patologie cns - i krvácení · emphysema pulmonum atrophicum. bronchopneumonia...
TRANSCRIPT
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Patologie CNS - I
Krvácení
v oblasti
hlavy
Jaroslava Dušková
https://www1.lf1.cuni.cz/~jdusk/
Ústav patologie 1.LF UK a VFN, Praha
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Krvácení v oblasti lebeční - obsah
extrakraniální
intrakraniální
extracerebrální
intracerebrální
traumata mozku
poruchy perfuze mozkuencefalomalacie bílá, červená, smíšená
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Krvácení v oblasti lebeční– intrakraniální krvácení
extracerebrální
epidurální
subdurální
subarachnoideální
intracerebrální
kapilární
venosní
arteriálníohraničené
neohraničené
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v.cerebri
magna Galeni
ED
SD
SA IP
doc. MUDr. Zd. Záhoř, CSc
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Nitrolební expanze – otlakové konusy
Konus Anatomie Patologické změny Klinické projevy
OkcipitálníHerniace tonsillae cerebelli do
foramen occipitale magnum
Komprese vitálních
center v medulla
oblongata
Apnoe. Cave:
kontraindikace dg.
lumbální punkce!
TemporálníTranstentoriální herniace uncus
gyri parahippocampalis.
Komprese kontralaterální
capsula interna.
Komprese hlavových
nervů a kontralaterální
capsula interna.
Komprese aa. cerebri
posteriores. Duretovy
hemorrhagie v kmeni.
Mydriáza,
oftalmoplegie.
Kernohanův falešný
lokalizační příznak.
Výpady zorného pole.
Interhemisferický Subfalcinní herniaceKomprese a. cerebri
anterior.
Dysfunkce frontálních
laloků.
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Haematoma epidurale
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!!!možný lucidní interval
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Haematoma
epidurale
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Haematoma epidurale
15.03.2009 died 18.03.
2009
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Head injury - 15.03.2009
Death - 18.03.2009 Actress Miss Richardson, 45, was flown from intensive care in Montreal
to the Lenox Hill Hospital in New York after suffering a head injury
during a private ski lesson at the exclusive Mont Tremblant resort on
Monday afternoon
Miss Richardson fell during a lesson but initially showed no visible
signs of injury
An hour later, she complained of a headache and was admitted to the
Hospitalier Laurentien in nearby Ste-Agathe.
She was later transferred to intensive care at the Sacre-Coeur Hospital
75 miles away in Montreal before being flown New York via private jet
One doctor said she had most likely suffered from a blood clot on the
brain, while another said her condition could be “talk and die
syndrome”, where a person at first seems unharmed by an impact but
later suffers a rapid collection of blood between the skull and the brain
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Haematoma
subdurale
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Haematoma
subdurale
Haematoma subdurale
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Haematoma
subdurale
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Haematoma
subdurale
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Haematoma
subdurale
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Haematoma subdurale vetustior fossae cerebri mediae lat. sin.
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Liquor cerebrospinalis
oil red
Fe
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Hygroma subdurale
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Circulus
arteriosus Willisi
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Aneurysma art.
vertebralis dx.
Aneurysma art.
vertebralis dx.
Aneurysma art.
vertebralis dx.
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Haematoma
subarachnoideale
hypoxicum
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Haematoma subarachnoideale hypoxicum convexitatis cerebri
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Hydrocefalus - zvýšené množství
mozkomíšního moku
obstrukční – nekomunikující
komunikující
– hypersekreční
– hyporesorpční (jizvení v obl.
Pacchionských granulací) – komb. s
obstrukčním
e vacuo
normotenzní (?
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Angioma racemosum cerebri et
meningum
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Malformatio arteriovenosa
vG-el
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Malformatio arteriovenosa
trichrom
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Fe
Malformatio arteriovenosa
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Typy cévních malformací CNS
arteriovenosní
kapilární teleangiektasie
kavernosní hemangiom (kavernom)
venosní angiom
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Haemorrhagia
subcorticalis
cerebri et cerebelli
circumscripta
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Haemorrhagiae cerebri circumscriptae
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Haemorrhagia
comminutiva
cerebri et
haemocephalus
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Haemorrhagia
comminutiva
cerebelli
Haemorrhagia
vetustior
cerebri
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Muž – 33 let N ***/2006
Klin. dg.
Ethylismus chronicus
Epilepsia
Moribundus adlatus
Haemorrhagia intracranialis lat. dx.
Aneurysma arteriae baseos cerebri ruptum??
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Haemorrhagia
extensa
ggl.basalium ad
ventriculos
cerebri
progressaAtherosclerosis aortae et peripherica gr. II
Haemocephalus
Circulus Willisi
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Purpura cerebri
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Pseudocystes posthaemorrhagicae
cerebri
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CSF Fe
Fe
Fe
HE
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FeHE
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Sekundární mozková krvácení
Systémové nemoci
nebo léčba
– leukemie
– koagulopatie
– antikoagulační léky
Abusus drog
– kokain
– amfetamin
– antiobesitika
– ….
