Hemorragia Intracerebral Espontánea.
Dr. J. Sales Llopis;
Dr. C. Botella Asunción
Servicio de Neurocirugía del Hospital General Universitario
de Alicante.
Fecha de la última actualización: 28/06/2005
|
Introducción |
La hemorragia intracerebral espontánea es una colección hemática dentro del parénquima cerebral en ausencia de traumatismo o cirugía previa.
|
Epidemiología |
Es la 3ª causa de muerte
Se estima la duplicación de su incidencia en el año 2050
Se presenta con doble de frecuencia que la hemorragia subaracnoidea
y tiene peor pronóstico que esta.
A partir de los 55 años de edad frecuencia se doble por cada década que pasa.
Se produce con mayor
frecuencia en personas de raza negra y japoneses.
En cuanto al sexo, no se observan diferencias significativas entre ellos.
Más frecuente por la mañana y en invierno.
|
Clasificación |
Primaria :debido a ruptura espontánea de los pequeños vasos dañados por hipertensión o angiopatía amiloide
Secundaria
: asociado con
lesiones congénitas o adquiridas como anomalías vasculares, coagulopatías,
tumores,medicamentos...
Según su localización:
Ganglios basales con una frecuencia del 50%.
Tálamo 15%.
Lobares 15%.
Pontinos
Cerebelo10%.
|
Etiología |
La patogenia de
Secundaria
Malformaciones vasculares
Malformaciones arteriovenosas
Aneurisma
¿Microaneurisma de Charcot-Bouchard ?
Tumores intracraneales
Anticoagulantes Agentes trombolíticos
Drogas simpatomiméticas
Abuso de cocaína,
anfetamina
Discrasias sanguíneas
Vasculitis
Trombosis de seno
Endarterectomía carotídea
Infecciones del SNC (micóticos, herpes...)
Eclampsia
Trombosis venosa
Enfermedad de Moya-Moya.
Otros y desconocidos..
Clínica
La clínica va a depender de la localización , del tamaño, del edema acompañante y la presencia de hidrocefalia entre otros.
Característicamente se produce un intenso dolor de cabeza, vómitos y alteración en el nivel de conciencia.
Puede presentarse como una parálisis de la mitad del cuerpo, disminución de la apertura y desviación de los ojos hacia el lado del cerebro donde se produjo la hemorragia y dificultad para hablar. También puede manifestarse con una alteración para mover los ojos y disminución en la sensibilidad.
Uno de cada 4 pacientes
va a presentar un deterioro clínico en las próximas 24 horas sobre todo en
alcoholismo, hematoma irregular,nivel de conciencia
bajo y niveles bajos de fibrinógeno.Antecedentes de
isquemia cerebral,enfermedad hepática,niveles
altos de glucosa,y tensión arterial por encima de
Diagnóstico
El TAC nos debe mostrar la
información necesaria para tomar la decisión de realizar una evacuación quirúrgica
urgente del hematoma (Volumen, compresión de estructuras y desplazamiento de la
línea media…)l
Volumen del hematoma:
La fórmula Ax B X C / 2 es el volúmen
aproximado de una elipse.
A Diametro
B Diametro a 90º
C Cortes TAC x anchura del corte.
(Con permiso de Arikan et al.)
Sin
invasión ventricular 
Con
invasión ventricular
Se muestra hiperdenso y su tamaño disminuye a razón de 0,75 , y dos HE por día.
RM
La resonancia nos sirve para valorar la edad de hematoma.y la presencia de una angiopatía congofílica El agudo aparece hipointenso, el subagudo muy hiperintenso y el crónico isointenso.
|
Cambios Temporales del Hematoma Intracerebral en RM |
|||
|
|
Tipo de señal en RM |
||
|
Etapa de evolución |
Tipo de hemoglobina |
Secuencia T1 |
Secuencia T2 |
|
Primeras horas |
Oxihemoglobina |
Isodensa o ¯ |
|
|
Horas - días |
Deoxihemoglobina |
Isodensa o ¯ |
¯ ¯ |
|
Semanas |
Metahemoglobina, |
|
¯ |
|
Semanas - Meses |
Metahemoglobina, |
|
|
|
Meses - Años |
Hemosiderina |
Isodensa o ¯ |
¯ ¯ |
Se realizará angiografía
cerebral en todas las hemorragias lobares o en
pacientes jóvenes.
La angiografía cerebral se repetirá en las hemorragias y en los pacientes
jóvenes tras la completa desaparición en el TAC de la hemorragia.
En mayores de 45 años con HTA conocida y hemorragia talámica , putaminal o de fosa posterior se puede prescindir de la angiografía cerebral.
En caso de no detectarse la etiología del sangrado se practicará una RM Cerebral para descartar una malformación vascular angiográficamente oculta o tumor.
Tratamiento
Resolución de la hipertensión arterial si la hubiere.
Corregir la discrasia sanguínea
Antiepilépticos
Cirugía (Controvertido):
El paciente ideal para una intervención quirúrgica:
1. Paciente que sufre
deterioro neurológico de inicio reciente.
2. GCS entre 6 y 10
3. Edad igual o menor de 50 años.
4. Volumen de sangre entre
5. Localización lobar en hemisferio no dominante
6. Coagulación normal
Paciente con mal pronóstico a pesar de cirugía:
1.Deterioro que persiste 24 horas o más.
2.GCS menor de 5
3.Edad elevada (> 75 años) o enfermedad de base importante
4.Volumen de sangre mayor de 30 cc.
5.Hemorragia masiva en hemisferio dominante o área
elocuente.
6.Coagulopatía severa
Hemorragia Intracerebral en recién nacido.
La prueba diagnóstica de elección:
Ultrasonidos.
TAC indicado en los casos en que los hallazgos de ultrasonidos son dudosos (Variaciones anatómicas...)
Indicación quirúrgica.-
Sólo se evacuarán las infratentoriales que produzcan compresión del mesencéfalo con ventriculomegalia
progresiva y que no
responden a tratamiento médico.
Las supratentoriales
que produzcan ventriculomegalia progresiva y que no
respondan con tratamiento médico se tratarán con
punción ventricular.
En el caso de no resolverse se tratarán con shunt
ventrículo-peritoneal.
Pronóstico
Solo un 20 % podrán realizar una vida independiente 6 meses después.
El 50 % fallecen en el primer mes.
Los volúmenes de >60 cm3 tienen una mortalidad del 90 %
Conclusiones
No esta clara la
estrategia a seguir.
Estudios mal diseñados.
Deben de agruparse en Localización, tamaño, GCS.
No agrupar sistemáticamente
todos los tipos de intervención quirúrgica.
Hasta el momento, ninguna
intervención en particular es claramente superior.
Una revisión de los
estudios aleatorios disponibles, sin embargo indica que las opciones menos invasivas puedan mostrar resultados mejores.
Esto puede ser en particular verdadero en pacientes jóvenes con signos de deterioro neurológico reciente.
Reducir el volumen de
hematoma permanece como pilar básico.
Las futuras
investigaciones e intervenciones van indudablemente en esta dirección.
Este interés en
identificar mecanismos bioquímicos refleja el aumento reciente de publicaciones
de investigación de mecanismos celulares y moleculares
Mientras tanto, la
responsabilidad permanece sobre el clínico para hacer el juicio terapéutico lo
mejor posible.
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