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MlNtsrERUt
EDUcAIIEI
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lNvATAMiNrutul
Prof. dr. doc' CONSTANTIN
ARSENI
Prol' dr'
doc' tlvlu POPOVICIU
sEtvllol"offilE
(DE
LA SIMPTOM
LA BOALA)
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BE MIOLOSI-N NEU RO LOGIC A
Probleme d,e cl,iagnosti,c topograJic pi.
etiopato-
genie Ln: l,eziunile nerailor cranieni,, paralizii,
tulburdri d,e tonus muscul,ar,, ataaii,, migadri
i nool u nl are, l ul burdri de sensi bi l i tate, ti ndroame
algiae, tulbnnd,ri troJice, agnoeii, aJazii,, apraoii,
tulburd,ri de conptiittld, gi gtsihoorganice,
PRETATA
Pd,rerea noastrd, baza,td pa o eaperienld, 6nd,elun-
ltatd'
esta cd orice semiologie d,i.n orice domeni.u medical
rute bi,nauenitd, iar d,u1td, apari,l,ia sa se {Lftee?tii cu
erd,bilare sd, aind, o akd, semiologie cu acela,si proJil.
Orice semiologie poale
li
a4tusd, 4,tr, mriate
feluri.
pi.
cste ind,epend,entd ile altarilia ao , nui a tratatalor iJe
aul,a7i, profil. Deoarece 4n literaturt med,icald, uni-
wrrald, sdrtl d,estul de pwline semiologii - noi ored,em
ritr sl,nt mai. d,i.ficil de sois d,eait url tra,tat - e bine a
w scrie cl.tr rnai. rnult, cd,ci
fiecare
clinician, d,apd,
rtttt4tcytf,ia
Si
enperi,enla 3&, o Da scrie nntr-un alt mod
d(
{ltnd,ire
.
Nu trabuie sd, surprindd, pe nimeni, apari,tia
uoe ci $emiologii. Neurologice, d,ugtd, ce dtrinele librd-
rii.l,or au odzut 4n acapti. ultimi d,oi. ani llratatwl nostru
d,o N ettrologlie nn cinci uolurne. Aceastd, carte a noaatrd
pinq
da.fapl, sd, umple un gol e*istent:l,n aetiaitatea
th
pi
au
pi
o, nxed,ieilor neurologi,. neu,rochirurgi
',,si
okiat da fl,l,te specia,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'ntul uni-
acfd'l/j.r pi
!)ostuniaersitrar'
Ne-anz gtropus sd aborddm,
ln pogini,l,o o,oestea, o alNd' morl'al,i'tata, mai practicd'.,
nai
qfioCan'ld,, itre 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, lnltlni toala noilalitd,l'il'a ila bnbinnra n ll,nt.
Tttomotror,
o sinl,aal, ila ternne ou lllo diagnottia, oara
td-l orienteza inreiliat 4,ntr"o ileci,zi,e diann,orfliad, d,a
urgenld pi,, itnTtldoit, [nlr-o atitud'i'ne l,arapuulicd' atlcc'
tatd. XmT inim, grrin munco d'epusd' I'n sistamatizarea
a,castui, material cara refleotd, o dndalungatd' praat'ied'
tra patul bolnamr,lui, 4,ntr- o asid'ud, actioi,tafia alinicdl
un d,eaidaat major, dltctatr d'e misiwnea med'isttlu'i
practiciatt,: ajulorarea bol,naawlui. Nd'd'd,iilui'm cd'
prin acea,std, carte ne aom
Jace
wtili nobi'lei' sarai,ni'
cnre ne std, tn
fald,,
4n sistemul nou d'e d'sistenld' med'ical,d,
d,i.n patria noastrd,.
AAIORII
CUPNI,NB
l . l rl r| durnt o
l, ln)lrlnmc di dloUnostlc topogrnllc
tl
etloPAtogonlo h lezl[Dlle ncrvll'ol cioslonl
: t , 1. l r. rt ol ogl d Percchl i
I .
t . t , l , ut ol ogl { Pcl echi l
a I I -a
l.ll, l:robl0nlo dc diagno6tic ln exottalmii
" '
r
" " '
l.l. Itrottlor ) dc dlagnostic tn patologie sistemelor oculo otorii
' ' ' '
l.h, Prohlorno de dlagnostlc lr! patologia nelvului trigemen
Li lrroblGt o dc diag:nostic ld patologiA nervului laeial
L?. lintltlnnrc de diagnostic in patologia nervului scustic (cochlear)
' ' '
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
'J,lil,
lrro}|lrnrc do diagnostic in patologia paraliziilo! rnultiple ale nervlor
r' f l rrl r! rl bul bari
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
' ' '
L Fmlhrnr dn dlo0nostle h tulhurirlle tonusulul mu6euhl
a, l , l l hol onl l l o musaul are .
a, t , l l l Df rt orl l o mucoul qre .
1,9, l)lrtonlllo
l .S,0onvul .tl l o
l, ?nltror dr dle0Do.tlo h tolburlrllc do i'rtlb lrob
t,t. nloonundlrl mctodoloSlao do sandologlo
?,3. Froblomo d0 dlsgno0tlc topogtqllc $
otlopqtogenlc'
?,!1. Froblono do dlngnoltlc ottologlo tn 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$
l, litltenl$
do dlo0trostlc h ottrxll
ll,l, FrobLrrno do mctodologie seiniologica
}1, PmllloDro do dlegnostic etioDatogonlc ti
topogratic
l, ltrotlmr ao ilhgnorilo tn semlolo0la ml|oitllof tEvohtlt[lr
' ' ' ' ' '
| | l , !l l Drrl hrorl l l c
0
t 0
TO
t 6
g?
40
78
84
92
0tt
11r
116
t 18
[10
721
183
13S
194
19t
168
i 08
170
r80
180
[81
101
191
100
,08
210
t10
,16
It6
246
,46
!{t
t02
9. l "ol , l onr n
' t n
dt h x, ^t i . I n r r 0r , ozt l
11. l . Agl n) zi i l r l . r r ct i t o
l ) . : 1.
t Jnozi i i c vi zual c
: r . ; J. gl l ozi i L!
: r u( i i t i \ c
270
27(t
275
315
:\,17
3. 19
: i 51
352
l ) . . 1. At j nozi i l e i nl agi ni l or . cor por al c
I0. l|rubll.|Do dc diagnostic in tulburdlite d0 vorbiro gi lD afrzil
t ( ) . 1. ct l si i i car ca
t ul bur : i r i l or de vor bi r c
1O. 2. l ul bur. ; i ri al e rnri si uni i si arl i cul i ri i cuvi nt el or
I o. : 1. ' l Ul br r f i r i r i i r ] t r cpl i ci , conr pr r j hcDsi uni i ,
I or Dr ut i r i i si
r , . r L. r l c
rf xp}esici siurbolurilor
276
2'.19
2',7 S
275
282
295
;J02
J02
I t . | | | r t t r nr ( !
dr , di
l , Dosl i c i t l l r pr a\ i i
l l . l . I ) f f i | l i t i i
I 1. 2. l , l \ i ur ) cnul l l pr ar i i i l oi . .
l l . : 1. l i r r Jl , l ( . r l i i cc. . t 1c apl , ar i i r i
l i : . Pr r bl el n( r l r {l i r l l nor t i ( i n l ut bur i r i l e i t e conl t i ( at i ( r unost i l r i )
l : 1. 1. l , r i r ) r i l ) i j l f
r nf i {) l t ot opi {r c sr r r i ot ogi ceJ
de di aguost i c et i ol ogi c si t opogr : r t i c
I i l . l i r l bur ' t i r i
t ) r i hor , r r f t r i . r , .
l l ]..i :1,,,1",
,' (ti ro.l r
i ezi uni tc ,ti Il p,,";",
*.,1r...;";.; *u.,,,*,,,,i .,
,,""0l "i
l : 1. : J. Si r xl r o l | r t , ( l 1r i ! ( i e l ezi ur i i r 1 nucl ci i bazal i
l i l . i l . s; ndr . ) ur r x, ( ht c
cl r l L: zi uni cor t i cui c
I : 1. . 1. Si I ( l r r J l l r c i ht f r t r
j czi r nj
di l uzu
l : l . l ) . l . i i udr oanr c ( t l t c ( l r l ozi ur i si t ust e D
. \ , . r r i at c
et r j c
1.INTRODUCERE
Penlru a veni in spdjinul rnedicului practician neurolog
l l , l l l l
l l rr)pl fs si i scri em
^ceasi ta
I en?,i ol ogi e neurol ogi cd d,e urgenl i i , i tt <:l ra
rl ' r rrrr .r rrrr prezenti ,m i n mod anal i ti c tti versel e semne subi ecti ve
;i
,,r' r,, tr\
' ..
r.i r, i rr numeroasel e semi ol ogi i cl asi ce, ci sd, sugeri ,m qi si , col ti l _
r rrrr rrrrrIIr1,Il Il posi bi l i t5,ti
di agnosti ce si ndromati ce qi de boa,l i ,, porni nri
,l r l r , rrrr.l rrqi rr
el ementarS, cu al te cuvi nte Sd, potni m de l n si nt|tl trnt,
,l | ,rl rr' ., rr l l , boal i i r l a di agnosti cul neurol ogi c, care si , perrl l i i j ti i ur(r(l i rLl
r i l l r r , . r r r r r r . i r r , i i l , r r di ni pr act i ce, de ur gent f .
. I r ebui e
sd por ni r n dc l a i r l r t l r ,
r.r ,l r,,"r' , l rrrrl nel rrol ogi c necesi td, cunoa$terea unei semi ol ogi i prl ci sr.,
r r I rr.,, r, ,r urrl i di sci pl i ne aproapo matemati ce.
| | ,
l r,,,
I rrrl ,ua 5, metodel e paracl i ni ce modeme de rrri n,c
Drrrcrzrc
L | ,r,
'
rr
' ' rl i
l l [ {i ael e (el ectl oencef:}l ografi a
cl asi ci ,
$i
cea i nrl rogi i (i l i r
, rl ,, 1,"1, rrrri dc i nformati ci , sci nti grafi a cerebl al i ,, ecoenctl ri l onr.rr I.i rr,
rr , rl ' rr\ , rl i gal ,i i ul tl asoni ce, angi ografi a cel ebral d,, studi ul cfi xri rrl rri
l r , , t , t , l , ' ,
l r r r ' r r r not ' ncef al ogr af i a cl asi ci
i i
f r ac. f i onat l , angi ogl l , {i r r spi -
, r , l , , l , , l r or r r i ogl l f i : r
cu r i r ul t r pl el e sal e adj uvant e, el cct r odi agl osl i l r r l
r l r l r r r r r r l r , r ' r ' r i r l o dct ec! i e si i ndeosebi el cgant a, mi r i {i ca, spcct acuLl l t sr r
r , , r , , ' j , r . , t r i
r r , i r r l i r or nput el i zat : ' i
)
au l i i r gi t consi der abi l ci mpl l i l c i nr r os
l t1, 1,, ,,, ,i rt(,l []gi o
fi
i n neurochi r.urgi e. Cu toa,1e &coste&, c)i tl ,i t ot,(,I i ui t r.i t,
l r , r r r r
l r . r l r r r ( i ; i
pl cci zi e nu pot sd,
, , dct r ongzs' ,
exandl ul cl i ni c, r r r l i , r r t i
, r , , , , , r , r r r r : r r ' i r i l r r l r i , f i ne{. e t l ebui r r si , r l i r i j cze
al , i t i ndi c: r , {i i l o nr . l , , r l ol r r
l ' ,
, , 1, | | , . , , \
l ) r ' r i o
l ni t i SuS, ci i i
f i
i ust a, i t ) t of pr . cl t t , c l t cer ' C0t ?i l , i i i nsi r r . r r r r 0n-
I l r
'
1, r i , ( ( (
l {, { i . r l ( , r l cl ( j df ,
( : , t : Li ; l r c,
cl i t r i ci anul nt r
l t ol l t c l l psi , r r l nr t
| , , , r 1r ,
l r , , r ' I r r r r i r I r r L) ' r l i n ci nr l i ul r l r , l t r pl l i , t r r t l , ot l ol ogi c r l l ( xl ( r . 11, r l r u: ni oi
t r r
l r r r r l .
l r
' , l i r sr r , l ,
( xt l i j {t ) i ' ) ) r l r "r , i i l l r r nr ol ' odol ogi l l r t l r xl 0r ' r r i i . Nr r l r . ol r r r i r r
' , r
r r i r l r , r ' r l r t l l r I r v l I i , i t r : r i l l 0 r l f 1t r l t l c, i sc vl t , 1: kt o t t t r t r xi t r t t r , t t t l l i t t i 0
' ,
t r l r i . t r l r r , r r r r ci t i 0 i t r r r ui sr r t i r $i i ,
( xi ( ' t t l . ( r zt .
1xr
0l i r r i t . i i r r r l r l gr | l t
i r r t , r . sl , i -
t , r l r t l r ' r | | I I I : | ( , I i | | i r u. t . l r r r r l t r ' l r t r i t . r r f r . r r l t I t l r . .
Intlad,ucere, Fatoiogia nervilor cranieni este deosebit
Irogu,l;ri,
ryi
de rl,rial5,, atit stb
.aspeetul
proceselor morbide xesponsa
' .i t,
fi
$t[r asl rcct,rrl conti gurati i l oi
;i
al contextel or patol ogi ce
.\r:r.:r,:,t,i r, compl oxi tc,te patol ogi ct,
de mul tc ori l uxui i anti ,
si ,
.\cr.irtrir,ir oomplo-xrrc,re patologrot,
d.e multe ori luxuriantx qi cler
,.,r1,' \ (l (,1;{runrnatrr,
pe dc o parte de pozi l i a strategi c[ a nuol ei ]or de
rr,u tlo 1;crminare in trunchiul cerebial
;i
in iorma.tiunile
r ul i t oont o &cest or a,
porrl ;o-ocrebel os,
i n stl nca
rrtrr rorfi i rnrgi cal c.
2.1, PAT0L0GIA PERECHII t tNERVUir 0LFACTIV)
ll.l.l. tn prozonla unor disosmii la indivizi la caro un eorocr 6xam
C' PROBLEME DE DIAGNOSTIC TOPOGRAFIC
4.
$I
ETIOPATOGENIC i N LEZIUNILE
NIiRVILOR CRANIENI
l ' l l l t r ' l i t r t r i i n. l l n. nr l t t t i i ( r t t r l cot r l r i vi r t l i t ' t ' , t t t t t i r t l t ' t i gl i l t i t l r ' ) , r : i t t l
l ", l I ' r t r l r r r . r '
r r r r vt i l , r ' ol l r r cl i vo r t r , t t l r zi t t t t i t i r t l t t cr , l : r I i l r ' . l l i l l t r t i r t ,
l l t t o
l t r l r l , r ,
.
|
| | r | | | | | r
(
' i I 11i : r l l r , i t r [ . r ' ( i i gct r ol l t l o
l t r r l ,
pt ' ot l t t r t ' t l l i l r l t t t l t t t r i l t t t r vt i l r '
r , l l , r , l r r r 11/ r r r r r uor r i r r gor , r r r r r ' l : r l i l r ' . Sr ' 1xr l , i r r l Jl t r i t t t l t t i t t gr t t ' t t r r cf l l i l r , ( pt t t t t
l r r r l , . l t r l r r , r ' r r r l r r r r sr ' , l r r t r l i l r ' ) ,
( . 1( j r , f r r l i f t \
r , i r t t l ' i ct ' , t t t ct t i t t gi l r r r r 1t i r I t r I I r i cr ' .
l l l ' l ' t r t t t l t t l i snt r : ( l ( t ! l , r r t . i l , i r l i i t : t : l u. l , i or : , r , t t r l i vl r so I r t ' r t l i zi l r ' i
r yi
k'
r t r r r r ,
l r r ' l r r r r r r i r r l r r t r r l l r t r r : r ,
l r i l l r t t t i r l ci
r i r zl l ( f ,
( ' ( l t ' t i t ( t l , I l t t t r t r t l i t u' i l l l zt r r r i
r l l , r . l nr , , l l r r cl r r l i r r kr l l r t r r ci ci t r t r t i f i r r t , r l t noi t l r t l ui ( cu l t ' zi l t r r t l f i kr t i ' l r r l
r l l r , , i r l t \ | | l r . | |
( ,
| | r ' (
) | | i |
(
) r '
l xr l i l i t | ' i ci I i ,
ov( t r l , l l i Ll , ou sl | pl i t i nr ' f l , t , i i st , ct t t t t l i t l c
r t r r \ r l r . , r I l ; r r . I i vr ' ) . l Jr r col i r ur osr ni i l o po$t - l r : t uma l i oo pl ) 1, t ' ( ! ( i t t l l oi t I l t
r 1l r r l . r r r r r r l l r r r r r ur r r i l ct Ll i ,
I ) l i r
( x) nt l r l l ovi i , ur i ,
l r , bul l l ul ui t t l l l t cl ' i v
r yi / sr t , t t
rr Irl rrrIr' Ir.Ir,Iol ol l ucl i vrr. Al l coI' i ba,ndel otcl e ol 1' acti ve pot' Ii l ozrr,l ' o pl i tt
l l r , , r u.
pl r r l i ; r i Lr r ni ci ul c sl onoj dul ui . Jl xi st l si l , t t a{i i i n t ' at t t r i t t ot t t st t l
i t| "r Irl ' .rr' ' r1i i r roU r' ochi ru] gi o c, ri di carca l obul uj frrrul al ptti l l o l tftrt' l ,a
I r r r t r r I r
.
I r ' I r
.
I r
,
rrl l rrr,l i vtr,
(i i l ro
se atl al po l :a!a, i nl :ori oru' i , a, l obul ni orbi l rrr.
Al l , . , , r t , l r r r r r r ur l i sr r r cl c, dat
l i
l ezi uni l o vascul l uc
l ot
i r nt l ' ol r r l upl , ur N'
n' | | r ,r l rrrri r
1r| rIi crrIrrIrri
vnscul ar provcni l j di u artur:l oerobral i l ruti ;trl ' i tti t I l ' t .
r rr r. r,r, rl r. r' ;i vrrscrrl rrti zeazi i bul bul ol facti v (Dr*l oi x
fi
fri l rtt' fl a, 1l )l -;$,
I l l ' r l l r l {, l \ l r l r 16r . scu, 1l }?5) .
' | ' r r r r r r r r r r I r r r r r r r ' | c
cl ani o- cer ebr al o pot pl oduco r nosmi i , hi posnr i i , t l : r l
r l
I r | | | | f
t r r r , r . r r r : ost r r i i
Si
hal uoi na, l i i ol f aot i ve.
l ,r,l l rrrrl ,. l r:rzci crani ul ui artreneazl tl cstul i l rl frecvent hi po- srttr
. l l l l r nl l r l l
1, 11111111111r r 11i N i ccol l i ni ( 1958, oi t a, {, i dc }I i l oqescu, 1975) a, u ar i , l t t l
i ,l l | | | | |
i
,
'
| | I r I I t
.
r r r.rrl cfal opati i l or posttraumat' i co oonsecut' i vo l tzi uni l ot' r' ol t
ItDl ,,rl l rl ,
1rr,
zrrrl :i i n contextul cl i ni c tul burl ri scnzori al c, i ncl usi v aartsrni i
I t t ul l t , r l r r r l r t , 1r r r
r r pr t i xi mat i v 10o/ o di n t r aumat i smel e cl l l ni o- cor ol ) Ul L'
f l ' l r
'
I
l l i , r l , ) nt l t t t r ( l r : ul ur ( cer cbr a, Le ant l eneazi , r ar ' eor i t ul br t l i r l i r ) l l i r r '
l l t r , \ r r r r r r l r . i r r r r l r r r l r t i ol cI ochzi a pedi cul ul ui vascul al pr ovol l i l , ( l i I l
r t t l r ' r r r r , l l r l r l r r l r r l r , r i ol r l i , cal o vascul ar i zazi , bul bul ol f l l el i v ( I ) r xl l oi r
t l l , l l r , r , r , l l r l r H, ( l i l r r {i r l e 1! l i l oqescu, 1975) , poat e pr oduc{) r l n( , Bl nj o.
l l l Itrh nrl o.t:i ut.l i i (cu atropi rri ,, cu rnodi nX, cocai ni i , sul futi r,
(l ('
r,rrrfrrrrr ,, r ) ri r .!l ri ,.i /(r
l ostnarceXi ,(e
se pot fl ol da cu hi po- s:ru l tl tostrti i
| | r l l l , l l "r i l
:' | ' I' l )i vt:fl tti u (unosmi a, hi posm,i a
Fi
eaenl ual parosmi a
)
cu,' i nut -
lntt' ltrti rt prr4tnwit:d. ridicii ulrrlitoarr:lc problomo ct'io-po,togonioo :
l l l ' l ' trl l ' tt,trt
,l .f,rt' ti tt ol a-zi w
,,fi ai ol ogi ce"
, Sunescenl a po&tc 6i t ror,-
l l rr,rr,
"
l rrl r" r' l l l r( (i $, i ' ot|8(' (nti vi r procosel or' fl l nol i co al o neuroni l ol ol fa,o-
l f vf
;l
rrl r l rrrrl ri urri l or rru,sl om. Unel e std' ri ,
Ji zi ol ogi ce
l o
femai
(graoi i l i .-
Itl rt ttu n,,ftu::tl
/
rrrrl l enei rzi i , uneo porturbtrr' i l n perccpl i a, mi l osuri l or' .
Fh I l rrnrttri , rl r,
l )i l (l i ,
hi ;xrrosnti i r di n pri mul tl i mostru de gravi di ttttrl
l l
l rl pruuri rr rl i rr rr,l rl oi k,i r,
1i
al l ,rci l l l tri mcstru, cu roverBi bi l i ta,totu l ,tl l bu-
l {t l hr | | | ur ( , 1l r , r ol l i t r r t i vl dt r pr i nr r qt r . nr ,
ff) l ,nr,l l l ul i
l ynual t
(r, (l i ab(l l ,ul ,
ur' (' mi a, pa,l udi BInul , homopnl ,i i l o
l Il r,]l l r,
l r,l /r' r.rri i q,u,.)
1xrl ,
af,r' ct{t, r)ouxmi i c{,i l or ol ftrcl ,i vo, pl ' i n (l i Yortt(,}
l r r , r , r | | r l xn| | ' , r , r r r r . l l t r t i Bl l l i ( . i cJl i cl : r I i l i cl r l , ( 1,
f i )
' /' r,,r
rrv,
l l nrral t
tatt, l rx,c&r.' ntorl i l ru, $l [l ,ul ni fi nl ul , l l r,bngi l nrul ,
*l I r r l t l I r , i ( x I I r , l t | r , nl ( ] l ul , r ' I t r l dn
,
r i t r ' l | 1ul
( 1( ]
n. r gi nl , , 0l onl r f l
( l o
zl hat ,
rtrl l urx i l r\ r.rfl rrr, l l rl i ri rr(,rr l or' i rl i l rl c sol uti i hi ;rol toni ctr (cl t.t' u sr' ,
1l i r.
t:11,
| l l l r , l | l r I r l l l r ol l i r ot i r ' i ) .
rrorrrol ol ;l o l rxt[ i ntogri tatea neuroni l or gi n ci i l or ol l aeti vo, esto vorba
dl rosrrri i rl o nnturd
_ri nol og,i ed
-
("Mi l oqescu, 1925
;
Chusi d, 19?0
;
Ri r
llll"r9.; l'opoyiciu.Fi Pascu, 1.980), Acestoa se caractorizoa,zd, pril'anos
ryi
hiJrosrnli respiratorii (unilaterale
sau bilatralo) provoctto
ale
rori,at|,
e ra. impioclici accesul curentului respirator- la zona olfactivtr
l,) rtonozo
ii
sinoohii naza,le; b) hipertrofii ale cornotolor nazalo i o)
pozo (t:ol
mir,i &desea inJectate) : d) de;viatii de scrt: c't rinifa'c.i
pozo (r:ol mir,i &desea infectato); d) devialii rlo l,llzo
(oot rn&l &desea rdectato); cl) deviarii do Bept
i e) rinite acuto
orouitlrl do divorse naturi
I
f). ozen*.; g) reactii alergice uazalo; h) tum
ll'i;
iii;, .t
;j
"i'.]t-i"i#
.
i:
""""ir
if
'
r
ii.'# fil,.rd
sT
H' .#. J,T,ii ii
j)
sl;il,r'i.dupl, intorvenfii ohirurgicalo po etajul supeiior iazal qi pe sin
nrrr.i ; rr) diverso dorssH,ri resDiratorii. fi ul i
;
l ()
rvellrr o,orruJgrcato po
dorogld,ri respiratorii.
.
2:1,2, Disosmii produse prin aleetarea neuronilor ollaotivi gi a
ol l ncti vo.
?.1.2.1:.
Di eosmi a (anosmi a, hi posmi a gi eaentual parovni o),
ituttalowd, brutal y.i asta
Ji9
un ilaturAld,
Jie'ile
obicei bilaterald,'ie
nrtgr,r:l rr l t rri l l .oi r,r' rrl rr l r,tor.!i uni :
l t l
l l
,,,( N,H r
(.
i
.
i,u lbu;x;i, ti"t-iii^ rifi t li,ii ?':ri:"if
ff
,.f T1,,T*1ilT%11
:rrkrsoir bollavul se prezinti, Ia medic aor" .to""i-
"i"dliur
sau se il
rifilr'i, cof i ce,a qi_tulburirile
oc olare *sociat!;;;;ifi
ifii*roi, , ou
l)r:.rrrrrllc.ori,
cin<I cstc recunoscuti,
.1"
"iii;
p;;i;;t]-,
Ja' este atritr
::l::l ll:,:ci'l,rl,1.l,l lli 9"qrg
locale nesemnificrti""'iri"itiil
iirofla mucc
rr;rzrl ' r,l t:.)r rkrci t; unei l ezi uni cerebral e
ci ,
;i i t;.;,,' ;r;i se* acoroa
l : , r t i r ,
'
uv! . r i t r j . ( Ar s. ni
5i cohb. , . 19?J) . ' ; "; ; ; i ; d] J"r l r nn, oe
:i:,::l1ll1l,t..lll],'l,t:i:
poale insoli un sinaroi" F;;;l{";;;d;;';;;ii,fi
i r(fr.r' rf r pl t t,c cu
.tumol a $i
cu atrofi a opti ci ,, Deci , anosrni a' prerl
nrl ti r j .rr
u orol usi vi i ,
_de
o parte, qi coi nci zi nd cu al i e' se;ne tumo
:r lr' (
| lt)irit (f
vil|ra,r'e diagnostici'in
meningioa-"rc ofircli"".
A rrrrv 1l;1111111 de arteri, ca?otidd intein-d,,
osteomul frontal,
gi ot rt t t l
st t l l t i l scl i t t . i j Dmori l c r' l a , r. r' i n; . mi . ; , l j
"i ^; : ri ; , ; : ^' ^
-.
l .l r{' rr,r||l sul rrrsr' l i rr,
tumori l e de adpd, mi cd cl e sfenoi A
si unel e tumori
rl f ) rrrl f l . l .l
l n)L
(t(,Lermi na
tul burdrt-uni l al eral e
al e mi rosul ui , cu deoset
::,ll:il,: lgE:,1i-rrtolie.(Arseni
si-
corab., isii,lsd)."-;;rmii
bi.tatel
s. p.l, irrlilrri in meningioame
bffactivJ giganiq
"ri6'r" ""ii"a
ql d"
l:::: lllll,-itt
in t umori hilofizare expansivZ
!i
in iiO_"oc"rariic"
-""e
I
:::i.T::lll: iillill"Jl,lie:lii
jArsen.i
qi iota'b,-1'erz).-iiu-u,i'i''au.i,
ur
y::
:ll.:1.,.':' i":.i::-?lli
I anosmiei precoce in cu rsul meningioamelor
iltrlorior, in vreme ce aceasta e-st"
-u1t
*ai u"ri" iffia1i oe cetre
l:liillj,,
it
-jt?.,1"-
.":emptu .
neorgmaliunte
rruruilro"iif
ii
n r"
"on
r:rlus,. t'.r'aniofaringioimele,
g[oambte
;;"r"r;i-;fi1"
"fr'
jumoriie
::)-1;li,lil,?"9"_:,-11
gtioamae
Eentrale .r" rol"i"t
"i"ontJi
pragur t
,l"ll,Jg t,
ri"lmin:i rionnal multd, vreme, ir" ;;;;'.;;hJta estu rare
Inl,iluitri,
1,lnliv. .h rr,prorpc o treime'din ;-;;l;gr";;;il aripii mici
rli.rroirhtlui,
so pt'orlucc
in-itria,l o crcgtoro a prag"utul.
olfacnv. resnec
r{o pl ' o(Il l eo
tnrUrl (,
crc}l ,oro a pragul ui .
ol facti v, res
r i [
( r (
] { r r l r ' l | : I r 1 r i r , r r l r r sr . l i i
. l l r r r . l . i vr r Fi r l {. st : r l r l c I i r zi u sr , i nsbal , l t i i i r r t
i Jrsi l nl ' rrri uhL r,urrrori i (l ti srrr, l r)fi r).' Arsrni
r' i
,r,ri i i i .
i r.9i ]l j -rorl ,r,rrl ,z{,
, '
l "rt . .
. 11 | I t , l t , ' , r ' . l t r l i r '
"
) r l t t t r l t r r
' l l r ut t t , t l i t t nt
r r u, t t i o- t t n' ebt ' aht
( l xt zr t ' l o, I t ' l r l t l l l Lt l , t t t t t r t t - l t i l xt -
| , , | l r l ' l ' | , r r I r ( ' t r c| I I t I i t , t ' ) .
l 1 t
j ",
1t , nt i
t , nr l r ' t t i . I ak:
; i
r nt t i t
At t r i nt i m, - r l r '
l t i kl i 1,
r l i s1t l ut i n
, t l r ' t , , r 1, r t t l , r l t ", ' r r t , ' i i i st t nl c: r zi l
, t l r , 1t r , 1i c t i n' ' t l t r t ' 1 i t : i ( r l l hi Do- - si l ' l l i l ' l l oi l
' , i ,
, , , , , , , , , , , , , , , , t , t i z, , t t noi r l t t t t l )
qi st : r nr t t l
r l t r i r r t a, nf i l i sr r l gt t t i l ; i l l ( Al vool r ' ,
l l l , I l \ l l l l l ' . r , l l l {i l ) ) .
l l l l t r l l , r r t r r r i
Tr si l t i t : a
"
nt vnl zt r ,
l l si l t r r zt r '
Anosr ni : l i sl ' cI i ol i , t l r r
. pi l t l i i ,
",
, , i i , , ' 1, ' , r , , , r ' l r r r r r i bi r t c 4i n4 bol i r a' r t r l t r i si l r r t i r oa' s. i l r nt t t t i i t ' t r ' As1' l i ' 1,
r| | r,r,l ,r
,
,l ,
'
r
1'
r | z i r rl ri Rl l t,rl tl nazo-l acri rnnl
(pl ' i n sti mul trtn' tri gtrtntl tl ttl tti .t kr
, l t r , , r r l , , l i r r l : , i l i t t r r r i r i ) , l ur l ecr noa, , st c r ni r osul , t l cr yi l i i cr i t t t I r r t ' a' l kl i t i
l . r l r '
'
l i r r r l {. t r l r i ( , , \ r ' soni qi co1ab. , : 11) 77)
l ttttt t' l r
l )t
t)11' !)o cura i ntereseazd' ratl i al i i l e
^ol f
ud' i ' tr(t.
.8tt' 11'
txtrl ttrttt' l
l t r r r r r , r r r ,
r : r r cl l t l i l e, t r aur nat i sme oi ; t l ' ) nu
- si nl .
i nso{' i t o ni r r t ot l r r ' l ' r i
,,,,,, ,1,,
' t
i rr crtzuri l e de kvi uni l l i l l ,t' cI i l l o, hl ttttttrtrtt- trxpl i trl t' l ti l
,,,, , ,,, ,, ,
j i i l ol
i ntracu ebl al e (Al scni qi col i l ' b' , l 1)?7) Itt
.rtstt
, , i , , , r ,
, ,
' ,
r r r l r ( r r , , l l l r oi i vt r qi , dc ur ul 1, c r l r i , l cnomcnc do, t l l ! {l }ozi o i l I l t i r l )
"l l l t
t \ r , ,
r r r
. r
l ol r l b. , 1977) '
l ,l
l . l l l l ,' r' tl "rrri (or' o$terci l , cl pl ci ti r,{i i ol l l ' cti vc) sc i ' r.tl ' i l l rcl kr tl | sl ttl
t l t , r . i r , , , t , i l r r t r i l . r r i r r i ni i t e l a subcr , 1. 2. 1. 2. ' c1- oxc. . p[ ; i i t ' i t ' f r xr f i t t t t i l ' t
i l "r f , r '
,
, , "
, r , , . ' ,
, l , , r r l r ozr ' ) .
Hi per osmi l
por r . ' si . r cl l i zt ' zr ' . r r l r {{' t i r ' [ or ' r r r i l
; ' , f r ' r
"l l
l , l , 1,
, , t , ,
t r , , ' . r i
"t . l odi t ) t i ",
r r r ( ' so i l l Li l l r c: l {' l l l l l ( ' l l l i r sl . l l l ( l '
I ' t i , , , , , , , , , , . , r 1, , l Nr t | i l r i i ' i n' cur sul l 1r sS, t ur i l or
gr avi t l i t xl , l ' l t r ovt r 4}t ' {i
ai t , , , , , ' , , t , ' l r \ r 1r . . r I r I t r t | | : | I i . Al t ( ' u1i , l l i pet ' ost r t i i t ' si ' pr r r t l . l l sr ) ci : t ' cl l l l l l
i , ' , , i u, r '
, , 1, , r r r . r r . ; r l r .
1\ i
( . r r
l i . n, nl cuu r Jo hi pr . r r . r t i t r l r i l i l r t i c l r i g( ' l r r i r r r r Ji r l r
l l l I l t
l t I l \ | t t . , , r r cr r , l l l ?I i ) .
l l l r r l r Ur l r . t r r , l I i i r r l i hr i t r :
qi i r r ur r el c cazur i do opi l ( , , psi o, l t t t t l t ol o
| | | | | | | | , , , | | , ,
I , , , , r : r | | ; , , , r , t l . l ) t : r l r . , i r r I i r zr . l t ' dt . t l t br Ll . : l l ' l l l l t , r l ul l l l ) l i
( r ' l {'
i , t nt u,
, , , l r r l r r , r l r . , i r l i sr r r , i r r pi u, , l i zi . gr r ol al l l , i n- mi g- ur t o
r yi
i t r un. l t r sl i t ' r i
i i i r, i l i " , , \ i , , r' rrr
ri , , , t rri r. , i 1)7?; l \ l i l orycscu, 1$75; l l ' i sot ' ' 1{)52)'
l f I l , I' r| | .orrrri i l r. ri rrl , rl i sosrni i 0i | -0 cuttsti ttt l u i rtl ,erpl oti t,t l ri t, i l rrtttl t,l ,r' 1,
t l l l r l r l l r , l l l l l l ' l
I l t , t t r I r r r | ' r t r {r ' l l ' t l r r r t pl t l i l i l l r
l r l r l ' r l f l r t i i l {) l
r t i t r t l i l ul r ' vi t r i : l l r i l t r ' l t r t ' i l -
l t l r r r l r
, t '
r l , l , r ' , ' r , , , ' t ' r , t ' i l i l i i
1i
t ' r r r r l csl r ' r ' l i r r l : t t ogt ' t l i l r :
; i
t opt t gt ' l r l i t xr ;
, t
t I I l ' rt t t t t nt i i l r l nt t rt l t , nt d, ot ul ' t t ' f l I rur t i mTt l i i t t ' nt ' i t t t t t rri ' l , l t ' :
l ) ' , , r r r |
/ r
f t t l t ' t l i t \ ' : gt ' r r vi t l i l : t ' l c.
) l l l l , , l t t t t t t t t t t ,
l t : t i hi t
"
l l ( r vl ou( ' ;
l ) si l l o' ( \ ;
sl i l r i r l t l l t t r t t t t r t t l t ' j
1
l l l r , , . 1,
r r r t l l l t r r ' 1i I
t r l t I t | i i .
l l l r t , ' t t t t ul ul ni ui t t l t i t ' i i r r not ' t t t ul i ut ut t : t t l r : ( I r t r I i
1
r i t i t t i i
, l l l ! 1r r l ' l l l l ' i \
t l r ' I r , l r ; t r l r r r t t l l l l t ") .
l \ l
r r l l r | ,
'
i
t l t t r r l ' , '
rk'.jrr, trilltcratil. S-a ardtat astlet
lerseni
qi
"biffi,
is?ej;;, degi ant
;:,i ' :1:] l i i i :.1:i l .:"T-1-q' i ol i ppr
i n ri reni ngi ormer;.1;,rul ;i
i i tacti v, i n
z|' r(.rx|||l rl vu,)r' i t,cerSti i
dcvi l l e sesi zabi l i , doar atunCi ci nd este bi l atr
i i i r ",
'
, i ' r , ' r ' r ' r l : r l , ' t r t l sr r , l L bi l at cr al o, st l
l l t t l l t c
t l t ) r ) ' s1' l [ i ' i r t l r t l t t ' t t t l i t t t i -
i , ", ,
, ,
i i r 1
l s
r i
l t
,,,,,,,!,:,1,,,0;o;,fl{tffi
?lffi&:"\':2i1.-peroeperea.unorcu.rodsubir
f :
j;iffii{{Z#:d.
jr":"_d,p';ffinn"T,il'H:ABffi
ji:"U/fr
:
Iii-,:1fi
.i$";"f;*r*"
"-;*t':#*::l[it:,"ffJ,",S"JT,,?il,*.f*j
xl hr , l t v l xr r r l , o
l . i i nkr or r i i r l l t r or ul r t r l r r t ' i zoi t t t t t : i nt l l , t r t l r r t t l , t t l l t t t r r l r t r
t x
r ' r l r r l r r . . n{' "r r r yl , i i nt ' t i or r l r r i ( r l , i t r r i t l ot l 0pt ' t r xi u, t l ot t , t t xi t r l , t t , l , osl t , t t dot t uf or i o,
11" Lr . ' , I r | . r r r I r r r , r ) , ot , r {r $r r pol , l r r so{i
r yi
r l o si nt l t t ot no r l i r t st t r r l l ot r l i t r
9i , , r r , l i -
l tl Fl trrt."
(rr,tt l ,otrtrt,l ,i xtrto
(l o
l tl t,Bl ' i trl l ti t!, rl o sl tl i v:r,t' i o, si tl tl tl ,tl ttttt vi utl rtrtt-
q*rtrl l l ri ' r,ri /Hi r,tt v i scrrt' o- tnol ,ori i ) ( I' rr ssotttt,l Iti , 1.002; l ' ol xl vi oi t ti i col l r,b.,
l t t l r t l , l r l o i r r r l xr hr , t r L xi i r r r {, i nr r t t t ci l , i t t upr t t xi l nt d; i v f i oJ[ t l i n c1[ r l t t i o{i sl i l t
r r *nn. i , . r , ' r l r r I r r r I t r ci t ur , t , i i r t l t aol , i vr r r 1i gt t sLl t l ; i vc ( [ ' r t ssou: r r t t , 11102) , r l l t i l nt r l o
l i i l rl , rl ,, r r r r r
,
r r r r r r r r r r r,
,
rl tul l gt' ott,l ti l o, txrhr tttl ui tr t;i puri tl o ttxprcsi i oti l ;i co strn-
r r r r t , r l r
; r . t r r r r r l
Hr i sr . r ur t t t l l l t i , ozo i t t oxpr csi l l l or ( Pr l povi r r i t t qi l l l t sr r t t ' 19t 10) -
rtd rrrr rrrl .rrrr, rl (l rsl rrI{rn{l l , ri 1,
,,l i l l sl "
porcopfi o ol {l l cl ,i vi r, pol r,l o I' i i trso{,i l l i ' ,
l r
, , , 1 , 1, , r r r r r r u| r r r : r l , : i
; i
r l o: r , l t o t i pt t t i r l o r n: r , n i l i t l g hr l ' r ' i psi l t t t - sl l nzot ' i i t l t r l l r r
l t l r I r , I r r ' r r r : r I or ( r i zr r : r 1. , : l ur l i t , i vc, Lr , t r i r i nl , i co, sonr cst ozi co) . I l n0l t r r ' t i zr r
r r l i , r , l r r , , p, r l . r r : i , l i r r i r r so{r i t o t l o
, , st t nzr r t ; i i "
soxt t l l o, r nol gi t xI pi nl l , l l r o. l r r i -
! r l r t ' , r i r l i i ( r \ . j t t t i r r gt t t t ut l
f i
l t l a, nc, l l ) Gl . ) . I ' l t ssouant ( l 9t i 2) N,
PI ' {{i i zi r l ,
r l r r r r , l r l ' r i r r r r r r r r r | osi | l l t oi l , r t i r ni t osl , r i l i l ol cl i ni m l l t r
, , cl i zt l i
t l l f l t cl ; i vr r ":
l , r h, r
l ,
r , ,
1r ( r '
ol l r t cl , i vi , ( hi l l t t ci nt ' t i r t ' ol ! r r r r l , i vi i )
L, st l r nt r
t l o vi s" sr l , t t t l r ,
r 11, 1' r , , , r r , r l r zr , r r . . S r r , l r vl t t t snt i pol ; t zr t , ct i t t , t t l t ol f : r , cl ; i vi i t l o Ll t l t r l t t t l , t t l
| t r . t
' r ' '
r r r r ' ' r r l l r l , o l r r l i i decl i l nql l t i l t l 0, , t i l l encof al ul ol f a, cl ; i vt ' , t l l l r t t
( r sl ' t r
l , l "'
. , , ' l L' 1. r l l r r or ' l , r r xr r l pr opi r i f onn ( ut r cus) , cl , r o t : st o l t r gl t t . l t r I ct l t r l t l ; or i i
t r , r t l ' r t , r ; ' r r r r
l r r r l l r r r l ol l r r , r . l bi v ( . 1[ r r c l ] cr r n
l i
ool &l ) . r 1952;
( i l oor r
l l l ( i l ;
I
q' , , , , r nr i , t l t t ; : ; . l r r Hchi r nl ) , r n*r l i f ( ) st i , t ' i l c cor r t l t l oxt r psi hosor r zor i r r | ( i s( \
rl r,,l ,rrr, r' ' r ,rrl rrl ri , (' l l propa,garotl d tl sci i l ci r,r' i i l i l
,,ti nontl ol ' l l l ttl
nttol l l ttrl ,i v"
| | r | ; r , l
, r , r I r r , , r r r t t opr ozi nt i i un vor i t i l bi l
, , cl ' oi or
t i ut r t t cof l i r l ", t r ot r sl i l ' t t i i ;
r l l t
t r r r r , ' r l r r r l r r l , r r s ( cl r pa, r t c r eccpt or i c)
[ i
( l i r I
ct t r l l l r ] l ui At nt r t on ( cl l
l l l t r i ' o
r - l r {, 1"r l ' I
t , r r r r l r l . r r l ; r l r . r r , sor r t i ol ogi cl a t t l i zoLt r t t t t t t i nl t t t , r osput t , i v i t t l t i cl t t ol r ,
t t | , I i I I | | , , | , | | | I | , | ( r' i l ,i (x)
?si hosenzori l l l c
cu forttttnonul de
"{l l (rarny
sl i i l l o",
r . r r r r , r r r , r
| ' : | | | r , I r l I ni ( ) i i , , , i l t r ocut ul ui t ' ,
ct t r ca, cl i i l o t t r no! , i ol t t t ' l o
r yi
t l t r i , r r I
l r l r , r r l l ,
; , , r r , ' i r r l
i cc i r l o
, , oonf l t i i Dl , oi t t
eul ui , st t pot i nf cl ego f ol t . t , t r l r i l t r r
rl Hi .i t
l l rrr' nr
r.rrti r,
(l o
contpl oxi tatel l func{i i l or dtl i ntcgt' :rrtl al c
,,ti rttl tttrtrl i t
I r r l l l r r , ,
'
| |
'
r , I r r ' ' , r l spr r t r l i v t l c r ol ul
j uci r , l ; r l o I t i poc: l r r t 1
l i
I or r ni l ( i t t I t i l t t
r r r rr ' rl ,i rrr:rr rr r,i rri rnrv{tl nti i l i rnbi cc i n exprcsi a tnto{i on:l l i i ,
[i
l rl
rrttl o(l {}
l r l t r r r " r r r r . I r r r r I r r r r r . I oI r l r r t t t omot i e, i n 1i x: l r ca, t l al t l ot r nnt r zi r l t r , i n r r r gl l t -
t!,{
nl r| | tl i ,r
' l r,
v(.gl ro ri i tl t: somn, procurn
Di
i n l cgl :r,rcJ' vi scoral l qi soxual i l ,
l l ' or ' , r ' r r , , r ' t ,
t l r r ; ' - t
i
( l l ' ) "r ' ,
l 06l ; Or r , di l l t t o r ) i col r b. , 1962; St ' gcr qi col i l l t . ,
l l t l t t 1
1, , 1' , ' r r l i r r r i i cr r l r r , l l . , 1{) ?8) .
' I tt ,l t't it! r lltilc\tl,ioa ilttzi,on,ulc oL.Jacti'Da Bn clr.N,cl,e rizoll'zi' prin
l +' r r , , , 11,
r , l l r r r ' l r vr r : r l l r r nt t t .
Ui
l t t l st t ger t r i t zt l , o t l t l t t t l i i r cal t t nt l ul oni l l f i , N,
( l ( , t ' '
l r l r l r r t
, r l l r r , l r r r pr . r ' i f i c nl r t t t l i n vt r r i ni i ' t at t , puf , l nd t aco par t o di t l <r t i zr t ,
l l f l , l l ' r l , l
( l l r r t r t r r t l l , l ( 17i 3) -
tt | ' , I ttti r' l r tpi l opti ce o$acti tse
,,tel fl cna"
((l nstl l ut, 19?i i ) si nl , ori zrr
xfl l | r1l tr r, rIr.r' Irrrrrl r| ,rr ytti tt rt' l tl i tl l rotl urrui 8t' i rnul rl l l tcti v, tj rsp(to1,i v
1tl ' i n'
t ; f r f r r , r . r l r ' r r l , ; r l r r r r r couxci r t i l zl l kr . Act r st t t ol i zo Bl nl ; r t xt r or n t l o r l o( Mot l i s,
l l l l l I
| ' , , I r ' r ' i l r r t r i i r xr l r r l r , , l l ) 70; Sct vi l
r yl
ur l l t l t . , 1002i St ' oi ul r l 9( i l J
Fl t hl l
, l r , , \ r r r r . r r r 11i ( xr l l l , l ) . , l l ) Tu) .
'
I ft h Ntrr,l rtn' ul hnl ' u,oi rtuhr oroni o
,y' l a
n,l ,r i bttl i a' t (,,r1o i nfl ttcrrl ' ri ' "
r qr l
, r l ,
' r (
( l r r r \ ") ( l t i sr ' , r , l {}l i 9) sr c: t t ' l t r l l t t r i zt r t l z; I pr i t t l ' r - o
gl , l l r o
t l ol i t ' i r t r l ' i i
l l . t l t , r l t ,
r i , , r . r ' r l l r , i l ( , nr 1r l , i or 1, r ' sl 0 r ' on sl , i l t t i l , r l r l i | l ol t r r r t r r nf i r l t i l l t t oi t t i t l ' ot ' i i
r r l l ! i r , l l r r , l r r l r , r
'
r ' r ' i l i r '
,
r r , xpl r i i v i t t r t ' [ i t , t : t ' r ' pi r ol t t l t r Lr l l t l l l t t t : i t l i l kr r i i , l t ol t t t l v i i
l r l t , ut l l r ' ; t l r r r r , r l r r l r r r i l o$| l t i l o, l t t t t t t xl
; t r t t r : i r 1i
t r t t l t t ol i t r t t l ozi l t t , l o, {l l l l l l ( {' l ( ' t l
I t t l t l l
r r r r r r l r , r r r l l ot
, , r xl ' i l "
t 1i t l r '
, , ; r . t gt , r r t t I i t r ".
ll.l.5. Ilalucinaliile
;i
iluziile
olfaetive paroxistiee
r' Iptrrl t{\
o(l ol :trl l ,j i
l n oursul
rr.r',', J;1;''.f iii';,?':gi.uJ,"'1,.y:ioz
sint rorme de crize e1r'eprico
;rli;irt'ii:;rl#i:i,:ix:fri:ijir:::{b1.r$'",'.r'-;;:T,'3i,: , t i,,., r r t r.' r i : e u(a.t i o e, t r *i"i
"G'td
i
"#
i,i,, r-r'r:" :i .f"ii
iiH,f r:;
:..::ll:i"' ,.'
j, ;i
r.otab.,
.
t9Z6).
Reprezinrd.
rezulta[ui
' uiJr-.
ior"a"",i"i i r ' | | : r t r .
: r t ( . r , ( , t l , . xul ui
r r nr . i nat ( cr i ze
unci nat e) ,
,.. ...,:,.!:.!!:,! . lriret,c.
u,nainate ,,:::!
Wr!ir|.
Crizele epilepuce
care de
' i tzi l
l rntt l x.l .(,(,p{,j i n unor mj
srrrrrdrrr' : ,
rr/ i r, , , rr' i {, r([
, i J"-"j : "' i l ' . j ?t S^f l *: l l f ot
sl rt i are
t z- rl oTo
;:
;,
lili* r
i iiii : niis rllTf;,], {l{,!,'ff
' }::: i]ji, :l $::fl i:,r;l: {t'.' r l )$ r,: r r r
{,r,,,'gimioi r-i.".
-a"
p"[,"g;,Jfi
.;i:;h#","r",ryHr
;tl
li: I i :
:i,'i'
(,lll;, :J': i
i
:ll,'#i;
"ff:T,'*
::,- f +
;*; ;ilffi
'sT,
rura r
"t
c.
1
Il:i'iil'
,11i;il;ti,i.'i;i''I:;.fff;
#.it;;'";il:';;'ffi"f,1,",iii'161i,[ii;)r
:l:lil,'lli:,,11:;l';:ii-':;ilil;,'i"'t#iT[ll1'"u0"",i11Y,;m:.yffil"il ru:
i l lr
ji
tl;i t i l * i ti,s'#, :1,i tili ibili: rgiliid
qil fl',,i?.fl "iT
#,#
14
I I t
l 6
l ' t
,,,,' ,,i;;;l' rli;ll$;rlt'
rliavrrostie rdinic' lopogruric
si
.tiopatogenic
'11llll{ffiJi,Jcaititlii
uizuote se pot
exprima in urmatoarete
l l l . 4 nbl i opi o l epl . czj nt d
t l i mj nuar er
acui t r i l i i vi zur l e.
ll\ Cecitalea silsiu amauroza reDrezintd, nicrrl,,roo rnnoti .,
,,,'',,iJrv'ffi
"i'#trXl:::iu^K:T:##,ffi:-ii"$:iilrTi,l":?Xr*,J
lrilatoal[ (6i in accepliuneia,
c*orect
Eiinli*iX,-piiiiizt;ne' ce.nt.",u
i?: {?::;,;,i:!:,"'i##ii
tlllLLi,'#'ii?'ifdi""lffi
"'f """11?Y1
D) Ilemerabpia reprezinti
iliminualea
acuitelii
"irort"
..io
*,
l.l
spl:c Seara.
r: I l'lr!{,?i'[]i,'i1iii."1iL,slf
"':?n
#,l:'tiH" i' _lTi,$"",i,",1
]jlj,,lltu'l]:l;.,o:11
j:311",
llry:fant
se se Lci' oiieiene#iea
tap ae
.,,.itri1i,
{ininel seama indeos?binc
.rmai.oarete-;i.;l,iii,
iiJpiltir",i
r.rrul al fundului de ochi gi pi,strarea
r"tf"iofui p'r!i"ar
la tuminri.
... l') !):l!r"*,atoysja _peytyy
alb negru
fi tentru iulori reprezintri
:l:,1l,,,1o'1'"]T3"jlrlt-,*:.ll?1
in-considerare,'inirucit
aceasia poare
sd,
l
cr,rr,rli o scrio de lezinni ale chiasmei
"pti"b
$
"in "ail'* i ! . 2. 1. 1. Ambl i oni i l e si , am. t urncpl o n. al ra <; a, , t , -. . , ] - *^
:!./,,.1.1. Amb_Iiop.iile
;i,
amaurozele
acute si sul.tacute
se iatilnesc in
rors(| ir1(:(i1i1tni, de diverse etiotogii qi cu vdriate tocatizXri pe clitc
:.4.2.l.l.1. AJecJiunile in lamatorii
ale nerl)I.tlui,
wtic
:!.:4. l. /. l. l. Perinct:ritele, optice (nearitele
rr.l rl czi rri i i o i rrIl l Lrnl .r,t,i o
Dri m:rri , a, teci l or nprl
rl rr ol ri r,ci , r,xtcrrsi ci rrl ui pr.oces i nfl amatrol
Ae fa' r"ei l i nl d"' Ja"
.i " fa
:ii]'ll:1,',;.1":i:,1^'j;'l:1.'.",':'si:l_::t11i.obi$nuilisinttacteitiepiugenc
(
r l r r r r r ul l , r r or , i , r l c
i r i l l l
r l r \ ul t l l , r or , i , r l c
i t i l l l i i ,
i n nr cl i ngi t a
l ou; r
1i
l r r l sr r l ( l ) r r kc
l l ) l dcr
f i Sco- t t .
n| l rngrl a-SUpUrJl i vi cprr.bro_spi n
al ri t, i
sr scnl t .
l 97l ) . Esl c vor ba de
- di f uzi uni (|i .|
Jr
||l |st. (t,ut({r l rj l (l cr
l i
Scott, 19?1). Este vorba de ai nzl tfi
l rrl rr;rti r' :r|. rrrrr rr'
.rr
cni ngi te bazai e baci eri e.ne
1i nc1u-si i i acl arc
l.l:1,',','f,':1,1
i'.1,):.,.'.',ii,'flll lil)..1::ll::t
sau ale, altor p"occs"
'rniiai,ato"ti
1
::' l : ;:1,r, I l l
,i l :]:l :
rl :l i j :_"1,"T: si nuzj i e sfenoi dar"
;
r.r. i ,' al arc,
se
j l ;:1,:1:
l ]l ,i ::,..1:l l r,
r' ti ni cc: peri nevri ta
"pi i .a
"".i i aJi i "#c;i l r;I
, , 1r l r l r i pr r r . r r l l t t l l ' 1, .
|)i Ir11rrosl ,i crrJ trsto ori entat de: contextul general
pollrurli
.
r"rre cx_plic:i ambliopia
*
$i
cu
la*traiua
-irn"eor,
*
rcrrllrr,|r,). lrr cu,zlrl dispari,tiei qi a vecleiii centiale se lnsiJeaza
o
2, ! . l ' l 1I ) l nXl l A
l , l , ) Rl r i ( ] l l
r r t r - l ( Nl i l l vUt ,
ot , 1, l 0)
r r r vcl l t l r l c i t r l l r r t l i r , vi r sr r hr t r r , l t t t i t ' t t r , i t t t t cl t ' ,
I i t t l l ,
l i t r ' I t i l t l l t I t I l , l r l r l i ( ' i l r l i ' l l
l r r . r r r l u , i r r f i t r r l r onr t t l
l xxl t l i ol mr t r
l r l , r ol r t t l l r i r t ' ( t t r r l i l i t o; t i ' i l r i ' t ' r ' l r ol r t t l l t l t l ' I ) .
AJ I \ pi l i t u. ( si t t r l t ot t t r t l t r t l t r i u j r t , r t l ohr t l har suu si ndr ont . r t l . dr po. Tt i l o
n, tti l i ttl ,t1| | ,i 0/ousti ,
(r' ttt.l ri nu.rt sul nrc' u,l i ) (l l i ntrr, l 115!; l \' l l ttrol cxrrtt, l l )fi l {1
1u,:rl rr
fi t.ttri l i tt,tui rl ?i Hi l u l )i l l l rfr' l l l t si rrrri l i zcl t zi ' t, tta,t"r l rtl btrrti t"i ,
l l ti l r
l rzi tr
r r r l " i t r l l ur r t at or i j <l e t u, vt i l l , i n1 t , r ' s1, i f i al 1'
i t t xl l r hul l r l r r ' l i , :
r t ) Ar r t t i l i t l t ' i r
r r : r r r r r l i i sr : ade t ot doar ut a l api t l , l t l l t al , i n ci l , cva zi l t : , ut t i l ai . t ' l r t l , sl t t l l r i l l t
l .r;rl (cga,l sau
j negal ),
pi ni l r o drarnnti ci arntntrozi l ; l l )
(l i rrrprrl
vi zrrrrl
, ri r. rl rr ol l i cei i ngustat concentri c, dar uncori tl oar sectol i al
1si
trtt st ttl nl tttt,'
l ,l ri rrt ccntl al c), vedel ea macul ar' [ l i i nd mai rcspectati ,; o) i l i tttItl l rrtrr
rrr:rl i c cste foarte a terat (cu mocl i fi cS,ri al e ci r,rpul i l or ct' ttml fti r,tr, l l tt st,,r
l ,,i rrr{f pontru cul ori , cu di scromatopsi i qi chi ar acronl i l topsi tr I' ol rtl i );
,l r \rl rrptarea l a i ntuneri c este l oarte defi ci tari
I
e) Adcscn l o1' ol tsi i
' 1i
tl tr
, rr l l rrti l ci ,ri l e gl obi l or ccul ari
I
f) Pronunl at edern pa,pi l a' r, prrpi l rr, Ii i ttrl
r,,.rr,,, l rrl bl re, tumefi at5, cu conturul i foarte qtel se, cu sl l ' i i
( r 1 | I '
I I I i t
'
I t l i | | r { '
,,.rrrl ,i i -rozate. Mani festi ,ri l e edematoase peri papi l tl l e se i trt' i tttl
l trr
zott,
,r;rri rrLr ci mpul ui oftal moscopi c, r' eal i zi nd aspectul rl c
,,ntrl ttorrrti rti l ri ,".
' , , r r r 1i r r Jl c
papi l ei deveni nd, i n accst c si t ual i i , i nvi zi bi l c ( l l i sr r t , l 1) l ' : l ;
\ 1. n( ) l ( ' s( i u, 1958; Duke El del
$i
Sco1, t , 19?1)
;
g) Yel el e
; i
t , I I
I
t i I I t t r ' I t ' st t r l
t , r . r r i r . r l i ht at e qi si nuoase, ar t er el e sl nt i necat e i n et l cmul l t t r t si r ' 1 l t ) l t r
, i l ,,:rr' (' l (i papi l are
$i
pedpapi l al e se obscrr' ' X hemoragi i si ctstttl rtl t' , r' l ' r' tt
t l , , l i r sl l cct e de t r ombozd vel t l a, s: i cu zone vast e t l c t ' t l t r t t t l l t ' t t t t i I r r I l i l t t t
l r r r r r l
: r cr . st or l ezi uni ; i ) Coaf e, ct ar ea vi t r osul t i se po: l l , o r ( r l r l i zr l i l r
l ) r r l t i l i l , r '
l rr, l rl i i (,\,[anol escu, 1958)
;
j ) fn forma de ner-r' i 1,L opti ci l trtl t' tttrtl ortsri rtl ttl ;r
r r l r : r l r r nr r . l i cul ar i descr i si i dc Rcnar d ( ci t at t l e Ri scr ' , . t 95! )
, ' , i
r r cl l r r l nl r l i r r
; , r i r r r r l i
o r nasi vi , t umcf i cl c, cu i l spect t 1c
, , nr Lci r t ci i ' "
l N' i t t l t ' r t t l r t ct r t l r r
r I rLri ,rr' i l canal ul ui op1,i c.
l rr l rr!r unui tabl ou dc papi l i t[ trebui o si i pl eci zi trrl
.l ut,l rtt
i i r l i o1ul ,,
, , / / r i r
l ) r ' i n
i nvest i ga. {, i i si si emat r i cc
qi r ni nul i oase: a. ) i nl cc( i i kx, r t L' r r l t t l . r t r :
r r r , l , r i , i l l i t e, cor oi di t , pl i i gi per f or at e i nf cct at e al c gl t t l r t t l t t i oct t i : r t ) ;
l ' ) rrrrzi i ,o (anteri oare, sfenoi ti al c qi ctmoi tl al e postcri rl l urr)
I
tr) rrl i rr' l i ttrrr
r r r I I : r r r r r r i ol i i al e ur echi i medi i ; t l ) f ocar e dent ar e
I
c) ost oi t t r I l ) r r , l r r i i ", r l r r
trl ,
; r1) i nl rc!,i i general e (scarl ati nl , vari ol [, fol rrl ' i , l i l oi rl i i , rl i l l ' r' r i r' , gl i ;rrr.
, , , Lr r i r l i i - un, t i f os exant emat i c et c. )
;
h) papi l i t c l L, l l 1( r $i l t l f i t l l ) i r ( l l l l ( ,
I t i , l
r t ' : r r r , r r , , 5j i n scl er oz: l i n pl i ci i t
l l usr ' l u
ocul t t r ' , i t L l i x: ni l l go- cl l ( x l l l l i l ( :
r1 rrrl trr{i i vi roti ce ncurot' ropc (o{tral moncul ol n i trl i l ri i , l rol l rt l rti l )rrvi rr;
, r ' , r ' l r r l ot ni c- l i t o demi el i ni zant c; I t er pcs zost e: ' I cr r cr i al i l , o; I t t t ' t t i I t I ' ; i i c r t r , t t l t '
, i , , l i v| ' i so nai ur i ) .
l i l N c1)ri tct, apti cd, refrahul hard &cl tti i ' :tan' stthur"uti i (t;l ndnntttrl
7r' sl t
/ , , r /
/
s{, <ur act er i zeaaX, i I r pl i nci pi l r , sPt r l t l t r oscl r i t t r t l t l pi Ll t i kr t l i , t ' r ' i l l t
l r r r i
r l r r r l b: r r i l , pr i n l i ps: l sar r r I i scl ef i a, mor l i f i ci i , r i l ol t t ] t i r xl , i vc r r l l r t l t r t t r st r r t
l ' r (
| r r r i t chi mb pr i n pr czonl ' l l i l r al i l or l , t t l but i i vi zt t l t Lr l t t t i t ' {i ot I I t hr .
I !txtri ori sti ci
cl i ni l : l t) l )cl )Ii , l )l ' uj r(f, i tt c,i l cvu, zi L' trrrl i zi ttti tt tl r' ,,
, l l r . r , r ' r , r l l l r nat i c: i a t cr t i 1t i f i i vi zr t l t l t r , pi r r i i ' l : l ct ' t t i l r t ' l r t r ( t t t t t r t t t t l t zi i ) t r ot t t
1, 1
l : i , cl r i l r l ct t r l i spr t r i {, i i r , pt r t copl i t r i I t l t ni l t l t i t . st ' ; l r ) i l t r i t r l r r t ' r ' l r l t r r t t i l i r {i r
r r i r r : r l , r ci i {, r pt ' ouxl t t , l i i , si t r t i r r sr l {, i 1i i t l i r l t l gi i or l r i l t l r t r sl t l t
l t r , t i ot ' l t i l i r , t r ' ,
r ' sr t
r , r ' l r r l ( ' sl l , l r t l t ' t , l l r t ql l l r i l o l t l r t i r i i l i l o gk r i l ol t t ( l t l l l l r i
;
r i ) i J( r ai ( l ' l l ( ' r r ' v1\ l r ' r i l
. i Ll r l i , r , r I l . i {( i i l r f i t t r t r t t i l i col ot t t t t ct t l t ' i l l t , t t r r t t i t l i t r t t , t l si t t t l i , t t t t l r l t i
31r ; 1l t t t l ,
| | Jr '
l r o, r l ( f
: r l ] ol r r r r i i t r l r r ' { r , i nt l l t t l vi zt t l l l ( l t ' t t t t t t t t ' t t t l c
, , t t I l ' t i l l ' i
t t l t r r l l t r l
l r r r r r : r r i r r ! r ' i ) ' l ) l t | i r ' | , l LI l l i Li i ' ' r : ol i , l l ) 71) . l l t r cr r l i t i t r t I I ot t t t r I I ' ( ' I t | | i r |
( r l l ( \
, l r , : r r .
l r r . r r i r r l
r r r t l l t , i ; r l ) 1' t r cr r zt t t i l r . Fi i t r ' r 1, ,
( t l : r I r , r ' I I t t r , : r i t t l t l , gt t l t t i t t t , t t
l , , l ( vl i l i i | | i r t I r i | r , I i . i i ' ' l \ ' l t t t r t t l t st ' t t , l l t l ' l "i ) , $( ' i l t l l l t l l l r zl i
( )
i l l r l i l l l l ! ) zl l l ol l l
i n
SI
, r . r r t r ' : r L. ) - l r r r , r z, r l r i i r pr r i l i "i
t i - ; - ; . d. ; i i
:lllj,,.ll.' ,11:1, f,ln
;i
consecin{d a-eclematui pupitr" ;"riuiloio" q,
"
( ' l ' l l r ' {.
I i t
l ) j '
Jo.
,1.,,,ir1.,1i,!.1.,,fl"'l:.it'i, "fiff,
J"i,*"
-l'iTl,:*gx,"ll,';ji,:l*$"1
..r'rr.1; rl. neyritc optice) iealizeaa:i.tabtorii
"ti"i""-,iitrirJ"f"Si."
li:::f:.lll,f13"ll:
t1e scciiuJ afecrdrii
".r-""l"i
;t;;;'fr
il.i,", I """.*.
*,:.:i ."
.rr|r
vu,ur up0rc : pc pl .rma por
. i r r r l : l l r r r l l r ar J, cl . r e cupr i nde pt pi l a
"i
n( . r . 1 ul opi i ( 1
l r i r r ; i
I : r ' zuua r t c i
l vl l scl or centratc atc t"ctrncr i n l crv (10_.LZ
ml n), real i zi ndri -so
si ud
Nrrl (,Ji ol ' ,
i *xt,abuJbar, p4l i l i ta
sau si nrl rol .ul dri
l ri l pi l .
_
rr.vri l r;.i , .domz
I . r r si i , i r cr r 1, l ' l ' sr r u sr r l l i r i l t r f i i ; i l '
( r ) r : r
l x) r {r r t , r ' , r . r r . ol r r r l r r : ' i i ,
i r r l , i t r sr , i r l r r I
a ved
l l l
)
l )l .l fl ,,l l r' ' I' l
,,,l . i rrol ' L,\i r!
l )' J)i l l t,l .ri ryi
rni tl .i rr,zrl (rr.v.l l ,, r.rrl ,r' l ' rl l l nri tr
l l , , j : l ] 1l , , ", 11: : l : l l l . 1: . f i i . , ": 1t , , ; t l ri ; r1; , , , 1' r, ", , ' ' , Li i i , , i , , l i ' i , ri i ' , ' r, , , r, i r, , r. rmrno
rr.r' rrrrl i L,r.rrl l r
un.' ,,,.,,,r,i ,, ri ,",i ,],i i ui r,' ,1*i ' i i l i ;i fi ' i ,,i ;;;' ,;,i ;i ;l l l i r",l "' T.l l l l
rt,rLt,i r . rl {' (x)l or.i tr.
Dl pi h' 1.1,, rtr. obi cei t"mporati t, i t,i i .,,,;;;i ' ,;;,,,,,.,,, rrn ri i snraf
sl rLl .rr o | | {
'
{
. (
| | | ) |
.r
I r
.r .
prr
l ri h
l i 1,_ (l r. ,,fri cci
f' enrpo.a t,i . r t' i rr,l l i r,ro nn rl i scrot
,j1lf,;'
rt,'t,it,,.
(tt.s.'-ryi
.Ashrvorrh, rsos,'oit*U'd;"ijor.,"
iir,r"" gi Scott,
I n71).
ht l , , t r t "' l ' r , r r r r . r r l i r r r r r ' , ( r ( .
r r r \ \ r I i r r , , 1r r i . r ' ; . )
l t r r . t t t r x' : r r t : r t t . i r r , t t r , t t r t
I t r l t *' . , . r 1, r r , . . \ t f i l i t ,
' r r
r r r i . r i v r \ 1. ' t
l | r , r . i l , i t l 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 ,
' . t kr
, l t r r
l
, , , r t r r r t , . I r i . r r r . r ' ; r ; : i i , r i .
l ) ( ) l , . t t . l l
r l i l . i . r r l l , i i ( i r l r r r l i ; r gt r , si , i . r i i l i r ' r , l r
l l Bt '
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 t r l ' r r l r . l r \ , 1, ( i ( , 1, ( r i l . Ht , r , l l , ' i t v
l l l r t ' , t r
; t , ; r , ' r l r I t r l : r t ' r l r i r ' : t t l r l r l i t r gr r 0sl l r , , ( i r r i t r r l sr . r r r t l t r {l o t , t t l i , l n) l t r r , L,
pl l t . l l l
. ' l ,
l ' r r l r r l : r r r r I r I r oI r i r . i r . t l r r r r ; r i l l r , t r s, l r r i i l . r r r l l , z: r vl , ' {\ t {x, l ' t , i t l t . : l
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 | | ul r r f l i r i l l r l I sl o l i r ar , l , 0 r , r l , i r r s,
. l , r , r r r , Lr
si l r l l r ul l
Sl l . l l : , l , : , 1, ,
r . ' , l r , . r r r , , r ' i r Ai i l , ,
i l i ni , . l l l l {l r , r ) i t sr r
; r i
I i l r r , l , r r r i xl , i r r sr r pr , i r r i l . g
l l l l t l ' r l
r , l r r r , r , ,
l r r r i r
l : r
1x. r ' r l i , r ' i r , ,
r l . l r l r r ' u. r r l v. t r . Lr r , ( . r r . l r
r , r r r r r i t , , i r r l r i
Fl i t l , l | |
t '
'
t '
r l r l r '
)
;;i^1xrs.to|io.rl c)
;
.e)
Oftalinoneu"rpj:llte
ft;;i;'t"ib;;;;; ty no".
:]ll,l Ii:l.l-,1
virotic(. (ruieotd,
parolirtild
"piau-i.;,
or.ioiil' ur,c"ira"e
\':tlrorr.it,, zonil zoster, variceld,l--bacteriene
(diverse),
riclettsiene qi
t,rr,l (.,,,{' i rr(. (i n speci al matari a,
' i ri p,a,no^*]r;r-
qi ;;Ai i i i l oza)
; s)
' l ' rr l rl rl rri kt cl i ni ce descri se anteri or (vezi 2.2.1,.1.1.) pot fi rcal i zate
t l c t l l i
. l u, ckr i :
;;' i ,r,' n(i r
j
n {,i r,r ( j i l zar
o
"Ireyrl tra"
retrobul bar6r
cu scotom i ni ti al centrL,l ,
rrl rrrrrIri _rl rr
o rrl ,rnfi o opti c:fi progresi vi ,
cu i ntens?i ,
"*ouor"u
a papi l ei r
;l:,1,:l'; 'lii],,i,jl:.1.,,,:11,1.s11""^o-3joas';,^{sf,annon,
t$2; Eiiazzoni, i6[f :
l i l , r r {i . r l r r l ) 1l r q- l ! | l cr
f i
Scot t , 19?i ) .
.
-.
N tu.r.oltutitr. o1tt.icd, chininicd apare in urma ingerilii cle dozo mari
(ci l.v;r grrrrrrc).rltr
chirrinii (in scop teiap_eltic sau abofiFj qi p"oauce
amaul
|r' r| iiir, :r,rrblir4rii, irrsolite
;i
de suiclitate, re_marcatd
OulA ieqirea tiin
.trr,(' ;t rrr' r,l,oirHli, rlo citeva
' re,
Examenul oftalmologic arald, ciieva elo.
rrnrrtr. rliti,r' rrrrl,irr,lo.tu,ff
de alte nouropatii toxicu , asiecf isclemic aI re-
lllll' ' l i' ' ,
r^r,r.l,rrr.o
,Iiliforme,.
cu paloare
a F.O.; TACR
^este
mult crescut[.
l t t I t l t nl t t l t t nt t l t
t i ol t nl l t l t t t r r ul ui oJr t i r j
l \ r l ,
r ur l i zi r , ct l ct r r o ; r
l , l l , , l 1, ,
,
1, r 1' r t . r r , ,
. r 1, .
r r l r i . r . i , , . , , , . i i ( l , . 11. i r i ni . t l i r r t i , , , , . , r , i t , i 1i i ui i , , , , i , .
l l | '
r r l , | | | l r '
, l l l t ; O) .
I r . r l r nr i l o i r r di r c<r l t : r k, r r er r ul r r i op( i c i l r Lr at r ur a I i sr n r l t .
r.t u rri o-rrrtbrrtl e i nehi s0
I r ' ' r r r r r r r ' I r r r r r r r r : r r i r r r r i adi l r *i r ' ( r r . r *r v ( u) r i ( .
st ' i r t t i r r t t r ga i t t r , r . '
1r t .
I t {t . l t '
, 1, | , ", , r l r r r l r r r r r r ' r l i sr r r r . l r . r , r . l r r r i ' r , r , r i . b' l r L,
i r r . hi r i r , . l . ) L. r l , . , , 1i i , , , . ,
l [ h. l
r , r , t t ' , t , r r r l r ' , I I 1 I
j
1 I 1 I | ; 1 | ; ; ; 1 | t r si r r r r r i I *. avar r i n sr , i ngi .
- - r i , ,
i r r i ; i r r r . s. r r r .
I Hr r ' ' r
r " r ' L' r r ' | i r {r r r r r ' . . l 5- r 0 i t l i , i r r nl xr r i i r l i r r r r i nr i . ' l , i sr r r . r . r ' r ' . ' i *r r . -
l St l r ' r ' , r
, r , t , r r i r . r l : r r r r . r Lt *r l , l . pr l i r . , r t . r , v, l pol l t , . I i <xr t t r l l r i t r ' r 1. , l r , z; t l ,
l l f l ' , ' , 1, "'
t , , t : r t
. 1, : r
l , r r ci r . r r [ i i
i r r oour i , , i l r ol , t , zi ul r r i l czi r r r r r l ncr . r , r r l r r r
t l l l l l r , , , 1, , r r , . r . r r l ur r l i r r r i r l r . i l r zl r , t r r r . l ' | , i t r . , t t sgl t suol ool l t i ( r t , vi l , l , .
.
r r r I r l ' l , , r r r r ol oi l , ' u
l 0zi r r r r i l or i r r r l i r ' . ol o , . r t r , r , vi kr l 0pl , i . , i i r r l , r , r r . I r r r r l i r
f l l ri h
r r' rrrt ' ' , , r. rrrrrI r' rrr. l ri s. r' l i . vi t ri ui , i i , . J)ur, ri rrur' ri r1, ur
, , p, ur. i {i , , i ni , l i
f i l l l r, l , , r
, , , rrl ; rr. r, l c
Jxrl
I i gnrl l r, t c i n i l crLt t t ol i i :
- ,
l ; [ t , ' r ' r l r r t , r r r ( | pl i | t .
l ol l , l
r , l r r r r nl r t , j ( t i mr r t l i i r l c. l r ) kr si r r l , hr , r . v0r r l ' | ,
l l , i , i , , , ' , "
I r '
' "r r l r r
r t r r r r r r r r ' . r ( , ; r s( f
vr r I i r r {i i l l t , i t cr r , gr u, vi l r r l {'
t r i i , r l i ( xr
r r sl x, r . l ,
,rn,,,i'l,li'i",l,i"i,r;,iiil;;liil;llililii;lfi1'lilll;iillLi;,ii,:lli.i,;i;,lll:ihll,,l,,i;i,,1:lil
l 4l l i rt
l , ' t , , r, r' , r, , , r r, rr : rrrr. rr{i t . zi ui ri r, r'
1r, rpi l ,
r- ri , t i ri t , vr; ; , , ; , i ; i i
, , , rl . . r : rs1). rrr,
$l l l t t r r l , '
l r r , ,
r r r l l r r r . r I r l i r ) l r t i ( . i r . r . l r 1) l , l l l l ) : u. i t r , : r r r *vor sl i .
^, . ,
1r r r r r r r | , I I r ,
1
r r r , r r r r i Hl . u l r i l l , t or , ; r , l i i , scr ni r ni <l r . i r r zr i <t r r r l i l r r ut l r r r l r
r cl l r r
lillil,,lill;J,' ;i:i":i,,lii,;ii,,]::ljij' lij;l' 1rNcor,"' |r'
.,' t:' rrirr :,r,s,rrrr,,,r,' r,i
:in' ,' "i ii,,
,d,,,,1' ,ill:ilill::,i'il
'ij,ll,,,Il,'i,,1"1i,j,ljlili,1
ilxlillilii;l,ii;ili:",'
r,r'r, 1,,,,,,,,r,
r l t r l r . l t ' . r t r l r . r . i r r r t r r t zr r : r l t l r . I . i p l r r . ur i t , r r , , l r , , i ,
r r r r i I r r t cl i r I , , , r . i z, , t r l i t l
l l Fr i l | l | | l i | | l i . l t r l t , r t r r r i t t l r t
i f rt r, t r. r rrr prrr, r. hrpi rl ri ri ri ,
, , , l l . l l i l l i l i ; , , rt nl . "i . rl '
l t ' t t t pt t t ' rl , rt t rt i . rt ' t t ; t z^1,
| | nt | | | | | I or r | | . t ' I |
i zoLr l i i , l r , r : l nr pr r l ui vi zul r l ,
. .
l t r r r r r I r I r ' I r I r r ' t r i
ni r , l r i l t r l t r l , ul i ( l o ( , t , i l Ji t r {!
l unc( i ' r r l r l i l ,
r r t r r . l l . x l i r kr
l r l o r ' r l r . l ' r ur r r . *r r . dr r ; r . r r i r at r , vi zui r r i
4i
*i ni p
' i r r r at ' nr i i r hi r . f i t
l l l t l {r l r , r l r . r r l r l i l t , r r r r r
r r , l r . t t l ui u, t t t r aL, l r r i , t i l r r , i _
l , / . r , l *r . t ,
( l r ,
l t ( ' ' ' t 1ont t r r l . r r . r r ,
' t , t ' t r l r r i
oI t i . ( ( , ( l ( , . t
, l t t , , ' n) r . i r r , {t .
H
I r,*r,'
l rl l
I tl
)
l " , , : l l , , l l i i ' 1, , t . , , ' 0ri
()l )t i (, r
Jrort l . ru
un urt i l r, , ubu, rr, nl r, rl nPl ? l (l zi l r rt r,
I' rrl ri l .hr si rrl , i nl ,0ns mi dri ati ce, i ar refl exul fotomotor
este atroti t.
Nrur,,,u,tr1.1r,. oTttice din
.alte _i
nto,ri,calii
.(optgchin,
f"iiix mas, barbitu.
t i l r.,. ,
' r
i rl
(l o.
' ,.r,r.l rl n,
bromuri , i nj toform,
' aci ri
i al i ci l i c, snl i "i tnti
' etc.)
si ni
Irrr' tr' :r,u,rrri ' i tol rft! cu cel e chi ni ni ce, dal ,ori ti *u' ""oi rro"i ' o.
;;;G;;i
v;r.r.rrl :r.r.,. rrsrrpr.rr. ccl rrl el or
_gangl
i onare di n rei i nd ,i ,r"pau fi Lrui oa' n"uI
v,r;u,r. (\frrrrrrl r.sr.t' , t.Di 8). N.europati d. opti cd di n i ntoi i eal i i i autd araeni nel d
,i 1]l i ' .,.r.,.,,r:,r..,1,,' l ]],' (,1)u
rmporr:)nl e, cu evol uf i e spre amaurozi i n ci teva zi l e,
llill,i,.,
!1.
,l:::l9ll.l"Irn,!,yii,,
cu. srrimtorarea coneertrici a cimpurilor vi]
z : r r , . , ( . l t
i r l r : l l t l t a Unet mpor t ant e al r of i i Opt i Ce.
jl)
,,r,i::1,::.i^i
,,:!!r!!ci
por realiza nevrite
-optice,
inctusiv papilte.
1 | r' n.?rsc nutt rascutare pot produce
reti nopal ,i i
;i
reti nopi pi l i te
ede.
r (.1.1)tr*r,
.^r'u r.tllizeazl dramntije
-ambliopii_amaur
oze, carc tiebuie cu
gri j :r rti l i ' r.r.rr.{i :rl .r.rl c prpi l i tc :.r,) Rrti nopati i e di n atrrusi i eri a
si d,i n hi po_
r | ' | t i t t t | | t t t r t ' r t t t t u
l n, L
si i ( l oCl ar l f czo
i nr pol . t ant e
exSUdl t o pl , pi l ur t , qi pCr i .
F: l l r i l i r t l '
( . ( l ( . t
l l ' uI s( ' , . pr r . cl un
1i
l cmor . : r I i i , cJr , ( . t nt r , . ncl zl : sr , , i r t r : r i
ma- ui vo
: f rr\ I ' r' {rf , f l f
;
l t ) I t oDt l )t t 3(l t ' r( oeSe S(. , 1. 0 Af t eri nl e
gO
l rt S0l , r, S0 rl 0 i rr rI l l , ul . oz{},
i r l , , r ' : 11: t t - r , i l ] i | r r r | | ( . | {| | ( . \ i Nl ( , l t l i r
i r r sl l t l l l l r r t t r r , t l r : r l r l
l r i r
l r , t r r r i t h. t t l , l
,
: r p: r l i f l t I | | i ( , I I I i I I I
|
, i ( | | ! ) ( r i t r cr i si cr Ll , t r l l u
l l r i r r r r r l
{\ \ r r r ( \ l : r r l cr u pa1t i ,
l : r t , r r r r r r I i l i r r I i r
,
i t l c r , i r nl r r . i zLi nl ct c.
rl r.col ol i rnr papi l al i
l i
atrol i e opti c[ secundari unei pseudopapi l i to;
rlrtolonLro pr.1lil.ui,
apirutd tardiv prin calus dupn traumatisrrj
r l l cr r r r : r l oJi l i c;
I | |
)
Nl ; r,r r i l i .r I,i i ,r,i opl .i oo pnsttl rur[:]ti cc 1,al ' di y0
r r r r r r i r i : r r r l r r ui r l t r l t Ncoi dont :
.Iruu rI rnr I o prpi l l ri i pri mi ti vi (consecuti vd,
f r r r l l r : r r r . )
I
1. 1, ' 11' , 1,
r r r I r ' . r , r I t t I r I t r , t t I : r I I i l t i t t I t ' I t
'
r r t I t i I I t
'
I t l l l r ' t l r ' l ! l l l l l l '
( | \ ( r ' | | [ ' l I t I | 1l I
i
' . '
'
r , r r r r t r r l ' r ' t l l i
, r ' r l
r r l t t t r t ot l i ' t l t l ' t r t ot r t t l r t t r t
I
j ) r \ l l ol r r r . l r l i r r : r '
l .
r . . , r , . r r . 1 , , | | | I I | | I I I I I
r l t l l l l l l t ( ' i 1l r r i t t l : r ' l r cs, l i t t , r r . l I r i I : t I r ' r ' : r I I r
'
t r ' r t l t
. r , , I ' , | , l , , 11 . r r l ( r ! l l : l t l r l
l
r l i l r ' l r l r t ' i t t i t t t r r r t i t r ( | ) r r l i t ' I r ) I r I r ' r ' i "i f i r r . l ' l ' l 1) i l ) '
*1. r . . , , , r 1' t r ' , 1' r i '
; , t r t t
l l l i t t t l , , t ; t r ' ( r l l '
t x) l l ( 11\ l l l l i r f l i l l t r ) *t l r f l i \ ' ' i
i l '
( f l l t ) l r l l l l l l
l =r . l
, ! r
t
'
r
'
, , . l l l l r l r
' l
) { f l l l t r l r o; l t ) , t t t sol , ' i l ' l i
r l l r r r pl r ' r ' i ( ' i l r ' t . t l t ol
"
l ol o
l t si i "
l . r r r r ' , , , , . . , ' l , r r r r l r ' r t l 11) r i l l ' \ ' ; 11l {' : l l l t i l l
s: r l l r l qi r r l i . t r ( l l l r l ' l r of i ' l l ) 0j t '
r r , r , 1, l r , r l . , l ) l r l r r | r i i l r r ol , l ,
l ! l r l l ' t l l l l ' r
( r r 11' r i
| f
i r l ( l l r sl : t l r l o r l l l r l l r l
,
' "l '
{ r r r . , l l l l t l r ' : l l r t r r t
l r l l l : l
l : l I l l l \ i l : r l l i l
l l l 1. , t t t t , t t t ul t t r r r r t t Lt r r ) S1: l ( 11' zr r r t r t t l l i l | l ' t l ' l ' i , " t r "r l l l i l i I t t ' t r vr f l l l : r '
, 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 f i ; t ' r r l l i s, . l l l {i l i I
l l r r r r l l . r ' v, r ' i
l l l , i r l , r ' , r l : r l t r l . I ' r r ' . r i ' i r t si l ' : r s' ' t t , l l r s( ) ; l ) r l l i t l t l l r l ct
f i
St ' t t l t ' '
l , t , l r I r l l r r ' ' l : I , r r r r i r r l i l l r ' r l r ; , l "i t t r t l : r : l ( l t l i r
;
r ' ) N, r ' t t t ' r t t t i r ' l i l ' ; t '
r r l r l l t l t
r l , , ' , 1 1, ' l r , r r i ' t . r ' r r l i l l r l c I l t l r ' ' r l I t t r t l l l ' r ' r t t i , pt i t t t t t r xl t t l I I t t t i I t I t I I
t I r ' I r t t | '
, , , , , ,
, ' , , , , , , , , r r l , l , l r r r ' r r I i I i r I I i l i I i ' I r i r I i I r . r r '
' ' i
pl i r . r l r ' r ' l t t ( . i r r ' , sr l
|
'
i I I I i { I I I I I I I I I
'
'
, . ,
1, r
, l , r Lr L r r r l . r l r I l l l : t t czt t t r r i l ot
pi i r ' r ' , l r ' r l r i ' r ' | , t t l i l r zl t , . r , l r l sl f l ( ' l l r z: l l l l l l l
, , f i ,
' t , '
l l l ' r l r . ol r r l r . , l ! ) ?i l ; l ) r "i ur r r r l sl r l
si . . "' l r r l ' , I l l l i l ; | ) | I I i (
'
- . I
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I
(
. I . '
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r '
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, , , t r ; , l r
(
r . r ! x' l i r | i , , , , , i
' r , , i
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\ i
Vl l l l sol Ll l ( r l r l ) ( r t g
( l 1l i ( i )
, , , . ,
' , , ,
, , , , , , , f i , , , , , r t , t i t l l r I t t I t t I I r t t t i t
'
I i 1 I f i r 1r 1 i r r i ' r ' t l r r l i p i ) t r vi l r
l ) r ' ( r zi l r l r r '
r r r r ' , r ' l , l r r , r r l r ol r l r r t l ct t t i t r l i t t i zl t t l l r r
qi t i i ' r r r l r ' . i ot i l l l i t ' i l ' l l ( r ( ' f ' 1' ol
( l l l zl l l l
' ,
r , , r . l "t ' , 1r , l r , 1l 1r l i ( i l I i ol l l ( ' zi l l l f l l ' l l l i i si \ ' l i i l t l t ' t vi l t t t ol l t i oi l ( ' 1) t ( l zl l t l i l '
, t r
' ; t
' , 1, ,
t ' Lr t r r r l l t r r i r l l i t l i zi l , l l l {r l ) l i l r .
l r t ( ( ' i t l r i r l t r l i I I I 1 I
,
I i I I I I t I I
( |
;
r l )
. l r ) t r cr '
t . l r r ,
i , , , ' ,
' , 1. r
r l r l r r zr i ( l r or l l l t t i Sr l r r l ' l l r l ;
r ' ) l r i v{ r i i ' l ' l i l t t t t i t l t l cl l l t t
, . 1, 1' , l r l r i '
t t l l ' l t t t t t t t t t t ) | | | | I t | t | | t t ! I i 1"t : t t t r l r : l r t t t t ' i ui st t t t l t t . t t t Li t : l t ) l r r t t r r or l i s
, '
l r ,
r ' r , , l , , , l r r l , , r r r r r ; r t t l oI ' i t I t I
( l t r t l t l r t ' l ' r t t ' Sr t l r l t ' l l i i l r l t ' r l
gr l r t gl i ozi r l r r zr ' )
;
, I l ' , , 1, | , , | , l , r ' r ( : r l t ol t r t opt ' i r r i i ' r r r r ' r l i l r r ' t l i l l l l l i I r ( l l ) ( ! t )
1i
l t l l i r l r r t l i t t ct t t t t
r r l | , 1,
' 1,
, , r , l , l r ' r r r r l l l r , l l t l l {r ' t t t l l i t r ( ( l t : ot t r t i ' t t ot ' l r t t , l l ) 7f i 1l ' l l r l t l l i gl i or r t "
l ! ) ' i ' r ' ) -
| | | 1
' , 1|
| , |
' | . 1| I l | | 1'
: | \ | i t t i r ' t ' i l : t l r
.
t t t
1
r l l t ' i I I l i
( | | l ( j ( l l l l - i ( l
Ei gi t , I t t , r l
( l t r l l t l l t l t t t
l l ' , r , r r
' , l | ,
r r r i , r , r l r ' l r r 1r 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 Ll ( l gt r l l l ( f l l l ( 1r l
r l
1
, , . , r i , . , , , , , , ' t , ' r ' ' , , . r u. l i i t ' , t l r r , r ' i l l r l i r l cl r ' ,
"t t l t t
l l r t ' i
' . '
t t 1 l
.
t l ' i l
1
(
i
(
) | 1
'
t | : I I ( | I t ' i
, , i . , r , , , , , , 1"". , 1, . , , : r l l ( . r ' 1. r 1, . I r r r l i r , l r l 1l . r . si i - r ( . . i | ( l l J7l ) r ! r t
l ) l ( . . ! zi r l '
, L ,
' ,
'
, l ' r l | r ' l r r r r r { : r ; r : r r l t t l l r r t t i i t ' i or i l i l i l l ( f i l l l 0 i r {) t ] {r t l i t t l r l t zt t t ' i '
I l | . . 1| . . | . l r . . t t , r r r l ; r I l ' t ' ; r I r ' , r l l ' r t t t t l l l ' ( ) l ' i ( : | | l I l l l t I l i l l i ( j l l l l I I l i | , 1| t . {) z( 1, | ) t ' l I l
u, t , , ' t , , 1 r , ' 1r l r r ' . r r r , l r , ' t r r i ci i , I l t r t t t t sl ' t '
( l l l zt l I i ( x' t l t l i l l ' i l l t l t t - st r st r t t t t t r r t l c
dl , l ! ' , ( . r l ' r r ' : r r r r t or : l i l zt r ' ) ' , t i t t l ' ' t t ' i t l l r t t l t l l kr l t I l i l i t l ( r i ( l l l l l i l l Jl '
, l 1l l j i l ;
i , . ,
r
' t , ,
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 : r . l r ' , l l r l ; : l
-
ci l r ( i r l r r I ) t t l i r r
i r t , l ' ,
'
l , , ' l l , l l r i l ) ; l r ) i i ' r r l i r r
' '
1
r : r I i i I r ' r I i t r : r l t ' r ' osl l r . r ' r ' zi 1i
r l i r t h i l t t t l r ' t t
- , , , , , ' ,
, t , ' r , 1. ,
1, , , 1
i r r r pr ' , ' zi l t l r t i t t t
1
I r I I I I t t t I I r I ' r st t r l l t ' l t ' I ) i l ' l ) i l i i r i ! l i l xr l i pi l '
' ' 1.
t , ,
' 1, ,
| |
, l l t . .
r ' r l l r l
. r
l r cr r r "r "r gi i
( r l 1 : r l l l r l l l i i l zr . {r ' i r l ( r i l t l : l r i l ( '
' , f , , , .
'
t , i ' , . f l , f , . , t uf , , , i r ' . r . r ' t t l . r r : i r r l , r : l r l r ' ' r ' t i l t t l t ' l "r ' : r t l ( i ' r i - "{si
l . l : r l r -
r l , r
r ' l ' t r . ' , r r l i l r r l r t l l l l l ( ( ' I l l l r l ( r r i r i S( r ol l , l 1) ' / l ) Al l r r t r r . l : r i l l ( l i vi zi i l l l ' r r '
' ,
, , , , 1, r r , | | |
I
| ( ,
| | ( I I I t i I i 11i : r l r l t , t i r l l ' l l i l , r l t ' t i ( ) s( i l {) t ( t l i t l i , l l l t l l t t t r
l t t
i t t
r l , , r l , l r r l , r r ' r r ' r r t r l t i l l r ' l r r i ' t i t r cr sr ' pol ' r l t ' zvol l l u l t sl i r r r r l ' r ' I r l l I t I t I t oi r I r I
I I L I , | , I | , I I | ' | | | . | | I i | | | I I r r / , r ' r r r . r . I r . r I i r r 1' r r 1r r I r I ,
'
I ' | | | t I t I I | |
I , ' I I ) i I I ! I 1.
r i i I I I ' | | | ( |
i l , , . , ,
'
;
,
, ,
r
, , t . , , ,
,
, ' , , , , r I r t r , l r t : r l l l l i i
"pl i ' '
' \ r ' "
i ' , r r l i r ' {i r r t r i 6i r r i ' r r r r r ' ol r
r r r I t ' ,
' 1,
, r r r l r ' l r ' , ' 1. t l zr t l t l , : t , , , t I i t t ' ' | ' t | ' ' l "
"""'
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 '
, r , , 1. , ' l . r r I r r . r l
l ) r l l l r
l r r l t t r t l t t l t t ' zi i ' <' "t l r ; r l r ' l i r ;
r l ) l r j r i t i l i i
.
cl r z r t l i
( r l l r l l l r ' r ' r l l
, , 1, , , i . ' l l , r l r I 1; ( , I l i l l r I I I I i i ' r ' t i r t t : I I i ' I I l i i f i l l r r
\ i l r l ( ' ( ' l l t t ' l t ' l l l l l ' l l t ' r \ l l l Ul ) l l ( 1
' , ,
, , ,
, , , ' , , t ,
1' ,
r , , , , , i , , , I r cI i r r i I r r ' ' ' \ r ' t ' t r l i ^
t I cI I ct t I ' t i | I I ' r ' I I I i I i i l
( r l r r r r t r r r ' 1 '
"l ' r l l
I
i r , , , , t r , , , . , , ' l l r l l t r l l l l r ' r r , t l t , t i r
r l r ' r l r vt ' t ; t r l
i l t i t t l r "
l r t l r l r ' [ r ' r r l c t t t i t t ' t r
i . r I r r r I r r r l r ' r , l r t l l r o t l t t t l l t l t ;
r ' ) ' l ' r r ' t t t l r ozr ' l r '
: l t l r ' l ( ' l
( l l l ol l ( l r '
l r l l l l l l l l vr '
{!r r pi rr dupi sl pti t'
pseudonevdtei retro"
I952
i rrl l rrrl l i l i l uncl i onal e tardi ve.
:' .:;. |
-:!.
..l rnhl ,,i opi i l e si amaus.azel e croni ce
(' urrtl r
ri sl i .r:i
(l i ?i ?ce..
aproape l otdeauna este
yorJl a
{l e nevnte
\ | r r I I i I r r r I i I r r
,
I r tlc.
.lucl,ori
etiopatogenici ai nevritelor optice
t' r1r' r,
ri \ r. rr l i rsi si sl ,rrrrur,ti z:tbi , dc noi (Popovi ci u
$i
Pasou, 1980),
: r I r | | r I r | . r ' r | i r s( | si r t r l i i sl r r , l i st i cc, publ i ct i l c i ndeosebi de Dukc- l Jkl er
( r 1r i r ) :
pe
SI Sco
l l l "ttt rt\i i tt.l l tuutl .ar.i . Lor:al i ,1i ai B.i [.C. .. a) Uvei tc si I' eti ni te
i
l r ) l r r t r r ' ( i i i r r l r , r r r r l l r i l r r r . c; c) , \ I oni ngi t e ot oni ce ( i ndeosebi br ci l ar a gi
l r , l r i : r ) ; r l l \ r ' r r l r r r oi r l i i , r r opl o chi i i sr na, l , i ce ( cu ext en. si e ant or i or l t i , cu r ea-
l rr:rr, r,l rr:rl rl r. rl vl i l (l
.j
rrx l ,l ,l i ul l rtre
,si
papi l i to)
;
e) Si nuzi te antedoaJe
fi t
tr.ri ,.r
r,, rl r'
;
l ) ' l ' ()\opl l tsruozi r,; g) Tubel cul oza, fi c pri n
l ropagare,
di recti /
rl r. Lr ri l rrcl rrl i l r vooi rrc (proceso tbo i ntra-ocul a,re, i ri doci cl i te, ostei te etc,),
l r,. rl r' l rr o rrrcrri rrgi l ,i i tbo bl ,ztl i ,, {treterml ni i , ferromenc de ne.t-r' i ti , gi rI0
t)(.rrr,vr
i l ;r opl i ci r,, cl ri rn dc pl .pi l i td, (Sverdl i ck, 1964, ci tai de l )uke-Ekl of
rrr l l ,ri l , l !)7l ). l i ,l l ,rl \rl i
l j oi tte
dctermi na un tubercul om Sol i tar masi v
pr, p;r.prl ;r opl i ci i , crr rol l i z:l rei l urrui tabl ou de pseudogl i om
opti c (cn si m-
l rl r)nri
, r ;ri i l rrri ri s{)v(l ro c1t ci t i ,ubercul omrl se exti nde
;i
spre apexul
,' r' l )rl ru
);
l r) Nl vl i l :r, ol )1,i ci :i si fi l i ti cd de obi cei provi nc de l a o meni nEi tf
r r : r r r r r r r . r r i r r l l r l l r r r ' l r r l i l i l uet i ci i l , i n st adi nl secundr sau t er t i ar al l uesul uj .
' \r1,.r.rr
rl ri sl i rrrL l :l l ri i rttrrrcn, cr' ncomi tenti , a neryi l ol ' ocul omotol i , faci al l
r.r r.r,l rl co yr:rl i l rrrl rrl i .
i l l tr l Lnri i r.i l tr
_
rl c r*cdere si nt
yal i abi l e,
,te h u$oi r,l .[
: r r r r |
'
I r , r
I
r i r
,
;ri rr' i
l t rrrrri r,unrzi 1ofl tl i ,. fl al acl ,eri sti ce si n1, stri mtori i ,r.i l e corr
l cr Lt l r l l r r l r l i r r r l r r r l r r i vi zl l l l L pcnt t r r al b
f i l xr nt
r u cr or i , pr ecunr si s0o.
l or r r ' 1, ( ( . r l l i r l r ,
si / si ul
l ) i ui l r ol ) l l al c.
l ) i i Lgnosl , i cul se bNzcazi i , po dl i l ( ! l r
i r I r : | | | r I r |
,
I i i i { r r
,
, pr r , l cst r ' l c scr oi ogi c( ' ,
l x)
r i r o( l i l i ci i . t ' i . l ( ) r : l i r r 1r "( l . l L. ( cr r pkr r
( r l ! r zi r
I | | 1
( I ( ) r | | i I r I r r r i
l i r r r l i xr i l r r | i i , , ct r pozi i . i vi i l r l oi i r t l r ( j i i i l or
l l i . r i , r ' r r
l i l | s) ,
1r r .
r r r r r r I i l i ( , i r l i I r r
l r r t pi l t r r r , 1i 1x.
r r or r l i ' cl l t l r l t , . t r r , r ' r ' i I r I t ( , I I r r r i | r r i
i r r r s t r r 0l r t i r r
r r : r l r ; i ) l l or r r l l l r r I i I i I i l l r r I r . | | 1 r ' \ r I I I r i r r l r l i {j si r r l l i r r r r l r , r r r r i . , l or , : r l i zi t r r l r r sr r
' ' t ! '.t.
I
l ) . 1
r ' r ' : r l i z; r l r ct r r i l r L' gi ; r , r r l l | r ' r l i ' r i l l l i o0- 1r i | l t r r i r l r r , l i r ,
r l r . r r r , r r r L: r r l r , l l , l r r l , , vi r
| l t i . Ll r n{' r l ( 11) , 1I t ) , i t ' r r l r r s| r r sOci i t zi , dj
}un( 1, r l c r | r l r , r . r , r , l i r r i <r , o hcr r r
pl l ri rr rl rr
I)Nr' 1ol
ol )l rsi j r i Ji o rrmaurozi :i , pri n atrol
j ri
opi i l r' i , rl r. :r<,r,r;a6i pl tr' l
rr r
I
r' ocrrsrr l i stdrerni r: (catc i ntcr.eseazi i , artera ofi ,l t,i rrri ci ,).
ll\ Ilol.i. .sistem,ica
li
toaico-metabolice : a) Diabel,ul lealizcazi, neulr
lrrl
irr, rrlrl,ici, dirbctic5,,. relatatii, destul de frecvent in evolulia diabetuh
rr.r,rrtrli r,hiirr., cu, se_ml
-inilial
al bolii (Skillern qi lackhar"t,' 19i9
;
Duk
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
rrl l r:rsl l rr, ul tori or gi pentm al b-negm). Modi Ji ci ri l e
' papi l are
(
rrl,r' o rlccololare cu predominanll
temporald,, la ilebut iuilnalu-se in
' .r l , n{)monr, (' rl omatoas{' i
b) Anenri i Je, i n l peci al a.ne-mi a perni si r
;rlrxirro
ndeseu novrite- (neuropatii, n.n.) retrobulbare (Oliva;ius, 1961
.l trru' n, 11)61 - ci tati de Duke-El der
$i Scott, 19?1); cj
pofi neur' onati i l .r(,l H(' l r, 11,6I - ci tati de Duke-El der
Si Scott, 1971); c)
pol
rrrrLlil,iorlrle, oarentriale-, diqmetabolice pot afecta qi' nerwii o
rur,r'rl,ronllro, oarenlrare-, o'rsmetabolrce pot atecta qi nervii optici (:
rrrirrozrrlo (lin pclagr5,, din beri-beri, din deficientele tle vita,rnini, B,;
lilro|Irlvinls din su-ferinlele rligestive cu fenomen ile malabsorbliil
rrl rrrr4rr,l ,i i l e l a eti l i ci ).
lt) Sutcri.nlele endocrine (tireotocicoza
),
l;)_ l,olin.euro?aliile paraneoplaaire pot implica qi neuropa,tii
r - r r l r t r r ) r l i opi i .
lI) ln trlt,imii ani se relateazi, aparilia de tabloud clinice de
p:rl i i (i rrcl usi v.l ,abl orui de
,,neul omi el i td,
opti ci ,r' asem5nl toa.r,e cu s
rrrr.l rr f )r' r' i o) i tr b<tl .i l c de col agen, cc, dc ef empl u i n l upusul eri tema
(A.l )ri l $. Vl i l s(l tnenbcrg,
-19?6;-Ful ford
qi co1eb., l 9?2; Shephcri l
ci r l : r l r . . l l r Tl
;
\ - i i : t | .
; i
r ' ul r b. , l g73) .
.
ll 'ltor:itt u:oqene
fi.end,o.gene
(ambliapii gi &md,uroBe to(xice
).
S_al
rl .r.r' i ri rr.l rrrr.rrrfi Iarl ,ol i toxi ci , care pot, si i prorl uci , nevri te (noui opati i )
l .rrr i cr., rl j rr
,cl ro
l t)(fnl i ori l m pe^coi mai i mportanl i (cl upi ,\hnoGscui
l {r I r i 11i I ) r r l c l , ) kl t ' r qi Scot t , 1971) :
r) N icol.irtu, delorrninii, cele mai frecvcnte amblioDii toxicc.
rrrrrl rl rrnrxri i rzi ' r cu i ntoxi cl l i eti l i ci . Arnbl i opj a tnbagi ci i este' b
l rr rl ' oi orrr rurnl ral (i ni l i al pontTu r' o$u qi r.erdc) cal e u-i teri or se I
r' rr r{' oi orrr rurnhal (i ni l i al pontru rosu qi verdc) caxe
Irrrrl r spro zonrl o_ pel i feri ce, i ndoosabi
-tmporal e
superi oare. Ui eol i
rii, rr palri rnili mullio Bcotoame centrftle cu mareini difuze {Dr:ke-Etd
rri i , rr pal ri rni l i mul to Bcotoame centr.al o cu rtrargi l i di fuze (Duke_El ri ei
l i r r r r l , l
,
Mi l
) .
b) Al<nolul ?rilic produce
,,amblyopi&
potal,orum;', probabit pdn
I ilxr vil rrntinozil, IJ, cu tablou clinico-oftalmoltgic a.semlnd,1.or eu nevrito
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 Bo aBo{iuii I miihiazl, parezo $l;
rrrrrrrchilor' (,xtrinscci
oculari (cu diplopie, divl'se strabisme qi
thztr
pol.
prrl rl l l i ),) gi al l tr l .ul buri ri ncur.o-psi hi ce.
d) N uropalii opticl
?rin
dioerce alt.e mecan.i:tnte loui<urmetabolkn
tnl l ol Jttttr l -rr,u mai dercri s i n: auJl rri l $ l uti nnc, tl rnol i (nour.opa,l ,i a
r.4l t;i o6
prl ru nouphzi trrl ), In trrtnrr, htmoragi i l ol mtsi vo, l rr grtl l ,i (l i l l t,l ,rf, In ptri on.
r|r,l o drr l a,ut,tr,l ,i rr ol rr,
' . 1. 4
poat ox
,
I
Nt ' t t t nl , ql i l ' ! , pl i t t i i
l t r i t t
t t t l . l r t t ' i i r l r t cr l f l r ( ' r r ' l l ' l ) l l t ( 1. l l r t t t r i i t t t t t t t t ' i I I r I i
l l , l l , t r t r r ' l t
1r l , i r
r r r r l r l i l t i t r r i c r r r : ' l l t r sr , , r l r r ci r , t l r i t l c
r ' l , r r . )
1i
sr r l l l l \ l l , l l l i l ' l l j l ,
( , l l
' r , r
, , 1, , ' , ' l ' r l t t l r : r gi cr t : : r . t t r I I I i r ,
I
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l l r l , r l r l r r r l t r r l i ei o; l l i l r ' .
t r l i i r ( ( r r
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' l i , , l ' , , , ,
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r : l l r r l czi r r r r i l l l t t l r l r r gl t t i l t t l l t l r ' ,
( i l
l l ( i l l f i l l i l t l r ' l t t l l l l i t t r t l l i t l t \ r ' $l ( ! l l l l
I r r , , i ' r l r r . l r r i l l r i l .
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; i
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si i t t t t r r vi t l t ' l r {i t ' zt r I t t r t t t i l t t t r t l t si l t . l t t st t l t i t t t l r .
r l . r , r ,
; , r i , zr r r l r r
Jr ol t l r vt t l t t i si t t t t t i i l t t t r l ot t t i ol t i l i ' l r ' - l t ' sl l t t t l i sl i r t t l l i r , gl r l l r
l , ! l r , l '
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l t l t ' t ' i I t t 1t t t | i I o| t i zt t r t l t ' r t L'
t , ' , r r r r r , ' r ' t r i , l r r r l t r r , r ' r r l vl r
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l ) ( ' l l l l l l
l czi t t t l i L' r ' r r t l i r r : t L' oi ' l ' t
11, , 1,
r r r ol ci l r i l ol t r r l i l l , l t L' .
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l r , r . r r r r r r l r r i r I | { ) | | r r | | r i I I t
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l r , r , , r , r ' , ' 1r l . r i l l r r r r ot r i l t r ' i t t cot t ut t l , t r l o sl t t t i t t t t r t l t i i t t scci r r t t t r ' , i l s( ) l l i l l ( ' l l l l r \ r r
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r r r r r r l r l r r t r r . I r . r r r 1r ot ' I t I r r t ( , 1, ( ' l i l l ol t l ( ' .
l r t l , r ' zr t r t r i l r . Lr l t t t l t t i
l r t . t i cl l t l
t or t l i zr r azi i t l t ' l i ' r ' l c t l r r | i t t t I t i zr t r r l r l r
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f i
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l r l , , r r r r .
| | t i ( , r l i \ r . : r r sl I
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I ' 1, , ,
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i r r up r i zr l r l
f . l r .
( \ \ ' r r u i t r gi ot t , 1l Xi ) J) ,
l , t l , r ' zr t t t r i l r . r t t kr l t t t l r t <' ci l t i l l t l si i t t t r ot l t : r t l l \ i zt l t l l
( ' ol l l i ' l ' : ' i l l l t l l l i l r ' ) l
t r l l , , r
; r : r I oI r r 11i l l
l i zt r t l l ' o st ' t i r , t l t , t ' t t l l t t ' 1r ' t i sl i t ' i : r t ) I l r l ' ni : t I ' r r r . r l t i zr
, r r r . r l , . r ' l l r r r r r l l r r r r ( l l i i l l - r r i , l r r t t t i t t i l , i t r t ' ot t l t asl t ' t t ct i zt ' | r ^ r i zt t l t l t ' t r ol t l l r l l r r '
l ,
| | r ' ' r . r | | | | i r \ , r l i t r l r , zi r r t r i L' l ol t t t l t t i l l t t t l xr t ' l t l ; l r ) l ) r ' l i ' t ' l cL' t l l
( 1\ l {l l l l l l I
sl l l
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r r 1l , r r r : r r . ( ' | ' t r r r 1t t : r i t . l l l l {) , r ' i l r { r l r ' \ \ ' r r l sl r
i i
l l r ) ) 1, l 1) {; 1) ) I <' )
( ' i t r t l
l l zi t t t t i l ,
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l r r r r ( i r r t r i k, ; i osl r ' t ' i r r r t t t '
l r l l . t I t r | i I t {i i I r I ol t l i t ' t ' , st ' I | l t l i z| l t zl i t t
. 1, , ,
r , l r l r . l i ' r ' l r , t l r , r , i t t t p vi zul t l t ' r i t t gl t t t ' t t l t ' , i l t t ci t l t l pt t r t ' t ' st ' l t r
l l i l l ol ogi r '
i r t , r , ( r zr r
l r r t l t r t r l t , i zt r t l
; i l , ( ' r l i l t t r i l ( '
l t t ; t t ' t i r t l t l t ' l r l t ' t r ul i r t {i i l ot ol r l i r ' r
,
l r , r l
t l r r l t zr r l t t l l st ' r t t l r ' l i ' t l t ' : t I I i I t t t I i I t I t I t ' , t ' t l l t l l t ' t l t t t ' l t ci t l t ; t t r t ' i l t t t ' t i zt t l t I
r r l , r r ' i r r r ' ( \ \ ' : r l r , l r si l t ol l , l t | l i l l ) ;
r l ) i {' ol or t t t t l l t ' I t i l i t I t ' t ; t L' I ' t ' t t l t : t l t
,
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r r r r l r r r l r i i pr r t r <' l r ' l c r l r . l i r r r ( i t ' , si t t l I r t ' t r t l t t l c i t r r l i sl t t t r , {i i l c l r ' l c t r r r r
, l r . t r r r ' : r l r ' pol i l r r r r t cci ; t i l r t l i ( l k' r r r l r r r ' qi l "t l l l {r \ Y, l l , ' l . r t ; \ Vl r l i r l r
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l l or I
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, ' r l Lr ( ' I ' r ; I r
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l , r l . r l ' , t , r l l r qi 0r l r . r , l t r t r , r ' l ct i sl i | i i l t ' zi t t l r i l ot l r i l I l r . t l t | r ' l t l I n| i zt t t i i t ' l t l t r l t , t i t t
r \ \
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, , r r r r r r . , t l r u | t ' l t t r : t i l t t l | st ' l t t l t ' l t spt r ' l t l l t l r ( Li l r , si l l l gl [ l l x' l l l i r ( 1t t t t t l t t l l i t t i l o
r , , r , 1, q11i ' 1, , t r r t t l l t z, r r ot t i t I t i t I r ' . l i l t ' ; xr t l t t r i l t ' t l 0 t t i vl ^l si t l { t t r r l t t l l t l t ' , t l r t t
' r r . 1, . r r r t t i l i r r r l i r r sr t l r {i l ' i , I i I i l t | | I | I ( ' . . \ ( r l l i hl l ol l
l r t l zi t t l i i
l r r t i r r l l
qr ' : r r l r ' r l r !
r l l r t r , , i i | n r ' i l | t ; r t t l t i zt t l t l t ' si ( ' sl ' t i t r t l t t t l t l t I oI t ct ' t t I t i I '
' '
i 1 l ) 1. . l l t r l i i l ( ' ol t l i t t '
l t t ) t l l t t t
l f i t , i f l t ( r ( spt \ Li r
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) '
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; i i
r r 0t | gl l l : r l , r . , l l l l r \ , l i ( , l l
l l t l l l i r l ( \ l , i l {l l l l ! l l -
I , 1, . \ r ' l r , r ' r . L' t , t t r l r l i r r l t r ' l r . l l I | | | I | , I i I I t , i l r t vt r t t t ' l l t r t t t l t l t l l t i ; t l r ' , r l l l r i t l ! l l l )
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y
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Yi zr t i r l
l l i r . r , .
, r , . , r , r r , \ , , i i / o, i , i , i n. Lr r , . ! . i ccnr . , , , . ". ", i "11;
l - , . . ** **, *"r "ar e a r er l r ei ; d_ co, oi r r i r r .
r
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l rtrrt,rrri rr.rrJi , i ar cl i sco^l anta di ntre stri mtorarea artc' ekl t,
t l r l r r l l ( i i r r or l , l or r , . 1r , i i mai evi t l ent i i
I t r . r , r ' r t l t , r t , t l r , r i l r i t ' r ' i t l t , r ut l ont t t ' r t pl t l r i l r t t ' r i i t r l l t l l t l l t zi i t l ol t t t l t l sr gl l l l ' l l l
$l p' r I r l l r , r ' r ' l t t t : r i r t t l t , st . l t I t t t l l I r r t l r l t t l t ' r r t l t ' r t r l r t f l t l t r : l
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,
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l l l , , t r t
oI l i | r .
l r r t t i i r t l r t
l czi ut t t r r i t t l t ' r ' r ' sr ' : t zi i l : t soi r , t l l t t l
1
t I I
I
t i I t t - t t t I t t I t t I I r I ,
sr '
I
f t l ' 1.
r l r r , l i r
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ut r sc0l ot r r
( x' l t l l t t l ( l ) ( ' l l l l r l ( - , l l l {) l ' i i i i
l ) cl l ( . l l l
i l l l ) ) '
t -- -
l t i l t r t u t ) ,
r t i : r '
t r i l r , , l c n, n l i l J.
r l l l l r I r I i | , r I r r ; r i i cr r r r r : r r r r pl r r ci zl t l , qi i r t t l r ' t i or ( l ' ol ) ol i t l j l t
I i
l ' i t s( , 11, l l l , q( ] ) ,
t l , ! l | r r l r ' ' r l i i r 0pl i t , i | i i i r . si l r r t t i r ni i
( r l l ( 1. ( ' ( ' ( ) l t ) r ' l l I ( ' i l ' pi l l t i l l t f i i , N{i 0sl l Nl ) t ,
l l l r r . l r r r r i r l l l t l r , r , o l ol l r t t l t ,
l l t l r i l l t l l ' i
( l ( , t l ( , l i i
i o1( l ci l l l 1111, 11 11111r f i 1r ol i l i t r i l
r , r t , r t l : r l l i r ' l ; r l I r . t r r r r , t r t r ht i ' t
t , koB l , t , l M l , : t )t A(i N( )l . i ' t ' t c l N t , l )i ot f f A l , i \ , l t l
I ' t , ' l l r r l r ni n. 11, p1r ' zi t t l i l , o
( l . ol r l l t vi r l ' r gl t ) l ) t l l t l i r ) ct l l i t l ' i l t r r l i r t r t r t t l r i l t ' i '
l f r f , f f ,
l l r l r l l l r . r r r . l i i r r r t t l r i l l r i r , r r r l l i i i
l r or r l r r
t ' r , r t l i z: t l t ci . ' l t ' r l l l ( ' : : t )
l \ t l t t t
. i t t
l f r r f r r r l r r r r r r , r t l r r t ' ( r , r ol i r r l t t t i o
t t l ol ul ) l r ) r , t t t . l l ul ut i r t nt r t l t t r r l i : t ' \ t nt t hi l i t t r nul .
f . i l . l .
, l pf r , r . i oI nr
r l i ni r i l $r , l r r r , r , l t t t ' : t | ot ' 1, r , t t
I ozi ( i r r
r {r t l t i ' ( ' i l i r t : i r l t '
l l l r t r r
r 11r . 11111' t ( ' i r r r ,
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; ' / . / / / . Sul , l i l i ( , r l r t l i nt : ot t l ut t ! r : l o t , , l t ul mot ol t i ( : o- . 11t t 1t : ! i ot t al r ' . r t l o &t t a. l i i t ot '
Jf t ' , ' ,
l ) r r
l r t . r ' ' l i cl
st '
f 1i r . ( t i i
l l sl ( \ r l , ( ' l t l r r t l l i t ' r r r l t ' t t st r l l i l ,
( [ ( r
f r ] ) l ' ( ' si \ ' ( ' l x) 1,
, l {
' , t ", r r . r l r .
l r r l r ol t r r vi r , r l {)
J) r ozi l l l i l
l i t l t r cf i i vi zt r r t kl l r l t l oi t l t r l t t r t t t t t l t l c,
l , Xt l
l ' l r r r , r l , r l r r l r r cr r r r : r r r r pl r r ci zl t l , qi i r t t l r , t i or ( l ' ol t ol i ci t t
[ i
l ) i t s( , 11, l 1l , ' 10) ,
'
Lt . . l l t ol i i l r qt l i t r : l t t , t i cc ( r ' t ' zi t Lt : r t i t cl o u111, i l c t r r xi co)
l l t . l l t t t l i i l t r 4l , i r : r : l e t ' l i al oui ( t t t ' t ' t l t t osct t l . t i i t l , , r l
j l t
l r r t l r l r t l t t i
l , r t r ,
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l l l ' r '
,
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' f l r r ,
' , '
l r ' ; r t r sr r i si , . t i . r {1i ' i dol n i l Ll t I r l , I
) ,
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l t i t
ar ni t l l Ll r ' , t t i sl , a! t t t t l s,
r l l l , ' 1"
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r r t r r I r I i o1r i r r l sl t ' t r t ul i , i i l r ' ( r i l o st t l l i ol l t l t ' i i
11.
t r t t l t , i l t l t gt r l l r
l l | | r t | | , , , 1i r
( \ ' r r n
l ] ogl l oI l ,
f i
Yr t I r [ , o( {1No}1, 19. 19, ci t l i f i r 1( : I ) t t l <r r - l l l t l ( ' r ' qi
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t t ( ' f r : r 1, . l i i t r r l t l r . l ; , l t i t 1111, , , . , ,
I I r 1' I
l r t :
I l l l | r 1. t .
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.
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r ' , t ' r i sl | ' t t l l t
t l c r ' t t l l t t t i 1t | t | t ' 1r t t I | '
t l r '
I ' l ' l . r nt t t r t t t r l r r l t i l l l i l t t l l l l r i l j i : 1\ l t t t l t r t l i t r
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gl 0l r l t l t t t
11
r , l , , , , l l r l r r r r r ' ( l l l l ( r , l , r l l , "t l l t r s: r r r t t r t , i t r t r t t r ' i l ' l l r ' . st t gt r l l l zl i
sr ' r l i l t l l t
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r ' xo| I I t I t I t i .
t ' r t
l ! l
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r , , , , . . | \ | | | ( | : I i
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r t | t t l : t t ' '
l t ' r . r l r ,
l r l l l l
l r ' r r "l r '
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I I I i I I I
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l t st t l l t l l t t l r t l i r l ol l t t l o: t ' I I ' t t t t ' t t I t
:
l t
r r r l , , , r l r r l r l l l ( : r s: r r r t t t ' r r t t l l i l l i l i l l l l t l l
t ' - r r l l ' l l i l r t t i t ' i ; I ) , ) r l l l l ) l ' l l l ( l ( ' l ( ' r l
l t t r r ,
, r l r r L J r ' 1 , t , , , , , t i r , , , , , , , t i ' "' i 1i i t ""' t t ' )
' ' l r t l t l t
t l t ' . 1t ' l t si t t t t c
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; ; r ' , . , '
, l ) l : r l r r
l r r r l r ' r r l i l r i
sr r t t t Lt l t r t l sr t l i l i i : t gl t t l t t r l t t i or r t t l i t t '
, | , t t t l , t t t r t r l i r r ' , t : i t l t l t u' r t sl i t i ot l t i l r r t r i ; i 1t I t i t t r bi l ut
| t ' t t t t i l r
t t r r
1
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l t I t t t t t r t t t t l t t t r t t i ! i I i i ! i t ul ul t t t l t t i
t n' t t l t t l
r l r ' ' r l | r t zi I i t ' t t
l t l t t t ' zr ' i
l l t l t
; t t r ,
f
"'
, f ,
"' , ' , , , ,
, i ' , - t ' , , . l i i ' r t t r l l ' t ' r ' t r l . . t r r Ul r ' l r t r r l '
{' r ' r l l i r l
'
l ) l
i l r
l ' t r "
r ' '
l l i l r
, i l ' l r l
I I l ' : t t ut l t ' t t ' t r I r
'
l
l r t I t t t
' '
I t t
1 1
i
'
t xl r l l ' l i 4t l r t t : , - l )
'
( t l
i t t i t t sl
I r r ) l r l c
. 1, , t ' r t t t l r l l t l t l t l
1r I I ' r r : i ; r l l r r t ,
' l l t t r l t t ' *i s,
r ' l i ' t t i t t l r l : r r l l ct l t l i i i i ' t t ct t t t zl l
t , r r . , , , I
I I
,
| | I .
I : I | |
.
: |
: l r ' r r l
l l l r 0r ' l l l l t l .
I
| : I I I
'
'
l l : I I I I I i i
. t l r ' t r r r ' l r t i : r
- l ' r l t t t l t t t
; ; ] ; '
;
' , ' ; i , ' ; ; , i ' t , ' r r r t r r
( l i i r sr ' | r ' ' r t r ' "t t I ' t ' r t t "t t t t
t ": i t ' r t i '
'
t "r t ' '
' i i i
'
' ' , , , , ,
r i t r t l ; i r t l
. ' l \ r r t
ul ui r l t
' ' l hi
l t t t ' r . i zat t zi i l t l ot cscl t ' ( 1r r 11r
r r r l t l r '
; ; , .
, ' , r r r l , , 1r 1 i r ' ,
l r r r pi i : r ,
, l t i l r ' 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 r l r l r t l r l t l ) i s
i r , , . ' ' "
r t r l t , r t r r l i ' l ct l i | ' r r t r r ' r l r .
r r sl l t zi i
l r l l l t ) l l l l i r
I l ( '
' l : I l . l ' l l at t t i t t i i t i l r ' l t r r t t r di t r i t : r t t t l i l esi ' l bsol t r l
r r l cr xr r r t
i t t : t i nr l t ' t t t nul
1t t r , , l t t t t , r r r I osl i ct : t l ' l i i zr i l c
t l l Ar sl t t i
1i
r r ol l r l r '
( 1117?) :
I l t , , l t t t l t t t ot t t d) ' i r t , : t l i xl ' : r t t t i t l l i ( i i i l l l l ' t l or '
t ) I I
'
t I | | I t t t I t ' t | | r ' r l r t ot r ' : t zi i vl r l i l r ( i i l r ' 1r l ' r ' si t t t t i i
. i t r I ' t ' I t oI I t i LI t t r ' '
Lt l r r l t r !
Cr L, t , l r l ) r l r 1: r l ( . I t r r ' , r I r r , . I i bi I i I I r 1r ' ' I r I
t ' , r o l l : r l t t t i c i
,
pt ' r ' t l t i l i t r t l l l l l ( \ r l i t ]
; i i t ,
"; , ,
,
,
. , ;
, , , , 11 1 , , 1 r , , i ,
.
1 r l r . o| i ui r r | or . l i i l r r l j i r l . r , r . r r r . r r r l . or r f l r r r i r r r r i
r , 1r ' .
. , t
l t , l , t , , t . i r i l r r t r t | , i , , | , , r 1i t r , . i r r I r r r r r r ( i c
r k, l i r l r l ot t l cl i r r i r i , i
oI l l t l r t r r r l ogi r ' ,
Ft r ' I
r , , , l , r r z: r I t t r r r r r l l l ' i
l r l ol r l r l r i l i l "l t '
1111
l r l r r r r t ' s
p: r 1ol 1r gi r '
' l
t t I I : t t I t I t I r i I t t t
i i f
r r
"r ' r r p,
l I r I I i I i I l r ' l r ' . \ r ' st ' r r i
1i
l r r l r r l r ' ( t l l l i s r r ' l r ' r ' ' l ! l "i i ) ' sr '
l t t r t t
t '
, I i , t r I t r t r
1
t r t
. l
i i si t t r l t l r ' t l . ot l r i l r ' , : r l t ' l i t t t l r ' l r r t i l r ' l
'
r i i r l r r l r
'
; i
r r l l r r t i l r i l ol
r l r I ' r , , , i l , r l l l r t t t r t l c . l ) l r ( ' i
'
I j r ( l r r ; qt i r l i i
: ' l r '
1' '
r ' ' I i | ' ' r '
. r ' t ' I r i I I Lt i '
: r l l nl t t
| "r | '
l , l ) : r : / , r , ' l : ' l l l . t l l r . : r l r ' ' l t l l ' l i l i l ' ' r
: | "t t
"": | "i
l r ' l ' l r '
' l
"' i "l l l
I l , :
, , , , 1
, , , , t r , r ' i r t r i r ' l l ( i t r r l i t t t t r l r ' i t r l | i r I r ' r r ! r ' ' l ot t t ot l t l r . l i i ot l r i l r t r " I i I I I I i ' ' | | | | |
1, , , ,
r r l t : r r i i r ' , ! r r r l i ( ) ql i l l i i r t l t ' ; ; l i t t t r i l {' t l I
'
t | |
I
| { ) ! I I | |
' f i
1'
I t r I I t | , t
I
t | |
|
i |
( t t \ t t l t : ; l t t t t l t r r l r t ' t t t l t r t t l :
'
r t I I i I r r t I t
' I t 1 i r ' '
l l l I r r I I 1I : t I t I '
, r t l , r r , . r t l r ' t l or l l : r l t r ' , , t 1 ,
'
l r t t : t ,
: r t l l t i or ' l l t l i i l r r l r r l i r l i r ' t r r ' ,
1' r L'
t t t r r o t . t t I r ' 1 : l l
'
r
t , r
r , , i . t r I r i ( I | | | ' l l I i I l l r ' .
I I ) l t t l r t , r t t
l , t
l r t l t t r
I
t r r
'
' t
I I l t l t ' t t t t t ' : l t r r i , r l r :
r ' r ' o"r ' r r l i ' ot l r r l : r t ' r r ' r l r r ' ' t t | r ' l r Ll ' r i ' t l r l i r . ,
r r | . l t r l t
I r ' . 1i , | , r r r r , r
;
,
t r r I i I i l \ l l l l : l , I I I I | | | | I I I r t 7: I I : I
i r ( | (
' | l
t l t l | r
: 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
Dti DIAGNostrrc
INRPATOLOGIA
SISTEMHL0R
: if
if
f *liflri,ilffi i;$tiFrl
;,r"*.rm,m
fu
",x[
**l,-;'pg,f
*l*fftl',i"lffi
f
i';ffi
;3Hl*T.1
,riri;r
jiril"lr',',","ff
ilf t{i,:}}}"{*;1$
j$ti:p1r,ir"*:r
ri
jiilililtf
ld'*f
t:flr.rriffi'ft;ffi
T-pfroq:*ffi
jiri'i,r1ir,J'llidnilltl[lFt*l::r;i"ilr3rp;;1:;i*:""*r::
,,,,,'
"il
j
li
:ili
l,i I ii;,n:Ttj"i,{'fiii1"fii.
T\;:i
i,,i
lx."lljy,,
;l il
il:lixl
iiil
jinrl:ii;rril{}1l*#il}:ryfffi$il,r1if#*#r,lxrY
Uii:i,ii*i**i$*,ii,;'tr'{it'1fi;,'{#:ffi{f;;i;g$
iii:ii: ;i i
r'
-
*fl t +ury$ffi*ffiffi
,iiiiit
-iii
i|'i,::,*i#iilii$#*:#11lt
*;,;
,,v:"
,, i,,
:
ll;iil;ill'lx;''
'
'i:',ii;lilr'u*l,,i
d1?"iih:,,,"',,,,,'
,ll1#i:i''',1fl'
, .
: ; . . t . I . l . , \ t t r r l
i r r l uot i l i l dl i i ,
:,,,:iii:,:i[,i,!!i:,:ii,i,,,,:i,,ii,|inri'i:i{;*|;;,-*,1,:,,i-*
l 0
r r r t t Nt l t , i t t l t t i
Pr r r l r l i zl r t
( Hl u l l Hr , l ui l t i l r , r r r r l l r i l l r l , o r r l r , , I I 1t i r r r r i I r I 1 l t l t f cl l i l ol .
t r l i r ' , l r t {i l t r f i : r zr r I i l o r l c
l r r r l r r l l zi i
r r r r I I I , i
1
I I r r
)
. , \ t r csl , ci r r r l r t l r r r nr r l i l i l l r l r , xr ,
l )ol l l o Ai l )l t(j i i t, foarto oxaal , ftt rrJtrl ()t' ri l pt[.i rrrot1' rr l tr i i rri l ,.i i l st,r,r' , r' rr,rrri i
l r r : t t r . l a l i nr i i r . t i i ne[ f i zi ol r gi | r , : : r )
, {r r l , ( . r . i or _
45. ; [ r r t ( . t
I , r , r . r l
I . i :
, r i r r l cr . i or
- 50"; d) i nf i , r ol r r zi r l : l i -
, {0":
t , ) nr r zr t l
_
4. - , ".
Bl I.i .mi l oreo
ctmpul ui d( not i t0l p ;tt pt.;t)i rea, bi n<,t.t,l a1i .
:-p
.1i ,.
, :r rrr ctzul i n care ochi ul sdni i ,tos este fi xator, del afecta,t va sui cri l i rrri l ,rri r,a,
rrri ;ci ri l or i n mani era i ndi catd, mai sus. | n cazr i n care ot,l i ul l xrl l rrv
cnI' c_fi xator, o-chi ul si nd,tos
ya
prezenta o exti nd.ere a ci mpul rri rl rr Ii xrr(,i o
iu,.tlircclia
,,liperacliunii' , miqchiului sinergic contrllaicrl) ,clrri
lirr-
I i \ l ( Lal ,
Cl T. i mi t ar ea
cf mpul ui r L.
mot i l i t qt e ocul ar d, coni uaat r ; .
11, , 1 i l i l l i r ' l l
"' rrj uga.l d
vol un rd sc
pxpj oreazl
pri n i n.pccl a.rea
-ex"cursl i l or
gl ,bi Lr|
or, t3rl t0. col ]l Itzl l e de p-ri vte i n sus, i n i os.l a dreapl ,a
5i
l a sti ngrr,
Ir.t.r.rIr
r
,,i l i l sol i ci l area
bol navul ui de a rrrmdr"i un obi eci cai c sc dci l ni i .l zr' i i r,
rl i vct,se di recl i i : ori zontal , verti cal , obl i c qi i n pl an medi o-sagi tl al (corrvrrr.
r ( ' nt { ) .
2.4.1.2. El utl i ul ntoti l i td!i i canj uool e aul ttmal i co-refl etr uti l i zci rz:' i
rl r' tl i procedee:
a) Depl csarea i n ci mpri l vi zual a unui obi hct-1cst l umi no*,
,)l'servindu-se
ulmdxirea acestuia prin miqcirile globilor oculari (,,tloll's
' ' \,' . .movements ") ;
b) Modi fi carea pasi v5 a pozi l .j i i r.apuJui (maLrr.vi ,:r. l ui
Al rj ou.ani ne), l a care subi ectul arel endi nta i l e a' -si mei rl i ne gl obi i ucrrl :tri
Itr pozi f i a
,,pri mard,'
(,dol l ' s
bcrd fenomehon"). l i si fel , i a roi arer crrprrl ui
rtrre dreapta, globii
oculari tind sd, rd,mind, in pozitia anterioa,r,ri,, ori a,ll,o
, trvi l i e,
fal i
.de
nou_a.pozi l i e a capul ui ,
.r
or pri vi s' prc sti nga. l _i roti rr.rr.
,' rr puJ ui spre sti nga, gl obi i oc}l ari r.or av"tr, o
,,p-ozl trl c
ri el ati vX' : spl t dr.cl ;rl r,.
Lrr }ti perextensi a
capr.rJui , gl obl i ocrdrri vorl i ua
i l ozi fi a
rel al i v i nfori ri i rl rl ,
r:rr' l [r fl exi ul ea .apul ui ,
acesl i a ror l ua pozi l i a
rcj rti v' s r rl cr i onri . Ll | l l r(l i
t[trea capului pe un um5,r sau pe celdJali, sc vor produce^miqc?ili tonjugfl,t,0
tr' l l r' -tc cu ca^ra_cl cr ghai or, i n si ns orar ci nd cal ui csm apl ccl l spo rti r.i 1l .rr.
rl,r ituterior.cind
eapul
-este
aplecat spre stinga.^Se va ruriri,ri qi cirmxrrr,ll,ir1,1,
r l | l l r r e
I i mr t al ea ml $cr r or coj r j ngxl o r . ol ul l ar c
5i
r r . f l e: r . cu r r i . t : r gl l r r r st r l
; , r ' , r vocai
pr i n csci t ar er l abf uj t r i i ci pr i x t esl cl , . cl nsi cc ( r ol l t or . i i , l c| r r r i cc) .
... ?:4.1.4.
Stud,iul d,erialiei paralitice a globut,ni. oautar (Strati.smul,
).
slr abismrl se. exploreazS, urmdrind pozilia
"globilor
oc.;ula,ri ia privirr:l ln
l l l l i .Di 14. pri yi rea
i n toate di l ' ecl i i te. Sr.&bi si al
1sl .rati ti c
(tl ctuti ri t
,1tn.rutr-
,.,,tni,tent"
).se.
ca,racterizeazl prin
laptul cX sc acrentncaz:i,
1xr
rniitrri, r,o
l ,ri l rr:wul i qi di ri j eazd, pri vi rea i n rl i rci tri a, mrqchi ul ni fl ,Il eota,ti . i ,ukrm l nl i l l i
trl trLi toarIe-
ti prr-ri de strabi sm a) donr:ergmt, pri n
l l aral i zi l
rnrr6chi l or
l l nl rl ctori ;
b) Di aergent, pri u paral j zi a, nl i 6chi tri i : atl i tuctrx.i ; o) i u1,ru
tt ticnl. (.surcumrergent
)1
prin paralizia mrrqChilol colxrlll,orj
;
rl) l\lrr.,-
tt tttcttr (subsumaugcnl
),
pl i l paral i zi a mu"schi l or ri rl i ci i l ot' i .
I$to necesar ca strabismul (cirrd rru es1,o }r'ca cvitlcnt) sli, fi{\ rf)iilrr)inl1
r r l i f .
l r r i n
t est ul dr ui a! . i ei
l t r i mt r r
( ei ncI ur hi ul - I i xl . t r 11, ca{6' 1, , . 1 si l l i i l ( }$) ,
( . 1t ,
rri .l rri n l esi ri Z deti al i ei secuntl are (ci rxl ocl i ul rfccl ,or cstc i l ral or), ovtr:ri ul ,l
t r f
jliziniln-so
Ei
p arirnetrul, lu,i I' i)rst.er.
2.4J,4, Ii wmi n-qrca pfti l i d t' o ttt1t tttsrt ttr i I a MInl ?ti ,ri rr gfi rrl rr.i ,
1.i rrr.
t t l t l t t a du r cgul n:
, , bol n: l vnl
i ; i t hr <r ' r , l t pr r l t r r ol r r i r r r r l c l r t . r , r i ' l r or r t i r ' r l i t i r .
, . l t i t t l pu, r ol i zol ; t t , l n l ncol ct t t r , a, t a r l . i t t , . , nJ, ( , l t Hl t , I t t t r r r {r i l t l r t t 4r l r i r r l t t i
4t
t l i r t l l t l , \ t t l l r ' 1,
l l i r (
l {, l r l l l l r i l r
l ) r t i t l r
t r ( ' l r ( i l ( f ci l , l ) ul i r l r l r , r r r r l i r r r r l r or l r r i i l l i t -
l i i l r ,
111 1111, . l t l r ' r t
l t ol r l l
t r t l r r r r ocl r i i . l , r r l i r l ,
l t ozi l i l r
qt , l l l x\ 111q1t .
1.
l r ( , 1t 111
11
r i r r r l i r i ( .
( l r 1 ( l 11. l , l ,
r l \ l , r r r t t i t l r r 0l t l i . i
( r st , o
ooi t 1[ 1r
ql q, 11; q111,
r . r , r . i l ql l l i , i ]
, r r pr r l r r i 11i l r
gi l l t l ui ,
r . r r r r l j z, i r u[ - - r ui ni os l a oopi i r r sl r r . r , l , r r l cl i r Li r r r j . e
, l r r I l
i I r r l i s" o{, l t l l t r ' , r l l r ( 1l l
oi t I i r ( : ' l r edl r ( t i bi - l ( pl . i l l l i | i i l l r l ) st nul ui sau
r l r r I l r r r , {i ci ut r r l r l r i r r l r r i s1cl l , r t . l ei r l o- mest oi {l i an)
l Ri i or ,
i Ol Z
;
Aneni
1i
l o l r r h. , 11) 67
) .
1.1 .1.5. lltumenul d,iplop,iei. Diplopia (perceplia a clouL imagini alo
rrrui si rrsul ol ti ect) apare doar i n l ezi uni l e ocul omotori l or cu strabi sm
,rIr,or0orni 1,otrt", fi i nd absenti ,
j n
strabi Bmel e
,,concomi tentet' .
De obi cei ,
'olrrrrvrrl
rlisliugc cu uqur,in!d,, in majoritatea cazurilor, imaginea
,,ade-
'rilrr,lir' (rrdicii, cea, perceptt5, d9. o_chiul norma,l), care este n15,
Si
imobiii,
rrir.:r.nr.rrr fi pozitia calului, fa!5 de
,,imaginea
falsd,t', care este mai puliri
l l ri l rrci i ,oarc, mai pul i n neti , d.ar mai al es mobi H i n raport cu depl asXi i l e
r l i v i r i i
( I i i sur .
1952) .
ln diagnosticul
$i
tn interf)retarea d,iplopiei, trebuie si se
tin?l
seama
lrr rrlr r rii,l,oart>lo prdncipii. (Riser, 1952
I
Sachsenweger, 1966, 1969) :
r) Irrirginol care trpar{ine ochiului afectat (imaginea
,,fals5tt)
este totdea;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
rrrrrri chi uhri paral i zat; c) Oi nat pri vi rea este astfel di ri i ati , i nci t.cel e
orrl irrrir,rrirri $int indepf,rtate la maximum, imaginea cea mai perifericd)
l rrr
l ti trc ochi ul ui afectat.
.
I)rul,nr, sl,ud,i,u,l mai preais al iliplopiei se practici,
testul d,e d,iltlopie (al,
li(lt i t.tlotul.(
).
Acosta se ofectueazfi solicitlacl bolnavului s5, fixeze gi
sd,
rrrri i rc:rsri trrr
l tr.i vi rea
(capul fi i nd fi xat) o sursd, l umi troasd, de mi ci ,
rl r' rr$i l ,l l .c (tl i r,cri rl ul oi l umi nfl ri ) rDezatd ]a o di stante de 4 m. Do
r l i l r , i r l r . ( r , r r , hi r r l r r i dr ept de pt ascr zi o st i cl d r osi e, pr i n
car c Sur sa
rrrri rrorrsi i , rrl tl rc col oratri . Apoi sursa l umi noasS, va fi al epl asati , i n di recti e
l i zorrl ,rr,l l , v(x1,i (n1,1,
;i
obl i ci . Bol navul va rel ata pozi l i a qi di recl i a depi a-
i ri i i rrrrr,gi ni l rr., prcc[m qi di stanl a di ntre el e. Una di ntr.e i magi ni (fi b6
r rr r,rrsi r., r' r,s|i ' cti y cca, fal sf,) se i ndepi ,rteazi de cea rea15, mai mul t sau
rrri pr(,i rr, i n l :urr(rti e de di recfi a pri vi ri i . Astfel , rl i stal ta rti ntre i magi ni
,
rrrirrrrql,rr
1xr
rnrisurri ce bohavul pli'veqte in ctireclia cle acliuno a mu$-
t i r r l t t i l t , l i r ci r t t .
l )i 1rl o1ri r, po:.,t,(' ,l i ot' i rontdl .d (produsd de afeetarea muschi l or ztbductori
rrrIrIrrrrIol i ), rerti ca,Id, (prorl us[ rl e a,fectarea muqchi l or ri al i c[tori sau
r l , r r | i l , r r I i ) , ". i obl i ci i ( f t ! 1. i , 8, 9) .
l )rl i r i nri r,gi l l oi t {al sri i .l pare de aceeaqi parte
cn ochi ul afectat vorbi rn
':ln'o
o d.illtltic h,ononimd, (sau, d,i,rectd,
),
iar dacl a,ceasti, imagine fal$d,
l ,
l , l r r . : r t : r
r h,
l | r r t r ' i l
( x. hi ul ui
sADi t os, vol bi m despr e o d, i pl opt i I hel er o-
; t t , , r
( s, r r r i t t ( r t t ( i yt i
) . 1n
goncr al , i t i pl opi * homoni mi l sc a5oei r l zi l c ut r
nrl ri rrrr corrvo!' !l ori l , i )r di pl opi a hei ,eroni m,i (i ncruci $atd,)
- cu
' ut
stri ti -
t t t r r r l i t ' r r l got t l .
l )(
l i l tl i i ,:
I)i ,pl o7ti ,(, o|i zont.al d h,unzon.i ,mi i poato fi prodl l si , do
l ul oz:r,
r r l r l r i r r l t r i r l l r pl , r , si or r r t l t r l : r 0, I J. , i l c l a, 0. S. s: l u do I a, a, l nbi i ochi . l ) r ur j l ,
l t,gi rrrl r sc rl o;l i ,r' l cuzr l i r rLrl rIl ts:l l tl , srrrsci )utrri nol se sl rtr
(1t{.i l ,l )tri t, (,sj n
r r r l , r r l , r l l l pl t r l r r r l ' r r r l r r i l r ,
( ) . . 1) .
l r r si t r r at t i l l r r ol ( , r ar i o, t st , c nf ocl ; ; l {r t l r r , l r f i t t l
I r r r r r r L, I : r
( ) , i J.
Nl i , r ' i r r l r ( [ i i t l l , r ( , ( , i
r l i r r l l c i r nr r . gi r r i l r r l nr l t t r l r r xoi r ; r r l i r l r r
+a
*a)l
Moo
vl . qK
o
-01@,,
I
s
N l i l
!
I IN IN
I IN I
N
N
b
Fi ?. 7. l nvest i gal i a unei di pl opi i pri D paral i zi e a nel vul ui aot or ocul ar
(xl f r| l (l r(' l )l '
ochi l Ll st i ng f i i nd normal :
.- StiLla r6ie s-! Dllsl in fdta o.hi. ui Prrc
?d lnagnra @lorait F tufL
pc' e
relr' znkli
'
i' llnii
' ln
cont i nr , o. Se i . r s"r va' ca eLo
' oi u
a" o di i ' l Pn
homor i n l mJ8i ' ea r o' i e s" dPpl r . e?e r r al l r ' , nl Dul r ' s
Li r bol navLl Dr i vesl e sDr e Dar t . a sa dFapi r , . di cd dF PJr ' 1ed
! ( hi ! hl t "nl i ' al O Pal i t i e
d dFl r r ! i ht l ' r '
. t r r gar a" o i i pt opi e or i ani al A
j , n"i sr e, . u ac@. i t azj t i F d i Er 8i ni l . r : i , , d' *"t i denusdr ' . l . r . t l n1i , ' l
lEvrJ' spre pLn drPrfr3:
, - Aceea. i i nvesr i r a! i e, d"r , r i , l a r o: n' . c at l a i a. ' i r
r n l - l r . i h' Lr ! : $f i r i . . nF af r sr t dr ".
", . r r i ' ni
- l r I
dFPl "/ l I
t r
Fi sPr '
o52l
"el
;, eita,J
r,-" I tf,Vt,,
os(
) l V/ / t Ll nt ,
\_.//
|
\.4,'/
| t g. 8. Di pl opi e pri D p: uRl i zi r nrut chi ul t ri
d]'ept intern, carc se :lIL'i llllr-ulr u$or slri'
l ri snr di vergent (sprc drcnpt a). St l cl n f o$i (
s{ rl l d pl asat t r 1l r f nf a oohi ul ui pal rl l ri l
t , i l ' l opi l l r ' sl , r i | | cl uci ) ut , i | r l i r t r x, r i , r ' r
r1, l r)ml I i ri rof l t (t nrr(r1, f i {l Lr l i l ri i ol )l l (f )
nr. {l l )l l rs(: rrzi l sl r(j ! t t l t l I rt , ol t l nt l rl l l rl l ), , 1_
' r r \ r l
Ji r i \ ' f f l o$! r cr l 1l r 8n(
r I d / l / sf / , l l l s: l ) .
I r i 0. , . 1) i pl 0l ) i c geuct al i r t l c
l l l | nr l l zI r I I r t
dr i l l ui dr ol ) t i r r h' r ' i or d0
l ) l t t l r r r l f , . i r ! t r t .
st i r l i r r r ) i i r s
I l r sr r l
i n l xl t r , f l t l ul l r l
l l r t ! l
l l r l 1. l r l I r Ui D( r r ol i ) r xl i i l r r r ol [ ( t i r ! | | cnl i l ( : r l
l i ni i ) s, . i | ,
I ) | r | , I , : | 2n
\ l ) t f l " i ' f . I r l l l l l I I l | |
r l r r l l (
r
( 1l
t ) r i \ i | r r
: r r i l l r l l r i r l n i [ , , r \
t l
r l r r ' , r l r , r r l r l r ( ( l r r l r r , l i t $r r l , l l l l : r ) .
t aat
n$
UH
u8
H
n
H
t{
u w I
r l , l j l r l l l l r '
; i l t t l r i t t i i , t t ( ' t t ] r l t , i r l r , t 1i I l r , l
l t t t i l ) j l r , t ( l l , r , l , l t ( . r l r | | r
I r i r i r l i i ,
i l l l : r l . t l
l ) i pl ul t i t r t ' t i . i l l i l t i I I t I t ) t ) t I i t ) | ; | . r , t i l c r . {r i l l i zi l l i L r l , , l r . . r r r r r L, . . r r j r , l ) {r 1. ) r
l l l r r r r l ( \ I r
( ) . 1) . ,
r l r . l r
( ) . u. .
i i l ur t k, l r i i r , r nbi i ocl t i . . \ sl i r i , , ] l , , , , , , , , , , , ui l i l e
.
r t r sl r r . r r ( r , r r zl i
, l : t
r l r r l l l l r sr r l cr r
sr r l r , r , j " l t r - r r t i t r uasc *i , a" . f i a, . , 1, i , , , , i l ( , i l i {. t i cl
l t l
r r l , , ( ' i r
csl r , l l i , ( 11r 1
( l t t l ) l
l i r i 1i 11111
O. S. l n si t i t e! i r l i r r l , r : sr i , r , ezul t i i , ci ,
I . r r l r r r ' l r r i r i . r ' 1i r . i i r r l t ' i r r r r
( J. r ) .
- A. 1, ul ci
"i ua
i i t i agi "
"' s"
i . del f i r t oazi
..r' r' l rl .pl rrsi .l i
ruLsci l rrrni Lroase 1n ambel e cl i rec_ti i
-*rl rol "tr_
ateotarea
r r l r i l o l r l r , r ' 1r l i i t r t or ni .

d
@
s$'l
E
d d
N
rut
d Tru I
wao dttl I
w
p
e
EE
I;sS
w
#
v
',o1 m,,
Fi g. , ?. Di pl opi c
genr r JLd
.
d. l '
r r r l j r i l
muqchi ul ui obl i " mar c
( sr u onl l r s"I r ' r r ( ' r
'
de
par t ea cl r eapt d, cnr e h nl ot i r r or ' r t l r r l
depl : ceaze
gl obul ocul ar I n af ' uJ si
l r r j "
'
St i cl a col or at i ( l i ni i obl i ce) s' i i r l i l i f nl
inaintea oehinlui PamliTrrt '
D
5
,
li:
"lli:",:';,:#:;'#;:;,,:::!,,t:;,,","_3;',?'"J't,Jj'lil;,"i"
iyJffi il
-l::::iiii.qinH't,iiiilt*,:,*.#ii,:;:,?#;,rl*,ru;11;,1*"*1".ru;; r .r, I:r slirrg,,. Sc sta'ilegte ciircc.tia dc A"pfi*.r. , i"iJ"i'i ir,,_oo*u
"r."
t,r;lril:1ilriiiii,ll,$l1x-"#:'oin{ff
,;t*m:"*|i",:,*;lTg"%f.?
:ll,rliliii;;t:i',ii,Jillll.t""ir.:'*-## ji,i":;:-..#,J,jljf
;I
r
paralizie
l nr rl orri i rrrrr,gi ni , pri n
i ncl i nz
,,, ii,,ii,'i, riiicr t' i".
^;,,#ilX
;?d;L1'JJJ
fr#ii:flf
#friH
.l"r,
u t,rrrr.i. rkfiicicnla
aparli:re mqchildr
conoriioi,i, ia"-iaca distanta
.rlrr lrr, irr.lintu.ta
spre in sus, este-vorba cle. p"";rt;;di;;#il;
rrr,rrr{r,lr,s
sc ilnlunc ileterm,,inarea.
ochiului pi a mu-;ctttului aJectat. Astfat,
c vollrl rlr ochiul drcpt, daci, imaginea
iann
lrosle) est",ma,
jos
sau
-o1
m,,
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
sc
-l ri i "azri
spre l n sus 5i
spre dreapLa'
j e poi t c r emar ca. i obl i ci l at ea i magi ni i
' ' ol oi al e spre sl i ncu (dupi Ri rer' 1952)'
r!rs.
I
iit".rl hdh
lO
la ridicarea sursei luminoase (sau 1a ritti_
,,
I
--T-----l
f"?:,iff;"|;;H"Jil"f,,",1J"J;'"ffi,,f1
b, I 1
rerpecbi_v oblicirl mare sau dreptul irfe' _
_
I n. I
rror pp de o prr le (coborifori
a.i globnlui
. -r,
]
*
l q I
oc. ul ar) Mu drept ul superi or si -obl i cr
.:....., I |
---
.rl1' !,
p:.
qo
a.l1,i p.Irtc lridicitori/.
Asrlel,
I , ". . . .
I
/ _ |
orca_drpt ol rr
vert i cal f l so l ccenl rreazi ,
2./r.2. Paralizia nervului oeulomotor eomun
Exi sti i ,,sri se si tual i i sen' i ol ogi ce i n cadrul paral i zi i l or
perechi i I Il l -tt' I
.' t oaral i 2i a ertri nseed
po$i al d (i nconpl el d
)
cu al ectarea uJr ttrl l sl rl r rtl i r' r
rl ,,i ti r." . o..ti l i u:.i ri nsi "i i i l
p)arat' i zi i t' ertri nsecd compl etd'
(cu rfr^r' l rrt' r' rt
i ri *""' *t*i l i fi "
""tri nsi ' ci j
;' c\ Ttaral i zi a
i rt\ri nsecd-
(cu
afl ctl r' (' r'
i l r' rrr
;, i l ;;"i l l *i i ;;
pi l ocor' st ri dtra re
i
: d) paral i zi a total d'
(cu pri ntl "l ' rr :rl ri -
; ;;;;;;i ;i i &i Gi ".i .i i
qi ,
"*l ei
i ntri nseci ) ; e, r) i rt ml l ort ctt.frr.trr' i i
i;;;;"s;;;;;i*iiri"
p6tn"nii a rrr-a poate fi : wnilateraLd' sau bil'axatatd'
2.4.2.1. Paralizia tctald' a nenu'lui oculomotor aomtLm ilmpliax' o-.ptond
""f""fr"aie
oo*rrieta ;i
un glob ocular imobil in dirocliile- ilo a'o{iuno a'
i ' rr(.ri rr"" ati ,
"T
i "i "t", arupi i nferi or (mi ;ci ' ri l e i u
j os fi i nd tol ' ttqi i tttt tr -
,:ii*]"p"!u' t"
ir";"
-".ii*"i
rnuqcbiului bbuc-mar' ' ) |i
drc' pr sulx' ri' r'
St:rabi .i mul tti vi rsent csbe foarte' evi denb,
i rr rl i pl opi a cste ori zontl l fi ;r
i ' "i "-i i *i ,.
ptpi ta
este mi dri abi cl
$i ,,fi xa",
nercacfi ol ri rnl
l r l ttmi tri i ' '
Ir! fl comodare
gi l a converAoo!6.
2.4.2.2. Itaralizirt'
parliatrd, a nerawlui ocuLomotot coT'?lzzr, osl'o ltlllll
,no,i i reoventl ,feci t oca
' cori rpl el ,ri .
l )i ur trcbui o rol i nut fl l rl ' l l l ci l ' tttl tttrrrtxtsr
i , , i t r i i t i l
", , i "t t t , l t r :
ul cc I r t i n
nl , r l r l i t r l i ncompl eL
( pr r ' r l i r Ll l
. l i r '
l r l t h' bt r l t t
i ,i ,,..r.i ""i i . i i ,:' i "-i ' ,,i *ui .,' ,,,u
1x' .' t
I' i i
1r:rr:r' l i zi ci '
Ar:r' sl :r'
p:Lrl rl i zi i prrrIi rrl o rtr
;;;;;i l i ,t bl l i ,i ,, s,,h t' rtrti l l l zi trtri i ' i i noi
si ng.r. rl ' rtrttti , srt' tt $l rb l l ),nN
i i i i rr ,,*,,i ,,i i vrr,r,i tbi l . rl o nrl r*rr* tl .rr
^f(nJl i [,tr)
ttr tttr!i rnttl l ,,t rrl l l l l tl ' i l rol ' vr)l r' Hr!
i l ,i ,' ,i l i i ' l i ' ,' n,,
' ' ,' ,,fi zol ,zr1,
i rr,bl ,rrrl i tl tl i l tl ' trtrttl tt' ttr vrrri rl l ri Ll ' tl
l ti t' tozohtt
Hrl l l
l ' l rrl l
/i Ess
,/--\ | ./h.
o' (
\ | / / / / / Ann
\ I I V/////t
--
\*..
I
Yal
/ r , l , i l r l r , pi ( i
$( f n*r r I I dc pl r r al i zi a
' hl l l l , r i
l | r i ( r ) l ) l l ( : ( s obl l c i nf l r l i or )
, I r . l r I r l f .
I t i i ,
( l nr c
Ll nr Dal t r or msl
r r r r zn
{l i , l r r l
r ) r : ul r t r l n oLr i r ' [
t l h sus.
I r ' , r l i r r t l
l r l
sl t l I ol n[ cd od) t ul ui
l l / l l , I l r df l ) r l f l r l r ol i nl l r ; t i l l col o-
r 1r l t , I | l l xl I l i l nl t r t r ( : l d
( l
bol ul vul
, l l r '
l I Mt i
I l i t I r ' r \ I gn ( dt r t ) {
/ t i r ' r . , 11) 5. t ) ,
carea_ capului), ochi l fiinal in adrluctie,
muqchiul afectat este obticut mic (/2.q. JOjl
llntry
dcpistarca pdrtii paralii1,i",
oi_
tarmo,ogrj Dbtlizcazd" si prob&
lui Eott-
rnann qi Bielcho.n-sky : dacf, indepi rlarer,
imaginilor se mx,re$te prin inelinarea
ca-
pului la d.reapta, inseamnd,
ci, oblicul
pic
sting este palalizat,
ln sittratia in
care diplopia nu se accentueazi, in aceastd,
pozilie
cle adduolie a ochiului, estre vorba
de paralizia
dreptului superior (fig. l1).
Daci, diplopia se accentueazd la cofori_
lea sursei luminoase (sau la coborirea
capului), ochiul fiintl iu arlclucl;re, rnury-
chiril poralizat
cste oblicul maro
i,11,,g.
tZ
),
in sohimb rlacii, diplopia nu so rcoclrtru-.
irzil
jn
lcou,sti, pozifio,
a[unci lllul1(jhiul
Irrrrll,lizDli rrsl,o rlr0llt,rrl itrl' rilior,
: ' . ! : ' , : . ! ' t ! , l j l t l t r t l t t l i t r ut t t *l i r : l 47t , t t 1t o. [ i a pL t : l i qxr l t r yt t t t , 1t
1t , t t . , t i ; : i i l c
t l t t t t t l l t I t ) t t t l t U) l ( , l t ) t t ( ) l , l t .
:' .1.:!..;.1. I' urul i .,:i i l c l roncul are i ti nt i j el c tn:l i l utnet,oi l .se, i n speci a!
|rrrr
:rl ,,, i i ' ,i (.11t.
se
(l ezvol t;i
l a ni r,el ul bazei crani ul ui (J,hnsi ,ori qi
l ' r ' , 1I . l ol l r i ou, l 1) 6?i l i ucker , 1966; Ri ser , 19i 2;
popr i vi ci u
l i
l ?ascu,
I : lr;0
). li. r r rl r'li'gc
'iL,
ilrt,rL]cit nerYll ocu]or:rrotor cor1tun p:i}isoqte tt,unchiul
( f' r' , 1' r' i rl
l )l
i r l i ) i l a$oi oul c, l ezi uni k:
,,rad,i cul are,1
l i l accsl , rri vr:l l tai i zcazL
: r l , . i . r ' i
l ' l l t i l l ( '
si i r Lcual e al o muschi l ol ocul omot or j . i l schi r nb, l . r r l t e
It ttt,tl t. l rr ' ,i .t,drr[, l rttttchi ul ui rertos prod' c o
]tt.al i zi e
l otal i ' i dc pcrtcho
l l l . r u (,\(1{i l ,1i fr
i ' i brel ol pentru mUscul atura ocul ari i i ntri nse0i . care
..r i . l ,r(
' r' ri rr(l c
o ol ul ' ci i te protecti e speci al i r i n l ozi rLni l e bl za.l e.
l tri n
;i :rptrrl
r' :r r.l r. rr, rrl l i si l rrLl ,tr i ntr-o pozi !i e ari al i r i r.r i nteri onrl nervrrhri . doar
Itrl trtl r ttsi ttntrr i tt l tut' t anti rttd pl otl uci ntl a.fectaroa pfr,(i orrr l t l l ce\l oI[L
1l
r , l r i , r ' l i l i i gi l r r , 1! ) 50) .
' '
l .:.' .;;.1.1. I)u.ru.l i ' ' "i ( [rcnrcttl ard i zol utd, si ngu,l atri a nrrvu]ui o0.rl o-
, ,1,,r' (l ,r' ' r
p,rri c l i i r.r,al i za1,i i do procesc nevri ti ce, meni ngi ti ce (i ri cl usi v
l rrr,l rl r' ), r' rrl r,ori do al i e pl uceBe bazal e (dupi i cul rr rom r.etl ea), ri :r, de
ol rrr l i ,
l rl i rr
\' (rri t)i i l i t1c1l l cestui terv cu cei l al ti nervi ocul on$tori fi i (,n' tl ti
rr, r' r r r.l trrri Irri , sc rt' l l l i zeazI si ndrol rne tt.otLctrhrc r.-\1r.i l rre\"r,i t,\i n]e al e.
l , r r i , , ' r l t i ; r l i r l r . r r , r ' \ i ( . l t t r i , , r . i .
:' .1.:!.:j .l .:.' _,\i nrl ntu,utt
tronc:ttl r.r,t r: entraneuoJ)i al e d,c It::i .tttti rnul l i fi e
, 1, t r , r r i l nr t i r , t r i ( r u, r : oi nl er esar ea si a mot ot acul ar l l l t l i {: o. t , t u, n, ) :
\t l l i trtttrr, o
It
rt l ..tn ol tk:ai ai i - Se
l ti e
ci , trunchi ul l err.ri l ui ocul ori totor.
i .,' | | | | l | r \rrr{l l rr
(,l | l l l ,l t(,1] (1l t
1,r' ei :ul cl e (:uttCra
bazi l ar5, a;r1.era. cerel i r,l oaSl i
rrl rr.r' rrrri r ri l ;uJr.r' l r,t' r,r,l rl al :j
l l osLcri oari ). Aceste confi gul ei ri i topog.al l i ce
t , r ' r
r r l l l zr l r ( ' i r r r r , r ' r r r l r r i
j r r
ar r cr - r , i smel c qi i n pr ocesel c l j , er o- sf al t er i o-
I l "1, l l , ' l l ' . : l . l . . t , r t i I , . l ' . . nl i r s( . r , \ i r l i ( , 1 , t
nt i , t r nt t t r
, , : ! r l r t t 6pt l l i . t
l i n
l r l r , , r r l r l i r r i r , r r l r r nr i t . r i r i cvr j sr r t i , r r l t , eccst r , r r ' - ] a". . - l Ui gr "t i , , c, f t ai r ni pl egi ci ,
r1' .,r' r.r| . ,l ri .r' i i rr rr.l ri l i i l i o sa,u adol esi l cnl i , (ti i ckerst:i ff, 19{l +), l r, si i l i i i rcti
, , r ' , . r r r r r r r l , r , r . r j t ' t r l l r t i l i gr ot l oaso, l i e t ami l i al e, f i e per son: r l e.
I {i gl en: r , of t al
r r r , , | ' l I r , r r
I I ) : r i ( . si i
l 11r ' t , l l ( f z0sal si r ni ' mcr ze r l upi i O ni gr el t i si r npl i . I l nr er Oa
,
l , l , , l , l , r r , r i r
1r ' i r r r r r l
si r t r l r l , , r r r . l ! : . r r , ; 1c uni l at er a i l , cu i ol l l i i z: i r . e or 1; i i i l i
| | r
; r , , r r 0r I r i ( I r I i i
I , i r , i | l t dj 0r o Nl ] l ' {r vct t ex, i l p: r r c c obi cet 1l r cr i zr l . cU
i l , , l , r t
l ' , 1. ( 1 r l i t , r r t . r r | i r t r l , u.
l t ul s: r i i l ,
, r r l esr . t i , i usr l r Lr t l cr gr . . r 1, t i
si r - i i r ' si i t ul i ,
1, , "r , . r r ' r
' r ( t , i r . , r t ,
- ,
I l Jul ( . . . \ l r , - . 1, f r o, . , . t , , , , . , , , , , i ; 1, , , . . , . i r r t , r z" t l : 1, r .
, , l . l , l ; ' i r . , , ( , r r ) t r r l i l ui ( , l i r : r r t r r r r ut i r l si r 0al i zoazl - r , . t el
mai f r , ( {r r 1: er }t o at i gcr e
, r r r r r l r l r l : r - : r
I r , r ' r ' r , l t i i
l r t r l l . r t , r cspt r ct i r i d uncor i i nel vl l i i t i i : r 1. r , i nseci i , i . l {o,
, l f l , . : r l \ r r . i r r 1l r r , r i r r l i t Lt | r . r : st i l , 0 r nul t nl i r i l l t , , ai l csi r t , i t . r l soci r t i | cu
. r l r r ; , , . r ' i : r
1r l r . r ' r , l r i i l I l 1 r i . I n r r ndc ca. zr r l i poai . c f i i n1, ( , i ( , f i l l , r i r r ci . r ul
, ' Jl : r l r r ( ( \ \ ' i r l r l r r i
( ) r l ) {r i r ( ' r l ) . ,
l 1}( i l ) ; . [ 1. l r r . <ur , 1. . 96$) . S- r r Lr r l t , s, r i i s l i r l Lnr : .
r r r r r (
' "
r ' : r ' i r ( ' 1r ' r ' r zr l . r l t | r r , i pr i r r r l i I l opi i 1r , t : ci i i o: r , t r r , l . l i l i i r l r ucl ' i , sl Lr [ 0r , i r r 0
r r l l r r t r : r r l r . , r l l r r r i r l r r . r r i i r i r ngr Ji
6i
r i r i ; ' i r . r , r r i i ol l : r l r r r oI l r , i r i t i ( l l <l l L: z
5i
Sol l r a-
r l i
'
r , l l l t i l , ) - , , \ l i ' r , i , r r l l l r r r r , r , r ' i I r r , I I r r r | or I r l r I r r l i
r r r . I i r [ r 1or i l i i r r r r r i l r l r r r r : l l i r
. u, r , r i ol l {r r ' \ ' i , i t r Ll r r i cr l r r l l ol
j r r l l l r <r i r vt , r ' i r os,
l l c l t i i r . r r : r t . l cl r r l r r r r r l i t l l i
r r l , ' r ' ' ' r , , , i ' r .
l r ' r ' zr r r l r r l r r . r ' r . t i i
r l i l : r l ' ( i r r i . r I r , r r r r r I i I r t i ( \ \ , : r l r l r r r i
( ) , l r r l r i
r l r , ,
l l ) t ; l l t .
4t l
l r , "r r l . r r l . r r r r r r l . l r r r l r ,
l r l
. r r l r ( l . t . r ' , r l r . r , 1r i i r I . r ' i ' r ' , r l ' r , 1r l r r r r r , , l r l r , r , , . , , i /
; r t r r r r l r | t r l or ' l : r
Jr l r "r l r l r r . r
I I t I , r ' I I r I I | | ( , .
l i \ l l r t t t l r t t t t t r r l r l r '
l t t t r t t , r
, , r t ' t t , t t t ; \ t t l ) t ' t i ( ' t t t i t ( Nt t t t r l ,
l , t t l r t
: . 1| t t , , i i ' r l i )
t . ( , l l i / r ' i t zr i . r l r ' 1r r 1r 1, r r l u r r r l l r . r r t t l I t , r r t 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
| ol r r l r . " l l ) ( i l l
;
l i i r i , l . l l l . , i l ) :
i \ ) f i i rul t ' onl 1t i . t : l u, si t l t
l , rt t l t r.
x. l t t t rt i dul i i , rt l . l ui l i rrht t t t I )t rt i r1t t rurt | : i t '
cai t a{r t er i zeaT. [
] xi u1, 1' ( ] l ) l r l r l l i zi l '
l l ( l cl ol 1, 1| i l l ( l r vi o( ' l l l 1] 1l I oi ( n i . i l l i r i Ll l i r l ( '
af ect ar ( ' a f f ) nconr i t ent i r , t i ol l ahui oul ui ' Sc r e: i l i zt l r t zi i : l l l l Ji l l ' r i
( ' \ ( ) l l i r l l l ) i ( '
( uqol r educl i bi l i ) , , pt ozi , pal pebr al i , ol t al mopl egi r ' ( r ' t r vJol r
( , ( ' I I I i I I ( I ) | | I I ) I ( ' | '
i mobi l
l ri n 1l al al i zi a l e. rechi l or
I I I ' l YSi YI ), t rxt t l i t i ci t ri
1)l rl )i Lrl ! '
(l i ri l ri l : i
areact i r. -i l a l umi ni i
Si
l a acomodare), hi po - si l i t l nest ozi (r i t r 1r' r' i l o| i rt l
oftal mi cdui , refl ox cornean abol i t' dureri i n teri tol i ul l l orl ' rrl tri rtl l rtl ttti c.
Daei , si nt a;fectade
$i
fi brel e si mpati ce ocul al ' e, apare o l ti ozti l trri trIIItctrIrrIIi
r1e cocai ni i . AceastS, tr,i ozi l ne i ndi ci , respectatea g^rurgl i onul i t' i l i rtr'
;i ,
r' rr,
.afare, o l r:zj une exttaorbi tl ri . Di mpotri vi i , apl ri l ,i a mi dri r.zl i rr(' rrl trrl l ^
atenti :i rsl l pra unei l ezi uni i ntr:rorbi tarc, ct l l decta}.ea fi l rt' t' l oi ' rh' Lr tl :rtr
.El i onul .1i l i af.
b\ Si ntl romul de apen orbi td,l ' al l ui Jacob
ti
Eol l cl sol l mi rri
(' rr
l rrl ' (' {r-
dentul , dar,
l ri n
di strugerea soncomi tel l ti , qi a gi ul ' i i opti (' t, s(' rtrl trt::;:i o
l ezi une progresi vi i , de nerY opti c cu ceci tal ,e Trrogl ' esi Yri r
i ^rtsol i l i ' r si rl rr
chemo$j s. Dxoftal mi a estc mai
l rronunl atl ' i ,
rl eci t i rt si i l tl l ottrl l l
l l t(\l rtl l trl l
.qi pul sl ti l i ,
{pri n compri mal ea
$i
a Yonel or ol l i i i l l ni cc).
Iractorii etiolol\ici care irebnie dccelati sint :
- L-actori traumati ci : i ri terven-i i i l e chi rurgi otl e (peJl Ll l r si rrr;' ' i l i .'
.de
exernpl rri ; fractrui l e
(,ral u' cnL'
care i ntercseazl i '
i i
orl )i tn: l t:t| Itr| i l rr
.ari pi i mi ci a ,i fenoi drl ui (cu afec{area i ni .ti al i l a
l el ' fcl i l i l r'
Il l
;i
l \' . rl rl r
ul tel i or si a tl i gemennl ui - Rol l vet' 195?r ci tat tl e Il oger
fi
(' trl rrl ), l l ,(i l ));
tractura crtstei supraorhi tare (i n aceasi i n si ttati e, oeti t:l tcl l
l rl rr{,trtl {'
ol l rul -
m0pi egi :l ).
- Iunrcri l e: neopl asmel e orbi tare
i
tncl l i l tgi oanl el (' ,' i i ul i ,r:rrrtl l r'
eryul ui optl o: t, Inori l e osoasc (osteoamo' rnot:l sl ' Nze osoi l s(r, l l l l ri ot' r rrrl
.ostcocl a"cte,
chi stul i osoa.se)
t
meni ngoencefl l ocel
;
cl i stut i tl t' t tttrti rtr'
;
l rr' l i
prol i ferti ti yc dt si stcdr (gri l l ul oame eozi uofi l e, boal a, l l Li Il i ttl l Sr,l ttrl l r,r'
Ch' j sti ari , rri el oame, boal a' l ui Il odgki n)
;
turnol i tl e l -ecj l ti ti ,tti
(1 (l tttttot i rrl r'
r3i nusuhl i sfenoi dal , tumori hi pofi za.re; tumori n:tzol :l l ' i l rgi {fl )c, i tttl cosr' l tr
arci noarne rpki {.xmoi de, l i mfoe.pi tel i oame, hemangi ot^pi l i :l i rrrt' ti to St t tt i
l ' asarl si col ab., 19i 5), Aceste ul ti rne tumori rl azi l l c
1i
tri tzol rrt' i ttr.1t(' l r,
pot l enl i za i l tti i si ' ndronu,tr cl e
Josi Ttl eri
yopal nl i n i al I rri l i r ht stttt si utl t,,nul .
, t l e pl an\ eu ot bi . t $ d, l l l t i Dej er u, i n cl t o se r cl l i zpuzr - r i t t i i i r I l . zi t l t t r r r t t t ct t t t l t t r
,{nl ri l al superi or qi a non' ul rri cl nal ul [i
]i erj goi (l i l r.l r
(l i ,rxct'
1i
.ol rtl r.,
1969; Sr i ni vt sl t q. i col ab. , 191i r ) ; i l mor i m{- : t asf i l l r i r {} ( t r t L
l r t t t t r , i
r l i '
l ) l r ' r ' i r r ! '
'ntit
lntr sau Df[,siallc l.
- tr- scl i ,i i l \uscl l l ari : l tner' ri sn c]; i i ngi ol nxr (i r spi ,ci i rl crrr.l ttorr' rr' )
;
ti o I icc u:.e sr caro t idir .
- Ll -i p crrt,' tee, cu al e1brti l at' orl fi sul i i or' bi l nl c sttpt' t' i urt t"r' .
ttJ Si ntl rt' tnttL i n.fracl tnoi di an al l ai I)rtwl .tl st' tl tl ' rl rrl oti zcrtzi t pt i tr
r ci un0l o si n( h{) r }r ul ui do al l \
( n: l ) i t al ,
dt r csl t
l }r {xl t l s
( l 1r
l l l r / r / r i l r i ! r r ,
<d. t . t l t t "ei , cat t ) l i l l o i l f i ar r La si l , Ll l l t i I l pi i r t ( f i r , l t l l l t r l ' i r ) l l l i i r r si t t t t st t l t t i ( ' | | \ r ' | | | | ) r I ,
r . l r l q t , r 1t ! : a, zr i l l l r t t l ' i zgl t t r r l i t t oi t i i r : l r l l t l t ' i ol l l
( f ( ( l ( t t l l l ( l c
l ) l ( , \ ' i l r ( f
I I r ' | | | | | | | i I t
'
| |
r : j r r h' or r i r r l t r i ) f r i
Ff r ( ' 1, ( r l {r
l l r l r ' r t l r t l t ut t t t t l t t l t t i oI i i r ' .
( l )
, Si l / / r ' ) / / / ?f l t l t r i i sl t r t t l . i r '
7' 1l 1t t
t . l 7: noi dr t l i i t t l l t r i , l r r &! l r ' - r l c l cr r l i z: t l ,
r i r , l , r l I r r ( | t i cu l r t t t t r I t l r r
l t l t ' f l t t r '
l l l l r l l l '
l t r l ] l r r r i i , l l I
i t t zr ) l r i r r l l l ) l l r l r r ar r l l l r r ,
: , r r r r i , t r sl i ' t r r r i t l r r l r i . ; . i sl i t t | r r l , ' l r l l l l ' t l t l l l l l l i . i {t ' l t t i r t l ol f i I r ' sl l . r ; i t t t i l l t I t l l r i l r l i l r i )
, , r r r r l r l , , l r l r l r , ' r ' l r i l r r t ( l , r r t t t r i r r l l l l i l ) 1": 1r cl l l I t i I r ' l l , l l l , l V r r i \ ) ,
l t r ' I ' t r t r l
4' I
lii:,;/,,1';11,,,",n ^;,,i ';;;l,l';,i;i;'l;;'ll;;;i;Ji,lliii:l'lil",llilllil,"Lilll,ll,il,li:i,i,ll;lll
I t) N iurl.nnn.ul, ilo ,nt
:tr,r::i,:,1:;t,;,*,ii#x;!i:x*[ffi
ffir:;li#j:P"*:Trl;:3:;
l' tii,;;ll,l;
; t;t*:ll,*lt,ru
Ff
til;,"l;l;fu".,?ftritlts#Hl;{i
I ;;..;i' ii
']
'l1l'|fili*,1:"'n'*"
i"
^t"'ito"iuriliiifri".\i.ii
p""uri,ia
perechilor
,,,r,i,;j,:iill,JllI:i,,gl?j"t:
Eoger qi
corab., 1e0e qi de Arseni qi corab.,
tr) t|,in.d,rornul
anNerior-
e,ste identic
cu sindromul
de fisurX orbitard,
ri
l rr,r,r{|l rri i ,
(cu
coafeCtare& qi
-a
nervu]ui
opU"l .' ^--*
.
tt) N,intlromul
med,,ian coafecte?zd,
to.,i icuiomotorii
6i
primele rloud,
J:l:l:l
j,lilil!lT:f;it*.1i{1'jx'H',",r"1,Hffi
1r;ll"t*;;":nf,I;i
j?rtl#
,,,,,,
j;l
ll;iilj;fif'l
"#:mi:
atecteazd,:.
toate ramurire
ri:;,r;ni;,**uili::,,J,ffi
#i'"'#m'Fl:,-k*#?#i
;iil;litil;'li",ll:,T,1#**,ff
i'*1116*:f1ti*_T,%trf
;Hr,i"#fd
r r r r p| ' r . l i l i r r | ( ( , r r I i i ct ' i mar e) , p
:ry,,,rr,,r,1,riirrri,li;l,,1if
?*1i"-?H1fl*T*1":i'fli*i"",S1llf
fml*:
,,,,,,,,',t'1,t,,"'i,l,i"'i;'i,"0!,rll.on')
se adaugr' d pQ'tro' l)ariantii,:
sindromut' gtaratrise-
Ir't <ttori tli.ol,ollici :
,,,,,,,,1,1,,,'11i,11:,T,ill,;il,H11i,f,l"Jifig:'.ljx"l?,:i"tfdeosebi
"'anior,rin-
l ol : r l r . , l ! t ( i l ) )
;
b) l l \ r mor i r n
i;,lll
l,,ll)(;ili,'ii,1,,,,,,".,,'*i*l,'iff-:"'i;"if,fl:x;"^'ii*iiL
tigt!,",",Lq;
,r; ,.ri ,.t
,t,,,,ur,tr,u:
al e arterai caroti d,e (Jeftercol ,
1958;
Arseni qi
col ab.,
.
:il
,l,t.u.t.t,Dtul.i,rzr
c/c, incleosetri
cr. realizarea
de fistule
carotjrlo_ca.yer-
r,,' i u,.! r.i rrt i rr.rrri ol rgi s rtal i zrnzdL
rapi O : ottal mopt"egl i
?ri ftaml i puts:"ti te
r , r LI | | | | , | | | I | | I \
i , r ' i l l oni r r r l c ( I i oger
i r l
col ab. , l gOi O) . "
|
)
'l,nutlnfhltitt:le
sin .sului
caaernos
,tealiz(,azri
: exottalmie
masivd,,
,,ri .rrr
IrrrIIrr.Irl rrI rj u (,xtensi c
l fre
ftuni 9 qf _p""
""gr""#i emporata,
stare
rrr,;rt rl r,rrri r.i , p.rrvi i ,
5i
Jczi uni l e
respecti ve
Ae ocrri i moi ori
$i
tri gemen.
!) i.l ll(
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
tttrttl ri u yi Q rrn:i tt, sutt, si nd,romul tui
..Bc.rtol otti -.Gai ri l ,"i ' i o"tu real i za, i n
..ri r,xl ,{rl .l i rri u rkr rna,si vl l ,
Bi r:xtcrrsi vi ,
utu"t""" i i " o".Ji ;i ,' i eni ,
qi p' ,ra_
lil:jl,l,,;iililli:11;lrrlui
conmn (cu rorlizal,oa,
a" r"r,f,l'r""i
ori;, nroprosii
t 8
It, Si .Ml ,fomu| Lui .It' hrhn'
( | tl l rl i ) H(\ t' rtt i ttrl t' t' i ztrttz' i 1' ,l tl i rr ol l r!l l n(' pl (!grr,'
rrta,,ri o' rtri rt,rrdl oxi rr. l )o l ' rr,1rl ,, 1,1rr, r,ri rl ri , tr ftrl trri r t l .i rt' .' ' .i i ' t1*.7t1 i ' nauroytrtl i rt
l i kx, , i wi r r $i
l l osor ' l ! ) ( i l l ; {l i l r l r , l r ' , 1 r ; i l ( t l l 1' , l l l {i l . ; \ V( i r r l t
l "i
l ' r l r r r ) , l l l ( i l ' ' )
'
t; Bi )mtrom' u' l ' de ar(xutl tL ,r' t' l i ttttsu,l rti rt, Iosl ; tl osl rl ' i s tkr Ifi scl rot' -l l ri i Agl
( Lgi i f f i
l i
se da; t or c' Uo
( x) t ' l ) r . ( ' Hi l r r i i . cr vt t l ui
' cl t l t t t t t t t l , , t '
<, t t t t t t t t t t l . . r ' i , l t r r
,,i ' casta i l i vus' l ui , ca urttt:i ro , proccscl ol hrl oc,i t' l r. t[. sl ti tl ' i tt (rxl rttr
"ei ebral ,
hematori r subdul at q.a.i . Succcsi unea
-de
i ttsl ' al aro rt'
1ta' l ' rtl i zi t' i
,,ste
'r'in5,toa.rea:
miozi tranziiorie unilaterali - lrritf iazr'i'
;-i
'rrpili' fixd -
ptozd palpebrali'
- in final, paralizie completi a perccltii l' I I [-rt'
Fischer:Briigi iiolo;
a izolat dou5, forms clinic-e : a)
lorma
aau't'd', itt t"'ttt'
naralizia ocirloniotorrllui este urtratd, ime4iat de pierderea o111lofliilrfoi i
i ,'
Surn,n
progresi ad,, i n care paral i zi a perechi i a [II-l sc.ast.rci :rzi i tr tttrNI
l repl ar cu somnol enl i
qi apoi cu pi ertl erea cunostrntol '
'
H1 Bi ndromul Iotoi a-Eunt' Ol i al m' opl egi a dureroasd" (si trtl trrtn-ttl
.
l i r-
tosa-gi*t) reprezintd, entitatea nosologic-5,.in catc se-asociazii o oft;n'ltno-
pf"ei "
"u
o ndrratgi e bri gemi nal S de aceeagi parte' Tol os:r (I9j 41 a. tk' rcti r+
i tri i munfeei a, dur-eroasi l a ul caz cu l e' i unj peri a.rteri ul c :rl o ri ti rrrrrl rri
"r"otioini.-iut
llunt
gi
colab.
(1961) la qaso cazuri cu inflamalii
gri ttrlo-
-rJomu
lente ale sinusului ealvernos' Smith
qi Taxtlal (1966) alr folo$il'
iermenut de
,,sind.rom
Tolosa-Ilultt', Ia cazurile care au lespuns tavoltltil
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
iini produse de'leziuni, in s1]ecial tumoralo sau inflamatolii, care tttt ctrtltrltzii
oromnt l a tratamentul cu torti costeroi zi
(Other. 1967;
' \ti l sl ci tr
;i
[l ottr' .
i i o, i bzi ; nnl l f,l t". 19?3)' Lapresl e
qi Desi
(197?) consi dct' ri ci i It' r' rttrrttttl
tle'sindroin Toiosajllunt trebuie folo8it numai la caz*rile la
('!,t{) llll n(!
poate stabili cu certitudine etiologia'
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
"*i"-prio",
prin leziuni la nivelul sinusului cavernos anterior qi nl fisru,ii
ornitiale sun,jri"are. Structurile care pot fi implicate incltd nervii rttrttlo
*.io"i,
""ii"t
oftalmic, fibrele pupiloiilatatoari parasimlrilf ico t t
l
t r r t ' t r t
'
l l i i
a IIf-a, qi fi brel e pupi l oconstri cl oare si mpati ce al e pl e\u1Li
l ttl ri tl i l ttrl ,i rIi rl tt.
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.
Caf uu, I ' not ol ogi ool si ndr om, nt ' l ui ' I ol ow' Hunt l oa[ ( ) 1: i r t st l ' ol si st ' r r t t t ; t
t i za' t {I [ unt , I 961; 19?6; Lapr esl o qi I }' ' ' i . l l }77) : i r ) r r l ' r r r l i t r
I ' t r r l t r r t ( i t
"nuf l
' i *
ambel e spxe; b) debut ul mL ci ' " l cci Lt do
r yi r sl . i r ( r l i t r . t r 1, i I : ' i t i t '
rrl o;
i t A""ua" a VI-;), cu
predomi nl r,rtl ,l l l l vi rsLtdo nri i 6ci i ; o)
(l (' l )l l l ' l rl
i l ai e fi nroel esi v, i n ci tcv:l zi l e sau i n i nni tntLl to tti ;n1to
(l o-?l
l l l l rgl rl l l l l oi
ii,ota-itrii; ii) seninul
rlc debut ce1 nai <xtnsl,rlrtt'
()sto
'Lrre're&'
olro lllllll'1r
br-usc, de obi cci ct cl t(rvr zi l o i na,i ttl ,oa' oftal mopl ogi ci , oontx)l l l i l ' (rrl l
(111
oaar *i u,
*uu, i u r ar c ci r zur i r l l
l , ni i r r
l i l r t l r t I t t ' : i i t r : r l r l r t Lt u' oI l ' : r l t t t ' 1l l t ' gi . i I
; i - ; ; r "i ai r ' ct i unea
( [ t ' bul eazi
Fi l r
: t l i , , r al r ' a sl i r i i gont r r aL' , r : t r . I r r l r t ' i i '
r nodeTAt d; f ) dUr er ea esLe l l ni l At ol : l l i i ,
' cr l r . ' i ; i t r r I
r l {1 t ( gt t l i i 1r ! r r l t ) r l . l l l
""i ,o,"l i .i
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in unete cazuri o uilpr""e t"coriiri,.,iii
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; S, r r r l l r . i r r L. r .
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. , r r . . : i ; r r : i r r r i r r i
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;
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r esl xt ct dr e: l . , . , sc*l I t ur i i i r r 1, r , i r r ; . r r . r , r
t l : r r r r . r l .
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dr i : 1. sr i i i r r r r r I r r i Al , r l r ,
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r l r t t I t r r r r ' l l l l r l / r l r |
, r t t t t t l t
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' r t l r i l l r l '
r l I r r l I t r oi t l i t l l . sl t i t l O. i i i r , : r t , "r ' r r 0r r r r , t r ' l r r l r zi l t i ' i ' t l t t l i i i ' l ' l t r t t r r l t : l
si \
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; i
col r l b. ( 1f ) ??) . Ul t
1I I t I t I oI I 1i t . i
( l ( r l i i l "; ,
( l ! r l
t , ' , , , ,
r r l . l I i , xpl t t L, si r - e cst o
( ( ) l l st i i i l i l , f i o r l r - t i r Lr - : t t l i l t r l t ' l t l l l l i t t r xr l t l r t sl r t t t r t z' t
i ' ,
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(
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i i t I i I I *
I r r Lr ' : t zi t t t t nol i l t r i nt r acl ani oni , pr i mi t i ve ( nl et t i ngi ol t l t t r " I t t [ t t t I r I t t r r r
I t , , r i i r r r r r r , , cnr t t i ol i ut i ngi oame, cor doameJ t umor i o0i del r noj ( l o
( ' l ( 1
) ' l , t ' {' r l ' t l
r t rrrrrol i l <' , , ru, t *, ,
1, r' i mi t i ve
' (ost eoame,
mi el oame, si l rcoal l t i )
rrh' )
(' \ r' rrcrri
, . 1: r l r . , I l ) 17; l l l hor nas si Yoss' 1970) .
i \l rrl l i rl rrrai i i l o \::l sctl ai ' e reprezi nti r d.upti , ' I' horl a' s fi
\' ' (tss (l 1l ' ;0)
, 1, r , r r i t r I l r i i Y f O
91,
, i i n cazr ui , ml ar ea f r ecvenl . i a accst o}r t f i i t t t l r t l i t ' r t r r r l r r
' ' , l ,
Ar sr , t t j q; , , i i ' ab. ( 197?) . bi nt r e acesi , car : r l l er i r i smcl t ' . st t 1t t ' r t r l i t r oi r l i ct r r ' '
r l r : r l r l r r i r i , r l cs 1a or ; i gi nea ar t er ei coml l ni cant c
po' sbcr i o: u( ' , l l ' l t l t {' l l {' r r zi t
, , l t . r l r r r ol r l t ' gi i t l Lt r t r ' , , , i se cu i nst al l r e r api dl , cu: r ; I oct al ' i t
r r : t l r t si r ' : i i l i
, , , r ' r l ) l ( , l i i r i ' pcr ' cdr i i a I I I - a si cu dur or t - : l ocal i zat L
pe
- t cr j f ' r t . i r l l
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, ,1,. .' i tr.vr' i stu' l e i nl i i acl i noi dj enc
(i ntr:rcaverno:nsc) si l l i ' resl t,trsrtl ri l '
, , ,,l l rrl rrropl euJi (l tl l ett)rt$o
ctrro se i nst:r' l eaz5, prop5resi ' l ' (,,pst' tl tLrl tItrtIIl ItI' ' 1,
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l l ar oot ' i st r p' r r r l c gi : i si o dol i comeg: r t ' : l r r
r 1 i r l i sr r t t . I i sl t t l i t
, | , r l i r l o {. l l Vr . r ' nOi l Si .
l r r l i ' r 1 i i l c ol r t t i t t ol ogi t , r : ( : t r l est r l
l l r i n
i nt cr r n( ' l I i i I I
- ul Loi
l r ( t r r r l ' r ' zr '
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! Lr r . : t , \ : {, 1, t , os) si nl sct ni i , . l at c r l i r r r r i r r
( , , . ] t i l i
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i r L I i I | I r t 1t r t I r t t l l i t r r r l , t l
r ' j i l , 11t i i ni , t i t t t i l r t ' r t zLi : i t t l t t l i i l , , r l r l t t nt r l r r i s; l ' t l r r l r ' 1: r t i t t l r ' l t t r ' i l L r r r r r r l
i
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si nt t zi l r ' 1r ' , cl r t t t oj t l i t el c.
' ' .1.:1.:i .:1.
I' ara,l i :i i l e rutl i L.' u,Ll ;t' e (i .tLt.ttr' tttttrrt' r:i u' l r,
tl (t t tl l ' t) tt' l ttttt j
, r r l i i l t ot ( i i t t l t zi t l r t i vl t st l r t l i t l o, i nl l l a, r nLi t or i i ; i
1I t t t t t t t t I t I 0 l t t r . zI t t r r r ' 1: r l i r ' r "
t r f
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I i bl r ' l r t I l r t ' r ' r ' t t l t t i i ) | l l l ol l l ol , o!
( ' ol I l l l 11 ( : l l t r t t ( , l {' t t l t r t r t t ,
r l , r i r r l l l l l f i t gl i
; i
ct t ! l t st i r l t t l t l l t r s( ' l l zi l i l ' ( f si t t l ol l i r i i ' sl r l l t i oi ol ' i : r L' u i r t r r r :
; , ,
r , f l r i i r r I l l - l r so t r t r l r r | l r ' l ci l zi
( ' l l s( l t l l l r t l i t al t l i l l l Ll r r ,
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'
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r r , r l l , r l l r ( ' t l c l t t t t r l cl t l ' t l st t
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sr r t t r l t r l t t l l i r t t i i t ' i sct t zi l i l I
i i
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l t r r l t t t r t t l , t t
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l r r r t
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l , r , i r r I , r , i r . r ,
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l l , l l l {l i l ( ' r ( ' l l l , i i f l i t t l t t ' t ' r t i l r r hi l t t l si ' r l n' nt l l t l t r t , r | ' r ; t ' t i : i t t t l t i l r l l
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, , t , l t ' , t t r l l t ht
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t ' r r t t t , , l i ; nt r t t l i ! t | t l t ( l t l t t l nt r . t t t t : t . l t l i t ,
( "l l l t r
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1, , 11, r r
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: t i t t r l t t t r r nt t l l t / r t l ",
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t I t I r '
( l i i r l r I
, r r . r r r , . t r l r , : r t l r , r r , r | l r t oi t ( | , t t r l ( . t | l r . ( r l i l :
) ,
l l ( . r r r ' l r . l ( ' l r ' ( | | | | | | t I I t I I I I I I
l , , r
l , r ' l | : r r ' r ' r : t r t r t l , : t t i , ' t I i r , ' t , l t t ; r l , '
I r oI I I t
t i r I I Lt r ' ' r ' : t r r ' I r I t r t I t t i t t t I r l l r t r r I
, , , r r r l r , , ' t t I ot t t , , I r ! I
( i l r r t l r r l
, r l r r r ' ot t t l I
r r ' t I t t t t r I t t I t t I t t t ( Nl cl t ( l ol \ l l , l ! ' r | )
l:llr iriliiixt,,liilii;ilril;iri::iiii:r,li,,l,,ij11liil,'i'rl]rr11
;;;,;,;:r :rir;m;
'.;i
t' )
b i nl .trl ttrtl t, nucl tttl
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;
f ,',i,,1',ir*rili**p,;ti*;.t,;ifiixr*ilfiit1{{;ll*
'r*ii;iliiltifi;riiifii:;#xrrn!:,;"!i,:":i',iiru#*,
;r,;;1iil;1;iif#l*li,r*""""**-;ii#!{;i;x$*l,4,fr*#r
i ;, i
j,,
i: iI ;r ii, IiiI
I
Iri
hr*li*rtl
st.,.ffi ;.}l
gtt'1,,ru
I I I ;, t, : I l';r:'':t, i i, lj-;.;,t
*
5 $;*g*iiffi
;
gi,hT,ii,,i
,:-i[t'id**,f*iir***"1,*n*i*l**rui:?',","l[
: l, :i;il,,,il-;,ii
*i,'illJ:?j**ffi:ii."i?:*""
"..,"."",i1{iitfli*s:;
I ' orrl rr Ii
l rr.orhrs 5i
de tumori ai e gl antl ei pi neal e.
.ir,11;li,'lll{rii3i#i3{,,1fr{$Sl1"fu
*",+,,grf:if
:uffi.r*?;
; ii lllli i
; ir
li*':i*$*?i*ruTlfl
*t+ffi$-**+*ffi
lll,ir;i;.lirl;
j:lir,l",1",x'1"{lli*ii:i":"dl?:':il"J'"{"'rT;
jffi,".it';;:;;Xg
l;:l:t
jlliril;'{i,',ri,iffi
#j:ifiT!:i{{:{il1'.::.,rj'-,:f
otareamuscu.
I rriiiil:i-
iili*i*
i!4ffiiq1ll;giEil{iti
;*lffi
,l::l:l::':l?l'1,:"il'l,il,,ii,,il,il,,',il,itli,"l';,ll,,l*ii,iS;jUruifii.,*f
n:ll t l r l "; t
l ) r r l r i l l , i 11i pr r r r r l - r r r
t r , r r or r r
i*ili
mrniil,-'lr'-*'i-ili
iiil*iff
tlrft;t*'iti,liifi
5tl
t r ( ' l l r l i r l r r r l r r r or j l r zi i , i t r r r r , l r r r
l ) r ' o( l l l so
r Lo l r . zl l ' ot r t i I , t ' t t r r | . t t l i I r t t ' r {, r \ ' r Jl r {r t
l l l \ ' ( r ' t l l i l l l ' .
' \ )
t Ji nr . l nt t ul l l uni t l , r I , , r . l r r l , t l l ( Vi cl ol qi r , ol r r l t , , l l ) i l ) , r l l i t l i z{. : r zi ' i
. i t t r l t {r r t nl t ol ogi r r t i . i t t i r l r r zi l r , , l r ol i oct t ct r l . al i t d, l r ct t l , r i I t r t t t ur t : r t i ' ' i r sr p, t i -
t ' l t ' i " (: i i nt l ront ul Gt t l l rl l l rt ni t l i t : ). Sernuel e ei Lrt l i t ri rl c i t , l c : rcrrsl , ui ri i t t -
rl rorr si nt : a) oftal mrpl t,gi c [ri l rrl ,el al ti i n gl atkr
(l i fol i 1,(r;
l r) sorrrrro-
l cri tri : c) ataxi e; i t) l i s1,:i ,grnus; e) del i r i n faza acul ;l i ri i stal o arrrtrcsl i l o
r,oufabul atori e i n fazel e tardi l e. Pzrral i z:i i l e ocuki mol ,ol i l or si nl rrrrcl rri rl r,,
i ncompl ete sau ctl mpl ete, cu prezenl a l a peste 50]i di n cazul i r
l rl ozci
|:rl pr' l rral e fi
cu oxi stenl a rrneoti a t' ul buri ri l or pupi l al o. Acrsl si nrl rorrr
1,s11' rrodus pri ntr-un defi c,i t de ti ami nd, (eti l i sm, tui bul i i ri rnol ,ul x rl i l r' ).
B) Bintlromu,l I{estenbaum ( Bindronlul periapetlttataL
)
rcr,lizoir,zii rrrr
rontp\l , cl i ni c consti tui t tl i ntr' -un si ndrom Pari nr"ud, l a, c:ne sc rrsLrci rrzri ,
irisf:rqmus disju:rctiv, mioclonii oculo-retractorii, tulburiiri pupilaro
ryi
pnllzc
rLucl ea,re al e perechi l or III
;i
IY.In acest si ntl rom este ai ectal ,i i srrl rsl rur{rr,
cem;i e pei i apcrl uctal a, nucl ei i ocul omotori si barLtl el etl L, l ongi l ,rrri i rrrrl i i ,
posterioarS,. Leziiutile cele mai fr"ecvente sint da natut'il infcclioasr'i s:r,rr
ischernicii, (ocluzii rle arterelor plandui posterior al pediculului rotr.urnrl-
rniler, 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,
posteri oarl (Bentl er, 1965; Taube qi col ab. 1965; Pasi k, 1965
I
Sh rzor,,
1965 - ci tai i ci e Popovi ci u qi A,;gi an, 1968). Popovi ci u
$i
ADgi rn (l l xi s)
nu plopus - pontru fenomenul de
,,nistagmus
retractorius"
*
torrrrrrrrrl
de
,,mioclonie
oculoretractorie", ari,tind ci aceasta are ca, substrnt rnollir-
logic 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(i-
teuzeazd, fie prin palalizie bilaterali, ile new oculomotor connnr
(1n
midriazS,, sonuolertri
fi
uneori paralizia miqcd,rilor riculare cle vcrticir,l il;rr ttr,
{ie prin spasm de convor'gentd, qi mioz6,. I:eziunile rcsponsabilo dtr
}rorl.rrrxr-
lea acestui sindrom sint de naturi, inflamatorie sau. prolifclai,ivi,.
D) Leeiuni,le ttu,cleure ala ocxr,lonxoton ,ui comun, tnai illos ookt rlo
naturd sifilitici, duc, la teducerea tonusului in murschii oculnri, irr sprr,irr,l
al ridicitorului pleoapei superioare qi, in conseciniai,, la a,parilia urroi pl,ozo
lalpebrale
bilaterale. fL unel) cazuri, diferenlicroa fu,lii rlo sinrlrornrrl
Olaude Bernard-Ilorner este thficilS,.
E) Sindlornwl arterei. nuclatr,lwi, oculornotorull,wi co rnu.n (ALlllolli
4i
col a,b., 1952) i mpl i c5, afectarea n ucl eul ui ocul omotoml ui oonrun, nn{,l oi i
(,omi suri i posteri oare gi conexi uni l c vesti bul o-corti r:a,l o. Artori l rrrr0l orrl rti
perechi i a Il .I-a pare s5, ti c o ramurti a artoroi sul orrsrrl ui htonl l , rrrxl rrrrl ,i v
tu a,nastomozii intro artcra cc,rebeloasi, supotionril,
{i
itrbolr! corrrlrrir,lrl,
ix.r
s be r io i n'ir, .
'Ir)
$iw)romnl Lwl Aaenlald, Sohuranberg gi llu,m'pol,tli (nil;rr,t rlo Alsorri
6i
<xl l l b., 1.1)67) csi o o n ri r,tt i l i rgl u,r' u l i ri l r,to tar[, oi r,r' l l c1;or.i znl i i pl i n uxi sl ,rrtrf,u
rl o oi rl trl i ,
(ru o
(l uti ti i ;i ' i ,
l rrrxl i o tl o 90 Noo rr(Lr, l rt r:l ,r' o i r,l l ,ur.tr r r:tzr),
l l l ri l l i zi rr,
cornpl ol ,i t, rr
;tol rxrhi i
rt, l l .l .l , cu i r,r:l ,i v i l ;rl ,ou, axngorrr,l ,rl , l r, rrrrri rorrl n,t,ur.i i l rrcr.-
v: t l r f l , t l o r r cr r : r , sl , i l ( f ot t r r t r r r t t t t l
, , r r i cl i c"
: r , l ooul or r l l l , or . u l r t i r r onr r t t r ) . Anl l i r l ,
It8
lll' l\i' lll"lli' ,illii;l;' i:11i;;:;j1i1' 1,,1::.' ::lllrllll.' tLfi"
rrr'
rr*' rrrrrri. r' rrrJii :r
1r,,r' r,.rrii
;rillrf iiilri
ri, ll,ir;ii,,ri imi:lii;iiUiU_i,
:liji;li,illrili;l-.ll$r
i I r i I
ril
lli : i
n,
ii;
i
jitit
lii tiiii*l'l;
ltw
jn*ltt
llr,,l t*xxl * ;t:
li",'1,,li,i.]'"ili?l;'i*t'rLitr
binc contr',tr'r
rs,,-*"'ri s*iiiii''re?4;
\,oiculescu
iJ,4.it. lhrolizia
ncrvului paletie (trohlear)
:!..1.;1./. N n(r de semi c,Iogi ,e
Nrrr.vrrl
lrrrl,ctic
(trohlear)
iaerveazd,
-
mu;chiul
oblicul ma,re,
care
", , l r o: r . t j i
t : Lr l r r t l ot , t l r , , pr oduc
ll,;ll;l;,-;li':till,:';itx",{if;i#ii#?;31[.i"_fi
fJSf iff*"ur?#j":
. ,
(' lriilr
r prrr' :r,rizic
d. grad
med.iu a muqchiurui
obric mare este suficienti
liliill,iil,,'1,,1,1,',',,1,':Ji'i'ill#3fi
,!g-P.u"1':'
vertislrd
a imaginilo"
94di;
;;I
;j;
:;I
llj;il;ir,
il,#[Ii$:1ff:i!i
".'"
i;iff
. *'" inciina'li
:;ll;iili'l',1;,,11:;1i.,:l1;*gT{,i;;ff
:i'TT,:'^'f
1tild-1#l
r;;;q1,;1;riiiiiurriLi,rhn1ir,:{lir:lrr{,rf*ir#jirilnti
;rliiri:l,tl;iir,;iiril:l.;lriu,*r,;'an'l*lxl*:i*#lii*#
l::t1:':l:r.:lll riiir'il;
li:.;f,:i#,1i:""..""'t'lTirui"?llTHHii#,f*.tiilii
ll ; i' 11,,:,:i:1 1,,
1'll
i
"l",
l
;1,,,:1, 11),lillil::;l
;,r\{;1*?J,?*1.1ijli
l lilil
rr ,..rr.rrl
t' :rl rrj i zi i krl r.rrrhi - i n
i artr s_au i nstal i l t
,i s""i " d"' i i i pr*_
sau l i po-
,i;l;ll"i",,"lllil;ll"llll
,,ll,,i];lii':i,,:l;lilr,ii';Trlli3i*;+i*i":i"i*i""
para,iziei
, , ,.,,i i l,',"
,j,',,,,',',',,:'"lt
t t t d rt tl'iu gnosl,ic
etiogtntoienic
,si
toltograf
ic 6tt pa.al.iziile
,.., ,
t,.,. ,' ,,.:,r,,,i ,i i l t,
t,rl )rcu,l .are.
i nso!,esc
j l e-cj i eni pa.ral i -ai i l e percchi i
i i
jllil,,,','l,,ii"ii]",liiilil,,,ili,/"lilnll"9""oas
'
(rcrrers;n)i'i"-'i"a"ui""r
i"i't"i
, . , , , , , , rr , r, , r. , , . , 1, rrrri r,
, , , , , . , "o. , l Xi ul i l ""l t , l l ,
, rj "{X1", ' si roi l cr
; i
' u' . : n-
,lll'li,!:r:l;i;i;ii;'trltTi.t#'iT*fflti,rli!i:,r-1J*?:{'l,1'r'4
iii,tii'l
jii:,i['t,Hf ;f il"ill,,;lli;,,tt]:",:;#;;,:;y3ilii";;;i;
:n,liil
iiili,r'li,,if:i:;i!i':,,,{:i:'i
:i:;Kili;E:f:::i#,,Jffi,/,,:i1l
lL?"li
1l
)
!\tratiziih:
nttderr,rr: rlp
, t rr i l (\ r1(l t (\ l r, rr. rl i r, rrr
^, , , ,
; , , | i : j ; l i : Ji : ' . rr
I Va si nl gr' (t rt (l (r (l i [ (' r! ' rrt i i t l ;
t
l r ) l ' l r l ' r t l i zi 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 t l i i r l t l r N' l l l l
l t t r r t ' t r l t i i
t t I I l r r t l t '
: Lct . or t l i
l t ar l ' t l
si t t t t l r '
l t t t t ' l l l t
r r l r t t l i i r r sl r r
( [ ( ' l t i ] l l l t l ' - l l l l ( 11( t l t t i i
l r t i t t l t t ' t xl t ' sl t
t uu"i i t i o, r . l t t oef l l l i l i t ' t ' : ; t t t t I t t t t t ot I t I r ' ' l ) i l r ci [ l l zi l
( [ ( ' ( l l l sl l t i ( \ i
l t ol ' r ' t l l t i i
r t l V: l
i t r
por t i unea posl , cl ' l oi r t : r : t l t t l r sl ' l t t t ! ' t ' i oonr l f i i l ) ( ' l ' i i l p( r l l t t r l ' l t l c'
l ozi t t t l I l t
;;;"i ";;;;td;";.1i i i ' ti rl ,' rrrrrrl .hi ul ri i obl i c ri rrr<' tl o
l ri t' t' l rtrt'
ol )rrsi .' I' ^r' rr
l i zi a bi l ateral d, i zol al i t rr ttt' t' vrtl tti patt:ti c i ncti ci
rr l ezi uno nu(l (l ' l ' ti 1' Hi vrr
1pp13pi {i - f er enr i r t d
r L' . i t r r I t Dt t t t t I f hgcodr | - - l l "l l wr I '
b\ Si ndromut de ortcrd, cerebel oasd superi oarri
^(s.i trdronl l l
[x' rt' i trl r.i i
*,,r]oi ' i n-" a tesmcBtul ui ) este un si l drom i nezcl cefal i c
al l ' crrr'
(I()IIj ' Li 1' IIi I'
a#' ,' t".tl i i i . o""*"ni i
n-i v-u .oot"*l atcral r'
bemi si ndrom cctt' l t"l os
l t.l l t.
lrtn"Jf- *,i 1""iirin6rom senzitiv
tle tip slringomk'Iic,
d" pil,r'trotl olrrltlil
leziunii. Se loate
asocra ot *-d"o- Ciaude Eernerd-Ilornor
i
I
t
"l
i I t I 1 r
'
I ' I t I
si chiar o hipoacuzie *u. *"*Oitni"' Leziultile lntereseMi' lxxlttntrttlttl
i;";;;;,
"r,,oJ"io",-1"*"iscui
metliat, lemniscul latoral, fibrelo
prrpil r('
;i
coliculii inferiori.
c) Nucleul perechii a pa,tra mai poate fi implicat itt
.
sirldromtr'l :ttt'h
*n ii il*iii tt":riipia"ctati sili,sizd'rimut
tectl piotlus ile lcziuni opifiznnr'
2.&.4. Paralizia nervului oculomotor extorn
2-4.4.7. Bum'at d'e d'ate semiologiae
Per echeaaYl - ae$t eaf ect at 5, i n30- 500/ u. t l i nt t l at t l t l t . l ' zt l r i l t l l l l t t . l '
implicn
paralizii ale mugchilor oculomotori
(!hrad31-
5i
Schlczingtrr'' llXll)'
ci t i i gi - ad Popovi ci u qi Pascu' 1980; I l at sud: r, 1' q63)'
Di nl ' opi a este bornol ateral i 5i
ori zont' al i i " Fi rl szr' i nrrgi ttt' .ttrt' i L
rtl ' rt' rJi
se i nci eb1i teazi , ori zontal i tr pri vi rca i n
j os, col ror.l rL. u.gor
\r
s. i rl )r' i .)' r.
