l r r ti i , r .i r ,1, lrr'. r.uur-rrl"riir sttre d0 r,oLll)s, (]orrir ail odcri.r pulmonar.,

l;j.l.ii. Problenre rie diagnostic i.,r tuanilestjirile silrcopalrrsi rrllc lrrllrririrri de constiuri.rtde scrlrli Jut,niir ll.l.:).1. DeJini.li.i,. rtti::t\ri tle tet'yaeni P iiirr"!i,i, io lr:',lrrLcJrriul,,r pier.derr: rr;:r.i:-i dt, st.ulrri {lr,r.:rlit br :r ' ','.rill.,.i. iu:otiti slu ul r:t tnrnilt,stiri tonru:ri1(,, lrrr.r.r.rl.rl.:i rrl :lrrr ilt' rlrilttolnLr preaccesuale, determinisnll ci,reia intclyirru U tr,rror, in ir. ,, r!'l)urJL gensralizati[, ?roil-.rsii,- lildrLl r.i tic o oplilc r:onrplr,{ii, l:r rrru : ,r,rrpe cornplel,i, a ci}culatici sii'salL :r respir,afici (Oollurirr, |);1i;
.r,1rrr.l si \ i g r r u l o U \. l U ;1 . 1 \l :r .i i n v, Ig L i l ) .

( orrrloils{r. l,l, r.lozemai nra,ri dc.hidr:lzide, coma, sd instalcazd rapirt, rrrrrrl ilii rkr hipol,onsiule, tulburir.i respilatorii (cu impoltanl,i, bipdlsr, , r('tro J)rt)ltf ioii) f i de hipertcrmie. pupilele slni m:irlrjatice. t (t,.il,:: it, s,,t.iaitg!i,o,ta rarj. putinJ ii ancirleulrli \r.u m:Ii !:t lrutirlll ' .. .rt':ua.rir ur'rnrr{ltnirisltit i! tleaspirinj in dozernrr.ill ,.ul_,ii tlcshidrrr,rrr(l situ:t'ii,nlro permit.r^umuil|ot .tli,.ilctiluf. Jnrurina,i:r ,.1'.. .t ',li..rrtir.,. , r ii, li r rririj.Lllin (Vui,.ulcscu_ Stoica, 196? GaL tier ql $i colab.;196(;): I r,rrr)||r(,r|(, rlc e-rcitafie nellroasii, ct tremur[turi, i anxietate; agitali6 psjlrir rrr.lolirr, sliri l\alu cinator,delir-a,nte. (uneori) conrulsii. qi Apioape titrt,,rr rrlt ,.,' irfx)(,iir,zai t,ulburi,ri digcsti'e (grof,uri,r iir B:rturi,-colici ;i abdorrri r,:rl() r{i t|ir,rispirn{ii abunrlenic. . ,ficspirttijlc sin1, ll,mlle qi irnbracii rrrr :r rlrlli rlo lip l{iissnriurl. Faza rlc excrtilic lrccc it'torpoare si colrii, ,lr':rl,t., irri!iu,ir-r fiitrrl inloc*itl de acidozd,. l]e cele rnai'ilutte bri- ajr,,,: I'i||{||rri'r)() (x11 lr (n'tugipirre nivelul tegumcntelor la ;i ar rmrcoaselor(carilr, I r.r'rsl tr1rs1li itLl;oricA!ii). rr,rr i 1 t;.i t:.t;.',,,'.:,:., aryonoJus:Io , d iizopr,,pilfluoroIost:) _ l)1,1,; t . tr !.,,'.).i. r, .. i ,, l r,t .'r,,,'- l i rl t l tt1)t, , l'1.)l'l) h|ril.,.1 iltclrafosh { _ U"ef t'; ociumctilpjrl,' ;. ' . . .. l::,],,i ]l:1,.,()ut-.\;.t1ir.ti_rpararitrofcnilfos fat_paraoion;c1ietitlia,r,rr, ,rrr1'rr' rtr.rrtost,Jt I'lr1.rr,thion. EhatoxI metiltrimebilpropanituorofoslilr,l i ",r,rI r ; rlrrr.lrtruLrriri.eluxirianfosfe,t. _ Tabun). Ne pnat6 atrage aterr{,irr |, ,:r:r, 1r'r'r,rl l.)tolesir)na] l,[. (aparilia, la rnuncitori a.lricoli care milui0l| ii\r'rrr'rtr' lirfrr r.ctr rlramenl,de proteNtie),fie inciden{a lor accidrrrr . r:', t:r tl i i,it11. colrnunal lructe sau logun]e stlopito cu {tccsi,tt itll 't.t\ rlr l:rrl., ;ii'l .rtL{}.u utilizai ace$ti pi'odu$ipent'ru dcparazitarea loollirr 1r,l,r. ll,ii('. rr.rrl:tt..rc simplomal,ololia geneiat5 tlc iiaciivarea coli.os ,i (t,.r,i'lsc(rlwlt, tlclllrlulare r,,:,/i | excesivir, acetitcolini, cu fenomrirlrr de itr. lrl, r,rrN1.',r'i'ic: triozii; hiper,itll\.ftlie; rlal'ioreeI hipersutlo*l(,i. ; lr'orr.ic:r; L,ronllucnnSlri.l.,.;rrisprr,.r,r,tntllit,ur.ririr j ' r{,i" ; lll,, i-,.r.r,.lin :,r' .r.r l, r,rlll,. rtr.edem l)ulmonar acut; brarlicar.rlio; hiDotcngiuyl6l 111,. Lr.rt:.: \ :r . ,, I r|:, I IrI ir, r.nlini :rlr,lornirnlo.dirrr jrrrlr,,r.ir|rsr.. er,: rrri,,rirriri I I .,ttr,otr rlorrl tr,nxiohl,c, :rgilrr,t _1rsil191lt,,j lt,cmlir.tituii, ir, ,,t,i., 1:r,sr,i ,lrptrr': turn'l,c t10r,r,rrr ILsii,.11I1ri |nr', s,.jrrsllllr,zil coln:l,, 'iIr:rr|| ,l||r]j{1lr|)rIrr (,ir,r!\ lrrilrl, i rr ltliurclrrl0 !{) rtl oirr tlcIir,illoricillitr prin prr,r,it,li |,o:rIr.r'irrIrrIr, r'r. r,' lri,'rri'rirr"Iir,rrrrr.rr.lrlrilrr, rr{ii liL (l(,zorri.,irl. ai,r,rlii'ii I.lrr. r,rrsl i Irrr,Lrrrr'll'rrrl'Jrl lrlrrsrlc rlilrUrrrrsi t'rr ir..
l , ) ( lr t t t r r lt r in o t i rl tl l u trl n tu c ti r I4 IIIr.:r,rrrrIr yxl l l !j l i , rl rr 11l .rtl 16 pt,l trl r.r i i r. \ r r r r , . lr r . i r . i rrg i l trl i r,. (t.trri r l . i rrr,l r.rl . rl . I r i rr,r I rrr rrr i , , rl .. , ; ;It0

i'l{r ltic c:i piertlerite d,euLno\\tin\d ile saurtti durafti sitri, rnlr,i r,l,,ri i/, ,.,r rt..::ri tteurololliati, _centrul acestot manifestlri situindu-se lr,.a.li.l,rr,1,r in l, 1rlirr., rlil. pot./i intilnite foarte fr.or:ent $i in diyersa]'<r tu,lbu.rii,i t,ri4t tt, tl. , ,t:it urd, cu crxplesioneurriloglticii,ca de pikli) sincoTtele divlr,str rrr i r.r d.e r Ir r .ll i,lisilri, carc iusE trsbnie tol,dcarua difererLliu,iirde : .fu,lselc tittr.t,1t,: -llrcbuic lrl'rlit.ii srL' sirnplc ,,leqinuri,,(Faii.re, J.9?2). aco*irr,iii,r rr rlrrrl,art!:ir, sincopelortagale cane,,nc conduc la o ncurologio 'r:rr.,, ,ti 1rlr.itllir,.r ct l,rrllicrrlari".l, sau f[.r5, reflexe rascrltio r-aso-vagfl,Je vagir vrr,11:u1,,, snu , i rrlii.lurminologia arrglo-saxoni., c*rc fac tlil ilcest secior hibir.rl, rrrr,ii.rr'i ,1, rr ii1,rc in1rr.cardiologic.lincurologicr'(Faivre, 19?2).Asl,icl,rlrrr.ii lrl,r , rl,i" (1,.I'il,r.si nce fibr'ulor.telntirrrlu llo rugulrri (iu lr:u|trrl rlig,.;,trr . i rl ()r'iitil,r.inge pildi) sc r.olbpDbe Jcsplc rcJi.ru aayt,uagu,l.c , rle ( llatlli.ts ) , r 'l:rr-i ri llr _rrrldr.cl&nfrlul dr, sinropc pl,.r"i tlin \isu, c:r {l,i IiLl:i rlirr ' li',lll4 iru d||r tltc ad'.ro, cSfe to|lr:r tlv rrJllls DaSo.tdqnlr. 1,,:rr,, lrr .r' i'ii1. (razul'icstc I-orba de intcrIcn!,ia ulot tcflexc ri:[l{o_{].1,r{r1.1{,:t,t.r,i'/ rrr rl. clcctc cardio-inhibitorii. ln accstc c{r,zul,i, corclxl rilsprrrrrl. lrr,lrilrr,r' r rr.rri.Iio lio prin tulblriili silro z],[ricu]iare, jolcriotialtr (1r.irr fic {,r.rrrrl,rrl J"r( (ior)ul atlio-vcutliculrr). Iiielderile dc crrnogtinf,ir, vagal(J),1(! irrlr',r,lrr,, ,rrlto pt1ohrgie dc grani(ii nouro-ca,rd io,vnscu1."lr5)' (.Ir,ilivrr),It)i:jl. I r slir'5ii. sc insistii in Lrltitrriifttri asupll i4o-rruntit(\lor ,,sincopirrrrir I,r,,, r | )rrlr,l li grial:., 1954),ttro poi I't colscr,ittlrlr, itrull or rr,fco{iLtrri rrll,;r, rrnr,i sjrl rrr
r,.rl l (, \'ILIi ('IL i t, l (). l

l :!.1.:1.' ! , \ t ut 'l( lu pit nlr r i

t lt ' t . ut j( , it t i.t it dr r uu: , i

nr ur ologir : il,

| ' i | |I (| rII'{' I t,rI rr cu r r nl, irr (lr lol: r l: i li r uI r r r 1I lr i: 'i trp t i<, 11, t t ( , il lr lr r Lr r , lr \ : r , ir r lisol rtr(ti 1tsi l ri .. ( lii: ilr , r r {r r ,ir r r , r r r , . , r r ') ,: r , r ir , ( ii r lr r r . r , lr r , ( , ir r r r t r , ( ii sr r r r z't . ir r ( lr trtrrl .ti i ) 1i 11, ir , ( r i r r r ; ir , l: r i r . ir ': r r r ii, f ir , lr r r r . i; r l) .lr r r r . ||r r l, I i r ii 1r r r I r r r . r r : I I . r . ir r l rrl rl l rl r.ol r r lr , r r r : r i nlr ll r , r r r r r r r pr r {r r r r . or r r lr lr . : r |, r , r , r 1r lir r r ( r r i,r . r r r lr , lr
:t:f I

rrr:r lrilrliLltr ct'i;ck psihoulol,orti, hr alrd s/dri lnsotito do tlivrrr.so n il't:st,r1,r'l ryi to1,ot'ii vrgrtativo. qi turt rzot'io-rt tfrlrrlrrric a,\'(xlrin vcdere aci doud,gru,pede pierd,eri ile cunoftinlt\ Bfi rlt sou,rl.tl, dura&[ (;\ruold, 197?; Popr,iviciu gi Pascu, 19?9). 1t.1.3.2.1. Crisele d,e epilopie, care comport5 o disolulie scurt[, tt t.orriii,iolferi, dar cu hiperacl,ivitato sau activitate normal5 sau cvasi. trrototic $i vegctativii, pot fi: a) Crize generalitate, respectiv rrrrlrrrrr,Iii, ll rrl,r'orLnrl'llicc (Crantl Mnl, Pctit Mal) ib) Crize parliulo, fie cu ,,somiologiu rrlrr urnia,r'ir,!' rr (rnotorii, senzitive, senzoriale), dar fd,r5 alterarea cnnqtienfol, lirr rru ,,stirrriologi.o elaborati)', ca de pildi, c]'izeletemporale, crizele insularo, rlizclrr psihomotorii cu moalific5,ri ale congtienlei ctc. Diagnosticul pozitiv ll cljzckrr cpiloptice se bazeazi, pe o bun; anamnezd,gi observalie 61inic , ;ru rlirl,ulo ltltG (standard qi mai ales prin actil'5,ri) qi pe datele complo. rrrrrrr1,rr,r'c (a,rtcriografice,pneumoenccfalografice, gama-cncefalografice eti.) t r,) (irfuctc de peXit m,ql ahinetic (saa amiotonic-akinetiee) nu trebuie confuntlrlc t:t.r, ututut'ile co,ts,plectice ilin ncolepsie, in care disolulia tonudulul rrrurculil,r' la lrembrele inferioare, eventual generalizati,, se proaiuco do olrilci rlupii o cmol,ie, firi, nici o tulburare anigilenlci qi ffrf motlificnrl l,)lt(i ((bltariu, 1971; Corfariu gi Popoviciu, 1971; PasBouant, Popovioiu 1968; Popoviciu gi colab., 1-97A, 1972, 19?8). Derutante slnt ryi r.rrlrr,h., clizclo cltaplccl,ico inso{ito $i de oareca}e tulburd,ri de vigllenlX (Corfariu qi I'opoviciu, 1971 ;Popoviciu si colab., 19?2, 19?8). ln sfirgit, crizolo rlu rnirl akinctic nu pot fi confundate cu acceselede kiryersomnie ulo 1xr1,ib u an:o[t:TrLicilor,ale cSror manifestid clinico-EEG qi poligrafice slnt Ilrr,rrryirrLi,o (Popoviciu qi colab., L972, 7978). ln sfirgit, la oamenii mai h l ilrl,ir, (inrleosebi dupl 50 do ani), care de altfol rareori pot prezenta crizo rltr pctit rrLalalcinotic (Arnoulcl, 1972; Popoviciu si co1ab.,19?6, L9?8i lblxrviciu ryiPascu, 19?9), o c5,dere brutal5, in genunchi (prin alerobamo t(!rrr l)rolo1 infcrioare), fd,ri, pierdere de cuno$tinld,, fXr5, sau cu veltij, tto rr de caLe cel mai adesea este declanqatd cle tor'. rrvrru"i, cr'f,pd ,,rlt"o7t-attacktl, gil;rrlrri qi rotalia capului, care antreneazS,o obliterare tranzitorio rrirrnrrrr, r, l,t lor'(ji vcltr',brale qi, in consecil!5," o ischemie acutl a sistemelor rei;iou. Lrlo rlirLlrutrchiul ccrr:bral (Arnould, 19?2; Aqgian, 1968; A$gian qi Po. 19?Er lrovicirr, l ${i91A;gian qi colab.,1969 ; Popoviciu qi colab., 1967, J-969, tll?t)). Atn'N,gcr atentria asupra faptului cd, fenomene de insuficien!5 vol" i,rrln'obrr,zilillii, cu crize do ,,drop-attack" qi cu obnubild,ri pasagero d0 rrorr5l,ion{,ir, }retabile la confuzii cu crizo de tipul absenlelor epileptico potr nrnvrrrri 1i l& indivizi tinori, purtdtori de unco'discartrozi, cervicald,I rll (h'imla psi,hornotoriiprin leziuni tomporale, limbioe (Alnould, 19?3 I Itrlroviciufi colab.,1976,19?8;Sagerqicolab.,1970),sau alo triunghiulul lxilrorrurl,or(Dimitriu, 1972) sint lesne tle rccunoscut din punct tle vocloto ofilio ,,rillliG. Acestoa nu trebuie conJund,ale ,,ictusul,omneziol,, sar} cu Irll)rozintr, o staro confuzional5, do mai multo ore, cu alezorienta,ro tompolo. Hptlitlll, dal in cato $taroa do vigilerth, qi funcliilo sonzot'io-motorii Blnt pul,irr altorato (Arnould, 1072; Iiisor, it962; Popoviciu qi },asou, 10?0), Acusl, islru'r aurnozio, duptr,cnro br:Lravul mauifcstb o arrutozio o fonornsno. $o klr a'ooorJr.ru,lo,(ll,l,oloflto umri irrsulioiorilo cir,oulalrorii, cu o consooutiv[ ttt ttt I brtli r,ro Ittttol,ior ltL totttJxrrtr,l[.

I)ia(ln,o,iott'/" d,lfot0,ttl,Jdl lrrrlrrl 1rrNi1, olirrrirro ttllt rnrr. ln tr ni.ltttl,ll.t'i n t u,ro-psi.h i.u,l.riat,, flirt n r. nl nt tlt' ttturrl, r pilrlttitil, li uti 0 u, tnt,porlll 0 1,(t ikr,l)il.d rlittol.u,l,i( ntuylir'nlr'i tr : l. Oritcl( ),mearopal,iorrt) (lriut ntnLnld. plodu outrr cir.(ill fl1,rrl(\ ..n) So lrr l rprrcitlo,si ou trn,,sor)l) rr1,ililtr,r")(Alrrorrld, 1972; J?opoviciurli colrllr., ll)713), qcolarr'!, socia,l)t obsol'vindu-so rnrrtlicirlr,,,rIIr,r.rIrl'III)i,'t, irr (oxl)ol. sau l,izr'i). Sirnularca,esto grosolruril,rlrl rrra,i adeseavizibil ,,volunta,ri,tt,lir,l'i, lrtlltnt'ii,rivasomotorii (in slxtcia,lla fa!ir,), firi rnitlriazi, Id,rI tulbrrr'fiti Ilill()toliene, fLrX somns piramitl:r,loeta. b) Cripelepitiatice pot rca,lizl,fi(! lrsorrdo-comeletargice, dar cu absenla tulburXrilor nourovogetnl,ivu, r'rr , cosdo tezistenfi ia tentativele de ,,trezire, t $i cu ,,impresiott dc vigilol rl il , 'r lir! crize pseutlo-convulsiyo,dar care nu comportd, nici citlole br,rrlllfi, rrici apnee, nici clonii, nici stortor, nici hebetudine postoiticl. So nlr,i lo, lrrrte nota ur tremor palpebral qi circumstante emolionale docla,nqa,rr r\ Criza afeatiad, banald,,.omare a unui $oc emotiv, poate comporlrL llltol{r pot preto la erori tliagnostice : stupoare, hebetuclino, il,gi1 rlio '.lolnente care psihomotorie dezordonatS, rlar totul clerulindu-se pe un registru do torr,rnil, rji {1o anxietate. 2. Criaele m,atebol,ice: Criaele kigtogl,icenicese manifost?t do obicrl a) rlupi un efort, la un inttlrval mai lung clupX,alimentalie $i sint pr.o(1(xllrl,(l rhr tlanspiralii $i ale o sonzatie de foame bruscd qi violentd,, Dsrulilroil lrl porlte fi similard cu cea a crizelor epileptice, chiar cu prezenla do furrr|lrrr 1riltrrridale. Efectuarea unoi glicemii trangeazd diagnosticul. b) Oritt'lrt xpnsmofilice, Experienia ciinicS a diverqilor autori (Arnoulal, J.0?2) rii l ruiu,strS, ultimii ani (tr'Xg5ri,gan colab., 1971 ; Popoviciu qi r:olirlr., din gi ltJ70, 1.972, 19?8) aratd, cH,acests erize spasmofilice $int alostul (lo I'l,r vrt il,rbile crize ,,tetanice" prin tulburare primiiivi, a rnctabolisrrrrrlrri .rrlcic. De multe ori este vorba cle crize de agitaiie anxioasd, cu pal;ril,rr,l,ii, rrr irnpresia de ,,moarte iminentE tt, cu tendinie lipotimico llsol,il,rr rlo rrr,nzalii de rd,cile gi clo furnicituri, dured $i amorleli in oxtrornit,i,fi rii l;r rrivelul buzelor, precum $i de contracturt in membre. Amintirlr oil, nrrrrlrr { r'izo spasrnolilice pot imbri,ca aspecte ale crize pitiatico, iar alt,olo pol, lrrru:r,specte clinico aproape tipice de ,,absenfett,sau chiar do qnvrrlsii lonico sau tonico-clonice epileptice. I)oar prezenla spasmului clt.rlll inainte, in timpul criZei iau postcritid precrirr, ryi aspocl,{rlo.ltiri( I 1,,rrlu,l (rk'scd,rci,rilc d.e unde lento asculite hipersincrone gi/ sau clo undo lorrl,rr rrirrrrsoidale induse cle hiperpnee; absenla modificd,rilor do tilr opilolrl,io lrr, st;imularea foto-carclidzolicS, qi la activS,rile cu Mdgimido) 'puf t,r,it,,irr' rlirgnosticul in fa,r'oarea spasmofilioi, oventual diagnosticul do slxr,rrrurf ilirr :rvrcilr,t5.c-u epilepsie (I'A,gArE $an $i colab., 1971 ; Popoviciu fi c(,lub., l r)?0,1972, 1978), .12.1.3.2.2.Iotusurile de saurtd, duratd, Al[,turi do ictusul apolloot,io, ,r,lr r{,r'ui rnanifcstd,ri pot 1iiile lungi tluratf,,, so pot obsorva la unii vtscu, lrriJ i{}lilr$uri$curto, atkrsoartpotatc, caro survin do multo ofi cu oqlzill rrrroiilohinrbii,ri pozi{io in spaliu, dor unoori chiar Iu ropaus (Arrroull, rlo lll72 i.llopovicirr ryi.I.)ascrr, 1{)71}). paro citrln &ooctocinzuriogl,ovot'lu do So o l,nlbuto,to d0 iriga,llg oorobmlfi,, produ*Itr prin hiloto:nsiurri t,ol tivo, rot{" uilrIrrIrr,|rolii rrlr.obrtloty[nzito]'ii Ii/ snrrint;olrniln)r]1r(l ;xrrl,ivpt'in it tufioianl,o (rIr,1,1 l,rorrrlxrzo rlo o l)r! slnl,orrrrr'l oaroti(li0,n).lfupil, n<ttrtllio t.l,rr,rrrrri lx!rlir irrltonlln(l(ort (lltrr!1, (lo ollr!\,1, noctrtrdo ln oil,ovn rrrlrrll,rr) rll,lnltr 1rlrr11,

irrttji, olrirltrittrtclr.rrtir,ilit.rturrttIrtIt.rrIrrI"icr,: tlr' 1r1q:1r51,1,7i1, lll1riu.r,, J,iu.(,/.(, rlr:rrrrrrlrr l,rtllrtrr:ifi ltfllzi(Nl {)1,o I!.1.3.i2.;i.XIui.f stiirilc si &pqt(, l::,.;.3.1!.:J.1. l) tIini.!.i?,{rnirL.Lt:ir,rrr$i)tcoP(, ti), r.tlrrlzirrlii o l)i(jrilr,rlr . Ir..rir-ii,1(rrlior':nii, a crrrxrqtintci,do dlu'atli scuilit, pl'(l.o(lrii srrLirrrr rl,, (,i.l,tIz:.ttii (} tl,nori0 crtrtb|alii .qi itillrsocrili,lri r.r|lrliln|lrto (lo rlr, l)t'(iir]c(10stL|.1r, olricr,i ilo rrrorlilir:ir,ri orgllnioc ccrcbralc (Oorfar.iu,t g?g ; Wrlvnc, l tlti l ), Sirr.r1rr,l.sn u;1, intrluh.a, iu.r';rnprrlaccosclolrliitlnc riccpiioplicc ((irr,lrr,r,irr, llrilr lll?il). tia$taut [i (iastatt (1956) au a,{irilat loati;c sugcst,ir. sirr r,i lulr,lr', r'rr,rollu ayut totrlcllunl soarta ,,p:irinli.lor silraci)i in cor,l,cilirrl ,r Ir'.Ir,r irrr rrrrIrIr. pa,r'it.risl,icc, r.e1xczintilin re:llit:tte-cauza cea ma,i fl,covrilrlr! ;r lrioltlr'rilrrl rlo c u n0,5l;in!:_"r, s:tu :tsocille cu convrLlsiitonicc;i t,ii lure, r*rr';ilar rrrrr'rriftrsfii|i tlcbuirr in rirod cltegodc difclcnliate in p]'irurl r.i},11 rlr, rrizrlc clrilcl;ticc, l:'./..1.i1.,i.2. Ula:tiJictititr BilLupelor sint Ioarl,e clifcritc rle 1a rlor, I:r:r.rr.l'r'. llrit,l (1U.50) li gel ;i i.otab.rlg.-,.1 r-i I relr.ter,zi ciuci etuzo rr.r..1,,r.,. ,:rprrl'ilr.s)r,lrr,otluci sirLcope:iulbtrrriri rle cir.culalie perifericri, aliec{irrrri r,:rIrIr:rr'|', r.r'|tLZLr Iorlu.i!t{'rii, rfertiuni ccrobra,]e boli psihice $i, ca,[11r,, qi ;lrr llrol)us rurniitoruca cla.sificare l) 'Iulb".trdri ale cirau,laliei : ltcri.fn.il : ;t sir{:i,l)N, 'r'l.r,so_-tlepreso:lre (raso-\.agalii) b) sincopa din }Lipoterrsirrorr, Lr i rrr'lrrsl,rrlicii. Af(,cliuni cardiace: a) tultluriiri de ri[m cartlia,c lin spcr.ill ,2) rrrrrlrrrrrrrrl tllm Stolics); b) sincopa,din biperreflectivitatel ,sino,ll,r.r, ,,\ lirlirrrrii; rr) sincopa prin aitc tulbuliri ; rellex6 vaso-vagale,r,efltxe g.lrrrrr lrrlirrrlovrulir,lc,rcflexe oculo-ra,ga,le. Sincope prin iawze respiritorii: l) :r1 ..,rr,-rr1:r, rlt' 1L i r ipr.r'reril iJri,lic b) Silrop:r, la trse. 4) Sincopa tlin tlif rit.r, ; . ttlhurtiri ffrrl.trqle (sinc,,1ri psih.icl). fi)- Alte lrpari; sinc,opa do tiri(,li
rn I r I ll,( ] .

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1' ,.t\i ttutlt t ' 1t r in, nr r , |: it ', 1 i it t lt t t l, o: iliq, iit t lr lt t i: l ) .l \t' i n hipor , it : r ) r r r r ) , r ( ii1ii r . lc : Llii1iidiur , I lr ) ir r ir oli r '( 'r q( nii: r l( l , l l rfi i r(r{ ' .2) l) t 'ir t ,h. i, 1t ot r r .ir (rr i; Liolr c lt ir L liii; t , r 'i cr {, illt 1u: 1.ll) I 'r it t lt ilt 'r 1't ,,ri rtri r (i rr r:or r t lif ii t lc lslir ir , , ir r z) : or r t i r t 1- r : ljillc) .11) 1'r 'ir i It i 1 r,r1I i , r' tt t i , . t :' ) I' ri n tu.Ibur d, r 'i nulr iiir . de U . S i nco pc pr in t lisju. nt f ii r c) t tt 'cir : 1) I i' r1,i t ' 7, ir '. 'l) S it t ntlt r r. : ir t t r : : r lt ti t i r,' l i rl .i q,n(.far na cent r ald, ) . 3'1I n ist t ir '. I ) {, t lt t'' : : , ', , 1i . . : , ) ln lt t t t t t i t 'ut " ,, tt l l i tl ,a. l'1{roiz[m cii rrra.ioritl,tea crcr.ttftli iirtilt}r de la irrrrrrt:lc ll si lt rrrr rrrl rcri tl bi l c sincope, ci. le f alt r epr czint ii t Lt lLr t Lr iilillc i. or r slicr r ( r , ir i, , ,l r, rr:r' :t,i .i pr i r I r l^ |li. Jt , i. l, . |:!.l.3.2.3,:). I i.tt1ttont nt.olog clixiari ie tnainte de a aborda, clj.rcrselg entitiili clinice, al,r'tgolr ir,r,(lrrlt rrrpr:r, , rtttltt.ont,clol' r' {lenarole, camune \\i, a 4inpreju.rdrilor in cllLo so {I('(,IiIIIrilir?.rI I r(' o pa, r\ntliza iirlprejurililor carc ilu dLrsla inltalarea picltlt'r'ii ilr lrrrrorji irrl;r , ir rlc o deossllit[ inipoltaril,ii, in s1,a,l;iiirca dingno-qliorilrii ((]or'lirrr, I l) , I , 19?8). Tlebuie si, so liiiil so:lina de sohimbi.i'ilc dc pozil lc rrlc l. r tru l ri , rl c e.,.en t uala deciau$ar e la t use, t iicliunc, f elt r l. r , oLr r lr lr : sir r rlrir llr o r i , r'\ iclrle, la einoitii, sl,irii de "lrisii si rie lerrsitrre elc. .r\lictr:rIrrL1rl,, lrr'r'r,, rrrl o r e bol nar . uhi sint t ic inar e \ - aloar o: t t ecliiur ile cilr r lililr , I ) llnr lr ir ( . . , rl orl i l er un ele sr lf er in! e ne. ', r xologicc sir ingom ielie, lt it t s i, lr '. ) . , \ r 1, . , . r , ( r l,i( r'(lcrca cunoqtin!ci esto prccedati gi,/slu urm:r1,ir,(lo lrr{,r,r r.irI r | )| | ,rI r. , t)r | i nsi ncopale'' ( G asLaut , i9j0) . O or lar iil ( 111'i. t.J 19?8,\ r i ( . lo|llt iir t i l', r t , , r ilitL (19?1) a,Lr insista'. Rsup]'* il tlou i, gt'rps do sirnpl.omo; u,) sirrr;rlorrrr,lr, l, r lir{rcesualc,care rnoori se poi lnallitegto filrir, sii, {ie xr'mt1{) (lr) 1rir,IrIr.r,,r , rrrrosti l ei , put ind deli 0oDst it ui un , , echivalcnt ) ' al sincol) ol0r '; lr ) r r I r . r 'r ir r l t'r'r,ln:iu-zis c) siinptomrrlc !ostaccesltlo. ; pr,lneig cu aproxinutir' S imptomele f)rcacces1Ld,le 5. jl{) rlrr rrrlrrrrrlr, rrrrl rrl al ca pi cr dcr ii de cuno{iini: 5, r nan iloslinr iu'se pinlr - o s1, r r , rr lr . r l* 'r r ,orrl i rL' t, translilalii ieoi, inccf oqar r : 1,Teder i; , am clcli, gr i'lr r li, pr r lor r r , , , r, rrzrt,ti e p r ir bniit 'e. - ilccst e siinpt or nc pr eacoosuilo , , r lr , lr r ct lizr r r r '" |t l'l de /rl ' ;i i , { i :r,de p il<iit ir i sincopa 1a nir r l; it : nc. Ln schim b in cuzr r l r ir r lr , 1, ,i r lr r r rrrlrlt'c1.ul it-Liocartlic sau dirr angirra pcotolaJl, pr: lingii ir,r'rliio sirrrplrrrrr. p l crr,r.r:cs o obi$nuit e, pot zpar e: dur cr i plccoLr iiillc ir r lor s, ', I lilii r lr , ttal r r,rrrt,c q.ll., pc lilgil semnelc stilrii rlc qoc. ,4ccasulpropriu,-zis tle pia,rtlereda at,nofttnl{:tcstc sourl (i {i{) si r.rrrrlr'), Lr (' utsu1 oi " tr uia so lcr nllcii ilii ir r , l o f lllscit lit lll, t , r lt iscr r lr r r ii 1i lr r r lr r r lr . , ,l r! (l i t(,i 1, a,ccr r : srsc J) r 'ulnngar llc,sc l) olt . lc insl, r t , lt o r , or t llt r oir r t , i lr r r r ilr r , rl '. ,rr' trrtl i i , tti tco t 'i ( lc ( , ii( jvil <'ot r r t r lsii ( , 1{) lt i{. r ( , r t r lr r t . it lr 'i, 1, 1 l( l r r r r . r r r r r lr , . l1e Ir {' l tstl l l l l zr, i 1, r li<t , llr r lcr r r lr sir , ir rllt ,o lt ; t r r t , ir , r lr ii lr Lr r r ,llr slir 'qilt r l : r r t . . i ilr l , rr, i tr l ttl str l Jr zr : i llor r ill r li lr r r r lr r lr , csr lr lirr r ^llr ilt r ii: r r lr . r ilr r r ll r r lr i,r . i l r,tl otrr:tsi i , ( lt 'nr nl r $i Irt rr1rI i I t rr I i t rr' . Alr , llr . rrr ir I r ili sI iiI i I or ricor 'I or r ilr ' |r , , 1 r. r i ttti {o rr l l izii r lr , r '1r ilr , ; rr , 1qt : r t r r lr r r r l. r fi i rttl tl rut r r lr 'lt t t t lr r t , r ', 't r r r r lt '.r I r i r 'lr r r izt r , r r :r . r 'it , i, r lr , ; r ir '1r I lr , , , : rr r r l, r . . llr Irttl rri , l rrl tl t,t ' t l 1r lr . , . it r|, , r r r lir lr r r il r , r lr i r l' r ', r r r lr r , r ir '. lr r lr r i: r r , r 'ir i r | l ovi trr. r' otrtl lr 'l , t l; r l lr lr , r r r l r , , r , r , lr r r r r l, I r r I r r r : I r I r r , , l: r , lr rtrr lr lr r . , r lr t r lr r l
.l i r

