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

Oliveira-Souza, Ricardo De; Benchimol, Marcos

doi:10.1590/S0004-282X1995000500019

Resumos

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.

coma; herniação transtentorial; sistema reticular ativador ascendente; diásquise

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.

coma; transtentorial herniation; ascending reticular activating system; diaschisis

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-Souza^I; Marcos Benchimol^II

^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

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Aceite: 15-agosto-1995.

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

1. Adametz JH. Rate of recovery of functioning in cats with rostral reticular lesions: an experimental study. J Neurosurg 1959, 16:85-98.
2. Feeney DM, Baron JC. Diaschisis. Stroke 1986, 17:817-830.
3. Feldmann E, Gandy SE, Becker R, Zimmerman R, Thaler HT, Posner JB, Plum F. MRI demonstrates descending transtentorial herniation. Neurology 1988, 38:697-701.
4. Fisher CM. Acute brain herniation: a revised concept. Semin Neurol 1984, 4:417-421.
5. Fisher CM. Concerning the mechanism of recovery in stroke hemiplegia. Can J Neurol Sci 1992, 19:57-63.
6. Jagger J, Jane JA, Rimei R. The Glasgow Coma Scale: to sum or not to sum? Lancet 1983, 2:97.
7. Marie P, Foix C. Le phénomène de la face. Rev Neurol (Paris) 1914-1915, 28:778-779.
8. Masson C, Cambier J, Masson M. Mécanisme physiopathologique des comas. Rev Pract (Paris) 1989, 39:2393-2396.
9. Plum F, Posner JB. The diagnosis of stupor and coma. Ed 3. Philadelphia. F.A.Davis, 1980, p 103-113.
10. Ropper AH. Lateral displacement of the brain and level of consciousness in patients with an acute hemispheral mass. N Engl J Med 1986, 314:953-958.
11. Ropper AH. A preliminary MRI study of the geometry of brain displacement and level of consciousness with acute intracranial mass. Neurology 1989, 39:622-627.
12. Ross ED, Stewart RM. Akinetic mutism from hypothalamic damage: successful recovery with dopamine agonists. Neurology, 1981, 31:1435-1439.
13. Rossitti S, Starmark J-E, Stalhammar D. Manual operacional da Escala de Nível Reativo (RLS85). Arq Neuropsiquiatr 1993, 51:103-106.
14. Sacco RL, VanGool R, Mohr JP, Hauser WA. Nontraumatic coma. Glasgow Coma Score and coma etiology as predictors of 2-week outcome. Arch Neurol 1990, 47:1181-1184.
15. Salazar A, Grafman JH, Vance SC, Weingartner H, Dillon JD, Ludlow C. Consciousness and amnesia after penetrating head injury: neurology and anatomy. Neurology 1986, 36:178-187.
16. Saper CB. Diffuse cortical projection systems: anatomical organization and role in cortical function. In Mount castle VB, Plum F (eds). Handbook of Physiology I, The Nervous System V, Higher Functions of the Brain. Bethesda: American Physiological Society, 1987 p169-210.
17. Starmark J-E, Lindgren S. Is it possible to define a general "conscious level"? Acta Neurochir (Wien), 1986. 36 (Suppl):103-105.
18. Vincent C, David M, Thiébaut F. Le cone de pression temporal dans les tumeurs des hémisphères cérébraux: sa symptomatologie, sa gravité; les traitements qu'il convient de lui opposer. Rev Neurol (Paris), 1936, 65:536-545.
19. Weisberg L, Nice C. Cerebral computed tomography, a text-atlas, Ed 3. Philadelphia: W.B.Saunders, 1989, p 249-253.

Datas de Publicação

Publicação nesta coleção
08 Dez 2010
Data do Fascículo
Dez 1995

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

[1] 1. Adametz JH. Rate of recovery of functioning in cats with rostral reticular lesions: an experimental study. J Neurosurg 1959, 16:85-98.

[2] 2. Feeney DM, Baron JC. Diaschisis. Stroke 1986, 17:817-830.

[3] 3. Feldmann E, Gandy SE, Becker R, Zimmerman R, Thaler HT, Posner JB, Plum F. MRI demonstrates descending transtentorial herniation. Neurology 1988, 38:697-701.

[4] 4. Fisher CM. Acute brain herniation: a revised concept. Semin Neurol 1984, 4:417-421.

[5] 5. Fisher CM. Concerning the mechanism of recovery in stroke hemiplegia. Can J Neurol Sci 1992, 19:57-63.

[6] 6. Jagger J, Jane JA, Rimei R. The Glasgow Coma Scale: to sum or not to sum? Lancet 1983, 2:97.

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

[8] 8. Masson C, Cambier J, Masson M. Mécanisme physiopathologique des comas. Rev Pract (Paris) 1989, 39:2393-2396.

[9] 9. Plum F, Posner JB. The diagnosis of stupor and coma. Ed 3. Philadelphia. F.A.Davis, 1980, p 103-113.

[10] 10. Ropper AH. Lateral displacement of the brain and level of consciousness in patients with an acute hemispheral mass. N Engl J Med 1986, 314:953-958.

[11] 11. Ropper AH. A preliminary MRI study of the geometry of brain displacement and level of consciousness with acute intracranial mass. Neurology 1989, 39:622-627.

[12] 12. Ross ED, Stewart RM. Akinetic mutism from hypothalamic damage: successful recovery with dopamine agonists. Neurology, 1981, 31:1435-1439.

[13] 13. Rossitti S, Starmark J-E, Stalhammar D. Manual operacional da Escala de Nível Reativo (RLS85). Arq Neuropsiquiatr 1993, 51:103-106.

[14] 14. Sacco RL, VanGool R, Mohr JP, Hauser WA. Nontraumatic coma. Glasgow Coma Score and coma etiology as predictors of 2-week outcome. Arch Neurol 1990, 47:1181-1184.

[15] 15. Salazar A, Grafman JH, Vance SC, Weingartner H, Dillon JD, Ludlow C. Consciousness and amnesia after penetrating head injury: neurology and anatomy. Neurology 1986, 36:178-187.

[16] 16. Saper CB. Diffuse cortical projection systems: anatomical organization and role in cortical function. In Mount castle VB, Plum F (eds). Handbook of Physiology I, The Nervous System V, Higher Functions of the Brain. Bethesda: American Physiological Society, 1987 p169-210.

[17] 17. Starmark J-E, Lindgren S. Is it possible to define a general "conscious level"? Acta Neurochir (Wien), 1986. 36 (Suppl):103-105.

[18] 18. Vincent C, David M, Thiébaut F. Le cone de pression temporal dans les tumeurs des hémisphères cérébraux: sa symptomatologie, sa gravité; les traitements qu'il convient de lui opposer. Rev Neurol (Paris), 1936, 65:536-545.

[19] 19. Weisberg L, Nice C. Cerebral computed tomography, a text-atlas, Ed 3. Philadelphia: W.B.Saunders, 1989, p 249-253.