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BEMIOLOSI-N NEU ROLOGICA

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

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

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

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

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

h tulhurirlle tonusulul mu6euhl L Fmlhrnr dn dlo0nostle

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

' '

'

' ' '

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

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

9 . l "o l, lonrn

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

I n r r 0 r ,o ztl

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

siurbolurilor

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

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

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

si rfxp}esici

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

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

282

1.INTRODUCERE

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

:1,,,1", lll]..i :1.:J . Sirx lro

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

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

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

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

porrl;o-ocrebelos, in stlnca rrtrr rorfiirnrgicalc.

2.1,PAT0L0GIA PERECHII t tNERVUir 0LFACTIV)

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

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

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

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

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

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

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

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

trilltcratil. S-aardtatastletlerseniqi is?ej;;, degi ant in rireningiormer;.1;,rul;i "biffi, iitactiv, in ;:,i':1:] liii:.1:il .:"T-1-q'iolippr z|'r(.rx|||lrlvu,)r'it,cerStii locale "iii; nesemnificrti""'iri"itiil iirofla mucc ::l::l ll:,:ci'l,rl,1.l,l lli unei 9"qrg rr;rzrl' r,lt:.)rrkrcit; leziuni cerebrale
optici,, Deci, anosrnia'prerl .tumola $i nrltir j.rr u orolusivii, o parte, qi coincizind cu alie'se;ne tumo _de :rlr' (| lt)irit (f vil|ra,r'e diagnostici'in meningioa-"rc ofircli"". A rrrrv 1l;1111111 de arteri, ca?otidd intein-d,, osteomul frontal, giotrtttl sulrrrsr'lirr,ijDmorilc sttlltilsclitt. l.lr{'rr,r||l tumorile r'la de ,r.r'in;. adpd, mi.; micd ,lj cle sfenoiA si unele tumori "i^;:ri;,;:^'^ rlf ) rrrlf l. l.l ln)L (t(,Lermina tulburdrt-unilaleraleale mirosului, cu -. deoset

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

14

lr lr l i( 'ilr li'll rrrvcl l tl rl c i trl l rrtl i r, vi rsrrhr tr r , lt t t it 't t r ,it t t t clt ', I it t ll, lit r 'I t ilt llt I t I l, l rr.rrrl u ,i rrfi trrl ronrttl l xxl tl i olm r t r lr l, r olr t t llr ir t '( t t r r lilit o; t i'ilr i't 'r 'lr olr t t llt lt l'I ) . dr po. Tt ilo A J I\pi l i tu. (si ttrl totttrtl t r t lt r iu jr t , r t lohr t lharsuu sindr ont . r t l. (r'ttt.lrinu.rtsulnrc'u,li) (llintrr, l115!; l\'llttrolcxrrtt, ll)fil{1 rliavrrostie n, ttili ttl,t1||,i0/ousti, rdinic' lopogruric si .tiopatogenic ,,,,',,i;;;l'rli;ll$;rlt' Hilu l)illlrfr'lllt si rrrrilizcltzi't,tta,t"r lrtlbtrrtit"i, lltilr lrzitr 1u,:rlrrfi t.ttrilitt,tuirl?i rrrl " i trl l urrtatori j < l e tu,vtill, in1t , r 's1, if ial1' it t xllr hullr lr r 'li, : r t ) Ar r t t ilit lt 'ir uizuote r r:rrrrrl sr:ade in cil, cva zilt : , ut t ilai. t 'lr t l, slt t l lr illt ii totdoaruta l ap it l, lt llt al, sepot exprimain urmatoarete l.r;rl (cga,l sau jnegal), pini lr o drarnntici arntntrozil; ll) (lirrrprrl vizrrrrl '11llll{ffiJi,Jcaititlii lll .4nbliopio lepl.czjntdtlimjnuarer acuitrilii trtt st ttlnltttt,' , rir. rlrr ollicei ingustat concentric, dar uncori tloar sectolial 1si vizurle. ll\ Cecitalea silsiu amauroza reDrezintd, nicrrl,,roo rnnoti ., l,lrirrt ccntlalc), vedelea macular'[ liind mai rcspectati,; o) ilitttItll rrtrr rrr:rlic cste foarte a terat (cu moclificS,ri ale cir,rpulilor ct'ttmlftir,tr,lltt st,,r lrilatoal[ (6i in accepliuneia, l,,irrr{f pontru culori, cu discromatopsii qi chiar acronliltopsitr I'olrtli); c*orectEiinli*iX,-piiiiizt;ne' ce.nt.",u ,lr \rlrrptarea la intuneric este loarte deficitari I e) Adcscn lo1'oltsii '1i tltr ..io D) Ilemerabpia reprezinti iliminualea acuitelii , rr ll rrtilci,rile globilor cculari I f) Pronunlat edern pa,pila'r, prrpilrr,Iiittrl *, l.l spl:c Seara. r,,.rr,,, lrrlblre, tumefiat5, cu conturuli foarte qtelse, cu sll'ii (r1| I ' I I Ii t'I t l i | |r{' "irort" ,,.rrrl,ii-rozate. Manifesti,rile edematoase peripapiltlle se itrt'itttl ltrr zott, ,r;rri rrLr cimpului oftalmoscopic, r'ealizind aspectul rlc ,,ntrlttorrrtirtilri,". invizibilc ( llisr r t , l1) l': l; ' ,,rrr1i rrJl cpapi l ei deveni nd , in accst c sit ualii, .,,.itri1i, {ininelseama indeos?binc.rmai.oarete-;i.;l,iii, iiJpiltir",i \1. n()l (' s(i u, 1958; D uke E l d el $i Sco1, t ,19?1) ; g) Yelele ; i t ,II I t i IIt tr ' It ' st t r l r.rrul al fundului de ochi gi pi,strarea t,r.rri r. rl i htate qi si nuoase , ar t er ele slnt inecat e in et lcm ul lt t r t sir '1 lt ) lt r r"tf"iofui p'r!i"ar la tuminri. , i l,,:rr'('l(i papilare $i pedpapilale se obscrr''Xhemoragii si ctstttlrtlt', r'l'r'tt ... l') !):l!r"*,atoysja_peytyyalb negru fi tentru iulori reprezintri tl ,,l i rsl l ccte de trombozd velt la, s: i cu zone vast e t lc t 't lt r t t t llt 't t t t iI r r I lil t t t in-considerare,'inirucit l aceasia poaresd, :l:,1l,,,1o'1'"]T3"jlrlt-,*:.ll?1 cr,rr,rli o scrio de lezinni ale chiasmei l rrrrrl :rcr.storl ezi uni ; i ) C o af e, ct ar eavit r osult i se po: ll, o r ( r lr lizr lilr l) r r lt ilil, r ' $ rtlttl;r lrr, lrlii (,\,[anolescu,1958) ; j) fn forma de ner-r'i1,L opticil trtlt'tttrtlortsri i!.2.1.1. Amb_Iiop.iile :!./,,.1.1. "in "ail'* Amblioniile si,amaurozele am.turncplo "pti"b n.alra <; a,,t,-..,]*^ acute si sul.tacute ;i, se iatilnesc in nlr l ir r ( cit at r r cllr r l t le Riscr ', . t 95! ) rrl r:rl rrnrr.l i cul ari dc Rcnar d descri si i , ', i rors(| ir1(:(i1i1tni, de diverse etiotogii qi cu vdriate tocatizXri pe clitc t 1c , , nr Lcir t cii'" lN' it t lt 'r t t lr t ct r t lr r ilspect o rnasi vi , tumcfi clc, cu ;,ri rrrrl i :.4.2.l.l.1. AJecJiunile in lamatorii ale nerl)I.tlui, r I rLri,rr'il canalului op1,ic. wtic l. /. l. l. Perinct:ritele,optice (nearitele :!.:4. ii r lio1ul,, lrr lrr!r unui tablou dc papilit[ trebuio sii plecizitrrl .lut,lrtt rr.lrlczirriiio irrIllLrnl.r,t,io Drim:rri, a, tecilor nprl qi kx, r t L' r r lt t l. r t r : inlcc( ii r ninulioase: a. ) //ri r i nvesti ga.{ ,i i si si em at r icc ,, l )r' i n rlrr olrir,ci,r,xtcrrsicirrlui pr.oces inflamatrol Ae fa'r"eilinld"'Ja" .i" fa r rr,l ,ri ,i l l i te, coroi di t, pl i igi per f or at e inf cct at e alc glt t lr t t lt t i oct t i: r t ) ; ( l') rrrrzii,o (anterioare, sfenoitialc qi ctmoitlale postcrirllurr) I tr) rrlirr'littrrr :ii]'ll:1,',;.1":i:,1^'j;'l:1.'.",':'si:l_::t11i.obi$nuilisinttacteitiepiugenc r lr r \ ul r rru l ,rr tl l l,r o r, i, r lc it rc l i n g i taa-SUpUrJlivi cprr.bro_spin ir illlii, illl in nn|lrngrl alri i rrrII:rrrrrri ol i ial e urechi i me dii; t l) f ocar e dent ar e I c) ost oit t r I l) r r , lr r ii", r lr r t, -di fuzi uni l(|i.| o u; r Jr rrl sr r l ( l) r r k c ll) (t,ut({r scn t. 19?1). lrjl(lcr ldcr s 1 i l||l|st. Sc ol-tt. fir Scott, l 9 7 l ). Este E s l c vorba v o rb a de ainzltfi in li trl, ; r1) inlrc!,ii generale (scarlatinl, variol[, folrrl'i,liloirlii, rlill'r'r ir', gli;rrr. lrrl rr;rtir' :r|. rrrrr rr'.rrcningite bazaie bacierie.ne1inc1u-sii iaclarc S I ,,,Lrri rl i i -un, ti fos exantema t ic et c. ) ; h) papilit c lL, ll1( r $ilt l f it ll) ir ( llll( ,I t i, l 'rniiai,ato"ti i'.1,):.,.'.',ii,'flll lil)..1::ll::t sau ale, altor p"occs" rt' :rrr,rr, ,5j i n scl eroz:l i n plici it llusr 'lu ocult t r ', it L lix: nillgo- cll( x llllil( : l.l:1,',','f,':1,1 1 ,il:]:l:rl:lij:_"1,"T: sinuzjie sfenoidar" i,'alarc,se r.r. r1 rrrltrr{ii virotice ncurot'ropc (o{tralmonculoln itrlilrii, lrollrt lrti l)rrvirr; ; ::'l: ;:1,r, I ll r'tinicc: perinevrita jl;:1,:1: , r' , r' l rrl otni c-l i to demi el i ni za nt c; I t er pcs zost e: 'I cr r cr ialil, o; I t t t 't t iI t I '; iicr t r , t t lt ' l]l,i::,..1:llr, , , 1rlr l ri p rrr.rr llt t ll' 1, . "pii.a"".iiaJii"#c;ilr;I ,i , ,l i v| ' i so nai uri ). |)iIr11rrosl,icrrJ trsto orientat de: contextul general lil N c1)ritct, apticd, refrahulhard &clttii' :tan' stthur"utii (t;lndnntttrl 7r'slt /,,r/ s{ , < uracteri zeaaX , i Ir plincipilr , sPt r l t lt r osclr it t r t lt l piLlt ikrt li, t 'r 'illt -irn"eor, / pollrurli r"rre cx_plic:iambliopia * $i cu la*traiua . pri n * a l i ps:l sa r r r I isclef ia, m or lif icii, r ilol t t ] t ir xl, ivc r r llr t lt r t t r st r r t ved rl rrrl b:rri l , l rrri ,rcrrllrr,|r,). r.rrtr':rL.)lrr r,rz,rl cu,zlrlriirprr ili"i qi dispari,tiei a vecleiii centiale se lnsiJeaza o ti-;-;.d.;ii | prczo nl'll ilr alilor l, t t lbut i i vizt t lt Lr lt t t it '{iot I I t hr . rrr pri n i tchi mb l ' r( a-eclematui pupitr" ;"riuiloio" q, ;i consecin{d !txtrioristici :lllj,,.ll.',11:1, f,ln I clinil : lt) l)cl)Ii, l)l'ujr(f, itt c,ilcvu, ziL' trrrlizitttitt tlr' ,, ('l' llr'{. I it l)j' J o . " ,l l r.r,r' r, rl l l rnati c:i a tcrti 1 t if ii vizr t lt lt r , pir r ii' l: l ct 't t ilr t 'lr t(rt t t t t r t t t t lt zii) t r ot t t pt r tcoplit r i I t lt nilt lt it . st '; lr ) ilt r it r lr r t 'r 'lr lt r r t t ilir {ir 1,1l :i , cl ri l rl ctt rl i sprtri {,i ir , r 'sr t , trt ir r sr l{, i1ii r ri rr:rl ,rci i { ,r pt' ouxl tt,l i i si t lir lt lgii or lr ilt lr t r slt lt lt r , t iot 'lt ilir , t r ', ..r'rr.1;rl. neyritc optice) iealizeaa:i.tabtorii v1\ r ' lr 'r il r,r' l rrl (' sl l ,l r tl t' t,l l rtql l l ri l o l t lr t i r iililo gk r ilol t t ( lt llllr i ; r i) iJ( r ai( l'll( 'r t1e scciiuJ "ti"i""-,iitrirJ"f"Si." afecrdrii vu,ur ;t;;;'fr up0rc: pc pl.rma . i Ll rl i ,r,rIl .i { (i i l rfitrtrtti t """.*. *,:.:i." l i col o t t t t t ct t lt 'i llt , t t r r t t i t lit r t t , t lsit t t li, t t t t lr lt i 31r ; 1lt t t l, li:::f:.lll,f13"ll: il.i,", por I ".r-""l"i cl.recuprinde ptpila .rr|r .irrrl:llrrrllrarJ, n(.r.1 opii(1 ul | | Jr' l ro,rl (f :rl ]ol rrrri i trl rr' { r , int llt t l vizt t lll ( lt 't t t t t t t t 't t t lc , , t t I l't ill'i t t lt r r llt r l lrirr;iI:r'zuuartc i "i l vllsclor centratc atc t"ctrncrin lcrv (10_.LZ mln), realizindri-so ( r ll( \ siud l )l t| i r' | ,l LIll iLi i''r : oli, ll) 71) . llt r cr r l i t it r t I I ot t t t r I I '( 'I t ||ir | l r rrrr :rri rr!r' i )' Nrrl(,Jiol', i*xt,abuJbar, p4lilita sau sinrlrol.ul dri lrilpil. _ ( : r I r , r 'I I t t r , : r t it t lt l, gt t lt t i t t , tt ,l r,:rr. l rr.rri rrl rrrtl l t,i ; rl ) 1' t r cr r zt t t ilr . Fiit r 'r 1, , t l rr.vrilr;.i, .domz I.rrsii,ircrr1,l'l' srrusrrlliriltrfii; il' (r)r:r lx)r{rrt,r', r.rr.olrrrlrr:'ii, ( ) llt l'l"i) , ilt lllt lllr zli illr lillll! ) zll lolll l \'lt t t r t t lt $( ' st 't t , irrl,itrsr,i rlrrI l ,,l ( vl i l i i | | i rtIri | r,Ii .i i ' '

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

(NlillvUt, ot,1,l0)

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

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

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

l6

l't

l)l.lfl,,ll

r''I'l

,,,l.

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

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

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

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

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

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

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

ltt ll|'

I tltnlttlttnttlt ,

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

ti o l t n l l

tl t

ttr r u l u i

o Jr ti r j l \r l ,

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

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

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

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

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

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

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

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

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

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

r,r'r, 1,,,,, 'ij,ll,,,Il,'i,,1"1i,j,ljlili,1 ,d,,,,1' ,ill:ilill::,i'il ilxlillilii;l,ii;ili:",' rl t rl r.l t' .rt rl r. r.i rrrtr r t zr r : r l t lr .
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\ | rrI I i I rrrI i Irr,Ir tlc. .lucl,ori etiopatogenici ai nevritelor optice dc noi (Popoviciu $i Pasou, 1980),pe t'r1r'r,ri\ r. rr lirsi sisl,rrrrur,tiz:tbi, :r Ir||rIr|.r'r|irs(| publictilc indeosebi sirtrlii slrr,listicc, de Dukc-lJkler SI Sco (r1rir):
ll l"ttt rt\i itt.lltuutl.ar.i. Lor:ali ,1i ai B.i[.C. .. a) Uveitc si I'etinite i l r ) lrrtrr'(i i ir r lr , r rr r llr ilr r r.c ; c ) ,\Io n i n g i te o to n i c e (i ndeosebi brci l ara gi lr , lri :r);rl l \ r ' r r lr r r oir lii,rr o p l o c h i i i s rn a ,l ,i c e (c u e x te n .si eantori orl ti , cu realrr:rr, r,lrr:rl rlr. rlvlil(l .jrrxl,l,liullrtre ,sipapilito) ; e) Sinuzite antedoaJe fit tr.ri,.r r,, rlr' ; l) 'l'()\oplltsruozir,;g) Tubelculoza, fic prin lropagare, directi/ rlr. Lr ri lrrclrrlilr vooirrc (proceso tbo intra-ocula,re, iridociclite, osteite etc,), lr,. rlr' lrr o rrrcrrirrgil,iitbo bl,ztli,, {tretermlnii,ferromenc de ne.t-r'iti, gi rI0 t)(.rrr,vr il;r oplicir,, clrirn dc pl.pilitd, (Sverdlick, 1964, citai de l)uke-Eklof rrr ll ,ri l, l!)7l). li,ll,rl\rli ljoitte dctermina un tuberculom Solitar masiv pr, p;r.prl;roplicii, crr rolliz:lreil urrui tablou de pseudogliom optic (cn simlrlr)nri , r ;riil rrriri s{)v(lro c1t cit i,uberculomrl se extinde ;i spre apexul ,'r'l)rlru ); lr) Nlvlil:r, ol)1,ici:i sifiliticd de obicei provinc de la o meninEitf r r :rrrrrrr.rri rrllr llr r r ' lr r lili lue ti c i i l , i n s ta d i n l s e c u n d r sau terti ar al l uesul uj . '\r1,.r.rr rlrislirrrL l:l lriirttrrrcn, cr'ncomitenti, a neryilol' oculomotoli, faciall r.r r.r,lrlco yr:rlilrrrlrrli. illtrlLnrii r.iltr rl c r*cdere sint yaliabile, ,te h u$oir,l.[ _ :rrrr| I r, rI rir, ;rirr'i lt rrrrrir,unrzi 1ofltli,. flalacl,eristice sin1, strimtorii,r.ile corr ' l c r Lt lrl l rrl r lir r r lr r r lr r i v izl l l l L p c n ttrr a l b fi l x rn t ru cr ori , precunr si s0o. l o rrr'1 , ((.rllir lr , s i/ s iul l )i u i l ro l )l l a l c . l )i i L g n o s l ,i c u l se bN zcazi i ,po dl i l (!l r i r I r: | | | rI r| ,Ii i i {rr,, pr r , lc s t r ' lc sc ro i o g i c (' , l x ) ri ro (l i l i c i i .t' i . l () r:l i rr 1r" (l .l L. (crr pkrr ( rl! r zi r I|| 1(I( ) r ||iI r I r r r ilir r r l i x ri l rr| i i ,,c tr p o z i i .i v i i l rl o i i rtl r(j i i i l or l l i .ri ,r' rr l i l | s), (,IIrrri | rri i rrrstrr0l rti rr 1 rr . r rrrrrIi l i (, ir liI r r lr r t pilt r r r , 1 i 1 x . rro rrl i ' c l l tl rl t,.trr,r' r' i IrIt r r :rlr ; i ) l l o rrr lll r r I iI iI ill rrIr.| | 1r' \rIIIri rrl rl i { j s i rrl l i rrrrl r, rrrri ., l or,:rl i zi trrl rr srr
' 't !

( |\( r '||['l ItI|1 l I r r r I r '. r ,rI t t Ir I t r, t t I : r I I i l t i t t I t'I t'rr t I t i I I t' I t l l l r ' tl r 'l !l l l l l l ' j ) r \l l o l r r r .l r l i r r :r ' o tr ttl r ttr t tl tl 'tr t l tttr to tl i ' rr I r , r r r r t r r l 'r 't l l i ' i ,r 'r l l i tt,r r .l I r i I : t I r' r': r I I r ' tr 'r tl t l :r 'l r cs, i tt '. r l tl l l l l l t( 'i 1 l r r ' , r . . , r . r r . 1 ,,|||II||IIIII l. l1)i l)' ,, 11 . r r l ( r ! l l : l t l rl l r l i l r' l r l r t' i tti tttr r r t i tr ( |) r r l i t' Ir ) Ir Ir 'r 'i "i fi r r .l 'l ' . r , , I ', | , l ( fl l t) l r l l l l l l i l ' tx) l l ( 1 1 \l l l l i r fl i l l tr ) * tl r fl i \''i , , , r 1 't r ', 1 'r i ' ; , t r t t l ll i tttl ,,t;tr '( r l l ' *1 . r . . , ! r t r , , . l l l l rl r' l ){f l l l t rl r o ;l t) , tttso l ,'i l 'l i r l l r r r p l r 'r 'i ( 'i l r 't.tl to l " l o l o l tsi i " l =r . l ' ' l l ) 0 j t' s:r l l r l q i r r l i .tr ( l l l r l 'l r o fi ' 1 1 ) r i l l ' \'; 1 1 l {':l l l ti l l l . r r r r ', , , , . . , 'l , r r r r l r 'r t l o r l l lrllrl ( r r 1 1 'r i l l r sl :tl r l i r l ( tl l l l 'r l l ' l !l r |f r r , r , 1 , l r , r l . , l ) l r l r r | r i i l r r o l ,l , I i l :r l l i l l l l \ l :l t l r ' l r tr r t r r . , :l l l l l r { , l r l l l :l ' "l ' l 'l 'i ," t r "r l l l i l i Itt'tr vr fl l l :r ' l l l 1 . , t t t t ,t t t u l t t r r r r ttL t r r ) S1 :l ( 1 1 'zr r r tr ttl l i l |l 't I l l r r r r l l .r 'v,r 'i , r r , 1 , r r r l r r r r r r l r r r r r t i ( 't'r r r r l i ;i l i r r r l 't r ', l l fi ;t'r r l l i s,.l l l {i l i l tl l r l ct fi St'ttl t'' l ) r l l i t l l r s( ) ; l ':r s''tt, i r t si , r l : r l t r l . I'r r '.r i ' l,r' lll,ir r ') N ,r 'ttt'r ttti r 'l i l ';t' r r l r l l tl t :l ( l tl i r l "i ttr tl :r r l r ;, I , r r r r i r r l i l l r ' ; l l r r '' l : Ir l,t,lr tIr 'Ir tt|' p t tttr xl ttl IIttti ItItII i tt 1 , ' l r , r r i 't . r 'r r l i l l r l c I l tl r '' r l I ttr tl l l 'r ' r tti , r l , , ', 1 I I I I I I I I I' { I I i i I l r 'r 'l tt( .i r r ',sr l p l i r .r r .r r ' | Ir i r Ii I ''i , , , , , , , ', , , , , , , , r r l , l , l r r r 'r r I i Ii r IIi l i Ii ' ' ( 'l l r z:l l l l l l l ' sl fl r '|,ttl i l r zl t,.r ,l r l p i i r 'r ', l r 'r l r i ' tcztttr r i l o t , l : t , r L r Lr r r l . r l r I l l l ,., 1,r r' | ) | I Ii (' - .I 'l I ( ' '. Il l l i l ; r . o l r r l r . , l !) ? i l ; l ) r "i u r r r r l sl r l si .."'l r r l ', .I . ,,fi, 't , ' l l l 'r l ( l 1 l i ( i ) r \p |i l Vl l l l so l L l l ( r l r l ) ( r tg l r r i , ( ,,]i , \i ,,, ,' tr;, lr r . r ! x 'l i r | i ,,,,,i 'r ,,i i r r i 'r 'tl r r l i p i ) tr vi l r l ) r '( r zi l r l r r ' , , , . , ', , , , , , , , , , f i , , , , , r t,ti tl l r I t t I t t I I rt t t i t ' I i 1If i r 1 r 1 l l ( r ( 'f'1 'o l ( l l l zl l l l r r r r ' , r ' l , l r r , r r l r o l r l r r tl cttti tr l i tti zl ttl l r r q i ti i ' r r r l r '.i o ti l l l i t'i l ' o l l ti o i l ( '1 ) t( l zl l tl i l ' tl t'tvi l ttt i l l l l i i si \'l i ', r , , r . l " t ', 1 r , l r , 1 l 1 r l i ( i l Ii o l l l ( 'zi l l l fl l ' ', 1 , , t 'L r t r r r l l t r r i r l l i tl i zi l ,l l l {r 1I I i I I I I t I I (| ; r l ) .l r ) tr cr ' I I r l tr l i I l r t( ( 'i tl r i , t r '; t l)lilr. , l cl l l tt r ') l r i v{ r i i ' l ' l i l tttti tl t r l r l r r z r i (l r o r l l l tti Sr l r r l 'l l r l ; t . l r r , i , , , ', ', 1 . r , . 1 , 1 ', l r l r i ' l r r ttr r o r l i s tt l l 'l t t t t t t t t t t ) | |||It |t||tt!Ii 1 "t: ttt r l r :l r tttt'i u i sttt tl tt.tttL i t: l t) g r l r tg l i o zi r l r r zr ') ; l r l t'r l 'l 'r tt' Sr tl r l t'l l i i ( l tr tl tl r t ,' lr, r 'r , , l , , , l r r l , , r r r r r ;r ttl o I'i tItI l r r tl i ttcttttt , I l ' , , 1 , | , , | , l , r 'r ( : r l t o l t rt o p t'i r r i i ' r r r r 'r l i l r r 'tl i l l l l l i Ir ( l l ) ( !t) 1 i l tl l i r l !) 'i 'r ') r r l | , 1 , '1 , , , r , l , l r 'r r r r l l l r , l ltl l {r 'tttl l i tr ( ( l t:o ttr ti 'tto t'l r tt,l l ) 7 fi 1 l 'l l r l tl l i g l i o r r t" ( l tr l l tl l t l ttt ( j ( l l l l i ( l ( ||l . ' Ei g i t,Itt,r l l r t t t 1rl l t i I I l i | | | 1 ', 1 | | , | '| . 1 | I l | | 1 : ' |\| i tt i r 't'i l :t i {) l ) i L l ( l g tr l l l ( f lll(1rl r r r i , r , r l r 'l r r 1 r l , r r r r l l r 'r 'i "l 'l l l ( '.'i i i i 'r 'l r l i r 'l l ,'l r '.r '1 l l ', r , r r ', l | , ' i l 1 ( i ( ) |1 t | : I I ( | I t ' i ' 1 l i t l t l t t l r r 'i l l r l i r l cl r ', , i t',tl r r , ri ,. , , , , , 't , 'r '', ,.r u .l i rl 1 ,,., "ttl tt '.' . ' ( l l J7 l ) r !r t l ) l ( ..!zi r l ' r , , , , , , 1 " " . , 1 , . , , : r ll ( . r '1 .r 1 ,. Ir r r l i r , l r l 1 l .r . si i - r ( ..i | ,,i., i r {) t]{r tl i tt l r l tzttt'i ' r l | r 'l r r r r r { :r ;r :r r l ttl l r r tti i t'i o r i l i l i l l ( f i l l l 0 , L , ', ' , l ' I l | . . 1 | . . | . l r . . t t , r r r l ; r I l 't '; r I r ', r ll 'r ttttl l l '( ) l 'i ( :||l Il l l tIl i l l i ( j l l l l IIl i |,1 |t.{) z( 1 ,|) t'l Il ( x'tl tl i l l 'i l l tl tt- str str tttttr r tl c r , '1 r l r r '. r r r , l r ,'tr r i ci i , Il t r ttttsl 't' ( l l l ztl Ii u , t , , 't , , 1 l t Il i l i tl ( r i ( l l l l l i l l Jl ' tl l r ttl tl l kr i ttl ''tt'i ( ,l 1 l l j i l ; d l , l ! ', 't.,r,l ' r r ': r r r r t o r : li l ztr ') ',t r l r r I) ttl i r r ci l r ( i l l r l ;:l .''r l :r .l r ', i ;r . \\l r r l l i r l r l l 1 ) l t{i r r r r l , rrf,, ; i,., r r l i r t h i l ttt l r 't t l , , 'l l , l l r i l ) ; lr ) i i 'r r l i r r' ' 1r: r I i i I r' r I i t r :r l t'r 'o sl l r .r 'r 'zi 1 i i r t , l ', ' r I I I'r sttr l l t'l t' r I I I t t t i t t I I t I) i l 'l ) i l i i r i ! l i l xr l i p i l ' , t , 'r , 1 . , 1 , , , 1 i r r r p r ','zi l tl r t 1 - , , , , , ', ( r l 1 :r l l l r l l l i i l zr . {r 'i r l ( r i l tl :l r i l ( ' l r cr r r "r "r g i i r 'r l l r l | | t , , , llt.. .r ''1 . '1 , , l .l :r l r ', f , ,,. t , i ', . f l , f , . ,tu f,,,i r '.r .r 'ttl .r r :i r r l ,r :l r l r ''r 'ti l ttl t'l "r ':r tl ( i 'r i - "{si i l l l 'r r ' i l l ( l i vi zi ' Al l r r tr r .l :r l 1 ) '/l ) S( r o l l , Il l l r l ( r r i r i l 't r . ', r r l i l r r l r t ll l l l ( ( ' r ',l , r r ' l l l tl l tttr l tt i tt i ( ) s( i l {) t( tl i tl i , , i l ,r l t't i r l l 'l l ( ( :r l r l t,t i 1 1 i | I I I t i I | | | r r , | ,,,,1, | I Ir l l ItItIto i r Ir I r r l , r r 'r r 'r r t r l ti l l r ' l r r i 't i tr cr sr ' p o l ' r l t'zvo l l l u l tsl i r r r r l 'r ' rl,, rl ,l I'|| |tItII|| I,'II) i II!I1 . r i i III'|||( | I I | '| | | . | | I i | | | I I r r/, r 'r r r .r .Ir .r Ii r r 1 'r r 1 r r Ir I, IIL I,|,I|, ' r '{i r r tr i 6 i r r i ' r r r r r 'o l r i ', r r l i l r t :r l l l l i i r Ir tr , , , , , , '\r '" . , , , , , ; , , t , il,,., , ' "p l i '' ' , r 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 r r I t ', '1 , , r r r l r 'l r ', '1 . tl zr tl tl ,: t,,, tIi tt''|'t|'' l " """' r i til i i cl r z rt l i ( r l l r l l l r 'r ' r l l r l ) l r j , r , , 1 . , 'l . r r I r r . r l l ) r l l l r l r r l ttr tl ttl tt'zi i '<'"tl r ;r l r 'l i r ; . \i l r l ( '( 'l l tt' l t'l l l l l ' l l t'r \l l l U l ) l l ( 1 r IIIIi i 'r 'ti r tt:IIi 'IIl i i fi l l r r , , 1 , , , i . 'l l , rlr I1;(,Ilill (r rr t r rr' 1' I , , , ', , t , 1 ', r , , , , , i , , ,Ir cIi r r i Ir r '' '\r 't'tr l i ^ tIcIIcttI'ti |II'r 'IIIi I i i l l rr "l 'r l l ', , , , , ttt i tt'tr r l r '[r 'r r l c l r tl r l r vt't;tr l r l r ' i l ti ttl r " l l r l l t r l l l l r ' r r ,tl t,ti r ir ,,,,tr,,,.,,' ( l l l o l l ( l r ' l r l l l l l l l l vr ' i .r I r r r I r r r l r 'r , l r t l l r o t l tttl l tl t ; r ') 'l 'r r 'tttl r o zr 'l r ' :l tl r 'l ( 'l 1. 1 , '1 1 ', 1 , '.t.I

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

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

llr t t t r ii t t t t t t t t 'iI I r I i ' llt ( 1. , I N t' tttnl ,ql i l ' !,pl i tt ii lt r it t t t t l. lr t t 'iir lr t cr lf lr ( 'r rll'l) ( , ll l l ,l l ,trtrr' l t 1rl ,i r rrrrl rl i l ti tr r ic r r r : 'llt r sr ,r,lr r cir , t lr it lc r 'l, r r . ) 1i sr r llll\ ll, lllil'lljl, I |clll ill' I t lll r , t t 'll s( 't ) l r i ,,1,,' ,' l ' rl ttl r:rgi crt: : r. t t rI I I i I ' r,r ( r slo ( lo ol) i( xr i r lo lip t clr olt t t llr lt r ( r r t r tt t\tutol )ttl i a opl .i , r 'iit t r t t t ': . r t inii '. 1i.it 'slxNll'rttlt r plr lr ilil'li'' (r r t lt r r [ l) ' pol[ 1, ( rI 't r t llizlr t {llll tIrl ,l t,,1,rr ,' ,r' ,r," ,1,,,r,' r rl . Itttrl l o.r'i r r r r iir l'r r Jizii ( xlt l[ ( t I x) l'{) r ii qi t lt r I t t l, t r t lxllt {'ir " llr r t i i ,,' ,,,,' ,,,r,i I t ivr r lt t l rl rr rr r' r rrl l c ttl t,tti frr sll-it l liilt r , t lt t t t t lsllr t l'o: r 't llill( ir $lt t t gt t it t o, llt ' ( pr llit r t : t t r r t palii) ' p( f I 'it or it r i I l( ) r 'vilot ' Ior' 1i l l r Iri vol tt l IrIl .rr' r.r, llr' t t ivr 'lt t l lt ( r lvllllli olt t it l sint '. r ilt r ', lr t t lit r r lt t s" l l l ttl r:rl r,l i i l rtr.rrfu - i. lr t : "'t t t t r opllt slt t ozit , ( Zilnt noit r r llt l, 1{) li{i; I r llt r lir 'l r yi ir r ,,, ol rl ' i ctr i ri l ri It,ti ' | l ,,, ,,,,t,,, l l tl ,u r:i l rr{,irlt I ) tI Ii I ri I')I rI trI r ii Sco1, [ ,1{) ?1) , ct r t r it r sii' I t r llizt 'r t zr t ' Ir ,,1t, rr.nrro rt,.ttrri Lt git t o( lo $llf of it lliii, ct r lilt l l'. u'tt ttlol1irn, cu'. srttt ,lrird rrkrlil lr) ,\r'r,rrtr,/rroltlitrt tit'r ir:a ;ilsatt i trt sii' r r pr r t r iI I it 'vr lilc olt i'icr o. t nult o 1xr 1' I "or liiir ,u ,' t,' ,,' ,, tntdt.i pl i i l ,!. , 'lI ') . ( l( 'H sit ll I X) slill[ ( f ( i( ilr ll${i ,rt l rr ,,,trl ,' rl ttl i tl ,,,ti ,t t t ct ^lir lt t lt t it lilt it r lt 'cl'iolr sr r lr llllllr l lllr r r ( r llllt li r l ( ) iu ir r t 'ir zilr lii o t lollt pliclt lit r , l tr 1,.rr.rrrrl | (1{ i ors|) 1r, ; b) ( Wllslr 1i r lt r l'ult t : lgt t r sit t t r r r t i , , , , , t , t i , , t , t , l i , , rl t" ,' i 1,,:i t t '1, . u", , *, , ', ( 1ol1r l'''I 1l?l'; ' ,,,1, i t,,,,, rl u;r' ; trri hi r-tl l lir r lsi li( lir t t ' 1l) it 1'Nilioskr 'lr r ilr oll iii clr 'r r ls'r t 't tlr t r r cizr t 'l l! ) ?l) , t r : , r lt cllol, tt i ,,,,,,ri ,,,,11 . 1{t ?d; 1l'o ri l ,Lttri i i rrrl i ( l( r "d', , i. , ( lblt r r vicir r $i l't ls( ir l' r t lr i N, lI t ( nior ,, sit r l; t *izlil, ll rrrt,, r,l ,,l rrti i urrttrol i rgico, lit t , , ( , \ r . il, 1r , l, t i, . ( , ( r r . i r r ull. l. . r lr . . jr r r r r r r l: rrl, f;,..,,,, ..1 t,, .,,.1ri r' t,,,1 s, . r 'i, . , 1, . izo t l) ir 'r 'olr l' r r pf icl ir t ililr lo t r li'r 'ilr r ,,,,,,,,i ,l r,,l rrr' ' rzrii,tr' cllt h'ul ll. I l', s: r t t llll'( r lit ) l t lt ' sll' s( ' illiJr '1'( iit s{il'i' ri' l it , r ntonosir npf , t t r ir 1,,t, rrr,l , 11, , 1 ', t t colr r 'lr ', (M c Alf ir r qi g, , lr r t , . , llt ?: t ; Nilt r . 'sl<r 'lr t ilt t rqi rrrrtr. u,,| ' ,,, ,.1,,' $.,1' r' ttrl .trl tl ,

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

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

rlo iilt,'irt il'i',t," ,i i t"1., .*u,strtatc iir clr'zurilcbillo tlolittil'tr ,,,,'1",i ,"i Li,', (rB1'{r ('llro ill i.tt cvolttlir'r, rlcci, o otnritili,t inrlelungatd, nil' ;t,, i,,,1,,,tt,t, (lJrr'llrlS'M' rii opticri rLt'vlitlr' ilitrh6 i:t'lrr,(ii ovllnl,ua,lelt, ni ni'rru"izirzt, 111it,r1r.i ll r1, ry llirrkrr, lll?it) . o sclio (lo lno(llllil'i'l'ido trll'o ii.il,i!. Morlitirtfirilotinlpului vizrtll oforrii,
lor, rr rrru.ll,rrur,.(]i!I.(l nO p0t fUrniZA, Ctll rUli

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

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

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

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

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

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

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

clM P VTZUAL

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

I 12

I \3

cAt ontcE

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

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

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

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

in

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

l r r ! ! ', r , i

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

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

tl c

r 'ttl l ttti

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

tl r '

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

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

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

l l ) - I( tl l l l i l r l l l ) i l l : 1 \ l tttl tr tl i tr ttl l l l r i l j i l 'l . r n t t t r t t t r l r r l ti l l l i l " l r ) .l l r zi {'i l r g l 0 l r l tl ttt i t'tl 'i l "tt'; r Y t 'l r ) 1 , " tl t l l .g tttttt ttl |l o t 1 "'i l ,r, r io lt "rr lrlllill s:r r r ttr t, i tr tr ttr 'i l ' l l r '. sttg tr l l l zl i sr 'r l i l tl 1 1r , l , , , , l l r l r r r r r ' ( l l l l ( r , l , r l l ,"tl l tr t'rt I 'r l , r r l l l r t r ( l l l i l l ,r,,1' l!l ,,,"l "i t'l i t' |r ) zl l r :l t'- r o l l r r l l tr i l 'i i tt Itttr r '{i r '( l t' I r r , r , , , , . . | \ | | | ( |: I i ( I ; I I I rr r l r i i l ti l i l l l l ( 'l r l t <'t ] t'l l ' ( l ( ' (x rl l l l )l t r l r ' i l r l l t t i tr l r i tl l e ) l l r l r ttl tti : r [ l l r l t t t l t r 'i r r l l .l l t 'i l l |r i r r r r i .l }l 'o \'o {'1 1 1 1 '\ t u 1 ', t , ' , ' 1 r , |i l r r ( i r r i l i t ' t t t t l ""t' si i l i t l r r; r l r{' \Il r '' ,l,, t|"rrlrrt l r t|ttl :tt'' r l r ' II|:IIIi l i r i ttt II( xl i ( r l l r r r l i l r l l l r l t tr ] l , , r t , , l l , { i t t r 1Ir rt I I t t I t 1 " i,,,,, - | | | I I: I I I i II I I I I | ' ' ' l t 'r . r l r , l r l l l l l r 'r r "l r ' t'II'tttt'ttIt : l tsttl l tl l ttl r tl i r l o l l ttl o : tte .i ttl tl tl ttl 'i tzi i t ', 1 1 , , , , i , , t t i t l i t u l i r l l l l ) l 'l l l ( l ( 'l ( 'r l I) ,) t'- r r l l 'l l i l r tti t'i ; s : r r r ttt'r r ttl l i l l i l i l l l l tl l rrrl,,, rlrrlrlll(:r lt i r r ''l r ) l ) l l l l l i tl t'.1 t'l tsi ttttc t') , r l rr LJr ' 1, t , , , , , t i r , , , , ,,,ti '"'i 1 i i t""'t ''l r tl tl t lttrr, o r r ttl i tt' g l ttl ttr l tti :t i l i i tL tl tr tl sr tl sr r tt ,l) l:rlrr l r r r l r 'r r l i lr i ; ; r ', . , ' |t'tttti l r o tl ti l r r tr i ;i 1 tIti ttr b i l u t :i tl tl tu 'r tsl i ti , | , t t t l , t t t r t r l i r r ', t ( ''l l ( r l i ( l ( ) ( 1 i l \'( 'l l i si tr l i sl tl l ( l tttt'l l 'i stl t sttl l tt t t rr 1, , , , , , , , , r, t t t t t r i , , t , , , 1 t , ,,1 llt r,| , Ii t' tt l tl ttt'zr 'i l l tl t r ',t,t,t,t l t t t r t t i ! i I i i !i t u l u l tttl tti tn 'ttl ttl r l r '' r l |r tzi l t I t t t t"t', i l r l 'tr " r '' {'r 'r l l i r l r l .. tr r U l r 'l r tr r l ' ,f, , i ', - t ', , . l i i ' r ttr l l ' t' r 't ' l)l f "' ;ttr, llilr , il' l rl ( tl i tti tt sl Ir r ) l r l c txl r l l 'l i 4 tl r tt:,- l ) 1i ' I I l ': t t u t l t 't t 't r I r' l l rt I t t t ' ' I t t1 'l l ctl tl i i i i ' ttct tttzl l r r 'l i 'tti ttl r l :r l t l 1 r I I ' r r :i ;r l l r r t, .1,, t' rttt lrlltlt 'l l ttr l tt'* i s, i tl r 'tr r r 'l r ti :r i - l 'r l tttl ttt I |: I I I ' ' l l : I I I I I . t, rr.,,, I II , | | I . I : I | | .: | : l r 'r r l l l l r 0 r 'l l l l tl . t":i t'r ti ' ( l i i r sr '|r ''r tr '"tt I't'r tt"tttt ' t"r t'' ' , '; i , '; ; , i 't , 'r r rtr r ; ;;];' rrrlt lr' 'i i i r l t l tl o tcscl t'( 1 r r 1 1 r r t l . 'l\r r t u l u i ri trtl;i ''l h i l ttt'r .i za ttzi i ' ( 'r '( 'r r l r l r tl r l tl ) i s , '', ', , ,r, ,r r l , , 1 r 1 i r ', l r r r p i i : r , ,l ti 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 '' ;;,. Il ( ' r r sl l tzi i l r l l l t) l l l l i r l i |'r r tr r 'r l r . r t r l t , r t r r l i 'l c t ir,,.' '" r r l cr xr r r t i tt:ti n r l t'tttn u l ' l : I l . l 'l l a t t t i t t i i t i l r'l tr r ttr d i tr i t:r tttl i l e si 'l b so l tr l ( 1 117?): r r o l l r l r ' 1 t t r , , l t t t t , r r r I o s l i c t : t l 'l i izr i l c tl l Ar sl tti 1 i i i l l l l 'tl o r ' l t , , l t t t l t t t o t t t d ) 'i r t , : t l i xl ' :r ttti tl l i ( i I l r r l tr! t )I I t I | | I t t t I t 't | | r 'r l r t otr ':tzi i vl r l i l r ( i i l r ' 1 r l 'r 'si tttti i.i tr I't'Ito IIti L Ittr '' L t ' r l i t] l l l l ( \ p t'r 'tl ti l i tr tl c i i : r l t t t ,r l l , C r L , t , l r l ) r l r 1 : r l ( . I t r r ', rIr r ,.Ii b i Ii IIr 1 r ''Ir I t ' o

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

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

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

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

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

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

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

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

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

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

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

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

prin,

cranio-e.mefalici:

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

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

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

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

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

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

r,1r'. r.rrrl.orrflrrrirrrri r, , i, .1 rlr.o|iuirr| or.liilrrljirl. r,r.rr 1,, 1 ;iit, ";,, ,, ., ; ,, , , 11 .,t lt,l,t,,t.irilr rtrt|,i,,|,,r1itr,. rk, lirlrlottlclirrir i,i oIlltlrtrrrlogir', irr Irrrrrr(ic 'l ttt
Ftr' iif t' t t : t t I t I t I ri I 1111 l r l r r r r t's p :r 1 o l 1 r g i r ' I I I r , , , l , r r z : r I t t r r r r r l l l 'i l r l o l r l r l r i l i l "l t' l !l "i i ) ' sr ' l ttr tt r r " r 'r r p , l I r I I i I i I l r 'l r ' .\r 'st'r r i 1 i l r r l r r l r ' ( tl l l i s r r ' l r 'r ''

a) A fecgi uni r:rrl ,

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

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

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

"iliiJiiitli.,tin"

porr,r.u,,,,i

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

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

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

:i i !

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

r.4. pfioBLEME Dti DIAGNostrrc INRPATOLOGIA SISTEMHL0R

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

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

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

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

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

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

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

Cl T.imitareacfmpului rL. motilitqte oculard,coniuaatr;. 11,,1 ilillir'll pxpjoreazl prin in.pccla.rea-ex"curslilor volun rd sc gl,biLr| "'rrjuga.ld or, t3rl t0.col]lItzlle de p-rivte in sus, in ios.la dreapl,a5i la stingrr, r Ir.t.r.rIr ,,i lil solicilarea bolnavului de a rrrmdr"iun obieci caic sc dcilnii.lzr'i ir, rlivct,se direclii: orizontal, vertical, oblic qi in plan medio-sagitlal (corrvrrr. r('nt{ ).

r' i iii:ii: ;i *fl t +ury$ffi*ffiffi ,,v:" : ,, ,iiiiit i,, i|'i,::,*i#iilii$#*:#11lt *;,; -iii
' 'i:',ii;lilr'u*l,,i ,ll1#i:i''',1fl' ll;iil;ill'lx;'' d1?"iih:,,,"',,,,,'
I. l.,\ttrrl irrl uotilildlii, , . :;..t. l0

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

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

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

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

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

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

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

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

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

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

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

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

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

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:ll,rliliii;;t:i',ii,Jillll.t""ir.:'*-## ji,i":;:-..#,J,jljf ;I r

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

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

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

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

Jriq. .17.Diplopie generatd de paralizia rniEchiului drept superior de Partea dreaptA. Sti;]a coloraLl s-a plasat ln fata ochiului paralizai. Imaginea colorate se depiaseazl snrc in sus, cu atit mai mu1t, cu cit privirea spre ln sus 5i spre dreapLa' sc j e -lrii"azri p o i t c r e m a r c a . i o b l i ci l a te a i m a g i n i i ''oloiale spre slincu (dupi Rirer' 1952)'

m,, m,, ',o1 -o1

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

2./r.2. Paralizia nervului oeulomotor eomun

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

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

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

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

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

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

lrlr ,,rrl r l ir r ir , r r l r r nr it .r i ri c v rj s rrti ,rrl t, e c c s tr,rr' -]a " . .-l U i gr" ti ,,c,ftai rni pl egi ci , r1'.,r'r.r|. ,lri.r'i irr rr.lriliilio sa,uadolesilcnli, (tiickerst:iff, 19{l+), lr, siiliiircti , , r',.rrrrrrr l, r , r . r jt ' t r llr t ilig ro tl o a s o ,l i e ta m i l i a l e , fi e p erson:rl e. I{ i gl en:r, oftal r rr, ,| 'l I r, rr I I ) : r i( . s ii l11r ' t,l l (fz 0 s a s l i r n i ' m c rz e rl u p i i O n i grel ti si rnpl i . Il nrerOa , l, l ,,l ,l , r r , r ir 1r ' ir r r r r l s i rtrl rl ,,rrr.l !:.r r,;1 c u n i l a te ra i l , cu i ol l l i i z:i r.e or1;i i i l i ||r ;r,,rr0r I r i( I r I iiI , i r , i | l td j 0 ro N l ]l ' { rv c tte x , i l p :rrc c obi cet 1l r cri zrl . cU il, , l,rt l ',1 . ( 1 r li t , r r t . r r |irtrl ,u . , s rl rL r tl cr gr..r1,tisi r-i i r' si i tul i , iu l tu l s :ri i l , ,rrl e s r.ti 1, , "r,. rr ' r I l J u l (...\l r,-.1 , fr o ,.,.t, ,,,.,,,,,i ;1,,,. .,.i rrt,rz"tl :1,r. ' r ( t , ir . , r t , - , , , l. l ,l ;'i r., , ( , r r ) t r r lilui( ,l i r:rrtrrrru ti rl s i r0 a l i z o a z l -r, .te l mai fr,({ rr1:er}t o ati gcre , r rrrrl rl lr:r-: r I r , r ' r ' r , lt iilr t rl l .rt, rc s p trc ti ri d u n c o ri i n e l vl l i i ti i :r1.r,i nseci i .l , { o, ,lf l, .:r l \ r r . i r r 1lr r , r i rrl i tL t| r.r:s ti l ,0 rn u l t n l i ri l l t,, ai l csi rt, i t.rl soci rti | cu .rlr r;,,.r'i :r 1r lr . r ' r , lr ii l I l1 ri . In rrn d c c a .z rrl i p o a i .c fi i n1,(,i (,fi l l ri , rrci .rul , 'Jl: rl rr( (\ \ ' ir lr lr r i ( ) r l) { ri r(' rl )., l 1 } (i l ); .[1 .l rr.< u 1 r,.. 96$). S -rrLrrl t,s,ri i s l i rl Lnr:. r rrr r( '" r':r'i r ( ' 1r ' r ' r z r l.r lt |rr,i p ri rr rl i Il o p i i 1 r,t:c i i o i :r,t rr , l .l i l i i rl rucl ' i , sl Lr [0r,i rr0 rrllrrtr: rrl r., r ll r r r ir lr r . r r iri i rn g rJ i 6 i ri ri ;' i r.r,rri o il l :rl rrroIl r,i ri ti (l l < l l L:z5i S ol l rarli r, l l l ti l, ) - , , \ li' r , i, r r ll l rrrr,r,r' i Irr ,IIrrr| o rIrl rIrrl rrr. i I i r[r1ori l i i rrrrri l rl rrrr:l l i r ' . u, r ,ri o l l {r r ' \ ' i, it r Llr r ic rl rrl l o l j rrl l l r< ri rv t,r' i ro s l l,c l ti i r.rr :rt.l cl r rl rrrrrl i tl l i rrl, 'r'''r, ,,i ' r . lr ' r ' z r r r lr r lr r.r' r.ti irl i l :rl ' (i rri .rIr,rrrrrIi Irti(\\,:rl rl r rri (),l rrl ri rl r,, ll) t ; l l t. 4t l

.t l i n

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

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

4'I

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

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

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

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

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

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

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

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

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

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

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

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

t8

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

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

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

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

l"i $i llosor' l!)(ill; {lilrlr,lr',1 likx,,iwirr ' tkr Ifisclrot'-llriiAgl rt,Iosl; tloslrl'is ,r' t'littttsu,lrti de ar(xutltL t; Bi)mtrom'u'l' tl..r'i,ltrr <,ttttttttt (x)t'l)r.('Hilrrii .crvttlui (Lgiiffili se da;torc'Uo 'cltltttttttl,,t' t[. sltitl'itt (rxlrttr ,,i'castailivus'lui, ca urttt:iro , proccsclol hrloc,it'lr. ittsl'alaro rt' 1ta'l'rtlizit'i hematorir subdulat q.a.i. Succcsiunea -de "eiebral, lrritf iazr'i' ;-i unilaterali miozi tranziiorie ,,ste I I [-rt' 'r'in5,toa.rea: a perccltii l' 'rrpili' paralizie ptozd palpebrali' completi in final, fixd itt t"'ttt' Fischer:Briigi iiolo; a izolat dou5, forms clinic-e: a) lorma aau't'd', i naralizia ocirloniotorrllui este urtratd, ime4iat de pierderea o111lofliilrfoi itr tttrNI progresiad,, i,' Surn,n in care paralizia perechii a [II-l sc.ast.rci:rzi lreplar cu somnolenli qi apoi cu piertlerea cunostrntol' ' H1 Bindromul Iotoia-Eunt' Olialm'oplegia lir(sitrtltrrtn-ttl dureroasd" . o oft;n'ltnose-asociazii nosologic-5,.in catc entitatea reprezintd, tosa-gi*t) parte' Tolos:r (I9j41 a. tk'rctir+ de aceeagi pf"ei" o ndrratgie brigeminalS peria.rteriulc :rlo ritirrrrrlrri "u le'iunj itriimunfeeia, dur-eroasi la ul caz cu llunt gi colab. (1961) la qaso cazuri cu inflamalii gri ttrlo"r"otioini.-iut lente ale sinusului ealvernos' Smith qi Taxtlal (1966) alr folo$il' -rJomu de ,,sind.rom Tolosa-Ilultt', Ia cazurile care au lespuns tavoltltil iermenut ta tra'tamentui cu corticosteroizi. ln acest fel se pare ci' se t'intlo sit' srr fac6 o clistinclie clari, fa!d, de alte sintlroame asemdnii'toarc, diu'.citrtr tumoralo sau inflamatolii, care tttt ctrtltrltzii iini produse de'leziuni, in s1]ecial (Other. 1967; '\tilslcitr ;i [lottr'. cu torticosteroizi la tratamentul oromnt iio, ibzi; nnllf,lt". 19?3)' Lapresle qi Desi (197?) considct'ricii It'r'rttrrttttl ('!,t{) llll n(! tle'sindroin Toiosajllunt trebuie folo8it numai la caz*rile la etiologia' poate stabili cu certitudine Mai recent, I[unt (19?6) a stabilit urms,toarele criierii pclrl'm tLingttttx ticul tle sindrom fotosa-nunt : a) Criteriwl, anat'omic: deficitul tttrtttolttgitt prin leziuni la nivelul sinusului cavernos anterior qi nl fisru,ii "*i"-prio", ornitiale sun,jri"are. Structurile care pot fi implicate incltd nervii rttrttlo oftalmic, fibrele pupiloiilatatoari parasimlrilf ico tt l trrt'trt' l l i i *.io"i, ""ii"t a IIf-a, qi fibrele pupiloconstricloaresimpatice ale ple\u1Li lttlritlilttrl,irIirltt. b) Cri,t'eriut etiolioi6 qi' terapeu'tic: atingerea forrna{'iunikrr ilmittlil'rt csl'r' iiatizatA de un iirodes inflamator granuloma'tos oronicr 1i botrigtt, citto reaclioneazd, favorabil 1a corticoterapie. Cafuu,I'notologioolsindrom,nt'lui'Iolow'Huntloa[()1:irtstl'olsist'rrttt;t tiza't {I[unt, I961; 19?6; Lapreslo qi I}'''i. ll}77) : ir) rrl'rrrl itr I'trrltrrt(it 'i* ambele spxe; b) debutul mL ci'" lcciLt do ryirsl.ir (rlitr .tr1,iI:'itit' nrii6cii; o) (l('l)lll'lrl "nufl predominlr,rtl,l lll virsLtdo cu a VI-;), A""ua" it rrlo; (lo-?l lllloi llllrglrl tti;n1to ilaie fi nroelesiv, in citcv:l zile sau in inni tntLlto ()sto lllllll'1r olro rlc nai <xtnsl,rlrtt' debut ce1 ii,ota-itrii; ii) seninul (111 oontx)lllil'(rrll oftalmoplogici, 'Lrre're&' br-usc, de obicci ct clt(rvr zilo ina,ittl,oa' I oIl':rlttt'1llt'gi.i tItt':i itr:rlrlrtLtu' oaar*iu, *uu, iu rarc cirzurirll l,niirr lilrtlr gontrraL', r:tr.Irrlrt'ii' slirii ([t'buleazi :tli,,ralr'a air'ctiunea ;i-;;r"i Filr rnodeTAtd;f) dUrerea esLellnilAtol:llii, 'crlr.'i;itrrI rl{1t(gttlii 1r!rrlt)rl.lll g) rlrrorilo oital*ic, raroo'i prezonLin{f i*,rliri'. ilr horrrir:rarrju; qi. u'0o U)il'pnroxitttioo. oxu'c"arbrtrri ""i,o,"li.i urt sin't severe, cu caracl,cr contitnru ii :r,ti.,"r,nzii, tn t'ori do eurLsibilil;rr'i'. I trrllrrrrilr'i ll1r ou na,t iii^iu ao '5icri'ivo ttltxiltr qi ortr.''r{illtttl lrrl,vltlrri iirririf n-ffii-i",1lrri, urrtrrri hr i,r,r,iI,r,irrI li tlo rttit,itttttll,o h) olil,n,hnollogit, 1xrrr10 ir, ,*t .,1 rrurvrrlrri'lrra,lrdibul,.r; izulnl;ll, oxt,rl.n.cll, li,ti'g.r'. (liit rtirr r,rrzrrti) cornplri;ll, ,rxtornn I iiprii;i I

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

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

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

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

,.1:rl r., Il )17; lllhor nas si Yoss' 1970) . i\lrrllirlrrraiiilo \::lsctlai'e reprezintir d.upti, 'I'horla's fi \''(tss (l1l';0) ,1,r,rri trIl ri i Y fO 91,, iin cazr ui, m lar ea f r ecvenl. i a accst o}r t f iit t t l r t lit 'r t r r r lr r : r ller ir ism clt '. st t 1t t 'r t r lit r oir lict r r '' A rsr,ttj q; ,,i i 'ab. ( 197?) . bint r e acesi, car ' ' ,l , rl r:rl rl rri ri ,rl cs 1 a or ; iginea ar t er ei com llnicant c po'sbcr io: u( ',ll'lt lt {'ll{'r r zit ,,l t.rl rrrol rl t' gi i tl Lt r t r ', , , ise cu inst allr e r apidl, cu: r ; I oct al'it r r : t lr t sir ': i ili r r t 't 'r r lr r i ,,,r' rl )l (,l i i ri ' pcr' cdr ii a I I I - a si cu dur or t - : localizat L pe - t cr jf 'r t . ir ll ,,tt:ri rrri r,f[ri i si l se ir r soleasci dc r egr : lii t le t llbur iir i obit divo t lt 'sct t silr i , ,1,. .'itr.vr'istu'le inliiaclinoidjenc (intr:rcaverno:nsc) silli' reslt,trsrtlril' (,,pst'tltLrltItrtIIlItI''1, prop5resi'l' , , ,,llrrlrrropleuJi(ltllett)rt$o ctrro se inst:r'leaz5, tlttc lxrrtlr' trigtlrn-irrat'i nevralgie o ,, complt*il' oculolnolorjo $i l,rrlulizic ' ' d'' t r r lbr r lr 'ir ir t lr i. r r iir ' qi s, : , r com paniaz'r i r , f t 'llm ic n et vului l ,oi l ori rrl ' t, 1,:rri sr r t t . I isl t t lit r 1 ir li o gi: isi dolicom eg: r t ': lr r llar oot 'i st r p'r r r lc " ' " rrsi l l i l i l al c , | ,rl i rl o {.l l V r.r' nO ilSi. lr ( t r r r l'r 'zr ' ( ll l rrl i ' r1i i l c ol rt t it t ologit , r : ( : t r lest r l llr in int cr r n( 'lI iiI I ulLoi ! Lr r.:t,\:{,1,t,os) si nl sct nii, . lat c r lir r r r ir r ( , , . ] t ili [ ] t lf , ilrir L I iI |I r t 1t r t I r t t llit r r r l, t l r' j i l , 11ti i ni ,ti t t t ilr t 'r t zLi : it t lt t liil, , r lr lt t nt r lr r i s; l't lr r lr ' 1: r tit t lr 'lt t r ' ilL r r r r r r l i " ,l rl r.l (' j si nttzi l r '1r ',clr t t t ojt lit elc. tl(t t tll't) tt'lttttt j ''.1.:1.:i.:1. (i.tLt.ttr'tttttrrt'r:iu'lr, I'ara,li:iile rutliL.'u,Ll;t'e lt t r . zI t t r r r '1: r lir 'r " 1I t t t t t t ttItI0 inllla, r nLit or ii rrl i i l tot(i i tt l tzit lr t i vlt st lr t lit lo, ;i t rf Ir(' ri rri Ll ri 0r t I iblr 'lr t I lr t 'r 'r 't t lt t i i) |lllolllol, o! ( 'olI lll11( : ll t r t t ( , l{'t t l t r t r t t , rl ,r i rrl l l l l fi tgl i ; i ct t ! lt st ir ltt lt llt r s( 'llzilil'( f si t t lollir ii' slr llt ioiol'i: r L' uir t r r r : tl ' ;,, r, fl ri i rr Il l -l r so t r t r lr r |lr 'lcilzi ( 'll s( lt lllr t lit alt lilllLlr r ,t 'r i'l'lt lr it r t r r t ir lr r l"' r '( 'lt lr r 'lr r r il' sr r t t r lt r lt t llir t t iit 'i sct t zililI ii rr,rl l ,rl l r(' tl c l tttt r lclt l't lst t - 'ir / pr t lt r t t t ult 't l) t t t ( t t l( t lit t t t t 't lt lt t t l' lt r i ll r lnt ( : t it t r lr r t t nt r l' ,\l ,S i trr/t,,,r t t t i/ J t t lr t t t r llt t t t , il : ; t t '1t r t r or r lr t,,,i ,t' rttrl rl t ' ti t: ir 'r lt r r lt t t r t t l, t t . t r t t r I t lt t t i1t I r ''1i, ( ) : 1 1': r r r llr "r r r lr l11 t lollt t lll li , r,r u l ):l l rl l i zii' ilr silr r lr 'llr lii t lI I r I 't t I t t I t iol, t t ( lr I ll- lt t lslc lr r llt lr r lr t t t lr r r t 1,,rrrr rl r,,:i r,) 'r r' otrI 't I r , t I LI r 't 'ir IIr Lllr r lizill llt lt lt ii r ,l r.r rro tl l tl ot' r 'llt r l( '7il llii I il) r r 'lor I lt t li|r t llt l! r ll| ll( f i\ 'lt llli I ll r r r lt r r i" lr ll t i sr 'l: l( i r lr jll'lr , , i l, ) iiic ir r r 1I ot '|, I t Isil l ,r ,i r rI,r,i r.r, 1rl i r r lr iciolr r l ll( . 2( , 1{, ( , lllir 1. t ilr r hilt t l si' r ln'nt ll t lt r t , r |'r ; t 't i: i t t t lt i lr ll ' r li / r l1'r r i/ l l , l l l {l i l (' r(' l l l ,i i fl it t lt t ' t 'r i ! t |t lt ( lt lt t l nt r . t t t t : t . lt lit , ( "lllt r i) lllilir "l r r ,,t,l t' ,ttr l l tht lLt it t t 'r r t t t , , li; nt r t t l r lr r r 'l'iir 'ai il( . li( . il t r r olr I r l I ||r 't I r I ||{I ( ||t I I I lll|, 1' ,.rl i zi ,,i ol rrl ri r r I r , r . r , r , lr ii ( li ir lr I 1,,11,rr trl rttsri . l ' ) r lt llr : r r t llr , , lr r lv : t it t r lt t t r r nt t ll t / r t l", ll|'t t ' t I t I r ' ,
t r l r , : r t l r , rr ,r |l r to i t( |, l , , r l , r 'l | : r r 'r ' r : t r t r tl , :tti ,'tIi ,,,rrrl r , , 't t I o t t t , , Ir !I ( i l r r tl r r l ,rr.rrr,. ttr l ( .t|l r . ( r l i l : ) , l l ( . r r r 'l r .l ( 'l r '( ||||||tIIt IIIIII r ,'t,l tt;r l ,' Ir o IIIt ti r IIL tr '' r ':tr r ' Ir Itr tItti tttIr l l r tr r I I rr' t I t t t t rI t t I t t I t t t ( N l cl t( l o l \l l , l !'r |) ,r l r r r 'o tttl

tl c p e l cchea l t ffl -:r,. D c l rrtrl l ,, i'. rI r,! r'r.r . r r I I r r I r r r . I r Ir,.:i rl i rr i s .' i ^ l l i ,.' re s l x tc td re :l .,.,sc* l Ituri i i rr1,r,i rr;.rr.r,r t l: rrrr.rl . r i l) r ' r i, r 1) T i ). u r* rr.i s o p o ,tr: r' i rn a ,r' cr dri :1. sri i i rrrrr Irri A l ,rl r, r i. lr,.1! ;1 111( \ l; r r r , { ir i) . l1) l i t,s 1 rl ' r,1 .r| r,rr rrrrr* c l j l i tu r.i i n l ri nre(i ,l l tt:ol rrrri l ri rrrrrl l r, , || |',.r| , , r. r| .r. r I rI r. r l tr.r.,ri rr- .i ,.r,1 :,1 r. I ' 1 l ti .,;r. I| r l .al )Ll l c:i rrr.tt i r:r L| l rr, L"'i I rr'rr( r r ' , lr r . r ' r " ir l.r I' r* 1 ,' rr.r' rrl r' ;rl i i1 r 1 ,ru n (i h i uhrir)a.vi rl ' i r,(,rJ.rrrl .t r r " il) 1' r r i' :lr i ir' l (' i r ;r.r' i l i ' r' i rrri ,trrttrr,' ti i ,i l t..rrtl ti trgrrrrl ,rrl ',' Ii l r.r,l rrr. ' I', ,', i i i , ,'.' i , ', I )l 'l :rlr r r r r lr ic gr rr I r r r r.ro Il :ulItr rrr:ri Io s l , rl r,s r,r,i sr i rr l rrrl i rl r, r,ol i $,1t,,l i ;t. ' I , rI rt t I i t tr,rrri i , I r oI ir ; r r I il rrIIrIrr,rrr,,| | ,i | | iIII(.i i , i | ,Ir..
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, ,i Dintrnerviibciiornoturr, 0t,l rlri , ' ll , 1 ..,', ::., it r. .lf',,1i..ir',,]..1e?{)). ' '. :ir, t i:l ts , . lv l l l )(l l to (,i rs , tu ,rrta ,1 ,

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

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

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

t') b i nl.trl ttrtlt, nucltttl

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

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

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

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

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

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

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

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

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

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

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

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

It8

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

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

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

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

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

., r prrr':r,rizic d. gradmed.iu a muqchiurui obricmareestesuficienti

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

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

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

*n ii il*iii

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

opifiznnr'

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

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

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

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

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

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

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

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

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

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

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

carurifd ""nirliouitut initi;lo dacfl teziunile

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

:lp"*1'

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

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

ti'tt1to'rnli;iilrt pt t'oTtogra[i'a e'ti'o'pntogen'itt 2.4.4.2. Problemade dinllnostic neruultti oculotflotor artern. A)Para|.iziilalron'tn,arc,sitttflelcventittl'ilrti|tl,r1ll1;rrril,i1|'rr;rltrlttirlit ttcrltltitttttl'tttt ou"n"fr6r-,r-iii-o'ai t, t,rrs"rrl o.l m,i lung dirrtr. 1,.fi norvii vttlttrr'irltil trut,i rxil,. nr{uri. 1)l rliforif. rt* !"pii*t rn f,,i.',i,t ;i;;;;";"r.i-j tnzonainca,rctrcotpur,,,,-*fitt""t'1'otnporl'ltlltriqiltil'trrrrrtlolttsittttxttl cavetnos. a)Pt'oaesauuS|lll'I'(t.(11t,'sittct'r'ulrtt:ttlttttlttl'ot"'rltttttn,portxlllott'tlVli"r'itii lirrttic :tIrrrlrirtli'rttt rtr ( sd lttittt:' Arlf..l' ittlol'tt' til, ( I ' I I r :l 'r ( !t) ( \' t "-,riuiuu,i, "ao. t , , r z i l 't r , - l , L t ( '{r ,'l tt'i l l 1 l i .r i r kr i ttl .t'vi ttt'ttl o ttttl L tl r i t.r L t'l tti , t I t ' i I | ' I ' llitr rItr|.'Itt'||'tI il itttrrttt,irtrt't'I' iiilrr,i'r,pl 4i rr,r,hr'ulrt,biritrt,itlil {ra,rul lrn1;r*o. ('iu'ot'l(l{! rrfl{tr.i tt lrl6rrlll' ir,lli"t s. l)(r li:n'ti. Itt s!tlltslll 'llv('rlr's tt lx)l llli(]l'll tlotvttl txtttlttltlttl'rtt' tttl,tt ',llt'l'(rll AiLtt'pro(t('x(ul ttl'ttudtrotlt itl,tirrtc, I li llr i,r' l5

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l,'l';,iliiil,j;l:;iiillill;jl,

l-l l,lll'ililiifiilr;iritiJii,iiiii::rlliiilr;lil;l;l"ll';11,i:'il1'll1;t l;li;"i;11,,:ilil, r'rrrl'r't,''r( :rtr'r't'rt' Ni rtrtzir:tttt rt'' r1i.''"'.'".''''

gi l o,

pu"ro'J,ili,io,."u. r,ezi.nea ;ll,I ' ];l ; l";i';;;l'ii";:"r"..1;?; fll,t"-l" ^u"."';i

l:r r;:' lr ; ;r, li: ljr riln ir#rl*i:",ffi 1;i:{"g:#qJ#$t? i, :, ii' Illi1,ji ;i, I';I iii[,*31g rl,.;l1ii'1illl::t,,tr:,*!#itr#::*#"*{,ffi "k::rilr*11#x"ii;*t .;x?d,Ti:Tif"::,ff;:H:
Lr,,,,il,il iili it Ijii1,liiriili i'ili*i

,l.'',,';,il;lll'1,*f '.,il;1,i{x'ffi i1t"#:?",'"'":HtJf,[gilii*1',?l;,

ll;;ii: l;:lll;:ll''ll'i'l;,iliih"3 ,*t":1rgoame 'runo'"i

"l'":#i::tlfi ri;i;itr1*llr*rl*l"l'ai*ffi *"!*;l{6ryffi.,##i rli'll-li,:*l',::*;,:,lh$.t"i"rli,*xJi""';ii#.#o"",."*,.., '"'n"ii"i,

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;,,:1i:iliimk#;il**i5xrl?*atr,':ur#fff :: ;l;;,ll;;ir-l,,lll#Tif i,:,ilTiiT,?fiii"*k*t"li:x

jl.ii,l,i;l'lil'i,:ii:,'i?*ffi lr"*",:i:t":*;*lii;)*T""*,tT.ff "i,:":#;

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;i,,,i;-iir;:i*zui*$*"#ti+*i*$ffiiluts,i+rffi

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

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

i, i' liii :i I lil ;ririlii?*ii, ffi ,'[l jd'jff'I' i j jlt',lltiliil;l i'dtr{trf*lil,Hi ,t I

iil;r ilnriliix#"*n* iipl4*1n,htikirilH

r.Hrr* irrfr )vlrriru rrrr z.rirz.frr(\rr 4ig,,rr,ri, irrli,r,{ii rrxl'rrr,,;:ill,ll'l'lil'lJll,'r
[$

r.96 9). h) Paralizia percclriirr V I ir :r,llilrerle :r,scnrorcrr Si.irt sinilrttnu,l.,liutlti ^ pi 4n, celL sJewidale al ,uirl\tlui or:bttar. i).Tu.mori ale fosti 1tl,ru'ir1o-Ttalatine ptotTLa ltilroestezio qi rrcvlrlgirr . jn teritoriu-l ramu-r.ii 1r,.ll-1, l ncrvului trigcmcn, hiposecrc!,io lrr,r'irnali, si pa.ralizia ner.vului oculomoror e:lern. j) Paralizia cronici a neryului oculomotor exl,ern poate consl,itrri prinrul semn aI unei lu,mori din regiunea tli nl,rt drful stincii yi sirt.r.r,tlrt L carernt (Sakalas qi colab., 19?5). . B ) Paralizi,ile rad,iculare (intranearaniale ectranucleare) a1tlr. (rrl mai fi'ecr-ent ale porliunii ventrale a protuberan{,oi. -in,,lezitni ,\ ind;rotnul ]Iitlard-Gublei esie lrodus iie leziuni ischemicc itr l,tl.il,o riul arterclor medianeale alterei bazilare. Clinic se traduce prin tnrrirlizirr facia,li si de ncrt, oculomotor extern ipsilateral, cu herniplcgic tli. 1rrr,r.L,'rr, opusl'i_. Forma clasici a acestni sindrom are u:rele variantc, h funclic rto extinderea leziunii: a) dac5, leziunea se intinde posterolatcrrr,l ryi iirfi,rrr. seazi nucleul sru riid:icina principali, a trigemcnului, la tabloul cljrrio amiirtil se-adaugi fcnomene senzitive de tip ilgic sau parestczic pc Lcrrri, fala homohtelali ; b) dacri leziunea se intinde nurnai in diroclic 1xrsh, rioa,r:i si afecteazd,pa[glica 1ui Reil, realizeazraqi un sindroru sctrziliv alte-rn; c) dacl, leziuncase intinde in direcfie medi.rnir. qi cupr.ildr: trolvrrl oculornotor ertern de partea opusi,, apmc o parelizie si a acr.stlri nrtv ; cl) rnar::i leziunea se intinde in diledlia crlotci plotubeiantirL,, alirol,rrrz:i qi n:untleleta longiturlinald, posteriod,ri,. Q ) Pu,raliziile nuclearesint in gener,alrare ;i aprl rnri eltu irrprr,rrrril, cu al.ctarea altor sttuoturi neryoase din \-ecinr: i,iit r.. .\stlr.l. Dlirillizirr nuclenri, de ocu-lomotor exterrt apare aproape tot(lc:runa lsocilrti t'rr 1,rr ralizie facialiL periferici.. Nucleul perechii a lrl-a sc :rfLi aproape elc rr:rrtrul porrtin l,onl,frt plivir..l ipsilateralir, de la care o cale tlc asociatiecorxlticc,prirr intrrr.nrrrrl irrl bantlt'letei lotgitudinale postelioare, la nuclirul pcltlu nrn;clrirrl rlr.rpl, oxtern de partea opusti,. Acst ccntru ponti estc Nd{rserllfccttt (lc lcziunee care inteleseazi, nucleul oculomotorului cxtcln, qa incit, po lirrgr"l paratizia de nuqchi rircpt cxtelrr, :ll):ll.e;i o paralizic rr prilir.ii lir,1,i,r'rr,lo rlo ilc|p11r.i prrt' qi tlerilfia coniugatir I globilor ocrrlitri rlc prrrtcrl,oprrsi. O rfr.clltne limitet.i h norvul facial si alxtucerlsilc rrcrct;i lrarltr {i fiiri, pararLlizja miqci,ritorconjueatc r1r,latcrialil:rt,r, sugcr,c;rzi o loziirrrulcni,r.;rll, la m:rllinca infcrioat.ri ;r ltrrniii, lndo lctsiti rloi no'l-i lliliisr:sl lr,rrrrclrirrl certl,r,rl foarle :lplr,4c lrtrul do r:itlirlrl1,.t)llnllizirr,rirrtleu,rii irilrrl,rrlrrli de ootlornotol ertenr nu txtc rlr.ii, rlacr'ii:irrcurslrrrrlr rlo lattl rrl ri, cli rkri ('oncornilr.trl; trucleise giscsc in apr',11itrr'. s(rlLsoci:lzii llrrlalizilrrrriscir.ilor rle la-crilltate ;i plr';rlizi r rrrrilrrtcllliisirrrlriluict'rrli Irrri:r,lii puiliilicri. at Sinrlromttl lui (lus?tiui (sittrlln,ntl ilot;;o-[t lu.or:a urLulftl lrqnt: . tttlui pontin) s(' lrlllit(i1(nizl'llzi (t.llIti(ji V, rlt.fioil lrl tt('l\.il()r 1rIirri,t.rrIr TI,YII qiYItrIrl, lrurl,r':r llzirrrrii,lrrl)rrrlrilir|^ scrrsilriliiirlr'l,r'r.rnoll!:.r'zill, (1('\'iil1 de pi,rfor,ol)r tsii, il illolrilol oirrrlltlisl)l\. 1)itt1r!ll sililolrsli rii lirlrrgrnus {ilrc bfi1c tlr 1|rr,lr':r lr,zitrrrii(l{r,rrlr.rrlriilrl lllir?: ,l,rrrrr 1i \-lrsrrlgil, r|()rrisi .Nlonl,rrrtN,l'i, l!r(i0). lt\ Sintl.tonrt,l. Lu.[ ll,utturtntl (*irrltrnu.l urrrrltl tl lt,ilnht't'(nl(i ) \rl tliU'irrllt'fizu ,zii 1rt.itt lt \'1.:r rlr' 1Ir1l1,1q lr.zirrrrri si Drrrr llrr,rrlizirr 1l(\n,('lrii
l l t r r t rr I i t t o z i l , d ( ' l ) i ttl l i r o l r r H i i .

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

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

rt

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

t
il 1
I
ll

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

'in

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

lr

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

,,,. r rr

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

ir r r J r li|l. r:

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

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

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

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

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

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

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

) 'l'r-'xlurau ( tl"stctgnustrltti farei l.ente ttptoltittetic. ,t Utl ect:ul tiriutcat |' ,, t)t'/t \l'rticaie de curo.i dileritc este in Ilta pacrelt,rrlr, i.r. .str r'i" soricil,atsii tiui,p'ir-irea u't 'riicat pe ceni,.lr er,-r11'r{rr ,, rlrri, ii'rt) irr salp ngeslj, esti miscat-l;^il#;,i;;jtr.u "ruJ'"u"..t,,ir'i direci,ii.ln ,.,rrriitr l{)t.lrlll(j apari: nistagmu-"ul -- ' optokinetic. ) ,. , ,, , ,., , ttirttt0tnusul.ui,_;c11t!Uuia,r rotator srLr\ tlistq(nt| ).tllu .rt ',, ,( _ i t ..,.! tttt , t t t . : l. t ., .t, (lir1 i r n l r ot,la l]t ^

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

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

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

r) r, irrr,,.lr,rraliziti

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

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

;iI; : r1 l, i, lli:liilu ;1, i#]r liix nsft ,,;li [mlri#"1*,uffi I i r;, 1 i

r , r rrl ,rrl i riI r , or r t ir lir ljr r a; rtb tl c t,

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

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

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

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

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

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

c,'i,'l,t,il's'ipsilatoral f i hotrliliipo.sl'r'zi'

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

'll

tl( ll )llZ\').

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

'",'is;,,air,rr1 fstiTll In.fPrioi (ptolltl)rtta!ial itll.'.itttl crlr gr'ttlt;rl ii st malrilc'\lI ptitr p;rlirlr/r:' O" l"riooi ,i".ailol oculogiri-ub inciucjsarp nl)11' a globilur o(:rllirri coniugatir alevjereririi:i.iiirrt" pn,1oaleziunii, cu siI(lr','t'l jnfeliol ,.rr urr s. loir,. rsocia.$i i'r,1"^i'-ii,gi SioO,omufTorlillc tl' siluirii sislemelo' tle asoci{rlio:rlr'.irlr. ijnj"tI ilin'"nua fif;iijt.r-"d i"cdmpt"te ale privirii de latiralitateorizorlh, c"."i i-pn" cintl globii oculrri silrt itttlrtrlrlrrii nistrE "tii,r,ii paraliziei. ln diieclia I'itt I'iraliaiile migcdrilor conjugo'te tle tertic:ttlilate (sintlttittrttl !) jll'rlischtrwil s' h "u'?Jrlunlt" comisulii albe posterioare, alc nucllilor lui din reglllll{'aLllrtr'lrrrrr.i .i Crial si ale iubstrn(ei cenuEiipcriapedu('lirl( I rrl.' i bupranucloa'r'rlitt rttrr aoietlo"i p.ino tibrele ocirlomor'o'i ;;"r;l';t.;;;i (ar\':r' si'-' L;ltiur!i vcrlicalp' ryivirii " iiir:'riiliilTj.'i;l o pu'i-li,i" r'r'l('(:tx rr'l inri-aor"rio' (craniait prorl'ucparalizia pr-ivilii i.n-'us, iar mai posterioare (cautlal) realizeazi parallzla prwrr]r rn Jos' rt' fn cazul in care pa'ralizia migcirilol, conirgate de vertiur'lilrt'1't' irr lta'ttthrl.lrt gdseqte se purlotizia miqcAritor orizontale, teziuiica din regiuner 1ep12li 1J.5olli qi Srrlli' llrtil "*o"irn'* r"i'"ii'iur"i5cle veit icalitate nrr apar in leziunilc 'irt;:ttl:tt' paializiil,' ""tio"io"ii Si;"i,bl;;i;i .i in leziunile care a'fecteazi' zotlil l)r{'l"r ntmai ci sup'eriori, r-" tooz; Pasikqi colab 1966;Bnderl1)(i1r) i.rx"oli*fifo" . colabl, ibt}t;.rttltli ' oxtrltrlrrrtt Sindromul Parinaud se mani{e)t; prin imposibilitalcl portlr'lr ocuJari' globilot' a -hlr dr. coborir(' rolr"Ariiol de titlicare;i1 sau paralizio itttrttttilrigcare de verticali{ate' lntr-o ,n"iiiA-.ti."' i"ii rr'.|rit rtpui in sit''' priririi "";,Jf.ia" t"ri it:"cl,"nr,afcctarca i,i"ti. i'iiiriitat l'ir'trk'trir jos foartc "el apare in numai to ti.p ce i; ilb;];; ;;;! ;i lrr l1r ilr_?irir,", il--ll.s L asociizi rdesea cu absenla rcaclici l)ulilxl.(i (lollv('l'g('rr1rr dtr ' ;i; miclriazS, relativ2i li tu menlinelea ree-c{ici ;;t-. It''" tlisprtt'i{'irl jos, plus ln rparc in privire Daci,'*;';ierd; si iniqcareade modirii qi a oonvergenlei. aplorpr. do uumJrlo\lllllll(l{'irf rl ReEiuncr precolic(llal'lnsle fl':.rl'lc I rr ..indlomul Pat inaur[ {{' 'rt(rt'iirzii rn si, ca alal.-' itl lidicrilrx' "",lotrrJi-Gi'ctm l" l)l(r()tr l a rrilu', in special a llruscbitLlui ;;;;;;-;i;. o;;"}ii (x)ltvtf'gr'rrl.r tr ' rl.'omodal a1e Sr lupilei, i'ncrioare ii tleficite in )ol,ilitatcp. -ebt{i il" krzitrnilt' i()tlir'Li excepl a I\''-i p""".hii .In A'r:oli;"ll-a' rr"t*lrl.i in tirtrli.l,t' trtiq|r'i.r'il' ;i;cdrile t1eurmirile pot ti pristri't^e, ;;;';;ljidt'tit irr ParrrliziilrL'v.r'1" t i"t oinitt''" DiIlopia 1'o'rt''Ii 1r'oz' i.,i."i;" ttu ittrlttr'' tlirlitqttl't satt vestibttlalr't opl orl tiiri",- ,st,it,',rtarea 'irLeiic,-r lerl,ical. Sintctizincl4llpjgtlinlitr.r':l1Ltr.i,Il{'ILdcr'(]{)U|r)iLlillli(jiiil||,iu'll'llxIiI .,t91, tttltti'l'l'trittr'l'' lsi'ciit,ttttnlsntiIrrlti tttttllr,rlitt lloi,4elqrl.iculitatosir ,,ris,,,i: r'('gt,rrrlrti s:rtt ltttpilltt'lrt tliirrirrrtleit : a,) ltit'ttlctt'it t;ii;ii,,;";i,,t;irlorii (1r)rr\'('r'gt'rr{'('i sittt ; | ) (' b) sp:tritrr i;;;;;i;i,;; i'i;; r'otr*trtgr:til,ir; I I I III I |)|||1 I I f1 l!rlrllrtl' tlislrtAtttlls i,'r', ittr,lttsit,'ir't'rtlizia vitlirrllrlt,ir riqoirilol nisl,rrgrrr
r i: l

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

rl ,"r i l r{, i- lor r ils l) t . r ,l) r l r' l (,i l ,.l l )l i tr1 l r,z i rtn i i . I)rrn rl i zi l ,l :tri tt,i i i r,stc , rl c l i l l oq11 r,l r,l ,r r.i ('l t l' lii,it r r ; r r ' r . r r rrl 0 tr I rr,I rr i ; I Ir,; I i I r, rl r' l rrrr' l r.rr rr1r rrsl l r' zi rrrri i (l rol i rrr vrrl i ;i l ,t rvo l lr , t lr , lr llr ( , 1r , ;rrtl rrl i z l rl ,rr). 0 :l

r||rInrirl.Firrii rrifl. vrlIrlr..( lrii. (1r'iz('l('rt'Il(,{.if.rir,|t{rr rr]n)(i(hl(1(rllll{.(', :rr(,ti.li, slttr^rl. r gil.r(t.,.irr\.rr,l,.ir. si (1. r,,t.ilil,, trrlli,rr.,,,.r rlri rrrtrrStiirr(,i, Ar'fhl" irrlrlirrrc.sivi 1lr,,v.rri{,i rlrrrl.zirrri iriliac(r}l,o "r'iz. rirrl 1r'rxlrrsr'(lr'sr criilrrl r.or.l iro trtrr,ltrart pr'tr l lrr rrrJ;r,iirilc coi r.iugat ci (rlst)ilatliru firls1ri, irr- lr;rrril,ia uror urisrr:ili (x,llrlrc l,) ) r,lipidc $i . -in lr;r.li.(., rtislilg,l'irk'sntt nri,rr.l,r ri.c, specialorizc,.ialt., tllr. qi v-ortical'e srrrr .rrrlirl,r,ii,ir'etliat inairrlr,rle a fixa un obiect (u'tel de,,tremordo lrrr'lrxrrrr"'). ,\r,cste.miqciri pot fi acompaniate de tlemor il capului. ()lrr.(,k)lriir rr fos1,descrisrli,.in dir-e'se cncefalite, iiinel prod'si, de i6ziuni rrL,olivtri bulbar.e;i a,lenucleilor ditla{i din cei.ebcl(Jicnder, 1969i. l,') ,ll i.oclouiile ritmice ole globitor oculari pot upiire:l in leziuni ale rrtl l, l i rIirrr:ttrlirr.cerebel. rrle ruclctrlui roiu. oli\-ei' lrrrllrale si7sau ale r'r'r'rrr1r.lr,r' lrrlrunorrrbroolir-ure. Se manifesti, prin contraclii riimice ale llnlrilol or,trlali ('u o flecvenld, de 50"-90 pe lfinut, clrora'Ii *" o*o"i*rii, rrr rr.r.lrrqi ri1,rn,tnioclonii ale.palalului mdale, ale f01ei,Iinlbii, faringeluij lr,'r.rrr'r('lri, rl irLl'r'lgn*rlui si chi:rr ale membrelor. Dc 'rrrrilte' miocl6niile rl|,Iri|'r'.rrrrllr'i silr1, $e'de diferenl,iatde nistag'mus, i.si. o 'ri' elaJizi, clinici rrr:rrlrllrrlli rrc alllri, cii nu eristi, fa.z[ lelti_ (i ) p|in ;lqilatiu alobiloroculuri,(,,ocular bobb:ng',) se craracterizeazii rrrrlr'rrliirrvolrrrrtrrr.c sincrone ale ochilor 1n ios,-cu reyenirea,imetliati in A fost- d.escrisi, lrrrzi{io rrOr.rnrlii. in leziuni iiisiructi\-c intinse alc protu_ lr.r:rrr(r.i(Jrishcr,19e4).ln leziuni ce,rebeloase s-au d.e"qclis mi6ciiri ini-oltnlrrrr. si Ir.IrrlrrlIrr,u r.i ni$ciiri oriznntale ale globilor.ocdari, cu apa{iti:r in r,r(,l|||i, ilr llrriDul lirririi ur[ri obiect. :i.1.7. I'roblcnre de diagnostie etiolo.{tie in palalogia sistemelor 0rtrl0|[{rI0tii irr lcristl tt ,prinriltalelorrouze ale olal no,plegi,ilor prezinti, .'l'r't,r.r,rt'rr rrrrrL'osr,bilirrlr,r,trs pr,actic,cr rltale procerld.m la u"sintczit, etiopaiogenich (rlrrpri .,\r'slrrisi r.olali., 19?? ;i Popor.iciu si Fa,scu, lgg0). l)oli. .inJec!base ;i in.feclios-ulet gtce acute si srlbttcltte: ..:!..1,.7..1. rr) || rrrrI'I irIi I Ir 'r-i.riticepr.imitir.e(t-pidernicrii, z,,siiriani, ubici, prin arbo_ .1..). b) )lncefalite necundare(rariceld, vari'olii, rrijeoli,, 'r'rrsrrr.i 'ir'o1ico infectioas:'i, |rr.rl irlili rlrirl'rnictr, n)onontl'.leozri gripi elc.). c) Encetalite rli. I''r'srr.linl*(iiilor generalo Ifebr'i, litoidri, scar.lafini, lrise 'conYulsivd,r iir,;rIirrltrrii, ttrurnii, richetis jr'ze, malar.ie ttc.) al) Nc.11ingite ltrtrrt acpte sau rrrrlrirrrrrlr.(r'cningococic5,_.}ncumococici, t uber'cuJoasii,, s#itis rr]o.niogor;rs.rrLr' rri..) tr) J.)oliradic,loneuopa,Lii (polirad.iculoirer.-ritd, Guillar-nlli'r.(t1 r,{li,i{'tk)z(: prrnneoplazice etc.). f) Nevrite interstil ir}lc secunda,re rrrrrrr irrlr'<rl,ii rl0 r'ccini"lato (sirr zitc,_o-tite, ostei1,e, abceseetc.). g) Nevritc rlir..ltrslrl .u',r' h,li . inlcc{,i.lrso.(tlifteria, botrilismul, tetriniiiul, s.a.) lr) Nr*r'il. irnr'ro,k*c,i.. (lt.slvlr.crinale: asa-ziscle rccurenic,ial6 ,,p,r'aiizii
r't I ll( J t ctallli It 01 c.) .

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

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

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

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

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

pi l"*

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

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

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

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lrr' rrlrrl

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

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

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

7il

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

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

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

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

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

l r : i t r . r ti

t,r,, ,

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

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

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

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

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

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

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

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

r t ) ( t t t r , r o{io it t lt t ;l r i (l (,s( . r 'is lni. liyr u, r i t lc t r t ] r t i0 Tt r t , lt ilu. rttot i r . i. oit : rrri l rr, l rrrr r ir r ir ( si't t t lr ot t t l ll t sNTt ln, tP'it , - t r ) ; lr ) r r t t car {io lt r lilzillir lr r , ,,,r, r' !r' rl r ( sindr t ut r l Nur , n. gt r ') qi t r ) int it zit lclt , sr t , t t it hr lit t lt t lir r , Lit , iI r i( r r ,l I trl l rl !r)i rr i, cii, r yi lr r ,r , ot t vr , r 'i; ll1, ii ( r int lr t t wt t , l,l. t t i,; lr l, ir : su, t .ttr,l lr t i ll r ill il r i ,,r ,1.i 1r. qr: r lcr li colc llc! l, ipt r r i r kr pt t lr ilc 1, ot r ir , tr:t 'plt 'zit t l'ii nuir r l, ,, ' l , rrrsi I rrI I rrrr': 'i l i , it r t r lr , t t t r ul r t t t Lr lt i, r rlisDt t liut jlr r pt t I illt r ' r jt t l t lt t r t i rr:,1. ri rrl l r ir r r lilr ', I ic ir r r 1r I lt t t t r ', lic r , i( 'lJlu'lli. tt , s; r t 'ol, t t l ,\i nl t,,,ttt t l lui lt lir : ( sr t r . t r l lt r i ll t it . l. / , lrils ) r 't r I r lir r r I r r;,r r lit t ; , ; rr rl i prrl ri l ;i l o r r ilir , 1i t I it r r it r t t r r t lr r , ' , r lr x'ln't t r lit r lili( , . sir t t ir , l'r r lil( : r t r , llr r r r , lr r r ( l ' rrIrl :r l rrrri r. : rr lit t lt ilt lt r r t t t t t l Ar lil cir lc t t t r xlr , t r t l r lillt , llr l: i, ,r t , |lt t 'r 'I t lt vt 't t l, rrrrrIr: I r' r'rrI {s( t "i, r lir r |r r zt l| i) . liclr f ( ir r , 1r u I illr t 'ii l: t lt t r t irr :i t lit |r l: j lji r xr r r lr , t t

't't

ru rl :r r . il r r lr r ?ir ll, l (.trl l rl rl r , rl r l :r o l l ri rrl :rl i .r,l :ri l i l i )tl ti tl l l :t rl r' l rL :rtt: r lol.( loI r s I t ir r (i :r l r g rrl :rr:rl r , , | | | \ r' I I ' (.| | | i I l )0:l i c Ii :tl l N i ' rIl l l tl l l t l i )l ttl l . trrrrl l r r r i|lz ilr lii, S ir rrl to rrrrrl \rl r .r l ,rrl ,l < ' rl r,r.i s i ri l l l | s l i r l l ' | | ' l i tr rl r.r:rrl l r. trl rr i l l i :r \ 1lr lr . r |( (I(,I{' I t r: I i I r| | | I I 1 i ' r' r l :r rrrro c l r i si l t l l oi l l r (,{ .l ti l i l l i . l ,r' zi rrri l r, r|rl )r)Dr r ill) ilr f l, ( ' |l|u s j l t(l r()n rrrl \rl rr' l ro l Ii s ituttl ( i rr: si si t' rrrrrlri l nl )rl i {, Iti l ro l : ilr r r r r r s , ( 1( t le \i l u ti l (' l ri l ro l l rl rrrrro D rc z c l rcefal i co, I,{' gi uri (' l t Ii t(,h (rl l l i t, ,,:rrrriI iot r r r (I, iliir r . . l)u D i i ,H Iu ti ]l :l l l s i (i u rl a l d (19ti 8) k' zi uni l r, gl l rgl i r)ri ul tu ,rl ri rr r iI ir iji) lc s r ] ! i d e l e z i u n j i rr g i rrrg l i o n i i s p i tal j , fapl i rral c l rI r,xpl i Irr fr : rr.l l r . r . i: rI r si. ( r { ) ci na l i n o a F J .i iu rtisl.trtfia i)tltsc,ulat'd ntiotolticd, (boala lui Steinolt) lr [os1, (k'N('ri$rl urr'(,ri {) l)upili mjotir:li cu contraclie lelt5, Ei slabi,la lumini fi cotrl'('r.g-cr r1ii . lt) ll,i.?,pltsul 'lLtpiiar ciJnsti'l inttlo serie de tniscriri allcrnllnl;r, r,rrlrirlr, rll' r,rrrl|rrol,ie {i dc dil:r.1atiopupilar.c clonice Si ritmice, amlli, |Ji d{'stnil rl',, r{ r'lrlirl0, cNre intol'cseazil irisul atit in lepaus, cit mai alos la ,,lrrovocln clr," rrrirrr,rrliIrrr' l)Lrpilare (de piltli,, cn ocdzia eJplorirjl reflernlui fotornolor.). \{,('ri Ji'roul'Il p{)lrio e\ista irr sta{e ,,frnstii" qi lil unii subiecti ltorlrrit,li, rl :rr' .r. r r J r s lt ' r ' i ir r t l e o s e l tii n : a ) p a l a l i z i i l e o cul omotorri l ui corrun ]l {i cl l (. ri l rr,r lr ' r ' s ilr nr , ) c o l e c , l 1 re s ,s c l c ro z i i i n l l i c i (oa un fel al e ,,ni stl gnuN 11r prrrlrilrrr'") (liis(!', l9ll2) ; c) miastenil gr.r,\-is; d) rl1]eori f:il.ii valoale scnrir) l .r' i l ri r lc lit r iir i ( 1lis tr,, 1 l )i ? ).