Wlyrro .(11)61) propls cea mai complet5,clasilicare a sincol)(ll(l!., lr,. , rlr..,i r'r'iiilrr,]rilir, liirsr rlc procizitrne 11e plin ryi exactitatc a unor itoiirrrrir ,\ " NirrooTrr_. n isch,amieaet"ebrald, pri gener&Lie&Nd : l. l'rin scdil,r.narezistenleiperi,ferice: Atiire: - sinropa r':rs,r r;r;1rlii, sircopl, simtsrlui cmotk'li*i,n, -- ^) sincopa de liper-.lenl illt ir,, sirrlo;lr, plirr rci'lexe ccrcbralo (sincopr 1a tuse), - sincopa, prin lollr,rr, rrrllrr r:rlrlilrr) (siritnpn din stalrozn qi insuficienla aorticit), , sin()l)ir (ilfl:t'r.ct anginir,pectora,lir,), sincopa pliu rolll(,\rt lrt irt tollrrro (,nlorrlLt'c ;i prrlrrrorlr,rrr (sincop:r, 1,use, 11 sirrr:opa din onlLioliapulmonari,. sincopa rJirr Irrlrr,r'lcrrsiurron plihnonafit, sincop:l prin pulerei! in joc a nnor iefltrxo rrrll,ir-r'), I)usiae: - liipotcn$iune o.r'tostaticil(in convalesccllii, lrr.irr lr) j lr.:r,r'{ii rrritdorlrogLrliI postsitnpalie{itortrie), hipoterrsiurLc l:r ortosjllicrl ll'rricii (irliopr'r,tirrii, secnndarii unot: lloli nel.voasc). slu .r.rni,r l. I'rirr, scrirlt:rtntlebitrt,l,tr,i cardi.dc: 1) stoyt card,itc (srruurprr, r:rgrr,lii (r,lrrlioinlrihii;oric), sinoolr, s;imrsulrri rrmotirliinr, silcopt rlirr rrlrtctrl Atfrt,trr-Slol<<rs1prin descrafl.rrfi tnlu.tn-hci\d,ii 1;1 rrardilrrt (sitrrrozjl jrrsrtiirriorr(ji rroll,ici, irrltloL tniocitrdic, a,nginir, pecl,rtllllir, lrlil,lnic caldia,ci,) rrrrr'I ;i sl,orozr'r, it,:'i mih:r,ll). il" I'rin. tnu,.tu (t,l,rftcot\Iilti(: lripr.r.l ilrsirntu lrLr)rnonltr.ii sitrlr'1rrr, ir,) I lr) l:r. ll$(,r; r.) ll.irr rrra,rrovllr, Vlr,lsrrlt,rr. ll. NIttcrtltt 1trin. iwhrrnr.it u.tthnt,hi, Iurtli:tlii :
l. :t:f.l llo li tur.srulq . t t rt r t r lu' llt : lr , ) lr , l, , r ' o r ii : r l i l l i o s c l c r r r z t i ; lr) irontltor,;i.

(u ri t rl t r r r lr oir ir : r , ir r ll rr,| r).,\r.r,| i o rti rrrl rl ,,rr(' t:r, rl rroi .i cl | }i frrl r.fi ,rl rrti rrrIl o rrrri o l rr r lr r , ollr . r ilir ' 1 ir' 1 ri Ir,IrIi l Ii ,l )l i l (i l ti .i l l l l l o l l r.rrr.l i i ,r,l r,;i lr Jrl i rr(,t)l l (,\l l l l t rr 1 1rrrrr:r1rr. rl i t r r til i i IrrrttI]o Ittr,. r l . |ir t t l) t lt : , , , , ' U ..,u ,t,' .. , 1 r' rr.irz i i , ((i i l i l r.rLl i .rrrrl z,l l ti ti ) i .i , l rrr.1,.1q1,; l .i r ;L rr.rr1 r r r I r ,l. ' . r ' ir J irri i rl u l l i rIi rr o s l o a k i rl )1 { ))i i rnr}lv I l l o si rrrrrpo, rl ..rr i rrIi . * Irr I is I i. i r l, llii (i i l ,l r l )r' o (]{ rJ rtio l 0 % d o a,l :or(,i l ,' ri u' rl i o-vi ,scrrl rr,rrr (l r.' I rL l r' l i lt r . r ' iqir r . r r s i ttl u rp .l 0 r' , l l o c i r, i ri i u U l s i ]tcopol ol , (i i u,di i l fi l osl ,(, l .l , rl .rrrrrr ' r r i' r ' lr r ii, I iir rrl r,r' b l r, { l o o fi rl l )n } l ,r' o h em-' di nami oi i cl e grrvi l rr,r. lio .i rl r.rrlii r r r . ilrliili : rr,)_ -' p ,rrz i r c n l rl i L c ri r,r ' i n rl cl 1i crnscci nt i .' i rn.r Ii :rIrr, ,^ ,r ,Ir'i .r' . r , i' r ' r r I I r , I r I.|i i r;b ) l i c o ttrl b rr| ru o d e ri trn , uttri l rtcl rl rl l a, trn gl l rl rl r, i rr, Ii .rr' iI r r I r r . lr r lili' il, I r) fi e ri s i mp l i l l r' i b r' .;ir:c :l cl cbi trdni , c:r,ro D { ),rl t, r1( rn r)r r t r ' r r r r r i r nr rl l o l ro c :1 rri s r' n cr' ro g rn s N i cr l l rccstol si ncopc { r:l ,ri l i rr.r, . l rl r, Io I r I r , r r , r r r r glt r r' , o x i s ti n tl l i s c ti l rrL rtr' !;isrLl ti te. rI i r," linrttlrtIa. rl.in t:u.rsuI r:tt tliopltiilor rr) lrr .r./aro:c {{0rli&i sinoop:t :u.q ciu'itotoro prtognoixoDice: sullirrrr L II(| ( i || iI r ir ir r or r i. s [ l i tf0 r' 1 ,u ri l o r, s 1 ;c l a l l i i , i l u r etl td 1:Z mi n te si l i l sr,rtr. e to ,,'..r'rrl ,.1,ilt1rlifrrr.rnr', rle\i prczerrl:r, a,oestiola, nu elimini iiilglroi t,irr rrl .iil, ' ir (t;rl ',r'rr t , r 1r 1 lllil) . (i rl t1 :l\.a i ' d i n , p t' e c rrtn Di ]Jammarst0n l C i tal i rt,, (lrll',{'rl{r'''lz, l9?ti) N,ur.r'llta,l, e:isloD{a rlrror tulJ:urH,ri premoniiorii, r.rr,r.,, l',.r'rrrii.lrr.rlrlr,r'rrlui sit-fi , rprcgiitea$o['r {10 multe ori iXclerea: clisltrrr,rr senzir,f hitllJir, tle ,,glmbe de vat5,,, ovr.rr ie Ir orilr,sir ii, plo,siruro i,olr-ucicil, lrrrrl o. r r.r'il,l,lrilr"r. itizii, r1e St. r(lttitr,.il ,, pibuqire {r, T.A., ptils f ili lngor'. l,,r'rr. (,11.'s('il, pci,r.tptibil). a,sur.zi'eil zgomotelor cardiace, arleiea s.llrr irn .1,_,1i,rI i rrri rrrrr,t r'r, s Ln {ii\lriu ilia ttil{hri sistolic. Dupi, Trendgre (cilrrl, , ,r ,1 , {:i r, ' , r r l. r ' r r r t r . lir;? t. s i rr..u l ):ltl " o fo i , -rrl r i rru i o :b% di n" sl enozr,t,. : ,r.i ir r', r'rr r.is. dc t.o:lr|c subil.i si r.r, p.oEnostic ulter.iur reZervat (mour,l,r rrr rrrr,r lil ir r r lr r r r r ls d o :' -4 a n i d u p i t p l i m a si ncop;). lt) Itt, ttti.tot"tttr.l le,u trotnboz& u,u,riculo,rd,(afec{iune rari,), tuiburilr ill r. 1r'rrlrr. r,cl rrl,i rilr'sou,r,u ocazii:l schitnlllililor de pozi!:ie : crti, digpnoi(,il, , rri r)zi l , ( lr llt llli s i c t.c rr{ ,u a ls i n t:o p i r,. , ) lrr h i1t.r'tlerLs iunea 7tulm,onari1,, pierderiie de cuno;tinli sinl 1rulil I cl rr.rlr ( ( lilgc r r lit r .rrl ,z ,1 .9 7 2 ), Ii i n d l l l o re rl a te- de cl i spl cc qi consti i ,,i i ,, l,,r:,r, r (1,irrii,lrr,, ll*ntrri, d u.e'e llrrginrrir,sril. ln cadr-ul hip'ertensiurr ilrrr. l rrrl rrl rrr:rr . , rrrr.lot. spcci:ll-i) o',rr1u, hipcltcrrsiunea puhnondrX primil,ivir, rrr .rr|r' I ir r r ur I r r r I u in t m a i tl c rv e l tc . l i r s rh i n rl r , hi pcrtensi uni l e -securrtl ,u,,, s rr.r'r,| || ! I ir ) I ) iI I ii dr lri u d i te s rn l c o n g c n i trl l . &r d t si ncol c tl oar i n 2/o rl i rr , i l l r i r fiir l, ir S r , . 1) l ' .. , i u l rl c G i l l n .n l u a n l z , l C 72).rl\. ltt i tt*rtlioientu. coronq,ri(Lr1.d, t)ot Bit so producii si,ii,ri sincopalc, rlrr,r. 1 l rrrrr rrllr r r r r r i, ; t , t r is r n .. rr i ' l a rc fl rl trti o c a rd i c ,p o a,tc sul reni , i n faza a,rtrrl ,i 1, lr ltrrtrt rlr Ilrrr.,vgrrl;r sinCgpli, :ltlCSea, o mOltit]ri" lllt,I, Aoeeaisil,radu1r,,r,ri ,l rrrr':i r ; ir r . olr r l: ' i, [ 1 l ,tll i i 1 r| o rl u s i i ,d e c l l rtz e d i l 0]' i i i e: 1,ul btrr.nL,e l i l ,rrr, 1x dc r',.l l r,r r : r t ir r lr s r r r r r . rl u 1 rs . l i 0 c u n o i l q to , tb p i l d ri , gt,i t t,at,ci t, vi 1,ul l tut.i i ,r,i l ,ri (1 ,' Ii l n r ( lir ) ir r I t t r r l, i rL s l c l i l l i n b l o c ru i l o ll t,r' i o-venl ;I,i (tr l :Lfo. I)unrr.t]l t, :| | r|| I I t I j i, i I I t t rt tI t t trt I 1t t I d cttlttrr',rit,t,ii l{jftr)Z(ri I)olt1,o l)fovotjlI o sincol)it,ro1lcXil,. Irr i rrri rrI i r. i rrrrI l r, r , oir l rl n .i l n ri ' t, r' o rti i ri l i c c rtrr,l rr i i r r' l ,,l l ngoru I si trr,,ol ti tl r).)l ||IiI I| | I r\| |t III ! lr it t l, r t t t t r ts t,trl o l tt,r' i tl trtrl r' l o ;rrrl ri l ,r' rl i rtIIr| rIi o1rItIi i IrIi st' l l {rrrri | r,. ll" |;i tt,ln'lt tlil turlt"ttl l,tt,lhuriitilrt rle ri.l,n utnlit,r: r\ r r r c ilr r r r rr rrrri rrl l i rI r' rrI, rrrrn rrJ rl l i r.r' rrl rr l r l oi :rl l i rr r l rrIl i rrrrI:r,r, l rrrrr,l ri L tttttIr'It ' t I I r r r t r lt r t t tArl l l tttrtl { l o l i trs . I' t i tr r.rl i trrl r' rr' ,rrr' r t l rrr' Iroi IIr' rrrrrrIti rIo { ,l rIi ,l l ri

l l l tttti ttol rtgi c;,r t r , it t r l , 'r iir , r lr l, r , 1, ii l, i rL l , rr) rr l i r l l : t ilr t t lr r r lilr r r ( ( lilt 1r 't r J,r' ;r l z, l l tt:l ). I lit I' i i tttrtt1rt'It1| t sit t r lr ot r rt l \ r lr r r r r ; 1i, r l\ 'r r I ( r l) l( r zir r lii ; l, l'11, ( lilr l( ) lr r lr r l ( lr r t I r r r ir , rrzttti l ot sl rtrl ilLlo r lo \ \ r t r r r '( ll( ; ll , r i t ) r : , ili, {lill st r t lir {, iiit , lt t i ( l( j llt t i, t llili lt li's ilr ' lr r 'it jr it li I t L (l 1l ;l J). ,r\l )rtr tlc ol) i( 'i'i r lr llr r r \ r r 'r l: r r lr l l0 :rrrl ccctl cri to c{. ! Tdit t f t ) i : lI I I r,rt rrLI ( ,|| | (i . illli, llt or r lcliuic r lt ljr t , zli it t I t t t t r '{t r ' f : aa rl rf 1,i pu1tl e asislolie, 1r r I rt t t t t r ii r lr r p r tr '1, icir l iliilile r t 'pcr cr lt r ir t r Lii r st t l't : t , ir r,Lrl:r,!ici ocrobralo. lJll{rii s1.ol)ul cludiac tluieazi ci{ cr;ll stttttLtltrr ltprtttr ,lorrr o st&te dc slil,biciuno, itLso!it,il,do pftlo:lrc) alneloli, ;ri tLlllrrrlili, tlr' rrrrlcre. :\sislolia r1e pesle .10 secnnde produce piet tlcr'cll c1n1(rltiltl('i,.(1ll , irr,rtozir, turgescenla i'enelor jugulale, Ii"rirea qi suler{icjllizir r' rt, r'l'slrirrl i 11)0 I ( 'olIrt't itt , l i(fi (pin:l li. npneir) 1i convulsil tonico-olonice (tr1-a1'ne, rl ri l i ). dc lii,m, ''je descritl: ln cadrul 1tll-rlriu'ilol 1) I'ulbtu i'rile (le co duc(re, ca'ie sini celc rrrtli Jritrc cunoscttttr trtttzr' rI0 sincopelor : (rLlar. De obicei, pic,rdelea ile cuirorllilt{ii t'rlt' t)etLtri Blocltl etri.o^) qi imprevizibilir,. '\Itrll, rlrai r:ll oa estc dccl:rn;atir, in-tirtLltttl tttrrrr 'rlNrtrtllnir, pilrti, mictiune:t slrn defccalia. Sc-;tie cir, daci' blr.tcttl ' \' ,,iirrt, ca, Oe '\ t ir lir : r ,,,rrrfl et se i tiagnost ichcazf r r . ur ' ( ii3. j; ; ) , l, loculile - pr r r isI ir r t r (le L L1lrof \ diu tblt.rctrriltr'\ 't'in1ii' l,rrbleme di{icile t1e diagnostic. PiFrllt'rcir,

/t

D i 4' \i rrt,,l ,:l i 'i t. 3?. l nrc gi s trare po)i gr.rl i c i h bol nav ul S .I.,61 dc ^[j Ios L i nternal i n 19i 0 c n dg. S tx tus c l )i l opti trrs ' (si ndrorn A dams -S tok er). 'l pcnhLr l rec \c nl c .ri z c dc I i c rdc rc a c l 1nol l i nl l i , l ns ol i te dc mttl Lc ori d(i Tg. Ii uret ex anc r[rl U l i (; con\arl s i i i unj c ! ri oni c c . I I c i i ni c a ^v c nrol ogi c i r i rtcrcri ti c a l os t D eg.l ti 1' .E -\anrc n]rl pc ,l i grai i c a eY i denfi aL un ])]oc nl l i rl ' vcnLri cu l ar pe E C G, c u uD l i l nl v rri aLi l (i nl ro 22 $i 18 bi rl i l i pc rrri ' r), s . P e fi gur;t s e v ede aprti l i a pc l i l l (; cu D unc roas c x s i s tol i i , i utrc 1i -3i de undc l ente bi l atel al c , s i rc ronc ti s i rnetl i c e (Irc domi rx nte dc dc ri trrl i i l r' arrl eri oa rc ), dupi c arc , odat:r c u i l s Lx l arc a & s i s tol i ei fi pi trdc rc x c rrrr(' ) primei conLreclii c:1rdittco fuco rii-t tilllei, trascul se aptatizcazir, Aprdlia rtrpar'5 l l nc l c l e di n barrdx de1ta. C uuofLi l rl l l rc nparc Lrc ptet, odLIl .i (rrr r{ri uarca ac ti .i i ti tri i c ardi rc e $i rc \.c ni rc a l .i no nal N rc Li v i l i i l i i fl r(:l ri r' (' corcbrale. l ntreaga P c ri oadd dc 1a i ns tnl :trea as i s tol i (i P i ni Ir ror(rrri rc rr cunofti nl fi l )ol nx v ul ui a dtrat 3B s i :c Lr[dt. S l i j r:rl .a i rl di c r"r r({ tri r(i :r l c l i ' c x tati { c 0 (drrptr C orl drtl r, 1!' 17, C otl i ui tt } i l )opori |i rr, 1071 fi vi l i rl i i l ,.,l at,i ri rr ti c ak l )., 1tti 3).

z, | rrrl rrr0l r,5l ,0 li r r {. {'r r , r iir r r '( ( lih1r 'r r lr t 'lr , t r i,l{f ?! ) : lio o lI t 'llzii,vot t l, r 'ir 'lll1L|r i l ,tr (' i l ;r/, (l i r) r,rr, zr r I i) ,I ir . o lilr |ilr r lio lr r r I I t it r t t I it t ii ( 9{t r ) i, ) ' lir t o I r t I r t I i|I t I r I io , ' r.l ,nrtt . ri l t\ l l l oru.l. xit t r tqlt i, r l, t r r Lt ll t r r r . i t t t t t lt , t 'll lt t r ', r 'r lct t lt t l, lr r t t t lt 't t t lr '; t lli' ,l i tri r:1r' i tr rr,,r 'lr '; r ,trrrit r r l'l, , r , r r ' r : r t <l rrr" i ro rl i r 't rl l lir ' lr r r l r 'I r 'r 'I r 'olI r 't r I i, r I 1r ir , lr i.

lr, ,slir;itLrl, rtrustrlui,,pr.iripa,Llzir, auriculari, post_tifirifdliej. SiiiL, 'r'ri , r'rLr lr(.llcUl()rNc, stlLirnb,tahicardiile rrr/ i;r ile vontricula'c,prin riscurllo vontriculalc, prin
l o l rl r los olt il, o, rri, -l l)u liulDtl rlo hcrnodinarrrice tlurati, Ae l-iO setunde, ru)lr pr:r'turbiililc llclnodin&nice cu druati, de b _10 cu tulllu. llrlil r, .i'.rr l.1,t',iittr. osle de obicci .tsinriitii tle hotnav, perioacia cirrrrrlll,tx,iit trn osle de obicei losinll;jtii de bolnav, fiirrd

, I ,l,,lrrr'r ,\'1' l' rroI)ol..rii rrl,,o{o0,s.i t,i,,"ac"i .*;,rliir,iii, ,, |lri',,1,il, su se dr'1rir.r'dr.ri c urro;r rt9 rh: ,t,, irr[.11, :1.',i]1. sl l]l1]l.il:]:]:,iil,,lru.it,^ltitl icepot.sil insot,ensci, 'l i]:l .\rrr)l)('r(! ,i I r'iu'r' r ' c r'rl lr. supra-ventriculili'e(J3oriver"b, i\rr!)r)cirt srrti .i,l'r' irr rrhicrrr'<iiilo SUp"A onlr,ir.u]rr|e I . FittLlirt,, lllotrvCrcl Firruiu,, 'sincopa h ibr il r{i.,a,r:ri.ulll.ri lllr,xistitiL I irr ulltirna va.ictu,1e, pbato surl
'l' uI [ou.[,sincultul poale irnbri,ca urrniitoarcle configurafii :

( ) lloo' 1. &iit *, ' tti . s (' r' ' .,r' l r.ri ' i /,' rz i r, t r rr.i , rLI I r.|' | |rr,) (l r, r:r l rr,.l rt,5il ' l trn,v, l rt, l trr , i : r lilr r r ii r'r rrr I rIr' I r. 1 ' r' i rr rrl rl i l rrl i ,,i ,tu .i l l l i rl i l ' . ;,i ,, rrrr,.i l ri :r,,l i cl rrrl l i ir "\tl r'tt t { \ P t l t lt ! t t i i l )N ltl ttl i \' . ,{ r.r,s i 0 1 r!t,r .t,i l rr.trl ,:t,lrl r, l i t tttr t,i l ttt l tt, rrl l rr,l 1r ' l lr ' r r. r r . ll- rri rr.r[a ' i rr. t' rrr.rl L i rr{ i r,, i t'. l c i l ri rri r, rr apr:l i r, rrr,rrr* tri r,tl rr ,.i |,IrI , I ( ' I I I I I I ) I r I r c lt rc trrrs i s l ,o l j c(p l i rr p 1 r,r,1 1 r)i rr,), i i r.rsr.:ri t 1 tl i i i rruft,ni l L' ) sl p1i l r'ri r;r c rlr ir r ' lt r lr . . r .:r i rt s l rrr0 t rl l r I i 1 ,. , !, !l\tr,l,lnu ii,rilp de ?raitabili,t lt'.. I,rjrrilc ltcslclr, trit,rrl,ioniun fiiblill,!ln trtrl l i rr r lllli, r lr c iu e i c o rrs c c l i u !ri i trrc rl i l tl estu ol ri l el t,' c i t,cul tl ;ori o. i )o

ptlrr st,ttrtit. (iol t rr-ult, sl rrrl,ir,. n tul i- holns , r . ' r r lresimben stare r;ag5, t ^ . UeJ holtrar-nlr es inr t o o ( f ala. r d ; r1e,,rb,u,,-sau efemot{r -x.1r-^-,. o s"rr,zrr,(it^ rle i.tv'ior", cr_i,re-i pemrit evitare"acXa6i.iiin cazul in cftr,(l ",,vitl ,lr)l,|1rrcrL Lcnlodiritnli(.i lI liude Si se prciungeaSCH. b) Lr. pcllutbirile hernodinamice ae 1O-ZO -seeunde, manitestlrilo . , ;,r|lI l,ulnurut [|r'Czerrlind pal oAr,. b.ruiati a fetei, VOrtil. O ,lrrirt ltrlr.lrsr., ir,i t.r'i. I'r r\ r11. rsr.rr opr rfc .r \ oJlJirii $i I acr iv iln lji mo tori i, d u pir cari: inai viOtji
rijr ttrlli ilol,rv ttatc:t.

c) lli 1't.t lrtrl,rir'iJo snls dcpiqcs,.20 de secunde. piol'dct,ea cuxoqtiritN, rle r.rilr.r.'si\ ri, (.u rboli.r'il rcllexr.rluicorneln dupd, iO O" ,-"*A".-fl-,i.,r,iii Irr' i :r.il^li dr' iilr,.uljuse sirucazi jnlre t ,ci3 frinute. l r.l) Itr ,,ineuptle cu dur'lltI de pestc B*4 minute, leziunile cerobralo . sirrl irrrr. clsihiloIlin(liu|olcs, in contcxtul clinic al tuturor a,cesnol slnoope so }ot
i rri cl l , c liz e c onv r ds i i .e , ,\rl,1il tlc accrirltirite in repctilie corstituic

de ,rstaren rdu

.{iar',r7,1/,,oJ tla. Einaopa uaso-uagald, re.f\efi, po:tte Ii tlofi-uittt . .ll. I)rllt ' l,l'l'(rorouc cutroltlu{a scu_rte, sau f5ri convulsii, sccundar, cu rlrfr Iriurz,!(1il,ldl&ue unei prd,buqiri tensionale reflexe (W;ber, s&t 1g?2). I trr.l;rDl,, *crstr: sirx.ope,cele mai frecvcnte qi mai benigner'sint pluriotiri(|ilI r(,lirr'r'! r o:l.Lo ull ctcmcnl cumun : tercnul pe t ar.esurrin aceite alr nranl" o .labilita,teimporraniI a sisl,crnuiui ncrwos wegctativ. Aprw ]1..1.1:ll:.lr:f l& 40. dc i:t r', r,'tr1t lrrnlr, r a,ni $i sint mult mai fr ccve.ntela femei decit- lO rr:l,u,ir.lr_ t,)tctut.srn('ololor l)rn studiatc de CnIflriu si popovicin (Ig78), l.(r'rlr' tr)r'ln{, tl.ilttzAt ptocc {nj de 93,l o/o, antocedcnl,ele llll un In :r,costrji r)r)Ilir \ Iu ,.ru r sc||ltrl'lutzii obicci bo.liorgallir.e, rJt.r,eguli, de ci, Simptotno vcgo.tarivcJ tutburtrripsihicotle ortlirL diccti" ta'peiuo. :llll,i,jll,"l,trrlburiiri ..'rrrir{.r or.otive' instahire 9i labiio vegetatir,'. uneoli in antecedefrtoso Hr''rrr lr'irzi,fillcIt( sirrnc artcrialil,. ca fncl;ori declanSatoriso somnalo&rll (( lr)r'l:'i, f i : ,l,opovicill, lg?J; Co'f ,r'in,1.0?g) frioa, sii,rilo de crnotir,iiai"o sl r'cssrtrilo, sul,;IliIll|1nitliil, ilrsolll|liilo, aorul tlolttUt, fi l dl:rl.,titl.il,lo,. r\\ril, (t(':l,tcrxrt, (l(,in,it'cliii.t. ,ll)1i lrccqi;i n(ttlrinirtll,a.ron, facloli iloclanJ t:trrrr'zr\, mai uf(n'rl.,osrrl sirr.rrprr,l rrttrlt riur,,i, bulna,vrriso ntlll in ol,r]ostrol,iHm. ' llttpil, rrbiryrtuilrrlrr rrlr,lili'nlr"r,r,i ntrnollzij, sr,url,ru ior,rl Jllr':rircrrsrrrr,l0, p ririr ciO rrrtrroEl,irrt,i'I,, :|tfi

.*t,rr l,t.r'sl.i litrt,,Itr, 1r''1,. fi .rrrt,lizrriit , .\tr,xitr,r,*trrbru,lt'1,, r,[1. r,rr,rri',rr rttorut,trlxtrItr lllrr ltliUitttttll,o t1,).lilr,i,'t rrlr,rr{iaJ Il 0s1ri r.olxrrzotritr,l,,!l!'f, lrr (lil .ir')tn'i' rlrrp)i(lir,xl,rrrrl' .rrlrlr. (rri(;), {lo o on r,ri rdio-irr ilriIio. (]clul:r,lii, lr .rr,ztt,r'i.ritrl, . in r''' .trr,1ror'1, ,r l r i l x rl r rrr i rr o tt'ilrrzit,oriollt,itr v|,xorli[a,1,1t,{,i ru*Lirl,(nirr.'pi, r,rrrrr rlrrplr.sil.il,) cu o illiibitio rospir,:.r,1,'i,it ;x.r'il.ricir, .sau (illslrr,rrL cola.b.(1956)au a,r.ijlili; l,lpnecNru clli:l,r:r1rrrr.r'), qi ixi$1,trlrl,u, 1].,':rl' rtnrrrI,)rme \.aso-rtol, i r 1' 1trr.. il sincopei,al5turi de fot:na cauli,_ilhiliit'('$ lottc puli ;i dc fonnr,lo rrri_r.1o.-l)o faptl aqa cum arn r.emarcal, rr{)j(( lrr $i l:rriu si?opoviciu t9-/l ; (:urfi'i., .t928), aceili ftctot.i bc pot ai't:ilt, lrr.rl, Webcr (1972):ttirmd, pare iluzorirr6J, tlifrrr,,.rr1i,.z,. l)c bunA.drepfate. cL, sc ,[iversc iipuri de sil_ cope (r''.utfalc, vaso-depr?sire, vago-vagr,lcslu vin,]r,r.,, vagrre. rcsluiitorLi. vaSo-vagale cu bradica,rdie primitivi). Do l|,r.r,r,:r \\-obe1 i1972; susline cd,.estepr:oferabil ca.toate acesie $incope sit $o rrri{lr pez: cu llp nxm e1ede. ,,s;ncopetaso-aagale,,, atit mai mu1t, cu <:il,rist,, pt'obabil c5, se asociazX sau succed o cardioinhibil,ie yagali 6i o r,ir,so tlepresie simpa_tic5,qi cL do aceste diferite m'ecanisine pol, ir,von,rr -fapt origine comund, depinzind..de un reflcs care pune in joc Ir. Tl,. ponto bulbrtS. care.conline centrii respirarori qi circulatori qi in special c:urli,r. rnoderatori Bi vaso-deDresori. Starea sincopali propriu-zisd(in mod impropriu denumit{ dtr Wr.jx.r (L572)..rtazd,ictald,") esre dc obicei precetlati, dd o fazd,prutlromtlrl (irl propr'iu dcnumitd dc Weber ,,{azd pre.ictald.',;. . Faza prodromald,( pre-accesuald,; pre-ictald, dupd Weber cu rltl.Lt.rr. , ^1 ), dc.zU-J0 Becunde, manitcstd,prin impresic de ,,rd,ugcneral", t,rrurrsIi se lafii, am6{,911, zgomote.auriculare, alteraJii ale peiceptici vizLraio,lri1,i,r. s_ialoree, senzafii iie ,rvid ce.falic", parestezii in extremitl1i, palou,i,,,. nrtrr, (tunpotrivi, roleata, t-egumentelor,uneori dureri opigastric6iitrrr rl,,l,irrit,., grelud $i exceplional vi,rsS,turi lOorfariu, 19?1 ;'Weber, 1g?2). 2. Atacal sincoptal (,,Jaea ictald,ii d,upd,Weber ) corespllodo piorrlrrr,ir cat.eesl,ccompletS, urmattr dc cd.clrrolI'rrlnrrl Iropliu-zjse a-_cunogtiafej. $i ,'st'e stnt siabe'sau ab$ente,dar nr,rpiru,Lirr .inscsizabil,zgomotelo ca.rdiace dc obicei este conseryat5,. Reluarea congtien{eiesto rapidi, drrrrur,,r,'t.,riiiiii a sincopei fiinrl sub 10 secuncle, iar treiirea iiinii totain, fd,rt, oburrLrlhl'. plelungit5,. secundari, amnezia fiincl limitati, doar la durata pierdorii urrr pjielpi. Sinco.lete-cole mai grave, aproximativ o.trsime din-cazud, so 1xrt, Insolr de manfesttri conyulgiye : spasmetonico ln opistol,onuB, oxcotrt,hr.

