UNIVERSITATEA DE MEDICINĂ ŞI FARMACIE
UNIVERSITATEA DE MEDICIN I FARMACIE CRAIOVA
COALA DOCTORAL
TEZ DE
DOCTORAT
CONTRIBUII LA STUDIUL PROFILULUI CLINICO-MORFOLOGIC
AL HEMORAGIEI CEREBRALE
- REZUMAT -
Conductor de Doctorat:
Profesor Universitar Dr. Iancu Emil PLEEA
Student - Doctorand:
Carmen Corina STANCU
2013
CUPRINS
C U P R I N S ......................................................................I A B R E V I E R I.............................................................. VI I N T R O D U C E R E .......................................................1 STADIUL CUNOATERII .................................................4 CAPITOLUL I ELEMENTE DE MORFOLOGIE CEREBRAL ...........................................................................5
VASCULARIZAIA CEREBRAL..............................................................................6 Vascularizaia arterial.................................................................................6 Sistemul venos cerebral.............................................................................27
UNITATEA NEUROVASCULAR............................................................................33 Generaliti ................................................................................................33 Descrierea anatomic ................................................................................34 Alterarea jonciunilor ..................................................................................40
SPAIILE LICHIDIENE CEREBRALE.......................................................................41 Spaiile derivate din tubul neural primitiv....................................................41 Spaiul subarahnoidian ..............................................................................44
CAPITOLUL II HEMORAGIA CEREBRAL...................47
INTRODUCERE .................................................................................................48 DEFINIIE I CLASIFICARE .................................................................................48 EPIDEMIOLOGIE ...............................................................................................49 FACTORI DE RISC .............................................................................................49
Modificabili .................................................................................................49 Nemodificabili ............................................................................................50 ETIOLOGIE....................................................................................................... 51 Hipertensiunea arterial.............................................................................51 Angiopatia amiloid....................................................................................52 Malformaiile vasculare ..............................................................................52 FACTORI DECLANANI.....................................................................................55 Factorii endogeni .......................................................................................55 Factorii exogeni .........................................................................................55 PATOGENIA .....................................................................................................56 Modul de formare al hematomului .............................................................56 ANATOMIE PATOLOGIC....................................................................................57 Localizare ..................................................................................................57 Aspecte macroscopice ale ICH..................................................................60 CLINICA HEMORAGIEI CEREBRALE......................................................................66 Scale de evaluare clinic ...........................................................................67 INVETIGAII IMAGISTICE ....................................................................................69 Computer Tomografia nativ .....................................................................69 Angiografia CT ...........................................................................................69 Rezonana Magnetic Nuclear.................................................................70 NOI TENDINE TERAPEUTICE .............................................................................70 EVOLUIE I PROGNOSTIC.................................................................................72
I
PROFILAXIA ICH ..............................................................................................73
CONTRIBUIA PERSONAL.........................................74 CAPITOLUL III MATERIAL I METODE ........................75
MATERIALUL STUDIAT.......................................................................................76 Criteriile de includere .................................................................................76 Loturile de Studiu .......................................................................................77 Sursele de date..........................................................................................78
METODE DE LUCRU..........................................................................................78 Tipul de studiu ...........................................................................................78 Obiective ....................................................................................................78 Parametri analizai .....................................................................................79 Achiziia imaginilor microscopice ...............................................................85 Prelucrarea statistic a datelor ..................................................................85 Scalele de stratificare a parametrilor..........................................................86
CAPITOLUL IV STUDIUL CLINIC...................................91
HEMORAGIA CEREBRAL ?N STATISTICA INTERNAIONAL.....................................92 DISTRIBUIA TEMPORAL..................................................................................93
