8/19/2019 avc hemoragic + cvt
1/27
Herniile cerebrale
8/19/2019 avc hemoragic + cvt
2/27
8/19/2019 avc hemoragic + cvt
3/27
Transtentoriala
8/19/2019 avc hemoragic + cvt
4/27
Amigdaliana
8/19/2019 avc hemoragic + cvt
5/27
Hemoragiile cerebrale
8/19/2019 avc hemoragic + cvt
6/27
• 15% din bolile vasculare cerebrale
• Def: suferinta cerebrala datorata efractiei
unui vas - extravazarea sangelui in:
– parenchimul cerebral hemoragie
intraparenchimatoasa
– extracerebral hemoragie subarahnoidiana
8/19/2019 avc hemoragic + cvt
7/27
Hemoragia intraparenchimatoasa
!hemoragia cerebrala" apoplexia#• $ 1% din A&'( 1)-15*1+
• rata decese , 5%
• actori de risc:
• varsta peste 55 ani" sex .
• consumul de alcool" droguri
8/19/2019 avc hemoragic + cvt
8/27
actori de risc medicali
• HTA
• malformatii vasculare
• amiloidoza cerebrala• iatrogen: antitrombotice" simpatomimetice
• coagulopatii
•
leucoze• tumori
8/19/2019 avc hemoragic + cvt
9/27
Topografie
• /rofunda: HTA - stresshemodinamic
– ganglioni bazali
– talamus
– punte
– cerebel
• 0obara:
amiloidoza
malformatii vasculare
toxice !alcool#
• ara predilectie:
coagulopatiitumori
8/19/2019 avc hemoragic + cvt
10/27
Diagnostic clinic
• Debut brusc !in activitate#" agravare
progresiva !ore#
• cefalee intensa *- varsaturi
• salt tensional !$ A&' ischemic#
• alterarea starii constienta - coma
• deficit neurologic focal coresp topografiei:
hemiplegie" paralizii nn cranieni" tulb
sensibilitate" coordonare
8/19/2019 avc hemoragic + cvt
11/27
Diagnostic paraclinic
• 'T urgenta * 23.
• dg etiologic
8/19/2019 avc hemoragic + cvt
12/27
'omplicatii
• 3esangerare
• edem cerebral
• efractie ventriculara - hidrocefalie acutaobstructiva
• 4fractie subarahnoidiana
• complicatii generale: infectii" trombozevenoase" tulburari cardiace
8/19/2019 avc hemoragic + cvt
13/27
Tratament
•.edical: – factor &22a recombinat activat !ovo6even# -
abandonat
– antiedematoase
– TA6 7 18 mmHg – trat etiologic !tulb coagulare#
• 'hirurgical !*-#:
– evacuare: superficiale" risc letal !dimens" poz#" tumori
– drena9 ventricular
– decompresie !si in A&' ischemice#
8/19/2019 avc hemoragic + cvt
14/27
Hemoragia subarahnoidiana
8/19/2019 avc hemoragic + cvt
15/27
4tiologie
• Anevrisme intracraniene !5%#
• traumatisme
•disectii arteriale
• coagulopatii
• vasculite
8/19/2019 avc hemoragic + cvt
16/27
Diagnostic clinic
• Debut brusc" agravare progresiva
• salt tensional
• 6indrom meningeal
– cefalee" varsaturi" fotofobie
– semne meningeale: redoare de ceafa" ;ernig"
8/19/2019 avc hemoragic + cvt
17/27
6cala Hunt si Hess
• 1+ Asimptomatic * usoara rigiditate ceafa
• )+ /aralizii nn cranieni" redoare ceafa
• =+ Deficit focal minor" somnolenta*confuzie
• >+ Deficit focal moderat*sever" stupor"
rigiditate decerebrata incipienta
• 5+ 'oma profunda" rigiditate decerebrata
8/19/2019 avc hemoragic + cvt
18/27
Diagnostic paraclinic
• 'T
• punctie lombara
• angiografie !2 ) h#
8/19/2019 avc hemoragic + cvt
19/27
'omplicatii
• 3esangerare - max z 1" 1>
• Hidrocefalia normotensiva
• vasospasm - z =-1( deficit focal !infarct#
• hiponatremia - pierdere cerebrala de a
• tulburari vegetative !cardiace:tulb ritm"
conducere#
8/19/2019 avc hemoragic + cvt
20/27
Tratament
• 'hirurgical: ? 1-= sau $ 1>
– Hunt si Hess 1-=
• .edical: – blocanti ' 'a: nimodipina
– Hiperhidratare !@# nou: discutabil
– supliment a !corector# – controlul TA
– antiedematoase" simptomatice !durereB#
8/19/2019 avc hemoragic + cvt
21/27
6istemul venos
8/19/2019 avc hemoragic + cvt
22/27
Tromboza venoasa cerebrala
4tiologie
• ocar infectios de vecinatate
• Traumatism
• 'oagulopatii
• 2atrogen
• 6arcina
• eoplazii
8/19/2019 avc hemoragic + cvt
23/27
'linic
• 'efalee
• 6indrom meningeal
• 'rize epileptice
• 6emne neurologice de focar
– Ccluzie venoasa
– 2nfarct venos
– Transformare hemoragica
8/19/2019 avc hemoragic + cvt
24/27
/araclinic
• 't cerebralurgenta
• .32 angio timpvenos
• Angiografie
• /rofil coagulare
• ocarul infectios
8/19/2019 avc hemoragic + cvt
25/27
Diagnostic diferential
• .eningite" meningoencefalite
• H6A
• A&' ischemic * hemoragic
• Tumori
• Abcese
8/19/2019 avc hemoragic + cvt
26/27
Tratament • Anticoagulant: heparina fractionata * standard• 'orticoterapie Ab• 6imptomatic: antialgic" antiepileptic• Tromboliza" trombectomie" decompresie
• Anticoagulant cronic: – ara factori risc: =- l – eprecizat: -1) l – Trombofilie: nedefinit
8/19/2019 avc hemoragic + cvt
27/27
4volutie
• orme usoare: remisiune
spontana
• orme medii: raspund laterapie" remisiune completa
• orme severe: sinusuri
profunde" infarcte masivehemoragice deces !1%#