Cortariu Popoviciu,19?1i Weber,19ZZ). A"cobto nnuti rosra{rconvursrvo se,lnsolesc totdeaunado o rnarcat[ midri&zd,, u[.(,r'i de trtstaf,'mus.. hrpJrsatlvatie, emisiode urind gi mugcarcalimbii, rin ltrxrr,rr smr expucabrre dlrrcuitaFile diagnostic epilopsia do crL (fig. Bg). tn htorllr.i anto_rioaro (Corfariu qi Popowiciu, 19?1; Corlariu, fOZ"A;Ijopovioiir fi colab., 1976, 19?8) am oxpus pe larg criteri.i,te diagnostic, o.iro rlrlrr,r. d,e po
le Tom lezuma :

r1rm?F uneorido ctonii girrr"ruririii", lpl r: 9*p-"9!!oto^nq, gi sauprccectate (CorIariu,| 97.1.;

a) Examenul clinio este negativ, iar traseeleXEG (standarrl plirr ryi nctivS,ri) din fazolo intorcritico sint normalo (Cir,lcii,ianu Stoio,,,'.lli{tfi $i _ ; Oorfariu, 1971; Corfn,r,iu P,opoviciu,19?1; Gastaut, tO6f; flnsirr,rrtiqi ,si .olab., 1956; It&illofl,1000 Slioica0i Bro$toanu, lgit9). DoartV.rcolhrl,1,ir ; (1960)a gfl'siila 30'1, rlirr lr'lnrlvii cu sincop., anolnaliilr.r!(1 r',rro.rr,1,. rrlrr.l,r'i.u ilslxrcrt rro cornifin,l, si Itul-0% {,n"{,rnrIlii inrl.osobi sLrbi.'l,ii.rr l,l $irl(Dpevll,Bo-vlulllo,
3:)tl

srr rrrrdolont(!, I) iIiI I i II.i|,I(I .llt tclritrrlr,irr LitrrIrrllirrcolroisirrrlrlo r,rtlrrg (l(! tiiiBiIl(,r"r,IIir, xrrlr|lr,r (1lto Irr!ov(!l)1,i1, .l r,/rr ol1,lr,l,rr,iIlul.i'i, sirrrtsoirllr,lli,, il0 it. ((|rrfrU'i]t]. ll)71.; (l(irlal'irlryi l,,1r,vic'irr,u)?tl Wt,brrr, lt)?J). lrr sirrrr,lrl (lr) .rrrIrrlsiIr'i,lrrrlirut.ilo rn(lo lcrrto sirr1, rnai Jrirrgi siirl irrtrurrrpio irn rlo 6i (,:rrl1. Ilrr.l'r'irL rrilrrrr{'irr lIplo '1loo0rnplr.t, c(u{.NI,uur[o sl]lr,s]lllrllri loiric. ,,t <rcsl, lil.l {ir rlrrrclrz'ii' rrilcla,sccundoqi cstc urrrr:r,t lcirlllr,r'i{ir dc lrr}(|j'loli{'l11o, .rr|. o Il,rrr rIlzii, lrr0grosir', pinii h rcculrc}a}t,llurrr-ri r.iirri rronrrrrl,l\rsti r1r'iii(r cx isl;i,ilrxrrna,lii llt llDG. (.lrr,sl,rr,rr1; . (I950) . a . doscris sirtolpi], nrrcturnir,a hiperl.agotorjicilor Si rr.r,r,r,iLirI.it, lir|crr'(;iorii ili a,ocstciade- opile+sia rnodei;i,. Aiestr: sincolNr \r,,o \ ir,gir,l(, sirrl l:lyoriz:11,c oursul nopl.ii, de ridicarea in tirto,.talijin in I.rirlc rrrrvoiir, ir,.rLriru,la vagotorricii constitnlionali irL faza ch hipor,rlo rr'ot,ulnr"l. Asocierca acestor diterili factori (staliunc l,ertic:Lli, 'rr,g.i.rrirr prcalabil culcat $i cu tonus vascuiar r:eclus, rrr lrili'l lr, ln srrbicci, afer,r,nlo r irrrrrr':rJrr ctrrl;r'ipcl,cr nocturlX a reactiviti,lii vagald) oxpljcll J)rovalen1,[ .'r'rr,vil:rlorr il,cosl,ol sirrcopeqi asociereafreclenti a nra,iifeBtSrilorcoiyul_ riVrr Iirlifi1, u.ol)lonM, tliagnosticului diferenlial cn epilepsia rnorfoici-r,, 'l'oIrr1i, lrr.ozon{,:r, tloar a tnei contmclii tonic6 in opistAtoius (pl.cccdlr1,rj, rrrr uIrIrt'i rkrlr r10 1*2 sccuso muscnlare gcnel;lizate, ilar'-Iiciorl:r,1ri, irrrrolilii,rlo o 1'rr,z[ c]onicii ritmicii propriu-zisi), precesiuneacidorii ;i rr, dc ;riclrlolii .orlLory1,inloi c5,tle o stare de riiu gencral cu gre!.uri, paltiilr.o ,,i tr':r,rrslrir':r1irr nli!, a-llscotIr r!lrund, ncmoolorEEG de epilppsi;. 1,r.ecur,r si rxri 1rroIrII..rlo npro$iunc .a globilor oc[lftTi pozitivi,, etimind, Olignosticril rlrr rrpilrrpsio lnorleicd, qi obiectiveazi, hipeivagotodia (Gastaut,'i9I0). l)orli.s-1,orczu-t tri sincop-ayaso-vagald, reprezint[ u ri,spnns teusio_ . r.lrrIr'rriror {).lt,l{r()sirne }r psihici,,cercctiri ale rioastre(Corfariu $i l,opor.icirr, l!r?.ll ( iorInlitr, I97-8)au arltat c5,existir,o irnportanti participarti cardiol ; rrrlriliil,oirnl 38), carc oste capabila prin ea ilsh,-;i sb, declanriezc o .(1i11. rrrr,rrio cottll'i,|,il"t. l'onl,ru rlocllnqarea unei sincope, respeoi;iv pentru leprodueerea irt . lrIr()r'ltl,rt:..1, nroocsllhlisinco_pal, se.utilizeazi, conprcsiunea oculari, compr\)_ rrirrrrur, rJilrusulr.ricr,roljidian qi rnanevra Valsalva f Corfariir. l9?t. I lr78; ( lrrl'ariu Si Popoviciu:,19?1.;Gastaut, 1950; Gasta,rit cola,ti., ObO qi f i ( lirrrlrr.ri, 1_956; YercclJctto, 1960 j \ycber, 19 Z2)..Oompresiun{t; 6i ^(h,$1,lr,ut, olrrlir,riitrr fu,rxr tirnp de 10-15 secunrle,etecbuindu-se concomitent o inrollirrl,nrlr ;xrligrtfici, (EEG, ECG, pneunfograrnd,, eventual $i pletismogra. nrii,). l\,llrnovla, o$to pozitiyi dac}, aceasta antreneazl, nauli cardi;,rr?.i rlrr 5.,I l:lu rnai nultI _ririrea,. ftec\.enlei cardiace cu c6t pulilr 50o/o; rrrrrrilcll;flri1r'o.siucopale (prc-ictale), sventual chiar o siircopn 1vb)i lirzlrltoto poziti.l'e cI valoare , _diagnosticr,au ob{,iDut Gastaut (1950) i1 (.il, 1,rnr'1,4i colab. (19-lir6), Vcrcellctto (19ti0), Corfariu (1971, 19?S) fi l Irr'l'rrlil ;ri l'oqovicin (1971).r,s, uncle djn cazurilc noastre, pe lingi nlrrd(rrlrrobiqrlril,odo opriro cardiac5(la 4? 0/o din cazuri) am obsbr-vat gibloruri rrrrrrr rirrkr ,,ltr lanltt, lil intervale iie 2-3 secunde.La cazurile obsorvtlo rr,l lrri. ((lorj:)l'iu,19?1, 1978; (,trrJariu qi Popoviciu, 19i.t) nu arn putul; 'l(' irr.rrvidonftr prin acuastL.probii riispunsuri ,,corrrphtetr itrU(i, <nr 1'rrrrrr lrl l.trri rlo.rrnilokl-nt scpu,r0.bi 1x.r'itr.r,tlLr tl, ]rrrlsjr.t,luutr.ici-r,, iflntt o rlr: tk' il,Dil, I r'.rri[t(,i!lVorcollt:1,10 ei t)1,)(i ,,irrtiorri1rl0.lr,)t .11{}60), rloir} r.its1rrrrrsrrri (frrtlottt'i uttrlo.lontti,.lrillll,olllle, rlo sirrcrtrrr', sirirui rJru., llru'|,sirLrrsoirlrr,lii). ri,r (l 1r...Irp1r,atl,iul't6iorlitb. (ll]5(i) ltu lu'i,tir,l r'rlrrtsiit ulxrl,r'rx,rrc.lrr,l.g'ri.ii, lirrt'I, onlo rltri,rrntritlr,lli, rlrrlrr,l,ll rlc :mliri1,ol,irur llloc rrlrrrlillo : tirro.lliriirl J30
iii

pl tri l l :r,(i scrr r r r ( lr lu r r r or lr llril l. r 'r r r r r r r r l ) ( 1, r r lr , xislar lir r t xr sl, r 6 Hr . r . r r r llr r lllr r lr r l tttl ! r r t t 'i r lo t t t t r lo lr lr r , r , r rr lr 'll: r , gclr ct : lliz- ir i, c, t ' r t t t slolr clr , : 'r lir t , t r ia, l trotl ttcc ctr o rl rrt' 1r,l;ril, 1r c$lo lil r ilr r r r l{' [ lr , ir .sii, r r , llllli ( loscl- [ r ( r ir i( lo ull{l1r h, ul, o lo bi l l r,l ,rrnl l rIi il|l( 11r 'i( , rr r r I r , lr . r lr r lr lr lI lizilr r ': l t I 'ilsor t lr r i ( ( 1{) x) lnil ol ll, t lll ) n( ollrtultiliura, clinir:ri, 6i cl o (.ol nrrrl,io irr opistotonuS, proccdill,i, {lif I :l cJortii gcntilllizate). Nirriorlrr,tii, nu ti4)l,l'e insi o fazl convulsi\'li, clr)r)i(,r'[ l)l olrli[-zisai,. CastlfirL;ri c01 lr. (.1050) au mai demonstrat cir, Ja, trioi rrrr p teE o LI4

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.lrig. .r3. Proba comprcsi(i octl]arn ln cursul unei lnregistreri poljgralico Ir bol nav ul P .D ., 23 de ani . D g. s i nc opi v as ov agal i . R ohav ul s -a i i k ' r)rul pieldcri dc ctnoqlinl:i de scurti durat:i, declanFate in special d(l lcntru crnol i i ti de eD erv i rj , l ns ol i tc uneori fi de c onv ul s i i Loni c o-c l oni c ., Ii i ' r(l suspcct!t cle epil clJsie. 'foate iDreejstrir.jle EEO intercdLice eu iost nci{aLi\'( . Proba comprcsiei oculare evidenliazd, dupi 6 secunde de la inceperea nlArl( yr ei, o nrodilicare a ri[mnlui cardiac(de ]a 84 bltli pc ninu t 1ai0 b:itnii tnin L), nul ncroas e bj oc rrri s i noatri al e c u dural e de 2-3 s ec unde i n ,,s |i tc ", Iri t.i nod if icarua 'f .l\. si a activitilii EEG. TesLele de cornpresie siDo'carolidi r)ii gi maDcua Valsalva a fosi negati.ic (dupi Corfcriu, 1W7, Cotlilriu tii P opoD i c i rl , 1977 ;1 P opoD i c i & s i c nl ab., 7978),

ca,z de sincopl vaso-vagal5,,actiyarea c&rdiazolic5,lru pro(luco li(,ilrl lit de reactivitatc epilepticS,,dar c5 aceast[ ac1]ivarede multc ori l)t o\,r)it,('ii sitrcopa, in cantit;,li rnici ale substant5 injectati,. poate antrena o pr5,bulir'(iloltii(l Masajul regiunii sino-carotialiene lra15, cazul unor sincopeyaso-depresoare in (Corfariu, 19?1., 1978; Cio}lrrlirr Popoviciu, 1971 ; Weber, 1972). 1i In sfirgit, in sincopele prin inhibilie respiratorie poate fi rrl,ilii ptrrrl,r'rr rliagnostic proba lui Yalsalva (dup5, o inEpiralie profuldii, so plrlciicir, rrrrefort expirator cu glota inchis5,,ceeace produ ce un blocaj tl Irrlo:r,rr.,'r'ii prob[, practiclltlt qi rlr loi vonoase,prin hiperpresiuntoracici). AceastS, (Corfariu, 19?1, 1978 I Corfariu qi Popoviciu, 1971) a ploduH Lr rrrrr.l,r sincope vaso-vagale o reaclie cu totul particularS. Antfr:1, h slir;il,rrl probei, s-a produs intii o reacrie bratlicardicS,de lungi, durntr:r.irll lrr,jl li socunde de Ia terminarea manelrei s-au produs blocuri sirxr"rl1,r'ilhr rr ,,r |l,rr],".Accstu roaclii au fost interpretatc de noi drept consccirr!o trl(! luror mI'lcxe exagcl':ltri dc tip va,go-r, agal (13 <1-J ch) cu tcJ)()t'(lltsil ozol aris li (Oorfarir, 1971, 1978). rr,srrpra norhrlulrri sirxr-a,l,r'irl Ilu,clori,,i tl.irfut11it,i, :titttoptil.or' tti tttso-ota,guLr rrrrrrrrl'o;i ((I()r'lrIIiI|, sir11, 1071, .l07llI (rotlttirr tii I'o1rolicitr, l()?.1 Wrlx r, l1l?l-r) : I l. llittoltrt, tnulit'rt,: ltitri,, sliiri tkr irttto|,it r,, ctl't'tiilir sllll+rrrli itiII
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| ,ttriu l .ir | 1)povici . 197.1: :t,) ripul vagal sau c:rrdio_inhibilor;l)) ) I iprri l,r,rrsio-tloplcsor' tiptrl cer:ebral.I c) (':r, :Ll,il,r'u r-or' 1i expuse pe larg intr_un subcapitol separat. l1l. It'luxtrl,lar[ngiott.esLe.o formi de sincap[-gal"s r,pare la indivizi ((!vi!. rr&i r.i'slilici (50 de ani), pnrti,tori ai uior afecgiuni respiratorii de ' r'{)ri,r', Irr .rr.. r'iLcurnstanfele aparilie sint chintele de fuse. b fornril, n|l |J, ir. t''lus0l|ll t]rrngtan cSte ,,LuSea obnubilantai,,.. | | ". Si.ncopel,e post-traumati,ce.Se confuncli, arlesea cu epilspsia posF ,
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rl u ' tr' 1 tri l l ,rr 1 Irrrrrl ' t' .ttl ,iri , sttt:rt' ri i 1i l rr,rrr4ri i i rr l ,i rrrl rrrl l .. i Ir | ' I I | |! r LI iI r . , I I rt I.r.' | | , r',I" 1] l] ii" . hipttl r r.l nrl i rri ,rc l ,r.c i tL rri rtt,o l tcl ' i i url r,oi rl tttrrl tr,i ,o r ru ti otr r,ol rti tl1. H||t|l I I I | )r,| | r\ I I I rI ( r.. S|) rrlt,i so ]uN,loil,zi, sitrrxiJi0lil itrr livjzi r:ltt,trsl,: Il,io oil,zi,[ rl | rrc r r r r . lllr r r r g; r ' 1.r i u l i -r,1 rc liirrc h i s c , s rrp l rr,- i trci l Jzi to, i, rr grt l t,st' i rrrpul i ri l i rr, .i. ,\ Ltt'ol),ttt,tt tluH)t.c u1l:lrt in caznl tnrol dur.rli viscer.tkt (t:olfui lro. , I':rl ri .r' s : t ||r . I ||. I I (' . , c t i z r. a trg i u u u ,s r.) i L rt n u t i rt i (,r,. s 1.. S;; roplh tl,i. cu,rsul efitr)lordrilor inslru.rcntu[,e al)i]r ildoosol,i iu n .lr.|rrl rrrrr)r stirrrnlir,ri in teritoliul r.ilgului (risofagn.iu1,u, ganrrus,,,,lri i ckr.) ''- S it c up, lr , t r los tttl i r a p l r.i n tu rs u l u rru r l U rrgi sl rLl i onari i rr pi r,i 6111q1, r:r.'rl :r r ir lii. lr r r ' : rr lir r 1 rrr,t.l (.D n v i rl e s c c n l ad u p :i rrui l c rnrr,t,l tl i i . j i i U rr i rr.l uri :rr r sr s [ l( , ) pc t o lI lr . t ,l (,trtte ({ o rl & ri . 1 9 7 1 . ttTE W eb(.r, 1972). tl ._i i rr ; :r.,r.sl .r . : r r t r r lv inc li rl i S L .n ,.{ i t. c Z i c a l a . Si r_ r, :trpol ortostaLi cc ir \' ,, ;i cot,. l ;r, r|| r'l || |l ) o v r ) r ' t r lr llr , tr. rl c n o i S c p a rtt 1 r| z i i n | onl i nua:,t). ll.. 8 i,runl(.Lc i.atrogene: dupil ingerarea, unor rnedicamente sr.rlr lll r rrrl srrlt nr ot iujec { ii. i. il irr,cop ele tlupii r:onsu,,m, d,e alrtxtl s. ,\itttttltcle d,upo. ttuu in cursul tt t,t,r r Iurturi Iizice. lt,. Sitropclc pri.n tse s;biLitutt^ t sinusultii rortiidiatt au I,t,,l. . .h;11t rrl,rirt itf cad].ul sincopelor vaso-'agale? crezi'du_se c;, intervirro 'r{rirrse rr lrilr.r'r.:terl,u,h,iJilate r...r,g,,1i.. Da_r_ lapt eld constituie o entitate apariir, tle_

( lot {l) fi r l (f s(fttttt 0r r t slt t , r 'r u'r t t t t t lt ', , lr r 'r 'r rir r lir r lr , llll) 5 I ( lr t t lir lit t , l1) ?lt ) . lt (l l rr,r' i rr l )Ttr) 6 i( ior lir lir r f jr I 'olr r vr r r t ( llli l) , r t t t t 't it lon( iill, l: r ar r t '; li lr olt t ilvi 3! it o l ri porscrLsilr ilil, ir l, o , r ir r lt Hulni lr t t oI it I iit t t ( . 1: i11. )) . it t l )i n obsc lva, liilr r lr r r r illr ( ( I r r r 'lr L,r , l1) 78; Llor : I : lr iu qil\ r llt lvit r it t , l9?l) (vtrzi 5i 1Jg. 139), rticsrr cri, irr sitrlolrt, lrl tuse pilrtricipii hr miuc rn[sttrli ( i ' i 1,,' rserrsi i i lit aiea sir r r sr lr r i lr r lr r t , ir I ir r , r r , t 1 im pbr t alt r ilspuns t 'lr dioit r lt i
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urrr"^rrtr.l.r-^.Ap*.^^r.r^^.^i" irig. 39. Inregistrare poligrafic! tn titnpul compresieisiDusuluicarotidiaD dr:ept.le bolnavul L-'\., 47 de ani De mai multi ani prezinte rare c ze (2-3 pe an) de picrdelc a cuDoqtiniei, declansate de tuse (de obicel), dar ti de rls. Esie mare fumdtor $i are o brcnqilti cronicd. Proba (k: compresiea globilor oculari a fost negativd. Se poate lemarca laptul ctr la compresia siriusului carotidian drept apare o pronunlatd bradicnrdie (cu 16 bitii/min lali de valoarea initiall). Concohitent s a produs o scidere a T.A. de ]a 150/80 la 85/40 mmHg, cu revenire la valorilc initiale dupi 22 secuntle, L:r manevra Valsalva, scddrea tensional{ {usese si mai mare (ta 10 seculde dupi lnceperea acesieia), iar dupf n4nqvrei, s-a evidentiat o rcaclie hipertonic{, cu cre$tefl alc itrsu1314s '1.A. pini le 170/B0. Ileicsc o hiperscnsibilitatc a sinusului carotidian dc Lip crrdioinhibi Lor$i t ensiodepresor o reactie hipertensiv{ exagcralI fi (lup[ tcminarea manevrei Valsalvs (dupi Corfdair.l, i971' Corturiu 19'17 Popooiciu$i doldr., 1978). 6i Fi I'opauiciLl,

l).. f:ii,runpele1tr_inalte d,i,oerse cause: subalimentalie, dupX insomnii ur,rr sLir,r.i obosealil ctc. rlrr tle este , .l1l...Nin!\1,? ^lt,ipuaentriLalia mai rareori intilniti,. Aparo indoo..'.\r,r t,'rI|t,r tr! InLrc z0 -40 rle ani,.cu-tulburhri Iuncl,ionale gaitl,o_intcsl,i.: .r,/ ir,lr .i mlb-.r,.:,sculare. tractorii d6clanganfi sint'totcleadna de naturr"r, :r.rrllr.rintl_o simptomalologie ;,,,i,lri.ri, preacceiualLmai lunga (3*l rni_ |lrr,(.),,r'irr':tl'I.(:t'rza,l,i prin^palfi1,a1ii,sl,arcde rd,u, transpiratii ieci, senzatii rI|,,,,1)rrrIrr, cong0sl,l& lclci, usctciuneagurii, incetogarca, , vederii, furni. ir.r.'r'r *'rr)rtotr in exlrmititi, prccum l| !i respira(ii frecvcnte. Aecosrrl rlo.lrirrrkl.o rucuno$tintei este de scurtd,duiath iZO secl, in ti-prl U"oiii lr,rl.rr;r'rrl r..rrriirt'riscito cd,-vedc, cd,nu poatc rlsprilrde.Acestemanidar r'.. :r.fr ..Illr, l,l.orlusoprrrr htpervenlilltia pulmonard (wayne, l96t). Ia . lY."Nitr,rropa truseesta ugor.de diagnoslicat,.Aparo tle obicei tlupitr r l rrlr rlr.:li -4{i ilc lni. la btrrbalii carr:lquferJ. dii,crscafecliuni Irrrir. rje lr,rpulnl r.)n:trr.., t1'rricr. (bron;ito cr.onice, crnfizcmlrulmonar, a,$tn) $.i..),do rrrl(,r'tst Ac{,eJUl sIIlcopftlsc pl,o(lltcu litttpul tttsci, lI irt ''l.t.t 'ltn:Ltorr, pr)ziIirl,. f,,.1:(,:irrrlil,rn'rrt-rlo col.Plrlli, iir sirrrprorr.rclc l)t,esrl,,rll):r,lo l:il':l rrr'tz:t.rrt.';llrli rlrtrr,:r.zii,.lnt.rr. tr|,.x.,r('. ll0,\o.l'r(lo 1- :l_;l rrrirrrr[o rii'rrrt (r inHo(r''il,(r co,'vrrlsiil,oniu]-( rlo [r)lli(:o, rrolrrrr,rrtr rr,vturirrtrrr-;i lrr,pitrr'f;,r,ri rr'rl.rrrr.i'rr.irrl,l rro rurrrhrzio do ilrrrrrazir', l'lt rillsi r rio rirgrrrI 'Irrrl'irrrtrIii, : l:l:l

)ilt' se lrit.ol qi tensioclepresor.Da11,1e.1, pare c; acosto zone b&r)rls('llsjl :rr pul,ea sd, fie influentate qi de hipertensiunea artorialfi protltlsil, tlttpir rr,ocesul tuse (ca tlealtfel qi dup[ incetarea manevrei ValsaJva,itt oltst't de vrll,iile noastre) ,.sial conduce implicit la instalarea unui bloc sitlortlt itt'l sitrloltti. srnLla o pd,bu$ilc a tcnsiunii arteriale, cu ro1 in cleclanqarcrr, \t. Sincopu ortosttLticiieste socotiiX' de cei mai rul!'i (Dod.irlol;' I lli'll ; ( iilgenklantz, 19?2 i Hrs, 1972 ; Weber, 1972) tlrept o sinoollt, vlg;Il?l,. l,h reprezinti 5,5 o/" din totalul sincopclor studiate de Wayno (l 91jl) {i 1,3% din sincopele studi:r,tcde Coliariu (19?8) Si Clortaliu ryi.l'opovitritt ( l$?1). Apare cleobicoi la' inclivizi treculi de 40 de ani. Forma ,rprlitilg('r'I'" iNtIt rr, u,ccstei sinoopo sc tlulnrt;oirzX, dupir, o pcrl'ioadl lungi, tlo ot'l,o'!1,1!f qi (1,)irrhno oola,l).,1f).17, r'il:r,\;i Corfr,rirtqi Popovilirr, J97l)' lt'rrlrrrrr' do rlitr hipotottsittnofl posl]ulrLlir vl'lirlcrrzil, i6i rrrrrricil, ([!rrgol, l1)fi0);ri folrrrrr' , irr ctttt5tiott{,tli,tt t tt tttttt t1ttI I ttrtrtu'ii ptrtruu!rlogi:r,, il lrirrrlrt!rillrrttlrtllj,lt, sirrr Jl prll'io:t'rlll' tttrrit rlirr clirrosilt,l;isrrrot'Lolti'rrIirrtrt, i dtlJ)iL scllrl l"r' o ltr l)l'('lt{'(r(rNlI .i itt1fi, ln crr rrlr'i lrt,lrirn,rrlitr, rrlrzl(rrr rlri 1''i11 ilmo{trli.I'itrrlotrriltltt trtttto{1 lorr lrr, r.lotrilo, lfotrrlt llottir'fiit,ltitrtt lroltttt,vii i Itrso{r,1lrr tlrrror rIt lorrt rrlrrrr ir.rr
rli:rlr|l i|i, r r ,r ItIi n o tti t,tr t, tti tItt1 i r r tr r i r 'Itr 'i H l t,l l l ttl ,r !l i ( 'i . l '1 tt,tt r l r .g t'ti N L i tt|o l ttt

:t:t:t

oflosl,iIl,irio sirrrlrornrtlShy-l)nlgtrr',bol,[il rlogurroltr,l,ivir, r:rt'opo lingil, lrr ln lripol,orrsirrrrou, or'krstalicii, sc cunslal,ii, urrhidrozil, impotcn!,i srxuali,, rrxrl,urnii,,abolirea roflexclol pupilare, simptomo cxtrftpirtuni' 1roI;Ihittliu rlir,lrr ryi rr,bs0!l crc$torii orijostatice a catecolaminolor. lrtrrvis (1904) a descris un sindrom de hipotonsiuno ortrc,staticil,{||,rIIiliirlii, i,ir,r'r,loplozinti, o boali degenerativd, cu transmisie er'odilarIJ.
PNEUMO COMPRESIUNE.4 SINUSULUI CARA|IqAN DREPf
.^\.-/2\

(' l rl { ' H c l ,l u if l: 'i . ior r lli,r r r r lol t r r r 1r olir r , r r I r r lr r r llt r r r slr r r r iur . r r sl,Hir r lopr r ,plir r ir lr , r.i i tcl ,i tLtrir,rllrlio ir rlrilr ilol ir . l i l l , Nt ncopokt lt 'it t , t t u. t : . r r r i, r f u l) or linot , 1972) sint lr lor lr r sr r pr , ir r ( rni[i rnu]to alooljiulri (,il,r1lilrirr,rrcrrlologicc sau vag:lIc, prtiirrrlrt-so ;rlrrtizlr ou lnaro dilicultato rlr,rtzlr, crurtii a, acestora,
PNEUMA COMPRFSIUI,IEA SINUSULUI AROIIDIAN DREPT

ECG

TA, 120/75

-l+\

FM. -4.4. Plus 66lmin. u a. - 4. F D. - C. D.

P D,- T,D.

