leucoaraiozå la un pacient cu stenozå medie de arterå ... - medica.ro
leucoaraiozå la un pacient cu stenozå medie de arterå ... - medica.ro
leucoaraiozå la un pacient cu stenozå medie de arterå ... - medica.ro
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PREZENTARE DE CAZ<br />
LEUCOARAIOZÅ LA UN PACIENT<br />
CU STENOZÅ MEDIE DE ARTERÅ CAROTIDÅ<br />
INTERNÅ DREAPTÅ – ASOCIERE<br />
ÎNTÂMPLÅTOARE SAU DETERMINANTÅ?<br />
Monica Sabåu, Petru Mihancea, Dan Sirca, Andrada O<strong>ro</strong>s-Iova<br />
Universitatea din Ora<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>a<br />
INTRODUCERE<br />
Leucoaraioza (LA) este <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> termen int<strong>ro</strong>dus <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
Hachinski în 1987 (din greces<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>l leuko-alb ¿i araiosisrarefiere)<br />
pentru a <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>semna anomaliile substan¡ei albe<br />
emisferice i<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ntificate <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> examinarea TC ca arii hipo<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>nse<br />
difuze, ete<strong>ro</strong>gene, imprecis <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>limitate. Ele<br />
intereseazå <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> precå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>re centrul substan¡ei albe centrale,<br />
nu substan¡a albå periventri<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>rå sau zonele<br />
imediat subcorticale. Examinarea IRM în secven¡e<br />
pon<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rate T1 aratå zone <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> hipointensitate, iar secven-<br />
¡ele pon<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rate T2 aratå zone <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> hiperintensitate. Uneori<br />
lezi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ile <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>tectate TC ¿i IRM nu s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t superpozabile<br />
ca numår, localizare, extin<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>re, pentru cå cele douå<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>tecteazå alteråri ale substan¡ei albe care au semnifica¡ie<br />
patologicå diferitå.<br />
Nu este <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ci o entitate ci <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> fenomen <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> asocieri<br />
multiple.<br />
Mac<strong>ro</strong>scopic se constatå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>coloråri insu<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng><br />
nivelul substan¡ei albe<br />
Lezi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ile tisu<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re care p<strong>ro</strong>duc modificårile neu<strong>ro</strong>imagistice<br />
s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t reprezentate <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> rarefierea difuzå a<br />
substan¡ei albe cerebrale, lårgirea spa¡iilor perivas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re<br />
Virchow-Robin, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>mielinizare, pier<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ri axonale<br />
¿i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> oligo<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>nd<strong>ro</strong>cite, gliozå reactivå, cre¿terea con-<br />
¡inutului <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> apå ¿i <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>eori infarcte mici. În esen¡å,<br />
modificårile neu<strong>ro</strong>imagistice reflectå cre¿terea con¡inutului<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> apå.<br />
Mecanismele fiziopatologice prin care apare acest<br />
fenomen s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t multiple ¿i cont<strong>ro</strong>versate. S<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t invoca¡i<br />
factori ce ¡in <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> scå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rea <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>bitului cir<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>tor, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
alterarea barierei hematoencefalice, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> alterarea<br />
cir<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡iei lichidului cefalorahidian (1).<br />
Într-o manierå mai extinså a acestor imagini, aceea<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> leucoencefalopatie s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t implica¡i ¿i factori toxici<br />
10<br />
REZUMAT<br />
Este prezentat cazul <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> 68 ani <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>stenozå</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> ca<strong>ro</strong>tidå internå dreaptå care este internat în mod repetat pentru <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficit<br />
focal neu<strong>ro</strong>logic: hemiparezå stângå. Imagistica aratå infarcte <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>c<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>are, <st<strong>ro</strong>ng>leucoaraiozå</st<strong>ro</strong>ng>. Este dis<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>tabil dacå existå o re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡ie directå<br />
între stenoza ca<strong>ro</strong>tidianå ¿i evolu¡ia <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ului.<br />
(antineop<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>zice, im<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>osupresoare, solven¡i organici,<br />
alcool, cocainå, monoxid <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> carbon ), infec¡io¿i<br />
(HIV, PES, panencefalita rubeolicå, zona-zoster,<br />
CMV, boa<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> Lyme), boli <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> sistem (LED, PAR, boa<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng><br />
Behcet, sdr Sjögren, sarcoidoza, vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>lite), genetici<br />
(CADASIL, leucodist<strong>ro</strong>fii, aminoacidurii), metabolici<br />
(<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficitul <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> vitamina B12, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> fo<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡i, hiopxia),<br />
traumatisme (2, 3).<br />
LA este frecvent <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>pistatå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> examinarea TC ¿i<br />