"l#Jii' r
ii""tii' i.", r" ttt. Aiest ultim finomen sc explicS'
priJr !(tnlirrlrr
i#il"ei"a ;li .""unre""t"
lr privir' u in jos
;i
tit,div15t1n1;t
I"
l' .11.]ll.::
i n Susl Sr r abi sn?al csl e conver gr . nl ,
i ar mi $c. ' . or d( ' i r u( t l l opc l r .
l {l . r ' r r l r r r
""i""'r.ip."il"
esie lirnitat5." Capul
-este-rotal'
compcn'satll
1:'
-l:ll.li1
af ecr al 5. i n par ezel , ' dc per cchc VJ do gr ad l r r cr l l l l
l l
( t ( l
l t l l l gi l r l r r r : r r ; l
.;;';;;iil";;i" mod gr,,hat ;; echilibrii intre hipor;a'c{'iunr:u'
rlt'opl'trltti
i"t".i'
iiirrp"'ritri"n""
-.rtopt..r"i cxtorn cto partoa
:lp"*1'
-::iitt.l
.lllli'l Jll
carurifd
""nirliouitut
pctrlru prirnrl rlatil in :lccast'ii lilzi! osl'tt
llr('u
{tt' slirl}rlrl'
dacfl teziunile initi;lo au ?ost tlrcpLc satt stingi'
2.4.4.2. Probl ema de di nl l nosti c e' ti ' o' pntogen' i tt
pt t' oTtogra[i ' a
ti ' tt
1to' rnl i ;i i l rt
neruultti ocul otflotor artern.
A) Par a| . i zi i l al r on' t n, ar c, si t t t f l el cvent i t t l ' i l r t i | t l , r 1l l 1; r r r i l , i 1| ' r r ; r l t r l t t i r l i t
ou"n"fr6r-,r- i i i -o' ai t, t,rrs"rrl o.l m,i l ung di rrtr. 1,.fi norvi i ttcrl tl ti tttttl ' tttt
;i ;;;;";"r.i -j
!"pi i *t rn f,,i .' ,i ,t rt* rl i fori f. nr{uri . 1)l rxi l ,. trut,i vttl ttrr' i rl ti l
t nzonai nca, r ct r cot pur , , , , - *f i t t ""t ' 1' ot npor l ' l t l l t r i qi l t i l ' t r r r r r t l ol t t si t t t t xt t l
cavetnos.
a) Pt ' oaesauuS| l l l ' I ' ( t . ( 11t , ' si t t ct ' r ' ul r t t : t t l t t t t l t t l ' ot "' r l t t t t t n, por t xl l l ot t ' t l Vl - t t
"ao.
t i l ,
"- , r i ui uu, i ,
i "r ' i t i i l i r r t t i c : t I r r r l r i r t l i ' r t t t r t r ( sd
l t t i t t t : '
Ar l f . . l ' i t t l ol ' t t '
t , , r zi l ' t r , - l , Lt ( ' {r , ' l t t ' i l l 1
l i . r i r kr i t t l . t ' vi t t t ' t t l ot t t t l Lt l r i t . r Lt ' l t t i , t I t t ' i I | ' I
(
' I ' I I r : l ' r ( ! t ) ( \ '
{ra,rul l r n1;r*o. i i i l rr,i ' r,pl
4i
rr,r,hr' u l rt,bi ri trt,i tl i l i l i tttrrttt,i rtrt' t' I' l l i tr rItr|.' Itt' ||' tI
l i :n' ti .
Itt s!tl l tsl l l
' l l v(' rl r' s
s. i r,l l i "t
l )(r
' ,l l t' l ' (rl l
l rl 6rrl l l ' tt rrfl {tr.i
(' i u' ot' l (l {!
i t l , t i rrt c, I l i l l r i , r'
t t t l , t t Ai Lt t ' pro(t (' x( ul t t l ' t t ud t rot l t t t
l x)l
l l l i (] l ' l l t l ot vt t l t xt t t l t t l t l t t l ' rt t '
{! r 1i ( ! l ' l l , ul l ( ' , ol ' i l t i l a, l ' t ' r l t l .
il
l 5
l,lll'ililiifiilr;iritiJii,iiiii::rlliiilr;lil;l;l"ll';11,i:'il1'll1;t l;li;"i;11,,:ilil,
l , ' l ' ; , i l i i i l , j ; l : ; i i i l l i l l ; j l ,
r' rrrl ' r' t , ' ' r(
Ni
: rt r' r' t ' rt '
rt rt zi r: t t t t
rt ' ' r1i . ' ' "' . ' ". ' ' ' '
rr:,;,,,,,,,
,,,,,(,,:,,i{,,,,
,
;l,i;i';'iiih.lill;lill,i,',J;illiij;l',1,;ii;*;l
l,:,.,!,:.).!:':"r::i,'!::':i;j!:,li:",,#H::^
#:;';:::,:,i",!'i:w*.,t,f3,wi.
stincii te,n.
;i,,,i;-iir;:i*zui*$*"#ti+*i*$ffiiluts,i+rffi
i-isrr*,t*i*i+g***g'l'am':ln*}i;ffi
jl.ii,l,i;l'lil'i,:ii:,'i?*ffi
lr"*",:i:t":*;*lii;)*T""*,tT.ff
"i,:":#;
;,,:1i:iliimk#;il**i5xrl?*atr,':ur#fff ::
;l;;,ll;;ir-l,,lll#Tif
"l'":#i::tlfi
i,:,ilTiiT,?fiii"*k*t"li:x
ri;i;itr1*llr*rl*l"l'ai*ffi
*"!*;l{6ryffi.,##i
rli'll-li,:*l',::*;,:,lh$.t"i"rli,*xJi""';ii#.#o"",."*,..,
ll;;ii: l;:lll;:ll''ll'i'l;,iliih"3
,*t":1rgoame 'ru
no'"i
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.i""ii"",fr"
,l.'',,';,il;lll'1,*f '.,il;1,i{x'ffi
i1t"#:?",'"'":HtJf,[gilii*1',?l;,
r ; :' l r ; ;r, l i:
l
:r
l
j r
r iln
ir#rl*i:",ffi
1;i:{"g:#qJ#$t?
I';I
:, ii' Illi1,ji
;i, iii[,*31g
i,
"k::rilr*11#x"ii;*t
rl,.;l1ii'1illl::t,,tr:,*!#itr#::*#"*{,ffi
.;x?d,Ti:Tif"::,ff;:H:
;ll, I
'
];l ; l";i';;;l'ii";:"r"..1;?;
fll,t"-l" ^u"."';i
pu"ro'J,ili,io,."u.
r,ezi.nea
1,'.,,;11:r,iilir;ii.,Uil{-$1$l=qitr#,*i':iI:}{1.+l
$
i' i, liii : i
I
l
il
; ri r il ii?*ii,
ffi
,'[l
l'. :'n**" $"'JiT,'""!
i
trigenicu':L
i'tii
,t
j
I Lr,,,,il,il
i ili it
jlt',lltiliil;l
I i' il i *i
jd'jff'I'
i'dtr{trf*lil,Hi
iipl4*1n,htikirilH
jii1,liiriili
ilnriliix#"*n*
iil;r
r.H rr* i rrfr )vl rri ru rrrr
4i
g,,rr,ri ,
z.ri r z.frr(\rr i rrl i ,r,{i i
rrxl ' rrr,,;:i l l ,l l ' l ' l i l ' l Jl l ,' r
[ $
gi l o,
. a, t ' i t l ur oi di t r
( l t ot r nr , l
,
l l t t ) i ' i l ) l l r ,
usi
r r ol l r , b. , t l Xi 0; l i i ) g( , r qi col r r , l r . ,
r . 96 9) .
^
h) Paral i zi a perccl ri i rr V I i r :r,l l i l re rl e :r,scnrorcrr
Si .
i rt si ni l rttnu,l .,l i utl ti
sJewidale pi 4n, celL al
,uirl\tlui
or:bttar.
.
i ).Tu.mori al e
fosti 1tl ,ru' i r1o-Ttal ati ne
ptotTLa l ti l roestezi o qi rrcvl rl gi rr
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 (Sakal as qi
col ab., 19?5).
.
B
)
Paralizi,ile rad,iculare (intranearaniale ectranucleare
)
a1tlr.
(rrl
mai fi'ecr-ent
-in,,lezitni
ale porliunii ventrale a protuberan{,oi.
,\ ind;rotnul ]Iitlard-Gublei esie lrodus iie leziuni ischemicc itr l,tl.il,o
ri ul artercl or medi ane al e al terei bazi l are. Cl i ni c se traduce pri n
tnrri rl i zi rr
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, realizeazra qi un sindroru sctrziliv
al te-rn; c) dacl , l ezi unca se i nti nde i n di recfi e medi .rni r. qi cupr.i l dr: trol vrrl
oculornotor ertern de partea opusi,, apmc o parelizie si a acr.stlri nrtv
;
cl ) rnar::i l ezi unea se i nti nde i n di l edl i a crl otci pl otubei anti rL,, al i rol ,rrrz:i
qi n:untleleta longiturlinald, posteriod,ri,.
Q
)
Pu,raliziile nucleare sint in gener,al rare
;i
aprl rnri eltu irrprr,rrrril,
cu al .ctarea al tor sttuoturi neryoase di n \-eci nr: i ,i i t r. . .\stl r.l . Dl i ri l l i zi rr
nucl enri , de ocu-l omotor exterrt apare aproape tot(l c:runa l soci l rti t' rr
1,rr
ralizie facialiL periferici..
Nucl eul perechi i a l rl -a sc :rfLi aproape el c rr:rrtrul porrti n
l ,onl ,frt
pl i vi r..l i psi l ateral i r, de l a care o cal e tl c asoci ati e corxl ti cc, pri rr i ntrrr.nrrrrl i rrl
bantlt'letei lotgitudinale postelioare, la nuclirul pcltlu nrn;clrirrl rlr.rpl,
oxtern de partea opusti ,. Acst ccntru ponti estc Nd{rser l l fccttt
(l c
l czi -
unee care i ntel eseazi , nucl eul ocul omotorul ui cxtcl n, qa i nci t, po l i rrgr"l
parati zi a de nuqchi ri rcpt cxtel rr, :l l ):l l .e
;i
o paral i zi c rr pri l i r.i i l i r,1,i ,r' rr,l o rl o
i l c|p11r.i prrt' qi tl eri l fi a coni ugati r I gl obi l or ocrrl i tri rl c prrrtcrl , oprrsi .
O rfr.cl l tne l i mi tet.i h norvul faci al si al xtucerl s i l c rrcrct;i
l rarl tr {i
fi i ri ,
pararLl i zj a mi qci ,ri tor conj ueatc r1r, l atcri al i l :rt,r, sugcr,c;rzi o l ozi i rrru l cni ,r.;rl l ,
l a m: r l l i nca i nf cr i oat . r i ; r
l t r r ni i i ,
l ndo l ct si t i r l oi no' l - i
l l i l i i sr : sl
l r , r r r r cl r i r r l
certl ,r,rl foarl e :l pl r,4c l rtrul do r:i tl i rl rl 1,. t)l l nl l i zi rr, ri rrtl eu,ri i i ri l rrl ,rrl rrl i
de ootl ornotol ertenr nu txtc rl r.i i , rl acr' i i :i rrcur sl rrrrl r rl o l attl rrl ri , cl i rkri
t r ucl ei se gi scsc i n apr ' , 11i t r r ' .
( ' oncor ni l r . t r l ;
s( r l Lsoci : l zi i
l l r r l al i zi l r
r r r i sci r . i l or
r l e l a- cr i l l t at e
; i
pl r ' ; r l i zi r r r r r i l r r t cl l l i i si r r r l r i l ui ct ' r r l i I r r r i : r , l i i pui l i i l i cr i .
at Si nrl romttl l ui
(l us?ti ui
(si ttrl l n,ntl i l ot ;; o-[t l u.or:a urLul ftl l rqnt:
.
t t t l ui pont i n
)
s( ' l r l l l i t ( i 1( ni zl ' l l zi
1r I i r r i , t . r r I r
r l t . f i oi l l r l t t ( ' l \ . i l ( ) r ( t . l l I t i ( j
i V,
TI , YI I qi YI t r I r l ,
l r ur l , r ' : r
l l zi r r r r i i , l r r l ) r r r l r i l i r | ^ scr r si l r i l i i i r l r ' l , r ' r . r nol l ! : . r ' zi l l ,
de pi , r f or , ol ) r t si i ,
( 1( ' \ ' i i l 1
i l
i l l ol r i l ol
oi r r r l l t l i sl ) l \ .
1) i t t 1r ! l l
si l i l ol r sl i r i i l i r l r r g-
r nus {i l r c bf i 1c t l r
1| r r , l r ' : r
l r , zi t r r r i i ( l {r , r r l r . r r l r i i l r l
1i
\ - l r sr r l gi l , l l l i r ?:
, l , r r r r r
r | ( ) r r i si . Nl onl , r r r t N, l ' i , l ! r ( i 0) .
l t \ Si nt l . t onr t , l . Lu. [ l l , ut t ur t nt l ( *i r r l t r nu. l ur r r r l t l t l
l t , i l nht ' t ' ( nl ( i )
\ r l
t l i U' i r r l l t ' f i zu , zi i
1r t . i t t l l r r , r r l i zi r r 1l ( \ n, ( ' l r i i
l t \ ' 1. : r r l r '
1I r 1l 1, 1q
l r . zi r r r r r i si
Dr r r r
l l t r r t r r
I i t t ozi l ,
d( '
l ) i t t l l i r
ol r r Hi i .
l-l
rt
: 1, 4. ! i . l hr nl l zi i l r r i t t l ct r r ur ' k' r t r r ' ( ol l l l r t r opkl l i i k' i t t l or t t t t t l t ' nr o)
o,l tnl .n11l t11i i l .r ' i ul (t' t' ttt:l (xt.t' t t' r' zttl l ,i i , rl i l l I(rza,r' ol l I ) i I t I I I I
'
I I ' I t ' i l otrgi l tttl i
r r r r l r .
j r oi l I cl i i r r r l r ' . ( l l t t ' l r ' 1t ' t ' ol r , t ' st ' t r f i r t ) r ' i t l o pal al i zi i k- r t ' i t t l t ' l l t t t r r l t ' i t l t r si l t t
( sr t. l rs(' l rw(,grfr' , l l )(i 9) : a) rrt
sol ti ul
drept i l l tern este para,l i z.Il ,
]rcntr' l ]
|||rr1r' i ri (.r|
(,rl rr.i ugal ri , tl e l Rtcl r' ti tatr:, i nsi , funcl i oneaz5, norrnal i n ti mpul
r,,rri r l l gl rr{r' i
;
l l ) prozerrl a ni stagmusul ui tl i soci ai , si ngul ar sau_ prepol gc-
l .rrl l rr, orrl ri ul oi ro pri vefte i n afarri ; c) prezerl ta paral ol i smul ui gl o}l i l or
,r' rrl rrl i l rr pl i vi l ca, i nai nte, i n ci uda parezei bi l atel al e a muqohi ul ui drept
r l l l ( . l l r .
' i n
1.,' .:i rrn,i l e pozl i na (i ndeosebi vascul are) se poi i nti l ni doui forrl e
1rrrr
i i l rrl rrl rr rIo ol tal mopl egi i
j nternucl eare
:
|
)
(),lltlnto1tlegiu
i.nternttalrard, anlet'ioa'rd, cea tnai frt'r,r'cntil, aparl+
,,;r ,r ,,orsr.r,i trti i a l ezi i i ' i i fi bl el c)l care l eagi i nucl cul pcrcchi i t ffl -a, cu
(r' rl r' Il
Donl ,i tI
petttru mi ;ca.r' ea oonj ugat5' ori zontal :"1 rl e partea oi :us[
(l rl rl r,l l rrscrtrtl rl rtr: al e bandel etei l ongi tudi nal e
l ostf
i oare). Cl i tti c si r
|' , |||rrIr' ;i , l rr pl i vi l ' ca l aterai d, paral i zi a muqchi ul ui drept i rttel n (de p,rt' tca
r r r r l r . sr . r r l l i l r r zi t t nca, ) , t l i pt opi e i ncr uci Eat b,
$i
l r j st aguus ul i zont al l a ot hi ul
r' :rr' ,.pr' i rl si c i rr l rfrri i . AJoste l enomone se expl i cr' i
?r' i i r
1ri ' tnl ci , nrtcl eul
;rr,rrl l rr
rrrrryrl ri ul dropt i ntern nu pri meqte i mpul srrl ' i pentrt mi l eatea'
r.orri rri :,rrIi 1, l rrl ,rtrrJi , rl e l n centrul ponti n de partca ol )trs:i . Pe de al ti i pnrte,
rrrrr,l orl rrrrl vrrl rti rl bdncens pri meqte i mpdsuri cerebral e
qi vesti buJare
r
;
r r r i I r r I r
,
r ' r r I r r
fi
r sl,lit funcl,ioneazi normal. Convergenia se produce, intrucit
r:rr r lr.
l)r.r
1 r'u rc('rstir, mifiare nu trc
?rin
centrul pontin aI mi;clrii la1'erale
, ' { , | |
i
| | r
i
r r I r
'
. I)rrrri leziurrea este bi1il,terald, apal'e o paralizie a adducl,iei
l ,l ol rrrl ui
rrrrl ar i rt arnbel c sensu' i (dar cu conservarea convergen{ei )l
| | i I i I i r
:
fi | | r r I r.r Irr liot'alo din ochii afla{,i in abduc.tie
li
nistagmus lt} privircir.
rrr rr|11. \i N1i rgl nusul opi ,ol ri eti c qi i ndus pri n exci tal ri e vesti bul tri l cvi
r l r ' r r l r : zi r l i st ) r r sr l i t l i f er i t e l a cei r l oi ocl i ( Bender , 1969' ci t a, t de Popo-
r r cr r r si l ' r r sr , t t , l {) . B0) .
li
)
| ).llrtl trtrryilrlti( internucle d,
Ttoslerioard'
este adesea greu tle
_diag_-
r,rtrri . i )
1rrr,r' :rl i zi e
supranucl earl a, perechi i a Vf-a este foarte di fi ci l
rl l rl i l !.r' r' rr(,i l r,t, l i l {i i , tl o o afi ngere l a ni vel ul nucl ear sau radi cul a,r a' net' r-ul ui
\ t (l l rl l rl ri si rtl ab.. f9;$). I{u$chi ul drept i ntern de partea nel ezai ' :i sc
r' .rrr1rrrrIi i rrol rrl L), i ri schi mb ml ;chi ul dfopt exterl de partea ]czi uni i rni
l rrr! i i onl l i l zi ' i i rr r.tu' sri l Ini sci i l or dc l ate,ral i l ,ate. In aceastl ' formi ' l si nt
l ,' zrrl r' l i l rl r,l c rk,srrr,trrl entc al e bandel etel or l ongi tucl i nal c posteri oal e {i l e l tr
{.r' ri rrl porl ' i l r rr1 rni l ci i t' i l or dc }ateral i tate l a nucl eul tr' bducens de aceea' ;i
l ri rr' l r' ).
(l )rvl l g(,r11l l ,
srr
l l rotl rroc
rrormal , Ni stagmusLrl ori zontal aprl re de
; r i r r ' l r , r r
ol r r t si , l czi ur r i i l : t ool i i t t l c: Lr e
?r j veqt e
i n af l r i i
l )i l i ,f(' r1,i i ^r' (,rr i ntl c cel r tl oul i forrne se facc pf i i ' l l rul i za' compr,tr' tl ri i
rrrrrrrr' Iri Ior' ( i rl r, i tr:ti {)l l rl rzi i , i n seng ori zorLtal . Astl .el , i n forma antu i oi i r;l t
rl r r,1rl rrl r,r l c|rr i l (f
l )l utea
l ezi uni i funcl i ol l eazi normi rl , i n ti rup oe cl rcptul
rrl r' r' || rl r'
|rrr' l 0rl
ol tttsl i cste
I)al ' al i zat
pentru mi qcarea conj ugati l , de l :r,te-
l rl i l rrl r. s1rl r.
l )l l tetu
l czi uni i , i nsL ful c{,i oneazi , nori rral i n convergel ti t'
Irr l i rrrrrr pos l t,r' i r i a i ' i i , rtmhi i drtpl i
j ntcrni
:ru o arti ' r-i tate normal i l , a1,i t
rrr l i rrrl rrrl rrri r;r' r' i l i i rkr l .r Lcl t.tl i t,:tte, r:i t
"ri
i 11 ti mpul corn-ergen1,oi . N rnai
r l r ' r , l ) l r l ( ' \ l {, 1' r r r Lr pr t r ' 1t , i r l ozi uni i cst c pat ' al i zal pcr t t l r ' u. mi ; car ea t l ' l r t t e-
r ' : r l i l i r i r ' . l f r r l r r l r
l r or i ct ' i oi l t ' i i 1xr r r 1, o
I i t l i ' l i r t ' ct t ( ' i a, i i r , t l t l
l t al i r l i zi l ,
pt r 4l l i t t zi si
I t
1r | t t ' t ' l t i i
r t \ l i r t t t t t t l i t i
l t r i l t
l t ' l l r ' l I t l t l sf i t t t t t l t t t ' t ' l l t ' i ) i l ' i l l f i f i t .
( kr l l r r t r l
1i
' ' ol r r l r ,
( l l l i l l t r r r t r r t r Ll l r l , : t ,
l t r r l t l r t t t
l , ' t t t r i t t r r l r t gi r ' , r ' sl r ' l l l i r i l ogi r , sf i t ' r ' 1i r t I l r l
5u
t
ll
il
1
I
1r ' t ' t r r . t t i i dc
, , o1l r r I nt o1t l , 6i r '
r l l l l r t l r l l r l l ' i i t L' : r l xl r l r ' ( ' i l "' ( 1i t r t t
l xr sl ct
i or t ' t i )
1i
t l r
, , o
l l t , i r l l r t ol l l t r gi c i t t 1 r ' t ' t t t t r , I r ' : t t r i t l t l r l t l t l . ut r l i t l " ( 1i l t t t l t t t l l r i r l l t l ' i l ) '
l )i aqnosti c eti ol ogi o: l t)
' rr' /rto;-rl ' i n
pl i i ci esl r'
(1:l ' l l zi l ti (rl l ' tttrti l t' trtrvtrtl l ' ri
l of l al mopl egi i l or i ni crttttcl t,i u r, ttl ti - sau bi l ater:l l tr; l r) l czi tttri l tr vi rs( rl l i l t(t
se i au i rL consi derare i n tj otttoxtul cl i ni c (Ifa i ngtorr si cttl ab., l 1)61i ; \!rl l Hl l
;i
l l oyt, 1969; Cogan, 19?0; tr' dtzsch, 19?1
;
Gonyoa' 11f74)
CJ Oltalmoplegiile internucleare pot si apari' de ambth piirli,.trsr.t
ci i rtrl u-se qi o oai ecare asi nergi e a gl obi l or ocul ari , precum ,1i pi tt' rr' l i zi i rtl rr
pri r.i ri i vei ti cai e, 1l sus, al e gl obi l or ocdari (pri n extcnsi a l ozi tttti l trl
l rott.
iinc in paltct'| inferioarS, a rnezencefalului (Cogan gi colab., 11)5() --
r'iirt,l'i
r L' . i i ot l echt el , l C6j ) .
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
(lir
ril'(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'
paci enti l or este atraBri spre un obi ect cal e nu se afl d, i n fata krt' ,.l ti . trtt
1i
pot depl asa ochi i pentru a-l pri vi . Eri stl
$i
o crestere l l
,,toni ci i ;i ' l ' i i "
ttl ttrl
chilor antagoniqti, care duc Ia o devialie a globilor ocul&ri de
l)rrl(rir,
ol)rr$ .
\r apal fenomenc rliplopice
b ) Itttensi fi ,aareo, Dl ec&ni smel or refl etel or de
.f
i tal i c st' pttxl tttrrr
;tti tt
pi el cl erea
conti ' ol ul ui i nhi bi tor. l n mod normal , i i rl rtt *,r i tl l i l sLtl r col r
trol ul r-oi nfei qi ochi i pot fi mi qcal i de l a un obi ect i a a[1,uI tl tpi i , rLrl i tr(ri .
!n p.r' ' rl i zi i l e supranu-cl "are, bol navul l u poate sri -l i tr2rnsl i x\r or,l ti i tl r'
pe un obiect pe altul Ia comand5, insd poate uuniti i [u obiotrl; orttrr so
rni ;ci . i n di recl .i a paral i zi ei . De asemenea, se pot e!' i den tj tl ui cl l rsj i Lri l l l rrfr'
rol rnal o l a sti rnLrl area l abi ri nti ci i . Pi e}derea rni sci i l ' i l or vol l l l l l ,i Irrr i rl ('
globilcr ocula,ri, cu lespectarea trtulor mi;cirilor ooulal'o r{rflo\(', $(\
ri urnegte pseudo-oftal nnpl egi e. Parati zi i l c m\ci Lri l or dc l tttttrl i trtl t' , rrtr
pistr:.rer
-conrergiltei,
indicii o leziune corticdld' sar pe c(idl. tnrl,ittol'tt
11ult,
i nai nte ca acestea si , a,ti ngi centri i subcorti cal i . In untl c cazttti , i l t rrrt' tr'
contloltl voluntar se pirde, reflexele de fixalic pot dovdii t t t '
i t I I t i I t I r I I
' ,
pri r-i rea se,,ancoreazi " de un obi ect, l nci t o mi ;cart ul tcri orl ' ri l Il l l
l xri rl r'
l i fi r.urtri deci t ti upi , ce se el i mi l i i rnpul srl ti l e l cti rti cno (i trcl ti tl t,t l rt rrt,tt
acoperi rea ochi l or). :Lceste si tua' !i i ar1 fost dcnul ]Ii l ;r'
,,a' l !1t,1:i t
o()ttl ' !ri
tttol ori e' 1 (Gol dstei n
l i
Cogan' 1965).
t
)
Intensi .fi cutea rcl l (.rel or propri oaepti u ci l l o
l )or' 11{l s('
rl rr Irt. l rrl ri ti trl '
si de l a rnurschi i gi tul ui epa' e atunoi ci ncl l ezi unt' l r sc:rl l r-t' tl ci l sul )l i l l l l l (l f i l t)r
ponti ni ai si stemul ui l ' esti bul al . Astfel , tl e pi kl i r l a l ttr cl z l i l crtt' tr ttri l t' ri t i l l
vol untrro i tL sus sau spre dreapta si nt i rrrfosi J]i l {' , l Lrl tri i i nsi
(' rt,l )l l l (' sl ,r'
br s' r (obori t sau i l l tori sl )rt! sl ,i nga, otrl ri i str r.ott' i t.zri sttl r tttt tttt$l ti rr{ttl
i n srrs i 1i sl r' (f {l rol rpt,i t, ct' :t1xl i i l t Il l o(l aul ,ornfl 1 si i srr t t
'
i r t I
'
r I I t t ' t I i i , l tt
l rozi l
i l r
I r r t ' r r t ' i zot l l ; f i i . I l sl , t ' . l cnonent t l
, , oohi l ot
i l t
Tt i t yt t t ; i ' ".
t t t | t l i l t l t hr <' i l , r r r t ' t ' l l 0xt ' l t r
LrrLri l i rtl i cr' , dl r,ci l , l l l i ri { i l rl i l ' crr,pl l l tl i r^s14' l rt' tts<ri i ,
;i
rl t, crl i ;t' t' i t t r p t t l s t t t i l r
'
l r l opl i ogr r p{, i vr ,
t l c l t t , t t i l cl t t l I I l I I f j ( I I i I ( | | . ' t l l t t l t i j ' r l l r r , r i , t t t i ; t : l t t t ' i t , t ' i t l r t t l t t t
t l l ; , r r r r ui k' t t t i i , .
lr
l')11
r t t ' r t nt 4l t t t
l ) t
l t t i l t ) t . . x I l t , t l i t / i r r r Jr l i | l . r
:
,, ,,,:;,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;
rl . rrrrrrrr' r' : rzi
, r. zi rrrr.
r' r r' : rrr' r' l i . rrrol r, , i i t l "", ' ; , r"
r' , , i i l ] , , , , , , , ", u
' ri scri ri l o'
: i ' : l i ' i , ' ; , ' , ; : i l l ; ); ; : ; i , l ' , ; ; l : ] ' i l i . -: 1i l , i ; : ; , , r. zi unei ,
", , ri , """
l l , i i , . ; . i i i r. . . i , ri l i "l i
,,,,1,,,,,,,,i,.
,i,,.;i.,,,;i,;;,;''il;';ili"Ji
;|?1iil11:# T,;:i:i:".
sint pii'r"1.te
,,,.
tt
) t,t i x:i i r.i tc
da
.u,tmd,ri re
si nt l ,estate sofi "i ti l J
l aci "ntuhi si 1
j i reze
r r r l ' l ) | ( . 1,
| l r t 0 se t ni sct j , di ;
r, , r, , , , , . r, i r, , , l . i rl , , i ; , ; . , i l i l | ": ; : l l : i ^t u: ! "i "
ri t a, l a aproxi rnat i v
60 t , rl i rr
,r;ri ir,,.,,
1,,i"i,,,-ioai.i'T1il::"ffi.'i:-Jii:tfiil?"1i?llff:lif;,yui*or'i
,
) ' l ' rxttt!. ntet:u.n,i s.mul ui ,d.e
l .i xuJi e:
pi Lci erhul
csi o sol ;i ,;tat
",;.
pri - \ i .:, r' rr rl r' (' l )1i
rJl - fat. crami rxtorui ui ,
i l mp i n care .ro A.ai ru;o,rrL
ui r ,i i ' i ul , , l , r r ' .
t ; r
l , ( , r i l i , r ' i ' , . i ml t ul ui
vi zual ( #i ; r : ar i t : a
, "i i "i i , _"i i ) , ' i _, s*
dc l Li , l *i l ) i ) . t r r r , , r t r r l . t r ur l ,
st :
l t r oduce o r ni scar e
- a
pr i vi l i i
i pl r st i nl nl ui
r , e: j l j r , ! . Li \ , . r 11 r' rr.r!' '
rr.r' srr:i
rni sci i ri s.gereazi i
o t,,ri *"
","u' l i
t"ri """ur,i
cr-i i Lr. ;rri r_
r( rrr' |r
' |",
(' ' !*1r'
rrc re' ei nrui
occi pi tal oi
"i ""ri i t
i , ri i r" i rre ri r,,:*:.
, .. .
"
,
.,'
t \t,4t, tt( t ttttt' p)
gen,rri ..,
exami natol ul
cr' l e borr[r \' rLrui
si _i rl r,rnr-
ii,
I
' ,,
,' i,;.; ' rrr,
(' .rr. (e
rni..:j5. lerN ir fatra ochitor ip,:" .,io,i,,;", ,ia"iiiiii
,, ,t
) ' l ' r-' xl urau
farei
l .ente (
tl "stctgnustrl tti
ttptol ti tteti c.
Utl ect:ul ti ri utcat | ' t ) t ' / t
\ l ' r t i cai e
de cur o. i di l er i t c
est e
' r i i cat
i n I l t a pacr el t , r r l r ,
i . r .
r' i "
' r{rr
.str sori ci l ,at
si i ti ui ,p' i r-i rea
u' t
"ruJ' "u"..t,,i r' i
pe
ceni ,.l r er,-r11- , , r l r r i , i i ' r t ) i r r sal p ngesl j , est i mi scat - l ; ^i l #; , i ; ; j t r . u
di r eci , i i . l n , . , r r r i i t r
l {) t . l r l l l ( j
apar i : ni st agmu- "ul
opt oki net i c.
- -
'
..,.!
)
.
,.
,, . .,
, , ,
, ,., ,
,
tti rttt0tnusul .ui ,_;c11t!Uui a,r
rotator
srLr\
^
tl i stq(nt|
).tl l u i t t t t t , t t t . : r t ' l t . t , ( l i r 1( _
i r nl r ot , l al ] t
r) r,
,
irrr ,,.lr,rraliziti
;
,"nu"u,-#iiii:,:?".,?,::t;,",i,",,x"::,r11:ij:;;;illi;
\ , , , l rr, rt r'
si rrt ,
J)ri _. . 1rat e, l ezi u, rcl
t r. t
"i "
-ri i . , , i i a-' , 1; ; ; ; ; , "
arc, t ui r. eUr-
'
l 1i I
rl , t i hrrt l r
(ncrvul
r, , est i l ul ur
_nucl cut
_, . r t , , f r, l , ni i ui Dei t et , s
i"iilI lltllli,li
;li,lLl];,Il;?:ii:;lJ,Jl;L';';,1'f,1i,'"_,ii;1;tl":l,";:lfll:
rrrr, rrrr.rl ' rl , (J(,l l sl tl l rl
nucl ei l ur nervi l or,
.ocul oi n"t""i -
aral
' r._,i ..,.' .,i
\, .1rl )rl r1 ( sI{l i l rl rft.
l n_prezenfa paraUri l ".
i ri l 21i "r"l J al i ' prs,i ri i
l l ri ,r:ral e , I r r ,r
'
, r | | i I I (
. r|
j l :rrt,rr
ul echi i protl uce
numai rni qci i l i teni e. afe ochi uhi i .
:'. t.( i.:.1. l, uihl tu e rI e di a
Elttostic
toltograJia .,si
etir.tpat ogenic
,,,,, ,., !,:,'i;,,i ,,1 ,,,',;::'i',:i;li,{:i:,:,:,,;"x!;i:1,i.:,1:,^1i,,r"'1;,*;T:l:.fiH:T,,;"_,:
. l ' r . r l r ' t ' l t , r l r r r l t <, r ^t r l t . i l oi
OLt t t l o
.,,,,ir,ri
',,rrr,r'.1,;;
;ilii d;illli"ftlrliii'iTlift:J.,,*"TT;l'Ii
ii"i,.li,?i];
r , r r r l , r r l i r i
I r , or r t i r l i r l j r r a; r t bt l c t ,
I
r1 l,
i
i,
:
;
i
I I ;
r;,
1
;1, ll i :li
ilu
i #]r liix nsft ,,;li [mlri#"1*,uffi
i l t ' r r r j l i ' r ' r ) l i l r i i l o: l si i . l r r
i l l r i r l l r , , l r r r r , : r l . i z, i i l r ,
pr , Jl i l i i
l l r r r r ht st .
f [ ( ] l ozi l , l r i i n
I l l l l i l l ul l l l r , l r r , t r l
r , i t r l r i r . r l l r
r , r r Nr ( ' r r ( . r . .
: r l l i I t t l t i l t l t t l l i ' t L' r ' i t r i ' l r l pr ot l t l sLr r l q l , zi Lt l j
| ) I ' , t t ' l l i . : i i l ( nt i s: r r r i l t t . | , , , t | i t | | | , | t |
, , t i . , , t t l r r l r .
( r i 4t l ) , , ) 4. 1t 1t t ,
l i . t , ; l l t ,
)
.
,
I
, :
r l I r I
j
z r r I r
,
r r r i , r , I r r , r I r . r l r i r . l t r l r . t , t r l i l l r l r . , . , , r r , l , r r r
i r r i I r I
J
r r | : i i | | i I i I : I I r
,
. L I r r i r ,
( ' , t r ,
l r , ol . i l . , r t r r r l l
l , l ol r r l r r l ol r r l r l , r ,
l r l r , 1r r , , r l t , , : r ; , 1: r l
f i , ,
.
i , r , ,
i , , , , i , i
l l t )
( I
t ) I |
( I ( ) l | | i I (
' | | I sc
l t t r t t l t t l r r
r r r l . t r r l L, l r l r i l r l ( ' r l l . l l l gl l l i i ; l gl r r l t i l r l t r x, t t l r r t t
i n
( l i r cl l i l l
ol i r t si i
l l t r r l i zi r . r ; r r
r r r l r L.
l ) ccr l sl r 1j a l i br el ol or , r r l oui l r ' pr , t r i t t t t ni ; cr i i t ' i l r ,
( ( nl , j r l gr r l ( ' I l t , i ' r ' r ' : t l l i l : r
I r i l el
! eduncul ar
i nf er i or '
f i l xl r r l , i l r
st t pur i r t t
)
al r : t t n t ol i ; t qt ol ' t ' al t l ; i t r : l r r
bi l i rc:r, di agnosti cul ui topogral i c al It-' zi trni l or' . Astl cl , i Irtrcl npcrc:l Ii l rl ' ' 1,,r'
deasupra i ncruci qi ri i i nduce pi tl al i zi a mi l ci l i i l atcral o sl fc
?l 11crl '
(i l )rrfi ,.
I : i {/ . 11. Lt . i ul r i i e c. i i l ar acul ol t t c:
.l : N.Eon .artnrl :rdliocnl:rrat.r;
-B
: Ne!rc! mezo.cialnr hcDicrrltrrnrr ;
C: \ . r {on neT. . el al ni xl . . ! l onr . l . r , ] r i i . onr : n; 7 - ' I ' . hl i zi c l i . r i r er ni
a . cl l on
'
l.rt ll:i .\tdn : I - Pi.rli2ie n!(l.arr .onjlgali | ., - I-rerialic conjrrgai' lrnr leTirx
'
)pNte' di.il 4
_-
Dc;irlie tunjlgat: lrin
itTnD' crnisJ' r('
i n 1, i r r r 1r cc i r i l l cl u1t el ca' 1ot sr b t l ccusal i e cat r zet zl j , pl r l l i zi r i
l r t
i t t i l i i l r r l l t . r l '
ci 1r r , r t ct , ou5i
l t l r t ' 1r ' .
I t r f t t t t cl i r r t l t , l r t t t t l i zl t l t ' i t l t , zi t r t r i i
1i
r l r r pt i t t t kr t ' t , r t ' l t l l ot s] r ' t t r r l t t t t t r ' ' t
vr r i r sr . r l r r vt ' r , i I r r ' i 1l t I r r : st ' t l t ' r t ' ; ' i t l l r t i l i l t t t r i t l . t ' si r t r ! t ' ol t t t t t ' I r or i l l t ' ( l i l . i l : i
. i
l l g. I l ) .
.
: r ) . , {i r r r l . r , r r i t r l l t ' t ' t i l l t r t t l r ' t , i r t ( t nt i l l I r i r
$i ?
l . I t , nl at . ) r , r r l r ,
l r r . . r l r t n
r l 0
I ' r r r i l ' . r ' : i i l ul ol r r l o; i l r ' r L. i r sul r r , i r , l r r nl cj sj l l i i ( t nl i l L, x l t r r r i vr , l i r r , psul r r , r ) .
l i , , r r r : r r r i l i . r l i i
1r r i r r l , r ' - o l r r r r i r , l i zi r ,
r l c l l r l cl l l i l at e a
] ) f i vi r i i ,
r j l l ( [ {f vi oi ( ] r \
gl o-
l , r l , ' r , , r ' ul : r . r ' i , r r r r r or . i qi i i r l l l ) l l ui , sl ) r ' ( , t r ) ar t ea l ezi uni i ( bol l r ayt r l i ; i pr i vi t qt e
I i ' zr r r . : r ) , l : L r . : u' r . s( . r r soci l l zi - r , ( ) pat , ?l l i zi o f aci ai 5 t l e t i p cent r al
, i
o hemi _
l rl cgi r' .rtc l )i tl l ,(fr
ol l nsi r l czi nni i . L,ezi ul i l e cauzal e si nt hemoragi i l e, i nfal rc-
t r . l r . i . i l r r r r ur r i l r cmi sf cr i ee.
.
Nlrrriii'stiir.ilo inverse, ilitative, pleced aleviatii conjrgate alo globilor
,,, rrl rl i (rrrruor,i
si al c capul ui ) sprc
l artea
oprrsi l (confotm l egi i l ui
pr6vost
I
' l l
t l ( l l ) l l Z\ ' ) .
It\
' {i nrl n,nul
Fot,i l l e m i j l oci tt, (protuberanl i al superi ,or
)
cste real i zat
(1,
1,,,:rl , i r i i l rl el or ocnl ogi re dup5, i ncruci Dare
$i
astfel gl obi i ocul ari si nt
S xl . r ot t t ul f l ( r gr t t nt t l -
(
l r Nl t t t t ( l i l l t l l t ) l l l l l l
' supct ' i ( n' t l l - l t ' gl t t l ' t r l t t l t t i
l t ot t
t,i n) cul ri rrdtr,
i n conl j exl ,ul sorrti rrl i rgi r' ,
tttt si rLrj ' rotn l rovi l l o ttri j l oci l l ' l rt' t rtl r'
l,;' i;;;;;it ;;;ililii' ;tti c,' i,' l,t,il' s' ipsilatoral f
i hotrliliipo.sl' r' zi'
gl' 5rrli
de parlea olusl leziunii.
- '
' ", ' i s; , , ai r , r r 1 f st i Tl l I n. f Pr i oi
( pt ol l t l ) r t t a! i al i t l l . ' . i t t t
l
cr l r
gr ' t t l t ; r l
O" l "r i ooi , i ". ai l ol ocul ogi r i - ub
i nci ucj sar p i i
st mal r i l c' \ l I pt i t r p; r l i r l r / r : '
i r i i : i . i i i r r t "
pn, 1oa l ezi uni i , cu al evj er er - coni ugat i r a gl obi l ur o( : r l l i r r i
nl ) 11'
i ' r , 1"^i ' - i i , gi Si oO, omuf
Tor l i l l c
j nf el i ol
s.
l oi r , .
r soci a. $i , . r r ur r si I ( l r ' , ' t ' l
f i f ; i i j t . r - "d i j nj "t I i l i n' "nua si l ui r i i si sl emel o'
t l e asoci {r l i o : r l r ' . i r l r .
t l '
ii'iiiiiii"X#"i, oil"iiriir"
p"tl"e sint aclesea bilalerale, iirs:i i'og^ltr'
irtt
risnunsulile li
-irnpulsruili'
rostibulale silt pierilute'
'
*"-.'i"o*firiifn
i"cdmpt"te ale privirii de latiralitate-
pot irnbrlca, lirirrt
ni strE
"ti i ,r,i i
ori zorl h, c"."i i -pn" ci ntl gl obi i ocul rri si l rt i tttl rtrl rl rri i
ln diieclia paraliziei.
!)
I'iraliaiile migcdrilor conjugo'te tle tertic:ttlilate
(sintlttittrttl I'itt
"u'?Jrlunlt"
comisulii
albe posterioare, alc nucllilor lui
jll'rlischtrwil s' h
. i Cr i al si al e i ubst r n( ei cenuEi i pcr i apedu( ' l i r l ( di n r egl l l l l {' a Ll l r t r ' l r r r r r . i
;;"r;l ' ;t.;;;i aoi etl o"i
p.i no ti brel e oci rl omor' o' i i bupran ucl oa' r'
r l i tt rt trr I rr l .'
i i i r:' ri i l i i l Tj .' i ;l
o pu' i -l i ,i " ryi vi ri i
vcrl i cal p' L;l ti ur!i
(ar\' :r'
si ' -'
"
i nr i - aor "r i o'
( cr ani ai t pr or l ' uc par al i zi a pr - i vi l i i i . n- ' us, i ar r ' r ' l ( ' ( : t x r r ' l
mai posterioare (cautlal) realizeazi
parallzla prwrr]r rn
Jos'
fn cazul i n care
pa' ral i zi a mi gci ri l ol , coni rgate de verti ur' l i l rt' 1' t'
rt'
"*o"irn'*
purlotizia miqcAritor orizontale,
teziuiica se gdseqte irr lta'ttthrl.lrt
r "i ' "i i ' i ur "i 5-
""t i o"i o"i i
di n r egi uner 1ep12l i 1J. 5ol l i
qi Sr r l l i ' l l r t i l
Si ; "i , bl ; ; i ; i . i
pai al i zi i l , ' cl e vei t i cal i t at e nr r apar i n l ezi uni l c
' i r t ; : t t l : t t '
r-"
"oli*fifo"
sup'eriori, ci ntmai in leziunile care a'fecteazi' zotlil l)r{'l"r
i.rx
ibt}t;.rttlt li
colabl, tooz; Pasik qi colab
'
1966; Bnder l1)(i1r)
Si ndromul
.
Pari naud se mani {e)t; pri n i mposi bi l i tal cl oxtrl trl rrrtt
r ol r "Ar i i ol de t i t l i car e; i 1 sau dr . cobor i r ( ' a gl obi l ot ' ocuJar i '
- hl r
por t l r ' l r
"";,Jf.ia"
,n"iiiA-.ti."' ilrigcare de verticali{ate' lntr-o
paralizio itttrtttt-
i , i "t i . i ' i i i r i i -
"el
t "r i i t : "cl , "nr , af cct ar ca pr i r i r i i i n si t ' ' ' r t pui r r ' . | r i t i "i i
i ; i l b; ] ; ; ; ; ; ! ; i t o t i . p ce numai i n j os apar e f oar t c t at l ' i r ' t r k' t r i r
ilr_?irir,", il--ll.s L asociizi rdesea cu absenla rcaclici
l)ulilxl.(i
lrr l1r
;;t-. ;i; miclriazS, relativ2i
li
tu menlinelea ree-c{ici dtr
(lollv('l'g('rr1rr
'
Daci ,' *;' ;i erd; si i ni qcarea de pri vi re i n
j os,
rparc l n pl us tl i sprtt' i {' i rl It' ' "
modirii qi a oonvergenlei.
ReEi uncr
pr ecol i c( l l al ' l nsl e f l ' : . r l ' l c apl or pr . do uumJr l o\ l l l
l l l l ( l {' i r f r l
"", l ot r r Ji - Gi ' ct m
r n si , ca al al . - '
. . i ndl omul
Pat i naur [
{{' ' r t ( r t ' i i r zi i I r r
;;;;;;-;i ;. o;;"}i i
a rri l u' , i n speci al a l l ruscbi tLl ui l i di cri l rx' i tl
l )l (r()tr l "
l
i ' ncri oare i i tl efi ci te i n )ol ,i l i tatcp.
l upi l ei ,
a1e rl .' omodal tr
Sr
(x)l tvtf' gr' rrl .r
'
A'r:oli;"ll-a' rr"t*lrl.i
p""".hii a I\''-i
-ebt{i
excepl i()tlir'Li
.In
krzitrnilt' il"
;;;' ;;l j i d-
;i ;cdri l e t1e urmi ri l e pot ti pri stri ' t^e, i n ti rtrl i .l ,t' trti q|r' i .r' i l '
i . , i . "i ; " i "t oi ni t t ' ' "
Di I l opi a
1' o' r t ' '
I i
1r ' oz'
t ' t i t i r r
Par r r l i zi i l
r L' v. r ' 1" t
t i i r i ", - , st , i t , ' , r t ar ea opl or l
' i r Lei i c, - r
sat t vest i bt t l al r ' t t t u i t t r l t t r ' ' t l i r l i t qt t l ' t
l erl ,i cal .
Si nt ct i zi ncl 4l l pj gt l i nl i t r . r ' : l 1Lt r . i , I l {' I Ldcr ' ( ] {) U| r ) i Ll i l l l i ( j i i i l | | , i u' l l ' l l xI i I
, , r i s, , , i : l l oi , 4e l qr l . i cul i t at o si r
. , t 91,
l si ' ci i t , t t t t nl snt i I r r l t i t t t t t l l r , r l i t t t t t l t t i ' l ' l ' t r i t t r ' l ' '
t ; i i ; i i , , ; "; i , , t ; i r l or i i
: a, ) t l i i r r i r r r t l ei t s: r t t
l t i t ' t t l ct t ' i t
r ' ( ' gt , r r r l r t i
l t t t pi l l t t '
l r t
i ; ; ; ; ; i ; i , ; ; i ' i ; ; r ' ot r *t r t gr : t i l , i r ;
b) sp: t r i t r r si t t t
' i r ' t ' r t l i zi a
( 1r ) r r \ ' ( ' r ' gt ' r r {' ( ' i
;
| )
( '
vi t l i r r l l r l t , i r r i qoi r i l ol ni sl , r r gr r r i , ' r ' , i t t r , l t t si t , t l i sl r t At t t l l s l ! r l r l l r t l ' I I I f 1 I I I
I I
I | ) | | | 1
I l!1, . Sl lltoulnele Lui FoDiItre:
/ . l . L' r ! l l l i r r hl r l i l . / r . I r l &l ! , ui \ , r r l onl nor i i ( ocul osnc) j r . - r i l r r ecol t i codr dur e
l l r dr n, l . ! . hl ) j i , - SLr | | , J"nl
' r
l r , ) vr l t . por t j h( xr t *; Z
_ Si r r t r dmr t l Lj i Fovi l ) c p. {nr ne-
r hLl i , t r I r r yn{; , t - : i r ' r , t
' ' I r t
t ! i l t vi l .
l ) r nr l u. r nl i r t i nf c. i or ,
r l , "r i l r {, i - l or r i l sl ) t . r ,
l ) r l r ' l ( , i l , . l l ) l i t r 1
l r , zi r t ni i . I ) r r nr l i zi l , l : t r i t t , i i i , r , st c r l c l i l l oq11 r , l r , l
, r r . i ( ' l t l ' l i i , i t r r ; r r ' r . r r r r l 0t r I r r
,
I r r i
;
I I r
,
; I i I r
,
r l r '
l
r r r r ' l r . r r r r
1r
r r sl l r ' zi r r r r i i ( l r ol i r r r vr r l i ; i
l , t
r vol l r , t l r , l r l l r ( , 1r ,
; r r t l r r l i zl r l , r r ) .
0: l
r i : l
r | | r
I nr i r l . Fi r r i i r r i f l . vr l I r l r . . ( l r i i .
( 1r ' i z( ' l ( ' r t ' I l ( , {. i f . r i r , | t {r r
r r ] n) ( i ( hl ( 1( r l l l l {. ( ' ,
: r r ( , t i . l i , sl t t r ^r l . r gi l . r ( t . , . i r r \ . r r , l , . i r .
si
( 1.
r , , t . i l i l , , t r r l l i , r r . , , , . r r l r i r r r t r r St i i r r ( , i ,
Ar ' f hl "
"r ' i z.
r i r r l
1r ' r xl r r sr ' ( l r ' sr
i r r l r l i r r r c. si vi
1l r , , v. r r i {, i
r l r r r l . zi r r r i i r i l i ac( r }l , o
cr i i l r r l r . or . l i r o t r t r r , l t r ar t pr ' t r l l r r r r r J; r , i i r i l c coi r . i ugat ci
.
l ,)
)
(rl st)i l atl i ru
fi rl s1ri , i rr- l r;rrri l ,i a uror uri srr:i l i (x,l l rl rc
r,l i pi dc
$i
l r ; r . l i . ( . , r t i sl i l g, l ' i r k' snt t
nr i , r r . l , r r i . c,
- i n
speci al or i zc, . i al t . , t l l r . qi v- or t i cal ' e
sr r r r
. r r r l i r l , r , i i ,
i r ' et l i at i nai r r l r , r l e a f i xa un obi ect ( u' t el de, , t r emor do
l rrr' l rxrrrr"' ). ,\r,cste. mi qci ri pot fi acompani ate de tl emor i l capul ui .
()l rr.(,k)l ri i r
rr fos1, descri srl i ,.i n di r-e' se cncefal i te, i i i nel prod' si ,
de i 6zi uni
rrL,ol i vtri bul bar.e;i a,l e nucl ei l or di tl a{i di n cei .ebcl (Ji cnder, 1969i .
l ,' ) ,l l i .ocl oui i l e ri tmi ce ol e gl obi tor ocul ari pot upi i re:l i n l ezi uni al e
r r t l l , l i r I i r r r : t t r l i r r . cer ebel . r r l e r ucl ct r l ui r oi u. ol i \ - ei ' l r r r l l r al e si 7 sau al e
r' r' r' rrr1r.l r,r' l r r l runorrrbrool i r-ure.
Se mani festi , pri n contracl i i ri i mi ce al e
l l nl ri l ol or,trl al i (' u
o fl ecvenl d, de 50"-90 pe l fi nut, cl rora' Ii *" o*o"i *ri i ,
rrr rr.r.l rrqi ri 1,rn, tni ocl oni i al e.pal al ul ui mdal e, al e f01ei , Ii nl bi i , fari ngel ui j
l r,' r.rrr' r(' l ri , rl i rLl ' r' l gn*rl ui
si chi :rr al e membrel or. Dc
' rrrri l te'
' ri '
mi ocl 6ni i l e
rl |,Iri |' r' .rrrrl l r' i si l r1,
$e' de di ferenl ,i at de ni stag' mus, i .si . o el aJi zi , cl i ni ci
r r r : r r l r l l r r l l i r r c al l l r i , ci i nu er i st i , f a. z[ l el t i _
(i
)
;l qi l ati u
al obi l or ocul uri , (,,ocul ar
bobb:ng' ,) se craracteri zeazi i p|i n
rrrrl r' rrl i i rrvol rrrrtrrr.c si ncrone al e ochi l or 1n
i os,-cu reyeni rea, i metl i ati i n
l rrrzi {i o
rrOr.rnrl i i . A fost- d.escri si , i n l ezi uni i i i si ructi \-c i nti nse al c protu_
l r.r:rrr(r.i (Jri shcr, 19e4). l n l ezi uni ce,rebel oase s-au d.e"qcl i s mi 6ci i ri i ni -ol tn-
l rrrr. si
Ir.Irrl rrl Irr,u
r.i ni $ci i ri ori znntal e al e gl obi l or. ocdari , cu apa{i ti :r i n
r , r ( , l | | | i , i l r l l r r i Dul l i r r i r i i ur [ r i obi ect .
:i .1.7. I' robl cnre de di agnosti e eti ol o.{ti e i n pal al ogi a
si stemel or
0r t r l 0| [ {r I 0t i i
.' l ' r' t,r.r,rt' rr
i rr l cri stl tt
,pri nri l tal el or
rouze
al e ol al no,pl egi ,i l or prezi nti ,
rrrr rL' osr,bi l i rrl r,r,trs pr,acti c, cr rl tal e procerl d.m l a u" si ntczi t, eti opai ogeni ch
(rl rrpri .,\r' sl rri si r.ol al i ., 19??
;i
Popor.i ci u si Fa,scu, l gg0).
-
..:!..1,.7..1.
l )ol i .
.i nJec!base
;i
i n.fecl i os-ul et gtce acute si srl bttcl tte:
rr) | | r r r r I ' I i r I i I I r ' r-i .ri ti ce
pr.i mi ti r.e (t-pi derni cri i ,
z,,si i ri ani , ubi ci , pri n arbo_
' r' rrsrrr.i
.1..). b) )l ncefal i te
' i r' o1i co
necundare (rari cel d, vari ' ol i i , rri j eol i ,,
|rr.rl
i rl i l i rl ri rl ' rni ctr, n)onontl ' .l eozri i nfecti oas:' i , gri pi el c.). c) Encetal i te
rl i . I' ' r' srr.l i nl *(i i i l or general o
Ifebr' i , l i toi dri , scar.l afi ni , l ri se
' conYul si vd,r
i i r,;rIi rrl trri i ,
l trtrrt
ttrurni i , ri cheti s
j r' ze,
mal ar.i e ttc.) al ) Nc.11i ngi te acpte sau
rrrrl ri rrrrrl r.(r' cni ngococi c5,_.}ncumococi ci ,
t uber' cuJoasi i ,, s#i ti s rr]o.ni ogo-
r;rs.rrLr' rri ..) tr) J.)ol i radi c,l oneuopa,Li i (pol i rad.i cul oi rer.-ri td,
Gui l l ar-n-
l l i ' r.(t1 r,{l i ,i {' tk)z(: prrnneopl azi ce
etc.). f) Nevri te i ntersti l i r}l c secunda,re
rrrrrrr i rrl r' <rl ,i i rl 0 r' cci ni "l ato (si rr zi tc,_o-ti te, ostei 1,e, abcese etc.). g) Nevri tc
rl i r..l trsl rl
.u' ,r'
h,l i
.
i nl cc{,i .l rso
.(tl i fteri a,
botri l i smul , tetri ni i i ul , s.a.)
l r ) Nr *r ' i l . i r nr ' r o, k*c, i . . ( l t . sl vl r . cr i nal e:
asa- zi scl e
, , p, r ' ai i zi i
r ccur eni c, i al 6
r ' t I l l ( Jt ct al l l i I t 01c. ) .
:!.4.' i .i l . l ti l i ,tdahol i ut: i l ) {)l i (i ri rexti rl c
(}ri ' del i i ci l , (l c
i i i rrrl i nri '
: r . i r l r r i r , o| ' i r r i r ' , l r ci r l r r sr , , r ' l r i t . r c. ) , | ) i r r , br , 1; zi r l i l r i r ( . g)
, {r r r . r r r i ' . r l ) l ?ol l i i r . i cl
) 1. 1. 7. i i . I t t l r . t : . i r r ul i i r ' , ut ur t t r . . r r , ) l l o1i r l i r , r , ( pl r r r r r l r
; . r r . ) .
l r ) Fi r r l nl r l r l l
| ' t gi l t r I r , ( t t t ot r r r i t l t l 0 ( | l r r ' l l | | r ,
l I l l sl , l t , r r ( , r , r r r . gl r t r o I 0sf 0t . i l ' i r sl | i r ot , i i - i l I o( , t ( , t t xt
( , 1r , . ) .
r ' ) \ l . . , r l r r r r r . r l l 1\ l . r l i . l t r r r , r r l r r : r sr . ( | r I r I
,
) r i | | I |
,
i I
,
I
,
,
( | i I ,
i I : I I i . I , , l r . r r r ' , l r i l i
( l t i
. r r r l r r , i r r I t r I l i | ' ot ' i t l t r l t t ot t t t t t t t l l t t , , , ' , t r l i r zr ' ,
i t ' l t l i t t t i l l i t l i l ' r r ol ' l t
) '
r ' ) I ) t l l r t t ' t t t t t l t '
I r l l l l l l l l ' i i l n\ Zl l .
' ' ' 1' i ' . . 1. 1' t ' ' ' i ut t i l . I | ! ( l t ] , t t l ' : | | | I t t | ' , l r ( ! ( 1i hr nt . , l ' , t 1t i i r , . ' t ' . r I t t ' i r l r ' sl r t t r I r .
l r
qt t cl t i
r r r r l cl r r i t l .
i l t ) t l nt n' r i st t t r ' . ' l \ ' ' l r r i i o r ' ' ' ! ' i r r r r . t ci t - u' nr r : i "wel t ut Tol ' i r l i t w'
, , t t t , t , l i t r , , i r l i r u, t ) t or l u( '
o si t t r l t l t r t r t l ' t l ogi r ' '
' l i l i ' l
i l i i t r | ' r r t r r { i " r h'
D"z
i I i r t
t , r '
1, t , . l l i
r ' . i r t r , l l i j i x;
( i ' gr r l t
' i
Nl r r t t t r l . t 96l l ;
( i ' r ' ct r
a\ 1. ( a) l r r l r ' 1
l l r t ' l ; r l l s| . r r l
. , i ,i ,' l ' ., l rrtri , l .9t.r, 197?) : ctkt unti ri oare l eze:r' zi l t' o!' i l tot' vi i octtLrtttttl .ri
, , , , , 1, , , sr , I ' t i t , , t t i u. r l super i o, ui i l l , pcr et hi i a l t t - a)
, si
t l l t nt t t l t ' t t I i
'
I t I t t t i t I I t l t
t r r ; ' , ' r r r l r r r r I t r i ) ;
t de r ni i t oai i l ezeai 5, l a f et t o! ' i ner vi i , oul l l ul r Lok) r l
t l ) t 1\ r l l r r l
' 1,,
i i ' ,,' ri , i t,Jti l i rormu:i al e tri gerncndui ;
ui el ti srnt' l c ptttteri ' oaro l oztt"tr' i r
'
r r r r , l r i r r i l r , n( ' r ' \ ' ul ocul omot or ; r t er u ( VI )
$i
r r el ' vul t r i ger uet L i r I l ( ) l r r l i l t l l ' r . '
,,,,,;;;;i ,;-' _,; _i rrri si ndrom cl aude Bernard l l ol ner
([t' zi urLet ,1rri t,$l o;tt"Zl \r
,,,a,,' i i ,",' *i ,*",t' i ,' rrn). Anet:ri sm,el e aaroti d' i ' ene s' upt' acl i noi tl i eut
pttl l t' zrt ttt
,,,,,,i i r,,l al tt,' , t' tLl ocul omotor comtl tt. Att' euri smel e de urterd ti o nt' l t tI i t:Qrt' l t1
,' ,,,,ti ,,:;,,,,r:A
s1'
11rL
mani testa atl csea- cl oar pl i n pl ozi i ' pl l pti l t' l l i i ' l rl r' fti rtl i i
r r r t r r l i t l r ' i . .
' l nr t r i snt e[ , e
nr t er ei bazi l ur t
poi pr ot l t ce
j r l r : r l i zi i t xr t t t l t i t r r t ' l ' r "
, t . , , , , , i , ". i , i 1u, , r r l l l - . r , . , i
^
f I - . r , - i a" d. hr r l l t oLi t t l t si nr l r t , t t t I ' r t r i t t : t r t r l
'
'
i ;;;;,:,;,' ;i ;
' ' ,t,u-r' i ri ,tal i rr". ' ,Lt
A n.i te i e tt.i Jeri tc eti utuqi i ' t' t
' t' r"ntt' l t
t t , l , r l r r
' si t l t t r
l ni ( Ll t Pr t t u^. t ) t ' i sl e r ( t ol i do' ( t t Dcr t t oust
l !.1.?,5. ' 1' t' {trunttt i tnl e ctal t i t,cttctful i ce : t1
-F\' mtrrri
cl rrtri trl to i tl t' l trtzt' t
, , , , , , i , i i r , i *i l *r , i r l e or bi t ei . b) Coni uzi i cer ebr al t ' . I ) c pi l t l t ' r , i n. n) nl l l zi r r '
, , ; ,'l;;:;ii iiffiil;il
pi l"* iniit"i paralizii izolat'e^ *lt'
ltet'rx'hii
rt \/ l rt
'
,rrt ttl tl l tl i zi i mul ti pl c l )a,l ' tti l ' l c
(l e
ocul omotol i ' l n col i ' ttzi l t
(x' l ' 1rl )rl l l tl
, . , , 1. ", , , "i , : r l , , i ' i , 1, : , l ' , , i ; ; i ' l ct r ob' l l , pot I i i nl r ' 11' \ 11( i . ( i r L
gr r r r k r l i l i ' r i l ")
, ", ' , , i
' t l i i
. , , ' ut , , i , , , , ' r , i ' i t r I t : r . t t t r i l . c*i t r i t ' n.
r 1c et : r ' j r t r i j l o. i t t
l t t t l r ' t t t
t . t t
i.,; ;
' r' ,;;;i;;1i,,";,;;' ;r.ir,t,:
iit oi
vt, ,l-n' urteo..i trururri irl(' pc.' (1hii u v I rr
,
1 l ,l l i ' rl ttrcl l ' al
posttl rl umal .i t. d-) nl ecrni rtrru hi tl rr,' tl i narni co'
erl (' l tr 4l
r ' ' . , ' , u, , , ai ; r , ". i "
pcdl , ' t a l e. t ' ) l l n( o{ul opi l i i
l ' o"t t l ' r
ul nal i c{' 1t ' r ' l l
l t t r t i vr t t i : t l t '
,,,,;,i;;;;' iiii ii"
' int,ilizi;
p, r' ite' ic' t' , duclcrire, srrrltr' -
$i
ilrt(t' rIu(rl(rrr' r1' )
' ' .,1.7.6. .PrtrcseL( enptttl si te i tttracruni ene
pl othrc rtl l l ' l t' l rnopl r' gi i l i r'
' ,rr
(( )rrru
(' rri l l l re tti l tx' ,ti , Ii o i trtl i rtci ;
l )I' i l l
rl cPl asar.t' a
tl rl or' 1i )l ' l l l l l t i l l l l l
l ' , , , , ", - , , , ' , "f i , t i t ,
' hi l ; ( ' ; i ' , ' 1, *i l ut g
i l t l , r ' i l cr . l I I i l l n I i
-
( - r \ l scr r i
1i
( x) l r ! l )
'
l l Xi i ' '
r r / l , l l i ??) :
l ) I l i t t r l t , r . t t si t t t x' i l ,
l ] l t t i l ol l ul i l l t l i l l r r r l r l r '
r h l r : t l l Li t t i t
l r i t t ' r l i zi i
t [ r r t r l t t kr '
,
' 1, , ' i , ' i t l ' ; i ; ' , , i i r i
i i
l N, r t ct r i i
i 0 Jl - r , ur r i l i r l cl i r l : i '
sr t ' t t l r i l i ct ' a' l l '
:1 Si l rtl rrl rrrrl l do tl l l l ti r s
j i rrLrl i tl i tl l i
1i
si nt[r' otttul dr' rtl rtrx rl t' l l i l ' l t' xi trl '
, , r , l i z: i l r , t l t t t t t t l t i t t gi t i i l nl t l r l e r l r i l t i sl i ' r r oi dal i , t t t ' 1' t t t t r ot t r ' \ oi l s( r ' l l l ( ' l ' i r sl ' i l z( ' r
l r r r r r r l i l t l r r si t t t t st t t i l r t t ' , l t l l ' t t : r zr t l i i t i t t gol t t i t ' 1t "
i I ) ' | ' t r r or . i I r , hi l xr l i zr r l t , r . r 1 cr . i t t t ' i zt t t , t r t xt l r t l t r i t t l i i | l ( ' l ' ( 11( dr '
l r l l ( ' l l r I l l l
, , , , , u, i t , i i
"i i "- ' , r ' , , us
1i
r r s1l i ' l 1xr 1 ; t t r t r l t t t ' o
pal r r l i zi i r t t r ot ' t t l ot t t t t i ' or i '
, t ) ( ' r ' l t r r i t l f l t l i l t gi t t l t r t t ' l r r
l t ol
t l t l r t t l a t t t r t ' t l r i cn t r l i t I t i : t zi i I
] I I t ' I r I i I |
(
' : i
'
1, , , . , , , , , , '
, 1i l r r l t i t l i r i st l r l t t ' l l - r ( 1, : t r ct r
1i
Ar scl l i r l l X; 0) t t r t t ' vl t l t t {i t r
pt t t gt ' t ' r i r l l
, 1, r ' ,
l r t r l t l i zi t '
r t t t t l t l t r t i i l t
l xr t ' i r cl t i i
l r l l l - i t '
l , ; ' l , r r r r r ol i l I
I ol r ul r r i l t or r i : r l
l r ol l t l r r vr t ci t ,
t L' vi cr i t ' ot r . i t t 1; i l l ( l
t t l o gl r t l r i l ol '
, r r l . r : i , l i ( ' i l r '
' r t t l ' t ' r t
, , 1t r t s, ' i l ' ' zi t r r r i i , i t t i l l t zr r l t r i t t ci ' i . r r l .
qi i . i t . l i vt " I ' i r '
i l ' ,
l r i | r ' i {, , r ,
l | zi t t t r i i l r l l l t zt t l t t I r t t r l i r t ' l t ' zi r t t t i t l t . '
( i )
' l ' ul l t or i l ( r
I l l l t t l t t i l r t r l i cl : t l l xr l f J' l t ( ' r l l
l l t r vi I l ' i r . t I t I , i t t i i ; r i r I r l l r , gl Dl r i l ot
, , r , r r l r r l t r l r r
| t : t t
l l l t r l l r t t si l k' zi t t t t t t .
tt7
i 1 ' | ' r r r r r l l i I r ' r ol r ur r r r r , r i r r , ' , r , l
r , r i , r r r r . r r i r r r r r l r i l i i r r r r r r r l i i l i r l gr r r r r i r or
, r ' t t l : t l t , . i t r t qr t l i i l l l {' l _t l l l ) r l r r : r
r r r r r , r . : r r pr r l r r l cl r r l r
1; r r r r r r i r I 1i r r i . , ; r 1r
l r r r . l . r r l |
l )
I l r | ) i l ( , l | r . ( f
l ) | 1xl l l ( ] t .
r , ol
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fl",i,i";.r,,,,t lacior,r',rlLi,rrii,
s) l l \nnol i l o
' l obrdui
occi pi trl pot
si i pror1rrci .
tl evj ol ea
col .j ueati r rr
' ' L, I ' r | , r r ' . . , r r
r r l r r I i dp paTt et
UI | l : : ; .
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' l i \ t z
( 1966) , Zi t t l z si \ r ' l l i q| r ' i l l | r ; , ) ,
l r , ' : L , i \ 1, ) st , r ' ( 11) i t ) ) si t l t r l ) i t i t : t i t t o r i t ol r r l t . ( 11) i l i ) . . \ . o| i r r zi
i r l l r r l r r ! r
l , l
,
r i , ( i i , r i I r ' I l i {, .
r l i sl a. , i c si r i ( l l i f i f l l ol of
l l or i t t t l t l
t t t ot l cl : t l
l t t t l t t t t r
r t
' t
, , , r r r r r l r r r t r r r r r scr r l l t f i r [ r ' gJi t , ogr . t i .
t ' ) . 1l i <ni l t r r : t r l u. r t i st .
( ' i i n' i
t ( 1
( ^r ' i z0azi i pr i u er t . r l i l l t l t t l i i ' ; i o| ' I I r I t r l r 1r I l I I t ' ,
r , , r , \ i sl ( ' 1r i l l scr r Lr t r , l or t l e l t i pcr ' 1 i l oi t l i sl l r
( l , j \ r ( ' l s( ' ( 19( , l l l ( ; : i ) .
r l
1
' l l
i t 4t t r l i u ot : l t l ur i l i t ' t ot r t . i ' i t , t i , st r t ' i l t ' r t , 1r ' t i zt ' l t zi t
l t t i t r
r ^r r I I i I r I r r I I ' . r
, 11 , r Lr r l ) l {' si r ,
l r t og- r ' {r si vi i
r ' \ t ( . r l l i ( l ) r u( l t t nr t l , I 1}{t 8; I i t i st ' t r l t l l u, r i
I r ' l : r l '
1' r t ' r l 1 \ r r l r r | i l l i l oi t l j l ur i , a l r t csl 0r ' ol l l t l t nr i l t J| qi i
I t ol l l t '
I i t I | ' t t r , , t L , I t ,
'
I I t
r r
r I i r
(
I i r , ( ,
i L
I
) 1 I I r ' 1 | ( J( . l l j nr l r , l 1) ( i f ) ) .
l l l ' l
( ) . l l ol
t ol l ( ai i . l t r t ' or t i t c yt n4r t xi t t r l i n t t t i r r t l r t t i t
\ l r t sl r ' t r i r t gr i r ni s
J) oi r i f
t l ol r t t l l t r ' t L pl r i zr ' i pi t l pcl t r r r l i : i oI l r t I r r r o1' I , ' I r '
L\ \ r l r l r si l l ( ) \ ' 1 , I {}0$) . l ) ( , i l st , l l r ( Jl ( , i l , l i l zi t r i r r i ' t t t st t l t ' t ol t l l . i t ' i t t t i r l l ct r t l t
"r . r r r r ,
r i l l r t l t t t oul cgi l t csl r ' r l ) J{) i r l ) c ( , oI t st r t nl i ( S( ) ", ,
( l i i r ( , l l zr l t i l i : r r l l r ,
t ' t , , , l l l ?1) ) ,
l r ct r nl ur ot r l i "r
si t . r ' l r n; r i i l t l cst ' l t t t r t t ( f N( 1( i ol l cr l zi l r t l r t l t t t i t t i r l t r t t r ' : t
, , r r i r l ol : r r r t i ( j ol i | ( . st {, r ' l l zj ( r j . Sl r i l l j l i r | r r , r l i l r ut i osl i ( ' t t l t t i I l ( ' t t ) i i r sl r ' l l i i l
j t l l r \ r r l
, l r r i l I i o
1r ' i t r
l t r . [ t ni t t i st t r ut ' t l . l t r l r ol t l t t t t t i r t ( l t ' t t si I t t r ) , t ' i t t t l oI I I t I t t t r I 1I I r ' I ' t : r
t , , , , l r
r r ' ( l i t , I i r r
1l }i t t
r t t l t t r i t t i sl l r u l ' t L,
(
I - I I I | ) i l 1 r r I l r I t ' i I I i i
,
r I t t l r i i | r t r | ol l : r l r r t ' r
t , l ,
r ; r : r . r r , ( , ( ' t ) 1. l l r ' : l zi i , ( l esl r t l r l l r r l xr r ' r ur r l i r r l i sc cl l ' r ' 1 t t t t t zi l r l l r r l r l r l i l
. r UI i l ( . l t t r ( l ( , l , r ' sl l ] l
( l t 1( ' r t si l or r t t t r t I osl 0r I i I j t ' i t i r r t ) .
: l - i . l l . I ' r ohl t , r r r e r l i ar yr r osl i l t i r r pr r l ol oqi r r
l r nl r i l ar i i
' . 1. : . 1. l l t , r l i . l i r i i r i I t ' sl t r l i t r t l t ' pt t l t i l r , i
I ' . . r t r t t t l r t t I si r r l r c i r l pr r pi l cl r ) f ( '
Jl t ( ' ( f l r t l t l t t t i t t l t zi l , ' i sr t t t l r r 1r l l r r l r r r i l
r , l r i r : t l r t t r t or I r ' t ' ; t I i | , ( ' i l t r ' si i
l l i t t t t t l czl r l i t t r r l r ' l : t si t t t r r - : l t i . i i t r . r ' ' r ' {: r ' t
l r l r r
| , , ' | | r , i l | | r I r | i
( , r , | r i .
| ) r t r r r
.
t r r i t t I r i l r
.
r t r t r
,
i
;
r t I
; t
i l r '
I t { ) f I r | ; r | {
' l r I r ) I t t t l r t l t i l l r t o( i r ' l : r l r r
,
r L. r ! . r r | l l r r ' : j | l r | | l ( l ] r ' r i , r ' l r ol r i r ' r , 1r ' : r l r t ol r i r t l n' ) r i i I l r r r l t l l r l ' t r i l Ll
, , 1) l r ' r ' l r '
, , 1, ; r : r I l : r l l ' l I ' t t l r r l , ' l I t r o I r r r : r l r
.
s i t r | : r r l , . r r r . r r | | r ' 1 ( l ! l r i r l {' , t t sr t t r l r ' l r l r t . r t l r '
l t t t '
, ,
,
t r r r i ; r r : r r : r l t r r i r t t r ' l | | r . r Lr j o: r . I | i : r r r r , I t ' , I r .
l r r r l r i l : r r r ' l r , l
1L t , l r L L
' i r l , l
1. r
r r t r r i l or l r '
1r r t ; r r I r r r I l l r I i l r .
( ( l : r i , , i i . l l r r l r . , l l l l i l i ) .
\ l r r r r r r r , , : r
l r r r I i l {' l | l r '
r ' . 1r , i l r ' l cr r r r t r r l r r l i r l : r r ' r ' r r l o, r l r r r t t t t r r Lt l t t t , r l ,
1, r , , ' r r , t , l ' r ' l r l t r r r l c t l r ' l r r r r r , l t r l
l ( ) r r ' l
r r r I r , r r r or r r r l t t i ; r t r " t t , t t r ' , r l r '
, , l r r l r l r r r r l r l r t r l r r
.
r l i t r r r r l r ; i r r r pr : r i r , r
1r : r l r r
i t r r gr : r l t l r r l r ' l r r l : r
, , r ' r r ,
1: r l : l
. r , , i r , r r r l r r r t r t l r r r t l I l r t r
.
i ' . / , , r . ; ' . . l i t . r t t , l . i t , t t t l r . ut . l t r r l t t l r l , , t
l t r l i . l , . i l . sn. hsl . *) t l . i r r r l , i l ; r , l r r i r r st r . r t l
, o| | I I r | r r . | | \ : | |
ol i , r l pr r ni l r i l r I r r l r , r r r l r . r r r l r r l r i l i r , or r r l xr r r oi r l , i r , si sl , r r r r r r r l r r i vr , Ar r ,
l : t l i t ( si t t r ; r r r t i . si l
l l l l nl r , i ' r l , i r t r r . ; r l r . r . . r ' r . : r 1I r r , {. i r r r , h. zi r r r t r . : r r , ; r r r . , ,
l , r , ul r l r r
: r r r l l | t i t t l : r ( l r .
t I : i r i l I ( . : l
I
| | |
|
, | | |
.
| | , |
.
. A. . l l i . l , s I I L { | | I I | ( r
,
l r
.
r . r r l i r r r . r gi | r .
; i
r . r , l n
; | Jr . r r ( r r r ] r . st r t i t zr ct r
l l r oduc
| or r l t ; r ( l {i t r
l ) ul ) i l ci ,
i n t i mp u) Sl t l ) sl j Al | i , el t , l r l i "
i r l i r r . r ' {i l c r i i , r i r nl r r , Li "nmi r r r r . l , i r . r ,
o i i i l r r i ; i . I ) e cel e mai r nul t o ol i , I I i r or r uI | i i I I r
: 1l i l ' j ' l l : :
; r l o pupi l cl or . sl r r L
I r ' , , , hr "( , t i c
do l czi uni r l c
l :
. i r si l | r l , | ' l
i , , I l l r r l ,
. ' r , r , r ' . Zl l l l u r t p Sl mDal , t CLt l Ui .
, ,.,\)
,\rii,s/arrlr
l" cu)e ,,Jecteaad actiritatea pard,simp(
ix(i si se folosoFtc
. 1 D r r ) r ' r r i i , r 1, . r . ar ?r f Tr enl r u
di ngnus[ i cu] di l cr eni i l l al aDoLnal i i l ot , d, , mi l , i nt o
I r r r I i l : r l i . . i r r l par asi mpaf i com i mol . i ce
Si
pt r asi mpai i col i t i cc. l r i nl t c cr . l o
' t)tt)u\ntputLu)ntmctrcp
emmti m |
^)
physoswrnhLa
(ezei na) O,Zi
% Uo_
rlrrlr' lrr rrrr ochi normal o contrac_ti;-madmai; a pupiGlor
;$
f Aolir$iio
.r,' lllil
I ",, i)r.oduce
r.r zrctiule similari, ezerineif ins5 Ae
' ittensitate
-mli
l fl l ' ' rl
Ir:) rtttttcotl _na sol l tti e 2,5
7o.nu
produce ni ci o modi fi care i a o pupi l ),
r or ' r | | i r t : r . t l r ( r zI I
i D car e i ner vr - t i , r . pf l r asi mpat i el ost e i xt r er ul t d, m
si hi i
c,,rsl ri cl r)t' i
rl evi n mai sonsi bi l i
_$!
astfcl hetacol i nn 2,5
o/o
-va' prori uco
r , , r r r . r l i , r i , .
l r l pi l r r . r i 1
r l l
Ceg maj l ol oi i t d . s/ r sl onl d p, t r usi nt pi t i cot . i i i ca
esi e
r l t ut t t t t , l t t
t t hl dr obr omi "d 5o/ o. l n r i mp de 40_60 mi nut e de l t i nsl i l r Lr e: ] ,
I r | ) | , | : | | | r ,
|
, I I | { ' i . cr pupi l i normal i i se di l rl r] l a maxi mum. DacJ i nervabi a,
: , r r . t , : r l r | i r ' . i r . i r r l r er upt i r r l i l al r r r r . r esf e t ni ci sal t i ) b; : eat i .
,
f f ; 1t 111. 11( ' "_r l st anl el pe4r pal ecl pd: doct i Di t at p( t si / , . ?d/ i cdsi car esef oj oscf l c
. ] , , ] l : i i , l i
t b aol i r e, ^cer mr i ur i l i zar i e, . t e coco; na 4o7o. I nsi i l ar ea de par r u
l r,
., l
' r' r
(i
r. r ' ' (.r
' i
i i i n sr cul con
j uDcti vrl produce, i n motl normal , d i l ai :r,rr.a
|,tt1rrl rr"ri .
' i rr
sa2u1 i tr cnre i nerrati a si fopati ;n' este i ntrerupte i n afarn,
.i r' l .r' rl l l i ..l r' \os corrtt' ri l , acest fenome.' nu apare. Dacd, exi si $ o acti vi tato
;.r:rr' .rri rrrprri ,i .i .
(
11' suuti , ef,cctul di l atator
.aI
-cocai nei
este sl ab. Se poai u
t.t tt' t ..t..l tt' )rtt.l Il gangl i utt,l tri
stel ol cU 5 rnl rl e procai n:t hi ctl "ool ori ci l
ol ..
r t r | ' oD{t r ( | | l r ol r t r l ( . ,
l ) l t pi l r r
devi no mi Ot i Cd di t cauza aCt i ur i i par asi mp; _
l r r ' r r l r r l
l.,l lll rlurlo,[.oq.i( tt.tilizd,rii probelctr colirelor este urmltoarea ; a) Dd,od,
lt
t.t
lt
t ltr t :tlt'
.ttt
ith i.atiLrii, se ta testa in primul lincl cu metacolin i, 2,i
t/o.
Api_
l r{r:r pr;ri l rr ( r
' l si r.i c1-i ei
demonstreazL o l ezi une parasi mpati ci :"
Li i sa
i )rri i rr' ,
r n\:rtl l tt puprl are ]trage atenti a asupra unei Sti ri de excl tati O
rLrrrrIrrrIi .i i ,
r,r*.
|.rN{r
ti confi rmatl pri ntr-ri n-bkrcai
aI ga' gl i ouul ui
i i efi i
rrl rrl ,r:, :r.r.,t
1,11,(' r{rl er
api -(i nd
,co-nsi ri ci
i a pupi l ei )' ;
ni
\i cA
pupUa i si i
r / , ' , ' . / , , , , . . sr . . \
1' , sl j r r L. pr i mul r i nd cu homaLr opi xd i oo. l n cl zr t i n car , l
l ) r r l ' r l : r
r l r . v| | r ' . 1i , : r 11"
mr dr i r t i ci , r vem dc, r f r ce cu o sl ar e d. c cr ci l l l r i l i t r t o
l ,;l l :l l l
,l '
j ri :.::
:l :i cu1i ,
i ar rtaci se md:e$te pu1i 1,
l e
afl ai m i n fa,1a ui ;;
i r(,,rrr, r' r i r trl runul ur
si mpati c. Du1ri -trecerea efectrl ui homatropi nei ,' pul enl
rrr'{ r r.r (lo{liritril,.
Darli pupila se dilati in mod oviclentr probibil
li-ziuaca
r, r r r r
I
r r r I i r r iii, sc ir,i'lir, in caclrul S.N.C., iar dac[, acest fenomen nu se
Droduco,
l .zrrrrr.rr
s. gri st.rj l {' i rr:r,ftta S.N.C., I* ni vel ' l f.i brel or pl e- sau posl ;gangl i o-
t r r r l r , ( N1r : r l r t i r r r , l t l t i f ) ) .
"
: . ) . . 1. , \ . , : j . , l t i : r x: ur i t ( i uHt , l i t l t , t , yt Ti l ar d) - ' l n r nod r xr r . r r n, l , pupi l r . l o
*r , ' l r l ( ' r ( x. ' r r \ i i r r r i i l i r r r r '
1i
I 0r r cl i r r r r . nzi l r r gl r l l r st i r nt l i . l l aci l pr r l i l cJr , i r r
Al i t f r ' ( l {f r t , f r : l l t i . r si l r l i l l gl t , l , , t r .
l xr i t l nr
l r t l l t i t l r r
q
t t t t , i : pt 1xt , i t , , r f 4 / 1. r , r i , i ; r r r l : r r i l ,
r t r r , r . I ; r I i I r r I l i r i r l ) i r r ( ' ur l i r r r I r r l t , r , l l r , r r , l or .
1r r r 1r i l r r r , r , ,
i t vot n o / l xi : or , / ) f / / r r . / i r i ( , 1
'l i'.
l r ' , , .
( )
r l i f l l r r r r t i i r l r r i t t t l r l l , ' l l ' r r r r r r i t t l r c r I i I t I t t t I I I r
' I I I l l l ot r l ot t i i
l t t t l t i l c
1, , , t ,
1i l or r si r l l i l r ' l ' i r , t ' r r , I i zr , , i , , ;
' . r
r r r i 1) r r ( l i ( i i sl l t l i t ' . ' , I , t l ' i r l r r r : r i o r r sl l i l
i l , r r r , l i : r I i i : t I r r st r l t , t l ot ' l t l t t ol t al t r i r l r r r r l r r t l t r r t r l t r t r r ( i t ' i sl r r t r l i l l t l r i l i i , i t t l r l r t t r i r r I
t ,
' , , , , r i r r i i ,
t : t l t l t r vi r t c Et l t t t t t i l i r r : t I t r I t
( )
l t t Li zr x: t - r l ' i c s1l l 1j ( i i
l r oi l i ( r
I i
I i t ' r t t l t t r r l t
t l , \ , l t : . i t nt ( i t t , t t i l t t t t : r r t l , t i , . l i r i r i l ul i t t i i , , l i e
pur eLi ad' , t ' t t ; t ' r i i t [ t ' l ' 1t ' : l zl ' i r ct t l t t t l
1' l l 1, r 1, ,
r , 0t r sl , t i 01t i r qi cl i , i kr Nl l l | ' l l f {' l ( ' l l t r ' ( ' par asl nl }: l ' 1' l cor
l l l Ll l l l l l r r l r l
f l
( ' r ) r r r
i , 1, , . , 1, , , , , , 1, , si nr p: r 1, i ci r , . I ) ( , t s( : l r I ( r l ca, ani zocor i a poal ' c si ' l l l ' : l l i i ' : i l l t l r r i r l r '
i , , ' ' , , , , , r , , i i , r i i i i r t r L i nhi bi ! , i i a, ct r i t r ul ui co' st r i ct or , co. s{j ( r ul ' i ' r '
l t ' zi t t t r i l . t '
, , r r , , r . r r r r r oL, r r [ r r . Ar Li zucor i : j cal o sc accent ueazi , i n t i ml ul di Jr Lt i i r i i
l r t t l r i l . ' i
r l , r l l r r l r i t ' r ' i l r l odusi , de l t zi ul i al e si r npat i cul ui '
i n t i l r l p r x ( ' t ' i l . {r r l ( '
, ' , , , , , . 1, , t , i r r , l r i r l cont r acl i ei est e conseci nl a l ezi r i i par asi l ) r l ) r ' l i ( ' l r l r r i "
:' ,t.ti .,t.
-/,I
i dri aza (creFterea di um' etrul tti
l tttTti l o' r
pesl e 4' . 5 tttttt.)
r' ,,.rt, l r rrrt,i l ni l tj , si i n condi ti i nol rnal e. Astfel , pupi l a trstc nl ai
(l i l ' l l 1 i l l rr
i ,
' ' , , '
, , ' I : r l r i t l ' r r l i , I a m opi , l l ' : r r l ol escenr i '
l l l ' . i t r t t i ul r ci i l ur t ' l t l i t r
l l i (t.t' i .a,f;(t Qrtaur(i ,i ci i se nal l i l estri
pri n faptul cti l tupi l rt'
l rr ocl r i ttl
,,r l ' { Hl (f i rrk' sca' Inai mare deci l , ]a ochi ul s;ni l ' tos Acel a6i fl ]rrol tl otr Ntr
' ui ,t,,,i ,,i ,'
l i
i rr rrhi ul ambi i opi c. l l :rmautoza bi l ateral [' , apart rt ttti th' i :rzi i
l , r r r t r r l r i i t t t l t t .
l l l Ltri tt"rti ul a centri l or l i
cdi l or i nJeri oare
|
) .l l l i dri .ur(,
tr)aral i ti ci i
(patrl i zi a ah-sol rrl i :I prrpi l ci ) i rl )i rrrl ci r
(l
, , , r r r , r
.
i i r I i i . a l (^zi l [r-i l or centrui i ri
pul i l al r' l i u nrtzenct.fl l qi /,surr rr, t' rr,rl or'
, t,,,.r,1,.
' 1rrrr:rsi r
rLpati co' Dacri l ozj ul ei estc l ocal i zati
proxi l a' l tl c grrrr*l i tl
, , , , t , , 1, ' , r ' l r t r i t hi : r ) a l oat e
sl i nu I i e col r pl cl l i ' ' - i l I t i mp. ce o l czi nt t o r r I i l r t r ' l r r t
1, , , , , l 1, , , t , gl i , , t t l t , t ' o
( gi ngi i or r r r l ci l i : r l si r r el vi i
- ' ' i l i al i , sl t t r l i )
r t r r i l i zr r t t zr r
r r
1,,' ,r,,,,ri ,,r,,,.,i tr,,ti i i - La l nce4ut
' ,[l e,nr
i rsi bl a \t' tt nel i ni $"
1tn' ytl kti r' '
ttptti ,
, , r l , l r , ' t t I l i t t t k' r ' t r a f i a l : i br dl or pent l u r l uschi i ci l i i ' : i ' so
l r i t ' t ' t l t r
si l t t r t t t t t r r
,t.,,,..
1
,,1:ti l ,u rytl egi e i nternd,
)'
i i r i l rtr' ' o l l tti nrri ' trzi j j ol ' ,si i ' al rrtl i i ' fi orrrt(r
,1, ,t,r,' ,"i l rrr ,",ri rpi i ,1r' i , a perei hi i :r, III-n. Nu tol i ,e l czi urtj l t
(1;:rr\r l i (' (ri ,{rrrzi l
r , r r \ | | l ( | ( t l l ol l l t ) l i ( l ' I ' oonl ul t
poi i mpl i cr r I i br el ' 1' r r 1l i 1' r r ' ' r t r si t i | 1' t l : t 1. ( l ' ' l l t l t t t t r t l '
r r r r , l . r r l r r i l , ) r l i t i ger - Wr : st pi r a, l l l ul t . 1cr r z. r , o
ql l i ' i 1' r l l "' i ' ' pogt r t l i t r i i st ' 1t l t
i ,t.1 l l l .:l (l r..l rxri npl tx*l rLi nu.1ut1'
' cUl ott' tol .t' tt
,
rt l cr' i trttrt tl .ttdcfi ti i i t,
l ,tt' t'
r l r r , r r l l l - r l ,
i ) oi r t , o
I ' oNpo{}l l l ' noof i l ] i col l l i r i
pl t l l t si l r l l r l t l i t ' i l ) i t t I or t l ' t l t ' o
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1. r t , t t l , r i t r l i t i t t i l r t t nr l t i r l i l t t r ' l t osl t t i r t r t t r t I r ' *r t l t t t r t t l t l t ] t t ( t r i t 4l t i ni t t t , ' , t t ,
, , , ' t : , , r l r . \ ul ) t t i t ) i t t ( 1r : r r ' I r i t r r ct r i t I r I i Li l r r , ' l i , r r , l I r l i l oz; i . l r r r l r l r r i r l i r r r I
r i l r l r r l r . , l xr r r l r r l l r l l . l t ( ' l t t i t t o: t l l l {' ) . l } l l l l i t i l r r t t i l l r l l r I I i I I I I I ' r ) ; r | ! L I l .
, r , , ul t t i
l t t r t hi ul
,
t r t r t r r l r i r . r i t t l t ' r l r t t t l t ' : t r I i r r t t I l r I l r r l r l , . i l l l i t r l i l i l r I l l r l i ( i r ' r r r
I r r r l r l , r ' ) r ; {' r r r i o{( vl
( l c
Jr i ozr r r i t r t
I
r r t i i t ' r r . l , . i t t t i l r l r , l , r ( i r r ' r ' i r t r '
l }r t t r r l
r r r l r r l
1
, I r L r r r i t r t t I I t i l j i r l o ur t l l
; r l l r t r t
I ( i ' ; i t t t I r o t r r I I I l ' r l I t r . : 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 t t l r l r r l r t ( l t r t t t ot i
l r l ct r r r I
| | I I | | | | ) | | i | | (
,
l | | l r - r , | l l r ) zr , Lt l t r r l }| i r t t | t I i r t r 1i I r r I l r ' t l t i l l l r ' ,
l l t t (
l t r r l dl o| i t \ t | | I l (
' \ ' I I r l I I I t
^
l l r '
or l r r ; x"r ' r r ( i i l or : t {r i ( (
) .
l t t
l r l r l r ,
t r l t t t r t pt r l i i l r l l l r t , nt t ' t i nr l t r r l i t t : l r r l r ' : r '
r l , r . : r r l r , f l r r l r r ) nr
( ' l l r r r i l r ' l t l t t r r t t t l
I I i r t t r l t I I i t t t I r l r r r t l o: t t t t r ' , l r ot t l : r l l , r r l l ' l ' l t r )
I I r l r
.
r
,
l : l l r
.
i I r t r r t t I I r t t t l i i r r I i I r r
I
J i I i r r ' I I I I I I I r r l t r ' r t r l , r t , r , r t I r r r t t r r I ot i
l r r r : t l t
r
l r r r t r ' : r
' r
I ' i r r t t t , I ( i . t l r ' : i l t l t Jt l t l t l t t t l t
l i t t t t i
, , r l ' t l , r l , t | I ) | ) I t , | | ) t
l l l l , i t ot i t t l t t t nl t t l , , r : t , , t l , t
. ) t l ) t
t i t ) t u. t .
| ) t t t r r z] t
| r r : r l r '
l r pl . , r r l r r Lr r l r , r l r ! l l , Ll j . l t ! : l r r . r , l l i l r f r t ul t l i t l t r t l t l . ( . , . 1r .
r l , r l l i r i o ! r t
l
r ) ( l l l ( f l l
( .
S i l i (
.
I l l | | l t \ , r . , . 1: t l r \ , r l r ,
l r i kl i i
( l t
i I I i
( ,
I
.
I I r
.
I
.
i I t i , l l l t S l | | l
r t r l r i l r r l . r ' r r i i r . r
r
I r r I
'
i ( i : l ; {, 1) r ' i r r ( ' r r r r l r
| { ( ) r r r r . i . i ot
r l i r r i r
r , . r , ; r l : . , r , s.
r ' r ' i r l
: r ( ' , I I r _ | (
'
( I r r I |
.
r l i l r ) i i - l l i ' r f \ l ) l i r ' i r r r r r zr ( l i l
I r ol t l l r , l , l uki t r sot r , i ! l n' r 1, f i r i u\ r l ) zi r ,
| r "r ' r ' Jr r ' : r I r i , l r i l ) ( ' r l l l l l si r L( j r i r r r r ' : r r
,
r ' r r r r r : r r r r i
f i
l ur ol ( j f nr r , 1 r r i , i 1i r r r r i r r r r r r , r l r , si
r r ( l r ' r i r r i r
l r r l Nl i l , i ci
est t t l t r s( , t l l l nl l t t n: r i obi $l l ui 1 .
'.'
.'l .,\
"
/ ). lI r d,,iJ ic ti r i,le d,i,nantic ii,p tt
tr)
il.jr c
ll 'l'ttlht.cdrile relleaului
;folomotor
apar ca lezultat al leziilii oljcir.ci
1,,rr' (i rrrri
rl i rr coml ti cata sa cal e, fi e peTea uJercl i i i , fi c pe ccrr, c/r,i l i r.l ri ,
l r rri l rl ul
un eti urLi l ot mezeuccfal i ce. Exi sti i " dozd eucnl i tal ,i [i i ti :
.1.)
.l ' ural .i .ti i
' pztpi l ure &saci al .e cu trul burdri de uerl ere, L.l ul rri u.(, :r,
rrtt)r' l (.zi rrri carc afecteaz5, ati t fi brel e pupi l are, ci t qi fi ].l i cl e opti $f,
l )(!
I| :| | (| r.L.rrI l or comun (i ntre reti ni ,, ri i zona d.i nai ntc:I coryi br g;ni cri l ;t,i
, \l ,r' ri , l rr)do fi brel e pupi i at:e se al espart cl e cel e opti ce) i
:t\ I'u'rulilia pu?ile,rd, amaurotici, rezulti, dintr-o leziune tlistraetivii,
,r' rrl )l cl ,i rr l cti nci sau a nervul ui opti c. Se pi erdo rcr,cti a tl i rect:-r, si corr
' . r r , . : , 1: r . l : r
l r Lmi r r i , l n r i mpul sl i mul i i r i i pai t i i ochi ' ] r i i
' f er . l al ,
i r r sr r s, .
l rr
i i r.i rzi i , r' .110(i l r' corLsensua,l i l a sti nrul are; l umi noasti a ochi ul ui ' si ,ni ' rl ,r)$.
I r r llz i.rr rrilo. r.rniLrtorale, rlc obice:i prrpila F"ste dilatati (midriaza arn:ruloticii
),
r r r l l r . l l cr r r l r l r : l t cont odal e est e nor mal .
l r) I' rrroza, pupi l arl ambl i opi c:i apare i n cazuri l e i ]t care l ezi uni l r
rr.l i rrr,i srrrr ,kr' .r' .l ui opti c sl nt i rrcompl etc. Rc:r,cti a l ul i l ar:i l a I' nti rrl
..i . l ..l :' i
5i
p.rrl uri gi t.i , a' ti t cea di rcctri . ci t
6i
cea coi rsensri al d. l n l czi ruri l rr
unrl ;ri l rrl (' , (x)l l l ,ri ncfi i a,
consensual i obl i nuti , pri n si ;i mu1::r,rea ochi rrl rri
ri rrrrl ,s .i rl . rr' r,i nrl a.c rl oci t r.i r,spunsul di rcct l a l urni ni i .
pareza
pupi l
.i i ,
i r | | | | ) | i ( |
|
'
;
r ' i i rr i i rs1, d.sol i si i i u nc-r' ri tel e rctrobul barc, l europati i l e dl abd;i r*,
r r r r r r r l r l i r r l r i l r I l r l r r r gi r , l ' r _
l l i t.i r l (' zi l ' r.rt .i i i krr a,l i rro.tc se g!' tseftc Ia ni vel ul chi asrnoi upti rr.
. : r r r
I r : r r r r I i I ' I . I ' r ' r ) r r r r ( ' r ' , r ' r . l l t r - r ol c pupi l ar e
sl nt pi cr dnt e nunl ai I i ! sl i r ) l I
I r r r
' r I r . r r r i r , ' I i r r r ' | ' r r ' , ' r r ' I ' ' .
i , i l cosl , o cdr r ut i i , l Ycm o heni : l nopsi e i r s{) oi l r t i i
rtr ,' r
l tttl i
i i
l tttpi l trl
h urt..i urt ol tsi ce (rtrxti -,i a hcmi al opsi ci r, :t_ l l ti 1,Vl l
trrr' l , l | , r ' :,r i r r r r i I r r ccrrl l l r.l o trl o
^cl i l srnei
11roduc
o
l r,rral i ri e
yr,pi l u,rd, i n.
,,rtttrtrl , ri ,rtl r hi l (tt)?oftr,l c, i .' i ,i anp co l ezi rl rLi l e l atcral e i l r' chi l srrL.i
l ttttrt rt
l t,rttl i
i r
1ru,yt.i .l ,a.rd,
i .n, ai mpuri l c ui zual c hi naxtl e.
l :
)
l ' rtl tl i i i prtl ti l u,re
Jd,rci
tt,tl bl h,dri tl e uetl are, ca, Ll rmi tt.c i r rrrr()r.
l i . | | I l , r
l , i
l | r r i . r , l r l o
I upi I uc,
r cl spcct i v dr r pl i ce so pl , oduce i f us1}i r i ; i | r , r ,
l r r ol r i r r , r ' r l r r r , i r l t r l r . t {, I : l cxul l l i pul j l a, r .
.
:t) l ' ,rnl i :.i tt. i :t;kr.l .,i l rel l r.t uLui
.l ol omol or
(pupi l a tL: ti p Ar.l .t4 | l i rr
I ' r ' r ' r , r r I r , ' r r r r r r r i . I r ' : r i , r ' i
( r i r ' r i o] r r i r
: r ; r , . f l cxi r .
1t ' r l i l , i r f
r r hr r r i r r i i ( r r , t i i
' r I i r r ' , , r i r
r l r r , , , r r ; I . r r I I r r I r I I i ) .
l ) i sl , l
l l j l of l , r caCl , i ei pupi l Uc pol t t ; r , u 1, ( , ( l . r ) l , ot : ) l ) l , ol r i l l i r ,
, r l ) i r
l ' i ' r . i l t r . r r i l , r r l ; i i vi zi uLl c, , \ I i ozi . r , ( ou r t i , spuns f oar . 1, r , : sl l r l r l l r , l i ' n' r i . r
I
r , r t i , r i l r i zt ) ( xl l i i t sj l l l , l i ( f l t l no cl i ni co oi t r 0 : t cor npani l l zi i i t l t l ol r , l t c i t r r , l t l i r r l r i l
r r , ' r , l r i . r l , : r l : r , l r r r i r r : r . r r , pupi l l l o11 ut 1gcl 1j l r sol i al , i i - qi gr r
f l . cl , i i l nr r r i l l t
1r t r 1r i l 1| r r . ,
i i , t t l r , ' t t t r l l nt t l l l t r l ur l "t t t t i t r s, {. ; 1. ?i - . - 100i ) 1, r I i ' r . i r zr r r . i l . i l , i si l . i l i , r
t t , t r . r i r t r sl r r . r . i r r l l r r l r cs si
; r r r ' : r l i zi c
gt r r r cl l l i
I ni g1l qsi 1, ; 1. ' l r r sl , r r , r l i i L, i r r ci
l ' r '
' r l , r ,
r ' ' . l l r \ , l r l . l : r l r r r r r i r r : r
l r r r r r l , o
l i kr r r l
5i
i r r I I or r r 1I | r , I . l ) r r r , , l l r r l r l r i r r r r r l l l r r r i ,
l r : r ' : r l r / r i r
r z, , l : r l : i : r 11. l l r \ l l l l t i l i l l Qr r ) l r l 0r 0sl , | l r i l l t l , r r r ; t l i i . l . l r r r r r l | l | r , i r . , , ; r zr t t i
, l l t , i r l | l . t i | t | | A| r l t ' l l I i r I I r r
,
r ' I I I r I r r r I r r i I I r I r
,
r
.
I r | . i r r t r | r , sl r i l , r I r {i i , i r r r t r r
i j | r i l l | | t u.
l , r r r r or , l r i r t l : r l r . r i : r l r r r r ol , ( r r ) ( f l r r i l i r l ) l l t f i r l i l cr l , l l l r r r r r i r i : i , i r r ; r t r | , i I i r I , | | | | sI I I
't
It
, , , r r . , t r l t t : r I l l r i l r . . l ) j r ( r l r r r r l r r r r r t l r ' r r zr , r r ' l t t t t l r r r t t t r l o: t , t ; r r l r t t r r l t t l
, l r l r l r ". l , r '
l r t r . z,
t r i , r t t l t t r r l r , , , , 1 , or r l ( r t r t r l t l l r . I r ' : r I r I L t t i . i i l t t {: r l l r r r r ' f r t r r r
, | , : r r ' r ' l r r r i r r f i l t r r r {, i r ' , r t r
1r r t l r l r r L: r . l , r r I r l i l r ' : i
: l r t r r r t l f r ] i , i ci t , ; t l i t t t t t l l t t r ' : t r r l r t r t l t t i
r , r ' l r r l t t t t
l r t ot l t t r r r
r . ot t l l r r r ( t , . l r r t , r t , ,
l r t t l r i ! r t ,
i t r l i r r r l r r u' i I I t i t t i t t I t t l I r or ' l t r t t
, r r r l r t r : i l os i l 1( l l l ( f ( , ( , ( | | | i l i l ( r t I r r : r nr l r r ' I r t
l t t t ; t i l r ' .
l , , r r r r t l k' zi t t t t i i i t t l i i t r t l t ot r r t t I r \ r ' g\ ' l J I i ol r t ' t l sot l r l , r l l i l l l l i i sl i l i r r r or r l t 0
, ,
'
. : r i . i i cr l i ul ( i {' l mai pl i [ uzi l ' i l : r l l r . zi t t t i i i se r l l l i l a t t i l t ' ] t t l r i i i l ot t t t l z, t t l r
J , , ' i r l {' r ( ' l l cxul ui f ot our ot ol ' ,
( i l t ( L( r ) scbi l e l l r r i vcI t r ]
( xr l r t i i i l l t i i
I r ) r l cr i or r r l '
r : r l st t l r sl , r Lt Ll j oi conn$i i por i
l ) {) duct i , l c,
Ci t l t i r , t t t o{i t t i 0 i t t ol l r r r t t l r r i r l r '
,
' '
r r r ot l l i t c- r or r yoi gon, l i , se gi sa, l t e mai vcnt r nl
f i
cst i o r ' cspt ct ' r l i i . I l i r ) z: r ,
r , , i , \ 1' r r 1 i r r l i l r l i l i i , est e
l r odusi n
dc at i l ) gel el f i br ol or
l t Ll pi | r - t l i l r t l ' i t l l , : r t r ' ,
r' , r,obol i trtl de l a regi unea tuberi and, trece i n fatra corrj stu' i i l )osl ,r' r' i orrrl ' .
f i cr(l or{ri r si ngul ari , a refl exul ui l otomotor (si ndrr.,n
' l trl l l l
l i tfurl st,tt
i ,/r, l so porutc i nti l ni i n: tumori mezencefal i ctr, cn(rcti [l i i ,i ' l rrl ' rttgi r,ri ,
,l Lrl x,l
za,l tul tt, poU oencefal i ti
,
-
scl erozi , mtl ti pl i r,, a,l conl i $nr, zrrttrl zrrrrl ' r,t,
r r.l l rl l ,i ,i sl no Orani o-ccrebral e, In acuste ci l zuri fr.rl orl r(.l tl ,r si rrl trrri l rrl l
.r1,.. Ii i ri l , rni ozl i , l i ?i ,ri ca pupJl a si , fi e cxcentl i ci ,
fi
ru)rcgl tl :r1ri , i :rt r' ,i sl rLtrr
rl l r l i ol nNl ,i ' opi ni :i )ste evi dent
;i
rapi cl .
I l )' l ttt [bu, r i i r i L e r eJl el x *l ui . [,a' i ntuneri c
l i cl i l extrl pupi l o-tl i l atator l a i ntul eri c este Inul t rnrl i vttl ttcrrrl ri l i tr
, , , r r ' l i t i i pel ol ogi ce c: , r , ccl pupi l o- const r i ct or I a l unf ni l .
- t \ t nbul o
si t t l r r l r ol i l .
, r r l . zi t r l r i l t : ci i l or comul e f i zual e
$i
pupi l ar e, i nsl pot t i i r ] t t r ' {r r Jr r l r ' ( l i l r ' r ' r l
I l ,.zi urLi l c de trunchi cor,cbr: .
l rr oazri l i n cal e ac1,i vi t2r1n' .1,
pul i l ar' ri a l rl rui ochi osto
(
[ i I r ] i r I r I i t I l L i i i u r
,1,(,l i ri i , r' efi exul consensual l a i ntuneri c, pro\.oni t rl u l i t ccl i l rt' l l , ol l rr,
l ' , , l l l r '
( l onr i r i a
r c&t i vi t at ea p1t ] r i l ar : i i ( semnt t l l ni ) I ar cus
( i t r nr
) .
l t : t r t
,, l rrrl sl i r i i tos este sti mul at qi cdi i l al t este i t,oop(x' i 1, pttl i l rt, ri r' tttrtIo:r:i :r
, ,,orLI,r' r,i ri ,ri nol i nal . DacA se i l umi neazi , oohi ul zrfocl ,rt1,;i ccl i i l :rl l , r' rl r,
, , , 1, r ' r i l i , al l i {r c nr mai o r er , ct i e mi ni mal i l , , 11t r ] Li i , t i de o
( 1i l l l i 1l r ' 1r
st l t pt i t r zr r
,, r, r' . Ai rr.sl semrl a fost doscri s i n neui tel e t' ctrobu.l ,l rur?.
llll '1.'t
tlln r,rd,r il.e rel'l,eltnllLi. de a,ptt'opierc (tlc ul:trnndlrc
)
.\l l ol i l L' ;L
j zol l l t:i
l pupi l ooonstri ol i ei l l
l tl i vi tt' tt
aprtl tl trr
/si rr/torrr
l nttl l IJri *:r' !totL i tn:r:rsu.l ,
)
a fos1, ti esori si i i l I ol t(xfl l i rl i i rl ,
(,1)i ([(' ttri (j ai rti i tt
r' r r r r r l i sr ) t| r
(i l t,]i i o]l {r
cl t i ntel esat' o1l ol ' bi tci .
NV) l rl r rrl i ri
Tnrpi l .uri :
l on,i cc
; , i t r r l r r ; i r ; r t l pupi l ci l r ol r i cr : col t sLi i n: t l i t l t ' i l l zi L, t cl i l t >. l i t Lt t nur l ot sl l t b,
, " l r ' : r c{j i i
l ) l l i ) i l ui l ,
kt r t i i , i t r 1; i t i r pt t l r t t l l r i xt t l t t i l l o l t pt r t l t i t r l r ; i i l t t l l r t t t ' r i r i
! | r r ' ( ) I l | ( ) ( I i I J r ' .
; l r i
( l ( , s( . r ' i s
l ni . l i yr u, r i t l c t r t ] r t i 0
Tt r t , l t i l u. r t i
t ot r . i . oi t : r t ) ( t t t r , r o{i o i t t l t t
r r r i l r r , l r r r r r i r r i r ( si ' t t t l r ot t t l l l t sNTt l n, t , - P' i t t r )
;
l r ) r r t t car {i o l t r l i l zi l l i r l r r ,
, , , r , r ' ! r ' r l r ( si ndr t ut r l Nur , n. gt r ' ) qi t r ) i nt i t zi t l cl t , sr t , t t i t hr l i t t l t t l i r r , Li t , i I r i ( r r
, l I t r l l r l ! r ) i r r i , ci i ,
r yi
l r r , r , ot t vr , r ' i ; l l 1, i i ( r i nt l r t t wt t , l , l . t t i , ; l r l , i r : su, t . t , t r l l r t i l l r i l l
i , , r
, 1.
i 1r . qr : r l c r l i col c l l c! l , i pt r r i r kr pt t l r i l c 1, ot r i r , t : r t ' pl t ' zi t t l ' i i nui r r l , i l r
, ,
'
l ,
r r r si I r r I I r r r r ' : ' i l i
,
i t r t r l r , t t t r ul r t t t Lr l t i , r r l i sDt t l i ut j l r r pt t I i l l t r ' r j t t l t l t t r t i
r r : , 1. r i r r l l r i r r r l i l r ' , I i c i r r r 1r I l t t t t r ' , l i c r , i ( ' l Jl u' l l i .
, \ i nl t , , , t t t t l l ui l t l i r : ( sr t r . t r l l t r i l l t i t . l . / , l r i l s
)
r ' t r I r l i r r r I r r ,
; r r
l i t t ; , ; r t , r t s; r t ' ol , t t l
r l i pr r l r i l ; i l or r i l i r ,
1i
t I i t r r i t r t t r r t l r r , si r t t i r , l ' r r l i l ( : r t r , l l r r r r , l r r r '
( , r l r x' l n' t t r l i t r l i l i ( , .
l ' r r I r l : r l r r r r i r . : r r l i t t l t i l t l t r r t t t t t l Ar l i l ci r l c t t t r xl r , t r t l r l i l l t , l l r l : i , , r t , | l t t ' r ' I t l t vt ' t t l ,
r r r r r I r : I r ' r ' r r I {s( t "i ,
r l i r r | r r zt l | i ) . l i cl r f ( i r r ,
1r u I i l l r
t ' i i l : t l t t r t i r r : i t l i t | r l : j l j i r xr r r l r , t t
't't
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)I],. I' IT0III]Ii MI] I)I' DIA(i NOSTIC i N PATOLOGIA NIIRVULU] TRIGI,]MI]N
:!.i r. l . Ntvral rtri t l ri ryerrri nal i i
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r , ' t t i l ; r l r
1r : r i r r l r qi l r ' ) ,
cl r r , , t t upi Ar sel i si Opr esct l ( 19i [ ] ) . qe r t ' f et ' i , l : r ,
: r l . | l l , l I r l r ' | | | i | | : r Lr r : 111, 1, i 11| . I 111I 1, "r I t i Dci cr i t er i i : : r ) si nl t
l l al ' oxi st i ce;
l l )
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I , r . r , r . r r I r i I r ' i
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r i r l l l i l r t cl al oI 11) si nt Fr i r i ct l ocal i zi i t c i n t er i t or . i r r l
t r r , ' r ' r r r r r : r l
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l , , r r l r ' r , . l r r i r r r , r r l ol r ' r qi cc) . I ) ut ) i i , {1ser }i
[ i
O] j r escu ( 19i ! ] ) , t l r r cl cr f i i r , r l
, , ' r r r r l r ' , . r i : r r ' r r i l sj t r l r l r ) l l l i ul t ct i o boaJi , , i t n
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, , r - , $t c
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l r r r l i l , , r r , r r l r r l i i i r r l i r l r r ul : r ; r r z; i si r
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( l {r
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, , r r r l r nl r ' i i r r , ( ' \ r ' sct r i si
( r l x' cs( f u,
l 9i f ) ) .
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, , l r i t Ji i t i \ r f i ",
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l , l r l r ' por i l r i l i r r sl r r r l i r r l l r , t l r r i ,
l l t , i r r
r ni . j Joi t ci r
l r ol f cci i or nl r r
r l r ^i r r i r , sl i
l r ( r r ' , r l i r s{.
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I r I ' or I r r r r cI r , I r
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l r r l r r r i : r l r r i r r i r
.
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i l i \ : {, t t r i l r ' r l r l ( . l t l c r r l i
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, 1r
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l i
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f ] pn1nt .
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( 1c( ' l ul r sr l ( ' , ' l l l l l t ( , 1t l l i r r l l I r t r zcr
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l l l , zi l .
l c l ; r l l i r ur r r i i st r r si t t i t l a1r , t I t ' l t t r t t r t t l i r l i i l r ' ( l i ] I
( r l l i i l l t l l l l t r i r r l gi t t vi t r r l r 1r . r ,
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l r t r xl t t r r r
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r r f i i "; r r ' ) sr r r r t , t ul i qnt ( ct t r t . i , t oi i r r ( , , l r t t ! r l | i l r n^l r sl i r l i ( 1( ' ) .
l t , 1 I ' r l nr t i : i i i r
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l , {' f i : t 11r ' r i i l t
r t ot l oul r t ,
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; . ; t .
l t l l t t t t l i . : ; u. l r r t i t l i , , i t l i qt , t l i ci i "
( . l r i r i i , r l i t , l t , qi r
)
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; i
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I f ) , {Tr r r . r al r / nt I l i t t t ul l t r i ] l I i l t r ,
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1r r r 1
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si ; r I r r gi l t t l t t i , t ' r ' r ' : t
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l t t i i ( l i l i ' t t sl t | r ' l i r t l I sl t r t ut r r | t t t
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; i
r l 0 st . r . r | r r . 1r ' l t qt r t | t r l : t t r ,
( sl t t t I l t sr ' i | t t l l r l r r ) l t r
, r r , l Lr i l i r r , i l r l I l t r i r r l i , r ' i r r r . { r . i zr . i r , , r r r
.
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r , t i zr r l r i r r l l t si . i t t l 0r l r 1r ' t l t l r ' l L' ( l ) l r ) 111 . \ ( l t ' i - l '
I ' i {l l l l ) l l r l l l
, 1, l ' , ! r r r i r o j r . r , i r r r cr i , ' t i i , ; r r or l r i r i r
i i
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, , , \ r ' l i r . l : r l i l r ' I l l l zi l r l l ) i \ l l l t l i i l i l l t t l i l i l l r ' l l ' : ' , i t t t t i t t I t r ol t r r ' , r l ; t t r r '
l r r r | r '
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' i )
Sr ' l t r r ' : t t r t \ t t r \
Ll l l r , t l \ l r f r r l l l r r ' l r '
l , r r : u, . l , r ' t , r [ ' 1t , t l t
nl t l t l i l i r t .
r ' l r t l i r r ' :
: r ' l r "r l Lr / i
'
r
' r l l r
i | l t l l l r c r I r : r
1
r r t I r t r r t r I I r | t ( l ' r "r ' l r r t t t l ' : t i l l ' l 1) l ' i l l '
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1
l l 1t , r : . t t , t r l
l , t r
t , r l , l i t t | r t : ; t r l t t t t "t : i t t t | | | ' t t t t | t l ' t r l l "'
l "' t t i t r r
( r ; t i 1| Lt l "t r ' ,
i r r r r r , i t r l r ' , r l r t , r r l l . t r r zr r t r t r r l l r pl l r , r l r r r ; L I t t r
' '
r r I I r t | | r t I
)
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( l I
i : i r r l r ! ) l | | t r f l t l l r ' r ' l | l .
: : . 1; . 1i " Si l r l r ' {r r nul l ui }l t ' l l i cr ssor r - l l ossr r l l r r l r onst i i r l i r r t l o pt r r . ; r l i zr , ,
l r . i r l i i i r l l i l i u( j l cl r l i ' , a, descl I r i I l I . r ' i r I r ' i , car c sc r ) or ) t c r t ' l r cl r r r t r o r nr i r t i r l l r
, r r i l r r i r r l ( ' r ' r - ul ( | d0 l uni sau ani ( Snl r | r ' r D: r n
; i
l l ent e, 1gt j 6; t i r \ - or n( , r J l J) ( i t | 1.
Ii Iri rrrrrrrL' Irr
l )i l rl l ,l i 1]i cc
se pot i nsoti
do urt si mpl u
,,bl oc
de r:onrl ucci ,t' ., r,u
r rrrrl cl rrl o l oi l rl i i , dl l r cu ocazti a repeti i l .i l or se pot i l rsti r]a
yal i $i l e grl l rrl r.
{l i . rl i rr.r' \.r1r
J)o
l nUsctl atura faCi a,l i ,, Cu pareze rezi cl Ui rl . si cu Col tsl ,(rul i \
(,
, 1r : r r r r r r ' l r r ci l r l c. Apt r e de pr ef er i l t l l a f emei
Si ] a. Ti r sl o t l ai 1i ner , t , t l , r , r l
; r r r r ' : r l i zi r r
l r r i l l el l . Rosel t hal ( 1931, ci t ai j de i l l aver ner , 1969) a l el at at cr r zr r l i
r | | i rr,i rl onl i r l ' utni l i al e. Acest si ndrom se i nsoteste dc cel e mrri nLul l o rtri si
, l , , . , l cr r r r ' n, . r l l r , , l u; r soi l ( . i ct ' , i
, . i . r l r . hr r zel or ' , car . l r of l i bi l ar . . r . : I , . . r . r , , t r . t l , t l
rrrrr| r' rr Ir' 1oi , rfti al drc:i ptl r:i l i zi a fuci :r1[ este Ini l aterr]ri . [-rr rl l r.rri l 0rr
r r upl or r r , ( i i l l e
est e i nst i i nconst ant , es1, e r el r ezer t at r i , , o
i r l j cnl i i i r r l c
r r
l i r r r l r i i ( l i t r l t t r
l ) l i cat u) .
Hal eor i t umcf i er ea f et ei poa: t e sr ' L
l i t ei "ur l i L l r r r r r l i zr : r
l r r , r : r l r r t r r l l t r r i si t u l ni 11e zi l e, per nr i t i nr . l un di agnosl i r . r ct l ospcct i r l ' l , l
\ , r l i r ' , 11, ( i 1) ) .
l .l i .7. Si rrl ronul l ui Xl oobi us este o rar5, afecti utrt, {.(rl geni t{ i i i i 1l (,
, l r r r l or l i c i r r r , : i r r cpl eci zat i l , car e asoci t . , zi i , o
! al . l l l ' zi p
l t Lr xl a i t ni - sau l ) i l : r
l . r ' r r l : r . cr r
l l r l ai i zi i
ocul o: not or i i ( i ndcosebi de abi l ucens) .
:l .l i .l | . Si ndromul l ui l {eerl ord l eprezi nti i , o cor}rl l i cal i e treul okrgi r,:r
:r rrrtrri rhrzci , i rr cnrsrrl cr[ei a poate api rea o p:],]al i zi c faci al i pel i {r,r,i crr
: r r r x i r r l r i r r r yr r r l ot i r l i t r ' i si cu uvci t i i ,
:]..;. I' II0ItLIINIIi J)I' I)IAGNOSTIC IN PATOLOGIA NERVULUI
A(IUSTIC (COCHIEAR)
1.7-1. l rrrr.sl i (l i rti :r srrtni rl l o.r;i c:i 11 l rer\.ul ui acrsti c l u' mi I' cste:
| ) I ' . ' . t r t t t t i t t r r t ' ut r r l nr l i i r t , r r r a st oi r l t l ot , N ut ecl l i i t xt o. nc, : r conr l r r l
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l ; . , 1
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l l ) ?s) .
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,
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; l \ l i l i , f csr i r t , l l ) ?S) .
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l oni t t
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t r . r l : r l ot t . , k. l r r , t r t r or . t r t r . r l i l t r r l ( \ 1l , r ,
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, , , r , l r r l t kr | l t t l t ol t ,
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vr . si i l r t t l r r t . si I t I t ' r ' r ' I t t I . I , t '
:
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' r r : r i
I i l r i c c\ cnpl u.
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1, r i r r
l , ' zi t t t t i l e l abi r l i nt i co, i l l o nr ol ei l or '
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r r i l i , sl i l i l t t r t i g; i nol se sj nt dooscbj l ; r l t ' i r l l , t l nst ' [ l t I r l l t i t r l l i t r 1 r r r i I r
I
i l i
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' , r
, , r ' i , r , , t i l l t , ' gi r : i 1( ) l ' ( t l c ol ) i ( ' ci bi . i at r el al ) ,
gl cr r ' {: l si vr ) r r i r i r t t ( ' t r i ( " l : t . r t t . sr '
t , , , : r l c: r sr ) {, i i !
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I ( )
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pt Ts, i st : r nl l i r i i ul t ; i i Vr l ' l ! r r " I ) r r {r ' l r l i l
t , , l l r l ( 1, i l i i , i 1i i l ezj r r i r i l or si u . ' t r i l xr r r i , ' t . i r i l - . t ' t i 1t i l i r , . , s*. t xi l r ' i l r t l i i
r t l t t . t i , r
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pr obt l c \ ' ( sl , j hl l l i l l t ' l r t ' l t ' t r ' ' t r r l
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( l l l i r r l l ' zi t l l r i : r i i l
( r ' l r 1r ' r r l t "
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pl i l r l i i i 1- ' oi l l Lt zi i , t l o. pt ' r i r r ' 1. r 1i c
t t l cr r r l t ' l Lr '
l r t '
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i 1r ! "i i ) , r i ' l czsazi L r i l , l j r i t r t r t l 1{' ) $1 I ) ( , r ' r r {' si r ' , , 1 r l r . ,
r ' r . , ' , , { i i i l t l t l t : Ll r r u' t . l t onl t r r l r ol t r l r ' , l 1}( i l ) ) '
' (
l l t i . t t i , , ) u t . ' - a: r ar l j l r l r i i i i r ' l r i l t t i l ( l i l r i l
( 111 ; t r t pl t l t t t i t : i t t l L' 1I i r I t I t t ci t I I I
r t t
r , r ' . i cr r r r i i l t '
r i i r i l . q: ni l r l i I t ' l r ' l i t r r Lvel l ' l . , l i l i Lni l l osl i i r , j 1: 1' 1' l ' i l j 11111r t : r ' l r t t r l r t l r "
r oi i l i ' t l r gf l ' t , r l l i , 1' l - i r ) r i i i , 1i r i , hi l r ol t , nzi r ' ; i zi l r t noi r l I t I I t i t I t t I I t I I ' ,
1l I I t t r r i : l
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, r l r i ( r r ( i l r r : l ; i t Li l t i . l l zi i l i l i l {l
( l o( l i l l ( ' 1l I r i r ; i l t f i t ' r ' r - l ' r ' si l t t l t "
l t ) " ol ost , { t ' o' t . L
i }i , l t l ( '
: i l i \ l 1l si l r r }i i t i t r t t t l r | sf i l r r r l l t t '
I
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; j
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Nf . t " i l r : ni . f r : *l i ' , t i t t t t r l i r l i nr : o. : t e i t r r ' t t t l e l t i l i
. gt nt t ' Lt ' l t :
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( j i t l i t : ! d
] l l u( hr ( 1o
l i l ut t i i l t ol t t r l l i r r t t r t l i i i t , r r t r r l '
, 1, , t i i , i Jl r bi r ; l i i l l r r i r I , Sl i l nr l r r r ' , i n: r t r j l ogl ai .
l - . r i l l
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1
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; i
cr - l ci t si l t cl l l r t t l t l i i i i i i ; sol , i r , r ' qi t kr r i r r si l l t l l r t t r l i , l l t l n( ' ! ' i
( \ ' r
r t l i r l
, ' r r l l i l i r cot l si cl t ' t ' i i
, , 1el sr ' ' or l r ' i '
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r r r ' ' ' ( ' : r { Lt l t i l r t r t ' r ' r l i i r r l r i l i l ' r r l r '
, r i i l r r r l l i | i , t , t r l t i l r ol r r r zj 0 r l , ' r r ' r ' , r . Jr l r " l , i l l r 1"l : l j i f i
( ' l l . "- l ( l l r l {i l {r l l l l l , r l l l l i l r l \
r ! L( . r ' onr ! t l l l
I ) l l l sl l l ,
I t ) . I I : r ' 1t , t i t t t t ' i r u r a t t i
( r i al ' ( i ( Lc l l sl l ) t 1' 1l o1l
l ) ( r r r i c
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, , , 1i l r r , , i r r ' 111' 111' 111 Si i t or ' : r
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t , \
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t l t t t t t r r t r i l i r i r l i i t i r , ' t ' t i i gi t t ' l t sr '
'
i \ I t r t l , l i ol t t l , t t . l , at t l t t t t t [ . \ i t r \ Jt i
l xr t
si l t l l l t l l i ' r l t ' i zt ' v<' t l i r l t t r r r : r ' . l ' i 11' 11
, , , , . , r
1, i , i t , nr | t , s, cv0l r t i r r r I i t r
l r l U' el t r l
0t t vaJr t l i l t . l t i pt : r : I l i r r | r r r i r . r ' . l l r : l r ' r ' ] l r \
, , r zr r t i . cl r r i , t ' r t t t i sl i l gl t t {}l t t ' i l l l l l l , - | ol t l ' r r
t l vi t l cr t l i l t o l t i l t r nt l ' l l l ' l i r i l r t i o l r l l r r
, , r r l i ci i I t i I r r I t '
t I t I i i
,
t l t r t r l t i r , t ' i si t r t l l t i r r i i
'
t ) l t r t t Tut xt t t oj i l i r
1i
i t t si i t r r l t ' r ' a r l l 8l I t Nt t t o. l i l . i t t .
. 1t ( l t t o| t t t (
: t t
l t t t l
' , , i r l t r i
i t t l . sr i r t t , , , , i i i l i ' *1i i l i
' r ' t
l i i - l i t t I r : t t I I ' , i t r s, I i i r r t l t r i t ' sl l r l r i l i l r r i r r l l r r ) t l ' . i i l : r -
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 t i l i l t oi i r l l i t ' r ' ,
( r ( ' l i I 11! ' ,
l ) l l r ( ' r i l ( ' zl l
l r l
r r ( , l r t l r t {. , l t t l n' l l l t f
f !
r i l t l l f i t l l ( r
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l xt pl r l : r l r '
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1i
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,
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I
l \ l r l , ' r , g( 1' , t 1) i sl ) - l i l i l . r . i , t i ( , '
( l l l i l - i ) r , <, l r r l r ' ; r z: r . r ' r r , r 1r . . r ' i l r , r l r . l r , . : r l . t i . r r
1, , , i
' , , ui , t , ' , r , 11, ,
r ' r l r i pct l , , r r . r l r r l r i l i l r r i r . t r . sl , i l r r t l : r l r i ,
r ' r ' t osi r r r i l : r I r ' i I I r t I r I I i I i ,
1. , r , ; ' , : r ' i i r i i t , i , , , t , , ' l t , ' r ' , ' r cr l r l r t r l o r | i ' r ' I : t Li r I r t l i
( i r l l r f ' l ) ( l l , t l i l t t r i t zt t t i ' r ' l l . r r
1, . , , r , r I L, JI r r , , ' I I r , ' r r r r : r , Jr or r l r ,
: r r . i r l r r l l r r r , . r . l r i Pcl l ol l l r l l r l l l i l r
l r l l i l l t l r '
rt!
t 0$
s).
N e,fritele_. cronica (trtritr rkrzrxrhililrrele hidro-clcctrolitico ou rc.pc[.
cnsi ul ti cFl
Dra
l i chi del or orral ol i l nfl ,i oo qi pri n hemoragi i l o l abi ri rrti ce)l xl t
rri rlrrl,trllrine crize vertiginoase, urroori de tip rndnidriforrn.
lt) llt,iirile. alergice
.prodttc,
adesea
$i
leziuni ale urechii intcrno,
cU
rti sl rtrol ,i i l abi ri rrti ce qi m:r,ni festi ,ri verti gi noase (Wi l l i ams, 1056, oi l nt
rL' 1!l i kr;oscu, 1978).
ll) It'orme particulara d,e aertij 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,&roMstic
d,in
,,rdul
d,e ma,re1' se traduce printr-o simpto.
r r rrl 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
l or r sr ' r ' t t . i vc t angaj ul ui pr odus pe mar ea r gi l aLi . . Apar j t i a cr i zel or ' r l o
l rrl l ,i ,j rl i rr ri ,ul de mare a fost cxpl i cati i pri n fenomene hi drodi rrami co do
rlr'lrlrrsrutr lrruta,Li a lichidului eldolimfiltic, aare tuctiolteazi, asupra ftl)fl.
nrt,rrl rri otol i ti c. Yerti j ul di n ri ul t1c mare se i nsol e;te qi de hi potonsi ur0
rr.r' l rrl i rr,l i , grel rul i , vti rsi i turi , hi persal i vahi e,._di aree gi transpi rafi i rcci
6l
ri r, oJri coi oodeazi l , dupi i , i ncei area exci ta!i i l ox de ci l Ltori e.
b) ll utij,al. d,!,n
,,rd,u]
de at:ionl'apare ca
;i
riiul rle mare, la acoloir,rll
l rrl ,r,grl i i rl o i ndi vi zi $ensi bi l i , traduci ndu-se pri n verti j pr,roxi sti c si l l .gl rl r,
si r,tr l ri ooi l l ,i ;
(,tl
i tl te semne vesti bul are. In cazul zborul ui cu ayi onul mai DotJ
rrl l ' rrt,rr urrrrol i scnza&i i bru$te de verti j , i nsol i te de durere :r,uri cul u,t rl ,
i rrl ,r,rr|ri
ryi
rl Lr srr|tl i tato uni - sau bi l ateral S,, pri n rl ,ero-oti t5, l a i ndi vi zi i cu
r r r i r r l l l l r i r r I I ni l i t 1, ( ' r al ( l ?i quet qi Pi quet , 1965, ci t at i de St oi ca, 19?B) .
.
I'J.. ,4tkt.
.lo'tna
d.e.. Dertij
,.labirintic:.
vertijul de ascensor, vert,ijrrl
I ) ' l ' ul hur i t r i l . u l ) i l \t,l burrfu i h naurot)ol l nl l ,l M ol i nntol ar,i oc po0 i rrrl rl i r:t l n ooutontt{
rrl i tri f
1i
r rul t r i l osl ,r' 1,r.i vtrr' l i gi rrorr,xr,r, l rrsrr(i l ,rr t.[o rrrul l o ori rLt zgornol ,rl rrrrti 1111. ori r[rr zgurrurl ,o rr,rrri ou.
Lrr.c
5i
rkl i ,ul [rul ri t' i do ocl ti l i l rrrr, (11,
l l nni tro i L l trror Iti pot' c.soi trtbi l i ti l
fl
l i r l ri l i t t l i ctr (ovi tl cn!i tt bi l e l :l prrrl ri r, ur l ol i oi i ,).
rlrllrrrrinnl; rlo unornaliilc rle retraclie (astigmatism, hipcrmetropie, mioflo
rrl,c,), vcrl,i.iul onlcl)t,i:rl, vertiiul inotitor.ilor. Ultimele slni, in roalitui o.
ol ,c,), vcrl ,i .i ul onl cl )1,i :rl , verti j ul i no
l ' , r l r u. r , r r r l , i . i c.
lil.
,,1,'ttlsol,o
wrtija't sint amefeli in infelesul cei mai trannl gl
l uyi t t l , t t l t t i :
rr,) fi r,l ttr:l o
I r nt l i ut t ' t l i i l o
b) l ' l l st*r
r r pi l ol t si o
I
o) llrlsolo vcrtijo ds origine psihici, (indeosebi din std,rile fobice):
_voltije
de. origine c:i,rdio-vasculari, (boala Arla,ln-Stokotr,
sinuzale, aritmiile, tahicardiile, stenozclo aortict, eic.):
vr*tije din unele sti,ri prodrornalc ale anumitor crizo d0
r[)..1)r.r,l,solo vertij_e do carzd, oculnrl
din
tllburii,rile do rofraofie,
grul rrJi zi i u,l o rnuqchi l or' ocul ari , l a, i ndi vi zi i cal e poartl l onti l o
prrrrzrl l ,orl ru vi ci ul ui ds rcfrl c{,i e q,a.)
;
c) I'u,lstrkr vortijo dupii hiperventilalie
;
f) tu,lsrrle vorti;ic prin tulburriri de statici, (a,st,ilzo-a,bnz ice -
ttr l ,ul btrrl l ,ri l c tl o <:oordonaro de natur5, cersbol oa,si i ):
in unolo
ncC0l 0l .
ln tftboa,
g) faholo vortijo
(lin
st5,rilo hipoglicemico
{i
din hipomeflocbivitatol
sino crrrotidifl,nli, (l' opovioiu tii colab,, 1.978; Popoviciu gi Pasou, 1081).
2.8,i,2, Munfeak\riIt oarl,'i
11iru'a'x
rt
molo rotrolahrinlin|
)
B\nl:' pro(luse (lc
(thoot[, (prlntr-un prooott do norritifi
[06
ila orillina wstibulatlt (d,in
tind,roq,
sufsrin|ia ugfvIlrrl
yostibul&r,
rl0
stlu do notuolr&tlo), .lio ilrlI root{,
mi opi o
rlitrrl o,
l r t r i r ur r ur ' l ( l t l i t t
1u' oot ' l i o
t [ o vt l ci t t i l hr l o: t , t t t t t
l r t r r gi t l
t t i , ci t r l t l r i t r t r ( r l ' ( i . ) ,
l l ' ( r 1
t i r r ( \ i l , Jl ( ' t ' vl r l ui vcx( , i bt . t l ar
l i or r l l , r i r yi
t l ot i t t r t r i t ' ca, t l o
, , si t t t l t t l l r t
r ol , r ol : t l t i t ' i t t l i t r t ' .
I
'ur
liaul ar il,d!,i stmiologice:
V tti
j ul aesti bul atr ( denumi t
Si .
rel ' rol al ti ri nti .c
J
oste tnai
l ttl {i tt
i ttl l tts,
rrrri pul i ri zgomotos
fi
rnai puti n cal actcl i sti o drxri t crrl l al ti ri ttfi c. I' ort1r'
rrrsi i , si , ai b5 un caracter
pa,roxi sti c, de 1;i p rndni <)l i fol mr ol l
(!\l c(' t' Jri l ri
l rl
r,ri l cri ri l c capul ui . I)urata accstui vcl ti j vesti bul tl r (qi a si trpl ,otttcl ot rrsrr
,ri rrl c) cste vari abi l X, i n functi et de natul a fa' cl ,orul rti et' i ttl ttgl i c, crtt tl rr
' rl ri cci
antrcneazi , o hi poexci tabi l i l ,ato sau chi ttr o i rtcxci i abi l i l l tl rr vcsl i
' , r . l r r t
i l t l e par l or l qzal i .
J! osib ili.t d,!i
7t
al, ol og ie e :
A
)
N etri tel a aesti bul arc i nfaJi octse (l ues secundar
$i
ttrl ,i ar,
Irrtl oI,i rIi Li i
,
l ri dcmi ci i ,,
herpes zostcr, febr5. ti foi dri , ti fos cx:urtomal ,i c, In(rti l rgi l i
l ol t#rospi nal i mi crobi an[, meui ngi l j c vi roti ce, mcni ugi tc tul tt' tctti ortsr' ,
ri pi i , di fteri e, mal ari e, ruj eol i , brucel ozl i etc.), I)etal i cm rl ol tr ci l ' r,r' rr ;
^)
Neurita ustibulard si.filiticd' (satt neurolabirinl,itu l'uetiad'
),
I'tl, nni
,r l i i n ul ti mi i ani , cste
produs:i pri n mecani smc dc rrre
j ugo-vi rsoul l
l ' i l fi
rrr stadi i l e secundare
$i
tor' l i ruc al e bol i i
Si
oste car:l ctori zatti pri tr vt,r' l ,i i l
,1,,
l rl are Yi ol en{5,, crr eri &ccrbl ri l a mi Eci ' r' i l e oapul ui , ol r hi po:l ( uzi c
f
i
' ,l l
q,rrri l uri i n urechi . Pe l i ngi l l i sta-gmus qi rl cvi al i a bral cl or, se ovi (l (,l r
l
i r z.ri
, ' l t i poe: ci t abi l i t al c vcsl i b l ar i .
I:) Meni ngoneuri fut oesti bul ard, u,rl i di td' sc pro{l uce l l r l l )roxi l }nl i \
l , -10 zi l e cl e l a a,par:i ti a pa.rot,i tl i tei cpi dcmi ctt, asoci i nrl tt' sr' rn,\rl i ri
(l
tczi une concomi tenl ,i , a faci al ul ui , e\' cntual si :r' i tl tor' l rcr.vi cl l |rri {rtl i .
'
trr,ni festi ri l s vesti buJaa' e, uncori bruta.l e, si n1, docl i nn$al ,e
l ri rt
l czi rttti rrrrvl i
l , co, rneni ngeal e, precum
Di
pl i n r:dtl m consccut,i v tl ot' cgl i i ri l ol ci rrrrrl rrl ol i i
lrrriferice
intraiabilintice. Se realizcazzi astifel utl sintlronr tlirl coclrlco
'
r' sl ,i bul ar, care debuteazi l pri n acufeno, hi poa' cuzi c gi rna i fost,i l i \,(' sl i -
l rrrl nre,
Il i poacuzi a poate l i uni - sau bi l ateral i i , de ti p percel l l i e, cu ovol u{,i ,.
l rrl ri rl i i ,, uneori pi ni l a sul di tate (uneori defi ni ti vl , al l ;oori t' oversi bi l i , orl rrl i
(.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, od a,1,[ cu il,1)l,t'it,ir,
rrr[pti ei , i n contextul scmi ol ogi c al unui Fi ndrom vesti bul ar aru)()]ri oH,
rrrr duratii de 3*8 zile. Se poate asocia o hipoacuzie do pcrccpl,io, rldrli{cir,
,,r' ol uti v5,r pi ni i l a sural i tate total i ,
$i
defi ni ti vS. Unoori , i nstr, si nrl ronrrrl
vrl sti bul ar este foal ttl di scret, cu ame.fel i moderate, pc pri nl pl an si l ,utudrr-sc
rllt]o simptomc ale herpcsului zost'er cefalic'
dJ Sdndromul l,ui, V ogt- I{oy unagi, vorosimil dc originr: virol,icri, tsrr-
r, ilr,z6, I ncvritl'i, oochlco-vostibularli, (cu sualitate qi crizc verl,igiJlol,so),
uvoit[ l)ilatoreltr, vitiligo' rrloleoio
5i
polioztr.
a\ Si nd,romuL l ,u,t Il arada, fourtc ri l ,r, tot tl e l a,tuni vi rol ;i cl , ol [.rr
t,Boml un[tot cu
I)t' $ft{l ol tl ,ul ,
rntxl i i ttd i l t pl us qi dt)t{l i l l i rr:
(l o
r(11,i }rI.
I\ Il teni nl l o-net.nt-hrtrcnl rnal t,
.l r' ri tl l l (l (!
l ' rt' t:vtrttl .o i rr rrnck'
f[ri ,
sn
tr.rrrl tr0 TLi n Sl nthom ooohl oo-vrtt' l ,i l )l l l l tr, ct' l ttttt' i tttl t' uol l , ttxttci rtl ou l czhrrri
rl rl l ti nl o do rrorvi ofttol ortl
El
ou Sotnl l o tl c pol i rml i ctt l otrcvl i l [ 1,tl oroa, orr
si nrl rri rrr l i ol ri di uu do l l n Oul l l l ,l n' l tu' r' r{.
107
,r{. ri ,,,r,,,.i ,,,2:,
,ri ,, i ,i .* ,; ,i ,, i l l i l l ,,,l ,,,i ;i l :i l ;i l ,i l ' l ,i ;,]]l i ;l l ,,l l ,l );.j ,,;i 1i i ,,,,;
l i
) , \ t , ut . t \ ) ( l i i l r
r ( : t l i l
;.li.r'r l'
rir;ii';illi'lrt*i,ll,,i*-r:,
tilf,"li''j.
rxr iirllriri''iiri
., ,.,,,,:, ,
t' , ;,.,,;;;,;,i ,,.:' ,i q,:i l i l :],,]:l i l .,Il l ,^u;;.;1,' ' ' :1,,
,n,,,r,.r:,, ,. (r,,
, , , , , 1, , i , , , "1i , 1", , 0' ' r' : t ' , : , ' i i , : i :
di n unhrt oi di t rt r
t t r unohi n. , , , t , (t t , i ), t , , \
, t , t l
z,:rri,, rrr, r,,rj^:, i*p"t d"*,1.i.11;::li:"[Jill
iit;l
:,;illi:l;,;l,n:l.
:ll: ,,;,',:i'l","t"""lli,rti;_r,i1i,".9*tbul;Lr
,si ce,r,er,er,j'. ,r"',1'i"i,itin
,iiiri;,l,\
; ; ; ; irt ii;, d;
1;*:*i*|j{{,|"",iti:i,Li;ttr1
iii:,l ili* i
"'i,gi,
., iii, i,,,
;;;rr r,;rl',l,lll',
Jil#3;[*i
#"r#hfif:f
i:.#'tl#!'{i11ifu
f ii-{ r
r
""""i;'i'li;i;;l;i:l';llfj:,ili*",precizate
larse'ri;: ci,rai.lliiii,f
illi,ii:
llt;;,;;*;lll;;;,irij#t#l,i#il""ii'l_;il","#1,ffi
#":ft ;,,'lil',lii
, l;i, llllllruj'*i
;,f;#4;:.,*ri"''#
*t'i.ifr.lllJ pie'os,,.oar
iz,,
,,,r,,i,,
ii,,,i,jii'";,;,:;;i;.'r;;';i',lfr'H;,ii:,";li.iti::.1ll,1.iJj"::-'iogic:1,,r
,ii.y:.'yy1';,i '!',,f
i;iii,lil',11,,'ff:;:{f;iii',,ii*i,i
u;i !lil,l,!:,0{;,,,"u',
,,ebtibt,t.,,,,,
( I t l Dt ( ) r ' i ,
l l r t ) ( , ( , s. , r L| gl r ngj , ai ; 1. ,
,r.
: rr r.,..). r,,,,r,.,,,",,,,,Jtf
l'lii]j.,ii'
{;j}ffi,.'i[1;i$?,#1ilili
. j
r l r \ r t i , r l {) 1, I or l i l >r r l ai . i .
,
,,,
,"i,i,'l,i"ii,'i",fii,
lllfiif,ril,li
ii,:i:,iili:{L:,,!",,i{,'!,,,ii,j,i,i)1,1;1ui,,,
,,,
: l:,;,;,1'l:,',,',li,l',
ll;,,:i'i;1,,?:';,f
3i,.1yt,.1111i,r,,
i;;;;"-;;i
-,Li','*..
iuror zir,, ,i
, i, lr ir i, r, rr i
;
ii
t1t;hfr
*ifr:iitilfl,'iiffi;l
:r i
"ir
i;r r ;, ; r
ll;l;;l , li:l,i;l;l;:",,,;nllfl1ijf,illiiili;ll,..,iili"'J'l,il'1i?;ll,T;
j'i1,"Jii;l,1ll;
';:l;
, , ,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
i l l l ;11' ;l l ;;,' r,:' ",,1;l t;i l i l ,i l i fl ,r,i v,,sri r,rri ,rr1.
1i ;i ;;i ;' .;i ;;i i ;
o(,,1,,,,rr,o,,r,\
i
j
,,1:
,,.. {,\.. ,iroii,i,
,,,iiil..'l;-iiil;l;i,:':lJi,,i:,il;il;lillll:;,;l;j;llll;
,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 : l l f r l l
t t r ' r r r r l l r l r r l
r r r r r r i si 4r l t r r r , i
t , t . , t l i bt t l ( t , t . i r . , , r , , , , r , i ; , i . '
,,,,,r11),,1i,,' ljli;;,' l;l;1' ;;ll,,lllllt' ,1' l' ,;j,ll;iiiljlili;,ilt;,,ii;ll,",Jt,lll;;1,;' ;ill,,i;;,liij
l r r l
l r r l r \ l r ( i r l
1r . i r r I r r ' , r I r r . I r ' i r r r r I ' r I r r r r . r r I : r I r r
l i
' r , r r i r t r i i r r
. f , , , : , . , i i j
i r r l i r r r l . , r r r ' l
l 0l t
r l r t l t t t l u r l r , ot i , : i t t r r ot r r t i l l t l i i st r r t zr t ' l i l l t I t ' I i
'
t t t t I
I
t I t I I i , pr r l r 1t ' l i i ' l i l t sl l t ; ; r ' r r '
i l r ". r r . i sl , i i , r r r l r r t t t t r r i st t l gt nus I oi l l t o vi ol cl r t , .
,,,
Drrci i i tL si ntl romui - vesti bul ar
l i eri ft-T
i o i trt' i hri rrL rl i sl i l rgl rrrrsrtl r' r' i
r,rrrrl a,i
-si /
sau l otator, i n si ndromrd vesti bul i rl de ol l gi l i tl .ctri rl tl i i ' tti sLrg
,rrs.] i si ,c atl esea
,,schi mbl tor
de sens" (a' di ci , bate i n m:ri r' ul ttr tl i t' rrrl ' i i )
ri . i :,
Irl us,
aparc nl stagmusul Yerti cal , care nu so i nti l ncfj l o Iri rIi oti It' i i i i tr
r l l r i i el e peri feri cc.
i , i rr si ndrom' l vesl ,i bul ar central , di recti a ci l deri i corptl l Lti [i t'
l rr.l ri r
i i {,}rrl )i ts rl r cste i nfl uentl ti de schi mbi ri l e de pozi !,i e trl o (r:l ' l uLl i
r ?"n aceste sirrrlroiuile centra'lo se pot remarca nodilicr-lti I t i I I t' I t ' I ' i r I i I
t:r,
;,i ' ,1i ek.
i nstrumental e l ti c hi poexci tabi l i i ate, fi o hi pere\oi tl l bi l i l ' rt l t' )'
' '
i i ' r trcmpl t i n scl eroz:r' i n pl 5' ti , i n ca;re aproape con' strt' tti so i tti ' i l rrrrl l l
,, l r i pr:rc-r:ci tabi l i tate l t toa' te probel e.
1ti Ne dentteazi i , doar nturi l e cri ze aerl i gi noase cu grea!' i r si vr' 1' l ' ri i ' l ' ttti '
(' i rr('
l i ot
l i Incori i nti tni to qi i n unete verti j e central et. ca de pi l d' -l ' i rr ri tr
<llolr-r:iele vasoulare bu.lbo-pnntine
(Wa1lenberg, Geli, R:rynond 1k'r'jlrrrl
r
(:t,-.tan-Chenai s
),
i n scl eroza i n pl xci (uneori )r i n l rnol c cl l fi )ftl l i l (r
(l t!
tIri rLr,i i i cerebral , i n si i ' i ngnbul bi e si i n nneLe ttrmori de fosi t' posttrt tttl t' trr,
r,l rri i l l {,s aturci ' ci nd" i n contextul
' serni ol ogi c
apare q:i o hi port' cuzi tr
(p|i rr
l r.zi ri l i ,i soci al e ak-. tncl ei l or cochl eari ), si tuaJ,i i carc poi pf{:}te' l t[
(j r]1rl :l rzi i
, ri .
rdroamele vcstib'da,re periferice.
i , i n si ndroanel e vesl i bul ar:e central e reacti i l e ni sti l gnrki {)
,,i tt
rl ' rttr'
l , r r i ' , i : ' si nt
r ai e ( Oar vt hor nc qi co1ab. , 1969; l i i ser , 1952) '
- {st l el ,
i t t t r r t zt r l
r,1,",' l i rri i tuturor nucl ei l or r;l )sti bul ari , ni stagmrl snl bai e i n trtrti ttrtti l r'
,l i rl l :ri i . c1a,r krzi ul ea ueci om:i nanti
a rl ui a dj ntre :rccqNi mrcl ci l rtrrrr crr'
' ,' ,' ' i l -i ti ti rgi "i i sul
st' pretl omi ne i ntr-o anuni ti , t' l i }eo!,i e' hi si l rrrr{' i rr rtr
, r' r, i ,ste :r{e"ctat l n si ngrr nutdtl l l vesti bul tl r,
pui ,cm i nti l tti l l l i l l i sl i rsrrrrrrl
,,,r Ir)rnl i l p' .r;' ". Astfef l ezi tnea l ucl eLrl ui l ui ]l ei t' ers
1tt' otti rcu
ttrt tti rl ' rtt1
rru.r o|i zontel r i a.l o l czi une bul bo-ponl ,i nl dteu]l i l l :i 11l l Il l sl i rl l l rrrr I
\ (.i
i ir:11 st.x predominant, reriical, Cintl lezirurilc irilotesc'il zi cott t is ttlrt' pr t;; I t'
I i (,i r i r-, se p-ot i ttti l t-ti di i .erso ti puri de ni stagmus, t1:rt prci l ttrtri r Lr"t' l ol ' t|1r
rr I ri rl rnl tul vorti cal .
;)
E:{i sten{,a, l ezi uni l or t*,l ti bol ^t" oerl tral c osl ,t' l ti ' st:Ll ri
fi Irl i rr
1' ' ,,ti l r,1;1
ri si agmusul ui p,:l dul ai , c:l .l c nn si l i tLti l trttl i e tri ci rl rl l tl l i i i t l czi rr
, ) 11,
j i (rl i f ol i cc.
)l t ' 0t ' me et i {)' pa, l ogex. i ce t l e mani f csNd"ri t : et l i l t i t t ot se ae] t Lrt t l 0:
/ ) I ' arot i snt : h rerl ' i gi t t oasa t l e ori , gi t t t : l xn n' t t l i t : t i ' l ' t t ' Li i r. t l ' cr: rt l t t . rl
t t rt r; i . rl ; i c const l i u
-ssrl "rat i r. t
dc t l t -rsi gut at ri i t , i n t ri t : ; t i i rt i ' t t rl l ' t ri . , r. r' l i l r
, r t r l ' l l ul r r i . {) r l t r i t r al i , i t r r l r l
i l , l {, t i r vol t i j r t l Lt i nr t i r l i i ' t ' i l i r t r t L l l r t t t t t t r t l i r r
, , , r : i ' . r i n l i l sr l scr t zl l r i i l r . l t l i r r : t l l r l i i '
. ' r i
t i c i ot r t i i ( ' ' \ t r r u. r i
; i
( ) 1; i ' r ' r ( 1l l '
l l ) ' r ' : l l
l l i r l l i {- l o t : i t : u. t [ ' ) t o, t i ur t t ! r t r . . i t t nl i t t sr : pol i l r l i l l t i t ni l t r i l l r ' ; t ' i t i \ ' r ] l i ' i i l i r r oi r ' r r '
r ' r , ) l
Lr ( 1l t {x) l i f r i l l r , vt t l i , i t r ) , t l l t t i r r l . i t $t l Ll t i i r t r - o l l r t t z: t l i . l l t r i t t ' si qt t t r t l r l l r
r r r r r Lct s, l t s. r i i t i i i r t t . r ' l l i l r ' ' , 1t ' I I I I ; t i : i i
' i i l t t l t l r r ,
i l i f l ' r ) . l l i i
' ' i
i r r l ) r r r ' ' l i . i r l l
' , ,
r , , , t i r ' , t : r ' t ' ot i i t t l i l t t i t t r l t r l l ' i l l t r i r l i r qr t l t l s {l t '
! ' r ) f i
l i r "
: ! ) l / r : r l i i t t l | ) | | t t ) t i | | i i | |
t ] l t "t t i i r ; l dt t , dt r t t i r l i nt l r t ' r l r r / r t t i i Vl r ' l i . i t l l
I '
r , r r i r l i . t r i , l t r i i t i l i r t t r r . r ' i l l , ' l r l i
i r
' t 1' r ' l l
( ) I ) l i l i ! r I j r ' ( ' r r r l l l , i i i t r r l i l ' r ' t st ' l r r
, , r , ' , i , , , t t r r , r i ( . i l r i i r t I i ( , i i '
I
,
I r i l . i | r t i i , l r , t i t ' l r "t l l ' l r t o l r l t l r i l : t t r r i t i I 0t t t t i I r ' t r I I t .
l r : r i i j r r l r r ur t l l l t t t l l l l r i r Li , r ' i l r , l t t t l r l l l t l i . l Ll r r i : l i r r r r l r r l i {i i l l t t t r : t t c l t l r r t t r ' ,
r r i
l r l t ;
l r ' r t i i r r zi l r l i t t r r r t t r l l l l : r l ) Lt i i l i l r l ( r ' i l {l ' / : l l l l l ( l \ l l l l l l l l l r t l i I I ) | | ( I ( ) | | | | I
'
t ' I I I
'
1, , : r i , r , . , , l t r , r l , l | l i , l r t r t r l l t t i i , r l l l l , l l r l l , r l l l r r ) l r ' l i r l l l l l l l f l l r l r l t l l r ' ; r l 1i l l t l r r
, . r r , i r l r r r r
,
r , r I r I I
'
r I ,
'
I r L t r l ! r ' 1, . r \ r ' t l l , {' 1. r ' r r l r . 1' r r r r l t l , t r i r ' r r r 0l : r r ' 1, ' r ' i : r l | r ' l
,,1&,1
t{)11
l r . l r ' . . l ' r , zi Lur . . ( l ' ' 1r ' vi . i r r
r , , i . . l r r t r . , l l t ; l t , l l ) ??, Jl ) l {0; }1r 1xr vi . i r r r i l , i r , s. r r ,
' 8t l
"
:i ) )t si r' i nl tl tbul bi a
)l l i l ,l |i l !,81,!i Ii j (r \ or,l ,i g,i rorso sc pl i trsoi rrzi !
trrl l rn.!
1rr
i rri ,r' si rrrpl ,' rncl o i ni ti al c, pul i rr<l ,,pi i ,rtl t, Ji c' i n cri ze foai l ,o vi ' l *nl r, i ri .
rr r,i ,l L(,ul r l l ur ufoal c, aproapc i ol dcartrra accentuate l a schi rl bi i ri l rr dt
t , dr
r r ' : [ I ,
( . 1] pl l r ur
$r
asocl at ( . cu
j ul bul i r i
de ec] i l i br r .
I
)
I )t lt ttconert arfte tulbu{rile vestibu,lare apar in pesi;e
90}i, rlirr
,rrzrrri , r rri l ni l rl sti ndu-se
sub forrua unor cri ze verti gi noasg cu ahuri ' rntt-
rri l l i l i rl rrri l ,
i !.speci ai i n cursul .py.seul i l or evoj hti ve
-al e
scl erozei ruul ti pl c,
, . 1: "r ' , r r r r r . l , r i
, . Li ar ca sj mpl o. nl e. i ni l i al o.
Cr i zej c vi ol eni c. br . u1r t , . , sj ; , i r r Lr r , .
\ |
, r r , , t r l l I I S I I |
' . St c.
DUi t l or a[ , de oj Jj cei ol i zot t al ; i schi mbi l r r 1' r l o. oUs,
r I i | | | r I r r . r ) | | si 1( , . t 1( . , 1 st u | ot al or .
i nso{i 1 dc l ul bur i r i dc ocbi l j br r r .
Ur : cot , j ,
rl rrl .r,i tr' i rruci par.eze
ci e ooul omotor ci tern, putern
constata un
' i stagri rni
r l j ri or.i i t,l t rtol tri cul at,
,, ,f.) ,l
,..l tgc. oetu|l el c sp_i tao-eerebel oase pi erra_Xl arte,
L]t, boal e l xti ,
I t u\t! t, rh .:t
,1.n
di .' , rstl c
Jut' ne
de al toJi i cerebel octsr puD apj rca accc,.^ Tei ti _
.
' ' r ) : r , \ {'
t | . cl or l - t nt c.
cl t dur aLc dc l a {. i t or a mi nut c
I i ni
l a ci t cr i . i , zi l t . ,
ir,rioqlriLlo olt ttaxie ccrebeloasii,
D-i
cu nistagmus,
cao",
-,1"
obicei, eiito oril
, , t r l : - 1, l , i b. {r . r ' , r i
i i
l cnt , pct bi si j nd
si i nr i e g, i zel c
i cr t i si uoo- i .
p, ot
"t , ,
, i | l ' , r ' r { { . , . 1 I oi r t u] l i si t r l r or nl {l , l e, . dar
de mu_l i c ot . i i l r al a J hi l r er | xci f abi l i _
l rLl (1,
l )l l ,i l d
fi :u.ni za ohi ar unpl e i ndi cat. cl e di agnosti c prec6ae
l a adtl i ,i i
l rr(' r i
r
i r' (' si rn],ti omai ,i ci
di n fami l i a rerfi ecti vi (Fh
cox' si L"i *tl
-i gi l ;i .
.
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 r rrri( ) (i'iiri tr,pt'oape totdea.una de tulburi,ri cle echilibru, nirtagmu s d'izont,o:
: r t ; r , l ot
, <i
\
' , r l i ( , i r l ,
\ ' i . t si i Lul i ,
semne Cn! . pbcl oase, di vcr se i *Lnnc de t l i r r _r r Li
,' rr.,)rrl r, ,.(r(.||]
f' ol ,rl ar, ]si
n]al i fegtet,i verti gi noaSe i l ] c,l i ze, tl e obi cei
rL (,|i i ,r|,l I|L{)
si acccnl ,uate de scl i mbi ri Je de p6zi l i e al e capul ui . Se I;rri tt
r'\ i(l('rtiii, hir,u- st:,' i'excitabiritate
vestibulird t'" p""t
"r.'i".i"""i"ilt,ir",
r r l u r r col i Jr i Jxt acr t zi e.
I'rrr.rrritrlr
ax1;ansive vel.Tiene qi rle ventric'l al lv-lea p'ezi'tii
cel
rruri l qfl r;r,1, i rr contcxtul cl i ni c
6i
i i ndrom,ut l ui Bruns, arr"
""osti
,ti n
' 1. ' 1] l l : : l : : l . i ; . 1
i .
y, l 1
-! r, t . . , , posrurat ", . r-i ol cLrt f i nsori r
dc cri f at cc qi vi r. Jt ul t ,
I r r : Ll ' i r . r ' r l r , . t i r , j ( . hl ml ) j i r ' l c
do pozi i i c
Al e capuI Ui . Bol na. i , , ul i ; i mt . nt i r r r l
, : r. 1, rrl rrrr, , t ri t
1i
I rrri sc{ oda{I cri coi pul
1i n
. , , -60""*
". , l i l "i i -. . i i "i
i "i . , , l t "i _
r r , r , l r , ) .
7
)
N ut,rnnita testibulard
(Dr1
$
Hallpi,le, 1962
;
Cawthorne
$i
colftb.,
l l rt ; 1, ; l \ I i I
'
| .
,
r
' ri
( .
I |
,
I SZg) cupri nde B f orme t l i ni ce :
, ..,::!,.\'::::,,,:!ta
uas,t[bulurd p^ro1triu.-.zi.sd
este o afecl,iuno benignl, cri inoi"
lji. ".t I L l
,
iii!l]9 i$ulte
(30
-5qde_ ani), care interescaid neuronifvestibular.i,
::l: :l.ilill' 1ll;lll.!
$r
i.cr-qenr4,.
Debureazi, brusc prin crize vertiginoaso cri
rr (' ||s||
t"lr,rr.
Irrogrcslvir in citcva ore sau zile, ciup' carc disparc.-Nu luting0
r r i . i r x I r r, I r'i, irl,onsitatea
crizelor Mdniire,
dar qr6bek
".*tii;6;;
(ir..i;;T;
l'l,N
(
l) .virltrnli*zii,
'n
sindrom veslribur'ar cu-rripoexcitibitiitate
de
lar1,*r
rt l i rrrl l r,l ,tl .
_ .
l ,)-
-ryr' i ' r"a,r' i l a
rerti gi ttoasd,
satt tsr.rl i j ul
rpi denti c (Ci rxthurne
5i
r.,rl rr,l r.,
l l l l ; 1, ; Ni r . l s, . r r
; i
. r r l r Lb. ,
ci l . t ( i r i r r l Vi l , r ; , 1scu, ' l C?g)
l t , j or o t . , , s, . , i r r l , i r ' i , i i
r' ;ri n.rl i rrri r' {i ' s .rr rul rru' i rri r' ,' spi .ati ,r.i i
i i l i ",i
"' ,i ;,Ji "r:i trto$ti .?!
t(, Fi .'
, r | | | | r r ' r r I r | ( ' r r r t r r ( r ' r I r ' r ' f r | I i l i . r ' . T' r u' t . r ' i f i c o i r r f cr ' {, i c vi r , t i c, i r ,
l i l r i l l ( r
s, i : "i r
ri rl rr
l rl rri .i ' 1' rzrr,
l i .hi rri l nl i , ri m{ooi ta' ri ,,-
aqa i r,,i t' i n"t-.i .,"i .rr' ,,at
;i
rr,i rrr
l ' r t r I r r r r . r r cr . l : uI i I r . ( l ) r r r nl , T\ r novi l i u
. 5i
r ui l r l l . , I {r Cf
;
l l i f ur ' t i i r , sr , u
r yi
r , ol l l r . ,
l r r {l i r ) . ' l ! r , l r t . r l
r ' r i r i ( ( ' ) . hr i ' r r r
r r : ur r i i i ' r *l i . r i t l . i r ; l i ' , i , , i n, , , - ! i , i : r ul l r ,
r ; . i r . ni t r r r i ,
I t 0
,L' (' l i !l (' {,, i r,i \i r(,11i (:, Bl j xl c sl tl }l i l l u i l :i , ri i , tl o cokr rnl l i rtttl {;tl ttf i , sotrttttr do l l tt' cl l ttrr
ru rl cl vi l or octtl omotori , ott rl i pl ol ri tr.
c) B'inrlromut
Ttseutlontti
tt i i,ri,.lorn.
(aI
.lui .!'iytlty
),
tlr'ii td'ittlttgitr
r,r..tz*ti i . se c*ractdri zc:l zrr, t,r' i rr
i nani tci t;rri ver"l i gi noasc i rrst*l rl ' r' rru' i rl ,
i l ,r,, :m,i nrrti n brul ,al deci b-i n boal a Mdn.i dre.
S
1
VeitlSul paroai'sti'c epiteptia,. tr'orna cea mxi pctent:r' do vtrrli.i
lraroxlsiic
epil'epnii este repr6zedtat:a de criaa tampo,ali' psihoselttoritt'l
.ii
", t ,
. er : ai i e l l e i nel eal , i 3i - r ost ogol i r e
( Ar seni
i i
col ab" 1978; Gr sl ' : ut t l '
r : r ; r r F6Jovi ci u r i col ab. , 1976
i
St oi ca' 1978; Popovi ci u
\ si
Pascu' l ( l i i {) '
ii,,' r
' .
-vd"iijo1
.lueptic
{,oato
il apgl
{ie .sponran
(in cazul cxisl' r' tr1r' i
urrrt
j
octr cl l epl oEetr treoseui t de adti vl , fi e i n mod rel l ex, sub i trl l ttctt(rt
.i ,' nr
"""i t*i i i
' o.si i bul rtu,
care real i zeaza cxacerbrrea paroxi sl i cl :r
l'ocaru-lui.
V erri.iwl' enitepl,r'c
(epiteBsi'a lrestibutogatud'
)
poate fi cliferen{'iat tlo rrllo
tor ruc , l i l i cc
' de ' verti j -
cu
'
al uri paroxi sti ci , (Sl oi ca 1969' 1978
;
.
S:t' gt' t'
, i . ui r b. , f ' gl O; Gast aut , I 973; f opovi ci u
i i
col ab" 1976. ; . Pr i nci Pr ul cl ' r
' i :ti te;i r
de di atti osti c di terpn!i tl , si nt : a) al terarca cunotIi n{er i o) 1l ' Fr' r' rl rrr'
r cr Li i ul ui
( I i e-
i nde
pendent , f i e al t er mndcu al t e si ul pt omc cl i t i cc
( l o ( ' l ' r
i,';"'";;d;rH,-tie ci si buli, in cadrul unei crize epileptice convulsiv.
., i
' ' ul *
g' *o.tri i zat"l : i t cousl abarea anol ral i i l or EEG pr' rori st i l r' ,r' pi
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'
t,r,rle. Astfel, bolnaivii idcedrci, senzalii .le ghalie, alorid.ica,re sau dc loltot il'r''
rlu rle
proiectie in diferitele
pianuri ale spaliu1ui' inso.lite sau nu
(L(!
irrrllr
r,,no
l Ci ostaut,
19?3; Popovi ci u qi col ab., 19?6; Popovi ci u
$i
Pascu' l 1)$o;
| 9E1).
2.f). .PROBLtsMI] DE DIAGNOSTIC IN PATOINGIA NIIRVULUI
GLOSOFARINGIAN
2.9.1. Invcstigaria semiologiei a nervului glosofaringian ilnlrlicri' :
a\ Entrnenwl fwnc! i.ei motorii.: Se celcetcazti'
motilitatca
ptrrcLt'ltti
r,,,tt.r1io"
al tr,rinfetui, tlcglutilia
pentru Folitle' cYcntuala plczettfi a'
.r
rnuLtlui coltiuci tl lui Ycrncf.
It\ Itrnu'menul fitnalict
sanzitiar, &nalizind scn$ibilittte:r' ltorr:ltrltti
t , onl . rri Lr
t l f l ri rrg, l rri
; i
i r, t l rj i Lrr l l nri gd: l l i cnc'
t:,\ lil,t;urnr:rt'rt'L
.[tr'na!iei,
ttr:n:nrialo constii, irr investig&ii1l'
.glsl'ulrti.ltt
t,,,i,nu.' i li
rsii' .i,
' .r,r' il
,r, lim5ii (tltt , s,iu(rio l' u.i,, lrttltr,sobi 1o r:litrinl' t)'
i \ l ' : \ t unul . I unol i r i
ul t et di r i r
( ' ( , t r Hl , i - t i r l l t l t r ct ' i t ' t r ' : t nr t t ' t ' ! i r r i l ) l t r oi ' j t l t \
, 1l r i I o , r : r , r r hi I r . r r r r . r i . l i ' ' i l ul i vr t r ' ; 1) qi r r r r . l l r . xt t l r r i si t l i v$r l r r {' K{' i l i t l l l r gr t Bl , l ! l , r vr .
{\\ lt){.tuLu t,t,t'[ n,llttrlu
turingirvte.
l l I
! . l f . i ! . Novr r r l l l i u
gl osol t t r i t r l ; i r r r r r i . l l i : r gl l r si ' i cr r l
. st
sI r t hi l c, , sl , o pr ^ r ' r i s-
1( , l r f 1[ ul l ot '
l ) r l r ' l , i ot l l l l r i t l i l i r
i t t l t t t r ,
l i r '
( l ( ' {' cl c / r r l
Jt ' ] ' t t t (
cLl t ur e:
l) Nnrrutgia glosoJu'in11i att 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
l rrrl rrrvi i peste 40 tte ani . puti nd i nsi Bl i apar5'
;i
l a ti neri .
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:i trl i rrri tri sau ci fcva 1uni , peri oacl i , va' ri i ntl mul t de l a caz l a caz. Cri zti l rr
rnni l orr(f rl evi n di n ce i n ce mai fl ecvente.
l )l l r' rror debuterzd brusc, vi ol ent, l a baza l i mbi i sau i ntr-o zoni i ' di tt
l ,,i rr rrnri sthl i a ti i . Locnl dureri i maxi mal e se afl i ' i n regi u:rea fari rgi arl i i i
lrrigrrrrli
"inelr-ati,
rle nervnl glosofaringian' I)nrexea qi zonele
"s:i
e tlo
i l rrrl i .r' o si nt sl ,ri ct l ocal i za;te uDi l atel al
(Arsenl
fi
Oprescu. 1979; Dcptui $
| 1l {;8). I,l ' i {rl (son (1963, ci tat de Arseni
$i
Oprescu' 1979).a stahi l i t kl cal i zal err
rl rrr,' i i i i rr l rd. ,o1u?, i n funcl i e de {or:ma cl i ni ci : a) i n
forma
tl ctsi r:d' : l i r'
l rrzrr l i rrrbi i , i n regi unea arni gda,l i ani , cu i racl i eri ^ spre.ti mpan' ruri "l j l l l
rrrrrrrrl i l rrrl rt
6i
l ggi unca submari l ar5:t:J l n.forma
fat' .i ,ngi ani i :
i n regi unci t'
rrliirl(l,rliirnrj, '" r) \tt
fonnu
ti.mpanicii satt' oti.cd: in rcgiunc'a awicrrlari' pro-
l urr(l i l , s:ru nr condl i ctul l utl i ti v exte.rn
;
d) i n mari l e ytatoti sme i l ' ' trcreu'
rr,,rrl ,r' i r' ;rrl i n sj .i n zotre m:ri i l ti nsc, respecti Y rl ai i nferi oaro fa' tl i i ' t1e ccl tl
i ,.l rrl rrl c ttrai i l s
(Arseni
l i
Oprescr, 19?9)' Bol navi i
' "1i (
hel ' eaz5' dl rrorei l
,.rr
j ' i i i rl
tk' oseLti t i l e vi ol ei rtS,
' 5i
de ahoce, l scmui l rl -o cu o
,,l ol i tl r:i i
cl o
|rrl i l ,". .^rtrr soc devtl i c" etc. In rare si t a;l i i , durerea estc apreci ati i ca o
,, ri z,,i i ,. ,[,,
' rl i st' onfot
t
(BoJrm qi Strang, 1962
;
-Bues, -
196ts,
,ci t' a;l i
dtr
' \r' rr,ri i
i l i
()l )r{rsctl , l 9?9). Durata unei ori ze csi e l a debttul bol i i de 20*i l 0
' ,' ,,,rrr,i ,l ,
rl rl r-se nri l ol 1,t odat5, cu cvol nti a bol i i . l ncetarca cl trerl i cst' tr
l rrl , rrl rl . i l rr l :t' tLft,i i ort si d ebul ,ul ci , i ntel ' ]' al eJe i ntel pl }l oxi st-i ce fi i l cl asi tri -
1rIrrrrri rIi tur.
I' t' l i ol i ktl e l i bcrtl i ntru cri zel e du]el oasc r-al ' i ez5, de l a uI bol n:w
i rr rrl l ,rrl , rhr l rr, ci l ,oi ,rt Itri rutte
1ti ni ,
1a ci tevi l orc s:l * Ll i teva, zi l c. Roal a!o:Il ()
, , i , r l r r i i t r
l , t t sct t t ' i
r l t t l t r oast l qi r emi si uni var i abi l e oa dur : i t e ( ca; t
l l t t l '
:I|l ||,1r, t)r,r;r
l rr' I -i atLi ). Cl i zcl o apaT tl c cel e m:ri mul te ori zi ul l . cl tt
,1,' t,,' i ,,' i t i rrs:i si tton,Dtc:t
j n
fazol e al vi nsa,te 2l l o bol i i De asentenea, cl i zt' l tt
;r,
l r.,i ,
r1r' ul )r i i t sl h' t,, care se rel ct,i l a i nterval e de tj mp val i nbi l '
filrthi.liIrtr ilittrtttotl'i,r:t,t.ltti' corect
"d.e
neTralgie glosofaringianri presrlpinl0
rrrrrLrl i r' ,' :r l rol r Lri r.tj l tLi i n ti mpul unei cri zor anl l i za facl ,ori l or caxe determj l l i l '
rrl rrrl i {i rr rl i zci
qi l ocatri zarei zonel or decl artqatoa,r' e
(,,tri gger zones") (Ar-
r , : r r i si {}l r l csct t , 19?9; Popovi ci u
qi Pascu. r 1981) '
Illrriirirol), pacieirtului in timpul crizelor- permite ollscrvarea crisptirii
Ir,tr,i . rr, r rt rr' l :i t i i i ul ol untarc a mi i ni i ta ni vel ul zonei i nferi oare t[ l ti l ei
fi
,rllr. l:r,r'illr.,, sa,u sDre urcche, intrerupexea masticaliei etc' Fenomcrl:lo
r I
'
, , , , r r , , , t , , r
i
i i : . i . r r t l ' l r r '
. "
i se pot mani f t ' st n pt i n i nr oSi r r ' : r homi f ot r ' i
f i
pr i t r
rrsci rci uncrr grrt' i i tl c partca- dul ol i i . In ti rnpul cri zci
-
tl urerorl sc bohrnvj i
F,l ,i rr.
(l (!
rrbi cei , ol i sl trti , cu fnci t:s i mobi l
,si
a' pl ccfl 1i i nai nl ;or pcl l tl ' u l l
l rr, i l i l rr srrrrl g,r' cr snl i vei . l n al te
(i azrl ri r bol navul i qi monti nc cal l ul a' l l ooatt
rrr,rri rrr :r rrrl i i .r:r, nrtts.ttl l l ttra h 1;r' r' txrcrvi cal l i , sn,rt i l i aptrtd, 01 mi na' urochon
i t . r ' , , gr r nt r l ,
l ur l i t l l r gt r , i l l l 1i / sl r t t
r ' : r t t l t l t t l l l l l ( l i 1: i v r ' \ 1' \ r l ) '
Atrtl i zi t, frtol ,ot' i l ot' tl n,trr Irr' ci pi l ,i !
ttprtt' i {' i rr cl i z|l ot rcfi rozi nl i r' o (l l l pi l r
i t r xr t ' l , t t , r r ( i t r L cnl sr r l or r t r r t i t t t i l i i t t t t t l i l r r r l nl t v
( i l t l l r ' vt i l l gi {r gl ono l i l t ' t ' i t t gi i t nt ' [ .
l ) r , , r r l r r l i l i r r i or r l i l
t t t t
' ' , , ,
t "", , t t t l ot t l r l t l i t t t l | ! r l l l l nql t t t r n' t l t ' i zt r l ot ' , l t t HJr t ' t r i : t ' l t l
i i , r t i i , l , ' 1, 1" Dr ' , ' , t r , r l , l , r : t t l 1t t "' r r i
t t r f i i , . ; ' i , t t r t l r t l r r , r Lr gl t t l i f i r r i , r ' r i sl ' i i ' r i i
: r l {i I r r ol ot ' i
, t r r , ,
I r ' , ' , i pi l , t
r t pr r t r ( i r r cr i z, ' l , r l : r r i i t r r r : t i ' t t l i , Hl ' r i i t l t t l , t t l , l t l sr r r t ' r r t t I l r t l ' t t l l t : r sr t l t t i ,
rl , . s, . hi rt r. r, r. , r srr' i r.
r' i . . carr' : r, i l , l l . "i , , ; , . ! ; , ' ' i 1. , i : i l l , "; , i ; 1. ] , ' ; . ' . ""'
r' i . rrrrt l i r
t ' t t rt vrt t t
'
'"
f"l"."ir',llrJ",i]:i:$ri*:"t:i*l,,iiii;li:;li':ltti;,,i;;1,i,;,r'i,,(',rliii,,l
;l:rll#i::*'l#::;l#y#til'itli;*r"*l!tri:,irii:;iir
,t
lflf,
ilrrt::;rx;li
ulr, irri'r
:o
*:i
:tiriril;i, lil
jtr
liri:
; i ; i ; ; ; i ; ; ral r"nducl rrl
: ' l di t ; i ' ct t ' r' r'
-' i
rcsi uncr
mt t -' r
[:4tkly;l
*:l
:;
ir *nl'';:
;l::
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lo:
:'jl'I| i:;'
l''I
'II
I : Ii
, , i l i L.
"t n; oi
t i o' or "n ol r t ' i ngol ogi cc '
-"'
s-,,n rles'is caz*i
*'t;n#:
r:i",.#*r:":il,i:!i:il
liii$
*i:iilli::
:ili,:t',tlii*1"'!i?Fi:Li
t"*yil".:ji,."""',f
;iltrui
ji,
d{ 1.}i;r
j[i:i]]
li , i i
l?il"].i*tT;-ti*[:ii".:i!H1':rgil';
p"p"'i.".
;i
e;o]]1"
1e?8 r
rrrrrrrr i. rr
"
'S:ll*:ii);*,""r1,-q,e:Ld,";';?,,:?;.i
ll;1i,T;"#!'::ffij'l;,.'"""""''
1,irl,cr motrorii salr gusia Ye'
;*tlti'{,,j;{,;:i;,^r,.|,0;'il,i,ll;,i,',!l:;i,!:Ililid"iljiili,ll;i
];lj
*T*{ft'"'?l#::tii';tll*'.i:ilr:!"i:l{'rinl;i"'
dc'l rr s :'
l',, rl;ji::l;l -:
:il"
:.'
ll';:::';
ill ; ; lll lll'jil:
l;;;
jlr
;
I ill;l
, , r r , bi i
. i
ur pcr , i . .
. 1,
, , r u' , 1, . "; i ; i . ; '
; , ; - ! : '
^l l : i l l , '
t r r r r t r r i i r ' r r l i r r ' '
r "
"r ' '
;*:*l**i'lr-i*rli
1r
iiri,i i1
iil'In*?im
J-$Sr:;l
i*;lii;i, (?"
:,*iT xlT*i$:1;'":"'"""1';;liti:iliii'li;;ii;
\s
l,lq:";lrihi{",,$ff
lff
:{ii?fr'{h-itffTfr
iihi#hiili'"H::*;:*$#,*u!'*;d'i-1*
il
I
I
/
-'nii'fifiTJ,:iij'lyli:'iil,',*':*,:'';,'',1"{fiiJ'i';
ltiLi':iil;tii,:lit"ir,il,i
rt sind'r om,ttl nel"D'u|Il't
LarN1
", "i
1r.#:i ;iiin;i
j
g
i
"irf
;
g
ili
q*iTl::d
iilliilil,;,
i,,iri ii
::r',,lnl,l
l,
l'flllil'ii
il ll
l,.)/'li,{t,ill,i],:fi*il,,r*
iifr ,t:frin
tlll,
r k' r k' gl r r l , i {, i l '
sl r l i vci 1i
l r l t i t t t
;i::[tl,llil"'
llil;i: lll,; lll:l;',;;1
";;i lll;l
l'll],':iii
lniil"
",'ri',flllJi
, i , . "i t t , ' , f i t ' , , ' , , ,
t 1111"1: ""r r i '
r r l r r {r l r l : r ' - l t t f r l i r
r ; i l r l l l F( 1
- r
f l i
l r ' r r ' l l el ' 1
t f r , v*r . X
r ' ' '
I r i
' ' r r , ,
I \ , , l t ' t , r ' I I:t
, 16
, , i i | I t I Jl i i , ' r
l ) t l l , r , l t oi l i r ! v: t l t i l l l , r , . Hl t t ( l t . r I r I l uI I , sl , ( ! (
1
(
) I t I t ) I
( ,
I , i t , l , r Lt u l , t r i _i r r cl t i t r -
1( ' : t , Ni r ' . l r s: u( i i | nl . o vi or ( f r , r ' , r sr r r , r i r r r i r r r i , ( l u
t l $ur i nt i r o novr ' t l r gi L\ gl ( ] sol r ! -
1, , . i t f l l , l l i
\ i ,
I oNl l t ' oI i v, t r r r l i r : {i r r r r r , t : r r i gi r r , l i . bo s, : r nu dc t l i agnost , i o cst 0
r l r || ,' r' (.. r,.
.l )r' r.,vor.i i tr-r,
i n_ puncl ul
l l l ri rrgrrl rri superi or, adi cd, i ntre ci }nu] car1,i -
r:tjr rr' Lrn ( 1.[
fr
osul l]roi.l. lloba rlccisivd este alcoolizarea nrvului, cr,r,o
l ' l ||rl |rr rl tl l erca,.
Uneori se constal ,ti asoci erea si ndromul ui l ari ngri tri
rrpcliur'
ou sindromul cle ganglion
sfenopalatin.
I I
)
Neuralgia glosofuringianii
secund,ard (simptomatici)
. .. ):.1.1..:l*l
g]os.ofaringir,ni, s^eoundari, se d.eosebegte ctini,c d,e aea, primari,
t ' r ' t r i n : r L( , al ' ct e el emnnt e: &) f ond dr r r er os cont i nuu, pe cal e se supr opul l
'
Ii .i ,r:r,rl r.
r.[rrrcroasc- pr,ro\i sbi ce:
Lr) tl urol qa, nrr at i dqi
-
i ntcnsi t ateb, dctci
, | | | | . r , ' \ l : l l gl l l pnmr f l r : c) dul er ca so . l ocal i zeazi i apr oaDc t or cl pauna i t r
,:.,,
1' 11 l j ^,pro.,l y-dc-
al . g-i bul i . crr i radi eri r,uri cutare si frr:r,ndi bul *r.e; rt.1
, , ' , . ' , l r \ t : Lt , i
l t i po- cal r t nr st ozi : l l oj i i . ami gdal i enc- si a r ngi uni i f ar l ngi e' n, . :
r') r'ris1;i
5i
semne de afectare lsociatd ii trunchi.tui
-
dotor ar neryuru i
rl l osofrrl i i rgi an; f) se a,soci aza qi semne di n partea
al tor nervi crani cni
rr\ (
r,rrrl r; g) sc constati , exti ndel ea ari ei durcrol se peste
l i mi tel e anato-
"
, ,.
j ,;1l
,l l :.1I"]!i
gl ooof*r
i ngi a o
;
h ) evotur i a cs[e progrfsi vi ,
cu agrav:]r(,rr,
. |
'
\.r rl ,t.r.r' ' ":l i
r' :l pl d:i r si mpl omat ol ogi oi , fdri rcmi si uni .
l | l , . r r r r t i L
unor l or r np l l . i pi ce. si
i ncompl et c l j , dcb t , si r npt oma{ ol ogi r r ,
t , , t r : r l r i ' i gl osOl al i ngi pnC
r ecundar . r ' eSLe dc cel e mai *r , Lt " OI
j
SuJi Ci r . l l i i
r r | , i r ' l : r cl ( ' 1
l st , l Cu. l \ l UI f e t ot me r l p nevr al gi e gl OSOf a
r . i ngi ani 1 S{. Cundr ui .
prri i rrsi rl cbuta cu tabl ou cJi ni c rl e ncvrai gi e
1l ;i m;r;. i ;i " aceste moti v(!
11r rrl)11'r.i tz.'t cii orice ,er'ralgic glosofaria-ngidnJ,
irebuic consirlerati, rlo
l l r r , , ' ' (
1. ' r l l
1
. r
l nl ynr l ar ; , r i
n, r mzr i dr r pi ef ect uCr ea
i n\ . obI
j o: ]
I . i i l or par acl i ni t , , .
r
' | | )
| , t ' r ' r . : t Ul nr l ( . zUl l . bc r t eqaf i \ o o vom cOnSi dr . r * pr . j mi t , i v; ,
('ttu,xclc
acle mai ft ccvenJe aie rrcwalgiei gloso{aririgiene
secun{larlr
..' ,::.1 .:.."\ .t"".' :t:!j ' :"^:l J !7l i l t
i l P t./r bazei .cto rti ul ai
l i uai
al ei ,;1";"
-pi ' ;";
.i ,'
tl l ..(.' i l ,l r'
,{,Un..r' rnol rfl ngc);
b) tr&umdl i smel e
crani ene
i c\ arahnoi d,i tel e cen:-
r)ttrt: () t(,tt,crce 7unrcti : meni ngi oame,
neuri noani e
: e\ anel )ti sme ul r\
|rr,r' rrIi rIr,i (j l ,l runc
i
t) i ,nfec,ti i l ocai e, i ndeosebi ami gda,i i e;e
etc.
I II
)
N eualgiu glosofaringiand,
,,Junc!,ionald,, (simpatalgia)
,\r,r':r,stii, llormd, d.e ne\Tc,lgie glosofaringiani,
se caracterizeazd,
mirr
r I rr!.r r cr r ritt,totjer cle arsur:i, 1.1 b:r,za limbii si in regiulea
trUgq"ii*ei'
ai,
r,ir,rlr{.r,{' rll}ro trompa lui Eustachio, spre ur-echea foedie, oar
Dl
spre alto
zr rr.r (
ir'o depii,qesc teritoriul nervuluiglosofaringian.
Std,rea dd dii;;i;;i;
:t, l r.l trLvi l rl r[r.vi uo
mai prosnant:L
i n-1i frp-u] cl egti l t,i l i ei -.. i n
Soi ;' .
-ti l i di ;
l ' l r r : r . r i i : ur r i r r r pr csi n unui "cor p si r {i n. ' Di n , 1; ; ; ; ; ; ; c, cesl , i n: }ci {! nt . i
Ir|' r' rrrrri r sl ,l Lsnl t' trl tr-ogl enc r,U LUSC. rn i neerCxri l e l or de a Cl i mi l a l .co"nri t
rri,r' riirr)' ..fi.,za!ia
do arsur.X se-.asociazi
O"-rii"ti" *i
""
;;;ilriili""1i
l'1.'1,'j:.l,,i.ll,lli._u-tii,,care
nu po_f fi.obiectivate ra un er"-ui
"du"t
al gusi";;i:
|,r! | r,irt r! ctzrrlrtc se noteinzl ,li rut conte_xt newotic,
care
Joac6 un rol
irtrl)orlrltul; in intrerincrm
clur.erlor.
i,l.9.ll.-Puralizia rrorvului glosoftringian
I,,l,l' rrtizi|, nurvului
uk,*"1:11_iilti,l.r= so
-m.r,nifesti1
l)rir: disfagio ponNru
i tl i trtc[1,o i l o]i rl o ; tr:l ftl l i zi ru rnr
0i,,,,,",;*,,1';;ii,;h,,1:ii',,;iiiiiiliiiilllli';Iill,iil'ilJ'lfffi;,yilliiilll,fl!,lfiii$flllli
t l i l r bi l ,
;l t t.l
. l
) ' l ' ut t , t t , , , t i l " d, f ul l ul i t i ,
1t t t l i t
: ' l i t l ' r "' t r : ' l i l r t i r
'
.
\ r ' r r r r r r r l t | l r r r ' r r
r r r r I r , , t l i t t t l . l ' : r ' t : ul j zi : i , r nr r . ' t i i i r r l r r i l t i t t r ' l t i r ' l ' r t ' 111"
t i r r l r r l | ; r ' t i t t I ' ' I t I i l r l l r ' t l i L' ' : l
'
l ,' t' ,l rtl 5ar' l ra
;ri
dcsfi i qural i cl "'
pl i mrLi rti f i trrl i rtl -tl rrel rri i {i ci
1rt' ttl
l tt rrol i rl i ' l l t'
,,f' ,i i i i i , a"i d,,t.toasi
poato' antr' "n1,
l l l i l ,i urr(l {
r(' rt rul i .trtl ttl rl ttl ' i tr Lt' t i ttc' r"
r,, ,l *r"t i ezi ' ni l or b-i l ateral e at nt' n t,hri gl ostrl u.i n gi l rr, l ,ttl l rtrtri ' ' i l rr rl .
, 1. . : . l r r l i t i . si nl
qr l r e.
S- a sr ' mnal : l l . {Ll ' asf l l ! {' nc1, u l not [ i l i ' i t ' t r ' : t ' l i t r t l ' t t t l t t r
' , i i i i '
i i ' i " , , i o- . l i i i "r t n* aspecl ul ui l : r ' t i nqol ui
1r ' r
' i
cul i o t l c t t ' zot t : ut r l r r \ '
B) Par ut i zi at t i . usel t ' i ul ui cot l sl t t r : t or super i or al Jar i t t gt t ht ' i ' i l ol ; r ' r ' t t t i n: r
, r , . r ' r i J' c, i al . r t l , - " a i : r , r i ng' t ui
] r Lt l t l i z&1 ,
si ' r '
1' al i or L
sJni l l . r r r ' r r f i l ' r l l i r r
' r
. ' us ( sci l i nl ] coI t j U, i l , i ] ui \ / c] ' r cl J) . A. nn\ 1.
( l nl l I i l ) | l , l . c | \ {. I I J: ' {' ' . | | | | | {' i I Z' I
r r , r , r , t ount i a
{onomcl or . ' o" sl ] l l
, r a' ' 5i
Ja or t i t el ea hr i n3' l r : i . r I l r l r : l i l r ' 1'
r
"i ,J' -i i "i i
ai w*e repei i e
p"i n
j i l i oti c:,
coml rnsatori o,, ccl ' r.l ,l l i
rrrrrsrl ri
f,ri ,i i rgi .ti . Rett-exui fai i ngi ai n de partea paral i zatri r csl c cl j rtti l ttt:ti ' si utt i t,l xrl i l .
A) Tul burri ri l e de scttsi bi l i tate l i
senzori al e se cal 1i (rl ei i z{i l z' i
prrrr
t,i poci i ezi e sau anesl ,czi e pe fri ,r i nge
;i
pc
Jre19c3
l onftl i r' rt' ti
:r l i trrl ri i , r' tt
l r i f r sl f l aSuc; i o
1' cnr t t l
at ner , i n 5l ' al
' l {
\ ' l ! l ul I i r r r l l i ' l
Pa,ral i zi i ]c uni l ater' al c sau bi l at(j ]' al e i zol :l te al c nttvl tl ui gl osol ru|i trl l i l ttt
,,i rrt' excepti oaal e, el e i n' ri i ni nc]x se rnai {r' t' cvcnt i npl etttri
(' tr
l rrrr' :l l i zi i
rrl ('
rrcl vi l or i nvcci nai ;i .
2.10. PR0BL,EI|u Du IIIAGN0STIC
i N
patol ttti t,q
Nl i RVl l l ' ,tl l
PNI'UilOGAS1'RIC
2.10.1. Invcsti gel i a serni ol ogi ci a l trvul ui vag (X) i [r}l i tri i ' :
A) Dsanterutl futtcl i e.i
ntotori i somal i rt: consti l i n exattri tl nt tl l tttol ' tl i
r ,ti i vxJui l rai atufrl i
6i
i l a:' i ngel ui , prcturn
5i
a degl ut' i l i oi (pcrrl rrr l i r' l ri rl t' )'
Enanzei t' I si nl i a : vi l ul pal atr:Iui se el ami neazi i ' aprcci i tl dtt i pozi (i ru
r,t,,i ,"i .' "u.ttu"a si si rnetri *, r' i i ul ti , prccum
;i
evcl tu: a 11N1sl i o
1i
cl cttl ' ttrt'
llo iriqc[r' inrl'oluntare velo-palaiile.
Daamenul d' i nanti c: r' om {ace apreci t' 1i *supl a trrol i l i l ' l i l i i i r:ul t' , trr' rl ' i r
r(J.Ltru care se cere bol na,vul ui si r, promrnl ;c al l urri to l roc:rl r' (tt:r' '
' .' I(' ' ' ' )'
i i ."^A"t"t*l U,
"i
l i crnn, vi ' l ul ui r l [etr' nti n]i rri l du,-sc l ' c
l i l ]i r)' l tr(tl i i t' rri i '
tri l ezi uni uni l ateral e se remarci u asi uret.i e a *i ' l uTi , ttt .ttl r' t i rt' l l ' ri :t' tl i
,fi ,"i u"*, i -pr"u"I cu l tctj ar <1e pl rtta sl l rri toasi ' .
l n.1i l l )l ul
(rxl l ttri l l r' i ' r' i
"' , , t i t l t ; t i i ,
s' r . r t l nat t ' i l . t ct ' , ' nl t t l t t l a i Lsi mcl t i ci Lr ' zi t t t t i l c I I i I : r ' i . ' t I t I r ' r l cl t ' r '
i,iiiil' li iiirri"*" ,i nirr"tui ln ambelc prr' 1i, accsta liind inr' r' ' alil sil' rrr
c()lI [Ta0tre.
Dt . Ql Ut i ! t A i ; e r . l ami r r t r r , zl i r l r l r d l r ol l t ar t t l t t i si t l ) ( 11, , {' l l - i j l i j i ' r r t : l t r l i l i t i . r '
, t , . , ont , . "l u i r . zi r r ni u r r i l *1, , r ' r ul ' . r i r , ( r l ' Nl . i r l i
. r
' r
.
l l t t I r t t
.
: r , I i cl t i t l r ' l r r t
' t r ol r i Ls
r , l /
, i , r r i r i i r u. 11, ' . n, r , l . t l l t 1t : ul t r ' , ' , t l l
( l r ' r ' l i Ll r \ i Lt l t ' : r ' t l t nt i l
' l 1l
{l ( ' l t l N( " l 1l l {' zl
, , i i i t , i Jr i l at *r , , nt , r , l i ohi dr do
l ) i i 1t . u) r ( l
, r t r r r ; r r I i r r l l i i r - t r : uh| r . .
{1l r i l r ,
( l i n
r uI l l l l
, i , , r , i
"r i f , r *
i , , i i r r , , , l l , t . , sl i l , . t i , , i t , r r l r l cgi r r i i {i . i l i t . l r j r l . l r r ' . [ ) {r i t s. r l ( ' ' ( r l , l r l
r l t t ' i l , i r , l , , gi , r t , i i i t ' i , t t t ' 1' r ' r r ' l ' r ' l ! t r r r r l t : r '
' Jr r l ) i ' i r l
( ' i i . l l r ' l i l r gt ' l t t t r t t st t l i t l i ci i t l r r
i ,' u,' ni i r, i r,?r r,,,i
'
r,:i r,l i rr
l
i
l rr r,rr,1xr.i , r.rr 1.zi ur,r,' I r r I : r, I r.' r
'
,.
r, I i L i xnr 1ni h,l ,cl 1tl i l tL
t r r , t vt r l t i vl l g
( si , r r l l i l l l
, , t t t i i t t r i r r i
l t t i Ar l r t t r r ", r l . s. t i r t l r r ' Lt r l ' t t l i , . i l ' i t ' l '
t l r r
l ' ol r ovi oi t t | t i | ! r , l | r r , l {l sl ) .
-dli
I I li'
tf
I ' ) . t ( |
, t
I I t
,
i I t I I l t
. t ' i t t 4t l t t i
i , l r l , r
j 1
l , l r r r r Lt l t , i t 1l l l l 1ol 1r . l , i i i j i t f l l t . l r , l , l l l t l
t l ) r , l l . ; r
i , r r l l | | r | l r | i l r u r i , sl r i t , ; r i {| t . r r
, . r
r r r , , l r . r r t l r r i ( [ o
l , l l s( , . l \ , 1f u
Jr | r , r , i zr r | r , : r
, :
' ] : l l l : ] : : i , l : :
] , r i r r , r r r .
Lr r i r r ui r r , r r r r . r , i : , , , r t i ci i r r . r l n o, \ i ur r on l l , r . i l gi r t , r r i , , . i i r
l i l , : , 1' zi r , r i '
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lLri" Ilin cauza actriunii sternocteidomastoiclianului de partea.oprrsir,l"ozitrn ii.,
oapul poate si fie'ugor inclinat ci,tre partea sinS,toasf,' Paralizia unilntclrr,lii,
lu, inuiciriului sternbcleidomastoiilian nu impieteazd, prea mltlt miqrrfil iln
,,apului din ca.uza intelvenliei celorlalli mugchi ai gitului. In clzttl
lt:r
rtr'
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,alizeazia urmS,torul tnblou cliltir: : rr,)
rrrrrl rul rl e partoa l ezati este cobori t qi proi ectat i nai nte
I
b) mugi nci r i r,tr h'
Ii uari l a porti uni i superi oare a trapezul ui este qtearsd,
;
c) spD0i ul suJrrl t ohl -
vi crrl ar. ei te hdi nci t, i ar r:l avi cul a apare mai bi ne rel i ofatd,
$i
paro proi {j ol tl l i ri
tl l ai te; tl ) cobori rea scapul ei
;
e) cl evi erea i n afari r, a margi ni i - spi ttrl l o i r,
on,upl ai ul ui ; f) di ti cul tatea efectud,ri i mi qci ri i de abducl i o
6i
.tl o
t' i tl i cl ,r' r'
a bri i l ul ni ; g) i mposi bi l i tatea de ri di care
,,i n
coa,te" di rl . pozi l ,i rl l l l l l l nl ,;
h) rl i fi cul tatea efcctui ri i mi qci ,ri l or di n arti cul al i a nm:i rul ui l i )
1l ,r' t' gctl rt,
r:,l i ei ul ui qi hi potoni a muqchi ul n) trapez;
i )
a,trofi a, tnu;ohi ttl tti l ,rrtl cz
l l urul i zi a si ttgul atd' a neraul ui spi ual este rari l . l Jfl , :l l l rtto rl o ttl rl trrri
i . rrl rrerLnd, cu paral i zi a ul ti mi l or nervi bul bui (i n spcci al ctt port' rl ti l o tt,
I X-a
i i
a X-a) (vezi i n conti nuare), ' l ol ul i ,
procese care se gd' sesc tn i n nl i a l ,t
tt
lrof)iere
a
foram,enu,Ltri
magnuln
;if
sau' u, regiuttii, cetuicule $tt,lcriottrr
(l r)carc
osteomi el i bi ce, pahi meni ngi ta speci fi c5, qi nespoci fi cft) pttt prtttl ttco
l rrl al i zi i
nni l aterzl l e sa' i t l ti l ateral e de nerv spi nal , Adesorl , oparul ' i i l o tn
i tqi unea cerui ,aal d l nal td (ca, tl e pi l di ' , sec{i unea spi nal ul ui i n torti ut' 1i *)
si l rt rosponsabi l e tl e procl ucerea paral i zi i l or nervul tl i sl ti ttttl
'
Ane,tri tmttl
^rterei
rcrl ebraLe cal o se dezvol i i )
i l
canal ul sl ri tl tl l superi or pott,e t:otttl rri mtl
norvtrl spi nal qi poate si pl ovoace o paral i z,i e trrri l atoral .i '
(l j or' l oohl ;ttl ' 10(|6)'
l;li:liil ""
cel practicat
p&tru
compolenta motorie
;;""Jrir,iiilll"Sli
Ftg, 77 a,
"Astr'{te
lch,rnatice ale examenulu.d
lalrjngoscopic:
;;:lllili#;
li'iriii:i;l'1
ii';"':i:l'';'?'i;ll*,i,,5x*TiffiJJ':i
iil:i::ilI
:1.11.3. lraralizia nervului spinal
ir;,i,i*ii,:q-$*ll#":$|liii,:,yli::,*imiti;$::t{^*Ti*: ir I lrl,or nii). C drcirLoltlul
liroidi
,,iil,i*i+*!#_*ii#_',E,5,1,:*ri:;t'*r{jrft,:ffi
jni
ti
j
! :j:i'
i
i:,
"i,###,:fll{f
trtr'",::*
!.i,il;:'Jt ;i:r
r t r v ;
w::;v;r:;i
;i';li,:',\"Yf *'f ::'u1":*$,,i:il,#:::fi
'ffi
"'#,fi
):;*'J'1T:Ha
i.iir,rr rrc rroui\, nri
-oi'co*ilJi'ir'rfiL),',"o!!,lJ1f?t1,fl.1
utrvului
.""*"nt
illl,l-llHl-""lHlglinn:Ysx$itni"';''i;;i";;;;ilifr:'J#il.i|#i:
1
i r.z r, i p s ir a rc*ri
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lll,ll;iylii,-',l,,.
*" 1i"""?, iii,*l"ll;i,li:r".i,",1;,,f,1,J#lH":T;iil,f,H,,,:$it
I'a.ralitia bi.IateraLii de nt
ri:,iliii11fii,n,lilii!:y;;,*f
i"#t{{i,TEH"{,#l1,;b*nuiindeeir
,ri,',,,,ii,ii'"i,i,n,i"i:;;;';^;:;ii:,:'tr::^;i",iltfgT"fi
,:lyitd:'-l",Pml:
I lj8
9.12. PROBLI]MD DF] DIAGNOSTIC IN PATOIOGIA NDRVUI/UI HIPOOLOS
9.1L1. lnvostigutria somiolofliolt n norvrrlrri hipolllos (XtI) lmXrllod:
I )
(
)hsurva,t,irr 1,ozi1;ici ."i
a nn;rootului limbii in sbore tls rolf&ult
rrln
gi t ut t .
I) Inrplorarso mol,illtillli Umbll, solloitlndu.ss bolnavdul rl1, oroouto
,r
outo mtgodrllo
podblle on t I mbn.
' l r 0
t
l , ' , l , l \ ' t i | l l r | r ' l l i r r | , l i ( . I I i | ( | | I r r r r l r r r .
1r . r r l I r r
st t | . l , r , i l l ( l ( . r t , l l l r l l ' l i i l r , t . r r r r i .
Hi | l r l ) i l i l l 0t i t l r ' .
. / / , /
OI r sl l r "l r , {i l r
; r r . t ' zt ' r r l , r , i
r l r , l t r < r t l l r r l i j i l i c. \ ' eni ul l , l r l l {}r . ul t i r . r r , l
r l | ! . ) I I l l I l t ( , -
:1. l :1.:!. l l aral i zi a nervul ui hi pogl os
.l
1
1'o.rulizia u,nil alerald, tuiertru,lui iti.ytoglas; realizeazi\ o dtr:irtit.
I r r ' 1r : r . i . i r
- si i ni t oasi i
a, vi r l ul ui I i r nbi i
, , i n
si nu, , . Daci bol n[ r . r r ] cf ( . t . t {r {. i r z: r
Ir' ,rl Irrzi rr
Ii rni i i i , wi r.l ul i l (,cstei i t est.j {l et' i at spre par.trr boi l }rtvi i .
[)l ,i l r
r( ttturri r l t[i sd]i ul rd
-Eeni ogl os
de p:rr' l ea opus:i ]eZi uni i . I]c :rse:l t,,i ,orr,
l :rl .rl .*' (l ' i l l ] al l i rbi i fot]Il l eazi t o curbi L Lu corca\-i tatei t, spl ,e
i l ri t,1,(.i r
r :i rrl l oi rfi .
-\t:casti i
deri abi e esto produsri
i j ri n
acti nnei l mri fohi nhti r{i i {).
,' l ()i r
*) ;(l ; r (,!(,:1tuea
z:i i n ti i nl pul cfor.tLrri l or de t ducc i i tnba ci c
1[r,r.1rrrr
i r r l t r r r r i l . Li nt l xr est c{t t r of i al ( i t i et l adt , *par ' nl i zi r l l i Lqi pr ezi nt i i pl i l ' i . , Ji , i bi l .
;r.
rrrl rr' :rl ri ri l j rnbi i . 11 herni j i nba rrl ettal i : se poi remarc,a,.Jasci ::r.l u!,,i .i
tnt\t tt[/t) t: i rr cori di {,i i 1i : i n cr.r' o i ezi i rl e:r sc:rl l l i l r, ni vel ul ntc]trdi i ne}i .l i i ui
l r1r,r,:l os.
l )fi l
i ri tti ti a {.rrol i i rI a i l ctonel roni k;t,.
1t
)
N'rrroli::irl itil.atert;ld, a er,nri.ui ]ti,ito1lios praiar:e tuil.lirlrj iirrrr-
l r,rrri l , r' r' Ive al (.. t| r{rl l l i ti ,i i i
j i rntri i .
