Hematomas intracerebral espontâneos estudo de 121 casos

Werneck, Lineu Cesar; Scola, Rosana Hermínia; Ferraz, Leila Elizabeth

doi:10.1590/S0004-282X1991000100003

Resumos

Foram analisados retrospectivamente 121 pacientes com hematomas intracerebrais espontâneos (HIE): com média de idade de 53,4 ±14,8 anos, 62,8% do sexo masculino, tempo médio de sangramento na admissão de 36 horas (3 horas a 12 dias); 63,5% estavam acima de 7 na escala de Glasgow e 81,9% com grau igual ou maior que 3 na escala de Botterel. Os HIE eram: em gânglios da base em 45,5%, multilobares em 14,7%, lobares em 22,8%, no tronco cerebral em 4% e cerebelares em 2%. Seus diâmetros médios eram de 46,6 mm (16 a 33) e a área média de 1422,9 mm2 (60 a 4818). O LCR em 67 casos revelou pressão inicial média de 234 mmH20 (30 a 700) e concentrarão proteica média de 416,9 mg/dl (30 a 1960). O tratamento foi conservador em 107 casos e cirúrgico em 14. Sobreviveram 55,8% dos pacientes; a maioria dos que faleceram estava em grau acima de 3 na escala de Boterell e abaixo de 9 na de Glasgow. Houve correlação estatística entre a sobrevida e óbito com a escala de Glasgow e com a de Boterell, paralisia de músculos oculares, déficit motor, sinais de descerebração, broncopneumonia, diâmetro e área do hematoma; não houve relação estatística com uso de dexametasona, antifibrinolítico, anticonvulsivantes e diuréticos. O uso de manitol e a queda da pressão arterial nos primeiros dias tiveram relação com maior mortalidade Dos 14 casos submetidos a cirurgia, 11 faleceram. A principal complicação que levou a óbito foi broncopneumonia. São feitos comentários sobre a patogenia dos HIE, incidência atual, sinais clínicos» localização, tamanho, causas de óbito e tratamento empregado em relação ao prognóstico.

Results are reported on the study of 121 patients commited by spontaneous intracerebral haematomas (HIE): mean age 53.4 years, 62.8% males, mean admission time of 36 hours (3 hours to 12 days) from onset; 63.5% were graded over 7 in the Glasgow scale and 81.9% were graded 3 or over in the Boterell scale. The HIE location was 45.5% in the basal ganglia, multilobar in 14.7%, lobar in 22.8%, brain stem in 4%, and cerebelum in 2%. The mean diameter was 46.6 mm (16-93) and mean area was 1422.9 mm2 (60-4818). CSF in 67 cases showed mean opening pressure of 234 mmH20 and mean protein content of 416.9 mg/dl. Treatment was conservative in 107 cases and surgical in 14; 55.8% cases survived. The majority of patients who died were graded 3 in the Boterell scale and below 9 in the Glasgow scale. It was found a statistical correlation between death and: low Glasgow and high Boterell scales grading, motor ocular nerve palsy, motor deficit, decerebration signs, broncopneumonia, large diameter and area of hematomas. No statistical correlation was found regarding survival and treatment with dexametasone, antifibrinolitics, anticonvulsivants, antihypertensive drugs and diuretics. Use of manitol, fall in the systolic blood pressure and surgical therapy increased the mortality rate. From 14 patients who underwent surgical drainage, 11 died. The main complication who lead to death was broncopneumonia. A discussion is made on HIE pathogenesis, localization, present day incidence, clinical findings, death causes, size of hematomas and type of treatment used.