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

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

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

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)I],. I'IT0III]IiMI] I)I' DIA(iNOSTIC iN PATOLOGIA NIIRVULU] TRIGI,]MI]N :!.ir.l. Ntvralrtrit lriryerrrinalii ''.;t l-1. \'rt.trtlrlirr. lri4c,ntinriri,)primitil)ii11 (irnproprirr sr.r,u, ,,pt i,marir1) il, rrlril:r rrror ,.irIioIIIIIicIi)I) irotrsliluie o cniitate patologicli(sarrmai lrirrr, r ,'t til;rlr 1r:rirrlrqilr'), clrr,, ttupi Arseli si Opresctl(19i[]) .qert'fet'i,l:r,

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

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

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

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

1,,rrr o l ara lizic a per echii : l Yt r - ir '. sr' (rillrlirl('r'izcrtzit pt ttt 9 ) Si.trilntmul ?aratf i,lleminctl td I'tti .Raer.lrtr r ligl't llLi, sit t t I t 'lr t t t l'lr r r t r lr ' l] r 'r ' ,, rrtl ti t i rt 1 eli1, t t lilt l ncnr ului olt alr nic) n YI-ll. r.rri lllnrr paraiizii alc fcrechii $i enoidd,l'ii ul lrt''i''lu''ul t lrtliz' rtz:t l0 ) f i.ndrontn,l tle r,:isplnlie ?eLro-sf t, :ri r rti i nul l ,i plc t 'le ncr r . i cr at r icni: pcl: chilc I l, lI I , lV ; i Y, 1r r 'lr t it r r plr r r r rlr'irrlu-s(. felralgia o{i,ahnicri ii }irratljzia, dc pcnrlrtr l ll. rt ttltttrt o'r'nn 11) ,lnetrism.elc de (|'rterd. bo'zil'arti ;i. ntal,.f ! ii It .trtlt t'i.t) rIt rt i t rI rIr' rI r' 1 l r rlrlsirl.ri dj n fosa cerebrali, po.<tet'ioalri )pot sri rilll,llzczcrt)gii t t' i g r,y, rrrrri ' al gi c,it t sol. it cuneor iSir loheinisliasr t r f r lci: t l( , \ r sct r i; i( ) Pr l's( 1r l, llr ; 1) ) l!) Lea tn,i,leinflarnatorii lot fi l:tlctr)ri (rl,llzirli (l{r ll(rvrrrlsi; irlil, ttl i , rrrri l tti gtm it r l l, r Tif elic, r : il, f i in ce1c0nt lr 'l] ( - '\ lscni f i olt r ( lsr lr r , lllill) l rr si ui i i nul lr t llunint Ll pdiJer it i t r t ni l, im : [ ) Ar t r hw) id"iltlr lr t lt nt titxtrd, (tio tnrghi 1rottlo -ccrcl:cltts \ti jurtapolrtirr(') ; lt) 1'r'tlutoirliltlr 1'.'::it rlrri t,,r rrlr ; <t\ Zrtt,u postcr g8tlcria'tt(i po.'Ltedoclan$il,violt'l(ic ll('vl rllgii l t itl< i. t r t t bit r t 'i r r lr : r r l ,,1r., l rxral i zate indeosr : bi lr t t cr il'oliul llcr vr lui oI 1, aJ) l) i( l) --po 1.mni;t,,llo l)l(roiLl)tr' , , ,lt!iil, lt()rpeticil - bittc outLtisctLtir, Irrr('r)tlr,'t , ,t , r i rl l nl qi po t . er it ot 'iul cilLlt , t r ir tlll n: L. 't ilt luht i i] lll) cli{) r . St r it sr t t r ir t zrr r r lt r r \ : r t 1e m t llt c or i I i li( 'lr liilli' I ll( ] ( r llr lr r iii' l ,Ll rrr.rl rzi t' pc t er il liul r ( r sp( xlt 'iv, \ ' ,i i l o l )ol l )('r 'sisl: I t : ] 'r t no il idclr r t r glr l, i, iur leosir bi llt , blilr 'ilt i. i\ r lI sr . r P, r ; r lr ' ri sl l r o ,,(l i sir si. czio ;,,.r l) ost hetp( ir jci " ( . Ar scni5i O pr csct t , 1l) ?1);) t l) t it : ; ': r t t lt t t lict tI it : i ) ( liisr r ', l1}5: l) <r ' it t l, ilt r . r ll r/r/i i i r,ri , (rrso ciit i, r icll o u( t r ills{ ) - 1'n pr t ) zullt r Lst lt t lt llt lt t i lui A|gI ll llr t lr r 'tl , r t t , , t:rri l orr| j o }ir . l. - \ nlor r '{1( 'ilii( lo, ;i t t t L r' , lt t t '. i: r l. t t lr ', r, i ri l r sttrtloqit ur li cilnlol, {'r Ll1dr Llt 'r 'jLt r ( r t 'lgii I It I t t1 t li; t alt or iilt t l L , rr,ri rrrl l l rpit l 1ot t l, t iiut t ilf ilo ii it lr 'r ni'r r r r lt li)1, t lt , t t ; r 'it zii l .i ) Lt:;:it t ; t i. lti) t llLt t lt t Li&)t,llt t r t pliclllt ' t llt lt r ict , t t li llr t r it r 'lr ll : t pr ': r t lr L lt r xl, lr t r 'zit r lr lr ', ir t lr ,,,,i Ir.rr l i rot 'lr I <.i, ii ir t r r t r liJt t lr t ir li( o I ) ( , s1, - 11'll'lllll1i1, it , t,,' ,rr1i r,i ri rl ti l'i) r ir r lilllii, i ( , \ r nolr i si ( ) 1t ir 't r r r t l,ll) il) ) . l .l ) l ,r::': i. unilt nuck: ilor r lr or 'i4it t r : ; i r r l. r t . lilt nI r t inlr t t , - h't t lbopr olt t lt , t t r , '; irr r r ( llis( 'r ', ll) i, : l) r t ) < : l: r r : iot i {ioLt llir , i r lt ' t it r t t r ilolii l c: t lir , r t t r r l ri ' 1N rlIi , it r t 'r r ir rt t lt t t 'zt 't t l, lt l,l|'lr ilr o < t 'is1 , '. ,,t ,' i It i tr. rrr r , r t t 'ltlt . Ij rr s, . 1i lr it r ii l: t lt t t l i, zr , ' , r t ", r , r r 'r ', ir r i'it r r r it lor llr i I t {'t t r illt ! I I '( x l t l l l r i i rr l r'rr( i l ,l ,,, :ri i i r.r' t r r ( }: t l. , r 'zi( ii 1r , r llt ,, Li :r ru ;r lr 'ler r , . il11ll1111jr li'r l'r r sillil, llt llr llt t livr , llt l llii t llt t i r ilt l r t r t r t r l , r,l rr rrrl rr.t l o t r r lt t t ir " r llt it t r ' I r t t llr r rlxr t t lit t lr ; lt ) l, r : it r nilr r r r : it t t lt r r , t +it t dr ut t , t tlt l,t i ll qllt t t hr , l rrrr r 'lr . / r r lr or rlt l t olt r l; t t r r r t l. ir r lt 1r r l, t 'r ': r lizlt ' ., ti i tt, ::i r r li: r lr r ,rttr ttl rl t t( ( ': t ! t t ir r , it t c: t t t ' r r r ' I 'o'r 1, , 'ilr lilr r i o lt cr t t ilt ilr oI . r l, r lzirl: nt t t t lii' r lit t llt , llr t oz; tt t t l'l r t r ,,,., l l l r ri rl rl r li I rc t t t i I l tt rtrI II r ; r ', , , t m lqit I t 'ir 1r ( liir r 'r ', l1lj, : i) , l , l r tLr i ' IIIr I ) |I ||iii i ' ' .t' .l .i l . t 't t lt t t r r r r lt r lilt nt , : ; lt r it t r llr , lr nt it t lqi.ti t t t t '! t t u lt t [ ) t t it t t 't , t t . ! t t ) t t rr ttttttt r [ qir lt ir lt t t t it t r r lr t ' l ,tl , l ' r.trl l tt r.r 'lc t t r : r i t r t t t lllt lt t t lt 'r ': t r t r lcr t , I iiI I , 't ( |I ) I ; 1|)t t lilizllt zlt ' lct t r r lt t t t l l. t r 7, jllt \ lr t it t : r lt t t lt i t t t ; t l r r it t iv r ir ' , , 'r 14ii lt r t t ; lr r ulr ) ',( ': r r '; l( l ,,.l fl l rrrl i r.r ll rl rtr!trl r' , r' u I , r I r , r r I t : t I i, vlr r r r r lr r lr , lr i lr l! 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I' rrrr t lr z. r iloI r r iir lr r :' .1;.::.1 !,'t , t li: iilr ' . lt t r ir r lr t t l! t t t lt ( st t llr t t t t t t t l't t t t ) j'r r ! i r l'r r r r l( r 'r ' rrrr(' rtfU l l )r' i t: r r ) I it r r it : r t cr t l, ilt r llizif i iir l, t 'ti{r , r ir ll lr r llil lr r ll|| l; r I ir t lr t lr t i (l trr lt t l r . t lt t , r r i, 'r t li't r lr r t 'r r t t t , l't ir '( lr r t t . zii lr r . ir r lr i) ; r r ) , '\ ir , r r i. t r ': r ' rl r' ,rrrr' ;l rl lllll l( '; ( [ ) l'ilslt t r t r r r lilr , , i l r)r' i )l tr(' zollt , t lt r sir r llt t : lt t l) ir lllt ii( [ lll {i( r il, ( l( : ( 'il'si Ii l 1' r, cl 0| 1r,0J] r i0glilli( , ( ,ir , lli) ( liii( iit il( r ' I l'llt l\ ( ', ijr . nz{) f ilt lr .sr t t t llllr lr t lt l t tit r t lr t r r ilt lil'st r t llit llt lt lr l'il ilollt llll ill t , t t r lilii v, lr rr' , ; r' ) Ihr..t'i t t r : t r sr : t t llt ,,,rr:rl r., rl It:rl l r r r '{, ( lf llioi{it l r llllijclr ilor l) or i( nl1li, lll t lt i; llllt 'olt 't 't t t o{t r r t t : t I I t t rrroi l ot al riilr ill . c{robsclr ii ii. t t t t m t r it lt l invt r t 's: lt ist r lt t t 'lt ' lt r i'1"r 'r 'ii "t r r l r : r 'lr r r,rrl {,, (l l r tl (, i'iir il;r . 0li1it lnal. O 0onlt t zir l cu lozilllli i'lll}lir nllr : lclr 'r ( lxr ocI ziot it l ir r cur 's, l vilI ( l( f ai. ii l) il*r liziilo. I ir . ir , lo | ;rl ' ti i i (:1o , . ir r L 1, ip I lt ll, I : iI ilct r f t i bolt r lr i, r t liur t f lr ll I lllr ( 11i( 'i ( lc r 'llr t.rrrr r,l i ol ogi tr ( it ui, 't or gr lll) ( 'l( 't ' lt llli( llN c( 'iL' c( 'odt r lolt lcar in: l 1) {! 1ll 1' ,l .t' l l ttrst:ttl llr esll] ) ( 'r 'ioilt o t le lclit llt 'r 't r rl'oir lr r I ) ( 'r sisiil' 1,r," i rrl i .ri rl :tt'r 'qi,ur i a1. lr e, in sl, lr r liilt 'llivlllr silt o ( Ll|f ( ' r ll'( 'lllir ( f1 ] ( lit i l) alr lr lizil! supr llllll( , 1( . lr f li) ,rrrrl cl i oj t, rrrIsr , ii] ar , siinilil] ( 11. ,.rrrrri D N l c si ull l) ll ist ot ilr : r l lllllii polt c pl'lf Y{r lli or i( i( ' ( r ) lr lllz't '' llt t tr lt r llr ', t r r ' l ' ;rr' :tl i zi a llet , i: lli lclt t t 'ali, ( llit olil, ii Llziur lii ijbr r lor s Lt pLlt r ( [ ( ] ci, ] f ir t t t sl; oolillr ( lll. par t ialii a 1: t t lil t t lui sr llt r 'lit ] l' r r r r t l. r ,,' r:rr,tt,r' i zr" rr zii, !lltiilrlf trtrlirrltli , rrllrirrIii, jttorvalfl ttc taciatrlt supofiol avilld o l o Llt(iz( r, rIIrI r,r,IrI ii . Astlel, lxtlnavuL po:11,c illor.01iIruritol 1i ltu l)rozi|l l,it lrtgoll,rtlrrtir,, r is, clc li1( Li) asilnclnin, , 'li''I i{'ii ( li''r iDr r ' rrr ri ri sci ti l e a ulji) r nu, 1i( x) , r 'ollor(0 rlllt.{)rnlto, oa'lorrvollllliiiuii Iiilril rnol,ot'ii ,r,i^ tll;tolitil ilti;cEli1:lil,iitr[ilot' rrrr' ,t,i l i ntct' .si. t ii 'f . it 1, i, , ", du'i culn ar n lillt ir t t il' t r ut i sus, st r t 't t t t slr t 'i: ir lr r pirrl,c (xt prr,ralizia,Irr,irirr'li''llrl r11r, tlir rt't.retrali ,1,r,:r,i o h.rniplcgie lr.stii'irl1ii, c.tt'lrtrrl., i'ttttrori (plin 1r:rsoll]zrre srtfori.]c ila,cirllcc.n1r'alc ' rrtrr 1'ra..r,lizii citrr4lir,,'ritl:llo, ltsitlrrrl.irt lr'{"r tt'lt 1i.,.iiilor t, l, irt .u,r'e, prirL ir rt.r't:sit ( ;r(1iontuerlzii,(,u oca,ziil' c\l-)rosiei elnotioni[lo. rii itrlr'rl :.1.6.t.2. t.)ard.ieiile Jnt:ial,a y iJi'rice (frin l''zitiIIi rrrt(1ltriit'(' ( lr ' \ 'r lt lo lopout r r lir it r : ' l .:rl r' l l r" l li {r 'ul'al' dit r l, ut r cl prirt lPniu.lli ttttt:lcure. [r]si'r' r'rrtlr:r rl'' r\) -f'oroli:rri faria!,a peri,fet'i,ce ,rr,,ri r ii' lt t it t r ': t lr r r 'lo r ni l, ttttt,l t: ului iLt r vuhii f icit l ii l) or '1iunolli111r 'r t 1i(ir 1,,i i uri (vl ,!( 1ulilr t , l, um olale' inI lr inat or ii ot c. ) . 1ir iL( {isi, ( 'siir r r r ( it r ( \ r, tIi I' Ii I t t i t I rrI , cr r 't L,l ;,rLi i )(l o ohict i, lir r r r liziei f aei: ile, o lcziut Lt : t ,lilt , soioLilt t lt 1 ( ; i t ! 't r i lozir lir ii ,:t\i r,t' uzi t o lt t 'nLipleplicalli( t 'nii, aalicli opusi, ir r r t r r lizr lr L rrrl r.), l i l oalt - se lt ot a"r oeia qi t ulbur lif i d( ' sor lsil) ili[ 11( ]lx! h( r lrit r i( I l'lll r . <i. i, Jr r z, r r''r t ir r ,;,rrs(j ' i ' l i ,ziur t e: riir ilor scnzil, iYc) ; i, d. t r r 1. lt r lli r r r lr li, ( r r ll' illlt f lt l{' ( jf lt llicnir t t ivt 'r 'st 'lll . ! jlr ( [ r o: ilr x) r 1i ,(l { j l r(' t1 'j or i'c collt ur eaz?i r r rrrrl l ti cl i cl rt 'it 1. tt'it:e pritu Le2iulli iu.;lranuclcnrt l'r' lrrtzrr' ll) !'ant,li:;i'i, Juuialt: p ari,J l :,1,t,rI rrr.r rri o l0ilit t r t lit r ir : r i, ilt r r t r of iziologice lj I ) e I ) l'z: 1, lt t t t lt t r lt r t lr lt r r r {ir r t t t r t 'r 't llr t i I r r {'i: r l' ll, l lczjllllii osl i. ul, lof ) olJr Q I 'i| , 1,, fo Itort ; l, rsllt r / t iiyr r ' lr ili \,' . l (' l )rrl xf lit ll( ( ir t t |it lc sit r i': icr lt t l liiolir niilii ( s|t r l, ir slt t l lt r i S{1lt iI t r r t ") , r gisir : ir r 'lil o 5i r lcI i t or r |t t sl ir ') , ri ( i( lius ( 'iir lr l r,l i rl l | ri ]l cr0lot ir r t t , '1r 'lr r t r ltiililJ) iI r t si lr r lt t t it 'lt t r lt 't r it r r $r t ; l'ot t t t 'l trrrl rrtl s| ttri lr ililii( ii gr r r . lt r livr ', I ) i1'( r 1r l) l rrri i l rrl i rl i (( lr : lr lr cr ', ll) ii'; 'l'r r ir r t lr 'lt r i r , ollt }. , ll) {i'/ ; I 't t llr r , lll?l; I 'l1t 't \ r, r| r ri l ' i rs( lr ! lt ) 3( ) ) l, r 'zir r t r il( .ilr llll, lll( il{'lll1f 1xr l, I i gr t t lr : t lt l lr slli'l llit t l rl r, tl tl lr r ' : r l: r lr r t t r t r ' {'l'r t llr t r lt , ll) ( i{); I 'ollovir r it t 1i I 'r t lr r t t , ll}i'io) : 1,rrrr, '
u l , l ', tti l tr t:r l t:ti r n ttt 1 n r l ,'l r t1 1 tr 'r t t r I t t I i t t t I I t t t tt ' I t r l r ' tl t tr n l l h r l ttttl tt r tn Iu :l o :; ( i r r r l l o l o l ti : r ) 'l 't r t t t pttl , ' i l r r r r l ti ;r l ,i r l r ,) p l ,l , l r Ic|l ;l , l tttttl ) t I r . r | t | r | r Ir ',:II;r l l !l D i l l i l ti l r ', r r I t f i , . r \ l t . [ ] r l i r ', I t I ' ;' |. l 't t ) a t :t

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

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

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

t|tl

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

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

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

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

t,rlrlrri),i.' .s.r,liti rr, l.ont:rhrl,i. lle.un fontl O" ii]u,.ir,,, r('rtir. ro lrrrxlrrl slrrrli, sccuseparl,iale, cind po"oriiro"ti"'Oi*"1"t ur ,.r.r"qi.fti, cr,,,i lle iill ul. . r'r,srrlrr.ilalt,, i.tt,o rlt.car. (i. scc.se dezorrlonateri1i1 r.rr l,,i;1..,,', ] ,r r.irlirrr ;r rr.(trr.( rl tL,autr.itie,c:Lte itrtertseazii pe linrl inlr.eaea rnust:trllr Irrrrr Ir.rrrilrr.i;rrii ;i rr, rrilrrrlcrr. rco\te criz..u'r,irziL urecl.i d,nr,oit.rrr rLi.( rr(1r,, rr;r'rr:1rr'lrrlrr sc r.rr r.,,i'lrciiil,, tn ri.,"_ci,ro;"" iliiocate Oe ,lx,.i t:rlr:r .lr..l :r r.,r,r.rrlrri. Sc..onsiatri ;i p"ez"n1ait"i-siricrgirrnor.rnal,, 'ir.r'i l:r r.,rr tr.:rr.ii.r I'r,rlaiiilui,," ur,,,,iirri*",iri',i,i'"uon,r.a,,, ,,,. l,l, D r, ||1'.t,t,. r:|l ||l|. i r . l. , 1 rtl ,.,r,.1 ' rz i l o r.h i u l u i . c i rrr " ,rzl , l a or,l Izi t,,,.hi rrtrri .,.,. ..,i ' .

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

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\ , l l r a s i ttttl .]r r t:i tl t,o r ti tu tl tttt t,stt', i tt tr r l tl i l l tl r ^ , l l l l . sl ) l l r i tl l l l r ( l i l l ' r 'l 'r 'ti :ti stttl ' l ti i l tl ttti l i '{r 't t , r , r r 'l i r t l t, o .i u l ;:tr tn i ttn i i l o tr l tl i zl tl l i l l t tr ttt- r ( l ( r l l r :t ttr \( 'ti l l l l 'i l ttl , 1 , t , , I r | | i s t iti Io tti Io tItItIi ct', cl tti l sl 'tl i l i 'ttl t( i tl 7 'i tr rrrrl i tt p tr xl tt|r ' st'. ( i , ( {) l l l l i l ( '!i i L ttttl si 'tl i r tl 'r i i l ( ' I1 r l ;l , t . . i 1 r | i i r l l r l ) i ti l 'i tt a t,l 'l l tsi ti tr tl t o <'l ttzi l t l r l co l r l x'i , ||Ii I( i II|':I ,r,r, r . , \ s l 1 L .j . tttt * ,,,,l r r ,'tr i l o l l r r t ( l r r ( t sl l { r '( r r tr l r r r ' p l i r tl 'i l l l r i i u ttl i i , t 'r ', 1r,] f i , r ( . i s i ,,r l ,.i 'r r l ttl tr ca " "g 1 1 ' "1 ,,t, tr tttl cl ti , i , r 'r 'i r l i l oi .i i tcl i so tr i tr tl i l ,, 1 ,,' 1 tt'r l l l tl l , r 'i i zl t l l tti i ttr l r r r r '' 1 r " r r r r l o t t t t 't r i ti l l r r l i r r l ttl tti i r r l i 'r 'i o r ', i i t' Ix"t't'l l r l l r Il i i r Iti Itti stl p 'i i 'r t, 'r r 1 "' l , r l r r \ 1 r 'l r s i1 ' 1 r r ' It{,r tti tIr I;IttI 1 1 'sl ) ( 'r r i i \ ;i t'l ti r tt i 'L r g ^ 1 '1 1 ( 'l l l l l z:l r t'' tl ) 4 r .n " ( h 'l i l l tr l i l l l l l ( 'r i r ) t u l l tr i ]l Ii l tr , I f ) , {T r r r .r a l r / n tIl i ttt ',1 ) tt'r tl r r l i 'r ' r 'r ;1 r 'o i 1 ) l !|) , , , . , 1 S i r l r r r rl r i t I I rt t I t t t ' rt : t t t , l 1 ) 'i i , r 'i l r r l i tl t' Il r tl ttl l r r ttr ' ;tt t l l tr t i tt r I t I t r I I t I t I I l t tl str i l ' ' t , l t i l r r l r t r r l i ,t'r r i r ':r 'l tr tl Itttr '1 ,i i ,',,,i ttr i ,'l r t ; , ; tttt'r r ':l tr sr ' i r so ti i t l to ttl l r l i l t ttttts,'l ti l r r t r l , , I l r r I r I t i t I Ii r t.i tl l tl i ci 1rrr1 g i l ttl tti , t'r 'r ':t si ;r Ir r l r ttzcl o t ,,, .r 'ttt1 r 'r tl t' l ttl l s( 'l l i l r ) l .IttI'tIIo ttttItr i rl.Lvr." tl I sl tr tu tr r | ttt ttsl t|r 'l i r , l r , '. r . r l r ) r l i , tl l i r si i Ii r ' :ttti tttl t,l l i ( l ( ' l tti i ( l i l i ' ,l,l I l ! l r r .i tr l l tti ,r tl l r .t,i o t, ;i r l 0 st.r .r |r r . 1 r 'l tq tr t|tr l :ttr , ( sl ttt Il tsr 'i |ttl l r l r r ) l tr i r r l i ,r 'i r r r . { r .i zr .i r ,, rrr. i r r | | rrr, t rI i r I ( ' tl |' r 'r ti ttl l i , r 'r 'r l |l tr 'l l r l tr , r r , l L r i l i r r , i lr l Il tr .\( l t'i - l ' I'i {l l l l ) l l r l l l , , 1 , r , , , r r t I r , z i l i r , r ,ti zr r l r i r r l l t si .i ttl 0 r l r 1 r 'tl tl r 'l L '( l ) l r ) 1 1 1 , 1 , l ' , ! r r r i r o j r .r , i r r r cr i ,'ti i ,;r r o r l r i r i r i i :t I rI i t t tl I r i ; t I i r 'i Stl tvi tr l l l t i ttr i tt tztl , , , \ r ' l i r . l : r li l r ' Il l l zi l r l l ) i \l l l tl i i l i l l ttl i l i l l r ' l l ':',i tttti ttIt r o l tr r ', r l ;tt r r ' l r r r |r ' I I I I I r' : | 1 \ i l fi ( 'l l l i l l ;i ;l i L l 1r 'l l r |l :l l i i tr 'i ) Sr ' l tr r ':ttr t\ttr \ ' I I , I I rl . r r ' i ,I r ' r I , rrI t , 1I t t r ' r )| I ', :r ' l r "r l L r /i r 'l r tl i r r ': Llllr,tl\lr f r r l l l r r 'l r ' l ,r r :u , .l ,r 't,r [' 1 t,tl t n l tl tl i l i r t. ( l 'r "r 'l r r tt t l ':t i l l ' l 1 ) l 'i l l ' ' r 'r l l r i | l t l l lr c r I r : r 1rr t I r t rr t r I Ir|t ( , 1 l l 1 t , r :.tt,tr ll ,tr t,r l ,l i tt |r t:;tr l tttt"t : i ttt|||'tttt|t l 'tr l l "' l "'tti tr r ( r ;ti 1 |L tl "tr ', i r r r r r , i t r l r ', r l r t, r r l l .tr r zr r tr tr r l l r p l l r , r l r r r ; LI t t r' ' r rI I rt | | rt I ) l l r l l i r l l l ( r 'l l l r '\l l l l 1 |l

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

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

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

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

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

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

r zi( i. i r r r t ; t t t lt t t l ,,,i ,,,,r t" " ' i ntl- o cluzi lpar cm il, t t ll( 't t i lr r selr iubr t . l- r ': '; " i ';;'r:l;;,;;,r : rr)itr lrrrrrliziiti si cliolosii "i diYflso i i*r'iriit" r rr\r'lrtli{ "p)'1t'iii', ill(" ilt t'tllsttl (tluT)al lttrntttttils-" (''Taniocorcl)l t, ittnilt |.s.bit'1,tttic r r l' "t" L zit r t 'i ir r ilr " ,rrrl l ol unol ttr r1 e hi per t ensm nr '- it t t r . - '"n"i'"i', ir r . lllr ilir r l r ''r " ( t r . r 't il. r t . r t r r i : b) i. ie: ii', r t ae n?r t t illt i. t 101t st i( i ' , ,.i i ' i :,;r;;" ,;i , , ; c. j l l oxi ce. r r culiloam e il( llslit 'r ', lur llor i si : r llt ' lr l'r r ( 't r \ r "( ) I ||I I f |sI \I r| ,.| | r0D l rl i i
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;i'.,;']:;'ijitti.-afx;iiii;,:)(|rtfn,,i,1itesi',l|t-7l'toct*,|||,,,,,'.,,,'',],,,,,,||,,,,i,| t tt t).t tI' tt!ttt i t i s i S otr nl ' ' ti i t ' ; ' t, ;u ; ,,1, tt,tt' l r i t,' t,' ,,rs i (\n(1('llrlil('r sotni' rrilL ll)i{" sirinsoi)u ;,iiilli',iiiil", t.Lt , ,]ti;,,;;,,;' l 'to r . ]tt't) ( 't'sr tt"l ) ttttsttl e i ,e .) "",,tilL*", i e ) i 'tl cl tr sl l ' a to [tt!ta i t 'i r , ', '. l t r r r t m e t isl l c
('lr' (('/?'-/ir' r) il. 1c;iir,i1t '|t.t'4.t.tti ;;1";;;;;r:o *" parult:ii ltrtt tirllr ill lttitlt ,lLrclsr ei iologii, lltcnl,ron e:interluj;11) sf irIir( r' : it' inrl'rtrmlrri,t trspt'.1 ')i (t\tt't'tI /,,:; ;"it';ir;1i;;iilrir iii.r;"rtlnt torsori ai f (l'ilrltli( , i',, crizclorniQrr'nout7;rl) in cursul unor' tt'( "i,r'rui 1li?S; (iastaut', l9?3)' .19?3' , r.olirb., "ili r'li'rrtt'ttlrtt (irlrrclr'r'\ {zrlt' ?lir,:i""i"t ,i,,ii"l :rrxlitiie l'r"zinli.rr,rr
, t , t t n r , l t n l 'o t 'i t t l t ( tr l l n o r 'l [e m p n ;ttl t, l r l c t r u i l ci l r r r l ,:r zr r l i l ( Ar ''n n i 'r r " ,'iti , r 'i lttiili'";t'": tu n "'r i - :r ]r ' 'i ( 'l r l r '' vt'i tl r 'i r r tl r tl tti l :r ' t' l :r r /J' rrl lll l 'r t'

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si ir lrrl irrti(rtro Lii illinri(x tsirtr ,l,;i;;;;,,'i,,i,,i,,t"],:',i,,rt irr absc i a hiperltrr rl :l trl('r'ir tlo s ttrttr str tle rll'c ;i , i;;;i;;;'1-ii :'i-: qi, ile obicrri,so acompiir i:'t'zii ';; ,l, 1,r,tuporal. ' lolr ' ")';;;;;;;;ie sirtl' reprezcntatc rltr zgornrtltrtttl't'itctrtttr..tr' i:\ ,,oltiectit'e" urehro',t srttt tl. /ir/rrir r'rrt't ,,,,.,:;L,i;'ail,"htl,rlllii'ii,rtt-''ito.i <lt i'rLllittatttt:
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'\ . 1 . 1 . . lIt]t:.ti o e u si 'n tTtl tttttt[o r s h i tt:l i tt' l ttzo ti r '' t[i 'l l l r tsi ttr ' tL ' 'l 'r . r i t r t l , r t l l t t t t ,. r 'l l tr ttl l t'l 'i z:r 1 , l ) l j l l tl '( J s( l l i zi tl i ( ' ', l ) r ) l tr 1 r \tl l l l i \r 'l l l l , ! , r r . : r . . r ( , l r i r't'1 t h r t' j n t;r l r {'l i ( 1 l r sl l l ) i i \'1 u l si l l l l i i Ii l l l r | , , . ! l r l I r l l r s{ l t$ r l r 'l r l 'l tl i tt:ti , tl l tr sl ' i r \i l ( '( 'l l ) l 'i !zi r ]i l l l s{ r r r l l |l tr i :l i :r rrio(lrll , , r r r r r l i t ( l ( l l ) t) zi l i i l ( l l l ) l l l l l i j l l sp tr .l i tl . \'( 'r l i j r d l l l l i 'r l ( ', i l l l l r 'l r ( l i r l ' ( 1 " o i r ( "tr l l r ( ' l ) r i \'r 'l tsl r ' tIr l sl i l r l t'cr th i l r tl ttc '\tl o st'r i ' . , 1 , l , , r i r 'l t t z i r t o ch i l o l ;i , , 'l I r l r 'i t t c t l c zct'l tj l j Jtr tr , l ) L l i i i l l ( 1 tl l r 'l 'u ( ' l ) i l l i ' l i r ( l i l r l ( 't1 " tl :tt l 'i i ti Ii .tr l r t':t ( ( ,1 ( ,t'( ,,1 t,i .r 1 i :tl r l t. ([ i i I i I l I ( )i rt i ( I l ]l tl i i t1 ' Ittr i tti l r 'si :tL r l , ,1 'r , ! , ( . , ', r i l i l r l i i I l , 1 , 1 r , , r .s i s i i u ' o p l l r ' \r l so vN g i l l {') ( l l l p o r - i tl i r r fi l 'l l fl ( 'tt.,1 1 1 1 {l ; l 'r r ;r o t'r r :r r tti 'tt * r .r l ) r r i ' r i , . , l r r l r . , l l | ? $ ) . 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( t l ( '1 ti . l x) l l l l t,\'l l l l l r i sl r r r a zi i ' o l l 1 ) zi l i r r i ttl 'l r i l i zl r i i t, \ r 'r 'l i .i l tl t';r l ) l l l l l i ' i l r ( ' i l Il l i f( Il l i ( 'i t't'l t l i tl ti ( 1 . ( , . . r r l r {i {' l l tr g ,i r r si i r ( r tl |i i ,l i t , . r r r r r t r i l i , s l l i 1 tt:i ttl t . sr 'n zr tl i tr l tt'r l l a l l i ,l ) r 'l l i l ) i l r i r .- {[( l tl t''l l tsr t.r ' si r l . r l "'z'' , t r l r l ) r . 'r . l r .i r r ,l i r r l r r i . ( ,l tj tr r . i r r .l l 1 'l tl .'( .i i IIr .I) i l i Ir i !i r r r tttII1 1 'Ir '. 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l l )',:i ; \ t i! , x f Nc lt . I i)? 8 ). 7-, I t tlil_r'lt wltIi.t'.iJorwr., cnrat;l,efizate pri'tr_o mrre srmililu(li,rj .' :rl,, , jr' \r.r'tr!: rrr:rserlilL lrr,r,r,lu ll.jnidre, se datot,.sc ltt\or ceulc Lrnultt sar. , \ s llel, r lc i i ,l c (N l ,e rn x n j fe s l i ri v c rl i gi ttoti st tttttttl t. si rLi , rL, rnul l ,c ol r p rr| rr"is ljc r ' , r ' 10 nu a u _l tu i i i rrl i n c i ta rl ,e a c ri zel l ur di rL bui l l l r,.N [i rrri r)rrr, I)rr i Iri r'Ir.' r r ( |irlr Jis t lulnlls u l , L rrl l [rri rti ]c tl c c c l i i l i ]rr:u l ani ffsl i ri hr vogol :tl ,i vI ryi ri rtl i ) r lll' r r r i r lir c ..r.' ,\s r,rr,' rri ' r,rn u ,rri l b s tr i rii nrr' i r)ri ri rrrrr. s. i rr,i rrr,s. t.tl.,'itrl,, tttrlt:,,,ti rrr.ntit,:r,itr |ttl,4,t\tl.t,tLbl,, i\ lt,ou) ,el,t) rrdirslir;r,, itr tttroltr .,,i .!,',., , ! I , . l. \ |w' 1l||ll ' | ' | ' ,\| l tl l ,1 ' ' l t' l | ' ' | 1 1 l t.rrl rttttt1i i l tttl tt' l t' dtrt4| ' dri | l | :l !l ' | ,.l ,(| | | | Il ' | .| | |l i r\\ l tr( , t . 1, , i |lt irt, , l l )ti !); l i ,i rt(fr, l { } ri :.1 ; l \l i l i ,fcsri rt, l l )?S ). I r r li. jt lt , . t lr u t.u rtti (ttl tn l th i t,i ttl i h,l t, l oni tt ). N l rrl pl :rl ri r.i rr. l o j ;d x .l l I t I r'l r, I rrr t l r, t r . r l: rlot t.,k . l rr, trtro r.trtr.rl i l trrl (\1 l ,r, 1l l (. I,rr,,' .,, r.1trl l trt)l ' r.l lt I t).t rt!

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ir r t t I r t Lt t r I , 'r 'I t '' , t i( i ir t : r ' r . t il'lr r t r t r t , it t il' , | l t, I{IrIIIIIrIII,I r |:|L |1\ l I I i( 'i | |i | . ( 1lt it r i|llr r ' ( 'f r llllt { ' I llr ! ' r lll( l\ lt r illlt t lt t ot I it r llt 't r zt 't t ir r i) , ,,,r,l rrl tkr | l tt l to lt , lr r ollt t qii vr . siilr t t lr r t . si I t I t 'r 'r 'I t t I . I , t ' ;,r,rrl rr.Ir,zi rrrri r l. g. it . r . lr li'r . lr l. I ilt , 'r 'l. r 'r ( ir v( , ils. : r,ql i ornr.r,. l )c iiqr t vlr l, i. iit l diu ir r liixicr r iilt ll, ilit 'ii r r cLt la r '( 'r r slilllr . r '' l ' rr:ri I i l ri c c\cnp lu. r 't 1i. lc t lo r r t i'lit r r ' ( '"ir ': r ' S l rr:i ottti ciia llr o( hlce ( j( lo r n2t i f r {l( '\ - r 'll1( vt 1 t r lr t t r " \ r 'r ''r lr ' : r lr : t iilr r t ' r 'r 'r : ilt nr oleilor ' illo |i 1,ri rr l ,' zi tttti l e l a bir lint ico, sjnt dooscbjl; r lt ' ir ll, t lnst ' [ l t I r llt it r ll i t r1rrr i I rI il i rri l i ,sl i l i l ttrt ig; inolse 'r Il i Zi i 0).i rtsotj tr : r |cnlil] 'jt lll}) 111'ijr i( |( '}}}lJ's'( l|, 'lljsillI lllll|] |}l'I Zi''I ljlI ( t lc ol) i( 'ci bi. iat r elal) ,glcr r '{: l si vr ) r r ir ir t t ( 't r i( "l: t . r t t . sr ' ' ,r ,,r' i ,r,,ti l l t,' gir : i1( ) l' si t jnit i1 lr r {'chi. il'ulbu. iI 'il. r 1r t , r 'lt ili}r . r rir i t ll t r r . t r i i r: , r 1i1: , . 1i t,,,:rl c:rsr){,i i ! I () 1rs(,l l ri soiizr it iai f lo r - cr 1, ij lxr l, pt Ts, ist : r nlli r iiult ; ii Vr l'l! r r " I ) r r {r 'lr lil t,,l l rl (1,i l i i ,i 1i i l e zjr r ir ilor si u . 't r ilxr r r i, 't . ir il- . t 't i1t ilir , . , s*. t xilr 'ilr t lii r t lt t . t i , r I' r,r:r i l c si sl ,erl lLl izlt t 'c l, r iLsllt lst r iilol'la pr obt lc \ '( sl, jhlllillt ' lr t 'lt 't r ''t r r l ''' ( lel( ] r i{r i t olir l{'r i( ', lJI rr 'r r r r l ,,l ,rrUfi r, l ti po- - <lt i it Lcr r t ii: r ir ilii: t t t l. t 1n'ollr , iir - si {llt ulif ouisli, llln( llir alil'r l( lllir r ll'zit llr i : r iil ( r 'lr 1r 'r r lt " ,, rrl rl l rl ;i zl l ri 'il llr iue( t ( ) f r it l 1r r t r lilr . r , {ir , . r r 1r r r I r lr r l , rl si i rcri j i Itt,i ,) . I iq, t u. nt it in, o. . . int : r t t it iit o ir I ( , 01n, i12i{ t l cr r r lt 'lLr ' lr t ' ,,, i rl ,1rrr' , orl tt t , it Lr llr c lr t it . t rplilr l iii1- 'oillLt zii, t lo. pt 'r ir r '1. rt1ic i ri r lr . , I ) ( , r 'r r {'sir ', , 1 1{') $1 l, ljr it r t r t l r i r i' lczsaziL ,,,,i i i rrtr' ,i l l i l r,sr , s( r r , i1r ! "ii) , r' r.,' ,, { i i i l tl tl t : Llr r u't . lt onlt rr l r olt r lr ', l1}( il) ) ' '( ; t r t plt lt t t it : it t lL' 1I ir I t I t t cit I I I r t t l l t i .tti ,,)ut.'- a: r ar ljlr lr i iiir 'lr ilt t il( lilr il ( 111 r,r' .i crrrri i l t' liliLnillosliir , j1: 1'1'l'ilj11111r t : r 'lr t t r lr t lr " lit r r Lvell'l. , ri ir i l. q: nilr liI t 'lr ' i, olt , nzir '; i zilr t noir l It I I t i t I t t I It I I ' , 1lI I t t r r i: l r oi i l i ' tl r gfl 't , r lli, 1'l- ir ) r iii, 1irhilr ' I ,,,r.,,,,,:i zt' ,,i r,', r iicvli. zil. . i. i. l: llr ilr 'r . : l slilr iiilr r ili. lt r sr , llir nlt ,it t i t t1rI I it 'rI rrIr ( lo( lill( '1lI r i it 'r 'r l'r 'silt t lt " r ; ilt f ,rl ri (rr (i l r r:l ;it Lilt i. llziililil{l l t)" ol ost,{t'o't . Li}i, lt l( ' : ili\ l1l si lr r }iit it r t t t l r |sf ilr r r llt t ' III rtrI t r' ' i t r' I r 1 r t 'r ( : r l l rl l l i , r' li qi ttrl a.srr l tl r ini r l( ) ( lt 'ill11'.r 1, r ; I 't r ir jr I i] r 'r t ill t r ' n'r zit ir r rrl r' 1 ' ' ili, 'i'ir l, : r r s'r ( ilr -; j 'Lr ''r ''r lll'r ' si I t iI t o|t r I t 'r r ' tt,,i i i i n rl r:r:csrt,h^ 1, ip t r x'nii. |l it r r 't t t le lt ili . gt nt t 'Lt 'lt : N f.t" i l r:ni. f r : *li', t it t t t r lir linr : o. : t e ( jit lit : ! d ] llu( hr ( 1o lil ut t ii lt olt t r ll i r r t t r t liiit , r t r r l' r) Il i [tarl t : r t : 'it , t t a( t II i l i r' :r i r' l: r I rt I I 1 ,1,,ti i ,i Jl rbi r;liillr r i r I , Slilnr lr r r ', in: r t r jloglai. l- . r ill 1r r '1, i, j( ', ( \ 'r r t lir l ln( '! 'i r ir r sillt llr t t r li, llt qi t kr ii; sol, ir , r ' .i :r iii , ;i cr-l cit silt clllr t t lt li '' Sr lr o' ir r : r r r '''( ': r { Lt lt ilr t r t 'r 'r liir r lr ilil'r r lr ' ,' rrl l i l i r cotl si clt 't 'ii ' , , 1elsr ''or lr 'i' l l l l l ,rl l l l i l rl \ , ri i l rrrl l i | i , t,tr lt ilr olr r r zj0 r l, 'r r ' r ', r . Jr lr "l, illr 1"l: lji f i ( 'll . "- l( llr l{il{r
r ! L ( . r 'o n r !t l l l I ) l l l sl l l , ( l ( '( 'L l r l i i l l t'r 'r tr r ( i i l :tl r r t'i r u r a tti ( r i a l '( i ( L c l l sl l ) t1 '1 l o 1 l l ) ( r r r i c I t ) . II : r '1 t , ti ttt \'i '1 "( 'l i l l l \:( r i l t t l t l l l t t L t'L $ 0 sj l 'u cl tzi i , , , 1 i l r r , , i r r '1 1 1 ' 1 1 1 '1 Si to r ':r 1 ) ( ,l r i r u l r l l tr r 1 i1 '- s ' vi l si l 'tl l i ) r :3 r r l ttti ' ' , 1 , , , 1 , , r r r r , ,l l r r r t sp i t'l L i r i i , l i .r r ttL i r l 'r l i l t i i ItIi ti i I'IIr I q i 1 tItt'It1 i Ir ti r Ii .tr r ') l r ' 1 r "l t , \ " 4 , / a , : t itti i t( r ttd u :r i Jtt'( h r r l tr .s.l l i tl tt tt t r rt ri l i r i rl i i t i r ,'t'ti i g i tt'l tsr ' , , , , . , 1 i ', i r , 'l r i l r . r r,x.i i l l ti l i l l r i 'r "l l tJr i r i r l l r i .i l ' l tl l l tl l i ' r l t'i zt' v<'t l i r l ttr r r :r '.l ' i 1 1 '1 1 si [. \i tr \Jti l ,tt.l ,a ttl ttttt i \ I t r t l , l i o l tt l xr t , , , , . , r 1 , i , i t , n r | t,s, cv0 l r ti r r r I i tr l r l U 'e l tr l 0 tt va Jr tl i l t. l ti p t:r :Il i r r |r r r i r .r '. l l r :l r 'r ']l r \ , , r z r r t i . c l r r i , t 'r ttti sl i l g l tt{}l tt'i l l l l l l ,- |o l tl 'r r tl vi tl cr tl i l t o l ti l tr n tl 'l l l 'l i r i l r ti o l r l l r r , , r r l i c i i I t i I rr I t ' t I t I i i , tl tr tr l ti r ,t'i si t r tl l t i r r i i' :tt l tttl t ) l t r t t T u txttto j i l i r 1 i i tt si i tr r l t'r 'a r l l 8 l ItN ttto .l i l .i tt. .1 t( l tto |ttt( r ) tl '.i i l :r l l r tl tr i t'sl l r l r i l i l r r i r r i tr s,Ii i r r i l i i l i ttIr :ttII', t,,,,i i i l i '* 1 i i l ittl.srirt ', , i r l t r i ( r ( 'l i I1 1 !', l ) l l r ( 'r i l ( 'zl l l r l 'r 't t l i r r r i i t t t l t l i , l r r l l r r l l i i l i r L ' r 'r 'I t i I i I I l t t , l r i l r ti l i l to i i r l l i t'r ', ( l 'r r l N r vi tr i r t 1 i r r o l l l l l , l l l ? ti I ( r r t r r ( , l r t l r t {. , l t t l n 'l l l tf f! r i l tl l fi tl l ( r l xtp l r l :r l r ' r 1 r ..r 'i l r ,r l r .l r , .:r l .ti .r r r 'r r , ( l l l i l i ) r ,<,l r r l r ';r z:r . l i l i l .r .i ,ti ( ,' t 1) i sl ) l \ l r l , 'r , g ( 1 ', ', , u i , t , ', r , 1 1 ,, r 'r r 'r 'to si r r r i l :r Ir 'i IIr tIr IIi Ii , l r i p ctl ,,r r .r l r r l r i l i l r r i r .tr .sl ,i l r r tl :r l r i , 1,,,i r 'l l .r r 1 . , r , ; ', : r 'i i r i i t , i , ,,t ,,'l t,'r ',' r cr l r l r tr l o r |i 'r 'I:tL i r Ir tl i ( i r l l r f'l ) ( l l , tl i l t tr i tzttti ' r l l l i l r l r l l i l l tl r ' r ,.r . l r i Pcl l o l l l r l l :r r .i r l r r l l r r 1 , . , , r , r I L , J I r r , , 'IIr ,'r r r r :r , orrlr, Jr

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

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

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

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

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

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

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

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

107

,r{. ri,,,r,,,.i,,,2:, ,ri,, i,i.* ,;,i,,illill,,,l,,,i;il:il;il,il'l,i;,]]li;ll,,ll,l);.j,,;i1ii,,,,; li ) ,\ t,u t.t\)(liilr

,n,,,r,.r:,, ,.(r,, , t', ;,.,,;;;,;,i,,.:',iq,:ilil:],,]:lil.,Ill,^u;;.;1,' .,,.,,,,:, '':1,,
,sice,r,er,er,j'. ,r"',1'i"i,itin :ll:,,;,',:i'l","t"""lli,rti;_r,i1i,".9*tbul;Lr ,iiiri;,l,\

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

r ( : t lil

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

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

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

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

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

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

:r i i;r r ;, ; , r i, lr ir t1t;hfr i, r, rr i ii ; *ifr:iitilfl,'iiffi;l "ir j'i1,"Jii;l,1ll; ';:l; ll;l;;l ,li:l,i;l;l;:",,,;nllfl1ijf,illiiili;ll,..,iili"'J'l,il'1i?;ll,T;

,) 11, ji(rlifolicc.

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

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

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

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

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

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

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

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

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

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

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

ii,,'r

.lueptic {,oatoil apgl

(in cazulcxisl'r'tr1r'i .sponran

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

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

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

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

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

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

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

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

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

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,,ii|ItIJlii,'r ltilll,r,. Hltt(lt.rIrIluI (1 ()ItI t)I(,I,it, l)tll,r,ltoilir!v:t I,sl,(! l, rLt u l,tri_irr cltitr1(':t,Nir' .lr s:u(ii|nl.o vior(f r,r',rsrrr,rirrrirrri, (lu tl$urintiro novr'tlrgiL\ gl(]solr!tr rrlir:{irrrrr, t:rrigirr, \i, IoNllt'oIiv, li. bo s,:rnudc tliagnost,io cst0 1,,.itfll,lli rlr|| ,'r'(.. r,. punclul in_ lllrirrgrrlrri superior, adicd,intre ci}nu] car1,i.l)r'r.,vor.iitr-r, r:tjr rr' Lrn ( 1.[ fr osul l]roi.l. lloba rlccisivd este alcoolizarea nrvului, cr,r,o l'l||rl|rr rltllerca,. Uneori se constal,ti asocierea sindromului laringritri rrpcliur' ou sindromul cle ganglion sfenopalatin. I I ) Neuralgia glosofuringianii secund,ard(simptomatici) g]os.ofaringir,ni,s^eoundari, se d.eosebegte ctini,c d,e aea, primari, . .. rin :rL(,al'cte t ):.1.1..:l*l t'r' elemnnte:&) fond drrreros continuu,pe cale se supropull r.[rrrcroascpr,ro\isbice: Lr) tlurolqa, nrr at idqi - intcnsitateb, dctci ' Ii.i,r:r,rlr. ,||||.r,'\ l:llglll pnm rf lr : c) dulerca so .localizeazii aproaDctorclpaunaitr ,:.,, al. g-ibul i. crr iradieri r,uricutare si frr:r,ndibul*r.e; rt.1 1'11 lj^,pro.,ly-dc,,' ,.',lr\t:Lt,i ltipo- calr tnrstozi:l lojii.amigdaliencsi a rngiunii farlngie'n,.: r') r'ris1;i 5i semne de afectare lsociatd ii trunchi.tui dotor ar neryuru i rllosofrrliirgian; f) se a,sociaza qi semne din partea altor nervi cranicni rr\ ( r,rrrlr; g) sc constati, extindelea ariei durcrolse peste limitele anato, ,. j,;1l glooof*ringiao ; h ) evoturia cs[e progrfsivi, cu agrav:]r(,rr, " ,ll:.1I"]!i . | ' \.rrl,t.r.r''":li r':lpld:i r simplomat ologioi, fdri rcmisiuni. l |l ,.rrrrtiL unor lorrnp ll.ipice.si incompletclj, dcb t, sirnptoma{ ologirr, t,, t r:rlri' i glosOlalingipnC recundar.r' eSLe dc cele mai *r,Lt" OIj SuJiCir.llii rr| , ir'l ('1 :rcl lst,lCu.l\lUIf e tot me rlp nevralgie glOSOfa r.ingiani1 S{.Cundrui. prri irrsi rlcbuta cu tablou cJinic rle ncvraigie i;i" aceste motiv(! 1l;im;r;. 11rrrl)11'r.i tz.'t cii orice ,er'ralgic glosofaria-ngidnJ,irebuic consirlerati, rlo ll rr,,''( n,rmzri jo:]I.iilor 1.'rll .r drrpi efectuCrea in\.obI paraclinit,,. 1 lnlynrlar;,ri r '||) |,t' r'r.:t Ulnr l(.zUll.bc rteqaf i\ o o vom cOnSidr.r* pr.jmit,iv;, ('ttu,xclc acle mai ft ccvenJe aie rrcwalgiei gloso{aririgiene secun{larlr -pi';"; ilP t./r bazei.cto rtiulai liuai alei ,;1";" .i,' ..',::.1 .:.."\ .t"".':t:!j':"^:lJ !7lilt tll..(.'il,lr' b) tr&umdlismele cranienei c\ arahnoid,itele ,{,Un..r'rnolrflngc); cen:r)ttrt: () t(,tt,crce 7unrcti: meningioame, neurinoanie : e\ anel)tisme ulr\ |rr,r'rrIirIr,i (jl,lrunc i t) i,nfec,tiilocaie, indeosebi amigda,iie;e etc. I II ) N eualgiu glosofaringiand, ,,Junc!,ionald,, (simpatalgia) ,\r,r':r,stii, llormd, d.e ne\Tc,lgie glosofaringiani, se caracterizeazd, mirr rI rr!.r r cr rritt,totjercle arsur:i, 1.1 b:r,zalimbii si in regiulea ai, r,ir,rlr{.r,{' rll}ro trompa lui Eustachio, spre ur-echeafoedie, trUgq"ii*ei' oar Dl spre alto ( zrrr.r ir'o depii,qesc teritoriul nervuluiglosofaringian. Std,readd dii;;i;;i; -tilidi; :t,lr.ltrLvilrl r[r.viuomai prosnant:Lin-1ifrp-u] clegtilt,iliei-.. in Soi;'. l'lrr:r.rii :urrirrrprcsinunui"corp sir{in.'Din ,1;;;;;;; c,cesl,i n:}ci{!nt.i sl,lLsnlt' trltr-oglenc r,U LUSC. Ir|'r'rrrrrir rn ineerCxrilelor de a Climila l.co"nrit rri,r'riirr)'..fi.,za!ia

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

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

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

irtrl)orlrltul; in intrerincrm clur.erlor.

do arsur.X se-.asociazi O"-rii"ti" *i ;;;ilriili""1i nu po_f fi.obiectivate raun er"-ui"" al gusi";;i: l'1.'1,'j:.l,,i.ll,lli._u-tii,,care |,r! | r,irt r! ctzrrlrtc se noteinzl ,li rut conte_xt "du"t newotic, care Joac6 un rol

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

i,l.9.ll.-Puralizia rrorvului glosoftringian I,,l,l'rrtizi|, nurvului uk,*"1:11_iilti,l.r= so l)rir: disfagioponNru itlitrtc[1,o ilo]irlo ; tr:lftlliziru rnr -m.r,nifesti1
t lil rbil, ;lt t.l

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

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

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

f . 10,3. Paralizia nervutrui ilner{mo{Jatstri(i .l ' ru' el i zi l r ic] , t - ldui ] }lcur nogasi. r ic sr , r r r illif e"r l, ir t it i r ) l( ) r '||, I t 'i'l 1. 111] ) it r it {.r!zrlir-n si t'{,gola1tir1'.l)unli:irt ttttil.airrqlit, rlr.urcJa, iu^rrtiillt|rrlizil' v|1{' r li. pir lt r l, , \ ir r iior r , ir ) . \ , r r . , , r r I' rl rrti l ri L (hcrniviil t izut , liil; ot ot r . liir , 1li t l'r r , , {iir rl r' \ i l rl ni l zoi )at , i) : iiill t ullt ur ': ili 'ir r r XcghL1 it ir Llir . lhir l, Jor .r,, Lrlr dlr i: ur , r rlr r r ' 1r , . ,rrr. S t' cri trst at ii o ir em iar l: i0zir 'il r . ilullr i l) ill|1 uillt ir L ir |jir r , l iI I I r , I L|. r I , I ij'. , il r lr lr lr . r 1r;l rel i l or alicl'ior i si lt ost r "r 'ir li, t ) t 1, cluJlr i lt jiult ililii l :rIi trgcl uj . Il rlil, i. ul r r cLopllal iJl {'slo ( i; nlir lt iLl silr t air 0liL llr . I lr , t r 'r r lI r : r l. r r . i ,' : i i tttl !e bi .l t!t ; 'uI t 1t : 'cxLt t l: tt t ] ir Lt ;iili i. ilr t rl it r r L. . girl til ir Jit lririr lr r r. l rr llr r r ': r r L I l i )l ri i i !1r rl diiilolr i{) r t Lr : r lir t ir . . ll'r illlL; 'r lt ilc \ i'11 llli\ '( ' , lir r lr r r r r r l , ; l ' l ri i r' t' i tl i ri r, 1|( 't t '|l t r i {'0|; l- iiit ir }: L|: I I }|I I ii] . i|li, it i. ilr lo, , ii I t , r lr r r. r |r l , , - , '; t 1] ) ir l t l ot ji cr r lr ior iI o1t ir , 11ic, r ic r r olr :lni r r r r illr ' ( l, i r , il ir ll, . ll .i l ri l l .l l ri ).ri I'it s. ,,l rl . ;l.l{}./.r" l!oain hri iloska:n { hipelroikrclilll nt tir sitrourrolirlir rrlil irr i r| i i i r1cl r' el za i in Jr r ilf iLt l I i: r il lt r . ir r nt : , n. i. lr sli! t i sit r t , , p, t l, , . r ir r ': r |r , r 'l r , U i rrtl rl !i tra1;i tloglaJt ti] ilur r i- L t lo t r or t lI r , sir ir r r , lr sir t r r sr r lf i r . ir ] ( , i, ( liir ir r . l, r 'l rrl {l i r" i rl ual i z: L t lt i it r nLr ' ( ( ] ir 'f t r r . iil ; i . 11; policir r , llr i: l i ( 1) l, lr l i t r lt ) ', . . i; I\)pr,\,i (l i l : si Pr ur Ll, 11) E1) : .l ) Ti f)u L r auul ( r nr dic; iLt lt ,if il ur 'J so ( ll, r 'ir ill u izoilzil lilir r lr p; r r , ilir , r r r llr Tr rl t,l ruttrl 0r r t r t 1llr ] : r irsir , i ) lr r ir r ir t J, lr , r 'lit 'iiii t lot r I tI t r r i, iiI r I r{, , t r |r ' lr 0i ' r ) r ( |iit r . r r . rrrr' t11, , {[ ilt . t ] ii vr r ljlr ir ilir ( l- , lf r , , 1'f ) . li iI i r llr . r r r r r l ri tl i l rt r ioir r . r t ll1iut . cll ,t i nr,r' l r l rti u iir llr tt lir i , , r . t iolzii , 1i lit r ir t r l lr r t r n; r J sr l, r 'r lllr illiil, r '. . , \ l'. ot ) ili rrrtut, ri ctt(rt vrr Lor r t, r lt li( lr t uonl, oll: li r ilt t t lLt hniir islr 'r t llr .lt r , r r r lr r , r r ir iilii 1r 1r . r 'r l r,x,.,l .ol i ,l ro1rr , r c (1 i r I i I j I)i rI I ri I )i I r l : i, t . l ciir ot , it it l; , r ll{, i sc ir r r , lr ir lr . ir r I 'r llr . i :) ' f i ;l tt. it t t : , it , t |t , I t t r r ; r tr i', r , ir sir i ilr r r lliiililr , ir i; r r , ior silr r ir r r lr . r ', : r 1, . , . , j. ill, t lr r Jr ii, rrtIrrIr,.rttIl ttI, r lr hl i ( I j1I ir , r '{I ir ilLlr r , , 'r r ill ir r lr ilr r sir r or r r r . ol, ir lit r r r : r \rtr l l ttrrrtti li': llr 'it i t lt t lit r l it r l'I t t r , I r I : r I o t I r r lr li'ot r ir ii. ilr sir lir l l ,r'rrr r,rr i i r. r l , r,l l rr i ,ri l rrl l rr 1r llr r ) r r I r iI li r lr , r t r lllr r r lit r li. tl ) ' l ' i 1tu l,t , r t t lt , r l st , r . t ; r ll, . r ilr , r r zt r I t ir r r I ir r I r r r r r r r lr ': r t l: ilii r l. r lr r r r . r ' r ' i r.rr' 1:i . r i I r r , I r r r ' I r i | l, r ) lt t iilt lr r i I | | I il r | | i r ) 1llr ) lr {) 1, . ir lli r i r lir t r , , : r r r r r '( r , li,i, r t l ' 1 .rl 1 i rl rt tr.rllt L', , , i r lt ir t lot t vt t llii r ll lilr r 'pr ir , plir . . r \ r 'r . r ilr ' lllnr r . l( , l rur' :rr :rrni , i rrl l trr,trlr lr , r lr r r ir . r r r . r 'r , : r lr 'rrrr t r r r r r lr r r cr r ', , I r r I i: r r , .

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le lealizeazi, ramulile periferico llri :r'r,i rri Irr ]'unitrilc altor ner..vrcr..l] ri,:li i (irt(kroucbi cu iervLrl gloso_ . |.r, r| ,IIII 'r('r'v r I I I 1r ilt iill^r ; J l l o d i n c c t,r_ i cl -l e (U r_L].) fi c* si si cnLrrl rrrrl,rriir. trr ir(x,st s1.irsintrri ' .in i i r[:i ..i n i l r diqoirtie a,;i".in LtoritrLr{m1,r.t.ii si t'tt tt'tttrt r rl,r'1r irf{) si un irnrorr:rlt "irritg'i,;i conriingcnt d" fit it iiitr i1r.s'irrr'i rr, rrr t r . ",l""'l | ) l)i.:r:tlt.::irt, ttnn,u,ti.i tttr,t,irulureu nenulu.i,ldq rr, liosl rlcsrt.isi, rlrr \ r.r'rrr l ( . ii, r r l, , i[ ( ' I I . ! .r]{ .,)i l l r, 1 1 )1 ,,} ) c o n s tti i .,rt ' ,ti , ri ,* ,, l or:rl i zrti i r_,i , fi i rr ,,,,1i11j,,,,1,j,,1,f,,,i.,,,,',,'\.

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

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

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

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

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

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

: 11) int t l) r r t rr lr t ir t t lr lc lczt l', ) E i ttl tottr t l lt i St lt nt r ll 1 t ut lt ot t ui t \ t lt ) slt it t lt l r r l : l lill( lr 'lt llli slr illill ll( ( 't 'sol, slt t l lt lilr t 'r r lt r t tttri i tti tcl rrttl tti 1 '; lgr v ill lllll ( ) l rl l i l rtl rrl c l t,k,ttt t r iot t lt ii v: r , 1or r lr it t ; t L Er r lr t ir t lt git 'st l t r lt t lt llt r t 'izt 'lt z; I V Olill', lir i, illir , lr r , i, r 'zilt , r '\ 'ocale, st {, r llo( il( 'j( l. ln, sloj( liir lr lt llli Itt:rrri prtr.l rl i zi c ' ri, tlaoezului. '.i -]iip{ )sl( i(') irrlr'rl ('{inthomul s})in{} vag'o4 )-ELnrltontrI lui Jotl;:'rttt' 's ( t it t t r t t r r r l rett{ l ; paral i zie unilat er alii a r er \ r ilor ct anioni I X, - \ , \ I irirr t()lllrillirl(ll helniparez'i le cal'c se poatc asocia o .lirlrLi ) ,si \II, ( ( ( I t t I I I I I ll) {i}; ' ] I e"Ye] , ' Loeb de c t ai' 'I ' I , $i tLi ni l [ei rr' ' i A l rj our nir r c, ] 935, 196i ). lui -{r-el1is, Srhurirll iii 'lrr('lis('rr -{rn aruintit an1,eriol'cir sin(lroan}tlB l r,i rrt,cel tl l ai ad eset j de or igine l}eliiet icr l "i I l|] coli r i. c 'r t 'iililr t r '( 'ir lr r r li] . cl l.ezultinil dinir.o-leziune l]| ]}el]-il(' r.enpo.ti\ i h lr;r t.lul g]i||I]'ii |'l||)l(l (} DoBteri{}lte san al sr:rliuhli rctluntili&ll llr r'l1L'le (irl'rlli ilr r'lil'(r s'illl I)l iir:r.,srt rtu.l,tttt ir: l6i,ni dir rezultii elc iluso printr_o ati'gire br lb:_''ii, (litr l|zirrlri l }Jedsebi iu,noruitl, intrlr, SaI etitrabull-litr e, ii nttrtrtti rrll('oli trlll Irrlrrrrr) srlli'lililtl fie i,usct are,8:lre realizeaz:Llie sLrferintc pnr nulleartl, (r\l)lit'rr' oc zt,)l}c, tiirr r''ertl' folrrr.L{iril,i pirr nllcl6,rl',1,ci li aie altor 'frel ',rsocie'e:r, tie alie sinptone. rlupil tc'iot'(l'ii;rrrt1;lrr': ltnriltlit-:rr ll.rr si ''xlir rgOi, !os"" ;i cohb., 1969: trir-rpor-:iritsi colttr" 1llE0; I'oltrrlilirr 'i paseri , l gsi ). fn acest e'nlf im e ( r it z1l1i n[ se m ui lor t c lolir i t jt 'sit r {lr r ) ir r r r l lisoir' ci rie fallt (le lrl irutl'(l rrl(' Jtif sau Scbmidt ,\volli.q, t)rue. ,,cla!icoil 'iio,ttu".n,, 1"llsclilalc bulbrre asindlom rctr., olir-lti \1-itllcttlrttr'. ,'. tio,,l si |trsdl, 19El; Jlrltttt i.itt 't (I'opovicirL r;espectiv sin(lr{lrr interoli'll ) .ol ab., 1f180 ). :i i 8 iti.titontr1 lrttti'cl' ctl tttttbultri. o'intlrorttrl listrt'ii [tullnrr Iultttrl" xrrrr*rtr (uL l.u,iD, jt,i't' I' sit'ltuttttrl ltr'[ 11-'1[lt'ttbt:r'11 sittt",rc,niu,l,':'et]'o-()1.i1:qr tetizr::rzi s.riri.l':ri' c:rttr ii' (:?rebelodse ,ii'ornt,til arlcrd Ttotl,irinlr:rioar'' : rurlltoaleLe llil (sau lttlntiltilrol '"" - .!.)r',tc,,r,,,Fi Parl', t:J lezitnea : e) IJemianestczie Jocalizrtlii rrrrl|rr (terrno-algezic[ disoc,iatr: ;i ) rnaj ldesea 1;ezit) fa'tiali^ cel t lc r lr r glt r li{ir ' r l' f our lio 'I ullr r r r ir i l i i i " .l tot" ,,l cf t alm ict ihi; bt .r-oclllc . 1i li('r'rrrtr'.l " " fri i Ultruil'r Siitdrotrrrtl t1 ; {i,tr.,t .',i.*,tgtti1)6i ptrraiizia cotzii ( li r r ir r r r r ve. lilr t r lr r r '. r l) Sit t , L'. r r L sit nl, r lir c coloanei l i i rrt.r" , l ,ai ri t" r iuir ell . '- , i. . r r t Lr ii. . r 11rsr ' t r t t t r r tt' t r tli L,,ri .i i ,i o-l ,:iitl i l n nasc, gr et , , , r . iqii . t r ir t r : r nr t t t ', ; i t t l it t li't ior " t lt llt i : I r Lt r I 1 I I I I llt r I I I I I i t i t rs. l I,I{ l tul nl ' e: e) l i i mi siniir ijr n 6161s11sLr (rl rrr:I r lisr "'i: r 1r '' t lr lr r ! r I t il) o^'t czi" oPi, sd: -' f,)t Ttu, r lea 't llr . zj( 'i' { ''' r r ilir 'it ' t r r r r l" i', r I r 't 'r I : L1I rrrl t' rca respi t,l ,ir r t l f nll ( nu t ot t lcr Lt t lr r l. 'i li111r r 1 l) 2 r : ', balr . lliU; r . ,l ,.ti j rtat't r ( lr il , it , t lr oDt t t lt r i lt i ' ' :r.i ii,.l j ,ste l " ri r,o t r nt sii iecnlt o : l, cir r i, r r l, r r , / / t l, , . lr uit , t i, (-,.oziPopoviciu Fi ]'r.'irltl' I llSll : ll: ol[cttbt"t'!l ' l " orntu r lllt ttl tr ; t ir : r i, 1i1r icr i' 1'lllli il t {) st r lcr r 'r isit t lc f \ ir ll1'r r lr l't l ir r l$ll " I r,l l l ri rti i ,l rti ti s1 1s. ( r l) I ( t r r lil i i i tul rotttttlt 1l'uL[ t , nlt t 'r 1't li] 1i"' it ""'l'l't ' 't t t r . lr r t xlt : i. t lllil( li i, 1r it r . I it I I t I t t it 'r r l, l. r f i ir ,rr ,,l ,rj r,l t,zi l rrr , 'r I r li( , lc1l1li lr r r r liiJl't r . i |ir t ! I t t l( lllt t t Lt I r Li, lr t 11r 'I '' \ 1i1r '\ r c}] isl11r 1 1,,,,t1,,ti lt' , {rl l l i z ill( illll sir nlt om 'i'' l ,,,i ,i t ,.i a,i t,,,t, , " i. lit , i'r ', nr r . lLii 11. lilr r r lr r r i sj r , ir r lit t . s f , it 11 I r r r ( i l) r r ( r r r l r,:,l rl i ,rrri tl i zi l l r lllr r lt st r llLr r t lt r r t sill( llt ) r r lll( 'lr lt l'lilr lt r 'it t I '( ) t t t 1t I I 'I . t I I {I ') f r i||( i|( ||t |||I l ri tl r,sl ,l rrr tl l tct t r r is, t 'r t l1r lr t lt slr ' t lit lt 'o llir t t t ilt lt t r slczit " t t t t t ilr t ll( ) r t l
( l i | r t l {\ i i t 'l l l i l l ( l r r r s r . l t i r r r l r t r r , I I i t|l rl:rrllllrr' . t i r r i,r l l o t ttr r t, ttr i ' i :i ( r l l l t) ( r l ( f l |zi tttto l t ttttt'l l ,ttl tti l tttl l r i l l tttt' r r l r t ;r r , tr tt l i r r r l to ttt r t'r i i l r tL l r tt l i ) l l l l r r i || I ( 'III||i II l ,l r r tr ;i l tr r l r t t t t l l l ttt l l ;r l r tttr I'i N r r "r 'r 'l l '' ( 'fl i r " l l l ;r ( 'r 'r 'l l i i r r r l r r ,l t

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

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

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

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

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

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

l{)(iliI rolnnii Ii/sr,u rrrrrlisrro (Aqgin,tr 1rl(irrot,ico ,,si Vrriu,,11)l-rl3; l.)01xrvioiu, l'rtyrviciu f i -^Dgiil,r, 19ii8; Aflgilur li cola,b., 1975 I l'opovi0itt i1i coltlt., 1980). II) Afecliun,ile inJec,lioase s'i imunoalergice d,etntnah,i cercbral (polfur\tcirfitlitels de tip inferior sau superior, rombcncefalitele, sclorozr rnull,iyrli"l, qi afecliunile demielinizante inmdito) produc variate tablouri srrniologice, cu configuraiii variabile, complexe, de lcziune a norvilol orlrriolri, rle cele mai mult ori nesistcmatizate. 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 $inahom in cadrul unor variato lxrli r)curologice. In tonrte raro cazuri, P.B.P apare in mod singular, oil oonsfituind cle cele rnai multe ori o modalitate cle debut a acestei sufcrinlo rroulologice. ln cadrul P.B.P: unii autori inclual qi aspectele serniologioo din scleroza lateral5. amiotroficd, (Norris gi Kurland, 1969). Contexl settrioluoie Cele mai multc ;azuri tlebuteazd, cu tulbuldri de vorbirc (clificu ll')l,t, i de fohalie, in special cu rinolalie), Apoi se asociazS, dificultd,l,i in doglui,i{ia lichiclelor lsi a solidelor, atrofii faciomasticatorii, faseiculalii po linrbil, ;i pe muqchii rnaseteri qi tulburi,ri ile masticalie. Iieflexul faringin,n rlisp:lr'e la multe cazuri in plimele faze ale bolii (Bonduelle, 1965 ; (iirho qi Kovarik, 1970). In alte cazuri, imediat clupi elebut, s-au inst;aluh 1,ul buriri de respiratie, uneori gr&yo (Black gi llyatt, 19?1 ; Castaigrx) {i colab., 1971). Completa paralizie a mu$culaturii masticaliei duce la dl,rlorr rr r, rnandibulei, iar afectarea orbiculaluldi buzelor pelmito scurgereasalivei rlirr gura intredeschisai,'Asocierea aproape constant5, a tulburlrilor dc doglutilie duee la acumularea salivei, alind impresia unei hipersalivalii. Palatul noale devine imobil qi aton, pemitincl regurgitarea fluirlokrr: pe nas. TulburXrile de deglutilie sint frecvente, ceeace face necesartrirrl,rorlucerea unei sonde nazogastrice. Bolul alimentar sau lichiilele Du pot fi l'c!,inute de citre buze, iar gura nu poate fi suficient de bine inchisX,. ltolrravul este, de asemenea,in imposibilitatea de a impinge cu limba alinlontcle in fariDge, motiv pentru care t^z^ reflcxS, a rleglutiliei nu poato {i rleclanFatd. Bolaavii se ineaci uqor cu alimentele. I)iza,rtria este frecyenti, $i evolueazi, rapid pinii lzu anar[rie. Ao|ul soapir,prin nas in timpul fonaliei, iar corziie vocalo sint in pozilie &nol'rnali,. Dificultii,!,ile iniliale in vorbire sint proclusede hipomobilitatoa limbii, Ll ca,r'ese atiaugii, paralizia pa,latului moalo. Bolnavii n[ pot pro]rur|,lr, rolect lingualelc, tirnblul vocii captrt5,o tona,litatc nazalX t;i dispa,rornorhth,tiu, vocii. l,ipsrr,clo inchiiloro contpletl zr,glolci, palalizia, mrrsorrlai,rr rii t'iit'iLralo tosl)irr11,io buzclor', cit;i i,ulbLr cornplotanzii tftbloul serrriuloilio tlo vot'lritr:in I.r,l!.11. rr,ltulbrrrtrrilot' Atrofiilo ttluscrrlrrlotirrl' plozrrnto rJi vizibitc. lrirrrb;r, osl,o Iltrsorl,, r lin irrrobilil, ll,rof icit,. llo irrrrrrrrrrrrrr, irrcrl, prirnolo [rr,zo lrlo lrolii, $irrtrnrrrrrltr ryi tttrtryoltilrtt tn:t,url,r,,ti, lrlclil'ot t'r,lirrl'r rrlrolilt, Ll oxrlrttotrttl sl,rr,l.io 4i lu *l,rlngol: ! t )
| 11

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

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

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

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

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

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

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

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p-iimetor segrnenrc j:i':lig $il.or9r1ial gi fald de com-prosiunile cewicale-9i {uo.r)ulDurur, cal.eartrg-neaz6 adeseatulburxri paretjee Ei atrofiee Elos<iruur)gol|,rlngee(boala I:9tt inalta, .tumori ale giurii oceipitale, iumori llrl ltmedu laro tnalte, glioze mie)o-bulbare,pachimeningiti hip'ertrofied cetljcalcinalte E.a.). afecliuredesrulde l,ar.i,cauzal d"de o , -, t') lnyJqlo1ati.a .lui-fVprnickr, tloliciant[,_ de thiamina,(de obicei ]a alcoolicii eronici), asociazA, o oftalfii{i. I otalS), o ala.:i ic si demenfi, progrcsi.r.d (Vicl,or qi colab., I,.lr:qio .(ldeyai J 071; Iilank gi colab.,1975).
lniduva cor-vioaH qi bulbul), ocle tloud, cauzo mdi I|('ovonro Illnd Bclerozalaterah a,miotrofici (inclusiv sindroamele de SIA) qi niringobulbia. In. aceste-situalii se nai impune G*; sd; fa,cd, un aUgl

O.

PNOBLEME DE DIAGNOSTIC

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

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:1.,3.1.L2.Eemiplegi.a spinald este ipsilaterali,, intereseazi' numai rrrr.rrrIrlo|o, iar'leziunea medularS, este situa't5, cleasupra intumescenlei .'r'r'iolt,lo. l)c cele mai multe ori hemiplegia spinal5, este asociati, cu semne r,lirrilo r1ohemisecliune medulal5,: sindrorn Bro'n'n'S6quard. Nu se conrrlrrLri rrir:i urr semn de paralizie supra-medulari,, nici paralizie faciald,r nici :rlirzir, nioi dizartrie. Ilemiplegia se instaleazi, f6rf, ictus $i fd,rd nici o :rll.r'rrrr a, stirii de constienli,. Se recunosc cu u$urin![ e]ementele senziLivrr lhr sindromului Brown-S6quartl : abolhea sensibilitSrilor profunde rlc prrltul hemiplegic[' gi hemianestezie termo-algezicS, ale partea opusr,. Nrr rrrrri pot fi utile in stabilirea cliagnosticului de hemiplegie spinal5, ($i rrrr plirr lcziune emisfedcd,)tulburirile sfincteriene care de obicei nu lipsesc, plrrorrrn qi prezenl,a unor mici atrofii radiculare ale muqchilor scapulari qi :rlrr I nllrozului. flrrrniplegia spinalf pouta Ji' reut'izatd'de : :r) 'l'rrurnatisme. b) Mielite (virotice, luetice). c) SclerozS,multipld,. tl) liilirrgrrnielie. e) Tumori, care de multe ori realizeazi" de fapt o tetraplegie xpirrrr,lir,, tllr cu pretlominanli pe un hemicorp. f) Discopatie cervicald, (lirrr'l,o ra,r). g) Sinilromul lui Mills, tle etiologie necunoscuti incS,(probabil progresivd,, e1ectiv5,,a fasciculului piramiclal) so tra;rlirr rlrgcrrerescen!5, rlrrur priutr-o monoplegie inferioari (crurali,), care se extinde lent gi la rrrrrrnbml superior, reallzind o hemiplegie spinalS, f5,r5,tulburS,ri de sensi lrilil,ir,1,o. :1.i1.1.2. Paraplegia poale fi realizati atit de leziuni ale neuronrrlui rrol,or' rxrrrlrftl, cit qi de afecliuni a1encuronului motor periteric. Oa atare, rlirr rrrol,ivotlirlactice, in acest capitol vom aborda pe scurt pamplegiilo lrlirr lrziurri r1o neuronului motor central (cortico-spinal), care pot fi re:llrzirl,o rrl numai Ir nivel spinal (indeosebi),dar gi Ia orice nivel al lreYrnrrrlrri, rlrcr"r,sint interesate fibrele piramitlalo (ad.eseacu realizarea de l,.lr',r,plrrgii). Nr: vom permite ca in continuare s5,abordi,m separat problorrrr,lr rkr rlitguostic topografic qi etiopatogedc ale paraplegiilor in sensul (atit piramidale, cit qi periferice). rrl rlrrl'itril.iei lrrr';1 l) I't,ntp[egl,u spinald,. Forma cetu mai caractelistici este realizatii rlrr iririrllornul de sectiune ttansvers'i,, care intruneqte o para'plegie cu insolit5, tle anesteziepentru toate modurile ale sensirrlrrrrrr, trilrr,rnirlir,Ie, lrilii,.rlo,plroLrmSi de tulbuli,ri vegetative qi trolice, cu neti, limitale snbprin apreciereamodilrrziorrrL'r,. Nivcltl leziunii me:lulare se poate preciz2r, l'iciiliIrl rrrllorolor qi l nivclttltri trrlbtrdrilor rle sensibilitate ;i, in rnrtrl olrligirl,orirr,plitt crrrrnonul l./.0.1i. tli prin rndiogr:r,fiiio $implo Ii prin rlo rurni;trr,sI,. lrrrl,orlrr (simiLt,t'o lli rlo lrrrrrplogio spiltrr,lii srxt{iuniitt'rlnsvot'so) '|'ir,Irlrrrlikr 1tol, tultnltt'rrsitttti In(nlulrlro, tnirrlil,c, lroli rlt' crrl6 tnr,i vrrliitt;rt lrrrrlizrr,l,rr llt'oottsc: rlrrrlirrlitrizrrttlrr, lroli r lcgcttot';t'1ivr, 1. tt,. t: l A

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

+r'rrziiir(scrrrlrr'lr. r':rrlir,rr grr,lilirr.ic lr 1rloIorrr.rrlrrrrrrIrri r.,i i, lr,rtllrrrrluitrtill,otl

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

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

t 31l

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

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

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

l{tl ,fl

||irlorl |)| | ()| |ri | |i! |(. (rrrr t,irkrrr trr l' rIol{r'|| l|zirrtrii).Axl lrrl,tlt' ltirii, l0trlt'rrsr,rlirrl piklll, itr lrolrlrtoililrttik) Ll ttivrrlrrl lrlxlotrrittttLl l)tr, lrrz, trllcxolo crr1lt,tlt,l,o rrrrprrtiolrtc i ncr:r, rliu rni,ilooii r'ai,lnhl rlll(l\(ll(i outanato lrbd{)rninlllc 1trozonl,o, rii itrlirliorrro sint abolite. fu stititrtlr, irt compresiunile sub Du, r'cflt-rdo :r,|rrIlrrrirrIrlrr In cazul unei compresiuni sub l), r1itleaso mcnlin pii,strate. rirrl, r'1, Hoglrrorrtului Dro sepoate evidenlia semnul lui Beevor (itr1, de Arsoni ,,i lolrrlr., l1)?7): la ritlicarea capului $1a trunchiului, ombiJicul se deplarrorrzir, irr sLuir datoritd, laptului cd,porliunea superioard,a muqchiului ilrept rrlrrlorrrinal primeqte impulsuri motorii, in vreme ce porliunea inferiotr,r':i ( lrnn?resiu,ni,le med,ulare lombare suptaioare realizea,zn parapareze r|r' I i;r lrilurnidal, cu Bpasticitate (neobligatorii) qi cu unele indicalii de nivel. i\ltli.l, iu complesiunile I-.,1-L,2,reflexul cutanat abdominal inledol' esto prrrlrrl, ia,r'rtflexul rotulian (cu inchiclerela ltr-ln) este eriagerrlt.In lorrrplr.sirrttile Ll :rivelul Lu- la, a,tlt reflexul cutanat abdominal infelior r.rl r1i lr,llcxul ll,nal sint prezente, in schinb reflexul rotulia,n este alrolit. (iirrrl cornplesiunca lornbali se oxtinde spro coada cle cal, tulliurflile do rrrolililrrlr,inftr'acii,un caractel flasc, cu fenortene de neuron rnotor pcriI r ' l r(,r. i rlc lrirllllizitl,i,.

liut prcsi,unile m,ed,llla,re s&ar ,te realizeaz5, paralizii fd,r',i, sprnne pirarrrirlrrlr,, itr schimb cu nete fenomene raaliculare.Astfel, complesinnile la rrir r.lul opiconului (L,b-S?) se manifestd aaleseadoar printr'o paralizie llrscii in tcritoliul sciaticului popliteu interrr, iar compresiunile conului rrrlr I rrlirr' (S, - Su)se recunosc pdn a,bolireareflexolor anale, prin tulburdrile rlrr st'rrsibilitate perianale (in qea) qi pril marile tullurd,ri sfincteriene, :rbia rrrri lirzirL pul,ind si, apali, ma.nifestS'rileparaparetice. (lonpresiu,nile la nioelul cozii de cal realizeazS"paraplegie iloar in lrrzrrl sirrrllotttnluitotal al cozii i1e cal (r5,cl5,cini1e Lr-Su), insolite totdearrrrr,rlrr lulh uri,li de sensibilitate extinse r:e dermatomerele restectiTe si de rrrrrli r rrrr li l,rrlbu l,rrlhullli llli stincteriene.in schirnb, s]nclroarnele tle t1c compresiune comliesiune parnarprin l:tl-toUlan prln qi dc Oitt se CalaCleltzeaz:], ttlbur'dni m0lolrr motolii rotolii Sr si Senzltrl'l.e senzitir.e ln in rr (x,Zll cozii (le cirl SO caracterizeaz:'i senzitir.e {irr,li r llr,lir Irrrciic rlrr li1ul supe.rior(L.-Ln), mijlociu (Lu-Sr) sau inferior (Sr-Su) r|r' rrirriIr'orrr de corilil tle cal, intlr'unin.l $1telburdri , timul (cel inferior) intrr'unin.l rr.lctir.trc irnportante. rLlir I'rrtrxr'lt erpansiae intramed,ulare, indcosebi cer"r''icale (glioamo ,1rlrrrIiIrrrrrrrrrrr, i nbclculoame) reakzeafld,tablouri semiologice cu totul prrr'licrrlrr,rrr, r,rrrt i.rebuie cu grij5, diferenliate cle S.I-.,.A. sau de alte sil,lrrr:rrrrrr rlo S.1,.4., precurn 1i de siringomielie.Astfel, aceste:n se manift:stii r irr lr'lllrlrlcgii ploglesive cu semnepiramidale (mai exprimate 1amernblei.o 1r ou sllrsticitate), cu aljlofii musculale de 1,ip Aran-I)ucherrner, rrrli'r'iorrrrr lrr lrrrr, firr rlsociazili, tulburi,ri de sensibilitate suspendate (irritirrl) sau subIr,ziorrrlirrlo l;ip siringomielic, cu clisocialietermoalgezici. Pot s* lpa,rl plecum qi dureri de tip radicular la metrblt'le supoli. corrlorrirle, rli rlru'r,r'i ,rrrlr, lir rlr,rosc asociaai qi fenomeneyegeiati\.e (va,somotoriigi sudollrlc) rrrr1rolIrrtrItr. Irnnginca rnielografic[, descrisl inci, cle Sicard Si l{i],guc1rilu (lltJt!, cilrr,fido ll,iscr',1952),tlesemnindaspcctul in fus almldrvei dilattt,o, riu Hculllol'orr slrbslartlei radio-oplce po pi,rtilc laterale, snb fon:n:l lr rlorrii, rtrIrirrrc lirriir,rtrlirstrinlrto,vino sii confiune tliagrxrstictl tlr trrruoli, irri,r'it. rrr.tlr l:rIii. ttoscrr a) I irirtllom. i tl'i.a, rrslrrttlit,tiv lr;iot'tlc t'ccrr t,, ptin ilsocicrrlr, l:r,rrlr (srur lrrl,ltlrr,trrzil) pirrr,rrrirlrrJrl, irrso{,ilrlc lrrlnrlili Irrlrlorlrlrr l)r,r1rl)l,rt'zii t42

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

l.l:i

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

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

N r. i l

t,
I

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

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

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

C" Co

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

Coborirea umi r hri

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

,1

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

ca cn clcl ca

cs c" cs cu ot

Nervrtl rnxr(hri Ner.JulsuIs.:tll

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

Supraspinos Subspinos Rotund rnic

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

Cr cu 0r Cu
Cn- Ct

Abduclia bralului
fi

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

CircumUex Ncrlrl sul scl

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

Fl exi a 4nlebratrului

Biceps Brahiai anlerior Ltrng supjnator

Tl.iceps

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

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

rygrl
Ii adi rl Mcdian

Pahrafii (mare qi rnic) Cubital arrLerior

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

C t* C e

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

Dlepli antcrioli Sternocleidornosloidieni

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

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

Cr-C" Ct-C'

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

tt

Ilxtensia r:liinii

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

Splenius (lomplexul nrare Drcpti posteriori Micii oblici

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

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

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

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

t:t

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

Scurt il cxor' Lung

ri t

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

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

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

c?-, T)1

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

.!,!. t

1l

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

Per, XI -F

cr"-c" or--c,

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

cr , (:x or -- 0N

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

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

l -(? ' r)r i

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

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

t44

l4ir

cqbcllI Corllnuarc
tl

(:o|l,llllalo trnbol

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

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

I /

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

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

o o -o ! Cu-C"
Ct Dt

iixtcn\iA Flexia pioiorqlui

c fl rrIl popl i l eu

I I '
10

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

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

c"- Dr C"-Dt ce D.

Extensia piciorului

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

dductia pollcelui

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

Abdrctta (lcgctclor

Interosoti dorsali Abductotul degetului 5

Rotatia piciorului induntru piciorului in alar{

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

2l

Alrductia pollcelui

Scuftul abduclor al policelui

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

TABEL NT. IIL MlgeiTile membroloi lqlodoare

liJ

Irlexia halrlcehi Prima lalangd - Celelalte falange

Tibial posterior

vl

(l(llrclln A l, (luc llu

c o l l p Hcl

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

L"- Ln

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

IJ

Extensia halrcelui

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

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

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

t5

Fl exia celorlalte degete - Pdma falange - A doua falange

Lr-Ln

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

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

Lr* fr
Lo-'- Sr

'jxl

0xlu g0r bol

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

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

llxtensia celorlnlte dcgcte

Lr- sr Lr- L*

r40

t4r

-Ttiaeps corPr - Exlensor rodidlis lonqus

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

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

sibiifiis Flexarccryi Abdrc.btdigili .flixor djgilj quintibretlts

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

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

SFt

* ciis

&
.8

Atubusntdits noxinug Gluleus ailis Gto

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

2a

Exlensor digilorun longus

Anloiot

Fastetilr

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

.i-,i.1!.)!. l'roltlrutr dr l.itr1tt,*lrtlrt1t,tt1rulir pritr li tliol.oqiritt ltrr.t,r.l,i:iilr I, irttti rr.lt|tI t|t|)|1.t||tt,i tttrlrtt1ntilr trl l\ l., itttil" p rirrtt'iunulr : l) I'olirnn.irlilr a,nlui.ourd, (lM,l,(, l,ut IIein,c-llh:tliri). l)rliciltrl &u,u,l,(i, rroiol sc irrsiirLulzii bl'utal in decut'sdc citeva oro sau zilc, rle obicei dupii o iorrrliilirlrlili, (lo nrulte ori inso{,iti,cle fenornenedigesl,ive, I'espilatolii 1r,,r i.r rlr. rr,rrrrrrnrorringe&le), dar uncori Ei in plini, sfnS,tate (,,pam1iziilede I rI rrrrrrrr.rr, {i r' ). Sc lcalizeazd, tablouri I'ariallile, cu paralizii limitate, parccl:n(1, riur, rIirrLllotlir-Lfoalte oxtinse, tuteoli cu caractexeascendento(sinsht abolite in zonele 'lr,rrr l,rrt(ly). 'I'otdeaunareflexele osteo-tendinoase ll)il,r'rapi{l attlfii musculancDihipotonii remarcabile. 1r:rlrrIiiicrr, jbilitatt-,. l,ipslsc 1,rrl brrliililc de sens ')) I'rtl irtm,itl,i.tn, plin deficite motorii o,nteri,oud, cronicd se caracterizeazS, lrr rrllolii lnuscrrla,r'c (rle rnulte ori rii cr fascicldalii), cu instalare fi evolutie l{'rrl plrrgrrrgivi,, orr loc ,lizare bilaterali, !i simetricd sau cvasisimetric[. l\l:rjr)r'ii lrljol,lrcos1iol ,r sint degeneraLive(rareori cu caractero erdo-familiale), c,rk, rrrri rrnrltc iiinrl dc fapt forme atipice de S.L.A. (Ratlu, 1978; Trillet rli |olrrlr., I070), iar unele cazuri putind reprezenta forne subacut-croDice rlrr prrlirruriolile qi colab., 1962) sau sechelelounei vilotiice (Drd,gi,nescu a,nterioat'e acute (Ileine-Modirr), in care atrofiile musculale 1roIiorrrir,IiIu rrrrlrlir.iirlc rlotolii, dupi mai muui ani de la stinger.ea procesului acu[, rtrlcp ;li, so extirrclil {i si se accentucze ptogresiv. Drpi, Radu (1978) {l \ rirlrlrrlrr, cir,ontil itli distincte a atrofiei nusculare progresiyo Aran-Duchetrrrr., r.rr,rlc lal)ir fi {l pa,raliziej bulbare proglesive Duchenne este indoielr r(ir,, rt'l,i.ii1oil leplezentind mai probabil forme atipice ale altor afecliuni rr'lr,rrrrrIr'orrrrIrli lnoitor (S.Ir.A., sindroame r1e S.L,.A. el,c.). Crdem, deci, r':r lrrlnurLrrlrlc ,,lrolionrieliLiilanter.ioar.i, cronici], devine incorect in etapa, :rIlrrr,lii rr,orrrLo;Lin{elo| noastre, pentt.u cazut'ilec1l otio)ogieneprecizati" Iritrrl lrlrlirlir,bil si $e nlilizeze telmenii dc ,,sindron tle S.L.A. atipictt rrr,rrrlrr ,,sirullo])r I )(r'icalion:t l anterior oronic de etiologie nepleciza;bii,'r. 'l'ilrrrl lrl rilr,i IrccvorLtintilnit este siuchomul amiott.oficAran-Dlchenne, rrr crr,r'r, rloiir,ilrrl rroi,or qi atrofia rnuscular5, incepe la triye.lul rniinilor, rr.:rlizrrrrl, oi)ritentolor tenari, |i hipotenarii [i :r, interosoIr'irr rr,i,r'olil, ,rl,,r',,,rrririt, sirrrirr,tiii') atrofiei ;i ,,rrrila in ghear5", dupi cale progresiunea l:r rrrrclrrl rr,rLi oll|ir,l,t1or, tg lrzaa,z\,,m ta t1elredicator.,, $i ,,mina Si antolrrrr,l rrl rrr'Irrrlrrl,icJ'. -,\tl'{rfia ss poate exti de qi Ia nivelul nusculatur ii bra,I rrlrri |i r'lriitI lrl rIl so[]inturalizomelici a memltrelor Supelioare. ii:ur (lrF(,r'ir.i rji cazut'i de ,,poliomlelitrd cronich" in ctre atrolia debu1,.rrz,: lrr nilrrlrrl utl$ct atut'ii proximaie armembrelor superioare,realizind :r,r lc prorrrlolrriopa,tice (Yulpian). tr'ormole de ,,poliomielitl donicS', 1,i., r r rlr.lrrrt, lir rrrcrrrlrlele itlforjoat'e (pe glupele tnuscxlare peroniene) sint
l l l r ll l t r r'.