Pius51/min. l 5 A rV
^^.^4 Vu^,ve-

JlqtuW

^e,\^4^^ryu4,^^\/r/q.^^'/lJ,1lA/(\4r'^l-ar-t^^1^A/!^d^"a.-y1^

PS. - tS. Ii0. lr, Inrcgistiare I)oli$afici tn timpul compresiei sinusului carolidiu drept lli bolnavul A. I., 3? de ani, alg. crizc sincopale orto_ statice. Boln4Yul prezinli erizc sincopdc tnatinale la trccerca din ciino- ln ortostatism. TA. ln clinostatism era de 120/?0 nmHg' irr in orl,ostatism de 90/60 nmHg. Comprcsia globilor oculari a drept se {ost negalivi. ln schiarb, (jomprtsi.rsinusuluicaroLidian voalc ci produce o scidere a tmului caldiac cll 12 ]ritdtlmiDut, crr la o cliscretl scitlere a T.A. (de l^ 1201'15 11/75)' Manevla Yalselva a proalus o masivi scidero tctlsionali dc la 120/75 la 75145mmHg 1s71 ei -PopoDictu ((rupi alorlariu, tn t, $i ""Il:i"i:.qisP|apa'icilt'

itir, d?. Inrcgistrare poligraficd 1abolnavuM.L., 53 de arli. l)g. sillcof, la nliclirne, La compresia sinuslllri carotidian clrepl s produce lrrr bloc sinoalr'ial de 5 sec., insolit de o senzalie de letin iDinenl. Lr clir( ttarea unei manevre Valsr1va prezentat - spte sfi$itul acesleix - 0 a intonsi reactic tensionald, insoliti de extrasistole ti bradicardic (dul)ir {:arfariu, 19'11, Corfaria;i Papariciu,1971 PapaDictv$i co1or., 197t1). ,i

ItrrlriL, Oorfariu (19?8) qi Corfariu qi Popoviciu (1971)' multe sincopr' r,r'{,rslrrlico siut, rle fapt, consecinla unor hiperreflectivitS,fi sino-carotltli' rr' 1.1i4.lr) ). \1, SirLcopade micliune este destul tle raril, (3,30/6in statistica ltti \\ r yrrr, .1lil0L i].13oloinstatistica lui Corfariu, 1978). Se intilneqte indeos0lri lrr,lriillrl,{,i, dupii, yirsta de 40 de anir alo obicei ilupd, coasum de alottttl plcmfrgiitoare a'ccesIni. Dup'i un timp variabil de somn, bolirr s,,rrlrr, rrrr,r rr.spr,<.l,iv scoali, Qi imediat dupi, micliuno se produce o sculir'1, rrl se ilo de ;rir,r'rlr,r'o curio$tinlE, 1-2 minute. l)oar uncori se pot semnala simlt' (amelelir gleluri, amo{eli in mernbre), dc obicsi actrsltttt, li,nrr' | r()il,c0esuale ' lipxirrrl (Oor'l'ariu,1978). Criza sincopal[ dlrea,zi, 1-2 tninute, ra'tottti |rirro(.irrrlrr (lo conyulsii tonice sau tonico-clonice, iar postaccesutl hol so rrir,vrrl :ltuzr"r, ailtonie, amclrelircefaloo ,5i o stare do te&lni'r.Waync (l9tll) tolm',i in cadrul acceselotsinoopalo llrin hipotonsiullo rr,lrrcrr,rlllr,t at:casth, oll,osl,irl,ioL, ()asta,ut (1950) :r, pla$ft1jsin(iopa tlo micliulo irt otdrttl irl sirrcolrolorvrs()-virErllorliirrd fnvorizrltt'i,do orto,gtatisfirrInl,r-o ftzit, tlrt lir, Irilrrrlvir,guLorrio rrocl,ut'nir, indivizi vtl,gotr)lli{'i.In doclanqarcil ittrosl,oi irtlri, irro 11i ipol,onsirtttsit lt :tt'1,ttt tcllox[, prodttsLplil] golirou, nirrolro irrl,olr (lrr'Irr,r'irr (lf]?lt) qi Oor[rtt'irt l'olxrvicitt(11)71)utovirltttr(irll, i1i vrrei,,ii rrlirlrro. (Jig. a| ), qi r' lri;rolrotrsilrililtr,lositrttsttltti Ir, trtt,trtlirlilt'tt l rr,rr,r'rrril'i lrolrrir,r'i :r:t4

lr
'i

il I
L:.

, 1. Cauzanzi,rtecardiace(ctepilcld,stenozi aortici, qi bloc a,tr.io-vr,rrlli curar palotiis0rc). 2.Oau'ze miute tago-cartlidc.Este vorba de piltlir, do irri,rrlvr,rr{iru nnui factor vagal in docklnqareade sincope la bolnavi purtr'ltoli rlo lrlor. al rio-ventricular comolet. 3. Cnztzemiute niuro-card,iace: a) Epilepsie pi s,indlctm,A.tltuns Sl,tl,t:r. Se ''stio ci sincopa Adams-Stokes, fiind f-oarte aclesca txrrrltrlsivrr,rrlii, poate fi confundati cu o criz5, de epilepsie, iar Dorlinot (19?2) l tlr,rr,r,irr un caz de comilialitate interpretat ca un sindrom Adams-Slokcs,rlir,l,oli lir, unor tblburS.ri de ritm car:diacapirlte dupl episoadele talricirrrlito rlirr cach'ul manifestirilor sale epilepticc si la care o ttrra,lic anl,it,orl (irrli :r i dus la suprimarea acestor mo{lificif i.-Tot Doclinot (19?2) t,clrrlt':rzir|r,uu cazrrricare prezentau concomitent celedoui afecfiuni (epikrpsirr sirrrll0rrr 6i .pe Acb,r'rs-Stokes).Totugi, Doclinot se intreabi, buirri rir.tr1rLir|,rr, 11i r,rr nai, dac5,aceasti,manifestare eliloptic5, nu reprezintii in rclrlilllo rtrr,lrr'lrr, anorial a unui sindrom Adams-Stokes. lt) Sincoped,e rrilin trt.l'':ulru.tt, Tot Dodinot (19?2) relateazj,i cir,zrrr,i r.irrr, 5i, si nilrotn A.dams-Slokes, lir, ltlocurile paroxistice Adams-Stohs pot agraya urele tullnlttili viriilrrlrrrr, <rcrcl;r'ale bolnavi cu insu{icienfe fie vcrtebro-bazilaro, 1io oIro|,irlir,rrr,, la lrodncindu-so sincolo t1o etioJogiernixt:i, do aceoa, l)tolnuto rngtrrrizirr,r,ir, ttnot cortsnllra,{ii lo-tr lrliologico la bolnavii calc plczintri lrirrtrlrrr,i rrorr rlo
( l l r i f ) ) t l l i t t ( i t'i i r t o l ttIi tl i tl ,r r ,

O sor.io irrrlor,i rlrr (llrrrr, l|t7ll; {ir)l(lllr)'(!t,i1i icor', l{}?0; ,\lorrrrrrl 11l colir,lt., lllTl; liolrrrr11i r,ll:rlr,, ll)?l yi lrl{ii) ;rl l)t,(}lrllll osorio rlrr rrllor rfrr tt,tltrort tt,.l\rtrr'!ir i ttrrlultlui titttwultrit.irr trli.rtili!ii l)iarltt'( ptin ntrlrtlt
I
tl t ,,t! ttl ')'t'nl ,t! ! ul ' r r,l rl tutti tl ,,l i t' ,rttti l uItt.

VVffl . Nir r lr , 2r ir ' lt r i tl . h i y tn l l t(l i t.i l rrl l ti tto u nl ,i tl i t.rl i . l l i rrvilillr . ( ll) 5 1, l { )J )7 )rr i ri s l ,r' ttl rl i z rrls i rrrpl ol rrl rr i )i t)(,tr,(,l l ccti vi tri { i i r rrr,' ('rtr'ol lir r t t t ir t I I I I t )i i | ()l r!'1I (r g t ttl rt, rk r i rrl )} l r| i r i (crr (ol tl l )l l ' 1i i t,i l (l ,i trrr,{' r | it r]i ! i) r l i rIi s i llr pr iY ii. ir r , l 1 )7 2 )I /. 'l\tll\t,r'ritilt, l(,t.l\)us(j: tl l'lttrttttLttttlt prod,rotnak sirrlr int,otrslitrrl c (lirxl rrrcslclr, r.rjrl:'iy r 'rrr rr,l rlt , z r , r r lt r lcr li' o s 1 :i ,r' t' (' t.u rx i rj l :1 1 cc u ( .o s1ti 0l i (, 1r,tr' acj r.i:r.l gi i , d r. , | l I r r'( i | | (| jII (.1 , (li$lll{,(i sj sonzlltio de sufoc:}t.e. l)) ,4t u'tltl xi?r(,r1lrrl ,,pNt'edo obic{}i dup:'l,\-irs1,i}dc 30 :lni, rle l)l l,li\. lillr llt, sr'\rrl lllrscrrlin, dlpli cum I'ezulti li rlin obsetr.atiikr rorrslr,c (( tr lllil, ll)71 i []ot'lll iu $i llopoviciu, 1972). Acegti bohra,vi sint tlr rrtrirci :rllloririr,lo;i fi hipi{'tLlrsiyi. Arlf,'1, NlthtrLsnu (citr,t d'r Wa)rrc, tliilJ ir, :rr:rlrrl (i'i 1t,l)r'o)(itntitiv 0lreimo djn bolnavii cu afcctjuni oor(,ni.r,l !1..\Lrri i(:r : rr j :i rri i l x ( ' t ' , lir li : r r r r i Ii p c | re n .i l ,i l i ,Il ' te s i ]ro ,c tr,]fi rl j anrj . l rrrr.,r i ., t,,,t, lrrrrrc iri ovidtrnfti, dirrel.sc ft)rmaliulri ganglionare latolo-ce.rvisale si pliiir, rllrrrlo localo. Sinoolii propriu-zisi, se declanqeazii do obicei lrr rr.,r. i.ilri o irirrr1i orrur,l ologio plesifrcopali, apilind in colditii in oare clc).1c ii,lrr I rrrrlt, (l c l:r,n ivolul gil,uhri (comptesiuni in di\rorse circumstantc, iltl I)i!_r'(11,(,ir r,r r iisl rt| lrt.(,a oa,plrlrli la b5.r]:.it'.r,, miqoi,ri bruste ale ca,pului (rto.). _\1rcp-\trl riir( ol)l,l (,iilo rlc sourti, duati (10 -60 secunde) ,i poatc ti irrs<if rlc lorii1 r ulrii .lolricrr'cloni0(', cale pot imita pcr.tect o criz;, epileptioi. ilt, la,pt, rrrrr,ioliirrIr,Irltolnavilol no$tri au iost fuldrull}.ati cu dia,Enosticul ,lr. criz0 , l'rl ' t,l i , (1 ( ( ur J : U. ir r ; i l o p o t j c i u , 1 9 i 2 ). t $til.ro clr'o.pus. . ) .i:lin?lonrclc ?ostacceslt( e se c&ractcl.izeazii printr,o r'rIlrt ii {l(t (,ii ot'a nitrrl e, printr-o Senzaliede anxietato $i de mal.i_,ftl.i iista,}tic/ r,u rlulirlr'i {lc cit cva ole, pini la, citeva zile (tr{invieille, 1$,1?),tulbluiiri rlI r'rr,ri r,01,cl',nc}r,ozi1a,tc, somnolenti, prelungiti,, st;ri de depr.esie, i(l(ri rlr rl i ti ttri o t r lc , ( lllrrhr ir,(|r:t,so po1, Irozcnla manifestdri tle tip nal,colefl ic (_\Iayollr ;i ('hr,N.iogr'('s, cila{,i d0 Minvieillc, 1957). Turne.r: fi I/ealu}onth (19,1S) u,u rllir(.r'ir.i lsi :r,lr'r,ctui ou criderta elpului, ca in accesole al{r petit Ijral rle lill prlrrrl,lrl ic. S-au rnai descris 6i echivalerrle verliginoasr, ilccese cn tnlllulifl i ltl lliri o {lo r.c(]cr'o ulri- Br]u bi1ate.1.a1e. Weiss iii Bzr,lier. (1983) gi \.f.r,risr+ ijr lolrrlr. (11|110, ojtali de Cor{a,riu qi Bopoviciu, 19?:,) au individuriiizll lirrufl(J o('r'oblir,lo rr,L(.jhiperleflectiYithlii sino-caroXidiele, Dnnifesta,l,o lrlirr clizo rlrr ollrubilalc, tulburiri de volbire, atacuri irntste de sl.ibiriuuo , , . r l l ri ,l )|l ] , jlj : r lr . lr r t r r r " rrl u i mu s c l u r' , r' p l l l o d n s o I ' r.i t! ,i ntl ,l & cunrpri ...i r r(' rr ; i rrrn l l r r i c ilJ( ) ' l, idi: ll 1 . :!. .ll.t( lrltrniltstdrri : Il.anifestiirilc ca,r'dhce ci)nstau in tulbur.irIi ilr.r r iirrr r.:rr r li: r r .. . i lr r iur i[i ' i i i l i l n g i rro ;ts r' . ''1. (trilrtiil,r ila d,iagnos'tia t c hiperreflet:tir:itd!ii, s i.tlocq.roti(l,ie,ira lrol, sr. |r rrl |i r l ls l, f ( f l: t) I ! intt,tuslrr,rt,lt.l,( tl,eil.unSQ,re: rni;tltr,t lfusoir, ll cit,pului (il11ttrsflri da O rrrlIitrrrlrrlrillr.poi sluttlN,1,eraJ{i,) itt rttettcil,zli, ci,rlolc ort picldeltlt, rjoniiliierIloi. o ,\liIoIi lrrlliu|ti,r'i]o su(lced ulxri c(]l] r])r0Ftiutr (.('t\,ioa,le (gult.r'1rrr,rr, i silirrs, i||,iIr.iir|r,ir, r[irri.l irL tllr])ul bi,tlbj(r'ituhr.i, rlu,Lr[iil,ul ]irlor:r'l](j olot.lrit l)tot, r'rr r lr rl i r cl o .) $r lr ( lu} L r r l rri rrl i tl c trrs o (Ii o i rr d c rtL bi i , (l or.si ul Ii o i rr 1r,rzi (i l , ot lrrslrr,l icii) ; lt) Utt tLt:tu,tt,l. (Jt i.lt.l)ot'lttn.:|. t:i.t:slrt olrl<roiIcsl,o l'.'0 tr,rri) tskt tlr, t , i l ttczl tt(ir lr lt r t r t s t ic t t r z rri i /s l t,tt tr, I r iI )(rr I | ' Irtii I I | | i i l l rl cl j l rl o; c) (.l i rrrl,rsl ,rr ri r rrtl Ir tl rr int lir " ir t it t t ui I .i n tt" i ., n l o ri i ,l tt1 ' t)t l i , F i l i rl , l rl z(,l tl i l ,ti (l rJ i r\.i l i r i ::tt rol ,l lr ili l r'i {i r,r r r r r lit r r , lr r , r lri l i l i i l i \r,i T e l l l i \' (.i i r lr rrI\i { ,1i i l ,i rrovl rrl i r' rr\| i rrIr,.i | | rr, llll'i ; (trt lr r r il, l! l?l) ; rl ) N l rri l l r,r.N (\l ,r' tl ru l ,l i rr lvj rl rrrr{ i i , (' i nrz,' r)r!1,Lrri ,,rr : t : t {i
../Itu r-d-rr {l r f ( r i l l {I i t t t t 'g i t l t t r r l t , s i t t o r r l tto l i tl i l t,ttl t : :tI|' tr ''I'Ir Ir r ' 1 r r 'r i r r r JItL i l r "..{.1 1 ) l l i l xl zi i ( l r r l lrllill l {}i "i i r ':i r "l i r l r "tl r ' ( i \l i r l l i l i l l r ', t r t l i , i r t r t t o t i t , r ,tvi Il t,l r , r tl ttr ,tttt'

otr $i'rf.l)tl.lo .rrrzirt ittlt't i'ii"i,li,i,l,,r. t$t:t; ,.) Sirr{ r'itrrtr,;rr,r'irIrrtrI.Ir: rl,.r,.rrrl i rl:rr'r,.,.-r t.,i {"r i ;1.11 i. r,rrrrlr ,,,,iiii;;,,',iilltl-l:*i*,r,.i'rr r.,.1rrrrr,.:,

sllllt : lllr lr ' rrti tl t' cj trrl so it |lclit l' I t lt \ r 'lr lit t ' l' r ': r ilr iz: r 't l'it ' idic'tt'r' I'lrcilrrr.rt si'tr' tl' s ernn'ele obier:ltt;t'trlt lti1"rn llrLlirila!ii ' "urot ido lrL cal(11 prttct icii pr iir crrirrplo'irnca digitrli r se ,,i,n-"*rliiOiaoi ',,if"riil' "unei oN,r'(liruu'" utinic poljgr:lliu('1r,1.ri. sr._

r,ii.li.iliei, ..i g1r1r.rt'l I itl 'rmi'iril. r,irrsirirale.respiniorii Si cerebl'ale.Itroitaxea sino-ca'ro1 i rl ri '""liiixdiyidrhi de a-1i llsiurna cllpul i]rlrl).i. iii" ,, ,itl.o'ri iolicita,rea car are dfirl)t lrl lrrir'r'(' ,', ,J. si -arilor comlr'csiuncacarotidci llimitiYe' colnplclj rI'li'tr'1tt'' ;' j ,,, "tt"ii* mai pulin ldier i'rnrti nrlltl salr fr-ria ('rr(losr r l|l'zt's-Rueft, 1953), care antlt'nellzi - rc:i'c!ii.prin Lipott'tsiuno:l, ir' endosin-uzdi-t' lrrrtlr' rrrtz-iLli * 1]rorlxci. Prohl itrvot.:] rlc hipcrtlnsiLure ,,Iri: o-'-- ".."ui 0,'t'rsr.' (Ntinvi.jllc.I9L7)sau p irr pr'rbaluiY:tl'ir'lt;'

t'olfariu. 19?8): 1\' I i.pul aag*L tatt c{ 'dto'1'nllibilor fnci' ]a <lel:utul excitilrii' rlsifliirtr ' ] upoi chiar la o oprile cardiaci timp de 10 stttttttk'' l.Lo;tu;e';'e;;'i"iui, ,"^r,ia la frecrcnla i'o'mali' lllectrocardiogra'Ir. it'r'it'llt ;ll,i,i;;; i" r ""t:i"" datdrefte urui b16caj sino-atrial sru. atrio-vtll1.r'i(iull ia ,.iL'bradicaltl s prevu]f rr{r'nl(' r\ tlopinizarca pralabilX sau ld inistraJca de adrtrrlini' rulbrirnri. Ar iitra in ioc u:r rnocanism bulbar (nfinvieille, 195?)' consl,S,intr-o hipotensiune altoriitlil irKl(l b\ fitrut lttnsio-d,epresor 'Oe t t:l,rc s-ar d*tot'a unei va'sodilatafii g(trcrirl('r,rm"irtri "ud.i"utjdi", ta adrenalidi li o. sht inflrenlate d(*r1r'.1)itrrl i cdazii, i"-"it. joo iirl rrrl -o"itn*tl', ifriin i";lfc, t95?l Corfari[ [i ?opovicili, 19?2). Ar inira in (Minf ieille' 1957). uiecanism bnlbal c\ Iivut c??rr&l cor($Iulde tablourilor de hipelTefleci'ivil it'il sitttt j modif ic5-r'cattlirttr':i srttr ,:'rut idian'I (are nu |.c ilso!r'sf de rprct'inl-ri)c dr- adrr'tur'litr'r' rrt ddo atropilri sa,tt ,, rt.ioooi. ..i carc nu .ilt in{luenlaf 'l ,l,i,rcrvarca iino-crr.titljanil Iijnr.le{icrce(Minvieillc,19571. -A.r'rtili I.t trti. r,rfebrali, n fosi individurlizati' inci de lTeiss $i Raker (1933), rlltrti tltr t1'flris. UaDrs si Weiss (193T,cita1i de Corfariu $i Popoviciu' l1)?!), trrttro i ,,, iof'Jti rLou)itreiini .1in caiu,r.ile4e hiperreflectivitatc situr.r,rrtrrl ".i forlllri, tleqi llilvicille (19i7) Fi Corl lirl {11)il) rlir,ni, realizeazi' aceaJttd, llr ai.[tat cE,,de fapt, este Tot.bacle ccle mai multc uri r.lc folrru, rrrirlrr,\ liji autori ilaSeurl, in cadrul formel'r cerebrale Sindroanl(trf tl.r' lt ilrt't j,4ifrtrrtttl ('rt'('ir' li r,,liectivitatei, a cirot simptomatologieesto nervoasi, rrrutriicst.it obi(cl i\ e de Laz*. ilo Mjnvieille (195?) a individralizat mai multc Jomt' ; tlc pr,in rr'trrtrsc rlittti (rara) ^se caracterizoazil cet a,) U'anneLe ebraLe Pxrr(i li llJtlrl(( lL t|rtalc a s15rii tlc cort:lticnl,ii,piolderoa, totLusriitti lLlsoulinl', $0.l',iriiialrfsli,ltitrittttrr, d0 r,tirrvulsii ti, ()pjl(rllLio, au'icu lar'(',.hiu' zl_L,rrot. Ii rk' lt(j(1(rs(' lllitts ttctrlot'ivlr'1 il(l('s{'it, , tliurr1ro1' tr'1rt' do ti]ibrLlir,ri yt'drrtir, (,iir1)i .lliIXrt''tt{r\ }rrirr rltr.l. i(litur,I)lill rirrrrsrrtrri $i ,tiisc *i f1,lr, l)1.(,si'r'r,,
t prrrrl l s'Il i rtrrl t,t , llr t git r r , ,ll, t lr r I 'r lt l: i l) t ilr r llllt t it r ihLlilt l r lr '. ll'( lili lli( t 'l llli( 1 l l )b'l) , I lr lit t t |lr l lt |t slr 't r r r r xsr \ |r 'l' I i t ' \ ' i' I | |tI I i ||'| (I r l t lr '( llr r i l \l i rrvi rri l | ,, i i ' l l ,)(i rl rr ti I rrl rilr , |)io ( Nir r r i|illr , , llllr 'i) , ir r I lr u t r ot t lt r r l olir t lt t t Dlr t gir ',t r t or lt l l roi rti rr| ' vi rN ( ol lt 'l llr l{'lt t ',
:t:l i

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Iltlri,rrrrtr l ilt r , r l, t , t , n. lt x r l ; i, r r ,lilt t r . l, u i ( t t . t , d i r t . s , , l . t t s i r t r t r l , , ltt ltt,tl, I J):.rlllir Ir. l'r.Z;r r llr t , . l' r l. r lit r r r . , . : , , . , r , , iir r r l l l i i , t , {l , t i . r , r l r r r., r rr - I i , . I I t . | ( , . 1 :,t I i,r'ir rlirr\'l.iir.,,1, r ir , . : r r . r , r r lr r lr r i . i f r r lt r r i r . : i r i l . r., . ; r i r : . r , , r, i i . l r r l . i l l i , r " | | l1, .,r | .lr zi|r' :rlr. . it r ir r lr r i , . : r r , r t ir lilr t r 1dr . r L , . r t : r r , , . l ; , r r . , t , . 2 i , . : i ) . r t , r . . r l l r l r i r r \ lir i i"rlr,, (l|,:,t)' r ir L' iiur L' - s u1t r os iv ii lr , iupll s i i r . 0 {) 1 ) ( ! 1 0 1 l r n ) . {j l r r 1 ) 1r l i ( 'r ( \ , s i I )lrlr r ''.'\l.t1 it, Ir':r g . il' , t r l. CO t liiiiir t t lir , Si p t , i i t . l i l X , r , l ] , t r , : I f 'r , t r i l r , f i r r r r i l , r l rrrllr lllrr.

I'jiili i;li, :r';'trll*[rtf; *rsi11i.rtih,**;lx|rl: ;]ri;iriliiiffii i;-i,p"l#ii;t$tru**l,:";lf ;)'ffi

ii"'*u t lu tl' pt"'io iult ri trl ' r'irr'lir)' (l01 vilitii sino-carol,idiene .o 't'i p"o-i*iox a activ.jtaiii clcclrir"r lr.trtrtlir'1" ii'bi lr;t" *"prinde o'rJ.r'irc 'pio*

t"';iy:;t,ltiil'li'f,Lllr;.liiit

rt'grrlrrlir..rrrrl.lrl. rlir irrflrrx'r'ikruo.iirepl,i\ao'(i rti.'l l^ ,r'igiru,ri sirrr,,r i limp sir r.zlste l:l ilchcmirr,t\dati;ir, I|(i1' | . , I)(,i rIL I i I |(I irr rr,rrtrlirfi {i itrl(,r.

,.1.. )l,trli.li,<irilr Illiri it hiperref Lecth|tuteasi.,o_carctlidiartii. Jt)l.t,l,, r* *rir,rrg"'.1('l, 1r'ltti*lir,r in pelioadelo interditice sint cel mai r 'i [rlrrrur, rrlrrrrir,L, lrllilrv,ifiilc,, tUtT l Cor1a,riu, 19?1 ; Corfariu qi Fopoviciu, 1{t?:,}). ,,,ll,,ll ut l,ir lrrl ,siicupel0r,, la excltarea sinisuluf(prin corrr[r,ii sau l]l ll, pr.irr prin stirndarcm6canicl, ,'llill:'l.1,cil-!,1,.,1'xl,ulii,, rnasaj,.sau il.trr r,l'.l, ugrliu([iDr,li1, asupra axului carotidian, rcaliza,lEprin rii,sl,Lrirur, ilrrlR.,tr) rr':L,:rjlltt't r,..spdctiv p.in variatiilc dc presiunc cntlrrsi.rrzrLlrr 'lr-rput), irr ;rrrrr.or:rl,',:Lti0 lripor','rrsiu{ru cil, lcomprcJiu;e subsin-uzali,), si irr lripr.r. t(.r.rirrr,'(iiu,luiiij luse, prubl lui yalsalva), se pot obfin6 o seiie de tlc iirrli (.rl,llr {r(,:r,i0, cit}.e tost sistemat,__zate n[invieille (19bT)in J tilturi: r,u l,r1 de rr') I'r'irrrLrl ip ; uu ,r)ri,r'Jnici o modifioare EEG. Doai. sistemul crir.rri. i \,:r.,.'ii' ; b) AJ tloilea tip: arnp.lil,udinea riflnurilor Iilr '.il(. ol| | ll| llr r.:lzjL l i.i! tit { t c 0ut ||[ r t x CiLal ini gi Sc nO r m a l j z C a z L l a s t . i r q i t u l p I t | i x . l , 'nlcrcsii,.l | , r.i, iri' ir,c{-.l de r.iispuns tip 1,1,r!. EEG ; c} Al treilna tip: rrrodifici.r,iIr 'ri, r'.r',t,s'rt tr' m&i plu'utrfr,tc, l,raducindu_sc prin rdriii ale trils.rrLrr. rrirlrt,,rlii rol:rtr.,.1.952; .tIinvieillc,1957).Astfel, limp de citeva scclulllr jci. lr:r.;,'.rl :'r:rrrrrdil r,poi scadr.ampliturlinea,iar -drLpi5_10 gccrrlrrlrr rr|l :r'r' r' riJr.rlr'ii.ur,ll'\'ollrrle (to t0 ci'ri/scc si undc rtate, mai cvitlerrt,o rrrr lr;lirtrril', I'ttrtrirLl . d:lr .lrifu.lr.rulr.. cu o ur.olru,prcdominanln de prr,r,f.i,ru ., rlt.. t'r r'\(,r1.;[1 , /\,...il,, rrrlu]ente Sint la inCcpUtdin bAnda l,cl,a1 rr.||rrl ir1r.r'itt.so rr)rl,itn[1], odat5 cu crcDtereaamplitudinii. realizinil'rrrirl. fi rlrrlirrrlrr I,r'rrri, sirrrrs,idal5,. Oda,tricu-e,pa.ilil u-ndclorlente, bolnavut i4l putind lrrr,r'rl.r',,11ir..1f,,, s,i _l)l,eze'ta _citevaconvulsii. Unrielc 1e.1,. lrit, l(,_ r'|r'r'$rrlir -l() s'' {'nd'', tlar' uneoxi chiar 1-2 minute. ccl mai arrrrrsarr ,r.r:{;r,,' r'r.Lr,{io ct.'r'lugitiu intre ri,rirea ttaseelor EEG qi br:ldioa r.rllrr, tl:r,r 1lrr,rrzu, diacii nu depiqe;te 6 secuntle,lr,rr,oeul EEG nu srrlirrii 'r'rr1r.r'Lrr du,cii a,julgc lir,rir,tri, rlL]. ia 10-1b secuntle,apar modificii,ri EE(i, crxru .rr .r'r'ii' rulrrl u'rroxi.i ccrcbralo *,uzate dc abseuJasistolei ventricirluftr, rl, li :rr,lrirr.r.rr csr, singuta t,auzri, lMinrl.illo, j9j7), jntrucit cor.r.r,trlli :rl, ltti.l,ltrg,,l. r,r'lrrb. (19j4) a'r rqtrrrrtti, rnoclifjciri -E-DGin :llrar,rr1rr, ii ,,r'rr';r.r lJnr.rlr(,ilnrlll ;:r,ll hilrotcnsiuni ar.teriale.Aceste constati,r,i altrnf,$ ' \r.ltr,llt,ir, lot. lbLlrrourlollralti. purc, aliluri d0 formo intricate, irr rr lrr .r,;r,l|,rrtlu, irrllrrr'r{:"r, r',,r't,bta,li, diro.ctd, 1i.r,r,tOrii la, cardi:r,rr sau 1jonsiorrrr,l. 'I r'olrtl"irrll,irrvudrrt:lr,ptulcir,p_o.Ill)Gnuscpuuileviclenij, manilcxl,i,fl ,,1,,.1,r'ir',' clilr.Ii,it.. irr lirtrlrrrl p.ob.ktr dc .xcii:r,1li.sirLo-oar6tidiarrii (.Nllrr, rr'.rllr'.,l^l)fi.7|!')|.Ii,iir|,lU7l, l.9Zlii Liorlariu i ryi l:bpoviciu, 19?2). illllor ir|,,|r(r('||rt l,r'r,trir' Ir:r'Irirliir iiri prirllr!0 pi0r'rLrr.0 eotrril,icrrl,ii, rnirycr'l,r'l rLl crt rlrrI'iIll lrrl,o|.lr,l,isrrurLrr'qicil,trvll orr clolrii,rrtr sc i rrrrrgis l,rr1r,zir, rlrlgil,itrrrln l.rrl. rri rrr..Il,i,r'rl .ii,.rir I'ir'|i-rrrrrI. (Cor.fa,rirr ltrl,ovicirr, I1)?2),l)rrrrl ryi tt,tr,tt,ll,lr, lr,lxrrrr(li, IcrrIr,o-rrIiIrirrii, 1,ollt,l rr r'sirr rlilirr.ilrii, it,lrstrrrlit, |rrl,ilt rlrr rlirr trlrl 1i rlr,,,lillltr.lr" irlrrir,rrlrr 1;rrrrrIrolrIIr,.
:J;Il

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L'rrrrrrr,'rrl Jiirrrlbihte-ral sincrond,]tiina ae fapt idlentic'cu rirr,.{iil,i ,qi, rr" .lr'rr'(1 rzr:urc dc irlta natulir,. \ sftu Irodiiic.irile cardiace sau tcnsi0rr[|.

