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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

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

https://doi.org/10.1590/S0004-282X1995000500019 

Coma e síndrome de herniação transtentorial consequentes a lesão hemisférica não expansiva aguda

 

Coma and central herniation syndrome due to an acute non-expanding hemispheral mass

 

 

Ricardo De Oliveira-SouzaI; Marcos BenchimolII

IProfessor Assistente. Serviço de Clínica Médica C (Prof. Dr. Omar da Rosa Santos), Hospital Universitário Gaffrée e Guinle (UNI-RIO), Rio de Janeiro, RJ
IIProfessor Auxiliar. Serviço de Clínica Médica C (Prof. Dr. Omar da Rosa Santos), Hospital Universitário Gaffrée e Guinle (UNI-RIO), Rio de Janeiro, RJ

 

 


RESUMO

O presente trabalho retrata o caso de uma paciente que entrou em coma por infarto extenso do hemisfério cerebral direito e desenvolveu sinais clínicos característicos do estágio diencefálico da herniação transtentorial central. A TC, todavia, não evidenciou os efeitos classicamente descritos de compressão ou distorção da transição mesodiencefálica, mas duas imagens hipodensas, de idades diferentes, alojadas, repectivamente, nos territórios superficial e profundo das artérias cerebral média e anterior e no lobo frontal direito. Concordando com a piora clínica ao longo dos seis dias que antecederam a morte, a última TC revelou as imagens esperadas de deslocamentos do encéfalo. O caso se assemelha a outros da literatura, em testemunho de que os sinais clínicos de efeitos de massa no interior do crânio podem ser reproduzidos por comprometimento funcional agudo mono-hemisférico na ausência de deslocamentos físicos da massa encefálica. O papel desempenhado por distorções encefálicas na gênese e no prognóstico de curto-prazo do coma permanece em aberto.

Palavras-chave:coma, herniação transtentorial, sistema reticular ativador ascendente, diásquise.


SUMMARY

An 81 -year-old woman developed left hemiplegia and coma due to a right hemisphere infarct and died 6 days later. When first seen in coma she had the classical signs of descending central herniation in the diencephalic stage. The CT scan of the third day showed a large hypodense area occupying the superficial and deep territories of the middle and anterior cerebral arteries on the left as well as a frontal cortico-subcortical hypodense area indicative of an older infarct on the opposite hemisphere. No mass effects were apparent. She followed a downhill course with signs of brainstem deterioration. A second CT scan a few hours before death revealed the expected pattern of brain shift and herniations. This case adds to the available evidence showing that the clinical signs of encroachment of supratentorial structures upon the basal forebrain can be reproduced by an acute mono-hemispheral lesion without visible mass effects. It indicates, further, that the role of intracranial displacements in the genesis and short-term prognosis of coma remains an unsettled matter. In at least a few number of cases, diaschisis might play a major role.

Key words:coma, transtentorial herniation, ascending reticular activating system, diaschisis


 

 

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

 

 

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Aceite: 15-agosto-1995.

 

 

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