CONTEÚDO CONTENTS

Lineu Cesar Werneck^I; Rosana Hermínia Scola^II; Leila Elizabeth Ferraz^II

^IProfessor Adjunto de Neurologia. Trabalho realizado no Serviço de Doenças Neuromusculares e Especialidade de Neurologia do Departamento de Clínica Médica, Hospital de Clínicas (HC) da Universidade Federal do Paraná (UFPR)

^IINeurologista e Estagiária do Serviço de Doenças Neuromusculares. Trabalho realizado com o auxílio do CNPq, bolsa 820224/88-O/CL

RESUMO

Foram analisados retrospectivamente 121 pacientes com hematomas intracerebrais espontâneos (HIE): com média de idade de 53,4 ±14,8 anos, 62,8% do sexo masculino, tempo médio de sangramento na admissão de 36 horas (3 horas a 12 dias); 63,5% estavam acima de 7 na escala de Glasgow e 81,9% com grau igual ou maior que 3 na escala de Botterel. Os HIE eram: em gânglios da base em 45,5%, multilobares em 14,7%, lobares em 22,8%, no tronco cerebral em 4% e cerebelares em 2%. Seus diâmetros médios eram de 46,6 mm (16 a 33) e a área média de 1422,9 mm2 (60 a 4818). O LCR em 67 casos revelou pressão inicial média de 234 mmH20 (30 a 700) e concentrarão proteica média de 416,9 mg/dl (30 a 1960). O tratamento foi conservador em 107 casos e cirúrgico em 14. Sobreviveram 55,8% dos pacientes; a maioria dos que faleceram estava em grau acima de 3 na escala de Boterell e abaixo de 9 na de Glasgow. Houve correlação estatística entre a sobrevida e óbito com a escala de Glasgow e com a de Boterell, paralisia de músculos oculares, déficit motor, sinais de descerebração, broncopneumonia, diâmetro e área do hematoma; não houve relação estatística com uso de dexametasona, antifibrinolítico, anticonvulsivantes e diuréticos. O uso de manitol e a queda da pressão arterial nos primeiros dias tiveram relação com maior mortalidade Dos 14 casos submetidos a cirurgia, 11 faleceram. A principal complicação que levou a óbito foi broncopneumonia. São feitos comentários sobre a patogenia dos HIE, incidência atual, sinais clínicos» localização, tamanho, causas de óbito e tratamento empregado em relação ao prognóstico.

SUMMARY

Results are reported on the study of 121 patients commited by spontaneous intracerebral haematomas (HIE): mean age 53.4 years, 62.8% males, mean admission time of 36 hours (3 hours to 12 days) from onset; 63.5% were graded over 7 in the Glasgow scale and 81.9% were graded 3 or over in the Boterell scale. The HIE location was 45.5% in the basal ganglia, multilobar in 14.7%, lobar in 22.8%, brain stem in 4%, and cerebelum in 2%. The mean diameter was 46.6 mm (16-93) and mean area was 1422.9 mm2 (60-4818). CSF in 67 cases showed mean opening pressure of 234 mmH20 and mean protein content of 416.9 mg/dl. Treatment was conservative in 107 cases and surgical in 14; 55.8% cases survived. The majority of patients who died were graded 3 in the Boterell scale and below 9 in the Glasgow scale. It was found a statistical correlation between death and: low Glasgow and high Boterell scales grading, motor ocular nerve palsy, motor deficit, decerebration signs, broncopneumonia, large diameter and area of hematomas. No statistical correlation was found regarding survival and treatment with dexametasone, antifibrinolitics, anticonvulsivants, antihypertensive drugs and diuretics. Use of manitol, fall in the systolic blood pressure and surgical therapy increased the mortality rate. From 14 patients who underwent surgical drainage, 11 died. The main complication who lead to death was broncopneumonia. A discussion is made on HIE pathogenesis, localization, present day incidence, clinical findings, death causes, size of hematomas and type of treatment used.

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Agradecimento - Agradecemos ao Dr. M. Vinicius Ferreira, pela orientação no estudo tomográfico.

Dr. Lineu César Werneck - Rua Ewaldo Schiebler 780 - 82600 Curitiba PR - Brasil.

