semiologie neurologica- bucuresti
DESCRIPTION
Semiologie neurologicaTRANSCRIPT
GJS:ot.s_49 "3A n)H 5> MlNtsrERUt EDUcAIIEI gl lNvATAMiNrutul
Prof. dr. doc' CONSTANTIN ARSENI Prol' dr' doc' tlvlu POPOVICIU
sEtvllol"offilE
(DE LA SIMPTOM LA BOALA)
ci MFr' ' [
QTq L,' ^0u J"/ €A*Af'l
.rq.qEPlDllunA DloACrlcA fl rlo^ooolcA - lucuitlll
BE MIOLOSI-N NEU RO LOGIC A
Probleme d,e cl,iagnosti,c topograJic pi. etiopato-genie Ln: l,eziunile nerailor cranieni,, paralizii,tulburdri d,e tonus muscul,ar,, ataaii,, migadriinoolu nlare, lulburdri de sensibilitate, tindroamealgiae, tulbnnd,ri troJice, agnoeii, aJazii,, apraoii,tulburd,ri de conptiittld, gi gtsihoorganice,
PRETATA
Pd,rerea noastrd, baza,td pa o eaperienld, 6nd,elun-
ltatd' esta cd orice semiologie d,i.n orice domeni.u medicalrute bi,nauenitd, iar d,u1td, apari,l,ia sa se {Lftee?tii cu
erd,bilare sd, aind, o akd, semiologie cu acela,si proJil.Orice semiologie poale li a4tusd, 4,tr, mriate feluri. pi.cste ind,epend,entd ile altarilia ao , nui a tratatalor iJeaul,a7i, profil. Deoarece 4n literaturt med,icald, uni-wrrald, sdrtl d,estul de pwline semiologii - noi ored,emritr sl,nt mai. d,i.ficil de sois d,eait url tra,tat - e bine aw scrie cl.tr rnai. rnult, cd,ci fiecare clinician, d,apd,rtttt4tcytf,ia Si enperi,enla 3&, o Da scrie nntr-un alt modd( {ltnd,ire .
Nu trabuie sd, surprindd, pe nimeni, apari,tiauoe ci $emiologii. Neurologice, d,ugtd, ce dtrinele librd-rii.l,or au odzut 4n acapti. ultimi d,oi. ani llratatwl nostrud,o N ettrologlie nn cinci uolurne. Aceastd, carte a noaatrdpinq da.fapl, sd, umple un gol e*istent:l,n aetiaitateath pi au pi o, nxed,ieilor neurologi,. neu,rochirurgi ',,si
okiat da fl,l,te specia,litd'li, - medicind' generald, inler-,niil,il o,tt, alte cuvi,nte oricd,rui' clinici'an ind'iferent d,eptojill yeaum Fi tn a,ctiDitatea, d'in 4nad!'d,m'i'ntul uni-acfd'l/j.r pi !)ostuniaersitrar' Ne-anz gtropus sd aborddm,ln pogini,l,o o,oestea, o alNd' morl'al,i'tata, mai practicd'.,
nai qfioCan'ld,, itre anpunere a rnatari('lul,ui serniologic,
?lrrnlnil da I,a dmptomul' iaolal, tau tn' conteatul. rnaihrg pl alungtnd La boald, In nocaato oonstd' noulalao,.
ll - ortdql|n nod - nli0l6tNta odrlii nonntre, 0iti'lortt'1,
,t)u, putoa, lnltlni toala noilalitd,l'il'a ila bnbinnra n ll,nt.
Tttomotror, o sinl,aal, ila ternne ou lllo diagnottia, oaratd-l orienteza inreiliat 4,ntr"o ileci,zi,e diann,orfliad, d,aurgenld pi,, itnTtldoit, [nlr-o atitud'i'ne l,arapuulicd' atlcc'tatd. XmT inim, grrin munco d'epusd' I'n sistamatizareaa,castui, material cara refleotd, o dndalungatd' praat'ied'tra patul bolnamr,lui, 4,ntr- o asid'ud, actioi,tafia alinicdlun d,eaidaat major, dltctatr d'e misiwnea med'isttlu'ipracticiatt,: ajulorarea bol,naawlui. Nd'd'd,iilui'm cd'prin acea,std, carte ne aom Jace wtili nobi'lei' sarai,ni'cnre ne std, tn fald,, 4n sistemul nou d'e d'sistenld' med'ical,d,d,i.n patria noastrd,.
AAIORII
CUPNI,NB
l . l r l r |durntol, ln)lrlnmc di dloUnostlc topogrnllc tl etloPAtogonlo h lezl[Dlle ncrvll'ol cioslonl
: t ,1. lr .r tologld Percchl i I .
t . t , l ,utologl{ Pclechi l a I I-a
l.ll, l:robl0nlo dc diagno6tic ln exottalmii " ' r " " 'l.l. Itrottlor ) dc dlagnostic tn patologie sistemelor oculo otorii ' ' ' 'l.h, Prohlorno de dlagnostlc lr! patologia nelvului trigemen
Li lrroblGt o dc diag:nostic ld patologiA nervului laeial
L?. lintltlnnrc de diagnostic in patologia nervului scustic (cochlear) ' ' 'g,l, t robklrno do diagnosttc tn patotogis slctomului vestibular
t,g, l1$ltonrc dc dlagnostic in patologia nervulul Slorofaringian ' ' ' ' '
l.ltl, I'robl no dc diagno8tic ln patologia n€rvulul pneumogastric ' ' ' '
l,ll. lrobl' rtr de di{gnostic ln patologia nexvului spinal
Lll. t|rot,l(uc dc diagnostic tn patologia nervului hipoglos
'J,lil, lrro}|lrnrc do diagnostic in patologia paraliziilo! rnultiple ale nervlor
r ' f l rr lr !r l bulbari
l, }ltrtlrtlr do dlo0trostlc In parallzti
ll,l, llrDlofltrcu scnlologic{ a delicitelor motolil
11,2, ltllnrh0roo t0lsclor pareze sau Paralizll!l,il, I'rohl{ttlo do dlognostic etiologic ai topograllc ln divo$e pamli'ii ' ' '
L Fmlhrnr dn dlo0nostle h tulhurirlle tonusulul mu6euhl
a,l , l lholonl l lo musaulare .
a,t , l l lDfrtorl lo mucoulqre .
1,9, l)lrtonlllol.S,0onvul.t l lo
l, ?nltror dr dle0Do.tlo h tolburlrllc do i'rtlb lrob
t,t. nloonundlrl mctodoloSlao do sandologlo?,3. Froblomo d0 dlsgno0tlc topogtqllc $ otlopqtogenlc'
?,!1. Froblono do dlngnoltlc ottologlo tn dlvo!'so ilndtoamc atglco
l trulhur do lth0Do.tl0 tn iuuurtrlllc troll0o do orhhr lirlor|' ' ' ' ' 't,i, ?ulbt|rdrl trotloo alo plolll, al6 frnelclor $ ilo lo'uturllor $ol ' ' ' 'l.!. T lburirl tt0tlor orteo0rtrlcuhr!l tl. Tdb$rirl trollco nrurol|lo$
l, litltenl$ do dlo0trostlc h ottrxll
ll,l, FrobLrrno do mctodologie seiniologica
}1, PmllloDro do dlegnostic etioDatogonlc ti topogratic
l, ltrotlmr ao ilhgnorilo tn semlolo0la ml|oitllof tEvohtlt[lr ' ' ' ' ' '
| | l , ! l lDrrlhrorl l lc
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l ) . .1. At jnozi i le in lagini lor . corporalc
I0. l|rubll.|Do dc diagnostic in tulburdlite d0 vorbiro gi lD afrzilt ( ) .1. ct ls i i icarca tulbur: i r i lor de vorbirc1O.2. l ulbur.; ir i ale rnrisiuni i si arl icul ir i i cuvintelorIo. :1. ' l Ulbrr f i r i r i i r ] t rcpl ic i , conrprr jhcDsiuni i , IorDrut i r i i s i
r , . r L. r lcrf xp}esici siurbolurilor
276
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282
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I t . | | | r t t rnr( ! dr ,d i l ,Dosl ic i t l l rpra\ i il l . l . I ) f f i | l i t i iI 1.2. l , l \ iur)cnul l lprar i i i lo i . .l l . :1. l i r rJ l , l ( . r l i icc. . t1c apl ,ar i i r i
l i : . Prrbleln( r l r { l i r l lnort i ( in lutbur i r i le i te conl t i (at i ( runost i l r i )l :1.1. l , r i r ) r i l ) i j l f rnf i { ) l totopi{rc srrr iotogiceJ de diaguost ic et io logic s i topogr:r t ic
I i l . l i r lbur ' t i r i t ) r ihor,rr f t r i . r , .
l l ] .. i :1,,,1", , ' (t iro.lr ieziunitc ,t iI l p,,";", *.,1r...;";.; *u.,,,*,,,, i ., ,,""0l"il :1. :J. Sirx l ro l | r t , ( l1r i ! ( ie leziur i i r1 nuclc i i bazal i
l i l . i l . s ;ndr.)urrx, (htc c l r lL:z iuni cort icuicI :1. .1. Si I ( l r rJ l l rc iht f r t r jcz i rn j d i luzul : l . l ) . l . i iudroanrc ( t l tc ( l r loziur i s i tuste D . \ , . r r iatc etr jc
1.INTRODUCERE
Penlru a veni in spdjinul rnedicului practician neurologll, l l l l l lrr)plfs sii scriem
^ceasita I en?,iologie neurologicd d,e urgenlii, itt <:lra
rl'r rrrr .r rrrr prezenti,m in mod analitic ttiversele semne subiective ;i,,r'r,, tr\ '.. r.ir, irr numeroasele semiologii clasice, ci sd, sugeri,m qi si, coltil_r rrrr rrrrrIIr1,IlIl posibilit5,ti diagnostice sindromatice qi de boa,li,, porninri,lr lr , rrrr.lrrqirr elementarS, cu alte cuvinte Sd, potnim de ln sint|tltrnt,,l | ,rlrr'., rr ll, boaliir la diagnosticul neurologic, care si, perrlli i jt i iur(r(lirLlr i l l r r , . r r r r r r . i r r , i i l , r rd in i pract ice, de urgentf . . I rebuie sd pornirn dc la i r l r t l r ,r.r ,lr,,"r', lrrrrl nelrrologic necesitd, cunoa$terea unei semiologii prlcisr.,r r I rr.,, r, ,r urrli discipline aproapo matematice.
| | , lr,,, I rrrl,ua 5, metodele paraclinice modeme de rrrin,c DrrrcrzrcL | ,r, ' rr ' 'rl i l l[ {iaele (electloencef:}lografia clasici, $i cea inrlrogii(il ir, rl,, 1,"1, rrrri dc informatici, scintigrafia cereblali,, ecoenctl ri lonr.rr I.irr,rr , rl ' rr\ , rligal,ii ultlasonice, angiografia celebrald,, studiul cfixrirrlrril r , , t , t , l , ' , l r r r ' r r rnot 'ncefalograf ia c lasic i i i f rac. f ionat l , angiogl l , { i r r spi-, r , l , , l , , l rorrr iogl l f i : r cu r i ru l t rp le le sale adjuvante, e lcctrodiaglosl i l r r lr l r l r r r r r r l r , r ' r ' r i r lo dctec! ie s i indeosebi e lcganta, mir i { ica, spcctacuLl l tsrrr , , r , , ' j , r . , t r i r r , i r r l i rornputel izat : ' i ) au l i i rg i t considerabi l c impl l i lc inrroslt1, 1,, ,,, ,i rt(,l[]gio fi in neurochir.urgie. Cu toa,1e &coste&, c)itl,it ot,(,I iuit r.it,l r , r r r r l r . r l r r r ( i ; i p lcciz ie nu pot sd, , ,dctrongzs' , exandlul c l in ic, r r r l i , r r t i, r , , , , , r , r r r r : r r ' i r i l r r l r i , f ine{.e t lebuirr s i , r l i r i jcze al , i t indic:r , { i i lo nr. l , , r lo l r rl ' , , , 1, | | , . , , \ l ) r ' r io ln i t i SuS, c i i i f i iusta, i t ) tofpr.c l t t ,c l t cer 'C0t?i l , i i insirr . r r r r0n-I l r ' 1, r i , ( ( ( l { , { i . r l ( , r lc l ( jdf , ( : , t :L i ; l rc, c l i t r ic ianul ntr l to l l tc l lpsi , r r l nr t| , , , r1r , l r , , r ' I r r r r i r I r rL) ' r l in c inr l iu l r l r , l t rp l l i , t r r t l ,ot lo logic r l l (x l ( r .11, r l ru: n io it r r l r r r r l . l r
' , l i rsrr , l , (xt l i j { t ) i ' ) ) r l r " r , i i l l r r nrol 'odologi l l r t l rx l0r ' r r i i . Nrr l r .o l r r r i r r
' , r r r i r l r , r ' r l r t l l r I rv l I i , i t r : r i l l0 r l f 1tr l t lc , isc v l t , 1:kto t t t r t rx i t r t t r , t t t l l i t t i0
' , t r l r i . t r l r r , r r r r c i t i0 i t r r ru isrr t i r $ i i , (x i ( ' t t l . ( rzt . 1xr 0l i r r i t . i i r r r l r l gr | l t i r r t , r .s l , i -
t , r l r t l r ' r | | I I I : | ( , I i | | i ru. t . l r r r r l t r ' l r t r i t . r r f r . r r l t I t l r . .
Intlad,ucere, Fatoiogia nervilor cranieni este deosebitIrogu,l;ri, ryi de rl,rial5,, atit stb .aspeetul proceselor morbide xesponsa'.it, fi $t[r aslrcct,rrl contiguratiiloi ;i al contextelor patologice.\r:r.:r,:,t,ir, comploxitc,te patologict, de multc ori luxuiianti, si,.\cr.irtrir,ir oomplo-xrrc,re patologrot, d.e multe ori luxuriantx qi cler,.,r1,'\ (l(,1;{runrnatrr, pe dc o parte de pozilia strategic[ a nuolei]or derr,u tlo 1;crminare in trunchiul cerebial ;i in iorma.tiunileru l i toonto &cestora,
porrl;o-ocrebelos, in stlnca
rrtrr rorfiirnrgicalc.
2.1, PAT0L0GIA PERECHII t tNERVUir 0LFACTIV)
ll.l.l. tn prozonla unor disosmii la indivizi la caro un eorocr 6xam
C' PROBLEME DE DIAGNOSTIC TOPOGRAFIC4. $I ETIOPATOGENIC iN LEZIUNILE
NIiRVILOR CRANIENI
l ' l l l t r ' l i t r t r i in. l ln.nr l t t t i i ( r t t r lcotr l r i v i r t l i t ' t ' , t t t t t i r t l t ' t i g l i l t i t l r ' ) , r : i t t l
l " , l I ' r t r l r r r . r ' r r r rvt i l , r ' o l l r rc l ivo r t r , t t l rz i t t t t i t i r t l t tcr , l : r I i l r ' . l l i l l t r t i r t , l l t tol t r l r l , r , . | | | r | | | | | r ( ' i I 11i : r l l r , i t r [ . r ' ( i i gctrol l t lo l t r r l , pt 'ot l t t r t ' t l l i l r l t t t l t t t r i l t t t rvt i l r 'r , l l , r , l r r r 11/rrrr ruorr i r rgor,rrrrr ' l : r l i l r ' . Sr '1xr l , i r r lJ l t r i t t t l t t i t tgr t t ' t t r rcf l l i l r , (pt t t t tl r r r l , . l t r l r r , r ' r r r l r r r rsr ' , l r r t r l i l r ' ) , ( .1( j r , f r r l i f t \ r , i r t t l ' ic t ' , t t tc t t i t tg i l r r r r1t i r I t r I I r icr ' .
l l l ' l ' t r t t t l t t l isntr : ( l ( t ! l , r r t . i l , i r l i i t : t : lu. l , ior : , r , t t r l iv l rso I r t ' r t l iz i l r ' i ry i k 'r t r r r r , l r r ' l r r r r r r i r r l r r t r r l l r t r r : r , l r i l l r t t t i r lc i r i rz l l ( f , ( ' ( l t ' t i t ( t l , I l t t t r t r t l i tu ' i l l l z t r r r ir l l , r . lnr , , l l r rc l r r l i r rkr l l r t r rc i c i t r t r t i f i r r t , r l tnoi t l r t lu i (cu l t 'z i l t r r t l f ikr t i ' l r r lr l l r , , i r l t \ | | l r . | | ( , | | r ' ( ) | | i | ( ) r ' lxr l i l i t | ' ic i I i , ov(tr l , l l iL l , ou s l |p l i t inr ' f l , t , i i s t ,ct t t t t l i t lcr t r r \ r l r . , r I l ; r r . I ivr ' ) . lJrrcol i rurosrni i lo po$t- l r : tuma l ioo pl)1, t ' ( ! ( i t t l lo i t I l tr1 l r r l . r r r r r r l l r r r r rurrr i lc tL l i , I ) l i r (x)nt l r l lovi i ,ur i , l r , bul l lu lu i t t l l l tc l ' iv ry i /sr t , t trr Ir l rrrIr ' Ir.Ir,Iol olluclivrr. AllcoI' i ba,ndelotcle ol1'active pot' I i lozrr,l 'o plitt
l l r , , ru. p l r r l i ; r iLr rn ic i u lc s lonojdului . J lx ist l s i l , t ta{ i i in t 'at t t r i t t ot t tst t li t |"r Ir l ' .rr ' 'r1ii r roU r'ochiru] gio c, ridicarca lobuluj frrrulal ptti l lo ltftrt ' l ,aI r r r t r r I r . I r ' I r . I r , rrl lrrr, l ivtr, (i i lro se atlal po l:a!a, inl:orioru'i, a, lobulni orbilrrr.Al l , . , , r t , l r r r r r rur l isrrrc lc, dat l i leziuni lo vascul luc lot i rnt l 'o l r r lupl ,urN'n'||r ,r lrrrrir 1r|rI icrrIrrIrri vnscular provcnil j diu artur:l oerobrali l ruti;tr l ' i t t i t I l ' t .r rr r. r,r, r lr. r ' ; i vrrscrrlrrt izeazii bulbul olfactiv (Dr*loix fi fr i lrtt ' f la, 1l)l-;$,I l l ' r l l r l { , l \ l r l r16r.scu, 1l}?5).
' | ' r r r r r r r r r r I r r r r r r r ' |c c lanio-cerebralo pot ploduco rnosmii , h iposnr i i , t l : r lr l I r | | | | f t r r r , r . r r r :ostrr i i Si haluoina, l i i o l faot ive.
l,r, l lrrrrl,. lr:rzci craniului artreneazl t lcstul i lr l frecvent hipo- srttr. l l l l rn l l r l l
1,11111111111rr 11i N iccol l in i (1958, oi ta,{ , i dc } I i loqescu, 1975) a,u ar i , l t t li , l l | | | | | i , ' | | I r I I t
. r r r.rrlcfalopatii lor posttraumat'ico oonsecut' ivo ltziunilot'r 'oltItDl,,rl lr l, 1rr, zrrrl: i in contextul clinic tulburlri scnzorialc, inclusiv aartsrnii
I t tu l l t , r l r r r l r t , 1rrr r rpr t ix imat iv 10o/o din t raumat ismele c l l ln io-corol)Ul L '
f l ' l r ' Il l i , r l , )nt l t t t r ( l r :u lur( cercbra,Le ant leneazi , rar 'eor i tu lbr t l i r l i r ) l l i r r '
l l t r , \ r r r r r r l r . i r r r r l r r r l r t io l cI ochzia pediculului vasculal provol l i l , ( l i I lr t t l r ' r r r r , l l r l r l r r l r r l r , r io l r l i , calo vascular iz€azi , bulbul o l f l le l iv ( I ) rx l lo i rt l l , l l r , r , r , l l r l rH, ( l i l r r { i r le 1! l i loqescu, 1975), poate produc{) r ln( ,Blnjo.
l l l Itrh nrlo.t: iut. l i i (cu atropirri,, cu rnodinX, cocainii, sulfutir, ( l( 'r,rrrfrrrrr ,, r ) rir .! lr i,. i /(r lostnarceXi,(e se pot f lolda cu hipo- s:ru lt l tostrti i| | r l l l , l l " r i l
: ' | 'I ' l)ivt:flttiu (unosmia, hiposm,ia Fi eaenlual parosmia ) cu,'inut -lntt' ltrti rt prr4tnwit:d. ridicii ulrrlitoarr:lc problomo ct'io-po,togonioo :
ll l ' l 'trl l 'tt,trt ,l.f,rt'titt ola-ziw ,,fiaiologice" , Sunescenla po&tc 6it ror,-llrr,rr, " lrrlr" r' l l lr( (i$, i 'ot|8('(ntivir procoselor' fl lnolico alo neuronilol olfa,o-lf vf ;l rrlr lrrrrlriurrilor rru,slom. Unele std'ri, Jiziologice lo femai (graoiili.-Itlrt ttu n,,ftu::tl / rrrrl leneirzii, uneo porturbtrr'i ln perccplia, milosurilor'.Fh I lrrnrttri, rlr, l)i l(l i, hi;xrrosntiir din primul tlimostru de gravidittttrll l lrlpruurirr rlirr rr,l rloik,ir, 1i al l,rcill l trimcstru, cu roverBibilita,totu l,tl lbu-l { t lhr | | |ur( ,1 l r , r o l l i t r r t iv l dtrpr i nrrqtr .nr ,
ff) l,nr,ll luli lynualt (r, (liab(ll,ul, ur'('mia, pa,ludiBInul, homopnl,ii lolIlr,]l lr, lr,l/r'r.rrii q,u,.) 1xrl, af,r'ct{t, r)ouxmii c{,ilor olftrcl,ivo, pl'in (liYortt(,}l r r , r , r | | r lxn| | ' , r , r r r r . l l t r t i Bl l l i ( . icJ l i c l : r I i l ic l r l , (1,
f i) '/ 'r,,r rrv, llnrralt tatt, lrx,c&r.' ntorlilru, $l[l,ulnifinlul, l lr,bngilnrul,* l I r r l t l I r , i (x I I r , l t | r ,n l ( ] lu l , r ' I t r ldn , r i t r ' l |1ul (1( ] n.rginl , , 0 lonlr f l ( lo z lhat ,rtrllurx ilr\ r.rflrrr, l lrl irirr(,rr lor'irl i l rlc solutii hi;roltonictr (clt.t 'u sr', 1lir. t:11,| l l l r , l | l r I r l l l r o l l i r ot i r ' i ) .
rrorrrolol;lo lrxt[ intogritatea neuronilor gi n ciilor ollaetivo, esto vorbadlrosrrrii rlo nnturd _rinolog,ied -
("Miloqescu, 1925 ; Chusid, 19?0 ; Rirllll"r9.; l'opoyiciu.Fi Pascu, 1.980), Acestoa se caractorizoa,zd, pril'anosryi hiJrosrnli respiratorii (unilaterale sau bilat€ralo) provoctto alerori,at|, e ra. impioclici accesul curentului respirator- la zona olfactivtrl,) rtonozo ii sinoohii naza,le; b) hipertrofii ale cornotolor nazalo i o)pozo (t:ol mir,i &desea inJectate) : d) de;viatii de scrt: c't rinifa'c.ipozo (r:ol mir,i &desea infectato); d) devialii rlol,llzo (oot rn&l &desea rdectato); cl) deviarii do Bept i e) rinite acutoorouitlrl do divorse naturi I f). ozen*.; g) reactii alergice uazalo; h) tumll'i; iii;, .t ;j "i'.]t-i"i# . i:
""""ir if ' r ii.'# fil,.rd sT H' .#. J,T,ii iij) sl;il,r'i.dupl, intorvenfii ohirurgicalo po etajul supeiior iazal qi pe sinnrrr.i ; rr) diverso dorssH,ri resDiratorii.f iuli ; l()
rvellrr o,orruJgrcato podorogld,ri respiratorii.
. 2:1,2, Disosmii produse prin aleetarea neuronilor ollaotivi gi aollnctivo.
?.1.2.1:. Dieosmia (anosmi a, hiposmia gi eaentual parovnio),ituttalowd, brutal y.i asta Ji9 un ilaturAld, Jie'ile obicei bilaterald,'ienrtgr,r:l rr lt rril l.oi r,r'rrlrr lr,tor.!iuni :
l t ll l
,,,( N,H r (. i . i,u lbu;x;i, ti"t-iii^ rifi t li,ii ?':ri:"if ff ,.f T1,,T*1ilT%11:rrkrsoir bollavul se prezinti, Ia medic aor" .to""i- "i"dliur
sau se ilrifilr'i, cof i ce,a qi_tulburirile oc olare *sociat!;;;;ifi ifii*roi, , ou
l)r:.rrrrrllc.ori, cin<I cstc recunoscuti, .1" "iii;
p;;i;;t]-, Ja'este atritr::l::l ll:,:ci'l,rl,1.l,l lli 9"qrg locale nesemnificrti""'iri"itiil iirofla muccrr;rzrl' r,lt:.)r rkrcit; unei leziuni cerebrale ci, ;i it;.;,, ';r;i se* acoroal : , r t i r , ' uv! . r i t r j . (Ars.ni 5 i cohb., .19?J). ' ; " ; ; ; i ; d]J"r l rnn,oe:i:,::l1ll1l,t..lll],'l,t:i: poale insoli un sinaroi" F;;;l{";;;d;;';;;ii,fiir(fr.r'rf r pl t t,c cu .tumola $i cu atrofia optici,, Deci, anosrnia'prerlnrltir j.rr u orolusivii, _de o parte, qi coincizind cu alie'se;ne tumo:r lr' ( | lt)irit (f vil|ra,r'e diagnostici'in meningioa-"rc ofircli"".
A rrrrv 1l;1111111 de arteri, ca?otidd intein-d,, osteomul frontal,giotrt t t l stt l l t i lscl i t t . i jDmori lc r ' la ,r .r ' in;. mi.; , l j " i^;:r i ; , ; :^ '^ -.
l. lr{'rr,r||l sulrrrsr'l irr, tumorile de adpd, micd cle sfenoiA si unele tumorirlf ) rrrlf l. l.l ln)L (t(,Lermina tulburdrt-unilalerale ale mirosului, cu deoset::,ll:il,: lgE:,1i-rrtolie.(Arseni si- corab., isii,lsd)."-;;rmii bi.tatels. p.l, irrlilrri in meningioame bffactivJ giganiq
"ri6'r" ""ii"a ql d"
l:::: lllll,-itt in t umori hilofizare expansivZ !i in iiO_"oc"rariic" -""e
I:::i.T::lll: iillill"Jl,lie:lii
jArsen.i qi iota'b,-1'erz).-iiu-u,i'i''au.i, ury:: :ll.:1.,.':' i":.i::-?lli I anosmiei precoce in cu rsul meningioameloriltrlorior, in vreme ce aceasta e-st"
-u1t *ai u"ri" iffia1i oe cetre
l:liillj,, it -jt?.,1"- .":emptu . neorgmaliunte rruruilro"iif ii n r"
"onr:rlus,. t'.r'aniofaringioimele, g[oambte ;;"r"r;i-;fi1" "fr' jumoriie
::)-1;li,lil,?"9"_:,-11 gtioamae Eentrale .r" rol"i"t "i"ontJi
pragur t,l"ll,Jg t, ri"lmin:i rionnal multd, vreme, ir" ;;;;'.;;hJta estu rareInl,iluitri, 1,lnliv. .h rr,prorpc o treime'din ;-;;l;gr";;;il aripii micirli.rroirhtlui, so pt'orlucc in-itria,l o crcgtoro a prag"utul. olfacnv. resnecr{o pl'o(Illeo tnrUrl (, crc}l,oro a pragului. olfactiv, resr i [ ( r ( ] { r r l r ' l | : I r 1 r i r , r r l r rsr . l i i . l l r r r . l . ivrr Fi r l { .st : r l r lc I i rz iu sr , insbal , l t i i i r r tiJrsilnl'rrriuhL r,urrrorii (ltisrrr, lr)fir).'Arsrni r' i ,r,rii i i. ir.9i]lj-rorl,r,rrl,z{,
, ' l "r t . .