IRM a pacien¡ilor <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> suferin¡e vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re cerebrale.<br />
Frecven¡a este mai mare <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> pacien¡ii vârstnici, <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> cei<br />
<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> HTA ¿i DZ. Prezen¡a LA este frecvent asociatå<br />
<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> prezen¡a infarctelor <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>c<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>are (IL) ¿i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ci <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><br />
afectarea vaselor mici cerebrale, mecanismele<br />
ischemice <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> p<strong>ro</strong>ducere ale LA ¿i IL fiind în mare<br />
måsurå superpozabile. Legåtura dintre stenozele<br />
ca<strong>ro</strong>tidiene ¿i prezen¡a LA este înså nec<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>rå. Pare<br />
mai <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>grabå cå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>zvoltarea ¿i p<strong>ro</strong>gresia LA <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> ace¿ti<br />
pacien¡i ¡ine mai <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>grabå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> prezen¡a <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>or factori<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> risc com<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i (4, 5).<br />
PREZENTAREA CAZULUI<br />
Pacientul ML, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> 68 ani este internat pentru prima<br />
datå în i<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ie 2005 pentru parestezii ¿i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficit motor<br />
pe hemicorpul stâng.<br />
Pacientul nu prezintå antece<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>nte familiale semnificative.<br />
Pårin¡ii au <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>cedat <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> vârste înaintate, nu<br />
poate preciza cauza <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>cesului, dar re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teazå cå nu au<br />
urmat nici <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> tratament c<strong>ro</strong>nic. Fra¡ii s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t sånåto¿i,<br />
nu urmeazå nici <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> tratament. Are doi copii sånåto¿i.<br />
A avut nume<strong>ro</strong>ase internåri în sec¡ii <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> reumatologie<br />
¿i balneofizioterapie pentru spodilodiscart<strong>ro</strong>zå<br />
<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> radi<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>lgii ¿i gonart<strong>ro</strong>zå bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral. Ultima internare<br />
a fost în Spitalul <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> Re<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>perare Felix <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> ¿ase l<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i în<br />
REVISTA ROMÂNÅ DE NEUROLOGIE – VOL. V, NR. 1, AN 2006 51
52 REVISTA ROMÂNÅ DE NEUROLOGIE – VOL. V, NR. 1, AN 2006<br />
urmå. Nu urmeazå nici <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> tratament <st<strong>ro</strong>ng>medica</st<strong>ro</strong>ng>mentos.<br />
Este din mediu rural, a fost miner într-o minå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> uraniu<br />
peste 20 ani, obi¿nuie¿te så consume alcool ap<strong>ro</strong>ape<br />
zilnic (100-150 ml ¡uicå pe zi, <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> masa <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> prânz ¿i<br />
seara).<br />
Boa<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> a <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>butat <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> douå zile înaintea internårii<br />
prin parestezii pe hemicorpul stâng, urmate <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> scå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rea<br />
for¡ei mus<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> ace<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¿i nivel. Treptat nu<br />
mai poate merge <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>cât <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> sprijin, prezintå instabilitate<br />
emo¡ionalå. Nu a urmat nici <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> tratament.<br />
Examenul obiectiv general <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> internare <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>celeazå:<br />
<st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> obezitate abdominalå (înål¡ime 1,69,<br />
greutate 101 Kg), facies pletoric, rubeoza pome¡ilor,<br />
câteva stelu¡e vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul fe¡ei dar nu ¿i pe<br />
torace, ¡esut celu<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r sub<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>tanat ab<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng><st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>nt prepon<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rent<br />
<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul abdomenului. Sistemul ganglionar nu se<br />
palpeazå, prezintå discretå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>formare, redoare arti<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>rå<br />
¿i cracmente <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> mobilizarea gen<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>chilor bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral.<br />
Respirator: sonoritate pulmonarå, murmur vezi<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r<br />
prezent. Cardiovas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r: AMP în limite normale,<br />
zgomote ritmice, bine båtute, TA-110/ 80 mm Hg,<br />
egalå stânga-dreapta. Abdomenul este mårit <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> volum<br />
pe seama ¡esutului celu<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r sub<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>tanat, tranzitul intestinal<br />
este prezent. Ficatul este <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> rebord, nedure<strong>ro</strong>s <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng><br />
palpare. Lojile renale s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t libere, mic¡i<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ile s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t spontane,<br />