1. Brott T, Thalinger K, Hertz berg V - Hypertension as a risk factor for spontaneous intracerebral hemorrhage. Stroke 1986, 17:1078-1083.
2. Calandre L, Arnal C, Ortega JF, Bermejo F, Felgeroso B, Del Ser T, Vallejo A - Risk factor for spontaneous cerebral hematomas: case-control study. Stroke 1986, 17:1126-1128.
3. Caplan L - Intracerebral hemorrhage revisited. Neurology 1988, 38:624-627.
4. Cole FM, Yates PO - The occurrence and significance of intracerebral micro-aneurysms. J Path Bact 1967, 93:393-411.
5. Douglas MA, Haerer AF - Long-term prognosis of hypertensive intracerebral hemorrhage. Stroke 1982, 13:488-491.
6. Drury I, Whisnant JP, Garraway M - Primary intracerebral hemorrhage: impact of CT on incidence. Neurology 1984, 34:653-657.
7. Fieschi C, Carolei A, Fiorelli M, Argentino C, Bozzao I, Fazio C, Salvetti M, Bastianello S - Changing prognosis of primary intracerebral hemorrhage: results of a clinical and computed tomographic follow-up study of 104 patients. Stroke 1988, 19:192-195.
8. Fitch W, Mcdowall DG, Keaney NP, Pickerodt WA - Systemic vascular responses to increased intracranial pressure. J Neurol Neurosurg Psychiat 1977, 40:843-852.
9. Furlan AJ, Whisnant JO, Elveback LR - The decreasing incidence of primary intracerebral hemorrhage: a population study. Ann Neurol 1979, 5:367-373.
10. Hayashi M, Kobayashi H, Kavano H, Handa Y, Hirose S - Treatment of systemic hypertension and intracranial hypertension in cases of brain hemorrhage. Stroke 1988, 19:314-321.
11. Helweg-Larsen S. Sommer W. Strange, P, Lester J, Boysen G - Prognosis for patients treated conservatively for spontaneous intracerebral hematomas. Stroke 1984, 15:1045-1048.
12. Kano T, Sano H, Shinomiya Y, Katada K, Nagata J, Hoshino M, Mitsuyama F - Role of surgery in hypertensive intracerebral hematoma: a comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg 1984, 61:1091-1099.
13. Kase CS - Intracerebral hemorrhage : non-hypertensive causes. Stroke 1986, 17:590-595.
14. Koba T, Yokayama T, Kaneko M - Correlation between the location of hematoma and its clinical symptoms in the lateral type of hypertensive intracerebral hemorrhage. Stroke 1977, 8:676-680.
15. Lavin P - Management of hypertension in patients with acute stroke. Arch Intern Med 1986, 146:66-68.
16. Mohr JP, Caplan LR, Melski JW, Goldstein RJ, Duncan GW, Kistler JP, Pessin MS, Blech HL - The Harvard cooperative stroke registry : a prospective registry. Neurology 1978, 28:754-762.
17. Mona B - Hazards of therapy for excessive hypertension in acute stroke. Acta Med Scand 1980, 207:253-257.
18. Paillas JE, Alliez B - Surgical treatment of spontaneous intracerebral hemorrhage: immediate and long-term results in 250 cases. J Neurosurg 1973, 39:145-151.
19. Portenoy RK, Lipton RB, Berger AR, Lesser ML, Lantos G - Intracerebral haemorrhage : a model for the prediction of outcome. J Neurol Neurosurg Psychiat 1987, 50:976-979.
20. Poungvarin N, Bhoopat W, Virivave.iakul A, Rodprasert P, Buranasiri P, Sukondhabhant S, Hensley MJ, Strom BL - Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987, 316:1229-1233.
21. Russell RWR - Observation on intracerebral aneurysm. Brain 1963, 86:425-442.
22. Santos-Buch CA, Goodhue WW, Ewald BH - Experimental production of miliary aneurysm with hypertension. In Whisnant JP, Sandok BA (eds) : Ninth Conference Cerebral Vascular Disease, Princeton, 1974. New York: Grune & Stratton, 1975.
23. Scott WR, Miller BR - Intracerebral hemorrhage with rapid recovery. Arch Neurol 1985, 42:133-136.
24. Silver FL, Norris JW, Lewis AJ, Hachinski V - Early mortality following stroke : a prospective review. Stroke 1984, 15:492-496.
25. Sundt TM, Whisnant J - Subarachnoid hemorrhage from intracranial aneurysm. N Engl J Med 1978, 299:116-122.
26. Steiner I, Gomori JM, Melamed E - The prognostic value of the CT Scan in conservatively treated patients with intracerebral hematoma. Stroke 1984, 15:279-282.
27. Teasdale G, Jennet B - Assessment of coma and impaired counsciouness : a practical scale. Lancet 1974, 2:81-83.
28. Tellez H, Bauer RS - Dexamethasone as treatment in cerebrovascular disease: 1. A controlled study in intracerebral hemorrhage. Stroke 1973, 4 : 541-546.
29. Tsementzis SA - Surgical manejament of intracerebral hematomas. Neurosurgery 1985, 16:562-572.
30. Tuhrim S, Dambrosia JM, Price RT, Mohr JP, Wolf AP, Heyman A, Kase CS - Prediction of intracerebral hemorrhage survival. Ann Neurol 1988, 24:258-263.
31. Volpin L, Cervellini P, Colombo F, Zanusso M, Benedetti A - Spontaneous intracerebral hematomas; a new proposal about the usefulness and limits of surgical treatment. Neurosurgery 1984, 15:663-666.
32. Weisberg L - Computerized tomography in intracranial hemorrhage. Arch Neurol 1979, 36:422-426.
33. Wiggins WS, Moody DM, Toole JF Laster DW, Ball MR - Clinical and computerized tomographic study of hypertensive intracerebral hemorrhage. Arch Neurol 1978, 35:832-833.