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pind, la 24 de ore)' e delir (Passouant gi Minvieille, 1954)' ""

ll,,,llilil:;;,l,,li,ij,,lli l*!:,,lii;,jllilr,i;,i'ill"llilll,, ,;l;ii;,1;lt,,i,i,li;1.;l,l:ill1 ,, ;;;ii,,i.i: i,

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\ rrIL i I|i r I r . , I I ii( ! . llir l r l o s i rrrg rl o rrrc ;tl i rr1 fi Ir,1tttrrl 1s9 i 1 { ,1!trl )1.(.ti ;111,!l At tr,rt , I)l r,i ttu strlr r ir ' : r r r r l, ir lilt ,rr ri s s ,1 i l l tl l i (l r, I l l i l j l ). (\l l )i l l. l) llr ( 11, r [ { r ! { x ]0 ro l i z i ri l i l ,l ;0 1 tl g i rr, i n (l rol rttrl (l o l l i l )(i rt]\(l i l l rl )i l i 1r!i ,rr s rr,lli.rrrs lI i r so .r,rr,r0t,irlilr,rr pou,to l,ratluco lio pritrtr,-un r0lIrr <lo tip c1t,r'(lil|rrrlrilril,or' (lig. ,12), fic pr,irrl,r.-rrnrcl:lcx tdnsi o(lcpl'osol'. itr unrikr crr,zrrr.i rrllslt rlorrir, lirlnrrt rlc r rlt,nil'os1,a,ro nutindll-se inti'ica,
COMPRES/UNEA SINUSULIJI CAROTIDIAN SII NG

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l r ) 1 1 ) ( l fi cl L l l l l ( r q i sl l 'i l i l ( r tr zttl l 'l . D U l l i i , c t t t t r i l l tl i l l i L l :r l :r l .r 'l l l 'l l r r l ' ( l l i l ]g l l t) s i o |\i l ,ttl i l r i r ,r 'i 1 r :r r :r r .Ittti t{1i l l ([i $ P( 'xl 'i u l )l l ( p o l 1 1 'l tl I X ) l i g f a f i o o t l ) l l i i 1 ,i 1 , i i .- i l r '1 i tIi I.tr :tr 1 i :r I :r l si tr .,1 ' I.r '' t,utiiir n u r l l r 'l i r l r '"1 'i * t i i I I t' ! t I ; r' I i i ;;l tttti t:t\ t:t.t, stttd ti r t . \ '. - i , , r " q i i t , A i i k ' (ort'r'r'irt, 19?1, 1978; (.lollir'r'rll (Gast*ut, 1t)"56i Oilcfia,ulL qi 51oic.t,, lutj;; g a si l l r ' 3 u o /o tl j l r cr tztt.tt Vo t"t l l ctto ( 1 9 6 0 / 3 l C 7 :.j i . l ) o r t .iFrno"iaiu,

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?t1*\t'$^^&4!t'{ry&+@
./.it. :{.9. I cflistmrc lolisralici (compresiunea sinusului earoLiCian dupi |ilx'ryDce) Ii bolnr\,ut C.ll., 48 dc ani. Dg, cr.izc sincopate p n hipclreflecli\'il.ntc sinocar.otjdian:I. Pentlu cr.izcle de pierdorc a euno$tintrei, deti IirA collvuisii lo i(!)-clonicc ti lir;r njci o simptonratologie preacces[a]d, a lost r.lidrctr)t:1 drelt epileptjci. lll clinica noastri loate invesligaljilc clinice \ i t , r r , l i l l i c e t i n r l .iv UEG .i I' F :b ) cr r fo .t n cg rti vc. C ompi restun, gtt,a l r j l o r o c u l r l i a i o st lr e g a tivi. In sch in jtJ p t llg u r a ie r edc cum_conl prcsrunca sir rsului curolidiAn sting (dupi hiperpnee) produce rrn bloc siu;atrial cu ( l r r r N l i r d c I s r c nn d e , In so lit d c u n b u fcu d e u n d e lente bi l ateral e, si ncrol l e similflre s-au produs 9i prin comptesiunea sinusrlui ii ni )rilrict, llodiliciri rirolidiln d r c p l . lla n cr r a Va lsh h :a a lo st. Dcg a tiYi (dupd L'ortori u, 1971, ( h r l a r i u$ i ? o p o Diciu , tg ? l si p o lo r i.iu $i col ab.,Tgj B ),

din uringianti. Ri1cy i1g42, citat rlo .-. l\. r9inccrpzle- net:ralgia ltlosof \Vr!,yn0, .11)01) ()oltu[olla (1OiT, citai de Coriariu, 19i8) au d'escrislsO;i r.ilri rlrr.rr':rr.&lSii gluso jr.i,t.,, taringir.lc (.u sincopc pr.in b ipersousibjl rr, H|llrs||tut {:t.1..r1.1(lli! sl.c loTmc . Ac' ; ,plrf iculare dc sincope intrtttr,,u,, rrr,r'r'rr,lgi..gl',solnringianLaccescduicr'oase in sfir;itc prin aciese sincoprr,Lr, Irilrr,r'rr.rrsilrililrr,t,c sino-r:aro lidil,iti, 6i prezen!a unui h.ig-qer zone, a i,iir.,,r ir r':r,(ir. irrrlrrr.rr .r,izlr, sincoplli. Dur.rilc alri in rcnnseuiolentecu dr,,rr,ll, {l(. :j(t..ltl,-s, IiirLrl r.rr,ntorrir,trr la.baza linibii, i n amigdali, qi in unghitrl rrrrrrrlilrrrlot', irrr.intro crize dc obiceri bolnavul nu:lcuZ[ nici'un simpl:ot', lriris|,ii I r)L rii lxrl nlrl i car,.acuzil dureri pcrrnanente,peste care sesnpt.it l)lrrl pr o.,-,ilruc lr,lgiilrYiolt:trtc,I'io_spontano, tlec]an;a,le deglntilid;i/'srr,rr fie de rl^ i'il,rr'.rr,z,rr.l'r' ilrcLyatn rlc glosofaringian,rle.rnulte orioontimirii. si rlilrilrr Ir'irr rrplr,r'il,ia, sincolci qi insoi;i1,e nu de convulsiii,rnico_.loli,,,, sfl,u i-l rr| si 1,rlr, i i il r,rrrosineop:l su declanqoazir i r I rruml,i la ,,nevralgia rl: inulri. !,irrr"(i'ir i.' si rr,lub., lt)5? I I?:iillu,s, 1lltio),d l d. muli;c o.i sincopclr pr1;fi rlrr.Lrrrsrrl,.l.in corIqutsiurL.:l sinutlrrlui cir,r.otirlilrr (|.'l,illrr,s, 1i Jg00), irrrprf rlirt11r11,'q,1,,,, rrrl'rlit.t,trrrrntoitsii, ll, sirttrsu]rri pot itrl,r'crtuxt so nocosolc sjrrrrr rrrr lrr lrrlrr,rlir,r' ryiclizclo ncvllrJgicc. rrrullo sitrra,(ii, trrrtirol,olniil, lllrl,a.l.lt,rrilul'i, rrolvulrrii{losrlinilrgil,lt ir, irr.l,r.t',tuprr rrt,izcl. rr,(il, 1rolrlo lilgicr,,r,il, yi rt,llrttili rt, lt,sinl,rrlci r.lr,trlirr,r,rr sirrrrolrci cotl;tr,r,siltrcrt l, lil sirllsutrl ,.rrrrrt 5i r.
r l t : l| l. : l ll)

,i"o"rloiii nroilcr,rte'Silu 10o/odin 10O de bolna'i cu sincolo, itld',str1i tl. tip 1-aso-ragal), anomalii EllG de tip epiieptic' rltlrrr'L(ltr tri, I'nregistrd'tile potigrdfice pot furniza- clate pre!io:l's() lu 'iar -Inecanismele carc concurS' h instit'irlt rrrr' ,tia,g";sti;, ryi ref'erit6ar; la sll]oopol, i. In.reaistrarea accesttlui,oste posibili, foatte rat, dar clnd se lx'irl'(l Ir-r,ce. tlifdrentiazX, in motl net aCcsul slncopal de accesul cpilolf i(r' ie clirerselor nrcto'lo de testalr rr p1'rl,cticarle& 2. lt .faBeleintercri'xi,cet roncdr rofiexogelre (testle d; compresie a glollilur oculari, de corltpt(!$i(l caiotitiih,n, netoda Vtlsa'l"rr') pot surplinde po poligli)'rtiir' ,r" ti"iu.if"i liincrrettcxiritatea zonelot reflcxogencr evetrtuill chiar s5' lptodtr('ii' irt iaborator acoesul sincoPal. se a,\ Test ta'eT refletului aculo-card,iao fir,ceprin crjmpresil gkrbilrrr' 1,culi.lii,ur rnirin{lu:se p0 poligrami, actiYitatoa ECG' re,spira!ia' 'I'r\- 9i.l't:t'' i], testind roflexul oculo^-cardiac, ol)l'irrrrI i,lpC. L.tf"t,Verceilefto 1iOO0), ' ""ot ,iin 33 cte cazuri cu si[cope' stopuri ca,rdia,ce 2 -9 s' cu de lo'iz "lil'r]rtlrr$ $imotrice), iar lt!.rrlli li'n O lncomptet" (unde lente dihterale, sincrone $i li3 studiali;, stopuri cardiace cu ,,ri'spuns EEG cotttltLrl')l l- t oi"r"i toi" ""i u*de Ieutc cripate tle pcriuldc de -dePrr:sieeloct't"gr':r'lir':r) 'rrui"uii cic globilor ocrrlmi Lr 'l() rl.' ilr;ui t Lf iOr utilizind iretoda. cornplesici ctL ritmului ctr'rrliac mai lrr[lL de l0 lrillii P'' irof"ot:i. J, obtinut sc l:rea ii, io*t" cazurilc, pauze pc ECC cu dun'ta dc 2-3 -s (Ii'ri rrisprrtr'r "'i""i U 18 cazuri, pauzi pe ECG uai m*ri de 6 s (cu.ulde lcnto ltila'l'r' llnei !io"r"o" Si sim-otricclre EEG) la 4 cazuri, sljoluri caraliaco ntli tttrt,ti "nt". s (cu undo foerte lente bilaterale, sillclone $i simetricct ul'lna'l.! ,l,r iii -(l(r instalalea piorderii de conqticnttr') la' lllli li "uolu,tirrr,i"otraseului $i de i16lna,r-i. - -i.,a ele bolnavii obserYa,ti loi (Corfariu, 1971' 1978; Corlariu usilhltoi, a ticlu.'igfZ. l9?3) s-a obtinul' prin testul dc cotnpresio globihrr rrcrtliLt la 47 o/o di[fie bolnavi, cu alur.ir tlrr lrlrr.rrri , reacr-iedi oprirc cafdiaci 2-3 s. I.ta unelo cqzuri ann evidotrtil'li bl)lrrtrt ^ri.ro-otiiat" cu d.ura,totle iant", la intervale do 2-3 s. ln cazuistica noastl i'i' Iru rlrrr ;;;i;i; 'accstei probe, clenivcliri tcnsiolalo 9i nici IJrlttttrsttt'i -iu "i;; ,,f,*"."oi, it""*,'sul trr pierddea c6nqticnfei, ca in relat5'rilc lui Vt't crrlhrl -.,ro,noi'i"; uuG cu (19?1' 1978) gi Cortariu 6i l'r.rii.s-ooi- iteatttoi. Gasfaut (1956), Corfaiiu rlt' EEG csto doloI'milrrL{iL i,.rt:i.i" irszz, isza) au c,picciatci' ,.t:xpresia)' cu Asitut uri bl,rcsirr,-:-ulrial tlltIaLAstlb 6 $, trrrlrlixlili{ ii 1i,,,*i* ^iir,otti. schitnb o rlsisl,olioruai rnato do 6 sr prodlrco lr{1 l'r'ir'r'iorrl ia'r.r,scul EEG. in gotroralizal;0, cilro oLos. i1 ilrttltlitt-ttlit't iiiJC lr,rt"u.i rlo *rtrlo 1,IrIILII.rLrIItir, tltl lJtt tirrrrtItttItr, n1',' tlludiltl tltr, durill;ir' 12--1'l tt lrrrrr rl.o,ii,trvrl iiril,,err.s irro, l;ii $irr(jlrtlro sitttirl,t krtrl,o lti[:r,l,ortlo, rlrr rloscrilrr:ilr rrrrrkr ,ii,r,irlrr,r:itr uo lt)lC(.1
I't'i l ,;Io ttItIt,I I t r I t I i I i I Ii t t 'tI ( !i !l ( r i l to tl t'tr l tl tl r l r tl l l tt r ttl I tt r t I tl ', r 'r r r ', l 1 , r t i r l r , l t l lr l ,i tl t,tl !i t , , f i r r i , , i , r *1 , , , , 1 *t,t,,, to l '{l r 'tl , r l r r r r tl tr l ;l .i ttl r 'i ,. l l tt l l r l :l l l t t'l \l tl i l l ( l l u i i r 'l l l ttl l r i i tr lr

./141

lctrl'0s-rr, I,'orlus dr|r"r'_?-l0 $(1(,utulc, pi,";.t,,",ro rulsiill,,i s-1,irrs1,rr,t1r; iru iiiir rlrrpii,. .sistoli. va'i*bilii fintre 12 qi fS s;, i'frurc{,ic t1i ptirt,ic,I*il ii,1ii. oilollrrtorti alo fiecilrrri bolnav. b) Oonlpr*il,jrea sirtttst.Llui cttrotitlion,dnpii cutrL un pl,eorzil,ti :tnto,iot,,, r lrrirrllln tcstmrr:l re ,ctiviirilii lcr,sl,,i irnpoitante zonc ieflexog"ui., lirtli .iislrLrrrrn.ile rt,Jupra, activititl,ii ti,rdiacc, a;f-.1. Ui a't.ai.irlrii 'lrlilrrt.e 5{. poL r',rirr. trr lti.t{.(,ilzllr'i olrLin(. lnrogisLrijTj polig|afic,.ulo urrUr.,.r,izo sirr,-r,1r;r.lr'. \\',.isr:i lJlk,,r rlb3l/ &u lnr:ri ju,jir izji ll'..luoo r.llr,r,.. !rr.(.izati.ir, r{') rrirtt! I r) t[,le;.i lt{,1] sinusul i carofidiAn tru prodUcenici Utl lJsl $ rr,rrrrtrnal, iu,r'ltr, rostul inclivizilor, rcrj[str, cornpres'iune i,'tluce o braclici|rlitr rrr','rl(.rrtii 1sub.0bdthi/;rrirrI11ili r.alorr.-rinilirla) 5i o scnrJero ,1,..\, d! u : r, ll, |l rr I l:i- lalii jnilirli. l 'l{, irloJrea Irr schimb, la bolnavii cu hippr.r,,flt.ctir-jtat siro-corobicliani, mns*iul c r,r-.,steiregiuni anl,reneazi o serie de noditic5ri, rliqrt[ y]]l!]^"!l"l:"1 ):,:ii. irI|rr lUxr(:tzlr, j('ille. 1957; Corfariu. 1971. 19?g; t 1_\tr.o\ urfrriu ;i'J-,,prrrr' rr, 1972,.t913i. 1) fi,. nurnrli rrru,lirjcili ECri, firii mudificlri ,t-.Ei;: 1,.) ite .1..r-'ortrlrult'rttl(jc, ins{Jl dc apatilia de unde iente din bancla thet,. r:hiur delt:r,,po toate deriyatiite, carc c'oincid cliu punet d;;;ii;;i;i,l r rr iordu] or, cu Di,l blnlei tinrp c1e -30 s, clar cu pirsistenla modificiriior. 10 .[, lrjirl(i t"l LLe 1ir(.n 1-2 minute. Rezulli5 ci, Ia bolnavii c. hiperreflcctivilrr,i,t'r,i rru-e:.ro1idiitnJ,,comp.esiunea sinusului carotidian deteiminX, itilcol)r i.i( rr,'id.liciti ca.dioiuhibitor \i nrai pulin ii cu scirlor(.ib 'blu{.ul 1.,-rrsirrrrii 'csodep.rcsorii iiriorirl(.., oxperionrl 1rr sin6-airial O"ntan.ai',i .nua,strA, ir,v|l1, rtLrr';tt,' ]-i.trubile (itrtre 2^qi 15 s) Di a fost faTorizat de hipcrpueoir, Modificirite pEG sirit crependentenu nrmai de duratii, *isisto|r'tr.,labilii'. litri, rlilr';i de uncle reactivitiili indir,'iduale,in sensul ci, la unii bohavi irrr apii,rut unde lente biiaterale, sinerone Ei'simetrice (mai exprimatc tx) rh.r'i.r'ir.liiL.&nterioar(') o asi"ioliedo 8 s, in schimb Ia al!,ii;io ti;Ii I dupa rfll(.r,r:r..t. rlc l2-14 s (fobdcaunadupd hiperpnee). lU (.j'|rl,riu (1971,.1978)ft.demorstrat ce dcncrvarex, iprio infilrrrr{irr, ir.rr(.i1.{.,,'ci) a siuusului r.a.or idian a coudus la suspendarei. muditicirri'r. p.ligltlic. ltr, compresiunea sinusului carotidian, in-clusiv cu o desincrlni. zrrro olocl,roencefalograf icd ipsilaterald,, ,;:) Maneura Yalsaloo paate induce modificd,ri ale dinamieii circul*ttirji l)r l cr'o$tolea_presiunii intratoracice, cu aparilia de uncle lente r,hctrt. r|rlt,rr,yxr pHG ;! ghiar cu decianqarea ile accesesincopale (Clkfi, i:rrrrrsi -traseelo Sr6i11r, 1963; Sbcrpey-Sbater,t953). ( orfariu 1lgi.l, ji?xt *j t.rl;rljrr fi Popoyiciu(1C72, lgZJ),pracricinrl manerraValsaira la Uohiavi , I snl ,rl,n ul.fosfalice. ]a-mieliunc Si la 1,llse, ob[,.inut au pe poliliralnr.[ trrrrrlili.ili drr Lip n'oOibilo[, cu instalr,reaunor b]ocuii sino-atrilrlr, rt{. Hrultr-rr "rtO thrrati, (B-4 s), .lar {H,r[,modifici,ri EEG concomitente. .l,rr, r,lrrl{r(,irizul colcrtilLrl nostru a rnrarcat ue$terea T.A. cu 60_g0 n}m}lg i, Irrl'ir, drr r.rlloaloli,-injtiali. Sciiclerile T.A. in cursul manevlei valsalvrii lr\xlrru fi roac!;iikrhipertensive ap5,rut dupX sfirqitul acestei manov:rr, s nr\'ir,lrrJrro('r"rl irkxxl cii aooasl,il nrrl,ncvrii putea infhrcnla zonele rrfhiro. ar gr,rrrlrrrrrrsrrnsilrik:, irr cir,z l igllscnsi lrilitalc,pot lcaclktna,irukxrc&r'o, dc ri(lr l,r'rrrl,r'-r crrrrlioinhibil,olio (Corlar'iu,J.f)2J., 19?,$; Oor1llIiu 'rriliviirlto Ir llfl)(f! ioi , L!72, l!'l:J). it,l:l

Itl rl i t t , , l: l r : r lr jr lll rrrrIj rr,r' i , ,I r,| , . r1 ,. rrr:rri rrrr rrr. 0 rl r. r.' .I r :i I l rtl ,l t | tut' c sc r.r,i I. si lr,lolr,zii, 1,r''.,r0rrl Ir)l!(i rlri brr,ziilr)r'lrxLI. lri.,,.,nrL,.il.,r,t,,rsir,.,, l,pa,r,r{,iir, rrrrrl.lrl.

,l:llli,i',.rfl,.,l,r''r.rlrLtirir, r'r.rr1lrr, biilirilrr crrr,rlrrlui, rllpri,t,ir,rrr tlirr.t.rrl ljl'j;j',,1:. ;rr. rrjrljrir'rllIr, rr(.N| rrrrrlr'lrr lr.rtlr'. tl.r,rrllrr,lizlr,ir,, itylt,lrsi, ssrr,rlii,'.irr r,ru.c lrrrpli.

1 :1.I .;i,:!.,".in . I 'xlt llt t r 'dt

r lr t r 4t l*t t l li. lt , t t t t ! . ial. , it t si, t r ult l

\(r' l rIl tto: r . : r ', . r ; r r lr lr lir r . qi lr l ; r lr I l. it , r r llr I it r r lilr r r ': r . r , , , . , 1oI. izr . . r.r (i ,ri ;tl t r . |. r c1t t lr t 1, , I |iI 1I |iI ||o|I |( |r I i1,p( 'r r l, r , rirrr sr rI rr .irIrr I cir . r I I llu tr. (j . .4. !r I,l rol rc \r' r' l l l ri ' l rl/ jlr , t ir r , r r : r lr r r r I r 'r 'j; , r , r r ,plir r ilolr r l, lr t , r r lir , l,iir . ii,r it r r 1r I or r r r r zr jr I t (r| r l rt' i i i r,(t(f{r$t[[l i ] \'( |t ||, I I 'LIlo: r r , Pr r r r l|I t , '|ll{. Nli , i t l'r , I , i; ii111r ; 111I . t ) lr i|r , i l r lr r ; ,

.irn pallet Dolnavului $i/Sau A apar{indtorilor, poate lrr,liL h u {,rrriLI0 ,lr!gn,,s] rcX, srnco]Jcte pot fj Conlundalcindeosebicu accoselr. ,.1jlr,1rti|'1 rrkinetice sau a,niotonicu, dar (in cazul coexistentci convulsiilor- toirioo,l,lnice) qi cu clizole upileptice grand mal. Existi-totusi ulele elclncrri,rr i,rtr(r pot fi utilc in oricntS.riledi:r,g-nosticuhri sincopit.(Gastaut, 195(ii dc -Popor-iciu, t'orfariur. 10?1, 1978 I Corfarit ;i 19?2 ; Fopoviciu ;i'cohtr. j lll?ti) : chiar lu sincopa con.i-ulsivi,, faza tonicii Si jaza ?Ionicii Jint, rrnrlt, rrLli scurte si irrai t stonp:lte, iar dup5,epuizarealor nu se ingtalcazi, currlr, cale este (rlra(t:criolici l, 'jlcr'rtrcJ. acce\rrlui cpil,.p.ic.l,rcsigur., iic irr|r.qi;. 'ririlc EE(i. sf:lntla.r.tl. rna,i drI ales pri,r actir jti, plec m qi iil,r.girir,,r.r:i1,, ll, lr{ralr.o (ln',luSr\, u lc.iarcc toDelo.r reliexogcne) ulucidr.azidiir.;rr,,sl i_ lrLl in marca maioritaiie a cazurilor. . 2. Acceselede hipersotnnie cu apari{ie brutali, qi de s,rurti, tlulll,ii, sr,, lot confunda uneori cu crizel{r bincopale. lnrleoscbi narcolupsia cu 1,.1it,,*lii, 1umplet5,, cu ataclri cataplectice, cu hajucinatii'hipn*gog,ir,rr ryi , rr lrrclizii.re,specl,iv p|ei na.rrj croii alodiagnost Lrar,, de sonrn la, ic. rc"isul ,lt, ..,,r,,i, rrirrcoltlljc lI{' o dul'trti rnr,ilu_ngd, clrcurrr,,tanlo apari1i,.Di crr ,,t,,r,,. du .lilice qi poligraficc. (inclusiv_ de-orgalizare a iomnuliri;, calc l,rarrqoir,ri, rli:rgriosticul(Pop-oviciu-li colab., 16?2, 19?E). Mai Oifiiil Oo rlif0lr.rr{irr,t, r ,iiu uneori accesul calaTtlectir,, al,unci cind sun ine izolat. Acest ilccls r,lrl:r 5c. pri-nll o p.rir l,lcr'1rc ctl'acIetizc;tzd bu\ile a boj:rartlui. c[Lo I r , I ri, .,.i Ij I j , r.prerdcl'rDrulttealonuSutuimuscultr.inclusiv l)osluraj. logttri rlrrrrrrrli ,,r'i atc(l[v-eJnotio_nali. lnsd, spre dcosdbirc aecisul sirrrr,;rrrl, t]e .de.factori |lr runpul &taculul catap]ccLiu COnqlieUla CStepr\TlC,1d, C.(,acu (,(,lrIt.t,ii. ,,,rr \alid semnde dilgnosfic difercnlial. Dcalrfol, iffegislrirljlc puligr.:rIi,.,. ccrceta tori (Elishikarva cotabi, 190g; Co|firli ,si. "locttratedc::unrc-rogi ;i l'opov_i.ciu, I973; Popoviciu 9i colab., tC72, lti;g $i allii) au dcrr,,lrtrr;1, ('ir praougrea totuSu.lurmuSculu,r.S,.Ju{cc decurs in de cilIvir, s|r.rrrrrlr., tiind :rdesea inso{ilri de urjF.ar'i oculare ,.a in sonrllulRE,\I, Iiri rrrurljti,,rrli ruporianl,eale alior pararnorripoligrafir.i,sprc doosebjre r.J.iz:r, tlr. sirrr,,r inregrstrtr.ea p9]lg1afi9d apar modificdri IIOG, ,kr lll.A., |rLtal rn carc p_e^ Jrlccum qi modific5ri ale activitilii EDG (untle lente ditr ut jr, ,", ,,,,,,i .rrrrplc), concomitcritcu pierdercacuno;l ;n1{,ilColfaIiu, JC?i, l t}7rt r'rrr.. 1 i.'r'ju li Po"poviciu, 1972, t973). Cit rlespreparali ziil.ede wmn, &c(]steaau caractcre r:linice qi poliglli l.irro ,'u,l'lcteristice,care lranqcl,zii diagnosticul (Oorfuiu, 19?t, .iO?Z .l,opo_ ; r iciu qi colab,, 1072, 19?8). q.ltutu,l,u.i, 3. Crizek:iic cirtlcratlin ou.rsu.l ]ll htii:n, itrs.{,ii,. r.'r.'r,i si tl. : i 1,r,.tr! i rln l lUxr[1 li.r,sr' Ir,l rlilr,urrosl,it,rr, ,,rr rr\irtritifi, r'rorrlrirl,rrl irr I,rrllrrr
rrl rl " l

{,) r,n:unnrzi, prrp.,tl, .sau o relatare inexactX a sirnptonr:ll,irlogiiri

l . )N pi .l ,t1 t : : . iu. zir r lii, r r , I r ,((t r I I r ( ) : |,, r r , , : r , r '. r 't p'. r silcopoLl s. lxr t . , , f r r r r r lll . :rrl l sea. l :)str' ctr r io; 1r r , llr r l lr r r lir r ir r . slo: J00 ( t ( r bolnai. i invcii, iga! ; i r lr r r r oi, ,,lt ruTcllc lurmd rto iil]l.,)J)r't (l.oitr il,lr'o)iirMtiv 5o/o au {ost indlrrrrrat,i crr rl rr,g)l ostl cuI cor ent . t lc. sjur . upi, r est - ul all f ust djl}, Sno. 1ica, 1 r f lbr r la1or .lr l i: l, ? ,l j \' r' rrcl e.sorri cji polir . ) iline, dr cpt cpilr . pl jcj, ceet ic culjnor ( li ; i , . r r r r r i, , l, . ,'l,surla!l a1e lui.Gastaut qi Broughton (19?Z) si ale lui \-v-ayne (11)(il).

343

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t t ttttl I l tti I | |I |(| i I i i ]Ii,I iI I i I r : lx l z i l ,i o l l l rr rl l t,l ttt , l rrtl tl l t,v tt l rtcz.rrtri o l rl rtl .tl :i Lt ;' I ] I :I I : I t (N l l t' i l ' i t' l l 1' l (rl '' l l l rl l l l l l Itl l, l l i tr nit t lt lot r ' r t , rl trtts ttl tril l ru s (l l l l i l rr Ii i tl tI p t' r' l i rl l l ' (S trcrrl l ,ol l ,l ,o l rxrl rrr,rr trl rt' l t.t ;i ],rr,. , , ' i, , i. u, ' i, r . r it . $ i v o rl ri l c u , ri i i ,ru i rL i rri t (i trt " (' v o r,1 . I iU ,u r_r' ,j .9 U 5 ; I' o p o v i c i rt 1 i col rt' l r' , l 1)(i 1l W i l l i rr' trts 1i r1 rr; r i, i, lu, t r Ni l ' l l ' l (i r ttttrroti tLrsl ;ttl tl o r,, tl , , L . iir r ; : : : ' O or )' r,ri ri , l t,? i , t9 ? u ). l l -o d i i k :ri l i Itr ru1'rrIitt ,",ll'.,-ii*'u..i"l,tt-ir,s,iiiclcri1,1, vortcllrobazilrrtir il'1it'r rrlui rlhrs Ll i ri ri tr.i rrn i n i (P rr,r rti r:i Lt;i c,' )rr' l r' ,l l l G0T l l rr.' r' l .,'i " i' ii' iii" , ' li" t io. ' i n o ,i u a p a ,' p i ttrrr:gi sltrrti l o l ' l l ' l (; :ttl i vi i j i (l ,,,'i i , r , if i' " i" , t f . f " - l. rl ,e l rro -l ra z i l rr' ,

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,r, t ,.rzu l'sin uu pci ac es f e anoD] ; r lii l: l. l( l lpJ l l n t t i l r l l r i u r r t g l i i l . l r '( '& : l i ) l r l r r r l l

I A IE'.

