Hemoragiile cerebrale

• 15% din bolile vasculare cerebrale

• Def: suferinta cerebrala datorata efractiei

unui vas - extravazarea sangelui in:
– parenchimul cerebral = hemoragie
intraparenchimatoasa
– extracerebral = hemoragie subarahnoidiana
Hemoragia intraparenchimatoasa
(hemoragia cerebrala, apoplexia)
• > 10% din AVC; 12-15/100.000
• rata decese ~ 50%

Factori de risc:
• varsta peste 55 ani, sex M
• consumul de alcool, droguri
 Factori de risc medicali
• HTA
• malformatii vasculare
• amiloidoza cerebrala
• iatrogen: antitrombotice, simpatomimetice
• coagulopatii
• leucoze
• tumori
 Topografie
• Profunda: • Lobara:
HTA - stress amiloidoza
hemodinamic
malformatii vasculare
– ganglioni bazali
– talamus toxice (alcool)
– Punte,
– cerebel • Fara predilectie:
coagulopatii
tumori
 Diagnostic clinic
• Debut brusc (in activitate), agravare
progresiva (ore)
• cefalee intensa +/- varsaturi
• salt tensional (> AVC ischemic)
• alterarea starii constienta - coma
• deficit neurologic focal coresp topografiei:
hemiplegie, paralizii nn cranieni, tulb
sensibilitate, coordonare
 Diagnostic paraclinic
• CT urgenta / IRM
• dg etiologic
Angiopatie amiloida
 Complicatii
• Resangerare
• edem cerebral
• efractie ventriculara - hidrocefalie acuta
obstructiva
• Efractie subarahnoidiana

• complicatii generale: infectii, tromboze

venoase ->TEP, tulburari cardiace
 Tratament
• Medical:
– Antiedematos: Manitol 20% PIV
– TAS < 180 mmHg
– trat etiologic (tulb coagulare)
• Chirurgical (+/-):
– evacuare: superficiale, risc letal (dimens, poz), tumori
– drenaj ventricular
– decompresie (si in AVC ischemice)
Hemoragia subarahnoidiana
 Etiologie

• Anevrisme intracraniene (75%)

• traumatisme
• disectii arteriale
• coagulopatii
• vasculite
 Diagnostic clinic
• Debut brusc, agravare progresiva
• salt tensional
• Sindrom meningeal
– cefalee, varsaturi, fotofobie
– semne meningeale: redoare de ceafa, Kernig,
Brudzinschi
• alterarea starii de constienta
• semne neurologice de focar
 Scala Hunt si Hess
1. Asimptomatic / usoara rigiditate ceafa
2. Paralizii nn cranieni, redoare ceafa
3. Deficit focal minor, somnolenta/confuzie
4. Deficit focal moderat/sever, stupor/coma,
rigiditate decerebrata incipienta
5. Coma profunda, rigiditate decerebrata
Diagnostic paraclinic

• CT
• punctie lombara
• angiografie (I 72 h)
 Complicatii
• Resangerare - max z 1, 14
• Efractia intraparenchimatoasa / acumularea
• Hidrocefalia normotensiva
• vasospasm - z 3-10 -> deficit focal (infarct)
• hiponatremia - pierdere cerebrala de Na
• tulburari vegetative (cardiace: tulb ritm,
conducere)
 Tratament
• Chirurgical: Z 1-3 sau > 14
– Hunt si Hess 1-3
• Medical:
– blocanti Ca: nimodipina
– supliment Na (corector) – la nevoie
– controlul TA: sub 150 mmHg
– antiedematoase, simptomatice (durere!)
Sistemul venos
 Tromboza venoasa cerebrala
Etiologie
• Focar infectios de vecinatate
• Traumatism
• Coagulopatii
• Iatrogen
• Sarcina
• Neoplazii
 Clinic
• Cefalee
• Sindrom meningeal
• Crize epileptice
• Semne neurologice de focar – date de:
– Ocluzie venoasa
– Infarct venos
– Transformare hemoragica
Paraclinic
• Ct cerebral
urgenta
• MRI – angio timp
venos
• Angiografie

• Profil coagulare
• Focarul infectios
 Diagnostic diferential
• Meningite, meningoencefalite
• HSA
• AVC ischemic / hemoragic

• Tumori
• Abcese
 Tratament

• Anticoagulant: heparina
fractionata -> standard

• Corticoterapie + Ab

• Simptomatic: antialgic,
antiepileptic

• Tromboliza,
trombectomie,
decompresie

• Anticoagulant cronic:
– Fara factori risc: 3-6 l
– Neprecizat: 6-12 l
– Trombofilie: nedefinit
Evolutie
• Forme usoare: remisiune
spontana

• Forme medii: raspund la

terapie, remisiune completa

• Forme severe: sinusuri

profunde, infarcte masive
hemoragice – deces (10%)