Alterações neurológicas nas cardiopatias congênitas um estudo neuropatológico

Rosemberg, S.; Andrade, A. F.; Brandão, C. M. A.

doi:10.1590/S0004-282X1992000100012

Resumos

Estudo neuropatológico foi realizado em 190 autópsias consecutivas de pacientes com cardiopatias congênitas: 116 casos foram operados (grupo cirúrgico, GCg) e os 74 restantes formam o grupo clínico (GCI). Alterações neuropatológicas foram observadas em 71 casos (41 no GCg e 30 no GCI). Entretanto, a maior parte dos 129 casos com exame normal morreu nas primeiras 72 horas após a cirurgia ou os eventos clínicos responsáveis pela morte. Quase todas as alterações foram hipóxico-isquêmicas. Infartos, únicos ou múltiplos, foram encontrados em 41 casos (23 no GCg e 18 no GCI). Mecanismo embólico foi detectado em 12 casos. Alterações hipóxicas difusas estavam presentes em 17 casos (10 no GCg e 7 no GCI). Hemorragias foram encontradas em 11 (6 no GCg e 5 no GCI). Em 17 casos (5 no GCI e 12 no GCg), o quadro foi o de uma leucomalacia periventricular. Todos os casos eram concernentes a crianças abaixo de 6 meses de idade. Em 7 casos, alterações inflamatórias foram detectadas (micro-abscessos difusos em 6 e abscesso de lobo frontal em 1). Quase todos os casos em ambos os grupos apresentaram complicações clínicas, isoladas ou associadas, potencialmente danosas para o cérebro, como parada cardíaca, baixo débito cardíaco, hipoxemia e insuficiência respiratória. Foi impossível determinar, em cada caso, a magnitude do fator ou fatores responsáveis pelo padrão neuropatológico correspondente. Não houve diferenças do padrão neuropatológico entre as cardiopatias com hiper ou hipofluxo pulmonar.

encéfalo; cardiopatias congênitas; neuropatologia

A neuropathologic study in 190 consecutives autopsies of patients with congenital cardiopathy was performed: 116 cases underwent a surgical procedure (S group) and the remaining 74 were non-surgical (NS group). Neuropathologic alterations were observed in 71 cases (41 in the S group and 30 in the NS group). However, most of the 129 cases with a normal examination had died in the first 72 hours either after surgery or the clinical events responsible for the death. Almost all the neuropathologic alterations were hypoxic--ischemic. Infarctions, single or multiple, were found in 41 cases (23 in the S and 18 in the NS group). An embolic mechanism could be detected in 12 cases. Diffuse hypoxic changes were present in 17 cases (10 in the S and 7 in the NS group). Hemorrhages were found in 11 (6 in the S and 5 in NS group), 4 of which were related to a disseminated intravascular coagulation. In 17 cases (5 in the NS and 12 in the S group), the picture was of a periventricular leukomalacia. All these cases concerned children under 6 months of age. In 7 cases inflammatory alterations were present (diffuse micro-abscesses in 6 and a frontal lobe abscess in 1). Almost all cases in both groups presented clinical complications, isolated or associated, potentially harmful to the brain, as cardiac arrest, cardiac low output, hypoxemia, and respiratory distress. If was impossible to determine in each case the magnitude of the factor or factors responsible for the correspondent pattern of neuropathology damage. There was no difference as to the neuropathology pattern between congenital cardiopathies leading to increased or decreased pulmonary blood flow.

brain; congenital cardiopathies; neuropathology

Alterações neurológicas nas cardiopatias congênitas um estudo neuropatológico

Neuropathology alterations in congenital cardiopathies

S. Rosemberg^I; A. F. Andrade^II; C. M. A. Brandão^II

^IProfessor Associado, Departamento de Patologia, FMUSP. Trabalho realizado no Departamento de Patologia do Instituto do Coração do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP)

^IIMonitor, Departamento de Patologia, FMUSP. Trabalho realizado no Departamento de Patologia do Instituto do Coração do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP)

