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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.53 no.4 São Paulo Dec. 1995

http://dx.doi.org/10.1590/S0004-282X1995000500018 

Hematoma tegmento-mesencefálico espontâneo. Aspectos neurocomportamentais do terço rostral do tronco encefálico humano

 

Spontaneous tegmento-mesencephalic hematoma: neurobehavioral insights concerning the rostral human brainstem

 

 

Ricardo de Oliveira-SouzaI; Márcio Luciano de Souza BezerraII; Wagner Martignoni de FigueiredoIII; Pedro Ângelo AndreiuoloIV

INeurologista, Professor Assistente, Serviço de Clínica Médica C (Prof. Omar da Rosa Santos), Hospital Universitário Gaffrée e Guinle (HUGG — UNI-RIO)
IIMestrando em Neurologia, Hospital Universitário Antonio Pedro (UFF— RJ)
IIIProfessor Adjunto, Clínica Médica C (Prof. Ormar da Rosa Santos), HUGG-UNI-RIO

IVRadioIogista, Hospital da Beneficiência Portuguesa (Niterói, RJ) e X-LABS (RJ)

 

 


RESUMO

O tegmento do mesencéfalo é área complexa, dada a quantidade de fibras que o atravessam, provenientes de circuitos locais, de sistemas ativadores ascendentes e de feixes descendentes dos hemisférios cerebrais. No presente artigo, relatamos o caso de um senhor de 67 anos, que sofreu hemorragia mesencefálica de localização tegmental, vindo a falecer 1 mês depois. Inicialmente, foi julgado em coma, por apresentar ptose bilateral, ausência de fala e de movimentos espontâneos. Por volta da segunda semana, descobriu-se que podia cumprir comandos verbais, sentar, sustentar-se de pé e andar. O caso demonstra o quanto o diagnóstico do coma em bases clínicas pode ser enganoso em pacientes como esse, no qual a aparente irresponsividade de olhos fechados se deve à combinação inesperada de abulia e oftalmoplegia.

Palavras-chave:abulia, coma, sistema ativador ascendente, sistema extrapiramidal, mesencéfalo


SUMMARY

The tegmentum of the midbrain is a complex area traversed by a number of anatomical and functional systems, including local circuits, ascending activating systems and descending fibers from the cerebral hemispheres. In the present paper we report on the case of a 67-year-old man who suffered a spontaneous central tegmental hemorrhage and was initially supposed to be in coma due to bilateral ptosis and lack of speech and initiative. By the second hospital week, however, he was shown to be able to respond to verbal commands, sit, stand and walk. He died in sepsis one month later. This case shows that the clinical diagnosis of coma may be misleading in certain patients in whom wakefulness is preserved, though concealed from a casual bedside examination due to abulia and ophthalmoplegia.

Key words:coma, ascending activating system, extrapyramidal system, midbrain.


 

 

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

 

 

Agradecimento - Agradecemos ao Dr. Flávio Freinkel Rodrigues as críticas e sugestões ao manuscrito.

 

REFERÊNCIAS

1.  Anderson SW, Damasio H, Tranel D. Neuropsychological impairments associated with lesions caused by tumor or stroke. Arch Neurol 1990; 47:397-405.         [ Links ]

2.  Biller J, Shapiro R, Evans LS, Haag JR, Fine M. Oculomotor nuclear complex infarction: clinical and radiologic correlation. Arch Neurol 1984; 41:985-987.         [ Links ]

3.  Bogousslavsky J. Syndromes oculomoteurs resultant de lésions mésencéphaliques chez l'homme. Rev Neurol (Paris) 1989; 145:546-559.         [ Links ]

4.  Bogousslavsky J, Regli F, Uské A, Maeder P. Pure midbrain infarction: clinical syndromes, MRI, and etiologic patterns. Neurology 1994; 41:837-840.         [ Links ]