.11 | I t , l t , ' , r ' . l t r l i r ' ") r l t t t r l t r r
' l l rut t t , t l i t tnt r ru, t t io- t tn 'ebt 'aht ( lx tzr t ' lo, I t ' l r l t l l lLt l , t t t t t r t t - l t i lx t -
| , , | l r l ' l ' | , r r I r ( ' t rc | I I t I i t , t ' ) .l1 t j " , 1t ,nt i t ,nr l r ' t t i . Iak: ; i rnt t i t At t r int im,- r l r ' l t ik l i1, r l is1t lut in
, t l r ' t , , r1,r t t l , r l t " , ' r r t , ' i i is t tn lc:rz i l , t l r ,1tr ,1 ic t in ' ' t l t r t '1 i t : i ( r l l h iDo--s i l ' l l i l ' l lo i l
' , i , , , , , , , , , , , , , , , , , t , t iz , , t tnoir l t t t t l ) q i st : rnr t t l r l t r i r r ta,nf i l isrr l gt t t i l ; i l l (Alvoolr ' ,
l l l , I l \ l l l l l ' . r , l l l { i l ) ) .
l l l l t r l l , r r t r r r i Trs i l t i t :a "
ntvnlztr , l ls i l t r rztr ' Anosrni : l is l 'c I io l i , t l r r .p i l t l i i ,
" , , , i i , , '1, ' , r , , , r ' l r r r r r i b i r tc 4in4 bol i ra ' r t r l t r i s i l r r t i roa's. i l rnt t t t i i t ' t r ' As1' l i '1,
r|| r,r, l ,r , , l , ' r 1' r |z ir rl r i Rl lt,r lt l nazo-lacrirnnl (pl ' in stimultrtn' tr igtrtntlt l tt l tt i .t kr
, l t r , , r r l , , l i r r l : , i l i t t r r r i r i ) , lur lecrnoa,,stc rnirosul , t lcry i l i icr i t t t I r r t 'a ' lk l i t i
l . r l r ' ' l i r r r l { . t r l r i ( , , \ r 'soni q i co1ab., :11)77)
lttttt t ' lr l)t t)11'!)o cura intereseazd' ratl iali i le ^olf
ud'i ' tr(t. .8tt '11' txtrlttrttt ' l
l t r r r r r , r r r , r : r rc l l t l i le, t raurnat isme oi ; t l ' ) nu -s in l .
inso{ ' i to nirr tot l r r ' l ' r i
,,,,,, ,1,, ' t
irr crtzurile de kviuni l l i l l , t 'cI i l lo, hlttttttrtrtt- trxplitr lt ' l t i l
, ,,, , ,,, ,, , j i i lol intracu eblale (Alscni qi coli l 'b', l1)?7) Itt .rtstt
, , i , , , r , , , ' , r r r l r ( r r , , l l l ro i iv t r q i , dc urul1,c r l r i , lcnomcnc do,t l l ! { l }ozio i l I l t i r l )
" l l l t t \ r , , r r r . r lo l r lb. , 1977) '
l, l l . l l l l , 'r ' t l"rrri (or'o$tercil, clplcit ir,{ i i oll l 'ctivc) sc i 'r.t l ' i l lrclkr t l |sltt l
t l t , r . i r , , , t , i l r r t r i l . r r i r r in i i te la subcr,1. 2.1.2. ' c1-oxc. .p[ ; i i t ' i t ' f rxr f i t t t t i l ' t
i l " r f , r ' , , , " , r , , . ' , , l , , r r l rozr ' ) . Hiperosmi l porr . ' s i . rc l l iz t 'zr ' . r r l r { { ' t i r ' [or ' r r r i l
; ' , f r ' r " l l l , l ,1, , , t , , t r , , ' . r i " t . lodi t ) t i " ,
r r r ( ' so i l lL i l l rc: l { ' l l l l l ( ' l l l i rs l . l l l ( l '
I ' t i , , , , , , , , , , . , r 1, , l Nrt | i l r i i ' in 'cursul l1rsS,tur i lor gravi t l i tx l , l ' l t rovtr4}t ' { i
a i t , , , , , ' , , t , ' l r \ r1r . . r I r I t r t | | : | I i . Al t ( 'u1i , l l ipet 'ost r t i i t ' s i ' prrr t l . l lsr)c i : t ' c l l l l l l
i , ' , , iu,r ' , ,1, , r r r . r r . ; r l r . 1\ i ( . r r l i .n,nlcuu rJo hipr.rr . r t i t r l r i l i l r t ic l r ig( ' l r r i r r r rJ i r l r
l l l I l t l t I l \ | t t . , , r rcrr , l l l?I i ) .
l l l r r l rUr l r . t r r , l I i i r r l ihr i t r : q i i r r urrelc cazur i do opi l ( , ,psio, l t t t t l to lo
| | | | | | | | , , , | | , , I , , , , r : r | | ; , , , r , t l . l ) t : r l r . , i r r I i rzr . l t ' dt . t l tbrLl . : l l ' l l l l t , r lu l l l l ) l i ( r ' l { '
i , tntu, , , , l r r l r r , r l r . , i r l isrrr , i r r p iu, , l iz i . grrolal l l , in-mig-urto ry i i t r un. l t r s l i t ' r i
i i i r , i l i " , , \ i , , r ' r r r r i , , , t r r i r . , i1)7?; l \ l i lorycscu, 1$75; l l ' isot ' ' 1{)52) '
l f I l , I 'r| |.orrrri i lr. r irrl, r l isosrnii 0i|-0 cuttstittt lu irt l,erplotit,t lr it, i lrrttt l t, l ,r '1,
t l l l r l r l l r , l l l l l l ' l
I l t , t t r I r r r | ' r t r { r ' l l ' t l r r r tp l t l i l i l l r l r l r l ' r l f l r t i i l { ) l r t i t r t l i lu l r ' v i t r i : l l r i l t r ' l t r t ' i l -
l t l r r r l r , t ' r l , l , r ' , ' r , , , ' t ' r , t ' i l i l i i 1 i t ' r r r r lcs l r ' r ' l i r r l : t togt ' t l i l r : ; i topt tgt ' l r l i txr ;
, t t I I l ' r t t t t tnt i i l r lnttr t l t , nt d,otul ' t t ' f l I rur t imTtl i i t t ' nt ' i t t t t trr i ' l , l t ' :
l ) ' , , r r r | / r f t t l t ' t l i t \ ' : gt ' r rv i t l i l : t ' lc .
) l l l l , , l t t t t t t t t t t , l t : t ih i t "
l l ( rv lou( ' ; l )s i l lo ' ( \ ; s l i l r i r l t l l t t r t t t t r t t l t ' j 1
l l l r , , . 1, r r r t l l l t r r ' 1 i I t r l t I t | i i .
l l l r t , ' t t t tu l u ln iu i t t l t i t ' i i r rnot ' t t tu l iutut t : t t l r : ( I r t r I i 1 r i t i t t i i , l l l !1rr l ' l l l l ' i \
t l r ' I r , l r ; t r l r r r t t l l l l t " ) .
l \ lr r l l r | ,
' i
t l t t r r l ' , '
rk'.jrr, trilltcratil. S-a ardtat astlet lerseni qi "biffi,
is?ej;;, degi ant;:, i ' :1:] l i i i : .1:i l . :"T-1-q'iol ippr in rireningiormer;.1;,rul; i i i tactiv, inz|'r(.rx|||lrlvu,)r'it,cerStii dcville sesizabili, doar atunCi cind este bilatr
i i i r " , '
, i ' r , ' r ' r ' r l : r l , ' t r t l srr , lL bi latcralo, st l l l t t l l tc t l t ) r ) 's1 ' l [ i ' i r t l r t l t t ' t t t l i t t t i -
i , " , , , , i i r1 lsr i
l t
,,,,,,,!,:,1,,,0;o;,fl{tffi ?lffi&:"\':2i1.-peroeperea.unorcu.rodsubirf : j;iffii{{Z#:d. jr":"_d,p';ffinn"T,il'H:ABffi ji:"U/fr :Iii-,:1fi .i$";"f;*r*" "-;*t':#*::l[it:,"ffJ,",S"JT,,?il,*.f*j
xlhr, l tv lxrrr l ,o l . i inkrorr i i r l l t r orulr t r l r r t ' izoi t t t t t : int l l , t r t l r r t t l , t t l l t t t r r l r t r
tx r ' r l r r l r r . .n{ ' " r r ry l , i int ' t i orr l r r i ( r l , i t r r i t lot l0pt ' t rx iu, t lot t , t tx i t r l , t t , l ,osl t , t tdot tufor io,11" Lr. ' , I r | . r r r I r r r , r ) , ot , r { r $rr pol , l r rso{ i ry i r lo s int l t totno r l i r t st t r r l l otr l i t r 9 i , , r r , l i -l t lFltrrt." (rr,tt l ,otrtrt, l, ixtrto (lo lt l t,Bl' i tr l l t i t!, r lo slt l iv:r,t ' io, sit lt l t l ,t l ttttt viutlrtrtt-q*rtrl l lr i ' r,r i/Hir,tt v iscrrt 'o- tnol,ori i) ( I 'rr ssotttt, l It i , 1.002; l 'olxlvioit t i i collr,b.,l t t l r t l , l r lo i r r r lxrhr, t rL x i i r r r { , inrr t t t c i l , i t t uprt tx i lntd; iv f ioJ[ t l in c1[r l t t i o{ is l i l tr r *nn. i , . r , ' r l r r I r r r I t rc i tur , t , i i r t l taol , ivrr r1 i gt tsLl t l ; ivc ( [ ' r tssou:rr t t , 11102), r l l t i lntr loli i lr l , r l,, r r r r r , r r r r r r r r r r r, , r l tullgt'ott, lt i lo, txrhr ttt luitr t; ipuri t lo ttxprcsii oti l ; ico strn-rrrr t , r l r ; r . t r r r r r l Hr i sr . rur t t t l l l t i ,ozo i t t oxprcsi l l lor (Pr lpovirr i t t q i l l l tsrr t t ' 19t10)-rtd rrrr rrrl.rrrr, rl( l rslrrI{rn{l l, r i1, ,, l i l lsl" porcopfio ol{l lcl, ivir, polr, lo I ' i i trso{,i l l i ' ,
l r , , ,1 ,1, , r r r r r r u|rrr : r l , : i ; i r lo:r , l to t ipt t t i r lo rn:r ,n i l i t lg hr l ' r ' i psi l t t t -s l lnzot ' i i t l t r l l r rl t l r I r , I r r ' r r r : r Ior ( r izrr : r1. , : lur l i t , ivc, Lr , t r i r in l , ico, sonrcstozico). I ln0l t r r ' t izrrrr l i , r , l r r , , p,r l . r r : i , l i r r i r rso{r i to t lo , ,st tnzrr t ; i i " soxt t l lo, rnolgi txI p in l l , l l r o. l r r i -! r l r t ' , r i r l i i ( r \ . j t t t i r rgt t t tut l f i l t la,nc, l l )Gl . ) . I ' l tssouant ( l9t i2) N, PI ' { { i iz i r l ,r l r r r r , l r l ' r i r r r r r r r r r |osi | l l to i l , r t i rn i tosl , r i l i lo l c l in im l l t r , ,c l iz t l i t l l f l tc l ; ivrr" :l , rh,r l , r , , 1r(r ' o l l r tc l , iv i , (h i l l t tc int ' t i r t ' o l ! r r r r l , iv i i ) L,st l rntr t lo v is" sr l , t t t l r ,r11,1 ' r , , , r r , r l rzr , r r . . S rr , l rv l t t tsnt ipol ; tzr t , ct i t t , t t l t o l f : r ,c l ; iv i i t lo Ll t l t r l t t t l , t t l
| t r . t ' r ' ' r r r r ' ' r r l l r l ,o l r r l i i decl i lnql l t i l t l0, , t i l lencofalul o l fa,c l ; iv t ' , t l l l r t t ( rs l ' t r
l , l " ' . , , ' lL '1. r l l r ror ' l , r rxrr l propir i fonn (utrcus), c l , ro t :sto l t rg l t t . l t r Ict l t r l t l ;or i i
t r , r t l ' r t , r ; ' r r r r l r r r l l r r r l o l l r r , r . lb iv ( .1[rrc l ]crrn l i ool&l) . r 1952; ( i loorr l l l ( i l ;I q ' , , , , rnr i , t l t t ; : ; . l r r Hchirnl) , rn*r l i f ( )st i , t ' i lc corr t l t loxtr psihosorrzor i r r | ( i s( \rlr,, l ,rrr, r ' 'r ,rrlrrlr i, ( ' l l propa,garotl d tlscii lcir,r ' i i l i l ,,t inontlol ' l l l t t l nttoll l ttr l, iv"| | r | ; r , l , r , r I r r , , r r r t toprozint i i un vor i t i lb i l , ,c l 'o ior t iutr t tcof l i r l " , t rotrs l i l ' t t i i ;r l l t t r r r r , ' r l r r r l r r l , r rs (c l r pa,r tc reccptor ic) [ i ( l i r I ct t r l l l r ] lu i Atntr ton (c l l l l l t r i 'or- l r { ,1"r l ' I
t , r r r r l r l . r r l ; r l r . r r , sorr t io logic l a t t l izoLtr t t t t t t in l t t t , rosputt , iv i t t l t ic l t to l r ,t t | , I i I I | | , , | , | | | I | , | ( r ' i l , i(x) ?sihosenzoril l lc cu forttttnonul de
"{l l(rarny sli i l lo",
r . r r r r , r r r , r | ' : | | | r , I r l In i ( ) i i , , , i l t rocutului t ' , c t t rca,c l i i lo t t rno! , io l t t t ' lo ry i t l t r i , r r Il r l r , r r l l , ; , , r r , ' i r r l icc i r lo , ,oonf l t i iDl ,o i t t eului , st t pot infc lego fol t . t , t r l r i l t r rrlHi.it l lrrr 'nr r.rrt ir, ( lo contploxitatell func{ii lor dtl intcgt':rrt l alc ,,t irtt l tttrtrl i tI r r l l l r r , , ' | | ' r , I r r ' ' , r lsprr t r l iv t lc ro lu l jucir , l ; r lo I t ipoc: l r r t1 l i Iorrni l ( i t t I t i l t tr r r rr 'r l, i rrr:rr rr r, irrirnrv{tlnti i l irnbicc in exprcsia tnto{ion:l l i i , [ i lr l rrtt lo(l{}l r l t r r r" r r r r . I r r r r I r r r r r . IoI r l r r t t tomot ie, in 1ix: l rca, t la l t lot rnntrz i r l t r , in rrrgl l t -
t!,{ nlr|| t l i ,r ' lr, v(.glro ri i t l t: somn, procurn Di in lcgl:r,rcJ' viscorall qi soxuali l,
l l 'or ' , r ' r r , , r ' t , t l r r ; ' - t i ( l l ' ) " r ' , l06l ; Orr ,d i l l t to r) i colrb. , 1962; St 'gcr qi col i l l t . ,l l t l t t 1 1, ,1 ' , ' r r l i r r r i i crr l r r , l l . , 1{)?8).
' I tt ,l t't it! r lltilc\tl,ioa ilttzi,on,ulc oL.Jacti'Da Bn clr.N,cl,e rizoll'zi' prin
l+ ' r r , , ,11, r , l l r r r ' l rvrr : r l l r rnt t t . Ui l t t l s t tgertr i tzt l , o t l t l t t t l i i rcal t t nt lu loni l l f i , N, ( l ( , t ' '
l r l r l r r t , r l l r r , l r r rpr . r ' i f ic n l r t t t l in vtrr in i i ' tat t , puf , lnd taco parto di t l <r t izr t ,
l l f l , l l ' r l , l ( l l r r t r t r r t l l , l (17i3)-tt | ' , I ttt ir ' lr tpiloptice o$actitse ,,telf lcna" ((lnstl lut, 19?ii) sinl, orizrr
xfl l |r1ltr r, rIr.r ' Irrrrrlr|,rr ytt itt rt ' l t l i t l lrotl urrui 8t' irnul rl l l tctiv, t jrsp(to1,iv 1tl ' in't ; f r f r r , r . r l r ' r r l , ; r l r r r r rcouxci r t i lz l lkr . Actrst t t o l izo Blnl ; r txtrorn t lo r lo(Mot l is ,l l l l l I | ' , , I r ' r ' i l r r t r i i rxr l r r l r , , l l )70; Sctv i l ry l ur l l t l t . , 1002i St 'o iu l r l9( i lJ
Fl th l l , l r , , \ r r r r . r r r 11i (xr l l l , l ) . , l l )Tu).
' I ft h Ntrr,lrtn'ul hnl'u,oirtuhr oronio ,y' la n,l,r ibtt l i a't (,,r1o inflttcrrl 'r i '"rqr l , r l , ' r ( ( l r r r \ " ) ( l t isr ' , r , l { } l i9) sr c: t t ' l t r l l t t r iz t r t lz ; I pr i t t l ' r -o gl , l l ro t lo l i t ' i r t r l ' i i
l l . t l t , r l t , r i , , r . r ' r l l r , i l ( ,nr1r l , ior1, r 's l0 r 'on s l , i l t t i l , r l r l i | l o l t r r r t r rnf i r l t i l l t to i t t i t l 'o t ' i ir r l l ! i r , l l r r , l r r l r , r ' r ' r ' i l i r ' , r r ,xplr i iv i t t r t ' [ i t , t : t ' r 'p i ro l t t l t rLr l l t l l l t t t : i t l i lkrr i i , l to l t t t lv i i
l r l t ,ut l l r ' ; t l r r r r , r l r r l r r r i lo$| l t i lo, l t t t t t tx l ; t r t t r : i r 1 i t r t t l t to l i t r t t lozi l t t , lo, { l l l l l l ( { ' l ( ' t l
I t t l t l l r r r r r r l r , r r r l lot , , rx l ' i l " t1 i t l r ' , , ; r . tgt , r r t t I i t r " .
ll.l.5. Ilalucinaliile ;i iluziile olfaetive paroxistiee
r 'Iptrrlt{\ o(lol:trl l , j i ln oursul
rr.r',', J;1;''.f iii';,?':gi.uJ,"'1,.y:ioz sint rorme de crize e1r'eprico;rli;irt'ii:;rl#i:i,:ix:fri:ijir:::{b1.r$'",'.r'-;;:T,'3i,:, t i,,., r r t r.' r i : e u(a.t i o e, t r *i"i "G'td i "# i,i,, r-r'r:" :i .f"ii iiH,f r:;:..::ll:i"',.' j, ;i r.otab., . t9Z6). Reprezinrd. rezulta[ui
'uiJr-. ior"a"",i"ii r ' | | : r t r . : r t ( . r , ( , t l , .xului r rnr . inat (cr ize uncinate),
,.. ...,:,.!:.!!:,! . lriret,c. u,nainate ,,:::! Wr!ir|. Crizele epilepuce care de' i tzi l lrntt lx.l.(,(,p{,j in unor mjsrrrrrdrrr ' : , rr / i r , , ,rr ' i { ,r( [ , i J"-" j :" ' i l ' . j?tS^fl*: l l fot slrt iare tz- r loTo
;: ;, lili* r i iiii : niis rllTf;,], {l{,!,'ff ' }::: i]ji, :l $::fl i:,r;l:{t'.' r l )$ r,: r r r {,r,,,'gimioi r-i.". -a" p"[,"g;,Jfi .;i:;h#","r",ryHr ;tlli: I i : :i,'i' (,lll;, :J': i i :ll,'#i; "ff:T,'* ::,- f + ;*; ;ilffi 'sT, rura r "t c. 1Il:i'iil' ,11i;il;ti,i.'i;i''I:;.fff; #.it;;'";il:';;'ffi"f,1,",iii'161i,[ii;)r:l:lil,'lli:,,11:;l';:ii-':;ilil;,'i"'t#iT[ll1'"u0"",i11Y,;m:.yffil"il ru:i l lr ji tl;i t i l * i ti,s'#, :1,i tili ibili: rgiliid qil fl',,i?.fl "iT #,#
14I I t
l6 l ' t
,,,,',,i;;;l'rli;ll$;rlt' rliavrrostie rdinic' lopogruric si .tiopatogenic
'11llll{ffiJi,Jcaititlii uizuote se pot exprima in urmatoarete
l l l .4 nbl iopio lepl .czjntd t l imjnuarer acui t r i l i i v izur le.ll\ Cecitalea silsiu amauroza reDrezintd, nicrrl,,roo rnnoti .,,,,'',,iJrv'ffi "i'#trXl:::iu^K:T:##,ffi:-ii"$:iilrTi,l":?Xr*,Jlrilatoal[ (6i in accepliuneia, c*orect Eiinli*iX,-piiiiizt;ne' ce.nt.",ui?: {?::;,;,i:!:,"'i##ii tlllLLi,'#'ii?'ifdi""lffi "'f """11?Y1D) Ilemerabpia reprezinti iliminualea acuitelii
"irort"
..io *,l.l spl:c Seara.
r: I l'lr!{,?i'[]i,'i1iii."1iL,slf "':?n
#,l:'tiH" i' _lTi,$"",i,",1]jlj,,lltu'l]:l;.,o:11 j:311", llry:fant se se Lci' oiieiene#iea tap ae.,,.itri1i, {ininel seama indeos?binc .rmai.oarete-;i.;l,iii, iiJpiltir",ir.rrul al fundului de ochi gi pi,strarea r"tf"iofui p'r!i"ar la tuminri.... l') !):l!r"*,atoysja _peytyy alb negru fi tentru iulori reprezintri
:l:,1l,,,1o'1'"]T3"jlrlt-,*:.ll?1 in-considerare,'inirucit aceasia poare sd, lcr,rr,rli o scrio de lezinni ale chiasmei "pti"b $
"in "ail'*i ! .2.1.1. Amblioni i le si , am.turncplo n.alra <; a,, t ,- . . , ]- *^:!./,,.1.1. Amb_Iiop.iile ;i, amaurozele acute si sul.tacute se iatilnesc inrors(| ir1(:(i1i1tni, de diverse etiotogii qi cu vdriate tocatizXri pe clitc:.4.2.l.l.1. AJecJiunile in lamatorii ale nerl)I.tlui, wtic:!.:4. l. /. l. l. Perinct:ritele, optice (nearitele
rr.lrlczirrii i o irrIllLrnl.r,t,io Drim:rri, a, tecilor nprlrlrr olrir,ci, r,xtcrrsici rrlui pr.oces inflamatrol Ae fa'r"eilinld"'Ja" .i" fa:ii]'ll:1,',;.1":i:,1^'j;'l:1.'.",':'si:l_::t11i.obi$nuilisinttacteitiepiugenc (r l r r r r ru l l , r r or , i , r lc i r i l l lr l r \ u l t l l , r or , i , r lc i t i l l l i i , in nrcl ingi talou;r 1 i l r r lsrr l ( l ) r rkc l l ) ldcr f i Sco-t t .
n|lrngrl a-SUpUrJl ivi cprr.bro_spin alri t, isr scnl t . l97l) . Eslc vorba de
-di fuziuni(|i.| Jr ||l|st. (t,ut({r lrjl(lcr li Scott, 19?1). Este vorba de ainzltfilrrl rr;rtir' :r|. rrrrr rr' .rr cningite bazaie bacierie.ne 1inc1u-sii iaclarcl.l:1,',','f,':1,1
i'.1,):.,.'.',ii,'flll lil)..1::ll::t sau ale, altor p"occs" 'rniiai,ato"ti
1:: ' l : ; :1,r, I l l
, i l : ] : l : r l : l i j :_"1,"T: sinuzjie sfenoidar" ; r.r. i , 'alarc, sej l ;:1,:1: l] l, i::,..1:l lr, r 't inicc: perinevrita "pii.a "".i iaJii"#c;ilr;I, ,1r l r l r i prr r . r r l l t t l l '1 , .
|)iIr11rrosl,icrrJ trsto orientat de: contextul general
pollrurli . r"rre cx_plic:i ambliopia * $i cu la*traiua -irn"eor,
*rcrrllrr,|r,). lrr cu,zlrl dispari,tiei qi a vecleiii centiale se lnsiJeaza o
2,! . l ' l1I) lnXl lA l , l , )Rlr i ( ] l l r r t r - l (Nl i l lvUt, ot ,1, l0) r r rvcl l t l r lc i t r l l r r t l i r , v i rsrrhrt r r , l t t t i t ' t t r , i t t t tc l t ' , I i t t l l , l i t r ' I t i l t l l t I t I l , l r l r l i ( ' i l r l i ' l ll r r . r r r lu , i r r f i t r r l ronrt t l lxx l t l io lmrtr l r l , ro l r t t l l r i r t ' ( t t r r l i l i t o; t i ' i l r i ' t ' r ' l ro l r t t l l t l t l ' I ) .
AJ I \p i l i tu. (s i t t r l tot t t r t l t r t l t r iu j r t , r t lohrt lhar suu sindront.r t l . dr po.Tt i lon, tt i l i tt l ,t1||, i0/ousti, (r 'ttt. lr i nu.rt sulnrc'u,l i) ( l l intrr, l115!; l\ ' l l t trolcxrrtt, l l)f i l{1
1u,:rlrr f i t.ttr i l i t t,tuirl?i Hilu l) i l l lrfr ' l l l t si rrrri l izclt zi ' t, tta,t"r lrt lbtrrt it"i, l l t i lr lrzitrr r r l " i t r l lurr tator i j < le tu,vt i l l , in1 t , r 's1, i f ia l1 ' i t tx l l rhul l r l r r ' l i , : r t ) Arr t t i l i t l t ' i rr r : r r r r r l i i sr :ade totdoaruta lapi t l , l t l l ta l , in c i l ,cva z i l t : , ut t i la i . t ' l r t l , s l t t l l r i l l tl .r;r l (cga,l sau jnegal), pini lr o drarnntici arntntrozil; l l) ( l irrrprrl vizrrrrl, r ir. r lrr oll icei ingustat concentric, dar uncori t loar sectolial 1si trtt st tt lnltttt, 'l , lr irrt ccntlalc), vedelea macular'[ l i ind mai rcspectati,; o) i l i tttIt l l rrtrrrrr:rl ic cste foarte a terat (cu moclif icS,ri ale cir,rpuli lor ct'ttmlft ir,tr, l l tt st,,rl,, irrr{f pontru culori, cu discromatopsii qi chiar acronli ltopsitr I 'olrt l i);, lr \r lrrptarea la intuneric este loarte deficitari I e) Adcscn lo1'oltsii '1i t l tr, rr l l rrt i lci,r i le globilor cculari I f) Pronunlat edern pa,pila'r, prrpilrr, I i i ttr l
r,,.rr,,, lrrlblre, tumefiat5, cu conturuli foarte qtelse, cu sll ' i i ( r 1 | I ' I I I i t ' I t l i | | r { ',,.rrrl, i i-rozate. Manifesti,r i le edematoase peripapilt l le se itrt ' i t tt l l trr zott,,r;rri rrLr cimpului oftalmoscopic, r 'ealizind aspectul rlc ,,ntrlttorrrt irt i lr i ,".