Nonvaskulární mozkové
choroby
– gliom
– metastáza
melanom
choriocarcinom
carcinomy (manif.!)
– disseminované
angioinvasivní mykózy
– srpkovitá anemie
– ….
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Fetální & neonatální
krvácení
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Krvácení v oblasti lebeční
extrakraniální
(kefalhaematoma externum,
subperiostální, subaponeurotické)
intrakraniální
extracerebrální
intracerebrální
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Kefal
haema-
toma
ext.
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Haematoma
subapo-
neuroticum
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Haematoma subarachnoidale hypoxicum
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Haemorrhagiae subependymales
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Krvácení
do zárodečné zóny (ZZ)
25% předčasně narozených novorozenců (dříve více)
ZZ: periventrikulárně, kapiláry velkého kalibru, silná vaskularizace zejm. ve 3. trimestru
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Haemorrhagia
strati
germinalis
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Patogeneze krvácenído zárodečné zóny
Perinatální ev. intranatální hypoxie– poruchy autoregulace mozkové perfuze
– ischemické léze endotelu kapilár zárodečné zóny
– vyčerpání energetických rezerv myokardu
– perinatální cirkulační selhání
– hypoxie mozku venózní hemoragie
Vzestup krevního tlaku– svalová aktivita novorozence
– resuscitace
– arteficiální ventilace
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„Létání miminek“ vs. Shaken Baby Syndrome
RIZIKA
1. intermeningeální &
intracerebrální krvácení
2. retinální krvácení
3. poškození kloubů a
růstových zón dlouhých
kostí
4. poškození krčních
obratlů a vazů
5. vysmeknutí dítěte a
těžké zranění
Pediatři & neurologové & PATOLOGOVÉ jednoznačně PROTI !!!
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Josephsen JB et al.:
Life-Threatening Neonatal Epidural Hematoma
Caused by Precipitous Vaginal Delivery. 1/3Am J Case Rep. 2015; 16: 50–52.
2977 g male infant was born at 40 5/7 weeks
gestation to a 26 year-old gravida 5, para 5 woman
the patient refused external monitoring and did not
remain consistently in bed due to discomfort.
rupture of membranes occurred while the patient was
standing at the bedside
precipitous, vertex delivery. The neonate fell
approximately 80 cm to the linoleum floor below,
striking his head.
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Josephsen JB et al.:
Life-Threatening Neonatal Epidural Hematoma
Caused by Precipitous Vaginal Delivery. 2/3Am J Case Rep. 2015; 16: 50–52.
The child had a normal neurological exam with no signs
of local trauma to the skull on initial evaluation; Apgar
scores were 8 and 9 at 1 and 5 minutes, respectively
At 5 hours of life, an apneic episode associated with
cyanosis and bradycardia
The neurological exam results continued to be normal
an area of left parietal scalp edema was newly
appreciated
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Josephsen JB et al.:
Life-Threatening Neonatal Epidural Hematoma
Caused by Precipitous Vaginal Delivery. 3/3Am J Case Rep. 2015; 16: 50–52.
CT scan of the head revealed a mildly displaced left parietal bone fracture with an
underlying acute epidural hematoma measuring 1.3 cm at its maximal thickness,
and adjacent traumatic subarachnoid hemorrhage.
an emergent craniotomy with evacuation of the epidural hematoma.
At 3 months of age, a CT scan showed well-healed bone around the craniotomy
site without any residual intracranial hemorrhage.
Pre-operative axial non-contrast brain CT that shows a
lenticularly-shaped hyperdensity, consistent with an epidural
hematoma, exerting a mass effect on the adjacent left parietal
lobe.
Immediate post-operative axial non-contrast brain CT shows
resolution of the mass effect after evacuation of epidural
hematoma. There is minimal post-operative
pneumocephalus.
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Chronická traumatická encefalopatie Punch-Drunk Syndrome – dementia pugilistica
manifestní roky po ukončení boxerských aktivit
tři stadia:
– afektivní poruchy, mírná inkoordinace
– dysfázie, apraxie, agnózie, apatie, otupení pocitů
– globální kognitivní úbytek & parkinsonismus
u 20% of profes. boxerů nad 50
častější u déle boxujících
SN degenerace, ztráty neuronů,
Alzheimerovy intracelulární změny
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Acta Neuropathologica, 2018, 135:303–305
Keene CD et al.: First confirmed case
of chronic traumatic encephalopathy
in a professional bull rider
First-diagnosed concussion at age 16 with confirmed loss of
consciousness (LOC)
additional exposures approximately biennially until age 21 when he
sustained five head injuries over the course of a 12-month period.
At age 23, stepped on by a rearing bull crushing his helmet with LOC
for 1 h, meeting criteria for moderate brain injury.