<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> po<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>chiurie nocturnå ¿i scå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rea intensitå¡ii<br />
jetului urinar. Organe <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> sim¡, în limite normale.<br />
Examenul neu<strong>ro</strong>logic: <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng> con¿tient, orientat<br />
tempo<strong>ro</strong>spa¡ial ¿i asupra p<strong>ro</strong>priei persoane, prezintå<br />
plâns spasmodic, fårå tulburåri <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> limbaj, memorie,<br />
<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> eupraxie. Prezintå paralizie facialå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> tip central în<br />
stânga, globii o<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>ri au axe paralele, mi¿cårile s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t<br />
posibile în toate direc¡iile, RFM este prezent bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral,<br />
pupilele s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t egale. Pacientul stå greu în ortostatism,<br />
are tendin¡å <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> cå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>re spre stânga, merge doar <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> sprijin,<br />
prezintå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficit motor <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul membrelor stângi<br />
(gradul 4 dupå MRC scale), are u¿oarå hipertonie <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
tip piramidal <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul membrelor stângi, ROT vii<br />
bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral, mai vii în stânga <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>cât în dreapta, prezintå<br />
reflexe patologice: semnul Babiski în stânga, R. palmo-mentonier<br />
bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral, Toulousse prezent. Sensibilitatea<br />
obiectivå este în limite normele, <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul a<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>zå<br />
parestezii pe hemicorpul stâng. Prezintå u¿oarå dismetrie<br />
<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> p<strong>ro</strong>bele indice – nas ¿i cålcâi – gen<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>chi în<br />
stânga.<br />
LCR este c<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r, incolor, normotensiv. Pandy ++,<br />
elemente 4/3, monocite, p<strong>ro</strong>teine 120 mg%, glicorahie<br />
54 mg%, cloru<strong>ro</strong>rahie 734 mg%. Analiza p<strong>ro</strong>teinorahiei<br />
nu se poate face din motive tehnice. La repetare:<br />
Pandy ++, p<strong>ro</strong>teine 110 mg%, elemente 6/3 (mononucleare),<br />
glicorahie 50 mg%, cloruri 764 mg%.<br />
TC cerebralå fårå substan¡å <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> contrast, efectuatå<br />
<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> trei zile <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> internare (cinci zile <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>butul<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficitului focal neu<strong>ro</strong>logic) aratå: ¿an¡uri corticale<br />
¿i våi silviene mult accentuate, sistem ventri<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r<br />
ectaziat, normal pozi¡ionat.<br />
Concluzii: at<strong>ro</strong>fie cerebralå marcatå.<br />
Examinårile <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>borator: VSH 11/24, hemoglobinå<br />
12,1 g%, hematii 4,2 mil/mm 3 , leucocite 5700/ mm 3 ,<br />
(neut<strong>ro</strong>file segmentate 57%, limfocite 36%, eozinofile<br />
2%, monocite 4%), t<strong>ro</strong>mbocite 250.000, T Howel<br />
2 min 30 sec, tipm <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> p<strong>ro</strong>t<strong>ro</strong>mbinå 98%, glicemie<br />
77 mg%, uree 29 mg%, coleste<strong>ro</strong>l 180 mg%, timol 3,<br />
bilirubinå totalå 0, 36 mg%, indirectå 0,36 mg%, directå<br />
0%, GPT 22 UI, ex urinå negativ. Pacientul refuzå<br />
efectuarea testului HIV ¿i VDRL.<br />
EKG: ritm sinusal normal, fårå modificåri patologice.<br />
EEG: traseu alfa hipovoltat, intricat <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> beta, fårå<br />
elemente patologice spontane sau <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> hiperpnee.<br />
Examenul f<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>doscopic: aspect normal al papilei<br />
nervului optic, vase îngustate.<br />
Rgf. Pulmonarå: cord <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> u¿oarå reducere a diametrului<br />
longitudinal, mici opacitå¡i reti<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re supradiafragmatic<br />
¿i parahi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r drept. Sinusuri costo-diafragmatice<br />
libere.<br />
Examenul Doppler al vaselor precerebrale: ACC,<br />
ACI ¿i bulb ca<strong>ro</strong>tidian <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> plåci fib<strong>ro</strong>ca<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>care milimetrice,<br />
multiple. În segmentul cranial al ACI drepte se<br />
evi<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>n¡iazå accelerarea vitezei sistolice <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> 110cm/sec<br />
(<st<strong>ro</strong>ng>stenozå</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> ap<strong>ro</strong>ximativ 40%). P<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>toul diastolic este<br />
coborât. ACC, ACI ¿i bulbul ca<strong>ro</strong>tidian în stânga prezintå<br />
plåci milimetrice, fårå modificare semnificativå<br />
a vitezelor <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> flux. V sist 63 cm/sec, V diast 24 cm/<br />
sec. arterele vertebrale fårå fereastrå Doppler bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral.<br />
Se instituie tratament antiagregant (Aspenter), hemoreologic<br />
(Pentoxifilin), neu<strong>ro</strong>p<strong>ro</strong>tector (Piracetam),<br />
vitaminic (vitamina B1 ¿i itamina B6). Se practicå<br />
gimnasticå re<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>peratoare ¿i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficitul neu<strong>ro</strong>logic regreseazå<br />
semnificativ, <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul merge singur, persistå<br />
frust <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficit motor pe hemicorpul stâng ¿i <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul<br />
a<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>zå în continuare parestezii pe hemicorpul stâng,<br />
dureri <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul gen<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>chilor, mai ales în stânga. Pe<br />