' , , r r r1 i r rJ lc papi le i devenind, in accstc s i tual i i , inviz ib i lc ( l l isrr t , l1) l ' : l ;\1. n() l ( 's( iu, 1958; Duke Eldel $ i Sco1,t , 19?1) ; g) Yelele ; i t , I I I t i I I t t r ' I t ' s t t r lt , r . r r i r . r l ihtate qi s inuoase, arterele s lnt inecate in et lcmul l t t r ts i r '1 l t ) l t r, i l ,,:rr '( ' l( i papilare $i pedpapilale se obscrr' 'X hemoragii si ctsttt lrt l t ' , r ' l 'r ' t t
t l , , l i rs l lccte de trombozd vel t la,s: i cu zone vaste t lc t ' t l t r t t t l l t ' t t t t i I r r I l i l t t t
l r r r r r l : rcr .stor leziuni ; i ) Coafe,ctarea vi t rosul t i se po: l l ,o r(r l r l izr l i l r l ) r r l t i l i l , r 'lrr, lr l i i (,\,[anolescu, 1958) ; j) fn forma de ner-r' i1,L opticil trt lt ' t ttrt lortsri rt ltt l ;rr r l r : r l r rnrr . l icular i descr is i i dc Rcnard (c i tat t le Riscr ' , . t95!) , ' , i r rc l l r r l n l r l i r r
; , r i r r r r l i o rnasiv i , tumcf ic lc, cu i lspect t1c , ,nrLcir tc i i ' " lN' i t t l t ' r t t l r t ctr t l r rr I rLri,rr ' i l canalului op1,ic.
lrr lrr!r unui tablou dc papil it[ trebuio sii plecizitrrl . lut, lrtt i i r l io1ul,,, , / / r i r l ) r ' in invest iga.{ , i i s is iematr icc qi rn inul ioase: a.) in lcc( i i kx,r tL ' r r l t t l . r t r :r r r , l , r i , i l l i te, coroidi t€, p l i ig i perforate infcctate alc gl t t l r t t l t t i oct t i : r t ) ;l ') rrrrzii,o (anterioare, sfenoitialc qi ctmoitlale postcrirl lurr) I tr) rrl irr ' l i t trrrr r r I I : r r r r r r io l i i a le urechi i medi i ; t l ) focare dentare I c) ostoi t t r I l ) r r , l r r i i " , r l r rtrl, ; r1) inlrc!,i i generale (scarlatinl, variol[, folrrl ' i , l i loirl i i , r l i l l 'r 'r ir ' , gli;rrr., , ,Lrr i r l i i -un, t i fos exantemat ic etc.) ; h) papi l i tc lL, l l1(r $ i l t l f i t l l ) i r ( l l l l ( , I t i , lr t ' : r r r , r r , ,5 j in scleroz: l in pl ic i i t l lusr ' lu ocul t t r ' , i tL l ix :n i l lgo-cl l (x l l l l i l ( :
r1 rrrltrr{i i virotice ncurot'ropc (o{tralmonculoln itr l i lr i i , lrollrt lrt i l)rrvirr;, r ' , r ' l r r lotnic- l i to demiel in izantc; I terpcs zoste: ' I crrcr ia l i l ,o; I t t t ' t t i I t I ' ; i ic r t r , t t l t ', i , , l iv | ' iso naiur i ) .
l i l N c1)ritct, apticd, refrahulhard &cltt i i ' :tan' stthur"uti i (t; lndnntttrl 7r'slt/ , , r / / s{ , <uracter izeaaX, i I r p l incipi l r , sPtr l t l t rosclr i t t r t l t l p iL l t ikr t l i , t ' r ' i l l t
l r r r i r l r r r lb:rr i l , pr in l ips: l sarr r I isc lef ia, morl i f ic i i , r i lo l t t ] t i rx l , ivc rr l l r t l t r t t rstrr t
l ' r ( | r r r i tchimb pr in prczonl ' l l i l ra l i lor l , t t lbut i i v izt t l tLr l t t t i t ' { iot I I thr .
I !txtrioristici cl inil : l t) l)cl)I i, l) l 'ujr(f, i tt c,i lcvu, ziL' trrrl izittt i tt t lr ' ,,, l l r . r , r ' r , r l l l rnat ic: i a tcr t i1t i f i i v izr t l t l t r , p i r r i i ' l : l c t ' t t i l r t ' l r t r ( t t t t t r t t t t l tz i i ) t rot t t
1,1 l : i , c l r i l r l c t t r l isprtr i { , i i r , ptr t copl i t r i I t l tn i l t l t i t .s t ' ; l r ) i l t r i t r l r r t ' r ' l r l t r r t t i l i r { i rr r i r r : r l , r c i i { , r pt 'ouxl t t , l i i , s i t r t i r rsr l { , i1 i i t l i r l t lg i i or l r i l t l r t r s l t l t l t r , t iot ' l t i l i r , t r ' , r 'sr tr , r ' l r r l ( 's l l , l r t l t ' t , l l r tq l l l r i lo l t l r t i r i i l i lo gk r i lo l t t ( l t l l l l r i ; r i ) iJ(rai( l ' l l ( ' r r ' v1\ l r ' r i l. iL l r l i , r , r I l . i { ( i i l r f i t t r t r t t i l icolot t t t tct t l t ' i l l t , t t r r t t i t l i t r t t , t ls i t t t l i , t t t t l r l t i 31r;1l t t t l ,| |Jr ' l ro,r l ( f : r l ]o l r r r r i i t r l r r ' { r , int l l t t l v izt t l l l ( l t ' t t t t t t t t ' t t t lc , , t t I l ' t i l l ' i t t l t r r l l t r ll r r r r r : r r i r r ! r ' i ) ' l ) l t | i r ' | , lLI l l iL i i ' ' r :o l i , l l )71). l l t rcrr l i t i t r t I Iot t t t r I I ' ( ' I t | | i r | ( r l l ( \, l r , : r r . l r r . r r i r r l r r r t l l t , i ; r l ) 1 ' t r crrzt t t i l r . Fi i t r ' r1, , ( t l : r I r , r ' I I t t r , : r i t t l t l ,gt t l t t i t t t , t t
l , , l ( v l i l i i | | i r t I r i | r , I i . i i ' ' l \ ' l t t t r t t l t s t ' t t , l l t l ' l " i ) , $( ' i l t l l l t l l l rz l i ( ) i l l r l i l l l l ! )z l l lo l l l
inSI
, r . r r t r ' : rL.)- l r r r , rz,r l r i i rprr i l i " i t i - ; - ; .d. ; i i:lllj,,.ll.',11:1, f,ln ;i consecin{d a-eclematui pupitr" ;"riuiloio" q,
"( ' l ' l l r ' { . I i t l ) j ' Jo.
,1.,,,ir1.,1i,!.1.,,fl"'l:.it'i, "fiff, J"i,*" -l'iTl,:*gx,"ll,';ji,:l*$"1..r'rr.1; rl. neyritc optice) iealizeaa:i.tabtorii "ti"i""-,iitrirJ"f"Si."li:::f:.lll,f13"ll: t1e scciiuJ afecrdrii
".r-""l"i ;t;;;'fr il.i,", I""".*. *,:.:i." .rr|r vu,ur up0rc : pc pl.rma por. i r r r l : l l r r r l l rarJ, c l . re cupr inde ptpi la
" i n( . r .1 ul opi i (1 l r i r r ; i I : r 'zuua r tc il vllsclor centratc atc t"ctrncr in lcrv (10_.LZ mln), realizindri-so siudNrrl(,Jiol', i*xt,abuJbar, p4lil ita sau sinrlrol.ul dri lrilpil. _ rr.vrilr;.i, .domzI.rrs i i , i rcrr1, l ' l ' srru srr l l i r i l t r f i i ; i l ' ( r ) r : r lx)r{rr t , r ' , r . r r .o l r r r l r r : ' i i , i r r l , i t rsr , i r l r r I
a ved
l l l
)
l) l . l f l ,, l l r ' ' I ' l ,,, l . irrol 'L,\ ir! l) 'J)i l l t, l .r i ryi rnit l. irr,zrl (rr.v.l l ,, r.rrl,r ' l 'r l l lnritr
l l , , j : l ]1l , ," ,11:: l : l l l .1:. f i i . ," :1t, , ; t l r i ;r1;, , ,1'r ,", , ' ' ,Li i i , , i , , l i ' i , r i i ' , ' r , , ,r , i r , ,r .rmrnorr.r'rrrrliL,r.rrllr un.',,,.,,,r,i,, ri,",i,],iiuir,',1*i'iil i;ifi ' i,,i;;;',;,i;i;lll ir",l"'T.llllrt,rLt,ir . rl{'(x)lor.itr. Dlpih'1.1,, rtr. obicei t"mporatit, it,i i.,,,;;;i ' ,;;,,,,,.,,, rrn riisnrafslrLl.rr o | | { ' { . ( | | | ) | .r I r .r . prr lr ih l i1,_ (lr. ,,fr icci f 'enrpo.a t, i. r t ' i rr, l l ir,ro nn rl iscrot,j1lf,;' rt,'t,it,,. (tt.s.'-ryi .Ashrvorrh, rsos,'oit*U'd;"ijor.," iir,r"" gi Scott,I n71).
ht l , , t r t " ' l ' r , r r r r . r r l i r r r r r ' , ( r ( . r r r \ \ r I i r r , ,1rr i . r ' ; . ) l t r r . t t t rx ' : r r t : r t t . i r r , t t r , t t r tI t r l t * ' . , . r 1,rr , . . \ t f i l i t ,
' r r r r r i . r iv r \1. ' t l | r , r . i l , i t l r i l : l r , v.r r r r r l i l l r i , l r l l r l i r r i r r ,
' . tkr , l t r r l , , , r t r r r t , . I r i . r r r . r ' ; r ; : i i , r i . l ) ( ) l , . t t . l l r l i l . i . r r l l , i i ( i r l r r r l i ; rgtr ,s i , i . r i i l i r ' r , l r
l lBt ' r ' l ' , r l ' r t r t . r , . i r l l l , t ' i i i r r r r r l l , . r t . i l i t r l ' r r l r . l r \ ,1,( i ( ,1,(r i l .Ht , r , l l , ' i tv
l l l r t ' , t r ; t , ; r , ' r l r I t r l : r t ' r l r i r ' : t t l r l r l i t rgrr0sl l r , , ( i r r i t r r l sr . r r r t l t r { lo t , t t l i , ln) l t r r ,L,pl l t . l l l
. ' l , l ' r r l r r l : r r r r I r I roIr i r . i r . t l r r r r ; r i l l r , t rs, l r r i i l . r r r l l ,z : r v l , ' { \ t {x, l ' t , i t l t . : l
t t r l r r . r r r , I r r r r | . r l , r l r l r . , r . | l r ' r | |u l r r f l i r i l l r l Is lo l i rar , l ,0 r , r l , i r rs, . l , r , r r r ,Lr s i l r l l ru l l
Sl l . l l : , l , : ,1, , r . ' , l r , . r r r , , r ' i rAi i l , , i l in i , . l l l l { l r , r ) i tsrr ; r i I i l r r , l , r r r ix l , i r rsrr pr , i r r i l .g
l l l l t l ' r l r , l r r r , r , , l r r r i r l : r 1x.r ' r l i , r ' i r , , r l . l r l r r 'u.rr l v. t r .Lrr , ( . r r . l r r , r r r r r i t , , i r r l r iFl i t l , l | | t ' ' t '
r l r l r ' )
;;i^1xrs.to|io.rl c) ; .e) Oftalinoneu"rpj:llte ft;;i;'t"ib;;;;; ty no".:]ll,l Ii:l.l-,1 virotic(. (ruieotd, parolirtild
"piau-i.;, or.ioiil'ur,c"ira"e\':tlrorr.it,, zonil zoster, variceld,l--bacteriene (diverse), riclettsiene qi
t,rr,l(.,,,{' irr(. (in special mataria, ' irip,a,no^*]r;r- qi;;Aiii i loza) ; s)
'l 'rr lrlrlrrikt clinice descrise anterior (vezi 2.2.1,.1.1.) pot fi rcalizatet lc t l l i . lu,ckr i :
;; ' i,r, ' n(i r j n {,ir,r ( ji lzar o "Ireyrltra"
retrobulbar6r cu scotom initial centrL,l,rrlrrrrrIri_rlrr o rrl,rnfio optic:fi progresivi, cu intens?i, "*ouor"u
a papileir;l:,1,:l'; 'lii],,i,jl:.1.,,,:11,1.s11""^o-3joas';,^{sf,annon, t$2; Eiiazzoni, i6[f :l i l , r r { i . r l r r l )1 l rq- l ! | lcr f i Scott , 19?i) .. -.
N tu.r.oltutitr. o1tt.icd, chininicd apare in urma ingerilii cle dozo mari(ci l.v;r grrrrrrc).rltr chirrinii (in scop teiap_eltic sau abofiFj qi p"oauce amaul|r'r| iiir, :r,rrblir4rii, irrsolite ;i de suiclitate, re_marcatd OulA ieqirea tiin.trr,(';t rrr'r,l,oirHli, rlo citeva 're,
Examenul oftalmologic arald, ciieva elo.rrnrrtr. rliti,r'rrrrl,irr,lo.tu,ff de alte nouropatii toxicu , asiecf isclemic aI re-lllll ' ' l i ' ', r^r,r.l,rrr.o ,Iiliforme,. cu paloare a F.O.; TACR ̂ este mult crescut[.
l t t I t l tn l t t l t tnt t l t t io l t n l l t l t t t r ru lu i oJrt i r j l \ r l , rur l iz i r , ct lctr ro ; r
l , l l , , l 1, , , 1,r1 ' r t . r r , , . r1, . r r l r i . r . i , , . , , , . i i ( l , .11. i r in i . t l i r r t i , , , , . , r , i t , i1 i i u i i , , , , i , .
l l | ' r r l , | | | l r ' , l l l t ;O).
I r . r l rnr i lo i r rd i rc<r l t : rk, r rerrulrr i op( ic i l r Lratr ura I isrn r l t .r.t u rrio-rrrtbrrtle inehis0
I r ' ' r r r r r r r ' I r r r r r r r r : r r i r r r r iadi l r* i r ' ( r r . r*rv (u)r i ( . st ' i r t t i r r t t rga i t t r , r . ' 1r t .I t { t . l t '
,1, | , " , , r l r r r l r r r r r r ' r l isrrrr . l r . r , r . l r r r i ' r , r , r i .b ' l rL, i r r .h i r i r , . l . )L.r l , . , ,1 i i , , , . ,l [h. l r , r , t t ' , t , r r r l r ' , I I 1 I j 1 I 1 I | ; 1 | ; ; ; 1 | t r s i r r r r r i I* .avarr in sr , ingi .
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\ | r r I I i I r r r I i I r r , I r tlc. .lucl,ori etiopatogenici ai nevritelor opticet'r1r'r, ri\ r. rr lirsi sisl,rrrrur,tiz:tbi, dc noi (Popoviciu $i Pasou, 1980),: r I r | | r I r | . r ' r | i rs( | s i r t r l i i s l r r , l is t icc, publ ict i lc indeosebi de Dukc- lJkler(r1r i r ) :
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l l l"ttt rt\ i i tt. l l tuutl.ar.i. Lor:ali ,1i ai B.i[.C. .. a) Uveitc si I 'etinite il r ) l r r t r r ' ( i i i r r l r , r r r r l l r i l r r r .c; c) , \ Ioningi te otonice ( indeosebi brc i lara gil r , l r i : r ) ; r l l \ r ' r r l r r ro i r l i i , r r oplo chi i isrna, l , ice (cu exten.sie antor ior l t i , cu rea-lrr:rr, r, lrr:rl r lr. r lvl i l( l . j rrx l, l , l iul lrtre ,si papil ito) ; e) Sinuzite antedoaJe fittr.ri,.r r,, r lr ' ; l) ' l '()\oplltsruozir,; g) Tubelculoza, f ic prin lropagare, directi/r lr. Lr ri lrrclrrl i lr vooirrc (proceso tbo intra-ocula,re, ir idociclite, osteite etc,),lr,. r lr ' lrr o rrrcrrirrgil, i i tbo bl,ztl i ,, {tretermlnii, ferromenc de ne.t-r ' i t i , gi rI0t)(.rrr,vr i l ;r oplicir,, clrirn dc pl.pil i td, (Sverdlick, 1964, citai de l)uke-Eklofrrr l l ,r i l , l !)7l). l i , l l ,r l\r l i l joitte dctermina un tuberculom Solitar masivpr, p;r.prl;r oplici i, crr roll iz:lreil urrui tablou de pseudogliom optic (cn sim-lrlr)nri , r ;r i i l rrrir i s{)v(lro c1t cit i ,uberculomrl se extinde ;i spre apexul, 'r ' l)r lru ); lr) Nlvli l :r, ol)1,ici: i sif i l i t icd de obicei provinc de la o meninEitfr r : r r r r r r r . r r i r r l l r l l r r r ' l r r l i l i luet ic i i l , in stadinl secundr sau tert iar a l luesuluj .' \r1,.r.rr rlr isl irrrL l: l lr i irttrrrcn, cr'ncomitenti, a neryilol ' oculomotoli, faciallr.r r.r, lr lco yr:rl i lrrrlrrl i . i l l tr lLnrii r. i l tr _ rl c r*cdere sint yaliabile, ,te h u$oir,l.[: r r r r | ' I r
, r I r i r , ;r irr ' i l t rrrrrir,unrzi 1oflt l i ,. f lalacl,eristice sin1, strimtorii,r. i le corrlcrLt l r l l r r l r l i r r r l r r r l r r i v iz l l l lL pcnttrr a lb f i lxrnt ru cr or i , precunr s i s0o.lorrr '1, ( ( . r l l i r l r , s i /s iu l l ) iu i l ro l ) l la lc. l ) i iLgnosl , icul se bNzcazi i , po dl i l ( ! l ri r I r : | | | r I r | , I i i i { r r , , prr , lcstr ' lc scroiogic( ' , lx) r i ro( l i l ic i i . t ' i . l ( ) r : l i r r 1r"( l . lL. (crr pkrr( r l ! rz i r I | |1 ( I ( ) r | | i I r I r r r i l i r r r l ixr i l r r | i i , , c t r pozi i . iv i i l r lo i i r t l r ( j i i i lor l l i . r i , r ' r r l i l |s) ,1rr . r r r r r r I i l i ( , i r l i I r r l r r tp i l t r r r , 1 i 1x. r rorr l i 'c l l t l r l t , . t r r , r ' r ' i I r I t ( , I I r r r i | r r i i r r rs t r r0 l r t i r rr r : r l r ; i ) l lorrr l l l r r I i I i I i l l r r I r . | |1 r ' \ r I I I r i r r l r l i { j s i r r l l i r r r r l r , r r r r i . , lor , : r l iz i t r r l r r srr
' ' t ! '.t. I
l ) .1 r ' r ' : r l iz ; r l rctrr i l rL 'g i ; r , r r l l | r ' r l i ' r i l l l io0-1r i | l t r r i r l r r , l i r , r l r . r r r , r r rL:r r l r , l l , l r r l , ,v i r| l t i . L l rn{ ' r l (11),1I t ) , i t ' r r l r r s | r rsOci i tz i , d j }un(1, r lc r | r l r , r . r , r , l i r r i<r , o hcrrrpllr irr rlrr I)Nr'1ol ol)lrsijr iJi o rrmaurozi:i, prin atrol jr i opii lr ' i , r lr. :r<,r,r;a6i pltr ' lrr r I r 'ocrrsrr l istdrernir: (catc intcr.eseazii, artera ofi, l t, irrrici,).
ll\ Ilol.i. .sistem,ica li toaico-metabolice : a) Diabel,ul lealizcazi, neulrlrrl irr, rrlrl,ici, dirbctic5,,. relatatii, destul de frecvent in evolulia diabetuhrr.r,rrtrli r,hiirr., cu, se_ml
-inilial al bolii (Skillern qi lackhar"t,' 19i9 ; Duk
l,llrltr si Scott, 1971)-. Nevrita optic5, diabeticl (retrobulbarl, adeieaci:rlii ,ri crr ,,pu,pitjti,',) nu este atit toxicii, ci mai alegrabe froclusi,rrrcclrrisnro vl,soulare. Apare in diabetul zaharat cri acid6zi,. anro-a.rrri.rrsiv lrl biirbali, este dc obicei bilateratd,, cu evolu{ie cronic6; re;lizilre:'irlcrtir vr:derii (cu scotom central, inilial pentru culori, in Bpecialrrllr:rsllrr, ultorior gi pentm alb-negm). ModiJicirile
'papilare (rrl,r' o rlccololare cu predominanll temporald,, la ilebut iuilnalu-se in'.r l, n{)monr, ('rlomatoas{'i b) AnenriiJe, in lpecial a.ne-mia pernisir;rlrxirro ndeseu novrite- (neuropatii, n.n.) retrobulbare (Oliva;ius, 1961.ltrru'n, 11)61 - citati de Duke-Elder $i Scott, 19?1); cj pofineur'onatiil.r(,lH('lr, 11,6I - citati de Duke-Elder Si Scott, 1971); c) polrrrrLlil,iorlrle, oarentriale-, diqmetabolice pot afecta qi' nerwii orur,r'rl,ronllro, oarenlrare-, o'rsmetabolrce pot atecta qi nervii optici (:rrrirrozrrlo (lin pclagr5,, din beri-beri, din deficientele tle vita,rnini, B,;lilro|Irlvinls din su-ferinlele rligestive cu fenomen€ ile malabsorbliilrrlrrrr4rr,l,i i le la etil ici).
lt) Sutcri.nlele endocrine (tireotocicoza ),l;)_ l,olin.euro?aliile paraneoplaaire pot implica qi neuropa,tii
r - r r l r t r r ) r l iopi i .lI) ln trlt,imii ani se relateazi, aparilia de tabloud clinice de
p:rlii (irrclusiv.l,ablorui de ,,neulomielitd, optici,r' asem5nltoa.r,e cu srrrr.lrr f )r'r' io) itr b<tl.i lc de colagen, cc, dc ef emplu in lupusul eritema(A.l)ril $. Vl ils(ltnenbcrg,
-19?6;-Fulford qi co1eb., l9?2; Shephcrilc i r l : r l r . . l l rTl ; \ - i i : t | . ; i r 'u l rb. , lg73).
. ll 'ltor:itt u:oqene fi.end,o.gene (ambliapii gi &md,uroBe to(xice ). S_alrl.r.r' iri rr.lrrrr.rrrfi Iarl,oli toxici, care pot, sii prorluci, nevrite (nouiopatii)l.rrr icr., rljrr ,clro lt)(fnliorilm pe^coi mai importanli (clupi ,\hnoGscuil { r I r i 11i I ) r r lc l , )k l t ' r q i Scott , 1971) :
r) N icol.irtu, delorrninii, cele mai frecvcnte amblioDii toxicc.rrrrrl rl rrnrxriirzi'r cu intoxiclli€ etil ici. Arnbliopja tnbagicii este'blrr rl 'oiorrr rurnlral (inilial pontTu r'o$u qi r.erdc) cale u-iterior se Ir'rr r{'oiorrr rurnhal (inilial pontru rosu qi verdc) caxeIrrrrlr spro zonrlo_ peliferice, indoosabi -t€mporale
superioare. Uieolirii, rr palri rnili mullio Bcotoame centrftle cu mareini difuze {Dr:ke-Etdrrii, rr palri rnili multo Bcotoame centr.alo cu rtrargili difuze (Duke_Elrieil i r r r r l , l , Mi l ) .
b) Al<nolul ?rilic produce ,,amblyopi& potal,orum;', probabit pdnI ilxr vil rrntinozil, IJ, cu tablou clinico-oftalmoltgic a.semlnd,1.or eu nevritoopi,iri), din intoxicalia tabagicd, cu ovolutie oonici, Rple al,rolie oDtic{,
t) Al.utolul. metdlk prodrtce mai ales ,rnevlite" (neuropatii, n.t,)opl,irlr u,rruttr cu:lmbliopio soverl, lar care Bo aBo{iuii I miihiazl, parezo $l;rrrrrrrchilor' (,xtrinscci oculari (cu diplopie, div€l'se strabisme qi thztr pol.prrlrll l i),) gi alltr l.ulburiri ncur.o-psihice.
d) N uropalii opticl ?rin dioerce alt.e mecan.i:tnte loui<urmetabolkntnllolJttttr l-rr,u mai dercris in: auJlrril$ lutinnc, tlrnoli (nour.opa,l,ia r.4lt;io6prlru nouphzitrrl), In trrtnrr, htmoragiilol mtsivo, lrr grtll,i(l i l lt,l,rf, In ptrion.r|r,lo drr la,ut,tr,l,irr olrr,
' .1.4
poat€ ox
, I Nt ' t t tn l ,q l i l ' ! ,p l i t t i i l t r i t t t t t l . l r t t ' i i r l r t cr l f l r ( ' r r ' l l ' l ) l l t (1. l l r t t t r i i t t t t t t t t ' i I I r I i
l l , l l , t r t r r ' l t 1r l , i r r r r r l r l i l t i t r r ic r r r : ' l l t rsr , , r l r r c i r , t l r i t lc r ' l , r r . ) 1 i srr l l l l \ l l , l l l i l ' l l j l , ( , l l
' r , r , ,1, , ' , ' l ' r l t t l r : rg icr t : : r . t t r I I I i r , I r i t t ' l l s( ' t ) l I t l l l |c l l l I i l l '
t t t \ tutol) t t l ia opl . i , r ' i i t t r t t t ' : . r t in i i ( rs lo ( lo ol) i (xr i r lo l ip tc l ro l t t t l l r l t r ( r r t r
t I r l , l t , ,1,rr , ' , r ' , r , " ,1, , , r , ' r ( r r t l t r r [ l ) ' { l l l l pol [1,(r I ' t r t l l iz l r ' . t1 i . i t 's lxNl l ' r t t l t r p l r l r i l i l ' l i ' '
i i , , ' , , , , ' , , , r , i r l . I t t t r l lo.r ' i r r r r i i r l ' r rJ iz i i (x l t l [ ( t Ix) l ' { ) r i i q i t l t r I t t l , t r t lx l l t { ' i r " l l r r t
r l r r r r r ' r r r l lc t t l t , t t i f r rs l l - t l i l i i l t r , t l t t t t t ls l l r t l 'o: r ' t l l i l l ( i r $ l t t tgt t i t to, l l t ' I t ivrr l t t l
I r I l . r r ' r . r , Ior ' 1 i l l r I r ivol t t l I l ( ) r 'v i lot ' p( f I ' i tor i t r i (pr l l i t r t : t t r r tpal i i ) '
l l l t t l r : r l r , l i i l r t r . r r fu- i . l r t : " ' t ' l l r t t ivr ' l t t l l t ( r l v l l l l l i o l t t i t l s int ' . r i l t r ' , l r t t l i t r r l t t s"
I t , t i l , , , , , , i r i l r i o l r l ' ic t r i r r t t t ropl l ts l t tozi t , (Zi lntnoi t r r l l t l , 1{) l i { i ; I r l l t r l i r ' l ry i' |
, , , , t , , , l l t l ,u r : i l r r { , i r l t I ) t I I i I r i I ' ) I r I t r I r i i Sco1,[ , 1{)?1), ctr t r i t rs i i ' I t r l l iz t ' r tzr t '
I r , ,1t , r r .nrro r t , . t t r r iLtgi t to ( lo $l l fof i t l l i i i , c t r l i l t l l ' .