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

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

ll, l

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

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

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

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

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

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

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

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

i
I i

t 0il

I t i || t{ r.

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

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

r0r'ror rui1 rr r'ir,iDitill .. rrI uu,uri ri ryi ''i,1";;;lil;l,; 'l ,;r,,litt'r, ili',,'li,lliiil:,jil

Sl qlf plerului

ctriar..r.u snrulsprea I'iitticinitorl;

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

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

Muschiui biceps

br cnhial Circumflex Ramuri cu.onle ale antebralului

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

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

/rr.

.r. \"f\i i

c i i c url rU c \ \i

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

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

| fi[

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

(n
m ei i i anul uj .

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

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

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

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

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

23'i

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

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

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

rl I l ).r

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

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

1t,?

cutanat a! cubitql

Gheora cubitald

FlexoruL profund
'ol degetelor

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

Abductcr

po{icelui

Abductor

Opozant

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

',': lt )

ferloriul cutand

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

lr "

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

Itltsrrrrolzii Irrrrgrrlrri srrpirurlor'. ll'irtell (citrr,ttkr liisor, 1952)r lirrruicir, olico prrlrrliziclirrlillii, ealr: rcspcotl lungul supina,tor' (in al'r.r,ra unoi leziunijolrso, ,rrlr lri[rrrrrll'1,i , rrcrvului) se dato]qte unei pnlalizii radiculo-rnodulxre, rrur,i lxrlirrcvrite satutnirrc sau unei isterii. i.,) I'oral.izia radiaki antebrctltialdtnaltd, este roalizal,X, ale trautnrtrisme, rl,. lr( lrlli infccfioqi qi toxici (indeosebide satrmism). Respectd, lungul rrlririrlor' qi permite r.idicalea pumnului, intmcit lezirmea atinge nervul rtrlr rrrrr:ichiiepicondilieni. i',t) ).'arulizia radialti antebraltiald, joasii este intllniti, indeosebi in rr.rrrrriismc (de pild:fi,in fracturile radiusului) qi in nevrite. Intereseazi, rll:rt lrrrnrrrilc radiale ale policelui (scurtul qi lungul extensor, lurrgul abducI()r') si (lxirensot'ulptopriu al indexului, cu tulburS,rile motorii Si atrofiile r',,trsrrtrrtivc. Tulburiirile rle sensibilitate sint limitate la o mic5, zon[ Ia r'ivolrrl bir,zei dorsale a policelui ,sia primului spaliu interosos. li) I?aralizi.tt,nerLr ui obtu,ra.tor se recunoaqte prin constatarea unui rlclicit; rnotor 1)l adducliei coapsei a] rotariei exteme a cu atro-acesti,a, lr,r loirlsrri fi plinbr-o ansteziepe -i fa{a internS a coapsei.In timpul mersulrti lrolrrrvrrl prezintii o deplasare in a,fard, a gambei qi a piciorului. Este rrrIusriprirr traurla,tisme qi la fcmei, in tra."-ali,w prelnngit, prit:' compresi1rt Lttrorr, oxclcitatii, tle capul fetal in timpul traversiirii bazinului. i'jo irnpune si recunoaqtem sindl'omrLl ltti HowshiTt-Rombarg,, realizat 1r'itr cornpresiunea ner/ului prin hernie obturatorie. ln acesta, pe prim lrlrrn sc l,flir, o durele care imdiazi, pe marginea intem5, a coapsei, atingincl r'r rrirnuru de iltensitate la nivelul senunchiului. i) Puraliziu nerralu,i crural (cu cele patr'u llnuri telminale ale se,le : ,,r'i vrrl musculocutarat exterr, nerl'ul musculocrta,n,.t intern, nerl'nl , \ r(llioepsului qi ne vul safen intern) se manilesti prin; a) ImposibiliIrlcir fbxioi coapsci pe bazil; b) Deficitul ertensiei gambei pe coapsi I , r 'i'rrlbuliili rie staliune qi de mers prin irnposibilitatea, ertensiei $erunr lrirtlrri- Aceste tulburi,r'i de staliune qi de mers silt mai mari irt para,lizin, Irr,rrcrrIIrlii, inalti,. situa{ie in care bolnavul est oltigat si-$i ,,trag[" ]x?tnlrrrrl irrfeliol in1,r'edoui, cirji. In schimb, in palalizir, troncularir .jo:*1, lrolrrrvrrlp(,rile merge, dar cu contlilia s[-Di mellini, genunchiul ,,hlor,,it" Ir ('\t|rrsilr. l)acli se prorluceflexia, gamba se derobeazS,; d) Urcntul sci,r'i1,,r crt,r:irrrlxrsibilsiu {oarte dificil; e) Bolrrayul nu poa-tes{, se rneniin.S, rrr ,,pozi(irr 1x'r'ino':; f) Reflexul rotulian este abolit; g) In lrtostaliune se llrrllvii o lxrz:i(ie cle ,jgenurecurvatum"; h) Atrofia telei antt'rionre a coaprli ; i) 1l\rrrllrnul rotuli:rn este flaso, depresibil; j) Tulburi,ri de sensibilitate 1,r.lrr(t rrrrltto-intelri :r coapsei si pc fala internd, a genlbei. Ir'ul tt'i,tt'itlogici: a) Atecliuni vertebra,le Di ale cozii rle cirl (traumatice, Irurrolrrlo1.t.); b) Turnori pelviene; c) Comprsiuni de alte naturi (prin rl(.r'lrl g|il,vi{l, in cursul unor inter"venlii chhurgicale, cind coapsele sint rrr rrlxlrrclir rnirximi, sau irr cazul purti,rli unor banclajeherniare compre,,rvr,); rl) Abccsc ale muqchiului psoas iiiac; e) Intervenlii clirurgicale pe ruilrrl lrilzirrl f) Irractud aJebazilului qi ale porliunii superioale a femurulrii ; g) .s!tnevro de rerlucere a luxaliei coxofemalale I h) Anevlisme a1o rrrlrloi lemulille I i) 'I'tr,untatisme directe ale nervului (de obicel cu cointerr.sirlcil,corrcouritontl qi a ri,r'tereilcmurale) ; j) nevrito ,si neuopatii (diaIrr.l icii, yrrtilinrtric[, toxicl). it) I'rr,r'llizirr, rrtrlvrrlrri lir:siol srrllorior(rc:rlizati (lc frr],ctnrri irlo l)Mirnllui, rlc irrrrroli rllrligrro rlrrlrirurrtiitislrc tkr iix, sit,tt lr,urto NI'nIr! it,lrr llrlzirrrrlrri, l)rin rltr i.irllul{olll in crruttl Ilrlir,tii, sltttrlrt llrr'rrllrt., tlrrcorrrgrtt.r'rittrri rrrrrrrilirll' l0tl
1

1lO COtlUl.aCUe,

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

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

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

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

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

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

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

l{r I

poil,i,(! 1i plrlsat nici hr addlc,licr-nici" starp.cvh'firl ?ioiorrlti, (,irtor)ll ?o?t.t(r rrr lol,rr,{,irr iltu ni, qi nu poatc sd-fii fle,ctezedegetele: e) },iolta plantard esl;tr csle dilicil, de alurd tal'$3ld ; ,') Atrofia.i+telesea,za lrtllrrrsilii; d1.1\lcrsrrl l''girrrrr.rr. pl:lnla}i, rnargieiJepiciorului $i moletul gainbier; f1 'Tcndoqgl 'frint abolite l,.,lrilirln .,s1,o depresibil ; g) Eellexelc achilian fi medioplantar ; lr) { l1q117xlgigi 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 tlegote,,in ciocan": j) Tesiul lui Fromunt: in staliunea intr-un picior, tendonul lui Achile ri.mine flasc, depresibil, iar gemenii nu se contractfl tle parted paralizatd';- k) Testui ,,piciorului balant') : bolnavtl, plasat in decubit ventral, este solicitat s5, llecteze energic gamba pe coapsi- Ie partea bolnavS, piciorul rimine balant: l1)l TulburSrile de sensibilitate obiectivS, sin1, rjecelate pe ta1, plaiitard, * piciomlui ({iq. 26); m} Sopot eviden!idii [ulbur;ri vaso' ni ricrii qi trofici (edem aI piciorului, ,rlter.alii ale pielii !i ale unghiilor. ulcere l,rofice nalca-

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

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

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

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

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

lrl;l

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

r'\l(,t'lt)fi rtri){il)(ltt.Nr.rrrlrisl,lr ri rlo srrrrurc tlo ottcrrllt,lr llrr(xtt.illl 4lt 1,irt, ((.rrstllrtl(!rlr.r'rllrrrl0lts0 llri Jrt,irrr ;rlllrr), lotr:it'o aat,l,r:-su,lta.at,l,c (11'itt iuriliri, lrli,lol, . . Alty.1nl,,inr;u,ro1xr,lii lrr.trz'rl,srrlIr';i rlc rarJr'n, trioltoclozilfostat, tclanclorel;nn) s,, 'r.,,< ,Irr,, ,1, ,, t.r rlc (la rmrlcitori oale lucreaz:'1, ou loxi(,.1. rrrsp.r,l,ivr,) ','/rf('n1,ul aparif_ir, ri plin asoeierea de paralizii do nervj cranieni (oculrrnolor,ii oplir.i, .fi rrtolrleo-vestibulari), tulbur.iri psihicc gi sau semne henurl,olog iiur. / tulicd.fste rard. P.ealizeazh o for.nii rlixl,ri (r,rr 1rr,r, .- P.olineuropat.i_a , ,l''rrLirrllni,.r tulburririlol senzitive)qiseasociazricusimDtonrcr,rr':rol,rrr,isl,ir :rlopccie, o\ l,t,rI .altera{h uxghiiior (cu striile lui Mees),convulsii, Bi}rrl)l,ornc ;ii'rri.irhle (tremuriluri, miscX'i coreice),sirnptome psihicc (rlirrlrrzi'.rrl
l,r Illl0s1;]ce).

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

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

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

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

100

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

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

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

ttlrrz,r, tr.r'I lIrrrrIr';ri/srrrr r,r'r'r'IrlIiIr,, I rrir,IrrIrrIrr,, irrli)lllr{ii |r,rIrrtrrrilr,,, lxrrr,lir Ilulgkltt ;,rt.), l'olilrrrrrrrrl)itliilt r'r'lrrtiv l$or', so t({l los(1 l)iLliut{,('l)llLzictr scrtzitir,i),irrll rlr lorr lttitt lthlrrrl lrr trrirl; (rlrrl crr trotti, lrtrlor n irlrrrl,i't, lr,rl rlo ,,irrrplt'gnalo" ttcttcrtrli treoplazicl, cu cvolu!,io prtrgrr.sivir. lt) I',litturuyuliilr tlcgru.cruti,rc. Aoi so inculrt'azir ir5rr,-zisir ,,1r,/ilr, .t tt it,i" hip, r(n,.1;,.,i tamitiali ,.r c,./piliti?; (buofu ly; D(jlrin, sutt,tx\ rrlulttr(ti (t;ptil, lt;dpsi tourjttrr). SiLr b4li dcgr.rr|r':rtiv| ril l' rl ',\',trrlir. Irrgtcsi-i'r'i 1r , in care atrofiile musculare cLrdebut distal itiiing ilr rrlo(l In)A11,. sir', in tlectls de ciliva ani, toate cele patlu rncrnbre (rlul x,slxrclii r.orr;r stk', bra,lcle,ct'nl,urile qi fa!a). Se inso(escde mari tulbulriri rlr scrrsilrilr lrt,lc do tip ectlomelic, cu caracl,ererlisociate (cu nlaforilii hiporrslr.zir', ltini )r anestezieprofuntl[) si eu mar'e atarie. Cel rnai iiilescrilrr,rli'lrrrl,rrl lr'rlii, b,rlnrrvii acuz; si clureri fulgurante. Un simptonr pirlrierr0l 0rrir, ({'.rt'.l)crlnitu rli:lgnosticulfftti r}e ,,tabesularniotroJic',)il corrs1,i1,uir, lrrgr,,r liitile foarte ugor palpabile, strlr folni, de ,,mitrinii, r]]r, 1r'ul0hilllill r(.r'\-orse,crlc) itr intregime pot fi hipcrtrofiate. Sint prtztnlr'lrrlr.sr,rr 1i l.rs.ir'uhlii musculare, c-ares6 qtie cd,"sint,cu tolul excepiionrrlr. ir rr.lr,,i t,iile pe.riferice1ra D) Poliracliculortr:rri,tele realizeazi sindroa;me senzitir,o-rrr o1rir,ii lrilrr lrtale . Di.sirnetriee, cu diBtributie atit pluriradiculall,, cit si (rl,rr)tl('licir, rlo obicei foarte extinse, putintl gelera tablouri paraplegice sur rrriri rll ut abi1 .tetraplegice, cu axeflexie osteo-tendinoasi,, cu nrlrt:lti Iripolorrirr trrtsctrlari,qi cu atrofii precoce gi lapide. Sindromll ile profouelrrrrr sr,rr z,iliv (cu tulbur[ri globale de sensibilita;be) ptezintii aLeasclnclr{,1 ilt,tt ,r rlistt'ibulie poliractricula,ri, clt qi ectr,omclicl. Cel m:ri iulesea sc li:(lclr,lzil ;i trlvii cranjeni (perechiie III, Itrr, VI, Y motor, VII, fX, X, -\t ;i I I I ). ill,rrlilir.r'i,rile lichitliene, cel rr..u i ailesea cu disociatie albumin*r.ilol rgir.ii, 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, paroxisticcse caracterizeazf,, ptin bruschcfca cle aparilie qi prin tlurafa scur.t5, (citeva secunde sau
| | llI l[ e) :

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

;tE?C";g:yj*ti1d;Jd#1,fi
t',",!llr{ff'::"t:t'tilt:?{f ;'!'!t"-'ie ("rarvate" - Devic rrxi?; $i col'rl)'

*+*#*t*ms[t*f r{]niilil i *fi#jt!!i?:,T""{$*,il:'lf"{'t*:"tkl'k

;Aj"ilf*T,lil,l

iUU;ilg;ilt*11l iii,--:[-l,li'* i;lr)litiri *l*i

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

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B) Boata Lai, lJnrerrillrt

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,:,:,.:;,:,iiyi;fiiil!;,f,l:jiii,':,!ij,

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

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

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

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

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

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

llrt,rL ill,

lot nbar '

o: r c r aL) .

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

rllra,t,t),

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

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

rrirl'iilxii. l)lr', irr.lr,llr rlr'lrrrl, rrr i'izrr r.1riIr'1rIr.ir, s. p|0rliic0 o rrl)lr(,(,, ,lrrpir. r'irrr.tr.,pir':r{iills,. -rr,r:r.rll,rtr rrrr,rJ rllsl rrl rlr.r.r,j{ul;rl, I,r,Olurrd(,i, ,{r'r'l()lrrir'slr, (1lrt(}frd (lii(i'iL(i do criz,, tonici a hri Jaaksun. -tn schirltr, .rr.r.il. r'r'izr. lunice tlc_Iosii, posterioari, cu rluratii de aBerncnea Bcurtii,, nu .,. rrrr lr..r.ttc.obit.ei tle pierdoread,. cuno[tlntr] si ecl rnai tdesex dispar rrr ;rozilicde decubit dorsal (drs.ri li cohb., 19?8).Arseni (1050) a einis i.,r'ir v.'Lricu1ari, confomo sireiir aceste crizc se produc printr-rin rueca.rrrsrr rr'1icula,i, ceea, ce erpliri qi_fuptul de cc lrcesiecrize-pot si, apani in IrrrIr: pr,ocosele patologice care iriti perelii r'e1}triculari. t,) 0.izele h,tptertonice d,in letartostlcbtteazi, prin trismus gi ris salilonic. ,lllrir r.:rr',. coultactura segencrrlizctrzi,cumpletixdu sc eu rerlua rea cefei, , rr rlivr.rsr. inllexiuriiale trrnchiului (ir:ainte.inapoi ;i Jat,.t,al), clr reduareJ rrrrrr..cl_rilor, tlrepli abdominalj si a muSchilor pectrxali, plecum si clr contrac_ irrli alt rnembrelor. Aceste hipcrtonii ttanice sint pielungitg persistenie, rtrrrl'roaso, fiind eracerbate prin paroxisme tonice vioientii initise ae c"*ij l:rI ii scnzoliirlo si psihice (zgomote, lumin5, emotii etc.). t 1 .7 t urb.o r e apar conrracLuri bnrslo I rringo-tarjngu-d iafr.aema I ir"e, .t ,t(.,,.,.hir d,. riolente..insolirpde cri"e de apnec $i ttc blo'cajlrrin;ia;; itiI l.rrlrr,tivtde deglutilie a;ntreneazi, desciirrca.ri tonico-cloni"ce ale*buzelor. -de faciali qi ale constrictotilor faringieni. :rl. rrur;chilor Ca gi in crizele-cliri t'.l, rrr)s,acoste conlnacturi tonice rabice sint, in moil caracte'istic, declan_ ,rrlrr ii .xacerbate Ia cel mai mic zgomot sau Ia eea mai micii rniscai'e aol,iv6 rrr.rr llilsivii, ,{1it crizele tonice <Iil tetanos, cit qi celc rabice, sp iusolegodc oxago_ ttilet_telor idiom, sctrla,re, ostcotendinoase Si mai rles i unor rofleie 'rr.r.ir ,lc llrrnchi cerebral (nazo-palpebnl, mtscter.in, Chwostek). t) In intonica!,ia cu stricwtnd (sau, tn su.pradotareaterapeuticd) poate :rlriirtir ti sttire de contracturi d e., tip tctatic, cu t,rrucorb[-l.i p""6rliti"e, . :',i, .,':r r,llorrrind crr convtrl;ii clunice_ 'f .i!.1.2. II ipertoniile paroristice localizate t) Crizcle epilepslice localizate (tonice sau tonico_clonice) tle tio iack_ rr'rirrr ((,u f.i1 fii,rd lierderea de cunoqtir-LlL,cu sau fi,r6 der-iatia'cilj u_ ,lrrl.rr rr r.rrpului$i a ochilor')se recunoscprin durala lor scurta, uneoriipie_ lr.rlirrrlo crizii generalizatl, precum [i pri]r contextul clinico-EEG. ' b) 'I't:tunia ;i, spasm,oJiliase poi manifesta printr-o crizd, de contr"ac_ lrrlii.lirrr.itiiti la un segrnentcorpoml. Oontextul clinic gi EMG o" pr..izr.:rz:irlirrgnosticul. () (hitete ocwlogireposl,encelalil,ice realtaeazd Im context semioloEic rrryolrlo roounoscut: {ixalea brusci,, penrbilA, coercitivd, a globilor oculi,ri rrr nrr H,itxoliid de,deflexiunea capului. MuIt mai rar se reaU;eazi un spasm hipr.r,torric latelal (cu sa} flri devialia conjugatd, a capului), Irr fpilrirn ou coborirea globilor oculari. Une6ri in cursui crize'i ""*p'*iio oolifogi"" rl, lrollu r.err)in]'&r, midriazd, sau miozd,, iar alteori bolnavul poate meniile irr cursrrl crizoi o a,titudine statuiticatd, rigid6, a intregutui c6rp. Niciodati tr Hrl(xrnst,rtd, :r,ltelarea sttrrii de conqtirn{d, in timpul crizei -(element de rllrrgrrost,iu dilorcul,ialfa{,ii, de,unr.lc crize opiloltice cir devi:r,6ia conjugaid a ;lLrlrilr. oculari itr-ilus,ou [ti1; mlli t ult, cu cit s,l|'rr d escriscrizc o-cu"logi|o ,lo ltnprrtl, tlx ricctttl rnic,,rlrtlti"l trnt'olo Iixrnzii in tlcvia!,io sursllnvor.gcll,:1, l{}Ii2)^(lrizu ll,isrrr', ilr., lrr g.rrtiHtl, rlrrrl,l,ilIutrgl (ri. lr, tiit.ovrr 'trulogi.i"r, ,rr ; ri rri i, llr cittrt'lr rrrrrrrr1 orr'), llrtlirul Ii rtrtcori rrrplirnir,tr'l volrr rrtlrr,,tlirr. llrr

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

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

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

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

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

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

t't't

r{r rnolllino l)n |lt] }ioior', cin([ $e lirlicii, $uu oilrLltn{.rge,respcctiv atruDci r rrrl i{i i r.lir)i'r, irr:-riote. '."r'Dul - Jl,ellloxcle <le posturd, sint exagerate. ' Uitracterele contracturii imprimd, bolnavilor o serie de aspecte prr,r'l;iculare 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 Lip r[tropillic. -- Llipeltonia parkinsoniani, antreneazX disparilia unor sincinezii ronlule gi se insoleqte de o serig de sincinezii paradoxale, ca cte pild5,: lioxiunca precoce, anticipath a lungului supinator la inilierea flexiunii rrrrt;obla,{ului. faradicii, decontraclia musculari, se prorluce mai :. l)up5, teLanizarea" . lctri; rkrcit ln mugchiul normal, iar cronaxiile tind sii, se egalizeze. - In cursul ,,kineziilor paradoxale', hipertonia dimlnui| in mod net. -. I{ipertonia pa,tkinsoniand se insofeqte qi de diminuare& auiomalisnrrrlol rnotorii, plecum gi de bradikinezie. 1r) Sii nn gitnm combinaliile tariabile de h,ipertonie ectrapi,ramiilald, ti p irn,rn [d,ald.dtn sind,romul pseud,obulbar,combinalii1e d"e conlrq,ctul.d, si ,lr'.:tltusrne 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 din disronia musculolum deformausq.a. 'lcrrl'r.r'ubrir"e. tl) Rigitlitutea ile deaerebrare, prin leziuni ale sistemelor reticulate rJlsrrcrxlontedin ca]ota mezencefalici este caracteristici,. Este vorba ds o r,orrlrlacturi, foarte puternic;, a membrelor, a, capului qi a ceiei, care este rrrir.jola1,ii, sau diminuati, prin schirnb)i,rilede pozilie ale capului (fenomerrrrl Lui l\Iagnus qi De Klejn). Crizele de rigiditate prin decerebrare realizi,l,zi, t> hiperextensie a capului $i a coloanei, extensia membrelor infeliol,r'e, in vLeme ce pozilia membrelor superioare este variabil5, (in flexie, rlir,r'rnti ales in extensie). Se insoleqte de reflexe tonice cervicale si labirinlicc. Il,igiditi.tite prin decerebrare pot fi reatizate cle procese rliferile (tumo|rrlrr, irrfocilioase,vasculare, tra;Lrmatice)care iDtereseazd, incleosebi calota rrrczcr rccfirlicii, sau structudle vecine (epifiza, tuberculii quadrigemeni). rr) Arseni (1950) :i, d.escris crise untriculare au a,spectde rigidi,tate dwtLrelnald, 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 rlivorse localiz[ri. - Tumori supratentoriale asociate cu angejd,ri do Iob temporal. ln gloamele frontale profulrde, care prind peretele ventricular, ln tumori sau hemoragii extinse pe scoarla cerebra15,, situato bila(henatoame cronice subtirrale bilaterale, tumori parieto-occipitale h,,r'rr,l lrilrri,rrlc). I)rrpir,Arseni (1950) $i Arseni qi colab. (1978) cxizele ventriculare nu rrn r!$poottipic de rigiditate decerebratd,,intrucit membrele superioare sint rlo colo rnl,i rnrrlto oli in hipedlcxie qi nu in hiperextensie. Pe de alt5, pa,rte, rlcrsl,o liu'oitpitl bnlsc, la sohimbnfc:r, clizc vor)l;r'i0u d.epozi!ie, petrtrn ctr, sri ltrlczrr irrurlirilco lrolrrrr,vttl ptczcnl,rr,te se crrlcii.l)in obsct vn{,iilc rlo Arsorri (llllt(l) iii Alsr,rri (ll]?lt) rr,iirsrr cii,i,orr1,tr rrrizolri rlo hiprrrl,rrrrirr prrxllss 1i colrIl]. lTrl

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

fl

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

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

6.

pnosr,Eurg D0DIAGT,{osrrc IN ATAXIi

5.1. pR0EtEt{}N DE tttiT0l]Ol0clti

SEMIOL0L}I0I

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

tI

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

[, nrrtrzilivii oHit!i l l l ' t l l t' i rlil l J o*1r,;lrltIicttItr't:rr vl\rlrlr trtt ltt,tttiitltlriit ;.1nr,lio qtirrtt ltrzi plttl,trtrtl lt'zitltttrit' (tltrttlt'r'rt,'1i rrr.trrlrr'|trtsli, t'slotlitrrci'ii Irorrrirtl,rrrirl ltr rrriLr lrrLvilot rrtlrtritrtti), or oxcrp(il sitrrrriiikrltlo llrzitttti ;tt',tltttttrttllttr', ltti Wtrl'Ittrkitth. rlttltii,iturlttci;rtt'tta, rrirr'lul rrrrclrrtrltti ro1tL, srr,tt nl l,rt,ttt it' Iozirrnilol nclvtrltti, rrlrrtLr'iilot' 5.it.P. Ataxia voltibulard cslo t'cz (,rl,r'rt t.lcrLir{,ittttrr plitt t,Lrlburrili rt rrlo ttuclcilol vesl,il)ttla,ri c t olizcrlzi-"t $o Ii illil,inh)'illill)rri fil'll iii rlo rncls, cu oscil&tii ryiou tlcvit,tt in lcchqi scrrsr lezinttij. r'\'io rtsrxrirr.zri lrr,lolrrl, irL l'Lrncltic r[e trivchtl, rlc tilrul ;i tlo rrrtsivitrltea' rr sorllu lionrberg pozitiv (olcmont impoltant (le dilglloslic)t l)tll(lttrrriii rrislrry4rnus $i ame.teli. Este ul,il de lctinul, lrytu1 c:i sensibilitiitt(]a,pt'ol]l'irt crrplivtr, reflcxclo osteo-tendinoase, probelc de r:oordonarc qi volbit'trrr,ttittl' rrorntlllc.Ata,xia vosiibularii,nu uroclific5, mi$ci,riloizolttc alo tnctttlrtr'lrrt ryi, rir, ;r,1;N,r'or in sindloatnclc vtrsl,iltttlrrt'r, spre doosebirede bolnavii cerebeloqi, rrrr sc constati, tulburd,ri scgmentare de coordonalc. :rpiitittll lit lroltrrtti 5.9.3, Ataxifl cerebeloasise recunoaqteuqor, o1,r, ,rrrrr rLu ptezintl nici tulburi,ri obiecti\-e dr: scnsibilil,rr,to, ttici sitttltl,ottto vrsl,ibulare. 5.2.3.1, Sumar de d,ata senziologice Sindromutr oarebelos la om se cari,cterizeazh prin trei gt'upo ttrtli rlrr f lt 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,tcL 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, trrlbrrnrlea, s D. a, g6,tul/ui'slrlolBd.Cerebolo$ul nu izbutoiito sii,-tti b) Proba sti,ol,ad irrt;r'oduci tlegetul in ori.ficiul unoi sticlor sau uu e in stare sX,apuco glttrl sl,iolei. el dmerind al6turi, ci Probd, iniliaa-inilioa. Bolnavul cr oshii inchiqir nu esto ca,pabil Brt, {i rr,plopioin mod corect Yirfurilo celor doud dcgete inilicatoa,ro. ' 11 frobo Linidlor paral.ele. Se traseaz6 dou6, linii Yorticalor bolrtilvttl l'iind solicitat st tragi o linio orizonta,lfi, lntro aoo$toa, Oerobolosul nu r4o iilr,rl lxnllre opri exact la nivelul liniei vortioale tlin droapta' oi o alop6qo[t,o' inailtoa, oi. r{r ODrcgto - 'Proba prekenaiunii (eatt poharului), IJa solicitaroa do a apuctt }ltltrr, a) rrrl, po de o p rte cerebolosul tlop5gogtesau nu ajungo pahar'[l' po (lo olltl, p:r,r'to minil tui so deschidemai mul[ docit ests nocos&r. l.) Proba p notului. Solioitlnd bolua,vul s[ faol un purtot rlu ol'oiorlul' slth rxurbolosul tl oxecutS,diticit, frloiltlu-I tlin mai multo liniir introt{,i1t1,o forrnil unoi gtolo. g) Pruba lotisului', Sot'i*ul oolobolosului orl,o tlifttt'trt, tlt'ntttrlttnttl,, lit,ololo Iiinrl rnlt'i, ttutogulilltt, itrttgtrltr. lB3

ttttlun,lt,i lrr rlcrrrbjLrlor.srrl, ririscrr.r,cii u(f ,r pllll{f,ilijl ,,,,,tt.!..t..":.,,,,,.'::.: ! rrrrr llrllr(il,i,i lrrtl (,[rrrs lfr' .1( rr. laCoCUdCpl;ilr:a SltitOLl riirt,ile* iA t:ii,:t til]tri r :'lrirr rl,'r'i rii.r'rl rniqcliri de e.resaie, 'boi"""oi p"ot" olrogegenuntrriur" ,i tt i'nrtu 7tr'ir,bd'r'i,i cdrcti.*ru,i pe creastatibiei.-ra eri,rurarca ti. rnis,. {':r |.' lltco <_ru uu CiLractel,feStonat, cU oSCilatii. !. l rliutloc.ohi,neaia ( Disctiadocokinezig) 'con$,j, in tncapacrtilto.i , rl. rr .r.r,rri.ir.t'ifcL.i altel:lratiye-succ.sive. S6 e:rploreazi,.u aJuiorul urxnat_ iltr 11l9t' llrobc : t) .l?rohannrioneteloy. Bolna''i cste solicitati s.i,facii, titi$cxri :iltrer_ rrrr\'(, (1.9 pr.onalie-supimlie irnlebralelor,,prin :rtixgel,e& altel.nal,rvii _rlc rr t,or| soi cI pe mele, apoi cu dosrrl rniinrior. De p'artea bo.frraYd, rniqcl,ltlr, si, , rcrrriiu irrtr-un r.itm mai lenf, mali glloi, inteie.dinil o sc o pa,orii,,r,a,,,, , , mjsciiulor succlsive, sau notnavil-gre|e;te rniqclrc:r ' i]i.,.;:jilr-" i,n":ilca " it i'h)aa JkrtutllL zr.dla'd. ;i entensiunii clegetelor Se constati rrceasi , ,rrtrr'zr,rr. sru gJrc6ir,e a miqci,rii de partla bollavi,. r ) 1'r^br. baterii tobei ca" Bolnavul os1,e solicit&t si loyeascil .d,e.1tetele. r)rririr (iu {iegetele aubelor miini, const:r,tinA"_suac""rr.i-luburr,.e Lo-r*iiii Itl)l,1.lo procedente, .rl) })r.abaJleriunii dorsale gi Ttlantare ct,p icioarelot. lJolnaml yl irr_ , r.rzri',r-ll|l.\J gloci miscar,.xll tnt.tDbrul rlc pitt.u l,,zifririr. ,,. .rrLnerataconstt in imposibilii;atea de a, coordona artiunea tlifc_ r il /'l{n glupi trusculare in vede-reaexecuti.rii . cornplexc. Ast, |{ 1, rIril(r}ilo ('rnrplerc..se tlesconpun in cornponentele ";"ir;,ii;j; 1or clemeul,iue. sr)&te(proha asinergigi sratioe a tui Babinski). ,,. ,,'.'..!,_':,.:":::,:o:y:"!:::::!, |,, |lr{r(|nr)r.tnal, rasl,urntret pe spale compolti, flexiunea asociat[,, conco_ rrrrl.rrl,r'1r a trunchiul.ui;i a mimbi.elor infei,ioare rlin genunohi. Cerebetosrit (lrlfrxlurl)une miqcarea qi la accasti,probi lipseqte tt&iunea ga,mbelord ir: :'r'rrrrrrclri, incit cerebelosul cade pe spatc. pe gi a ao*pseipe bazm, \probli" cnl_ fk.rtunii gaml.,ei irr ,.1,)-,['rabo -ioapsZielebel6sul -rlescompune tir,:r) sr. erecu15, in decrrbit. rlorsal. aceasti rrriqrr,:rro, irr sensul cd,intr-un prim timp va 1iace it"r,lo"".ni tirlicil_ peplanul fatutrri 6ihou" i" uf a-rir",ii*p "ou1rrni, rr.,:{rea,sii fle, l,il.ii 1',,1y,.!^,:lt.de
\ |l | ||('li g,at]'t bet.

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

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

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

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

',

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

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

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

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

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

lll

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

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

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

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

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

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

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

I rl7

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

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

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

ci

jt",*]f; T":rrt,il",f H:",1,f,i",":;ff :i*:F:lt-,""""Xi:?li" rrltlii:iffi r',r\'(tir'.rru.ui hemal,omcerebelos. 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' lll l I I (,cl'('r'e luJia ( . . lO f
i

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

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

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

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

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

iz|rtziilttitrlt rllr lrllrf'' rI IIrIrr| 0lirrir s0 fltt'rltllttt rlrrrrii, rl(l il{) tltrlrrri,iIrr. i ,I vh'trtrt, tltr l('zilllll ir :rllrrl rl'1' scrttlttr I ii ctt ovoltt{iolrlogttsivll sirr,lrorntxrttrbclrtx , ttct voil N{r. llttt01'uli (u detsruLin'ilm sittt;.ltryrtrlt' rt\'rrtrtl aonge'n'ila'l lt) Atro! iiLa aerebrioase ilr l)rillrt l'' rr:rr'nilt'slrrl oelebelos ,,rr1,, unui funpo*ant sindrom lriin pr6zen!a, fiinrl evidenl; lcg,'1i.rlL' ittl'trt L,,,i hup[tna-steie,suferinti, cere1,eloas:1 (ir It 't'It{iIr rrrrrrri pzr,lotoeic su.ueniLin tinrpul vielii inlrartl.r'itrr'{:rrl ',ii,ii niin"a lptctrirt' se, clinicc entitSll lttr.ltrtzrt t,.s1ll''c Iot <liscdbriopiazic[. I)iversele lczionrtlii'ltt.p.' gi a semnelol de indica.!'ic celebeloase rrrlcnsit:itii '- su{eri-ntei cere-beloaslt' i. . (tl'ln iptazia congenitald,toiald'; - herniaplazia ' gi, arhiattlaiia "i'rii":r a lui.:Vogt i li,r, n,eocerebelitasd' Ttaleoceretlloasd l)ilrgtr, ' pe rrtliografiikl I'A itt pozift' lirrtl osto facilitat de pneuinoencefaloglafie, rrursiv l;lgit, rtct.rl tlitt itrr.rlr' evitlenliindu-s6spaliul subtentor'1al .r,zirrrli, tttt its,tN:i rrrt'trr. la;terali tlin ventriculii ce1 irrrr. t'ealizlnr1 irno"eunii cu rl l.ristic de X. in fozilia cu capul adirnat, aelul Se ac'rnul.^zr'i ltrrlr.ii\' li'sir posl,el:ioar"l, desemnind gradul tle ap-Iazie." cu- apari'lie tard'iud sint' {:'\plesiir rrrr{'t'l)ri)('t " ti; Atrofi,ile cerobeloasa ,' lriotmfice,' degenetativc, cu irrjtere,sa,rocereboloasil r:leci:ii'i - l)ivtrtsllr' 6cstttl rt. rlilir,il. se pot incli'idurr.lizlt taraLive de atrStii cerebeioase r rr,r'i*rrte rt lt'zittttil.'r topogralico gi a extensiei debuieazii, la care rr,, liaza virstei ,u'rrrbeloase. Tftomns tiratrr itt itrrrrl a lui Ddjdrina^ ANrofia o:Li,ao-ponto-earebeloasd, -ani, cerellelox, t'll trvrtl.tr(ir' siirdrom rlrr ll]Lr,r'o realizinrl i'stei 50 rie r cl"e ataria' 1i 1f(nl]tl rii'l I l,lrl de mers, predomin[ tu1bur5,rile (in cale l)rr,gfesirr6 ttxltitlrilittttitlrtl', stttttittr i ,rt;riiiliona,td,;, la cire pe parcrus se avrciaz5_,1i rtlir glolrtl"t cottjrigli,l't' mi;clrilor rrle qi oculbrnotorii.si 1,,r'cuil iialeze u' Lu'i I'ittr' ta,rd'i,td cu prellorninanld' --- Atrofia cerebeloasd, -@rticnlii r. It (,ie-Ioifr:At04nrani,e apare mai tirzi' decit celelalte iti:t'fii .r.'t't'Irtr1'I trtttrl'r'rlttl iar itt leniil, r,lrrrriivirsta d; 60-65 dd ani), are evolu-tiemai l( mod net (sau sint crclllsiYli) iit'lrtlr( ' r'iiulosic oretiomin[ in tttt'ts, tlc s1,aliune de irnportante lttlltrt'r tulburitri ;i 1',,Ir:oceiebel6ase: 'ri tutburd,ri de vorbire. a lui Lejonne'[ifunn'tlid it1l:llo ttt AtroJia olitso-rubro-aercbelousd' itt lentri 9i s. uitlir{jt(.r'iztritzrj, are evolulie 50 de ani, virsiei"cle .;rrrrrl uu r!:tli tulbr'ir'r'i itrl'rrrr(ir'' 'ritttttl prin importanll ati,xie a memb.-,'lor',. 'irrrl vr'1" gi mioolonii (lLtrooti ,,,,1,, {i o'oziijonale,' la c:lre se asociazil, 'it'tttitrir) globibl o('lllrtl'i' ale diafragmltice falingolar:ingienc, ti lr,rLr,1inei ' (l('(rl ' Atrofia' cerebeToatd d'ifuzd tr twi llr6utoa :l'prirolnai (l{rvt('rrr(' (intie 40 si f'0 lnj ), are o evolu{iemai rnpid; qi rc*liz.i,z}; lttr trlrtir y , ,,l,,lrr,ltc lrr rr' . rrr,ltotn ccrolrclos compl''l'lirlhi, pslco- 1i lcuc''r' Liel'r'i-lril:rl''lrll' ' (lurrt -rlll)llc(')' (itrcJusir' r,r' rrsrtciazi, Si semne extlapillmirlalo (rt,tlttlit sa irrl,iltcsc in iltoricl(,i* trl,ilitlit, troaica lt. Atunii,te carabeloase ptr'trtlttt plgrnb ttltlttttr, crt pt'ofesiori:r,1e crorLicc ri r,runici,) itr intoxica,liilo '1i -cronictl eu tloze rntli tlo hitlll(oitlt' (ilr sllrvrirrlt' ,i i,' ,l,tlsul tlatarncnl,elor prirnitlont, 5.,u. lr,rrobru'bi1,*1, I ittittrl trawnatkle sitrl; ttqol llo tccuttosott1, li. sinilrowtcta acrubeLouga ('r,lll ltt'tttit illttt llr'lrlolttgii Zii, rtll,l,ie, crllrl l)r'rrllt(xr rir.irrrrit do fitotlrrrtltr,t,rtr ('nt'r vrrtirltil tltt llr t,ltz lit, tl;tlr', (ltrrl,oxl,til sr,rrri.l,rgir' . lolutc oot.ol,,rtlousr,, llillulllll'i(x" lrrzittttilot' t':i l,ottlirt, ttt Ittltofio tltt lrttrtllizttttrl 1i rlitl ( I'r.nti+lltt) (xrrrsl'ii' ht'i honkt' iod' Ataoitr, Ialtupinoht'z ll, Jonili'd'
:rxur.ir,rr,n, t t t r tti si tr r l t'i l tr r tt,t't,|,,'i ,,xl tt n to l tr l i t' l tr r r g ttr si ttt, l t tl tttl l 'l t'l ttttg i t'r '
, r'l l l i tl l.

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

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

:!.'ltroJiile

r8 0

180

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

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

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

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

i:',"i.}}"x'ffiry**ili|I'; r{iti'qT#{f ;J[Iiugsl$',1ffi1"a,i'fl ei Botezi r1);)t qi cora).r.,, i srsor r;r;, F.ff"'fi

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

F O.

lt'tspl'ttot,,otitlt DEDIAONOsrlc PROBLEME INVoLUNTARE MIscARILoR

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

nlunel t n)-mipolittii {a iiiitoiti W"orotir'ote Jragnrenlafe, u,"roi'orfiiirioiu coqro' irtttroulntu'li nlo vrriat'o'p&r!! ;il{ ll nrjinotrlo 6n.f0 nl0olloutn rlltlFttl(lo, rrlnerono blla,tor|l.1o, nrnr il nncluo at{oolond{ rnlg i "ft,ift;ti;Jnoron b)
ill

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

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

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

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

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

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

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

insoiir.r, rruoori gil!l,,ili.rnl",, ;i de urrciipcriinozii lipisnrt. I I'll] ,-' r : r u n .t utur .r ale nrembi j .,,',, elo-r.. , le ru rs iu u , . spa s me , c ru if rlio n r, b ] . 1 1.r , r r ( t r r l l|c ) . A p rt L r (.Op i i rl' |r.n
s l d ri i

c5 -r5

1 l I ll l(t'

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

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

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

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

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

Irt1tlI Iotrirro lrilxrJrirrr,l,ic (;llrrliirrsorrilr,lr) rlrrrlivcrsrrrrl,ioplrlogrrrii (poslorrcr, lrrlilic, rrirI'urrrIIrl', posl,lntrrrrurlic, strrrilrrl,c.).Alrir,r'o ltr rrrI' rr( i rIr,r'r,Il, llror rzi(ii(ittrtlttsiv irrlrozi{ilttir:ttrltit us),cslc t il trritrirr rlo Irrrr1rIiLtrtIitrrr rttor I(,t lrr rLl,i'h, rll Itr'rl.r,rr(ii, rrrir:ii, (J l{) oscilr,{ii/sr,c.), r'oi,r'ornt'lit:i (irrrilil, ;i llrt,rlrlogr.sl,rrrrli, rrrrrrrrrilc:rtr(,itttri ; dc lrutniirar,c n ltarrilot., tlo,,flr,r,rrr,,ir, rlrr llr,lrrrrr lrilrr|.lor', :r lolrci crr rlogel,clc ci.c.), dilritrrroluti, slnrclisplrcirrcrrlstrl .rrriqr,l'i,r.ilrrt. lrqlivr,, l irrlrursiliciila cmof,ii qi tlisparc in somrr. l)c rnllli,o ori irrlrrrrrsclzi, rri , rlrcrrrilir,t;o:r, ccfalici (rniscIli ,,tlc afinna,r'cr) sau ,,rlo rrcgrr,{irr,)). :!. 'l'ten.ulr\I,ulaintenlionalii,(d,ea<:! tn,nt) ap:rrc il sirxlrorrlrl rrr,rr,lx,krrr irr lirrrpnl nisclit.ilor acl,irjer, :r,oceritnirllu-sc'progrusiv otlairi rrrrrlczlollrrr,r,l rrrir.r'iilii (ovcrrtualtlori,rlrr,slh.qitulrniqcirii). Ilstu rnai arnlli'l dtcil, lrr,rltrr.rr lrlr Jlrr')r insonitr,n[,rrereg'ulatd,, rlisparc complet in reparrsqi Irr rrrt,rr{irrorr.ir rrrrr.i1rostuli. Se insr:festede alto sernnecorebclolse. :i.. Tr.enlurdlura optoz,l]ion alii este tot o trcmn.rii,turir ilc rr,o[irrrrc,rupi lrrrl lu sfirqitul uriqcririlor activc, da.r'esbeconstiluitl r)in osciLl(ii lirrrr.lrr rrIrl,lr, (iirniste,,biit{i,, dea,rip:i,ca?etind sii indeplidrczo rrrflu[)nll lr,nprxrtiv lrlrr obicci supcrior) dc lintii (de unde tennenul tlc ,,oyrozi nrru rlt {iortali'i," antagonistL"). Este ca,racteristiczi pentm sintlroa,lrokrrlcrrt,o ,,irc1iu1ro rrrlr.t'itro dc, diverse etiopatogenii qi pentru degenerescctll elo hellll,o 0o|rr lrlrrl' (lioala lui \lrilson qi pseutlosclroza lui Wcstphal-stliimpt,ll), rrsor,i Irr I u sc a,f)roapel,otdeauna si do miqciri de tip coreic qi de spasrirc v iololr1,r,. ,1..il'r.emurd,ttuile permanlnte 86 obscrri,;tit in rdpaus,-cil, 6i ll (irtrprrt rrrl rr{i rcrii r:nor postuii qi constau ln oscil{ii neregulatd ale ilegrt'ck.rr( ulrooli ir.r (tle iltosr,:rl,i11i rl,, ',r :rlr. lruzelot) de mici rmplituclinc. Pot fi : .fi:-iolcrg lt4t), (moli1)e (simultnil boal* lui B:r,sedow)," lt i pcrii r,itliene, \rt tt,ilittrtrtt. rlrrrric,ln intor'icaliile en mereur, cu nicotin[, cu coteinti. Nu so lrrsol,onc (lf, $('funo extrapiramidale, eu exeeplia ccTor senile. ;,. Trcntoru,l isltric ,si al sirnulan!,ilor trebuie diferonliat do vtrirurl,okr Irrt.r\trlnte do 1,remu$,tufti. Acost tremor nu are car.actelo rituri<,o qi rlu.rvr lilx', eri dimpotriv{,: apare intemitsnt, apare in prezenla epr:otu,trxllor', lrrl o 1l1yq1la, neregrrlat, heterotipie, Iiinit variabil tlela un morncnt; lrr, oll,ul\lrirlc_fio ln, repaus, fie in miqoare, are caracter net circurnstau I,ilr,l, l'iilrl rlr.pcrrrlent de_sil,ualiile emotionale qi/sau levenrlicativo (Soflo1,(rt,, J1r0?) 'llizrr.rr.'. qi de ticrrr;i, tlc spasmt:;i rkr curilorsiulri .r .lr.rrrtltc ori sc.insofesto p;r lrrrloxulc, clownieno(Riser, 1952). {i.l.i}. Iliperkinezii bru;te, iliseonl,irmc, rapide, dc ounrolrr rdorrir, tlozor . rkrrrrlrr (ncrilmicel 1. . Ii;cd,rila coreice sint rniqciiri involunta,re gencmlizrd,r: (dc ohicr,i). ,,rr pr rrrrlominanld, la,fa,t5 ryila rnrrnrblcle supcrioarc, bruql,tr,dworrlr.rlllo, rIrfir,(,, il,$irne1;r'tioo schirubintlu-se noirrccl;:r,1, do lir, llrr gl'ltp $i asincr,ono, rrrrrslullll ll altul. Sinl; va,r'iabilcdc la un monrcnt lir,altul, so inl,rrrsilicir, ( ii, lir,eforl,uri 6i ln cfcclirilrtu,rrnor acNiun lrrr.rrro i rnrr$cul:llcicllmcl,or,ncrrri rrl(,nfional) 1rlra,zi1,ind rniqcir,r.ilo vohrntalr', ca,rtrdcvin asl,lrrlilra,tlrxrvll,r,. iir. rrluLrrcl,z ii, pinr'i, lrr rlispari{,io irr loptus doplin lr pl,i, ill lrr routn rlilprr,t'. I rrr.olisirr! linritrr,l,o Ia,rrn ltt:rnirrorlt (lrcrnitnroi),irlr, do }iklir, ltr r.rirrrliorr, rrrr'lr.llrllr.rttir.rr qi .jttxttrllt.l:trrtitr'. Nfitt,ririfrrr,orlioo ,vr, inlthuso )n: q) (lol'rrrrt rt.tu,lii ( tl'utl.t,thtr,ttt), tr:[ttr rtpltr lit rtrlrii,rlrr ollirrci in1,ro fi lfl rlrril oli nrrr,l rrtri,l'iitrrl lrocvrrtrlll, ltr, 1irl,ilo. lCrcr,pl,iorrrrl ro lnlllturnl,o 11vl r,lr|'t rrrlrrllil. \lrrrrri ilr rrrrrlrul,rrl rlrrri lloli rlrrrrrtl,ixrr lr,lo.

ozintir,o-m;$care involuutar; rapidi, sf orcolipit, rIc irtcn. .'l'rr utor_ul.r'a1lr silirlc viLlir rili, prc rlo Lininrl la nivclui c-xtremitirlilor.Sc impune ililcrcn_ I i(rr(rir,lrrrnll,toil,rcktt',formo semiologice fi, pa,l,ogenice : .1. lltrentlLrdlura ila posturiL. (a,ry1,-zisi1, lcp&us" -- lolmon vechi, ,,do tlrv:0trrx.llrttrzriltrr') 0sl.ot.ltrtltl t,or.iHl i(ir'1, sirxlrotrrtrl rrxlrlrfrjt,tr,rnirllri lxtnt,t.u

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r(x1r*(,s(r*(lrr so i* .,rrlcxt,I scmiological rospectir-ei onc,t.riiin ,i rrllor' (l(r irLloctic gencr:ll[. "i ""m] c) (lort:eo, itronicii a lu,i Eu,.ntington aplre la vir.sti adultti, fiild eredi_ lrrli si l'arniliilliJ.cu transmisie.dom;n:lnb,i.Atingc ir mocl'egal ambele ,,,.i'_.:",11!]i,. lr'nr-pli|gresild. biperkinrziiio sirt rnri emptc, mri ;1,)i.: ,rzirrr'. rr:tt.r,cvl rnitr tcnto decil in cureea S.rderrbam, tnr.r..uliiind ntrri .,rrrrrrricrAt";i mai ,,dansant',. Eruluetzr-r, cii tlnrnrr,iii f"o.t_pi,,,gr_esii;ii. ;i rp,rre 1lr, indivizi in r'ir.st[, pe tondul suferiniei va.sculare ::!rild :. , , ' ...,,1),..,'r.,-,,r::
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o l r l l tr 'l ' l tti I't1 1 :t) l r 'l r l l zi l r l i r ( ti r ttl r u n ttl : '. l l r n t i l nl i sttttl ''r tl ttr l tti l r r r r ', 'r , l | | r | l . r 'r i , Ir Ii r l :t, t l i sru t t t l i r t t l ri , IIItt II|' tIII||1 | I t t rt 1t I i I t t t I i t t r' , l l l ( l tr i i l l l , , r , r r r r r r c r r r Ir r r 'Ir 'r Ir ,o ;l ti l r .si tti r l i r r l o cr tl r ' l r ti tt tl r '1 tl i tsl tti l r l tt,i l r '1 i r r l l l t'l l tr o l tr t' t r l r '. r r t ( r t r l l l ttr ,:r zr i si i ,r 1 t,'tttl ttl tttr r l ttttl t,i t l t I I t I t t t ' I r i t I I t I i . St'l to l tl t , r r t r r r r r . r i ti ( ( ) t!,i r '( ' tl ttr l l l ( '. l ) i l u l i : t n t ul , r i Il r 'Ii tttI,' r 'tcti o l r tr r r i l i r L l i i ( tr r r i i ) r t' t r tt'r ttr l l t i zr ':r z:t l r tttt r , , , , r r r i I rr, t r ri I rri I i i ' ( ( 'i r l ) l ttl \ i tt j tt ttttxl si ttto tt i r r tl l l ttr tl tr r l r l l l r i t ( 'i l tt tr r i l r r t' 1 , , ' r 1 , . , l r l r , i r tr t r l i l i r i r tl l o cvo l tt{i o l ci ti p to l l ttr si vi ,. {i . t . i i . | | iIr 'r 'l i i r r czi i l r .r tl r ', Ii ti t t'r r l i l t'l ct cl o tti t'

l)iril,rllidille ;i dc lacunarisin celebrel (inctusiv cLr nerrrrrcile ,rr"ol.igic-psi Iricii). (',tttik ?)'on,ice s;mptomd,ticepot ap[re:t in t raurrrJt isrnole clajtio., ) (.or\.t,t'irlc sr rr unele clcctalopatii toxice (indeosei:i cLr oxid de ca|botr) .ri t.ltslula,rc. {',tt,",t rlln ptcrlr'upoliile inlunlil" r,,prr.riUl I rl,ty ult qindrum ,. ..i ) qcminlogic jl|rporl.rntr. clr ;r,rn,rL, pir...rmidaI,. r.\l,.,pi|ami:ll.ritrll||l,:9rrfe\l ,lrl{'. l)sr,)rcc (tcl ,ird.tr.c minL-llril,e\pnl ,ri si r.u ciiz,, opilepr i6...Du obicci r.sli.rrrrbatle Dc, mi;c5rile coreiceliind asciat; artesea, cu misciiri -hcmicule :|l (.]r,ltcr., toallzinrt o Coreo_eletOZj rytre'r hpnipleqiriIur est,' o bomicor{'ocrr. :lplli, rudlu.cbi in . 7). lr'ttllrl(.gllp infrni ilc ..i uneori ir horrtiplegiiiu sascrrl.rie. Sr. irr.,rfoslo dc olricti qi de rnigci,ri atetozice. h.) I{ernicarei,le d,in, leaiunile mezencefaliae (sindroanrcLe de ,n,uclezt, ) ttlt r-tllln.i.oarp snt infertoarc), talatnice ;i ju,nlatalamiu sint tle obicei \;r\('t.rre lr se .ecunoscin contextul semiologic de suferinli xrr rr tiilamicX. 'rclcncet:rlicd, i) istpric{irp:r_t r, Ia copii t1e vilsl,ri scoltrr,X, t1r. obicsi il nici .. .(.lareeu ( ||r1.r.'.rlrrr..rTrtrritLcoliTe, prin ,,contamin:lle', psihogenit, do Ia un caz cu col,ee \ r,r'rtirhrlt,Irin,rmitatic- Slilcirrile coreica au calacl,erc to:r,tlalc, apar ir1 specllr1o.Ijlor,srut mai a.mpleqi rnai d:lnsanle;i so evirlcnliazri qi |r1'r'rrf:rJ ;r||(' I'ielnenle Dtihoqen e. i,wnlu,rtalr:iliseuntiluc, inulto, rapide, dlr rnutt mni .. .l;.t.l..,tfloc;r; li||rilitlf .i InHi rtcroolipe({l!.r.r., 19-,.,: . Tiaurtle , ,/ .silt ;nisc,rli inyoluni;are intelmitenie (discontinte), c,Leslrl ,1,.,,-r,,lrlorrr1rN, corrtplere,. brn;tc, repet:.te, rapide ,,litle clr:rcicr clonic, Ir.r.rr Lpc.-\cestc acio sillt inoportrlne gl absurdc, ailerea :.ealizind ,,ges_ lrti incomplt:tre'r, tloar schifate. Sint loarte cliferite ca morlalil,ate tle"ex_ jucrnntlrr, Jttitrt rtr. (clipit, blelerospasm, grirn:rse,tuse, rtisucirea gitului sr,r,r ,' LPului,rniccili :rlp_membrelor). Acela;i tic po:r,tgsi'r, fie lepetat timp ,lr..lrrrri_r'lu_ rr,ni,ri,minind absolut sterectip, pinii'cind pozrtc sti tlisp:llii, .r'rlirrrl locul altuin. Ticurile ccrleaziiin sorirl !i, la incep'ut,pot fi influonl rl(l critro voin.fri. Sc exagereaziiIa emobii. 1r,l,{i llorr,l,rr. (a l,ui Gtlles d,elu Ilourette) so polNe l'esunoi]lbcplill tk.tttri,ktr {lr. ii(uIi rnLrliiII,',gorreritliza1'0, lt1.z''rrlir la, nivclul 1c{,0i cn pt'orlornilrrur!ri .1r,;-lrlrllut,ir,N(,('ii|,t,'. s i Ulr [,rilbtrli-r,r'i psilricesi 1,uIbLLlr'i,r'i {10 vol.l)ir'{) ((]ol)r{,lrt'lic.i ciroIrr,IiIr). l)obrrtr:rr,zii in copil,;iriil, tlc rrlriccicrr ticLu.iir,r,riirlo, iritri,sir r,rlittrl lrlourtsit', po rnir,sur.rt, lutorrnl,rti,r'ii psi!to1lri,irr,. Nrr ;ii rr Lrt)IIttr.riliIor, tio {,otrIrI,IrIr'i, trici rrrrll\rntrrlr, srtt0ritri,i llrrr.v0l r,si, olgrl,lli(:ii.
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r t l tJl r 't l i i ttczi c tl i 'r ti ttt'r 'i r ttl ti l ctr l i r l l r ,i l ttti ',i r l i 'i t 1 . . l l t l , t : r l r 'l r l czi ttl i t t t t t I t t I I t t t I t r, l t|r 'r l ,r tr tt , , , r , r , : i , r , r r t lr l ,i |t'i zi tttl r r sr r i r ) 'j l l In i fci i fi i l IV{}l l t]l l r l l l ' l r t tti t'r l ttl i r r i tttn i l i i l Ji l tl r r l l r sl tctr i r tl Ir t tl cg r 'l r 'l l r r r i i r r . r r r l . r i : r r r c l ll r r si t'r ' Si l tt' r n i l tl i ti i ,t'l l l 'i ttr ttl r l tr ', \'( 'l 'rl r l r 'l r l i l r l ', | | l ! , r , ( l ( ' rr t r r 1rI i I rrr I i t rr r tn o tl ct'l ti L |,r' l l l l ( 's{'r ]' l r j zr l tt', r 'tt r l t'tti tr 'l r ttl .r r | l | | l r I i l | r i ( l ( 'g ( ,1 |l o l si r n i i n i i :tl i l tr tl i l l i u r l cg t'i cl o t', ti tL tl ttttttl i ttl l tr r ,i c' t'i ti r l r tl l l tl i tt t'r l r r ttsi r ', 1 1 1 "1 r 'l r 'l r ' r,' rrrr(lllrj ''r l L r L r l r r i r . i t r tr to tl i r ttl r 'p ctttl e ttl , i ttt'i l ci l c, tl e r ti vtl ttl t' tttr r tl Ii r ( l 'i r l c l r 'l l r l l r l l , , r r r r r r r l l . r l t rl l i s( 'r i r i vi r t'i i ) l ) i l 1 r l to ttl r 'tt fi cr ,tl l c tl i n l r tr cL ', tl t' l ti 1 tItIr l .'tr r l i r ' ttti ti si l 'l tr r tl i l tt'' tl r tl tzttr r r r r l . l l t 'r i r r l i r l {i r l i . l ,i r Ii ti l r t r n i r l l 'i r l l r r si tr l 'l l tt{i l l , l r r ; r i . r r r i s c r i li r l e i r r ti cl r r i tl l r tc l tl cg r i t,l o i l i r l c tl i l 'i .i r ti t l r vi l l l l l tti l ti l i o tttl tr t , r , l r l r r r . i r r i u ttl n r , r 'i r r tl sl tl r j tt a 1 r ti i , $ l ttr l ttl r i i fcl r :i ;i r i l i tt ttto tl ( ( ,r r ,l :r r r l , r r r r r r r r t i , r 't . l r l i zj r r tl r tr n i i r r i t,i i tl i vt:tsr fxp t'( .si vi r o u g ti tti i tst,l t'( x'l ( 'ttl i l i |.i l l ( l i r l r ' i tt r t{i l ttr l tl tr r i str l r i l i Irrri r {. 1 ) r '('vi r z ttr , i l n ' ttttti i th i i Si tu l i r i l e a l i zo l l zi , , , , 1 , . p l r r i r , . i tr t'r n str l r i r i ;i r i i r i l o r , h i p ti l l i i r tl z i l t' r tl r r l o zi t'i i l ) i l l i r r r l , i r zr l r r r . L r I i I l r I l 'l r l r c1 i vl j : r ,i ttt tl ct'i tte i r n ti ccvl tl i ,. \i"lf)zl l ) {l r i ( ' l i ttn .i l u .l r ttl .i stt;r t l ti l r t.l e r ttIr i , l u 'r tIi ::u .l r i . si \tt tl tl tttttl t t!l tt r t t t r | r r t i i tr r r t'i l tl i i tr tt i tl ttr ttt:l tti l tr sti Ii st'tr ti r I l o g i 0 l ', i tttl l ',r st'l r i tl i tt r r |ttr r , I rrr;rilirrrrirlrilii. rr) ltdo::rt, dubtii' (st.:,tu.s )u Q,t ttto'a,lll* al hti lt o!ll.) t'r'lt'vi rlc rrlrtlli 'r , 1 , , ( i r n r ' ( 'o ng ( fl i tr l ,i ,, sr tl r e ste co l l str o i n l a , n tl tl l tr r ttr tr fl l l i l tr i tl tr l r tttttt'i r ',r ;r t I r r r r i u r r l l n o l se ch cl o ( l o e 1 I( i e f:l l o p l l l 'i c i n fl ttr l i l i i ' ( i l r tl r ,l l stl r i l ) l i l l l l r l ) .\r l l l l r co l i c.q i c i tso ci l r l r 'i l tt o r l i l t!'i 1 i r , I ri I'I t t t t i r I I r |: r tl r ' 'r r : r l l i I r r c l r i ti r r e o u tl a l i ) . t r l r r r l l r o l i i l u i l ,i ti .l c, r 'u l u l l ) r ':ir i l l si l l i ( '( r fi 1 l ( l ( r s{'i t {1 l r 1 'r 'i z( ' ( x,tl \ l l l r i v{'. l t ) l l o a l u. l 'u i l l r l l l r l r i l u t fl tl I: * i b tu l t. l tr i l 'o tl r i r tl r r l i 'r '( i tttr i I'tl r l l r l , ; . r r r r . t 'r r l i r c i a tn i l i r r l c ( cr r i r tst'ci r t{r t' r tl tt'i l tl r td i i }r i Ir I1 r 'tr tIo I) r l l i ( l r r l r r $ i :r ( 'r ) t ( l i r tttti t Vtr g i ) r r r r t ttr l , r r l r r i l r r i l , l l l 's) . ,\l ) l r tl n p r i r ttt;i tr t't' i l ttt l It l tr i ti tttl r ttt r 'o l l l r '\l ,,l,,lr rtlli i tl l l 'l l t N ( 'l r l i r ,l n l 't. ( ) r o l r l r r l r r i Jl r tl l t,tvo tr l ctt- Sl ) l l l 7 ) , t'o t|o tl r i 0 zr t q r r tr ctr tl i zn l i i , r t r . r r ; r o | i l t zi : t'\1 l tl l ) i l i l l l l i ( l l l l i l , l ti l x'ti r ttti 0 l , l . r 1 r , r 'r r l i i , ( i tr r ,l r r r i r 'l i r tn tr r r cl ti i i i '( r ,i ) , l i r l l l tr l i i l i tl t' t'ttl l r i tr '( tl i r l r r g i r ' "l ti r tl i ) ' r r l t( |i i r r o l tf i t'i , l !'l i l ) i 1 i i l ) i u l l l ( 'l l l r l r r r . tl i i ttti tsl i t,i tl ttl i i , l ' | l r , ' o ( 'u L|l l ] r .r r r r , r r {r r ; r r u g r tr i vl 'i r 1 i t.r i l r r s ( i r r ci l l vr t l tr tti i l l i r tttti r i l tl r r r r l i l i l i r l tti \ o ;1 1 i i l ) l tl z) . , rrr liiilrr i rr r i i tt Io tttl t,.i u vctti l i i , r t, l tti l l r tl k'tr o ttl ( 'l I , 1 , l t t L t ,l i r r p o l i r l r , l u l l ti tn i i IIt|) ti n 'u i t'i i tr . l tr i tr r tt Iktl r tr tl csl c o r r l to l tl , 1 , 1 , r r , 't r r l i r , i Il l i r i l i i r l i i ( tr tti i ) , r 'r r tt ttso l i i tzi i : Iti 1 tctIr ttti tr r 'r i tr tl ti t'r tttti tl r tl :r r , , r r l r 'l r r r l l r r Ittr "tttIr It Il , i ttl i 'ti o r tl '( ' si l ttttr l t!r 'r i ttttl ' tl s( x'l l ( l ( 'l l {i i ) , l l i |( 'l l \ l l r |z r l , r r r r l r i l l ', ( , r ) l ttIl r '\r , ( ;tl r 'l o tr i , l r i l r r ( r 'r r r l i , s;l ttttttl ' tl 0 i tttsi ttttr ', I t r ' t t t i I r: r I i ,t r t ) l tttt rl) liult /ti ( ttr tl ;l r l r l ,l r l i r tl ( l tr ,l i r tn tt'.l i r l r tl tr tl .i l l ttr ttr ti l ti n ttl tttl ttl tt r r r r .l r ), I I | , ' tl r ' vi tn i i r , Ita l;tlrl)(lil' i tl r tttt' l r t I ,{i I l '' tl t.l tttl i .l i tt ttti i ttl xr ,ttl i ) l r r , 'r r , , I r r t r r l {Ir '|{ ||tIi Il l r Ii tl r , o t ttl r 'l :tIr 1 r :r Ii l l i tr r Ir i l tt cvo l r tl i r , l ctr l l i ( ( l r t I , l r r r . l r i l r r l r r l r., |!) r 'i I, r 'i i r r ( i ( |( , l ) tl i i ,l r r tl i i i tl 1 i l 'r r .j r r l , l l ) i l ) tttt'tr r l ti r i l tt l r r r tr l r t l r r r \ l z l r r . i t r , r . :\r i r r r r r r z;i ttt l r tl r l r r ttl r tl tttr r r !r ;1 i r r : l i tl l r ttl 'i i t'r {l r ' \'r '( l ( ^ r l , ( tr l l

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

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

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dltrt{ m.al poate face.parte.qi_ tlin cortegiul simpromatic .,.",,{] 1,t}..1:1.

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accidenbelor vasculare cerebrale exceplioryi

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

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

in frod_srereotip, f1;arie lrlcvent qi -adesea

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

201

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

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

ii.ft CONVULSIiLE (i.il.l. Aspcetesc.rniologiot'. rltrisdbilt'rlcaltc rniir,irlj irnolrrrrlrrlr,, S1r'e ,,rrrvrrlsiiklso pl\izitrtii s lt formi-t,tlc acatBe. lllo llol 1li y(uutrlt:;rrlt,,tl\t ir lotalilatc rnust:ul;ll,urn, corliotalii fi insolindu-suct:l rirrrilrrlr.rr. ;.rrrrl r rl. ,' picrrlcre tutali srrr rcl:tf,ivti:r, siiuii de constiitltti, sirrr,rIirrr1roIrirri, silul!ii in caro intercseazilun gmp rn iir:rtln,r. 7,,rr'lirll:, ttrtri irrtrll itrrI rrrlrr s. lr1r lin 0xirilt l. (lon,mtts i ilc tonir:osittl re,prczenl.iltc tie conlrrrc{,iirrrrrst,lltrr,prt.lrrrr atrtron(l:lzat, o stiu\) p[,ro)iisl.ioii])0 t)lln(, 1i'i,, i,rlr', (r1lr'o tllrI r'lrIirl lr.ri,r.ri l,rlri,rlr: iigirlital,e, (.,,r'l){rlill, crrt0antLent':rz,:i urr scgrnt'rrl srrrr, ilirrrlrol riIrr, rrrlrt,lrgtr, lnuscul ,ttilii t0tpol:rlli, JJrcrnplulr.r'lrrr:rirl rrorrsl,r'rr,liv cilr, l;rzri ,l'' r'oltla(1uri, lotricl gonu'aliznl iurr, tliilepsiciglllnrl rnrrlturrrvrtlsir, lrrrir,rr , lorricr',itr (iu(', luzilulrll st'c11s;olol (x)rrvlllsirr si hipt'r1,rxriLr, rt't,lizcilzir, lprrir,ir rrr llrrric sl,r] irr cx1t,r'rsiu, irrso1it:i r1irlc o piclrleltrlolaLi,rr sliit,ii(l(f .rl!l r
i tr(,i .

!. (l utt: ul. siilt clot ir l sinl r ni6r r ir i it r voluni, llu r list , or r r r r r r r r ,$lr , , l{\ l l r.l ,r' , i l rrpl ('r r o1t , li1ir . r . , r r lr , l, ltr . 'r r 11 'izt t( .) l l) lit r ilp, t i( iit lr r *t r . r r r i; . iil, i lr r , r r qlr , , .' 1..i {' r,} i rkr . r nilr i g. u p. nr r r s<r r r lr rr', 'Lr . r lur ill, rscr i nl. ii ( zt x, i r l. sr r . r r ir r lr r , r r ir r r r i, , l, { rl i N l )l l ri ( , iir r,'r r pit ir i1i r , or r r lllclli, ir t lt , solt t r l l) r , ol) illf illo ( chir r l . r r g. r r . r , r r li z:.| r' ) l i (l c ( , r 'lr rr r I r i r r r r r llo r r I i oI | sr r sllor r r llt r 'r sliiI 'lr ii t lr , t 'igilI r r {, i, , li, r , , r r r r , , r r [[l !)t l i l l l l lr olilt r t ir lt 't r lif icit f ( , i1, t lr r 0lr ic|t [ i i) t ol( ) gir I t I t , cl! r r ilr t r ilr , sllr t , c r' 1r i k' pl ,i ci i . r\r' ci i i r I r r t r r l'r lir r r nr r r ji,( lr r r r ir , irqi , ( r llli{r ii) I n) 1. rr r , r r r illolr , r r r L, $i ir r r lr r , ir r rr Irrhl :tu.ri ..tt r : ut it loqilr '; lt ) ( lr . lr . t lor r ii lir lr r r r , r lo t ur r r vr I I iiil sr , l, ( , r r ll( , 1, r . t lnf r.rrl i zi nrl folr r r ' l'r r i. o . lr r r i. i . ir , r , lr ilr '1r si. igr , r ( 'r r r lizr ilr , ,llzlr , lor r ilii, ( r r r r r i | ' ' rr' l i i ) l )r!'( . 'lir r r l |or r Vr r I r r ii|r.r'l0li( 'r '; [ r ) ( 1r r r r t r r l. . iiL, l( ] , , ir ', rr . lr r r i( , r tlr il f ii1 :10J

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

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

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

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

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

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

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

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(pgloyier3 'rsrsr rriio. ni ",irnr,.,' : 11 crizd, :,1")11."-i]"3::rj,.:j::]l:!1"t"

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

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

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

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

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

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

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

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

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

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

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

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

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

l)rt'rrrort, rll l,i1trrritlgio rrsl,o rllr,l;rrlil,L rrrrcisli,t'i rlo lrilrrrloxrril,irlrililrr,lrr lr,ut'ornllxcttllr,tii, itr rutt;clri, nlrtr,ro prin cortrprrrsirtrtoir, r.Irllrrirrii [rlorlrriti, vr,trlfrrlo. l)il llr, tnrrlrrlri,irrrprrlsrtrilo sirri;oorrrlrrsrr rlrlrlrilxrl; pr.irr ni,rlLr.irrrr, ,lrrlrrllir, crtro$llrrnzir,torr,r'o, I)rrrcftlr,trsl,o sl,rio t,Ioolr,lizlt,l'l, irr rrtrrgoltii irrrrr.v r,(,i rlr, rirlrioilrilo vorrbrtln oxcil,rrl(f qi uir osl,0abolil,ii ciIrl. r.tlrlir,r:irrrr, tlors:llrI rrorrlr I.orr,lo osl,o aucgl;oziir,l,ii, sllu sgotioniltii,. ; rrrrrzii liidii,oinile vontr':r,kl sinl cornpusndin {llltr groa,so oo l,rausrnil,irrrlrrrl. ,rlilo r[ot]oilrc Lr,muschi i1i din fibro rnl,i subtiri oaro pol pftrrlrlco o nl,rr,r'rr rrrlrrlir.i in fasoiculelclnuscuLtr(r,I)urr:rilo obscty:tttr rtnoori lrr crrrltrrr^ni rrrrr,rr ri,tltrcinii ventrale uu $lnt inso!its do corrtrrrc!ii nrusnrrlirrrr, ,1,'rirr,.,,' ,l(' iirnt, provoc[tc de exr:itareafi]rrolor radiouhro vontrilkr lino. lrr regiuncr ccrvicalL, o hernie rle disc intru,fora,rninn,lil Doll,lorrrrrrrri o comprosiune selectivi, a r5d:li,ciniirrontrtllo, tri,siirl lrl,rlr1, irrrr, trr'orlrroo ,1,'r':rli mai rnu[t s,lu mri pu{in intaotii. Acclstii, ovontlrl.t,]ilill,(\ Irr{xlu.r\ do tip nrielgic. ln astfel de cazuri nr'. cxisl;ii sullnrprrrroirr irrl,r'r, '' rlrr'{.r'c ,',rrr (lo distribuire a durerii ;i dermatom. Daci, ]rct'niu, rlo rlisc rrorrl1r r,irrrII rrrrlxrlo rridi,cini, cxistd,o combinatio ale durcre dc tip millgio iii rrovr.rr,tgic. llrrtrrnrt intereseaziio arie mai ma,rs decit cea I unui rlorurrrl;ont; rlorrr'lrr, rlr,;lrrlar distribulia durcrii corespunde dennatomului. Nllncvrele pentru proclucerea durcrilor snu acccntnrlrcrlkrl sirrl lrrlkr lrrrzi{iille capului, glttlui qi bralclor, cum ar fi: intoarcorot or,yrrrlrri sprrr rleafectatdqintoarccroa capnlui spre pr,rten afecta,l,ii I'r,r'l,r'it, rii pli0rr,rr.l, pr,sirrrrii pe veltex; hiperextensia coloanei ccrvic:r,lo I floxirl coloirirrrir.r,r' r rlrrloI cornpresiuneaexercil;a,t5, asupra gitului I prx'cuilirr, rr,lro l'izrr lor. Hpi rrr'rsosiru percu,tiaparavcrtebralS la nivclul leziunii ilpliur,rrrr,prrrsilrrii I ,lri,,ilrlr pe trunchiurile plerului brahial (durclo;t s,rLr'prrrrsl,cziikr rirrl .r in aril tlerm;tom ui rospect,iv 1rr.r'roptrlo sl,u pc itlilorl,gtt, tr,r'io) I Ir, I rIi rrrr,r .rI po mu;chinl scalcn, Atit in leziunilo rrulicrrliLu!r t,r!'sirurii oil ;i irr crlr, rr,lrr l,lr'\ului,-sint ilurcri pe trunc.hiurile plexuhri su,rrprr rnrrriclrirrl scrrlr,rr ,rrrlctior'. In leziunileplexului cif&ctelistic esto llptul oii sirnlrl,orr rrrlrrllrrl, rrrlrrrrsilicate de miqciirileqi poziliile umd,rnlui irr llzirrrriL, li brtlului. l)rr,r'qi rr rli{rLllilre mi$cii,tile membrnlui afectat ryiin speciilltr,l.o rr1rl rr bltl rrlui (rlrr rrrr,r ,rrrrl so imbracii sau se pia,ptF,n5,) decia,lqenzi, rlur.olil purrtr.rr l,orsl rrr,ri,iv ili limiteazii,accstetipuri de ni;ctrri, frr,pb I'rr.iotL1,Lt1 ci,rir so rlirl,or'rr;rlirr rrrrrri ,prsr.rr muqchilor scapulo-umerali,qi nu trrlc{iunii po t,r'rr rrclr irri.ilrr 1rk, _al ,.ttltri.Mi;clrilo urnlrului nu au nici o influcufil, ruuplrllrrrz i(,irriliirli,rirrilor. \r'r,rrsl:r, cxplici, tle ce unii pncienli pot sri nri;to tl.ourbl,rrl illtxrl,rr,l,, crr lolrl,rr ,lrr''.r'ilr' rni,ri po curo )e atr. t|pIiclt,rclr tr',.r"uLiurrii po blrulrrl:rli,cl..rt., rr.r.r.rrl.r trtrrrl iu a,bducfio cu capul intors corrtr:r,lit*r'Dl (s.nrurrllui i,rlxfgrro ryisupinaJ,io l:r gil,) (icclan;o,tzriclureri itr nemllrul suporiol. rcsprxil;ir. I rrtensificare:ldurerii so oblino prin tuso qi striinut, tkxrilurco lrr ptrr. I r{i(|o clostorobrrrsc}, qi intriltoltc i.o. .Atr.ir,rl,rr, a pr,csiuniiintr.*ab{lomina,lo ' ru' pont,r:.oxplicaplin f,r,p[ulor), s0 pfoduco o sl,r,zii, vonoiwtr furvlsolo opi. rlrlll(! Di, r.tsttol,$0 comprilnij, $itoul tlural qi rir,d.tioirr ikr ; oorlplruirr rroir, :r.t,rrr,sl,l! so polfo rtlor yr:_rillis I I'il,ejn,lu-so rnioluscopio qi so vir, vtdol cttr rrrlrr.t Iniclo#r,trrt.ri sO irtlj.rsl,o:r,zri. l\plioa,roaplr)$ilrnii po prtrrlolo ntilllgioo rlor:la,ni1cazil, tlllorj Irrrnr|r^ (.1()nll)r'()silllol, riuli0lrliirii provoitlriX hipor.rr,lgrrz ia rnrrgultilor', frr,pl, orr,rrr lrto. (l0oLrlIBlr,ltllr,rrr ttrirllgltxrttt'ulll)1, zonolr) rlrrrtriij..l'tttr<il,ol|l ll,Lr , tltlooltttttttttll(, trrilllgir:o rIulotrlr,Ho r,l,o nitrl,loo.r,liz lit, rr.iyolrrl rlrilo rlr,rrrrrlilrr lrruvoilno rrrrri. ,111,r* lirt'ir"1 B ,ll ltntlitf(u,zii, i'rr,l.luir[. l)tttrrttlur+r rrr 1,rr l'loolrt,l,r1, Hi (fN1i1x:1,'lllt,g ltt rtrirt H(tgtltoll l,lr, t i1, ittl,rrrrrnll,l,; rlu 1,t'iroo rlrr1li1, (, i rrl'i I i ,r,r r. I i lor,rill crt rrov,rrrri"

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

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

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

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.nulu.Inra 1. llin,tlrtnmole sanli,l,i1)e L Sinilrornt,Ll ( com.plcte) sacli,u,n'ii.l,otala u nddlu,no i rhl,cnuinri,rrJlr,r'ifirr, rrtrciitnrstozii glollnlo subiocl;ivo qi oLricctil.crlorlcsulrtullczirrtrii (l;rrllrrr. trrto tlrr scttsibilitrr,{;o krl,t'rrllk,g ir', srr,rr ,,otr nivol"), ittsotitri (lo l)ir,r'itl}lcgio gi l,ttl'ico.N ivrrlrr ItrllrtLtiLt l lu lhu t r],t i irlrttr.llrrr.r'Lrt, l,rrlllurrit i v(Hot,iIt,ivo ikrt' rlrrsr,nsilt rl opirrlo rlo rrivoluI lrrzirrrr ililrr,l,r, ii urtxlu lu,ru, i rlokrrrrr irru,r'ou I r'rri,lrui, ry :r trivlltrlrti l,rrllrrrlr\,rilor rlrr sotrsilrilil,rr.l,r,, u,r'o dr,oxolriirii, villonrr itr nl,rr,bjll rli:rgrrorlilrrlrtilollir. rl ft,zirrtrii. tr,rr, grr,rr i!. Sindronn,l rlt hlntirrliun.rtu, rrriulrrlr'i rildrlrrrrrl llnnon Nrtquuxl, lrilrrr,lrr xotnilrilil,rLlii fiitrtI rlilr,r:1,r' 6i 11,11. 1ql1r lorrnilrllilrl,l.ll lr,t'tro. ;rtol'rrruIrr
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1 rl [(zi (, f l' iir ) ( l it r ( r ' u rri [rri c , ]rt,rrri s o c l i L r c rr rrri rl rrvtri vi t gencra - pe i i l gi i j rrl i ,r' i o l s l i u l r,rn t,n rb L e l o lde accea,fipal te cu l czi ui ter, r r r c r r r I r lr r I r ri l rrrrrl i zi; r , i rl rrri rrrii rI rr v c i . o rlisuci:l!itr fa,bcticri horloLll,ct,alii leziutii qri o disotinlie r irirrlorrrir,lior"l toll,r'tlatelali leziutrii. Astfelr o lcziune in legiuner ri.ir.ali (irr|rrr.rrlii) [ Irorniuriir]ur'. ei stilrgi r.* g;cnela i (] tnonoplcgie crula]ii Jting?:? sctrsjbilii.i,l,ii plofulde conDtiente in membrul infcricr sting si trr('r'rl('rt.ir, pir.rrlorr.rrslrrsibiiil,rii,ii tenrro-algtzice in partea ch.eapt5, cu nivel pi*i Ia,
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,.1 \i nrl tonr t t I t ( n) ut ll. i loxl. ( , t 'iott r . r t lizr , ir zi o 1( , lnlr r llit lg( 'zit ' t t t lopr r 1i r:rl r,, trtl i r,lt l, r t i, it r sr , gnl, t t ( 'r 'kt cr t llr olit lr t col'r , slt t t t t llilt llt t t ' lI li{f loll: {r f (lr 'l' ,l r i r,r ,' , r' tr piir l ut , r l"r s|ir ilr ' ( r lcf i t lc ii; r r t it it t ; 1' t silr ililiiii pt of t nr t lr r ; i l, r r oi rrrrr' l i ,j , rl rrl rlc r r cccit yili '1c lll lczir t lt cr t . St r ir t t ilt t 'slr , ir t r lt 'olr 'lt i I ll lnt llll 1,rrrri ,l i ,' . rti ((n'bn|1. IL Si arIntunu'lt srn.-iIi'ta o,lt' I,tttrtrrh itt,l t, i rtt ' l r: l ) lb t t 't ii, pr r t ubr nr , n! it le in. , f ar iour tit t t ct t st azii t . r iiilt r r r t t r 'r ) r t lilr r {r r trrrr r.l ri Ll rri r. r j nr r , r lllt 'olol r f t 12r iir cr ucir lt r t c: r l{) r '. ia, r ciiilc st r r silr iliiii{ii li'{r 'r rr,:i ,rl , rl r' i tr I r 'r t t , i1lnt r .l) {) il( ic( r LL, it t . {t slolcZiilni l. ol g{'il( f l'il Nit t t ll't it t lt t st t t t I t 'it t t 't 'I I r jilr r t tll r t t tl i t,rtl ti ttr;l ir lllt t llilit lciicnsil) ilillr loglollir , lii, alt lt 'ici l r,,r,Ll !r' l r )i bcilt ilr r t t st czic r ror t t lt l nt ellr li , ( t t ilo ixlos( '( ) li illl' I r lt ; r i ll l' , r ,,,,i rl si t i t t glor ni( '1i0. Aceir st ir ,t ullr r lt t 'e alt t , r 'r l"t ; i r lir ocir r li t lt ' r lt t r ilr ilt .rl r' yrri c i n r : ir , ost t hi in sint L'om ullui \ Yallr t nlr ct g, lllt t i llr r lr it t r lii Nr r ; : 'r 'r r ll, ' r ri l rri ( l cst r r n- ( lh{llliir ( \ 'czi ci) p, 1) . pcr lt r t t . t ular t t lr t t t lt t llr lt t r lli r lt t : t c 1'L t.,:i rrtti lc'pr r iubct ut t ! it t le su, 1t tioat .,1r\ (' (,oi lh ii. l. i c. r '|, le alo f r , {ci, lt r r t r c}r i. t ilt t i ; i r nt 'r nlr f t r loi. I Lrrtc llrrolrilci ltlitl rrI r I i I r' t I t t r' ;I ll lc;ittrtiIt bu, tu,re intrt'oli t:nrr:,riel,ot'rrti iI ft lscr ict t I Lr ht i1t it 't t t t ,rri , r' r' isl i i nl le lt t t t cl ioiu'erpt lin1; r ilcz: lr : ol. rI iI I iii : t t t lt t r t l rrr l r,| ogl os ( r : ille genot 'oaz: i o hom iple! {ic cr ) lt i. it f lii t our l; - 1, ; , i lr lr t r r lizir r lr t , r i llt r il ir r r ! ir r r lr ; r , l r' ' rti r l rout ilinr ir ii ipsillt t t a, lo) sc lczliizit ; i pr lt r glir r r tlr , r.i i r Ii . t(l n r f ( r t l, zt i 0 lt t r nti[ ncs1r ] 2i0 oolll. lilliLt ( , 1'r Llii l] l't lllli st 'r t ; r ilr ililr t i|'r r r lc i: ip lnlr olit : ) r 't L lt 's; r t r i'ir t r t r t 'sr 'l| . il , i I i i : rt i I l ,r,rl i rrrri ri (t1m i o r lisr . r cir l! 'iir
I t ( r ', . lll. S i n i r o tL tl ttl t l u ki n i cr : i tt l tttl o l o g tu , 'tr tr tr ti tti .' si ttl IIIIII|{'Ii ) i Ii .t,l l l i l l l l , l l l r i t t t i c s t li st l i cl l l t( ]su i i L c i n r i l ti n :e l l d e ccl ti i ,.l tl i l tl i 'o l tttt i .i l i r tr r l l tttr r r ,l l ) r 'l r r i o r r \ I r z l i L . r l t t . I '1 tl e i l o i l i l h l n i ci i t co n 0 !i u l l i l {}r 'l l ( r csto r r l ,I) l ( r Il l l l l li tl r ' l r r tl r r l r r '1 r ,' ', , r r r r , , , t r l l r t cl o l r tl o r 'Io ftr n cti o l l .t ] o , a ct- 'l o t ( '\l ) ( r l i l l l ( 'tr l i r l ( 'si 1 .9 6 7 I L l r tr r r r r i l {1 r , l l ) .) i , l l l Ji l i I |,Ir ctttr i IIr ' r r r r . t r i ( S i t g tr ', 1 9 6 0 ; f,i i zo tl h cs, A,i u r i .r g r L tr r tl , L 1 ) l i {i ' ci l l <l tr l l ]r g |l ', l l l ( ;0 ; |'r tIto Ii Ii tt, . r 'l r r '1 k r s , 1 9 l i t; l 1 l , i t i l ) o l ) ( i t.i !i i r r ,i i 0 r r L l r b ., 1 l i i "i 0 ) . l 'o l l l tl t i tl l e Jl 'g t'r ,t.l r i' tt'tr sl r tl i t tr 'l r tr r r l ttr 0 ttr , , r , 'l l t r r i i i r lr o l $ tl i , ( l 'o p o vi r i tt, l {) 7 {) ) ( 1 ,'i q . i tl ) ) . g l .o l ,u l cl n si t' l q o n , tl t'scr i s tl r r l ) ( i ,i ( i l 'i tr ( ' si l i ,tt r r t ' I . s i i u l ro n n l l r .r l tr ,tr ti tt tr l ) t!r tl f r f l l s l r ( {t i t l ttl l l l i i .l {ti l t( l l ( ) sj l l l l ) l o l tt( l : i \) I]( t i a ttfttl ( '!i ( tl r l ) ( l l ttt r l l so t'i i r l c ( r r u l i tt<l ctr tl l t.tl tl l Ir i 'l l l l l l l r ( 'l l i i l r l l , i r t t t i i . t , t t o l ti ( \o l u l i r i tl i tfttl ( i l r l r r t , : r p t o l u tttl i i ) . l ,) r i sl i i , si l r r r r {i i i r L tr i l r t i 'ttl ) t ttl i t'i l ' tl t s( 'ttsi l r i l i l r r l r ' r r l r i Ir t r r l r 1 , o l i t r t l tl i i cl t i r sl tco l t' tl tr l l cttzi p s( 'l l {l o l i l ( l i ( l l l l l l l '( ! i 'l r l l l i tl i ( 'l l l l i tl l l r l l ( 'l l ( 1 r [i r r l ) ( 'l r i i i r l !{'tl ( 'zi i l r ^ 1 r r r r ( i r r l l r l r ' I r r , i . r r r l i s l ti l r r t{i r r i :r xl i r r |i i sr ttr l tr l r i l r i l i ) , ] l r r r l . | | r , ( x ) i l i( i i l i i , i tt i tst'ttto ttti t $ i l l l r l l i i , ( l j i l g l l o sl i t'r r l l l i l i 'r ? tr ( i l l i tti tr 'l t|.tr r i qi l tctr ti l tttt'sl t'zi :t t'o t1 i t'ttl l i tl tr vi ttr ' l i l ttl r r r l i l i l i l I , r r r 'r t ( , z i i l i r r l l tl ti t'r 'i l l r 'l l l l r l l ' I t 1 t l t t t t i l r r r tr :i i t,r ,yi r l r r l l r ...|i r i i ( si tttl tl ttttl ( 'i l l ( ' l l l i l r { l l l l Ir l l i l l tIl t' l l tl i tl ttttsttl tr i , r 'i r r tr ';l i tttti r , r r 1 r r r , r 'i r r zi il r r tttt ( i ttr , l ,l r l r ti l t l a i s ( l l l l zi l l l l fi t t'tl t ' tt |'i t t ' I r' t I ' rr r r r,, , i t trr i rr r r , t r r ;r ,l l r .i i n l ( 'tl tr ') ; c) l l t'tti r r l ,tr ',r i t u r ttl .ttl tl r ttl ti l \//tl xr r r i r l r . ( r 'r , t t . l r r ,l l r r n ( ,,i l i r 'tt,r i i tl r r l Iti ttl tl l l ti ttr 'r r l r to l ) t'i ( tl t'( 'l 'l r 1 i t'i ) tl l ) ( | l \I ' I t i t I | | I I I ( i | , t || | I Ii ) i i ( I I I r Ittttr tttr i 1 ttt'i i tl t r ,/r tl ;i r . I t r t t l t r 'l , , r x t i ' l ttl r t i {'|( ' l p |r 'i r tl r ' ( t |zi l l tl l i ,j o l ) tl t' ;tl ttl t'i t o l tttl tti ; r 'l l l r t t , t i {//r ,r '. r i I r 'i |,t'r || l l 'l ', t l t t n I n r , : i r ' ( I rl rrrI r. t r I t t I tttt l tr r l r ' l r x'ttl i l r ,l t zr r l ttt c r tr i l l r l i i , ;tr ' l tt'l r ti ctttp ttl

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

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

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

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

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

(ttltir't' (itullorolri rlozugrr,rrJrikr), tt'rttttLici ttttlIr' rrrirrrHrrli cttto!iiL',rrvlriLllr{,ii rlrrlrr,tt tlttttli tIo rrrllrxlii) 11i t, lirit,r'l,tr vii rrsti(,ir,t,iikr viHorrt:r,Lr ;ttttI't'rt, Jrol, tlrr Sr!g('t! .l{l{i(l)r'r'il lroltrrt,vr'1,. Ani,fol,ttltul dirr lrolna,viilui Iltrrrrl(<ritrrt'1, tt'ili rlr.orrrlrii rlo aflxrNilt rlc rnt:zilii,, lttci{,,,tttrlltrtort, sI rt'zislrt It, ittttttui t lrt1,r t't'l do par'1;ort, sll bolnilvii,", iill rtlt lrtoirrnl, rrl ltri Ilrrrt,tlit,l'it'ttttt, rrr,ttzrllilkrr gt'oiLzttirlit tlirt lltt't'trtt, vtrrtltt' IloIrtltt'i'1'', r:intl oinl,itcotul, o srrrtzlt{ir: ,,lrl'rttroi tlo t t'tr:t,c! iOtllt oxoosiv ltt 0ticu 0x0itit(io s0ttei leritlinl,ir, 'l'r'o|llil,ii],ceastii, lirl, srinzoritrllsa,upsilricr'i Ir'1rl,zin1ii, fenoructtulrlo supt'rrrcrtc{ir'lrtltr (,,ovct-teaction"-IJe:r,d st' t'r ltlit ii rrrirr'i, d o ltiylpatirt" A ccstolonottttttto ) sa,u (Sager, c-roil,lll'ii rrfi1,tlitt in nuclcii latorali convttg lrlptul 1960) cil, lrlirr rrrr.rlirrl rril,iii tlitt tttr'tlittl itrtern (prin intermediul nuclcului dolso-mtx.lian), r.rl'r,r'rr, a,tit prin nucleii tjalanici de releu pc cit'iledivcrsclol ilf('r'olrlr\H|tl t'trlitrtt zil'ivrr,cit 6iprin nucleii talnmici nespecifici,in lela{'iecu fotttta,tiit, lrrlri, rcspectiv chiar stalii pe sisternul reticulat asccntlcnt (v(lzi lig. iil)). hilx't' I lqr,rl1i f161p"* (citat'i de Sager,1960), incercind sL explicc tlut'ot't'tr talamicX. au ar5tat cd,lezarea fibrelor cortico-tlllatnicu rt,t t'IiItt'trt rrrrl,it.,li, ,'r'lrtlelo senzitive talamice de snb in{luenla colt'ical5 inltibitolitr 6i rlo tttrrrrrrt' rr('r,g1,i nouloni senzitiYi ar prezenta o ,,supraleact,icr'ln olitto r'rcilrt,ttl, llrirr,r subliminal. Dup5, alli auttli (citali do Sagor, 1960), rlivcrsohr 2rolr"v (tasoalare, tumorala, i,nflamatorii, cticatricialeelc',) an cxcil,rt,txrlttlt'lt' Ir'. ion,a,le rrr,rrzibivc talamice qiar producedurelea. Incerclrile cloinl,olrotrrrtt rt tllttt' lilol talamice au dus Ia ilispute incd' incomplet elucidato. S-rltr rr'lt'iltttil tlrr rt rui,fol talamugului, in afard de rolul si,u ds re]eur qi unelo prtnibilit'rl,{,i r'nlrjbui Ia elaborarea senzaliilor tlate tle stimulii nociccpt,ivi tlo l ip pt'tr ' lolxr,tic (Mori.n, 1955; Ilead, Ilolmes, 1912r cita!,i do Sagor, I9(il))' lrltot' rt'li't' rrrill,e (1936) a ard,tat c5,alterarca nucleilor laterali exalttl, lronalil.rr'l,r,rt, livil, & senzatiilor, intruclt aceastS altelnre ,,Buprimil, un l[n:]ljj. trl,or, lrll lill,nr selectiv aI sonsibilitd,lii gsnsrale", a cd,rui func!'ie csto tlo tt,ttllri trtttt dureroagogi protopatice ale acestei sensibilit[]'i. l)uror('r\'lihltl ||rrrrcntele $onzatie, esto fd,r6 indoialS rezultal,ul uneri funclii coltionlo, lnl,ntt'il, " rlorlr la nivelul scoarfei excitatia se transform5, in senza'l,io. Desigur, dnrorile rlin sindromul talamic ritlioit, plolllornrl rtivtrlttltti lrrlrnlior al integririi senzaliei dureroase, iar o ,,soluJic irtrprrr;abill' qi rltrttl rr problemei nu existd qi mdte tlin concepliilo mai vochi 6i mtli trtotlottttr pe interpretd,ri $i fapte totuqi obiective, difur\' tlo lit lrutol ltl n,ttl,ot"' lrrr,zrr,to (Alnoni qi Operscu, 196?). Scoarta cerelrralii, rcprozint;ii lt,pll.rlll,ulsttporiot rlc porceplie a clurerii, Dar qi talamusului Ii levirrc, dcsigul rttt rrtl lttlltlt' <:il,qi llrr itrrportant, atit do releu pe cd,ilesenzitive (inclusiv dunt'o?r,H{i)' lt lill,ru seloctiv,precnm gi de a ,,moclttla" qi do n contribui ln,ttlttlxrrlut'trtt rrivolul scoar'fei a unor senzc,triiparl,icularc * tlupil, cttttt trlllillt(llllll rrttotior'- prin convcrgonla,ln nucklii latera,li n' unei lnulti[utlitti tltr ttLr' tttttrloi t'tt ittrtrst,rtr tr,tr!o extcto -,proprio-gi visooroocptivo ;i prin I'oltrl,iik) liltnal,ia, rel,icnlarit' qi cu sc.oa,rfa ccrclbrt i*l(Sllgcr,l.$60 1,\rscrti qti()l)r('H('lt' (,or(o'at(totit:t', \'1\t't\ Itl f lf(i?; IloDovioiu, 19?9); i) Mrri pot apiirtr:l rnirscrirti I'ilrrtrlot' la nivrdu) rniinii (prin ltrzitrnrrll tlr.norlrlsitrf tliscrcl,ttiii lot:a'liz11,e ti,trl-ttttttl ilttt l,l Itri Lu,r-s);j) ,,J\llrrrr, lrrlit,ttto'8trirto, r'os1:txrtiv t trucltttlrti trot tltt trtllt o i volrll,tr sin1, tltrrl t,i't, drrgrdcltr lir,liunir{r," cu't'it tttol'int,irfi rrsLc , ltt sttttsttl rrri6oil,r'iloltotozi<xt(utStt"zisr,lotfit,utlittitlo,,tlt'gcl,trittglttrlrtlot'prinnri4r ntnlotittkt Hitlt rtl)roz(flltnlrr lltr: lt'trttltittrt'oltttitt rt,l,ol,rrzitrr) i k) ll'rt,l,hurllriIrt cor]1tt I tti gcttic ttlrt'l trxlr'rttuttt l)l ill I'r{rtlll)l,rlr (ll'itt lrrzlttttr,;r hk'ntlilltont,oni'ntd rrrrt'li<'nl rr,l ttt'cll,t,i, |,zirrrtr, lrr Irrilolirtl prxlrrriqtrrr, li rrrt rrn1;cin,ltl tt r1t.r,lrt.rtlcI

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

l r ,ttl tr ttl ,t 0 l tl tt ( r 'l r r r ' l l l j i I r r l tr r l i Itr l u l Ii r ) i t i n l t , , tttttl tl t r l l i l |tr r tr t'r ttr r tr l t'ti z|r tzi t ,r l :r l It'r r l i ) r r r r r r r r|1 ,'i i ;tti tt 1 r t'zr 'tt{r t l ) ( ' tr r 'l l r l l ) l r l r i r 1 u 'r 'i r r l , l r r r , i r i i ( r t t l o r l ( ' (l i r l i r(' l r' l l ' l (' l ti l l l t ;r l r l i l r ') , I r t'r tl i z:t l l t tr r r r i tl tttl l Il r tttl r r tl r tttl ( 1 po si 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 |tIl r tU l sttl tr .ti o t si l :t l r i .l t,:r r ttr r l r r r t . 'r . i D r '1 i r r r i l r , ( }l r i r .r ,l i v| r l I r r ,"tt'r i lirl r i , , rrrr I i I rr i r , , i , l i ,,.l i I r ,r ,g cl r l i r ,i 'i r l cr |r 'i r i i .'l 'r r l l i irir' li1rr1.1q1 sl ',ttt si ttl n ti tti ttr r '. St' l r str r ,i r tzi si o l l t'ttti l tl r t'r 'zl i co tl i t'tl ' l l l r r l :t l r r r r , r : , , i r l r r i i 'r l i l l i i i j i tl ( '|l ) sl l l ( 'i i l r l ( l 'l i l ' \'{'( r r l r ( ') . I'ti t .i tr i | | r i t t :t i l l tt i ') tttttti ttt \ '. r ! i t t r l tn ttttt1 r i i sl ti tr l i |i ,,h i l t,,l ,tl 'r tti tr " 'tt ' :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 '' 1 1 }sl l ) rlltll, si t'r r l r r i '.r r 'i l : r {i 1 1 t, l 'r l r .i i ti tt r , i r r i 'l t 't 't ' t l i tt g r ttp ttl tl l i ( l l ( 'l {) r ' ttr si i i i l tr ti o |i l 'i t'i i l r ' ;t1 r r tl i tl l r l i l 'r 'r Io r 'r l l r r ' r ttl r l r tl ttttt, r r i , r r r r r ' ( r 'l t r r r t r l i a l o i ,o l tr }n r L ,i 1 ,') J.,l i l l 1 1 ) r i i i i ,:,i tl l i i t,r l .tt : l , t r l t i ( ) t t t c k ' si ttl cr ttr l l l l tl xc ;1 i ( 1 '1 r l i l 'r l : l r , tr r i l r i l - l i . I I ' I | | | : I I : I i (' t : I I Ii " l l i r r r l :r r l , r , 'l 1 '( 'l ( l ) ( r l l ) s t,rtn 1 ,r 'tla l 'tct l l ] , h tttl i i ttr ti l l si tr ttti l o tr i ttl ;' I'o ttIIIr I:r Il .t r |:t l tt'ttt , r r , r i c z i c c o t L l ti l l ti tcl i l l i i p l o i l o r n i n :- i r ) l U o i l l l l {l i , 1 i i tsl t'r l o q tt'r ztt" tr ' l r ttti l l ) t 'i r t 1 i l r , ['o Jxtt'i ci u ;i co 1 e 1 r . ( 1 $ ( i 9 ) tr r l l tl l ci t:r t1 r 'i i i ttl tttr i l , r r l , , r ' l ) i : l ] , i n i tl .r l e , t'\ 1 r i l p i n l l l i {l r l 1 ., {x'l \'l ) {'l o 'r L ( ', ;r 'r tzi l i vt' 'i vi Tr r r r l ' r t | ' ' r , . 1 r ' i i i I l ' g i u tl e :t h i p o tl l L a l r i " r , ,'r r l r ., i r ;r i l :,l i r i ' r .l ' 'Ir III r r l l i r l L r r r r r r L l r r . r l c t t t t t l i l t 'lt, co r 'fl l ti l l i l ttl cl l L r i si l tr l t,'ttl , sl , r i r ' .,.l tttl tr ttl l ( l ( r 'i r r Ir i l l l l rl , l r l . t n t i t , i i " .