RESUMO

Estudo neuropatológico foi realizado em 190 autópsias consecutivas de pacientes com cardiopatias congênitas: 116 casos foram operados (grupo cirúrgico, GCg) e os 74 restantes formam o grupo clínico (GCI). Alterações neuropatológicas foram observadas em 71 casos (41 no GCg e 30 no GCI). Entretanto, a maior parte dos 129 casos com exame normal morreu nas primeiras 72 horas após a cirurgia ou os eventos clínicos responsáveis pela morte. Quase todas as alterações foram hipóxico-isquêmicas. Infartos, únicos ou múltiplos, foram encontrados em 41 casos (23 no GCg e 18 no GCI). Mecanismo embólico foi detectado em 12 casos. Alterações hipóxicas difusas estavam presentes em 17 casos (10 no GCg e 7 no GCI). Hemorragias foram encontradas em 11 (6 no GCg e 5 no GCI). Em 17 casos (5 no GCI e 12 no GCg), o quadro foi o de uma leucomalacia periventricular. Todos os casos eram concernentes a crianças abaixo de 6 meses de idade. Em 7 casos, alterações inflamatórias foram detectadas (micro-abscessos difusos em 6 e abscesso de lobo frontal em 1). Quase todos os casos em ambos os grupos apresentaram complicações clínicas, isoladas ou associadas, potencialmente danosas para o cérebro, como parada cardíaca, baixo débito cardíaco, hipoxemia e insuficiência respiratória. Foi impossível determinar, em cada caso, a magnitude do fator ou fatores responsáveis pelo padrão neuropatológico correspondente. Não houve diferenças do padrão neuropatológico entre as cardiopatias com hiper ou hipofluxo pulmonar.

palavras chave: encéfalo, cardiopatias congênitas, neuropatologia.

SUMMARY

A neuropathologic study in 190 consecutives autopsies of patients with congenital cardiopathy was performed: 116 cases underwent a surgical procedure (S group) and the remaining 74 were non-surgical (NS group). Neuropathologic alterations were observed in 71 cases (41 in the S group and 30 in the NS group). However, most of the 129 cases with a normal examination had died in the first 72 hours either after surgery or the clinical events responsible for the death. Almost all the neuropathologic alterations were hypoxic--ischemic. Infarctions, single or multiple, were found in 41 cases (23 in the S and 18 in the NS group). An embolic mechanism could be detected in 12 cases. Diffuse hypoxic changes were present in 17 cases (10 in the S and 7 in the NS group). Hemorrhages were found in 11 (6 in the S and 5 in NS group), 4 of which were related to a disseminated intravascular coagulation. In 17 cases (5 in the NS and 12 in the S group), the picture was of a periventricular leukomalacia. All these cases concerned children under 6 months of age. In 7 cases inflammatory alterations were present (diffuse micro-abscesses in 6 and a frontal lobe abscess in 1). Almost all cases in both groups presented clinical complications, isolated or associated, potentially harmful to the brain, as cardiac arrest, cardiac low output, hypoxemia, and respiratory distress. If was impossible to determine in each case the magnitude of the factor or factors responsible for the correspondent pattern of neuropathology damage. There was no difference as to the neuropathology pattern between congenital cardiopathies leading to increased or decreased pulmonary blood flow.

Key words: brain, congenital cardiopathies, neuropathology.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Dr. Sérgio Rosemberg Departamento de Patologia, Instituto do Coração, Hospital das Clínicas, FMUSP - Av. Dr. Enéas Carvalho Aguiar 44- 05403 São Paulo - Brasil.