par<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>rsul internårii, måsurarea repetatå a TA <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> diferite<br />
ore ale zile Este externat dupå 14 zile. Se recomandå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng><br />
domiciliu Aspenter 75 mg/zi, Pentoxifilin 3 x 1 tb/zi,<br />
Piracetam 2-2-0 tb/zi.<br />
Dupå o l<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>å starea <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ului este b<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>å, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficitul<br />
motor minimal, valorile TA s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t normale, a<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>zå în<br />
continuare dureri <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul gen<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>chilor ¿i coloanei<br />
dorso-lombare.<br />
Revine dupå douå l<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i a<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>zând dureri intense <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng><br />
nivelul umårului stâng. Deficitul motor este minim,<br />
prezintå importantå limitare antalgicå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul arti<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡iei<br />
scapulo-humerale în stânga. Persistå instabilitatea<br />
emo¡ionalå, nu mai prezintå plâns spasmodic. valorile<br />
TA aj<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>g <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> câteva ori în regi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ea <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> grani¡å (150/<br />
80 mmHg). Analizele <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>borator s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t simi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re,
REVISTA ROMÂNÅ DE NEUROLOGIE – VOL. V, NR. 1, AN 2006<br />
înafara <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ei eozinofilii <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> 12 %, iar <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> examenul<br />
cop<strong>ro</strong>paraziltologic se evi<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>n¡iazå infestare parazitarå<br />
<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> Ascaris lumbricoi<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>s. Radiografia arti<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡iei<br />
scapulo-humerale stângi aratå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>mineralizarea difuzå<br />
a regi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ii scapulohumerale, mici zone <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> calcificare<br />
<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul capsulei arti<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re. Se interpreteazå ca<br />
periatritå scapulo-humeralå, se face tratament AINS,<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>riva¡i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> ergotoxin, fizioterapie, gimnasticå <st<strong>ro</strong>ng>medica</st<strong>ro</strong>ng>lå.<br />
Se administreazå antiparazitare (Mebendazol 2x1<br />
tb/zi, trei zile). Simptomatologia se amelioreazå. Se<br />
externeazå ameliorat dupå 12 zile. Pacientul continuå<br />
acaså tratament re<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>perator ¿i <st<strong>ro</strong>ng>medica</st<strong>ro</strong>ng>mentos, evolu¡ia<br />
este favorabilå, se întoarce <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> activitå¡ile anterioare.<br />
Nu se mai prezintå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> cont<strong>ro</strong>l.<br />
Dupå ¿apte l<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> prima internare <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul<br />
se prezintå seara în serviciul <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> urgen¡å pentru<br />
reinsta<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>rea bruscå a <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficitului motor pe hemicorpul<br />
stâng, în <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>rsul dimine¡ii. Re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teazå prezen¡a <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>or<br />
importante tulburåri <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> memorie, agravarea instabilitå¡ii<br />
emo¡ionale, tulburåri <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> somn <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> tendin¡a <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
inversare a ritmului somn-veghe. A<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>zå în continuare<br />
dureri <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul gen<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>chilor ¿i dureri <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul<br />
membrului superior stâng. Afirmativ, a urmat tratament<br />
permanent <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> Aspenter ¿i Pentoxifilin, nu a<br />
mai consumat alcool. Intermitent a luat AINS în<br />
aplica¡ii locale sau pe cale generalå. În urmå <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> o<br />
såptåmânå a prezentat o IACRS pentru care a luat<br />
Ampicilinå trei zile.<br />
Examenul obiectiv: orientat tempo<strong>ro</strong>-spa¡ial ¿i<br />
asupra p<strong>ro</strong>priei persoane, plâns spasmodic, se concentreazå<br />
greu, re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>tarea simptomatologie este p<strong>ro</strong>lixå,<br />
prezintå paralizie facialå perifericå, este disartric,<br />
prezintå discrete tulburåri <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>gluti¡ie predominant<br />
pentru lichi<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>, p<strong>ro</strong>bele <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> parezå s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t pozitive <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng><br />
membrele stângi, dar poate efectua ¿i mi¿cåri antigravita¡ionale.<br />
Mi¿cårile antirezeisten¡å s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t reduse.<br />
(gradul 4 MRC Scale), ROT s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t vii bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral, clonoi<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
chiar în stânga, reflexele patologice avute anterior s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t<br />
prezente, prezintå hipertonie <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> tip piramidal, mai<br />
accentuatå în stânga. Pacientul nu poate men¡ine<br />