lr) ,\r 'r,rrtr,/rr olt l i trt t i t 'r ir:a ;i lsatt i trt u'tt tt lol1irn, cu'. srttt , lr ird rrkrl i l
,u , ' t , ' , , ' , , tntdt . ip l i i l , ! . , ' l I ' ) . I "or l i i i r tnul to I i t 'vr l i lc o l t i ' icro. 1xr1' s i i ' r rprr t r i I
, r t l r r , , , t r l , ' r l t t l i t l , , , t i , t t tc t^ l i r l t t l t t i t l i l t i t r l t 'c l ' io l rsrr s i t l l IX)sl i l l [ ( f ( i ( i l r l l${ i ( l ( 'H
1r, , l t r 1, . r r . r r r r l | (1{ iors|) ;b) ( ) iu o t lo l l tp l ic l t l i t r i r r t ' i rz i l r l i i r l l l l l t l i l l l r r r ( r l r l l l l l l r l
l i , , r l t " , ' i ' , , ,1, 1, , : i t t '1, .u", ,* , , , t , t t i , , i , , , , , t t , ' ,
r l t r l 'u l t t - : lgt t rs i t t t r r r (Wl ls l r 1 i
i t , , , , , r lu;r ' ; t r r ih i r - t l l l i r r ls i l i ( l i r t t ' 1 l ) i t1 'Ni l ioskr ' l r r i l ro l l i i i (1ol1r l ' ' ' I1 l? l ' ;
i , , , , , , r i , , , ,11 r i l ,Lt t r i i i r r r l i "d ' , , i . ,
.1{ t?d; 1 l 'o t t r l tc l lo l , t r : , l ! )? l ) , c l r ' r r l s ' r t ' t t l r t r rc izr t ' l '
r r r t , , , , r , l , , l r r t i iurr t t ro l i rg ico, s i t r l ; t * iz l i l , l l N, l I t (n ior ( l ( r r t l r i ( lb l t r rv ic i r r $ i l ' t ls( i r l '
f ; , . . , , , , . .1 t , , . , , .1r i r ' t , , ,1 s, . r ' i , . ,1, . , , ( , \ r . i l ,1 r , l , t i , . ( , ( r r . i r ru l l . l . . r l r . . j r r r r r r r l : r l , r l i t t
, , , , , , , , i , l r , , l r r r ' ' rzr i , i t r 'c l l th 'u l l l . I l ' , s : r t t t r l i ' r ' i l r r r rpf ic l i r t i l i l r lo t l ) i r ' r 'o l r l ' izo
1,, t , r r r , l , ' r ' t t r l . t r l t l ,
ntonosirnp f , t t r i r l r i ' i t , r ' , 11, ,1 s l l ' s( ' i l l iJr '1 ' ( i i ts{ i l ' i ' l l l l ' ( r l i t ) l t l t '
u, , | ' , , , , .1, , ' r r r r t r . $. ,1- (Mc Al f i r r q i g, , l r r t , . , l l t?: t ; Ni l t r . 's l<r ' l r t i l t t r t t q i colrr ' l r ' ,
r ' , i , i , r l i ; l ' ; i , , ' t r i , i - ; i ' t t1a5., 'J9?+; S.rr , l '5o.g-\ \7,Llh. i tn, 11) ' i l - i I Srrr . l lx ' t '11
' t l r r r '1,r . , l i )7 i t , t9?l ' , ; t r l r , ton'e , r i coJ.rr l r . , l1 l? ' l ; Sclrrr fc l i \ j Ol i i l r r r r r r t l l l { i l } ;
l r r , , , , , i1 i r ' , , l l r '1r . , tOi4); t l ) 1 l r iLr ,1 i , l l l l l i ) ( ' ro l rst t r t l r i I r ' r 'p l ' icc l l l l l { ! l t l l l r )H(1
,r,, l , , r rrir*'rttt istt ic ttr, ioil i togrlri i",r ' , ir, S.l l. l i lr ici-l l lr .vrl lrt( lN'zi ' spnr i{ ' l \ ' l ' '
rfr1t rri,rrI i l irr i i l i lr of l,rr, lr iotofico :t itt ttearttr:Le ,p'ice ([(1.,t ' tulzii Itrrpttrtrizrtlr i
,,,, '1",i ,"i Li,', i i lt, ' irt i l ' i ',t," ,i i t"1., .*u,strtatc iir clr'zurilc billo tlolitti l 'tr rlo
nil ' ;t,, i,,,1,,,tt,t, rlcci, o otnriti l i,t inrlelungatd, i.tt cvolttlir 'r, (' l lro (rB1'{r il l
111it,r1r.i ni ni'rru"izirzt, ovllnl,ua,lelt, i:t ' lrr,(ii i l itrh6 rLt'vlitlr' opticri rii S'M' (lJrr'l lrl-
l l r1, ry l l i r rkrr , l l l? i t ) .
ii.i l, i!. Morlitirtfiri lo tinlpului vizrtll oforrii, o sclio (lo lno(lll l i l ' i ' l ' i do trll 'o
lor, rr rrru. l l ,rrur,. ( ] i ! I .( l nO p0t fUrniZA, Ctl l rUl i a' t l0SOA, l) I ' l {) iSO OOR'SpOnlt( l l t [ ' { !
i '; , '1, ',;;;';': ;;;d,,'ilii i ',,-t.' *iii- t,iietetia tenionattt, cll'- osi ovont'ru ii Jattt'or it l t " r"r l 'unniai t ) ( . c l r rc. i Dl l fern l l lc l l tn lna.-" ' i . , , : i : , : ; ; i ' i , , i pr l i , , ip,r i t " tnodat i t t i l i srm,oloui i .c al terdre a otnptt . tu it ' l-rt,rl t!r
",,rrr1,r)ndonlela Ttal'oktgiac p.t o,,'., lu "nt'gttrt' lrzl (tlu![ ]\ri$Ili,rJi
r , , t , r l r , ' l l l l i?, ' l { )??; ' I t , is i r , f l r iZ; 'etnrsiA, 19?0; t ) r rke- l ik lor q i St : r t t ' l '
l I i r r ( l rH. l ) ;
' ' ' r.t.l) orhi'r'tt ,rrtirrru'mJcranlitlti i" , c:lro rctrliztltt 'zi' ,r'I).ed(tca tuhtll 'driN"
1q1. 1,11g,,t r,ir,zi'1, : r4 novi:iti l, opfi,IL jL xtrr,birllrrr,r' i l ' (prqriliti l); lr) novt'it 'r ' l ' ttrtrrr
I r l l r , r r i i l c) iHl ' i r r io,
' :1.:1.!. o orhirc lal,/j ld tntilttu.tld, l0 tllt.l,oltr6to tlltoi lt 'zitttti tIottI1tIt'I 'tIr . r r | | t t l r r rv olr l i t r ( t l l r l t lxolr i l r i r ' t t l t l l t l 'k l i l , l ' t t t tx t t ' l t l i i gt t t t i t t I I I I t r t t t ( ' r I I i r ' ) '
' : ' . : . ' , :1, I In t t r to l ,o 'nt t t r t t t ln t tn i l .a l tu l , i t l t t l ro l t t l t ' t l i t t t tot t t t l tv t t l t l i o l l i r r
| | ' | , I t | , r ' | | \ ' ,
: l . t
clM P VTZUAL
12I\3 1I
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Fasciculd( ' rol!: : nlzf l l t Dl 'r l (n,.l r ' r I r , r . , r l t r r t ( r ' t , , r ,
ll l;' : 1 lt;i' i,''mliii,{i"',';;, njj* iHiili f iiii,l
' ' : ' :!-4. I ln tT)|,.r ' ttt ' unl'rdl hrtttt irttto,xia hrtlttt ' ttrt irtt | l l 'rr t t lvtrl l l lr0t' ptrtt l,ttt| | l , ' r l r | | ( \ loorr , l iz l rL i r , 1xr 0hirrst t l l t , o l t f i t r i ! - l ) r r tnt t l l l r r r t ' i , l t l l i l ' l t t t t t r t t ' i lo t l t l t '11| , r r t t r I r t r r r r i i , 1lt,t i ,ult, 1xrslol iort t i l , a, clt itstntri, t lntlo trHl,tt locttl t lo i I Icrtl (! i l l l l{!r l l i l trr ' lor trrtt ltt l l l tr, 1x11, prodtlco tt lr $(lt lt,rtttt hcttt irrt ltt l ,t l t ' l $t l (x)l l lnl l
Ir lrrt rrrlr o l l l ,oll,r 'u jroi ' l tcrfcri u, vtrloli i (I l ,cl lv, t!)(i2 I Wilsotr l i lr 'rJ(x)l l(! l ' ,l l l l lr{ r ' i l ,rr,[, i r lo I ) tt l<c'lt] l tkrt r,{i Scotir, l.(}71.)-
' :1.:1.lt. l ln ;tu,l,onr c(lntTaL hernia'n.opsi,a hontonim oiJl (r 1'(\voll l l 'ot lxrrl 'l | tr r, l IziIr(, Irxra,l iza,tir, 1xr zona postolit l :rri i i l chiasrnci oll l i trt ' , 1lo lt l t ' t tt lr 'l . l r r , l r l ic : ' i , o l i 1rr lxr luI occipi ta l .
' .: ' . i !.1;. I l nnian opsiiLe hetaro'nime b'item'poru,le se itt l i l tLcsc itt [r: irrtt i lrt,t, t lrtr ttr rrlr t irr,sm.ei oytl ice, t."alizttte in special de tt l ' tnii i .<r:ltt l tr r l l ixt{, ittt l i ;' r t l i r ' { i r r t r i sagi l , l ,k , i lc c i r iasmci; b) i fumoi ' i schre { in( l t r )s({ i i h i l r r r l i .
, i , |, ' t rorr,rt i ir, tt lcrtoca'lcinoame, clrcinoarntl mel :r,sl,t l t ' i(Nl) I .tr) ' l ' t trtrrtt l
1r , r r ' , l r r t r r ( t t tot t i rg ioame parascl f t le, tnmol i a lc gl lg l ionulrr i l t l i ( l r ts i r l r ,
I r r r r | ' r r r r l r r osrrLui r fonoid (osteoame, ostcocondrolnmo' s lu ' (x)Nl I l ( f ) ' l l l l l r ( rul r r , Lrr)r l l t ( ! , 0 l t ' to inoa,me, salcolme rnctastat ict ' l i .a.) \s i chist l l l i : t lc t r t t ' t t i t t,,, l ,,r l,rrzr t i, lrrtrxxi (orl l i tale, :nazale sau nazofaringi{'tttr ct: ittvl l l l t tr ' rrl , , r , , r , ' r ' r r r i r r l i r i . .s i a, zoi ic i pamsolare) ; 11) i t ' ru lor i supr '2rsol i r r ' ( ' I o l t t t io I r t t i t l
t . r , , , , r r ( , | l ror) i i lg ioamc Suprasel l r '1, , tut t ror i [ i abcos,o l c l r l t t t l t l i i t ' r t t t l l t l ,
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' , i , ' r , r ' , , 1t , , , ,a, , o l i l ' i r l r i ' (dc ( ' r ( ! r lPl t l i t t ncnlr i i l r r ' ' t t t r r t i lz i r ) ; l l ) i t t l ' ro l -
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, ; r , , r , ' ; ' .1; ' i , - , ' , ' i , ' , i ' l l ' i "p l i ' r i : ' ! l ' i ' , b i t r l dcl i r r t i t r r l i ' I t r r i tp" t l . r r r i
,1, r ' r , l r r , r ' r r l r I r ' , t l l r t l i t lL l t r r t r r str l l ! i r i , l i i i f i rn lc- ; i - t t l t t ror i l l l t t t r l i r r -
r ' r ' ,1, r t . r t r t jo.r l r . l t l l l r l . Vrxl t r t l r cst ic r i l l ' t t ra ' l ' l i , t l t i l l r ' t l isctc i i : I t t t I t I io1t i t '
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l ' , , i , , ' ,1" i , , r , ' ,
l i ( r , t , ' r ' ' , i , 'J , ' r .z i r , s i t rgcr i ' i l l l l rs iv.r^ s l ( ) l ) ( ' r t r ( l i i l0 ( l ' . ' ) ;
r lt l , r l, r.,,rr, l.r, 'zi i r lrr ncrrr. ' , ir l , i . ir ' l i . ir, ischornicir, l tr) i I t I t, t I t r t t t i I t, IJ(\ ' l l i{ j ir ) i l ' l i ' .
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1 l , r r r l . r r r ln l , t t l l i ) l t t lo (1r l t i l , ( i ior lB t ' ia 1. f i1t" i ) r 's to o t 'x t ' lwa! i t l r l l [s iv i i ' 1 ' l ) l l ! l i i
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t ) i r l r ' r ' i1, i i t (1 's1l t i f l lp l , v l rscl( l l l l rc cotur i lx : ln lu 'g in(r i l ' prr l r i l r i , 1r ' t r l t ' t t, ' r ' r r l r ' . r colxr t t i t r t tc i i !a1ir ' . { ' i l r l l } l l l v izt la l tLtr ' - I t i I I | | I } I ' I I I , l t l ( t t 'o\( ' l r l
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, ' . l l l r ' l , r l . i : t t tq l iot t r t to t t t ' t t t r r t t i i t l t r ot ig i t t l ' i t i I t t ' t 'v i lor opl ic i ' l l r l ' I i : r t ' )
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, r r r , l r l lo l i r r | r ' I . i r r i : t t r r ' i p ig l t t | t t l : t t i , i l t l i t t t t l t ' lo i t r i t t t l i lo f i i l lv t ' l l i l ( ' t l ( t
1,1r, ' l r t . r r l lut( ! l i r r i I l r t r r i I i I r I I i ' , i t t t l t t l ' l l t t t iopi i s l r ' ) ' l ' l t l t i l l l l rp l r l ' r ' l r l l l i i '
, , r r r r r r . , t l ru | t ' l t t r : t i l t t l |s t ' l t t l t ' l tsptr ' l t l l t l r (L i l r , s i l l l g l [ l lx ' l l l i r (1t t t t t l t t l l i t t i lo
r , , r ,1,q11i '1, , t r r t t l l tz , r rot t i t I t i t I r ' . l i l t ' ;xr t l t t r i l t ' t l0 t t iv l^ l s i t l { t t r r l t t l l t l t ' , t l r t t
' r r .1, . r r r t t i l i r r r l i r r sr t l r { i l ' i , I i I i l t | | I | I ( ' . . \ ( r l l ih l lo l l l r t lz i t t l i i l r r t i r r l l qr ' : r r l r ' r l r !
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, , ; , I r r , , , : r | | r I i , r l lu, r , r r r r l i r Ig i t r i l , , r l | r ' r r r , ; i i r r0t |g l l l : r l , r . , l l l l r \ , l i ( , l l l l t l l l i r l ( \ l , i l { l l l l ! l l -
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: l ;
l , i t t r l Vrrr . i r r l r i l r l i { i r r I i r . i r I r r r r I r , , ( , i t r r l r r r l Yizr t i r ll l i r . r , .
, r , . , r , r r , \ , , i i / o, i , i , in.Lrr , . ! . iccnr. , , , . " . " , i "11; l - , . .** ** , *"r"are a rer l re i ; d_ co,oirr i r r .
r .r.lr.(,r'r, lrtrrt,rrrirr.rrJi, iar clisco^lanta dintre strimtorarea artc'eklt,t l r l r r l l ( i i r ror l , lor r , .1r , i i mai evi t lent i i
I t r . r , r ' r t l t , r t , t l r , r i l r i t ' r ' i t l t , rut lont t t ' r t p l t l r i l r t t ' r i i t r l l t l l t l l tz i i t lo l t t t l t l srgl l l l ' l l l
$ l p ' r I r l l r , r ' r ' l t t t : r i r t t l t ,s t . l t I t t t l l I r r t l r l t t l t ' r r t l t ' r t r l r t f l t l t r : l , i I | | I I i I I i I t . i i ( !x l1 ' l ' l l r '
f f l r r l l , ' r r l r ' ) \ ( , l i t1, t ; ) - l t t gt ' t tc t : t l , p l r ; r i l : r , r " l r ' l r i t tc r I r ' I i r r r i I I t I i t , i l t l r r t ; r ' l t t
; l r ' r ; ' , ' r l r t t t l l r l r , t t ivr ' l s i t t l t to l t t t ; r l l l : r t l r r1r I r t l r1r t ' t IoI t r t I t I r ' . l t l t t t t t i l i t t l t r rcsl t r
l l l , , t r t oI l i | r . l r r t t i i r t l r t lcz iut t t r r i t t l t ' r ' r 'sr ' : tz i i l : tsoir , t l l t t l 1 t I I I t i I t t - t t t I t t I t t I I r I , sr '
I f t l '1 . r l r r , l i r 1 i utr sc0lotrr (x ' l t l l t t l ( l ) ( ' l l l l r l ( - , l l l { ) l ' i i i i l )c l l ( . l l l i l l l ) ) '
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l t i l t r tu t ) ,r t i : r ' t r i l r , , lc n,n l i lJ .
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r , r t , r t l : r l l i r ' l ; r l I r . t r r r r , t r t rht i ' t
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I ' t , ' l l r r l rn in. 11,p1r 'z i t t l i l , o ( l .o l r l l tv i r l ' r g l t ) l ) t l l t l i r )ct l l i t l ' i l t r r l i r t r t r t t l r i l t ' i 'l f r f , f f , l l r l r l l l r . r r r . l i i r r r t t l r i l l r i r , r r r l l i i i l rorr l r r t ' r , r t l iz : t l tc i . ' l t ' r l l l ( ' : : t ) l \ t l t t t . i t t
l f r r f r r r l r r r r r r , r t l r r t ' ( r , ro l i r r l t t t io t t lo lu l ) l r ) r , t t t . l lu lut i r t ntr t l t t r r l i : t ' \ t nt th i l i t t rnul .
f . i l . l . , lpfr , r . ioInr r l in i r i l $r , l r r r , r , l t t t ' : t |ot '1, r , t t Iozi( i r r r { r t l t i ' ( ' i l i r t : i r l t 'l l l r t r r r11r.11111' t ( ' i r r r , r 'o l r r r r l l t l r r l l r : r t | ' r r t l r t f l r l r t l | r ' l to i ts i . . ' \ l r t | r ' i | ' t I l t Iot ' r ' r ' l i t ,
; ' / . / / / . Sul , l i l i ( , r l r t l int :ot t lut t ! r : lo t , , l tu lmotol t i ( :o- .11t t1t : ! iot ta l r ' . r t lo &tt a. l i i tot '
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, l { ' , t " , r r . r l r . l r r l ro l t r rv i r , r l { ) J)rozi l l l i l l i t l t rcf i i v iztrr tk l l r l t lo i t l t r l t t r t t t t t l t lc ,
l ,Xt l l ' l r r r , r l , r l r r l r r crrrr : r r r r p l r rc iz l t l , q i i r t t l r , t ior ( l 'o l to l ic i t t [ i l ) i ts( ,11, l1 l , '10),
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l r ' ; r t rsrr is i , . t i . r {1 i ' i doln i l L l t I r l , I ) , i l r t rune$1,o o i lh\r f ic ( } l ) l ic i i l ) i l1r-
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' , ' r . , l : r l r r t r r I r I io1r i r r ls l t ' t r tu l i , i i l r ' ( r i lo st t l l io l l t l t ' i i 11. t r t t l t , i l t l tgtr l l r
l l | | r t | | , , ,1 i r ( \ ' r rn l ]ogl loI l , f i Yrt I r [ ,o({1No}1, 19.19, c i t l i f i r1( : I ) t t l<rr- l l l t l ( ' r 'q i' l l r ' l l , l1 l / l ) .
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ili,;.,lj;l:11,'.'"i,lll..,ill::1,""^lll{,i "pri. 1_"in,ii,i"""oiiioiuo.,I",,rl,.l;r.rrr;111., 'r(.ti.'staze), fr""';;;;" i;;g,"'ii,i."if1i,r'ilt'Hii#j'rJi;llrrrr){ r ' , , i , - i : r l l i l :ourn,"vi n. 1;urot iL,rof i r i " ; ; l ;1 ; ; ; iht f ingh,, , , ,
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ale ochillui : d.iversc tumori, facomatoze, glaucom,
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l l ) - I ( t l l l l i l r l l l ) i l l
io l , r , r " r r l r l l l i l l rYt ' l r )1 ," t l t l l .gt t t t t t t t l | lot 1" ' i i t ' t l ' i l " t t ' ; l r ) . l l rz i { ' i l r g l0 l r l t l t t t
11 r , l , , , , l l r l r r r r r ' ( l l l l ( r , l , r l l , " t l l t r s:rrr t t r t , i t r t r t t r ' i l ' l l r ' . s t tgtr l l lz l i sr ' r l i l t l l t
, i i r ' , , , , , , r r l r r i l l r r l ' ( ) l ( ) { i r ' ) ; "1 Vrr l iabi l i l l i r ' " ,1{ t : l t l '11111.. : .1. t ' r 'xo| I I t I t I t i . t ' r t
l ! l , r , ,1 ' I ' r l , r r l l l r t r ( l l l i l l , , , " l " i t ' l i t '
( i t r r l tot l l t r r l i t r , r l i l rgtr l rs l i r r r r l I is l l t l t ' i
I r r , r , , , , . . | \ | | | ( | : I i ( I ; I I I r r r l r i i l t i l i l l l l ( ' l r t ' - ro l l r r l l t r i l ' i i t t I t t t r r ' { i r ' ( l t ' | r )z l l r : l
tu1 ' , t , ' , ' 1r , r ' i r r l : r [ l l r l t t t l t l l r l r t t l t t i i t r l r i t l le) l . l l t t t r l l l t < ' t ] t ' l l ' ( l ( ' ( x r l l l l ) l t r l r ' i l
l , l , , t | " r r l r r t i l i t l r r ; r l r { ' \ I l r ' ' i t ' t t t t l " " t ' s i ' i l l | r i r r r r i . l } l 'o\ 'o{ '111 1' \ | i l r r ( i r r i l
i , , , , , ] l , , r t , , l l , { i t t r 1 I r r t I I t t I t - 1" l r l t t r r l i l r l l r r x l i ( r l l r l r ' I I ( I I | : I I I i l i r i t t t r t | t t l : t t ' '
l t ' r . r l r , l r l l l l l r ' r r " l r ' | | | I I : ' I I I i I I I ' I I I | '
t ' ,11, , , , i , , t t i t l i tu l i t te. i t t l t l t l t t l ' i tz i i l ts t t l l t l l t t l r t l i r l o l l t t lo: t ' I I ' t t t t ' t t I t :
l t r r r l , , , r l r r l r l l l ( : r s:rrr t t t ' r r t t l l i l l i l i l l l l t l l t ' - r r l l ' l l i l r t t i t ' i ; I ) , ) r l l l l ) l ' l l l ( l ( ' l ( ' r l
l t t r r , , r l r r L J r ' 1 , t , , , , , t i r , , , , , , , t i ' " ' i1 i i t "" ' t t ' ) ' ' l r t l t l t t l t ' .1t ' l ts i t t t tc i r r ' ' l r ) l ) l l l l l i
; ; r ' , . , ' , l ) l : r l r r l r r r l r ' r r l i l r i srr t t tLt l t r t lsr t l i l i i : t g l t t l t t r l t t i orr t t l i t t '
, | , t t t l , t t t r t r l i r r ' , t : i t l t l tu ' r ts l i t i ot l t i l r r t r i ; i 1t I t i t t rb i lut | t ' t t t t i l r
t t r r 1 , , , , , , , , , r , t t t t t r i , , t , , ,1t , , ,1 st t l l t t ( l t t t t ' l l ' is t l t s l t l l l is i t r l i ( ' ' l l ( r l i ( l ( ) (1 i l \ ' ( ' l
l l t r , | ,
l t I t t t t t r t t t t l t t t r t t i ! i I i i ! i t u lu l t t t l t t i tn ' t t l t t l r l r ' ' r l | r tz i I i t ' t t l t l t t t 'zr ' i l l t l t
; t t r , f
" ' , f ,
" ' , ' , , , , , i ' , - t ' , , . l i i ' r t t r l l ' t ' r ' t r l . . t r rUlr ' l r t r r l ' { ' r ' r l l i r l ' l ) l i l r l ' t r " r ' '
l l i l r , i l ' l r l
I I l ' : t tut l t ' t t ' t r I r ' l
l r t I t t t ' ' I t t 1 1 i ' tx l r l l ' l i4 t l r t t : , - l )
' ( t l i t t i t t s l I r r ) l r lc
.1, , t ' r t t t l r l l t l t l t l 1r I I ' r r : i ; r l l r r t , ' l l t t r l t t ' * is , r ' l i ' t t i t t l r l : r r l lc t l t l i i i i ' t tc t t t tz l l
t , r r . , , , I I I , | | I . I : I | | . : | : l r ' r r l l l l r 0r ' l l l l t l . I | : I I I ' ' l l : I I I I I i i . t l r ' t r r r ' l r t i : r - l ' r l t t t l t t t
; ; ] ; ' ; ' , ' ; i , ' ; ; , i ' t , ' r r r t r r ( l i i rsr ' | r ' ' r t r ' " t t I ' t ' r t t " t t t t t " : i t ' r t i ' ' t " r t ' '
' i i i '
' ' , , , , , r i t r t l ; i r t l . ' l \ r r t u lu i r l t
' ' lh i l t t t ' r . izat tz i i l t lotcscl t ' (1rr11r rrr l t l r '
; ; , . , ' , r r r l , ,1r1 i r ' , l r r rp i i : r , , l t i l r ' i " " ; i l i ' r ' r i r i r l , i r r r r i l . ' . r ; r i r r i ' ' ( ' r ' ( ' r r l r l r t l r l t l ) is
i r , , . ' ' " r t r l t , r t r r l i ' lc t l i | ' r r t r r ' r l r . r r s l l tz i i l r l l l t ) l l l l i r I l ( '
' l : I l . l ' l lat t t i t t i i t i l r ' l t r r t t rd i t r i t : r t t t l i lesi ' lbsol t r l r r lcrxrrr t i t t : t inr l t ' t t tnul
1t t r , , l t t t t , r r r Iosl ic t : t l ' l i izr i lc t l l Arsl t t i 1 i r ro l l r l r ' (1117?):
I l t , , l t t t l t t tot t td) ' i r t , : t l ix l ' : r t t t i t l l i ( i i i l l l l ' t lor '
t ) I I ' t I | | I t t t I t ' t | | r ' r l r totr ' : tz i i v l r l i l r ( i i l r ' 1r l ' r 's i t t t t i i . i t r I ' t ' I toI I t iLI t t r ' '
Lt l r r l t r !
Cr L, t , l r l ) r l r1:r l ( . I t r r ' , r I r r , . I ib i I i I I r1r ' ' I r I t ' , r o l l : r l t t t i c i , pt ' r ' t l t i l i t r t l l l l l ( \ r l i t ]
; i i t , " ; , , , , . , ; , , , , 11 1 , , 1 r , , i , . 1 r l r .o| iu i r r | or . l i i l r r l j i r l . r , r . r r r . r r r l .orr f l r r r i r r r r i r ,1r ' .