1. Aguilar MJ, Gerbode FD, Hill JD. Neuropathologie complication of cardiac surgery. J Thorac Cardiovasc Surg 1971, 61:676-685.
2. Armstrong D, Norman MG. Periventricular leukomalacia in neonates: complications and sequelae. Arch Dis Child 1974, 49:367-375.
3. Banker BQ, Larroche JC. Periventricular leukomalacy in infancy: a form of neonatal anoxic encephalopathy. Arch Neurol 1962, 7:386-410.
4. Bender HW Jr, Fisher RD, Walker WE, Graham JP. Reparative cardiac surgery in infants and small children: five years experience with profound hypothermia and circulatory arrest. Ann Surg 1979, 190:437-443.
5. Berthrong GM, Sabiston DC. Cerebral lesions in congenital heart disease: a review of autopsies on one hundred and sixty-two cases. Johns Hopkins Hosp Bull 1951, 89:384-401.
6. Blackwood MJA, Haka-Ikse K, Steward DJ. Developmental outcome in children undergoing surgery with profound hypothermia. Anesthesiology 1986, 65:437-440.
7. Bozoky B, Bara D, Hertész E. Autopsy study of cerebral complications of congenital heart disease and cardiac surgery. J Neurol 1984, 231:153-161.
8. Cassie AB, Ridell AG, Yates PO. Hazard of antifoam emboli from a bubble oxygenator. Thorax 1960, 15:22-29.
9. Clarkson PM, Gomez MR, Wallace RB, Weidman WH. Central nervous system complications following Blalock-Taussig operation. Pediatrics 1967, 39:18-23.
10. Cohen MM. The central nervous system in congenital heart disease. Neurology 1960, 10:452-456.
11. De Reuck J, Chattha AS, Richardson EP. Pathogenesis and evolution of periventricular leukomalacy in infancy. Arch Neurol 1972, 27:229-235.
12. Dickinson DF, Sambrooks JE. Intellectual performance in children after circulatory arrest with profound hypothermia in infancy. Arch Dis Child 1979, 54:1-6.
13. Ehrenhart JD, Claman MA, Layton JM, Zimmerman GR. Cerebral complications of open-heart surgery: further observations. J Thorac Cardiovasc Surg 1961, 42:514-526.
14. Ferry PC. Neurologic sequelae of cardic surgery in children. Am J Dis Child 1987, 141:309-312.
15. Gardner TJ, Horneffer PJ, Manolio TA, Pearson TA, Gott V, Baumgartner WA, Borkin AM, Watkins L, Reitz BA. Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 1985, 40:574-578.
16. Javid H, Tufo HM, Najafi H, Hunter JA, Julian OC, Dye WS. Neurological abnormalities following open-heart surgery. J Thorac Cardiovasc Surg 1969, 58:502-509.
17. Luzio J. Isquemia cerebral pós-circulação extracorpórea. Arq Bras Cardiol 1984, 43:123-126.
18. Newton EM. Hematogenous brain abscess in cyanotic congenital heart disease. Quart J Med 1956, 25:201-207.
19. Poirier J, Gray F, Escourolle R. In Manual of Basic Neuropathology. Ed 3. Philadel-fia: Saunders 1990, p 89.
20. Robain O, Rosemberg S. Ramollissements cérébraux localisés à la substance blanche paraventricular au cours des cardiopathies congénitales de l'enfant. Ann Anat Pathol 1974, 19:311-319.
21. Robinson RO, Samuels M, Pohl KRE. Choreic syndrome after cardiac surgery. Arch Dis Child 1988, 63:1466-1469.
22. Stockard JJ, Bickford RG, Wyers RR, Aung MH, Diller RB, Schauble JF. Hypotension--induced changes in cerebral function during cardiac surgery. Stroke 1974, 5:730-734.
23. Terplan KL Patterns of brain damage in infants and children with congenital heart disease: association with catheterization and surgical procedures. Am J Dis Child 1973, 125:175-185.
24. Wells FC, Coghill S, Caplan HL., Lincoln C. Duration of circulatory arrest does influence the psychological development of children after cardiac operation in early life. J Thorac Cardiovasc Surg 1983, 86:823-831.

Datas de Publicação

Publicação nesta coleção
22 Fev 2011
Data do Fascículo
Mar 1992

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Aguilar MJ, Gerbode FD, Hill JD. Neuropathologie complication of cardiac surgery. J Thorac Cardiovasc Surg 1971, 61:676-685.

[2] 2. Armstrong D, Norman MG. Periventricular leukomalacia in neonates: complications and sequelae. Arch Dis Child 1974, 49:367-375.