Ir) S rrLr rlcrrrris Jitrntc heniotgice pltre sindromului tr"lamic (L,hor. rrl l (', I l) ilji ; ( lr Lr r :i rr,1 9 l i i , c i ta ,t r1 e S a ,g o r, ^le 1 960; Foerstcr, 1926 I S ager, l 1 )l i (l )lliir r lt , z ir r ni u L c n u c l e i l o r 1 a tc ftr1 i . ,1. fiill(lr'{)iulolo [ulln[r:p ruscrthu, sint tot I ind,rotunepu,yli&le, Tez,li, ,i,rll l)iirl plotlsc vilscniale loca,lizate hr teritor.iul ut:ruia di-tr cei cinci pedir rl i rrr lc li: r li t lc r . c r .i q ii n c ..ii n 1 9 2 5 d c l l o i r, Il i l i e mand si N i cul esut: :i ,rtcrcl c Lrlilrl){} i('ri(,rriil|1, si tallirno pe}folate (r'amlrli alc :llterei cerebralc posi( r'rorr('), |1,1()1.,r l{_'lrt irulo- opticx (r'l]}rtrii a, rrterei siir.ienc), arteri:I,iuberoIrrlirrrricri,(r'lunuli a itrtcrci romunicante posterioare) .,si artcra coroidi , rrr rrrrlllionlii (r:rnnu,ii a artt:rei silr-ienc)" Cele mai iinportaute qi mai frec\,'lrlr. !ilrlrl)itrre till:llnice \.il,scu1:lt,c sinl cdle trei rarietd,li {lescrise de lherrrrrl l r.r. i r ir r r i ul{ r sdc Si tg e r s i c o l a b . (v e z i Sa g e r' ,1960) : t) ;il(l)\Dtu,l Lle.obliterare e, patlic,tLlu,llLi l(.1& xo-qeniclllat (carc irigi, |)otlirrtroii llltcrl|lii si l]oiitelio:ir;1, indeoselti nurle1rl yentral postcr'o-lal,erirl). fi1' rlrnr{,t{riizr,rrzl plin tulbur.iiri t'lc sensibiliiato obicctivi, la mernbre lttt:ti i'rplirrlLl,c Ir rncmbrul in{orior), fiirii afeciar:ea sensibititi,lii felei. I )tttr.tcr'. rJ,rr.i1 e-ristii, se tlli pc 1rltn secnndar $i este pulin explimatd,. Se trrr,r loi,ilrzi o herlialropsic homonimd,. l)irrsttosrlir,rlli]rr imllicii tiiiiicultiili atunci cind apar $i alte simptome, ttt :rlrrlrr cr,loi scnzitirt : ririrtii tl.rlamici, miqor,ri coroo-atretozice,tulburi, .r,|r.I)('I().I)j('si irrrrnilrtolts!e hurnitnim,i laleralti (cal.e insj, eslc de origine ro tl i r':r l; 1, r lr ' 1r r ' r r r lo l l i id c l c z i ttrc a c o l ti c a l i :r,i n . tel i l ,ori ul al tcrei col .cbral o tro rl r.ri oiui, r lil ( ' r r (' p rrl r i re ri i 1 l e ri i c u h l ta l a mo-geni ci rl at). Iiit innr'\. rltur'lttt t't'rolo11ic, silldxomnl talarnic gIobu,l (cn de altfel qi rrrrrJtrr:rrrrIIrr lIi.trniirtr p,li.ii'tlo) cstc re:r1iza,tLl.e !x)c6p, t:usctilare (ramolist trf l r ri ItItrr'rr.l11ii),It' ottt!1i(:e,l itla)'e,le (indeosebi glioir,me), tlegeneratiue t tu Il u t t t t r t t , ii ( o1 ,(t' .fi l l i te ). \litltitt)ltltl l\\ rl.e oitliterorc o, pddic'ul'uLai tu,l ma-perJor&t (c'r,re iligd,, exti:ttalanlicr], nucleul se.nilunar :r,llui lt'Iechsig). lr,. lrrr,tri r,ltr. l()riri.n{,irLri c trrclclizlriilii iullrur':ili de sersibilitate obiectiY:i ]a nivelul felei, '-lr. llin rr i<i lrr rrrr,rrrlilrrlslrl)ct'ior'rji :ibsente 14,merrrbrul inferior, L:l fe1 durerea, rl:rlr r.ris1ii, r<csilur::Lzli1u,rrir-e1u1 fc;lei i1i er-entlal al mcmblului superior r |i,l , l)rrl in r\pfinrir,ti;. Se pot asor:iii un homisin{lrom cerebelos, mifcd,r'i lirrr,rrrrlr,lozire 5i ,,min5, i:llarriicit,". Prcciziim c:i din date lurnizate dc I'r,r! || ', r ( , r r( 11) { i6, 19? 6 ) 6 i rb I? o p o v i c i n D i c o l a b., (1980) si nrl rol nul de obl i lr,r'rrll rLl lrrrrliculului 1r:llarlo-per'1oi'a1 poato fi rnnll rn:ii gl':tl, tnai boga,l, trr .rrrr lir r r r l, it iir t r c it, i rr l rl )ro p j t.rc i Ll i n i c i rn e tl i anc, fi ecal e di ntl e artcl cItt lrljitr,r Ir('r'li)llL{r ro iLnp,n't.trirL rlouii r':rmnli, cil}r sc dirijeazil bilatcrrl r r lik r ll l tn u o -s rrl rL l rl rD .]j c cs j rn e l l ico- Tn l tcest fel , l rl ,etol e pc ,i i ri g r r s l lr Lr , l rl i l rrl rrlr r i lllr r r r r o pi. t' l i o l l rti l i q i l ri rn l .trl i :tr.g i u tL i i l i rncefl l l i ce, l udi fcrerrt tl i tt r':rtt l ) r r ' j( f plr r v r r r . I ' o rrrl rc t o n ( l !){ i (i , 1 1 )? 0 ) ;i l >opovi ci n 1i col rtl l . (1!} l i 0), tt,l t l!l <.r g o ttrti t,l ,c drt o)l stt' ttttl i i t tttttri rt i l r r llr , l c r J ili|r r { i rr { i (| (rr' | ' l Irr| ()Ii } i Ii r(| tt1 tItr rl ttrl tl ' r |r ' llr . jlJ lr ' 11, r' r.i rl i z r,i rz i il l rri l )r' { fil l i l ;tl ttt l i l , rl rr ,,fl tLl trtrr" , (rtt tt i ' i i l tr l tl i,. Ic z i rtttr,tl i t' ttr,t' l rrl i l i t l ri l l r l rrt' lr l i i (i tr< ' l ttsi vtrtt rrttttti). 1 ri o trtr r I oI o; 1ir , ; 1t r r rr1 :l l :t

ill

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

r, . '\iniJrontu.l, san[li,L, rcrti.(:sl lltrielo['

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rnr rile subiectiw de )r,rT',t din sinalromulparietal con,r,^,,.,,, 'ensiiitita4

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a,morferi, potprera carc ra .,,,,,,il,,0'Ji'''Jifil',i*.."13"'*1ff**n'J".ll;;H:

l:ititlii:; 'ii:ii";11"-iliilililli'hllli"'Tl?#ii.,i?i,,fffil_X"-1m;;sticui,rircrino 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,* i:lll:,; cL irr imp'r,oir rr., .:displriri.,,. a, meor_ !!ii'Iiiil","iil,ii,r"eori illi;:, ,,'irfl rr'sUn()rly. Bu-perlor . sau itfefior, a miinii, slu doar rr, unor dcrelet^ .lJ [)c

jfl l3'fiit"il:;I?f ,*li;l[tx,T"llJH3.:*;l: :r;r:,rl,i i:::ii,;T'fiiLi;,tf '(;il',l:"jlili',J",;;Bli:

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IrrLrLrrlrrIii, rlrr olriooi ir cvltlrrrttl, ilrli',r'irrr') ; lt) A'ir{hr)rrrtllui 'ltrl,ttt t1i rrrir rrl ir,, ll,rl,inxl,:i (ltrrtr rirrsotttrtlogttozirttrtzollttttzir', I i) A'irrrlt 5i itttozrrtlilLlirt'irr) tli\ lr, (itrcttltrtoilrt'k'it, tltr ll, I(tcllllorl!Jl'rr' lrt lit t'til,uL tligil,ltlil' \n,' ltgtl(rzio tltt llltclrrIl,ttl ttttr'ltr itt tllltrrt'1, rl,,rrrrrrri qi tltr lt,tlilittttr{,il ctrlocittci tlsgtritr, lltr tilrttl ,,r,ltrsi1tg Irr:rllr (lc orit.ttl,rllo tlroaltt'lr-sl,ilga I ltcalcttliel rtgtiu{itr iit,lltitti tltt$tltt ttrtll:t lllrr\i rrr'rr, lrri Illlyor'-(iross(irr spocirr'l lltltrtltt cxtxlttl llzittttilor" ,,,rr.llrrefii) icc corticnle, ptilt osl,ttrl*irt, ;-j) Altc sernncl,oqtogxlJ l,r Ior'rniri,iurlile vocine. t, I t tin :)) lir cailrnl sinih'ornului pu,riotal sa pot itlanti'.li.caur nt,iil,tut rlr',rr rtttr topograJica : r1 iliidront'ul senzitiaparietal global, clasic, lvl lrti, ).)(i6rint xi. l/lyt tr'lrt prin tulburxrilc de sonsibilitatesuhiocl,ilL rii obitrol,ivr'i' r,. r'r,o[noaqte trlo ttterior, Exceplion asoci;r,zi\: antiotrofic, hctnitlllollsio qi rtlrtzirt lrrr Ir,ziunilestingi). rt ll Sintlromul, de girus puietal su'peric'r (a'riile \tu, 5b) t'tl.r'lizo'tnti, .rll.r'.rrcrnai pulin marcatS,a tuturor sensibiliti,iilort 1o ltt:trticorltttlrrott lrrrlrloral, cu test&urarearapirli, a sensibititii,filorttlcl,ilo,toltlticii;i tlttt'r'. li Lii'l,i krr 1It'rIIttIItII' r,r.rri, tllr cu rnenlinerea indelungatd'a abolirii solrsil,ri t,l,ltritt c) Bindromu,llui Anton' 1i Bn'binski (vezi :ltrtcriot) cslo Ittrt,liz lr',riritrimri ertinse, cate implicii,: puietala, anteriolt'ii, ltt'itttrt uri ri, rlottrr, r rr, rrrnvoluliepr,rietali,, girusul suprarnillgirralqi u p.r,tlc r[itr pliort,trttrltrlirtl(\r('i{(firzii, tl) Sind.romul, lui, Gerstmannestc produs priu luzirtni (1il,l'lr i cit'ctttrtvoltt lrrrr.!i'tle trecere.lintre circumvolulia parietalii inlloliollir, ,,s \', ," \'il,it'lla mijlocie clin pirtea sfingi. ${) l1!olllrt)rl,'1l'(\ t) Sindromul parietol p08terior al lui. An'drd Th,ottt'tt'tt rrr' portt,r'tt pentru irr predominanti, ilrttsiltil il,rrlr tact ; henianestezie 1i 1rr orxril,rt'ltt rrrrl rL vrrtltrtlii. qi apraxie idoltolicI rrili'i, disrnatrie, br':rdihinezie 1 I p ro.f l) Eittdromul' wfl' al' lui tr'oir (prin lozitrncslirrgii)itttlttttt,rrrzrtr Ttarietal rrrrrrit,otul conteit semiotogic: tulburS,ri souzitit'o billl,rll'rrlo, illirttlntirrrl trtrri lles simlul pozifiilor, apraxio ideomotorie bililtotrtlit Illtilzitt tttrrrlrrritl,il (,1,,tip mixt); hemiplegie rl ro-r,ptri.

DIIIOI,,()(iI0 ?.3. PROBLEMII] D!] DIAGNOSTIC IN DIVF]RSE SINDROAMII AI,GIOiI 7.3.1. Cefalalgiilc (Colnlcilr)

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I,la o ce d, raloara d,iagnodicd silt ;i ,remzeleserniologiceasociate

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Il,fflil;JilfrlT,::li,;,"i:;i,i;'):z!"n,ii:;,yii,.l*:ll',li*rlli*,yl ii n(.nzrlry propriocoptiv); d) Tu ru.rdti oest ibutire.1r.arr,, suir flll::. iti.l',,:'.rl

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

tth

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

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

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

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

x27

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

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

' ,11 i qrr'nr r ( t . st 'nu i) t t t t u'r t lor lit r t dt iu: [ iu ( t t Jr t lr r t t l( l. il) t t t i|t t t|t 't || r t l 1,,,tl ' 1,4t(, tl lr : it , lt r nit nolt t it t *i t r lt sit t t lt lt lt t obI r t : l, it rt r lt nt loqir r ') t ir lr r '; r rrrr IIui rrr.l (' r'vcllt t t liiili : tl l l i rttt, uii t uilabild, it r silr r r r liilir it t r . : ur r sit r r I l, or r r 'lr r r r r . r r r r lr r gir , l rl rl rl l :rl r, 1r.r! , r r il, r xlillt 'r , cr r cr izli, lr lgicir ,sl, r r ir r r or liI r Ir,|r r pl'iclizii, r r r r r r ir . r l, ul rl rr, .rl )i u( r,r t t r cclr t iiicon( ir ir t t ( lo iicr ir l'( )t lr t il'1,ir r t ilvr , sl igr r f iilc cot r r plr . lr r rr,, l r r! rrrrgio; llr lir r r r r , t r bur li) t r r r ovit ler t ! ir r zr 'it r it t t ir r ot gr r r ir . , r. It1 l ' :i rttrlant i. r lr t nt t liu r tn. giot t , nt , eLc t : er eLr u, ltir , ) r 'lr t \ r st 'lr lt r 'lr r u{lr t 'r ) l! r ilii rl , ,rr,rrrrIrrrrr iir r r r r 't r t , r t ispar i( i : Ji r lupii r r cllr la, luici, sr 1 ir $( r 'r . r l) lr 1, 1x'r sislr i, ; i rr , r' 1rrIr.1rI ilrir ',r t lr r ,it r vcsligr t l, iilc I it t liologit 'c si t t t t giogt r lir r r scr l''pixlt "r r zi, ' rrr rl i , ,r r r.r i ti t, r , I t Sot t lll t 'ii. | | l':r ttl.otJtiqt'()tq, tlitt, rt,tt,ttrti.sttttlr <:crtbrall: totrpot lr'i o iu,t'irrrl,' r.lr. rr rl , r.rni (,lr ) gir ut t lif ct elr ( illc 1l! it t lt : I uigt t 't r l pt r r pt ir r 'zisI ( \ t 'r r r 't r i i1t l t,r, ,( n, l l ){i 7i / \ r 's( ini ; i colr . lh. , 1974) : - Vilslr r , r r lr i i rrI ri rr|,Ir I ji, it r r . : z r rrl ,,nr \ | .| | rl ,l or' psr ru. r lorIrigr t : r r l) Ur ': r lr r pr , r r islr , r r {r 'r ot r sc ( 30- . 10 r lu r r r r i) . iDLr r lilll;r lt r lt ; i I r 'izlr ,r u'lt r lr r l, ii|'i, 0ir t c nU r ot t r lot xleir zii, ' r r' | | r.1,' f rrr.r r t r r kr gicc, , I rrr rrrrrrll (.r l f i/ sllr ilicot r ) plot . i,r; r 'r I no( , lilioiit iI r l slllii r lr r lor r lli Pt 'r ^zt 't i ,rrl .r , rr l rrl rlit t icl, t l iu ilr r evlislnr r ll) r t r pl, o. l) r r 'zct r {, ir r , r r or I ilir '. r li|ot ' | | rI|| ' II r.rl i | (. (r lcili noYizullizit r el r ] nni 11r r ev|ist r1xr t ungir r gr ': r liir , nlr rpr t lr ilr l

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

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

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

orcipito-ccrvicalc riclici, urmi,toarolo ploltk,rrro r lrr rl irrgrrorl to

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i

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

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

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t rrIt I rrt tt r r t I r l r tttttr tl t|r ') l tl ' l r l Ii r r l ttt l r tr r 1 , , , l l , , r : rI , ) , r l i I i i l l l Ir r l r l r ' ( t t t I I ' t l r r l r 'r ;i ' r l r r ,I'Ir Ir 'r 'r tr Ir . ( r 'r t]r l |i l ) l l l tl l 'l 'r l l i r 1 l [r , , , , r l r l r r i l i r l tl l tttr l l ,i ,rlt lrrrl r :t ttl r t " .r r 'r 'l r "tr r r tl l l l i I'i r l l r '"r I l "l 'l :r :l ' 'l ' tttr t \ " ; : t n t l ) t ,r tttl ttti l ,t tr ttti r t l :;i n r l tr tn tu l l tti l "r r ::'tttr r 1 "l 'tttttr t) :;'' l ttl l r ttt;ttI r r t r r r l tr i i ;' r ttr tr r t l ,i ( ttr r ' l r i l i n ) { i t tl r r , tl r r r l tttl tr ,,Ir i Ir l t:Ih '' . , , , , l , , , , ,r 'l .r ,,i i r i r l r t r r i r r ,l r r l rr rr. r , r | , r rrI rr i i .r r 1 r Ir 'i ,r r '( r .r l r .r r r ,', l ,r r l l r r r |r i Ii Ir r r ,, l , rr r rrr i : I 1 ( r r r r 'r r r 'l i r l tr r l i i , , , , . , , ', i , i,f,,'l i l i i l l l i ( 'r r l i l r \', , , , '' ;i l r sl 'r r o l tr i tr r zi ) l tr l rt' I t' l tt' l l i tl r l i r r r Ir t ttttr l l r . .r, I r r l l r r i r ) l i fg i t, IIr , si IttIIr Itti ,,r r r i r l i i tr r r i i r '" 1 t'r 'l l tti r r sl i ' {ttr :tt r r l tr r tttl i l r ttl tr tzr '.r 't.t , l l i i l i l ) r ) i 'j l 'l l r ;r l l ) l r l l i l l ', ,i .|i ;Ill r :r Itt ', , , f i , , f,,'l i ,i : {) l l l !r { I1lr l ' l 1 l {;r ' p fi Sr tt[tl . 1 r " u r r r l il r r r , si tr r l to i r l 'sl l r "r r L tn r l i t:- ( '\t'r 'l l r 1 l ) i fr ) ' Fi i r r 'l l o r r r r r l r tl ;1 " r 'r r r r r t'r " Si l r l t, r i r r r i l ',r r r t,tt. l 1 ) ? 1 ) ; \\'l l i tt':;i ",.,rr, l ttr ti , r l r 'r r l r i r ci ( r l l l l r r l l r r L r l , l r , r i ,fi ,,,,,l r 'l 'o tl r L r :r l o i l cv,l ;'i 1 'l i tttr tti i r r tt r tttt r r 'r tl r r t' ' 't,i 'j ,,p tl r ,l ,i ,,.i l ) r tt' r tl r 'o l i i l .' s}l o j r L i r r r i ' cl 'i r r i r i ; i ; , '; , ';;, p o 1 ' r n ti e u l u o l l tr r si sl l r .r 'r 'r 'r tr r r r r r r l .l r r r r , , 1 , i ,,,'r ,,,,r i ,i ,i r i i ;i r cr l o l i l l tttt r "l l r r r r i " d c t,l l g o l l i sl tr r fi l t , r l . t t ttr l t' r l l l i l 'r i q i i cn tr t't'l tl Tl :'l i l t) "l t l , I r : r z i r l r r r r tr i i tr i i r tl ci cn i p ttttl tr a o csl ' sl r l ( l l ( 'l l l ' tt l o r '1 r 1 . i , . I : t n h i n l .r ti i .l tt tr tn m t'u ti r ,e( i n sp tci 'r l P"i l t l l l r l l i r l l l i 'i :r l r l ttr r l vr "'l .'l "r 1 r \ ' r r r {'l r r Ii i ' s.'r r zi l i r " c"In l r i r 'i c 1 ,r i t .l l l l |i , , 1 , , , i ', f , 'i i ,r !.L i zl ,:tzi i , r l i zr i Ii ( '1 l o l r r l " , | , 1 r r '- t) r tt'cti L r l ',stp r r o sto ti i l c l o f i l Yti l r - i l 'i i l t'to $ i si ,r r r r , | , l . r i 0 i r r !l l i i o n cd xl c) .

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r l ,' Irrr. r c . r it L il l. ( r t c i t. Itr l. r r . r l liir r ' r ' ( L 0 i J ;l ) u , $ frr,rri ,l i tt,.i } r.h i r , l rri A i l rrorr-O.fl .v I,rrl r. l r Itrztl tt: r , lr : li' lo r lir rl ,rrls rb i rru { ,i i tro i .i n tl i , u i i ,r Ii l ci l c cj i i rrri rrl crl rr i r .,1.1,.,,,,, r | |.IrI r|1 ) i I i rj I I I r lLrs ir r . l l o rI l c l l i ,,rj c v u I r,rl l ri tis i i t ,l i rrri rri i rrr i rr,tr l i rl ri rrl l ul i l o, r'l l rl r. , , lr , r r r i: r r r jr " r' i rrl r.tr. r r.r,l r,l rr,rr,l (ir, rrc l rrri v ri i ;.rl ri p,l i i l r., ;r r, ,I r, I i I i I , ,I r. 1 , :l :i ri

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

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

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

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

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

r r 'l r tczr ttl r i tl tl i r i tr tl r l o tr t r 'l ttr r r ' ;1 i tr r 'tr r l r l r ' tl tttl L l r / r / r/r r r tttl t tt tr :.l tt!tt' r r tr l r l ' l ;r Il ' tr ttl t i ttl l ttr r 'r l r r l '. ,,., t , , , , , i i tl l l r r l i l r r l ,', ,,,',l i t t" '1 , , '' 'tl r l ;1 i i / / .i ,l )l ./ l l / l .' ||l l r ||( 'l I i ] l / n t'r tl Iq i i l t't'i l l r l r i l r . l l i tr l ' , '. t , , r , t ''i,l 'l 1 i l Il ,l tt, ttr r r '1 .. r ttr 'l r ':r r t i r tl l r r r o l r l ':tl i o cttl i l i l tl r tr 'l i l t , , r 'r r t l ii l ti l r ttl i r r i r cr t i i 'r t ( o tr 'l p L l l l z;l l ( r r r11' ( ll . , , , r r r r '{r r r r r 1i'I tIr ' ( 1 l l ' r i i I i i t I i i (i i I I i I t I ti tIti IIi cttII l l r l i tr l l r l tr ( l i 1 r l l l ( \r ;r l rl r,., i l l i l r r 'l t'r l i l i ,,i ] si , f.t'l l r r o r cl r tl tstr i ' o ti ttl i cttl r tl g i tr l o l r l ( 1 i ( r l i r r ;';tt( |r lr Ittl .r l '' Sl 'l r l r i .l i :tl t'l tl , r .i r r r r r r .tt l l l t l l o l r l ( \ , , r | , . r I . o I I I r Ii i . r, '1 ,( |1 l l fl , I i I t I 1t I ' rI r t t ' l r t t r Ir r r I I : f i , ' i ; ; i I l , I i t , rrI ; i r 'i' ' ; , l ) r 'i tt ( l {1 x1 i :r 'l ( 'i t'i 'o cr i sl tr r l r :i ( l ctr ttr l l r tl ti L t tl l r l i tl ttl ;tl 'l i l l 'zi tttl r r l t' tl tl , , , r . , 1 , , , ', ', ,i l i tL tti l r l l ' tl tl i ttl i r l r r sl tl o ( 'l {1 .) ( ) so l l s{l i r '. . , r " l r l il t tl r ', l :r tt r l r ' l r I L l | r 't l l 'i r , ,,,t'cl l |l l 0 i cl tl L l .i tttr g l r i , tl t'. r r ti tttr t' 'l l . r ''r r r r i l r r 'Ii " ttr r ci l .r r ''l r " ( r l r 'r t l r t,tr l ttl r l l l r , r 't1 1 l r I n i l l t , , ; 1 1 1, i r r b i i r u tl L , ' l r l i si l i l l r l i t 'I ( l l l l l r ( ) 1 l r r i r \r l r r ( x) n sti r l 'i i ' tl l l ( l c1 s{l r r r |i l ttl r 'stl l t l ) l l l l ( 1 1 'r r l r i l t r l |tl tl i ,. tl ttttt':t a l l tr l p l u stcL m l l ,.l t,tl i tttr tl ;l t'si L 1 1 1 i r l xtr r l t'tl cl l ;tttr i r r 1 , , , , , 'l , l , r : , , 1 1 i , 1 , z r r r r r | r r r l sl 0 si l L r i tl i i i n tl r l :r 'i L l i i tl i i r n s^ r ,i tL g "':"tttl 'r co ttj ttg r r |r "r l ttt't"' ', r Ir ) fl ( 'r r r tr ( |'r l , , , 1 . , . , . 1 ,r i r r r r i n u l l tco r i ,r l o i p o l i r l cl r l i r \i ti l i i l r l ( r l l si l r r l tr :ttttttl ( r r r |r 'tr Ii ItI' r r 'l tttt ttt r Ii l i r r i ' r 'l ' l r r { , l , l 'r r r l ) si a l i ,u l a l r te 'l i o r i p ,tr ,l sr tL l t"l l I r t I t I I t l i l tr tt"r r l t' I t I I r t : I t ' tl l l r '.'tr "r ' i n tcl co su tl , I ' ; i i l ; i i "r i i r "i j " ' ', . I r 'l i r ( ( r 'r r t"i l :l u l o l i b i l tr tt'r 'l l l i tl r 'l l r l l ' ( l l l tl 'l i i ' Ir l - ( 'r 'l l l r l t , , , , r r r , t t t , it. r tti u tr m "* -fa l 'z'r r r r r l ( l ( i 'l r i r 'r 'i r l I l l t'l :r r l r '1 " r r {i r ' , , " '. f ,i ,' l ;t l ttso ' i r i l l t!l - si ( l l l 1 1 'tr ':r Ir r l r t\ r 'r : r :l i i i t'r l l i r l ;r zi ttttr r L i i tl , , , 1 , , r l r | r i . l lxi sti l q i a i c i n d i cl r ,l \ {' I I (' I } | I I I | ' ; l ) ' l , , , , '. , r l t l tr t'si r n r cr r ' tr ';;i r ttr i i |r ';i " tl i cl a n l a ti 1 1 11 't r l " I r tt "' 1 1 ' t i l r l i r l r ' ' ', , , ', i , l :i l cl r 'to i tn p t i ri,,'i r i u '1 ' ' , ' 'i m i tci l i l o tl l t'ttl r i i tr i ttl :ttt.tt " ; , i r r 1 cr ( 'sr tl '( " r ') i d i r 'ci r r i i , , . i ', 1 , ', ', 'r ,i - r ,,l u r e r e i , ]:t Ir i ve l L r l ( l i l r '( \ l l tr i i l to l r r r t\'i tr r Ir 'l t" r ', . , i i , , , r,tr l l c o r i d u r e r i l e , l n o t'i ]' p t'l l l l l l r r r r i l r tl ' tr r l ' tl tt i t t i tl o l i n sa u i n o r '1 o o l :tti sr n l 'l tl tr 'tr 'r t tl ' l r t,r l ' 'r ,z'r '. t , l , r ( r ttr ti r r l ' r ' r l ' t:r 'l r l r tl r tr r l ' .'s' p l r " , r I , , , 1 , ' st,tiOt';vi u c r a p i tt b i l l r t''r 'l tl l ' ; ', , I I | I I 1 I | l l r l t'tl l i 'ci n i sr l t'r 'r 'i r \ t ; ' | ' I | | I | | | I I r l r l r "l , , " , , r . r l r ') p l i r xl {o a r te i a l i se l 2 r 'tt,' r ( , i , t , , , , , . '<l .r n ftl e tca zi i co tl te xtu l So n r i {) l o g i ' .l t fii I I I I )I r )t t I i r l . r l .l t.tl 'I t t rt tr | ' r I r t tt t t i ttr tr r ' r l r ',st ttsti t'i ''tr '" cu 1 , ,,' ' t"r i i ttti tt,,,t1 l l l i l r c, ' ', ', , f , , , 1 , 1 ti :'l tt :i r Itr r r ttr ;" t' 1 n l u .l r l l sr r r .i l ) i l i l r r l ( ' tr l '' l :r tr j .r "l r tl l i r ttr 1 r t' ' t r i r : , i ,1 ti l , , i t t t t r tttt * i ci te va d e ta l i i l u p o g r a Ji ca ( $ o {l r 'l ':r '.1 1 1 ( ;i ) : i r ) l r |zr r r tr r "' t

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

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

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

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

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

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

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

B.

PROBLEME DE DIAGNOSTIC iN TULI}URANIUI TftOFICEDE ORIGINE NBRVOASA

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

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

itt 1olirtr, v ril,r,, 10. Ihhnl rh dirr:rtttt lipu,ri 1i h)pollt' Jii lol' Ii itri'ilrrilrr tttiolttl'rtl liotl ilt tlttccl lt'lrtilc, polinotttrtpttlii,colagotroztr, 1,r'lrlrr,rliouLrrrrvt ltl lrti l)r'pt6 tl}irlotlritl" (irusir,-zirstrl neurrt-cdelrtal,us l,'rr.r,r'ite ,,sindlorn \l,rrrrr), in unolo cornpresiunimielo-radicukr're , in silingontiolitr, itr Itritttilrlc (,,1ritrrr' I' rrI,, rIrrrliverseorigini (Arseni si Botcz, 1971), in sintllrttrtttI l trtt it'l,ir'l ,! |r'oriLl,or,siitt din sindromnl parieta,l) $.a. mai rnult slu rnai pitl,itr pigtttctrlllrr, rlrr IL Ar:len aarnek cuta'no,tet (de de linte pinii la o circlg:i), rril,ttitlo itt tttorl la un bob 'rrrrliririclifeli.itl r{illl, r.tr,rt'irr in jlilul gurii $i al na$ului (dar gi in alte zono 1;ogrlrtl('lllrrr{r) peni]u sclcroza tuberoasi' a lui BournoYillo, ',r',,fi[toare se po&to t'trcttltttrtrslrr l2- N tutfiibrctnato!(r lui Becltlinghausen, ltt'itt pedicula,te cle tip multiplu de tLunori ,,rnollLtsr.lultttlt ; trrrtrI tt I tt tt t ' ' 1,r,.zr.rrlu, grt'llrltto), rrepediculate), de consistenli moale, pigmcntate (brttttc srt,tt lrrrrrr I ii I'tttttori , r!, {rolmai arlesei) pete br'[ncoirlol ott coexist5, cu 1i ligmentare rr lollni de qiraguri de mi,td,nii rotuujite sau fuziformtr, tlispusrtlrtr I'trt,irrrr 1,,1,. lroryilor leriferici. pktn hernifacial, adesca voltttnittos, sil'rrrti,ilr 13. Ang ialnul cutrd,urt liinr :lltgirttttrt'ltrzrt, ,l,r|rrrLiultrigernenului, este revelator qi nc obligir,sli oil,u i.r.l1rlo-trige.rninali, a iui Sturge-Weber-Krabbo. ,,rr (tle culoareacafolci olt Lr4rl,o) itrrlivrrllo pi'gmenta,te 14. Preaen,ta de ytete . 1L;rps11ls, ilsolite tle novi pigmentari $i pilofii po zonolttttt'rtctt rrlttlrt 'rrrr r,rrrr:rl), Ll un copil sau la un adolescent,ne cvocii o rncli[tl(tziillotlr(t olll!rttrrttrttrr rrrr lri, rnir,i ales tlaci ln contextul clinic existl ;i crize olilopl,ico6i/srt,tl ,lu l)n)cesexparsir intracranian, la nivolttl trtornlrtrtlor, tll l,ttr:rrtrltli tti. f um{'facliilecutanqte noLlulare ,r ,rl :rlrdonelulii, insolite de crcqtereain volutn ir, $irlilot' siltt tttrrtrrrltr Lu,i I)trouttt, r rl ir.o pentlu adipoza durero&sd,din sind,ronzu,l ' I'lrrl'irrtl' tu 16. Pana,riliu,l ana,lgezi,a, earactorizat pt'ittr-o l,trllrttlrt,ttt llll'i r r|lu|ilol unuia sau mai multor degete (merginrl pinii lrl N,lIll)lll'll'r{n[ ' rrrr,il:rhngo)r in absenla durerilor spontane sau pl'ovo(ill,ortlrt't'tltt rltrtroltt tr tttttli r"rr rlo tulburii,ri de sensibilitate tle tip siringotniolio, ovcttlrtttt'l ,rrilr'{)mamiotlofie de tip Aran-I)uchenne qi:r, uuol sctttltopinltltitlttlrr, ltrr I rrrr,' si'r I tlo nitttltttttt Hilittne orientezespre diagnosticul de siringorniclio stl,t l.,rrrriclictle alti naturl, tltt lulbtrt'flli pigttrr,tt l7- Panari,!iul anulgt:zic, insolit de faoics.ltxtttin, nLtlnilifornri,tl trotv ilttt',t lo tt,ltttn I rrrrr,rlc leproame cutanate, ile hiper"trofilr, l,rrri,,1.oo"ot, " (eu protlominanli, tormoillalgczicii, ittifirtl, n4roigkrbrt,hl'), pituitare, no orionl,oil,zilnpro (l it,l{ttu$l,i(!u I '1" ,rr{}ficxie, do loziunea mucoasei ,l,r hpril, obliginalu-ne sA,ci,ut5,m bacilul lui l{ansou ln tttttounul trt,ztt,lryi r,Lr pnlcbic5,m reaolia lui Midsutla, 18, Ulcarwl perforant (mal perforant) ylunl'ur attt tlttbrri, innirlior ryi Htl(nos[v' rrrrlo!rr'. Inilial aparo o zon6 tle hiporkeratozl, apoi so dozvrtli,il,t tlo Ildittclrot rotunjitti sau oYalrrtr cu tondilr{,i1, l lirl,cni {i apoi o ulceratrio ',,rr rrrrr,r'gini ploeminentg, cu fundul acopolit tlo 'o sorozitrto giiJltttitttltltt rrrr,rrrrrr irroloni;ri. Ulooralia gi togrrmoltelo din jur sint indoloro, Siu[ $l[ul!' in profunzimo, atingo orliiottlnl,llltl clozvolCindu-so irr crllo ulcoraii&, [,ri pulfrtt'rltrl, r1irrrrrl. Ilvolufia, osbotorpidtr, cu oioD1;tizflti otomoro. Ulor:r'Lrl fio [a,nivoluI rlrtlott' fio t.litlonnoan, rr.rrr',r rl$ obicoi ln Labos,so locolizoDzfl, lrr(,rrrr rrrrrtirl;ilr$otir,ltngionot lllltrooltri, fio lrlnisolul tlrtpttltti <xtlttltlrt tll qisolloitlo itsoci:!titt (livor$o:!Tl;l'ol)tllii l,tlhttl,lcrr, r.rrroilc,r rnol'lr,ht,r'sitn ltt'tr' r![o [r!lrtn{(!lol',MlIi pol[l,o tt,pgl'otr, ,rrrrr 11i ort lozirrtri rt,lt'DIi0u 1i rtrtbrrrttil,ioo rlrrltt'[ rlrt rtort,tlrl, tlo crt,l, rrulicol,otttiilo irt uitult'untru.lo Irr rrrrirrgorrriolio, 1rt'lttttr.

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

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

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

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

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

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

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

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

r r lr . r r t ,. s i l rr,r,{ i i , rrrl i rrIrrrl .i rr, (rrl ri l r i rrrrzi s (j i rfr,\i l ) rsl ,rr rl i l .uzi , ,, p ....'. : L, ' , lt I ., . lr r . |ll r.tf '.i .l r.r r r 'i] r ::r |' i l l ,.s rtl rrl rti l r,rl i p rts . I)0 r rrrtl ht ()t.i ,sol rs0(]i i tzi ,0tt t| l t , : . . : li" J ll rr, { i i r , tl rl l ri r u,.i chi pl uvnu,ci r, i ]l l )1 ,,i . ] ,'r .rrrIi l )rrt,0 r' rr i { 1i . . r r r.rl ,,l x .r' ' 1 ,t,irrlrr ,, l'.rrr.tl.t I r 1;1151'1'1'Sir,l, Clt0 pcrsislii citovlr, st{I,'i l.,. iieflcxclo -rnusculrre rr llr)ilrrlirolsri sirri, ctirrsclvai:cr nr]_ la,scicrihlif spou, l i rl r. i r ilu pr r ) v ( ' 0iL( ,0i , -rxistil rt,r' t:x i l tn c l tu l IG e s te n ofrna,l .' rj c f)L ,rt,, l .e c u n o i r:te pIi n rr.l ul i r si cu cpi sor._ .,.,.,.'). . 't( .'"r:,,s :. rr r.,( l: ,. rr .t . rr\r,,j t.ti ti rir1 t,,t l { r':1 1r r,v lr tc ,.l i l i c i . p t.i n p rc d o rni nanpa,h r,i daci n.r, m.i nbrc -

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

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

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

(cx transmisie autosomalL_recesivA),

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

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

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

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

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

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

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

:r (I|('r'IrI|'ir(I{i.i rrrl(ilriUlri sl.irri, r.rrlizirrrl rrrr.lilr rrri'|,,rri'ii,.Asl,Itl, . rlrt,)rl Iri'{iir rurf( rlirii (,sl,clollii, si prrlrrrrgili, rlrrl irrrlolor,ii, rrcggsiLirrri | ,. r'lr,r'i\'ol nlilt rlr.rrtrlril. lcoltsiii,lnrorrrllio ll tlccottltir,cIiei pott,t,e sut,vgtti (lltl)ri o c()l]1]t,t[o1,i0. lll. ,rt)rl.Al/r),talr,r, v ohrrrtrLrii, sir[ (lo o trtitniitir,Ttronncatd, :rrlilrr rl.rr.pii r) (i{)lllir(i1ioiru.lusii,_: lic_.prinl;r.oac!iruro rncornicii'(percuf,iri rrr,l' r' ' l,i ;r.r'rrri rrr.rI I ,.i t(.rr)r'r.. ir lirnbij. srrr ll lurrgulrri $upilrrtor),iic pt,illIr ,, ;'i111111 111. r.l,r.lrir..r. li{.rr(,rn(,rrul nriutonicpuilc fi torr.ic l]et cvidcu_ tirrl r.rr ocrrzilrrli;0itilot tlo plehonsiune. I. lirtrr.llt,Lui, Sleiu.t'rl (,niottnia atroficd, sau. clislrrf ia rni,otonicd, ) st ||a ||r|,,:|-i(r'r'lrrIiIrr.,,rr, UrmiIurului conluxt Sp-miOlugif l)o l_,rz,l : t 1 I'rt.cttlrt ,ttnl,tr,t.litlar, sub acest aspect boal& lui Sfeinert fiind lif. lill,l \rlrl,tr'.rIII,.'.tirrrrr. ,lirr r|est grup CtrC re|tlizoazi, rlrolii muSCul$TC. ,\r.rsllrr,.<,.1 t rqrogr.ir fitr, sinti faciaL 5i diitele la, membre, atilginel trmdtorr,i rrrrri;drii1cfei, rcalizind un facies inexpresiv, atoir, de aspect .rrrrr;chi.: ..llirrrulrirrlilr.'), cu lipsa cutclor fruntii, cu deficit;I ol6icdarilor ociilor .i irl lIlz,r'lr)r': r'iriir':ttoIii pleorpclor_:uperioare (cu plozir pJtpebr.nli,); , r.-( t)lrllli t 3{Ir(.Jlont (cu cvldcnta alrolic)i slernoclcidornastuidi_ ,r|'r {tl{ :r{,.) ,.rr,..r cu {.\'i(l{.nt:i.rll.o[ie) ; musc]ii ,ntcb|rtulrri 5i ei rniinii; rrrrr., lrii rli.iirli I,i r tLelbr{l,rT inioliolrc {mult mai taldiv}. l,) .1' t't: ( tl Iu, ! ttt rttnenultti m,iotonio relatat anterior. t ) o)illi: cu Q(|t?lic(i, c\ anurnite caractere particulare: I trrrlsririsio c[r'e urrnclzli o moda]itate clomidanti,, srrb aces, aspec[ liirrrl o llrrr{irurc rlotr:nninat:ide o gen5, ploiotropr,autosomalf clominait[, r'|| |)I.rI(,I|II||tii rurrnplcti, s&u_i]pruitpe completi, ifarii sri sr,rtipeste genelaliii ..r' ,r r .,r',.\:rriir bililrlt' dc crp|r,siviilte (Crughe-y li Mwienr[onoulos. l:rr;r,i 1..'r,.,s. I:1.,7 citali rle nrrdu, tgTd); apxre Oin ce in cc 6ai dcr t.,rrr,.ii irrrl'r'rcrr, rrs.l('rtrclinice dince in ce mai graye dc-a lungul genera_ (l( ,rll](.Jr'(l(.nLrrilc ,):rntepozitiert 1|l1,,'r SAU,,anti0ipAigio, qi ,"rprOlreSie,, -de-n,adu, lir.r,, lru,l; ( 'rrugli(J' ,si lWyri:rnthopoulos, cit;!i" ,.,1icr .1966,' r:rrs); rt(.|' 1r'irz:-r rle olricei in arlolescen![si inainte de 30 rle ani. l\t':tnlo iJc tttlburd,.ri tndocrine; - alopecie precoce, ptogresivt .rl1 r rr rl, Lrrr Irrrrrlrtl: (,I)ircifier.i generaloire do catnra6ld <it, cr.isiulinicne l rp \ , r;ll s:l r rt,. 1i1rJrJeisubut * atrofie l,esticulari,, cu sci,derea activifi,_ l r.rlr r, )r,,,tr(r'r iru :rz,rosllcrntie eliminlrii de 1?_cetosteroizi ,sicu scdllerea I l:, 1(ir, i, It'r'cvcn!:rl, a enol'cei, a aTorturilor iterr,ltiYe saU ft StedlitS,iii; r rr rlrrlr,n.:r r:Llolilor oestrogonilor ' si a pregnantlioluiui. <'\ )lorl,i.Jittiri ItrtrI{}: Prezen\a tlescSlcdrilor bioelectrice musculrut.o r',rr';LIll,r'i.rl iirrr oill.oloalizeazd,,,rafa,lele,,,,,avorselot, sau,,sayele" mioto_ rr'( (lr'rrllrr rlcttlii, vozi liadu, 19?8). ". Iirnlt, l.tt,i I'hontsen clasicd replezintd, ula diltrs formele clinico rrl, rrri,lrrri.i .rilgc'iti e qi so diferenliaz5, de boala lui steinerbprin urrniil,' r, L'.I i,rirrr,.r',.:.:rrApJrili3 rnulI mri mrJ I b) Exirtcnla rue-i bipnrtloIrr l r1 I1 I.1 ,,1 ;1 ,,,, r'rirl'icirrilor membrelor supcrioare qi in{crioale, a geflsnik)f ' rr :r rrolr.rrlrllrli; o) Iieacfie miotonic[ mai marcr],tit, Ia nivclul membrelor,, rlrr.r'rrrrloli prrtiml intcresa intreg ansamblul muscu]aturii, cl) Absculli IrrIIrrrr;r.r'iIol lnrlrxl'ine I e) lrognostic .mai bun, felti1i1,ate,. speranli rio r rrtrr ri crrprrcil.;11c tkr rmrncl putin alicctatc, sirnpiomltologie de obicci rrlrr{iorrrui (lll,rlrr, .11)78 1906, citnli tto I Caughcv qi nlyri.:r,nthopoulos, li rrr Irr, ll)?fi). ,i. I' t'lltiolilil t.on,trn.il,ald (hoal,a, Lrr,il.'qtt lNtl,tnbu.rl ), nrultii yt,crrur l rrrrI rrrrrI rrI ir rrr lrorrlir lrri 'l'lrorrscr rr 1ro:r,1c fi tol,tr6i rlilirrr,rr(irr,ll'i, rlo lrolr,lil ltti '| 'IIr|| rrrrr^tI lrtirr rrrrolo rlr,r'llolcrl ttltr lrrrlii,sirrlri irlt'slrlrrlirriorrIrrrrrrIrri nriol,ollir(i

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

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

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

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

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

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

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

.rrloalte etiopatogenn.

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

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

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

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

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

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

ut

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

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

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

trr" i rl i ' i ,x i lr {ii l, . r '''r {r : t it lg, . r j|r f r lr . lil sir , ir r g0t r r ir , li( r ,1 sllr r1,\ (.Ii I I i )i | |I , l, . . , . lt , r l I' trrrA ol rllr 'lr r 'r . I I lt t r r t I r r t I t ir 'I itNr l t t tt t t t sit r r lt r r r r r lor r isr r llr l r lr , r r lll'i r 'lir ilr r r lir , : i ,r,r,r' r r' l r, - {; ) lr gr 'r r ( . t . jll, r r sir r l, iI r r 1r o|I , I r r r I r r llr r r liili slir r |lcr , i|r r r , . i. I l. .,1 ttiol.xtliilt tttit,lapulict rl, t,r,ol,r.tlir: rnlidi, 1.. ,,1ttt. id rolti.tr,tli.tt, bau[u, Lui, .lI t:irrt+ f,It:rlirt, (paliotttitlilrt. rnttt.it)tu,tl ' , rl ,t! )..n. r , : 'r t . lr . r iz. lr zi p. ir r : it , ) Jr Lsl, , hr r : r alr it li, j b) _Al, ir r g. r r , rr it iir \ ir ir r, rr' | r' rror' r r r I s', r lillr r alir r , 1 l, 0 1r ) . 1. : 0ca, lizlrriLr lt igr r llr , lo, t r r , l r r r r i : r r lr . r r r ! r , I r 'rtrtolIir0, irr grriru':ll lrt'ixln'.rir ritnt0 lil rn.|rbrtlir irrlirriorr,rrr ( i rrrI r,rrrlr, I rr 1,, !' r' ttl xrl ( ] r Tr u, alc, ; i, pclonict 'c) , ilr l la r not t r lir u'kr sI l) ct , i{r i , ( l ; ir r ; 1r , f l1, , , 1, , r,ttr,,U l i r/rr Lr r r r r Trlr r llhilr , lr , l 11) ; \ r niol, l, of iit , sc llsociizij, t , r r ; pr r r |lr li, , ir . ,: ,., i , sljr , lj'c lir r r r 'lc r r r pir Li. Lr , t r r lit ., . r lr , rI i rrri rrr.:I 1i r , r r lr r r 11'r 'r r . lizir r l\L l, I l' - llll) r '1r ) llr . loit . r l( . illpor . l: t niJ ; lr lxr lir , , , lr , t , ( . ll{. \ r . lr t , r , t , lr . r , i , rr.rl rrr.l l ,No i r nzilivc olr ir . r . t irr , , i. c) Nu Be const at i f asciculalii, t ulLr ur r i, r , sr IrrIl .,rrr' Ii liil lir n, icli( r r c ( t l: ar 1n, , ot t , 1; r ecI inir c) r r ici 1, r r lbr n, ii, rpr , i r ilr ilr r i ; i r rr, (r' tr.l ll: t Ull, . , , r i. Si 1 pr czcnlc; i : _] t ipr . r t r . r r r r ir . . r , , . l. : r h: r : , sr . t r I . ir r l, r . r . ' rr.r ,. rj ,.| |. r 'ir lr '. ixlgji. r caci. ie I n( : njlr gr . r "li l: r , r ir . lr 111,, 1, 1111, , , ^r t hit lXii, . r trIr.r' Itl rI.l , i. n LCR {pli. i, ) cit ozi. apoi_ r si hipr r , *llr ur r r ir r ozi r r r oilr . r r r t l; ; 1'r lir.rr,.{,irr, dc <legcnerescenfzipc mlschii cor;spunziil,ol,i l.zirrrrii .,r,rrrrliri .r,1,ri or' .r: iir slr il'. r zi lr pid. ; h; pot , i 1px1, . -si |, r lt , . lr r llr r r |ir . i llr , t i{, r . r , . i ' ,l :r.l i rr:: i) I iind vor ba r lc u r f cr . qjunelir olici, , r . lr c t ) n, ilt r rr . ( 1, .r r r lt ; , ,'rr l,,j/.il*i rnai extinsc (poliocncefalomielitri) po{ sil ,,ira.i, 5i si,rIl.rrr. , | | r '(
| I| | I( | ( ) -

b) Deneruareo,incompletd,.' conservarea excitabilit;lii galvanice qi lrrlrrrlicc u,nelvilor, contracliile avind ins5, o amplitudine scflzut5 ; la nivoIrrl rrnrqchilor se remalcd o oarecare excitabilitate a unor fibre musculato lrr crrtcntul faradic, dar cu r5,spulsuri heterogene la curentul galvalic, in sctrsrrlcir,uriele fibre au o contractie 1ent5, la prag mai sclzut, iar allete au o corrl,nrc!,icdestul 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 (.lrirr' l)r'(!cliliice, de reinervare. ;r) I )11t1cy1)o,ys(r cotngtleld,se caractedzeazE prin: - Existenla unci rrotivil,i,{,ispontane perrnanente a fibrei musculare, cu prezenla de potenfil,lr tlo fiblila!;ie tle scurt5, durati, de slabd, ampliturline qi de frecven!tr rlir,t'rrrlal,iv sl,abilii, .jorr,si-r,, ; - Absenla oricS,ruipotenlial de unitate motoric crr rxllziir, conl;ra,c{,iei voluntare. par,tiald, se caracteizeaz\ prin : - Prezenta in repaus )t\ I)cnart)eree, rlr. plit,rr{i:rle tle fib4lalie sau cle fasciculalie qi atlesea de potenliale ilo l ilirlr. Ir'rtoti!', - In timpul contmcllei voluntare, se inregistreazl o riiliicilrr :r,poton!,iatrelor de unitate ;rrotorie, care pot prezenta uneori chiar rrrrr1 rIi I rrrI i rri cvasinormale. In cazuri extreme, un efort deosebit poate der,lir rrllr, l,r'irsr:ul simplu (i. .l)i.opsinmusc't d,rd, ofer5, de obicei imagini histopatologice net difr:lr,rrlirrl,o l'rt,t ii dc amiotrofia miogend,: a) Existenla de Ieziuni in insultr, srrtr itr pliioi, care corespund atingerii fibrelor unei aceleiaqi unit5li motolii, i vr'ornoce fibrele unii,5,lilor motorii nelezate prezinti aspectenonnrlc I lr) ltilrrrrloiozate sint atrofiate qi inlocuite de lesut fibros sau adipos. ,\.:l.!.:1.:a.AmiotroJiile mielopatice l. (:u,ntdere sam,iologice gen,erale: 1) Amiotrofia este de obicei bilal,olrrlri, rlrrl rrl cste toldeauna simetrici,. 2) Amiotrofia debuteazi, cel rnai rrrllscl rlisl,tr,l,tll,t cxamonul electric nc irrdicii totus,i o leziunc mai tlifuzil, Jl) l,)volrr(irr, tlc obicoi progresiv ascondcntl. 4) Irasciculaliile sint do os1;o rlgrrlii lrlt,zrrrttr, dar ele cel ntai adcscll tlcpiiricrsczoncle musculart ilt,roli:rt,c.4) li,ofloxoloos1,co-1;ondino:lso sinl; abolitc (eventull rlirrrinut1o) lrr lt,trl;ctionro tlar.,silt dc rirgttlil ;roIiorrrirrIiI,oIc 6i ln sinr'lrolrmclo ,,r'ccirrtr)t, r,xrrgrrlllc'in fll,A (plin rirxlrrrnrulpirrr,lnirla,l ti) Trr gr,rrllrl trrr aso0il1,), oxixl i trrllrrrtlri sulrirrcl;iyc ulrtr olrir,cl,iyo rlc sonlrilrililtrlr,, rllrr"r,rislrrtrt,lr, ll(,0

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

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

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

20ll

! li lulij - I,'rwr;iotr la,(,iikr prrrzrrlir. sirr1,. 1rrl,dqlu1lI -. ,l.rrlbrLrii,L,ilo sfincfr.l'irrtrllitrl litu., iir.l'(li\'(1 ;i rlisr.r',:i,' t Duilorri, rnalignill, Ii .a.pig evolntiyii, &fcctcazil inil,iaI .u,,r)It'orn.ut, $i rrlrsiv rrrrrscula,l,uril irrorvati5,cle nucleii motori bulbopontini. Tiebui'o rni{i:rl..rlili.r't'l!i:r1,1 de polioencefalitii infcrioar:i $i, dineirlrelcs, cle o ? | |lt r)r'ii(to 1r.ltrleltl c(jlcDlut,l. udultol I ncuri,tri,cii tle SLA (form6 lui patrihios ) pr(,do_ . .t.;) I,'orntu Ttst r||Iir trr, t''x t l'ctntnin. sn caractorjzerzS, priu al-ingerea de obiceia gr.rrpcI' i,rl rrrrI i r.[| |Ir, I (. jur.rvrlc dc sciaticu] p-opliteu nyLorn,cle scil I icrrl po.-ptiicu rrlrtr'tr, sir,u:I amhelor, de crampe _musculare in repa-uJqi h ,insotindu-se. rrr),'sfr {le all')lirea reflexului achilian, eventual si a celui rotullan. j .lt) ll'ipul uaenil de BLA .ear semlalat) apaie snb 30 de ani fi realir,,orrzii,. cu 1trcc,;rde,re amiotro{ii proxirnale pseuclomiopaticc scapulo'_humer.r1'lr.;i/,sau pclvi-lombarq sau-formc scapulo-peronieie iNclsoni5i prensky, ll|7:. (.il (i tle.Rutlu, 1978; Cioran. ICZ9). r.arc por diticultiDi diai: ",:ca r'|:ir ,r,r', 1l&nsflrte tnsa prin prezen{a [asi.iculatiilot,) a lrlse,atol E-\IG,; rro(l t (,llttol Dlopstc^sr a ovoluIlot. Q. llormu Jarnil,iald,d,eBLA lpare inlr-o proportie tle 1?o/odin totalul ,r'ir,zurikn dc SLA (Haberlanalt,1964), atectinclde fapt, tn paii,Iel, celulele t'r'r.rrrIrri, antcrior, tracturile posterioare, spino-ccrebeloasi ,si piiamidale, {tr''.r unelc semne ce;rebeloase, de posterior corclon qipiramidald li -rrrptrcin(.1 ( lil,rlu, 19?8 ; Kurlancl ;i Mulder, 195b; iTaberlandt; 1964 Cibr'an,19riij. ; d\ n'orma d,e SLA d,in cotnplerul Gtmm, ( SLA - parkinsonism * dtvtt:ttlti ) rru ridici, probleme riiagnostice la noi in 1ari, cleiit in misura it {r,rr lrrti),stjii, formd, are etiologie virotici, (virus leni) li in cazul unor sinrl'r.r:rrrrrr rlr.-Sl,A.rntilni[e 5i .la noi in larii iu ialrloul senriologic cfrror.a i]LI J)ot sir :rpilrit fr altc simptorneoarecum asemxnd,toare cu cele din ,,compler.rl, ( lrrir,rn') (fenomene ext_rapiramidnle)tulburd,r.i psihice qi altel6') qi 6aro ,i.rrI llr.l in'.xdrrbilc nozologic.dar care,probabil-rcprozinti forme .,sim_ (popoviciu ,Xil?ascn, 19?9i. S_a , ' | (' rrrrIi i,:r.' ' (yilot,ir,c Nnu_degeneratit.e) { r'r|$Ii11ir,1; plcvrr,lon{:r, crr, SLA este de 100 de ori mai marc in insulele Guam rri l rlu,,rlrlci[ in oricc altir,regiune a lumii (Iieed qi colab.,1966),o frecvenl,i, rrrr.lri5rrrrit rlc t'arc intilnindu-se si in F,itipine si in Nour, Griinee.Ilirario :ri.r' Lrlr. (ll,tj7) alr rrjLtl ci, rle frl'1, ..,"ornpli,xul Crm,rn'. tlcbrrloazi ll \ rIir|r..||rirI lll(.r'u Fr lt,lco cyolufie mai leriti, semnelepiramiilale precedintl lrrr cr'lo lrrrlllilrr. progresitd,Aran-.Duchenne, prccum fi Tsoralizin , ,..\\..lIlt\li& ]nusculard, 4trllurrl.TtrytqresiM, DucltctLne se p_are cd,nu reprezintii 6ntit;!i aiisiincte, ci r,ii,, rrrrr,,jolil,a-tctr, acestora, in realitate roprezintd, forme al,ipice dc S.L.A. ( llurlrr, 1971J). l) ,uLault.plue hbrm.aLa t,utr atipice u,e d,eDr_1t B-t-4 (_(Irinuu, (Raclu, 1978 19?9) OSte este tmpor.tani important ; Cioran, 19/U) 't -ryi6;Utofan, Hll,,lio locrrrLoscutc in plactica rreurblogici: - foima mo:roparetici, (cu rlrrlrrrl, rlrrlrrrl,. lr runrl rurtrl.din din membre, membre, de cleobicei obicei dlstat; pariplegici, (tot forma ptraplegice (iot ; - forma 'membru
('l 0 lr { , ( cu | (l rlolrrr{, rlisl;nl,cvcntual intii

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

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

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

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

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

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

a0$

lrzir,l,(1, ,rirrl,r'il, r'i1,(lii,i1iIilor rlrrrll r;rr,lr,zii, rlrrrrrriltr frr ptoior'{irrirr loIil,0r'iul lrrlrrtrrl lrl rrrt'sl,ot riirlicirri. l,lsl,tr Irrcvorri.il, rlc lntrirxrtlrr\r lrilillola,lil,rtlca, (fxitrr rIrrlllikrr', I\'lirncvttlrrrlo oklrrga,{,it: llc lli,rLicirrikrrrkrcliltr;ca,ziiJitru crtlrrrrzr'i rr,lgiilo do scnsibilil*tc obicctivir,s(, 0&l'aotolizoilzr"t, ; b) 'Urtlbtttir,t'ilo plirr lrilrrxrsl,ozii, l,lLcslczii,unoori 1)rin hipercstczii, cu ilspect global fi prrrlrotfiotrill,(lo ilsorncncaou topografie speciali in bcnzi ra,diculilr'c. 'i ) ,\ pr'orr,lxr t{)tdoaunr, gi.sim trtoclificilri ale ICIi : fic de tip in{eclios lu me rrirrgo-r'u,rliorrlil,olc virale, luetice sau prin alte infeclii, fic tle tipul disocia( iihrl lllrtuniuo-r,itologico in compresiunlle radicularc. (1. AtniotroJiila d,in ntonon,eurite(9i mononeuropatii de ilba'se c.,rigini) (rltrpil (.1u,ibert Si,Quibut, 1974): l, |u,racl,(/rcgenerale : r,) A riotrotia reprezintai un semn constant, alar precocitatefl, $i irrrlxrr'la,ntra acestia variaz5, tn func,tie dr natura leziunii I este precoco r;i inrportuntii in sindroamele tle secliune $i de fuitalie; tardivii $i discretl rrr sirrrllotrrulde compresiune. lr) Arrtiotrotia se insole$te de: parez6,sau paralizie flascS,cu topo. IlrrIi,r Iloncularil ncti; diminuarea $au abolirea reflexelor osteo-tendi. rrorrsc iri toil,oriul jneryat de nervul respecti-r; tulbur5ri de sensibilitato iiulrirri,ivo 5i obicctivc cu topografie periferici,, do asemeneade intensitato irr luncfie de natura leziunii I tulburi,ri trofice cutanate qi vasovrrlirr,lrilii, rrroiolii irnportante in sindromul de iritalie; L,CII,este normal. r) I)rucrilc pot fi foarte vii, spontane ira,u proyocate d.e citlo rrrirlr.irli,rrrrroli ou hiperesteziecutanati, $i durere la presiunea maselol rrrrI sr,r l Iirrrr11i l, trunchiurilor nenroase. rl) ltollcxolc locale sint abolite. qi vindecarea sint posibile, cu restaurare muscularii. o) ll,ogr'oiiiunea, di.feren!'iatetn J unclie d,e natllro leziunii: l. lllor)tL(l,ascntiol.oclice tfu secliune aompletd: - Amiotrofia este precoce, proit,) lli.tulnn,t.r,l. glr.sivii,i1ilirir,t'h:cxplimati, pe tnuqchii paraliz^\i ) - Asist[m la o paralizio rurrrr;r|rrLr'i, crr hipo- sir,tr atonio; -lieflexele osteo-tendinoase sint abolite; li,rrl'lrrrrrl irlio-rnusculareste. de asemenea, abolit I - Nu sint tulbur5,ri ilir ll lrrrlrioctivo, rir,rrz nici alureri Ia presiunea maselor musculare , i a trunr'lrirrli|rl rroLv()rs{i slrb niyelul seclidnii; - Se constati, a,nesiiezie superf! r,irr lir gbbr li, I - 'I'ulbur'5,ri1e vasomotorii sint putin exprimate ; - So lrr rul,rr,l,i, I ). Ii. l)iasivl. It) Sinrlrom,ul,tle iritalia: - Amiotrofia este de asemenea precoce, .r'rrprirlri Asistim do:lr la o parezi,, cu conservareatonusului muscular; I lirrllrrxrrlo ostco-tendinoase $i cutanate sint diminuate, rareori abolito; llr,l[rr rrl irlio-mnscular poate fi exageratI - Se constatii impon;ante lrrllrrrllili rrrrzil,ivc subicctive: dureri vii, Bpontane,exacerbatede frig, rlrr pllrirlrrlr rrLasclor muscularo ;i cle migchrile de elongalie; - Adesea rrrtlrlirrrlrrrrlriporcstozie cutanat'),I * Se remarci, tulburiri trofice imporlrurlr: tkr pirrlii, ostcoarticllare qi ale Janerelor. 11 r\inlxntuL da compresittne:* Amiotrofitu estc tardivri $i mai prr{irrirrlrrrrsi,; poal,oii c(,rlrplol,il, tl*r tolusul rnuscularosto - |)rr,r'illizil, qi cttltttLill.osint clirrLitr,litl,iv ('r)llr.rolv|,t, 1 '-.ll,ofkrxclo ostft)-1,(irxlirIor,so (1t)tIs(tt rrr,lo rir,u l,lxrlitoI - Liol'lc.r-rrI irlio-tttttscttlar c$li(J virL; - 'l]rtllrrryrr,r'itbiLi, lrt tiililo solrzil,ivo Asislir,ttr tt ltipttttrsl'ozitr strlriccl,ivo silrl,r'rt,t'itr,bikr I Iilrii,i'rrlJrrrliilj tlo sottsilrilil,lr,l.l (rrilirr rlrr,lri rrrrrrsl,rrzirr) li l)rtir irlilrf,,ir,, lrlrrl0$

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

:( t'/

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

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

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

9.

PROBLEME DEDIAGNOSTIC IN AGNoZII

A III

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

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

;'

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

r" rt r' r"

Brncrin,r

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

.rrr '- rn/r""'

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

VIZUAI,I,] 9.2. AGNOZIILU

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

'.','ll

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

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

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

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

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

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

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

r crk,r'r',r,i csk) necesar si recurgi, $i la atte mijloacc senzltivo_ienzoriiiel ri I 1ri1r.iic,sit audil oyentual zgomotul pe car-e-l prodllce un obiect, sau .:i I rr.rir'rlsr.. J)ifr.rcrrtadintre cecitatea lsihici, qi-cea corticalX rezidn l; l:rl)llll rl rr Irnmir,^:el,il.rdo drra.rreprczentarea (imagioca) I izualii a ,, r,|)r'a ||.Ir,|. icall, se pierde comple1211p61,s I'r' clLd rn crcilrtea COrl 61j6,6 irlrzirlic si vizualai. Cecitatea ?.sihic.i se insole,ste,de obicei, _p(,I'ceptje rr rlc ir.ltc rrlcmentcagnozice .r-izulle (aleiie, acromatognbzie), ae Ue_ll :rrrr'1r.i.. ..i rl. lprarir. (LrDntrucli\i. ii.. X)roroPnllrrozia lagnozia pontru fizionornii) se crrrclelizeazi prit) rlll',' rL)rlrl:rlcit Uolna\trlut dc a r'.Cunuasle pcrcoatj.lcdin jurul oiu, cLiar pr, r'r'lr,rrnri:tllropiatrc. Recunoa;terel.persol.n ei rr.spectir-e se poate r.ealiza rlorrI rl pii :r"llc olorneutc carncter.istice (imbrriciniinte, talicl voce etc.). ll,rlr r.rrrri nl Ir\'ulrrtsle ni,.i figuru unr.ipersotncintr-ungnrpdefnlografii. .' l ,r,:rt ,. rIr,. r'I ir'. rrrirIr i,.ltpor:oa n(.lordin fot ogrl fin. nu poir t e facc d if&e;i;; rrrci lizir.rnonrii rlo lirjrb:lt sau de lerleie, dc om tind,r sai l,i,tritl etc. Uneoil rrr,;i .ici 1r.opria sa fa_tiiin oglindi,. Unii bolnavi prezinif .r'ir.rrrrl,r1lu rlilicrrllili {lrr 1'(:1111,u,,,0r""" a r}numitot segmente faciale, ca de n^ildb iu_ rriilrr(r'ir,srrlr,ri'ari silu iirferioari a felei, iumitatea dreapti, sait stinid. lr,11irrrrtr, oolrilor', regiulea truntii etc. (Glonning gi colab., 196?, citli rll l( r'r.irrrllcr', lg7?). Stttttt.i.l itrt!i.rr, t9.lo-lyof!a(n ogae:i_ilor Agnoziile yizuale au ca , . r.i":unle. r;rrlrrl.rrl lr,zirrrLi u,le klbrrlrri rccipitll sting la drepiaci, c[ci leziuni alo r,r,izrrr.ii si alc. regiunii_paracalcarine stingi (cuprinzina intreg .r,irlr.arino ( rrr(l.rrrl) pr,rluc :r,grrozii bilatcrale. Adeseaeste volba rle l6ziuni simetricl :rl. rrrrrlril.r l'1ri occipitali (fig. t,31. T,hermitte a subdivizat aceast5zo;L irr rlorrri rrgirrni : una clestinatilformelor qi culorilor (aria 19) Si alta. mai rr,rrI,'r'i,rrrlii, rlcst,jnilhii cleserului,litelalor, cifrelor. Tulburi,rile'dg 61i.r6rr,. slr;rlia,l.)sint rlatorite unor lezi'ni profunde :rle pir_iii superioaro 1:r;'rr,ziilr. ,r irrir'r'rrrl l,lr, u,r'ioi par':l{jalcarjrrc r,r'i.r, 18), e{ingind si mlirile fascjcule dc 1: :rrrocirriirr. 'l'lll)uliu'ile memolioi ton,rgllficc depin,l insi, de obicei, do lr zrrrrrilril:rlrr':rlr. rrlr.rr,spintini {r'rrrlruro-o,.r.ipifrle. ,Agnozilr, r.izu,.snrtirrli , lr' Ir',rrlrr'.i lri rl. l.zirrrri:,lo'i.pinri' iprrir'looccipirrlc diri ir.lr',rs, "inir/i,r'rrl rlrr'l,1.Nl'i r,ru.'rlr,It,r. (11)04, citai; dc triirrin.llcr,l!,)i?) a arittat.iJ ir,li|,i )]/iiilrf,riz,flirl(r.sirrl;^l)rrrlrrso rlo rlrrconectarca,iilor sonzolirlie roo{rl)1oirr(! rlrrrrliilo I i rrrIrrr,j rrI rr i . In lrirclr'sl,i, v izirr no, l,{rroziiJrr riplico so a,d rni6 rlil si1l, pilt,ilor, lr:lzl,lririlc lo btrlrr lttrrrlrro lrlirr lczirrrriIri III I rrr';rI rr. lr,lrr i riccillil,a,l, l,/r'zitrrtil('silltirl{\ trririitl)rt)il'l,rt rlrr lolrll lrriliclrrlilt'Ilrrrlrtcc sirrrlrlorrri ptr,. tItrtrtitrotri, olrlir,rr sllr{,irr,lrr, irr ir.r,rrrrr crr lirzirrtrilc ulr,i Ir1rr,o1rirr,ii, ,lrr lrilrll :n4

t t,t

i r.

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

al e

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

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

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

it'10

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

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

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

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

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

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

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

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

)'t'l

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

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votuutuJ DD iu rtrr,uuR,4nu,D $tlNAt'AZtl

DE DTAGNOSTIC r)lt()trLEME

:illlli l rrl l rlrlll::',,b1y..ll,L1zjr : r . r ' , . au tliie\te llir i ,.{ l e o o haiucina,lie h a -l u c i n a ti e heautosco;iricir,, h o a u l oi copi ci . in i n tn1, fa(a .,rro" rrnor ai *irro al o .Fau ' ii']].'.,.1:,"_l

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

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

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

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

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

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

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

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

:It /

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

l::illl,lll

,:,'l:l

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

indicind prin moiliiic,ri ale fclei nasl plin gesluri, ooea ce estc incapabil si, cxprim6 prin grai. uLr.r Exprimarca r u loirrrlrri (lurniratul, denllrir.ea zilelor tlii si,pfdmin? sau a lunilor rrrrrrlui,cintatul, recitarea ulei poezii etc.) este inai line conseryata. rf:rzi:r intilni urmiiorrele grupc }Julorn dc tulbur.iri .irr ^rnotor.ie ( ., \rir.t,';l|rIlrn.(Jmtlredaoe li J)urrnd, j939; llolal- li Lhct,rnj 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

Alreori t"t"'avii uiiiizui"x p""i rlroruntii,substa,ntivele. ll:il.^.,ll:l.9iflii1 tjl loc d_e sptn :.,,[sta ,,qutri" estecn caresetaie',). Deieori l], i:']il::-I. r",llrir\.ut r{r rcrzi nrilrri,.a.crpros.i\.ir,

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

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

p0sibiLif ititor de,crprirnare, pinilla tulilurii,ri

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

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

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

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

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

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

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

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in-i1,tfl"u4i'''"1'il Fllif;;i,fii ;:il:il:;t,,1,;,,1,j\,,llt:),-i1,1,,,11+1,,,lt31if iii'frr,j,r,l'ti,r,,"iil,i,,J;r,i,fdljl'lliJ,:"J:i;,,;:i.]l,tt'l;

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

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D0DrAcNosrrc iN ApRAXrr 11. pBoBl,EME

r l r r r r ) ti r r r r l r r ) : r r ') {l l i : L c i il i i r tl r l tr tzi l i r r ' ( l 'r r f( r l l tl i r ttl l l i r r i t' tr IIt'tti 1 r ttIi Il i ti ' r i tl tt ;i tL r r scl l i tl tr tr r l t'o o l ti l r tt' r t t l t r r tt',i l i t't. ( l t) n I( :l tl t.L t( t: i 1 n 'Ii l l l r l i r l r,r,,",tt i i tr g ttto tl l . l tl t' tl i [o ti i cl ttt r r r l 'tl ttsi l l r l r r ' r 'r t t i i , $ r r ttl l l 'r l ttr l t,l i r r l l r i i , l l tl xi i L ;i i g i tl r l .tti i n cl - tl tt l tr r l i r l tl I r r i t r l Ii .r 'l o t r , ' r ,r | , r . l 't , s I t i ttttj t i 'l l 1 trt t t t r t t t l i l i , t',t"'t'l 't't'l t l t\ r tt'i 1 r :i i r t i r ! r tl tt':i l i t'tt l tr t ttt tt't' r f , ' , r r , r . r t , , ' t , ,ti ,,,'r 't,l ti vi l l 'r r l p i i r i o r r r l tr i "ti 'c' i (I I (\ g r r sl ttl tl I l l ,l II( r 1 Ii n 1 1 r r o ,i n tl t tL r i 'l l tr r a '. cl 'tr '' I i l \ I ' I I l 'ir 1 , , , ', ' , , r , ) : stl l i h L l l r i n l r tn ti l 'i ttr : r l r sttti l tl i ,,t : , 1 , , 1 ', , , , , 1 , ', r l 'tl r i tl sr l i t l l r i tl i r r r i l 'l r '( ;i o I r N r r r i l r ;r i r ti p ti tttl c o l i r l l 'so 'l ' r l ( j r l ' ]i l l l l i l ' p , , 1 , , 't , t , , : r s r : l r i tl r i o r i , tl tr l t, b :r to tttr ctL i , tl l r t' tl o l t',.l tr i tL tl a ' tl tr i r l r tt i ' l l , l , '1 r , l r '1 , ( lr l l , sl l l ) i l l N ' so n cl i t\) t.kl t' si t sr l i l r p i n a , r .tt , f , , ', ', , , , , t ', , i , , rr r i i r r r i r ti g i r ,ctc.;d ) i n i ;t'i i r i 'i n l r a "zi l i ':ct"t'ttl ttr ttr 'Tte l l tsi r ttl r 'l i ) \( r ( 1 1 l i l l 'l '( 'i | ;l r 'fl l l l l rll 2 l t\p l i l l l ( l i ) ' *n , , t t l t , , t t r t l i i: sl i ,l tL l ti l tl i i l i ta r , g o stu l d ( r i n ' cu n l i n &, !s l r r r ', r r r r r r l r r l t t i , i I' g o stu h l i d e l l r l i o r l ( r /l ) f:i ' ( ctn o i tr i l l l i cl ' l n a n i p []a r ( xt' r l r r o l r i tr tl tr ) : I l l i s c r i l i l r i ttr zi l i l e ( r N l r p ttl t stl 'i n g {) ] l a cr a vr 'ti ', l i ttl 'ttl tti ' r , , r r , , , l | r l r 1 1 i fi t'to a , l i n ccL {i i l r L ,r tl u l r r i

1.11. DUFINITII

Pnntlu cxecutareaunor acte mai cornplexe, nu estesuliciun0 ,'ri cr r,ri,r'il,r olcrn:nLatosi {il nor'nale tloar c} for!:a$i cooidonare. ci sc iutqi inlir-o &numiti, forinS,si succegiuno. ExecLrfit , ,r r,oir s:r, so desfir,loare ;rrrrr ,r,rr,,rrrLii, a geslrurilor, ittr-o formi qi succesiunoadecval,itr l, iniSc-"urilor, iat aprania este o tulburare a gesiualiljfl,ilt aLLpra.ritT, xrrrrllrlrri,crrrrstil,uie pcntru un subiect caro nu estenici paralizlr,trt r,rrr,oorrstir, in irnposibilibl,taa, efoctuft corect gesturile. Cu 4,11,(t nici coroic, nici doment, t1e:1, rriri rr,l,rr,ctio, csl,o incapl,cit:ttea de a orecuta mitrc5,riailecvate unrtl \.|\ i\1,\',, nproixitt, rlr;i lrolnavul nu prezintl parozi, tulburii,ri de sensibilitate, ataxio, uoo1r, rrri,r,r rli i rrvoIttnta,l'ouou tnlburilri psihice. Srr sl,irroii roalizrlrcl unei acliuni voluntare in vederea indopliniril rrrrrrist,rp lrlrr,vrt su rlestiiqonriiin mcd grailai;, la trei nivelo succcgivo (f(r,,irrrf lrr', l1)77; Zl,urvill, 1960) : Primul esre nitselulclnceptwul,\L atrL\ irrrliri,lrrl i1i pr:opunrii-li stttbilelto un aoumit scop al acliunii motorll i1i rrlrrlrolcn,zri o schilii,,o schem;ianiicipatoare a actului. Al r,,lrrrrlrrrc, rlrrr1,. r l il,rrn i atl.ul, nzul,iirii lrinaticea actului) a gestului, in caro indivit] ul ,[or lr rlcrloerr,r'ou,, din cadrul stosul[i innozical foimule]or kinotiotr Irr',r,,',1,'r,zri irrr. Lll,c, rr,rr,cokrT lirnnLrlocntir sint colo ma,l aalccyaterealiz'irii ac{,iunii, A1 i;rr;iloacsto ni,uelali,neruw!,i,ei n otori,i, ccntrillu 6l rr, rl,rirrlrri 1r,,r1rrt,r. joc (f if|r'ir!r |l inllrLr'{Ji, in piramitl',llc, extra,pir'&mi" * sistolnclor rnotorii lItl si spitlrlo), ilalo conourii lll rolllizlurol ac!iunii vrtluntllt'o, rlrlr, rrr'r'clrrllr,so lor: oolor l,t'rrl I'r'rlrirl roztrlt;i't, lr,cl,i v it ir,fi doci, rIit irnllirr,llrlit, l rrcsl,rrlilrt,
r,rirl t,I r rl) t "lr t iz r ll, lr ) t I ir ' i N|lJ , I , r lr s I r t r r r I r f , r r L l l i $ t r u , t l t t p t l t l g t . l l t r t i ! t t t Irrr,'l,r l rrtrrt,iorrr rlrslo crr,r'r, in lr iLt r f , , lln r z ir t , ; ] os l, ulli, J ' t ', r 1 l t 'r r z i l l , i , o t o t t t ; t r i t l r t l t l i u t l r t t t " tr.lril rll i,lt I irtrprrt lrr t t lii.

tt;ii, I t i rr; r|'I i t rI r'|' tt | , ,1,.,, , ,,,,,,i r,ltillrit, tpr.indcrcr, til]ci ligir,ri, incuirr,l,nl pt r t r ir {' {lr r t l rr,:r i cl clir t t t t lr Li, ar t t ncilr t t l ningii, punt lr cll ocllclr lt iLr t 1r,1,' lt t i r r l'r " r l ri ,t, r,:r rtri i cLl ohciar pllner cil unei hir t ii in plic ; i li; r it r r r t lil't t t t I 'r 't r ,t. l ' r' i rri r r ( 'ot lsl. I t r oli\ il : descuul din nlcnt ot ic, l'olt ilt ' t t t t t r i o1'(r' ohibrituri din nnoi tiguli ir, rr r, , , { r)rrs{r'lrtll,irl gr r slt t : t lilt t l" r 't t l l ,l r\ (l r' of ic] ) it d0 lr npolLaut ca t oat e acest c pr olxr t lo ir r slllr r it r r r r or l I ir r sr 'i t m nzit 'iv( i) ( r cs}ect ,rl l rr.r *t t it iv int r anzit ive $i ' l ri l tl ' t r t 'r tt't i'it t ll: i l') r r lr r qi pcr r ir r r cit pent t u nr in: l dr cn'pt d, l r, l ,l rl ri r i r,;r r r ; r r t , ilt {r r lr '4o' it t lr 'r r r . il' t t o bolr r llvt t l si, ne : I sjgul; m cL , rrr l rl ' i r ir lt por '1. t lnt rl , lt t r r t t it r lt illt t t it l l) o &s( 'lt l( r t lr . il', rrrr, ' l ,Lr\i (' i r in- t ir t a, r claqit inlpi; i af : lzici t t r r t lolii r t i'it r r t t l' t lr r . t icillr t t t lot pt t lzeli{, t li 1,,' ,t,1,,1,l rc t r lt lt : t ,nu gr '( lgi,a, sr llt ll, t r { ir r t lt r a'( r l lt r nt t r t l 1i t lr r it r ilir rlr r r r ' , i , ,, ,,,,, ,, t' ,* i i, lI ult r ] r 'i. ulbr u llj t l t : cor i'lr n ( 1t l lr llr r sr r t t r t r ilr 'r r 'l'r t i'oilll r t l. ( ' a'r r rr :rl l ot lr , lir o! 'iuuin( rut 'o- Dsihi( l( l'1i 1,r,,1 1,' ,,,1,,;,r' r ;i I ollogt r , f ico.