. , t l t , l , t , , t . i r i l r r t r t | , i , , | , , r1 i t r , . i r r I r r r r r r ( ic rk, l i r l r lot t l c l i r r i r i , i oI l l t l r t r r r logir ' ,
Ftr ' I r , , , l , r rz:r I t t r r r r r l l l ' i l r lo l r l r l r i l i l " l t ' 1111 l r l r r r r t 's p:r1ol1rgir ' ' l t t I I : t t I t I t I r i I t t t
i i f r r " r ' r rp, l I r I I i I i I l r ' l r ' . \ r 's t ' r r i 1 i l r r l r r l r ' ( t l l l is r r ' l r ' r ' ' l ! l " i i ) ' sr ' l t t r t t
t ' , I i , t r I t r t r 1 t r t . l i i s i t t r l t l r ' t l . ot l r i l r ' , : r l t ' l i t t t l r ' l r r t i l r ' l
' r i i r l r r l r
' ; i r r l l r r t i l r i lo l
r l r I ' r , , , i l , r l l l r t t t r t lc . l ) l r ( ' i '
I j r ( l r r ;qt i r l i i : ' l r ' 1 ' ' r ' ' I i | ' ' r ' . r ' t ' I r i I ILt i '
: r l l n l t t
| " r | ' l , l ) : r : / , r , ' l : ' l l l . t l l r . : r l r ' ' l t l l ' l i l i l ' ' r : | " t t "" : | " i
l r ' l ' l r ' ' l " ' i " l l l
I l , :
, , , ,1 , , , , t r , r ' i r t r i r ' l l ( i t r r l i t t t t r l r ' i t r l | i r I r ' r r ! r ' ' lot t tot l t l r . l i i ot l r i l r t r " I i I I I I i ' ' | | | | |
1, , , , r r l t : r r i i r ' , ! r r r l i ( )q l i l l i i r t l t ' ; ; l i t t t r i l { ' t l I ' t | | I | { ) ! I I | | ' f i
1 ' I t r I I t | , t I t | | | i | ( t t \ t t l t : ; l t t t t l t r r l r t ' t t t l t r t t l : ' r t I I i I r r t I t ' I t 1 i r ' ' l l l I r r I I1I : t I t I '
, r t l , r r , . r t l r ' t lor l l : r l t r ' , , t 1 , ' l r t t : t , : r t l l t ior ' l l t l i i l r r l r r l i r l i r ' t r r ' , 1 ' rL ' t t t r r o t . t t I r ' 1 : l l
' r
t , r r , , i . t r I r i ( I | | | ' l l I i I l l r ' .
I I ) l t t l r t , r t t l , t l r t l t t r I t r r '
' t I I l t l t ' t t t t t ' : l t r r i , r l r : r ' r 'o"r ' r r l i ' ot l r r l : r t ' r r ' r l r r ' ' t t | r ' l rL l ' r i ' t l r l i r . , r r | . l t r l t
I r ' .1 i , | , r r r r , r ; , t r r I i I i l \ l l l l : l , I I I I | | | | I I I r t7: I I : Ii r ( | (
' | l t l t l | r
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r.4. pfioBLEME Dti DIAGNostrrc INRPATOLOGIA SISTEMHL0R
: if if f *liflri,ilffi i;$tiFrl ;,r"*.rm,m fu ",x[**l,-;'pg,f *l*fftl',i"lffi f i';ffi ;3Hl*T.1,riri;r jiril"lr',',","ff ilf t{i,:}}}"{*;1$ j$ti:p1r,ir"*:r
ri jiilililtf ld'*f t:flr.rriffi'ft;ffi T-pfroq:*ffijiri'i,r1ir,J'llidnilltl[lFt*l::r;i"ilr3rp;;1:;i*:""*r::,,,,,' "il j li :ili l,i I ii;,n:Ttj"i,{'fiii1"fii. T\;:i i,,i lx."lljy,, ;l il il:lixliiil jinrl:ii;rril{}1l*#il}:ryfffi$il,r1if#*#r,lxrY
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:,,,:iii:,:i[,i,!!i:,:ii,i,,,,:i,,ii,|inri'i:i{;*|;;,-*,1,:,,i-*l0
r r r t tNt l t , i t t l t t i Prrr l r l iz l r t (Hlu l l Hr, lu i l t i l r , r r r r l l r i l l r l ,o rr l r , , I I1t i r r r r i I r I1 l t l t fc l l i lo l .t r l i r ' , l r t { i l t r f i : rzrr I i lo r lc l r r r l r r l lz i i r r r r I I I , i 1 I I r r ) . , \ t rcsl , c i r r r l r t l r r rnrr l i l i l l r l r , xr ,l)oll lo Ail)lt( j i i t , foarto oxaal, ftt rrJtrl()t 'r i l pt[. irrrot1' rr ltr i irr i l ,. i i lst,r,r ' , r 'rr,rrri il r r : t t r . la l inr i i r . t i ine[ f iz io l rg i | r , : : r ) , { r r l , ( . r . ior _ 45.; [ r r t ( . t I , r , r . r l I . i :, r i r r lcr . ior - 50"; d) inf i , ro l r rz i r l : l i - , {0": t , ) nrrzr t l _ 4.- ," .
Bl I. i .miloreo ctmpului d( not it0lp ;tt pt.;t) irea, bin<,t.t, la1i. :-p .1i,., :r rrr ctzul in care ochiul sdnii,tos este fixator, del afecta,t va suicri l irrri l ,rrir,a,rrri;ciri lor in maniera indicatd, mai sus. |n cazr in care ot,l iul lxrl lrrvcnI'c_fixator, o-chiul sind,tos ya prezenta o extind.ere a cimpulrri r lrr I ixrr(, ioiu,.tlircclia ,,liperacliunii', miqchiului sinergic contrllaicrl) ,clrri lirr-I i \ l (Lal ,
Cl T. imitarea cf mpului rL. mot i l i tqte oculard, coniuaatr ; . 11, ,1 i l i l l i r ' l l"'rrjuga.ld volun €rd sc pxpjoreazl prin in.pccla.rea -ex"curslilor gl,biLr|or, t3rl t0. col]l€Itzlle de p-rivte in sus, in ios.la dreapl,a 5i la stingrr, Ir.t.r.rIr r,,i l i l solicilarea bolnavului de a rrrmdr"i un obieci caic sc dcilnii.lzr'i ir,rlivct,se direclii: orizontal, vertical, oblic qi in plan medio-sagitlal (corrvrrr.r ( 'nt { ) .
2.4.1.2. El utliul ntotil itd!ii canjuoole aulttmal ico-refletr util izcirz:'irlr'tl i procedee: a) Deplcsarea in cimpril vizual a unui obihct-1cst lumino*,,)l'servindu-se ulmdxirea acestuia prin miqcirile globilor oculari (,,tloll's' '\, '. .movements ") ; b) Modificarea pasiv5 a pozil.j i i r.apuJui (maLrr.vi,:r. luiAlrjou.anine), la care subiectul arelendinta ile a'-si meirline globii ucrrl:triItr pozif ia ,,primard,' (,doll's bcrd fenomehon"). lisifel, ia roiarer crrprrluirtrre dreapta, globii oculari tind sd, rd,mind, in pozitia anterioa,r,ri,, ori a,ll,o, trvilie, fali .de nou_a.pozilie a capului, .r or privi s'prc stinga. l_i rotirr.rr.,'rr puJ ui spre stinga, globii oc}lari r.or av"tr, o ,,p-ozltrlc rielativX': splt dr.cl;rl r,.Lrr }tiperextensia capr.rJui, globli ocrdrri vorliua ilozifia relaliv infoririirlrl,r:rr' l[r flexiulea .apului, acesl ia ror lua pozilia rcjrtiv' s r rlcr ionri . Ll| l lr(lit[trea capului pe un um5,r sau pe celdJali, sc vor produce^miqc?ili tonjugfl,t,0tr'l lr '-tc cu ca^ra_clcr ghaior, in sins orar cind calui csm aplccll spo rtir.i1l.rr.rl,r ituterior.cind eapul
-este aplecat spre stinga.^Se va ruriri,ri qi cirmxrrr,ll,ir1,1,r l | l l r re I imrtalea ml$crr or cojr jngxl o r .o lu l larc 5i r r . f le:r . cu rr i . t : rg l l r r rstr l
; , r ' , rvocai pr in csci tarer labfuj t r i ic i pr ix teslc l , . c lnsicc (rol l tor . i i , lc | r r r icc) .
... ?:4.1.4. Stud,iul d,erialiei paralitice a globut,ni. oautar (Strati.smul, ).slr abismrl se. exploreazS, urmdrind pozilia "globilor oc.;ula,ri ia privirr:l ln
lll l i.Di 14. priyirea in toate dil 'ecliite. Sr.&bi sial 1sl.ratitic (tlctutirit ,1tn.rutr-,.,,tni,tent" ).se. ca,racterizeazl prin laptul cX sc acrentncaz:i, 1xr rniitrri, r,ol,rilrr:wul iqi dirijeazd, privirea in rlircitria, mrqchiulni fl,Ileota,ti. i,ukrm lnlil l itrltrLitoar€Ie- tiprr-ri de strabism a) donr:ergmt, prin llaralizil rnrr6chilorllnlrlctori; b) Diaergent, priu paraljzia, nli6chitrii: atlituctrx.i; o) iu1,rutt ticnl. (.surcumrergent )1 prin paralizia mrrqChilol colxrlll,orj ; rl) l\lrr.,-tt tttcttr (subsumaugcnl ), plil paralizia mu"schilor rirliciilot'i.
I$to necesar ca strabismul (cirrd rru es1,o }r'ca cvitlcnt) sli, fi{\ rf)iilrr)inl1rr l i f . l r r in testul druia! . ie i l t r imtrr (e incI urhiul- I ix l . t r11,ca{6'1, , .1 s i l l i i l ( }$) , ( .1t ,rri.lrrin lesiriZ detialiei secuntlare (cirxl ocliul rfccl,or cstc ilralor), ovtr:riul,lt r f jliziniln-so Ei p arirnetrul, lu,i I' i)rst.er.
2.4J,4, Iiwmin-qrca pftil id t'o ttt1t tttsrt ttr i I a MInl?ti,ri rr gfi rrlrr.i, 1.irrr.t t l t l t ta du rcguln: , ,boln: lvnl i ; i thr<r ' r , l tprr l t r ro l r r i r r r r lc l r t . r , r i ' l rorr t i r ' r l i t i r ., . l t i t t l pu,rol izol ; t t , ln lncolct t t r ,a, ta r l . i t t , . ,nJ,( , l tHl t , I t t t r r r { r i l t l r t t4r l r i r r l t t i
4t
t l i r t l l t l , \ t t l l r '1, l l i r ( l { , l r l l l l r i l r l ) r t i t l r t r ( ' l r ( i l ( f c i l , l )u l i r l r l r , r r r r l i r r r r l ror l r r i i l l i t -l i i l r , 111 1111,. l t l r ' r t l to l r l l t r t l r r r r oclr i i . l , r r l i r l , l tozi l i l r qt , l l lx \111q1t. 1. l r ( ,1t111 11r i r r r l i r i ( . ( l r1 ( l11. l , l , r l \ l , r r r t t i t l r r 0 l t l i . i ( rst ,o ooi t 1[1r qlq,11;q111, r . r , r . i lq l l l i , i ], r rprr l r r i 11i l r g i l l t lu i , r . r r r r l jz , i ru[ - - ru in i os la oopi i r rs l r r . r , l , r r l c l i rL i r r r j .e, l r r I l i I r r l is" o{ , l t l l t r ' , r l l r (1 l l o i t I i r ( : ' l redlr( t ib i - l (p l . i l l l i | i i l l r l ) stnului saur l r r I l r r r , { ic i utrr l r l r i r r l r r i s1cl l , r t . l e i r lo-mestoi{ l ian) lRi ior , iOlZ ; Aneni1i lo l r rh. , 11)67 ) .
1.1 .1.5. lltumenul d,iplop,iei. Diplopia (perceplia a clouL imagini alorrrui sirrsul oltiect) apare doar in leziunile oculomotorilor cu strabism,rIr,or0orni1,otrt", fi ind absenti, jn strabiBmele ,,concomitentet'. De obicei,'olrrrrvrrl rlisliugc cu uqur,in!d,, in majoritatea cazurilor, imaginea ,,ade-'rilrr,lir' (rrdicii, cea, perceptt5, d9. o_chiul norma,l), care este n€15, Si imobiii,rrir.:r.nr.rrr fi pozitia calului, fa!5 de ,,imaginea falsd,t', care este mai puliril lri lrrcii,oarc, mai pulin neti, d.ar mai ales mobiH in raport cu deplasXiiler l iv i r i i ( I i isur. 1952).
ln diagnosticul $i tn interf)retarea d,iplopiei, trebuie si se tin?l seamalrr rrlr r rii,l,oart>lo prdncipii. (Riser, 1952 I Sachsenweger, 1966, 1969) :r) Irrirginol care trpar{ine ochiului afectat (imaginea ,,fals5tt) este totdea;unafullirrcrrlrii il dieclia_ de acliune a mlgchiului paraliza.t,, de piltl5, sprglrrr:r,1rl,rr, strbiectului, dacd abd.uctorul drept este in cauzi, I b) Oaracteiul[r rrrobilitlto estc deosebit de important, in sensrt cd, ,,indepd,rta,r'ea"r,|,rl rkrrrii, Lna,gini este mai mare Ia dirijarea privirii in direcfia de acliuno
rrrrrrichiuhri paralizat; c) Oinat privirea este astfel diriiati, incit.celeorrl irrrir,rrirri $int indepf,rtate la maximum, imaginea cea mai perifericd)lrrr ltitrc ochiului afectat.
. I)rul,nr, sl,ud,i,u,l mai preais al iliplopiei se practici, testul d,e d,iltlopie (al,li(lt i t.tlotul.( ). Acosta se ofectueazfi solicitlacl bolnavului s5, fixeze gi sd,rrrriirc:rsri trrr ltr.ivirea (capul fiind fixat) o sursd, lumitroasd, de mici,rlr'rr$il,l l.c (tlir,crirl uloi luminflri) rDezatd ]a o distante de 4 m. Dor l i l r , i r l r . ( r , r r ,h i r r l r r i drept de ptascrzi o st ic ld rosie, pr in carc Sursarrrrirrorrsii, rrltlrc coloratri. Apoi sursa luminoasS, va fi aleplasati, in directielizorrl,rr,ll, v(x1,i(n1,1, ;i oblici. Bolnavul va relata pozilia qi direclia depia-irii irrrrr,ginilrr., prcc[m qi distanla dintre ele. Una dintr.e imagini (fib6r rr r,rrsir., r'r,s|i 'ctiy cca, falsf,) se indepi,rteazi de cea rea15, mai mult saurrri pr(,irr, in l:urr(rtie de direcfia privirii. Astfel, rlistalta rtintre imagini, rrrirrrrql,rr 1xr rnrisurri ce bohavul pli'veqte in ctireclia cle acliuno a mu$-t i r r l t t i l t , l i rc i r t t .
l)i1rlo1rir, po:.,t,(',l i ot'irontdl.d (produsd de afeetarea muschilor ztbductorirrrIrIrrrrIoli), rertica,Id, (prorlus[ rle a,fectarea muqchilor rialic[tori sau
r l , r r | i l , r r I i ) , " . i obl ic i i ( f t !1. i ,8,9).l)rlir inrir,gilloit {alsri i.lpare de aceeaqi parte cn ochiul afectat vorbirn
':ln'o o d.illtltic h,ononimd, (sau, d,i,rectd, ), iar dacl a,ceasti, imagine fal$d,l , l , l r r . : r t : r rh, l | r r t r ' i l (x.hiului sADitos, volbim despre o d, ip lopt i I helero-; t t , , r (s,rrr i t t ( r t t ( iy t i ) .1n goncral , i t ip lopi* homonimi l sc a5oeir lz i l c utrnrlrirrrr corrvo!'!loril, i)r diplopia hei,eronim,i (incruci$atd,) - cu 'ut striti-t t t r r r l i t ' r r lgot t l .
l)( l i lt l i i,: I)i,plo7ti,(, o|izont.ald h,unzon.i,mii poato fi prodllsi, do luloz:r,r r l r l r i r r l t r i r l l rp l , r ,s iorrr t l t r l : r 0, IJ. , i lc la, 0.S. s: lu do Ia, a, lnbi i ochi . l ) rur j l ,lt,girrrlr sc rlo;li,r' lcuzr lir rLrlrIlts:lltl, srrrsci )utrrinolse slrtr (1t{.il,l)trit, (,sjnrrr l , r r l , r l l lp l t r l r r r l ' r r r l r r i l r , ( ) . .1) . l r r s i t r rat t i l l r ro l ( , rar io, tst ,c nfocl ; ; l { r t l r r , l r f i t t lI r r r r r rL, I : r ( ) , iJ . Nl i , r ' i r r l r ( [ i i t l l , r ( , ( , i r l i r r l lc i rnrr .g i r r i l r r lnr l t t r l r r xoir ; r r l i r l r r
+a*a)l Moovl .qK
o
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Fi?. 7. lnvestigal ia unei diplopi i pr iD paral izie a nelvului aotor ocular (xl fr | l ( l r( ' l ) l 'ochi lLl st ing f i ind normal :
.- StiLla r6ie s-! Dllsl in fdta o.hi. ui Prrc ?d lnagnra @lorait F tufL pc'e relr'znkli '
i' llnii 'lncont inr ,o. Se i . rs"rva'ca eLo
'o iu a" o di i ' l Pn homorin lmJ8i ' ea ro ' ie s" dPplr .e?e rr a l l r ' ,n lDulr 's
Lir bolnavLl Dr ivesle sDre Dart .a sa dFapir , .d icd dF PJr '1ed !(hi !h l t "n l i 'a l O Pa€l i t ie d dFlrr ! i ht l ' r '. t r rgara" o i iptopie or ianialA j ,n" isre, .u [email protected] tazj t iF d iEr8ini l . r : i , , d '*" t i denusdr ' . l . r . t ln1i , ' l
lEvrJ' spre pLn€ drPrfr3:, - Aceea. i invesr i ra! ie, d"r , r i , la ro:n ' .c at la ia. ' i r rn l - l r . ih 'Lr ! : $f i r i . . nF afrsr t dr" .
" , . r r i 'n i - l r IdFPl" / l I t r FisPr ' o52l
"el;, eita,J
r,-" I tf,Vt,,os( ) lV/ / tL lnt ,
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\.4,'/
| tg.8. Diplopie priD p:uRlizir nrutchiultr id]'ept intern, carc se :lIL'i llllr-ulr u$or slri'l r isnr divergent (sprc drcnpta). Stlcln fo$i(s{ r l ld plasattr 1lr fnfa oohiului palr l l r i lt , i l ' lopi l l r 's l , r i | |c luci)ut , i | r l i r t rx,r i , r ' rr1, lr)mlI i r i rof l t ( tnrr(r1,f i { lLr l i l r i i ol) l l ( f)nr. { l l ) l l rs(:rrzi l slr( j ! t t l t l I r t , ol t lnt l r l l l r l l ) , ,1_
'rr \ r l J i r i \ ' f f lo$!rcr l1 l r8n( r Id / l /s f / , l l ls : l ) .
I r i0. , . 1) ip l0 l ) ic geuctal i r t lc l l l |nr l lz I r I I r tdr i l lu i drol) t i r rh ' r ' ior d0 l ) l t t l r r r l f , . i r ! t r t .st i r l i r r r ) i i r s I l rsrr l in lx l t r , f l t lu l l r l l l r t ! ll l r l1. l r l I rUiD( r r o l i ) rx l i i l r r ro l [ ( t i r ! | |cnl i l ( : r ll in i i ) s, . i | , I ) | r | , I , : |2n \ l ) t f l " i ' f . I r l l l l l I I l | |r l r r l l ( r (1 l t ) r i \ i | r r : r r i l l r l l r i r ln i [ , , r \ t l
r l r r ' , r l r , r r l r l r ( ( l r r l r r , l i t$rr l , l l l l : r ) .
t aa tn $ UH
u8 Hn
Ht{u w I
r l , l j l r l l l l r ' ; i l t t l r i t t i i , t t ( ' t t ] r l t , i r l r , t1 i I l r , l l t t t i l ) j l r , t ( l l , r , l , l t ( . r l r | | r I r i r i r l i i ,i l l l : r l . t l
l ) ip lu l t i t r t ' t i . i l l i l t i I I t I t ) t ) t I i t ) | ; | . r , t i lc r . { r i l l iz i l l iL r l , , l r . . r r r r rL, . . r r j r , l ) { r1.)rl l l r r r r l ( \ I r ( ) .1) . , r l r . l r ( ) .u. . i i lur tk, l r i i r , rnbi i ocl t i . . \s l i r i , , ] l , , , , , , , , , , ,u i l i le.
r t rs l r r . r r ( r , r rz l i , l : t
r l r r l l l l rsrr lcrr srr l r , r , j " l t r - r r t i t ruasc * i ,a" . f ia, . ,1, i , , , , i l ( , i l i { . t ic ll t l r r l , , ( ' i r csl r , l l i , ( 11r1 ( l t t l ) l l i r i1 i11111 O.S. ln s i t i te! i r l i r r l , r :sr i , r ,ezul t i i , c i ,I . r r l r r r ' l r r i r i . r '1 i r . i i r r l t ' i r r r r (J.r) .
-A.1,ulc i " iua
i i t iagi" " 's"
i .del f i r toazi..r 'r ' l r l.plrrsi. l i ruLsci lrrrniLroase 1n ambele clirec_ti i -*rlrol"tr_
ateotarearr l r i lo l r l r , r '1r l i i t r torni .
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E
d dN
rut
d Tru I
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',o1 m,,Fig. ,?. Diplopic genrrJLd . d. l ' r r r l j r i l
muqchiului obl i " marc (sru onl l r s" I r ' r r ( ' r '
de partea clreaptd, cnre h nlot i r ror ' r t l r r l
depl :ceaze globul ocular In af 'uJ s i l r r j " 'St ic la colorat i ( l in i i obl ice) s ' i i r l i l i fn l
inaintea oehinlui PamliTrrt '
D5
, li: "lli:",:';,:#:;'#;:;,,:::!,,t:;,,","_3;',?'"J't,Jj'lil;,"i" iyJffi il-l::::iiii.qinH't,iiiilt*,:,*.#ii,:;:,?#;,rl*,ru;11;,1*"*1".ru;;r .r, I:r slirrg,,. Sc sta'ilegte ciircc.tia dc A"pfi*.r. , i"iJ"i'i ir,,_oo*u
"r."t,r;lril:1ilriiiii,ll,$l1x-"#:'oin{ff ,;t*m:"*|i",:,*;lTg"%f.?:ll,rliliii;;t:i',ii,Jillll.t""ir.:'*-## ji,i":;:-..#,J,jljf ;I r paralizie
lnr rlorri irrrrr,gini, prin inclinz,,, ii,,ii,'i, riiicr t' i". ̂;,,#ilX ;?d;L1'JJJ fr#ii:flf #friH.l"r, u t,rrrr.i. rkfiicicnla aparli:re mqchildr conoriioi,i, ia"-iaca distanta.rlrr lrr, irr.lintu.ta spre in sus, este-vorba cle. p"";rt;;di;;#il;rrr,rrr{r,lr,s sc ilnlunc ileterm,,inarea. ochiului pi a mu-;ctttului aJectat. Astfat,c vollrl rlr ochiul drcpt, daci, imaginea iann lrosle) est",ma, jos sau
-o1 m,,Jriq. .17. Diplopie generatd de paraliziarniEchiului drept superior de Partea dreaptA.Sti;]a coloraLl s-a plasat ln fata ochiuluiparalizai. Imaginea colorate se depiaseazlsnrc in sus, cu atit mai mu1t, cu cit privireasc
- lr i i "azri spre ln sus 5i spre dreapLa'
je poi tc remarca. i obl ic i latea imagini i' 'oloiale spre sl incu (dupi Rirer ' 1952)'
r!rs. I iit".rl hdh lO la ridicarea sursei luminoase (sau 1a ritti_
,, I --T-----l f"?:,iff;"|;;H"Jil"f,,",1J"J;'"ffi,,f1b, I 1 rerpecbi_v oblicirl mare sau dreptul irfe'__
I n. I rror pp de o prr le (coborifori a.i globnlui. -r , ] * lq I oc.ular) Mu dreptul superior s i -obl icr
.:....., I | --- .rl1'!, p:. qo a.l1,i p.Irtc lridicitori/. Asrlel,
I , " . . . . I /_ | orca_drptolrr vert ical f l so lccenl rreazi ,
2./r.2. Paralizia nervului oeulomotor eomun
Existii,,srise situalii sen'iologice in cadrul paraliziilor perechii I Il l-tt ' I
. 't oarali2ia ertrinseed po$iald (inconpleld ) cu alectarea uJr ttrll slrlr rtlir 'r
rl,,itir." . o..til i u:.irinsi"i i i l p)arat'iziit ' ertrinsecd completd' (cu rfr^r'lrrt'r 'rt
iri*""'*t*il if i" ""trinsi'cij
; 'c\ Ttaralizia i rt\rinsecd- (cu aflctlr'('r ' i lr 'rrr
;, i l;;"il l*ii ;; pilocor'st ridtra re i : d) paralizia totald' (cu printl"l 'rr :rlri-
; ;;;;;;i;i i &iGi".i.i i qi, "*lei
intrinseci) ; e, r) irt mllort ctt.frr.trr' i i
i;;;;"s;;;;;i*iiri" p6tn"nii a rrr-a poate fi : wnilateraLd' sau bil'axatatd'
2.4.2.1. Paralizia tctald' a nenu'lui oculomotor aomtLm ilmpliax' o-.ptond
""f""fr"aie oo*rrieta ;i un glob ocular imobil in dirocliile- ilo a'o{iuno a'
i 'rr(.rirr"" ati, "T
i"i"t", arupi inferior (mi;ci'rile iu jos fi ind tol'ttqi itttt tr -
,:ii*]"p"!u't" ir";" -".ii*"i
rnuqcbiului bbuc-mar'') |i drc'pr sulx'ri'r'St:rabi.imul ttivirsent csbe foarte'evidenb, irr rliplopia cste orizontllfi ;ri '"i"-ii*i,. ptpita este midriabicl $i ,,fixa", nercacfiolrirnl lr lttmitrii ' '
Ir! flcomodare gi la converAoo!6.
2.4.2.2. Itaralizirt' parliatrd, a nerawlui ocuLomotot coT'?lzzr, osl'o ltlllll
,no,i ireoventl ,fecit oca 'corirplel,ri. l)iur trcbuio rolinut fllrl ' l l l cil ' tttltttrrrtxtsr
i , , i t r i i t i l " , , i " t t t , l t r :
u lcc I r t in nl , r l r l i t r l incompleL (prr ' r l i rL l l . l i r ' l r l th 'btr l t t
i,i,,..r.i""ii. i i,: ' i"-i ',,i*ui ., ',,,u 1x'.'t I ' i i 1r:rr:r' l izici' Ar:r'sl:r' p:Lrlrlizii prrrIirrlo rtr
;;;;;i l i,t blli,i,, s,,h t'rtrti l l lzitrtrii ' i inoi sing.r. rl 'rtrttti, srt'tt $lrb ll),nN
iiii rr ,,*,,i,,i i vrr,r,itbil. rlo nrlr*rr* tl.rr ^f(nJli[,tr)
ttr tttr!i rnttll,,t rrll l l lt l ' i lrol'vr)lr'Hr!
il,i, ', i l i i ' l i ', 'n,, ' ', ',,fizol,zr1,
irr,bl,rrrli tltl i lt l 'trtrttltt 'ttr vrrrirllriLl' tl ltit 'tozohtt Hrlll l ' lrrll
/i Ess,/--\ | ./h.
o ' ( \ | / / / / /Ann\ I I V/////t --\*..