Initial Glasgow Coma Scale was 10, and remained 10 for 24 h before
returning to 14 out of 15 by day 2.
CT evaluation : negative for pathoanatomical brain injury lesions.
MRI Evaluation 3 months later: multiple regions of hemorrhagic foci
bilaterally in the frontal lobes, right temporal lobe, left hippocampus,
and left brainstem, consistent with microhemorrhage following shear
injury meeting radiographic criteria for diffuse axonal injury
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Acta Neuropathologica, 2018, 135:303–305
Keene CD et al.: First confirmed case
of chronic traumatic encephalopathy
in a professional bull rider
Post-traumatic headache, memory loss, concentration problems,
attentional dysfunction.
Mood lability, disinhibition, irritability, explosivity, depression, anxiety.
Diplopia, photophobia, phonophobia, vestibular dysfunction, insomnia.
Dysarthria with mild aphasia, difficulty with mental flexibility and
planning, motor slowing,
Exaggerated somatic concern, hostility, and conceptual disorganization.
Family members described a very bright, jovial, and affable young man
who was conscientious and loving but in the last 6–9 months of life
rapidly deteriorated, becoming reclusive and hypervigilant with
paralyzing panic attacks, and displaying significant behavioral changes
characterized by erratic and impulsive decisions until he commited a
suicide at 25.
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Acta Neuropathologica, 2018, 135:303–305
Keene CD et al.: First confirmed case
of chronic traumatic encephalopathy
in a professional bull rider
The fresh whole brain 1360 g
external examination normal
for age
no evidence of mass lesions,
destructive lesions,
hemorrhage, herniations, or
cortical atrophy.
Multifocal traumatic white
matter lesions, axonal loss
hemosiderin, foamy
macrophages
Positive phospho-tau
immunostaining of
neurofibrillary tangles, neurites,
and glial inclusions in bilateral
orbitofrontal cortex
Microscopy
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Uzavřené mozkové trauma–traumatologická klasifikace
Typ zranění
Difúzní – komoce - otřes
– difúzní axonální poranění
Fokální– kontuze
Komprese– hematomy (epidurální,
subdurální, intrakraniální)
– hygrom
Léčba
konzervativní
konzervativní
někdy evakuace
CHIRURGICKÉ
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Poruchy perfuze mozku
Encefalomalaciebílá
červená
smíšená
Příčinyischemie
venostázaPostencefalomalatická pseudocysta (event.)
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Arteriosclerosis
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Atheroskleroza mozkových cév
Morfologické projevy – encefalomalacie
– encephalopathia angiosclerotica:
atrophia cerebri diffusa
status cribrosus
status lacunaris
hydrocephalus ext. et int. e vacuo
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Encephalomalacia
partim rubra
cerebri
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Encephalomalaciae partim rubrae
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sin.
sin.
Pseudocystis cerebri
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trichrom - el
Embolia thrombotica a. cerebri mediae
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Status cribrosus
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Úklidová
reakce
Makrofágy
Astrocyty
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Pseudocystis postencephalomalacica
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Atheroskleroza mozkových cév
Klinické projevy – mozková mrtvice (event. smrt)
– pyramidové a extrapyramidové poruchy
– atherosklerotická (multiinfarktová) demence
(-100ml!)
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žena 92 let
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Anamnéza
nalezena doma v bezvědomí
na CT atypická expanzivní frontální léze
nejspíše metastáza
sonografie – pankreatická léze – nádor ?
zemřela za měsíc po prolongovaném
komatu
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Dura mater bez metastatického rozsevu – normální nález
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?
Multifokální hemoragické mozkové léze
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Encephalomalaciae rubrae vetustiores cerebri
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Encephalomalaciae rubrae vetustiores cerebri
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?
Pancreatitis chronica fibroproductiva
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Pancreatitis chronica fibroproductiva
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Emphysema pulmonum atrophicum
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Bronchopneumonia fibrinosoproductiva
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Bronchopneumonia fibrinosoproductiva
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Diagnosis
Morbus principalis
Aetas provecta (92 anni).
Atherosclerosis universalis gravis
praecipue aa. basalium cerebri.
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Diagnosis
Complicationes
Encephalomalaciae partim rubrae corticis et subst.
albae loborum frontalium cerebri.
Pancreatitis chronica fibroproductiva. Pseudocystis
postnecrotica capitis pancreatis. Emphysema
pulmonum vesiculare atrophicum. Bronchopneumonia
fibrinosoproductiva focalis
Causa mortis
Oedema cerebri.
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Malignity nepotvrzené
pitvou
klinická úvaha vede k metastáze
vzhledem k vzrůstající incidenci a
prodlužujícímu se dožití
nedostatečné diferenciálně diagnostické
myšlení
„ZLATÝ STANDARD“
PRO POTVRZENÍ MALIGNITY JE
BIOPSIE
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