Hemoragiile cerebrale

15% din bolile vasculare cerebrale

Def: suferinta cerebrala datorata efractiei
unui vas - extravazarea sangelui in:
parenchimul cerebral = hemoragie
intraparenchimatoasa
extracerebral = hemoragie subarahnoidiana

Hemoragia intraparenchimatoasa
(hemoragia cerebrala, apoplexia)
> 10% din AVC; 12-15/100.000
rata decese ~ 50%
Factori de risc:
varsta peste 55 ani, sex M
consumul de alcool, droguri

Factori de risc medicali

HTA
malformatii vasculare
amiloidoza cerebrala
iatrogen: antitrombotice, simpatomimetice
coagulopatii
leucoze
tumori

Topografie
Profunda: HTA stress hemodinamic

ganglioni bazali
talamus
punte
cerebel

Lobara:
amiloidoza
malformatii vasculare
toxice (alcool)
Fara predilectie:
coagulopatii
tumori

Diagnostic clinic
Debut brusc (in activitate), agravare
progresiva (ore)
cefalee intensa +/- varsaturi
salt tensional (> AVC ischemic)
alterarea starii constienta - coma
deficit neurologic focal coresp topografiei:
hemiplegie, paralizii nn cranieni, tulb
sensibilitate, coordonare

Diagnostic paraclinic
CT urgenta / IRM
dg etiologic

Complicatii
Resangerare
efractie ventriculara - hidrocefalie acuta
obstructiva
Efractie subarahnoidiana
edem cerebral
complicatii generale: infectii, tromboze
venoase, tulburari cardiace

Herniile cerebrale

Transtentoriala

Amigdaliana

Tratament
Medical:
factor VIIa recombinat activat (NovoSeven) abandonat
antiedematoase
TAS < 180 mmHg
trat etiologic (tulb coagulare)
Chirurgical (+/-):
evacuare: superficiale, risc letal (dimens, poz), tumori
drenaj ventricular
decompresie (si in AVC ischemice)

Hemoragia subarahnoidiana

Etiologie

Anevrisme intracraniene (75%)

traumatisme
disectii arteriale
coagulopatii
vasculite

Diagnostic clinic
Debut brusc, agravare progresiva
salt tensional
Sindrom meningeal
cefalee, varsaturi, fotofobie
semne meningeale: redoare de ceafa, Kernig,
Brudzinschi

alterarea starii de constienta

semne neurologice de focar

Scala Hunt si Hess

1. Asimptomatic / usoara rigiditate ceafa

2. Paralizii nn cranieni, redoare ceafa
3. Deficit focal minor, somnolenta/confuzie
4. Deficit focal moderat/sever, stupor,
rigiditate decerebrata incipienta
5. Coma profunda, rigiditate decerebrata

Diagnostic paraclinic
CT
punctie lombara
angiografie (I 72 h)

Complicatii

Resangerare - max z 1, 14
Hidrocefalia normotensiva
vasospasm - z 3-10 => deficit focal (infarct)
hiponatremia - pierdere cerebrala de Na
tulburari vegetative (cardiace:tulb ritm,
conducere)

Tratament
Chirurgical: Z 1-3 sau > 14
Hunt si Hess 1-3

Medical:
Preventia vasospasm:
blocanti C Ca: nimodipina
Hiperhidratare (?) nou: discutabil

supliment Na (corector)
controlul TA
antiedematoase, simptomatice (durere!)

Sistemul venos

Tromboza venoasa cerebrala

Etiologie
Focar infectios de vecinatate
Traumatism
Coagulopatii
Iatrogen
Sarcina
Neoplazii

Clinic

Cefalee
Sindrom meningeal
Crize epileptice
Semne neurologice de focar date de:
Ocluzie venoasa
Infarct venos
Transformare hemoragica

Paraclinic
Ct cerebral
urgenta
MRI angio timp
venos
Angiografie
Profil coagulare
Focarul infectios

Diagnostic diferential
Meningite, meningoencefalite
HSA
AVC ischemic / hemoragic
Tumori
Abcese

Tratament
Anticoagulant:
heparina fractionata ->
standard
Corticoterapie + Ab
Simptomatic:
antialgic, antiepileptic
Tromboliza,
trombectomie,
decompresie
Anticoagulant cronic:
Fara factori risc: 3-6
l
Neprecizat: 6-12 l
Trombofilie:
nedefinit

Evolutie
Forme usoare: remisiune
spontana
Forme medii: raspund la
terapie, remisiune completa
Forme severe: sinusuri
profunde, infarcte masive
hemoragice deces (10%)