Acessta-nu pca.i g
fi .r:ri ;catr), r-i l ni r"o
i ' ri l ,
rrr ;rl i i i , rti ci i ni rrrNr-rl
6i
ni r:i i n aftrr.a gnl ,i i . Atr.ofi a i i drbi i este bi l rt(' .
r:rl :r, rl . r,r,l .' .ti rr tl l ,{: o' i ca rnui ti pJe
l i
e\.i al ette fl sci ctl ati i *tusrt i rl r.,
\p tr
si lrt tr:t'ii,ri, t!e mostica.rtie, deqlt,:ti!,;e
lsi
tle pranut$*re ro con s ou.jtt:lttr.
. . l l i l l (1i l :r!11.1
rrt(,t afectat, !n gcnel al , tL, er:erl el rsi afcc.ti uni sa
Si pei ei j j l i l (,
I l',. \ sj
-\
l, !l'r cr,r.rnt.o.tismele craniot:erebrc(l.e cit frac1,lrti rie itazli pot-1,:t,Dtlncr,
t:tt' t\t t t!.1(\:)ti t ()(!
3i ' t1.gukt]"ri $, nen:ui ' ui hi i togi os. Attetsri ti ,nttl ql te;:ai
1),,1{h;(l t,
r,rtl ' r' r' :tl i zl r rr
1:rr:rl i zi c
nl i l at,j r1r.l i . a nerr-ul ai hi pogl os. l ez;uni l e reqi t.tn.i i
t.t ) t i tl tl t' ;ttq[te pot aft' cta re.rvi .rl ]ri pogl i os i n pol ti unea sa extracnrri a Il j ,.
l rr ;rr,.,r.1r, r,orrtl i i i r' rr:
1,t' i trrl c
si si tnpati tul
l .reri i cl rrr l ,i d,l rn si l l si st:i m tra rrtr
i rrl rl rtr r,l j l i i , sol tprl l di a pal ,l i zi e i r11j l :tpri .l i . p"
11.,tr-uh.Li l ti l j Ogi os
;i
ri n_
rI| rrrr
(' l r
nl <, J l erI rartl -Tfutrtrl de a,ceeasi paute (Taverneri f.-Oel ;.'
:i i ri t.tr;r,Lrrl hi a
l )otte
l csl a s1i
l rodtor:
o heni a_trofi e a l i n):i i , rrr.r,r,
. r l i l . I r I r ' : r r r r r r l l sor i r l r i cu l . ul bur i i r i l l e r t , t i si bi i i t at e i : r r egi t nea' t l ' i g.
Dr , , r r Lr l I i -
,
,.\tl (tt)1tt l rrtt:.yui .aL anti -tti ro.fi cd (q.L4.) st si ,nd,roamel e tl e tt-.[,.A.
1xtl ,
rl r' l rrrl rr ,,rr ,i . l tzi tr.' ro dc i i pogl os, da,r de obi cei se asoci azi l
\si
sentno {l o
l .zi rri Lc rr cr,l ol l u,l ti rcl :vi i rul bari , preonnr
[i
si mptome pi rami tl al e.
lr' irr,uil.rt Ltnrtor*l,c
fi
it'ur.*t1{ttice ale g6,u,rii, cont'l,il.iene anlerioare ttrl,.s,tv
rrr' :rzrr rrrl .ri rrri r l rcrvul ui hi pogl os (si ncl roi l ul l ui ool l et). rrezi uni trmorrl o
r,i I.rrrrrrr:rIi .r' rrl . gl j ,rui i
c' l rl i l i .ne qi al e gd,r;ri i ruptc postc.xi oare rea[i z{)l r,zi ,
:,t,rl | o)ttul . ..tr.tl i l .o-qnu,ri i ru,pl .i pottefi aurd, al l ui S,i cu,ri l , asl pra ci ,rui a, l .orrr
' r,vr,rri
rnrri l ;i | zi rr, rl i nd vom {l l l orda,
;i
si ndrou,m.el e bul bare ct l ntofestl ,ol t
r r r . r ' v r r l r r i I t i l t ogkr s.
l u l ,rr ttrl i i l .e l t
.l ?b,[e].ot
otrrl i {' (.l t superi ,()are fto
l ot
obsor,va,
l )l l rl i l i zi i
r l c nl ' r ' v l l i l ) 0gl ( | s.
l ' r r r t l . i : i i l r l i nt l r i i dt ot ' i t i t t r ' t , t nl , t , u, l d, pl i r r l r r zi r r r r i i r l o f i t sci ( xl l t l l l t i q. . r r i _
r ' ul : r ' l r I sr i r r so{r , st : r t c r r l , r ' ol i i ul , u f i l ) r ' i l l t i i i r r r r r scr r l l l , nr . I r czi r r r r i l s I i l l r , i , r , 1l l 1
: r l . I r r
gr
l i r r r r I r r I r r i r r r r | | i r r r r r r r l . I r r l r , r ' l r r *
l r r r ' 1' .
t l i n r . t i ndt t r t t r u[
?*ut &
t n, Lb( , r
l i
so
r r , t r i l ' r . , 1l i r . l i r r i r ,
l r r , i r r
| , t r I I r r r | r i I i l ' r r I r r r {i or t I t I i r i r r r Jr . l l t : t r r l r r , i t r l r , r , r . sl t r r l [ t | t sl i -
r ' : r ( i : r , r l l j , l l l i ( i t r
6i
r r l l i l r r l : r l l r r r r r vi r r l , r , l or ' .
| :t0
: . 1; i . l , I t t ) I JLEl t uD| l l ] I AGNUS, I I 0i N| , 4' t r t t , r l r i t , t l , ^l i ^1, I Zl l | , ( ) | t Mt l | , 1. 1| ' | . | , :
AI.,E NIIRVIL0R
0l tAN
l l ' l N I l l l l l ' l tAl i l
3.i 3.1. Atoel i uai extranel raxi al o
crt i tl octi rri
ml l l ti i ]l c
tl c ttorvi l or
0r:rnie i bulbari.
ilTi'lli#,{l,",,;ir;#*ht,ilHiTffi
;i1'*:1i4i*?,'rfi
:li
"-.iili,Hiitimixa
::::uiir'lr
uul'l
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;i ir 1;'
rl:;:";i,"q.;,,;,;r;#:;;l,l;*;*f
{li$ffi iti',illl*,il,,i;,lilll,,il;
l;":il:r #*:',lillf l**;i,l'll-"*4i!tiT"i$i$:ltil,*t^li;lllr;;:
illi:,:j;jtiti:tiJ11lJtfi1":ii'iii1H!!:HTi::,:,,:.,j
o1,T,,.",
"i,,,r
'u,.'',,'
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,
ffi
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r r ' br "' r r er ' '
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:*$i'.ii;Hffi
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1,,i,,.,l,rl,
i,,il,l,, ;
tii,i"'.lit|),,T,','l,l,i:;":t::::i:,,,i
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t'#;lil,;,,,Li,l,tl,;,,!,|'li,,l,i,i.)lii'ijili,;,,":,"1,,;",,i.,.,,,k,,tr*i1'1.,'D,,,"'t
,,,,, . ; f
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i'
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nn#i;i:lfii
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lnit
i;i
l':il.;l.lil,
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p,i/i,i'tr .,'
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'lliill1:'ii,';:irllli'l:"i;''';)li''''"'''
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t I r t I t . t t I i I i ' '
r i r r l r r l t r l r l r ' )
: l ) l . l i l . l t \ Dnt . l l . ui t \ r Lnt i r l t r . r t r ,
l r r , r r l r r r
r l c J( . zj t l t i l l l j l , i l l o l , j l r r t , i l
l l , : l i i l . 1, , , , 1r ] ", i r ) ,
r , i l
5
i
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r . l l l r r r
,
( r
l
r r r r r r t r
, )
: r l r u, yul r r i Xl ( sl r i t l t l ) . l ) i r r
; , r ; r r r , t
, r ' , . \ ( ' u{
t , . sr . r r r r l r , t l r {, , I i r si l r l r , ol r l l l ur , \ \ ( l l i ssoi l soci l t zi ol t l r i r l i zi o
t t : i i l ; Ll r ,
l : l . l i l l l r
, {. t r r t , r t
, l r , t U( , l r : j r l , , t : l sl r , i ( l t : l i r r l pez. t l 0Or ; at t t i : r : r
. . Jr t i .
t , , , r , ' , : . , . ' , : , . t . , ; . - . 1- , . t , t l i : i t t
, r cop. t t ut l t t i , , 11i , , , t , , : ' l , i i t u, r ; i , t ; o) ' ag; r : i ci r , i
. ,
, ,
: r ; :
,
, I
r i r : l | | I l r , mUl
nl onel l cLL.
I
) f i udrtntttl l .i i ,Iackson
-este
produs ci e obi eei cl e o i czi unc r-r qi rrr-
l rorrrrl rri i l l cr,i or, (l l cri fol rn)
al vagul ui
$i
a nervul ui Jri pogJos (Ll otri :r: si
,' ,Lrl r., l l )(i l )
;
Pr.rpovi ci u si Fascu, i OSf y.
i n, si mptcrni atotSgi a
si ndrornrJui
I
r, r' , rl.rrr, rrr rui scr,nitlt' se adaugS ,i p"*iiri"-d-
ii-rrfil,-ii' actorii
it;utoiril
, l : , r r i . , _r i , , : : , r i L 1nl r . , [ ou, l , r ' ndr ur nr , ,
t ] r { c. d( . nl c.
t,
)
,\i ttrl *nni t.[ l .Lti Col l et-R,card cst,. proi hu de i ezi uni c' t,c al fr]f,i ti i ,i i ,t
r' r,,.,,| r*i l i tr.rl r l ol tc for:na,l i uni l e
car.c tr-cc pri l {or.arl cnul j tgul ar (l :l l i nr
r rl ,l rr
l r.r1.r,j ' l i r' :-r,) qi can:rl l i caroti di atl r,oci rr, rrroti ' pent' *
care sr l :ra.i
l Ll r l r { i l l r
f i , . t i ni {t . ot nnl
r i i , s, pi nl i ci canr l l l c, - gaut i r t pt i
T, ot t er i oqt . t i u! l t r i
r ,,l l r' l t\i trrd-l ' enrcd:' .
L' onti rti rl scmi oJogi 6 i l rl ,l ;r,i i i cl i urrea ::soi j i :rr.r i r.
, l Ji r i , "l , ) r '
l , . , t r r r
p| r ' , chi r l c uer vi . cr ani er r i ( TX, ' l i , XI si ) i I I ) i ] ] u, i r r n-
.
r| rrj : ,,rr. l i rrtr(' , dtsl i tl i ^, pl l r:i i i zi c {ari ngi al ri
ru set}]nrl col i ,i ]i | l r:,,1 .i Lri
\
. r
i r ( 1. t l r l r l ' - f l u t i l ( , zi c l n t r ei mea
l oSt oi i car i ! , a l i r nbi i , pal ai i zi | . l {] 10_
i . r l i r l i r r i , l , r i l al ; zi t cor zi i voc: r l c, hemi gl o, . o1l e3i c
1i
r r t r ot i a l i r ' bi i , r r r ei : ur t r
I o.l )i ui ri i zi o i psi l atcr:r1[
a rrru;chi Jcrri tr.ql ez
fi
s i
(1,[otl ei cl omai .i
r:, i d i l l r"
l t,
.l or,i i
t:{i ol c,rj i ci ai acesl u
j
compl i crt
j i ndr.or,,
l ]oi -
fi ri i l ra- ,qal i d;rr;.o-
. ,' ,
' t ,,,t' -,
'
t1:.dc ol ' i {i xc oti ci i ,
l aroti rl i ani i ,, a}e bazei crani ul ui , i l ei a.
r:r ri r' , i rfl ,.r,)j ri l t u c, r(,l nonri rtoasc,
reti cul oz0 (J:oal a l ui Ji odghi n),.tui r:rori
, rrrgl ri
;rr;rrl rr,ccrr,.Jtel os cu ortensi e bazai i ,, tumori epi cl ermoi tc, cori l oanrr,
, , r , r r r l l i p i l l r l c
6. i r , ,
.,..| .t) ,' i
t,u tttnrr.ti tsal c (pl i rr fr:]ctu,i al e bazei crarri ul ui , pri l pl d,gi ,
1r,i tr
. r ' l r ( . . r 1| l o( 1 r , t
l l t r n ar r r t t r al be et c. ) .
t.j l ' tt)(tr( rtst:u.Lan e ::tncvri stne i 1c arto.ei caroti de si t' ate sub bazl l
, ri .ri rl *i 1 .r{r\ Ii ' ' c al e artcrci .r' ertebr.al e
;i
bazi l arc, Il ebi te
;i
trombofl e_
, 1r . r l r ' . r r r r l i j r r gl l r r , r o,
t unol i gJont i cc j r i gr r l al e
l i r i
qx, ci al j .
, , . . , 1t . 1, ' t ' , , . . ' , i t l l r , t uul nt
i i : , hr i nl i l , , .
ui j l c, . ; l , uzi i ( .
j , r o[ r syat c, r . . l 1l i 1r .
, , ' . : , , 1, : r ' r l l _r r
, ul r ' r , - , , ! L, . . l t
j i r . .
oc, i pi t r l c
; i
r , l c La; , r j i r ar . i u1i 1i .
*n^n
r ' r r - ' , ' r , l , t
l i r t r ' . t t r zt l t , , i l . t I . t , oi d: l ( , , b: l zr l t . . n: eni nEo r r t l i ( . ul i t c. ; , i , l i r t _
/
' ,
r i r ) r , \ i , . {r ' t l t r | n. , ( l r t r , t , . l t l j l {, i
zi si nr l t , omi , l l ui l r j Shcr r . l l i Set . I t , 2;
l , ' , , ' r ' , . i . r , r l ; , 1, . . l l r CC. : [ i r . r z s; I I ol t ! . r , . r .
I gi L] . 1, , : r l , r o; 1, , . i ul e sr ! r r 1i , l , ,
| : ( | r | l ] l t {, . .
I
t , , r . r }, . t ^ ci . l l l Zi t l o
l ) ol
Ul l el , i , , r si sc e: t i ni l i i
; :
sJ i . i l : zf Zr .
r i i . r r r r
i r i ol i r r . l ( j ; i l i kr l i cn' i l ol ocul omot or . i
i i
ehi ar al e t ni ul or r i el vi l or ,
r : r r r r r r i ( r i l r r l t ol l l l Ci l l . ci n) ,
t ' ) , \ i t r l r l t t . t t t i
' l t
*l r t t l i u. r ' dr o- T. t ar ol i di an
aL h l , i l l ar ef se Oat , : l ot el l -
. ' : : I
I . r . r r
r r . ' ' , t , I r . u, . r Jr .
1, i r r ; . l i i i i
al , " t r l l i n, l r , r pat t , u
1e, . r . chi
de l r . r r i cr . , r
r ' r ' r r ( ' , , r r .
i | 1' t | ' l l l j ' r , , { \ {r , , t r ( ( ( "ol i r
r . Si , , A| r l / l . l l r t n
S: l t df onr { I : l | l r l ( .
|
' , ' : r t r t
, ' r ' t . ,
r r . \ ' { l
j t l
, i , . U ( }
Jj i nJl i zj o
I r Cj l l i J.
.
l ,' rrtl or.i .i rl ' i t!l oti (i . si l rl re| ' rl cz,etrtr1i dc afecti l rni l cl ci ,rl i zatc i n sp".r,l i I
, l t f l t r , yr r l t
i r ] i 1r r . r
i r i / i l r r r
t , t l r opar , , l i di r ni
r ) I r ar u n: r i i st r r L,
; L) i unl or l ( l j ; u, i l .
t r , l r , r t ' l ) ( , l r Jt . i t . l c r i l r r r r r l i qr r r , , t ul r r or - i t l r , \ l l l r l j j l . r r , t r z; i l |
l l , ) st ( , l , j oi l , r o,
i i l r r t r . r r _
r ; I r t l : I r t ) | , r r r i l r r i r 1r r r I i i ,
I r or r l l r l l or hl i i r r , t r l , i cr r l r r zr , , r r oi ht l i I i r r r l , r r f i i r j , r l r .
, , Jr r l l i r r cr r l r l : r zi r , i 1;
r , ) pr ol l sc i nl l l r t r : r l oi , i i I r , r r l c (
1
r i r I
.
r I 1 i r I i 1 r
,
, r t l r cl r , i . : u, i r r
I ' l r ' l r ( . r ( | , 1(
i l ' , r . l ( f . . ) .
, , ,
)
, \ i t t r l t t ' t t t t t I l t t i ' l ' , r 1t , t t ( l l r r t
Jr : r | l r l i zi t t
r l l oso l l t t . i t r gi t r r r i
1
{. ) t r . r i r . , l {r . i l f
' ' i
r "zr r r r ' ' | | i | | | r I i | | J| | ' l l r r ' r ' ! r I Ul . r ' i r r t t l r | t , r t r t i l t r i
r r l t . r r t t t : t i L I r r r t r r r r r r I I
r I r , 11
t 2\
r i t t r l I r t t t o r 1 i t r : r l t t l r i i l r l x) l l l r , r r l r I r ' r I i
'
r t r I r i t t I
' i
; i | | ! i
I i
(
) I I I I I I I i
1, 1
r i l i r I r r r ( l I ' l l , l ,
l 1) . 1| i ; l i i sl t , 1l ) i i Ll ; l l r por i ci t t r . t l ' : t , ; r r t t . , l t ) i j l )
[ i
s{' r r r r r l l t r l l t i zt ' r t zi i
1t t ' i t t
l r t t ' r l l i , , , i r t ,
si i t i t ot i l t I t r , I r t i I i t r r I r r i
,
pr nt ) i zi c i l ) $i l r l i ; ( f r i t l i i i l ,
( r r l t ' 7i i vi t . i l l r t ( ( ' l l
i l r l r i , r r r i t , vi i l ul ui pal z[ t ul ui qi r r I r r I i r r gcl l t i )
l i
( , \ - cr ] t . ui l l
l ) i ' i r l l ] r r l r r l j zi ( ' r r s( , ( r i : r l r l
I r t t t t ; chi l or st er nocl oi t l ol i r i r s r i t l i an si t r ; l pt : 2. Ut t oor i
I u1
l i r r l i l , l l t , {i r t
i tcrvi i si mpati ci cel vi cal i , o1t si ndrom Cl trtdc l i ol ' nrl r(l l krl ' tti ' t (l i ory I I,t
r ol al t . , 1. 969) .
t r ' act ot i i et i cl oyl i . cr i si nt : : ' . ) I r aumal i ci , i n speci : t ' l , Ll r Li r r , l r t l qi l , t t l r t r ;
h) Fat:tori , ttt.tno"ral i pi c,ti npresi ,ti
(turnori al e gl ari dttor ptLl rrl i tl r' , 1f i ' i l rrtl ozr' ,
l rctastaze l ,:.,cel e, adencpati i , l l mfosarcorrno s.a.)
;
c) l :' utl ori i i l l l rtutrrl 0tr
(par{}i i (l i te) :i i rcese, cel i rl i te q.a.).
3) , \ i xt l r r ; mr l , de hemi bazt i ( si t t dNt nLul [ t t i Gal r : i n, si t ul nt nt ul l r r i ( i t r t ]
' Lai n
;i
{i oci .n sau si ndromul l ui Bertol ol ti ' G arai n
).
' 1' abl ott' l ' semi ol agi c este consti tutt tl i n po' ral ,i l l i l :rt11i ;rl r: tl t' trl t i I
{' ra}i i cni , i n {ol mel e l i pi cc qi compl etc fi i ntl ai ccl ,:rte tttrtttr c| l i ' Il 1
l ' r' r' '
r' l rt
tLc nenri cr:l nl eni <l e o p:trte, da.t cu cl emsi l i -c s(xni ol oi l i ot) l l .o tLri rrtl , I rr| i :r
1; i l e, i n f uncl i c cl e sedi Lr t r i ni l ; i al el l ezi uni i . i l f ol t nt ' l o i nt ' ot r t l t l t ' l r r r l t ' r t t r
rl rotn t1o i i i :ni hazri . tttl i i ncrvi cr:i i ri cni
' q1ni ,
crul i :i 1,i
(f1' {' i l l rrrrl i l .rti t' rt l . r
i nti ftecyenti l ), i :l r nl tl ri or afect*rorl l ]ervi l ol ci ' l ni cl ]i sc {rtrro l i l ' tl i tt rrl r'
r i ntcro-postfl ' ;or, fi e ri i n srns
}ostoi o-al l totj oi ' ,
ol l pl i rxl et' i ' rl i i ri l i rl l ,i l i r'
'
rrcrvi i t)l ;
c1' :1ni {,ni rl i n fosa oerebral ai mi j l oci c, fi e I ul ti l ttl ol i j l l l rl (l
l rl tl ,
l rl
( 1r
r : r i ' Ti cr ar Li oni ( I Jl omor r t i si cr ) 1: t b. , 195i , ci t a1 i de. I l ogcr f i i i ' ol r r J, . , l l l l ; 1r r '
i ri l i te si tut,i ri i , i to l l ot :l i o!:i ta
l i
unul sa' .1 l i l l ri :i l l i l l l l i n(l l vi rti tl l i {fl Ii {i ,'
i )i rl l r
i r,
;,ontl oi ttteral i , (Arsol ]i
1i
col :r.b." 19?3; Il oi l er
i ri
c(trl J-), 11){i 1i )
l i ul ti r ;remc, i tr tvol ttfi i l si l drotttt' l ol Gr;l ci rt tL' -t srr sl )rrr,rl (' rr'
romni : dc l ti tcl tonsi un{r i ntracrtl l ti at}l i
,
cero i w| 1rc ndosea1,xl ' (!i v' { r, \IItrl ,r]'
r' {l crui hri pi 1:i ht' , r::u' o aIl i i e m:i t.l ci ;rtrnc. l l s i 11{1ro tl l nci t)
1r' rtl
rl tr l t.rrtr
i "l r::ri rm sc i l crrl a' azi i , l l el l tl e tl s l tzi i ute l t, tri i ttl ri l ot' senzi tri | rr sr' rrzrrIi i rl {
r
r r rotori i i l tr' :ri i er-r"i l xi al r.
i ' u:l o: ti et,ol ttgtt-:i tti s i i ztl toa ,ti ctor Cor{:i .11 de h(nti b,L.i i .
: : . )
' 1' t . mor i l e:
t t r t nor i ol l ] ' N si l {l t }z\ - o1t al i r r i r r si i ; i l r , l zr i , ' t r i t t i t r l t t l I
Lr i ) I r or i ci i
l l l r I ] ct
di ] gr l ccl | i ' t l i n: i i l ' l l ct r i i nai
, j {r s
s; l Ll r l l {' ^ t l r , r t l r i I r ' i l i r r , '
vol b: l de t umol i l i nol a, r i t r gi cl r : cl t o i t l l t l o: t zf i , bl l : r l l t r l r l t r i t t l t i i .
( l r ' l c
t r r : r L
l l t ccvent c $i i r b t r r l t l of i l 0 a, t t r i c: ul l l t ' , l l i ' l zi t l c. r i l l Ll r : r l ( r si r t l t ' l r t t i t r l r ' l r r i ( i r t r l '
"
. r , bi cpi l cl i o: r mc al c : j 1) af j i l oi ' bazal o posl t ' r i or t l c
i t i
r l l c r i i l Lt ut t t i l t r r ' , r t t i r o: r t r r ' '
i i ml l sar t l r l l t r l o : l l o l i nol ar i ngt l l l i , l l i t r ' ( i i r t vl l i l ( r l Lzi ' ot r l i t i t t l
l t t
i l r r l i v. t r l '
: of r r f l l l ne) ,
1r
scut i t
1i
t umor i l e
1; t
i t ni l i l t : l l l i r t t l scl ot l l l L, zci
; i
l t l r ' l I I I I i I i I : , t ' I r r
{l i l r r osar coat l c,
sl l coi mc qi osl , cosl l co: t t t xr
) '
}I r l i r i l r csi nt Ll i l t t ol i i t r l t t t t r t l '
'
l ni Ii tr.\tacl ri (), i r,l r:
}nl al ul ui
s:t,l al o gl andcl ol sl l i vl tl t, ({l rtr;1' rri i l ttrr
;i
rrol rrl , ,
1l ) l i 5; , \ r ' st t r i
; i
r l ol l t ' b. l 9?4) ,
l l l i "r t Lr r l ; i
t t t r r t ot i l t t r r i t r I l t sl i l t ' i t I ' r r kr l r r r zr '
r l l l t r i l r i , r , i t
l t i t ui . l
r l i r
l l l r : r , al c
r l i t r ci u
( r i t t t xt t no l l l i i l ) ) l l l i ' sl l t l
1
t t t I r t t t I r t i t t r ' .
i i i t r t i t l l l r r ot r , t coi l ' i l l o,
I , i ' ( ' ( r t t l t t .
l i r l i n l r l t o l , Lt t t xl r i l l l 0l l l l ol l l l l t t t t t t t l t t t ' , : r l r r
r l ) i r , I i l l , ul t t i
l 5t r i r i d
r , i r t i gest i v ( , \ l ; cni
1i
cohl b. , l 1) 74;
j i r - r gcr ' 1i
t , ol r r l t . , l l l t ; l t ;
; {i r , ) i n
1i
[ . r r r t t l ni r ' r ' , l l ] 51
;
{l l al l l ; i i r ol r l b. ' 10{i L) .
\ 1l ; s l r t nt gt i l l l t c
l l t t l ,
t l t t l , ct ' t r t i t t t t si r t t l t t l i l l t t t l t 1o l t t r r t t i l t l l zl t : l l l t t t t ' t ' l
, 1' 1, i r l i ' r t t l r i r l t ' , t r t t ' t Li t t gi t t l t t t t r , , t ' t I t r I t I I I ' t t t t I i l l {r
.
j ( ) r I { 1 l , i I I I I
j
i sl i r t l t I ot ' l r i pi l ' l r l r ' ,
r r r r r r I I oI l l r r r . l r r zr r l r , , i , t t t r t ot i t l l ot t t i t r t , ,
l r l l t sl t t r xr i l o: t t t t l r ,
t t t i i ' I oI I r r r I ' t t t t l l l i l r l r ' ,
' I l I r , r ' r r r i t r r ' i , r ' i
i t r l r , r : r l : t l r r i l t or l t l l . i r r
{. i r .
( l i og( ' l
1i
cr r l r t l r ' , l l l l i l l ; \ r r i l ' ! r l I
, ol , r l r . , l l l i j i l l ) i 1) .
l t ) ' l ' t t ul 1t ! l i : 1t t l . l r r : t i r i \ ! l t l t r l r l t zr r l t t l t t t i t t l t t i '
t : t ; r
, 11) u' l t r yl r r l i t t r r i t ' r r : : t t t . | , r t r : l t r nt t r l t , t nu l l r . l r i r xr 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 ' l l l l r l I I i , ogr ' t
; i
r . ol r r l r . , l l t i ; i r l ; . r r . t t i r t ur ' i t t f . t "r t r , t r t : r ' r t nt \ t t ( , 1(
4i l t t ' t , i
, ' . t t l i t l t
i l l t t nt ( l ( i s' ' r ' . 1l J5: l ; . \ t . f i r ' l i
, r
l r r i l b. r 11. ) 7, 1) ,
r l t
( l i xl i t t
t r o: r l t t i nl i Lj pl r , ( , r L
l o( . l l i zl t ( , bazal i l , \ r scl r i sj f ( t l l i ) . , l 1, i , l
;
l j , , , r | {, r l l ) . .
t | | r i 9. / .
ct I i rrl i rt r, l I l el t , rzr: z, i ' i l cl r: rnLLl t i pl c t l r, ncl vi cr. ani eni
1i l t ol , t ru. di t u. i , i
l r l t
r r i r r , r r i vi l ot i i r c, zr l i r at or "se, cl i l t er i ce
i . a. ) ,
car e pot f i nneol ' i
( i ol r r 1l ) i -
t . r l I l i l l {' -
l l ' . i sl ,rr roi tl rnorLte fornto parti c[i a.r' e dr: pol i l a' Ji cu]orcn.i te t.ri ri i i gl o
r l , t r l r
( l r r i l Lr i r r - i 3r ul e,
cn al : ect i l , I ea bi l at er nl i i ( ul eor , i pr edami nal l t r t l i -
l . l , r ' : r l : r 1r r r r l l i r | r 0] ot
I J?l 1, t u- }et ool i i
( i e r r ei l i et ' ani el i si a oc L1l 0t l l ol r ' , r i j oi , ,
, r r , I i r l r r . i : r I i r r r r l l r ur l i r l l - ci t oJogi c: i . r u
genne
I , l l I G cl e ] {' zi ul r c t r cr . , , , _. , l n
1r ' ' r r t . l l i [ : , si I r r r r r - ol ul i e f ar - o| r . bi l : ] , ( I r i sl er . l 9i 6; Ke1, z si l : {ol der r or " 111i 6;
\ l r r r . , r l ,
1i
I l r r l r i l ' s, 1l | f i 5; l l avt , 196?; l l opor i ci u t i Pxsr . i r " i ! 1, ! 1) . Fi r i l t r u
, r , , , i / : l r t f r i r
l r f ( ) pl l r i
t i : i l ut nr l r l i r , , si nal l ' {}t nul l ui I r i sht r : , r ,
{I i et z ; i
f {{, 1! l ! t i er ' ,
l ! , {; ) .
l /
/
I rl ol r. ti tul rtrt t( l l ( u,nqhi p ctri <,,terth el ot
Il {}t
i l rtt.rni
j n
uttt!t' .' :tttl
, r t i r , l t , r l i , si l czi r r ni ?r l e pcr ef l r i l ol I I . X,
i i
- \ I
( r ar eol i , r i al e hi pogl o; I i l i i i ) ,
rr rl r,' r r.l ri
| ri r
l t,ni ori (nl cni r' ]1^i o:)rner tur] ol i c}i tl ermrl i (l c. gl i o:rrti ._ere-
I , i ,r r . l rl rrrrrrrgi oi l n)(r arl ,{rbol (}tse: tl l rrri ]r"i :r,l c pi l rl i i Ll tel al e i i !entri r,;l nl ui
r l
1r : r t : r l ci r ,
i r r r r ur r i r i r . r
! : i onl us
j ugLi l t r ,
t ur not , i met t r t t r t l ce, t l ent . i noi r . i t ; e i i l e
' | , , r r r I : r l i r r I r ' i r r r r r r I r r i , r ' agr : I ui , : i
spi nal ul ui
1. , \ . 1,
&] . . i | *i ( j i di . i ? r / i i sl i cr :
1i
. , : l c-
t ) t : t nt i t l t l ni nt ) t i ; ( de ( i ' i ( r C
. t : (
, ebr u d p' i . l t at i l , r r t i ( Al aj ol ani l e qi r : ' ; i r t l i , .
r ' r l : r
: l i , r , t l r
; i r : ol ul r . ,
1! i 69: 1r sel l i ; i r ' i i hl l . , 19i . i ; Pol r ot ' i ci Li si Pascr , l $31) .
l "l ;1.)- t[{' cttunl i nl ranel raxi al tr cu l ozi u}i l r}ul ti F}c dc nerri eratri rni .
|
)
,' i i trtI*ttrttrIt rIts{ti | | | !t' a tLt: ttu,ttcl ti ccrebrctl ,
\ 1, \ i t t , l t , r r nt r l r l ut l b( i . t '
/ )
' \ i t t , I nt t t r t l ] nt t l n! ui i . q1L
( l i l r r i ] oi t , , U, i l l ent oul
. t i
Scho{. i l
) ,
t u+
' . , t t t I t , , , r t r t I tni t ).tl ;t' tt ul l tti Dl j i ri t.t, :ti ,ttl ,ro' ttt.t[ i trl tfuLi trr a[ !ui , ]Le| /tokl -
I' , ttl l rrl l t,:l r' ti ttt xrrtr. h utt i ;tl r:t1i tr, ol tr:t,ni r i ttferi oard) .ql r tt ti duae sel ri ,,l ogi c
t,r
rl r , l r rrrj rrrrl zi i i trrr I i el l i Jr l cl i l .i e a oI)1r' ri l i l teta][
j n1' eri otr.t!
(r' esi .x,t.l i ntl
i . r r ,
| |
r i , t i r Li l ( ' l r , i l
l ) i ( i i ol l t l l i i l l i t at r ! i r l ci
Lul l l ar e, i . r i scl f i t i i r l ] neor . i : i i
' l c
o
r ' r r i r r l l r ". i L. , . 1 r I i
. r (
) ( , j
I I 1 i {. r i e t i p t ahr f f u
( pl i n
l ezi i r l ea
}r el gi i ci i
i r i l i ei l )
r
; r r
f r
l r r
I r r l i zi r r i r r r i l r r t cl l t l i a, l i t nbi ; , ou : r l i . ) f i o si cu f asr : i t , ub. t i r , ai , , , , t i , r i t i
l ' . , r r r r i i , , ' ; r l r r r r r i Lr I r Li i r i t l r i pi i gk) r l r l ui ( p; i r i
i czi nnca f i l l , el or r . ar l i cui i l . ' , , al o
: r , , t l r , i r r t , r r i | r . l r r l 1r ; r ' i l i r , : r - hr r ] Jt a| i t l i r : gi l t nea i - i r Ll bar i par a r r i t r I i : r l i i
) .
I r Ll r r l r r l r l i t l i y, t : t t , i t ui r r i l Ll t l t r si i xl t ot t r ,
] - . t j t i
l t zj l t ner l at t r l l ' l r t zonc
j r r l r ' t , o-
l r r r r , ' , r ' r i l l l r r l r l cci o
1i 1_l r r r r l i zi e
l r i b, t t r l al : i
i i pel cl hi i I I t r
i pr i n
l r . l l t zi r r
r r r r i r r ' l oI r r I l , r ' l | sl r i t [ t I ( : l ] l i i ( r ' i o: i l ' c) .
' '
I
t : ; r t l t t ) t t t ul l i t i l r i ' l l . i : : ( si l i ( h. oi t l l t I
nuol 0t i l Ll i l i nr ] - , i g1111) i . , ! r sl i
r l r , l r
' r
l r ' ; - , i r r r r r r i zol l r i : : i l t r r r cl ct r l t r i l r nl r i gr r r i
( I ] i ,
X) . t r , l l dur i r sel r ; n] r , : t j r ,
l r r r t r l r l
r r l t r . r r r i pr r l r r l i zi l l ' r r r i r r go l a, r i r r go- r . r , I opa l : i t i r r ; 1 . i ) r t l l l l l ( ) r t i . so
, r o' , l r i t r i r t r , r l r r zi r r t t r ,
l r i r
r t ui r l l Ji si : i f i t ! ci a. ul i i l l t i n[ ) i r ] ot r r l l r ni ( , f l i l l l r l r r
I r ' i r t r t I l l ' l f l r zl r l , r r l r i | r t l i l t r t t czl j si
/ r l l . r r
( )
hr r i i i i ] r i l r r r t , sl r , zj o 1t . r ' r r r ( ) l : i l , ' i l i I r ' i
t r r t LI l r r | r r I r ' r ' r r l r i , t r , i r l i zi r r r l si r t r l nt zt r l l t r . i l ) t t i , l l l ' ol . l t l r i t t ( l , ot l r
si l , i r ' t r r . ,
l l ) t i ) ) . i r r l r r zr t l i l t
j r r
( , l , r t f : r i r soi . i ; r r l l r i f , ' t r l Lr r l r . t r r l r r . l ol t - r , t l l i n l r ' l i t , l l {, , r
, , , r
l , t t l t t i
r l r l i l i r r t r r ) , t ' r t t l i r t l z. ; t r i r , , i r , , r t t r t l i r i ) l i l i r r t t ' i . l l t t r ui l i , , t : l t
| 1l ' \ r ' r ' , I ' l t i l r )
I : 14
l ' ,
)
Ei t t l t ot t r t l l t i St l t nt r l l
1
t ut l t ot t ui t \ t l t ) : 11) i nt t l ) r r t r r l r t i r t t l r l c l czt
t t t r i i t t i t cl r r t t l t t i 1' ; l gr v sl t i t t l t l r r l : l l i l l ( l r ' l t l l l i sl r i l l i l l l l (
( ' t ' sol
,
sl t t l l t l i l r t ' r r l t r t
l r l l i l r t l r r l c l t , k, t t t t r i ot t l t i i v: r , 1o r r l r i t t ; t L Er r l r t i r t l t gi t ' st l t r l t t l t l l t r t ' i zt ' l t z; i l I l
l l l l l
( )
I t t : r r r i pr t r . l r l i zi c VOl i l l ' , l i r i , i l l i r , l r r , i , r ' zi l t , r ' \ ' ocal e,
'
st {, r l l o( i l ( ' j ( l . l n, sl oj ( l i i r l r l t l l l i
' .i
ri , tl aoezul ui .
4 )-ELnrl tontrI l ui Jotl ;:' rttt'
(' {i nthomul vag' o- s})i n{} -]i i p{ )sl (
' s
i (' )
i rrl r' rl
l r et t {l ; par al i zi e uni l at er al i i a r er \ r i l or ct ani oni I X,
- \ ,
\ I ( t i t t t r t t r r r
.l i rl rLi ) ,si \II, l e cal ' c se poatc asoci a o hel ni parez' i t()l l l ri l l i rl (l l i ri rr
t Li ni l [ ei r r ' ' i
Al r j our ni r r c, ] 935, c t ai ' de Loeb
$i
] I e"Ye] , l l ) {i - }; I t I t (
I
(
'
(
' I I I
'
I ' I
,
19 6i
) .
-{rn
arui nti t an1,eri ol ' ci r si n(l roan}tl B l ui
-{r-el 1i s,
Srhuri rl l i i i
' l rr(' l i s(' rr
l r , i r r t , cel t l l ai adeset j de or i gi ne
l }el i i et i cr l
"i
I l | ] col i r i . c
' r t ' i i l i l r t
r ' ( ' i r l r r r l i ] .
cl l .ezul ti ni l di ni r.o-l ezi une l ]| ]}el ]-i l (' r.enpo.ti \ i h l r;r t.l ul g]i | | I]' i i | ' l | | )l (l
DoBteri {}l te san al sr:rl i uhl i rctl unti l i &l l l l r r' l 1L' l e
(i rl ' rl l i i l r r' l i l ' (r s' i l l l
I)l
(}
i l uso pri ntr_o ati ' gi re br l b:_' ' i i , el c rezul ti i di r l 6i ,ni i r: i i r:r.,srt rtu.l ,tttt
l }Jedsebi i u,norui tl , i ntrl r, SaI eti trabul l -l i tr e
,
i i nttrtrtti rrl l (' ol i
(l i tr
l | zi rrl ri
i ,usct are,8:l re real i zeaz:L l i e sLrferi ntc pnr nul l eartl , fi e srl l i ' l i l i l tl trl l l Irrl rrrrr)
pi rr nl l cl 6,rl ' ,1, ci
l i
ai e al tor fol rrr.L{i ri l ,i ti i rr r' ' ertl ' zt,)l }c,
' frel
oc
(r\l )l i t' rr'
' ,rsoci e' e:r,
si ti e al i e si nptone.
rl upi l
' ' xl i r
l l .rr l tnri l tl i t-:rr tc' i ot' (l ' i i ;rrrt1;l rr' :
rgOi , !os"" ;i cohb., 1969: tri r-rpor-:i ri t si col ttr" 1l l E0; I' ol trrl i l i rr
' i
paser i ,
l gsi ) . f n acest e' nl f i me
( r i t z1l 1i n[ se mui
l or t c
l ol i r i t j t ' si t r {l r r ) i r r r r l
t)rue. ,,cl a!i coi l
,\vol l i .q, Scbmi dt sau Jti f l i soi r' ci ri e fal l t
(l e l rl i rutl ' (l rrl ('
,' . ti o,,l
' i i o,ttu".n,,
1"l l scl i l al c bul brre asi ndl om rctr., ol i r-l ti \1-i tl l cttl rttr' .
r;especti v si n(l r{l rr i nterol i ' l l
)
(I' opovi ci rL si | trsdl , 19El ; Jl rl tttt i .i tt
' t
. ol ab. , 1f 180
) .
:i i 8 i ti .ti t ontr1 l rttti ' cl ' ctl tttttbul tri . o' i ntl rorttrl l i strt' i i
[tul l nrr Iul tttrl "
si ttt",rc,ni u,l ,' :' et]' o-()1.i 1:qr
(uL l .u,i D, j t,i ' t'
I' si t' l tuttttrl l tr' [ 11-' 1[l t' ttbt:r' 11
xrrrr *rtr
,i i ' ornt,ti l arl crd
(:?rebel odse
Ttotl ,i ri nl r:ri oar' '
i i ' c:rttr
teti zr::rzi s.ri ri .l ' :ri '
llil rurlltoaleLe :
' ""
- .!.)r' ,tc,,r,,,Fi
Parl ' ,
t:J l ezi tnea : e) IJemi anestczi e
(sau l ttl nti l ti l rol
1;ezi t) fa' ti al i ^ cel rnaj l desea di soc,i atr:
(terrno-al gezi c[
) ;i
Jocal i zrtl i i rrrrl | rr
""f r i
l i i i ". l t ot ", , l cf t al mi ct i hi ; bt ' I ul l r r r r i r i
r l ' f our l i o
. 1i
t l c r l r r gl t r l i {i r '
{i ,tr.,t i
.' ,i .*,tgtti 1) 6i
ptrrai i zi a cotzi i
.r-ocl l l c
; t1 Si i tdrotrrrtl Ul trui l ' r l i (' r' rrrtr' .l
l i i r r t . r ", l , ai r i t "r i ui r el l col oanei si t nl , r l i r c r l ) Si t t , L' . r r L ve. l i l r t r l r r r ' .
(
l i r r i r r r r r
L, , r i . i i , i o- l , : i t i l i l n nasc, gr et , , , r . i qi i
. ' - , i . . r r t Lr i i .
. t r i r t r : r nr t t t ' , ; i
. r 11r ' sr t r t t t r r t ' t t r t l i
l t ul nl ' e: e) l i i mi si ni i r i j r n 6161s11sLr s. t r l I , I {
r i i I I I I I 1 I i I I I I : t l l t I r Lt r t l t l l t t t l i t t l i ' t i or "
- ' f , ) t
Tt u, r l ea
oPi , sd: I t i l ) o^' t czi "
r l i sr "' i : r 1r ' ' t l r l r r ! r
' t l l r . zj ( ' i '
{
( r l r r r : I
r r r l t ' r ca r espi t , l , i r r t l f nl l ( nu t ot t l cr Lt t l r r l . ' i
l i 111r r 1 i ' , r I r ' t ' r I : L1I
' ' ' r r i l i r ' i t ' t r r r r l "
' : r . i i , . l , l , . t i j r t at ' t r (
l r i l l ) 2 r : ' , bal r . l l i U; r .
'
i j , st e l "r i r , ot r nt si i i ecnl t o : l , ci r r
i , r r l , r r , / / t l , , . l r ui t , t i , , i t , t l r oDt t t l t r i l t i
l l : ol [cttbt"t' !l (-,.ozi Popovi ci u Fi
]' r.' i rl tl ' I l l Sl l :
' l "or nt u
t t l t r ; t i r : r i , 1i 1r i cr i '
r l l l t 1' l l l l i i l t {) st r l cr r ' r i si t t l c f \ i r l l 1' r r l r l ' t l i r r l $l l
"
I r , l l l r i r t i i , l r t i t i s11s.
i i i t ul r ot t t t t l t 1l ' uL[ t , nl t t ' r 1
' t l i ] 1i "'
i t ""' l ' l ' t '
' t t t r . l r r t xl t :
( r l ) I ( t r r l i l
, r r , , l , r j r , l t , zi l r r r , ' r I r l i ( , l c1l 1l i l r r r r l i i Jl ' t r . i i r l . r f i i . t l l l i l ( l i i , 1r i t r . I i t I I t I t t i t '
r r l ,
1, , , , t 1, , t i l ,
t ' {r l l l i zi l l ( i l l l l si r nl t om' i ' ' 1i 1r ' \ r c}] i sl 11r 1
\ I r Li , l r t 11r ' I ' ' t Lt | i r t !
I t t l ( l l l t t
l , , , i , i t , . i a, i t , , , t , , " i . l i t , i ' r ' , nr r . l Li i 11. l i l r r r l r r r i sj r , i r r l i t t . s f , i t 11 I r r r ( i
l ) r r ( r r r
l r , : , l r l i , r r r i t l i zi l l r l l l r r l t st r l l Lr r t l t r r t si l l ( l l t ) r r l l l ( ' l r l t l ' l i l r l t r ' i t t I ' ( ) t t t 1t I I ' I . t I I {I ' ) f r i | | ( i | ( | | t | | | I
l r i t l r , sl , l r r r t l l t ct t r r i s, t ' r t l 1r l r t l t sl r ' t l i t l t ' o l l i r t t t i l t l t t r sl czi t " t t t t t i l r t l l ( ) r t l
(
l i | r t l {\ i i t ' l l l i l l ( l l l ot t t r r t , t t r i ' i : i ( r l l l t ) ( r l ( f l | zi t t t t o l t t t t t t ' l l , t t l t t i l t t t l l r i l l t t t t '
r r r sr . l t i r r r l r t r r , I I i t | l l , l r r t r ; i l t r
r r l r t ; r r , t r t t l i r r r l t ot t t r t ' r i i l r t Ll r t t l i ) l l l l r r i | | I ( ' I I I | | i I I
r l : r r l l l l r r ' . t i r r i , r r , l t i l i r r r l r r r t t t t l l l t t t l l ; r l r t t t r I ' i Nr r "r ' r ' l l ' '
( ' f l i r " l l l ; r ( ' r ' r ' l l
T
{i l 1r ' r ,
t r I ( | r I ( r I I r i i ,
( ,
i t l l , i i , vi t , r l r t , l r l . r r l t ' l l zi l l t r ( ' i l , l l , l ' l , ( t t ' ( ' i l i t st ' l , r ' i I l t t t ' t t l l l r l r , l l t t l -
i r r r l r r i , r i r r , r ' . t t
1l ' t r t kr t t t i t r r r ' t r 1r r
r i i t t t i , I r r r l - i i ' I i , i u l Jcl nl l ( f l ol '
( l o. $f l l or i t l l i i l l r l Li
l r r , i r . *i l i i , r r , l r r r i l r r i l r r i ( t r i gr , r r r r i r t r r l I i r l r r i r r i r
( l c obi cui i udoml l
l ]
vl l go- i i pi nl l l t l l
r . : r l o I ol l I l , o
l ) u1; i n
&1, i ns; cor ' Dt t l t , l i r l ot r r L si nl Lcl ei i vest i bul l , r i si nt l : o{l , r 1] {\
rrri r.r' r,srr,l ,i , r[c i rndc rezdl ti i ri n ;rt:t,tr' ;.i ttdt om vesti hul o-ccl ebel os, ctl m&r(!
r , . r I . i i . r r r r r r i - i , si nor gi c, hcmi at r ni o
! i
l &l cr opul ni c de
l ar t ca
l czi ut r i i l
r Li r z! ) r I l r ( , i , l l ) 07 ;
"Bodecht Pl ,
l 96i )
;
( e; l i ndr oamol e bul bar e nucl c: t ' t t '
i z,,l l rk'
(Avcl l i s, Schi ni dt si Jackson), care i n mod excepti onal l ezrl l ti r'
;i;'"i;f ;, :'k'*;;;' *r itl*iire o"itnlirau ;
(r) sin{l,roame },iind pe prirn
r ' l : r , r r I . r r l br r r ' : r r i r l . , scnci bi l i l al " ( Sar adi i Svi l i
' i
SI r , ! - , \ t - cvcl i dze. 1960) ;
l r r
l r , . r r r i : r , r r , , . l r . zi ( . al Ler ni l ' r mo r l gnzi ( ' i r , pc f al i
I i
pc hor ni col pul opus;
r.rr lrlrrriri,ttt'slczic termo-:]lgezlca! contrulaieral:i, ;
cu tulburriri dc sensibi-
l ri rr,l r { r' r' tmr-i t l gczi cS, hi l atel ' al e pc faJi , i ar pe cxti ' cmi ti ti doar tl e pa' rtctt'
,,trrrri i ' l ozi trni i
i 1g1
Si noro:r,me \Tal l enberg i i ,ri , tul l :uri l i ^ di l pa' rtea cor' -
,.rkrl r,,rr,rt,l c
(I1l i Ju,
196i , ci i r-r,t cl e Popovi i i u qi Pascu, 19$0)
;
(h) Cazut' i
, r r I r r l l , i t l l l r i i l t ' s, nsi bi l i t r r , t , bi l ar er ah l l c f oi r ' i , pr e"uul
' i
' ' azt i r i
cu t ul bl l -
r' :u i sr,trzi l ,i l ' c bi l ate-ra1c, dar l uci tl i zate tl oar peri oral , i nci usi v pe 1i mb5, ctt
: r . : r r l zi r . t Sr l r , l t i i cul {r , b. ' i 9G; , .
'
t,,,ri i t srnttol c,l ti ce de si ndrom l Tattenbtt' g mai ' enti i nser. cu i nteresa' re
fi
t ) , r r l i r r i ,
( l ${' l })
19i ?; Schol j t
gi
cohb. , 1965) , car e. ast ci azS, . qi suf er i nt r l
i ,rr, l ,.i l or' ' r' r' l l ni cni VI
l i
VII $i
chi ar al ectarea fasci cul ui ui pi rami dal (cl t
1r'rrilrr,rozi'1, controlal,cr:t'lii), sau forme in care coexisti' qi trulburdri vaso-
r,r,rl ,oi i i (ctr orractci ' :tl tei n)
fi
l l gi i hcmi f:l ci al e' - &soci ate- tneori cu al gi i
l r,,rrri r,rrr' ;rrl ' i t1c corti ,ral atral e
(l sch, 19;7). S-t rel at-at si nl rcm' tt' l sub-bul bal
,l t t i
(
);al rl i i
(crL l l pocstezi e faci ai i , si adrom cerebol os
qi Cl aude Bernard --
ll.r'rr.rl rl. rr,r,r:r:a'i
-palte,
hemi:lnestezio clisociati qi eveltuaL hemipa-rezri
1
r i l r r r r r i r I rr i i i rtl rtrri l ai eral S,, dar l dri ati ngerea ncrri l or
,
I-XI)'
l chol ' l t
.i r' ,rl rr,l r. (l 1i l i 5) qi l ?0pori i ci u
1i
col ab. (1980) au
-rcl atat,.
qi si ndroamr!
\\ rr' l l r.rrl x,rl u i rrsl i l i l ;c si de si ntL' om Pa,ri natd' 52111 {l e paral i zi a perechi l t-rt'
I l l r . r r , ' i l \ ) i i t t t s{r . i , I cl ' i n l "zi : Lne; i aar l . r ci
| cr cl ' ol . Jt l ' {c supe' r i oar ( ' )
s, ' , i , i , . . , , , i . , . - i i r l l l r r r t r r r i asocj r ' 1e r i zual c de r i p uc' "i pi t a) . cr t hAm! anopsi r ' ,
r .r' i l rl r col i i rLl i i satL al cxi c (Il cyer si col *b., 1956
;
tr' i rchor
-$i
col ab' ' 1961)'
li ) flitrl.roirtu,L Lui lJabinstii_Jageoltc
sau' sind nmll hemibulbttlu'i
' r ut , t , , , t . \ i u, l r , t , , ul cl qsi " , l I ' L; B' ; hi nRt : i - \ - ageat t c sr
' ar ac
t el i zeazi t -
, . l l i , ' f , ' , , i ' r ui r ,
t t "r ni f t nr . ' r : i s", l l bcmi pl egi c
noht r al at ct al i ' pl i n l l ( ' l l r i
' r r r . . . l , . zr r ' I cl r , r , r - i ul g"zi cl i p, ' benr i cot i : ul r onl r al al e[ a1- \ si
pe. l l el r ul af a ] l ) nl '
Lhr , r r l , r , I r I i | I
t l i sr ncl t i r ' , I l , sj ner gi e. l l l t er opu- l si e ( i psi l at er x] c) ,
- pr l ' n
soml r i r
t ' l t ' i l : u' ' t i
ul r (
( , r ' j pl i n Ler r r i par l l i zi e
l ' el opal aLuf t .
. t ul bur ' ; r r
de ocgl ur l l r t '
. r
r l . r , t t I r i t c
i i Jl r i u l ' : l l
i Ll i zi l - l , i phl l *1' ' I al i , o cor zl r vocal c'
7 | sittrlrotntr'l lui C estan - Chenatls este asemd'n5'tor cu sindrorlltll
t , ' , t i , , r , i t , *i . i N, i gnnr t , ' , i r r l abl oul cl i ni c asoci i nd t ot dPauna
( pe
, l i n' {i t r
,' i ,,rrr,.rri l kr r,cestui si ndrom)
qi semne datori te tnei
-
l ezi uni * nuc.toul l l l
r rt|l)i*I
,
l0rlpoctrY cu o par:]i;ie. ipsilatera15, a I'[]ului palatului
\i
8' corzii
,\ ) Uirul,t otnt+I, lLutJleLtIL[i ltt'i Dei'tart se caractelizea zil' prin crizo vcrlri'
si ", , ' i "1. .
r , i i "r "' i r i , i *i i
1, t , ' ' , i r , i "ni
t l c
1ar l , c: r
l czi uni i ) , ni sl t ' [ i nr us or i zot t l *[
i ,i i i ' ,i i ' i ' ,5i
",' i ti ?,tl t
$i /i au
rotatj or)' l i ur:um 5i
pl i n devi el ea brai Tel or sPro
l t t l , ( ' l l l ( f zl l l l l l l .
l \) i l i n tht r u nt,tt l e
Pottti trc
I ) fi i txl rtn
,ttl
ht,; "i l l .
i t.t(t)d,-(i l .bl d. r.r' rr l i zt,i l zri ,, sol rri ol ogi c, o
l xurtl i zl tt
r r l i r r , I r i , ' I r i r t i f l t i l i i ,
i l r si Lul r ' r ' r l l i , i nso{' i l , i i ' , r kr ol l i cci ,
( 10
l ) n' l ' czi l '
l l {l l l pl ! l ' l ! l l zl l r
l ! ( l
t t t ui l r l r i r r l t r i dl t , pl r r xl ' r r l t t , i l l l r l i l r l opi r '
; l i
sl , t l t bi st t t r ol r v( ' 1' g( ' l r l r ,
l ) t ' c(
l l l l r 11l
rl o o Itortti pl trczi i s:l u Ltottti l l t,gi r, r.ottl ,t l tl l ttcri l l ?l .
l!) lli,nilrotnul, I'or:iLIc irt,lrtior sau sindromul Itr,i llot:i.llrt-llillurrl-'
(
i rLbl ,a: se ca,racteri zeazS, pri rr prl l di zi a rni qcSri l or ooni ugatc i tl tr ttt' l ti l ot'
i l l r' o pal i rea l ezi uni i (,,paral i zi e conj ugati i di rect5,"), pl i n paral i zi tt, l rcr vi ki r'
(.I' l Lni crri
YI qi YII, i ar ci nd l ezi unea depLqeqte zo el e dosi :tl o al o
l ,l rl l fi i '
rrpi l rc qi o hemi parezh contral ateral i . Se poate asoci a
,si
o hemi al r(' Nl (' zi (r
rl terni i faci o-col poral d (faci al 5 i psi l ateral i ,
fi
corl oral l , di soci al i l l r' tl i ro-
rul gozi cl , de partea opusi ,).
3
)
Bi,ndlomul lui. Grenet satt
,,paralizia
sen.zit'it:ri" tnutt,ci;ltir consf ii
rLirtl,l-o a,restezio faci:lll ipsilaterald, (de obicei termo-al61ezicii, tlirl tttrt'ot i
:i gl obal i ,),
;i
i l i ntr-o anestezi e pe h.erni corpul control ateral .,{t[r' st' rt, sl
rusoci azl o paral i zi e i psi l ateral 5, a rnuschi ]or masti oatori
;i
ttn hcnti si ti th ottt
r'orebelos ipsilateral.
4) Bi,ndromul lui Raymand, - C estan (sau' tiptttl str'perior al sitdro'
ttului lui tr'or:illb
)
t'ealizeazia, semiologic, o paralizio a miqci,rilol corlitl$Ltt"
rr,lo ochilor spre partca, leziunii, alterarea sensibilitiii,lii supelficittlc r1i
lrtrr-
i unale, semne cerebcloase (ataxie, asinergie, dismetrie)
$i
milcr:,l
j (lo
1 ilr
.,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 reaTizeaziu
1ri' 1t'itrt
lrlan
o leziune importa,nti' a perechii \rlII, cu snrditate
;i
cll r','rt isii,
pl cc1111
Ui
cn l ateropul si i de acceaqi parte cu l ezi une?) Ia cnrc se i uso(' i i r,z:i
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"
l cnl i al ct rl n proces tl e unghi ponto-cerebel os.
6 ) Si,nd,ronul lui Pierre Mari,e-I'oi'n saw
,,hetni'pa'reza
cerebchxr:tir"
u l ni ,' Mari e
,s' i
Toi r (,,si ndromul l atera|' ) i nmi nunchcazS,, $cmi (' |)gi t' '
lulburii,ri de echiliblu ipsilaterale, cu clismetrie, tlisilergie
$i
dindill(l(x'o
llrinezle,
rsi,
exceplional, semno piranridale conl,t alateralc.
7 ) Sind,rom,ul ntioclonic al trunclzittlwi cerebral &l lui Gu'illain, llol.llrtt'I
,i ilertrand, (1933) Bau sindromul posterior aI calotei (Sohotl
'
l l ,6?) se cara,ctcri zeezi ,
l ri n
apari ti a unor mi ocl oni i vel opal ato-fal ' i ngi 0l l (' '
rrtlcsca limitate 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 peri or
fschott,
196?; Popovi ci u qi col ab., 1.973' 1980; Popovi ti rr
6i
I ' r l scu, 1981) .
$ )
Sindronnr,l, lui Gasperirti, cupriticle nn con1,cx1; ,semiologic lrtlrNl i
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,rt-
t r : t l i , 1960) .
!) O.ltalm,oplagiile i,nlertt'1t'clettre ,li lost c).prlsc dc noi llnl,cliot lir
1rrr,l ;ol ogi a
si stemcl ol ool rl or)l otorj i .
O) Sirulntu.trn'Lc pe tl,nn<ttlure (nte;c tr,el tr,lice,) :
I
)
iJ'intltou,u,l. ltti lfr:Jxr, si.ndrunnt['
Ttr
u,nr:u'lctt' pr.',r'rr'nttt],'iatt, utrtlt'r'1,
'
i n rl,to trtr.t,l, d,(
?itJiat
pttl,tr,naufttr (srr,tr, htrniTrlallia (Ll,(t'i1.i1' sILpo'iorLrii'
)
At\
'
r r , t ' i l , ct ( f f i z( ' r r , zi r ,
l r l i t r h' "o
pr r t i t l i zi r , i t
I r ' r t t ' l t i i
1[ I l [ - l t i l ) si l l t l , or i l l i i , l i l cl l r o no
: r
. t ooi l r , zi 1,
o l t or t t i ; t i t , t ' ozi i , st t , t t l t t ' t t t i l t l l gi r r
( ' {) l l l r t t hl l , {r t : t l i i , . . l ' a, t : t l i zi r l , pct t ' r ' l l i i
l l I r , st xr l , oi l l l i i l i r , n pl t , r ' {i r r , l i i
1i
r , i t csl , r r pt or l t t t i i i ,
l r t
i t Ll l zi t t t t l i t , l i I r t ' r ' kr l t I t t I i t I r t -
l i r , r r , , r , l c r r ur t , ol r xl t r l r r , t ul t t i l ont t r l , i t r {t ' r t i l l l ul l t t r pt ' i t r
l t i r , i ot ' t t l
t t t t ' zt ' t t t ' t ' f r l l i r ' .
A
| :t
'i
, \ r ' r r l l l r , r i l aI i / , r i r r r r r l r l l r / r r ' l r r . l r r r r r , r l r l r r r ' nl i ul t {r , si ut l nnt u. l \ l t ht t '
trnrl i tntl ttl i tr. l t' 11tnrttl u.l
I
) | t I | | | t t ' t | | t t t . r' tt prttl l l i zi t: 1,o1;i tl i i i t
l )cr(r(:hi i
r l r r l l l r l i i r l r , l i ci l nr {r i , ol i l l r r t ct r r I r l r ' I or ' I I i ' l , i r f t r t i r opl r s?i .
r ol nni i
I i / sr , u
r r r r r l i sr r o 1r l ( i r r ot , i co ( Aqgi n, t r , , si Vr r i u, , 11) l - r l 3; l . ) 01xr vi oi u, l {) ( i l i
I
l ' rtyrvi ci u
f
i
-^Dgi i l ,r,
19i i 8; Afl gi l ur
l i
col a,b., 1975
I
l ' opovi 0i tt i 1i
col t l t . , 1980) .
II) Afecliun,ile inJec,lioase s'i imunoalergice d,e tntnah,i cercbral (polfur\t-
cirfitlitels de tip inferior sau superior, rombcncefalitele, sclorozr rnull,i-
yrli"l, qi afecliunile demielinizante inmdito) produc variate tablouri srrnio-
logice, cu configuraiii variabile, complexe, de lcziune a norvilol orlrriolri,
rl e cel e mai mul t ori nesi stcmati zate.
III) Bolikt eredoilegeneratinte .:i d,egenerative 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 ai ultilnii{)r neryi emnieni (do Ia perechea a Y-a la perechea a XfI-rr,).
.,\celsii, P.B.I' I'eprezintd, doar un $inahom in cadrul unor variato lxrli
r)curologice. In tonrte raro cazuri, P.B.P apare in mod singular, oil oon-
sfituind cle cele rnai multe ori o modalitate cle debut a acestei sufcrinlo
rroulologice. ln cadrul P.B.P: unii autori inclual qi aspectele serniologioo
din scleroza lateral5. amiotroficd, (Norris gi Kurland, 1969).
Cont exl set t r i ol uoi e
Cele mai multc ;azuri tlebuteazd, cu tulbuldri de vorbirc
(clificu
ll')l,t, i
de fohalie, in special cu rinolalie), Apoi se asociazS, dificultd,l,i in doglui,i-
{ia
lichiclelor
lsi
a solidelor, atrofii faciomasticatorii, faseiculalii po linrbil,
;i
pe muqchii rnaseteri qi tulburi,ri ile masticalie. Iieflexul faringin,n rlis-
p:lr'e la multe cazuri in plimele faze ale bolii (Bonduelle, 1965
;
(iirho
qi Kovarik, 1970). In alte cazuri, imediat clupi elebut, s-au inst;aluh 1,ul
buriri de respiratie, uneori gr&yo (Black gi llyatt, 19?1
;
Castaigrx)
{i
colab., 1971). Completa paralizie a mu$culaturii masticaliei duce la dl,r lorr rr r,
rnandibulei, iar afectarea orbiculaluldi buzelor pelmito scurgerea salivei rlirr
gura intredeschisai,' Asocierea aproape constant5, a tulburlrilor dc doglu-
tilie duee la acumularea salivei, alind impresia unei hipersalivalii.
Palatul noale devine imobil qi aton, pemitincl regurgitarea fluirlokrr:
pe nas. TulburXrile de deglutilie sint frecvente, ceea ce face necesartr irrl,ro-
rlucerea 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,. ltol-
rravul este, de asemenea, in imposibilitatea de a impinge cu limba alinlon-
tcle 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 procluse de hipomobilitatoa limbii,
Ll ca,r'e se atiaugii, paralizia pa,latului moalo. Bolnavii n[ pot pro]rur|,lr,
rolect lingualelc, tirnblul vocii captrt5, o tona,litatc nazalX t;i dispa,ro rnorht-
h,ti u, voci i . l ,i psrr, cl o i nchi i l oro contpl etl zr, gl ol ci , pal al i zi a, mrrsorrl ai ,rr ri i
buzcl or' , ci t;i i ,ul bLr t' i i t' i Lr al o tosl )i rr11,i o cornpl otanzi i tftbl oul serrri ul oi l i o
r r , l t ul br r r t r r i l ot ' t l o vot ' l r i t r : i n I . r , l ! . 11.
At r of i i l o t t l uscr r l r r l o t i r r l ' pl ozr r nt o r Ji vi zi bi t c. l r i r r r b; r , osl , o I l t r sor l , ,
i r r r obi l i l ,
r yi
l l , r of i ci t , . l l o i r r r r r r r r r r r r r r , i r r cr l , r l i n pr i r nol o [ r r , zo l r l o l r ol i i , $i r r t r nr r r r r l t r
r r l r ol i l t , t t t r t r yol t i l r t t t n: t , ur l , r , , t i , l r l cl i l ' ot t ' r , l i r r l ' r Ll oxr l r t t ot r t t l sl , r r , l . i o
4i
l u *l , r l ngo-
l )t
t )t
l I r ,
l i xi si i i si
, , l i r l se
si nt l ur at t t o \ \ r ' bl r ' ",
l t l i r r
al cvl i sm l ocal i zat
l e
i i l t ur r '
' rrl ol
i rl r' i , i rrl ,ol rri , i n r.eci ni i t:l tci l l ul or' (]i crre,b]al e posteri oare' p(r al ' t{tti l
.orrrrrrri r.i rrrl ,i , pi rsteri oari ,, care compl i mi i n rnod dl ect nervul Il Ir pl i ' -
r rrrrr si
l ri r.i otttl
poduncul ar (Il eadorvs, 1951).
:!
)
Nirult'oamele trucleu,Itr,i ropu (sau, sindroanzele
ltedu,ncu'ln'e
dorsule
)
1rr
rl , I i r rs I fol si stetnati zate (Loeb si l feyer, 1965
;
Bodechtel 1965
;
Popovi ci u
; , r r l ol r r l r . . l 9S0; Popol . i ci u qi Pascu, 1980) :
qj ,\ i nd rot.ntel e i .nferi .oare ul e rLttal eul ui royw:
ttt Ni ' nrl ronrul l ' u,i , Cl aude-Laye?j ("' (u si l l dromul l ui Xothnagel
)
se
r ,r r' :rr' 1 rrl i zrrri rz,-r pri ri tr-o paral i zi e pzrrl i al i i ft ocul omotorul ui comun cl e
prrr' l r.rr l rrzi rrrri i
;i l rri n
tul brrr:i r' i extrapi rami dal e
;i
cerebel oase de partea
r ' l r l l i : 1.
It1 fl i tul ronul hti .Il enad,i l ;t, asemSnl tor cu pl ecedentul t se mani fest[
1r' i r l rrrl rrl i zi rr
otrul otnotol ul ti comun de partea l ezi uni i qi pri n hemi parezi ,
.i rrri ,' i i l i i nrl )l rl ntare (de ti p corei c, parki nsoni ene qi i ntenl i onal e, acl esea
r ' l r i r r l r r r i r r . l or r i i
; i
t ui or i t r ni i ) de par t ea opusal .
l ' ,| si nr|rorttt:I.t s1.t?eri o{Lre al e nl r,cl ewl ui roptt :
:t1 Sittdronul lai CltiraE-7'oir-[icolercu se caractedzeazd,
prin hipel'
(
irrcz ii rl ir.r,r'st,, rigiditate extrapiramiclal5,, herniataxie, disdiaclocochine-
zi r' , prl r.r.rrrn si pri u hemi parezi r, toate 1l hemi corpul contral ateral l ezi uni i
rrr, l i .rl rri r' ,r1u
{l a
care se poai e asoci a
fi
o l ezi une di scrti pi r"ami tl al d,
$i
rr;.orrr' ,, l ul l rr ri }i dc sensi bi l i tate, respecti rr ul t si nd]om tal ami c, care si n1,
l r r r . r r l i zr r l c r l c nser nenca i l c par t ea opusi , .
It1 triurltrtrn,ul ltti Niaolesctt, este asemiinai,tor cu precedentulr dn',
rl rl ori l ri l rpl rrl ui tri l ezi unea est si tuati , i napoi a nucl eul ui rogu, poate fi
rl i ' r' l rrl rr i ,r i i l rv.rrsrr
!
i u' hLi Wcl neki nl i
;i ,
ca atarc, se produc mi l ci i l i i nvoL[n'
l : r t r ' l r i l l r I l l t r l r . .
il I in rlr'rr.ttt.do lctltnultQle cu]rrind mai multe grupe de sintlroamtr
( l , r r cl r
i i
. \ l 11 r ' r ' , l l ) ( i i r
I
l Jopovi ci n
t i
co1ab. ] 19?2' 1973, 1976' 1980; Popt l -
t i l i r r i : i l ' r r sr l t , 1980) :
t)
' \i nrl ' rrtnrLtl
fl rl erai cefebel a{1se sl l peri oare se cal aci eri zctzX, sel ni o-
l rrl l rr' .
l rl i rr
rri ;rr,ri tr cctcbcl orl sfl homol atcraH,
$i
pri n hi po- sau anestezi o
rl rrrr.rrrl i r, l r.r' rrxr-a,l gezi ci l (sau un"eori pentl u toate s,eqsi b i l i tel i l e
)t
| ' r' | | Il rIl rrI(,r' l l i t. Sc poate rsoci zt l rtl si ndrom Cl aucl e Bernard-Ifsrner i Dsi -
l rr l rl i rl , o pi rl rl l i zi e a, percchi i a IY-.r, contral ateral l , datori td i ncmci l d,t' i i
l rl rrr,l ri
l ri i cl i cLLl ni
qi l uneori , chi &r o hi ?oacuzi e sau surdi tate (cl atoti l ;r' i
l r . zi r r r r l i r r ol i r r r r l r r l ui i nl er i or ) .
l t) N i ni romul ,tU nori nau' i l tr:ri l uce o l ezi une 1a ni vel ul eol i cul ul ui
ri rr1rl l i rrt' , rtspecti l ' r regi uui i a.nteri oare a tubercul i l or
quadri gemeni l 1i
rrr, nrrrrri l csi .rj , pl i l pal al i Zi :,t mi l ci ui l or
(l e
ri di cnre qi /sau de cobori re Il l (r
rrr' l ri Lrr' , rrrl t,sci i ts,rti i al t' cu o par:l l i zi t do col Ycl genl i ,t cu o mi dri az5, ptl l tt-
l ri i cri
;i
orr tl u,bol i te rl refl exel or
?tpi l are.
oJ Sirulroutul lui l{esxenbau,tl realil'earn un cont\t clinic constil,ui1,
rl i rrl r' .ri rr si url l orn .| .' al i ui l ud, Ll crtrc so asoci azi [' ; 1)i sl i tgmug di sj unoti v'
rrri rx,hrrri i oc rt kr- t ol ,r' a,cl o ti i , l ttl bnl i l l i pupi l i l rt ,,si pal eze i zol ote
(l o
ntl r.vi
I I I
;i
I V. 1,)strr rut si tttl urrri de suft' ri nl l i i l substrr"n{ci cenufi i pori rp()duot,rl l (!
ri i rr, IrrrrrtIr,Ir,Ici Iorrgi t,url i tl t,l o l tosl ,ct
i rti l to, pti tr protr' .te oal uti r:tt ztl t' ,:t,t Ltrt' ttl or'
pl r r l t r l r r i
l xxl t ' t i or "r r ' t
pr r r l i ct t l i r l t l i t r ' , t t r , t r t l r t r t i Lr , i , t r t t r t r r l o i t l st t l i
l x{l i or r l l l l t l i
i r , t l r r r r r r r r r i i I r r r ' , r r r r r r pl i i r yt r t r ' *r i u, l t t l i r ur sl qi , r ' i t l t l i t ' t t ' , xt r
I r I I
l t sr t t ' i l t , I t i 1x' t -
l : l t l
|
- 0,
11
l : ! t )
T
l , r t r l i t t f i l or ' , r . si l r l c r r r r r l i c or i r , l l l r . f . l l ol r r or r l ci t l or l l r sl oi r l j l l l r r l
; i
l , r ' l r l l r r zr r l
l ; r . r t l l ol i l zl i , t t t i r i i i r zi r r i r r r , r r r ' ' r r r l r . t r r l l {i ci l r ol i i . [ . ] r r t r ot i l ] al l t l i zi i l , qi l l 1, r oI i r r ,
: t cr , sl , ot ' t t r r r f cl r i l r u ponr Li l l r ol r l r vi l ol si ; i l i r l i co cl r pul t l t ci t cu aj ul , ol l l l
rrri i rri l or' ..l l rrsci t-rul i rl i i l crrpa,t prr Ii rrr bi ,
}r
tul seteri
$i
urr0or.i
i i
pe muscul atu-
| r I l l uI l ( 11t .
S l,r rlescris tulburili ale motilitiiiii esofagiene
li
gastlointostinal(j
{l i rrrrl ucl l c, t965; Bouti i n qi col ab., 1971), precum qi tul burl ri cardi aco
i trlr Iiovrlscrrlare. Tulbut'ilile respiratorii pot fi cauzate de pareze al(l
rrrrrsorrl i rl uri i l t:spi ral ,ori i , de para,l i zi i al e corzi l or vocal e
[i
chi ar de cri zo
l csl ri l rrl ol i i central e (Caral a$
l i
col ab., 1966).
l)(lgcneratea ciiiior corticobulbir,re, relativ rar intilnitii in P.B.P purir,,
;rrl rrugr' i t' l crncnte semi ol ogi cc de paral i zi e pseudobul bad. l ,.,ezi uni l e centl i -
Lrl vr'11r,tliivi duc frec\.ent la tulburdri circulatorii
gi respiratorii foartc
ul i t v{' '
iladrc nozologiee
1) Paralizia bu,lbard, progresiril crotui.cd la adolescenli qi la adul{i
;xrirl,o
rp[rea fie ca,
Jorntd
sptoratlicdr lie 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.rc P.B.P apale fie la debut, fie in cursul eyolutioi (Hirano
r i r ur l ub. , 1967
;
Br ot l y
f
i cot a; b. , 1971) .
.r,\ !l'i1tul sporudic al B.L,A. cuprinale cortextul clinic de P.IJ.P in cel
1ru {,i rr
l i i
o/o
di n cazuri (Ni shi gaki , 1970
;
L972; }Ii i l l er-Jensen
Fi
Be1' nhardt,
ll)7;t). I,'r(.{,vrr1,a P.B.P in eadrul acstor forrne sporadice de S.L.A. es1;o
rrrri rrrarrr l a bi i rbatj deci t l a l emei (Gi rke qi Kovari k, 1970; Rai qi Jol l y,
l 1)?1
;
.Ni shi gaki r 1972). S-a raportat o creqtere i n ul ti mi i ani a, frecvn1ei
irnnoi bulbare fa!d, de forma spinal-d, a S.L.A., indeosebi in jurul qi pestc
vhsl ol c rl c 50 i l e ani (Dazzi gi col al :. 1969; Campbel l , 1965; Saha-
r l l l r r t r , 1969) .
lr) f ipul
,rd,e
Guamt' reprezint;, o asociere intro S.I-,.A,, parkinso-
rrisrrr
1i
rlcrncnfi,. Tipul
,,de
Guam"'prezinti mai frecvent sernne bulbaro
11i ri yrrrsl i rri l i rl e <l rci t forna sporadi cfi de S.L.A. Ti pul
,,de
Guamrt are o evo-
hr(i rr rrrri k' n1t1 deci t cel el a]te formc (Il i rano qi col ab., 196?).
l ,' ol ' rn(r dt) S.L.A. asemdn[toare cu cel e
,,de.Guam"se
i nti l nesc, se pare,
r1i i rr l ,)rrropl . Nu s-a putut i nsi preci za ni ci un factor eredi tar, ni ci sub-
Ir' :rIrrl i rrfccl i os pl i ntr-un vi rus l ent (Gi bbs qi Gaj ctusek, 1972), deqi so
prrrrr ci i ui l t, mul te ozul i cu si ndrom de S.L,.A. real mente vi roti ce (Popovi ci u
: r I ' r r r r : u, 1. 980) .
It,rl al i l tl i l tre compl exul parki nsotri sm-demenl i , si S.fl .A. s-a vel i -
l i trrl l rr l 5-2i o,( di n cazuri (Brady
;i
eo1ab., 1971
),
f:r,pl . ronfi rmat
5i
do
: r l l i i ( ( l r r l r l ; r ; si col a, b. , 1966; Bonduel l c si ml al r . , 196E; l l l a, i t
6i
cohb. ,
l t ?l t ) .
c,)
' l ' i ytrl tri l ,i l ar tl e i S.7,...| ., r.l esttl rl rr l ar' , pl czi rrl i i u l rarrsrni sj rrrro
:r,ul osorrl l l douri nl mtl , i a,r scrnnol e bul bal o si nt tnai frecvenl ,() ((1as1;l r,i grrrr
r i col i r l r . , l 1) 70
I
. l l i l r r , t r o
; i
r : ol t r b. , J067; I l r r gl r t r s
[ i
Jol ] r ] m{! , 11170) .
i l ) I\tul i : i tr, hnl l ttrni ,
l ttol yni nti ,
tl i tt, uytr,-ti srkt
,,t
|.nt,l .i i rttu.xr,ttl urt
l : l {l
t ) t l l nt l i t r t t t r st ul ur i r pi t t ul i i n. l ut l i l i i ( l nxr . l r r . l t r . i l l t r r l . ni q I l o. l l ur t nt )
, t t t l cl t ' t t ni l t i st t t gct t r , l i c ( t r l r i t r l r r s r r r r osi v i r r r i , osur r ur l ) s( r
l ) oi r l , r '
i r r i ur l i r l r ,
l l zi r r r r i l r t r l l l l l t ' o ( l ) t ' r r , cht nl Lr r
l i
I l l l nl i {f r , 1001
I
M r r r ncr r l , hr r , l r r r ' , , si Vr r st r , l l : r ,
l l l i 0) . r \ ( ' o! l i col ) i i , i nci i r l o Lr r l l st r r l c,
l r \ ) zi r Ll ; i t
l , r r l br r r i ' r , r ' i r l c xr r pl
1i
r l r ,
r l l gl r r l i ( i c,
al r ur l f i l ci cs i r r t r xl t l csi v, r nt r xl i bul i l cst o ci i zr r l i i , l i r r r l l r l r , l l ol i l r r
,r trrfl cxcl c l ml l ta,r' e di rni mtl l ,c. Ocl o rnai rnu]bc cazul i rl ccrrl crrzi i i rr l rri rrrul
:rrr rl e v i a!,i i ,. l tr forrrLcl e rua,i l l cni gl c, cu supnrvi e!ui ro pi rri r, i rr rrrl oi csr,r' rr
i
'r
,
I rr lbuliirilc bulbalc pol, fi intilnil,e pin5, lzr, douii, tlcitni
(li
rr olz u li ( Nl u l ln l
r col r r , b. , 1969; I l r i ul
f
i l t r nof y, 1{}71) .
l tl Atroti a nyuscu,l u,rd, tpi nul i i j uaeni l d ( boal a l {,u11r:l l tu
q l l :tl rrnthr)
l otntctel i zeazd, pri r) |l ,ttofi i spi ual e proxi mal e pseui l omi oprbi cc r,i i l l r. rrrr
,1,,1(.nni ni sm
goneti c autosornal recesi v (Srri th qi Patel , .l .t)65
I
l ,' rrrl krrrr
r , ol l b. , 1969
;
Namb*
f i
col ah. , 1969) . Exi st L
$i
cazui sl or ' , r ( l i ( l ( , . l r r l r l i
,rrrri r,Il eryi l ol (frani eni (i ncl usi v bul bari ) a putut fi demonsl ,r' l tI, l rl :.i 1,' i ;,
rl rrr crrzrri
{,\{eadows
qi col ab., 1969; Narnba
l i
co}ab., 190{,r.
a) Atrofi a muscul ard, spi nal d, l o,rd,i M (boal a Yul pi an- l l cl l hrr l r l l ,)
;rl r.
zi trl r' i , un dcterrni ti sm geneti c de ti p autosomal tl omi na[1., dl t,r si rrl
,si
rrrrrl l o
, r,zrrri sporadi ce (Cazzator 1969; tr' ri ei l
Si Dmery,
1971
l
Zel l rvcgrrr' ;i
(' ol rrb.,
l l r72). Doar pul i ne cazuri pl ezi nti ,,si l czi nni bul bare (Dyck i Ji I r I | | r I I )
'
' r '
| ,
,
l l rl ;,q; Bobowi ck
$i
Broal y, 19?3).
,1)
P,B.P i n al te bol i degenerati ,t:e. Di ntre atecl i uni l c degerr.ri rl i r' ,,
|l r (ri ue
poate Si apar5, P.B.P, ami nti m:
tu) Hi.potentitnea orlostalic.d, (sindromul Shy-Drager') s(r 0r|r,olr,r I
z|rtzi i i n pl i mul ri nd pl i n l i psa transpi ral i ei , rnani festi ,f i si rrrrPrrk,, pi r.r'
,l l rr.l l
control ul ui sfi l oterel or' , si ndrom pal ki nsoni an, atrrri r.,ri sr.rrrrr,.
l r r r l l l r l t ' .
l t ) Si r t l r ot t t r l Ri l ey- Day est e pl ot l us de o
( ' l egcl l er ar c
r r l i r l r r r r r ( i r , r
t , l i cul are a bul brrl ti , cu i nl eresaLea qi a newi l or bul l :ar' i (Il rtruri sl cr' , I l )i l
).
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
col l l r.,
{?0;
Boudi n qi co1ab., 1971
;
Serr.atri ce
fi
Gastaut, .11)7i l ).
tf) P.B.P asoci ai d, corcei croni t:e Il urtti ttgtol cste l i trl i (l rnrl i rj r
V rr i n, 19?3).
o) P.B.P asoci,atd, sindromului Bteele-Richardson-Olsaewsk i u, lirsl, r'r.-
rrr:rrr,l 1i i
chi ar ti i n arti col ul pfi nceps al acestol autori (1964)
l i
(l ()l rfi l nrrl ri ,
, 1, ' l . | . hr r n: r nn si col ab. ( 1969)
; i
Const ant i ni di s
$i
col ab. , ( Jt ) ?{}) . Ast n. l ,
1' ,'
l i rrgi i sel rl el e cuntrsrute t1e acestui si ndl om, au fost des(rri so l l r l orr rl r.
r , | | r l t l ' r . uzl r | i . i t ul bur dr i t l e t l cgl ul i {i , . .
' i J
P.B.P d,soci atd. nL afectareo, al tor si sterne; nucl ei i nrl zt' rrcr,l rl i l i
t I i or r r I r r t . I I t . r i col ab. , 19?0l , t al amusul ( Van Bogaer t
Si
ool r r l , . , [ Xi f i ) ,
( 1, t ( ,
r "' l r l
( \ ' : r r r JJogaer ' t ; i col ab. , J965; t sr bwnel l qi cot at i . , t Of O; .
!) I' .tj .P a*oci al d bol i l or paraneopl azi ce al e si ste.i l u.l u,i turtttr. l ' .1\.1,
rtr tottl tl i tul
umri si ntl om tl c scl el ozi i l ateri Ll i l i , ami ol ,l rl i i t,i i rri rl rrr,,ol trrzr,,
rr l osl tl rscti i r i n ci l l ci noa,mo bl onhopul nronarc
;i
al l r, 1i trl r.i rl t, ti l ,r,' r' r
r r nl i gt r r , ( l l l r r i r r qi coLl b. , 1{}( i 5;
( i ol l i ne
qi S' r xr l st , 1
,
i i ) 0?; Nor . r . i r r
1i
r "ol l l r . . l l Xi 9) .
l l \ , \ i r i qt , hr l l t i u . si sr . / r ' l ot a l t r l r t ( l u, t t t i ul t o, / i r r r r pol r r . l r l i zr r , l ( , zi uni
r r r r r l l i l r l r . . r ' or r r I I i r r r r I r ' , r r L' t r l l t i kr l , r , r r r r r i r . r r i l r r i l l r l r r i
1i
por r l , i l i , I Ct r l o
r r r l x[ l i r r r l r l ( . r {. 1i l t l ( t i i ur , r ' , l l t , ' : i ) r . r ' i i r r
l r r t zr , r r {l r
r r r r r r i i . l i I r r I r
,
r r I r r r l o
l I r l l r l i
l t r ' l : r l r i o gl osr r l : r l i t r go l r r r . r r r i i r . r ' , r , or r I r I i r I : r l l r r l t r r . i : r l i r r ; 1r l i l i r or i : r l r . l t r n, l , .
t r r r . t r I r . I oI | | | i
.
r I r I I i I t I '
( '
, t
{
| l r ( . t . l
i i r ' r | r r . l i r I i t l : i r r r r r r r r "r I i r r l t r r r | oz i l i : r l r . zi r r r r i i
.d
l : t l
]:fllpTlglo
Si
4riforico
a per:eohilol IX,
T,
XI qt XtI gi rii1, ilcrimind,rn tnsu;i
lr:tlrl uorros (rospctiy
lniduva
cor-vioaH qi bulbul), ocle tloud, cauzo mdi
I|('ovonro Illnd Bcleroza laterah a,miotrofici (inclusiv
sindroamele de SIA)
qi niringobulbia. In. aceste-situalii se nai impune G*; sd; fa,cd, un aUgl
j:i':lig
$il.or9r1ial
gi fald de com-prosiunile p-iimetor
segrnenrc cewicale
-9i
{uo.r)ulDurur, cal.e artrg-neaz6 adesea tulburxri paretjee
Ei
atrofiee
Elos<i-
r uur)gol|,rlngee (boala I:9tt inalta, .tumori ale giurii oceipitale, iumori
llrl ltmedu laro tnalte, glioze mie)o-bulbare, pachimeningiti
hip'ertrofied
cet l j cal c i nal t e
E. a. ).
,
-,
t' )
lnyJqlo1ati.a .lui-fVprnickr,
afecliure desrul de l,ar.i, cauzal d" de o
tloliciant[,_ de thiamina, (de obicei ]a alcoolicii eronici), asociazA, o oftalfii{i.
I,.lr:qio .(ldeyai
I otalS
),
o ala.:i ic si demenfi, progrcsi.r.d (Vicl,or qi colab.
,
J 071
;
Iilank gi colab., 1975).
' t J
i ' l i r , l .
, . . 1- r ' , , r ,
O PNOBLEME DE DIAGNOSTIC
O.
Iw
paRauzu
3,1 EXPLORAREA SEMIOLOGICA A DEFICITNLOR MOTONII
_
E:plorarea seiniologic5, a tleficitelor motoxii (p&rezo gl
I&-
nrljzii sc faoe prin :
7,) Examina,re:| a,teutd a m,otititd,lii actiue (s a voluntare) ca,ro ropro-
zint:i ansamblul tle'nrlgc[ri pe czre un individ Ie oiecutd, in motl vohtntnr,
incepinal de la nivelul celulelor giganto-piramidal'o ale lui Setz dln cor.
l,oxul prerolandic qi pin5, Ia nivelul muschilor striali, care Blnt axocutorll
dilecli qi nemijlocilj iri miqcirii. Se procedeazS,
tottleauna Ia ca:atninurt,
not,ili,td,lii actit;a segmentara, adicd, invitind pacientul sd, execute tn nurd
sistomatic toate miqeirile fiziologice, alin toato ar"ticulagiile, obsol'vlntlu,ro
{1u atontio amplitudinea, rapiditatea qi precizia executdrii lor.
2) Tottleauna acest examen se comptleteaad, au: a) aag oraraa,fotlai
nnnculare segmgnlure}. b) probele
speciak pentru depietarua pareaalot
(lrobele lui Band, llingazzini; .Gr4sset, Vasilescu, Ba,rr6
-Iiohuror);
u\ enarnenul, staliunii ortostatice (bipeda, uniperld, pe virfuri qi po c{,lciio);
rl) euam,enul mersul,ui, al saltulwi, unipeil pi al
Jugii;
e\ eaptlorarea molilildlii
ytutiaa (a tonusulbi muscular)
;
t) enplorarea motil,itdlii. dutomata
i
g) erti-
d,enlierea et;enlualelor mifcdli, si,ncinetioe; h) eoid,enlderea a:anhtalelor
ni.ycrlr I inrclunlarc,
3
)
Semnele asoaiate sint deosebit ale importante pentul. diagn.oatlaul,
lopogralia al paraliziilor: a) atrofia muscularf, importantit
$i
progrosivd,
ilno{itX de modificfui de excitabilitate electriod, inrlicd ils obicoi o lsziuno
r! Trouronulni motor periferic
i
b) nmdificdrile refloxelor ostoo-teud inoos6,
$uta,nats, a,rticuliro
Ei
dccelaroa roflexolor patologice phamida,ls
il
do
,,olihoraro"
(sinoinezii, rofloxo ds trip16, retrac{ie otc,) contribuio ln, treD,
rt ,l,oa diagnosticului diferqnliial lntrs o leziuno do neuron motor coutl el
8o,u poriforio,
4
)
lluantenul, elcol,rio olaaia, emmenul, fr,M,Q,,
paameai,
oto aai.
rfl(rrdo
Ei
alte euplordri newotiaiologioe (lsu protiodso inrlicnlli d0 dia,tsnortlo
littp gra{lo : lozlnno po ncruontrl r. otor' fi0ntru,l na,u por,lforlo
nl
lo 0o nlvol,
lsliun6 muBcIlor[,, tttlbrrrnr,o funol lonul{, ol,(,,,).
"=:ii;
i!;l
;liiiirilial*;iiiigliii
ii::i:i
:
:21;iii;ilisiisiii:lgslllii*lii;iiiiiiiiitl"i::
1!iE4;jiiti,:iiliiilliiEliiiiEiii*itiiiii1;r!:;:,,
=iEiiiiilsiiiiliiiii:iiiE,E:giiigiilriii;
i
iii;i:ii?;Eiiii;iiEiiiffl
E= ;i3
iiiii=i:i,
t
iiEiiirliiaiii?aiiiiEii;i
s
'ii
i1!i
;;i
:,
-
i;::i::1:;:;!+iiiFi:ii!
=
t
:;:
i'=,i=
ii:+=,
i
ts
::l1iiifi
iii
iii'
giiiiiiiai
i
ia ri
;
;
ii
:
j'u
{::
: i := i
ti
;a?Etl::E!
!
:
i;6i
; 3
i
{
ig E;
IElEgE:E:i;i::
*
g=F;isigsi':;vi=
sF
i: iiEflit;;:*;.,
;
;i.iEEEi;iEi3;i=
iili;?riii;i,iir;"
;::' =:' :?liti I
i:;ii:
=
E
s
fi;:i its
34
E! E. ; 3
e E l l F
o
oE
E Er i Ei i E
"
o' . i
E: ' s
j - : :
r
s
3 iEeiri
i E= ! : i ; E!
i , =? Ei 5! i
; g;
[ ai i r
r ;
: ! i f :
5i ?i
r$t
t \ d
"- N3! 9
, . r , .
i {
{\
r l
{_--_
._-
i . l El ; s
: - A65 F
-
cB: l
. r . : = P. ' : !
9 : "TE T
A A. =- . v
; c- ^ hD
! 1 o t i ; d)
1 Q A a=
I d d
0) . ! l
: t X. d.
s-
. ?!
F. ^i
= N! ! 5
=
; : : -
H
' ;
' l i
E.- I
I
oi t r u
'
EE. . 9E
"5
r : Gt ! I
i ; : ; . Y=
= O^v^
=
o"< | i
^ - NO. i
' - :3 ci
-!l -F
:
I ! i i i
. i
"i
F:
()
l l i =.-.,'
I
- 5
H. 3
3
s*
i F
:
. : >
_ 3
*:
i
- ; - 7
. r , . \ - ^=
i . ' ==t 1=
. :
- -
>
== =a=
>}
T
) ) I t t oot ' t t 1' , 1' pr t . t 1si . t t t i t t . l , r , u nt t t , nt . l , r Ll t l r t i cot obr l l hr
I ) r ' i t l i l ' i \ ' {r
si t , t t
r r r r l r r sl i r l , i r r r , I r ot t l t l ol l t ne ( st r l r r l r r l l r , l , r ' ' l l i r l t t t al , i nt r apar enchi ml t os) , i t l t coso
| ' r. rr.l r Il r hr, Lrr bct Oul oame, pat i tzi t ozt: i l l 1,r' i t,cri l ,ni ene,
:lJ It n.r:cfulitele, enceJalomielitele, boli ilemi,elinizan a (scleroze mulii-
pl i r, l c rrcoencefa,l i te
$.
a.)
1) linceJaloptLtiti inJantile
!;l !l\r , ,lnatistne crani,o-cerebru,le
:1.,3.1.L2. Eemi pl egi .a spi nal d este i psi l ateral i ,, i ntereseazi ' numai
rrrr.rrrIrl o|o, i ar' l ezi unea medul arS, este si tua' t5, cl easupra i ntumescenl ei
.'r'r'iolt,lo. l)c cele mai multe ori hemiplegia spinal5, este asociati, cu semne
r,l i rri l o r1o hemi secl i une medul al 5,: si ndrorn Bro' n' n' S6quard. Nu se con-
rrl rr Lri 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 senzi-
Livrr 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
:rl rr I nl l rozul ui .
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
;rlirr
rlrgcrrerescen!5, progresivd,, e1ectiv5,, a fasciculului piramiclal) so tra-
rlrrur priutr-o monoplegie inferioari (crurali,), care se extinde lent gi la
rrrrrrnbml superior, reallzind o hemiplegie spinalS, f5,r5, tulburS,ri de sensi
l r i l i l , i r , 1, o.
:1.i1.1.2. Paraplegia poale fi realizati atit de leziuni ale neuronrrlui
rrol,or' rxrrrlrftl, cit qi de afecliuni a1e ncuronului motor periteric. Oa atare,
rl i rr rrrol ,i vo tl i rl acti ce, i n acest capi tol vom aborda pe scurt pampl egi i l o
lrlirr
lrziurri r1o neuronului motor central (cortico-spinal), care pot fi re:l-
l rzi rl ,o rrl numai Ir ni vel spi nal (i ndeosebi ), dar gi Ia ori ce ni vel al l reYrn-
rrrlrri, rlrcr"r, sint interesate fibrele piramitlalo (ad.esea cu realizarea de
l ,.l r' ,r,pl rrgi i ). Nr: vom permi te ca i n conti nuare s5, abordi ,m separat probl o-
rrrr,lr rkr rlitguostic topografic qi etiopatogedc ale paraplegiilor in sensul
l rrr' ;1 rrl rl rrl ' i tri l .i ei (ati t pi rami dal e, ci t qi peri feri ce).
l) I't,ntp[egl,u spinald,. Forma cetu mai caractelistici este realizatii
rl rr i ri ri rl l ornul de secti une ttansvers' i ,, care i ntruneqte o para' pl egi e cu
rrl rrrrrr,
tri l rr,rni rl i r,Ie,
i nsol i t5, tl e anestezi e pentru toate moduri l e al e sensi -
l ri l i i ,.rl o, pl roLrm
Si
de tul bul i ,ri vegetati ve qi trol i ce, cu neti , l i mi tal e snb-
l rrzi orrrL' r,. Ni vcl tl l ezi uni i me:l ul are se poate preci z2r, pri n apreci erea modi -
l ' i ci i l i Irl rrrl l orol or qi l ni vcl ttl tri trrl btrdri l or rl e sensi bi l i tate
;i ,
i n rnrtrl
ol rl i gi rl ,ori rr, pl i tt crrrrnonul l ./.0.1i . tl i pri n rndi ogr:r,fi i i o $i mpl o
Ii
pri n
l r r r l , or l r r r l o r ur ni ; t r r , sI , .
' | ' i r , I r l r r r l i kr
r l o
l r r r r r pl ogi o
spi l t r r , l i i ( si mi Lt , t ' o sr xt {i uni i t t ' r l nsvot ' so)
1t ol ,
l l i
l r r r r l i zr r , l , r r r l t ' cr r l 6 t nr , i vr r l i i t t ; r t
l l t ' oot t sc:
t ul t nl t t ' r r si t t t t i I n( nl ul r l r o, t ni r r l i l , c, l r ol i
r l r r r l i r r l i t r i zr r t t l r r , l r ol i r l cgct t ot ' ; t ' 1i vr ,
1.
t t , .
t : l
! ) J. ' uxt , 1t l , r ' ui t t
l r i t l i t t r i l r oi t l r r
l i pl r r t l t t si i pt ' i r r st l l t t i . t t {r r vI t i ' r t I t t I i t t t ' ( ot ' I t t
zi r at ' i ol ol or pl l l at t t t t t l i l l t t c r t L' si sl l t t t t t l t t i vt r t t t l r l r l - l t l t zi l i t t ) ,
i ) t r ) ( 1( ' s( r
l l t ' ol ol
mati vo care compri mL pi tti ri t' ttl portti n, bol i tl erni t,l i ni zrtn l r'
;.
rt.
' 3l Purapl eei a
paraunl ' ral d este reznl t.r,l ,ul l c' zi uti i l ot' I t i I I t
'
I I r t I t I r '
:' l l
l obuftui pai aci ntrdl (meni ngi oame parasagi ta' l e, troml rol krhi l ri tl t' si ttrtr
lonEituclinal, sindroame bilaterale ale suferinlii a altelelot
(j('l! fl)I'iI l(| itI| | ('r'i
oar' 6 etc.). Este i mportant de rel i nut faptul cd' dcfi ci tul trtol rtt'
l rtrt
l r' l ' i
precetl at sau i nso-ti t de cri ze
j aksoni el l e l oca i zate Ia nrt' rrtl t(' l | i tti i rt i orl tr' ,
lrecum $i
de tulburf,,ri sfincteriene.
'
4l Parapteqto-
pri n l eatuni nt' ul ti pl e. In atel o-
$i
al ' ttl i {)s(' l i ' r!tzrr txrt(' -
brali,,'multiflel"e hlune de clezintegrare ischemicS, pot a,fecta, t'tt
ltrtrciirltrtrr
fibrele corticoslinale ale membrelor inferioare la nivelul cmisli'rrrltl cllrr
brale (centrii dvaii, capsuia interrri,) sau in trunchiul. ccrobtrl, Irrlt'lizlttrl
paraplegii sau tetraplegii (cu predominenll pl raplegiei). Pfi n t ttrrtrrt'r t ist t ttr
iimil-arJse realizeazfi p:r,raplegi1le prin ]eziuni multiple din sclororll llr plii('i'
din unele encefalo-mielite, din boala lui Little q. a.
3.3.1.3. Probl eme d,e di agnosti c topogral i c
Si
el i op&Iogeni a
l i n
si ndnnnr l o
paraplegice,
In diagnosticlt'l sind,romuhti parapleg'ic este necesar sL so
I),rtrrrrlgr'i
i n mod l ogi c
$i
succesi Y url f,5.toarel e etape (Ri ser' 1952
;
-$ol l ci rrrr
'
l l ){i ?;
Bodechtel ;1965) : a) di agnosti cul tl i fercn.ti al i ntre o parapl egi (' ri i {r.,11rr1,' rl
doparapl egi e"; b) di agnosti cul de ti p al parapl egi ei (pi rami dal i l
;
tl rr ttl tt
ron motoi peiiferic; pedcadon:lla' poliradiculoncvriticd,
.
polittrrv.t'il i|l
;
rnuscul i l ri )
;-c)
tl i agnosl i cul dc ni vel i rr crzul parapl egi ei pi l l rtti rl rrl rr (rpi
rtald qi topografia acesteia; cerebralal)
;
d) tliagnosticul etiopttl rtgcl t it"
1l Pseu,i l .oparapl egi i l e Yor fi el i mi nato i n pl i ma et:tpi i i t tl i rrgttosl i l rt
l ui :
:l ) Pseutl oparapl egi i i e pri n artri te acute sau cl oni cc qi
tr)l i rr
rrl l l orr\
protLuc fal se dAfi ci te rnotori i pl i n anchi l ozd,;i pri n i mobi l i zrl r' (' i r' rr l ' r tl Ar|ri '
{rtumati smul
pol i arti cul ar acut, pol i artdta croni ci l c\-ol uti l i ) ul )t)||(|i Ii Ii t
:r rrcl l i l opoi ei i ci ,, artrogl i poza congeni tal i l , rnul ti pi f,, coxNrNl t)z"l t'
f.
:t
);
b) Psetttoparapl egi i l e pri l afec.ti uni carc cl ol ucl l zri cu rtti tti l .ti l rrrl o
rri i , cu l taxi e
gi /sau cu tul buri ri t1e echi l i bm (ata;i e 1' rrl -rcl i t' i i , si l ttl tttrrtrtt'
r{ ul ui rnel ni ce, erodoataxi i spi l o-cerebe}oase' si ndrol l ntl 1,cs(i l rrl l ;rrrr, ri rr
rl l orrme cerebel oase, al ,axi a frontal [ a l ui l ]rrrns)
;
.
tr) Pseudoparapl egi i l e pl i n tul buri l i psi hi ce :
t,pi rtrrpl r' g..i rr
"
rsl l t' i l rr
I
r | | i r Zr ) . : t l ) aZt a.
2) E' Lt' rdroam,el e parapl egi ce Q(ul ,e sutt,
Jrnrte
rul ti tl , t' usl i l rri l l ri tl . ti '
r rrrrri oal cl e probl eme di agnosl i ce :
t ) Mi et i t et e ( t r ansl ' c*er i n spcci al , dr t l qi col c t l i st ' t t t i l t i t i c si r t t r l i l t r zr ' )
r i l ol , i co sau bact er i cne, ant r cnc: i zi l i l nt t i t l t l t l t mal i c, bt t t l r t l , o i l l i r t r '
l , i r l r r '
l rl ogi o,
ctL scrnne pi rami dai c i rl so{,i tc.si r.l tr t' ul bl rri r,r' i tl c stl l rsi l ri l i l rrl rr
u"i i
sl i rrrr
i ,' r' i ,' t,", t,u sau JarL sei nnc prt' tttttni tol i i gcntt' i i l t,
5i /srttt
l tttttol ogi cr' .
h),41.i al ,o-rai l i tttl 1el 1tpv' i N1i 1t(r' cttpttrl i t' rtt.i cl n-1tal i rrul l ,i ctrIo.ntt' ri l tl r.t)1wl rl e
l , r r l i l ( , 111, r l r l l d0 obi t ' t ' i nt ' r ' ot t t ' I i I t t i I i t t
( i i t ' vr t zi l t ' , pt t l i t t t l l | l r l i zi l
l r i r t , l
Pl | gi i
sr t t t l , et ' t ' l t , pl 0gi i ( : r , r l t ' s0l r
( ' t t | , r ' ol t t ( i 0 r t st I t t r l I l t i r l ) i {( ' l l l t t r ' l {' t l t ' l | , zl t t t t I
i , l r , r t l l r r r r l ui t r t i l l , ot l gr r , l i l i r r . i c r . , i l r
1r l oI or r r . r r l r r r r r r I r r i
+r ' r r zi i i r ( scr r r l r r ' l r . r ' : r r l i r , r r
I r r t t l r , r ' i | , i cr r )
l t t i nt t r l t z{
I r r {f r r l l l l l t ' t t t l r I t t | : t t r ' ,
A
t 31l
c) l \ l i t r r l , i r t t . [ nt t t t , t i l t l r
l '
r l t r . r r l r r r r t t r i ( i r r l
l r i t r r pl cgi i ,
l r l ) oi i l r r ' \ {' l l l l ' i ( r t
l ol , r ' r r , I l r r gi i r
( 1l l r r i t , r ' i Lt t I I r r r t r r , t t l r \ r zr l r l i r r t r ol , ot i i , t t r l l i co
1i
vt , i Jr r l , i t l i vt t ,
r r r l r , l r nr r r r cvol t Lt i ca, st : ot t t l r r nl r i l j i r , t r r r l r . r i i r , r ' cl i 1i i I ncl vi l ( ) r ' cl l t l l i ( ' i . i J{) l l Ll l ( t 1f
,l rr l rrzi rrno trcyl axi u,Li (i rrrl trosol ri i rr,rrrrLcl c pi l arni dal e) Ii pscsc. .\Iocl i l i i i i ri l o
rrr 1,.(
l .l i .
si rrl , cl ,r' actcri si ,i co.
tl) l'olk nieli,ta, &cut{i e ltri. II ei.ne- Metlin intli, totdeauna in cliscu{io
lrr rtlr copil s:l,rt Ia 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
' rl l ,cl rrrl rr,
str:i ,r' i i goneral c), al gi i pori feri ce, ce{al ee,
ytl si ,turi ,
radi cul al gi i ,
.r lgii rrrrcl,h:, fa lialgii, semne meningeale (subiective gi/sau obiective).
| 'rr lrr
lrlr{iir, loate
ti dintr-odati' masivd,, hipoton:i (,,paraliz izr, de dimilea-
i rr' )
rl cscl i si de West), cu refl exe abol i te, sau se poate i nstal a doar o mono-
lr
l,'{ic, cventual paralizii parcelare. De
^obicei
fenomenele generale qi menin-
u( rl(i
l)r'ecod
partrliziile cu 3-5 zile. In unele situalii, pierdelea blutali,,
rl l rrrrrrl ,i ci i ,, a fortei muscul are este i mpoftanti , qi erti ns5,, ati ngi nd mu;chi i
rr.rlurilor', i:r,i trunchiului, ai membtelot, cu extensie chiar la nivelul mugchi-
lol irrrrlvrll,i de pericarionii bulbopontini. Atlofia rnuscularS, este precoco
si i rr rrortantd,.
q N euromielitn optiad, ( oftalmoneuromielita, boala l,u,i Deuic) deba-
I rrrr,z
ji,
r lo obicei brutal, de multe ori paraplegia precedind semnele de nevriti
opl ,i ri i , (Dri ,gi nescu qi col ab., 1962, 1963).
l') Ilxistd gi cazuri ile scler oad, in 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",
g) A.lte encefalornielite pot realiza in contextul clinic malifest5,ri para-
;rl rgi co
brutal e, I& care se asoci azd qi semne supl aspi ual e.
\) Spond,ilita tuberculoasd (boala lui Pott) trebuie suspicionatii tot-
rLrr,rrur, in liulrr unei paraplegii acute la un adolescent (indeosebi) sau Ia un
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
rl rr pl ri ,l rrrryi l o vertebral d,.
i) llr,nrtnu,I primi,tits rah,id,ian al ltti Ewing poate realiza o pa'raplegio
lrrrl,rr,lj1, Lr, copii qi Lr, atlolescenli. Djagnosticul se verificS, prin imaginilo
lrrr l ioglrr,[icr: plulifocale, in geocle, pludver"tebrale qi costale.
.iI
JLl,l,c tumori primiti,De se,u securl.dare i,ntrarahid'iane, intra- sau extrn.
rlrrlrr,lo pot plorluce paraplegii acute
gau
cu ingtalare rapicl5,, precedato
rrrlrnrrir rlo o sourtl periorLdfl tle rahialgie qi ciaudicalie spinal5,.
lil l[t,n.in,go-mteli.ta sifiliti,aii a,eutti intfi, astS,zi prea puiit in discufio.
l) Il telom,ataciile (rumolismen'tul, total, transaars
li
ranxolisrnentul
ttpintl rnl,rtrior) pot realiza fie paraplegii, lie tetraplegii dramatice (Lazot'
I l r r l r . l l ) ?2) .
ill 8 intlroanzele paraplegice 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 evolu-
l,ivil, (url rn:r,i rl(losoi) ou puserrri). Iformele ou evolul,io lont progresivir,, liiirrl,
l rrrrl orrrj
cu s{)rrrno mi ci r1i i noorto h mombrol o Bupori oa,ro qi . fi ,rl l rr,l to scttrno
nrrl rl rl -npi rri rl o rl o scl orrrzi , rnul l ,i pl i i l i rl i oi i , rl osi gLrr,
l rl obl cl no
tl o rl i ul 4rrusl i n
r l i l i r r r r r r l , i r r , l cr t t r t i ol i l , ol o or ot r i co, or t cot r r pl osi t t t t i l o t nr dt t l i . t t ' o
r r i
ou i ! nr l l r l oi .
140
r l i l , i , l r r s1t i t r r , l r . , l l r r ol r i r r , i , i t t ni i , r r l t t t t t t ' l t t r l l l r l i , cl , i t , l c; r ,
r . l , i t . j r r l ol sr r l r cr , i ot r r o
t t cvl r r r i l t l r r l r , t r . l r i r l i l t t zi ut t t l r ' t t r
' i t r i Ll l i t nc. l r
- l . zi r r r r i i ,
r , r r n, , i r r r r r ,
1
r i r i r r r r i r I I r I r r
l l r , t r l l t l , r r r r t r ' r r r l t r r , l c, r , u sr , t nt t o r r sooi i t i ' t r cl t t ' l t t ' l r r r t so,
vcsl i br t l r t l o s. i r , . , r , r r . ur i \ nr ,
cr t nl i al pot r l t t r i . l i ugl nost i cu1 S. . \ I . I t r 1ot r t t r r
{' i i l r r r r r l t r sc t l o i r r vi , sl , i gr r , {, i i 1, r , l . r ,
t r r r l i r }e1, i ce qi i munoe l e ct r of ol e t i co scl j ce, I [ i l |
r l r , i l i l l | s
r l j r r 1, . ( j . 1, ] . r r r l r r 0
r r l qr r r ner l t e i n pl us pent r u di agnost i ct l
, l ,
S. I I . , i l sr , cl t l r r cr {o r u' t . r r i i l : r ,
;l sti i ,zi socoti ti , ca o JJoaU, autoi muni rl e aut9ag1gsi 11l 0
(l ' cl rrl ro
l i
,l ol vi rr,
l l ):14
;
Il a.bat, 1957
;
Li i rventhl l
l i
col ah
,
1960
i l rl rl srl en 1i
c' l u i r., I 15tt
;
I )nmi i , qi cotab., 190-1, 1965
;
Schapi ra qi Pal ki
1961
;
Vari Su rrrl r,,' I l l ri ?
;
l 3r *us qi col ab. , 19i 2, 19?9; Coj ocar u
l i
c, ", Ja\ , 19?8; ' Pop6vi ci u
r yi
t , r r r . r r ,
l $80; Kri ght, 197?; Col by qi col ab.' 1977).
b) Neuromi el l ta opti cd' ( oJtftl monti el i l a, boal a l ui , Dpui c) poi r,t;o ,
y()r
f
i
o evol ul i e subacut-croni ci i , x11
..tl ebut
?xl i l l l rrl eti c - parapl i rgi c, rl .5i i i r
rn:l j ori tatea si tual i i i or debuteazd, acu' l saLr sr-i bacut (Dri i g-nncscrr
1i
coi :rl r.,
1962. 1963) .
cJ Mi el i ta
.cro
,i ci i ,
.l ueti cd
-(Er.b),
p.oru1' 1egi n
spas t,-ttl i cd, r:rt:d,oti .l i l i .
l i cd" u, l ui XIarJun gi si n(l ronr,ul tui Gui Ll ai n
ti Thi on {asoci oto
rl c s,.i rrrr,,
de encefal i ti , ci l tabes qi .cu mi ei i ti l Erb), frqi ysnl s
al tddati r, si rl .r l r.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
l r i pef r l bum i nozei qi po^zi t i vi r at ea
- r eact i i l or B. W. si 5 benzoi r ' , r 1r i r l r r . l r r , ,
' . l r r i l i ci
di agnosl i cut . Tn pl us. i n pat apl egi a
r pasmodi ci c1or l . - si t i l i t . i . r ,
rr. lui Marian apar gi : keratiti,, tulburd,ri psihise
importante (ca11,c1;r'r'irr,1r qi
, 1, ' t i p demenf i al l
; i ,
adeser . convul si i .
J) Compresi uni l e medwl are de di ver:e naturi (tumoral o
sa,u i l rfl rr.nr!r.-
colii, primiiive sau metastatice, subdurale, extracluraLe
sau intramoriu lllr.o)
|eailiz.eaad,, in funclie,.de
livelul
acestora,
_plraplegii
sau tetrrrpkrgii. l,)rirr'
1, , r nj ' i mul l e pobi bi l i t i l i de r eaLi zl r e a del l si [ 11[ 1
6e6o, ' -
- 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 bi l ateral ) precedd, i nstal mea al efi ci tul ui
motor cu ci tei a si l ,,l ,i ,ri ri rri ,
Irrni, sau chiar ani, fenomen cu male valoar'e
diagnostici.
-
Al teori parapl egi a esto l ent-progreSi va,
de l a i ncerrut sDrrrt i ci l .
,l rr de mu l te ori precedal d, cu mul t ti mp i nahte
de fenumene tl o cl nurl i crrl l ri
$pinal5, oel mai adesea fir5, clureri.
- Alteori evolutia lent-progresivl nu esls precedati, de fonorncrtrr rlo
rrl :urdi cal i e spi nal i , i n scbi mb pot apxrea
1y15i op11i sfi nctori ene pl nooor..
- Dvolulia cea mai tipicS, este unndtoaroa:
mai intii faztr, rodlc'.
LrrL ilureroas5,, apoj perioadi, de clauclica,lie,
apoi sindrom Brown-sdqnrrlrl
r..i , i Lr shri i t, parapl egi e spa8ti ci ,, i nso!i td
5i
rl e tul buri ri tl c scusi bi i i t.l t.o
( r ' r r r c t l e mul Le or i
Pot
l i Psi ) .
Compresi,uni,Ie rneilulara ceruicala superioare prorluc
rnono- s^,ll h.rrrl.
plegie, urma,to r1e tetraplegie spasticS,, cu
tulburd,ri de se.sibilit;,6 ,rr
l I l vet .
C ompresi:,unila
-
aeraicd'la inletrioare rea5zeazir,
o paraplegio fiptrsl,l.ft
Bubj u,cent5, i nsol :i ti r, do hrl bul [,r' i pftreto-atrofi co
tl c ti p *i dl cri i n,r'
' i
rr.rrr.
Irrel o supol i otttrr
(Ll r- D' )'
Oomptroaiunila nvdulara dmtalo ttti,,Lthaa,zi'i,
1r'oooc. 4ollioit. rnol,'rlt
( t l r r , 1, 0r i l i l l ngr r st r ' r l i i t I I t t t ; t , I t t I t t i t t t | t l t t l r l t ) ,
( 1l t
nl r nl i f i i , l l ' i
Hi
r r l o r of l oxol or . ( j I
t l l .
I
,fl
l{tl
| | i r l o r l | ) | |
(
) | | r i | | i ! |
( .
( r r r r t , i r k r r r t r r l ' r I ol { r ' | | l t i r i i ,
l 0t r l t ' r r
sr , r l i r r l l | zi r r t r i i ) . Axl l r r l , t l t '
pi kl l l , i t r l r ol r l r t oi l i l r t t i k) Ll t t i vr r l r r l l ) t r , l r r z, t r l l cxol o cr r 1l t , t l t , l , o l r l xl ot r r i t t t t Ll
rrrrprrti ol rtc r' ai ,l nhl i ncr:r,
1trozonl ,o,
rl i u rl l l (l \(l l (i outanato l rbd{)rni nl l l c rni ,i l ooi i
ri i i trl i rl i orrro si nt abol i te. fu sti ti trtl r, i rt compresi uni l e sub Du, r' cfl t-rdo
:r,|rrIl rrri rrIrl rr so mcnl i n pi i ,strate. In cazul unei compresi uni sub l ), r1i tl ea-
ri rr
l,
r'1, Hoglrrorrtului Dro se poate evidenlia semnul lui Beevor (itr1, de Arsoni
,,i
l ol rrl r., l 1)?7) : l a ri tl i carea capul ui
$1
a trunchi ul ui , ombi Ji cul se depl a-
rrorrzir, irr sLuir datoritd, laptului cd, porliunea superioard, a muqchiului ilrept
rrl rrl orrri nal pri meqte i mpul suri motori i , i n vreme ce porl i unea i nferi otr,r' :i
r . i r l c
l r i r l l l l i zi t l , i , .
( lr
nn?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
prrrl rrl , i a,r' rtfl exul rotul i an (cu i nchi cl ere l a l tr-l n) este eri agerrl t. 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
rrrol i l i l rrl r, i nftr' aci i , un caractel fl asc, cu fenortene de neuron rnotor pcri -
I r ' l r ( , -
liut prcsi,unile m,ed,llla,re s&ar ,te realizeaz5, paralizii fd,r',i, sprnne pira-
rrri rl rrl r,, i tr schi mb cu nete fenomene raal i cul are. Astfel , compl esi nni l e l a
rrir r.lul opiconului (L,b-S?) se manifestd aalesea doar printr'o paralizie
llrscii in tcritoliul sciaticului popliteu interrr, iar compresiunile conului
r r rlr I rrlir r' (S, - Su) se recunosc pdn a,bolirea reflexolor anale, prin tulburdrile
rlrr st'rrsibilitate perianale (in qea) qi pril marile tullurd,ri sfincteriene, :rbia
rrrri lirzirL pul,ind si, apali, ma.nifestS'rile paraparetice.
(lonpresiu,nile
la nioelul cozii de cal realizeazS" paraplegie iloar in
l rrzrrl si rrrl l otttnl ui total al cozi i i 1e cal (r5,cl 5,ci ni 1e Lr-Su), i nsol i te totdea-
rrrrr, rlrr lulh uri,li de sensibilitate extinse r:e dermatomerele restectiTe si de
rrrrrl i l ,rrl hul l l i sti ncteri ene. i n schi rnb, s]ncl roarnel e t1c coml i esi une nar- r r rrr l i l ,rrl bu l l l i sti ncteri ene. i n schi rnb, tle compresiune par-
rotolii si senzitir.e in
{i rr,l i
rr cozi i dc ci rl se caracteri zeaz:' i pri n ttl bur' dni motol i i qi senzi ti r.e i n
l l r, l i r
r
(x, Zl l (l e
Oi t t SO Cal aCl el t zeaz: ] , prl n l : t l -t oUl an m0l ol rr
Sr
Senzl t rl ' l . e l n
Irrrci i c rl rr l i 1ul supe.ri or (L.-Ln), mi j l oci u (Lu-Sr) sau i nferi or (Sr-Su)
r|r' rri rri Ir' orrr de cori l i l tl e cal , ti mul (cel i nferi or) i ntl r' uni n.l
$1
tel burdri
,
timul (cel inferior) intrr'unin.l
$1
telburdri
r Ll i r r r . l ct i r . t r c i r npor t ant e.
I'rrtrxr'lt erpansiae intramed,ulare, indcosebi cer"r''icale (glioamo
,1rl rrrIi Irrrrrrrrrrr, i nbcl cul oame) reakzeafl d, tabl ouri semi ol ogi ce cu totul
prr r' l i crrl rr,rrr, r,rrrt i .rebui e cu gri j 5, di ferenl i ate cl e S.I-.,.A. sau de al te si l -
,l rrr:rrrrrr rl o S.1,.4., precurn
1i
de si ri ngomi el i e. Astfel , aceste:n se mani ft:sti i
1r
r i rr l r' l l l rl rl cgi i pl ogl esi ve cu semne pi rami dal e (mai expri mate 1a mernbl ei .o
rrrl i ' r' i orrrrr ou sl l rsti ci tate), cu al j l ofi i muscul al e de 1,i p Aran-I)ucherrner,
lrr lrrrr, firr rlsociazili, tulburi,ri de sensibilitate suspendate (irritirrl) sau sub-
Ir,zi orrrl i r rl o l ;i p si ri ngomi el i c, cu cl i soci al i e termoal gezi ci . Pot s* l pa,rl
rl i rl ru' r,r' i corrl orri rl e, pl ecum qi dureri de ti p radi cul ar l a metrbl t' l e supol i .
,rrrl r, l i r rl r,ro sc asoci aai qi fenomene
yegei ati \.e
(va,somotori i gi sudol l rl c)
rrrr1rol IrrtrItr. Irnngi nca rni el ografi c[, descri sl i nci , cl e Si card
Si
l {i ],guc1ri l u
(l l tJt!, ci l rr,fi do l l ,i scr' , 1952), tl esemni nd aspcctul i n fus al ml drvei di l attt,o,
ri u Hcul l l ol ' orr sl rbsl artl ei radi o-opl ce po pi ,rti l c l ateral e, snb fon:n:l l r rl orri i ,
rtrIri rrrc l i rri i r,rtr l i rstri nl rto, vi no si i confi une tl i agrxrsti ctl tl r trrruol i , i rri ,r' i t.
r r r . t l r l : r I i i .
a) I i ri rtl l om. i tl ' i .a, rrsl rr ttl i t,ti v l r;i ot' tl c t' ccrr ttoscrr t,, pti n i l soci crrl r, l :r, rrl r
I r r l r l or l r l r r
l ) r , r 1r l ) l , r t ' zi i
( sr ur l r r l , l t l r r , t r r zi l ) pi r r r , r r r i r l r r Jr l , i r r so{, i l r l c l r r l nr l i l i
t42
r l l ' s( l l r si l r i l i l l r l r , , r r r r I | r , t r r l l t l , r , ( i r r i ( i r r l )
, . l r r r st t l r l t ' zi ot t i t l
r l | . l i ; r si t ' i l t gr r t t l i r ' l i r ' ,
i l l I t ot . t ) I . ( f t , 0| ( , si r r l t t , i l t t l l r r r r i t i i , r r r l i r t t r , i r r l t scl r t t I t t I , i I I t t I I , r '
,
pt ' r ' t l r l t t I i t t l t t t l r '
l r r r r i vt i l i r l t r r i i r r i l . r ' qi l r 1 r l . 961r , l ' r , l r l r t r r 1t , r l r l 1r , l , t
,
i t , i r t r , l i . zr . i , i l . i t r l I t ' r t
t i i l r r si I a1, r 0l i i Lr r , t l c {i D , \ r ' ur ) , 1) ur , l ( ' r r r r r ' .
Nl r xl i l i ci r l i k, 1, . ( l . l l . si t t l : t l t -
r . r r l r . i : r u l ui i r r
i t np, r r t : r t r i t ' ( cvel t t t t al r l i scr t i i t l t i pcl t r l l t t t t t t i t t ozi ) ' l ' r t l t t ' ; i '
,.ri st.r, si ri ri gomi ,.l i i i u evoi ufi b rni l i r1pi rl l i , .. 5l .crrj l i dri rl i rtrr qi t' tt i l ttrtgi rti
rl ,, l i ni orl ol i n,,Lerrzi
peri me4ul *re' t cr,r, i ' tumor.i l c i l tra,rcrl ul i rtr,, si i ttt{i i
, r r r . : r r t c d i a
gnosl
i cul
- d
ev i l c f u: r r l e di [ i l i l .
I Deqe tr eresccntek sp i no-cerebektase
(boal n l ui L' ri odtei ch
l i tx' tl o
tl rr' t' i tt
,, r,L,i l oasi a l ui 2i e*e
-Mari e)
corl rrporl ;i t, mi ni me ol orncul t:
l ti rrtrl
i .tr
' i trt' rrri rl l l e. ne Dri m Dl an si tui ndu-se sernnel c cerebel oasc
1i
tl e col ' (l oi l l l (r Int$'
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'
rrila,iiegia li"ait iAaia cu contl'actur5r asociazd, in contextul
glrtrLiologitr
.i semnE cefubel oase
(uneori di screte), pe l i ng5, un caracter eredo-ti l rtti l i rt' l '
hl Arahnoiditele sqiinale compresiae
(diJuze sau local.e.);i
-art'lmo'n
itt
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
iruronsta,ntie ale Ir.C.R,. (in funclie de efectuarea punciiilor etajat., .tl.5ltt
0rr,i ncrequl at $au Dar-t-i al , cu l entoaxe de i ntoarcere l a presi ul l erl ' i l ti l i rrl i i t
l ' l "cl j ul "fi i ntl mai i et i n pozi l i e aqezati deci t i n pozi l i e cul cati ' srtl i l l v{rr$)'
j \ l i r . l oer at i a
( . st e car acl ei j sl i c, ( Ar seni
$i
col ab. t 9?3) '
i) Mielopatii.le subct cute
Fi
aronice t:ascwlare pot realiza palilpirt(^'r'- rlrr||
rrrrlallegii le-nt-lrogresive, al cdror iliagnostic este extrem tlo tlifitril
1i'
,,,1r.,si ,r,.-se face
pl ri n"el i mi narea al tor cauzer di agnosti cul l or prtNri s ptti i tttl tt
so stnbili cloarlrin arteriografii selective. Se qtie cd ischemiilr t crlrrlrrr!
pot fi real i zate pri n l ezi uni Yascul are pri mare gi pri n compLt' si t.ttti vrtrt tt.
]rrrt in cadrul inor afec.tiuni ale m[duvei
$i
ale rneningdor ((irrrrritt r,ti
Ii rxr(l ot, L966, ci tal i cl e I-,azor"thes, 1972; Lazorthes, 1972)' Atotrt-
ryi
rur' l ' tt
r iosclo.oza vaielor lpinale este mult mai rar5, decit arterioscl:tttzit v:trr'1tr'
ct' r' cbl ul e (Jel l i nger, 196?
;
Lazorthes, 1972).
i ) Sel erosa tl ateram afi ,i otro.7i cd'
(BLA) este u$ol ' l l e rtl cttnoscttl '
1tt' i tr
,r.zr]nt'zl atrotiilor musculare tipice, indeosebi dista,le la mern5lrrlc sttlt.t i
i ,' rrt (cu si ndrom Aran-Duchenne), cu fasci cul al i i
)' l i
c-u somk) pi trl ttti rl rtl rr
lrr iorite membrele (mai exprimate totuqi la membrelo infolioa't'c).
k) B i nal .rcamel e de scl eroBd' l ateral i i am' i ol rofi cd pol , l i l ea' i i ztt' 1t: tl rr l i rrt' tl rr
rrrrrl t,e i rl ecti uni : compresi uni cer"vi ca,l e tl e tl i verse naturi , pa,chi rl r(' rri rr!{i l t'
.r'r'r'vic:
c liipertroficd luetice, arahnoidite., encefalomielil,c fortno
.irrrlrr',
' r ' r ' r l ' r r r i nl ni
spi nal e
( a: a- zi sc
' , cen1r ' opt ' l
i t er j ce"
) .
Ll l r unl i LLi st r l o v. t l t ' l r t "
i r r ,
.
, I r r | . . I
.
, . i nr . l r ( ) q. r . ( Ar scni
! i
col r b. , 1973; l ) r agi l ncsct t {i r {' l r r l t . , l l }l i : i ,
r 1xi 3, t 965) .
l \ Stndroatne' p&ropl egi ( ;i
l el rupl egl te
l tol
si i aprl ri i ' i l l Itl l l nttl ttrl xo
. r l i , , , t i r r r r i ; r l r '
l l ' ur ol ; l l l ui I n, i t ut ' l r cl i f cr i c. {' ar o vul l i r r Lr ur r l l r I r ' i t t st t I r . r t l t i l ' '
l r r l r r r r r r : r t ut
. - i
cl l e . c di l t ' t ou{i r r zr i l t i or , i l l conl r , r l ul t l i t Li r ' , r l "
1l ; r ' t ' : r ' I l | gi i l '
r r r I r . t , r ' : r r r l cui i l eDi l uni t hr l e: gr ol i ot r t i 0l i l , asnl t i l cLr l , i i sa, usubor l ) ni ( i i l , ( [ i ( 1r r ) l r l t ' i i )
r r r r r i , , t l . r j l i , i - Lr i i ' hr l l u, r t - M' r r ; i . , , l r ni ot , r ot i i l 0 r l pi ni l l o pl r ) ! {r ' oi ; i vr r , pol i t t t r vl ' i i ' ol t r
( $i
1l l , ( ! 1t ( ' l i l gl t r r r t r l r , t i i ) , l l ul i r . i r ' r l i or t l ot t ovl i l , t r l u.
. , \ l ni l l l , o[ , l I l l l l , ( 11' i ol
( ! , ( l r , f i
, i t , , , , r r r . , t i , r ' i i . , I 1i ' r t i r , l i zr r l r ' \ i
dt l t d, i l t nt t r , t t r t t t l a' r c
{r l i s1' r ' ol ' i i
l t t t l t t ot t l i r r l r
l t t r '
pl r r r si vr , , r r t i 0zi l r , , p0l i r r r i ozi l r . ) , r r t
. t ' l
t l r , l r i {r ' t r r ol ) r r r r r t i r l r t r yot ' t l r r t I i l t gr t r t sl i 11l l l ,
I t r oo t t
( r , r
i t t I i i t ' t t t i t t l t l | j i l , '
I
l . l : i
i | . i l . i l . I ' l l r r l i zi i pl i r r l ozi r r r r i r r l o r r r r r l or r r r l t r i nr ol i t l ' pr l i f or i ( 1
;i .;1.:!.1. Oorakt!;i i rttorfo-ttt tt,cl i ortrr,l t si se' ni ol oqi ce An l ezi l l n' a l t(uro-
n u l.rt i tttol orperileric.
l) fic
5t,ie
cil, indiferent de setliul lezi:lrlii, si,nd,romul d,e neui'on molor
yrri.li'rit: irrrplicii o serie de caractere generale : a) deficit motol' proportio'
rrrrl crr rrni 1,i ,!,i l c motori i l ezatc
i
b) hi potoni e muscul ari '
I
c) retl exe osteo-
l (,rrl i rorl sc di mi nnate Bau abol i te; d) contracl i e i di omuscul ari pi ,strata
l rrrri i
l a rrr gr:rd al atl ofi ei muscul are; atrofi e muscl l ard precoce
l i
i rupor'
l:rrrl,ii, irr crrzurile in care este compromisi, integritatea neurollului motor;
r,) plczorr{,r, fasciculaliilor (indeosebi in leziunile pericarionale)
;
l) i'eacliile
rlrr r lrgruorrscon!,ir, electrici,; g) modificlri EMG caracteristice de tip neu-
f 0l f cl t .
3) ]tr-'ris&l insii' o serie de particularitii,li ale distribuliei paraliziilort
rrl rr rrl rrrl l i i l or' qi al e acti vi t5l i i el ectri ce muscul are, precum
$i
al e unor si m-
;rl rrrrrrr
rrsrxri a' te, ca' re prmi t i l i .ferenl i eri . al e tol tograJi ei . l ezi onal e: a) l a ni
vllrrl
lrcrirrrrrionului
motor
I
b) la uivelul ridS,cinilor anterioare
I
cr) la nive-
l rrl pl ,rrrl Lri l tl ) l a i ri vel ul nervul ui pel i feri c.
lf) I'onlrr aprecieraa topografiei ieziuniior nsulonului nlot'or periferic
rrrlc ut,ifii, olrnoaDtrea pri.ncipalelor ac!'inni molot'ii segmcnlo,re
;i
coretpon-
t nla. i erl)etie' rad,iculo-med,ulare ,ti, perifc,riaa (a. tabelele nr. I' II, III
Si,
Ii o.
l [i , 19, 20,21t
@up}"
Ii i ser, 1952 qi Chusi d, 1970 - cu moal i fi c5,ri l o
r r ol r n{ r t l J.
TABEL NT. I
lligeirile capdui
l I i gl . i r i l {r r r n' ml , | 1' l ol st l p( . r l onr o
' l Al l l . l .
Nr . i l
i pi nosul r I
al r l ui r r r r , ,
ndul r r i r r f .
, l
t ) r , , \ , . r l l l
i ) r r l r i : r l
i r r i i ( 1( ' i
r , r \ |
{
( l i l l l : Ll
hoi r l r l r i
r i Lr l Nnr l l | i
Dlepli antcrioli
Sternocleido-
rnosl oi di eni
Pr' ni i ner\ . i ar. ni eni
n. spi nal I - ramura n (l ol r: l
ccrv;cali
l , l \ l ( r si l
I i l l ) l r l I l
I | | f l i l l r r r cu
l r l . {' r r l l i
Spl eni us
(lomplexul
nrare
Drcpti posteriori
Mi ci i obl i ci
Scal cni
'I'rtlpcz
Spl eni us
l{xrele rlen' {rrcipilxl
Marele n.n' occipital
Pri mul ner' \ ' eervi ca]
Marelc rLcrv
Pdmi i 6 n{r r i ccr vi r r l i
Spi nal - l - Fl i mi i
d, , i i r . f , r ' \ ' i
cali
Mal cl c l r er v occi pi Lt r l
SDinal l- C,
l \ l r r cl o nt ' r ! {. i I i Lr l
Nt r l r dr f r cr v r k ( i l Jl l r l
M{r r ! l o t r ( . r v ( x ( i pi t l l
I t 0l ol i j r
cr t l ) 1r hr i
( sr ' f c
dr r : r l , t r t )
Sl cr nocl ci do-
r r : r st oi di al r sl l ng
( l r nr Ur l r xul
Dr I | r ( )
sl l ug
St ) l f l r hr s
( l 11
l ) t
Mnr'oh
(lr'll.
t xr r l l ' l l ( n
r l r ' r I ) t
Per, XI -F
cr"-c"
or--c,
cr
, (: x
or -- 0N
cr;.C,
Per. XI. crao+
c, - ct
Cr-C"
Ct -C'
q-c"
cr-c,
C, - Co
Pcr. XI -l-
cr-c,
I
t ,
I l i di car ca
r r mi ml ui
'1'raprz
Dintat mare
3
"- - *I 3r * C, C..
Spj nnl I r r i r r i i
( cI . \ i | r l i
NcNul
. r r l l r {
( l i
Ci r cunr f l ( \ i
l l i di car ea
bratuhri
Ileltoid C" Co
3 Coborirea
umi r hr i
I t omboi d
IL'tghiular
Pectoral ,nic
ca cs
cn c"
cl- cs
Ner vul l 0l l r ho
Nen'lll llDi.jhiLr
Ner vul pe{ Lor l
,1
Rotalia bratu-
l i l i i nai Dt e
$i
inrpci
J)orsahrl mitre
Subscapularrl
cl cu
ca ot
Nervrt l rnxr(hri
Ner. Jul suI s. : t l l
Rotatia bratu-
l ui i n ahri
Supraspinos
Subspinos
Rotund rnic
Cr cu
0r Cu
Cn- Ct
Ner vul sl r pf ) spi
Ner l ul sr l spi t l (
CircuDrflc\
-Cdrtuclia
braf ul ui
Dorsollil mare
l l ot und mar e
Peotolaiul ma].e
SLrbscapularnl
c, cu
ca-cs
cl -cs
C,-Cu
NeNul dor sal r l r
Net vr l l r ot Lr ndul
\ I ai I nul l i ncr \ ' l
cl i ] r pl c) ' r r l i )
Abducl i a
bralului
Del l oi d
Sup!aspinos
cs-ce
C" Cu
Ci rcumUex
Ncrl rl sul scl
fi Fl exi a
4nlebratrului
Biceps
Brahiai anlerior
Ltrng supjnator
ce -cr
ce cr
c6-c?
\ I r r scnl o' ( ut i r r r I
l l usct l o r Lr t r r r t l
rygrl
I i adi r l
Mcdian
crbi!1l
i l adi al
n adi:rl
I t acl i al
Cubi Lr l
tr{cdiaIl
ilubit:rl
l l cdi ar r
( t r 1) i t j ] l
N{c( t i xr l
(
l r r l r l l : r l
ExteDsia
ant ebrat ul ui
Tl.iceps Co C"
t o l ' 1e\ i a nr i i r i i Pahrafii
(mare qi rnic)
Cubital arrLerior
Ct * Ce
1l
t t
t : t
r i t
Ilxtensia
r:liinii
Fl 0xi a poi i cel ui
( pr i ma
f i
a
(loua falangd)
l l cxi a i ndext l ui
$i
a mcdi usul [ i
( Dr i ma f al angA)
l r l cxi r {l t l angcl or
. ! , ! . t
-
i l ( ) , i a dcgct cl ol
' l [ i
5
( pr i r nr f t l nnl i i )
( r L ( l ouu t N l t l
' r l . {i )
( r ' I r ' i r l
l r l r t Vr i )
Scurt
Lung
il cxor'
Prinrul
;i
al doilea
radial extcrn
Extensoflrl
degetcl or
Cubi f { post cr i or
I t l t er {) l n, si pal mxr i
fi
doIS.rli
Fl cxor comun
( sl | per l ,
f i
pr 0f . )
Ll Lcr osl , t i p: t l r r r r i
f i
dor sr ' l i
r , | l t , r r l r ( i r l
Cu -' Ce
co- 0u
,9L9,
o? 1)1
C' D'
cr l )1
c? -, T)1
l - '
i
(? r)r
j , ' , , , ,
] , ' , , , ,
t 44 l 4i r
Corl l nuarc cqbcl l I
2l
l t l
l l J
pol l cel ui
Abdrctta
(l cgctcl or
Al rduct i a
A l , ( l ucl l u
TABEL NT. IIL
MlgeiTile membroloi lqlodoare
l l o[ n
l r
( f r
co[ pi d
l , f l or l l l
I l xl orBl [ r
l ){
l ccrl ui
l l xl cr r sl d
l r l Ur r r l or 4
rl {: grd. c (pri mn
hl u rgl l )
( r ( l or o
$i
a
lrchr ftrlanEtr)
Lung
f i
scurt
oxtensot
Extcnsor comun
Plopriu
al indexu-
lui qi a1 auricula-
rului
Intcrosogi
Lombuicali
tl
oo- o!
Cu-C"
Ct Dt
' / -
liadial
I
/
Radial I
Cubital
I
Cubital
'
A{l (l rr(Li n
Fi
| , Pr)rl l l a
rhgcl.olor
Interosofi
Palmari
c"- Dr
C"-Dt
Cubital
Cubital
dductia Opozant ce D. Median
Adduclorul
policclui
cr-Dr Cubital
Interosoti dorsali
Abductotul
degetului 5
cr- Dt
cr- Dr
Cubital
Cubital
pollcelui
Scuftul abduclor
al policelui
ce- Dt Cubital + Median
(l (l l rcl l n Adductorii L"- Ln :urator, musculo-cutanat
interll, Bciatic mare.
col l pHcl
Fesierul mic
ii
mijlociu
Lo-L fesier superior
t ot of l a
I i t l rnLru a
(roI pt cr
Abductori
Fesiexi miilocii
L, - S
Ln- St
fesier superio!
fesier superior
' I nt h
(fl rl l
{
Obturator
Pdtlatul crural
Croitor
L^_L.
Ls- L4
Lo- L"
Obtumtox
Obturator
Nervul musculo-cutandt extern
(li)rpsci Psoas iliac Lr-Ln NerYul crural + ramuri
colaterale ale Plexului lamba!
'jxl
(!n$ln Marele fesier
scia!ici
0xlu
g0r bol
Drept iltern
Ilicep$ cluxal
Somlte$dlrros
somllllenrbrtnos
Poplltcu
0rol l or
L^-Lo
Lo- Sn
I-o- sr
I ' o- Sr
Lr- sr
Lr- L*
sciatic mare
Sciatic mqre
Sclatlc male
Sclallc poplibou intd
Muiculo-cutaDot cltorn
r40 t4r
o I z I
cf l r r I l i i xt cn\ i A
QnAdJicep$ul
crulal
L'n-l't
Flexia
pioiorqlui
Gambier antelio?
(Si rotalia
ineuntlu)
Peronier anterior
($i rotatia ln afardl
Extensor al
degetelor (tn mod
L4-r"6
Lu- st
Lu- S.
popl i l eu
' f i bi anul
ant cri or
Sciatic poplitcu
cxtcrD
fll
anrenol
10 Extensia
piciorului
Gemeni si solea!
Gambier postedor
(qi rotatia
iniunttu)
Ltng peronier
latelal
(9i rotatta
in alard)
Ln- s,
Ln* S"
Lu- S'
Sciatic popliteu
inlerD
Tibial posterior
Sciatic poplitcr
exLot.n
n Rotatia
piciorului
induntru
Ganbier anterior
Extensor propri[
al detului mare
Lr*Lu.
Sciatic poplitcu
cxLerD
Ti}ial antealor
Sciatic poplitcu
intern
Musculo-cutanat
Iibial anterlor
Tibial posterior
Nervii planlui
cx[(,nl
tdrn
Iibisl posterior
n. plantar intern
n.. plantar htorn
Sciatic popllLcLr
exlcrn
vl
plant{r
inlorn
il
Planl inlcln
plantar
int(r:t
plant0r
lntcfn
I _.1 Rot al i a,
piciorului
in alar{
Iixtensor comun
al degetelor
J-ung peronier
later4
Peronier anlerior
L._ S.
Ls- Sr
Ls-
Q
l i J Irlexia
halrlcehi
Prima
lalangd
- Celelalte
falange
Lungul flexor
propriu
Lornbricali
ti
interoso9i
Lrngul fle)ror
proprm
Scurt llexor
proplrlr
Adductor propriu
La- Sr
Ln- S.
Ll- Sr
Ln- St
L"_ S.
I J Extensia
halrcelui
I-ombricali qi
interoso$i (pt.
ultihele doid
falange)
Extensor propriu
Pedios
Lu- Sr
t 5
t 0
Fl exia
celorlalte
degete
-
Pdma
falange
- A doua
falange
Loinbricalt
$i
intr06oqi
Flexor comun
Scurt flexor
plahtar
Flexot comun
Ln- Sr
Ll- St
Lr*
fr
llxtensia
celorlnlte
dcgct e
Extensor comun
Pedios (ln afala
degetulul 5)
I"omhlcall
ti
lnterosoil (pcntr
ul [ hnd( doul
f sl un{c)
Lo
-'- Sr
Dl aut mi l nt qr: 1
l l
(:o|l,llllalo
trnbol
cxl 0I D
B{qrh lcte d ia I is
,flex ar,'.carpi
ra0talts
,Pqlflchs lcnilus
Apponens pallitis.
Abdua.f.or
pallicis
brevts
flexat
pollicis
Drevls
,Abduclor
Po
icis
sibiifiis
Flexar ccryi
Abdrc.bt digili
.flixor
djgilj
quinti bretlts
-Ttiaeps
-
Exlensor corPr
rodidlis lonqus
Exlensor coai
'tudiolis
brcvis
'fxlensor
cffpi ulnoris
Exiensot digikrun
Abductar potliais
lon1u5
Abdwlot Pollicis
brcvts
Atubus ntdits
Gluleus noxinug
Gto ai l i s
Percueus
tonquS
fibiql,is
Ex lensor
digilorun
longus
&
2a
SFt r
ciis
* . 8
F, t , 20. Muqchi i superf l ci al i si membrLrl ui superi or (drept )'
Senilendinosus
Eiceps fenoris
Voslus blerolis
Sen inenhronosu,s
Anloiot
Fastetilr
Irl0. lr, Mur4hlt rtrpol'llsldl al mdmltlulrrt Inlopl0r (droDt)'
. i - , i . 1! . ) ! . l ' r ol t l r ut r dr l . i t r 1t t , *l r t l r t 1t , t t 1r ul i r
l i
t l i ol . oqi r i t t
l t r r . t , r . l , i : i i l r
pr i t r
I , i r t t t i r r . l t | t I t | t | ) | 1. t | | t t , i t t t r l r t t
1n
t i l r t r l
l \ l . , i t t t i l " p r i r r t t ' i unul r :
l ) I' ol i rnn.i rl i l r a,nl ui .ourd, &u,u,l ,(i , (l M,l ,(, l ,ut IIei n,c- l l h:tl i ri ). l )rl i ci l trl
rroi ol sc i rrsi i rLul zi i bl ' utal i n decut' s dc ci teva oro sau zi l c, rl e obi cei dupi i o
1r,,r
i orrrl i i l i rl rl i l i , (l o nrul te ori i nso{,i ti , cl e fenornene di gesl ,i ve, I' espi l atol i i
i . r rl r. rr,rrrrrr nrorri nge&l e), dar uncori
Ei
i n pl i ni , sfnS,tate (,,pam1i zi i l e de
r I r r r r r r r r
.
r r,
{
i r
'
I
)
. Sc lcalizeazd, tablouri I'ariallile, cu paralizii limitate, parcc-
l :n(1, ri ur, rIi rrLl l otl i r-L foal te oxti nse, tuteol i cu caractexe ascendento (si n-
' l r,rrr
l ,rrt(l y). ' I' otdeauna refl exel e osteo-tendi noase sht abol i te i n zonel e
1r:rl rrIi i i crr, l l )i l ,r' rapi {l attl fi i muscul anc
Di
hi potoni i remarcabi l e.
l ,i psl sc 1,rrl brrl i i l i l c de sens
j bi l i tatt-,.
'))
I'r tl irtm,itl,i.tn, o,nteri,oud, cronicd se caracterizeazS, plin deficite motorii
l rr rrl l ol i i l nuscrrl a,r' c (rl e rnul te ori ri i cr fasci cl dal i i ), cu i nstal are
fi
evol uti e
l {' rrl pl rrgrrrgi vi ,, orr l oc ,l i zare bi l ateral i ,
!i
si metri cd sau cvasi si metri c[.
l\l:r jr ) r'ii lrljol, lrcos1iol ,r sint degeneraLive (rareori cu caractero erdo-familiale),
c,rk, rrrri rrnrl tc i i i nrl dc fapt forme ati pi ce de S.L.A. (Ratl u, 1978
;
Tri l l et
rl i |ol rrl r., I070), i ar unel e cazuri puti nd reprezenta forne subacut-croDi ce
rl rr prrl i rruri ol i l e vi l oti i ce (Drd,gi ,nescu qi col ab., 1962) sau sechel el o unei
1roIi orrri r,Ii Iu a,nteri oat' e acute (Il ei ne-Modi rr), i n care atrofi i l e muscul al e
rrr rl rl i r.i i rl c rl otol i i , dupi mai muui ani de l a sti nger.ea procesul ui acu[,
rtrl cp ;l i , so exti rrcl i l
{i
si se accentucze ptogresi v. Drpi , Radu (1978)
{l \ rirl rlrrlrr, cir, ontil itli distincte a atrofiei nusculare progresiyo Aran-Duchetr-
rrr., r.rr, rlc lal)ir
fi
{l pa,raliziej bulbare proglesive Duchenne este indoiel-
r r( ir,, rt'l,i.ii1oil leplezentind mai probabil forme atipice ale altor afecliuni
rr' l r, rrrrrIr' orrrrIrl i l noi tor (S.Ir.A., si ndroame r1e S.L,.A. el ,c.). Crdem, deci ,
r' :r l rrl nurLrrl rl c
,,l rol i onri el i Li i l
anter.i oar.i , croni ci ], devi ne i ncorect i n etapa,
:rIl rrr,l i i rr, orrrLo;Li n{el o| noastre, pentt.u cazut' i l e c1l oti o)ogi e nepreci zati "
Iri trrl
l rl rl i rl i r,bi l si $e nl i l i zeze tel meni i dc
,,si ndron
tl e S.L.A. ati pi ctt
rrr,rr rl rr
,,si rul l o])r I
)(r' i cal i on:t l anteri or oroni c de eti ol ogi e nepl eci za;bi i ,' r.
' l ' i l rrrl l rl ri l r,i IrccvorLt i nti l ni t este si uchomul ami ott.ofi c Aran-Dl chenne,
rrr crr,r' r, rl oi i r,i l rrl rroi ,or qi atrofi a rnuscul ar5, i ncepe l a tri ye.l ul rni i ni l or,
rr.:rl i zrrrrl ,
Ir' i rr
rr,i ,r' ol i l , oi )ri tentol or tenari ,
|i
hi potenari i
[i
:r, i nteroso-
,rl ,,r' ,
,,rrri ri t, si rrri rr,ti i i ' )
;i ,,rrri l a
i n ghear5", dupi cal e progresi unea atrofi ei
l :r rrrrcl rrl rr,rLi ol l |i r,l ,t1or, tg l rzaa,z\,,m ta t1e
l redi cator.,, $i ,,mi na Si
anto-
l rrrr,l rrl rrr' Irrrl rrl ,i cJ' .
-,\t
l ' {rfi a ss poate exti de qi Ia ni vel ul nuscul atur i i bra,-
I r rl rr i |i r' l r i i t I l rl rIl so[]i ntura l i zomel i ci a meml trel or Supel i oare.
i i :ur (l rF(,r' i r.i
rj i cazut' i de
,,pol i oml el i trd
croni ch" i n ctre atrol i a debu-
1,.rrz,: l rr ni l rrl rrl utl $ct atut' i i proxi mai e ar membrel or superi oare, real i zi nd
:r,r
1,i .,
l c prorrrl ol rri opa,ti ce (Yul pi an). tr' ormol e de
,,pol i omi el i tl
doni cS' ,
r r rl r.l rrrt, l i r rrrcrrrl rl el e i tl forj oat' e (pe gl upel e tnuscxl are peroni ene) si nt
l l l r l l l t r r ' .
'l .l nirlrol'i il.t: s1ti.tt.u.le progresior (aniotro{ia progresivi, in{a,ntilii,
\\r' rrl rrr;1 l l ol l rrul rur, arr)i o{i rofi a spi nal ti
j nveni l i i , pseudomi opati cS, Wohl -
l rrl l , l i r rgi rl l rol g-Wel anri er) pot fi recunoscute
[i
di agnosi ri cate pri n car.:rc-
| ,'r'r r I lr rl lorr ol ic olc(lo-1atrilial, prin masivitatea sji bilater.alita,ta atrofiilor
I t I r I r L r | | | I r I r ' ( |
,
irrirrl(,il,c
;i
de al1,c sernne de afecijare degenera,ti\.:'i a motonuro-
rri l ol rpi rrrl i : rr,r' ol l trxi l , osi .cotondi noasri , modi fi oXti l c l l .M.G. de ti p l teur.o-
11r . r r
r r r i r , I o1r r r I i r . , l i pst st r r r r nt r l ot
t r i r ' l nr i dal o [ i
a, l ul bnr i r i l or d sensi bi l i l ai t c,
gr l l r . r r r r r
1i l ) t ' i l
o\ ' ol l l {i l l ( n,
l }1n1, i ct r l i
' i j ( . l l Ndl , l 9?8, t 971}) .
, i ) I Jr r yl u. ( t t j r , i t , i r o. l i ( ) l . i
( l l t t t , t ' . n| .
J/ o' i I sr xi r r zj i , i r r cor r l or l l r l f ( . I l r i o
l oyJi l r or r t l l r l l l t r zi r r t r t l r , r r 0r r l r I r r i | r I t r r r oI ol i
; r r , r , i l i I l i r r i i r I j I
l l r r r i vi r l r r l
| r t ' r ' i t . l r ,
i 0
r i ot t r t , l ( t t t t i i t t t r l t ot r t r l t '
, , I
) ( ) | i
(
t I I I i { | I i I I ' i
1
' I t t t I t r t i oI t I i i t l ot t i t ' i t ) , r ' i I i 1i I ' t ol t r t l l r r t '
pr r t i l i r t i r , ,
l r r r r l ut t t ; i
sot t t t t t l t l t l t j ot ' t I t I i t ' t t t I
l ) osl ( n
i {r l l l t f . l i r l l l l t l t , l t t
( ' i l l ' l l l r l l ' f
t j r ' ur l o. I l r , r r r i I i l r , I , r l r : Lr t t Lc: t ' zi r i t l c0pi l l i , l i t l st t l l l i t , \ ' i l ' sl {r . 1, i t l 0l ( ' ,
l , r i t l
r l ' i , t ol i i
rl i s[al c l ocal i zi ,to 1:l rnombl cl t i nl eri oare, cupl i nzi r([ i ttl ,i i ttttl st' tl l rtl tt|rt'
1rr' rrr
rri or' [, apoi pe cea gambi er' ; post,eri oarr",!, l a i l l ccpul ou
(l ol i oi l l rr()l t)r l rrr
plc:r, irnporta,rlt, menlinind mu1t5, vreme sta,liunca
fi
rnol'sul (c,,trr ilttrii rlrr lrr
j l rcep[t
poate l ua un aspect stepat). Apoi r 1en1j -progr osi vr l l ,Il ri ol r' ( ]l i i l rrr
o\ti nde i n mod si metri c qi l a trei mea i nferi oari i a co[],J)s()l or' Iol l l i zi rr(l
frl,rofia caracteri,sticd,
,,in
picior ale coco,i' (sau
,,in
cizmii iltaJl,il,")
li
l rozi {i e
de mrus-equi r a pi ci oarel or, cu consecuti Yl e tul but' i i t i rl o tttol i
l i l nte, i nsol i l e
l i
do tul bl rrd,ri i l e sensi bi l i tate ectromel i ce (strbi ()(l i i vo fi i
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
$i
eredo-ataxia cerebeloas;, (boa1a lui Fritxh'tr irrlt),
situatii in caro se asociazd si tulburiri de sensibilitate profundX, cu irl,l \jl'
{prin"leziur ea fibrelor radicuiare lungi din coraloanele posterioare)
li,
ov(rlr'
t,ual cifo-scolioz5,, picior scobit cu dgete in ciocan, precum
!i
mioi
fi
lirr
dive semne cerebeloaso.
4) Itt siringr.tmiel'ia se constat5, lrecvent semne motorii poricariorl:rl(t,
cu sindrom Aran-l)uchenne. Amiotrofia, cel mai adesea simet'ricii, int{no'
{ea,zd, membrolo suporioare cu fasciculalii' excoptional de rar apil,r'irrrl lrr,
lrlembrele inferioare. Prezenta tulburd,rilor de sensibilitato di$o(lirLt(1
:iirigomielic, suspondate, a imporbantolor tulburbri trofice, a sindrolrrlrllri
}iramirlal
asociat, procum
$i
Yolulia foarte lentd, ne sugereazri
(li:rglxtH
liicul.
5\ Iurnori,le intramed'ulare
ti
traumutismele aortebro-mcdulu,rtt (:tr'
hnnal,omi,eli,e) pot genera siDdroame motorii pericarionaler asociirl,c
(1ll rt,ll(\
$ernne comisurale, indeosebi cu tulbur5,ri de sensibilitato de tilt si|ittgrt
rni el i c, de obi cei i ni l ,i al suspondater apoi subl ezi onal e (cu ni Yol
(l {,5(!rr$i
bi l i tate
).
ll\ Leziunila rdd,ic'LLlare .mteriodre prezintr, o serie de particllllll if i,li.
I)istribulia topografici' segmentarS, a deficitului motor
$i
a celol'Lrliro sorr rrri I
colelate a1e sindr'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
rli,o &fectimi vertebrale compresive, tumori vertebrale primitiYo s2l,tl s(xlllrr
rf i rrt, boal a l ui Fott .s.a.)
teal l zetuz[' cel e mai Yal i ate si ndroamo tol x)gtrrl i ( 1r
(rorvi cal e,
dorsal e, l ombare, sacrate) mai mul t sau mai pul i n o\l ,i rrsr!.
l l rrrl i ti ci l ri l s de refl exe (osteotendi :roasor cutanater a,rti cul l ,re' pi l ol rrol (,l i i ,
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
rl o l l to cti ol ogi i pot fi uni l al rorl l l o (n&i mul t sri tt ]nfti
l )ul i n
oKl i i ns(r) $rr' rl
l )i l r,l ,(n i l ,l o.
Jl ) I' ol i rtdi a.tl .on,(,,1n i l d(
l t\tl
t' ol l i zl i rttbl ortri i ;r{,t tl tl cgi tl tr (trti ti ti w tl orrt
1r l r , r ' l l pl 0gi co ) ,
| ) ol ' i ci l , ol o r r l ol ( t i i i t , JI l , t ' i t t l l t t t l , cr i ' t t l l t l l ol ' l l I l ) 11) l t l i
( ] l l
i t ol l l l l {l
. . l : r , r ' 1 r l 9 t L{! l t t ( , l r r r i l l ot '
; r r r t
i l i r r i t ( ot t l t , t t r l l t r xi o t l sl r ot t l , ot l t l i t l t i t , si i , t l t t l t i ; t r t
l oui r ! i {i l , l t l r , i , ot r i r r t r t l t sf [ | t t i i 11i I r r i r , l t 0l i i ) t 1i
( l o
[ t 1) 1ol t r \ l l t l t t t
st t t t zi l , i t ' r r t t
l
l l , l
r l l r l l i l r t ( i r ! : r l , i l , pi r i Lnt i r l l t , l i i , r ' i l , 11i l r r I , r . or r r r r I i r r i i , . X' l a i r l i f i oi i po: r , kl l i r r I r oor . i
r l i r t r l r osl , i r : r r l i t r si l r r r r , ! , i i l r r i r r r . r r l r r r I r , I j | i i r . | , 1 r r l l ' ) r ' i i
l l t r . r l r r t ) r i ni l ,
l l l r , i ul i . ci l
t r r r , t r r I r l r r I oI ,
l r t r r r l r r ci r t i l
t r t t l l r l r l or r t l i l i c
I ) s( i l t ( l {) nt i o}{, i t i ( r . . l ) t bu1, t r l
bnr sc
rrrrr Ir,Ir,l ,i y l nrrs(1,
yi rsi N,
do .r,pl ,r' i l i {) (l |, or.i oe vl rstS,), a,l )ol i rea ]rtl ct{ol (r'
,rl rrrrkrrrrl i rul tso (rl rol i cn pi strrr,rea r.el l exel or i di omuscul are), l i psa atr:o-
l i i l rrr rrrrrsrrrrl u,r' o i n si ,adi ul de debut si mai al es n.otl i fi cXri l e l i chi di enc, cet
rrrr.i rrrlosoil (xr
disociatie albumino-citologicX, vin sE, para,feze cliagnosticul
r I r r
1
ro I i lr r r I icr rlone.vriti.
Gtrillain,Baud.
I) ilind,roamele coai,i d,e aal rbaltzeazi, tablouri multiradicuJare par"li-
lrrlrrrrr, rr,rlcsc:l, cu paraplegle,
4A$cd,,
hilg-tp[6r
?ISflexiE[ $L
s11 at{oJii-rnrs-
ortkllo. 'l'rrlburzirile de sensibiljta.tg pella4aler.
in
ga.Si tqlb.gr'rilc sfinete-
lr,ro irnlx)rtitnte ttimiln diagnosticut Oe potiomiitith; tifrsa tulbur{rilor.
, l ( . , . r r l i l ) i l i r a. h.
ucl l or r r el i cd Gubi ect i vc
$i
obi cct i ve) el i r nf i ai ' dl ; gnbi l i ar i l
r l r . l l zi r r r r r . r nct l ul a: i i .
Jt)'isl,i\ trei til)uri de shdroa,rne cu coadr, de cal :
n,1\8intlrom.utV6ffi.\ol aoai,i. ite cal realiwnzd, oteritabild; p,ar-aplegie,pet!
Irrli*i,, 1ltr,scd,, arafloxigd,r.i1lierosird ioate
$rrlelo
rnusctlale.alo rnembrelor-
rr|rri ol r' o (cu
i ntegri tatea psoasul ui i l i ac)
5i cu
masj ve tul burdri sfi no_
l i i r t l t
1i
l r r r t t t i i r l i st l l l r cl t r t t
l r ol '
I oi t l i zl t , t t l t si t t t l t r t t t t t l r r t o: r l l i t l o r , l r l ' l ) o pi kl l t t
r,i trtl i rtr bol trr,v rr, rrouzrr,L l ri t0vi t sri ,l l ti t,tni ni soi ,hr,l gi i l u brrsottl i i ,, tl ;tt i 1i rrtt
i l l r r l i ar i l , osl i aul r I r ' o i ] i
1xr r i noi [ l o, ] r ooul r l I i
t - l t t i t t l l r t t l i i l i sl i t t r l I r t ' i cr t r ' , i t t
tl rol rl enl ,ul i l t ci rr.e au sui ' vcni t Ei
l orl o ]onol o
l i l tel i otr ;i
l ,tLl b tt t i i l i l tt tl 0 srrtrl i
l ri l i [a1,c i n
;a,
trebui e categori c si i i nbi ],ndorti ' l m rl i ri grtosti cul tl o l otttl ttr
scilticri ban:rH,,,si ilii xe gindirn la o compresiuno in cozii
(10 (,i
'
b) In cattr,L rtrvi euol ul i i suba,oute sau cron.i ca l an' t-progrtsi uo rrogi ttrl i ttt
i rr pri rrtul ri nd l a o campresi una a cozi i de cal , i n spoci al pri n tutrrol i srtl xl tt
l e pri mi ti ve (neuri noame i ndeosebi ; l i mfosarcoame
;.rr.)
si ttt ttl ol ,rr' "
si :l ti ce (subdural e sau extradutal e), al te tumori extrrl dttl rrl c, borul a, IIotl '
el ci rr, al ahnoi di te chi sti ce pseudotumoral e, sau l a comptosi tttti rl rr rrl i ' r' 1,
rrri nri r. i ncl usi v rertebral e (boal a Pott, metastaze
!s.tr.)
l l l ) Lezi ' uni l e pl emLral e te^l i zeaz\ si l l droame de neutott tttrtl ttt
;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.
Arnintim pe icuri colt.stela,ti0, sanxiologicd'
9'i
problem'ele {k dr(llttorlio
r:liologic Ln sindladmela pleaulare :
1.) Si nd,rotnul d' e pl en cemi u' l i mpi i ci : al teratea mi $cl ri l or ti c IL' xi rr,
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
$i
trtll.trrtrlri tlr',
n'nsibilitato in teritoriile ratliculare Cs -Cn.
E*te reahzat de mul ti pl e afecl i utti I tr' aumati ce (rl t col onnl i tl tvi
ra,Lr. i nal te), tumoral e, i nfi cl i or-r,se, mal formrti ve {r-r' zi Arsel i
,si
rrol l l r.,
l l ) i i t i .
" "' 1;1'
g
i nd.ronut dal tl el ,i ru.bdpoate fi reati zat l i e tl e l ezi uni t' rr,rl i crr
l , r ' ,
1i ' u- [ r , ) ,
l i c, l e' t r "z. i uni - al e t - mnehi ur i ] or
l t r i m1
r e
( sl l l n' l i oI ' ,
t r t i . j l r xt r t
.;r i ,Ui ..r:i ur), Ii e rl r' l ezi ui ri rte tri nchi l l i tor sccundul t
-(supori orr
i rrf(rri (rr
q,i ptxt|r' i or), fi e ' .rl e ptexul ui i nsuqi . Ca atai e, se pot rl i sti trge patnt, I)trri ttttl t'
' ' "' ' ".i]{rifl,i,o,rutde.mialiiri-tiitiio pterutr+i braltial st cirruct.rrz{trLl
l rl i rrtr-n
paral i zi e c-o4qd9-t[;-exf6d"-ta i ntreg membml superi or rb$l xr(rl ,i v,
|rr anestezie gtroba}i iL teril'oriul intregului plex'
b\ si ntl r<.nnul si pel i oi ,rte pl ea btaki al (
By' .9fu94.?q-Hrb ),
i tr ci tl rr l trzi tt
rLr.:r i ntereseazd, ri rl i i ci ni l e Cr-Q, respecti v teri tori ul nervi l or l -nruo$l rl
, , l t i r . l r &l l i al r i i cl l ci ni i er pe. gl e! med! 4nul yi . se r r r act er i zcazr ' i pl i r l i l t \ l i l ' r l
l l r r r uL. i at r of i n r t nr r r , . b i l or l l el t oi d, / b i cr psr / bl ahi al l nl el i or dt ut g r t t ; r r t r i r
l or' ;i nui pul i n a muqchi l or dorsal mare, pectora tnarc, di l tfl rl tttrt' tl i i i
rr,1,ni r(l mai e. Rel l exel e bi ci pi tal
gi sti l oretl i 4l si nt rrbol i te. Tul bl tl i -rI i l ' , tl t'
", . r r si bi l i t at e
"i nf
p| ezcnt r ' - [ r ' der ma- i oFi er ?t r '
( . , r r cspr t ozi l L{) at r ' ( ( r . - ( "! ) .
r' 1 si ndrcmrt
i nj er.i or,
da pl ex broh;Ltl
(
4t,l rupLv' l M#t;rl dJ
,
i tt crrtr'
. , . zi uncr L i nl er cl cazr . i ' . , ' l Aci ni I e Co- D, , r espcct i v l el i l r r | i ul t r ct Vi l ot , l i : ubi l r t l
l i
par l i : r , l al sncr l i auut ui , sc ca t act - er i zeazr l pl i u r l r ' l i i , i l - l l oJgl i i l t l ut . f uul r r r r
r
"Li l ol
rni i ni i
ti
ri gruputui i ntern el antobrat/ul ui ' tul butri ri rl o srrtrsi bi l i
l rrl i r pt tL:rrni i l ttrnerol i cot' cspurrzi r,toa,rc (Cr-D1), l l t, trl l tc sc i tstxri l tzri (i tt
l czi r r r l oa r i ul i or r [ ur i i ' ) r t t L si nt l t ' om Ol : ur t l c Ber na, r r l - I I ot nct , i i t t t r ' l l l r r t l
l :rrl ri Co-prrrntl t;ot' tsl ,o rr,l xrl .i t.
r l \
, ^- i nt l r onr t l
t t r i . j l , r i u i r
1' l t . t :
ht t hi ' r l
. (
Hc. mt , t l cl i t r {' : r t r ' l { / r i t r t r r ' . r r r l
l , . 11. s( ; r r i i ui t l r i l i t r : t O' t r ' . pl r ' l i v t ' ' l i l ' , l i t l l ( ' i l ( l r r l r l l l "\ l l l l l i ; i r t l f r ul i : r l r t l r r r .
i r . , ' r ! r ' : r i , l r l i zt . i r z: ' ,
Pl i r i
r l r , l i ci l , t t t r t t ot ' 1i l t ' l t i r l i u t t , l r r t t 4r r l t i l l l t / t l ' i t r opx, r ' i ' xt r , r r
I ' rrt ' j t uul .
lt) N [rulrontr isutrter'ior \ql, cozi,i,Lle ca,l.
prrlriir,l sint abolite ixl cqle achilicne qi medio-plantare sint pishate.
r t xi ndr onuL
f f i r i or ' ( sauat 1
ol r azi i dr aul ( I o - J", ) . I nl egr i l at ea
rrrrr;r' hi l ri r a,ntri ori ai coapsei col l rastcazi ru i ml ortai i ta
-.pari Uzi e -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
rl ol i ci l , rl u fl cxi e a garnLrei qi mari tul burd,ri de se)rsi bi l i tate peri anal e,
1rrl rrrrrr
si pe fal a posteri oard gi externS, a coapsei gi a gambei . Refl exul
r' )l rl i l r
fi
rnedi o-pubi an si nt p5,si rate, i n schi mb rofl exel e achi l i eno qi
rrrrrrlio.planta,ro sint abolite, lt]ulbgrlrile sllgleriene r i,irin pe primul plan.
l i , . f l l r cL. r r r r r l c ( cxl er n
$i
i nt er r l - si nt abol i i e. Pot . ' i apal r i si es' car e.
I' r' ol rr.k, rl o el ongal i e pentru sci ati c pot si , fi e pozi ti vc. Teoreti c ai .Ti
1r,'
rl ri l :r r/i /i ,r' r nl i l ttt i rtrc l eBi uni l e corrul ui
Fi
al e ep,i conul ui medul dr.fal d
,l r tt i ttui l r,,' ^-i IL]e rtrl .Inc[ Lhermi tte (1919, ci tat de Ri ser, 1952) preci zase
rrrr,l r, rrl i l ,rrl i i rl o tl i agrnsti c di ferenl i al : i n l ezi uni l e conul ui qi epi conul ui
,l rl l l i l r s' i rrl n)l i
])ul i n
vi i gi mai pu-ti n persi stente i n membrel e i nferi oare,
r \ r,nr iiorrnll lrri Babinski, asistd,m la o simetrie a tulbur'[rilor cle scnsibi-
l rl rri rr;i rl e rtoti l i tate, l a mari tul burl ri sfi ncteri ene si geni to-ur.i nare,
I' r' ,' r
rrrrr
fi
l rr o paral i zi e atrofi cl i mportantS, si a, muqc]ri l or ani eri ori ai
Sc irrrprrrnc
;i
tl,iagnosti,cu,l tliferenlial fa\d, de afec!,iunile prostatice, in
rrllrrlcrr, lrolrravii simlind pasajul urinii prin canalul uretral, precum qi
l:tlti, rlc, ltti.tr,tti ontinpe al,e pleuului, lonzbo-sawat (ca de pilcli, in invaziile
Irrrrrol rrl i r rrl c mi cul ui bazi n), care pot si mul a un si nal rom de coatl S, de cal .
lrr frr[a unui sindrom ele coadd, de cal se rialic5, foarte malte probleme
rlt rl.it r ttt.o;sl,ic tl,iologic :
t,) .Ln, cltzttl rlnei, i.nstald,ri rapid,e, aaute sau subaautre, ne gindim in
l rl i rrrrrl
rl rrrl l n o borl l l I?o1;1;
j oa,si i (l ombari r,), l a o rneni ngorrdi cul i l ,i , i nfoc-
(i orr,si i rr, r' ozi i rl o ci l l , l l , o prr' i ,l rtr6i ro vorl ,cl l l l l i i pl i u tunrot' i l
1r' i rni l i r.i i
rarr
r r r , r , nr r r l r r t i i , r r , r r ol o; t t t 0i vt u' t , ol r t ' t t l o l ot nl t i t , t r ' . l r t r r l i t t t l i r ut ' l t t r r r l ot r t ; r i , ozi ' i ; r cr r l i .
t 5: l
i
I
i
j t 0il
ili',,'li,lliiil:,jil
''i,1";;;lil;l,; 'l
,;r,,litt'r,
r0r'ror rr rui 1 r'ir,iDitill
ryi
.. rr I uu,uri r i
l ' ;rLa,l i z,i rr do
l rhrx
l l rl rLi i l l r.nl a.
2r.r,r/usri
rl c tl i atrtrr: ,tl i t,!,i nni :
,
,
tl 'laniu,ni l,r&
ryjeliq?
Irr, rrivr.lil colorrngi/cerricrr,t,, inierioartr
li,dior-
r{ir,l(, Nl
lxrljr)rrre,
sa,u la nivclufclu,viculei,
a/riL,xilei si l-[ zonelor sujpia_ si
i rul rl l rrr.i l rrl l rr; frl cturi al e cl avi cul ei , l dxai i i scapul o_humeral e.
cl otrEai .i i
1,,,.1,,:]i l,l, l' ..],,
,1
;
lrir
(.t
uIi,a te rtr viculei,
.luxa.l.ii
scapu lu.h u mcl1l lc. cl,irrga r ii
l , f . i l l ' , f l . l l l l , , l i
Sl ql f pl erul ui
, (ureori
ct ri ar. . r. u snrul sprea I ' i i t t i ci ni t orl ;
, r , r r l ) r l sl | l l l | t i l \ l t a. ca de pt l dA l a pur l dt or i i
de ( , i I i c. j nl ( }r vent , i i
chi nr i ,
|,,rrrl )rr' sl |rl rL,l |f
i l ,\rl a, ca
_de
pi l .l d, i a purthtori i
de ci rj e, i ntewenfi i chi mr,-
l : r , . r ( , , 1) r . : r r ' r ' t , ' ' t s- l I cgl uur do mai SUS; t r aumal i sme obst cl r i caj e, cu L. zi r r ne: r
! f : : ) , ' ] , 1' . ' . , , ' : : nl r r , r n
r I mpl l t
. nr l l er i i
( consecut i ve
xnui bazi n si r i mt , r r nei
l )r' r' ?r' hri rl rrrtel {' ctuo-i rNc, unei eompresi uni exerci tate tl e manevrel e obi i tetri _
, :rrr.,
l )r' l r,\l
l ptcxul ui i ntre cl avi cul d,
Di
pri ma coast5, el ongafi ei sau smul _
l l r
r i i I ' j ul i r . i r r i l or ' )
el c.
, b\ .
I , ' \ ' . yi l , t sa. * r ( : I i cul i t r
, (
f t sl p?t ; , r udi aut , , pnt i i ) t ' i nt ec! i ( ) 1sr . . . . "4oxi . c
l , r ' : r sr . t 1r 1
r . t : t pr r , ( . , pur l \ ac. t nt l n.
, . 1)
Su.feriu,!e
-uertebrale
tlc ditserse naturi : hpondilite (indeosebi
morbul
r.rr r.(rr r.('r'vrcar)
;
,tumori
Yertebr.ale,
i.tr_ara,hidiene ;i
extrarahidiene;
l r r r r . l r r l i
; i
r l i si ocl l i i ver t el r r ' ah. ; / her r r i i
de t l i sc cer vi cul e. _
. . . , ' . r t . l ' : ' r r ! ! : i
cosl t ) ner t pbr ol c
^si
. al c
deJi l eu. t u i sr al ar i r r r 6oast r i cen. i cal i i ,
: . | | I nr r r | l r {,
Ni . r t cnl ce, r cal i zal o i ndeosebi pr i n t r i bcnr of j a nr u^chi r r l r r i scr j
r r . r : r . r r l ( ' l l ot ,
cr r e l xgr sl caz{
, . def i i eul scal eni c' , ( sapt i ul r l i l t r e cei doi
i f l ,l i , l l ' i l ,,l :' ,,
Ei
pnnra coa-sl i i )
rqi
care i D acesl mod r.ompri mi , pl e.rul br.;r_
rrrr sr i rr' 1(,l l t suDctavi cul ard, (Arseni qi Oprescu, 196?; Ionescu,*
popovi ci n
r r i cul al r . . . 1. 921
;
Ri ser , 19b2) .
.
,.1
rl'lrmori
ale, virtulyi
p.1r$g-n?T.
i
Sinilromul
paneoast_Tobias,
in
cru,.
,lr.
Insii p,aralizia plexuliri biafiial, inti]ninr dureri qi un siDaliorn
I t i | | t {r . l JI t t }: l r o_l i or ner .
:l) I,'arlrliziile d,e ple* lom,bar
.(traumatiee,
tumola,le, infecfioasc etc)-
r r ' r i ' r r ' 1r ' r i zi ' | i l zi l
p. i r def i ci l e mot or i i cu at r uf i i al e coapsei gi pr i n dur ei i
, . r r i I I i I r ' I L| | I r {.
}n l ct ' i l ol i i l e ner vi l ol , abdomi nogeni l al i , - f er nur ocut : r , nat , . i
, {t , l i l { }{, t u t . Nl .
. ,ll
I'ut li,ritle_d.1
tt(lt
sstat realizeand, rin context semiologic in care
I
| |
'
. (.
I r | | | I r | | i t 1' l l ' ui i ri l c di n parl ea, ner"vul ui sci al i c, l a ca-rc se c,soci azi I tro_
t r t r . sr . n. , r l r r r r . r ' i pet . i nel l e si l ul bur dr i sf j nct er i ene ( pl i n
af ect ar e: i sf i nc.
I r ' t l l r r i l t r ut l r r xl ; el n ) .
.. l:tl
l.:,
:
i,,:
,, :
i
,t
,
lterr
ur periJeriri pdt. fi izolate (nevrite,
neuropatii),
i ri roi .rrr., r)Irl t rl tc (ml l l Unevi .i te)
sau exti nse, bi l ateml e gi si metri ce-(pol i _
r r r , r l i l r ' ,
l xr l i r r eul opat i i ) .
| ) I\rul i :i i l e i :ol nl e fl te npt ri l or pcri .tpt.;(.i
:
l) I'uru,lizia
,ner.uului
circumJler se traduct
lrintr-
n tleficit motor al
r r r r . . r ' l r i l r r i r l | l l r r i r l , . "cr , ( , r , cr ccazd
di f i cul t al ea, 5i 11r . , i . i . i
p; oi cc[ i ei i r r ai nl e
I r r r ' : r l r t ! t {' s- l , r {. t t v. i r t nent i ner i i acest ui a l a ur i zonl t
j i .
At l , ot i a mu) r , hi ul i
| | r.|| |,.|| I r,r' r' r' rzi ] r r|l _rrgi nea rl e
,,umi ,r
i n epol etr) sau de
,,umi r
tfi i at cl e secur.tr,,
!r | | r
.
| |
.
| | | | t | | : I o relilxue a articula-tiei
scapulo_umerale.
paralizia
muqchiu-
Irrr l .l ,r111rl rrri r,.,i mpi etcazi i
l tri ;oarea de rol al i e ertem5 a bral ul ui . l i ul bu_
I i r r r.: I r tr' $(' r rNi l )i l i 1 Ltc sr. di stri hui e i ntr-o
,,zoni r,
de r:l cheti ,)' pe' fal a rxternl ,
i r l l f ) r i t l r l n' ( . l , i U, 22) -
,......,1r.::.",,,,r: ,i ,:.,' l ,rt.t1i ri
u,ni tts
ti ,nt
ni .ti .. fractul i
;i
rl i sl or::i ri al e cu,pul ui
: l l l , , , l l ; , 1,
t ' t i r gr
1r ' ur unr r 1i r , , ( pl j n
N, r mc nl l ) o $i r n de f or _)
;
com] ) r csi f t i l N,
r r \ ' . r , r l ' ' ; ' r r t r ' ( l ) r r , l i , si {nl ' 1, , ,
i r t cut , snl sor nnt r l ui , si l r r i l r cur l r ul i r r r . sl r , _
, | | l r t
; . 1| . | | |
I i r | |
1, .
r r r . , r r r ol l r l i i 1( l r i r l r ( ( l 11 0xi r l r l r r r l t | ' l r or t ) , r , r r r l 0. t 0xi ct , ( t l i i r
l r ' l l | r . t I r ' {. ) . i t t l r . (
t i oi t st , ,
"r , t l ) l r , t , l t Dt | r .
{- l t .
l i r r l
) ) L' dr ' t . i . r i t . t nr t r u, l t t , i .
. : ar . l : +( t t , l r t
nt l ( . . t l , sr ' l l r t t l t l t , t '
l l r i t t
t l ol i t r i l , t t t ol or ,
rrl tnrrrychi l or' l ri cops, l rrrr[ri l rl i ul l ,ori of
osi
cot rtt,ol rra,l ti i t' I, r' ospccl i v
(1l r
I):l I(' zl ,
I l t t xi ci l r r Lel r r i r l ul ui ( supl i ni t i L do hr ngul supi l l r r t or ' ) ; ; i r r , r ' i r l i cl i ' r ' i i t t t t t i t t t l t t i ,
i rso{,i tr"r de o hi pol ,rofi c;i hi potoni e a rl ui i ohi l or l o.j i i i r,nt t' ,r' i orrrca, l rt' rrl ' tl l tri .
1l ' rrl burri ri l e do strnsi bi l i tate si nt mi ci (vezi f i g. 22).
h' uctori eti ol ogi ci mai i mporl anJi r pl i gi pl ' hl at' mc al bt, srttt tl o l i xr
I
It i l cl ,ul i al e hurnerusul ui
I
anevri sme al e al teroi Axi l ttt' e
I
r:ottrptr' si ttl ti
(1u'oi'csiorrale
san in cursul somnului)
;
nor.lile (fotrrtc rtlr).
Muschiul dellaid
,qomufl culanate
Nervul ci rcumfl ex
Muschtul ratuhd mtc
NervuI muscul oai anat
Muschi ui bi ceps
Circumflex
Ramuri cu.onle
ale antebralului
/ r r . . r . \ "f \ i i ci i cur l r Uc\ \ i
". ' r s,
u1ocr , l l l : r l ,
1r,
rz i (i t: i n a,bducl i o
r:rr lr'l t olie rl eririnon
qi pr r r n r r s<r r r l l r l ; r r t ' r rr r t r I r
,
I r t i r ,
{
r r I r r i ( , 1i 11. i l : ' i a) . l , r r l r , xl t t l r l c i t t r l t i r l t , t r ' : t pt t t t t
r r r r l ui ( r r , l l r t i I ' i l l or r i ' l ' r , sl , t t l , ,
, l : i . u. l ! i l
l , ) pol i r , r . l r .
1i
r l cgr ' l t t l r r t ' i l i i l , ot r l t t xr r
lr
li rr cnbitalul :rnterior, lungul supinator qi fasciculele cubitale ale flox rtrtr lt I i
i,ornrrrr plofund). Iilexia falangelor distale a,le {legetolor_?r[-4.{t'or
li.ttt.ijkr
r,i rr r,sl .o i mposi bi ki . l l \carea de opozi l i e u, pol i cel rri trLt st.poal ,c trl t,ol tttt'
Ii i rrrl i nl ocdi l S, pri rrtr' -o rni Scal c rG n[duZl l i .ai
fi ,]i cl ri .
Sl l eal i zcl zl l
d, pol i cohl i po l tnl al i
l l an
r:u ool el a' l to <l ttgci r' ,t
( r , ml na, r i i t t t i a4r i ") , r t I t ol i t , t , t t t t so
l x) 11( '
( f
x I i l l l l i r
br cnhi al
| fi [
l l .r' l .rrzi i , i rn { I(,gd,ul l n i j l ot,i Lr
s. i ' l rrrl urrzi i , doa,r, ptrr,f,i nl , rorl i zi nd ohi ar rrrr
:rH;rr.r' l ,.tl rr.
,,gr.{i i .
medi anl ,l ' . J,:r,
,,pr:oba,
bucl ei l , (a tui Pi tres qi
,I.estut)
(.1i1..
.:!:i
c)r lllangeta irrdexului Du poxte si, se u,propie de cea a'policelui,
rrr;l l i .l i rrcl l ; tri ci nu poal ,e sL stri ng5.1n obi ect i nl re
]ol i ce si extremi tatei ,
cr.lrrr'l:rllo rfrrgcte. l,a proba.
,,{g!!ilgr_-!_nsnrciqate,'
(.fig. ZJ (t,),
lTd,exal
ri r rrrrrl i rrsrrl rl mi n i nti nse
,,i n
sdg---e-at$1' . Un al t test eonsta i n' i i nposi bi l i -
(n
i ,
^
l r , l
! 1. , , LL, r i L : l r r r u, i ) l j r - Pa. al i zj r !
Fi g' 23' i
ilu,rll,il'ir
ii";l;;,ll;fijlir,.il*:tf,',.:}"!!!iliiri'Jll'''::'ill.i5'Jll"L"'r;#:tl'Ll,i'ji1::l*ill;
tin.\ , t.\t..!, r
.
r
",,ri,i.,,,k
,,,, ,
,.,,.,,.,;"' ,' i,ii.;,Jf;-J' .ii"ll 1"il :i.::. :' ,"jJ' "' , ;:"J^fr,I ll"f..l;
"nr . I . . | , . d, - ; g' dt A' r . j . ' t ) p' t r a: , ?. \ 1r l ) j ?*t "i r o. r : _, an": Jl
mei i i anul uj .
l rrl l rr l l rxi ci rrl ti mci fal ange a rl egetul ui ari l ti tor' , astfel i nei t, atutci ci nd
r' |rri r ,.rl (! rrrj ozi rl ai . cu fal a pa]mari i pe masd,, boLnl r-ul gg pq_?!9_-l g-ZCi l !g
rr:rr,rr rj l l urrghfu degetul ui aei tnl otl Unel o mi s(.i i ri coEi .h,
"
srtrcrur,j i {.,,
.rl r, pol i r,r.l rri
1i
rr,l e cel orl al te degete si nt i mposi bi l e sa,u i ncoi npl ete (i ndeo_
ri ' .1)r Itri ri (
j l Ii I(r
rl o prehensi une qi t1e pri ndcre i r, obi ecl el or). Ni r trebui e sri
Ii l ,i r||r |i i rl e rnul to ori apal dureri cauzal gi ce, r]rboti te t1s tul bur,:i ri vaso_
rrrrrl ol i i
;i
l rrrl i i cc, l i mi tate l dhl vehi l i nAe.i i i tui ,.i ai merl
j usul ui ,
i n speci al
r l I l ) . r l | i l r r r i r l i n- t (
l r . net - vUI l t i mer l i al }.
.
'l'u
I tru t i}'i}:.
tlp- S-eg51bili.tpl-c sc consl,ati dolr
l)c
ur.l i,-,ritoriu par{ial
r r l z, r r r r ' i r l r . i t r l l vr r l i c
l r , I u' r r r r l r r i mr t l i r . r ( . [ i , t . : ' . j , ^i .
,
I' ri n.ci ptl i i .l urhti tti doui t,i t a,\ l czi l uni l rautta.l tce h rri vol rrl br,:r[,ul ui
( Dl r t i i r
l ) r ' i t )
r t t r t r , i r l l r r r sl r r r r l r r l i r r . , I , , t [ l , l ! r Hi l l l r i , L, zi ur r i pr i r r sol u{, i i i r r , j r , , r I I I r L|
l , j r t ; r \
r , ni ) r l r r r r i r r . l r r l
l r l i l i i
l ol r r l r r r ) ; l ' ) r r r , vl i l r , i t r l ( , r , l i , r . r A( , ; r . i r ) r , r i i 1p11, i i
I h0
l r r xi co ( t i r t l ' , r t i i zo| r l c l r nt vt ' l ul t t t t r l i : r t t t t l r r i ; ;
r l ) l ' zi - t t r r r ' : r . t t t t ' t l j : r t t t t l t t i
r t t
*i ". i ""- t i f . f nr , ""Jcar Di a8csl ccr r l cl et i st i t i r ,
i r r t abl ot t l r l i t l i r ' l t l ot l ot r t i t r i t r r l
*l *i i i uoe. e i o". o i n t 6i , i i ori ul ncr. rul ui l nudj : r, D, i rrbu{i t {' rl r. rrrrrl i o rrl i qi rl , -
. i , : l ; "i t ; -; ; i ", i i
. i dc at l ol i i muscul arc i n t eri l ot i ul t l i sl al (sul rr: : rt l ri rrt rl : ' l
totali a nervului cubitl,l so
(11rt
r t('
Ialangi a degetelor se
i cuhru de mi nh
,,i n
gl l fA cu' bi LrId" :
l tri ttt' r
i n exl ensi e, i ar | ei i l r l t r ' r l ot t i I r Ll at t gc i t r
iiu"i"l-r""".ie atitudide fiind mai exprimatn h ultimele rlouri, r1.g.lr' ;
frl U"e"i J mi "
se menfi ne i n
--qbd,i ;i e,
i ar sl aLi i l e.
j ni cro$o' so ,.ri trl
,i""ri,i". inift'ebi
primul spal iii inierosos
(''a qqu"a' t,+bachc'ii xllirt(r
*i .a,t-
"
l "i S-i .rrd).' b" asnni nnea crrri rent& hi pofcnari cste i 4rl rl i zi ti i r I
. i ' i o f
"r i r "
i l . ot . t i ' a
l c, i or so 1l e
ni vel uT
! or : 1i ui l
i i i nf or i oar c r t : r ' t l 1r ' l t r r r t t t l t r i
;l;;;ii;J;i
';.iinii), 'd'.r,torit5,
cru!5,rii fleror'lui c.o1u1 prof.ntl
;i
.ttlri
' r f . l r i
, - nt ". i oi f
^l i i l t n
l a o pozi {i e a nr i i ni j cu ul l i mel e d( ' ui i l ogcl ( r r l
t[\;; Ji P;i "
pi ral i zi a i ntel osoi i l or se compromi l tni l ci i ti l c rl ' ' ubrl rrr' l i r'
"i -0" ",Oi *i *
i te degetcl or
;
e) befi ci l ul Ino-tor i nrcres"r' zi 1i
tl cx i rr' rtl l i
t "f ot aor e i "g. i e, ddeosebi a degPt ul ui mi c' pr ecunL. ) i udduc! i r r
p' r l i "
l ui
( bol navul c6mpenseazd, par [ i al aceast i t ul bur ar u pt i t r mi qc: l r t ' : t
t l t ' r t l t ' t
r i i i ". . *i l t . i ; . p"i i r nemr l medi anl ; t ) Par al i zi a muqchi ul Lr i ct t hi Lr r l r r n l . t i ' r r
; ; ; i ' ; ; ; , ; ; . [ un t l cf i ci t r l adduc! i ei ! i d l l exi ci r ni i Lr i i
i gr
Test ul l t t i [ r r ' r t r r . t r l
;;i;;ifi;t !;irtiria
ailtluctoniiui
policelui, in sensul,c5' bolna'vul tttt izlrtt
i ;-t";6;i ;; cu mi na un zi ar si u o hi rt' i e i ntre pol i cel e i nti trs
.6i
i rttl .r
i;l';i;;i;;;;
rla face doar prin flectxlea ultimei fala'ng-e a polictrhr i- rti
;rl ;-;;;;l l i ;
pol i cel ui , rcal i zei a pri n ucrvul medi an)
l -h' ;,
Test' ul tl t:
,,r' i i *
i i r ' , r , "' i , deEet el of i at unci ci nd r - ni i ni l e si nt apl i cal e una pcst c i t ' l l i )
l ' r ' r r r
ti ,tel e l or pa*Imaro
.qi
cu degetel e_
_i .n
abduel .i c e:trem6' de par,l l i
P:";:' :i
,"ie .". .iia"tiirre ina14"
"fi"
o r) istanli rnult, mri micd' intre tlegol'tr iri{ir'
,i" o"tLo *X"Xl.asX I
ii trlina fiind a6ez-atd, cu fala
lrLnara
pe rnas[''. rrriti
ciegeiglui m-j
i ar txrl , t l r'
l
iutmrrii"t" ri"
Oegetului-midiint'ebOIitA f
f
;cu
mina.plasat'i cu Ia1*
ltrtl
.
;;;;;; rrr.rsd, bo"6a u' ul tru poat' e sd zgi ri c"masa cq d.9gc-tul .l 4j q (scrrr' rrl
iri
' piir"rt
;
r.r Tulburi,rlle. d!
se=qlbj-titaLQ
sint localiTate
4"
ilSY*,f
' l:' :'
I ti"*g*xil],*:'*g*r**gttl'*tm*'"'11"'#f
x'i#A#il
ii ;'
;t;
i , i ; , . ; : ; ;
"^. "^- ; "";
Xi a. ' . ^"; i , , ' r ' qr aat , er car r zal pi c: m) Tul bur i r i l o vul ' u-
ri U,,eo,i se asoci azd Ii
dur' cri cu-cai acter cauzal gi c;
m)-Tr-rl b-u rl ri l tl ' -t' ut' tt'
; r r , . r r or i i si t r of i ce se i nt i l ncsc at l obea i n l el i t or i ul ner f ul ul ( del onnt l l l i r l r '
;;";hiii";; o*c,i"ioi."a
pielii, cianozd,
pielo lucioasS'
qi subliatfi, txlt'tttr.'
ovdntual chiar ulceralii a,Ie degetulqi mic).
r l i s{ i r r go
1; t , 1t u
va' t ' i r t i i l , i :
l \ , ) ) l n pt r r n, l . i zi . r r hl di i u t t t "t r t t l t r i xt i n[ ( pur al i : i r r ' , , , l t nhi r t l i r " t nyt t t
, ur . t i r , " i t r u , r , t i i l ur d , r ' t nht i l . t dr r xi t ' i I l i r t ' r , l 9l : ' )
"
r u) ' ; \ t r i r l r ' r t {' t t l r r l t i r t "
I ' r i nci pot i i f aal or i
el i nl ogi r i : a) Lezi uni I r cunaI l ( l a. ni vcl nl coi t t l r r r
r , , , , r , o""t t i r i huni nr usr t ni 1- di
r aI , ; ' pl ngi al e ncr vul ui l & ni r el ul i t l r l cl ' r i l
i , i i , , t i
"i
"f
r ni i ui i
( adesea
"
o. 1i o41' so- ; i l i zi unea : l r Lel ei cubi t ' al ' ' ; 1
cont l r t r '
i i i i i i i , 1" 1t ' nut i t o.
ner vo: l , sc- t r ' r m i na I e pc osul pi si l ol m ( par ' r l i zi i r
' , (
i r ' l i -
l j l or"' l : b i U
' ?bm
nti i
' .{.sto,]:i t' tci i a1"
g;' dl e d' eJi l eutui soal eni c
rco:tsti i ' trot ti
( , : r l l i ; l r i ] ) ( ' Jl r of i a r nuschj ul ui snl l cn an[ er i ol , cu i ngu"l : r t ' ea- , , deJi l ot t l t t - i
r i r
.
r r , I r
.
r r i i
. i
) 1 , ' ;
r ) aol i l e
r ul t i l al e i t t Tec! i oase
pot ap, l cl r i r r / l r l ( s, / l cl t i l ' / l i ' l r r i '
l i i ( ' i ' l i i
( l i vct ' se vi r oze, t nal ur i e
9.
a.
:,:,),1?araLi zi a neruth,i tatl ' i al se carrl cteri zcaai l ' 1tt' i nl r-rt
sct' i tr tl o strttttt"
l rrrl rrgi ri rrrr,,ni .r,,
i ' l i rrC1i o rl tr srrTi *l l t:ti utti ,i , i tt l \1111,{i tr tl t' (' rl ,l ' o
s{!
l r' l '
1t , ?
cutanat a!
r ol ol ' ( f xl ' ( , r I r . l 1) l i l ( ) l ' ( l ogoi ( ' l r ) l
i
n) ' I ( r st , l l l
, , r ' i l sl i l ' i Xl ' i i
( l ogcl t r l or ' "( a, l l ui l r ' I ot t l ol l l )
l l cfcctuarrrl tni qoi l ,ri i dc cxl ,ensi c qi i ndepl rtarc (r' i i sl ' i raro) a-tl trgtrkrl rr,
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
l i . a l c r al i zi t i r , nu se evi d"nl i azd ni ci t endoanel e cxl onr or i l or , ni r i
I ) r ' ( t t ' t r r l
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,pucd obiecte-, intrucit pe de o parte este imposibilS ridicalon, miinii si rr'
ni j mel or
f al ange al e dcget el or , pe dc al t b par l c I I e- \ i unoi r "
( l ( g' ' i t ' l ( , r ' {"
i l ce t t i f i ci l si cu f or ( i r cr l usd, nu i l at or i t i par al i zi ei l l cxor i l ot , r ' i r l r t l ol i t : ,
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
lusirciune"
(Pitres)
;
r)
fulburd,rdej.e.-.sen-s,ib,-.ilitate
se rer:narc5, po 1r'r'il'l
liu-I cutanat al nervului, dal mai ales la nivelul pr!4ulUi. gpaliu inlrtrrrtsttx
tl orsal si ruai al cs l a ni vel ul ta bt cherei anal orAi ce
ff;g'
2d d). Este rf i rl i zrt l i
t l r l ezi . i ni t Jau mgt i ce
t i . n.
t t i l d
( pi i n l uxal i i al e umi r ul ui . f t act t t l i i t t i r ' l l r ' : r l '
br r r r i er r r sui uj
ef . ' . ) , sau ol t e pr cr csP ar i l o' e ( t ut not i l .
cubitql
FlexoruL profund
'ol degetelor
Gheora
cubi t al d
Abductcr po{icelui Abductor
Opozant
|^,,,*,*
Interasosi dorsali
Interosast palmari
Lambticali iIl, IV
/ i./. 3./, NrNul cubitnl: ramuri nervoqse, distdbulia Dusculali
fi
crtanoti. Crila
cubitald.
ferl ori ul
cutand
-Fig.
2r. Nelvul Edial :
r - r!ri. ,,itr Eit de lebede"; ! - Sequl ,,rasfitnni dertrelot" lF/otuettJ t , - Senntrl ,,std!8erii mlt,il" (l".ott.i,) lr
rrrl.a nJrili;tl ntr se obsenl tenddN' F eteDsonlor it m.i proeminmla tadialtrhi crternj d-T.ilornrl .ulirrr
"
l,\ Iurnlizitr, rad,iata tt,Lilf,cil
(aBa-zisd
,.brahialf inferioafti," a, rt'ttlo
ri l ol ri l r.i ci - Ri ser, 1952) e;i e cea ni ai frecvenl i r l ormri de paral i zi rr r:rrl i
:r,l i r,
.si
rezrrl l i i , di n l ezi unea nervul ui i n partea
mi j l oci e a.brai l ,ul ui , l i t' tti vr' l trl
,"'rrn {,nlui
rlc torsiunc a} liuq,ro usului, Apare in cazuli de {rntlturi aJo htttr tcltr
srrl ui snu i n di verse trnumal i sntc humcra' l e, l a purttl ,1,ol i i <l o oi t' ,i i ' l u, l rtrl i vl
qi i rr rri l crrl rstl nfc rl e coutprcsi urtc a' ttetvttl tti (cl tl $i ca' ,,p nl y$i o tl tl g ttl tttttt
totrxr) dtxcui si , rl c l )i l ,tts satt
,,pa,I' al i zi :t,
rl o rl utni l i tfi ")' Itt ttt:trrtsi i l ' fot' ttti
t , sl , 9 pl si bi l f i uxI r 1l l i i t , i r r t I ' gI r t ' r r , {' t t I t t i , i t r I ' t t t ci l ' 1t ' i t t t r l r st t l cnl g ot t t t Bt r l ' vi l , 1' St '
r r r t r sl l l l i or r i c i l r r r r t r r . | t ' t | | |
,
r I
t
i r , | | i | | |
' i t t t l l t ' i r t t ' ( l l t
l l t , r r r l i zi r t
i r r l r r ' l I ) , i r r r ' l Lr r i l
',':
lt
)
i l l
I l i ! |
Itl tsrr rrol zi i Irrrrgrrl rri srrpi rurl or' . l l ' i rtel l (ci trr,t tkr l i i sor, 1952) r l i rrrui ci r, ol i co
prrl rrl i zi c l i rrl i l l i i , eal r: rcspcotl l ungul supi na,tor' (i n al ' r.r,ra unoi l ezi uni j ol rso,
,rrl r l ri [rrrrrl l ' 1,i , rrcrvul ui ) se dato]qte unei pnl al i zi i radi cul o-rnodul xre,
rrur,i
l xrl i rrcvri te
satutni rrc sau unei i steri i .
i.,) I'oral.izia radiaki antebrctltiald tnaltd, este roalizal,X, ale trautnrtrisme,
rl ,. l r( l rl l i i nfccfi oqi qi toxi ci (i ndeosebi de satrmi sm). Respectd, l ungul
rrlririrlor' qi permite r.idicalea pumnului, intmcit lezirmea atinge nervul
rtrl r rrrrr:i chi i epi condi l i eni .
i',t) ).'arulizia radialti antebraltiald,
joasii
este intllniti, indeosebi in
rr.rrrrri i smc (de pi l d:fi , i n fracturi l e radi usul ui ) qi i n nevri te. Intereseazi ,
rll:rt lrrrnrrrilc radiale ale policelui (scurtul qi lungul extensor, lurrgul abduc-
I()r') si (lxirensot'ul
ptopriu al indexului, cu tulburS,rile motorii
Si
atrofiile
r' ,,trsrrtrrti vc. Tul buri i ri l e rl e sensi bi l i tate si nt l i mi tate l a o mi c5, zon[ Ia
r' i vol rrl
bi r,zei dorsal e a pol i cel ui
,si
a pri mul ui spal i u i nterosos.
li) I?aralizi.tt, nerLr ui obtu,ra.tor se recunoaqte prin constatarea unui
rlclicit; rnotor 1)l adducliei coapsei
-i
a] rotariei exteme a
-acesti,a,
cu atro-
lr,r loirlsrri
fi
plinbr-o anstezie pe fa{a internS a coapsei. In timpul mersu-
lrti lrolrrrvrrl prezintii o deplasare in a,fard, a gambei qi a piciorului. Este
1rt
rrrIusri prirr traurla,tisme qi la fcmei, in tra."-ali,w prelnngit, prit:' compresi-
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 rri rnuru de i l tensi tate l a ni vel ul senunchi ul ui .
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) Imposibili-
Irl ci r fbxi oi coapsci pe bazi l ; b) Defi ci tul ertensi ei gambei pe coapsi
I
, r
'i'rrlbuliili
rie staliune qi de mers prin irnposibilitatea, ertensiei
$erun-
r lrirtlrri- Aceste tulburi,r'i de staliune qi de mers silt mai mari irt para,lizin,
Irr,rrcrrIIrl i i , i nal ti ,. si tua{i e i n care bol navul est ol ti gat si -$i
,,trag["
]x?tn-
lrrrrl irrfeliol in1,r'e doui, cirji. In schimb, in palalizir, troncularir
.jo:*1,
l rol rrrvrrl p(,ri l e merge, dar cu contl i l i a s[-Di mel l i ni , genunchi ul
,,hl or,,i t"
Ir (' \t|rrsi l r.
l )acl i se prorl uce fl exi a, gamba se derobeazS,; d) Urcntul sci ,r' i -
1,,r crt,r: i rrrl xrsi bi l si u {oarte di fi ci l ; e) Bol rrayul nu poa-te s{, se rneni i n.S,
rrr ,,pozi (i rr
1x' r' i no' :;
f) Refl exul rotul i an este abol i t; g) In l rtostal i une se
l l rrl l vi i o
l xrz:i (i e
cl e
,j genu
recurvatum"; h) Atrofi a tel ei antt' ri onre a coap-
rli
;
i) 1l\rrrllrnul rotuli:rn este flaso, depresibil; j) Tulburi,ri de sensibilitate
1,r.
l rr(t rr r r l tto-i ntel ri :r coapsei si pc fal a i nternd, a genl bei .
Ir'ul tt'i, tt'itlogici: a) Atecliuni vertebra,le
Di
ale cozii rle cirl (traumatice,
Irurrol rrl o
1.t.);
b) Turnori pel vi ene; c) Comprsi uni de al te naturi (pri n
rl(.r'lrl g|il,vi{l, in cursul unor inter"venlii chhurgicale, cind coapsele sint
rrr rrl xl rrcl i r rni rxi mi , sau i rr cazul purti ,rl i unor bancl aj e herni are compre-
,,rvr,)
;
rl) Abccsc ale muqchiului psoas iiiac; e) Intervenlii clirurgicale pe
ruilrrl lrilzirrl f) Irractud aJe bazilului qi ale porliunii superioale a femuru-
lrii
;
g) .s! tnevro de rerlucere a luxaliei coxofemalale
I
h) Anevlisme a1o
rrr lrloi lemulille
I
i)
'I'tr,untatisme
directe ale nervului (de obicel cu cointe-
r r.sirlcil, corrcouritontl qi a ri,r'terei lcmurale)
;
j)
nevrito
,si
neuopatii (dia-
I r r . l i ci i , yr r t i l i nr t r i c[ , t oxi cl ) .
i t) I' rr,r' l l i zi rr, rrtrl vrrl rri l i r:si ol srrl l ori or (rc:rl i zati (l c
frr],ctnrri i rl o l )Mi rnl l ui ,
r l c i r r r r r ol i r l l r l i gr r o i t , l r r l l r l zi r r r r l r r i , r l r r l r i r ur r t i i t i sl r c
l ) r i n
NI ' nI r ! t kr i i x, si t , t t l r , ur t o
r r l l r t . , t l r r cor r r gr t t . r ' r i t t r r i r r r r r r r i l i r l l ' r l t r i . i r l l ul {ol l l i n cr r ut t l I l r l i r , t i i , sl t t t r l r t l l r r ' -
l 0t l
l cl t ; i , . 1r r r 1r 1r {, i or l r l r l c t r r , vr , i l c i or i cc l r r r r t i t r l i r o{i or r so) so t , r r cr t r r ol t , qi l l r
l r l i r r :
r' ) l ) i nl i rrLri Ll ri r for' {,ci rl o tbttrrr:l i u .r, cr.ri Ll tsei cvi rl err(,i l r,Li i , rul r,i tr,l t,s i rr l ;i i rrIrrl
, . l t l . i l t r i i
1i
: r l t r r , . r ' . , r r Jr r i p' i r r i r r ,
.
I i r r I r r ' ,
, ,
r l xzi n r r l r r i r i r : p; r r . l r . : r , r {}' r : i . , : r t l . , . i
, t t ul bul r r uvr r l . 1.
spf i j i ' i pe mcml r . r r l i nf . t i r . , r t l l cct r r l ; I ' l . r l i zl u [ r i l r r t . r r r . ; r l . r
ro llil(luce priu meriiul legi,nat
,,de
ra!:i':.
.
t t t l ' or al i ; ' i t t t . ei , , ul ' r i j , si t y i nl er i u' ( pr i o. f ue l oL. i et i , r l ugi l i i r l r . l t i r , i , . r r
, r ' r
r . Xl )
l t
t i r pi , t t i t l t Zl : t pl , , r . ( , ! Lcnl i )
S( , r ocUnOt st u pr i n
LU, nLi i t 0l l . t , ( . l c Ji . | | l l r
;r.ri r.ri rte,rl c_paral i zj nrufchi ul ui Jesi er rnare: i ,) Ii cttrrc{,i 1,
j .krxol i l ol
,
' . ) r psAi :
b) Di mi l - uur r ' l f ur l ei de a\ - t r ' nsi c a cor psei pc Lt t zi n
j q
I Li r I i r , ; r r . , . : r
, l r t r . pozi l i r ' l czi ndi ,
ost e di l i ci l f , ; d) l n or t osbar i si r uoi or n: r pr czi r r l i r , , l r i 1r r . r .
LIr,l rrzi ,.l o-rnhrrrri
(?entm,r,
componsa,
$i
a egal i za contrai l i l l ,rri ,u,gori i sl i r,
,1,
I,r1;\ouror coaps-el)
;
c) ijcolioz.i
cu concavitatea spre pat.to|,
siirriil,o;r,rii ;
l ) Lu{.r' sul -$i mti s,l es rucatr . sci ri l or se face cu di fi cl ul tai e; g) Itr rkrcrrbi l ,
i crrl;r'al, dacl se lixeazL baziul bolnavutui, acesta nu-rsi
]oatc
r.irlirrrr,
q|rnb:l
de pe pl anrt1 patul ui ; h) l a contracl i a fesei , so remi rci i o i tsi rn(!1,ri 0
1l O COt l Ul . aCUe,
. ,]0!PgratjZltlg
s.ctatice
_prezintii,,
in funclie d.e topograJin ltziurrii, rrrri
r rLl l t+j I' artant(' semi ol oEi ce :
, ..,,_!0tl _P"qr-ol.i
r.ia
railiculard,
to.:l!' trqnoatqlrd'
Lnutrli, testa realizrltii plirr
r , r r r nce
r udaci nj l or , gr , u
a ner yui r i i s, . i aLi c
i ] !
bazi n, l a i e5i r ol di n l r i zi r r
.,l |r.rn.
r.rerrnct l g4rl rq superi oaTi a.go]apgql Se recrtnoagte pri rt r r r
.
r I r : i I r r r
.
r r I
' ' ttt(
t!t::l u9togtr..
carc .rezul bS rl i n asoci orea pal ati zi ei
sci *ti crrl tri prr|ti
rr, r r.Klefir, r_t ,scrr,tlcului poplilieu intern;i a ramurilor musculare al0-l;r,irrr
, rllttur
ncr\-'lut mar.e sciatic la nirelul m.sculaturii posterioar.c
it ooitrl)rior :
',']:llt]iri"
tu$1o1 myryh1t91_ garrrb--ei
"qr..
ai
+iciorutrii,
realizincl un
;ii,ri,,,.