Hematomas intracerebral espontâneos estudo de 121 casos

Spontaneous intracerebral haematomas: a study of 121 cases.

Datas de Publicação

Publicação nesta coleção
22 Fev 2011
Data do Fascículo
Mar 1991

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

[1] 1. Brott T, Thalinger K, Hertz berg V - Hypertension as a risk factor for spontaneous intracerebral hemorrhage. Stroke 1986, 17:1078-1083.

[2] 2. Calandre L, Arnal C, Ortega JF, Bermejo F, Felgeroso B, Del Ser T, Vallejo A - Risk factor for spontaneous cerebral hematomas: case-control study. Stroke 1986, 17:1126-1128.

[3] 3. Caplan L - Intracerebral hemorrhage revisited. Neurology 1988, 38:624-627.

[4] 4. Cole FM, Yates PO - The occurrence and significance of intracerebral micro-aneurysms. J Path Bact 1967, 93:393-411.

[5] 5. Douglas MA, Haerer AF - Long-term prognosis of hypertensive intracerebral hemorrhage. Stroke 1982, 13:488-491.

[6] 6. Drury I, Whisnant JP, Garraway M - Primary intracerebral hemorrhage: impact of CT on incidence. Neurology 1984, 34:653-657.

[7] 7. Fieschi C, Carolei A, Fiorelli M, Argentino C, Bozzao I, Fazio C, Salvetti M, Bastianello S - Changing prognosis of primary intracerebral hemorrhage: results of a clinical and computed tomographic follow-up study of 104 patients. Stroke 1988, 19:192-195.

[8] 8. Fitch W, Mcdowall DG, Keaney NP, Pickerodt WA - Systemic vascular responses to increased intracranial pressure. J Neurol Neurosurg Psychiat 1977, 40:843-852.

[9] 9. Furlan AJ, Whisnant JO, Elveback LR - The decreasing incidence of primary intracerebral hemorrhage: a population study. Ann Neurol 1979, 5:367-373.

[10] 10. Hayashi M, Kobayashi H, Kavano H, Handa Y, Hirose S - Treatment of systemic hypertension and intracranial hypertension in cases of brain hemorrhage. Stroke 1988, 19:314-321.

[11] 11. Helweg-Larsen S. Sommer W. Strange, P, Lester J, Boysen G - Prognosis for patients treated conservatively for spontaneous intracerebral hematomas. Stroke 1984, 15:1045-1048.