I Yal
/ r , l , i l r l r ,p i ( i $( fn*rr I I dc plrral iz ia'h l l l l , r i l | r i ( r ) l ) l l ( : (s obl lc inf l r l ior), I r . l r I r l f . I t i i , ( lnrc Ll nrDal t rormsl
rrrrzn { l i , l r r l r ) r :u l r t r ln oLr i r ' [ t l h sus.I r ' , r l i r r t l l r l s l t l Io ln[cd od)tuluil l / l l , I l rdf l ) r l f l r l ro l in l l r ; t i l l colo-r1r l t , I | l lx l I l i l n l t r t r ( : l d ( l bolulvul
, l l r ' l I Mt i I l i t I r ' r \ Ign (dtr t ) {/ t i r ' r . , 11)5. t ) ,
carea_ capului), ochi l fiinal in adrluctie,muqchiul afectat este obticut mic (/2.q. JOjlllntry dcpistarca pdrtii paralii1,i", oi_tarmo,ogrj Dbtlizcazd" si prob& lui Eott-rnann qi Bielcho.n-sky : dacf, indepi rlarer,imaginilor se mx,re$te prin inelinarea ca-pului la d.reapta, inseamnd, ci, obliculpic sting este palalizat, ln sittratia incare diplopia nu se accentueazi, in aceastd,pozilie cle adduolie a ochiului, estre vorbade paralizia dreptului superior (fig. l1).Daci, diplopia se accentueazd la cofori_lea sursei luminoase (sau la coborireacapului), ochiul fiintl iu arlclucl;re, rnury-chiril poralizat cste oblicul maro i,11,,g. tZ ),in sohimb rlacii, diplopia nu so rcoclrtru-.irzil jn lcou,sti, pozifio, a[unci lllul1(jhiulIrrrrll,lizDli rrsl,o rlr0llt,rrl itrl'rilior,
: ' . ! : ' , : . ! ' t ! , l j l t l t r t l t t l i t rut t t* l i r : l47t , t t1to. [ ia pL t : l iqxr l t ryt t t t , 1t 1t , t t . , t i ; : i i lct l t t t t t l l t I t ) t t t l tU) l ( , l t ) t t ( ) l , l t .
: '.1.:!..;.1. I'uruli.,:i i lc lronculare itint ijelc tn:li lutnet,oil.se, in specia!|rrrr :rl,,, i i ', i (.11t. se (lezvolt;i la nir,elul bazei craniului (J,hnsi,ori qil ' r ' , 1I . lo l l r iou, l1)6?i l iucker, 1966; Riser, 19i2; popr iv ic iu l i l?ascu,I : lr;0 ). li. r r rl r'li'gc
'iL, ilrt,rL]cit nerYll ocu]or:rrotor cor1tun p:i}isoqte tt,unchiul
( f'r ', 1'r' irl l)l ir l i) i la$oioulc, leziunik: ,,rad,iculare,1 lil accsl, rrivr:l ltaiizcazL:r l , . i . r ' i l ' l l t i l l ( ' s i i rLcuale alo muschi lo l oculomotor j . i l schirnb, l . r r l teIt ttt,tlt. lrr ',i.t,drr[, lrttttchiului rertos prod'c o ]tt.alizie lotali ' i dc pcrtchol l l. r u (,\(1{il,1ifr i ' ibrelol pentru mUsculatura ocularii intrinse0i. care..r i. l,r(
'r 'rirr(lc o olul'ciite protectie specialir in lozirLnile blza.le. ltrin ;i:rptrrl
r':r r.lr. rr, rrll i silrrLl,tr intr-o pozi!ie arialir ir.r interionrl nervrrhri. doarItr ltrt lr ttsittntrr itt l tut't antirttd plotlucintl a.fectaroa pfr,(iorrr lt l lce\loI[L1l r , l r i , r ' l i l i ig i l r r , 1!)50).
' ' l .:. ' . ;;.1.1. I)u.ru.l i ' '" i( [rcnrcttlard izolutd, singu,latri a nrrvu]ui o0.rlo-, ,1,,r ' ( l,r ' 'r p,rric l i i r.r,aliza1,i i do procesc nevrit ice, meningitice (ir iclusivlrrr, lr lr '), r 'rrlr,ori do alie pluceBe bazale (dupii culrr rom r.etlea), ri:r, deolrrr l i , lr l irr \ '(rrit) i i l i t1c1l lcestui terv cu ceilalt i nervi oculon$tori f i i (,n't lt irr, r 'r r r. ltrrriIrri, sc rt ' l l l izeazI sindrolrne tt.otLctrhrc r.-\1r.i lrre\"r, it,\ in]e ale.l , r r i , , ' r l t i ; r l i r l r . r r , r ' \ i ( . l t t r i , , r . i .
: ' .1.:!.: j . l .:. '_,\ inrlntu,utt tronc:tt lr.r,t r: entraneuoJ)iale d,c It:: i .tttt i rnull if ie,1, t r , r r i lnr t i r , t r i ( ru, r :o in leresarea si a mototacular l l l t l i { :o. t , tu,n,) :
\t l l i trtttrr, o It rt l ..tn oltk:aiaii- Se lt ie ci, trunchiul lerr.ri lui oculoritotor.i., ' | | | | l |r \rrr{l lrr (, l | l l l , l t(,1] (1lt 1,r 'ei :ulcle (:uttCra bazilar5, a;r1.era. cerelir, loaSli
rrlrr.r 'rrrrir ri l ;uJr.r ' l r,t 'r,r, lr lal: j l losLcrioari). Aceste configuleiri i topog.all icet , r ' r r r l l lzr l r ( ' i r r r r , r ' r r r l r r i j r r arrcr-r , ismelc qi in proceselc l j ,ero- sf a l ter io-I l "1, l l , ' l l ' . : l . l . . t , r t i I , . l ' . . n l i r s( . r , \ i r l i ( ,1 , t nt i , t rnt t t r , , : ! r l r t t6pt l l i . t l in
l r l r , , r r l r l i r r i r , r r l r rnr i t . r i r icvr jsrr t i , r r l t , eccstr , r r ' - ]a" . . - lUigr" t i , , c, f ta i rn ip legic i ,r1'.,r 'r.r|. , lr i.r ' i irr rr. lr i l i i l io sa,u adolesilcnli, (t i ickerst:iff, 19{l+), lr, si i l i i ircti
, , r ' , . r r r r r r r l , r , r . r j t ' t r l l r t i l igrot loaso, l ie tami l ia le, f ie person:r le. I { ig len:r , of ta lr r r , , | ' l I r , r r I I ) : r i ( .s i i l11r ' t , l l ( fz0sal s i r n i 'mcrze r lupi i O nigrel t i s i rnpl i . I lnrerOa, l , l , , l , l , r r , r i r 1r ' i r r r r r l s i r t r l r l , , r r r . l ! : . r r , ;1c uni latera i l , cu io l l l i iz : i r .e or1; i i i l i
| | r ; r , , r r0r I r i ( I r I i i I , i r , i | l td j0ro Nl ] l ' { r vct tex, i lp:rrc c obicet 1 l r cr izr l . cUi l , , l , r t l ' ,1.(1 r l i t , r r t . r r | i r t r l ,u. l tu ls:r i i l , , r r lesr. t i , iusr l rLr t lcr gr . . r1, t i s i r - i i r 's i i tu l i ,1, ," r , . r r ' r
' r ( t , i r . , r t , - , I lJul( . . . \ l r , - .1, f r o, . , . t , , , , . , , , , , i ;1, , , . . , . i r r t , rz" t l :1,r ., , l . l , l ; ' i r . , , ( , r r ) t r r l i lu i ( , l i r : r r t r r r rut i r l s i r0al izoazl-r , . te l mai f r , ( { r r1:er} t o at i gcre, r r r r r l r l r l : r - : r I r , r ' r ' r , l t i i l r t r l l . r t , rcsptrct i r id uncor i inelv l l i i t i i : r1.r , inseci i , i . l {o,, l f l , . : r l \ r r . i r r 1 l r r , r i r r l i tLt | r . r :st i l ,0 rnul t n l i r i l l t , , a i lcs i r t , i t . r lsocir t i | cu.r l r r ; , , . r ' i : r 1r l r . r ' r , l r i i l I l1 r i . In rrndc ca.zrr l i poai .c f i in1,( , i ( , f i l l , r i r rc i . ru l, 'J l : r l r r ( ( \ \ ' i r l r l r r i ( ) r l ) { r i r ( ' r l ) . , l1}( i l ) ; . [1. l r r .<ur, 1. .96$). S-rrLr r l t ,s, r i is l i r lLnr: .r r r r r ( ' " r ' : r ' i r ( '1r ' r ' rzr l . r l t | r r , i pr i r r r l i I lopi i 1r , t :c i i i o:r , t r r , l . l i l i i r l rucl ' i , s lLr [0r , i r r0rr l l r r t r : r r l r . , r l l r r r i r l r r . r r i i r i rngrJi 6 i r i r i ; ' i r . r , r r i i o l l : r l r r roI l r , i r i t i ( l l< l lL:z 5i Sol l ra-r l i
' r , l l l t i l , ) - , , \ l i ' r , i , r r l l l r r r r , r , r ' i I r r , I I r r r |or I r l r I r r l i r r r . I i r [ r1or i l i i r r r r r i l r l r r r r : l l i r
.u,r , r io l l { r r ' \ ' i , i t r L l r r icr l r r l lo l j r r l l l r<r i rvt , r ' i ros, l lc l t i i r . r r : r t . lc l r r l r r r r r l i t l l ir r l , ' r ' ' ' r , , , i ' r . l r ' r 'zrrr l r r l r r . r ' r . t i i r l i l : r l ' ( i r r i . r I r , r r r r r I i I r t i ( \ \ , : r l r l r r r i ( ) , l r r l r i r l r , ,l l ) t ; l l t .
4t l
l r , " r r l . r r l . r r r r r r l . l r r r l r , l r l . r r l r ( l . t . r ' , r l r . r ,1r i i r I . r ' i ' r ' , r l ' r ,1r l r r r r r , , l r l r , r , , . , , i /; r t r r r r l r | t r lor ' l : r Jr l r"r l r l r r . r I I t I , r ' I I r I I | | ( , .
l i \ l l r t t t l r t t t t t r r l r l r ' l t t t r t t , r , , r t ' t t , t t t ; \ t t l ) t ' t i ( ' t t t i t (Ntt t t r l , l , t t l r t : .1| t t , , i i ' r l i )
t . ( , l l i / r ' i tzr i . r l r ' 1rr1r1, r r lu rrr l l r . r r t t l I t , r r t t t t r ' , ( l l l l ) l l r r l l l r r l l l l l l l ' i lz l l ( l i r , r ' , t ' l l t
|o l r r l r . " l l ) ( i l l ; l i i r i , l . l l l . , i l ) :i \ ) f i i rul t 'onl1t i . t : lu,si t l t l , r t t l t r . x. l t t tr t idul i i , r t l . lui l i rrhtt t t I) tr t i r1ttrurt | : i t '
cai ta{r ter izeaT.[ ]x iu1,1 ' ( ] l ) l r l r l l iz i l ' l l ( lc lo l 1,1| i l l ( l rv i o( ' l l l1]1l Io i (n i . i l l i r iL l l i r l ( '
afectar( 'a f f )nconr i tent i r , t i o l lahuioului ' Sc re: i l iz t l r tz i i : l l l lJ i l l ' r i ( ' \ ( ) l l i r l l l ) i ( '
(uqol reducl ib i l i ) , , ptozi , palpebral i , o l ta lmoplegir ' ( r ' t r vJolr ( , ( ' I I I i I I ( I ) | | I I ) I ( ' | '
imobil l r in 1lalal izia le.rechi lor I I I ' lYSi YI), trxtt l i t ic i tr i 1) lr l) iLr l ! ' ( l i r i l r i l : i
areactir .- i la lumini i Si la acomodare), hipo - si l i t lnestozi(r i tr 1r 'r ' i lo| ir t l
oftalmicdui, reflox cornean abolit ' dureri in teritoliul l lorl 'rr ltr i rt l lrt l ttt ic.Daei, sint a;fectade $i f ibrele simpatice oculal'e, apare o lt iozti l trritrIIItctrIrrII ir1e cocainii. AceastS, tr, iozil ne indici, respectatea g^rurglionul i t ' i l irtr ' ; i , r 'rr,.afare, o lr:zjune exttaorbitlr i. Dimpotrivi i, aplri l , ia midrir.zl i rr( ' rrltrrl l^atenti: i rsl lpra unei leziuni intr:rorbitarc, ct l ldecta}.ea fi lrt ' t ' loi ' rh' Lr t l:rtr.Elionul .1il iaf.
b\ Sintlromul de apen orbitd,l ' al lui Jacob ti Eollcl sollmirri ( 'rr lrrl '( '{r-dentul, dar, lr in distrugerea soncomitellt i , qi a giul ' i i opti( ' t, s(' rtrltrt::;: i oleziune progresivii, de nerY optic cu cecital,e Trrogl'esiYri r i^rtsoli l i 'r si rlrr
chemo$js. Dxoftalmia estc mai lrronunlatl ' i , r lecit irt si i l t l lottrl l l l l t(\ lrt l l tr l l.qi pulslt i l i , {prin comprimalea $i a Yonelor oll i i i l lnicc).
Iractorii etiolol\ici care irebnie dccelati sint :- L-actori traumatici: ir iterven-ii i le chirurgiotle (peJlLllr sirrr; ' ' i l i . '
.de exernplrri ; fractruile (,ralu'cnL' care intercseazli ' i i orl)itn: lt:t|Itr| i lrr
.aripii mici a ,ifenoidrlui (cu afec{area ini.t iali l a lel 'fcl i l i lr ' I l l ; i l \ ' . r lr lrultelior si a tl igemennlui - Rollvet' 195?r citat t le I loger fi ( ' tr lrrl), l l ,( i l));tractura crtstei supraorhitare (in aceasiin sittatie, oetit: l tcl l lr lrr{,trt l{ ' ollrul-m0piegi:l).
- Iunrcri le: neoplasmele orbitare i tncll i l tgioanlel( ' , ' i i uli,r:rrrt l lr 'eryului optlo: t, Inorile osoasc (osteoamo' rnot:lsl 'Nze osoils(r, l l l lr iot 'r rrrl
.ostcocla"cte, chistuli osoa.se) t meningoencefllocel ; cl istut i t l t ' t tttrt irtr ' ; lrr ' l iprolifertit iyc dt sistcdr (gri l luloame eoziuofi le, boala, l lLi I l i tt l l Sr,lttr l lr,r 'Ch'jstiari, rrieloame, boala' lui I lodgkin) ; turnoli t le l-ecjlt i t i ,tt i (1 (ltttttot i rrlr 'r3inusuhli sfenoidal, tumori hipofiza.re; tumori n:tzol:l l ' i lrgi{f l)c, ittt lcosr' ltr€arcinoarne rpki{.xmoide, l imfoe.pitelioame, hemangiot^pil i: l irrrt ' t i to St t tt il 'asarl si colab., 19i5), Aceste ult irne tumori rlazil lc 1i tritzolrrt ' i ttr.1t( ' lr,pot lenliza i ltt i i si 'ndronu,tr cle Josi Ttleri yopalnl i n i al I rri l ir ht stttt siutlt,,nul., t le plan\eu otbi . t$ d, l l l t i Dejeru, in c l to se rc l l izpuzr-r i t t i i i r I l .z i t l t t r r r t t tct t t t l t t r,{nlri lal superior qi a non'ulrri clnalul[ i ] ierjgoi(l i lr. lr ( l i ,rxct' 1i .olrt lr.,1969; Sr in ivts l t q. i colab., 191ir) ; i lmor i m{-: tasf i l l r i r { } ( t r tL l r t t t t r , i r l i ' l ) l r ' r ' i r r ! ''ntit lntr sau Df[,siallc l.
- tr- scli, i i l \uscll lari: l tner'risn c]; i ingiolnxr (ir spi,ciir l crrr. l ttorr'rr ') ;ti o I icc u:.e sr caro t idir .
- Ll-ip crrt, ' tee, cu ale1brti lat 'orl f isuli i or'bilnlc sttpt't ' iurt t"r '.
ttJ Sintlrt ' tnttL in.fracltnoidian al lai I)rtwl.t l st ' t l t l 'r lrrlotizcrtzit pt itrrc iun0lo s in(h{)r}rului do al l€\ (n: l ) i ta l , dtr csl t l } r {x l t ls ( l1r l l l r / r / r i l r i ! r r ,<d. t . t l t t "e i , cat t ) l i l lo i l f iarrLa si l ,L l l l t i I l p i i r t ( f i r , l t l l l t r l ' i r ) l l l i i r r s i t t t tst t l t t i ( ' | | \ r ' | | | | ) r I ,r . l r lq t , r1t ! :a,zr i l l l r t t l ' izgl t t r r l i t to i t i i r : l r l l t l t ' io l l l ( f ( ( l ( t t l l l ( lc l ) l ( , \ ' i l r ( f I I r ' | | | | | | | i I t ' | |r : j r rh 'orr i r r l t r i ) f r i Ffr( '1,(r l { r l l r l r ' r t l r t l tut t t t t l t t l t t i oI i i r ' .
( l ) ,Si l / / r ' ) / / /?f l t l t r i is l t r t t l . i r ' 7 '1 l1t t t . l7:noidrt l i i t t l l t r i , l r r&! l r ' - r lc lcrr l iz : t l ,r i r , l , r l I r r ( | t i cu l r t t t t r I t l r r l t l t ' f l t t r ' l l l l r l l l ' l t r l ] l r r r i i , l l I i t t zr) l r i r r l l l ) l l r l r rar r l l l r r ,: , r r r r i , t r s l i ' t r r r i t l r r l r i . ; . i s l i t t | r r l , ' l r l l l l ' t l t l l l l l l i . i { t ' l t t i r t lo l f i I r 's l l . r ; i t t t i l l t I t l l r i l r l i l r i ), , r r r r l r l , , l r l r l r , ' r ' l r i l r r t ( l , r r t t t r i r r l l l l i l )1" :1rc l l l I t i I r ' l l , l l l , lV rr i \ ) , l t r ' I ' t r t r l
4' I
lii:,;/,,1';11,,,",n ^;,,i ';;;l,l';,i;i;'l;;'ll;;;i;Ji,lliii:l'lil",llilllil,"Lilll,ll,il,li:i,i,ll;lllI t) N iurl.nnn.ul, ilo ,nt
:tr,r::i,:,1:;t,;,*,ii#x;!i:x*[ffi ffir:;li#j:P"*:Trl;:3:;l' tii,;;ll,l; ; t;t*:ll,*lt,ru Ff til;,"l;l;fu".,?ftritlts#Hl;{iI ;;..;i' ii '] 'l1l'|fili*,1:"'n'*"
i" ̂ t"'ito"iuriliiifri".\i.ii p""uri,ia perechilor
,,,r,i,;j,:iill,JllI:i,,gl?j"t: Eoger qi corab., 1e0e qi de Arseni qi corab.,tr) t|,in.d,rornul anNerior- e,ste identic cu sindromul de fisurX orbitard,ri lrr,r,r{|lrrii, (cu coafeCtare& qi
-a nervu]ui opU"l.'^--*
.
tt) N,intlromul med,,ian coafecte?zd, to.,i icuiomotorii 6i primele rloud,J:l:l:l j,lilil!lT:f;it*.1i{1'jx'H',",r"1,Hffi 1r;ll"t*;;":nf,I;i j?rtl#,,,,,, j;l ll;iilj;fif'l
"#:mi: atecteazd,:. toate ramurireri:;,r;ni;,**uili::,,J,ffi #i'"'#m'Fl:,-k*#?#i
;iil;litil;'li",ll:,T,1#**,ff i'*1116*:f1ti*_T,%trf ;Hr,i"#fdr r r rp| ' r . l i l i r r | ( ( , r r I i ic t ' imare), p:ry,,,rr,,r,1,riirrri,li;l,,1if ?*1i"-?H1fl*T*1":i'fli*i"",S1llf fml*:,,,,,,,,',t'1,t,,"'i,l,i"'i;'i,"0!,rll.on')
se adaugr' d pQ'tro' l)ariantii,: sindromut' gtaratrise-Ir't <ttori tli.ol,ollici :
,,,,,,,,1,1,,,'11i,11:,T,ill,;il,H11i,f,l"Jifig:'.ljx"l?,:i"tfdeosebi "'anior,rin-lo l : r l r . , l ! t ( i l ) ) ; b) l l \ rmori rn
i;,lll l,,ll)(;ili,'ii,1,,,,,,".,,'*i*l,'iff-:"'i;"if,fl:x;"^'ii*iiL tigt!,",",Lq;,r; ,.ri,.t
,t,,,,ur,tr,u: ale arterai carotid,e (Jeftercol, 1958; Arseni qi colab.,
. :il ,l,t.u.t.t,Dtul.i,rzr c/c, incleosetri cr. realizarea de fistule carotjrlo_ca.yer-r,,' iu,.! r.irrt irr.rrriolrgis rtalizrnzdL rapiO : ottalmopt"egli ?riftamli puts:"titer , r LI | | | | , | | | I | | I \ i , r ' i l lonirrr lc ( I ioger i r l colab., lgOiO)."| ) 'l,nutlnfhltitt:le sin .sului caaernos ,tealiz(,azri : exottalmie masivd,,,,ri.rrr IrrrIIrr.IrlrrI rju (,xtensic
lfre ftuni9 qf _p""
""gr""#iemporata, starerrr,;rt rlr,rrrir.i, p.rrvii, 5i Jcziunile respective Ae ocrriimoiori $i trigemen.!) i.l ll( lr.ro.ta,ea infecJi,oase : meningite t rrrtn, o.oiogite sifr_litice.ti) ltol.i d,o sxrtarz.. mir{om. multiplu (boala iui foft.1 5.*.t,',) tlintlrr.trnn,l da hemiboad, ,
(sindromul lu,i Garaii, tintl,rotnul lt6tttrttlriu yi Q rrn:itt, sutt, sind,romul tui ..Bc.rtolotti-.Gairil,"i ' io"tu realiza, in..rir,xl,{rl .l irriu rkr rna,sivll, Bi r:xtcrrsivi, utu"t""" ii" o".Ji;i, ' ieni, qi p',ra_
lil:jl,l,,;iililli:11;lrrlui conmn (cu rorlizal,oa, a" r"r,f,l'r""i ori;, nroprosii
t8
It, Si.Ml,fomu| Lui .It 'hrhn' ( | tl lrl i) H(\ t'rtt ittrlt 't ' iztrttz'i1',ltl irr ollr!l ln('pl(!grr,'rrta,,rio'rtri rt,rrdloxirr. l)o l 'rr,1rl,, 1,1rr, r,rirlri, tr ftrltrrir t l.irt '. ' '. i i ' t1*.7t1 i'nauroytrtlirt
l ikx, , iwirr $ i l losor ' l ! ) ( i l l ; { l i l r l r , l r ' ,1 r ; i l ( t l l1 ' , l l l { i l . ; \V( i r r l t l " i l ' r l r r r ) , l l l ( i l ' ' )' t; Bi)mtrom'u'l ' de ar(xutltL ,r' t ' l ittttsu,lrti rt, Iosl; tloslrl ' is tkr Ifisclrot'-llri iAgl(Lgi i f f i l i se da;torc 'Uo (x) t ' l ) r . ( 'Hi l r r i i .crvt t lu i
'c l t l t t t t t t t l , , t ' <, t t t t t t t t t t l . . r ' i , l t r r
,,i 'casta ilivus'lui, ca urttt:iro , proccsclol hrloc,it ' lr. t[. sltitl ' itt (rxlrttr
"eiebral, hematorir subdulat q.a.i. Succcsiunea
-de ittsl'alaro rt' 1ta'l 'rtl izit ' i
,,ste 'r'in5,toa.rea:
miozi tranziiorie unilaterali - lrritf iazr'i' ;-i 'rrpili'fixd - ptozd palpebrali' - in final, paralizie completi a perccltii l' I I [-rt'
Fischer:Briigi€ iiolo; a izolat dou5, forms clinic-e : a) lorma aau't'd', itt t"'ttt'
naralizia ocirloniotorrllui este urtratd, ime4iat de pierderea o111lofliilrfoi ii, ' Surn,n progresiad,, in care paralizia perechii a [II-l sc.ast.rci:rzi itr tttrNI
lreplar cu somnolenli qi apoi cu piertlerea cunostrntol'' H1 Bindromul Iotoia-Eunt' Olialm'oplegia dureroasd" (sitrtltrrtn-ttl . l ir-
tosa-gi*t) reprezintd, entitatea nosologic-5,.in catc se-asociazii o oft;n'ltno-pf"ei"
"u o ndrratgie brigeminalS de aceeagi parte' Tolos:r (I9j41 a. tk'rctir+
itriimunfeeia, dur-eroasi la ul caz cu le'iunj peria.rteriulc :rlo ritirrrrrlrri
"r"otioini.-iut llunt gi colab. (1961) la qaso cazuri cu inflamalii gri ttrlo-
-rJomu lente ale sinusului ealvernos' Smith qi Taxtlal (1966) alr folo$il'
iermenut de ,,sind.rom Tolosa-Ilultt', Ia cazurile care au lespuns tavoltltilta tra'tamentui cu corticosteroizi. ln acest fel se pare ci' se t'intlo sit' srr
fac6 o clistinclie clari, fa!d, de alte sintlroame asemdnii'toarc, diu'.citrtriini produse de'leziuni, in s1]ecial tumoralo sau inflamatolii, care tttt ctrtltrltziioromnt la tratamentul cu torticosteroizi (Other. 1967; '\ti lslcitr ;i [lottr'.