:,..,,,-,]],,1.
f,_
corrplct rmobil;
b )
rUersd,eEte,.Etepatn ridicarea pc vi|l. tlrir.irr
. , . , . ' , ' ] l
, , : . l rl i ' 1. '
bl a! . 1-yoe?. p: vj duri
t i pc
ci i ci i c est e i mposi b[ J
I
r. ) t r, rt i r: rv l
, )u
l )r): rr' rgr : f t ) r' rrrri zi a n. rrot i ci
_
a
. muqcul al uri i
post eri oaro
l L uD , l l r0j
' '
,rrr1 rrr r. l.', i*rposibilitatea frexiei gambei (test semiologiic ae
tararizi
.,
rl,,i'iiri
) ;
,.r r\ lrofiile muscdare interesor;z;
]r_q-Eq4gt _"lSlrscriatuxfi"-_postoriol,rd, ri
' ' ,r,t' r.x
i ,.i Inrisclrlalur' , gjmbei : tt firlB' ufir-ife de scnBibilirat,. s(, r.\t.rl
l.l,' ,,,11' ll
tl, rrrl-elnl rntregului picior_(cu
gxceptia pirlii interrrc rt,
|lrrrlr' i
| .,, nri ,l e.' l er fi r,l ertl e
),,
precum si pe fal a l ateral d, a gamboi
I
t) J)c ci ,l rr rrrr,r
l , l l l l , : : l l ' l -"l E111"
sci aI i ce
si , , ' t pn n rol c
. si mpJome
si -so si l rri -. rzj r
t , , . I , r. i rl rl
l , r : r r
l l l | l . ] t r t , l Zt UI ] l l e I Jd, cul af ( . Ci t , si i n cel , . t t "ont 1uhr o. g)
Sr :
l r | ' l
: r . ur ci :
r lrllrtri,ri vasornotorii
Fi
-Uaf]gs
_(crleme g,rnhiero qi atc piiorulii, tript,r,
l, (' r,rLlozir,.
plnntare,
"rnbritticXii
ale pl:lii' ;i
^f" "iigLiifuii".rlce' .,1ii
pi,r,,
l i r r r l s. d, . ) .
i u; fui l tt:i ttc
,,|oni
tttti t.C_7og.re
] si nt rnui t mai fi ,eavei rtc, l rt(,11ri {rrl
, r'\ rr ,rcrr-L1jrc t'ru in trcimer mijlocie a coapsei fie sub ni]Iehtl tle crrrorgt,lltii
r l rrti ruri l or
dcsti ni i te l a muschi i regi ul i i
]ostcri ouc
l r, crrq)sri . 0rr, rr,j ,rrri ,,
rl r' ri .trtrl rl
srrrnhl -i po co..psr este i n pi ,rte cdnservat:i , i ,r,r pl ri i l i zi l
o$tc(l i H(l
r"rr' )' ri r sr ri i rL ri l i i rL u' .tt:xfrrl cl i ' i c predomi ni
fi e semnel e pa.r1l i l ,i *r
rrr,
. ] ' . , , ; . 1: l l l l l i Jl l l , l *, l , cr u.
i i e ccl e de sci ai i opopl i t eu i nt ( . r n. r l r r r oi i t r i l : r pt r r t r r r
' , r r ur t n( ' nl r i t l l t i r l i l r t r nor vs{, i : r t i ci i l r i : oJr . t r ct . t oi _l st . , i cst i | | : t l ol , r . r : r , l ur l ' , r l ]
I r l l l l t l i l nl l , l l t i i l l ( r si r | t r l oi i r , L0r Lni 1r , i n i l ; r sci cl ] l e di sl ; i l r cl t .
lt).,\ l)t,r.u,licitt
aointiaiWTwfiitc.Ii-iitam)
1s,i
,, ,..t,t.,,1,i tiltirtl, ttost,,ior
I t t t r t t ' , t , t
l t ) t t , ) t . r . , l l t J t 1, : r l i zr l l zi i , : t r ) I r a, r , l r l i zi a, ' 1, 1. \ {) t i l t }r
1i
l r ddi t ct . t , l l ' r
| ' r ( : | | r | I | | I I I ,
( , \ r r l {. | l l , i l I | | l I i r .
. u
| | t {( , l t i l {) t .
I
t odl . r , l . i r r t i j t r i ga. f r . r r . i ( l l r . r ( }r . r
. t t ; r r . t l i ei ; ' l i
. . r pr 1' l r , r / , i .
; ! . r r r r . r i . , , , r 1, . : r r . . g, , , r i | , i , . , ,
1, , , , , f , r i , , i f , Li i r t r r l r r r i , l
r r r | | . r r ' | | | | r | | , , r | r l t i r . | l i r I i " : r r
l ) t r . i 0
l l Ut , 1,
cr c( r p{, i l l
[ r , r l i r r st t l t t i
( I r t I i I t t r r I Ot , i i
. r u, \ ( | l l t r I r . ; 1r ' I i I r . l l r , r , r r r r , ; r l r r l r r r i ol i j ) i l r ) i t ' r
( ' r r r r r | r . i nI r l ,
I r r ' r I r t r r , r
,
r r I r r r r
1
I
l{r I
poi l ,i ,(!
star
p.c vh' fi rl
?i oi orrl ti ,
(,i rto
r)l l
?o?t.t(r
1i pl rl sat ni ci hr addl c,l i cr-ni ci "
rrr lol,rr,{,irr iltu ni, qi nu poatc sd-fii fle,cteze degetele: e) },iolta plantard esl;tr
l rtl l rrrsi l i i ;
d1.1\l crsrrl csl e di l i ci l , de al urd tal ' $3l d
;
,' ) Atrofi a.i +tel esea,za
l ' ' gi rrrrr.rr. pl :l nl a}i , rnargi ei Je pi ci orul ui
$i
mol etul gai nbi er; f1
' Tcndoqgl
l,.,lrilirln .,s1,o depresibil
;
g) Eellexelc achilian
fi
medioplantar
'frint
abolite
;
lr) { l1q117xlgi- gi dureritre de, tip-rne-v.riiicf
'
sint destul ile frecvente; i) Une-
,rli xr, rtrriir.r'ci $i
$tergerea lgheibulul
retromaleolar
;i
picior
,,in
gheeri,",
cu t l egot e
, , i n
ci ocan":
j ) Tesi ul l ui Fr omunt :
in staliunea intr-un picior, tendonul lui Achile
ri.mine flasc, depresibil, iar gemenii nu se con-
tractfl tle parted paralizatd';- k) Testui
,,picio-
rului balant') : bolnavtl, plasat in decubit ven-
tral, este solicitat s5, llecteze energic
gamba pe
coapsi- Ie partea bolnavS, piciorul rimine ba-
lant: l1)l TulburSrile de sensibilitate obiectivS,
sin1, rjecelate pe ta1, plaiitard, * piciomlui
( {i q.
26) ; m} So
pot evi den! i d i i
[ ul bur ; r i vaso-
ni ri cri i
'
qi trofi ci (edem aI pi ci orul ui , ,rl ter.al i i
al e pi el i i
!i
al e unghi i l or. ul cere l ,rofi ce
nal ca-
,i;i='--\',',)\ neenen maleolato qi/sau digito-pl&ntarc).
--'-\:iv
'r}a]}
Patdlizia neraul'wi c.ialia poplilea entern'
ttervut.
dknhr
este reaizatd in. special prin leziune ln nivelui
'
tatirat
.qgDdui leralgd]Li
qi interescazi celqgsg m.rl.!-ch]
/ , J. ; , ; . t i . r i t or i ul cuL. Luat cI
ant er i or i ai
gamboi . t abl oul sel i r i ol ugi c consf i nd
r ' , ; r r , l r r i s, i l l i cpnpl i t ( r i nl cr r . di n: a) Pi ci or ci zul , hal anL, i u va"r us- equt n ct l
primele falange in {lexiune
I
b)'
Impo:ibilitatea
lLrxiei dolsale a piciorulu{i a falangelor ptoximale ale degetelor
I
diticulta-
l ,,rL tbtl ucti ei pi ci orul ui ; c) Imposi bi l i tatea de a
,.bate
gl dsum" 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
'
i l schi mb si ol
$te"rse
de partea paral i zatS, (prob:'
sral ,i uoi i uxi pede a l ui }' roment) : c) Ia proba-. n,-
pi ngel i i i napbi .
qe
cunsl al d, at' el al i fenurnen de Ii psri
ile ividentiere a acestor tendoane
I
f
)Mers
stepat ;
q1 f mposi bi fi t' atea de sta(i ul c
.pe
cdl ci i
;
b) Er l en' i :t
pl i r' rei fahngel i t I)i screte tul buri ri senzi l i ve,p' '
oartea l a t' el al d, a
gambei
5i
pe dosul pi ci orul tri
j .Si g.
ZZ.), secl el ori i , r asomol ori i
gi trofi ce;
j r
' l l r' -
l i ei el e i chi l i ene
Ei
medi opl l nl ar e si nt coneet val ' ' .
- Fact or i i
el i ol al i ci r n l ezi uni l e nor ur l ul sr ' i ul i r
pot acliona, ia nivel radicuhr (In-Su) sau Ia
livtl
troncular' : a) tr'actorii vertobmli sint cei mai trer:'
venli (hernii diseale; morb Pott; tumori
-primi-
tive. sau metastatice
;
traumal,isrne
;
in ultimclr
situalii, paralizia sciaticS, poate a#5rea in cadrul
unui sinalrom de coadd, tle cal)
; b)'
Traurnatismolo
,,
Si
rtiverss afecliuni a,Ie bazinului: Iuxalii coxo'
Di sl fi bUti e sm:,,,v
j Sl
drverso al ecl runr al e D&zrutrrur: ruxi r,l rr uur(r'
-' -"' -' i
:tcnnrral e ;
o$teo-artri ti , s&cro-i l i Dol
i
frrottl ri a,l (l
1, 4f . 11: . , 11; ' l l l l i l f . l ' l l l l l ' . ". 1
l r r r zi nr r hi
;
l r r nr or i r l l o l r i t zi nt t l ni i
{: ( , r t r l ) t ' r ' Ni r r r r i
l l rrr' r' \rrrrrrr r\r' rrru(
Di ' l )rrrl rr
,,..,,rci l nl rJ rl rt 0rt,l l
.l ' ()i ;l r,1
sl l rt rl o l l i r' <,r,ps
I
tl i vl )r' sr.
I
16'J l r l ; l
' f , r : {i r r r r i ,
r r r , l i r l . l r r l i l i r r , . r r . i ul l ; , r r r : r l . r | i i r l i t r r r r i r . r r l l r : r zi r r
;
c) l , t , : t . ut nkl , i Ht n( .
r l r l r {r l ( ' | : r l '
r ' t vr l r i
' r ' i r r r i .
l ; r r r i vr . ht l r r r : . r ' i i . r ' r r l r i l r r r . i s. i i r r i i . ( . ,
. L
[ r . s. i , r . r r r r
1.l
frr{:t
1rosl ,' r i o:rtr' r,
..i r
-currpsrri
(l ezi rrl ri pri rr rl nrre i r,l l l c srnt
j rri tr
l r,l ,l rrrr rl r,
l'r
;
,
lolrg.i ii'
-
dupri i'iectrr,r'e accidentlalir, in trnuchiul sciiflic ir, rnr.r.
srrr)stu,nl c nrr
j rtl camenl
uase , al gog! peni ci ti ni i
sau al te sol nf,i i r:u rrr,{,i _
tttur destrucliyS
a nervului)
;
{}
Nevrite virotice
;
tN Noulopatii l,oxii:lr
suu toxicoalerEice.
_. _,..}:r,;,11
sci i t.i c
popti ttu i ntern_poate fi l ezat pri n traumati snt c f, n x:ei ttrtur,
l1,t)pIdec, l.rltcturi lle oaselor gambei, prin tra rme directe (cu
anlc ulirt, srrrr
' r , '
r ( x. r s,
t r . oor i pr i a l cvr i l e ( l o: i ce sau i nf cct i of , sc) .
.
M-rrl ri l sci al tc popl i teu rfrtet' r
est.e l ezat de obi cei i n tl i trrIn:l l ,i $l l (
j
l i r,
' 1Y,
, ' ] l
! "pr - t ql
per oneul ui , i n
r numi Jo condi l j i pr of {, si ol r i t l e ( h r r l n( 1i t , , r i
, ; : r r r
s l . l . ) - u ml
. t
qhemui t i . pc
! i nc I a pr , r - at r r J st r dzi l or . I r pr r r . bct l l I i r j . r _) ,
: 1, ' . j ' ", , ' *n! l i
r n ner r i l c
( r usi cr . .
vi r oi i r o el c. ) . Tr cbui e r el i nut I r r , pl r i l r , : r
rr rvtl
,scra,lic
p_opliteu
ertcrn por"ie fi lezat qi ilr rrod izolai; chiln. irr rrli,r,
r r r r r l r l c l r uDcl t i ul ui
sci l r i i c r l t u aJo pl er ul ui sr cmr .
..,.,!),-fI:r-l !,1::r,/i te|.
reprezi nti ,
constel al i i cl i ni ce i n care serni ol ogi r. sr,
, ' - . ' ) l : ,
t , par ' 2t l z
5aL
l ) a
r ' , zr r r l o nr ai mul l or . ner r i per i f cr i ci ( r r r r r , , r l i : . i
, l i r nr cnl ) .
r pt r ut e l i c si mr r l r un. f i , . si t ccr . si v, dr r c o r l i ql }i bul i {' l r r l , . , , . : r
.xp.icioasii, qi nesistematizati, p.ezenfa
r,nui trbk u semiologic
'rl.
rrrrrlli
l l i . : i ] 1. . i :
. . ys. : l : 32i . ( i n hr nf ui c dc n. odut de i nst al ur c pi de cv"ol u( i c; r r r . r , r , ,
,t.t:t,t l :1'
l rostbtttt,{j .l i
eti opol sgpn;.,
: J) l l ul t;npwi tp ri rol i ce (pri n
vi i .rrsrrr i L.
l .::.,.,' ,,,,
rr\s1ckre,
.
tl erpes zoster, rareori pri n
arborri rusuri r, Z) Ml t(ti nt,
t t
' i t ' t t . ?l : ct ,
( pusi vacci nr l c.
po"l ser o t er api ce
;
r l or gi i medi cr r r | l , . r , 1, , , , . ,
. . , : i . r . . ") l
I
ot ogp o: p . St bot t o [ ot mu
a (
pol i neur omi oz
j i
e, I UpUS cl i l r . r r r : r t r r . ,
- r ' l f ' r ' o( r r . l r nj o.
i ) o. r r ar t or i l i nodoa- . i r . "l l . l 4 r t l t i
pLt r i t e
( n ul I i i eu r o po I i i
)
l t x
; y. '
t ; t bt t i ae t r i i abel i cr . ;
, n cvol ul . i i l Lr nor pol f i r i i ; car euqi ai c; pr . i r r r . r : i r r gh,
l f l ' f l | r , . ) . . , r
- t t
t t r l t c( , ul ol i ; pt xt nect pl uzi ae ( t a. r c1.
t' ),1' rl tl rrri ttl e
.si
p ol i nearopatL r.l a (metabol i ce,
torrce, onr.ol l l ,i rtr,
. . . , . i I i , t
l {. ' , za dol t ct l o t uuscr r h| e dc er t cl si e l et r r pl egi cl sau r t r I i I r ,
1r I r | I r .
lrlt'gie,r'i,, totdelula
cu localizale p-rerlornlnant .ct"om'effi, insolitc rto iripo
]
o tr
1' ,..
t
,a
trofii
.nir
r,scuiale," de are{le:ie osteo-tendinoasii, prccurn si rlrr l,rrl
l r l l l : r r r r l p s{. n' r bi l i t al c
sr LLr i er . l i i : i si , r bi oct i v. i . cu r a_f acl ?r . dl . i r \ r . l r r , r r . : r ,
r r i l : , r l r . r l ,
si r r i ct l i c, ; i
ecl r omel i ( . . , \ bscol a or i "ar ui sci m Jn h, zi r r r r r , pi l r r r i
,l rl r, {btr r-, col di }i e esenti al i i n stabi l i rea di agnosti cul ui . Masel r i rLrrs,,l
I r ' 1' . , pl ' r l r . r po l ul Ll eat r na st nt duLr . r ul se l l pr osi unc, i ar el ongul . i : l r r r . r . vi l r r r .
t , , ' l
i l l l ] gi c. l , ' a dc- scl ,
.
i I Lsupor t a h i l i . t ' , , l i f pyy; 6. 1. ' . 1 pol i nr i u. opt t i i l r , r r r r
' , ' r r r 1i or La. ,
dc r . - gr r l d. ni ci mudi l i ci r i : r l c L. C. H, . , nj l i t , ui br u, i l i sf i r r r . l cl i r . r r , . .
| , r ' ' , i ' , ' el .
I ; r del r r r l pa| r l i zi i l o j nc( ?
i i
pr edomi nl l a cl l r enr i Li i l . i , r l r r r .
1r ' , r .
: ; t sr " \ l r r dt . t j ( o l Di I l i ( . i : :
si m, - t r i cl i , >i put si r pal j zezr . r . [ i i : i r r t i . , t , r , l t
1, l , gi , ,
' ( ' l . r l i r . . r , l
; l u
l t i r . i pa r . i r i r r el r i si r . a muscul at ur i i gi t ul ui ,
I I l unchi ui ui
l i
, . r t ,
r t t t r . ' l l i ; r r '
r ' . r l i ul j l gr r r ul ui . Pul al i zi i l e si ni t t t Jear Ln: l i n. u1. i l , e r l l r r r r r . i i
l l rl rotr)l ru
rrl u\(.l l l a,rc si cu i rnportante
al ,rofi i rnuscul a,re, di l r ri i 0i rxl l ,l ;ti , l r,1rr,
,1. ttrrtsi vt.
c:r i n l czi uni l e ti i r.cte al e pcri car.i .nul ui
moi o. rti n .oi ut,,(,| .
' rrrfi ' i i ri i r,r' c
(
l
rr rl i r r rr r i r I i 1 i si ul l e si l nl roa,ri i e pe.i cari onl l l c).
fi efl exr,l tr ,rr,r,.
l i l l r l l l r ( ) : r t ( . F| l r l ( l {.
t r . g l i i r I i t r r i t r r t I r I r : st r t r : r l t r r l i t e, r i l r I l , r , l l , r r , l t , t 1l l l . j l Ll r .
, I r l ( l ' .
r I | l l ( . or i i r r l : r l t r : st r r t r l , , l . r r I i r I t i t r t I r u I i
.
. Nl i f r , e, l l Bt j , t t i l . I t r i r I
j
r : I t [ , r t r r
r r t l l scl r l l l t t , .
. Nor l i l i ci l i l r t l r l cx( , i l , 1l ) i l i 1, . t , l 1 sh, r r l r . i si . i , r r r l l i zo1, zi , t , r l al t {, i i r l r ,
t l t ' gr "r *t . r i . r ' r r {i i
l i r . i r r I r r I r ' , r ' r r r r i r t ' i l r r {, i r r pr t r r r r r r i r r : r r r r , r xr r l r t r nr r l i r r i r , , r r r r
t t t vl ' l r l i gl t ' f i i L' l ' ) ' M' ( I . l r I l r r t r r ,
r ' r t t t t 1r k' | ' r t . | , r r r t r l r npLr l r r , r r r i r r , i i r r zr r l r r l r r 1( j r ) pr r 1( ! r 1\
l t t ol n) t r o i ] r sr . r r zl l i I i l
4i
t l i i t r r l r r l ol ' r l r . l r r , l r r l r {, i l pt , or i r r r r r l t i
r i r r l i nl t l hl
l ) 01
l t i
zr
( l l l , o
I ) t r r l i ol so l xr r r i r l l l
sl r r , l r i l i r r r r r r l i r r gr r ost i cul ui de kr zi une t r oncul ar i l ,
l r.rpr.cl i v pol i l l otroul ari , (pol i nortrrrpl l i ci i ).
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 etiopato-
r1r' rri l o (Ii i scr, 1952; IIareq si Ni si peanu, 1976; Mareq
$i
Stamatoi nr
l l t t i s
; l ' ( ' r r Ll of unda, I 976 :
f o{l et ea,
1067; .
l) l. prezcnld unui sindram poline,ari.tric (polineuropalic) cu ilrstalare
rt trli. .ti. str.bacutii ne gintlim ln primul rinal la urmetoatele posi,bi.li.td,li eti,o-
l )trl .t)u(tn(e:
r\ Polinetu'o1tatii, toni.ce
{profesionale,
med,iaatnentoase, crilninale,
s t t i r i il u,yv, eti.l ice
).
- 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 lelt-
lrrrrglrisivti.
Para iziile mari sint exceplionale, 'Iulburiirile
trofice
ryi
vosrl rri,ir-e sint 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
1rrrrl
rrnd:i
[i
ataxi e.
*
Polineuropatia d,iabetic:d, cu instalare subacut5, este rarii. De obicei
rc rr:n,lizcir,zii forma cronici,.
.
Polinatroltatio, arsenicalii eeutd,-sub&cutd, este cle obicei profcsio-
rrrrli, 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 gastmintesti-
rrillu grave, precum qi ali;e simptome neurologice (convulsii, sinthom hole-
lilirlrrr rr,rseuical), tulburi,ri cutanate qi ale fanerelor (stria transversa,ld
r, lrri .Nloes la nivelul unghiilor). TabIouI polineuropatic este mixt, dar cu
lrrrrr
lon rinrln!'a tulburi,rilor senzitive
;i
trofice.
.
PoLineuroytul,ia sutrurnind, aautd-subdc'utii este tle asemenea deose-
lril, rlr glrvrii, predomininrl in tabloal clinlc tulbudrile psihice (confuzie
rrrirri,r,lit rgii;atd, sau torpoare), tulburiri cardiace) hepatice qi renale,
plrrcrrrr
6i
tulburd,ri tligestive (clureri, virs5,turi, constipalie) ,1i hemato-
lrrgirr (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 musctt-
l rrrrr l i l pi do.
' .\'oLineuropatia mercuiiald, acutii-sttbacutd' este tle obicei acciclcntalai.
rrrr,rr volrrrlbar-suicidard,, la cei care lucreazS, in przenta toxicului: disti-
lirlcrr, rnorcnrului, fabricarea lSmpilor de incanalescenli, qi a ampulelor'
lrr,rliokrgico cu 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,
oiirr[rl'l <[o m.ercur, sublimat). Totdeauna
(l
igosl;ivo (sto ntite me,rcurial5, cu gingivild
lizolrul girgiva,l), somr:olo gonet' ale
Fi
renale.
l bl i rl rrrrrl u,t;i l l , os1,o
J)r' orl oni nr[rt
rrotori ,
Duti n(l
(l obul l t
t)l ' i n l ri tl tl otr
r ur r r i ol r gi <l t l o t r nt l l , i t t ot t r ol t l f i r r ( nr r l i r r l , r t t t t nct t l o- t r l t l , i t t t i t ' 1
,
l t ' i l t l i l
l r opl i l ' t r t t
l 0{
sint prezente tulbur[rilo
ulcerativ5
Si
hilersalivalie,
r ' \ l ( , t ' l t )
f i
r t r i ) {i l ) ( l t t . Nr . r r r l r i sl , l r r i r l o sr r r r ur c t l o ot t cr r l l t , l r
4l t
1, i r t , l l r r ( xt t . i l l l
( ( . r r st l l r t l ( ! r l r . r ' r l l r r r l 0l t s0
l l r i Jr t , i r r r ; r l l l r r ) ,
. .
Al ty.1nl ,,i nr;u,ro1xr,l i i l otr:i t' o aat,l ,r:-su,l ta.at,l ,c (11' i tt i uri l i ri , l rl i ,l ol ,
l rr.trz' rl , srrl Ir' ;i rl c rarJr' n, tri ol tocl ozi l fostat, tcl ancl orel ;nn) s,,
' r
.
, , < , I r r , , , 1, ,
,
t.r
' ,' /rf(' n1,ul
rl c apari f_i r, (l a rmrl ci tori oal e l ucreaz:' 1, ou l oxi (,.1. rrrsp.r,l ,i vr,)
ri pl i n asoei erea
.fi
de paral i zi i do nervj crani eni (ocul rrnol or,i i
opl i r.i ,
rrtol rl eo-vesti bul ari ),
tul bur.i ri psi hi cc gi
/
sau semne hen url ,ol og i i u r.
, .-
P.ol i neuropat.i _a tul i cd.fste rard. P.eal i zeazh o for.ni i rl i xl ,ri (r,rr
1rr,r,
, l ' ' r r Li r r l l ni , . r
t ul bur r i r i l ol senzi t i ve) qi seasoci azr i cusi mDt onr cr , r r ' : r ol , r r r , i sl , i r r r r :
:r l opcci e,
.al tera{h
uxghi i i or (cu stri i l e l ui Mees), convul si i , Bi }rrl )l ,ornc o\ l ,t,rI
;i i ' rri .i rhl e
(tremuri l uri , mi scX' i corei ce), si rnptome psi hi cc (rl i rrl rrzi ' .rrl
l , r I l l l 0s1; ] ce).
l t) P. ol i neuropati i i ,nfecl i ouse. Cel e mai obi fnui te si nt :
' ' -Pol ttrcDri tu
cl tl trri cd i ntereseazi , i n speci al nervi i crl ui el rj (rrrr
1Ir|rr
l i z,i ;r r-r' rl ul ui pal atul ui ,
tul bur5ri ti e degl uti ti e qi de fonai i c, rrnrxrl i ' r1i r,l
l .ql l ruri -ri l ' .' sp_l ratori r, adesea qi cu paral i zi a rl e acomodal i c rr
;n,i vi l i i
l rr,
rl i si anl i ,)r
i ar l a ni vel ul membrol or afecteazi , i ndeosebi tmncl ri ul ,i l t, rrrr,r,,
l l i ,l or i nferi oare, real i zi nd o formS senzi ti vo-motori e di soci al i i
(crr
rrl r.rl o
rr r i rrlnJ;a tulburirilor de sensibilitate profundd,).
*
Pol i neari tu, brucel ozi cd (rari i a noi ) se i n,coteqte
fi
(l e
sortrnrl t r, i rr
r3' rrl e qi de a,l te si nptome (heprrti cc s.a.).
-- Pol i n.e,:ri tel e secundere ttnor bel i i nfecl i oase qt
l tt,.tl .. si l d l i u,rr ri rr,
r ( , t t l r r q. i 6 noni ,
1Jl l bol i i d" \ az: r t f el r r r i t i l oi t l i , l i l l i , , . \ | l r r l cr r : , 1i , , . , l i zr , r l
| ,' r i r r,
l al udi sm).
- Tj ol i ntt*,i tet l toi ,ul i ni cri deb.teazi , aproape totcl en' ua (1l l (l i sl i rl ,,i r.,
Ir,' ( i ' i i i l l ne& guri i ,
l aral i zi a \-i l uhi
l al atul ui ,
tarl buri ri rl e vcrl t,r,rr
1i ,i
i ri
t , , ur l i zi l t acomot l at i ei
; i
mi dr i azi ) , ot t al mopl egi i ext r j nsccj hi l r l l l l r r | r , ,
l :r l rr' {r s{)
1rol , l soci a tl efi ci i e:r,l e meml l .el ol cu p}edol }l ' ni t1t 1i j l i zorrrr.l i l i r.
l rr' ,' r' rrrr 1i
tul bru{ri
gfi ncteri ene
(consti pal i e si retenl i e rtri na:,i i ).
t.' \ J' o[. 1e1 ' af]al i i
Ttostraccbtal e l i :postseroterutpi ce
. Si nl I' i rfr,(|osi ,rrrrrr,i
trorrl )i 0i i ,
l ostsel odi i tel i cd s.a.) qi -de obi cei nri sc i l sL:rl ttrzi i rl rrl rrl , rrr
rr i)r,lllcsa procesului a,lergic r.ilccinal sau postserotcrapic.
:!) JIL
fn' eeen!&
unui si ndront ptl i ncrri ti c (pol beuropu l ,i () (u
.i rtskt,l rttr
l , nl
Uoqr$i ui se pun i n cl i scuti c toatc cauzei c posi bi l ,.
l xl
(,l t.o (tt,i
,
tl l
"r
tl no|i nl succi nt:
r) ,Pt,/ tnett i te.l e i nfecl i .oase i ntri pul i rr i n (l i scu(i e (pol i ncvl i l rr
l ,prrrrrurr
.
'
\ , . nl l l r l . pol i nel r ' i r : r l uot i cu) .
,..
1)
Poti ne-uropat.i i .It to.ri ce (satur.l l i D,;,
ul scni c:l l i , rl t(l l 1l I,i i l l i , 1;tl i (!i l
, , t t l l r r ' , 1r ' bon1{f i , . hl l i c5,
r nt di cl r nent oasi t ) s{r l ccLr r r oso i r t l or r l or ' l , r r l pr . o
l ' l {r l l l r l , Cl Jnt {, {r . unl cXl nl {o
l l t cl r ) T n( ' t i l l i , L( . . vi scCr l l , . . gr . r
. r ' r t l , , ,
r l r . l : r l r r , r ,
I t l . t t t )
6i
sol r i ol ogi c ucur ol ogi c ( r L sr , 1' cr ' [ r i r ser r l r r cl r ' ei r l l r ci , . r i sl i cr r i l i vt l r i l l o,
1r ol i r r or l . r opat i i t oxi ce) ( , \ I ar c5 si t r t l mi r , t oi u, 1968; gof l ot ou,
l t l ( i ?; l l i r l r , ,
t t , | : . 1
; l Jr >dccl r l ol . 196i ) .
. . r ' )
P- ol , i , n cw"opal , i i t c r . l i abel i . t : e i r . r dl ni c suspi ci ot r N, t c l ol r l pr r r pr i r l l r r r r r r l i r r
l r r ' l , i ( . [ {1, ; 11' 1, r l i al x, l ar l sr )
( l ( r so( , l xr l , i i ,
r l or r r , ci i r r l t l pr i l . ${r nut ( , i {1 r l ( , pol i t r r . r r | o
l r t l i cr
r , r t t r ' ( ' s1o
scnzi t i vo- l nol r r l i o ( cr r pr r xl or r i i r l r r r {r i sr , r t r i l i r : i , r r r r r . r r t , r
r ' l t i r t ' psor r r l . l r r l l t . l i ci i ) ,
l | i r r
r r r r ' I r r i st r r ni l r i t , r r r l i , l , i t s. r r l r r r , ( l r r , l r , r i opr r l i r , )
t l l l r l ' r r r r l r r l ol i r ' . l l r r r , r r l i r r r t ur l i zr ' t v, i i o l ol r r r i
l r i r r l i r r r r l l r r i i ,
sl r r r r r r l r t l r i i r r l i l ,
r l r . l f , gr . r ' . f i l J"Ui l or | H( l r , t l , i l . ( i r l r r l t i sr r r , l l t i i : r ) , ( ,
t r , r r l i r r Er r r r r r r r : r l r , r
r r r r r r r ' l r i i r r I r r I r r r ' I r r l r . ' r r "r r l r s, i l i . ' r l i ' r t x I i i gr r r r r hr , i , r r r l r r l l r r r r , j r l i r l r , r r r r r r , r
( l t r l r : r l r ' F l : r r t l r ' r r l r r l r r r . i r r l r r r ' 1. l l t t r , r r t i gt r t r , r l i zt , r t zl l I ot . l t r ,
l r 8r , l uol l l r Jl l , l , t , ,
100
i\ I'ot.trt,eurttltuliiltt r:ttrtn,!iu,[,tt sini; urttLt' rr-tiri [t"cvctrl'o doci[ so ol'tx[('lt'
Ii i rrrl i oul i zi ttt tl e tl i verse ntcc{,i utLi tti gcsl i ve, ri rrl hbsurbl i Yo, dc.anaci di -
i , , 1, f , .
j , , - r r . i ""
; i
de al l i
- f act oi i
( l - nul usi v al ( ool i smul . si . r r l t e
l uLi ce)
' : t l c
ti tttnj rt' tti l carenl c de si l ,ami ne tl h grupul B qi d' ' ani i l ^fr' l i t ($oIl cl ea,
l l | l i /
i l \ l r r r oi 1i
Si ar nar ci u, 1968: Popovi ci u
; i
col : t l - r ' . 198[ , '
r ' t l ' , , l i nt ur onat i i l e di smet abol i ce. f n I at a unor t l 1bl oul t ct r or ce oe por r -
rr,',r r',,ilL'tii croni&, neolucidate
prin ilvesi,ig:r'liile curontc, trebuie si' ne
t',',ri'i, li
fu acesd gnrp de polfoeuropatii clismetabolicu ;i
si' praciicim
i r r ! r ' . l i l r r l i i si i n acest sens. mai a, l es l a l ni l l vr zl t Ll ner l :
- Ilolineurupatia
porflricd sc poate rccunoa$te prin sirnptomatologia
|r|r, rrolvo:r.sli
(cLr
-tlblo-uri"
tle multinevrite,, uneoti l1lononerrito radiale'
, . v, r l r r i i , r l . nt ' e puhncur opat i i ) , vi s{' cr al d, ( si r }dr . , mul abt l omi nal l , cul at r af i '
1, r r , . , , , : i
, , pi , i r , , i i : i per sen. i bi l i t ar e l a t umi na, cu pcl e pi gment ar e caf cui i
, l r ' l i I r l l ' t ni i , l ct o' ' , ' r c{pcct i v cu l czi uni cuLan' 1t c
"vacci ni f on
oe") . gl r l e
t,rl,,,r'',ltrr (sinitromul uiinar';
preze$a, respectiv cleqterea uroporfirineiol
qi rr coproporfirinelor).
'
-^ l'rlttirunlropatii,le d,isgtobulittemice sint' ra,re' Amintim polileuropa-
t i i l , r ' i r r l so l of i ot i l ni i n r er i cul ozel e pa r apr ot ei ncmi ce ( mec r ogl obu l i . n r ' -
, ' r "' t V, , t , i "' , *i nOt
; i
l - , oal r l ui Kahl cr ) . i n une) e l umor ! - sar L i n t l i scl i ogl obu-
I i r r o, r i , ' ( l l t i chor r r i cohb. , 1959; Faqon
; i
Sct r wr r t z. 1963; $of l ct ' ea,
1967;
t ' , , i , . ' vi ci i i i i . , , Lr b. , 1968) . Coot exi ul
cl i n! c dc sr l t el i nt t i l cr voas5
( pol i -
,,..,i,,,p,il,i,. 1ent-progrcsivi,l, osoasi, (aspectelc de leziuni multiplo oso-as.e
,,i,,,'i"l,ii
"""t".Liale'si
in iasole late),
-hematologice,
cr alterarea sti'rii
1r,""'irrl,r'll
tti p"*ruot^ hipergamrnaglob Lll ineruicf (cu.spectr'u1 caracteris-
ili,;i ;,i;;,r'i;rrt"J; aft"osti""i ae
'eticuloza
paraproteinemicii' 1n schiml,
,,tl,it'r1;a, cepricioasd', 6t instalr,rea sau agra,valen trbloului clinic (cu
-mrlti-
r r , r ' r ' i t , ' t ni gr l ut c . 1i pol i neur op r l i e t l e oi j i cei ar i meLr i cd) i n pcr i ol t l cl e l eci
i,t,,
','.riii"si
la"ritiiica""a ciioglobulinelor ne o.ienteazi' spre
'
tliscrio-
*""'Titli},ii;rr,
trntiite din, colallenoze sint ulor de incadrat nozologic
,t,,,,,i ,,,srx,.tivlr, iulecenoz,i,
(periii"terita norloai5,, lnpusul edtemir'tost der-
r r nl ur r r . r r i r r r ni ozi l a, l . "oLi ueur oh
i o"i t a, scl er oder mi ar boal t r BehqeL
t ' a )
se
"',,',i
ti*i,iu cu simft6matologia
tipici. Eristir insii'. crzuri-care
pot
.delut&
,.i r.r.'lllir r^rrltiir vreine cu simptoine neryoase pc.ite.ice.. Sint totrqi citeYr'
i ' r' i t,,r' i i ol i r' ntl ti ve: - Evohi ti a
progresi va qi c:rpri ci oasi '
I
- Prezen-ta
l r,rrrrrr,l ot gr,rtel al c (asi eni e, sti ri {el ri l "e, al gi i rrl ti crrl areqi rnuscul are etc' )
I
i ,,,l ,l ,,i ti i [i "
,,rnul ti nevri te"
capri ci oase
' fi ,-ri o
pol i neul opati i asi metri ce ;
i\toilil'icrili
'ide
obicei vascuiare) a1e I'.0.
;
:
Hipelten$iune :lrterialil'
(i rr pl r i rl rteri tn l odoasS,)
;
- Semne de arteri opati e
peri feri ci '
;i ,
de.ce1e
rrni ' rrrrrl te ori qi cerebri l L; Sderi n
i u,
l rLl scubri ,
(d ti p
Ei ozi ti c)
pe
t r l r r r r t r l r r t L i i n t l er mr , mpol i
eul oi ni ozi l e) ;
- Nl
od i I i ' "i r i r k' V' S Fl ' , . al e
i ; . ' ; i , , 1, ' 1: A3l ' o *i waal er i Ro"e,
p' ecum qi r l c t est el or de di spr ut ei r ' emi e t i
,,ii', ii"i,r"Gt".torezei ; - Prez6n{,a rnod.ilici.rilor cutanate
(in dermato-
rrri ,rzi l ;o, i n scl erodermi e
qi i n l upusul en' i tematos).
l,lxtltni itrile E.M.G. qi moditic5rile histopatologice
mirscnlare, vas-
r ' I l r 11' , i Ll c f i br el ot uet vuase
Si
al e ] . esut ul ui
( l t I nr n- cpi dr ' r ' r ni ' ( i n ) r i upr i i t '
' ' , i ; ; ; i i l , ; ' , ; , t
, ; ; i . i ,
"". "
, t "ui n. obl i gnt or i l i n uc' ' r t c si l r : i ' 1i i )
- pol
{i - r r r i l ( '
|r.rrrtt' rr
rl i a,grLosti o (Dul nn, qi col ab., 1960 ar b
I
Dtma
tst
(otaD
'
tvttd
;
l (ft,l rtr6,rr, .L9$l
).
: : l l , , , l i nt t t t , , l , r . l i i t {'
par d r cpl ( t t i ( : f
' c
l nl i l r r t ' i c t r t t r ' t Li l l l e nt l l ' ) cl ) ui o
, , , r , | , Tr r , 1, , . t , . , r , , , i i t , t . i t t i r i . r , , l r , t r Lr ' ' nt ' t t t o1t gi . t ' l ' r ( xl r l sr ! l ) l
i t l r : t t t t t l t l t ' si t t l t r '
r l i r t r 0l , i r t , xi , r . t j i l r r , l , i i r l r r r , i i l l t
I r ot ' 0st t l
t t ci , l t l : t zl r ' ( 1 t t r r t r r t i
l t r i t r l i l i vt r ,
r t t r ' l ' i t -
l 0( i
t t l r r z, r , t r . r ' I l I r r r r I r '
; r i / sr r r r
r , r ' r ' r ' I r l I i I r , , I r r i r
,
I r r I r r I r r
,
,
i r r l i ) l l l r {i i | r , r I r r t r r r i l r , , , l xr r r , l i r
I l ul gkl t t
; , r t . ) ,
l ' ol i l r r r r r r r r l ) i t l i i l t
l ) i Ll i ut {, ( ' l ) l l Lzi ct r
so t ( {l l os( 1 r ' r ' l r r t i v l $or ' ,
l t t i t t
l t hl r r r l l r r t r r i r l ; ( r l r r l cr r t r ot t i ,
l r t r l or
n i r l r r r
l , i ' t ,
scr t zi t i r , i ) , i r r l l r l r l or r
l r,rl rl o
,,i rrrpl t' gnal o"
ttcttcrtrl i treopl azi cl , cu cvol u!,i o prtrgrr.si vi r.
l t) I' ,l i tturuyul i i l r tl cgru.cruti ,rc. Aoi so i ncul rt' azi r i r5rr,-zi si r
,,1r,/i l r,
tt i t,i " hi p, r(n,.1;,.,i
tami ti al i
,.r c,./pi l i ti ?; (buofu l y; D(j l ri n, sutt,tx\
.t
r r l ul t t r ( t i ( t ; pt i l ,
l t ; dp si t our j t t r r ) . Si Lr b4l i dcgr . r r | r ' : r t i v| r i l
' , \ ' , t r r l i r .
l ' r l
1r
Irrgt csi -i ' r' i
,
i n care atrofi i l e muscul are cLr debut di stal i ti i i ng i l r rrl o(l
In)A11,.
si r' , i n tl ectl s de ci l i va ani , toate cel e patl u rncrnbre (rl ul x,sl xrcl i i r.orr;r
stk' , bra,l cl e, ct' nl ,uri l e qi fa!a). Se i nso(esc de mari tul bul ri ri rl r scrrsi l ri l r
l rt,l c do ti p ectl omel i c, cu caracl ,ere rl i soci ate (cu nl afori l i i hi porrsl r.zi r' ,
l ti ni
)r anestezi e profuntl [) si eu mar' e atari e. Cel rnai i i i l escri l rr, rl i ' l rrrl ,rrl
l r' rl i i , b,rl nrrvi i acuz; si cl ureri ful gurante. Un si mptonr pi rl ri err0l 0rri r,
({' .rt' .
l )crl ni tu
rl i :l gnosti cul fftti r}e
,,tabesul
arni otroJi c' ,) i l corrs1,i 1,ui r, l rrgr,,r
l i i ti l e
foarte ugor pal pabi l e, strl r fol ni , de
,,mi tri ni i ,
r] ]r, 1r' ul 0hi l l l i l l
r(.r' \-orse, crl c) i tr i ntregi me pot fi hi pcrtrofi ate. Si nt prtztnl r' l rrl r.sr,rr
1i
l .rs.i r' uhl i i muscul are, c-are s6 qti e cd,
"si nt,
cu tol ul excepi i onrrl r. i r rr.l r,,i
1ra
t,iile pe.riferice-
D) Poliracliculortr:rri,tele realizeazi sindroa;me senzitir,o-rrr o1 ri r,i i lrilrr
l rtal e
.
Di .
si rnetri ee, cu di Btri buti e ati t pl uri radi cul al l ,, ci t si
(rl ,rr)tl (' l i ci r,
rlo obicei foarte extinse, putintl gelera tablouri paraplegice sur rrriri rll
ut abi 1
.tetrapl egi ce,
cu axefl exi e osteo-tendi noasi ,, cu nrl rt:l ti Iri pol orri rr
trrtsctrl ari , qi cu atrofi i precoce gi l api de. Si ndroml l i l e profouel rrrrr sr,rr
z,i l i v (cu tul bur[ri gl obal e de sensi bi l i ta;be) ptezi nti i aLe ascl ncl r{,1 i l t,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
).
i l l ,rrl i l i r.r' i ,ri l e l i chi tl i ene, cel rr..u i ai l esea cu di soci ati e al bumi n*r.i l ol rgi r.i i ,
r ir r'i palafeze diagnosticul tle poliratliculoncvr,itir t.irrillain-Ila ll'r.
I
PROBLEME DE DIACNOSTTC
+. Itr TULSURARILE TONUSULUI MUSCULAR
4.1. HIPOTONIILO MUSCULARI'
4.1.1. Hipotoniile t/anzitorii, paroxisticc se caracterizeazf,,
ptin bruschcfca cle aparilie qi prin tlurafa scur.t5, (citeva secunde sau
| | l l I l [ e) :
L) Atacli cala,pLectia consti intr-o pierdele brusc5, drarnatici,, a
iorrrrsulrri muscnlat qi a motilitd,lii voluntare qi printr-o pritbusire
,,pos-
irrr:rlii') ca,re cortrasteaz5 - de obicei - ct perfecta csnseryare a conqti-
r.rr{,t,i (.Devi c qi col ab., 1967; Popovi ci u qi col ab., 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,
l l l {i O; Popovi oi u qi col ab., 1978). Uneori accesul ca;tapl ecti c 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|Ji rrl i i l l r, ri c l l o hhi bi l i e total 5,, cu cl cl ere (mar.i l e acccso catapl ecti co),
l rrrrrr
l rr o rl i rni rrua.rc toni cX l ocal i zati , l a ta tel i tol i n rnuscul ar (cri zek,
r.:r I rL
l rl 00l
i Irl pi rrl i a,l e).
t) l[r.uilc urcese cataplectics su,u atacuriie crtaplectice severe (Dal.r"
1i
Y oss, 1l )?i t
;
Corfari u gi Popo.' -i ci u, 19?3, 19?4
;
Popovi ci u
ryi
col ab.,
l l )i l {; Irol x)r.i (fi u, 1,979) si nt ti pi ce ca rnal i festare: i n rnod b|rsc, mancti -
l rrrl rr l u)rol ti , gura se i ntretl esohi rl e, pl eoapel e se i nchi d, capul se i l cl i rri ,
pr'
lrir'1i1,,
urcmbrele superiod,re cacl c1e-a, lungul corpllui, obiectele cacl dilt
rrrri rri i , gcrrLrnchi i se i ndoai e
rsi
bol navul sc pri ,buqeryte. PrS"buqi rea 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
:l ri sl ;i rrrrrl t,i ent l a at' acul si u de
,,pr5,bus,i ret' cai apl ecti ei i ,
d:rr r5mi ne de
.lrilci corrrplct irnobil
fi
afon, ca intr-o staro tle
,,cLuarizare"
si inccarcil'l
rrrl r.ri r.rr o sorztl .,i e de nel i ni qte, de anxi tate. Uneori sepoate l cl n:rl ca : rni ozti ' t
rl l rr l ri srrr ri i vcl gout, mi ci tresi ,rl ri mi ocl oni oo
l i ,
cxc0!f,i {)na1, rehxi r,r' j
rrf i rrr i cl i rnr, Si nt
1i
cazul i , l a care i nhi bi l i a moti i i ti ,{' i i Dn eti te totu' ,l i i }bso-
Irrl ,r' i . prrl ,i nrl Lr-sr: rr,rul r,l ci r,, i n cul sul cl i zoi , rl l i oi rni 6ci i ri l ol utttl t' r:, l i ti ti l ;rtl rr
l r r r r r r ' l o i , r , r ' i | , r r l i i , pr ?l r r r n
1i
or Lr oci r l c
posj l ' j l i l r l t i pi r r t i r r l ( r ( l e
l l ' t i c, l t l r ut ( r 1r ,
r r t r , r ' r ' t t vi nl o, r l r , ol r i cr r i t ur i t r i ; cl i gi l r i h, . [ n l i r r r l r t t l t ' t i zci sl i r t t t t sl l t l i i : l t i l t o'
I r t t i r *r r t t r , r ' r r l i zr t l r i .
r t l t ol i t r r t t t o1| l r r t ' kt t r t t l oo l l t t r l i l t oi t sr ' , r t l r ol i t t . ' l l t r ' l ' l t r -
l f i l l
iUU;ilg;ilt*11l
* l*i
iii,--:[-l,li'* i;lr)litiri,riiij
*+*#*t*ms[t*ffiw*t*rr'
*f i#jt!!i?:,T""{$*,il:'lf"{'t*:"tkl'k#ffit'ii,",ff
r{]niililif i
i*{i-T*l,l-'*:*"*}T*l$i.*"-tlu?-"+l.a
j'ml*:*+lrlr
;tE?C";g:yj*ti1d;Jd#1,fi
B'lrH":it'il:l:$;'iilf,l
t',",!llr{ff'::"t:t'tilt:?{f
;'!'!t"-'ie
("rarvate"
- Devic
$i
col'rl)' rrxi?;
lli3;*r"'ffi
iil,:i,fi.:*:b::
ii":Hi-""3il*
*:.ql#fr
il iiill,
:ii*xli**l##ir,r,,",n'lii]*iiiii.!3?i3d':i"il#i3i,iuri*ir,iu,r,i,l
lif
"f
*lff
"###f*j:":,fiif
**,'-ffiiiffi
t','"inrui,s,,,,,ii
i:tiff i,"",H#Ti*"T*,H[r..{"3-;1"+$tiA;i*r#:lt"*m[liiilii
i;l*F1;?''1i'hiJt',:3'ff
lf,'(t:ii"
"-,'::ff;l'l;
;Aj"ilf
*T,lil,l
jl,fl],
:::fi.li:!i6,:#:;t#f,:! f::;::
"!i
;,;,1/;:,;'"Ti,f i'*tf 3; *1
";fl
,
:;il il
ltrrffi d,$gl;ftt*l{r,i. i?;j:f##i"+hlfl*
1[,.*firt1;;[****L:riliiiJ::i:l.i:T,1,,.J,:",:tl'llli
li ; ;i;
B) Boata Lai, lJnrerrillrt
ll'tl*'#'r;ilt*#illG:!:i'i"":iK:?i'1"1'":TJ:3J3*,TiJHillill
llllni,l.f,i:{'1j.ffi
T1,iii:'{Jpjjt_*i,';#,:lx''f
l,""lr;}ir;;i:il;
,:,:,.:;,:,iiyi;fiiil!;,f,l:jiii,':,!ij,:;',,;\j.:ffil;$ill'l,f,ift*.lifd.#ifi
liitlrii{iiit'fi',1-:l'itl11ll,;;lx,l,iJ,fi:iL,:":l"tl,:il*il,:*,i,lilliilili:liij
iiilfril;li:t
i,r,ir[ iliiillilililifriil;i:
il,llin;f
l*-irui
l (| 0
r' rl ,i r, rrxi r.nrtl l ri , l rrl rtavul l rl ozi rrt,i i
l ,m' rrspi rati i
;i
pol i ul i e'
' 1' ottl ei l utra
rrrrrsrrrrl rr,Ll rl i | osl o tl uretoasi |
ryi
i n ti rnpul cri zei se cYi denl i az' i hi pokal i emi a'
in sr,hirrrlr, itr
palalizia perioclicd, familiali hiperkaliemicd (boala lui Garn-
i , , i , , , , , , r "t . , , o' , r dc obi cei i l r l c . . , si 10 aui ( 90% di n cr zur i ; , se dccl an-
r , : ' zi '
I ' r ' r r , , r , , i ud, os, bi zi ua, mai al cs pe nemi D. cat e. duph i nani {i e qi dupd'
,' ,1,,r' r rri rri trscul are i ntense, paral i zi i l e predomi ni nd pe mu$chi i crani el i '
trr I i rrrtrrrL r,r:i zci se constat[ d cre;ter" l r$oari i a i onul ui de K+ (crr rnetl i e.i te
' ,
' , ' l ; , , ' i r .
t i i zr , poal " f i pi ovocr f apr i n adt r Li ni st ' t ar ca de I 3 g de CLK
r , r
"igrir
rtt rliiglostic. iare insi, trebuie efectuat cu pruden!d')'
lt\
(lri'.rr
de dt,m atlacl: se mlrrifesti printr-o pierdere brusci a tonu-
. rrl rri rrr' ;i uti r[, tu,ri ti i ,l e pri buqi rea, bol navul ui . l )ebutul este bruscr f[r6
,.' ,' 1' ..' 1,r,.,,,.",sr:rl e,
r-Ll tr se pro{l uco de obi cei i n ti mpui rotal i ei sau exten-
r,.i ,,.i rrrrl rri r,i rtu se i nsul rq1e de pi erdel ea cuno$ti ntei ' Auzul , vederea qi
, r,rl ri l i i r rLtti Ll l erl trtl te.
i ' ri za cl e drop al ,tnck este un si mptom al i nsu-
ti l i crrl i ,j r,i rcul l tl ,ori i vertebro' bazi l are Cori ari u, 1971
;
Kubai a qi Mi l -
l rl i rrrr. l 1){i l ; l l opovi ci u si co1ab., 1968; 19?6, 1980)' Di agnosti cul tl i teren-
' ,'
I ,,rr , r,zr,l t' epi l epti ce aki neti ce (ami otoni c-l l ki neti ce) se i mptne tot-
, l , . r , r l ' , r . i r , ni ci r l r r cr z nu se evi t l cnt i azi modi f i cdr i
- t l EG
dc t i p epi l epl i c.
nt,,,fi ti ,,i i ri l e l i l l G al e atacul ui de dl op uttack nu pot fi suryri nse, di n
I , r
r , i r r i r i r npl i vi zi bi Ji ci ! i i epal i r i ei cr i zei , r l ai c\ r meaul
9l FG
esl " necesar t
i , , t , r r , r t nu. r l , evi dent i a oar "cat e anom: l i i cl cct r ogr aI l ce ca' r aci er i sl i ce
rrrsrrl i l i t' rLi .ti
r-ertebro-bi l zi tare
(PopoYi ci u si col ab' , 1968r 1976r 19?8t
| 1)r' i ()1,
l'l lr)ristii' ft,rine dc cptlepsie in care dominf pierderile tonusului de
,,,,ti t,rri l i n,
" (cpi l epsi i l e ,,si ati ce"
al e l ui l l ,amsav
-El unt,
cri zel e de peti t
1,,,,t ,,,,,i,rtonici-akinetice,
crizeie epileptice temporale amiotonic-akine-
ri ,.,,
(i tstaut
1i
col ab., 1969; [i astau-b qi Broughton,. 1972;. Gastaut'
l : r 7; , : I ' ,
' r ) ,
) v i ci u i i col a b. , i 9707. Con t er t ul s"m i ol ogi c ne or i ent eaz; ' de obi cei
. , i , , i , r ' r r i . l , . . . l nr ct i zoi , r ' t t dt t r al i scuut i , pr i n asoci er , ' a f oar l e f r ecvenLd
lr, pllt LLr l,ir,r'iliri conltiinfei, de obicei cle tipul ulei obnubi]iiri sau absenle'
,,
'*iii
i'ir,,' colf uzionale
-pdstaccesuale,
a amneziei accesului si, mai ales,
rrrrorrrrrl i i l r
IIEG qi pohgral i ce di n aceste cri ze'
Gt I ' t r uLi zi i l e dP sont l ( par al i zi i l e hi pnagogi ce, cat apl exi i l e hi poe'
, , , ' ' r ( r . i i r l r ct l t . ol el i i l e cl e , , acl or mi r c"
si r ' u de
' , l , r ezhe")
si t r t ' i n r eal i t at e,
ii,.il
.*,. ,r,', rr,t,'rrii musculari, prin inhibilie musculari generatS, cie structu-
,iil,, .,,,nll,,ni,ofalice ale sistemului somnului REM, apirind de obicei la
i rol rrrrvi i
tttl url epti ci
(Dal y qi Yoss, 19?4; Yoss
Ei
D3' l y'
-1-q59;
Ei s^hi kawa
. i , , , r , , n- . l Coi r : - Pompei an6, f OOZ; Nan' no
; i
col ab. ' I 970; Cor {ar i u
9i
i ' , , . , , ' i , ' i i r . f 974. 19751 Popovi ci u t i
col ab. , 1978) ' Tr ebui e d i f er ent i at e cl e
,,,'i,r,, r,,.'o" tte cpilepsie rnolfelcd, prin inYestigalii EEG qi poligrafice, in
,,,,,,rl i zi ,l ,r tLe sodn i ecxi sthcl anomal i i EEG, i n al arX de contextul pol i -
r:r"r,lir,, cir,tt: arlti c5, paralizia de sonl, fie in forma sa izolatd" fie la narco-
icrrl rci^ implicri aplrilia inhibiliei musculare caractedsticai somnului R'EM'
1ul
ti,'gil ,ri, fulcl tle ielativS, stare de veghe (Nan'no qi colab., 1970; Cor-
frr,r' i rr
6i
l bpovi ci u' 19?4' 19?5).
1.t.2. Il i Potoni i l c durabi l o :
It) II iytokniil,a
lqnarllisate
sint raro:
L M.i ul ,uni u,
(rtri ]l rtnkt' ) mn!/ ni .l al d' a l tti Oppcnh r,i tn $o l l l l ' i l no$l ' o
l r r , r ' r r Di i . r r l ol r i r r , t r t i l | t , , t t l : r l l 1 I ' i i t t t l [ l t l t , r l , t r oxl l r i t t r l i i , , t l i t ' t l t , t f , t l t ' i sl , i t l i l ' , gr t t r r r r r l l i -
I ?{l
r . ; r l r i ,
1r l l r r r i I i r i r I
r r i i sr {i , r , i
l l r r r i v,
r l r ' , r r r . l r i l r l r . ; r r r r p) o ( si n1; r r r si r , - r r r l r r i l i i
, , r , opr r
r l c l r r r r ci r t ci ' l i i set . 1952) .
:!-
l:t.lt'r
i n
lcl.c
aerebeloase nta;ine ( atrofi,i,le cerebelo(s(: ).
;i.
Iltt(.|c tl.is{rofii musculat e progresire.
4..' l ' s,besi tL (forma ami otoni cd,).
B,l J{i potoni .i l e nzo,i mul N sal l mdi gtul i tr, l ocal i ,zate (tl e 1,i p l rrtrri ;rl ,gi r,,
l rrl a,pi egi e,
l ,etrapl egi c sau doar l a ci teva se,gmente al e corpul rri ) rrl rrrr.i rr
, r r r r r i l r : , r , ' l t . s; l ual ; ; pul ol ogi ce :
1.
,ln-
najoxii;atea cazurilor, hipotonia se instaleaai, brasc
6i
esl,c llrr
liziil,ri tle Le.zitttti ale 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 rir li l
:rrportant). Ilipotonia este cu atit mai importanti,, cu cit lcziun(fl, rr, lojrl
rirri bnrscl. De pildi, sectiunile miiduvei tealizeaz:a cea 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 r rii I prin comolii medulare
)
qi lrcnzatamielia realizeazd, paralizii hipoi,orr ir,,,
rrrr atonice imccli:rte, de tip para sau tetraplogic. Adesea debuteiuii
;rr.irr
i l o fazi i de
+oc,
i nsol i ti l rl e un raasi v defi ci t motor
ni
atoni e crr rr,i ' |,.,,,.
'
rslco-fendinoase
!i
critanate abolite, cu incoltinen{.I sfincl,cr,iu rr ii ri r rr
r r rr rt'i tulbur'dri de sensibilitate. Aceast[ atonie musculari in ]eziurr ikr r rir.r I rr
l rr' c masi ye persi stf pi ni , ci nd se i nstal eazd, i enomencl e de aul ,orl rr,i ,i sr rr
rrrrl ul i rL, cu respccti vel e si mptome de el i bera,re, cu si nci nezi i gl obrrl r.. l rr
, rrl srrl compresi uni l ol medul al c br.utal e de di verso ori gi ni , sa,u i rr l rrzrrl
ri ror' frpcti uni
spi nal c i ncornpl ete, se observS, adeseori acel agi dcfi rri l , rrrol rrr,,
rlrr trr hipotonie mai pulin marcat[, qi mai pulin clurabili,.
Lc;iunile medulara a.arle nelraxnn(rttce tealtzezzd acelaiii sirrrllorrr
I' rl l l l i ti c cu l ri potoni e. Itste vorba de m,i el i tete aar,te transoerff
$i
rl rr
2,,/r,,
tti tl i kt acndd,, i n care pal al i zi a hi potoni ci , qi aretl exi cri l tl otni i ri 1:i l rl orrl
'
iirric:! 0u topografie tetra- sau paraplegici,.
l n ytol i am,i t:l i l el e subasute sau tw i nstal are prr.rgresi ,t:i i , pc pri rrrrrl
|l rrrr
r r srl,ueazi, paralizia atroficii, hipotonia {iind ins[ nolipsil,il.
!, In compresi utti i e ntetl ul are progresi oe (pri n i ,umol i tl e rl i vei ' so rr:ri rrl i ,
rl tcrxe, pachi meni ngi ti i ,, arahnoi tl i tn q.a.) hi pol oni a^cstc ri l rtxl ' i i rrl ,i l ni l ,i r,
rl rr obi cei constati ndu-se contrl cturi muscul ari . l n scl i i mb i rr ti r,i rrro
trti rrl i e qi i n tumori l e i ntramedul are, l ezi unea, peri crl i ona,l rl poatr: l l ri rr,rrr
r rrci, de la inceput hipotonie muscularl.
3. I'eziunile progresil)e spinala posterioare pri,n leziun i ale atnlaqntlrn.
l t,tsl l ri oare
(al e fasci cul el or l ui
(i ol l
qi Burdach) sa.u pr' i n l eBi uni r(r(l i (ut(rt
l oxtari oare
real i zcazd, de tsorn(l noa, l ri pol ,oni i pl i n i nl ,el fl n:trei l u,tt' ttl rri rrrl h' r
l r)nl {r Ol ementi u.
a. i l i pnl tt,<)ostor rodi dl l o
' m i (l i te pol tl ffi aor,r.r estc rr,prtzl rr l ,rr,l rl rr
l rrbrl , nl ti nkrs i rr ri l ,rrt{;i i l o cu i rnpol trr rrt rr tul l ;ul r1l :i r[o stqr si ]r i l i l ,i !1,{r
l r
rol l rl ri ri ,.
b, H i .rul ;uq,nt d,t' r t
Ji hrr
l u,rrgi (dt. .nr(l oun(
Ttusl rti ourt,) ?v:u.l ththr
, r ' r ' {r i nt nl l l ( ' i i o l ul
( x) ut , ( f xl ,
r r . r r r i ol ogi r i r r t : l r r c pc
1r t ' i r r r r r l
pl l r n so t r , l [ ' i , l r r l l r r r
l i l i l o r l r r pt ol ) t i ( ) nr {{r l ) ( i {r , r r r ; r r r , l l r . l i l osl r ' ol , r t r r l i l o: l , . l l i , r i cr r l r i pr r l or r i r . r r r r r r r
l r r f r r . r i i . Adct r , l r , r . sl , r , vol l r : r t l t ' ni i t ou. t t ' d( t t r l u t ) t i i t t t uhi nt l l i , l t r l r r r r . i r r
( , or i r , \ l ul cl i r r i c: r 1l r r ' 4i r , r r r r r r ,
1r i l I r r r r i r | I r l r r .
f . {r ' gi r r r l i t r r , i r r : r r . r . nl r . r r r l r r l r l i r ,
t 7l
\t s irr,rLl'ou,nte l,e n'au,ronn'ent,i,.xt, lit' sindroamele tle salerozd, com'bind'td caren-
liolri,
lrr, rrtrolo d'egeneresce ;!'a sp i nrt- cer,ebeloase
(indeosebi eredo-ataxia sau
irorrJrr, hLi I'rieaheich) (majoritatea rlegenerescenlelor spilo-cerebeloaso,
irrrlrrscbi eele de tipul Piene-]farie evoluind, de fapt' cu spasticitato
lrilrrrrrirlnld,).
Rareori existS, scleroze in p15,-ci care teallzeazS" folTa pseudo-.
i.rIr{'l,it,ri,, cr marcati tulburare de sensibilitate profri:nld, cu hipotonie
$i
l ri rr,rrr.Il ,i .,ri e osteo-tendi noas5,,
i n cate qi semnel e cerebel oase apar ceva
r r r r i l i t zi u.
.1.
t,a: tu'nil,e periJeriae ale orat'Iui refLen c\7 hipotonie consecutivi',
rrrrrl, irrl,ilrrite in iumbroase afectiuni |
^)
Polirad,i'culo-nevdte
;
b\ Poli-
ttt t,ri :r' . ni tt ol tttc ur o
puti i i l ' e di uerse ori gi ni , (ve capi tol ul precedent)
;
,
)
V,,,,r i ft,' si
neu,ropati l . (tl aumati ce' tori ce' metabol i ce
$.a.) ;
d) Lezi uni
, , l t pl , . t t t 1i l t , i
l l r t , r Li l l ,
l ot nbar '
o: r cr aL) .
l . Al eal i uni l e rl ascul ttre, ca c1o pi 1t15 i n di stro{i i 1e i l uscul are pl ogte-
; i r,.
(rrL ri .rzul i l u i n c.ne se i rxtal eazi atl ofi i i mportante, degi :rrcul retl ex
r . i l c r l l r a, t , t ) ,
0. It;:tutlilc ftttmaliuttllor
cu acliune
Jaci'Li.latoare
osupta dtaxt'lui'
t t llt ,t) Lt)tLioen
( prin intemediul sistemului rei;iculat facilitator tlescentlent),
si i rr,r(i i i ri cLr,rJhi potoni a
muscul ard se datoreqte preva,Ienl e i acl i uni i for-
r r r : r t i r r r r i l ot i nhi bi r or i i
et escendent e :
t\ I'eziunile aerebeloo'se
(infec-tioase, traumatice, degenerative, atrofi-
ilr coictreloase cu tliversele lol forrne clinice) se pot insoli de hipotonie
rrrrrscrrlat'd
(uni1aterald, sau bilaterali, erentual crr predominantd'
'le
o
p: l u), care se poaLe evi dcnl i a, pe l i nga-ptobel e cl asi ce de e:.pl orare a
i ' r , , r i t i i zi l i i pasi ve, qi pr i n al l c pr obe senr i ol cgi ce: pr oba pasi vi t dt i i a' l ui
A rrrlr'6 Tioriias (dd rS,sucire pasivS, a tmnchiuiui bolnavului, remarcindu-se
rrrisciililo rnai ample ale bia-tului de paltea hemisindromului cerebelos)
;
prolrrr,
,,r'ezistenlei"
a tui llolrnes-Ste,ivar"t
;
proba reflexelor pateiare
"'o"ttlll^rl;r*,*or,
neostriate
(coreile tle diverse tipuri qi etiologii, acute qi
crrrnicol sindroa,rnele atetozice) asooiazS, hiperkinezia caracteristicS, qi
lrip,rl,uttia rle iltensitS,li variabile.
c) Llnale sind,roatna aesti'bulave se pot insoli de o discret5 hipotonie
r r r r r *r , r r l r r l l i i nsi l at er al i l ezi uni i '
d\ It l&lunite neuron'ilor tnotori'centrali, hipotonia muscularS, poato
Hri ti (' i rrl ,i hri ti i , numai i n si tuafi i l e i n care si ndromul pi rami dal s-a i nsbal at
l rl rrsc. dl r si i l accsl e cazrrri hi potoni a dureazi doar ti mp de ci teva sdp-
tri rrri ri i . i n cal e asi st[m l a o hemi pl egi o fl ascS, (si ndromul pi rami dal defi ci -
i:r,r:rl iui Barr6), dupd, care se instaleazS, hipertonia piramiilald, c&racteris'
l,irrr'i. Nlonfioni'ni ru:rele parali.ai'i
fl'a,ece
centrale pseud'opariJwical
-inso"litg
si rlrr u,1,xrlii muscula,re, adesea cu distribulie pseuclora,tliculari (dar fd'ri
ii. | ). ,r,,,tlo*usculard), rea,lizate d.e unele tumori fronto'parietale (menin-
giorr,rno, glioame) sau de suferinle vasculare.
4.2, HIPERTONIILE MUSOULARE
4,2,1. Iliporl.orriilo
plroxistioo sint roprezentata la diversa crize de
(ont,'tu,hffd, cliro inturosor.tzii, Iitr orrt'pul ln int.regilne, Iio auumito scgmonto
oor.Dori 0 i i :ol a,to ti
u, oi "!l ' ol ' durl l l ,i i r
l rr Iunofi o i ]o rnocl l ni gmul contnl cburi i '
rtxl ,0 <1() tl 00Lttttl r.}-ttti ttttl ,o, t{l l ,l l
(l (l
i )l (1.
l't !,
4.1!,1.1 . I l i pul ,ott i ,i l .u pu.roti ttl ,i tl rtutt,r' ttul ,i zttl ,t:
|) l r' onnt:l t Lort,i ,r d,r: qti k4tsi c q(n,ar
l i zal ,i i (gl arl rn:r,l
}r,i rntr,r.
grrrrrrr,l l ' l i
zi rl r i tl ,u $ootrtr(l i rl gonot' ,l i za,1;) si nt rcl ,ti y nryor rl o rxtnrroscrrt, pri l r l rrrsl r,,n.
rl rrrt* brusci l rr, corr;Li orrl ,ei , pri rr carrl r,torul oonvul si oi i ,oni (x),
l )ri l t
{l ut,t[l ,n
sorrrti i (mi nuto), pri n tul burf,l i l o respi ratori i , vi t sor]ro1;ol ' i i rl o a,rxrrrrprrrri
rrrnonl ;, pl i n erni si a dc uri n.i i n cri zi ,, pri rr mul scaroa l i rnbi i , pri n prrrzrrtl (,rr,
rlo ottioei a miclrirlzei qi prin surprinderoa moclificririlor lrllr)(l (Ar.sorri
[i
,
"l r b. ,
1978
;
Popovi ci u . , qi col ab. , 1970) .
l r\ Marca cri zd pi l i ati ci poate sd, real i zeze o corLtrrrci trr,i l , grrrrrrr.rr,l i
zt,bii, da,r, spre deosebire de criza tonicd, epilepticS,, ar.e o dulttii tnli lrrrrgrr
,
rru se i nsol eqte de apnee, ni ci tl e emi si e de uri nI qi do murscl rrl r, l i rrrl r ri ,
rti oi de sernne EEG, apare i ntr-un context psi hi c revehtor., i l l r.si rrr;rl ,rr
rlr,l,ologia critic5, este
,,neulomimetic5'
t,
adicil, are o topogr:r,tir: cN,r.o rrrlrr.
sj{)ir {ru colespunde structulilor anatomice reale, ci
,,itleii,, 1o
otlr lrolrrr,
vul o are dcspre
,,organizarea"
Ba corporald,, creintlu-se zr,sblirl o Irr,lsrr,
.,schem5, corporald,'J (Enitescu gi Popoviciu, 19?8).
c) Tetani (si sind,roamele spasmoJil.ice) pot s5, realizezo (x)trl
r.rrrl u ll
spasmoclice ale extremitd,lilor (cu spasm carpo-pedal, minil rlo rrurrrro4
ii
cu planti, excavati,, cu inclestarea pumnului), a1o trunchiului (orr rrl,trrr.
ci ri al e torsul ui ), al e muqchi l or fel ei (cu,,ri s sartl oni c,)), spnsrrLtr orrrrkr
rrrotolii, ale limbii, a1e laringelui qi chiar crizc tonice gcnei.r,liia,0o rkr lrll r.t,
pscudoepi l epti ci , (Ri ser, 1952; Fi gi ,rd,qan qi Popovi ci u, 19?8). I' rr,zr,rr(,rr
srrrrrncl or l ui Chwostek, Trousseau gi Erb, l i psa pi erder.i i cunosl ,i uf(\i , :l rl ,(,
,.rl {l ontel e, modi {l cd,ri l e EEG qi EI}IG (1a proba g:l roul ui ), motl i l i i ci ' l r' i l rr c:rl
lcrrrici qi/sau als magneziemiei, clarificd, dlagnosticul (f ir,glriiqrr,n
;i
l.,opo
vi r i r r , 1978) .
)
Cri zel e troni ce de
Josi i
posteri oari i au fost i l escri sc i ni l i al rl c .l rrr' l i sorr
(l l {?1, oi tnt de Arseni qi col ab., 1978) sub termeni i cl e
,,cercbol l i l r. l i l rr",
, , l , r l r r r nr s_l i ke sei zur est ' $au
, , cr i ze
post edoar e, t . Apar mai : l l os Lr , r ' r r pi r
rr rr l :r adul l i ti neri , i n speci al i n tumori l e mecl i ane cl e fosri ,
l rosl ol i ori l rr
(1rrl , po un
Tateri al
de 1040 caauri de tumori cl e fos[ posteri orr,i .i , pul rti ,.r,i
rl r, Arscni gi co1ab., 1974). Aceqti bol navi prezi nti i de obi cci
;i
|i ' rrorrrr,rr,"
rlo Iripcrl,ensiune intracraniani,, insolit5, adesea si de o r.cclo:lro l i1(\l'(,i
lr
:r lrrhisului, precum qi d.e pozitsia
,,ceremonioasi,"
a tnpultri.
.
l n mod brusc, de regul d, i n urma unei mi gci ri bru;tu a ca4trrl l i , col
prrl se pl aseazd i ntr-o contractqd, toni c5, i n extonsi e, i n opi stotorrri s, i rr,r.
rl l pul este.aruncat_i nal oi , eu ochi i depl asal i i n sus, mcmbrcl o l i i nrl
Jrl ri srr,tr,
i rr l i l exi e qi pronal i e. Uneori se asoci az^
$i
tri smus qi i nconti norrl ,rl sf i rrl l
trrrir,nir,.
^R,espiralia
devin-e foarte neregulatH, qi supcr.ficialtr, stnt
(lr!
i,ill
t l l rovne-Stokes, apare bratl i cardi e, pul sul este fi l i form, bol nrr,- l I I' j i rrrl rl orri .
rr rroori obnubilat . Criza dtreazra do obicei clteva minute, putind
I'i nro r,l,rr,lil,.
t)rr!ir,
.crizd,
cefaleea
$i
vd,rsS,turile se intensificS,. S-au deicris qi
lonnrr
pn.r
l|ak) da $tza tonioe, caracterizato doar printr-o contracturfl
;la,rrrx
inl,irrrl,
l rxrfci, sau a membrelor qi a oefei, dar nu lipsesc aproa,po nioiodrt,l,it, i'trllrrr
|i tri l e r' <l spi ratori i , pal oarea qi cefal eea. S-nu descri s
i i
cri zo tol ri m 0rr prrrrl rr
nri rrrrn(;i r, uni l atcral i , cu asl oct rl o torsi uno a,xi rl l 5, (Va,n Bogl orl ;;i Mur' l ,i rr,
l l l ' ..11"t, oi l rrti d.o Arseni
6i
ool rr,b., 19711). Mrr,i ori tatol r, i r,cosl i or orl zo l ,l rri rr.
ri rtI rryol a,torl ro pontr,u. trrmori l o rl o frrstl postori otl i ' i , (i nrl oosol ri
vol l rl t,l r\)
ri i
;rorrl ,r' u
nngt.j fi ,ri l o l ;errrpor.l l c, t5i r.l rtrrl o l ,sl ,l i l l do rl ri zo i n ctr,to so H1i l l 1,1rl r.i
t r r r r r | | ; i ot r l , r t t r . r t 1; r ' r r l l ui o r I I r r r l r I r r r I r 11; o 0u 0r ' i z0kr r r pi l opi i r r r r i t ) l l i r {r ( l i , i Hr , r ' , l 0l t l l
,
At l ot r i qi r l r l r r , l r , , l l l ?l t 1 Al ' Hor r i
1i
l ' opnvi l i r r , l {) Bt ) ) , t l {! l r r t , {! , r t o I I i l
( ,
I r I r
\
I | | \
I | ,
j f po; r l , o l r r l i l t t i o f i {ut t ol t r f n, r . o l t r r , t l l , r i , I , r r t r i t , i l , i t r xl r t i l , i L r l t r r r i l l r r ozi i ,
1i r l r '
t i / ]
r r i r l ' i i l xi i . l ) l r ' , i r r . l r , l l r r l r ' l r r r l , r r r i ' i zr r
r . 1r i I r ' 1r I r . i r , s. p| 0r l i i c0
o r r l ) l r ( , ( , ,
, l r r pi r . r ' i r r r . t r . , pi r ' : r {i i l l s, .
- r r ,
r : r . r l l , r t r r r r r , r J r l l sl r r l r l r . r . r , j {ul ; r l ,
I , r , Ol ur r d( , i ,
,{r' r' l ()l rri r' sl r, (1l r
t(}frd
(l i i (i ' i L(i
do cri z,, toni ci a hri Jaaksun.
-tn
schi rl tr,
.rr.r.i l . r' r' i zr. l uni ce tl c_Iosi i , posteri oari , cu rl urati i de aBerncnea Bcurti i ,, nu
. , . r r r r l r . . r . t t c. obi t . ei t l e pi er dor ea d, . cuno[ t l nt r ]
si ecl r nai t desex di spar
r r r
; r ozi l i c
de decubi t dor sal ( dr s. r i
l i
cohb. , 19?8) . Ar seni ( 1050) a ei ni s
i.,r'ir v.'Lricu1ari, confomo sireiir aceste crizc se produc printr-rin rueca.-
rrrsrr rr' 1i cul a,i , ceea, ce erpl i ri qi _fuptul de cc l rcesi e cri ze-pot si , apani i n
IrrrIr: pr,ocosel e patol ogi ce care i ri ti perel i i r' e1}tri cul ari .
t,) 0.izele h,tptertonice d,in letartos tlcbtteazi, prin trismus gi
ris salilonic.
, l l l r i r r . : r r ' , . coul t act ur a se gencr r l i zct r zi , cum pl et i xd u sc eu r er l ua r ea cef ei ,
, r r r l i vr . r sr . i nl l exi ur i i al e t r r nchi ul ui ( i r : ai nt e.
i napoi
; i
Jat , . t , al ) , cl r r eduar eJ
rr rrrr..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 :r I i i scnzol i i rl o si psi hi ce (zgomote, l umi n5, emoti i etc.).
t
1
. 7
t
. t
u r b. o r e apar conr r acLur i bnr sl o I r r i ngo- t ar j ngu- d i af r . aema I i r "e,
, t ( . , , . , . hi r d, . r i ol ent e. . i nsol i r p de cr i "e de apnec
$i
t t c bl o' caj l r r i n; i a; ; i t i I
l.rrlrr,tivtde
-de
deglutilie a;ntreneazi, desciirrca.ri tonico-cloni"ce ale*buzelor.
:rl . rrur;chi l or faci al i qi al e constri ctoti l or fari ngi eni . Ca gi i n cri zel e-cl i ri
t'.l, rrr)s, acoste conlnacturi tonice rabice sint, in moil caracte'istic, declan_
,rr lrr
ii
.xacerbate Ia cel mai mic zgomot sau Ia eea mai micii rniscai'e aol,iv6
rrr.rr
l l i l si vi i ,
,{1i t cri zel e toni ce <Ii l tetanos, ci t qi cel c rabi ce, sp i usol ego dc oxago_
' rr.r.i r
tti l et_tel or i di om, sctrl a,re, ostcotendi noase
Si
mai rl es i unor rofl ei e
,l c l l rrnchi cerebral (nazo-pal pebnl , mtscter.i n, Chwostek).
t) In intonica!,ia cu stricwtnd (sau, tn su.pradotarea terapeuticd) poate
:rl ri i rti r ti stti re de contracturi
.
d e., ti p tctati c, cu t,rrucorb[-l .i p""6rl i ti "e,
: ' , i , . , ' : r r , l l or r r i nd cr r convt r l ; i i cl uni ce_
' f .i !.1 .2. II i pertoni i l e parori sti ce l ocal i zate
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_
,l rrl .rr
rr r.rrpul ui
$i
a ochi l or' ) se recunosc pri n dural a l or scurta, uneori i pi e_
l r.rl i rrrl o cri zi i general i zatl , precum
[i
pri ]r contextul cl i ni co-EEG.
'
b) 'I't:tun ia
;i,
spasm,oJilia se poi manifesta printr-o crizd, de contr"ac_
l rrl i i .l i rrr.i ti i ti l a un segrnent corpoml . Oontextul cl i ni c gi EMG o" pr..i -
zr.:rz:i rl i rrgnosti cul .
() (hitete
ocwlogire posl,encelalil,ice
realtaeazd Im context semioloEic
rrryol rlo roounoscut: {ixalea brusci,, penrbilA, coercitivd, a globilor
oculi,ri
rrr nrr H, itxoliid de, deflexiunea capului. MuIt mai rar se reaU;eazi
un spasm
hipr.r,torric latelal (cu sa} flri devialia conjugatd, a capului),
""*p'*iio Irr fpilrirn ou coborirea globilor oculari. Une6ri in cursui crize'i 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
rl l rrgrrost,i u di l orcul ,i al fa{,i i , de, unr.l c cri ze opi l ol ti ce ci r devi :r,6i a
conj ugai d a
;l Lrl ri l r.
ocul ari i tr-i l us, ou [ti 1; ml l i t ul t, cu ci t s,l |' rr d escri s cri zc o-cu"l ogi |o
,l o l tnprrtl , tl x r i cct- ttl rn i c,, rl rtl ti "l trnt' o l o Ii xrnzi i i n tl cvi a!,i o sursl l nvor.gcl l ,:1,
l l ,i srrr' , l {}Ii 2)^
(l ri zu
' trul ogi .i "r,
i l r., l rr g.rrti Htl , rl rrrl ,l ,i l Iutrgl (ri . l r, ti i t.ovrr
r r r r r r r r 1 , r r
;
r i r r i i , l l r ci t t r t ' l r or r ' ) ,
l l r t l
i r ul I i r t r t cor i r r r pl i r ni r , t r ' l vol r r r r t l r r , , t l i r r . l l r r
ol t i t l t ' i t t t r 6t r l t t t t t l i l ; t t t t | ' t t t t t r t i o
gi
l a, i r l t r t i t t i sl , r i l l ol r l r r
l l l t l l l r . i t , l o
r l o : t 1, r o1r i l r i i ,
r l l t u Ncr r uol : r , r r r i t r
j i , .
, .rl )
I l l rl u,nnptsrtt..nl . si sl tttsrnu,l
.faai o,t,
l tn,i <t l i rl i cl i , i rrr.Jrorl ,l rrrl (r
I)| .6I)Ir\| r| | ,
r.l u rl i rugrrosl i c, pul ,i rul l i expl ori rl urrol rnl l ni l ' estl i ri spasti crr p' ri prr.rrl i zi .
Irt,ci u,L' i ,, a unnl rnrr,ni fesi ,Lri extrapi rarni di l l e, s.m l unc!,i otur,l c, i rrdri si v gri l ,i
i r h( i {) .
.
a) Crampa scriitorilor se caracterizeazti, plintr-o contr'tt'otuI'ii
1[rsa,grrlii,,
,,(,ora,1;ivi,, a murschilor miinii (uneori
[i
ai antob]'atului), cu otisplu orr, irr liipr,r.'
l ' kr.r i e a.degetel or, care apare i n co!ci i l i i bi nc rteteuni nate
;i
ri h,l i v i r l or rtl i r.r,,
respecti v i n mornentel e i n care boLnavul i ncepe si , scti c.
()r' runj )1,
rsl ,rr r l rrl r,
l ol ,sri ,5i se exti nde adesea qi l a mugchi i braful ui , ai umi ntl rri
ryi
rr,i gi l rrl rr r.
Do ael e mai mul te ori este vorba de crampe
,,funcfi onal o,, i rrrrl ri si orrrl ,,
(Lr, drcti l ografe,- l a_funcl i onari , l a pi ani qti , l a vi ol oni qti oto.), i rr l l rrri ti ,rr
l i i l i di stoni ce decl anqate qi /sau exacerbate de o fobi e a sti r,i sul rri r-i :rrr :r
prlctici,rli profesiunii
lii
de o fatigabilitate excesiv5. Unrxllj insii csl,o vollrr,
rl o o di ski nezi e el trapi rami dal i ,, sugerati i , i nci i de Il ,i ser (19f2) qi vrr,i t.i cr tl ,
clectromiograflc de Aqgian gi Popovi.iu ( 1980). Astfel, se pructirli,
cx i r,l rrl trr I
l ) l I G si mxl t an at i L pe r goni i t i . ci t , l i po i ] , nt agoni l t i
f pr r r t , r r , , i r r r . r . v; r ( . r , . r
r ' e, ' i pt occ") . I n cr ampr , ncr r ol i cS, , l a accasl A pl obl ' r : r
, ,
i r I r
.
r ' v r ,
1
i c i l r . r . r
l rtoce)t
.se
tl epi steazS, o funcl i onal i tate norml h, l n scl sul i :i l l , txrrr l ,r.:rr.(i rr
rgoni ,l ti l or se constat[ decontracl i a antl goni pti l or. fn schi rnb, rl rrri i r.i i ,,
vor' l l a de o di tq.ki nezi e extrapi rami cl al i ,, Ia contracl ,i a rgorri Fi ,i i ol sr, r,r,rr
l .r' tct[
.$i
rnu$chi i antagoni ;ti , adi ci . apare o acti vi tnte EM(i
;i 1xr
l ,r,rrsr,rrl
rrrrr;ohi ul ui antagoni st, i nregi stratd i n mod si mul tan cu cont,r.l ,c 1, i r r, rl rr rr,.
1r' rr,soul EMG.al muqchl ul ui agoni st..Credem cd, aceasti i , prob;i
l rl ozi rri ;r,' o
lrrkrilre semiologicS, pen!ry diagnosticul diferenliat intldcrarnpirlo rrrrvlo
I irrr si ccle extrapiramidale
,si
pentru olientarea tratamentnhii.
l )..I.n
-m,i otoni i ,
(boal a Lui Stei nert
i
boal a l ui Tl tomsen) l n o\i r,rrr\rl
,rrr;rr' r' l i ci al ne-ar putea duce i n eroa,te, sugeri ndu-se i n mod i rr<rorrrcl , r,ri
r.ri l r vorba de o l ri pertoni e. De fapt,.dupi i , cums-a preci zai , i rr ul i ,i rrri r :rrri ,
.,i rr ci i Lda aparenl el or qi contrar defi ni l i ei cl asi ce, mi otoni r.r, nu cshr o l rrl
l rrrrrr' o de rel axare, ci o contracti e prel ungi ti , determi natri do i rcl i vi l ,rrl ,r,rr,
I r.i r x' l cetri cS" i nteracti v[,_ susl i nut[ a sarcol emei " (Radu, 19?l l ). l )i :rgrrorr
Iicrrl este relatiy u$or de stabilit, gratie ulm5,toarelor elomcn{,o :
Caracterul eredo-familial atit al miotouiei congenittlo hipori,r.ol.ico
(l xrrl a l ui Thomsen), ci t qi . aI di strofi oi mi otoni ce, (bo;l a l ui Si ;oi rror.i );
- Prezenla hipertroiiei maselor musculare irL boa,la lui ll,horrrxoir ur
:r rll;rofijLor musculare in troala lui Steinert;
-.Prezenf,a fenomenului miotonic, care se gtio cri nu ptozint:L torrru,rir
i u l otrsi tate i n toato grupel o muscul are. Astfel , sc poate l o-rnl ,r,ci r r, l rr.rrrl rr
rrri rrl nl l a fenomenul ui mi otoni c l a muscul atura <l i stl l i i a l norrrl rr,i l ,,r_' 1,,
rri ol ,oni :l , conge_ni tal d,. (Thomson). fenomenul mi oto i c aprl ro gorrot,:[l i zl r,l ,,
rr vrome cc in distrofia miotonicir, Steinert este mai limitat, alleirlirrrl r|rrr,r"
ci l i vr , . muqchi sau gr upe muscuhr e ( mugchi i pol i ceht i , r nuqr chi i l i r r r l r i i ,
r rr rrqrhi i fl exori ai rl egetol or,' mu;ch i i orb!cul al i ui pl oo.r,pol rr.ryi odu krrrrol ,or.i i ).
l rr
l rrr
|rl mi ol ;oni a congoni tal i i t, Iui . rl ul t' nl ; rrrg l errr)l uernrl rni ol ,rtrri o porrl ,r,
rrrl cl csi l l n rnorl oxcl usi v nruqchi i faoi al i (l i l ri l u, l -9?8)
;
-- or )rrBi ,rIl i l ' ol , Ii l 0xi r,rrr{)nIl l r)l \l
(l
rr, srr,l voi rrri okrni 0rr r i i r , r
.
r r, r r I , r , r
.
i r r I r r r r r
( r r t r l r r t ' l ul i l , pi l r r ' i , l r r , ! l ) s) , cor r r l , i l , ui l i , t l i r r pot , r r r r {, i l r , l r r l r l xr i , i l , i vs qr ! r {,
r , r l , r {r r
; I r r ' r l l r ' l '
i r r r r r l pl i i r r r l i r r o qi i r r l r r r r r vr r r r {r ' i , r r , i r r r r r i nr l r r xr r r Doi i r r r r ' r r i , r . r r , r f H
( x, n{l ( '
l ( ' l t l , ;
. . .
l ' t ' . zr f al i r , r . r i r r r I r , r r r r r I r r i r , r r r l r r r . r ' i t i t r r l i l l . r r l i r r , r r r i , i , r r i . i r , l Ji , r r i r r r r l . i .
l Tft
, l . I . l l . l l i ; l or l or r i i l c pt r r r r r r r r r ^r r l o ( sr r bt r r r l c si r , r oni ca)
' l -:!.:1.1.
I I
.i i l t.l ' t
oni i l ,e ruh,i tl i ute (rtthi totai i l e) cl u,yproase .sc pot i nti Lni
i r r r r r r r ot oi r , se Nt cct i i uni :
t) ilinrlrotnul mentnge&l, realizat de meningite qi de hemola,giilo sub-
i url rrr)i rl i (' no i mpl i ci , i n tabl oul semi ol ogi c o hi pel toni e dureroa,s5,, erti nsi i
irli'${,ir lir i,u{,i muqchii cen'icali postedori qi ra;hidieni dorso-1i:mbari, inso-
Li i ri
(l (l
rl xl oarea nei i i , a cefei , de pozi l i a cancteri sl ,i cd, i n
,,cocory
de puqci ' ,
1i
pozil,ivil,ater bingcunoscutelor manevre Kcrnig f
,
Kernig trI, Lasdgue
,
l l r r r r l zi t r sl i i I , Rr udzi nski I I
r y.
a.
lt) tlii,ttdromu,l
pseud.o-nz,eningeu,l, al
f6ei
posterioara trebuic dilerenbiat
rlc sinilrrrilmelc meninge,ale propiiu-zise. Acest sindrom pseud o-lr cningeal
csl r, rr.rrl Jzat de procese l ocal i zate i n fosa postel i oari ,, dal ' qi de al tc proi ese
r.)i
l):ll)sivc
supratentodale, ca,re produc fenomene de angaja,re a cercbc-
trrl rri , r' ,.spor.ti v r l obul ui temporal . Se poate astfel evi denl i a, o l edoare
rl rur.r' ,rrsi rahi tl i .tui i cel vi co-dorsal S cu Bemnul l ui Kerni g prezeut, cu o
lrozilio
rleflectati| a capului, cu membrele inferioare in flexie, cu atitudine
lr
,,(xxiol
de puqci'". l)ar aceastS, hiper-tonie dureroasi, a cefei qi a rahisl-
Irri porrl,e prezenta exacerbiri qi remisiuni, fiind va,riabili in iritensitate, ia,l
rrrrrrrlirr
lornbard, (periculoasi in aceste situalii) poate s5, tie urmat5, de o
lr.rrlrrrlrsot:nli a, algiilor occipito-cernicale
$i
a semnelor meninge:lle. Un
r.rrrrrrr,n l rtont
,i
si stenati c al fundul ui de ochi este suscepti bi l sd, previ n6,
i l
g(' rrrcl l ol n el ' ol l .
r:) Ilt"pertonia rahi.dialxd, dureroatii,ipolatd,, interesind doi.rr unii musch i
rri cofiri
;i
trapezul, imprimind o atitudine vicioasX (cu torticolis)
loato
fi
i rrl i l rri l i i i n cutsul unor l eai a ni , endoarani ene qi ' i ntra-rahi di ene ce|Di cal e.
iir.ril rlc;te irita,lici nervilor spinali
Si
cervicali. In contextul serniologic
litrsirsit,
(lzri,:i tle sinclroamele preceilente) contlacl,ura rahiiliand, krmbJrS,
1i'rr nrunblclor inferioare,de ase-menea nu Be evidenliazi, semnnl. lui Kernig
r' r ,' , l ,Lrl 1r. scrrrne l r|ni ngeal e. 1n pl us, contractura mt$chi l ol cefci rnl ni -
i ,,;l :r L1r.turr1ei i . De obi cej capul este pl asat i ntr-o ati tudi ne cl e antefl exi e,
ll;pr.r'1 iv rlc antellexie
Si
u$oari, rota-fie laterali (in tor"ticolis). In plus,
l r6l l rrrvrrl rnen-ti ne capul i ntr-o
,,i mobi l i tate
ceremoni oasi " (Yan
Boo;rcri
- r
I l : r r t i r r ,
l t r 28, cj l ar . i de Ri se. r ' . 1952) . AcesI ci . t r r cl er de l ur t i col i s . , pcr ' .
l r : r r r , r r t . nl ; r 1i , ' , f i r at , puf i n schi mbi i or "
' i
dunet os i l di i er cul i r zi
' i . . i or -
t,i {u)l i sl l l Fprsmodi c
(vezi l n conti nual e, ca,p' 0: Probl eme de di l g' nosl ,i c
irr rrr,rrr iul.rlia, lniiqod,rilox involuntare). Aceasl,S atitudine vicion,sX a capului
rr'prlzirt,ii, lrn somn precoc, care apare in tumorile subtentoriale, al.e fosei
rrlslr rliolr lc, intl eosebi ale ventriculului al fY-Iea qi mult mai ral in st:rtliile
r,rcr|,i cr,I,. rrl e trrmori l ol rl e unghi ponto-cerobel os qi al e emi sferel or *grobe-
1,,.rs,.. Acr' l sth
pozi l i e vi ci oasi , de
,to$i col i s
ceten:oni os" trebui e di f,ercn-
l i :rl ,r rl ,' Dozi ti i l e
l i ci oase al e capul ul conscctti vo unor l ezi uni al e col o*uei
i rrri t,.,,s,.[i
pri n morb .Pott cervi ca,i
$i
pri n traumati sme ccrvi rnl e). trIxi st;,
si ri l trtti i i n oare unel e tumori al e {osei posteri oarer mi grate spre rl r,hi ;u}
(,.r vi r.rrl t)r' j rr
gaura occi pi i ,al S, unel e neoformal i i extra- sau i ntre,dnrl l e
1r.t,vi grrl r,- i l al tc si
mai rl r o herni e cl i scal 5, po1, tl cl ,errni na nn torti ool i s
l)rnrr,nrnl;,
lnsolit, t1e tt ledoa,ro dureroasi a mu;chiltir ceiei, a traputului
i ri rr rrrni i ,nrl ui .' l ' r' ebtti c,
rl eci , sti rgl i nem faptul ci , maj ori l ul ea caztrri l rt'
i l rr l or' 1i col i s nn si nl , tl c ori gi ne rounati ci i , b&nal i i ,. l Tueori rahi atgi a l i pstq.te,
Irr rl rrr v rrl arfl rzl nd
(l or[r
o crtttrl l ee tl i ftrzi "t,,
j l l obi l i zrtl ' ott
acosti ol ' b(]l ni l vi tr' {d)ui 0
, i i I i r , I i i , ( r r 1i i , f r r l r t t t l l i i ,
I t ' r t t l t r r r ( i t ,
i l r l l l l ( i i {; o l t t i l t r t t vt ' i i ,
l t t r r
l r I r t t ; i t l i i '
l xr l r l ; r r
i Ll l l \ l i t ,
o r , t l t l r . t , bl ur r l r t ' r t sl i i l t , i i j t t t l t r i t t t t t l ui
r l t ' l t i l l t r l l , t , t r si t t t t c i t r t l i r ( j r i l l i l l r i ,
l Tl r
o l l i zr r l or r r l r L, o ; r i r r t ur l l i r , i , t r ur ur t i , t , l t r t t o t t r l t t i r , l t r l r i l r r ( l i i r t t , l l l l , l ' ;
, \ t r r . t t i r i r , , ol r l r . . l 1l i , l ) .
, \ r , t , l r sl , j i r r , r l o: t r t r l t ccl i r i so
l l ol t l o
I uI r r r 1r Lr | , I r , , r l r r l r i i cr t r r l l l i I t . l l l l i r (
: ur 1{r i ol , 0u o t r l l si t , i
( , ont l l o1, nI ' i ' i ,
l t , i t r l t t l l Ji
( x) l oi r l t cr
l ) l ( r r t nt
si t t t r uzl t ,
l onj cc t l escl i so t l c Jacksot L qi i l e Ar scni
. si
t ur l t t l t . ' l ' t r r l l t t i o ; i r t r r {' i t t t ' t t t t ' i r .
nurl c i rnportanl i i pl acti oi i prezi nl i ttl pl ul cti turbi l i zrl l or, cruprtl tri csl o tl ttt.
|orrs[ qi ci , se i nso-teSte foarte frooYont d.o pal oi i l ' (], q1(' 1i l r|j .
IMI||i l |i i Ir I
rtri'tiginoase qi rnociifie5ri carclio-vasculale qi iespir:l'1,ot'ii.
d) Contraeturi tt' ni - sau bi ,l ateral e,l ocal i zate, u' l e col .outtti .1i . Jntt,stul ql u t i l
t:erti cal e, tkrrsal e
;i
d,orso-l ombare pot fi i nti l ni te i n cel e mrti tl i vr:tsr' :tl l r' 1
uni al e col oanei (spondi l oze, spondi l i te, puseuri de rertntal i sttt t' ti tLrr|rtrrI
hr:rni i dc di sc, tumori vertebral e), dar si i n al te proccse (aLrccsc trrr i , c
l t
rr I rr
l i to do di ver"se eti ol ogi i , arahnoi di te, meni ngoradi cul i t c l o<rtl i zrrl r, ,' r.:r.,
\u trebui e si ui ti m ni ci i nqel i ,torul
,,l umbago
pri mi fi v
l l rrl rrtrrqrh.gi r
'
rl escl i s de Si card (ci tat de l i i ser, L952) c semu dedebut (fazi , t r r t I i r r r r I r r r ' :
'
r
ri r cvol ul i a unor tumori extradul al e satr subdural e, i n snre i nsi i si tttl t0ttrrr]
uranometri c qi ci to-chi mi c l i chi di a,n de bl ocaj rahi di a,n si nt rr1 i l tr
1r.tr
{ r r
l:r'an$area diag:rosticului.
4,2.2,2. Hfutertoni .i l ,e
{
t:onl racl uri l e
)
d,e ori gi .ne ce,ntraLri (ernrrr.l i :.trl ,
tuzt. toc,alizate)
a) trIfuiertonia (contractura) piramidald prezintd, p:llticul;r,riiil
{iLr
lrirr,
(l nnoEcute:
predomi nanl d ectromel i c5,; caracter el ecti v sau
(1r' i rsi r' l (\' l r\
(1troponderenl ,i pe fl exod
$i
pronatod l a mei nbrel e supel j oar' (' , r.rp(,rl r\
1rc
ertensori la membrele inferioare)
;
atitudinea caxactcristicii a, lnrr r lr rr,l, ,r
i ntcresate (de ti p Wcmi cke Mann), consecuti vi acestoi contl ' i |,(,1,rrIi r,l ,' ,
l i 1' e; prezenl a si nci nezi i l or (gl obal e, de i mi tal i e
;i
de conj uga!,i o)
I
crrl rrl
Icrtl de cedate
,,conti nu5,"
qi el asti ci l a probel e de mobi l i zrl rt prrrri vl
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
/i c
]rrezi ntd,
semnel e asoci ate
,,de
etaj " (spi na1e, de tnnchi cctcl rl rrl , rtrr
l i crLl e, subcorbi cal e), care trebui e cl utate cu gri j 6.
lt) Eiptertonia (conlracturo) entrapiram'id,alii (paLr:oslriutil din sinrlr,
tttu.l , l t' i ,ytntoni .co-hi paki nettc sau porhi ,nsotzi m d) prezi nl ,ri ,
])[ri ,i {]uLr' r' i l ,r(i l ,
l ) l t t ( j cunosout e:
De obi cei este general i zal ,i ,, Ia tol i muqchi i pet' i fot' i ci , tl l t,r' i trl orr'
rrorrai i ndeosobi muscul ati ura axo-ri zomel i ci n stati ci i
[i
:l echi l i l tl rrl rri (r rr rr;
r,hi i cetei , ai g' uti erel or vortebml e qi :r,i centul i l or scapul nl ' i t,
1i
prrl vi rrrri i
l .
!,(' mult'e ori se poabe lealiza un homip*rkinsonisr .
- Este gl obal i r' , adi c5, i ntereseazi , i n rni suri i , sensi bi l ogi l l i i i t,1i l , gl rrl rr rl ,'
l l r,xori i , ci t
Si
pe cel o cxtonsori i , rl vi nd toi ufi o uDol rl pl ul ortti tl r' rr{rr
1r,'
rr\ (. )f t .
.*
trlsl,e ceroa,sX" nla,sticir.
- Di tri mrt' r,rzi i i i r cnrsrrl .\otnu ul ui "
*
Ocder zl i n s ( . ; r , r l t r r l oa, l i zi r r r l scr r r t i r r l l i Negl o ( r r , l t r r ( i i r l i r r {r r , l r . ) .
I
i \ ( l l r
(
) r r )
(
' r r r r I r r r ( , i i r l i t r {l t , l r r
g1;
1111, 1r 11{, 111r i vi r , , ov i r l or
I '
i i r r r l r t s0 t ) r i r , i
l , r r l f i
r nr r t
j r r
<t t t l t r r l r . i i r cl , r r i t i i uur ) r ' l r i ul ovr ' ( ! t l c t r t i r i ui l i nl l i vr , t ' - , t r r l t t , l , hr t : t r i r l l i r
I r r ' I , r r r r r I r Lt r I r r t t r t ' r t t l r t r ,
( l r , r r r t r t r l I t t i Noi cl ) .
I ' r t r l ) 1, , , ( | ( | | | | r l | | I I l r i ' t r r l t r i l , ' r ' ot t t l t t L r vi r l i r r t {i l t zl r r cr r r t r l r l t r l l r , l r r l r r , t
i or t i r i l n l r r r r Dr r l t r r , I r i t r r I t l r t i i r r . r , l
l r l l l r r r ,
r . r r r l r ' I i l r l i i r r l , t t t t r , i ci r r r l l r r r l r r l vul
t't't
r{r rnol l l i no
l )n
|l t]
}i oi or' ,
ci n([ $e l i rl i ci i , $uu oi l rLl tn{.rge, respccti v atruDci
r r r r l i {i i r . l i r ) i ' r ,
' . "r ' Dul
i r r : - r i ot e.
- Jl,ellloxcle <le posturd, sint exagerate.
'
Uitracterele contracturii imprimd, bolnavilor o serie de aspecte
prr,r'l;iculare cle posturS, qi de migcare : atiiudine statuificatd, qi,,in sein de
irrl,robure", mers rigial
$i_cu
alur5, tle
,,fug5,
dupi centrul rle groutate,,,
- Diminueazl la aclministrarea de scopolamini qi de substanle do
Li p r[tropi l l i c.
-- 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
rr rr t;obla,{ului.
. :. l)up5,
teLanizarea" faradicii, decontraclia musculari, se prorluce mai
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& auioma-
l i snrrrl ol rnotori i , pl ecum gi de bradi ki nezi e.
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
dill d,egeneresaenlele 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
' l cr r l ' r . r ' ubr i r "e.
di n di sr oni a muscul ol um def or maus q. a.
tl) Rigitlitutea ile deaerebrare, prin leziuni ale sistemelor reticulate
rJlsrrcrxlonte din 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, sau diminuati, prin schirnb)i,rile de pozilie ale capului (fenome-
rrrrl Lui l\Iagnus qi De Klejn). Crizele de rigiditate prin decerebrare rea-
lizi,l,zi, t> hiperextensie a capului
$i
a coloanei, extensia membrelor infe-
liol,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 labirin-
licc. Il,igiditi.tite prin decerebrare pot fi reatizate cle procese rliferile (tumo-
|rrlrr, irrfocilioase, vasculare, tra;Lrmatice) care iDtereseazd, incleosebi calota
r r rczcr rccfirlicii, sau structudle vecine (epifiza, tuberculii quadrigemeni).
rr) Arseni (1950) :i, d.escris crise untriculare au a,spect de rigidi,tate
dwtLrelnald, in tumori cerebrale cu variate localizS,ri:
-- '{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 rl i vorse l ocal i z[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-
h,,r'rr,l (henatoame cronice subtirrale bilaterale, tumori parieto-occipitale
l r i l r r i , r r l c) .
I)rrpir, Arseni (1950)
$i
Arseni qi colab. (1978) cxizele ventriculare nu
rrn r!$poot tipic de rigiditate decerebratd,, intrucit membrele superioare sint
rlo colo rnl,i rnrrlto oli in hipedlcxie qi nu in hiperextensie. Pe de alt5, pa,rte,
rl crsl ,o cl i zc vor )l ;r' i 0u l i u' o i tpi tl bnl sc, l a sohi mbnfc:r, d.e pozi !i e, petrtrn ctr, sri
l t r l czr r i r r ur l i r i l co l r ol r r r r , vt t l se cr r l ci i . l ) i n obsct vn{, i i l c pt czcnl , r r , t e
r l o Ar sor r i
( l l l l t ( l ) i i i Al sr , r r i
1i
col r I l ] . ( l l ] ?l t ) r r , i i r sr r ci i , i , or r 1, t r r r r i zol r i r l o hi pr r r l , r r r r i r r pr r xl l ss
l Tr l
r l r , i , t r r t ot r l r
.
r r r l r r r r i r '
l
x
l i {
l r r l ( f l " vr ' | | | | i I I | | r t I r i t t l i r l r ' t r i i | r ' , i l r l l i l , t r ' t t I r l t ' vr t t r
r ' l ; r l l i r l ol ) r , i "r ' i t l r r i r r r ; r u' r l , ot r t , r ' l r I i i t r r l pt r r r l t i sc r l l i t ' i l r r ( i r r
l l t ' t t ' 1( ' l l t t
l cl r i t L
, r r l r r t , r l i t t cr r t r zr r pt t l t t t l r i t l i i I r t l t i t l l r xl i r l t r r r i r l t l i t t l i t r t l r t t i st r l t i t t t l r i i t i i
l t ozt
l r , i l r t l t t t l t . t i . Aocsl c r , t i zc si t r l , t l r r l i r , [ r {' r r l i zr r r ' 1t i l r ' ; r i i ( ' r l . . t ]
'
I i
( I | | I i r I I r
)
' ( \ r ' i l ( ' r r t
i l oLr b. , l {}7i i ) .
l ) r r pi i , Ar st ui
; i
ur l r r l l . ( t {) Tl : i ) r l i agr r osi i ci t l t l t r l t t t t t r t t r ' i \ t ' t t I t i l t t I r r t r I
l r r r r r l r r
r l . l l l i l i pc hl zl pr t : zen! oi l l t t t xf i t r cr j zo
( l o
l ] i l nr t l , r , l t i c, i t t r r l i l , , r ' r r l i r r r ' , ,
Itrtttot' [:r se taoe rl upi t ccl ehl te si trrptotntt tl rrtl l tt' rt;ttl c
(l (r
i ol ](tgl l i Ii i r
l )l !rIr' i l l
l r , i I r Ur r o| r r l , t l r r l l r t , ur n ur m( , r ! zi :
(l ri zcl c
prot' l use t1e tumol i l e tl tr l i osi , posLt:r' i ol ri i l tttpl i r,rr r1i gtrrr,'
i rrl l rrrri l i cal di o-r' espi ratori i (bratti or,rtl i c, pul s net' cgul tl t ctr vrtti rt{i i trrpi rl ,
, r r i l r r r , cr r sual ecl el a 60 120/ mi n. r espi ur , l , i enet eguht r i ( l et i p( ' l r Yr r ( ' Sl r r l i l r .
l nl i , l r ' o
sau ci anozi ) , pr ecur n qi i t npor t l nt c mat r i l i r st l i l i ( l f
l r i l ) ( ' r l r ' l l i i l r l r "
rrl lurrranianfi
;i
fenonene cerebeloase.
- f i zel e pl otl use de l ' url ol i l c fi untal e ca,rc i l fc(i cri zi i pt' rr' l rrl t' t t' ttl tt
, Lrl rr si nt deseori asoci ate cu;ri erderi al o cunosti l rtci
1i
ctt l ttl l rttl i i ti prrr
l ri l c do l .i p frontal .
Cri zel e de vtnl ,r' i oul al III' Ie:t, se i nsol cse de l i ' ttti ttrcrrt l ti Jxrl rt,l rttrtr.r'
rl rlc crize convr sive cu pierderea cunoittintei.
Cr i zel e cl c
yent r i cul
l al , er al ss i nso{csc de i r l l spi r ' : r ( i i , t t t i r l t i r t r : r
i pirrost'ezii in rflcmble.
'i )
Contr&ctur'ile psihogene :
;' l i ndromul , catal i ti c (al l ui , Kal tl baun,
l t
K' rappdi n
)
Htr t' rtl rtt' l t' r' tzt:tz r
lrlirrl,r.o
imobilitate prelungiti, cu durate do ore sau tlc zilo rt l r r r l t r r r t t t l t t t .
(' :uc pi rstreazd, o ati tudi nc catapl eai ,i cX ,.qi tegati vi sti i . l ' t' t i rtrl i t' , :r,r' rri rl rr
r1:rro orl tatoni ci poate fi i nl ocLri tl de sl ,i l i de agi l l t{i o, trtt i t t t
I
t t r l s i r t t r t ,t
:r;1r' r' si vi tete. i ,i psa sennel or nel uol ogi ce obi ccti vo, pt(x,tl rtr
\' i
t rtIrtl IctttI
trrrrr,i .i onal qi pasager el i rni l S ul
gi ndron
extra,Ii t i ul l i (l l l I si ur rtl l rt i rttl ,
'
rrlii olg:rnicd, a, sistemului nervcs.
(l ontTactx$a
(hi perl oni a) pi l i at' i cd, se i i rrpuri e oi } tl l l
(r])i [r' l r(]frl , tt ttrl t tttL
, r'rr t crt semiologjc crrncieristic cu ccloraturS, nevroticil.
,1.2.2.3.
Contt&atur' i l .e re.fLere, l ocal e pot si t apari ' i tr al l ti l r' , rt,tl ttri rr' .
,l i rl l su
adec.ti ul i vi sceral e, precri m
;i
i n unel o si ttt:l rtttrxr t,rt' ttzl t,l gi c,' tj i i l
,rfi r zi Bul si ndrom extenso-progre si v a,l l ui Si c:r,rrl
;i
l l rurr!.
(l rttl {.rl ttl
,' l i rr i (1 r.ste I eYel a,t0r' .
fl
6.
pnosr,Eurg
D0 DIAGT,{osrrc IN ATAXIi
5.1.
pR0EtEt{}N
DE tttiT0l]Ol0clti SEMIOL0L}I0I
Ptntru aprecierea serniologicii,
;i
topograficii, a unei ataxii
, r' ,1)rrn o seri o de con{l i l i ,i , l netodoLogi ce d,e enatnen:
/, lu:iinfe de toate rrebnitl apleciati, sterel r,l e conltiot{i,. Sc
;tie
eii,
))rr{rl {l r1i rl , htntc:l rca procesel ol psi hi ce, obnub.i l area qi dezori ental eR nu
l )r.r' i ||i l
(j
Trl ni ccorrl onare a rtri scri ri l or., ci ,ci rri l astfcl , t|tl eser, rl el l 1tc i n
I or.(.i{'tlrit,
cxi).ottr a probelor cle ccortlonl-r,rc.
i.l. l_)'ticitele motorii pril tcziuni a,ie neuLonului motor periferic sau
ri r Irrri oi cul el oi .pi rami dal e poi co l i ti ona rt) mcl s ezi tant, rl i fi ci l , 1cnt,
1r
rl i rr l rrrl oni os, precuur qi
,,fal sd,"
i ncoorrl ona,r,e a rni sci ,ri l ol pri l tl i ccti u,ea
r r ri s|r' l |i l Lrr l cti ve sr:gmentare.
.'i. I'Iisciirilc involuntare pot parr.zita rlano.vrele de coorilonrre.
.1.
Ilrtcizi:r, unei misci,ri poatc Ii, r.Le ascr:renca, pertrLrbati, printr-o
rrrl r,rr' (rrrtri , tnl bura,re de tonus muscul a,r, regl tr,rea toni c:i a ati tudi ni i si a
rrri sr.ri ' i i l ' i i nl l unul rl i atre factori i edenl i al i ai coortl ol l ri i . Ati l hi poto;i i l e
rrrrrrr,rrLtrrrr
cit
;i
corLtra,ctLrlile (pirarnidale qi extr:.Lpilarnitlale) pot sd per-
Irr|l rr. r' recutal ca perfeeti . a unol mi gci l t.i , crei ncl i mpresi a
_
cl aci i , nu si n_
l.r.rrr r l,r'tr{;i cd, este vorba qi rier r: tulburlre cle coordonare
l. inlinte de a trpreci:r, o tulburale do coordonaro tirebuie s:i eliminilm
ri i ( | (
vctrtullt:r, astazo-abazie (func{ion:r,lir,
sau orgl,nici), plecurn gi un
i rrri r ri st' rni ol ogi c z1 unui si ndrom pseni l obdbar.
/i, ,\tr,xi:1, tr.ebuio totdea rma si, fie diferenliati de o apraxie (indeosobi
rrI|IrIrr|i tr)r cu (i i l t,c
se col tul dri adcscl l 2t, rn eti anten supedi ci al .
i . i tr s1i ' si i , i ' l :l !:r u' eri l rl rtri i sc i ' rptl ne
' n
examen si stcrn,t,i .r
l , ( . | l l r
I r
l ) r ' o( j i ( , r or r
1; i pt t l ui r l c i t f t r sj c ( l ) r , i ) r l i ul t l [ t 1i t , i : r , l e ser ] si l t i l i t l i {i i pt , op| i o-
. o1l l , i vr . ,
Dr , i r r
l f zi t r r r i t . , . Lr r r l r . l , r r sr ^ sr r r i i r , sl , i l l . . l t r | l ) , l l t opog| l f i oi l l i r r , xi oi
11( i i r r r r {i l i ' i i , r l r r r r . r ' r r l i zl r t r i i l r r u l : r I r r r . i i r gr | l nr cl r r bl t t ) , r l r : l l r r l r t l r r i . , i
: r , i r r {r , r r -
r r i i l r l r i : l r r . , r . i ( sl , r r l , r cr , r l i r r t r r r i r l i ; l r l
, r r l r i ,
r . i l : t l l I r I r I I I i i ( r r i i , I r
) ,
l Jl l r
i r . J. l ' l i ol r ! , l , l i \ l l , i l r l , l l r l A{i N{) s' l ' l ( l l , l ' l ' l l }l ' A' l ' l ) ( i l ' l Nl ( i sl
' l \ ) l ' {) ( i l l AI l ( l
i r r pl r r , , l , i r l l r t t t t t t ol ogi ci i t l l r t gt r osl i l r t l l t t t t t r i l t l , i t r i i sl r l t l t zr r : t zr i l r r l t r l l l r r i l l
r r " r ' . r t r r c| , r ' I t t i
l t t o1t r i t t
l t l l csl r l cl i vl i i r r I I r t t l l ' i l i t l t r t r r r ot t l ot t l t t t ' , r ' i l i p" t r r
r , l c r l r r l I r r ot t t I l l t I r i r r t r t t t t 1; si
I t '
r r t t t t t ' r l t t l t r l i t l i c.
i i . ! . 1. Al , r t {i pl i r r l ul l r r r r i i r i dr , sot r si hi l i l l t r r pl opr i r N' r ' pl i vi i i r l \ r ' l i r l
, . r i r r r r i
1l 1l i l i , r ' i cr r
sr t t t t xr t t l ; t r t l t cr t t r i t t t t ' t t ' r ' t t : t zi , l i l i kr st r r l si l r i l i l i i {i i 1I t I r I t t t r t I r '
, ) r r r i l i r f I l l o, [ i i t ( 1 00t ' 0l l t t r t l i t c{' sl i ( ) ] l t l l bl l l i l i pr r t pl i l xl l r pf i Vr r . r \ t r t ' r t si : i r r i r r ' '
i ur , I l i t r l l r i i r , l r l or t t egr r i dcl t : pr t ; l i i r i l t ' ; i r r , r l t u| ogl l t i ' i t ' r ' l t t ' i r t l r i l i i
( ut ' t t l l r t l t zr r l r r .
I r , l r,
1)l l i {ri ,i
l rt
rl l l rtni l i nd l a mctn}l nrl ,: i nferi ol tl c)
' !o
l i rl rl ;r' rt;rri sl rt i t tt t r. r
r , ' r ' r r r l , l 0f i vi l i l i i kr l not or i i . [ n 0l r t t l i l c t l i sr , r ' el
( ] , pr ohcl r l ni i f r t t t l i l ' t {' r r I r l r r
, , i l r l t ot l r xt l i t i t : ust ' l ; i l i . l ! st ci r npr ) t t l r n1, ( l r t r ol , ; i n t r ' i , t ni l t r l l t t l csl t ' t " r ' r ' r "1"
, r l . r i i r ci i t l e l i r i ncl ' put nl i ) cost ei i l : di r col j I ge i ] r l l l i i i i i r i {l r r l l , ' r ' ; r l r i i r r r r r i r l ' l I
, J! l r l r l Ul r l r i ) t t ar vl l r i t ' t spct c' r , i r . e, ou i mpr ) 1i i l ] 11o r l cvi l {, i i i r r r i i t ' ot r t ' l r r sr , r r r r t r r ' r ' r ' r l
i i l r r l i i : r - r k: i r cl l l l r [ t , ] , Lo i nt r - t ul sot l s si l l L i n : 11f i l ] . l i t t t ' l r ' t t r t ' r t l , i I I I I t , ) I I I I I | |
,.rrri l rl i rgi c {ri ,t,.' l apl u1 ci ve{1erei i , corcstel rzi n tl Ll brrl l i i ' i l o tl e crxr| ri ottrttrr
Dri rr
l ]|
1rr' ,
rp; i or' :cepf i s
fi
ci r, ocl uzi a, oohi l al l ' l e agr| l vl ::t' zi i l )i tt rtct' rl ' l trol i r,
rr' ,rl rr l rti Hornberg cste pozi ti vi l i rl i l toal o pl rtbol e rl o rr.l ,rt' ' ri rr (rri i l ' rrr
, ' r . r r r r r chi ,
pl i l nl - ) ar ei i ci l l oi i r i l ui pc cr el l st l ! t i Ll i ci ,
?r ol ) i l ,
cor ci l l ui ,
l ) t ol ,
I i ! l r l r r
l i r i r , . i r , ) oi l uzi . l ochi i r , r r r nl i r el t e cvj dent ( r t r l t : ol i chi at t r ot t si r l t , t r t l r i l ) I r t l l r r r
,,!( rl 0 c,-{rt,:i 0u&ti t.
i i c r n: l j i t soci azi ' cl e obi cei
l i
bi l ot oni c ml r soul r r i u si , r l t r t t t t r l l "' t i ,
rr
i L.l i er
cl si ;eo tefr[i i uoe,si ,, fenourene ci -!.r' c si ti i i
(l c
i ]sotl l {)rt(i i r cttttsrrtti ttl (. rrl ,'
,
jri
i t irii ciiilot selsibilitirtii pt'oftrntle.
i l sto i mportant tl e rel i nut c[ l i psesc amr)tol i l o 1i
tti sl ' 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 r t r ; r I ,
'
, , r , I ,
rrr r l rl cme cl i ;rgnosf i ce ;
t. Pol i .ri r r"i ti ,l e
{. 1.tal i neurol .tati i fu.
Si : i nsol csc
1i
rl tr
i rri rrrsl ,r' zi i ,
rl l i ' rrl
,rrr' :i l t ti tr stn$i bi l i ttte obl ccti ve cu di sl ,ri l )rti .i o p1l i {l orl l i l }i l i l i i t r t I 1 t r t t r t r
'
I i t ' I t
r r i i i ' ) . up( r ' l i oi i t l c, ci 1,
l i
pi ot ul l l 1o) , t l e i i l cf l er i e osl i c( ) 1, ol ] ( l i l r r ) r r $i l , r l c r l l l i
,,i i r. rrrotori i
(i [l i i cteri st' i oe, ova' l ]tua]
i si
de ai i l {}1i i . []tttrl rt' i ti l l tsi vi l rtl ' rrrr I' rtl
l ,Iri i ri l ol i ' i e scnsi bi l i ti ],to
profund:i
;i
i l i tLl r,x i ci Irr:rl i zr,rtzri ,
,,pscrt{l o
I' i rl }rl rrrl
pr,l i l rl i c". .Dureri l e l a presi unea fi ra$el ol l tl l l scul l u() i i i l i l
l rrcsi tl t
tol t, 1,l l tr rrl l r I rl
,i l ,,r' rrervoase si n1, consttl l to. .A1bc somnc
(l i [
ctt)l ,()\t' l l l s(rrl )i ol ogi r' $rl ri
r l i l('
li';rftru.
stabiliroa diagnosticultli e1;ioktgio.
!: Po!,i ,rti l ' i cutonet)ri ,tal e l rrtruncso i rr trrl )l ol l l sottti rtl ogi tr,
1rl
l tttl ;:r
,
.
I r
.
r r r ,
.
I i i ; { i I t I
gxI.l Ise
atr]l ,ori ol ,
pozi tj i vi tal ,e& scmne]rl rl ti ckrrrgrr,{,i o trr,rti rrr l i r,r' rr
; i
r r i nr l | ot nr r l l i ci r i di , r , r r pl ; ognot uoni c pol L{t r t
j t i t r dr {) ml r l ( }l l i l l i r i r ] - l l : r ' r ' r ' r ' )
l i l t , r l t l .
i l . ;J i n,thonuJ meduLu' r tl t
Ji btt
l uugi (d, d)nl t,tt: po:tl cri o4l ' 1r) srr trrrt:trr
Itt tr,t::tzi \, rxtrl ttsi v pI' i l t l ,uIbul i l ri ti c sttrsri Li l i trrtc pt' trl uttrl i i (()l I$1,i 1I I I' i t
'
(rrl
r r r r l r ot t 1t r l i l , i i , l , 1xi c ( pr r r l l r l t r t i nl l t t l , l ' i , st l u {) x( t ur j i l i i l i t , t r t t t t r br l ' l l r i t r l i r t ' i r r l r , t r ' ) t r r
. l r r r r t r ' l ' l t r xi i r osl r 00- kr l t t l i r ur asi i , . l , i I $of , ( , r l r t t r r I i l 0 l l t
I ) r c$i t l i l ( f r ,
t t t l t t ^i oI ot t r t t t t i r ' t t
l r r | r .
; i : r , L| t t t t oI t i t t t i I ot l r ( : l vi ) i t sr ' '
l r l ' ( ' ( t l l l l l i 1i
l : t , Lr l 0t r gl l {i l t ' t i i r I I ' i r I i t r i Lt t
i ) ' l \ t , l nt r . l , r ) : l l i z( l i r zi i ' col t t t : t ' i
l t r r l ct t l '
i , r r l t l t t t t r l r r r i r r l i r t i l r ( i i , l l r r l r I t r I r r I t t t r '
116l l r 1; i 9l t , t r r ,
( j l l t r r . r l l : l l t l t \ i r i r
( i l l
: t , t t l l l t ' r i t t t i i r : t t : r l l r r ' i t l t t t l t l r t l t ' l t t i ' r t t r l t t "t t
i l r . r r r r r r r l
l ui i \ l gr r l l t i , o| r r r | I i r ot I ) r
l l l r f ( r l l l t l l i
l i ! r ' l l l ' l l i l l t t t pl | zt ' t t l l r t ' r r r ' {t | t
r r r , r r i r r 11r . r , l pr ' ( ' r l r ( r ' . l r l ol r i l l i i l l i l l i l i i r l ( r r zr i r i l I , ' I t t t ' : I l t : t l t ' t t l
l r t r ' 1i t r ' ; t i l ,
t I
'
I r I r ' r ' \ i f I r ' i ' qi l i r | r r r c l t , t r r r l , r r r l r r l l r i r i r r .
( Jl i zr ' l t r
vi sccl l l c si r r i , r l t r r nul t u ol i ul i l r r
rrr | ! | \, r
'
I I i t (
,
,
| |
.(
' l t0rrLrrr
rl i agl l osl ,i tr.
h) Ato,r' ti .l e
_aauta
pri ri
l ,,zi urri ^ al c co.rl uune]or posteri o..rrc (rnkl l i Le,
'
t r r l ) t 1. si uni mer l ul a: ' e, cpi dur i f l , ) si nt mr c.
,
) . 4. l . t p. l e: ; uni aLe
Ji hr el or
l r r agi so por i ul i l ni i n:
\ t ndr ol nuI ncur oonemi c sc poi ] l e r Fcuouagl e pr i n
: ar bi l i e East r i cf .
: r r r . r r r i r . l r i per cr omi , scmn{, de c, t r r l uane post el i ol r e, *r ef l exi e o- r i ; ; ; : ; _
rlirrorrsle lil oare ins5, se adaugd, qi semne de cordoan6 Uterate
lsimpioine
p i l rr r ni tl :l l c).
.
- Nind,romul nauroachilic.. hipocloftirlde qi achilie, semne de cor-
(l,i'x..
postcrioare, de obicei cu sellne mai pulin impurl,ante tle co*loan.
l i r i , ' r ' i r l r ' . d: r r L[ e ] nul l e ol i gi r . u scmnc dp pot i onr r or i ui i ".
I l oal a I ui Fr i edr ei ah. i nt r unc. l e r r n mi nr r nr . bi , r e si mpt or nc pcr t i _
(,ulirr,(!;
caracter ere.1o-familial,
.fenomene-
cordonale posteri6aro (itaxie
Lrlbctif omi,, tulburiri de sensibilitate profurrdd,
hipotoinic, a,reflexie osteo_
Lendimas5,), semne de leziune a f:mciculelor spino:cerebeioase qi eventual
rr corebelului.(cu ataxie cerebeloasi, tulburiri de echiiibru, adia,docotrri-
j
l i l i l :]Ji i ^l l l I:,
tremor i nl enti onal , t ul bu r:t ti de vorb i re), sem ne pi ra,m i dal e.
u||rrnran trotl ce (c l l o- scol i ozd,, pi ci or scobi l - cu deg..fe In ci oca:r;, uncori
, i
j r l r r i ' , l l ot i i
dc t i p Ar an- Ducbcnne sau C. ha l cot l : \ [ l r l i e.
Itrred,o-ataaia cerebeloasd,- a lui
pierre
Mq,rie asociazd pe prim plnn
sr,rnrro,cereboloase qi pira,midale,
simptomcie cortlonale posterioare
{iind
r I U ( l t scr et e.
.. ...
.,-
,!o:!!trSia
lantiliald
Btrilm?elt L(rr&,in. prezintii,
exceplional dc
I i||
.ir
stn]pto_me coldonale posterioare,
sitir:r,lie in care *taxia este mixtii
( ,
'
r , . l x' 1, ' cof t j ona15
) , ^. dJ
r pe pl ar i secur r dr r ' [ u1i i r l e pr i , . r pl egi a pi r ami d: r Lt .
,
I)l sl ,azi a.0rcJl ettcd
aongrni tal d Ruusq_ Li rg
"al rl noa"zi
un si nd|our
,,l r]l l l i
r,posrerl or. (cu
^l i ,tl txi l r
,1i rrefl e-ri {] ostco-tendi noasi i ,), apXmt i n
' .,)l ,i i ;rr' re
((tr,ol l rcel ) s i nti ntc de pube]' ti i te.
Oal tcte|ul e,redofa,rdl i al , evo_
lrt{,ii!
^ai
benigni, si asocierea uneor.i de niotrofic sitaeazf, ace,,st''atoc-
(rntc cl r o formd, de trecere i nt,r,c boei rr l ui Fri crl rei ch
si boai a Oharcot,
l \! r r t' i r^.
tt.:!.1.2. Hemiataniile rru, tulbu.r.dr i de se sibil itale
Ttn,jundd,
d,ar ur,
rqfktn. ost,eo-te,nd,inoo.se eonseraate ridicii urrlilolrele proilcine ile'rliagnos-
l i l i op' ' gr ' . r I i . si el i up. r i og. , ni c: '
.l .
4tari a pari cl al d esl e. produoi pri n l ezi uui vascul l ,re, tumoral e, trau-
rtri l ,l r(,,(r rl c..:rl e ei rcrtmcol ufi ei pa::i etal c
asr-,endente sl u :r pnri ec[i i i or pe
: r r ' . ' : r ql i i r i
i i i r r r r r ' .
( i ' nl (
\ Lul semi ol ogi c i nr I r ur ei t c l ul br l r ; f i d- e scn- i bi l i t al e
r r r i r l r ' ( r l u r ct r pr cr l omi na nl i - L pr of u nr l u r , h, . mi : , t l x i e, nst er eognUzi e, dar de
r r r l l r , of l Fr - al t c sj mpt or no de l ocal i zr r ' .
l , ar j ct al d, {cl . i zr .
j {r ckdoni ene
scnzi _
r rvt, rilllr ol il' sr[zrttvomotorii, apt&xie, hemiasom* tognozie, hemianopsie).
l. Ag*ig talamind, (din
-sindrornul
talamic al .lui Ddj6rine-Roussy)
rrlllr. continlatr'al leziunii (de
obicei vasculare sau tumolale) nucleif;,
l rrl unl l cl l uterah, i nsoti ndu-sc de hetni anestczi e p}ofrurdd i mportrnt;
fi
pr.r' ,ri str,nti ,
_rl e
al gi i de ti p hi pel ' pal i c (.,overrea
cti orr"
.-
EIcrrI-;i Eobnei )
ir
t|o ruttcIln coreo-3.col,ozl0o.
S..l .Al nni i l e pedunaul o-pontu-bul bare.
r)i vel ' sc procese patol ogi ce (l ,umori l
l i l rnrrrHri \j nt:c, tl ctnot.t.gl t) l uci tl i zi Lh) i i t ctl ol a truuCbi nl Ui cercbral pot
trrr,l i zl l ,.di l r(l r()i r.l rl rr i Ll t0r' nrrr i tr cotrt,,rtul {)i l r' ori r, dr i nti l rr,' sc
ryi
trrl l ruri l .ri d.o
d. nBl r Dl r t i r t ( ' pr r , l l | | r ( l i l cr r r r "l i r r i r , . Ar : or r Lr r i l i r xl r 0r ut r c i I l l {' l n0 pot , r r i t r r p) i ce
r r , l l l ; r r , 1' l r r i i pr opr i ( n1r , l l t i vo,
ci l qi r l r r l i l r cr r r r r hol os, l , l
( t l r ol , i l nt : t , i ) hr r
t i ) l ) r ) -
t 82
; . 1nr , l i o
o*1r ,
; l r l t I i ct t I t r ' t :
r r vl \ r l r l r t r t t l t t , t t t i i t l t l r i i t nr r t r zi l i vi i oHi t ! i l l l '
t l l t
'
i r
l i
l l J [
,
I r or r r i r t l , r r r i r l r r r . t r r l r r ' | t r t sl i , t ' sl o t l i t r r ci ' i i ( t l t r t t l t ' r ' r t , ' 1i pl t t l , t r t r t l l t ' zi t l t t t r i t ' qt i r r t t l t r zi
r r r i Lr l r r Lvi l ot r r t l r t r i t r t t i ) , or oxcr p( i l si t r r r r i i i kr l t l o l l r zi t t t t i
; t t ' , t l t t t t t r t t l l t t r ' ,
l t r
r r i r r ' l ul r r r r cl r r t r l t t i r o1t L, sr r , t t r l t t l t i i , i t ur l t t ci ; r t t ' t t a, l t t i Wt r l ' I t t r ki t t h.
5.i t.P. Ataxi a vol ti bul ard csl o t' cz nl l ,rt,ttt i t' Iozi rrni l ol ncl vtrl tti , rrl rr tLr' i i l ot'
rt rrl o ttucl ci l ol vesl ,i l )ttl a,ri
Ii
$o
(,rl ,r' rt
c t ol i zcrl zi -"t pl i tt t,Lrl burri l i t.l c rLi r{,i ttttrr
i i i r l o r ncl s, cu osci l &t i i
r yi
ou t l cvi t , t t i n l cchqi scr r sr i l l i l , i nh) ' i l l i l l ) r r i f i l ' l l
l rr,l ol rrl , i rL l ' Lrncl ti c r[e tri vchtl , rl c ti l rul
;i
tl o rrrtsi vi trl tea' l ezi ntti j . r' \' i o rtsrxri rr.zri
rr sorl l u l i onrberg pozi ti v (ol cmont i mpol tant
(l e
di l gl l osl i c)t
l )tl l (l ttrrr
i i i
rrislrry4rnus
$i
ame.teli. Este ul,il de lctinul, lrytu1 c:i sensibilitiitt(]a,
pt'ol]l'irt
crrplivtr, reflcxclo osteo-tendinoase, probelc de r:oordonarc qi volbit'trrr, ttittl'
rrorntl l l c. Ata,xi a vosi i bul ari i , nu urocl i fi c5, mi $ci ,ri l o i zol ttc al o tnctttl rtr' l rrt
ryi ,
ri r, ;r,1;N,r' or spre doosebi re de bol navi i cerebel oqi , i n si ndl oatncl c vtrsl ,i l tttl rrt' r,
rrrr sc constati, tulburd,ri scgmentare de coordonalc.
5.9.3, Ataxi fl cerebel oasi se recunoaqte uqor, o1,r, :rpi i ti ttl l l i t l rol trrtt i
,rrrrr rLu ptezi ntl ni ci tul buri ,ri obi ecti \-e dr: scnsi bi l i l ,rr,to, tti ci si tttl tl ,ottto
vrs l ,i bul are.
5.2.3.1, Sumar de d,ata senziologice
Sindromutr oarebelos la om se cari,cterizeazh prin trei gt'upo ttrtli rlrr
f l t ptomg :
l!., Ata*ia asrabalaasd' se traduce plin urmltoarele sorrrilo:
L Dismetuia consti, intr-o dimensionare grcqitii, n, uriqc:irilot', lxrltrrr,
vrrl neliind capabil s5, ajungi, la
linti,
in sensul ci firi o depflqolto (ltipttr
rrrotrie), fie se opreqte inaintea
lintei
(hipometrie). Ilsl,e itnpot tilnl, tlr,, ptl
r,izrr,t cL bolnavul nu eziti, la polnilea niigci,rii, crt tttitxioul pclilirt'ic, rut,rt
ol posed5,, cu toat; tlismetria qi tremurdtura inten.tionalii, tlirect,iu, gcttr^r'rtlrr'
rr, rrriqcii,rii, Dismetria se examineazii, prin umttoarele plobe :
a) Proba i,ndice-nas. I-.,a solicitarea de a-gi duce indexul lrr, vit l'lrl
rlrsului, bolnavul so oprEte inailte de
!int6,,
sau trece dincolo tlo ott,, iz
birrdu-qi degetele de obraz, de frunte sau de ochi. Direclia genclalit itti!inln,
:r, rniqcirii nu este alteratd,, iar ocluziunea ochilor nu influonleazfi, trrlbrr-
nrlea,
b) Proba sti,ol,ad s D. a, g6,tul/ui' slrlolBd. Cerebolo$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,plopio in 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$toa, Oerobolosul nu r4o
lxnllre
opri exact la nivelul liniei vortioale tlin droapta' oi o alop6qo[t,o' iilr,rl
r{r ODrcgto inailtoa, oi.
-
a)
'Proba
prekenaiunii (eatt poharului), IJa solicitaroa do a apuctt
}ltltrr,
rrrl, po de o p rte cerebolosul tlop5gogte sau nu ajungo pahar'[l' po
(lo
olltl,
p:r,r' to mi ni l tui so deschi de mai mul [ doci t ests nocos&r.
l.) Proba p notului. Solioitlnd bolua,vul s[ faol un purtot rlu ol'oiorlul'
rxurbolosul tl oxecutS, diticit, frloiltlu-I tlin mai multo liniir introt{,i1t1,o slth
forrni l unoi
gtol o.
g) Pruba l oti sul ui ' , Sot' i *ul ool obol osul ui orl ,o tl i fttt' trt, tl t' n tttrl ttnttl ,,
l i t,ol ol o Ii i nrl rnl t' i , ttutogul i l l tt, i trttgtrl tr.
l B3
, , , , , t t . ! . . t . . ": . , , , , , . ' : : . : i l , i , i
t t t t l un, l t , i l r r r l cr r r bj L r l or . sr r l , r i r i scr r . r , ci i u( f , r pl l l l {f , i l i j l
! r r r r r
l f r ' . 1(
l l r l l r ( l r r t l ( , [ r r r s
r r . l aCo CU dCpl ; i l r : a Sl t i t OLl r i i r t , i l e* i A t : i i , : t t i l ] t r i
r :' l ri rr rl ,' r' i ri i .r' rl rni qcl i ri de
,i
e.resai e,
' boi """oi
p"ot" ol roge genuntrri ur"
tt i ' nrtu
7tr' i r,bd' r' i ,i cdrcti .*ru,i pe creasta ti bi ei .-ra
eri ,rurarca ti . rni s-
,. {' :r |.' l l tco <_ru uu Ci Lractel ,feStonat,
cU oSCi l ati i .
,
!. l rl iutloc.ohi,neaia ( Disctiadocokinezig)
'con$,j,
in tncapacrtilto.i
rl . rr .r.r,rri .i r.t' i fcL.i
al tel :l rati ye-succ.si ve.
S6 e:rpl oreazi ,.u
aJui orul urxnat_
i l t r 11l 9t '
l l r obc
:
t) .l?roha nnrioneteloy.
Bolna''i cste solicitati s.i, facii, titi$cxri :iltrer_
rrrr\' (, (1.9
pr.onal i e-supi ml i e
_rl c
i rnl ebral el or,, pri n :rti xgel ,e& al tel .nal ,rvi i
rr t,or| soi cI pe mele, apoi cu dosrrl rniinrior. De p'artea bo.frraYd, rniqcl,ltlr,
si,
, rcrrri i u i rrtr-un r.i tm mai l enf, mal i gl l oi , i ntei e.di ni l
o sc o pa,ori i ,,
r,a,,,,
'
, ,
i]i.,.;:jilr-" i,n":ilca
mjsciiulor succlsive, sau notnavil-gre|e;te
rniqclrc:r
"
,
i t i ' h)aa
Jkrtutl l L ;i
entensi uni i cl egetel or zr.dl a' d. Se constati rrceasi
,rrtrr' zr,rr.
sru gJrc6i r,e a mi qci ,ri i de partl a
bol l avi ,.
r
)
1'r^br. baterii tobei ca"
.d,e.1tetele.
Bolnavul os1,e solicit&t si loyeascil
r)rririr (iu {iegetele
aubelor miini, const:r,tinA"_su ac""rr.i-luburr,.e
Lo-r*iiii
Itl )l ,1.l o
procedente,
,
.rl)
})r.aba
Jleriunii
dorsale gi
Ttlantare
ct, p icioarelot. lJolnaml yl
irr_
r . r zr i ' , r - l l | l . \ J gl oci
mi scar , . x l l t nt . t Dbr ul r l c pi t t . u
l , , zi f r i r i r .
,,. .rrLnerata
constt i n i mposi bi l i i ;atea
de a, coordona arti unea tl i fc_
r il /'l{n
.
glupi
trusculare in vede-rea executi.rii
";"ir;,ii;j;
cornplexc. Ast,
|{ 1, rIri l (r}i l o (' rnrpl erc..se
tl esconpun i n cornponentel e 1or cl emeul ,i ue.
,,. ,,'.'..!,_':,.:":::,:o:y:"!:::::!,
sr)&te (proha asinergigi sratioe a tui Babinski).
|,, |l r{r(| nr)r.tnal , rasl ,urntret pe spal e compol ti , fl exi unea asoci at[,, conco_
rrrrl.rrl,r'1r
a trunchiul.ui;i a mimbi.elor infei,ioare rlin genunohi.
Cerebetosrit
(l rl frxl url )une
mi qcarea qi l a accasti , probi l i pseqte tt&i unea ga,mbel or
d i r:
:' r' rrrrrrcl ri ,
i nci t cerebel osul cade pe spatc.
,.1,)-,[' rabo
fk.rtuni i
gaml .,ei pe
-i oapsZ
gi a ao*psei pe bazm,
\probl i " cnl _
i rr ti r,:r) sr. erecu15, i n decrrbi t. rl orsal . i el ebel 6sul
-rl escompune
aceasti
rrriqrr,:rro, irr sensul cd, intr-un prim timp va 1iace it"r,lo"".ni
"ou1rrni,
tirlicil_
l,il. ii 1',,1y,.!^,:lt.de
pe planul
fatutrri 6ihou"
i" uf a-rir", ii*p rr.,:{rea,sii fle,
\ | l | | | (' l i g, at ] ' t
bet .
. , , . ' ,
' ,
! ' : ' . : ! ' :
o. : l , l ! ! ' L' -
n; ci gr ut ui
pe sasva
{r Ji n
f ' r zi t i .
ot l ust r r i ' i ) .
s{'
'
r , | ' : r : , r i r i
( . ct ct
eosi ut i t pUxet o
a l xi t ( . t i i . i i , i n Scn. u I Cr i i l l p | i r nu l I . i mn f ace
r r r . r r r r . r ' r r {ar i r l | 5cr pe l l r zl r l cu nr cml j r ul i nf | r . i or t , xt i ni qi i bi e
i n r l ci oj l er "
i I
i )
r : l ( , i r ' \ r unca gi r mhci pe cot T] Ji ' i .
rl1. I\.olxr, ind,ice-nas. Li a_ceasid, miD&r,re so observi, cri ce'ebelosul
lrr.r' irr l,i i. :r}ducfia braf'lui
$i
abia, apoi fiexiune:i n"i"t
"o1lrtni
$i
dii;;;;
r r r l r . r
ul ui I l l na, s.
.
')
,L'r'tha
mrrsulu,.i- Iipsind coordonar,*r intro acl,ilnea srrmrttanii, :r
I i .:,,11.,i 11.
tl i tn(,l t)utu1
$i
.1 membrel or i ri fcri onre, i n ti mpul mersul ui ,
r' :,. Nr\ ri t(.{. c* i ' Jzi l ,
(,e
sustcntaj i e l ni ri td,,_ trunchi l l l l ]nl ne i n urm' fal i
,l ( rrr1' rrl )r' c,
i nci t, bol navul poate chi ar cri i t"a p"
sl ,ate.--
-
./.
I)i l 1,ol i 1i i tui buri i ,ri l or de ccordonare .^"o pot i rLteresa, si mu;chi i
l , ' l r i r l , r r i , t , t r bi r ea asl e r l t cl ai i ( sacadar I
sar r exnl ozi vi j .
, ' .
' l ' t t
t
, ut d. l at o
i t pn! i o ul . i . . Po: r l o l I i r r ea i zol t - r , 1, r : r r r r r SUr . r : I l a
CU {l i S_
r i ' , | l r ' . t , . i l f l r . t t l l c l I : l l dt
. : t t l i l i i
, si t n; r i l r r r r l r l i
l Jr i l l
( , oi n
f Cr cBt _u ou, l UCl Ci l Or
' l i rrl ' rrl i .
l r)i i i :rr l i i rr.ti tl $, 1 i ntorri i (,' rl l tr,
l rr,ri i ;rrr-
cri . i rl ,xc ul crrrsur .xrcu-
l r r
' i i
rrrrr ri r rr i s.i i .i .ryi J i psoryl o i rr
' r4i rr
r*r. s.i rbs.r i .ri l rr, i i i .ti p u tr rl ,,n,,i n, i sm,i rl l ,
r l r r ' r r r r i
r r l . ' l i r , sr i r l i r ' r r r r r r i ; . 1) r ' i i
; r i
s. r ' r ' i r r . r i ( i r r zr i ,
r , ' a, i r t [ i . r . r r r
Dr r r r r . i i r pr l i 11l -
r r i i r ,
I
l | ! , 1 r
,
I r I r r r r I I t l r I l i l l i zol r r l i i . l i r , r r l t , i l t l i i I r l r l i si D, , l l . i ; r .
, | , r
| , r r I I I | , i i | | r | I I
t . l
r r i r ' r r I r or r : r I r r ,
( l r t r l l r l , ui r '
, r r
l r , : r l l l . t l t t t , : t l l r r j i l t t l t t i ,
( r r l 1' l l r j \ ' l r l r ' l l l r l l t l l l r l '
, , ,
r . 11r r l r r ( , r , r r i l . t | i l i r r l r r l t t t r t | l i r r l ot i l r r l i t ' ( l i l r r r r r r l r l t | i
1i
i l t 0ul l l r r ) .
l l . f i i t t t . l t l . t t t r t . t t : ut l ul u t ' t ' s l , i l t ' n ht ' r r . At r csl , <' i t , : l l t r t t t l l t i r t t i l l l
( r ! | I I I \ | I | | | I I I I
l , , r r l i "sl , t i ni l t . r l i l l t l ct r r t r l r r r l
1i
l r l l l t l l t l , t t L vcsl , i l l l t l l t , t
-
! . t l s! , u, | ' i q, oot t i l i , i , i t t l ' r ' o i t r si ' abi l i t a, i ; t l , cl n' t l r t t t
l r r r l t l t i k' t l r ( ' t l l l t r r ' r ' r ' i t
r l l i l
r r , r r i i vel ' l , i cl f t l . [ i ol l t l t vt t ! t t sci l 0l t zi i t t l l t l l l r r sl ' t t st t t j l t r t r t t l ' t l t t r cl t i t r l , l t t l l r l
, , 1, l i 1"; i , l i si i , -$i l )ri i , r' oru; ol "l bi t zi i , t I t t sLt st cl l l , al i i u. Osci Lrt , (' i i l t r l t t l
L; oLl pt i t t t I rr st t ' r' I t '
rrrrl : r, i , t ' l t , ccf : l l i ci , .
:!. l l crsuL cstc ebri osr ezi ta,nt qi ti tubant. l Jol l tr vj i l ul
Pr)l l )i i sl
rrr l t' rri i
, rrrrl {ri , i n tri nl ul rnel sul ui , ci devi azti
i i
a,ubi nza do s ustol l l j i l l , i {r l l ri rtrl rr'
I r , r ' r l r : r nl , t t l i t el o s' l u r et r opul si a. I r oba r net sul r t i i t t sl t r a. r i t t r i t r i r l r
1r , i r r l l oi ' u1 vt r st i bul ar ,
I oat s
?l a r el al i i p: l t o1, gi cc, bol r t r t vt t l t l . t ' i i t t r l r r '
r, ri rottstanl de partea leziunii cerebeloase'
ii. lr eftijlrl
,,:i
nlStugmusuL L.r, un cerebelOS intliCii lcziLLttcrt, t u r t I t
.
r i I t t r r I 0 I
, r' r*l rrl o-vcsti bul i i l e.
4. Proba tl et:i eri ' i bra,tel or. Br*l el e tl evi a,zi l dc- partci l l trzi tttri i rrrrl r' l r'
l ,)i rri ' , sl ,u i 1e partca emi sl erul ui cerc,bel os ccl mai l czl t.
4t..
't'ulbu,itiri
care se ea:plicd,
?rin
alter&red a,JerenleLor yropt"irtLttplirt :
l . Hi pot oni *' m' t Lscul &/ i i . Secar act er i zeazi i pr i nl l asci di i ' r t ' l ; t ' r t t t t r t s| t t
,l ru i i . l l i cLtm ;i
pri rr aropl i tudi ncr exi rgerat[ a mi qci ' ri l ol pl l si vr" l i o
' '
,l ' ,r{"' 2,-i , pri n ui r,i i , tr,erel e pl ol :c: ' ,t' ). I' a mobi Li zuTect pasbi i u tttttt l ' t' ttl ttt
:.,t
1,,' ri ot' ,
"!e
ati l ge cu uquri nl i , umi i ' rul cu arti cul af i a rttl l o-.rl tl ri rrtrri I l rt
t,ru l tra.xi urLi l e prri i Te a10 membr' l ui i nl eri or, se pol l tc ati ngc f.srt .tt .i tl .r
rl . i ,rl fl exi LLi *i t coapsei pe bazl n se facc c* mtl t:-"t' rrql l ri 1ri i l ' !
' 1i
tl t' rttrr' l r
,l i rr* oxagcrl ,i i
i
t
)
i ti ntei ,si a mti tti i Sc l acc,ostc l i l ni t. l i zi ,l ,r1i .i i
(1rt ,l ,'
, ' i
, , , l t l Tr bo
p, . . t "i L: i l dt , i i u l ui l 3ar a, ng. I mpl i r nar ca ut r ct t t t i l t r i l l i : r l i l r r r ' '
r ' , l t , r i sr r r i r t . , 1t L, r r t hj t r l ui l a un col ebi l l os i n sl l ! i i r r i t r l t r r ' f i t r r t l : t r l ' l ' r
r r r , r i , r l t r pi Lr : 1. t i t l r ohar ' : i excur si i r r ui ampl e i t l o t r r cr ut l x' t t 1ui st t l t t l i , t r l r r r
i i rrl :r!,i i i i ri l
i rr
Il o -hrtl neri l l i a
;
e) Probu rczi utuqei '
,tt
Iui l l ol tnts
' \l t
tr"rtt
l l ,;l rri ";i i l cstr: i ol i ci l ' at si l frrci -l fl exj unea :mtebral l rrl ui pc btrr(. l rt . L r"
1,,' ,1,' r,t.
l u i tron i enl Ltl i n c:r,re dti tn dl ' utl ul r":utebtLi ' 1ti tl Ll i r
.ti t
l ' rLl ttttt
'
i , r ( l i , r ' 1, r r t l {r l i i r i ui r i i I l l r t l ' i pi cpt t Ll or L mi r l r l ( r l l i ' t I i t ' i r r t l t i
l t r l l i t r
l r r l "
, , i , ; . t l r i : : 1i i : ! i [ r 11] : , t l l 11or i t i i l i l i ei - i nt r i i r i i 1a t i nr p i n 1' ut t r ' ! i o r t ' r r r r l r r r l r t r ! r
l r . r Ll bLt t : r . r ' e c r L{- ' . I }oi i l 1i i i uux cl t t 1e t l i scr onomcl ; r ' ) c) ( ' \ t t t l t r ' r ' l ' l t ot t t r r ) r '
\ ! ' t r r l t ( t ' t ' e. f l ?, r / ' l r , r pi t t t Tt t Lar r . 1) ccl l t t qi t i i l t
t cl l t r t t l t t i i r r l t t l i r t t t l i t t t t t i r ol t r : r t
, , : r l i
1t u
r i r i r si L, 1r t ; gi t l t l bol e at i . ' i ' 11, t l *Lt : r r r r i i i i r r t t n' l l t "- r t , l , t r l i : t t t
1r ,
t , , l r r
l L. r i i ' i o si ' t i t , t i l l ni l ci i l i i uei l n4l l o
1i
i t t r t u' l r t l i l i t i r l t t t r r t i t t r I t | | i
I r I
t L' I r r
1 ,r Ll ,'
1;:' ,:' i :ci r
i .:,,rl ttr-i i
I
!) Praba ti sl ,n,t' t,ri ci t' oni ft ( l )]i tl l ti tttsrrtr
ri l r"rr
'
, ' , , ; .
j c
i r ci ' t l r i r l t r . r , r ' t t i L. i i
' si
f i t l i o( j r l i l ) cl ( i bt ' r t 11l r i ; i i r i l l t r r t 1) t l r r t sl ' r t l r t t t r ' r l '
, , , 1, 1, , , , r , *l i ; r , j r i t i s i r r
l i r i zi {i r
r ) l . i z( ) t l i r r l i . l ) t r pl r t i , t : i r l t ' zi t t t t i i r r . t r ' I r r ' | . ' r r , ,
, r t i r l l ' or r r sl l t t i r : l i i , r f s{r l ' i t l i ( j i t l i ai sl i st l t x' i l t r t ' l
t l t t Lt i t i t L
' \ t r r r i t l l r r
l l t l l r r t
t t r t l t I
r l l r i pr , i t r r i r l , r ' i a si t l i scl r t l t ot r l t l , r ' i i r , pt i t t
. i I t 1r ' l i l t ' I t
1' ar t l i "i i l l I l i r r r r L
, , . r ' , , i t i ; i , i l or , ( , i I i j i l i i l n) t oni i I t i r t i sou] i l l i .
: : . ' 1. ' u, l , l r u; r r i t i , i nu' pr u. t i t t cr t l t r t , zi l ' i i l t t t r r ) l ' l {) l l l i l vt l l t r t r ' t t {i r t t r l r r I t t t l r t ' l '
t l r ( . r . r / i t t , . i r r
1r t , t r r . , i , 1i r t r r c, , , , 11i - i oI I l l ' r , 1
ci t ot l r i i t t r t , l t i , si . I i i r l j <: i t r r r l t r l r r r ' l Lr l r / l l
. , 1r , , r s. l i . i l , i i ; r r l r ' i t ' l ' t r l sl i l j I i *l r : r ' l i l t r 1, r , . Ni t ' t r r l r t t t l l r i t l t t : t v t t t t t , i r t r ,
, , r , i l r pozi i i r i r t i ( i r r l r i , ci r , i i r r Lr r r , l ; r r r r i r r i yr , l r t t r t i r i r I i l l r I ;
l r 1 l l , r l t t r r t t t l l r t r r '
' ,
, , , , , , , 1, , , , r ' i r i i r r r i , l r r r r t i zr r t r l l t l l t , i {r l i r i l l i t r t l r o l t t : t t ' t t l t t i r l r t : ' i I r l t l l r r
. r l "
i , . l ; r l ; r i f , I r r . r r r , Lr t l i l t r l i l l i t t t r ' . l i r ' 1' l t t l l l L l "' l t t r r vl t t t r ' t t l l r t t t l t t i r l i l r r r r r : r r t r
, i l ' r , , t t t r st , l i , ' t l t t i )
. l t r t t r l i t r ' t t i t
t r r r l i 4r ur i l i t ( Lt ' t t t t l l r r )
l i t r r r ' '
I
I ' i i
r l r t l l t t t t , l t i , t t l l r ' , l l r l r t t t l t t r r r
' ' , r l Lr I : r I l
r I r ' l i l ' I l i ; i ,
' r
I l r ' r r ' r ' l r ' \ {' ' Ll l r
| ' t '
l r t r r t r r l t r t r ; , I l t r i ( , ( . r l t l i t l , ol l i l t l | . , I I I
.
| | | I t I I I I I I I i I l l r t l l l r t i l l : r l l i l i l ( i ' i '
j
l l l I
l .srrl rri . str .' k' rrrrcrrzl i , gi unr,.i rri sl l l rro ..rnpl tr,. Irr scrri ' rrr 1 r,ctrtuti i t tr r,a
.rl |upi ' rrrrri rl i rl i l ,nu.stc
i nfhren!,i [t?i ; i a' ' p.' l ei a, pi l anri da,l ti ,
se accentueazi l .
It. tlrilelc auebeloase. Unii bolnlvi-pr ezinidu crize tle opistotonus, crr
l ri l x)roxl ,ousi o a msmbl el or. Aceste c' i ze- se aseamd,ni , cu i ,l gi ai tatJi Ae
r lr,r,r'rrrbranrr
oblinutir, la animale prin secliune mezcnceiatiEA d;;;;pi:;
r r r r cl l l l t i i l o6u,
.t- Li1..2. Prlbleme etirpatogenicp, 4n sind,romul cerebelos
. 1. I I r ( ) r t l pcpr phel 4oscr i a. t r ppt ezenl af ei napJ' oxi maf
i v60o/ odi Lr cazur i
il: .clj:11,1,,;
^ll.1llt
,.1. r0lo fiild hemargiobla sioame. cnisrufi, abcese
li
r ' ( , t , agt *ze. ( A' sr , - ni ci col ab. . _1974) .
- \ e
or i eol i . m spr e di l guost i cr r l ci c t u-
r l l ol i l , C( . l n0r . l Oi i sa al Ll Dct ci o( i l n. . ooi er LUl cl i ni c, pe l t n. qr i semnel C r , er f l be_
Iorlno, irprlt
f
i simptome tle hipertelsiune intrasraif:l,n[,, oi,re este insil r.aria_
D ir..cit- trrjnsrrilre_
$r
tnoment- de aparilie, in funolie tle rapiditatea tlez-
l.:,1]l:.ii]1119.li ]-l
de peltlr.bd,rile pe care.te.tletermiin. r,a c6pii ne gtndim
r u
l r r r r r ul
I i xr l l t ur r mcdul obl ast om, cr r . e do mul i e or . i t l e"but eai d nr i n
'
r . l . l ' . {' . vhr sal ur . i ( de ubi r . ei ! , aJi nal e. f i r A gr eat e
si f ar e ef or i ur i ai n
i , , i .
lcl, bolna,vului), tulburlri de echilibm qi ata;i& indsului (sindromul
&re-
I'r'l)N vclrr an), staz:i papila-r5, precoce, creryterea dimensiunilor
cutiei cra-
rt|(.nr'. r'll .te.h r$cenl|t suturilor pe
ladiografia
erania,n[ simpld,,
,rzgornot
rlr,,
'rrli,
spar1,5t, la cioc5,nirea craliului
;i
adesea atitucline
,,cireinonioasf,t
r r r ' : r p. r r hr i . i
r r gi t ul r r i r pr ecum si . , l i ze l oni cc t , , cor . ebcl l aL, f i t s; ' j .
n l i t r n t umor i l c cu l ocal j zar e emi sf er i ci
i gl i oame:
j ndeosebi
l st r o_
.ilrtrrrrr',;,.tuberc.lo_ante;
hemangioblastomul
ietino_cerebelos
sau boala
tru r trl r Hrppel ,l mtl au
f
.a.), ci t-$i i n cel e vermi ene, Bi mptomel c di n
l artea
rr.r viloi cmDieni, precum. si cele din partea marilor cdi senzitivo-r.riotorii
r r ( l l s( . t | 1, . .
l l r l chj t nL, . i n l umot
j l e
uug. hi r r l ui pont o_cer ebel os
ap: r
t r r r e_
'r)r,c
s{,rnnc cochleovestibrrlnrc
{per. YIIII, precufo si dc afectare a
irereihi_
l , r r ' \ '
- . j
VI I , ser r r uel e cel cbcl oase api r i u, i i nai t i r zi u.
ll. ,4.f ecti.tmile inf njioate ale
-
cerebelului :
,1)
.in, erotulm enr,eJalitelor de diverse origini, primitive
siu secund ,re,
irc'l() $a,u ct'onice, apar adesea.simptome
cerebeio-ase. Dxisti *nele situalii
rr
(1llrc,
loc:tllzalea-
pro_ces3lui infectios se face cu pre<lileclie i" c"rcb"t,
rr rr.t'si. cazu.i tabloul clinic fiind dominat sau fiiirl constit*it excxus#
rlr rr11 11i1;1111'11
g1'rebelos.
Pentru aceste cazuri se folosegte adesea l,errncnLtl
rlc urtbeli.ld,.
t' el t' br.l i tel r.
-si nt
rl e, fapL nemari te arul e i n.fecl i oase, eel rnai udesea
l ) t ' | l r r r ) r r '
( {l ar , f t seeundar e}, r ouni l e al t i dal r , s b l or mcnul ( 1, .
?. at ar i i
:r..rrr(." i rr(, l nl r-_,eyden.(
l j ecourt, 1922). Se pot i nti l ni i n cel e ma,i vari atc
i rrl or' ti i
{{r
l rrd 1 i l oi r Ii i ., d i fr t.ri e, ru.i co]-d , sr.&rl a i i ni . vari ohi . g;.i pi , pn.r,,,noj ",
r l r zr . I l r . t ] r . . \ 3t ! l - cel l . t usc convul si v5. di r "er qenevr ar i l p"i r ol i ce_cu: ur bu-
vi l trsrrl i rl tr pi l di l , encefal i tX epi demi ci )
;.a.
:! . AhceselE carebetdase sint relativ frocvente, ma,i ales in cazul abceselor
r.rrl i l l ctrl r' (otogene gi ri l ogene) care rl au i n 34% al i n caauri abcese cerebe-
r' ,i rHr, rn oel e oJogene
{Arseni
si col ab., I9Z4)
Fi
mai pul i n i n cazul abcesel o:r
nl (.rl nl i l tl cc. l )eDul ul subacut, cu sernne general e
hfeeti oase, cu di scret
lirrrlrrrrn d-e hipertensiune intracraniand, lf debut, dar cir aglavareit, pro_
gt'r'sir,ii,
lr,tlcsoa
ryi
cu semne mcnilgiene nc sugereazii, djagnosticul.
ii.
'l\tbereulonu,l cu, Iooali:ure enre.lalicd, aDalc mlri ales la conii si lrr
r r r Lr h *' r ' r r ( i . , l o. i r . l i zi r
' or r . . dr .
1. r . r . r l i h' c1i r .
l i j nr l r r x. mr r i i u c, i r , . t , el
; i i n- t f i i i , , . i , i , i i
.r' r' i !rr.i rr (A.s.l i i
ry.i
.rl rl r., 1074). l l ' rrhcrrcul oa.m.l o
cerebcl 0aFc r' (,al i z(,l l l zr' l
rr r.rrr' (' rrzr.i r.
si nrrTonr d$ hi pr.fl 0nFi uno i ntrtucrnni rmi i , sl ndrorn do fr r,rr
l ) oH
|
( ! r i {r r
r i r , i r r l ) i l r z, r l i r r cuzr r I i r l : r l r r r r nr r i i r r r i ! f ^ r l i , , r , r r zr r r i Fi r r dr r r r r r
180
I r , r r r l r | [ r H, i t t t l l f ot t t t l l . t t t l r ' t r r I t i t I I r r t I r
'
I i r , I i r
' ; l
i t t t t l ' ol i ; l i t t r l t r r t t t t l 0 l l l l gl l i
l l ( l l l l l l
r l t r r l r t ' l os' ( , \ t ' r i r ^t t i
1i
r r ol r t l t , I 1) ?' 1)
( l t ' t r r r
t r t r t ' xl ' t r t l l l t l ht l t l
l ' ( ' l l l t l l
t l i i t gr l r t $l r (
. r l . l ' i r I t , r i l ci r , i r r l r cr l ul or r , r i r r r k, ,
r i r r ! r r , r r l i zr r , r r r t , r , t r ' l r t l oi r si i t t t t r l r r l ot t t t i t t i r l r '
, r l r i r : r i i r r t r t l r ! . {r , t r t t l i l l o, l , i l , l l
gt j l l t r l ( l i l zi i t l r r l t t ' l i i t t t pkl l l Lt t
t l i st l t r ' l ' ( ) ( sl ' l l | t r st t l t
, ' r , r r l ; r , r r sl l t r i r i . . i sr ' i i i l cr t i t t gt r ' t t l l r i r ' , r : el l r l t ' r ' ) .
l ' . . l Jol i t ecl em' i al ' i ni zunLa( i , t t t l r t ost t ' st t l , at eu' mnl ' Li St l i ) t r r l t r t r zi t t i r i r r I t r t r
ri rrrri hr
(,l ro l czeazi r, ccl rrui tt' o0yorl L cetcbcl ul . Irrt i ntl i vi zi i l ,i l L(\fj '
l l l (12(' l rt' i r
rrrrri si utl torrt ccrebol os
()u oYol uti e l enti r, qi ml ,i Dl s$ ou pu$r)ul i i 1i tottti si
' i i i i
ri ,ti ,i i , l ;otrl e:r,una suspi ci unoa unci l euconovrui i tcr
l IIi Li rrl tts tl rt.rt' rt' '
' rxx,i u' z,i i ,
si si mptomel e ,,i i rami dal e Si
vesl j i bul a' rc" I!xi sti i i ttsri ,' l i tl trtt'
i ,,,,,t,,j i orr' "".1c' scl eroz,i
i nul ti pH, i n cnre sernnol c cori i rel oa,so l ){tL
(r,l l $l ,i
I u i rrruliril
yl'ttno
singllrele manifnstd,ri ciinice .
\1. Afeclittttile rasctdare a[e cerebelul,ui
l . l l enmagi o cerebel oasd' nu este chi al asa de r:*r' i r, cl l l rl sl t
(' l r' zl l l '
, i r rt.uri zenti n{i : de fapt 10-13% di n total ul hemomgi i l or
pti rl rrtr' (! i rrl ti r
,,.n bi al e tl tpl , uneJe sl l ti sti ci (McKi ssock,;i col ab., 1960;
(i orn' vi l l o) l {l ]' ;l l ;
\l i l ,di el l
1i ,i .ngri st,
1942). Ce]e mai mul te hcmoragi i ccrc' }{' ' l orl sc tl rl | rrrl
ol rsorvttte ttc P"opovi ci u qi col l b. (1980) i n zona de vascul al i ztl { i r I tt' l rl ' t' t' r' t
. , r ' r . l r l ol se t nLer o- supel t ol r ( .
Sr Do&t.r recunoaste tlulft debutul brusc, cu grcluri
fi
viirsil'tttt'i lrr
r , , . sl c 90V di n
( azur i , l cai c se l soci l zS, o t r i adi ' cat act cr i sf i cl r : : t t nr t t '
i , . ' . . t
ci oas"r i *"t n, pr "r l i r i , pr i Yi r i i i psi ht er al c
; i
p: r r al i zi c f aci l r l {
.
1x' t ' i f r '
,i,,ii."ifltt .,.1 .otrir' , rgf+), dup,i car-e se instale?zi. ttilburilri rtxpilnlot' ir'
"' rrsl' ind
in speci iri riiplr:r' 1ie peti' rtlicri (llc
- -tci
ssrrclt ri irolll' l)
'
tl)(illl
r , l , ' , r l r i cni ,
oumi l t l pi di i f t omai ) . i Rogpl . l $?5) .
$o nut tl i sti nge 5 ti puri al e i nstahre , si l l l ptomrl Lol ogi rl i i tr Itl trIot' IrI' .i IIr'
, , r,' l ,r l ,i i se (rl up.r- Schobl gi col nb., 1965
;
!' i sher
,si
col ab
,
l {){i i
I
Il tl xtv.tt' ttt'
l ' ,' rrtrci l ntl a
;i
-Pascu,
19801 : a) Ti pul
,rtumotal ",
cara' otcri zrtt
l tti tt
xttttl t
t,,rrr. t,c.ebel brso cu' ti cbuf l cri t s.i . pi ogresi r' , rtsoci l te cu l i rttrtttrt' tr. rl r'
i r i
txri
t orl si ul re i ntracrani and. b) Ti put
rrrmi ngi an",
-
c,.rri l ,utol i zi rl '
l tti tt
rtl r' r
ri l i rr, rrcui l , ]trul ,i l 1i r, a unni i ,tuarel Dr si rnptomt : cr,' f:l l ec, vl l t' tsi ' !trttti , st' ttrttt'
rr,.rri l ge:rl e. fcl ornene confuzi onal e, sl nptome ccre' hel otl sc sl l ' Ll ol fl l ' l )r' l rr-
, , , r i t , r i n. si 1. . ( . 1i . sr ugbi nol cnt . c) Ti pul i u aspoct dc si nel t r t m t l t ' 1t ' t t t r r ' l t i
, , . t : , ' t t t *f , ' i o- t t i *r t - , 1 , i t at . r ' u comi , pr uf r r ndi '
l ) t i pi l t '
r r r i r r l i c{" l i r t l r i t r shr
r,i i ,r1,<.r' a,1, hi pol ,ol i c
$i
tui buri l i motoi i i ml ri (c-rrL, rnrrsch(rl l zi l , tul l rrt' i i t' i l '
. r ' t r dr ol t ase' ; i r neni l i gi ene) . E\ i st [
l i
f ' t mr t
, ' l r t l t t t i r t r t t r l i "
( r l . sr r ' i si l ' r l "
t' l r,,ti as
;i
l i ogerr' , 1925
;i ' I(i nni er'
\fi l son,-Itl 5i )),-ctt ,i .u' l .r' t' i t'
l rttti rtl ' t :r
, orusti cLri ei si i .u b rnotrl e rapi dtr,).
(l )
Ti prrl cu debut mai puf i n gr!r\' ' t' rl
' ,
r ' l r i . r l nsi {. l t r i nt i l ,
ql r ' 2Li i , vi r si l l l l i ' ccf ul co vi ol ct r t i i , l ; t
'
r t t t ' ' r t st t l ' i r r zl
rl l r,i i ,,t l ,Lrl i ru: r-tI i tt. con;ti ,l 1' )i . er) {i pul
l n care dupd' o saurtn 1{tl i ol l (l rr
rl o rnm[," bol narrul i gi revi no, ' ^cuzi nd i n conl i nuatc rl tttct' i i tt I' t' gi ttttt' rr
, . , , gr i r LI i , gl r ] t ul i
"i
vi , r ' si t . r r r ' i l t t t i ui
ul es l i r schi r nl r i l i l " r l r .
. l t ozi l i c
r r l { r ' : t l r r l
r ' r r r
' . i
r umr ' i cl i ' r i ul ' r r t c. Obi t r ' 1i v t r i ' t t t ul t r gi r ' , sr ' p( r i r l , ( ' . {' \ ' i ' l ( ' t l t i i r l l t r l l i $l r r i l
,rrr, ,,r,i z.' .i ,1 (car,c tl rr,ci i , esi ,r uni l :.toral , i nrIi .ri sul i rtl Iozi l l ni i )
fi
tl l l l rr' l rrl
,l | rrl l i tr cor?b0l 0s fuOrnOIatOral . I)o l rtrtl to rl ti stt pttl ttc OVj dtrl Iti l l , i 1i rt.
Itrt
r r r r r r t r r l i i l 0r l ot r , I ( , r Lt coal i i , , t l r i cI r l I i r nl i r r l r l t , t t g[ , i : t t r l t i t r l l l i g( l l l l ol of ( ' {r l l l l r ( ' l ol l f i r '
:!. I:l tmal nnnrL cerl bAl j A
?rrrr0df
(,,spo l ,l tr
rt
i tr rkrn ttttt i t' (!i l , vo{' l l (' , rl l
, r r r ' , ^r ' 1r t At r . i ct t i
1i
col r b. , l t ) ?1) cst ( t
( l osl l r l r l o t ' r t t ( r t l t t t t r i t t t r t l i t l i l i ' i , '
' l i r ' , r r t I t ' i l ( '
t l r ' l t ot t t r l l , oi l t l t ( ' i t t t ' l l l ' 1t r t t ' r ' t t t l l i t t l r t l ' 0i t l r t r l t l i t l t r t t r ' )
i i ( '
l r l r i l l i
r l i gr Lr r sl , i r r r r
l ) t i l |
{l ol ) l t l l t l br , t t l r r l
( i r r l r l r r t r , l t , i t t ; Lt l r . )
r r t t ut r f i t l t ' t ' ot ' r , i I i l ul r l ,
vi r r ; ; I , t ur , i , vi , r . l i j , r ' i [ dcr o l i l , r : r 1,
gr i t r t r l t , r , . {hr nl l l t of l , i t t ( l l , r l r r ' r r
( ' i r l .
i t l r r ' r l i r r l
I rl7
(lrrrri
^(' ci(l.lr1'
(irL lirrlrr.r. irrtrtrN sil* rrupi, oiteva zile (in formere subacut.e)
. ir* lrr,lrrrzr' i, r, sindrorn neo- sa! paleo- cerebelos,' in fi;;1ri; ;;"I"' *ilj
ri rr' | i r I r( r I r i r r ' |
'
r r r r r I r r i
(Arseni
5i
co ru b. . r
g; 4
r. s' . po, t . ' ^*-cra sLaza oaD ar: i -
-ir,rrllorrrul do irilal,ie meningeali,. prr.cum
si ;-"; pir"*;;;i;ili--:;1;
| . , | | i r r . ( .
r
'
, I r r I
f r
so. r nD' . de t nt | r cl t i cer cbr al ( Ar scni
1i
col uh. , i 9Z4) . Exj st i ci
l:ll,' i:l; .' l,.llr::' n,^"_r' ,:,:,11 "rf"
e\irut run.in' e rapi.t. indnoseiri-;;iJ
";;' rJ;"' ,
:r|||l i i ri rr(,rul '
cercbel oase
] _
gaJ?
OcCi pi tal i ,. Al teori bol navul i gi "revi ne
, t l l r : l
' ) r '
r r . Ur n: r l oasi i
i ni l i : r l r . f r r i a pf ezet r Ll ,
Scmsc pr et m, r r i cer cbel oase.
' "r , r ' r
( . , ( l , r pi i
r . i r cva zi l e . A apar i i i emne de ni p". i "nJi , r ne
' i n; ; ; ; ; ^"; ; . i
rrltlii:iffi
T":rrt,il",f H:",1,f,i",":;ff :i*:F:lt-,""""Xi:?li"
jt",*]f;
r',r\'(tir'.rr u.ui hemal,om cerebelos. ri" ;;l; ;;i;;lti-"Jrr insl e'olufia
(' iri
r.rr- p.og' r' si' ii,.aspectul
crinic fiind asemi,ndtor cu cer al unei neo-
|
( , r ' l
l l l
i
I I
( , cl ' ( ' r ' el uJi a ( . . l Of
i n: t
l l SCU. l ut
U m, Jr al ; ! r r ) .
:1.
Eindtoamele iscltemice cerebeloase. Infarctele cerebeloase izolate.
lrrrl',
sint in general destul de rare, intmcr. se qtie cir,
"i..rfi,tir"."f"i"ilil
:r .r.rqbelului
ests relativ bogati. Astfel, ocluzia'a,r"berei cerel:eloase antero_
::l,il.l:ll::,..,"1i" 3,s.imqromalied,r
inrrucft infarcrele cerebeloa,"se produse
r , r r r ' r ' r r , r r ' r ut
, cest al l l 11er p
<i nt . mi , . i
si di spr , r st t e ( popovi ci u, pendef uncl : r ,
,i...]' ].1..]1.: ,11101:-it :9bl-lr,
ocluzia arrerei cexcb;rolLse anrero_supL,_
"r;rr(!
pfufluce, pe- linga, leziuni cerebel0ase la niyelul nucleukri dint-at.
il,J:,i,fil]:.Ji,l:y"I"t
J.9l"tt"ooit
ponto-meze.ncefa,lice
(popoviciu
si cod,t.j
r:'nrJ. rfdure sa nu_ urtam t:,ptur ci, reziuni burbare cu simne cei,ebeloase
,rrrri ,rr' \r, (.tl
mar Rdesea numero&Se si nal roame i schemi ce al e trunchi ul ui
'i'r'r1'll.NI
(sildromul
arterei cerebe_loase postero-inferioare
c* r,',iantele s:rlez
, . i , ' , "l l l ' . ' : ' l ' ]
l r l i r ' e' r an- | - b, ' nai s,
si nd| . or r r ul t ui sr bi n. t r i ' . r ' r g, nr t c,
- r ndl ' onr I t
] . i i l : , 1) . ] "' : "u l . . s1r n.
dj udr omut t r r i
pi , . r r r ,
I l ar i e. Foi r
hr r . . h<, mi pr r . , . z, r
, , r "- r , , . l o; , {, 1 .
- \ ' ezi cJp. l ) , i nt f t r - i r I nl r el gd
j l i gJl i .
i ,
. . r cl . ; o! ul r i i
e"t , .
. , \ r r r r - , Ul r {r , l , r t m u e cot . cbel o. r s| l ' j scui c Lt i o l t "uo( bi l t J
bazi l : r , . sc nLr i
'
rrrr's. r'irn.rismentere
cerebel0ase bilaterale trin trombozcre vertebrcr,
l ,rrzi l i rr(. (l )ol oyi ci u,
-pende{untl a si l ?ascu., fOSO; Scoti f fO6T a,, b).
l l .,:LtroJi i .l e cerebel oase
/. \r' si rrdi m l a o otro.fi e aercbpl oosd seaundord, s[n$)l omal i cd. t] nr(.
/ ' r r l . r . l l r l l l ur r c. i Lnr l r um ccl ebel os, car c s_a
j nsl : t l al
l a un- bol nar t i car e nLt
r I r '
1
r is I ii r r r,. rrl1. iiictul. et,iologic, dari la,care eviilenlieia in antecerlente un
r : r ' l | t | - t . t ocTl os. r oxl c.
l r aumat i c. r , l Scul ar , ct c. , po. i bi t gencf t t or
cI cor r _
: : , ) : i l ] I i l l l l ] "1?i - L( .
c. r . ouot os si , l : r i . i _Lr c. pr i n
j nvpst i gdl
i i Jo r . f or . t ur f o
1l ncn.
r.rr' .( { ri rl (rgtal l c, tomogral i e ari al { computexi zati ,l
s_a evi i l enl i at ;-trofi :}
l l l r ' l r l l ul ui .
:!.' l troJi i l e
cerebel oose pri tni Li l e :
.. ,,,.,::.).,,1,!.,f .!il:
-!t!:!il*yt
ered.o
famitiate
ne sint sugerate ite intervenlia,
'
\ r r {, . r r r , i r
, i r .
nnot l ?cl or i . gt nef i ci . As el . se sur pr i n. l e
car acl r r ul cr er i o.
r i | | r | | r i | | , ( l r , Dt
. ut i ] r ' c l oc
j 0
cnpi l dr i o Sau I n- adol escent i . cvol ut i a
bol i i er f e
|l'trl
Ploglcsir'5,,
iar in conteitul semirrlogie o,pal n*irf,rl.t
si alte elernente,
:.:l:.:ll f:::l-1,1:".,lglli
respTtil-e:-
.
pcta^la tui. frri,ed.rei,ck tmphcli' qi l;zi""i
1.,]'-1'l
,jl:,111
l?)r"froarc
$i
tulbur5,ri trofice.
_
Hredn_ataoi.a
.&pinacirebeloa,aA
t t l l t . t r t t r t ' e JA41L. d i t soe i r zi L
f
i
. {Cr nnr ,
pi Unt i dal e
Ji ,
cv{. nLur . l , i l emeul ( . l r nr i , , _
l r , l r ( ( . ( t nl r ) ( r i l f i L
l ur
(
hu| r , r , l .
.
I ) i si ner gi a oer ebel oasi i , mi oel oni ad u, l r t i
l.knnwy Hu,nt rk'.ltrttrlzii clt tlizc rlo r:$ik,psio ia,l .sindromul
cerobclor,
ill:,' ::,' 1:i, .,1". l":,1r
rlt,ir rrt,, s,, :riirxriirzi, qi oi rriioclonii t,"liizlt,, la urulrhii
r. r. r
f r
. r l r{ rrr)rr' k)r' rr-rr1x' r' i rri r' r. ,
I r' , ' r' rrrrr 1i
. u (l r. i r. r' i r, ri r. rrr
i nt . r' rrrrr. i r: rri
l | l 1, ] {r-f . rl vi f .
. t f . rol t a ot rl , od(Vt l t t l t nxd, u l t t i eof t ] on_t I t l i t t r, $ rl ri rt t l r. rrz, i
r 80
r l r r r r i i , vh' t r t r t , r l ( l i l {) t l t r l r r r i , i I r r
.
i , I r I I I r I r r | 0l i r r i r s0 f l t t ' r l t l l t t t i z| r t zi i
l t t i t r l t
r l l r l r l l r f ' '
si r r , l r or n t xr t t r bcl r t x ct t ovol t t {i o
l r l ogt t si vl l ,
I i i r l ' 1' scr t t l t t r t l t r l ( ' zi l l l l l i r : r l l r r l
l l t t t 01' ul i t t ct voi l N{r .
l t) Atro! i i La aerebri oase
(u
detsruLi n' i l m aonge' n' i l a' l si ttt;
.l tryrt
rl t' rt\' rrtrtl
,,rr1,,
l ri i n
pr6zen!a, unui funpo*ant si ndrom oel ebel os rr:rr' ni l t' sl rrl
i l r
l )ri l l rt
l ' '
L,,,i hup[tna-stei e, suferi nti , cere1,el oas:1 fi i nrl evi denl ; l cg,' 1i . rl L' i ttl ' trt
' t' It{i Ir
' , i i , i i
ni i n"a
pzr , l ot oei c su. ueni L i n t i nr pul vi el i i i nl r ar t l . r ' i t r r ' {: r r l
( i r I t r r r r r r r i
t,.s1l l ' ' c <l i scdbri opi azi c[. I)i versel e enti tSl l cl i ni cc se,
Iot
l ptctri rt'
l ttr.l trtzrt
rrrl cnsi t:i ti i su{eri -ntei cel ebel oase
gi
a semnel ol de i ndi ca.!' i c l czi onrtl i i ' l tt.p.'
"i'rii":r
'
'-
iptazia congenitald, toiald'; - herniaplazia cere-beloaslt'
i.
.
(tl'ln
li,r, n,eocerebelitasd' a lui.:Vogt
i
- attlaiia arhi- gi,
Ttaleoceretlloasd
l)ilrgtr,
'
l i rrtl osto faci l i tat de pneui noencefal ogl afi e,
pe rrtl i ografi i kl I' A i tt pozi ft'
.r,zi rrrl i ,
evi tl enl i i ndu-s6 spal i ul subtentor' 1al rrursi v l ;l gi t, rtct.rl tl i tt i trr.rl r'
irrrr. t'ealizlnr1 irno"eunii cu ce1 tlin ventriculii la;terali tttt its,tN:i rrrt'trr.
l .ri sti c de X. i n
fozi l i a
cu capul adi rnat, ael ul Se ac' rnul .^zr' i l trrl r.i i \' rl
li'sir posl,el:ioar"l, desemnind gradul tle ap-Iazie."
ti; Atrofi,ile cerobeloasa cu- apari'lie tard'iud sint' {:'\plesiir rrrr{'t'l)ri)('t
"
,' lriotmfice,' degenetativc, cu irrjtere,sa,ro cereboloasil r:leci:ii'i
-
l)ivtrtsllr'
r rr,r' i *rrte de atrSti i cerebei oase taraLi ve se pot i ncl i ' i durr.l i zl t 6cstttl rt. rl i l i r,i l .
rr,, l i aza vi rstei l a care debui eazi i , gi a extensi ei topogral i co rt l t' zi tttti l .' r
, u' rrrbel oase.
ANrofi a o:Li ,ao-ponto-earebel oasd, a l ui Ddj dri na^ Tftomns ti ratrr i tt
i trrrrl
r i'stei cl"e 50 rie
-ani,
realizinrl rlrr ll]Lr,r'o siirdrom cerellelox, t'll trvrtl.tr(ir'
l)rr,gfesirr6
(in cale predomin[ tu1bur5,rile de mers, ataria'
1i
1 f(nl] tl rii'l I l,l rl
i , rt;ri i i l i ona,td,;, l a ci re pe parcrus se avrci az5
_,1i
sttttti ttr ttxl ti tl ri l i tttti tl rtl ' ,
1,,r' cui l
qi
i i al eze
ocul brnotori i .si rrl e mi ;cl ri l or cottj ri gl i ,l ' t' rtl i r
gl ol rtl "t
, r ' l l l i t l l .
--- Atrofia cerebeloasd, ta,rd'i,td cu prellorninanld'
-@rticnlii
u' Lu'i I'ittr'
It (,ie-Ioifr:At04nrani,e apare mai tirzi' decit celelalte iti:t'fii .r.'t't'Irtr1'I r .
r,l rrrri i vi rsta d; 60-65 dd ani ), are evol u-ti e mai l eni i l , i ar i tt trtttrl ' r' rl ttl
'
r' i i ul osi c oreti omi n[ i n mod net (sau si nt crcl l l si Yl i ) i i t' l rtl r( l (
1' ,,Ir:ocei ebel 6ase:
tul buri tri i rnportante de s1,al i une
;i
tl c tttt' ts,
l ttl l trt' r
ri tutburd,ri de vorbire.
'
AtroJi a ol i tso-rubro-aercbel ousd' a l ui Lej onne' [i funn' tl i d i t1l :l l o ttt
.;rrrrrl
vi rsi ei "cl e 50 de ani , are evol ul i e l entri
9i
s. ui tl i r{j t(.r' i ztri tzrj , i tt
' ri tttttl
' i rrrl
pri n i mportanl l ati ,xi e a memb.-,' l or' ,. uu
r!:tl i tul br' i r' r' i i trl ' rrrr(i r' '
,,,,1,,
{i
o' ozi i j onal e,' l a c:l re se asoci azi l , gi mi ool oni i
(l Ltrooti
' i t' ttti tri r)
vr' 1"
l r,rLr,1i nei fal i ngol ar:i ngi enc, di afragml ti ce
ti
al e gl obi bl o(' l l l rtl ' i '
'
' Atrofi a' cerebeToatd d' i fuzd tr twi l l r6utoa :l ' pri ro l nai
(l {rvt(' rrr(' (l (' ( rl
, ,,l ,,l rr,l tc
(i nti e
40 si f' 0 l nj ), are o evol u{i e mai rnpi d; qi rc*l i z.i ,z}; l ttr tr l rt i r
y
. r r r , l t ot n ccr ol r cl os compl ' ' l ' l i r l hi ,
psl co-
1i
l cuc' ' r ' Li el ' r ' i - l r i l : r l ' ' l r l l ' l r r
'
r r '
r,r' rrsrtci azi ,
Si
semne extl api l l mi rl al o
(i trcJusi r'
(l urrt -rl l l )l l c(' )'
l t. Atuni i ,te carabel oase troai ca sa i rrl ,i l tcsc i n i l tori cl (,i * trl ,i l i tl i t, (rt,tl ttl i t
ri r,runici,) itr intoxica,liilo pt'ofesiori:r,1e crorLicc crt plgrnb
'1i
ttltlttttr,
ptr'trtlttt
,i
i ,' ,l ,tl sul tl atarncnl ,el or
-croni ctl
eu tl oze rntl i tl o hi tl l l (oi tl t'
(i l r sl l rvri rrl t'
l r , r r obr u' bi 1, *1, pr i r ni t l ont ,
5. , u.
l i . si ni l rowtcta acrubeLouga trawnatkl e si trl ; ttqol l l o tccuttosott1, I
i tti ttrl
r i r . i r r r r i t do f i t ot l r r r t l t r , t , r t r r t l l , l , i e, cr l l r l l ) r ' r r l l t ( xr
( ' r , l l l Zi i , l l r ' l r l ol t t gi i i l l t t t l t t ' t t t i t
. l ol ut c oot . ol , , r t l ousr , ,
( l t r r l , oxl , t i l sr , r r r i . l , r gi r '
( ' nt ' r
vr r t i r l t i l
t l t t l l r t , l t z l i t , t l ; t l r ' ,
t t t I t t l t of i o t l t t l r t t r t l l i zt t t t r l
1i
t ' : i l , ot t l i r t , l r r zi t t t t i l ot ' l l i l l ul l l l l ' i ( x"
l l , Ataoi tr, Ial tupi noht' z i od'
Joni l i ' d'
( honkt' ht' i I' r.nti + l l tt)
(xrrrsl ' i i ' rl i tl
: r xur . i r , r r , n, t t t r t t i si t r r l t ' i l t r r t t , t ' t , | , , ' i , , x l t t nt ol t r l i t '
l t r r r gt t r si t t t ,
l t t l t t t l l ' l t ' l t t t t gi t ' r '
180
l"i',i,;lliJ,ijii,.u':tili,oo"_T$'f;,lt
alo losuDrerrolor.
ttin jurul
_trasusu.rui
si
rn(. .rrt(,sorulu
' cr.csiv*]
*t
olo"-*;*ti"11?rlter
-famiiial
(cu tiansmisi
:::tl:l'lt:f
'"^iffi
fi l#xtrall,#ffi
t;:"#3"T'fi
li{.i:#-Hffi*
iij ijiHil F::::;,,"i,!"
t"*i tix'3;Hyt3:l#ff;
:"3lidl3i#5#ft
iii:.ilillii;i; Affi'#-1"Xt'#ignetizare"
a lui Dennv'nrowq;
dnexae ae
;J[Iiugsl$',1ffi1"a,i'fl r{iti'qT#{f
i:',"i.}}"x'ffiry**ili|I';
r 1);)t
i
srsor qi
cora).r.,, r;r;, F.ff"'fi
"ul,Ti;lh,t?3t;,.Fradis
ei
Botezi
F PROBLEME
DE DIAONOsrlc
lt't spl'ttot,,otitlt
O. MIscARILoR INVoLUNTARE
6.1. HIPERKINEZIILE
Sint migcx;ri involunta,re, rrariabils ca aopect sorniologic'
r,rr, topogufie
qi- ca eti6patogenie'
Majoritatea aoestora sint tle orlgittt'
oxtrapira,rnitlalS,.
6,1.1. Hi.nerkinezii
bruqte
;i
clonioo, fir[ dcplasdri sesmenl'ar'('.' xtllt
r.u deplasiri iegmonlare dd obieci limilatc'
l. Mioctoni' ila sint eontra,clii rrusculare involu-ntat' e,
(li)r
colllli(lllr'
r,.u*ia, J" iil clonie, arirmicc
5i
uneori rsincrone, alteo' i sittcrottr' 1i
nlttr.
rria"."ii-iiri" lr un' lascicul :nuscula. sru numai la un rnurochi
(c.vt' ttl ttttl
i,fri*t
""
mai mulLc
grupe muscutare). Sint asemlni' toare cu 0{)n1trt(tlllr'
ino..ri-u
ptoOrie di e^xcitegiite electticc
galva
.no-tarariice'
fntctt*itnlt' tr
iii"ii"" mt"'J""ii este foarte'variatril; tle 1a individ
_la
intlivitl
'i
tlo
.lrt'
iiir'^ia i" rr"ri;. u"ele sint discrete, cle micii, amplit.dine, f[r]l
'ir'i,rrrr
fr,l
il,, ,lellasare a segmenielor corpolale
lespeativcl pntinclu' sc oottiittttlrt r' tt
i;,-;i;;i;tiii; *ui-cutu"e. Altele; dimpotiivi, sint tttlgertrtoarc, :trn1tlt"
;i;;"r,;;r.i-;;r;lor"
-o,lu.nt)
s' egmcniet' corpornle respectivo $trtr
(' lrirrl
iiifii:*,ii
"J"p.
-eiirix
i
rnin6to# ritmiec, sfereolipc, conrinut'
(ttrirr' ll"
ii' ril"te;;
9i
mioctoiii mai a,tnple, care pot prod uco
(lorctl' ?o!:' j t' lottit' r'
musculare mai intense.
"
il;d cum ne fune dreptrr,te au remalcat Ga$ttuut fi
colab
"
(l97J)'
,*,naaoiii d'J,ffiucro"i"" a
'reprezentat
multd, vreme o. sut's[ dtt t'rt:r l'ttzit'
ii ,i"'!ir"tt*iirli. i"t*.oot ad
,,*ioelonio"
trobuie s{ fie utilizat ltt st'ttvttl
nf.
"*tii.l""ii-"ioei.,
udi"n s[, iniptice orice contraclic musoularf involtttt'
i'iiiii,"r'."i"ti,'"J-;o* I ot"tilit lictr, Muskens
(1928' cit{tt <lo Gastnut 4i
r:olab., 19?4; qi do Popoviciu
5i
oolab.' 19?0).
Contraotia'sourtd
iivoluntai{,
poato afecta, unul sart mni mulli rnu6chit
ri,, no'ptoauclna-nici o mlgcoro (ttoflnsare), otunci olntl ttcli()neftz[
!(r
lnn'l'
i,hi
mlioi,lle producind o rnirlcaro.
'
ln luuctio ritt tliatribulia lor splJio-tetnpwald, pot' Il dlsiinro doutl
u,"roi'orfiiirioiu {a iiiitoiti W"orotir'ote
t n)- mipolittii
Jragnrenlafe,
nlunel
;il{
"ft,ift;ti;Jnoron
ll nrjinotrlo vrriat'o'p&r!! nlo irtttroulntu'li coqro'
rnlg
i
b) at{oolond{ nncluo nrnr blla,tor|l.1o, rrlnerono
il
rlltlFttl(lo, 6n.f0 nl0olloutn
ill
. l l : : : i ] , 1
l "
r r i r i r l r . l . l r . I , gi u, r . r i , \ l i t r s{j qi ohi r r , r . i r r t t . cgr r l 0or ! . Accst o r l ( , l t i - i ,
i r l r r l I r , ( i , r r r ' ( ' r f ) r l r i g, . r Lr ' r ' : r l i zr r l , ( )
l r cbui o si l , f i c r t i st i nse i c i ni ocl oni , i l , e un. i _
tttttt.It\' l u4
l tutl l tl t I
(
i Lr' \) r' i rni ]I l OCal i zate l n o j Urni r,t*te
at cor?Ul Ui , SaU h
i ur s{' l l r i I ( r }t t o; por l l .
.lll::;f,l"ll]:..
"-:11f9!
fi impi,r!fte
fi
in:
3)
mioctonii sporadiee, aticit,
I ] ., ll':.ili_,ll'-r.Tlljj^u*,,
nesisrematizat5
I
b) mioctonii
,,pseuttoriknice,, ,
, , , 1. n. p| ur t t r r t t u, r nl Ft Ti r l l . r npi mul i i aU mai pul i r r
f i xe.
l)i\,pxLnct tle ,ed,ere cldnic, ruiocloniile pot f-i ciasificate tn umi,toarel
,11-{i,
.(ll: ;l^ _.i.il ].1!o,:,.Gr.h,lt, ii
r.otub... r"or.r
;.popovicru ;i colatr., Jgz2,
: . . . , r . , ) ,
, , ,
, l
, : l o' l l t cP
( t t t . uf ne
l !
. hi pni ct
)
t bJ pot ol ogi ae. car poI f i , l a r l nr l ul
t.t.' !,. i -. ttttn?rotl t' org.unt?e.ncppi l epl tcc, care pol , fi dc di vcrsi eti opatogeni i :
rl |r.r,r r,ri rsrj (encr.Il l i tc), to)i i ce, degenerati ve, metabol i ce
etc.
1
*_
m-i oc1o-
rrr ol gani cc epi l epti ce.
L) ,l[ ioclon iile orllani@ lnepileptricepot fi intilnite in nlmeroase afecliuni :
, !. .I!?r,y,i j ,e.
di ,,t enaeJtl i kr
epi Ll em;ct, (fort,o
tt,i ortoni cd
sau, atgo-
,,,,,' .,,,..,.,,,u,,ru
) l t
l ttL
ul tp tt,ptyo V[t? eunl rope Srnr l ,i rpi dc. ri fmi ce, Unebri
' r ,
i r L| | . r t o
r mpt e ( nu- d{' pl aser i
segr nent ar e) . Apur r l e obi cei i n coDl . cst ul
. . ' : l . l : , . i i r : l l - r l : i ! ,
t chr a. r adi cr r t at gi i . par e- l i zi i ouul a! . c. bi p( , r somni e ( sr r r
1. , , . 1: : l ] , "' , ] , i : : l or , n. ! 9
meni r geal e. sl i i i I i - c. ont u: zi ve.
chi ar cu evol ugi e sl r e
, , r r r r r ' . . r t . r r Ln{t t
f
t cr i al t e mc. ni l esl i r i r i
er t r a pi r a mi dal , .
l par ki nsoni eno
. . . l | r *l r i ) snr
do I ol i i t r Lo)
, si cer nbeJoasc,
(.lorcaa
electriad, a tu,i Dubiu i cste o formii, pari,ic'iari,
de nevraxitii,
'
r i ' r l , t r r ni ci . cr r r r r l ocl oni i ampJc. br usl e si r l pi t l "e.
, i l:: 1r,,,,:,*J1!i.tc,te-25!ygzonte
sub,:Utp
1r,eSS7
qi;n tpucoenaclat.ite.
t : \ t t "^. / t nt pst t t nr , , / . 1Ll _Js/ r l eLt pvanBogaer . t , r ni or , l oni i l esi nl mr ai t cr i __
, r , {. .
I j , r r ^nr i . . unool r r t oi r Lur i br l i st i el
) i m-
l l r r r ai or l i nr e ( r "bi r , r
hemi g, , n, . _
I I ' l l ] , -' :
gi l ! l , , i l i . rnl ", ,
i nsoi i r. r, rruoori
; i
de urrc i i pcri i nozi i
l i pi snrt .
] ' . 11,
j . , , ' , ,
r r un. t ut ur
. r
al e nr embi el o- r . . spasme , l e r ur si uu, . , bcr ui f r l i onr ,
r l | r . n. r r r (
t r r l l | c) . Apr t Lr
( . Opi i
\ i
l u t {l ol e\ Cent j , l Ll r _uu | Ot r r e: l r . l i ni n Cr r
. . 1' {. r ' r r , . i ' pl ' , gr CSr vi
l sl dr i i
. geUer l l e.
: r r l esca oA f cbr j .
( , u
, l {. nt eol i ch,
l , ' . , . , : i . : . l l ' , . ' , i , -, , I l , : i : : . I
pI , ' pl i r. e. l 1y, r1x_1; . esrc s, i bacurr. rnorl : rt i . rl upi t .
I i i r i r , . ' ! r r Lr
| o{: 1, . l t l r l l ) . }l j r i cr r ueckpr ( 1974r si _[ ' opot i r . ; Lr
- , i
, . , , 1Jb. ( t gi 6]
, ,
i , r r i , r r r i i l i .
1t 1i 1, t - ! 51, : l
t t i n
pESS
pr r . zr nr a
o . : , , . i n i t n, . r r , i n, , , r "
t t i t , , r , . nr , i at ^
r.
I.r
{r,. i r11r' .rrr1r,(l onl l ree.pi l epti ce
;i
epi l epl ,i ce: a) tarea reacti vi tate i a
r | | r , Ur . : i \ | l zt I . \ o- l c- 0zof t al r
; b) dur i l t a l n: l ' i l ung, r ) aJ, . "el Seci r Sel C nt i Ocl o_
r " r ' r r | l t U' r r j , t .
' t c
u cont . r a, . l , i ( . l oni cJ r ez; dur Li
l i
t l " hj per ki n, , zi i vr r | j r r _
l ri |, (rczi ri i l i i sus -, i nrl ecscbi cnrei ce)1c) l cpeti qi l pei otl i c:i
a rni ocl o_
rri l rl t,u i trt;crr:l l t' rLesi ,ul cl e regul .,l te (i ntre 1_' 1b ,""i oAa; d) pl ezenl a
1,,,rrt,h' \(,Lor' l ttr(+
al e hri R:l rl ei mecker, c:l ' e de cel .e mai *.i i i " Jri i "so,t"sc
' I , r ' | ' , t r i i ] r ' . .
. ' . , i r , l . c3
; i
nr i ocl 6ni i l c o r er nr r c: Li t i pel i ocl i ci r . , r , . .
,
. , . , . \ t , t ! t t t ! t t . L pt , t l t t
) t , ( r epr ' ozl oi a, n l ' or mJ. ol i go, j i r npl oni ut i ci de er r ccf a_
| | , r r , l ) t l . t l l ' l . a
s: | t
( {, ,
: l r J. nt t LUi t . i n ct r r e ml , cl oni i l e di r f r agl n*i i c{,
'
' . I | r . r i . , l : - L ; r t l r , , , 1. . sr r gl l ; t cl t dr r r 2l g 4a zi l . SNu
caDi . : t ni l i .
L I' ottl )Di u([ottusul
tt,ul ti ,pl en (al
.l ui
tl ri ,etl rei cl r, aparo l a adu11;i si
, crr lrrrl,clizr,lrz,i pril nioclonii sinctxice, frccvente
'(1,12
pe s), lotali_
r . , l ' l . t r l . , . l t . i Ui r p' - 2, dcl t ui r l , hj 4o! 5
; i
cvl dr i ceps. Se r cc, , Jl t l i ci l zr l i r
' r
, ) l | 1
l Lt
r l l r | : l l ( 1. , Ll . r j
j
Su l u] r r i , Si r r t de, r bi Ct . i l Or i nt , r . f i obS, . ( ni , \ i . r r _
' r r c) , I ' l , l ( ' r ) r , i r r , i r i i t . i r t r i l i L psi l ur pat i .
,.
W)
,)l i ,trl rtni i Ic
cl i l t1tt,i tu
l toi
Ii i n{,i l rri l c i tt ntnna,r.tasl
Jot
tttt: tl ,r:L:l rr.,.
1 l I l l l ( t ' ( l t l
l ) l ) l l t ) t Jt ) t :
l . , ' l l ut t t 1, : 1"
, r t i r x: l r t t t i t t t r
( . t . ' 1t . i r t pt i i r . r ' r r , i l , f f ur t , i t t r , r , r t n i r t ' ) r * t ' r r , r
, i
r r , r r : , r
,
i -
1, r ' i l r ; i [ ( l l l l
l ] l I r r ' 1
r l r , t r . r l i r | r r r , l i t r i r .
l r r
i t r S, r t , t t r i | r r I r I I I
.
r r I i r r r r r l t l l , i 1r r r r i 01I t ot t r r : .
| 9: l
( 1l l t o
l ) ol ,
l t t r l t t i i cl , t l i vt , t Hl usl t t r cl c, t l t r l t i i i t t l , ot t si l r r l r r r t , t 1i t . t i l i t t t l r r t t ' : t l t ct r sl t t t r t
( ( l i r , s{; r r r r l , , l l l l i l J, l l l l ; l l ;
( l r t r l , a, t r l , , , si
I }I r t t t gl t i ot t , l l ) 71JI I ' r t povi r r i t t
6i
ool t l r . ,
l l ) ?( i ; i l l t $si r ) . r t i , , si col r b. , J {Xi t }) : l t ) Mi ockr t r i i t t r Lt l i vo si t , t l gt r l t ot ' r r l . i zr t l t ' , ni t t
cl rxrt,, [l i l afi rt' rrk' , rl o obi coi si l ttol ,ri oo, l tl ttxrl i i trsi i , i tsi ttttrl ' ri co
5i
i tt l rl tsrtttl i i
(rrl i ,errri nd d.ol ao cri zri l a al ttr,, tl e o p:i rto srtu rtl tl l ttrrni oot' 1xrt' l l i 1). Artsl crr,
i t r l ;cl csoi l zi i , cu pl cczfi dero rl l uscul at ra axo-ti zornol i ci l l i i l nu;cl ri i l l rrri ol i '
yrl rxl rrci nd o brusci i fl exi e a capuhl i qi o proi cc{i c i rul i nt,tt i t, l r,(,l l bt' ,,l ,rt i t' t1r'
liorr:c, mult mai rar fiind intercsate
$i
membl'ele itdcrioilrtl (r.rtt ciitlctr').
lr) llioolonii parcelare, localizate la rnici srrgnrcnto oor?orfrlor sitll clt irtr t ttt t tr r i
lrr, r.numitc fascicule musculare (fil,ri tleplasi,ri segneDtir,ro).
Aceste rni ocl oni i i nsol esc o
pi erdere de cunoi i ti nl ,i l , (l tbsol tl ,i i ,), :l rrrl rr' k'
iilri)rnene (rniocloniilc qi a'bsenla) filntl cxtrem de scultc ca rltltrt,lit (ilrr lrr'
ril,cv:l zecirni dc seculdi, pini, la citeva secunde)
$i
pot sil, sur'\rirrir, firr Blxrll
l rrtt, fi e dnp5, unel e sti mul i ri senzcri al e i nsol i te (,rrcacl j tr s(tl l zo"ol ol ti ri i "
rr, hri l l usi rens). Un al t el ement semi ol ogi c i mpol l ,ant, csto trpl cz(rrl Lrrl ,
(l (l
rIcscii,rcarea electroencefa;1ogra{icd,
generalizati,, bilil,t{rrN,lir, Hi,)cr()111,
fi
pEf
t f MAL l \ 4I ACLO Nt C
! ' f 0. , 8, ARp(, (l t Ml (i dc Pf l t t Ml rl rl ri ocl onl c l copl l ul l l "NI " 4 nnl . sr
ob$(f rvl l dcsoi l r(r' l ri rl o
Jxt l l vl rl url ul l do
bi l i t t orl rl o, 6l t l ct ol l cf Si
, l l l l t 0l t i rl rl
(drt l I l ' . r/ nxrl . l r $l
coLrb, ' 1070).
ri t rrrd, t i 0i i , , rl o ut xl rr t ' rxrt ' t r[ : r, t rl , rr t rrrgf l l , i vo t l o l 0 o/ rrrrt l . , i zol l l t o nl l t t t t t ' l t t t t ' l , t t t l t r
rrt t i r, rkl ui l , ut I (l o l cn1, (\ t t l rgt l i vrr, cl r, t ' rr l t t r t I t l t t t , I t t I t I t t I l {)t ' t u! l i r(\ i l , zi i dot t t l t t t t
l r i r r : hr
out n, c' l ; t r r i r l , l co:
Jt ol l vl t f r r r l l o 4l
pol i vl l t - t t t r t l r r l o ( / i g' l 4' l / . l l l ' r r uvl t r [ ' r t
r r l r r sl , ot ' l t ol i vi t ' I t t nt l r r r r l l , r r vr r , r ' i r t Jt l l r l , t l r r l r r , l t r r l l l ' l l l r r , l t r r l i vi r l
1i
r l r r Ll ct l zi l
c5 - r 5
l (l N
t r t ct t zr i ( r l r . , i 3
^r ' i r l i , . ,
r l t , I t , , / nr , i , . , r l r r {i ( , , / r j ( , ( 1. ,
sr l l r l r r l 0 r . i scc. ) ( l \ r l r ovi r , i u
r r r l ol , r l r . ,
l 1) ?l i ) .
,
l l t r r . l r . t r i . ui sr . r ui r r l ogr l i t r ) j ) or t ant cBt e l cpt ezenl r at 11o ( l escei r ci r , t , ct
de
l ) r i r r r r r : r h. | | I I r i \ r . I i I I I | ' ; r l r r pl u
! o
. Ul I G, pot el l i l l l e
oar e t r a( i l . t c si t cus. i e mi ' _
I l ,,l ' ,,' ,
rrl r' u(i t l i tr.:rl c l rrrl ri I' ecrutan1,1i , I' esl ecti y, fi ecal e
,,vl rf' ,
t1c pt,
l ,l l ,l {,1
i i r
,rl rr)i f(' stti
pr,i ntr.o d.,soai rcare ntuscnl ri i l ri ocl oni c5' i Tassi l u,i ' ;i
t r l r r r r . ,
I l l ( i 1| ) .