[12] 12. Kano T, Sano H, Shinomiya Y, Katada K, Nagata J, Hoshino M, Mitsuyama F - Role of surgery in hypertensive intracerebral hematoma: a comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg 1984, 61:1091-1099.

[13] 13. Kase CS - Intracerebral hemorrhage : non-hypertensive causes. Stroke 1986, 17:590-595.

[14] 14. Koba T, Yokayama T, Kaneko M - Correlation between the location of hematoma and its clinical symptoms in the lateral type of hypertensive intracerebral hemorrhage. Stroke 1977, 8:676-680.

[15] 15. Lavin P - Management of hypertension in patients with acute stroke. Arch Intern Med 1986, 146:66-68.

[16] 16. Mohr JP, Caplan LR, Melski JW, Goldstein RJ, Duncan GW, Kistler JP, Pessin MS, Blech HL - The Harvard cooperative stroke registry : a prospective registry. Neurology 1978, 28:754-762.

[17] 17. Mona B - Hazards of therapy for excessive hypertension in acute stroke. Acta Med Scand 1980, 207:253-257.

[18] 18. Paillas JE, Alliez B - Surgical treatment of spontaneous intracerebral hemorrhage: immediate and long-term results in 250 cases. J Neurosurg 1973, 39:145-151.

[19] 19. Portenoy RK, Lipton RB, Berger AR, Lesser ML, Lantos G - Intracerebral haemorrhage : a model for the prediction of outcome. J Neurol Neurosurg Psychiat 1987, 50:976-979.

[20] 20. Poungvarin N, Bhoopat W, Virivave.iakul A, Rodprasert P, Buranasiri P, Sukondhabhant S, Hensley MJ, Strom BL - Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987, 316:1229-1233.

[21] 21. Russell RWR - Observation on intracerebral aneurysm. Brain 1963, 86:425-442.

[22] 22. Santos-Buch CA, Goodhue WW, Ewald BH - Experimental production of miliary aneurysm with hypertension. In Whisnant JP, Sandok BA (eds) : Ninth Conference Cerebral Vascular Disease, Princeton, 1974. New York: Grune & Stratton, 1975.

[23] 23. Scott WR, Miller BR - Intracerebral hemorrhage with rapid recovery. Arch Neurol 1985, 42:133-136.

[24] 24. Silver FL, Norris JW, Lewis AJ, Hachinski V - Early mortality following stroke : a prospective review. Stroke 1984, 15:492-496.

[25] 25. Sundt TM, Whisnant J - Subarachnoid hemorrhage from intracranial aneurysm. N Engl J Med 1978, 299:116-122.

[26] 26. Steiner I, Gomori JM, Melamed E - The prognostic value of the CT Scan in conservatively treated patients with intracerebral hematoma. Stroke 1984, 15:279-282.

[27] 27. Teasdale G, Jennet B - Assessment of coma and impaired counsciouness : a practical scale. Lancet 1974, 2:81-83.

[28] 28. Tellez H, Bauer RS - Dexamethasone as treatment in cerebrovascular disease: 1. A controlled study in intracerebral hemorrhage. Stroke 1973, 4 : 541-546.

[29] 29. Tsementzis SA - Surgical manejament of intracerebral hematomas. Neurosurgery 1985, 16:562-572.

[30] 30. Tuhrim S, Dambrosia JM, Price RT, Mohr JP, Wolf AP, Heyman A, Kase CS - Prediction of intracerebral hemorrhage survival. Ann Neurol 1988, 24:258-263.

[31] 31. Volpin L, Cervellini P, Colombo F, Zanusso M, Benedetti A - Spontaneous intracerebral hematomas; a new proposal about the usefulness and limits of surgical treatment. Neurosurgery 1984, 15:663-666.

[32] 32. Weisberg L - Computerized tomography in intracranial hemorrhage. Arch Neurol 1979, 36:422-426.

[33] 33. Wiggins WS, Moody DM, Toole JF Laster DW, Ball MR - Clinical and computerized tomographic study of hypertensive intracerebral hemorrhage. Arch Neurol 1978, 35:832-833.