ortostatismul ¿i nu poate merge <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>cât <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> sprijin<br />
bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral. Valorile TA s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t normale, dar <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul<br />
re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teazå cå diminea¡a, <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> måsurarea få<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>tå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> medi<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>l<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> familie TA a fost cres<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>tå: 180/100 mm Hg ¿i i s-a<br />
administrat Captopril 1 tb sublingual.<br />
Analizele <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>borator: VSH 8/17, leucocite 5500/<br />
mm 3 , (neut<strong>ro</strong>file segmentate 58%, limfocite 37%,<br />
monocite 4%, eozinofile 1%), hemoglobinå 14,5<br />
mg%, hematii 4,1 mil/mm 3 , fibrinogen 603 mg%,<br />
p<strong>ro</strong>teina C reactivå-negativ, factor reumatoid –<br />
negativ, glicemie 77 mg%, uree 27 mg%, coleste<strong>ro</strong>l<br />
total 249 mg%, timol 2 UI, bilirubinå totalå 0,35<br />
mg%, în totalitate conjugatå, GPT 8 UI, Examen <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
urinå – negativ.<br />
53<br />
Rgf pulmonarå aratå tendin¡a <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> orizontalizare<br />
a cordului, în rest normal.<br />
LCR este în continuare <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> hiperp<strong>ro</strong>teinorahie:<br />
128 mg%.<br />
Se face examinåri im<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ologice pentru treponema,<br />
din sânge ¿i LCR, care s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t negative. Se face ¿i<br />
restul HIV, care este negativ.<br />
Examenul Doppler al vaselor precerebrale aratå<br />
ace<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¿i aspect ca <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> examinarea anterioarå.<br />
Examenul <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> f<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>d <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> ochi: angiopatie hipertensivå<br />
stadiul II.<br />
Examinarea MRI cerebralå aratå lezi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i discrete<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>leucoaraiozå</st<strong>ro</strong>ng>, infarcte <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>c<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>are ¿i at<strong>ro</strong>fie cerebralå<br />
difuzå, bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teral (figura 1).<br />
Angio MRI nu då elemente importante <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> diagnostic.<br />
În toate secven¡ele <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> angio MRI, <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> diferite<br />
gra<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <strong>ro</strong>ta¡ie, pare så existe o variantå anatomicå<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> AcomA în care cele douå ACA com<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>icå în mod<br />
direct, fårå så existe <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> vas intermediar. (Com<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>icarea<br />
se face pe o l<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>gime mai mare, dar acest lucru nu<br />
afecteazå f<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>c¡ionalitatea poligonului Willis) (figurile<br />
2-4). MRA <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> reconstruc¡ie 3D (figurile 3, 4) aratå <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng><br />
flux ceva mai scåzut <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul ACI drepte. Desigur,<br />
aceste date s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t orientative, doar agiografia poate da<br />
elemente <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> certitudine.<br />
Se trece <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> tratament antiagregant <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> P<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>vix, se<br />
adaugå tratament hipolipemiant <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> statine, se men¡ine<br />
Pentoxifilin, se face o <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>rå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> Cereb<strong>ro</strong>lisyne. Evolu¡ia<br />
este favorabilå, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficitul neu<strong>ro</strong>logic se amelioreazå<br />
semnificativ: <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul poate umb<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> singur, fårå sprijin,<br />
se amelioreazå ¿i tulburårile <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>gluti¡ie. Persistå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>bilitate<br />
emo¡ionalå, u¿oarå anxietate ¿i tulburåri <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> somn.<br />
Pe par<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>rsul internårii valorile TA råmân normale.<br />
Figura 1<br />
Figura 2
54 REVISTA ROMÂNÅ DE NEUROLOGIE – VOL. V, NR. 1, AN 2006<br />
Dupå o l<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>å este internat într-o altå clinicå, se<br />
repetå examinarea MRI ¿i angio MRI, datele s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t<br />
perfect superpozabile, înafara minimei diferen¡e cå<br />
stenoza ACI drepte este apreciatå ca fiind 50-60%.<br />
Atitudinea terapeuticå råmâne aceea¿i.<br />
DISCUºII<br />
Figura 3<br />
Figura 4<br />
Apari¡ia <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficit neu<strong>ro</strong>logic <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> focar <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng><br />
<st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>stenozå</st<strong>ro</strong>ng> ca<strong>ro</strong>tidianå cont<strong>ro</strong><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>teralå este cel<br />
mai a<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>sea rezultatul <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui infarct pe vas cerebral mare<br />
sau al <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui infarct <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> grani¡å. Apari¡ia infarctelor<br />
<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>c<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>are ¿i a leucoaraiozei <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> pacien¡ii <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> stenoze<br />
