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Hematoma tegmento-mesencefálico espontâneo: aspectos neurocomportamentais do terço rostral do tronco encefálico humano

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

Resumos

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.

abulia; coma; sistema ativador ascendente; sistema extrapiramidal; mesencéfalo


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.

coma; ascending activating system; extrapyramidal system; midbrain


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.

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

Dr. Ricardo de Oliveira Souza - Rua General Belford 226 - 20961-000 Rio de Janeiro RJ - Brasil.

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Datas de Publicação

  • Publicação nesta coleção
    08 Dez 2010
  • Data do Fascículo
    Dez 1995
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