(]t , l N I ( r l ,A l l , l ' lA l ' l l l x l l ' l l l l " ; t .t , I ) l l M l t l , l ,

tttl tt tttl tt r l l l ( fl ( r g ( r l 't'tt,.l o t ttt,tl o r r tl "i n i u t u 'l tt d 'l l 'tt' t i i l o r I'tr tl i i ttt l ', f l l l l l tl o l i l r r i tttl l r r ', l 1 }7 7 ) t cr t'ttt tr ttttttttt - , l , , t t 'r , l , , s i t ' i r , t l tr i l ,i .r p n tu r u ( l !|0 1 i , {'i 1 l l l : t t i i tr tl l tr Ir t r .r '' r IIr '|'i t' , , r l 'r l r r l r r , , r l r ,r tl l r :,r il.) ttPi t l ,i r ';tttr l t r r tt,0 l i cl r I'r i r yttl t't0r 'o l tr .ll.t i r l t,l r l o r r 'l r r "r tl l r | sr t ( r l l l l r o I t i r 'l l l ' ,1, l , l t , r r 1.i r .r t|IIr IIItr Ii i i 1 tIt,Io t, tl r r o ,,n r r l r i fi , 'r , , i tItr tIttto Iu t'' l 'r 'l l ttttttti t'tt,,r r r ttl tttl tti 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 ,ti l r '1 0 ) i ti 'u ' I'r 'l r l l l l l I ,rlr,rl r r I o lr ttl l to ttl l t,l l l r r l i l ( r r l i r r ' {i ) , i l l t' rri 'll l l l rr l r' I I I | !t | | | )1| )| ' i t l l l ||1 | l l l ,l l l l i r i l l tr l r f t rrl rt ' r' z ' ' t t l i i t' i l r r l r r r tl o t i i t rI r' t t I I ' t rI i |' | , 1 ,{'||II|:It||I l r i ', , r r r r r l o t :'l tl l

| .i ttrr LiI I t r ' I . . . r ' : t t rr:t,tl l rl l i tt rl i ti .i r1 ,trrl 1 o c i rrl r.orrl rr,ri ii ri l c(,i rLrr,rrrrtgrrtrtrr1tl 1q(xfS l htal i l o r.. A (.t\ri 1 (\),rl g ti r,l r)o Ii i | || |i ,i {r(\1) $o l ,nl ,nsunt, s(,l l t,tl i !l Il o (lll( x \ r ii r r r ilc i i ,t rrrrrl" ' r ' ii, . r ' ' I : r r r r Iir1 .r...:r' r' r' ;.rJ i i (r (l { r.l ,l l rt(' l .1rrrsi i(| , r,i rr..r1l rrl rl r,l ,rs;, l ;rt .l l l l t fi | '.l l ||r I rI i :r' | {| i Lr'(:: ! rrL rs l ' l i Ii i . | )o l l ,o r)o l lIrz , i rtni l t 0ttri srb| (} i rna,j 0r' tr (sl i i rl .gt; \1or rt(jru)rir,rr,plrt,rio bi lli,l,olrt lir,, llr. i,ulrl lczjrrrrjlu corlrrlrLi ctlos srr,u rr,lri .rrri rl.r'.i ririrrr.o (rlropto) relLizurr,zir, rp.*lie_ urriJll,cr.al.i stirrgri. ijupt ,,;i,r; 11,y1,,11 1l1r rr,1lrliio 0rr o lozirrn(] a, rrnuii.r, slln :t alhtia alin acclti cdntli, ;si$irt'l

)'r

la llifcritc l,ipuri dc apraxic: ideatorie (lozirr nea centrului ideator parietal), apraxiLl rrrrr lori,'sau melokiueti,d, llcziu'nca conI.r,rr I I ld{'L,nlolol ) $i irl,.omulorie (lcziunoc ciilirt' .tro uu{.scr.ei dei c,.nlri) [fig.36i. uxi*trr, ' binointplr':. .i u,Ltn forme - clc apr.rr,ri,,, seiniologiit crirora o \rom exp lre in (xll l,lnuale,

, , , 1 , r , r l l r , rr ,l r l ttl r r u l r r r :r l r tr ,;r ti ttr l ,r Ittttr i tr l ttI l |) l ) tl l r i r t r t'ttl tr :t,l t ttl i l r , r l l , l r r l , r , l r r r r l ) , ,1 r . l r r tr r i tr i ttr r t;t r ,o ttttl r r t'r 'l r t tr tr ti t ttl i o l tn r r fi i t tI t, t I rrt rr : t I rr r tr l r r . , r t r , t , r . r t l r . r 'r i i l i ( ,r l l r l r ,l l l r r ,r ,Ir r r l r ,i l r l l r r r tr l o l r r ,( i r r tr i , r l r : l ti l r l i i , i tr l ttr r l r r l l r r ':r , , 1 , , I ' r | , r r ': r , l r r ,u i ttl r 'r 'r 'r ttl i t, q l r r 1 1;i r r , , 1r i t r1r I l t t I I |,) I r r tt tttt l tt i l t'l tg , l l l t,tt r l r r ;t, , ', r r , , r r r l r r i r ,r 'r r g sr r ,r rctr o !ttttti i , si i sttg i t r l i tt ttti ttl ttr l tttto i r ':r tti , t:r tr ti :r , r r r , r , r , , , 1 , r r r r l I:r ti tttttti |r r tr l r '. l l t g ctr r r l tl , l i o l ttl tr tr l r l i i i tttPtl si r r tl r r o tr t r l i l i tIcr IIttr tIo t, r 'r r r tttl l t \ | 'r r r " . r r r r l i r l fr r ,l o r ', sl r tr r r l r r r t;r l l ti ttr tl o r tp ti !r i t,ttl tr,l l , r L 'r r . I 1 , , ir r r r l r r l ) r i l i u r i i l l l r i , r l l l i l , l l l o tr l i tt. l ,'i i tr l vo t'l l l l tl r ,o k zi tr tr r , l l r , 1 1 , ' l r l r l r t r i r r r l r l i r ,n l r tg l i tr r ,l c r i i ttg i l r t,ti r t 'l ( ) ) , tr t'r ';i i l to l tr r r ,vi si ttl l ,i :t,l i tzr r . ' \ ; r r ; r r i r r i r Io r tr r r o Io r i r , :r , l tti L i r l r ttl l r r t l r o l t,l c Ii ttl i l l ti t'r 'r r l i r l r r r r r l r r l ;r r , r , ' i r | l r r : r l r ,l i ) , I rr I I r t r t l r r t ' rt, i t;r ti tr i t'i r , l ) l j \ i l r l l l l l i i i l tr l l r l tr t r Ittt Ir Ii |i r Ir '. r tl . I l , ' , 1 , . r 'r ; rr si r r r l r l r ', r l l l t tr r r ttr i r ,i 1 l c tr r l c r tr ct'L tl l t,1 o l l u tr ttl i tt, tr tt ti i ;r r ' ,,,l r r . ; r o r r i l n i .r r r ,ri r n tl o ttr i l l ,. Al ( l i '1 , b o l l l l r L tl l to l r i t, ( l i :r i \( r n Il r , r r ,r i l ' ",l.il' 1,, 1,,, I r r r : rr ,Ir l r cl i r r r I o l :t,r ,ci t,r tlo r tl l r l ,l l l u tttt tt'tr st'sl r l l t tttr l i tt. l r r r r r ',r r 'l r r t,,r, rl,r:r n r s|r ,'i :r l tr r i ;ci i l i !r i r tl t'l u tz,i l i r r '. .l ) l tt'i t'r 'tcttt l r r l tr r ,r r r l tl , r1. :r l r r l r r l r r r i l i l :r r ', s:'l ,tL l l tr l ) N .l l i r ,l si , l l ) l l ( {r , t:l tr tr r l l l ,r l r 'i r l l ( r J r , , r , , , . , , r r : 'i l i n r l r r ;1 i r r r i r r :t, i r r i l {i l , i Jl ,l r , tl c l r i l r l i l , tl i t<'i i ' so l i t'i l i i r r r l to l tr r r r tr l I i , ( U r i r i l i i r r r l l i l tr i tstr l , o l t[t tr 'tt;r 'sl 0 si t't( ( |l i o ]l t r r ttl i tr :r ,, r I i , l r r r l l r l r r i r l r , l \'l tl i ztl n l i i ( l l i o t i tttl r ccr l l ti l , f( ) t( '( 'i \l i f.;to ttl r t,tr , r r tr r l r, t'i l tr r s( \l l r l l r r r r r ;r l r , ', r . r ' r '. Sp r c r l co scL i j r t d c i ,tl t r l xi e u l i tl t'r t,1 t- tt', r , , r r l i , r r r r r r , r r r r r l i sl 1 .1 u t,l t,Pti txi IttI i tl o o ttt0 '1 ttt'sti l i s|l r Itl ti l l i i tr l t,i tl cr l r r ) r r r r r t r i l : r,r i r u u r r ( 'o l r j ( i si '1 r 'cl ;u i c n i ttl l i r i tl ctr ( i o l r t'tti l tt l r , r l i i l t, r r tr ;l w, ,i l , l r r ':r \i o ( l o l L 1 ,r ) ,\i l f;l r ( l o l o l e ( '. , 1 1,1 1 1 1 1r1 1 l cstc se ttti o l u g i tu r p o tl tr l l l l r ,i c i ttl tl tttr r i r t, i r Ir 'r r tr L r r i .r r r . lo M ? ? ) : l r ,ct,sl i b o l n l tr i n tt tl l i l ,i l ) o l L '\r 'l r l r t i t r rl t t rt rrr ' rr l r. ', 1 , , 1 , , l , r , r ! l l r . r', r r r r r , r l , r r r r so 1 xtl , s( tIi d o N ti l o l r l x|]) i l l I i ) , s( 'l i l r ( l tL i l l |l '\ ti tttl tt I tt r r l | .r |, | , I L r l r ol ttl r l i zi t {l ,c1 l ( l o l l ttl cL c ,,1 r i t'i o t l r t'l 1 c p i l i o r '", tr tt 1 ,,r 1 l ,'r r r , r r r t ' ' , r r l l i ( .i o r l , tr r t Io i i tL ci l fa , co to ct, tttt l .) l [l i o l r |l I l ) o l ( l ' , r .r ' r l i tIr 'ttttr o Io t i c i r \ r 'i r || .' r,rr, | l 'r r l r i r ,i t) tr r l l i i u u Ii g co r n e l ,r i c{i g .i t,. r \l r l l xi i l , 'r r r,i,, . ' t ( l ul r i , Kr 'o i r xl l r r r ', 1 9 7 7 ) i l r tl tr o so l ti 1 ) l 'i 1 1( 'o l r Il l zi r t, i ttl tr , tttt,r ,r tr l ,' ', , r 'r 1 , , , r r rr r l r r l l l r r r tr tci i r ,c{i n i , l l r i n r ,( l ( i l i l ,i ( fr o i ttr l t,t'r 'sl r i t tn i i r 'l r .t i i ,;r r , r r l tl t.,it,,lr | | r rrri r t t I : r,r' rt l tcN ,tl ccl 'l l ) sl ]i l p l i tt , ) sl l l ) l '{r si tl t r{'i tl ' r r tr r l ( ( ,tl ||,r ,r |, r IIr r \ll,
,r l r '

I. Apraxia idcatorie. ln aceasti lrrrrrfl este perturbat insuqi planul general, lrpl'rr. zertilrea generalir, a, executiei actului, r,tl / i, r. . r / i . S c h r i n a d t sici a lu i f"i(,pma[n: incapacitatea de a utiliza, corect obiorlr,lrr i! , 1 i , | ! r i ) r r i e h l t s i hg A; B:Ce n .l uzuale. Clasicii inl,erpreta,u acest feno||r{,tl rL, .,' ) !lil slingi; C-- Ccltrji moldi rlir dreatta, cil,o ,,uil,are" a formulei kinelice, ca o ,,uitllrrllr a identificirii simbolice utilil,are a obirrr,. irrlrri. ,\r. fi vor'l:a de o n,gnozie_ cle utilizare a obiecteior. Apltxln rilr':rl,rli'rr.ni,ci,llroa,p,j tol"dorr,irna bilateralzi ;i se caracterizeazH, prii rr,ll,rr r'1,r,.1 plorrr.hrr cato implicd, utilizaTa de obiecte (migcX,rile tr-anzitivrr), It,,l r.trrl l, .l,L;,.uIecul I acte rirnplo,dlr nu poato ln6nplini x,ctccomll(,\r,. ,\si,li,l, :litt,clcparrialc, elementare (hrnte iiotat) pot fi execuraro col,or,tl rl:ll .,sr.oy1.11f;1 Ior lo]]ici'r,, a,rmonioac;)' estc tullruraLi (Zaurwill. I tttlo i Iil, irrrlL,r', ll,7/). Urrlll.i lrtrlnavulscoprc<tulr primuI acbeleinenlarctlri i:r,":l):Ll l,. rlirr c'r'p,rzifiir,{(.ltul i o'ilou}t. Altei'i. el nu r.ospect:i,0r,rlitrr,rl rrtt'rrrrt.r, :r,gi.sl,rrutor. I)ezordinoa,este cu atit mai exprinatt cu cit {[(1l,lll (;1rr:rl,rrl) s'licitlr,i,ostc mai complex. pacientul nrr cste-capabiL nici sL irrrll,it r, rriricrrl!, l)o (rirrLr o dclatureazi- prin bulversa,reasecienlior gesLrrlrri, I,'r'rr :r,r',..-ir' r.l iculr,r.itir,!i, apl.,,&ia idcatoare (ideatorie) de difei.cn 1r: ri I,irr,r ,1i , ,, r i,l(.,,rir.r.Llrir,, in clrt. qi gcstuite simplo sint tulbural,e, datirlil,lt r r,'i Jrir,nsnrisii(lefcctuoilse a Comenzilor li centrii motori. I ) . ) t i , s r r L i ) [ t ) i t llpr.lricul idoator pottc sL irnite mi$cili nu Droa (x, li j,l'o norur nu po,r,r.,r'ca,lizl , i t t v t ' r ) l n i r , ';r,l)r.i,\;r.ltl I l, , rrcerqlri pr.r.lirt
rttrr ilri, Io titin i, I() ririnrriascii, r r il, s oi, . da, r r r nc nr . i r nf , ir ' "i ] " o i . t ^ creoaz5i '- ^ . i " ; , , , .n dar uneoli actiilnile si,le irnprisia, rr1 ""^,,."; , \r. , ; r r t |l i. r : t 11 ,(i ,rtl ' g ra lrl e _ :rg l ]Oti C .D n pl [, l A ll,

, t , ( l l . ( ll l r r l l vl r , i t'ci vl u 'i cl i i ],i tl o 1 tt,tstr t:tt'ti t'i ,r 'l r tc tl r r t,l l l i 'l l r o l Ii r tr l r l r r r r : r , l rl r r ,xi l r i r kl l l ,o r i o : tt) 1 tt:r se t:cr u ,r i,rl' ta , /r ) r i i ( '/i ( g ( ,sl ' ,,1 i g n ") ; l r ) 1 r ,r r r . , , , ', , t , l , t n i r :i l . ( t'0 i l ,r i r i u ( ,i i r ,l r l i l l ,o {tl r i i l i {i g r r sl ,) ; c) I) ( tsttl l ti tttt'( i u l tn !i i r ttl .l u ' r , r r i r . l , r l , r i r r kr xi r r r ,{,i t l ) r i n i r ,( i l i ) , cl ,l {i ( 'o l sl i l , i tr l u ,}ttr I ti r IIo Ittr t,t'ttI, r tl tt,.r tr tl , , ! 1 , I r r , r l 0 r 'si i n vi l l r ,l , Ii i r r r l Si l cx{|ctr l ,( ) tr l l , i l r ,l r r 1 l l t,r 'yr r 'l i j r r r fr ,,r r r r |i r r l

'.

l r ttttt.

Irr :r,1rlrr,r ii! idol,l,oric bolnavul lccirno&$le)irr gcnet.&l, obiectolc D0 (,lr1r

l rrOU fti pri rrrl r.t.l t ' ,\ct I, 'rr", { i, 1. ' r ' i. l: r r . ' ,rt.j t r.rr r.h i rrl i trrr.i fri ri s ii , sr.,r rr ,,l ri bi i tul , sau rl rr.r,i irrr.,rlr., sl,i. ,. sir,fac.i cu ol I sau fi'clr,cir, grosit chibrilnll, pari,ctr, clc l.il,rlt ': r, u 1,l"r i'll,rr, au,r rtri'' r irrllrr,rrlr,ltilir, r r r i r J r r r ,0 r r lr i! ir l,r Uu cLrticiI tr lOl; St.ll sr.rrr inc,.,r,r.ri, l]O^ l!l' Cu rrinrlii,

{,ii, r,l sir, S l tr:trl r n([i r] 1,rgi tiu cl O11 clrilrlii,rrl tj l )t,i l ,ul _tI,a l,igira rrrrrr,1rIirr|, srt,l., irr finlll, lnl stin{r. <.hiIrIi|,rrI. llri lr,tt, l,csi,"rocot na, tulrt,l rln

orrri, r r

(lr),{l.ilt1,i, 0 l,),rll,r rrrt1ilr,r,l:rtil, o gtrrrrii,, rrrrlllci,l,crr o clulirr; o lrrlrril:lr.rr 1i ri lul,, rlrrolrilrr.il,rrri.. Alloi.srr solicil,iilrolrrir,vrrl sii, irt irr nrirrr'i, lrtr r.irrrltlrisl,rr
rjt lI, r l|ltflt t l, 0 lir g|Sl, t t r i Sli,r lr r Dr or r s l , r '| z l \ ( 1 r t t r r L r t r i i l i z r l t , z i i , , j {r t , l l |

l rl l i rr r lllr ' ( - l: ) ji) rrs l l rrl rn i i l o l rrl : s o l s l tr,z i i, i rr f,i r,!l l rol rrl ,vrrl rriurr t,i or,rr,l rr

i tto t'r i tl tl ti t r r l r r i l i l l i st. l tr , | \ u r : r 'ri r r ttttl ttl ti l ttl i r ,;i si r r i tl r tr xi l , 1 , , , r r r r r r l r r l ll l l l i i ,:r ,cl i l s1 ,i i , l t,p l i r r i r sr 1 to :t,1 o l i ttti l r t. ti ti i u l :l ttl t I t ' ; trt t I rt t t t , tr I 1 , , , 'r r l r r ti l ttt tl t, r i tttl i r tr l l r , l l r ,r '\r 'n r l ) l r t,n tr l r i o cl u l tr tr r :t l r ttl ci t si - ;i l l l l l l zl , l , r , 1 , , n r l ll r ,i i , r 'o tr Itr r r r ( ,i i |o t r ';1 o ti r tt o l g r r tti r tl i t, i i ttt, r l ,' sr r <r ,o ti i r r r r cr r , lrr, p r r tr r i r l i i , ttr i Sr 'i i ti r l r i l tr i l r tttr :l l r tr i r tl ttl r r l l i cr r r r l i r r l , r l , l I , r r 1 r o r r ,l ,o L | , , r lir N Ii ;r 'l i t'i l c r l l l o l r l i r l i , l ]l l r l I r | | r l r 'r l j r .sl n l u r t l r ttl o tt. si i r r ,;r |sr Jr o l,i r ' | , 1 , r l , , l : r ,l r ., r 'l r , i r i r r r 'l c r o l tr tr l r r ,ttr . ( 'i tttr :t, r tt'r 'sl ci l r r ttttr r tl r ' :1 1 't:r ,\r i . 1 1 |l , , l , r r r r r . r l . r ,l r u i r t, r 'r l l r r r ttl r r i tr r r r l o t l r l i l tr r l ttl r r tl r l . \ 1 , r . r . r r ; r, ttr r ,Io |'i ttr .|,i r r i 1 r tr .r i ttIi i , o l r r 1 to g l tl l l i I l o :ttl r ' Ir t|r t,Ii :zr tIi t, ttr l , t, | , , 'l , 1 , , L r l | t||r i 'r o r r |:r ,r i r tr r r 'r r l rr r rt rrr' t I I I r r' , ;r r 'rr l i l Ir i r r r :t I|Ji i r 'tl r l tttL tl l r r ,:t l l '. r l ttr ./r ) r i r , Ir r 'r tl r 'i ,,r 'r , r l r , , r l r r ,l r , r,, r r rI r' rr I rr I r. r' ; r | ; r r r r r r 'i l r .r r tttr i

,I | |I ; (i ) . r \ l i ,r' t .i rz tr Ii trrrl .l r ,,.i ' r,rrl rri rrrr,l ,rri rr.,' :rl rrrrrfr.l ri krr.trl r,r,.r:rrr.tt[i { | ,I l t' l r|, , r.. tr' i .rq l ,,r.t.:r i i (' Nl, ' r ' i. |r. . 1. r r ri l ,i i l i l i rl rrrr(,i rr,1 (,\.j si l l ,1.l ,i )l L, l {l (i t). (.l osl ,u;:l l ;
rlrv Jrr Ii1rsi1,0rlo t t t r t r r r ( r ' r El. lr s r r lir , r iU, r r , it r r l, r l r r i l j , 1 , l i r , r . , , , r l c n i t r c 1 1 rlizitto", I r,;Lo cu,.;li0r11, (,ii, .,l] 1,. lrirt1,r. ,,1,.r,1,1r,r, |,:r,r'Ir'IrLrII srr,U,li, u |'r,cul o u:oit,t,o.

(,1,r iil,r'u ril,r'll(,1,r lri|tic la \- alu[(]ii alu[(]ii pc pc lriltic la hazard hazardlrngmeltelc lrngmeltelcfclei, fclei, fir5 a line seamil, tlS
{, (,irJrr.iir/ r,T,u. tr t.od analug-, Lronsl,luc{,ia do figuri geometricc Sau de lil,old | r { ' r r l( . din br ' 1 r.l ,t.rL i L ,r:i t A}rl}\lil' constructivil poirl'rl ',:r , ir 1i ,.,..,ri.,,.1 .,r.. r^-i.,-i ^-,.1:,:,"- it:il9:1')rld' qiire?tc. Ii .r,rr lizr.L,l,il, rtit cii, -+i{. rle Lcziuniemisfericc.stlngi, AsttA, in teriuiiiiii

l,r'irrrrgLri, ..r'c .1,c.). f.i.ii;lt si desc..zco fafl o'reneaJoX,, up.^"i",ii'iriiii

'1. rlpra,ria colstrrrclilii a iui l(leist consl; in imposibilitatea do I (.)r'rl{',,, sprr,ri*[actolo'rotol.ii rcce,s:]Jru crci!,tieiutei ,,foime,,, Ita se lrrlrri. l{ r$1 ri rnlti al(jrjin ir,otulde a dosenlt,, }il tomanclri, o Iornrai, Itrmiii getrrrretricii, geotDetr'icii, (p,Ltt,ltt,, {pLtt,lll,,

t',:,.]l].-1.]J,l.1l,t jlir afir.rir,ror,,rL. La fel, crnd-i se ieri) si, deseneze o cu,xttr,

ir, ri r! , ,rJL I I ) r'I I | ) | I I rrr' ' iuc os l, t r it t lt r r : n ls r r I r ' r r ir , liz :r . j i | r , r , i i r l r u l r , L r [ r l i r r or l . t l ; r , ti t ll,ivo -J,,

|rnislcrci .rrislcr.i stingi, stingi, apra,xia apra,xiacorrstructirii corrstructiriise. se.manrfesti, manlf n'in im,osihilit,,r,r'rr, rl, :, r'r.;uli:rir, r.hj:'r' cr l. mri simplu ,rbir(.le $i tjgut.i tpAlr,at,, dreDlunslll, ttrrrrrslri. r1.,i..,.r'lr..c clc.r. ln leziuLril. t.rnist;.r,,.i.lrnpi". tr l6r;,;;;;-;J;r;;: r i(rr, irrl,rlrcscazlrlrai alcs dcsunelc compluxe, cvidi.ntiindu_se tulbulil,r.l rlrr rrliutLtr,r'r_r spatriali, a-,,cle-mentelor'-constructivc,,, rlisproporlii qi r:l1xrr," 1rr i gr,rjsiln) :r,k:diversolor lenf.ute dc cunstructie,'irnposiEititato de i.r,l, lirrrrr. rr,lrorspeclivei spalirle si, dc multc ori, neglil#ea pd,rlii stirqaiiu Iirrrii lcsortctivel'r,olrtilc tlo dingriostic seilioJugic sint reprezunt:lte do probcle rln . r|l's.rr ;i d* .o'sl,rur{ic rlin cuburi,.diu belc dd chibrituri g.a.-Se solicilrl, il;il,lirlrL)sc|larcila dir.erse obicclu, iroagini figuri. tr-,a piobele rle urtr. ;i ,irrrr'1,i.s. snlicitii pr,cio,tur si' culstruiasci, din;hibrrturi'un triunghi, riit pl I r';r 1,,rrrrrltt4rl,ulghi eto., sii,construiascd, din cuburi un scaun, ui girrl, , ,'rriir, ur) l rLurJsi lc_cofirpun;i un orlr d.]n pnrlile lui componeirte tIial,,i ,irrr .r11.rr, sr-r,,kragi1 din1,r-'n 11'I Xr dc be.te-p6 celc cu dhiensiuni cg.lrr, r;rr, rrrrrl.lrrzrr rlirL plastilini. construcl,,i,r, tridirnensionald, se testeazri'irli, ,,r] $rr. r'(.pr.odu{,,X din buci,li rle lemn de diverse foruur :.lli.ll:1.,t','1,1, 4{ 'll rr:lrru. rrl,,tr.t(1. rlrlcrjte, sau sJ, transpul_rd, o iruaginc bid nelsiorlr,lil (r,tiilirll.lie rr t,r!, tridimension:r,Iir (Kreindler, 19?Z). Testul lui Abcls,tt (rl.lr;r l(r'(1i')([lr)i, 1.97?) co'st;, i' solicitarea bolnavuiui de a marca pilr.l,uu ,orrrrr :r, l,rci tig.trli goorrrotrice suprapuse. llrrl.rrrr,vii.crr rt,praxieconstructivi, comit urmX,toarelctilturi tle arttstr,ll , (rlrrlr;r t977):-a) Conturul.clcsenului ap&re nerel'lat qi'irrt,rrr, ,lir..irrrllrr', lr) I'rir'(ili rlt:sc'urui sint- grcgit asamblatc,-putirrtl Ii izolalc lrrt,r.rr I 'rrIr, r'1. t,,' 1;1l,r7i;1, rl,:\,.1r'l'i.".J (.it,. 11.irl ir:r,tmir,isirrrplifiulf,sr:t'," ; C) I)"soUUl rrr:rl.r/:r.t, rrr, rrl.r_rrrl rI rr,r'ii ;.i r.rtliuii irtrr rslul.c,ri irr r,,t;riirnrti'rnici slrtt rr tl dJ t)ctirulr rI.rrricrrtrili.rlin,r.1iuirrr,lu,ut,,,f".ui,,,i,ri .rrro'.1,'IrrII flr'l :1,,l ll r,i :| ' I i' iI(i| |.III||tIi ,') Ift ln) lr I . lt r t I r l. ._ , r ClO Silt g- iUt t , t l . S r r t 'i S t l . l \ , l . l r V r U O foSS (lllilli, .il;r,1il. l(r'r:irrrllr',r, ll)7'l) c,rrsl,ii, irr i,rrrulin!,rr, rl'Ir,,,irrI,r,ir,'t irr rrrJrtol'ryi rlri rlr,rirrrril, si ,,l.i.ri,rl. s|:r,(.i, llirrr'rrr.rr .) ;1,r1',);
rrtt f r lf :Lli rr:r,p lr,lrilrilr ,r , |pr r ) llt t t , li, t t ir , i lir |r r I t , r . r .: t r r t l r , i , l i r r r I l : r , r . , , , t , r 1 1 i r 1 1 1 111,,11

t rr t L l |) , lr r r poI r ilr ilillr 'l'lr r r ll t t ' l ri ,i ,rl rrr :rrrr r r r lir ,liili. i, t t ili o I ' 1' :I I rt t :r' . 1t t I r lllllii" r l. : l'l lll t r ': r li'/ lr 'r r lr r 'l r,l rr,,rl rr,r' rrr r t lr r i( f t t lt l 1, t 't t - ; t , "'i 'r li, llt : I t t r 'lr t t \ tr lt lt t lr t t r lt t ''r ''i. r r I ,rr rrl: r , f r ilr l t t t t t lr r r r li. / r 't ''ont . lt , u, t lit lil' t t r r r 'i lr r r r r r t t r lii) ( r lr r r '11lr 1 t t t d't r . t t it t 'r t t . lil , ' , : it t 'ir . 1t : t ii ,t " ,,,,,' t,, i ,, i1ii, t , , , , ', : , lr l) r r ( r lsilr g f i r , . lr r lr '' 11l{; l) ; r ''r lr r 'lr 'r si I 'i( 'r ( v lll{i2; ,' ,f,,,,,,' :,' r;I il v", , jl', , t , , r r r t lr t 'lt ll) {i{}1 i ;,' , - ,,,,u: '11,t , ; t , , t iV: t t 'ii, gllll', lll{ilr ; - A. ilr r i: r t lt r . r r ': L'- isi ' ) t t t 'I t t : r r ) / l] r ', . l! ) i7) lit . 'it r r lI r . lo r 'iir r '{i l ,' ,,,,' l ;' ,l rril r 1i , ", 1r , li. , t 1l( i! lr t llr t r t r r t i 1.,, t,,,, t,,,, , 1, t : nr is. loiilolt it r , t t t l. ir ( siir r gi, ) Hr -r 'alr , '1r 'r iztu, zi,1lt it r t lr r lr ir ! r " t t t t t t lir ot lt r l, ilt r lr ii' ; lt t t t t lr t t t r |, r, r r I : r 't t i't I t t i ,, . 1i trr ,l r ''t "'t 11t lt r ] ilt iiir , ii, 1r r t lr r sr it r r llst 'lt t 't lla'i'ic . ollit r t 'lclor lit t r ; r lr r ' ,,,u, ,, 1,,, , , , , , , 1, 1, , 'sl r l, ir ii ( 10 r ': ur r I silt r lr lilit ii) ' l) f ilt l'r 'r 'ir t r lr r r ( li ii{ l lt r r r l) 0r 'r , . llr rri , ! , ,, l l't t lr it lt llr r t t t t t l lt r r 1,,,,,, ,,,' r,,' , l, , , , , it , , r i', , : 'ilr "'f i lt ill iisot 'it t ll'l' adosr or i t t t u: t lt t t t lit 'ii 1'tt t t ill ult r u't ir t it " ( 1ll it t lt zt lt , lr , it t t t t lsl'it fr, I l r l l tl r r l/ t ll, ll r . 'ir r 'zi' lr it r r r li1'r r r r 'r ( t lr c: r '1r li) , i, i . it , , iiiL"uir 1'. cit 'ir 1r . r l ;,' ; ,i , ;,i, ii'r 1: , r :,:,ii ( '; l{' t t li'lr : " r lir r t 'r r r t r r r r ll'' ?, r r r 1i' ,,' , t , i. 'i, i'r , : i, , 'r i l, 't ' l, r r r r lr t r r il'( 1 ", ' t 'r r 'lizr r r r ': r li"t ' t t l"r I r r '. lr 'l r sl' r,, , r r r l ir , 1', r ',1x, r 'lir ir ' t 't t lr osibil' :, r 't r t t lt t t r 't ll' | I I I i : i I I i r I I I llr ' I I ' t r r ': '1i. 1: r llr r r t t | .' , lr ' , l, sl r ' '' i .. ''t it t : lr r l t l l r l rl t ' l{ t t 'r r 'l lr lr 'l r \ '' ,r". lr i 'r 't : 'lizi r r zr t i( 'r r ll( ll( i( r lur r '' I r t t li ' l : r l ll ,,,,, ,r, r , rl :r r lr ,*1i lr r lnlvilol ( i1 l( . zir t ni ilLr it nisf ot t t i ll{f ( l{illlillllt llr ' I t t llr t t t r r lt ( lt t it t lo lt I i7'uopt ''t '( '( 'l) it l g( 'r lt l'alo i lllt r liit iI t ' t l, , ,, ,,' ,, l) r 'ilr 'r r . lr \ ' ,' ,i, , , 't , , i, i I !,,, t.l r,rIr slt t t Pt it t ct lTt t pot t it Lt er le agr r ozi| lizlr oslr r l1, 'ilt lit ') llir gr r r r 'lr lir lr ' lr r r t r r i sit t i nl{ ( , t r iislil. i ledut uir n t,,,r, ,' ,t,,, , , r r lr . zir ir r i ill( i sl) l! 1, ilt 'lr ) ) ' r claljik) r a {l r' ,,, ,1 l ,, rilr , i( r ( r lovr , t lillt l }it lr dolc llr l lr r r t l t;,,l rrrtii r . t l lr r zit t r ii t lc t . liiisl( r lil donlillanlr l lnr r r liol( r r 7t i llr r ) r l( | iI rrrr I ( r t liFli'lii ) | | | I | | i I t | | I | I |I ( d( ) lcziuni ' ..t,1, , t,r lir r r l llr , boht alii lr r nr ot l' l si r l'r ''t r t t l Lt t r olilil: t t ' ,' ' l r r l', i, it : ilt t r r colt it t t r t ' t ilt pir ' r 1'lr " r r . l lr lllt r lllt r l r r ; r 'lr i lr ilr t lr r 'it l' t r lilr 'zi i ' r,," ,1, , rr r ir t li't it iilor r r illr r t l sr " | | I| |I | | | | |' t' | | | i I | | l't r 'i llt r i r clr ' : ull iI t r 'it t 11 r, Ll L l t,lr r ir r i t 'olt slt Lt ct ivt , lt ' 1r . t 'r I lr r lr lr ll''' lt r,ili: Ll'- I lllllir lllilit r "t t olt r t 'lit "t ' ,,," ,' ,, , , , , ', 1, , , 1, u1, " ' r1 I t r I lr '{lllr I l( r l/ r,' ||, r 't il. . l{lt 4) lll lt z, it lnilil om i$f cr ( li n( 'dolll illil t l lt ') \ ,,rr ' 0}i Jir t ic elt lir t ir l, t lalr n'iili t t t r t 'i , , t I r lr t r t l, . t t t t l. r r , t ,r t . , 1ll1l11'] . , , . r.'r r r l' " )) ' lr r : t lt t lt r , ir r lot t t r lt t t r 'lr t , , , ri ' ,, t i, ii Np; ! il, lo" ( Zlngv'i11,. l lJG ( r ' r r ''r ' lr "'|lr |t lr t ir lc , r i't , r : r lr 'r isi ill') 'nclilit i lr r ', l) ( r r lr r l'r r ' ,," r., i l r'l, t r r lt lr "r r t r r r lit . r 'i, ', , , , , , , in , , s'r 'ilt l""'i 1'r 'r t {i r lr 'f i. it r r 'l"r '," ,,,.,,' ' i ' ,,: 'i iUtt I r |'' r i" r ''t t t r I t i' r: i ,' , ,lt i'*r t , ii't ; , ', , . 1, , t r t t r isilil r lr opt Fit t l' rIrt I tt It Ii II 1 t ; i. ', { ollh1 I lt r 'lr \ r ' lllr llt r iilr r I 'r r r ', ilt t l't 'llt r : , t lt r t r pl; ivt l spl, i, il ,t,' ,,,1,.,,,,r ii, : i1,lt r lo ; r rr . , .r . . , I ir r r lr r r . r i ii r t . ' lt t r llr r r |ir il, r in cur r l, , . , r l ,i , ,, i ,.,. , iii, , ll ir , lr lalsr , : lzii lll{; ii; lir '( r r r r ll|r ' r,1,,1,,r. r r i/ slr r r ir l, t ut r ol r . 'r it r ( 'Air t liir 'gu0t Tll osi ll'issol' r , t )t lt t l) t l : ; t ] t t l't 'l l , rl , lllir r lir r i, t l, t qlt [ dii\ t . in. diuSr t oslir t r l.st nit , louir I r t I t t t I ( r niisl( ii( r i I t i t t I tI tI t tt ir l|r lr lr ') : L|r ' l: t ' , ,' ,, , , i, , l, 'i lr i t ' , , it 'r t it t ' it LI r t ir r : t t r '' t t t t t r ; ill1: 't 'r '' t lt l {1ll ill) l'll\ ill' ' ,,, , ' ( ot r llllt l( 'ilvlt , st r it sr r l'ilt zi' ( t li( r t r r lr r l 1o|oqlr licr illiir r r r , r r r r lici r . u lullr r r r iili f li | ,,, , i, i , , r i, r r r l, t t ir l't : r '\ i; r ' 'r 'r ' r r t i t r t t r t r l ' ' ' ; lr ) ir r l' zir r r r il"111i I r I . 'i ; ' ': 1, iili, i; r lo: r 1r t t 't " t 'r t t r . t ir t lr t ' r t I r t zi" t '" r t t r ; '1ot r r r '. t I I r ,,,,' r,, i, , , , it n',, i', i, , , 'i, u lt t lr r l ( lt t ( i it ; lt lt lir '( r llli ', , l r l' t : l l r i l l l 1 l ' t 't t llit 't lt ''t l' ,,1, i ,,' ' , , r ir l'r , ot t r oI ot ir : , l , , ,' r rl , lr r r r lr r r . j) .
\r, r. ti :r IrttI rI-l :rr,i Ir|:r (5i |ItII It-[rrt"i o' Ii IrIIrIi I|:i ] ttl tti ' i t' 1' l l l i l t' l Il r"r' i r/l l l rIl l
t , i l

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, rLr

tttt l rt)l l ' l rr rl l r rl r L rrrl ttrti tt:l l ot i r l ttttl rrl l l t IIoIi I i IIutl Ir' ' \i l l t' t,ttl " 11\u1rl ol i i rrr:rl orl i rrl i i ,rrr ru ,t,,,r,,,r,i j ,rrrrr, Irr r.Ir1ri l rl r., l r' l '

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1l,,:]ri ,,lrl)ls .l . . ; l ,l. ,:I1 ::;I.r , 'I i .\ (i,! ',r l{ l, llls ilu tn L u i i. iul i ril:rtulrriintr,o lurnintrc. ,t,
lI r]::-t|llrl:, lt oL , . \ r jpUl u ir - , , . iLC O r , aliU . .

,,, , , ,,1,',. nir/ nrx,ir , , it i, I , r ll, I lSl, lr lt t |I l) , [ . N l l p O i t , L O t t i C i S i r , i t t o l L i t l i l i t r rrr,rl r.,.,rlrll,.iLr.riu _, . lr i, . s r "r , - ; i ur nllt . Lr r . , r , . ii i , s i r ,i . r , c i t tt. ,rir,sl,i(,irtir! , l] ', , , , , ' , , r r , . r r 'i rrrl r.,rrr 't itil;;;;i' ;ciiri rtrrrri;i i /su ,u ,,,r i rur clc u;",r _l' i,' Li,il,. ,,. ., ... rrrl' r grrst[ | 1, u lil,ului,, r r i, a.[ r;rrru r ll , l str;-r,nu1,ului, l 'l respir.ll!;ioi r . t \ l ) I . i l , l l r . t prol|.r al p r u l t ru | | lrr lr, ;1 ]'.,,,.1 1,...1,1.,, ',.1;, ,i

| | rI i {|r'rr | ,,rI I rr i , l l 1 rIc s rrri ,i L rrIrri rl i rr l i rrrbi i . N rr 'i' lli"l;;l,ili 'i,,,llli it, ;;;ir 'J','1";',;,,.,il" ;:";;i'l,lliill,'r ,,ll:i'l; ill,,,llii;,,,lll { Ic nri r,sl ,i (,i rl i r! l i ri l u l

Uuiuairii,,r [:].uL'rrr,'rliL, 1"'l r.r::lLi1,i drl,lizbutrse si"r, inghitii,lnrnoJrenex. ".,..f,i l]ac:i, bol'*vil , r rr1 ,:l

,, , , . r1 ,ri r.i rr b , u L rri. tu d iu n;Ls. I' r r cor r i iu 1r ,,:r r ,r

pot fi cxe'utulr' la -u rt linp , o 1I i irrrlc p liu it rr

l r r 'r , I I r, t r I i | | i t r' (r,,ri , r l tr r r l Il l r i ,,l ;tl :r /l r r r l r ' l i p l i t o |l t. i \tr ':tl l 'i i ' Io ttl tr i ' l r l r tl r ,.rlir r l ', r tl r tl r r i | r ';l o to r tl i zl tl l t r l r r l o zi tttti l l l r r t'tl tl ttl l tti t'l l l r tr ( i l tr l |r r l r 'l r t t rI ;i i tt Ittttto t i l 'r It'ttttl 'r r tr l tIr l r l r ') , ', , , , l r t z t i l c l t,t'l 'o to i tr r r ttr l tttl l r r I I I t I t rt i t t I t, i i ' . ' l r u r r ( l r i l ( l [l ) l r tr t, I1 ) l i :]) . l l l - l l r rtr i :l :tttttl zi t:i ( a tl ttttzi a vo e tl i i sl ttt:tvo l a l i a l tti l l r r ttse h r r r r ) r ';tl 'r llrrittl';rrlttr r,, .i ' ti. il,lltlt,xirl t.trlooltirLtri.;ic,i, lollllizltl,i 1xr ttttt;.ltii 'rr:r 'ii,

) - :':' rrr .., ) .1;'l l||,|| ,:\'i']i r\: .i: t rn i:9lt'nu mod itutolrru,l . I)c IO: ,te rnUlLe ori apr*sir bUCuf*r,i;Lll ,',rr . . rri,r,.rr,,r,',,,\l*irnl,[urnJ,tiC,I,SOCi in:],1 a[rrzi:lmO1'o.e Si a lrri lrr(){.ir,. rr r','r:'rrr"lr inr',fior,riia e'ir.i pr+ceutrare r'rrr, r{"/.ra'r (Dcrlv-si Lber,rrir.r.,,. r:'r'.,; \r:1..1,)'iutltn{r 1960: K'oind.lcr.,tgll; Ar.seni IJ.l,rz, :l LUe.nt1,lc, ;i ltt0{)). P..tru rr,sr: prod*cc accaiti, apraxie, trebJie si, exiite rlrrrrl, ,ll)l)!,, r'lrrli rul,! rr r,cgnrnen ilterio]tii a, ariei preccntrale gi a iloua lezirrtrrr |Ir)rrrt,lr lr) iurrlu.r)t cmrst,lrj sau in ernisfetaopusi, (Arscni, 1959. lg7g).
l;, ,\l)raKi' l.ru'chiul'i se.caracterizeazir, prin dificulti,lile bolnavulrri , ,.,.llc:t, rn pr1. do a q" r,irlica ctin piur,tlc,, aj-loio*."n si de a urirl 'l{..r rl)) r,r,'\iu r:r,p'rr. lic J5o(.iiul,i unnori ii c,t iemnc dc lpraric a' rncmbr,lt,,r,. lrlsl,,1 rrsir,toarte g_rerde rlitelenliat dc nra\ia t""ncnii f"i ryi Ae asincigi". .\ p.rltr irL krziuni dc rlivcrse ulturi (_intlcosebi tunori) lr,iebrrpof"i-rii* j lr u I l,,llt;ilk),prccum gi il bo.r,l:t lui pick (la nge, 1930, cita,t A"' X"oiriai,,ii I l); ;
i.

l{fruLOGIC 11.4. I)IA(iNOSTI0

lrr lrlruclir,ii,,:tplilxiile api:l,tde celc mil,i llullto tlti itr lt:'iurtr t'.tt(ttlttt' , ,t ,, Lrl i i scit t , t uict t i r llm olisnelr t u, het nor r r , gii, Lct r ulor t r t Lr ') \ i it t . l. t r nt "tt l' ,,i ,r,r/r.srr r r r aiir t lilr t escinal't o. liit e( Uebr alclt r t sct t ilL ( lt t nl4lt r i ll hr int t t , t't,1,), it\ I {d,Itrnat'i's ne ar&nio-urebw,Ia l'1.,.

al.mcmbrelor interioar" fali Aeiol, cliiru,. l;].,1 ,'. l,.lll.rl.'tj'ir.,ra,or:r,iion) r,.r ,r r,,: rr ,,r's tr: rrfe p.rctroOtalc popovir.iu (Kleinrl_lfl,,
1977; tr)ri; \t,,y{.r. pi ttrrrrunl 1900, citaii a" XrcinUier,' fOi?;". qi'Aggirlrr, ll. \pr.rrxia rlr imbrieare (descrisi, de Ildeaen) se caracterizeazil pr.irr rrrrprrrrlrilil,rr,lrt, lxrl nar.uluidc,a.seimbr5oa,. de-a se A"rn"i.o, Oe a qiirgii I r.r,\.rl:r si ;i|rr1.rrril,.rle la panloli, dc a maDipula, ilr mod adecvat div|r,lolrr ,', (il,Lr1, spontan, qi cit la coma,nrli). Se asocirr,zr-L r:t1 llli,, r'r,,,r"'t ''r'iL('.'r.'rlrr LJ'||1IIIi||rI itrcapta.sl,ingJ,J cu tulburir.i vizrtor urrsl ruclivo ,l',. ti/ .,r,,r lu rll)ut.:u.r:r.t,: s,.tl0mci corporalo5i alto trtlburiiri grruzir,c (lc-li,j:rrirrl lrrrrrris'rr(irlrri sri.g.t,c.), evont-ualqi un rrurnirlniipir,"rr,rrxr'irnistirrgitr lrlrrr. loziruri prrr.i ctllo,lospcotir ptrioto_ocoipil;tlorllopto (llCclon 4i ,\ jrtlirr,urrrrlr':r, ll)51), l). ,1;rrrrxi:r ,.sirnpll,ol.ir:ii " (,,sirrrp:r,l,icil,r) -lclluol lo(r,rc(j1,, rr.rr,)rnl,rr Itt tlllilrtic rrtrsitrllorrrtrtlt,i corrrIlcl, r,tr,l, rt,srroiit,zli o tr,Illr,lirr lr,rrIorrrI rfrrlrrt. ;t0{)

tncrsului pirioarele se inciur.iSolzl, 'r||rir.r ,r,,||,.,\ lll,.Tgc|| l,Jil rnici. pr. virfurilo piciOarelor,bat, nasul Oe toc tlri r'||)!,;r,,/r,.]. *t,rr rl,,.pr rnrl grcrr picioarelc tlc pe sol, iar lrunchiul iimin,r.irr rr'rr,:.., .\i t,r\:r.il1ru il,l)rir\iu mursul.,i u,pat,e ln Ieziuni liniloosebi tumorllrr) 'u car,' irnp-lic; 111,rrkI,p rtlon1;rt, arrl erioari. $i.pllrtca a corprrlrri ',,',]1,,,1 :111 ,.rrr, .,ii. ,'(:r1...r'rrllin ttenlie discrnii,mintin iclentific,area acestei fbr'rrr -$i r'.|| rLt.l'urr li cou[unda ld,cu lipsade iniliativl 1i dn,torrrr,r " ,r" :rIr'ir\ , lr{:n1 p,.trlrrl, .rr rr,1;lr,xiN trunchiului a lui'Brun.qsau-cufenornind d";,;;g,ni;i;-

(d{,n.risa dc cersrrnann qi Schitdcr, t926, cit.,r,l.r .. ,.: ltlJ|:tllrrr{|llui / )"s,e. c,r ctcrizcazir, prin piuderr.* ini[,iariici ;i I ilrtl q l]1,l),ij,,,ll1l.r: l11/ |l. t|l.r.ittt t. A$1lel. in timpul

{ l rtl l i l r' rt' l rl i t' l | | I I t | i III t i I ' Ii | | | | | | I I t I I I i I i l r' , r r. r, t rr' i r ,: i rr ) l l l l ,fl l l l r' l l rrl l ' ' ttr ' rl ' r"r' l (l i l (i l l l ti l ' pt ttt l rrrr' trr' l i :rrrIroI:r' Ii i ,l ,t l ,ttttrr' l l i L' , ,', i fi " ',' { ' trv rtl ttl ' ' i rr rtrl rri l rl trl ri ' ' rl rr' l "rl i i trrttttrt, l t' r:r' 1 I r!\ or! l rr I t,.: rt, i tLi l ,i l r,l ri , ,

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rrrir'r lrrrrrrl tr-';cI :r'i;i1'r'rtrtt'Lri u,,-.clt'in't ,ii,,i:irL,, .rtr'ri. , i ,;i;i--;,1 "lll]]1.*"'"

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1I. I. PRINCIPIILE M]ITODOIOGICE SEIIIOLOGICI, 1)B DIAL.INOSTIC IITIOTOGICSI TOPOGRAI,'IC 12.I.1, Prceiziri de {tr.meqi Qi alc Droblerxati*i. in:r,r.t,rrl .rr,lril,rrlvorir abtirtla succilt problcrnctc de diienosfic doan itt std,ri.te t:attrr lr.,a*r qi.in.alte su,spnd.d.I'i de con$tienli, de scurtj, tlurati, ca dt, }illii irr rrlurrifcstilrile silcepale. I) irrruno51 iu15salr cunriienti Se1n lifatca clea fi i.rl-r.rr.r t, lolegcposibi rtrl :r,:r,v(.iri siru a ltu crrrro;lirrlii de cer&, de a sii in ruor] iust de obi(.,.i,,1,. '-i lr.rr,r|lrr.nole inconjurltoal.e 1dc rcalitatea inconjuldtbarcl. J pir.rrl,. .rrr,rsl,ir4,ir, inseamnii it,nu Dti de sine (Dicfionarul lirnbii romf ne tnc,il"r,,,,, r1,l'7). il'rrlburdlile care survin in sfera cunoqtintei constau nu in rnoriijir,rlrr rl,r rliloril,c gr':r,rL., cum.se.s1une, liinrl vorba-numai dcspre pr,czen{rr rrir,l

;Ji ,;.';"; rr.ttLttrr' ' r ;,, .i,,1 rie t'uilur:r,riv";ciativc, niti rlr ln'rrlili.i'ti rlrr .rtrr l,\r',1 ',:,",t",r";,rrrl, iicurologlc tlir,i r'r. . ,l ',,i,iii 'rzirrrr. "" "i'*iriJ"or,, r';tr ttl..gttr' cuvirrl i.n ' irsiarc ori$irel com5, c1e l',,,r,r,,ont "litttttrr"''"rt ,

l;,J"l:li'J;:l''",' i llll" ,i,ii'illllll,u'l"i';";ll.1,,Xin"."s'',iil ,,i:1.';llll ';i:"T;; tr" r"rr.rrrrrl' i1i,,r',:t..'1" i rr'sut l)e rrri ,,ri't,i,. ,,

Es: Leo clct r se, bir t i ' t, .rl r rl i | o il st ilr ii de conlt , eili' r. ' lr r r'. ' ir t t t r r t lt t t r [ O o" t " lunct 'ii vir sol; r ll L r' , I rl i r o{) nLr , cllcu m adiul t . ii't ir lir r llr r r r i lr r ' co- 1, unAe exlst ii' o leziunc r r ' Slt 'A'\ .irlr' " ' , , ' ,,,"i"f , r r iici li s,rrrrrrrl prr <'irttl , i;i,i;6f ;;1;.'co** 6siu-ostareprtologicr-r''

iirl'i'rr ,;ti';,;il-;-t""0.'1"p'r'r'ot'isi"ttlli'::.::l-.l',lll:1.rt'rIrltl'rt'r'(rrr illt r o. iolt r lI ' t r r t Trtr|r lr I '

r r. lizioLogici,. NL1.2, Problcms rte diagnostic in s{irrile tolnlloilt(l Y niotogiac ; '-1.2.1.As7e?te

i' r ' ' ,rrtn icl) loz; nli, o slt r ': p'l't oloqicii, r n *r ' r : r t : r ' lr 'r 'iz' 'r "! r r r r lt l: r ' l. r r r r ' , lt r . t ! t l . r ' 11 a con, . ricuici cu 4ispar i, . ir i, . . nit r r , ,,1 "", nilni* {\ lr lr r r 'r r '' lt r t r t ": t ' slilnulii la l t,,i ,,,' ,t' .. ir or , t l"cval', : r r eacliilor 'lit t rlit r r ilr r r ll: t ) t r r 'r lt lr i r ( r r cu supr im nr cr ' ( sir 'r . i , i l ,; : i"t i"i"". "lcd; i. it t t t c{t i vt r qr 'llr lr vr " r t lr ' ,,,l Lr rl rrl ) . ou m o{lt r calr u, i"iut 'it o i'lo t livot sclt " qi umor:llo' ,,,',, r,,,,i',in" hidro-etectlolitico

:r,I| {| | lllL {1r n ilrU L, ons llt ut e c Um a.

Oorna csto un sindrom care, prin definilie, Se traduce prin abolirrr[ * element constant;i dorninani * asociatii, lrrlrr,Li, rr,conrytion{ci frecl,t,rrt, r:' :r,lhr'ii,r.ialc luncliilor tulburi,ri biochimice ryi, evcntuill .rr ^ve,getativo, irrrrrrrrrr r.urr)lr)gico de diferite grade, dup6 intinrlerea laterali, a bziurril rrr Llrrrrr:IrirtI urrebral. du fiziopatolugic, ncuropaiuJogie qi clinicXau dus la cot,.lr,,irl ,l)rrlulu i:, :.r),'rrro u slant de cunolllnlti, csle expresiaunei L.ziuni sau lcrtu|lri||,1 rr.rr l lrr ri,rn'a f-orma,liulii roJiculare ascondcnte de pe linia median-d, din tr.rlrr" ,lrrrrl lcr.rrbral.Porturbi,rile legetati-ve, care insolesc fi.ecr.cnt $tal,orl(ll implic5rii stlucl,urilor vegetative din trunchiul ccnrlrrrrl ''r,rrir, f{) {lirl,oroBc :r,lr,r.irrlc.rIraccoali leziunc, prin intindcro:l ei laterali,, caro dtlpitfr,ltl.(, :r'r'iil. :r'rirrlr ryi_pcriariialo *le formaf,iurii roticularc. Nuriai o.xporirr,irri:r,r , r',rrri p,rut,o[i dctcrmilati, printr-o l.ziurLopurii fu SIiAA rtin 1,r,rrrrr.lri, Irr r lirrifir,lrzirrui puro .il trunclri sc irrtilncsc r;ir,r'; ccl rna,i iL,4os11, 1rz,irrr1'rr, r, l. rliluzii, crrflinzind,,si<ltrriclrrrl. l)oci irr corri, o.xisliidc Irrlrt o Lrzirrrrr, ,, lr rrrr.lri llsooia,l cu ;5 lrzirrri ir lrx rl <rr.irrrrrlrri, slrLl, lr,rrl,ori r.:li. lnr {l.ir(.r'ri r,trrl. itr lozittttisttlD'itl,r!rlorilrLl, ftt itrl,r.ti|i 1,lrl,o:l Ilrrtrr,IrirrIrri .rrr'r'IrllrI. lrr ;r'rirrr'rrfrIr, zrt|i Ir|rrl)ir'lril rii rr';r,rr i rrllrrrr]i,i,i rl0 rrorrrr'l,iirr(r'i, (olrrrtrlril; r,r,, r'otrlttzir',rrorrrrrlrl'trt,i'i,) {,r)rrii rrrlr,r rr;lrl:r, 5i rrtrIr:r'ii;ilrilii ; IirI rr, rIi I r,:| ,,,.,,,,.ur,,,
Ir;.i rrr r ilr :lllut lc r r ioli ;l l r :t(| 1 l r,rrrI rrI r,r.rrri rrI ri , r.r,l Lrr, l rrl l i rrri r.r.i l t!l t t i r)l l Ll r. ((l l

cottstil'ttio sitttltl'rrtrttrl l t t t rrI I t't tt ' ' t r | :.1.2.1.1. 'l'ttlba'area ite t:ons'tienlii' itit"* diagnosticului dc cotrrii' ,,, ,,, 'lt^t trrlr'l:r l'rrr ' Ii rulrlilrtir' , I i )'.tL'rt.lsl altlele d"e inst(llare n std'rii d'e aotnii 1xt|' l'r r r r ' r,,nr' Itl l i lgnosil", ^t r o""'o'^iiit xI t locolt lt na'it r t it llor r t iI I I ) I 'i|||IrIr |: |'I II r r r r lr . rr' rrl r 'r 'r r r r r l' l ri , it il iic cbnqr ; i. *t 1";la t n int livit l in r t 'plt . t t lr i li ( \ \ l, r r , rr r ! r r t r ' , lir , r ' r ^r lr i r r r ult I r 'r '( , \ ) r r r cr g6r 1l ; i ,, ;,.;.,ri . ; ; i- t ; o; i{icni'vasc, ul1, r : :,t,r',,t,r:,1

irr rrrrl,r,r,r,rlrrrrt,.L) *n.tcrnnio-oirlobnrl ,;r ,.,,,., i,ii;,;:"ii;; i.:.ir,r-,,nu r r i r l t l l 'l fi l ' l r 'r 'l r

( r r xi 'r l r 'tl ttt:tl 1 q , 1 r o : t 'lo ti l tq {) ti n o l to r n o tl l 'g i tl sl t'tt ttl t l ttl ttti l l o tr l i tttl i r r r l l r r r vr r tr l 'tr :tl r t' r ''r r r r r r Ittt ttl i t* i 0 r l l l i '" ( ) l l r tl t'l 'tl l ttti l tn n o zl t, r r l , r l t r | r l l) . ,,p t I

lil,.,,',rr(r , , , . , ' , , , r i i l i : i , r ' , r , r i a , , r , , - , r i , l r i i J , , , r . L r l t r r '(iliit i , riit h 'or r . rtr' ,tr ' l i ' r r , _ l r ' oir rrrl" r r rt'l" ii,r t t t , r : r 't r r lr l:
1 "'l 1 l' ' A ttl r r l r r l l r l ttl l ' l tr l i l ti tr tl l l l t'tt l o r i l 'o tr l r 'tti " l , r , r r t , t t l r' r l i t l : l 't t t l tl t l ' l )l l 'i 'i ( l ' r l r "" r j l l l ) l i l r l .'i r r l 'o tttl i o r l ttt i tl 'tL r l r ti r r Ir IIt'tIi ' IItti t tr ttttti i , , , , , , , 'l , t i tt,ItIt'tr ':t' tr r Io l r r i r r r r r r l r "r "r ' , i , , r : , , i , , , i ',i ;,';tr i ttl r t r ttl i i ,r cl t'r 'r .r l r r tttr ttr tl r t tr r Ii 'l tl r .r t l 'l r r l ttl tl r '' l l l 'ftl i l l i l tl r i r l l 'tt ' r tt l r tr r , r 'r , , l r r l l t,l , tr l tl r , i l ,l l tl ) tl t l r l l r r l Ir l t'tt't'r ';1 i i rrr ( ' r l i r r tr r ;r ' rl" l r i r i ( r r l r l r r r r t'r 'r r r r r r l l I , ; ; , , , ; , , ; ', ;;. ( ',,.r ,,,'L ' p i "r '"r l :r l ' ""l r r 'l r r i

r 'li'r sr r 'i'r t t 'r r ir r ii) ' ir r r r , 'l'r '1" 1i' ' ; ' .;' ' ' i ;, ; i, ; , i, i I r r r r I r 'r r r r ' rr tt't l l tl t' t t t l t t i lr ( r r ': r 'r r r {lr { ,' .,i ,,, | J"', , , 'i, , i, i t , , i; t , t 'it tn'i" it l r t Dt 'olt ir r t r r J r rr' r

i \ \ I,| | | | IIIl||(r ]l( t 'r'r.fi rlr r r iit t ! o lir l, ( t li : i {tl

, t, 1,,rrri Iri I r I I r I r r,r rr r,iiiI r 'r r i, r r r r u| | | (, | | | :|,i | | | | | r ll plt t i, t lot r r r oi lr , lr rr t t lr r t lr r r . . I 'r t , t , 'rt t I l i ,rl rr | |I Lr r jI r r , I I lt : , lit r t lr r r ; t o1,lr lc<lr r ;, t r r r t lt t t o t , ot t t r ir '1r iI r , I t iicli. " ' rr, ,' 11 r.: rrLr r', r lr lczir r liro , rrrrtr tr tiI it 'lr , ( , irllr r r cilicii, I lr t lt t l; i st r it t lilt t r , ; i l t r r : r , r t' 1, , I ur l trr r r r olllgir r , it t r , ot t lt ,c( ilir r ii ; i t t r t t r oli it t r lr t t t r t ,lr r t ) r t it t r r r t r r I llllt ii, ,r, , ( ri r,l ozl ! t r c st t gllclt zii, t lc olt ir , r t io cr t t t t i,ilL clt , t or r xlslr 'i( , sl'ir , zlr \( ' 't r ) : r i: l , 1,,rtrrl l ri i t : i ir r I r r r r liiilct cspir t , {r nii ( r , ot t t clt ipr t t 'cr ult t t it 'c) . ( lt llr t lt , tttlzr r lr r l; r rlrrrrrrriirrsir'. sr)r(), ilf..(irr*r v'sclilirr:1, irit',it.rjtui i,..ilt.br.,r ,,,,' r,, (ci rrsir ) lt 'pir lii t t c 1t ot t 1,ot o t r t t nij, l, r r jr i'r ,or it ': t t lr ot r r r l: r ' bazil,r,r,. t r ior r l' sl) l'( ) l'r.rlrr'rrfr.lrl .clir..,ritt:poi 1i rorr:latoalc p(rlltr. r Li l ,, ,,:r, i rl ct ilr r , li, t cgr r r r r ur t cln'( c\ 'olr i, ur t l Ei pr ozct t lr t ,t lc , , ; ( clulc" r : r r r.melc a]crr.lir,,,, rr,'Jrrrir.r...rii,Ll,crjr ' !l ,' r rrc ol i r r r r lor z, i'i. r.. rlonrice,,ii,",u:ii,pr.rli1r,, it lt r {, 1r , ( 'ilt 1t r r t t t r t r lt t l, slir c o t ot t r ii, helt : t t icr i, .l l. ipor 'pigt \, :ii: .il. l:ll ll l1,]r. i,, r,r1, ||||''{ |||,:|.,,. ( r . r I { , , . t iI I iL. , ljr oJ r i. Ur . t . : , o. I| , rrr( r) r n{}lol r t c por lil ir r dr t , l- r t lt pt it t i t rs t r I i . i . rri rr u, 1, cI t i, , iii, t t t lt lt t r i' sllt 't r ' , , rr, r' r,,,.Ditrp,,,,rri.i,jlrr r,, , , . , , t r , ' ll.r. |||(|l|||(|I)1rrrrIrIr|)rrii,slrt)l,iocrnii).(.t.lu,lllgiilnvit,,:nt.ii;rsufirct1e,hip,.1,*rrrri,,, ,,t' ,r, rrrl rr. [ 'r 'r 'zcr Lir l, it L t lit lqt t or lilt t l t t t r , r r ut ui hcr pcs pot ll, c f i LLLilr i, .rr .i1<'ri rnt su,ri.zilc 1,.11r.r'r,r,rlrl ,, ' ,' r' rl .' r' r'r t lr r r r spir r t lo slt t r al t t noi pnout r t or t ii. I 't l1, t r ; iih ll{i ( ) |iI r t I I i i| | institarlca cum"iir. ..ii"r*rit",, or"riu.,lir,,, r,r'lrrrr'$r.r'r'('I)r'ir|(^, l.rrrLlro{r.Lritc rl rtrr r r suli, r 'int li hep: li, it : i, , sllo o scpliuNt r ie sit , t L spt r r o lr r r r r l: rr l. cc*rbrare.o ar*ri i,."""a".1,ii, dc cor,r,rrirr ,,,,,,.1i1r ,' r tkrauna l l t.,r,t ir iLlr t cit , t [ cst , t t l t lr : r 'r r r , r lll t im cillt sclol r sl, r j ':,,;,,11:::l ,sprt it , iLt guur clt clor ' ; i o arecliunei"tntiacramanri ll"ll,lLi 'lurrrot,i .i:l.ll:,. 1u,,,,,,,1 ,|||,){ rr Iir'r,{r,' i\lr1|,r i )III I i (|, it t r , r 'lr r r r r lr situ lcmatorrr in plirrrnl rind _, clritrrlilrr, ' ,. ' l rr' rrl t 'r Lt ollt , r liu, bct 'ict i $i pont r u cot t r li, t lo i II r 'i rr, lrrl,pirli. lrigr.r'1.rrsi'ii. ,, encrlrlopirtie,ir " i rl,,"rirt'i"biti (rcr.ci'irrir), ' l ,rr.ri i i l rr t , bt t r ir lt ulc pot f i r cr . clilt ot lc pct t lt 't t cot t ll I I ipo, lli, r 't r t r , : , , ,,r. rrirr|J lri1r.;llirrtrrrio "rri";', ,,r ,,)rrr! r liir int or icai, iilo cu iDSe{1{, iaii(tl( strr'al1,d, r :rir r tulbrlra,r.,: l , t t}, t l, it t t t lit t t r sit r t r t , zir ruetaboiicd,. lr lt r llr t f,a,o temeieg}a,i,irlri, ' ,,l r,. ,,rrrrr oricnr,eazi, i lillilo, j j j spr" o .o,ria,'.*t"irp1ici. De i.,r,r ulr : I : I I ) : I I I I I . .li:.lll:.I:..tt"t,l l, i "r\l i l r ll{ u, I I I I : . l. |,,. 1 { . l , I' l r. i tJ p l .c r n l J t,e t .rl OA l ,odi f l ' , i rl rr , ccit inr ozclor , a, cseor ialiilol I i il, 1r n{) r pliui I 'r t pir i, r r L,r '' :, i . rJ,tt.trr.rl 1n0S J .,, ,1 ,. r lt ' ' l 1, r , . , ' 11:r ,,.In rr' ;ri rl i rl r.s c l n r(. i 1 schi mfi , ,_,1r,,i .,,,1 ' ,' r,rr i l rrrrr r ir , iic: l sim 1l{) st cr il, ioilla, Lin t lr ilr lbic, l) r t z( 'r 1r t ( |( I r 'I r I r '|( ||r , ' rl .,l i p lir *r l lr r : l' r i. s i i r1 o (' r' i c l ri ' ,2 { r tp .,, " i i z" i n . ,,,:r,.:r i l ) r i) r ) couii"L i r.,c.i i ,ri ,rrr,, t r r cr nicr i, ccllm pt icii, f i ult {r ( }r 'islt t ir t t t t r r l, 't r r , ', t , ' 1 ".o.,.r" - ,i .,i " -t (lr'r)r'ii, (ii ' r'{rl ) r'ir 1 ri,. abc.s cc'e),r'r,1,truuirottit rte, eu""}uiital. " ^r" \,iir.sri1rrr,ir. rl r,r,uno1o ,rrl t.:tsculal'c, rnerrilgifiec, p"i" into:;ic,1i,l r,rr ' r rrr1rr.r.i, crrorirl rlc c:r,ibon 'r'...r1,, """r"i"a, (slal1t, ' lt tit.pt|u,llti"a tori,:e;, corn"le r'11tl ,,) ,r.l Gidi.;. urpor*\d,. Ilipotorflriil, poi}to sii t,rritttrirl:i' t;;;il;ii ,' rli:r,lr,t ic poril,o iltra in rliscuiiLr r,ii1, o curni i.ip"ig1i"or"ia lrlr p1,ir1rlt r,, r, r)\ if i! r Jt {}nat ii, lt ilr r pii, uilr t lr i. sm hipot ir oit li*t r il r,t,r,l), ' rL ' ,r , . ' . : : l: ,, r."i* n i. ri-oiii, oia b " r 1tt;r,.2gp.,11 i, r, 1 , , : . . , , , , , l ttl ' ttl t' t.i( , h debut 1ioalc f i t evolat olt t 'c lt t , t t l'tt t r r lt t t r t lr r ir r li r 'li, r : r l 1 ,,:l ':,l l j l l '.Jlinr.r,r.in,, i) i ':r "rrir/ J'r'|l11r'n lccrctcnt vascular cercbral (arteriopatia atolonrairrir rrr , l rr tr r t rrc t t it t go- encef illit li, abces cel'cbr it Ls: r . t tl, t t t t r t lr o llr 'lr ilr r r , r ', 1'r ': r lr rr rli:rlrrrti*'i) sir,rr chi*r' o corrrir, hiperosmot";i".i."-i;;;ili; .siitiii.r :rl,.r,ri ,i ,1r I r r ', t t t t l r r t l I rrrl r, pe par ct t lsul t t t t r r i l tilxr lt er t r dla *pr ir ut ir , lr r r '/ ir r i l'r , lrr lrr1rl rrl .i, . r,,.ri, la rrrrbolnr,r. dpileptic ioiO"*"l*-" ."ir,; ,1,i' ,, ,ri (l r!l s, ilr t r uclir int cr vinc in conlicr t ul t iLt t llol t r r t t t c: r t l) nlr l, , | , . , ' l, ;rl,i,:r, ,,'r'r' s.", r'i 1;1p,,;r,tc "*t" {i rlaforif,i;";l"., h.,;il;;:i;i*anio_ctr.r,tr.rr,t , ,rr .rl i ri i ,, i rL st at [ s cpilcpt ic, t um or i ccl: br r r lc lu lt t r gr r '. ir ili, it t lor r , r ( r , Irr,,\r)(i:, llt r.rt|lrut Il lt ll{.{,(]s conr,_ulsir,, unei suferinte ccrcbrale Jrrr,,,,. ,I' I' l r| i (i i i i lr , t r opir r ici ct c. ) . ,li :r, s,,r..r',r.1 _.i ,.r',,'sr.lo.r.pit,.l,1icu (iumor.-' rbcns, Lenr:r:,,r,r. .i..]li l , rrrpct'l ur a, pr ezint r i per t ur blir i st t t t t t t iI it llt it 'o lt t lt r r ili ilr t r lr r ti , , 'r r r r r r: |lil,l: | r. rr' , r :L l.lr1,\:rsr,rrtjr , l; l, . . r il|| ir l] i i|ll' nlinli v : t "c r t l l r i , s&u chiAr u A1, , Ii,ut, r, ,, t,r' r)l un ilc - - in cor nelc do gr aalclo li iji'l | \ | r:r' r' 11 .,D:l,rr,. , :l rlr. pt l, li u t l t dnt r uln in< u I u r , r lr r r r iilr ( r l'7llli ( , r r lr '; r t r t t t goor.rtt ur lll li r.l 1r a n r . t , c a 1 i c r,r,l , o , lr ilr , 'r llr iir lii, r lr r lr , l1r t lir ( ir t r) l )1 1, bt t llr . lcil, |' |1,r|\ rri| |rrI Ir Iri1r,ulit*nrii r inf er ioar i, lt , pll) ijii ; i d*cl*tU*tornede con'vulsii) qi ii,,i,,r, s",i 1Voft"fe 1,,' ,1,, r lo zilr r cr ir r l. r ' pr oglt si\ '. t r lt t Lt t t t t iit pl ilt ou", i\ sllcl, lirr;i; Arl,llli.. cu. car act or ,.rr ti .colNb.,tg?3;- popoyiciu lt .fhi,.,"-ibzg; Arstli ,,,i ,1,,1,, r1(.rrrj o r not lcr at ii, ( il jul do i] 8') ; i t r r I I r f it r r r ii, r t '1t t tit i r I t lt t r iil, r : r t , 1, , I'r)lro\ 11,il llll"j0). /\ rrtcccdontr;lr'hepatice, pohlo^rc, a<lclisorrilrrl zi l, r ; lr ,] : r ,: r t , l: r ; . r ""o"t", , o , n n . , ' l , | l r{ l i rl l vjr r c 0 noui clclt ct c ( 0u o( 'lr l") soi 'ur ; l! t lr t t t r l, h " p o r i .i; .;' i i1 ,, :,,.::i tr,lr:rcrtrs,lliln:t, j'] ':.till. 'l: , lli l l i l l i() " , rr,orrrii ; , . :tpiruti l :r iJt.;,' i;." n a rh ,:,t,rr,r r, , | 1,,i rr pl rr t our ') , pent r u cir , st t llr il iilr si, st : I it li<r , , , ilt zit t : t r t t r r r r r l, , : r r , un b6lnl,r hipor.tr.i,.,rr' lr t t ; t l, r:r,lrrl i g.rrr'rr,t,iirl. bou,r, .o b*zii,1r' ' 1,, ..l l r pl i li( ) u) '( Alsoni 1072) 5i r Lql,si sc r olt t ll, t t Pit t ii l: u r r lr t r lt t t l frip""i"osrvii,),dir,' r.l icnccfatop*l,ia -*ii ,l i u\i r(1 r i lt illcli, clt nio r io 11" siLt t lllli t i1ul1" r'li ;r..irl.rrr, vr,s.rrla. c,rub'*l' 1'r'rrr iltac ischerrri,,1, 1r,"irr,rr.'gi. l|r i l l | || r , irl|f f r r i|i, J rl ! ttrt i t,l c rru l i c1 , ,f,,b u i es ..,l l i ern i rr rtrri cl ,c rtrai rrrrl l ,r : l l ta.rt lt t l, t 6- lt it f t lor ; i cr ut lio'nat t r : t t lt t t :t ) ll, t lt t r r t I t oI I t r I r t r I t I i 1r , r ; r l" rrrr, rI rrI rI rr { r : . r.'rrrir, *lrr,,li.ii pr,lxiu_zisii, 1 , ,rrurit, tr,,"iii, 11,rcil (rrrril o , t ,r r rl rr,gr r osl it t t l, t 'r ^t t <l sc ct t t t sllllil t , i, r r r lllii ( t li lt t ili, s t lo : t llr t ol lr lr r r . , ,,,), o coriiri.prin intoxiorlic ic,ii,nltr,r,a, ,,,,r,,,r o il: l:.1;:.,1 ,ll::,:: :.:::,.t1,:li]i tl ,' r). rl c t lt t t t r . t 'r '( r f ( t ( ic ( r t r t r t : t ,I I i: r , I r r , I icii) ,lr , lr r l lr r '1': r lr , rr r lr lot t ii, sllt r | | ,,i r|l,,r.,rir,|| I l. t r , . t , r r r r r r r i r . 1r il. Dt i, . i. r . r r . r r l r . : r l ' r t' r' i ( t : r . i I , l t , t , ), , ( . , r r , r i l , ' ,r l rr' l rrrl, ir i) $ u lr t t t r t t t ir t t lt 'l( t 'r r r t r lrt,t lr , t r r i, r ; i) 1lt ) linr iilt t t t |r r 11'1, o; r lr ' l(r 'l:rl,,lj:rli(,,.1 ili, , r r l ' r rr, 1r i1r , y , . l. \ \ , I , r iir L, . l. ,' Lr,l r,r rr r' ,rr t t r 'LrI t r t r lt llt r r lit it t oI ilr , t 'r 'r rir i ill llll{r lr r t 't t t t t t l I t I t , t I t t I t t tr ', , , ) t ;' r,rti rr. l trolt nt t l'i,r lt t ilt h iixst t t r t , t iir r t t lr r r iclt it t r 'or r r : rr lr , r l) li , I t l t t t t t t I t t t 'it , l :.1.;!.1.:i, l u,l,out crr,dtld.or tr,rrrt ttnttltr.i, qtttrru.l. li p( (l)(t.(rla Jllr t v{r ,( 'Lt t t llllr 'r r r {; rlr t r ll'. r t . , , , ' Ii , r' orrr r r : r r r ir |, I ; , . ir r 'r lr ', r lr ii r r r lr lr ic r 'r r t t t r , lr | | : l nti l i tt pr r it r li, ii. t lr lt lt ( 'hr t lt t r t , \ r / / , r r r lr lr lll'r illr r I r ; l r r ir r t l, t t r r l L lr t r l I . l'tUu t()tld r: f i, t t t t t r ' , t r ut r , l. r 'Nr , r r r r l olt t r r r t r , I rIr ri I r rr, r r I rrIr r ltrprr lrrr, l. i ,,Ii ,rl l )t " t t t t t r t , ir lr 'r r l r r , t r l; r . r l )t , ). ' l l () t l trl ilt : , t ' t t r t t rIt |, , r' i I Ir I r'rr <r r t r r r r |, r I r { , liln r rr{\o Irirrrr|,ir:I lt r 6ilr ilil; q, lr , 1r r , r r nr iI , r , : r r r r r r : r l i ; i r r r . ,
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(,i.r,rl irix.r,!(. l:l:ii ,irrrli(:r ,t.t., ( lri L l,t r : | / .I I : r I rr r r li) ( : it liliir i r ) ( n, ( r l) r , l I h rI r, l t n t o ] , i ( x r ; , i r l ) f : t 1 . , l t *l l t l | |. t, .i lo:r,nr! ( rrrI | )I | | | I LII I rrrI r , i lulc t r ) , r u. or r tic , r lir r , lr r r l, r l i i , , l l n r r i r r i r l r r c l r , l , i i , srtlllt,l l r' r' r)llrr f ({lt o rirl rlc c lt , t lt r ir r , plr t r r t ll, r lr r r , iv lll; i r l o l t , t , s c r t c l ; o . ) . ' | ' rrIIrrr.ii,I.iIrrrlri v . r k r r c ( lr , r ir bli' pii, r : lr lips o r . i z r r i l l * . .r \ r . i t , . ) i ) r . l r r {r '*i i , t , r) i l , r r t (x)J r(! rt0 0r'i0 rrr , 0r r , z li, rr" i[ r [ il0s o] r i s r ) r . 0 lui pf o 0 c s i l r l , r , ; [ ( j r r r , r i r r , ri I rr[rl0rrir,rr]

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i I I n,utnarat,lipu,Luiraspirator' (ijoiaoic lrr,blrba'li qi abdominal la femei) rtrlicii, rr ulrvilirto rrraxirnil a comeii g) Bradiaard,iaeste caracteristici, rrrrlirlirr{,rltr in ca,drulsindlori,melor bulba,ro de hipertensiunoiDtracranian[ plirr lrorrror:rgiecelcbralX, hematoame intracranieno, tumoni si abcese cf |ob|r,lrr ntrningite , ineningo-encefalite. IIai apare ln comsle din nixerlr,rrr qi in rxrle pril hipopituitarisrn ; h\ Ta,hieard,iaapare in multe come, irrrlrroscbiil cele infeclioase, in comele in care apar complicatii pulmonare i i1 NotntLc|a d,al.e:iune aaloul,ard, ca,rd,iacd, ne olienteaz;, spre o embolie cerej) irlrr,lir, ,lritnii.le card,ince alte mod,if icd,ri card,iaceie pot sugera mecaFi, ; rrisnrc oxtraccrebra,lo ale unci come (embolie, infarct, iusuficientd circulalrrlic lrermodinarnicS, etc.) ; k) Eipertensi,unea d,rterid,ld, cu intXrirea zgomolrrtui a1 doilea la nivelul orificiului aortic $i cu hiportlofia ventriculului sl inq ne poate orienta sprc o hemolagie cerebralS,,encefalopatie hipertenr'ir.ii sau urcrnie; l) Eitrtotensiuneaatteri&ld, Ia debut poate sugcra o insuricrrLil saptatenali,, o comX cliabeticS,,o com5, prin tleshiilratarc, o com5, l.oxiu"r,, sau rnctabolicii, (prin oxitl de carbon, barbiturice, alcool, suferinle lLop*ticc, boala lui Addison), o com5,hemoiiina:nicii prin hemoragie masiyS, r;rlrr prin infatct mioca,rdic etc. 4. iligesti.ts, Vd,rsd,turile sint ncaracteri$tice, putintl st -A.paratul :rprlrii, in nuureroase come de origine neuroiogicr, toxici sa,umetabolic5,. Ilepatosplenonegaiia ne poate sugera o comd, hepatici,, leucemic5, malarir:L, in boli de colagen sau a,1teatecl;iuni d.e sistem. Dagluti,li.aeste perturbati, in leziuni caudale ale trunchiului cerebral qi este un elemcnt de prim ordin in tirrrlinl nucleilor :rervilor IX*XI) rrprrrcicrea grtulului de profunzime a comoi. Deglutilia are aloi timpi. 'l'iurpul I (lzr,bial): bolnavuiui inconrstiont i se apropie o liugurili, cu apd rlo )ruzorel intinde buzele, o suge gi o inghiie normal sau nu intintle buze]o - iltunci vom spune c5, timpul I (labial) este prezent sau abolit. Timpul )rrbi:rl are o reprezentale cort,ical5,qi una la limita superioard a trunchiului lur:olrral. Timpul II (degiutifia propriu-zisd,) zicem c5, este bun atunci rrirrrl tirnpul labial este absent (pacientul nu intinele buzele sH,sug5,aprd,), rlrr,r'cind, introducinal apa intro dinli, eI o inghite bine. Timpul II al tlotlrri'i{,ioi csto intirziat atunci cind o introd.uccm in guri,, paoientul lino rr,pl,irr gurii, rn timp gi apoi o inghite, Leziunea eslo Ia nivelul nervilor crrr,nioniIX I inl,roducem a,pii,in gura holnavului, pacientul trine a,pa, cars lrolboloseqte, dar nu o inghlte, are un refler c1otuse, o parte tlin ap[ irrllri in ci,ile rospiratorii $i se ineacS. Spunem c5, timpul II al d.oglutijiei osl,r a,bsent, cu sau f[IH, reflex de tuse. Ireziunea este la niyelu] nueleilor rror'r, ilot cranieni X-XI. I udoral,io este semnificativi, numai in cazurile f5,r5,hipertensiune. lioziurrol, csto in ium;,tatea in{erioard, a bulbului. 'lluto tulburirile vegotative (afari ile deglntilie) au valoare daod in ansamblu (tabeiul IV); izolat, elo nu au y&loare. nirrl, lrrl,1;o menului neurol,og I 2. 1.2. 1.3, Y al,oarea d,atelorefro, ic 1.. Il;ri.ttcn;la harniplegioi,l,robrLie vcrilical,i, din capul locului. Constal,ir,r'oir, r nci ho,niplogii irrstalir,tobLusc sugottnzii -a,ploilpc totrlcauna un ylrii0rtljr,r Itr sohirnb, su]prirriloron) mrobral $ll,I lln(x)ri {] r,11.q?}jilro. rlr.rcirlr:rtl; ir ri;r'-o itr.l;rr,lll,ri lrorniplogii cotrtrt in trrorIlotrl t1uporr,1;o rrrrrri $ugoni] Fi u,l1;c' (1;utttrrr,r'o oot'ullt'1tr1, rrii,rloqirlrr itrr,lr r!b00$ hrttttrt,li0rn Nlrlxl|rnrl, Jrosilrilil,r"r,l,i ;10 0

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rrroningitS,tuberculoas[', parazitozd, cerebrald,, mai ra1' cncolil,lil't'I, ltsrrtttl,r 'hrrnorald,): a) ln comele superficiale, deficitele motorii silt uryor do I'0orllrorrrrl'r rl,r prin probele motilitS,lii active gi pasive, cit $i prin inogtll if ir,l,r,rr' rr,1,it roactie a membrelor la Dracticarea stimul5,rilor dur'otoitsa. 'b) ln comeie profu,udo Be ror practica o serie de pr'obo : . lrlf ul;(tnlt[ rrrcmbrelorparalizate, care cad mai rapid pe planul Jxll,tthtilrr ttttt,tttrvrl|r (lc ddicare qi d Hsare brusc5,; -,,semnul piciorului totilr In nlh,rfi)'nl prt,tlirii, lrri Bogolepov (citat de Yoiculeseu qi Stoica, 1907): - trrl:tt;irt, rrrir,ximI, ln afar5, a membrelor evidenliazl' lipsa do lovolliro itr lozi{irl irridial5, a mernbrului paralizat, plin hipotonia rotatorilol intrrtrti I . lrtl t,xltt" 1rit.ift1cs t}lt ttrritzjlt parezei faciale dc tip centlal (eviden{,i:r,bilir, z.rr{,a rlr, prin ,,semnulpilr'i" sau ztl ,,pinztrido cutitbiottI lll plrtlrrrlr, lrr,{iilur', rrrl,r'ortrarrtl ii lltt trlltlttl globii rtlillgirroi! illttla't srltt pe rrpir,t oculati, illo lxJ 1rr prr,ra lizlll rl')I - ltntzrtttl:t, Itl tt tIi IrrI r' I'tr, l:rlirrlrrhri,rn lipsl grittr:rsti tlo 1r*rl,tlit, tilt,tt It' tr^lh, lllxrlinlil ttlrill'1,r',rilli'1, ltri ltiulritrtlii;- tlitttittttirtt'lt' rr llt,rrrrrrhri rclltrxrrlot' r)$t,(r(t hrll(luroirrltt. t;ii Iriritrtrl;t'iit, rllot' ctt1,ir,ttir,1,r.r it,lxlrtrrirriikr trNr).u(rt't'{lltuHpilU{ 1111v,i 1'rrl'lrt't'd( roJlox) rtrrtt it" I'rn( l,t.tuttilu.l'ttt'tl<L,, rriittii, rr'l;rit Ilt ttIrti,ltl gtlt'ii,lrttzllor (,lr,,l'iljl tr'l|r,;i):r,l rlrrlrlrrrcrrfr. lr)rll!1ii,
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ri :t'l litttlrir' ptt,ztrtt(it, ttttiIiutrrlrlIit ir liislllnslllrri Iorric lll uirrior,rrIrri ill ]rri h rrll (l.lrlsl.irr ll rrrrlrolrr;r,r, rblrrrbilill srr,Lr corrLill,os iroatoiugcra o loznllx) trrrri,r,rrl[1.r.r.r,I/u. LIrr gr(]spiugrotlox bil;1,el'tt,l IrtrrIr.rrl,rr,lii, .]ru il,t,cIaloa,t,o lrrr.rlizrr,lolio, lLrcsLusrrgctiltl o su:tilinli, dc lrunclri cet,ebr,il. :';. .4ho[.it.'ctlre!l.et;ektr o1teoleniliuoase sc poal,e constata in diabr:tr , . rr lrcrrLor.ilgiiic subiuahnoidiole, irr unelc mcningil,c blcilare, in situali:i, 1r,{l\isL{)lrl,ci urror polincvrite (polineuropa,tij) inteitiorsr', etihde,cliabeticc, r:o.lirgritrozicc, lxccurn fi in hts. hr stntlii ar arisr,tl alc'coneloi, abolirea lolIrxr,lul ost(]o-tondinoaso nu prezinti somnificalie patologici, (ce1mult prrrgr rrrsl,icii). de rigitlitate prin decerebrare pi a cel,rtr de ri,oiditate . L L'rczerrla sem,.nelctr prin lcc,o.rlir:are (y. a.)poato fi constata,tii irr rnulte corne(vasculare,'toxice, rrlri rr,l,rolicc, tunoralc, cncefa,litice) qi pot indica sediul leziunii (Jouvet, I l)0{)) |ii scnrrifica,Iiilc prognostice. 5. [trezo]]t& temnelor meningeale intr-o comX, instalatir, ictiform no irrrlicir,in prirnul rinrl o hemorlgie subtrahnoialiax,i,, dar si o hemoragio ,r'(,rcl)r'o-rnellingoc s:l,u o inundalie ventriculard,. jDtr-o coni, fcbrild,, semrrr:lcnctir4leale sint lerela,toare puntm o meningil,i (urruilles) sau pentru 'absen?e rnr lbces ccrcbral. Recloareacefei (cl atte s,,rnn6merringeale sau rLrr,r'schi!,:r,te) se poate intilni in proceselc expansile intralcraniene (tumori, tlrctrscr Lernatoame) cu fenomene de angajare. 6. _Prezerrla unr_ rnipcdri au,tomatico-rejlerech co;r&ctar stereolip, o":dtLu.1,,if,cle_miFcltri caqfologice (readocerea cuverturii ori cle citc ori desc-ofeiim Irolrull'ul1 miscd,ri do apucare qi de frecare a organelor geriitale, a na;ului, lnr r'r,ltcrni,sciri ges1,ua1e storcotipe) se intilnesc irrrloosebi in comele mai ,,ul,,r'ti,.illo din irrtcclii, in[o:ic-r,1ii ,ii unclc mo n iugo-cnccflli re. '/. 1't nurdturi ole e.ttrenitd!ilot tu a*p.(t ttc ,,biitdi de oripi', (,,Jtappinl lrrmoi" 1 apr in cornr.lehepatice. 8. Mod,iJicd,rilepuptil.are. .Pnpileie se prozinti miotice in intoxicalia , rr o;rinrr.c. in.conLa uro-nrice;i in unclc l,.ziuniprotu bcra,ntialrl (benloragio l rornbozii. bazilar'ri, t unrorj puni inc). pupilele midrirLticesugerca*zi, 1,,,rrl.ini., ,r rrrr,'rrc:trtre al,roplmcAstu o comd,gravd,vascularS,O midriazx unilaterrrlrt (ipsilai;er-ali, sc intilncqte iu heruatoame epiclurale, Nubd.uralo -lezirnii) r,;ru irrtr;lcercbr ale, in tumori cerebrale cu anga,jare a tonutui temporal ryiirr anovlisrnele de arterd, cerebralil mijlocie sau postrrioard (asociaid cu lrt,oziipllpebralil), 9. Pre:renld.anai oftalmoplegit (ptozh, strabism gi rnidriazd,) asociatd, ('r.ri.crrnc rnenrngrale ne sugereazl o meningitd, s&u o hemoragie subarah_ ruritlia,nd prorlusi^ prin rupturi de anevrfum. O oftalmopl6gie masivd, ilrl,r'-rnr corrtext infcclios ne poate indr.uma sprc o tromboflibi[i, de sinus , iivr.r'r',r. socieroa, oftnlmoplcgicicu bcmnc piramiclalc.caro realizeazd ,r lr'.rripL'gio:rlLernfi,, nc sugfroazii, u leziunerle tnlnr:hi ocrcbral (tunrori, i,rrr.r'Irr,Ii1,o, tt ombozll dc afieri, bazilar[ s.a.). tU. n,flr.ru| Iolo.n?,otar ti abolir, in conrele protundc, in unelo -poi\I " motorocularnlui coinun qi/ |'' ro irr ciLr.(f srj &Nociazi afcctarea Sau nervul ol)1ic, pr'ocunl qi in comele vascularo prin a, jeriti lueticA. a globiior oculari constituio un semn important , ,I1.. .l)euialiaconjugatd rll lt.zirrnn.el,ir focar._I)eria_!ia,. eonjugati, a globilor oculari spre-partoa oprrsi, Ircmiplegioi indicil o lezirLnc eniisfcricil 1l_,olnavul,,iqi privegf,e lezi*spre'partoa rtrirr,", conf{rrrn.Icgii Jui IlrCv,'sh f i L:r,nilouz.y).Ilcvii,lil, h.rrriplugitii, inilicir, ilo obicr,i . l(,zitnlc nlr,i ji,risr'i, in lrLrnchiiLl <drcbt.li,l (ri rrrl l rnr ltovil lo [t11,r rlrrrr,lr,rrl,irII i nlor:ior), :i{)tl

-1

l:!, Nln:rrl)t!ltl ttl pl:rll rrrr,:r. rrrrrllrplc llrrrrrilir,lrtii : l)11,(x'.r r,\l,lt,liltv r| | t rr(1 I ir,Irii r, It , lr!rlrl)ollrlllir r r,r'r'IrI;IIII, r,rrcr'lltlii,rj r'rrlr,ltr,lrsottrloirrlror.lrlii, iolrirl'ilrII i I)r' r'I r.rr ri r Ii , r.Irlr.IrrIo1rrr,I r.cclllrrr!tioi, lrotrollt,gicsrrllrr,lllrrrrrr Itrr,t rii. 13. Alrof iu opLioiiutlilolet&l,ri, la, un bolnav couli)los porrl,csr'i rro irr Ilrrrrrsgp16 o hcmor.agit subarahnoidianirprin anelrisnL lupl, (rlilcii rirrl, ri scrrLlemcniageale), sple o tronbozii, de alterri carotirl"L (rllrci, r,sl,rri rr lr(:rriplegic contralaterali) s&u spre un sindrorn l.ostel .Kcrrrrcrlr' lilirr rrrrrnli bazrlii {lo claj rnterio). 14. Motli.;f icitrile reJlernlui cornean, pot,si, ofcre inrlict,lii rlo prrrlrrrrzirrrrr r,rortteiriat uneori prezinli, ,sit-aloarelocalizatorie. Asl,fcl, tbolilclr, rrrrilrr, it'raiinne sugcle:lzilo leziunc pontind,, iar o abolirc llilftLcl.itlil(rrrrrrrlrliorlrr, irtiu gradul de profunzime al comei) ne sugelea,zlo lcziunrrrrxlirrsii rrr tlttl chiLrl cerebrul. Prezenla rutlexului corrrcu-pteligoir_liu,n (ur, ,si :r rr,llor, r',.llcxearhaice) lre poato intliel o suferinl,i f trun]chiului ircrtir,rrt, ,lrr,r. lr'rflLilte oli nu are valoa,re ]ocalizatorie (reflexo clc clibor.lr.c). 1i. Abolirea reJlerelorJaringi,an ,si 1)elo-p&latin, rr:prczilti'i, irrrIir:rr,Ior,i 1,. l)rol[nziur(' i.i,comei, dlr uncori qi semnc cle srLfclilfii brrll)lr,r'iI rr:r|| i,rtcuilobulbin'ir,. 12.1.2,2. Clinica sintl,ro mu,lui comatos Olinic, siridromul comatos,ue uriniitoarele co[1pouc]11,o : 1. Abolirea, total[, a stS,riidu cuno;tinld (cou;iienfn;. fir corrrii,rrrr rrrr ' otte vorbi de eristen_ta altor tipuri do porturbiiri ale $1rii,rii d.ocrrrrollnrlrr,. alr)ua $9 poa,te agrava, ducind. la exitus, san so poate a,tnclioll, Irr, I rrirrrrI rrI rrr'ozertinalin a,ccst caz simptome de trezire. !. Tulbur:lri vujjetativc.
.J. -LtL.DUraIl OCUm,IC.