ca<strong>ro</strong>tidiene nu pare så fie în legåturå <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> prezen¡a<br />
stenozei ci mai <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>grabå <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> prezenta factorilor <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> risc<br />
(4, 5).<br />
Chiar dacå Fisher, întemeietorul i<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ii <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> IL nu<br />
p<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ea între factorii cauzatori stenozele vaselor precerebrale,<br />
existå studii care aratå cå ar putea fi o legåturå<br />
între aceste stenoze ¿i IL care apar în teritoriul vasului<br />
respectiv (6). Nu gåsesc înså o legåturå între stenozele<br />
ca<strong>ro</strong>tidiene ¿i LA (7, 8). Alte studii aratå cå LA este<br />
mai severå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> pacien¡ii <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> gra<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>stenozå</st<strong>ro</strong>ng> mai mare,<br />
dar gåsesc cå severitatea LA nu se coreleazå <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><br />
scå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rea <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>bitului cerebral. Re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡ia dintre gradul<br />
stenozei ¿i severitatea LA poate fi <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ci <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng><st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>va tot <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng><br />
nivelul factorilor com<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> risc (9). Mecanismul prin<br />
care în stenozele ca<strong>ro</strong>tidiene pot så aparå lezi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
tip LA <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul substan¡ei albe cerebrale pare a fi<br />
hemodinamic (10). Patternul iriga¡iei substan¡ei albe<br />
oferå condi¡ii <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> scå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>re rapidå ¿i marcatå a <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>bitului<br />
cerebral regional în mijlo<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>l emisferului, <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> limita celor<br />
douå teritorii, realizând o mare sensibilitate <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> ischemie<br />
a substan¡ei albe emisferice (1, 10, 11). Faptul cå nu<br />
existå, înså, o re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡ie <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> cauzalitate directå între stenoza<br />
vaselor extracraniene ¿i IL sau LA reiese din datele<br />
<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>or <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>rgi studii în care au fost urmårite în timp<br />
rezultatele endarterectomiilor (4, 12). Dupå interven-<br />
¡ie, beneficiul pacien¡ilor <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> IL a fost foarte mic.<br />
Prezen¡a leucoaraiozei nu constituie indica¡ie operatorie,<br />
dar pare cå ea constituie <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> important factor <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
risc pentru <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> AVC ¿i chiar dacå ris<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>rile operatorii<br />
s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t cres<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>te <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> pacien¡ii <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> LA, recomandarea chirurgicalizårii<br />
este fermå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> pacien¡ii <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> evenimente<br />
vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re ¿i <st<strong>ro</strong>ng>leucoaraiozå</st<strong>ro</strong>ng> (12).<br />
La <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul nostru apari¡ia recidivelor, stereotipia<br />
lor, prezen¡a <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficitului motor re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>tiv important ¿i<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>stul <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> persistent, duce <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> gândul <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> acci<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>nte<br />
repetate în teritoriul ca<strong>ro</strong>tidian drept. Prezintå, înså,<br />
doar IL multiplå ¿i <st<strong>ro</strong>ng>leucoaraiozå</st<strong>ro</strong>ng>. Este extrem <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> interesant<br />
faptul cå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>¿i prezintå lezi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>i bi<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>terale, LA<br />
chiar mai severå în stânga, simptomatice s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t doar<br />
evenimentele vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re p<strong>ro</strong>duse <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul emisferului<br />
drept. Acest lucru trebuie acceptat în lumina faptului<br />
cå existå mult evenimente vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re cerebrale<br />
din toate categoriile, care nu s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t simptomatice.<br />
Examinarea Doppler situeazå stenoza într-<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> interval<br />
în care nu are indica¡ie operatorie. (40% <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> prima<br />
examinare, 60% <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> cea <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>-a doua examinare). Acest<br />
lucru, dacå este asimptomaticå. Dacå evenimentele<br />
vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t datorate stenozei ca<strong>ro</strong>tidiene ¿i nu<br />
suferin¡ei vaselor mici cerebrale, indica¡ia chirurgicalå<br />
intrå în dis<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>¡ie. P<strong>ro</strong>babil cå arteriografia ar aduce date<br />
mai c<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re, dar realizarea ei implicå ris<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>ri iar <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul<br />
este, cel pu¡in <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> momentul acesta, împotriva examinårilor<br />
invazive ¿i împotriva abordårii chirurgicale.<br />
Un studiu, din 2002 få<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>t pe 2618 pacien¡i selecta¡i<br />