,
' ..
(' ti ,:,
l " cpi l eTt.i re ti otl oni ce qenerrl i zate
bi ktter(Il .e ntttsi re (1| mgocl oni c
/,
/./i ,\
'
l rl .l ,' frni l i rrl ogi l r,
rrrrl u' i l or angl o-saxoni ) pot si l apa,*.i i tt tty.,t[rtc*rel e
r ttl tl rr!i cl i n i ut tl ti l e.pl i cr::
,;r
) i n l ,ncl ,. t' r' l ri rl p ,!.i l epsi e.l teti t
zral (rcl atate
antcri o].) i n o:,.r,e
: r ' , r r i '
' ' , , ( . t {' t u
sr nl
9, , , r *r ' r r Ji z: r t o, l l t pt Cal e j USt i f i Cl i
r . l et r r ni i l c: . r , t l e, , mi o_
r ' l r r t r i i t l l r sj t ' c) ) .
i r) i rr :rrul l c tl i n cazuri l c l c tpi l .c:psi i t:atrLtl si ,tL
11rrLnd,-ntu[. 1tr-i uvtt,
! , l
t , ' t , r ! ; | t . | , 1, , t , i . t . , . , . | ot , . i , ,
Jr Ot
si . j r l ) . . | r . i r r spr , , . ' 1, 1 I t , r 1, . [ 1; 1 1; y f i i z, i , i r , ; r i ul , l
r : r / 1 r t ( , r r , ( . , r r u, r r ' l , r t i t r usi . e, de. obi cei i n f l e, r i r : , Ast f el , t i upi [ i l r sdaut , si
l r r l r l r . ( l l t 7' 1) o t t ' ei r r r c r l i r r bohr ar i i r . r 1 ct i zr . t L, j l i uLr cl uni ce pl t zi nt i l si nr i i i _
'
l . t r i r t r r ' r si r r . I ' i l ; , t or . , l ,
i t r , . r r r t , . r l ul , r , i zr . l ' r . r . , ! r l \ ' l \ i \ r . f , , , , , . "' . ] , r i , i , ".
' 1. , , r / , , i
r l l | i . t i i l
( 19: , 7r . ( , i l at i , l .
Cr . t i r . ut Si col ul r . . l ! ] 71
j , t r
, nsi . l : , t r ,
, , 1] t . l
I I I i | \ ' | , ) I I I I I . | | hl l : r l , t . t 1, . t r st \ t s
- ci
: r t t r l i l i z: r t l o n| l I i l l d{. . . i t r l l , | t l , i \ . . , p; l i t
r| | ,rl ' )
l ).,
1nl trri ocl oni i l i ] care apftr fi . c] uni . fc1l otl l rn rpi l cpti i c (109, di n
. rz.rr' i l , f i o p' ecoti ri
.(50.0/o
di n c:rzuri ), fi e
' rmeazi ,
(3?f/o), I-i e si i t
(i ;l co_
r r l {, l t 1o
ol t 0r i zel e t oni co- cl onr ce.
,.) Ii .,i ;.i i i , qi cl zuri de cpi l epsi i mani fesl ,:l te pri n
cri :e et:cl usi .u nti o-
,' /,,rrr,1
. ;1;.,,;1,,1"..i rr sl eci Ll i n adol escen_ti
_(dar.
untori si i n mi ca copi l i r.i e),
l r , r i
' ,
rrri r,(l ,rni i 1c m.rsi re se produc rl e obi cei 1a trezi i c
.si ti ot t,i l i ci l i t-l te
l r . , l ' , l r
l i . i ' l r . t 1' . . r ocl r j l ui . . I i c t l n depr i vr l or d. o: r ml . t , r r r ni i Lr , , 1n r vi , mi o.
,l orri i T,. (".j r.r' l i s")
p,rt fi pr ur.oc:l ,tc de sti rnul arerr, l urni noa,sl i nti rrmi tcnt.),
i l i r r ' 1, f , r r r l , si cql f . i l ,
:
- 19i 2
;
G, r st aut
; i
cot ab. , 19?4; Ar seni
; i
col r r b. , 1O?8) ,
r' rr Ir rIl ,,,i l rtt, l ent:r,l ,l C rl zel e S-o1arc, de l umi na de tCl eYi zOr, rl e
,,Urmri ri l
r1 ,",\ i zI
rl .' L (J.' rerr
i i rg epi l el sy,' ) s1u do sti mul i i rten,ti onai i
l pi i ml .r:rrea
r.rprrl i ..:r rrri i ri i i i n fi rf:r, u,.hi l ur, sti mul a,rea l umi noesti sl ,r6boscopi i i ,i . Foi ,o-
i r, rrri l ri l i i l t,i ei r i r,ccsl ,Or desc:i ' ci ri este bi ne cui Loscttri (Gastaui
si ' col ab.,
t : ) ; t . ; \ r r . ' . r , i . r . j cuhJr . . 10; b; Naquet si Wekl r ui n, 19?2) . Acest e mi ocl o_
"
, r.rt
,t' rt,rl .r' :rl e ' i
si rl ctr.j ce, uneorl l i l ri tate cl oar ]a rtru.cchi i peri ol ,bi tui
,rr
pr rl pr.l r,;rl i , da. rte' bi cei si nt di frue, debuti ntl pe rnrrschi i axr,r_r:i zome]i ci
r1r rrl rrri crl ,i nzi nrl u
se qi pe tnu;chi i peri teri ci . l l i ocl oni i l e masi rre pot
l vei l
l 11!,\' (' rl 4r
r' -i i l i l bi i o (rl e obi cci 1-n/s1 si aprr rn ,,el i su.tde mi ocl oni ce)'
l r r r l r i r ' , r l l r ( l o
2- I 0 s, dar un, r Jr i si r n , , sf r t i i s mi or l bni c, . cu Cnl r r , t i t 1e
trri rrr1r.
..
Ul | hi :rt rl ' - o| e, puti ni t cui rni na.i ntr-o cri zi i Ee]reri i l i z?1ti toni c<t_
, 1, ' r , r ' . r . l r r r r i zr ' ' , nt i u. l Oni , ' ^, U, l l l : r l i r / r , i I . r Lgr . pol . , i
i 1l , r i . r . i r : , , ", , . i ; i
:r1,, rl ri l i i .i l c vi gi l cnfi , i nsol ri te
fi
rl e tul bncr-r,ri r-l getrti r.v. l )i Jgnosti cul
i . i 11r' r' {,r' i z. epi l .pti ce ci t mi ocl Dni i masi ve este con{i rmat
,*i
p.i ri i t*,esl i -
rl rrl i i l r, l rl tl (i , cu,ro c\-i {1 efri ;i azl pcl i r.i rf u;:i -Inde (s:r,u ungo' i r,!rf-ur[l e si
trrl rrrl i , l l csoi l r' l i ri (1o
undo l entr, eel el al i zetc, i ti l ,,tr-rral l ., si .rrtrrrn. ;i
l r i t r r l l t i l . c.
l l l i , t l , Ui t r : t cr . sl ot ' i r t , j z, " r I ) i i )
(
I I ( ) I I
j
( j ( | r l i , i r nl t l i zr t . t l
j i t asi \ ' ( r
eS1r , r . l t r . i t r l r i l i ,
l r r r l i r r r l
si i , r r l l ni i r r t ncqf ul . i t r , t , nr ' ql l t . l ot c t , t , . ,
l i
r ndogut r : si 4n ut cr ] i l t t l t t t l i i
t t t i r xl t ui . t t r ' t t . t r l t t ! i . . r ' . r r y' r , r i ( r r r i . r . l r r r r x' Di 1r
l i si r r , l l r r gr r ' si vi
I r r r r r i l i r r l i i l l , r r
l r , r r l r r l r r i l l r r vr i l i <' l r l I r I I I I I I I ) r ) t 1l
;
r l i si t r i , r gi r r c. I . I r r , I , I r I I l i t r r i . r , I ' r r i . i i : r l t t i
l i r t r r r . r r l l l ur r l ) .
t ! ) , 1
ti
tl
t l
lt
t l t l ' l ' i l t
l r t t t
l t i l r l , , t t i r r r
l t t ' r \ l r t . t i r r r . l r t nr i l i r r l , r
( l xt t l r l r r i l t r l l , n : r r t t
I t , ul t r
l r t i l t nt , r r i , l t l l , t t ur l l xt r r t ) i l r .
l , l | l l ( ' 11, ( , I r r r j t sl {, ; l r , i r r
r . I r | I r r . ( r ' r ' r r I l l r r r r i l i . r l ,
l r l r ' !
t r r
. r i
l r l i t r
l l i r r r i r r cl r r si r , i i : r . I i l r ' l r si r ' . r r r i r r l j or r i r , r i r l r . r r r ur l i i , cr r r r i r l i r r r r l
l r t t t i t t : r l . l l n: r l r l r l r r r l c i r r l r r r l l ) l l l l t r r i ( cl i i l l i r r l r l r , vi r sl i i
( r r r I i r r r , r r r I o: r I r .
, l t r r r , r r , , "i i , . r i ) 1i l r l l o r l r r l l t l . i r , r l i r ! I {l l l . l i ( i u o r r r cr l i r . r l r . ; t r sr . t r r r i ( Vr r . t r l l r . . i
, ( ,
I
r i r
' I I I I l r , | | , l 1) 7. 1
) . I l i l r t , l i t r , t ' Ol ol r zi i r r r r I l t i r r L l l o I i t zr ' : p| i r r r r I l t zr i
( ' f l l r | ( ' r . ] t
, r r . Dr r , . r l si i l l l t r , l l i l i . pl , i cf gor r r ' r ' r t l i zr t , i r . . l t r l i t zr t r r . t l r r r t r t , sr r l I l : t r r gi i ,
1i
r r r i or ' l , r
r t t | , r ' r 1l t , si l l j i pi l l l r i oo, l Lsi r r t cl l i sc, l l si r t gt l t Lq, t ' r upi r l c; i vl l r . i i l l ) i l ( j ( i r r i i r r r p
r t t r l , t r si i r t i r , ) . r \ ccst c r ni ocl i t ni i po1, I i 1l , t I ' f i l r , l c si r , r r gut r r r , i l l i z: r l r . Sl r l i i l r . t l r ,
, I r ' r ' I i l r t I r r t r i or , kr r r i i l l ' si nt l r pr \ r zont r l , l c r [ c r nr r 5ol Li i nnr t ' r i l or ' 1i l r i r r l , nr l r r t
l L, r ' I i I i I i ' I i ( ) I I I {, . l ) col r i cr ei , r l osi t i l r ' ci i , r ' i l cr l i ocl ot r i t t nt t soi r r sol cst r l r ' ; t i r , t r l , ' t , r r
, t t t t or l i r r {r ' i
si si r r l i l mpl i l i cr r l ( r al c nl i s( f i r f i l ( r i nt en{i or Ll r l c. l ) i r r i nl l r r r l
r l t : p u i r i r {) r r ) t ) . - ht c1r s1l uvgl u1, , i oi l . r ol i i sg l r , si st i i , t ol r l sl , r l p l t r o r l cr r r r , r r {r
'
r ' r '
l ) r 1\ qr ' ( , si Yr i , . i t r f i i z1I r kt l l r i l , f i l , Si n 1, cnui l l : l l po1. t pi i | c: l
l i
s0t t | l l i r r . r l | r r pi t : r
r r r t r l r r l l r i r r r Lcor i si t ul buvi r i cer r ebel ol r , sc,
r' 1 ))i :ti trcryti rL tn' tel otsri mi .ocl oni ci i (o, LuI l l tnr,su.y ,l /rrri l ) rr.
l rrrrr
1,,
r , r r t , , r r sl ; c pr i r L cr r ) bext ul ser ni ol ogi o ci t l g l , s0ci : r zi r , i r npr ) t l i l l ( f l | t i i ) r ' l o| l i l
i , u i r r ( xJl l , r [ : r n) i t t l t , nl i ot r r Ll r r , ) , cr i ze o] ) i l t ' pi i i cLf cor r r . ul si r . i r gcr r . l i r l i zr l r ,
1
,i ,rfi
rr l ri {)cLoi ri cc i nl si ve)
;i
l n si nr.l rom atol cbol os crr cr.ol rrl i o pl ogl r.rri r;r
l l l i r i r , r ' t r r ! i 1( {, 1, t t ) i . 1) . I n r ni l i ot i t al , ci t c, t zl t r i l or , S. L, . I . i r i r l r r cr , i r r r
1
r r r r I r r r r I ,
,
r I r
'
. r , r r i
'
r ' r r t i rri or:l oni ce
fi
descri roi rl i l l i l (l t1o pol i v' i l fut i - rl l (l {r rl rr i l 1"' r' i r
r l r r l r ' r r i si : r r r t c do 1i l i sccnndc ( I i nr l cr . mecl i cr , , 19?4
I
l l l , si r r r r l i
; i
l ol r r l , ,
l l r r ' l ) .
ti fn t n t+:.fakryt ctti u,
' ni ocl otti ci i
cu, l ti .1t xr,r i L' rn. i c (It.1l .L.l l .) (funl r l rt t
l l ,
' i 7
i rrl i l ni i rr (l e
l r,sel nener] rni ocl oni i , i i {l osoa rnl t,si \.1-, ("i rtl ,ssi vo rrrr' ,,, l ,r
rrr j i rl i s' r). r\i l t,l cl , 11r orzul .i l e i n caro sp:.ts]Il ol e i nt0r,esol r,zl i ]' l l Ll ,oi l {"ti tr l rrr.
l r r I r t : i r , ! r ' i r t t i , so r cl l i zer zi l i t spcct ul do l ni ocl ol r i i mr ) si r . . t l , 0r r l kr r i r r or r pr r l r t t
1, , 1r
pl , i r r . L {' l exi t nr er r l i ' cl or snpr r i oi t l c; i cu l i l c- xi n nr cr r i bl cl ol i r r l i , r ' i , r : r l r . ,
r , . 1
r 1111' 111- 5, . ,
i r r l r r sr r nl r ht : i t i t udi noa
, , 1[ t , u1ui
i n Lr Not ] ' ,
( xl ] ] l ] i l r l , i l i r , r l
, , t t r I i i r I r r t l r l
unr Li bl i ei : r r , g' ) ( t i asl , r , ut
; i
col : l b. , 19i i - l ) . l hoi , spi l , sr ui . l o i r l ,
r' rr' r,,i i
{l r)i l ,r' rnuscuLl tur' :l Lr' utchi ul ui
;i
a l l i di rci rti i rrrornl )i ' cl or' , fl (' r' ,,rl l
j : r zi 1
r pr r snt i l l i l r i ] - l i zomoj i {t , c&r ' e i l , 1, , sr . . r s! r I i 1t l ' f l r 1i : r zr i ' , r t gr t ' r t r l i r l r r r r r . r l r . l , '
, r i zl t r Li r ; i r l ol Li cr r r i usi ye ( r ' r nI ' ocl oni c j er ks") . ( l ol
nl l i I i r r cr , cr r l
1i
r r r r i r . r Lr r l
1, r r . l i ( , Li } de spasr n ( pi l t cgt t ol r i or Li c pcn1, r 1r l ) oi r l i l l r r i \ \ r csl
) ( \ si {l
f , l ) i r , r r l l
I ' . ' , i , ' ( T1) ( ) / o di n ci i zl r i t l upr i , Jcovons si i ] or vcr ' , l l ) ?4, r i t i l r ) / , r l r r pi i I ' op r r i
, r r r , i i ur l r l ; . r 1l i 7( j ) , i i t r r e const i i i r r l . r ' l l l l sl ) i l sr r ) r I r i I ) ( | I r ) r I i
( I ( J' l r \ o( l or r ( '
t ,
r l .
/
l ) r ' l i su, soul t , f ul gcr i i | n, ' , got or i [ l i zl [ 1, , r u I I o: . i r , gi i r r l r r i , r r . l l t r t r r ' l r i l
l r t r . i r r t t r t r t l r t ' t r l ol i t t l et ' i o: t t or i n
yr t r nt ,
ct r l l l i t . l t kr si r r 1, l t l t t t r r , l r i r r i r r r r l , r r r r r r
r r r l r l l ' , r j i r t t l t [ g r l t r t i r . i r , si t l 6t t t t t ni t ' r . l r , r l r r sl l r sr r t
, , S: t l r r . t t r t "
sl u , )
I I I r | | { r r ] , r ' , I
t r t 1, l ", i t t l nr ci l l r , nsl r nbl ul pozi l , i ol r l i , l s{r i l r r r i l l l i i cu sal ut r r l or i cr r l r r l , , f {r r l r r r r r r ".
\ l r r t t i i i r r , r , ccsi r ot l t t l t r i l osl , l i l ' i l i l sLr gr l r ( i r r
l r t ' i i i r ul
i r , r r r l r r r i t r l i i ) , t r . i r r t
i l ul r
l ) si l i onr ol i or i c ; r i
i r sl t ccl ul I i l t ) ( i cl , r ' i i t l , el i si , i o ( , , l r i psi r l i l nr i r r " r i ; r r r
, , r l i r l i l t r i r l ur r f i t nl , j ot ' i " -
( i i l r l l s
si coi u1. r . , l l ) 54;
( i asl r r r r r l ,
1i
l t r , t r r ot r r l ,
l 1l , ) i j ) 1l i l ) i r l i l , zi , i l l r n{) r l ( l i l i ' r l i agt t l ) sl , i ( 1r t l .
l l .
t l l
i ot i l ui i l t f opr r r zi nl r i , o
yr r , t i ol r r r l , o
r l o r ni 0ol or t i i ,
( , l r
t l l ur I r
1r ; r , r ' l
r r l r l
l r r r l r l t ; r r t r r i r r l ogi t r , i l sor r sr r l ci si r r l r ' j l l r r i r r r r ,
1
r , r r r r I r r I r r , r ' r
' ,
r , i t r r t t r t r r ' ,
r l t t t , r , l r r 1, .
, r r I
' '
; 1 r I 1
1
I I i | , 1 1
r
I i 1 1 , r r , q. r l i i , , s1, r , r ' r r ol , i ; ) 1. l r l \ r i v( f l r l : r r r l r , s1, r r r , r , t r sl l r l i l i . r ' i i i i r l , r l r r
l | 1r r ' : i r , | | l l , l l I . i l r ' r
j l 0
r i l l 0l ) ost r i l r r {i i , / r r r i r r , r l r r ' , i r r g, . r r r . r ' t r , l , r ' i i t r t i t r
'
, , ' , r r r
r l r r I i I r r , , r ' l r r . i l r r r l t l r t , ,
; t . t si r r l i t t t l
r r r , l t r Lr , i : r ' l r ' : l r , r l i i r r l Lt t : t t t l $r ) r l l l l l l
( l r r | a r , r , i r l
. t i
| r r l r l r . , l l l l i f l
;
Sr r l t l ' r ' t i r ' , l 1) {i i ;
l ' r r 1r r Vi i r i t t
1i
r r ol r t , l r . , 11, i i l ) . Ar ' ( , r l ' \
r r r i , r r ' l r i r l i l i I r r r i l r ' ( t r r i r r l i I r r t i r ) i t r l , r r t ' r r t l r z r t l r r ol r i r r r r i
i i l
t l ) r l l r t t r . t t l r r t r . t r , l r l , i r
Lr
l 115
r ' ( , r l r l r H( .
5i
p' ef i ' r ' cr r ( i : r k, :
r r r r r r ychi i r Jl ul ui p: r l : r l ul ui ( , . ni st i ) Sr r
r ur , . ' , l \ i i l l r _
I r r i ) . , l i I ; r l i ngt ' l ui , h. r i ng( . l ui , ai pl an; cul ui 6ucal , ai t i mUi i
1cu
mi sl i r i i r l l ct r
rrrrl ,r' rl rt pr.ri ccl i c - retracti e), ai gl .oi ri l or ocul ari (cu
,,ni stagmus' , ocul ar
l)r.rrtltrLr,
girstor sau retractor)r_ ridicdtorii pleoapelor, rliafragrnul (cu
sr r gl r i 0, r r r u. . r . hi i i nr er cosbal i , mui cbi i gi t ul ui si ; usct i i i di i l at i r i r ncmbr cl or
j . l | l ] r . r ' i r nr r c
( cu- mi i ci r i al e degel el or qi cu
_mi gel r i
al t emant e r i o
l r r onal i e-
rrrpirrir,{ie). Cele rnai frecvente
-sint_
miocloniilo (mioritmiile)
or'ofa,rin!1o-
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"atoare peltru
a.[u,;!,i,wni ale_triunghiului oliao-dentorubria (&uillaln si Mollaret, 19Bb; Bon_
(l uol l o,
1968i Gastau-t, 1968;
4l aj ouani ne
qi col ab., 19b6;
popovi ci u
qi
colt,b., 1973) prin leziuni
yasculare,
ercefatitice, tumorale siu tiaumatici.
..
Ill.
.Miokinlile.
s.au
Jascicu,l.aliile
musculare sint contraclii musculare
l ,ri i ( i (:l i l i rre. dc,mi ci arnpl i tudi ne. eare nu produc depl asi ri 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
^lirccvente
qi neregulate. Aceste fasciculatii' apar uneori pe teritorii
rrruffi11s1, alteori pe grupo musculare intinse, chiai gc nelrallzaie. Sint net
rrurrrntuate de 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.
.
V ulo-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-croniee gteri
-
oru.ionala (sclerozd, lateral* a,miotroficf
;
poliomielite
subacuts qi croiice;
r.nr.cl l opol i omi cl i to l i roti ce subacute
9i
croni co - Dr[El noscu
si Otteanu.
M56 ;
gi 1i ng66i 6l
i e).. So i gpune mul td atenl i e i n si ndi oamel o de pseucl o-
nr.l crozl l ateral S, ami otrofi cd (Barrd gi Roger, ci l a!i do Ei ser, 1952) pri n
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' i z,' l or j acktoni ene
odenteazi de obi cei di agnosti cul .
_
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 aero-
rlirrioi, t,rrlburd,ri trofice qi sudoralo qi eveutual tulburari do somn,
.
.fr'usc.iculalii_ musculare.
izoJate
la nivelul mugchilcr felei pot fi obser-
v rr,l;c in sptasmul
facial
peri.feri.c paslp6ral,iti.c.
".
INncep!,ional,d,a ra,r. pot ti intilnito Jasciculafiilo musculare ln potira-
rliut.l.on.earitre qi in unele p olin etri,te inJeclioase
fi
tasi.cs.
,
J,l..ri,std, uneori-fasciculalrii izolate_la basedowieni, la i:rdivizii surmena_ti
5i
rrntxrri dupd, o obosealS, musculard, intensfl la indivizii normali {miokimiile
l r r i {' r r r t ' ho1) .
{i,1.!. ll{igctrri involuntare alternatile, regulate, rilmiec
;i
stereotipo
. .' l ' rr
ut or_ul .r' a1l r ozi nti r, o-m;$care i nvol uutar; rapi di , sf orcol i pi t, rIc i rtcn-
si l i r l c vi Ll i r r i l i , pr cr l o Li ni nr l l a ni vcl ui c- xt r emi t i r l i l or . Sc i mpune i l i l cr cn_
I
i(rr(rir, lrrrnll,toil,rcktt'
,formo
semiologice
fi,
pa,l,ogenice :
.1. lltrentlLrdlura ila posturiL. (a,ry1,-zisi1,
,,do
lcp&us" -- lolmon vechi,
tl rv:0trrx.l l rttrzri l trr' ) 0sl .o t.l trtl tl t,or.i Hl i (i r' 1,
l xtnt,t.u
si rxl rotrrtrl rrxl rl rfrj t,tr,rni rl l ri
'|
t0
I r t 1t l I I ot r i r r o l r i l xr Jr i r r r , l , i c ( ; l l r r l i i r r sor r i l r , l r ) r l r r r l i vcr sr r r r l , i opl r l ogr r r i i ( posl or r cr ,
l r r l i l i c, r r i r I ' ur r r I I r l ' , posl , l nt r r r r ur l i c, st r r r i l r r l , c. ) . Al r i r , r ' o l t r r r r I
'
r r ( i r I r
,
r ' r
,
I l , l l r or
l r r
r zi ( i i ( i t t r t l t t si v i r r
l r ozi {i l t
t i r : t t r l t i t us) , csl c t i l t r r i t r i r r r l o I r r r r 1r I i Lt r t I i t r r r r t t or I ( , t r Ll , i ' h,
r l l I t r ' r l . r , r r ( i i , r r r i r : i i , ( J l {) osci l r , {i i / sr , c. ) , r ' oi , r ' or nt ' l i t : i
; i l l r t , r l r l ogr . sl , r r r r l i ,
( i r r r i l i l ,
r r r r r r r r r i l c: r t r ( , i t t t r i ; dc l r ut ni i r ar , c n l t ar r i l ot . , t l o, , f l r , r , r r r , , i r ,
l r i l r r | . l or ' ,
r l r r l l r , l r r r r r
: r l ol r ci cr r r l ogel , cl c ci . c. ) , di l r i t r r r ol ut i , sl nr cl i spl r ci r r cr r l st r l . r r r i qr , l ' i , r . i l r r t . l r ql i vr , ,
l i rrl rursi l i ci i l a cmof,i i qi tl i sparc i n somrr. l )c rnl l l i ,o ori i rrl rrrrrscl zi , rri
, rl rcrrri l i r,t;o:r, ccfal i ci (rni scIl i
,,tl c
afi nna,r' cr) sau
,,rl o
rrcgrr,{i rr,)).
:!. ' l ' te n.ul r\I,ul a i ntenl i onal i i , (d,e a<:! tn,nt) ap:rrc i l si rxl rorrl rl rrr,rr,l x,krrr
i rr l i rrrpnl ni scl i t.i l or acl ,i rj er, :r,oceri tni rl l u-sc' progrusi v otl ai ri rrrr rl czl ol l rrr,r,l
rrri r.r' i i l i i (ovcrrtual tl ori ,r l rr, sl h.qi tul rni qci ri i ). Il stu rnai arnl l i ' l dtci l , l rr,rl trr.rr
l rl r
Jl rr' )r
i nsoni tr,n[, rrereg' ul atd,, rl i sparc compl et i n reparrs qi Irr rrrt,rr{i rrorr.i r
rrrrr.i
1rostul i .
Se i nsr:feste de al to sernne corebcl ol se.
:i.. Tr.enlurdlura optoz,l]ion alii este tot o trcmn.rii,turir ilc rr,o[irrrrc, rupi
l rrrl l u sfi rqi tul uri qcri ri l or acti vc, da.r' esbe consti l ui tl r)i n osci Ll (i i l i rrrr.l rr
rrIrl ,l r, (i i r
ni ste,,bi i t{i ,, dea,ri p:i , ca?e ti nd si i i ndepl i drczo rrrfl u[)nl l l r,nprxrti v
l rl rr obi cci supcri or) dc
l i nti i
(de unde tennenul tl c
,,oyrozi {i ortal i ' i ,"
nrru rl t
,,i rc1i u1ro antagoni stL"). Este ca,racteri sti czi pentm si ntl roa,l rokr rl crrt,o
rrrl r.t' i tro dc, di verse eti opatogeni i qi pentru degenerescctl l el o hel l l l ,o 0o|rr
l rl rrl ' (l i oal a l ui \l ri l son qi pseutl oscl roza l ui Wcstphal -stl i i mpt,l l ), rrsor,i
I r r I u sc a,f)roape l,otdeauna si do miqciri de tip coreic qi de spa srirc v iololr 1,r,.
,1..
i l ' r.emurd,ttui l e permanl nte 86 obscrri ,;ti t i n rdpaus,-ci l ,
6i
l l
(i rtrprrt
r r rl r r
{i
rcrii r:nor postuii qi constau ln oscil{ii neregulatd ale ilegrt'ck.rr ( u lrooli
' ,r
:rl r. l ruzel ot) de mi ci rmpl i tucl i nc. Pot fi :
.fi :-i ol crg
i r.r (tl e
i l tosr,:rl ,i 11i rl ,,
lt4t), (moli1)e (simultnil boal* lui B:r,sedow)," lt i pc rii r,itliene, \rt tt,ilittrtrtt.
rl rrrri c, l n i ntor' i cal i i l e en mereur, cu ni coti n[, cu cotei nti . Nu so l rrsol ,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,u l-
\lrirlc_fio ln, repaus, fie in miqoare, are caracter net circurnstau
I,ilr,l,
l'iilrl
rl r.pcrrrl ent de_ si l ,ual i i l e emoti onal e qi /sau l evenrl i cati vo (Sofl o1,(rt,, J1r0?)
. r
. l r . r r r t l t c
or i sc. i nsof est o qi de t i cr r r ; i , t l c spasmt : ; i r kr cur i l or si ul r i
' l l i zr r . r r . ' .
p; r l r r r l oxul c, cl owni eno ( Ri ser , 1952) .
-
.
{i .l .i }. Il i perki nezi i bru;te, i l i seonl ,i rmc, rapi de, dc ounrol rr rdorri r, tl ozor
rkrrrrl rr
(ncri l mi cel
1. . Ii;cd,rila coreice sint rniqciiri involunta,re gencmlizrd,r: (dc ohicr,i).
,,rr pr rrrrl omi nanl d, l a, fa,t5
ryi
l a rnrrnrbl cl e supcri oarc, bruql ,tr, dworrl r.rl l l o,
rIrfi r,(,, i l ,$i rne1;r' ti oo
$i
asi ncr,ono, schi rubi ntl u-se noi rrccl ;:r,1, do l i r, l l rr gl ' l tp
rrrrrsl ul l l l l l al tul . Si nl ; va,r' i abi l c dc l a un monrcnt l i r, al tul , so i nl ,rrrsi l i ci r,
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_Eh i ntrutre:te de fo:l rtc mul te ori i n tabl oul
i (\rrU,)i gl c col .co.atel ,ozi ,
bi l ateraLi ,.
-
geoer.al i zabJ,,
,soci atd cu spasm de
].::lll:lll,:l Llt::' :ll.
."".]lapiramidalni
ar,axie cnier"ioaJ? l,erraparezi,
{ ( , r vt
sr r ol , r t ( . pt l co
f t
det i Ci b i ni cl pCt ual .
.,.",,{] 1,t}..1:1.
dltrt{ m.al poate face.parte. qi_ tlin cortegiul simpromatic
,:l li:i11 iJ"i/#'f# ;#i'fi,1 ifi
ll$T5lll,lil:l*,Ll"",^fi i;Hf $,.1"",*f l,li;
(listnnin
lcnticulard,,
corcea iui-Ilnntington
;
.r"ao-oi"iI, cerebeloasb.
11 ),Ilamiatetoza esto rezdtatul unor leziuui localizate, care generaza
jiil
].lli?l
.ggt"togic cu hemipa,rezi,, silriro.ln t aramic qi'nip"rk'inezie
de
r r p
.i )l
r.ri uzr(. (Bj l .u. coreo-atel ozi c). La copi i tabl ouI a parr. dupL tr?umaf i gme
, , i ) sr r Ll r ( , Jl o gr
dupa cUcr . t i l l i r e
. ( r uj eol i cd. . scar l aui noasj , .
L. ul r eol i ci . dupJ,
l rrst'. oonvulsivi,,
.diftericd 5.a.),
La ,aury;.,',Je JUi""i-u*i"'to"*ucutivd
tra;u_
lii;l'':ft]'$'
iitti3i,T"Lo"""'
accidenbelor vasculare cerebrale
ryi
exceplio-
(',!.
I)IS?ONIILE (SINDEOAMELE
DISTONICE
SAU DISTONIII,,E KINETICE
SPASMODICE
_
RISER. 1952)
,'lirrt
mirycxri involuntare
cu caiacter tonic c:!re teurizcazia o atitudine
pllti':Il;tr]i,
cnrc se mrn!ine un timp rrariabi] (citeva *""aro,l" *uo mlnutet.
l,r'rrr
ilrpcl r,irnra mal mult sAu mai pulin durabild, pe care o induc. SpaSmrii
lll"j:,.::--!]lli lll,.!ll, !o Tgp:t1
in frod_srereotip, f1;arie lrlcvent qi
-adesea
| | ( . o Ur i l l ut i t suOr ot r i r ot t i n t ol cur sr i l st , l r i i de l , ogl ( , ( l l npol . i
"i
i n sont n) .
. \ r ' r . , - t r r r l . i sr oni i , ki uci i cc
pot sj l i e. r naj mul t s, u- ur r i ' pr : . i ;
; r ' ; ", : ; i ; ; ; i ;
i \i r,l l /i x?/,3nt.. l Je obrcer se i nsol esc,1i de hi pe.r.boni i
e.rl ,rapi rami di l c, precum
rii rf rr- liipolliinezii, Aceste distoaii hirletice tealizeazl o'a"phr*"u'*'"g;""_
l . : ' ] i . l l : , I i .
{l nr ur i t i i unei cont r r cLi i spasmodi t , e l or ens" a
$nr p, , l o.
. , , i uscu-
r j Ul ' r l r . ( ! r ' r - f i ; 11( r , conl . r t ct i e- cr r r ccst cpr ogr esi vi . r e[ r , r i 1. dur ; l ) . f - . ( , ar act cr ul
r(!l)r.r,rr,lr/
itt mlfcar rnroluntars realizate so datorreryle unor varialii nein_
rotnlr: rlc tonrrs mrsclhr', bmsc_diminuat
_si
apoi 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,sibile la 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. qi. o_ piolosrrlui gitr ui do acooaqi parte, .rareori qi r murichilol
i trvoci nrl ri
,i gl bul rri ).
uuor:r' i rxruLrac{i a, toni crn a col or doi n.rry.hi i no' rrrr,t,i
{lo
(pinull
oiri,o billtorluki,, il,r: cu,prl to flccto',zil 1,oni(r spro u.u.fI (rol.rrrcolini.
20{t
\r' rrrrl l ' ri , rrorrl ,rl cl i r l otrft,i i l trl rrl zi ' l , l l l ,rrnl rl rtprl o trcrrr' 1i l , yrtu' i rri rrl l l , (notrrnrl r,),
, r r ! t t l l i t r i r , i r r r l xr t r r ' vi r r r l i r r
l xr zi l , i r r ,
r r or r r l r l i \ , r l t r . i r r r cr l i r r , l , l o
l r t . or l t t r , r r
t t n r r l i ,
, l r r r l t t ] , ( f i l r r "l
l r . pr r r i r . ct . r , l r zi i , l r r
l xr zi ( , i r r , vi 0i ol r , s: i , *i I 11l l t r t ' l l i r l r r pr r r hr , r l t r r r t r r l i ,
r l r , r ' r r i i , o sol i r r r l c osci [ i r , {i i I ot r kr , i r r cgl l l c, ci l r c
] l ol ,
l ' i r ni r i l c r l r r r , f r 1111, 1 1u, 1t t , ,
r r r l r r i , cl l t , r , on; ( i r . r r {, si ! l r l ut , s( } ol l ut l t l l r , r l t r l t Ll sal cl t , ol r pr r l t r i ,
l t l i l r
goHl , r r l
r r r r l r r gor r i r l r l r r cor t l \ i c, r ni l i r l cgr t l l i i , sj r r r Jxr l i c r l oci l , ol i c: t co ( l . i , i Br r , l l ) f ! :
l l r l l r l l t , l f ) i r i ) , ci 1, t r , t . t l t
$of l r r l i r t [ ,
1$( i 7) . J3ol r , l l i l pl l r t r l o obi r , r ' i l l u l r l l l ( i l i
rrr.r' |Il toh)r
l rrrrgl trsi v.
l r:i , trn i t(l ol osoorrt tto Vorn gi di i rt
f
i tnLrl rl trrl l l r, ,r
, rrr' ,' f;rl i l ri ol ti dcrrri oi , si tn l [ o secl ttrl i i , postcr rccfa,l i {,i .i i , rnl t,i i l krs rl l roi i , gi xi rrr
I i rl l l r $cul no rl i n sel i rr, exl rrl pi rl ,rrri dl l i i qi dacr' l pl r:zi ni ;i i , gi r:r.i zc rrcrrl ogi rr,
r r,vrrrtur'r,l - pareza c,onvcrgenfci globilol ocula,ri.
f,)st,rr rl u o dcosebi l ,i i , i rnptntl n!i i , practi cr-l tl i l en!i ?r' m ,i :l l i tul ui
,l trrtttttotl i t (tl c ori .gi .nc e ra,pi raml dul d,) d.t: aLte
J' orma
dc turl ,i r;ol i x, r.l npfi
, rrrrr l rrrrrti :r,z:i : a,\ l .l orl i col i ,sttl con.geni ,t&l csto perrnnncnt, i rrstl {i l rrtr0rl r,i
r rl r. rrsi mctl i i trl .nni o-fa,ci al e. Acest torti col i s congcri i tal l ol tro I' i i :ol ,vrrl rl i l
ttn' ,t nml l atrnati i crutt,i cne, ocr:i pi tal e, ratebrnl e sau, nru,trcu,fuxt (rl rr ol ri ru,i
,,r i rfcrr{i abi l e ratl i ol ogi c)
;
b) I' orti col ,i snl si mptomati c cste rnnstxrrrl ,i v rrrror,
,'r izr. loc,ir'le : tnimitd, localli (roumaticit,
virol,icd, atc.\, red,i(rtLilii uroi.aqll
rul tni ot' i t,s1ton.d,i ,l ,i td,,
arahnoi rl i ,td, ceroi .t:aki , l n acesto si tu:t,l .,i i , tol .t,i ool i Hul
r,rrl r, i rrsol i t tl c durcl i i n muqchi i contractati , dl rreri ci l re dc ,.rbi r.ci si nl , r.r,rr
, , r'b, I rr slu dcclanqatc tle tuse, de stri,nut qi de migcilrile oapul ui
ryi:llc
gi t,r r lr I i
I
rl I'rri!,ii.le aici.oase ale atpztlui tleterminate tle l,umoli ale losci postoliorr,rri
' . r rl ' . L.zi uui vetfehrc,l o (dc^pi l di i , un morb Pott cervi c:r,I, o ftaci uri i , ru,rvi
, rrl :i , ry ]11' 111i p rLscal i i etc.).
j n
aceste si tunl i i , de obi cei totti i col i $ul crl .o Ii rrrl r
tl l r.r i c.i rni ntc, cu i ncl i narea, .l ateral i , a capul l i ), tl acl nu drrfi l i ti v, ccl prr( i rr
l rrrrp rl c. srl pt5.mi ni , fi rl exaccrbi l ri toni co, fi l r' L mani l i t' stri ri l e spu,strri xl i l o
I
rrr l r,rr i i i l i cc
;i
rapi d i ntcrmi te;nte, o& i n cazul vcri l j abi l ul l ti torti col i s sl rrrn
rrr,xl i r... Si !u, el rerrtual , :tti tudi nea vi ci oasi i a capul ui
(.' s1c par.oxi sl ,i rr' l ,' rl rrl
,l rrl r' ;rzi i ,
ci tcva, orc, so i l sol eqte rl e ce{al ee brri fal l ;i tl c vi r,r,sri turi (ci i zr,hr
'li'
,.r I r rgxjiirr')
;
rl) It'alsul torticolis spasmodia ad,re insole,ltc, 3u11, axtr(J s(u
.
tl.t r l .t i net:ralgii a
_m.arelu.i
nera occiptital al lui, Arnold,, se rccunorulo rr4r rr,,
,l r(' i r I,i ncrtr sea,ma de ]ocal i zarea dureri i qi de scmnel o dc a<rornpi r,rri rr,rr ri ,rr l ,
l ,l i tuur
1i
ntl i ol ogi ce) de l ezi rrne rrtl i cul rr,r' i i
(' r-(' o
(rr11r' rrze, rl i rtrt,l ci f i rLl ,r,i
l rr|rr.l i zrr1c,
]ri perostoze, deform:r,]i i al e l Nrl ui
-
ol os ctc.)
;
ri )
,I,ttt,l ,i tnl i yLtl
,,rrrri c (r' echi ul torl ,i coi i s mental al ]ui Rri ssaurl qi }kri gr' , ci 1;rL,{,i dc l i i rrrr' ,
l l rl ,2) $o_ r ccunoaqte uqor, pl i n car.acterul ati pi c (pozi fi onu,l ),
l l l i n
i rrkrrrsi "
l rrl r.,rr, l trl l l uri ,ri i (maj orati i r1e enrcl i i ), pr.i n cal l cl ,enrl i nttrl rrri l ,trrrl , (i ru' {i l l
,r
(l (!
rj t,l uo{1, anxi oasi ,) qi pri n depi sta,r' ca faol i ot' i l ol psi l rogtrni
ctruzu,l i .
!. Spas,nul ntonopl agi ,c (Ji i scr, J 952) (' Iorrnt' n i ncorcct,, l l .l l .
,l \.rnr(\nul
rrrri oorcet ar fi
,,Spasm
rl e 1;orsi urrc l rr,aobi l ,l t,). Actstn i l t.r", i rr
1yrrrr,r,rl ,
| , ti r(1l i rl o si mi l i r,r"c cu tor.ti url i sul spasrnorl i c, da,r' otr l oonl i zi l r.o l l l urr rrrrrrrrl trrr
rrrr1r.r' i rIr' .
Dsto vor,ba, do 0 nri qcnrc de l orsi unc i rcestui rnti rnl rrrr i tr
.i rrl rrl
rrrrrl rri sIu, dc pronrl ,ti c
;i
i l o supi nl ,ti o {orl tl ,:' r, l l t,rrrnati vi tr, r:u, urr Icl rl rr
,,rrl ul i u(r' ) i l l ttnrrrr,ti vi i . Oorri ra,o(,i rr, spi rsmfi l j ci [ esl e l ehl j i v l cnti l , qi pl ogrr,.
rrvi r, r,!t' (tori cOvtr, rni l i r:tpi di i (d1Ir ni ci odnl ,l i , 0u r:i l l i l ctc|ul d0 brusr;hoh,
l otr,i ci l ),
l l stfrl i nci l pozi !,i a l norrnl l l i r, estc nl rrrti nul .i l oi tcvt, sturtrndo
Jrl ru' l
l r r . r ' i t ovl , r t r i nr r l r , , pl i nl , r - o
, , hi pcr . 1, oni o
r l o
l r oi t i , ul t ) , , '
( l t i scr , l {}I ?) , Al l r i n
rrl rrrl rntl srrl l rrr,i ol r.r,sprcLi v rtvi nrr Ll l oc,
l l r.i rr
trl i trx l l t(yr rrrrstrrrl rrl ,trri l .
' r r l l ' l r , Ht , i ,
r l ooor r t l r ur {i o l i i r r r l t l o r r sr r r ncr r t , r r , l t r nl , [ ( i n ! . - I i nl cr r r r r l r r ) , r l r u r 1t r , 6r i ,
r rrrrorr rl l trl ,t' [, i t t1r' ttci l l r rh.o l ,i n tp xrl v i rrr, l l rr l rou Hpl l l {|l ], t,l ,l r r1\l )i Jl ,l i r,()l 11,fl ,(]t,i l l u.
; t t t t r t ' t l t t t t hr .
( 1r u
I i
l t t t r t t zt t l l , ( ] r l i ( r ol i mt l ui t t l t r r . xt r r r xl h, , , {t , l r r i l ) ul t t r r r r r l l or t r t , l o.
201
l i t r vi zi i l i
; $l ) . l r i t t t t r l l t r ( r l t t r
( ]
r t ' i l , r 11. r ' i l upi r | i t , l , i v, ( i o( ] r oi l i \ ' ,
i r ur i l r r i <, i v0i r r l r r , r
r i {, i
l , r , st , l l t i r ,
t r i oi r ni 4cl i l i l r r i r r l ct L{, i or r *l e s: r u aut , or nat c, t r i ci r nl novr r : l o i l o
ol rl i rr^ l l spl l srrrul ui (i rrcl usi v r.[on3a1,i i ] l tcl i vi r.,:i n p rsi ri r' r, rr, nrcrnbrul ui re$-
1rofi l i v)
rru
l l ot
supri rna spastnr:l t,. T)ol l sornnul l e abol ,5te.
.
r\ccst slastn brahial ap:r,re in sti,ri postencefalitice (de obicei), in sufe-
l i l {o \/tl ,scul are, tra[mai i ce eti ],
{i .i l .2. 1}i stoni i l e ki l oti ce gencrnl i zatc sau cxl i nse
..
1.. lJpasmul de [,rrt;une. (tlisbutia, lord,otit:ti a, l.u.i. Ziehen *i Opytt:nhcim
;
tl,i:tlotr irt l.entit:ulard, progresird,
)
prezinl,il douii elt'melte somioloEice : dis-
r , ' 0i ; . r i l ur i i un( , 1
( l l a. . l i . r .
19. . 3. _ci t r t de Soi l , . l er . l C6i r . . \ . r f pl . i i ,
l r nz; i i r .
ri {. ropl l ,us. i I1 decrLbi l ,, :rceqti bol nar i
l rrr
apl orrp., n(,rl Dal i (cu er-c,,p{i a
corriil,atrilii :\lNor eyentmle semne- t1e encefalopir,tic : herniparezri, nins-ciri
r,rrl cu' l tr,l ozi ce q.a.).,1n momentul i n o:l ,r e $o l i di ri i , !l i n pet, t-rLrnttri i rl i ni epe
Lii sr,irrilbozo in lordozii, crpul se re-rroflectcazit,, iar eOoi, ollatil cn o:recir-
l rr\,| pri mi l Dl ' pa;i , ap*re (sl l ] se er.rcel bei -Lzi ) u I l rurrrro r:l e i ,onus pos-
i rrr' rl , o:u' c i ntereseaz5, ati t trunchi ul , ci t si rnembl cti :. l l ol navul se ri i i cd,
l xr
vi l l i rl pi oi oarel or pri ntr-o e\t,,nsi t' a mombrrl or i D{cri otre, a,poi trunchi ul
l sl t i nr:ul bnt i n rnod pl ogl esi v i ntr-o ptterni cfi l ordozi l qi rot:1i ,. l xtr:nl r,
l i rrrl r i n ou,r' e capul sc pl aseaz:i i r]tr,o pozi l ,i e da tol ti col i s.sau dc rctrocol i s,
irrl rncLnbrelc
janpcrioarc
se r'risuctrsc irr 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, contor-
si orrrrtor i nci t :i cest i l speot grotcsc a,l bol navul ui :l fort fo:l rl c l l asti c
rorrl )l ri rl (Lc
ci tre l i i ser (1.959) .-u
,j Iraocoon
i nl i rnt ui l i ,,,j ,tu rL.
(.ri trc
\\i urmer
(r' i l rr1 rl c_l i i ser) cu-rn
,,cl orvn
mrci rbr.u' ). Di l
l rri ci nr l rcestor sl a$mer mi s-
r,i i l i l c vol untare si l t i nadccyat: si , apl l rent, rrecc{)r{1on!,te,
-i ar
rnel sul
csl rr r.rtl em do.cl i ti ci l . l )e f:l pi , se prodti c i .' :tl i al i i toni {ro (i n scns de hi per-
s rrr ilt, hilxrlolie) la un grup muscular fa$ii tle alt Lrl iji dintf-un monrent
i rr rr,l l l l (l i e si ruul tan, l i e al terul ti r.; i nert s-l qi sug?r,rt (,.i
l t accastj l []oa1{,
l rl rr
yrn' ba
rl c o
,,di smetri c
a r' ,pl r turi l ol
f
i :i !r
j u.ti fi l or
toni ce,' (Ri ser,
l 1r ' l ) .
r l r,
i j i i n caznl boh:Ivi l or pr,rki ns;ri eni st p:)t ri r
j tfol ,
;i
l :r, aoe91,i
l rrrl rrr,r' i , ki nezi i pr,ra.l ox:l l e. De obi cl i rn,rschi i fetei si :r,i l i rnbi i nu sfnt
i rrl ol r,r i i i , 11.l r s-::r,u rl escL.i s cazuri ei l cci ntefe3,l ret aceJNorl , roxl i zi nLl u-se :
r ' r L \ l l i i r r r r l i r , . l , t l ' l u"ar i de vor ' l | l r ' e . i l i o r n yr 1
i . . , 11. ,
l )i n,. puttct.d,e
"l ei l re eti ,op{rtog6??,i c, sepot rl i sti nge mai nrul te tormedo
i rl )i trsl rt (l o
t{)rsl uno :
r) I)istonia cle l,ortiltne agu-zisd,
,,id,ictpr.tlicd",
ialentificati do unii cu
,,rl,isl.rtrt it.r,
,masr:u,lorum.
-tleforrnans))
,
,elte
in realitate o boali, clegenerativii,,
l l l osi rrri l rne' l abol i cd, (Wooten qi co1ab., 19?3), de obi cei cu c,.t t' a-cter eredo-
l rrrri l i rl , c' r,r' c ap.tre i r copi H,ri e s.r,u i n adol escenti l (El dri dge, 19?0
;
Marsrl en
rri l l rr,r' r' i son 1974) si ci rro poate fi recunoscutti , pr.i n evol uti r sa ptogresi y-
uctttt' . r,l i zrt ti t .
.
il l)isknin de tol"r.iule sitnptomaticri est{l mult n-rai frecvent5 qi aparo
rfrrlri, srrrr in crrrsul svoluliei rl.nor {LJc.a!,i,toLi a.la stru,cf,urilor entrapiramiilala-
rl .(! (l i vol sl r
tntt,uti :
.
A ncc.fal i tri t:p,i rl ,eni cti (cel mai arl esea)
;
- Al te e nctfn,
l i l ,rrl - Il nrrrfrr,Io p tr,l , i i , toni .oa (crr oxi rl d0 cl ,rbotr de pi kl i )
i
- I)e11c.netrcs-
)nb
lutltolo hnl i.r:t.r,l.rt rc (hou,lu, Lu,i lYil,son;i boa,kt Iu,i, lV e t I, p htr,l,- Striint,p r .
)
I n r t , t t r r t , 1t l , l ' r i i r , l i , l ) sot ni t u t r sl t . r , l l i t . r , t t r i r I r l l c ( i uol r r si u sl ) i t $l no {j . l , r i [ ol ( ] l . i st i t l o
l r l o i r r ( , r r i , r r . i i l i , r ' i ur ) r ' ( f o . I l ; 01, r ) zi ( ) t \ , r {Lr t r i l r \
( l o
l i ; l
; l . r , r ' l i i t i sr r l i r , r r ) ,
| , r r I I I r r r
. i l ,
r
.
. r l l t r r l l i r I r r r I r r , r r r r I I r r i r , r r I r t r l t t i , Hr , r r r r r l r l l r r r l i , r ' i r r
{i r
l t r ' | r r I i l i i , i r r r . l r r l l t r i l i r r r u, r
l i l l r r r , l r r , r ' r i i , r r l ; , l r r ' l r r , , t t t l ' l u: r t r . r r l r r r t , ' l r r i ", l l l r r l r . r ' r ' r r l r . r , r r l , r I l r r sr r r i l r l r ,
, r r zl r ' 1r i l r . 1r ( i r , , . r ' l r ' ,
I
l , ) t t r t . l i t l r t l t r t l i i i t t . l i r t r l i l t
\ l t r i t r
l t i l r r r i r , t t cor r r r I r r I i i , I r r r r r r r r r r i i r r r r r r , r r l r r l r . i r i
, , r l r ' . I r I r r 1r r I r I i r r r r r r r si ct r cr , [ I r I i I l r r r r r r i cl t t , ol t i l i t i r . r , l r . ) ;
l l l ! i t ' t l i dt qt , t t t t i i r , r ( i r ( , r l 11' r l i sl or r i l r r l I l r r i s i r r r | (
.
i r r l r i , i r r r r r r r ' l r , gi r r l r r , r | l r
, r l , r , , Lr . t r I r i r , ( ) l l r i i l ( . \ i r l l r , , r ' l l 0t ' i r
;
t t r i sci i t i ( r ol t ' r ) . l r l {, l ozi ( . r , r
r r l t r r i r , . r i r . r r I r r ,
1, r r : r r r r
i t l l l r ci t . ) .
2. l l nr l c r t i t : t t t l t i I t l , ' l i t r r l , i s] , i u r l . i t ' r l t ) l t l r t ) al r pol r , r l i l i zr r l r sl r l l l l r i , ,
r r Lr r r l r r l o l , I i t r r Lt I r i t t l I r i
; i
l t r r r r - r t t l t i cl oi ' , r r or r t pl i i l r r {r r r , r t ui l l r , t i i ,
( , r t r . l r l
I , l t i r . . l
. r r r I i t i t l t t t ' i r i l r ( ' 11) i l l r r
. si
si i ( t ' | , ze i r r t l r t csi l r , ( i i
t r 0 [ 1] i i t n i l ) [ l t 1i t I I I | | r |
( | i r i | ( | | | | I
( l l
i ot si l l r r ( ' . , \ sl t l r l , ar r l unt r i l i sr ncl c 0i r cr r r ncr l si vc ( si r r or r i r l c ;
, , ( , t i z( , 1r ,
( , l r l
l ,
l ' l i ( , ( '
r ' ol r t r Jl i i r ' 1
, . r , r
i zt ' l t r f l ) i kr pl i co t i l r r uncr r | si vt r ") ( r ot i sl , i t U
i l r . ( ) r t l
t , ' i r ' {' ( ' l f ( ' i l cl t l i r r i ,
cl r t l c pol t t r r ut t r i r t l i ct i r npkr i r i r , r , l r r Ll r i l ut t l t t r ocol r t r i pl
, : r l r , l r ol r t avr r l l c f l t r c 1n j l ui r l
si i . r r . l ) c l scmonot , I ' r i sl , l i l r bsl r r {r , qi l r r l r r i i r
r r r i zr : l or r l r ol i r kr i l cl ue gi l l l i : r pol , i , c 1i i nl ol t r i l , i ct r o I i l r cl l or r i t r r r r i l r r l l
r r r l r r ( ( l r r sl l r r r l
; i
col l r l t . , . l 1174) , on] 0 i r l i t : i Li r r l r sDer r t t l c sl l i sr r r r l r , l ol r i l t r r . .
I t r : ' I r r osLi r : r t l r c 1r ' at r f r l r z: i t t ; 0r ' i l l f i l vOr t t t , t i t r r r ci cl i zt . r , l r i l cpt i t . t , , 1i r r r r r r
r r r r l r r l i sl i i ngzi i t , : r l r t ] t i l ar ni dal cr pr i n a, l t r r a cl , i l i c: i , t l ul r r i , r r l i r i r l l l r l ur , l r r ,
,| | II r' i | 1{Ii L sti i ,ti i dc r:rxi rl i crrti si rui ol r}i rl i i l e l ,11tr
(i
l rr-rl .rtorrl c.
i i .ft CONVULSIi LE
( i . i l . l .
Aspcet e sc. r ni ol ogi ot ' . S1r ' e r l t r i sdbi l t ' r l c al t c r ni i r , i r l j i r nol r r r r l r r l r , ,
,,rrrvrrl si i kl so pl \i zi trti i s l t formi -t, tl c acatBe. l l l o
l l ol
1l i y(uutrl t:;rrl t,, tl \t
; . r r r r l
i r l ot al i l at c r nust : ul ; l l , ur n, cor l i ot al i i
f i
i nsol i ndu- su ct : l r i r r r i l r r l r . r r . r r l .
, ' pi cr r l cr e t ut al i sr r r r cl : t f , i vt i : r , si i ui i de const i i t l t t i , si r r r , r I i r r r 1r oI r i r r i ,
7,,rr' l i rl l :,
si l ul !i i i n caro i ntercseazi l un gmp rn i i r:rtl n,r. ttrtri i rrtrl l i trrI rrrl rr
l r
1r
l i n
0xi r i l t s.
l .
(l on,mtts
i i l c toni r:o si ttl re,prczenl .i l tc ti e conl rrrc{,i i rrrrrst,l l trr, prt.l rrrr
i ,rl r' ,
(r1l r' o
atrtron(l :l zat, o sti u\) p[,ro)i i sl .i oi i
])0
t)l l n(, 1i ' i ,, tl l rI r' l rIi rl l r.ri ,r.ri
l , r l r i , r l r : i i gi r l i t al , e, cr r t 0 ant Lent ' : r z, : i ur r scgr nt ' r r l ( . , , r ' l ) {r l i l l ,
sr r r r , i l i r r r l r ol r i I r r ,
r r r l r t , l r gt r , l nuscul , t t i l i i t 0t pol : r l l i , JJr cr npl ul r . r ' l r r r : r i r l r r or r sl , r ' r r , l i v ci l r , l ; r zr i
, l ' ' r ' ol t l a( 1ur i , l ot r i cl gonu' al i znl i u r r , t l i i l epsi ci gl l l nr l r nr r l t ur r r vr t l si r , l r r r i r , r r
, l orri cr' , i tr (i u(' , l uzi l ul rl l st' c11s;ol ol si hi pt' r1,rxri Lr, rt' t,l i zci l zi r, (x)rrvl l l si rr
l prri r,i r
r r r l l r r r i c sl , r ] i r r cx1t , r ' r si u, i r r so1i t : i r 1i r l c o pi cl r l el t r l ol aLi , r r sl i i t , i i ( l ( f
. r l ! l r
i t r ( , i .
! .
( l ut t : ul . si i l t
cl ot i r l si nl r ni 6r r i r i i t r vol uni , l l u r l i st , or r r r r r r r r , , $l r , l {\ l
l r . l , r ' , i l r r pl ( ' r r o1t , l i 1i r . r . , r r l r , l , l t . r 11 r ' r ' i zt t . l ( )
l ) l i t r
i l p, t i ( i i t l r r *t r . r r r i ; . i i l , i l r r , r r ql r , ,
. ' 1. . i {' r , } i r kr . r ni l r i g. u p. nr r r s<r r r l r r ' , r ' Lr . r l ur i l l , r i scr nl . i i ( zt x, i r l . sr r . r r i r r l r , r r r i r r r r i , , l ,
{ r l i Nl ) l l r i ( , i i r , r ' r r pi t i r i
1i
r , or r r l l l cl l i , i r t l t , sol t t r l
l ) r , ol ) i l l f i l l o
( chi r r l . r r g. r r . r , r r l i
z: . | r ' )
l i
( l c ( , r ' l r r
r r I r i r r r r r l l o r r I i oI | sr r sl l or r r l l t r ' r ' l r sl i i I i i t l r , t ' i gi l I r r {, i , , l i , r , , r r r r , , r r
[ [ l ! ) t l i l l l l
l r ol i l t r t
i r l t ' t r l i f i ci t f ( , i 1,
[ i
i ) t ol ( ) gi r I t I t , cl ! r r i l r t r i l r , sl l r t , c t l r r 0l r i c| t
r ' 1r i k' pl , i ci i .
r \ r ' ci i i r I r r t r r l ' r l i r r r nr r r j i , ( l r r r r i r , i r , qi
( r l l l i {r i i )
I n) 1.
$i i r r r l r r , i r r r r r r r , r r r i l l ol r , r r r L,
I r r hl : t u. r i . . t t r : ut i t l oqi l r ' ; l t )
( l r . l r .
t l or r i i l i r l r r r r , r l o t ur r r vr I I i i i l sr ,
l , ( , r
r l l ( , 1, r . t l nf
r . r r l i zi nr l f ol r r r ' l ' r r i . o . l r r r i . i
. i r ,
r , l r i l r ' 1r si . i gr , r ( ' r r r l i zr i l r , , l l zl r , l or r i l i i , ( r r r r r i
| ' ' r r ' l i i )
l ) r ! ' ( . ' l i r r r l
| or r Vr r I r r i i | r r . ' l 0l i ( ' r ' ; [ r )
( 1r r r r t r r l . . i i L,
l ( ] , , i r ' , r r . l r r r i ( , r t
l r i l f i i 1
:10J
,{{r
g' (r' .rul
, i . l r,t.i rr, I' l ,r.rl i trl ,(ft,vul l i l n' ., l rrl rl i zi trrl sl ,ur.cd, dtt ri l ,tt rpi .l rnl ,i ,
1{)rior} ohr)i(:; .)
(r.ru
rkr'i, rirrrn. p'r Jil cxistti ir.irtii, i.*iir[,,r''i,,irii,
t'rri.ir nr,' t'r.r.* .[oni.L ,,, t,pit,,,siol
'gr.aii
i il;i; ;iC;il dou[, fon'o pot
nr), srr pr.rxlucii
bilatcral-siuroirioo (,epiGpsia
to"l"o'_"io"i"i generalizati,),
ri.ur. ruril,tr:ral. (epilepsia
tonico_itcinici
ir"*igu"Lri;tey,"
sau numii
;:',fl i:llii' i i.i l&"'"t#,#?ljlli".",ln,1"b
u t' roc'r,'ioci r i sa,' Ibcr r,i : r,J rmi,
(i,iJ.2.
l,roblcme de diagnostic etiopatogenie gi topografir:
.I.
ln fal;a- rlnei crize conrrrlsive.se pune in primul rind importanta
Jrroblcml a sl,abilirii dacX este
"o+?
g" d".ir;
"pii.pli";
sau, dimpotrivE,
{frc{, este rrorba de o cridd, conaalsiud, neepiLelttiid,,
'care
poate
s, survind,
:,1")11."-i]"3::rj,.:j::]l:!1"t"
(pgloyier3
ni
",irnr,.,'
r riio.
'rsrsr
: 11 crizd,
;::::l:,ii3-X,:fi'Jifilj".'*lffffHi3,.f,,J.,F,;:,A{:l{;.'\f"n,:J:;Xf:;,,;
tt(iriLc
urenl'ica. s). c on,)itsiite ah cnceJo.ropiii
h$itlt-plitita.
6) centoutsiile
i i n. k,r e n ; o, gra ui tli ad. T
)
C o tt a u l s iile, rt i n' i n t or tta
!
i o ;t tian ; n icd. Z1 C o o ii t
xi i l t di n t u. t bur , i i I p
pnr l oar i n"
l r , ct r ni e. pi *uJbni i op, , , f
i . i Oi **
; . 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-
(i l ,o
6i .,atente. Astfet, Gastaut.(19?3)._$i
eop""t"i "
"1i
"rtrU.
ffSZ6i ;"
pl "_
lrrrs
d illercnllie.ea clintre
,,atac.l
ckr.epilbpsie.''
lresp"ctiv A"?""r,ulsie tonico_
,lll,ll'lll[)
!i t,gpilupsia
propriu-zisi,,
,, '"uri"l,i,ra'-
ads i'ouiir" u",_"o puor,"o
f|rzr'tlr
ctre sc repoti! dc o aiurd, mai mult sau mai pulh
cronici
{i
care
rr'zrrlti-r, rlin..dcsci,rcara
hiporsincrcni, 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
"r,i"tu
tolice,
rrrcl,tbolico
$_.a.)
nu constituie o veritabili'epil"pri.,.';;p;
cum nu consti-
1 rr
jo
o voritabilii epilepsie nici rcpetalea mai-muit s;u ;;i pugin frecveni.d,
ir lnror crizo conyulsiye in crtrsul.unci
afecliuni acute (eniefilopatia
ure-
rrri.i, rlin boola lui tsright, encefalitele acuti). CrirJ" .irii.pt,"e veritabile
:rrr, tlrxri, un c&racter iterativ, crnnic, ele repetinclu_se lat anumite intervale
(r)rrr,i i !(j l l rte sau mai l ungi ).
..
I flngem atjenlia indeosebi
asup ra oo,nawlsi,iloy
kiltoglicemtca din hiperin-
strl i n.i :tnt.uL
t
u_ncftonal gi cl i n ki pti ri nsul i ni smul
orgi nl , (i "oo
sru ca,r-
(r|r,)nt
irJt celulelol belra pancreatice),
Caro tle obicei se confuncli cu epilep-
rrirr,. l,)xist[ insii, citeva elemento care ne pot
orienta asupra ulei conmlsii
l i ;xrql i ..rni ce: a) precesi unea
cri zei pi i n
unel e si mpti me revel &toare:
1rrIn,r'c,
tchicardie, tremurd,turl,
hidriazb,, patiitalii,
anxietateI
l)).if r ist,(ilL!,a unor simptome interorilice,_ca
: so-noterrali,,"concentrare
ilificili,,
itrrilrlrr'rru, ir,1;entiei, a mernoriei qi a
inlelegerii
unor nogiuni abstracte, st[ri
il:li:,1,.1,,1.:
qi de dezoricntare, aprtie, brirtipsihie, irclerenfi,
sti,ri de ag!
I i l I , l i \
(
l l i l {l ( ' Sl Vr t at e.
ll. ,\tumar de d,ata etiopl,togenice 4n, uieele conaulsirse epileptice
...
A ..
()r.i .zel e
epi l epN,i ce conuu,l ,s.i ra l a sugari .l l aj ori ta,tcLl
cri zel or convul si yo
i trl rrrrl i l rr
' si rrl ;
i .r' (i trr r.r. pi *r' r1e.o rt' cunoqti nfi r, i tr,u cro obnubi r.,rc. Nu tre.
rrIr' 1 srL l i l ' i rr]rr r}i u|i r{,rr, rreos.l l i r,i i cu oal o copi l ul mi o pr.zi trLi t
0 cr,i zi t, r.l o
204
r , pl l r , pHi l l i r , t r l ' l r nt l t t t i c l l cl or pr t l l r gr , t r i l . Vot t t I ' ozt t t r t i l r l r , uzt Lr ot gr r , t r i r : r t : r r l 6
r r l r I l r \ l v( ! l l , ( \ r t l n ot i zt r l ot ' opi l opl , i cr r l i l t t t t gr r , t ' i :
I
)
l l l tnt,nqo. trn,ar' .l ul o1xtl ,i u, l ,m,ut ,l ,i ttd, (pt' i rr frr,ctori i trl rtIl rrrrl ;rr,l i ol rnl ,o.
Itrl rrl i ) r' gl ,o c:urzl r ooi r rnl l i 1t' rrrvonti t l l r rrcol sh' 1, vi rnt' fi ,, I' txl to sl ' [ fi o orl rrr,
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. oi di ck0, I t t ovoci r t ul l r i t r : oi r cul l l n"ut l ooor t l ot t t t r t , t t i t not r ul l i i r l ocul r l or t
orrrIri Ii r111|, l t' l ,vr.r,l i u prol urrgi t, munopot' o l l l utal o do tl cga,j u,r' o foIi rL' [, rr,l rl i
,,rt,, rl r forctrps, vi tl ext,t' i t,c{,i o, cxpul zi i l rtl tori oi l so (prczotrl t,l ,i i vi rri rrl rHr.,
rl trrl rxri i , i ror' {,i o utcri nt' r,), opora,{i i crzi l ri cne (pri n sol ti mbti l o l tl rrsci l rl o pro
,rtrrr,), l tj l i zi Ir' o tl o oci toci cc, b]oo:l l ci t, cr' ti l ol rcspl ri l tot' i i uJo frl t,ul rri
l rl i rr
rrrpi l i r(i u tl o l i chi d arnni oti o, rl pl ,uri i , tl c pl a,ccnt' :i 1, q.a.
)!
)
.Mani,nllitre
,s,i
encefa,lita
.lcDrile
: mtningito acutu ba,ctrrt'iotro nrrpl,L.r,,
r.r rl l I rr,I i 1,o n,cnto bactcri cne, vi roti cc, ri chettsi ono, l ucti cc ntc.
ii
)
I I em,u,toama subd,urale (fotrtc frccvente lil sugar, pinr), lt 60'/, rlrrlrr'i,
\ri r(' ui
[i
col rb.), angi oame (28o/s dupl Arseni
6i
col ab., 1071).
.l
)
Putapi toza (ci sti cercoztl ,, hi dati dozd), do ascrncnul l ' oi r,r' l ,o l ' rrrcvcrrl ,o
l rr rtrrgl r' (Arsoni .1i col a,b., 19?4).
t),Ll l eence,fal optal i ,i Ttri ,nJactori prenatral i (careaunol i oui rti trprrr.i orr,tl l
{l |z\ ()f
i i i .r' i i ombri onarc
5i
fctal e) : a) Anomal i i congerl i tal .a (i uol rrsi v i l ,l roDtl l i i
.,rl ' rrr()zonLi u,l o),
carc produc di sembl i ophzi i l c {ct:r,Io: ml rl fOl ' l l l l l {,i i r : r ' : r, r r i r
,
r r r r
(rrr' r,(' rfi tl i c,
oxi ccfdi e, turi cefal i e, scafocefi l l i e, pi ati bl rzi r., i rrrpl r,ri rrrr,,
l rrni l :rl i i ). b) Mal fortna!,i i cerebral e (mi crogi ri e, pol enco{al i c, tnl l l i rl rrl r,(i r,.
\r' rrrrl rf
(
l l ti rrl i ). c) Anoma,l i i occi ,Tttto-cerai cal e, <1) Mu,Ifor,nru]i i rtutturtl tn'
(i ,l l Ai ()rri Ll i ozi r,
_
cerebro-tri gemi nal i ,, boi r,l a, l ui Li nd.a,u d,0.). ti ) AJi t,l ,i u.tt i
' l trnrtl rLhol ,.i ce.feXal e 1i
tel &urfumoza (pri n factol i gcntrti ci ) : l a.*txtd i ntJi i l t,
,{rrIr' )ti rI foni l pi rul ' i ci i , si nrl romul l ui ILutnup di n por.Iti rr,l rcl l l ,l i ot' l ,
sol ,rrrzi r,
l : r r r r i l i r r l i i di i uzi i ct c. )
;
l i pot l i st r of i i l c sau sl i ngol i pi t i ozdo ( i r l i o( i i r , I r r r ni I i r r I I r ,
, r r r l r r r l r r l i c; i a l ui Tu, y- Sacr hs; boal a l ui Ni er nl l n- Pi ok
I
gi r , r , goi l i r r r r r r r l ;
l r r r r r l r r
l l rl
(l i urol rol
el ,c,). f) Atte, aJeel i uni , metubol i ca eraLl i l &re: ftrl i l rrri otrrrr,i rr.,
l r,rrrrrrr.i si i l rnl i i r,, zl ci derni a hi perfol i ci i , pi ri doxi n-tl epcrul cn{,i l nou-rri i scul ,rrl rri ,
r,l
Ni utl to&me gcneti ae au tul burd,ri al e
formul ei ,
cromozomi ,o,Le.' ri rl j rrrrrrrrl
l rri l t l i noftl tcr, si l rrl romul l ui Patau (tri zomi u l ) s:tu tti zol ni :! l i , l b),
rt|||(||{|rIruI l ui Erl wards (' l ,ri zorni a E sa tl i zorni :r, f 6-l .fJ), i tl i 0{,i rr, rrrorr60-
f,,l (l i r (i l i zorni :r, 27),h) Infec!,i i materne (l at.srl tol i or,rrpti vo l r,l t. rrrrrrrrri , rrrri l rr,
rl r,, rr,l ti r bol i i nfocfi ol ,so). i ) Afec!,i .uni . parati tara uLl rnunari ( rxopl rr,xrrrozrr)
,11
I,)rtrr,[t lopta,l,ii p,rin aplenli
tizi,ci
asu,pra norzci.' tr,trunrr,t,isrrur I I I I r .l r I r I r
j
r r r I I I r
rl {\ l rl l uurl i gosl ,i l ntc, i radi ol i cu rul i t{i i Ii oontgt:n. k)
' 1' ttl l tu,rdri . nu:hr,hl ,i rt
ttl t l unttr(\ oa;' o pot prod[co oncel i rl l opl l ,i i i rrl a,nl ,i l o (tl i l r,hoi ,, l i rtrrl ,oxi r,ozi ),
t' l t.). L) It) tt ctfu,l opul i .i pri n aJenl ,i u' ni ambri onare
6i ,fttuk l tri t
i rl oorn1rrr,Li Iri -
f rl rri ,rr rl rr f, rc t,rrr'
-Zfl i ,
ou i c1,<t' rruckri l r. n) ALl i
faaktr,i
u,ntennktl l (vl l i rri rr r l trr
l rr
l i l ri l rrxrf i oo otc.). rr) l ' rcrnd,tur,;l ,atp..
f / i r l r ol . l l i l , scul ; vr r , l r t r hr t i si i I cct r t r ol r i l or n oonr ul s, i i l t ot r . , t r t
t r t r *i n, L r t t i t r . . t , b. i I ep i . Le p l i oe
,
dr l r or l r o l ut ool i pol , l i l sr r , o pl o-
' l r
r p, r zi ( i r r t r l i kl r l , i r r i :
l -,\pttt l u,l , l tol tttl ,u,Lrti de pl ,ti .n,s (,,sp/rsl }r,c tht sLnol ol ,l t:r,l l rri Itrrl rr,tl ri i
l , r ' r vr ' ; , l ' r , r r r Hi l l i o t l t ol i gi no l l f i r cl ; i v- or r r of i onl l i , oi t , o t . oi r c( i o r l r r l l l r r r r i l xt r i t
r l r , r r r r r r i , , . l l | r r sc sr r r l ( xi l r t , n, ! t i i l zi l s1t r sr r r r i l r l r ,
l r l i t r s,
i t r H| r , r , l r r l r r l l t . r i i t t l l i , r t pol
t t t l t ol r ol , t r
1r I ' r r f t t t uI r , ,
ot t i r gi i ; l ( i c,
gt r
l r i l , j r i r l i r r pi l i gl r r r t r i i s1 1vi , r i l , r r l i i l i l ,
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i rrI' t' rr' .ol cl rri rl i i
I
i ) I' )pi l r' 1r:tt
l t,:r
t rt tr ttt,.r,i .tti . tu.rtl l i ti i (<:tr rrprr,r' i (i r Lr,
(i
l rrrri ,
| : , Nni r l r r l i i ' i r r r r r r r r r , l i snr ) r , r r r r . r ' r ' r r l i zr r , l i "r , r kr ci ca, 1, r . i ccu, i r gr i nuo- sr , r l l r r a{i i ,
rl tr l l .Lrrrrzl r, rl i l rrzrl , l i rri u r' :r. i l ,r rrr.l o conLpl i cl {i i tal tl i vc (rbr.str
, r r ' , . 1, r ' : r h. . r . l r i sl Ul i . l . l ,
| i r
, \ l . r , . r r r si {, , , 1i r t , . ( [ t 17, {) , m
j or i i . at el
a, . csl or
( , r i zu
r . r r r l r l r . I . i 1r
l l i t l r ' l
t i r l
( . 1! t , , / .
, | i t r
i . r zl i / , dupi l . ur e ur . meazd cr i zcl u l , ocaJe,
i,u (1v('tr1,uli,l?i
generalizarc (lfio/o rlin botnavi) qi alte tipuri de crize.
-
2.^.(lr'izale. c,pitep,liaa An meningite g^i encefalite, foarte frecvente l$ copii,
' . ' . i r r l i l r r r . ; r . . i
. h aduUi . eLi ol ogi l i nf ccf j or sr i pl asi ndu
se
pr i nr r c
or i m- el c
r r i . i r ' : r uz( . i r upL, r t anl o al e r nani f csl l i r i l or : cpi l cpl i co ( Gudr n- ur Lr l sson.
t C6C-
r r t : r t . r l r . , {r ' r nni
1i
cot ab. , 1C78; . ?n cazul cr i zel oi er , i l eDl i ce sur \ . cni t p r Ll r - 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)
I
at) Meningitd, triberculoasi,l
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 accese pot si, survini,
rlrrpiL, luni sau ani de la sting_erea procesului infeclios (Arieni;i
cotab.,
l 1)73; I' opoyi ci u
ryi
col ab., 1076).
.
ij. Orizele epileptice ca simptome de ilehut sau I,n cursul et:oluliei proce-
sr'.lrr
,r,t:pamsire
intracraniene.
,sinl
deosebit
.de
frecventc, putintt ijungo
l i r r l
. l : r
50
o/ u
di n r ol al ul cour - ul si i l ur - l r a, dul t ( Ar seni si r . ul r t b. . l 97S) . Ar t i ; | ,
, . r i zr . l r . r 1J) ept i r . e d. i n pel i oar Ja de t l ebut a pr ocesel or er pl nsi r e i nt r l cr aj
rrir,lr (22o/o) reprezinti un prelios gimltornde
alarmii,, cu-tleosebiti, valoarc
l , r , r r l j zr r t o: r r e. de f ocar , put i nd udpsea i nt l i cl qi nat r r r a pr ocesul ui
e\ pt nsi v.
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 mo-
iolii
.si
scnzitive ale cor"terului, in specia,l astrocitoamele, oligodeldrogli-
r
'ir
r )r{rl{', rncningioamele si glioblastoamele,
l. lrizele epileptice prorlase d,e uJecli,unile aasculure neurochintrqicala
l rrr
l rl rxl u{l
i rl ungi oarnel e cerebral e suprateutori al e, i n aneuri sntel e :.rterei
|rrtrrl itltt irtternc si alc rarnurilor acesteia, \n boalo Bturge-Weber
.si
tfuai, rar
I tt. ltt ttt tr,[otn, ul prinr,&r i.ntraparellckintdtos (netmuma,l,ic
).
5.
(irixtle
e.pileptice nn pt"ocesela inflatnatorii, tt eurochirurgicale se in.til-
rrcsc irr : l) Tuberculoamo cerebru,le (fcrarte frecvent
- 850/o dn cazuri dupd
,\r'rcrii rli rrolab., 19?8); lt) Abcese cerebrale
I
c) Ifai rar in araltnctid,ila
wio-
rhir*utt,l,icd, qi in go'mele sifil,itice.
(i. (lri.zele
e,pileptice in
Tsarazitozele
cerebrale: a) Cisticercoza cerebrald,
l1l')1,
tl, sirnptome de debtit, fie focale, {ie generalizate, dupd, Arseni
ryi
l r rf r r I r., t.f )78)
1
l s) H i i l ati d,oza cerebral d.
7. Ortzele epilaptrice t:ascalure ss intilnesc indeosebi la adultii mai ln
vi l sl i qi l a bi i tri ni , fi i nd real i zato de: a) Ramol i stnental a
Tsseu
otuntoral e
1
It\ INnlr.fal.upa,ti.a hiputcnsid
;
c) Unele hemoragii cet'ebrale. Debutul icti-
lirr.r)r si oonlioxtul clinic sint rcvolttoale pentru accste manifestiri
r . 1r i l cpl , i cc.
,\. Ori::i.r api.l.e;plito in, bolikt rlrttontnlite
$h1t m.ult miri lrur:
tJ I)i ti nuqi t, t:r' rrhttkn,vi rtt,i or:l tnti ri i
i
b) It)pi k' psi n mi or:l ,oni cd,proTTt*i rnl , n,Iu,i
i t 0tJ
l t pnr t i dt l Lut r t l l ' ur q Lt . l l , r t ; c) l i ur l t l t i l , , r r l , i t : t ou ( r ' r r r r . or i ) 1
r l ) , l i , ar l , r
I t r i l l t l l r t nt r r l t u, \ 1, ( l :
;
( , )
l i or r l r r l r r i
( r r r , r r l zl i . l r l
. l r r t , or l .
! ) .
( t r i
r ' 1. r
l t i l t
pl i t r : i t t i t t l . . t i . u! i i l r t t t , t t t . r t , s. l |
,
t t r | | | | I t
,
t I t
-
/ \ l ' l r l . i . r l
. r t r I l t ' j ol r r I i i r r r r r r t l i t i r r l oxi cr r ( i i po1 si i l r l l t r i r cr i zl r . r r r r r ul r i r . r , ,
1xr
( , i r r , ur n
. r r r l . r ' i t r r r l o I ' or r si r l or , i i r l t r r 1t 1, r , r r r
.
i I r r I r i I r r t , I i l r , ; r si i , r , i r l . l r r , , , r , . r I yr r I r . i i r r r . r . r
r l , r r l r t l o' ) : t t , ) i t t , i nl nl ; i u! , i i h e, t : t r t t t t e ( r , l i l i l i i ,
r r r r
1r ) r r r r r f l ,
r , 11 i l l r ; r , n, ( . u r r , r r i
, r r l r l o cl r l l xl l r ou sul f ul l i dr r oul i ot r , r , t r l x, l l l i r l oLr j . cr r sl l i l r r i r r r , r . r t r i r r l r l r l r ,
,l t l i l trtl
-4.n
att.[\r.t, l n,l l ,scori s.a,.)
;
Ir) i n i rk*i ur!,i i l t tni ortl ttr.,(urr,l ri r,. r,rr.r.
l :rl rrl l rl i c pol tal i , cncofi rl opa,l i (f
l ri t
t(r r' (,;[1 i ci
)
.
il
;i
i i
,ii
ilil
il:
{l
,il
I
ry PfiOI]LEN,IE DE DIAGNOSTIC
{ . tm ruLBunARiLE Dlt snnsuitltt*tCu
?.1 RIICOX{ANDARI MIiTODO],OIiICI] DI' SF]MIOLOGIE
7.1,1,,{l tnl i za {nl hi rrl i .i l or snbi esl i ve do sansi bi l i tate
,r. l ,t(,c pi i l tl ,r LLn i nteroSl ,rtori u l tonl ,, cu,o pLeci zt rzi i prczenl a rl i ,Lrcri l cr
,;i ,' .rrur l r, i r,l toL senzl ],i i :rnol m r,l ^, topogr' a{i .i i rrestor' .t, J\L)ci cretr cu al te
i r{rrzr si rbi (' ri ti rre, oi arul de ap-rri i i e, c:u' aotcre,l e drl rcri i etc.
L Sint
.sittutlii..1tt.
cuye du,rerile
;i,fsau,
pareste:iile constitLtie si,nlyut u,l
' tt t . sU b i erl i t al bcl i i , st u, s i mptornuL senzi ti r: i l ol .t,i :tu,tut, Ll l b:rri .ri l c obi e;ti ve
fi i ,,(l ri ri i ri rne si l u l i rsi ni l ) crr, rLr; pi l l ri rrr cefrl ,i , i r ari Err:rrr:, i n unel e n:vri te
, i
l r Lr l i r r t r l i t :
( {or n* st nzi t i vi r i p, r Ji r nvl Jt ci et i l i ccl , i i L uncl e r , l r l i l r l one,
vt i I r ' .
?. I,l ri sti i si ttttl i i i n ctre ,l ntpt,l e
si sa prr,' t,sl t:i rl e
Dneei | al te seny.e
trr rrtrl rtl i .ae. si , cl cci , au t.:r,i or,.r' t,
,[,, si , ptonl s, mnQl :
.,t
1
rLrtl eri l o mu:;cul are
ri i ru 1i crrl rr' .. i r pe| i oada i .l e i nr.-i r,zi e prcp],rati ti c:i a poi i ol .ri cl i tci i r,i ri Lrri o:l re
rrrrri r_;
.l r)
-l l gi i l e
premoni tori i
ccl vi cal e s.l u dorsri e i l hern r,torni el i i ;
r ) . l Lr l ui i l r r i nr r ol i oi . , t i . l decl cbut l unei par l l i zi i f aci al o; r i )
el gi a i r r ' r ugur al d, a
rrl ri l rrl l x' s zostcr
I
e) drl rei .i l i . cl hi Ji cl e c.r pr.edoni nr
nti l nocti rrnd, i n
i ri l i l i s l rrr' (l 1i l u; f) dui eri l e l J Li rl rl -rre di ,r r,,j rnpl | si mri l u medul are.
.
;j . l f ri rl i ,. si l tutl i i i n cwe urrrtl r c;t ea, pri i i npari (1j qt:L l or,, tari ta_
hi l t
.l l tturc
rl .i n.i ce nl e u,nor afer:l i u ni I i ,1 forrn r, ,l e.i ci , a crmpl esi uni l or rnei l u_
I rl r.
;, l r ). l "r' n r tl gi ui . a
.mrof _pol i ner-ri to
qi pol i neurop:tti i
;
c) forrn,l al go_
I l I r | | { | ( | | | | ( . : | ; l nr . vr J\ t r - l cpt : l r . t nt pp,
L
'L.'ul.bn rd,tile de sensibilitete subiectiud, pot sd, aibti o
,rnure
uLlo&re
t tl t x' .n l t)4..rt u, nnor
-a.fec!,i tm,i
.neurol ogi ce
(Gui bl rt
;i
Gui bert, 1g?4) ; :i ) Teri no_
rrrrrl qczi :t, srl mnal ati de ci ' ,tre
-boi n.,w
poi ni he
eyoc:l rea unci ,si ri ngctni el i i
rrrrrr rr rrLti si ndrorn si ri tgorni el i c; b) l l ,el .l tarei 1 rl c ci i tre bol n:,l v-* unei
i rrcrr;r,rri l i l ,i rl c l ecunol stere a ohi cctel trl
cu l i uturul pi pi i tul ui ,
rre face sri
rrr. qrrrrl i rn
1i
1:r, o agnozi e t:}cti l :i , pl r)Iri e l uui si nr1r' orn p rri et:l i ; c) Rel a_
l i u(.:r ul r,' r' rl treti (cuntl nut-, dar cu execcrbl i i i i n p.r.rori srne i ttl oce hemi
|
' )r' | ),,Ii LIr.,
L.\i r{cl .rtu rl c
prl }uti i ,
precurn qi cu 0 coi or:l turi i afecti yl cl ezi l ,
grt,' l ri l i i ) srrsctci .uzi i donri p0si i ti i i tri l i : - l ) rl ur.i l r.e tzl :l rni ci i oLt c..l ractor
Ir.i ;xrr' 1rr Ii c
I
- o Iczi LLuc r, fi rsci ri Ll l ul ui sl i i r' t.' hrl i c (l tunci ci ntl sc col strr,ti i
8i o l ,0u1l {)rr,l rrrl i t0zi (r.
5.
( l q. r t t , l . u' d: '
l t l r r t l . r : i i l ot
( r l i st , sl t , zi i i r r i )
t r t r j r r r i r , si i l i o l r i r r u
1l , t , ci z
r , i , o,
j t ccsi ( ' [
I i i t t r l t t l r r l r r , i r , r i r r l i i l r r l r r i l r l i vi sr r ! l r i i l i ' ; , i l ; r r r s; ) r ' r l r : , , r ni ( c, r , l i , ,
I r t l t r i r r i i I r r l i , sr , r r zt r ! i i r l o l t r l r l st r t r r l c l or u' r , 1r . , , \ r l r "st r r r r Jr - r l r r , r ,
r , <i l r , r i t r r t i r c
: i I I )
l r ol t r r t i r
; r r i
r t r l r , l r ' gy' r , i t t r pi ot r r l r l i l i , t i i r , , , \ r l 1, l , t r t t r l ( r l r , r l t r r r t i t r r l , l r , ; . 1
l r r r r r
. r Lr t ot ( r ' r r I r r ,
l r r r t r r l i zi r r
t t t r t r i t r t , ' t r t l r t t t , I l t t ' i r r : r l i r ' r ' r r t l r r r t i l ' i ) r ( ' Dzi r l r r '
l ' . l | 1
]
l l i r i t r r . l l r r I I i . i (
' t | | r
.
t l (
' r l
( r ' r , l r
t r i r . l r i t t r .
1r t
r . r , i zr r 1 i r r i l o' i r l
; r , r t ' l ' si l zi , .
r l l or r t , , , , .
. l r l r , sl ( ' l i
I r t ( {r i zi t t t ' r t ,
l t r , r ' si l r i i r . t i l {r t i r l ot t r , t t l r ' : r zr r t l i r t gnosl i l t t l . l \ t r : t l r t r l t
t pr r l t r t . l t r ! i t r t r i l t nl t r i l ot
l t t ' r i . l t t i r i ,
i t r l r ' : . i r t t r i l r t t t r t l t t l l r l r i l oi l l ' l ' i L( l ( . r l r , r l
r t t ut ' t t ) : . ! \ i l t r r | r ' sl r ' l t t l i t t r t l t t r i l l 0l t ogi i r i i r i
l ) r r l l , sl | zi i l
| l i i l r t l t r t ' r t ; l I r
,
r r r , r I r
, r i r i . i t t r r l r t t t i t l c l l r l i l c t t i , t ul l ogi t , r , ,
l t i r t r . sl t , zi i l r , pul
r r pl l r r . i r t , i t r
l t r t l t r t l nt
t t l ' t ' i t t t t l r r l or i . t
l t t r i . l l r [ ut
( s1r r ; l t c t r r sct t Lr l r ' , i t ot i r l r r t r al i i : L ol r l i l r ' r ' r r r r l : r
, l r ' . ) .
l ) t ( \ ' unI ; i
i t t di t ' r ' t ' i l t l e r r . l t t : i i t t ui l ( ol t t t ot ( l ot i ) t l t / / r ,
( ' i r r l r ' l i pu: r r l r
, l cr r r r t r r i l l r r r l t r . , I l t r t ' s1t ' zi i " \ ' i sc( , t l l l {r ( l cr r t i or r i t r r ; r r r r l r ' i u. l r . l . ) r : l u {' , / r , l
l , , l ' t t l i i . l \ t l l ' r , r t l , o ci t zLt i i , l xr l r i r t vi i ect t zi l s( nr zi l l i i {l 1r l t r r i ' {i ut r c i r ; l r
( l r .
l r '
r r l i ; u( , l sl r l ) l l r i i f el i l . t ' l ot s( ' gi n( r l l 1( f i r l c l r r l r ul r r i r l i gt sl i r ' , pr l I r l r r l r r i r r r
; , r r zr r {i l t r l o r i pl i r r r l t . i ni nr i i r : t c,
( i . ( ) anr t Lr r t l . r :
{i xr ?' i i r r i nl a( l csci r r ' ( ' v( ' l l I ( ) l i i
l xr r r l t t t
sl r r l r i l i t r ' : r r l i r r i , , r r r r i
l i ' r t l r r i r r f i - ' r l i r r r r i i . I l t u' er eu,
( , or r s1: i l ui ( )
o sr : i t zi t l i o
l r r , t t i l r i l r i ,
t r r ' l r l r r r r r l r r . l r r
i r r : uul r . : r i L t t ur r , r ' i i , t r cl l ui e 1o1( l eauol l si i pt t N, i zi t t t : r l r . r ' i r r r l r r r r ' l r r , l r r : r r r r l
r l r r t l t i k' r l ocal i zi uca l ol pr cci sl i , r i ur ' r i cni r ci r l ot ( t r ot t I i t r t l t t ,
1u, r ' i or l i r ' ,
, r r r r
, ' , , r l j uut t
cl t er ai ccr l ) i j , f i
) , dut ' et t t , t i zt i r t r '
( l uf ( , r i ) i r s( ' r l r ' : r z r l c r l r r r r ' r i
l r r . r
r o
, t i l r ' , i r t cnsi t l t ea, t i r nl l r r l dc al r [ 1i 1i r ' , t ' r r t ' l t , r , l t , t t t l r <, r t zr r l i i ] ot r l r r r cr r r : r , . r ' ,
, l r r ci si r r t sr Lr r i n i r ] so1, j t o dt i f cr r r l l r r t r o i ur i l ol i i si nr l r , gr t i r , l i r c si r r r r l r r l r r
r r l l sl ol l , 1i el ul de i nst nl : r l c zl l dul cl i l or ' ( l r r r 1, sl r u ) l t r t sr , r ' 1r ' . ) . l l r r l r ' t i l r . r , ,
, l : r si i i cr i
aci r al r nr : nt c i n t r ei l r i l ) ul i l ] r i l , . i ol ' o ( . , \ r sor i si
( ) 1, 11' sr . r r ,
l 1r {i i ;
t l t r l ' l ou, 19?2; Wr i l t on, . [ t ] 75) : t l ut ' cl t : : t sul ) l i ) r ' l r r ' i i l c i I r
{, cl
l l I I r l r i
,
r l r r r , r r ' , r
r r l r l i ) r ' r l [ t l e i usr t l i
[ i
dr l en] a
.
, J( l ur ' ol ' o) ' l i l opt i r r
zi sr i ( , , r r l l r i r r q
1r : r i n"1.
i {' p{) 1i : l ( l i i ugu, : dul ( i l cl , pul . ql r i , i l i r , dur cr r r t i t r : xr ( i t i
( l {f gl {' l l l r , r i r r r r . r ' r ' r r r r l ,
l or ruai (l c
cl ampai ,,qi durcrel l l i rnei ni l nl i .
7. l n l apol t ou r c( , st i
1l i l t i l r l t cl l i
t l c r t t r t i st t s, dt t t , ' t i l , ' xr '
l t t l
r l i . l t t t l t , r
t| : nrrral gi i , tl tteyi rdrl i tu.Lar4 dl t| ' rf i .
()t' tl t)| a.l (.j
dutt' t i l ql dti ti t' t :\t ttl l l
,l ttttri
r:entral e ,<,i tl u.reri . [i ftrt' ul t. [.-Il ] l oo l l ]rLr{o ot' .u1ti tr' ,l tl nrr strrr rl rrttr,,r
l ) t t " r : a al gi n, est c dl r r er ei l cn l oc: i zi l l ' ( ' pt r i l l i l r t t ' i t t l t t t t t t i nct r . N. t r r l
r : i r
l ) oi r r t i i
nur nel e ncr vul ui i n t ot ' i t i l r i t r l t , t i l t t i r t l t pi t t r ' ; t t r r vut l gi : r i t i i l , r r r r
r r : r l i , r t evl i t l gi i l sci r t i ci i ct c. [ , r ueoI ' i t t cvi r t l gi r t t , r t t t sl i l ' t t i t , t t t t i r , t t l si t r t pl ot r t
r l ( s l 1 f or i l i t i i , : r l ncr ' \ . r i l ui r ospocl , i \ r . I l u t ' r i i c r l t l t ' t t t t i t l t l i t l c o l l zi t t t r c r r t r ct r r t
l r r i
l r r l i f cl i c,
ci r l e unt ) r t i uu l l r i . r n' nr i r l r ' i , r i i l l l t ' r i t t t pl ot t r ' , O vr r l i l l r r i c r l c
t r cvl i r l gi c o ool st i Lui o ci t uzal gi r i , i t t cl r l t ' st ' t t zl t l i r t t l t t t t ' t t r i t i l t r ' f i i ( ' r ' $i l l r ( i l : r ,
' r t l r
I r i nr i , ( . l o
al sur i ! , ct l t r l , i r ur i , i r t sLt pLr r 1: t l r i l i i , t ' l t l t t t i t t t l t t r ; r ' l r r r r ; r I i cr r {i r r t r t I r '
r 1' r l i , r r ot i v pdl t nl cal r ar r csl i l l ol r t r t vi i ; i i t t vr ' l t ' sc t i t i i t r i l l i t r t ' i t pr , t t r l r . r , r
r i ' r i ) N, j ur r gi r r ( l sl i , a, i br i ,
, , r i t i i r r i
t l l spi i l i l or t r t sr i "; l r r r r r r t r I i I j l r l i I c r r l l i t l l r r r , ,
l t ol
l r t l l i r i gi l t r r l l r r r t ' r i t ' i i r r r l j ct ' l t l r , I l t t l ' t t l or ' ,
; i
i t r l l r r l t i ' I i t r t sot t t r r l ot i i .
( ' r t t t zi r l
; 1i r r
st r r l l r , l or t , st o I r r zi i | i i f i l l t cl r i t r . r ' gr ' 1l r 1. i t t ' i l l ( r l i ( ' l Yi l ( t l
; t | t ' i l i ' t
i ( i
f i
i r l ) r t l I r l '
, , l r i | r . i
1xr
1r ' t ' i l ot i ul ] | ( l l ' \ ' Ul l l i l l r c( l i i l l r r ' . l t l : t l l t t ' l t , t t l t t i s| i i t l i r r
l r r r l r l i l | r r
r r r Lt ' t ' n.
l t ) I ) ur t t i . l t r r udi r t t l qr r ' t t t t t t t i t zi l l t i l t t t i t t l t I t ' t t I t I t 1r t t t t t ' t cI r r I : , l t ; t i t i r r r l
r l ' ' i t l I I r g l r r | r nl t t r ' Lt t , i l l r l i r ni v( ' l l r l i t I I | | { ' | | i r | | I I i l t t i t t t l f i t t i t r . l | t
r r t t t
| r ' t t
I r r l i i ". Sr r l vi r r sr r l l l i r ur r i t l c si i nr ' 1i ( r t t i sr i t t r l r ' l t t l gr r t ' i t l t t r i i ,
l r t oPr gr t l i l
r l t r r
r , l | r r
l r t t r l i t t l l r l
s; l t ' o r l i sl i r l . St t t t i t t l t t l t ' s| l t i t t l r l i zt r t l t t t ct t l i l sl ' , t l l t t
l t ol
l l t , t
l ol i i r l o cl t
( ' \ i r qr l l ) i i r i
l l t t oxi sl i t ' r ' ,
I l r t r l i l t r l l l gi i L' l t r t ", l t t ' r ' t ' l r t ' l t zi i l l t l t t l t r ' ,
r l l r ' i r l l sr r r r ' l i r r ' l t r t ' i I i zi l r . , l r ' i r l i t r r l i t r l l t r l t t l r t ' t t r ' 1l r ' t ' i i
l ) 11' r i i l l t r i i
l r ( l l l t n{t l
l r t i r
l r i ( l i r . i l i i l r . z: r l r . . l ) t t t l t i l l t : t r l i t ' t t l r t l l l t t t t l l r t l r i t ' r ' i l l t l r i r zl i i t t l l I t t r t r r ( r t
r , r , r r i l i l r r ( i i : 1r t r l r , r r , r t st t l r : t l t t l r ' l t . l r , t r i r I r i r r i t r i I oI t r t I t i I I i I ' t t r '
, i l i l l l t r i l l l zr
\ ( l i '
\ r ' r I
r r r r l r r l r . : l r t t r t r r t i t r r l r I t t I r t I t , r r t r t I t t r r r t r I i I r ' , r t t r r l l r t t l l t t i l l r l l , l t l t t t r i t l r , t l i r t r : r ' l r ' .
l l l l
(
) r r r r r r r (, i r r r r I r
.nprvri u,l fi
rrrrrt,i l i l rl rr' r' ,i l i r l rrl grn.rl rrkr tl boti co: ?toestoa ap,rt sul )
l i rrrrrri , rl rr .r.i zo rl o si l g.l l l rrri s:r,rr Irrl gr,r' Ll trr.i tl . i nt.usi tate foarte-mi ro.
i nt,tl i i tttl
Jtf
tt' rt,i txl l ;0kr sti rr,l ri 0rrl rri , rLr obi coi l u :,mbel e membre i nferi oa,i c.
ul i nl rrs i n.f i mpul uopl i i -ryi nrxxrl i nrl l a tratl ,mentel e anti nevral gi ce obi ql
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.
mani-
l i .l :tl i t |rt o tl n,rn| 1sx1' s el ecl ri c5,
$i
este asoci aLi -cU
l arestezi i . tunni cd,turi
nrr,rl i i rrrl
.rapi d
pe i nLrcl gl di sl ri bu{i e a rddi ,ei ni i (tl e
^l a
umi r i n j os,
i n tot
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:rlgic ctilrintle de la
irrcrlut lotrnembrul sau se poate manifesta nrimai in reglunea- proximalX,
col l ori rLrl ul teri or.
[ ) t t r er el cl p t i p ncvr al gi c ar e doud aspect o pr i nci pal e.
--
^o.senzatie
slrpel{iciali de inlepi,tur5, cir acul in zona perifericd,
.r'rrrr
so 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 i si l i bu{,i e superfi ci al l
;
- o t.lurere situati, profund, constrictiv5 si limitatd,, c&re so accen-
Lrrtu,z:'i, ln mlqcd,ri. Este asociatX, lrecvent cu o redoare
lroiurdi 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 dorsalle ce iner-
vcrr,zir, lolmaliunile profunCe: muEchi, fascie, pcrigst,
capsule articulare.
'l\rritoriul durerii radicutare esto mult mni intins decit distribrrlia
r krlrrlri,otnului, deoarece clurerea iradiazd, qi in muqchii inervali de r[cl],-
ci ni l l r,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, o suprapu:rere topografici, exicti, intre distiibulia
sltp(n lioia]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 ast-
li.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_ea- simptome dc pseudo,angind, pectorali,,
i l r i r z ( ' i dur cr ea est e I ocal i zal d i n st Lnga.
..
l)urcrca precordial5, poate fi dat5, de hernia cliscului Cu-C,
I
acest
rlisrt cornprim5, ridi,cina care formeazi, nerwul toracic anterior'
'medial
(t l,
1i 'l\) sl],u ner-yul toracic antero-l:,teral (Cu qi C")
;
Ice$tiJ, inet"vei],2i, marelo
4i
rrricLrl peetoral gi astfel bolnr,vul poate rvca o clurete localizati Dre-
l l r t , l i r t r : .
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,zli uu rcrlo:uo
It rrrsr:ttl rr,t' 1i ,.
l ) Lu' or' oi ,I rni tl gi ci l rl otrri rri r, rrrl trsl on Li bl oul cl i rri c
ryi
ci l trsl ,. rl o obi ooi
. l ) t
i l r l r , l r i l . t . r i l i . $l : : r nr {i r l ' r r ) l r $i . .
' r 0i
l ) r t ' r r r or t , r l l l , i 1t r r r i t l gi o r r sl , o r l l r , l ; r r l i l , L r r r r ci sl i , t ' i r l o l r i l r r r l oxr r i l , i r l r i l i l r r , l r r
l r , ut ' o r nl l xct t l l r , t i i , i t r r ut t ; cl r i , nl r t r , r o
[ r l or l r r i t i ,
pr i n cor t r pr r r si r t r t oi r , r . I r l l r r i r r i i
vr , t r l f r r l o. l ) i l l l r , t nr r l r r l r i , i r r r pr r l sr t r i l o si r r i ; oor r r l r r sr r r l r l r l r i l xr l ; pr . i r r ni , r l Lr . i r r r r ,
,l rrl rrl l i r, crtro$l l rrnzi r,torr,r' o, I)rrrcftl r, trsl ,o sl ,ri o t, Iool r,l i zl t,l ' l , i rr rrtrrgol ti i i rrrrr.v r,(,i rl r,
ri rl ri oi l ri l o vorrbrtl n oxci l ,rrl (f qi ui r osl ,0 abol i l ,i i ci Irl . r.tl rl i r,r:i rrrr, tl ors:l l rI rrorrl r
;
rr r rrzi i I.orr,l o osl ,o aucgl ;ozi i r,l ,i i , sl l u sgoti oni l ti i ,.
l i i di i ,oi ni l e vontr' :r,kl si nl cornpusn di n {l l l tr groa,so oo l ,rausrni l , i rrrl rrrl .
,rl i l o r[ot]oi l rc Lr, muschi i 1i di n fi bro rnl ,i subti ri oaro pol pftrrl rl co o nl ,rr,r' rr
rrrl rrl i r.i i n fasoi cul el c l nuscuLtr(r, I)urr:ri l o obscty:tttr rtnoori l rr crrrl trrr^ni
rrrrr,rr ri ,tl trci ni i ventral e uu $l nt i nso!i ts do corrtrrrc!i i nrusnrrl i rrrr, ,1,' ri rr,.,,'
,l (' i i rnt, provoc[tc de exr:i tarea fi ]rrol or radi ouhro vontri l kr l i no.
l rr regi uncr ccrvi cal L, o herni e rl e di sc i ntru,fora,rni nn,l i l
Dol l ,l o
rrrrrrrri
trr' orl rroo o comprosi une sel ecti vi , a r5d:l i ,ci ni i rrontrtl l o, tri ,si i rl l rl ,rl r1, i rrrr,
,1,' r' :rl i mai rnu[t s,l u mri pu{i n i ntaoti i . Accl sti i , ovont l rl .t,]i l i l l ,(\
Irr{xl u.r\
' '
rl rr' {.r' c do ti p nri el gi c. l n astfel de cazuri nr' . cxi sl ;i i sul l nrprrrroi rr i rrl ,r' r,
,' ,rrr (l o
di stri bui re a dureri i
;i
dermatom. Daci , ]rct' ni u, rl o rl i sc rrorrl 1r r,i rrrII
rrrrl xrl o rri di ,ci ni , cxi std, o combi nati o al e durcre dc ti p mi l l gi o i i i rrovr.rr,tgi c.
l l rrtrrnrt i ntereseazi i o ari e mai ma,rs deci t cea I unui rl orurrrl ;ont; rl orrr' l rr,
rl r,;l rrl ar di stri bul i a durcri i corespunde dennatomul ui .
Nl l ncvrel e pentru procl ucerea durcri l or snu acccntnrl rcrl krl si rrl l rrl kr
l rrrzi {i i
l l e capul ui , gl ttl ui qi bral cl or, cum ar fi : i ntoarcorot or,yrrrl rri sprrr
I' r,r' l ,r' i t,
rl eafectatdq i ntoarccroa capnl ui spre pr,rten afecta,l ,i i ri i pl i 0rr,rr.l ,
pr,si rrrri i pe vel tex; hi perextensi a col oanei ccrvi c:r,l o
I
fl oxi rl col oi ri rrri r.r,r'
r rl rrl o
I
cornpresi unea exerci l ;a,t5, asupra gi tul ui
I
prx' cui l i rr, rr,l ro l ' i zrr l or. Hpi
rrr' rso
si ru percu,ti a paravcrtebral S l a ni vcl ul l ezi uni i
I
i l pl i ur,rrrr, prrrsi l rri i
, l r i , , i l r l r pe t r unchi ur i l e pl er ul ui br ahi al ( dur cl o; t s, r Lr ' p r r r r sl , czi i kr r i r r l
1rr.r' roptrl o i n ari l tl erm;tom ui rospect,i v sl ,u pc i tl i l orl ,gtt, tr,r' i o)
I
I r,
I
r I i r r r r , r
.r .
r I
t,r!' si ruri i
po mu;chi nl scal cn, Ati t i n l ezi uni l o rrul i crrl i Lu!r oi l
;i
i rr crl r, rr,l rr
l , l r ' \ ul ui , - si nt i l ur cr i pe t r unc. hi ur i l e pl exuhr i su, r r pr r r nr r r i cl r i r r l scr r l r , r r
,rrrl cti or' . In l ezi uni l e pl exul ui ci f&ctel i sti c esto l l ptul oi i si rn
l rl ,orr
rrrl rr l l rrl ,
r r r l r r r r si l i cat e
de mi qci i r i l e qi pozi l i i l e umd, r nl ui
l i
br t l ul ui . l ) r r , r ' qi i r r l l zi r r r r i L,
r r r l i {r Ll l i l re mi $ci i ,ti l e membrnl ui afectat
ryi
i n speci i l l tr,l .o bl tl rrl u i (rl rr rrr r,r rr
1rl
rr
,rrrrl
so i mbraci i sau se pi a,ptF,n5,) deci a,l qenzi , rl ur.ol i l purrtr.rr l ,orsl rrr,ri ,i v
I' rr.i otL1,Lt1 i l i l i mi teazi i , accste ti puri de ni ;ctrri , frr,pb ci ,ri r so rl i rl ,or' rr;rl i rr rrrrrri
,prsr.rr
_al
muqchi l or scapul o-umeral i , qi nu trrl c{i uni i po t,r' rr rrcl r i rr i .i l rr
1rk,
,.ttl tri .
Mi ;cl ri l o urnl rul ui nu au ni ci o i nfl ucufi l , ruupl rl l rrrz i (,i rri l i i rl i ,ri rri l or.
\r' r,rrsl :r, cxpl i ci , tl e ce uni i pnci enl i pot sri nri ;to tl .ourbl ,rrl i l l txrl ,rr,l ,, crr l ol rl ,rr
, l r r ' ' . r ' i l r '
r ni , r i po cur o ) e at r . t | pI i cl t , r cl r t r ' , . r "uLi ur r i i po bl r ul r r l : r l i , cl . . r t . , r r . r . r . r r l . r
trtrrrl i u a,bducfi o
ryi
supi naJ,i o cu capul i ntors corrtr:r,l i t*r' Dl (s.nrurrl l ui i ,rl xf grro
l :r gi l ,) (i ccl an;o,tzri
cl ureri i tr neml l rul supori ol . rcsprxi l ;i r.
I r rtensi fi care:l dureri i so obl i no pri n tuso qi stri i nut, tkxri l urco l rr ptrr.
'
I r{i (| o cl ostoro brrrsc}, a pr,csi uni i i ntr.*ab{l omi na,l o qi i ntri l tol tc i .o. .Atr.i r,rl ,rr,
ru' pont,r:.oxpl i ca- pl i n f,r,p[ul or), s0 pfoduco o sl ,r,zi i , vonoi wtr fur vl sol o opi .
rl rl l l (!
Di ,
r.tsttol , $0 compri l ni j , $i toul tl ural qi ri r,d.ti oi rr i kr
;
oorl pl rui rr rroi r,
:r.t,rrr,sl ,l ! so pol fo rtl or
yr:_ri l l i s
I I' i l ,ej n,l u-so rni ol uscopi o qi so vi r, vtdol cttr
r r r l r r . t I ni cl o#r , t r r t . r i sO i r t l j . r sl , o: r , zr i .
l \pl i oa,roa pl r)$i l rni i po prtrrl ol o nti l l l gi oo rl or:l a,ni 1cazi l , tl l l orj Irrrnr|r^
(.1()nl l )r' ()si l l l ol ,
ri ul i 0l rl i i ri i provoi tl ri X hi por.rr,l grrz i a rnrrgul ti l or' , frr,pl , orr,rrr
l rto.
,
t l t l oo
l t t t t t t t t t l l ( ,
t t r i r l l gl t xr t t t ' u l l l ) 1, zonol r )
( l 0oLr l I Bl r , l t l l r , r r r
l l , Lr r l r r r t r i i j . . l ' t t t r <i l , ol | l
t r r i l l l gi r : o r I ul ot r l r , Ho ni t r l , l oo. r , l i z r , l , o l i t , r r . i yol r r l r l r i l o r l r , r r r r r l i l r r l r r uvoi l no r r r r r i .
l i r t ' i r "1
, 111, r *
B , l l
l t nt l i t f ( u, zi i ,
i ' r r , l . l ui r [ . l ) t t t r r t t l u r +r 1, r r r r r l ' l ool r t , l , r 1, Hi ( f N1i 1x: 1, ' l l l t , g
l t t r t r i r t H( t gt l t ol l l , l r , t i 1, i t t l , r r r r r nl l , l , ; r l u 1, t ' i r oo r l r r 1l i 1, i r r l ' i I i , r
, r
r . ( , I i l or , r i l l cr t r r ov, r r r r i "
' fiimrii^,;
,;i,f[
i r r r ' r , l r r r r pl i r t sr c( , i ot t i r r r . l r l i i r l i r ( r r i l ol t l ot sr r Lr . Vi t t t l t x' l r ( , l r
( l t t l r t l i i
l ) l ' i t t
i t r l j l
l l r r ( i i k' l r x, r r , kr r . u I r ot , oci r i t r i r r r r pr r t l r . l r ' t l t t t t ' t r l l xt r t l t r t l r t l i i ' r ' i i
l t t t t t r i ol i r
r l t t l r r -
r , i r i i r l i ' i i l l sLt t st , l o
I t i t t t i t t t , r r l c
r . r l i l r t {i r , i . t l t r i i r t ui ot i ( l t l l i r n) r r r r l r r i i . r , 1 r ' i
spi r sr r cl o r r r r r scLr l ul c l or l r l i zl r l t , r ' r . . 1) r ' r ' zi l l i i sur $l dl l r ' ot j i , ! j i i r cdoi t t ' ei l r t l l $or -
l ru r,, rl orl urr{ur c\i rJti i i o de s(fi i 1(' i t tc t,rtuti ntui tl e poterrl ,i i l l di n pri ncl t' 1e, i l ttro-
I r ) r sr ' r ul r i Ol Ll l l l ' ( r ,
t.) I)urqile r:rnlatLale sinl
(.trrter]nirat'e de leztrta cordortllclor laierale
ilJ l
l)os1
('1
ioa,r'o t],lc m:iduvei spiri,rii, in special ale f:rsciculelot' spino-tala-
rrri l r,. Si n1, dul el i surde, nepl eci se, l epal ' tj zate pe un teri ti ori u r1al e
fi
si nt
rl r.ol ri tci i rrso{i te de tul burl ri do sensi bi l i t:rtc obi ecti v:i cn l ' el .}arti zal ' e
}e
l ti r l l |l ni (orp srl u cu ni ve-l l a un anumi t segment.
rl) f)ut:orca n,eni,n,gi,alii $e rraractclizeazii plin dureri oel:alice difuze
r rr rrrrloiilc tle ceafi, qi oste deti, in turnorile cerehelo:lrie
;i
hemor:lgiile'
s u ira lrllrnoid
jt:ne
I
durerea mr:ningittlL sil,uati, spinal trste datoritS, tunorilor
rrrrrlulillo
1i
hclniilor de disc
;i
se calarterizea,zin priti coiltrootar'ea pilrir
vcr{;Lrbrtrlir, asoc:iatl"l cu dureri pe ma,i multe segmente.
L:) D,urerile Lalamice apar in leziunile cturc adecteazf grupele nucleare
l i rl r,r' al c al e 1,al amnsul ui . I)ul eri l e se l ocal i ze*zl pe hcrni corpul opus tal a-
rrrrrsrrl rri l t:zat,, rrai al es pe fat-i ,
l i
pe rnernbml superi or, au o accentuata
l rrrrtl i l tto ai ecl ,i vS, nepH,cutd, qi se i nsol esc de l ul buri ' ri tl e sensi bi l i tate
oIirrrlivil,, rnti a]es proprioceptivi,. Aceste dtrcri apar indcosebi irr ll:zinnile
virroulare ale talamusulli;i anurne in afecliunile din teritoliul alterei
lr,rr liculo-optice
I
leziunile vascularc tlin tcritoriul artet elor talamo-gt*1icu-
lrrir'i, si talamo-pedol'tltii dau aStere la tulbul'5ri de sensibilil;ate obieciiYl'
cu l.opografie caracteristici, da,r nu genereaz:i durerei'l talamicl propriu-
zisii, slu goneleazi1 doar dureri tle mai mici, intensitate.
.l)urelel t:llamici poate fi conl,inuX cu exacerbiri, sau po:r,te surveni
tliscorrl,inuu. Soarte acleseori ap:Lri!ia durerii sau exacerbarca ci est'e rleter-
rrrirl ii, de survenirea unor excitalii liziologice, liminale sau unoori chiar
srrl rl i mi nal .e. Astl el , dri rcri l e pot si aprrl l l rl pl i czr,rel upei reci pe o1l raz,
irr lirnpul picptinatului, a survenirii ultui culent tle acr reoe
I
lrlteori
r t)rrritirr
dril'erii cste determinrtd' de excitan!,i senzoriali
(mirosuri deza'
gitrllrile, zgomote sau lumini putelnice) sau chiar a unol factori t'rrolio-
irlrli.
-,\cca,sti,
integlare in durere a excitaliilor senzitiYo senzoriale sau
i,*il,i,r', ,r I'ost denluurili, tle citre
lead
ovel'reaction (stprarcacfie). ln
ilgi I ruli cu tlurerile talamice, mli trehuic emitrtite noi-iunile de hiperal-
gizitr
1i
.lriporla,tie. Il/teral.gezin, se traduce printlo sensibilitate dureroasi,
r.r r,rsi vi,
plintr-o scidere a pragului durerii, astfei, incit uir stimul ile inten-
si l l t(, r r({l -rrreroa si r, poduce^tl ui ' ere . Hi perpati a este tot o hi peral gezi e, i n
r.rrrrr ilsir, tlurerea are o tonalitate afectiYd' nepli.'cutd
fi,
palalel, e\ist6,
I,rrllrrrliirj. da sensibilitate obiectivi, in sensul unei hipoestezii mai rrult
;.rr,rr rrrni pu(in accentuate. Iliperpatia apare foarte adeseori in cadml sin-
, l r r r r r r r r l ui l al cnr i o, al ; t ur i t l e dur et ' ea spont r ni '
11 I)urerile [isceralc. in eazurile de lezare a dilerselor organe intcrne
l rohrarui i ecuzi , rl oui , categol i i de senzal i i nepl i ,cute : pe de o parte dl ueri l e
l:uu,|rr ilc sufclinla nt'rnijlc citi, a forrna{iilor recept'oare de Ia nivelui orga-
rrrrl ni rtsDectj v, i ar p.' dc al ti , parte, d' ureri , proi ect te (re.feri te) l a ri i vel ul
l cgurrrcrrt^r,l or' . As1{e[ bol navi i cn angi nI pectoml S, acnzi ' durel i i n rogi unea
ll r'ocor'd iir,lir,
qii pe fr,tl intorYrd, tu brllnlu.i sting, srferinzii de ficai; acuzztr
i l rrr' ,' r' i i rr rrrrri l t i Ll rl rcl ' l , bol navi i cu ol ' j zc tenal c 2l ouzi l , dtl ef i pl oi cctato i n
rogi {)a, i trghi tro"scti rtn,L' l , ol j c. A&\$1.(} t' ori tori i pon' rt:1 Yrul ncl (f
' l o
,zonel 0
I r r i I l at ul t ' .
1I 4
I r r pt ' r r r , l l nr , t t r . r t t ' ol r t gl t r i l , cl , l i t t t t t t ' , l l t , t l t t t t r r i r ' i r i t r ct l t l l r si l ) l i i l l l i l ni t l \
r | l 1r r r r r r r r i i l r , f r \ t l i t r ( l ( ul . t i ] ( t l r t l t di r t ' , t ' . t t r t
( r t t t t l r l : t t t i t t r l t t t ' t r t i vi r r l r , t t l ' l r i t t t ' t ' t l l
t t i r cr t r l r i gi t , sl t i ci i , i t r sf i r l r l l r r l r r l t l o
1i
i t t so{ i l r r r l t t l t ' st ' r l t l t r vi i t ' sl ' l l t t ' i
l t ot
si sl ' r ' t r l r ' ,
r l r r r ' , . r r l , t i got i r , 1t ) r i l ' l l l r t . t l g I t I i t t t t r I t I I t
I
i r r . A. t r sl t r l t i t l t r t l t t t t ' i t zi i t r i l t ' \ ' i t , r r t t '
. r l r ! r l ( ' i : r zi k: , cpui zi r t t l 1t c
l t ol t t i t , v. Nt t t ' t r l ci l zr ' i , l l t , l t ' t ' i t l t i i l ol r i qt t t t i l r i ' r t
, r r l i I i r r 1r , l o: gr r . sl l i i r ' . I t t l t i , , t , ,
( ' t ' i zI l ' r l ' gi l l l l i ( r ' l i t l r t l i | ' r ' i | t t t l t i t ' t l t t ' r st ' - ' l t
, r l t r , . t t . : e t : i i car al . e:
( t ' i l a
. l ( t r i nl l i
e; i cso. f ur i ngi l nt ' ( r l t asnt t ' t l l t t t ' t t t i t sl . l t t
l r r l i t r {r si csoi t l g, ct t i cni l l a dcgl ut i l i ( \ ) ' oi l ( t l ^t i at kur ' ( st r t t z, t t ( i i - t l r '
l t r r r '
( i r r r r r ; r l r Lr t r r or $i i n t est i cul ul ui ) , t t r i za r : l i t or i i l i or p ( st : r r zl l i i i t t i {i r l l Vr I I t t ; I I oI r I r r ' ,
, , : r r l r i r l t r nr i f onni i , l r ept at i n t l ur cr i vi ol cnt o) , ar i ze ur i nut t ( r l t t t l t ' i t t t
r
' .zi r' .i
i 1i rLl e tri l ), cri zc hri ngi ene (foal te pertcul ottso pri l t l rpl ,rtl l ri prrl
, l r r r ' , ' l r L : r , si i xi t ' ) . l n t oat c l cest o cr i zc, nt ss al e1l i st azi ' l l r t zi uni
l r l ol t t i i t r t ' ; 1r t
rrrrl rri l l tri vol Lrl c[rui a se resi rnte durerca
7,1.2. Anal i z:r tul bur{r"i l or obi toti vc al e tl i versol or sl rrri fui l i l i rl i . l )rrr
r r r i r r i r , r cn acest ot ' cat egor i i t l e scnsi bi l i t at o poat o scof t t ( t i u ovi t l l t t {r i t l i l l t i l l
rrl )(' (,fo pi l tol ogi co
Di
anurno : i n uncl o i rnpftrj rtri i ri sti pl ' o{l l l (1rr
(,
r\\l rl .l r' r' l r l ' r\
,, no r r s i l ri l i ti ,!,i i , sbi l ro nurni ti i hi perestazi a
l
al toori i l l )i tr(f tr t l i t t t i t r t t r t t , ' : r
'
'
rrl ' :r
l i l ;i i i i rcco1tti vo, care sc nutl e$1c hi ,podtni et c:l l (l
l )orl l r(r
l l l l tl ' Al f
l tl l ri l
l rL
Iri rrl rIr,r' oi l
Cap:r,ci ti {,i i recopti vc' sta,re numi l i i . ansra3i P. IIi l )r)(f$11' ,i l r, ri rrt
rrrrcsl r,zi a
pot i ntcl esa 7;e i tr)tl i aroncttl u,re, radi tttt,l u.ra r,' ,t t1 ttor' t' ttptt)1:ttl t4!tt|
t t ) t t ) t t ( ut nant e mad, ul a, r e. t r j Le l ot i nt oi ' csi t i ; o: t t c r nol l t t t ' i l o t l r r sr r t t sj l r i l i l l t l r l '
,,rrrl rrri ' bi rn rl e hi Ttoestezi e sau' anest' ezi e gl .oha,l d, s' ,t' tt
l rttt
i ttl t' t' t' srt' rttttttrtr
r r r r r r r r r i t o cat eg0Li i i l e sensi hi l i t ; , 1i i , cel el : r 1t 0 f i i nr l i i r l i r o{r r , <, i r r r l I oI l r i r r r r l , .
h i l t or ' : r t , . zi e sau al l et t e! i e t l ' i soai ol d' Exi st r i t l oul i f t r l t t t ' i t l c i l ' s{' l r l ( ' t r {' r r t l r r r l
, r r r ( i i :
1. . Di soci aJi a si r i t t gom i el i cd. , i n ci l t ' c br t l t r l vt t l l t i ct r l r r
r r r t t si l t i l i l r t i t ' r t
i , , r r r r l , r Ll gozi ci i , scnsi bi l i t l r t e: r , t act i l i i
; i
st nsi bi l i l r r i cr r
l r t
ol ' r r l r t l i i I i i t r t i i t r l r r , r ' 1r , .
\
1rrr
tt i ri s l ri zgo i i t. i el i r:
1i
\rL si ntl ronm,e l c si rtrtJl ont i rtl i rrtr
.ri
st' tl rtl ot| i 1l r. [' zti t tt
l rl rl r' l oL tormo:r,l gezi ce :l l c fasci oul ul ui spi tto-l ,tl l tt,ttt i tl , l l t, tti yt,l ttl tttctttl i
r : i l i i t l i n comi si i r a ocnt l l i e : i nt er i o: r i i l , sa, u 1a' ni vol t t l I r l st r i t ' t t l t l l t t i r l r i l t o
I r r l r r r r r i c post er i or .
:!. I;i soci t1,l i a l ,abel ,i cd,, \l L care bol navul
l ri et' rl tr
strrtsi bi l i ti tl tri t'
Ittttl tttttItt
ri s.r^i bi l i tatci , tacl ,i l d, opi cri ti cl i , sensi bi l i tl tcrt l ,ot ttto-l rl grrz i .i l , ,1i t' rrrt, l i t.
l rl l r rt L rl ' r,pati ci t fi i n,.1 i rLti rctc. Apare i n. trabr:s si t' tt i t si ndrottttt' l t'
1t:st' trl rl t
t,r' l i r' ,; si ei te dctermi rutri tl c i ezi rc' .r, col l l ol l n0l ()l
[)()si t' ri oi rrl ' .
?.2.
pl toBl l j Ml ,l
DU DIAGNOSTI0 T0P0(i ttArl 0 l i l
I,l 1' 11)l ,AT(xl l rNl (
j .
SINDIi OAMIJ SIINZITtVII l I0PO(i RAII(JII
(i i i ,i h
seusi b i l i tri {i l ol pot l l i l czn,1,o i n ttti caro
l trtttcl ;
rtl l rtl i cr' 1' ttl tti hrr,
I r r i r r t l r r , st t cl r r a, l hor o si r l r r r : r r r r o
( 1l i ni co r l i l i r r . i t c, l cga, t 0 t i i l r vr i , r l {J kr r r r r l i zr r
l r' l r, l r,zi utti i . ' l l ul l turi i ri kr tl o sr.rl rsi bi l i taLo pot, sti ooul xr o
j tttttrl ,l ,:rl ' o i r' {1r,tIrl '
I r r i . r r r r r nor r r br ' t r si t r t nur nr ui ut r cl o t 0r . i t ol i i l r , l <r ut r ui r ncr nbr u, l ) r r r r , Hr . l | t r , t t r , t t
r,l ri rrrrt i rrl o' osi l
(l ol t'
l tnol o l rl o(l ul ' i
(l o
$(rl l si l )i l i l ;i rto. Iati l , rl txl i ,
(fi
l ' t,pttl l t' tt
l i r, I.ul l turdri l or
xr:nzi l i rc
;i
l u,l i ful at' l or, t' csl ttrtrti v notl ttl l or rl o
$t' l l l rl rl ' t.,
t r , r l , D| c0i zi t ; 1( ' ( [ i l r l l L, zi l t l l i i . ' l ' i t t i t t t l soant a
( l o
i ux) Ft 0 t l t t t t si t l ot ' t ut t t r ,
l t t t l '
l ' l
, r . l r i [ : ' I r r t t t t t t t l I r r : t t r ' l r
g
i t t r . l r r t i t t t t r r
' r ct t zl l i vr '
:
A. Si r t t l t ' ont nol o
gl r t t zl l i vl ! pl u' i l {- r i t t t .
l . S i ndrxr,rnttl t, l ,t' uuot[u,ut
( rttortotttrtt' i l i rr) . l ,r' zi tttri l t' l l (!l ' vi l ol '
l )(\t' l l l \'
r i oi r l r , l ol r r r i nr ' i Lr r I br r l i , t ' i t l t ' nt r t t r i l r i l i l l r l , o, . l 1, 11, st r
1t t t 1
l i t r r i l . r t l r r , t t t r t . l t i l l , xl , t ' 1' r l
#lllilil !iii,#{"rr"ffi
i{#irt"3:l rii#il'
#*"il*g
l,;ii,:t;1l;.
,,r,lp,m"pirlT*ffi
ffi
iili*tr#t;:l1'-.;iilH$H;xr*;:#i
it,rli[$ip;i*:Tf
ifl *]*:ff
,."#HTi"",H11"*ir[*W,e"":;
,,,,,,,.1;*1*l"liilill
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ti'r,i.i.,
.t,)'te
clr,racterizat prin diminui,re-a gi"rr"i;L--iri"i"r
modurilor
cle
::iilliiitii:q3":,::lJ#J:'rtxif
3*s,,;tl"":#**;r"x*wii
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sc i nstal eazi , atrof
iilii'*ls*;#I;
*,::lffi
titl#1ff i;#:"'tri
i:l1"il"i,"fd' ;i,','+3il:
,,*,,!,':,1!,i;!Tlt,,u'.';:ff;:ty*yvdritor
senai'tit:e
sint in runclie
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,.,,,,,1;1.l111;,#,lJlfr',3'y,:Xril:!:iJiffi",tlifrl1"$itgli,iK:tr;r,li*:
lliil';|U;,,llti.JJ1trl3i.**?1?o".ui
aitt'elic;.
plli'i"i'.ii"G
postserorera-
'i;i
;,!;;;: i;.;il#i#,?#;*flJf*l'?J,1f""#TlHf,"#?'i:
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fot.me
spn?i ttt)e purc
;lnt;1lxl",ni***i"ffi
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prrrp l i rx:tpl ,i ve.
iril'll;l##iry##Jiff
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llllll*j;
fl 0
r r r ur i r I ct t I r r t 1( l r t ) l ( l t l r l ) i c( , , r l i r t l r ol l l l r , l ui I l r , sr r i r r r ' . I l ocl i Sr r l t l l r r r r r i t . t r r r r r l i t r l r ' ; r l l i ,
r l i r r pol f i r i i
1i
r l i r r r r r r r r l t r i r r hr xi cl r , l , i i cu sr t l i ' t r nr i r l r r r oxi r l r l c cl r , r ' l r or r qi l l r r .
I r i l t n i cl .
l r,
t\i n;l xtl tttl rarl ,i ottl ,arsi 7tol ,i ,tni l i tttl rtt' i rrrrti i rtrrrrcl toi t,zr' t, tIrrl ol i cu rl i l
l , r ' r l r t r ( i i t l , t l i cuhl r o, pi t , f o$t ozi i si t uLbr r l r i l i r l . o sur si l l i l i l , i r t , o obi r r cl , i r . i , ,
l ) t . c( r l r r t
r r l r r l l r r r l i i l i al or cl l excl ol i n t t r : ' i l , ol i ul r t r l i r , ci r r i kx' i r r t or i : sr t o. l , ) sl o cr r , r ' i r , r l r ,
r ul i cl i , t Ii sl ;r:i b n1,i i l net tndi oul i l ri l , dot' rnl tornori ci i , l r, 1;ul bur.i i ,r' i l o l rl rr su rri l r i
l r l r l r ' , r . l r c t , sl ; o t l o obi cei gkl l t l l i , . l ) cbut r L[ r l ur cr i l or si l l 1 sr r r r l nr l ol t r . i or . j r r l r .
r r r , ol i r , t r l , u: l zr i t l i ngnosCi cr r l .
^{ccsl
r r cst c bl r r t , i r , l i i t 1, r : r Lur nl r l , i sr r r o, i r r r r l r , r r r
r rl l i l i tri i ccl ;i i qi progl csi v i n tumol i . Adcseori l czi uncrt i nt cttrsci tzi i rrt r r, i rr l l l l
r r r r l r ' i ci r i i , oi nr l voi ' bi m de pol i r : l di cul i t e, sau i r r bcr oscl , zi i , l r , l i l , r ' i i r l i i r r i r r i l r ,
rrl ri rl i {fl c, ci l ,
1i
norvi i peri feri ci , ci nd vorLri rrr de pol ,i rni l i t:u,l orrrt,ti l t. l n
rrl r.sl ,r si trurl !i i , semnol e motori i si rrt i rrrporbd,nto, cu pu' i l l i z i i l l rxro pr,r.r
l ' r' r' i r' 1 . ,l .ccs1,c pol i ratl i cul onevri te si nt dc obi oci i rrl i ccfi orl su vi l rrl i rr|
.rr prr1, l ui l un cl t' a,ctcl asccndent. Al teori se l eal i zcl zi i ruorti rrgorrri r,l o po l i
r' ;rr I i r.r rl ol cyri to.
5. S' i ,ndrom,ul , d,e
,,gangl i oni ti i "
so cal i l oteri zol ui r, pl i n srrrrurrr rl rr l r,z i
rtrr: rrrcl usi vi i a gangl i onul ui spi nal
;i
a l i i ,t1.[oi rri i posl ,ol i oi r,r' o (srurzi l i vo;
pl i tr l tectarea
,,pri .r' i l egi atd,)'
de c5,trc vi rusul hcrpcsul ui zos1,trr, crr rr,l ' i rri
l i rl r l rcuroectoderrni ci l ,. In l ocal i zarea cl asi cri , si ntl rornul sorrzi l i y :rrrr rr
l .rl l )ogr' r.t' fi e radi cul ar5, mani testi ntl u-so pri ntr' -o nevral gi o rl o t,i p
,,i rrl ,r,r'
rrr,i i .rrl " uni l atel al d,, vi ol enti , conti nuX, da,r cu exi rccl l ti i ri pi l rrrri sl i ru' , rrrr
l rrt:url ,ere al e constti cl i e, de i mpuns5,tul i r,
1i
rl o arsuri i , l i l cu,r.o $o i l r1r,(1i rzl ,
:rl rtoupc obl i gi l tori u o enLpl i e cri tema,to-vezi cul aL' :i r-rrr i rrxrrl ;i hrl rrrgl rrl ' i r..
l rr practi ci i ,
asi st:i n l a vari l te l oca,l i zi i l i : cul vi ci r,l o, col vi co Irl i r,r' l rr
;rl r,, l rrri l cn,l e (,,i ntercosta1e"), l ornbo-i nghi ntl c, krmbol l ornrLl i r,Lr, ri :1,(,1' {) i i {r1l ri
,rl i cr' . .Sr-r, mr ui tLrn tormel e crani ene, cu l czi urtoi l nctvi l or. rrl i trIi crri , V, Vl l
\ | I l r i s, YI I I , I X, qi X.
l i . S i ntl rom,u.I tl e
Ju,n
i ur,l i td, tt,l , hti Bi cartl .
1i
l ,' ot' trsl ,i n' (,sl o rxrrrl r{' i trl rr,
l r,zi tttti i l i ,tl i tci ni i i n por!i unea sa eri ttr-Incn i l gcu,l i i , Lr, l i vcl ul l ,r' i r,rrtl i i i t l l
,l ri rni i
t1e conj ugare (JtU. 29)
r r ) ) n si ni l r om. u, L de i r i t ul i e
f uni cul af i ,
Lul bur i i r i kr si nl ,
; r r r l
l r . r r zi l i vr ,
r1i ri . 1utrl uc pri n durel i vi i , a,soci :rtc Fi l rr l u cLt o bl Ll rt{i , rl c l r i l rocsl l z i o, rIrrrr'
r i l c l i i t l l cxacet bat e t l e mi ; cr i r i l e ool ounei
1i
t l r i
i r n, si r r r r r , l ,
pr r l l l cr ' l i ' l r l r r l i r .
;' i , i rsoci .rz:"r,
;i
trti tutl i l i antl l gi co ou conl ra,cl rrt' l t, trrr ri rol r i l or'
1l r,r' l rvc
l l r.l r l i r l r
.
1t) l n sbtdromttl tl a aomprui utta
,f
vni att l ut' ri , s(tunrkf rl r l rl ,i trrl r.tt. rroi o
l i r ^ si t t t pc pr i r nul pl an, i at ccl o t l c al t r cl ; r r , nr si r t r zi l i vi so l l i ul r r c pl i t r ; r l gi i
,;i
l rl i rr
hi poestezi i i n benzi (uul i cLrl n,rc).
Il . Si ndroarncl o srqrzi ti vo ccnl rul o
1 . llin,tlrtnmole sanli,l,i1)e
.nulu.Inra
L Si ni l rornt,Ll sacl i ,u,n' i i .l ,otal a ( com.pl cte) u nddl u,no i rhl ,cnui nri , rrJl r,r' i fi rr,
r r t r ci i t nr st ozi i gl ol l nl o subi ocl ; i vo qi oLr i cct i l . c r l or l csul r t ul l czi r r t r i i ( l ; r r l l r r r .
t r r t o t l r r sct t si bi l i t r r , {; o
, , ot r
ni vol ") , i t t sot i t r i
( l o
l ) i r , r ' i t l }l cgi o
sr r , r r kr l , t ' r r l l k, g i r ' ,
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I t t r . l r r t , l ) r r l i i i t r I i t r r I r ' r ' l r r l r zi r r r r i i ,
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r r r r , r l Lr l r r r , Ll l i ot r r r r l r r l r r . , l r r l t ol i i t r I t i r t t r l r I r r | r r t r . t l r , t l i t ct ' sc t t r t l t t t i , l t i r l t t
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1, r r r r i , l i , ' .
IL Si arIntunu' l t srn.-i Ii ' ta o,l t' I,t ttrtrrh i tt,l rt i
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t r r r r r . l r i Ll r r i r . r j nr r , r l l l t ' ol ol r f t 12r i i r cr uci r l t r t c: r l {) r ' . i a, r ci i i l c st r r si l r i l i i i i {i i l i ' {r ' r
r r , : i , r l , r l r ' i t r I r ' r t t , i 1l nt r . l ) {) i l ( i c( r LL, i t t . {t sl o l cZi i l ni l . ol g{' i l ( f l ' i l Ni t t t l l ' t i t t l t t st t t
t l i t , r t l t i t t r ; l i r l l l t t l l i l i t l ci i cnsi l ) i l i l l r l ogl ol l i r , l i i , al t l t ' i ci t I t ' i t t t ' t ' I I r j i
l r r t t
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l r , , r , Ll ! r ' l r
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,
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, r , , , , i r l si t i t t gl or ni ( ' 1i 0. Acei r st i r , t ul l r r l t t ' e al t t , r ' r l "t ; i r l i r oci r r l i t l t ' r l t t r i l r i l t
. r l r ' yr r i c i nr : i r , ost t hi i n si nt L' omul l ui \ Yal l r t nl r ct g, l l l t t i l l r r l r i t t r l i i Nr r ; : ' r ' r r l l , '
r r i l r r i
( l cst r r n- ( l h{l l l i i r ( \ ' czi ci ) p, 1) .
t . , : i r r t t i l c' pr r i ubct ut t ! i t t l e su, 1t t : t i oat c
1' L
pcr l t r t t . t ul ar t t l r t t t l t t l l r l t t r l l i r l t t
. , 1r \ ( ' ( , oi l
h i i . i l . c. r ' | , l e al o f r , {ci , l t r r t r c}r i . t i l t t i
; i
r nt ' r nl r f t r l oi .
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; , i l r l r t r r l i zi r r
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l ] l ' t l l l l i
st ' r t ; r i l r i l i l r t i | ' r r
l , r , r l i r r r r i r i
( t 1mi o r l i sr . r ci r l ! ' i i r r l c i : i p l nl r ol i t : ) r ' t L l t ' s; r t r i ' i r t r t r t ' sr ' l | . i l , i I i i : r
t
i I
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l l l . Si ni r ot Lt l t t l t l uki ni cr : i t t
l t t t l ol ogt u,
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, l l l r i t t t i cst l i st
l i
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l t t t t
i . i l i r t r r l l t t t r r
I r zl i L. r l t t . I ' 1t l ei l oi l i l hl ni ci
l i
i t con0! i ul l i l {}r ' l l ( r cst or r l , I ) l ( r I l l l l l r , l
l ) r ' l r r
i or r \
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( ' \ l ) ( r l i l l l ( ' t r l i r l ( ' si t l r '
l r r t l r r l r r ' 1r , '
r r r r . t r i ( Si t gt r ' , 1960; f , i i zot l hcs, 1. 967
I
Ll r t r r r r r i l {1r , l l ) . ) i , l l l Ji l i
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l 1l , i t i l ) ol ) ( i t . i ! i i r r , i i 0r r Ll r b. , 1l i i "i 0) . l ' ol l l t l t i t l
l eJl ' gt ' r , t . l r '
i t t ' t r sl r t l i t t r ' l r t r r r l t t r 0t t r
, , r , ' l l t r r i i i r l r ol $t l i , ( l ' opovi r i t t , l {) 7{) ) ( 1, ' i q. i t l ) ) .
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'
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l ) ( l l t t t
t r l ) t ! r t l
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I r i ' l l l l l l
l r ( ' l l i i l r l
l r l r r t , : r pt ol ut t t l i i ) . l , ) r i sl i i , si l r r r r {i i i r L t r i l r t i ' t t l ) t t t l i t ' i l ' t l t s( ' t t si l r i l i l r r l r ' r r l r i I r
t r r l r
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i t l i ( ' l l l l i t l l l r l l ( ' l l
I r r ,
i . r r
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( 1r [ i r r l ) ( ' l r i i i r l ! {' t l ( ' zi i l r ^1r r r r ( i r r l l
r l r '
] l r r r l . | | r , ( x) i l i ( i i l i i , i t t i t st ' t t t ot t t i t $i l l l r l l i i ,
( l j i l gl l osl i t ' r r l l l i l i ' r ?t r ( i l l i t t i t r ' l t | . t r r i
, r r r ' r t ( , zi i l i r r l l t l t i t ' r ' i qi l t ct r t i l t t t t ' sl t ' zi : t t ' ot 1i t ' t t l l i t l t r vi t t r ' l i l t t l r r r l i l i l i l I
I t 1 t l t t t t i l r r r t r : i i t , r , yi r l r r l l r . . . | i r i i
( si t t t l t l t t t t l ( ' i l l ( '
l l l i l r
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l , l r l r t i l t
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l r t ol ) t ' i ( t l t ' ( ' l ' l r 1i t ' i ) t l l )
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t r t t l t r ' l , , r xt t l t
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LECENDA
6r nucleilor Gr nrcleilor 6r hucl ei l or t6a
nucleilor
CL:N. Cq'p gedcuto,
laEral
CM;Ncory genbulol
OM: N.l)f,Rp-
+N. furdfasci:ul.
3U : N. Sutndib
VL (W j:N.
Veitr. ld. CL: N. Cehtral
l-D: N- lateral
Jriq. Jr, Nucleii talamrisului
$i concxiunile acestora (poporiciu, 1979, sehem$
({'rnbinnLi
dupd sislematizareatf,nucleit";"?;.r,n
n" Wa tct, Sager, Le Gx)s
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psi hl u) sc, , i rrt (. grcazi " i r. r durcr, . .
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rt , , pi l i l i i , o c\ (. i t t l i (.
I i r(. l i l i i , dl l r(. rl )t f i
qrrr
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l r ol t r r t , vr ' 1, . Ani , f ol , t t l t ul di r r l r ol na, vi i l ui I l t r r r r l ( <r i t r r t ' 1, t l r r Sr ! g( ' t ! . l {l {i ( l ) r ' r ' i l
r l r . or r r l r i i r l o af l xr Ni l t r l c r nt : zi l i i , , l t t ci {,
, , t t t r l l t r t or t , sI r t ' zi sl r t I t , i t t t t t t u i t l r t 1, r t t ' i l i
rrr,ttzrl l i l krr do par' 1;ort, sl l bol ni l vi i ,", i i l l rtl t
l rtoi rrnl ,
rrl l tri Il rrrt,tl i t,l ' i t' ttttt, t' t' l
, , l r l ' r t t r oi r : i nt l oi nl , i t cot ul , o sr r r t zl t {i r : gt ' oi Lzt t i r l i t vt r r t l t t ' t l i r t
l l t t ' t ' t r t t , I l oI r t l t t ' i ' 1' ' ,
' l ' r' o|l l i l ,i i ],ceasti i , l eri tl i nl ,i r, tl o t t' tr:t,c! i Otl l t oxoosi v l tt 0ti cu 0x0i ti t(i o s0ttei
l i r l , sr i nzor i t r l l sa, u psi l r i cr ' i I r ' 1r l , zi n1i i , f enor uct t ul r l o supt ' r r r cr t c{i r ' l r t l t r
r rr i rr' i , (,,ovct-teacti on"-IJe:r,d
)
sa,u d o l ti yl pati rt" A ccsto l onottttttto st' t' r
l tl i t
i i
l rl i rr
l rl ptul (Sager, 1960) ci l , i n nucl ci i l atoral i convttg c-roi l ,l l l ' i i rrfi 1, tl i tt
rrrr.rl i rrl i trtern (pri n i ntermedi ul nucl cul ui dol so-mtx.l i an), rri l , i i i tl i tt tttr' tl i ttl
r.rl ' r,r' rr, a,ti t pri n nucl ei i tj al ani ci de rel eu pc ci t' i l e di vcrscl ol i l f(' r' ol rl r\ H|tl
zi l ' i vrr, ci t
6i pri n
nucl ei i tal nmi ci nespeci fi ci , i n l el a{' i e cu fotttta,ti i t, t' trl i trtt
l rrl ri , rcspecti v chi ar stal i i pe si sternul reti cul at asccntl cnt (v(l zi l i g. i i l )).
I l qr,rl
1i
f161p"* (ci tat' i de Sager, 1960), i ncerci nd sL e xpl i cc tl ut' ot' t' tr hi l x' t'
rrrrl ,i t.,l i , tal ami cX. au ar5tat cd, l ezarea fi brel or corti co-tl l l atni cu rt,t t' Ii Itt' trt
,' r' l rtl el o senzi ti ve tal ami ce de snb i n{l uenl a col t' i cal 5 i nl ti bi tol i tr
6i
rl o tttrrrrrrt'
rr(' r,g1,i noul oni senzi ti Yi ar prezenta o
,,supral eact,i cr'
l n ol i tto r' rci l rt,ttl ,
llrirr,r subliminal. Dup5, alli auttli (citali do Sagor, 1960), rlivcrsohr
2rolr"v
Ir'. ion,a,le (tasoalare, tumorala, i,nflamatorii, cticatriciale elc',
)
an cxcil,rt, txrltt lt'lt'
rrr,rrzi bi vc tal ami ce qi ar produce durel ea. Incercl ri l e cl o i nl ,ol rotrrrtt rt tl l ttt'
l i l ol tal ami ce au dus Ia i l i spute i ncd' i ncompl et el uci dato. S-rl tr rr' l t' i l ttti l
rui ,fol tal amugul ui , i n afard de rol ul si ,u ds re]eur qi unel o prtni bi l i t' rl ,{,i tl rr rt
'
r'nlrjbui Ia elaborarea senzaliilor tlate tle stimulii nociccpt,ivi tlo l ip pt'tr
l ol xr,ti c (Mori .n, 1955; Il ead, Il ol mes, 1912r ci ta!,i do Sagor, I9(i l ))' l rl tot'
rrrill,e (1936) a ard,tat c5, alterarca nucleilor laterali exalttl, lronalil.rr'l,r,rt, rt'li't'
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
||rrrrcntel e
dureroago gi protopati ce al e acestei sensi bi l i t[]' i . l )uror(' r\' l i hl tl
"
$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
lrrr,zrr,to pe 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,ul sttporiot
rl c porcepl i e a cl ureri i , Dar qi tal amusul ui Ii l evi rrc, dcsi gul rttt rrtl l ttl l tl t'
i trrportant, ati t do rel eu pe cd,i l e senzi ti ve (i ncl usi v dunt' o?r,H{i )' <:i l , qi l l rr
l i l l ,ru sel octi v, precnm gi de a
,,mocl ttl a"
qi do n contri bui l n, ttl ttl xrrl ut' trtt l t
rri vol ul scoar' fei a unor senzc,tri i parl ,i cul arc
*
tl upi l , cttttt trl l l i l l t(l l l l l l
rrttoti or' - pri n convcrgonl a, l n nuckl i i l atera,l i n' unei l nul ti [utl i tti tl tr ttLr'
tr,tr!o extcto -,propri o-gi vi sooroocpti vo
;i
pri n I' ol trl ,i i k) i ttrtrst,rtr tttttrl oi t' tt
l i l tnal ,i a, rel ,i cnl ari t' qi cu sc.oa,rfa ccrcl brt i *l (Sl l gcr, l .$60
1,\rscrti
qti
()l )r(' H(' l t'
f l f(i ?
;
Il oDovi oi u, 19?9)
;
i ) Mrri pot api i rtr:l rni rscri rti
(,or(o' at(toti t:t' , \' 1\t' t\ Itl
tl r.norl rl
si trf tl i scrcl ,tt i i i l ot:a' l i z11,e l a ni vrdu) rni i ni i (pri n l trzi trnrrl l I' i l rrtrl ot'
l rrl i t,ttto' 8tri rto, r' os1:txrti v t trucl tttl rti trot ti ,t r l -ttttttl i l tt t l ,l Itri Lu,r-s);
j )
,,J\l l rrrr,
l i r,l i uni r{r," rrsLc cu' t' i t ttt ol ' i nt,i rfi
,
l tt sttttsttl t,i ' t, drrgrdcl tr si n1, tl trrl i vol rl l ,tr tl tt trtl l t o
r r r i 6oi l , r ' i l ol t ot ozi <xt ( ut St t "zi sr , l ot f i t , ut l i t t i t l o, , t l t ' gcl , t r i t t gl t t r l r t l ot ' pr i nnr i 4r r dl l l l
rt,l ,ol ,rrzi trr)
i
k) l l ' rt,l ,hurl l ri Irt ntnl oti ttkt Hi tl t rtl )roz(fl l tnl rr l l tr: l t' trttl ti ttrt' ol ttti tt
hk' nt l i l l t ont , oni ' nt d ( l l ' i t t l r r zl t t t t r , ; r cor ] 1t t I t t i gct t i c t t l r t ' l t r xl r ' r t t ut t t
l ) l
i l l I ' r {r t l l l ) l , r l r
r r n1; ci n, l t l t t r 1t . r , l r t . r t l cI pr xl r r r i qt r r r , l i r r r t | , zi r r r t r , l r r I r r i l ol i r t l r r r r t ' l i <' nl r r , l t t t ' cl l , t , i ,
zrl
, ! l { r . ) l l i t l t t t l t i hi l ) t t l t t l i r l t t ) t t . i t oNI t i Nd Jt i l ) o. t }( t t . ( | / ) , ! ?}? i c ( f t , i l t l . zi r r r r r , l t
r r r t l r r t r l l l r sol i l r l i t . cr r l i t I l r r r . r ' I I r , I t t I ) .
:.' . t\i ttr,l trrrtttt l t.l ttnti cr
l trttl i uIt,.
rt) [)a,tc i r ni l t ut rro-cl i ni ce (a1e l ui | hor,
r r r r l l r ' , l 1) 1. r , l 1) j i l i ,
l , ) {\ . l t i i r si
l l c I ui l l i r r , i t escu
f i
Ni cul t sc
, 1925,
ci t al i r l c
)i rl l (' r
,
I
j ){i o
j i ' .j
(
.
I ) L i
j .
1.
( | I
,
,
19;i {i , ci 1,al de S:tg01,, 1960
;
?opor.i ci u si coi al }.,
l 1r' i l ' . l l r$1)) ,l u
(l oi l Lurri i l rut
cri st{tnl t ttr\ot s i ,trtl T ao,rl a l al ami ce at l ui bu,rd,ri
tl, :;t n:;iltil.ilrrl,t, itrsd
.lrirri
dureri, prin lezrrea, exclusivii :r, nucleilor ventrali
l ) o: l | {' t i ( | I i .
Ir) S rrLr rl crrrri s
Ji trntc
heni otgi ce pl tre
^l e
si ndromul ui tr"l ami c (L,hor.
r r l l ( ' , I l ) i l j i
;
( l r Lr r : i r r ,
19l i i , ci t a, t r 1e Sa, gor , 1960; Foer st cr , 1926
I
Sager ,
l 1) l i ( l )
l l i i r r
l t , zi r r ni uLc nucl ei l or 1at cf t r 1i .
,1. fi i l l (l r' {)i ul ol o [ul l n[r:p ruscrthu, si nt tot I i nd,rotune pu,yl i &l e, Tez,l i ,
,i ,rl l
l )i i rl
pl otl sc vi l scni al e l oca,l i zate hr teri tor.i ul ut:rui a di -tr cei ci nci pedi -
r r l i r r r l cl i : r l i t l cr . cr . i qi i nc. . i i n 1925 dc l l oi r , I l i l i emand si Ni cul esut : : i , r t cr cl c
Lrl i l rl ){}
i (' ri (,rri i l | 1, si tal l i rno pe}fol ate (r' aml rl i al c :l l terei cerebral c pos-
i ( r' rorr(' ), | 1,1()1.,r l {_' l rt i rul o- opti cx (r' l ]}rtri i a, rrterei si i r.i enc), arteri :I, i ubero-
Irrl i rrrri cri , (r' l unul i a i trtcrci romuni cante posteri oare) .,si artcra coroi di
, rrr rrrrl l l i onl i i (r:rnnu,i i a artt:rei si l r-i enc)" Cel e mai i i nportaute qi mai frec-
\,' l rl r. !i l rl rl )i trre ti l l :l l ni ce \.i l ,scu1:l t,c si nl cdl e trei rari etd,l i {l escri se de l her-
r r r r l l r . r . i r i r r r i ul {r s dc Si t ger si col ab. ( vezi Sager ' , 1960) :
t) ;i l (l )\Dtu,l Ll e. obl i terare e, patl i c,tLl u,l l Li l (.1& xo-qeni cl l l at (carc i ri gi ,
| )otl i rrtroi i l l l tcrl | l i i si
l ]oi i tel i o:i r;1,
i ndeosel ti nurl e1rl
yentral
postcr' o-l al ,e-
ri rl ). fi 1' rl rnr{,t{ri i zr,rrzl pl i n tul bur.i i ri t' l c sensi bi l i i ato obi ccti vi , l a mernbre
l ttt:ti i ' rpl i rrl Ll ,c Ir rncmbrul i n{ori or), fi i ri i afeci ar:ea sensi bi ti ti ,l i i fel ei .
I )tttr.tcr' .
rJ,rr.i 1 e-ri sti i , se tl l i pc
1rl tn
secnndar
$i
este pul i n expl i matd,. Se
trrr,r l oi ,i l rzi o herl i al ropsi c homoni md,.
l )i rrsttosrl i r,rl l i ]rr i ml l i ci i ti i i i i cul ti i l i atunci ci nd apar
$i
al te si mptome,
ttt :rl rrl rr cr,l oi scnzi ti rt : ri ri rti i tl .rl ami ci , mi qor,ri coroo-atretozi ce, tul buri ,
.r,| r.I)(' I().I)j (' si i rrrrni l rtol ts!e
hurni tni m,i l al eral ti (cal .e i nsj , esl c de ori gi ne
r ot l i r ' : r l ; 1, r l r ' 1r r ' r r r l ol l i i dc l czi t t r ca col t i cal i : r , i n. t el i l , or i ul al t cr ei col . cbr al o
t r o
r l r . r i oi ui , r l i l ( ' r r ( ' pr r l r i r e r i i
1l er i i cuhl
t al amo- geni ci r l at ) .
Ii i t
i nnr' \.
rl tur' l ttt t' t' rol o11i c, si l l dxomnl tal arni c gIobu,l (cn de al tfel qi
rrrrrJtrr:rrrrIIrr
l Ii .trni i rtr p,l i .i i ' tl o) cstc re:r1i za,t Ll .e
!x)c6p,
t:uscti l are (ramol i s-
t trf l r ri ItItrr' rr.l 11i i ), It' ottt!1i (:e, l i tl a)' e,l e (i ndeosebi gl i oi r,me), tl egenerati ue
t t u
I l u
t t t t r t , t i i ( o1, ( t ' . f i l l i t e) .
l \\
\l i tl ti tt)l tl tl
rl .e oi tl i terorc o, pddi c' ul ' uLai tu,l ma-perJor&t (c' r,re i l i gd,,
l r,.
l rrr,tri r,l tr. l ()ri ri .n{,i rLri exti :ttal anl i cr], nucl eul se.ni l unar :r,l l ui l t' Iechsi g).
' -l r.
c trrcl cl i zl ri i l i i
l l i n
i ul l rur' :i l i de sersi bi l i tate obi ecti Y:i ]a ni vel ul fel ei ,
rr i < i l rr rrrr,rrrl i l rrl sl rl )ct' i or' rj i :i bsente 14, merrrbrul i nferi or, L:l fe1 durerea,
rl :rl r r.ri s1i i , r<c si l ur::Lzl i 1u, rri r-e1u1 fc;l ei i 1i er-entl al al mcmbl ul ui superi or
r | i ,l ,
l )rrl
i n r\pfi nri r,ti ;. Se pot asor:i i i un homi si n{l rom cerebel os, mi fcd,r' i
l i rrr,rrrrl r,l ozi re
5i ,,mi n5, i :l l arri i ci t,". Prcci zi i m c:i di n date l urni zate dc
I ' r , r ! | | ' , r ( , r r ( 11) {i 6, 19?6)
6i
r b I ?opovi ci n
Di
col ab. , ( 1980) si nr l r ol nul de obl i -
l r,r' rrl l rLl
l rrrrl i cul ul ui
1r:l l arl o-per' 1oi ' a1 poato fi rnnl l rn:i i gl ' :tl , tnai boga,l ,
t r r . r r r r l i r r r r l , i t i i r t r ci t , i r r l r l ) r opj t . r ci L l i ni ci r net l i anc, f i ecal e di nt l e ar t cl cI t t
l rl j i tr,r
Ir(' r' l i )l l L{r
ro i Lnp,n' t.tr i rL rl oui i r' :rmnl i , ci l }r sc di ri j eazi l bi l atcrrl
, i
i r i gr r sl l r Lr , l r r l i kr l l l t nuo- sr r l r Ll r l r D. ] j cc sj r nel l i co- Tn l t cest f el , l r l , et ol e pc
r l i l r r l r r l r r i l l l r r r r r o pi . t ' l i ol l r t i l i qi l r i r nl . t r l i : t r . gi ut Li i l i r ncef l l l i ce, l udi f cr er r t t l i t t
r ' : r t t
l )
r r ' j ( f pl r r v r r r . I ' or r r l r ct on ( l ! ) {i ( i , 11) ?0)
; i
l >opovi ci n
1i
col r t l l . ( 1! }l i 0) , t t , l t
l ! l <. r i l r r l l r , l cr Ji l i | r r {i r r {i ( | ( r r ' | ' l I r r | ( ) I i }i I i r ( | t t 1t I t r got t r t i t , l , c dr t o) l st t ' t t t t l i i t t t t t t r i r t
r l t t r l t l ' r | r ' l l r .
j l J
l r ' 11, r ' r . i r l i zr , i r zi i l l r r i l ) r ' {f i l l i l ; t l t t t l i l , r l r r
, , f l t Ll t r t r r ",
( r t t t t i ' i i l t r
1r i ot r t r r I oI o; 1i r , ; 1t r r r r 1,
t l i . I czi r t t t r , t l i t ' t t r , t ' l r r l i l i t l r i l l r l r r t ' l r l i i ( i t r <' l t t si v t r t t r r t t t t t i l
) .
: l l : t
r ) i t i nl t , , t t t t t l t l t r l l i l | t r r t r r r
l t r r l i I t r l ul I i
l r , t t l t r t t l , t 0l t l t t ( r ' l r r r ' l l l j i I
, r
1u' r ' i r r l
r r r r | 1, ' i i l : r l I t ' r r l i ) r r r r t ' r t t r r t r l t ' t i z| r t zi t ; t t i t t 1r t ' zr ' t t {r t l ) ( ' t r r ' l l r l l ) l
r l r i r
, l r r r , i r i i ( r t t l or l ( '
(
l i r l i r
(
' l r ' l l ' l (
'
l t i l l l t
; r l r l i l r ' ) ,
I r t ' r t l i z: t l l t t r r r r i t l t t t l l I l r t t t l r r t l r t t t l
r r r t . ' r . i Dr ' 1 ( 1 posi l r i l i l i i ! i r l I i t ' l r r i i , . r r . ; i l r r r r r | t I l r t Ul st t l t r . t i ot si l : t l r i . l t , : r r t t r r l
i , , r r r r I i I r r i r , , i , l i , , . l i I r , r , gcl r l i r , i ' i r l cr | r ' i r i i . ' l ' r r l l i i r r r i l r ,
( }l r i r . r , l i v| r l I r r , "t t ' r i l r i l r
i r i r ' l i 1r r 1. 1q1' , sl t t t si t t l nt i t t i t t r r ' . St ' l r st r r , i r t zi si o l l t ' t t t i l t l r t ' r ' zl i cot l i t ' t l ' l l l r r l : t
l r r r r , r : , , i r l r r i i ' r l i l l i i i j i t l
( ' | l ) sl l l ( ' i i l r l ( l ' l i l ' \ ' {' ( r r l r ( ' ) .
\ ' . r ! i t t r l t nt t t t t 1 r i i sl t i t r l i | i , , hi l t , , l , t l ' r t t i t r "
' t t
I ' t i t
. i
t r i | |
'
r i t t : t i l l t t
i ' ) t t t t t t i t t t
r l l t l l , r ' i l : r {i 11t , l ' r l r . i i t i t t si t ' r r l r r i ' . r 11}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 ' '
r , i r r i ' l t ' t ' t ' t l i t t gr t t pt t l t l l i ( l l ( ' l {) r ' t t r si i i i l t r t i o| i l ' i t ' i i l r ' ; t 1r r t l i t l l r l i
l ' r ' r I or ' r l l r r '
i , r r r r r ' ( r ' l t r r r t r l i al o i , ol t r }nr L, i
1, ' ) J. , l i l
l 11 )
r i i i i , : , i t l l i i t , r l . t t r t t l r l r t l t t t t t , r r
: l , t r l t i ( ) t t t ck'
si t t l cr t t r l l l l t l xc ; 1i
(
1' 1r l i l ' r l : l r , t r r i l r i l - l i . I I
'
I | | | : I I : I i (
' t : I I I i
"
l l i r r r l : r r l
, r , ' l 1' ( ' l ( l ) ( r l l ) s t , r t n 1, r ' t l l a' t ct l l ]
,
ht t t l i i t t r t i l l si t r t t t i l ot r i t t l ; ' I ' ot t I I I r I : r I l . t r | : t l t t ' t t t
, r r , r i czi c cot Ll t i l l t i t cl i l l i i pl oi l or ni n: - i r ) l
Uoi l l l l {l i , 1i
i t sl t ' r l oqt t ' r zt t "
l ) t ' i r t 1i l r , [ ' oJxt t ' i ci u; i co1e1r .
( 1$( i 9) t r r l
l t l l ci t : r t 1
r ' i i i t t l t t t r i l t r '
l r t t t i l
, r r l , , r '
l ) i :
l ] , i ni t l . r l e, t ' \ 1r i l pi nl l l i {l r l 1. , {x' l \ ' l ) {' l o' r L( ' , ; r ' r t zi l i vt '
' i
vi Tr r r r l ' r t |
'
' r ,
. 1r '
i i i I l ' gi ut l e: t hi pot l l Lal r i " r , , ' r r l r . , i r ; r i l : , l i r i ' r . l '
' I r I I I
r r l l i r l Lr r r r r r Ll
r r . r l ct t t t t l i l t ' l t , cor ' f l l t i l l i l t t l cl l Lr i si l t r l t , ' t t l , sl , r i r ' . , . l t t t l t r t t l l
( l ( r ' i r r I r i l l l l
r l , l r l . t n t i t , i i ".
r,
.
' \i ni Jrontu.l ,
san[l i ,L, rcrti .(:sl
l l tri el o['
/ ) l , czi uni l o par i et i l l c pot t l et ct l ni nr t 111) i l l i l i l i l l l i ol l t t l l t t t t t i t i t l t
'
t t
r l t i l i i t t l t r t nnpl er r i , cul u si nl , t r r l l l ul ' i t r i kr r l c r r l l r i ' t t t i 1 t ' r r t
1
I r r t : t I I t . : t
' l '
" ' t
, , r r , ' , r i . r ,
l l t r - ; l oenozi l , t l ot ' t t r 0l ] cx i : i ( i ml l i l si ] l i l i l r l l | l r t l r ' l t t t t t t t r o r r l ' ' l r t t t
1,
r t i . i , r i : t ' vi i ui l l S
I
ci f r . l cr l i t ci i l l c sl l t l
( l ( ' s"l l . l . l t : t st l . r l "
'
"r t t t r t t r r t l '
t , ,
l l ur l l t ) t , l l t do l : ur l i t l r t t l t t i , cr t r l j l l i {) l ' t l l l t r t l t i I ' r t ' j l i t r t l i r r ' l i l ) r ' 1r
'
l t r l l t
i , r i l (
l l i \ l
i et , l e cl l ' t t i t Lt c: osct t t ; i r
( ' i l cr i l n\ n) l ni i l l r ! {' i t
l r r t ; i t
l r r l : r i r r l ' r ' l 1r l r t l l
t 1' . \ . ) j i 1' r oi r uca ani , ct ' i ol u' r i r ' ci t c' , t t l r - ol u( i l t t t i 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 si i r i l i l , l i ( i i pc j nl l t i t t i t ca ol usi l l l cor l nl l l l i , I t t r i i I t t ' I '
r ' t t I t I I r I i t r ' ' I t . t r r I I t '
I nr , i i l l {' s po i nci nhi ul supcf i or . l l l Ll JJmr i i r t ' l t
1t r t r r l r "
i i ul ol r r r l r i ,
i r r l "r ' r r r r r ' l
i , , LL ! {r 1r ( l Lr i i l c r l e sensi bi l i t l l t e, s' i t l
1. t oi t l t , l l t t r l r r t t t i t r 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
1r
r l t t t t r l i r . Ani ' st t t ; l i i l t ' gl <t bakr ; i nr : l si vt r r t i c t t t t l i i t t l l l t i i
. ] t t t t t l l l r r l t
r r
"' t
l r r r
l r r r r . i t r i i t t t i ' ot i l ' oi t t l l o st t sl l t ct o l l l r
1; i t i : t l i st r t -
, \ ! r ' 1) l t ' l l i ' : r l t t t t ' sl t zr i r l l r l r t l '
I | | l r r si \ {, i ) i }l l l pi l ( , t r ol ) i ( x1{i \ - r l Ol t I i r r i . : l zt l t r l i . : zi r r r | (
pr r r i r . l : r l : r i t r t t t t t t t i t , : t r t r t t t
, r , r ' r r t r r r r i i i t t t t t t l - t t 1
1l : . t t
i et i t l si ncor t sl , l t t l t t l t t ' i t l
1l r ' , i r t r r r l l t
i t r t l t l i r t l | | | t | | i I I I I I | | '
l , i ; i r r r r i i .
t i t t cot ' i l t t l l r t t l ' at ' t t , t l l t r st r t t si I r i l i 1 i r 1 r I l t l l ' l Lc st l l l t i r t t l t l t r r i I I { | | I | | I I I I I I i . ' r l
r l r t l r r t i i t ' r t l t l t ' sl t i s t l t ' V, ' l gl 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 t r l r t ' t r t r t l ' t
l r l . r t i i I r . l l i l c
( ' pi ( ' l ' i 1
i r ' {} si r r si i l l si }r i l i l i t i j
pf ol ' 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
r r r l r r l r t i l r t r r l i l
I I I ' t t i o; t t I i t ' '
r t t ' cl t t i i r r t t t l o- r t l i j , zi ( r
f i
r l t l l t t i t ' i l r r r t l ' r t ' t l r r l t
r r r r l r i i ' r i t t vq' r ' i t i r bi | i I t l i sol i r r l i , r ' t i l i , i 1l l r r l r l l i c
| | l , ' t r r l t r t ' ( r r i i t I I l r ' ( i t r i l r l t ' l si
( l t t i l t cr {,
l l l i l ) : l i r l r i sl : r l I l sr l pI r r l r r r r r l r r I .
t t t r t t , t t i l ) t r l t t t i l i l i
' r l <' si t t t l t l t t t r l l r t i
sl t t zi l i t '
t ) i i i ( f l
l l r r ) ; t l . i t r x' ' r ' r ' r r r ' 1r ' r ' r l
. i
' r r , r i I r i I i I r ' i I i I , r r '
;
t t i r I t t t I t i r ' ,
i t t r l i l , r | l r i i r si l l r {t t l i r i r t l i ( l t ' l i t r i l l ' t sr ' r f r r r l . r r l : r r I
r r r Si r r r l r r l r r i \ i l t | i l l ot ( pi r l r . l i | zi t r r r l I ) | l i i , t l l ( , I
I ' l ' l !
( . l r l i , . ! l l r I I I I ( ' I I | |
( : r l r r , l
l , i . l ' r i ar , i
) ,
r t
; t t ' t ' r ' t ' 1r I i l . i
, r I t t t l ' I t I t i i . r r r r t {l { r ' i r l i t i r t j
( ' I r ' I ' r ' I I ' I r I r ' ( r l r i l r ' i ' t t r ' t r t
t l r r I i I I r I i | ol I t I oI r ' r ' t t I i t r ' ( r . . t r ' , t 1,
r i , 1r ' t r r 1' ' t r 1I t t i . l r l r I r r ' i l l l l ' ) ;
I
) l r l l '
t t l r r i t t r ( t t l t t i l , r r ! i , r ' r i i
, l i r r r r l i l , r ' ( r r l t , 1r , ' ; l t t ozi r r t
, i
r r r I i I I I i I I I | 1 | I | | | |
;
( | ) 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 t l I l | t r l , t l ' t t l
I ' t l l r
l r "L t r t I i t t i r ( t I t t I ' ' r ' ' I t zt l r ) '
' | ' I t I i , r r t I r t i I , . i l f r ' t | . "I LI | | LI i i i . r ' l r l \ r l Ll , l . r I l : r r t t
l l
: r
' i I 1I I I | '
| | i ' l l ( .
ill
tr
iii,,iiiii,i;;1,,ril;Li'll,iiili-#l**[qt*[,#;#i'fl"'ii]
;.i;r;;"';i:Iii;itijlil'i'li#,:lii",
rrc.seusib'itateselocalizeaza
po mini, sau
,,' ' ,,..,
' "1.
111;*,lll..
jr:
lbi:u_r
t ul]:uririte Au s""silriiitat" ,i-oiaor,ht" d" tot-
, (,i ,,,,
,' ,ru,rrr,
ri .l L(l rr(r Icz.l roa
conccrni tenti ,
a fi ,ontal ei assendeate i n
il;iiiiliili.
rr,rlir,ccrrto
;i
rrc l,l,rofii oror"oraro-*"*itn.iJiJ.i^o"."rlre
de-Sii"
gg,lii$11;!li',1$lll;itt,*
;x"Jilill?1,"#"*'jtl:,'"'i",ij""'*'.*t'11:
lil
lilli'Ji;J ltii:i?:1TrJ.........,fi";:ilr1,'1,';*i*",'S"iliflili,":"i;*rroduto
aproa.
; I I tn, li'l
"
:;;, ;lt*lui
il,1,lj: ,t,1*riil"*,y*::[;9l;:ll_itffi:ff
f
iiiiriliffi
!jri,"*lf
#i*:i?rdffi
,rrurmnay,*,i:i:s"*1
,r,^,,.,,,
)r,rT',t rnr rile subiectiw de
'ensiiitita4
din sinalromul parietal con-
.,,,,,,il,,0'Ji'''Jifil',i*.."13"'*1ff**n'J".ll;;H:
a,morferi, carc pot prera ra
r,,,,il,i{!i.':,i'if#tll#?ll;,'i
j?Htli,"i*Hi'"r,"jT;;c?},^pi"si'ci
,,,,,^,,?,.,1liii,iil#':f::ifj'iij?,1,fi.*1,"*
llj*,llgf;y,i:r
obiccte, care
:r;r:,rl,i
jfl
i:::ii,;T'fiiLi;,tf
l3'fiit"il:;I?f
,*li;l[tx,T"llJH3.:*;l:
l:ititlii:;
'(;il',l:"jlili',J",;;Bli:
i.:,fi'J;i;"1.#ll"T?;"jji"il,lJ,:*.i*:
'ii:ii";11"-iliilililli'hllli"'Tl?#ii.,i?i,,fffil_X"-1m;;sticui,rircrin-
.lJ [)c o tenld, t:aloare d,i,
s,,ttitttt,,
h,,,,:.ttiz'r..o
de obicei'JLi'jJ:,:]#:;i;iji,i{x.f,jj";,"ir,,tr",,lf;,::f.
r,' ztt
{s' trz':rlii rre artLor(crl'ti' ri,,illlf,i'l:,,];"il|ll,l;l,U:lliifi,,i:T,*
illi;:,
i:lll:,;
!!ii'Iiiil","iil,ii,r"eori
cL ir r imp'r,oir rr., .:displriri.,,. a, meor_
,,' i rfl
.
rr' sUn()rl y.
Bu-perl or sau i tfefi or, a mi i ni i , sl u doar rr, unor dcrel et^
ijt:ililil.tiili::; i,T,:l:;r.,1;';#i;;j;."H"ilffif'J."JilJ,.HX?"",1""'Js,;i;
,,r! {} r1r' rzl ' t,
nl ororl c dc 1j p R rav&i s-Jackson.
. !)
I,la o ce d, raloara d,ia gnodicd
silt
;i
,remzele serniologice asociate
lli!li,!i:d;f;
ff
i'i'l,',v!,##l?f f f,i,{ti#t"l1.HT,Lr,i:*;n"x*{4*-xi
l:l:l't.:Yf::,i:.3- Temb,rur
Burorior, indeosebi la muDchii mici ai miinii, rale-
olr r(,illzuld
un srndrum um6r_mind,), insoliti do tulbur{,ri vasornotorii
Il,fflil;JilfrlT,::li,;,"i:;i,i;'):z!"n,ii:;,yii,.l*:ll',li*rlli*,yl
ii
f l l l : : . i t i . l ' , , : ' . rl
n(. nzrl ry propri ocopt i v);
d) Tu ru. rdt i oest i but i re. 1r. arr, , sui r
f i'i'l-ir'iil,iil r,lli)|;,!)tiiillffi'iflffiK'ff,(#d:fiiHil,iilli'f
i,,ll;l,i;i;il;
xl , i t t gi ( vr r zi gl p.
l 0)
;
g)
, t , t Ll . bni ar i
l i zr i , r l r , ( l r r . mi r r , r r i r l r si , , l r , r r not r i r nr l , t , , , r r -
224
I r r Lr Lr r l r r I i i , r l r r ol r i ooi i r cvl t l r r r t t l , i l r l i ' , r ' i r r r ' )
;
l t ) A' i r {hr ) r r r t l l ui
' l t r l , t t t
t 1i
l l , r l , i nxl , : i ( l t r r t r r i r r sot t t r t l ogt t oz i r , , i r t t r t zol l t t t t zi r ' ,
5i
i t t t ozr r t l i l Ll i r t ' i r r )
I
i ) A' i r r r l t r r r i r r r l
l r t l i t t ' t i l , uL \ n, ' l t gt l ( r zi o t l i gi l , l t l i l ' ( i t r ct t l t r t oi l r t ' k' i t , t l t r l l , I ( t cl l l l or l ! Jl ' r r ' t l i \ l r ,
r l , , r r r r r r r i qi t l t r l t , t l i l i t t t t r {, i l ct r l o ci t t ci t l sgt r i t r , t t t t r ' l t r i t t t l l l t r r t ' 1, t l t t l l l t cl r r I l , t t l
I r r : r l l r
( l c
or i t . t t l , r l l o t l r oal t t ' l r - sl , i l ga
I
l t cal ct t l i el r t gt i u{i t r l l t r t i l r t t l
, , r , l t r si 1t g
r r r ' r r , l r r i I l l l yor ' - ( i r oss ( i r r spoci r r ' l
l l t l t r t l t t
cxt xl t t l i i t , l l t i t t i t l t t $t l t t t t r t l l : t l l l r r \ i
, , , r r . l l r r ef i i )
; - j )
Al t c ser nnc l , oqt ogxl J i cc cor t i cnl e, pt i l t osl , t t r l *i r t , l l zi t t t t i l or "
l ,r I o r' rni ri ,i url i l e voci ne .
:)) lir cailrnl sinih'ornului pu,riotal sa pot itlanti'.li.ca ur nt,iil,tut t, I t tin
rl r
' ,rr
rtttr topograJi ca :
r1 i l i i dront' ul senzi ti a pari etal gl obal , cl asi c, l vl l rti , ).)(i 6ri nt xi . l /l yt
r,. r' r,o[noaqte pri n tul burxri l c de sonsi bi l i tate suhi ocl ,i l L ri i obi trol ,i vr' i ' tr' l rt
trl o ttteri or, Excepl i on asoci ;r,zi \: anti otrofi c, hctni tl l l ol l si o qi rtl rtzi rt
l r r r I r , zi uni l e st i ngi ) .
ll Sintlromul, de girus puietal su'peric'r (a'riile \tu, 5b
)
t'tl.r'lizo'tnti, rt
.rl l .r' .rrc rnai pul i n marcatS, a tuturor sensi bi l i ti ,i i l ort 1o
l tt:trti corl tttl rrott
l rrrl rl oral , cu test&urarea rapi rl i , a sensi bi ti ti i ,fi l or ttl cl ,i l o, tol tl ti ci i ;i tl ttt' r' .
r,r.rri , tl l r cu rnenl i nerea i ndel ungatd' a abol i ri i sol rsi l ,ri l i Li i ' l ,i krr 1It' rIIttIItII'
c) Bi ndromu,l l ui Anton'
1i
Bn' bi nski (vezi :l trtcri ot
)
csl o Ittrt,l i z t,l ,
l tri tt
l r' ,ri ri tri mri erti nse, cate i mpl i ci i , : pui etal a, anteri ol t' i i ,
l tt' i tttrt uri
ri , rl ottrr,
r rr, rrrnvol ul i e pr,ri etal i ,, gi rusul suprarni l l gi rral qi u p.r,tl c r[i tr pl i ort, trttrl trl -
tl ) Si nd.romul , l ui , Gerstmann estc produs pri u l uzi rtni
(1i l ,l ' l r
i rt l (\r(' i {(fi rzi i ,
l rrrr.!i ' tl e trecere.l i ntre ci rcumvol ul i a
pari etal i i i nl l ol i ol l i r, ,,s i ci t' ctttrtvol tt
\ ' ,
, " \ ' i l , i t ' l l a mi j l oci e cl i n pi r t ea sf i ngi .
t) Sindromul parietol p08terior al lui. An'drd Th,ottt'tt'tt ${) l1!olllrt)rl,'1l'(\
1rr
i rr ; heni anestezi e predomi nanti , pentru tact
1i
portt,r' tt i l rttsi l ti l i l ,rrl r rrr'
1
r r r r l r L r ri l i ' i ,
I
br' :rdi hi nezi e qi di srnatri e, apraxi e i dol tol i cI orxri l ,rt' l tt vrrtl trtl i i .
l ) Ei ttdromul '
Ttari etal
p ro.f wfl ' al ' l ui tr' oi r (pri n l ozi trnc sl i rrgi i ) i tttl ttttt,rrrzrtr
rrrrrri t,otul contei t semi otogi c: tul burS,ri souzi t i t' o bi l l l ,rl l ' rrl o, i l l i rttl nti rrrl
trtrri l l es si ml ul pozi fi i l or, apraxi o i deomotori e bi l i l totrtl i t
Il l ti l zi tt
tttrrrl rrri tl ,i l
( , 1, , t i p mi xt ) ; hemi pl egi e r l r o- r , pt r i .
?.3. PROBLEMII] D!] DIAGNOSTIC DIIIOI,,()(i I0
IN DIVF]RSE SINDROAMII AI,GIOi I
7.3.1. Cefal al gi i l c (Col nl ci l r)
\\ Cefalalgiilc acule trc srrgcrcazri,, evitlcnt, o co,ttzd nrt,lli,,
lxr
or,r'o rl
Inrrrrr i n consi dol arc qi o i nvosti gi l rrr i n Iunc{,i c de l ootl i zl ,r' ol cofl l t' oi
6i
rl o
r orrl l ri ,r.LI cl i ni c i n c;u' o apu,to (Arsturi qi Oproscrr, 1007; l l rrrri s
ryi
Wrrl l l ' ,
I l rl ' 1,
(ri t,trfi
dc Arsoni
6i
Oprosorr
;
I]otrovi 0i u ri i .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,[ii
.' s irr u z i h]
l r r r r Li r l i r , si l , u ot r noi dr r , l r l , l cr r i i , l gl l r r r ur r r r l i l i l l ' i su, u i l i r l oci cl i l , i i ; l r r r r ' ; x' s l l i
1J, , r r i r r i r , l
I
r r , r ' t ot i t i r , si r , r r i r r ' l cl i opr r i i o ( t , cr r r 1xn' t 1I ) r l o r l i vr r r so t r l , 1; r r I i ( I r r r k, o8r r I t I
l , r or r , r r r l t r i i i r r
yi t i r l i ) 1
i r r xr r l i ci r r t r l r i , r i r t t r l l r 1, r r t i r r cr r r ol , i r l i r r t r i l ,
I
Lt ' r r , ut t r r r , l i nt t t
r l . f r l i r l l i l r l I n r t l l i t t t t t r t t u' ui 1t i l , t . t l . / r , , ' t r r vl l l gi r r ocoi pi l , l , l i i ,
- Al t t ol t l
I
l t r zi t t t t i
l i ' t \ i ci r , l o st r ; xr t ' i ol , l t ( | r ' r r r r t r r i r , I i r r r r
,
t r r l t r r i r , l , i cr , , r l r ot ' r r i o r l i r cr r l i r , , t r t r r u r . t l i l ct t , t ' "
I l r r zi r ) 1 l l r r f r r r r r l t r l r i pr r t l r , r r Ni r r r r r r r r , r ' l , r r r i l l i l
;
( ! \ ' ( ! n
l , u[ l r ' i , r r r t , r r i r r gi t , i l , ( r t r vn
{i t r r r
t r , , r r t t i r 11i t l r , r r ot r l i , t l t t l r r l i r r i r r )
;
| l l , , Xi r r or ur i 1r i I r r I i 1 r , i ol I nl l r l t r r l r ,
l r t t l , t t , t t t t t t i
l ! - r Ll l
t t h
l r ' r t r ' r l l gi i , - sl r l ) r r i r l : r t . i r l i t , l r c ( l l r , bol r r l vi i hi p. r ' t cnsi vi , r r t , t el i osckl l r r i i ci qi
l : r , i r r r l i vi zi i l n t , i l , Nl , i i , \ -
,
l/ lrr u.lekrl.yiil(1 gtnuali::a.le : a) Protc.sc i.nlt,ucraniene acute (ltenn
"
I rr rr(!
;
ll{rmo}'ugii iltr,:rcerebtrlc - in c*re cefaleea, se instaleaai, deosebit
rlr, lrlrrl;tlr plcccrlind
coma - srru extracer.el:rale
I
turnori cerebrale cu evo.
l rr{i r, rr,ri rrrpi ,omi l ti ci
Bau cu al te si n4rtome pi ni i n moment}l decl al qJ,ri l
rrrl:rkrr:i, plin creqtere bruscit a tensiunii iniracraniene; procese
infla'ma.
l .' l ri i , l l )ccsc cel cbl l l c. nreni ngi te, rneni ngoencefal i te
;
i rdrnboze al e si nu-
, r l l r l l r r ' r ' on( , r se . - i r l e \ ' oncl or cer ebr al c)
;
l - >) I n. f er t i i qenpr al e
sud t . , cr t l l
(sc
vrr, ctiutil contextul clilic infecfi_os.1
i
c) Altc inJbatii; ineningite, arterito,
f l rrl ri tq, 1,..r' rarUebi te cerebral e
I
.d.1 .Traunoti smc
' crani ene
1
71
' n6n
Ai
lt i.lr( t lt.ttsiunp afieri^ali.
I
f)
.Int
oaica!,ii, (cu monoxid de ci,rbon, ititri{i,
r r i l r ' : r {i q. r . ) : g) S' r f / . i i r l f r i scr r al e acut c sou acul i zat e ( car e
t r t , br r j e, ; r r t r i o
l , r l r l l i i l r nr r . i nd nr 1
ge
poat c cl uci da ut r met , ani sr n cer ebr al ) .
ll)
.C^efalalgiile
perioilice (Amcli qi Opreecu, t|)6?; Botez qi gerbi,.
rtcsr:rr,,.1965
I
Br"uetman, 19{4
;
Kudrow, 19?4
;
popovi ci u
Di
pasci l ,
19?9)
;
, l . l , l ! i g11l . o( i n. si t ual . i i l ci nmr . eal gi i l epr e2i ul i uncar act cr her ni cr r ni c,
l rrrl srrti l ,
i nso{i t
$i
de al te si mptome, i ndeosebi ocul are). Vom reveni rnai
l i | z i r r i ul r - un subcr pi t ol seDar at .
-
,2
)
,
.l [ a(ormo! i i t.e
-r-ascul ore
cerbrol c (angi oamc. anevl i sme,; se pot
i r"ol i dc cri ze cefal al gi ce pscudomi groroase (dar
aproape totdeauna' rl o
: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 aater i, comunicanti, posterioard si in cele de a.rteri[
Ir' r' |' hrrLi posteIi oari ).
.. .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.u do
',.l:ll(.e
c()ntinuii cu exacerbi.ri paroxistice (Arseni qi Opreseu, 196?). ABt-
h'1, cefrllccfl, prroxisticl pcriodicri este car&eteristic5, pcntru fazele rie detrirt
;rk, lurrrolilor dc vcntrictli laterali qi de ventricul al treilea, tiind declan-
r;r.rlii rlc
_rnoditici,rile
de pozilie ale capului, de trecerea in ortostatism, do
, ' f ot l
; i dc
sl r i nul ( Ar seni
si Opr escu, l 967) si ost e i n, l ol . i t i
$i
do al [ c , onr r r o
r , . t t t ol , ' gi ct . ( obnubi l _5, r i paSager e : r l e vedcr i i , t ul bur i r i di n pa, r l e: L Lt n r
rrr.r' v l cl ' i |,nt(.nl sI endoerrno),
!
)
Aefalceu
Ttaronisticd,
d,in, hipertensiunea urteri.ald, poate fi tlifuzll,
*rrr locirlizrtL (fronto-tcmpora,15 sau in rertex de obicei), api,rincl brusc,
rl {, rj r' l o rui l ,i mul tc ori spl e rl i mi nea,ti . Se poate real i za qi o formi psettl o-
rrrigrrirou,sf. Examenul funduiui de ochi arati modificd,ri nete vnsc:rlaro
lrprrslrrc
ilrteriale, edem sau clia,r hemoragii).
5)
(
ofaleaa paronisticd, 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
rrrcrrrrrl i rl i l , tl i vorgi l or frl otori ) rto csto sugcl al l l pri n surveni l ca accstt.i i r, Ii o
l rt l tururl ol r, i rr di nosl l t,t;i nnt (,,ccl i l r,kl r rl o pot ni l " - I
)i i rt
rrcsctr,1)rxIotl l Iu, l 1];8),
I i r ' , r l i t r t poh' i t , r l , l r t , l , t r r 11' 11' , 1 i t t ot l 6nt l l , i st r r ( l t i l xr l t ' l t si t r t r r t r r , 6t ' i 1s1: r l i r , : i ) ,
it"\(l
t r r r l r l | r r I r t r r l r r r , [ r r l r r , , l t Hr r l r cr r t r t l t r t t t i l r zi l , qi t l r r l r ur l r t i t t t t r , , vi . j i i l , t r I . i i t t t t t | r r l Ll ,
i r r r , , l , l r ,
; r r r l l r i l r r l , i i ; i
r r t r r I r i l i ' n I i l i
l r t r , si t t co; t : r l t
Hl t t t si l t col l t l t , ,
'
) t' rl rl u' t,
1
t r t, t t t . t : i :t I i r : i r. d,i n. r.nr h su.l rt' i .ttI.rr
!rrt.l tttottrr.t
r:
1i
l tl i rl i rrt rrr,
. l . , , r ' r 1r r r r r r r zr i r l c cr i r l t r t ' l l r t t : l l , t r l i l i oi i , r r , f t t t l r t t t ct t r : l ol l r t t l i i
1t t t I t t t ot t i t , t t r
xt t t t
l , r , l 1 r , r . ' l r . l r t r z. l i .
1t 1
t' ,
l ,rl urr,
prt,t' o,ti sl .i ti i rl ,i n, rLi rvt' sd,r sttl oi tx!0 tl i .gtsl ,i .ru i rl ti rl l r i tl r' orl
l , , l r l , r r r r pl , or r l l l i c i r l l t . r r , sI r t st t l i r l i nl c,
|
1
t' t
l i rl r' i l r
pu,rori ,i t:t: urrr su,r' pi n pa ut.
Iond
dc ot.fu,l ot ttn.l ,i .nutt, ti rl t<' L,
r l | | | , , ' r , , r r i l ( . sr r spi oi r r r r i , cr r l o t r t l r i i I l r p0t l , l t , t t t e,
( ] | , 1' ( ! i r t l pur l t l l i l sl r l i r l r ! l l l gr , l l t l ! ,
I l t r , I l nl t : t l l ) i u1) l c:
i
)
' l ' rrrun' i l t:
cercbrul e (tl o obi oci sc i rtsof,eso
6i
rl o rr,l l ,o si tttl tl otttr' ).
' )
l n t r ol t t . l i t r , hi per t ensi u, ni . i i nl r acr uni ene t l i t t i t t t gi oi l t t r t r Hi t l l r r l r r r
r t l I r ' |
,
t
,
r ' ( \ | ) | I I I
( | .
' |
) l n ral u' l i u, tratt mati s mal or crani o-cerebral e,, cl rttl po ftttttl ttl ctrl ' rt,l rrrri
pr ' l l r ur r i r ( i co so
l l or l uco
o ccf al al gi c Dar oxi sl , i cr i '
t l vi r l onl , ; i , r r xi sl , l ' i t r r l i
r 1r t t ,
I , r r r r I r r r . r r l i i
l nr ui hel nat or n i nt r a, pal enchi nt at os t ( i l 11, ( Ar sot r i
f i ( ) l l r ol ( ' l r t
l r r r , , r , r i r r l r r r r r r r i l t l t c compl i cat r i i col ebl al o.
I ) l )11N111ev7,., angaj i i ,ri l or (a nnuri l or i l a,
1n' t:t;' i ,' unr: )
i tt l ,ttrttol i trtrl rr
l , r r l ' . , I r r r r r r r r | , oi l r r r r r , abccse, chi st ur i par azi t Dr o
f , a.
( l ( x' l i i l l , , oi t zt ' 1 t r t i zo vi , t
l r , l l , r l r , r ' r , l r r l cr r , ( 1r r r e si nt i nso{, i t o qi do f onomcnc dc st r f t r r i t t ( , i t ' i t , | ' t t t t t t r I t i t t I t t i
' '
r , 1, ' . r l , r l o i r cgl i l i t at e pupi l ar i , or r ent i ual qi do I ' o. t l oxo
( l o
i l l ) t t ( r , r r
( \ ( ! {r r r f i
pl l r ' l l . ' \ ) : r l ot ni ; ci l r i pendul ar eal egl obi l or ocul r r i ) dol , l t l l ) l l t t i t ' i t ' oxl t i t r t '
l r ' r , r | , 1, . r r r r l t l or i ( l o comi
nr oAr esi vr i .
,) tt,.ftl ti
Ttl s
oni sti ce
?e Jondul
unor caJul u,l l l i i trrnl .i tr.tr' rt pol rtl tr' rtrrrt'
1l
Itt l t' t:t' rl ot,ttt.t: su,Itdural e croni ce, \n l Tfel a procese tl c
JoYti ,
potsl t' t' i o(t ri (i l t r' 1i i l l tt,
l l l l ,
l l l , Lr ( ' ( l of l | , l oca
Be exacer beazd, l a mi osct r r i l o cal t ul t t i ) ' i t t t r i t kr r t t ( ht t oi t l i l r
,' ,r,1,,,' /r (1rosl l ,r' nr ma1,i co, postmeni ngocncefal i ti co)r l tt .rl dri /r'
l trt:rl
tri l i t' t'
t' 1,t1'
tttttt t
i rr
.l enonenel c
d,e ki perterni une aenousd, (\tt l rl i r(l l ,i l l l ri trrtttl i tt,t' rr
rl l , | , | , |
|
| r
'
| | i i i |
(
, I r sau i n compresi uni pe venel o j ugul aro)
$.t1,.
t'
) l tl tt' i l ,& tentporal d' (Boal a l ui Tl orton) ponta ow)l l l l l , t' tt trol l r,l rrl
| | ,r' ,
r,rl i rl rf. No ori cnti m i n ci i agnosti c tl upri tabl oul cl i tti tl
1
r I t t ' | , i t I t t I t t t '
i r,r,l rl ,,r'
trrrl srrl ,i l i l ui - sau bi l ateral i r, Iocal i za,tl i , Irrtrd,t)- 1' ol l I
I
x rl ' i [],
(\ti r(' rrt
l r r r l , , l l ol i r r ' 1, r r l i , de apl eci , r i i e capul ui
$i
cl o ol i nosl , : l [ ' i st r r
r yi
i l r xr t l i l o. t l t t
i r r r l ' , , r ' t r {r i pul snl , i l i a, a; r t r el or t empol al e St t l t t r l ' f i ci t t l r r
1i
r l r r t t t t t l l oot i
5i
r l r ,
' r l t r r
l i . r r r r r r r r nc ccr cbr al o
; i
cl t i ar col ona, r ' i ono) ( Wol l l , l l xi ; l ) .
, )
(ttl al (' uL
d,i n atero- ti arteri oscl eroza tertbrt' Li l t,1ti t,t' tl tl tt l tl ti crri i tr
, , 1, r ' l l l l . ,
r l i r l r t i l t o al e acest or af ect i uni , dar do mul t o or i
f i l nsl , r t t l i i l o; t t r r l ol r r ,
r l r , r l ' , l r r r l r r or r r : I st cni c al e at er oscl or ozoi ccr obr a' l o
( l ' opovi r r i t t
1i
r r r t l r t l r . ,
f r f r , r ' l ' r r l r r r vi r . i r r qi Pascu, 1977, 1979) .
l t I t' t' l ttl (.t(i .i l e conti nue progresi t c ne srgotoi vi l urttri l l ,ort,rtdrr l tl ' rrr' l i tl tti :
| ) ' l tt ot i aertbraLe i n pri mul r\T\(1, 2\ Il atnabattac (i ttl ,rrl ctrl rrl tt' rtl l rrtt
, t r l r r l r i r r r l ) , r l o obi col soci i ndu- t i o 1i
r r , , o si mpt unt u r l u sr t l l *' i nl ' i i , t r ot t t l r t ; l l t l ,
t l r , l r , r \ : r l r \ sl , i , r ' i i <l c vi gi l onl l gi sct uno ol r i r r t i vo l l t ' t t t l ) l ( r gi o( ) ) . i l )
- . f t r r r r r | nd
rn| | ,,ttt,rItti i rtnhn t (rr,Lccsti , ti qrnbtrl l ebi tc ct:rol rt:r,l t' , 1;tuttrl xtIl ol ri l ,rr tl o
al rrr ,' i r1(,nros, l ,rrrutl xrfkl bi l ;rj , tl o si ntts IIttortl , bt' otttl xrl l l ol l i tr' i ,
rl o rl tttttt
, r ' r 1, r l r r l , r r r r . r r i r r gi l , o, r noni ngoot r ct t l l r l i t ; o) , f i r l t ni l i i t , t l o$ot l , i r t t l r t t t l ; t l xb sot t t i ol r t gi t r
I r |
,
I r t ,
'
| |
'
i i
i ( i
1i
i rrfrrol ,i os rnvol i l l ;or' .
,l l
II i
l tri ,an
t i tt,nrut i n,l ruontni tr' ttr\' $(\
l )t)l l i t\
. l r , 1, , l I r l ( r r r r , l ' r r , l r r o oor r l , i r r t t i l
l l r r r gl cxi vr ' t .
l i ) {) r r f r r , l r , i t xt t t t , i t t t t o
l }11) gl o' {i vl r l ) l l l , t ! t l l
f l f l r f t r r
l r
l t i n. f u, ! i i ,
17n, ur , l i , [ t ' hr i l t
( hr l r t r r r , t ' t t ; t l , i vr r , f r r l r l r l l i f oi r | r \ ' I ' i I on ol t t t t '
l r ' r r r l l f r t l l r l I r ' i ( , , , t t r r t t ot t t t l l l t r t zi l , i t t l ' r xt {, i ot t t t i ] , gt ' i l i i ) , i l l t r r l r t r $t r I t , f t t l t r i r l i t t l ,
r r l r r t l r Li r l r r r l i , qf i 6H l ! , , l r 1i l , l i r r r l l l r l r r l r r l , r r i r r {r , r r l r
( 1! i l , r r t t l ) l I f l i t , cr l l t l t xr l l t l
x27
i r +r . , r t l , t i r t r nt '
1i / sr r t t
r l t f ct r t t {i t , l ) r , t l i l i ci l i al c sl i l i i r l e cLt t t s{: i i n1, r i
6i
pr ' r bcl t t
r l r . I : r l r ot l r l ot t ' c\ ' cl at oi - t r ( , .
l'))
(lt'[ulutqii
co'ntinue curstante sau cM sicotrst{r?rr, (eYentual cu \{r-
.r' r' l ri i ri px,r' i rxl i ce) apar i n foarte numetoase afecl l i urri I L) Leti /ul l i oso(i se
,,trr. tttrtirttlt'tn aie cotoonei. ceraicale su?erioare (fn acestia cefaleea cstc
,rr' r' i l ri i o-rrrrcrrl i , so cxacerbcaz;l l a schi mbi ri l e de pozi ti e al e capul ti
$i
se
irrro(cslo i,,i ilc :lrnedeli.) Ilste vorba de: unco-iliscartroze cen'icale, rrrt-rlfor-
rrri r{i i rrl o
.i orrc{i uni i
occi pi to-cervj cal e, rni ozi te etc. 2) Insufi ci enl e ci rcu-
I r 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 Dlrscula-
l ru i i r:ryLLl ui
;i
a gi tul ui (,,mtscl e tensi on headache"). 5) Di verse o.f(]i 1ttl i
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 r r r I i ) . 8t Ctfql peo, bol tat' i l or hi perl ensi r. 9) CaJal een aroni ri a
,ti ,thri i ri l ,tr.
' 10;
l n' di rerse suferi nl o hi pati ce., dttoheni bi l i are
fi
t' ettal e,
Il) i4 prstuf i,l,iila de d.iaerse origitti, (endocrine, neurogenc, in diverse sufet'inlc
rli;1r'slivr:
,s.a,.)
pot prezenta in contextul clinic cefalei persistente, zdesea,
|rr rrrirr:cl'bii,ri paroxistice, 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
rl(f sr)rnr rolcntii,, sti,ri de obnubilare, transpiratii
$i
uneori cdze conY lsiv.
lii)
'\i,
nu uititrm cefalalgiile din aJealiunil e octtlarc (ghucom' tulburiri.ito
lcllirc{'io, iridociclite, cheratitc
Di
alte boli inflamatodi ocularc), din gfec.-.
lirrtti.
na:ale, rnastoidtene si. sinttaqle (tralrmal,ice, tumnu e prin infeclii
rlrr frrcrr,r' kroale
5s.a.)
qi dit:r ir'fecliunile mauilo-dentare (infeclii de focar, perios'
i ittr, l,umori q.t.). f +) Cefti,lalgii.le hot'monale (1* femei cu disfurclii oYat i"
r,rrc, cu mcl,ritc eronice, in proclimaxr in climax etc').
lt) Ceful,algii,le c\nl,inue regr$i1i),
(Arsni
$i
Oprescu' 1967)-sint t'epro"
zr,rri'rrio ile: lj Cefaleile din encefalopatia
posttrm.malicd'' 2) Cefale;iie ltl
h iprrltn.si.ttii tralali . 3) CeJaleea
Stsihogenti
(hr lemisie). 4) Alte a.;feeliuni
{venl
rr:ri sus) i n curs de vi ndecare.
7.11.3. nl i grcnel e
Nligrtrrt l,r'ebuie diferen{iati, de restul cefalalgiilor
7}ritL
utrs.at$el'.e
xrlt: xrtirtiologtco paz"ticu.lare, in sensul unei cefalalgii periodicer predonti"
rr:nrl; srrrr o)iclusiv unilaterall, pulsatilXr insolit5, tle obicei de tcttomcrttt
,rrrrlu rr (l'otopsii, hemianopsii, oltalmoplegii), de tulburiri velietiltivo
(itrr'(rfi, vr'i rsil,tui'i). De multe ori migrena are o incidenfi, familirtiri. Litt
rrl l i .k.rr' rl rrl i l yoai )o deci si y de tl i agnosti c cste reprezcntal , {l e r!.l l ' i 1i rl
,rl ri i rrrri l i i rr l i l ol estenl i (pi nd, l a vi rsta dc 1A-25 tl c ani ), astfcl i nci l ul l
ri i rrrl rri rrr rrri gl enos apd,rut tl up5, ti rsta t1e 2,5-30 de ani sugcreazi r l l l tLi
rlr.glrrbiu o lcziunc organic:i intracllniani,, cri de pikli, un tune\-r'ism' rtll
:rrrgi orrr, o turuol i l ctc.
(Arsel l i qi Opl cscu, 1967; I)i amond, 1974; Ii l bol n
r ; i I ) r . I i i r r c Ol i vr r r i us, t 07l ) .
I ' t ohk. r r t c t k' r . t i opr t l ol l e t r i r r
l , l l l i l l tutrt' dtti tl t ui l rtnu ttnnmri i
' ,ti
rtti gttttrr'
,,ti n
r I i r I t' r ' /t i t t r
'
' (,,i tt
, , ( l | i zr r
i t t I i i t r
{
t t i I r r '
)
, , , f l t t Hl t ' t . l t t r i t , t l t t , t r l t r r ' ) )
i r i t r l , t r ' l i t i i v r t ; r , t ( l ( r l ( \ r l l r ) r , 1r 1l l l ,
,.'',,,,||
l , r r r r ; r t r ; r l t r ( : r ,
r ' r ' l ot l . t r , i sl , : t r l i i ( pl l r ' r . [ r l r r l gi r ' , r , r ' I r r I r r I
i i
i r r r l i por i l cr ' l r r I r l ; i t , ' )
, r r r r r r r l r | r r i r r gr . r t r ' r ' ; r l r r l l c
l r t ol r l | t r r r r
r , I i o| t l r I ot | , t r i | r . r l o l r . zi t r t r r '
' r t i j r r r i , , r
, , r , l r t , r l . r .
l l r i i r l ; r , i t r *i I l r . i i i l r r r t i r l r t r r i gt r . l t ; i , t r t t t i t t t l t t r t t , r l t t pr ' i t t t r i i r r t r l r r t i ( At . t l t r i
| | ) l ' t l ' r , , | | , l t l {i i ; l ) i I l | l ' ' | | {1, l 1}?. 1
;
l , ] l i l ) or r ! i l ) " l i ' i nr ,
( ) l i vr r | i t r s,
l l l i ' I
;
I l l r r , ' , r r , l l , i ) f ; ) , l r ul ( ( l
1I t l l r r t t l . i i
i t t si , r t l r i l i l cl r , r l i r r gt t osi i r t t l r r i , r r r , r r oHi i i r ul ,
,
'
r l , r r r ' , i r r vcsl , i gr r {i i i l l ' . r r l ' ' ( i r ( , l r r si v l ul r , t i ogr r l i cr ' ,
|
) t I r
"
t r I r |
( ) (
' r |
( | I
'
i | | , ,
| 1
r
'
r I
l l , , I r ' l r , ( , i l r x' r ( f cl l r l r i gl l r l ' i l r ' ) , i t r l t l l i l i t t spr t l r . l l l r t l r l oul r r i t r r i gl r . r r oi i t r r .
l r , r r l r r
'
, l l r , , l f f ,
l ' \ t ' ul u
t i 4t t l t t t t , r , l t t t i , , i :
' , 11 i qr r ' nr r ( t . st ' nu i ) t t t t u' r t l or l i t r t dt i u: [ i u ( t t Jr t l r r t t l ( l . i l ) t t t i | t t t | t ' t | | r t l
1, , , t l ' 1, 4t ( , t l l r : i t , l t r ni t nol t t i t t *i t r l t si t t t l t l t l t t obI r t : l , i t r t r l t nt l oqi r r ' ) t i r l r r ' ; r
r r r r I I ui r r r . l ( ' r ' vcl l t t t l i i i l i :
t l l l i r t t t , ui i t ui l abi l d, i t r si l r r r r l i i l i r i t t r . : ur r si t r r I l , or r r r ' l r r r r r . r r r r l r r gi r , l
r l r l r l l : r l r , 1r . r ! , r r i l , r xl i l l t ' r , cr r cr i zl i , l r l gi ci r , sl , r r i r r r or l i I r I , r | r r pl ' i cl i zi i , r r r r r r i r . r l , ul
r l r r , . r l ) i u( r , r t t r ccl r t i i i con( i r i r t t
( l o
i i cr i r l ' ( ) t l r t i l ' 1, i r r t i l vr , sl i gr r f i i l c cot r r pl r . l r r
r r , , l r r ! r r r r gi o; l l r l i r r r r r , t r bur l i ) t r r r ovi t l er t ! i r r zr ' i t r i t t t i r r ot gr r r i r . ,
I t 1 l ' : i r t t r l ant i . r l r t nt t l i u r t n. gi ot t , nt , eLc t : er eLr u, l t , i r ) r ' l r t \ r st ' l r l t r ' l r r u{l r t ' r ) l ! r i l i i r .
r l , , r r , r r r r I r r r r r i i r r r r r ' t r t ,
1x' r si sl r i , ; i
r l upi i r t i spar i ( i r r cl l r l a, l ui ci , sr 1
l ) l r 1,
i r $( r ' r . r : Ji
'
r r , r ' 1r r I r . 1r I i l r ' , i r r t l r r , i t r vcsl i gr t l , i i l c I i t t l i ol ogi t ' c si t t t t gi ogt r l i r r r scr l ' ' pi xl t "r r zi ,
r r r r l i , , r r r . r i t i t , r , I t Sot t l l l t ' i i .
| | l ' :r ttl .otJti qt' ()tq, tl i tt, rt,tt,ttrti .sttttl r <:crtbral l : totrpot l r' i o i u,t' i rr rl ,' r.l r.
r r r l , r . r ni ( , l r ) gi r ut t l i f ct el r ( i l l c 1l ! i t t l t : I ui gt t ' t r l pt r r pt i r r ' zi sI ( \ t ' r r r ' t r i i 1t
l t , r , , ( n, l l ) {i 7i / \ r ' s( i ni
; i
col r . l h. , 1974) : - Vi l sl r r , r r l r i i r r I r i r r | , I r I
j
i , i t r r . : r z r r l
, , nr \ | . | | r l , l or ' psr r r u. l or r I i gr t : r r ot r sc ( 30- . 10 r l u r r r r i ) . l ) Ur ' : r l r r pr , r r i sl r , r r {r ' r
' r
r ' | | r . 1, ' f r r r . r r t r r kr gi cc, 0i r t c nU r ot t r l ot xl ei r zi i , i DLr r l i l l l ; r l t r l t ; i I r ' i zl r , r u' l t r l r r l , i i | ' i ,
, I r r r r r r r r r l l ( . r l
f i / sl l r
i l i cot r ) pl ot . Pt ' r ^zt ' t r i , ; r ' r , I no( l i l i oi i t i I r l sl l l i i r l r r l or r l l i
i , r r l . r , r r l r r l r l i t t i cl , t l i u i l r r evl i sl nr r l l ) r t r pl , o. l ) r r ' zct r {, i r , r r r or I i l i r ' . r l i | ot '
| | r I | | ' I I r . r l i | ( . ( r l ci l i noYi zul l i zi t r el r ] nni 11r r ev| i st r t
1xr
ungi r r gr ' : r l i i r , nl r r pr t l r i l r l
Lt
t t ; "j , r l i r r t r zr ui , r l upi l , Ar seui
r yi
Opr cscn, l ! ) 07) . - l , ) vi r l cr r l i r , r ' i . r r r r r r r r r
i i ur gui r ol cnl , i n ca. z Lr I anevl i snr el or f i gur l l t c sl Lr r r I pl r . f i r r r l i l r r zr
,.' rl , I i rr i i rr sp|!i i l c subarrl hnoi d i ont' .
i l l i qn' nr , of l , u I nopl cyl t t t i i r soci azi i , o r x: [ l l i r l gi r r r r r i gr r r r r or r r i l ,
; i
o
' l l r r l
111, r ; r l ' ; ' r , , r l r si l r r , l , ot ' al i l .