4. Tulbur5ri neurologice, 12,L2.;i, Gradarea Si clasiJicurea comeilor

llator-itir,clracterului evolutiy al leziunilor, c:r, fi Ltltilil,ii,(ii lx\fi,ll i)r'lrilory&sornotorii existi o variabilitate a aspeoteloi r,linioo rii rlc i1t",,,,r, ,, sl,riutl cl$siiici]rcrru cste posibili practic. nst:e ins[ }osil)ilL (; grrrlrrrrrl i I,ri, t'.r'',turzimiicomci $i aceastaesteindispensabilsi fie reaLizl,tir, d irr rlooo* Ii clinice qi practice, adicfl ds rS,spuns (lc apr'c(Jiol,o la tratamcnt pr.r,;jr'r,t I rc,l,. 'i profunzime rls poate a comei nu fi i1, cert stabilil, rlrrril, 1;11f ,G,raclul rrivelnl gi intindsrea leziunii majore din trunchiul oerobrtl, (lol,orrtitxrt rlrrpri criterii clinice Si paraclinico. Dup5, acest criteriu al lcziunii clominante, noi am propu$ siiitorlrl i zrr,r'ea in 5 grado de comi,, cu urm5,tora,le caractorc (tabcltrl V) : Grailul I. Bolnavul este inconltient, functiiis vogota,tivosinl; ln linritrr rrorinalc sau_,uqor modifricatc, toli timpii ds aleglutitio slnl; plczorrli, rlo rri{rrrruc&Iel'lexolc rlo apirr,r.o $i autom&to plozonto. _tictloxrrlrkr rr,[11,r'rr,r,' lrlo prozcnt, boln*yul so apillri la, cxcitaliilo oxtorocoplivo (srr:r,l)iI,r"d, rlrr o rrLrLsoii,). .Il,oflorclo rr,ul,urnlll;o sirrl;plrrzonto, bolrllvul so apilrii,h oxoil,rr,l,irll (Li.!rjiir rnirll lll,oit.U il rlollro,so:lcopor,i'l 1rt'opriorotxrlrt,ivr,(rlrrcrr crr o lriil,rrlrr, rlrr,oii ii oirl,ollig). l,rt;rilolohilti norrnlln $ll rtfr)t.ruirli.ilttirui, r,rr lrrllux Irlllltr(rl,i)r rlitrtitrttrr,l s:t,u nlrulil,.Irrr, so rrotr.tlillii, lrtolr.lrlIrr.icli, voil,ilrttllr.ji,
:()tl

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I rl r r l rrr ' , , r' r rl t r I i i i ItL , l ) l L r l ( l l l , i l 'i q l l l i i " l ,l r zi ttttttl t' r , ( 1 1 'v i r , t r ll r r t r ir ,r i |o tr ,j r r IIIII;r tr ;,. ( i cl o b r i l l ' l Il l ,r l l tl l l l l l l l l l i Ii r tl l l r l , t . i r r s c u t t r rr r tl tr l fttu o ]'i i l t: vo g ( !l l t't'i vo l l l r xl ( 1 l IIl ' ( l r l , r l t t l L l ,l i tr l ti i l vttl i tttr o tti l fi ctr t, oilrr

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rlttrttrltttttir' r-:stc abulit, iii'y,t'i i it.tri,,tll,l rltrglrrfilici ,', ,,"'':rl,'i,i,, '1'fJ:'),1'1" vt:slilittlit'til' t'rtIrti.lt'
I.rir'Ilobii r,olti tlo ,r,irir,r;,r,itiT i, ,,, ,",iLst','r'vrrti., 'boiitt'' llr gr r r ir ' ,. ,l i i o dovi|lc ler it cor l. iugr ll, ira , globilor ocula'r 'i spr '( j ] ) r r lliil 1,,,.,l| lci} este lnedin-pontini. l)il'l'i .i!l(! rttqd,ul LII. Bolnalul este inconqtient, exist':i- gravo lnn'trll ' I l it r lit zir r 'l , ,l f,o u" u"iur j'e, i ilr t ul f nf J"gr r iit i, . i, lor cabolil. t ir r r lr r t l

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git'1 a glrbilor oculari, frecvent .discorrjtt r, r'rr,iri'i, u (Ii'l1'role ' oscilarLl'i',ou 1(\lr(lilrlri' ,l, r illii ocliilor'. Hipertcrmle qi i"tt"iooo "t"riali' c p nlll' lr .r,ltut'r'. Lezitrncl cbl,c in parlca' in[r'tioati ii.ltt t tt4tt" {i rud,u.I I{. Bolnar-ui este inconqticnt, 1'otll areactit', liuno! stll)Ill'vr{rlllrrtrir" cu curnl"atil''ilitrr'.tii limiirr, ,rlr,, iiiiii"te gr:aypertltrbate' kr, 's.au abolil;' Nli'ltirr'zo ',r, .r,,tlr.'ia-aliiiii,, 'reilexul ae iuse p"c,ent,*intirziat i,bolit"' rit'tl"t"ltr ttottlotrtrrrt'lt i .'',';,,il"il;;,l"'r;i;;;;;t-$i;iii-o;pi"r'l .r t'trttrirr , r,.. r)r{llo-l.tr,iibulare sint *froiii".'ff*t"iAita,te muscula'ii, quperioar[ bulbultri' a' pattea io 'i ;s!" i, i,"''ii,',l" l.i;;;.-i";il;

i':r tt" i* pr'ba rt' jurrlrr'ri ''rtl'tt lt'ttstttrl'u i srt'tt

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crr circullr'{'irr' t1i t irrttlLrl | (eoma tlepir,qitd,) ' Bcrlnav total inconglicnt, zit t t r f r r '. r "'lt t r, r,,r' :LI ;rr rl l ilic; al sust r nule- 'piin m et or lc de r csus, cit ut '" l" \ l) llllt lr \ ( 'r 'r r r rr r r ct ] l{ rr,r.rt.r trr sc! r nenl0le bulbar c inier ioar e. Sindr ot nt r l l l c i i cr eielului". .r,rr,:r (lo$otr$ trr' lllr,;iic. tailloul tle comd' depnqiti' - a,,& cuin t' li)sl ( l( r sit r r l'lt ) r r r r r : r' . ti r,,i l u,tl ei li it . G odon, in 1959- - bupr inct e t r ci oit 'logor ii

,r) ,\br:lirca totalii a tuncl,iilor vielii do relal'ic' l,) ,\bo1irea, marilor f unc!,ii vegcttltive ' (,) llEG cu traseu izoelectric persistent' t'rt'tt' ttton'r1'ttu' lliD(rl,oniacor]leeicu lipsa cletransparenld'a ei tlonot?1' l'rrrilrrtirtl , cttlt'itts Ieziunet cd, denoti, i."i*'."t""e t, ,';:il;"".i.i;iii. t r t,l,rrit,nuhti tli:f zona bulbo-medularS'' I :l . I .2.4. Probtame d'e d'id,gn\stic etiololia N . Oont epibpticd. Ctiz:r,cpilepticri,grant-lmal $'r ill\olr1iln)l:i:l,],1:,,1:l itnrrrrt,i' ,t, t,.r,,.t{, .r prolunhi, tulburar,. a, ('on$titulci, cftr"o tn rnoclbrusc, sau r lu 1ti'r'i' rir,sll,I);l(ll,',,;;,ll;i:i: , rr l" o t iro idtt'a- si poetaccosuate.

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,L L nr r o o sorioasa tlt .l)ltt .si o catarmxlzi', caro rto lii'ttrut'ttq[tr'

,lill;lll: .,;lll,'il;li**lr;h";:;*;,tl*t';*'*rr*qLll;t'" 'lili;i.i"p#ffi;;il. rrrrrrlir" rfi't't'. ari asistrtir lost b;A;"r,-'" , :l il

aroactiv la- sfirnnlt'i'rila ;,,,;'';'i,,,ri;; i;;lu"uuf iiii"itt,t incirnrytiont, in cLrlllul poi rtrtnnrca' S,t sbcrtorolsir,, ,rrrr',,, r'rtttrsltit'rt,llia, it'll:i l::::ilit'11:l] l r 'l i 'l '
n l ) l l l t) r r l l si t, l l tl r r sr ':t l sl l t,tl {l l l l l ( r l ( !l l l i r t , , , ', . , . r r ', . 1 r l i r r r l r i i , r ( 'r 'r r '{i :r J l i Il i \ 'I'r i "t , , , , r ', 1 l . i r , tr ,r l tr ,l i i o tl ,r r i tt',r ,r r * 1 ,i r "r ['i 'ip 'o l r r z:'t',.r 'v'ttr l 'ttr u l tr l tt l ( r zi l l l r i .l l l l r l l l l l l l ' t'i '1 "'ttti i tt:u l i ,r i tl l t'xt'l t'r 'tl l l ttt:Il r tIIIIr Ir ttr r i ttttIt' r r r l r r r r r r t r l , 'ti 'zci .t,'l r ttt,,l ,',t,','i 'l'l,i,ii;t':

lr Hlirfil'rrl intru(iii) "o^tnr.ro'r,i ."u,ltntor' , ,,l,,ii','i''it,ir^i^;,ffi;;;;";;i;t-l",uiu-'ii .rl'itt't

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p'iir investigatii riri?i

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2. Oonxele d,in accid,entela aasaalnre cerebra\e

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r,:liliiuis:t r"w,,n*i,li, ?*:d:;*Htix,"ti;i : :iiiiiil', :{rl,"i iu ":3f li,riiiil:ii, iii"".lil; iT'lili;i,T.i,J,'i1f,.',",r1',Hi"d" ifT,.fj,li1.:"iTi,T'1,#
lilcrrlrlltllii cotoJ.rralo lrin me

1i.:.,1'#1"i3;i,*",""'sf,f ji tl ffi1""i"f;Tli l fifi i ,,i !] lir:.,i:lt{*jijrlJ i irr v..rl.r.. cii,,,pari1,iD unei corneh un.tind,r po^t" porinifit"ioii "" "".1"0" iti ;;il,iitiitfil*Ji"v,lliih*11,1?"ilfiliiti*t"Ji i""i:tt*il.i*,*"i#il

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. rrI itrI.r't r,r.r'r't,lrtirl rrir l,o lrtitttii,it'tttrI'IIt,ttttritLit', r,Lr I rr ,rI rI rrrrtIt, 0x ilkltr (tri ltrrr lrr,r (xrllll)., lll? l) $tlll ll' I ,\r'ltlrtti tii ittt'ttltrrl' tr, tt r,' ., ,,.it ..Ltr,,tti,It,tr''Llt ijiI tlrr trt,t.t ttttt (trrrrrI t i rtt ' It, r,',zrr.i r.ii, llr rrrrrrlr Hrrrll.irr ,,,,,; ,,,',ii,,iirrrrrrlrr':Ltrr. ttrrttttrlrr tlrr[itriltr tlivt'ts| (itrsttttLitr'l i( ltii,tirr:i, rL:r r rrztli,) sitnll{,0tltlti,olrtgilt, (! (1tt'itt lttrttt'rrt';1it (, (1.(, .5r'lllt' .trt t,Ltru(,i!l liz.lr,l,i' rti:i r.i coirrir,) r1',',, lioato fi '"'t"'irrrnoralir'!i l.tlrrttlii' ctloln,prirLl'rrgl j i'ri lle unor tutnori ltt .r'ttltl{'irr IlrPitli'r' r-rvolLtfio cu 1i rrtt ,,rr,r li'!rlr r oirient tlai;, prin mlt, staze cereLrrnlo . ttmr intt lt bcmolagic i,',' l,o1ont itl edemaio=s ;i 'r'll;' orl r'\t'lrrtir' r"ijdentintna unei hemiplegii la un boln:rv colnftloJ (srr'll itr frrt,,:ttr';r' atgutttr.ttl. bot;,rilor un r.rr,.,i ;nro tom5) reprezinti-in-general l(rr':r'trll irr ('rl'r'(r ,, ] ,.,,'iident o aicuia" cercbrali TotuSi, in unelc sixufl'tii' fa!5, de cd'jlonrultlii l)inrltI i(lrr|1' I r i,rrr,r,l vascular s-a constituit la ttistan!5, poato lipsi, dar putem constaiaalliesemneneurologi.. l't(\21\lr(r! r,,."'ifttcgia jttsl'rrlitirr l,rl,rit,tr,l-La unor- semno neurologice (indeosebi pirlq'1i{alg)' I t mai multe posibiliti (i : ' ' tt trrt :t ;ii rr .,' .,, :iLitent sau in tloi t,impi, suger-eazd, procis ocluziv bazilar, hcmatolrr (lr' 1r'tllrr'lrl , u ri tt(latie vcutriculard',tl() (ctt marc cdcm lii sau irl)grr"iitIt\ :,r.Ll. cercbral ,, r, h'".atom emisJeiic tr{rr' l',1,,, ,,r|oral, cu c,rlrenareain suferinl1 ;i a enristmului optts)' l'r'r'z' l l{lrt:r splo ('{rlrrii la un paciont cate cvolu-cnzd. ,rr',r lr,,mipl"giiinr"omplote ittlt't' htrlttrt'lotrt subdural, : hcmatom expansiv , ,, Licirineaunui Drbces ,,' tumoale cirebraiS.(Lrseni qi colab., 1974 ; Yoicultstltt ryiNloit'rt'' ',r,,),,1. ||r(;; ). ne mai invali' ci, tol'deauna, i'aitrtt: tlrr rt'rt'littttrt' i'r':lcticaneurologicS, isrrlttrttrir'), Fr,ltill,rt,t: vascul:lr cerebral (hemor:agit, rlr,r.l|,rsticljll de accid"ent i'lirri(''r ;i ||itlrr''lirri"': . r, ',l,lit:l1o|irlrd,climini,m, prin cxatniniti tlr'nlo l lrlrrrrlrr(' iti slll)ll'('lll)' l raumaticecxlraduml $i subdulat (iL('uL 1,,,' trrrr, ilcle tttr'ltr{t" rrr;lirli rl1u ilrslitlitlc r'l{ illgoce{aUl li mcn ,, ", t ,.,lo, r'rcningitcle fi ( r|ir' si crrllLru hipertcnsivi l)]l{'l'l l Irr ,,'rnil, encr'[alopalir, tlrr ir|,lllliIt|, tttltlt. osi,e]'ol:L1,iV hi.pcftensinii lti|r,grrt,s|icul de mcefaloptt,tie rrtt I t' tt1 crt'z' in falil urui afl6,r ; a) n6 'tttItrt II ' tt|'rr r, , ,r i. nl toarelor eleircnie lirr tir" tttt cstrnl'irrlii', i,,,,,,1,,r,si..e {fie cu hipertensiune a'terialii, a.sa-zisir' r,rrl lrrlr'l ,t,ir.r:lrcfr.Se;Amaial6s,irrcadr"ulunuifeocromocitotrsil,llrr,rrlrlli i tttt'trttr, rrl ttlr' i-1 lrLltorli(, rll ,,,unla-rnoal, unei coarctalii in cadrul ,,,',' trlllir;i trtt ittt'rrl' t r]1't! lr.ttsi. , ,.lrrri,tsii'sau al unui Satu'risrn),cu masir-r' 'lirodific[ri ale Il.O. (pini la maro edcrnprr,liLtt ) 1. b) Ootttittttt t'rtl" tr rli tltr tttttllrr rtl'i ;rlttttt trs1,t: c) O'trta, tranzitorio cste de obiceli lrr.ofunr15,, I 'r,,rr iiui asotriit' 1i :rll'tt rtrtttttrr lr,,r,l I il) Cefaleeaesteintensii; e) Se 1lr-tt' .bicci I rtttItrl rt,IrIIrIt I tIt' f) J)c "oo""i*ii (uriu importantul etlem cerobra,l) ,i,i r,,,,,.," ; 'lrccetlatS, ittlrrttttil, ltt (trtrlrlltrtr protlrottti.t fenor*ene rle t, ,,,,l,,,ir"iaid, este rrr'r,'r rrnii, episoacle-deconfuzic qi obnubilare)' de obic.i nu crccuzi, rI i I i r,rr| |,ii, t i rlirr,ifrr, ilamoriaia subayahnoid,iand, 'r : s.rttttrrttt.ttitt*rrtrlrr , i, ,,. ,,, inilr"iiot *amiologicliind cel mai adcseare't'lil1,ot' tu vii,rsl,t'ltri,rrrotliticili :r'Lr'lr''O (itrrlxrrlirttl' cefalee inf,erLsit, 'rrrrr,tiri,ntc" 1 rnici tulbrrrlri d{! oonltiinli, (t || I II I| / |' ,,, I irri, n,'), ret ,,1, i f ,d^o.*gii ( '( '1, , lt r ir r lr r r lllr '
t lo Sd||lr r ulr 'l) ( : i,t : lr , . or i cr t t ni) , r 'lut r r .r.,rt,,t;;. l )^. ih, r nr O 1O Tic, 'lcziuuilor r t lli't t t 't r t 'r r t t i t t r t lr r de nor vi cr ani{t ni ,,i :i .t,i u,rj t ipS"*". plgzon! ; , n ''i trrltlli)lrtrrrl'i.i \rr'r{ qi latttrt topogtalilt, p.1; srrn.r.i:r, r*,i,,,,,, 6.o lioalizaro ilt r I lt t t tt ot 'll, git r 'pI 'ilt I 'll1lt ulii'' ,' rrl rrt,,ti ,slt t t t Lzi, t t t it'o t 't t ir Pl't 'i( ili t t t r r 't r i t tIl, it t l ri ti rrrr t lit i t li: t gt t r r ; ,ilr 1 : pt r llt r l t t I I i t t I 1 'iiir t : r '{ir r ' ( | r| | rr{ | | | It)ii l, i[ , : r ll t r l't 'llt t t zilr r t lt l: r 'r I r' I rt t I t t | :r t' (' i | I I I I llllll l ll : lr 't : lr r Hlllllllll rlt t i lt l o t 't r t 'it li't t , r 'r r ,'i lt r t t t t ll, r t t t tr r r t t 'olt r ir ," ,,u,f,,i i , ui'if i f ir r lil r ur r r *I iLr r ir . or ttttttl it t nl'lt llt 't t r lt {it l lr l r . r , , r t r lr t 0. t t t t , , t t it t gr r t ', lir , o lr lt lr . , |il$io lir r ," Ll ,,,,,r,r , t i, , i,

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i rrl ra l u n L U l a l i ) , r.r(j It, l l I ttr,ui bemutum. Q ) I ' t t , t , t t s t t t , ! a I o r i .l u < u r' o n l p ti o a f, , 1 rn l uui l u i l l ,u:rtri i prf,cpdeJrti ). j' r , l) r' 1 tr.a l l .tro r rl a r,l rri r i n l oros:trcl l ac,,hri r.sj fe| i rOri i i l\' rsr'rri' 1 .,..i ' , " . 1 . : ) l' lrrr ringrLf:trzi-L trrr i.laLct cerebral. Atacuriie iSchemico-tranzitorii ( \ | | ) nr.:r,11/ r.r'rtpnie pledcazii t()t pentru un atac ischenucr, t\) | it r.t.ttt to lturLrni(d srur.eniti concomitent cu instalalcr ictusurilor, iir'r |)11 {Irr(IiII(I<,u citeva }nomente o'apoplexic lr,r pute* constilui un argl J ,tt Jr,'rrrrrr t) .0{a1e cai-e procerli, ci rnnlt t:imp un actittenl; a gJir'']:.:]], ll,;i :rl!'lL'r'r l(. l,(,ltte I i f|\ clat, rilt,e l)ettrn un artevrjsm care s_:l riupt, pentl,u L lrrlrlrrlol.tr,tic liportcnsii,'d, s2!Lrpenltn un plocos ocluzlr, vasculai,. l) | | r!1norir$ii.r, sc insl,a,Icazii -rr.ai frecveit Ari ci:rii-rlle;, in vrr.rnc err , :tl :,, rrl i , lr , , r I i, , ic n ru rl u r" c m:l i l rl r.S,.i t i tt ti n p tl trot,,l i i . r r i' ) r ' i : r r r r r i r::, rrn c ' h ru d i c o ttri i rr d c L rurur ui ri i rccr,rr.nr, \i .r.rrri r. ,f i ' r' ,"' r'r' : r r l, , , it t r . lt r p \.u l i tto i n l ) p e U tIU h e m o ra g i e (dN ,r nuD ai Jrl tk:bri t !). .iTtsilaterald116.:.rului It) llirlr"itr'..:rr, cstt ri,veiit.ar. l'clecsebi lltrir.ir ,
lrt ltt''I ilI l( -

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i lt t ir r r ilir . r r r r r t nc ( t 't lt t t ot eaponsir e ir r t r r t cnt 'nie 1. 0ontt:le Dt it t 'pr r . r cele r lont pr . gt , 'si\ '' r ': r r r '( rL inst aleazit . t c. ) se , ,, l ,rrl rrl i ct, a[ ccSc' ccr ebr ald ' in (,lllii' l)ttirllr ( \ I , , lrrl,,t 1.en,,iune - intlacli.r,rrianil. Dxarnelul nolrlologio atlesoa bila't'crale (pt'in torsiurLrrli L!'IIIII'IIiIII||| ,i ,,], 'iar,r"" pir r,tr.tit.t:r,to ,, r,'.,,t *i rr, iu'her'rri,r,anicdillelor rltlr.,belo:lsegi/ srru lr' tttitlttsttltti lrr;r" 'crir" ', ,1c lLi|o-ttolric, anizocolic ctr midriazi ) etlottL }ltltilrt't ' r, ,), t i. (lorne[e prin uJoqitllLi cerebr&le de origi'ne inJ ecJi.ou 'i I'tttttt rt'sttltr':t' ntor{'ill Ne a1'rnge ,i ) C,,rrn tfin troibillebitele cerebrale' r r llir r ir 'l: r ' f t ! 1n, bt u'lc {r 'r r r n'r r 'lii cu ic sir npt or r it t t,,,l l , l ri t.cl or r Ln cor t egiu rrrrl l{r l: r 'l' lr lc pild'r r 'f t : r lt r r r r lr lr ": ii ' ' ,," ,' ,,' ,,,,i ,. it " 'i ', i, n" do iuc, r 'iiznt 'o r , t 'ir . r r . r ir r r r . r r lr r r ir 'r r t . r r r si r r r \ I lv ,r' .,.,tl . l ;;i o i"r lr , , "" f , , . n. ct r ilor f l1, lr il: r ' t it r t t : : t t lr t t qt ingl dl: oupLJ' j rnr , r ir r al', 'zc it l I t ot r r lr oll' alt "r 't r ant c ' , , ,,,,,;; i''ir |: i) ' \ r 'r '- l "', t ' cot t t ulsit - c ir t - t lot r r bt 'f lcbit u' r ''r r 'I , , .,i .,ol ,i t if , "r ir . " l:rl'irrl" ' srr!rrr':lrti"'..irriirc{'ii O-tri"oirc ap:'L,retlupiL' "ti1(j , ,i ttl lr:t"rtr itt tttit itrtc'r''rr{ii ",,',ii'"i"n:i" t.rpi! c\-eiturr'1 ,,', r,, t,iii trfi,ii go-arnigtlalie'n,' ' l r l otttl i . t rr(rt rrr rri l l ' ' ltl (lotntt mettittttiticii apllc itr motl progresiv in cursttl lll)iri t r . t . t t ir t 'il: r lt t l"t . t t duP: r sau st u r ublr ut n' ,i" , , f r i, i{r ulo ' ' ' ,;, ;,: "i, ' ,,,,,," " t" l " ti"t iei'ipt ihnini. : luluni'I ) iagnuslit : ult Lr r . ir r r lr lili'r I ilr lr r I I t :t rr{r ' I i l.i r':r t t rrr ,' rrrrl itr vcdeit prcre-n1a selllnelor rncningealo ltcrr-risi;trnltr,..lt , li' I I iI r . r r I iir 1i r ' t l' I r t lir r gct Lct r t 'io t ior . t : c ;i r,' ' i rj . .i . . set ir n, 'le, l'in[ ct I 'r , r r , ,r , ,.i i ,:. . 1, ut "r , , ir , r it , , pin: t lr r , r . upii qi. 1l lr a{r 'ir r i. .r r : ilr ir liil" sl ( r r ll\ 'lllill ( t l , rntti l rt sc ir ''t : i, lol, i l, l'u: c ''ollllr ' olr il r , at it a , t i et t ccJ't lr l' lr r r lr r li( 'ii' r lr r rn ele,ilit t nt eninloen, : I t: ) (.l r.t t t t t lt r r l' sit r r lt . r r t t t " ,r,r , i ,i r,ti i i rliaenosl, icc.- \ st - f el, cir r r elc sit r l' lr r er ''r lalr r r {'otr'l.lrri r';rIirrlrr currvulsii tlt' 1i ii,,,';i;iiJil;;'iiui.i.;lt,nt'ii,.iir"-r{itu .rl'.' t lr r iip it t ll; t t r t r lt f t 'lt r il, r 't l r nor lilil lilj t lc r t r gr t lt l' "t ,' ,' rl,l ,rgi ooir t i, r - un. ct t r t 1't lxt rrr LI l l l .
n d ubo[ice li. ( lo rtr:ltt rli.s j ttsi i l l tr l l zi r l r r r tl ti t'ci tl ttl ti ' tr r t l l ) l r o r l l r r r l , t . ) ( 1 , tttt,t,l t'L tr tr l l i r ttn t,i tti str t' l t r tsp i t:r l tt I't"l tt ' r l r ' I|:r tr r r '. "l l r l "' 'l r , , r 'l r l r s , l|'r "t i , i i i r t,, r 'i ,,r r 'r '' r tr tt ,r 'i r t r r r r r r l r ,l :r . ..'r tr tttl l , r i l r ,, l !1 'r tl r t' , , , , , . . , 1 , , f . . i,'.i ,u ..,,',fi ,.', i ,'r tu /i , ( l l l l ) i r r ''l l ' r r l . r r r i r l 'i i r zr i r r r i .zr r , .t'.tr l ttr t,l l l tl tti tttr ' .l r .l l D i ( 'l .l l i l l r ') , , I I , . r' rrrr rr I , | " r l r o l r l c ti |||I!||I( |i r ' o .r 'r r tr r r i r Ir i i ttIt tr IIi I:tI'r ' 1 ;1 1 i 1 1 'fr i l l iSr .,1,,,r " t i r i t l o t ttl l l si r ,'r ,i I;r i Ir '1 ,Ir l Ir ' cr r r r r r t , i r , 1 r i I , , 1 r ; r i r r1 ,i 1 r o r l cl i l i ti r ' '1 , r r l l l r . r '1 11 r r l '/i l I I rI rrI rt I | : r ( r' :r 'ir tr r r t I r tr r l ) t ', , t tr ,r i tl i ttl tr l i ,"i r l r r r r l r l cl r r 'rr { r ' t r' t l l l r l r' : r t " i ( . l l r l l I l l : L . , 1, ,, , , , i ,, , , , , r l i :r l r l i i l r r ', l r t, r 'tttl r l i 'l l l ' r l l r 'l r '' l l l r r l r ' '.tI I

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$ernnc de rigidititit rlI ( r('l,trrrr'o, rl,r', ;i ,:lirrt,trr.rrc r,cgcLatir.,e it,prlrtiirtit. EIcc:tu:r,i*i g:i,.r.ii rl. Ir, l )i r r ' \ lr t r ) l. ill0r ' ii c s 1 ,00 b l i g a to ri c . tl IL rtttrIrttrttrI ittlrqtorr:Ln i,l dcitt er-olucitzii lil fcl in 1,rei statlii, rrrt rrrr rrrl , r\rI lilr lr , lir , lr ' irri l n l l trrl l i ri r1 c t:u n ;ti c n 1 i . t;e f,rtul i , Ll c obi r.ri ,i .,,rr ,,

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li, t,,,tjttlt n t\l,tl, t t t t ll|t i. ut L inlr l t ) a. |. I . ibt r n t i j t o c i r L ( " 1 I . t " . i i . , ) : t ttt ttt'tltttt ul :r t t lt t lt t r t t l r ul\ . r l t . \ , , lr t r . lr . z ; r rI rlr.r rirr,j,i, .,,rrttr, , ri.U ' ' ..:ll l"r':rl'zrrt'r { t r ' ir lt i: uz : r ii lr , r r it , ; , r ' r , r ' I i r l , 'r 'u r , , r r " , , 1 r r r 'i l , . r l r 1 , ]..] . l\ lrl, l i (.r'l | \ itlr):.t1 . : L I r ,, ,; r,I i , . , 1, , , .; , . . lt) llt u tttlt)nn tl it t lt r r t ot t lt t t t l s r r f r r lll r r r lr r r i l i , i r i t i , r l r r r r , : 1 r r l r i , , . . , i r i r r r _ r lrrir. rr. r rr llr.i lirrrlri, r , r r ir r I llr r r I I r I r r,r,rIr, r : l , i, i , j , , , , i i " i , , 1 , , j , , r ,.,,r.,,,,,,t, l lllrr' :r |r| | | |rr I r )| l I I r I rI r i, r ' r r r r r t r il, l: t j, l. i|| : r lr ; ll. ; ii] L , t i r rr 1ri r , r rrr, I , , : rl r, I r r r . I . L , . iit{ i

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lirr rrIrt,i,oIr,r'rI sirrl,tlili;clo r.r-lbrtrrlrlluigonctrll, p(. irrpli,t.l.Itc, ]lcurol(\lil ;,i rl. IrIIr'r,ii,lo} r ' llsltcct tltshi,l|ltlut it t,t,tnrri-tLtui, cu tegurn(x]i.lr\ .ii*r I.. I'(l(li - gl.bii ocul.L,ri h.iytrtori la p:ll1:lrc - itratiilrrrr,, Ii ciurLotict:.1 (llJ Irl,irrriri),crr iuspiralie pr.'ihngiti, apoi pauz{ tt-upi,I bare cxpii;l(,itr, {,ilr) irrlurli) rilrrtlr,ii,rlr.o:r,ltir p:r,trzr'r rn:],ilunE:t,(r,espirllic ascnri,niit, o i l, r'rr (r.rrr {l{r i,ip li.iissnnrrl); ,-- in haloni, se pcrCepclniroslrl de acetoni,; lrilrolr'lrsiurur l,t{ct il,lij,, l)uls slab si r.rWidl - hipotrrrnic,i _ nalcati; lri 'ostco-ien(Linoas[, hipo- sau arefletiu lrrrl.rri* rrL'srrrrlrr,r,i,; I * nidriazii : , inu|rtir. d jrl'otir.irnu n)ici hemortqii h l'.O.; _ pt.nz,.lrl:i 'r.rr,'rlr:r',,1 , ,,lLrrrrzr.i si rr,r.oll)il{rr(etnnici in urin5,1 - gliccrnia rnult cresenti,irezcr.r;rr, rrr,lirrii :r,lr sciizutli. t ) Ct)ntq tlre ricd Nste relativ usor de rccunoscut : _ antececlcnl,rr rr|lloprrlicel - arproalc totd{ aun:t r.str. Irr.:cet1rr,1,ii tlc Drotltoarne ca,r0 rrrrrlurrrrrrlrcezii : oboseal5,cefalee, anorciie, glealri, v:.irs[turi, diarr:o, (liril)rcr',n).iodozopsii (,,,rnuqte z}uritoara,,), eclipsevi2uate (pini, la amlrr r',,r...1,r'rrrrz,ltririi), rnioclonii,,sitresiriri fnscicll:lre mlscuhre, ufteorl ortl i rrlsiiI - l'rillonii, lu.c rriros a.mouitcll; respirrr,{i:r, r:s1,e de in[lte ori rlr, lrlr (rirr1'11s Stokes; - bolnar-ul Ostc palirl, hilotelmic, cu pleoapol(l r,rlrrrrr,l iir,lc fi lrozinlii, sughit; - pulsul este f,,irtc binc bi,ttti Ourl l.rr.irrrrrrr, rr,r,tclia,lil este cr.cscut5, - cordul estc rnirii,, cu zgomote dlllr .i lr lrlrriii.uli pcuicardiacc semlr{, i * la examenul nelrologic'sc cons1,atrX, rrr.rrrrgitrlri,rniozir,. hiperr.eflexicosteo-ten(1inoasii,, ilneori seinne pitatrri ,lrL, ii c x I rrlpi r:lrnidillc (inclusiv flapping tremorj ; - la exaucail F.(). ,r, r.irirslrrl;iL: ncur.orci,irritil albnminurici, cu nLorlificiri evidente vas(ilr i;rr',',r.rrirr.srrrllll,rr cu cdern sau s,lazX papilar[ cl hemoragii I ,,il stca,,',. ,. r,orrrirlii oliguri(i, :r,lbruninurio, azotemie ma,siv6,acicLozJ, tl ) ('ort.tt,.ttotrnir:ti sc irst&lcazit trpta,ij I,r,un bolnav carc a prezentu,t, , rr;r:rlrrii*rlrirl,ltc (pri1ra{ociiuni gas.iiro-intcsitinale salr vi.r,situricentra,l.) r,i , :i,r',, rnr t)it,r:i[1,11 rles]ridratat. Se,rllne1e proclrornrlloSint asemxni,toitr\\ .rr r.r'1.riirr (,o riL ltr01)t.icil, ca fi,tar.e diaglosticul difcrenlial va Ltrre scanlr, lr, ( rl,:\ir r,lcirrcnl.c t.cr.olatoare:, bolnav tleshidratat; * TA scizLrtrl; r,rrrlrirr,zii i :lzotemiei, a alcalozel qi a cloiopeniei. l)l.ozon1:n , ) il,ttttrr, tr:itr,ny|ioi este u,sol.de recunosou.t:- ilsoleqtc o toxicozi rlirr:r,rlorutimniil_rte:i, 'r'rrrrlrr':i sa,rcinii san in crrsul nastariii _ prczirll,i, | | r, ;rlii Ii 1r|,lli orlr!,lc I ovelatoare (r:elaiee, v5rsi,tori, cdlme , ilbuilimrr ir,, 'r:r lrlrr.ri,.rr.irrrrr', oligillitr pin:"lla arulie) I -- coma debtteazf,'cu mioclonii, lrrrr rr i rrIri rrI r.rriIII .,ir.,,.lsii l,onico,clonice(:rdescasubiriIante) qi chirrr; r,r lo crrlclrrir,lo (parcze,mftniiestiiri alazice etc.)" l rl.r rrr, Ior.:r ( itttrttt. lu ut ridicir |) , ltrrLirii lroblemc cliagnosticedir,ci,_tiflomSca,rI| rl. rr.rrrrri.rrr.Irr .l.rrrcrri(::-- antooetlctrte ]ropatil-ro gr:il\'e1i{)xio{r thcp:i,tite rrl rrr|r'r'irorlrc, r irtzc, nctiltlitsrrL liep:tlic), eltrnluil etilism cloniol rrrrrilr.sliililrr,r rrltuttlt,ltrorta,r,r.r.rrlnlrcltinslcsjrll;r,tllrlrr,,N,l)atiorx,Ni(\ni(r rrr:r.rrrlrt,suiilri(,yirsil,lri,nl{'i,'i,r,is r.,,iirr;1i1,rr{i,.,s.rrrrr,,l,,rr(,r.i,progrosiViI,, r'lrirrr:r'1. r'orrlrrz'iorrirlo, sl,iili rlrr rrqir'rrriir. Illscicttlrrlii si sprr,srnc rrllrsrirrrtrlr, rrrr,,olr r',rrrvrlsiirl r lilr o;rilrr!lir,; ,\rpr.cl ,rrl I rrIIrrrrt,rrI rri r:liirrlrrlrr|rrl,ol,:
r1, I 1 rI I I r' ri i. or r . irrrt.,lr' |1 11 1 i \l 1 :t It l ,i .l ( t.t{ ,r,. r.rr Ir' | :rr, l rr rl ri 1,.,i ,fl i i ri rl o l rr,rrrol .l rgi i

tr r ' l ' tr l r ' l r tr r l t:' Ir ' r tl l r l ' tttl r l t' r lrr l r I l l r ,l l l l tt r tl 1 'r ' ' r r r l I r r r 'q r r : r 1 ,1 r 'r ) r 1 r l l :r l :l r r r l i 'r ' l r r 1 r r Io Ir tl I'IIItr '; , l , r t r ': r l : r , 1 ,* ,1 1 1 1 l r l r 1 r l tl l r ', r tl r "r l r r ' l r ' l r i l r r l Il l r l ' r 'tl l r l { r l r ' l "r r r L r r 'r l l tr tr r tr r r r l : r r r , l t o r t t t t r, t t t t I I t II i I t I , 1 ,,tIr r Ir ,,r I ' i r r tl ) ( r 7 .l l l o l l i r l ' lrrlrlr' lrrlllrrl , , , 'r r , , ' r l t l t l ,i i l t l r l i rl l 1 , t' i l l l l " .l ) r ) r l l l l l i l l i l l :\l ( ' r i l l i l r sl r i i r l ) '.r r \( l l l l l r r l r l r 'l ;r i r l tl o r ',',, r r l r 'l 'r r r ', i , r r l r i l i ( l {'l i p ci tr l i r l i r r l i i i Sl r tr 'l o r 'l ' r t r r i I r t ', , r r r l l l ri i p l tl i ,'i i r r c t t r I I : ' : ' 1 r t'r g r l r i t '.i tl r r r |r 'Ittr r l l l l i fi ) ' |'ti 1 ) r tvi t'i tt' Ii l r r l i r l r ' ( i I l o i l , , r , l !'( ;r i l i ( ,r 'l ( r r illii?; 'r , l ; t l l tti tL 'l l r i tr 'i Jl r l l r r r l l l ) tr ) l l l l .l l l l l Ir l , r r l r t l t 's c g r i tl l tl r i ,, l ti l tr :tso tr r r r t" i 'i n tl r 'l L r ''vti . i j l .r 'l r ''l i i tl n n l r r r u l ( r i ( r l r l ) r ttstti .i i t,r i i ', , , , , ''l i , i " i *i',, ,n l :i t) tr ';r ttzi ttl " l tr l t- t't.t' l xttu e i ce fu l .o p u ti ,t , , i b , i , , r i ,i i i 1 t':tl "'l ttttl u l t j r t r ttr r r r l o ttr ,,r r 'l ' , , , , ': i 'i , , i , r a i j ti ,,,tr .i ,u cl ti ,,to r r r i i l r tp r L 'i i '''r " 1 1 'r i r r l r cIu L r r 'l r r r r i

; i,; ,.,,i; ,iiltiilui,oili"i.r,19?d),c,ll,elnrnltrLur-,herzio_sirrrlrrorrrrlolrf'r, ltr'prtltr ' htpalic qi neuiopsihict'\pll s in cadllrl t(il)r(ri , ,''1,,ii, ,,i taLrioul t'\lr'l lr(rlrr('l tlll in sladiul precornntos;i subr'otnalos' | ,rro so aclarlgil'J elcnLuiib ,'ll.lllils ti'' root)) (Slr.r'l,r'l' ,;' ;,i;; ,apffii'at"pr., a rrriirrilor', i'.1;r: l!)?!i; iiir Iropxrr-ii'irt, : 19il{1 T'rrpuvjcirL, tle cii,it,1i ijilieJ, 19iiT iiii;ri.'i"EIII'diagriosticul"'':"r'rLileqtcliplinlrrulrtrlctIt'IItIt.tItIIIt ";. ' |,L ie). )r.r'rluronient I slli( trrlir :r Spa!,iulnu ne permitc decit clumtTlttrr'f lo,riee. 7. Ootnele jrrljltrilr": tlt:s mai to)'icc come citeva in ,,,,,r'rr,criterii tlc diagnoitic rr''trl oste precodat'; de citeYa serrne dc rtltrottlisttt ,r ) Cotn,r,alroolicci l s(' {-rr11' rlupJ \ilri'lllii' Irr'"tlrr{ ulr\i' rliznrilie, , r ,',i,i'r:,.L,1rtzic, ' t. ',f lr''Iit:r'{it laLicardi( 'l' ilolot' tnidrirzS. 5i , ,'i.', iii, t.1ni ,.i i ' on.itrrrcr ,,',,,,;il.Apoi aoar lenomenede colups:palut'rertransltjrltiiit ;ttll:rt:r;rrrl ilor ''$io ( {'rrr'r ,i,,t, tr:iiiri, iipotensiune, cianozir, r'lcirea cxtr emitr'il , Ll filr)li('r(, CI(r).r(i tlltutil rellcxelol, cLl respira.lie ,,,,,i,,,*fii-"ii-Oiula'ri1ia (rrcDr tlt(crthlrrrr' de rigitlitalc de ,,,,,r rrlsii f,.rr"o"i) si'clria" cu tenourene ,t, l,roundstic gtli- ). Coma dureazi pini' la 20 de orc' tltirrrrl'. rlrrlril se instaleazi| brusc (chiar 1& ('ii;tlYr'r' It ) Ooma mc'titicd, : Irtri. r I rrl silllptt)rnc ulmXtoalc'le realizfutl metilio)' ,,,, ,.,,ri,r, ,i,,uufiiliti ,r..!Ilb r,.lrr' , rrrrrIi t.rr|i pulilt , , |',,,r""r* ccf"i, ,.onIul.ii. areUcrie tltt lrlr"" lrt' ie) txitrrs respfuatol Jttrslt aloi paralizie ;i 1,,rri f1r1ripnec,
, ,r ' 7l ' l t' i l t. i

r loll' r r t r r iir r ilr r r r r l C ,r, no bar bilur icd, . in c: r 'zu'i r D'lllc sr ' I caliz. ir l; r cr r l"t i' lninlt r 'li' ) ' 'lf r t tt t r r 'lr ' gt : t r ' conlvie , ,' ,,' ,r' t,' u d izalt l'je, at axie, 5j lr , ,,sl ri tal l zi,r,alid, c. , Som n lr ogr esit - J p, of und, t , r r pulc'r r lr ',r r r iozii, r lit t r r '' I I t I t r I iI r t r lt lt il"'l' hiliut el: ir r nc' .r, * 1,' i l ilot lt "ulail, blldi''lr ''lic' t l' t l. z' lt l: r | \ ilr '' iir t r "zr r t li: r 't r ii: r 'i ' L , Li ' ; tl i i, , 't r cnnin) . ar cll( - xi{'' ' r t{ t u_ r {0 er t ilr r lir ' I r I r iI r r r r r I rr I r r , ,l i c,rtnt at t lpinicil dcbuLor zil cll 0 st , li, r o ( ' 1I I | |I I\| | I t' | lll ,l i r' cr it om t xpr inlllt ' I t r m alcil; .1i halucin'r f ii. Se ,,r , , l( 11( 'r ' r lll r I r li'r '" I ri Lr(' or:.or ls{llr lc,t ulbur i, r j t io deglulilit r qi dt r lt l] lalir r , lt r l}r r r r iiI i ( l( r ( t I I |\ I I I I ( '||\ iI I 't t t r lt not ot li i , r nrl si yi t t r r it lr iizir ) , disl}lll'ilia 1'0f i( 'r t 'lor ( 'olI I cj' lr \ ( : r r "il r ) l'l( '( ijt f it r sl: r lilr ( '11' {) r ilr , ii I r r r, r' rri ti l l ttl i, r o|or r t it l't t t it r lit i r '( l( 'r t rI r llr r r r r f" , ,,fi ,' , pr , l, sf ilif , , lr t r , ll ipoi ct t silt r t t r ,lt llt r lr liir it t r sllit lt l'olii' r lr '( l llt I I I iit r t l i lt io; r 'i: t t r r it t ii ,,| | r,' l | 1 fi inollllr , ( r l, r zli lt 'ir r lii r lo: l{t r r lr it t r i t li'lr t t lt lt r r r t r t or 'lit r il) lr t r t t lt " r ) (| or t t r r lJt it t t t lt it t t Nt '( ir r r lllr sllr i r lt t |ii' ' ,1,, t lt i. zr t t t ir ii ll'r t I r l'' r ot it ii lt t it t t t r r r iit lr r r llt l ,,r' , l rt r r ii'llr ir ', I lr t 't t ll, , i ii t lt t t il' t t t ( t t t lr : lt t z'r t r r r r t r it lr lor ) r r I t r I i; r t r |r ' lr t lr t lil'; llt li. , ' 1' rrrrr' l i l i rt t t t t r ") , rrrr 'r r lr , ', t r 1ir ', , 'r r r r ir I r 'l r lr , , I I I |, i|||'I i( ' 1r t t ir r I I ir ': i'') 'l""t t ,,: rr,,rrl rrrrglilli r llr t lr r r lr r rr' l l { rl r' !j tr l t t t lt r 't l( f ,I 'I I |' |||: I it 'I t t I ' , i r : r llir ', ir lr r r i r lr 't ' t r it t r l t 'r 'i llr llilt 'r lllll I liI olr r r r r : r ' llr lit lr llil I l r r r l: r lllr ": r lt t r t r , 'lr , , . 11i t.,1,,, ri l ,,trll

tr, I I i I I I I | { | | rI i I lt :rlr ' lilr lt . llr f \ t . lt f lr f llr ollit ( , lr i l ; r r l o z t r r l t . {) , l 0 tl (lr(,t.of) , r ll. llJ ri' (nr()llrn ir ir r . ilt lt r , lr illr ) ir c I I rI )I Lr,i (.i r , . ll! liu( . ( f lt s ( , lul) iinli i r r l i r r i i r r l r , r . i ( . l l r o l r i r , .l ) tlt)tttt l)nt) t lt ut ulioll( 4i( ?' s c llin

r :r'rrl.li.. r^ilr.rrr,1r'i. si.rL rra,rrroirrarii. obicat,ili ir ,,.0irsi,ipar.r''ilrrrr, 'i rr .irrrrrlr lrr,( i. .rl...s.l*llopo1, Iir.vrllu|r:r'r.((l:l'liir.r,hi i,i,lrrl)., .ll)66): rrri'l_ lrr,lrrrir',...trrirl.irr,zii, i,*lr i.a,rrl i.,. (,r'iic'r .,1 fc!oi, h,anipirrr,!ii,h\re.icnsirr ir,, :rrl.r.r'irrIii, lriIrr.t.r.riri..I)oslul ila .r,pir1se insialclzi, cu'.a, aio0iatin.' : I,:r1,,.'r-,. I'rrli l,'|ll.. li]ilor' l. lpslrirllit.ncrcglrlul:i.tr.lt" spirurii r.eci,slrr,r.,.
| | r' I t:ll).r. 1,,'zjt t, t t il r t r . r , s r . 111g; r . . ln l_2 g I 'o r o t , , l *: u . 2 u u r j t {} A rrr rrrI r rr in islL lr,t,o l)i[r c n1, oi' a] i, . ). (,','t' tlit.itr , l". t . i, ' , t lia hidt a. : i. , lic g c lebu l c r z J r . u i a g i r l t i o p i i L o r r r , r " . r"ri , 1, . i. t)',r, t . t lll I t , r , n1 , , 1a' ' 1oni. o_r . l u n i n o , : r l c o s n j , , r . o n , u l " s i 'r , .'tL'lt .ij trn r . ir r inr . lnr > UbinL|ant . rll: l, | | r rrl tr O(ltt:-r CU anrOlJndtt.oa SlliIii

) (1rn tt uxrtitt , it , r i. . s l( ) llr ". r ) ( liLli, r l. ' s ir r r . i n 11

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(r, ir.xicllr,r(\

L 'I r I r i | | | l t r ) ? :i |:I r l l .l i l r .,j 1 , r 1 ,, l r tr i r i r I r, r ,r, I r , t rr; Li r r r tr l l r o r i 1 ,,.n l l u r,li |ori r l r i i , l cr I,r r r r ,:r . r { l , I l L l ,r r r .r r r r , Ir r r i o r 'r i r r r r l i , r .r l ,,l r Ir r r Itr r r r r r l l l L l r l l r t t i L 'i tl i '1 'l ( r i ,r r ' I'r ,',r ||r r ,L 'r , l l r ( i 'r ') r 'r r l . 1 r r l r r l . r l r ' fj ,l l .l .r r , ' t : r . l r , r 'i r r l i . r i :r r Ii i r r l r r r r r r l r r .,r . r l r , I r l ,.l r :r ,t 1 r r 'l l i i r r r l r r r r l :r ,r ,r r l .r .:r ,l r . r " r r '. r i L \ r i 'r r r I r 'r 'Ir i .i r i L r r :r r l . r r r ,', r l , l :r r r r i r r r l i l j r l si i ,r r i [r r r ]i i o ( r l ,:r r .r " [ ) ( l t t t r r , L l i tt i ttl o tt,i .tr r l i r t r tr ,ttr l ,r i ,.i r l cb i L l .o i r ,zi i 1 n ]t,( l {j l r u i t1 r l, ,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 ( co l i r i r r Ir r I.r r r i r r r Ir ', vi i .si 1 .r .i , t1 i l n ,a c, c) ti l l . i t,l .r .r ,r r l r i r l ;. \ 1 r r r 1 1 , 1 1 i 1 ,1 r :r ':'i t,cr r r cu i i l ,i tl . r ,i r l 'i r r zl i , i ,l l h i * L r i l i r :. si tt"o ( l r ) ._ r .i l r r ti i , r .i r ,1, lrr'. r.uur-rrl"riir sttre d0 r,oLll)s, (]orrir ail odcri.r pulmonar.,

l;j.l.ii. Problenre rie diagnostic i.,r tuanilestjirile silrcopalrrsi rrllc lrrllrririrri de constiuri.rtde scrlrli Jut,niir ll.l.:).1. DeJini.li.i,. P rtti::t\ri tle tet'yaeni iiirr"!i,i, io lr:',lrrLcJrriul,,r pier.derr: br rr;:r.i:-i dt, st.ulrri {lr,r.:rlit :r ' ','.rill.,.i. iu:otiti slu ul r:t tnrnilt,stiri tonru:ri1(,, lrrr.r.r.rl.rl.:i :lrrr rrl ilt' rlrilttolnLr preaccesuale, in determinisnll ci,reia intclyirru U tr,rror, ir. ,, r!'l)urJL gensralizati[, ?roil-.rsii,l:r lildrLl r.i tic o oplilc r:onrplr,{ii, rrru : ,r,rrpe cornplel,i, a ci}culatici sii'salL :r respir,afici (Oollurirr, |);1i;
.r,1rrr.l si \ i g r r u l o U \. l U ;1 . 1 \l :r .i i n v, Ig L i l ) .

( orrrloils{r. l,l, r.lozemai nra,ri dc.hidr:lzide, coma, sd instalcazd rapirt, rrrrrrl ilii rkr hipol,onsiule, tulburir.i respilatorii (cu impoltanl,i, bipdlsr, , r('tro J)rt)ltf ioii) f i de hipertcrmie. pupilele slni m:irlrjatice. t (t,.il,:: it, s,,t.iaitg!i,o,ta m:Ii rarj. putinJ ii ancirleulrli \r.u lrutirlll !:t r{ltnirisltit ' .. .rt':ua.rir ur'rnr i! tleaspirinj in dozernrr.ill ,.ul_,ii tlcshidrrr,rrr(l situ:t'ii,nlro permit.r^umuil|ot .tli,.ilctiluf. Jnrurina,i:r ,.1'.. .t ',li..rrtir.,. , r ii, li r rririj.Lllin (Vui,.ulcscu_ ql Stoica, 196? GaL tier $i colab.;196(;): I r,rrr)||r(,r|(, rlc e-rcitafie nellroasii, ct tremur[turi, i anxietate; agitali6 psjlrir rrr.lolirr, sliri l\alu cinator,delir-a,nte. qi (uneori) conrulsii. Apioape titrt,,rr -colici rrlt ,.,' irfx)(,iir,zai ;i t,ulburi,ri digcsti'e (grof,uri,r iir B:rturi, abdorrri r,:rl() r{i t|ir,rispirn{ii abunrlenic. sin1, ll,mlle qi irnbracii rrrr . ,ficspirttijlc :r rlrlli rlo lip l{iissnriurl. Faza rlc excrtilic lrccc it'torpoare si colrii, ,lr':rl,t., irri!iu,ir-r fiitrrl inloc*itl de acidozd,. l]e cele rnai'ilutte bri- ajr,,,: (n'tugipirre I'i||{||rri'r)() lr(x11 la nivelul tegumcntelor ;i ar rmrcoaselor(carilr, I r.r'rsl rr,rr tr1rs1li itLl;oricA!ii). i 1 .'r,,,' t:.t;.',,,'.:,:., aryonoJus:Io t;.i , d iizopr,,pilfluoroIost:) t _ l)1,1,; . .. !.,,'.).i. r, t r i ,, l r,t t l tt1)t, , - l i rl _ U"ef t'; ociumctilpjrl,' l'1.)l'l) h|ril.,.1 iltclra fosh ;. { ' . . .. l::,],,i ]l:1,.,()ut-.\;.t1ir.ti_rpararitrofcnilfos fat_paraoion;c1ietitlia,r,rr, ,rrr1'rr' rtr.rrtost,Jt I'lr1.rr,thion. EhatoxI metiltrimebilpropanituorofoslilr,l i ",r,rI r ; rlrrr.lrtruLrriri.eluxirianfosfe,t. _ Tabun). Ne pnat6 atrage aterr{,irr |, ,:r:r, 1r'r'r,rl l,[. l.)tolesir)na] (aparilia, la rnuncitori a.lricoli care milui0l| ii\r'rrr'rtr' lirfrr r.ctr rlramenl,de proteNtie),fie inciden{a lor accidrrrr . r:', t:r tl i i,it11. itll colrnunal lructe sau logun]e stlopito cu {tccsi,tt 't.t\;ii'l .rtL{}.u utilizai rlr l:rrl., ace$ti pi'odu$ipent'ru dcparazitarealoollirr 1r,l,r. ll,ii('. rr.rrl:tt..rc simplomal,ololia geneiat5 tlc iiaciivarea coli.os r,,:,/i | ,i (t,.r,i'lsc(rlwlt, tlclllrlulare excesivir, de acetitcolini, cu fenomrirlrr itr. lrl, r,rrN1.',r'i'ic: triozii; hiper,itll\.ftlie; rlal'ioreeI hipersutlo*l(,i. ; lr'orr.ic:r; L,ronllucnnSlri.l.,.;rrisprr,.r,r,tntllit,ur.ririr j ' r{,i" ; lll,, i-,.r.r,.lin :,r' .r.r l, r,rlll,. rtr.edem l)ulmonar acut; brarlicar.rlio; hiDotcngiuyl6l 111,. Lr.rt:.: \ :r . ,, I r|:, I IrI ir, r.nlini :rlr,lornirnlo.dirrr jrrrlr,,r.ir|rsr.. er,: rrri,,rirriri I I .,ttr,otr rlorrl tr,nxiohl,c, :rgilrr,t ir, ,,t,i., lt,cmlir.tituii, 1rsil191lt,,j 1:r,sr,i ,lrptrr': _ turn'l,c t10r,r,rrr ILsii,.11I1ri |nr', s,.jrrsllllr,zil coln:l,, 'iIr:rr|| ,l||r]j{1lr|)rIrr (,ir,r!\ lrrilrl, i rr ltliurclrrl0 !{) rtl oirr tlcIir,illoricillitr prin prr,r,it,li |,o:rIr.r'irrIrrIr, r'r. r,' lri,'rri'rirr"Iir,rrrrr.rr.lrlrilrr, I.lrr. rr{ii liL (l(,zorri.,irl. ai,r,rlii'ii r,rrsl i Irrr,Lrrrr'll'rrrl'Jrl t'rr lrlrrsrlc rlilrUrrrrsi ir..
l , ) ( lr t t t r r lt r in o t i rl tl l u trl n tu c ti r I4 IIIr.:r,rrrrIr pt,l yxl l l !j l i , rl rr 11l .rtl 16 trl r.r i i r. \ r r r r , . lr r . i r . i rrg i l trl i r,. (t.trri r l . i rrr,l r.rl . rl . I r i rr,r I rrr rrr i , , rl .. , ; ;It0

i'l{r ltic c:i piertlerite d,euLno\\tin\d ile saurtti durafti sitri, rnlr,i r,l,,ri i/, ,.,r rt..::ri tteurololliati, in _centrul acestot manifestlri situindu-se lr,.a.li.l,rr,1,r l, 1rlirr., rlil. pot./i intilnite foarte fr.or:ent $i in diyersa]'<r tu,lbu.rii,i tl. t,ri4t tt, , ,t:it urd, cu crxplesioneurriloglticii,ca de pikli) sincoTtele d.edivlr,str rrrr I r r i r.r .ll i,lisilri, carc iusE trsbnie tol,dcarua difererLliu,iirde tittr.t,1t,: : .fu,lselc -llrcbuic lrl'rlit.ii srL' sirnplc ,,leqinuri,,(Faii.re, J.9?2). aco*irr,iii,r rr rlrrrl,art!:ir, 'r:rr.,, ,ti sincopelortagale cane,,nc conduc la o ncurologio 1rlr.itllir,.r ct sau f[.r5, reflexe rascrltio r-aso-vagfl,Je l,rrllicrrlari".l, snu vagir vrr,11:u1,,, , i rrlii.lurminologia arrglo-saxoni., c*rc fac tlil ilcest secior hibir.rl, rrrr,ii.rr'i ,1, rr ii1,rc in1rr.cardiologic.lincurologicr'(Faivre, 19?2).Asl,icl,rlrrr.ii lrl,r , rl,i" (1,.I'il,r.si nce fibr'ulor.telntirrrlu llo rugulrri (iu lr:u|trrl rlig,.;,trr . i rl ()r'iitil,r.inge Jcsplc rcJi.ru aayt,uagu,l.c , rle pildi) sc r.olbpDbe ( llatlli.ts ) , r 'l:rr-i ri llr _rrrldr.cl&nfrlul dr, sinropc pl,.r"i tlin \isu, c:r {l,i IiLl:i rlirr ' li',lll4 iru d||r tltc ad'.ro, cSfe to|lr:r tlv rrJllls DaSo.tdqnlr. lrr 1,,:rr,, .r' i'ii1. (razul'icstc I-orba de intcrIcn!,ia ulot tcflexc ri:[l{o_{].1,r{r1.1{,:t,t.r,i'/ rrr rl. clcctc cardio-inhibitorii. ln accstc c{r,zul,i, corclxl rilsprrrrrl. lrr,lrilrr,r' r rr.rri.Iio lio prin tulblriili silro z],[ricu]iare, fic jolcriotialtr (1r.irr {,r.rrrrl,rrl J"r( (ior)ul atlio-vcutliculrr). Iiielderile dc crrnogtinf,ir, vagal(J),1(! irrlr',r,lrr,, ,rrlto pt1ohrgie dc grani(ii nouro-ca,rd io,vnscu1."lr5)' (.Ir,ilivrr),It)i:jl. I r slir'5ii. sc insistii in Lrltitrriifttri asupll i4o-rruntit(\lor ,,sincopirrrrir I,r,,, r | )rrlr,l li grial:., 1954),ttro poi I't colscr,ittlrlr, rrnr,i itrull or rr,fco{iLtrri sjrl rrll,;r, rrr
r,.rl l (, \'ILIi ('IL l i t, l ().

l :!.1.:1.' ! , \ t ut 'l( lu pit nlr r i

t lt ' t . ut j( , it t i.t it dr r uu: , i

nr ur ologir : il,

| ' i | |I (| rII'{' I t,rI rr cu r r nl, irr (lr lol: r l: i li r uI r r r 1I lr i: 'i ir trp t i<, 11, r lisol t t ( , il lr lr r Lr r , lr \ : r , rtr(ti 1tsi l ri .. ( lii: ilr , r r {r r ,ir r r , r r r , . , r r ') ,: r , r ir , ( ii r lr r r . r , lr r , ( , ir r r r t r , ( ii sr r r r z't . ir r ( lr trtrrl .ti i ) 1i 11, f ir , ( r i r r r ; ir , l: r i ir r . ir ': r r r ii, 1r r r I r r r . r r : I I . r . ir , lr r r r . i; r l) .lr r r r . ||r r l, I i r ii r l rrl rl l rl r.ol r r lr , r r r : r i nlr ll r , r r r r r r r pr r {r r r r . or r r lr lr lr . : r |, r , r , r 1r lir r r ( r r i,r . r r r lr ,
:t:f I

rrr:r n il't:st,r1,r'l lrilrliLltr ct'i;ck psihoulol,orti, ryihr alrd s/dri lnsotito do tlivrrr.so to1,ot'ii qi vrgrtativo. turt rzot'io-rt tfrlrrlrrric Bfi a,\'(xlrin vcdere aci doud,gru,pede pierd,eri ile cunoftinlt\ rlt sou,rl.tl, dura&[ (;\ruold, 197?; Popr,iviciu gi Pascu, 19?9). 1t.1.3.2.1. Crisele d,e epilopie, care comport5 o disolulie scurt[, tt t.orriii,iolferi, dar cu hiperacl,ivitato sau activitate normal5 sau cvasi. trrototic $i vegctativii, pot fi: a) Crize generalitate, respectiv rrrrlrrrrr,Iii, ll rrl,r'orLnrl'llicc (Crantl Mnl, Pctit Mal) ib) Crize parliulo, fie cu ,,somiologiu rrlrr rrurnia,r'ir,!' (rnotorii, senzitive, senzoriale), dar fd,r5 alterarea cnnqtienfol, lirr rru ,,stirrriologi.o elaborati)', ca de pildi, c]'izeletemporale, crizele insularo, rlizclrr psihomotorii cu moalific5,ri ale congtienlei ctc. Diagnosticul pozitiv ll cljzckrr cpiloptice se bazeazi, pe o bun; anamnezd,gi observalie 61inic , ;ru rlirl,ulo ltltG (standard qi mai ales prin actil'5,ri) qi pe datele complo. rrrrrrr1,rr,r'c (a,rtcriografice,pneumoenccfalografice, gama-cncefalografice eti.) t r,) (irfuctc de peXit m,ql ahinetic (saa amiotonic-akinetiee) nu trebuie confuntlrlc t:t.r, ututut'ile co,ts,plectice ilin ncolepsie, in care disolulia tonudulul rrrurculil,r' la lrembrele inferioare, eventual generalizati,, se proaiuco do olrilci rlupii o cmol,ie, firi, nici o tulburare anigilenlci qi ffrf motlificnrl l,)lt(i ((bltariu, 1971; Corfariu gi Popoviciu, 1971; PasBouant, Popovioiu 1968; Popoviciu gi colab., 1-97A, 1972, 19?8). Derutante slnt ryi r.rrlrr,h., clizclo cltaplccl,ico inso{ito $i de oareca}e tulburd,ri de vigllenlX (Corfariu qi I'opoviciu, 1971 ;Popoviciu si colab., 19?2, 19?8). ln sfirgit, crizolo rlu rnirl akinctic nu pot fi confundate cu acceselede kiryersomnie ulo 1xr1,ib u an:o[t:TrLicilor,ale cSror manifestid clinico-EEG qi poligrafice slnt Ilrr,rrryirrLi,o (Popoviciu qi colab., L972, 7978). ln sfirgit, la oamenii mai h l ilrl,ir, (inrleosebi dupl 50 do ani), care de altfol rareori pot prezenta crizo rltr pctit rrLalalcinotic (Arnoulcl, 1972; Popoviciu si co1ab.,19?6, L9?8i lblxrviciu ryiPascu, 19?9), o c5,dere brutal5, in genunchi (prin alerobamo t(!rrr l)rolo1 infcrioare), fd,ri, pierdere de cuno$tinld,, fXr5, sau cu veltij, tto rr cr'f,pd de ,,rlt"o7t-attacktl, caLe cel mai adesea este declanqatd cle tor'. rrvrru"i, gil;rrlrri qi rotalia capului, care antreneazS,o obliterare tranzitorio rrirrnrrrr, r, l,t lor'(ji vcltr',brale qi, in consecil!5," o ischemie acutl a sistemelor rei;iou. Lrlo rlirLlrutrchiul ccrr:bral (Arnould, 19?2; Aqgian, 1968; A$gian qi Po. 19?Er lrovicirr, l ${i91A;gian qi colab.,1969 ; Popoviciu qi colab., 1967, J-969, tll?t)). Atn'N,gcr atentria asupra faptului cd, fenomene de insuficien!5 vol" i,rrln'obrr,zilillii, cu crize do ,,drop-attack" qi cu obnubild,ri pasagero d0 rrorr5l,ion{,ir, }retabile la confuzii cu crizo de tipul absenlelor epileptico potr nrnvrrrri 1i l& indivizi tinori, purtdtori de unco'discartrozi, cervicald,I rll (h'imla psi,hornotoriiprin leziuni tomporale, limbioe (Alnould, 19?3 I Itrlroviciufi colab.,1976,19?8;Sagerqicolab.,1970),sau alo triunghiulul lxilrorrurl,or(Dimitriu, 1972) sint lesne tle rccunoscut din punct tle vocloto ofilio ,,rillliG. Acestoa nu trebuie conJund,ale cu ,,ictusul,omneziol,, 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,irr altorato (Arnould, 1072; Iiisor, it962; Popoviciu qi },asou, 10?0), Acusl, islru'r aurnozio, duptr,cnro br:Lravul mauifcstb o arrutozio o fonornsno. $o (ll,l,oloflto umri irrsulioiorilo cir,oulalrorii, cu o consooutiv[ klr a'ooorJr.ru,lo, tttltL totttJxrrtr,l[. ttt I brtli r,ro Ittttol,ior

I)ia(ln,o,iott'/" d,lfot0,ttl,Jdl ln lrrrlrrl 1rrNi1, tr olirrrirro ttllt rnrr. ni.ltttl,ll.t'i n t u,ro-psi.h i.u,l.riat,, flirt n r. nl nt tlt' ttturrl, r pilrlttitil, li uti 0 u, tnt,porlll 0 1,(t ikr,l)il.d rlittol.u,l,i( tr ntuylir'nlr'i : l. Oritcl( ),mearopal,iorrt) ..n) (lriut ntnLnld. l l(\ Soplodu outrr cir.(ill lrrfl1,rr rprrcitlo,si ou trn,,sor)l) rr1,ililtr,r")(Alrrorrld, 1972; J?opoviciurli colrllr., ll)713), qcolarr'!, obsol'vindu-so irr rnrrtlicirlr,,,rIIr,r.rIrl'III)i,'t, (oxl)ol. sau socia,l)t l,izr'i). Sirnularca,esto grosolruril,rlrl rrra,i adeseavizibil ,,volunta,ri,tt,lir,l'i, lrtlltnt'ii,rivasomotorii (in slxtcia,lla fa!ir,), firi rnitlriazi, Id,rI tulbrrr'fiti Ilill()toliene, fLrX somns piramitl:r,loeta. b) Cripelepitiatice pot rca,lizl,fi(! lrsorrdo-comeletargice, dar cu absenla tulburXrilor nourovogetnl,ivu, r'rr , cosdo tezistenfi ia tentativele de ,,trezire, t $i cu ,,impresiott dc vigilol rl il , 'r lir! crize pseutlo-convulsiyo,dar care nu comportd, nici citlole br,rrlllfi, rrici apnee, nici clonii, nici stortor, nici hebetudine postoiticl. So nlr,i lo, lrrrte nota ur tremor palpebral qi circumstante emolionale docla,nqa,rr r\ Criza afeatiad, banald,,.omare a unui $oc emotiv, poate comporlrL llltol{r pot preto la erori tliagnostice : stupoare, hebetuclino, il,gi1 rlio '.lolnente care psihomotorie dezordonatS, rlar totul clerulindu-se pe un registru do torr,rnil, rji {1o anxietate. 2. Criaele m,atebol,ice: a) Criaele kigtogl,icenicese 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 ruiu,strS, din ultimii ani (tr'Xg5ri,gan gi colab., 1971 ; Popoviciu qi r:olirlr., ltJ70, 1.972, 19?8) aratd, cH,acests erize spasmofilice $int alostul (lo I'l,r vrt il,rbile crize ,,tetanice" prin tulburare primiiivi, a rnctabolisrrrrrlrri .rrlcic. De multe ori este vorba cle crize de agitaiie anxioasd, cu pal;ril,rr,l,ii, rrr irnpresia de ,,moarte iminentE tt, cu tendinie lipotimico llsol,il,rr rlo rrr,nzalii de rd,cile gi clo furnicituri, dured $i amorleli in oxtrornit,i,fi rii l;r rrivelul buzelor, precum $i de contracturt in membre. Amintirlr oil, nrrrrlrr { r'izo spasrnolilice pot imbri,ca aspecte ale crize pitiatico, iar alt,olo pol, lrrru:r,specte clinico aproape tipice de ,,absenfett,sau chiar do qnvrrlsii lonico sau tonico-clonice epileptice. I)oar prezenla spasmului clt.rlll inainte, in timpul criZei iau postcritid precrirr, ryi aspocl,{rlo.ltiri( I 1,,rrlu,l (rk'scd,rci,rilc d.e unde lento asculite hipersincrone gi/ sau clo undo lorrl,rr rrirrrrsoidale induse cle hiperpnee; absenla modificd,rilor do tilr opilolrl,io lrr, st;imularea foto-carclidzolicS, qi la activS,rile cu Mdgimido) 'puf t,r,it,,irr' rlirgnosticul in fa,r'oarea spasmofilioi, oventual diagnosticul do slxr,rrrurf ilirr :rvrcilr,t5.c-u epilepsie (I'A,gArE $an $i colab., 1971 ; Popoviciu fi c(,lub., l r)?0,1972, 1978), .12.1.3.2.2.Iotusurile de saurtd, duratd, Al[,turi do ictusul apolloot,io, ,r,lr r{,r'ui rnanifcstd,ri pot 1iiile lungi tluratf,,, so pot obsorva la unii vtscu, lrriJ i{}lilr$uri$curto, atkrsoartpotatc, caro survin do multo ofi cu oqlzill rrrroiilohinrbii,ri rlo pozi{io in spaliu, dor unoori chiar Iu ropaus (Arrroull, lll72 i.llopovicirr ryi.I.)ascrr, 1{)71}). So paro citrln &ooctocinzuriogl,ovot'lu do o l,nlbuto,to d0 iriga,llg oorobmlfi,, produ*Itr prin hiloto:nsiurri t,ol tivo, rot{" uilrIrrIrr,|rolii rrlr.obrtloty[nzito]'ii Ii/ snrrint;olrniln)r]1r(l ;xrrl,ivpt'in it tufioianl,o (rIr,1,1 rlo l,rorrrlxrzo o slnl,orrrrr'l oaroti(li0,n).lfupil, n<ttrtllio t.l,rr,rrrrri lx!rlir l)r! irrltonlln(l(ort (lltrr!1, (lo ollr!\,1, noctrtrdo ln rrrlrrll,rr) rll,lnltr oil,ovn 1rlrr11,

irrttji, tlr' olrirltrittrtclr.rrtir,ilit.rturrttIrtIt.rrIrrI"icr,: lll1riu.r,, 1r1q:1r51,1,7i1, J,iu.(,/.(, rlr:rrrrrrlrr l,rtllrtrr:ifi ltfllzi(Nl {)1,o I!.1.3.i2.;i.XIui.f stiirilc si &pqt(, l::,.;.3.1!.:J.1. l) tIini.!.i?,{rnirL.Lt:ir,rrr ti), $i)tcoP(, r.tlrrlzirrlii o l)i(jrilr,rlr . Ir..rir-ii,1(rrlior':nii, a crrrxrqtintci,do dlu'atli scuilit, pl'(l.o(lrii srrLirrrr rl,, (,i.l,tIz:.ttii r.r|lrliln|lrto (lo (} tl,nori0 crtrtb|alii .qi itillrsocrili,lri rlr, l)t'(iir]c(10stL|.1r, olricr,i ilo rrrorlilir:ir,ri orgllnioc ccrcbralc (Oorfar.iu,t g?g ; Wrlvnc, l tlti l ), Sirr.r1rr,l.sn u;1, intrluh.a, iu.r';rnprrlaccosclolrliitlnc riccpiioplicc ((irr,lrr,r,irr, llrilr lll?il). tia$taut [i (iastatt (1956) au a,{irilat loati;c sugcst,ir. r,i sirr lulr,lr', r'rr,rollu ayut totrlcllunl soarta ,,p:irinli.lor silraci)i in cor,l,cilirrl ,r irrr rrrrIrIr. Ir'.Ir,r pa,r'it.risl,icc, r.e1xczintilin re:llit:tte-cauza cea ma,i fl,covrilrlr! ;r lrioltlr'rilrrl rlo c u n0,5l;in!:_"r, lure, s:tu :tsocille cu convrLlsiitonicc;i t,ii r*rr';ilar rrrrr'rriftrsfii|i tlcbuirr in rirod cltegodc difclcnliate in p]'irurl r.i},11 rlr, rrizrlc clrilcl;ticc, l:'./..1.i1.,i.2. Ula:tiJictititr BilLupelor sint Ioarl,e clifcritc rle 1a rlor, I:r:r.rr.l'r'. llrit,l (1U.50) r-i li gel ;i i.otab.rlg.-,.1 I relr.ter,zi ciuci etuzo rr.r..1,,r.,. ,:rprrl'ilr.s)r,lrr,otluci sirLcope:iulbtrrriri rle cir.culalie perifericri, aliec{irrrri r,:rIrIr:rr'|', r.r'|tLZLr Iorlu.i!t{'rii, rfertiuni ccrobra,]e qi boli psihice $i, ca,[11r,, ;lrr llrol)us rurniitoruca cla.sificare : l) 'Iulb".trdri ale cirau,laliei ltcri.fn.il : ;t sir{:i,l)N, 'r'l.r,so_-tlepreso:lre (raso-\.agalii) rrorr, Lr i b) sincopa din }Lipoterrsi rrr'lrrsl,rrlicii. Af(,cliuni cardiace: a) tultluriiri de ri[m cartlia,c lin spcr.ill ,2) rrrrrlrrrrrrrrl ,,\tllm Stolics); b) sincopa,din biperreflectivitatel ,sino,ll,r.r, lirlirrrrii; rr) sincopa prin aitc tulbuliri ; rellex6 vaso-vagale,r,efltxe g.lrrrrr lrrlirrrlovrulir,lc,rcflexe oculo-ra,ga,le. l) Sincope prin iawze respiritorii: :r1 .., i rr,-rr1 rlt' r : r, 1L ipr.r'reril iJri,lic b) Silrop:r, la trse. 4) Sincopa tlin tlif rit.r, ; . ttlhurtiri ffrrl.trqle (sinc,,1ri psih.icl). fi)- Alte lrpari; sinc,opa do tiri(,li
rn I r I ll,( ] .

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, r r l r r l :r t( . r 'l l r l l ,r 't i r :r tt i l o r r r l r ,r i r r l i r r l t rl l i : r i l 1rrr 1i : r Iti 1 r ,,ri r .tr l i t:r ; tL l i r o t i tr r tl l r {l r ; l l ,i l ,.r ,l l r l i r r r r

1' ,.t\i ttutlt t ' 1t r in, nr r , |: it ', 1 i it t lt t t l, o: iliq, iit t lr lt t i: l ) .l \t' i n hipor , it : r ) r r r r ) , r ( ii1ii r . lc : Llii1iidiur , I lr ) ir r ir oli r '( 'r q( nii: r l( l , l l rfi i r(r{ ' .2) l) t 'ir t ,h. i, 1t ot r r .ir 1't(rr i; Liolr c lt ir L liii; t , r 'i cr {, illt 1u: 1.ll) I 'r it t lt ilt 'r ,,ri rtri r (i rr r:or r t lif ii t lc lslir ir , , ir r z) : or r t i r t 1- r : ljillc) .11) 1'r 'ir i It i 1 t r,r1I i , r' tt t i , . :' ) I' ri n tu.Ibur d, r 'i de nulr iiir . U . S i nco pc pr in t lisju. nt f ii r c) t tt 'cir : 1) I i' r1,i t ' 7, ir '. 'l) S it t ntlt r r. : ir t ti i t t r : : r lt '' r,' l i rl .i q,n ist t ir '. {, t (.far na I n I ) lt t t : : , ', , 1i ln cent r ald, ) . 3'1 lt t t t t t i 'ut . . : , ) " ,, tt l l i tl ,a. l'1{roiz[m cii rrra.ioritl,tea crcr.ttftli iirtilt}r de la irrrrrrt:lc ll si lt rrrr rrrl rcri tl bi l c sincope, ci. le f alt r epr czint ii t Lt lLr t Lr iilillc i. or r slicr r ( r , ir i, , ,l r, rr:r' :t,i .i pr i r I r l^ |li. Jt , i. l, . |:!.l.3.2.3,:). I i.tt1ttont nt.olog ie clixiari tnainte de a aborda, clj.rcrselg entitiili clinice, al,r'tgolr ir,r,(lrrlt rrrpr:r, , rtttltt.ont,clol' r' {lenarole, camune \\i, a 4inpreju.rdrilor in cllLo so {I('(,IiIIIrilir?.rI I r(' o pa, r\ntliza iirlprejurililor carc ilu dLrsla inltalarea picltlt'r'ii ilr lrrrrorji irrl;r , ir rlc o deossllit[ inipoltaril,ii, in s1,a,l;iiirca dingno-qliorilrii ((]or'lirrr, I l) , I , 19?8). Tlebuie si, so liiiil so:lina de sohimbi.i'ilc dc pozil lc rrlc l. r tru l ri , rl c e.,.en t uala deciau$ar e la t use, t iicliunc, f elt r l. r , oLr r lr lr : sir r rlr r ir llr o i , r'\ iclrle, la einoitii, sl,irii de "lrisii si rie lerrsitrre elc. .r\lictr:rIrrL1rl,, lrr'r'r,, rrrl o r e bol nar . uhi sint t ic inar e \ - aloar o: t t ecliiur ile cilr r lililr , I ) llnr lr ir ( . . , rl orl i l er un ele sr lf er in! e ne. ', r xologicc ( sir ingom ielie, lt it t s i, lr '. ) . , \ r 1, . , . r , rrI r | )| | ,rI r. l,i( r'(lcrca cunoqtin!ci esto prccedati gi,/slu urm:r1,ir,(lo lrr{,r,r r.i , t)r | i nsi ncopale'' ( G asLaut , i9j0) . O or lar iil ( 111'i. t.J 19?8,\ r i ( . lo|llt iir t i l', r t , , r ilitL (19?1) a,Lr insista'. Rsup]'* il tlou i, gt'rps do sirnpl.omo; u,) sirrr;rlorrrr,lr, l, r lir{rcesualc,care rnoori se poi lnallitegto filrir, sii, {ie xr'mt1{) (lr) 1rir,IrIr.r,,r , rrrrosti l ei , put ind deli 0oDst it ui un , , echivalcnt ) ' al sincol) ol0r '; lr ) r r I r . r 'r ir r l t'r'r,ln:iu-zis ; c) siinptomrrlc !ostaccesltlo. pr,lneig cu aproxinutir' S imptomele f)rcacces1Ld,le 5. jl{) rlrr rrrlrrrrrlr, rrrrl rrl al ca pi cr dcr ii de cuno{iini: 5, r nan iloslinr iu'se pinlr - o s1, r r , rr lr 'r r. r l* ,orrl i rL' t, translilalii ieoi, inccf oqar r : 1,Teder i; , am clcli, gr i'lr r li, pr r lor r r , , , r, rrzrt,ti e de p r ir bniit 'e. - ilccst e siinpt or nc pr eacoosuilo , , r lr , lr r ct lizr r r r '" |t l'l /rl ' ;i i , { i :r,de p il<iit ir i sincopa 1a nir r l; it : nc. Ln schim b in cuzr r l r ir r lr , 1, ,i r lr r r rrrlrlt'c1.ul it-Liocartlic sau dirr angirra pcotolaJl, pr: lingii ir,r'rliio sirrrplrrrrr. p l crr,r.r:cs ttal o obi$nuit e, pot zpar e: dur cr i plccoLr iiillc ir r lor s, ', I lilii r lr , r r,rrrt,c q.ll., pc lilgil semnelc stilrii rlc qoc. ,4ccasulpropriu,-zis tle pia,rtlereda at,nofttnl{:tcstc sourl (i {i{) si r.rrrrlr'), Lr (' utsu1 oi " tr uia so lcr nllcii ilii ir r , l o f lllscit lit lll, t , r lt iscr r lr r r ii 1i lr r r lr r r lr . , ,l r! (l i t(,i 1, a,ccr r : srsc r l J) r 'ulnngar llc,sc l) olt . lc insl, r t , lt o r , or t llt r oir r t , i lr r r r ilr r , '., r t r lr r t . it lr 'i, ,rr' trrtl i i , tti tco t 'i ( lc ( , ii( jvil <'ot r r t r lsii ( , 1{) lt i{. r ( l1e 1, 1 l( l r r r r . r r r r r lr , . Ir {' l tstl l l l l zr, i 1, r li<t , llr r lcr r r lr sir , ir rllt ,o lt ; t r r t , ir , ilr r lr ii lr Lr r r ,llr slir 'qilt r l : r r t . . i l , rr, i tr l ttl str l Jr zr : i llor r ill r li lr r r r lr r lr , csr lr lirr r ^llr ilt r ii: r r lr . r ilr r r ll r r lr i,r . i l r,tl otrr:tsi i , r sI iiI i I or ricor 'I or r ilr ' |r , , 1 $i ( lt 'nr nl Irt rr1rI i I t rr I i t rr' . Alr , llr . rrr ir I r ili r. r i ttti {o rr l l izii r lr , r '1r ilr , ; rr , 1qt : r t r r lr r r r l. r. r 'it , i, r lr , ; r ir '1r I lr , , , : rr r r l, r . . fi i rttl tl rut r r lr 'lt t t t lr r t , r ', 't r r r r lt llr '.r I r i r 'lr r r izt r , r r :r Irttl rri , l rrl tl t,t ' t l 1r lr . , . it r|, r lr r lr r i: r r , r 'ir i | , r r r lir lr r r il r , r lr i r l' r ', r r r lr r , r ir '. l ovi trr. r' otrtl lr 'l , t l; r l lr lr , r r r l r , , r , r , lr r r r r l, I r r I r r r : I r I r r , , l: r , lr rtrr lr lr r . , r lr t r lr r l
.l i r

Wlyrro .(11)61) propls cea mai complet5,clasilicare a sincol)(ll(l!., lr,. , rlr..,i r'r'iiilrr,]rilir, plin liirsr rlc procizitrne exactitatc a unor itoiirrrrir ryi11e ,\ " NirrooTrr_. pri n isch,amieaet"ebrald, gener&Lie&Nd : l. l'rin scdil,r.narezistenleiperi,ferice: Atiire: - sinropa r':rs,r r;r;1rlii, sircopl, simtsrlui cmotk'li*i,n, -- ^) sincopa de liper-.lenl illt ir,, sirrlo;lr, plirr rci'lexe ccrcbralo (sincopr 1a tuse), - sincopa, prin lollr,rr, rrrllrr r:rlrlilrr) (siritnpn din stalrozn qi insuficienla aorticit), , sin()l)ir (ilfl:t'r.ct - sincopa pliu rolll(,\rt lrt irt tollrrro (,nlorrlLt'c ;i anginir,pectora,lir,), prrlrrrorlr,rrr (sincop:r, 11 1,use, sirrr:opa din onlLioliapulmonari,. sincopa rJirr Irrlrr,r'lcrrsiurron plihnonafit, sincop:l prin pulerei! in joc a nnor iefltrxo rrrll,ir-r'), lr) I)usiae: - liipotcn$iune o.r'tostaticil(in convalesccllii, j lrr.irr lr.:r,r'{ii l:r rrritdorlrogLrliI postsitnpalie{itortrie), - hipoterrsiurLc ortosjllicrl ll'rricii (irliopr'r,tirrii, slu secnndarii unot: lloli nel.voasc). .r.rni,r l. I'rirr, scrirlt:rtntlebitrt,l,tr,i cardi.dc: 1) stoyt card,itc (srruurprr, r:rgrr,lii (r,lrrlioinlrihii;oric), sinoolr, s;imrsulrri rrmotirliinr, silcopt rlirr rrlrtctrl Atfrt,trr-Slol<<rs1 1;1prin descrafl.rrfi tnlu.tn-hci\d,ii rrardilrrt (sitrrrozjl jrrsrtiirriorr(ji rroll,ici, irrltloL tniocitrdic, a,nginir, pecl,rtllllir, lrlil,lnic caldia,ci,) rrrrr'I it,:'i;i sl,orozr'r, mih:r,ll). il" I'rin. tnu,.tu (t,l,rftcot\Iilti(: ilrsirntu lrLr)rnonltr.ii ir,)lripr.r.l I lr) sitrlr'1rrr, l:r. ll$(,r; r.) ll.irr rrra,rrovllr, Vlr,lsrrlt,rr. ll. NIttcrtltt 1trin. iwhrrnr.it u.tthnt,hi, Iurtli:tlii :
l. :t:f.l llo li tur.srulq . t t rt r t r lu' llt : lr , ) lr , l, , r ' o r ii : r l i l l i o s c l c r r r z t i ; lr) irontltor,;i.