5.  Bremer F. Cerveau "isolé" et physiologie du sommeil. CR Soc Biol (Paris), 1935;118: 1235-1241.         [ Links ]

6.  Dawson K, Hourihan MD, Wiles CM, Chawla JC. Separation of voluntary and limbic activation of facial and respiratory muscles in ventral pontine infarction. J Neurol Neurosurg Psychiatry 1994; 57:1281-1282.         [ Links ]

7.  Durward Q, Barnett HJM, Barr HWK. Presentation and management of mesencephalic hematoma. Report of two cases. J Neurosurg 1982; 56:123-127.         [ Links ]

8.  Fisher CM. Some neuro-ophthalmologic observations. J Neurol Neurosurg Psychiatry, 1967; 30:383-392.         [ Links ]

9.  Fisher CM. Abulia minor vs. agitated behavior. Clin Neurosurg 1984; 31:9-31.         [ Links ]

10.  Gaymard B, Larmande P, Toffol B, Autret A. Reversible nuclear oculomotor nerve paralysis. Caused by a primary mesencephalic hemorrhage. Eur Neurol 1990; 30:128-131.         [ Links ]

11.  Getenet JC, Vighetto A, Nighoghossian N, Trouillas P. Isolated bilateral third nerve palsy caused by a mesencephalic hematoma. Neurology 1994; 44: 981-982.         [ Links ]

12.  Growdon JH, Winkler GF, Wray SH. Midbrain ptosis: a case with clinicopathologic correlation. Arch Neurol 1974; 30:179-181.         [ Links ]

13.  Guiot G. Le réflexe cornéo-ptérygoïdien: le phénomène de la diduction lente du maxillaire. Rev Neurol (Paris) 1946; 78:48-49.         [ Links ]

14.  Humphreys RP. Computerized tomographic definition of mesencephalic hematoma with evacuation through pedunculotomy. Case report. J Neurosurg 1978; 49:749-752.         [ Links ]

15.  Iwatsubo T, Kuzuhara S, Kanemitsu A, Shimada H, Toyokura Y. Corticofugal projections to the motor nuclei of the brainstem and spinal cord in humans. Neurology 1990; 40:309-312.         [ Links ]

16.  Jain VK, Multani VK, Reddy AK, Das BS. Mesencephalic hematoma, successful surgical evacuation. Case report. Clin Neurol Neurosurg 1990; 92:159-163.         [ Links ]

17.  Jampel RS, Haidt SJ Bell's phenomenon and idiopathic polyneuritis. Arch Ophthalmol 1972; 74:145-153.         [ Links ]

18.  Jenny AB, Saper CB. Organization of the facial nucleus and corticofacial projection in the monkey: a reconsideration of the upper motor neuron facial palsy. Neurology 1987; 37:930-939.         [ Links ]

19.  Kinney HC, Samuels MA. Neuropathology of the persistent vegetative state: a review. J Neuropathol Exp Neurol 1994; 53:548-558.         [ Links ]

20.  Kremer M. Sitting, standing, and walking (duas partes).Br Med J 1958; 2:63-68; 2:121-126.         [ Links ]

21.  La Torre E, Delitala A, Sorano V. Hematoma of the quadrigeminal plate. J Neurosurg 1978; 49:610-613.         [ Links ]

22.  Lawrence DG, Kuypers HGJM. The functional organization of the motor system in the monkey. II. The effects of lesions of the descending brain-stem pathways. Brain 1969; 91:15-36.         [ Links ]

23.  Lindsley DB, Bowden JW, Magoun HW. Effect upon the EEG of acute injury to the brain stem activating system. Electroenceph Clin Neurophysiol 1949; 1:475-486.         [ Links ]

24.  Marie P, Foix C. Le phénomène de la face. Rev Neurol (Paris), 1914/1915; 28:778-779.         [ Links ]

25.  Martin JP. A short essay on posture and movement. J Neurol Neurosurg Psychiatry 1977; 40:25-29.         [ Links ]

26.  Mendonça A, Pimentel J, Morgado F, Ferro JM. Mesencephalic haematoma: case report with autopsy study. J Neurol 1990; 237:55-58.         [ Links ]