( ) f t [ l t nopl cgi l
l r pf i , t ' 0 r l o t l l r i r r r r i i r r sl , r r r l i r r l r u. l : r I r r | ; . 1i r ' ,
I r l r l l l
' r t 1'
( l {r
l u, i t t st l l i l t en t l Ll t cr i i qi I at r n}r ' i l r ! | l l l zi L' . l ' l t ' r r l i zi i l , , , ' , , r r
1, , ' r , ' 1, ' r r r
l r r r l ,
I i pr t , r ' {i l t l c ( per ccl t ca, t JI [ - l t , ) sl r t r l ol ; t Lr ( pr r t r ' r , l r i l , l l l , l \ / l i
\ l l , . , L. , i r r l ( ' ct t f t cl , i l t ' el l pr u' t , i l t , l , i , l r t t ot vt r l r r i l t i got r r r t r , So f i ' r ur r r I r l r r l , i r , r r
i , r r r r , r r r l r l r , r l i gr t r r i i , of l , l l r r upl cgi ci i , si l r ' i i l l r i l i ' t r r zr r r vl r 1 r l or r r ' l r r l r r zr r r r l , ,
| | r , r r , | l r r i r r
Dr t l , t t l , cvi dr r r t {i l r
0l czi r Dr o ot ' gl t , t t i cl i , i t r l r r r f i l , r . r i l l l i | | | I | | | | r r | , I r t i r
, r . r r r r r l r . ni , 1t no o, l l . t t . l . t n o pl t , 11i r n
l r r odt t t t
r l o ut t . t t : r i : ; ut ( r l r r r r r l l l i i , r ' : r t ul i r l r i
r , , i nr r r r l l i r \ ' {' r ' r ) oNr r l c l r l r r l i , t ur t r r r r r r i ol t t r l i
l ) osl cl i ol l nj , j
r l r r l r t l , r , r ' r i l or t l ' r ' : r l i l
t . ' l
I ' r r r l r l l l l : r t r t l c r r t l r ' t i , r , r ' t l r , l r l 1t l i i
)
sr i r l o
( / / f l
t . , l i r ! i r t t t i . r t hi l r r t t t r ot
I r ) l l , r l i t r t pl r qi i l t
i l , l t t ' t ' r xt : t t l i t r l , , r l c I r t l t i
, l r scr t r l ot r r i gl r r t r r r
l t t r r l t r l
r r r r r l r l , , . r r , , r ' i l r l r i r l ) : l l i t t
. l ' i t l t l r r ,
t t r r r l . i dr t ct r r r t t t on, r r i ( t r r r cvt i i r r r r r r l t l r . I r l r , t i i
r r r , r l l r l , r r r
. i r , i {t r r r t r l
l
( , l t o l r i t \ ' c| s{l r Zi , si t r t r sr r l
( l \ ' ( '
l {' N) , Hr ,
j t r i l l r r l | t r zr r
l ' r r , r , r l l . r l r r ( , l l | gi o i r | r , r {i l l r I I r ' I u, l l t | r ' r r i | }t i l t I i ( ' f l l l l i , l : t , r . l | r r r i r : r r r . r l r zt r
, , r l l r l r r r r r ' ( 1r r r r i , I l r r r or ' l r i l , i l r r r ) , l r i pr r csl l zi o i t r l r l i l ot i r r l Lt i gr , r r r r . r r r r l r r r l r r r
r t r , r , , l ) r
| r .
r ' i r r r t r t : r , ol l : r I t r r i r r l ' i ) qi t t t r r i t r l l t r si t r ct r r t t t , l
I r r l
r r r l l r r l l l l r l l I l l l
r , l r r r l r l l | l l n, , r | l r i l , r r oor r l r t i . . r \ t l | r ' i r 4gt ' l t l i l r r i z r r r r I i z | t r z l i | . i sl t r l l r .
l i r t , l r r i t r r i ,
; i
t r . l l r ' r t . l ' l t r l nt pl t t l i i
1t r ' r i r r l i cr
i r t : r l i l t ' t ( r , , . l l l ul gr t
1' , r r ' ,
, , / r , , r t r i r I r r
,
\ ' I t r i r r r r
.
I r r r l r r l t t l l t ' l r l o t r r t t t r t r ' : t t r I I t
l r r
r t l r . t i r r i r t r r ,
I r ' r ' r ' l r r
i j t ,
/ / , r /
r. ttltltlii, tl,tLt'rn)(LNc (
t utr t:Llf reourehlid,I, ihrr tttmi1runoatri ln ptuc0s0
i rrl Irrrri l i xrIi i i l l o si rursul ui ci l vcr.nos sti u al o ol bi toi .
'
O 0 rrrlr[o}krgio rlrrroroasii cu.. caract()] recu}elli,i:r,l (in care algia, nu
rr ri
,
,
.
rr'il'( l{}r' I Lr:mic.alic,. ci prezi,-Itii,
o localizare ret.oorbitari sau i"n tori-
l{ i I r rf l { rr t,rltr'r(i) rLpa, e
$i
in
ldfiaft,erita
cdroti.tl,i&nd, i.ntramternoasd, (descriSii
r l ' . I l l u,
i i
, ' r r l r r , Jr . , . 1- 00t . ci t : t , l i d0Ar sct r i qi Opr escu. 1962) . t n t at r l oul semi _
r ' r , , , 4t ( . sr j
l ) L, [
us, Jci u[
st
scmne de l czi une a oer f ul ui opt i c.
.,1.1.3.
Sindroamcle pseudomigrenoase
(sindroarne migrenoase simpto.
nr r l r ( xl ) :
1. IIem,aragiil,e subarahnoidiene din_ mafforna!iita
,t)aso,u,larc
(aneuris"
tttr:, rr,ttliname
)
pot genera
cefalci pseudomigrenoi,se
cu caracter recuren_
( i i r l . . r r sur r l r ' r l i l gnosl i cet pr i n debuf ul br ut al - al cef al cei , pr i t r semnel e semi _
(l r,):j rr' ,.rtc
uoompal ament oare persi sti , mai mul ti rreme, pri n
constatarei u
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
rl rr' .i t l rrpi ,l ..l drA frze preci se pre-
9i
posteefrr,l al gi ce
cai n mi grenr cl asi cd,
r:'| t|r
.(jv'rturt:I,
ultenoari], apar semne de hipertensiune intracranian[
(;\ r sol ri qi Oprescu, 1967).
ii. Tt.r,m,orile de aentri,clr,l
.III
-pot
g.exera Ia 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.
l ri i r i l ' ,
-rl .t.
prrzi ;i e r,l e capul l i , i a r evol u
f
i a t ra nseai i i d i agno\ti cul , pu
-i su.*
i n"r:.l i l i i .si odr.omul ui rl e hi peruensi unc i ntrl crani ani i i p:rr qi semne neuro-
l ,rgi ,' , obi ocl i rre erol ul ,i vo (si ndrom
pari nautl ,
si ndrod Arl l yl t_Robertson,
l)rllz{)
ooulale, semne tliencefalice etc).
, ,1..
l l ' ttmori l e occi pi ta-l e pot.genera l a debui cri ze pseudomi grcnoase
cu
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"" r I r Ll,,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 .:rl r..;. crfrrl rrr. pul sati l i i . (cu l ocal i zare i udeoscbi postcri oard. i n regi unor,
ol ci l ri rrrl i i ), rr r;r,ni festi ,ri vcrLi g-i noase. fel omene ccrebe]oase, zgomotd auri -
llrl.lr', rliziLrlrie, parestezii
bilaterale atit la membrele suireiioare, cit rtrl
l r rrr,rrrl rrr.l c i nferi oare si l a fa!d, (peri bucal e
$i
l i nEual e) si
-chi ar
al te*,rca
, r l r ' r r i i . r l r . r ' i gi l ent d ( obnubi l a, r e, . bi per somi e) .
Sc p6t asoci a: ni st agmus , i i
l r.rr.rl i zi i
rrcul omotorj i trenzi tori i , Acest contcxl , scmi ol ogi c trebui ei u gri j ' d
r.l.i.lrlttliut
a mi,grena bazilard (Binkerstaff, 1961
;
popovi*ciu
qi colab., 1".9gd
;
l l r Jr r . - r . r r . i f ur n, 1977) . pe car e de al t f el uni i o coni i st l , si sJ ne or i cnt ozr i
r r r
1' r i r r r r r l
r . i nt l spr e o af eal i une or gani ca i n t er i l , or i ut ' uer t ebr o- bazi l ar :
,. .t)
lnsuJicien!,ir,
.
c.irculatorie aertebro-bazilard, alercscleroticd, (forrnolo
cl i r r i r . i ) 1r ' i r nzi t or i i qi i ni cr m i t cnl o) .
, ..lt)
Mu1,Jormnlii uasuilare (anenrisme,
angiodtna) ln teritoriul veltcbl.o"
l ) i r z I i l t f .
rl I't'oluse l,nlocui,l,oure il,c spnli.u r.tl,c
fowi ?ostarioare,
S' - i t ' l ) u' , r k. . i , i r r vr , r l . i g, r . {, i i l t t . . r r t , o
4i
t J( , t nl }l . xi ! ( ol : r r r r or r r , , l Lr r hr r ' l ' -
, {l r " : l r l l l r l {10 r X' l l t , : r , r i l l r LI . o vi z| l : Ll i l , , ci r r r l t vi zt | l r l
I
| ' r l t r r r i t r I r , i I r r r l i l ( ) gi cr r
2:t{l
t r , r r r ci r l r , t r l r r s1x' i , i l r l r r l
l r r r , r r r r or r r r r r ' l r r l ogl l r l i r r
f l l r r : ( i or r l r i l i , r ' r , sPl cl i v l l r r l l i
, r r I , r ; i t r t I i r ' , r r l , i l i zi t r t l r l r , l r i {
( ,
t r | ( ,
| |
( | l r , i t t ci t I r r t t ( r , I r t t i ur l i ol ogi r r r r spr r r : i r r l . pr , t r l t ' t t
l r r , r
;
r osl , ot i ol t , t i i ,
l
l t t ' l ct i ogt t r f i r r vr ' , r l r r ) l l r l i ' i , ; sr : i t r l , i gt r r l i r ,
l
l onr ogt r r l i r , : r r i r r l 1L
, r , r r r
; r r r
h' r ' i z11 l i , r , | t ' cl , t t x, t r cr . l i t l r gl i r f i c q. 1, . ) .
tl J l l t,l ,l utntt
!i i .
uIt
.l osti
t:url n' u.l r
l tttsl tt
i ttrtrt yi tl t
;i onl i rnti i .
rrrtni o
, , / i r r ! r r ' ( i nr I r ( . $i r t t r o br r zi l i r t i , pl r r l i buzi i r , si r r r l | or r r I i l i ppl ' l l t \ , i l q. r r . ) .
| | | | | | ' ' | | i . n( : l ; c| ' l ' u. l t t . t ' t t , ut t t i ' u. | i l . ! i l t ' n' i ' t t t ' 11t t t t i t l : t l t l t : u| . t t l ' t ' , t t t ' t l . | . t l t l l l | i l l
' ' , r t r t t t t l . l br t nat i , t o r i i r l r l ci sr r t t spr r ct , [ cl i l , cl i i l c sr r gr r l t r l o r l r r l l i r Lcl r r l r r , l l
l l l r l ; l ) , i n( l cosel ) i apl r r i f , i i r st r l r vi l sl l t r l c l l 5 r l o i r r r i r ; i nr vt r l si l r i l i l , : r , l r , r r l ol r r l l ,
, r r Lr r r r l r i onr {r l r L obj ect i vc l l r scr r r l . i , vr t ' r r : t r r l r r pi i , 1l ( i ces, s{!
l x) l t l r r
$l , r r l r i l i r l l l
1, r r "
l i cl l r l t . r l i gr ' , r r i b: r zi l ; r l r i .
l rr sl i r' qi l r, rti ri tl eJrui c avut i rr vtrl cl r ftrpl u). ci i
\i
u,n.rl t ari tr l ti prul i
, , t t t t t r
1xt 1,
si t nul r r o mi gl eni , l l azi l i t t i i ( sl u ot i cu r r l i i , f ot r ni r r l i r r i r . i i r l r ,
t r r r l l r ' r r i i ) . Oar t at t r , s- asi pr opus ( l ' opcscu qi kr l n, . t 9?7) pl oht , r l i r r gr r r r l i r l
, r f
l r r r ; xr t r t i ci i , cu sol ul i o t l g gl ucozi i 20- 30% ( 20 - 00 nr l ) , r r r nr i r r xi l r r i r ( i i L'
rrr ,,:rrrr ptorhce di sprl ri l i a mani fcstri dl or nenl opsi hi ur, rrl pul (fl , ol i .r' i rrrr
i ,rLl (l i ' (' onfi unLrc
a ori gi ni i hi pogl i ccrLi cc l urror cl i zl rrr i grl rro:r rr' .
7.11.4. l l gi i l c orci pi to-ccrvi cal c
Al yi i l o
.oeoi pi l o-eervi eal e
ri cl i ci , urmi ,toarol o pl ol tk,rrro r l rr rl i rrgr rorl to
| | r l l l l t l r ) gol i l ( j i
n ) ' I\ruumo,l i sme aertebral e tau
,rterl el )ro-marl rr,l rrrr.
' l ' rr,l l rri o
rrrrtl i tr
r r r l , . r ' r . I r r , l l t , r r l ( Ar scni qi Opr escu, 196?; Al sl nl i qi ool r r b. , l 1) ?: t ) r ' i L r l r r
l l , r ' , . r I l t uur at i smel e vet t ebr o- r ngl ul l n u eot vi cukr i r r cut r r l r i , o r l r vr sr , l r r l i r ,
l r r , r r
r l : r l c
1i
ci i t r ebr i e ci i ui at e cu gl i j r i , i r ni r l i a[ r l r r pi l l l r r l r r l r l i r r r r , r r , r r r
ri ,' l l rl c k' zi rnre u,ti t ver"tebml d,, ci t si mti dul eri l ,. Si l rl si l ,rrrrt,i i i rr oi l ro
grr[r,r' rrr(rr,
rrrl rIrrIrrl i i esto ol i gosi mptomati ci t snu i nexi sl ;ontri , i n schi rrrl r rrrrxl i l ' i l nl rl rr
r l t l r . l r t ; r l o haumat l ce si nt i mpor t l nt r : , sni cl i nl , a l i r l i cr r l l r r 1 l , t r ul r r r l r r r l t t Nt r
, ' l t t r r r ,
l r t i u
t l ur cr i cr l r vi cal e sau cel vi co- br ah i i r l c, l nt l c, , st ' l r i r l i skxl r l i i l r , r r , t '
l r,l rr:rl r, si i l rcturi l e-di sl oca{i i rl etenni ni i si ml roi uno l r l i (j l tl rur' , i l r.rr' r\
l , , l r r r r l r r l l r cnzi ) , l l gi i put er ni ce i n ceaf i i , , cu i l i r di ol i sl t r t r r t gi r r t t ol r r r , ci pi ,
l r r l . r r i spr r um5, r , i nsol i t e de cont r ' . . r ct l u a r nl scr r l r r , t , r r r i i r r r r r r r r ! '
4i
r l r r l i r r r i -
l r' r' .r ui fj r-ri i Ii l or col oarrei ver"tebral e cor.vi oal c. l r)sto i rrl xrr' 1,rr l , xl , srr ptr,r,i .
r l l zr . r l r r r i i , si r r t sau nr L; i si t t pt one asoci al . o
( l o
l r r f r , r i r r ( i i , r r r r l l t r l r r l l ' 1.
l t
) Il i saryati i l e Lefi &)ral .e cerai t.:al a
' |;trttrl tte
rl ut0r' i ou (j i rt1tr11(,ro (l i l i ,rr\rt
{l , r l '
r r l r n( j i i o de st t di r l al t er i r i i di scal c.
- Asl , f t J,
i r r l i vr r , I ( i I r l I ; r i r , r r I . r l ,
' l r '
. , r l i r t l i r i onl i i , t l i scnl i i dur : er oasi i , t ' * . Do Sdze) dl t l r l r r i l , r ' sl r r r l ol r l I r ' r r l i ,
l l t r t t l r r l i r l i r r r n scgr ncnt vct t r ' . br i l , l , oa, l i j r xl da1; ol i 1, i , i r , i l , r r {i ci I |
,
r
.
I | | i I I I r
1
i i | | | |
r r , r \ r r r i ( l r l i r r r l i scul al t cl at , I ) r r r . el ca, sc t l t zvol t ?i r l uobi cci I l t l , pr r r gr , , . r i r r
l i r t r r r ) r ' l r r z"' i l pl t l cr r t i i ovi {l cr 1; i 1, . l ) oar uncol i l r , l gi r r , r l ohul cl r zr ' i , l l l r sr : , l r pr r r r , r r l ,
r I r ' r ' I r r r r r I r I r ' i r l o r r n 1] l l r , ut ut l , i gr n t ni r t i t n, r l c
( )
t ni ; ol l r 0 l l t t t soi ,
gl r r t ( l t \ ( r xt r ) I t t ( , f t l
l , t l r t l 1 r i r r r r r ozci l l i l . J) ut t r r , r l osl cl r ur i vi ol cr r l , l i r l i r r r i t r cl r l l r , r : u( , cl t zi i t , oxr \ l l l , t i i
l r t r r r ' l r t
r r i qr i l i l r kt cof t r i nr ci , i al pr , r r : r r {, i a l ooul l j i r r , ct , l r l ; r r t , i r zr l i t l gi i r , . l t r r r r '
t l l r , r l ur : r ( . {l i t sl , l ' i l t r zi l , cvol t r r r azi i , r l o ol l i cci i t r
l r t t scl r i
qi r r u sr r i t r Ho{r , l c r l r ,
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l l ' i r sooi i l zi l i i i t ' l t l buf i [ f i t t ' ol i cc ot t i ; l t ' t t l t ' i ' t l t l nl l s{) t l l i l l l r
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r l {\ r ' r t r r l r r r r t r ' ' r r r r ' l
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l r p| r , l , , l t i ,
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sl al cni ce qi a gi tul ui . Ne c.:r.j l rr
tiim sprc di:ignosticul de sinrh'urrr
sc:rlenic in siluafiile in carc lrrrl
nr\-ii acuzir durori ce..rvico-br'rr
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cubital al anlebr:llrrlui), carr sl
cxacer*leaz:i diurn, mr:i ales I rr
ocazi i l prrrti l i i de greuti ,l i si r,rr
rr.; rr {r r(,i,,r),i,ii,i
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o set . i e de' t t r l bur i j r . i y: l , scul l r r , r , :
| r , r r r r r t | 1. . t r t r r l , l t l
i t | [ r t r r J, r l r l i - supcr i or ,
car e pf ezi t t t i
o pi el e r nai r t t , , ,
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rrr r.l ui ' :i ' :)rsi , (l i
i i nrri rr?,r aml l i tui ri ni i
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t , r , .
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t l cr r 51p1r 1 cl :
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,r' l r rrrl r, rrrrl sl l zi r zonci do i nscr,!;i e a rnusphi ul ni
scal en anteri or supt,i rl r,
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l rri
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I rl l l l .l .rl l ttt. fi ul ,,r ruf
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gemnx;t
l ui Al s,nt
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t ; , , r . r vl l t . l l : r l i t r . _czuf cu r r r r i r r i l e
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r
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I , i r i , . . r , l r r ' i . i r r r r r , t Lbr . ul
s' psr i or dur er os si o di mi n' r ' e a ar . pl ; t u, 1i i , ; i 1, , r t
' ,tl trt.tl ) l l ,rtrr
rrt l vi I l al steo,tl , : ' Irl c,l i uncl r, i u j os
i n axtl membrul rri
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fi
cu c,t,pul l otttt cl oi rt;t,al rl tci ,l tl , exuccl ,bt,i l zi i . j i i
l
r l , ' I r r r . r c. r i t L i l l . ( r t ci t .
I t r l . r r . r l l i i r r ' r ' ( L0i J; l )
u, $f r r , r r i , l i t t , . i
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l r r i Ai l r r or r - O. f l . v
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l r
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. , 1. 1, . , , , , ,
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r ' l l r l r . , , l r , r r r i : r r r j r "r ' i r r l r . t r . r r . r , l r , l r r , r r , l r , ( i r r cl r r r i v
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Di r l c
r r r 1i 11
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l i , ' r ' l r i r r l r ' , oVr . nl l l i r l cl l ( 1i l n( , 2i , ( j r t ( r {l cl nl l i , , i ( j ; t \ i l ,
nt i i ni i si sl l t 1l , 1 i 1l r 1, gl l l 1l
r r . r r r l r l r r . r i r r ' 1xr I i or ) si {' r r r l i co or t , i t l sc ( 1, ( ' gl r ur ct r t r ur t r , t r r r t sot r l ar ( i r r i r l r \
l : r t t r r l r ' l ot ) .
i r l r(,r tnl ri i Lscrn(ruol l l ,abl ou ol i ni c trebui e si , ne
Ei ndi m cri si l r,l l l rrrrrl
l r r r z; r l ; i i "
l r ol l r f
l i ger r ( r l i t . r l c l i r r r r l e nt l l . i
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ct i opa, l oget l i ( ; \ r sol i 1i
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el , ea,
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: a) I , r , zi r r r i i
Ir' rrrrrrrrri i < rr (rrLri rrl cs), i l {1a,rn:rtori i
sau toxi ce al c nenl i l ur peri feri r,l si rr|.,
l rl r' ...rrl ui 1
Ir)..l )r.oct' so r:on4rl esi v-e rcgj onal e sau l ocal e cu readl i i conj ul ci i r o
i .i .rl ' i r:. i i l rr..s. crr,r.. i ngl obeazi , nervd
Si vasel e; c) Iractnri c' rl .
. I r r i r . l l r r l c; . {l ) . l ( l cf i ) ?: r 1i i ( boal n, I [ odgki n, t uber cul ozi i )
I
e)
- 4f eul l r r r r i
: r l { r l r ) r }I l l I i
l ) l ( , t t l ' i [ l .
l )rrpi .A.r' serri rl i Otr)r.rscu (1962) cauzal gi ,r, pfczi tti , trei grade : gri ,,{l ,tl I
rrrr r.r zi rl si rr Lrcrrl i ; g|l dul tl _Il -l e:t, uru ca;rzal gi a regi on' ab (ci i rl {tri ,,
rrrrrrr.l . ..p.i rul i ,1r,cg rncmbrul .respccti v); gradul al Il f_l ea sa.u csatz,rl
, i i r r ,
r l i l r r zi i ( . i , r l l . ' , r ' cnel e sl : ext i ndpeo j ur ni , t at c
r l e cor p qi pot chi ar . sr r
l rl r(' .
ri
rl .
1,' hi l opusi ,, cu tendi nfi i de gencral i zar' t
). cr6tl eri ci i aci .srrr
r.l rrri l i .rrrr' _rl i u.ti pr.cfi oase i ndi cl {i i de di agnosl ,i c i n cazu.i l e cu sri rpror..,l
t.Lrr' ,i r, p.l i ' L' rfi r,,
,,ba,sl ard[,),
cu topogi afi e nesi sl i enati zati
;i l i errrri r,,
r rr |{
I,i Ir' I
i I r' (|Il rrr ror tcl rrrerri pcri ma],i c:r,
,,si url r' orn f i zi oprti c" (al
l ui ]Je,-hi r,rl r i
l r , , r ' | , r r l ]
- . i
. . - i r r r l r ' , ' r r r ( . \ t ( . r ) sop| ogr , r r i v' ,
( r r l l ui t , r 116; .
7.i |.{}. rl l 11i i l o l oraco-:rbdomi l al e
|. h' rn\t,l 0 i .o
.f
Nni cu}ui (f renal gi a) este real i zati , r1o l ezi uni i l i tati r.t r 1,,
rr, r' vrrl rri
,l ' r' rri .
i rr l rrngul si i ' trai cct di n regi urea
cervi cal i i ((rr-Lu) pi rri r
I:r, rri r.l rrl r l i rrh,gri Lul ui . In prezenl a unei frenal gi i trebui e si ,
' c
gi ri r,l i l rr t,,
rrrrr,r' r' i srrrr rrl o l rl ol el or i nveci natc (al e arterei subcl avi cul arri sal rrL,
1rl rIi rrrrI.LIIrrJ. }Lrl rnonur' ),
h tumori sau. i nfl ?mal i j rl edi asl ,i nal e, l *, pkuri l rr
r r r r r r
.
I i r r r. I i r r r r, I r r s[rr rl i i l l i ' rrgmati co, l i l pcri cartl i te
sau ]t un abces' subl i i rl |rg
t | l l I t ( 1.
| )' .l r' (\i t si 1 l oci rl i z.azri , l :r, Jtezrl gi tul *i , i l }a,poi i l mJrgi Di i sternrrl rri ,
1r' r' rrrrrI
qi Lr brr' z,.' tol .Icc]rri (cu.proi ecl i e
l ntel i ou,ri ), fi i nr[ i "nsol i t:i arl tsr' ,r,
, 1, . r r r yl l r i { si r l o i oni i , r ospi r at or r e.
(
i r)rri (.\hrl
sl mi t ogi c se compl cteazi , cu prezoni i a
umti i i oarf l or
I
) tt ) t (
I | | | t t |
(t't )( | 8
(t
|e1)d&toen pentl? adeastri neVralgie :
,
:r) |' r' r' ri rrrrr.;r puu.l ul ui
Jreni c,-
si tua,ti i ntre cel e doui . i nserl i i i ufcl i .rrrr,
' 1, .
r r r r L: r ' I r i r I I r r i st ' . t uoch. i ( I ol l ast oi di Jn.
f)) I)r{)Hi un{tr, i rt pri mel e spal i i i ntercostal a, i medi at i n afara rnargi rri i
r l , , r ' r r : r l c r t s1t c01, i vc.
,
)
,,\l ri i sl rl ol ,. i n punctul - d.i aJragma,ti c, si tuat l a i ncl ' uci qat,ca tl i rrl ri ,
1r r , l r r ; 1i l r . r r ,
l i t r i ci par ast el nal e
cu coasf , a i a X- a.
r11..\;r:i srr,r' rr:r pa regtunea tl e i nscr!i e trJraci ci a di LtJtagnul ui (1xtnr:t 1,,
t r t t r , ur t , t t , r t t , 1, l [ us4
)
pl o, t uco, r l , . aSpl n{, neJ, r l r r r c| i .
"
.
!" It' routt.artl i n,- descri si l . d_e cl i l ri r' i crri i m:ti vl chi , sr: traducc pri rri r o
rl r' ;i r' 1,.:tl i zi r,l ;i i , h, ni vcl nl vi rhrl ni cturl i rc, sui r {' r' rnri ti i e i rr!ep:i turi , i rrs,rl i l rr,
r l r , . r r r r r i . t r r 1, . , i l pi l i n{l
Dr )
r r t r f ond ncvr t r t i . c. l l osl ; r , pl t t i cJ i r r spcci l l l r l i r l r r r ,
I r ' i r r zr r i
. ' pi . l l s( 1, cl l r o i u' dr , , i l r r ni l t l r , t l i l t r r r r si . g. r st , r i i : i i , , l [ l r r r gr i s i , r . i 0 si , / si r r
r r l t r x' ol i r ' ( Sol l r r i or t , l {Xi ?) . Al gi i l c l r r . nr xr r r r l i l cr r r r r , r i pot r i pi r r , r r , si l r r l r oi r i ; r , r , i r
. r r l r . l r : r l . i l r r r sl t l 0r r t l l [ t , r f r r l i r ' ,
I ' 1! ]
l l t l j i i r r . r r | t r r l sr r i t , i r r i i . Nr t l r , , , l r I i r ,
r ' r r r r I r r r r r I I r I r l cr r r l r t t t r t i l r l i l t j i | l ( ) i | l i t
. r r
cr r r t i r t ' r : r l i j i r r , i | | l r . r ' t ! r l i l l l i l .
: t : t 1l
t L l r / r / r / r r r t t t l t t t t r : . l t t ! t t ' r r ' l r t czr t t l r i t l t l i r i t r t l r l ot r t
r ' l t t r r r '
; 1i
t r r ' t r r l r l r ' t l t t t l
, , . ,
' 1, ,
t , , , , , i i t l l l r r l i l r r l , ' , , , , ' , l i t t "
' t l r l ; 1i i
i t t l l t t r r ' r l r r l ' .
r r t r l r l ' l ; r I l ' t r t t l t
' '
, ' . t , , r , t ' ' i , l ' l 1i l I l , l t t , t t r r r ' 1. . l l i t r l ' l t ' t ' i l l r l r i l r . nt ' r t l I qi i i ] l / / /
.
i
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.
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t , , r ' r r t l i i l t i l r t t l i r r i r cr t i i ' r t i r t l l r r r ol r l ' : t l i
oct t l i l i
l t l r t r ' l i l
r t t r ' l r ' : r r t
. , , , r r r r ' {r r r r r 1' I i t I r ' ( 1l l ' r i i I i i t I i i
( i i I I i I t I t i t I t i I I i ct t I I l l r l i t r l l r l t r
( ot r ' l pLl l l z; l l ( r r r 11'
(
l l
r , . , i l l i l r r ' l t ' r l i l i , , i ] si , f . t ' l l r r or cl r t l t st r i '
o t i t t l i ct t l r t l gi t r l ol r l ( 1i ( r l
( l i 1 r l l l ( \ r ; r l
r , , , r | , . r I . oI I I r I i i . ' 1, ( | 1l l f l ,
l l l t r . i r r r r r r . t t : t l t ' l t l ,
l l ol r l ( \
Sl ' l r l r i . l i r l i r r ; ' ; t t ( | r l r I t t l
. r l ' '
I I : f i , '
i ; ;
i I l , I i t , r r I ; i r ' i
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( l {1x1i : r ' l ( ' i t ' i ' ocr i sl t r r l r : i I i I t I
1
t I
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r I r t t
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l r t t r I r r r
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t l t l l l ' zi t t t l r r l t ' t l l r l i t l t t l ; t l ' l i
( l ct r t t r l l r t l t i Lt
' ,
i r ' . . , r "l r t l i l t l r
( ) sol l s{l ( ' l {1. )
Ll | r ' t l l ' i r , , , , t ' cl l | l l 0i cl t l Ll
. i t t t r gl r i ,
t l t ' . r r t i t t t r t '
' l l .
r ' ' r r r r i l r r ' I i " l : r t t r l r ' l r I
' I
,
, ; 111' , l r l i si l i l l r l i t i r r bi i r ut l L, ni l l t l r I
( r ' t 11 r l l l r , r l r ' - r t l r t , t r l t t l t t r r ci l . r r ' ' l r "
' r r
l r i l t r l | t l t l i , .
( l c1
r r r | i l t t l r ' st l l t s{l
( x) nst i r l ' i i ' t l l l
l ) l l l l ( 11
( l l l l l r ( ) 1 l r r i r \ r l r r
1, , , , , ' l , l , r : , , 11i
al l t r l pl ust cLml l , . l t , t l i t t t r t l ; l t ' si L111i r l xt r r l t ' t l cl l ; t t t r i r r
t l t t t t t ' : t
,
' , r
1, zr r r r r | r r r l sl 0si l Lr i t l i i i nt l r l : r ' i Ll i i t l i i r ns^r , i t Lg"' : "t t t l ' r cot t j t t gr r | r "r l t t t ' t "'
, , , 1. , . , . 1, i r r r r r i nul l t cor i , r l oi pol i r l cl r l i r \ i t i l i i l r l ( r l l si l r r l t r : t t t t t t l
I r ) f l ( ' r r r t r
( | ' r l
, l , l ' r r r l ) si al i , ul al r t e' l i or i p, t r , l sr t Ll t "l l
( r r r
r ' l ' l r r { r r i ' r I i l i | r ' t r I i I t I ' r r ' l t t t t t t t
' , .
I ; i i l ; i i "r i i r "i j "
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t l l l r ' . ' t r "r
I
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; "
, i t t t t r t t t t *i ci t eva det al i i l upogr aJi ca
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t ' ,
, l r , i ' r t t t ovl i - Ll gi c ci mt onl t i , ,
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, r r l r r r r r l ' r ' t f r r l , t l ) l ' , ni t t t t t r t
, ' r l t r i t ! ' ' r l l : l l r t t t t r i i nl t t ' : "sl n l
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I ' r ol r l ot t t t , dl r l i r r l r r t sl i t r ' l i of t r r 1i l :
, , 1 i t t , , r t zt t l t t t t r i i r , t ' t , r l l i i
i t r l ' n' i "sl ' r l ' l t t ' l t t i t t
: i t l t , t l t ' l l i r t t l i t r t
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i l scl l o{t cn{oI Jt , t , , j . Lel or
nc p ) . [ t o r ugur , r
l r er , ni , l r I i s; ul r r r
L, | , , , .
.
f r r l r , . r ' r r i i l u , l i . : - r , l o p. i u coi npr ci i unr pi ur i r . r di cul i r ' i ,
se pcat o r ec, l i zr ,
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er i cr n, dc nor . r
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i ntern s:)u cl :i ,' oi nrL.' m (heni di fah;m)
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i ) I' tt' .:(,nj d tul bu,rd.ri l or sl i ,tt cteri en e ne poal c i ntl i ca herni i medi a,rr.
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)
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cr z, r l . i ) "sr r r t i , l , or i , qi nc r er t "
t 4\ t t , , t t t st l t t t ( \ . t ( ' i [ )
\ r Lr y pL. t r r i I l sor l , r ' ozr "t
Si
hof ni i r l i scl l e ( r \ r soni . ; i
f a, r ur l r ,
l i f : l l
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i r \ t scni r yi
col l h. ,
l 1J' / l
;
(
) l ) l ' r i i I i ' s' , l t , {; l l ; I ' . p' vi . i r r si r , r r t , l r . r l t . i i ! ; l \ , i ) r ) vi ( , i *
l i
i l i r , , f , ,
I r ) i i ; ) .
/ , ) ; I i t l r l r r r t r r l l l t t : , t i I oI r I r , r t t t t t l t , ; j i : t t r , t t t t t t t r vl l t t ' r r : t t ' r t l t l t t r ' t t zt t t t
l ' , r , r r a. r l c r l i r t r I t t r r r r r r r
.
l r l gi r r o ( sr x: i r r l , r r r l c r r | l f t r t : t t t t t t t l l r r r r t r l t r r t t : r l l i '
i l l l l , r l r ( ' r , r l r . \ l r r l
I l i t I i f )
1t 0l '
si i i r i l r l i , , ; : i al l t t l i ol r t t l i i .
( ' t t I I I | | t | i ] | | I I I I l : r l l l | l l
l r
; , r r r r
l r t r r r ol i ( t r r r t t t i r r oI t t r t r r , col csl cr t l ol r t r t r ' r 1. r t . ) sr t t t pt i t t : t I r t I r t t r , t r I r I r ' ,
, , , ' , l , r r l l r r i l l r l l , ( l t l col i t u l r ( 1( ' i l sl i i , l t t ci t l i zr t t r r ) , l t l t t t l t t l t l i st t t t r vl r I l I r I r r | r ' ,
,
' , , ,
l r ,
r i t l r t l i ct t l r t t r ' , sl i r l r t r l i Lr l i si czi s, nl l i t t t l i l r r t l r r t l i vct nc t t r t l r t t t l l r '
I t , , r l r i l oi , i r t si , sr i r t l ' i cl r , t r t r I i ct t | l t ' t r ' i
; t t or l t t si l t t
i r r i r si ' l r l ( l t or r r r t t l zt cr t l t r
l , l l , r . r l r r i r l t r l r ul l o r i l i
l l czi r r i i i 6i
t ut si t t t l t r t r t t t l c t ur t r l i i r l r r r ' : r I r r r ' ' i r r r , t r | : r I ,
, r r r l r . r l r r t r l t l , r r l l l r t i r t i st t t zi l , i vr t - r r l r i ot i i .
. ) , \ r i t r l i l r t ,
1t I r t t t l t r i i
csl ' t ' t ' r ' r t l i zt t l r ' i
( l t ( l i v( r ' so
J] t ( xx' s( '
sl l t l : r l ( r Lr r r r r , r l l
| , I L ( Lnr \ i ( c, l ut r t ot ' i i r l c sl i ct t t l t t i , r t l t l t ' sr r
l l t t ' sr t t l t l t t ' ( ' j
I ' l r l r r ) t i
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 nt xi i r l r ; . r . ) . I ) o r t r t t l l c ot ' i r t l Li i l r ' , r ' i ol ct r l r ' , r r r r r l l r r l r
, , , 1, r r I r I o1. i r r r I r r scsj i l c si nr l l o: r ut o i r l gi co r nl i cr l i t t st , i t t l r . r i l ol i r r l
1r l , , r r l t t r
, l ) , \ t i t ! ! i t 1L l r ot t Lt i t r d, cl t ' ; i t ' r Lt ' i , 1t ' t bt t i r r l oi r t l i r t vr r l r i i r r vcr l l r r ' . l l r
r "
, l r t t l vt i l . i oi i , ( i t r t l oscl l . i vi t t r l i ci ) , st l , t . l
l x) l l i ( f
I i
l t or l t r r i r
r l c r r l t r t r r r r ' r
'
r i r r l r i scj t l i o ( t i or t l i nont ) , t l c t i {: t t t t r r t i t l t t vct , i r r j i l l r l r r ( or r l cot r r . o r l l , r
, , ' r r r 1, r l t t ni cl t l us osos vi ci os^ ol t l o
( I (
) I I I
I
) t i I I I i i l t cl 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 t l r r i sci r i t i c. I r l r "col t st , i , r t l l . i t t r i si l , t r t {i r r ( r : t t i i ) , r l r r r l ' t r l , '
t '
1,
r r r r cl i r i osl , : t l i sr r l
l i
l cr p: r , r i I I or ' &) sl i r 1 i st r t , ci t t t l st ' t ' t t t t r l r t l : t r ; i
1r r ' ,
r r , r r {: r
, , ,
' , . r l r r l i l ot
l l t i b sul ) cut l l ml c, ci t
1i
sul l I i r t t t ul t l t t r ' i l t t t t r l l i l t t t l t t t . t , r r : , '
' I '
i r r r l
l r r r pl i f r ' Lt
s: t r t I a ni vel ul ci l , puhr i p( t l ot x) l r l t r i ( l j ol l t ' 1r ' r r , l l l t i , 1.
' ' .
\ t t ' t l qi f t c] ' t {r al d:
, ,
I \ r ' t t al gi t t cr ur ul d t l t t or ' i gi t t t t ' . ' r f . ( t b) t t l i , t l i : : ul , r ' . , \ r r l ' l l l ' r t r , : r i r r r l
,
' , ,
l r , r r i i r l i scr t l o I i i , L1- L2, sc pt ( xl t t t 1,
( l o
ol r i t ci t l t l r : r , t t t r r ' l ot l , r l r r t , r r
r l , , r r l r : r , r r r r i t ' at l i el i i n l cgi uncr r : l l t l , cl i ol t l i i
r si
st t l l t t ' i , r r r t r r r t r ul t l r : r l r . l r r , r r r t l
, , r l r , r ' r r i i i r
( l i scul ui
l s- I - r u, r l ul er i l t t i t i l t l i l i l , r r i t t 11' 9- i l l t t t ' i r : l r t l l r \ ) r r r t t r r r ' l
'
", 1,
r r . : ui i i r co: l l sei , de- n l ungul not ' vt t l t i i s t , i i r t t i t t l ' ct ' t t , pt l ct t t r t
, i
i r r
; r r
r r l
'
'
, , r r r ' I r i r r I r r i . Sr : const r , t i i ,
; i
o hi por r : st ozi c i l t l , cr i r t i t t l t t t t t l r Ll t t l r t r . l i , ' l r r ' r
, , 1 r i r , . r r l i r ) {1 l l t l osel l ooapsi t dl l r cl oi r si ' r , f l t xr t r t l , i r
1l r
l r r , zi t t .
l r r r ) nt ( f \ t u1 scmi ol ogi c se nl ai
l oi r
t sr 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 Lr r ' , r
'
l l , r r l r r i t ol ul i : l t r , nncl e def i ci t o t l ut t ol i i ( I i t t t i I
'
r t t t r r t cr l l t t r r i l i
i l i r r r r l r '
r
l r , ,
, ' r 1, . r
1i
l r I l cxi ei cor r psci pe N, b( l {) l l l r {l ) ,
l t l t r l t t t t t ; i
I I i I r ( | I t l ' l i I t t r r r r i . l {' l r r r l
t , , ' , r . r l r i r r l t s, Si r t dr or nul t l ecr ur i l l r t l gi i r l ) {) l t l ( ' l i l l r r ' ol i l r i l r t l ct r t l , i r r l r r : r {l l
, ,
'
, r 1 11r gi l r di r n l i o l * o r nt si vi l hor t t i r l t l i scl ul i i t r t t r r l i r t t r i i , l i r ' l r t o r r l l . r r t l , ,
r r r r , r . t hr hl l l Li ( spont l i l i t i , t t t mt l t i i , vct l r r l t r . l l , i ) sr r r t i r t i r r r r : r l t i r l i r r t r : r ( t r , t t
, , , ' , ' r r r , r ' r r l l st ct t l ; om, r r i r hnoi di t i i {i ( r . ) .
l , ] ; \ t : ont l . Qi t t t i t t l . t (I l d pri n al , t o t ; rt , t t ' : t : (t u, nt ori . , ul t rt t sr: t t t 4l l r
l , t
' ,
t t : t
t , nt t t l . l t t t i n) t sl , c t l o ol l i l oi t I t t i I l t i r : r '
r r I r ' i , qi t l o t t t t t l l . r r ot i l r r
Jr : r l ; , : r t ,
r ,
l , I r i l r | l i r l i i
l t t r r i t t t t t l i t ,
st r
] t t ) i t t 0 l ) ot l xl l ) l )
( )
t t ' qi t t t t t t t t t r l l l l l l ( r l l r : t i {r r
i i
l l t t r r | ,
t r Ni . r , r : r l qi r r s{) l l ) ol t l i z0l r , zi ' t , pr l f , l l . r , t r , r r l , 0r ' r r - i t r l , Ot t t r i , t t c{) l l t : r r . i r r t r ?, , l r | l
. r r r , I r i r r l t t i , i t r ul i i t ul si t t c f r r l . , l r l t , t t l l r t r t - i t t l r r l t r i : r ' i i l r i r r i . Al t t ur t l t c I oI r | , I r I t I r : r ,
, r ' , , r r , z, i l r i p r r i ' l l Lr r i l t . r l r l i r r r ' i ,
1i
l r i p r l t r l i t , cvI l l i r r l ) : i l t l r l i .
' ' 1,
\ t t t i l qi ( t t r r | ul ui r l t l t t t r r l ol s( ' I l ( t l t r ( r l l l l ( ' t t ; ' t
; r r i t l
t l t t t ' r ' t i l , ,
' t r
i
' r
r l '
l r '
l : r {: r , i l l l l t ) i : t r r r t l 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 ' | , ,
I
r , . . r : r , t t t r t 1r r I r i I oI : t I t r I r t r r I ol t . l l ) r t l o t ( ' r r l i zr I l r i i r r ' I t i l t I l zt t t t t i r l i r r l r l , ( 1, 1, ,
L l
,
1, . , ) , l i r
l r l i l r
l r t t l , r t i l r t r r t l r r i l t t : t t t i t r t t r r l t t l l r : r zi t r ( t l zr , t t t r r t t t
,
l t t
r , r r : r l l . r . r r ' l r t r ' ; r l t r
) -
, , 1
L
i . \ ' r t r , r l l t i r r
I t ' ut r r t o
t t r l r r t r r l t r ( t t r r ' r , t l t t i r t
l t t t t t
t l t i i t I l ui l i r l h
)
u\
r ' , r r r r , r : r r i , r r l ot pt i t t l ot , r l i zr t t t r t i l t t t l t i i pt r l : t , l : t : t t t l ct oct l t r l r ) l t , r t
( ' ( r i t pr l l l ,
, r ol r r r u, i r r r r i I r r I r '
t r r I l i , i t r so! i l l i , l r 1t I r l r t Pr r I r t I t I l r t t t I t I t , l l t : r t I t i 1t l r ' 1r r t I i o l t ( r 1r l i i r l t l r l
r r r l r l r r r r r : r r r r r l i sl t t zr t l i i r t l gr l ) i t l i ' : i l i ( ' zi ( x) t l ct l r r l t i , i t r l l i t l r t ' xci l , l l t t l i l t r l t ' t t l t r .
. , r r r r i r r r r l i ) . Sr i r r r r r r i l i i t l t ' i , r t t t i ur t i l t r , t : r Lsl i i , t nt r t ; t l Ei t )
I l l t r ( f sl ozi ( i i
so
l xr l r l r ,
, r , r , , r r r : i I r r n r r ql qi r r , t t t ) t ) t . t . l u i
l l i :
i t i Lo'
( r ' I Ll ' &l ( oi t l o pf ovi l l o di r l l [ oect l l i I i i r l : l
, r r r : r I : , r i r uc r r r r {t r r i ool , I ol t . i l t ' i r pr opi l l L ct t f ot nr r o oul t ur i l t ul i t t t l r i l t t l
, . r zr r r
; r i
r r r r r l . r ( , l r i ul
l ) sr ) i [ s) ,
si f ui [ f i ( ] i n cl r c so: r soci r . t zi l , o dul ' cr e po 1r 1r l
r r r l cl i r r r r i r : 1, cot | sr , i , i t t r t t l i r l , sul l l t f cl l t l t l cnt ut i l l i i .
t , ' r t t l ' , r i t l i ol , t ! l i ci : l ) $pon( l i L) zc l our bi i t t - ' , cl i scop*t i i ; b) Spot t t l i l i l r , ;
. )
' l ' r r r r r r i r i r , ' r ' l r , bt . l t l f si l r L i r l l t i i r r i hi t l i cno ( oar c t r r ebui e ci i ut at e t ot t l ci t t t r r i r
rrr l Lz rl o
1xr' ,ri si i ' rrl i i , l i
i l gt' l yi ul i i tl ul eri l or)
;
t1) ArLhnoi di te sphtrl (!; i ,)
I i r r r I i r
.
r r I i I r r , fr l r rrri )nono| l i [' i ' , r' i | oti ci l
I
f) Procese i nl hntntori i si i u tunl {)] i r l r!
, l r r r r r r i r r r l l r r r zi r r : i 1)
I ' ; oi i i ' . ; h) Compr esi Lr nea, I r el r Lr h. Li de cX, t r e r t l ' r r l r r l
, .
r ' r \ t r l .
:"- Ni ndrorn,rLL;ohJ-pi ci or repl czi nti i ' corespontl artul sl ncl romul ui utttri ' t
:rri rLrr rl r l rr, trri rnLrrttl supol i or' , fi i nd gencrat (fofl ctea, 1967) tl c faol ' )r' i
! rr! i r{
t.i or(,i ri ri r,
r,snpri \ l i utul ni gangl i onar prevei ' tebral s:l u asul l ra pl (,
rIi l ,)r' \' (l ,fol i r 1,i v() trl )(l omi no-peh' i ene (afec{i uni al c por!:i uni l or tel mi ttrrl r,
.' i .. l rrl i rrl rri rl i gcsl ri r' , rtocl ;i uni uter' o-anexi tl e qi
.t,-ezi cal e,
procese i nfl i l l trrr
i ,rri i ,i rrrl i ' r' trrl ,i l rl o
l l cri to| el l e Di
rctropcri tol real c, psoi ' l o .,q.4.), precul )l ti l
ri r. l czi rrrri l rr,ri i cul rut (sponi l i l utl oze, spi ncl i l i te
ry.a.).
Se poate recunorrtl r'
l ,r
i rl r o rl rrrol c l sooi i rti , cu. rn:rni {est;d l .egetati Ye de ti p si mpatl l gi c t1t
( r r l l r r r l i i l i
v. r sr r ' r t r r t ol i i . Dur er ea sc l ocal i zcazi , i n ar f i cul nl i a qol dul ui , r ' r r r
r, r' l rrrrl r sr, l i r rui ;ci r,ri l e mai ampl al e acestei arti cni t[l i i r i ar epi sodi c i l rr
,l rrr,l rrl tc zortcl i : i .nt' eci nate (r' egi uDet i nghi nal d,, l ontbi l rd,, fesi eri i ,, Irr' l rr
rrrl .r' o i rrl ol ni i r, coi rpsoi ), Irecrl m l i
di sta] (i n regi uni l e ti bi o-ta,rsi al ti i , r1t
l rr.r' t" rrrr(rrhl r' ;i rL,ni i ,). l l obi l i ztre:i acti Yi l ,
Si
pasi Yri a membrul ui i nfori ol
,. , ' r i ! r l r
(.i r zi i { i r! r(.r' {)i r' ) i l l l rcpl usu1 o am0l i oreazi t) de;i de rnul 0e ori se i rsi nl ri .
| ! r ' . i r r r {r r l ) r i l i
l r t r t r i i l . i l c
noct ur ne.
,\l rl orr,pr' l ,oi ,rhrrnurt s9 cr.i tl errl i azi r, m{l i ol ogi c motl i fi ci ri osl j eoco]l rl f.
ri i r.i rl (, (.(,l oi rri ri
vi l rl i {rbral e {orso-l onl bl re, mcci i ti ci ,ri al e arl ,i cul al i ci t' r' r,,
t l r r r r r l r r l r
1i i
r r r r t ut i
( ) si col or oze t l l so- r net at ar si ene ( $of l et et r l - 96?) .
l i . Si trl ,rr,nrul ctnal tr,hri tursi utt,
i Keck,
1969, ci trr,t ds
Dofl etea'
11)l i ?)
. rl r., ol rrrrrrrr, r)tnol ogul si nal romul ui cnrpi an tl e l a membrul supu' j ot
'
l ,l rl r' .rl ' rrol rrl , rl rr i ri trtri a nervul ui ti bi al posteri or i n canal ul l Lri l l ,i cl rrrl '
rr:rrr rl rrl I,i bi o i r$i r-i l gi rl .o-ci rl cel rcan). Se
$ti e
ci i , i n acest canal osteo-fi l )rrl
Ir;,,' r,,.' ,,,,' r| (r| r.Lrl ti bi al posteri or qi r-asel c ci l i toresc i ntr-o teaci fi brorrHrl ,
rrr r.r,i rrr i rrl ,crr, i ;oci i si novi rl e a tendon' ,rl ui m[l chi dui Il eror propri rt rtl
l r rl rrr.r.l rri . i rr l ,i i csl , ci l nrl , ncrrul ti bi al poi teri or sc bi furci , i ncei doi rxrt' r' r
1,1
,rrl .rl r, r' rr rl r,sti ni l l i o notori e In l nul chi i pi a,trtari qi senzi ti Yl l a pl ttti ' i i
i i rrrrIl orrrrrI rr,l ;1i o csLe fi i vori zat de traum:}tri sme l ocal e (l ractnri l ni tl rr,r
l i r rl , rrr l r.i ' r1
)
(l )rr l rr:,j i i , ontorsc, di ' ,-ofse i ntcn' eri l i i chi rurgi cal e)
;si
do pi ci o
rrrl
1rl
rl , ri i ri r, c,rr' .i ol ,cti zc:trzi i pri n furtl i cri turi , i nfcpS' trLl i , a' mof$el i
1i
dttl trr i
,
' r
, . , r ' r r , l i , ,
( l {i
r r ! sul i ' r , 1r r , ni vcl uL o. I t t . t l LLl i r i t : t t si i t l , i n
}l l ) nl i i i l i
i n dcgol r , ,
: r 1, , , : ' r cr r i l r , l i l l i
; i 1r o
l r t , ! l i t r l , oL' t r i t l i , gl , ur l ) {r i .
\ 1, r ; i i l r r
1i 1r r , t ' r l l ' ui i I l
s1r Nr 01, i r l t {i l l l ) t zi - t i t r t r l l or i ' r i , l i st n; i i t t l i t nl t t t l l t t r r l
qr r l r r i r i , r l r , r r t t t l l c r t t i , t t r t t l r i l i . I i t t l r i i l i Ll l t I I r r l i I t I I : i , l r i l t or r r l l r r l r i i
l ) l r l ' l l l i l ' t ( r
l i l
r l r ' r ' ,
.
I
, .
r | ,
.
I i r r i | . \ r r | ) r ' i i i t t l , ' r ' , r r i i t l l l ' r t l i i si r t l r Ll t t c i ' t i i r l r "1r 1 r ' l or ' . l ) i r 11
r nr j t , l l r , t l r r l , r ; l l i i r l
' i
l ' t
1r ' i i r
I i ( r t l t l ' i {t t r r l l r t t i i r r l l 1! ' r , r | 1' r r r 11
f r r l
: ' t l
, , Ll r r r 11{, l r r l : r l r l 1r ' l l r , r ,
,
l t l r r (
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 I I i t I r I t I r t r t t t I t t t l t l l l r
1, r r ,
l r "; l i ( 1 l r r
| ,
r cLt l i l r
' ' , . i , i l l r
r t l l r l r , l t i t l i l t t t l t t t ' l l t t t t t i i t ' t ' I t ot t t I t I | I r I r t r ' , t r "I r ' t 1t r ,
'
, , , i r , l l i l cr i , r r l ol sr r l r r [ or ' l : r l r i , r r
1
r i < r i r t t t t I t t i .
7. i l ' Lt t t a! 4i t t
Tl t t nt at i
( ho( , l l ui
' l l or l r t u
)
si ^cl l t : t r r i l ' t i zcr t v, r l
l ) l r l r
r l l l r ' r ' t l
1". l i zr r l i , l t i Li vcl ul t r r l i cLi l r l i ; i i l of l t t i r t i t l r r t t sol i t l i t l t t f i r , l t o
( t l r r r l r ct i : r l l l ' l l l
| | \
i
i i i i t t si ) i t 1i i l o di ! {i l . t r l o i t t l ct r t r t t r t l r Ll si t l t t t ' , t r t t i l i t r l i t r l i r pt r ' r t t l t t l r l r ' ; 1'
I l , ' r si
( r i i l f s. p] ' c ci \ , l oi i
l i
Fl ) l {r l ' r l 1' 1r
1) {) st cl i oi i l
l ' i l l ur l r r r l r ( ' r ,
{ t l i r l r r r r r l r : r r r l
' r i , , l , . r f i st n si i r r t i npr r l r t t t - r t st t l t t i , l t ' t t l ol i ol ' i t , t t r i t t t ol l l t ; t t s r r i l r r . , i r l r r : r l ct ' r r
, r r r i r l i l ot i ' ( $' ; I l et : el , 19{i 7
;
Li dvl o
; i
I l uca, l ! ] i i O, 0i l r r
t i
t l o
[ r r l
h l t r r , l l t l i r l
l , r l : r i | ) I osf o un*i ner r or t si t uf l t po r nul di t t r l ci i l oi l I ( : l Yi l ) l i r l l l ' : r I i .
l , r r ' r r r ( l
, , r ' 1. r ,
i t cl vi l 1r | t i i gi t al i pl . r nt l | i . l ) ozvol t l l t ' cr ] l l ( l vl r ) l i l l l l l l i t ' $l I l : r t r r t r zr r l ; r
1, r r . r r i r i . i i i nl l al r r r t or i i l ocl t l e ( osoi r so
l i
net . l
( , i l t i t i ) , ( l i r (
' I t I I I
I
) I (
' r ' i i I I I I i r l r t r
l r : i l
r , . ,
j r r ci ' r , l f i ' r , mi : Lt l i ,
r 1e ost eof i t e, dc r oi l cf i i
}{) f i osl ' i l l l ' t l i vr r l sr r ,
t t r : r i r r l r ' : r l r r '
t , r r r ' i .
' l \ : el . r Lt i e
11i {cr cn! i at i i de l l t e al eoi , i r r r Li t t r l ol t r l l i or ' : t r t t r l : t l r r t r r r l l 1r r r l , '
, l r r , r ' so or ' i gi l i , osl oocondr i t c 4. 1( l oDpot cl ol l l l l r l i , i l l i j i ( ' l r ( f , t t I ( | : | | I I I i i | | I i Lr '
' r l , , r r , i - r , ( cr i ct ent ual a t l epi st ar e t l c t ol l i Eu1' osi l r l r t r l r r t i l .
11. Si t t d' ' ant al
, pi ci oar el or
nel i ni . : l i t e" ( , , l i t sl ' [ t sx l t 11t sr l t t r l r ot t t " l "' ul t
, t l . i boDr t l 96f / est cl el at i YuDor t l o t *", t 1n1511111' l t t i t i r t l t r t t i ( i r r , t l cl r : r t r ' r l l r ' t l r l
, , l r r l ' f t ' i i t r t t el r br cl o i nf el i ol uc ( i n gi unJ) o i i i col t l r i l r ' , l r i l r t l r ' t r t l r 11t I t r r t . '
r , r , , . 1, i r I xcpt ni l , i n: t . i al es noi l pt ea, i n ci Ll t . l t t r i i l l r t l t l l t l i ,
r ' r l
1r t l t I r r I r ' t l
I r r
t , r r l , i . r \ cest c p: r t ' or i sme a. l go- p; l r cst ozi oc
( 101, ( r l ' l l l i l l i
l ) ( '
l ) ol l r r r r r ' : r r ' \ r ' ( ' r t l i
, , r r , , ' : i | i : l l s l l t , r r r bi cl or , t 1e t , r t t e t l ol i vi i t r l t l t t ot t t t l . I Jt t I l l . t r t I r t l t r r r l r r ' r ' l : r r r l
I
, r i r i i l l osi , i c
cst e negr t i r i l : i t ca c- {l l r l or l t l l r l i ol t i t ' t r l i v t t t ' t t I oI r r ; 1i r ' ( l ' l l ' l r "t r r '
r ' r i 1) ; sDf l st ca qi cohl : . , i 90L) .
I t , ( 1uu: al ei i
}ot
f i i l l t , i l ni t e qi l i l t t t t I t r t I I t r ' 1 I I i t t I l t i r I : r t r ' , t t t l . t t l "r r t t l
, , , , r r i l r t i sci : r t i c, cu oar act cl ' cl e i l r ni l t i l o i i nl ( ' l i ol .
11. \ , i ) , {t et i l e t l ' bet i ce $ r ocur t osc I cl i l l , i v l l f or ,
l t Li l t
t I t t t t I r | . I t t . I '
' ; r t
r '
i r , r i r ) Al : r r . i n sai ve i l e dLr r cr i l l f [ l t er l t t l t Lt l l sl l l l t i ' t r ( r r t t r l t t r ' , t l l t l i r r 1r ' r
' r
'
r r r r l f ) , cu i l ] t ej . ] ' al e l i ber e I ' ar i ahi l e
i
l ) ) I r l l I I t I
'
I l I I ) I (
'
I I
'
i t t l ct i o: t t
"
; r r l | r r '
' r
' r
r r l i r r r ; i ' r , pc t i ni ec| : 1c sci r i t i cut ui ; c) At r t ] r t , t I t . i : I r I t l t t |
1. ' 1
t t t I t I r I
'
r ' i I I I I I r t I r t t | ,
r , , r , l r r t l Gci t cl ecl an, sat o de sl , i mul i
pf ol ) l i o( j ol , l ' i vi ( t l i r l t , r i t l o r r r l t i t r t l t r r t t l .
,
' ,
l , , r r ol ogi ec, ccuR ce r t neol i pol l i c i [ dl l ( xr l t t t r t r r r r t r ' )
; r l )
A; r : t t r r l l l t r r l r r l ' r '
, r l , r , r l t t l i v, ci t gi i u t : r . bcst f
, , f
i xr L1r "
I
t l ) St l l r soci r r ' zi i , r r t t : r l l c l . r ' t t t t t r ' l r r l "'
i , , r . ; l ) Se
] i ol
asoci a
$i
Cu l l , I t c cr i z{) i t l gl l ( ] Ll t l t t r l i t ' t r ( r
' i ; i I ' t ' I I
'
I r r
,
r t r I I t r I : r r ' I r r
, r l r I t i ' ) .
B.
PROBLEME DE DIAGNOSTIC iN TULI}URANIUI
TftOFICE DE ORIGINE NBRVOASA
8.1. TULBURARI TROFICE ALE PIELII, ALN FANERELOR
$I
ALE
TESU?UBII-/OR MOI
l. Pielpa usruld, sol2oaso, slriard prin fisuri, r.calizind uneori aspcctul
:tr'
l)rr.t' ,
.,(te crap" sau
1{e
gopirld" poate fi intihite in sirixgomielio gl
l n sl I|(| l ' oi l mete strtnqomtel tce.
' ?. Pi el ea_rece, nAkdd,.sub!.i a-l d, uneori pi tal d,, l i vi dd, cl e aspect I,amo-
l i l , rr. prrrrl c observl i n,pol i omi el i te, mi el i te;i al tc atecfi uni medul are, daL
r I | r r . or ' t sr r n ncl ] l r pl 0gr l j e vascul r r e
{Ar seni , i . 8o1ez. 19Zl ) .
' ' 1. I' rr.zcnl a tl e
Jl i rtens,
de erupl i i butoase
1i
d,6 aspci te scl erodermi oo
In,rLl,c
I t
-r'cvelatoare
pentru siringomielie
$i
alte atectiuni medulare.
. ,4.
.l \' l ot' mal ed,^,:I
Irfl !]i l i t.otpd.unghi i l or,
precum
;i
eJi l arca degetel or ss
r r l r l r r ' . j c l r ccvcnf i u r l i vr . r scl c al ec{, i uni al e ner v i l or ' pei . i t el i ci , pi ecur n gl
Irr ${i l u' ozrr i n pl ti ci .
^
5.^,lIipcrtroJia.
.n
i,inilor,. mergind pini, la aspectul d.e ckeirotnegati,o
rl \ l , l l l l l l {. : rl l o l n Sl TrngOmt el t e-
l ;. l tcq me l pl e reci , ci anozal e se i nti hese i n compresi un i i e med ul aro.
rl :rr'
,.i
i rr hcrrri pl cgi i l e vascul are,
i n' pol i nevri tr,, pol i r:adi cul onevri t c gi i ri
ul l ,rr nouropati i .
7. Arpootul do membru rogu, dureros, se intllne$ts in sindromul eri-
Il orrrol i ul gi o, i :r,r d ogetul al b, i schemi c este u$ol de recunoscut i n faza aga-
zi l ri
,,Hi l toopl l tr l ocal [t, di n si ndromul Raynaud.
' \' . ' l ' rofal emul crozi o (si noui me
: boal a l ui Mei ge i di stroti a edcmal oa-
u:' l
I
rrri rrrl trrurrl . l ocal Vat; edemul
,,reumati smal ,- ci oni c al l ui Desrnos
I
.rlrnr'l H.gr'cntar aI lui Debove; pseudo-elefantiaza
neuro_artritici, a lui
l\,lrrl,hirrrr
I
lr{)rrlu, luiMilroy) repre,.lintg, o v&rietate de e.dem crorlie aib, Aur,
rr{l r)l (,r' ,-ou l cl xurti l i o segmentari , avi nd
_cel
mai adesea_ sedi ul l a i neml
l, i {,to rl lct ior,l o, uni- sau bilateral. Nu are
*
se pare _
nici o specificitato,
Ilrrr,t,u lli congcnital, ererlitar gi 16afl.jal1 dar ddmulto ori inso^,teqte bolilo
r\rorlo-{logonot&tivo,
unelo boli do colagen, apd,rind chiar in rcuinatismnl
cl orri o crr pol i artri t5.
,
0; l l dcmul
.rozat
^aI
,fcl ci r..ul
obraj i l or, al gi trrl rri .
al spnt(.l ui
,"i
al i ol ol
, r ' HI | . r r .
i l , | l I nl ( r r . l i l l i i {r Li L l r noor i
f i
r l o pi gr n. r r l . r r {. i i
t r i
t l c l ( ) l r gi t , ct l zi i )
ho I r l . i l r ( , ! 1. ( , i r r pDi k i L x k, r ' r nl l l Dr ni r r zi Ll l ( l r i r l r l t l ui I ' ol r gor r - , 1: r r r ol r i . 1, -
24t
10. I hhnl r h di r r : r t t t t l i pu, r i
1i
h) pol l t '
Ji i l ol '
I i i t r i ' i l r r i l r r i t t
1ol i r t r ,
v r i l , r , ,
1, r ' l r l r r , r l i ouLr r r r vt
i l c, pol i not t t r t pt t l i i , col agot r ozt r , i l t t l t t ccl l t ' l r t - t t t i ol t t l ' r t l l i ot l
l , ' r r . r , r ' i t e ( i r usi r , - zi r st r l
, , si ndl or n
neur r t - cdel r t al , us t l }i r l ot l r i t l " l t l l r t i l ) r ' pt 6
\l ,rrrrr), i n unol o cornpresi uni mi el o-radi cukr' re
,
i n si l i ngonti ol i tr, i tr Itri ttti l rl c
I'
r r I,, r Irr rl i verse ori gi ni (Arseni si Botcz, 1971), i n si ntl l rttrttt I
l
trt t i t' l ,i r' l (,,1r i trrr'
,! | r' ori Ll ,or,si i tt di n si ndromnl pari eta,l )
$.a.
IL Ar:l en aarnek cuta' no,tet mai rnul t sl u rnai pi tl ,i tr pi gtttctrl l l rr, rl rr
' rrrrl i ri ri
cl i fel i .i tl (de l a un bob de l i nte pi ni i l a o ci rcl g:i ), rri l ,tti tl o i tt tttorl
r.tr,rt' i rr i n j l i l ul guri i
$i
al na$ul ui (dar gi i n al te zono 1;ogrl rtl (' l l l rrr{r) r{i l l l ,
' ,r' ,,fi [toare
peni ]u scl croza tuberoasi ' a l ui BournoYi l l o,
l 2- N tutfi i brctnato!(r l ui Becl tl i nghausen, se po&to t' trcttl tttrtrsl rr
l tt' i tt
1,r,.zr.rrl u,
de tLunori mul ti pl u pedi cul a,te cl e ti p
,,rnol l Ltsr.l ul tttl t ;
t r r r t r I t t I t t t t t
' '
l rrrrrr rrepedi cul ate), de consi stenl i moal e, pi gmcntate (brttttc srt,tt grt' l l rl tto),
, r!, {rol mai arl esei ) coexi st5, cu pete
l i gmentare
br' [nc- oi rl ol I i i
1i
ott I' tttttori
rr l ol l ni de qi raguri de mi ,td,ni i rotuuj i te sau fuzi formtr, tl i spusrt
l rtr
I' trt,i rrrr
1,,1,. l roryi l or l eri feri ci .
13. Ang i al nul cutrd,urt pktn herni faci al , adesca vol tttni ttos, si l ' rrrti , i l r
,l ,r|rrrLi ul tri gernenul ui , este revel ator qi nc obl i gi r, sl i oi l ,u l i i nr :l l tgi rttttrt' l trzrt,
,,rr i.r.l 1rlo-trige.rninali, a iui Sturge-Weber-Krabbo.
14. Preaen,ta de ytete pi ' gmenta,te (tl e cul oarea cafol ci ol t Lr4rl ,o) i trrl i vrrl l o
.
' rrrr
1L;rps11l s, i l sol i te tl e novi pi gmentari
$i
pi l ofi i po zonol tt ttt' rtctt rrl ttl rt
r,rrrr:rl ), Ll un copi l sau l a un adol escent, ne cvoci i o rncl i [tl (tzi i l l otl r(t ol l l !r-
rrrr l ri , rni r,i al es tl aci l n contextul cl i ni c exi stl
;i
cri ze ol i l opl ,i co
6i /srt,tl
ttrrttrttrr
,l u
l )n)ces
exparsi r i ntracrani an,
tti . f um{' facl i i l e cutanqte noLl ul are l a ni vol ttl trtornl rtrtl or, tl l l ,ttr:rrtrl tl i
,r
,rl :rl rdonel ul i i , i nsol i te de crcqterea i n vol utn i r, $i rl i l ot' si l tt tttrrtrrrl tr
'
r rl ir.o pentlu adipoza durero&sd, din sind,ronzu,l Lu,i I)trouttt,
16. Pana,ri l i u,l ana,l gezi ,a, earactori zat pt' i ttr-o l ,trl l rttl rt,ttt I' l rrl ' i rrtl ' tu
r r|l u|i l ol unui a sau mai mul tor degete (mergi nrl pi ni i l rl N,l Il l )l l l ' l l ' r{n[ l l l l ' i
rrrr,i l :rhngo)r i n absenl a dureri l or spontane sau pl ' ovo(i l l ,or tl rt' t' tl tt rl trtrol tt '
r"rr rl o tul buri i ,ri de sensi bi l i tate tl e ti p si ri ngotni ol i o, ovcttl rtttt' l tr tttttl i
,rri l r' {)m ami otl ofi e de ti p Aran-I)uchenne qi :r, uuol sctttl to pi nl tl ti tl ttl rr, l trr
I rr r r,' si ' r ne ori enteze spre di agnosti cul de si ri ngorn i cl i o stl ,t I tl o ni tttl tttttt Hi l i tt
-
l .,rrrri cl i c tl e al ti naturl ,
l 7- Panari ,!i ul anul gt:zi c, i nsol i t de faoi cs .l txttti n, tl tt l ul btrt' fl l i pi gttrr,tt
I rr rrr, r l c l eproame cutanate, i l e hi per"trofi l r, nLtl ni l i fornri , tl trot v i l ttt' , t l o tt,l tttn
l ,rrri ,, 1.oo"ot,
"
(eu protl omi nanl i , tormoi l l al gczi ci i , i tti fi rtl , n4roi gkrbrt,hl ' ),
'1"
,r r{}ficxie, do loziunea mucoasei pituitare, no orionl,oil,zil npro
(l
it,l{ttu$l,i(!u I
,l,r hpril, obliginalu-ne sA, ci,ut5,m bacilul lui l{ansou ln tttttounul trt,ztt,l
ryi
r,Lr pnlcbic5,m reaolia lui Midsutla,
18, Ul carwl perforant (mal perforant
)
yl unl ' ur attt tl ttbrri , i nni rl i or
ryi
rrrrl o!rr' . Ini l i al aparo o zon6 tl e hi porkeratozl , apoi so dozvrtl i ,i l ,t Htl (nos[v'
'
l l i rl ,cni
{i
apoi o ul ceratri o rotunj i tti sau oYal rrtr
'
cu tondi l r{,i 1, tl o Il d i ttcl rot
,,rr rrrrr,r' gi ni pl oemi nentg, cu fundul acopol i t tl o o sorozi trto gi i Jl ttti tt tl tl tt
rrrr,rrrrrr i rrol oni ;ri . Ul ooral i a
gi togrrmol tel o di n j ur
si nt i ndol oro, Si u[ $l [ul !'
[,ri
i rr crl l o ul corai i &, cl ozvol Ci ndu-so i n profunzi mo, ati ngo orl i i ottl nl ,l l l tl
r1i rrrrrl . Il vol ufi a, osbo torpi dtr, cu oi oD1;ti zfl ti otomoro. Ul or:r' Lrl pul frtt' rl trl ,
rr. rrr' ,r rl $ obi coi l n Labos, so l ocol i zoDzfl , fi o t.l i tl onnoan, fi o [a, ni vol uI rl rtl ott'
l rr(,rrrr rrrrrti rl ;i l r$o- ti r,l tngi ono t l l l l trool tri , fi o l rl ni sol ul tl rtpttl tti <xtl ttl tl rt tl l
r . r r r oi l c, r r nol ' l r , ht , r ' si t n qi sol l oi t l o i t soci : ! t i t t
( l i vor $o
: ! Tl ; l ' ol ) t l l i i l , t l ht t l , l cr r ,
l t t ' t r '
,rrrrr 11i ort l ozi rrtri rt,l t' DIi 0u
1i
rtrtbrrrtti l ,i oo r![o [r!l rtn{(!l ol ' , Ml Ii pol [l ,o tt,pgl ' otr,
I r r r r r r i r r gor r r i ol i o, i r t ui t ul t ' unt r u. l o r l r t r t or t , t l r l , t l o cr t , l , r l r r l t t ' [ r r ul i col , ot t t i i l o
1r t ' l t t t t r .
t4'l
| ' r t . t : r r I r i . i r r i
r r r . r ' r r l r ' , i r r r l i l r l xr l , i r r I . ; r ' i ' i ,
Dt r . r ' r r r r l i
i l r r r t l , i ) I ) i I Li i I ( | r l r {. r ' .
I t r l l r l i r l l r f r l i l si t l l r l t r r t t l I l l , r i t i l i l t l 1l l 1i ' l , l t gv. ot r i t r r l sl l t I I ( ,
I i I
r
I I i I i I I I
( r l r or ' : r ( l i ( , ) l r l l r r i l l r ut ' r r , r r - l l l r r . Li t ) r o ( {i r r i l xr r . {,
; i
( i r r i ) xr l i ; ,
. l ! }?4) ,
I ! t . l i J( ! ' t . . t . ! 1, pr t . l onr nt , . u, l
c, l 1l t i , t r l r t i i , t t l r t xi t l nr u. t , i l a, i ul t t i , t i t , l t , , r ,
/ , i ) r ' r . r l , .
' l l t l l ,
D' l i r , i l r ' . , {pl [ l r t ' . l r i cr , i r r r 1r r l , r , s, r ] r r si i ' Si r i ng' t l t i . I l
I r t t l l r t r .
:' (). l l i nft sttctt.l ttLi i u l tti J[a ncsat, so i rrti l trcst]e i n si ri ngorri i r,l i r r
rr rr' (
i rr]l (11{' r' i z(l i rzl i ' p| i tt1r| urL tl tl rrn i rl rtti i rri i
;i
l l rl cgei cl or, 0i r10 api nl r]rr
l l . l r : ,
I r i . l . r r
I i i r r r L r kr , l r i c. i ur ) l ut ' r cl r nr ht ci . l i l i . U' ci r i i nsi , pi el ea' p. r t . l i
r r r r : r l : r . r u$) i l f r i i
_f
i s( , l l i ur r oi l si . Unghi i l u t i ut r r t r uf i cu qi r i ^ef or m: l f u, i , r l
r l . r ' . l . l r r
1r r i l ,
I i r l . l i , ' r r r r L1, o si pr i i L ost co: ut l ol Jr t i i l c coc\ ' j 5t cnt e al e i ' I r r r "
r' ;,.Lrr' ,
1r' i r.st,.,l i z.kr
si pfi u resot bl i i l c schel cti ce, pri n frectl rri l c sl ,,)'
l : r r r r . ,
1r . i r r
r i I . , . r ' : LI i r | , , : r l ( , r r c
i i
pr i n pani r i l i i l e l , n g; z] ce
i r soci r Lt c. , l I r r i r r r r .
' , t t r i t l l r ' , 1, ' , . l r i r ' i I Lt l s{l ct t l ( . r , 1"-
:; t. l l i tur, i rt,ttttk:i t l , l ,tti Lhetl ti tte (tl i n si nrl romul tl ,l ami c al l ui l _ri i ,j ri
Ii rro l i rrrrsrt.) so ci l t i tci :cr.i zcl ztrr
.pf
i ntt.un aspect ci i i noti c al trri i ni i , cLr
i ri rr_
I.:r .rrIrIi rr,Ii i , ;ri l cce, cn unghi i l e recur.bate, fi sul atc si sfi l ,ri ni ci o:l sc] l rr
, rrtrr r. rrri oci rtzi r, l ti [ul i nosCUte]e pozi l i i deni r.el ate aIe rl cgettl or, car,! i i l ,
: r r r r r r r r l c r l o r l i sci i r i t t t : Lozi ce r l o l l exi e, ext ensi c gi abr l uci i c.
r'1. l,)sortt cle si lrtutili:eazti i:r, livelul legiunilor in care ccmprcsirr
f{ r,
{r' 1Ul ,rrl i Lr}l ' (si i rl l pLi ci t, i schcrl ri l ; cs1,e urrl i pronunt].r,ti r,,
arl i ci i Li ni v0
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fi al fefcl or
i trtcr..e l l e c,.r.Lpsel or. l n l rrzi r
,l ..rl .l rrrl ,
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, rl r,r| r. r' rrsi ,., rl rrl ri r,t| r: l i 1l nl o nesroza ti sul ari i , sub forma unci l Ll cet.
r r , . r I r I , r ' I i ' r , i | | r I
l l r ) $esi I
pi cl cr ",
l csut ul
ce] ul at sul ] cut anat
Di
mu$cl t i i ,
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r | , . r I cr , r I I r i L
r c i ul . i l t r csc i n: a) _ par . apl egi i de cl i - r ' er sc nat ur i si ol . i gi r r i
;
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cr L"nr i pl cgi i
;
d) pol i ncv. i t c, pol i r . ur i i cul , i r r , .
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;
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uoci : ur r l j i
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l ) 0
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: t l l ol l z. l 1) i I
I:T.,. TULBURARI TR(T.IOE OST}'OABTICULABE
.
1, 1.,'nr,cl,ut.il,c spontane indolora srttyit fie insidios si fd,rri o ctuzii irlr.r-
r' , rrl ri , Ii rr rl rrpr' i ,.urr tr' :urrnrl i i sm rni ni m. Indol cnl a aoestor fri acturi gcncrl r,,
. r utr'|' nnlsuinla ; a,) iliind igncratc de bolnav qi rlo medic, cintl anilr,,-
r, rzrr, rr I,rrl l rul l ,ro funol ri ol ta,Li moderatd,, ri scd, si i nu fi e ti ' atate. b) Anl ;r,o
n, rzr,
l ' rrr!o
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,,j r' , ri ", IIi rrL)ri i i Ii , i ' ounl ro (l c
pgcudo:utroze
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!i /sr1u
l ri .l l l rftr,
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, , . \ ,
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l ' ) l l r r r r r ' "' r r r i r ' l i r .
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1r | i r . r i s.
I
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l , r t t t t ul t r , r . '
i r ) l l r r
l ) ul r Ll l ,
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: I , I I I
l , , r ' , . ; i i i r l , t r r t I r i t zr i r l 0 ol r i ot r i i t t t l xt l I t l l o l i r r r i l r r l r ' 1 l r 1 l ) i t t
l r t t r r r r l
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.
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i r r t r ' l i r ' '
t . sl r . r ' l i i : ' l t l t i ' t r
l r
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r - \ ' | J. Ci t f i CSt nt Ct i \ ' ( ' r Ccl ' ml i
: t t l t ' ' r ' r r i ' l {. t t l t r r " l l l r l . i l r l l l r r
( l r ' I r r ' l
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t
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i
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ti ci
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'
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tr)e mul te od afi ropati a l oatc
consti tui semnr.l
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i rl rrrrl r :rl ' r I
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i , , i ; t l t "u ?t i i l nar i "i
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pscui l o- I I "gt n. , nos
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r ' r ' .
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qi -prczeni ta dtr vettti
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l l rt'
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:
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'
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' , r
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t r | , . . f ' t t ct t Li : c, . t ea, ci i t e Yar i : r hi l i r i l r {u' r ' ' l i ' r l ' l r r r ' r l r
r ' r r t zr r l r i : i r r l . l r r | "
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; i
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I
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: r r l ' r ' r r "r '
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t t t l r r t t
I , i ; ; i 1") , r r t i ' t r l at h gemr t r chi ul r i i
( , , r t t r i | r ' l t ' . q| t t t t t t t . l , r i
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t
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. r l r i r i ) ,
r r , , r , ; r i l c i n c. t r r l ezl unct
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l ' i
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: r r Lt , t r l r {i i i t r r r , r r , l , r 1i l , , , l t r t r '
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r I r ' ; r l l r i I r i I I i , r . l r r r l i l i i , r l r r l i i r , l r . . ) .
,
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i i l r t r l i r r l , r ' r r , t r I l r r t ( i l i
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| ol i l t i l r '
: r I I r I t ' i | r r I I r ( i i | ' r | t t t t I I t I I I I t t ' ' '
( i . \ ' l , t ' i l ' i l l l t l r ' l t ' r . l r r t t l l l r t l l i t ' i i t ' r ' | ' l l ' r r ' I r r t ' i r l i r r t t l I l st l t t I l l t ' . . : l t l r t l l r l r l l l l . t . t ' t t . ' '
, r r r l i sl t ol i i l r r t t t t t sr r t t l r t t t '
l t t r t gt t si vr '
( l ) l l l ' ) , r ' r l r qr r t l t l r r i t t r l i r l l r r l i i l r r r r r r t r i t t
i ' , . " t , t i , , i , i , t i , *' , r l l r t t l zl t l t i i . i i r si t ul r l i l t r t "l r l
t l t i l t st t l t t i r r t "
pt t ' zl r t r ( r ' r ' r r r l
( l i ) : ! r
, Lr r r r i r r r r i l l r t i t t i t t i r i oI t r I I i i I t I
I l ot l t t ) ! i ( ' 1) {) '
Z. V. r i l i t r l t r cr r , r . l 1' xc1r r . . sl r i i t l ct t l l i t t . l i sr ' : l l . l l l l l l l t r i t r r r t t r i . ' l t "l r r l '
, r , t i ct t t t r l t t gi cc, r l l ol i l t l sl l t t l l t t t l l ; r I i I i t i r L t t I t 1 t I i t r I t r t t i oi I oI i i I c
t | | I I 11I j ' i | | I
1, r , s1l t l c
ni t t l l i i . r ' 1' or r r c i r l l ) l l l ' .
l l '
( l nt r r r l ul t l i t - or sr : l t t l sr : r r si l r i l i l i l i , cr t r c l l i i l
1i r t l i l t r r f
i r r t r t r ' l " r l r
l r ( ' l i i l l cur ogcn( : ( r adi cr t l l r c,
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i ot ' , pol i i r t t l i t ' t t Lr t t | t
t t l r ( ' {
'
l r r ' r r r r r
l r r r c ct c, ) ,
$. Ckut r r t l , cxi st cnl ei posi bi l o t t ' t l r t r cr i l ot , t ' : t t t r pol l i
l t l cz. ' t t l r r l '
r Lr
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t t t i t l r ' : r r r r r r r l r r r l L l
r,, nenrol oEi ce,
10. n8t ar ca t l i vcr sel or at i t l t t l i l t i
pa t t i ct r l i t t ' t ' , t t r t cl i t l ' or t t l l ) ( ' t l l ! r l
r r r r r r "
l r,fi i l (: l i l i cgcner sat pcntru unt' l e :rttti otl ofi i l l ctl l ' og' (rl (r
(i l s(' \ t' (l (' i l rl r r' ' )rr
i r r r r l t t e) .
' ' ' ". i i . ,
yer i t i cal el l
or . i gi r i i i l l r i cgel e sl r U t r i l r l r gr . l r r . , r r si : r r i i . ' t ol r r l r r r ' . r
, '
1
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i pr i n i l ect l ot l i ' j gnost i c t ' i
pl i n . l r ' ' i t r r r r r r r t gl r t l i r r
( l ' ) \ l ( l r
'
1I. Ufcctuarea, i n unel e cttzul i , l l bi rl psi tl i rmrsctl l l rl ,tr t rrrctrl t rri rt .r:'
, r r.rr nl ui hi stopi l tol ogi c.
13. ] l f ecl r uar ca, unt l c est c cazul , : r unei ancl r ei t '
gt ' r i l l i . r '
; i
r l i t l t r l r
r'.r orrliotipului }rllnavului.
t4. Efectuaretl t1e tl etel nti ni ' r' i bi ochi nri r* l l l o rrtrri tl i tl rri si .tr":rl ttrttt' r
i ,ri ,, stri g;,Sl l l ri ri i )' 1 cxzi l ncl ol rnuscl rl i l to
(fosl oct' t' rtl i ttl l i rrl zrr'
IIrcIi ..rIi Irt
, r ' , ' j j "; ; l
: . t . ) ,
, r l l , l uhzel or , a t r ansani t t r r zt r l ot ,
l t r l i f t ' t t i I r r i r l r r zt i r ' l r ' '
8.3,2. I' robl eme do di agl osl i c stmi ol ogi e
| i
l opol l r' rrl i t'
. r , . J. 2.
t . . 4 t t ; ol r L, f i i I r uc- nr ur af , gi t t '
I . . 4i r cl i i h nr i n". def r cl " dr ut i l i : ' nt e
( ul t "Ji i l r r l t t uul i l i nt ") : r 1' : ' t r t r t t t t t t
'
' ' , , ' , t r l i i i n' l i i '
l na"I ur gat e ( i ndeosebi i n apar , 1' 1c gi }sr r l o) , i l t t r t t t st t l : t l | r ' {t t t t t t
r,,i i'ii;"iii""t
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r r r r l ' r ' r r l r r | o l . l r ' - l ' l r l t
' , ' i , , , , i , ' ; l
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' t i i our
1, . ' pl ul 6b nr r sp
( ' r ' nsl i r l i r t i r i t t t r
' '
t r r t t t l i r r r ' : : r r t l ' \ l ( i
, 1,
' l zi ur t e
l t neur or r ul uf mot or . per i i el ' i ( r ' i l l t ' t l i l t gt l osl i | r r l
( i i l r / ' r l I l r ' 1l or
, t , st , r bi t l t , i n cazul al , r of i i l or : ' - l ' i r t r r pi 11"p111111i ; ' 111r ' . i t t r ; t t r t l l t t t l r ' ( r "t t i
t t t
, r ", , oI a, *: i "ui qi col oana' ) , sl i nr r u' h' s' - r t r r t r t r *' ' l ' r ( r . r l "
r l r ' l i ' r ' l r r l ' t l '
' r t i i i zr r r e,
oi si t , cx1i l o}i r I n
1i
evol l ur l . l l t ' zi Lt t t t l t i t r I r I t t I I r t I I r r i : r
l r l r ' \ r r l r r r
l r r ' l
l r i r r l .
: / . . 4mi t t l r of i i l . e
, , nu- t r i l i r : nal e'
yi l l I st t t i l ul t t ' l i ct t
pol l i r r r l r l r r r l .
r r l i n cur si r l sr r l r l npi t pcr i oadc do l i psi dr r I t I i I t t ct t I , I I I i r ", - r ' t t t
' l t t l r ' '
t ' r ' . t
, , , r r l i
' l l l i ment l r o
r ' r : sl t i c^t i t . i si r r r dczr : i , l t i l i l r t ' r t l t r , t ' vl ' t t l t l l t l t l t i l t t r ' 1t t r . r t t l '
r , ' , r r l , r l canor i t xi co( pl i r r r t ' st l i cl i i t , gl ohr r l i sr t t t
cl l ' r l 1i l ' r i r l c r r l ) ( r r l i t l r r r r ( ' r r l Lr r '
l r ) l hr t l i ' l l j : t t ' ci ct r t t t i t , c, i r r 1or ", ' Ot r t i i r r l l i t t t i gi t r t l ' r
1t ' r
l t l t : t r r r l t t l
r l r ' 1r ' r l r r
'
. , r r l ' i l r ol nl l i i r t t r Lcl i ci t o t l c r t l r sr t t l r l i r r I
( )
i l t t r t t t st t l t t r t ot l t Ji ' i l l i t t t r i t ' t r t t t i | i l t l l l i i l ' t t l i zl l l i l {' : l l l l }( l ( l l l r / ' I
i i r ' r \ ' r '
, r , l , r ' i i i f t ot t i <u' , l t t l t t r t t i I t l l t l i l St t r ' ( i r I r I r '
'
I I r
' I I i vi sl l ut l Ll r ' ) , r ' ol r t gct t ' r zr " I l t t ' t
' '
l r i r l i r l c si sl l t t t
;
r l ) l , r r l r , r l Lr . r r i i l t t , l i r ct r l ' r l l t i {: r r r r i t r oz. ,
( i r r r r pl l i r l r l i r t l i t r r pl l l l i ' {
, r
t , t
) .
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T
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r r l r . r r t , . si l r r , r , {i i , r r r l i r r I r r r l . i r r , ( r r l r i l r i r r r r zi s ( j i r f r , \ i l )
r sl , r r r l i l . uzi ,
' . i p. l r . r r r ' r : r | ' l t , . l r r . | l l r . t f
i l
l , . sr t l r r l r t i l r , r l i pr t s. I ) 0 r r r r t l ht ( ) t . i , so
l r s0( ] i i t zi , 0t t t | l t
i ] l l ) 1, , i . ]
, : . . : l i "Jl l
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{i i r
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l ) r r t , 0r ' r r i {1i ,
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,t,i rrl rr ,' r ,, l ' .rrr.tl .t I r 1;1151' 1' 1' Si r,l , Cl t0 pcrsi sl i i
ci tovl r, st{I,' i l .,. i i efl cxcl o
rr l l r)i l rrl i rol sri
si rri , cti rrscl vai :cr nr]_
-rxi sti l
l a,sci cri hl i f
-rnuscul rre
spou,
l i r l r . i r i l u pr r ) v( ' 0i L( , 0,
i r t , r ' t : xi l t ncl t ul I G est e nof r na, l . '
. , . , . , . ' ) . . t . ": , : . , r r , l : , r . . t . t i t i r i t , , t
r j c
f ) L, r
t , , l . ecunoi r : t e pI i n r r . l ul i r si cu cpi sor . _
l { r ' : 11r ' ( ' r , sr vr . ( l r .
r t r r \ r , , j r 1t c, . l i l i ci . pt . i npr cdor ni nanpa, h
r , i daci n. r , m. i nbr c -
]] l ,,j ' l ,j .i l ]::' :.;
trrl r.,rgrosi rc cvi denti dupi , i ntreruperea toxi cul ui , pr\)-
, rrr'
f
r
l )r' i rr
I n.g:utrv rt i rl .ri !_c\umenul ui
cl i ni c neurol ogi c qi cl e cel e mai mi l t0
,
' f
i ,i ,;i i ,,' .,1"
' ' ,' *' ' S
,r I I l , )f l ,.uti (cu
excepti a pol i neuropati i l or
eti l i ce dej a cou_
.. .l l .' 1
..4ni ol n[i i [c
tl i n tm.el e
,.i .nto
r.i cal i i endogette. De pi i rl l , ami otrofi t
rtt.rrrr,ri sl trvi l L. i rL oursi tl i nsufi ci crLl rci renr,l e croni ce, ar6 o pi ecl omi nanti r,
pt,rr i.rrLrrlii,
so l,sooiazii :ldcsea cu.crainpe musculare, iar invesilgitffi"
"li#il
rrlr,r'ir.rlrr,
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-in'silualiiio
r r rr|:rIj i r.i i
l rol i rrouropa,ti ei ul cml ce.
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b:,r.ata l ui l l ac Ard"Ie-scttmi rl -peorsol , poate
crea
: , .
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r ' , .
l ) r ! , ' , 1| l l r ' .
r t l l guost i ce
c. u ami ot r of i i i c mi ogene. Do f r pi , ei l c o ami o-
I ' 1' r , ( , , | l . r \ '
t t vr t ur r ui t [ of i ci t cougeni t al al f osf or i ] r zci f r uscul , r r , . , car , ,
rrr
l,'
r'r.ril.{r Lrilnsfo|ntjrrcJ glicogenrilui
in acid lactic. Ii,eprezinta o boali,
l.llllll l.]l,l,,l ,l.l,rr,rlrir,
(cx transmisie autosomalL_recesivA), tegate
Si
ale
,
"J| ' i r l r Xl l l r l t . : r t r . . . SS
pol f e r ( , cunoi r : Lc pr i n cr r . r , ct ent l er et l i i ar , pr i n
apar i -
, : , I I | , r , , I I ) I | : | | L.
r r r ar l ol csccnt i . pr i n ami ot r ol i a r i zomcl i cd, i nso1, i U, i i d, r
r - | | | r . U, I r l : r l r . \ r
{t ( . . cn| npo.
p| i n apr r i l i a de si dr i epi sor l i cc de conbr act ur i
l l , ' i : : . , : . 1: , ' j ] : . . , j : . "1
dc cl or t ur i pi ur r nr t c de. mi ogt obi nr r r i c f f anzi r or i c ( r evo-
rl l rguo\t
rn), pri n
cs?mcnul ncurol ogi c ncg-r,ti v (i n afara
t , r r ' . ' , . | | l ( . r : | l r l , l l . ol t ( . i
di scr el c r i zouel i ce t l - t J0% di ncr zur i , ) j i pr i nor amenul
' . ; l ] . 1: , I
I
,
l ' : l l r: . , 11
p' obci de i schemi c r' , i i "' , i i ; ; ; ; ; e-p' i nd l a si t cnl i u
i rrl ttrr' ,.i r :rotr.yrl rtl i i -bi oel ect|i ce,
paral el
cu i nstal are:l coftracturi i cl ui c_
,"Lr{L
(ri i r
,
,/s'
ti orvl anrl
$i ggl g!., 1965, ci tal i de Radu, 197g; Sr,i or
,1r Sl i .l rrri , 1.0?5, r:i l ,Ll i de Raa1d, 19?g).'
. i . . l ! t i t ' t t , , l i ; t r de or i gi ne eu. r l oui nd se pot i nr i i ni i o:
.t .rt .l
tl t i ttl t' ttfi a,h i perti roi d,i ani i are- o pred.l omi nanl d, proxi mal i , (ce1 m:r,i
. r i r ' . , , r
l ) r \ r \ . r
, 1l t , . r t i r , r n: r l r ar sc. r pul oh umcr al i ; , sc asoci . r , zi i adcscl t cu f as.
, r , ' ur . ' l | |
1, . t , . r r , . t Sr . m i ol ogj c
- der . uh
nl ) . dar cxr menul cl i ni c neur ol ogi o
i lr r' ri.{r,r I v, lrr. ox&msnul llMG evidentiazi, semne minore d.e tip neurog6n.
.. ,..,.,), l,:.::.,,,r::!
t, prIn hip,ercortic-lsrru. (indeosebi ilin sinch.omut ti,i Cusn'i"gt
, r , , r ' t l | r i r r l r t cs, . i r r n3SCJl i i , dC obCZi t at e.
, ;t
l ui r t' f i i pdl tnr op&uz;ci l i ,_ sc i tsetmi l rd cu mi op-rti a
11rogresi vi i
r . , l t r r \ , ,
i r t l r \ r . vI t r . . \ pr r |
L, f emci i nt r oi 0si G0 dc ani , pi ecl omi nn
I a r hdi i -
r rr:r rr,.rl l rl l ot. (i rxl oosebi
l a rne-mbrel e i l feri oare) gi i d asoci azi , cu hi po"
l ,rrrrr. rrrrr.rrLrr.i -r,.
I)i .l r nu exi sti frl sci cul a,l i i , r,ei l exel e osteo_teni l i noi ,so
rrrl .r)rr,r' vi rl (!,
rru sc evi denl i azi i , al te seri n6 neurol ogi ce, i ar examenul
l l \l
(i
rrr rtl l vi , rrrrxl i fi q"l r.i
i ri rportanl ,e.
,\.:t.:!.' :.
i l ni oh.ol i .i l e mi ouerl ,e
I i l ol ' , cr r pt r r l r r t t r i l t l ul t i l ,
I ) l oxi l l l l r l i ' i ,
l r l i t r gi t t t l t t t l l i r t l cs t ' t ' t t l t l t i l c' t l r r r t t t t l t l t l t t t
i i , , . , i , , i , , i i ; , , i , , , , , , , i t , i . Su r r r r r r i t , i r r r i r r . , i . r i , : r . r . : r ' r i 1, , r r l i z, r t .
r ' - l . t : r l : t l r r l : r
' , , ' , ' ui : r
f - r . nr . p. i i p l l i r ch"nnn
; i
cl t " t ut t r r ' r r l . c' ' t r l r r t i l ' r t , r l r r r ' ' r r ' r ' \ r 5l : r
I ' i
r j : i . r Y. a' i - i ^r . ' i r o, ni r l ui r r , ; r r r r r l er ' . f uLr ur r l ui cur r . r ' i , r r r ' r r r : r l r i l ' l i . l r , '
i ", , l or i n, ' l
' ; i
6, ""s' r r dr f or nt r I ui L\ l t l l oni ) ; i
cel ' . o. r r l : r ! i '
r ' : r r r 1
I t r ' l
{' r i "l
t,' i i ""-"^ttl ""i te,t' i '
i i 2gnosti cc
(Ratl t, 19?E; Gui bert ;i
(l rri l )(' r' l I |1l ' i |)'
oi De nl ul te ol i ' a' mi otrofi a
pl ori mr J contrl str' :rz:i
t tt tt Iti l rrrtl tol i |
, , 1" ; r n; ' ; *; ; ; i ; Li r r n' : i i "t i e)
r r al t 6r mu- ' chi : gxr t t [ ' i t | i {t r r : r i i r l st '
l r i "l '
i ; ; ' h' ; i ;
' i l . j ; ,
i "r i "i , l : ' d)
consi sr enl a l nuqcr r hr r - r
t t t t r ' ' t . r r r r r r l r l r r ' : ' i r
,i ;;i l ' l ;-;;;i a"rj rotg,ri i de zonc fi broa,se ;i
i ], urr' r'
,srurl .l ri ' r' r' l
' rrl rr
.
,' r nefi e,' ul i di omuscul ar este totdeal ro' l abol i t
pr:ccori r". l rr t i i r' \( t' pt rr'
'
i
i
P;i l ;;i l i d;i o.-uJi i
ost"o-a' rr' i cul are
prog|osi vo, i rtvrtJ i rl rttrl t'
(i tt r;r|r' r' r I
i i ,-f";; nocnl m" de Boul ugne)
;
g) i Jl el tror ti ,r g , rsi i r. l
.rl r.
rrl i
.r,rrl ;rl |
;i;l i.,liiTJ;1"
:',-,l",\lil"Jl'
i:il",llilijljl; r,''::illil
illi"lilllii,"'li':j;r;ill ;
i ' i
gt , i ' i i . ""i
- U, l i ' C
ot r t e un t l as. ' u t i pi c t ni ou. r r ;
r l . gt r r l : r t "r r
l t . l . t t ( t "
i , i , " ?"-i i rl i "t " i r"t ori e, a c5ror <l urat a
qi l nrpl i t rrrl i rr. si rrl ,
rr. i l rrso
1r
rrrr
rtti asDccl ,
pol i fazi c cu componeni e
scul tt
I
rl dl orrl t' l rt' {l t' {trrfot' l l tttl tl l r' l ot'
;,;i t#-i Ltdl ;l i ratu"t"i t;
i raseu DMG dci rscbi t tl c-bogi rl ; i tr l i rttl rttl tr.tt
r.a"1i ei
-i i rl mi te,
care gencreazi ' vi rfuri nei denti l i cabi l tr ;
i )
' \spcrrl
rl csi ttl
rl e ti aracteri sti c,
i n geni ral , l n bi opsi a
.muscul ari i '
: rrl l ' r' r' rr' {i i l rrl i i rl r"
tl rri
1,ersate,
segmentare,' ct
i negal i ti ' ti i l e ti brc' l or muscttl i ttt'
(tIrtt tttItIr' ' l ti ;x t'
i .oi i ce l al r-nt.nti ce), c' coel i stenl i i
i n acel :rqi ftrsci ctrl , r' ' Ij l rtrr t.i r' rtIr|.Irr' r'
_i i i " i ri "' r"r"i ", ci i i nti ttral i o
gri sorsl rnl i mul l $i ru rl r.ri
1l (i l
i rrrp,r' l rrrr
i ,r.
' i .i ' i -"r' i .t:i "i i i
si
p,' ."o"L h' l perl l azi e a tesutul rri i rrt' cl rl ' i {i rrl ,
rl rt.t l rttrt
' ; , "i i "; , i ' ; l di nl l al i ar ot ' i ";
j t - Doz: ' r r ' t , r si r ngt t i t t : i . ; t . t ' r t zi t t r r ' h' t
r r r r r ' i t r l r r '
,,l r,i e.-al -i rrrrd,
"Gi erea
i mpoi tan a val uri l ,,r' rrkl ,,trrz,.i sr,r' i r,r" rr r,rr' rrl rrr
iiiii-lliqt";' i;iiioti"iia"og"i."rui,
in schinrh o sci,ttt' rr. ir v,rl.,r' i|.,r' rlili' rr,r
i i ;;i ;l "r"i
(i n unel e forme,-cl t de' pi l t}-r' Jorma l l rtch.rtttt' )
I
l i ) IIt.IrIi tIItrI:r
;:;;;;;";di""G&otx
(a"" nu eJtc
prtogn,_,rLronici' i
pt' .ir.' l)Nll"
lrrrl,rrr,l
i i;""";;16-
qid aite-amiotrof
ii rnioge?Le qi.neurogcnt ; 1
l
),
1' i
lrs|Kr
r l tr t ..t t L'
- """t r "c
i l ' f t n, r l par c; m)
l i psesc i r ampt ' l e t r r l l scl l l r r l l ' ; t t ) \ t t a" r ' r ' l r
' l
r l l
' : , i . 1i ""r or i i
- r i ar ' t "t , '
spoi r t a n" st u pnr vocul ' ' ; l ' i 1, s' s" r t l l c
i ct r t t t . . t t t t t t i '
i U;;' i ;;^
";;;pi l
to"i tel ot foarte dvol uatc, utLtl * srt
' ,1'
rrl t' l i rtrl l rrrr' ' '
, ri eotentl i l oi rsd si apar retracl i i muscul otctxl i nortstr) ;
o) l ' (l l f rr$l (\ rrr' rtrrl
; i Ji "al ; ; ; Ei l t a i i ' r onr "
al i l , udi ni
par l i cr r l : r r t
r . i r r . : r r t r . r ' i st . i . . r . : I r i I r . r | , ' r , I , r z. r
, : ' i
oi i l i ' i 1f
""
i , , r i nLl ' oI f r , f o*onul ui ' r i t al i : r
' . r l r '
r i r ' - pr "'
( i t r i . t t r t : t l l r t r ' l r '
,;,i ,1;;i ;"i ;i opai :i c
cu mi ndci ' l i j rrt:i , ctt rl .schi rl ct' ' :r
rrrrri l i rl ai l rr l i r rrl r'
i , , , : i t i f o"f , r . "i a,
. : u' buza , l e . , t l pi r ' ' ' . ci L r r sl r I
r ' 1
l : t t r sv( ' r ' s" i t t
"l r t t r t l
r l c
H
' t t r : r '
, , ; ' , ' ' ; ; "; ; ; i ; r l I l : ; r i n t . . l t ni n l : t ci u scal ' r t l ' r l r r Lr Lt ' t : t l i r t l r t r l r ' r t r r l ' r r r r \
l )6j 6r' i ne) ,,q.4.
E.3.2.2.2 I)i strtfi i te nti ol ott' i ce
(' ni ottttt i i l e
)'
S-tr
' 11' i o
ci r' :rl i l l rri rl l ' rrrrrrr
, , , ,
u; ; ; ; ; l ;
- i , ' ;
. ' i t r l uL
"i r ci , t
sc pL' s' ' , zi
; i . i i pr r l
. l ' .
r . . ' f t nt l i Y l r r r ' r l ' t l t r t
; i l i , , ; ' , , *"i i ^"f , i *i "l j , ' ' i i i st r ot i
r ,
' i j o! r ' i cL
( sr r r r b, ' i Lr , , l ui .
Sl . i t r . r ' l
) ,
t l i r t l t ' l t : r
, , , i , i , i ni , l i i i nt ani i l r ' i , ( congol i t al r r , ) , ci t
f i 1' r t l ' r r ' r t r i ul r r l r i i r ' .
r x) r r A( ' r r i l r [
( J) r ' i r l i l
l i i i V' r r l i ul . *l r r : r ' g) ,
pr t xt i i r t r
1i
r r , , i r r r ' r r r i , i l , , i r i i l e,
t ' r . ' t . zi t t l : i r r r r l i l : i {i t ' l t t t t t t t
{{' I t oi ; i o( r
( l i sl , i n( 11( ' i l l t
( l i l l {) t ni ol ' r r t t i l t
r r r l t t t zi t t t i t ' t l l r i t t t t t t l l i l t l pl ot t t 1i
t t t l r r
l r r r r r l i r ' ( l i l r r l r l , l l ) ?f i )
I t r i l r r pl ; , i , ol t l t l l t t r l ' sl t r : r l i r r r ( i t r t t i
si t t l t r l t t i t ' ol ' t r l i zr I I ' t t i t t
l t t i l t t r i ; t r t l l t t t t t
r not t t ct t t t l r t t i , , l , , ni t , t r l t l t r t t ' pt t zi t t i i i '
r t l t t l l r t t l r t t t ' I r t r r r
' I
i r r I r I r I i I
I
'
I I t ' I
'
i t
j
| | | i | | | | 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 r r l i r r i r ' ; r t i t r l t t r r l t t t r t l r t : l r r ol l r r : r l
( l l
I
'
| 1
' I I I t I
I
l i I |
'
t
, ,
' 1. , . . i , t '
1,
l ) i st r : 4i i t , t r nr scul or e pyognsi ac ( l l Nt . l , 1 r l t , obi cci nu
l l Ur " . r
{
r r t t , r l - { r }, r l l cr . .
l ) l . i l l
I l | 1r r i r t oi
, {. l u
c;
, : t Cl , ( , t . ( j
:
,
: r ) l ' . r l i r . l ( ' r '
A, ! r . l , i t r . r r {l o, t i t r r r i l i l l
( r r l r oor i l i i nr l spot ar l i ce)
;
l i r l
l , r , ! . oi
r ' , l r , vi r sl , r . l o r ni r : i
; i
r r vol t r i i o l r t ni , L, r l t r l i l r . oxol l l bj i
r r r l r ; r , ) . , \ l , r ' oi i . r , si t l r r l i ci l r r l r r r , r l , ol si r r i ; , i r r r r r t i r ul r nl . j ol i l t r , i , r r
l l l r4
ct'e0il,zii
l t) Do-
progto-
l [
( r i r zu'
.Jl
' . l l ' l l
: r ( I | ( ' r ' I r I | ' i r ( I {i . i
r r r l ( i l r i Ul r i sl . i r r i ,
.
r . r r l i zi r r r l r r r r . l i l r r r r i ' | , , r r i ' i i , . Asl , I t l ,
r l r t , ) r l I r i ' {i i r
r ur f ( r l i r i i
( , sl , c
l ol l i i , si pr r l r r r r gi l i , r l r r l i r r r l ol or , i i , r r cggsi Li r r r i
| , . r ' l r , r ' i \ ' ol nl i l t r l r . r r t r l r i l . l col t si i i , l nr or r r l l i o l l t l ccot t l t i r , cI i ei pot t , t , e sut , vgt t i
l l l . ,rt)rl . Al /r),tal r,r, (l l tl )ri
o c( ) l ] 1]t,t[o1,i 0. v oh r rrtrLri i , si r[
(l o
o trti t ni i ti r,
Ttronncatd,
:rrl i l rr rl .rr.pi i r) (i {)l l l i r(i 1i o
i ru.l usi i ,_: l i c_.pri nl ;r.o ac!i ruro rncorni ci i ' (percuf,i ri
r r r , l ' r '
'
l , i ; r . r ' r r r i r r r
.
r I I ,
.
i t ( . r r ) r ' r . . i r l i r n bi j . sr r r l l l ur r gul r r i $upi l r r t or ) , i i c pt , i l l -
I r , , ; ' i 111111 111. r . l , r . l r i r . . r . l i {. r r ( , r n( , r r ul nr i ut oni c pui l c f i t or r . i c l ] et cvi dcu_
t i r r l
r . r r ocr r zi l r r l i ; 0i t i l ot t l o pl ehonsi une.
I. lirtrr.llt, Lui, Sleiu.t'rl (,niottnia atroficd, sau. clislrrf ia rni,otonicd, ) st
| | a | | r | , , : | - i ( r ' r ' l r r I i I r r . , , r r ,
l ) o
l _, r z, l Ur mi I ur ul ui conl uxt Sp- mi Ol ugi f :
t
1
I' rt.cttl rt ,ttnl ,tr,t.l i tl ar, sub acest aspect boal & l ui Sfei nert fi i nd
l i f . l i l l , l \ r l r l , t r ' . r I I I , . ' . t i r r r r r . , l i r r r | est gr up Ct r C r e| t l i zoazi , r l r ol i i muSCul $TC.
,\r.rsl l rr,.<,.1 t rqrogr.i r fi tr, si nti faci aL
5i
di i tel e l a, membre, ati l gi nel trmdto-
rr,i
.rrrrr;chi .:
rrrrri ;dri i 1cfei , rcal i zi nd un faci es i nexpresi v, atoi r, de aspect
..l l i rrrul ri rrl i l r.' ), cu l i psa cutcl or frunti i , cu defi ci t;I ol 6i cdari l or oci i l or
. i i r l
,
l I l z, r ' l r ) r ' :
r ' i r i i r ' : t t oI i i pl eor pcl or _: uper i oar e ( cu pl ozi r pJt pebr . nl i , ) ;
r . - ( t ) l r l l l
i t 3{I r ( . Jl ont ( cu
cvl dcnt a al r ol i c) i sl er nocl ci dor nast ui di _
, r | ' r {t l { : r {, . ) , . r r , . . r cu {. \ ' i ( l {. nt : i . r l l . o[ i e)
;
musc] i i , nt cb| r t ul r r i
5i
ei r ni i ni i ;
r r r r r . , l r i i r l i . i i r l i I , i r t Lel br {l , r T i ni ol i ol r c {mul t mai t al di v}.
l,) .1' t' t:
( tl I u,
!
ttt rttnenultti m,iotonio relatat anterior.
t
)
o)illi: cu Q(|t?lic(i, c\ anurnite caractere particulare:
I trrrl sri ri si o c[r' e urrncl zl i o moda]i tate cl omi danti ,, srrb aces, aspec[
l i i rrrl o l l rrr{i rurc rl otr:nni nat:i de o gen5, pl oi otropr,
autosomal f cl omi nai t[,
r' ||
|)I.rI(,I|II||ti i rurrnpl cti , s&u_i ]prui tpe compl eti ,
i fari i
sri sr,rti peste genel al i i i
. . r
'
, r
r . , r ' , . \ : r r i i r bi l i l r l t ' dc cr p| r , si vi i l t e ( Cr ughe- y
l i Mwi enr [ onoul os.
l : r r ; r , i 1. . ' r , . , s. I : 1. , 7 ci t al i r l e nr r du, t gTd) ; apxr e Oi n ce i n cc 6ai dc-
r t., rrr,.i i i rrrl ' r' rcrr, rrs.l (' rtr cl i ni ce di nce i n ce mai graye dc-a l ungul genera_
1|l 1,,' r
(l ( ,rl l ](.Jr' (l (.nL
rri l c
,):rntepozi ti ert
SAU
,,anti 0i pAi gi o,
qi
,"rprOl reSi e,,
,.,1i cr
l i r.r,, l ru,l ; (
' rrugl i (J' ,si
l Wyri :rnthopoul os,
.1966,'
ci t;!i "
-de -n,adu,
r:rrs); rt(.|' 1r' i rz:-r rl e ol ri cei i n arl ol escen![ si i nai nte de 30 rl e ani .
.rl 1
l \t' :tnl o i Jc tttl burd,.ri tndocri ne; - al opeci e precoce, ptogresi vt
r r r r l , Lr r r I r r r r r l r t l : ( , I ) i r ci f i er . i
cr . i si ul i ni cne gener al oi r e do cat nr a6l d <i t ,
l r p \ , r;l l s:l r r t,. 1i1r JrJeisubut
l
*
atrofie l,esticulari,, cu sci,derea activifi,_
r.rl r
r, )r,,, tr( r' r i r u : r z, rosl l crnti e
,si
cu scdl l erea el i mi nl ri i de 1?_cetosteroi zi I
l:, 1( ir, i, It'r'cvcn!:rl, a enol'cei, a aTorturilor iterr,ltiYe saU ft StedlitS,iii;
r rr rl rrl r,n.:r r:Ll ol i l or oestrogoni l or
'
si a pregnantl i ol ui ui .
<'\ )lorl,i.Jittiri ItrtrI{}: Prezen\a tlescSlcdrilor bioelectrice musculrut.o
r ' , r r ' ; LI l l , r ' i . r l i i r r r oi l l . o l oal i zeazd, , , r af a, l el e, , , , , avor sel ot ,
sau, , sayel e" mi ot o_
r r ' ( ( l r ' r r l l r r
r l ct t l i i , vozi l i adu, 19?8) .
". Iirnlt, l.tt,i I'hontsen clasicd replezintd, ula diltrs formele clinico
rrl , rrri ,l rrri .i .ri l gc' i ti e qi so di ferenl i az5, de boal a l ui stei nerb pri n
urrni i -
l , ' r ,
L' .
I i , r i r r r , . r ' , . : . : r r ApJr i l i 3 r nul I mr i mr J
I
b) Exi r t cnl a r ue- i bi pnr t l o-
Irr l r 1 I 1 I
.1
,
,
1
'
; 1 , , ,
,
r'rirl'i cirrilor membrelor supcrioare qi in{crioale, a geflsnik)f
rr :r rrol r.rrl rl l rl i ; o) Ii eacfi e mi otoni c[ mai marcr],ti t, Ia ni vcl ul membrel or,,
rl rr.r' rrrrl ol i prrti ml i ntcresa i ntreg ansambl ul muscu]aturi i , cl ) Abscul l i
IrrIIrrrr;r.r' i Iol l nrl rxl ' i ne
I
e) l rognosti c
.mai
bun, fel ti 1i 1,ate,. speranl i ri o
r rrtrr ri crrprrci l .;11c tkr rmrncl puti n al i cctatc, si rnpi oml tol ogi e de obi cci
rrl rr{i orrrui (l l l ,rl rr, .11)78
I
Caughcv qi nl yri .:r,nthopoul os, 1906, ci tnl i tto
l i r r r I r r , l l ) ?f i ) .
,i . I' t' l l ti ol i l i l t.on,trn.i l ,al d (hoal ,a, Lrr,i l .' qtt l Ntl ,tnbu.rl
),
nrul ti i
yt,crrur
l r r r r I r r r r r I r r I i r r r r l r or r l i r l r r i
' l ' l r or r scr
r r
1r o: r , 1c
f i t ol , t r 6i r l i l i r r r , r r ( i r r , l l ' i , r l o l r ol r , l i l l t t i
' | ' I I r | | r r r r r
^ t I
l r t
i r r r r r r ol o r l r , r ' l l ol cr l t t l t r l r r r l i i
, si
r r l r i i r l t ' s l r l r r l i r r i or r I r r r r r r I r r i nr i ol , o-
l l i r
(
i
rri,, (r!.*kr,r, *)'i.' ri,1ll1,lll],il,["i,ll.il;]11,,:i;,;;;lil''i;i,,i'iill;'{:;l'i:il:'li'll;ll;
|iil#{;j;4i#:"1{H"i"*:1,;irtv:{rli*ii*ri;ilr;;;r'rri:
itr*,#,F,"?H',:g::'*".Te;:"x"*;;t"lr'***:.i1i;::li:';l';l
li",illii*i,
iilll*#*$nllt*s+:t$u""ttll{y#'i{i*ilrrn,ir,lirili,l;r:r
r,',r'mer1ul trapart al t*nr",]Tl'j.".1{'_!1['"ti,.f;"'.ltlii,il,l,,
,rirrr,.rri,.r
;,
illlili"rixffnJ:"T,:?;,u,n",ii,ila
in deglutilie, rlupii, co'sLr,r'
rtrr irrgr'.t:r{:r.
i'i''
"#
";;;;l*i"
*4, d.rr
"n".'1L*1?.',1;?11"1?iii"TlT,lil,
l{ : } l i l l l il l Jl ii i,
i
rli,'lil"ii",i,ll$i* "Hf-#lXit$Jil'*ililE#
#'tgdllt*"t'
ll$l L:
I
l
l
lj#ii #*""qf T+?,l3""i'ii,gT:?Tg#
#t;;
j*j*;,iitill,
l,
i
llli ti ir l
;
. r l', aroplitudinii
potenf ialelor
i ' i ; o; "' ni "t ""- ql i i ni oi i "t t " 1972, ci l at i dc I l r dr r , 1178)
4. N eurorni atoni i l l a
s-au i tl eni i ti cat
qi conl ' ' rat i ' .l f i .ri i i r' tri
1i
.ttl tt i rrrl
i,rei entiti,li cliliee :
;f i;*;:'"*J,'" :#3Y'Hi:#i11:'i:'1y?i1t,i"'f
"'T"'lll;l';:"1'
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1i
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l ' r r ' , l ' r , l r {r s( , u
1i
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l , r l , r r l l r l l i Ll ot i i l i mf o- pl asr noci t al e
; i
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;
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; . r , 111' 1. 1q
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r r r , r l , r ' i r ; l r ) I r upusul er . i t emat os r l i scnr i ni r , L
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c) I I t l i I r , r ' I r ' I , i I r r r r r r r l or r ; r r ;
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r r I r r ( si r r r r r l l i co l l r , r r l r gi r r r t l l i r r r r ) .
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I t ol r l i
;
l r ) l l r l r l i ct t l l r t i i r r r dr , l l i r t r ' , <ur t r , t i r r l r : : r l r cl r . r ' i l l i l i r i r r r l l r ur , l r i
l x' r r l r r t
?i l l l
f r , nr ( ' l o Hl ) i l l l l o Hul ) t ( 1l l l o
f i
cr ol l i ( xf . l l l r sci or r l l r , t i i l o si r r l ; r l r r ost f i i t t l o st r gr r sl , i vt r
l l , r r l l t t
r t t
; t l ocl s
r l o t l ct r ot ' \ ' l , t t r r ( l l ' l t l ) sr l t ( , t n l ot . nt t cxcl ur l o cl l r l ot Lr f ul nou-
l r41r' rr rrri cl ol l l l i c :rl nrni otroti ci , nta,i l ,l cs ci l
(l o pot {i rnascato dc
fcsul ,uri l o
r r I r
|
) | : r
I
r r I ii
( r
)
irrrlcostdli cind ili rlu origin{t& In fasciculclo lnusculare profuntlo
(l i rrrl rr, l l l ?l t).
' I' rchui c si i mai ;ti m ci fasci cul al i i l c, de rcgul d,, pl oced ami o.
l l ol i i r. c) Il trl krx i di o-rmrscul al conservat; rI) l i efl exe osteo-tendi noase col
nrri i rrl oi Jcl , di nj nuato sa,u abol i te; e) Tul buri l i vasomotodi
$i
sudo-
l rrl o rl cstrrl rl o frccventc
I
f) Exi sti i , i n unel e cazuri semne neurol ogi ce aso.
riiri(', rjil,r'c pulmit diagnosticul topografic: tulburi,ri de reflexe qi/sau do
si'rsilrilil,lto, cventual alte semne spinale.
4 . INl.tatrodiagnotticul cle rutind, incumb5, o sede de aspecte reyelatoaro :
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;,; len-
lrrr,r'ca,
,si
miiriren pragului contmcliilor la curentul galvanic
i
scidercil
plrrgrrlrri rcobazic a1 muqchiului; galvanotonus muscular pa.tologic
I
creq-
l 0l ' (rl r cron: l ' xl l l or,
b) Deneruareo, incompletd,.' conservarea excitabilit;lii galvanice qi
lrrlrrrlicc u, nelvilor, contracliile avind ins5, o amplitudine scflzut5
;
la nivo-
Irrl rrnrqchilor se remalcd o oarecare excitabilitate a unor fibre musculato
lrr crrtcntul faradic, dar cu r5,spulsuri heterogene la curentul galvalic, in
sctrsrrl cir, uriele fibre au o contractie 1ent5, la prag mai sclzut, iar allete au
o corrl,nrc!,ic destul de vie la ul pmg mai ridicat.
5. ,Eleatromiogra ia araLd o sd,rS.cire 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
(.l ri rr'
l )r' (!cl i l i i ce,
de rei nervare.
;r) I )11t1cy1)o,ys(r cotngtleld, se caractedzeazE prin:
- Existenla unci
rrotivil,i,{,i spontane perrnanente a fibrei musculare, cu prezenla de potenfi-
l,lr tlo fiblila!;ie tle scurt5, durati, de slabd, ampliturline qi de frecven!tr
.jorr,si-r,,
rlir,t' rrrlal,iv sl,abilii,
;
- Absenla oricS,rui potenlial de unitate moto-
ric crr rxllziir, conl;ra,c{,iei voluntare.
)t\ I)cnart)eree, par,tiald, se caracteizeaz\ prin : - Prezenta in repaus
rl r. pl i t,rr{i :rl e tl e fi b4l al i e sau cl e fasci cul al i e qi atl esea de potenl i al e i l o
l ilirlr. Ir'rtoti!', - In timpul contmcllei voluntare, se inregistreazl o
riiliicilrr :r, poton!,iatrelor de unitate
;rrotorie,
care pot prezenta uneori chiar
r r r r r
1
r I i I r r r I i r r i cvasinormale. In cazuri extreme, un efort deosebit poate de-
r,l i r rrl l r, l ,r' i rsr:ul si mpl u
(i.
.l)i.opsin musc't d,rd, ofer5, de obicei imagini histopatologice net difr:-
lr,rrlirrl,o l'rt,t ii dc amiotrofia miogend,: a) Existenla de Ieziuni in insultr,
srrtr itr pliioi, care corespund atingerii fibrelor unei aceleiaqi unit5li moto-
lii, i vr'orno ce fibrele unii,5,lilor motorii nelezate prezinti aspecte nonnrlc
I
l r) l ti l rrrrl o i ozate si nt atrofi ate qi i nl ocui te de
l esut
fi bros sau adi pos.
,\.:l.!.:1.:a. AmiotroJiile mielopatice
l.
(:u,ntdere
sam,iologice gen,erale: 1) Amiotrofia este de obicei bilal,o-
l rrl ri , rl rrl rrl cste tol deauna si metri ci ,. 2) Ami otrofi a debuteazi , cel rnai
rrrllscl rlisl,tr,l, tll,t cxamonul electric nc irrdicii totus,i o leziunc mai tlifuzil,
Jl ) l ,)vol rr(i rr, os1;o tl c obi coi progresi v ascondcntl . 4) Irasci cul al i i l e si nt do
rlgrrlii
lrlt,zrrrttr,
dar ele cel ntai adcscll tlcpiiricrsc zoncle musculart ilt,ro-
l i :rt,c. 4) l i ,ofl oxol o os1,co-1;ondi no:l so si nl ; abol i tc (eventul l rl i rrri nut1o) l rr
; r oI i or r r i r r I i I , oI c
l t , t r l ; ct i onr o
6i
l n si nr ' l r ol r mcl o
, , r ' cci r r t r ) t ,
t l ar . , si l t dc r i r gt t l i l
r , xr r gr r l l l c ' i n f l l , A ( pl i n r i r xl r r r nr ul pi r r r , l ni r l a, l
aso0i l 1, ) , t i ) Tr r gr , r r l l r l t r r r
oxi xl i t r r l l r r r t l r i sul r i r r cl ; i yc ul r t r ol r i r , cl , i yo r l c sonl r i l r i l i l t r l r , , r l l r r " r , r i sl r r t r t , l r ,
ll(,0
t r r "i r l i ' i , x i l r {i i l , . r ' ' ' r {r : t i t l g, . r j | r f r l r . l i l si r , i r r g0t r r i r , l i ( 1 r , sl l r r 1
,
\
( .
I i I I i ) i | | I
,
l , . . , . l t , r l
I ' t r r r Aol r l l r ' l r r ' r . I I l t t r r t I r r t I t i r ' I i t l
Nr t t t t t t t si t r r l t r r r r r l or r i sr r l l r l r l r , r r l l l ' i r ' l i r i l r r r l i r , :
i , r , r , r ' r r ' l r , - {; ) l r gr ' r r ( . t . j l l ,
r r si r r l , i I r r 1r o| I , I r r r I r r i . l l r r r l i i l i sl i r r | l cr , i | r r r , .
I l . .,1 tti ol .xtl i i l t ttti t,l apul i ct rl , t,r,ol ,r.tl i r: rnl i di ,
1.. ,,1ttt. i d rol ti .tr, tl i .tt, bau[u, Lui , .l I t:i rrt+ f,It:rl i rt, (pal i ottti tl i l rt.
rnttt.i t)tu,tl
' ,
r l , t !
) . . n. r , : ' r t . l r . r i z. l r zi p. i r r : i t , ) Jr Lsl , , hr r : r al r i t l i , j
b) _Al , i r r g. r r r , r i t i i r \ i r i r
r , r r ' | r ' r r or ' r r r I s' , r l i l l r r
al i r r , 1 l , 0
I
1r ) . 1. : 0ca, l i zl r i r Lr l t i gr r l l r , l o, t r r , l r r r r i : r r l r . r r r ! r ,
r
' rtrtol Ii r0, i rr grri ru' :l l
l rt' i xl n' .ri r ri t nt0 l i l rn.| rbrtl i r i rrl i rri orr,rrr ( i r r r I r
,
r r r l r , I r r
1, ,
! ' r ' t t l xr l ( ] r Tr u, al c, ; i , pcl oni ct ' c) ,
i l r l l a r not t r l i r u' kr
sI l ) ct , i {r i
, ( l
; i r r ; 1r , f l 1, , , 1, ,
r , t t r , , Ul i r / r r Lr r r r r Tr r l r l l hi l r , l r , l
11) ; \ r ni ol , l , of i i t , sc l l soci i zi j , t , r r ; pr r r | l r l i , , i r
l l ,
, : , . , i , sl j r , l j ' c l i r r r r ' l c r r r pi r Li . Lr , t r r l i t
11' r ' r r . l i zi r r , . . r l r , r I i r r r i r r r
.
: I
1
i r
.
,
r r l r r r
\ L I l ' - l l l l ) r ' 1r ) l l r . l oi t . r l ( . i l l por . l : t ni J
;
l r l xr l i r , , , l r , t , ( . l l {. \ r . l r t , r , t , l r . r ,
i , r r . r l r r r . l l , No
i .
c) Nu Be const at i f asci cul al i i , t ul Lr ur r i , r , i sr r nzi l i vc ol r i r . r . t i r r , ,
I r r I l . , r r r ' I i l i
i l l i r n, i cl i ( r r c
( t l : ar 1n, , ot t , 1; r ecI i ni r c)
; i
r r i ci 1, r r l br n, i i , r , i pr r i l r i l r r i
r r r , ( r ' t r . l l l :
t Ul l , . , , r i . Si 1 pr czcnl c; i :
_] t i pr . r t r . r r r r i r . . r , , . l . : r h: r : , sr . t
r I . i r r l , r . r .
' r r . r , . r j , . | | . r ' i r l r ' .
^r t hi t l Xi i ,
. r
i xl gj i . r caci . i e I n( : nj l r gr . r "l i l : r , r i r . l r 111, , 1, 1111, , ,
t r I r . r ' I t l r I . l , i . n LCR
{pl i . i , ) ci t ozi . apoi _
r si
hi pr r , *l l r ur r r i r r ozi r r r oi l r . r r r t l ; ;
1' r
l i r.rr,.{,i rr,
dc <l egcnerescenfzi pc ml schi i cor;spunzi i l ,ol ,i l .zi rrrri i .,r,rrrrl i ri
. r , 1,
r i or ' . r : i i r sl r i l ' . r zi l r pi d. ; h;
pot
, i 1px1, . - | , si r l t , . l r r l l r r r | i r . i l l r , t i {, r . r , . i
'
, l : r . l i r r : : i ) I i i nd vor ba r l c u r f cr . qj une l i r ol i ci , , r . l r c
t ) n, i l t r r r . ( 1, .
r r r l t ; ,
,' rr l ,,j /.i l *i rnai exti nsc (pol i ocncefal omi el i tri ) po{ si l ,,i ra.i ,
5i
si ,rIl .rrr.
, | | r ' ( | I | | I ( | ( ) -
' .).
A nt,i oNroJi n mi el .opati cd d,i n hentatomi el i c.. l ) So rttnl ,i l ,rri rr r,l rpi rl ,
t,r,r
r' ()rri l ,ri orea l ezi uni l or cIeate pri n hemol agi i l , i ri I.i r,rrrrrrIrIIIrr.i i
;
l r,) l i )*tri
l , ; ' . r l : i . r l r . , , un. {l ct or
. et i oi ogi c
gener at or
dc }i or . ni r , . l , or r r i r r l i o ( 1nur i r r r r i I i l r r ;
I r l , r r , r r r l "( , c1r oFi , , T"t ,
"q;
sau l a_ chesoni er i
I
a, r xr nr i r l i o vl r scr r l u. i i r , l r , . ) i
I J t.i *i r.i L ti i pcctul ate l i i p Al an-Duchenno Uni l i l tot..l
ga,.
I r i I i r | , r I r
.t
r , I l rl trrr
l r'
!
rr (
i rzal l ezi uni l or cervi -cal e cu cea mai bogal ,r.i , vi r,srrrrl rr,r,i zrrl ,i r,, r' r,
l , ' r r l ' osl , ( , r ' i l t i i , i n cazul l ezi uni l or segmeDt cl or 1, ": S, ; ( l )
$o: r , so| i r i zi i r r r r :
1,rr,rr
r,l i r.i .. f l i t,sc5,, cu abol i rea_mpi d5, a i .efl excl or osi co-ti ,i rrl i i r,rr,x., {1rr
l ,*1r.r(.rl
r r l l ) r . i i r i . s( ) nzi t i ve
cl e t i p t l i soci at si r i ngor ni cl i . , cr r r l i sl r , zi l , i r r i r r r r r r i r r r . r i r . r i ,
rr i ,
Ir,rrrl i Ll ,t-r, I
.o)
l n cazul unci hematoi ni .l i i rrrr i l rrl ,.r.i r, h,, $. l r,s,rri i l zi i , rl .
l r : r r l cr r
l ozi r r ni i , un si ndr om Rr or vn- SCcl unr r l
;
f ) l r r r r r r r . hr l . i r r r r l r r l o l r r , r r r r r , l , o.
r r r r , r l i r r Nc i nst a, l caz[ subl ezi onal un si ndr t i r r
; l r , r , l r 1l l r gi c,
l r r r r r r i pl ogi i r Hr r , r r
r l , r r r ph' si ( , h i nceput . f Jasc, a, poi spl , st i c
I
g) $r sr r l pr i r r r l r r r or i i I ' i i , i i r , i r r , l , ,
| | r i : , , s; ul gl t l l ol et r t r t a t nccput , a! oi xant ool r ) r ni c, ct t
pt t l , or r r i r , l
l r i ; x, r t r l l r u
r.rrrrr.,:r, ,.j i r nod erc,t i :i , crcrstere a cl crl cntcl or c.l nl i rt: (u,1,i l l i rrrl i r.i i ,zi i , r,i l ."
r r r ol i r r r r cl t xr zi l , ) .
l ' , .
. . l u. i ut t , t l i i . l e- l i t t or mct a
j oasr
ol o ncur u. ; i t t i t pi dr ui t nI r l l n, t t t t t r , ,
t , , t ' t r l t , r . , r l i t t r ny' r l nl ' , ' nt i , l i l i r
Vt i n
ul l r ui r usLt t i r i nL, i l r r ol r i l r . i , r . r r I o, . : r I i . , r r r , , ,
r r , r r r r r . l i l i . ( r r r : r i r ' . r r i l r .
l i P, \ r ' l r , n- l ) ucl Lr r r r r r . ) . r r t i r r s{l ui l r t . r r l r r I i r l i . , i r sl r , i i r r r l r r
r , r
l , r r r r r r l r l ' i r r i l ; r nr r LOt f l ascr r ccl r r r l i l r r l r . st l r , r u 1r ) | l . , i _t r r LI i ; r
I r r , i , r r , ; l
I r gi r , i i , Hi ,
r r l . ' r r r t 1. r sr 1
; i
pt i u cont r r xhr l i t r l i ' r . ] , i r r s, r . r : l l r l l r , i r r , r kr si r r , I ul r | i l , pr cf r r r r r
1l I r .
r
r r r ' r I i l ' i . i i l i | r r r kr 1i p i nl l i l r r r i r , l , or r l i r r 1, . ( 1. 11, .
or ' l r r l r i r f i l r . s. r r r i xi sl i i , ni r r r , i r r r r , r
r l r . | r . zi r r r r o I ' r r ct l i l l i r . i r , .
I I I
"
rl ttti ol rol i i l t nti tl ol url Ittr t:u. r rrol .tr!i 1 [r:rtUl ,
. . , \ , .
l ' \ t r t r t . t l l : .
, , 1t t t t ' t l '
d. t t t t i ol r o, l i i . r t t , i r l opt l i r , r u uol t t l i r r l r , l r l i t ( { i I i l r r , l . t r
. r
l i r r i l r r ' t l , l l ) i ' l ) :
, , 1. , . l nt i l l t "l i , r _r l . i n
l nt l i l ui di l t
t ul t t i l ur l l , r . r . r 1i 1r l . i l r r
l r l pl r \
r ( f ( . 11q1H16
r l , , l t r l r l t , r r Jr r I r l l
l l ( i r r | , r r r r t , t r , r r r i t , t l r , l : r l r l r r l | i i , t i r t
t t , r . r r I i r t r r , r , l i r r r , t t r r l I r r r t r i l i i r , l .
{ i l , i {ul vi l o
l )t.ofol ' (
i l (,i l I l u, arl ul {,i i rrl r,scrrl i rri (i rr1,r,,
g5
,l i
,l I
rl rt n,ni ), o arrti o_
1t' rtf i tt, (r:tt tl ofi rri I n1t;1,e1) Ar.o l i r, rl gbrr.l , 1 t opog4ti o' [i sta l i r, l a i ncl nbrgl g
l rrl x.r' i rr:rrrr (:r,nri ol rul i c ti p Atan-Duohonuo) qi i i i i , ovotuoazi i , l ent,_progresi v,
|l r l l ,l rnr\I)ral l y Ur.tntl ,ui trci L succcsi une ]ezi onal i i ,: rnu;chi i erni nen(oi
Irrrrr,rrr i i i . hi potrrni r,rc. (ni na si rni ani )
;
mu;chi i i nterusol i qi i ombri cal i
{r | | i l l : r
. $( . l t ( : l i . l i r ' i ) ;
f l cxor i i dr gt cl or . t mi na de pr cdi oal ol . ) ; esDensor i i
rl rrgr.l r.l or' (r.a,ro tl ansformi , mi na de predi cator i n r-ni ni i al e
,,mari onetX,D) I
rrrrrsl l ri i brt{,ul ui (,,brrr,f,ul i neft
$i
btl nnt' ,); muqchi i l i mbi i (mai ti rzi ri ).
l \l i r,i l rr' fi rrrul t rnai tarrl i v arni otrofi a ati nge qi mu;chi i rnembni l ui i nferi or,,
tnurs-cbii srlqrulari, murychii abdominali. Aini6troti'a se inso!e;te totdeauua
rl o l usci eul a,i ;i i ovi dcnter i ncd, di n peri oada 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
I t t t l l r r r , t i i pl ogr usj r . i ) .
. . .).
,Ini otroJi a.di n
,,atruJi a
m,uscul ard progresi ud, spi nal d, su,bacatd. a
1,.r1l l :l r,Zu"rt
7i
Al aj ounni nc' ,
/,
descri sX,
;i
Ce Stl ,te Dri gl i ncscu
$i
Ol teanu
( ll)l-t,";),
so instaleazd, destul de rapid la e,rtremitilile tiisiale ale rnembrclor
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,
i l rl ttl rrs_dc ci teva l uni pi nd, l a u.n an. S-ar pi ,rea (Dri gi ncscu qi Ol teanu,
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
)
te-
prrzi rrl i i ,, i n real i tate, una di n cel e mai fJecr' onte bol i geneti ce' ate copi l ul ui
(i ttt' i rl trn{,i r,
dc 1]a 20 000 de na;teri , dup5, Kri i ger
fi -Franke,
19?4, ci tal i
r h I t r r , r l u, 1978) .
r,l ' l ' i puL
,racuf'
mal i gn (Radu, 19?8) prezi nt5 urmi ttoarel e caractere:
- I,l'rNlitl,1,u rricesivii nclegati de sox; - At.ingcrea ambelor sexe
i
-
l )ol )l ri ; l i )rrr,[o prcrnoe (uneoi i fetal , dar i ri general l ntre 3-6 i uni - md,xi
trtrrrr I a,rr)1
-.Al i octarea muscul aturi i oste general i zati i , qi deosebi t tl c
r,rrvcrii,
I
*-llt
oarirotcr imlorl,ant al amiotrofiilor din boala lui llierdnig-
Il ol l trri r,rrtr
t:stc coi ntcresai ea, ,:i a muscul atur.i i par,avertebral e, care cai r-
./.ri l ./.;i {.i l rl ,.r' r.:1, i n fa!i , a copi l ul ui i n pozi {i e qezi ri dS,, i ntr-o ati tudi l c
, , I r i uI t i r , i I r r r : - t ' ' ( l l , r r , du, 1978) ; - Evoi ul i a est e r api dd ( 3*4 ani maxi mum) ;
r\ l,i|lgrrrrril trLrrsculaturii rospiratOrii determin,i, clispnee permanenti
;i
t cu;ril{,{;io rliafra,gmaticS,, p}eoum
Si
infeclii intercru'ente
i
- Aretlexia astc
l,olrt li
;i
gonoralizat;,
;
- Eipotonia este masiv*, generalizatX, sirnetricit,
(r'tt rurltloplcgie, hipcrlaxitate muscuto-ligameniar[, realizind-
,,p5,purya,
rl rr ri t' 1ri , dozarti cul atS,' ) - Gui bert qi Gui bert, L974); - Ii evel atoaro
lx)lrl
nr rla,$i! a, hipotonie sinti
Si
abdomenui bombat
Si
faciesul inexpresiv,
l l l r gfl r' i t, tl rst:hi sd, (Rari u, 1978); - Paral i zi a fl asci , este general i zatx,,
tl i l ttz.i i ,, ri l rLotri otr, rl ar mai expri matS, Ia ni vel ul mu$chi l or gi tul ui , ai trun"
trl ti ul tti
ryi
ai ri ' tdi i ci ni l or;
- Ii areori se constat5, fasci cul al i i ; - Progresi v
nrt ilfuc1,oa,zi:r,
$i
mu$chii limbii, masticatorii, muschii felei, ai faringelu i,
i rt,t' 1,i r,nl i v
,ri
tnugchi i di stal i ai membrol or
I
*
Se adaugS, ci foscol i ozd,, pi ci nl
i r vr,t' .o([ui D
5i
urroorl pal apl ogi o i n fl exi c; - Rcacl i a de degcncresccnfi i ,
rtrl o nrrxi vi t; DII(i ontc al o ti p naurogon (peri cari onal cl c regul i ,)
;
*
Nrr
oxi xtl l , ttrl fl rri i ri do sursi bi l i tato, sornno pi ra,mi dal c, trrl burh,ri psi hi co
(t' i tt' rxrt' i ol i gol i rrrri o) (l l ronkol , 19?i l , ci t&t do l i a,al u, 10?t/.
l t) l l ' i pu,l .
,,l tl tti y' nf
i rrcl rrrl rr cl rrn o l ;nri rno
(l i n oi l ,zuri qi so rri l ra,l l ,ori zoi r,zi l ,
l tl i rr
(l i rr,rl rr, 1.1)7t11
(i arrrstxrl p,
Il i 07) : -- I
)rodorn
i n&rrl i tr l rr, trrol nl )l ' ol o
! 0t
r r r I l r r oI r | ' r r ; I , ) r ' oI r r ( , i r r r r , l : r l i l r r r l r , i l r r r r r i l , r nl r i l r r r r gi ( ; r l r r , f i , l i r l r r l ol r sl r , r r t r l ) ,
, l , r r r l i r ' r yi i r r l . s1, . l r , . . l l r f i
I
l ) r . l r r r l r l r r Di , r , i r , r r i , l r , t l . I l t r r ; Nl r r s. r r l r r l i r r r r ,
I r r . i r r l r i l r l c nl l , i
l ) l t ( i l t
l r f r r r , l i r l , i , .
l . . l t t t i ol r o. l i t , spi r r t I d. ynr yr ' sl Lt i
. j nwui I d l t xr r r l ot t t i , t l t t r l i cl l
( l xt r r l t l ui
l l ' , l t l l 11yl l ' , ' 11r t 7l b1' t 4- l l ' r l t ul r t ' / - ' - l ) ( . 1) l l l i l / . i r i r r l r r l r i l i r . i i . sl r r r i r r l r r l ol r , l
, , r r l r r ,
( i 0' ) {,
r l i r r ci r z, t r r i t r , r ' i r r r l ur t c1r ' 1, sl gr i l i r r r i l i t r l ( r ' r r 1r ' l r , r r sr r r i si r r r . r . r , r . r r i r i i
I r i I r r I I r ) | | | | r I i i , ) ,
I r r sl r r l I i i t ul s0r l oi
j l . 0
cl r zr t r . i sl l ot ' i l , r l i ( r r ( Nt ) l ) l t f i i
( , t ) l i l l ] . , l t ] i 0
i
l . r r l , r r , 11osl r i
; i
l ol t b. , l {) ?0 - , - r i l , l i i i i c I i l , dr r , l l }i l t )
I
l , ) r ' r r l r r ( i r r l r r l r r
l , r r l
l r l ' gr r r r i i r , l i ,
r r r r 0r ' i r r r 1r t r r gi
l r ol i ol l do
r l o i i l , l l l r i l i zi r , r . r r
I
r \ r r r i , l l , r r l ' i r r ,
'
l ,
. r ( ' l . l ) . r ' 0\ i r r r r r , l i i , , r l r r I
i r r i r or i r r r u, st r al , i i r t o t r r I i l t ozi l , l l i c
I
| ) ( . I r t I I | i r , . , i | ,
, l , ol r i r , r , i l t r l cr nl t l cl c
j l {( n. i oar o,
: l l t ur , i t r r l ol t . ost l , {, i r r r ul r ,
; r
r r r r , r . i , r ur ;
l i r l l r r r l c {) : \ l r ! ( , 1{r t ) ( l i r r r ) i t so
l i ndcosc}r i r ot ul i er xr l r : ) si l i i r , l l ol i l c
l }t . ( l l r ) ( , r ;
l r r , i r . r r l r r {i i l r r $i 1, i nc{}t r sl , a] l t e
i
- - l ) i a, gnosl , i cul r l i l cr r r r ( i | l I r r {r i , r l r r o I r . M.
I ' ur I i r r r r pc ba, zi l c- r t mer l r l ui I l l l G, car c i t t boal a, hr i Wol r l l l r , r ' l - l i r r gr , l l r l r ' 1. 1.
\\,,11q11111' 1' l rl i ,l i L srrri rrc tl o ti p rrcurogen pcl i c:l ri cl rLl ,l .
.' . tl l rol i rt rnusau.Lard, sl ti trul i i sau.pul o-petnni td (boul t l tri . I)t r' ,i tl r ttl ;ttr,
'
t t ) t i t ; t t t l t i t nui
, r ecent
sub r t u, t nel , i e br t e[ a l ui Nt ut l , , ht r xt r ) $o
] ) oi l l r
r , ( , 1
r or r l o
l r l i t r
t Opogr af i a ami ol r ul i i l ur , r ' ar . o si r 1, t , ur r 1, , l l r r r i r r r . r , l i t r i Lr
, r r l , r r l r r r r r ( r ' r spoct i v t aci o- sc: r , pul ar e) qi i r r musr ul l l l , r r t i t
I r r r I . or I i ol l i ,
Sr r pl r r r r
, r r oz.ol o.,.l i c i t,pr,r,r' | i nc bol i i l ui \\' ohl l arl -Kugcl bcl ,g-Wrl l ri rrl rrr., r.rr, o r.:rl i r' rrrl i l
. r r r r l r l r i u, ( 1l adu, 1978) . Si i , nu se conl undo i r r st l cu hl r r r l , scr pl l o
l r r , r , r r r r i
, t , r r r | ) . l \ 1. [ ) .
l l . l , ' ot ut cl e
, , usaci al , et l
de ami ot r oJi i m, i cl opel i c( r u er ol u! i t / r i r l
1( i r t r
l ' , r i , i ( l r r i l r r r r ' 1, r
19?4) cl pr i nr l o sel i e desi ndr ' ot , t r r ( l i r r r r i ol , l r l i cr r r r r i oI r l l r l i r , r r
. rrl i r l r r.rr i tl tc si rrel roame sau conste)a,!,i i si nrl l o rrl r,l ,i r,tr :
l . , \ i ndxt r t mel , e d, a B. L. A. I i adu ( 19?8, l {) ?l ) ) ,
i i
pr l l r z: r sr r gor l i i hr r .
r l l ol r r ui ol i , t ' t , comant l i l ut i l i zar ea t er r ncm ui r l t r
, , si r r r l r , or r r
r l o H, 1, . , \ . , , '
l , r n
ci r r o i ( l dcf i nef t c
, , cor npl exql si mpt omat i o cor r sl , i l , r r i l ,
( l i l
l t , l t i ol t . l r l i l
r l r , i : r l r ' , I i r , sci cr Ll a! , i i
$i
semne pi r ami dal c,
t l i n cauzi r , vi l r i t r l t L( i i ci l r . r r r r r r l r r r r
1, 1, , r ' i n ( ' r r r {)
ace: r st i i si r t pt omat ol ogi e se i nt i l no; t o, i r r I r o ] i r | r t r i i r r l l r j r r r r r l l
, , r r t r r r r i pr r ( , i n t i pi c[ ; aceast S, vi ] det at o t l e ci r ct r r r r sl r r r r {o l i t , r r r r r , l t l i zl l t , u t r
l l . r ol i Pr r l f i l , A r n r ecl ur oa, r ; t e i n ni ci un
( : i t z
un r nr r r r i l or '
( , ol | | | l | l ( l i l t
l r l l ! , 1,
r l I r r , r l ( | r ' o r di ( ) i ogi c) ' .
I r r r r r l our t t r ddt i l c noai st r c da pl act i ci t , I r ct r t r r kr gi ci , I or r r r t l i l i zr r , r ' I r , l i
l r , r r l r , r r r l r t r r i ol ogi ci l a r . ar i ant cl or pr t zor r 1, al , o r l c l l l r . l r r ( l l ) ?H, l l ) ?| ) , r , l l
r r r , r , l i l i r , i i l i kr
5i
compl ct [ r i l e ] r oast r o :
. : r , )
[ , ' or nu,
Jl
en cr aLi zr . t l d, , al asi di , a S. - i I , . , 4. I ) i 19r r osl i cr r l r r r r r l r , Li l , , r l o
l , ,
l i r l i r l l r ' r r i i ( o1r , r ' r l or . cl r act r l t t sut r i ol ogi Li ( ) : - l l r i i r l t i , l i t l i j , r , r nt r l l t , r , r , r , r , r l r r
l , r r r r l i r r l ( r l oci f l ' i , r 5 uu dct cl r ni r r i sr r r gt ^1c1, i c)
;
.
- . Al i t r gr r l oi r , l r r r r r r r , h. i l i
r t r r l r r ' k' ; 1' 11, , r l ar ct r pr ct l ot ni r r an{i i
l l r r r i t nr
scxr r l t r r i l scul i r r . l r ) ! r l r l r l \ r ' r \ l l
l r "t r r , l i r i r l l i r r l . t r l c 20 t l c i l l i , I n, r . i 1, i r i a, i l l c t l c l ! 0 ( l o
t r , l j
f i
r l r r l l ' i , ?{) r l r , r r r i i "
I r r . r r l r | o: i r r r i r ( i v 30) {, r l i n t . i r , zr r r i sul vi nr r i r ( r c 4( }; i {i 0
( l o
l l , i ' | i ( , t
. ' l . \ ( l i '
r ( , r r r ' 0 r r r ol , 0l t , on( I r r , l si . r r 1, r l 0 obi r . r , i
l t r r
pr i l r r
l r l i r r r I
,
l l t , r r l i , , , r , r r zi i
, r r r r r r r I r , ol i i ( l {l
1, i l ) , \ r , i l t r - l ) l l ( , l l i r r t r cr r , r r ( f r l ( ! l t $i o
I ) r ogt r t i i vt i , l i r l r i r r r nl t l ,
t , r r , t . r r
r , 1r or I r r I r ' i r r r l
; i
l }r ( l r r r l l r cl o
j t r l i ' r i 0i r l o,
Mi l i r i l t ' r l ol l t t l , r r r i ar i , Ll t r l r t r y, l r r r
l r r r l , r r r l r i r r i r l or ' , l r i r , c! s, l x, l l r i r r l l r r r I , ol i ol r
l t ot ' i scr r , pr t l i l r i
, l i I \ ) i |
. (
I | | r r | | | ' i l r i
r . r r I r
.
I r r ' ; r , ( r r I L r i ( l x, ) ( , i r r ' o
i r r sl i i
l i l i r r r l r r
i r r r r r l sr r l cvol r r {i ci )
I
Al i xl , r l r r r l r l r r
l ' , / r r r r l r r l , i r l i sl l cl i i , ; i r r r l r i l r r l r l i l i i ,
1i
r r r r r r t l r l r i ! r l cr r l l i r r ul i ,
l ) ( r cl , ( , f nl i ,
t l l t l
r l r r l ur , l i , r ' or r r l r r ) i zi
I
l l oi r r , r r r r r , i l i t zi u t i l \ l t l l l r , l , ( \ i t , zi l
{i
| | I | | i t
( ,
I | | i | 1 , r I |
,
I I l r t r l l r r t t , r l , l
l i r r r l ( i l r , r , r l r r l r ' l r r 1, I ' r , r r r l r i r r r r i , r . i r , I i r l pr . . g| r , ni vi i , , i r r r , r i . r t ul r i l r r r ol i l r l l t r
20ll
! l i l ul i j - I , ' r wr ; i ot r l a, ( , i i kr si r r 1, . pr r r zr r l i r . 1r r l , dql u1l I - .
, l . r r l br Lr i i , L, i l o
sf i nc-
f r . l ' i r r t r l l i t r l l i t u. , i i r . l ' ( l i \ ' ( 1
; i
r l i sr . r ' , : i , '
t
.u,,r)
It'orn.ut, Duilorri, rnalignill,
Ii
.a.pig evolntiyii, &fcctcazil inil,iaI
$i
rrl rsi v rrrrrscul a,l ,uri l i rrorvati 5, cl e nucl ei i motori bul boponti ni . Ti ebui ' o
rni {i :rl ..rl i l i .r' t' l !i :r1,1 de
?
pol i oencefal i ti i i nfcri oar:i
$i ,
di nei rl rel cs, cl e o
| | l t r ) r ' i i
( t o
1r . l t r l el t l c( j l cDl ut , l .
. .t.;)
I,' orntu
Ttst
udul tol I n curi ,tri ,ci i tl e SLA (form6 l ui
patri hi os
)
pr(,do_
r | | I i r t r r , t ' ' x t l ' ct nt ni n.
I '
sn car act or j zer zS, pr i u al - i nger ea de obi cei a gr . r r pc-
i , r l r r r r I i r
.
[ | | I r , I
( . j ur . r vr
l c dc sci at i cu] p- opl i t eu nyLor n,
cl e sci l I i cr r l po. - pt i i cu
rrl rtr' tr, si r,u :I amhel or,
,i nsoti ndu-se.
de crampe
_muscul are
i n repa-uJ qi h
rrr),' s
fr
{l e al l ' )l i rea refl exul ui achi l i an, eventual si a cel ui rotul l an.
.lt)
ll'ipul j
uaenil de BLA
.ear
semlalat) apaie snb 30 de ani
fi
reali-
r,,orrzii,. cu
1trcc,;rde,re
amiotro{ii proxirnale pseuclomiopaticc
scapulo'_hume-
r.r1' l r.;i /,sau pcl vi -l ombarq
sau-formc scapul o-peroni ei e
i Ncl soni 5i
prensky,
l l | 7: . ( . i l ( i t l e. Rut l u, 1978; Ci or an. I CZ9) . r . ar c por
", : ca
di t i cul t i Di di ai :
r ' | : i r , r , r ' , 1l &nsf l r t e t nsa pr i n pr ezen{a [ asi . i cul at i i l ot , ) a l r l se, at ol E- \ I G, ;
r r o( l t
( , l l t t ol
Dl opst c^ sr a ovol uI l ot .
Q.
llormu
Jarnil,iald,
d,e BLA lpare inlr-o proportie tle 1?o/o din totalul
,r' i r,zuri kn
dc SLA (Haberl anal t, 1964), atecti ncl de fapt, tn pai i ,Iel , cel ul el e
t'r'r.rrr Irri, antcrior, tracturile posterioare,
spino-ccrebeloasi
,si
piiamidale,
{tr''.r
-rrrptrcin(.1
li
unelc semne ce;rebeloase, de corclon posterior qipiramidald
( l i l ,rl u, 19?8
;
Kurl ancl
;i
Mul der, 195b; i Taberl andt; 1964
;
Ci br' an, 19ri i j .
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 sin-
r l ' r . r : r r r r r r r l r . - Sl , A. r nt i l ni [ e
5i
. l a noi i n
l ar i i
i u i al r l oul senr i ol ogi c i ] LI cf r r or . a
J)ot
si r :rpi l ri t
fr
al tc si mptorne oarecum asemxnd,toare cu cel e di n
,,compl e-
r.rl,
(
lrrir,rn') (fenomene ext_rapiramidnle) tulburd,r.i psihice qi altel6') qi 6aro
, i . r r I
l l r . l i n' . xdr r bi l c nozol ogi c. dar car e, pr obabi l - r cpr ozi nt i
f or me . , si m_
,
'
|
(
'
r r r r I i i , : r
. '
' (yi l ot,i r,c Nnu_degenerati t.e) (popovi ci u ,Xi l ?ascn, 19?9i . S_a
{ r' r|$Ii 11i r,1; crr, pl cvrr,l on{:r,
SLA este de 100 de ori mai marc i n i nsul el e Guam
rri l rl u,, rl rl ci [ i n ori cc al ti r, regi une a l umi i (Ii eed qi col ab.,1966), o frecvenl ,i ,
rrrr.l ri 5rrrri t rl c t' arc i nti l ni ndu-se si i n F,i ti pi ne si i n Nour, Gri i nee. Il i rari o
: r i . r ' Lr l r . ( l l , t j 7) al r r r j Lt l ci , r l e f r l ' 1, . . , "or npl i , xul Cr m, r n' . t l cbr r l oazi l l
\ rIi r|r..||ri rI l l l (.r' u Fr l t,l c o cyol ufi e mai l eri ti , semnel e pi rami i l al e precedi ntl
l r r r
cr ' l o l r r r l l l i l r r .
, ,..\\..l Il t\l i & ]nuscul ard,
progresi td, Aran-.Duchenne, prccum
fi Tsoral i zi n
4trl l urrl .Ttrytqresi M, Ducl tctLne se p_are cd, nu reprezi nti i 6nti t;!i ai i si i ncte, ci
r,ii,, rrrrr,,jolil,a-tctr, acestora, in realitate roprezintd, forme al,ipice dc S.L.A.
( l l ur l r r , 1971J) .
' t
t , ut r , uLa ul t . pl ue u, e Dr_1t (_(I ri nuu,
-ryi 6; Ut of an,
19/ U) OSt e t mpor. t ani
Hl l ,,l i o l ocrrrLoscutc i n pl acti ca rreurbl ogi ci :
- foi ma mo:ropareti ci , (cu
rl rrl rrrl ,. l r rurtrl .di n membre, de obi cei dl stat;
;
- forma pari pl egi ci , (i ot
l) hbrm.aLa atipice d,e B-t-4 (Raclu, 1978
;
Cioran, 19?9) este important
r l r r l r r r l , l r r unr l di n membr e, cl e obi cei forma ptraplegice (tot
( ' l
|
( l 0l r
{,
( cu rlolrrr{, rlisl;nl, cvcntual intii la un singur
' membru
infirior);
a
foima
;
rlc rr l rrr r iopa,l,ioil (rolatati,
$i
a,nterior)
I
- forma cu debut brusc;
_
forma
|I| l Nrl t(.Il :r1,i i mu$cul are l a rl ebut; - forma mi aSteni formi , dC debUt,
( i t l
ctr rr,l l i rri (,i i u ul l ;ori oari de fasci cul ati i
Ei
dc ami otrofi i ; - founa cu tul burti ri
pti l ri r,o l {, dobut (confuzi onal c, dr:mel r!,i i nci pi el ti )
;
- forrna cu somno
ux l ,rl l l i l i uui t.l ul o.
i nci pi cl t i i ) 1 - f or ma cu sonl no
2.. It'tn.oortyti,i da amiol,ro.fii, neuro{lcn.a (<n i,ablout'i t r S.T:.A.) pot sir,
Jr
l )i l ,r' i r,
l n soni l i l ,:r,l ,o, i rr ncopl i r,zi i rnrl i grru
ryi
i rr rni ckrp:r,ti i l o i srdrcrrri go
i l i l ,tl rr,
l Tr J) .
l (i ' l
: 1. Ni t l t e( nt
, r Ni t nl l t )
t l l i ( r ' r l r t \ . 1, . . 4. i . r r r
r yl i o
r r i i , r r l r r r r l t l ul r r r r l l r r
r l r ' , ( r r r r r i r r r l t r l ol ogi | 0
; r 01,
t oi l l i zt , l r , s| r r r r l , r r si r r t l l ot r t l t 1, i r r 0 r l o i . {l r A, l l t , r I r . or .
r , , r r r r r l r r l , cr r r r , l i l i l r j , c$l , r r r kr osr r j l , r l r r i r t r 1xl r , 1 l t , r r l , i ,
l l ot r i , r r t r l i n, gr r ot l , i c 11i
t I i , I r r | | | r . r r L ; l r ) Nr r vr l , r i l , i r , ol l i r l or r r i cr Ll b) Si ndr oi l r r r cl o r l o l {l , A r l i r r
; r l r r r r r r r
, , Lr I r r r i I I i I r r I r r
; r r , i r r
r r l l xr vi t r r sr r l i ( l h. i i gi l l t csou
[ i
( ) l l , ( ] [ l I r ,
I t l l - , ; i ) 11l gl l
, r ' , r ' r r . Li ( , ( ) l , r l ' . ,
l l ) ( i 9r l l ) {; : }1. 1) r ur r t ; i col ab. , . l 9( i 0, l 9( ; ; t , l {t ( i r ' ' ) ; r ) l l t r r . r r
| , r | , , r r r r l I i I r ' I r r r l i r r r r r r cl c I i , l r r e t r l r r l i l , i ve
I
d) L' o) i or ni cl i [ a l r r t r r r i oi r l i i , xr r l r r r r . r r l i r
' r r
r , r ' or r i r . i i
I
c) , 4nor r r i r Ji i kr j ot r cf i r r ni i
occi l i t o- c( x' vi oi i l o
6i l r l o I r r l r i r r r l r r r
, r | \ r {; r l
( l , ( 1, ,
I
l ) {l ' r r r l or i l o col ' ! ' i ci l l t i r r a, l t c; g) ) ) i l chi r nor r i t r gi l , r r , r . r , r ' r i l l l r l
l r r p, r l l r r l i r . i i ( l r r r l i l i r , ; r i r l o aJl o ct i ol ogi i )
;
h) Al ahnoi di t cl o <ur r . r ' i r . I r I r r r 1i r l r r
l , ' |
| | osi cl ' i oi t ] i , 1i )
, \ mi ol l o: l ' i l r ] i n scl or oz- a i n pLi ci ( l i nr r r i r , i r , r r r i oI r . oI i I I r ,
r l , i l \ 1. : r , l r r i l , r , . i . r r r r r , ( i i t , al ,
do
( i u
i ber ' 1,
$i
Gui bcr t , l 9?4) . Ol r r r r r i i r r r r r r l r r r r r , zr i ,
l r r , r r r r r r ; i
t nr c- \ N, l n( i n t r cul , ol of l i o at cnt st t r pr . i l i l cy{l l l 1, i 1r , i r r pr r r r ' r r l r ,
l , r , , r r r r r
11i
l r l r : zcn( l r ,
u, l 1. ol set nr t i l ( cer cbel oase, t , est j bul i t o, r l r vl i l i i opl i l l r ,
r , l l . l r r r l l l r , r ' i , r r vr r nt ul l r l oar cu pal oal e papi l al i i , t t , r nl xni l l i t ; r l i r or , i r r , {r r r
, . r r r r r l l l i sl i l r ' i , I i l l oa, c! i r cu bonzol col oi dal ct c. ) 1 i ) Si r . i t r uor r r i r r l i r r , 11i l i r r
r l t or r r r r cl r r
si l i r r gor l i cl i cc pot r cal i za t abl our . i dc S. l r , "A, , r l l r , t ' r nr : r l r , l r l r r r t
,,r, rr rrr:ul rrl ogi c
l toatc
stupri nde cycl tual cl o scrnne :l sooi i l l ,rr rrrvrrl l l l otrrrr
1, I r r r r r l i r r ( i I r , . scnzi l i r i i si r i ngomi cl i ci
I
t ul bul i r , r ' i l asonr ol , ol . i i
; i
t r r r l i cr r
\ . . ' r l t l l l 1' l | l l ' ) .
,\., 1. :!..1. i l .' Lm i otr of i tl a r ad,i c ul on err i ti ce
. 1 .
( l qvn11[ py4
semi ol ogi ce genet al e: 1) Sur vi n l n or . i cr r l i l ' s1, i 1, . ! ) A r r , r r r
r ' , , r r , , r ' : r l , ur r r l cbut t l i st al , mai al es l a sxt l cmi l i l 1, r l t , r r l , l r r l r r r r l or i l l i ' r ' i r r i r r . r ,
i t l ' , r l , l i l r i l a, t t *: r , l c si si met r i ce ( i n pol i r adi cul onol l i l , u; i
; r oI i l I r r I i r r t r | r r r r r r r I r r r
t , . r l r )
r ; Lr r r t , si r r r el , t ' i ce, t l ar qi uni l a, t er al c, chi a, t ' l r ci r l i zl r l c. , l ) l , r . r ' zi r r l i t o
, l r r r r l opogl l r , f i c l i t di cul ar ' 5, sau t r oncnl &t , i , , ct t t xccp( i l r , pol i r r i r r r r r r pl r l i r Lr r
, ) l i ( l i r No( csc r kl t ul bur l r i senz, i t i vc subi ect i ve
$i /
sl r , r r ol r i r , cl i l r r
( , l t
l l i . r ' r r ] l
|,' Irrri 1r' ||i rr radi cul ari i , troncul arX, l ]rul ti novri ti ci r, $i ]u
l )0l i l tovri l i (,i i . )
i t,I
r r r , r 1i ' l i r r l c
( Li l ni nual ea
sau ab0l i r oa r ef l exr : l or osl t r r - t , cr r r l i r r ot ul r r . i ) Nl r r r
, l r r , r r , , i i , o cr ol ui i o f avor r r , bi l i , , r egr esi vS, cu cxccpl j r
] x) l j l {r vt . i l r ' l ur '
( [ ' r l r
r r , r r t oI r i r Li i I or ' ) gel et i cc t ami l i al c cr oni co. . 9) So a, soci l , zf l o l i , l ) , r l r r l r , ; i r r l i r ,
, l . r r r r .
; i
l i pi r . i r . ! . | ) I l ar eor i s0 i nsol esc de f asci cuLt ( , i i . l 0) Apl or r , ; r r r I r r I , r I r r r r r r r r r r ,
, |
'
,
1
r r ; r I r' i r r r scrrsi bi l i t*tca l a, prcsi unoa rni l ,sol or' trnrscrrl arrr
;i
l r, Ir.rl rrrIri rtl rIuI,
r L, r ' r or , s( , , 11) i l l ul bur : i r i l c sf i nct cl i cnc r l c ol . l i cei l i psosc ( cr r ( ! ) i r x! pt i i [
] 1i r l
r I l , r r r r r r r r Lr l r adi cnl ar e l ombo- sact , a1n, i ncl usi v i r , l c oozi i
( l o t f l l l ) . l : J)
, l , r r l l r r r
r , r r r l r , vl r sor r r ol , r l r i i , $ocr ot r l I . i i qi t l of i cc si nl ; f t ( ! ( r vcni , r ) i i i i l t l x) t . l , t ut l ( f .
l i . .l t' i oNfoJ i i .l c ru,tl ,i cttl a,rc so pot rcounon$to pri rr rrrrrri l ,l o:r,r.rrLr r11s1q,'
l , r ' , , sct r i ol ogi co: J. ) : \ r ni ot r of : i l , csl , o
1l r c( l oco
qi r r kr c1, i vi i , , l l , i ngi r ) ( l r l r , . l r . l r i l
I ' r r t i r l r zi r , {i . ! ) I r i psos( j c{) [ t ] : aol i i l ( ] l a, sci cul l r r c q, i l i br i l r r , r r r . l t ) Ai r i Hl i r r r l r r ,
l nr ' r l , / r
r i l r
l l l , t i r l i zi i
f l : t scc l l l t r gnt pol or . l l usa l al ( ) ( i ncl r , : l l r r r l i r t r r xl xr cl i r r r l l
r' ,rrIrrci rri ), cl l ro i rnl l rnri l , o l oDoJ{r' l l i () spoci u,l i i
,,r,rl di cLrLl l ri ,",
rIrr,I,or.i Ii i , l i rl r-
l r r l r r i l i i , l i r l r r r r r l f t l i i . oi t r i r , ( l i t ,
r ' i l nnl l i l i r r ni l i r r r ul {, i r r r t r qr r l r i
; , i
cr l , I i r r ' r r , r , r r
r r r r t r l l r i csl , r r i nr r r t ' a, l ; r l o r nl , i l nl r l t {r r r j r l i i , oi t r j . 4) I r l kr xol r r ( , $l nl o. i n}I t l i l t t l t Hr l
, r r , r r l ; r r l t i r (
| i l r r i t I r r i l 1 , ( ) sl l u i ) ol i t o pcr r r r i i ; t l i agr r osl , i t , r r l t l o Lr cr r l i zr r , r . l r r ,
i r l r r r l i l l i i nr r l i r r t l i r r r r , f r ) f i r r sr r r ' I r ' i r r r l r r o l t i l r ocxr , i l l r bi l i l i l l o gi l l vr r r r i l i l r 1r
I r r , t r r r I i cr ' l , . l i ) I l l r r , zr r l r r , l r cl , r ' i r i i
, , r
i r [ r ' i l r ] i i r , i r r i | o| ' posl r r l i oi r r r r , l , ul l r r r r j l , r i l r r r l r
r t r
,
t r t t i I r i I i 1 r r , I r r t ' i Nl i t r t r l r , t i i , ol i r l l ,
Jr osi l r i l i l i {i
i r r pl t u r l r l or . t r , l i zt r r o: l t ) ' l ' l t l l nt .
t ' r t t i l r r sr t r zi l , i vo sl l l ) i {r r l i \ {r r ' ( ' l , l i zcl l zi i {, t i zcl ( ! r l ( ! r i t r l i r t r l i gi i , r , r r , r ' r t , ol r , r ' l l r r r , l o
I l
i t t t , i r t l r r t r ( r t , i t | r ' hl ot ' i t , r
I r t ' j r t
i . r i r ( ' r , l l I r t ' r ' r r I ot ' t l t r o, i l l r \ I ot {r r r , r , l r , l $ r ' t r , t t r
r r t r l f r , t r l l l zf i o l t l r l t r t ' r ,
l l r r l t pr , t i i
i t , l t t r t t i t t t r i i l , {' l t r l i l l t t r , , t r , | r l t . t t l l t t t l U l r r
a0$
, r i r r l , r ' i l , r ' i 1, ( l i i , i 1i I i l or l r zi r , l , ( 1, r l r r r l l r ; r r , l r , zi i , r l r r r r r r i l t r f r r pt oi or ' {i r r i r r l oI i l , 0r ' i ul
l r r l r r t r r l l r l r r r t ' sl , ot r i i r l i ci r r i . l , l sl , t r I r r cvor r i . i l , l r i l i l l ol a, l i l , r t l ca, r l c
l nt r i r xr t l r r \ r
rr rIrrl l l i krr' , I\' l i rncvttl rr rl o okl rrga,{,i t: l l c l l i ,rLi ci rri krr rkrcl i l tr;ca,zi i Ji tru
(fxi t-
crtl rrrrzr' i rr,l gi i l o
;
b)
' Urtl bttti r,t' i l o do scnsi bi l i l *tc obi ccti vi r, s(, 0&l ' aotol i zoi l zr"t,
pl i rr l ri l rrxrsl ,ozi i , l ,l Lcsl czi i , unoori
1)ri n
hi percstczi i , cu i l spect gl obal
fi
prrrl rotfi otri l l , (l o
i l sorncnca ou topografi e speci al i i n bcnzi ra,di cul i l r' c.
'i
)
,\ pr'orr,lxr t{)tdoaunr, gi.sim trtoclificilri ale ICIi : fic de tip in{eclios lu me
rri rrgo-r' u,rl i orrl i l ,ol c vi ral e, l ueti ce sau pri n al te i nfecl i i , fi c tl e ti pul di soci a-
( iihrl lllrtuniuo-r,itologico in compresiunlle radicularc.
(1.
AtniotroJiila d,in ntonon,eurite (9i mononeuropatii de ilba'se c.,rigini
)
(rl trpi l
(.1u,i bert
Si ,
Qui but, 1974):
l, |u,racl,(/rc generale :
r,) A riotrotia reprezintai un semn constant, alar precocitatefl,
$i
i rrrl xrr' l a,ntra acesti a vari az5, tn func,ti e dr natura l ezi uni i
I
este precoco
r;i inrportuntii in sindroamele tle secliune
$i
de fuitalie; tardivii
$i
discretl
rrr si rrrl l otrrul de compresi une.
l r) Arrti otroti a se i nsol e$te de: parez6, sau paral i zi e fl ascS, cu topo.
Il rrIi ,r Il oncul ari l ncti ; di mi nuarea $au abol i rea refl exel or osteo-tendi .
rrorrsc i ri toi l ,ori ul
j neryat
de nervul respecti -r; tul bur5ri de sensi bi l i tato
iiulrirri,ivo
5i
obicctivc cu topografie periferici,, do asemenea de intensitato
vrrl i rr,l ri l i i , i rr l uncfi e de natura l ezi uni i
I
tul buri ,ri trofi ce cutanate qi vaso-
rrroi ol i i i rnportante i n si ndromul de i ri tal i e; L,CII, este normal .
r) I)rucri l c pot fi foarte vi i , spontane i ra,u proyocate d.e ci tl o
rrri rl r.i rl i , rrrrrol i ou hi perestezi e cutanati ,
$i
durere l a presi unea masel ol
r r r r I sr,r l Ii rrrr 11i l , trunchi uri l or nenroase.
rl ) l tol l cxol c l ocal e si nt abol i te.
o) ll,ogr'oiiiunea, qi vindecarea sint posibile, cu restaurare muscularii.
l. lllor)tL(l,a scntiol.oclice di.feren!'iate tn
J
unclie d,e natllro leziunii:
it,) lli.tulnn,t.r,l. tfu secliune aompletd: - Amiotrofia este precoce, pro-
glr.sivii, i1i lirir,t'h: cxplimati, pe tnuqchii paraliz^\i
)
- Asist[m la o paralizio
rurrrr;r|rrLr' i , crr hi po- si r,tr atoni o; -l i efl exel e osteo-tendi noase si nt abol i te;
l i ,rrl ' l rrrrrl i rl i o-rnuscul ar este. de asemenea, abol i t I - Nu si nt tul bur5,ri
ri r,rrz i l i r l l l rrrl ri octi vo, ni ci al ureri Ia presi unea masel or muscul are , i a trun-
r' l ri rrl i |rl rroLv()rs{i sl rb ni yel ul secl i dni i ; - Se constati , a,nesi i ezi e superf!
r,irr lir gbbr li,
I
- 'I'ulbur'5,ri1e vasomotorii sint putin exprimate
;
- So
l rr rul ,rr,l ,i , I ). Ii . l )i asi vl .
It) Sinrlrom,ul, tle iritalia: - Amiotrofia este de asemenea precoce,
.r' rrpri rl ri
I
Asi sti m do:l r l a o parezi ,, cu conservarea tonusul ui muscul ar;
l i rrl l rrxrrl o ostco-tendi noase
$i
cutanate si nt di mi nuate, rareori abol i to;
l l r,l [rr rrl i rl i o-mnscul ar poate fi exagerat
I
- Se constati i i mpon;ante
l r r l l r r r l l i l i r r r r zi l , i vc subi cct i ve: dur er i vi i , Bpont ane, exacer bat e de f r i g,
rl rr pl l ri rl rrl r rrLascl or muscul aro
;i
cl e mi gchri l e de el ongal i e; - Adesea
rrrtl rl i rrrl rrrr l ri porcstozi e cutanat' ),
I
*
Se remarci , tul buri ri trofi ce i mpor-
l r ur l r : t kr pi r r l i i , ost coar t i cl l ar e qi al e Janer el or .
11 r\i nl xntuL da compresi ttne:
*
Ami otrofi tu estc tardi vri
$i
mai
pr r {i r r i r r l r r r r si , ; - | ) r r , r ' i l l i zi l , poal , o i i c( , r l r pl ol , i l , t l *r t ol usul r nuscul ar ost o
tr,l i tl ,i v (' r)l l r.rol v|,t,
1
' -.l l ,ofkrxcl o ostft)-1,(i rxl i rIor,so qi cttl tt tLi l l .o si nt cl i rrLi -
r r r , l o r i r , u l , l xr l i t o
I
- Li ol ' l c. r - r r I i r l i o- t t t t t sct t l ar c$l i ( J
( 1t ) t I s( t t
vi r L; -
' l ] r t l l r r r -
t i i l i l o sol r zi l , i vo st r l r i ccl , i vo si l r l , r ' r t , t ' i t r , bi kr
I
Asi sl i r , t t r l r t t t l t i pt t t t r sl ' ozi t r
yr r , r ' i t bi Li ,
( r r i l i r r r l r r , l r i r r r r r r sl , r r zi r r )
l i l ) r t i r
i r l i l r f , , i r , , I i l r i i , i ' r r l Jr r r l i i l j t l o sot t si l r i l i l , l r , l . l
l r l r r -
l 0$
l r t t r l i i
; - - I \ l t t 6r ' l r i i
r yi
n. r \ i i t , i j nr r r r r r xi l r i l i l l l pr t Hi r r r ur I Nt t so r . r r r r xl r r l r l ,
l r r l l r r r l i r l i l r ol i t , o t r vi r l t r r r l , r , -
r l l N. l ndt t nt , uL t l t !
, , t . t , l t l t r ut . ( . r t , 1t Hul vi l o I i o $l ) ol t l , i l , n, l . i o r l r r ; r i 1, i r r l r r r vr . r r ( i o
t r r i r
1
r r r 1 r | , i r
,
1l ,
,
r . l r l l r r . l t l i zi r r r l r r . sr r
I r , i r r
: Al l r l i l , i l t r l o r l i r r ot , i Hj r or r l , l r r r r r i r . r r , i l i
: , , l l , f ; 1, . : l ] l l . l , l l
t r l r t t r l r r i , . i
t k. r i r r l r . r ' i
l l . r r vi r r . r t l i . l r l i r r 1
r r r
,
r i i r r r r t
.
r r . Hi r r t
l , r . r . {. r t l r l
| | | | | | ( r I | I r r ' | | ( , I ] | r r t \ r , : r sr I r l r . i t sul r l , i ( l t . zi r t t r i i , i f t r r l i i r r r l t pf l .
l xr l i l i . r i r r 1r _r , r r r t i r r l
| | r | | , | | . | | | r | | | i r l l Ul
' l
l cl l ; - 7, r t i r , t l {' l l r r r . l Lczi r , l i , . r . t . U. i r j - l {r , l r pr r i r l r . , [ : t , r . r . ,
r , r
' r ' r ' r i n' r ' i r r ' ( i r
s. r r si l r i l i l , i i l i i
sa 1, , r : r i r t u' r ni i t oa, r ' ul r , or r i i r r . , i . , , r r , , 1, , ; 1i , . i t i
'
| | r | | r | | | r r r r |
.
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r i ( j ( , i [
I , r r , 0t i l i i
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r yi ,
i r r I i r r r r l , r , r , l l r , r
r ' r r , : r
;
| ( | l t l l Sl t l l t l t r h( . I t u. r . ( t i l l ) i n. ( i
i
_
Rt l i of Ur i l 0 t t ut sct t l i t r l r r r t r r l r l r
r r r r "
1r I i r r
( ' r ' ( ' sr r l f ( 1
, i r r 1, "( ) l ur r r af r nasi r i r nuscur r t r : 1 - - . l t i , 1ci l r . i l r vor r r r r r r r r l ,
, l , \ | t r , i l r r nor l
1) t . ( ) gr r r xi v, r l i l r coi nccma, i t unl l o; - - ' Snpt l i l r r , , , , ,
11l ( , l l l l r , r , j r f ( , i r ,
1r
r r r r r r r r , l I i kI t . t r k: r l t i t , i .
l ) . . l ut . i ul r , ' J. i i l , , l i t
pr , l I r t t
Dt . ; l t ( f t *pel i D
l t t ) l i nt t r , ) Ut t i i ) :
: u . \ r r r i r ' ( r ' ' ' l i i k snr t t r i l i r l l l l t
. i t r , r r
i , r ai
1, i 1i l
: r r
.
r
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r r I r r : r I r
,
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l r r t r r , ( r .
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bt \ r r r i ut r , , f i i l r i "j l 1l , I r i | 1 1 | r
.
r : r I r
.
,
si r r r r . r l i l r .
1i l r .
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r J. , {' u- ( l r Fl i
l l ' l r t r e r l i st l l i ,
f i i l l
_t opogr , a, f i o
r i xl i cul t Ll , i i , si r , r r | . r . ( | | r r I I I i I r . i |
;
t I l i r l l L' xol . r i sl t ur - t . r i l i r oa, s.
. si n1; .
aboi i t i i
;
d) N. s. . r ' st i r t i i l r r r . i i , r r r l i i j
, t i i . r r , ; oci i l zi i t : u t ul bul i i l i
senzi t i vo r l uf i cot i yo
f i
ol ) i {yr 1, i \ , o t l i r l : r hr , ' r , r i
l r r l l r I f r i t i
vr l ; or r r ot ol i i ,
scc] . ct o] . i i si t r uf i ct ; I ) . l t . I ) .
( sl o
l r t ' r r zr r r r i , i l ol r l r , l r
r r r , . , . I U l , r | osl i r I i , . di sr r l i ; g)
S, . i t sot ' i i r r I
; i
r l Lo b, r l r r , .
1| ' r r | | r r r | I i I i
l | r , t r , , , , ,
|
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r i r r {' . . l r l l l l l l r , l ogl co
e1' 1. ) , i n f uncl i c de nat r t r a, pol i r r t r r r | o; I r I i r r i ( l ( ' r r . r r ,
I t r l . r ' {i oi t ; r 1,
pr r r l osi onal [ ,
car el Lt i al i , , t l i sr net abol i ci , i r , r r i oi r r r r I r r i i , r , r l l r r ; 1, _
Il . .l tr.i ol .roJ i i .l e di ,n
Ttol i n
europati i l e uoni ct
.l i tnti l i tl r
1. . . l t t t . I dr o. f i a r ] i t t pol t neur i t u
( t cr nen. i . nr : ur t r : | .
I
pn, l r t r r l t i l :
l r r l i l yl
111, ,
l , ' t l t , t ) i I l t n\ l i ! t el i i h. [ per t r oJ. i cd,
al ui Di j i r i ne_got , Lt : t ut , zi r t , t i , l r r r r l or r r r , I r
, . r r i r ( l ( ' 11r sct ni ol ogi ce i a) I ) ebut e; I zi i i n copi l i r , t , i c Hi r , r r i r r l | , r l ol r r r , r , r r t i r I r
r , ' r , l ul t r r t r r l r l r ) l or i nf er i oa, r e
I
b)
pr ei l omi r i i r ,
l t t r i r , r r l r t l r r r l r i r r sol i I r r . , r r l
t "
t r r t r i . r ' i kl r ' 1i - : t l
r r r uqchi l o.
pl ant ar i ,
anl , r . t i i nt l l nor . $ Hl {i l ) i t , l
, Pr . i , l . r r r , . l r r l
, r , r , ' t r ' t c nI ( l ocan
f l
cu gr i f a
degot cl or
I
c) . l , ozon, zi i r r [ r i
l r r r ( i r r
r r r r r l r , l r r i
I , , , , I ,
I i | | r ' i r r , i gi l mbei ( i u f Lzcl e i ni l , i ak) )
l i : t , i
( 1) 1t l ) soi
I
r l )
( l r r pl i l r r l l
l r r r r l r r
r r r r r r r ' l r i j r r r 0r r r l r r : l l cl ot
supcr i o: l l : , t , oal i zi nd ( )
l ui r i r i l , r r r l i 0 r l o l i p , , \ r , r r r r
l r r , l r l nr {r
i
r ) I I xl xr pl ; i onal
so oxl , i l l dc
f i
l l t l l uf ( 1hi i l i , {r r i
;
l ) l i r . i r l r r , r , l r i
r r r r t , r ' ' l r i i t ' i ' i , r l : i r r i t r i l or r l cr r r l l t ' cl 0r
1i
l r , i t mnchi t t l ni
I
g) . l l . l kr x. r r r , r l r r ' l r , r r r l r
r ' r ' r . r r i r r l , ul r , l i 1, .
t h)
( l r r i t cxl r r l
s. r . i , r ugi . i r r pl i t . i r qi r r r l l r r r r , r r ' i ! r , r r r r r r Lr r :
' l r r r ,
r ' r ( : l r l csr , t r , i ' ul gul anl r ) ,
hi 1r 9- sl , r r r ur ci i t t i zi c t up( r r , l i ci i r l j l gl r l r r l i r , r r r 1r or . .
t , r r l , ,
l t r l l r r r t ' i t l i ( [ o
$( l l t si l ) i l i l l t t ( ,
l nol ) r i ( ] ccl ) l i \ , c, l l cl i r ) r i l l oi l r i !
r l r , r r 1; r r r r , ;
r l l i t r t . l . r ' i sl i ( xr si r r l , l i p. r l r ' , i i i l . r r . r , r , i l t i t , r . l l l r 1r , i , f i . x1r l . r l r ( i p. i r r
; , t r l l r r . r , , , ,
, , , , 1, , ' I r i I r oI i r oI i i
l l r r t i l r r l I i
l
)
( l t
.
( . ( ,
i
) t t l -
( ,
sr r l r l ur uut , l t nol , ( x) 1, ( l oi 1l ( ! i t r r l r r r i r l r , ,
t , ; r r l r r l r l
, j )
l t . l ) . r ' I r r t , I l i r , i ' i , r , sl o i r r r l t or i r r l l i i , , so\ . cl i i , ; l i ) I l vol r r ( i r r , r , r r l r r
l ' . r l i r ,
I
, ( | r ' I I I i
t ,
i I r
(
| o hnr gl i ,
i r r r l l l i l vi t r l , r r i l t r .
' . ' , . , l nt i t l t r l l i t . l i n l nt l q l ui
( t ht . x. ol
l , I ut i r
, l , ool h. .
i l ) l r i , l ) l l r , l zi , l l
r r r l r t I u' i c
f , i l | l i u i | { I I ) | r I i i
(
'
( | I | ( i i
,
r , r r l r r [ l i l r , r l r r s| l r , i r r l r r r l t ) - g0 i l r r i ( r | | r r , or , i
r , l r i I I
t r r i r r r l l vl r , t r r o, I l r
. l
I l l r r i ) , l r r i t , i l l n. l r l t r r l l l i i 0 r l r r l r t r i , l t l i t r pl i nr l r r r r r l l , | r
l , r , \ r , ( l l t l l i I t ot , t r , t r l , xcr r r l t r r I r t i l t r I i r r ) , t l r t l r i i o r t r r r r I I r I i 1 I r I r r r l r r 1 t I t . I t n I r r r r r i r r
l , r , r , ' l ! ' ar r L, l i l r r I or r r i r r I r , r r I .
l r j r i r r l i r t I | r i i r i l l , i t t r $t i Bi r r r r i h, i , l i r r r r ( l
ui r , , r i i l
:( t' /
( l ( \
I ' i l ) r r r ( r i l i i v, {l I l ) i i ( i ul I
r i o f i r l r r , ' r i l l ( l l r zi i
f i
i i r f l r {r sI r or l l i 0( ! ; l ) ) , , \ r r i {, l nr ) l i i !
I l r r r zi r r l i ' i ,
o r r l l i i 1, o1xr gr . l l i o r l i sl i r l i , i r r
i l cr r t r l i r l
si r r r ct l i ci i , ; r , ) I ) cbr L. [ or zi r , l a,
r r r r r r r r I r r r r l t r i r r l i r r i ol t r i l , l czi r r t l i r r i t l el r , ur r l r t l l r , t . i or . si t r r ct r r l r r el c sul cr . i oi l r . o;
rl ) l )rrl i l i l rrl rri ol ,ol uvol ucl r,zi t, i n
l tat' :r,l cl fi
propol ,l i orl al
cu ani ol ,rofi u;
.) l ,l r i sl ,i i , o sl rc.o$i ul l o oronol ogi ci i , de di spozi fi c topografi ci l a mri otrol i oi ,
rl rrl ri i r,' rrr u notzi i : l ,:l nrel nbrcl e i nferi oarc: pcroni eri i , cxtensori i degc-
l i rl or' , gl rr,rnbi urul a,ntcl i or, muqchi i mol etul ui , apoi , mai tl i scret qi tardi v,
cvrr,rl l i trpsul (mai al es vastul i n1,er.n), ceea cr: real i zeazi , ami otrofi a .,i rr
.i rrl i
i rrl i ,)' a l Lri Cl arcot, cu
,,pi ci or
de coco;' , sau i n
,,l abe
dc barzX". l .,a
rrrcrrrl rl cl o supcri oare (dupX apl oxi mati v 2-b ani rl e evol uti e) ami otrofi a
rr,1,i 1rs1) suri {l csi y: muqchi i mi ci ai mi i ni i (i ntcrosogi i , apoi muqchi i tenari eni
li
lrilx',1,orrl,rieni), rcaliziml amioirofia aie tip Aran,Duchcnne, iar m&i tir_
zi rr, rnrrschi i a,nl j cbtal r ui (extcnsori i , apoi fl exori i ).
pronatori i
si scurtul
rrr1ri rrl IoI' si nt pu1,i n afectal i (sau de]oc)
;
f) Ami otrofi a respccti , urmi tori i
rrrrrs< lri : atlrluctorii coapselot', mugchii centurii peiviene, lungul supina-
l or,.rrrrrschi i braful ui , muqchi i centur.i i scapul are, muqchi i trunchi ul ui ,
rri gi i rrl ui
qi ai fel ,ei ; g) Ami otl ofi a se i nsotefte cl e fasci cul a,ti i (l u totrl ea-
rrrrrr
)
si rkt crampe musculare in perioada c,le debut, tle tulbru.ilri senzitive,
rri,il srrbicct.ivc (parcstezii: uneori dureri), cit qi obiective (tulblrdri tle
sirrrsibjlilu,l,o tactilf
fi
proprioceptivX
cu localiza.re distali, ectromelicd)
I
lr) 1l'rrJburir;r'ile
yasomotorii
sint importante (eritrocitozi,,
rd.cirea extremi-
1,ri (i Lrl etc.)
;
i ) Refl exel e osteo tend.i noi tse, i ndcosebi cel achi l i an, si nt
(l i rr)i rl l i l l ,e
sau abol i te; i )
,Iotdeauna
se constatl Ii .D. de
j ntensi tato
r rrr,i rrl ri l i , ri l ar progresi vS, si trasee EMG i i e ti p neurogen troncul ar;
f
)
l ,l vol l rl
j a
cste l cnt: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
(l i l i l rtrr{,i Nzi i
nol , de pol i nevri te qi ri e pol i neuropati i .
2) l n general , esto
l,li'r:1rrl, irrl,ii ln nerv, apoi, la intervale de ziie -sd,ptimini sint cointeresali
||l (i r,rvi . i l ) Tul bud,ri l e de sensi bi l i tate subl ecti vr, apar mai i nti i , mani -
l r' rrl i rr(1. s. pri n al goparestezi i , i ar mai ti rzi u apar
$i
tul bu' d,ri obi ecti ve,
r u
lrr l)lsc
po tu'itoriile de ilervali6 multinewiticd afectate. 4) Amiotro-
Iiilr 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
oucl l i l t.o,t, sprc urmS,toal el e afecl i uni : a) Col agenozd,: peri atri ta nodoas[
(borrLr l rri t(i i ssmaul -Mei er), l upusul cri tematos di semi ni t q.a.)
;
b) Di abet
z,rrl r:rl l l
;. rr) frrkrxi cati i (cu sul fami de, barbi turi ce, oxi d de carbon)
;
r l
)
li r li r L r s isttrm (boala lui Rue,rger, boala lui Besnier-Boeck- Schaumann,
l r , r r l , r l r r i \ V; r l r k. r r sl l i j r n) ; r , ) Lcpr i .
,\. : J. :!. J. L. A ntialrof iile d.a origi,ne centrulri
|. Alroliilc la hemipleui.i mai l)ech,i au fost relatate incii, do Marinescu
( l l ' i l t,ri )
5i
rk: rl {i l r,rrkrr.i cl l Lsi ui (ci l ,a{i de Arscni qi Jl otez, l g7j ), So i ntol cgo
{ri i
l )t(,2{rl l l l
Irrrrni l ,1.gi oi , 0u
(xnl trtLcturi i ,
qi i l nobi l i zr' ,ro, trrt l ro
1I,.rnti l ,o
I t i i ,
i r , r ' r , r i i r r r
r l i r r gr r oxl i <r r r l . l i i r ni r r u r knr . si i - i pt oi zt i r n ul i ol ogi l r .
: l {i t t
' '
. l l r ot i i l r : r t t r t : t t : ul ut t r l i t t l t ' . , i t r ni l t I t t ' Nl t t t
t t l r ( l ( ' ( pl t t ' i t r l l r l r r ) i l l l Hl l Hl r i l r t l '
, , , , , r r , ' , i , , *' t i ( i i ,
' , r l r i
r r l r , l l r i r , l r r
l r ol '
I i t t t r r "' t i t t r r l ' r r t l : t t t 1. r r . 1i
pr r l ' si i ' l t t t l r t l t t r t t
, , , , , i , r , '
1
, r r ' ,
'
t i r | , , r ' I r I t i r , I r I I t t I r ( I \ ' i r I i l l I
i r i
l l {r h( l l Hol r ' l l l l i l
;
( l l i l ' cl r kr vr l 1) ] i l '
, r l , r l r r l i r Al l ct r i
6i
l i r l , r ' 2, l t l ?l )
1i
i r r . sr r i t r s' r l ' l r s' . ' i
( i t r r r r r l r l
l t l t t l t t l or : t ' l )
r l , r r | r r r r r r ' l , ) NI ( l
( [ | l ( kl | l {' r vi l , l {)
Ei
r t ' , I t t "r l i l i ( ' i t ' i r l t i l t | . l r ' l i r - r ' ( l i r l r r z t Ji
( ] r i l r r r r
t r r r r r , l 1l {i l l ci l , r r I i t l o Al s( ] l r i r i i l ] ol , r ' 2, l l l ?l ) Nl r r i t t t r t l l , Al i l ( r r r i
f i
l kt l n' z
i , , , , i t , , l t l r l i i ' l ' r r l , r i l i , l l l t ' ol l i i l o t r t r l l , t t t r r i l l t r cvcl r t t '
; i
t t t : r i r r t r r t i sr r t t l t r ; r ' t t i l l t t
i , l , ' , ' , ' r , '
r , , ' i i i , i t t l o
r t kr r r t t t i r l t t t t t l r t i t l t ' op1, ' Ar soLi ; i I ni t r r z ( l l l ?l ) : t ' t r r r ' t r r l r t ' l
, , | | , , , l t r ' , l i i l , ' t l t r t t r i gi t t r r t l t r r Ll t l t l l i
i r Ll r ' : L i r r r l i sr ' l l l ' i r ' . ( t r ) l l : i . l l t {r ( ] l l l l i i l t l l t t I t l l l ' ( l
1. ,
f r | r ,
l r r r l i l i r t
i oo t t t l i i i r r t l xr t ' l l t t r l , | : i r t l r l t . r r l i i l o
l l l i l l
l {r zi l l l r i l ' l l l r l or l r l r \ r i r t '
t r , , , , , . 1, r i r r r l r i l l ss
( [ o
] i 1) si l ,
( x) l r t l r l ul r t i l , t r r l i o t l o or i gi l r o t r t t t ( t ' l t l i
( l r ,
, , r r r r t r l r t t
l r r r I r ' r , I i r r
) )
r L i r r gi t ' t l suI post cor r t l l r I 1, i n l r cr nc ct r , i u <' r l z' t l l , r r r I t ' . i r I I i I I i 1i i r r l r r r
i , , r , "l , i i i ' t r t ' r r r i l i t t ' gi i t c i r nsr t t r hr . ' , i ' sl o
' ' r ' r l ' i i '
i t t t l c' s. l r i
r [ ( o l i l r Hi i ' r l ( \ r t l ' r
l , r r ' , , : r , r r r r ur l r t ' r r l t r i pual i l , i c
$i
at l of i i l t .
9. PROBLEME DE DIAGNOSTIC IN AGNoZII
0.1. AGNOZIILE TACTILE (astereognoziile)
Constau intr-un deficit de recunoaqtere a obiectelor cu
a,irr1,,r'rrl
.pipiii,ului de c.),tre un subiect (cu ochii lnchili) ate cd,rui sensi-
l)ilil,il,ti olducrtale sint intacte.
r\ccstcl, apar in leziu,nile yasculare
_(homoragii,
ramolismente,
hema_
l(,rnrc), lntrrorale,- traumaticc. etc.,
-ale_
lobului
larietal
qi ate g' lrusuiui
rrrr;l.rrrnu,r' gin:r1 (aria tactognozici a, lui lhermittd: cimlurie Z qi iO firoa_
r r r t l r r ) .
.. .!l.l,l.
I)iagnosticnl tle agnozic taetiti
!i
al iliverselor sale formo
r.l i rri co so
fl .].l l i l g!!"
pri ntr-o i rpJorare-semi oi ugi ci i
ri guroasd,: a) Se stu_
rl i :rzi sursi hi l i l ,i l 1;i l e. ck)mcntare (superfi ci al e
_;i .-profui i l e) ;
b) Si ;"pi ;_
r ' , ' , : r t . l hi l u4. , t , , : i , r , i r r l i r . r i . . i df l r l i l i car cr
mf l l pr i ei di n r . ar e esl o f ol r nr l obi ei bul
{ l | | . , | | r i U( ' , r t r . l r t ( , sr t r r t st U r czi Sf oni . l el ed S: r u r ugos ct l . , . ; JCmn, f i er ,
I r r r ' l i r . , r i r r l i i . st i | l ' i or . . ) . \ i mor . t og ozi t t {f ol . m, L
$i
di mi nsj uni l o oUi . cLi f r i i
I
.) r\r. r'r1rfor.cu,zi tttpognoz.ia (se
-face-
o excit;tie cutanati,
Si
iridit-idili
I.rrl rrri r' *i i i rrrl i co sedi ul cu i ndxul ); d) Se' expl oreaze di sc ,ml ni i i i
l ucl i l i .: a) i ' ' rr;.111i 1.i 1; bol nar.ul sX, facfl detmni rea eti ctd a obi eatui zt; prti ei tl
j rr
t|rorl (,(
) tl )i u.|,l ;i v, cu ambel e mi i ni .
!1.1,!. l ,r.ol rl crro de di agnosti e cl i ni c:
..... !1,,,,1t/,' !,i ,i i l !
t!u!.j ,l ,e pri n^o:e
i
a,) Agnozi a,d.ei ntensi tatel ,
(ah,i ,Iognozi a
)
:
' t . r I r | | | | | r : I ( r | ( ' r ' t ( , r ncnt ar e si nl i nt acl c
f i t ol u$i sut r i ect ul
"r 1e
i i i cal abi l
r , r ' r r r , r ' ' r r . r r r r , : I
I r ' i n 1r a) pur o
nr r f cr i r di n cat , C esl o f or "ma t Obi e; t d:
t t t t t t nt ' . t ", , ' t t t , l cnsi t t t e' , ( a nor l ogno: i a
1
: dcsi 1111 6, "1a, ; l r dbwi r i obi ecj
l i vrr rl . s.rrsi l ri l i l :rl o, subi ectul este i ncapabi l sL rccunoasc?i form:l qi i i i _
r r r r , r r r i r r r r i f r r ol r i ocl , nl ui ( ! , i g. 32
) .
:J
)
.Agnoti .i tt: t.ucti l e sectmdare
.(asi nboti a
tacti l i
)-
In aces[e c&zul l ,
rIrl i
' ri n' l og.ozi *
qi )ri l og' ozi a si n[ i nl ,acl c, bo]nav.l nu.ccu.oaqto
obi ec-
Irrl . l ,)' l ,rr . Irrl l l rl l rrr do rtrcrrnoa6tcrc a semni ti oal ri ci si rnl xrl i c. a, obi rrrt,uhri
(vt' t,i
.1
i 11. :l l !
).
2?t)
l \ 1 l sl t r u4nor i l , l t . hi o hr r nr l i i ( r l t ' Hcl l r i i t l o
( l r i l cl t l r r y,
l {}5i 1, r r i l , t t ' | , r l t r
I l r r r r r l l r . r ' , l l l ??) r r r r r xl r i i t r i t t r 1r ot t i I t i I i 1I t I r ' I I t t t r t t r ot t t t t t i t , , st l r t o i t , t t l r i t ' t t l ' t r l t t t
, , I r l I r r r r I r , "
f r r
! j I r ' 1,
i {r r t t
( j l l
ol l vi l , i l l oi ! l ) l l ( l i l l i [ .
l ) .l trt,:i i (, t.u,tl .i l ,i i , srt i l l Eo((i H1' o tttl cot' i ctt u,1tnt' :ri a nti i tri i i rtfrtrl rl pl i tl
l r , r r r r r r r . i r r ur t
l l t l ui
r l t l os ( ( l t r sr l r r vi n( t
8i
Kr pl l ur , l 0( i 2) '
A III
/ i ,/. .rr. ' touograri a l czi uni l or care
".;Jroi i ,:l ri Yt"rttt"
tacl i l 0 ((l rrl ,h l ti sfr' l rrl ' 11.
' , , , ,
f , . r r \ $r pr . dl r ai r i i s; P. : t l i cdcl r b2t ; Pa: Pf i ct r l aas. o. dcol l t j , ' U' l r ' / i r nx' i ' 1r ' 1
r "r t r ' r "
, , 1
' ' l r ' i l i l ; Lr 1
\ r ni l l , i l . . l LdmJt Jl esl i zsi gcr di ndo! , l nor i e. or l i ( r l Jr i l ' r r ! l nr l l ; - 1l l ' l r l r '
;' L ."i, L r.!,oN',;/i"e, Brncrin,r Jjno/ic p(ri
f:'&:il':"1#.,i','jl.'
.4rlr
-
rczirno r,rdkr; .rrr '- rn/r""'
l ,) .,l sl (rmgnazi a bi l ateral ti poal ,c fi roN,l i zl tl i i
l tt
i ttl ,t tt l t' zi ttttrr :t .trrttr
t , r , r l cnr l r r ' : t l c st i ngi .
ti ) l l ul ostercoagn ozi a (Il al pern, 1945, ci tat tto I(tl ri tr(l l {n' , l l l ?7)(l (rtrrl l ri
i ' r l i r l r l l l ci r bol navul si mt e obi ect ul , pe car e- I
l l r i r t r l t l
i l l t t t i t t i t , t r t t t i r r r r r t , '
, 1, , r ' r I i t r r cnl i t at e.
9.2. AGNOZIILU VIZUAI,I,]
( l r r shl u
i n pi er der ca posi bi l i t i l , t i i t l c r t t ct t r t r t i t l i t r l t t i l
( ) l ) i l l t i l n\ l ot r ' l l
i r ; r r l r r l r r l vct l cr i i , t l e; i l l ol r r avr r l nt t i t r t t t t i t l i o r nul i I i cr t t ' t r r r vi t l t r t r l ' j i t l r ' ! l zi l i vr t -
rr' rzol i rl i ,, i rl r l i acul l ,Ifi to sa,l o mi rl ,a,l o si ttl ; contl crv:l t,tr' I\rt, fi rl r, tttrti tttttl l rt
l r l r r | i :
l . A1;rrozi a vi zunl "r
U)ntru
obi ttcttt txrt' esputl (l o
(xr(i i l ,i ,t' i i
l )$i l ri trri
rr l rri
l \ l r r r r r ' l i . l i r . t ol r nt l c gr avl r , r t col l i bol t t r t , vi r r l t l oct t l l {) f i ( , t t i oi t t t t ol r i t r r r l , t t i ci
' ,
|
) r ' r ' l 1 r l | | | i i ,
,
l i l i t i r i l t t ' pr opt i t l r l l I i gt t r i , , I ' t ' t r zot t i , at t : i t , t t l l t t i ol r i t r t r l l r t t t t r r l ,
I r r r r t l
l r r , r l i sl i l t t l , i t ' , i l l l Nnl l n' ( ! l t ( l i l zt i , t l ol t t t t ni t ' t l l l , ol t i r r l l ; t t l t l i , l l l o t r i i r t t i ( 1i l , t ' l l ( f l i ' 11\
pr i l l r l r r pot t , ol , r r 1i si l {i o t l ost r i st r , St t l r i t xr l t t l f i xol l zi t ol ) i ( x1i ' l l l r
I ) t ( ' zi l l l t t '
r l
r r r r r r r i r ' : i sr r r ' ; r r i r r Fl i
I i
l t l t r st ' l r , cor c r t , t t l ot i zl t {i i t , t l o l t I i l i , i t t gt r , t l t r I l ,
1t t t , l l t t t ,
ol r I r r '
i r r l , r , r . r ' l r , t o i l , t t l , t r l , r ol l zi i , t l r r t r t l t t t i t t l l sl t , t ' , xl t cl ' l i . l l o( l l l l t r ) : l , i j l ( t f oi l , l l l l l l i ol ) i ( , t ' l
l r r l r . r r r r r l i , i r r gl r r t t i r r l , i i t l i t , r ' i i i t , r ' t , sl i t t ' xl t r l t i l t t zl l i "i t t t l t r ot t t r l ' i , ct t l t l l r r l t r
r yi
t , l l ' r r
l r r i r l i l , r r r r , i r l i Li l i l , cr t l i l
, , r i t t t l r r t l "
r l o t t l t i r r r r l ' t r t r sl ' t t t t t l t , i t t l i [ t ' t ' .
r \ l l r r or i r t
1r t ' t t l ' t ' t t
ol r i t r r l r r
i i
i r r r r r ; l i r r i l i gr t t r r ' l i vt ' , Ht r t t st t t ' i l t zl i , r l t r t t l l l t , r t i
r , r r r l ur r , r i r , r or r sl , r t t ol i vi t , r l i r l r , r i r , l l r : r l i t r l i i , ' r l i r t ' t r , l t , t t l i t r xl ur , l i r r l r i , t t r t t l i l ' i r r t 1, t l
'.','ll
r hr l i 1q11y vi zut r l
; i
r l c r r r r r l l , o I l i cl t r ) r l i i ( l ( l l t ) l l , r I I r 1r I r r l i I i i , I i | or , i r r I r
,
I r r r : t r r I r I r
,
1l i
I r . i r r r l l cr , l l ) ' / 7) .
l f r l ) \ ! t ) ( 11) 71) i [
( ] cs( 1l i s
ut no: : i . n, t i zt r . ul i i upt r t : t ' 1t l i . r : i i . , i r r r . t r t : r . l t pr r l i
l r r l . r r r l . r l i scl i r r r i r l r l c a, obi t : r l ' r r l r r i r : s1o pi st i l i i l , i i , dai ' ccl , t l c r cr : ul ol r i i cl o
r.rl . l rrl l ru|rr,1i . i rr l rl to ci tzrrl ' i , s0 tnarri fes' tr:i o,fal i d, t.r:t:tt ttoal f,r:rc a abi i c' rtl u' ,
.r' r' rr ..r |r' l a,|rrrr,zi . l rul nl rvul i l vi nrl o ol recarc i rLrudi re dc l i ol mi i cu obi ffhti
r
q
i i |,l ri l (1tl t' l rg^nozi i r, opti r::i a l ui r.on n' Iayendorf). S&u, ctaci obi ectrd a
l .rl rr' (i ttr1r)scrrl ,, ri runel o s[u este ul teri ol ' apl i cat
;i
l a a,l l ,e obi ccte, fo:r.t,to
rl i l i ' r' i l t (,,i i r l oxi cai ;i o pt,i n obi ect),). Ei po1
si , nu rnai rocunoasci r.rj ci
, r l . r i l r . . ( , t 4t , , , : i t
. t . t t , t , t l t l i r n ) .