(u ri t rl t r r r lr oir ir : r , ir r ll rr,| r).,\r.r,| i o rti rrrl rl ,,rr(' t:r, rl rroi .i cl | }i frrl r.fi ,rl rrti rrrIl o rrrri o l rr r lr r , lr ollr . r ilir ' 1 ir' 1 ri Ir,IrIi l Ii ,l )l i l (i l ti .i l l l l l o l l r.rrr.l i i ,r,l r,;i Jrl i rr(,t)l l (,\l l l l t rr 1 r1rrrrr:r1rr. rl i t r r til i i IrrrttI]o Ittr,. l . |ir t t l) t lt : , , , , ' U ..,u ,t,' l .i.. , 1 r' rr.irz r i i , ((i i l i l r.rLl i .rrrrl z,l l ti ti ) i .i , l rrr.1,.1q1,; ;L rr.rr1 r r r I r r ' . r ' ir J irri i rl u l l i rIi r,l. o s l o a k i rl )1 { ))i i rnr}l i v I l l o si rrrrrpo, rl ..rr rrIi . * Irr I is I i. i r l, llii (i i l ,l r l )r' o (]{ rJ rti (l o l 0 % d o a,l :or(,i l ,' ri r.' u' rl i o-vi ,scrrl rr,rrr I rL l r' l i lt r . r ' iqir r . r r s i ttl u rp .l 0 r' , l l o c i r, i ri i u U l s i ]tcopol ol , (i i u,di i l fi l osl ,(, l .l , rl .rrrrrr ' r r i' r ' lr r ii, I iir rrl r,r' b l r, { l o o fi rl l )n } l ,r' o h em-' di nami oi i cl e grrvi l rr,r. l i o -' p ,rrz i r c n l rl i L c ri r,r .i rl r.rrlii r r r . ilrliili : rr,)_ ,^ ' i n rl cl 1i crnscci nt i .' i rn.r Ii :rIrr, ,r ,Ir'i .r' . r , i' r ' r r I I r , I r I.|i i r;b ) l i c o ttrl b rr| ru o d e ri trn , uttri l rtcl rl rl l a, trn gl l rl rl r, i rr, Ii .rr' iI r r I r r . lr r lili' il, I r) fi e ri s i mp l i l l r' i b r' .;ir:c :l cl cbi trdni , c:r,ro D { ),rl t, r1( rn r)r r t r ' r r r r r i r nr rl l o l ro c :1 rri s r' n cr' . ro g rn s N i cr l l rccstol si ncopc { r:l ,ri l i rr.r, l rl r, Io I r I r , r r , r r r r glt r I r r' , o x i s ti n tl l i s c ti l rrL rtr' !;isrLl i ti te. r," linrttlrtIa. rl.in t:u.rsuI r:tt tliopltiilor rr) lrr .r./aro:c {{0rli&i sinoop:t :u.q ciu'itotoro prtognoixoDice: sullirrrr L II(| ( i || iI r ir ir r or r i. s [ l i tf0 r' 1 ,u ri l o r, e s 1 ;c to l a l l i i , i l u r etl td 1:Z mi n te si l i l sr,rtr. ,,'..r'rrl ,.1,ilt1rlifrrr.rnr', rle\i prczerrl:r, a,oestiola, nu elimini iiilglroi t,irr rrl .iil, (t;rl ',r'rr t , r ' ir1r 1 lllil) . (i rl t1 :l\.a i ' d i n , p t' e c rrtn ]Jammarst0n l C i tal i rt,, Di (lrll',{'rl{r'''lz, l9?ti) N,ur.r'llta,l, e:isloD{a rlrror tulJ:urH,ri premoniiorii, r.rr,r.,, l',.r'rrrii.lrr.rlrlr,r'rrlui sit-fi , rprcgiitea$o['r {10 multe ori iXclerea: clisltrrr,rr senzir,f ie hitllJir, tle ,,glmbe de vat5,,, ovr.rr Ir orilr,sir ii, plo,siruro i,olr-ucicil, lrrrrl o. r r.r'il,l,lrilr"r. itizii, r1e St. r(lttitr,.il ,, pibuqire {r, T.A., ptils f ili lngor'. l,,r'rr. (,11.'s('il, irn pci,r.tptibil). a,sur.zi'eil zgomotelor cardiace, arleiea s.llrr .1,_,1i,rI i rrri rrrrr,t r'r, s Ln {ii\lriu ilia ttil{hri sistolic. Dupi, Trendgre (cilrrl, ,r, {:i r,,' , ,1 r r l. r ' r r r t r . lir;? t. s i rr..u l ):ltl " o fo i , -rrl r i rru i o :b% di n" sl enozr,t,. : ,r.i ir r', r'rr r.is. dc t.o:lr|c subil.i si r.r, p.oEnostic ulter.iur reZervat (mour,l,r rrr rrrr,r lil ir r r lr r r r r ls d o :' -4 a n i d u p i t p l i m a si ncop;). lt) Itt, ttti.tot"tttr.l le,u trotnboz& u,u,riculo,rd,(afec{iune rari,), tuiburilr ill r. 1r'rrlrr. r,cl rrl,i rilr'sou,r,u ocazii:l schitnlllililor de pozi!:ie : crti, digpnoi(,il, , rri r)zi l , ( lr llt llli s i c t.c rr{ ,u a ls i n t:o p i r,. , ) lrr h i1t.r'tlerLs iunea 7tulm,onari1,, pierderiie de cuno;tinli sinl 1rulil I cl rr.rlr ( ( lilgc r r lit r .rrl ,z ,1 .9 7 2 ), Ii i n d l l l o re rl a te- de cl i spl cc qi consti i ,,i i ,, l,,r:,r, r (1,irrii,lrr,, ll*ntrri, d u.e'e llrrginrrir,sril. ln cadr-ul hip'ertensiurr ilrrr. l rrrl rrl rrr:rr . , rrrr.lot. spcci:ll-i) o',rr1u, hipcltcrrsiunea puhnondrX primil,ivir, rrr .rr|r' I ir r r ur I r r r I u s in t m a i tl c rv e l tc . l i r s rh i n rl r , hi pcrtensi uni l e -securrtl ,u,,, rr.r'r,| || ! I ir ) I ) iI I ii dr lri u d i te s rn l c o n g c n i trl l . &r d t si ncol c tl oar i n 2/o rl i rr , i l l r i r fiir l, ir S r , . 1) l ' .. , i u l rl c G i l l n .n l u a n l z , l C 72).rl\. ltt i tt*rtlioientu. coronq,ri(Lr1.d, t)ot Bit so producii si,ii,ri sincopalc, rlrr,r. 1 rr i ' l a rc fl rl trti o c a rd i c ,p o a,tc sul reni , i n faza a,rtrrl ,i 1, l rrrrr rrllr r r r r r i, ; t , t r is r n .. lr ltrrtrt rlr Ilrrr.,vgrrl;r o sinCgpli, :ltlCSea, mOltit]ri" lllt,I, Aoeeaisil,radu1r,,r,ri ,l rrrr':i r ; ir r . olr r l: ' i, 1x [ 1 l ,tll i i 1 r| o rl u s i i ,d e c l l rtz e d i l 0]' i i i e: 1,ul btrr.nL,e dc l i l ,rrr, r',.l l r,r r : r t ir r lr s r r r r r . rl u 1 rs . l i 0 c u n o i l q to , tb p i l d ri , gt,i t vi t,at,ci t, 1,ul l tut.i i ,r,i l ,ri (1 ,' Ii l n r ( lir ) ir r I t t r r l, i rL s l c l i l l i n b l o c ru i l o ll t,r' i o-venl ;I,i (tr l :Lfo. I)unrr.t]l t, :| | r|| I I t I j i, i I I t t rt tI t t trt I 1t t I d cttlttrr',rit,t,ii l{jftr)Z(ri I)olt1,o o sincol)it,ro1lcXil,. l)fovotjlI Irr i rrri rrI i r. i rrrrI l r, r , oir l rl n .i l n ri ' t, r' r' o rti i ri l i c c rtrr,l rr i i r ,,l l ngoru I si trr,,ol ti tl r). l )l ||IiI I| | I r\| |t III ! lr it t l, r t t t t r ts t,trl o l tt,r' i tl trtrl r' l o ;rrrl ri l ,r' rl i rtIIr| rIi o1rItIi i IrIi st' l l {rrrri | r,. ll" |;i tt,ln'lt tlil turlt"ttl l,tt,lhuriitilrt rle ri.l,n utnlit,r: r\ r r r c ilr r r r rr rrrri rrl l i rI r' rrI, rrrrn rrJ rl l i r.r' rrl rr l r l oi :rl l i rr r l rrIl i rrrrI:r,r, l rrrrr,l ri L tttttIr'It ' t I I r r r r t r lt r t t tArl t l l tttrtl { l o l i trs . I' t i tr r.rl i trrl r' rr' ,rrr'Iroi IIr' rrrrrrIti rIo l rrr' { ,l rIi ,l l ri

l l , rr) rr l i r l l : t ilr t t lr r r lilr r r ( ( lilt 1r 't r l l tttti ttol rtgi c;,r t r , it t r l , 'r iir , r lr l, r , 1, ii l, i rL J,r' ;r I l z, l l tt:l ). lit t sit t r lr ot r rt l \ r lr r r r r ; 1i, r l\ 'r r I ( r l) l( r zir r lii ; l, l'11, ( lilr l( ) lr r lr r l I' i i tttrtt1rt'It1| ( lr r t I r r r ir , rrzttti l ot sl rtrl ilLlo r lo \ \ r t r r r '( ll( ; ll , r i t ) r : , ili, {lill st r t lir {, iiit , lt t i ( l( j ilr ' lr r 'it jr it li I t L lt li's llt t i, t llili (l 1l ;l J). ,r\l )rtr tlc ol) i( 'i'i r lr llr r r \ r r 'r l: r r lr l l0 ( ( it t I t t t t r '{t r ' i r lt ljr t , zli r , | | cliuic , r t r I | . illli, llt or r l :rrrl ccctl cri to c{. ! Tdit t f t ) I r L : lI I fi : r st t l't : t aa l iliilile r t 'pcr cr lt r ir t r Lii rl rf 1,i pu1tl e asislolie, 1r r I rt t t t t r ii r lr r p r tr '1, icir , ir r,Lrl:r,!ici ocrobralo. lJll{rii s1.ol)ul cludiac tluieazi ci{ cr;ll stttttLtltrr ltprtttr ,lorrr o st&te dc slil,biciuno, itLso!it,il,do pftlo:lrc) alneloli, ;ri tLlllrrrlili, tlr' rrrrlcre. :\sislolia r1e pesle .10 secnnde produce piet tlcr'cll c1n1(rltiltl('i,.(1ll , irr,rtozir, turgescenla i'enelor jugulale, Ii"rirea qi suler{icjllizir r' rt, r'l'slrirrl i I ( 'olIrt't itt , 11)0 l i(fi (pin:l li. npneir) 1i convulsil tonico-olonice (tr1-a1'ne, rl ri l i ). dc lii,m, ''je descritl: ln cadrul 1tll-rlriu'ilol 1) I'ulbtu i'rile (le co duc(re, ca'ie sini celc rrrtli Jritrc cunoscttttr trtttzr' rI0 sincopelor : (rLlar. De obicei, pic,rdelea ile cuirorllilt{ii t'rlt' t)etLtri Blocltl etri.o^) qi imprevizibilir,. '\Itrll, rlrai r:ll oa estc dccl:rn;atir, in-tirtLltttl tttrrrr 'rlNrtrtllnir, ' \' Sc-;tie cir, daci' blr.tcttl '\ ,,iirrt, ca, Oe pilrti, mictiune:t slrn defccalia. t ir lir : r ,,,rrrfl et se i tiagnost ichcazf r r . ur ' ( ii3. j; ; ) , l, loculile - pr t r r isI ir r t r (le L L1lrof \ diu 't'in1ii' blt.rctrriltr'\ l,rrbleme di{icile t1e diagnostic. PiFrllt'rcir,

/t

D i 4' \i rrt,,l ,:l i 'i t. 3?. l nrc gi s trare po)i gr.rl i c i h bol nav ul S .I.,61 dc ^[j Ios L i nternal i n 19i 0 c n dg. S tx tus c l )i l opti trrs ' (si ndrorn A dams -S tok er). ' l pcnhLr l rec \c nl c .ri z c dc I i c rdc rc a c l 1nol l i nl l i , l ns ol i te dc mttl Lc ori d(i Tg. Ii uret ex anc r[rl U l i (; con\arl s i i i unj c ! ri oni c c . I I c i i ni c a ^v c nrol ogi c i r i rtcrcri ti c a l os t D eg.l ti 1' .E -\anrc n]rl pc ,l i grai i c a eY i denfi aL un ])]oc nl l i rl ' vcnLri cu l ar pe E C G, c u uD l i l nl v rri aLi l (i nl ro 22 $i 18 bi rl i l i pc rrri ' r), s . P e fi gur;t s e v ede aprti l i a pc l i l l (; cu D unc roas c x s i s tol i i , i utrc 1i -3i de undc l ente bi l atel al c , s i rc ronc ti s i rnetl i c e (Irc domi rx nte dc dc ri trrl i i l r' arrl eri oa rc ), dupi c arc , odat:r c u i l s Lx l arc a & s i s tol i ei fi pi trdc rc x c rrrr(' ) primei conLreclii c:1rdittco fuco rii-t tilllei, trascul se aptatizcazir, Aprdlia rtrpar'5 l l nc l c l e di n barrdx de1ta. C uuofLi l rl l l rc nparc Lrc ptet, odLIl .i (rrr r{ri uarca ac ti .i i ti tri i c ardi rc e $i rc \.c ni rc a l .i no nal N rc Li v i l i i l i i fl r(:l ri r' (' corcbrale. l ntreaga P c ri oadd dc 1a i ns tnl :trea as i s tol i (i P i ni Ir ror(rrri rc rr cunofti nl fi l )ol nx v ul ui a dtrat 3B s i :c Lr[dt. S l i j r:rl .a i rl di c r"r r({ tri r(i :r l c l i ' c x tati { c 0 (drrptr C orl drtl r, 1!' 17, C otl i ui tt } i l )opori |i rr, 1071 fi vi l i rl i i l ,.,l at,i ri rr ti c ak l )., 1tti 3).

z, ?! ) : lio o lI t 'llzii,vot t l, r 'ir 'lll1L|r i | rrrl rrr0l r,5l ,0 l ,tr li r r {. {'r r , r iir r r '( ( lih1r 'r r lr t 'lr , t r i,l{f (' i l ;r/, (l i r) r,rr, zr r I i) ,I ir . o lilr |ilr r lio lr r r I I t it r t t I it t ii ( 9{t r ) i, ) ' lir t o I r t I r t I i|I t I r I io , ' r.l ,nrtt ri . l t\ l l l oru.l. xit t r tqlt i, r l, t r r Lt ll t r r r . i t t t t t lt , t 'll lt t r ', r 'r lct t lt t l, lr r t t t lt 't t t lr '; t lli' ,l i tri r:1r' i tr rr,,r 'lr '; r ,trrrit r r l'l, , r , r r ' r : r t <l rrr" i ro rl i r 't rl l lir ' lr r r l r 'I r 'r 'I r 'olI r 't r I i, r I 1r ir , lr i.

lr, ,slir;itLrl, rtrustrlui,,pr.iripa,Llzir, auriculari, post_tifirifdliej. SiiiL, 'r'ri rrr/ , r'rLr lr(.llcUl()rNc, i;r stlLirnb,tahicardiile ile vontriculalc, prin riscurllo vontricula'c,prin
l o l rl r los olt il, o, rri, -l ru) lr pr:r'turbiililc _10 setunde, hcrnodinarrrice l)u liulDtl rlo llclnodin&nice cu druati, cu tlurati, de Ae b l-iO tulllu. llrlil r, .i'.rr cirrrrrl.1,t',iit lll,tx,iit trn tr. osle osle de de obicei obicci losinll;jtii .tsinriitii de tle bolnav, hotnav, perioacia fiirrd

, I ,, ,l,,lrrr'r |lr,\'1' i',,1,il, iceI)ol..rii pot.sil seinsot,ensci, su rrl,,o{o0,s.i rt9 dr'1rir.r'dr.ri ,t,,c rh: urro;r .*;,rliir,iii, irr[.11, t,i,,"ac"i :1.',i]1. ' l' rro l] 'l :]:] l1]l.il i]:l :,iil,,lru.it,^ ,i I r'iu'r' .\rrr)l)('r(! i\rr!)r)cirt sl srrti .i,l'r' irr r ltitl c r'rl lr. SUp"A rrhicrrr'<iiilo supra-ventriculili'e I onlr,ir.u]rr|e (J3oriver"b, . FittLlirt,, Firruiu,, lllotrvCrcl 'sincopa h ibr il r{i.,a,r:ri.ulll.ri lllr,xistitiL I irr ulltirna va.ictu,1e, pbato surl
'l' uI [ou.[,sincultul poale irnbri,ca urrniitoarcle configurafii :

( ) lloo' 1. & t iit *, ' tti . s (' r' ' .,r' l r.ri ' i /,' rz i r,rr.i , rLI I r.|' | |rr, r) (l r, r:r l rr,.l rt,5i l l ' l trn,v, rt, l trr , i : r lilr r r ii r'r rrr I rIr' I r. 1 ' r' i rr rrl rl i l rrl i ,,i ,tu .i l l l i rl i l ' . ;,i ,, rrrr,.i l ri :r,,l i cl rrrl l i i rr, l i t tttr t,i l ttt l tt, "\tl r'tt t { \ P t l t lt ! t t i i l )N ltl ttl i \' . ,{ r.r,s i 0 1 r!t,r .t,i l rr.trl ,:t,lrl rrl l rr,l 1r ' l lr ' r r. l r r . ll- rri rr.r[a ' i rr. t' rrr.rl L i rr{ i r,, c i t'. l ri rri r, i rr apr:l i r, rrr,rrr* tri r,tl rr ,.i |,IrI , I ( ' I I I I I I ) I r I r c L' )rc trrrs i s l ,o l j c(p l i rr p 1 r,r,1 1 r)i rr,), lt sl i i r.rsr.:ri p1i t 1 tl i i i rruft,ni l l r'ri r;r c rlr ir r ' lt r lr . . r .:r i rt s l rrr0 t rl l r I i 1 , ,. !, !l\tr,l,lnu ii,rilp de ?raitabili,t lt'.. I,rjrrilc ltcslclr, trit,rrl,ioniun fiiblill,!ln trtrl l i rr r lllli, r lr c iu e i c o rrs c c l i u !ri i trrc rl i l tl estu ol ri l el t,' c i t,cul tl ;ori o. i )o

(iol ptlrr st,ttrtit. ( f ala. rr;ag5, d; sl rrrl,ir,. nrr-ult, tul i- holt holns , r . ' r r l resim r es inr tbe o o n stare . t^ UeJ t rar-nl r1e ,,rb,u,,-sau - x . 1 r - ^ - , . o efemot{r s"rr,zrr,(it^ rle i.tv'ior", cr_i,re-i pemrit evitare"acXa6i.iiin cazul in cftr,(l ",,vitl ,lr)l,|1rrcrL Lcnlodiritnli(.i lI liude Si se prciungeaSCH. -seeunde, b) pcllutbirile Lr. hernodinamice ae 1O-ZO manitestlrilo . , ;,r|lI l,ulnurut [|r'Czerrlind O pal oAr,. b.ruiati a fetei, VOrtil. ,lrrirt ltrlr.lrsr., rsr.rr ir,i t.r'i. opr rfc .r \ oJlJirii $i I acr iv iln lji mo tori i, d u pir cari: inai viOtji I'r r\ r11. rijr ttrlli ilol,rv ttatc:t.

c) lli 1't.t lrtrl,rir'iJo snls dcpiqcs,.20 de secunde. piol'dct,ea rle cuxoqtiritN, r.rilr.r.'si\ ri, (.u rboli.r'il rcllexr.rluicorneln dupd, iO O" ,-"*A".-fl-,i.,r,iii Irr' i :r.il^li l dr' iilr,.uljuse sirucazi jnlre t ,ci3 frinute. r.l) Itr ,,ineuptle cu dur'lltI de pestc B*4 minute, leziunile cerobralo . sirrl irrrr. clsihiloIlin(liu|olcs, in contcxtul clinic al tuturor a,cesnol slnoope so }ot
i rri cl l , c liz e c onv r ds i i .e , ,\rl,1il tlc accrirltirite in repctilie corstituic

de rdu ,rstaren

.{iar',r7,1/,,oJ tla. Einaopa uaso-uagald, re.f\efi, po:tte Ii tlofi-uittt . .ll. I)rllt ' l,l'l'(rorouc cutroltlu{a scu_rte, cu sau f5ri convulsii, sccundar, rlrfr Iriurz,!(1il,ldl&ue s&t unei prd,buqiri tensionale reflexe (W;ber, 1g?2). I trr.l;rDl,, *crstr: sirx.ope,cele mai frecvcnte qi mai benigner'sint pluriotiri(|ilI r o:l.Lo r(,lirr'r'! alr ull ctcmcnl cumun : tercnul pe t ar.esurrin aceite nranl" o .labilita,teimporraniI a sisl,crnuiui ncrwos wegctativ. Aprw ]1..1.1:ll:.lr:f i:t l& 40. dc r', r,'tr1t r lrrnlr, a,ni $i sint mult mai fr ccve.ntela femei decit- lO rr:l,u,ir.lr_ l)rn t,)tctut.srn('ololor studiatc de CnIflriu si popovicin (Ig78), l.(r'rlr' tr)r'ln{, llll tl.ilttzAt un ptocc {nj de 93,l o/o, In antocedcnl,ele :r,costrji r)r)Ilir \ r Iu ,.ru sc||ltrl'lutzii de obicci bo.liorgallir.e, ci, rJt.r,eguli, Simptotno vcgo.tarivcJ tutburtrripsihicotle ortlirL diccti" ta'peiuo. :llll,i,jll,"l,trrlburiiri ..'rrrir{.r or.otive' instahire 9i labiio vegetatir,'. uneoli in antecedefrtoso Hr''rrr lr'irzi,fillcIt( sirrnc artcrialil,. ca fncl;ori declanSatoriso somnalo&rll (( lr)r'l:'i, f i : frioa, sii,rilo de crnotir,iiai"o ,l,opovicill, lg?J; Co'f ,r'in,1.0?g) sl r'cssrtrilo, sul,;IliIll|1nitliil, ilrsolll|liilo, aorul tlolttUt, fi l dl:rl.,titl.il,lo,. r\\ril, (t(':l,tcrxrt, (l(,in,it'cliii.t. ,ll)1i lrccqi;i n(ttlrinirtll,a.ron, facloli iloclanJ t:trrrr'zr\, rrttrlt mai uf(n'rl.,osrrl sirr.rrprr,l riur,,i, bulna,vrriso ntlll in ol,r]ostrol,iHm. ' llttpil, rrbiryrtuilrrlrr rrlr,lili'nlr"r,r,i ntrnollzij, sr,url,ru Jllr':rircrrsrrrr,l0, p ior,rl ririr ciO rrrtrroEl,irrt,i'I,, :|tfi

.*t,rr r,[1. r,rr,rri',rr l,t.r'sl.i litrt,,Itr, 1r''1,. fi .rrrt,lizrriit , .\tr,xitr,r,*trrbru,lt'1,, rttorut,trlxtrItr lllrr ltliUitttttll,o t1,).lilr,i,'t Il rrlr,rr{iaJ 0s1ri r.olxrrzotritr,l,, lrr !l!'f, (lil .ir')tn'i' rlrrp)i(lir,xl,rrrrl' .rrlrlr. (rri(;), {lo o onrdio-irr r,ri lrilriIio. (]clul:r,lii, .rr,ztt,r'i.ritrl, in r''' ,r l r i l x rl r.rrr i rr o tt'ilrrzit,oriollt,itr v|,xorli[a,1,1t,{,i .trr,1ror'1, ru*Lirl,(nirr.'pi, r,rrrrr rlrrplr.sil.il,) ;x.r'il.ricir, .saucu o illiibitio rospir,:.r,1,'i,it (illslrr,rrL l,lpnecNru clli:l,r:r1rrrr.r'), qi cola.b.(1956)au a,r.ijlili; ixi$1,trlrl,u, 1].,':rl' rtnrrrI,)rme \.aso-rtol, t'('$ i r 1' 1trr.. il sincopei,al5turi de fot:na cauli,_ilhiliilottc puli ;i dc fonnr,lo rrri_r.1o.-l)o faptl aqa cum arn r.emarcal, $i rr{)j(( lrr l:rriu si?opoviciu t9-/l ; (:urfi'i., .t928), aceili ftctot.i bc pot ai't:ilt, lrr.rl, Webcr (1972):ttirmd, l)c bunA.drepfate. cL, pare iluzorirr6J, sc tlifrrr,,.rr1i,.z,. ,[iversc iipuri de sil_ cope (r''.utfalc, vaso-depr?sire, vago-vagr,lcslu vin,]r,r.,, vagrre. rcsluiitorLi. vaSo-vagale cu bradica,rdie primitivi). Do l|,r.r,r,:r \\-obe1 i1972; susline cd,.estepr:oferabil ca.toate acesie $incope sit $o rrri{lr pez: cu atit mai mu1t, cu <:il,rist,, llp nxm e1ede. ,,s;ncopetaso-aagale,,, pt'obabil c5, se asociazX sau succed o cardioinhibil,ie yagali 6i o r,ir,so tlepresie simpa_tic5,qi cL do aceste diferite m'ecanisine pol, ir,von,rr -fapt origine comund, depinzind..de un reflcs care pune in joc Ir. Tl,. ponto bulbrtS. care.conline centrii respirarori qi circulatori qi in special c:urli,r. rnoderatori Bi vaso-deDresori. Starea sincopali propriu-zisd(in mod impropriu denumit{ dtr Wr.jx.r (L572)..rtazd,ictald,") esre dc obicei precetlati, dd o fazd,prutlromtlrl (irl propr'iu dcnumitd dc Weber ,,{azd pre.ictald.',;. . Faza prodromald,( pre-accesuald,; pre-ictald, dupd Weber , ^1 ), cu rltl.Lt.rr. dc.zU-J0 Becunde, se manitcstd,prin impresic de ,,rd,ugcneral", t,rrurrsIi lafii, am6{,911, zgomote.auriculare, alteraJii ale peiceptici vizLraio,lri1,i,r. s_ialoree, senzafii iie ,rvid ce.falic", parestezii in extremitl1i, palou,i,,,. nrtrr, (tunpotrivi, roleata, t-egumentelor,uneori dureri opigastric6iitrrr rl,,l,irrit,., grelud $i exceplional vi,rsS,turi lOorfariu, 19?1 ;'Weber, 1g?2). 2. Atacal sincoptal (,,Jaea ictald,ii d,upd,Weber ) corespllodo piorrlrrr,ir cat.eesl,ccompletS, Iropliu-zjse a-_cunogtiafej. $i urmattr dc cd.clrrolI'rrlnrrl ,'st'e stnt siabe'sau ab$ente,dar nr,rpiru,Lirr .inscsizabil,zgomotelo ca.rdiace dc obicei este conseryat5,. Reluarea congtien{eiesto rapidi, drrrrur,,r,'t.,riiiiii a sincopei fiinrl sub 10 secuncle, iar treiirea iiinii totain, fd,rt, oburrLrlhl'. plelungit5,. secundari, amnezia fiincl limitati, doar la durata pierdorii urrr pjielpi. Sinco.lete-cole mai grave, aproximativ o.trsime din-cazud, so 1xrt, Insolr de manfesttri conyulgiye : spasmetonico ln opistol,onuB, oxcotrt,hr.

Cortariu Popoviciu,19?1i Weber,19ZZ). A"cobto nnuti rosra{rconvursrvo se,lnsolesc totdeaunado o rnarcat[ midri&zd,, u[.(,r'i de trtstaf,'mus.. hrpJrsatlvatie, emisiode urind gi mugcarcalimbii, rin ltrxrr,rr smr expucabrre dlrrcuitaFile do diagnostic crLepilopsia (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,ediagnostic, po o.iro rlrlrr,r.
le Tom lezuma :

r: 9*p-"9!!oto^nq, r1rm?Fsauprccectate uneorido ctonii girrr"ruririii", lpl (CorIariu, | 97.1.; gi

a) Examenul clinio este negativ, iar traseeleXEG (standarrl plirr ryi '.lli{tfi nctivS,ri) din fazolo intorcritico sint normalo (Cir,lcii,ianu $i Stoio,,, _ ; Oorfariu, 1971; Corfn,r,iu P,opoviciu, 19?1; Gastaut, tO6f; flnsirr,rrtiqi ,si .olab., 1956; It&illofl,1000 lgit9). DoartV.rcolhrl,1,ir ; Slioica0i Bro$toanu, (1960)a gfl'siila 30'1, rlirr lr'lnrlvii cu sincop., anolnaliilr.r!(1 r',rro.rr,1,. rrlrr.l,r'i.u rro ilslxrcrt cornifin,l, si Itul-0% {,n"{,rnrIlii inrl.osobi l,l sLrbi.'l,ii.rr $irl(Dpevll,Bo-vlulllo,
3:)tl

srrr,rtlrrg rrrrdolont(!, I) iIiI I i II.i|,I(I .llt tclritrrlr,irr LitrrIrrllirrcolroisirrrlrlo (l(!iIlul.i'i, tiiiBiIl(,r"r,IIir, xrrlr|lr,r (1lt ol1,lr,l,rr, sirrrtsoirllr,lli,,o Irr!ov(!l)1,i1, il0 it. .l r,/rr ((|rrfrU'i]t]. ll)71.; (l(irlal'irlryi l,,1r,vic'irr,u)?tl Wt,brrr, lt)?J). lrr sirrrr,lrl (lr)rn(lo lcrrto sirr1, .rrrIrrlsiIr'i,lrrrlirut.ilo rnai Jrirrgi rlo irn 6i siirl irrtrurrrpio (,:rrl1. Ilrr.l'r'irL rrilrrrr{'irr lIplo '1loo0rnplr.t, c(u{.NI,uur[o sl]lr,s]lllrllri loiric. ,,t <rcsl, lil.l {ir rlrrrclrz'ii' rrilcla,sccundoqi cstc urrrr:r,t dc lcirlllr,r'i{ir lrr}(|j'loli{'l11o, .rr|. o Il,rrr rIlzii, lrr0grosir', pinii h rcculrc}a}t,llurrr-ri r.iirri rronrrrrl,l\rsti r1r'iii(r llt cx isl;i,ilrxrrna,lii llDG. (.lrr,sl,rr,rr1; . (I950) . a . doscris sirtolpi], nrrcturnir,a hiperl.agotorjicilor Si rr.r,r,r,iLirI.it, ili lir|crr'(;iorii a,ocstciade- opile+sia rnodei;i,. Aiestr: sincolNr \r,,o \ ir,gir,l(, sirrl l:lyoriz:11,c in oursul nopl.ii, de ridicarea in tirto,.talijin I.rirlc rrrrvoiir, rlo ir,.rLriru,la vagotorricii constitnlionali irL faza ch hipor,rr'ot,ulnr"l. Asocierca acestor diterili factori (staliunc l,ertic:Lli, 'rr,g.i.rrirr prcalabil culcat $i cu tonus vascuiar r:eclus, rrr lrili'l lr, ln srrbicci, afer,r,nlo r irrrrrr':rJrr ctrrl;r'ipcl,cr nocturlX a reactiviti,lii vagald) oxpljcll J)rovalen1,[ .'r'rr,vil:rlorr il,cosl,ol sirrcopeqi asociereafreclenti a nra,iifeBtSrilorcoiyul_ riVrr Iirlifi1, u.ol)lonM, tliagnosticului diferenlial cn epilepsia rnorfoici-r,, 'l'oIrr1i, lrr.ozon{,:r, tloar a tnei contmclii tonic6 in opistAtoius (pl.cccdlr1,rj, rrrr uIrIrt'i rkrlr r10 1*2 sccuso muscnlare gcnel;lizate, ilar'-Iiciorl:r,1ri, irrrrolilii,rlo o 1'rr,z[ c]onicii ritmicii propriu-zisi), precesiuneacidorii ;i rr, dc c5,tle o stare de riiu gencral cu gre!.uri, paltiilr.o ;riclrlolii .orlLory1,inloi ,,i tr':r,rrslrir':r1irr r!lrund,nli!, a-llscotIr ncmoolorEEG de epilppsi;. 1,r.ecur,r si rxrinpro$iunc .a globilor oc[lftTi pozitivi,, etimind, Olignosticril 1rroIrII..rlo rlrr rrpilrrpsio lnorleicd, qi obiectiveazi, hipeivagotodia (Gastaut,'i9I0). l)orli.s-1,orczu-t tri sincop-ayaso-vagald, reprezint[ u ri,spnns teusio_ . r.lrrIr'rriror }r {).lt,l{r()sirne psihici,,cercctiri ale rioastre(Corfariu $i l,opor.icirr, l!r?.ll ; ( iorInlitr, I97-8)au arltat c5,existir,o irnportanti participarti cardiol rrrlriliil,oirnl 38), carc oste capabila prin ea ilsh,-;i sb, declanriezc o .(1i11. rrrr,rrio cottll'i,|,il"t. l'onl,ru rlocllnqarea unei sincope, respeoi;iv pentru leprodueerea irt . lrIr()r'ltl,rt:..1, nroocsllhlisinco_pal, se.utilizeazi, conprcsiunea oculari, compr\)_ rrirrrrur, rJilrusulr.ricr,roljidian qi rnanevra Valsalva f Corfariir. l9?t. I lr78; ( lrrl'ariu Si Popoviciu:,19?1.;Gastaut, 1950; Gasta,rit qi cola,ti., f ObO i ( lirrrlrr.ri, 1_956; YercclJctto, 1960 j \ycber, 19 Z2)..Oompresiun{t; 6i ^(h,$1,lr,ut, olrrlir,riitrr fu,rxr tirnp de 10-15 secunrle,etecbuindu-se concomitent o inrollirrl,nrlr ;xrligrtfici, (EEG, ECG, pneunfograrnd,, eventual $i pletismogra. nrii,). l\,llrnovla, o$to pozitiyi dac}, aceasta antreneazl, nauli cardi;,rr?.i rlrr 5.,I l:lu rnai nultI _ririrea,. ftec\.enlei cardiace cu c6t pulilr 50o/o; rrrrrrilcll;flri1r'o.siucopale (prc-ictale), sventual chiar o siircopn 1vb)i lirzlrltoto poziti.l'e cI valoare , _diagnosticr,au ob{,iDut Gastaut (1950) i1 (.il, 1,rnr'1,4i colab. (19-lir6), Vcrcellctto (19ti0), Corfariu (1971, 19?S) fi l Irr'l'rrlil ;ri l'oqovicin (1971).r,s, uncle djn cazurilc noastre, pe lingi nlrrd(rrlrrobiqrlril,odo opriro cardiac5(la 4? 0/o din cazuri) am obsbr-vat gibloruri rrrrrrr rr,l rirrkr ,,ltr lanltt, lil intervale iie 2-3 secunde.La cazurile obsorvtlo lrri. ((lorj:)l'iu,19?1, 1978; (,trrJariu qi Popoviciu, 19i.t) nu arn putul; 'l(' irr.rrvidonftr prin acuastL.probii riispunsuri ,,corrrphtetr itrU(i, <nr 1'rrrrrr lrl l.trri rlo.rrnilokl-nt o scpu,r0.bi rlr:1x.r'itr.r,tlLr tk' tl, ]rrrlsjr.t,luutr.ici-r,, il,Dil, iflntt I r'.rri[t(,i!lVorcollt:1,10 ei rloir} r.its1rrrrrsrrri t)1,)(i ,,irrtiorri1rl0.lr,)t .11{}60), (frrtlottt'i rlo uttrlo.lontti,.lrillll,olllle, sirrcrtrrr', sirirui rJru., ri,rllru'|,sirLrrsoirlrr,lii). (l atl,iul't6iorlitb. (ll]5(i) ltu lu'i,tir,l 1r...Irp1r, .ii, r'rlrrtsiit ulxrl,r'rx,rrc.lrr,l.g'rilirrt'I, onlo rltri,rrntritlr,lli, rlc rlrrlrr,l,ll :mliri1,ol,i : rur llloc rrlrrrlillo tirro.lliriirl J30
iii

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.lrig. .r3. Proba comprcsi(i octl]arn ln cursul unei lnregistreri poljgralico Ir bol nav ul P .D ., 23 de ani . D g. s i nc opi v as ov agal i . R ohav ul s -a i i k ' r)rul pieldcri dc ctnoqlinl:i de scurti durat:i, declanFate in special d(l lcntru crnol i i ti de eD erv i rj , l ns ol i tc uneori fi de c onv ul s i i Loni c o-c l oni c ., Ii i ' r(l suspcct!t cle epil clJsie. 'foate iDreejstrir.jle EEO intercdLice eu iost nci{aLi\'( . Proba comprcsiei oculare evidenliazd, dupi 6 secunde de la inceperea nlArl( yr ei, o nrodilicare a ri[mnlui cardiac(de ]a 84 bltli pc ninu t 1ai0 b:itnii tnin L), nul ncroas e bj oc rrri s i noatri al e c u dural e de 2-3 s ec unde i n ,,s |i tc ", Iri t.i nod if icarua 'f .l\. si a activitilii EEG. TesLele de cornpresie siDo'carolidi r)ii gi maDcua Valsalva a fosi negati.ic (dupi Corfcriu, 1W7, Cotlilriu tii P opoD i c i rl , 1977 ;1 P opoD i c i & s i c nl ab., 7978),

ca,z de sincopl vaso-vagal5,,actiyarea c&rdiazolic5,lru pro(luco li(,ilrl lit de reactivitatc epilepticS,,dar c5 aceast[ ac1]ivarede multc ori l)t o\,r)it,('ii sitrcopa, in cantit;,li rnici ale substant5 injectati,. poate antrena o pr5,bulir'(iloltii(l Masajul regiunii sino-carotialiene lra15, in cazul unor sincopeyaso-depresoare (Corfariu, 19?1., 1978; Cio}lrrlirr Popoviciu, 1971 1972). Weber, 1i ; In sfirgit, in sincopele prin inhibilie respiratorie poate fi rrl,ilii ptrrrl,r'rr rliagnostic proba lui Yalsalva (dup5, o inEpiralie profuldii, so plrlciicir, rrrrefort expirator cu glota inchis5,,ceeace produ ce un blocaj tl Irrlo:r,rr.,'r'ii prob[, practiclltlt qi rlr loi vonoase,prin hiperpresiuntoracici). AceastS, (Corfariu, 19?1, 1978 I Corfariu qi Popoviciu, 1971) a ploduH Lr rrrrr.l,r sincope vaso-vagale o reaclie cu totul particularS. Antfr:1, h slir;il,rrl probei, s-a produs intii o reacrie bratlicardicS,de lungi, durntr:r.irll lrr,jl li socunde de Ia terminarea manelrei s-au produs blocuri sirxr"rl1,r'ilhr ,,rrr |l,rr],".Accstu roaclii au fost interpretatc de noi drept consccirr!o trl(! luror mI'lcxe exagcl':ltri dc tip va,go-r, agal (13 ozol<1-J aris ch) cu tcJ)()t'(lltsil li (Oorfarir, 1971, 1978). rr,srrpra norhrlulrri sirxr-a,l,r'irl Ilu,clori,,i tl.irfut11it,i, tti :titttoptil.or' tttso-ota,guLr sir11, rrrrrrrrl'o;i ((I()r'lrIIiI|, 1071, .l07llI (rotlttirr tii I'o1rolicitr, l()?.1 : I Wrlx r, l1l?l-r) l. llittoltrt, tnulit'rt,: ltitri,, sliiri tkr irttto|,it itiII r,, ctl't'tiilir sllll+rrrli
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| ,ttriu l .ir | 1)povici . 197.1 ) : :t,) ripul vagal sau c:rrdio_inhibilor;l)) I iprri l,r,rrsio-tloplcsor' I c) tiptrl cer:ebral.(':r, :Ll,il,r'u r-or' 1i expuse pe larg intr_un subcapitol separat. l1l. It'luxtrl,lar[ngiott.esLe.o formi de sincap[-gal"s r,pare la indivizi ((!vi!. rr&i r.i'slilici (50 de ani), pnrti,tori ai uior afecgiuni respiratorii de aparilie sint chintele de fuse. b fornril, ' r'{)ri,r', Irr .rr.. r'iLcurnstanfele n|l |J, ir. t''lus0l|ll t]rrngtan cSte ,,LuSea obnubilantai,,.. | | ". Si.ncopel,e post-traumati,ce.Se confuncli, arlesea cu epilspsia posF ,
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1 l l ,rr Irrrrrl ' t' .ttl ,i l ri , sttt:rt' ri i 1i l rr,rrr4ri i i rr l ,i rrrl rrrl . hipttl r rl u ' tr' 1 tri .. ' ',I" II rt I. ir.' Ir| | , |r I1] I | l] |!ii" r LI iI r . , r ru r.l nrl i rri ,rc l ,r.c i tL rr tii rtt,o l tcl ' i i url r,oi rl tttrrl tr,i otr ,o r,ol rti tl1. H||t|l I I I | )r,| | r\ I I I rI ( r.. S|) rrlt,i so ]uN,loil,zi, sitrrxiJi0lil itrr livjzi r:ltt,trsl,: Il,io oil,zi,[ rl | rrc r r r r . lllr r r r g; r ' 1.r i, rri u l i -r,1 rc liirrc h i s c , s rrp l rr,- i trci l Jzi to, grt l t,st' i rrrpul i ri l i rr, .i. ,\ Ltt'ol),ttt,tt tluH)t.c u1l:lrt in caznl tnrol dur.rli viscer.tkt (t:olfui lro. , I':rl ri .r' s : t ||r . I ||. I I (' . , c t i z r. a trg i u u u ,s r.) s i L rt n u t i rt i (,r,. 1.. S;; roplh tl,i. n cu,rsul efitr)lordrilor inslru.rcntu[,e al)i]r ildoosol,i iu .lr.|rrl rrrrr)r stirrrnlir,ri in teritoliul r.ilgului (risofagn.iu1,u, ganrrus,,,,lri i ckr.) ''- S it c up, lr , t r los tttl i r a p l r.i n tu rs u l u rru r l U rrgi sl rLl i onari i rr pi r,i 6111q1, r:r.'rl :r r ir lii. lr r r ' : rr lir r 1 rrr,t. i l (.D n v i rl e s c c n l ad u p :i rrui l c rnrr,t,l tl i i . U rrj i i rr.l uri :rr r sr s [ l( , ) pc t o lI lr . t ,l (,trtte ({ o rl & ri . 1 9 7 1 . ttTE W eb(.r, 1972). tl ._i i rr ; :r.,r.sl .r . : r r t r r lv inc li rl i S L .n ,.{ i t. ir \' c Z i c a l a . Si r_ r, :trpol ortostaLi ,, cc ;i cot,. l ;r, r|| r'l || |l ) o v r ) r ' t r lr llr , tr. rl c n o i S c p a rtt 1 r| z i i n | onl i nua:,t). ll.. 8 i,runl(.Lc i.atrogene: dupil ingerarea, unor rnedicamente sr.rlr lll r rrrl srrlt nr ot iujec { ii. i. il irr,cop ele tlupii r:onsu,,m, d,e alrtxtl s. ,\itttttltcle d,upo. ttuu in cursul tt t,t,r r Iurturi Iizice. lt,. Sitropclc pri.n tse s;biLitutt^ t sinusultii rortiidiatt au I,t,,l. . .h;11t rrl,rirt itf cad].ul sincopelor vaso-'agale? crezi'du_se c;, intervirro 'r{rirrse rr lrilr.r'r.:terl,u,h,iJilate r...r,g,,1i.. Da_r_ tle_lapt eld constituie o entitate apariir,

( lot {l) fi r l (f s(fttttt 0r lt r t slt t , r 'r u'r t t t t t lt ', , lr r 'r 'r rir r lir r lr , llll) 5 I ( lr t t lir lit t , l1) ?lt ) . (l l )Ttr) 6 i( ior lir lir r f jr I 'olr r vr r r t ( llli l) , r t t t t 't it lon( iill, l: r ar r t '; li lr olt t ilvi l rr,r' i rr 3! )) . it , r ir r lt Hulni lr t t oI it I iit t t ( . 1: i11. o l ri porscrLsilr ilil, ir l, o it r t , l1) 78; Llor : I : lr iu qil\ r llt lvit r it t , l9?l) l )i n obsc lva, liilr r lr r r r illr ( ( I r r r 'lr L, (vtrzi 5i 1Jg. 139), rticsrr cri, irr sitrlolrt, lrl tuse pilrtricipii hr miuc rn[sttrli ( , t 1 im pbr t alt r ilspuns t 'lr dioit r lt i i ' i 1,,' rserrsi i i lit aiea sir r r sr lr r i lr r lr r t , ir I ir r , r r
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urrr"^rrtr.l.r-^.Ap*.^^r.r^^.^i" irig. 39. Inregistrare poligrafic! tn titnpul compresieisiDusuluicarotidiaD dr:ept.le bolnavul L-'\., 47 de ani De mai multi ani prezinte rare c ze (2-3 pe an) de picrdelc a cuDoqtiniei, declansate de tuse (de obicel), dar ti de rls. Esie mare fumdtor $i are o brcnqilti cronicd. Proba (k: compresiea globilor oculari a fost negativd. Se poate lemarca laptul ctr la compresia siriusului carotidian drept apare o pronunlatd bradicnrdie (cu 16 bitii/min lali de valoarea initiall). Concohitent s a produs o scidere a T.A. de ]a 150/80 la 85/40 mmHg, cu revenire la valorilc initiale dupi 22 secuntle, L:r manevra Valsalva, scddrea tensional{ {usese si mai mare (ta 10 seculde dupi lnceperea acesieia), iar dupf n4nqvrei, s-a evidentiat o rcaclie hipertonic{, cu cre$tefl alc itrsu1314s '1.A. pini le 170/B0. Ileicsc o hiperscnsibilitatc a sinusului carotidian dc Lip crrdioinhibi Lor$i t ensiodepresor fi o reactie hipertensiv{ exagcralI (lup[ tcminarea manevrei Valsalvs (dupi Corfdair.l, i971' Corturiu 19'17 6i Popooiciu$i doldr., 1978). Fi I'opauiciLl,

l).. f:ii,runpele1tr_inalte d,i,oerse cause: subalimentalie, dupX insomnii ur,rr sLir,r.i rlrr obosealil ctc. tle aentriLalia este mai rareori intilniti,. Aparo indoo, .l1l...Nin!\1,? ..'.\r,r tr! t,'rI|t,r InLrc ^lt,ipu z0 -40 rle ani,.cu-tulburhri Iuncl,ionale gaitl,o_intcsl,i.: .r,/ ir,lr .i mlb-.r,.:,sculare. tractorii d6clanganfi sint'totcleadna de naturr"r, :r.rrllr.rintl_o simptomalologie ;,,,i,lri.ri, preacceiualLmai lunga (3*l rni_ |lrr,(.),,r'irr':tl'I.(:t'rza,l,i prin^palfi1,a1ii,sl,arcde rd,u, transpiratii ieci, senzatii rI|,,,,1)rrrIrr, lclci, usctciuneagurii, incetogarca, , cong0sl,l& vederii, furni. ir.r.'r'r l| *'rr)rtotr in exlrmititi, prccum !i respira(ii frecvcnte. Aecosrrl rlo.lrirrrkl.o rucuno$tintei este de scurtd,duiath iZO secl, in ti-prl U"oiii lr,rl.rr;r'rrl r..rrriirt'riscito cd,-vedc, dar cd,nu poatc rlsprilrde.Acestemanir'.. :r.fr ..Illr, l,l.orlusoprrrr htpervenlilltia pulmonard (wayne, l96t). Ia truseesta ugor.de diagnoslicat,.Aparo tle obicei tlupitr . lY."Nitr,rropa r l rrlr rlr.:li -4{i ilc lni. la btrrbalii carr:lquferJ. rje dii,crscafecliuni Irrrir. lr,rpulnl r.)n:trr.., t1'rricr. (bron;ito cr.onice, crnfizcmlrulmonar, a,$tn) $.i..),do rrrl(,r'tst Ac{,eJUl sIIlcopftlsc pl,o(lltcu irt litttpul tttsci, lI ''l.t.t 'ltn:Ltorr, f,,.1:(,:irrrlil,rn'rrt-rlo pr)ziIirl,. col.Plrlli, iir sirrrprorr.rclc l)t,esrl,,rll):r,lo l:il':l rrr'tz:t.rrt.';llrli rlrtrr,:r.zii,.lnt.rr. tr|,.x.,r('. ll0,\o.l'r(lo 1- :l_;l rrrirrrr[o rii'rrrt (r inHo(r''il,(r rlo co,'vrrlsiil,oniu]-( [r)lli(:o, rrolrrrr,rrtr rr,vturirrtrrr-;i lrr,pitrr'f;,r,ri rr'rl.rrrr.i'rr.irrl,l rro rurrrhrzio l'lt do ilrrrrrazir', rillsi r rio rirgrrrI 'Irrrl'irrrtrIii, : l:l:l

)ilt' se pare c; acosto zone b&r)rls('llsjl lrit.ol qi tensioclepresor.Da11,1e.1, :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) ,.sial conduce implicit la instalarea unui bloc sitlortlt itt'l sitrloltti. srnLla o pd,bu$ilc a tcnsiunii arteriale, cu ro1 in cleclanqarcrr, \t. Sincopu ortosttLticiieste socotiiX' de cei mai rul!'i (Dod.irlol;' I lli'll ; ( iilgenklantz, 19?2 i Hrs, 1972 ; Weber, 1972) tlrept o sinoollt, vlg;Il?l,. l,h reprezinti 5,5 o/" din totalul sincopclor studiate de Wayno (l 91jl) {i 1,3% din sincopele studi:r,tcde Coliariu (19?8) Si Clortaliu ryi.l'opovitritt ( l$?1). Apare cleobicoi la' inclivizi treculi de 40 de ani. Forma ,rprlitilg('r'I'" iNtIt rr, u,ccstei sinoopo sc tlulnrt;oirzX, dupir, o pcrl'ioadl lungi, tlo ot'l,o'!1,1!f qi oola,l).,1f).17, (1,)irrhno r'il:r,\;i do Corfr,rirtqi Popovilirr, J97l)' lt'rrlrrrrr' rlitr hipotottsittnofl posl]ulrLlir i6i vl'lirlcrrzil, rrrrrricil, ([!rrgol, l1)fi0);ri folrrrrr' ,ttI I ttrtrtu'ii irr tt t tt tttttt t1 ctttt5tiott{,tli, ptrtruu!rlogi:r,, sirrr Jl il lrirrrlrt!rillrrttlrtllj,lt, prll'io:t'rlll' tttrrit i dtlJ)iL rlirr clirrosilt,l;isrrr o scllrl l"r' ltr ot'Lolti'rrIirrtrt, l)l'('lt{'(r(rNlI .i ilmo{trli.I'itrrlotrriltltt trtttto{1 itt1fi, ln crr lrt,lrirn,rrlitr, rrlr'i rrlrzl(rrr rlri 1''i11 lroltttt,vii lorrir.rr lrr, r.lotrilo, lfotrrlt llottir'fiit,ltitrtt i rIt lorrt rrlrrrr Itrso{r,1lrr tlrrror
rli:rlr|l i|i, r r ,r ItIi n o tti t,tr t, tti tItt1 i r r tr r i r 'Itr 'i H l t,l l l ttl ,r !l i ( 'i . l '1 tt,tt r l r .g t'ti N L i tt|o l ttt

:t:t:t

oflosl,iIl,irio lrr sirrrlrornrtlShy-l)nlgtrr',bol,[il rlogurroltr,l,ivir, ln r:rt'opo lingil, lripol,orrsirrrrou, or'krstalicii, sc cunslal,ii, urrhidrozil, impotcn!,i srxuali,, rrxrl,urnii,,abolirea roflexclol pupilare, simptomo cxtrftpirtuni' 1roI;Ihittliu rlir,lrr ryi rr,bs0!l crc$torii orijostatice a catecolaminolor. lrtrrvis (1904) a descris un sindrom de hipotonsiuno ortrc,staticil,{||,rIIiliirlii, i,ir,r'r,loplozinti, o boali degenerativd, cu transmisie er'odilarIJ.
PNEUMO COMPRESIUNE.4 SINUSULUI CARA|IqAN DREPf
.^\.-/2\

(' l rl { ' H c l ,l u if l: 'i . ior r lli,r r r r lol t r r r 1r olir r , r r ir I r r lr r r llt r r r slr r r r iu lr , r . r r sl,Hir r . i r lopr r ,plir r i tcl ,i tLtrir,rllrlio ir rlrilr ilol ir . l i l l , Nt ncopokt lt 'it t , t t u. t : . r r r i, r f u ( l) or linot , 1972) sint lr lor lr r sr r pr , ir r rni[i rnu]to alooljiulri (,il,r1lilrirr,rrcrrlologicc sau vag:lIc, prtiirrrlrt-so ;rlrrtizlr ou lnaro dilicultato rlr,rtzlr, crurtii a, acestora,
PNEUMA COMPRFSIUI,IEA SINUSULUI AROIIDIAN DREPT

ECG

TA, 120/75

-l+\

FM. -4.4. Plus 66lmin. u a. - 4. F D. - C. D.

P D,- T,D.

Pius51/min. l 5 A rV
^^.^4 Vu^,ve-

JlqtuW

^e,\^4^^ryu4,^^\/r/q.^^'/lJ,1lA/(\4r'^l-ar-t^^1^A/!^d^"a.-y1^

PS. - tS. Ii0. lr, Inrcgistiare I)oli$afici tn timpul compresiei sinusului carolidiu drept lli bolnavul A. I., 3? de ani, alg. crizc sincopale orto_ statice. Boln4Yul prezinli erizc sincopdc tnatinale la trccerca din ciino- ln ortostatism. TA. ln clinostatism era de 120/?0 nmHg' irr in orl,ostatism de 90/60 nmHg. Comprcsia globilor oculari a drept se {ost negalivi. ln schiarb, (jomprtsi.rsinusuluicaroLidian voalc ci produce o scidere a tmului caldiac cll 12 ]ritdtlmiDut, crr la 11/75)' Manevla Yalselva o cliscretl scitlere a T.A. (de l^ 1201'15 a proalus o masivi scidero tctlsionali dc la 120/75 la 75145mmHg 1s71 ei -PopoDictu ((rupi alorlariu, tn t, $i ""Il:i"i:.qisP|apa'icilt'

itir, d?. Inrcgistrare poligraficd 1abolnavuM.L., 53 de arli. l)g. sillcof, la nliclirne, La compresia sinuslllri carotidian clrepl s produce lrrr bloc sinoalr'ial de 5 sec., insolit de o senzalie de letin iDinenl. Lr clir( ttarea unei manevre Valsr1va a prezentat - spte sfi$itul acesleix - 0 intonsi reactic tensionald, insoliti de extrasistole ti bradicardic (dul)ir {:arfariu, 19'11, Corfaria;i Papariciu,1971 197t1). ,i PapaDictv$i co1or.,

ItrrlriL, Oorfariu (19?8) qi Corfariu qi Popoviciu (1971)' multe sincopr' r,r'{,rslrrlico siut, rle fapt, consecinla unor hiperreflectivitS,fi sino-carotltli' rr' 1.1i4.lr) ). \1, SirLcopade micliune este destul tle raril, (3,30/6in statistica ltti \\ r yrrr, .1lil0L i].13oloinstatistica lui Corfariu, 1978). Se intilneqte indeos0lri lrr,lriillrl,{,i, dupii, yirsta de 40 de anir alo obicei ilupd, coasum de alottttl plcmfrgiitoare a'ccesIni. Dup'i un timp variabil de somn, bolirr s,,rrlrr, rrrr,r rrl rr.spr,<.l,iv se scoali, Qi imediat dupi, micliuno se produce o sculir'1, ilo curio$tinlE, de 1-2 minute. l)oar uncori se pot semnala simlt' ;rir,r'rlr,r'o gleluri, amo{eli in mernbre), dc obicsi actrsltttt, (amelelir li,nrr' | r()il,c0esuale ' (Oor'l'ariu,1978). Criza sincopal[ dlrea,zi, 1-2 tninute, ra'tottti lipxirrrl |rirro(.irrrlrr so (lo conyulsii tonice sau tonico-clonice, iar postaccesutl hol rrir,vrrl :ltuzr"r, ailtonie, amclrelircefaloo ,5i o stare do te&lni'r.Waync (l9tll) tolm',i in cadrul acceselotsinoopalo llrin hipotonsiullo rr,lrrcrr,rlllr,t at:casth, oll,osl,irl,ioL, irl ()asta,ut (1950) :r, pla$ft1jsin(iopa tlo micliulo irt otdrttl sirrcolrolorvrs()-virErllorliirrd fnvorizrltt'i,do orto,gtatisfirrInl,r-o ftzit, tlrt lir, indivizi vtl,gotr)lli{'i.In doclanqarcil ittrosl,oi Irilrrrlvir,guLorrio rrocl,ut'nir, irtlri, tcllox[, prodttsLplil] golirou, irro 11i ltipol,onsirtttsit :tt'1,ttt nirrolro irrl,olr (lrr'Irr,r'irr qi (11)71)utovirltttr(irll, (lf]?lt) i1i l'olxrvicitt Oor[rtt'irt vrrei,,ii rrlirlrro. (Jig. a| ), qi Ir, trtt,trtlirlilt'tt r' lri;rolrotrsilrililtr,lo sitrttsttltti l rr,rr,r'rrril'i lrolrrir,r'i :r:t4

lr
'i

il I
L:.

, 1. Cauzanzi,rtecardiace(ctepilcld,stenozi aortici, qi bloc a,tr.io-vr,rrlli curar palotiis0rc). 2.Oau'ze miute tago-cartlidc.Este vorba de piltlir, do irri,rrlvr,rr{iru nnui factor vagal in docklnqareade sincope la bolnavi purtr'ltoli rlo lrlor. al rio-ventricular comolet. 3. Cnztzemiute niuro-card,iace: a) Epilepsie pi s,indlctm,A.tltuns Sl,tl,t:r. Se ''stio ci sincopa Adams-Stokes, fiind f-oarte aclesca txrrrltrlsivrr,rrlii, poate fi confundati cu o criz5, de epilepsie, iar Dorlinot (19?2) l tlr,rr,r,irr un caz de comilialitate interpretat ca un sindrom Adams-Slokcs,rlir,l,oli lir, unor tblburS.ri de ritm car:diacapirlte dupl episoadele talricirrrlito rlirr cach'ul manifestirilor sale epilepticc si la care o ttrra,lic anl,it,orl i (irrli :r dus la suprimarea acestor mo{lificif i.-Tot Doclinot (19?2) t,clrrlt':rzir|r,uu cazrrricare prezentau concomitent celedoui afecfiuni 6i sirrrll0rrr .pe (epikrpsirr Acb,r'rs-Stokes).Totugi, Doclinot se intreabi, buirri rir.tr1rLir|,rr, r,rr 11i nai, dac5,aceasti,manifestare eliloptic5, nu reprezintii in rclrlilllo rtrr,lrr'lrr, anorial a unui sindrom Adams-Stokes. lt) Sincoped,e rrilin trt.l'':ulru.tt, Tot Dodinot (19?2) relateazj,i cir,zrrr,i 5i, si nilrotn A.dams-Slokes, lir, r.irrr, ltlocurile paroxistice Adams-Stohs pot agraya urele tullnlttili viriilrrlrrrr, <rcrcl;r'ale la bolnavi cu insu{icienfe fie vcrtebro-bazilaro, 1io oIro|,irlir,rrr,, lrodncindu-so sincolo t1o etioJogiernixt:i, do aceoa, l)tolnuto rngtrrrizirr,r,ir, ttnot cortsnllra,{ii rrorr lo-tr lrliologico la bolnavii calc plczintri lrirrtrlrrr,i rlo
( l l r i f ) ) t l l i t t ( i t'i i r t o l ttIi tl i tl ,r r ,

O sor.io rlrrirrrlor,i (llrrrr, l|t7ll; {ir)l(lllr)'(!t,i1i icor', l{}?0; ,\lorrrrrrl 11l colir,lt., lllTl; liolrrrr11i r,ll:rlr,, ll)?l yi lrl{ii) ;rl l)t,(}lrllll osorio rlrr rrllor rfrr tt,tltrort tt,.l\rtrr'!ir i ttrrlultlui titttwultrit.irr trli.rtili!ii l)iarltt'( ptin ntrlrtlt
I
tl t ,,t! ttl ')'t'nl ,t! ! ul ' r r,l rl tutti tl ,,l i t' ,rttti l uItt.

VVffl . Nir r lr , 2r ir ' lt r i tl . h i y tn l l t(l i t.i l rrl l ti tto u nl ,i tl i t.rl i . l l i rrvilillr . ( ll) 5 1, l { )J )7 )rr i ri s l ,r' ttl rl i z rrls i rrrpl ol rrl rr i )i t)(,tr,(,l l ccti vi tri { i i r rrr,' ('rtr'ol |I (r g t ttl rt, rk r i rrl )} l r| i r i (crr (ol tl l )l l ' 1i i t,i l (l it lir r t t t ir t I I I I t )i i | ()l r!'1 r]i ,i trrr,{' r ! i) r l i rIi s i llr pr iY ii. ir r , l 1 )7 2 )I /. 'l\tll\t,r'ritilt, l(,t.l\)us(j: tl l'lttrttttLttttlt prod,rotnak sirrlr int,otrslitrrl c (lirxl rrrcslclr, r.rjrl:'iy r 'rrr rr,l rlt , z r , r r lt r lcr li' o s 1 :i ,r' t' , u ( .o s1ti 0l i (, 1r,tr' acj r.i:r.l d (' t.u rx i rj l :1 1 cc r. gi i , |, (li$lll{,(i sj sonzlltio de sufoc:}t.e. l I r r'( i | | (| jII (.1 l)) ,4t u'tltl xi?r(,r1lrrl ,,pNt'edo obic{}i dup:'l,\-irs1,i}dc 30 :lni, rle l)l l,li\. lillr llt, sr'\rrl lllrscrrlin, dlpli cum I'ezulti li rlin obsetr.atiikr rorrslr,c (( tr lllil, ll)71 i []ot'lll iu $i llopoviciu, 1972). Acegti bohra,vi sint tlr rrtrirci :rllloririr,lo;i fi hipi{'tLlrsiyi. Arlf,'1, NlthtrLsnu (citr,t d'r Wa)rrc, tliilJ ir, :rr:rlrrl (i'i 1t,l)r'o)(itntitiv 0lreimo djn bolnavii cu afcctjuni oor(,ni.r,l i(:r!1..\Lrri : rr j :i rri i l x ( ' t ' , lir li : r r r r i Ii p c | re n .i l ,i l i ,Il ' te s i ]ro ,c tr,]fi rl j anrj . l rrrr.,r i ., t,,,t, lrrrrrc iri ovidtrnfti, dirrel.sc ft)rmaliulri ganglionare latolo-ce.rvisale si pliiir, rllrrrlo localo. Sinoolii propriu-zisi, se declanqeazii do obicei lrr rr.,r. i.ilri o irirrr1i orrur,l ologio plesifrcopali, apilind in colditii in oare clc).1c ii,lrr I rrrrlt, (l c l:r,n ivolul gil,uhri (comptesiuni in di\rorse circumstantc, iltl I)i!_r'(11,(,ir r,r r iisl rt| lrt.(,a oa,plrlrli la b5.r]:.it'.r,, miqoi,ri bruste ale ca,pului (rto.). _\1rcp-\trl riir( ol)l,l (,iilo rlc sourti, duati (10 -60 secunde) ,i poatc ti irrs<if i1 rlc lorir ulrii .lolricrr'cloni0(', cale pot imita pcr.tect o criz;, epileptioi. ilt, la,pt, rrrrr,ioliirrIr,Irltolnavilol no$tri au iost fuldrull}.ati cu dia,Enosticul ,lr. criz0 , l'rl ' t,l i , (1 ( ( ur J : U. ir r ; i l o p o t j c i u , 1 9 i 2 ). t $til.ro clr'o.pus. . ) .i:lin?lonrclc ?ostacceslt( e se c&ractcl.izeazii printr,o r'rIlrt ii {l(t (,ii ot'a nitrrl e, printr-o Senzaliede anxietato $i de mal.i_,ftl.i iista,}tic/ r,u rlulirlr'i {lc cit cva ole, pini la, citeva zile (tr{invieille, 1$,1?),tulbluiiri rlI r'rr,ri r,01,cl',nc}r,ozi1a,tc, somnolenti, prelungiti,, st;ri de depr.esie, i(l(ri rlr rl i ti ttri o t r lc , ( lllrrhr ir,(|r:t,so po1, Irozcnla manifestdri tle tip nal,colefl ic (_\Iayollr ;i ('hr,N.iogr'('s, cila{,i d0 Minvieillc, 1957). Turne.r: fi I/ealu}onth (19,1S) u,u rllir(.r'ir.i lsi :r,lr'r,ctui ou criderta elpului, ca in accesole al{r petit Ijral rle lill prlrrrl,lrl ic. S-au rnai descris 6i echivalerrle verliginoasr, ilccese cn tnlllulifl i ltl lliri o {lo r.c(]cr'o ulri- Br]u bi1ate.1.a1e. Weiss iii Bzr,lier. (1983) gi \.f.r,risr+ ijr lolrrlr. (11|110, ojtali de Cor{a,riu qi Bopoviciu, 19?:,) au individuriiizll lirrufl(J o('r'oblir,lo rr,L(.jhiperleflectiYithlii sino-caroXidiele, Dnnifesta,l,o lrlirr clizo rlrr ollrubilalc, tulburiri de volbire, atacuri irntste de sl.ibiriuuo , , . r l l ri ,l )|l ] , jlj : r lr . lr r t r r r " rrl u i mu s c l u r' , r' p l l l o d n s o I ' r.i t! ,i ntl ,l & cunrpri ...i r r(' rr ; i rrrn l l r r i c ilJ( ) ' l, idi: ll 1 . :!. .ll.t( lrltrniltstdrri : Il.anifestiirilc ca,r'dhce ci)nstau in tulbur.irIi ilr.r r iirrr r.:rr r li: r r .. . i lr r iur i[i ' i i i l i l n g i rro ;ts r' . ''1. (trilrtiil,r ila d,iagnos'tia t c hiperreflet:tir:itd!ii, s i.tlocq.roti(l,ie,ira sr. lrol, |r rrl |i r l ls l, f ( f l: t) I ! intt,tuslrr,rt,lt.l,( da tl,eil.unSQ,re: O rni;tltr,t lfusoir, ll cit,pului (il11ttrsflri rrrlIitrrrlrrlrillr.poi sluttlN,1,eraJ{i,) itt rttettcil,zli, o ci,rlolc ort picldeltlt, rjoniiliierIloi. ,\liIoIi lrrlliu|ti,r'i]o su(lced ulxri c(]l] r])r0Ftiutr i (.('t\,ioa,le (gult.r'1rrr,rr, silirrs, i||,iIr.iir|r,ir, r'rr r[irri.l irL tllr])ul bi,tlbj(r'ituhr.i, rlu,Lr[iil,ul ]irlor:r'l](j olot.lrit l)tot, r lr rl i r cl o .) $r lr ( lu} L r r l rri rrl i tl c trrs o (Ii o i rr d c rtL bi i , (l or.si ul Ii , o i rr 1r,rzi (i l ot lrrslrr,l icii) ; lt) Utt tLt:tu,tt,l. (Jt olrl<roiIcsl,o l'.'0 i.lt.l)ot'lttn.:|. tskt t:i.t:slrt tlr, tr,rri) t , i l ttczl tt(ir lr lt r t r t s t ic t t r z rri ri i /s l t,tt tr, I r iI )(rr I | ' Irtii I I | | i i l l rl cl j l rl o; c) (.l i rrrl,rsl ,rr r rrtl Ir tl rr int lir " ir t it t t ui I .i n tt" i ., i ::tt l i , F i l i rl , rol l rl z(,l tl i l ,ti (l rJ i r\.i l i r ,l n l o ri i ,l tt1 ' t)t lr ili l r'i {i r,r r r r r lit r r , lr r , lr r lri l i l i i l i \r,i T e l l l i \' (.i i r rrI\i { ,1i i l ,i rrovl rrl i r' rr\| i rrIr,.i | | rr, llll'i ; (trt lr r r il, l! l?l) ; rl ) N l rri l l r,r.N (\l ,r' tl ru l ,l i rr lvj rl rrrr{ i i , (' i nrz,' r)r!1,Lrri ,,rr : t : t {i
../Itu r-d-rr {l r f ( r i l l {I i t t t t 'g i t l t t r r l t , s i t t o r r l tto l i tl i l t,ttl t : :tI|' tr ''I'Ir Ir r ' 1 r r 'r i r r r JItL i l r "..{.1 1 ) l l i l xl zi i ( l r r l lrllill l {}i "i i ( i \l i r l l i l i l l r ', r ':i r "l i r l r "tl r ' t r t l i , i r t r t t o t i t , r ,tvi Il t,l r , r tl ttr ,tttt'

otr .rrrzirt ittlt't $i'rf.l)tl.lo i'ii"i,li,i,l,,r. t$t:t; ,.) Sirr{ r'itrrtr,;rr,r'irIrrtrI.Ir: rl,.r,.rrrl {"r i ;1.11 t.,i i rl:rr' r,.,.-r i. r,rrrrlr ,,,,iiii;;,,',iilltl-l:*i*,r,.i'rr r.,.1rrrrr,.:,

sllllt : lllr lr ' ' rrti tl t' cj trrl so it |lclit l' I t lt \ r 'lr lit t ' l' r ': r ilr iz: r 't l'it idic'tt'r' I'lrcilrrr.rt si'tr' tl' s ernn'ele obier:ltt;t'trlt lti1"rn llrLlirila!ii ' "urot ido lrL cal(11 r digitrli pr iir crrirrplo'irnca prttct icii se ,,i,n-"*rliiOiaoi ',,if"riil' "unei oN,r'(liruu'" utinic poljgr:lliu('1r,1.ri. sr._

r,ii.li.iliei, ..i I itl i rl ri g1r1r.rt'l 'rmi'iril. respiniorii r,irrsirirale. Si cerebl'ale.Itroitaxea sino-ca'ro1 '""liiiii" i]rlrl).i. cllpul llsiurna a-1i de ixdiyidrhi ,, ,itl.o'ri iolicita,rea lrrir'r'(' ,', ,J. si comlr'csiuncacarotidci llimitiYe' car are dfirl)t lrl -arilor j ,,, "tt"ii* rI'li'tr'1tt'' pulin colnplclj ;' mai ldier i'rnrti nrlltl salr fr-ria ('rr(losr Lipott'tsiuno:l, rc:i'c!ii antlt'nellzi r l|l'zt's-Rueft, 1953), care .prin endosin-uzdi-t' ir' lrrrtlr' rrrtz-iLli * 1]rorlxci. Prohl itrvot.:] rlc hipcrtlnsiLure luiY:tl'ir'lt;' p pr'rba irr I9L7)sau ,,Iri: o-'-- ".."ui 0,'t'rsr.' (Ntinvi.jllc.

t'olfariu. 19?8): rlsifliirtr 1\' ' fnci' ]a <lel:utul excitilrii' ] I i.pul aag*L tatt c{ 'dto'1'nllibilor upoi chiar la o oprile cardiaci timp de 10 stttttttk'' l.Lo;tu;e';'e;;'i"iui, ,"^r,ia la frecrcnla i'o'mali' lllectrocardiogra'Ir. it'r'it'llt ;ll,i,i;;; i" r ""t:i"" ia s datdrefte urui b16caj sino-atrial sru. atrio-vtll1.r'i(iull ,.iL'bradicaltl prevu]f rr{r'nl(' r\ tlopinizarca pralabilX sau ld inistraJca de adrtrrlini' rulbrirnri. Ar iitra in ioc u:r rnocanism bulbar (nfinvieille, 195?)' consl,S,intr-o hipotensiune altoriitlil irKl(l b\ fitrut lttnsio-d,epresor 'Oe t:l,rc s-ar d*tot'a unei va'sodilatafii g(trcrirl('t r,rm"irtri "ud.i"utjdi", ta adrenalidi li o. sht inflrenlate d(*r1r'.1)itrrl i cdazii, i"-"it. t95?l Corfari[ [i ?opovicili, 19?2). Ar inira in joo iirl rrrl -o"itn*tl', ifriin i";lfc, uiecanism bnlbal (Minf ieille' 1957). c\ Iivut c??rr&l cor($Iulde tablourilor de hipelTefleci'ivil it'il sitttt j cattlirttr':i srttr modif ic5-r' ,:'rut idian'I (are nu |.c ilso!r'sf de rprct'inl-ri)c rrt drddo atropilri sa,tt adrr'tur'litr'r' ,, rt.ioooi. ..i carc nu .ilt in{luenlaf 'l trti. I.t (Minvieillc, 19571. ,l,i,rcrvarca iino-crr.titljanil Iijnr.le{icrce -A.r'rtili r,rfebrali, n fosi individurlizati' inci de lTeiss $i Raker (1933), rlltrti tltr t1'flris. UaDrs si Weiss (193T,cita1i de Corfariu $i Popoviciu' l1)?!), trrttro i ,,, iof'Jti rLou)itreiini .1in caiu,r.ile4e hiperreflectivitatc situr.r,rrtrrl ".i realizeazi' aceaJttd, forlllri, tleqi llilvicille (19i7) Fi Corl lirl {11)il) rlir,ni, llr ai.[tat cE,,de fapt, este Tot.bacle ccle mai multc uri r.lc folrru, rrrirlrr,\ liji autori ilaSeurl, in cadrul formel'r cerebrale Sindroanl(trf tl.r' lt ilrt't j,4ifrtrrtttl ('rt'('ir' li r,,liectivitatei, a cirot simptomatologieesto nervoasi, rrrutriicst.it ilo obi(cl i\ e de Laz*. Mjnvieille (195?) a individralizat mai multc Jomt' ; tlc rlittti pr,in rr'trrtrsc (rara) ^se caracterizoazil cet ebraLe a,) U'anneLe Pxrr(i li lL llJtlrl(( lLlsoulinl', t|rtalc a s15rii tlc cort:lticnl,ii,piolderoa, totLusriitti ()pjl(rllLio, sli,ltitrittttrr, alrf $0.l',iriii ti, d0 r,tirrvulsii au'icu lar'(',.hiu' zl_L,rrot. Ii tr'1rt' rk' lllitts ttctrlot'ivlr'1 lt(j(1(rs(' il(l('s{'it, , tliurr1ro1' do yt'drrtir, ti]ibrLlir,ri (,iir1)i .lliIXrt''tt{r\ i(litur,I)lill rirrrrsrrtrri $i }rrirr rltr.l. ,tiisc *i f1,lr, l)1.(,si'r'r,,
t ,ll, t lr r I 'r lt l: i l) t ilr r llllt t it r ihLlilt l r lr '. ll'( lili lli( t 'l llli( 1 prrrrl l s'Il i rtrrl t,t , llr t git r r , lit t t |lr l lt |t slr 't r r r r xsr \ |r 'l' I i t ' \ ' i' I | |tI I i ||'| (I r l t lr '( llr r I lr l l )b'l) , i l \l i rrvi rri l | ,, i ( Nir r r i|illr , , llllr 'i) , ir r I lr u t r ot t lt r r l olir t lt t t Dlr t gir ',t r t or lt i ' l l ,)(i rl rr ti I rrl rilr , |)io l ol lt 'l llr l{'lt t ', l roi rti rr| ' vi rN (
:t:l i

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Iltlri,rrrrtr l ilt r , r l, t , t , n. lt x r l ; i, r r ,lilt t r . l, u i ( t t . t , d i r t . s , , l . t t s i r t r t r l , , ltt ltt,tl, I J):.rlllir Ir. l'r.Z;r r llr t , . l' r l. r lit r r r . , . : , , . , r , , iir r r l l l i i , t , {l , t i . r , r l r r r., r rr - I i , . I I t . | ( , . 1 :,t I i,r'ir rlirr\'l.iir.,,1, r ir , . : r r . r , r r lr r lr r i . i f r r lt r r i r . : i r i l . r., . ; r i r : . r , , r, i i . l r r l . i l l i , r " | | l1, .,r | .lr zi|r' :rlr. . it r ir r lr r i , . : r r , r t ir lilr t r 1dr . r L , . r t : r r , , . l ; r, r r . , t , . 2 i , . : i ) . r t , r . . r l l r l r i r \ lir i i"rlr,, (l|,:,t)' r ir L' iiur L' - s u1t r os iv ii lr , iupll s i i r . 0 {) 1 ) ( ! 1 0 1 s l r n ) . {j l r r 1 ) 1 i r l i ( 'r ( \ , I )lrlr r ''.'\l.t1 it, Ir':r g . il' , t r l. CO t liiiiir t t lir , Si p t , i i t . l i l X , r , l ] , t r , : I f 'r , t r i l r , f i r r r r i l , r l rrrllr lllrr.

ri;iriliiiffii ;] I'jiili :r';'trll*[rtf; i;li, *rsi11i.rtih,**;lx|rl: i;-i,p"l#ii;t$tru**l,:";lf ;)'ffi

ii"'*u t lu tl' pt"'io iult ri trl ' r'irr'lir)' (l01 .o 't'i vilitii sino-carol,idiene 'pio* a activ.jtaiii clcclrir"r lr.trtrtlir'1" p"o-i*iox ii'bi lr;t" *"prinde o'rJ.r'irc

t"';iy:;t,ltiil'li'f,Lllr;.liiit

rt'grrlrrlir..rrrrl.lrl. rlir irrflrrx'r'ikruo.iirepl,i\ao'(i rti.'l l^ ,r'igiru,ri sirrr,,r i I i I |(I irr rr,rrtrlirfi limp sir r.zlste l:l ilchcmirr,t\dati;ir, I|(i1' | . , I)(,i rIL {i itrl(,r.

,.1.. )l,trli.li,<irilr Illiri it hiperref Lecth|tuteasi.,o_carctlidiartii. Jt)l.t,l,, r* *rir,rrg"'.1('l, r 1r'ltti*lir,r in pelioadelo interditice sint cel mai [rlrrrur, 'i rrlrrrrir,L, lrllilrv,ifiilc,, tUtT l Cor1a,riu, 19?1 ; Corfariu qi Fopoviciu, 1{t?:,}). ,,,ll,,ll ut l,ir lrrl ,siicupel0r,, sau la excltarea sinisuluf(prin corrr[r,ii l]l ll, pr.irrrnasaj,.sau prin stirndarcm6canicl, ,'llill:' l.1,cil-!,1,.,1'xl,ulii,, il.trr r,l'.l, ugrliu([iDr,li1, asupra axului carotidian, rcaliza,lEprin rii,sl,Lrirur, ilrrlR.,tr) rr':L,:rjlltt't r,..spdctiv p.in variatiilc dc presiunc cntlrrsi.rrzrLlrr 'lr-rput), irr lripor','rrsiu{ru ;rrrrr.or:rl,',:Lti0 cil, si irr lripr.r. lcomprcJiu;e subsin-uzali,), t(.r.rirrr,'(iiu,luiiij de luse, prubl lui yalsalva), se pot obfin6 o seiie tlc iirrli (.rl,llr cit}.e r,u tost sistemat,__zate l,r1{r(,:r,i0, de n[invieille (19bT)in J tilturi: rr') I'r'irrrLrl i ip ; uu ,r)ri,r'Jnici o modifioare EEG. Doai. sistemul crir.rri. \,:r.,.'ii' ; b) AJ tloilea tip: arnp.lil,udinea riflnurilor Iilr '.il(. ol| | ll| llr r.:lzjL l i.i! 'nlcrcsii,.l tit { t c 0ut ||[ r t x CiLal ini gi Sc nO r m a l j z C a z L l a s t . i r q i t u l p I t | i x . l , | , r.i, iri' ir,c{-.l tip de r.iispuns 1,1,r!. EEG ; c} Al treilna tip: rrrodifici.r,iIr 'ri, tr' r'.r',t,s'rt m&i plu'utrfr,tc, l,raducindu_sc prin rdriii ale trils.rrLrr. rrirlrt,,rlii rol:rtr.,.1.952; .tIinvieillc,1957).Astfel, limp de citeva scclulllr jci. r,poi scadr.ampliturlinea,iar -drLpi lr:r.;,'.rl rr|l :'r:rrrrrdil 5_10 gccrrlrrlrr :r'r' r' riJr.rlr'ii.ur,ll'\'ollrrle (to t0 ci'ri/scc si undc rtate, mai cvitlerrt,o rrrr lr;lirtrril', I'ttrtrirLl . d:lr cu o ur.olru,prcdominanln de prr,r,f.i,ru .lrifu.lr.rulr.. ., rlt.. t'r r'\(,r1.;[1 , /\,...il,, rrrlu]ente Sint la inCcpUtdin bAnda l,cl,a1 rr.||rrl ir1r.r'itt.so rr)rl,i tn[1], odat5 cu crcDtereaamplitudinii. realizinil'rrrirl. fi rlrrlirrrlrr I,r'rrri, sirrrrs,idal5,. Oda,tricu-e,pa.ilil u-ndclorlente, bolnavut i4l putind lrrr,r'rl.r',,11ir..1f,,, s,i _citevaconvulsii. Unrielc 1e.1,. lrit, _l)l,eze'ta l(,_ -l() s'' {'nd'', tlar' r'|r'r'$rrlir uneoxi chiar 1-2 minute. ccl mai arrrrrsarr ,r.r:{;r,,' r'r.Lr,{io ct.'r'lugitiu intre ri,rirea ttaseelor EEG qi br:ldioa r.rllrr, tl:r,r diacii nu depiqe;te 6 secuntle,lr,rr,oeul 1lrr,rrzu, EEG nu srrlirrii 'r'rr1r.r'Lrr lir,rir,tri, rlL]. du,cii a,julgc ia 10-1b secuntle,apar modificii,ri EE(i, crxru .rr .r'r'ii' rulrrl u'rroxi.i ccrcbralo *,uzate dc abseuJasistolei ventricirluftr, rl, li :rr,lrirr.r.rr csr, singuta t,auzri, lMinrl.illo, j9j7), jntrucit cor.r.r,trlli :rl, ltti.l,ltrg,,l. (19j4) a'r rqtrrrrtti, rnoclifjciri -E-DGin :llrar,rr1rr, ii r,r'lrrb. ,,r'rr';r.r lJnr.rlr(,ilnrlll ;:r,ll hilrotcnsiuni ar.teriale.Aceste constati,r,i altrnf,$ ' \r.ltr,llt,ir, lot. lbLlrrourlollralti. purc, aliluri d0 formo intricate, irr rr lrr .r,;r,l|,rrtlu, irrllrrr'r{:"r, r',,r't,bta,li, diro.ctd, la, 1i.r,r,tOrii cardi:r,rr sau 1jonsiorrrr,l. 'I r'olrtl"irrll,irrvudrrt:lr,ptulcir,p_o.Ill)Gnuscpuuileviclenij, manilcxl,i,fl ,,1,,.1,r'ir',' clilr.Ii,it.. irr lirtrlrrrl p.ob.ktr dc .xcii:r,1li.sirLo-oar6tidiarrii (.Nllrr, rr'.rllr'.,l^l)fi.7 i |!')|.Ii,iir|,lU7l, l.9Zlii Liorlariu ryi l:bpoviciu, 19?2). illllor ir|,,|r(r('||rt l,r'r,trir' iiri Ir:r'Irirliir prirllr!0 pi0r'rLrr.0 rLl eotrril,icrrl,ii, crt rnirycr'l,r'l rlrrI'iIll lrrl,o|.lr,l,isrrurLrr'qi orr cil,trvll clolrii,rrtr sc i rrrrrgis l,rr1r,zir, rlrlgil,itrrrln l.rrl. rri rrr..Il,i,r'rl .ii,.rir I'ir'|i-rrrrrI. (Cor.fa,rirr ryi ltrl,ovicirr, I1)?2),l)rrrrl tt,tr,tt,ll,lr, lr,lxrrrr(li, rr IcrrIr,o-rrIiIrirrii, r'sirr 1,ollt,l rlilirr.ilrii, rlrr it,lrstrrrlit, rlirr |rrl,ilt trlrl 1i rlr,,,lillltr.lr" irlrrir,rrlrr 1;rrrrrIrolrIIr,.
:J;Il

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L'rrrrrrr,'rrl Jiirrrlbihte-ral sincrond,]tiina ae fapt idlentic'cu rirr,.{iil,i ,qi, rr" .lr'rr'(1 \ rzr:urc sftudc irlta natulir,. Irodiiic.irile cardiace sau tcnsi0rr[|.

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ll,,,llilil:;;,l,,li,ij,,lli l*!:,,lii;,jllilr,i;,i'ill"llilll,, ,;l;ii;,1;lt,,i,i,li;1.;l,l:ill1 , , ;;;ii,,i.i: i,

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l r ) 1 1 ) ( l fi cl L l l l l ( r q i sl l 'i l i l ( r tr zttl l 'l . D U l l i i , c t t t t r i l l tl i l l i L l :r l :r l .r 'l l l 'l l r r l ' ( l l i l ]g l l t) s p o l 1 1 'l tl l l ( i l l ( [i $ P( 'xl 'i u l ) |\i l ,ttl i l r i r ,r 'i i o I X ) l i g f a f i o o t l ) l l i i 1 ,i 1 , 1 r :r r :r r .Ittti t{1 i i .ril '1 i tIi I.tr :tr 1 i :r I :r l si tr .,1 ' I.r '' t,utiiir n u r l l r 'l i r l r '"1 'i * t i i I I t' ! t I ; r' I i i ;;l tttti t:t\ t:t.t, stttd ti r t . \ '. - i , , r " q i i t , A i i k ' (ort'r'r'irt, 19?1, 1978; (.lollir'r'rll (Gast*ut, 1t)"56i Oilcfia,ulL qi 51oic.t,, lutj;; cr tztt.tt tl j l r l r ' 3 u o /o g a si l Vo t"t l l ctto ( 1 9 6 0 / 3 l C 7 :.j i . l ) o r t .iFrno"iaiu,

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?t1*\t'$^^&4!t'{ry&+@
./.it. :{.9. I cflistmrc lolisralici (compresiunea sinusului earoLiCian dupi |ilx'ryDce) Ii bolnr\,ut C.ll., 48 dc ani. Dg, cr.izc sincopate p n hipclreflecli\'il.ntc sinocar.otjdian:I. Pentlu cr.izcle de pierdorc a euno$tintrei, deti IirA collvuisii lo i(!)-clonicc ti lir;r njci o simptonratologie preacces[a]d, a lost r.lidrctr)t:1 drelt epileptjci. lll clinica noastri loate invesligaljilc clinice \ i t , r r , l i l l i c e t i n r l .iv UEG .i I' F :b ) cr r fo .t n cg rti vc. C ompi restun, a gtt,l r j l o r o c u l r l i a i o st lr e g a tivi. In sch in jtJ p t llg u r a ie r edc cum_conl prcsrunca sir rsului curolidiAn sting (dupi hiperpnee) produce rrn bloc siu;atrial cu ( l r r r N l i r d c I s r c nn d e , In so lit d c u n b u fcu d e u n d e lente bi l ateral e, si ncrol l e similflre s-au produs 9i prin comptesiunea sinusrlui ii ni )rilrict, llodiliciri rirolidiln d r c p l . lla n cr r a Va lsh h :a a lo st. Dcg a tiYi (dupd L'ortori u, 1971, ( h r l a r i u$ i ? o p o Diciu , tg ? l si p o lo r i.iu $i col ab.,Tgj B ),

din net:ralgia ltlosof uringianti. Ri1cy i1g42, citat rlo .-. l\. r9inccrpzle()oltu[olla \Vr!,yn0, .11)01) (1OiT, citai de Coriariu, 19i8) au d'escrislsO;i r.ilri rlrr.rr':rr.&lSii gluso jr.i,t.,, taringir.lc (.u sincopc pr.in b ipersousibjl rr, H|llrs||tut {:t.1..r1.1(lli! . Ac' sl.c loTmc ,plrf iculare dc sincope intrtttr,,u,, ; rrr,r'r'rr,lgi..gl',solnringianL in accescduicr'oase sfir;itc prin aciese sincoprr,Lr, Irilrr,r'rr.rrsilrililrr,t,c sino-r:aro lidil,iti, 6i prezen!a unui h.ig-qer zone, a i,iir.,,r ir r':r,(ir. irrrlrrr.rr .r,izlr, sincoplli. Dur.rilc alri in rcnnseuiolentecu dr,,rr,ll, {l(. :j(t..ltl,-s, IiirLrl r.rr,ntorrir,trr la.baza linibii, i n amigdali, qi in unghitrl rrrrrrrlilrrrlot', irrr.intro crize dc obiceri bolnavul nu:lcuZ[ nici'un simpl:ot', lriris|,ii I r)L rii lxrl nlrl i car,.acuzil dureri pcrrnanente,peste care sesnpt.it l)lrrl pr o.,-,ilruc lr,lgiilrYiolt:trtc,I'io_spontano, fie tlec]an;a,le de deglntilid;i/'srr,rr rl^ i'il,rr'.rr,z,rr.l'r' ilrcLyatn rlc glosofaringian,rle.rnulte orioontimirii. si rlilrilrr Ir'irr rrplr,r'il,ia, sincolci qi insoi;i1,e sfl,u nu de convulsiii,rnico_.loli,,,, i-l i rr| si 1, rrlr, i il i r,rrro sineop:l su declanqoazir rruml,i la ,,nevralgia rl: inulri. I !,irrr"(i'ir i.' si rr,lub., lt)5? I I?:iillu,s, 1lltio),d l d. muli;c o.i sincopclr pr1;fi rlrr.Lrrrsrrl,. sinutlrrlui cir,r.otirlilrr (|.'l,illrr,s, 1i l.in corIqutsiurL.:l Jg00), irrrprf rlirt11r11,'q,1,,,, rrrl'rlit.t,trrrrntoitsii, ll, sirttrsu]rri so pot itrl,r'crtuxt nocosolc sjrrrrr rrrrryiclizclo ncvllrJgicc. lrr rrrullo lrrlrr,rlir,r' sitrra,(ii, trrrtirol,olniil, lllrl,a.l.lt,rrilul'i, ir, rrolvulrrii{losrlinilrgil,lt irr.l,r.t',tuprr rr,(il, rrt,izcl. 1rolrlo lilgicr,,r,il, yi rt,llrttili rt, lt,sinl,rrlci r.lr,trlirr,r,rr sirrrrolrci l, lil cotl;tr,r,siltrcrt ,.rrrrrt sirllsutrl 5i r.
r l t : l| l. : l ll)

,i"o"rloiii nroilcr,rte'Silu 10o/odin 10O de bolna'i cu sincolo, itld',str1i tl. tip 1-aso-ragal), anomalii EllG de tip epiieptic' rltlrrr'L(ltr potigrdfice pot furniza- clate pre!io:l's() lu tri, I'nregistrd'tile 'iar -Inecanismele carc concurS' h instit'irlt rrrr' ,tia,g";sti;, ryi ref'erit6ar; la sll]oopol, i. In.reaistrarea accesttlui,oste posibili, foatte rat, dar clnd se lx'irl'(l Ir-r,ce. ie tlifdrentiazX, in motl net aCcsul slncopal de accesul cpilolf i(r' clirerselor nrcto'lo de testalr rr p1'rl,cticarle& 2. lt .faBeleintercri'xi,cet roncdr rofiexogelre (testle d; compresie a glollilur oculari, de corltpt(!$i(l caiotitiih,n, netoda Vtlsa'l"rr') pot surplinde po poligli)'rtiir' ,r" ti"iu.if"i liincrrettcxiritatea zonelot reflcxogencr evetrtuill chiar s5' lptodtr('ii' irt iaborator acoesul sincoPal. se fir,ceprin crjmpresil gkrbilrrr' a,\ Test ta'eT refletului aculo-card,iao 1,culi.lii,ur rnirin{lu:se p0 poligrami, actiYitatoa ECG' re,spira!ia' 'I'r\- 9i.l't:t'' i],ol)l'irrrrI testind roflexul oculo^-cardiac, i,lpC. L.tf"t,Verceilefto 1iOO0), ' 2 cu ""ot de s' ca,rdia,ce -9 stopuri si[cope' cu cte cazuri lo'iz ,iin 33 "lil'r]rtlrr$ lt!.rrlli iar $imotrice), li'n O lncomptet" (unde lente dihterale, sincrone $i li3 studiali;, stopuri cardiace cu ,,ri'spuns EEG cotttltLrl')l l- t oi"r"i toi" eloct't"gr':r'lir':r) ""i Ieutc cripate tle pcriuldc de u*de 'rrui"uii cic -dePrr:sie globilor ocrrlmi Lr 'l() rl.' cornplesici iretoda. utilizind ilr;ui Lf iOr t ctL mai lrr[lL de l0 lrillii P'' irof"ot:i. J, obtinut sc l:rea ritmului ctr'rrliac ii, io*t" cazurilc, pauze pc ECC cu dun'ta dc 2-3 -s (Ii'ri rrisprrtr'r "'i""i llnei U 18 cazuri, pauzi pe ECG uai m*ri de 6 s (cu.ulde lcnto ltila'l'r' !io"r"o" Si sim-otricclre EEG) la 4 cazuri, sljoluri caraliaco ntli tttrt,ti "nt". ,l,r iii s (cu undo foerte lente bilaterale, sillclone $i simetricct ul'lna'l.! -(l(r instalalea piorderii de conqticnttr') la' lllli li "uolu,tirrr,i"otraseului $i de i16lna,r-i. - -i.,a eleloi (Corfariu, 1971' 1978; Corlariu usilhltobolnavii obserYa,ti i, a globihrr rrcrtliLt ticlu.'igfZ. l9?3) s-a obtinul' prin testul dc cotnpresio o/o lrlrr.rrri tlrr alur.ir bolnavi, cu di[fie la 47 , reacr-iedi oprirc cafdiaci 2-3 s. I.ta unelo cqzuri ann evidotrtil'li bl)lrrtrt ^ri.ro-otiiat" cu d.ura,totle iant", la intervale do 2-3 s. ln cazuistica noastl i'i' Iru rlrrr ;;;i;i; 'accstei probe, clenivcliri tcnsiolalo 9i nici IJrlttttrsttt'i -iu "i;; ,,f,*"."oi, it""*,'sul trr pierddea c6nqticnfei, ca in relat5'rilc lui Vt't crrlhrl -.,ro,noi'i"; uuG cu gi l'r.rCortariu (19?1' 1978) 6i ii.s-ooi- iteatttoi. Gasfaut (1956), Corfaiiu rlt' EEG csto doloI'milrrL{iL i,.rt:i.i" irszz, isza) au c,picciatci' ,.t:xpresia)' cu tlltIaLAstlb 6 $, trrrlrlixlili{ ii Asitut uri bl,rcsirr,-:-ulrial 1i,,,*i* ^iir,otti. ia'r.r,scul EEG. in schitnb o rlsisl,olioruai rnato do 6 sr prodlrco lr{1 l'r'ir'r'iorrl gotroralizal;0, cilro oLos. i1 ilrttltlitt-ttlit't iiiJC lr,rt"u.i rlo *rtrlo 1,IrIILII.rLrIItir, tltl 12--1'l tt lrrrrr tlludiltl tltr, durill;ir' lJtt n1',' tirrrrtItttItr, rl.o,ii,trvrl iiril,,err.s irro, l;ii sitttirl,t $irr(jlrtlro rrrrrkr krtrl,o lti[:r,l,ortlo, rlrr rloscrilrr:ilr ,ii,r,irlrr,r:itr uo lt)lC(.1
( !i !l ( r i l to tl t'tr l tl tl r l r tl l l tt r ttl I tt r t I tt l i r l r , l t l lr l ,i tl t,tl !i t I't'i l ,;Io ttItIt,I I t r I t I i I i I Ii t t 'tI ', r 'r r r ', l 1 , r , , f i r r i , , i , r *1 , , , , 1 *t,t,,, l r to l '{l r 'tl , r l r r r r tl tr l ;l .i ttl r 'i ,. l l tt l l r l :l l l t t'l \l tl i l l ( l l u i i r 'l l l ttl l r i i tr

./141

lctrl'0s-rr, I,'orlus dr|r"r'_?-l0 $(1(,utulc, iru pi,";.t,,",ro iiiirrulsiill,,i s-1,irrs1,rr,t1r; rlrrpii,. .sistoli. va'i*bilii fintre 12 qi fS s;, i'frurc{,ic t1i ptirt,ic,I*il ii,1ii. oilollrrtorti alo fiecilrrri bolnav. b) Oonlpr*il,jrea sirtttst.Llui cttrotitlion,dnpii cutrL un pl,eorzil,ti :tnto,iot,,, r lrrirrllln tcstmrr:l re ,ctiviirilii lcr,sl,,i irnpoitante zonc ieflexog"ui., lirtli .iislrLrrrrn.ile rt,Jupra, activititl,ii ti,rdiacc, a;f-.1. Ui a't.ai.irlrii 'lrlilrrt.e r',rirr. trr lti.t{.(,ilzllr'i 5{. poL olrLin(. lnrogisLrijTj polig|afic,.ulo urrUr.,.r,izo sirr,-r,1r;r.lr'. lnr:ri\\',.isr:i lJlk,,r rlb3l/ &u !rr.(.izati.ir, ju,jir izji ll'..luoo r.llr,r,.. r{') rrirtt! I r) t[,le;.i lt{,1] sinusul i carofidiAn tru prodUcenici Utl lJsl $ rr,rrrrtrnal, iu,r'ltr, rostul inclivizilor, rcrj[str, cornpres'iune i,'tluce o braclici|rlitr rrr','rl(.rrtii 1sub.0bdthi/;rrirrI11ili d! r.alorr.-rinilirla) 5i o scnrJero u ,1,..\, : r, ll, |l rr I l:i- lalii l irloJrea jnilirli. 'l{, Irr schimb, la bolnavii cu hippr.r,,flt.ctir-jtat c siro-corobicliani, mns*iul r,r-.,steiregiuni anl,reneazi o serie de noditic5ri, rliqrt[ y]]l!]^"!l"l:"1 ):,:ii. lUxr(:tzlr, irI|rr j('ille. 1957; Corfariu. 1971. 19?g; t 1_\tr.o\ urfrriu ;i'J-,,prrrr' rr, 1972,.t913i. 1) fi,. nurnrli rrru,lirjcili ECri, firii mudificlri ,t-.Ei;: 1,.) ite dc apatilia de unde iente din bancla thet,. .1..r-'ortrlrult'rttl(jc, ins{Jl r:hiur delt:r,,po toate deriyatiite, carc c'oincid cliu punet d;;;ii;;i;i,l r rr iordu] or, cu Di,l blnlei tinrp c1e 10 -30 s, clar cu pirsistenla modificiriior. .[, lrjirl(i t"l LLe 1ir(.n 1-2 minute. Rezulli5 ci, Ia bolnavii c. hiperreflcctivilrr,i,t'r,i rru-e:.ro1idiitnJ,,comp.esiunea sinusului carotidian deteiminX, itilcol)r rr,'id.liciti ca.dioiuhibitor i.i( ii \i nrai pulin cu scirlor(.ib 'blu{.ul 1.,-rrsirrrrii 'csodep.rcsorii iiriorirl(.., 1rr oxperionrl sin6-airial O"ntan.ai',i .nua,strA, ir,v|l1, rtLrr';tt,' ]-i.trubile (itrtre 2^qi 15 s) Di a fost faTorizat de hipcrpueoir, pEG sirit crependentenu nrmai de duratii, Modificirite |r'tr.,labilii'. *isistolitri, rlilr';i de uncle reactivitiili indir,'iduale,in sensul ci, la unii bohavi irrr apii,rut unde lente biiaterale, sinerone Ei'simetrice (mai exprimatc tx) rh.r'i.r'ir.liiL.&nterioar(') dupa o asi"ioliedo 8 s, in schimb Ia al!,ii;io ti;Ii I rfll(.r,r:r..t. lU rlc l2-14 s (fobdcaunadupd hiperpnee). (.j'|rl,riu (1971,.1978)ft.demorstrat ce dcncrvarex, iprio infilrrrr{irr, ir.rr(.i1.{.,,'ci) a siuusului r.a.or idian a coudus la suspendarei. muditicirri'r. p.ligltlic. ltr, compresiunea sinusului carotidian, in-clusiv cu o desincrlni. zrrro olocl,roencefalograf icd ipsilaterald,, ,;:) Maneura Yalsaloo paate induce modificd,ri ale dinamieii circul*ttirji l)r l cr'o$tolea_presiunii intratoracice, cu aparilia de uncle lente r,hctrt. r|rlt,rr,yxr pHG ;! ghiar cu decianqarea ile accesesincopale (Clkfi, i:rrrrrsi -traseelo Sr6i11r, 1963; Sbcrpey-Sbater,t953). ( orfariu 1lgi.l, ji?xt *j t.rl;rljrr fi Popoyiciu(1C72, lgZJ),pracricinrl manerraValsaira la Uohiavi , I snl ,rl,n ul.fosfalice. ]a-mieliunc Si la 1,llse, au ob[,.inut pe poliliralnr.[ trrrrrlili.ili drr Lip n'oOibilo[, cu instalr,reaunor b]ocuii sino-atrilrlr, rt{. Hrultr-rr "rtO thrrati, (B -4 s), .lar {H,r[,modifici,ri EEG concomitente. .l,rr, r,lrrl{r(,irizul i, colcrtilLrl nostru a rnrarcat ue$terea T.A. cu 60_g0 n}m}lg Irrl'ir, drr r.rlloaloli,-injtiali. Sciiclerile T.A. in cursul manevlei valsalvrii lr\xlrru fi roac!;iikrhipertensive ap5,rut s dupX sfirqitul acestei manov:rr, nr\'ir,lrrJrro('r"rl irkxxl cii aooasl,il nrrl,ncvrii ar putea infhrcnla zonele rrfhiro. gr,rrrlrrrrrrsrrnsilrik:, c&r'o, irr cir,z dc l igllscnsi lrilitalc,pot lcaclktna,irukxrri(lr l,r'rrrl,r'-r crrrrlioinhibil,olio (Corlar'iu,J.f)2J., 19?,$; Oor1llIiu 'rriliviirlto Ir llfl)(f! ioi , L!72, l!'l:J). it,l:l

Itl rl i t t , , l: l r : r lr jr lll rrrrIj rr,r' i , ,I r, r | , . r1 ,. rrr:rri rrrr rrr. :i 0 rl r. r.' .I l rtl ,l t | tut' c sc r.r,i I. I si lr,lolr,zii, 1,r''.,r0rrl Ir)l!(i rlri brr,ziilr)r'lrxLI. lri.,,.,nrL,.il.,r,t,,rsir,.,, l,pa,r,r{,iir, rrrrrl.lrl.

,l:llli,i',.rfl,.,l,r''r.rlrLtirir, r'r.rr1lrr, biilirilrr crrr,rlrrlui, rllpri,t,ir,rrr ljl'j;j',,1:. ;rr.tlirr.t.rrl rrjrljrir'rllIr, rr(.N| rrrrrlr'lrr lr.rtlr'. tl.r,rrllrr,lizlr,ir,, r,ru.c itylt,lrsi, ssrr,rlii,'.irr lrrrpli.