i io, ibzi; nnllf,lt". 19?3)' Lapresle qi Desi (197?) considct'ri cii It 'r 'rttrrttttltle'sindroin Toiosajllunt trebuie folo8it numai la caz*rile la ('!,t{) llll n(!poate stabili cu certitudine etiologia'
Mai recent, I[unt (19?6) a stabilit urms,toarele criierii pclrl'm tLingttttx
ticul tle sindrom fotosa-nunt : a) Criteriwl, anat'omic: deficitul tttrtttolttgitt
"*i"-prio", prin leziuni la nivelul sinusului cavernos anterior qi nl fisru,ii
ornitiale sun,jri"are. Structurile care pot fi implicate incltd nervii rttrttlo
*.io"i, ""ii"t
oftalmic, fibrele pupiloiilatatoari parasimlrilf ico t t l t r r t ' t r t ' l l i i
a IIf-a, qi fibrele pupiloconstricloare simpatice ale ple\u1Li lttlritl i lttrl,irIirltt.b) Cri,t'eriut etiolioi6 qi' terapeu'tic: atingerea forrna{'iunikrr ilmittlil'rt csl'r'
iiatizatA de un iirodes inflamator granuloma'tos oronicr 1i botrigtt, citto
reaclioneazd, favorabil 1a corticoterapie.Cafuu,I 'notologiools indrom,nt ' lu i ' Io low'Hunt loa[()1: i r tst l 'o ls ist ' r r t t t ; t
t iza ' t { I [unt , I961; 19?6; Lapreslo qi I } ' ' ' i . l l }77) : i r ) r r l ' r r r l i t r I ' t r r l t r r t ( i t
"nuf l ' i * ambele spxe; b) debutul mL ci ' " lcc iLt do ry i rs l . i r ( r l i t r . t r1, i I : ' i t i t '
rrlo; it A""ua" a VI-;), cu predominlr,rtl,l l l l virsLtdo nrii6cii; o) (l(' l)l l l ' lrl
i laie fi nroelesiv, in citcv:l zile sau in inni tntLlto tti;n1to (lo-?l ll l lrglrl l l l loi
ii,ota-itrii; ii) seninul rlc debut ce1 nai <xtnsl,rlrtt' ()sto 'Lrre're&'
olro lllllll'1r
br-usc, de obicci ct clt(rvr zilo ina,ittl,oa' oftalmoplogici, oontx)lll i l '(rrll (111
oaar* iu, *uu, iu rarc c i rzur i r l l l ,n i i r r l i l r t l r t I t t ' : i i t r : r l r l r tLtu ' oI l ' : r l t t t '1 l l t 'g i . i I
; i - ; ; r " i a i r 'c t iunea ( [ t 'buleazi Fi l r : t l i , , ra l r 'a s l i r i i gontrraL' , r : t r . I r r l r t ' i i '
rnodeTAtd; f ) dUrerea esLe l ln i lAtol : l l i i , 'cr l r . ' i ; i t r r I
r l {1 t (gt t l i i 1r ! r r l t ) r l . l l l
""i,o,"li.i oital*ic, raroo'i prezonLin{f i*,rliri '. i lr horrrir:rarrju; g) rlrrorilo
sin't severe, cu caracl,cr contitnru ii urt oxu'c"arbrtrri pnroxitttioo. qi. u'0o U)il'-i i i^iu ao :r,ti.,"r,nzii, ou na,t ll1r I trrllrrrrilr' i
'5icri' ivo do eurLsibili l;rr' i '. tn t'ori
i i r r i r i f n- f f i i - i " ,1 l r r i , urr t r r r i hr i , r , r , i I , r , i r r I l r r l ,v l t l r r i t t l tx i l t r q i or t r . ' ' r { i l l t t t l
ir, ,*t .,1 rrurvrrlrri ' lrra,lrdibul,.r; h) olil,n,hnollogit, 1xrrr10 li tlo rttit,i tttttl l,o
iiprii;i I ,rxtornn cornplri;l l, (li it rtirr r,rrzrrti) I l i,ti 'g.r'. oxt,rl.n.cll, izulnl;ll,
{o
l r : r r l r r l i r I i t lo l t r l t r : r l r r , r , r , r . l t t | : r l l l t r ( l / i l r l r r r r r . . l l l r r r | r , r . r . r , : t t i l i ) t1 l i r i li " r , , r ' l r r r l t \ | : r { l . ' . , r l t r r , . : rzrrr . r ) ; ! : | l . t : t i r , I r , | | r l | l | l i r l r r . r l , , , r r r I r , I , r I r I r . . r i i r r , , r , r , r rr ' , . r r ' t t r , , t | | r . r t I r ) r r | |LI ILI I I ) | . I i i ) ] l l i l | l i r . r ! . i r l | |1t , . l , l r ] t / I I I I . I l I I I ( , I 1 | r , i l . r \' i r o l | t ] : r l t l . t l : l ' , { l i l ( , i rz | | r i ) Lr t ; r | j l r l r i l i r : r i r , l r , , l l r j t l t t l | . r i t l l l | l l r . t j rzr lr r . : r r , l i r r . l iut J l t l i r r | , ( , I I r , i | \ . j . r , . l ) t1. , r l . t t f i r ( [c l r . / , : l r . . r 1, . , r . , , , r r , 1, , r l i , , r r l r r i , , ,t , r t i rz:r r r r r l r t : r r l r , l |z : t t r , r r s i r r r l r : r , i i i , , r t l r r i n l ru rr i l l l l r l ] ( , t , , , ' , , r , .1,r , , ,1r | t , 1,ort l , . l lr l , , , . l i r i r
' l , l r l r lo l l r rur I i r . r . l r r . I . I ) r | r , I , r r l l i . l , , t l l , i r , , , , l , l , , , l , , i i s{ , l } r ) i r r { f r { , l l } l l i , t lI i l r r r ! r ' l t . : r . , , r ' r ' \ l i l l l j o l t l , ic (1, ' { ( [ i l r , ( , ; tZtU, i ) i t , t gr l r r t , . r ] , , r , I t l l i i0, Ou InrN; i , i i ;1 r . : r . r l , i t i i i r . i r ro( [ i l i ( j i r . i lor . I r rnt l r r l r r i dn ochi ; l r ) \ , .S. l I . cste r i rx l r , r , r r l' ' r ' ' r l i , , | ' , ' r i i r , r . rzrr ' i r . iur ' { . \ rnroDl l r r iehirrrr lu i , . . . t , , to, , , , t , i , r i , r i i , r , , , i , . '' ! . r . | l . \ r , t , . l r t : r ( j t l | l i , r , i iozi r l iscrcta ( l l6 din cazur iT; l r i l r ,ost i r r i i i l , .I ,r'.rr:lirrirr. r'rt:lrrr[ ,r.i.. t(t de_ proce'' in aflra G;rilri""";;;]]:;i;; ';],,,]i,l;1,,
,]:l.ll:.ll'].:lril_ll,,.lt,,,t,rrlt'rlfla in unete cazuri o uilpr""e t"coriiri,.,iii, ' | | r r . t r , : r \ ' . . r .1.o\ . : r o ol , . t r r r . t jF a r .enCi of la l rn ice l tu i lSr, , in . i l f l , , rr ' , . l r r r , t l r l ' l ; S,rrr l l r . i r rL.r . s i l t r r lpp, 19?3); n) s i r r .pto_, i i " pr i t i l ; ; ; i , ,. , r r . . : i ; r r : i r r r i r r i . f , i p(r l p.ozcnl , , - rbmisiuni
spontan'e,- -u
neor i cu def i t . i t .' , : ' . , ,11' ,19, , , : r r .zrr r i r r r . : ( , ) l :cnomcn., lo pol . reapFro l r jnterval , dr . l r r r r l
' , . i ' . , ; l l urn: tg l r , s lu l r lntn: t lo logie r ispunde [r lorabi l la ldmhistr : r r r . : r ,,, ' l i, l l l l l i::, i ' l l: '! i l},
or){Urilr(hr-se unoo4 o remisiune complerd, ilr cil,ovrr,. ,
, ,1 : : ' , , i : : .1
, l : : ' .1: l : l j l l l . r l \r iu'c:, I ez j : :^ la pr.es te si Desi. reTi); r) r t in prrrrr.r, ' . , , , r l11, ' . t r , r l 'Ntr lg, . l r . . r . d iscul i I ie exis lenla Lmui proces i : r f l lm:r lo l ., | | r I r r I I I r , | | I i I | , I ) fi 1rs.r.l.t,urno,l .(IIallpikc, 1g73 ;' flult, iOfOl, ti" a ii,,,,i,Jtr,r'r',,r' irrurrilrrrl| cil Ia clzrDile. Aeicrise Oe-Uathe* {i
-Clanhy ilSf 0l.ri ',rr,r,"rrr:rr,,r,rsi:r criuici, a sindromllui rolosa-rrnirt poate-fi intil irir,irt I t (4 t u t tt t tt't r t tt t tn ) e care:,par prin afeCtarea aceleagfzOne topOUrl,li|r,',, i lr. r':rr,{r lrrrl 'ri. sri,-l diferenlie-m, ,ieqi
"""orie;t;-0.#Jit a" di'i i i i i,,f. 'rritrlurlrl lrrrrl,r,i sfcnoirl:i le ( iloctton_Duvigueaud) ; b) Si"O"omut "1ru*ii,lrrr ,r"Iri|,:rr, (|IrII 'rI,) ; c) Sindroamele sin.sului cavtrnos; cLl Sintlromrrl rt,,r:',,lrrrlrr.
'.i,rrrslirlr.irlalri (Jacoti) ; e) Sindromul pereielui extern al si,,r,rrirr ,,ir,y(,rtr)s .( lnrix) ; i i) S."l,lr.uryrt paratrig6minai al lui Raerl,,r,;' 't i 'rrrIr' 'trrrrrrI rrri
'rrrr.rrirxo; rr) sinrtromirr tle dff'us aiiui-r,isoner-griilrg,,.
l) lrr ;rl;r,nr, sirrrlr.orrrrrltri ,l.olosir,-Hunt, a, cirui etiopatogenie a 1it$lr i r r l r r l : r l : r r r l r i sr l r i , o. l la l nol l ( :. . , . r l , . r i l l l . , r . r r r i r r . , ,^u"r , , r , r r ! | ] !o. t" t 'eroasd | to^te f i produsi i , ' t i t d. crrrzr ,
,,t,1,:,1 'i'ililli1,,":!:::,i!::,,i:,:,,{,i#[":,ii,,iil*fr,1i,\iJ,"?:rlif,fJJ,,,:flj;.'i;iililli' i ' i :, r i r'rr r';r'r,r irli irrr.r'ri i. r)rrrariziir. ocuromotorii qi ale
'erv'hii trig,r,i,,i,r l \ , r r l r , r r l r i r r . i i l r l r rLrrrrr j r r rn: i t i r l l i r , v iet i i , la i roLnavi caro ar fo l .nr ,r : , r ' r ' r I r . r I i r r I rcI , s l l r r r r r l i l l r r , i l r r i r .n1. f ) f f 1 i1 le1rtegja s i r rv ine brusssj n, ,, r , , t , t , t r ' : rz i r i r r . r : i ' l r .y i r ._ orc, ( . . i ' ' l te or l cu r i l . lerea tr ig"_, ," i i i , , i - i i , . ,
' , , : r r l , : ' l i " I i r . . i r l iv t l t ,s i t r1, 1.r , , r , r . " ' tc , . f i , , t le accea; i p: l r te,- i i r : de, par,k, ' ,, ' l l , 1 . . , ' ,
, : : . , i
, . i ' . i , i : l . l f ' , ,1i . . i r ' , , ] . .1e?{)). Dintr€ nervi i bci iornoturr, 0t, l r l r it r ' : r t ts , . lv l l l ) ( l l to( , i rs, tu,rr ta,1, t lc pelcchea l t f f l - : r , . Dc l r r t r l l , ,i ' . r I r , ! r ' r . r . r r I I r r I r r r . I r I r , . : i i r r r l is . ' i^ l l i , . ' reslxtctdre: l . , . ,sc* l I tur i i i r r1,r , i r r ; . r r . r , rt l : r r r r . r l . r i l ) r ' r i , r1)Ti) . ur*rr . i so po,tr : r ' i rna,r 'cr dr i :1. sr i i i r r r r r I r r i Al , r l r ,r i . l r , .1 ! ;1111(\ l ; r r r , l1){ i r i ) . l i t ,s1r l ' r ,1.r | r , r r r r r r r*c l j l i tur . i i in l r inre( i , l l t t :o l r r r r i l r i r r r r r l l r ,, | | | ' , . r | , , ' r . r | . r . r I r I I r . r l t r . r . , r i r r - . i , . r ,1: ,1r . 1 l t i . , ; r . I | r l .a l )L l l c: i r r r . t t i r : r L| l r r ,L" ' i I r r ' r r ( r r ' , l r r . r ' r " i r l . r I ' r*1, ' r r . r ' r r l r ' ; r l i i 1r 1,run( ih iuhr i r )a.v i r l ' i r , ( , rJ.rrr l . t
i , ' , I ' , ' , ' , ' , i i i , , ' . ' ' r r" i l )1 ' r r i ' : i l r i r ' l ( ' i r ; r . r ' i l i ' r ' i r r r i , t r r t t r r , ' t i i , i l t . . r r t l t i t rgrrrr l , r r l I i l r . r , l r r r .
I ) l ' l : r l r r r r r l r icgrr r I r r r r . roI l :uI l t r r r r : r i Iosl , r l r ,sr , r , isr i r r l r r r l i r l r , r ,o l i$,1t , , l i ; t .' I , r I r t t I i t t r , r r r i i , I roI i r ; r r I i l r r I I r I r r , r r r , , | | , i | | i i , I I I ( . i i | , I r . .
: , l l
l r ) ( ' r r r tzr ' l r . r ' t l r ' t t t r r t I r ' r i ' I r | , I r | , ' ' I I I r I t t t r r1r I r ' ;1r | r
r l r t t I t r r r r ' l l l l r l / r l r |
, r t t t t t l t lot t t r t t utrr t / r 11rtor ' r ' r I r ' l r . r l r ; r r r ' , t t t I t I | ' I t t t t I t { i i t : t r | t r l l r t r " t t t l t t ' l
, , I | i r . : r | ( ) .l ' r rx t ' t r r l t r ct ; t l t t ts i t , r ' r r t r r r ' l rxr l r l iz t ' l tz i i l i t t l iv t ' l t r l i t l r l r t l l t t i ' r t l r i l l r l '
r l I r r l I t ro i t l i t l l .s l t i t lO. i i i r , : r t , " r ' r r0rrrr , t r ' l r r l rz i l t i ' i ' t l t t l i i i ' l ' l t r t t r r l t : l s i \ ' r r r - r l l l l i ( l ), r t ' , , r l i t t lo l : t l t t l ( ' r l l lz t ; i { ) l l l t l l r lc lct t t t i t t i t , l r l i t l l l r t ro l l r rg i i l l l l lc lor tst"
"r ' t : t ' ' '. , , r , , l , r r l r i i . . i r r r t t l l t l t t l t r l l t i , , \ t r i i ' r r i ; i colr lb. (1f)??). Ul t 1I I t I t IoI I1 i t . i ( l ( r l i i l " ; , ( l ! r l
t , ' , , , , r r l . l I i ,xpl t tL,s i r -e csto (() l ls t i i i l i l , f io r l r - t i rLr- : t t l i l t r l t ' l t l l l l i t t rxr l t l r ts l r t t t r tz ' t
i ' , ' r r : i : r t r ,
I ic r lc r i r t tastazc c l re provir l de l i l nt ' ,o l r l ls t t l ' l l r i l i I I I ( I | ' | ' i i t I i I I *
I r rLr ' : tz i t t t tnol i l t r intraclanioni , pr imit ive (nlet t ingiol t l t t r " I t t [ t t t I r I t t r r r
I t , , r i i r r r r r r , , cnrt t io l iut ingioame, cordoameJ tumori o0idelrnoj( lo ( ' l (1 ) ' l , t ' { ' r l ' t l
r t rrrrrol i l<' , ,ru,t*, , 1,r ' imit ive '(osteoame,
mieloame, si lrcoal l t i ) rrh' ) ( ' \ r ' rrcrr i
, .1:r l r . , I l )17; l l lhornas si Yoss' 1970).
i\ lrrl l ir lrrraii i lo \:: lsctlai 'e reprezintir d.upti, ' I 'horla's f i \ ' '(tss (l1l ';0)
,1,r , r r i t r I l r i iY fO 91, , i in cazrui , mlarea frecvenl . i a accsto}r t f i i t t t l r t l i t ' r t r r r l r r
' ' , l , Arsr, t t j q; , , i i 'ab. (197?). b intre acesi ,car : r l ler i r ismcl t ' .s t t1t t ' r t r l i t ro i r l ic t r r ' '
r l r : r l r l r r i r i , r lcs 1a or; ig inea arterei coml ln icantc po'sbcr io:u( ' , l l ' l t l t { ' l l { ' r rz i t, , l t . r l r r ro l r l t 'g i i t lLtr t r ' , , , ise cu instal l re rapidl , cu:r ; Ioctal ' i t r r : t l r ts i r ' : i i l i
, , , r ' r l ) l ( , l i i r i 'pcr 'cdr i i a I I I -a s i cu durort- : local izatL pe - tcr j f ' r t . i r l l
r r t ' t ' r r l r r i
, , t t : r i r r r i r , f [ r i i s i l se i r rsoleasci dc regr: l i i t le t l lbur i i r i obi td ivo t l t 'sct ts i l r i
, ,1,. . ' i tr.vr' istu'le inli iaclinoidjenc (intr:rcaverno:nsc) sil l i ' reslt,trsrtlr i l ', , ,, l lrr lrrropleuJi (lt l lett)rt$o ctrro se inst:r ' leaz5, prop5resi' l ' (,,pst't l tLrl tItrtII l ItI ' '1,
' ' ,, l ,rrlulizic oculolnolorjo complt*i l ' $i o nevralgie trigtlrn-irrat' i t l ttc lxrrtlr '
' t , 1, : r r i l ,o i lor i r r l netvului r - , f t ' l lmic qi s, : , rcompaniaz'r i d ' ' t r r lbrr l r ' i r i r t l r i . r r i i r '
" ' " r rs i l l i l i la lc l laroot ' i s t r p ' r r r lc g i : is i o dol icomeg:r t ' : l r r r1 i r l i srr t t . I is l t t l i t
, | , r l i r lo { . l lVr.r 'nOi lSi .l r r l i ' r1 i i lc o l r t t i t to logi t , r : ( : t r lestr l l l r in intcrrn( ' l I i i I I
-u lLoi l r ( t r r r l ' r 'zr ' ( l l
! Lr r . : t , \ : { ,1, t ,os) s in l sctni i , . latc r l i r r r r i r r ( , , . ] t i l i [ ] t l f , i l r i rL I i I | I r t1tr t I r t t l l i t r r r l , t l
r ' j i l , 11t i in i , t i t t t i l r t ' r tzLi : i t t l t t l i i l , , r l r l t tntr l r r i s ; l ' t l r r l r ' 1:r t i t t l r ' l t t r ' i lL rrr r r r l
i " , l r l r . l ( ' j s int tz i l r '1r ' , c l r t t to j t l i te lc.
' ' .1.:1.:i.:1. I 'ara,l i: i i le rutl iL. 'u,Ll;t 'e (i.tLt.ttr ' tttttrrt 'r: iu' lr, t l(t t t l l ' t) tt ' l t tttt j
, r r l i i l tot( i i t t l tz i t l r t i v l tst l r t l i t lo, in l l la,rnLi tor i i ; i 1I t t t t t t t t I t I0 l t t r .zI t t r r r '1:r l i r ' r "t r f I r ( ' r i r r iL l r i0r t I ib l r ' l r t I l r t ' r ' r ' t t l t t i i ) | l l lo l l lo l ,o! ( 'o l I l l l11 ( : l l t r t t ( , l { ' t t l t r t r t t ,
r l , r i r r l l l l l f i tg l i ; i c t t ! l ts t i r l t t l t l l t r s( ' l lz i l i l ' ( f s i t t lo l l i r i i ' s l r l l t io io l ' i : r L ' u i r t r r r :
; , , r , f l r i i r r I l l - l r so t r t r l r r | l r ' lc i lz i ( ' l l s( l t l l l r t l i ta l t l i l l lL l r r , t ' r i ' l ' l t l r i t r t r r t i r l r r l " ' ' t l
r r , r l l , r l l r ( ' t lc l t t t t r lc l t l ' t ls t t - ' i r / srr t t r l t r l t t l l i r t t i i t ' i sct tz i l i l I i i r ' ( ' l t l r r ' l r r r i l '
, \ l ,Si t r r / t , , , r t t t i / l t r i l l r lnt ( : t i t t r l r r t tntr l ' pr t l t r t t tu l t ' t l ) t t t ( t t l ( t l i t t t t t ' t l t l t t t l '
t , , , i , t ' r t t r l r l t ' t i t : i r ' r l t r r l t t t r t t l , t t . t r t t r I t l t t t i1t I r ' '1 i , r t r l l t t t t , i l : ; t t '1tr t rorr l r J t t l r t t
, r , r u l ) : l l r l l iz i i ' i l rs i l r r l r ' l l r l i i t l I I r I ' t t I t t I t io l , t t t ( lo l l t t l l l l i ( ) l l r " r r r l r l11 :1 1 ' : r r r
1, , r r r r r l r , , : i r , ) r 'otr I ' t I r , t ILIr ' t ' i r I rL I ' r l l r r l iz i l l l l t l t l t i i l r I l l - l t t ls lc l r r l l t l r r l r t t t l r r r tr , l r . r r ro t l l t lot ' r ' l l t r l ( '7 i l l l i i I i l ) r r ' lor I l t t l i | r t l l t l ! r l l | l l ( f i \ ' l t l l l i I l l r r r l t r r i " l r l l
l , r , i r r I , r , i r . r , 1r l i r r l r ic io l r r l l l ( .2( ,1{ , ( , l l l i r1. l , ) i i ic i r r r1Iot ' | , I t I t i s i l sr ' l : l ( i r l r j l l ' l r , , i
l l , l l l { l i l ( ' r ( ' l l l , i i f l i t t l t t ' t ' r t i l r rh i l t t l s i ' r ln 'nt l l t l t r t , r | ' r ; t ' t i : i t t t l t i l r l l ' r l i / r l1 ' r r i /, , t , l t ' , t t r l l tht lLt i t t t ' r r t t t , , l i ;ntr t t l i ! t | t l t ( l t l t t l ntr . t t t t : t . l t l i t , ( " l l l t r i ) l l l i l i r " l r r
1 ' , . r l iz i , , io l r r l r i r r I r , r . r , r , l r i i I l l l | , r l r r r ' l ' i i r 'a i i l ( . l i ( . i l t r ro l r I r l I | | r ' t I r I | | { I ( | | t I I
1, ,11,rr t r l r t tsr i . l ' ) r l t l l r : r r t l l r , , l r r lv : t i t t r l t t t r rnt t l l t / r t l " , l l | ' t t ' t I t I r ' ( l i i r l r I
, r r . r r r , . t r l r , : r t l r , r r , r | l r to i t ( | , t t r l ( . t | l r . ( r l i l : ) , l l ( . r r r ' l r . l ( ' l r ' ( | | | | | | t I I t I I I I I I
l , , r l , r ' l | : r r ' r ' r : t r t r t l , : t t i , ' t I i r , ' t , l t t ; r l , ' I roI I I t t i r I ILtr ' ' r ' : t r r ' I r I t r t I t t i t t t I r l l r t r r I
, , , r r r l r , , ' t t Iot t t , , I r ! I ( i l r r t l r r l , r l r r r 'ot t t l I r r ' t I t t t t r I t t I t t I t t t (Nlc l t ( lo l \ l l , l ! ' r | )
l:llr iriliiixt,,liilii;ilril;iri::iiii:r,li,,l,,ij11liil,'i'rl]rr11 ;;;,;,;:r :rir;m; '.;it ') b i nl.tr l ttrt l t, nuclttt l
t;;: :''ili:ii,,l;iilfixr;,,iiiil[*"jlti4!ij1l{i"i1l;rlJl:,|':l'';]-:'"rI :l ;r'r,i;i;lillj; ';il;i;ji:[ji],iil,1j;.",:ii{i:[]:l,ffiiJ1,J*1-i,,i'{#;i;f ,',i,,1',ir*rili**p,;ti*;.t,;ifiixr*ilfiit1{{;ll*'r*ii;iliiltifi;riiifii:;#xrrn!:,;"!i,:":i',iiru#*,
;r,;;1iil;1;iif#l*li,r*""""**-;ii#!{;i;x$*l,4,fr*#ri ;, i j,, i: iI ;r ii, IiiI I Iri hr*li*rtl st.,.ffi ;.}l gtt'1,,ruI I I ;, t, : I l';r:'':t, i i, lj-;.;,t * 5 $;*g*iiffi ; gi,hT,ii,,i,:-i[t'id**,f*iir***"1,*n*i*l**rui:?',","l[: l, :i;il,,,il-;,ii *i,'illJ:?j**ffi:ii."i?:*"" "..,"."",i1{iitfli*s:;
I 'orrlrr Ii lrr.orhrs 5i de tumori aie glantlei pineale.
.ir,11;li,'lll{rii3i#i3{,,1fr{$Sl1"fu *",+,,grf:if :uffi.r*?;; ii lllli i ; ir li*':i*$*?i*ruTlfl *t+ffi$-**+*ffilll,ir;i;.lirl; j:lir,l",1",x'1"{lli*ii:i":"dl?:':il"J'"{"'rT; jffi,".it';;:;;Xg
l;:l:t jlliril;'{i,',ri,iffi #j:ifiT!:i{{:{il1'.::.,rj'-,:f otareamuscu.
I rriiiil:i- iili*i* i!4ffiiq1ll;giEil{iti ;*lffi,l::l:l::':l?l'1,:"il'l,il,,ii,,il,il,,',il,itli,"l';,ll,,l*ii,iS;jUruifii.,*f n:llt l r l " ; t l ) r r l r i l l , i 11i prrrrr l - r r r t r , r rorrr
i*ili mrniil,-'lr'-*'i-ili iiil*iff tlrft;t*'iti,liifi5tl
t r ( ' l l r l i r l r r r l r r ror j l rz i i , i t r r r r , l r r r l ) r 'o( l l lso rLo l r .z l l 'otr t i I , t ' t t r r | . t t l i I r t t ' r { , r \ ' rJ l r { r tl l l \ ' ( r ' t l l i l l l ' .
' \ ) tJ inr . lnt tu l l l uni t l , r I , , r . l r r l , t l l (Vic lo l q i r ,o l r r l t , , l l ) i l ) , r l l i t l iz{ . : rz i ' i
. i t t r l t { r r tn l to logirr t i . i t t i r l r r z i l r , , l ro l ioct tctr l .a l i td, l rct t l , r i I t r t t tur t : r t i ' ' i r srp, t i -t ' l t ' i " ( : i int lrontul Gtt l l r l l l r tni t l i t :) . Sernuele eiLrt l i t r i r lc i t , lc :rcrrsl,ui r i i t t-rlrorr sint : a) oftalmrplt,gic [rilrrl,elalti in glatkr (lifoli1,(r; lr) sorrrrro-lcritri: c) ataxie; it) l is1,:i,grnus; e) delir in faza acul;li rii stalo arrrtrcsl ilor,oufabulatorie in fazele tardile. Pzrraliz:ii le ocukimol,olilor sinl rrrrclrrirlr,,incomplete sau ctlmplete, cu prezenla la peste 50]i din cazuli r lrlozci|:rlpr'lrrale fi cu oxistenla rrneoti a t'ulburirilor pupilalo. Acrsl sinrlrorrr1,s11' rrodus printr-un defic,it de tiamind, (etil ism, tuibuliiri rnol,ulx rli lr ').
B) Bintlromu,l I{estenbaum ( Bindronlul periapetlttataL ) rcr,lizoir,zii rrrrrontp\l, clinic constituit tl intr'-un sindrom Parinr"ud, la, c:ne sc rrsLrcirrzri,irisf:rqmus disju:rctiv, mioclonii oculo-retractorii, tulburiiri pupilaro ryi pnllzcrLuclea,re ale perechilor III ;i IY.In acest sintlrom este aiectal,ii srrlrslrur{rr,cem;ie pei iapcrluctala, nucleii oculomotori si barLtleletlL, longil,rrriirrrrli i,posterioarS,. Leziiutile cele mai fr"ecvente sint da natut'il infcclioasr'i s:r,rrischernicii, (ocluzii rle arterelor plandui posterior al pediculului rotr.urnrl-rniler, sari ale ilsusi pediculu.lui retromamilar (Aqgian ryi Vuil, I l)5$ ;Pop.r.icir, 1965 ; Popoviciu $i Afgian, 196E ; Aqgian li cola,l)., I l)71-i).Zona responsabili de aparilia sindromului I{estenbaum este replczcnl rrl,lr,de un sistern morfo'fu:rclional periapeductal mezercefalo-diencciir,lic, crrrtrrrrc conexiuni cu nucleii oculomotorului qi cu centrii oculogiri din tnrntlrirrlcerebral, prin comisura albii, posterioari qi prin bandcleta krngil,rrrlirrrlli,posterioarl (Bentler, 1965; Taube qi colab. 1965; Pasik, 1965 I Sh rzor,,1965 - citaii cie Popoviciu qi A,;gian, 1968). Popoviciu $i ADgirn (l lxis)nu plopus - pontru fenomenul de ,,nistagmus retractorius" * torrrrrrrrrlde ,,mioclonie oculoretractorie", ari,tind ci aceasta are ca, substrnt rnollir-logic leziuni vasculare sau infectioase, reversibile sau irevcr.sibile, ils('til,ode multe oii de hipersomnii qi de mutisms akinetice (Popoviciu qi collb.,1980).