St u di f er oxl , , l e dr . r . ul or . i . i r r l
1i c, , ceI , r r l r , ,
l : , t : i : r l r .
l , | I l ' . i r ,
i r l ( . nl i l i cX ( o, si n, bol i p t r onul i L. 4
) .
.
l,l\ i$l,r"r,
\\i
o, ccail,(da corti.cctld penl,nt culori, calacterizat5 prin frptul
lri l,r lrl o crrlor,ilo sint virzute cenu$iu. Existil
,li
o hem,iagttrnie yteittru
,' rrl r,rri ((l l onni ng
;i
col aLr., 1966, ci t:tl i de l {rei ndl cr, l 9??J.
.
9. l guozi a pcnl ru. i magi rri poa1,e s5, exi ste i n mod i zol at. ,l stfel ,
Irol rr:r,r rrl recnnoafte obi cctel e co:rcrcte, dar nu recnnoaqte acel eaqi obi ectri
l rl l zl rrl l ri ,c_i n
i rnagi ni . Aceasti formi , de agtl ozi e se poal ,e i n\rcsti ga pr{)
zr,rrlirrl. ]rolnarru-lyi imgsini- harsruate cu linii sau im;gini la tabfrtofoolr
r,i rrrl i ci i i ntl u-1 si i , l s i dentri fl ce.
il. ,trgnozia vizuali asocialivi sc ca,racte.rize zi, plin imposibilit&telt,
rlo il
.lf[]ri,
tlo :l descrie
li/
sau a indica utilizarea nnui obiect perceput,
r izurL,l, in schimb cu conserla.rear posibitit;,-tii de a clesena obieciul qiritl
:r I i rl crri ;i fi or, pri n al te
,,canal o".
Di feren(a di ntro agnozi a vi zual i , apercep-
li\ ir,
iri
t(':t u,socia ivrj, consl,i in faptul ci, in aceastia din ur.inii, p e,r cep_t"ia
l rr|rrrr.i . si 1l co-nformn:ti ci si nt noml al e (Rro.$' n, 19?2; Nrei ndl ei , tO-t?)..
.\r' ;rrri zi rr, r.i zu:rl i , asoci :rti v5, ar fi ut.t fel de ,,asi mbol i e,, r.j zual i i .
.1.
,tlynozia viru:rli spaliali cuprinde o bog;.tie c1e manifestiri:
rr) .l r1ttrt;i 4, t:i zu.aki rl e l ocnl i zare
l cnoi tater,
pcntru spl .l qi u) const[ i n i ncapaci -
l rri r.rr. rl c l , sosi z:l rcl ati i l c sp.l fi al e i ntre obi ettc, de a l e l ocal i za -' mai
:rl l i r i rr
Irofr.rl zi rne
-, de a aptcei a di stantel e cal c seDarx. obi ectcl e i ntl r
r ' l r "r i ol r i r . r , l t l o l al i l de obser r - at or . Dl cd, t l e excnpt u,
su sot i ci t ; bohavul
' . r
, , r : ' r r ' l r ' zl r l i j l o' ul r r nei l i ni i dr gpt c. cl r r gr n. i .
l '
)
.l tl ttrri rt, tl i tu,ul d stet eoscopdcd, foal te l ari , constE i n i nposi bi l i tate*
r l c: r I i r i t ur osi mea ul t i ol : i cct t r i di mensi onat .
r
)
..111n.o::iile ttzuale topogra,;f,icc, strlius legatc de tull:urilile prece_
rl , rrl r., r,orrsl rr,n i n i nca,paci tatea cl e a se ori enta i n spati ul erteri or, de 1I
rl l rl rj c si
(l {)
l ,-Ei l eprezenta tl rurnul pc care trebui e s[-l uruezc. Acc$ti
l rrrl rrrrr i i r,i rl <rr' l .c <l rum*l ghi di ndu-sc, r1e pi l di , cl up[ afi qr:i e de pe zi dul i ,
rl Lrl r:i r i l l i rrr el c. Ei se l l tl i cesc adesea i n oraf, sau i n propri a 1or l ocui n!:i o
i rrl i rr rl ri l i rl grcl esc sal onul
$i
nu
Di
gi ,sesc patnt.
rl,i O lrrrrnir, ," aqno:ie,i spa:lialc cstt: r'eprezentatir, d.e agto:[a ai;tLo-
:,1trrl i nl i i , trruc I cl tt' czi ntr' i , ti l ;ul bruaro [
,,concetptl a,l i zi i ri i ),
r' cl a_ti i l or i rr
r l r r r {i r r l l xl nr , cor ' 1) ol ' l l , ( ) l r cl , cLi zal i ,
i n di i i cr r l t a, i r ei l ( l c
a, asambl 0, o sei . i ( }
r l r r r r r i l , r i l i r r r r i r l i r r r t r r r si on: r l c, l r sl l i l i r r ci t s. i , l onnozo
, , 1i gur i , '
sl _r , u
, , r ] l o{l l t l o) ,
l r i r l i t r t l r t r i r r t r t l o ( ( I i l cl r l r l ' , 11) 5; 1, r ' i l , 1l ; i l g . l i 1i ' i l r l l qr ' , l t ] ?7) .
( i nvi t ul , r r l r ,
: r , i r r ozi r r i r i zr r ospl r , l i r r l o I ' sl r , r l i l i l i l i . i \ sl , l r r l r i r r r r r r r , l c t , l r zr r r . i , I r r r l r r : r vl i sr r
l r l r t t ; 1
r l o: r . t t l t ' I r t l r l t t l t l i r r r t
l r r r l
r t l i l i zl r . r r r r l l {r , . l r r r r l t l r , l r zr r r . l , i r 1. i i , l r l l r r l r yj i
' , r r
, ' r r r
1r ol ,
r ' l r . r i r r : r t r 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 t r Pl r r t r t t , : t l r ' t t t r I r ' r r t i t t : r r r
I ' r l r . r l r 1l ( r ' r ' i r r r l l "r ' , l ! l i ' i
) ,
, \ r , r ' r l i r t , t r t t t r l r i
l r oi
r ^r r 1r i : t , l i l i t t t i
1' r ' r i t r r r l r r i r
r r l , l 1 , l r nr : r i
t r ) 1,
r l l r ( , l l i r r l i r r t r t r , t t t ot i r ' r l r r l t t r r t i
l r r r {,
t r ' l t l l t t t t l r l "t t l r r i r t r
l ' . 1, . l r t r r r r i
1r oi ,
: r si t r r r l r l l t r r ol ' 1t t t l t l t t t t i t r t t t l l i t r
Jr i r ' l r ' l t r
t r r t I t t
I
t t t t t r ' t t I r ' , l t t t
l r r gr , r l l ot t r r I t t t i , , i t i r I i t r t r r t t r r i r l t t : t I J) t r i t t r I l i ; t r t ' t , t r , si i , t l csr r t r czt r . {l t r i i l r ol r r : r ' i r
r ' r . r r r t r r t I t r r c r l r ' r t t t t t l i t r t l t t t r r ur l {, r t l
l , r l l l i l r i i ,
i l t ' t t r t t l t i t t , t t t
i | ' t t l t t r l
r "l ( r r r , r '
r r r , r r l . r ' i l t t t ot l l l t t l . , \ l {i l r ul r r r r . r i ci i r cl , t t cr ui i i t r vct sr i l i , , i t t or l l r t r r l r r ' ; r l ,
, 1, , r r r r l r r i . l : r r r l r r r l , or r r l i r r l r r ,
( l ( ' i [ {l ( ' si r r : r , ol l l i o ] i t t i i l r ' \ ' r ' t l i l i t l ( ' .
( ' r r
r l l . r ' Lr
r r l r ' , r ( i . r l , si r r r l l or r r i r r r pl i r . i i ,
; r
r i t l i l r r ur t t t 1r t r | t t ' I t I i r l t , l t l t r i l r ( l r t r r t r r l l , r
l ' , , 1 r r , l l ( ) zi l ol ) i , i r l i i , i i I I
(
'
r '
\ r r t t i t t I I i t t l t
l t ut t i l r
t ' ot t s l t t t t ' l i t i i ( t l z' i
(
i r l r t l l
,
) l r l nr t . i r r ' r l t : si t t t , t t l l unr i l t t l . r : ( r r '
( . t t , i
l l ' ol l t t t l
)
t , ol t sl i i i t r i t t t 1r r r I r I r r I r I I r | , r
. l , r
p; r i cr r , I t r r I t t i Lt t t I t I i , t l csi t i r : Lr t t t l l l j l t r t ' i l t t r l t , i I t I t I I I | | I | | I (
' r i i r r l r i l
I
I ' r ' , (
r l i r . r 1r gnr l i r l ' i
t t ut i cor t t pl cr r ' r , , t l t t i t , I l t t ' t l ut l l l ) i l l ( \ l t t ' I l t t t ct t I r ' | . t t z, l . r l ,
, , r l r Lr r r l ol sl r i l t i l i cl t , l , i r . . , \ st - t l l , cl l 1) ' ! ' l l l l ( Ji l f l i o
( l ( ' s( f l l ( ' l t r l l t l { l , t t r r ; , l r '
,
' r
, , , r 1i r r l r r r r r i t r g, t u obi t t ot , , t l r t t t l r l l ( l l l s{' sl ( i sl i , l r t r ' : i si t t l t r zl t l l r r r l l r l r ' , I
, , r , r r r i ul ' , r r L: Li coLt t pl i c, i : i 1r , {- t ut i r r i i t l i i l ( }r t zi i , o : t cl i t t t t r , .
| )
l qt t o: ; i r r , t , i : : u ospu! i ( r ! d sc i l I Sol ( l f t ( r , i t t si t t r l t r t t t t t t l
l t r t t i l l o
ocr
l r t l : r l
, l ' , r r r r . l i r r ' : i cr ' r ' ol r l r r l i , dr t apl , i i ( r r ; a, zi si ' i l l ( r {l ol t l i l r r l t t l i t ) t l t ' t , 4l i i , r t , , r l t , t t r r
t ' t t t t l ui sl i nt l l d\ ' ,
( J, ( : : 01' i ( t l t or c : t 1t t r ! i t r . l i r l t ' t ul t l u t l i n4r r , t l t t l t r t t t i , r l ' r t t t
' ' '
' ,
- i r l r , l
t t "t t i nl ' r
, t 4t I , ; i t .
i , " , \ r pr ozi i l e l i zual {) al o s! t nbol ul i l t t r r l r aI i ct r :
t
)
, l r 1no: ' : i u,
11t : ot t t t : t t i ci i ,
se o: l t ' l l I t cl i zt l i t zi
l t l i r r
i t r t l r o r i l r i l i l : r l cr r r l ' '
' , r r r r , r : r r l o t t t t t : l e r t l n' czon1i l ' i
qcol i l ( l 1l r i ( t ( r ( t t l t t ' r ' t r ' , t t t t
l t r r i t : t i ,
t t r r r l , r ' r '
'
, r , r , ' l r r r r zi t Lt i un ol . ) j e{i 1, )
;
b) : l 11not t ,
( l l 1r . r ' i r ' l i { '
(
'
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| | | | ! r I r I | r ' r ' i i r r i r r t | t l r ' r l '
1
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j )
l ) l {r ' c,
i n ci : r , l o l i nr l l aj t t l i nt ' i l t l i ot ' r r sl t r i t t l r t ' r ' l
'
l l ol t t r r r r l l I r ' r l . . I r r l r r l
L, l , r l r r : r , r ' cr r , po ni ql , c dosor o, l i i l r ' r , i l ,
[ ) Lt t {' l l
(
I t ' i ]
I
} I ' i t r r I r
'
r l i r r t l , r r l r ' , : r r , , r ,
1, , ' r r , l , r r ( r i , ; r r ) Oeci t at m mt t zi t : u, Li i ( i l l : x: r i xi i , i t t t l p. l l )
) .
l l r r l r r : r r t t l
'
i '
r r ,
| ' : r l r i l
si i
( kr st i i f l ' czo
t l r l t l ) t i 1, l i r t Lzi cl i l . l ) r r l r r i r t r r i i , r ' , r l r r
'
1' r r r r r : r
' l '
1, , , r i , . , r l r i pi i r l ! : i i o {on}r i r ,
( l o
aJa; r i ( ' "
l i . Si u( l l onl t l l ui I k i ul ( pr r r al i zi r r psi l r i ci r r r pr i r i r i i ) r r ' : r l r . , : r . ' r r r r r
, , ' 1, \ i r r ( ' t t l i ( ) i ( ) gi o ( x) t l st i i l t l i l r l i t r l t l i
' l i r r r 1r I or t I l
l r t t ' r l i t r r r l , ' ( l i i r l r r r l . l l t ( l l l
' r t
' t
r l , , l i i i ' i r r r l l ol r t {}?7; I I t i t ' l t cLr si . \ . j t t t i r t l ' l t t l t t r t , I l l l , l
;
I \ | I | | I I | | I I l l l , , )
1,
r r l r zkr
1) i l i l r i | i L
i t I i r i i i , r ' i i Vi zr r l r l , ' , l l i l r r i 0 opl i l , i r
. r l
i l l l l ' l t l r l r | i r : r {r ' l r l r r
, , , , t ( . .
t ' ot t t l i . . . i q
l t xi hi oi i
r r ,
I i t i i r i i
r i ". t r t l , : t i l t t l l t t t a' r r r t t l l t l l t t t | | t t t t l l
, , ' r r r r l , r l i r l r si l i r l : Jxr l i l t r t t l t t t t r t ' r l c t l cl i l ' t t l t t ; i I I LI t I t r I I I i l I I r r r l t r l r r r t r , r r r r t r l
, 1, 1
. r
r r t l l | i r i t l l r | l i i st : l t l t l r qr r r t l cl t i i r t i t r t t t r r r l i t l r i , l i l , t r l . r ' l l ( r r
. r ' I '
r ' l l
' ' r , r r r r r r ut i t ' l t , r l l i l i r t l l r r ol r i r r cl c
l r t l zt ' t l l l
i t t l i t t t ; r t l I r r . t t : ' l \ l r r l r r |
'
r r r l
, r l , 1r . , l r r r l r l r i t r l t r t t t r l t i l t t l c r t l t sol t t l t r i t t t i r r : t l i l ct l t t l l ct l l r i l l i l r '
. t
t t r
, . i r ' l i
1r c
l r r , r ' r , l r , r ' i l r ' 11r ' . l ) i ' i i t t ' l l t l r l ( ' i l ' t l t r l i i I i r l l t r , l r r t t r ol r i l l i ,
'
l r t r r
' , r
r
l ) (
| r ' r ' | l ) r t t i l i t r t t r t l l ' r t l r i l r I t l i t t i t t t l t l i l t l l t
l
r t r r
' .
i i r t i l r l l l l l : r l c r l r r i : r l ' : r r l
l , r . r
I
r i l r i r ' : i l r
; r t
i t i l i i si 1I I I | ) t I I r I I f i I l r l r ' l Ll ! r ' i \ l zl l l l l l i l ( f l t l i r l l l r r r l r r l r r l r I
1, r , r r
r r r r r r r r I r r t r t I l i ' t r r l t t l cl r : l t , r l t r t t ' t t l t t t t . i
l r r t : t l r r
t l I l t l l t r l l t ' i t r t t t r r l l t ' r l t l r r l . r t
t , r r \ r r , : t ,
r r t r r t t i l | l l i t t r l l r i l r t | ) or i l t t l : i ; l | l r r l t l r ' : r l r l I t r {i r ' i
l r ct r l I t t
I r r l r r "
' r r r
, l r l r l t t l r r r t : l 1i t r i I r ) | r ' i r r {' l r t r l l ) t r l l l l l l t r '
, . \ t ' t l l t t
l t l l t r I t I t | : r , l r l l r i l l l r l i r
'
, ' , r l r r
l r i r . r zi t t l l
i r r t l ' r l i r r l ol r r | r ' l t t l r l i t t I r 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
, , r r ; r l or r l i r . r ' r ' r t l l r r . l : t r r , r t r t ; r r l l t t t r r : t t l l t r t t l r l . l l r t r l r r ' l i l l r r ' l t l '
l r ; l i
l r ' l l l l l l
r ,
1r , , l r r l r r ' ( ' ?, r | l l r
| r i l l l t l r l l I l t l l , l l l l |
' . I
| | | ) I | | | r ) | I , , |
'
r l l t i l I l l l
, l l
I l l ol l l l r ,
; ' r r r r
i r r r r l r , r t j r ' , . r i r ' , : r
i l : r
| r r r ( r r , ' l ' r , I l Ll l
' : r l ,
r , r '
I t I r ' r ' . Lr r l r r . l ) r '
r ' : l l r ' l l l l r r
, r Ll ,
l l I i \ r ' l t zi i . ( i t ' : t
t r t i t i t t t
' i t t t t t ' t t t t t l t , I l i r l r r l l l r l l r , r ' r , l r , ol l i r r , l , t t l t r i pt r r r l t r r r o r l i t t t r or t
, , I r i . r ' r I r ' r ' r . I r sr r ) ' r l i ' . i r r r pr r I vi zr r t r l ( r | , 1i . sl . a I . , t , r , l . i r r qr . i , i i l r r t , ( I .
I , c{, i l r ul ,
l r r Jr , r l r l r vr r l l l t
l , r ( ! zi r r l i
l r r r r r r i i ur r opsi c) .
.
, l l t . t i r r . ol t l i ( t i
st ' , r r r l r , r r i l i . sl i r . . pl i r r 1r , - r r i r ul r or , i bi l i i l t ( r ( l o
i I pr . i n( I o (
rrri r' r
' rr
.l ri rrrl ,
.rl l r.
so
Ir{.?,i ,ti i
J,.l .i r,vrrl .i (di l L
}ri r:i nD
l rrrpol ,tantel or
r . r ' or i
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r r r . r , . r l r {t ( ' : r }r r r ( . l u( , bi l , r , _ sr r r hi ; r r . r d i m r . nr i una I o ( f i i l . , . r a t i un at act i c
I r ' r ' r 1, . H, ,
i i r I l , ( ' {' r 1. 1' cl os) . . U
i i bol navi cu si ndr om Bal i nt i l i apr i t r d
l i gar a
.. rir I irlr-rrlrrl r.c(\tcin, ci la rnijlocul ei, sau manevreazn eulitu.l in failurle
{rr.t)l l r' t{i rtc l ' )(.Ll [ i n c{u' e trebui si tai e o bucatx cl e cai ne (Kri ndl er,
t | ) ??) .
7. - l i . r ' i t r r t ca p"i l i ci r epl ezi nr i o r l l i i f or mX ( mai gr al A) de agnozi e
\ r / , : r l : , . \ s i . t . bol na\ . ul I l t t poat c r ecunoal t e obi ect ul excl usi v
nr i n
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.ri r' rl sr.. J)i fr.rcrrta di ntre ceci tatea
l si hi ci ,
qi -cea corti cal X rezi dn l ;
l : r l ) l l l l
, ,
r l r r
I r nmi r , ^: e l , i l . r do
dr r a. r r epr czent ar ea ( i magi oca)
I i zual i i a
r , | ) r ' a | | . I r , | .
I ' r '
cl Ld r n cr ci l r t ea COr l i cal l , se pi er de compl e1211p61, s
61j 6, 6
i rl rzi rl i c si
_p(,I' ceptj e
vi zual ai . Ceci tatea
?.si hi c.i
se i nsol e,ste, de obi cei ,
rr rl c i r.l tc rrl cmentc agnozi ce
.r-i zul l e
(al ei i e,
acromatognbzi e),
ae Ue_l l
: r r r r ' 1r . i . . . . i r l . l pr ar i r . ( Lr Dnt r ucl i \ i .
i i . . X) r or oPnl l r r ozi a
l agnozi a pont r u f i zi onor ni i ) se cr r r cl el i zeazi pr i t )
r l l l ' , ' r L) r l r l : r l ci t Uol na\ t r l ut dc a r ' . Cunuasl e pcr coat j . l c di n j ur ul
oi u, cLi ar
pr, r' r' l r, rrnri :tl l ropi atrc. Recunoa;terel . persol .n ei rr.specti r-e se poate r.eal i za
rl orrI rl pi i :r"l l c ol orneutc carncter.i sti ce (i mbrri ci ni i nte, tal i cl voce etc.).
l l , r l r r . r r r r i nl I r \ ' ul r r t sl e ni , . i f i gur u unr . i per sot nci nt r - ungnr pdef nl ogr af i i .
. '
l
, r , : r t ,
.
r I r
, . r ' I i r ' . r r r i r I r i , . l t por : oa n( . l or di n f ot ogr l f i n. nu poi r t e f acc d i f &e; i ; ;
rrrci l i zi r.rnonri i rl o l i rj rb:l t sau de l erl ei e, dc om ti nd,r sai l ,i ,tri tl etc. Uneoi l
rrr,;i
.r' i r.rrrrl ,r1l u
.i ci
1r.opri a sa fa_ti i i n ogl i ndi ,. Uni i bol navi prezi ni f
rl i l i crrl l i l i {l rr 1' (:1111,u,,,0r""" a r}numi tot segmente faci al e, ca de n^i l db i u_
rri i l rr(r' i r, srrl r,ri ' ari si l u i i rferi oari a fel ei ,
i umi tatea
dreapti , sai t sti ni d.
l r,11i rrrrtr, ool ri l or' , regi ul ea trunti i etc. (Gl onni ng gi col ab., 196?, ci tl i
r l l l ( r ' r . i r r r l l cr ' , l g7?) .
,
Stttt tt.i .l i trt!i .rr, t9.l o-l yof!a( n ogae:i _i l or
.
r.i ":unl e. Agnozi i l e yi zual e
au ca
r;rrl rrl .rrl l r,zi rrrLi u,l e kl brrl rri rcci pi tl l sti ng l a drepi aci , c[ci l ezi uni al o
r,r,i zrrr.i i
.r,i rl r.ari no
si al c. regi uni i _ paracal cari ne sti ngi (cupri nzi na
i ntreg
(
rrr(l .rrrl ) pr,rl uc :r,grrozi i bi l atcral e. Adesea este vol ba rl e l 6zi uni si metri cl
:rl . rrrrrl ri l .r l ' 1ri occi pi tal i (fi g. t,3
1.
T,hermi tte a subdi vi zat aceast5 zo;L
i rr rl orrri rrgi rrni : una cl esti nati l formel or qi cul ori l or (ari a
19) Si al ta. mai
rr,rrI,' r' i ,rrrl i i , rl cst,j ni l hi i cl eserul ui , l i tel al or, ci frel or. Tul buri ,ri l e' dg
61i .r6rr,.
1:r;' rr,zi i l r. sl r;rl i a,l .) si nt rl atori te unor l ezi ' ni profunde :rl e pi r_i i i superi oaro
,r i rri r' r' rrrl l ,l r, u,r' i oi par' :l {j al carj rrc
1:
r,r' i .r, 18), e{i ngi nd si ml i ri l e fascj cul e dc
: r r r oci r r i i r r .
' l ' l l l ) ul i u' i l e memol i oi t on, r gl l f i cc depi n, l i nsi ,
de obi cei , do
l r zr r r r r i l r i l : r l r r ' : r l r . r r l r . r r , spi nt i ni {r ' r r r l r ur o- o, . r . i pi f r l e. , Agnozi l r , r . i zu, . snr t i r r l i
, l r '
I r ' , r r l r r ' . i
i r . l r ' , r s, l r i r l . l . zi r r r r i : , l o' i . pi nr i ' i pr r i r ' l oocci pi r r l c
di r i
"i ni r -
/ i , r ' r r l r l r r ' l , 1. Nl ' i r , r u. ' r l r , I t , r . ( 11) 04, ci t ai ; dc t r i i r r i n. l l cr , l ! , ) i ?) a ar i t t at . i J
i r , l i | , i ) ] / i i i l r f , r i z, f l i r l ( r . si r r l ; ^l ) r r r l r r so r l o r l r r conect ar ca
, i i l or
sonzol i r l i e r oo{r l ) 1oi r r ( !
r l r r r r l i i l o I i r r r I r r r
,
j r r I r r i . I n l r i r cl r ' sl , i , v i zi r r no, l , {r r ozi i Jr r r i pl i co so a, d r n i 6 r l i l si 1l ,
l t t r r r l r r o l r l i r r
l czi r r r r i I r i I I I I r r r ' ; r I r r
.
l r , l r r pi l t , i l or , l r : l zl , l r i r i l c l o bt r l r r i r i cci l l i l , a, l ,
l , / r ' zi t r r t i l ( ' si l l t i r l {\ t r r i r i i t l ) r t ) i l ' l , r t r l r r l ol r l l
l r r i l i cl r r l
i l t ' I l r r r l r t cc si r r r l r l or r r i pt r , .
t I t r t r t i t r ot r i , ol r l i r , r r sl l r {, i r r , l r r , i r r i r . r , r r r r r cr r l i r zi r r t r i l c ul r , i I r 1r r , o1r i r r , i i , , l r r l r i l r l l
: n4
l r t r r ; r ot i r l l . t
l j ( ! nt f nt
t i r r r l l l ot r r r , pr r , r l ot r r i t r i t , r r l , opl i r r o of r i r , r ' l i t l t r ( l l t . s1, t 1| l ". l l
l l , r r r l t l t l l r "i i , r t gr t ozi i l l ol l i co
11r ' ot r r r , I r ' i r . r r i r i r r i gr , r r r r i r l c r l r r l czi r r r r i l l i l l r l r , r ' l r l l
r l , l , r l r i l or '
l l r l i ci : r l i
( i r r r , l uzi r r r l
1i
gi l r nr r l r r r l r r . l r r r ur , r ' gi r r : r , l
; i
pl r l l r ^: r , pol l r , r r
, , . r r . r : r , l ol r t t l t r i
Pl r l i r l t r l
sr t l t t ' t i or ' )
l r r r r ct t t r t
qi l r l r r ct r l ci t l o l r r l ot l r ,
5i
l r l r t i r r
, r r , r r r r r r oI r r ( i i ol r , i l t i l , aJr r
; i
akr
. j or r c{i r r ni i
cr r a, t l oul {' i r r l l l nr v{, l l t t , i r , 1( . r r l n,
r . r l . r l l i ' . cl , r . l t
5i
Ar r gol cl gucs ( l 00l t ) l l u
1ur r r . i zr l l
r , i i l czi ur r i r r l r , r r r r r i r i l l l l r
)
t t , t i r . ( hr r spr ) ndc
l c
t opogr at l ec al e
xgn{) zi i l or \ i zui l e :
, , r , , , , r L) . ar i a r ( : ! , ! $Ll Ji l i ' d, Lai l i hr . a al er i ei
, . ' i . r . l : , . . l "
' . ,
^ l i \ , ' , . i r . ' -
, ,
' r r f r
( r r i a l 8 s1n . . i i
l l . i cdl or nd) j l f l
, , ,
I
. . Lr i r 19, ! ( st ) or l r L, i l i L 1! n1! c mi sl r i r l e l f r
' ' '
,r
:i de ii t.grm. lormrlor
ii
a .d..il.r!,
, l r r
1r i r ' . pr ot l uo
i ndeoscbi agnozi i pent r u i r nagi ni I i gr r l r r I r r 1 pr r , i Lr , l ) r t l i I r 17r \ r . . r
,
r' rroz i i sl l l l i al c uni l ateral c,, i n vl eme cc l ezi utri kr cr rrj sl i ,rti sl r r r j l r
l i r.r
{,r r.r j /
,l
, ,r pli'r,ii,tkrrtl a,gnozie pentlu culoli.
e. 3. A(i NOZI I LE l ut )t Tt vt , )
( lrr
prirrd urrnii,toarele formc clilicc ;
l . l l ur di t t cu, psi hi ci i l , l uLt t sau r r . r l t u*i r r t r ur l i l i . i . r , r t ut 1t I r . l r r . l t r l r r r r r r r l
; ' ,
r ' r r ' 1r r r zgoi t t ot t i o, poi t , t c. r Or r r l r i t t i r i r t l , t , nsi l i l i l , , l t r t sl . , r , l r , r . i l r , pr r l r l r . l , r I t r l r zr r
1r ; r ( i r r l r r l l t t ' cst c. i ncapl l bi l si l r l l l i r l r r , , r , i t r l r , l r r l l r ,
I r l . r r I l r r i r . | r ( r r , i r r . r r r r r r r r r r r l r r r
l , ' r
'
( l r
l r l 1, o
( i l . r vi nl c
si ' 1, l c i d' r r l i l i . r ' . l r r . l l , ' r r r l l r , r . i r r ' l i r ' ' r r r r I l i r
.
r r r
.
: r t r ' ; r r r . r , l
, 1, : f l r r i r , ( i r ) l l sor \ . i i , t r . l t r skl i r r r l r or ' 1, : t r r t ( l ol , {i r i r r l
l l r I i r r l I i i l r ol r i r r r , r r l ( . u
: r ! . , r . , , r r r .
I ' r . r l l t
sl l l t r t , o
l r ct ' cc1l o
t l c r r r t t l l o ol i r r l r i l r i l l r r or , l r i l . r , r r t l r . r , r l r i ur t r , l r . l r .
I l yor r r ol r ' , l ot r ur i
f . i t . )
si l i i l t gt r ozi t t ,
l ) ( , nl t . u
l j l l l l ci o r r c\ r , r . l l r , l r r r r r t l r , l r .
i , r r r ) l r i nl i ( ' u
sur di l , r Lt ci t t ( r . l ) l t , l r i .
: : .
.
Su. l i t r i l i l o
l si l r i r , r
. . sp*r . i al i znt o. ' : r i ) Nt xl i l t r l t t r / . r r al r i . . i r r r , r r l r r r , . r
l r r i . r r r l * i r , r l i l i ' t r r r r l i i r , r kl r *' i i r r r r l r i r r r r l ' r r : r l r . r ' r r r l i sr : r r r {i r r r r i . l i r r r r ' r , r . l r , ;
l t t , \ , 1di l ( l r a snt , r r gno; i u t t t t l r xl i , , , r i r r r
,
: r
I
r . r r
.
i I : r I r
.
. r r l . i r i r l r . r r l t l t ( . r r . l ' t r . t r r l
- r ,
r r f r r , ( . r r i t r r : r . i r r r r r ) ( i . r ' , r r si r l . r ' l i r ' : r r r l i r r r r r i i r l r , l r l : r zi r , )
; r ) l i r t l i r ul r t r xau
, ut t r r t i r r t ' i l t t t i t i i : i t t r r : t
1
r i r , r
.
i I I r I r
.
I I r l r , l r r l , . r i i zi r l i i r r r r t l t r r r r . i l l l r i r . l r r r , i r r r l z r l i r l r , ,
r l r l t r l r
( ( \
1
r r
,
t r
.
r
,
1
r ( r : r , l or r : r , l l i r . r r l r . i t r l l r r ' l i r .
it'10
i l . Srrnl i l .rrl .ol vrtthrrl i r si rrr rl l rr)l i l r,orl )l l i t
Il l t.ri ,
.L' rl r,(x)
l tt,rl ,o
rl i rr
r t l i r zi r t , \ {r r r t t t i oko ( t t t t r l t vl t l i r l i r s<, r ' i sl i -
y( i zi
Ol p. 10) .
l ,rl zi rnti l o g(l l r
(fl i tl ,oar' (i
rl c i rgrrozi i u,LLrl i l ,i vc si nt col ti cr,l c, cu l oc:r,l i zl u(r
i rr
1ror' {i rrrrrrrl , l xrst,rrl i oa,r' i l
a pl i rnoi ci l curnvol uti i tcmporal e qi a ccl ci de
:r rl orrr, r,i r\rl l trr\' ol u1,i i l orr)poral c a cmi sferei doni nu,nto (Ni el sen, 1962),
rl cri rrrri i sl rsl ,i n cai l ozi uni l o gcncratoare de agnozi i audi ti ve si nt bi l ateral o
-F
i9, 31. Topografia lcziunilor care antreneaztr
cgnoTi 3 audi 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).
$.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,ii in pel'ct:perca
fi
reprezentarea exacti', in fiecarc moment, a exis-
Irrrr{,ci
,,eul ui ' )
rrosl ,m corporal i n ansambl u qi pe segmente. Integrarea
lul,rrlo:: cxciLu,liilor senzitive supedicialet profunde
$i
Yisceraler a1e celor
r i zrrrl c, l rl bi ri nl i co etc., permi te i n permanen!5
r,conqti i nl a' )
eul ui nostru
r,or'pollrl in ftnsamblu, precum
,si
volumulr pozi-tia exacti, in spaliu
$i
(lr,r
| |
|
ro r ror r
[a
diyerse]or segmente corporale.
f
,)\
isl,ir, urm5,toarele ti,puri de agnozii. ale im gi,nii (schemei,
)
corporale :
l. Asornatognozia constr, intr-o nerecunoa$tere sau o ignoranli, din
1r:r,r'l,r'ir,
subitxrtului (in lipsa altor hllburdri psihice) a imaginii propriului
Hl i , l t
(x)t l )
:
I I rntinsomutognozrla (sintlromul lui Alton qi Babinski) apare 1a bol-
rrr,vi i crr l rt:rrri pl ogi e sti ng5,, mani festi ndu-se l a ni vel ul acest' ui hemi corp
Ii
rrr lrrlrrcl,clizoilz[ prin citeva si,nrytome card,aterfut;iae : a) Nerecunoaqterea
rri rr|r' rrrrrLi r.i i ,
1ro
rl o o parte a tul burXri i morbi do, a paral i zi ei (anozognoai ' e
)t
rrrrgi rrrl l i i , r,r' i ,e pi rral i zat
I
b) nerecunoafterea hemi corpul ui sti l g sau a
l l rl l i H(l g)rl (!nl , rl hemi corpul ui (asomatognozi e propri u-zi sd,
) r'
c) uneol i
irslo vorlrl tlo o cornpletii indifcren!5 fa!5, de acest' hemico4r, pe care il
i grrrrl r' i ,, c[ l i i rrrl o
,,p:n' tc
i nuti ]i r, a corpul ui )' (u"nozoLl i aJori e
);
d) al teori
l rol rrrr,vi i i 6i r' (xi l l l ro$(, rrotttl l tel o, dal l o pol col l dota\sate dc cotp, sau defot-
l r r r l , r r ( : l l ur r gi l , o sl , u r na, i scr r r ' 1c)
I
o) i t t unol o cr t zt t r i oi per ccJl r l oLt t i , ht t t ni cor -
l r r r r i
sl , i r r gi ( i l r r zi r r , t t r r t t i i r , l l , t t t i l ur t , t t t i r t t t l r t u sul xr t i r ) t ) , si t t t
l t t r t t op
t t t i r yt i l r i
n; xr r r l , r r r r r i t r r r r r r t r r I l t r r | o I ' ol t r r yi i t t t ol l i l r r ( i l t r : t i i l ; i r t r s t zi r r l J; l ) r r r i r i t i t t ' i t r
!'t t;
, l ' , r l l r r : t l t - i r t . ' l ot . l t l i zi r , t t ' : t r l r , r ' i r , l t r r l r r r l t r : t t i t t
l t l t t l t ' i t
si i t t i t l o; t r l l i , l t l l i t t t t t -
l i r l
' r
r or zi l , i \ ' o r r ; r l i ( ' r r , l r ,
| l r ' , ; [ t , t
l | r r l r l ' l t r r vr i ,
l r r p; i l f t cr l l t i r ' l i l j ( l l ) l i l ) ) , l t gt t ozi r t
l t cr t l t l t
l r r r t r t i pl cgi r r t l ot t t 1I r t l I i i t l r r t t r ' i
, r
1",
i l r l i l i ' r ' i l , o: l r ) l l t r ozogt t ozi l t vot l r r t ' l i i ( t t cgr t t t r l t , vcl l r t r l i i , r r ' I t cI I t i 1r I I ' I 1i l t ) ,
,
' r '
, r l r r , l ol c; l , o
l ) r ' cz( l r l t i
t l c I t l t I t t I r i t t I t
i
i i l i i l t t r sl t r zi t ' t r ( r l r r r r r i ; r r r ' i l i ) i l t
1r r t t
l t - : r '
1,
r r . | , , r r l l i ' 1 l t ) : t t t t t zogur t zi l t
l r l i t r
l t t [ ) r t t r i , r i
( l ( ! ( ( ) l r t l ] ol l l ul l ( ' t ) 1, t ' r t l r t i t t t
r r r r r r l l r l r i , pl i r r l r ' - o l , t t l l r ul t t r r l t l , r ' t r ! i ci 1r r , ( ' i i r l t l j t t t r t i l , a, i . ( i l l , ( r ot l ) r ) t i t l i r
l t r r t i l
l i l r .
| , i t i l r t l ( 1( ' t ' ol ou: n, u. l , t t l t t r t t i us ont n. kt t t t t o: i r : i st t i t ' l ' l i , i l r ct t t i si t r t i t ' t l t t l r l t l r r
r , r , r l i r r l , ot
l l l , r ' i r l ; t l ,
gi l t t st t l
I ) i l r i ( l r t l
i t l i ol ' i ol ' , gi l t t st l l i i l l l ) l l l , l r r i l l i i i r t i r l ) .
l l , r , , r r or t t r r ; l , r ) gl l ozi r t i l pl t t i r t l o ol . r i cci i r L st l di t l l i l oul l t l t t t t t r i I t t I t t t i
I
I I r
' I
1
t t
,
r r '
1, r r "r ' l c
zi l u r l r r ; l i i i c1, ns
; i
st i . t r so! , i : 1t e
$i
( l c
r l l t ol t l l ) ( i l l l ' ( r gr i [ ( l ( l r r ( ' ( ] l l i r i , ' i r l
r , l , r l i u ol i cr Ll l r , t c. Ll l cor i l l ccst , si l t ( honl ar c t t t r vol t r ! , i n t t t l l i l t t t l gi i . i \ t r r r z,
r' r1" rrr
l r(l l l l
l l l l rtrtui pl cgi c sc i ri ,i l ntrl l ' c .trrrovtrtrl l l l l ol l rrt' v i i tl tt t r t l t t i l t t l l r t t l r t t t
, 1, , r r r i l r i l i l ' t t o ( sul r or l i ci al i i i 1i pr of undi , ) , t l eci t l t l i t r l t t r t l t r t , t t t ki t t t ' sl r r zi r ' : t '
, , r ,
l , r r t i
r nr r i r l i nt pol t l l nl , ' i i i
, , or gl ni zt r ol "
sl r i l ( i t t l r r i t l t I I ; t t t t i t | . l ) t t l t r t ,
' r r r
r r r r r i ol i ( I l r ul cna, n, 1925, ci l , : l I de Kl ci nr l l cr ' , [ 1) ??1 Ni r : l st r t t , l l l l i ' - l ) , t t r
r , , , 1, ( i r , zr ui l o dc : l gt l ozi c : r , r
j uca
uD r ol i ml or ' 1i i l , I L1;
; i
l t l l r zi t t t t r r i r t l i t r r t t r ' : t ,
, ,,, rrl ri . l ,oo*Ii zaro:r, l tl zi uni l i n crrri sfcrl rh ca1l l i i , (l l ;rr,-zi si i
'
,
I I r i t I r r t I r ' ' )
t , r , l r r r t r 0 ; i
oxi st cl ! a ul r or spcoi i i l i zi r r i di n or r t i sf t l r i r , i l l ' ( r l l l ) l i i , i l l i t t l t , gt l t l t r t
,r,,,r'
I
rl rl (tso vi zuospzr,fi al e.
: , ' , Si r r dr onr ul l ui Gcr s{mar t n
; i
SeLi l t l cr se oi r t i t cl , t r l ' i zt r r t zi i
; r t i t t
t l t t t t i t , ' r t
'
l ,r
r' l r o[{)rn{)ntc: ?,) O afqzi e-dgtrozi toa]' t(l sl ti l tri a l i i ' , t I I ' t t t t t t t i i i t, ,,l tttj i r.t
,
r , ' i , ' 1 : bol r r avul nu poat c di sl , l nl i e, al ' i t i i l t ' r i i
( l ( l t r r r r r r i t I i I r ' t i I r ' I r ' r l l i ' r ' 1"
, l , r , r r i r r i l ot ' sr i , l cf i col o: r , l cr l i i t r i i obscr Yr ut ol l t l l l i ( t t t t t t t t t t t r t i t r t t ocl t i t t t r l l t t , r t ,
, l r r r l t i r t t
f i
ot 1 ochi i deschi si )
t
l t ) . l ) c: or i . t nr l n t ' ( . ut t Y) t t t l i i t l t r t t l ) l t t xl t t t t l t l
r r r r r
l r r r : r , l c
sr i t l i st i ngi r par t ca dr ci pt i l a col Pl l l t l i t l t r r l ' : r sl i t r gr i , t i i \ r t l t r \ r r r r i : r ) . ;
, t l r , r l l t t l i . c ( l i psi r de est i mar c a vi l , ] or i i ci l t ol or ' , i t t r por i l r i l i l r r l r r r t , r l r r r r , r r l : r l , r l r
r r r r
l r l r nr
t [ t : oal cu]
f i
t l c a, r ezol va o pr obl ol l t l i ' r
l r Lt xr t t t r r 1i , , I t cI I I ct t I r l
I L; ' I t
i r . r l r r ", i r r ser Nul c[ bol n*r ' ul i gnor S, ser r r ni l i ot i ,
{
i l t l ot r t t l r t i ot , t t l t l t l r l o l t l t "
r,r rl l x' r' rrfi i l o matomal ;i cc)
;
d)- AgraJi a, i tar fi i ri r, 1 , t t I I I t t t ' i t
'
t ' r r rr I i r I r I r I r
. i
t t I t t r
r r r t , r ' r or ' . Aceast l agr ai i e se pr czi nt d, m2] i r nu11, t : l r o l l l r t l t , xi t r
( ' ot r r r l l l l l ' l r vi l
1' ,
r r l r r r i i t er e
Si
cuvi nt e,
l , r ' : : i t t , t t , ea i nt cr cseazi l , p5r l , i l o an1; ol i o: l , l ' o
f i
l ) i l zl I l {r l t ' l t t gi t t t st t l t t i t . t t ; t t r l
r r r , r , r ' : ' i r I 1l l i l l omi s{er ci st i ngi , pr col l l n , ) i T, ol l i l l l o l , t t r t r r t r t
l t l i t r i i
I t l r ' l r i r l l r
, , , r ' i l r i l r r , l ( ci r npur i l e 39, 40
l si
l - 9 l l r odt t t i t t t t t ) .
: 1. [ l l t ot opoaqnozi a so ca, r aot or i zo{r , zi l , ] ) l i l I
t l t r zt t l i t r r t f i t ' t t ' l t ' I t t I I I i or ' I t t I t t t
r r r t r r . p0t l ; ou Cor pi r l si t u
f i
pr i n i r r t posi bi l i t l t l , r l t t , t l t t t t r t , l ' i i ' l r r t I i t ' r ' t I I {. I r r t t r r l r r
r {. , r r r j ul n)
[ i
ost o g( ] t nr t al ; i r , ( i o l ( i zi uni pal ' i cl i i r l o ( t l r l ol r i r r r r i I r i I ; t I r , t I r I r
' )
l . | ) i si r sor r r r t o
1;
nozi i l t t t ' cl t t t zi nl , i r , i , t t l l r t l r i i l i ct t t t t l t l t , xt , r i i vl r t i l r ' l r i l r t ,
r ' , r r r : r , f i i
I xr , I ' l , i ct Ll l r , r r i
do sohi r r r l i r , t ( i i L
( x) t ' pl t l l l i i t r l t r r g
, si
l t , sr r gt t t r r t t l t , l r t t l l : r l r ' ,
r r r , .
l ) l ' i vosl , o
l or t t r a, , l t t t r gi l t xl r t , , gI ' ot t l , l t l ; ci t , vol t t t t t t t l , l l sl xr ci , t l l .
l -r, | | el tt l tl soopi i t ( I t i t I r r r r i r t : r
I
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I
r Lr r r ' : ui r , r l , of i zol , zi i ,
Pt ' i t r
f ct r or r r ot t r t l t r t ' r r r i i l ot ' : Ut r i l t t l r i r t ' i , , i r t ( f i t , ?, , \ ' ol l r 1 i r l ) r i l t l t t l
l r t r r r i r [ l t , r r , l t t i o i t t r l gi t t r r l l r t i i t t st r l i ,
l ) t t r l ) l ' i l t l
$i i ' t t
, , r l t t l r l t t ".
l r ) \ i f l t r l t l \
l r l r . r ' r r , r ' r r l l r r l , r 1oi . l l , l r i l i \ nor r ol gl i , l i r r t i t r
, , Nt t i l ,
t l r r l ) t ' r t r i i t t l l t l r r ) ' t l o l \ l t t t t l t i , l , ut
l l r , , l l ot ' l l ! 1' t l r r J\ r l t t , t t 1t i t , t l r t , t t l , . Vr t l , r t ' t t t l t , l r t l t ugl l ul i r : i : l r r zi t t t t i
l t : t t ' i t r l ' r t
ot ' t I i I r i | , I t , I r t
r r l t t r ; 1i .
)' t' l
. .
l i
.
Mel rrhrl Jr, hurrontl l :. t.\ ,l l rurl tul
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ul tul tutol i l ,r rr.pr.,.zi rrr.r.l
l r ' . r t . t . pt l : t
i k' ( . i I l . l l . I ' L| | | I | \ . | | | I I r r r 1r t r i r r , I
l r , r r r r t r r l l r . r t l t r i
1x. , r l r , ,
i r r r I r r r l r i
I
. r r . r l l ,
- \ l i ' r . l , nt l
r . sl r .
I , ( : I r ' | , | ) I I i ,
r , i r , l i , r i 0r r r r , r r r , . l r l , <. u r r r , , i , f ol Ogi a . i i r l i r r r . r r si r r r r i l r ,
i r l u, r r ' , i r . r
l xr : r t c
t r
l ) cl . ( : r T. r l t t
ct r i . uI i r r t l mi ; r , i u, i supr r se voi nl ei
; i
l r t . l r . se: l r . st r r
l ( ' f l r , l l r f f . f {f l nl r ' r t s; . l t ) l l [ r nLr eb, f oh- l omA
l u ur i r r t put u! i si nt i r xct , pr i ur l r | , .
r nl , / . l | u
.
i t , t i :
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l ) r ' r | | l i r
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p. , r r . ot i r r
rrrrrri . rrrr.rrrl rl u l i rntonl i suprti ul sau fLrzi onat membrai l ui
Daral i zat. .DIcm_
r r *. I : r . 1r ) r ' i
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l a bul oar i i cu secl i une compl el i i au l l t i
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Fi i n l czi uni t al ami ce
t
pal , i ct al e ( i r . , , pi , , .
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rrrl .,r(' sl {. fl ,-r t4)scDto un heni eorp, d, qi -a pi erdul r
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l r r l l r l r : r . r ' , . au
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' ii']].'.,.1:,"_l .Fau
tliie\te o haiucina,lie heautosco;iricir,, in tn1, .,rro" *irro
lli
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srndrm
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si l r ra,{,i i rro gi l di m
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l . ' l ' r r l bt t r i i , r i al o cr t i si uni i qi : r , r t i cr Ll i , t i i cuvi r t l t , l t t t ' ( l t l r ) I I I ( ! ( I l I | | I I t I | | | | | I
l , r r r . r l r r r '
; i
( l o
at t i oul ar e a ct r yi nt ol or ) .
l l . ' l ' ul i ) ur i t r i i l L) r coepl i ei , cor npt ohcl l s i t l r I i i , l i ) nl r l l l i j ' r ' i i
l t i
r , r I r ' r ' r i r ' t
, r "r l , , , l r r l i l i r vcr : bal e. Aces| t a cor ut i t ui e af l l zi i t , , t r l t t r t l t r r , i t t t t l t l r t l t t ' t : t t l r , r ' t l
' ,
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r t , r l i r r l ul bul i t i l c l or Li l i i .
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; , r r r r
l r r l l l ut ' i u' i f ona, t or i i
] ) r o?I ' i u- zi so
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; i
t l r t pl r r t t t t t t l r t t r , r t ,
l or r r : r r r cl ol
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r r r ol r r , i r r l , t ' 1"i , l oi t t ' t o r t t ul t c t nl br r r i i r i :
l .
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I bt t r i r r i l c t l o t t ni si unt t si
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l ) r onut t l i t r t
t t t
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) t l | | | | | |
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r r r r r r r r 1 r r r r r r kr gnr po r l o l ) l t , r l i l i f sf i i I ' i
( r i l l i ( x) :
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l r t t r t r r r t l l t
i r , t r t t t r t i l r , ; t t r r , l n
r , r r r , ' or , LI r i t r r r , l , i i r l o i i t r t l r 1, t r ( t l ot t i i l l c, l i t , bi t t ' l c, gt t l t t t l l t r i 1. l t . ) . t \ t r t i t t l i r r t t l or r t
l r l r r r l r l or t t l r r l t t r l i sl l t , l i r r ;
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su, nt ' l t ' l r r l r t r l t l r , . r ' ot r sl , l i i r t i t t t Posi l t i l i l r r l l r l r l l
; r r r r r r r r r r ( r r , r ' c,
t t i r , I pt ot t t nr ( i t , r r , l r , r l l l i r t ' l , t t oi t l i l , r u i . i t t t t r l r , l ot r l , 1, , H, z, r i , , i ,
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l r r l r r r : r l r r r r r vr r t r l i i r r , r r , r . r r sl r r i r l i Hl ; l l i i r , sl r r t i l l nr r . l i snt , n. l r : t Lt r i r i i r ul r t , t t t i r t t t l r r t t l r t l t t ,
l r l r I l r nl l {, i l t ' {\ i l
r l r l r r r l ' t r r r i r , si r , l t , t i t t t t r r l r l l ol n, z, t l , . j . At x) r l , Ni i j l r l I l i Hr t
l r oi l l t t
l l
I r r r r l ur
r l r ' r , i r , t zr , r l i \ r l , r , l o ( l t t l r r t t r l i i i r t i t r t I r l i t , t r I l t , r ' , ' r r , r l i t r ( i l ot , t i r , t t t t t l i r t t r r t t ,
11l r I r r r
;
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l , t ! , j t l l l ! , l i r l l , l r l o; i r t r i o) r yi
r l r r cl t ' t t zt r l t r r r l t ' t t l , t t I r
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i
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I
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I t
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l ,l i ri c
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)
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rrrl l l i ol csLc crl nsorvat, or.i care a,r fi i ntenri tr"tea paral i zi ei . Chi l r di ci i
IroIr.rrr,r,rrI
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rorl rr rl r o
l i rr,r.i Ll i zi e
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ql ol ,i ci
sau i r, l utol a rl i ntrc el ). Trezi l i tl er, poaLe l i
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(trou
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]
san r:ei ebrul d, (i i ,feci l r,rr:a
neuro
rrrrl rri rrr0i ,ol cerl l l ' i l ,l ). In c*zul i u$oal e, unel t) totrerno si t Del fect cOnsi l l ,.
| rrl o si l ul tol rt. rnul t i i ,l l ,crate, ci ti i r,r' SLrl t
j u,1t,,.
l D r.l t zui l e ari nsal ,e cl c pa| t
l r,,i . rri l r' (i r!,ti , sl r,u totl l l i l , ru.uschi l ol fonatr.ri , i -l si stti rn l i t o bLrp| t.i i Li xc i r,
l rrl rrrri rLurrrrl oi l sc Ionerne, pi nri l a i rnposi bi l i tatca total i l , l l , rrorbi l i i , rczu-
rrrrrl rr, l l ti l ,cr' :l sun{)ti } el ei :nei ttnrc, sau l :l o afoni c compl oi i l , l n i t;l di ul
l r r r r r l r r , l p4t i r i i r i i l t i r l o, bi o- gLoso- l . r t ) i
l ( , sp
l r l cel l e
dl , l {r zqor not ul t l ahco-
| . , r ' , : r r r : J , , , ' l . r : r r r . j
r 1, 1. 1 1, , t i t npul cr l i j l t i ni .
| | is.lo n I il rt so i nlil n.tst: fn .. a,) Atitigcr.i ale nervilor recuronli
$i 1)neurn(l
,1rr
l i i l i . Ii r rLi vcl i rl gi tui Lri
;i
rrrr:di asti nul ui , care anNl eneazi i l al i l gupl egi i
r rr
.ri rrl rrrri rr<r.
r' tl cLrrcrrl ,i l l l o_ (r' uce t.l i gtrsi tJ, [.,i tunl ri i i , cu ti nrbr:n i r,si ul i i ,,
, r i r r r r l oi r | , i r r l czj Lr ni l o uni l at cr al - ; , r ut L: r r t bni i ,
j r r '
l nzi r r l i bi hLcr at i )
;
l ,) 1,,..' i rrrri rrl c l rrzci crrtni nl ui , cu si udroal l e Col tet-Si card, verntl b, Scbrni rl i ,
( l r r l l r r . r .
r , l , r r : so i nsol esc de. pat dl i zi e
l r oSr cr i r r i !
vol o pl l al o- l : t ; ' i ngec
I
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1r:rr' :rl i i ,i rr
Vi rLr-l l ui nqeo sau l abi o-gl oso-r' e1o-l ari ngee
I
d) Lczi Ltni cxti url (\
,l ri rl r l rrrl l ro prol ,ubr:l an{i al c, c:r, de excmpl u si ri ngon:Li el obl l }:i zl ,
fi
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l :ri r;rrl ri r r,r i ri o i ,l rrti cLi
;
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l l r l ! r r : r 1i i x) l r r r l l l r r ; o si bul bo- pcnt i ue; f ) Pal al i zi i al c r mr l cl i i l or f ol r l t ot i
;rrrrr
l ,.,.i rl r,r ct t' ri l rtl r,l i l a
l ol i ;i uni i
i nferi oare a cel or dol i , ci l cunr-ol ui ,j i
I r or r l r Ll , . . r r | r r r r l onl ; c ( oper cul i i r ol : l ndi ci )
;
g) Lezi uni al e f asci . ekr | g, , r i i -
r r l i r l , l ( i | | ( | r ' r ) i Ll nr r p set t l obl Lbar e) ,
.
:.1. tl i si azi i l o (rl i si cmi i l e l ui {kr-rsx, 19i 8, sau al i storri i l e vorbi ri i ) si nt,
l rrl l rrrl i i l i rrl c rr,r' rrroui ci , a,kt urorhrl l i l i i , al e l i trnrl ui si a,l e cacl cnl ei \.tl i rl ti ri i .
I t r r t 0r ; i r r r , i r , u, t t l i r si l i l l l r r si r r r r I i nt e si nL I el t t i t i r t r l Sl l Sul t l i r nt t e, 1l l OC i , r , ,
i i r l r r ! , r i i l ( r sr r , <, l ul r r , 1 0r ' i s| r Lt ( 1t r , 1, , l l 1t c0t i , r l i t r c0r i h' l l , t r xpl ozi r . ( i t r uhcsui l , r l
r r r r r r l r ,
1i r r r . r i r r ; r . I I r r k. ) ,
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. ' 1. i t t r t l r t t l t , l t t l l i r t t l t t l l r t t t l i t i l t t t t r I i t t t I c t t I I t I r I ( si t t t l t ot t t t l l l t t r l r i r t l t t
r , , 1, , , i , ' "i si t t t l t ol t t t t l l l l i i l ' i ( r i l l l l r l r l ") , i t t l t l : r l r i : t \ \ r r r t t i i l ' l i l I r i t r l ; r t t l l r
t t r l l , t r t r r t i l t ot i i t t
2si , l t i r ' ,
l t r l t t l r t l r ci r t r t t l t r t i t t r r i sl : r ' i i r r r i i f i r r t t t ' i \ l r t t i . ' : l r l t t r t t t t
, , , , , , , , , , , i i t , , , , , i i , , . i r i I r ,
,
t r i z. i
1
i i I r
I
l . r . r l . r ' ' l l r r . r i . r r r r r r ' r i
l l i t r
t l r t l r ' l t r t I r ' t r t , t t I I t t , '
r l , ' r i Ll r t t i r ' , gco; . 1t ' : r l i l r ' l r ' . , r i r l i r r
l r t ol i ' l i r t '
l r t t
r
i l l l t I I I I I i I I I | | | I t I i l t i I I
(
'
| ' I | | I I I I
l r
| | r i | , I i ! i I | | {i | | ' l r t t i t r l r ' l | t l t t r t l i '
: I t /
. l l .
l , l t r : i r r , l r or ol i r cor r sr : j i r i r r l r r si r r i Ji t l r t cl
r l u t , - r pl i r nar , c vor . bi l , r i i , ,
, 4, r ' r r l l
sl l l l st , r . i si i . l . i ol r r : t vi i i l l r 4eg cr . el _ce l i se spune,
j ar
nu pt i t , cvoca
l::illl, lll
,:,' l:l
ll' ill,' rL1r' rr
crpriinlre, cu al1,c cuvinti ci s' " oru, in ii"posiiriii_
] . , ' 1. 1t : . 1] . . : ) , : , - , r l l .
r u r nl . r , i , i i f on; r t ur i . r ni . . nar i l e cor enpLUzr j l oal d
f cni l u
: r . s( , , . \ l ' t Uni r
t r r \ ' ut br l ' ' O. r l i i . . i nr r r . r r r r r u; , . Li i mi i ni i , pent r U a Sc Ci pr i ml
rrr vor l ri ro scri si . Afazi a, rnotol i e
cupri nde 2 forme- pri nci pal e:
i ,fazi a
rrrol ,ol ur prl rpri u-zi s?i ,
(al emi a) qi agrafi a.
.1..
Ll.,fcntkt
{.a;fazia
motorie propriu,_zisii, (mu,tria
lui
ptene
Marie )
lrrrrsl,ii,. il imposibiiitatea dc exlximare oralii. Este produsi,
ae feriri"i af,"
..r)11111' _i .
,,i rnagi ni l or.t)
yorbi r.i f:l rti oul :l te,
l ocal i zat' i n pi ci orul
trontatei
r
,
t
.
t ,
, i
; r .
.
r I i r r . t i l r {l r . nnl r u I l ui Bl uca; . r , u r oI i n eLabor ar ed-
m i sci l i l or mus_
{ r , ' r ' l , ) r r i r l , r f t r n l l r npul ! or bi r i i : r . r t i cul r l n. Spr " dcosebi r e de muLi sm,
i rrl l ul i rro(l urnrl e col o l utr i nasi \.e, bol tayi i fl ot pronunl a ci .te,un cuvi nt,
' rr
o,\i 1.,l )i i (ta-ta,_ti -ti ,
rni l -ma, da,._nu etc.). 6i fa; efo"i ui , urrror_,e p"' tru
r r r r r l r . i . : r r r L. dr ' zol a{i
; i
i ' a. ci hi l i r l i o- r . anza ner ou. i t ci Lent t l i vci
- l ur
de
. r r i , ) l r ' r . l ol u- r ocl t doi ol gl . sl U. l i l a| gi . l n l ULmel e mai Uf uar o, boi t r aVi i po0
r ' \ l r l l l r l ; b
' ' l l or : l
. ' U\ r Ul p
"aU
I I AZe Sr - Ut 1o. \ dcset Ci SpUt : . , sl i U, daf ' nU
ll:il.^. ,ll:l.9iflii1
rlroruntii,
substa,ntivele. Alreori t"t"'avii uiiiizui"x p""i
l], i:' ]il::-I.
tjl loc d_e
,,qutri" sptn :.,,[sta este cn care se taie' ,). Deieori
r ", l l r i r \ . ut
r {r
nasl
r cr zi nr i l r r i , . a. cr pr os. i \ . i r , i ndi ci nd pr i n moi l i i i c, r i al e f cl ei
uLr.r plin gesluri, ooea ce estc incapabil
si, cxprim6 prin grai. Exprimarca
r u loirrrlrri (lurniratul,
denllrir.ea zilelor tlii si,pfdmin? sau a lunilor
rrrrrrl ui , ci ntatul , reci tarea ul ei poezi i etc.) este i nai l i ne conseryata.
. , . i r r
r f : r zi : r
^r not or . i e
}Jul or n
i nt i l ni ur mi i or r el e gr upc
dc t ul bur . i r i
( \ r i r . t , ' ; l | r I l r n. ( Jmt l r edaoe
l i J) ur r nd,
j 939;
l l ol al -
l i
Lhct , r nj e.
. 1963) .
;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
:l,l.,,flli:.].1:1ll.l,i
p0sibiLif ititor de,crprirnare, pinilla
tulilurii,ri
-tA;;;1;;
r . \ l 4r , l | ol 1i J ( i n( , l a osl e nocc_' l , t , i r t t i l i zl r cr
dc l cst e speni al n. Di n' pr t nof
r.lr v1'11911- lorLcticr
'orbi.ea
estc net tletorrnnti. r-i"earizarea va-torilo'
' ,1
:1.]' l ::'
l l l l
ci rrc\e, rompLrre
l i mba,j ul necesi ti , o
"oor,l oo^l "
Ierfecti i ,
a
, l l l rrUl l r.Ll re[[, a tensi rmi i corzi l or vocal e, gi a
,,forrnul el oi , rnotori i
l rrrr' .
r' r' l r-l i l ri ngi ene' caro si nt propri i , adec.i i atl e ti etl i i rl i i -ton"m.
s,presi -
ri r (,,
si / ri i L. deteri orarea foncmel oi crpr.i nrl : el i zi .ni , asi mi l i i ri (ex.' ;;i i
l ] , 11"' j
, l l l , ' r i i . Fnni i i r ur i - . pr i , {r cl r nl uc, l c, . esl cl ct c. ) . or r br r i r i i i l i
11, ci .
i i l l l ' l l l : "l ' l l "' l ' 11' i ' 9t , t ,
mel : 1r ozo ( bel . r i l ou
i u i uc dc [ r i bel our . npc| | i nzo
( |) || , r, rr r I I r.i r i rL l u( de tl i bl i oteci ,). Se mai prodrl c unel o modi fi c5,ri f6neti ce,
r rr : rr lr zir,lizl,r.cil unor vocale dcschise,_ diiiongarea unor r,-ocale, asurzired
r' r' |)r' {' r)rso:rl re
sonorc' o red,cl i e g10bal [
a vari a.fi i l or mel 0di ce ai e vorbi ri i ,
r r r,,Lt:r,lizir,r..
a, accL'ntului tonic asupra fieci'ei silabe enuntate etc., merEitld
l i rri i
l rr rl i sl orsi uni foneti ce compl exe. A):i ,j oual i rre qi .,;trl r.
i i g3g,
-i ?.6ti
rrrr r.rrrri l , i .i [l i c aceste tul buri ,ri an:rtri ce qi fonei i ce *.,b i n";;;;i d;
. . ; r r r r l r r ' r r r r l , ' , r l ozi nl cgr l r e
f ont . l i ci . ' .
_! nsi "l i r i d 1i
ar upr a apr a. : i ei buco_
r : r r ' r i | l r . , i t r l r r t , r r r nt l JZt r cf l ar . oSt 0t , I t dl l ut , - r i ai e eSpr eSi ei oi . al e.
..l r)
l rr .url rul turb,rEr or de arti crrare are afazi ci ror motori se si tueazi
i tt i i .\l tt(.' : (4l .i i tc (Al aj ouani ne
;i
col ab., 1939, 1964; Il ori ad_Krohn,
tS+Z :
I i , )r r,z, | :r(i z). Ao(,rtrt,l toui c,. ri tmul , tonal i tatea,, ti mbrul si i ntensi tated,
r , r ' : r l i z, . r r zr r . r r r | ' l or l i : r , . si r u. l , r ozo( l i n
r or bi r i i . I ) . j n pr o. oai , oe ; t , t et eE var i at i i Lc
1r ' | l l | r . ] r i i i t t {. r t t t . l i , l ( l Dt o l , r t l Al r - t . : j do r i t m, cai , o cOnf Or i j t . Or bi r i i t l i VCr Se
].1.,.,:1ll!,..../.1' f' ,,*t1,
I)r1,2(,rlrc
oslo grosolan
altoratir, irL afaziilc motorii, incit
i l l . r s' ' r . ' , ' . 1r , (
( r , l r l
l , ( i l s( , , . . ul
, ul l xl l t r t vr t l r r i , f oi n, t . at l esoi t , vor l l i r t i ; l f i i nr l ' t yni si ,
( ' t
I l t i I r i
( .
| {
,
] , r I I I I I l L( ' ( ' 0| 1,
( l ( '
l i r r r br L sl l Li r r i i .
:.| t
r ' . ) f l t t , pr t : i i t t t t t r t . l i nt l t t j t t l r t t . t \ l r t t t l i I i r t . .
I
|
\
| | | I ) | | r '
I | | r I r I l o: r r r r : r , i i t r
l r or '
i i r l t l ' L l r , un( , f l r , l i t , zi r r i r r or ul j r i r r l l o l r r r l r l r {, i c l r , r t r l r r r xi r r i ol r r , l c. l r l r l r l r l r i l r ,
r cl l r i l l l i
1xt n, l c
l i i - - r l r r pi i , cl l n
j t , l n
l l r r r i r r l , i l , - 1, ul i r , l supl i t r r i r , l , i , sl r , r r l r , r l r r t i
i i l (
i tcva l ottc,rno: stol col ,i l l i i l o r.' ct l ti l l c. So i nl rel cgc pti n stttrol ,i l ti rt n' rl nl t
o t e ducti e a l i mbaj ul ui I' ol bi t, l i r, o e-rpresi e s1,oreo1,i pi r crr sl rr i r' 1,r' i i sr,,rrrrr i
l i rl ti c l i ngl ' i sti ci , ca un fel dc .Loi t-moti r., pe caro Jacksor) i l col IrIrIr,r' Ir, r' rr
tttL tefl en de org5. Aceasti , expresi e stereoti pX poato fi corrsl ,i l ,rri l ,i i , rl i rr
l rrrorne, tl i n cuvi nte sat di ntr,un fragment de frazi r. Io
}i tr(l l rrsul
r.orl rl
l ri l i ri i , afazi cul i $i poate recuper& unel e formul e &utomal ri zi tt,(), r,rr,r.rr pol ,
rl ot' eni , i n mod pasager, noi sterooti pi l . Se i nti l nerytc l roovenl ; i rr l rrrrrl r,
lornncle intra.er.ebrale (temporale; Arseni, 1980).
d\ Agramuti smul se mani festl pri n i mposi bi l i tatea rl o I rrl i l i zrr l rrr'
rrttri l e (moduri l e de a$ezaTe a cuyi nbcl o{ i n Im,zi ,), cuyi nl ,cl 0 rl ri l ogi i l ,rrl l i ,
rr roti l uri l e qi formel e grama,ti c e al e verbel or. In cl tl rnl l t,gnt,rni r(i ,rnl l u!
i rl l i i l ni m si rnl tomnl denumi t
,,sti hr,[
neori l or", carc consl i r i l rrl i l i zrr,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;i i l r, j
arou n a;f a,zi ,i k:, tl i si nteni i l e. Oa
;i
i n a{a,zi rr, sorrzol i l l :i ,
rl l i i ti l zi i r nrotori e sc pol , i nti hrj cel cmai l ari ate ti puri tl e pm.tl i tti i ,,ti ;j tnl rttt
rr/,r:i ;. l supra, r.i rol a nu mai i nsi sti i m. La acestea so Ldl rrgi i rrrrrl i l rr rl o
ri nt.;xi t,
(d,i si nl ari .i l e
),
care constau i n aceea c5, i rnbi utr,r' t.: r, :rr' :r,rr.|rrr, rr
l l l zel Dr comporti r, confuzi i . Di si ntani i l e, numi to qi
l rt
i l ,-l {l i l rrl l ,i sr rr l r rl
.,rl sl arnati sme i mpresi ve' ) se di ferenl i azi , de agl am;l ti srno
l )r' i r
l ,(,(\.r, r' r,
rl rrc tl eosebi re de agramati smul adevdrat sau exprcsi l ' , i rr r,l rrrr csl r, r' rrl l rr
rl (r ri ti l .i zarea unui l i mbaj si mpl i fi cat, i n di si ntaxi i csl o vol l l r rl rr o
;ri r,r' rl r,r' r'
rr r-i :tl ori i el enentel or gramati ci i si al e si ntaxei , cr,l ' o rl rrl r, l rr, rrl i l i zrrl r,;r, l ,,r'
rrfoorentii, la conluzii in orrlonan_ta cuvintelor'.
l )
$i
i n afazi a motori e se i nti l nesc p erseue t' i i .r i l .(
fi
i nl t).1 i tul i i l t'
l tttt
t ' u 11) | 1, ,
g) Uni i descri u i n afazi a motori e o anosognozi a u. ul t:.i r.trl rri , r' tl t
rti nst*, i n aceea cd,, cl e mul te ori , ca,racterul patol ogi c al
l )r' rr(l
(,ti i Irr
r r,r' l Ir,l r'
l rtl este perceput de bol navi , car so comporti , ca qi cLrrrr :r| vorl ri rro|rrrrl .
Accgti afazi ci anosognozi ci si nt i ntr-o staro do oxci l rr,!i o p),i l ro rrrol orrr,,
iin cruberanlX, qi logoree.
Pentru enamenul a.fazi ei , m<tl ori i se ul i l i zc:l zi r, o l rr,r' gi i grr,rrri i ,l , t,i i Li :
1r ) Test e car e apr eci azi i bi l anl u1 posi bi l i t i i f i l or l r l i r , r r l i l kr l i i : i r r l i i r r r r , r r , r l r r
a se expr i m& l i ber asupr a di ver sel or subi eoi , o; sol i | i i r r , r ' or r , , ; , r . 1, ; ' r , I r , l r r ,
l i )l }eme, cuvi nte qi fraze di n l i s1,e i ntocrni te de nr-ri i rr l fl , l i ' I, i n( rl , l r,
l upr i ndd, cel e mai di ver se var i et [ , ! i qi ansar nbl ul i <l c l i r nr r r r r r r , i l r r r , r vi r r l o
f i
de f r aze. b) Test e car e apr eci azS,
, , va, 1or i l e"
sol r i r , r r l i r . r r ; i gl i r r r r i r l r l r r l r ' .
, \ st f a' l , se vor st udi a si st emat i c : - l ) osi bi l i l i , t i l cal cov{x' i t l r ) r r l r r f r r r i r r l r r l or ' ;
: l t omal i i Le Yal or i l or f onenr i , e ei pr i r nr l , r ( r l cf o}r r r r i I i : r l o I | l vi r r l r , l or ' ,
i t i l t r cui r i dc cuvi nt e)
;
- nat ur a l i ngvi sl i . l i l i l cnvi ul ol r r r cr r I r I r r l l I I I r r i r , l
1rl )sl ' nte (substanti ve, a,rl l er' be, ol vi nl ,c rl c l cgi i ,1,rrl ri ,)
;
r r | , I r r i r , r ' r
.
r r, rl rr
i r l i t mal i e : l l i mb: l j Lr l ui oxpl i nr i r t
l
- sl l l Jf osi l . l r r i l o sar r l l ol i l o i r r r l l r r . l , r r l r r ,
.*rrrrrfi i cnl i i , rL I razol ol ,.
l nc: i r , . l l r i l l : r l g0r ' 1i , l i r r l i s( ) r r ( ci l r r {, i r l o' l ' i ssot , l 1) i ; ( i ) r r r r
1r | ol r r r r i
r . i r l i r r r -
l l t , j t t l sr i I i c si t t t l i l r , l i r r I t t t r c( , i l r l r r cor r l r r r {, r r l si l r r i r r I r r l or , ( , r r l r I
r yi
l r , l i r r , l i l , r r l l l r , l
l i t r | i 1^ i t r t r r r r l f t r t , r , r r l r r r r l 0 l l r r r l i r r r r , l i l l : r : r i r . i so r r l i l i z; r ' l t zi i i r r sl ur l i r r l r i cr r r i r r l , '
r l i c: - l i t r r l r r r , j r t l r i l l l \ 1l t t l r r r r l or r l r {i zt r l ( , , gi r l : r I i t r r r i ") ; l i r l r r r t r | r r | r r t l l
l r t t l i i , ' {r , ,
r l o l r r t ct t l i r ' , r l r r l r t r , , : r cr . r ' 1r i I r r r ' , r , r r l l t z
I
l i l r r l r ; r . i r r l r r r l i r , l i l l por r l r r . r r
i l l ' l r l ) i r l ' 1. r ' t t i l t t l r i cl i r ,
l xr r ' l ol ut l r \
( l r r r r r i l i r . ,
l r r r r l i ' l i ur r r ' .
r . i r l i r l i r l r , r ' 1r . , ) , r ' r r , r , ,
: l l i l ,
l r r r : r l r , r l r r r r i ul r i o l r l t t ( ' l i l r ct l . l t l r . i l l r l r , Lr , t r , r r l u\ i l l l cl r l t i i r l l l ol gi l l r r , r r l ( ' i r
1r ' : r zl i
I
l i r r r l r l r , j r r l
l r r i r r
pl r r l xr
, , <ol r I I I r I r . ' '
( r ! i l l i t i l ( ' l r [ c{, l i \ r ' .
' f \ l r l r . r r r r r ; l , or r , *r l oJ t . r r t ut i nr t
l t )
i t t : \ ' or bi l c: t Hp( ) nt i nl i i si r l - i r i , i l r , l r r
'
r or r l o| r r r i | sl cl 0t
( l o
r ni t i sl l s,
( l i l l
col l \
( r ' sl l , , l . i l l , ( r r l onl i ! ; I ) s ul i l j | i , r i
ol r i l r l r ' l ol sl , r L r r , i nt l gi ui kr t '
l l l ezcul i t t o l l r wr i ur r Lt t l ui ;
Ll oscr i cl e; - u t l o t l i l t l
l rol rr:r,r i l r, rn{ri $(i ori ) l Lri Ll c si uLl l i gut i nl ,o
})o
u}r tabl {)l r
I
.-
l ?or-esti l ti t, rl r,
.rrl l l
l rrr:i crrl ,
N rrl {j i i si ol i oar' o (are i -a i ost e-\}rrsi
i
- C' onstrutca tl t i .r' rtzrr
r.
(l ol i i ,
l | oi sj t,rr rl l :ri l mrl te c[\.i nte i npuse
;
- Sol i ci ti rl i tl c l cperrl l e ri ,,
r r r ( . 1( f J ( i l r \ i r r 1, c
; i
1r ' azc.
' !. i l gru.l i rr
(x)rsti l ,l ri o
o a,11;. forDri . t1e afazi e r-notori e, cai c eor;si i r i l
Irl rrrrl rrl r.r, l rosi bi l i ti r.t,i l ol
unui i ndi yi d dtl :l se cxpri ma c[ rj utoml sti ' i su]ri .
I,l rr, rc rl rrl urc\tc ur)ol l ozi uni l a ni vehi l centrul ui
,,i magi ni i or"
grai i rt l l {'
r orl ri l i i , l ol rrl i zat, i i r pi ci orul ci rcumvol ul i ei fuontal e, a doutl di n cni sfcr' :r,
r l | l ] i t .
,\gl l l i r csl e trra,i greu de :l prcci :l t l a bol nal i i afazi ci , dcoarece i i {azi i l rr
l rr rl l cl rt,l ci sc i rrso{:esc
1i
de htl mi l l egi i dl cpte. In aceste cazuri , se l ' ecul ' si l
i l i l l r prrl rc speai l l l c de exarni al e a, scri sul ui , pri n fol osi rea de l i tel e con{trr
i ir r rrr I c s i plin solicitarea bolna.r.ului dc a, sclie cu rlina stingii. Se poill o
,orrsi :ri rr cl i , bol nar.i i tru pot sct' i c ni ci spont:r,r:l , ni ci di cta1,, ni ci copi l l l .
l ,r
(,(' i
r.l nr' (!
j zl rrrteso
totuqi si r scri e, se consi al i ,
?oral Jrafi e,
j Mgonaj rl zi e
l i .
l)t
r!:rt\.t'&re (fonrirircno ascm[niitoare cu cclo descrise anterior).
I' tol tel .c ttti l i zttte i n so' tsttl sponl an, tl tctat pi aopi at si nt foarte vari ai rr
ri i .onsl ,l tr i rr : - Scri ci ' ea de l i l cre, cuvi nte
fi
propozi l i i (eventri i r,l , i rr
l rr.zrrl i l c
l l l rrver
i n consNrui rea de cuvi nte tl i n l i tere con{ecti onatq s,rl
ru l i srr po (i i l r' l oarrrc),
-
Denumi rea pri n seri s a unor obi eci ,e care s pr' c
l rrrl i i l rol rrri r.rrl ui . - Sol i oi tarea de a rd,spunde i n scri s Ia i ntrebi ,ri puso,
rl rr r rl csni o i n scl i s anumi te scene, de a povosti (i n seri s) scurte i stol ' i at:i r(' ,
rl 0 l r rurrrrl l l ct:r, ou anumi te cuyi l te o seri e de ftaze scri se, i n care l i pJos{:
rrrrrl rri i c crrvi nto. Se apreci az[ astfel defectel e de evocare scri si al e c
.i 11
i r,l or' (\ri
ur:r,rl rrl e rl csl Jora)) deformarea, cuvi ntel orr tul buri ri l e ortogfi fi ( o
rIl rrrrrl rIi r,l rIrr si dr si n trl ,-.i :i , etc., despre care anr ami nti t.
l',. tl.lt:iu ntirtd, (totalii satl tle tip Broca,
)
constd in a,socielea r:elit
i l l | r : r l i r | r ) r ' r , l i r r i t ' c dcscr i sc: Scr i zor i al [
[ i
mot ol i e. I n cont ext u] cl i ni r :
l xr l
; r l r , r I or r r i r r : r ,
r i r r r l r l onr cl e cel ei senzbr i al e, s: m al e cel ei mot ol i i .
l l . tl l l t.l o) ta i l i ni ae de aJuzi e. S-zru ]rl ai descl i s o sei :i e de :ful rrrt rl r,
: r l r r , T i r r , r r r r i r r r r r l l st Lr r l uaj pr l i i n bi nc i n r . l i r - i t ' l u al i zai e , , \ i acccpi Nt e ca el r t i i l i l i
r l r r l i r r l i r :
l " l
l t:i tr
t,nncsti ci i (t1tl sr:r:i s:i i ni l j nl de Pi tres qi de Wi l sol ): ronf ti i
r r r r r r r I r or r r I r i I i I l I t r r t t l c a pr r r r i un! r , , ( l c
a el oca anumi t c onl i nt e, mi l i i l l {' l
r r r r I r r Lr r r I r r r ' I r ' , l r ol r r r yr Ll i r . t i t ur $ul I or bi r i i di sr ur si l c l r t i l i zi ni l
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r r l r r I I l l r r I i i , r r l r . pcl i , r ' i i
1i
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: r , cel i i bcl r r \ i
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I : ol r r ' 1, '
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r r r r r r r ,
l r ol i l r i l i i ,
r l r u' i , i r , r l r r r r r t r l cl l c l r , j t r l l r , l , r l r c\ r i l i r i l l , or ' .
l ) r ' r ) l r r r ) l i l r l Ll
i xl
l r l i r r r r
r i l l t l r i i , r t r r r r v i r I i r r I r t i
,
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I r l or r _r r r r I i L
o sr r i l l i r l t r l i i i i r r i r ' ,
pt t r r l t r r r . : t t r t r r . r ' , 11; r r ' ; l o r i i r ' t t r , i t r i t t l t r r sl r r . r r l i i . I t t t t t r r . l r ' l ot t t t t t l r r r ' r , zt r '
, r r , r t r l l i i , : r ( r r t r r r , r i r t ct l r r r l i i r l t t 1t r i r t t r i i r t t l ol i ) l r ol r : t t r l r u
l r , r r l r '
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: , l l r )
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l , t , i t r l l l t ; r l , ' r ' : r t l r r , l : l i o) :
i l i r , l ol l l i i ,
I l I t t t r I I I I t t , l l t l r ' : t l l ol i l l : ' ' r t
r ' , , l : i r , r l r | r r i t r r l l r . t r r r l , ' r ' : t r l i t , l 1) r {) )
i l i t i l r r i l l l '
gr r r t t {' {}t t ( t I t , t i i I r I I i r I t t t I t , t t I t | r ' :
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L , r r l I l r r r r i r , r i 0r r t l l t , l i z: l r r r
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t , , , r r
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, r r r r ' r i l r i i , 1r ' o i ut i i , cl i l t ct l l t si i ' : Ll i t zi o l ul l l l o; i l i ( ' i )
( 1l l l l ( t i r ' l l l l l i r r i r r l l )
, , , l , Ll i
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l t al i ct o- t empol o
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, l Ll r r t ' st t t i sul t t i uni t i i i / i l or l i u*l i sl i t r t l ,
( 1i i r ' {! r ' r ' zr l l l i i r l r t r l r ' ' r . . t r ' 1i t ' '
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1l t ' r , r I or r r i r r r r l r ! I r ,
: r l , r i , r i .
l l , r r r : r l r r r r r r r l i n' l a' apt r cnchi r nat os r Li t ui bur i i r i dc vol l l i r ' ( , , , I r r ur \ ' r ' r r l r l l , r ' r ' o
l t l , r , , r r l l l l i l cl {l ' l l nt sc r , l }t c ar : Lcsca pune
, , i : r l , r cbi t
i " r l i r t , i l r ol r ur r r r l r r r r
r t ,
1r
t r l r i t ,
' ' . (l a,tnc
i .nl cLr!i oasc
Fi
tori ce (mcni ngi i ,i l cotcbro-sl i i rrrl .;i , r r r r r
,
r
.
I r r I i I r
.
,
r ' i l r l r L, r r l xr r i Jc cot ' obnr , l c, i nt oxi cal i i cLt opi u, ou bol l l t , t l ot r r r i r , , or i r l r l r r l r r r l xr r r
.) ' l ' u ntot i cerebral e al e l obul ui .ternporal .
;i
al c regi u r Li i
l xr,r' i cLo-l r.rrrp.r' rr
rrr , rtrl rrl rr sti ngi . Caractrfrul afazi ei oste c:i , ca cvol uo:l zi r, l ont
l rtogrr' .rrr,
r ! | l ' , , r I r ( l i r l ' l r t ear zi i
br usc, ci nd i n t ut nnr i i , sc l l aco ut r I hi s1; si r , t r l r or r , r ' r r , gr i , .
| . ' l ' nun&l bma cr ankt -c er ebr al e.
., i t atroJi i te corti cal e di n dcmcl fcl e prcsoni l o (bou,l r l rri i \l zl rr.i rrrt),
, r l r r . r l l r r l i zcl , z- i , t l e obi cei L- r , i nceput o af azi c anr mr sI i ci l , . Ar r r sl : r , sr , r r r o, r
r r , r r r l i l t i or cu a, l t e t [ l bur i l , r i cl e t i p af l zi c, cu al t . t i si t t t l r l r r t t t r r r l r r r r l r . t i t r l r i ,
r' r,,l rr;r,l ri
;i
cl l ,ul buri i l i de ti p derncnl i al .
f){,si grl r, I,n d,i agnosti cul , topograJi c pi eNi ol ,oJl i a l c i ri rri i ,
,ti
l ul htl tl ttl t
tr,ru"l t4i t:1: asr.tci ate: a) Il emi anopsi a l ateral [ hotrrorri rrri ,, rl l u,r' r, l r,/rrl (.1,
I r l r , ' r ' r r l xr t ' r r , r l i al i i l c opt i cs i n subst anl a ai bi i par i et o- t or t r pol i l l i r ,
I
l r ) l t r r r , t '
ri l i , rrtl )1orl l (i pari etal c, tcrnporal e
,si /
sau occi pi l ,al o
l )l ' r' z.i l rl ,i ],
rrrr i rrl ,,r' (1r
rl r rr L, l rrl , i rr sta,bi l i l ea exa,cti , a t,opografi ei ;
(t
Acrrl o l j n,, a,grrozi i r, rl i ' z t.rr,rr
l r r r r ' . r r l r r r i l l r 1; a- st i ngt qi t ul bur i l r i l e bi l at er al e r l o sor t t i r , l , ogt t ozi o ( r r gr r , zi r r
, l r 1. r i ; r l r r , t r t t ut opoagr xr zi e
$. a. )
cocr i st t i at unoi oi l t ( l l czi l r r c: r , l t i t r gr r
l r l r l i u
I r r l r i r r j i
l l i t r t cf t
post cr ' o- i t f cr i or u' i l a l obr . r l ui par i ol al ; r l ) Apl ' t xi r r ,
( xr r r $l
r ' ur l
l \ r , r r l col not ol i c
f i
nneol i i deat or i e sc i l soci a, z: "r , i n l czi r nr i l o pi u' i i , l r l r , r ur l
,
' 1, 1, 11, 1
r r ) l l ot t t i pl cgi a ( cu sat r f t i r i i t ul bur i l r i r l t : scnsi l r i l i l , a, l r r ) r , l r r f r i l
| ' r r r r l ( i l l , l {0r ' i o*r ' e, i nso}i nt [ l f r t zi i h l r ol ol ' i i , r ] ar r l r r l r t ul l , o ol i
1i
: r , l r r , zt t l r r
t r r ' . l , ' r i l l t i ar ' , i i col c sol l zol i , r , l o ( 1r l j n cxl , cnsi a l ozi r r ni Ll r r or ' l , i r , o sr r l r r r r t l . r
' r r l ,
t ; l ) | ' ( r t ' 1, r r l l t i r , r i h
l t l l xi oc,
dc cr ) ct r l r i i sor t i | , 1, ogl r ozi r , r r r I r r r r r r r r r , . I r ' ,
.
r r , z r r ,
I | | |
I
'
, , |
(
i L I r
1
i t , ur gi t t ni i
Di n
i ct o- t ct t I pul i c i t L cl l br l : r , t r r i l l l r l i r i l i i l i l ot ' r ' r , l r r t '
r r l r r l i l i r t ' ct r {i r u1, c. , \ r l i i r r gr r , l , o {, r r l l r r t l i j , r i l ol i r J' u, zi r c, r i l u f l i r r ci r , zi
; i
r r r i r i r nr r l l ,
r r 1' r . , r 1: i l , i l r r got l r t ' ; t l o
t Lr ct t i r r l r r l t Li qi r i r l i cl i ,
l l r t r bl cr r l r ,
I ' I t p( | r ' | , I I r i I r I | ' r l ' i r / i l i
, | | , r . ' r l , zi i r , si r r r r , pr i l xi l t , ( , \ l *. i our t , r i no si r nl i l b, , I l ) ( i ' 1
I
| | i t r I r t r ' I r t t r
,
I r r r r , t
,
t r r / l ) _
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r,,,.,i n,i ,r,,.gr,,iii,,
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,,,,,,,,111;';";,,li,J;illiiii'il''ii lil},,lii'ii,tix'#ili;"il:il,ff1:_imporra,,i,o
i l $l l l r l i l l r r r r 1, I . oI r i ci si t l r cr l
;:il:il:;t,,1,;,,1,j\,,llt:),-i1,1,,,11+1,,,lt31if
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,"i!,i,Ji!,,i,,i,,,,ii
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:l tl l l
11.
pBoBl,EME
D0 DrAcNosrrc iN ApRAXrr
1. 11. DUFI NI TI I
Pnntl u cxecutarea unor acte mai cornpl exe, nu este sul i ci un0
c r
,' ri
r,ri ,r' i l ,r ol crn:nLato si {i l nor' nal e tl oar c} for!:a
$i
cooi donare. ci sc i ut-
;rrrrr
, ,r r, oi r s:r, so desfi r,l oare qi i nl i r-o &numi ti , fori nS, si succegi uno. ExecLrfi t
,r,rr,,rrrLi i , l , i ni Sc-"uri l or, a gesl ruri l or, i ttr-o formi qi succesi uno adecval ,i tr
xrrrrl l rl rri , crrrrsti l ,ui e aLLpra.ri tT, i at aprani a este o tul burare a gesi ual i l j fl ,i l t
r,rrr, oorrsti r, i n i rnposi bi l i bl ,taa, pcntru un subi ect caro nu este ni ci paral i zl r,trt
rri ri rr,l ,rr,cti o, ni ci coroi c, ni ci doment, t1e:1, efoctuft corect gesturi l e. Cu 4,11,(t
\.|\ i \1,\' ,, nproi xi tt, csl ,o i ncapl ,ci t:ttea de a orecuta mi trc5,ri ai l ecvate unrtl
uoo1r, rl r;i l rol navul nu prezi ntl parozi , tul buri i ,ri de sensi bi l i tate, ataxi o,
r rr i ,r,r r l i i rr voI ttnta,l ' o uou tnl buri l ri psi hi ce.
Srr sl ,i rr oi i roal i zrl rcl unei acl i uni vol untare i n vederea i ndopl i ni ri l
rrrrrri st,rp l rl rr,vrt su rl esti i qonri i i n mcd grai l ai ;, l a trei ni vel o succcgi vo
(f(r,,i rrrf l rr' , l 1)77; Zl ,urvi l l , 1960) : Pri mul esre ni tsel ul cl nceptwul , \L atrL\
i r r r l i r i , l r r l i 1i pr : opunr
i i - l i
st t t bi l el t o un aoumi t scop al acl i uni i mot or l l
r , , l r r r r l r r r c, i 1i r r l r r l r ol cn, zr i o schi l i i , , o schem; i ani i ci pat oar e a act ul ui . Al
r l r r r 1,. r l i l ,rr n i atl .ul ,
,[or
nzul ,i i ri i l ri nati ce a actul ui ) a gestul ui , i n caro i ndi vi t] ul
Irr' ,r,,' ,1,' r,zri
l r rl crl oerr,r' ou,, di n cadrul stosul [i i nnozi c al foi mul e]or ki noti otr
i rrr.
Ll l ,c,
rr, rr,cokrT l i rnnLrl o cnti r si nt col o ma,l aal ccyate real i z' i ri i ac{,i uni i ,
r r , r l , r i r r l r r i
1r , , r 1r r t , r .
A1 i ; r r ; i l oa cst o ni , uel al i , ner uw! , i , ei n ot or i , i , ccnt r i l l u
6l
l Itl
i f|r' i r!r (f |l i nl l rLr' {Ji , i n j oc
* si stol ncl or rnotori i pi rami tl ' ,l l c, extra,pi r' &mi "
rl rl r, rrr' r' cl rrl l r,so si spi tl rl o), i l al o conouri i l l l rol l l i zl urol ac!i uni i vrtl untl l t' o,
l r r csl , r r l i l r t , I ' r ' r l r i r l r ozt r l t ; i ' t , doci , r I i t i r nl l i r r , l l r l i t , l r , cl , i v i t i r , f i l o r : ool or l , t ' r r l
I r r r , ' l , r l r r t r r t , i o r r r t , I r r
l ) t "l r t i zr l l , l r
) t I i r ' i N| l J,
I , r l r s I r
t r r r I r f , r r Ll l i $t r u, t l t t p t l t l gt . l l t r t i ! t t t
r , r i r l r l r sl ocr r , r ' r , i n l r i Lt r f
, , l l n
r zi r t ,
; ] osl , ul l i , J'
t ' , r 1l t ' r r zi l l , i , o t ot t t ; t r i t l r t l t l i u t l r t t t "
t r . l r i l r l l i r t r pr r t l r r t t l i i .
i , l t I
l l . r . l ' : \ A l \ l l ' l Nl l l ' Al ' l i A\ l l l ' l r l i
\ ,
'
, l i r ' s( r l l t t ' r " I t l l t j t l l t t t t t l
t t r l t t i i l r r l t ' t cl ol
pt r t l r t ' :
| {l l i : Lci i l i i r t l r l t r t zi l i r r ' ( l ' r r f ( r l l t l i r t t l l l i r r i t ' t r I I t ' t t i 1r t t I i I l i
r l r r r r ) t i r r r r l r r ) : r r ' )
r , r , , ", t t r t t l t r r t t ' , i l i t ' t .
( l t ) nI ( : l t l t . Lt ( t : i 1n' I i l l l r l i r l ; i
t Lr r scl l i t l t r t r r l t '
ool t i l r t t '
t i ' r i t l t t
r l r r ' r
' r t t i i ,
$r r t t l l l ' r l t t r l t ,
l i r r l l r i i , l l t l xi i L ; i i r r r l ' t l t t si l l t l i [ ot i i cl t t t i i t r gt t t ot l l .
l t l t '
t r , ' r , r | , r . l ' t
,
s I t i t t t t j t i ' l l
1t
r t t t t r t t t l i l i
,
t ' , t "' t ' l ' t ' t ' l t t l r l . t t i i ncl - t l t t l t r
r l i r l t l I r r
gi
i t r l I i . r ' l o
r f ,
'
, r r , r . r t , , ' t , , t i , , , ' r ' t , l t i vi l l ' r r l
pi i r i or r r l t r i "t i ' c'
i
l t \ r t t ' i 1r : i i r t i r !
r t l t t ' : i l i t ' t t l t r t t t t t t ' t '
1,
, , ' , ' , , r , ) :
st l l i hLl l r
gr r sl t t l t l I l l , l I I ( r 1I i n11r r o,
i nt l t t Lr i ' l l t r r a' .
cl ' t r ' ' I i l \ I
'
( I I I l ' i r I ( \
, 1, , 1' , , , , , 1, ' , r l ' t l r i t l sr l i t
l l r i t l
i r r r i l ' l r ' ( ; i oI r N r r r i l r ; r i r t i i nl r t nt i l ' i t t r :
r l r st t t i l t l i , , t
:
p, , 1, , ' t , t , , : r sr : l r i t l r i or i , t l t r l t , b: r t o t t t r ct Li , t l l r t ' pt i t t t l c o l i r l l ' so' l '
r l ( j r l ' ] i l l l l i l '
l l , l , ' 1r , l r ' 1,
( l r
l l , sl l l ) i l l N' soncl i t \ )
t . kl t ' si t sr l i l r pi na, t l o l t ' , . l t r i t Lt l a'
t l t r i r l r t t i '
, f , , ' , ' , , , , , t ' , , i , , r r r i i r r r i r t i gi r , ct c. ; d) i ni ; t ' i i r i ' i nl r a"zi l i ' : ct "t ' t t l t t r t t r ' Tt el l t si r t t l r ' l
r . t t
*n, , t t l t , , t t r t l i i : sl i , l t Ll t i l t l i i l i t ar , gost ul d( r 2l t \ pl i l l l ( l i ) '
i ) \ ( r ( 11l i l l ' l ' ( ' i | ; l r ' f l l l l l r l l
l r r r ' , r r r r r r l r r l t t i ,
i I ' gost uhl i de l l r l i o cu nl i n&,
! s
i n'
I l l i scr i l i l r i t t r zi l i l e ( ct no i t r i l l l i cl ' l nani p[ ] ar ( xt '
r l r r ol r i t r t l t r ) : r l ( r / l ) f : i '
r , , r r , , , l | r l r 11i f i t ' t oa, l i nccL{i i l r L, r t l ul r r i l a cr avr ' t i ' , st l ' i ng{) ]
( r N
l i t t l ' t t l t t i '
l r pt t l t
,1,.,, , ,,,,,,i r,l ti l l ri t, tpr.i ndcrcr, ti l ]ci
l i gi r,ri ,
i ncui rr,l ,nl tt;i i ,
I
t i r r
;
r |
'
I i t r I r
'
|
'
t t |
,
1r , 1, '
r r , : r i cl cl i r t t t t l r Li , ar t t nci l r t t l ni ngi i , punt l r cl l ocl l cl r l t i Lr t
pt r t r i r {' {l r r t l
r l r i , t , r , : r r t r i i cLl ohci ar
pl l ner ci l unei hi r t i i i n pl i c
; i
l i ; r i t r r r t l t t i r r l ' r "
, t . l ' r ' i r r i r r
( ' ot l sl . I t r ol i \ i l : descuul di n nl cnt ot i c, l ' ol t i l t ' t t t t t r i l i l ' t t t t I ' r ' t r
i r, rr r, ,
,
{ r)rrs{r' l rtl l ,i rl nnoi ti gul i di n ohi bri turi o1' (r'
l l , l r \
( l r ' of i c] ) i t d0 l r npol Laut ca t oat e acest c pr ol xr t l o gr r sl t t : t l i l t t l "
r ' t t
, r l l r r . r
' l r i l t l '
( r cs}ect i v i nt r anzi t i ve $i
t mnzi t ' i v( i ) sr ' i I i r r i r r sl l l r r i t r r r r or l
l r ,
l , l
r l r i r i r , ; r r r ; r r t ,
*t t i t
pent t u nr i n: l dr cn' pt d, ci t qi pcr r i r r r t r t ' r t ' t t i ' i t t l l : i l ' ) r r l r r
r l ,
, r r r l r l ' i r i r l t por ' 1. t l nt si , ne : I sj gul ; m cL bol r r l l vt t l t t o i l t {r r l r ' 4o' i t t l r ' r r r . i l '
r r r r ,
' l , Lr \ i ( ' i
r i n- t i r t a, r cl aqi t i nl pi ; i af : l zi ci l ) o &s( ' l t l ( r t l r . i l ' ,
l t t r r t t i t r l t i l l t t t i t l
1, , '
, t , 1, , 1,
l r ct r l t l t
: t , nu gr ' ( l gi , a, sr l l t l l , pt t l zel i {, t l i t t t l ot t l r r . t i ci l l r t t r r t l ol i i r t i ' i t r r t t l '
i , , , , , , , , , , t ' , * i i , l I ul t r ] r ' i . ul br u l l j t l t : cor i ' l r n l l t r nt t r t l
,
t l t r a' ( r t r { i r r
1i
t l r r i t r i l i r r l r r r r '
1, r , , 1
r r : r l l ot l r , l i r o! ' i uui n( r ut ' o- Dsi hi ( l ( l
' 1i
r t l . ( ' a' r r
( 1t l i ' oi l l l l r l l r r sr r t t r t r i l r ' r r ' l ' r t
1, ' , , , 1, , ; , r ' r ; i
I ol l ogt r , f i co.
l l "; t . t , I ) l l Ml t l , l , ]
( t , l NI ( r l , l Al , l ' l Al ' l l l xl l ' l l
l ' , f l l l l l r l l l ( f l ( r g( r l ' t ' t t ,
. l ot
t t t , t l or r t l "i ni ut u' l t t d' l l ' t t ' t i i l or I ' t r t l i i t t t t t t l t t t t t l t t
- ,
l , , t t ' r , l , , si t ' i r , t l t r i l , i . r pnt ur u ( l ! | 01i , {' i 1l l l t l o l i l r r i t t t l l r r ' , l 1}77) t cr t ' t t t t r t t t t t t t t t
, , r l ' r l r r l r r
, , r
l r , r t l l r : , r i . l ) t t Pi t l , i r ' ; t t t r l t r r t t , 0l i cl r I ' r i r yt t l t ' t 0 r ' o l t r . l . t l : t t i i t r t l l t r
I r t
r . r ' ' r I I r ' | ' i t '
, 1,
' r , ,
l , l t , r r 1. i r . r t | I I r I I I t r I i i
i 1t I t , I ot , t l r r o, , nr r l r i f i , i r l t , l r l or r ' l r r "r t l l r | sr t
( r l l l l r oI t i r ' l l l '
t r r 1, , l , i r l
l r r r , r i r ' l r r l
sl i r r g ( r r , t i l r ' 10)
i t i
' u'
l ' r ' l l t t t t t t t i t ' t t , , r r r t t l t t t l t t i
i t I t r t I t t t oI ut ' '
, r l r , r l r r I ol r t t l l t ot t l l t , l l l r r l i l
( r r l i r r ' {i ) , i l l t ' r r
i ' l
l l l l r r l r
' I
I I | ! t | | | ) 1 | ) | ' i t I l l l I ' r ' l r l l l l l
l r i ' , , r r r r r l ot l l l , l l l l i r i l l t r l r f t r r
l
r t ' r
' z
'
' t t l i i t
' i l r r l r r r t l ot i i t r I r ' t t I I
'
t r I i |
'
| |
, 1, {' | | I I | : I t | | I
| | 1
: ' l t l l
| . i t t r r Li I I t r ' I . . . r ' : t t r r : t , t l
l r l l i t t r l i t i . i r 1, t r r l 1 r r , r i oci r r l i i r . or r l r i l c( , i r Lr r , r r r r t gr r t r t r r 1t l
1q( xf Sl ht al
I l o( l l l ( x\ r i i
r r r i l ci i , t i l or . . A( . t \ r i 1( \
) , r l gt i r , l r ) o
I i i | | | | i , i { r ( \
1 )
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t r , l \ | ' r r r ". r r r r l i r l f r r , l or ' , sl r t r r r l r r r t ; r l l t i t t r t l o r t pt i ! r i t , t t l i t I cr I I t t r t I ot , r ' r r r t t t l l t
l , r L' r r .
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r ,
i , l r r r l l r
l r r i r l r ,
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\ l i
f . ; t ot t l r t , t r , r r t r r l
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M??) : l r , ct , sl i bol nl t r i nt t t l l i l , i
l ) ol
L' \ r ' l r l r t i t r r l t t r t r r r ' r r l r
.
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l i i uuI i gcor nel , r i c{i g. i t , . r \ l r l l xi i l , i t I r ' t t t t r oI ot i c i r \ r ' i r | | . '
r , i , , . ' t ( l ul r i , Kr ' oi r xl l r r r ' , 1977) i l r t l t r osol t i
1) l ' i 11
( ' ol r I l l zi r t , i t t l t r , t t t t , r , r t r l , '
' , , r ' r 1, , , r r r
r r l r r l l l r r r t r t ci i r , c{i ni ,
l l r i n r , ( l ( i l i l , i ( f r oi t t r
l t , t ' r ' sl r i t t ni i r ' l r . t i i , ; r r , r r l t l
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t , ( l l .
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r ' l r t c t l r r t , l l l i ' l
l r ol
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i , r l ' r r r r : r , l r l r r , xi l r i r kl l l , or i o : t t )
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| \ ur : r ' r i r r t t t t l t t l t i l t t l i r , ; i si r r i t l r t r xi l i t t ot ' r i t l t l t i t r r l r r i l i l l i st . l t r ,
, 1 , , , r r r r r r l r r l l l l l l i i , : r , cl i l s1, i i , l t , pl i r r i r sr
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r ' | , 1, r l , , l : r , l r . , r ' l r ,
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Ita se l rrl rri .
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i n a[ r r zi : l mO1' o. e
Si a l r r i l r r ( ) {. i r , .
r ' r
r r , r {"/ . r a' r r r r ' , ' r : ' r r r "l r i nr ' , f i or , r i i a e' i r . i pr +ceut r ar e ( Dcr l v- si
Lber , r r i r . r . , , .
r : ' r ' . , ; \ r : 1. . 1, ) ' i ut l t n{r
: l
LUe. nt 1, l c, 1960: K' oi nd. l cr . , t gl l ; Ar . seni
; i
I J. l , r z,
,l l )l )!,,
l tt0{)). P..tru rr, sr: prod*cc accai ti , apraxi e, trebJi e si , exi i te rl rrrrl ,
r' l rrl i rul ,! rr r,cgnrnen i l teri o]ti i a, ari ei preccntral e gi
a i l oua l ezi rrtrrr
|Ir)rrr t,l r l r) i urrl u.r)t cmrst,l rj sau i n erni sfeta opusi , (Arscni , 1959. l g7g).
,
l ;, ,\l )raKi ' l .ru' chi ul ' i
se. caracteri zeazi r, pri n di fi cul ti ,l i l e bol navul rri
' l {. . r
, . , . l l c: t , r n pr 1 . do a
q"
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si de a ur i r l
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r : r , p' r r . l i c J5o( . i i ul , i unnor i
i i
c, t i emnc dc l pr ar i c a' r ncmbr , l t , , r , .
lrlsl,,1 rrsir, toarte g_rer de rlitelenliat dc nra\ia t""ncnii f"i
ryi
Ae asincigi".
.\ p.rl tr i rL krzi uni dc rl i vcrse ul turi (_i ntl cosebi
tunori ) l r,i e brrpof"i -ri i *
j
l r u I l ,,l l t;i l k), prccum gi
i l bo.r,l :t l ui
pi ck
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,
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I l ) ; ; i .
. . , . : l t l J| : t l l rrr{| l l ui
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ini[,iariici
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| l . t | l . r . i t t t t . A$1l el . i n t i mpul t ncr sul ui pi r i oar el e
se i nci ur . i Sol zl ,
, r , , | | , . , \
l l l , . Tg c| |
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r ni ci . pr . vi r f ur i l o pi ci Oar el or ,
bat , nasul Oe t oc t l r i
r ' | | ) ! , ; r , , / r , . ] .
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r r ' r r , : . . , . \ i t , r \ : r . i l 1r u i l , l ) r i r \ i u
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mur sul . , i u, pat , e l n I ezi uni
l i ni l oosebi t umor l l r r )
: 111 ' , , ' , ] 1, , , 1
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car , ' i r np- l i c;
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r Lt . l ' ur r l i cou[ unda l d, cu l i psa de i ni l i at i vl
1i
dn, t or r r r , r
p,.trl rrl , .rr rr,1;l r,xi N trunchi ul ui a l ui ' Brun.q sau-cu fenorni nd
d";,;;g,ni ;i ;-
l ; ] . , 1 , ' . l , . l l l . rl . ' t j ' i r. , ra, or: r, i i on)
al . mcmbrel or i nt eri oar" f al i Ae i ol , cl i i ru, .
r , . r , r r , , : r r , , r ' s t r : r r f e p. r ct r oOt al c
( Kl ei nr l _l f l , ,
1977;
popovi r . i u
qi ' Aggi r l r r ,
t r ) r i ; \ t , , y{. r . pi t t r r r r unl 1900, ci t ai i a" Xr ci nUi er ,
'
f Oi ?; ".
ll. \pr.rrxia rlr imbrieare (descrisi,
de Ildeaen) se caracterizeazil pr.irr
r r r r pr r r r l r i l i l , r r , l r t ,
l xr l nar . ul ui dc, a. se i mbr 5oa, . de- a se A"r n"i . o, Oe a qi i r gi i
I r . r , \ . r l : r si
; i | r r 1. r r r i l , . r l e l a panl ol i , dc a maDi pul a, i l r mod adecvat di v| r , l ol r r
l l l i , ,
, ' ,
' ' r ' i L( ' . ' r . ' r l r r
( i l , Lr 1, spont an, ci t qi l a coma, nr l i ) . Se asoci r r , zr - L r : t 1
r ' r , , , r "' t
, l ' , .
LJ' | | 1I I I i | | r I i t r capt a. sl , i ngJ, J
cu t ul bur i r . i vi zr t or
ur r sl r ucl i vo t i /
. , r , , r l u r l l ) ut . : u. r : r . t , : s, . t l 0mci cor por al o
5i
al t o t r t l bur i i r i gr r uzi r , c
( l c- l i , j : r r i r r l
l r r r r r r i s' r r ( i r l r r i
sr i . g. t , c. ) , evont - ual qi un r r ur ni r l ni i pi r , "r r , r r xr ' i r ni
st i r r gi t r
l r l r r r .
l ozi r ur i pr r r . i ct l l o, l ospcot i r pt r i ot o_ocoi pi l ; t l o
r l l opt o ( l l Ccl on
4i
, \ j r t l i r r , ur r r r l r ' : r ,
l l ) 51) ,
l ) . , 1; r r r r xi : r , . s i r n pl l , ol . i r : i i " ( , , si r r r p: r , l , i ci l , r )
- l cl l uol l o( r , r c( j 1, , r r . r r , ) r nl , r r
I t t t l l l i l r t i c r r t r si t r l l or r r t r t l t , i cor r r I l cl , r , t r , l , r t , sr r oi i t , zl i o t r , I l l r , l i r r l r , r r I o r r r I r f r r l r r t .
; t 0{)
l r r ' r , I I r
,
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l r l r t l r
, . r l i r r l ' , r t l r t l r r i | r ' ; l o t or t l i zl t l l t r l r r l ozi t t t t i l l l r r t ' t l t l t t l l t t i t ' l l l r t r ( i l t r l | r r l r ' l r t
, ' , , , , l r t zt i l c l t , t ' l ' ot oi t r r r t t r l t t t l l r r I I I t I t r t i t t I t , t r I
; i
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i i ' . ' l r u r r ( l
r i
l ( l [ l ) l r t r t , I 1) l i : ] ) .
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l rr
l rl rucl i r,i i ,,
:tpl i l xi i l e api :l ,t de cel c mi l ,i l l ul l to tl ti i tr l t:' i urtr t' .tt(ttl ttt'
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1
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LLt.
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r l r r ( r l r r r l r r l
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r r . l i zi oLogi ci , .
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; ' - 1. 2. 1. As7e?t e Y ni ot ogi ac
' ' , r r t n i cl ) l oz; nl i , o sl t r ' : p' l ' t ol oqi ci i ,
r n *r ' r : r t : r ' l r ' r ' i z' r
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i '
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l t , , i , , , ' , t ' . . i r or , t l "cval ' ,
: r r eacl i i l or l a sl i l nul i i
' l i t t
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i , i
l , ;
: i "t i "i "". "l cd; i .
cu supr i mnr cr '
( si r ' r r
. l i t r r i l r r r l l : t )
t r r ' r l t l r i r ( r r
, , , l Lr r l r r l ) . ou mo{l t r cal r u, i "i ut ' i t o i ' l o t l i vot scl t "
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,,,' ,, r,,,,i ' ,i n" hi dro-etectl ol i ti co
qi umor:l l o'
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n std' ri i d' e aotni i
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Ii rul rl i l rti r' trrl r' l :r l ' rrr
'
r , , nr ' I t l l i l gnosi l ", ^t r o""' o' ^i i i t xI t l ocol t l t na' i t r t i t l l or r t i I I I ) I ' i | | | I I | : | ' I I I
l ' r r r r '
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; , . ; . , r i . ; ; i - t ; o; i {i cni ' vasc, ul 1, r :
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; i
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1q,
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( r r xi ' r l r ' t l t t t : t l r r i r l t l l ' l f i l ' l r ' r ' l r
r r l , r l t r | r l l ) .
( )
l t t t i l t nnozl t , , , pt
t t l i t *i 0r l l l i ' " I t t t
l l r t l t ' l ' t l
i t t t l i r r r l l r r r vr r t r l ' t r : t l r t '
r ' ' r r r r r r
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l i l , . , , ' , r r ( r
I
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( l i i t i i t ' or t ' t t t t , r : r ' t r r l r i r l : r
l "
t l "
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J r t t l l t l t
'
t t t l t t i l r ( r r ' : r ' r r r {l r { r r r r I r ' r r r r '
l , r , r r t , t t l r ' r l i t l : l ' t t t l t l t l
'
l ) l l ' i ' i 1 l
' '
A t t l r r l r r l l r l t t l l ' l t r l i l t i t r t l
l l l t ' t t l o r i l ' ot r r l r ' t t i " r r r '
1"' l
, , , , , , , ' l , t
' , i ; , ' ; t r t
t r t t t t t i i I I t t i t I r I I t ' t I i ' r l t t t i t l ' t Lr o l ' ot t t l i
l r t i r r
r j l l l ) l i l r l . ' i r r
( l ' r l r ""
, i , , r : , , i , , , i i t t l r r t t l i i , r cl t ' r ' r . r l r r
t t t r t t r t l r t t r r I i ' l t l r . r i t t , I t I t ' t r ' : t ' t r r I ol r r i r r r r r r l r "r "r '
, r ' r , , l r r l l t , l , t r l t l r , i l , l l t l ) t l t
l r l l r r l I r l t ' t t ' t ' r ' ; 1i i
t l ' l r r l t t l t l r ' ' l l l ' f t l i l l i l t l r i r l l ' t t
'
r t t l r t r r
, ; ; , , , ; , , ; ' , ; ; .
( ' , , . r , , , ' L' pi "r ' "r l : r l '
r l "
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( ' r l i r r t r r ; r ' 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 r r
It
1li
I
It
1 I. I. PRINCIPIILE M]ITODOIOGICE SEIIIOLOGICI,
1)B DIAL.INOSTIC IITIOTOGIC
SI TOPOGRAI,'IC
12.I.1, Prcei zi ri de {tr.meqi
Qi al c Drobl erxati *i . i n:r,r.t,rrl
.rr,lril,rrl- vorir abtirtla succilt problcrnctc
de diienosfic doan itt std,ri.te t:attrr
lr.,a*r qi.in.alte
su,spnd.d.I'i de con$tienli, de scurtj, tlurati, ca dt,
}illii
i rr rr l urri fcsti l ri l e si l cepal e.
I ) i r r r uno51 i u15 sa l r cunr i i en
t i
Se 1n
l ol egc
posi bi l i f at ca cl e a f i i . r l - r . r r . r t
,
r t r l : r , : r , v( . i r i si r u a l t u cr r r r o; l i r r l i i de cer &, de a si i i n r uor ] i ust de obi ( . , . i , , 1, .
' - i l r . r r , r | l r r . nol e i nconj ur l t oal . e
1dc
r cal i t a t ea i nconj ul dt bar cl . J pi r . r r l , .
.rrr,rsl,ir4,ir, inseamnii it, nu
Dti
de sine (Dicfionarul lirnbii romf ne tnc,il"r,,,,,
r 1, l ' 7) .
il'rrlburdlile care survin in sfera cunoqtintei constau nu in rnoriijir,rlrr
rl ,r rl i l ori l ,c gr' :r,rL., cum.se.s1une, l i i nrl vorba-numai dcspre pr,czen{rr rri r,l
: r , I | {| | l l l L {1r ni l r U L, onsl l t ut e cUma.
Oorna csto un sindrom care, prin definilie, Se traduce prin abolirrr[
l rrl rr,Li , rr, conryti on{ci
*
el ement constant;i dorni nani
*
asoci ati i , frecl ,t,rrt,
r:' :r,lhr'ii,r.i alc luncliilor
^ve,getativo,
tulburi,ri biochimice
ryi,
evcntuill .rr
i rrrrrrrrrr r.urr)l r)gi co de di feri te grade, dup6 i nti nrl erea l ateral i , a bzi urri l
r rr Ll rrrrr:Iri rtI urrebral .
, l ) r r l ul u
du f i zi opat ol ugi c, ncur opai uJogi e qi cl i ni cX au dus l a cot , . l r , , i r l
i : , : . r ) , ' r r r o u sl ant de cunol l l nl t i , csl e expr esi a unei L. zi uni sau
l cr t u| l r i | | , 1
r r.r r l lrr ri,rn'a f-orma,liulii roJiculare ascondcnte de pe linia median-d, din tr.rlr r"
,l rrrrl l cr.rrbral . Porturbi ,ri l e l egetati -ve, care i nsol esc fi .ecr.cnt $tal ,orl
(l l
' ' r,rri r,
f{) {l i rl ,oroBc i mpl i c5ri i stl ucl ,uri l or vegetati ve di n trunchi ul ccnrl rrrrl
:r,l r,r.i rrl c.rIr accoal i l ezi unc, pri n i nti ndcro:l ei l ateral i ,, caro dtl pi tfr,l tl .(,
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t , r r r l r r , gr r osl i t t t l , t ' r ^t t <l sc ct t t t sl l l l i l t , i , r r r l l l i i ( t l i l t t i l i , s t l o : t l l r t ol l r l r r r . ,
t l , ' r ) . r l c r r r l r l ot t i i , sl l t r t l t t t t r . t ' r '
( r f ( t ( i c ( r t r t r t : t , I I i : r , I r r , I i ci i ) , l r , l r r l l r r ' 1' : r l r ,
,
' , r
l r r ' l r r r l , i r i ) $ u l r t t t r t t t i r t t l t ' l ( t ' r r r t r l r , t t l r , t r r i , r ; i ) 1 l t ) l i nr i i l t t t t | r r 11'
1, o; r l r '
, ' Lr , l r , r r r r ' , r r t t r ' Lr
I t r t r l t l l t r r l i t i t t
oI i l r , t ' r ' r r
i r i
i l l l l l l {r l r r t ' t t t t t t l I t I t , t I t t I t t t r ' ,
, , )
t
; ' r , r t i r r . l t r ol t nt t l ' i ,
r l t t i l t h i i xst t t r t , t t l i i r t t t t t t I t t t ' i t , r t t l r r r i cl t i t t r ' or r r : r r l r , r l ) l i , I
, ,
' I i ,
r ' or r r r r : r r r i r | , I ; , . i r ' r ' , r l r r l r i i r r r l r l r i c r ' r r t t t r , l r Jl l r t v{r , ( ' Lt t t l l l l r ' r r r {; r l r t r l l ' . r t .
,
| | :
l nt i l i t t
pr r i t r l i , i i . t l r l t l t
( ' hr t l t t r t , \ r / / , r r r
l r l r l l l ' r
i l l r r I r ; l r r i r r t l , t t r r l L l r t r l
i , , I i , r l l
l
) t , )
.
'
l l
(
) t l t r l
i l t : ,
t ' t t r t t r I t
|
, , r ' i I I r I r ' r r < r r t r r r r | , r t ) " t t t t t r t , i r l r ' r r l r r , t r l ; r . r
r i ' ; . , l , l r l r r r t r , , t : i r ' r ' t , I r r '
r r | ; I j , r r t t r : t t r ' , t t t t r ' : t l t r ' t l l r i ' l l r i l l r ' \ l r ' l l t l l r ) l l r l r l r
'
1 .
;
i ' . : l t t t r r l t , r r l t | i 1t l ) t t , l . r i , t , l r ! : r r ' r r r r r r l t r r l r t r l i . l l l r r l l l l l : r l r r r r r l l ol r ' ' , r ' , , ;
: i l | ,
i I I n,utnarat, l i pu,Lui raspi rator' (i j oi aoi c l rr, bl rba' l i qi abdomi nal l a femei )
rtrl i ci i , rr ul rvi l i rto rrraxi rni l a comei i g) Bradi aard,i a este caracteri sti ci ,
rrrrl i rl i rr{,rl tr bul ba,ro i n ca,drul si ndl ori ,mel or de hi pertensi uno i Dtracrani an[
pl i rr l rorrror:rgi e cel cbral X, hematoame i ntracrani eno, tumoni si abcese
cf |ob|r,lrr ntrningite
,
ineningo-encefalite. IIai apare ln comsle din nixe-
rlr,rrr qi in rxrle pril hipopituitarisrn
;
h\ Ta,hieard,ia apare in multe come,
irrrlrroscbi il cele infeclioase, in comele in care apar complicatii pulmonare
i
i1 NotntLc|a d,a l.e:iune aaloul,ard, ca,rd,iacd, ne olienteaz;, spre o embolie cere-
irlrr,lir,
;
j) ,lritnii.le card,ince
Fi,
alte mod,if icd,ri card,iace ie pot sugera meca-
rrisnrc oxtraccrebra,lo ale unci come (embolie, infarct, iusuficientd circula-
lrrlic lrermodinarnicS, etc.)
;
k) Eipertensi,unea d,rterid,ld, cu intXrirea zgomo-
lrrtui a1 doilea la nivelul orificiului aortic
$i
cu hiportlofia ventriculului
sl inq ne poate orienta sprc o hemolagie cerebralS,, encefalopatie hiperten-
r'ir.ii sau urcrnie; l) Eitrtotensiunea atteri&ld, Ia debut poate sugcra o insu-
ricrrLil 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.
-A.paratul
iligesti.ts, Vd,rsd,turile sint ncaracteri$tice, putintl st
:rprlrii, in nuureroase come de origine neuroiogicr, toxici sa,u metabolic5,.
Ilepatosplenon egaiia ne poate sugera o comd, hepatici,, leucemic5, mala-
rir:L, in boli de colagen sau a,1te atecl;iuni d.e sistem.
Dagluti,li.a este perturbati, in leziuni caudale ale trunchiului cerebral
tirrrlinl nucleilor :rervilor IX*XI) qi este un elemcnt de prim ordin in
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 )ruzor el 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 tlo-
tlrri'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,nioni IX
I
inl,roducem a,pii, in gura holnavului, pacientul
trine
a,pa, cars
lrolboloseqte, dar nu o inghlte, are un refler c1o tuse, 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
ni rrl , l rrl ,1;o i n ansambl u (tabei ul IV); i zol at, el o nu au
y&l oare.
I 2. 1.2. 1.3, Y al ,oarea d,atel or efro, menul ui neurol ,og i c
1.. Il;ri.ttcn;la harniplegioi, l,robrLie vcrilical,i, din capul locului. Consta-
l ,i r,r' oi r, r nci ho,n i pl ogi i i rrstal i r,to bLusc sugottnzi i
-a,pl oi l pc
totrl cauna un
rl r.rci rl r:rtl ;
yl ri i 0rtl j r,r
mrobral $l l ,I l l n(x)ri {] r,11.q?}j i l ro. Itr sohi rnb, su]pri rri l oron)
r r r r r r i l r or ni pl ogi i i r r i ; r ' - o cot r t r t i t r . l ; r r , l l l , r i i n t r r or I l ot r l t 1u por r , 1; o
$ugoni ]
Fi
u, l 1; c'
Jr osi l r i l i l , r "r , l , i
r r i i , r l oqi r l r r ( 1; ut t t r r r , r ' o i t r r , l r r ! b00$ oot ' ul l t ' 1t r 1, hr t t t t r t , l i 0r n Nl r l xl | r nr l ,
; 10 0
' I r r npeI at UI a
I l odl f i c{}l l o l ul rr' l l l l ot r' ' l t (l rt h$ l rt f l rt )orl (: r
t l roi l rl
l ozl unl k}r
tl
llr{lic
lll
opclatorii
' l Al Jr ' ] , 1Jl . Nl l . r v
cer(llrirrkr r
ltollrrosllo
I ndi f ul i Lt , l , l , L r , , r r
t el ot l ul l L,
ahicardie
bmdi-
Sci i dcr ca pr 0l . t r r r l 1i ,
l ' l l l sul
arteriald
Impollant?i atunci clnd ccielalte
agravare
c0l ot l r l l l , '
curbe orarti coul l l r l
bradi-
I t 0$pi l l 11i a
(iullos,tii4a
Adinci, rapidi,
spuml
pe Lt r zc
l1olenld
l ) f gl r LLi t i a Tulbuleri greve in
deglutitie
IIemillegie
Iipilepsie
Si mpt ome de hernj e
lemporali
A( ( f r r l l r r r f r , r r
I ' r
r ' i l r .
si r r l n r I r I r ' l , r f r ,
r t r . ol ( , gr f L!
I nrport ant
cnl nr
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
rr,1,it prin probele motilitS,lii active gi pasive, cit
$i
prin inogtll if ir,l,r,rr' rl,r
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[
rrrcmbrel or paral i zate, care cad mai rapi d pe pl anul
Jxl l ,tthti
l rr ttttt,tttrvrl |r
(l c
ddi care qi d Hsare brusc5,; -,,semnul
pi ci orul ui toti l r In nl h,rfi )' nl
l rri Bogol epov (ci tat de Yoi cul eseu qi Stoi ca, 1907) : - trrl :tt;i rt, prt,tl i ri i ,
r r rir,ximI, ln afar5, a membrelor evidenliazl' lipsa do lovolliro itr
lozi{irl
i rri di al 5, a mernbrul ui paral i zat, pl i n hi potoni a rotatori l ol i ntrrtrti
I
.
l rtl
z.rr{,a parezei faci al e dc ti p centl al (evi den{,i :r,bi l i r, 1ri t.i ft1cs t}l t ttrri tzj l t t,x
l tt"
l r r , {i i l ur ' , pr i n
, , semnul
pi l r ' i " sau zt l
, , pi nzt r i
do cut i t bi ot t I l l l pl r t l r r r l r , r l r ,
rrpi r,t i l l o pe gl obi i ocul ati , l xJ
rtl i l l gi rroi ! rrrl ,r' ortrarrtl i l l ttl a' t i i srl tt
1rr
l l tt trl l tl ttl
l :rl i rrl rrhri , rn l i psl gri ttr:rsti tl o
1r*rl ,tl i t,
prr,ra l i zl l l rl ' )
I
-
l tntzrtttl :t,
t t t I i I r r I r
'
I ' t r, I tl
r r l l t , r r r r r r hr i l t r i l t i ul r i t r t l i i ; - t l i t t t i t t t t i r t t ' l t ' t i l t , t t l l l xr l i nl i l t t l r i l l ' 1, r ' , r i l l i ' 1, I t ' t r ^l h,
r l l ot ' ct t 1, i r , t t i r , 1, r . r i t , l xl r t r r i r r i i kr t ; i i I r i r i t r t r l ; t ' i i t , r cl l t r xr r l ot ' r ) $t , ( r ( t hr l l ( l ur oi r r l t t .
i t" I' rn(
l ,t.t
utti l u.l ' ttt' tl <L,, 1111v,i 1' rrl ' l rt' t' d( trNr).u(rt' t' {l l tuHpi l U{ roJl ox) rtrrtt
r l r r l r l r r r cr r f r . l r ) r l l ! 1i i , ( , l r , , l ' i l j l t r ' l | r , ; i ) : r , l r r i i t t i i , r r ' l
; r i t
I l t t t I r t i , l t l gt l t ' i i , l r t t zl l or
i i l l ' i
r i : t ' l l i t t t l r i r ' pt t , zt r t t ( i t , t t t t i I i ut r r l r l I i t i r l i i sl l l nsl l l r r i I or r i c l l l ui r r i or , r r I r r i i l l ] r r i
h r r l l
( l . l r l sl . i r r
l l r r r r l r ol r r ; r , r , r bl r r r bi l i l l sr r , Lr cor r Li l l , os
i r oat o
i ugcr a o l oznl l x)
IrtrrIr.rrl ,rr,l i i , trrrri ,r,rrl [1.r.r.r,I/u. LIrr gr(]spi ug rotl ox bi l ;1,el ' tt,l .]ru i l ,t,c Ial oa,t,o
l rrr.rl i zrr,l ol i o,
l LrcsLu srrgcti l tl o su:ti l i nl i , dc l runcl ri cet,ebr,i l .
,
:';. .4 ho[.it.'ctl re!l.et;ektr
.
o1teoleniliuoase sc poal,e constata in diabr:tr
rr l rcrrLor.i l gi i i c subi uahnoi di ol e, i rr unel c mcni ngi l ,c bl ci l are, i n si tual i :i ,
1r,{l \i sL{)l rl ,ci urror pol i ncvri te (pol i neuropa,ti j )
i ntei ti orsr' , eti hde, cl i abeti cc,
r:o.l i rgri trozi cc,
l xccurn
fi
i n hts. hr stntl i i ar ari sr,tl al c' conel oi , abol i rea
l ol Irxr,l ul ost
(]o-tondi noaso
nu prezi nti somni fi cal i e patol ogi ci , (ce1 mul t
prrrgr rr rsl ,i ci i ).
.
L L'rczerrla sem,.nelctr de rigitlitate prin decerebrare pi a cel,rtr de ri,oiditate
pri n l cc,o.rl i r:are (y. a.)poato fi constata,ti i i rr rnul te corne (vascul are,' toxi ce,
rrlri rr,l,rolicc, tunoralc, cncefa,litice) qi pot indica sediul le ziunii (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,, sem-
rrr:lc nctir4leale sint lerela,toare puntm o meningil,i (urrui lles) sau pentru
rnr l bces ccrcbral . Recl oarea cefei (cl atte s,,rnn6 merri ngeal e
' absen?e
sau
rLrr,r' schi!,:r,te) se poate intilni in proceselc expansile intralcraniene (tumori,
tl rctrscr Lernatoame) cu fenomene de angaj are.
6.
_Prezerrla
unr_ rnipcdri au,tomatico-rejlere ch co;r&ctar stereolip, o":d-
tLu. 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,ltc rni,sciri ges1,ua1e storcotipe) se intilnesc irrrloosebi in comele mai
, , ul , , r ' t i , . i l l o di n i r r t ccl i i , i n[ o: i c- r , 1i i , i i uncl c mo n i ugo- cnccf l l i r e.
' /.
1' t nurdturi ol e e.ttreni td!i l ot tu
a*p.(t ttc
,,bi i tdi
de ori pi ' , (,,Jtap-
pi nl
l rrmoi "
1
apr i n cornr.l e hepat i ce.
8. Mod,iJicd,rile puptil.are.
.Pnpileie
se prozinti miotice in intoxicalia
, r r o; r i nr r . c. i n. conLa ur o- nr i ce; i i n uncl c l , . zi uni pr ot u bcr a, nt i al r l ( benl or agi o
1,,,rrl .i ni .,
l rornbozi i . bazi l ar' ri , t unrorj puni i nc).
pupi l el e
mi dri rLti ce sugerca*zi ,
,r rrrr,' rrc:trtre al ,ropl mcA stu o comd, gravd,
vascul arS, O mi dri azx uni l ate-
rrrlrt (ipsilai;er-ali,
-lezirnii)
sc intilncqte iu heruatoame epiclurale, Nubd.uralo
r,;ru ir r tr;lcercbr ale, in tumori cerebrale cu anga,jare a tonutui temporal
ryi irr anovlisrnele de arterd, cerebralil mijlocie sau postrrioard (asociaid cu
l rt,ozi i
pl l pebral i l ),
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
, i i vr . r ' r ' , r . soci er oa, of t nl mopl cgi ci cu bcmnc
pi r ami cl al c.
car o r eal i zeazd
, r l r ' . r r i pL' gi o: r l Ler nf i , ,
nc sugf r oazi i , u l ezi une r l e t nl nr : hi ocr cbr al ( t unr or i ,
i ,rrr.r' Irr,Ii 1,o, tt ombozl l dc afi eri , bazi l ar[ s.a.).
tU. n,fl r.ru|
Iol o.n?,otar
-poi \I "
ti abol i r, i n conrel e protundc, i n unel o
|'' ro irr ciLr.(f srj &Nociazi afcctarea motorocularnlui coinun qi/ Sau nervul
ol)1 ic, pr'ocunl qi in comele vascularo prin a,
jeriti
lueticA.
, ,I1..
.l )eui al i a conj ugatd a gl obi i or ocul ari consti tui o un semn i mportant
rl l l t.zi rrnn.el ,i r focar.
_I)eri a_!i a,.
eonj ugati , a gl obi l or ocul ari spre-partoa
oprrsi, Ircmiplegioi indicil o lezirLnc eniisfcricil
1l_,olnavul ,,iqi
privegf,e lezi-
rtri rr,", conf{rrrn.Icgi i Jui Il rCv,' sh
f
i L:r,ni l ouz.y). Il cvi i ,l i l ,
*spre' partoa
h.rrri pl ugi ti i , i ni l i ci r, i l o obi cr,i . l (,zi tnl c nl r,i
j i ,ri sr' i ,
i n l rLrnchi i Ll <drcbt.l i ,l
(ri r rr l l rnr l tovi l l o
[t11,r r l rrrr,l r,rrl ,i rII i nl or:i or),
: i {) t l
l : ! , Nl n: r r
l ) t ! l t l
t t l pl : r l l r r r r , : r . r r r r r l l r pl c l l r r r r r i l i r , l r t i i :
l ) 11, ( x' . r
r , \ l , l t , l i l t v
r | | t r r ( 1 I i r , I r i i r , I t
,
l r ! r l r l ) ol l r l l l i r r r , r ' r ' I r I ; I I I I , r , r r cr ' l l t l i i , r j
l r sot t r l oi r r l r or . l r l i i ,
r ' r r l r , l t r , -
i ol r i r l ' i l r I I i
I
) r ' r ' I r
.
r r r i r I i
,
r . I r l r . I r r I o1r r r , I r . ccl l l r r r ! t i oi , l r ot r ol l t , gi c sr r l l r r , l l l r r r r r r
I t r r , t r i i .
13. Al rof i u opLi oi i utl i l ol et &l ,ri , l a, un bol nav coul i )l os porrl ,c sr' i rro i rr
Il rrrrrs
gp16
o hcmor.agi t subarahnoi di ani r pri n anel ri snL l upl , (rl i l ci i ri rrl ,
ri scrrLl e mcni ageal e), spl e o tronbozi i , de al terri caroti rl "L (rl l rci , r,sl ,r ri rr
l r(:rri pl egi c contral ateral i ) s&u spre un si ndrorn l .ostel .Kcrrrrcrl r'
l i l i rr
r r r r r nl i bazr l i i {l o cl aj r nt er i o) .
14. Motl i .;f i ci tri l e reJl ernl ui cornean, pot, si , ofcre i nrl i ct,l i i rl o prrrl rrrrzi rrrrr
r, rorttei r i at uneori prezi nl i ,
,si
t-al oare l ocal i zatori e. Asl ,fcl , tbol i l cl r, rrrri l rr,
i t' rai i n ne sugcl e:l zi l o l ezi unc ponti nd,, i ar o abol i rc l l i l ftLcl .i tl i l (rrrrrrrl rl i orl rr,
i r t i u
gr adul de pr of unzi me al comei ) ne sugel ea, zl o l czi unr r r r xl i r r si i r r r
tl ttl
chi Lrl cerebrul . Prezenl a rutl exul ui corrrcu-ptel i goi r_l i u,n (ur,
,si
:r rr,l l or,
r' ,.l l cxe
arhai ce) l re poato i ntl i el o suferi nl ,i f trun]chi ul ui i rcrti r,rrt, ,l rr,r.
l r' rfl Li l te ol i nu are val oa,re ]ocal i zatori e (refl exo cl c cl i bor.l r.c).
1i . Abol i rea reJl erel or
Jari ngi ,an ,si
1)el o-p&l ati n, rr:prczi l ti ' i , i rrrIi r:rr,Ior,i
1,.
l )rol [nzi ur('
i .i , comei , dl r uncori qi semnc cl e srLfcl i l fi i brrl l )l r,r' i I rr:r||
i,rtcuilobulbin'ir,.
12.1.2,2. Cl i ni ca si ntl ,ro mu,l ui comatos
Olinic, siridromul comatos,ue uriniitoarele co[1pouc]11,o :
1. Abol i rea, total [, a stS,ri i du cuno;ti nl d (cou;i i enfn;. fi r corrri i , rrrr rrrr
' otte vorbi de eri sten_ta al tor ti puri do porturbi i ri al e $1ri i ,ri i d.o crrrrol l nrl rr,.
a lr)ua
$9 poa,te agrava, ducind. la exitus, san so poate a,tnclioll,
I
I r r, r r i r r r r I r r I
rrr' ozerti nal i n a,ccst caz si mptome de trezi re.
! . Tul bur : l r i vuj j et at i vc.
.J.
-L
tL.DUraIl OCUm,IC.
4. Tulbur5ri neurologice,
12,L2.;i , Gradarea
Si
cl asi Ji curea comei l or
l l ator-i ti r, cl racterul ui evol uti y al l ezi uni l or, c:r,
fi
Ltl ti l i l ,i i ,(i i
l x\fi ,l l
i )r' l ri l or
y&sornotori i
exi sti o vari abi l i tate a aspeotel oi r,l i ni oo ri i rl c i 1t",,,,r,
,, sl ,ri utl cl $si i i ci ]rc rru cste posi bi l i practi c. nst:e i ns[
}osi l )i l L
(; grrrl rrrrr l
t' .r' ' ,turzi mi i comci
$i
aceasta este i ndi spensabi l si fi e reaLi zl ,ti r, d i rr rl ooo* i I,ri ,
I
i
cl i ni ce qi practi ce, adi cfl ds rS,spuns l a tratamcnt
' i
(l c
apr' c(Ji ol ,o pr.r,;j r' r,t
I rc,l,.
,G,racl ul
rl s profunzi me
a comei nu poate fi cert stabi l i l , rl rrri l , 1;11f i 1,
rri vel nl gi i nti ndsrea l ezi uni i maj ore di n trunchi ul oerobrtl ,
(l ol ,orrti txrt
rlrrpri criterii clinice
Si
paraclinico.
Dup5, acest cri teri u al l czi uni i cl omi nante, noi am propu$ si i i torl rl i
zrr,r'ea in 5 grado de comi,, cu urm5,tora,le caractorc (tabcltrl V) :
Grai l ul I. Bol navul este i nconl ti ent, functi i i s vogota,ti vo si nl ; l n l i nri trr
rrori nal c sau_,uqor modi fri catc, tol i ti mpi i ds al egl uti ti o sl nl ; pl czorrl i , rl o
rri {rrrruc& Iel ' l exol c rl o api rr,r.o
$i
autom&to pl ozonto. _ti ctl oxrrl rkr rr,[11,r' rr,r,'
l rl o prozcnt, bol n*yul so api l l ri l a, cxci tal i i l o oxtorocopl i vo (srr :r,l )i I,r"d, rl rr o
r r Lr Lsoi i , ) . . I l , of l or cl o r r , ul , ur nl l l ; o si r r l ; pl r r zont o, bol r l l vul so api l r i i , h oxoi l , r r , l , i r l l
1r t ' opr i or ot xr l r t , i vr , ( r l r r cr r r ni r l l l l l , oi t . U ( Li . ! r j i i r
i l r l ol l r o, so: l copor , i ' l cr r o
l r i i l , r r l r r ,
r l r r , oi i i i oi r l , o l l i g) . l , r t ; r i l ol o hi l t i nor r nl l n $l l r t f r ) t . r ui r l i . i l t t i r ui , r , r r l r r l l ux
I r l l l l t r ( r l , i ) r r l i t r t i t r t t r r , l s: t , u nl r ul i l , . I r r r ,
l r t ol r . l
r l I r r . i cl i , voi l , i l r t t l l r . j i , so r r ot r . t l i l l i i ,
-1
: ( ) t l
F,
J
r!
I
E
t l {)
+
: 5
<5
z
z
4
' a
6,1
r , ( 11' vi r , t r l l r r t r i r , r i | ot r , j r r I I I I I ; r t r
; , .
I r l r r l r r r ' , , r ' r r l t r I i i i I t L,
l ) l Lr l ( l l l ,
i l ' i ql l l i i " l , l r zi t t t t t t l t '
, t . i r r scut t r r r r t l t r l I i r t l l l r l l I l l , r l l t l l l l l l l l l l i
( i cl obr i l l '
(
l r l , r l t t l Ll , l i t r l t i i l vt t l oi l r r i t t t r ot t i l f i ct r t ,
f t t uo] ' i i l t : vog( ! l l t ' t ' i vo
l l l r xl ( 1l I I l '
, ' ,
, , "' ' : rl , ' i , i , , i i i ' y, t ' i i
i t . t ri , , t l
l , l rl t rgl rrf i l i ci r-: st c abul i t ,
' 1' f J: ' ), 1' 1"
rl t t rt t rl t t t t t i r'
i , ,,, ,",i Lst' ,' r' vrrti ., r,ol ti tl o ,r,i ri r,r;,r,i ti T
' boi i tt' '
I.ri r'
Il obi i
vt:sl i l i ttl i t' ti l '
t' rtIrti .l t'
, . , l i i o dovi | l c l er i t cor l . i ugr l l , i r , a gl obi l or ocul a' r ' i spr ' ( j
] ) r r l l i i l
l l r gr r r i r '
1,,,.,l | l ci } este l nedi n-ponti ni .
rttqd,ul LII. Bol nal ul este i nconqti ent, exi st' :i - gravo
l nn' trl l
l )i l ' l ' i
.i !l (!
, , l f , o u"u"i ur
j ' e,
i i l r t ul f nf J"gr r i i t i , . i , l or cabol i l . t i r r r l r r t l
I l i t r l i t zi r r ' l '
' , , 1
, , . ' ' 1, , j , , i . i , ; ; i ; ; ; i f f i i "i rt ri t , ' .
i * pr' ba rt '
j urrl rr' ri
' ' rt l ' t t
i ' : r t t "
r, r' rr,i ri ' i , u
(Ii ' l 1' rol e a gl rbi l or ocul ari ,
frecvent
.
di scorrj tt gi t' 1 i
'
srt' tt l t' ttstttrl ' u
,l , r i l l i i ocl i i l or' . Hi pertcrml e
qi i "tt"i ooo
"t"ri al i '
osci l arLl ' i ' ,
ou 1(\l r(l i l rl ri '
l r . r , l t ut ' r ' . Lezi t r ncl cbl , c i n par l ca' i n[ r ' t i oat i c p nl l l '
{ i rud,u.I I{. Bolnar-ui este inconqticnt, 1'otll areactit', liuno!
ii.ltt t tt4tt"
'
,rl r,, i i i i i i "te gr:ay pertl trbate' kr, l i mi i rr, curnl "ati l ' ' i l i trr' .ti i cu stl l )Il l ' vr{rl l l rrtri r"
,r,
.r,,t
l r.' i a-al i i i i i ,,
' rei l exul
ae i use p"c,ent,*i nti rzi at
' s.au
abol i l ;'
Nl i ' l ti rr' zo
i
.' ' ,' ;,,i l "i l ;;,l "' r;i ;;;;;t-$i ;i i i -o;pi "r' l i ,bol i t"' ri t' tl "t"l tr ttottl o
trtrrrt' l t
,
r,.. r )r{l l o-l .tr,i i bul are si nt *froi i i ".' ff*t"i Ai ta,te
muscul a' i i ,
' i
.r t' trttri rr
' ,
i, i,"' ' ii,' ,l" l.i;;;.-i";il; ;s!" io pattea
quperioar[ a' bulbultri'
t irrttlLrl | (eoma tlepir,qitd,)
'
Bcrlnav total inconglicnt,
crr circullr'{'irr'
t1i
r , r , , r ' : LI ; r r r l l i l i c; al sust r nul e- ' pi i n
met or l c de r csus, ci t ut ' " l " zi t t t r f r r ' . r "' l t t
r r , r . r t . r t r r sc! r nenl 0l e bul bar c i ni er i oar e. Si ndr ot nt r l
ct ] l { \ l ) l l l l t l r \
( ' r ' r r r r r r r
. r , r r , : r l l c i i cr ei el ul ui ".
l l l r,;i i c. tai l l oul tl e comd' depnqi ti ' - a,,& cui n t' l i )sl
(l o$otr$ trr'
r ' . t i r , , i l u, t l ei l i i t . Godon, i n 1959- - bupr i nct e t r ci oi t ' l ogor i i
( l ( r
si t r r l ' l t ) r r r r r :
,r) ,\br:lirca totalii a tuncl,iilor vielii do relal'ic'
l,) ,\bo1irea, marilor f unc!,ii vegcttltive
'
(,)
llEG cu traseu izoelectric persistent'
l l i D(rl ,oni a cor]l eei cu l i psa cl e transparenl d' a ei tl onot?1' ttton' r1' ttu'
t' rt' tt'
t, ,' ;:i l ;"".i .i ;i i i . i ."i *' ."t""e denoti , cd, Iezi unet , cttl t' i tts
l ' rrri l rrti rtl
t r t,
l,
r rit,nuhti tli:f zona bulbo-medularS''
I :l . I .2 .4. Probtame d'e d'id,gn\stic etiololia
N . Oont epi bpti cd. Cti z:r, cpi l epti cri ,
grant-l mal $' r i l l \ol r1i l n)
l :i :l ,],1:,,1:l
,t, t,.r,, .t{,
.r prol unhi , tul burar,. a,
(' on$ti tul ci , cftr"o i tnrrrrt, i '
ri r,sl l ,I);l (l l ,' ,,;;,l l ;i :i :
, r r l " o t i ro i dtt' a- si
poetaccosuate. tn r nocl brusc, sau r l u
1ti '
r' i '
i,i;ii',f;iiit#';i";'iiJA;ffi"'ili*-ffin;v;ryft,
aop'i
""u
ttrrittrit'zr'l'
Itittt'
.,;lll,'il;li**lr;h";:;*;,tl*t';*'*rr*qLll;t'":*lilT,f
,lill;lll:
:l il
'lili;i.i"p#ffi;;il.
b;A;"r,-'" , lost asistrtir
ari rfi't't'. rrrrrrlir"
,L L nr r o o sori oasa
"o^tnr.ro' r,i
.si
o catarmxl zi ' , caro rto l i i ' ttrut' ttq[tr'
.l )l tt
tl t
, ,,l,,ii','i''it,ir^i^;,ffi;;;;";;i;t-l",uiu-'ii
."u,ltntor' intru(iii) lr Hlirfil'rrl
;,,, ;' ' ;' i,,,ri;; i;;lu"uuf iiii"itt,t incirnrytiont, aroactiv la- sf irnnlt' i' rila
.rl' itt' t
,rrrr' ,,, r' rt ttrsltit' rt,llia, sbcrtorolsir,, S,t poi rtrtnnrca' in cLrlllul
it' ll:i l::::ilit' 11:l] '
, , , ' , . , . r r ' , . 1r l i r r r l r i i , r ( ' r ' r r ' {i : r J l i I l i \
' I ' r i "t
nl ) l l l t ) r r l l si t , l l t l r r sr ' : t l sl l t , t l {l l l l l ( r l ( ! l l l i r t
l r ' l i ' l
, , , , r ' , 1 l . i r , t r , r l t r , l i i o t l , r r i t t ' , r , r r *1, i r "r [ ' i ' i p' ol r r z: ' t ' , . r ' v' t t r l ' t t r ul t r l t t
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 , ' t i ' zci . t , ' l r t t t , , l , ' , t , ' , ' i t ' i ' 1"' t t t i i t t : ul i , r i t l l t ' xt ' l t ' r ' t l l l t t t : I l r t I I I I r I r t t r r i t t t t I t '
' l i , , l i , , i l , ' , , , rr, : ' , , i
, , , ; i ; , , ; , ; ; ; i
' l ' l , i , i i ; t ' :
i ri i ' rl n' r' "' i ' ", i ' t t t t t t rt t l t t rrrt ' t t t t rl i t ' t
. pr' rrl ' t t t rrl
, i , ' 1, ' r ' , i t i , r , , , , v, , t r l , t t r t l , , l , ' , r l r i l i i ' i l ' * r r r ol ' ol i i r i ' zi i l r t r r ' l ' r ( pl t l i l l i zi r r ' l t t i ' l ' l t l t l ; '
1, , r ' 1, r I , ' I , r , 1I i r I | i r r , i i ( r !
l l l i l , f , \ i l , r f l r \ o i t r t t t l l i l t t r I . r l : t ' r ' l ' i vo l i r ' l r t t r t i t t i i ' , t | l l r r r r r l r t
t t l t l ' t t t t
: l | l
l r . t r r l i r r r r : r , so: l l r sct r l , . ,
l l \ . r r r l i r r ( l r , l i r , r . r . l r r i . i r r r r r . sl r or r l . : r t r r i
i t , sl : .
ii'ii,iiii;.iil,l,:"{ijl
rlli,iilll
#iit,ilr',";ii'l}
r*li*ulr,rliiliili|l
l;iliilj;ii:l':i"1;".11'.lhl1!"flijll
ili.h$,J:;s,:i,;,.;:'.1.*,,','i.'
siriqrro'r,,
Itrrrrol ' i
i rrsi i , ooi rl a dovi uo
I
r
.,,,,
.,..ii
pi criv ;;i;;;ii;"li'i',:li;'i1i*it
i[in1til:,Hit*:
lj}*lim
i i ' l i ,;;:i l ,;l j :i l l i ;;,:l l ,;i i l i fl ' "1ci r'
&trrc se-i tnpunn' p' i i r i nvesti gati i ri ri ?i
;l;lj;i;:ii',lilji;i,iiiii,[i]""i:
'li'"il'l.ili'i;.T,J?f,$'Tl":l:iilill"lli
,,,, 1,., i
1ui 1
1,,",'cu,iilr, fi i ffi ililrt":?H_?t, *"""iL:,t$1ii;i,*
hip ertcn; i*i,i,
llig':f
*MJll]'l',:#i:::i"x
b""'"r*ir" il+ill#'i:'"
('1 ,.11ff,,:,"';
Iln'iltliii;i#,;,xxfti#fltii,"-1il,!:"xi.':',*':l"lfl lli."*o*i6t)tiebuio
lilti,I1uiilj,l,j;t
'l-n:*:,#.1*:-.*lxkill#";*i**ir'llili''""1'f"'u*#;
i J;ll, l;;;;
;;;;;';';ruu;;"1;;
i]",*if ?ffili"L'i""{1i:iii3'Tli:fir;
r f#'?i
t,r,',il;1,5';
j1T*,'?#*1.,.fi
;x*5:i-i;"*+i"rJ::i$il.iffi*m;J"l't{l;
2. Oonxele d,in accid,entela aasaalnre cerebra\e
;rllr:iitiHif#
jiti:ffi1"*']?:*:",*Iii*ilffi
'!1:':i,""#*ili
l::l tit
i,l:.*!t:::,,_,.n"i
hemiplef#lJi/
J;''J:,?li":iflli"i:.,,1ff?;*lf,;j,tr
,,i !]
l
lir:.,i:lt{*jijrlJ
fifi
1i.:.,1'#1"i3;i,*",""'sf,f
i
ji
tl ffi1""i"f;Tli i
irr v..rl.r.. cii,,,pari1,iD
unei corne h un.tind,r
""
po^t"
"".1"0"
porinifit"ioii
iti
;;il,iitiitfil*Ji"v,lliih*11,1?"ilfiliiti*t"Ji
i""i:tt*il.i*,*"i#il
: :iiiiiil', :{rl,"i iu
r,:liliiuis:t
":3f
r"w,,n*i,li, ?*:d:;*Htix,"ti;i
li,riiiil:ii, iii"".lil;
iT'lili;i,T.i,J,'i1f,.',",r1',Hi"d" ifT,.fj,li1.:"iTi,T'1,#
l;llii,il,i"i,?#i*:l1l*,?gH'Hhffi1"j_".i"11"i;*ii.lr's;r"il;;;
l i l crrl rl l tl l i i
cotoJ.rral o
l ri n
me
iiii,iil'i"lX"iiil,lili,t:l?Y*#.&?#,1#;"it#-"r*:#!;'#..ru
'i1,'
H, ri' .
f
r,,,,, r r rr, (Li-
r t; Jiff
stt.l?3f #til9,',ffi"*|t,1i#5,i#:filj'lii
r l r r l r r r r , . i r ' l . i t ' , r . r ' r . r r , . , i ", . 1' : . u, ] l l , l
unui hcr nal om post t r aumi t i c
et c. . 1.
, ,,,,r,lii,,itll,*;llili;,li,l'fil,)iLl"i'xlii
J";iffi""""_T,l,xl'3""T
imporLalrr ,'i
--iir*l*|lx'ffi
"i,h3ilii3xlihi3*11?J#j''il;3,{i$ {. 1 r ' ' ' nr i . ' t l i t r , ( 1v. l l t
l r : Ll
( l ol [ r .
ct r
_Eo. ' t ol 0n! i 1, ,
c' t t f uzi c sl t t t obnr t l >i l i ' . u, *l r r r
rrl l ' rr' i rr"r. l rr. r, zi [
-i rr
. . rrri r, , i n rr. . u. s t ru , i t ova u, , , uoi r' ar" . i t avl t , zi rrr, rrrt ,
r l ' ( ' t ' l l l ( l _r ' l l , / . l l l l ,
l , r t
l t t t i {i t t ut l r , l i uc i t {0l t ol r r i o t : t t i t r , l r t l t , l l l l o pt . ogt t r si vl ' i , ,
i l r
Dr l r r r
i Jt 2
ffroti '
J r , t t l r r ' .
r , Lr
I
r r
.
, r I r I r r r r t I t , 0 x i l kl t r ( t r i l t r r r l r r , r r r i r l , o r r I i t r I . r ' t r , r . r ' r ' t , l r t i r l
l r t
i t t t i i , i t ' t t t r I ' I I t , t t t t r i t Li t ' ,
r , ' . , , , . i t . . Lt r , , t t i , I t , t r ' '
I
Ll t t r , t t i t t t ' t t l t r r l ' , \ r ' l t l r t t i t i i
( xr l l l l ) . , l l l ? l ) $t l l l l l '
, , , , , ; , , , ' , i i , , i i r r r r r r l r r ' : Lt r r . Hr r r l l . i r r r . i i , l l r r r r r r r l r r , ' , zr r . i ( t r r r r r I t i r t t ' I t , i j i I t l r r t r t , t . t t t t t t
r L : r r r r zt l i , ) si t nl l {, 0t l t l t i , ol r t gi l t , i ( l t i i , t i r r : i , ( i t r st t t t Li t r ' l t l i vt ' t s| t l r r [ i t r i l t r t t r r t t t t r l r r
r1' ,' ,, r.i coi rri r,)
l i oato
fi rti :i l i z.l r,l ,i '
(1.(, (,
t,Ltru(,i !l
(! .trt .5r' l l l t' (1tt' i tt l ttrttt' rrt' ;1i t
' "' t "' i r r r nor al i r ' ! i
ct l ol n, pr i r L l ' r r gl
j i ' r i l l e unor t ut nor i l t t . r ' t t l t l {' i r r l . t l r r t t l i i '
,,rr,r
l i ' ! rl r r oi ri ent tl ai ;, pri n ml t, staze cereLrrnl o cu r-rvol Ltfi o Il rPi tl i ' r'
1i
rrtt
i , ' , '
.
l , o1ont
i t l edemai o=s
; i
bcmol agi c i nt t l t t t mr
' r ' l l ; '
r "i j dent i nt na unei hemi pl egi i l a un bol n: r v col nf t l oJ ( sr r ' l l or l r ' \ t ' l r r t i r '
r . r r , . , i ; nr o t om5) r epr ezi nt i - i n- gener al un bot ; , r i l or at gut t t r . t t l .
i t r f r r t , , : t t r ' ; r '
, , ] , . , , ' i i dent o ai cui a" cer cbr al i Tot uSi , i n unel c si xuf l ' t i i ' i r r
( ' r l ' r ' ( r l ( r r ' : r ' t r l l
I r i , rrr,r,l vascul ar s-a consti tui t l a tti stan!5, fa!5, de cd' j l o nrul tl i i
l )i nrl t
I i ( l rr|1'
r,,."' i fttcgi a poato l i psi , dar putem constai a al l i e semne neurol og i .. l ' t(\21\l r(r!
l ,rl ,ri t,tr,l -L a unor- semno neurol ogi ce (i ndeosebi pi rl q' 1i {al g)'
j ttsl ' rrl i ti rr
.,' .,, :i Li tent sau i n tl oi t,i mpi , suger-eazd, mai mul te posi bi l i ti (i : I t
' '
t t t r r t : t
; i i r r
, u r i t t ( l at i e vcut r i cul ar d' , -
pr oci s ocl uzi v bazi l ar , hcmat ol r r
( l r ' 1r ' t l l r r ' l r l
, , r ,
: , r . Ll .
h' ". at om emi sJei i c cer cbr al
( ct t mar c cdcm
l i i
sau i r l ) gr r "i i t I t \ t l ( )
l ' , 1, , ,
, , r | or al , cu c, r l r enar ea i n suf er i nl 1
; i
a enr i st mul ui opt t s) ' l ' r ' r ' z' t r {r r '
, r r ' , r l r , , mi pl "gi i i nr "ompl ot e l a un paci ont cat e cvol u- cnzd. spl o
( ' {r l r r i i l l {l r t : r
'
, , , Li ci r i nea unui Dr bces expansi v : hcmat om subdur al , ht r l t t r t ' l ot r t i t t l t ' t '
,,
' ,r,,),,1.
tumoal e ci rebrai S.
(Lrseni qi col ab., 1974
;
Yoi cul tstl tt
ryi
Nl oi t' rt' '
| | r ( ; ; ) .
i ' r' :l cti ca neurol ogi cS, ne mai i nval i ' ci , tol ' deauna, i ' ai trtt: tl rr rt' rt' l i ttttrt'
rl r,r.l |,rsti cl j l l de acci d"ent vascul :l r cerebral (hemor:agi t, Fr,l t i l l ,rt,t: i srrl ttrttri r' ),
. r ,
' , l , l i t : l 1o| i r l
r d, cl i mi ni , m,
pr i n cxat ni ni t i t l r ' nl o i ' l i r r i ( ' ' r
; i | | i t l r r ' ' l i r r i "' :
1, , , ' t r r r r , i l cl e l r aumat i ce cxl r aduml $i
subdul at
( i L( ' uL
i t i
sl l l ) l l ' ( ' l l l ) ' l l r l r r r r l r r ( '
, ,
",
t , . , l o,
r ' r cni ngi t cl e
f i
mcn i l l goce{aUl r ' l { r l 1u i l r sl i t l i t l c r r r ; l i r l i
l i
t t t r ' l t r {t "
l
I r r
, , ' r ni l , encr ' [ al opal i r , hi per t cnsi vi
si cr r l l Lr u
(
l ) ] l {' l ' l
r | i r '
l ti |r,grrt,s|i cul de mcefal optt,ti e hi .pcftensi ni i osi ,e ]' ol :L1,i V tttl tl t. tl rr i r|,l l l l i It|,
r,
, ,r i. nl toarelor eleircnie ; a) n6 afl6,r in falil urui crt'z' rrtt I t' t t 1
'
t t t I t r t I I
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, t , i r . r : l r cf r . Se; Amai al 6s, i r r cadr "ul unui f eocr omoci t ot r si l , l l r r , r r l r l l i
l r r l r ' l r , r r l
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, , . l r r r i , t si i ' sau al unui Sat u' r i sr n) , cu masi r - r ' t r ] 1' t ! l r . t t si . t r l l l i r
; i
t r t t i t t t ' r r l '
t r r l i
' l i r odi f i c[ r i
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) 1.
b) Oot t t i t t t t t t ' r t l "
' r,,rr
l rr.ofunr15,, cste de obi cel i tranzi tori o
I
c) O' trta, trs1,t: tl tr tttttl l rr rtl ' i
;rl ttt
tt
l r,,r,l i i ui
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asotri i t'
1i
:rl l ' tt rtrtttttrr
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(uri u i mportantul etl em cerobra,l )
;
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I
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'
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' l rccetl atS,
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i l amori ai a subayahnoi d,i and, de obi c.i nu crccuzi , r I i I i r , r r | | , i i ,
t
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l r i t i r r r r t l i t i t l i : t gt t r r ; , 1 i l r : pt r l l t r l t t I I i t t I
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loiate
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.
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' ; r : r l | ! r ( ' r , r l n, L| l t t t c t t cmot i t {j c i r r l r al unLUl al i ) , r . r ( j I t , l l I t t r , ui bemut um.
,
Q) I ' t t , t , t t st t t , ! a I or i . l u<ur '
onl pt i oaf ,
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j '
r ,
l ) r ' 1t r . a
l l . t r or r l ar , l r r i r i nl or os: t r cl l ac, , hr i r . sj f e| i r Or i i i
\ rsr' rri ' l rrr ri ngrLf:trzi -L trrr i .l aLct cerebral . Atacuri i e i Schemi co- tranzi tori i
( \ | |
) nr.:r,11/ r.r' rtpni e pl edcazi i
t()t pentru
un atac i schenucr,
t\) | i t
r.t.ttt to
l turLrni (d srur.eni ti concomi tent
cu i nstal al cr i ctusuri l or,
i i r' r
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o' apopl exi c l r,r pute* consti l ui un argl
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l l ,;i
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l ,(,l tt
e I i f| \ cl at, ri l t,e
l )ettrn
un artevrj sm care s_:l ri upt, pentl ,u L
l rrl rl rrl ol .tr,ti c
l i portcnsi i ,' d,
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sc insl,a,Icazii
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: t l : , , r r l i , l r , , r I i , , i c
nr ur l ur "c m: l i l r l r . S, . i t i t t t i npt l t r ot , , l i i .
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r r i ' ) r ' i : r r r r r i r : : , r r nc' hr udi cot t r i i r r
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i <, r r oxr , cr r l i i r r . r i r r r l r i l l . or r , r . l r ,
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l t l r ) t . l l si \ ,
( sor r r r ur Ll r r l l i , r l l sl r r l r l q l l i r t i , r r l xr i 1l r r r i i j ,
pr ct r r l r r . l , i r l r r . l r r r r l l ol r r uc ( ol l ost l l l i l , r l t t l ot ' i l t l t r l ol r r i t l l l o, ; t t r or . ur i i c, gl o{ur , r ,
r : r , r ' I r r r I r r I i ,
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l ) {) | t | l ) .
l i rr r rIrt,i ,oIr,r' rI
si rrl , tl i l i ;cl o r.r-l brtrrl rl l ui gonctrl l , p(. i rrpl i ,t.l .Itc, ]l curol (\l i l
; , i r l . I r I I r ' r , i i , l o} r ' l l sl t cct t l t shi , l | l t l ut i t t , t , t nr r i - t Lt ui , cu t egur n( x] i . l r \
.i i *r I.. I' (l (l i
Ii
ci urLoti ct:.1 - gl .bi i ocul .L,ri h.i ytrtori l a p:l l 1:l rc
I
- i trati i l rrrr,,
(l l J Irl ,i rrri ri ), crr i uspi ral i e pr.' i hngi ti , apoi pauz{ tt-upi , bare cxpi i ;l (,i tr,
{,i l r) i rrl url i ) ri l rrtl r,i i , rl r.o:r,l ti r p:r,trzr' r rn:],i l unE:t, (r,espi rl l i c
ascnri ,ni i t, o i l ,
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{l {r i ,i p l i .i i ssnnrrl )
;
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l )ul s
sl ab si r.rWi dl - hi potrrrni c,
i
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si rr, r.ol l )i l {rr (etnni ci
i n uri n5,1 - gl i ccrni a rnul t cresenti ,i rezcr.r;rr,
: r , l r r r r , l i r r i i sci i zut l i .
t
) Ct)ntq tlre ricd Nste relativ usor de rccunoscut :
_
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l
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rrrrrl urrrrrrl rcezi i : oboseal 5, cefal ee, anorci i e, gl eal ri , v:.i rs[turi , di arr:o,
(l i ri l )rcr' ,
n).i odozopsi i (,,,rnuqte z}uri toara,,),
ecl i pse vi 2uate (pi ni , l a aml rr
r' ,,r...1,r' rrrrz,l tri ri i ), rni ocl oni i ,,si tresi ri ri fnsci cl l :l re ml scuhre, ufteorl ortl
i rrl si i
I
- l ' ri l l oni i , l u.c rri ros a.moui tcl l ; respi rrr,{i :r, r:s1,e de i n[l te ori rl r,
l rl r
(ri rr1' 11s
Stokes; - bol nar-ul Ostc pal i rl , hi l otel mi c, cu pl eoapol (l
r,rl rrrrr,l i i r,l c
fi l rozi nl i i , sughi t; - pul sul este f,,i rtc bi nc bi ,ttti Ourl
l .rr.i rrrrrrr, rr,r,tcl i a,l i l este cr.cscut5, - cordul estc rni ri i ,, cu zgomote dl l l r
.i
l r l rl rri i i .ul i pcui cardi acc
i
*
l a examenul nel rol ogi c' sc cons1,atrX, seml r{,
rrr.rrrrgi trl ri , rni ozi r,. hi perr.efl exi c osteo-ten(1i noasi i ,, i l neori sei nne pi tatrri
,l rL, i i c x I rr l pi r:l rni di l l c (i ncl usi v fl appi ng tremorj
;
- l a exaucai l F.().
,r, r.i ri rsl rrl ;i L: ncur.orci ,i rri ti l al bnmi nuri ci , cu nLorl i fi ci ri evi dente vas(i l r
i ;rr' ,' , r.rr i rr.srrrl l l l ,rr
,,i l
stca,,' ,. cu cdern sau s,l azX papi l ar[ cl hemoragi i
I
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tl )
('ort.tt,
.ttotrnir:ti sc irst&lcazit trpta,ij I,r, un bolnav carc a prezentu,t,
, rr;r:rl rri i *rl ri rl ,l tc (pri 1r a{oci i uni gas.i i ro-i ntcsi ti nal e
sal r vi .r,si turi centra,l .)
r, i , :i ,r' ,, rnr
t)i t,r:i [1,11
rl es]ri dratat. Se,rl l ne1e procl rornrl l o Si nt asemxni ,toi tr\\
.rr r.r' 1. ri i rr (,o
ri L l tr01)t.i ci l , ca fi ,tar.e di agl osti cul di fcrenl i al va Ltrre scanl r,
l r, ( rl ,:\i r r,l ci rrcnl .c t.cr.ol atoare:
,
bol nav tl eshi dratat;
*
TA sci zLrtrl ;
r,rrrl ri rr,zi i i
l )l .ozon1:n
:l zotemi ei , a al cal ozel qi a cl oi openi ei .
,
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' r ' r r r
r l r r ' : i r l i r r : r , r l or ut
i mni i l _r t e: i , sa, r ci ni i san i n cr r sul nast ar i i
i
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pr czi r l l , i ,
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,
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I
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l rrrr
rr i r r I r i r r I r
.
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r , r
l
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| )
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i tttrttt. l u
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ut ri di ci r
l robl emc cl i agnosti ce di r,ci ,
_ti fl om
Sca,rI| ,
r l . r r . r r r r r i . r r r . I r r . l . r r r cr r i ( : : - - ant ooet l ct r t e ] r opat i l - r o
t hcp: i , t i t e
gr : i l \ ' e 1i {) xi o{r
r r l r r r | r ' r ' i r or l r c, r i r t zc, nct i l t l i t sr r L l i ep: t l i c) , el t r nl ui l et i l i sm cl oni ol
r r r r r i l r . sl i i l i l r r , r r r l t ut t l t , l t r or t a, r , r . r . r r l nl r cl t i nsl csj r l l ; r , t l l r l r r , , N, l ) at i or x, Ni ( \ ni ( r
r r r : r . r r r l r t , sui i l r i ( , yi r si l , l r i , nl {' i , ' i , r , i s
r . , , i i r r ; 1i 1, r r {i , . , s. r r r r r , , l , , r r ( , r . i , pr ogr osi Vi I , ,
r ' l r i r r r : r ' 1. r ' or r l r r z' i or r i r l o, sl , i i l i r l r r r r qi r ' r r r i i r . I l l sci ct t l r r l i i si spr r , sr nc r r l l r sr i r r r t r l r ,
r r r r , , ol r r ' , r r r vr l si i r l r l i l r o; r i l r r ! l i r , ; , \ r pr . cl , r r l I r r I I r r r r t
,
r r I r r i r : l i i r r l r r l r r | r r l , ol , :
| 1 r
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I
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l r r
l r I I r ' r t l l r l ' t t t l r l t ' t r r ' l ' t r l r ' l r t r r l t : '
, l , r t r ' : r l : r , 1, *, 1111 l r l r 1r l t l l r ' , r t l r "r l r r ' l r r
1r
r I oI r t l I ' I I I t r ' ;
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r r r , l t or t t t t r , t t t t I
I
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l "r r r Lr r ' r l r l r ' r ' t l l r l {
l t r t r r t r r r r l :
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l
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. l ) r ) r l l l l l i l l
i r r t l ) ( r 7. l l l ol l i r l '
i , r r l r i l i ( l {' l i p t l or ' , ' , , r r l r ' l ' r r r ' , r l r ' l ; r i r l r i l l i l r sl r i i r l ) ' . r r \ ( l l l l l r r l
i l l : \ l ( '
t ' , , r r r l l l r i i pl t l i , ' i i r r c t t r I I : r t r ' : r i
'
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ci t r l i r l i r r l i i i Sl r t r ' l or ' l '
' r , l ;
( i I l oi l , ,
i l l i i ?; l i ( , r ' l ( r r r , l ! ' ( ; r i I i l r r l i r l r ' | ' t i 1) r t vi t ' i t t ' l l l i f i ) ' r r r | r ' I t t r r l
, r r l r t l t ' sc gr i t l l t l r i , , l t i l t r : t sot r r r r t "
t l l t t i t L' l
l r i t r ' i
Jl r l l r r r l l
l ) t r ) l l l l . l l l l l
I r l
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"i *i ' , ,
r t t st t i . i i t , r i i
( r i ( r l r l ) i i t l nnl r r r ul i ' i nt l
r ' l Lr ' ' vt i . i j l . r ' l r ' ' l
, , i b, i , , r i , i i i ei cef ul . oput i , t
l t r
1t ' : t l "' l t t t t l ul t l xt t u l t - t ' t . t '
, nl : i t ) t r ' ; r t t zi t t l "
, , , , ' : i ' i , , i , r ai j t i , , , t r . i , u cl t i , , t or r r i i l r t pr L' i i ' ' ' r " 11' r i r r l r cI uLr r ' l r r r r i
j r t
r t t r r r r l ot t r , , r r ' l '
; i , ; , . , , i ;
, i i l t i i l ui , oi l i "i . r , 19?d) , c, l l , el nr nl t r Lur - , her zi o_si r r r l r r or r r r l ol r f ' r ,
, , ' ' 1, , i i , , , i t aLr i oul ht pal i c qi neui opsi hi c t ' \ pl l s i n cadl l r l t ( i l ) r ( r i l t r ' pr t l t r
'
| , r r o so acl ar l gi l ' J i n sl adi ul pr ecor nnt os; i subr ' ot nal os' t l l l l r ( r l r r ( ' l t ' \ l r ' l
i
,;' ;,i ;; ,apffi i ' at"pr.,
a rrri i rri l or' , el cnLui i b
,' l l .l l l i l s
ti ' ' root)) (Sl r.r' l ,r' l '
' . 1; r :
i j i l i eJ, 19i i T
:
ci i , i t , 1i t l e T' r r puvj ci r L, 19i l {1 I r opxr r - i i ' i r t , l ! ) ?! i ; i i i r
'
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i i i i ; r i . ' i "EI I I ' di agr i ost i cul "' ' : "r ' r Li l eqt cl i pl i nl r r ul r t r l ct I t ' I I t I t . t I t I I I t
| , L
I
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7. Oot nel e l o, r i ee. Spa! , i ul nu ne per mi t c deci t cl umt Tl t t r r ' f sl l i ( t r r l i r : r
, , , , , r ' r r , cr i t er i i t l c di agnoi t i c i n ci t eva come t o) ' i cc mai t l t : s
j r r l j l t r i l r ":
,r ) Cotn,r, al rool i cci oste precodat' ; de ci teYa serrne dc rtl trottl i sttt rr' ' trl
, r
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, ' , i , i ' r : , . L, 1r t zi c, r l i znr i l i e, ul r \ i '
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5i
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t .
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t : r ; r r r l
,i ,,t, tr:i i i ri , i i potensi une,
ci anozi r, r' l ci rea cxtr emi tr' i l i l or
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, Ll
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cu tenourene de ri gi tl i tal c de tl t(crthl rrrr'
(rrcDr
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l ,roundsti c
gtl i -
).
Coma dureazi pi ni ' l a 20 de orc'
It ) Ooma mc' ti ti cd, se i nstal eazi | brusc (chi ar 1&
(' i i ;tl Yr' r' tl ti rrrrl ' .
rl rrl ri l
,,,, ,.,,ri ,r, ,i ,,uufi i l i ti meti l i o)' real i zfutl ul mXtoal c' l e si l l l ptt)rnc : Irtr i . r I rrl
, , | ' , , , r ""r * ccf "i ,
, . onI ul . i i . ar eUcr i e pul i l t
, r . . ! I l b
t . r r | i r r r r r I i r , . l r r ' ,
1, , r r i f 1r 1r i pnec,
al oi par al i zi e r espf uat ol i e)
; i
t xi t r r s l r t '
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l r l r "" t l t t
, , r 7l l t t .
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i n c: r ' zu' i r D' l l l c sr ' I cal i z. i r l ; r
r l ol l ' r r t r r i i r r i l r r r r r l
, , ' , , ' , r ' t , ' u di zal t l ' j e, at axi e, conl vi e l ni nl t r ' l i ' 5j
cr r l "t i '
) ' ' l f r t t
t t r r ' l r ' gt : t r '
, , , sl r i t al l zi , , r al i d, c. , Somn
l r ogr esi t - J
p, of und, t , r r pul c' r r l r ' , r r r i ozi i , r l i t l r
. r ,
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hi l i ut el : i r r nc'
I I t I t r I i I r t r l t l t i l "' l ' t r r '
'
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I r I r i I r r r r r r
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qi dt r l t l ] l al i r r , l t r l }r r r r i i I i
r l l l r I r l i ' r ' "
i , r nr l si yi t t r r i t l r i i zi r ) , di sl }l l l ' i l i a 1' 0f i ( ' r t ' l or I ' t t t r l t not ot
l i
( l ( r ( t I I | \ I I I I ( ' | | \ i I
r , r ' r r i t i l l t t l i , r o| or r t i t l ' t t t i t r l i t i
{) r i l r , i i I r r i t r sl : r l i l r ( ' 11'
( ' ol I I cj ' i j t f r ) l ' l ( ' ( l r \
( : r r "i l
f ", , , f i , ' , pr , l , s f i l i f , , l r t r , l l i poi ct t si l t r t t r , l t l l t r l r l i i r i t t r sl l i t l t l ' ol i i '
r ' ( l ( ' r t r
I r l l r r r r r
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f i
i nol l l l r , ( r l , r zl i l t ' i r r l i i r l o: l {t r r l r i t t r i i l t i o; r ' i : t t r r i t t i i I i i t r t l r l r ' ( l l l t I I
r
)
( | or t t r r
l Jt i t t
t t l t i t t t Nt ' ( i r r r l l l r sl l r i r l t t | i i ' t r t or ' l i t r i l ) t l i ' l r t t l t l t r r r l r t r t t l t
"
l , , r ' ,
' , 1, ,
l r t r r i i ' l l r i r ' , I l r t ' t t l l , , i t t r r r i i t i t t r ot i t i i l t t
l r r r l l t
t t i r i i t l t i . zr t l l ' r t I r l ' '
1' r r r r r ' l i l i r t t t t t r ") ,
l r t l r t l i l ' ; l l t l i . , '
) r r I t r I i ; r t r | r '
( t t t
l r : l t t z' r
t r r r r t r i t l r l or i i t l t t t i l ' t t t
, , : r r , , r r l r r r r gl i l l i
' r r r r r r
l r , ' , t r 1i r ' , , ' r r r r i r I r ' l r l r , , I I I | , i | | | ' I i ( '
1r t t i r r I I i r ' : i ' ' )
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r r ' l l {r l r ' ! j t r l t t t l t r ' t l ( f , I ' I I | ' | | | : I i t ' I t t I '
, i
r : r l l i r ' , i r l r r r i r l r ' t ' t r i t t r l t ' r ' i r l l r t l r r r l r r
t . , 1, , , r i l , , t r l l 11i l t t r t r , ' l r , , .
I l r r r l : r l l l r ": r l l r l i t l r l l i l I l i I ol r r r r r : r ' l l r l l i l t ' r l l l l l
t r , I I i I I I I | {
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, r l l . l l J r i ( nr ( ) l l r ni r i r r . i l t l t r , l r i l l r ) i r c
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t l t ut ul i ol l ( 4i ( ?' sc
l t s( , l ul ) i i nl i i r r l i r r i i r r l r , r . i ( . l l
r ol r i r ,
l l i n
11 )
( 1r nt t
uxr t i t t , i t , r i . . sl ( )
l l r ". r ) ( l i Ll i ,
r l . ' si r r r . i n
| . r , i oi i ( l i i
( r ,
i r . xi cl l r , r ( \
' i
r : r ' r r l . l i . .
r ^i l r . r r r , 1r ' i . si . r L r r a, r r r oi r r ar i i . obi cat , i l i i r , , . 0i r si , i par . r ' ' i l r r r r ,
r r . i r r r r r l r l r r , ( i .
. r l . . . s. l *l l o
po1, I i r . vr l l u| r : r ' r . ( ( l : l ' l i i r . r , hi i , i , l r r l ) . ,
. l l ) 66) : r r r i ' l _
l rr,l rrri r' ,...trri rl .i rr,zi i ,
i ,*l r i .a,rrl i .,. (,r' i i c' r
.,1 fc!oi , h,ani pi rrr,!i i , h\re.i cnsi rr i r,,
: r r l . r . r ' i r r I i i , l r i I r r . t . r . r i r i . . I ) osl ul i l a . r , pi r 1 se i nsi al cl zi ,
cu' . a, ai o0i at i n . ' :
I , : r 1, , . ' r - , .
I ' r r l i
l , ' | l l . . l i ] i l or ' l . l psl r i r l l i t . ncr cgl r l ul : i .
t r . l t " spi r ur i i
r . eci , sl r r , r . , .
| | r ' I t : l l ) . r . 1, , ' zj t t , t t i l r t r . r , sr . 111g; r r . . l n l _2 g
I ' or
ot , , l *:
u. 2u ur j t {}
A
r r r r r r I r r r i n i sl Ll r , t , o
l ) i [ r cn1, oi ' a] i , .
. , 1,
) .
( , ' , ' t '
"
t l i t . i t r , l ". t . i , ' , t l i a hi dt a. : i . , l i cg cl ebul cr zJ r . u i agi r l t i o pi i Lor r r , r
r "r i .
. ' t L' l t
i . t ) ' , r , t . t l l l
I
t , r , n1 , , 1a' ' 1oni . o_r . l uni no, : r l cosnj , , r . on, ul "si ' r ,
l , | | r
r r l t r r l l : . i j
t r n r . i r r i nr . l nr
>Ubi nL| ant . O( l t t : - r CU anr Ol Jndt t . oa
Sl l i I i i
( orrrl oi l s{r. l ,l , r.l oze mai nra,ri dc.hi dr:l zi de, coma, sd i nstal cazd rapi rt,
rrrrrrl i l i i rkr hi pol ,onsi ul e, tul buri r.i respi l atori i (cu i mpol tanl ,i , bi pdl sr,
, r(' tro J)rt)l tf i oi i )
f
i de hi pertcrmi e.
pupi l el e
sl ni m:i rl rj ati ce.
t
( t , . i l , : :
! : t
i t ,
s, , t . i ai t g! i , o, t a m: I i r ar j . put i nJ i i anci r l eul r l i \ r . u
l r ut i r l l l
'
. . . r t ' : u a. r i r ur ' r nr r {l t ni r i sl t i t i ! t l easpi r i nj i n doze r nr r . i l l , . ul _, i i t l cshi dr r r , r r r ( l
. t
' , l i . . r r t i r . , .
si t u: t ' i i , nl r o per mi t . r ^umui l | ot . t l i , . i l ct i l uf .
Jnr ur i na, i : r , . 1' . .
, r i i , l i r rri ri
j .L
l l i n
(Vui ,.ul cscu_ ql Stoi ca, 196?
i
GaL ti er
$i
col ab.;196(;) :
I r
,
r r r ) | | r ( , r |
( ,
rlc e-rcitafie nellroasii, ct tremur[turi, anxietate; agitali6 psjlrir
rrr.l ol i rr, sl i ri l \al u ci nator,del i r-a,nte. qi (uneori ) conrul si i . Api oape ti trt,,rr
rrl t ,.,' i rfx)(,i i r,zai
;i
t,ul buri ,ri di gcsti ' e (grof,uri , r i i r B:rturi ,
-col i ci
abdorrri
r,:rl (
) r{i
.
t|i r,ri spi rn{i i abunrl eni c.
,fi cspi rtti j l c
si n1, l l ,ml l e qi i rnbraci i rrrr
:r rl rl l i rl o l i p l {i i ssnri url . Faza rl c excrti l i c l rccc i t' torpoare si col ri i ,
,l r' :rl ,t., i rri !i u,i r-r fi i trrl i nl oc*i tl de aci dozd,. l ]e cel e rnai ' i l utte bri - aj r,,,:
I' i ||{||rri ' r)() l r
(x11 (n' tugi pi rre
l a ni vel ul tegumcntel or
;i
ar rmrcoasel or (cari l r,
I r . r ' r sl r r , r r t r 1r s1l i i t Ll ; or i cA! i i ) .
. ..
i 1
,t
.' r,,,'
t:.t;.' ,
,,' .:,:.,
!.,,' .).i .
aryo noJus:Io t;.i , d i i zopr ,,pi l fl uoro Iost:) t
_
l )1,1,;
r , t r i , , l r t
l
'
t t 1 ) t
, ,
- l i r l
. . . .
l ' 1. ) l ' l )
; .
h| r i l . , . 1 i l t cl r a f osh {
_
U"e f t ' ; oci umct i l pj r l , '
l : : , ] , , i ] l : 1, . , ( ) ut - . \ ; . t 1i r . t i _r par ar i t r of cni l f osf at _par aoi on; c1i et i t l i a, r , r r ,
, r r r 1' r r ' r t r . r r t ost , Jt I ' l r 1. r r , t hi on.
Ehat oxI met i l t r i mebi l pr opani t uor of osl i l r , l
i
", r , r
I r
;
r l r r r . l r t r uLr r i r i . el uxi r i anf osf e, t . _
Tabun) . Ne pnat 6 at r age at er r {, i r r
|, ,:r:r, 1r' r' r,rl l ,[.
l .)tol esi r)na]
(apari l i a, l a rnunci tori a.l ri col i care mi l ui 0l |
i i \r' rrr' rtr' l i rfrr r.ctr rl ramenl , de proteNti e),
fi e i nci den{a l or acci drrrr
.
r:' , t:r
' t.t\
tl i i ,i t11.
i tl l col rnunal l ructe sau l ogun]e stl opi to cu {tccsi ,tt
rl r l :rrl ., ;i i ' l .rtL{} .u uti l i zai ace$ti pi ' odu$i pent' ru dcparazi tarea l ool l i rr
1r,l ,r. l l ,i i (' . rr.rrl :tt..rc si mpl omal ,ol ol i a genei at5
tl c i i aci i varea col i .os
r,,:,/i |
,i
(t,.r,i ' l sc(rl wl t,
tl cl l l rl ul are excesi vi r, de aceti tcol i ni , cu fenomri rl rr
i t r . l r l , r , r r N1. ' , r ' i ' i c: t r i ozi i ; hi per , i t l l \ . f t l i e; r l al ' i or eeI
hi per sut l o*l ( , i .
;
'
r {, i "
; l l l , , i - , . r . r , . l i n l r ' or r . i c: r ;
L, r onl l ucnnSl r i . l . , . ; r r i spr r , . r , r , t nt l l i t , ur . r i r i r j
: , r ' . r . r l , r , r l l l , . r t r . edem
l ) ul monar acut ; br ar l i car . r l i o; hi Dot cngi uyl 6l 111, .
Lr . r t : . : \ : r . , , I r | : , I I r I i r
,
I
r . nl i ni : r l r , l or ni r nl o. di r r r er , : r r r i , , r i r r i r i
j r r r l r , , r . i r | r sr . .
I . , t t r , ot r r l or r l
, l r pt r r ' :
t r , nxi ohl , c, : r gi l r r , t i r ,
_
1r si l 191l t , , j
, , t , i . , l t , cml i r . t i t ui i , 1: r , sr , i
' i
I r : r r | | , l | | r ] j {1l r | ) r I r r t ur n' l , c t 10 r , r , r r r I Lsi i , . 11I 1r i | nr ' , s, . j r r sl l l l r , zi l col n: l , ,
( , i r , r ! \
| , o: r I r . r ' i r r I r r I r , l r r i l r l , i r r
l t l i ur cl r r
l 0 ! {) r t l oi r r t l cI i r , i l l or i ci l l i t r pr i n pr r , r , i t , l i
r ' r . r , '
l r i , ' r r i ' r i r r "
I i r , r r r r r . r r . l r l r i l r r , I . l r r . r r {i i l i L ( l ( , zo
r r i . , i r l . ai , r , r l i i ' i i r , r r sl i
I r r r , Lr r r r ' l l ' r r r l ' Jr l t ' r r
l r l r r s
r l c r l i l r Ur r r r si i r . .
l ,
)
( l r t t t r r
l t r i n
ot i r l t l l ut r l nt u ct i r I 4I I I r . : r , r r r r I r pt , l yxl l l ! j l i , r l r r 11l . r t l 16
t r l r . r i i r . \ r r r r , . l r r . i r . i r r gi l t r l i r , .
( t . t r r i r
l . i r r r , l r . r l . r l . I r i
;
r r
,
r I r r r r r r i ,
,
, r l . .
;It0
L' I r I r i | | | l t r ) ?: i | : I r l l . l i l r . , j 1, r
1, ,
l r t r
1, , . nl l u
i r i r I r
,
r
,
r , I r
,
t r r ; L i r r r t r l l r or i
r , l i | or i r l r i i , l cr I , r r r r , : r . r { l , I l Ll , r r r . r r r r ,
I r r r i or ' r i
r r r r l i , r . r l , , l r
I r r r I t r r r r r r l l l
L l r l l r t t i L' i t l i ' 1' l ( r i , r r ' I ' r , ' , r | | r r , L' r ,
1r
r l r r l . r l r ' f j , l l . l . r r , l l r ( i ' r ' ) r ' r r l .
'
t : r . l r , r ' i r r l i . r i : r r
I i i r r l r r r r r
r l r r
. , r .
r l r , I r l , . l r : r , t
1r 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 ' I r i . i r i Lr 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 ,
Ll i t t i t t l ot t , i . t r r l i r t r t r , t t r
l , r i , . i
r l cbi Ll . oi r , zi i 1n] t , ( l {j l r ui t 1l , r , r r i r r l , r . r r r l
t r l l r r r . i . i r l i g. r ; l i ve ( col i r i r r I r r I . r r r i r r r I r ' , vi i . si 1. r . i , t 1i l n, ac, c) t i l l . i t , l . r . r , r r l r i r l ; .
\ 1r r r 11, 11i 1, 1' : r : r ' i t , cr r r cui i l , i t l . r , i r l ' i r r zl i , i , l l hi *Lr i l i r : . si t t "o ( l r )
. _r . i l r r t i i , r . i r
, 1, l rr' . r. uur-rrl "ri i r st t re d0 r, oLl l )s, (] orri r
ai l odcri . r pul monar. ,
l ;j .l .i i . Probl enre ri e di agnosti c i .,r tuani l estj i ri l e si l rcopal rr si rrl l c
l rrl l rri ri rri de consti uri .rt de scrl rl i Jut,ni i r
l l .l .:).1. DeJi ni .l i .i ,. P rtti ::t\ri tl e tet' yaeni
i i i r r "! i , i ,
i o l r : ' , l r r Lc
Jr r i ul , , r
pi er . der r : br r r ; : r . i : - i dt , st . ul r r i {l r , r . : r l i t : r
'
' , ' . r i l l . , . i .
i u: ot i t i sl u ul r : t t nr ni l t , st i r i t onr u: r i 1( , ,
l r r r . r . r . r l . r l . : i : l r r r r r l
i l t' rl ri l ttol nLr preaccesual e,
i n determi ni snl l ci ,rei a i ntcl yi rru U tr,rror, i r.
,, r!' l )urJL gensral i zati [,
?roi l -.rsi i ,-
l :r l i l drLl r.i ti c o opl i l c r:onrpl r,{i i , rrru
: ,r,rrpe
cornpl el ,i , a ci }cul ati ci si i ' sal L :r respi r,afi ci (Ool l uri rr, |);1i ;
. r , 1r r r . l si \ i gr r ul oU\ . l U; 1.
1
\ l : r . i i nv, I gLi l ) .
i'l{r
ltic
c:i piertlerite d,e uLno\\tin\d ile saurtti durafti sitri, rnlr,i r,l,,ri i/,
,.,r rt..::ri tteurol ol l i ati , i n
_centrul
acestot mani festl ri si tui ndu-se l r,.a.l i .l ,r r,1,r
l ,
1rl i rr.,
rl i l . pot./i i nti l ni te foarte fr.or:ent
$i
i n di yersa]' <r tu,l bu.ri i ,i tl . t,ri 4t tt,
, ,t:it
.ll
urd, cu crxplesio neurriloglticii, ca de pikli) sincoTtele d.e divlr,str r rrr I r r i r. r
i ,l i si l ri ,
carc i usE trsbni e tol ,dcarua di fererLl i u,i i r de
.fu,l sel c
ti ttr.t,1t,: :
l r l ' r l i t . i i
sr L' si r npl c
, , l eqi nur i , ,
( Fai i . r e, J. 9?2) .
- l l r cbui c
aco*i r r , i i i , r
' r : r r . , , rr rl rrrl ,art!:i r,
,ti
si ncopel or tagal e cane,,nc conduc l a o ncurol ogi o
1rl r.i tl l i r,.r
l ,rrl l i crrl ari ".l , ct sau f[.r5, refl exe rascrl ti o r-aso-vagfl ,Je snu vagi r vrr,11:u1,,,
, i rrl i i .l urmi nol ogi a
arrgl o-saxoni ., c*rc fac tl i l i l cest seci or hi bi r.rl , rrrr ,i i .rr' i
, 1, r r i i 1, r c i n1r r . car di ol ogi c. l i ncur ol ogi cr ' ( Fai vr e, 19?2) . Asl , i cl , r l r r r . i i l r l , r
, r l , i " ( 1, .
I ' i l , r . si nce f i br ' ul or . t el nt i r r r l u l l o r ugul r r i ( i u l r : u| t r r l r l i g, . ; , t r r
. i rl ( )r' i i - ti l ,r.i nge
,
rl e pi l di ) sc r.ol bpDbe Jcspl c rcJi .ru aayt,uagu,l .c ( l l atl l i .ts
) ,
r
' l : r r - i
r i l l r _r r r l dr . cl &nf r l ul dr , si nr opc pl , . r "i t l i n \ i su, c: r {l , i
I i Ll : i
r l i r r
'
l i ' , l l l 4 i r u
d| | r t l t c ad' . r o, cSf e t o| l r : r t l v r r Jl l l s DaSo. t dqnl r . l r r 1, , : r r , ,
.r' i ' i i 1. (razul ' i
cstc I-orba de i ntcrIcn!,i a ul ot tcfl exc ri :[l {o_{].1,r{r1.1{,:t,t.r,i ' /
rrr rl . cl cctc cardi o-i nhi bi tori i . l n accstc c{r,zul ,i , corcl xl ri l sprrrrrl . l rr, l ri l rr,r'
r rr.rri .Ii o l i o pri n tul bl ri i l i si l ro z],[ri cu]i are, fi c j ol cri oti al tr
(1r.i rr
{,r.rrrrl ,rrl
J"r(
(i or)ul atl i o-vcutl i cul rr). Ii i el deri l e dc crrnogti nf,i r, vagal (J
),1(!
i rrl r' ,r,l rr,,
, r r l t o pt 1ohr gi e dc gr ani ( i i nour o- ca, r d i o, vn scu1. "l r 5) ' ( . I r , i l i vr r ) , I t ) i : j l .
I r sl i r' 5i i . sc i nsi sti i i n Lrl ti trri i fttri asupl l i 4o-rrunti t(\l or
,,si ncopi r
rrri r I,r,,,
r | )r rl r,l
l i
gri al :.,
1954), ttro poi I' t col scr,i ttl rl r, r rnr,i i tr ul l or rr,fco{i Ltrri s
j rl
rr l l ,;r, r rr
r , . r l l ( , \ ' I LI i ( ' I L l i t , l ( ) .
l : ! . 1. : 1. ' ! , \ t ut ' l ( l u pi t nl r r i t l t ' t . ut j ( , i t t i . t i t dr r uu: , i nr ur ol ogi r : i l ,
| ' i | | I
(
| r I I ' { ' I t , r I r r cu r r nl , i r r ( l r l ol : r l : i l i r uI r r r 1I l r i : ' i i r t r p t i <, 11, r l i sol t t ( , i l l r l r r Lr r , l r \ : r ,
r t r ( t i
1t si l r i . .
( l i i : i l r , r r {r r , i r r r , r r r , . , r r ' ) , : r , r i r , ( i i r l r r r . r , l r r , ( , i r r ( l r r r t r , ( i i sr r r r z' t . i r r
t r t r r l . t i i )
1i
11, f i r , ( r i r r r ; i r , l : r i i r r .
i r ' : r r r i i ,
1r r r I r r r . r r : I I . r . i r r , l r r r r . i ; r l ) . l r r r r . | | r r l , I i r i i
l r r l r l l r l r . ol r r l r , r r r : r i nl r l l r , r r r r r r r pr r {r r r r . or r r l r l r l r . : r | , r , r , r 1r l i r r r ( r r i , r . r r r l r ,
: t : f I
l ri l rl i L
l tr ct' i ;ck psi houl ol ,orti ,
ryi
hr al rd s/dri l nsoti to do tl i vrrr.so rrr:r n i l ' t:st,r1,r' l
turt rzot' i o-rt to1,ot' i i qi vrgrtati vo.
tfrl rrl rrri c
Bfi a,\' (xl r i n vcdere aci doud, gru,pe de pi erd,eri i l e cunofti nl t\
rl t sou,rl .tl , dura&[ (;\ruol d, 197?; Popr,i vi ci u gi Pascu, 19?9).
1t.1.3.2.1. Cri sel e d,e epi l opi e, care comport5 o di sol ul i e scurt[, tt
t.orri i i ,i ol feri , dar cu hi peracl ,i vi tato sau acti vi tate normal 5 sau cvasi .
rrrrl rrrrr,Ii i , trrototi c
$i
vegctati vi i , pot fi : a) Cri ze general i tate, respecti v
ll rrl,r'orLnrl'llicc (Crantl Mnl, Pctit Mal)
ib)
Crize parliulo, fie cu
,,somiologiu
r r lrr rr ur nia,r'ir,!' (rnotorii, senzitive, senzoriale), dar fd,r5 alterarea cnnqtienfol,
lirr rru
,,stirrriologi.o
elaborati)', ca de pildi, c]'izele temporale, crizele insularo,
rl i zcl rr psi homotori i cu moal i fi c5,ri al e congti enl ei ctc. Di agnosti cul pozi ti v
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 confun-
tlrlc 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 ,)l t(i ((bl tari u, 1971
;
Corfari u gi Popovi ci u, 1971; PasBouant, Popovi oi u
ryi
r.rrl rr,h., 1968; Popovi ci u gi col ab., 1-97A, 1972, 19?8). Derutante sl nt
clizclo cltaplccl,ico inso{ito
$i
de oareca}e tulburd,ri de vigllenlX (Corfariu
qi I' opovi ci u, 1971
;Popovi ci u
si col ab., 19?2, 19?8). l n sfi rgi t, cri zol o rl u
1xr1,ib
rnirl akinctic nu pot fi confundate cu accesele de kiryersomnie ulo
u an:o[t:TrLicilor, ale cSror manifestid clinico-EEG qi poligrafice
slnt
Il rr,rrryi rrLi ,o (Popovi ci u qi col ab., L972, 7978). l n sfi rgi t, l a oameni i mai h
l ilrl,ir, (inrleosebi dupl 50 do ani), care de altfol rareori pot prezenta crizo
rl tr pcti t rrLal al ci noti c (Arnoul cl , 1972; Popovi ci u si co1ab., 19?6, L9?8i
l bl xrvi ci u
ryi
Pascu, 19?9), o c5,dere brutal 5, i n genunchi (pri n al erobamo
t(!rrr l)rolo1 infcrioare), fd,ri, pierdere de cuno$tinld,, fXr5, sau cu veltij, tto
rrvrru"i, rr cr'f,pd de
,,rlt"o7t-attacktl,
caLe cel mai adesea este declanqatd cle tor'.
rrirrnrrrr, gil;rrlrri qi rotalia capului, care antreneazS, o obliterare tranzitorio
r, l,t lor'(
ji
vcltr',brale qi, in consecil!5," o ischemie acutl a sistemelor rei;iou.
Lrl o rl i rL l rutrchi ul ccrr:bral (Arnoul d, 19?2; Aqgi an, 1968; A$gi an qi Po.
l rov
i ci rr, l ${i 9
1
A;gi an qi col ab., 1969
;
Popovi ci u qi col ab., 1967, J-969, 19?Er
tll?t)). Atn'N,gc r atentria asupra faptului cd, fenomene de insuficien!5 vol"
i,rrln'o brr,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,hornotorii prin leziuni tomporale, limbioe (Alnould, 19?3
I
I t r l r ovi ci u
f i
col ab. , 1976, 19?8; Sager qi col ab. , 1970) , sau al o t r i unghi ul ul
l xi l rorrurl ,or
(Di mi tri u, 1972) si nt l esne tl e rccunoscut di n punct tl e vocl oto
of i l i o ,,ri l l l i G. Acestoa nu trebui e conJund,al e cu
,,i ctusul ,
omnezi ol ,, sar}
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 ,i rr al torato (Arnoul d, 1072; Ii i sor, i t962; Popovi ci u qi },asou, 10?0),
Acusl, islru'r aurnozio, duptr, cnro br:Lravul mauifcstb o arrutozio o fonornsno.
klr a'ooorJr.ru,lo, $o
(ll,l,oloflto
umri irrsulioiorilo cir,oulalrorii, cu o consooutiv[
ttt I brt l i r,ro Itt t tol ,i or ttt l tL tottt
Jxrrtr,l [.
I)i a(l n,o ,i ott' /" d,l fot0,ttl ,Jdl l n l rrrl rrl 1rrNi 1, tr ol i rrri rro ttl l t rnrr. ni .l tttl ,l l .t' i
n t u,ro-psi .h i .u,l .ri at,, fl i rt n r. nl nt tl t' ttturrl , r pi l rl tti ti l ,
l i
uti 0 u, tnt,porl l l
0 1,(t i kr,l )i l .d rl i ttol .u,l ,i ( tr ntuyl i r' nl r' i :
l . Ori tcl (
),mearopal ,i orrt)
.. n)
(l ri ut
ntnLnl d. So pl odu ou trr ci r.(i l l l rr fl 1,rr l
l (\
r pr r ci t l o, si ou t r n, , sor ) l ) r r 1, i l i l t r , r ") ( Al r r or r l d, 1972; J?opovi ci u r l i col r l l r . ,
l l )713), obsol ' vi ndu-so i rr rnrrtl i ci rl r,
,,rIIr,r.rIrl ' III)i ,' t,
qcol arr' !, sau soci a,l )t (oxl )ol .
l ,i zr' i ). Si rnul arca, esto grosol ruri l , rl rl rrra,i adesea vi zi bi l
,,vol unta,ri ,tt,
l i r,l ' i ,
l rtl l tnt' i i ,ri vasomotori i (i n sl xtci a,l l a fa!i r,), fi ri rni tl ri azi , Id,rI tul brrr' fi t i
Il i l l ()tol i ene, fLrX somns pi rami tl :r,l o eta. b) Cri pel e pi ti ati ce pot rca,l i zl , fi (!
lrsorrdo-come
letargice, dar cu absenla tulburXrilor nourovogetnl,ivu, r'rr
,
'r
cos do tezistenfi ia tentativele de
,,trezire,
t
$i
cu
,,impresiott
dc vigilol rl il
,
l i r! cri ze pseutl o-convul si yo, dar care nu comportd, ni ci ci tl ol e br,rrl l l fi ,
rrici apnee, nici clonii, nici stortor, nici hebetudine postoiticl. So nlr,i
lrrrte
nota ur tremor palpebral qi circumstante emolionale docla,nqa,rr lo,
r\ Criza afeatiad, banald,,
.omare
a unui
$oc
emotiv, poate comporlrL llltol{r
'.lolnente
care pot preto la erori tliagnostice : stupoare, hebetuclino, il,gi1 rlio
psihomotorie
dezordonatS, rlar totul clerulindu-se pe un registru do torr,rnil,
rji {1o anxietate.
2. Criaele m,atebol,ice: a) Criaele kigtogl,icenice se manifost?t do obicrl
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
rui u,strS, di n ul ti mi i ani (tr' Xg5ri ,gan gi col ab., 1971
;
Popovi ci u qi r:ol i rl r.,
ltJ70, 1.972, 19?8) aratd, cH, acests erize spasmofilice $int alostul (lo I'l,r
vrt i l ,rbi l e cri ze
,,tetani ce"
pri n tul burare pri mi i i vi , a rnctabol i srrrrrl rri
.rrl ci c. De mul te ori este vorba cl e cri ze de agi tai i e anxi oasd, cu pal ;ri l ,rr,l ,i i ,
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,
l rrru :r,specte cl i ni co aproape ti pi ce de
,,absenfett,
sau chi ar do
qnvrrl si i
lonico sau tonico-clonice epileptice. I)oar prezenla spasmului clt.rlll
1,,rrlu,l
inainte, in timpul criZei iau postcritid precrirr,
ryi
aspocl,{rlo .ltiri( I
(r k'scd,rci,rilc d.e unde lento asculite hipersincrone gi/ sau clo undo lorrl,rr
rri rrrrsoi dal e i nduse cl e hi perpnee; absenl a modi fi cd,ri l or do ti l r opi l ol rl ,i o
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 $i
colab., 1971
;
Popoviciu
fi
c(,lub.,
l r ) ?0, 1972, 1978) ,
.12.1.3.2.2. Iotusurile de saurtd, duratd, Al[,turi do ictusul apolloot,io,
,r,lr r{,r'ui rnanifcstd,ri pot 1ii ile lungi tluratf,,, so pot obsorva la unii vtscu,
l rri J i {}l i l r$uri $curto, atkrsoa rtpotatc, caro survi n do mul to ofi cu oql zi l l
rrrroi i l ohi nrbi i ,ri rl o pozi {i o i n spal i u, dor unoori chi ar Iu ropaus (Arrroul l ,
l l l 72
i .l l opovi ci rr ryi .I.)ascrr,
1{)71}). So paro ci tr l n &oocto ci nzuri ogl ,o vot' l u do
o l,n lbuto,to d0 iriga,llg oorobmlfi,,
produ*Itr prin
hiloto:nsiurri t,ol tivo, rot{"
;xrrl ,i v
pt' i n i t tufi oi anl ,o ui l rIrrIrr,|rol i i rrl r.obrtl o ty[nzi to]' i i
Ii /
snrr i nt;ol rni l n)r]1r(l
(rIr,1,1 rl o l ,rorrrl xrzo
l x!rl i r
o
l )r!
sl nl ,orrrrr' l oaroti (l i 0,n). l fupi l , n<ttrtl l i o t.l ,rr,rrrrri
i r r l t onl l n( l ( or t ( l l t r r ! 1, ( l o
ol l r ! \ , 1, noct r t r do
1r l r r 11,
l n oi l , ovn r r r l r r l l , r r ) r l l , l nl t r
i r r t t j i , t l r ' ol r i r l t r i t t r t cl r . r r t i r , i l i t . r t ur r t t I r t I t . r r I r r I "i cr , :
1r 1q: 1r 51, 1, 7i 1, J, i u. ( , / . ( ,
l l l 1r i u. r , ,
r l r : r r r r r r l r r l , r t l l r t r r : i f i l t f l l zi ( Nl {) 1, o
I ! . 1. 3. i 2. ; i . XI ui . f st i i r i l c si &pqt ( ,
.
l : : , . ; . 3. 1! . : J. 1. l ) t I i ni . ! . i ?- , {r ni r L. Lt : i r , r r r t i ) , $i ) t coP( , r . t l r r l zi r r l i i o
l ) i ( j r i l r , r l r
Ir..ri r-i i , 1(rrl i or' :n i i , a crrrxrqti ntci , do dl u' atl i scui l i t, pl ' (l .o(l ri i srrLi rrrr rl ,,
r.r|l rl i l n|l rto
l )t' (i i r]c(10stL|.1r,
(,i .l ,tIz:.tti i (l o (}
tl ,nori 0 crtrtb|al i i .qi i ti l l rsocri l i ,l ri rl r,
ol ri cr,i i l o rrrorl i l i r:i r,ri orgl l ni oc ccrcbral c (Oorfar.i u, t
g?g
;
Wrl vnc, l tl ti l
),
Si rr.r1rr,l . sn
u;1,
i ntrl uh.a, i u.r' ;rnprrl accoscl ol rl i i tl nc ri ccpi i opl i cc ((i rr,l rr,r,i rr,
l l ri l r l l l ?i l ). ti a$taut
[i
(i astatt
(1956) au a,{i ri l at l oati ;c sugcst,i r. r,i si rr
l ul r,l r' , r' rr,ro l l u ayut totrl cl l unl soarta
,,p:i ri nl i .l or
si l raci )i i n cor,l ,ci l i rrl
,r
i rrr Ir' .Ir,r rrrrIrIr. pa,r' i t.ri sl ,i cc, r.e1xczi nti l i n re:l l i t:tte- cauza cea ma,i fl ,covri l rl r!
;r
l ri ol tl r' ri l rrl rl o c u n0,5l ;i n!:_"r,
l ure,
s:tu :tsoci l l e cu convrLl si i toni cc;i t,i i
r*rr' ;i l ar rrrrr' rri ftrsfi i |i tl cbui rr i n ri rod cl tegodc di fcl cnl i ate i n p]' i rurl r.i },11 rl r,
r r i zr l c cl r i l cl ; t i cc,
l :' ./..1.i 1.,i .2.
Ul a:ti Ji cti ti tr Bi l Lupel or si nt Ioarl ,e cl i fcri tc rl e 1a rl or,
I : r : r . r r . l ' r ' . l l r i t , l ( 1U. 50) r - i l i gel
; i
i . ot ab. r l g. - , . 1 I r el r . t er , zi ci uci et uzo r r . r . . 1, , r . , .
,:rprrl ' i l r.
s)r,
l rr,otl uci
si rLcope: i ul btrrri ri rl e ci r.cul al i e peri feri cri , al i ec{i rrrri
r,:rIrIr:rr' |' , r.r' |tLZLr Iorl u.i !t{' ri i , rferti uni ccrobra,]e qi bol i psi hi ce
$i ,
ca, [11r,,
;l rr
l l rol )us
rurni i toruca cl a.si fi care : l )
' Iul b".trdri al e ci rau,l al i ei
l tcri .fn.i l
:
;t si r{:i ,l )N, ' r' l .r,so_-tl epreso:l re (raso-\.agal i i )
i
b) si ncopa di n }Li poterrsi Lr rrorr,
rrr' l rrsl ,rrl i ci i .
,2)
Af(,cl i uni cardi ace: a) tul tl uri i ri de ri [m cartl i a,c
l i n
spcr.i l l
rrrrrl rrrrrrrrl ,,\ tl l m Stol i cs)
;
b) si ncopa, di n bi perrefl ecti vi tatel ,si no,l l ,r.r,
l i rl i rrrri i ;
rr) si ncopa pri n ai tc tul bul i ri ; rel l ex6 vaso-vagal e, r,efl txe g.l rrrrr
l rrl i rrrl o vrul i r,l c, rcfl exe ocul o-ra,ga,l e. l ) Si ncope pri n i awze respi ri tori i :
:r
1
.