1 :1.I .;i,:!.,".in . I 'xlt llt t r 'dt

r lr t r 4t l*t t l li. lt , t t t t ! . ial. , it t si, t r ult l

\(r' l rIl tto: r . : r ', . r ; r r lr lr lir r . qi lr l ; r lr I l. it , r r llr I it r r lilr r r ': r . r , , , . , 1oI r . r . izr . . (i ,ri ;tl t r . |. r c1t . lr t 1, , I |iI 1I |iI ||o|I |( |r I i1,p( t r t 'r r l, r , r r i I r r . I rr sr r ir rrI ,I (j . .4. !r l cir . r I I llu rol rc \r' r' l l l ri ' l rl/ jlr , t ir r , r r : r lr r r r I r 'r 'j; , r , r r ,plir zr jr r ilolr r l, lr t , r r lir , l, I iir . ii, t r it r r 1r I or r r r r (r| r lo: r r , Pr r r r l|I t , '|ll{. Nli , i t l'r , I , i; ii111r ; 111I ;) , lr i|r , i l l rt' i i i r,(t(f{r$t[[l i ] \'( |t ||, I I 'LI r lr r. t

.irn pallet Dolnavului $i/Sau A apar{indtorilor, poate lrr,liL h u {,rrriLI0 ,lr!gn,,s] rcX, srnco]Jcte pot fj Conlundalcindeosebicu accoselr. ,.1jlr,1rti|'1 rrkinetice sau a,niotonicu, dar (in cazul coexistentci convulsiilor- toirioo,l,lnice) qi cu clizole upileptice grand mal. Existi-totusi ulele elclncrri,rr i,rtr(r pot fi utilc in oricntS.riledi:r,g-nosticuhri dc sincopit.(Gastaut, 195(ii -Popor-iciu, t'orfariur. 10?1, 1978 I Corfarit ;i 19?2 ; Fopoviciu ;i'cohtr. j lll?ti) : chiar lu sincopa con.i-ulsivi,, faza tonicii Si jaza ?Ionicii Jint, rrnrlt, rrLli scurte si irrai t stonp:lte, iar dup5,epuizarealor nu se ingtalcazi, currlr, cale este (rlra(t:criolici l, 'jlcr'rtrcJ. acce\rrlui iic cpil,.p.ic.l,rcsigur., irr|r.qi;. 'ririlc EE(i. sf:lntla.r.tl. drI rna,i ales pri,r actir jti, plec m qi iil,r.girir,,r.r:i1,, ll, lr{ralr.o (ln',luSr\, u lc.iarcc toDelo.r reliexogcne) ulucidr.azidiir.;rr,,sl i_ lrLl in marca maioritaiie a cazurilor. . 2. Acceselede hipersotnnie cu apari{ie brutali, qi de s,rurti, tlulll,ii, sr,, lot confunda uneori cu crizel{r bincopale. lnrleoscbi narcolupsia cu 1,.1it,,*lii, 1umplet5,, cu ataclri cataplectice, cu hajucinatii'hipn*gog,ir,rr ryi , rr lrrclizii.re,specl,iv de sonrnp|ei na.rrj la,croii alodiagnost ic. Lrar,, rc"isul ,lt, ..,,r,,i, rrirrcoltlljc lI{' o dul'trti rnr,ilu_ngd, clrcurrr,,tanlo du apari1i,.Di crr ,,t,,r,,. .lilice qi poligraficc. (inclusiv_ de-orgalizare a iomnuliri;, calc l,rarrqoir,ri, rli:rgriosticul(Pop-oviciu-li colab., 16?2, 19?E). Mai Oifiiil Oo rlif0lr.rr{irr,t, r ,iiu uneori accesul calaTtlectir,, al,unci cind sun ine izolat. Acest ilccls r,lrl:r 5c.ctl'acIetizc;tzd pri-nll o p.rir l,lcr'1rc bu\ile a boj:rartlui. c[Lo I r , I ri, .,.i Ij I j , r.prerdcl'rDrulttealonuSutuimuscultr.inclusiv l)osluraj. logttri rlrrrrrrrli ,,r'i atc(l[v-eJnotio_nali. lnsd, spre dcosdbirc t]e aecisul sirrrr,;rrrl, .de.factori |lr runpul &taculul catap]ccLiu COnqlieUla CStepr\TlC,1d, C.(,acu (,(,lrIt.t,ii. ,,,rr \alid semnde dilgnosfic difercnlial. Dcalrfol, iffegislrirljlc puligr.:rIi,.,. ccrceta tori (Elishikarva "locttratedc::unrc-rogi ;i cotabi, 190g; Co|firli ,si. l'opov_i.ciu, I973; Popoviciu 9i colab., tC72, lti;g $i allii) au dcrr,,lrtrr;1, ('ir praougrea totuSu.lurmuSculu,r.S,.Ju{cc in decurs de cilIvir, s|r.rrrrrlr., tiind :rdesea inso{ilri de urjF.ar'i oculare ,.a in sonrllulRE,\I, Iiri rrrurljti,,rrli ruporianl,eale alior pararnorripoligrafir.i,sprc doosebjre tlr. r.J.iz:r, sirrr,,r inregrstrtr.ea p9]lg1afi9d apar modificdri IIOG, ,kr lll.A., |rLtal rn carc p_e^ Jrlccum qi modific5ri ale activitilii EDG (untle lente ditr ut jr, ,", ,,,,,,i .rrrrplc), concomitcritcu pierdercacuno;l ;n1{,ilColfaIiu, JC?i, l t}7rt r'rrr.. 1 i.'r'ju li Po"poviciu, 1972, t973). Cit rlespreparali ziil.ede wmn, &c(]steaau caractcre r:linice qi poliglli l.irro ,'u,l'lcteristice,care lranqcl,zii diagnosticul (Oorfuiu, 19?t, .iO?Z .l,opo_ ; r iciu qi colab,, 1072, 19?8). q.ltutu,l,u.i, 3. Crizek:iic cirtlcratlin ou.rsu.l ]ll htii:n, itrs.{,ii,. r.'r.'r,i si tl. : i rln l lUxr[1 i li.r,sr' Ir,l rlilr,urrosl,it,rr, 1,r,.tr! ,,rr rr\irtritifi, irr r'rorrlrirl,rrl I,rrllrrr
rrl rl " l

{,) r,n:unnrzi, prrp.,tl, .sau o relatare inexactX a sirnptonr:ll,irlogiiri

l . )N pi .l ,t1 t : : . r iu. 't p'. zir r lii, r r , I r ,((t r I I r ( ) : |, r , r r , , : r , r '. silcopoLl s. lxr t . , , f r r r r r lll . :rrl l sea. l :)str' ctr r io; 1r r , llr r l lr r r lir r ir r . slo: J00 ( t ( r bolnai. i invcii, iga! ; i r lr r r r oi, ,,lt ruTcllc lurmd rto iil]l.,)J)r't (l.oitr il,lr'o)iirMtiv 5o/o au {ost indlrrrrrat,i crr rl rr,g)l ostl cuI cor ent . t lc. sjur . upi, r est - ul all f ust djl}, Sno. 1ica, i:1 l, r f lbr r la1or .lr ?l ,l j \' r' rrcl e.sorri cji polir . ) iline, dr cpt cpilr . pl jcj, ceet ic culjnor ( li , . r r r r r i, , l, . ; i ,'l,surla!l a1e lui.Gastaut qi Broughton (19?Z) si ale lui \-v-ayne (11)(il).

343

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ttttl o l rl rtl .tl :i t t ' I l rtcz.rrtri l tti , l rrtl tl l t,v tt I | |I |(| i I i i ]Ii,I iI I i I r : lx l z i l ,i o l l l rr rl l t,l ttt Lt ' ; I ] I :I I : I t (N Itl l (rl ' l l l rl l l l l l l, rl trtts ttl tril l ru s (l l l l i l rr Ii i tl tI p t' r' l i rl l l ' l l t' i l ' i t' l l 1' l l i tr nit t lt lot r ' r t , (S l rxrl rrr,rr trcrrl l ,ol l ,l ,o t ;i trl rt' l t.t ],rr,. , , ' i, , i. u, ' i, r . r it . $ i v o rl ri l c u , ri i i ,ru i rL i rri j .9 U 5 ; I' o p o v i c i rt W i l l i rr' trts " ,u r_ r,1 . l 1)(i 1l 1i (i trt col rt' l r' , I iU (' v o r' , r1 rr; r i, i, lu, t r Ni 1i tLrsl ;ttl tl o ttttrroti l ' l l ' l (i r r,, tl , , L . iir r ; : : : ' O or )' r,ri ri , l t,? i , t9 ? u ). l l -o d i i k :ri l i Itr ru1'rrIitt Ll rrlui rlhrs il'1it'r vortcllrobazilrrtir ,",ll'.,-ii*'u..i"l,tt-ir,s,iiiclcri1,1, i ri ri tr.i rrn i n i (P rr,r rti r:i Lt;i c,' )rr' l r' ,l l l G0T l l rr.' r' l .,'i " i' ii' iii" , ' li" t io. ' i n o ,i u a p a ,' p i ttrrr:gi sltrrti l o l ' l l ' l (; :ttl i vi i j i (l ,,,'i i , r , if i' " i" , t f . f " - l. rl ,e l rro -l ra z i l rr' ,

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,r, t ,.rzu l'sin uu pci ac es f e anoD] ; r lii l: l. l( l lpJ l l n t t i l r l l r i u r r t g l i i l . l r '( '& : l i ) l r l r r r l l

I A IE'.

(TULIIUIIARI PSIHOOROANICE TULBURARI OIIGANI(;) CUSUBSTRAT DE CONSTIINTA

I. Con;tiin!g este forma cea mai inalti, de teflectare subicc lumii tir.i, a obiectiye (Dic{ionar enciclopeilicvo1. 1' 1962). Ea cuprirrrLr propriului cunoa;terea eu qi a mecliului ambiant. Este facultatea rlc rr, gintli;i a determina raporturile cu re:r,litatca inconjuritoare pe baza rtflt'rr td,rii realiti,tii obiective in gindire (Diclionaml limbii rom6,ne, trl.ii,ttr:r, Acadcrniei R.P.R, 1958 qi Diclionarul explical,iv al limbii romiino trtli{,iru J9?5). Starea de congtiinll este sttlrea ,,cle a-qi da seama clo tntirlitt 1i r1e sine ilsu;i" (Cobb, 1958). 2. Tdburdrile de conqtiinld, sint de "d-o;1i ca.tggorii: tulburirli tlrr conqtiin!5, firi, srhstrai eyldent de leziune anatomo-patologicil' (;xrrr,to avea tulbur5ri enzimatice, biochimice) cum se intilnesc in patologirt psi hiatrici, care nu aparlin probiemelor noastre de neutochitulgio, irrr':ttt tuiburiri psihice date de Ieziuni evitlente anatomoptttologice. Aoortsirt,rt, losr nunritii lulburere poihuorganicJ,care ue preocupi. 3. ln ce priveqte substratul ana,tomic a1 conqtiinlei, 1a tcaliztllcrt r,i p&fte toate structurile cerebrale, unele fiind de bazi, cuttt tiitrl : cut iau texu1, nucleii bazali qi trunchiul cerobral, Conqtiinla reprezint5, ult pr'o( (\H complex anatomic, fiziologic $i psihic. 1r. Tulbur5,rile psihoorganice sint de diferite gracle, in lnnol,irr rlrr sediul leziunii. 5. Orice leziune circumsclisi sau difuzii, a creierului poatc dol,ot'trtirur, psihoorganice. Tulburii,rile de conqtiin!5, datoritri hrziurriLu' tulburiri cerebrale pot fi grupate in tulburd'ri rle conqtiin!5,specifice localizir,t'ii, liiirrrl rlate de leziuni circumscdse, incit in clinicX aceste tulburlri siul, iirkrsil,rr ca simptome pentru iliagnosticul tle localizaro (moria, ,,antriebsnulttgr'1", sindromul Gertsmann, agnozia spalialE etc.) qi tulburii,ri psihicc gk-rbllo, oind leziunea este intinsi,, tabloul clinic fiind totu;i specific in rrpor'l, orr loziu nile etajelor encofalnlui intcrcsato. I)csif{ur aftsto luzirrrri difuzo, pe lingit, cri, dau tulburlr,r'ipsihico rrrr init,, poi, itrclurkrli.SIi-4.4, alc ciinri tulbulr1ri vol rlrr, <,:llaotclclinio llirrr,rlrrf plirr trrrrlificttrril o corrrporurr rl,r'1, irr plrrrr lulbuli,r'ii do cunrllioufil, l)itr u,r,rrsio i1 rlroIi, trtllltrt'ir,to rrr0t,iv0,:l,Pnrrr,Prr 1o(,i rr,rtlot'ii rl0 c0n,;1,i0nlir,trr'irr0 trr urrcrri trjrrrlnrl tlr'$lrr(ltrir,ci1, olt,rt lol,it,lii rirxl lozirttr,:r, r,rt trrllrrrrirtrrtrrrvt'rt,xinli[ 34t'

T trt'rt silttlt,fii pttt'tilllli', tllltri,Itzitlttttlt, (trotrrii) itt l,rrrtrcltittl otrtrrbtill ,sirrii rrNlrt (''rlrlll/i', il,ili sottttrttltrll(ii,' rlrrlrsrrpll, tnozottco{illulttil it,sl[olittcif ittglttlllt' Irr,{irr 1rr l,rrIbulrit'ilo lrrlr{ialr dc cot16tiicrL{,ii. ilo slts-l)l(tlArlrsl; pundr do votlcro nu trste coloctr dtxlattrctl1,ullrur'ilt cit itt utrttltr <litztlt'i liorrrlo sirrt lulllulrili t1o conql,iin!:iI osi,o a'dovai'rat (rioln rr()lonirir) cxistir,6i o cornpontlnti' rninirnii do tulburl,trl tltl cott;i'iclt{,ii,, fiintl insi, tulburarca de conry1;iinlrri, rn:r,jolir, Irrrr'|,ici1rir,r'ul, Arrrsto sintlroarnc sint foarte elocvente in lcziunilc traurnatioe cr'ruii(l (|r('olirliccgrirvc or,rc sc Iemit. Cind bolnavul iesc din comL, leziuuilc siltl, irr cnrislirrele cerebrale pinii in regiunea mezotlienccfalici'' I )u,<fr, loziunea din intreg creierul este pini, ileasupra capi,tului rostral rrl Llrrnchiului corobral per;iapetluctal duce la instalarea unui muti$ur lkirrrrtic sau h, sindromul de d.ezaterentarc. I)l,cii leziunca r5,nline cantonati, in emisferele cerebrs,Iepini l:r zona rrrczorIienccfalioS, apare,,staroa yegetativ5,". I)rcL lcziunile de intensitate variati, sinii cantonate in emisferolo r,r'r'ollale, inclusiv nucleii bazali dau sindromul cliencefalic. G, I)acii, Icziunea este in totalitatea, cortexului' in general provoacil pdn fa,ptuI o rl'ru'e tle agitalie, cu iusomnie, confuzie agitat5, sau anxioasS,r lri, iul,rca,gaactivitate rdmine sub controlul nucleilor bazali Dial trunchiultti ,lolollral, ;\dcseori, in diferite afecliuni, procese infeclioase' procese itrlocuitoaro toal,tJ rlo spu,fiu, traumatisme cranio-cerebrale etc., leziunile inte,reseazd, cclr t,roi ctaje ale encefalului - cortex, nuclei bazali, tr"unchi cerebral 1ap{;rarrr du"cela realizarea unor sindro'ame combina,tA lsiniiromui apalic), l)rrcori, intr-un sindrom pot fi implicate tliferite etaje separat (hiperkinezio r,rr Iogorcc, rigiditate decerebrati,). I),r1,orii,i, legii biologice, structurile anatomice cit qi funcliile cerebralo loh rrrir,inoi sii-t lezato p{i}Aqle Si cel mai uqor (cortoxul qi vorbirea); lrr ,,rrzrkr t'cYcnire (tlc la trunchi spre cortex) ele iqi revin ultimele, persistin(l irrcii,rrrr 1,imp dupf revenirea integralS a celorlalte funclii (surdomutitattl' rirrllornul vogelativ prefrontal tiescris tie Ttinnis). ItiNliitrrr][r,i ios aceste sindroatne Sindrotmclc generate de lcziuni Ia iliverso niveluri ale creierului /1. l,czi[ni situats in partea supcri{)r,r'ir, a trunchiului cerebral ll. l/{!z.iuni in nuclcii bazali siLtla'hc {1. Loziurri sil,uir1,o in coltex

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(l(rill(x)llijli{rl11il' il(r(l(1llr(rlr('i', rkr;ti lxrlrrrt'vii sil'll illll)t'(lsilr rji rrlllliHllrlll ltol,(lrrfil' qi trol. (Ort,itrrs rkr a'llii ll', rrort,sl irrtttilil';i I'irrrltrit pctlrtl''crtttill,iottfi. iirrl, 1f}(is; $dn)i'i, iii (r)1. .ll)(i5 Ifrlyattrl - lltttrrt,T,tl I ll).1 l; lll{i!; Skrr1l,01,y, (clriirr l,ir, (,slo cit oxislit,vit,rir[1,ii it,r'ir do lit, thitxrzirt ir(lov liissirl l..irrol., l1)(i{)) itr sottsulor(lirlr,r al otrvinliului) ;i rmrtisn (sart tloilt l,Ionitr)IItri 1r:rlrrlizic hipolsolnnio situ obnLbiir Lrrlbrrlanrolalil tle corr;liinlii, (sau doar u$oa'r'ii, lrrrr,) pi rri, la,o sirnpli'l apatie generalizati, cu reactivitat'c bun:i h exoita,lrli. o 1u ir, { l(ilrx;lirilc rroa,slrfa iln mai ari-rtat c5,,de ceic mai multo ori, dupai, qi I{cmpcr qi liomanul (196?), XIA (in folma clasici rlesclisil,rltr lrrlrr,lrrl' t lr,ilrrs si trol. t.i+t) rcprezintil un sindrom tle ocluzic a al'terei bazilare in tulburili rt" por(irttti r sa rnijlocil.sl,u joasi. la care unoori se pot asociz' atinginrl (prin" leziunea ialoi,ei pontine qi/ sau .mezencefb,lice, i,orr1iiin1,L
(l t' i rr' Lr1.1r . , 1. . llt i l) . lr r I ir , z. ilr 'r lilr r , r l. . i ( l'I ii, r lt i r r r r r ll. siPliir r r r r r i ri tttt. l tttri Ii r,l rr r lr I r vii c sr r ; ) I r t vio( , r r ir .,o r ,I ,r , li r l'it t l, r 'it sor , Lr r t r r r l0 , r 'r , g lr r r l r r , r , iiilr Itrttl t: sttpl i nr r lllr , lr slr , r rr , lr ilr r r r r r lilr r r : r lllr , rrrrrrrI Ir I i I i I .i I I ri Irr ir r sr i, lir sl ir r r r r lii t i zrl r,l i , a,rrr lilivi silr r nooicclll, r vr , ' l opogr' : r , t ia , zir r nilol nu llr r pr r lr r l,licr r r r r r l i{r r r lir r csir r lr ilill 1i inlinr kt r it r r Lt . rl t rol :l ti vel o put ino la, zur i st ldial, c. Au hisi, r lt , st r lisc clt ar r r i cu r r r lir r r o I.zittIri neocolticale. So cilea,zii cazuri crr lozirrrii t,rt..nsit'ir srrlr..r.i i.irlr,, rllrr cu crulat'oa structurilor. trunchiului cetr:ltlll si inr,crs rrr lr,:rinrri rlc lrunchi sau cu r:xtinse zone isr.hcrrtice tut iii,Lile s;r,u srrlxurr,l,it.rr,lr,.

s RAA ) .

13.2. SINDROAME DATEDE LEZIUNI IN NUCLEII BAZALI Sindromul diencefalic

Se earacterizeazX prin tulburS,r'i rle constiintf cle intensit:r,l,o r.:rlirrl,ji, ci.n'econsl,au intr-o sta,re de apai,ie, lolpoare, obnubilaro, soIIll(t (,1{i'i, 'il Ipoirre-Rcspirr(ia e\te de !ip Cheyne-stbkes cau t'espirrlir,.rr Iit r rr.*,,ri I r1'ttrgulat,", rnllerullt uncorr de pauze scurte, pupile mici, rtrilr,tivrrlll, lU r nrr;.lellexul cilio-spjntl este conservat, miqci,rile reflexe rlo gl0lriloI {r'uralr ln plan orlzontal slnt con$ervate,insi, uneori rnotilitate r,r:lltrrii rxrular5 rrerticall este.IimitatS sau abo]it;, (comprimarea rcgiulii l)t.ol,(r, fale) ; existS, reflex oculocefalogir (in lezidnile'de ironticrtii rIitrrr|r,IrrIo rrrczen cefal ici), deriere ronjugatd, a capului qi ochilor, ten0rnt,lrrrIrlrr ,.r.nr dc prpu$i,'. rinooli der it,re Ienti ti porsistenti a glolrilrrl rx,ul:rlr. So noteazi, semne de suferinta, pir*midal5 ditatcrali, (I3::r,blnslti hilrr,l('r.rr,l ). Ibt fi evidenliate o rci,istenjii, ^muscularii, tle l,ip paiitor,fu rrrr r,,ll,Ji .\i ,1,. ftpucarefortatA.;iD abscnla unui deticit rnoloi ri.eqtclnorliii{,riIip,rt Ii l,ihter:!le. Pot erista diskinezii. Tulburi,rile vegetative sint abscrrtr,. .par(,iall a t,ir$l,l rl ._Sttpoar_ea.**" *oilnoi&1" reprezinti, u p,ig_rdere sit'ilor la solicil,5rile mediului inconjurilor, iii starea-tle colt$liitrlii r)Hlrt rrtectati, r.ra,i rnult sau mai pulin. precurn d,ratii,denumjlile iu;_rirr,rrt,io rirte. pacientul prezinti o stare de somnolenli, mai mat,e sa,urnti rrrir.ir, elrr lr '.)ic aln sau ..hlat,.uncori. cpontan (dupn gl,a(lulslrrlrrlji) rr. l|r. z' rl' . l urbe:lo, (lA riispulrsuri ader.r at. compl"ie,lncornpl,.tri dinl tiurli\ r., (,,,r'e ce a}e ne\-orc, mill]rnci, singur sau rlacd,i se di, sL rniirrirr<:orlr.rrrrr I l|r'rroil.loule tlr'sr.lridc ochii, str (eara Si.$i fa(,i ncccsili{ile, rrrrr.rrIi rrri;r.:r, r. rrll(. Sponlrn. cbtrr potte urubla; [ulcqiile vi[lt,lcrjlt Lrlrrrr,. Sr.r,lrtlr,.t,. rizprtzi, printr-o. mai iltensi, cr.g;t-glqa plairurilor slzoriale, cilrt arrr rlrr,pl r|rrrrt: o recepl,ie intilziai,i, qi inadecYatd,o lentoal,esi o tllfi<:trl1,|lt rr rlr,s ii.-ttririi 1rror..esalot tsociatire, Bolnrr ul c.tr. lpllir, r,iitrrrtrrlr.r,rr irrlirzrclr. l:r itrlrr,biri. pr'in rri.punsuri vagi. apluxirnriir,,, irroirrpl,.tr. 1i, rlr, ,,,,1r. r,rrai rnulte ori, lipsite de sens. ,\ornn;leut, tlr'zurirrnill,;i corr -lltpori (,s1e Itz,. Evocaro:, ar'nczi(ii so efc(.tucazir, rliii,.il, rr't,rrri liirrrl irtrlrrisilrilri. llr'lrrrr,vnl cst c..lI;r11i1tsih iu ;i.lnitdikinetic, sc or.iirrrl,cl,zL ilifioil si irrr,'rr r1rIr,|, tr {l}t(ill .i .li'ri irrlir'rrrrrIii si irtr.s:r.lcrlr.sIr.r, *r P,.r,.,,r:rrri. lr',lr'itr 'rrli l,rt int,ila,{,ii rrritilc;x,lrrlir!i lllti irlr,lrfir., lrolrlrvrrlir,r,rli.trri.zcrrla, riurirrrllllr rii t'iirliI:r'|r'. Il.lh'rrtl rlr.r.lilrit l:r rrrrLr.rriir{*r,.si l,r'(\rizi. r',rlloxrtl .o|rr.irrr ;rittl lttcz,r'tttr,. lirlrrrrvrrj lrr lrrrir,lrr IrIi rrIrrrr|,Ir, , illl r,litr,l,i,r,ll Irrrrr:(iorrr,ir,zii, rlr,..rtbirrrri l.llu;Jgati);t ttottrtrr,l, r\sls rrllriytr,lslrli, (11 (,oglir, Vigilr\, llr,rrrr.rr rrliliz:ll, tl. ilrtirrr.ii I'r,rrrrr.r,zi. plr.it,trlrrl \,rl,lr, lr\ 4i trrr l)rr,r,tr, ltr, 'lt 'illDrtrrrlr,

Sindrornul de dezelerenlare (sindromul'oloked'in") Af octarea ci,ilor cortico-spinale qi cortico-bulbare printr-un mmolisrrtorl; localizat in piciorul piotuberanlei (I{emper qi Romanul, 1967), rlncind la tetraplegfu qi afonie, determind, o stlrtdo imobilitate com-pletf rr,lrolrulvului Eiin;apicitatea iui de a se exprima I'erbnl sau gestual. Tahlrrrl ciinic p6ate sugera o stare de mutism akinetic. Spre tleosebire dtr rrll,irlul sindi'om, car-acterizat pritr tulburi,ri mari in sfera- prceptq?lr,r irr sirllrornul de dezelerentare perceplia nu este altera,ta, bolnavii fiintl rrtiorL{,a,1,i tsmporo-spatial, putind face calculor a$a cum a ar5,tat-o (]onouni' ,.,,1,,,1 ,j11 irin iiteim;diul cotlirii miqclrilor ]or oeulare. "i Sttrea vcgclalivd persistentl dupi leziuni eercbmle. Jannett (1972) rlcsrrlit: sindroinul tle ftaro vegetativX, persistent5 in motlul urm5,tor : I)upii o perioadS, tle comi profuldS' de" reguli, cu-ItaJiate grade do Ii,spunsirri eftensoare (rigitlitate prin decerebrare sau prin decortlcare)r.cu o rlrrratii do o snptimini, sau mai mult' supravieluitorii i!-cep.s5,deschidit -numai ca o reaclie la stirnuli rlureroqi. Ulterior bolnavu I ochii la, inceptt periodic ochii deschisi, chiar in absenla oricirui stimul qi pa,re a rrrorrl,ine rrlrrr:'ili ci privirea, dar firX:r, fi atent, apoi recade intr-un somn apalen-1'. \rr poir,l c ii insrl r:orbr de un real ril,m lcghe - somn. fn perioadcle drr stlte rle tcghe nu exisli ldspuns de apdtare ptin ocluziepalpcIrIi'L :L||i|tI lrirrLil:L:rnrcuitrtalc. in unele cazuri i:.i;,1dmilcdl'i sponlanealc globilol' olrrlrr,ri,tlind impre$a ce bolnivul urrnire$ro cu privjrea un obiecl c:rttt in-cirnpul si,u vizual, dar nu se poate afirma cA este vorb{[ sr, ,1,'pllscrt'zr-r' ,1,.r' iirrrrr:ltlu aleulie. In alle cirzuria1larchiar lnj[cEri cert -cooralonah!t .r rlr.csr,rrrtrlu de scilpibtle sau de adueetua miinii spre locul de oxcibattt poate dtermina fie Yi$cAri rr,,r'i,rr.1rl ivii. Cx toate ci, cxcitarea nociceptivS, fic trismus sau grimase, bolnavul nu emite nici un ele}u-orl, rlr,,n rrr,il,i<lr,{,ic vclbrll irrt,cligibil, ci cel rnult'- sunetb artic-ulate' Starca de constiinf il' liirrrirxr rloci frofuncl alteri],1jI,bolnalul ri,mine inapt de. orice comunicall)t rrrr illr nioi ri leaclie aalaptivil, la mediu, nu este leceptiv la nici un lltxl irrirnnill,iv. J)in punct dd vedere legetat'iv, funcliite sint conserYate,du'r ltt slirrrrrlii nocicepLivi puternioi pot inducc rcacl,ii vogotative auortnalo-, loarlje inclclutt" rpocirrl t'cspilafrrrii. Strlrca vogetzllivf potrl,cpol'sisi2r,lim1l a,lil,l,irnp tlit; bolnavrtl stlpl'2l\'iolrt' g1,1, sopo&l,o 1lcurr2utdrtiza 6i, ovr',irtuu,l, r{rft,r), ltrzittltiIttttl t'tl lxlittsr' 1i gt:t,vtr itl t'ltr-ttriltt I,)li(i a,rrttl i[l,iL1', 'l't'rt,soclo trtttlltr sirlriiitrritti tttlti iz.r,lr,cl,tir', lirtrp tltr slr,ti totl'ictlo, ttll 1,l'ilsoll 1-rll11, (t4lr

,{il

it4rl

l,\lliI ' ilI iil(lll,l.l:.j,iIl(x)lltlit lt lqt . llt I t t ll, ilt l' r I lt r . iit ' iilllr t t t t ll t t t . i I r . l i t t I i t t r . r r r . l 'r , t r | 1 . ' s i t lt l ( l' s i ll|r t r ll l . . ' , . 1r. rt r l.t (l ..1:r1 1'r"' llillz i\ . ' . grll(lir: llttttii {rlltlttl tltl s r t nt t t r llet t ll- l ; lt t lr r r lr ' lllr ' r ' r l r ' l r l 'r l l l l l l l l l i s . r r r r r 'l " r r l : i ' : t r I . t I r t 't I r ' llr t t r z i" * t , it ' ' r t l, ': r t t rlr'{l:r ' lr r l Jriiti,,,l,',' ' i' l

s l i i t r l i r , r 't r ( \r r ,i t\r ' l l r r l r r r i .,. o r .r l ,, l r r r r l r r r l tr . r r r .zr r ;lr l r r l l r , r l l tr , Ir Ii r r i ,,r .o r i tr , o l r i l r 'l r l i r r l l r r l ) r tl \ r zr r r l , ,,i ,r r l ,,r , r r .r r :r l .r ;r r 'r 'lr l l r r tr r l r . r 'o Ir r 1 r o I.IIr r r Ir 'Ir |, , 't r r o ( i r t t t i t I | r l i tl r , r ',,r r r 1 r o r l i l r r 'l l r r '\u :tl

plrr'lirrJii rr'trlf(11('il1rr , slc tlatir,t1c troitrtcrosltrcl ,,1,rr,,f,ii,i':,., r,i,, 1,,'ip,,,'tr'., (lilr (lN(lo ilI (r:i' r)iscotrlil rtti, tnotLcr':r'til, i'"1,c Prr'(i"lt1rl sotrtttttlllrrl,rt l,rr,z,rtli: itto.ttjulitlut. tlitr tt.rcrlittl la oxciiat,iilu pulin ,,ii',,i ii, ,,irr,l qi {ra'ticlpir,
i ,. F o l l l (. d C fi n i r' :' ,i ttl o l r i dtZol i | Ji l i i ro Icntl tt' ror1t:t St:rr.r.: r l|t t , , r . ; r O ni,. t ,' :r,,ti l i i ,' ,' 2 i ,.s i r' .r s r i rl .rr' rr' l .nusttl l l i uf.r' l i ' r,,l i i .i ut.rr' l i i ,,i ,i . , . , , , . i, , r i" ir'liltlcttiiri ;i ruptiof. Stalcr tltr ii',iiiiirl*liri,"lt,.i" " , r sc,[t6.c:l ilifilr,tirli, oLr r) dirrinuaic ir' srnzorjirle ilur prrlgul :t, craqierri intro i,f,i,ili" ,r"*in groutabe 'li.ctr ilu oarecare rr,rsilrilit,ir,lilol rlc leccDtrie (care s6 rdalizeazi

,t ll\'l't,t Irti l,liztUNt ( j()tt'i,l( l:t.;i.sitfril)tioAi\' tAl,t,l lligiditallt prin docorlicarc

i,,i,,"i'ri.'I,rrAiiitotiiii tn*rti"tin"' preculn ;i cu dirnintarcr stplelei ;i r.r'

( l r't'l l i l

Eindrornll r'1c rlecorl,icare ale u}tuitoalele ea,r.l:ld,t'r'is1ir.i : -- r'igi{litate in elterrsie :,r c:}pillui li trnnclliului, ile jtil,rrrrsilrrlrr rrro;

=i,r"t"5tn lrstiLnuli' r'orbr'.i+ttuci)rirr{'cl'u' ,r ,', ,,ilin,,lr, itu1. jn nuolclt Uazllt' ir. rrrrrrr,.voic; l,'zitttrilpsini lrilaleralc ploturtdi' ITI (obnubilalct cslc r) nonrnnl{'nli. .st'iiru,itnn .t" gi:;uO,,t l:lleorl rnlleburl' ii l2 1 1nila1 pacieotrtl fi risfundc Jbia :rrrrrr:i,rrr.'t:onlin'li I lt'z!ttncr e'lie in nttclcii brzrli 1i irt bipotalrmut .,i ,il"i..t. ri ";;;;i-,r; tt' ;,',;,i;i'l';c.l;r;; r'c"tlrlui crcicr"ului; t|irn' birrl ctr"lrrrl csie ittdtt glave'-.iin cblale -oel crl'trio im,umatismelc in' intilneqte Strtloarea sc r', t"ii,r '"ot"'J" ,ne.ri.*r& fi"tix irr comil) sau in foruele {rarc se al11elio" ; :,;; in cn 'e[:rlit' .'i pro'es":\P:rnsi''rt'in'tr' t:'nir:ne i, i",l in.. ,iio "o,n;1. cole cc cumrvirni inrlirc('t dioncefrlrtl' : in )ii , r"",,,,t.iJ io.tlir*t" progI'rosnosticul este ill fimctic tlc e|olu{ic : daci sc amoiiorc:lzi,' .i" I dacii sttpoirel se tgral-cll'z[ ;i trcte in comil' prognos'',',tr'i,,iti-,r*i"'t I i(,r {.ltc er'3\. ' ll ''(i;;fJ*".,=1c o .'frrc psihicir, clati dc o leziune a cmisfclc'lor corcbralc ri'i;a'lc sint parrtial[, ',, ,,;iil;;;;;t;; ii insularit, n diencefalului; {rLnctiile ('r ir''lrt-ilc i"si 'e tico.clri I'rur('.t)ttrionlrrlt,uar" 'oelPrrl r'hirl prrliu ticlini'{il' "h'lt"ii,rLit" ostt uueqli innLlc'v:l.l' ,,, ,f:u'- .i',fi ; 'i"pito.uri : 1. , {il, l,1 t . Itolvcin inclutle torpozrrea' stlllJ{rlrr''t-]i oblu]rihre:r i[tr-ur] singnr )' r^r',",,u', ,,io""!olaie a cinrytiinlef"'(,,1'loucliirg of r'olscciousuess" Sindrornul Korsakol"

.'""''.1'i;1;ll.ilj;'hi bolnav'l ,''ai a":'certrltit'i,' !i'trLl lr osteo somnolerrti' ('cLl Lin(1}ri

postrrX, a, membrelor tuperioare cu contraetulii in fle_rirrrrr :r irr l rrlor srinentelol cu pt'cdominanlii a celor dista,le; - Iostuli a,rnembrelor infe.lioaye cu conlracturi, in cxlorrsir,,r'ol:r,l i,,, irrl elnii gi l1cxie planta,t:i. . fi,rotnencle.de rigitlitlte sint rrrai p[!in sau tleloc inl]uorrt;rll! rl0 , l[||rlJt noch,-pljri qau rle a]t 1i,1. - rellexul llagnus-rle l{leijn poate fi pns in e.r'irlerr {r'rI - semne de piramidalitate bilatemli,. - alterarea accentuat5 a stfrii de conqtiinti, dar nu r:onli |rrrrr rLr, rrrlilnesle in rigiclitatea prin dccttebt *re, ;i :r,socialii, cu pcrt,ulbiili vr.ril ll|ive ma.i pulin ample sau in unele cazuri chiar absenle . Snrdomulilatea nfai. pulin _{reclent ini,ilniti, dup[ tlaumal,isme grtlve, rtir,r, lr)jrlr\ rrpirrrca,-chiar qi dup:i.cele u$oarre:bolna,Tulqi-a rcvenit iornlilt,i, rlrr,i,r,r,,, 1r,r'risli"o itlutitnte timp de 1-2 slpti,mini, fXfX,alte sirrrpLonrr,rrrrulo I'gicp_p:rn rnanifestarceste clator.iti procesrihtirlrr irrlrilrili. tai61.c. A{-c|LSlii stLpralimintrrii a zorLelorcelor r:rai noi apifltte pe scari, onl,o- gi filogr.rrrrlirirr., t ouforln legilor biotrogice care au demonstrat ci, structurito :r,rrriorrrir,i, ,r Ittnc{iilelor revin cu aiit mai tardil', cu cit sint de :rchizi1i,, ;rrri rr,,.,.rrlrr -rinrlromul vegetativ profrontal (Tiinnis) 1t iI I r\ :r r u . ln partca supclioari, a ariei premotorii existri, o zolir \,(,11.( trtl de a, legla teasiunea ar1,t,r.iull-u ;i pulsul. Sindlonrrl irr)llt,irur trr,z:r rtrl rr,.t.r.lriljlo:r bclrt,rrrlui ,lupR difcr'iicpnc,.iulilo ,i rrui :,li.s lt.injtr:l,t r.rrl , r'rllr,)roleltlulc: ptcir.trl,ulOste to]nplct rtrstabjlit norrulklgi0 prrilrrr, 1i {llr })ersisti. ui}c1t: tnllturS.ricardio-vasculalo. l-,a,cicntul I:rr,cri lri;rrrl.i*irrrr,, r'1rrria,lti, si o taliica,rdieaturrci ti'i[ isi sr.]irrrLi,lozifiir rlirr ilrr,,rrlriirrr ()1 1{)s1.:rlisln. ,l(iesto tulb lli.li sirrl r.Liilr'lrrirlr.rlr irirrtr rlc l)t.olirr,rl r. rrr ri rrbilircl (iollllt,lcs(.('lt l (]i. lUil lirr
\ g i 1 l r , ( , i l l r r i r r r ;r l r r r l i r i o r .l :l i i i , r ,r r r r r :r r r i l i .sl l i l i r l r r r r l r z i t t t r r l r l r l r tr .l .r , ,r rI' I r, r r rI rt r r r ,tr .l r r ':i ,l . l r j l t.r ,ti l .r , r ,r i l r r H o tr r ,r ,l r l i r

|';\||.1|onIi|''Ier.iinir'."-laloIogi..ibincrIofinit:r.l'cz''].''r'ldin:rq,.!{'iotc} in ,1,, ,ririiiL..tffiii neurologice'dc tii polinerritic cu manitostilri psihicc' dt'zorientarca' confabulalin' clr'r tltttrtitlit, &mnezia antcrogradJ, "'i lJrrrl iul lcziunilor dominantc este mezencefalo-dicncetaUc' iu: marea lrr cliolottic, factoml dominant esto toxioo-metabolict o rrtiutrlilltt: otinlogico sttrvitr,intt t'onrlit,ii Alt. ,,,,ul,,llir,,t"','r'-7"r.Lrrjlor' rnetastazc' ii,, l,iil,,ri ri rt"i-tl,r riaturi, turno'al;i (tt*roL i tle uutJei brz2r1i, ic;" af t'r'atn slu t.r l,,,r,rrikra,rno),infectrioasil,, l'asculatit'
sitttlrtrtttttl Klii lc r - lNt t t ' r

t l i r i {n t t t 'i r t r Sirrrll0 rrrrrl lili i\ / ( ' f ilu( ' ) . lt 1} r t , , t t r t l, i : r l r l : r l i i s . u r l l t ''z i L l t t i l l i l ' {'o i l r l l l l t l l ( r , 1i lit r c r r ' ' t illr I ir r ' ( gilr t s r t l l t i 1 'r x 'r r t r r l 't t ' I ri I l t,1 ' r' t rt I t r lt'tttltltI'lllt l tlr' cott( } r : t l i i l i i r r : t l r t t t t l l l l ' il\ r ( { lt ' 1 ' lrti A rtrtrtritr, rrtirtlilc r t t l lr ' t r r igt llllillr t ) ;

:lti0

;i l ' I

A rnnoziikr posttrnutnll,irttl (jotrsfil;ttic urtttl tlinl,rc oelo rnai cornunofcnornone alc ctcoltlor ttitu- iltit lt:cento cit si tardive --- indifotcnt de inl,onsitltcit rrlrlictr rurrr'lrrille I r';r,rt rnlll,isrntt Itri. Amuttzia posxlraurnaticii propriu.zisd \rnrurzia posttlaumatic; propriu-zlsi (APT) este tlefinit5, ca perioada rio r,rnnezic dun5, revcnirea bolnavului la un anumit nir-el tle conDtiin-ti', clrirlr inoil, perturbati, sau la un nivel normal, in care persisti, nurnai rkrlli0ilul amnezic. I)ulatja amn0zici }osttraumatice este in diroct raport cu graYitatca Irrziunilor traumatice cerebrale .:i exist[' o relatie directii intre durata posl,iraumatice',ql virsta bolnalrului traumatizat. ru,rrurczici ,\prrocierea amnoziilor posttraumatice nu se 1loate. face {leriit rotrosrlupii ce bolnavul gi-a redobintlit un suficient nivel de_conftien!5. lxxrtiv, ' Exisbii, pertulbarea memoriei recente' chiat in condilii de completii, rorr,bilitare aparentd, a nivelului de congtien!5,, Si nu a1 legfturi, nici c_u glrr,vils,tea, I6ziunilor core.br&lernici cu virsta ori cu leziunile celebrale ploorcisbente.Nt ar exista dificultS,li in reamintirea vechilor engrame inrrcsticc. Bolnavul este in md,sur5, si,-qi rezolve problemele vielii cle fiecare iri, (lal este invalitlat in achizilia unor cunostinle noi. S[Jrs1;ratul moriologic, lezionaI, al amneziilor posttraumatice paro si, f ic in arilie hipoca,mpice ale lobilor temporali' Amnezia retfogradi (AR) este detiniti, ca imposibilitatea de a reme' rrrola, ta,pti] sau idei din perioatla imediat precedenti tmumatismuiu'i' ( k)rldiliia-cste c:] in momentul traumatismnlui oreieful sii, fi fost &lelt qi irr conrlitii functionale norma.le. citeva I)o regul5, AIl, cste tle foa,rte scrrrti' ahratil (tle ciieva -secunale, rrLirrrLi,c, mai lar dc citeva ore). l)urata AR este in prirnul rinil in laport r:rr u,ruploatea ii ou grayitatea leziunilor serebraltl traumatice. llxistii, cazuri ile AR <le foarte lungi durati, - citeva' luni sau chiar ci{,ilu,ir,rri. In aoestecazuri sint implicate pert[rblri gral-e qi ieziuni intinse ir sl,r'uctulilo rinencefalice (Russell' 1976).

vcgrrilrIivii.Ntt lrixlri nr'r rl lrlr rlrr lltt,r'(irr lrr rrrcrlirrl iurrlriiutl,, lrr rrrorl r'rislii o ;rltlttrllrlr, rr,r'rlrrrrrlrtr Itcct'r'ttl, r.iorrr tr-vogitr,,r,rr f,r,urltrpr,rioilrlr, (l(!sornr, rlil llrrrl lroltritvrrl tlttt cgltc (ll .l otr') lrllllrrrrrrlr tr lrrrrgilrlt iolrrlc r plin li rror.irur1rI,ir, i. l,t rrzil rlilrrrtli lxla b) Ilonomottolo r.irrrr corrsl.aLl irr Ucxiolr rrrrrrrrIr.r, irr 1tozi1il, l)oHlurill(!, Ior'. :\colt,sl,lt, so poakf lrr.r,orrlrrr llr, sclritnbtlet, pl,sir.l.'i, rle lozil,io a t,rr.pllrrr rii cste mai marcatii J,r rn(llnblrdo superi{)are.l'r'ttlchirrl csl{} in uf olll,ir, extensie. In timp apal a,rrkilozc, ret,rac!,iitendinoase ;i t:hirrl osiliclri. c) Fenomenele motolii prilnitivo stei ool,ipe-lurormakr. !'onomene veEetative Ilenomene oculo-motorii existi constant. Simptome pira'rnitlale. O tetraparezi, spastici),,in rnorl rrorrsllrrl,. Simptomele extrapiramiriale de tip parkinsonian sinl; frtrcvrrl t,i,. Tulburd,ri sfinctodene (incontinenld, total5 sau de vezicri rtrtlorri).

13,5. SINI]trIOAME DATE DI' LEZIUNI SITUATR IN VARIATE }.]1'A.III Existl sindroameneurologicecare pot fi date de leziuni irr to:r,l,o cl,u,irrlrr encefalului, uncori intr-unul (codical, subcortical, trunchi) sll,t.t rlot|ii etaje. Astfel, existi, : Sintlromril dc logoreo eu hiperkindzie (Arseni-Diniilii,) Urmiirind comportamentul bolnavilor cu dif erite afec{iuli uorrr,orlri rurgicale, am <lbservat c5, in afala sindromului de mritism akinetic, siir.r.r.l bolnaviior se poato marrifesta si in sens opus, imbricind. a,spcct,rrl rlrr lrr goroo cu hipelkinezie Eau o gamd de aspecte variate, interrnorliarrrirrlrrr aceste extreme (logo1eefhrd, hiperkineziE, hiperkinezie f,rtr logortrr,, hiprrl kinezie cu mutism). In tabelul Y sint indicate leziunile Si sind.r.orrnrl r,or,,,H. punzd,tor in cazul ceior 13 bolnari studiali. ln genclal, Ieziunile au fost de tip compresiv-clistructiv, ,1irrrr rlt, l,ip iritativ. Considerfm cd, sindromul de logor'eesu hipcrkinezio esto un sin(lr(rrl antagonist accluia de mutism akinetic. Ambele sindroalro il4)ilr (.r, r) consecintrria unor leziuni distructive (contuzie, hcrnoragie, r'nnnolii{rll{!l |1,, comptesiune cerebrall) Di numai exceplional poate fi vorba do o ovclll ln h, excitafie. Muti$rlul a,kinetic are la bazi, o leziune netlr, si1,uri1,r'1, 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,rilqi intcrnii, a lolnlrri t rrnrgror.rrl at plotht(ur u,ru.r1, $i cortexul cerebral) marchr:azL cl,lea SRIA, a ciirei lcza,ro sindrom, plozcnl,l1,L, ca,ro ostc ll,it tle d ivtrrxr\,,rrrr Simptouratologia., corcbr':r,lir, poa,tofi ()xpli(llr,l;ir, dtxrit plin irrl ticrlruil loziontlfl ooutxrrnil,unl,r'l {i in pltr(lo l{! :r,r11:rg()trlHl,rr j)orl,ii v:l,Ll,hil)ir, q.lol rl0rrL Nisl,r!rno r(i,i(jlllllir(!il,r{(,{r inhibitor t1i u,(11,iv 1,r,r', ,,t, Privrr6l,rltotrtilti1x,t'l< ln <:,t,lt, itrozirr, rlo ir,lrrr,ilrii ul,r'1r orr leziutrt*r,, (,xl)li(,r! $-ill'l)ltl,rtb rrrIrrriIrrlr,rr, lrrzittrti xlxlurrrrrlUi trrrrri il trrlicttltrrinhi l)rifl r'il r,ri llil,(llrrllll(ll'llhti r,rrrllrrl lprilllrlrrnr,l, Ir,rrr1ror.:r|, lrlil (1|rrnlrlr' Ir'r,Firrrro JUJ

DATE DE I,8ZIUNI.:.DIFUZ!] 13.4. SINDROAIIF] Sirrrlromul apalic Hinrlrornul clinic poate cxista in forma complet5, sau ir, forme parli*le, ircornpkrtc, ctrnosoute sub denmiroa de sintlroams,rdispalice". Sindromul complet, in perioada de stare, ere urmltoarele componorrto ((lcrBtonbrilndt, 190?) : rr') r\ltiora,roa sttrnii de ritttrqtiini';i,estc intt'-o oaroo:lle milstlril asemioohii deschitsi, rrii,l,olr,irr ctt crla tlin mtrtisrnul zr,kiletic. JJohllvLtl rnott{,itre rllr lru rrnntr,rc6to ott ptivirel, rtu ,r,torcfl(rxlll do clipirc ltr u,m(rlinhrot cnlo{ionlllil tliforrtrtNtt ntr ttbsorvii'ttitti o lrra,c{;io rrrr rut roJlo-rpll,lpoht'r,i. {lo lltll'llril, n,lorrrilto sint, ttttslxrcifirrtr, ('irr,l11, tttrt'lo Ptlutt{lttotttoiion oi rrrtrrtu,i JI'I'

?
grtspittgotrrrlrtillrIrr,1tdolttrlit lii plin lroz(rlll,il, rllurf(xllrl)r'inlir l,t'tttrcltiul insiltlttr:tlii. rr.l'lrrr rrlui tltt Drrrttr:t ciittr irr cunclu)ic, tablloul urrui bolnav cu logorec ryi hipcrl<inezi.o rrlrrriitorul : pacicntul prezinti, o dolinfi sau un irnpuls irezistibil ;i aproalxr rorrl,irrnrr spi'e acfiune, miqcare ,sivorbire cu : a) logoreer.cre$terca fluxuhLi irtcrr,liv(tahipsihic) $i a si$temi ui itleativ (tahifemie)' cind leziunile corl,i, rrlrr rru sint prea mati ; b) latenli, hiperroactiYfi (hiperprosexic) Di reflex rl,, oli,'ntlre prornpt; c) latcn!5, foarte micd in ri,spuusuri I d) incircare :r,frxrt,ivi, atiocvatS,aitualiilor e) hipermnezie, cu exagerare, el'oci,rilor7 caro rlrv irLtrrrnultuoase,intempestivo qi rapido ; f) sim! cxitic ascul,it; g) coerr,nl,r iii ].rttrfunzimea gindirii pot fi pistrate' dar de cele mai multe ori rk,tri iorate, fapt Cate depinde de leziunea cerebraH, $i tie fenomenul r-1r1, rlr, hipcrtensiune intracrania,nl, in cazul proceselor e{pansil'e; hipermlecare deYin tnmultuoascr intempestive qi zi,, (cu r.xagcraroa cvocS,r'i1or, cxagelareil atcnliei, u reflexului de orienl;are, logoreea, mobilitate r'.r,lriil,.), siini, critic ascu-tit,somn foarte pulin (2--3 nre din 24)r jud.ecatd ,.rrrr,.r',r,tri, ;ri lr iunamcnt- nortn:tle sau deteriorate dupX gratlul ;i localizarea leziuni.i
{ir)ttrl)raLc,

I}IB LIOGR A FIE

,{arli AcLa Neurol. Scand.} 19ti9, 45, 484-492, J. A.'I. - Ar ch . N e u o l ., 1 9 6 C , 2 0 ,2 5 3 - 2 5 tr . A b e r f c l d D . C ,, N a m b a i!juriaguerra J., B1ar!c C.- Le rhinenciphale dansI'organisalion cirlltrule.I'hysink4llt et palhologie du inencaplrcle, Xtasson ct Cic, Parjs, 1961, :97-3iJ2. A j u r i a g u o r l n J,, R . - En cycl o p 6 d i c Ti sso t m 6 d ,- ch i r ,, 1 9 6 3 , 1 ? 0 3 G 1 r r ,tt, I 1 l j g o u r i r l a e r e J., s s ot R. Enciclopidie :I' mCdi@-chirurticale,1004, sllj)I'|. .t, -\ 1 ? 0 3 6 .d r o , 1 - o ,\laiouanine Th ,, Om b l e d a n e A., D u r a n d M .- L c sg n d r cm e d c kt d l sl n l l u tl lian phont!iquc tlans I ophosi{, tlasson {L Cie, Prlis, 1930. Alajouanine Th ., L e b e a u J., Il o u d a r t R .- R e v. N .- e u r o l1 ., $ 4 B,3 a l ,:]:a l :t:t/ Alajouanine Th ., Sa b o u r a u d O., R i b o co u r t B. ( d e ) - J. Ii 'JJch o l ,, l l tJ,:f, 4,i, 158-330; 29F330. Alaiounrirc l 'h ., Gr r n e r J., Go u l o n l {., \* e Il l i l .J., L i o t l t,\'. l tr .. Neurol,, 1956, 9t, 357*373. 'f h ., Sa l r o u r a u d Alajouanine O.* En ctp h a l e ,1 9 6 q 3 , 5 5 - - 1 0 1 . Alajouanine Ir ., l - e d o u x R cn a u d t h ., L h e r m i tte D ., Vi g n o l r l L . A. Bev. Neu!oI., 19134,110, 5-20. .\lbe-Fes!iard O.* J. Ph ysi o l ,, 1 9 5 3 ,4 i , 1 6 - 2 9 . D ., Il e sse l\leksic S , N ., Bu d zi l o vi ch A. N .* J. G. i {,, L i e b e }n }a l r N o u l o l . Scl ., l l t;:t, 2A, 1,tr9-159. Appenzcller O.-The a\lonomicnefltous North I:IollandPubl, Co., Anrslenllrrr, sgslem, 1976, April R . S , , Va n so n r l e n b e r g C . * N e u o l o g y, 1 9 7 6 , r r , 1 0 6 &- 1 0 7 0 . A!nasoD B.G.W., Fu l l cr T,G., L e h r i ch .I.R ., Wr a y S. l I.- - J, N u r r ',t. Sei., 1974, 22, 419-_-428. Arnould !{e d . N }n cy,7 9 1 2 , 1 1 , S7 g - 9 i 6 . G.- An n . ,4.rseoi C., Iacob T. *.)-ciolica Derlebftld, Ed. Welther, Sibiu, 19.18. Arseni C.-Bul. $tiint., Edit. Acad. R.P.R,, 1950, ,, 4. A r s e n i O. - Neurol., Psihiat., Ncurochir., 1957, 2, 297-294. Arseni F.- Ac[a N e u r o l . Bcl g ,, 1 9 6 0 , r r , 9 0 1 * 0 0 4 . C . , L a sco .Arscni F,, N i co l csco M .- R e v. Oto - N cu r oOp h tq l n r .,1 0 0 0 ,J.l ],l . l l ,, C . , L a sco p sych i a t. n e r r r o l ,sca n d .,1 0 0 1 , Jd , 2 7 $ - - 2 1 J4 , Arseni M . I.- Actr C , , Bo te z Arseni M ., C h i l i m a n tr {,, Gl i va n I. I., l l a r ct6 l r 0 . , D a vi d gnostr. r&Ltooflalilolotic, Ed. trledicaltr, Illcure$tl, 1967, l l ,''fr i .r -

lliriditala nrin dt'ccrebrarc SintLomtl de rigirlitate prin dccerebrare, sub dileritele sale Yarianto r,i irr rliiirritclc ettpe posttraurnatic,r survino cu o incidentl relativ mare, intt'e t1lroximalir J00'o d;n cazuri in sPria,noasrr; ;i a proapr-r r':r'r'iirrrl .t0,1,(tin oazuriin atte serii (Bricolo qi coi'' 19?7), Deoareceun sindrom rlo'r irriditate prin decerebrare poate surloni imediat post-impact sau in ,,llsrr[ unui sindrom de agravare, incidenla cstc in furrclir; nu numai de Lrcrlliz.areasi,gravitatea leziunilor, oi. qi de promptitudinea qi eficienla sint, in ordinea priorit5,lii, antihiporrliruclrL misuii tera,peutice' -A.cesta in cazurile in care se reveleazd, un qi chilurgicale ieclenraioase rrt ri,.r,, rr, rrro(i(lscxDansiY 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 sinchomului" Iio slrb lorma dittritclor varianto clinice. Frecventr sindlolnul de decel,lililnr cste asociat cu alterXri ale stS,rii de con;tienli, ,sicu semno ncurolotioo, irr lunctio dc intindorea leziunilor clil tlunchiul corellralr precum $i il,' lrziutrilc lerebrale coexistonLe. ' !)xistil si o l/ariantii, f{iii, abolire total5, a stS,rii de conqtiin}L, care so olrsrrrvi't, erceptional de rar qi in literaturi, exist5, citate url numir restrins rlr. r'ir,z.rrri {uairn., tgi2; .Ralsevqi Downie, 1966 ; Arseni s.iOprescu' 1966). decereb.ratiiapare l]umai industr SrrrrrioLrgic. in ace.te cazuri r:igiditatea, tabloul clinic este mai atenuat sponta,I}; niciodatS, nociceptivi, <lo si irrrrili riirl urrLIi rccunoscutc toatc lementele. Ca nivel de conqtiinli, acesta so ochii deschigirde a negn sau de a lr.zrrirriiI.r,nusibilitate& do a mcn!,!rLe corrtirnu c6va prin rniqcXri ale c:Lpului, do a reacliona lont $i.mai mult r:r,rrrruri nul;in corrrplet la un ordin Yerbalt in unele ca,zuri de a incerca sI cuva inill,eh'{ibil sau de a incerca sii, rd,spundl grafic' de asorrrr,rrrrlbti irurrr,,rr, inill,elilibil. Triseelo E:ltrG efectuate ln unele dintre &cesto cazuri uorrIjlnrlt ilitgrrosticul. ru,rr

Arscnl Fi .i o p d l o l o g i e cl i n tcdsi l r tl d m e r r l ,Ii d . Acu ( 1 .l l .S,l l .l C , , Op r cscr t l - * I) u r cr t:d . llucrrrcltl, ll)(i7. ( ; , Si D r l o n cN o l l \1 ,.- I>a l o b l i a D ( tl n o - n l kl l r tl n r [0 .Ii a l r yi ( r l d , l i r l , I\1 r ,., Arscof (lk:nlil, Iltlcu.otlI, I{lli8, ( : . , O!r I c'' 1 ., [!n r r l BI$ Arrfnl ,\1 , - /) /l r l r |r l i ]l r i .i , l tl l l Sfl ,,l ', l 1 2 .

it5,l

305

.-|l l _ 1 ., \l :' r ' lr ir , \1 . t) ltttthdnui rt, t1|ri i t,. /,,:j l ) t ) | , s ( r , t., t\t :r | ,.t s lx ]t. t) llu lttr,tnl i t, tl l r;l t t,. /,, .^l ti 1t u1)t. l\ll'(tsisIt. Nfu f( ' 1 ., I,sitr i;r t., N| [r .,x.hi r., l t)?t), /.j , t|!t .:j :i 9, l,0lr,z t\I. 1 .. h tth u ttir i ) r isccr or tq | lu tit)t::. ttt tr:i tuti t. |\Ltl ti tr, ,:i tr,l i tt l, l ( 1 .A c a ( 1 . l l . S . l t . , Ilr ( .u r ( sli, t9 ? 1 " ( : . . ( j o D s t a ntin cs( :u A f rc lri ]\l . I._ Ncr ir o l., j t;, P si hi l rt., N eurochi r., l gi 1, ll) j j - l t { ) . ( 1 . , ( ; o n s L u n t i n e scll , \ rs rn; A,l,- ^ Hip e e n siu ea ttacrani arLd, E d..A .ced. II.S ,R _, I lr ( u r . { t t i , 1 9 7 2 . Ars c ui O., Oprcscu \* I' ? a u m a lo lo g ie cr a n io - c ercbrel d, Itd. fkdi cal d, E ucurcl ti , M2, (1., ,tlarotsis / \ rs rni lI.- Ro v. r .o [m . Ne u r o ]., 19?8, tr, 359_362. , \ rs f i ( 1 . , C o n s t a n l i n cscr 1 A. l.J lla r e tsislI., S tauci u]I., V oi rescu 7.., Itrocescle cxpLotsiDc ifitrdcrutliencr \'ol. L, Ecl. Acacl. tt.S.R., Bucurcsti, 1$?3. .It C . , C o n s L a n t i r o \. i c i Al., p a n o za G l .\._ tl unati smel e ue ebrc-med.u_ ' \ rs rui tut?. si ltl. tLcrDilor, Iad, IIcdicali, Bucnrc$ti, 10?3. , \ rs t lri C . , C o n s t a n l i n e so u A.t,, Co n sta n tin o vi ci A ., (]hi f esc! M., Nl 1 r r e t s i s lI.I) o cr sc e xp a n sir le itr lr e t! a n icn e , vol . II, Ij d. A cxd. R .S ,R ., B ucufcsti. 1974. .\ f s c I li(1 . , Ioncsou S., Ir ie tr a r u N., Ilie scu D . _ N cul ol ., psi hi at., N enroctri r., 10 7 4 , t r , 3 8 5 - 3 8 8. j U ., Din d itii , \ rs oni O., Golu psj hi at., N eurochi r., T - ., Alcxia n u D ._N curoi ., 1$ 1 t , , 2 1 , 2 4 1 - 2 5 : t . .\ rs c ni C . , C o n s L a n t i n e scu Al. I., M a r e isis l I._ S mi ol ogi errcurcchi rLrrgi col d, \ 1, . , . 11 r ii.. r\ | l. e, i ( : . , AI I r. rrI O - . \fsi ni ( 1 . , . lid i l . r l i d a c t i c i s i p cd a So g icl, BL r cu e tti, 1 l) ? 7 . lri C . . \ I a r e t s i s l[.- Se a r a m o d . Ne u r o c. ( Sao ptrl l o), 7gi i , t;, 1:JI_-1:.]5. (1., (ion!ea \ rs c ni .{ ., Op r o scu L , Sto ica E ._ S tnri tc rornal e,i pntol ogi ce rlc consticntii fi constiintd. Jn : C. Arsr:ni (Sub. recl.,), -hatat ato Ncurotogie, vol. II, li(]. M e d i c a l i , B r c ulc$ ti, 1 9 B0 . p sih ia t., Ncu r ochi r.., 1S ??, :?, j 31_18?. \rre rLi C . , P a I o z a Ch .- Ne u r o l,, (j., SLoica s eni I., 1 ' u clo r J.C' r ize lecp ile p tice, E al i t. S cri sul roma esc, C rai o\.a, '\f 197 I J . (1., Ilorvath .\ rs rni L ., Ciu ica A. \r , * Alc.,Ii ri l c eatuchi rnrgi .al e al e sugtrtul ui ali), Ed. I'Iedicalii, Bucurc$ti, 1979, ti copilului mic (0-3 i (1,, Opr.escu LDu r cr ilc cr ctio - fe .ia te . Io: 0. A rscni -\f s c (sub redacti a), 'l rulul de lieurcIogit, vo], V, Editrr4 MedicatI, Brcurefti, 1979, pp, 9*?5, ,\ r' s r, I i O , , P o p o v i c i u L .Asp e cte te clin i& a te m a ni fesl dri l or parc sti cc neepi l epti ce. I\oblcnle de diagnoslic difercntiul cu critete epilcptice, ln : Simpozionul ,,Epitepsii1e,,, (lluj - N r p o c a , 3 1 N l a i 1 9 8 0 , 1 3 1 *1 ? 9 . C., (iontea A., Op r e scu I., Slo ica Ii .S tri ri te normal e $i patal ogi ce ^r s I rri I c o n r l i . n l d ( su b r cd.), .Itetat de N eurol ogi e, 'vot. l I, $ i c o n $Iiit4 d , In : C. Ar se Di l, lrl i t . [ I e d i c : r 1 5 , B u c ur e iti, p , 1 J- 1 2 9 . Ash lJ p| r r r l i p sych ia t, n e u r Dl,, 1 9 3 5 , su p pl . V I, g47*3i 8. E.-Acta ,\r bc rt XI., Cazalis p,* R,, Au b cr t J,, M a r tin B r1U . S oc. Optrtat. Fr., 1952, r1. 1 , 3 1 1 - l ] 1 5 . p sih ia t., Ne u r o ch ir ., 1958, .?, b25*593. .\tl{irr4 11., Vuia O . - Ne u r o l., \ rs f n B. - Cercatdti .[iftice, biochi]nice, krdiologice si etecttuenceldtografice tn sprijinut Ilrr,r i lcrTcldrii sintlntnului ljarrC-Lieu cct o insulicienld circul(to e \erlcbro-b.tzilatd pin tctDicrlr[rozd, l'ezir de doctorat, I-VF. Cluj, 1968.

(,Ir.r,r'll

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( l i o | . | r ,l r s i c h l r L .N r l l f r '| n 1 , , l l ) ( i {t , , r t , lrLt rt . l lt,. lrlnizlo 11 S. , llr r , I r lllli A. 7l l 7.ll{, l)tf)rrs \', S., Iicrr A. - ( , o qh ! r . / n. opr( 'l l r o n l l r sl l r b l i s h c r . S p r . i i g l i f l ( l( l l l - ) , , lhNr l0s l0i)lt. l)rr:ourt J---,ll(:rir s oiguis , G as t on Doin et Ct o , P a r i s , 1 9 2 7 , (Iesaffectians f )l.i iri ll( .1.- Si-illaioloUie dd syrf{ilnc Trerrear, lt:rsson et Cte, Faris, 1{)14. l) r'l ir )u n I c .I.- Gez. Ntd. Flarce, 1979, 8d, 1651*1651. l)r' l:ry ,1., L hcrnritte F. - Enc y c lop6dic m 6d. - ch i r . , 1 9 6 3 ,1 7 0 1 9A 1 0 ,. 1 ,1 - 1 0 . l)t lry .I., Lh crmittc 11, - ' Enc y c lopodie m 6d. - c h i r . ,1 t 6 3 , 1 7 0 1 94 3 1 . 1 , 1 - 4 . l)f lry .l., Lh crr)rittc f , , Enc y c lopedie m d- c hi r . , 1 9 6 3 , 1 7 0 1 9A a o , 4 , 1 - . 4 , I )rr). DL \v.O., I{cc ht s c half en A. , c ulev ic h c.* Ncuriogy" 1Stj6, 16, I lt._33. f )e l)aris \I- - Glo s s ophar ungeal (Eds,), r r c ur algia. I n: P. J . V i n k e n , C.\\. Bruyn Ilundlrool; of clitical neurologp,\o1,5, Notth-IIollaud Publ. Co,, Amslcrdam, t968, pp. 35 0.3 61 . l)r' \ic M., Bou ch cr N. , I la\ ' ear lI . - J . iled . L y o n , 1 9 8 6 ,5 A v r i l , 5 3 7 - 5 4 7 . l)cvic Il., Aima rd P. , 1I ic hc let F", M as q r i n M . O . *R e v . neurol.r 1967, 11 6,4 67 -17 1. l) i r nr o n d S. - Postgrad. Med,, 1974, 56, 69*73. l)i| lr{ uro S., Scho t land D. L. , Boni} la E., Lee C.-P,, Cambetti P., Ilo wlan cl I- P.-Arch. Ne!rol., 1973, 29, 710*779. f)inritriu 0. R. \I. - Neurol., Psihiat., NeuroIlir., 1972, 11, 29-39I) i\ )I. R.J IIallp ike C, S. - I t oc . Roy . Soc .M ed . , 1 9 5 2 , 4 5 , 3 4 1 - 3 5 4 . f) ix n I. R., Ilxrrison lI . J . G . , Le$is Ncurol, Sci.,7C71, P. D, - J . X3,232-256, l)o(iinot B.-ADr. M ed. Nanc y , 1$72, t J , 987- 9 9 4 . f)i N chrr,1,1 D.4., Bank er B, G . - Ar c h. N. ur o l . , 1 9 6 1 , 5 , '1 7 *9 3 . f )rrf chnrcn D. A. - A. r c h, Ner r ol. , 1968, 18, 654- 6 1 4 . l,r' N chma n D. A., \ Vet z el N. , \ v as s c r m an II., Naito trI.-Arch, Ncurol., 19 60 ,21 , 1 ?0 -.18 3, f)rrchman plus: a classificalion D, A. - Op,il,taLmoplegia of the dis.rder$ associated uilfu proor.ssi?e ctter eLoplttltdlmoplegia, (Eds-) HdndIn: P, J. Vinken, G.W. Bruyn bt)okof clitlicaL neurctoltJ,\o1.22, part II, North-Ilol]and PDbl. Co., A}nste]daE], 1975, pp .20 3-2 16 , I) r:l f o !ecnu L. , G ilndis c h C., Popov ic iu G . - - N e u m l . ,P s i h i a t . ,N e u r - o e h i r , , 1 1t7 7,2 2,8 7-9 2, l)f ritlirncse u St,, O lt e anr l 1. * Er y ef alit . t i e r c e f a t o m i e l i tD ei a l i c e . P r t b l e f i e , l e Ncnologie, Editrua Yedicali, Bucure9ti, 1955, pp. 340-419. f)f il! l{ ne scu St,, Dr igines c u Dirottce N. , pet r c s c u Ar.* Encefalite utuane, lid. Ac.d. R.P.n., Bucure$ti, 1962. l)rrit{ I ncscu St., Dum a D. , Popov ic iu L, , T u r c u T., Driglnese u N", l!o tot Tr,, $ c r baD l{ . , Pops c u Gr., Fovrea D.-Rev. roum. Neurol., lli{ii), rl, 50-58. l)ril 4in cscu St,, Dun a f ) . Popov ic iu L. , D r i g i n c s c u N . *N c u r c l , , I)slhiiL., Ncrr'ochir.,1065, 8, 323-327. f) r i g i D c s c u N., 0 aj al N. - Enceldlile fi enccfalopattinirale co cuofulielnla, Ed, Acad. Il.S,Il., Iluclrrefti, 107.1. l)ro8dnl0 I), l'., Sch t l] t z c r M , , l\ I ic ut ir ! R. S . *A m e r . J . I 'l e d . , 1 9 5 1 , I ] , 6 8 6 . I )urnn l)., Pop oviciu L. , Vuia L , * N c u r o l - , P s i h i a t . ,N c u r o e h i l . , 01 St r oia
l)u 1I!'A, 1, 1'l-24. rir I ) . , I ) i r p i l i a n V, V., (lr r o c l , N N r o ] . , 1 $ 6 0 a , ],- 3 , P., Vu ia 1 6 9 - 1 7 J. ( ]ir n p r o n u Po p o vic i rr J.:., Y r|I!r

\.\., i l | O. \ \(.rrn,t., t,s i tri rrt., \r.r l {hi r.. l l x l :j , f, l !11 l ;l rl . l )uD rr l )., I")tro\i r.i (].' 1,., t,r.i )i |l ,,\ 1,., (;r' i .i .|| l r.. \l l l |Lr) I., l _urri r t.. P l rv l l ., (:i l Il i r It., 0o r.5 S .. .R c \' . r' ounr. N r.ufr)t.. t1)(j l , l ,:11,1, ]:|. I)ul nt D ., P N pi l i l [ \' .!., ]1., P opov i (:i t,- ,N c (r.r,t., I\ ri rt., i i i rbax N crroc i l i r., 1905, tr, 3.10 :ti )l J D nma D ., P s pi ti ar I-., S (r r' brrr \' . V ., l ,opov i c i u l I.--c tl l .i ut l l r{ i ,, t1||,],, J7,409_418. D trn1a D ., P api l i an \:. V ., ;erban II., P opov i c i u (i r1r.l . N ,.r|],t. I-.* S tu(t. 1965, I r,4S 9-515. D u l re-E l d er N . S .._ Iri s rral eal i n.Ii orr. R el al i D eheni otz ops i ft. In : Ter.l book ofo]l ttl rttntl ",rt. \.ol. I\', C. V. \losblr Company, St. Louisr 19tr0, pp. 3651--3652, D i i rstel er N eul ol ., 11]75, 210,25:j -269. \t. R .,-.1. D yck P .J., Letnbc rt E .I:I.-A rc h. N eurot., 1968, l t, 603-618; 611] (i :l t, E asl y R .M., S .-A & er. Gol ds tei n ll L b o nr Ii. - Ncurology, t$00, rr, 64-68. J . \Ied., 1071, ;A ,76t,--777,

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Ilkbom I i ., D c Fi n e Ol i va r i r s B. - H e a d a ch e ,1 9 7 ,1 ,ll, $7-10t. Eldridge R .- - N e u r o l o g y,1 9 7 0 ,2 0 , 1 * 1 8 , Ellenberg M .- h : El l e berg l \i ., R i l h i r J. ( Ed s.) , .Diob.Iusn(llil ls llt,rttt and practice, I\lccraN Hill Co., Ne\r York, 1970, 822-B47. Endtescu L .- C ti ze l ece r e b r a ld ee o r i g i tt p si h i ..i ( n l ,,r i l i t'l i t i l "h t \r ., Po p o vi ci u x i : : l i . ep si h i cc) ,In : L , Po p o vi ci u ( su b r e d .) , M a n i fe st.h i p a tu a i sti c\.tr ch r u l r t,t,l lellice, ljditu.^ l{rdicali, Bucurefti, 1S?8, 273-297. E n g c I G. L. - F'aiting, Charles Thomas publisher, Spi.ingfleld (lll.), 1150. Engel J., IIcI- i n T. R .* Ar ch . i n te r n . IIe d ., 1 0 1 - ) 4 G , L .: R o m a n o ? , .t, l ( x) |l r Esiri N I . M., To m l i n so n A. 1 I.- J. N e u r o l . Sci ., 1 9 7 2 ,1 t,:]:r - 'l B. Essle n E.-Dtsch. Z. Nervclheilk., 1951, fi6, 11.]-7'i2. lraton E , r Stcr i a d e tr {., We r th e i }n l I.- R e \'. N e u r o l .,1 9 5 8 ,9 5 , 1 1 7 .t']l r Fagon E . , Sch w a r tz B, * N e u r o l ., Psi h i a t., N e u o ch i r ., 1 9 6 3 , 8 , 2 0 3 1 0 1 t, Fagon I}., Gh e o r g h i u l I., i \Iu g ctca D u E . , Sch \ya r tz P.- l l f\', r !'u ||r . Ne!rol., 1966, 3, 22:J-234, I . a 9 o n E . , Il o r n ct Th ., Io n e !j cu I., D r i g h i ci L .- R v.N r u m l ., 1 1 1 {i 7 .l,r l r . 672-E73. Faivrc mcd. Nancy! 19?2, l/, 967-971. G.*An!!. Fsvarel-.Benazet cl insuffisance A. U.Thtomboses cirullioire du slplrk : r(rl.Irr ,dsilaire, Those Med., Toulouse, 1964. Figdr5f B,! Po p o vi l i u a n M ., D u l d u 8 ., AFg i a n L . - }l e v. M cd . ( T,{. M u ',r ,}) , 19?1, Ji, 165-168. Fdgdrbf L . - M a n i l e sti i r i sp a sm o l i l i tc.In : L . I,o p o r tr r r l a n M ., p o p o \;i ci l r (sub red.), Manifestdri pal oxislice cerebrale nccpileptice,Ld. Iledicaltr, llu(urrftl. lltTlt. pp. 335-388. I.crIaro Fischer Fische A., .Icr vi s G. A.* Ar cI. N cu r o l . Psi ch i i t.,7 9 4 4 , t2 ,4 4 tl - - .1 U i t, t r{.- N e v l tn g l , J. [tcd ., 1 9 5 6 , 9 5 r , 5 7 - 6 5 . r ( i M ,- - - ,\r ch . r \"0 r r o 1 ., 1 0 6 4 , JI, 5 4 3 - 5 4 $ .

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( i i l t l o r r l i f ! t, t. t\t \||,r N ,,t. t !,t. t1 r ,:1 ./,/, 1 l ;; 1 |i :,. (llrrttlrt {1., I ' r r r ,, ,, r ,r t t,, t.,r t.,r r ||_ ti ,.l r . t]t,.. l l |,:t, _ ,,r ,:fl N ./ :l l 1 tJ. ' ' '' (iiIli(: \ \ '. , l ( o \|r l l , t \r ,1 ,. t1 t,tfi r t. N ,.r v( ,ti r ,, 1 9 ./0 ::r /..1tOt) . 1 2 t) . (;loor l '. ,t tr tth n tq tt.,tL tl tt!r tr 'i tl n l l t,l tl sso n tt cl ", l ,l r i s, 1 l t( ;t. l '1 \l :ti ttl t\ttt ( l o ( i 1 . I r ' r l sl ' ,\ttI N ,. t.,t. s( ., |t., l 1 X;5 rIr ,4 :j .- 5 1 . L (; o o t z r lj, I;i:iotrttolqlt. t.,t. lUr(tir:rliJ IJrr(xu.ctti, 1103. (ioldreycr ti ., t!i It1 ,.,. .J. .t. - C i tci kti o n , 1 $ 7 0 , 4 ], g J:,.- .0 4 {,. (ioldstein .1 . 1 i ., c( ,i {:r n t) . c.,- l r .ch . Op h th a l ., 1 9 6 5 ,2 j , l b s- - j 5 t. G o n y e a il. F. . -l\r.rh. N(,uj.ot.,1!74, J/, 168-1?j. G o o d \ '" i n R . Ir ,, I) o scr C , l I.J.A.II.A., 1 9 6 3 , l d r , 2 5 3 - 2 5 9 . ( ; , , I ta g e I., Pe r r i e ! GraII p .* Acta N e l l l o l .Be l g ,,1 9 6 l ,6 /,4 1 1 7 .,t.t. O.,D u sti n G r e e D \ \ '. R ., l l a e ke tt D . R ., Sctr l e zi n g cr N , S.* Ar cL . Op h th r t., t{l l . i ,, 15,1*167. Greer l{.- ceriatrics, 1975, Jr, 133-136. Guibcrt A., Gu i b cr t C .* D u sg m p ti n e A kl m a l a ( l i c cn n e u r o l o g i eXtr , tr ) i r ( i \. ,\" Edit." Paris, 1974. p ., Be r tr a u d Guillain G., i 'Io l l a r e t I.- Ite \:. N cu r o t., 1 0 3 j ,3 , U fi ( ; ti ;t,. p ,- p l e sse I{6 d ., 1 9 3 5 , 4 J, 5 7 - ,6 0 . Guillain C ., M o l l a r e t G u i l l e m i n a u lt C ., \ti l so Il R . A., 1 ) e In e n t \\r . C .- Ar cL . N e n r .o l( . ( ]tr i c.) ,l !r ,t. 21, 255-_261. Guyton A. C.*.Strucf&re dnd tdnctiorr of lhe neNoussysfem, \V. B. SaundcrsCo., I'l,it ,t, t pbia, 1g?2. Ilaberlandt W. T. * :{rtio,ropii schen Late rlsclerose, Gustav Fischcr \rorlnd, StI ilr't, 196,1. Ilagerrau ( i r ,. I.- Pa th o l o l i e d e sn e r tscr u n i cn $l n : L e m i e !r e ,\., Lenorrnalrr P a g n i ez C h ., Sa vy P,, H e ssi n g e r N ,, D c Ge n n e s I- , :r \ 1 r ,,. A. (Cds.), fraitC dc mtdeciie, vol. J6. ilcsson et Cie. paris, 1C4S, pp, 02?- -{i{it. Itallpike J. 1.'.- J. Neurol, Neurosurg. psychiat., 19?3, ,r, ,180-.190. Ilarrin1an D . c. F., ca r l a n d H .- Br a i n , 1 9 6 g , 9 1 , 4 0 1 - - 4 1 8 . Ilarrington R , B,, Fl o l l e n h o r st R , \\i ., Sa yr e c. p .- Ar ch . N r u r o l ., l txi r ,. 15,29--34. IIauss \ V . IJ., Ar n a t T., D e r l a r n G,, Ke r r r p e r F.- Zsch r . I{r ci ssl l [r tfr "j n l '., 1954, {,?, 831_840. lleck A, !'.- J. Ncurol. Sei., 1964, 1, 22t -285. lleymans C ., Bo u ka e r t J. J.* Pr e ssen 6 d ., 1 9 3 3 , s6 , i 2 g - 7 i J}, II e y m a n s C., B o u k a e r t J. J,, R e g o i e r s P. - Le sinus catutidiot et Ltstortt I hor\l Iogueeca lto-ao iqus, Gaston Dotn ei Cte, palis, 1938 Ilecaen I l . , Aj u .i a g u e r r a J.* Br a i n , 1 9 5 4 , i 7 , 5 ? 3 * 4 0 0 . I - I 6 c a e n H . , Ao g e l e r g u e s R .- L a ca ci ti p sl l ch i q u e Il,a sso n e t C l c, p o r l s, tti ;t. II6caen I l . , An g e l e r g u e s Il .- Pd tl to l o g i c d u l a n g a g c. l .,.|p h a si e ,L n r o u n sr .l h r t\, 1965. Hilton G . F., H o yt W. F.- J.A.M ,A., 1 g ta 6 , 2 0 2 , 1 0 tB* 1 0 2 0 . Ilinterbuchner P. L .- Bu l l . N e w Yo r k l ca d . \Icd ,, 1 9 7 4 , ,r , b 8 9 - - $ 0 r , Ilirano A . , Ar a m u g a sm y N ., Zi m m e r m a n I'I. M .* Ar ch . N o o r o l . ( ( :h t,..) , L967, 16,357*3$5. Ilishikawa Y., Stl n r i t6 u j i N ., i l a tsr l n o to Ii ., l i o r e ko 2 ..- Ii tr .tr o t.r l crltr. cliD. Nr.rrrophlxlol,, 10f,5,,8, 487-.i92, Ilishik:rwn \'., l f r " r 'yl | ti .,Wr h xn r a tsu l L , \'o n r n r o ( o .].. - th ,I. I,t,Jsk, pollr. roil,, 107r, .v, I t:tlt tl. lloflrrrtr Ilu u (;, 1 .1 ( l |l r ttr xr . l 1 l 0 l , :,/, l '0 i t, l l ? . Ar r ', N I|| r , l 1 l ,:1 , ,l t" l 'l j :' .l tXi '.1 , ^llrl, ll. lr,

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.,|,,,1 l ,r,' i l )l |!r. r/. l :l l l l i i l ). rr \ \,.,,|' . ri ,j l l .:i .l l ., l l r' trfr' l l i , l 1r/(1, l /,{ /,i . l ,l f\rri rl A. \j rfu rr .t "1t,"rt. l ,l . \,,,,1,.ri r.i l t.S .l t.. Inr,rrr.s l i , l 1t?7. fi l l l l :rl r| N - l i .. \1 l l l rl ,' r r, l l i \r,.1,. N rrrrr)1. ((]' ri c .), j t{ i l . t!, l t)l 1l :,. f\rrrl row 1.. .l ' ,rrl l tr,rl . \1,,1. l 1r,l , :tt;, l l l ,r 111. Ii rf l! rl 1, . 1., \l r' l .l (.r l ). \\. N fIrol { ,gy (Mi [D orp.), 101,5, ;;,211] 26fi . l ,norl )crl tl . , l i i ,l )rr,l r l ;. Il . .1. l ,afr"ng., 1961, 73,681-{ i 93, l ,rprcsl o 1 ., Il ,:s i Nl. A c l l N ( rol . B c l tti c l , 1977,77,331-350. (1., ()prc s c u T,asco l .l ., A l .s c rri I., N i c ul es c u II. - N eul oc hi fl trA i ( . l \rr.rurl i r,l l \rf l, r \. ,l r,l l r| (l l , r 4.. Ir,,,1

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(,., l ' |r, f'.,f,,,\'l fl r' 1,., \![l ,rr l l . l ' ,1r,,, \,l ]t' rl Irt rr t. ti trl r' l (l r! tthrl ttrl urttt,tt' htt ,,t I , ' I It It t , , I , I | | ,t I t , r tl l t rttl l . rd Ir tl tl i )t:t l t s :;utrtt o trl tnttt,l r ,,,,i \ r, rl nt. ./ s 1/,/,. (i us l r' \ Ii s |h,,r \,,/t!l l , /r,q,r'r. fl r | .!. l ,' \ IIr tl ttl tt S tul tqr rl . l l rl l l . t,t,. l l l l , l .l l l '('po\,i r:i U 1,., /\i ,Ii i r l | l t., l ) Lru l .:., I' l s f u I., l ,al l rl c O. .ti rrrrl ,trr i \l (l i fr l i rl . (l i rA r. l r,rl ,\, l l ri :1, l l l (i , t). l ;i j . j r r L., \V ri l \fl P opo\i c l t l ' ., ( ; i i J i t) ri r' g 1., l (i k ol i 1,., Os l s z i rr ,{ ., tt:rrl ,' rl rol ., Irri l ri r|-. N , |l ro(l ri r., 1L)7t, 1t, 1]i --1tl t). tri .-N c (1., S z .rL] 6 L.-, t)|tl rttttutl utn P oD ovi ci rL I-, I' x s (:l | 1., (i of l rt' i u O,, ;i pot tl re t?Io ti ans bc l l !,tc nu:tl (i n l es i ons al U tc broi ns l c t dl Ld Ihe rrl odi l i c ati ar\ ac (u1!i ttt Lu tttl orl l dni .fl l i on ol s l etp an.{ l he poLl l gtuphi c (i nannl i es af s l c .p, S fc orrt Iutc urati orx l s t,.,,t, l l rscrrc l r C odgl c s s , i j di nbnfgh, 30.J une-4 J ul y , 1975, p. 159. ' f., C oi oc :1ru l ropa\_i ci u L., D ul i u ]J ., IJ c c u$ 1,. - U rtl c U oIh I tr i tl .:ti opdl onuri a at .rl .c l i uni tl c urc nus c ul are c u (]c l etl ni ti s m arrl oi l ndn, (b r. ti S t!_ Tg. l {u res , 12 i |l !;e 1975. Iropo\i ci u L. (r.d.) -.fi i l c ps i i !?, E d. D ac i a, C l uj -N apoc l , 1070. tsopo\:i ci r L,, l l i rc k L.C ol l c l uz i i fi IntbLrmi bi nl el o{ l ol oti c c .ID :C ous fi i l Lri ftI ti rLn!,, .otund.ii ,,.f-onros{ialica lteftcbraki lil pri.ti.a uedicald", Tg. Muref, 20 rl]ni l1);'(;. P opovi ci u L., P as c u I., ,)i po$ C ,, C orJ ari rL O., LA z trr L,, A S i ti :r r l t.. B e c u t ' I. - W s hi ng rnd S l c epi D g, 1970, l , 89-101. P opoIi ci l l L., P as c o I. - h ; S i mpoz i onul ,,l c htl l ;"Ldl i l rr pal ol al l i d oas (ul urd rrhtl ttt , S oral fl, 1077, 1-21, IropoY i ci r L. (s ub red.)i U dti fes l ti ri paroti s l i c e utebrtl e tl tepi [rt][i tc , t,i l - [l ,rti (,' t]r, B ucurr$1i , 19?8. P opo\,i ci u 1,. (s ub rc d.)-- t' i s al , ed. D ac i a, 0l uj -N apoc n, l 97i j , (1. fi S rt.c k P opo\i ci u L., l J ec x t T., D rl i u L., $i pof Maf t.r--(i rrl rrl ,r/r, l ( sl ud i ul .l i nfu s i el ec ranl i ogral i c ul putu\l i ol atni i [ot, C onr. S rs i unc r N rri rl :r r ti t. Tg. l l ure$ a S oc . S L. l l c di c al e, 2:] apri i i c 1978. vi ci u T,.- J n: { i . A rs eni (l i d.), al ' rattl L de neurc l ogi c , v ol , I, l i rt. } ti (l i (rl rl , I,rl rcsti , 1 970. P opoti ci n L., I):rs r|1 l .I' ri ux i pi i general e de l Lrapi e naw ol oti c ti , l rrrO.,\rr, rr r (l d.), ' !ral dL.l e x euob7i e, \' oi . \' ' ., Ii d, l i l rdi c al i , I]rour.c s ti , 1079,pp.25:t l ,ti r). P oFo tr,., P as c u l .-' Iul burbi l e de c an;ti i nl d c l i tt l c z i utti te s i s l t:ttrl ui t,ttl tl ,l r bu:i l ar. 1o. L.P opo\.i c i u, Gtt. P c ndofunda (s ul ) (rl .), /,,,/,/ S i I. P as c l l l a7i tr uos c ul ari i d !i s l c rntdui D ertc bto-bu.i l ar, Lr.l . .l uui nrc a, Ia;i , 1!?9 l )p. 2:ti t :l tti . Fopoyi ci u f,. (s ub red.)- S dnl i ol ogi a neutul ogi c ti , Li togul i l r Il l l .. l g. N l or(t, l l r/1r. i ci r P opo\ 1,., B c c ut T., W ai ts rk P ., D ul Me(l . (' l d. \l |r,,,r. i { u D .-l trt. P opovi ci u 1.- I,e{ obti (L nerD i l ar trani c ni " l n: (1. A rs c rr i (!rl , ' ,,t.), !ol, IiI, [4.]. iUedicali, Bucuresti, 1980. l ropo'i ci rr L,, P ende{ unda Gh., P as c u l .B ol i l c aas c [arc c ?t(hl l (tl i uN i rl ,|ul eetlcbro-buziltlr, Ild. Junimca, IaSi, 1S30. P opovi ci u L., W ai ts rl k P ., A s gi an R ., I)ul i u Il ., C l i s pr' rr S t., Il l |l t I 'l Zs.P ol i i eLtopati i h c atenl i al e (s Ludi u c l i ni c fi l i rl G), 1980 (l uc tN l c |l (.pl l l rl l (!rtrr). P opovi ci uL., Itnul i c l l ,* P ul ol o7i a s i s tu\ul ui netD oi D eotl al i Lt,l rJ . Mr' (l i (x 11, l l rr.(l r.rl Li , 1081. P o L t c r .I M. -- .1. Lar' l gol . Otol ., 106.1, ??t, { i 5.1-{ l -r7. I'o L1rr ,L .t. l ,rrry |l $)|. Otol ., 11)7:1,l l (i , ul J l tl 1l 2. . /' ri ri /r/ri ,, l ,:{ 1. ;\rc (l i (.l l i , l } |l i ror(.i l i , l 97l j . l | \' , I,ro(l csr \i r \' . l 'fi tc'l fl ., f' r' I, Il l rrl tou\\' l i l t,l rtl i ( I)t i l ri c d, l i l . 1111,;t . l 'r'ol r |'I l 0) 4.. l !|||r,.,r, .l ;t i , .1. L /\11l r. S ui \v \r,urri . N (r' r,r' l ri r. 19t9,:5,32.* .3s . popo\.i ci rt L., P i s c u 'trdtal de neurobgie,

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rr (1" l l r rrrrL' N l Il r" l ' l rr l 7 l "' l l \ rl ' I l ' l ' "i ' l :!rrl ' ('l l l ' i i rrr l l l ri rl l $ ' l l )(i ' l l i l i Ac tx N r tLr0l ' s (rl l rl rl' l rr/5' S I. s.rr /i :' 1(i 7 ' l ' l ti ' " A l l tx N trrf"l ' :' :rrrrl ' 11)/l i ' [1' i c D r t h g-\' o I l b e n d S a s ttl ttl l l ' ' s i ]r' l rdl rri l l fttl ni n 7f [1 \" I r N I , ,S a!-l r;v trl i tl S aracirr'oun* i i gvi l i ' i /iilrrs ri l ts /i l rS ' S ' n" Tl )i l i s i ' 1{ 10() ""'",,rl (i frrz l i oi tl ot0 6, ITl htel s tl :o A c tt(hrrri N rrrrl i ' A rr' l" ori i l (i nos hi l a ll' tto x' "' f n',-i r' o' ^rto' ' i s.t"'oj ;;;; ' "x J. Ophthel , 196i, i', 668-67:J' ps tc hi at" 1961' :l ' M--l l l ' N ol ros url i ' D ' C -J ' N c urol K ., P ark S chapi ra 131.-133' ri e' J. .- R e\" N e"rol ' 1968' t ; ; ir N c urol ' (C hi c ' )' 1969' 2' ' 132--1119' " " "; II' N ' .-A rc h' C l aman S .4., S chneck Il r' ' A rc h' N c ul ol ' 1964' 10"1' 33L' P ' D . I-.' R o\1 c l ard S choti aD C l @l l ri (l l t tttl !\' -' P tl tl tol ol i e Gorttl l e M' l ' r' i l l et C h' , 8., B ou rret S chott ct Cle' Paris' 1965' sislill1. 1)e.lebtu-hasildirc, llasson 2111J --21?0; 2?:13' -:i 5l J 1t' 1967' P trt' , B .-n"v. . s"l l "ti Os s f P'A' l I2.rhs II' E dc r f-P ' ' r"r' I' R oN c l rnd S chw artz l :i l ' 'l ' Ir . J r., f' ;l :l l t 1903' N c l ]r' ol 11"-' \rc h' g' A ndc rs ol l ' L' Ir., Il i rsc hberg 15!-4?0' 3J ' 193?' l ' P h-v s i ol " S'4 ., $' r i ght s"l .t*=i rr"" ^ 321-810' J ' L' - l l ars ei l l c l ]Ii d" 1972' -1"' G., Gas !aut' ti crratri ce

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