(TULIIUIIARI PSIHOOROANICE TULBURARI OIIGANI(;) CU DE CONSTIINTA SUBSTRAT

I. Con;tiin!g este forma cea mai inalti, de teflectare subicc lumii obiectiye (Dic{ionar enciclopeilicvo1. 1' 1962). Ea cuprirrrLr tir.i, a cunoa;terea propriului eu qi a mecliului ambiant. Este facultatea rlc rr, gintli;i a determina raporturile cu re:r,litatca inconjuritoare pe baza rtflt'rr td,rii realiti,tii obiective in gindire (Diclionaml limbii rom6,ne, trl.ii,ttr:r, Acadcrniei R.P.R, 1958 qi Diclionarul explical,iv al limbii romiino trtli{,iru J9?5). Starea de congtiinll este sttlrea ,,cle a-qi da seama clo tntirlitt 1i r1e sine ilsu;i" (Cobb, 1958). 2. Tdburdrile de conqtiinld, sint de "d-o;1i ca.tggorii: tulburirli tlrr conqtiin!5, firi, srhstrai eyldent de leziune anatomo-patologicil' (;xrrr,to avea tulbur5ri enzimatice, biochimice) cum se intilnesc in patologirt psi hiatrici, care nu aparlin probiemelor noastre de neutochitulgio, irrr':ttt tuiburiri psihice date de Ieziuni evitlente anatomoptttologice. Aoortsirt,rt, losr nunritii lulburere poihuorganicJ,care ue preocupi. 3. ln ce priveqte substratul ana,tomic a1 conqtiinlei, 1a tcaliztllcrt r,i p&fte toate structurile cerebrale, unele fiind de bazi, cuttt tiitrl : cut iau texu1, nucleii bazali qi trunchiul cerobral, Conqtiinla reprezint5, ult pr'o( (\H complex anatomic, fiziologic $i psihic. 1r. Tulbur5,rile psihoorganice sint de diferite gracle, in lnnol,irr rlrr sediul leziunii. 5. Orice leziune circumsclisi sau difuzii, a creierului poatc dol,ot'trtirur, psihoorganice. Tulburii,rile de conqtiin!5, datoritri hrziurriLu' tulburiri cerebrale pot fi grupate in tulburd'ri rle conqtiin!5,specifice localizir,t'ii, liiirrrl rlate de leziuni circumscdse, incit in clinicX aceste tulburlri siul, iirkrsil,rr ca simptome pentru iliagnosticul tle localizaro (moria, ,,antriebsnulttgr'1", sindromul Gertsmann, agnozia spalialE etc.) qi tulburii,ri psihicc gk-rbllo, oind leziunea este intinsi,, tabloul clinic fiind totu;i specific in rrpor'l, orr loziu nile etajelor encofalnlui intcrcsato. I)csif{ur aftsto luzirrrri difuzo, pe lingit, cri, dau tulburlr,r'ipsihico rrrr init,, poi, itrclurkrli.SIi-4.4, alc ciinri tulbulr1ri vol rlrr, <,:llaotclclinio llirrr,rlrrf o corrrporurr rl,r'1, plirr trrrrlificttrril irr plrrrr lulbuli,r'ii do cunrllioufil, l)itr u,r,rrsio i1 rrr0t,iv0,:l,Pnrrr,Prrrr,rtlot'ii urrcrri rlroIi, trtllltrt'ir,to c0n,;1,i0nlir,trr'irr0 1o(,i rl0 trr trjrrrlnrl tlr'$lrr(ltrir,ci1, olt,rt lol,it,lii rirxl lozirttr,:r, r,rt trrllrrrrirtrrtrrrvt'rt,xinli[ 34t'

T trt'rt pttt'tilllli', tllltri,Itzitlttttlt, silttlt,fii (trotrrii) rrii rrNlrt itt l,rrrtrcltittl otrtrrbtill ,si (''rlrlll/i', il,ili sottttrttltrll(ii,' rlrrlrsrrpll, tnozottco{illulttil it,sl[olittcif ittglttlllt' Irr,{irr l,rrIbulrit'ilo 1rr lrrlr{ialr dc cot16tiicrL{,ii. ilo Arlrsl; pundr do votlcro nu trste coloctr dtxlattrctl1,ullrur'ilt slts-l)l(tlcit liorrrlo sirrt lulllulrili t1o conql,iin!:iI osi,o a'dovai'rat itt utrttltr <litztlt'i (rioln rr()lonirir) cxistir,6i o cornpontlnti' rninirnii do tulburl,trl tltl cott;i'iclt{,ii,, fiintl insi, tulburarca de conry1;iinlrri, rn:r,jolir, Irrrr'|,ici1rir,r'ul, Arrrsto sintlroarnc sint foarte elocvente in lcziunilc traurnatioe cr'ruii(l (|r('olirliccgrirvc or,rc sc Iemit. Cind bolnavul iesc din comL, leziuuilc siltl, irr cnrislirrele cerebrale pinii in regiunea mezotlienccfalici'' I )u,<fr, loziunea din intreg creierul este pini, ileasupra capi,tului rostral rrl Llrrnchiului corobral per;iapetluctal duce la instalarea unui muti$ur lkirrrrtic sau h, sindromul de d.ezaterentarc. I)l,cii leziunca r5,nline cantonati, in emisferele cerebrs,Iepini l:r zona rrrczorIienccfalioS, apare,,staroa yegetativ5,". I)rcL lcziunile de intensitate variati, sinii cantonate in emisferolo r,r'r'ollale, inclusiv nucleii bazali dau sindromul cliencefalic. G, I)acii, Icziunea este in totalitatea, cortexului' in general provoacil pdn fa,ptuI o rl'ru'e tle agitalie, cu iusomnie, confuzie agitat5, sau anxioasS,r lri, iul,rca,gaactivitate rdmine sub controlul nucleilor bazali Dial trunchiultti ,lolollral, ;\dcseori, in diferite afecliuni, procese infeclioase' procese itrlocuitoaro toal,tJ rlo spu,fiu, traumatisme cranio-cerebrale etc., leziunile inte,reseazd, cclr t,roi ctaje ale encefalului - cortex, nuclei bazali, tr"unchi cerebral 1ap{;rarrr du"cela realizarea unor sindro'ame combina,tA lsiniiromui apalic), l)rrcori, intr-un sindrom pot fi implicate tliferite etaje separat (hiperkinezio r,rr Iogorcc, rigiditate decerebrati,). I),r1,orii,i, legii biologice, structurile anatomice cit qi funcliile cerebralo loh rrrir,inoi sii-t lezato p{i}Aqle Si cel mai uqor (cortoxul qi vorbirea); lrr ,,rrzrkr t'cYcnire (tlc la trunchi spre cortex) ele iqi revin ultimele, persistin(l irrcii,rrrr 1,imp dupf revenirea integralS a celorlalte funclii (surdomutitattl' rirrllornul vogelativ prefrontal tiescris tie Ttinnis). ItiNliitrrr][r,i ios aceste sindroatne Sindrotmclc generate de lcziuni Ia iliverso niveluri ale creierului /1. l,czi[ni situats in partea supcri{)r,r'ir, trunchiului cerebral a ll. l/{!z.iuni in siLtla'hc nuclcii bazali {1. Loziurri sil,uir1,o coltex in

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(l(r rkr;ti sil'll illll)t'(lsilr ill(x)llijli{rl11il' il(r(l(1llr(rlr('i', lxrlrrrt'vii rji rrlllliHllrlll (lrrfil' ltol, qi ll', I'irrrltrit rrort,sl irrtttilil';i rkr a'llii (Ort,itrrs trol. pctlrtl''crtttill,iottfi. iirrl, 1f}(is; $dn)i'i, iii (r)1. .ll)(i5 Ifrlyattrl - lltttrrt,T,tl I ll).1 lll{i!; Skrr1l,01,y, l; (,slo cit oxislit,vit,rir[1,ii lit, thitxrzirt ir(lov l,ir, it,r'ir (clriirr do liissirl l..irrol., l1)(i{)) itr 1r:rlrrlizic sottsulor(lirlr,r al otrvinliului) ;i rmrtisn (sart tloilt l,Ionitr)IItri hipolsolnnio situ obnLbiir Lrrlbrrlanrolalil tle corr;liinlii, (sau doar u$oa'r'ii, lrrrr,) pi rri, la,o sirnpli'l apatie generalizati, cu reactivitat'c bun:i h exoita,lrli. o { l(ilrx;lirilc rroa,slrfa mai ari-rtat c5,,de ceic mai multo ori, dupai, 1u ir, iln qi lrrlrr,lrrl' I{cmpcr qi liomanul (196?), XIA (in folma clasici rlesclisil,rltr t lr,ilrrs si trol. t.i+t) rcprezintil un sindrom tle ocluzic a al'terei bazilare in tulburili rt" por(irttti sa rnijlocil.sl,u joasi. la care unoori se pot asociz' r atinginrl (prin" leziunea ialoi,ei pontine qi/ sau .mezencefb,lice, i,orr1iiin1,L
(l t' i rr' Lr1.1r . , 1. . llt i l) . lr r I ir , z. ilr 'r lilr r , r l. . i ( l'I ii, r lt i r r r r r ll. siPliir r r r r r i ri tttt.tttri Ii r,l rr r lr I r vii c sr r ; ) I r t vio( , r r ir .,or 'r , g ,I ,r , li r l'it t l, r 'it sor , Lr r r , r , iiilr t r r r l0 l r r , lr r r l Itrttl t: sttpl i nr r lllr , lr slr , r rr , lr ilr r r r r r lilr r r : r lllr , rrrrrrrI Ir I i I i I .i I I ri Irr ir r sr i, sl ir r r r r lii lir t i zrl r,l i , a,rrr lilivi silr r nooicclll, r vr , ' l opogr' : r , t ia inlinr kt r it r r Lt zir r nilol nu llr r pr r lr r l,licr r r r r r l i{r r r lir r csir r lr ilill , 1i . rl t rol :l ti vel o put ino la, zur i st ldial, c. Au hisi, r lt , st r lisc clt ar r r i cu r r r lir r r o I.zittIri neocolticale. So cilea,zii cazuri crr lozirrrii t,rt..nsit'ir srrlr..r.i i.irlr,, rllrr cu crulat'oa structurilor. trunchiului cetr:ltlll si inr,crs rrr lr,:rinrri rlc lrunchi sau cu r:xtinse zone isr.hcrrtice tut iii,Lile s;r,u srrlxurr,l,it.rr,lr,.

s RAA ) .

13.2. SINDROAME DATEDE LEZIUNI NUCLEII IN BAZALI Sindromul diencefalic

Se earacterizeazX prin tulburS,r'i rle constiintf cle intensit:r,l,o r.:rlirrl,ji, ci.n'econsl,au intr-o sta,re de apai,ie, lolpoare, obnubilaro, soIIll(t (,1{i'i, 'il Ipoirre-Rcspirr(ia e\te de !ip Cheyne-stbkes cau t'espirrlir,.rr Iit r rr.*,,ri I r1'ttrgulat,", rnllerullt uncorr de pauze scurte, pupile mici, rtrilr,tivrrlll, lU r nrr;.lellexul cilio-spjntl este conservat, miqci,rile reflexe rlo gl0lriloI {r'uralr ln plan orlzontal slnt con$ervate,insi, uneori rnotilitate r,r:lltrrii rxrular5 rrerticall este.IimitatS sau abo]it;, (comprimarea rcgiulii l)t.ol,(r, fale) ; existS, reflex oculocefalogir (in lezidnile'de ironticrtii rIitrrr|r,IrrIo rrrczen cefal ici), deriere ronjugatd, a capului qi ochilor, ten0rnt,lrrrIrlrr ,.r.nr dc prpu$i,'. rinooli der it,re Ienti ti porsistenti a glolrilrrl rx,ul:rlr. So noteazi, semne de suferinta, pir*midal5 ditatcrali, (I3::r,blnslti hilrr,l('r.rr,l ). Ibt fi evidenliate o rci,istenjii, ^muscularii, tle l,ip paiitor,fu .\i rrrr r,,ll,Ji ,1,. ftpucarefortatA.;iD abscnla unui deticit rnoloi ri.eqtclnorliii{,riIip,rt Ii l,ihter:!le. Pot erista diskinezii. Tulburi,rile vegetative sint abscrrtr,. .par(,iall a t,ir$l,l rl ._Sttpoar_ea.**" *oilnoi&1" reprezinti, u p,ig_rdere sit'ilor la solicil,5rile mediului inconjurilor, iii starea-tle colt$liitrlii r)Hlrt rrtectati, r.ra,i rnult sau mai pulin. precurn d,ratii,denumjlile iu;_rirr,rrt,io rirte. pacientul prezinti o stare de somnolenli, mai mat,e sa,urnti rrrir.ir, elrr lr '.)ic aln sau ..hlat,.uncori. cpontan (dupn gl,a(lulslrrlrrlji) rr. l|r. z' rl' . l urbe:lo, (lA riispulrsuri ader.r at. compl"ie,lncornpl,.tri dinl tiurli\ r., (,,,r'e a}e ne\-orc, mill]rnci, singur sau rlacd,i se di, sL rniirrirr<:o ce I rlr.rrrrr l|r'rroil.loule tlr'sr.lridc ochii, str (eara Si.$i fa(,i ncccsili{ile, rrrrr.rrIi rrri;r.:r, r. rrll(. Sponlrn. cbtrr potte urubla; [ulcqiile vi[lt,lcrjlt Lrlrrrr,. Sr.r,lrtlr,.t,. rizprtzi, printr-o. mai iltensi, cr.g;t-glqa plairurilor slzoriale, cilrt arrr rlrr,pl r|rrrrt: o recepl,ie intilziai,i, qi inadecYatd,o lentoal,esi o tllfi<:trl1,|lt rlr,s rr ii.-ttririi 1rror..esalot tsociatire, Bolnrr ul c.tr. lpllir, r,iitrrrtrrlr.r,rr irrlirzrclr. l:r itrlrr,biri. pr'in rri.punsuri vagi. apluxirnriir,,, irroirrpl,.tr. 1i, rlr, ,,,,1r. r,rrai rnulte ori, lipsite de sens. ,\ornn;leut, tlr'zurirrnill,;i corr -lltpori (,s1e Itz,. Evocaro:, ar'nczi(ii so efc(.tucazir, rliii,.il, rr't,rrri liirrrl irtrlrrisilrilri. llr'lrrrr,vnl c..lI;r11i1tsih cst iu ;i.lnitdikinetic, sc or.iirrrl,cl,zL ilifioil si irrr,'rr1rIr,|, r tr {l}t(ill .i .li'ri irrlir'rrrrrIii si irtr.s:r.lcrlr.sIr.r, lr',lr'itr *r P,.r,.,,r:rrri. 'rrli l,rt int,ila,{,ii lc;x,lrrlir!i lllti irlr,lrfir., rrriti lrolrlrvrrlir,r,rli.trri.zcrrla, rrrllllr riuri rii t'iirliI:r'|r'.Il.lh'rrtl rlr.r.lilrit l:r rrrrLr.rriir{*r,.si l,r'(\rizi. r',rlloxrtl .o|rr.irrr ;rittl lttcz,r'tttr,. lirlrrrrvrrj lrr lrrrir,lrrIi rrIrrrr|,Ir, illl r,litr,l,i,r,ll Irrrrr:(iorrr,ir,zii, Ir , rlr,..rtbirrrri l.llu;Jgati);t ttottrtrr,l, r\sls rrllriytr,lslrli, (,oglir, (11 Vigilr\, llr,rrrr.rr rrliliz:ll, ilrtirrr.ii tl. I'r,rrrrr.r,zi. plr.it,trlrrl \,rl,lr, lr\ 4i trrr l)rr,r,tr, ltr, 'lt 'illDrtrrrlr,

Sindrornul de dezelerenlare (sindromul'oloked'in") Af octarea ci,ilor cortico-spinale qi cortico-bulbare printr-un mmolisrrtorl; localizat in piciorul piotuberanlei (I{emper qi Romanul, 1967), rlncind la tetraplegfu qi afonie, determind, o stlrtdo imobilitate com-pletf rr,lrolrulvului Eiin;apicitatea iui de a se exprima I'erbnl sau gestual. Tahlrrrl ciinic p6ate sugera o stare de mutism akinetic. Spre tleosebire dtr rrll,irlul sindi'om, car-acterizat pritr tulburi,ri mari in sfera- prceptq?lr,r irr sirllrornul de dezelerentare perceplia nu este altera,ta, bolnavii fiintl rrtiorL{,a,1,i tsmporo-spatial, putind face calculor a$a cum a ar5,tat-o (]onouni' ,.,,1,,,1 j11 irin iiteim;diul , cotlirii miqclrilor ]or oeulare. "i Sttrea vcgclalivd persistentl dupi leziuni eercbmle. Jannett (1972) rlcsrrlit: sindroinul tle ftaro vegetativX, persistent5 in motlul urm5,tor : I)upii o perioadS, tle comi profuldS' de" reguli, cu-ItaJiate grade do Ii,spunsirri eftensoare (rigitlitate prin decerebrare sau prin decortlcare)r.cu o rlrrratii do o snptimini, sau mai mult' supravieluitorii i!-cep.s5,deschidit -numai ca o reaclie la stirnuli rlureroqi. Ulterior bolnavu I ochii la, inceptt periodic ochii deschisi, chiar in absenla oricirui stimul qi pa,re a rrrorrl,ine rrlrrr:'ili ci privirea, dar firX:r, fi atent, apoi recade intr-un somn apalen-1'. \rr poir,l ii insrl r:orbr de un real ril,m lcghe - somn. fn perioadcle drr c stlte rle tcghe nu exisli ldspuns de apdtare ptin ocluziepalpcIrIi'L :L||i|tI lrirrLil:L:rnrcuitrtalc. unele cazuri i:.i;,1dmilcdl'i sponlanealc globilol' in olrrlrr,ri,tlind impre$a ce bolnivul urrnire$ro cu privjrea un obiecl c:rttt in-cirnpul si,u vizual, dar nu se poate afirma cA este vorb{[ sr, ,1,'pllscrt'zr-r' ,1,.r' iirrrrr:ltlu aleulie. In alle cirzuria1larchiar lnj[cEri cert -cooralonah!t .r rlr.csr,rrrtrlu scilpibtle sau de adueetua miinii spre locul de oxcibattt de poate dtermina fie Yi$cAri rr,,r'i,rr.1rl Cx toate ci, cxcitarea nociceptivS, ivii. fic rlr,,n rrr,il,i<lr,{,ic trismus sau grimase, bolnavul nu emite nici un ele}u-orl, vclbrll irrt,cligibil, ci cel rnult'- sunetb artic-ulate' Starca de constiinf il' liirrrirxr rloci frofuncl alteri],1jI,bolnalul ri,mine inapt de. orice comunicall)t rrrr illr nioi ri leaclie aalaptivil, la mediu, nu este leceptiv la nici un lltxl irrirnnill,iv. J)in punct dd vedere legetat'iv, funcliite sint conserYate,du'r ltt slirrrrrlii nocicepLivi puternioi pot inducc rcacl,ii vogotative auortnalo-, loarlje inclclutt" rpocirrl t'cspilafrrrii. Strlrca vogetzllivf potrl,cpol'sisi2r,lim1l a,lil,l,irnp tlit; bolnavrtl stlpl'2l\'iolrt' g1,1, ovr',irtuu,l, po&l,o so 1lcurr2utdrtiza 6i, r{rft,r), ltrzittltiIttttl t'tl itl I,)li(i a,rrttl i[l,iL1', t'ltr-ttriltt lxlittsr' 1i gt:t,vtr 'l't'rt,soclo lirtrp tltr tttlti trtttlltr sirlriiitrritti slr,tiiz.r,lr,cl,tir', totl'ictlo, ttll 1,l'ilsoll 1-rll11, (t4lr

,{il

it4rl

l,\lliI ' ilI iil(lll,l.l:.j,iIl(x)lltlit lt lqt . llt I t t ll, ilt l' r I lt r . iit ' iilllr t t t t ll t t t . i I r . l i t t I i t t r . r r r . l 'r , t r | 1 . ' s i t lt l ( l' s i ll|r t r ll l . . ' , . 1r. rt r l.t (l ..1:r1 1'r"' llillz i\ . ' . grll(lir: llttttii {rlltlttl tltl s r t nt t t r llet t ll- l ; lt t lr r r lr ' lllr ' r ' r l r ' l r l 'r l l l l l l l l l i l, * t , it ' ' r t ' i' l llr t t r z i" ': r t t : t r I . t I r t 't I r ' s . r r r r r 'l " r r l : i ' rlr'{l:r ' lr r l Jriiti,,,l,','

s l i i t r l i r , r 't r ( \r r ,i t\r ' l l r r l r r r i .,. o r .r l ,, l r r r r l r r r l tr . r r r .zr r ;lr l r r l l r , r l l tr , Ir Ii r r i ,,r .o r i tr , o l r i l r 'l r l i r r l l r r l ) r tl \ r zr r r l , ,,i ,r r l ,,r , r r .r r :r l .r ;r r 'r 'lr l l r r tr r l r . r 'o Ir r 1 r o I.IIr r r Ir 'Ir |, , 't r r o ( i r t t t i t I | r l i tl r , r ',,r r r 1 r o ri l r r 'l l l r r '\u :tl

plrr'lirrJii trlf(11('il1rr rr' , slc ,,1,rr,,f,ii,i':,., 1,,'ip,,,'tr'., tlatir,t1c troitrtcrosltrcl r,i,, (lilr (lN(lo (r:i' ilI r)iscotrlil rtti, i'"1,c Prr'(i"lt1rl sotrtttttlllrrl,rt tnotLcr':r'til, l,rr,z,rtli: pulin la oxciiat,iilu tlitr tt.rcrlittlitto.ttjulitlut. ,,ii',,i ii, ,,irr,l qi {ra'ticlpir,
i St:rr.r.: r l|t t , , r . ; r O ni,. ,. F o l l l (. d C fi n i r' :' ,i ttl o l r i dtZol i | Ji l i i ro Icntl tt' ror1t:t t ,' :r,,ti l i i ,' ,' 2 i ,.s i r' .r s r i rl .rr' rr' l .nusttl l l i uf.r' l i ' r,,l i i .i ut.rr' l i i ,,i ,i . , . , , , . i, , r i" ir'liltlcttiiri ;i ruptiof. Stalcr tltr ii',iiiiirl*liri,"lt,.i" " , r sc,[t6.c:l ilifilr,tirli, intro craqierri :t, prrlgul ilur srnzorjirle oLr r) dirrinuaic ir' i,f,i,ili" ,r"*in groutabe 'li.ctr rr,rsilrilit,ir,lilol rlc leccDtrie (care s6 rdalizeazi ilu oarecare

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i,,i,,"i'ri.'I,rrAiiitotiiii tn*rti"tin"' preculn ;i cu dirnintarcr stplelei ;i r.r'

( l r't'l l i l

Eindrornll r'1c rlecorl,icare ale u}tuitoalele ea,r.l:ld,t'r'is1ir.i : -- r'igi{litate in elterrsie :,r c:}pillui li trnnclliului, ile jtil,rrrrsilrrlrr rrro;

=i,r"t"5tn lrstiLnuli' r'orbr'.i+ttuci)rirr{'cl'u' ,r ,', ,,ilin,,lr, itu1. jn nuolclt Uazllt' ir. rrrrrrr,.voic; l,'zitttrilpsini lrilaleralc ploturtdi' ITI .st'iiru,itnn gi:;uO,,t (obnubilalct cslc r) nonrnnl{'nli. .t" ii pacieotrtl Jbia risfundc l2 11nila1 fi rnlleburl' l:lleorl :rrrrrr:i,rrr.'t:onlin'li I lt'z!ttncr e'lie in nttclcii brzrli 1i irt bipotalrmut .,i ,il"i..t. ri ";;;;i-,r; tt' ;,',;,i;i'l';c.l;r;; r'c"tlrlui crcicr"ului; t|irn' birrl ctr"lrrrl csie ittdtt intilneqte in' im,umatismelc crl'trio -oelcblale glave'-.iin Strtloarea sc r', t"ii,r '"ot"'J" ,ne.ri.*r& fi"tix irr comil) sau in foruele {rarc se al11elio:,;; i, i",l in.. ,iio ; " in cn 'e[:rlit' .'i pro'es":\P:rnsi''rt'in'tr' t:'nir:ne "o,n;1. cole cc cumrvirni inrlirc('t dioncefrlrtl' : )ii in , r"",,,,t.iJ io.tlir*t" progI'rosnosticul este ill fimctic tlc e|olu{ic : daci sc amoiiorc:lzi,' .i" I dacii sttpoirel se tgral-cll'z[ ;i trcte in comil' prognos'',',tr'i,,iti-,r*i"'t I i(,r {.ltc er'3\. ' ll ''(i;;fJ*".,=1c o .'frrc psihicir, clati dc o leziune a cmisfclc'lor corcbralc parrtial[, ii insularit, n diencefalului; {rLnctiile ri'i;a'lc sint ',, ,,;iil;;;;;t;; i"si ir''lrt-ilc 'oelPrrl ('r 'e tico.clri I'rur('.t)ttrionlrrlt,uar" "h'lt"ii,rLit" innLlc'v:l.l' uueqli ostt r'hirl prrliu ticlini'{il' ,,, ,f:u'- .i',fi ; 'i"pito.uri : 1. , {il, l,1 t . Itolvcin inclutle torpozrrea' stlllJ{rlrr''t-]i oblu]rihre:r i[tr-ur] singnr )' r^r',",,u', ,,io""!olaie a cinrytiinlef"'(,,1'loucliirg of r'olscciousuess" Sindrornul Korsakol"

.'""''.1'i;1;ll.ilj;'hi bolnav'l ,''ai !i'trLl lr osteo somnolerrti' a":'certrltit'i,'Lin(1}ri ('cLl

postrrX, a, membrelor tuperioare cu contraetulii in fle_rirrrrr irr :r l rrlor srinentelol cu pt'cdominanlii a celor dista,le; - Iostuli a,rnembrelor infe.lioaye conlracturi, in cxlorrsir,,r'ol:r,l cu i,,, irrl elnii gi l1cxie planta,t:i. . fi,rotnencle.de rigitlitlte sint rrrai p[!in sau tleloc inl]uorrt;rll! rl0 , l[||rlJt noch,-pljri qau rle a]t 1i,1. - rellexul llagnus-rle l{leijn poate fi pns in e.r'irlerr I {r'r - semne de piramidalitate bilatemli,. - alterarea accentuat5 a stfrii de conqtiinti, dar nu r:onli |rrrrr rLr, rrrlilnesle in rigiclitatea prin dccttebt *re, ;i :r,socialii, pcrt,ulbiili vr.ril cu ll|ive ma.i pulin ample sau in unele cazuri chiar absenle . Snrdomulilatea nfai. pulin _{reclent ini,ilniti, dup[ tlaumal,isme grtlve, rtir,r, lr\ lr)jr rrpirrrca,-chiar dup:i.cele u$oarre:bolna,Tulqi-a rcvenit iornlilt,i, rlrr,i,r,r,,, qi 1r,r'risli"o itlutitnte timp de 1-2 slpti,mini, fXfX,alte sirrrpLonrr,rrrrulo I'gicp_p:rn rnanifestarceste clator.iti procesrihtirlrr irrlrilrili. tai61.c. A{-c|LSlii stLpralimintrrii a zorLelorcelor r:rai noi apifltte pe scari, onl,o- gi filogr.rrrrlirirr., t ouforln legilor biotrogice care au demonstrat ci, structurito :r,rrriorrrir,i, ,r Ittnc{iilelor revin cu aiit mai tardil', cu cit sint de :rchizi1i,, ;rrri rr,,.,.rrlrr -rinrlromul vegetativ profrontal (Tiinnis) 1t I i . ln partca supclioari, a ariei premotorii existri, o zolir \,(,11.( I r\ :r r u trtl de a, legla teasiunea ar1,t,r.iull-upulsul. Sindlonrrl irr)llt,irur trr,z:r ;i rtrl rr,.t.r.lriljlo:r bclrt,rrrlui ,lupR difcr'iicpnc,.iulilo ,i rrui :,li.s lt.injtr:l,t r.rrl , r'rllr,)roleltlulc: ptcir.trl,ulOste to]nplct rtrstabjlit norrulklgi0 prrilrrr, 1i {llr })ersisti. ui}c1t: tnllturS.ricardio-vasculalo. l-,a,cicntul I:rr,cri lri;rrrl.i*irrrr,, r'1rrria,lti, o taliica,rdieaturrci ti'i[ isi sr.]irrrLi,lozifiir rlirr ilrr,,rrlriirrr si ()1 1{)s1.:rlisln. ,l(iesto tulb lli.li sirrl r.Liilr'lrrirlr.rlr irirrtr rlc l)t.olirr,rl rrr r. ri rrbilircl (iollllt,lcs(.('lt l (]i. lUil lirr
\ g i 1 l r , ( , i l l r r i r r r ;r l r r r l i r i o r .l :l i i i , r ,r r r r r :r r r i l i .sl l i l i r l r r r r l r z i t t t r r l r l r l r tr .l .r , ,r rI' I r, r r rI rt r r r ,tr .l r r ':i ,l . l r j l t.r ,ti l .r , r ,r i l r r H o tr r ,r ,l r l i r

|';\||.1|onIi|''Ier.iinir'."-laloIogi..ibincrIofinit:r.l'cz''].''r'ldin:rq,.!{'iotc} in ,1,, ,ririiiL..tffiii neurologice'dc tii polinerritic cu manitostilri psihicc' dt'zorientarca' confabulalin' clr'r tltttrtitlit, &mnezia antcrogradJ, "'i lJrrrl lcziunilor dominantc este mezencefalo-dicncetaUc' iul iu: marea lrr cliolottic, factoml dominant esto toxioo-metabolict t'onrlit,iiotinlogicosttrvitr,intt o rrtiutrlilltt: Alt. ,,,,ul,,llir,,t"','r'-7"r.Lrrjlor' rnetastazc' ii,, l,iil,,ri ri rt"i-tl,r riaturi, turno'al;i (tt*roL i tle uutJei brz2r1i, slu t'r'atn af ic;" t.r l,,,r,rrikra,rno),infectrioasil,, l'asculatit'
sitttlrtrtttttl Klii lc r - lNt t t ' r

t l i r i {n t t t 'i r t r Sirrrll0 rrrrrl lili i\ / ( ' f ilu( ' ) . lt 1} r t , , t t r t l, i : r l r l : r l i i s . u r l l t ''z i L l t t i l t l l ( l l i l ' {'o i l r l l l l t i 1 'r x 'r r t r r l 't t I ri I l t,1 ' t rt I t rr lt'tttltltI'lllt l , 1i lit r c r r ' ' t illr I ir r ' ( gilr t s r t l 'r ( } 1rt ' l l t t t l rl t l r ' : r'' : t l i i l i i t l r ' c o t t lrti A rtrtrtritr, rrtirtlilc r t t l lr ' t r r igt llllillr t ) ; il\ r ( { lt

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;i l ' I

A rnnoziikr posttrnutnll,irttl (jotrsfil;ttic urtttl tlinl,rc oelo rnai cornunofcnornone alc ctcoltlor ttiturrlrlictr rurrr'lrrille iltit lt:cento cit si tardive --- indifotcnt de inl,onsitltcit I r';r,rt rnlll,isrntt Itri. Amuttzia posxlraurnaticii propriu.zisd \rnrurzia posttlaumatic; propriu-zlsi (APT) este tlefinit5, ca perioada rio r,rnnezic dun5, revcnirea bolnavului la un anumit nir-el tle conDtiin-ti', clrirlr inoil, perturbati, sau la un nivel normal, in care persisti, nurnai rkrlli0ilul amnezic. I)ulatja amn0zici }osttraumatice este in diroct raport cu graYitatca Irrziunilor traumatice cerebrale .:i exist[' o relatie directii intre durata posl,iraumatice',ql virsta bolnalrului traumatizat. ru,rrurczici ,\prrocierea amnoziilor posttraumatice nu se 1loate. face {leriit rotroslxxrtiv, rlupii ce bolnavul gi-a redobintlit un suficient nivel de_conftien!5. ' Exisbii, pertulbarea memoriei recente' chiat in condilii de completii, rorr,bilitare aparentd, a nivelului de congtien!5,, Si nu a1 legfturi, nici c_u glrr,vils,tea, I6ziunilor core.br&lernici cu virsta ori cu leziunile celebrale ploorcisbente.Nt ar exista dificultS,li in reamintirea vechilor engrame inrrcsticc. Bolnavul este in md,sur5, si,-qi rezolve problemele vielii cle fiecare iri, (lal este invalitlat in achizilia unor cunostinle noi. S[Jrs1;ratul moriologic, lezionaI, al amneziilor posttraumatice paro si, f ic in arilie hipoca,mpice ale lobilor temporali' Amnezia retfogradi (AR) este detiniti, ca imposibilitatea de a reme' rrrola, ta,pti] sau idei din perioatla imediat precedenti tmumatismuiu'i' ( k)rldiliia-cste c:] in momentul traumatismnlui oreieful sii, fi fost &lelt qi irr conrlitii functionale norma.le. citeva I)o regul5, AIl, cste tle foa,rte scrrrti' ahratil (tle ciieva -secunale, rrLirrrLi,c, lar dc citeva ore). l)urata AR este in prirnul rinil in laport mai r:rr u,ruploatea ii ou grayitatea leziunilor serebraltl traumatice. llxistii, cazuri ile AR <le foarte lungi durati, - citeva' luni sau chiar ci{,ilu,ir,rri. aoestecazuri sint implicate pert[rblri gral-e qi ieziuni intinse In ir sl,r'uctulilo rinencefalice (Russell' 1976).

vcgrrilrIivii.Ntt lrixlri nr'r rl lrlr rlrr lltt,r'(irr rrrcrlirrl lrr iurrlriiutl,, rrrorl lrr r'rislii o ;rltlttrllrlr, rr,r'rlrrrrrlrtr tr-vogitr,,r,rr f,r,urltrpr,rioilrlr, Itcct'r'ttl, r.iorrr (l(! tlttt cgltc (ll .l otr') lrllllrrrrrrlr tr lrrrrgilrlt iolrrlc sornr, rlil llrrrl lroltritvrrl r li l,t rrzil plin rlilrrrtli rror.irur1rI,ir, i. lxla b) Ilonomottolo r.irrrr corrsl.aLl 1tozi1il, Ucxiolr rrrrrrrrIr.r, irr irr l)oHlurill(!, Ior'. :\colt,sl,lt, poakf lrr.r,orrlrrr sclritnbtlet, pl,sir.l.'i, lozil,io a t,rr.pllrrr so llr, rle rii cste mai marcatii J,r rn(llnblrdo superi{)are.l'r'ttlchirrl csl{} in uf olll,ir, extensie. In timp apal a,rrkilozc, ret,rac!,iitendinoase ;i t:hirrl osiliclri. c) Fenomenele motolii prilnitivo stei ool,ipe-lurormakr. !'onomene veEetative Ilenomene oculo-motorii existi constant. Simptome pira'rnitlale. O tetraparezi, spastici),,in rnorl rrorrsllrrl,. Simptomele extrapiramiriale de tip parkinsonian sinl; frtrcvrrl t,i,. Tulburd,ri sfinctodene (incontinenld, total5 sau de vezicri rtrtlorri).