din NASCET aratå cå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> pacien¡ii <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>stenozå</st<strong>ro</strong>ng><br />
ca<strong>ro</strong>tidianå ¿i care au prezentat AIT sau AVC minore<br />
fårå invalidare, prezen¡a LA cre¿te semnificativ ris<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>l<br />
<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui orice tip <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> AVC, al <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui AVC <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> mare invalidare<br />
sau <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>cesul <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ului. Ris<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>l este <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> atât<br />
mai mare <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> cât severitatea LA este mai mare. Ace<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¿i<br />
studiu aratå cå, în ciuda <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui risc preoperatoriu mai<br />
ridicat, <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> ace¿ti pacien¡i, realizarea EAE reduce ris<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>l<br />
<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui AVC (13). Alte studii contrazic acest lucru: <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng><br />
review efectuat în 2003 aratå cå între LA ¿i AVC<br />
ischemice sau hemoragice, nu existå re<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¡ie <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> cauzalitate,<br />
legåtura dintre ele fiind <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul existen¡ei<br />
suferin¡ei arterelor mici cerebrale (14).<br />
Prezen¡a hiperp<strong>ro</strong>teinorahiei a constituit ini¡ial o<br />
p<strong>ro</strong>blemå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> diagnostic, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> altfel p<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>c¡ia lombarå a
REVISTA ROMÂNÅ DE NEUROLOGIE – VOL. V, NR. 1, AN 2006<br />
fost repetatå dupå efectuarea TC. La o asemenea<br />
hiperp<strong>ro</strong>teinorahie ne-am a¿teptat ca imagistica så<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>scopere <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> p<strong>ro</strong>ces tumoral. Am pus p<strong>ro</strong>blema <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>or<br />
cauze infec¡ioase, dar celu<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>ritatea normalå a LCR a<br />
fost <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> contraargument. Reac¡iile efectuate pentru<br />
HIV, sifilis au fost negative. Alte investiga¡ii în acest<br />
sens am consi<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rat cå nu s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t necesare (15, 16).<br />
Din påcate, nu am putut face elect<strong>ro</strong>foreza LCR<br />
(¿i nu s-a få<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>t nici <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> internarea în alte clinici) motiv<br />
pentru care am avut îndoialå în ceea ce prive¿te existen¡ei<br />
<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ei boli vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re inf<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>matorii. Pacientul nu<br />
prezintå fenomene inf<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>matorii generale, examinårile<br />
paraclinice nu ple<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>azå pentru o boalå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> sistem, nici<br />
o boalå inf<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>matorie intestinalå, nu are nici o suferin¡å<br />
oncologicå, situa¡ii patologice care pot <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>termina<br />
vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>lite ale vaselor mici cerebrale. În vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>litete<br />
izo<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>te ale sistemului nervos existå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> regulå ¿i pleiocitozå,<br />
iar pacien¡ii s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> vârstå <st<strong>ro</strong>ng>medie</st<strong>ro</strong>ng> (15, 16).<br />
Afectarea BHE, <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> cre¿terea albuminorahiei apare<br />
frecvent în contextul suferin¡ei vaselor mici cerebrale<br />
(1, 11). Valorile TA måsurate în mod repetat aratå<br />
doar rareori valori ridicate. Totu¿i, existå modificårile<br />
vaselor retiniene care sus¡in prezen¡a hipertensi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ii ¿i<br />
care se agraveazå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> o examinare <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> alta. Intrå în<br />
dis<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>¡ie monitorizarea ambu<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>torie a TA, care ar putea<br />
aråta varia¡ii circardiene patologice <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>scrise <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> pacien¡ii<br />
<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> afectarea vaselor mici cerebrale (1). Pacientul nostru<br />
are o vârstå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> care este posibilå apari¡ia suferin¡ei<br />
vaselor mici cerebrale chiar în lipsa HTA. În ace<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¿i<br />
timp, <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul rec<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>oa¿te consumul c<strong>ro</strong>nic <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> alcool,<br />
d<strong>ro</strong>g care este amintit în categoria celor care pot<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>termina leucoencefalopatie (2). Pacientul nu este<br />
diabetic, are hipercoleste<strong>ro</strong>lemie, dar aceasta este <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng><br />
important factor <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> risc al ate<strong>ro</strong>scle<strong>ro</strong>zei, nu al suferin-<br />
¡ei vaselor mici cerebrale. Angiopatia amiloidå care<br />
vizeazå ¿i ea vasele medii ¿i mici cerebrale predisp<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>e<br />
<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>men¡å (<st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul prezintå o <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>teriorare treptatå a<br />
f<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>c¡iilor intelectuale) dar cel mai a<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>sea evenimentele<br />
vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t hemoragice.<br />