27.  Moruzzi G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroenceph Clin Neurophysiol 1949; 1:455-473.         [ Links ]

28.  Nauta WJH, Feirtag M. Fundamental neuroanatomy. New York: WH Freeman, 1986.         [ Links ]

29.  Oliveira-Souza R. Motor hemiplegia and the cerebral organization of movement in man. II. The myth of the human extrapyramidal system. Arq Neuropsiquiatr 1989; 47:16-27.         [ Links ]

30.  Oliveira-Souza R, Bezerra MLS, Gusmão DL, Schmidt SL. Oftalmoplegia bilateral e completa por hemorragia do tegmento mesencefálico (Abstr). Arq Neuropsiquiatr 1990; 48 (Supl):100.         [ Links ]

31.  Oliveira-Souza R, Figueiredo WM, Andreiuolo PA. Incontinêntia do choro e infarto protuberancial unilateral. Arq Neuropsiquiatr 1995, 53:680-699.         [ Links ]

32.  Oliveira-Souza R, Gusmão DL, Figueiredo WM, López JRRA, Mello JS, Ribeiro SA, Alvarenga H. Estado vegetativo-alfa persistente. Arq Neuropsiquiatr 1989; 47:212-223.         [ Links ]

33.  Oliver LC. The supranuclear arc of the corneal reflex. Acta Psychiat Scand 1952; 27:329-333.         [ Links ]

34.  Pierrot-Deseilligny C. Circuits oculomoteurs centraux. Rev Neurol (Paris) 1985: 141:349-370.         [ Links ]

35.  Plum F: Coma and related global disturbances of the human conscious state, In: Peters A (ed). The Cerebral Cortex, Vol 9. New York: Plenum Press, 1991, pp 359-425.         [ Links ]

36.  Prus J. Die Leitungsbahnen und Pathogenese der Rindenepilepsie (Feixes de condução e patogênese da epilepsia cortical). Wien Klin Wschr 1898; 11:857-863.         [ Links ]

37.  Roig C, Carvajal A, Ilia I, Escartin A, Grau JM, Barraquer L. Hémorragies mésencéphaliques isolées: trois cas diagnostiques par tomodensitométrie. Rev Neurol (Paris) 1982; 138:53-61.         [ Links ]

38.  Ropper A, Miller DC. Acute traumatic midbrain hemorrhage. Ann Neurol 1985; 18:80-86.         [ Links ]

39.  Rossitti S, Starmark JE, Stalhammar D. Manual operacional da Escala de Nível Reativo (RLS85). Arq Neuropsiquiatr 1993; 51:103-106.         [ Links ]

40.  Sand JJ, Biller J, Corbett JJ, Adams HP, Dunn V. Partial dorsal mesencephalic hemorrhages. Neurology 1986; 36:529-533.         [ Links ]

41.  Sandson J, Albert ML. Perseveration in behavioral neurology. Neurology 1987; 37:1736-1741.         [ Links ]

42.  Saper CB. Diffuse cortical projection systems: anatomical organization and role in cortical function In: Mountcastle VB, Plum F. (eds) Handbook of physiology I, The nervous system V, Higher functions of the brain. Bethesda: American Physiological Society, 1987, pp 169-210.         [ Links ]

43.  Scoville WB, Poppen JL. Intrapeduncular hemorrhage of the brain: successful operative approach with evacuation of clot and a seven and one fourth year observation period. Arch Neurol Psychiat 1949; 61:688-694.         [ Links ]

44.  Thompson GH. Cerebral area essential to consciousness. Bull Los Angeles Neurol Soc 1951; 16:311-334.         [ Links ]

45.  Weisberg L. Mesencephalic hemorrhages: clinical and computed tomographic correlations. Neurology 1986; 36:713-716.         [ Links ]

46.  Wiesendanger M. Some aspects of pyramidal tract function in primates, In: Desmedt JE (ed): New developments in electromyography and clinical neurophysiology. Basel: S. Karger, 1973 p 159-174.         [ Links ]

 

 

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