13,5. SINI]trIOAME DATE DI' LEZIUNI SITUATR IN VARIATE }.]1'A.III Existl sindroameneurologicecare pot fi date de leziuni irr to:r,l,o cl,u,irrlrr encefalului, uncori intr-unul (codical, subcortical, trunchi) sll,t.t rlot|ii etaje. Astfel, existi, : Sintlromril dc logoreo eu hiperkindzie (Arseni-Diniilii,) Urmiirind comportamentul bolnavilor cu dif erite afec{iuli uorrr,orlri rurgicale, am <lbservat c5, in afala sindromului de mritism akinetic, siir.r.r.l bolnaviior se poato marrifesta si in sens opus, imbricind. a,spcct,rrl lrr rlrr goroo cu hipelkinezie Eau o gamd de aspecte variate, interrnorliarrrirrlrrr aceste extreme (logo1eefhrd, hiperkineziE, hiperkinezie f,rtr logortrr,, hiprrl kinezie cu mutism). In tabelul Y sint indicate leziunile Si sind.r.orrnrl r,or,,,H. punzd,tor in cazul ceior 13 bolnari studiali. ln genclal, Ieziunile au fost de tip compresiv-clistructiv, ,1irrrr rlt, l,ip iritativ. Considerfm cd, sindromul de logor'eesu hipcrkinezio esto un sin(lr(rrl antagonist accluia de mutism akinetic. Ambele sindroalro il4)ilr (.r, r) consecintrria unor leziuni distructive (contuzie, hcrnoragie, r'nnnolii{rll{!l |1,, comptesiune cerebrall) Di numai exceplional poate fi vorba do o ovclll ln h, excitafie. Muti$rlul a,kinetic are la bazi, o leziune netlr, si1,uri1,r'1,irigolrrl lil formaliunii reticularo activatoare aseendente (SIiAA). $indrorrrrrl rl{, logoree qi hiperkinezie se produce, in contrast cu precetlantrrl, lrr clz rlrr leza.re a sistemului roticular inhibitor ascenitent (SIIIA). Leziunile gdsite in cazurile noalitl'e (punte, partca lostralil l lnlnr,hitr lui ccrebral, hipotalamus, partea a,nterioa,rilqi intcrnii, a lolnlrri t rrnrgror.rrl at $i cortexul cerebral) marchr:azL cl,lea SRIA, a ciirei lcza,ro plotht(ur u,ru.r1, sindrom, plozcnl,l1,L, ca,ro ostc ll,it tle d ivtrrxr\,,rrrr Simptouratologia., corcbr':r,lir, poa,tofi ()xpli(llr,l;ir, dtxrit plin irrl ticrlruil loziontlfl ooutxrrnil,unl,r'l in pltr{i (lo j)orl,ii v:l,Ll,hil)ir, q.lol rl0rrL Nisl,r!rno r(i,i(jlllllir(!il,r{(,{r l{! :r,r11:rg()trlHl,rr inhibitor t1i u,(11,iv 1,r,r', ,,t, ln <:,t,lt, Privrr6l,rltotrtilti1x,t'l< itrozirr, ir,lrrr,ilrii rlo ul,r'1r orr leziutrt*r,, (,xl)li(,r! $-ill'l)ltl,rtb rrrIrrriIrrlr,rr, lrrzittrti xlxlurrrrrlUi trrrrri il trrlicttltrrinhi l)rifl r'il lrlil (1|rrnlrlr' Ir'r,Firrrro llil,(llrrllll(ll'llhti r,rrrllrrl lprilllrlrrnr,l, r,ri Ir,rrr1ror.:r|, JUJ

DATE DE I,8ZIUNI.:.DIFUZ!] 13.4. SINDROAIIF] Sirrrlromul apalic Hinrlrornul clinic poate cxista in forma complet5, sau ir, forme parli*le, ircornpkrtc, ctrnosoute sub denmiroa de sintlroams,rdispalice". Sindromul complet, in perioada de stare, ere urmltoarele componorrto ((lcrBtonbrilndt, 190?) : rr') r\ltiora,roa sttrnii de ritttrqtiini';i,estc intt'-o oaroo:lle milstlril asemioohii deschitsi, rrii,l,olr,irr crla tlin mtrtisrnul zr,kiletic. JJohllvLtl rnott{,itre ctt rllr lru rrnntr,rc6to ptivirel, rtu ,r,torcfl(rxlll do clipirc ltr u,m(rlinhrot ott cnlo{ionlllil tliforrtrtNtt ntr ttbsorvii'ttitti o lrra,c{;io rrrr rut roJlo-rpll,lpoht'r,i. {lo n,lor ('irr,l11, rrrtrrtu,i tttrt'lo Ptlutt{lttotttoiion rrilto sint, ttttslxrcifirrtr, lltll'llril, oi JI'I'

?
grtspittgotrrrlrtillrIrr,1tdolttrlit lii plin lroz(rlll,il, rllurf(xllrl)r'inlir l,t'tttrcltiul insiltlttr:tlii. rr.l'lrrr i tltt Drrrttr:t rrlu ciittr irr cunclu)ic, tablloul urrui bolnav cu logorec ryi hipcrl<inezi.o rrlrrriitorul : pacicntul prezinti, o dolinfi sau un irnpuls irezistibil ;i aproalxr rorrl,irrnrr spi'e acfiune, miqcare ,sivorbire cu : a) logoreer.cre$terca fluxuhLi irtcrr,liv(tahipsihic) $i a si$temi ui itleativ (tahifemie)' cind leziunile corl,i, rrlrr rru sint prea mati ; b) latenli, hiperroactiYfi (hiperprosexic) Di reflex rl,, oli,'ntlre prornpt; c) latcn!5, foarte micd in ri,spuusuri I d) incircare :r,frxrt,ivi, atiocvatS,aitualiilor e) hipermnezie, cu exagerare, el'oci,rilor7 caro rlrv irLtrrrnultuoase,intempestivo qi rapido ; f) sim! cxitic ascul,it; g) coerr,nl,r iii ].rttrfunzimea gindirii pot fi pistrate' dar de cele mai multe ori rk,tri iorate, fapt Cate depinde de leziunea cerebraH, $i tie fenomenul r-1r1, rlr, hipcrtensiune intracrania,nl, in cazul proceselor e{pansil'e; hipermlecare deYin tnmultuoascr intempestive qi zi,, (cu r.xagcraroa cvocS,r'i1or, cxagelareil atcnliei, u reflexului de orienl;are, logoreea, mobilitate r'.r,lriil,.), siini, critic ascu-tit,somn foarte pulin (2--3 nre din 24)r jud.ecatd ,.rrrr,.r',r,tri, ;ri lr iunamcnt- nortn:tle sau deteriorate dupX gratlul ;i localizarea leziuni.i
{ir)ttrl)raLc,

I}IB LIOGR A FIE

,{arli AcLa Neurol. Scand.} 19ti9, 45, 484-492, J. A.'I. - Ar ch . N e u o l ., 1 9 6 C , 2 0 ,2 5 3 - 2 5 tr . A b e r f c l d D . C ,, N a m b a i!juriaguerra J., B1ar!c C.- Le rhinenciphale dansI'organisalion cirlltrule.I'hysink4llt et palhologie du inencaplrcle, Xtasson ct Cic, Parjs, 1961, :97-3iJ2. A j u r i a g u o r l n J,, R . - En cycl o p 6 d i c 6 d ,- ch i r ,, 1 9 6 3 , 1 ? 0 3 G 1 r r ,tt, I 1 l Ti sso t m j o r l a g u e r r e J., :I' i s s ot R. - EnciclopidiemCdi@-chirurticale,1004, sllj)I'|. .t, -\ 1 ? 0 3 6 .d r o , 1 - o ,\laiouanine Th ,, Om b l e d a n e A., D u r a n d M .- L c sg n d r cm e c kt d l sl n l l u tl d lian phont!iquc tlans I ophosi{, tlasson {L Cie, Prlis, 1930. Alajouanine Th ., L e b e a u J., Il o u d a r t R .- R e v. N .- e u r o l1 $ 4 B,3 a l ,:]:a l :t:t/ ., Alajouanine Th ., Sa b o u r a u d O., R i b o co u r t B. ( d e ) - J. Ii 'JJch o l ,, l tJ,:f, l 4,i, 158-330; 29F330. Alaiounrirc l 'h ., Gr r n e r J., Go u l o n l {., \* e Il l i l .J., L i o t l t,\'. l tr .. Neurol,, 1956, 9t, 357*373. 'f h ., Sa l r o u r a u d Alajouanine O.* En ctp h a l e ,1 9 6 q 3 , 5 5 - - 1 0 1 . Alajouanine Ir ., l - e d o u x R cn a u d t h ., L h e r m i tte D ., Vi g n o l r l L . A. Bev. Neu!oI., 19134,110, 5-20. .\lbe-Fes!iard O.* J. Ph ysi o l ,, 1 9 5 3 ,4 i , 1 6 - 2 9 . D ., Il e sse l\leksic S , N ., Bu d zi l o vi ch A. N .* J. G. i {,, L i e b e }n }a l r N o u l o l . Scl ., l l t;:t, 2A, 1,tr9-159. Appenzcller O.-The a\lonomicnefltous North I:IollandPubl, Co., Anrslenllrrr, sgslem, 1976, April R . S , , Va n so n r l e n b e r g C . * N e u o l o g y, 1 9 7 6 , r r , 1 0 6 &- 1 0 7 0 . A!nasoD B.G.W., Fu l l cr T,G., L e h r i ch .I.R ., Wr a y S. l I.- - J, N u r r ',t. Sei., 1974, 22, 419-_-428. Arnould !{e d . N }n cy,7 9 1 2 , 1 1 , S7 g - 9 i 6 . G.- An n . ,4.rseoi C., Iacob T. *.)-ciolica Derlebftld, Ed. Welther, Sibiu, 19.18. Arseni C.-Bul. $tiint., Edit. Acad. R.P.R,, 1950, ,, 4. A r s e n i O. - Neurol., Psihiat., Ncurochir., 1957, 2, 297-294. Arseni F.- Ac[a N e u r o l . Bcl g ,, 1 9 6 0 , r r , 9 0 1 * 0 0 4 . C . , L a sco .Arscni F,, N i co l csco M .- R e v. Oto - N cu r oOp h tq l n r .,1 0 0 0 ,J.l ],l . l l ,, C . , L a sco p sych i a t. n e r r r o l ,sca n d .,1 0 0 1 , Jd , 2 7 $ - - 2 1 J4 , Arseni M . I.- Actr C , , Bo te z Arseni M ., C h i l i m a n tr {,, Gl i va n I. I., l l a r ct6 l r 0 . , D a vi d gnostr. r&Ltooflalilolotic, Ed. trledicaltr, Illcure$tl, 1967, l l ,''fr i .r -

lliriditala nrin dt'ccrebrarc SintLomtl de rigirlitate prin dccerebrare, sub dileritele sale Yarianto r,i irr rliiirritclc ettpe posttraurnatic,r survino cu o incidentl relativ mare, intt'e t1lroximalir J00'o d;n cazuri in sPria,noasrr; ;i a proapr-r r':r'r'iirrrl .t0,1,(tin oazuriin atte serii (Bricolo qi coi'' 19?7), Deoareceun sindrom rlo'r irriditate prin decerebrare poate surloni imediat post-impact sau in ,,llsrr[ unui sindrom de agravare, incidenla cstc in furrclir; nu numai de Lrcrlliz.areasi,gravitatea leziunilor, oi. qi de promptitudinea qi eficienla sint, in ordinea priorit5,lii, antihiporrliruclrL misuii tera,peutice' -A.cesta ieclenraioase qi chilurgicale in cazurile in care se reveleazd, un rrt ri,.r,, rr, rrro(i(lscxDansiY intracrania,n. ' Sinrli'omul clinic. Sindroruul de rigiditate prin decerebrare poate s;J :r,rrr,r'rr, sub forrna $a completXr tipic;, rsprezenl,ind prototipul sinchomuIio lui" Iio slrb lorma dittritclor varianto clinice. Frecventr sindlolnul de decel,lililnr cste asociat cu alterXri ale stS,rii de con;tienli, ,sicu semno ncurolotioo, irr lunctio dc intindorea leziunilor clil tlunchiul corellralr precum $i il,' lrziutrilc lerebrale coexistonLe. ' !)xistil si o l/ariantii, f{iii, abolire total5, a stS,rii de conqtiin}L, care so olrsrrrvi't, erceptional de rar qi in literaturi, exist5, citate url numir restrins rlr. r'ir,z.rrri {uairn., tgi2; .Ralsevqi Downie, 1966 ; Arseni s.iOprescu' 1966). decereb.ratiiapare l]umai industr SrrrrrioLrgic. ace.te cazuri r:igiditatea, in nociceptivi, niciodatS, sponta,I}; tabloul clinic este mai atenuat <lo si irrrrili riirl urrLIi rccunoscutc toatc lementele. Ca nivel de conqtiinli, acesta so ochii deschigirde a negn sau de a lr.zrrirriiI.r,nusibilitate& do a mcn!,!rLe corrtirnu c6va prin rniqcXri ale c:Lpului, do a reacliona lont $i.mai mult r:r,rrrruri nul;in corrrplet la un ordin Yerbalt in unele ca,zuri de a incerca sI cuva inill,eh'{ibil sau de a incerca sii, rd,spundl grafic' de asorrrr,rrrrlbti irurrr,,rr, inill,elilibil. Triseelo E:ltrG efectuate ln unele dintre &cesto cazuri uorrIjlnrlt ilitgrrosticul. ru,rr

Arscnl Fi cl C , , Op r cscr t l - * I) u r cr t:d . .i o p d l o l o g i e i n tcdsi l r tl d m e r r l ,Ii d . Acu ( 1 .l l .S,l l .l llucrrrcltl, ll)(i7. ( ; , Si D r l o n cN o l l \1 ,.- I>a l o b l i a D ( tl n o - n l kl l r tl n r [0 .Ii a l r yi ( r l d , l i r l , I\1 r ,., Arscof (lk:nlil, Iltlcu.otlI, I{lli8, ( : . , O!r I c'' 1 ., [!n r r l BI$ Arrfnl ,\1 - - /) /l r l r |r l i ]l r i .i , l tl l l Sfl ,,l ', l 1 2 . ,

it5,l

305

.-|l l _ 1 ., \l :' r ' lr ir , \1 . t) ltttthdnui rt, t1|ri i t,. /,,:j l ) t ) | , s ( r , t., t\t :r | ,.t s lx ]t. t) llu lttr,tnl i t, tl l r;l t t,. /,, .^l ti 1t u1)t. l\ll'(tsisIt. Nfu f( ' 1 ., I,sitr i;r t., N| [r .,x.hi r., l t)?t), /.j , t|!t .:j :i 9, l,0lr,z t\I. 1 .. h tth u ttir i ) r isccr or tq | lu tit)t::. tr,l i tt ttt tr:i tuti t. |\Ltl ti tr, ,:i l, l ( 1 .A c a ( 1 . l l . S . l t . , Ilr ( .u r ( sli, t9 ? 1 " ( : . . ( j o D s t a ntin cs( :u A f rc lri ]\l . I._ Ncr ir o l., j t;, P si hi l rt., N eurochi r., l gi 1, ll) j j - l t { ) . ( 1 . , ( ; o n s L u n t i n e scll , \ rs rn; A,l,- ^ Hip e e n siu ea ttacrani arLd, E d..A .ced. II.S ,R _, I lr ( u r . { t t i , 1 9 7 2 . Ars c ui O., Oprcscu \* I' ? a u m a lo lo g ie cr a n io - c ercbrel d, Itd. fkdi cal d, E ucurcl ti , M2, (1., ,tlarotsis / \ rs rni lI.- Ro v. r .o [m . Ne u r o ]., 19?8, tr, 359_362. , \ rs f i ( 1 . , C o n s t a n l i n cscr 1 A. l.J lla r e tsislI., S tauci u]I., V oi rescu 7.., Itrocescle cxpLotsiDc ifitrdcrutliencr \'ol. L, Ecl. Acacl. tt.S.R., Bucurcsti, 1$?3. .It C . , C o n s L a n t i r o \. i c i Al., p a n o za G l .\._ tl unati smel e ue ebrc-med.u_ ' \ rs rui tut?. si ltl. tLcrDilor, Iad, IIcdicali, Bucnrc$ti, 10?3. , \ rs t lri C . , C o n s t a n l i n e so u A.t,, Co n sta n tin o vi ci A ., (]hi f esc! M., Nl 1 r r e t s i s lI.I) o cr sc e xp a n sir le itr lr e t! a n icn e , vol . II, Ij d. A cxd. R .S ,R ., B ucufcsti. 1974. .\ f s c I li(1 . , Ioncsou S., Ir ie tr a r u N., Ilie scu D . _ N cul ol ., psi hi at., N enroctri r., 10 7 4 , t r , 3 8 5 - 3 8 8. j U ., Din d itii , \ rs oni O., Golu psj hi at., N eurochi r., T - ., Alcxia n u D ._N curoi ., 1$ 1 t , , 2 1 , 2 4 1 - 2 5 : t . .\ rs c ni C . , C o n s L a n t i n e scu Al. I., M a r e isis l I._ S mi ol ogi errcurcchi rLrrgi col d, \ 1, . , . 11 i i . . r r\ | l. e, i ( : . , AI I r. rrI O - . \fsi ni ( 1 . , . lid i l . r l i d a c t i c i s i p cd a So g icl, BL r cu e tti, 1 l) ? 7 . lri C . . \ I a r e t s i s l[.- Se a r a m o d . Ne u r o c. ( Sao ptrl l o), 7gi i , t;, 1:JI_-1:.]5. (1., (ion!ea \ rs c ni .{ ., Op r o scu L , Sto ica E ._ S tnri tc rornal e,i pntol ogi ce rlc consticntii fi constiintd. Jn : C. Arsr:ni (Sub. recl.,), -hatat ato Ncurotogie, vol. II, li(]. M e d i c a l i , B r c ulc$ ti, 1 9 B0 . p sih ia t., Ncu r ochi r.., 1S ??, :?, j 31_18?. \rre rLi C . , P a I o z a Ch .- Ne u r o l,, (j., SLoica s eni I., 1 ' u clo r J.- C' r ize lecp ile p tice, E al i t. S cri sul roma esc, C rai o\.a, '\f 197 I J . (1., Ilorvath .\ rs rni L ., Ciu ica A. \r , * Alc.,Ii ri l c eatuchi rnrgi .al e al e sugtrtul ui ali), Ed. I'Iedicalii, Bucurc$ti, 1979, ti copilului mic (0-3 i (1,, Opr.escu LDu r cr ilc cr ctio - fe .ia te . Io: 0. A rscni -\f s c (sub redacti a), 'l rulul de lieurcIogit, vo], V, Editrr4 MedicatI, Brcurefti, 1979, pp, 9*?5, ,\ r' s r, I i O , , P o p o v i c i u L .Asp e cte te clin i& a te m a ni fesl dri l or parc sti cc neepi l epti ce. I\oblcnle de diagnoslic difercntiul cu critete epilcptice, ln : Simpozionul ,,Epitepsii1e,,, (lluj - N r p o c a , 3 1 N l a i 1 9 8 0 , 1 3 1 *1 ? 9 . C., (iontea A., Op r e scu I., Slo ica Ii .S tri ri te normal e $i patal ogi ce ^r s I rri I c o n r l i . n l d ( su b r cd.), .Itetat de N eurol ogi e, 'vot. l I, $ i c o n $Iiit4 d , In : C. Ar se Di l, lrl i t . [ I e d i c : r 1 5 , B u c ur e iti, p , 1 J- 1 2 9 . Ash lJ p| r r r l i p sych ia t, n e u r Dl,, 1 9 3 5 , su p pl . V I, g47*3i 8. E.-Acta ,\r bc rt XI., Cazalis p,* R,, Au b cr t J,, M a r tin B r1U . S oc. Optrtat. Fr., 1952, r1. 1 , 3 1 1 - l ] 1 5 . p sih ia t., Ne u r o ch ir ., 1958, .?, b25*593. .\tl{irr4 11., Vuia O . - Ne u r o l., \ rs f n B. - Cercatdti .[iftice, biochi]nice, krdiologice si etecttuenceldtografice tn sprijinut Ilrr,r i lcrTcldrii sintlntnului ljarrC-Lieu cct o insulicienld circul(to e \erlcbro-b.tzilatd pin tctDicrlr[rozd, l'ezir de doctorat, I-VF. Cluj, 1968.

(,Ir.r,r'll

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( l i o | . | r ,l r s i c h l r L .N r l l f r '| n 1 , , l l ) ( i {t , , r t , lrLt rt . l lt,. lrlnizlo 11 S. , llr r , I r lllli A. 7l l 7.ll{, l)tf)rrs \', S., Iicrr A. - ( , o qh ! r . / n. opr( lhNr l0s l r o n l l r sl l r b l i s h c r . S p r . i i g l i f l ( l( l l l - ) , 'l , l0i)lt. l)rr:ourt J---,ll(:rir s oiguis , G as t on Doin et Ct o , P a r i s , 1 9 2 7 , (Ies f )l.i iri ll( .1.- Si-illaioloUie affectians syrf{ilnc dd Trerrear, lt:rsson et Cte, Faris, 1{)14. l) r'l ir )u n I c .I.- Gez. Ntd. Flarce, 1979, 8d, 1651*1651. l)r' l:ry ,1., L hcrnritte F. - Enc y c lop6dic 6d. - ch i r . , 9 6 3 ,1 7 0 1 9A 1 0 ,. 1 ,1 - 1 0 . m 1 l)t lry .I., Lh crmittc 11, ' Enc y c lopodie m 6d. - c h i r . ,1 t 6 3 , 1 7 0 1 94 3 1 . 1 , 1 - 4 . l)f lry .l., Lh crr)rittc f , , Enc y c lopedie d- c hi r . , 1 9 6 3 , 1 7 0 1 9A a o , 4 , 1 - . 4 , m I )rr). DL \v.O., I{cc ht s c half en A. , c ulev ic h c.* Ncuriogy" 1Stj6, 16, I lt._33. f )e l)aris \I- - Glo s s ophar ungealur algia. n: P. J . V i n k e n , (Eds,), rrc I C.\\. Bruyn Ilundlrool; of clitical neurologp,\o1,5, Notth-IIollaud Publ. Co,, Amslcrdam, t968, pp. 35 0.3 61 . l)r' \ic M., Bou ch cr N. , I la\ ' ear lI . - J . iled . L y o n , 1 9 8 6 ,5 A v r i l , 5 3 7 - 5 4 7 . l)cvic Il., Aima rd P. , 1I ic hc let F", M as q r i n M . O . *R e v . neurol.r 1967, 11 6,4 67 -17 1. l) i r nr o n d S. - Postgrad. Med,, 1974, 56, 69*73. l)i| lr{ uro S., Scho t land D. L. , Boni} la E., Lee C.-P,, Cambetti P., Ilo wlan cl I- P.-Arch. Ne!rol., 1973, 29, 710*779. f)inritriu 0. R. \I. - Neurol., Psihiat., NeuroIlir., 1972, 11, 29-39I) i\ )I. R.J IIallp ike C, S. - I t oc . Roy . Soc .M ed . , 1 9 5 2 , 4 5 , 3 4 1 - 3 5 4 . f) ix n I. R., Ilxrrison lI . J . G . , Le$is Ncurol, Sci.,7C71, 3,232-256, P. D, - J . X l)o(iinot B.-ADr. M ed. Nanc y , 1$72, t J , 987- 9 9 4 . f)i N chrr,1,1 D.4., Bank er B, G . - Ar c h. N. ur o l . , 1 9 6 1 , 5 , '1 7 *9 3 . f )rrf chnrcn D. A. - A. r c h, Ner r ol. , 1968, 18, 654- 6 1 4 . l,r' N chma n D. A., \ Vet z el N. , \ v as s c r m an II., Naito trI.-Arch, Ncurol., 19 60 ,21 , 1 ?0 -.18 3, f)rrchman plus: a classificalion the dis.rder$ D, A. - Op,il,taLmoplegia of associated uilfu proor.ssi?e ctter eLoplttltdlmoplegia, P, J. Vinken, (Eds-) HdndIn: G.W. Bruyn bt)okof clitlicaL neurctoltJ,\o1.22, part II, North-Ilol]and PDbl. Co., A}nste]daE], 1975, pp .20 3-2 16 , I) r:l f o !ecnu L. , G ilndis c h C., Popov ic iu G . - - N e u m l . ,P s i h i a t . ,N e u r - o e h i r , , 1 1t7 7,2 2,8 7-9 2, l)f ritlirncse u St,, O lt e anr l 1. * Er y ef alit . t i e r c e f a t o m i e l i tD i a l i c e . P r t b l e f i e , l e e Ncnologie, Editrua Yedicali, Bucure9ti, 1955, pp. 340-419. f)f il! l{ ne scu St,, Dr igines c u D N. , pet r c s c u Ar.* Encefalite irottce tuane, u lid. Ac.d. R.P.n., Bucure$ti, 1962. l)rrit{ I ncscu St., Dum a D. , Popov ic iu L, , T u r c u T., Driglnese u N", l!o tot Tr,, $ c r baD l{ . , Pops c u Gr., Fovrea D.-Rev. roum. Neurol., lli{ii), rl, 50-58. l)ril 4in cscu St,, Dun a f ) . Popov ic iu L. , D r i g i n c s c u N . *N c u r c l , , I)slhiiL., Ncrr'ochir.,1065, 8, 323-327. f) r i g i D c s c u N., 0 aj al N. - Enceldlile fi enccfalopattinirale co cuofulielnla, Ed, Acad. Il.S,Il., Iluclrrefti, 107.1. l)ro8dnl0 I), l'., Sch t l] t z c r M , , l\ I ic ut ir ! R. S . *A m e r . J . I 'l e d . , 1 9 5 1 , I ] , 6 8 6 . I )urnn l)., Pop oviciu L. , Vuia L , * N c u r o l - , P s i h i a t . ,N c u r o e h i l . , 01 St r oia
l)u 1I!'A, 1, 1'l-24. rir I ) . , I ) i r p i l i a n V, V., (lr r o c l , N N r o ] . , 1 $ 6 0 a , ],- 3 , P., Vu ia 1 6 9 - 1 7 J. ( ]ir n p r o n u Po p o vic i rr J.:., Y r|I!r

\.\., i l | O. \ \(.rrn,t., t,s i tri rrt., \r.r l {hi r.. l l x l :j , f, l !11 l ;l rl . l )uD rr l )., I")tro\i r.i (].' 1,., t,r.i )i |l ,,\ 1,., (;r' i .i .|| l r.. \l l l |Lr) I., l _urri r t.. P l rv l l ., (:i l Il i r It., 0o r.5 S .. .R c \' . r' ounr. N r.ufr)t.. t1)(j l , l ,:11,1, ]:|. I)ul nt D ., P N pi l i l [ \' .!., ]1., P opov i (:i t,- ,N c (r.r,t., I\ ri rt., i i i rbax N crroc i l i r., 1905, tr, 3.10 :ti )l J D nma D ., P s pi ti ar I-., S (r r' brrr \' . V ., l ,opov i c i u l I.--c tl l .i ut l l r{ i ,, t1||,],, J7,409_418. D trn1a D ., P api l i an \:. V ., ;erban II., P opov i c i u (i r1r.l . N ,.r|],t. I-.* S tu(t. 1965, I r,4S 9-515. D u l re-E l d er N . S .._ Iri s rral eal i n.Ii orr. R el al i D eheni otz ops i ft. In : Ter.l book ofo]l ttl rttntl ",rt. \.ol. I\', C. V. \losblr Company, St. Louisr 19tr0, pp. 3651--3652, D i i rstel er N eul ol ., 11]75, 210,25:j -269. \t. R .,-.1. D yck P .J., Letnbc rt E .I:I.-A rc h. N eurot., 1968, l t, 603-618; 611] (i :l t, E asl y R .M., S .-A & er. Gol ds tei n ll L b o nr Ii. - Ncurology, t$00, rr, 64-68. J . \Ied., 1071, ;A ,76t,--777,

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Ilkbom I i ., D c Fi n e Ol i va r i r s B. - H e a d a ch e ,1 9 7 ,1 ,ll, $7-10t. Eldridge R .- - N e u r o l o g y,1 9 7 0 ,2 0 , 1 * 1 8 , Ellenberg M .- h : El l e berg l \i ., R i l h i r J. ( Ed s.) , .Diob.Iusn(llil ls llt,rttt and practice, I\lccraN Hill Co., Ne\r York, 1970, 822-B47. Endtescu L .- C ti ze l ece r e b r a ld e o r i g i tt p si h i ..i ( n l ,,r i l i t'l i t i l "h t e \r ., Po p o vi ci u x i : : l i . ep si h i cc) ,In : L , Po p o vi ci u ( su b r e d .) , M a n i fe st.h p a tu a i sti c\.tr ch r u l r t,t,l i lellice, ljditu.^ l{rdicali, Bucurefti, 1S?8, 273-297. E n g c I G. L. - F'aiting, Charles Thomas publisher, Spi.ingfleld (lll.), 1150. Engel J., IIcI- i n T. R .* Ar ch . i n te r n . IIe d ., 1 0 1 - ) 4 , .t, l ( x) |l r G , L .: R o m a n o ? Esiri N I . M., To m l i n so n A. 1 I.- J. N e u r o l . Sci ., 1 9 7 2 ,1 t,:]:r - 'l B. Essle n E.-Dtsch. Z. Nervclheilk., 1951, fi6, 11.]-7'i2. lraton E , r Stcr i a d e tr {., We r th e i }n l I.- R e \'. N e u r o l .,1 9 5 8 ,9 5 , 1 1 7 .t']l r Fagon E . , Sch w a r tz B, * N e u r o l ., Psi h i a t., N e u o ch i r ., 1 9 6 3 , 8 , 2 0 3 1 0 1 t, Fagon I}., Gh e o r g h i u l I., i \Iu g ctca D u E . , Sch \ya r tz P.- l l f\', r !'u ||r . Ne!rol., 1966, 3, 22:J-234, I . a 9 o n E . , Il o r n ct Th ., Io n e !j cu I., D r i g h i ci L .- R v.N r u m l ., 1 1 1 {i 7 ,r l r . .l 672-E73. Faivrc mcd. Nancy! 19?2, l/, 967-971. G.*An!!. Fsvarel-.Benazet cl A. U.Thtomboses insuffisance cirullioire du slplrk : r(rl.Irr ,dsilaire, Those Med., Toulouse, 1964. Figdr5f B,! Po p o vi l i u a n M ., D u l d u 8 ., AFg i a n L . - }l e v. M cd . ( T,{. M u ',r ,}) , 19?1, Ji, 165-168. Fdgdrbf L . - M a n i l e sti i r i sp a sm o l i l i tc.In : L . I,o p o r tr r r l a n M ., p o p o \;i ci l r (sub red.), Manifestdri pal oxislice cerebrale nccpileptice,Ld. Iledicaltr, llu(urrftl. lltTlt. pp. 335-388. I.crIaro Fischer Fische A., .Icr vi s G. A.* Ar cI. N cu r o l . Psi ch i i t.,7 9 4 4 , t2 ,4 4 tl - - .1 U i t, t r{.- N e v l tn g l , J. [tcd ., 1 9 5 6 , 9 5 r , 5 7 - 6 5 . r ( i M ,- - - ,\r ch . r \"0 r r o 1 ., 0 6 4 , JI, 5 4 3 - 5 4 $ . 1