Abrevieri:<br />
ACC- artera ca<strong>ro</strong>tidå com<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>å<br />
ACI – artera ca<strong>ro</strong>tidå internå<br />
AINS – antiinf<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>matoare neste<strong>ro</strong>idiene<br />
AIT – acci<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>nt ischemic tranzitor<br />
AMP – aria matitå¡ii precordiale<br />
AV- artera vertebralå<br />
AVC – acci<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>nt vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r cerebral/<br />
BHE – bariera hematoencefalicå<br />
CADASIL – cerebral autosomal-dominant arteriopathy<br />
with subcortical infarcts and leukoencephalopathy<br />
(arteriopatie cerebralå autosomal dominantå <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><br />
infarcte cerebrale subcorticale ¿i<br />
leucoencefalopatie)<br />
CMV – citomegalovirus<br />
DZ – diabet zaharat<br />
EAE – endarterectomie<br />
CONCLUZII<br />
55<br />
La cazul luat în observa¡ie existå afectarea concomitentå<br />
a tutu<strong>ro</strong>r teritoriilor vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re: boa<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> vaselor<br />
mici cerebrale ¿i ate<strong>ro</strong>scle<strong>ro</strong>za vaselor precerebrale.<br />
HTA ¿i vârsta <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ului constituie <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> factor <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng><br />
risc com<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> celor douå afectåri.<br />
Hipercoleste<strong>ro</strong>lemia poate fi puså în legåturå <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><br />
fenomenele ate<strong>ro</strong>scle<strong>ro</strong>tice.<br />
Consumul c<strong>ro</strong>nic <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> alcool <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>terminå afectarea<br />
difuzå a substan¡ei albe cerebrale, dar mecanismul<br />
nu este neapårat vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>r. În ceea ce prive¿te efectul<br />
lui p<strong>ro</strong>tector <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> nivelul vaselor mari în p<strong>ro</strong>cesul<br />
ate<strong>ro</strong>scle<strong>ro</strong>tic, stenoza ca<strong>ro</strong>tidianå este prezentå ¿i<br />
pare så p<strong>ro</strong>greseze.<br />
Evenimentele vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> care <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ul a fost<br />
internat, alterarea stårii neu<strong>ro</strong>logice, apari¡ia fenomenelor<br />
<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> pseudobulbarism, a tulburårilor <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> memorie<br />
s<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>t mai <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>grabå rezultatul suferin¡ei vaselor mici<br />
cerebrale. Stenoza ca<strong>ro</strong>tidianå pare asimptomaticå.<br />
Cre<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>m cå, în continuare se imp<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>e tratament care<br />
vizeazå ambele sectoare vas<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng><st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>re, factorii <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> risc ¿i<br />
neu<strong>ro</strong>p<strong>ro</strong>tec¡ia: antiagregant, administrarea <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> statine,<br />
neu<strong>ro</strong>p<strong>ro</strong>tectoare. Urmårirea TA este o p<strong>ro</strong>blemå.<br />
Valorile gåsite imp<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> pru<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>n¡å, pentru cå eventualele<br />
scå<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ri marcate ale TA pot <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>termina prin hipoperfuzie<br />
cerebralå atât agravarea suferin¡ei ischemice<br />
datoratå alterårilor vaselor mici cerebrale cât ¿i apari¡ia<br />
<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui infarct <st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng> mecanism hemodinamic în teritoriul<br />
ACI afectate. P<strong>ro</strong>babil cå într-o primå etapå restric¡ia<br />
sodatå ar fi suficientå. Se recomandå regim hipolipidic<br />
¿i exclu<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>rea consumului <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> alcool. Eventualele<br />
situa¡ii care ar imp<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>e tratament anticoangu<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>t (<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> ictus<br />
în p<strong>ro</strong>gresie) prezintå <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng> grad <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> risc ridicat, LA <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>terminând<br />
frecvent transformare hemoragicå. Aplicarea<br />
<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ui stent sau realizarea <st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ei EAE <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>pin<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> evolu¡ia<br />
stenozei ¿i în ace<st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>¿i timp <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> evolu¡ia stårii neu<strong>ro</strong>logice<br />
¿i psihice a <st<strong>ro</strong>ng>pacient</st<strong>ro</strong>ng>ului pânå <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng> momentul în care evolu¡ia<br />
stenozei ar imp<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>e interven¡ia.<br />
HIV – human <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ficiency virus<br />
HTA – hipertensi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>e arterialå<br />
IACRS – infec¡ie a<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>tå a cåilor respiratorii superioare<br />
IL – infarct <st<strong>ro</strong>ng>la</st<strong>ro</strong>ng>c<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ar<br />
IRM – imagerie prin rezonan¡å magneticå<br />
LA – <st<strong>ro</strong>ng>leucoaraiozå</st<strong>ro</strong>ng><br />
LCR – lichid cefalorahidian<br />
LED – lupus eritematos diseminat<br />
NASCET – North American Symptomatic Ca<strong>ro</strong>tid<br />
Endarterectomy Trial<br />
PAR – poliartrita reumatoidå<br />
PES – panencefalita scelozantå suba<st<strong>ro</strong>ng>cu</st<strong>ro</strong>ng>tå<br />
RFM – reflex fotomotor<br />
ROT – reflexe osteotendinoase<br />
TA – tensi<st<strong>ro</strong>ng>un</st<strong>ro</strong>ng>ea arterialå<br />
TC– tomografie computerizatå
56 REVISTA ROMÂNÅ DE NEUROLOGIE – VOL. V, NR. 1, AN 2006<br />
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