.., i r r , - r r
1
r : r, rl t' 1L i pr.r' reri l i Jri ,l i c
;
b) Si l rop:r, l a trse. 4) Si ncopa tl i n tl i f ri t.r,
ttl hurti ri ffrrl .trql e (si nc,,1ri psi h.i cl ). fi )- Al te l rpari ; si nc,opa do ti ri (,l i
r n I r I l l , ( ] .
,
Wl yrro
.(11)61)
l r,. propl s cea mai compl et5, cl asi l i care a si ncol )(l l (l !.,
r l r . . , i r ' r ' i i i l r r , ] r i l i r , pl i n l i i r sr r l c pr oci zi t r ne
r yi
11e exact i t at c a unor i t oi i r r r r i r
,\
"
NirrooTrr_. pri n isch,amie aet"ebrald, gener&Lie&Nd :
l . l ' ri n scdi l ,r.na rezi stenl ei peri ,feri ce:
^)
Ati i re: - si nropa r' :rs,r
r;r;1rl i i , si rcopl , si mtsrl ui cmotk' l i *i ,n, -- si ncopa de l i per-.l enl i l l t i r,,
si rrl o;l r, pl i rr rci ' l exe ccrcbral o (si ncopr 1a tuse), - si ncopa, pri n l ol l r,rr,
rrrl l rr r:rl rl i l rr) (si ri tnpn di n stal rozn qi i nsufi ci enl a aorti ci t),
,
si n()l )i r
l rt
i rt tol l rrro (,nl orrl Lt' c
(i l fl :t' r.ct
;i
angi ni r, pectora,l i r,), - si ncopa pl i u rol l l (,\rt
prrl rrrorl r,rrr (si ncop:r, 11 1,use, si rrr:opa di n onl Li ol i a pul monari ,. si ncopa rJi rr
Irrl rr,r' l crrsi urron pl i hnonafi t, si ncop:l pri n pul erei ! i n j oc
a nnor i efl trxo
rrrl l ,i r-r' ), l r) I)usi ae: - l i i potcn$i une o.r' tostati ci l (i n conval esccl l i i , j
l rr.i rr
l r.:r,r' {i i l :r rrri tdo rl rogLrl i I postsi tnpal i e{i tortri e), - hi poterrsi urLc ortosj l l i crl
l l ' rri ci i (i rl i opr' r,ti rri i ,
sl u secnndari i unot: l l ol i nel .voasc).
l . I' ri rr, scri rl t:rtn tl ebi trt,l ,tr,i cardi .dc: 1) stoyt card,i tc (srruurprr,
.r.rni ,r
r:rgrr,l i i (r,l rrl i oi nl ri hi i ;ori c),
si nool r, s;i mrsul rri rrmoti rl i i nr, si l copt rl i rr
rrl rtctrl Atfrt,trr-Sl ol <<rs1 1;1 pri n descrafl .rrfi tnl u.tn-hci \d,i i rrardi l rrt (si trrrozj l
rrol l ,i ci , i rrl tl oL tni oci trdi c, a,ngi ni r, pecl ,rtl l l l i r, l rl i l ,l ni c cal di a,ci ,)
j rrsrti i rri orr(j i
r r r r r ' I i t , : ' i
; i sl , or ozr ' r , mi h: r , l l ) .
i l " I ' r i n. t nu, . t u ( t , l , r f t cot \ I i l t i ( :
i r , ) l r i pr . r . l i l r si r nt u
l r Lr ) r nonl t r . i i I
l r ) si t r l r ' 1r r r ,
l : r . l l $( , r ; r . )
l l . i r r
r r r a, r r ovl l r , Vl r , l sr r l t , r r .
l l . NI t t cr t l t t
1t r i n.
i whr r nr . i t u. t t hnt , hi , I ur t l i : t l i i :
l . l l ol i t ur . sr ul q. t t r t r t r l u' l l t : l r , ) l r , l , , r ' o r i i : r l i l l i oscl cr r r zt i
; l r ) i r ont l t or , ; i .
: t : f . l
, 11r r i r l r l l L r l , ,
I r i
|
, r
,
r r , r r I r | , I ' ! l
r t t i l r t l oI I r I i r LI r ( r cr r l r t r r r i .
, r r l r r l : r t ( . r ' l l r l l , r ' t i r : r t t i l or r r l r , r
i r r l i r r l t r l l i : r i l
1
r r r 1 i : r I t i 1r , , r i r . t r l i t : r
;
t Ll i r o t i t r r t l l r {l r
;
l l , i l , . r , l l r
l i r r r r
1' , . t \ i t t ut l t t '
1t r i n,
nr r , | : i t ' , 1 i i t t l t t t l , o: i l i q, i i t t l r l t t i :
l ) . l \ t ' i n hi por , i t : r ) r r r r ) , r ( i i 1i i r . l c : Ll i i 1 i i di ur ,
I
l r ) i r r i r ol i r ' ( ' r q( ni i : r l ( l
, l l r f i i r ( r {' . 2) l ) t ' i r t , h. i , 1t ot r r . 1' t r i r ( r i ; Li ol r c
l t i r L
l i i i ; t , r ' i cr {, i l l t 1u: 1. l l ) I ' r i t t l t i l t ' r
, , r i r t r i r ( i r r r : or r t l i f i i t l c l sl i r i r , , i r r z) : or r t i r t 1- r : l j i l l c) . 11) 1' r ' i r i I t i
1
t r , r
1
I i , r '
t t t i , .
: ' ) I ' r i n t u. I bur d, r ' i de nul r i i i r .
U. Si ncopc pr i n t l i sj u. nt f i i r c) t t t ' ci r : 1) I i ' r
1,
i
t '
7,
' '
i r ' . ' l ) S i t t nt
l t r r . : i
i r t t r : : r t l t t i
"
r , ' l i r l . i q, n ( . f ar na cent r al d, ) . 3' 1 I n i st t i r ' . I ) {, t l t t t : : , ' , , 1i
' ut . . : , )
l n l t t t t t t i
, , t t l l i t l , a.
l ' 1{roi z[m ci i rrra.i ori tl ,tea crcr.ttftl i i i rti l t}r de l a
i rrrrrrt:l c
l l si l t rrrr
r r r l r cr i t l bi l c si ncope, ci . l e f al t r epr czi nt i i t Lt l Lr t Lr i i l i l l c i . or r sl i cr r ( r , i r i , ,
, l r , r r : r ' : t , i . i pr i r I r l ^ | l i . Jt , i . l , .
| :!.l .3.2.3,:). I i .tt1ttont nt.ol og i e cl i xi ari
tnai nte de a aborda, cl j .rcrsel g enti ti i l i cl i ni ce, al ,r' tgol r i r,r,(l rrl t rrrpr:r,
, rttt
l tt.ont,cl ol ' {l enarol e,
camune
\\i ,
a 4i nprej u.rdri l or i n cl l Lo so {I(' (,Ii IIIri l i r?.rI r'
I r ( ' o pa,
r\ntl i za i i rl prej uri l i l or carc i l u dLrs l a i nl tal area pi cl tl t' r' i i i l r l rrrrorj i i rrl ;r
, i r rl c o deossl l i t[ i ni pol tari l ,i i , i n s1,a,l ;i i i rca di ngno-ql i ori l ri i ((]or' l i rrr,
I l ) , I
,
19?8
).
Tl ebui e si , so
l i i i i l
so:l i na de sohi mbi .i ' i l c dc pozi l l c rr l c l . r
tr
u
l r i , r l c e. , . ent ual a deci au$ar e l a t use, t i i cl i unc, f el t r l . r , oLr r l r l r : si r r r r i l r r l l r o
i , r' \ i cl rl e, l a ei noi ti i , sl ,i ri i de
"l ri si i
si ri e l errsi trre el c. .r\l i ctr:rIrrL1rl ,,
l rr' r' r,,
r r r l o r e bol nar . uhi si nt t i c i nar e \ - al oar o: t t ecl i i ur i l e ci l r r l i l i l r ,
I ) l l nr l r i r ( . .
, r l or l i l er unel e sr l f er i n! e ne. ' , r xol ogi cc ( si r i ngomi el i e, l t i t t s i , l r ' . ) . , \ r 1, . , . r ,
l ,i (
r' (l crca cunoqti n!ci esto prccedati gi ,/ sl u urm:r1,i r,
(l o
l rr{,r,r r.i r r I r
|
) | | , r I r .
,
t ) r
| i nsi ncopal e' ' ( GasLaut , i 9j 0) . Oor l ar i i l ( 111' i . t J . 19?8,
\ r i
( . l o| l l t i i r
t i
l ' , r t , ,
r i l i tL (19?1) a,Lr i nsi sta' . Rsup]' * i l tl ou i , gt' rps do si rnpl .omo; u,) si rrr;rl orrrr,l r,
l ,
r l i r{rcesual c,
care rnoori se poi l nal l i tegto fi l ri r, si i , {i e xr' mt1{)
(l r)
1ri r,IrIr.r,,r
, r r r r ost i
l ei ,
put i nd del i 0oDst i t ui un
, , echi val cnt ) '
al si ncol ) ol 0r ' ; l r ) r r I r . r ' r i r r l
t' r' r,l n:i u-zi s ;
c) si i nptomrrl c
!ostaccesl tl o.
S i mptomel e
f)rcacces1Ld,l e
pr,l nei g cu aproxi nuti r' 5.
j l {)
rl rr rrrl rrrrrl r,
r r r r l r r l al ca pi cr dcr i i de cuno{i i ni : 5, r nan i l osl i nr i u' se pi nl r - o s1, r r , r ' r r r l r . r l *
, or r l i r L' t , t r ansl i l al i i i eoi , i nccf oqar r : 1, Teder i ; , amcl cl i , gr i ' l r r l i , pr r l or r r , , ,
r , r r zr t , t i e de pr i r bni i t ' e.
- i l ccst e
si i npt or nc pr eacoosui l o
, , r l r ,
l r r ct l i zr r r r ' "
| t l ' l
/ r l ' ; i i , {i : r , de pi l <i i t i r i si ncopa 1a ni r r l ; i t : nc. Ln schi mb i n cuzr r l r i r r l r , 1, , i r l r r r
rrrl rl t' c1.ul i t-Li ocartl i c sau di rr angi rra pcotol aJl , pr: l i ngi i i r,r' rl i i o si rrrpl rrrrr.
p l cr r , r . r : cs t t al o obi $nui t e, pot zpar e: dur cr i pl ccoLr i i i l l c i r r l or s, ' , I l i l i i r l r ,
r r,rrrt,c q.l l ., pc l i l gi l semnel c sti l ri i rl c qoc.
,4 ccasul propri u,-zi s tl e pi a,rtl ere da at,nofttnl {:t cstc sourl (i {i {) si r.rrrrl r' ),
Lr ( ' ut su1
oi "t r ui a so l cr nl l ci i i l i i i r r , l o f l l l sci t l i t l l l , t , r l t i scr r l r r r i i
1i l r r r l r r r l r . ,
, l r ! ( l i t ( , i 1,
a, ccr r : sr r l sc
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sc
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i nsl , r t , l t o r , or t l l t r oi r r t , i l r r r r i l r r ,
, r r ' t r r t l i i , t t i t cot ' i ( l c ( , i i ( j vi l
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I r {' l t st l l l l l zr , i 1, r l i <t ,
l l r r l cr r r
l r si r , i r r l l t , o l t ; t r r t , i r , i l r r l r i i l r Lr r r , l l r sl i r ' qi l t r l : r r t . . i
l , r r , i t r l t t l st r l Jr zr : i l l or r i l l r l i
l r r r r l r r l r , csr l r l i r
r r ^l l r i l t r i i : r r l r . r i l r r r l l r r l r i , r . i
l r , t l ot r r : t si i , $i
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' . Al r , l l r . r r r i r I r i l i r s I i i I i I or r i cor ' I or r i l r '
| r , , 1
r . r i t t t i {o r r l l i zi i r l r , r ' 1r i l r , ; r r ,
1qt : r t r r l
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f i i r t t l t l r ut r r l r ' l t t t t l r r t , r ' , ' t r r r r l t ' . l l r r I r i r ' l r r r i zt r , r r : r r . r ' i t , , i r l r ,
; r i r ' 1r I l r , , , : r
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1r l r . , . i t r |
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l r r
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l ovi t r r . r ' ot r t l l r ' l
,
t l ; r l l r l r , r r r l r , , r , r , l r r r r r l , I r r I r r r : I r I r r , , l : r , l r r r t r l r l r r .
, r l r t r l r r l
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r r r r i ol r r r l r r ,
l r ol l r . r
i l i r ' 1i r ' 1r i I r , I r I i l I i ,
l ) l i l
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l . | i r t t l ) t l t : , , , , ' U. . , u, t , ' . l . i . ,
1r ' r r . i r
r zi i , ( ( i i l i l r . r Ll i . r r r r l z, l l t i t i ) i . i , l r r r . 1, . 1q1, ;
; Lr r . r r 1r r r I r , r ' r l . . r ' i r Ji r r i i r l ul l i r I i osl o aki r l ) 1{) ) i i r nr }l i v I l l o si r r r r r po, r l . . r r
r r I i . *I r r I i sI i . i r l , l l i i
( i i
l , l r
l ) r ' o( ] {r Jr t i
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l 0% do a, l : or ( , i l , ' r i r . ' u' r l i o- vi , scr r l r r , r r r
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osl , ( , l . l ,
r l . r r r r r r ' r r i ' r ' l r r i i , I i i r r r l r , r ' bl r , {l o o f i r l l ) n}l , r ' o hem- ' di nami oi i cl e gr r vi l r r , r .
. i r l r . r r l i i r r r . i l r l i i l i
. :
r r , ) _ l i o- ' p, r r zi r cnl r l i Lcr i r , r , ^' i nr l cl
1i
cr nscci nt i . ' i r n. r I i : r I r r ,
, r , I r ' i . r ' . r , i ' r ' r r I I r , I r I | i i r ;
b) l i c o t t r l br r | r uo de r i t r n, ut t r i l r t cl r l r l l a, t r n gl l r l r l r ,
i r r , I i . r r ' i I r r I r r . l r r l i l i ' i l ,
I
r ) f i e r i si mpl i l
l r ' i br ' . ; i r : c
: l cl cbi t r dni , c: r , r o
D{) , r l t ,
r 1 ( r nr ) r r t r ' r r r r r i r nr r l l o l r oc: 1r r i sr ' nc. r ' r ogr nsNi cr l l r ccst ol si ncopc {r : l , r i l i r r . r ,
l r l r , I oI r I r , r r , r r r r r I gl t r r ' , oxi st i nt l l i sct i l r r Lr t r ' ! ; i i sr Ll t i t e.
r,"
l i nrttl rtIa. rl .i n t:u.rsuI r:tt tl i opl ti i l or
rr) l rr .r./aro:c {{0rl i &i si noop:t :u.q ci u' i t otoro prtognoi xoDi ce:
sul l i rrrr
LI I ( | ( i | | i I r i r i r r or r i . s[ l i t f 0r ' 1, ur i l or , es1; c t ol al l i i , i l ur et l t d 1: Z mi n t e si l i l sr , r t r .
,,' ..r' rrl
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( t ; r l ' , r ' r r t , r ' i r 1r 1 l l l i l ) .
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r l t 1: l \ . ai ' di n, pt ' ecr r t n
Di
] Jammar st 0n
l Ci t al i
r t , ,
(l rl l ' ,{' rl {r' ' ' l z,
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ori l r,si r i i , pl o,si ruro i ,ol r-uci ci l , senzi r,f i e hi tl l Ji r, tl e
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de vat5,,, ovr.rr
l rrrrl o. r r.r' i l ,l ,l ri l r"r. i ti zi i , r1e
l ngor' .
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l ,,r' rr. (,11.' s(' i l , i rn pci ,r.tpti bi l ). a,sur.zi ' ei l zgomotel or cardi ace, arl ei ea s.l l rr
,r
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,
r I i r r r i r r r r r,t r ' r, s Ln {i i \l ri u i l i a tti l {hri si stol i c. Dupi , Trendgre (ci l rrl ,
, 1, {: i r , ' , r r l . r ' r r r t r . l i r ; ?t . si r r . . ul ) : l t l " of oi ,
- r r l r
i r r u i o : b% di n"sl enozr , t , .
:
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i r r' , r' rr r.i s. dc t.o:l r| c subi l .i si r.r, p.oEnosti c ul ter.i ur reZervat (mour,l ,r
r r r r r r r , r l i l i r r r l r r r r r l s do: ' - 4 ani dupi t pl i ma si ncop; ) .
lt) Itt, ttti.t ot"tttr.l le,u trotnboz& u,u,riculo,rd, (afec{iune rari,), tuiburilr ill
r.
1r' rrl rr.
r,cl rrl ,i ri l r' sou, r,u ocazi i :l schi tnl l l i l i l or de pozi !:i e : crti , di gpnoi (,i l ,
, r r i r ) zi l , ( l r l l t l l l i
si ct . cr r {, ual si nt : opi r , .
, ) l rr h i 1t.r' tl erLs i unea
7tul m,onari 1,,
pi erderi i e de cuno;ti nl i si nl
1rul i l
I cl r r . r l r ( ( l i l gcr r l i t r . r r l , z,
1. 972) , I i i nd
l l l or er l at e-
de cl i spl cc qi const i i , , i i , ,
l ,,r:,r, r (1,i rri i ,
l rr,, l l *ntrri , d u.e' e l l rrgi nrri r,sri l . l n cadr-ul hi p' ertensi ur r i l r rr.
l
r r r l r r l r r r : r r .
, rrrr.l ot. spcci :l l -i ) o' ,rr1u, hi pcl tcrrsi unea puhnondrX pri mi l ,i vi r,
r r r . r r | r ' I i r r r ur I r r r I u si nt mai t l cr vel t c. l i r sr hi nr l r , hi pcr t ensi uni l e
- secur r t l , u, , ,
r r . r ' r , | | | ! I i r ) I ) i I I i i dr l r i udi t e sr nl congcni t r l l . &r dt si ncol c t l oar i n 2/ o r l i r r
, i l l r i r f i i r l , i r Sr , . 1) l ' . . , i ul r l c Gi l l n. nl uanl z, l C72) . -
rl\. ltt i tt*rt
lioientu.
coronq,ri(Lr1.d,
t)ot
Bit so producii si,ii,ri sincopalc, rlrr,r.
l r r r r r
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l r l trrtrt rl r Il rrr.,vgrrl ;r o si nCgpl i , :l tl CSea, mOl ti t]ri " l l l t,I, Aoeeai si l ,radu1r,,r,ri
, l r r r r ' : i r ; i r r . ol r r l : ' i ,
1x[ 1l , t l
l i i
1r | or l usi i ,
de cl l r t ze di l 0] ' i i i e: 1, ul bt r r . nL, e dc l i l , r r r ,
r ' , . l l r , r r : r t i r r l r sr r r r r . r l u1r s. l i 0 cunoi l qt o, t b pi l dr i , gt , i t vi t , at , ci t , 1, ul l t ut . i i , r , i l , r i
( 1, '
I i l nr ( l i r )
i r r I t t r r l , i r L sl cl i l l i n bl ocr ui l o l l t , r ' i o- venl ; I , i ( t r l : Lf o. I ) unr r . t ] l t ,
: |
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r | | I I t I
j
i , i I I t t r t t I t t t r t I 1 t t I d cttl tt rr' ,ri t,t,i i l {j ftr)Z(ri
I)ol t1,o l )fovotj l I
o si ncol )i t, ro1l cXi l ,.
I r r i r r r i r r I i r
.
i r r r r I l r , r , oi r l r l n. i l nr i ' t , r ' r ' or t i i r i l i c cr t r r , l r r i i r
, , l l ngor u
I si t r r , , ol t i t l r ) . l ) l
| | I i I I | | I r
\
| | t I I I ! l r i t t l , r t t t t r t st , t r l o l t t , r ' i t l t r t r l r ' l o; r r r l r i l , r ' r l i r t I I r | r I i o1r I t I i i I r I i st ' l l {r r r r i | r , .
l l " | ;i tt,l n' l t tl i l turl t"ttl l ,tt,l huri i ti l rt rl e ri .l ,n utnl i t,r:
r \ r r r ci l r r r r r r r r r r i r r l l i r I r ' r r I , r r r r nr r Jr l l i r . r ' r r l r r l r l oi : r l l i r r r l r r I l i r r r r I : r , r ,
l r r r r r , l r i
Lt t t t t I r ' I t ' t I I r r r r t r l t r t t t t Ar l l l t t t r t l {l ol i t r s. I ' t i t r r . r l i t r r l r ' r r ' , r r r '
I r oi I I r ' r r r r r r I t i r I o
l r r r ' {, l r I i
, l l r i
l l t t t t i t t ol r t gi c; , r t r , i t t r l , ' r i i r , r l r l , r
, 1, i i l , i r L l l , r r ) r r l i r l l : t i l r t t l r r r l i l r r r ( ( l i l t 1r ' t r
J, r ' ; r I l z, l l t t : l ) .
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( l i l r
l ( ) l r r l r r l
, r r zt t t i l ot sl r t r l i l Ll o r l o \ \ r t r r r ' ( l l ( ; l l , r i
t ) r : , i l i , {l i l l st r t l i r {, i i i t , l t t i
( l r r t
I r r r i r
( l 1l ; l J) . , r \ l ) r t r t l c ol ) i ( ' i ' i r l r l l r r r \ r r ' r l : r r l r l l 0
( l ( j
l l t t i , t l l i l i l t l i ' s i l r ' l r r ' i t j r i t l i I t L
: r r r l ccct l cr i t o c{. ! Tdi t t f t )
f i
: l I I I r , r t r r L I
(
, | | | ( i . i l l l i , l l t or r l cl i ui c r l t l j r t , zl i i t t I t t t t r ' {t r '
r l r f 1, i pu1 t l e asi sl ol i e,
1r r I r
t t t t t r i i r l r r p r t r ' 1, i ci r l aa i l i i l i l e r t ' pcr cr l t r i r t r Li i : r st t l ' t : t
, i r r,Lrl :r,!i ci ocrobral o. l Jl l {ri i s1.ol )ul cl udi ac tl ui eazi ci { cr;l l stttttLtl trr l tprtttr
,l orrr o st&te dc sl i l ,bi ci uno, i tLso!i t,i l , do pftl o:l rc) al nel ol i ,
;ri
tLl l l rrrl i l i , tl r'
rrrrl cre. :\si sl ol i a r1e pesl e .10 secnnde produce pi et tl cr' cl l c1n1(rl ti l tl (' i ,.
(1l l
, i rr,rtozi r, turgescenl a i ' enel or
j ugul al e, Ii "ri rea qi sul er{i cj l l i zi r
r' rt, r' l ' sl ri rrl
l i (f i (pi n:l l i . npnei r)
1i
convul si l toni co-ol oni ce (tr1-a1' ne, 11)0 i
I
(
' ol Irt' t i tt ,
r l r i l i ) .
ln cadrul 1tll-rlriu'ilol dc lii,m,
''je
descritl:
1) I' ul btu i ' ri l e
(l e
co duc(re, ca' i e si ni cel c rrrtl i Jri trc cunoscttttr trtttzr'
rI0 si ncopel or :
^)
Bl ocl tl etri .o- t)etLtri
(rLl ar . De obi cei , pi c,rdel ea i l e cui rorl l i l t{i i t' rl t'
' rl Nrtrtl l ni r,
qi i mprevi zi bi l i r,.
' \Itrl l ,
rl rai r:l l
'
oa estc dccl :rn;ati r, i n-ti rtLl tttl tttrrrr
,,i i rrt, ca, Oe pi l rti , mi cti une:t sl rn defccal i a. Sc-;ti e ci r, daci ' bl r.tcttl
' \
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, , , r r r f l et se i t i agnost i chcazf r r . ur ' ( i i 3.
j ; ; ) ,
l , l ocul i l e
- pr t r r i sI i r r t r
t i r l i r : r
l ,rrbl eme
di {i ci l e t1e di agnosti c. Pi Frl l t' rci r,
(l e
L L1l rof ' t' i n1i i ' di u bl t.rctrri l tr
' \
\
/ t
i ' i t . 3?. l nr cgi st r ar e po) i gr . r l i ci h bol navul S. I . , 61 dc
^[ j
Di 4' \ i r r t , , l , : l
( si ndr or n Adams- St oker ) .
' l
I osL i nt er nal i n 19i 0 cn dg. St xt us cl ) i l opt i t r r s'
pcnhLr l r ec\ cnl c . r i zc dc
I
i cr dcr c a cl 1nol l i nl l i , l nsol i t e dc mt t l Lc or i d( i
con\ ar l si i i unj c! r i oni cc. I I ci i ni ca
^vcnr ol ogi ci r
Tg. I i ur et exancr [ r l Ul i ( ;
i r t cr cr i t i c a l ost Deg. l t i 1' . E- \ anr cn] r l pc, l i gr ai i c a eYi denf i aL un ] ) ] oc nl l i r l '
vcnLr i cul ar pe ECG, cu uD l i l nl vr r i aLi l ( i nl r o 22 $i
18 bi r l i l i pc r r r i ' r ) ,
cu Duncr oasc xsi st ol i i , i ut r c 1i - 3i s. Pe f i gur ; t se vede apr t i l i a pc l i l l ( ;
de undc l ent e bi l at el al c, si r cr onc
t i
si r net l i ce ( I r cdomi r xnt e dc dcr i t r r l i i l r '
ar r l er i oar c) , dupi car c, odat : r cu i l sLxl ar ca &si st ol i ei f i
pi t r dcr cx cr r r r ( ' )
tilllei, trascul se aptatizcazir, Aprdlia primei conLreclii c:1rdittco fuco rii-t
r t r par ' 5 l l ncl cl e di n bar r dx de1t a. Cuuof Li l r l l l r cnpar c Lr cpt et , odLI l . i
( r r r
r {r i uar ca act i . i i t i t r i i car di r ce $i r c\ . cni r ca l . i no nal N r cLi vi l i i l i i f l r ( : l r i r ' ( '
cor cbr al e. l nt r eaga
Pcr i oadd
dc 1a i nst nl : t r ea asi st ol i ( i
Pi ni
I r r or ( r r r i r cr r
cunof t i nl f i l ) ol nxvul ui a dt r at 3B si : cLr [ dt . Sl i j r : r l . a i r l di cr "r r ( {t r i r ( i : r l cl i '
vi l i r l i i cxt at i {c0 ( dr r pt r Cor l dr t l r , 1! ' 17, Cot l i ui t t }i
l ) opor i | i r r , 1071 f i
l , . , l at , i r i r r
t i
cakl ) . , 1t t i 3) .
| r r r l r r r 0l r , 5l , 0 l , t r l i r r {. {' r r , r i i r r r ' ( ( l i h1r ' r r l r t ' l r , t r i , z, l {f ?! ) : l i o o
l I t ' l l zi i ,
vot t l , r ' i r ' l l l 1L| r i
( ' i l ; r / , ( l i r )
r , r r , zr r I i ) , I i r . o l i l r | i l r r l i o l r r r I I t i t r t t I i t t i i ( 9{t
r ) i , ) '
l i r t o I r t I r t I i | I t I r I i o
,
' r . l , nr t t
r i .
l t \ l l l or u. l . xi t t r t
ql t i , r l , t r r Lt l l t r r r . i t t t t t l t , t ' l l
l t t r ' ,
r ' r l ct t l t t l , l r r t t t l t ' t t t l r ' ; t l l i '
, l i t r i r : 1r ' i t r r r , , r ' l r ' ; r , r r t r i t r r l ' l , , r , r r ' r : r t < l r r r
"
i r o r l i r ' t r l l l i r '
l r r r l
r ' I r ' r ' I r ' ol I r ' t r I i , r I 1r i r , l r i .
( )
l l oo' 1. & t i i t *,
' t t i . s( ' r ' ' . , r ' l r . r i ' i / , ' r zi r ,
r r . i ,
r L I I r
.
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,
r : r l r r , . l r t , 5i l l ' l t r n, v,
r t , l t r r , i : r l i l r r r i i
.
r ' r
'
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I
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r r l r l i l r r l i , , i , t u. i l l l i r l i l
; , i
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"\ t l r ' t t t {\
Pt
l t l t ! t t i i l ) Nl t l t t l i \ ' . , {r . r , si 0 1r ! t , r . t , i l r r . t r l , : t , l i r r l r , l i t t t t r t , i l t t t l t t ,
r r l l r r , l
1r ' l
l r ' r r l . r r . l l -
r r i r r . r [ a' i
r r . t ' r r r . r l Li r r {i r , , ci t ' .
l r i r r i r ,
i r r apr : l i r , r r r , r r r *t r i r , t l r r
, . i | , I r I , I ( ' I I I I I I ) I r I r L' ) cl t r ct r r r si sl , ol j c ( pl i r r p1r , r , 11r ) i r r , ) ,
sl i i r . r sr . : r i t p1i 1 t l i i i r r uf t , ni l
l r ' r i r ; r cr r l i r r ' l t r l r . . r . : r i r t s l r r r 0 t r l l r I i 1 ,
,
.
!, !l \tr,l ,l nu i i ,ri l p de ?rai tabi l i ,t l t' .. I,rj rri l c l tcsl cl r, tri t,rrl ,i oni un fi i bl i l l ,!l n
t r t r l l i r r r l l l l i , r l r ci uei cor r sccl i u! r i i t r r cr l i l t l est u ol r i l el t ,
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i' ,,1,il, ice pot.sil se insot,ensci, rt9
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Fi rrui u,,
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. \ r r r ) l ) ( ' r ( ! sl I r ' i u' r ' r t i t l c r ' r l l r . SUp"A I onl r , i r . u] r r | e
l l l ot r vCr cl
. Fi t t Ll i r t , ,
h i br i l r{i .,a,r:ri .ul l l .ri
l l l r,xi sti ti L I
i rr ul l ti rna va.i ctu,1e,
' si ncopa
pbato
surl
' r' ri
lr, ,slir;itLrl, rtrustrlui,,pr.iri pa,Llzir, auriculari, post_tifirifdliej.
SiiiL,
rrr/ , r' rLr
lr(.llcUl()rNc,
i;r stlLirnb, tahicardiile vontricula' c, prin
riscurllo
ile vontriculalc, prin
l ol r l r l osol t i l , o,
'l' uI [ou.[, sincultul poale irnbri,ca urrniitoarcle configurafii :
ru) lr pr:r' turbiililc
hcrnodinarrrice cu tlurati, Ae l-iO setunde, tulllu.
r, .i' .rr l.1,t' ,iit tr. osle de obicci .tsinriitii tle hotnav, perioacia
fiirrd
st , t t r t i t .
( i ol
nt ul i - hol ns, r . ' r r l r esi nr t o n ( f al a. r d; . t ^
- x. 1r - ^- , .
rri ,
-l l )u
l i ul Dtl rl o l l cl nodi n&ni ce
cu druati , de b
_10
l l rl i l ci rrrrr l l l ,tx,i i t trn osl e de obi cei l osi nl l ;j ti i de bol nav,
pt l rr sl rrr l ,i r,. UeJ t rr-ul t, hol t rar-nl resi m be o stare r;ag5, r1e
,,rb,u,,-sau o efemot{r
Il i n(l i u|ol cs, i n contcxtul cl i ni c al tuturor
i r r i cl l , cl i ze conv r dsi i . e,
,\rl,1il tlc accrirltirite in repctilie corstituic
s"rr,zrr,(i t^ rl e
",,vi tl
i .tv' i or", cr_i ,re-i pemri t evi tare"a cXa6i .i i i n cazul i n cftr,(l
, l r ) l , | 1r r cr L Lcnl odi r i t nl i ( . i l I l i ude Si se pr ci ungeaSCH.
.
,
b) Lr. pcl l utbi ri l e hernodi nami ce ae 1O-ZO
-seeunde,
mani testl ri l o
; , r | l I
, l r r i r t
l t r l r . l r sr . , l , ul nur ut
[ | r ' Czer r l i nd
O pal oAr , . b. r ui at i a f et ei , VOr t i l .
I' r
r\ r 11. i r,i rsr.rr t.r' i . opr rfc .r \ oJ l Ji ri i
$i
I ac r i v i l n
l j i
mo tori i , d u pi r cari : i nai vi Otj i
ri j r t t rl l i i l ol , rv t t at c: t .
c) l l i
1' t.t
l rtrl ,ri r' i Jo snl s dcpi qcs,. 20 de secunde. pi ol ' dct,ea rl e cuxoqti ri tN,
r.ri l r. r.' si \ ri , (.u
rbol i .r' i l rcl l exr.rl ui cornel n dupd, i O O" ,-"*A".-fl -,i .,r,i i i
I r r ' i : r . i l ^l i l dr ' i i l r , . ul j u se si r ucazi
j nl r e
t , ci 3 f r i nut e.
.
r.l ) Itr ,,i neuptl e cu dur' l l tI de pestc B*4 mi nute, l ezi uni l e cerobral o
si r r l i r r r r . cl si hi l o-
,rstaren
de rdu
.
.l l .
.{i ar' ,r7,1/, ,oJ
tl a. Ei naopa uaso-uagal d, re.f\efi , po:tte Ii tl ofi -ui ttt
I ) r l l t
'
l , l ' l ' ( r or o
uc cut r ol t l u{a
scu_r t e, cu sau f 5r i convul si i , sccundar ,
rl rfr
Iri urz,!
(1i l ,l dl &ue
s&t unei prd,buqi ri tensi onal e refl exe (W;ber, 1g?2).
I trr.l ;rDl ,,
*crstr: si rx.ope, cel e mai frecvcnte qi mai beni gner' si nt pl uri oti ri -
r(,l i rr' r' ! (|i l I
r o:l .Lo al r ul l ctcmcnl cumun : tercnul pe t ar.e surri n acei te nranl "
]1..1.1:l l :.l r:f i :t
o .l abi l i ta,te i mporr ani I a si sl ,crnui ui ncrwos wegctati v.
Aprw
r' , r,' tr1t r
l rrnl r,
l & 40. dc a,ni
$i
si nt mul t mai fr ccve.nte l a femei deci t- l O
r r : l , u, i r . l r _
l ) r n t , ) t ct ut . sr n( ' ol ol or st udi at c de CnI f l r i u si
popovi ci n
( I g78) ,
l . ( r ' r l r ' t r ) r ' l n{, l l l l t l . i l t t zAt un pt occ {nj de 93, l
o/ o,
I n ant ocedcnl , el e : r , cost r j i
r ) r ) I l i r \ r I u , . r u sc| | l t r l ' l ut zi i de obi cci bo. l i or gal l i r . e, ci , r Jt . r , egul i ,
Si mpt ot no
: l l l l , i , j l l , "l , t r r l bur i i r i
vcgo. t ar i vcJ t ut bur t r r i psi hi co t l e or t l i r L di cct i " t a' pei uo.
..' rrri r{.r or.oti ve' i nstahi re
9i
l abi i o vegetati r,' . uneol i i n antecedefrto so
Hr' ' rrr l r' i rzi , fi l l cIt( si rrnc artcri al i l ,. ca fncl ;ori decl anSatori so somnal o&rl l
(( l r)r' l :' i ,
f
i
,l ,opovi ci l l ,
l g?J; Co' f ,r' i n, 1.0?g) : fri oa, si i ,ri l o de crnoti r,i i ai "o
f i
l dl : r l . , t i t l . i l , l o, . sl r ' cssr t r i l o, sul , ; I l i I l l | 1ni t l i i l , i l r sol l l | l i i l o,
aor ul t l ol t t Ut ,
r \ \ r i l , ( t ( ' : l , t cr xr t ,
n( t t l r i ni r t l l , a. r on, ( l ( , i n, i t ' cl i i
i . t .
, l l ) 1i
l r ccqi ; i f acl ol i i l ocl anJ
t:trrrr' zr\, rrttrl t mai uf(n' rl .,osrrl si rr.rrprr,l ri ur,,i , bul na,vrri so ntl l l i n ol ,r]ostrol ,i Hm.
l l ttpi l , rrbi ryrtui l rrl rr rrl r,l i l i ' nl r"r,r,i
Jl l r' :ri rcrrsrrrr,l 0, ntrnol l zi j , sr,url ,ru p i or,rl ri ri r
'
ci O
rr rt rroEl ,i rrt,i ' I,,
:|tfi
a,cesnol slnoope so
}ot
,
. \ t r , xi t r , r , *t r r br u, l t ' 1, , . *t , r r r , [ 1. r , r r , r r i ' , r r l , t . r ' sl . i l i t r t , , I t r ,
1r ' ' 1, .
f i . r r r t , l i zr r i i t
l l l r r
l t l i Ui t t t t t l l , o r t t or ut , t r l xt r I t r
t 1, ) . l i l r , i , ' t I l r r l r , r r {i aJ 0s1r i r . ol xr r zot r i t r , l , , l r r ! l ! ' f ,
( l i l
. i r ' ) t n' i ' r l r r p) i
( l i r , xl , r r r r l '
r , r i . r r l r l r . ( r r i ( ; ) , {l o o on r di o- i r r l r i l r i I i o.
( ] cl ul : r , l i i ,
.rr,ztt,r' i .ri trl , i n
.trr,1ror' 1,
r' ' ' ,r l r i
l
x r l r
.
r r r i r r o tt' i l rrzi t,ori o
l l t,i tr
v|,xorl i [a,1,1t,{,i o
; x. r ' i l . r i ci r ,
r u*Li r l , ( ni r r . ' pi , r , r r r r r r l r r pl r . si l . i l , ) . sau cu o i l l i i bi t i o r ospi r , : . r , 1, ' i , i t ,
1] . , ' : r l '
l , l pnec Nr u cl l i : l , r : r 1r r r r . r ' ) ,
( i l l sl r r , r r L
qi col a. b. ( 1956) au a, r . i j l i l i ; i xi $1, t r l r l , u,
rtnrrr I,)rme \.aso-rtol , t' (' $ i r 1'
1trr..
i l si ncopei , al 5turi de fot:na caul i ,_i l hi l i i -
l ottc pul i
;i
dc fonnr,l o rrri _r.1o.-l )o faptl aqa cum arn r.emarcal ,
$i
rr{)j (( l rr
l : r r i u si ?opovi ci u t 9- / l
;
( : ur f i ' i . ,
. t 928) , acei l i f t ct ot . i bc pot ai ' t : i l t , l r r . r l ,
l ) c
bunA. dr epf at e. Webcr ( 1972) : t t i r md, cL, par e i l uzor i r r 6J, sc t l i f r r r , , . r r 1i , . z, .
,[i versc i i puri de si l _ cope (r' ' .utfal c, vaso-depr?si re,
vago-vagr,l c sl u vi n,]r,r.,,
vagrre. rcsl ui i torLi . vaSo-vagal e cu bradi ca,rdi e pri mi ti vi ). Do l |,r.r,r,:r
\\-obe1
i1972; susline cd,.este pr:oferabil ca. toate acesie $incope sit $o rrri{lr
pez:
l l p
nxm e1e de.
,,s;ncope
taso-aagal e,,, cu ati t mai mu1t, cu <:i l , ri st,,
pt'obabil c5, se asociazX sau succed o cardioinhibil,ie yagali
6i
o r,ir,so
tlepresie simpa_tic5, qi cL do
-fapt
aceste diferite m'ecanisine pol, ir,von, rr
ori gi ne comund, depi nzi nd..de un refl cs care pune i n j oc
Ir. Tl ,. ponto
bul brtS. care. conl i ne centri i respi rarori qi ci rcul atori qi i n speci al c:url i ,r.
rnoderatori
Bi vaso-deDresori .
St ar ea si ncopal i pr opr i u- zi sd ( i n mod i mpr opr i u denumi t { dt r Wr . j x. r
(L572). .rtazd, i ctal d,") esre dc obi cei precetl ati , dd o fazd, prutl romtl rl (i rl
propr' i u dcnumi td dc Weber
,,{azd
pre.i ctal d.' ,;.
,
^1
. Faza prodromal d, ( pre-accesual d,; pre-i ctal d, dupd Weber
),
cu rl tl .Lt.rr.
dc. zU-J0 Becunde, se mani tcstd, pri n i mpresi c de
,,rd,u
gcneral ", t,rrurrsIi
l afi i , am6{,911, zgomote. auri cul are, al teraJi i al e pei cepti ci vi zLrai o, l ri 1,i ,r.
s_i al oree,
senzafi i i i e
,rvi d
ce.fal i c", parestezi i i n extremi tl 1i , pal ou,i ,,,.
nrtrr,
(tunpotri vi ,
rol eata, t-egumentel or, uneori dureri opi gastri c6 i i trrr rl ,,l ,i rri t,.,
grelud
$i
exceplional vi,rsS,turi
lOorfariu,
19?1
;'Weber,
1g?2).
2. Atacal sincoptal (,,Jaea
ictald,ii d,upd, Weber
)
corespllodo piorrlrrr,ir
Iropl i u-zj se
a-_cunogti afej . cat.e esl ,c compl etS,
$i
urmattr dc cd.cl rrol I' rrl nrrl
,' st' e
.i nscsi zabi l ,
zgomotel o ca.rdi ace stnt si abe' sau ab$ente, dar nr,rpi ru,Li rr
dc obi cei este conseryat5,. Rel uarea congti en{ei esto rapi di , drrrrur,,r,' t.,ri i i i i i
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,
Insol r de manfesttri conyul gi ye : spasme toni co l n opi stol ,onuB, oxcotrt,hr.
lpl
r:
9*p-"9!!oto^nq,
r1rm?F sau prccectate
uneori do ctonii girrr"ruririii",
(CorIariu, | 97.1.; Cortariu gi Popoviciu, 19?1
i
Weber, 19ZZ). A"cobto nnuti
rosra{r convursrvo se,lnsolesc totdeauna do o rnarcat[ midri&zd,, u[.(,r' i
de trtstaf,'mus.. hrpJrsatlvatie, emisio de urind gi mugcarca limbii, rin ltrxrr,rr
smr expucabrre dlrrcuitaFile do diagnostic crL epilopsia (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 d,e diagnostic, po o.iro rlrlrr,r.
le Tom lezuma :
a) Examenul clinio este negativ, iar traseele XEG (standarrl
ryi
plirr
nctivS,ri) din fazolo intorcritico sint
_
normalo (Cir,lcii,ianu
$i
Stoio,,,
'.lli{tfi
;
Oorfariu, 1971
;
Corfn,r,iu
,si
P,opoviciu, 19?1
;
Gastaut, tO6f; flnsirr,rrti qi
.olab., 1956
;
It&illofl, 1000
;
Slioica
0i
Bro$toanu, lgit9). Doart V.rcolhrl,1,ir
(1960) a gfl' sii la 30' 1, rlirr lr' lnrlvii cu sincop., anolnalii lr.r!(1 r' ,rro.rr,1,.
si
Itu l-0% {,n"{,rnrIlii rrlrr.l,r' i.u rro ilslxrcrt cornifin,l, inrl.osobi l,l sLrbi.' l,ii .rr
$irl(Dpe vll,Bo-vlulllo,
3:)tl
. l l t
t cl r i t r r l r , i r r Li t r r I r r l l i r r col r oi si r r r l r l o sr r r , r t l r r g r r r r do l ont ( ! , I ) i I i I I i I I
. i
| , I ( I
t i i i Bi I l ( , r "r , I I i r , xr r l r | l r , r ol 1, l r , l , r r , ( l ( !
i I l ul . i ' i , si r r r t soi r l l r , l l i , ,
( 1l t
o I r r ! ov( ! l ) 1, i 1, i l 0 i t .
. l
r , / r r
( ( | r r f r U' i ] t ] . l l ) 71. ;
( l ( i r l al ' i r l
r yi
l , , 1r , vi c' i r r , u) ?t l Wt , br r r , l t ) ?J) . l r r si r r r r , l r l
. r r r I r r l si I r ' i , l r r r l i r ut . i l o
( l r )
r n( l o l cr r t o si r r 1, r nai Jr i r r gi
6i
si i r l i r r t r ur r r pi o r l o i r n
r r i l r r r r {' i r r I l r r . l ' r ' i r L l I pl o
' 1l o
o0r npl r . t ,
( , : r r l 1.
c( u{. NI , uur [ o sl ] l r , s] l l l r l l r i l oi r i c. , , t <r csl ,
l i l . l {i r r l r r r cl r z' i i ' r r i l cl a, sccundo qi cst c ur r r r : r , t dc l ci r l l l r , r ' i {i r l r r }( | j ' l ol i {' l 11o,
.rr|. o Il ,rrr rIl zi i ,
l rr0grosi r' ,
pi ni i
h rccul rc}a}t,l l urrr-ri r.i i rri rronrrrrl , l \rsti
r 1r ' i i i ( r l l t cx i sl ; i , i l r xr r na, l i i l l DG.
(.l rr,sl ,rr,rr1;
.
(I950)
.
a
.
doscri s si rtol pi ], nrrcturni r, a hi perl .agotorj i ci l or
Si
rr.r,r,r,i Li rI.i t, i l i l i r|crr' (;i ori i a,ocstci a de- opi l e+si a rnodei ;i ,. Ai estr: si ncol Nr
\r,,o \ i r,gi r,l (, si rrl l :l yori z:11,c i n oursul nopl .i i , de ri di carea i n ti rto,.tal i j i n
I.ri rl c rrrrvoi i r, rl o i r,.rLri ru, l a vagotorri ci i consti tnl i onal i i rL faza ch hi por,-
' rr,g.i .rri rr
rr' ot,ul nr"l . Asoci erca acestor di teri l i factori (stal i unc l ,erti c:Ll i ,
rrr l ri l i ' l l r, l n srrbi cci , prcal abi l
cul cat
$i
cu tonus vascui ar r:ecl us, afer,r,nl o
r i rrrrrr' :rJrr ctrrl ;r' i pcl ,cr
J)roval en1,[
nocturl X a reacti vi ti ,l i i vagal d) oxpl j cl l
.' r' rr,vi l :rl orr
i l ,cosl ,ol si rrcope qi asoci erea frecl enti a nr a,i i feBtSri l or coi yul _
ri Vrr Ii rl i fi 1,
u.ol )l onM,
tl i agnosti cul ui di ferenl i al cn epi l epsi a rnorfoi ci -r,,
' l ' oIrr1i ,
l rr.ozon{,:r,
tl oar a tnei contmcl i i toni c6 i n opi stAtoi us (pl .cccdl r1,rj ,
rrrr uIrIrt' i rkrl r r10 1*2 sccuso muscnl are gcnel ;l i zate,
i l ar' -Ii ci orl :r,1ri ,
i rrrrol i l i i , rl o o 1' rr,z[ c]oni ci i ri tmi ci i propri u-zi si ), precesi unea
ci dori i
;i
rr,
;ri cl rl ol i i
.orl Lory1,i nl oi
dc c5,tl e o stare de ri i u gencral cu gre!.uri , pal ti i l r.o
, , i t r ' : r , r r sl r i r ' : r 1i r r r ! l r und, nl i ! , a- l l scot I r ncmool or EEG de epi l ppsi ; .
1, r . ecur , r
si
1rroIrII..rl o
rxri npro$i unc
.a
gl obi l or oc[l ftTi pozi ti vi ,, eti mi nd, Ol i gnosti cri l
rl rr rrpi l rrpsi o l norl ei cd, qi obi ecti veazi , hi pei vagotodi a (Gastaut,
' i 9I0).
.
l)orli.s-1, orczu-t tri sincop-a
yaso-vagald,
reprezint[ u ri,spnns teusio_
r.l rrIr' rri ror }r {).l t,l {r()si rne psi hi ci ,, cerccti ri al e ri oastre (Corfari u
$i
l ,opor.i ci rr,
l !r?.l l
;
( i orInl i tr, I97-8) au arl tat c5, exi sti r, o i rnportanti parti ci parti cardi ol
rrrl ri l i i l ,oi rnl
.(1i 11.
38), carc oste capabi l a pri n ea i l sh,-;i sb, decl anri ezc o
rr r r,rr i o cottl l ' i ,|,i l "t.
.
l'onl,ru rlocllnqarea unei sincope, respeoi;iv pentru leprodueerea irt
lrIr()r'ltl,rt: ..1, nroocsllhli sinco_pal, se.utilizeazi, conprcsiunea oculari, compr\)_
rri rrrrur, rJi l rusul r.ri cr,rol j i di an qi rnanevra Val sal va f Corfari i r. l 9?t.
I l r78
;
(
l rrl ' ari u
Si
Popovi ci u:,- 19?1.; Gastaut, 1950
;
Gasta,ri t qi col a,ti ., f ObO
i
(
l i rrrl rr.ri ,
6i
^(h,$1,l r,ut,
1_956; Yerccl Jctto, 1960 j \ycber, 19 Z2)..Oompresi un{t;
ol rrl i r,ri i trr fu,rxr ti rnp de 10-15 secunrl e, etecbui ndu-se concomi tent o i nro-
l l i rrl ,nrl r ;xrl i grtfi ci ,
(EEG, ECG, pneunfograrnd,,
eventual
$i
pl eti smogra.
nrii,). l\,llrnovla, o$to pozitiyi dac}, aceasta antreneazl, nauli cardi;,rr?.i
rl rr 5.,I l :l u rnai nul tI
_ri ri rea, .
ftec\.enl ei cardi ace cu c6t pul i l r 50o/o;
rrrrrri l cl l ;fl ri
1r' o.si ucopal e
(prc-i ctal e), sventual chi ar o si i rcopn
1vb)i
,
lirzlrltoto poziti.l'e cI valoare
_diagnosticr,
au ob{,iDut Gastaut (1950)
i 1
(.i l ,
1,rnr' 1,4i col ab. (19-l i r6), Vcrcel l ctto (19ti 0), Corfari u (1971, 19?S)
fi
l Irr' l ' rrl i l
;ri
l ' oqovi ci n (1971). r,s,
uncl e dj n cazuri l c noastre, pe l i ngi nl rrd-
(rrl rr obi qrl ri l ,o do opri ro cardi ac5 (l a 4?
0/o
di n cazuri ) am obsbr-vat gi bl oruri
rrrrrrr rr,l ri rrkr
,,l tr
l anl tt, l i l i nterval e i i e 2-3 secunde. La cazuri l e obsorvtl o
' l ('
l rri . (( l orj :)l ' i u,- 19?1, 1978;
(,trrJari u
qi Popovi ci u, 19i .t) nu arn putul ;
1' rrrrrr
i rr.rrvi donftr pri n acuastL. probi i ri i spunsuri
,,corrrphtetr
i trU(i , <nr
l rl l .trri rl o.rrni l o kl -nt o scpu,r0.bi rl r:
1x.r' i tr.r,tl Lr
tk' tl ,
]rrrl sj r.
t,l uutr.i ci -r,, i l ,Di l , i fl ntt
I r ' . r r i [ t ( , i ! l Vor col l t : 1, 10
. 11{}60) ,
ei r l oi r } r . i t s1r r r r r sr r r i t ) 1, ) ( i
, , i r r t i or r i 1r l 0. l r , ) t
( f r r t l ot t t ' i r l o ut t r l o. l ont t i , . l r i l l l l , ol l l l e, si r r cr t r r r ' , si r i r ui r Jr u. , r i , r l l r u' | , si r Lr r soi r l r r , l i i ) .
1r . . . I r p1r ,
( l at l , i ul ' t 6i
or l i t b. ( l l ] 5( i ) l t u l u' i , t i r , l . i i , r ' r l r r t si i t ul xr l , r ' r x, r r c. l r r , l . g' r i -
l i r r t ' I , onl o r l t r i , r r nt r i t l r , l l i , r l c r l r r l r r , l , l l : ml i r i 1, ol , i : r ur l l l oc r r l r r r l i l l o t i r r o. l l i r i i r l
J30
i i i
"t
pl t r i l l : r ,
( i
scr r r r r ( l r l u r r r or l r l l r i l l . r ' r r r r r r r r l l l l r ) ( 1, r r l r , xi sl ar l i r r r l r t xr sl , r r 6 Hr . r . r r r l l r r
l t r ot l t t cc
l t t t l ! r r t t ' i r l o t t t t r l o l r l r r , r , r r r l r ' l l : r , gcl r ct : l l i z- i r i , c, i a, t ' r t t t sl ol r cl r , : ' r l i r t , t r
ct r o r l r r t ' 1r , l ; i l , r l o
1r c$l o
l i l r i l r r r r l {' [ l r , i r . si i , r r , l l l l l i ( l oscl - [ r ( r i r i ( l o
ul l {l 1r h, ul , o
bi l l r , l , r r nl l r
I i
i l | l ( 11r ' i ( , r ) r r r I r , l r . r l r r l r l r l I l i zi l r r ' : l t I ' i l sor t l r r i ( ( 1{) n( x) l n i l ol l l , t l l l
ol l rtul ti l i ura, cl i ni r:ri ,
6i
cl o (.ol
nrrrl ,i o i rr opi stotonuS, proccdi l l ,i , {l i f I :l
cJorti i gcnti l l l i zate). Ni rri orl rr,ti i , nu ti 4)l ,l ' e i nsi o fazl convul si \' l i , cl r)r)i (,r' [
l )l
ol rl i [-zi sai ,. Castl fi rL;ri c01 l r. (.1050) au mai demonstrat ci r, Ja, tri oi rrrr
p
teE LI4 o c a L.t
pRE
s tJ t,t E 0.ur,1,ii-'--'']-;;:"--*
1-\.n'{>-f
--'
\,.a
ECG
-
f 81r' mt n.
1tY,:^\*.\
44-',4-/,-4"Nr"-.^-,v4,,'"--,\A^/,+"^
-+,,rt\
t-
"q^rnvl-t" VA
.
C
rA^
\^!1414^,{12\4/*!1/4/"^4^%
PD . D
Yry.^"*{i&a'
aaa^^'\&{/'{a,,a
" *'\'arv
}.@q..!,,\V/
.lrig. .r3. Proba comprcsi(i octl]arn ln cursul unei lnregistreri poljgralico Ir
bol navul P. D. , 23 de ani . Dg. si ncopi vasovagal i . Rohavul s- a i i k' r ) r ul
lcntru
pieldcri dc ctnoqlinl:i de scurti durat:i, declanFate in special d(l
cr nol i i
t i
de eDer vi r j , l nsol i t c uneor i
f i
de convul si i Loni co- cl oni c. , I i 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 ncr oase bj ocr r r i si noat r i al e cu dur al e de 2- 3 secunde i n
, , s| i t c",
I r i 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
PopoDi ci r l , 1977
; 1
PopoDi ci & si cnl ab. , 7978) ,
ca,z de si ncopl vaso-vagal 5,, acti yarea c&rdi azol i c5, l ru pro(l uco l i (,i l rl
lit de reactivitatc epilepticS,, dar c5 aceast[ ac1]ivare de multc ori
l)t
o\,r)it,('ii
sitrcopa, in cantit;,li rnici ale substant5 injectati,.
Masaj ul regi uni i si no-caroti al i ene poate antrena o pr5,bul i r' (i l ol ti i (l
l ra15, i n cazul unor si ncope
yaso-depresoare
(Corfari u, 19?1., 1978; Ci o}l rrl i rr
1i
Popovi ci u, 1971
;
Weber, 1972).
In sfirgit, in sincopele prin inhibilie respiratorie poate fi rrl,ilii ptrrrl,r'rr
rl i agnosti c proba l ui Yal sal va (dup5, o i nEpi ral i e proful di i , so pl rl ci i ci r,
rrrr efort expi rator cu gl ota i nchi s5,, ceea ce produ ce un bl ocaj tl Irrl o:r,rr.,' r' i i
vonoase, pri n hi perpresi un toraci ci ). AceastS, prob[, practi cl l tl t qi rl r l oi
(Corfari u, 19?1, 1978
I
Corfari u qi Popovi ci u, 1971) a pl oduH Lr rrrrr.l ,r
si ncope vaso-vagal e o reacl i e cu totul parti cul arS. Antfr:1, h sl i r;i l ,rrl
probei , s-a produs i nti i o reacri e bratl i cardi cS, de l ungi , durntr:r. i rl l l rr,
j l
l i
socunde de Ia termi narea manel rei s-au produs bl ocuri si rxr"rl 1,r' i l hr
,,r
rr
|l ,rr],". Accstu roacl i i au fost i nterpretatc de noi drept conscci rr!o trl (! l uror
mI' l cxe exagcl ' :l tri dc ti p va,go-r, agal (13 ozol <1-J ari s ch) cu tcJ)()t' (l l tsi l l i
r r , sr r pr a nor hr l ul r r i si r xr - a, l , r ' i r l ( Oor f ar i r , 1971, 1978) .
Il u,cl ori ,,i tl .i rfut11i t,i , tti :ti tttopti l .or' tttso-ota,guLr si r11, rrrrrrrrl ' o;i ((I()r' l rIIi I|,
1071, . l 07l l I
( r ot l t t i r r
t i i I ' o1r ol i ci t r , l ( ) ?. 1
I
Wr l x r , l 1l ?l - r ) :
l . l l i t t ol t r t , t nul i t ' r t , : l t i t r i , , sl i i r i t kr i r t t t o| , i t i t i I I r , , ct l ' t ' t i i l i r sl l l l +r r r l i
( l l vt ' t ' s( 1,
: l . i l
. . . . ' , ' , "1] l ] i i "
. hi pt t l r
r l u' t r ' 11 t r i l l , r r I r r r r r l ' t ' . t t l , i i , l r st t t : r t ' r i i 1i l r r , r r r 4r i i i r r l , i r r r l r r r l
I
I
r t I i r I r | | | r ' I I I | | ! r LI i I r . , r r ur . l n r l i r r i , r c l , r . ci t Lr r t i i r t t , ol t c l ' i i ur l r , oi r l t t t r r l t r , i , o ot r r , o l r t i t l 1.
H| | t| l I I I
|
) r
,
| | r \ I I I r I (
r
.
. S| ) rrl t,i so ]uN,l oi l ,zi , si trrxi Ji 0 l i l i trr l i vj zi r:l tt,tr s l ,: Il ,i o oi l ,zi ,[
r l | r r c r r r r . l l l r r r r g; r ' 1. r i , r r i ul i - r , 1r cl i i r r chi sc, sr r pl r r , - i t r ci l Jzi t o, gr t
l t , st ' i r r r pul i r i l i r r ,
. ,
.i . ,\ Ltt' ol ),tt t,tt tl uH)t.c u1l :l rt i n caznl tnrol dur.rl i vi scer.tkt (t:ol fui l ro-
I ' : r l r i . r '
s: t | | r . I | | . I I (
' . ,
ct i zr . at r gi uuu, sr . ) si Lr t nu t i r t i ( , r , .
1.. S;; ropl h tl ,i . n cu,rsul efi tr)l ordri l or i nsl ru.rcntu[,e al )i ]r i l doosol ,i i u
.l r.| rrl
rrrrr)r sti rrrnl i r,ri i n teri tol i ul r.i l gul ui (ri sofagn. i u1,u, ganrrus,,,,-
l r i i
ckr . ) -
' ' -
Si t cup, l r , t r l ost t t l i r apl r . i n t ur sul ur r ur l Ur r gi sl r Ll i onar i i r r pi r , i 6111q1,
r : r . ' r l : r r i r l i i . l r r r ' : r r l i r r
1r r r , t .
i l ( . Dnvi r l esccnl a
dup: i r r ui l c r nr r , t , l t l i i . Ur r
j i
i r r . l ur i
: r r r sr s[ l ( , ) pct o l I l r . t , l ( , t r t t e ( {
or l &r i . 1971. t t TE
;
Web( . r , 1972) . t l . _i i r r
: r . , r . sl . r . : r i r r t r r l vi nc
l i
r l i SL. n, . {i t . \ ' cZi cal a.
Si r _r , : t r pol , , or t ost aLi cc
; i
cot , . l ; r ,
r | | r ' l | | | l ) o vr ) r ' t r l r l l r , t r . r l c noi Scpar t t
1r | zi i n | onl i nua: , t ) .
ll.. 8 i,runl(.Lc i.atrogene : dupil ingerarea, unor rnedicamente sr.rlr lll
r r r r l sr r l t nr ot i uj ec{i i .
i. il irr,cop ele tlupii r:on su,,m, d,e alrtxtl
s. ,\i tttttl tcl e
d,upo. ttuu i n cursul tt t,t,r r
Iurturi Ii zi ce.
.
l t,. Si tropcl c pri .n
.h;11t
tse s;bi Li tutt^ t si nusul ti i rorti i di att
au I,t,,l .
rrl ,ri rt
' r{ri rrse
i tf cad].ul si ncopel or vaso-' agal e? crezi ' du_se c;, i ntervi rro
rr lrilr.r'r.:terl,u,h,iJilate r...r,g,,1i.. Da_r_ tle_ lapt eld constituie o entitate apariir,
j i l ; l l . l , ] 1, , ! , , 1( w", : s. f , {: 5: : , I 9i J3. ; }l i r r vi ei t t r ' . r u5i ; Cor r ar i u, t 9, i , i ezs;
| , t t r i u l . i r | 1) povi ci . 197. 1 ) : : t , ) r i pul vagal sau c: r r di o_i nhi bi l or ; l ) ) I i pr r i
l ,r,rrsi o-tl opl csor'
I
c) ti ptrl cer:ebral .-
(':r,
:Ll,il,r'u r-or' 1i expuse pe larg intr_un subcapitol separat.
l 1l . It' l uxtrl , l ar[ngi ott. esLe.o formi de si ncap[-gal "s r,pare l a i ndi vi zi
((!vi !.
rr&i r.i ' sl i l i ci (50 de ani ), pnrti ,tori ai ui or afecgi uni respi ratori i
'
r' {)ri , r' , Irr .rr.. r' i Lcurnstanfel e de apari l i e si nt chi ntel e de fuse. b fornri l ,
n| l | J, i r . t ' ' l us0l | l l t ] r r ngt an cSt e
, , LuSea obnubi l ant ai , , . .
,
| |
".
Si.ncopel,e post-traumati,ce.
Se confuncli, arle sea cu epilspsia posF
I t ' l r, t t rrul l , i cl ' i , -
l).. f:ii,runpele
1tr_in
alte d,i,oerse cause : subalimentalie,
dupX insomnii
ur,rr sLi r,r.i rl rr oboseal i l ctc.
,
.l 1l ...Ni n!\1,?
tl e
^l t,i pu
aentri Lal i a este mai rareori i nti l ni ti ,. Aparo i ndoo-
. . ' . \ r , r
t r ! t , ' r I | t , r I nLr c z0 - 40 r l e ani , . cu- t ul bur hr i I uncl , i onal e gai t l , o_i nt csl , i -
.:
.r,/
ir,lr .i mlb-.r,.:,sculare.
tractorii d6clanganfi sint'totcleadna de naturr"r,
; , , , i , l r i . r i ,
: r . r r l l r . r i nt l _o si mpt omal ol ogi e pr eaccei ual L
mai l unga ( 3*l r ni _
|l rr,(.),,r' i rr' :tl ' I.(:t' rza,l ,i pri n^pal fi 1,a1i i ,
sl ,arc de rd,u, transpi rati i i eci , senzati i
r I | , , , , 1) r r r I r r ,
,
cong0sl , l & l cl ci , usct ci unea gur i i , i ncet ogar ca, veder i i , f ur ni -
. i r.r.' r' r
l |
*' rr)rtotr i n exl rmi ti ti , prccum
!i
respi ra(i i frecvcnte. Aecosrrl
rl o.l ri rrrkl .o ru cuno$ti ntei este de scurtd, dui ath
i ZO
secl , i n ti -prl U"oi i i
l r , r l . r r ; r ' r r l r . . r r r i i r t ' r i sci t o
cd, - vedc, dar cd, nu poat c r l spr i l r de. Acest e mani -
r ' . . : r . f r . . I l l r ,
l , l . or l uso
pr r r r ht per venl i l l t i a pul monar d ( wayne, l 96t ) .
.
l Y."Ni tr,rropa Ia truse esta ugor.de di agnosl i cat,.
Aparo tl e obi cei tl upi tr
r l r r l r r l r . : l i - 4{i i l c l ni . l a bt r r bal i i car r : l quf er J. r j e di i , cr sc af ecl i uni I r r r i r .
l r , r pul nl r . ) n: t r r . . , t 1' r r i cr . ( br on; i t o
cr . oni ce, cr nf i zcm
l r ul monar ,
a, $t n)
$. i . . ) ,
do
r r r l ( , r ' t st
' ' l . t . t ' l t n: Lt or r ,
Ac{, eJUl sI I l copf t l sc pl , o( l l t cu i r t l i t t t pul t t t sci , l I
l : i l ' : l
f , , . 1: ( , : i r r r l i l , r n' r r t - r l o pr ) zi I i r l , . col . Pl r l l i , i i r si r r r pr or r . r cl c
l ) t , esr l , , r l l ) : r , l o
t r | , . x. , r ( ' . r r r ' t z: t . r r t . ' ; l l r l i r l r t r r , : r . zi i , . l nt . r r . l l 0, \ o. l ' r ( l o
1-
: l _; l r r r i r r r r [ o r i i ' r r r t
( r
i nHo( r ' ' i l , ( r r l o co, ' vr r l si i l , oni u] - ( [ r ) l l i ( : o, r r ol r r r r , r r t r r r , vt ur i r r t r r r - ; i l r r , pi t r r ' f ; , r , r i
r r ' r l . r r r r . i '
r r . i r r l , l
' I r r r l ' i r r r t r I i i ,
r r o r ur r r hr zi o l ' l t do i l r r r r r azi r ' , r i l l si r r i o r i r gr r r I
: l:l:l
f i
r l ( f s( f t t t t t 0r
l t r t sl t t , r ' r u' r t t t t t l t ' {l ) , , l r r ' r ' r r
i r r l i r r l r , l l l l ) 5
I ( l r t t
l i r l i t t , l 1) ?l t ) .
( l ot -
l r r , r ' i r r ( l l ) Tt r )
6i ( i or l i r l i r r
f j r I ' ol r r vr r r t ( l l l i l ) , r t t t t ' t i t l on( i i l l , l : r ar r t ' ; l i l r ol t t i l vi
o l r i por scr Lsi l r i l i l , i r l , o i t , r i r r l t Hul ni l r t t oI i t I i i t t t ( . 1: i 11. 3! )
) .
l ) i n obscl va, l i i l r r l r r r r i l l r ( ( I r r r ' l r L, t i t r , l 1) 78; Ll or : I : l r i u qi l \ r l l t l vi t r i t t , l 9?l )
(vtrzi
5i
1Jg. 139), rti csrr cri , i rr si trl ol rt, l rl tuse pi l rtri ci pi i hr mi uc rn[sttrl i
i ' i 1, , ' r ser r si i i l i t ai ea si r r r sr l r r i l r r l r r t , i r I i r r , r r , ( , t 1 i mpbr t al t r i l spuns t ' l r di oi t r l t i
PNEL. I MA CAI \ I PRESI UNEA, 5] NUSULUI CAROTI DI AN DRPT
-,/--'\-/----\,1
-\*-\---_\-7---\
-/^\_-'^\/--\,--l_-\,^/\_
ECG I T A $A/ 80 Pl ussl a/ mi n. T. r' ' 150/ 80
r-e@.-i!/t^"\*f
'r''lr-/i- 4@,t4-,\-1.4J
-^.-4r'4,.\"44.l'
Jv+4
T. A E5/ 1A
1i-\^^^,}r&&@^/qq^-1*w
urrr"^rrtr.l.r-^.Ap*.^^r.r^^.^i"
irig. 39. Inregistrare poligrafic! tn titnpul compresiei siDusului carotidiaD
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
$i
are o brcnqilti cronicd. Proba (k:
compresie a globilor oculari a fost negativd. Se poate lemarca laptul ctr
la compresia siriusului carotidian drept apare o pronunlatd bradicnr-
die (cu 16 bitii/min lali de valoarea initiall). Concohitent s a produs
o scidere a T.A. de ]a 150/80 la 85/40 mmHg, cu revenire la valorilc
initiale dupi 22 secuntle, L:r manevra Valsalva, scddrea tensional{
{usese si mai mare (ta 10 seculde dupi lnceperea acesieia), iar dupf
itrsu1314s n4nqvrei, s-a evidentiat o rcaclie hipertonic{, cu cre$tefl alc
'1.A. pini le 170/B0. Ileicsc o hiperscnsibilitatc a sinusului carotidian
dc Lip crrdioinhibi Lor
$i
t ensi odepresor fi
o reactie hipertensiv{ exagcral I
(lup[ tcminarea manevrei Valsalvs (dupi Corfdair.l, i971' Corturiu
Fi
I ' opaui ci Ll , 19' 17 6i
Popooi ci u
$i
dol dr. , 1978).
l ri t.ol qi tensi ocl epresor. Da11,1e.1, se pare c; acosto zone b&r)rl s(' l l sj l )i l t'
:rr pul,ea sd, fie influentate qi de hipertensiunea artorialfi protltlsil, tlttpir
rr,ocesul de tuse (ca tlealtfel qi dup[ incetarea manevrei ValsaJva, itt oltst't
vrll,iile noastre) ,.si al conduce implicit la instalarea unui bloc sitlortlt itt'l
srnL la o pd,bu$ilc a tcnsiunii arteriale, cu ro1 in cleclanqarcrr, sitrloltti.
\t. Sincopu ortosttLticii este socotiiX' de cei mai rul!'i (Dod.irlol;' I lli'll
;
(
i i l genkl antz, 19?2
i
Hrs, 1972
;
Weber, 1972) tl rept o si nool l t, vl g;Il ?l ,.
l,h reprezinti 5,5
o/"
din totalul sincopclor studiate de Wayno (l 91j l)
{i
1,3% di n si ncopel e studi :r,tc de Col i ari u (19?8)
Si
Cl ortal i u
ryi .l ' opovi tri tt
( l $?1). Apare cl e obi coi l a' i ncl i vi zi trecul i de 40 de ani . Forma
,rprl i ti l g(' r' I' "
rr, u,ccstei sinoopo sc tlulnrt;oirzX, dupir, o pcrl'ioadl lungi, tlo ot'l,o'!1,1!f iNtIt
( 1, ) i r r hno qi ool a, l ) . , 1f ) . 17, r ' i l : r , \ ; i do Cor f r , r i r t qi Popovi l i r r , J97l ) ' l t ' r r l r r r r r '
r r r r r r i ci l , ( [ ! r r gol , l 1) f i 0)
; r i
f ol r r r r r ' r l i t r hi pot ot t si t t nof l posl ] ul r Ll i r i 6i vl ' l i r l cr r zi l ,
s i r r r pt r t r uu! r l ogi : r , ,
Jl
i l
l r i r r r l r t ! r i l
l r r t t l r t l l j , l t , ct t t t 5t i ot t {, t l i , i r r t t t t t t t t t t t t 1 , t t I I t t r t r t u' i i
r l i r r cl i r r osi l t , l ; i sr r r l t r ot ' Lol t i ' r r I i r r t r t , t t t r r i t i dt l J) i L o scl l r l l "r ' pr l l ' i o: t ' r l l l '
l ) l ' ( ' l t {' ( r ( r Nl I
r r l r ' i cr r l r t , l r i r n, r r l i t r , r r l r zl ( r r r r l r i 1' ' i 11
. i
i l mo{t r l i . I ' i t r r l ot r r i l t l t t t r t t t t o{1 i t t 1f i , l n
I t r so{r , 1l r r t l r r r or i r I t l or r t r r l r r r r l or r i r . r r r . l ot r i l o, l f ot r r l t l l ot t i r ' f i i t , l t i t r t t l r r , l r ol t t t t , vi i
r l i : r l r | l i | i , r r , r I t I i not t i t , t r t , t t i t I t t 1i r r t r r i r ' I t r ' i Hl t , l l l t t l , r ! l i ( ' i . l ' 1 t t , t t r l r . gt ' t i N Li t t | ol t t t
: t : t : t
ofl osl ,i Il ,i ri o l rr si rrrl rornrtl Shy-l )nl gtrr' , bol ,[i l rl ogurrol tr,l ,i vi r, l n r:rt' o po l i ngi l ,
l ri pol ,orrsi rrrrou, or' krstal i ci i , sc cunsl al ,i i , urrhi drozi l , i mpotcn!,i srxual i ,,
1roI;Ihi ttl i u
rrxrl ,urni i ,, abol i rea rofl excl ol pupi l are, si mptomo cxtrftpi rtuni '
rlir,lrr
ryi
rr,bs0
!l
crc$torii orijostatice a catecolaminolor.
lrtrrvis (1904) a descris un sindrom de hipotonsiuno ortrc,staticil, {||,rIIi-
liirlii, i,ir,r'r, loplozinti, o boali degenerativd, cu transmisie er'odilarIJ.
SINUSULUI CARA|IqAN DREPf
ECG
( ' l r l {' Hc
l , l ui f
l : ' i
. i or r l l i ,
r r r r l ol t r r r 1r ol i r r , r r I i r r r l r r r l l t r r r sl r r r r i u l r , r . r r sl , r . i Hi r r l opr r , pl i r r
i t cl , i t Lt r i r , r l l r l i o i r r l r i l r i l ol i r .
l i l l , Nt ncopokt
l t ' i t t ,
t t u. t :
. r r r i , r f u
( l ) or l i not , 1972) si nt
l r l or l r r sr r
pr , i r r
rni [i rnu]to al ool j i ul ri
(,i l ,r1l i l ri rr,
rrcrrl ol ogi cc sau vag:l Ic, prti i rrrl rt-so
;rl rrti zl r
ou lnaro dilicultato rlr,rtzlr, crurtii a, acestora,
PNEUMA COMPRFSIUI,IEA SINUSULUI AROIIDIAN DREPT
itir, d?. Inrcgistrare poligraficd 1a bolnavuM.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 a prezentat
- spte sfi$itul acesleix - 0
intonsi reactic tensionald, insoliti de extrasistole
ti
bradicardic (dul)ir
{: arf ari u, 19' 11, Corf ari a; i Papari ci u, 1971
, i
PapaDi ct v
$i
co1or. , 197t 1).
,
1. Cauza nzi ,rte cardi ace (cte pi l cl d, stenozi aorti ci , qi bl oc a,tr.i o-vr,rrl l i
curar palotiis0rc).
2.Oau' ze mi ute tago-cartl i dc. Este vorba de pi l tl i r, do i rri ,rrl vr,rr{i ru
nnui factor vagal i n dockl nqarea de si ncope l a bol navi purtr' l tol i rl o l rl or.
al ri o-ventri cul ar comol et .
3. C nztze miute niuro-card,iace: a) Epilepsie pi s,indlctm ,A.tltuns Sl,tl,t:r.
Se
' ' sti o
ci si ncopa Adams-Stokes, fi i nd f-oarte acl esca txrrrl trl si vrr,rrl i i ,
poate fi confundati cu o cri z5, de epi l epsi e, i ar Dorl i not (19?2) l tl r,rr,r,i rr
un caz de comi l i al i tate i nterpretat ca un si ndrom Adams-Sl okcs, rl i r,l ,ol i l i r,
unor tbl burS.ri de ri tm car:di ac api rl te dupl epi soadel e tal ri ci rrrl i to rl i rr
cach' ul mani festi ri l or sal e epi l epti cc si l a care o ttrra,l i c anl ,i t,orl i (i rrl i :r
dus l a supri marea acestor mo{l i fi ci f i .-Tot Docl i not (19?2)
t,cl rrl t' :rzi r|r,uu
cazrrri care prezentau
concomi tent cel e doui afecfi uni (epi krpsi rr
6i
si rrrl l 0rrr
Acb,r' rs-Stokes). Totugi , Docl i not se i ntreabi ,
.pe
bui rri ri r.tr1rLi r|,rr, r,rr 11i
nai , dac5, aceasti , mani festare el i l opti c5, nu reprezi nti i i n rcl rl i l l l o rtrr,l rr' l rr,
anori al a unui si ndrom Adams-Stokes. l t) Si ncope d,e rri l i n trt.l ' ' :ul ru.tt,
5i ,
si ni l rotn A.dams-Sl okes, Tot Dodi not (19?2)
rel ateazj ,i ci r,zrrr,i l i r, r.i rrr,
l tl ocuri l e paroxi sti ce Adams-Stohs pot agraya urel e tul l nl tti l i vi ri i l rrl rrrr,
<rcrcl ;r' al e l a bol navi cu i nsu{i ci enfe fi e vcrtebro-bazi l ar o, 1i o oIro|,i rl i r,rrr,,
l rodnci ndu-so
si ncol o t1o eti oJogi e rni xt:i , do aceoa,
l )tol nuto
rngtrrri zi rr,r,i r,
t t not cor t snl l r a, {i i r r or r l o- t r l r l i ol ogi co l a bol navi i cal c pl czi nt r i
l r i r r t r l r r r , i
r l o
(
l l r i f ) ) t l l i t t ( i t ' i i r t ol t t I i t l i t l , r r ,
O sor . i o r l r r i r r r l or , i ( l l r r r r , l | t 7l l ; {i r ) l ( l l l r ) ' ( ! t , i 1i i cor ' , l {}?0; , \ l or r r r r r l 11l
col i r , l t . , l l l Tl ; l i ol r r r r 11i r , l l : r l r , , l l ) ?l yi l r l {i i ) ; r l
l ) t , ( }l r l l l l
osor i o r l r r r r l l or r f r r
t t , t l t r or t t t , . l \ r t r r ' ! i r i t t r r l ul t l ui t i t t t wul t r i t . i r r t r l i . r t i l i ! i i l ) i ar l t t ' ( pt i n nt r l r t l t
t l t
, , t !
t t l ' ) ' t ' nl , t ! ! ul ' r r , l r l t ut t i t l , , l i t ' , r t t t i l uI t t .
COMPRESIUNE.4
.^\.-/2\
-l+\
I
120/ 75 Y TA,
FM. -4.4. Pl us 66l mi n. Pi us 51/mi n.
u a. - 4.
F D. - C. D. l 5A r V
^e,\^4^^ryu4,^^\/r/q.^^'/lJ,1lA/(\4r'^l-ar-t^^1^A/!^d^"a.-y1^
^^.^4
Vu^,ve-
P D, - T, D.
PS. - t S.
Ii0. lr, Inrcgistiare I)oli$afici
tn timpul compresiei sinusului caro-
lidiu 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
{ost negal i vi . l n schi arb,
(j omprt si . r si nusul ui caroLi di an drept se
voalc ci produce o scidere a tmului caldiac cll 12 ]ritdtlmiDut, crr
o cliscretl scitlere a T.A. (de l^ 1201'15 la 11/75)' Manevla Yalselva
a proalus o masivi scidero tctlsionali dc la 120/75 la 75145 mmHg
((rupi alorlariu, tn t,
""Il:i"i:.qisP|apa'icilt'
1s71
ei -PopoDictu
$i
Itrrl ri L, Oorfari u (19?8) qi Corfari u qi Popovi ci u (1971)' mul te si ncopr'
r,r' {,rsl rrl i co si ut, rl e fapt, conseci nl a unor hi perrefl ecti vi tS,fi si no-carotl tl i '
r r '
1. 1i 4.
l r )
) .
\1, Si rLcopa de mi cl i une este destul tl e rari l , (3,3
0/6
i n stati sti ca l tti
\\ r
yrrr,
.1l i l 0L
i ].13ol oi n
stati sti ca l ui Corfari u, 1978). Se i nti l neqte i ndeos0l ri
l rr, l ri i l l rl ,{,i , dupi i ,
yi rsta
de 40 de ani r al o obi cei i l upd, coasum de al ottttl
i rr s,,rrl rr, pl cmfrgi i toare a' cces Ini . Dup' i un ti mp vari abi l de somn, bol -
rrrr,r rrl rr.spr,<.l ,i v se scoal i ,
Qi
i medi at dupi , mi cl i uno se produce o scul i r' 1,
;ri r,r' rl r,r' o
i l o curi o$ti nl E, de 1-2 mi nute. l )oar uncori se pot semnal a si ml t'
li,nrr'
|
'
r()il,c0esuale (amelelir gleluri, amo{eli in mernbre), dc obicsi actrsl tttt,
l i pxi rrrl (Oor' l ' ari u, 1978). Cri za si ncopal [ dl rea,zi , 1-2 tni nute, ra' tottti
|ri rro(.i rrrl rr so
(l o
conyul si i toni ce sau toni co-cl oni ce, i ar postaccesutl hol
rri r,vrrl :l tuzr"r, ai l toni e, amcl rel i r cefal oo ,5i o stare do te&l ni ' r. Waync (l 9tl l )
rr, l rrcrr,rl l l r,t at:casth, tol m' ,i i n cadrul accesel ot si noopal o l l ri n
hi potonsi ul l o
ol l ,osl ,i rl ,i oL, i rl
()asta,ut (1950) :r, pl a$ft1j si n(i opa tl o mi cl i ul o i rt otdrttl
si rrcol rol or vrs()-vi rErl l or l i i rrd fnvori zrl tt' i , do orto,gtati sfi rr Inl ,r-o ftzi t, tl rt
Iri l rrrl vi r,guLorri o rrocl ,ut' ni r, l i r, i ndi vi zi vtl ,gotr)l l i {' i . In docl anqarci l i ttrosl ,oi
ni r r ol r o i r r l , ol r i r r o 11i l t i pol , onsi r t t t si t : t t ' 1, t t t i r t l r i , t cl l ox[ , pr odt t sL pl i l ] gol i r ou,
vr r ei , , i i r r l i r l r r o.
( l r r ' I r r , r ' i r r
( l f ] ?l t ) qi Oor [ r t t ' i r t i 1i l ' ol xr vi ci t t ( 11) 71) ut ovi r l t t t r ( i r l l ,
l r r , r r , r ' r r r i l ' i l r ol r r i r , r ' i
qi r ' l r i ; r ol r ot r si l r i l i l t r , l o I r , si t r t t st t l t t i t r t t , t r t l i r l i l t ' t t ( Ji g. a|
) ,
: r : t 4
lr
' i
il
I
L: .
I
PNEUMO
JlqtuW
V-
Vf f l . Ni r r l r , 2r i r '
l t r i t l .
hi y t n
l l t ( l i t . i l r r l l
t i t t o unl , i t l i t . r l i .
l l i r r vi l i l l r . ( l l ) 5 1, l {) J) 7) r r i r i sl , r ' t t l r l i zr r l si r r r pl ol r r l r r i ) i t ) ( , t r , ( , l l cct i vi t r i {i i
r r r r , ' ( ' r t r ' ol
i t l i r r t t t i r t I I I I t ) i i |
(
) l r ! ' 1 | I
( r gt t t l r t , r kr i r r l ) }l r | i r i ( c r r ( ol t l l ) l l ' 1i i t , i l ( l
r ] i , i t r r r , {' r
! i ) r l i r I i si l l r pr i Yi i . i r r , l 1) 72) I
/. ' l \tl l \t,r' ri t i l t, l (,t.l \)us(j :
tl l ' l ttrttttLttttl t prod,rotnak si rrl r i nt,otrsl i trrl c
(l i rxl
rrrcsl cl r, r.rj rl :' i y
r ' r r r r r , l r l t , zr , r r l t r l c r l i ' o s1: i , r ' t ' d( ' t . ur xi r j l : 11c, cu
( . o
s1t i 0l i ( , 1r , t r ' acj r . i r . : r . l gi i
l
I r r ' (
,
i | | (
|
j
I I
( .
1 |
,
(li$lll{,(i
sj sonzlltio de sufoc:}t.e.
l )) ,4t u' tl tl xi ?r(,r1l rrl ,,pNt' e do obi c{}i dup:' l , \-i rs1,i } dc 30 :l ni , rl e
l )l
l ,l i \.
l i l l r l l t, sr' \rrl l l l rscrrl i n, dl pl i cum I' ezul ti
l i
rl i n obsetr.ati i kr rorrsl r,c
(( tr l l l i l , l l )71
i
[]ot' l l l i u
$i
l l opovi ci u, 1972). Acegti bohra,vi si nt tl r rrtri rci
:rl l l ori ri r,l o;i
fi
hi pi {' tLl rsi yi . Arl f,' 1, Nl thtrLsnu (ci tr,t d' r Wa)rrc, tl i i l J i r,
:rr:rl rrl (i ' i
1t,l )r' o)(i tnti ti v 0l rei mo dj n bol navi i cu afcctj uni oor(,ni .r,l i (:r !1. .\L rri
: r r j : i r r i i
l x( ' t ' , l i r l i
: r r r r i I i pc| r en. i l , i l i , I l ' t e si ] r o, ct r , ] f i r l j anr j . l r r r r . , r i . ,
t , , , t ,
l rrrrrc
i ri ovi dtrnfti , di rrel .sc ft)rmal i ul ri gangl i onare l atol o-ce.rvi sal e si pl i i i r,
rl l rrrl o l ocal o. Si nool i i propri u-zi si , se decl anqeazi i do obi cei l rr rr.,r. i .i l ri
o i ri r r r1i orrur,l ol ogi o pl esi frcopal i , api l i nd i n col di ti i i n oare cl c).1c i i ,l r-
r I r r rrlt,
(l
c l:r, n ivolul gil,uhri (comptesiuni in di\rorse circumstantc, iltl I)i!_r'(11,(,ir
r,r r iisl rt| lrt.(,a oa,plrlrli la b5.r]:.it'.r,, miqoi,ri bruste ale ca,pului (rto.).
_\1rcp-\trl
ri i r( ol )l ,l (,i i l o
rl c sourti , duati (10 -60 secunde) ,i poatc ti i rrs<i f i 1 rl c l ori -
r ul ri i
.l ol ri crr' cl oni 0(' ,
cal e pot i mi ta pcr.tect o cri z;, epi l epti oi . i l t, l a,pt,
rrrrr,i ol i i rrIr,Ir l tol navi l ol no$tri au i ost ful drul l }.ati cu di a,Enosti cul ,l r. cri z0
,
l ' r l ' t , l
i ,
( 1 ( (
ur J: U. i r r
; i
l opot
j ci u,
19i 2) .
.
t
)
.i:l
in?lonrclc
?ostacceslt(
e se c&ractcl.izeazii printr,o $til.ro clr'o.pus.
r' rIl rt i i {l (t (,i i
ot' a ni trrl e, pri ntr-o Senzal i e de anxi etato
$i
de mal .i _,ftl .i i i sta,}ti c/
r,u rl ul i rl r' i {l c ci t cva ol e, pi ni l a, ci teva zi l e (tr{i nvi ei l l e, 1$,1?), tul bl ui i ri
rlI r'rr,ri r,01,cl', nc}r,ozi1a,tc, somnolenti, prelungiti,,
st;ri de depr.esie, i(l(ri
r l r r l i t i t t r i o t r l c,
( lllrrhr ir,(|r:t,so po1,
Irozcnla
manifestdri tle tip nal,colefl ic (_\Iayollr
;i
(' hr,N.i ogr' (' s,
ci l a{,i d0 Mi nvi ei l l c, 1957). Turne.r:
fi
I/eal u}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
prl rrrl ,l rl i c. S-au rnai descri s
6i
echi val errl e verl i gi noasr, i l ccese cn tnl l l u-
lifl i ltl lliri o {lo r.c(]cr'o ulri- Br]u bi1ate.1.a1e. Weiss iii Bzr,lier. (1983) gi \.f.r,risr+
i j r l ol rrl r. (11| 110, oj tal i de Cor{a,ri u qi
Bopovi ci u,
19?:,) au i ndi vi duri i i zl l
lirrufl(J o('r'oblir,lo rr,L(.j hiperleflectiYithlii sino-caroXidiele, Dnnifesta,l,o
l rl i rr
cl i zo rl rr ol l rubi l al c, tul buri ri de vol bi re, atacuri i rntste de sl .i bi ri uuo
, , . r
l l r i , l ) | l ] , j l j
: r l r . l r r t r r r "r r l ui musc l ur ' , r ' pl l l odnso
I ' r . i t !
, i nt l , l & cunr pr i . . . i r r ( '
r r ; i r r r nl l r r i ci l J
( ) ' l , i di : l l 1.
:!. .ll.t( lrltrniltstdrri : Il.anifestiirilc ca,r'dhce ci)nstau in tulbur.irIi ilr.r
r i i r r r r . : r r r l i : r r .
. . i
l r r i ur i [ i ' i i i l i l ngi r r o; t sr ' .
''1.
(trilrtiil,r
ila d,iagnos'tia t c hiperreflet:tir:itd!ii, s i. tlocq.roti(l,ie,ira sr.
lrol,
| r r r l | i r l l sl , f ( f l :
t) I !
i ntt,tu sl rr,rt,l t.l ,( da tl ,ei l .unSQ,re: O rni ;tl tr,t l fusoi r, l l ci t,pul ui (i l 11ttrsf l ri
rrrl Ii trrrl rrl r i l l r.poi sl utt l N,1,eraJ{i ,) i tt rttettci l ,zl i , o ci ,rl ol c ort pi cl del tl t, rj oni i l i i erIl oi .
,\l i IoIi l rrl l i u| ti ,r' i ]o su(l ced ul xri c( ]l ] r])r0 Fti utr i
(.(' t\,i oa,l e
(gul t.r' 1rrr,rr, si l i rrs,
i | | ,i Ir.i i r| r,i r, r' rr r[i rri .l i rL tl l r])ul bi ,tl b
j (r' i tuhr.i ,
rl u,Lr[i i l ,ul ]i rl or:r' l
](j
ol ot.l ri t
l )tot,
r l r r l i r cl o. ) $r l r
( l u}L r r l r r i r r l i t l c t r r so ( I i o i r r dcr t Lbi i , ( l or . si ul ,
I i o i r r
1r , r zi ( i l
ot l rrsl rr,l i ci i )
;
l t) Utt tLt:tu,tt,l . i .l t.l )ot' l ttn.:| . tskt t:i .t:sl rt (Jt ol rl <roi
Icsl ,o
l ' .' 0 tl r, tr,rri )
t , i
l t t czl t t ( i r
l r l t r t r t st i ct t r zr r i r i i
/ sl t , t t
t r , I r i
I
)
( r r I | ' I r t i i I I | | i i l l r l cl j l r l o; c)
( . l i r r r l
, r sl , r r
r r r t l I r t l r r i nt l i r "i r t i t t t ui I . i nt t "i . ,
, l nl or i i , l t t 1' t ) t
i : : t t
l i ,
Fi l i r l , r ol l r l z( , l t l i l , t i ( l r J
i r \ . i l i r
l r i l i l r ' i {i r , r r r r r l i t r r , l r r , l r r l r i l i l i i l i \ r , i Tel l l i \ ' ( . i i r r r I \ i {, 1i i l , i r r ovl r r l i r ' r r \ | i r r I r , . i | | r r ,
l l l l ' i ;
( t r t
l r r r i l , l ! l ?l )
; r l )
Nl r r i l l r , r . N( \ l , r ' t
l r ul , l
i r r l vj r l r r r r {i i ,
( ' i nr z, ' r ) r ! 1, Lr r i , , r r
: t : t {i
i t t t t ' gi t l t t r r l t , si t t o r r l t t ol i t l i l t , t t l t : : t I | ' t r ' ' I ' I r I r r '
1r r ' r i r r r JI t Li l r ". . {. 11) l l i l xl zi i
{l r f
( r i l l {I
t r t l i , i r t r t t ot i t , r , t vi I l t , l r , r t l t t r , t t t t ' r ' : i r "l i r l r "t l r '
( i \ l i r l l i l i l l r ' , l {}i "i i
( l r r l
l r l l i l l
i ' i i "i , l i , i , l , , r . t $t : t ; , . ) Si r r { r ' i t r r t r , ; r r , r ' i r I r r t r I . I r : $i ' r f . l ) t l . l o ot r . r r r zi r t i t t l t ' t
, , , , i i i i ; ; , , ' , i i l l t l - l : *i *, r , . i ' r r r . , . 1r r r r r , . : , r , r r r r l r i . r l : r r ' r , . , . - r i t . , i {"r i ; 1. 11 r l , . r , . r r r l
r r t i t l t ' cj t r r l so i t | l cl i t l ' I t l t \ r ' l r l i t
t ' l ' r ' : r i l r i z: r ' t l ' i t ' sl l l l t : l l l r l r '
tl ' s ernn' el e obi er:l tt;t' trl t l ti 1" rn
l l rLl i ri l a!i i
si ' tr'
' "urot
i di c' tt' r' I' l rci l rrr.rt
,,i ,n-"*rl i i Oi aoi se prttct i ci i pr i i r crri rrpl o' i rnca
di gi trl i r
"unei
cal (11 i do l rL
' ,,if"riil-
r,ii.li.iliei,
'
' rmi' iril.
sr._ utinic
..i
poljgr:lliu
(' 1r,1.ri. oN,r' (liruu' "
r,i rrsi ri ral e. respi ni ori i Si
cerebl ' al e. Itroi taxea si no-ca' ro1 i tl i rl ri
g1r
1r.rt' l
I
,, ,i tl .o' ri
' ""l i i -
i ol i ci ta,rea i xdi yi drhi
de a-1i l l si urna cl l pul i ]rl rl ).i . i i i "
,' , ,J.
"tt"i i *
si coml r' csi unca caroti dci l l i mi ti Ye'
car are dfi rl )t l rl l rri r' r' ('
j
, , , f r - r i a
- ar i l or
l di er i ' r nr t i nr l l t l sal r mai pul i n col npl cl j
r I ' l i ' t r ' 1t t ' '
; '
r l |l ' zt' s-Rueft, 1953), care antl t' nel l zi
-
rc:i ' c!i i
.pri n
Li pott' tsi uno:l ,
(' rr(l osr
r r r t z- i Ll i 1] r or l xci . Pr ohl i t r vot . : ] r l c hi pcr t l nsi Lur e
endosi n- uzdi - t ' i r '
l r r r t l r '
, , I r i :
*
o- ' - -
". . "ui
0, ' t ' r sr . ' ( Nt i nvi . j l l c. I 9L7) sau
p i r r pr ' r ba l ui Y: t l ' i r ' l t ; '
,,,,f;i*#i",'0,,),2ufii$Jl:t"$ $'Jfii:1"Jt i"%"*{ri; fi
J:,{:Ti:{,1:"','[,iii.
t' ol fari u. 19?8) :
1\' ] I i.pul aag*L tatt c{
'dto'1'nllibilor
'
fnci' ]a <lel:utul excitilrii' rlsifliirtr
l .L o;tu;e' ;' e;;' i "i ui , upoi chi ar l a o opri l e cardi aci ti mp de 10 stttttttk' '
;ll,i,i;;; i"
""t:i""
,"^r,ia la frecrcnla i'o'mali'
lllectrocardiogra'Ir. it'r'it'llt
,.i L' bradi cal tl i a s datdrefte urui b16caj
si no-atri al sru. atri o-vtl l 1.r' i (i ul l
r
r\ tl opi ni zarca pral abi l X sau l d i ni straJca de adrtrrl i ni '
prevu]f rr{r' nl ('
rulbrirnri. Ar iitra in
ioc
u:r rnocanism bulbar (nfinvieille, 195?)'
b\ fitrut lttnsio-d,epresor consl,S, intr-o hipotensiune altoriitlil irKl(l
r,rm"irtri
'Oe
t
"ud.i"utjdi",
t:l,rc s-ar d*tot'a unei va'sodilatafii g(trcrirl('-
i"-"it.
-o"itn*tl',
i cdazii, ta adrenalidi li
o. sht inflrenlate d(*r1r'.1)itrrl
i fri i n i ";l fc, t95?l Corfari [ [i
?opovi ci l i , 19?2). Ar i ni ra i n
j oo i i rl rrrl
uiecanism bnlbal
(Minf ieille' 1957).
c\ Iivut c??rr&l cor($Iulde tablourilor de hipelTefleci'ivil it'i l sitttt
, : ' r ut i di an' I
( ar e
nu | . c i l so! r ' sf de r pr ct ' i nl - r i ) c mod i f i c5- r '
j
cat t l i r t t r ' : i
sr t t r
, , r t . i oooi . . . i car c nu
. i l t
i n{l uenl af ddo at r opi l r i sa, t t dr - adr r ' t ur ' l i t r ' r '
' l
r r t
, l , i , r cr var ca i i no- cr r . t i t l j ani l I i j nr . l e{i cr ce
( Mi nvi ei l l c, 19571.
- A. r ' r t i l i
I . t t r t i .
r,rfebral i , n fosi i ndi vi durl i zati ' i nci de l Tei ss
$i
Raker (1933), rl l trti tl tr
t1' fl ri s. UaDrs si Wei ss
(193T, ci ta1i de Corfari u
$i
Popovi ci u' l 1)?!), trrttro
,,,
".i
i of' Jti rLou)i trei i ni .1i n cai u,r.i l e 4e hi perrefl ecti vi tatc si tur.r,rrtrrl i
rl i r,ni , real i zeazi ' aceaJttd, forl l l ri , tl eqi l l i l vi ci l l e (19i 7)
Fi
Corl l i rl {11)i l )
l l r ai .[tat cE,, de fapt, este Tot.ba cl e ccl e mai mul tc uri r.l c fol rru, rrri rl rr-
,\ liji autori ilaSeurl, in cadrul formel'r cerebrale Sindroanl(trf tl.r' lt ilrt't
r,,l i ecti vi tatei , a ci rot si mptomatol ogi e
esto nervoasi ,
j ,4i frtrrtttl (' rt' (' i r' l i
r r r ut r i i cst . i t i l o obi ( cl i \ e de Laz*.
Mjnvieille (195?) a individralizat mai multc
Jomt'
;
a,) U' anneLe cet ebraLe
Pxrr(i
(rara)
^se
caracteri zoazi l
pr,i n rr' trrtrsc tl c rl i ttti
t|rtal c a s15ri i tl c cort:l ti cnl ,i i ,
pi ol deroa, totLusri i tti l Ll soul i nl ' , l l Jtl rl (( l i
l L
zl _L,rrot. au' i cu l ar' (' , .hi u' r,ti rrvul si i d0 ti ,
()pj l (rl l Li o, $0.l ' ,i ri i i al rf sl i ,l ti tri ttttrr,
t i ] i br Ll i r , r i do
yt ' dr r t i r ,
i l ( l ( ' s{' i t , l t ( j ( 1( r s( ' r k'
l l l i t t s
t t ct r l ot ' i vl r ' 1
,
t l i ur r
1r o1'
I i t r ' 1r t '
, t i i sc
*i f 1, l r , l ) 1. ( , si ' r ' r , ,
r i r r r r sr r t r r i
( , i i r 1) i
i ( l i t ur ,
I ) l i l l
. l l i I Xr t ' ' t t {r \
$i }r r i r r
r l t r . l .
pr r r r l l s' I l i r t r r l t , t , l l r t gi t r r , , t l l , t l r r
I ' r l t l : i l ) t
i l r r l l l l t t i t r i hLl i l t l r l r ' . l l ' ( l i l i l l i ( t ' l l l l i ( 1
i l \ l i r r vi r r i l | , ,
l l ) b' l ) , I l r l i t t t | l r l l t | t sl r ' t r r r r x sr \
| r ' l '
I i t ' \ ' i
'
I | | t I
I
i | |
'
|
( I r l t l r ' ( l l r r
i ' l l , ) ( i r l r r t i I r r l r i l r , | ) i i o ( Ni r r r i | i l l r , , l l l l r ' i ) , i r r I l r u t r ot t l t r r l ol i r t l t t t Dl r t gi r ' , t r t or l t
l r oi r t i r r | ' vi r N( l ol l t ' l l l r l {' l t t ' ,
. . / I t u r - d- r r
: t : l i
, l t t
I l t l r i , r r r r t r l i l t r , r l , t , t , n. l t xr l
; i ,
r r , l i l t t r . l , ui ( t t . t , di r t .
s, , l . t t si r t r t r l ,
l t t , t l ,
I J) : . r l l l i r
I r .
l ' r . Z; r r l l r t , . l ' r l . r l i t r r r . , . : , , . , r , , i i r r r l
l l i i , t , {l ,
t i . r , r l r r r
.
, r r r
- I i ,
.
I I
t
. | ( , . 1
: , t I i , r ' i r r l i r r \ ' l . i i r . , , 1, r i r , . : r r . r , r r l r r l r r i . i f r r l t 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
| | l 1, . , r | . l r
zi | r ' : r l r .
. i t r
i r r l r r i , . : r r , r t i r l i l r t r
1dr . r L, . r t : r r , , . l r
; , r r . , t , . 2i , . : i ) . r t , r . . r l l r l r i r
\ l i r i i "r l r , , ( l | , : , t ) ' r i r L' i i ur L' - su1t r osi vi i l r , i upl l si i r . 0{) 1) ( ! 101 sl r n) . {j l r r 1) 1 i r l i ( ' r ( \ ,
I ) l r l r
r ' ' . ' \ l . t 1 i t ,
I r ' : r g
. i l ' , t r l .
COt l i i i i i r t t l i r , Si pt , 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
r t ' gr r l r r l i r . . r r r r l . l r l .
r l i r i r r f l r r x' r ' i kr uo. i i r epl , i \ a o' ( i r t i . ' l l ^ , r ' i gi r u, r i si r r r , , r
I|(
i 1
'
|
.
,
I
) ( , i r I L i I i I | (
I i rr rr,rrtrl i rfi l i mp si r r.zl ste l :l i l chcmi rr, t\dati ;i r,
{i
i trl
(,r.
r r r l l r l l l r r .
,.1.. )l ,trl i .l i ,<i ri l r Il l i ri i t hi perref Lecth|tutea si .,o_carctl i di arti i . Jt)l .t,l ,,
' i
r* *ri r,rrg"' .1(' l , r
1r' l tti *l i r,r
i n pel i oadel o i nterdi ti ce si nt cel mai [rl rrrur,
rrl rrrri r,L,
l rl l i l rv,i f
i i l c,, tUtT
l
Cor1a,ri u, 19?1
;
Corfari u qi Fopovi ci u, 1{t?:,}).
l ] l l l ,
, , , l l , , l l ut l , i r
l r r l
, si i cupel 0r , , sau l a excl t ar ea si ni sul uf ( pr i n cor r r [ r , i i
,' llill:' l.1,cil-!,1,.,1' xl,ulii,,
pr.irr rnasaj,.sau prin stirndarc m6canicl,
il.trr
r,l ' .l ,
i l rrl R.,
tr) ugrl i u([i Dr,l i 1, asupra axul ui caroti di an, rcal i za,l E pri n ri i ,sl ,Lri rur,
r r ' : L , : r j l l t t ' t
' l r - r put ) ,
r , . . spdct i v p. i n var i at i i l c dc pr esi unc
cnt l r r si . r r zr Ll r r
; r r r r r . or : r l , ' , : Lt i 0 i r r l r i por ' , ' r r si u{r u
l compr cJi u; e subsi n- uzal i , ) , ci l , si i r r l r i pr . r .
t(.r.ri rrr,' (i i u,l ui i i j de l use, prubl l ui
yal sal va),
se pot obfi n6 o sei i e tl c i i rrl i
(.rl ,l l r
l ,r1 {r(,:r,i 0,
ci t}.e r,u tost si stemat,__zate de n[i nvi ei l l e (19bT) i n J ti l turi :
rr' ) I' r' i rrrLrl i i p ; uu ,r)ri ,r' J ni ci o modi fi oare EEG. Doai . si stemul cri r.rri .
\ , : r . , . ' i i '
' . i l ( .
' nl cr csi i , . l
;
b) AJ t l oi l ea t i p: ar np. l i l , udi nea r i f l nur i l or I i l r
ol | | l l | l l r r . : l zj L l i . i ! t i t {t c0ut | | [ r t xCi Lal i ni gi Sc nOr mal j zCazL l a st . i r qi t ul pI t | i x. l ,
L' rrrrrrr,' rrl Jiirrrl bihte-ral
,qi,
sincron d,] tiina ae fapt idlentic
' cu
rirr,.{iil,i
rr" .lr' rr' (1 \ rzr:urc sftu dc irlta natulir,. Irodiiic.irile cardiace sau tcnsi0rr[|.
1, 1, r ! .
|
' r i ,
, r . i , i r i ' i r , c{- . l t i p de r . i i spuns EEG
;
c} Al t r ei l na t i p: r r r odi f i ci . r , i I r
r ' . r ' , t , s' r t t r ' m&i pl u' ut r f r , t c, l , r aduci ndu_sc pr i n
r dr i i i al e t r i l s. r r Lr r .
r r i r l r t , , r l i i r ol : r t r . , . 1. 952; . t I i nvi ei l l c, 1957) . Ast f el , l i mp de ci t eva sccl ul l l r
l r : r . ; , ' . r l r r | l : ' r : r r r r r di l
j ci .
r , poi scadr . ampl i t ur l i nea, i ar
- dr Lpi
5_10
gccr r l r r l r r
: r ' r ' r ' r i Jr . r l r ' i i . ur , l l ' \ ' ol l r r l e ( t o
t 0 ci ' r i / scc si undc r t at e, mai cvi t l er r t , o r r r r
l r ; l i r t r r i l ' , I ' t t r t r i r Ll .
. l r i f u. l r . r ul r . .
d: l r cu o ur . ol r u, pr cdomi nanl n de pr r , r , f . i , r u
. , r l t . . t ' r r ' \ ( , r 1. ; [ 1 , / \ , . . . i l , , r r r l u ] ent e Si nt l a i nCcpUt di n bAnda l , cl , a1 r r . | | r r l
i r1r.r' i tt.so
fi
rr)rl ,i tn[1], odat5 cu crcDterea ampl i tudi ni i . real i zi ni l ' rrri rl .
rl rrl i rr rl rr I,r' rrri , si rrrrs,i dal 5,. Oda,tri cu- e,pa.i l i l u-ndcl or l ente, bol navut i 4l
l rrr,r' rl .
r' ,,11i r..1f,,, puti nd
_l )l ,eze' ta
s,i
_ci teva
convul si i . Unri el c 1e.1,.
l ri t,
r ' | r ' r ' $r r l i r
l ( , _
- l ( )
s' ' {' nd' ' , t l ar ' uneoxi chi ar 1- 2 mi nut e. ccl mai ar r r r r sar r
, r . r : {; r , , '
r ' r . Lr , {i o ct . ' r ' l ugi t i u i nt r e r i , r i r ea t t aseel or EEG qi br : l di oa r . r l l r r ,
' r' rr1r.r' Lrr
1l rr,rrzu,
tl :r,r di aci i nu depi qe;te 6 secuntl e, l r,rr,oeul EEG nu srrl i rri i
l i r,ri r,tri , rl L]. du,ci i a,j ul gc i a 10-1b secuntl e, apar modi fi ci i ,ri EE(i , crxru
.rr .r' r' i i ' rul rrl u' rroxi .i ccrcbral o *,uzate dc abseuJa si stol ei ventri ci rl uftr,
r l ,
l i
: r r , l r i r r . r . r r csr , si ngut a t , auzr i ,
l Mi nr l . i l l o,
j 9j 7) , j nt r uci t
cor . r . r , t r l l i
: r l , l t t i . l , l t r g, , l .
i i
r , r ' l r r b. ( 19j 4) a' r r qt r r r r t t i , r nocl i f j ci r i
- E- DG
i n : l l r ar , r r 1r r ,
,,r' rr' ;r.r
l Jnr.rl r(,i l nrl l l ;:r,l l hi l rotcnsi uni ar.teri al e. Aceste constati ,r,i al trnf,$
'
\r.l tr,l l t,i r, l ot. l bLl rro url ol l ra l ti . purc, al i l uri d0 formo i ntri cate, i rr rr l rr
.r,;r,l |,rrtl u, i rrl l rrr' r{:"r, r' ,,r' t,bta,l i ,
di ro.ctd, l a, 1i .r,r,tOri i cardi :r,rr sau 1j onsi orrrr,l .
' I
r ' ol r t l "i r r l l , i r r vudr r t : l r , pt ul ci r , p_o. I l l ) Gnuscpuui l evi cl eni j ,
mani l cxl , i , f l
,,1,,.1,r' i r' ,' cl i l r.Ii ,i t.. i rr l i rtrl rrrl p.ob.ktr dc .xci i :r,1l i . si rLo-oar6ti di arri i (.Nl l rr,
r r ' . r l l r ' . , l ^l ) f i . 7
i
| ! ' ) | . I i , i i r | , l U7l , l . 9Zl i i Li or l ar i u
r yi
l : bpovi ci u, 19?2) . i l l l l or
i r | , , | r ( r ( ' | | r t
l , r ' r , t r i r '
i i r i I r : r ' I r i r l i i r pr i r l l r ! 0 pi 0r ' r Lr r . 0 r Ll eot r r i l , i cr r l , i i , cr t r ni r ycr ' l , r ' l
r l r r I ' i I l l l r r l , o| . l r , l , i sr r ur Lr r ' qi
or r ci l , t r vl l cl ol r i i , r r t r sc i r r r r r gi s l , r r 1r , zi r , r l r l gi l , i t r r r l n
l . r r l . r r i r r r . . I l , i , r ' r l . i i , . r i r I ' i r ' | i - r r r r r I . ( Cor . f a, r i r r
r yi
l t r l , ovi ci r r , I 1) ?2) , l ) r r r r l
t t , t r , t t , l l , l r , l r , l xr r r r ( l i , r r I cr r I r , o- r r I i I r i r r i i , r ' si r r 1, ol l t , l r l i l i r r . i l r i i , r l r r i t , l r st r r r l i t , r l i r r
| r r l , i l t
t r l r l
1i
r l r , , , l i l l l t r . l r " i r l r r i r , r r l r r 1; r r r r r I r ol r I I r , .
*rsi11i.rtih,**;lx|rl:
i;li, I'jiili :r';'trll*[rtf;
;] ri;iriliiiffii
;)'ffi i;-i,p"l#ii;t$tru**l,:";lf
t"';iy:;t,ltiil'li'f,Lllr;.liiit;l
vi l i t i i si no- car ol , i di ene
( l 01 . o
' t ' i
' pi o*
i i "' *u t l u t l ' pt "' i o i ul t r i t r l
'
r ' i r r ' l i r ) '
i i ' bi
l r ; t "
*"pr i nde o' r J. r ' i r c
p"o- i *i ox a act i v. j t ai i i
cl ccl r i r "r l r . t r t r t l i r ' 1"
l,i}lrf \T:f".li::'tJ-ru"""t*ti?;','""*"#iJff
:'.i'lJ't't;lii;lill'iilii
,$11i;,**-;;*it*[:41"*6]t":1l3"Tlill'"',1'1ffi
,;il"r"''
t'ffli11uf#k*t44"-#.:*ili'lt"'*g_si::!"ii#li;i"i,,ll
i;t*m'
"*llx",*ril;ll
;lT$H"{:ii#"T .ti*a'lik
so pio,,r, ce .
*;*flX.*:\s{.l*$*f*1yi*tl*:"*d"""}ffi
*l"*fl1*"#*i}lti1i
;*?;,:"tntmm*t*iif
u-.*::,igm*1;)f
"il?xtl;'de-hipcrr.rr.r
-",,*gm'ttif
it*,T:".ii#,","'*##i*i-*l?H#4il1:"i:::t;':l;lll;il
,,I';iffi;l;r*t""on5ria"""i'iii"$""\1]#i:lllrsriJii:3i!,?lH"1l,;iill'
'ii,1::r:?T,ff
:,ff *1ii:ifii.g1*,.t11i""t*','f;:gffi
il*iil,l;ll;l
T:rj:i:rdf#"r"*rT{#:ni#"*;#"J,t'eii"*};','f
i#tltril;,
:li:' I ;:;llt"i:l'.i;l ;'ru;:l
m Ji,ri;:iirilllti,i*lt#"lii,''i:
ll ll il;;i
ililikn""l'Jl*"
j,l*,.ff
;?"*:pl*"-tf;:li,ll:""l,nl*'i,'il:ll;l':il,',1
al ci i rni i ;i i etc' ).
;d:::*il'i"i*lii:ilkij?{,*r
jl:,k#::L,$ffi
*:fi,lliil;fiil,
i{1, lr **llunHitr J;*ft
':l"""th
h- t
ji
:; :iit I
; ;
ll; ;ill;'
irii"i""1 .ir""rr"A ;;"tt;p'ii"i;;il.
Si*ptoro'atotrgia
post:}ccosua,lii
|o rrH I ii
''tr-o
icurtii, stare crcluscrit'I,.$:.ii1$"".:i;''ff1',i:1,%:t-ilL[llili,,l';l
dulatii
pind, la 24 de ore)' e
onitt'
""
delir (Passouant
gi Minvieille,
1954)'
se relateazs, faptui cr uneori*i:Si;i"tt?l,t'J:ff?r-li#iH:Il
:il]'lliil lil:
f'"iL:f ,ii:rHitff
i'.:titgp"ryt41*itrf
kilil[il,lif
t*l
It
i;i
ii,li:ln,lrl
lilll l'
;i
i iiiilli,*lii':ffi
t;
i; iifl }liiii i,1:
ilii]
l*!:,,lii;,jllilr,i;,i'ill"llilll,,
,ilil;;,;ill,li
ll,,,llilil:;;,l,,li,ij,,lli,ijt,llll
;;;ii,,i.i: i,
, ,
;lilllili:i,l;ll i:
lfl
,;l;ii;,1;lt,,i,i,li;1.;l,l:ill111'll,l,'ll,i'l,l;,:1;iilliii;lti
: r30
:J;Il
,"I
\ r r I Li I | i r I r . , I I i i ( ! . At l l i r l r l o si r r r gr l or r r c t r , r t
; t l i
r r 1, f i I r , 1t t t r r l 1s9
I ) l
i 1 {, 1! t r l ) 1. ( . t i ; 111, ! l
r , i t t ust r l r r i r ' : r r r r l , i r l i l t , r r ( \ l r i ss , 1i l l t l l i ( l r , I l l i l j l ) .
l ) i l l . l ) l l r ( 11, r [ {r ! {x] 0r o l i zi r i l i l , l ; 01t l gi r r , si n( l r ol r t t r l ( l o
l l i l ) ( i r t ] \ ( l i l l r l ) i l i 1r ! i , r r
rr, l l i .rr r rs l I i
.r,rr,r0t,i rl i l r,rr
so pou,to l ,ratl uco l i o pri trtr,-un r0l Irr <l o ti p c1t,r' (l i l | -
rrrl ri l ri l ,or' (l i g.
,12),
fi c pr,i rrl ,r.-rrn rcl :l cx tdnsi o(l cpl ' osol ' . i tr unri kr crr,zrrr.i
rrl l sl t rl orri r, l i rl nrrt rl c r rl t,n i l ' os1,a,ro
nuti ndl l -se i nti ' i ca,
t ' | . 1. : ; - : J, l . t " l l t l r l t r l r l t t l t , , l t , t l ' t l "4t t t l 1t i 1i
t l pr t l i r t r t l i t i i nr l i t t pr ": t
I i I t t , l , uc(Je: t ! o1 5I I I r: t t
1t rr
I r
. D Ul l i i , ct t t t r i l l t l i l l i Ll : r l : r l . r ' l l l ' l l r r l ' t r zt t l l ' l cl L l l l l ( r qi sl l ' i l i l ( r l r ) 11) ( l
f i
I X) l i gf af i oo t l ) l l i i 1, i 1, i o | \ i l , t t l i l r i r , r ' i
1r : r r : r r . I t t t i t {1
i l l ( [ i $P( ' xl ' i ul ) l l ( pol 11' l t l
( l l i l ] gl l t ) s
i i . r i l t , ut i i i r ' 1i
t I i I . t r : t r 1i : r I : r l si t r . , 1' I . r ' '
-
. \ ' . - i , , r "qi i t , Ai i k t : t . t , st t t dt i r t ; ; l t t t t i t : t \ nu r l l r ' l i r l r ' "1' i *t i i I I t
'
'
! t I ; r
'
I i i
(Gast *ut , 1t )"56 i Oi l cf i a, ul L
qi 51oi c. t , , l ut j ; ;
(ort ' r' r' i rt ,
19?1, 1978;
(. l ol l i r' r' rl l
. i Fr no"i ai u, l C7: . j i . l ) or t Vot "t l l ct t o ( 1960/ 3 gasi l l r ' 3uo/ o t l j l r cr t zt t . t t
,i "o"rl oi i i nroi l cr,rte' Si l u 10o/o di n 10O de bol na' i cu si ncol o, i tl d' ,str1i tl .
tip 1-aso-ragal), anomalii EllG de tip epiieptic'
tri, I'nregistrd'tile
potigrdfice pot furniza- clate pre!io:l's() lu rltlrrr'L
(ltr
,tia,g";sti;,
'iar
ryi
ref'erit6ar; la
-Inecanismele
carc concurS' h instit'irlt rrrr'
sll]oopol,
i. In.reaistrarea accesttlui, oste posibili, foatte rat, dar clnd se
lx'irl'(l
Ir-r,ce. ie tlifdrentiazX, in motl net aCcsul slncopal de accesul cpilolf i(r'
2. lt
.faBele
intercri'xi,cet
p1'rl,cticarle& clirerselor nrcto'lo de testalr rr
roncdr rofiexogelre (testle d; compresie a glollilur oculari, de corltpt(!$i(l
,r" ti"iu.if"i caiotitiih,n, netoda Vtlsa'l"rr') pot surplinde po poligli)'rtiir'
liincrrettcxiritatea
zonelot reflcxogencr evetrtuill chiar s5' lptodtr('ii' irt
iaborator acoesul sincoPal.
a,\ Test ta' eT refl etul ui acul o-card,i ao se fi r,ce pri n crj mpresi l
gkrbi l rrr'
1,culi.lii, ur rnirin{lu:se
p0 poligrami, actiYitatoa ECG' re,spira!ia' 'I'r\- 9i.
l't:t''
""ot
i,lpC. L.tf"t,Verceilefto 1iOO0),
testind roflexul oculo^-cardiac, i], ol)l'irrrr I
'
lo'iz ,iin 33 cte cazuri cu si[cope' stopuri ca,rdia,ce de 2 -9 s' cu
"lil'r]rtlrr$
li'n O lncomptet"
(unde lente dihterale, sincrone
$i
$imotrice), iar lt!.rrlli
l- t oi"r"i toi"
""i
li3 studiali;, stopuri cardiace cu
,,ri'spuns
EEG cotttltLrl')l
' rrui "ui i
ci c u*de Ieutc cri pate tl e pcri ul dc de
-dePrr:si e
el oct' t"gr' :r' l i r' :r)
i l r ; ui
t
Lf i Or ut i l i zi nd i r et oda. cor npl esi ci gl obi l or ocr r l mi Lr ' l ( ) r l . '
i rof"ot:i . J, obti nut sc l :rea ri tmul ui ctr' rrl i ac ctL mai l rr[l L de l 0 l ri l l i i
P' '
"' i ""i
i i , i o*t" cazuri l c, pauze pc ECC cu dun' ta dc 2-3
-s
(Ii ' ri rri sprrtr' r
l l nei U 18 cazuri ,
pauzi pe ECG uai m*ri de 6 s (cu.ul de l cnto l ti l a' l ' r'
"nt".
!io"r"o" Si sim-otricc lre
EEG) la 4 cazuri, sljoluri caraliaco ntli tttrt,ti
,l,r iii s
(cu
undo foerte lente bilaterale, sillclone
$i
simetricct ul'lna'l.!
-(l(r
"uolu,tirrr,i"o
traseului $i
de instalalea piorderii de conqticnttr') la' lllli li
i16lna,r-i.
- -i .,a
bol navi i obserYa,ti el e l oi (Corfari u, 1971' 1978; Corl ari u
usi
l hl to-
t i cl u. ' i gf Z. l 9?3) s- a obt i nul '
pr i n t est ul dc cot npr esi o a gl obi hr r r r cr t l i Lt i ,
, reacr-i e di opri rc cafdi aci l a 47
o/o
di [fi e bol navi , cu al ur.i r tl rr
l rl rr.rrri
^ri.ro-otiiat"
cu d.ura,to tle 2-3 s. I.ta unelo cqzuri ann evidotrtil'li bl)lrrtrt
"i;;
;;;i;i;
-iu
iant", la intervale do 2-3 s. ln cazuistica noastl i'i' Iru rlrrr
,,f,*"."oi , i t""*,' sul
' accstei
probe, cl eni vcl i ri tcnsi ol al o
9i
ni ci IJrl ttttrsttt' i
-.,ro,noi ' i ";
uuG cu
pi erddea c6nqti cnfei , ca i n rel at5' ri l c l ui Vt' t crrl hrl trr
ii.s-ooi- iteatttoi. Gasfaut
(1956), Corfaiiu (19?1' 1978) gi Cortariu
6i
l'r.r-
i , . r t : i . i " i r szz, i sza) au c, pi cci at ci '
, . t : xpr esi a) '
EEG cst o dol oI ' mi l r r L{i L r l t '
1i , , , *i *
^i i r , ot t i .
Asi t ut ur i bl , r c si r r , - : - ul r i al cu t l l t I aLA st l b 6 $, t r r r l r l i xl i l i { i i
i a' r.r,scul EEG. i n schi tnb o rl si sl ,ol i o ruai rnato do 6 sr prodl rco
l r{1
l ' r' i r' r' i orrl
i i i JC l r,rt"u.i rl o *rtrl o 1,IrIILII.rLrIIti r,
gotroral i zal ;0, ci l ro oLos. i 1 i l rttl tl i tt-ttl i t' t
i i r i l , , er r . s r l . o, i i , t r vr l t i r r r r t I t t t I t r , l Jt t n1' , ' t l l udi l t l t l t r , dur i l l ; i r ' t l t l 12- - 1' l t t l r r r r r
, i i , r , i r l r r , r : i t r uo l t ) l C( . 1 r l oscr i l r r : i l r r l r r r r r r r kr kr t r l , o l t i [ : r , l , or t l o, $i r r ( j l r t l r o l ; i i si t t t i r l , t i r r o,
' , r ' r r r ' , l 1, r t
t l i r l r , l t l l r l , i t l t , t l ! i t
I ' t ' i l , ; I ot t I t I t , I I t r I t I i I i I I i t t ' t I
( ! i ! l ( r
i l t o t l t ' t r l t l t l r l r t l l l t t r t t l I t t r t I
, , f i r r i , , i , r *1, , , , 1*t , t , , , l r t ol ' {l r ' t l ,
r l r r r r t l t r l ; l . i t t l r ' i , . l l t t
l l r l : l l l t
t ' l \ l t l i l l ( l l u i i r ' l l l t t l l r i i t r
COMPRES/UNEA SINUSULIJI CAROTIDIAN SII NG
Fffi---
\ / 1 nn f \ AnnAAr
^
. . , . ^ A
^
\
F. uGv
v
! 4
vvv v\ / vw- ' \ / vvv
vvl / v
a i{X!4^,4^,\^.&-^^.^.4ae@
FM- V/ \
@Va{Url^t*r^r,r.
"."".,,
{*:S***@
"Y-:-'":,;:*'
PD. - TO
"
l
?t1*\t'$^^&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 hipclreflec-
li\'il.ntc sinocar.otjdian:I. Pentlu cr.izcle de pierdorc a euno$tintrei, deti IirA
collvuisii lo i(!)-clonicc
ti
lir;r njci o simptonratologie preacces[a]d, a lost
r.lidrctr)t:1 drelt epileptjci. lll clinica noastri loate invesligaljilc clinice
\ i
t , r r
, l i l l i ce t i nr l . i v UEG . i I ' F: b) cr r f o. t ncgr t i vc. Compi r est un, a gt t , -
l r j l or ocul r l i a i ost l r egat i vi . I n schi nj t J pt l l gur a i e r edc cum_conl pr csr unca
sir rsului curolidiAn sting (dupi hiperpnee) produce rrn bloc siu;atrial cu
( l r r r Nl i r
dc I sr cnnde, I nsol i t dc un buf cu de unde l ent e bi l at er al e, si ncr ol l e
ii ni )rilrict, llodiliciri similflre s-au produs
9i
prin comptesiunea sinusrlui
r i r ol i di l n dr cpl . l l ancr r a Val shh: a a l ost . Dcgat i Yi ( dupd L' or t or i u, 1971,
( hr l ar i u$i
?opoDi ci u, t g?l si
pol or i . i u
$i
col ab. , Tgj B) ,
.-.
l \. r9i nccrpzl e- di n net:ral gi a
l tl osof
uri ngi anti . Ri 1cy
i 1g42,
ci tat rl o
\Vr!,yn0, .11)01)
;i
()ol tu[ol l a
(1Oi T, ci tai de Cori ari u, 19i 8) au d' escri s l sO-
r . i l r i r l r r . r r ' : r r . &l Si i gl uso t ar i ngi r . l c ( . u
si ncopc pr . i n b i per sousi bj l
j r . i , t . , ,
r r ,
H| l l r s| | t ut {: t . 1. . r 1. 1( l l i ! . Ac' sl . c l oTmc
, pl r f
i cul ar e dc si ncope i nt r t t t r , , u, , ;
r rr,r' r' rr,l gi ..gl ' ,sol nri ngi anL i n accesc dui cr' oase sfi r;i tc pri n aci ese si ncoprr,Lr,
Iri l rr,r' rr.rrsi l ri l i l rr,t,c si no-r:aro l i di l ,i ti ,
6i
prezen!a unui h.i g-qer zone, a i ,i i r.,,r
i r r ' : r , ( i r . i r r r l r r r . r r . r , i zl r , si ncopl l i . Dur . r i l c al r i i n r cnnse ui ol ent e cu dr , , r r , l l ,
{l ( . : j ( t . . l t l , - s, I i i r Lr l r . r r , nt or r i r , t r r l a. baza l i ni bi i , i n ami gdal i , qi i n unghi t r l
r r r r r r r l i l r r r l ot ' , i r r r . i nt r o cr i ze dc obi cer i bol navul nu: l cuZ[ ni ci ' un si mpl : ot ' ,
l ri r i s |,i i I r) L ri i l xrl nl rl i car,. acuzi l dureri pcrrnanente, peste care se snpt.i t
l )l rrl
pr o.,-,i l ruc l r,l gi i l r Yi ol t:trtc, I' i o_spontano, fi e tl ec]an;a,l e de degl nti l i d;i /' srr,rr
rl ^ i ' i l ,rr' .rr, z,rr.l ' r' i l rcLyatn rl c gl osofari ngi an, rl e.rnul te ori oonti mi ri i . si
r l i l r i l r r
I r ' i r r
r r pl r , r ' i l , i a, si ncol ci qi i nsoi ; i 1, e sf l , u nu de convul si i i , r ni co_. l ol i , , , ,
i -l i rr |
-
s i 1, r r l r,
I
i i i l r,rrro si neop:l su decl anqoazi r rruml ,i l a
,,nevral gi a
rl : i nul ri .
!,i rrr"
(i ' i r i .' si rr,l ub., l t)5?
I
I?:i i l l u,s, 1l l ti o), d l d. mul i ;c o.i si ncopcl r pr1; fi
r l r r . Lr r r sr r l , .
1i l . i n
cor I qut si ur L. : l si nut l r r l ui ci r , r . ot i r l i l r r ( | . ' l , i l l r r , s, Jg00) , i r r r pr f
r l i r t 11r 11, ' q, 1, , , , r r r l ' r l i t . t , t r r r r nt oi t si i , l l , si r t t r su] r r i so pot i t r l , r ' cr t uxt nocosol c sj r r r r r
l r r l r r ,
r l i r , r ' r r r r
r yi
cl i zcl o ncvl l r Jgi cc. l r r r r r ul l o si t r r a, ( i i , t r r r t i r ol , ol ni i l , l l l r l , a. l . l t , -
r r i l ul ' i , i r , r r ol vul r r i
i {l osr l i ni l r gi l , l t 1r ol r l o
i r r . l , r . t ' , t upr r r r , ( i l , r r t , i zcl . l i l gi cr , , r , i l , yi
r t , l l r t t i l i r t , l t , si nl , r r l ci r . l r , t r l i r r , r , r r
5i
l , si r r r r ol r ci l i l cot l ; t r , r , si l t r cr t si r l l sut r l , . r r r r r t r .
r l t : l | l .
: l l l )
./141
l j l ' j ; j ' , , 1: .
, l : l l l i , i ' , . r f l , . , l , r ' ' r . r l r Lt i r i r , r ' r . r r 1l r r , bi i l i r i l r r cr r r , r l r r l ui , r l l pr i , t , i r , r r r
; r r .
t l i r r . t . r r l
r r j r l j r i r ' r l l I r , r r ( . N| r r r r r l r ' l r r l r . r t l r ' . t l . r , r r l l r r , l i zl r , i r , , r , r u. c i t yl t , l r si , ssr r , r l i i , ' . i r r l r r r pl i .
I t l r l i t t , , l : l r : r l r j r l l l r r r r I j
I
r r , r
'
i , , I r , r |
,
.
r 1, . r r r : r r i r r r r r r r . : i 0 r l r . r . ' . I l r t l , l t | t ut ' c sc r . r , i I .
si l r,l ol r,zi i , 1,r' ' .,r0rrl Ir)l !(i rl ri brr,zi i l r)r' l rxLI. l ri .,,.,nrL,.i l ., r,t,,rsi r,.,, l ,pa,r,r{,i i r, rrrrrl .l rl .
l ctrl ' 0
s-rr,
I,' orl us
dr|r"r' _? -l 0 $(1(,utul c, i ru pi ,";.t,,",ro i i i i r rul si i l l ,,i s-1, i rrs1,rr,t1r;
rl rrpi i , . .si stol i . va' i *bi l i i fi ntre 12 qi fS s;, i ' frurc{,i c t1i pti rt,i c,I*i l i i ,1i i .
oi l ol l rrtorti al o fi eci l rrri bol nav.
b) Oonl pr*i l ,j rea si rtttst.Ll ui cttroti tl i on, dnpi i cutrL un pl ,eorzi l ,ti
:t nto,i ot,,,
r lrrirrllln
tcstmrr:l re ,ctiviirilii lcr,sl,,i irnpoitante zonc ieflexog"ui.,
lirtli
.i i sl rLrrrrn.i l e
' l rl i l rrt.e
rt,Jupra, acti vi ti tl ,i i ti ,rdi acc, a;f-.1.
Ui
a' t.ai .i rl ri i
r ' , r i r r . t r r l t i . t {. ( , i l zl l r ' i 5{. poL
ol r Li n( . l nr ogi sLr i j Tj pol i g| af i c, . ul o
ur r Ur . , . r , i zo
si r r , - r , 1r ; r . l r ' . l nr : r i \ \ ' , . i sr
: i
l Jl k, , r
r l b3l / &u
! r r . ( . i zat
i . i r , l l ' . . l uoo r . l l r , r , . .
j u, j i r
i zj i
r {' ) r r i r t t ! I r ) t [ , l e; . i l t {, 1] si nusul i car of i di An t r u pr odUce ni ci Ut l l Jsl $
rr,rrrrtrnal , i u,r' l tr, rostul i ncl i vi zi l or, rcrj [str, cornpres' i une i ,' tl uce o bracl i ci |rl i tr
r r r ' , ' r l ( . r r t i i
1sub. 0 bdt hi / ; r r i r r I 11i l i d! r . al or r . - r i ni l i r l a)
5i
o scnr Jer o u
, 1, . . \ ,
: r , l l , | l r r I l : i - l al i i
' l {,
l i r l oJ r ea
j ni l i r l i .
Irr schi mb, l a bol navi i cu hi ppr.r,,fl t.cti r-j tat c si ro-coro bi cl i ani , mns*i ul
):,:ii.
y]]l!]^"!l"l:"1
r,r-.,stei regiuni anl,reneazi o serie de noditic5ri, rliqrt[
i r I | r r
l Uxr ( : t zl r ,
1_\ t r . o\
j ( ' i l l e.
1957; Cor f ar i u. 1971. 19?g; t ur f r r i u
; i ' J- , , pr r -
r r ' r r , 1972, . t 913i .
1)
f i , . nur nr l i r r r u, l i r j ci l i ECr i , f i r i i mudi f i cl r i , t - . Ei ; :
1,.)
.1..r-' ortrl rul t' r
ttl (j c, i ns{Jl i te dc apati l i a de unde i ente di n bancl a thet,.
r:hi ur del t:r,, po toate deri yati i te, carc c' oi nci d cl i u punet
d;;;i i ;;i ;i ,l
r rr
.[,
iordu] or, cu Di,l blnlei tinrp c1e 10 -30 s, clar cu pirsistenla modificiriior.
l rj i rl (i t"l LLe 1i r(.n 1-2 mi nute. Rezul l i 5 ci , Ia bol navi i c. hi perrefl ccti vi -
lrr,i,t' r, i rru -e:.ro1idiitnJ,, comp.esiunea sinusului carotidian deteiminX, itilco-
i . i ( l ) r r r , ' i d. l i ci t i ca. di oi uhi bi t or i i
\ i
nr ai pul i n
' csodep. r csor i i
cu sci r l or ( . i b
1. , - r r si r r r r i i i i r i or i r l ( . . , 1r r oxper i onr l
. nua, st r A,
' bl u{. ul
si n6- ai r i al O"nt an. ai ' , i
i r,v|l 1, rtLrr' ;tt,' ]-i .tru bi l e (i trtre 2^ qi 15 s)
Di
a fost faTori zat de hi pcrpueoi r,
|r'tr.,labilii'.
Modificirite
pEG
sirit crependente nu nrmai de duratii, *isisto-
l i tri , rl i l r' ;i de uncl e reacti vi ti i l i i ndi r,' i dual e, i n sensul ci , l a uni i bohavi
irrr apii,rut unde lente biiaterale, sinerone
Ei'simetrice
(mai
exprimatc tx)
r h. r ' i . r ' i r . l i i L. &nt er i oar ( ' )
dupa o asi "i ol i e do 8 s, i n schi mb I a al ! , i i ; i o t i ; I i I
r f l l ( . r , r : r . . t . l U r l c l 2- 14 s ( f obdcauna dupd hi per pnee) .
( . j ' | r l
, r i u ( 1971, . 1978) f t . demor st r at ce dcncr var ex,
i pr i o
i nf i l r r r r {i r r ,
i r . r r ( . i 1. {. , , ' ci )
a si uusul ui r . a. or i di an a coudus l a suspendar ei . mudi t i ci r r i ' 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$tolea
_presiunii
intratoracice, cu aparilia de uncle lente r,hctrt.
r|rlt,rr, yxr
-traseelo
pHG
;!
ghiar cu decianqarea ile accese sincopale (Clkfi,
i : r r r r r si Sr 6i 11r ,
1963; Sbcr pey- Sbat er , t 953) .
(
or f ar i u
1l gi . l ,
j i ?xt
*j
t . r l ; r l j r r
f i
Popoyi ci u ( 1C72, l gZJ) , pr acr i ci nr l maner r aVal sai r a l a Uohi avi
, I snl , r l , n
ul . f osf al i ce. ] a- mi el i unc
Si
l a 1, l l se, au ob[ , . i nut pe pol i l i r al nr . [
t r r r r r l i l i . i l i
dr r Li p
"r t O
n' oOi bi l o[ , cu i nst al r , r ea unor b] ocui i si no- at r i l r l r ,
rt{. Hrul tr-rr thrrati , (B -4 s), .l ar {H,r[, modi fi ci ,ri EEG concomi tente. .l ,rr,
r,l rrl {r (,i ri zul
i , col crti l Lrl nostru a rnrarcat ue$terea T.A. cu 60_g0 n}m}l g
Irrl'ir, drr r.rlloaloli,- injtiali. Sciiclerile T.A. in cursul manevlei valsalvrii
l r\xl rru fi
roac!;i i kr hi pertensi ve ap5,rut s dupX sfi rqi tul acestei manov:rr,
nr\' i r,l r rJrro(' r"rl i rkxxl ci i aooasl ,i l nrrl ,ncvri i ar putea i nfhrcnl a zonel e rrfhi ro.
gr , r r r l r r r r r r sr r nsi l r i k: , c&r ' o, i r r ci r , z dc l i gl l scnsi l r i l i t al c, pot l cacl kt na, i r ukxr -
r i ( l r
l , r ' r r r l , r ' - r
' r r i l i vi i r l t o
cr r r r l i oi nhi bi l , ol i o ( Cor l ar ' i u, J. f ) 2J. , 19?, $; Oor 1l l I i u
I r
l l f l ) ( f ! i oi
,
L! 72, l ! ' l : J) .
i t , l : l
1 : 1. I . ; i , : ! . , "i . n. I ' xl t l l t t r ' dt r l r t r 4t l *t t l l i . l t , t t t t ! . i al . , i t t si , t r ul t l
.
l . ) Npi . l , t 1t : : . i u. r ' t p' . zi r r l i i , r r , I r , ( ( t r I I r ( ) : | , r , r r , , : r , r ' . si l copoLl s.
l xr t
. , , f r r r r r l l l
: r r l l sea. l : ) st r ' ct r r i o; 1r r , l l r r l l r r r l i r r
i r r . sl o: J00
( t ( r
bol nai . i i nvci i , i ga! ; i r l r r r r oi ,
,,l t ruTcl l c l urmd rto i i l ]l .,)J)r' t (l .oi tr
i l ,l r' o)i i rMti v 5o/o au {ost i ndl rrrrrat,i crr
r l r r , g) l ost l cuI cor ent . t l c.
sj ur . upi , r est - ul al l f ust dj l }, Sno. 1i ca, 1 i : l , r f l br r l a1or . ? l r l
, l j \ ' r ' r r cl e. sor r
i cj i pol i r . ) i l i ne, dr cpt cpi l r . pl
j cj ,
ceet i c cul j nor ( l i
; i
, . r r r r r i , , l , .
,' l ,surl a!l
a1e l ui .Gastaut qi Broughton (19?Z) si al e l ui \-v-ayne (11)(i l ).
{,)
r,n:unnrzi, prrp.,tl,
.sau
o relatare inexactX a sirnptonr:ll,irlogiiri
. i r n pal l et Dol navul ui
$i / Sau A apar {i ndt or i l or , poat e
l r r , l i L
h u {, r r r i LI 0
, l r ! gn, , s] r cX, sr nco] Jct e pot f j Conl undal c i ndeosebi cu accosel r . , . 1j l r , 1r t i | ' 1
rrkinetice sau a,niotonicu, dar (in cazul coexistentci convulsiilor- toirioo-
,l ,l ni ce) qi cu cl i zol e upi l epti ce grand mal . Exi sti -totusi ul el e el cl ncrri ,rr
i ,rtr(r pot fi uti l c i n ori cntS.ri l e di :r,g-nosti cuhri dc si ncopi t. (Gastaut, 195(i i
t' orfari ur.
10?1, 1978
I
Corfari t
;i
-Popor-i ci u,
19?2
;
Fopovi ci u
;i ' cohtr.
j
lll?ti) : chiar lu sincopa con.i-ulsivi,, faza tonicii
Si
jaza
?Ionicii Jint, rrnrlt,
rrLl i scurte si i rrai t stonp:l te, i ar dup5, epui zarea l or nu se i ngtal cazi , currl r,
l ,
' j l cr ' r t r cJ.
cal e est e ( r l r a( t : cr i ol i ci
acce\ r r l ui i i c cpi l , . p. i c. l , r csi gur . , i r r | r . qi ; .
' r i r i l c EE( i . sf : l nt l a. r . t l . dr I r na, i al es pr i , r
act i r
j t i ,
pl ec m qi i i l , r . gi r i r , , r . r : i 1, ,
l l ,
l r {r al r . o ( l n' , l uSr \ , u l c. i ar cc t oDel o. r r el i exogcne) ul uci dr . azi di i r . ; r r , , sl i _
l rLl i n marca mai ori tai i e a cazuri l or.
.
2. Accesele de 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,
1 umplet5,,
.re,specl,iv
cu ataclri cataplectice, cu hajucinatii'hipn*gog,ir,rr
ryi
, r r
l r r cl i zi i
de sonr n p| ei na. r r j l a, cr oi i al o di agnost i c. Lr ar , , r c"i sul , l t , . . , , r , , i ,
r r i r r col t l l j c l I {' o dul ' t r t i r nr , i l u_ngd, cl r cur r r , , t anl o du apar i 1i , .
Di
cr r , , t , , r , , .
.lilice qi poligraficc. (inclusiv_ de-orgalizare a iomnuliri;, calc l,rarrqoir,ri,
rl i :rgri osti cul (Pop-ovi ci u-l i col ab., 16?2, 19?E). Mai Oi fi i i l Oo rl i f0l r.rr{i rr,t,
r ,i i u uneori accesul cal aTtl ecti r,, al ,unci ci nd sun i ne i zol at. Acest i l ccl s r,l rl :r
l , l cr ' 1r c
5c. ct l ' acI et i zc; t zd pr i - nl l o p. r i r bu\ i l e a boj : r ar t l ui . c[ L o I r , I r i ,
. , .
i I
j
I
j
,
r . pr er dcl ' r
Dr ul t t eal onuSut ui muscul t r . i ncl usi v
l ) osl ur aj .
l ogt t r i r l r r r r r r r l i
, , r ' i
. de. f act or i
at c( l [ v- eJnot i o_nal i . l nsd, spr e dcosdbi r c t ] e aeci sul si r r r r , ; r r r l ,
| l r r unpul &t acul ul cat ap] ccLi u COnql i eUl a CSt e pr \ Tl C, 1d,
C. ( , a cu
( , ( , l r I t . t , i i .
, , , r r \ al i d semn de di l gnosf i c di f er cnl i al . Dcal r f ol , i f f egi sl r i r l j l c pul i gr . : r I i , . , .
"l oct t r at e
dc: : unr c- r ogi ccr cet a t or i ( El i shi kar va
; i
cot abi , 190g; Co| f i r l i
, si .
l ' opov_i . ci u, I 973; Popovi ci u
9i
col ab. , t C72, l t i ; g
$i
al l i i ) au dcr r , , l r t r r ; 1,
( ' i r
pr aougr ea t ot uSu. l ur muScul u, r . S, . Ju{cc i n decur s de ci l I vi r , s| r . r r r r r l r . ,
t i i nd : r desea i nso{i l r i de ur j F. ar ' i ocul ar e , . a i n sonr l l ul RE, \ I , I i r i r r r ur l j t i , , r r l i
r upor i anl , e al e al i or par ar nor r i pol i gr af i r . i , spr c doosebj r e t l r . r . J. i z: r , si r r r , , r
|rLtal
rn carc p_e^ inregrstrtr.ea
p9]lg1afi9d apar modificdri IIOG, ,kr lll.A.,
Jrl ccum
qi modi fi c5ri al e acti vi ti l i i EDG (untl e l ente di tr ut
j r,
,", ,,,,,,i
. r r r r pl c) , concomi t cr i t cu pi er der ca cuno; l ; n1{, i
l Col f aI i u, JC?i , l t }7r t
1
r ' r r r . .
i . ' r ' j u
l i
Po"povi ci u, 1972, t 973) .
Cit rlespre parali ziil.e de wmn, &c(]stea au caractcre r:linice qi poliglli l.irro
,' u,l ' l cteri sti ce,
care l ranqcl ,zi i di agnosti cul (Oorfui u, 19?t, .i O?Z
;
.l
,opo_
r i ci u qi col ab,, 1072, 19?8).
3. Cri zek: i i c ci rtl cra tl i n ou.rsu.l
q.l tutu,l ,u.i ,
]l l hti i :n, i trs.{,i i ,. r.' r.' r,i si tl .
1, r , . t r !
: i r l n l l Uxr [ 1 i
l i . r ,
sr '
I r , l
r l i l r , ur r osl , i t , r r , , , r r r r \ i r t r i t i f i , i r r r ' r or r l r i r l , r r l I , r r l l r r r
r r l r l "l \ ( r ' l r I l t t o: r . : r '
, . r ; r r l r l r l i r r .
qi l r l
; r l r I l . i t , r r l l r I i t r r l i l r r r ' : r . r , , , . , 1oI r . r . i zr . .
. . 4.
( i , r i ; t l t
! r
r . | . r c1t . t r t l r t 1, ,
I | i I 1I | i I | | o| I | ( | r I i 1, ( j
p( ' r r l , r , r r i r r s r r I r r . i r I r r
I , l
I ci r . r I I l l u
r ol r c \ r ' r ' l l l r i ' l r l / j l r , t i r r , r r : r l r r r r I r ' r ' j ; , r , r r , zr j r pl i r r i l ol r r l , l r t , r r l i r , l , I i i r . i i , t r i t r r 1r I or r r r r
l r t ' i i i r , ( t ( f {r $t [ [ l i ]
( r | \ ' ( | t | | , I I ' LI r l o: r r ,
Pr r r r
l | I t , ' | l l {. Nl i
, i
t l ' r , I , i ; i i 111r ; 111I . ; ,
r l r r t ) l r i | r , i l
,illll
343
I | | I |
(
| i I i i ] I i , I i I I i I r :
l xl zi l , i o
l l l r r r l l t , l t t t l t t i , l r r t l t l l t , vt t I
l r t cz. r r t r i
t t t t l o l r l r t l . t l : i t
Lt '
t
; ' I ] I : I I : I t
l l i t r ni t t l t l ot r ' r t , l , r l t r t t st t l t r i l l r us( l l l l i l r r I i i t l t I pt ' r ' l i r l l l '
( Nl l t ' i l ' i t ' l l 1' I t l l ( r l ' l l l r l l l l l l
] , r r , . , , ' i , , i . u, ' i , r . r i t .
", ur _r , 1.
$i vor l r i l cu, r i i i , r ui r Li r r i t t r cr r l l , ol l , l , o ( Sl r xr l r r r , r r
; i
t r l r t ' l t . t
r 1r r ; r i , i , l u, t r Ni i U( ' vor ' ,
j . 9U5;
I ' opovi ci r t
1i
col r t ' l r ' , l 1) ( i 1l
I
Wi l l i r r ' t r t s 1i
( i t r t
r , , t l , , L . i i r r ; : : : ' Oor ) ' r , r i r i ,
l t , ?i , t 9?u) . l l - odi i k: r i l i I t r l ' l l ' l ( i
r
t t t t r r ot i t Lr sl ; t t l t l o
,",l l ' .,-i i *' u..i "l ,tt-i r,s,i i i cl cri 1,1,
vortcl l robazi l rrti r i l ' 1i t' r rrl ui rl hrs Ll ru1' rrIi tt
. , ' i " i ' i i ' i i i ", ' l i "t i o. ' i no, i u
i r i r i t r . i r r ni ni ( Pr r , r r t i r : i Lt ; i c, ' ) r r ' l r ' ,
l l l G0T l l r r . ' r ' l
, , , ' i i , r , i f i ' "i ", t f . f "- l . r l , el r r o- l r azi l r r ' ,
apa, ' pi t t r r r : gi sl t r r t i l o l ' l l ' l ( ; : t t l i vi i j i ( l
; ; : "; ; : ; ' i . ' l t ;
' -
i egi ri ni l o rr, Lcri oi t r' (' ,
-t l (,
l l p Ft l i l ). \ i l i
l I l l A, ! t , "l l l l l l ] ] ; i l 1
. r ( ( , Lr l ) . . l t i t U) ' ci r r : c{' put , cunl l l l r di l , cl l ur r dt . Lr l ' l l l i
( 1i n c Ldl ul i l l : r ( l l l l l l l
. ; " , ; ; ; ; i l , I , t r
- i i o
i . "t , , t i l o : r , par i 1i , : a. l act sl ur
g. i r ' l o{ l "r I r . ut e . st c r l i l t ' t i l '
, r , t , . r zul ' si nuupci acesf e anoD] ; r l i i l : l . l ( l l pJl l nt t i l r l l r i u r r t gl i i l . l r ' ( ' & : l i ) l r l r r r l l
cnrdirr,r,, respo;tiv ilupri prir,trugirea T' d.,
I A
TULBURARI PSIHOOROANICE
(TULIIUIIARI
IE' . DE CONSTIINTA CU SUBSTRAT OIIGANI(;)
I. Con;tiin!g este forma cea mai inalti, de teflectare
subicc
ti r.i , a l umi i obi ecti ye (Di c{i onar enci cl opei l i c vo1. 1' 1962). Ea cupri rrrLr
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,
Acadcrni ei R.P.R, 1958 qi Di cl i onarul expl i cal ,i v al l i mbi i romi i no trtl i {,i ru
J9?5). Starea de congti i nl l este sttl rea
,,cl e
a-qi da seama cl o tnti rl i tt
1i
r1e si ne i l su;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
hi atri ci , care nu aparl i n probi emel or noastre de neutochi tul gi o, i rrr' :ttt
tuiburiri psihice date de Ieziuni evitlente anatomoptttologice. Aoortsirt, rt,
l osr nunr i t i i l ul bur er e poi huor gani cJ, car e ue pr eocupi .
3. ln ce priveqte substratul ana,tomic a1 conqtiinlei, 1a tcaliztllcrt r,i
iau p&fte toate structurile cerebrale, unele fiind de bazi, cuttt tiitrl : cut
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,
tulburiri psihoorganice. Tulburii,rile de conqtiin!5, datoritri hrziurriLu'
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)csi f{ur aftsto l uzi rrrri di fuzo, pe l i ngi t, cri , dau tul burl r,r' i psi hi co rrrr
<,:l l aotcl cl i ni o l l i rrr, rl rrf i ni t,, poi , i trcl urkr
l i .SIi -4.4,
al c ci i nri tul bul r1ri vol rl rr,
o cor r r por ur r r l , r ' 1, i r r pl r r r r pl i r r t r r r r l i f i ct t r r i l l ul bul i , r ' i i do cunr l l i ouf i l , l ) i t r u, r , r r si o
r r r 0t , i v0, : l , Pnr r r , Pr r 1o( , i r r , r t l ot ' i i t r r ur r cr r i i 1 r l r oI i , t r t l l l t r t ' i r , t o r l 0 c0n, ; 1, i 0nl i r , t r r ' i r r 0
trrl l rrrri rtrr trrrvt' rt,xi nl i [ trj rrrl nrl tl r' $l rr(l tri r, ci 1, ol t,rt l ol ,i t,l i i ri rxl l ozi rttr,:r, r,rt
34t '
T
i t t l , r r r t r cl t i t t l ot r t r r bt i l l ( t r ot r r i i )
, si
r r i i r r Nl r t pt t t ' t i l l l l i ' , t l l l t r i , I t zi t l t t t t l t , t r t ' r t si l t t l t , f i i
r l r r l r sr r pl l , t nozot t co{i l l ul t t i l i t , sl [ ol i t t ci f i t t gl t t l l l t ' sot t t t r t t l t r l l ( i i , '
( ' ' r l r l l l / i ' ,
i l , i l i
Irr,{i rr 1rr l ,rrIbul ri t' i l o l rrl r{i al r
dc cot16ti i crL{,i i .
Arl rsl ; pundr do votl cro nu trste col octr dtxl attrctl 1,ul l rur' i l t i l o sl ts-l )l (tl -
l i orrrl o si rrt l ul l l ul ri l i t1o conql ,i i n!:i
I
osi ,o a' dovai ' rat ci t i tt utrttl tr <l i tztl t' i
(ri ol n rr()l oni ri r) cxi sti r,6i o cornpontl nti ' rni ni rni i do tul burl ,trl tl tl cott;i ' i cl t{,i i ,,
Irrrr' |,i ci 1ri r,r' ul ,
rn:r,j ol i r, fi i ntl i nsi , tul burarca de conry1;i i nl rri ,
Arrrsto sintlroarnc sint foarte elocvente in lcziunilc traurnatioe cr'ruii(l
(|r(' ol i rl i cc gri rvc or,rc sc Iemi t. Ci nd bol navul i esc di n comL, l ezi uui l c si l tl ,
irr cnrislirrele cerebrale pinii in regiunea mezotlienccf alici''
I )u,<fr, loziunea din intreg creierul este pini, ileasupra capi,tului rostral
rrl Llrrnchiului corobral per;iapetluctal duce la instalarea unui muti$ur
l ki rrrrti c sau h, si ndromul de d.ezaterentarc.
I)l,cii leziunca r5,nline cantonati, in emisferele cerebrs,Ie pini l:r zona
rrrczorIi enccfal i oS, apare,,staroa
yegetati v5,".
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
o rl'ru'e tle agitalie, cu iusomnie, confuzie agitat5, sau anxioasS,r pdn fa,ptu I
lri, iul,rca,ga activitate rdmine sub controlul nucleilor bazali
Di
al trunchiultti
,l ol ol l ral ,
;\dcseori, in diferite afecliuni, procese infeclioase' procese itrlocuitoaro
rlo spu,fiu, traumatisme cranio-cerebrale etc., leziunile inte,reseazd, toal,tJ
cclr t,roi ctaje ale encefalului - cortex, nuclei bazali, tr"unchi cerebral -
1ap{; rarrr du"ce la realizarea unor sindro'ame combina,tA
lsiniiromui
apalic),
l)rrcori, intr-un sindrom pot fi implicate tliferite etaje separat
(hiperkinezio
r,r r Iogorcc, rigiditate decerebrati,).
I),r1,orii,i, legii biologice, structurile anatomice cit qi funcliile cerebralo
loh rrrir,i noi sii-t lezato p{i}Aqle
Si
cel mai uqor (cortoxul qi vorbirea); lrr
,,rrz rkr t'cYcnire (tlc la trunchi spre cortex) ele iqi revin ultimele, persistin(l
irrcii, rrrr 1,imp dupf revenirea integralS a celorlalte funclii (surdomutitattl'
ri rrl l ornul vogel ati v prefrontal ti escri s ti e Tti nni s).
Iti Nl i i trr r][r,i i os aceste si ndroatne
Sindrotmclc generate de lcziuni Ia iliverso niveluri ale creierului
/1. l ,czi [ni si tuats i n partea supc-
ri{)r,r'ir, a trunchiului cerebral
l l . l /{!z.i uni si Ltl a' hc i n nucl ci i bazal i
t1.
lfutismul akinetic
'12.
Sindromul de dczafectare
[3.
Starea
yegetativi persistent?t
lIJ.l. SINDIIOAMII
I)A1' I{ I)I' I,,IIZII]NII.,TI DIN PARTIJA SUPIIRIOAITT
A TIIUNCIIIULU
CEREBRAL
f#fjd
js?i','"',g;l#,i,|Uq*'ih"""?,1,,:'^1';"""Jiotuilarr'icu',r'rii"
;llil"';#l?'"1""J"?Iit:#;,t*$it*f":ihrl'tffi
it$li;
+j+1:;-*e*aH##tH*.;q",XT r,',',flt
Jl,iiij
ill"{*l"
g:*#ri"*i}!"'','ffi:ffi;iq'*w:lii,
It'"t'T"'*vniyll:l1lt*tirtlxktti+"#h,$#,{i$if'jirl.;iri:l;
llH*l"{ifl
yil,}*:_Tf*}:rd:F:diiFirmliir#:r*r,r1.""":uii
iffst$i
:ffi:*i"",Tffi
iJ"tii*#l'?*1",1?J**T]]H',1n","'*1J,1'1;,,i1,'l,l
Ilutismul
akinetic se cr
ff H:lli;;ffi*#'1#x"""t"ff
ri?"J l'"*"-ii:{{J:t:*i13ft';';;133
;';
ii 1 ;,;'
i;"!l"q.'":t.rH*idih*r,"r'*l'Xil
f;-
i',f i*{i;"##"";;r;;:f#1,"jt#*fitl*i:,":j:t"tTttr}i:liliii
t3l;llJ#d"f#rr:f
:d{i{Fii}-lilih'tii-i""""";;J'::*:nl,lt
lttliH"txt'.'ji.T#iiil",iljtril?i:'.*,?
'iJill;iif!it?,1!![i:l'i"llJill:
rr"ffi+e$*t}"m;at{[1,'ft
firi'{ft
f *;1
f*{ilfr;;grig+;:;;f4';:{'fl
};;if iiji'}:b'dr'"arii.i#i]1,ir,';i,ril
-t1ff
H,:t{il:#if,iir**irH"Jid,rhit'd;{"5rnqt:ll,,ffi
,l iri"l*ioiii*
i r1 lr Lr{11*r[t'iil1i1,fl1'trd].,'Till,,,1jJil
ili'.liillll,ll,lll:l'llliii:tl,,"ii,,ll,f,:l,i;llllli,ll
i;liik,w:ilii:li;$*li*llTli;
t ).
tt.
l r r r zi t t t l i r l i l t t r 0
Ni t t r l t oa, r r r r r r l t l , o r l o I ozi t r r r r
i tt t' l l ri i l l ,o cl ,l r,.i o.
J
l . l i i gi r l i l , r r , l , r r r r ,
r l r r r r r , r r r
[ r l u, l , i r ,
l f .
I l i l xr l ki r l t zi c
ol I r got r r r r
{1. Lozi urri si l ,ui r1,o i n col tex
dup5, leziuni cerebrale
Sindromul dienccfalic
Sindrornul Korsakorv
Sindromul Kliiver-J3ucy
R,igiditatm clc decorticalc
Surdo rutita,tca
Siridrorrrul vcgctativ prcfnrrrl tl
(Tatnnis)
A1;ita!ir
Ar r rttozin
l)o$1,1,t'lulrrtl,i(rir
Sintlror rttr l rt,prr,lio
I i
t ; :
t ;
lf:
: t 4
( l
. ) 1,
F
r j i r r l l l l i Hl l r l l l
l t ol ,
( l r r f i l ' i l l l l ) t ' ( l si l r
( l ( r
i l l ( x) l l i j l i {r l 11i l ' si l ' l l i l ( r
( l ( 1l l r ( r l r ( ' i ' ,
r kr ; t i l xr l r r r t ' vi i
i i r r l , pct l r t l ' ' cr t t t i l l , i ot t f i . I ' i r r r l t r i t r r or t , sl l l ' , i r r t t t i l i l ' ; i r kr a' l l i i ( Or t , i t r r s qi t r ol .
l l ) . 1 l ; l l l {i ! ; Skr r 1l , 01, y, 1f }( i s; $dn) i ' i , i i i
( r ) 1. . l l ) ( i 5 I f r l yat t r l - l l t t t r r t , T, t l
I
l i i ssi rl l ..i rrol ., l 1)(i {)) (,sl o
ci t oxi sl i t, vi t,ri r[1,i i do l i t, thi txrzi rt i r(l ov i t,r' i r l ,i r, (cl ri i rr
1r:rl rrl i zi c
i tr sottsul or(l i rl r,r al otrvi nl i ul ui )
;i
rmrti sn (sart tl oi l t l ,Ioni tr) IItri
i r Lrrl brrl anr ol al i l tl e corr;l i i nl i i , (sau doar u$oa' r' i i , hi pol sol nni o si tu obnLbi -
lrr rr,) pi rri, la, o sirnpli'l apatie generalizati, cu reactivitat'c bun:i h exoita,lrl i.
{ l (i l rx;l i ri l c
rroa,sl rfa i l n mai ari -rtat c5,, de cei c mai mul to ori , dupai , o 1u i r,
l rrl rr,l rrl ' qi I{cmpcr qi l i omanul (196?), XIA (i n fol ma cl asi ci rl escl i si l , rl tr
t lr,ilrrs si trol. t.i+t) rcprezintil un sindrom tle ocluzic a al'terei bazilare in
por ( i r t t t i r sa r ni j l oci l . sl , u
j oasi . l a car e unoor i se pot asoci z' t ul bur i l i r t "
i ,orr1i i i n1,L (pri n" l ezi unea i al oi ,ei ponti ne qi / sau
.mezencefb,l i ce,
ati ngi nrl
s RA A) .
Sindrornul de dezelerenlare
(sindromul'oloked'in")
Af octarea ci,ilor cortico-spinale
qi cortico-bulbare printr-un mmolis-
rrtorl; 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. Ta-
hlrrrl 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
rrt iorL{,a,1,i tsmporo-spatial,
putind face calculor a$a cum a ar5,tat-o
(]onouni'
,.,,1,,,1 ,
j11
"i
irin
iiteim;diul cotlirii miqclrilor ]or oeulare.
Sttrea vcgclalivd persistentl dupi leziuni eercbmle. Jannett (1972)
rlcsrrlit: sindroinul tle ftaro vegetativX, persistent5 in motlul urm5,tor :
I)upii o perioadS, tle comi profuldS' de" reguli, cu-ItaJiate grade do
Ii,spunsirri eftensoare (rigitlitate prin decerebrare sau prin decortlcare)r.cu
o rlrrratii do o snptimini, sau mai mult' supravieluitorii i!-cep. s5, deschidit
ochii la, inceptt
-numai
ca o reaclie la stirnuli rlureroqi. Ulterior bolnavu I
rrrorrl,ine
periodic ochii deschisi, chiar in absenla oricirui stimul qi pa,re a
rrlrrr:'ili ci privirea, dar firX:r, fi atent, apoi recade intr-un somn apalen-1'.
\rr poi r,l c i i i nsrl r:orbr de un real ri l ,m l cghe - somn. fn peri oadcl e drr
: L| | i | t I I r I i ' L st l t e r l e t cghe nu exi sl i l dspuns
de apdt ar e pt i n ocl uzi e pal pc-
l r i r r Li l : L: r nr cui t r t al c. i n unel e cazur i i : . i ; , 1d mi l cdl ' i sponl ane al c gl obi l ol '
ol rrl rr,ri , tl i nd i mpre$a ce bol ni vul urrni re$ro cu pri vj rea un obi ecl c:rt tt
sr, ,1,'pllscrt'zr-r' in-cirnpul si,u vizual, dar nu se poate afirma cA este vorb{[
, 1, . r ' i i r r r r r : l t l u al eul i e. I n al l e ci r zur i a1l ar chi ar l nj [ cEr i cer t
- coor al onah! t
. r r l r . csr , r r r t r l u de sci l pi bt l e sau de adueet u a mi i ni i spr e l ocul de oxci bat t t
rr,,r' i ,rr.1rl i vi i . Cx toate ci , cxci tarea noci cepti vS, poate dtermi na fi e
Yi $cAri
rlr,, n r r r,il,i<lr,{,ic fic 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
i rri rnni l l ,i v. J)i n punct dd vedere l egetat' i v, funcl i i te si nt conserYate, du' r
sl i rrrrrl i i noci cepLi vi puterni oi pot i nducc rcacl ,i i vogotati ve auortnal o-, l tt
rpoci rrl t' cspi l afrrri i . Strl rca vogetzl l i vf potrl ,c pol ' si si 2r,l i m1l l oarl j e i ncl cl utt"
g1,1,
6i ,
ovr' ,i rtuu,l , so po&l ,o
1l curr2utdrti za
a,l i l , l ,i rnp tl i t; bol navrtl stl pl ' 2l \' i ol rt'
r{rft,r),
' l ' t ' r t , socl o
I , ) l i ( i a, r r t t l i [ l , i L1' , i t l t ' l t r - t t r i l t t t ' t l l xl i t t sr '
1i
gt : t , vt r l t r zi t t l t i I t t t t l
t ot l ' i ct l o, t t l l 1, l ' i l sol l
1- r l l 11,
sl r , t i i z. r , l r , cl , t i r ' , l i r t r p t l t r t t t l t i t r t t t l l t r si r l r i i i t r r i t t i
(t4l r
( l t ' i r r ' Lr 1. 1r . , 1. . l l t i l ) . l r r I i r , z. i l r ' r l i l r r , r l . . i ( l ' I i i ,
r l t i r r r r r l l . si Pl i i r r r r r r i
r i t t t t . l t t t r i I i r , l r r r l r I r vi i c sr r ; ) I r t vi o( , r r i r . o
, ,
r ' r , g r , I , r r , l i r l ' i
t t
l , r ' i t sor , Lr
l r r r l
r r , r , i i i l r r t r r r l 0
I t r t t l t : st t pl i nr r l l l r , l r sl r , r r r , l r i l r r r r r r l i l r r r : r l l l r , r r r r r r r I I r I i I i I
.
i I I r i I r r i r r sr i , l i r sl i r r r r r l i i
t i zr l r , l i , a, r r r l i l i vi si l r r nooi ccl l l , r vr ,
.
' l opogr ' : r , t i a
1i
i nl i nr kt r i t r r , Lt zi r r ni l ol nu l l r r pr r l r r l , l i cr r r r r r l i {r r r l i r r csi r r l r i l i l l
r l t r ol : l t i vel o put i no l a, zur i st l di al , c. Au hi si , r l t , st r l i sc cl t ar r r i cu r r r l i r r r o
I.zi ttIri neocol ti cal e. So ci l ea,zi i cazuri crr l ozi rrri i t,rt..nsi t' i r srrl r..r.i i .i rl r,,
rl l rr
cu crul at' oa structuri l or. trunchi ul ui cetr:l tl l l si i nr,crs rrr l r,:ri nrri
rl c l runchi sau cu r:xti nse zone i sr.hcrrti ce tut i i i ,Li l e s;r,u srrl xurr,l ,i t.rr,l r,.
13.2. SINDROAME DATE DE LEZIUNI IN NUCLEII BAZALI
Sindromul diencefalic
Se earacterizeazX prin tulburS,r'i rle constiintf cle intensit:r,l,o r.:rlirrl,ji,
ci .n' e consl ,au i ntr-o sta,re de apai ,i e, l ol poare, obnubi l aro, soIIl l (t
(,1{i ' i ,
' i l I poi r r e- Rcspi r r ( i a e\ t e de
! i p
Cheyne- st bkes cau t ' espi r r l i r , . r r I i t r r r . *, , r i
I r1' ttrgul at,", rnl l erul l t uncorr de pauze scurte, pupi l e
mi ci , rtri l r,ti vrr l l l , l U
r nrr;.l el l exul
ci l i o-spj ntl este conservat, mi qci ,ri l e refl exe rl o gl 0l ri l oI
{r' ural r l n pl an orl zontal sl nt con$ervate, i nsi , uneori rnoti l i tate r,r:l l trri i
r xrular5 rrerticall este.IimitatS sau abo]it;, (comprimarea rcgiulii
l)t.ol,(r,
fale)
;
existS, reflex
oculocefalogir (in lezidnile'de ironticrtii rIitrrr|r,IrrIo
r r rczen cefal i ci ), deri ere ronj ugatd, a capul ui qi ochi l or, ten0rnt,l rrrI rl rr
, . r . nr dc pr pu$i , ' . r i nool i der i t , r e I ent i
t i
por si st ent i
a
gl ol r i l r r l r x, ul : r l r .
So noteazi, semne de suferinta, pir*midal5
ditatcrali, (I3::r,blnslti hilrr,l('r.rr,l
).
Ibt fi evidenliate o rci,istenjii,
^muscularii,
tle l,ip paiitor,fu
.\i
rrrr r,,ll,Ji
, 1, . f t pucar e f or t at A. ; i D abscnl a unui det i ci t r nol oi r i . eqt c l nor l i i i {, r i I i p, r t I i
l,ihter:!le. Pot erista diskinezii. Tulburi,rile vegetative sint abscrrtr,.
._
Sttpoar_ea. **" *oilnoi&1" reprezinti, u p,ig_rdere
.par(,iall
a t,ir$l,l rl
si t' i l or l a sol i ci l ,5ri l e medi ul ui i nconj uri l or, i i i starea
-tl e
col t$l i i trl i i r)Hl rt
rrtectati , r.r
a,i rnul t sau mai pul i n.
precurn
d,rati i , denumj l i l e i u;_ri rr,rrt,i o
ri rte. paci entul prezi nti o stare de somnol enl i , mai mat,e sa,u rnti rrri r.i r,
el r r l r
' . ) i c
al n sau . . hl at , .
uncor i . cpont an
( dupn gl , a( l ul sl r r l r r l j i ) r r . l | r .
z' r l ' . l ur be: l o,
( l A
r i i spul r sur i ader . r at . compl "i e, l ncor npl , . t r i di nl t i ur l i \ r . ,
(,,,r' e
ce a}e ne\-orc, mi l l ]rnci , si ngur sau rl acd, i se di , sL rni i rri rr<:o
I
rl r.rrrrr
l | r ' r r oi l .
l oul e
t l r ' sr . l r i dc ochi i , st r ( ear a
Si . $i f a( , i ncccsi l i {i l e, r r r r r . r r I i r r r i ; r . : r ,
r . r r l l ( . Sponl r n. cbt r r pot t e ur ubl a; [ ul cqi i l e vi [ l t , l c r j l t Lr l r r r r , . Sr . r , l r t l r , . t , .
rizprtzi, printr-o. mai iltensi,
cr.g;t-glq a plairurilor
slzoriale, cilrt arrr rlrr,pl
r|rrrrt: o recepl ,i e i nti l zi ai ,i , qi i nadecYatd,
o l entoal ,e
si o tl l fi <:trl 1,|l t rr rl r,s
i i . - t t r i r i i
1r r or . . esal ot
t soci at i r e, Bol nr r ul c. t r . l pl l i r , r , i i t r r r t r r l r . r , r r i r r l i r zr cl r .
l : r i t r l r r , bi r i . pr ' i n r r i . punsur i vagi . apl uxi r nr i i r , , , i r r oi r r pl , . t r .
1i ,
r l r , , , , , 1r .
r,rrai rnul te ori , l i psi te de sens.
-l l tpori
(,s1e
,\ornn;l eut, tl r' zuri rrni l l ,;i corr
Itz,. Evocaro:, ar' nczi (i i so efc(.tucazi r, rl i i i ,.i l , rr' t,rrri l i i rrrl i rtrl rri si l ri l ri .
l l r ' l r r r r , vnl cst c. . l I ; r 11i 1t si h i u
; i . l ni t di ki net i c,
sc or . i i r r r l , cl , zL i l i f i oi l si i r r r , ' r r r
1r I r , | ,
t r {l }t ( i l l . i . l i ' r i i r r l i r ' r r r r r I i i
' r r l i
si i r t r . s: r . l c r l r . sI r . r ,
l r ' , l r ' i t r
*r
P, . r , . , , r : r r r i .
l , r t i nt , i l a, {, i i r r r i t i l c; x, l r r l i r
! i
l l l t i i r l r , l r f i r . , l r ol r l r vr r l
i r , r , r l i . t r r i . zcr r l a, r i ur i r r r l l l l r
l , r ' ( \ r i zi .
r i i t ' i i r l i I : r ' | r ' . I l . l h' r r t l r l r . r . l i l r i t l : r r r r r Lr . r r i i r {*r , . si r ' , r l l oxr t l . o| r r . i r r r
; r i t t l
l t t cz, r ' t t t r , .
l i r l r r r r vr r j l r r
l r r r i r , l r r
I r I i r r I r r r r | , I r ,
,
i l l l r , l i t r , l , i , r , l l I r r r r r : ( i or r r , i r , zi i ,
r l r , . . r t bi r r r r i t t ot t r t r r , l , l . l l u; Jgat i ) ; t r \ sl s r r l l r i yt r , l sl r l i , ( 11 ( , ogl i r ,
Vi gi l r \ , l l r , r r r r . r r
r r l i l i z: l l , t l . i l r t i r r r . i i I ' r , r r r r r . r , zi . l ) r r , r , t r , pl r . i t , t r l r r l
' l t
\ , r l , l r , l r \
4i
t r r r
' i l l Dr t r r r l r ,
l t r ,
,{il
it4rl
l , \ l l i I ' i l I i i l ( l l l , l . l : . j , i I l ( x) l l t l i t l t l qt . l l t I t t l l , i l t l ' r I l t r . i i t ' i i l l l r t t t t l l t t t . i I r . l i t t I i t t r . r r r . l ' r , t r | 1. '
, . 1r . r t r l . t
( l . . 1: r 11' r "' l l i l l zi \ . ' . si t l t l
( l ' si l l | r t r l l l . .
'
l l t t t t i i {r l l t l t t l
t l t l sr t nt t t r l l et t l l - l ; l t t l r r r l r ' l l l r '
r ' r l r ' l r l ' r l l l l l l l l l i
gr l l ( l i r :
Jr i i t i , , , l , ' , ' r l r ' {l : r ' l r r l l , *t , i t ' ' r t
' i ' l
l l r t t r zi " ' : r t t
: t r I . t I r t ' t I r '
s. r r r r r ' l "r r l : i '
, , 1, r r , , f , i i , i ' : , . , r , i , , 1, , ' i p, , , ' t r ' . ,
, sl c t l at i r , t 1c t r oi t r t cr osl t r cl
pl r r ' l i r r Ji i r r ' t r l f ( 11( ' i l 1r r
l , r r , z, r t l i : sot r t t t t t l l l r r l , r t i ' "1, c t not Lcr ' : r ' t i l ,
r ) i scot r l i l r t t i ,
Pr r ' ( i "l t 1r l
( l N( l o i l I
( r : i ' ( l i l r
,,i i ' ,,i i i , ,,i rr,l qi
{ra' ti cl pi r,
pul i n l a oxci i at,i i l u
tl i tr tt.rcrl i ttl i tto.ttj ul i tl ut.
St : r r . r . : r r l | t t , , r . ; r Oni , . i , .
Fol l l ( .
dCf i ni
r ' : ' , i t t l ol r i dt Zol i | Ji l i i r o I cnt l t t ' r or 1t : t
i i , , i , i . , . , , , . i , , r i "
", r
t , ' : r , , t i l i i , ' , ' 2i , . si
r ' . r sr i r l . r r ' r r ' l . nust t l l l i uf . r ' l i ' r , , l i i . i ut . r r ' l
i i ' ,i i i i i rl *l i ri ,"l t,.i " sc,[t6.c:l i l i fi l r,ti rl i , i r' l i l tl ctti i ri
;i
rupti of. Stal cr tl tr
i ,f,i ,i l i " ,r"*i n i ntro craqi erri :t, prrl gul i l ur srnzorj i rl e oLr r) di rri nuai c i r'
rr,rsi l ri l i t,i r,l i l ol rl c l eccDtri e
(care s6 rdal i zeazi i l u oarecare
groutabe
' l i .ctr
i,,i,,"i' ri.' I,rr Aiiitotiiii tn*rti"t in"' preculn
;i
cu dirnintarcr stplelei
;i
r.r'
.'""''.1'i;1;ll.ilj;'hi
!i'trLl lr oste o somnolerrti' ,''ai a":'certrltit'i,' bolnav'l
, r , ' , , , i l i n, , l r , i t u1. =i , r "t "5t n l r st i Lnul i '
r ' or br ' . i + t t uci ) r i r r {' cl ' u'
( ' cLl Li n( 1}r i
i r . r r r r r r r , . voi c; l , ' zi t t t r i l p si ni l r i l al er al c
j n
nuol cl t Uazl l t '
. st ' i i r u, i t nn . t "
gi : ; uO, , t I TI ( obnubi l al ct csl c r ) nonr nnl {' nl i . pl ot ur t di '
: r r r r r r : i , r r r . ' t : onl i n' l i I
paci eot r t l Jbi a r i sf undc l 2 1 1ni l a1 i i
f i
r nl l ebur l ' l : l l eor l
. , i , i l "i . . t . r i
"; ; ; ; i - , r ;
l t ' z! t t ncr e' l i e i n nt t cl ci i br zr l i 1i
i r t bi pot al r mut
; , ' , ; , i ; i ' l ' ; c. l ; r ; ; r ' c"t l r l ui cr ci cr "ul ui ; t | i r n' bi r r l ct r "l r r r l csi e i t t dt t t t '
Strtloarea sc intilneqte in' im,umatismelc crl'trio -oel cblale glave'-.iin
r',
"
t"ii,r
'"ot"'J"
,ne.ri.*r& fi"tix
irr comil) sau in foruele {rarc se al11elio-
; : , ; ;
i , i ", l i n. . , i i o
"o, n; 1.
i n cn ' e[ : r l i t ' . ' i
pr o' es": \ P: r nsi ' ' r t ' i n' t r '
t : ' ni r : ne
, r "", , , , t . i J i o. t l i r *t "
: ) i i i n col e cc cumr vi r ni i nr l i r c( ' t di oncef r l r t l '
I'rosnosticul este ill fimctic tlc e|olu{ic : daci sc amoiiorc:lzi,' prog-
'',',tr'i,,iti-,r*i"'t
.i" I dacii sttpoirel se tgral-cll'z[
;i
trcte in comil' prognos-
I i ( , r l l {. l t c er ' 3\ .
' ''(i;;fJ*".,=1c
o .'frrc psihicir, clati dc o leziune a cmisfclc'lor corcbralc
',, ,,;iil;;;;;t;; parrtial[,
ii
insularit, n diencefalului; {rLnctiile ri'i;a'lc sint
I ' r ur ( ' . t ) t t r i onl r r l t , uar "
"h' l t "i i , r Li t "
i "si i r ' ' l r t - i l c
' oel Pr r l
( ' r
' e
t i co. cl r i
, , , , f : u' - . i ' , f i
' i "pi t o. ur i
i nnLl c' v: l . l '
;
uueql i
ost t r ' hi r l pr r l i u t i cl i ni ' {i l '
: 1. , {i l , l , 1t .
Itol vci n i ncl utl e torpozrrea' stl l l J{rl rr' ' t
-]i
obl u]ri hre:r i [tr-ur] si ngnr
r^r' ,",,u' ,
,,i o""!ol ai e
a ci nryti i nl ef"' (,,1' l oucl i i rg
of r' ol scci ousuess" )'
Si ndrornul Korsakol "
| ' ; \ | | . 1| onI i | ' ' I er . i i ni r ' . "- l al oI ogi . . i bi ncr I of i ni t : r . l ' cz' ' ] . ' ' r ' l di n: r q, . ! {' i ot c}
,1,, ,ririiiL..tffiii neurologice'dc tii polinerritic cu manitostilri
psihicc' in
clr'r tltttrtitlit, &mnezia antcrogradJ,
confabulalin'
"'i
dt'zorientarca'
lJrrrl iul lcziunilor dominantc este mezencefalo-dicncetaUc'
lrr cliolottic, factoml dominant esto toxioo-metabolict
iu: marea
, , , , ul , , l l i r , , t "' , ' r ' - 7"r . Lr r j l or ' Al t . t ' onr l i t , i i
ot i nl ogi co st t r vi t r , i nt t
o r r t i ut r l i l l t t :
i i ,, l ,i i l ,,ri ri rt"i -tl ,r ri aturi , turno' al ;i
(tt*roL i tl e uutJei brz2r1i , rnetastazc'
t.r l,,,r,rrikra,rno),
infectrioasil,, l'asculatit' slu t'r'atn af ic;"
si t t t l r t r t t t t t l Kl i i l cr - l Nt t t ' r
Si r r r l l 0r r r r r l l i l i i \ / ( ' f i l u( ' ) . l t 1}r t , , t t r t l , i : r l r l : r l i i s. ur l l t ' ' zi Ll t t i t l i r i {nt t t ' i r t r
I r i I l t , 1
'
r ' t r t I t
r
r
l t ' t t t l t l t I ' l l l t l , 1i l i t r cr r ' ' t i l l r I i r
r ' ( gi l r t sr t l l t i 1' r x' r r t r r l ' t t
'
l t l l ( l l i l ' {' oi l r l l l
l r t i Ar t r t r t r i t r , r r t i r t l i l cr t t l l r ' t r r i gt l l l l i l l r t ) ;
i l \ r ( {l t
( }
1
r t
'
l l t t t l r l t l r ' : r
'
: t l i i l i i t l r ' cot t -
:lti0
sl i i t r l i r , r ' t r (
\ r r , i t \ r ' l l r r l r r r i . , . or . r l , , l r r r r l r r r l t r . r r r . zr r ; l r l r r l l r , r l l t r , I r I i r r i , , r . or i t r ,
ol r i l r ' l r l i r r l l r r l ) r t l \ r zr r r l , , , i , r r l , , r , r r . r r : r l . r
; r r ' r ' l
r l l r r t r r l r . r ' oI r r 1r oI . I I r r r I r ' I r | ,
, ' t r r o( i r t t t i t I | r l i t l r , r ' , , r r r 1r or l i l r r ' l l r r ' \ u: t l
l : t . ; i . si t f r i l ) t i oAi \ '
, t
l l \ ' l ' t , t I r t i l , l i zt UNt
( j (
) t t ' i , l ( t A l , t , l
l l i gi di tal l t pri n docorl i carc
Eindrornll r'1c rlecorl,icare ale u}tuitoalele ea,r.l:ld,t'r'is1ir.i :
-- r' i gi {l i tate i n el terrsi e :,r c:}pi l l ui
l i
trnncl l i ul ui , i l e
j ti l ,rrrrsi l rrl rr
rrro-
(
l r ' t ' l l i l
;
postrrX, a, membrel or tuperi oare cu contraetul i i i n fl e_ri rrrrr :r i rr
l rrl or srinentelol cu pt'cdominanlii a celor dista,le
;
-
Iostul i
a, rnembrel or i nfe.l i oaye cu conl racturi , i n cxl orrsi r,, r' ol :r,l i ,,,
irrl elnii gi l1cxie planta,t:i.
, .
fi ,rotnencl e. de ri gi tl i tl te si nt rrrai p[!i n sau tl el oc i nl ]uorrt;rl l ! rl 0
l [ | | r l Jt noch, - pl j r i
qau
r l e a] t 1i , 1.
- rellexul llagnus-rle l{leijn poate fi pns in e.r'irlerr
{r'r I
- semne de piramidalitate bilatemli,.
- alterarea accentuat5 a stfrii de conqtiinti, dar nu r:onli |rrrrr rLr,
rrrl i l nesl e i n ri gi cl i tatea pri n dccttebt *re,
;i
:r,soci al i i , cu pcrt,ul bi i l i vr.ri l
l l |i ve ma.i pul i n ampl e sau i n unel e cazuri chi ar absenl e .
Snrdomulilatea
-
nfai . pul i n
_{recl ent
i ni ,i l ni ti , dup[ tl aumal ,i sme grtl ve, rti r,r,
l r)j r
l r\
rrpi rrrca,-chi ar qi dup:i .cel e u$oarre: bol na,Tul qi -a rcveni t i ornl i l t,i , rl rr,i ,r,r,,,
1r,r' ri sl i "
o i tl uti tnte ti mp de 1-2 sl pti ,mi ni , fXfX, al te si rrrpLonrr,rrrrul o
I' gi cp_p:rn
tai 61.c.
A{-c|LSl i i rnani festarc este cl ator.i ti procesri hti rl rr i rrl ri l ri l i .
s t Lpralimintrrii a zorLelor celor r:rai noi apifltte pe scari, onl,o- gi filogr.rr rrl irir r.,
t ouforl n l egi l or bi otrogi ce care au demonstrat ci , structuri to :r,rrri orrri r,i , ,r
I t t nc{i i l e l or r evi n cu ai i t mai t ar di l ' , cu ci t si nt de : r chi zi 1i , , ; r r r i r r , , . , . r r l r r
-rinrlromul
vegetativ profrontal (Tiinnis)
.
ln partca supclioari, a ariei premotorii existri, o zolir \,
(,11.( 1t i I I r \ : r r u
trtl de a, l egl a teasi unea ar1,t,r.i ul l -u
;i
pul sul .
Si ndl onrrl i rr)l l t,i r ur trr,z:r rtrl
r r , . t . r . l r i l j l o: r bcl r t , r r r l ui , l upR di f cr ' i i cpnc, . i ul i l o , i
r r ui : , l i . s l t . i nj t r : l , t r . r r l
, r ' r l l r , ) r ol el t l ul c: pt ci r . t r l , ul
Ost e t o] npl ct r t r st abj l i t nor r ul kl gi 0
1i
pr r i l r r r ,
{l l r
})ersi sti . ui }c1t: tnl l turS.ri cardi o-vascul al o. l -,a,ci cntul I:rr,c ri l ri ;rrrl .i *i rrrr,,
r ' 1r r r i a, l t i , si o t al i i ca, r di e at ur r ci t i ' i [ i si sr . ] i r r r Li ,
l ozi f i i r
r l i r r i l r r , , r r l r i i r r r
( ) 1
1{) s1. : r l i sl n. , l ( i est o t ul b l l i . l i si r r l r . Li i l r ' l r r i r l r . r l r i r i r r t r r l c
l ) t . ol i r r , r l
r . r r r
r i r r bi l i r cl ( i ol l l l t , l cs( . ( ' l t
l
( ] i .
l Ui l
l i r r
\ gi 1l r , ( , i l l r r i r r r ; r l r r r l i r i or . l : l i i i , r , r r r r r : r r r i l i . sl l i l i l r j l t . r , t i l . r , r , r i l r r
Hot r r , r , l r l i r
r l r r r r l r zi t t t r r l r l r l r t r . l . r ,
,
r r I
'
I r
,
r r r I r t r r r , t r . l r r ' : i , l .
; i l ' I
I
A rnnozi i kr posttrnutnl l ,i rttl
(j otrsf
i l ;tti c urtttl tl i nl ,rc oel o rnai cornuno fcnornone al c ctcol tl or tti tu-
rrl rl i ctr rurrr' l rri l l e - i l ti t l t:cento ci t si tardi ve --- i ndi fotcnt de i nl ,onsi tl tci t
I r' ;r,rt rnl l l ,i srntt 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
rkrl l i 0i l ul amnezi c.
I)ulatja amn0zici
}osttraumatice
este in diroct raport cu graYitatca
Irrziunilor traumatice cerebrale .:i exist[' o relatie directii intre durata
ru,rrurczici posl,iraumatice',ql virsta bolnalrului traumatizat.
,\prrocierea amnoziilor posttraumatice nu se
1loate.
face {leriit rotros-
lxxrtiv,
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,v ils,tea, I6ziunilor core.br&ler nici 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.
I)o regul5, AIl, cste tle foa,rte scrrrti' ahratil (tle ciieva
-secunale,
citeva
rrLi rrrLi ,c, mai l ar dc ci teva ore). l )urata AR este i n pri rnul ri ni l i n l aport
r:rr u,ruploatea
ii
ou grayitatea leziunilor serebraltl traumatice.
llxistii, cazuri ile AR <le foarte lungi durati, - citeva' luni sau chiar
ci {,i l u, i r,rri . In aoeste cazuri si nt i mpl i cate pert[rbl ri gral -e qi i ezi uni i nti nse
i r sl ,r' uctul i l o ri nencefal i ce (Russel l ' 1976).
1 3.4. SINDROAIIF] DATE DE I,8ZIUNI.:.DIFUZ!]
Sirrrlromul apalic
Hinrlrornul clinic poate cxista in forma complet5, sau ir, forme parli*le,
i rcornpkrtc, ctrnosoute sub denmi roa de si ntl roams,rdi spal i ce".
Sindromul complet, in perioada de stare, ere urmltoarele compo-
norrto ((l crBtonbri l ndt, 190?
)
:
rr') r\ltiora,roa sttrnii de ritttrqtiini';i, estc intt'-o oaroo:lle milstlril asemi-
rri i ,l ,ol r,i rr ctt crl a tl i n mtrti srnul zr,ki l eti c. JJohl l vLtl rnott{,i tre oohi i deschi tsi ,
rl l r l ru rrnntr,rc6to ott pti vi rel , rtu ,r,to rcfl (rxl l l do cl i pi rc l tr u,m(rl i nhrot
rrrr rut roJl o-r pl l ,l poht' r,i . Ntt ntr ttbsorvi i ' tti tti o l rra,c{;i o cnl o{i onl l l i l tl i forrtrt-
(' i rr,l 11, oi rrrtrrtu,i tttrt' l o
Ptl utt{l ttotttoi i on
n,l or rri l to si nt, ttttsl xrci fi rrtr, {l o l l tl l ' l l ri l ,
JI' I'
vcgr r i l r I i vi i . Nt t l r i xl r i nr ' r r l l r l r r l r r l l t t , r ' ( i r r l r r r r r cr l i r r l i ur r l r i i ut l , , l r r r r r or l
I t cct ' r ' t t l , r ' r i sl i i o
; r l t l t t r l l r l r ,
r r , r ' r l r r r r r l r t r r . i or r r t r - vogi t r , , r , r r f , r , ur l t r pr , r i oi l r l r ,
t l t t t cgl t c ( l l
. l
ot r ' ) l r l l l l r r r r r r l r t r l r r r r gi
l r l t
i ol r r l c ( l ( !
sor nr , r l i l l l r r r l l r ol t r i t vr r l
l xl a
r l i l , t r r zi l pl i n r l i l r r r t l i r r or . i r ur 1r I , i r , i .
b) I l onomot t ol o
l ) oHl ur i l l ( ! ,
r . i r r r r cor r sl . aLl i r r
1t ozi 1i l ,
i r r Ucxi o l r r r r r r r r r I r . r ,
Ior' . :\col t,sl ,l t, so poakf l rr.r,orrl rrr l l r, scl ri tnbtl et, pl ,si r.l .' i , rl e
l ozi l ,i o
a t,rr.pl l rrr
ri i cste mai marcati i J,r rn(l l nbl rdo superi {)are. l ' r' ttl chi rrl csl {} i n uf ol l l ,i r,
extensi e. In ti mp apal a,rrki l ozc, ret,rac!,i i tendi noase
;i
t:hi rrl osi l i cl ri .
c) Fenomenele motolii prilnitivo stei ool,ipe-lurormakr.
!'onomene veEetative
Ilenomene oculo-motorii existi constant.
Si mptome pi ra' rni tl al e. O tetraparezi , spasti ci ),, i n rnorl rrorrsl l rrl ,.
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
Exi stl si ndroame neurol ogi ce care pot fi date de l ezi uni i rr to:r,l ,o cl ,u,i rrl rr
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 uorr r,orlr i
rurgicale, am <lbservat c5, in afala sindromului de mritism akinetic, siir.r.r.l
bol navi i or se poato marri festa si i n sens opus, i mbri ci nd. a,spcct,rrl rl rr l rr
goroo cu hi pel ki nezi e Eau o gamd de aspecte vari ate, i nterrnorl i arrr i rrl rrr
aceste extreme (logo1ee fhrd, 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-cl istructiv, ,1i rrrr rlt, l,ip
iritativ.
Considerfm cd, sindromul de logor'ee su hipcrkinezio esto un sin(lr(rrl
antagonist accluia de mutism akinetic. Ambele sindroalro il4)ilr
(.r,
r)
consecintrri a 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, lil irigolrrl
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,ril qi intcrnii, a lolnlrri t rrnrgror.rrl
$i
cortexul cerebral) marchr:azL cl,lea SRIA, a ciirei lcza,ro at plotht(ur u,ru.r1,
sindrom,
Simptouratologia., corcbr':r,lir, plozcnl,l1,L, ca,ro ostc ll,it tle d ivtrrxr\,, rrrr
poa,to fi
()xpl i (l l r,l ;i r,
dtxri t pl i n i rrl ti crl rui l l ozi ontl fl ooutxrrni l ,unl ,r' l
{i
i n pl tr-
j )orl ,i i v:l ,Ll ,hi l ) i r,
q.l ol
rl 0rrL Ni sl ,r!rno r(i ,i (j l l l l l i r(! i l ,r{(,{r
(l o
l {! :r,r11:rg()trl Hl ,rr
i nhi bi tor t1i u,(11,i v 1,r,r' ,
l n <:,t,l t, ,,t,
Pri vrr6l ,r
l totr ti l t i 1x,t' l < i trozi rr, rl o i r,l rrr,i l ri i
ul ,r' 1r
orr l ezi utrt*r,,
$- i l l '
l ) l t l , r t b
( , xl ) l i ( , r !
l ) r i f l
r r r I r r r i I r r l r , r r , t r r r r r i l r r zi t t r t i i l xl xl ur r r r r l Ui t r r l i ct t l t r r i nhi
l l i l , ( l l r r l l l l ( l l ' l l ht i r , r r r l l r r l l pr i l l l r l r r nr , l , r ' i l r , r i
l r l i l
( 1| r r nl r l r '
I r ' r , Fi r r r r o
I r , r r r 1r or . : r | ,
JUJ
?
r l l ur f
( xl l r l ) r ' i nl i r
l , t ' t t t r cl t i ul ot r r r l r t i l l r I r r , 1t dol t t r l i t
l i i
pl i n
l r oz( r l l l , i l ,
gr t spi t t g-
r r . l ' l r r r r r l u i t l t t Dr r r t t r : t i nsi l t l t t r : t l i i .
i rr cuncl u)i c, tabl l oul urrui bol nav cu l ogorec
ryi
hi pcrl <i nezi .o ci i ttr
rrlrr riitorul : pacicntul prezinti, o dolinfi sau un irnpuls irezistibil
;i
aproalxr
rorrl,irrnrr spi'e acfiune, miqcare
,si
vorbire cu : a) logoreer. cre$terca fluxuhLi
i rtcrr,l i v (tahi psi hi c)
$i
a si $temi ui i tl eati v (tahi femi e)' ci nd l ezi uni l e corl ,i -
, rr lrr rr u 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
rl rv i rL trrrnul tuoase, i ntempesti vo
qi rapi do
;
f) si m! cxi ti c ascul ,i t
;
g) coe-
rr,nl,r iii ].rttrfunzimea
gindirii pot fi pistrate' dar de cele mai multe ori
r-1r1, rk,tri iorate, fapt Cate depinde de leziunea cerebraH,
$i
tie fenomenul
rlr, hipcrtensiune intracrania,nl, in cazul proceselor e{pansil'e; hipermle-
zi,,
(cu r.xagcraroa cvocS,r'i1or, care deYin tnmultuoascr intempestive qi
r'.r,lriil,.), cxagelareil atcnliei, u reflexului de orienl;are, logoreea, mobilitate
,.rrrr,.r' ,r,tri , s i i ni , cri ti c ascu-ti t, somn foarte pul i n (2--3 nre di n 24)r j ud.ecatd
;ri lr iunamcnt- nortn:tle sau deteriorate dupX gratlul
;i
localizarea leziuni.i
{i r)t t rl )raLc,
l l i ri di tal a nri n
dt' ccrebrarc
SintLomtl de rigirlitate prin dccerebrare, sub dileritele sale Yarianto
r,i irr rliiirritclc ettpe
posttraurnatic,r survino cu o incidentl relativ mare,
r ' : r ' r ' i i r r r l i nt t ' e t 1l r oxi mal i r J00' o d; n cazur i i n sPr i a, noasr r ;
; i
a pr oa pr - r
.t0,1, (ti n
oazuri i n atte seri i (Bri col o qi coi ' ' 19?7), Deoarece un si ndrom
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.area si,gravitatea leziunilor, oi. qi de promptitudinea qi eficienla
rrliruclrL misuii tera,peutice'
-A.cesta
sint, in ordinea priorit5,lii, antihipo-
ri,.r,, rr, rrt ieclenraioase qi chilurgicale in cazurile in care se reveleazd, un
rrro(i(ls cxDansiY intracrania,n.
'
Sinrli'omul clinic. Sindroruul de rigiditate prin decerebrare poate s;J
:r,rrr,r'rr, Iio sub forrna $a completXr tipic;, rsprezenl,ind prototipul sinchomu-
lui" Iio slrb lorma dittritclor varianto clinice. Frecventr sindlolnul de dece-
l,lililnr cste asociat cu alterXri ale stS,rii de con;tienli,
,si
cu semno ncurolo-
tioo, irr lunctio dc intindorea leziunilor clil tlunchiul corellralr precum
$i
i l ,' l rzi utri l c l erebral e coexi stonLe. '
!)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
rl r. r' i r,z.rrri {uai rn., tgi 2; .Ral sev qi Downi e, 1966
;
Arseni s.i Oprescu' 1966).
Srrrrri oLrgi c. i n ace.te cazuri r:i gi di tatea, decereb.rati i apare l ]umai i ndustr
<lo si irrrrili nociceptivi, niciodatS, sponta,I}; tabloul clinic este mai atenuat
riirl urrL Ii rccunoscutc toatc lementele. Ca nivel de conqtiinli, acesta so
l r.zrri rri i I.r, nusi bi l i tate&
do a mcn!,!rLe ochi i deschi gi r de a negn sau de a
corrtirnu c6va prin rniqcXri ale c:Lpului, do a reacliona lont
$i.mai
mult
r:r,rr rruri nul;in corrrplet la un ordin Yerbalt in unele ca,zuri de a incerca sI
rrrr,rrrrl bti cuva i ni l l ,eh' {i bi l sau de a i ncerca si i , rd,spundl grafi c' de aso-
irurrr,,rr, inill,elilibil. Triseelo E:ltrG efectuate ln unele dintre &cesto cazuri
ru,rr uorrIj l nrl t i l i tgrrosti cul .
I }I BLI OGRAFI E
, {arl i J. A. - AcLa Neurol . Scand. } 19t i 9, 45, 484-492,
Aber f cl d D. C, , Namba ' I . - Ar ch. Neuol . , 196C, 20, 253- 25t r .
i ! j uri aguerra J. , B1ar! c C. - Le rhi nenci phal e dans I ' organi sal i on ci rl l t rul e. I ' hysi nk4l l t
et palhologie du inencaplrcle, Xtasson ct Cic, Parjs, 1961, :97-3iJ2.
Aj ur i aguor l nJ, , Ti ssot R. - Encycl op6di c m6d, - chi r , , 1963, 1?03G
1r r ,
t t , I 1l
-\
j o r l a g u e r r e J. , : I ' i s s ot R.
-
Enci cl opi di e mCdi @-chi rurt i cal e, 1004, sl l j )I ' | . . t ,
1?036. dr o, 1- o
, \ l ai ouani ne Th, , Ombl edane A. , Dur and M. - Lc sgndr cme dc kt dl sl nl l ut l
l i an phont ! i quc t l ans I ophosi {, t l asson {L Ci e, Prl i s, 1930.
Al aj ouani ne Th. , Lebeau J. , I l oudar t R. - Rev. N. - eur ol . , 1$4B, 3al , : ] : al : t : t /
Al aj ouani ne Th. , Sabour aud O. , Ri bo cour t B. ( de) - J. I i ' JJchol , , l l t J, : f ,
4, i , 158-330; 29F330.
Al ai ounr i r c l ' h. , Gr r ner J. , Goul on l {. , \ *eI l l i l . J. , Li ot l t r . . l t , \ ' .
Neurol,, 1956, 9t, 357*373.
Al aj ouani ne ' f h. , Sal r our aud O. * Enct phal e, 196q 3, 55- - 101.
Al aj ouani ne t h. , Lher mi t t e I r . , l - edoux Rcnaud D. , Vi gnol r l L. A.
Bev. Neu!oI., 19134, 110, 5-20.
. \ l be- Fes! i ar d D. , I l esse O. *J. Physi ol , , 1953, 4i , 16- 29.
l \ l eksi c S, N. , Budzi l ovi ch G. i {, , Li ebe}n}al r A. N. *J. Noul ol . Scl . , l l t ; : t ,
2A, 1,tr9-159.
Appenzcl l er O. -The a\ l onomi c nef l t ous sgsl em, Nort h I : I ol l and Publ , Co. , Anrsl enl l rrr,
1976,
Apr i l R. S, , Vansonr l enber g C.
*
Neuol ogy, 1976, r r , 106&- 1070.
A! nasoD B. G. W. , Ful l cr T, G. , Lehr i ch . I . R. , Wr ay S. l I . - - J, Nur r ' , t .
Sei., 1974, 22, 419-_-428.
Ar noul d G. - Ann. ! {ed. N}ncy, 7912, 11, S7g- 9i 6.
, 4. rseoi C. , I acob T.
*. )-ci ol i ca
Derl ebf t l d, Ed. Wel t her, Si bi u, 19. 18.
Arseni C. -Bul .
$t i i nt . ,
Edi t . Acad. R. P. R, , 1950, , , 4.
A r s e n i O. -
Neurol., Psihiat., Ncurochir., 1957, 2, 297-294.
Ar seni C. , Lasco F. - Ac[ a Neur ol . Bcl g, , 1960, r r , 901*004.
. Ar scni C. , Lasco F, , Ni col csco M. - Rev. Ot o- Ncur o Opht ql nr . , 1000, J. l ] , l . l l , ,
Ar seni C, , Bot ez M. I . - Act r psychi at . ner r r ol , scand. , 1001, Jd, 27$- - 21J4,
Ar seni 0. , Davi d M. , Chi l i man t r {, , Gl i van I . I . , l l ar ct 6l r l l , ' ' f r i . r -
gnostr. r&Ltooflalilolotic, Ed. trledicaltr, Illcure$tl, 1967,
Ar scnl C, , Opr cscr t l - * I ) ur cr t : d. Fi . i opdl ol ogi e cl i nt cd
si
l r t l dmer r l , I i d. Acu( 1. l l . S, l l . l
l l ucrrrcl t l , l l )(i 7.
Ar scof
( ; ,
Si Dr l oncNol l \ 1, . - I >al obl i a D( t l no- nl kl l r t l nr [ 0. I i al r yi ( r l d, l i r l , I \ 1r , . ,
(l k: nl i l ,
I l t l cu. ot l I , I {l l i 8,
Ar r f nl
( : . ,
O! r I c' ' 1. , [ ! nr r l BI $ , \ 1,
- -
/ ) / l r l r | r l i ] l r i . i , l t l l l Sf l , , l ' , l 12.
i t5,l
305
\ 1, . , . 11 r i i . . ( , I r . r , r ' l l
1. , \ l : ' r ' l r i r , \ 1. t ) l t t t t hdnui r t , t 1| r i i t , . / , , : j
. - | l l _
r \ | l . e, i ( : . ,
l )
t )
| , s ( r , t . , t \ t : r | , . t s l x ] t . t ) l l ul t t r , t nl i t , t l l r ; l t t , . / , ,
. ^l t i 1t
u1) t .
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Dnvi r l N. . ' . , l l r ( kI v l i . 4. , Sr I l i l l t . , . I . . Ncr t r ol o, {v, l l ) l i l l , l , l , : 111} i l l ' l l ,
I ) f l vl n 1, . l : . , l ) r ' n, l r | | l l . Ar . l r . Ncl r r r r l , ( ( l t ' i i . ) . l 1r ?: ) , ' : 1t l t i l l l l ,
l ) r v l r l t , l . l ' | 1r r | . I r ' , l l , t \ n\ r ' . l t l r ' , l 1l 7l , / i t . ' l : l l ) l l , l -
I J, ' I r ' , t U. I . , Si r f I l ) I t ( . $ r : u ' 1.
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{i l t l Al ol l I ' i . , / \ r {l or r i or l ' . . 1, l l , | | , l , , r M. l l .
l l t r i : ] , , r i . l t i l l l l ( i .
' l ' 1r r r . Ar r i , r . N, r u( ' 1. Ar r r , , r . ,
i l l r l l
I
l r Lt r t . l l t , . l r l ni zl o 11 S. , l l r r , I r l l l l i A.
( l i o| . | r ,
l r si chl r L. Nr l l f r ' | n1, , l l ) ( i {t , , r t ,
7l l 7. l l {,
l ) t f ) r r s \ ' , S. , I i cr r A. -
( , o qh ! r . / n. opr , ( l hNr l 0s ' l l r onl l r s l l r bl i shcr . Spr . i i gl i f l ( l ( l l l - ) ,
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. 1,
1- 10.
l ) t l r y . I . , Lhcr mi t t c 11, - ' Encycl opodi e m6d. - chi r . , 1t 63, 17019 431
. 1,
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l ) f l r y. l . , Lhcr r ) r i t t c f , , Encycl opedi e md- chi r . , 1963, 17019 Aao, 4, 1- . 4,
I ) r r ) . DL \ v. O. , I {ccht schal f en A. , cul evi ch c. * Ncur i ogy" 1St j 6, 16,
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Nt , r r r ' ' r ( l r i r . , l l r l l ( r . , .
' l l
l , l ;
l ) r r
j l ' l
l ) . , I ) "1) r ' \ 1, . 1| 1. . , t , L, t , r l l r ' , i \ . \ . , \ i l | O. \ ( . r r n, t . , t , si t r i r r t . , \ r . r l
{hi r . . l l xl : j , f , l ! 11 l ; l r l .
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I r i shct
( : ,
I l . . l ' l r r r , l l : . l l . , l ' i ) l i r f t . ^. , l ) | l ! nI 1, . ,
( ) j r . r
nI l t ,
( t , .
- . t , Ni . r ! ,
t r l r , r l , l ) 1r . , l l r l l i r , / 1r , , l l , l l ' 7.
l l , $7-10t .
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l ) t | r Dn l ) ", I ' f l I i l i f l n V, V"
( ] i r npr onu
J. : . , Yr | I ! r
I ' Nl hl ul . , Ncr r f t x' hi r . , l 0( i l ) , l ) , J, 40: > - 411.
3l i 0
L. , I Jor os Tr , - - Sl r
O. , l i u
I
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*-
i . -rrrrol . ,
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l r l i (i . , V u i a O. -- Z. Ncrrl ol . , 1973, 205' 207-220'
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l ' l , x l i . T, . , l i l ( f nl l r r I
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( i i b l ) s l "' A' - - ' l \ r dl r t r l cs' 1$54'
' J'
06- 73'
( l i t r t r i l ( 1. 1, ,
( i
{}t t r r ! ( h l ) .
( l - t ' {) l i t r ' I ' r r t t ! ' l l ) 72' 6' 1: }: l - l 4( l '
it0:|
( i i l t l
or r l i f ! t , t . t \ t \ | | , r N, , t . t ! , t . t 1r , : 1. / , / , 1l ; ; 1| i : , .
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( i i I l i ( :
\ \ ' . , l ( o\ | r l l , t \ r , 1, . t 1t , t f i r t . N, . r v( , t i r , , 19. / 0: : r / . . 1. t Ot ) 12t ) .
( ; l oor
l ' . l ' 1\ l : t i t t l t \ t t t , t
t r t t hnt qt t . , t L t l t t ! r t r ' i t l nl l t , l t l sson t t cl ", l , l r i s, 1l t ( ; t .
( l o( i 1. I r '
r l sl ' L , \ t t I N, . t . , t . s( . , | t . , l 1X; 5r I r , 4: j . - 51.
(;
o o t z r l j , I ; i : i ot rt t ol ql t . t . , t . l Ur(t i r: rl i J I Jrr(xu. ct t i , 1103.
( i ol dr eycr
t i . , t ! i I t 1, . , . . J.
. t .
- Ci t ci kt i on, 1$70, 4] ,
gJ: , . - . 04{, .
( i ol dst ei n
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2:t0-2.1G.
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. - Re\ " Ne"r ol
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M' Gor t t l l e
! \ ' - ' Pt l t l t ol ol i e
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t t t l
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.
Schwar t z ' l '
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Shophor d
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1968' 19' 1- 14'
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