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l). I {, L s c fr Il. - ( )ltII l.I tIt I IItt)I()i i i || (llrrrn 1971, lt;2, "\:ll--"112' j\ { . I . - l} r lit r , 1058, EJ , 218- 2 1 1 0 ' l,f rrl is llote z ^ .., I | lr li (i., V u i a O. -- Z. Ncrrlol., 1973, 205' 207-220' 'l G ' \ v ' B r u y n ( E d s ') , H a n d l ) o a l c lI. - . 49noii. 1s . I n: P. J ' Vink c n, l rc(lclicks.I.r\. ol clinical ncutolog!1,\'ot. 4, North-llolland Publ' Comp', Amsierdam' 1969' G enet - 1971 , 2 ' 2 0 3 *2 0 9 ' A. E. I I . - Clin. lrf i(:,1 Ii., Dme ry an.l suddendea|h in dse.lses sgncope ciculata|lJ |ailufe' s]loc}:' l'Ii(](l]Jcrg c. It.- Acale al'ltE hea , \Y, B. SaundeN Co. Publ', Philadelphia, 1956' du trIatadie$ toeur, Massonet Cie, Paris, 1950' l,ricalborg C. K.I ' I '- B r a i n , 1 9 1 2 ' 9 5 , 3 7 3 - 3 7 7 ' R. D. , D elhant y f. lr lIor d K. W. M., C at t er all Y '- J ' Neurol' F I ', T o y o k a r a H. , Sugit a l llrul(awa T.. 'Isuk agos c hi \ci., ll09, r, 3bl- i9?. O t o- lx r y ng. ( Pads ) , 1967, 34 , 4 3 : ) - 4 5 0 ' lilrbcrsch V.-Ann . Neur ol. , 1968i 118' 481- 47l' { irrl)crs clt V.-Rev, (irrcin G . * I nt . J . Neur ol' , 197 0 , 8 , 7 0 - 8 1 ' R., lla nig an d ge A. R. - Tr ans ' Am e r ' N e u r o l A s s ', 1 9 6 2 , 37 , 2 0 4 - 2 0 6 ' (;rrrrctson l-I. D,, E lr id Neur ol. ' 1952 , 8 d , 5 9 6 - 6 0 9 ' A. - Rev , lirrsLart H., Remo nal C. - Ann. } I ed P s y c h o l ',1 9 5 5 ,I l '3 , t ? 6 - 2 0 6 ' I . , Ciov e { lrrsLdut lI.J Rog er (irLstaut Neur ol. ,1950, 95' 420- 427' If.-Rev. Ne r ol, , 1956, 9 5 ' 5 4 1 *5 '1 9 ' Y. - Rev . { ; 3sLau l. H., Gastar t N e u r o l ', 1 9 5 6 , 9 5 ' E-Rev' { ilst rrLt I_ 1.. }- i s c h e r _r - i I I i a m s X{ . , Lt r gar es i 5,12-541, G '- R e v ' N e u r o l '' 1 9 5 6 ' (;rtstrrtt M . Sal a m o n P. , Pit ot Il., Na va r r anne t5.511-542. { irstrut lI. - En c6 phaie,1963, 17045 Ar o N '- L 'e n c t p l n t o p a t l t tm t o ' e (;l$ta rlt H., Itog e r J . , Soulay r ol R' , Pins a r d Masson et Ct', Paris, 1964' clonique infanlile aDec|ll|psatlJthmie' llxstxut I'I.- Re v . Ner r ol' , 1968, 11t ' 7* 3O ' m r;rsLxut t{.- Psy c hot ogie 6d. , 19?2, 1' 5L- 62' feat res' (irrstrut A.- Epileptic seizutes- cllnicei and ele'trcgraphic I{., Broughton {Iiaonosisandlreateal,CharlesThomas,Publ'comp,Sprinstield(II')'L912'172-139; 22D-2,t0, (Ixsl.nut tI. fen collabolation1lvecun gloupe internaliorlal d'cxperts) Dictionafuede ! | Difinitiotrs, Organisalion llondiale de la Sant6' Genove' 19?3' l'EpiLepsie. Partie d C ' A '- G e n e r a l i z ec o n ' R. , Rog, er J ' , Tas s i n a r i t;nst . rut lI., Bro ug ht on (Eds')' EdndG' W' Bruyn In: P' J' Vinken, &ilhoul lacll onsI. oLrlsile scixures bool:of clil:]cal neuftIogrJ, 1ol. 15, Elsevier, Amsterdam, 7974' 107-729; 13O-744' J '- U n i l a l e r a le p i l e p l i c (irst aut C. A ', R o g e ! P. . , Ts s s inar i IL, Brou ght oI I seizure sln :P.J.V ink en, G . VBr uy n( Eds ' ) , Eond' o o l c o f c l i n i c a l f t e u t u I o g g ' vol. ?i, Illsevier, Amsterdam, f974' 236-245' B i o l ' c l i L , 1 9 6 6 ' 2 4 ' 327-A52, F' - An n ' Et . , M elt end lirullicr M., Fo rrr nie! M O d. , 1951, 52' 5 1 8 - 5 3 8 ' G . - Ann. li(f lln c., Sau lnie r J ' Physlol., H '- A m e r ' M ' , Ha i l m a n (iollhorr L. ' Ke s s lc l E., Ye si nic k t$,1 2,1 J7 ,39 6-4 03. (l.rling (i. M., Wo ols e y R. M . - M is s our iM ed ', 1 9 6 7 , 6 1 , 5 0 3 - 5 0 6 ' (l rch wina l E. - Neur ology ( M inn e a p ') ,1 9 6 2 , l '' 6 7 5 - 6 8 5 ' N., K aplan (ir,frrmIncanrr \t-- Pdtologieindusd enaIal,Ed' Medicali' Bucurctti' 1978' Medical Publicalions, Palo Alto, califor[iat (i lr s i (f G. .1.- cufrent ilidlnost$dndlre. mzrTl, 10fi0. 19G 4,67 ' f ) 5 7 - 6 6 4 ' (ii1)l)or(t n, I t . - nr ain, Ir. D., liclly 06-73' (ll l' l, x li. T,., li l (f nl lr r I Nl. N' t ' ,( i i b l) s l"' A' - - ' l\r d l r t r l c s ' 1 $ 5 4 ' 'J ' t ' { ) lit r ' I ' r r t t ! ' l l ) 7 2 ' 6 ' 1 : }: l - l 4 ( l ' (lit rt ril (1. 1,, (i {}tt r r ! ( h l) . ( l-

( i i l t l o r r l i f ! t, t. t\t \||,r N ,,t. t !,t. t1 r ,:1 ./,/, 1 l ;; 1 |i :,. (llrrttlrt {1., I ' r r r ,, ,, r ,r t t,, t.,r t.,r r ||_ ti ,.l r . t]t,.. l l |,:t, _ ,,r ,:fl N ./ :l l 1 tJ. ' ' '' (iiIli(: \ \ '. , l ( o \|r l l , t \r ,1 ,. t1 t,tfi r t. N ,.r v( ,ti r ,, 1 9 ./0 ::r /..1tOt) 1 2 t) . . (;loor l '. ,t l '1 \l :ti ttl t\ttt tr tth n tq tt.,tL tl tt!r tr 'i tl n l l t,l tl sso n tt cl ", l ,l r i s, 1 l t( ;t. ( l o ( i 1 . I r ' r l sl ' ,\ttI N ,. t.,t. s( ., |t., l 1 X;5 rIr ,4 :j .- 5 1 . L (; o o t z r lj, I;i:iotrttolqlt. t.,t. lUr(tir:rliJ IJrr(xu.ctti, 1103. (ioldreycr ti ., t!i It1 ,.,. .J. .t. - C i tci kti o n , 1 $ 7 0 , 4 ], g J:,.- .0 4 {,. (ioldstein .1 . 1 i ., c( ,i {:r n t) . c.,- l r .ch . Op h th a l ., 1 9 6 5 ,2 j , l b s- - j 5 t. G o n y e a il. F. . -l\r.rh. N(,uj.ot.,1!74, J/, 168-1?j. G o o d \ '" i n R . Ir ,, I) o scr C , l I.J.A.II.A., 1 9 6 3 , l d r , 2 5 3 - 2 5 9 . ( ; , , I ta g e I., Pe r r i e ! GraII p .* Acta N e l l l o l .Be l g ,,1 9 6 l ,6 /,4 1 1 7 .,t.t. O.,D u sti n G r e e D \ \ '. R ., l l a e ke tt D . R ., Sctr l e zi n g cr N , S.* Ar cL . Op h th r t., t{l l . i ,, 15,1*167. Greer l{.- ceriatrics, 1975, Jr, 133-136. Guibcrt A., Gu i b cr t C .* D u sg m p ti n e A kl m a l a ( l i c cn n e u r o l o g i eXtr tr ) i r ( i \. ,\" , Edit." Paris, 1974. p ., Be r tr a u d Guillain G., i 'Io l l a r e t I.- Ite \:. N cu r o t., 1 0 3 j ,3 , U fi ( ; ti ;t,. p ,- p l e sse I{6 d ., 1 9 3 5 , 4 J, 5 7 - ,6 0 . Guillain C ., M o l l a r e t G u i l l e m i n a u lt C ., \ti l so Il R . A., 1 ) e In e n t \\r . C .- Ar cL . N e n r .o l( ( ]tr i c.) ,l !r ,t. . 21, 255-_261. Guyton A. C.*.Strucf&re dnd tdnctiorr lhe neNoussysfem, B. SaundcrsCo., I'l,it ,t, t of \V. pbia, 1g?2. Ilaberlandt W. T. * :{rtio,ropii schen Late rlsclerose, Gustav Fischcr \rorlnd, StI ilr't, 196,1. Ilagerrau ( i r ,. I.- Pa th o l o l i e e sn e r tscr u n i cn $l n : L e m i e !r e ,\., d Lenorrnalrr P a g n i ez C h ., Sa vy P,, H e ssi n g e r N ,, D c Ge n n e s I- , :r \ 1 r ,,. A. (Cds.), fraitC dc mtdeciie, vol. J6. ilcsson et Cie. paris, 1C4S, pp, 02?- -{i{it. Itallpike J. 1.'.- J. Neurol, Neurosurg. psychiat., 19?3, ,r, ,180-.190. Ilarrin1an D . c. F., ca r l a n d H .- Br a i n , 1 9 6 g , 9 1 , 4 0 1 - - 4 1 8 . Ilarrington R , B,, Fl o l l e n h o r st R , \\i ., Sa yr e c. p .- Ar ch . N r u r o l ., l txi r ,. 15,29--34. IIauss \ V . IJ., Ar n a t T., D e r l a r n G,, Ke r r r p e r F.- Zsch r . I{r ci ssl l [r tfr "j n'., l 1954, {,?, 831_840. lleck A, !'.- J. Ncurol. Sei., 1964, 1, 22t -285. lleymans C ., Bo u ka e r t J. J.* Pr e ssen 6 d ., 1 9 3 3 , s6 , i 2 g - 7 i J}, II e y m a n s C., B o u k a e r t J. J,, R e g o i e r s P. - Le sinus catutidiot et Ltstortt I hor\l Iogueeca lto-ao iqus, Gaston Dotn ei Cte, palis, 1938 Ilecaen I l . , Aj u .i a g u e r r a J.* Br a i n , 1 9 5 4 , i 7 , 5 ? 3 * 4 0 0 . I - I 6 c a e n H . , Ao g e l e r g u e s R .- L a ca ci ti p sl l ch i q u e ,a sso n e t C l c, p o r l s, tti ;t. Il II6caen I l . , An g e l e r g u e s Il .- Pd tl to l o g i c u l a n g a g c. .,.|p h a si e ,L n r o u n sr .l h r t\, d l 1965. Hilton G . F., H o yt W. F.- J.A.M ,A., 1 g ta 6 , 0 2 , 1 0 tB* 1 0 2 0 . 2 Ilinterbuchner P. L .- Bu l l . N e w Yo r k l ca d . \Icd ,, 1 9 7 4 , ,r , b 8 9 - - $ 0 r , Ilirano A . , Ar a m u g a sm y N ., Zi m m e r m a n I'I. M .* Ar ch . N o o r o l . ( ( :h t,..) , L967, 16,357*3$5. Ilishikawa Y., Stl n r i t6 u j i N ., i l a tsr l n o to Ii ., l i o r e ko 2 ..- Ii tr .tr o t.r l crltr. cliD. Nr.rrrophlxlol,, 10f,5,,8, 487-.i92, Ilishik:rwn \'., l f r " r 'yl | ti .,Wr h xn r a tsu l L , \'o n r n r o ( o .].. - th ,I. I,t,Jsk, pollr. roil,, 107r, .v, I t:tlt tl. lloflrrrtr Ilu u (;, 1 .1 ( l |l r ttr xr . l 1 l 0 l , :,/, l '0 i t, l l ? . Ar r ', N I|| r , l 1 l ,:1 , ,l t" l 'l j :' .l tXi '.1 , ^llrl, ll. lr,

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. | | llih,r,1 . 1.,.l (rIo r jr r , . 1. \ ( |1, l. S{ : i. ,19 7 1 ) J; 1 , 3 8 1 1 - : t 1 t l ) . l) . / llo| | W. li., iUr: BIr l I . N. , L( I ov er I L L. , Zr r n x l r \ \ r . - N c u r o l o g y ,1 9 6 1 ,] 1 , t,lt (;2. ll| | | l. \\'. i:.. .J- Nr ur os lr r g. ,l! 76, J l, 511- 549. Irlt vrr l). I[., OroD c luis t I ] , k ber g n, , Ris bc r g J,, I.I o e d t,n a s m u s s e n Ii... -AcL l)sychiat. scand.,79'13,19, 233-241. I .rr n {rs lJ. -.r. Neurol. Nruroslug. Psych., 1961, ?4, 319-325, lsrircs ll.---.I. Ncu r ol. Neur os t r g. Ps y c h. , 1967, 3r , 1 2 6 - 1 3 0 , I ji {: I lr. - lle\'. Ncnl.ol., 1957, ,/, 350-365. f slrirLo lI., lkcda H. , O ls r l( i S. - J . Neur c l. S c i . , 1 9 t '5 , 2 4 , 4 i 1 *4 8 1 , li,r)r' scu L. , Papay NI., Pop ovic iu 2. , I le s z t e n b a u m Chirurgia E,(Brc.), 19?1, :r, 8111-824, .l r:lrvon s Ir. [I., 1]o we] B, D. lnlat r t it es pas r ns , : P . J . \ . i n k e n , Tn G , W. B r u y n (I,:ds.), Handbook oI Neurology, \,'ol. 7i, Elselier, Amslerdam, 1974, 219-23.1. .l ( f l c I s on G,- Bril. .1, Surg., 1938, 26, 2tt7*302. .l r)lIoI s orl ]I.- Bnio, 1952, 7i, 55- 67. .l rllinck I]. Ii.Br ain, 1969, 12, 35- 58. .f rllingcr I{.-J. :ic fol. \cl 'osurg. Psychiat., 1967, 3A, 195_-206. . lolrrso n R. II., Sp*lding J . l{ . K. - r is oade/ s l l & t u t o n o m i c e t u o u s g s l e r nB l a c k of n , well Sci. Publ.J Oxford, 19i.1. .l i)lrnsL on A. C., Pr at t - J ohns on J . A. - ' l1. nns . C R n a c lO p h t h a l . S o c . , 1 9 6 2 , : J , , :,r00-268. . f r)r(Lrrro ! J., Rub c n I L- Laf ic c t , 7t t ) ' i, 2, 9 1 5 - - 9 1 1 . ( , | . : d s . U a n ( l b a o o f c l i l t i c a ln e u r o [ o g g , ), . l (, lrlJot lI.In : P, J , Vink e! 1, c . \ \ iBr uy D k \'ol. ,?, North-Ilolla d Puhl. Co., Amsierdam, 1969, 62-79. ,lif lrrr l- r\.- In: \:I-i1ne (:on{/r,s ltiernational de Neurclogie, Acta f,ted. Belg., 1957, pp. ' .,,t.-t7 . l\ rosr' lr . - - Rev . Ne! r o1, ,1969, 1 2 0 , 4 3 0 - - 1 3 2 . Il. G., Co IbaL I ir.i Lor F,, Ilulla y L. , Haber i a n d J . J . , Fer ago K . - E l e c t r o e r c e p hc l i n . . Ncruophysiol., 195'i, 9, 4\1. l( ri 1rr r'L L., Conttibulii Id aspcclele.Litlicc, rr morfologice eleci1rniografice tuanifestilrilor si aIe rrcLtfologitt ir1 balile de calqqen,Tezi de doctoraL, IIIF. 'Ilrgu- !ues, 1980. li. rr u I nr r n W. - Am. ,I. Physiol., 1938, 123, 677-6A2, Iirl\' ti I., Sasaki K. - - J ap. J . Phy s iol. , 1S6. 1, 4 , 3 0 9 *3 1 8 . 7 l\ r r u c .I. R.-Arch. Nourol., 1975, ,32,1B5-190, filrtlns T. P.* Arch . O pht hal. , 19ij6, 16, 129- 133 . pcr T. L ., Roma nul lirr l' , C. - Neur ology ,196 ? , I ? , 7 1 - 8 0 . li {: n n ll r d M. - Neurology (Miuneap.), 1956, d, 563-573. l\.lz Ii., Ho ldcde r I l, - Sc hweiz .m ed. W s c hr . , 1 9 1 6 , 1 0 6 , 1 8 6 2 - 1 8 6 6 , f(i rricr Wilson S. A. A,*A te:rlbook clinical neufulogg, of Butlerworths, Lo{don, 1955. l!iss( l P., Schmid tJ., Bar r uc aud D. , Floquet J.-Ann. Mdd. Nancy,1969, 8,27 3-2 86 . li u i H h tr S. C. - Bfit. Mcd, Butl., 1977, 33, 45-50. l( r)lln!rn G., Bcrg cr ' . { . - - I liinc h, ned. W s c hr . , 1 9 6 4 , t r d , 9 3 8 *9 4 2 . l\i) Y., Ilrimru Ent m lr onNI . 1, . , M c . I nto s h I {. D . - C i r c u l a t i o n ,1 9 0 , 1 , ' rA ^. . , Jo, l01l-111t. li ,, . h lt. - Iilirf, Wschr'.,1!:\2, 11, 22it-227. ( r s k i i t l s r u Li r k t o n k u 4 c r t h G c b i c l d c r li rif vonI'tilrI II., Y as ar * il M . ( ; . - - l) i. | Atltrie Vtl(ht lis nntl ttluid llftzihtis, li. 'lhi(mc Vfrlrg, Sl. tlgrrt, 105?, It f r l" rl l(r L. -(:(rct lt lt i s ulr t t uuor r ulk . \ x t LI ht f fln t t t i t t t t s i + I i r l i l r r r {l c S l {1 , I }l l ( u ! ht t: rr!li. ll L ' :t{i I
.,|,,,1 l ,r,' i l )l |!r. r/. l :l l l l i i l ). rr \ \,.,,|' . ri ,j l l .:i .l l ., l l r' trfr' l l i , l 1r/(1, l /,{ /,i . l ,l f\rri rl A. \j rfu rr .t "1t,"rt. l ,l . \,,,,1,.ri r.i l t.S .l t.. Inr,rrr.s l i , l 1t?7. fi l l l l :rl r| N - l i .. \1 l l l rl ,' r r, l l i \r,.1,. N rrrrr)1. ((]' ri c .), j t{ i l . t!, l t)l 1l :,. f\rrrl row 1.. .l ' ,rrl l tr,rl . \1,,1. l 1r,l , :tt;, l l l ,r 111. Ii rf l! rl 1, . 1., \l r' l .l (.r l ). \\. N fIrol { ,gy (Mi [D orp.), 101,5, ;;,211] 26fi . l ,norl )crl tl . , l i i ,l )rr,l r l ;. Il . .1. l ,afr"ng., 1961, 73,681-{ i 93, l ,rprcsl o 1 ., Il ,:s i Nl. A c l l N ( rol . B c l tti c l , 1977,77,331-350. (1., ()prc s c u T,asco l .l ., A l .s c rri I., N i c ul es c u II. - N eul oc hi fl trA i ( . l \rr.rurl i r,l l \rf l, r \. ,l r,l l r| (l l , r 4.. Ir,,,1

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(,., l ' |r, f'.,f,,,\'l fl r' 1,., \![l ,rr l l . l ' ,1r,,, \,l ]t' rl Irt rr t. ti trl r' l (l r! tthrl ttrl urttt,tt' htt ,,t I , ' I It It t , , I , I | | ,t I t , r tl l t rttl l . rd Ir tl tl i )t:t l t s :;utrtt o trl tnttt,l r ,,,,i \ r, rl nt. ./ s 1/,/,. (i us l r' \ Ii s |h,,r \,,/t!l l , /r,q,r'r. fl r | .!. l ,' \ IIr tl ttl tt S tul tqr rl . l l rl l l . t,t,. l l l l , l .l l l '('po\,i r:i U 1,., /\i ,Ii i r l | l t., l ) Lru l .:., I' l s f u I., l ,al l rl c O. .ti rrrrl ,trr i \l (l i fr l i rl . (l i rA r. l r,rl ,\, l l ri :1, l l l (i , t). l ;i j . j r r L., \V ri l \fl P opo\i c l t l ' ., ( ; i i J i t) ri r' g 1., l (i k ol i 1,., Os l s z i rr ,{ ., tt:rrl ,' rl rol ., Irri l ri r|-. N , |l ro(l ri r., 1L)7t, 1t, 1]i --1tl t). tri .-N c (1., S z .rL] 6 L.-, t)|tl rttttutl utn P oD ovi ci rL I-, I' x s (:l | 1., (i of l rt' i u O,, ;i pot tl re t?Io ti ans bc l l !,tc nu:tl (i n l es i ons al U tc broi ns l c t dl Ld Ihe rrl odi l i c ati ar\ ac (u1!i ttt Lu tttl orl l dni .fl l i on ol s l etp an.{ l he poLl l gtuphi c (i nannl i es af s l c .p, S fc orrt Iutc urati orx l s t,.,,t, l l rscrrc l r C odgl c s s , i j di nbnfgh, 30.J une-4 J ul y , 1975, p. 159. ' f., C oi oc :1ru l ropa\_i ci u L., D ul i u ]J ., IJ c c u$ 1,. - U rtl c U oIh I tr i tl .:ti opdl onuri a at .rl .c l i uni tl c urc nus c ul are c u (]c l etl ni ti s m arrl oi l ndn, (b r. ti S t!_ Tg. l {u res , 12 i |l !;e 1975. Iropo\i ci u L. (r.d.) -.fi i l c ps i i !?, E d. D ac i a, C l uj -N apoc l , 1070. tsopo\:i ci r L,, l l i rc k L.C ol l c l uz i i fi IntbLrmi bi nl el o{ l ol oti c c .ID :C ous fi i l Lri ftI ti rLn!,, .otund.ii ,,.f-onros{ialica lteftcbraki lil pri.ti.a uedicald", Tg. Muref, 20 rl]ni l1);'(;. P opovi ci u L., P as c u I., ,)i po$ C ,, C orJ ari rL O., LA z trr L,, A S i ti :r r l t.. B e c u t ' I. - W s hi ng rnd S l c epi D g, 1970, l , 89-101. P opoIi ci l l L., P as c o I. - h ; S i mpoz i onul ,,l c htl l ;"Ldl i l rr pal ol al l i d oas (ul urd rrhtl ttt , S oral fl, 1077, 1-21, IropoY i ci r L. (s ub red.)i U dti fes l ti ri paroti s l i c e utebrtl e tl tepi [rt][i tc , t,i l - [l ,rti (,' t]r, B ucurr$1i , 19?8. P opo\,i ci u 1,. (s ub rc d.)-- t' i s al , ed. D ac i a, 0l uj -N apoc n, l 97i j , (1. fi S rt.c k P opo\i ci u L., l J ec x t T., D rl i u L., $i pof Maf t.r--(i rrl rrl ,r/r, l ( sl ud i ul .l i nfu s i el ec ranl i ogral i c ul putu\l i ol atni i [ot, C onr. S rs i unc r N rri rl :r r ti t. Tg. l l ure$ a S oc . S L. l l c di c al e, 2:] apri i i c 1978. vi ci u T,.- J n: { i . A rs eni (l i d.), al ' rattl L neurc l ogi c , v ol , I, l i rt. } ti (l i (rl rl , de I,rl rcsti , 1 970. P opoti ci n L., I):rs r|1 l .I' ri ux i pi i general e de l Lrapi e naw ol oti c ti , l rrrO.,\rr, rr r (l d.), ' !ral dL.l e x euob7i e, \' oi . \' ' ., Ii d, l i l rdi c al i , I]rour.c s ti , 1079,pp.25:t l ,ti r). P oFo tr,., P as c u l .-' Iul burbi l e de c an;ti i nl d c l i tt l c z i utti te s i s l t:ttrl ui t,ttl tl ,l r bu:i l ar. 1o. L.P opo\.i c i u, Gtt. P c ndofunda (s ul ) (rl .), /,,,/,/ S i I. P as c l l l a7i tr uos c ul ari i d !i s l c rntdui D ertc bto-bu.i l ar, Lr.l . .l uui nrc a, Ia;i , 1!?9 l )p. 2:ti t :l tti . Fopoyi ci u f,. (s ub red.)- S dnl i ol ogi a neutul ogi c ti , Li togul i l r Il l l .. l g. N l or(t, l l r/1r. i ci r P opo\ 1,., B c c ut T., W ai ts rk P ., D ul Me(l . (' l d. \l |r,,,r. i { u D .-l trt. P opovi ci u 1.- I,e{ obti (L nerD i l ar trani c ni " l n: (1. A rs c rr i (!rl , ' ,,t.), !ol, IiI, [4.]. iUedicali, Bucuresti, 1980. l ropo'i ci rr L,, P ende{ unda Gh., P as c u l .B ol i l c aas c [arc c ?t(hl l (tl i uN i rl ,|ul eetlcbro-buziltlr, Ild. Junimca, IaSi, 1S30. P opovi ci u L., W ai ts rl k P ., A s gi an R ., I)ul i u Il ., C l i s pr' rr S t., Il l |l t I 'l Zs.P ol i i eLtopati i h c atenl i al e (s Ludi u c l i ni c fi l i rl G), 1980 (l uc tN l c |l (.pl l l rl l (!rtrr). P opovi ci uL., Itnul i c l l ,* P ul ol o7i a s i s tu\ul ui netD oi D eotl al i Lt,l rJ . Mr' (l i (x 11, l l rr.(l r.rl Li , 1081. P o L t c r .I M. -- .1. Lar' l gol . Otol ., 106.1, ??t, { i 5.1- l -r7. -{ I'o L1rr ,L .t. l ,rrry |l $)|. Otol ., 11)7:1,l l (i , ul J l tl 1l 2. . /' ri ri /r/ri ,, l ,:{ 1. ;\rc (l i (.l l i , l } |l i ror(.i l i , l 97l j . l | \' , I,ro(l csr \i r \' . l 'fi tc'l fl ., f' r' I, Il l rrl tou\\' l i l t,l rtl i ( I)t i l ri c d, l i l . 1111,;t . l 'r'ol r |'I l 0) 4.. l !|||r,.,r, .l ;t i , .1. L /\11l r. S ui \v \r,urri . N (r' r,r' l ri r. 19t9,:5,32.* .3s . popo\.i ci rt L., P i s c u 'trdtal de neurobgie,

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f' { , pr)viciu I.., S tam : r t oiu 1. * Ropor l ld a X, I - a S e s i a r aE E G , E X I G t t N e a r o t i t i o Io!)ie clinicll, Tg. trlur'e$,9-10 oct. 1970, pp. 43-5B. l)opoviciu I-,, Prs c u 1. , At gir n trr. Al{d . l}a lh., 1971, , , 603* 606. 8, , $ipo$ C,, Moldovcanu M . *A r c h ,

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rr (1" l l r rrrrL' N l Il r" l ' l rr l 7 l "' l l \ rl ' I l ' l ' "i ' l :!rrl ' ('l l l ' i i rrr l l l ri rl l $ ' l l )(i ' llil i Ac tx N r tLr0l ' s (rl l rl rl' l rr/5' S I. s.rr /i :' 1(i 7 ' l ' l ti ' " A l l tx N trrf"l ' :' :rrrrl ' 11)/l i ' n d b e l g-\' o I t h c i D r [1' S a s ttl ttl l l ' ' s i ]r' l rdl rri l l fttl ni n 7f [1 \" I r N I , ,S a!-l r;v trl i tl S aracirr'oun* ' i /i ri l l i /i ""'",,rl i i gvi l i (i frrz ilrrstsoil rS ' S ' n" Tl )i l i s i ' 1{ 10() tl ot0 6, ITl htel s tl :o A c tt(hrrri N rrrrl i ' A rr' l" ori i l (i nos hi l a ll' tto x' "' f n',-i r' o' ^rto' ' i s.t"'oj ;;;; ' "x J. Ophthel , 196i, i', 668-67:J' ps tc hi at" 1961' :l ' M--l l l ' N ol ros url i ' D ' C -J ' N c urol K ., P ark S chapi ra ri e' 131.-133' J. .- R e\" N e"rol ' 1968' t ; ; ir N c urol ' (C hi c ' )' 1969' 2' ' 132--1119' " " "; II' N ' .-A rc h' C l aman S .4., S chneck Il r' ' A rc h' N c ul ol ' 1964' 10"1' 33L' P ' D . I-.' R o\1 c l ard S choti aD C l @l l ri (l l t tttl !\' -' P tl tl tol ol i e Gorttl l e M' l ' r' i l l et C h' , 8., B ou rret S chott ct Cle' Paris' 1965' sislill1. 1)e.lebtu-hasildirc, llasson 2?:13' -:i 5l J P trt' , 1967' 1t' 2111J --21?0; B .-n"v. . s"l l "ti Os s f P'A' l I2.rhs II' E dc r f-P ' ' r"r' I' R oN c l rnd S chw artz l :i l ' 'l ' Ir . J r., N c l ]r' ol 1903' f' ;l :l l t 11"-' \rc h' g' A ndc rs ol l ' L' Ir., Il i rsc hberg 193?' 3J ' 15!-4?0' l ' P h-v s i ol " S'4 ., $' r i ght s"l .t*=i rr"" ^ 321-810' J ' L' - l l ars ei l l c l ]Ii d" 1972' -1"' G., Gas !aut' ti crratri ce

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