[3] 3. Banker BQ, Larroche JC. Periventricular leukomalacy in infancy: a form of neonatal anoxic encephalopathy. Arch Neurol 1962, 7:386-410.

[4] 4. Bender HW Jr, Fisher RD, Walker WE, Graham JP. Reparative cardiac surgery in infants and small children: five years experience with profound hypothermia and circulatory arrest. Ann Surg 1979, 190:437-443.

[5] 5. Berthrong GM, Sabiston DC. Cerebral lesions in congenital heart disease: a review of autopsies on one hundred and sixty-two cases. Johns Hopkins Hosp Bull 1951, 89:384-401.

[6] 6. Blackwood MJA, Haka-Ikse K, Steward DJ. Developmental outcome in children undergoing surgery with profound hypothermia. Anesthesiology 1986, 65:437-440.

[7] 7. Bozoky B, Bara D, Hertész E. Autopsy study of cerebral complications of congenital heart disease and cardiac surgery. J Neurol 1984, 231:153-161.

[8] 8. Cassie AB, Ridell AG, Yates PO. Hazard of antifoam emboli from a bubble oxygenator. Thorax 1960, 15:22-29.

[9] 9. Clarkson PM, Gomez MR, Wallace RB, Weidman WH. Central nervous system complications following Blalock-Taussig operation. Pediatrics 1967, 39:18-23.

[10] 10. Cohen MM. The central nervous system in congenital heart disease. Neurology 1960, 10:452-456.

[11] 11. De Reuck J, Chattha AS, Richardson EP. Pathogenesis and evolution of periventricular leukomalacy in infancy. Arch Neurol 1972, 27:229-235.

[12] 12. Dickinson DF, Sambrooks JE. Intellectual performance in children after circulatory arrest with profound hypothermia in infancy. Arch Dis Child 1979, 54:1-6.

[13] 13. Ehrenhart JD, Claman MA, Layton JM, Zimmerman GR. Cerebral complications of open-heart surgery: further observations. J Thorac Cardiovasc Surg 1961, 42:514-526.

[14] 14. Ferry PC. Neurologic sequelae of cardic surgery in children. Am J Dis Child 1987, 141:309-312.

[15] 15. Gardner TJ, Horneffer PJ, Manolio TA, Pearson TA, Gott V, Baumgartner WA, Borkin AM, Watkins L, Reitz BA. Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 1985, 40:574-578.

[16] 16. Javid H, Tufo HM, Najafi H, Hunter JA, Julian OC, Dye WS. Neurological abnormalities following open-heart surgery. J Thorac Cardiovasc Surg 1969, 58:502-509.

[17] 17. Luzio J. Isquemia cerebral pós-circulação extracorpórea. Arq Bras Cardiol 1984, 43:123-126.

[18] 18. Newton EM. Hematogenous brain abscess in cyanotic congenital heart disease. Quart J Med 1956, 25:201-207.

[19] 19. Poirier J, Gray F, Escourolle R. In Manual of Basic Neuropathology. Ed 3. Philadel-fia: Saunders 1990, p 89.

[20] 20. Robain O, Rosemberg S. Ramollissements cérébraux localisés à la substance blanche paraventricular au cours des cardiopathies congénitales de l'enfant. Ann Anat Pathol 1974, 19:311-319.

[21] 21. Robinson RO, Samuels M, Pohl KRE. Choreic syndrome after cardiac surgery. Arch Dis Child 1988, 63:1466-1469.

[22] 22. Stockard JJ, Bickford RG, Wyers RR, Aung MH, Diller RB, Schauble JF. Hypotension--induced changes in cerebral function during cardiac surgery. Stroke 1974, 5:730-734.

[23] 23. Terplan KL Patterns of brain damage in infants and children with congenital heart disease: association with catheterization and surgical procedures. Am J Dis Child 1973, 125:175-185.

[24] 24. Wells FC, Coghill S, Caplan HL., Lincoln C. Duration of circulatory arrest does influence the psychological development of children after cardiac operation in early life. J Thorac Cardiovasc Surg 1983, 86:823-831.