Variaia anual...........................................................................................93 Variaia lunar............................................................................................94 Variaia sezonier ......................................................................................95 SEXUL PACIENILOR.........................................................................................96 MEDIUL SOCIAL................................................................................................97 GRUPA DE V?RST...........................................................................................98 SEVERITATEA HTA ........................................................................................100 ASOCIEREA CU ALI FACTORI DE RISC ..............................................................101 AFECTAREA STRII DE CONTIEN .................................................................103 GRADUL AFECTRII NEUROLOGICE...................................................................104 Scorul NIHSS la internare........................................................................104 Scorul NIHSS la externare.......................................................................105 EVENIMENTELE TROMBO-EMBOLICE.................................................................107 TIPUL EXTERNRII ..........................................................................................109 DURATA SPITALIZRII......................................................................................110 COMENTARII FINALE ASUPRA STUDIULUI CLINIC .................................................112
CAPITOLUL V STUDIUL MORFOLOGIC .....................114
STUDIUL ASPECTELOR MACROSCOPICE............................................................115 Localizarea focarelor hemoragice ............................................................115 Hemoragia intracerebral profund .........................................................118 Hemoragia intracerebral lobar .............................................................123 Hemoragia ?n trunchiul cerebral i cerebel...............................................130 Dimensiunile focarului de ICH..................................................................132 Complicarea cu inundaie ventricular i extensia ?n spaiul subarahnoidian
......................................................................................................................... 148 Edemul perilezional i efectul de mas....................................................150
STUDIUL MODIFICRILOR MORFOLOGICE ALE PERETELUI VASCULAR....................153 Generaliti ..............................................................................................153 Edemul perilezional..................................................................................159 Prezena microhemoragiilor .....................................................................161 Modificrile peretelui arterelor mari..........................................................163
II
Modificrile arterelor penetrante i arteriolelor .........................................168 Modificrile capilarului..............................................................................172 Geneza focarului hemoragic ....................................................................177 COMENTARII FINALE ASUPRA STUDIULUI MORFOLOGIC.......................................178
CAPITOLUL VI CORELAII CLINICO-MORFOLOGICE ............................................................................................. 183
INFLUENA TERAPIEI ASUPRA PROGNOSTICULUI PACIENILOR ............................184 STAREA LA EXTERNARE ? V?RSTA PACIENILOR................................................185 STAREA LA EXTERNARE ? HTA.........................................................................186 STAREA LA EXTERNARE ? SCORUL GSC ..........................................................186 STAREA LA EXTERNARE - SCORUL NIHSS........................................................187 STAREA LA EXTERNARE ? DURATA SPITALIZRII ................................................188 STAREA LA EXTERNARE ? EVENIMENTE TROMBOEMBOLICE ................................189 STAREA LA EXTERNARE ? TOPOGRAFIA HEMORAGIEI .........................................190 STAREA LA EXTERNARE ? VOLUMUL HEMATOMULUI ...........................................191 STAREA LA EXTERNARE ?INUNDAIE VENTRICULAR..........................................192 STAREA LA EXTERNARE ? HEMORAGIE SUBARAHNOIDIAN .................................192 TOPOGRAFIE HEMATOM ? V?RST ...................................................................193 TOPOGRAFIE HEMATOM ? HTA .......................................................................194 TOPOGRAFIE HEMATOM ? SCOR GSC..............................................................195 TOPOGRAFIE HEMATOM ? SCOR NIHSS...........................................................196 TOPOGRAFIE HEMATOM ? INUNDAIE VENTRICULAR.........................................197 TOPOGRAFIE HEMATOM ? DURAT SPITALIZARE ................................................198 VOLUM HEMATOM ? HTA................................................................................199 VOLUM HEMATOM - SCOR GSC .......................................................................200 VOLUM HEMATOM - SCOR NIHSS....................................................................201 VOLUM HEMATOM - INUNDAIE VENTRICULAR..................................................201 HEMORAGIE INTRAVENTRICULAR ? HTA.........................................................202 HEMORAGIE INTRAVENTRICULAR ? SCOR GSC ...............................................203 HEMORAGIE INTRAVENTRICULAR - SCOR NIHSS.............................................204 COMENTARII FINALE ASUPRA CORELAIILOR CLINICO-MORFOLOGICE...................205
C O N C L U Z I I............................................................207 B I B L I O G R A F I E...................................................210
REFERINE BIBLIOGRAFICE DIN LITERATURA DE SPECIALITATE ......211 REFERNIE BIBLIOGRAFICE PERSONALE .............................................233
III
ACA ACC AchA ACI ACM ACoA ACoP ACP ACS AICA AIT AngioCT AVC BHE CT DZ ECG GSC HE HIC HSA HTA HVS ICH IHC IMA IV LCR MAV NIHSS OMS PICA rFVIIa RMN TA TEPA Tn T TVP VSH
ABREVIERI
Artera cerebral anterioar Artera carotid comun Artera coroidian anterioar Artera carotid intern Artera cerebral medie Artera comunicant anterioar Artera comunicant posterioar Artera cerebral posterioar Artera cerebeloas superioar Artera cerebeloas antero-inferioar Accident ischemic tranzitoriu Angiografie Computer Tomograf Accident vascular cerebral Bariera hemato-encefalic Computer Tomograf Diabet zaharat Electrocardiogram Glasgow Coma Scale Hematoxilin ? Eozin Hipertensiune intracranian Hemoragie subarahnoidian Hipertensiune arterial Hipertrofie ventricular st?ng Hemoragie intracerebral Imunohistochimie Infarct miocardic acut Intraventricular Lichid cefalorahidian Malformaii arterio-venoase National Institutes of Health Stroke Scale Organizaia Mondial a Sntii Artera cerebeloas postero-inferioar Factor VII recombinat i activat Rezonan magnetic nuclear Tensiunea arterial Trombembolism pulmonar Troponina T Tromboz venoas profund Viteza de sedimentare a hematiilor
CUVINTE CHEIE:
Hemoragie cerebral, terapie hemostatic, volum hematom
IV
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