C) Sindromrr,l Lgle (o vaiantd a sindromului Kestenbaum) Bo (litrrl(i-teuzeazd, fie prin palalizie bilaterali, ile new oculomotor connnr (1nmidriazS,, sonuolertri fi uneori paralizia miqcd,rilor riculare cle vcrticir,l il;rr ttr,{ie prin spasm de convor'gentd, qi mioz6,. I:eziunile rcsponsabilo dtr }rorl.rrrxr-lea acestui sindrom sint de naturi, inflamatorie sau. prolifclai,ivi,.
D) Leeiuni,le ttu,cleure ala ocxr,lonxoton ,ui comun, tnai illos ookt rlonaturd sifilitici, duc, la teducerea tonusului in murschii oculnri, irr sprr,irr,lal ridicitorului pleoapei superioare qi, in conseciniai,, la a,parilia urroi pl,ozolalpebrale bilaterale. fL unel) cazuri, diferenlicroa fu,lii rlo sinrlrornrrlOlaude Bernard-Ilorner este thficilS,.
E) Sindlornwl arterei. nuclatr,lwi, oculornotorull,wi co rnu.n (ALlllolli 4icola,b., 1952) implic5, afectarea n ucleului oculomotomlui oonrun, nn{,loii(,omisurii posterioare gi conexiunilc vestibulo-cortir:a,lo. Artoril rrrr0lorrlrtiperechii a Il.I-a pare s5, tic o ramurti a artoroi sulorrsrrlui htonll, rrrxlrrrrl,ivtu a,nastomozii intro artcra cc,rebeloasi, supotionril, {i itrbolr! corrrlrrir,lrl,ix.r s be r io i n'ir, .
'Ir) $iw)romnl Lwl Aaenlald, Sohuranberg gi llu,m'pol,tli (nil;rr,t rlo Alsorri6i <xlllb., 1.1)67) csio o n rir,tt i l irglu,r'u liri lr,to tar[, oir,r' l lc1;or.iznlii plin uxisl,rrtrf,urlo oirltrli, (ru o (lutiti i; i ' i, lrrrxlio tlo 90 Noo rr(Lr, lrt r:l,r'o ir,l l,ur.tr r r:tzr), ll lri l l izirr,cornplol,it, rr ;tolrxrhii rt, l l. l.l, cu ir,r:l,iv il;rl,ou, axngorrr,l,rl, lr, rrrrrirorrln,t,ur.ii lrrcr.-v: t l r f l , t lo rrcrr : r ,s l , i l ( fot t r r t r r r t t t t l , , r r ic l ic" : r , l ooulorr l l l ,or .u l r t i r ronrr t t r ) . Anl l i r l ,
It8
lll 'l\i'lll"lli ',illii;l;'i:11i;;:;j1i1'1,,1::.'::lllrllll.'tLfi" rrr' rr*'rrrrrri. r'rrrJii :r 1r,,r'r,.rrii;rillrf iiilri ri, ll,ir;ii,,ri imi:lii;iiUiU_i, :liji;li,illrili;l-.ll$ri I r i I ril lli : i n, ii; i jitit lii tiiii*l'l; ltw jn*ltt llr,,l t*xxl * ;t:li",'1,,li,i.]'"ili?l;'i*t'rLitr
binc contr',tr'r rs,,-*"'ri s*iiiii''re?4; \,oiculescu
iJ,4.it. lhrolizia ncrvului paletie (trohlear)
:!..1.;1./. N n(r de semic,Iogi,e
Nrrr.vrrl lrrrl,ctic (trohlear) iaerveazd, - mu;chiul oblicul ma,re, care", , l ro:r . t j i t :Lr l r r t l ot , t l r , , produc
ll,;ll;l;,-;li':till,:';itx",{if;i#ii#?;31[.i"_fi fJSf iff*"ur?#j":. ,
('lriilr r prrr':r,rizic d. grad med.iu a muqchiurui obric mare este suficientililiill,iil,,'1,,1,1,',',,1,':Ji'i'ill#3fi ,!g-P.u"1':' vertislrd a imaginilo" 94di;;;I ;j; :;I llj;il;ir, il,#[Ii$:1ff:i!i ".'" i;iff
. *'" inciina'li:;ll;iili'l',1;,,11:;1i.,:l1;*gT{,i;;ff :i'TT,:'^'f 1tild-1#lr;;;q1,;1;riiiiiurriLi,rhn1ir,:{lir:lrr{,rf*ir#jirilnti;rliiri:l,tl;iir,;iiril:l.;lriu,*r,;'an'l*lxl*:i*#lii*#l::t1:':l:r.:lll riiir'il; li:.;f,:i#,1i:""..""'t'lTirui"?llTHHii#,f*.tiiliill ; i' 11,,:,:i:1 1,, 1'll i
"l", l ;1,,,:1, 11),lillil::;l ;,r\{;1*?J,?*1.1ijli l lililrr ,..rr.rrl t ':rlrrjiziikrl r.rrrhi- in iartr s_au instalilt ,i s""i" d"'i i ipr*_ sau lipo-,i;l;ll"i",,"lllil;ll"llll ,,ll,,i];lii':i,,:l;lilr,ii';Trlli3i*;+i*i":i"i*i"" para,iziei
, , ,.,,i i l,'," ,j,',,,,',',',,:'"lt t t t d rt tl'iu gnosl,ic etiogtntoienic ,si toltograf ic 6tt pa.al.iziile
,.., , t,.,. , ',,.:,r,,,i,i i lt, t,rl)rcu,l.are. inso!,esc jle-cjieni pa.rali-aiile percchii i ijllil,,,','l,,ii"ii]",liiilil,,,ili,/"lilnll"9""oas ' (rcrrers;n)i'i"-'i"a"ui""r i"i't"i
, . , , , , , , r r , r , , r . , , . ,1,rrrr i r , , , , , , . , "o. , lXiul i l "" l t , l l , , r j "{X1", ' s i roi lcr ; i 'u ' . :n-
,lll'li,!:r:l;i;i;ii;'trltTi.t#'iT*fflti,rli!i:,r-1J*?:{'l,1'r'4iii,tii'l jii:,i['t,Hf ;f il"ill,,;lli;,,tt]:",:;#;;,:;y3ilii";;;i;:n,liil iiili,r'li,,if:i:;i!i':,,,{:i:'i :i:;Kili;E:f:::i#,,Jffi,/,,:i1l lL?"li
1l ) !\tratiziih: nttderr,rr: rlp, t rr i l ( \ r1( l t ( \ l r , r r . r l i r , r r r
^, , , , ; , , | i : j ; l i :J i : ' . r r
IVa sinl gr ' ( t r t ( l ( r ( l i [ ( ' r ! ' r r t i i t l ;
t
l r ) l ' l r l ' r t l iz i i t l l t ' l ' \ ' l l l l l l l r r r i r ' l i l l r r r r l i i t l i i r l t l rN' l l l l l t t r r t ' t r l t i i t t I I l r r t l t '
:Lct .or t l i l tar l ' t l s i t t t t l r ' l t t t t ' l l l t r r l r t t l i i r rs l r r ( [ ( ' l t i ] l l l t l ' - l l l l (11(t l t t i i l r t i t t l t t ' tx l t 's l t
tuu" i i t io, r . l t toef l l l i l i t ' t ' : ; t t t t I t t t t tot I t I r ' ' l ) i l r c i [ l lz i l ( [ ( ' ( l l ls l l t i ( \ i l to l ' r ' t l l t i i r t lV: l
i t r port iunea posl ,c l ' lo i r t : r : t l t t l rs l ' l t t t ! ' t ' i oonr l f i i l ) ( ' l ' i i lp(r l l t t r l ' l t lc ' lozi t t t l I l t
;;;"i";;;;td;";.1ii i 't irl, ' rrrrrrl.hiulrii oblic rirrr<' tlo lrit 't ' lrtrt' ol)rrsi.' I '^r'rr
lizia bilaterald, izolalit rr ttt 't 'vrtltti patt:tic inctici rr leziuno nu(l(l ' l 't i1' Hi vrr
1pp13pi { i - ferenr i r td rL ' . i t r r I tDtt t t t I fhgcodr|-- l l " l lwrI '
b\ Sindromut de ortcrd, cerebeloasd superioarri ^(s.itrdronlll
[x'rt' itrlr.i i*,,r]oi' in-" a tesmcBtului) este un sildrom inezclcefalic all 'crrr' (I()IIj 'Li1'IIiI '
a#','t".tl i i i. o""*"nii n-iv-u .oot"*latcralr' bemisindrom cctt'lt"los lt.l lt.
lrtn"Jf- *,i 1""iirin6rom senzitiv tle tip slringomk'Iic, d" pil,r'trotl olrrltlil
leziunii. Se loate asocra ot *-d"o- Ciaude Eernerd-Ilornor i I t "l i I t I 1 r ' I ' I t I
si chiar o hipoacuzie *u. *"*Oitni"' Leziultile lntereseMi' lxxlttntrttlttli;";;;;,
"r,,oJ"io",-1"*"iscui metliat, lemniscul latoral, fibrelo prrpil r('
;i coliculii inferiori.c) Nucleul perechii a pa,tra mai poate fi implicat itt . sirldromtr'l :ttt'h
*n ii il*iii tt":riipia"ctati sili,sizd'rimut tectl piotlus ile lcziuni opifiznnr'
2.&.4. Paralizia nervului oculomotor extorn
2-4.4.7. Bum'at d'e d'ate semiologiae
PerecheaaYl-ae$teafectat5, in30-500/u. t l int t lat t l t l t . l 'z t l r i l t l l l l t t . l 'implicn paralizii ale mugchilor oculomotori (!hrad31- 5i Schlczingtrr'' llXll)'
ci t i ig i - ad Popoviciu qi Pascu' 1980; I latsud:r , 1 'q63) '
Dinl'opia este bornolaterali 5i orizont'alii" Firlszr' inrrgittt '.ttrt' iL rtl 'rt 'rJi
se incieb1iteazi, orizontal itr privirca in jos, colror.lrL. u.gor \r s. irl)r' i.)'r.
"l#Jii'r ii""tii'i.", r" ttt. Aiest ultim finomen sc explicS' priJr !(tnlirrlrr
i#il"ei"a ;li .""unre""t" lr privir' u in jos ;i tit,div15t1n1;t I" l'.11.]ll.::in Susl Srrabisn?al csle convergr.nl , iar mi$c. ' .or d( ' i ru( t l lopc l r . l { l . r ' r r l r r r
""i""'r.ip."il" esie lirnitat5." Capul -este-rotal'
compcn'satll 1:' -l:ll.li1afecral5. in parezel , ' dc percchc VJ do grad l r rcr l l l l l l ( t ( l l t l l lg i l r l r r r : r r ; l
.;;';;;iil";;i" mod gr,,hat ;; echilibrii intre hipor;a'c{'iunr:u' rlt'opl'trlttii"t".i' iiirrp"'ritri"n"" -.rtopt..r"i cxtorn cto partoa :lp"*1' -::iitt.l .lllli'l Jllcarurifd
""nirliouitut pctrlru prirnrl rlatil in :lccast'ii lilzi! osl'tt llr('u {tt' slirl}rlrl'
dacfl teziunile initi;lo au ?ost tlrcpLc satt stingi'
2.4.4.2. Problema de dinllnostic e'ti 'o'pntogen'itt pt t'oTtogra[i'a ti 'tt 1to'rnli;i i lrtneruultti ocul otflotor artern.
A)Para| . iz i i la l ron' tn,arc,s i t t t f le lcvent i t t l ' i l r t i | t l , r1 l l1;rrr i l , i1 | ' r r ; r l t r l t t i r l i tou"n"fr6r-,r- ii i-o'ai t, t,rrs"rrl o.l m,i lung dirrtr. 1,.fi norvii ttcrltltitttttl 'tttt
;i;;;;";"r.i-j !"pii*t rn f,,i. ', i,t rt* rliforif. nr{uri. 1)l rxil,. trut,i vttlttrr' irlti l
tnzonainca,rctrcotpur, , , , -* f i t t "" t '1 'otnpor l ' l t l l t r iq i l t i l ' t r r r r r t lo l t ts i t t t txt t lcavetnos.
a)Pt 'oaesauuS| l l l ' I ' ( t . (11t , 's i t tct ' r 'u l r t t : t t l t t t t l t t l 'o t" ' r l t t t t tn,portx l l lot t ' t lVl- t t
"ao. t i l ,
" - , r iu iuu, i , i " r ' i t i i l i r r t t ic : t I r r r l r i r t l i ' r t t t r t r ( sd l t t i t t t : ' Ar l f . . l ' i t t lo l ' t t '
t , , rz i l ' t r , - l , Lt( ' { r , ' l t t ' i l l1 l i . r i rkr i t t l . t 'v i t t t ' t t lot t t t lLt l r i t . rLt ' l t t i , t I t t ' i I | ' I ( ' I ' I I r : l ' r ( ! t ) ( \ '
{ra,rul lr n1;r*o. ii i lrr,i 'r,pl 4i rr,r,hr'u lrt,biritrt,itl i l i l itttrrttt,irtrt't 'I ' l l itr rItr|. 'Itt '|| 'tI
l i:n'ti. Itt s!tlltslll ' l lv('rlr's
s. ir,l l i"t l)(r ',l lt ' l '(rll
lrl6rrll l ' tt rrfl{tr.i (' iu'ot'l(l{!
i t l , t i rr tc, I l i l l r i , r ' t t t l , t t AiLtt 'pro(t( 'x( ul t t l ' t tud trot l t t t lx) l l l l i ( ] l ' l l t lotvtt l txtt t l t t l t l t t l ' r t t '
{ ! r1 i ( ! l ' l l , u l l ( ' ,o l ' i l t i la, l ' t ' r l t l .
il
l 5
l,lll'ililiifiilr;iritiJii,iiiii::rlliiilr;lil;l;l"ll';11,i:'il1'll1;t l;li;"i;11,,:ilil,l , ' l ' ; , i l i i i l , j ; l : ; i i i l l i l l ; j l ,
r ' rrr l ' r ' t , ' ' r( Ni :r tr ' r ' t ' r t ' r tr tzir : t t t t r t ' ' r1i. ' ' " ' . ' " . ' ' ' '
rr:,;,,,,,,, ,,,,,(,,:,,i{,,,, , ;l,i;i';'iiih.lill;lill,i,',J;illiij;l',1,;ii;*;l
l,:,.,!,:.).!:':"r::i,'!::':i;j!:,li:",,#H::^ #:;';:::,:,i",!'i:w*.,t,f3,wi. stincii te,n.
;i,,,i;-iir;:i*zui*$*"#ti+*i*$ffiiluts,i+rffii-isrr*,t*i*i+g***g'l'am':ln*}i;ffijl.ii,l,i;l'lil'i,:ii:,'i?*ffi lr"*",:i:t":*;*lii;)*T""*,tT.ff "i,:":#;;,,:1i:iliimk#;il**i5xrl?*atr,':ur#fff ::;l;;,ll;;ir-l,,lll#Tif "l'":#i::tlfi i,:,ilTiiT,?fiii"*k*t"li:xri;i;itr1*llr*rl*l"l'ai*ffi *"!*;l{6ryffi.,##irli'll-li,:*l',::*;,:,lh$.t"i"rli,*xJi""';ii#.#o"",."*,..,ll;;ii: l;:lll;:ll''ll'i'l;,iliih"3 ,*t":1rgoame 'ru no'"i '"'n"ii"i,
.i""ii"",fr",l.'',,';,il;lll'1,*f '.,il;1,i{x'ffi i1t"#:?",'"'":HtJf,[gilii*1',?l;,r ; :' l r ; ;r, l i: l :r l j r r iln ir#rl*i:",ffi 1;i:{"g:#qJ#$t?I';I :, ii' Illi1,ji ;i, iii[,*31g i,
"k::rilr*11#x"ii;*trl,.;l1ii'1illl::t,,tr:,*!#itr#::*#"*{,ffi .;x?d,Ti:Tif"::,ff;:H:;ll, I ' ];l ; l";i';;;l'ii";:"r"..1;?; fll,t"-l" ̂ u"."';i pu"ro'J,ili,io,."u. r,ezi.nea
1,'.,,;11:r,iilir;ii.,Uil{-$1$l=qitr#,*i':iI:}{1.+l $i' i, liii : i I l il ; ri r il ii?*ii, ffi ,'[l l'. :'n**" $"'JiT,'""! i trigenicu':L i'tii,t j I Lr,,,,il,il i ili it jlt',lltiliil;l I i' il i *i jd'jff'I' i'dtr{trf*lil,Hiiipl4*1n,htikirilH jii1,liiriili ilnriliix#"*n* iil;rr.H rr* irrfr )vlrr iru rrrr 4i g,,rr,r i , z.rir z.frr(\rr irr l i ,r,{ i i rrxl 'rrr,,;: i l l , l l ' l ' l i l ' lJl l , 'r[$
gi lo, .a, t ' i t luroidi t r ( l totrnr, l , l l t t ) i ' i l ) l l r , usi r ro l l r ,b. , t lXi0; l i i )g( , r q i colrr , l r . ,
r .96 9).
^ h) Paralizia percclrii rr V I ir :r,l l i lre rle :r,scnrorcrr Si. irt sinilrttnu,l.,l iutlti
sJewidale pi 4n, celL al ,uirl\tlui or:bttar.. i).Tu.mori ale fosti 1tl,ru'ir1o-Ttalatine ptotTLa ltilroestezio qi rrcvlrlgirrjn teritoriu-l ramu-r.ii 1r, .ll-1, l ncrvului trigcmcn, hiposecrc!,io lrr,r'irnali,si pa.ralizia ner.vului oculomoror e:lern.
j) Paralizia cronici a neryului oculomotor exl,ern poate consl,itrriprinrul semn aI unei lu,mori din regiunea tli nl,rt drful stincii yi sirt.r.r,tlrt Lcarernt (Sakalas qi colab., 19?5).
. B ) Paralizi,ile rad,iculare (intranearaniale ectranucleare ) a1tlr. (rrlmai fi'ecr-ent
-in,,lezitni ale porliunii ventrale a protuberan{,oi.,\ ind;rotnul ]Iitlard-Gublei esie lrodus iie leziuni ischemicc itr l,tl.il,o
riul arterclor mediane ale alterei bazilare. Clinic se traduce prin tnrrirlizirrfacia,li si de ncrt, oculomotor extern ipsilateral, cu herniplcgic tli. 1rrr,r.L,'rr,opusl'i_. Forma clasici a acestni sindrom are u:rele variantc, h funclic rtoextinderea leziunii: a) dac5, leziunea se intinde posterolatcrrr,l ryi iirfi,rrr.seazi nucleul sru riid:icina principali, a trigemcnului, la tabloul cljrrioamiirtil se-adaugi fcnomene senzitive de tip ilgic sau parestczic pc Lcrrri,fala homohtelali ; b) dacri leziunea se intinde nurnai in diroclic 1xrsh,rioa,r:i si afecteazd, pa[glica 1ui Reil, realizeazra qi un sindroru sctrzilivalte-rn; c) dacl, leziunca se intinde in direcfie medi.rnir. qi cupr.ildr: trolvrrloculornotor ertern de partea opusi,, apmc o parelizie si a acr.stlri nrtv ;cl) rnar::i leziunea se intinde in diledlia crlotci plotubeiantirL,, alirol,rrrz:iqi n:untleleta longiturlinald, posteriod,ri,.
Q ) Pu,raliziile nucleare sint in gener,al rare ;i aprl rnri eltu irrprr,rrrril,cu al.ctarea altor sttuoturi neryoase din \-ecinr: i,i i t r. . .\stlr.l. Dliril l izirrnuclenri, de ocu-lomotor exterrt apare aproape tot(lc:runa lsocilrti t 'rr 1,rrralizie facialiL periferici..
Nucleul perechii a lrl-a sc :rfLi aproape elc rr:rrtrul porrtin l,onl,frtplivir..l ipsilateralir, de la care o cale tlc asociatie corxlticc, prirr intrrr.nrrrrl irrlbantlt'letei lotgitudinale postelioare, la nuclirul pcltlu nrn;clrirrl rlr.rpl,oxtern de partea opusti,. Ac€st ccntru ponti estc Nd{rser llfccttt (lc lczi-unee care inteleseazi, nucleul oculomotorului cxtcln, qa incit, po lirrgr"lparatizia de nuqchi rircpt cxtelrr, :l l):l l.e ;i o paralizic rr prilir.i i l ir,1,i,r'rr,lo rloilc|p11r.i prrt' qi tlerilfia coniugatir I globilor ocrrlitri rlc prrrtcrl, oprrsi.O rfr.clltne limitet.i h norvul facial si alxtucerls ilc rrcrct;i lrarltr {i fi iri,pararLlizja miqci,ritor conjueatc r1r, latcrialil:rt,r, sugcr,c;rzi o loziirrru lcni,r.;rll,la m:r l l inca infcr ioat . r i ; r l t r rn i i i , lndo lcts i t i r lo i no' l - i l l i l i isr :s l l r , r r r rc l r i r r lcertl,r,rl foarle :lplr,4c lrtrul do r:itl irlrl1,. t)llnllizirr, rirrtleu,rii iri lrrl,rrlrrlide ootlornotol ertenr nu txtc rlr.i i, rlacr'i i:irrcur slrrrrlr rlo lattl rrl ri, cli rkrit ruclei se giscsc in apr ' ,11i t r r ' . ( 'oncorni l r . t r l ; s(r lLsoci : lz i i l l r r la l iz i l r r r r isc i r . i lorr le la-cr i l l tate ; i p l r ' ; r l iz i r r r r r i l r r tc l l l i i s i r r r l r i lu ict ' r r l i I r r r i : r , l i i pui l i i l icr i .
at Sinrlromttl lui (lus?tiui (sittrlln,ntl i lot ;; o-[t lu.or:a urLul ftl lrqnt: .t t t lu i pont in ) s( ' l r l l l i t ( i1(niz l ' l lz i 1r I i r r i , t . r r I r r l t . f io i l l r l t t ( ' l \ . i l ( ) r ( t . l l I t i ( j i V,TI ,YI I q iYI t r I r l , l rur l , r ' : r l lz i r r r r i i , l r r l ) r r r l r i l i r |^ scrrs i l r i l i i i r l r ' l , r ' r . rnol l ! : . r 'z i l l ,de pi , r for , o l ) r ts i i , (1( ' \ ' i i l1 i l i l lo l r i lo l o i r r r l l t l i s l ) l \ . 1) i t t1r ! l l s i l i lo l rs l i r i i l i r l r rg-rnus { i l rc bf i1c t l r 1|rr , l r ' : r l r ,z i t r r r i i ( l { r , r r l r . r r l r i i l r l 1 i \ - l rsrr lg i l , l l l i r?: , l , r r r r rr | ( ) r r i s i .Nlonl , r r r tN, l ' i , l ! r ( i0) .
l t \ Sint l . tonrt , l . Lu. [ l l ,ut tur tnt l (* i r r l t rnu. l urrrr l t l t l l t , i lnht ' t ' (n l ( i ) \ r lt l iU' i r r l l t ' f izu ,z i i 1r t . i t t l l r r , r r l iz i r r 1 l ( \n,( ' l r i i l t \ '1. : r r l r ' 1Ir1l1,1q l r .z i r r r r r i s i Drrrrl l t r r t r r I i t tozi l , d( ' l ) i t t l l i r o l r rHi i .
l-l
rt
:1,4. ! i . lhrnl lz i i l r r i t t lc t r rur 'k ' r t r r ' (o l l l l r t ropkl l i ik ' i t t lor t t t t t l t 'nro)
o,ltnl.n11l t11i il.r ' iul(t't 'ttt:l(xt.t't t 'r 'zttll,i i, rli l l I(rza,r'oll I ) i I t I I I I ' I I ' I t ' i lotrgil tttl ir r r r l r . j ro i l Ic l i i r r r l r ' . ( l l t t ' l r '1t ' t 'o l r , t 's t ' t r f i r t ) r ' i t lo palal iz i ik-r t ' i t t l t ' l l t t t r r l t ' i t l t r s i l t t( sr t. lrs('l rw(,grfr', l l)(i9) : a) rrt soltiul drept il ltern este para,liz.Il, ]rcntr'l]|||rr1r'iri(.r| (,rlrr.iugalri, tle lRtclr'titatr:, insi, funclioneaz5, norrnal in timpulr,,rrir l lglrr{r'i ; l l) prozerrla nistagmusului tlisociai, singular sau_ prepolgc-l.rrl lrr, orrlriul oiro privefte in afarri; c) prezerlta paralolismului glo}lilor,r'rrlrrli lrr plivilca, inainte, in ciuda parezei bilatelale a muqohiului dreptr l l l ( . l l r .
' in 1.,'.:irrn,ile pozlina (indeosebi vasculare) se poi intilni doui forrle1rrrr i i lrrlrrlrr rIo oltalmoplegii jnternucleare :
| ) (),lltlnto1tlegiu i.nternttalrard, anlet'ioa'rd, cea tnai frt'r,r'cntil, aparl+,,;r ,r ,,orsr.r,itrti i a leziii ' i i fiblelc)l care leagii nuclcul pcrcchii t ffl-a, cu(r'rlr'Il Donl,itI petttru mi;ca.r'ea oonjugat5' orizontal:"1 rle partea oi:us[(lrlrlr,l l rrscrtrtlrlrtr: ale bandeletei longitudinale lostf ioare). Clittic sir|', |||rrIr';i, lrr plivil 'ca lateraid, paralizia muqchiului drept irtteln (de p,rt'tcarrrr l r .sr . r r l l i l r rz i t tnca,) , t l iptopie incruciEatb, $ i l r js taguus ul izontal la othiulr':rr',.pr'irlsic irr lrfrrii. AJoste lenomone se explicr'i ?r'i ir 1ri'tnl ci, nrtcleul
;rr,rrllrr rrrrryrlriul dropt intern nu primeqte impulsrrl' i pentrt mileatea'r.orrirri:,rrIi1, lrrl,rtrrJi, rle ln centrul pontin de partca ol)trs:i. Pe de altii pnrte,rrrrr,lorl rrrrlvrrlrti rlbdncens primeqte impdsuri cerebrale qi vestibuJarer ; r r r i I r r I r , r ' r r I r r fi r sl,lit funcl,ioneazi normal. Convergenia se produce, intrucitr:rr r lr. l)r.r 1 r'u rc('rstir, mifiare nu tr€c ?rin centrul pontin aI mi;clrii la1'erale, ' { , | | i | | r i r r I r ' . I)rrrri leziurrea este bi1il,terald, apal'e o paralizie a adducl,ieil,lolrrrlui rrrrlar irt arnbelc sensu'i (dar cu conservarea convergen{ei)l| | i I i I i r : fi | | r r I r.r Irr liot'alo din ochii afla{,i in abduc.tie li nistagmus lt} privircir.rrr rr|11. \iN1irglnusul opi,olri etic qi indus prin excitalrie vestibultril cvir l r ' r r l r : z i r l is t ) r rsr l i t l i fer i te la cei r lo i ocl i (Bender, 1969' c i ta, t de Popo-r rcrrr s i l ' r rsr , t t , l { ) .B0).
li ) | ).llrtl trtrryilrlti( internucle d, Ttoslerioard' este adesea greu tle _diag_-r,rtrri. i) 1rrr,r':rlizie supranuclearl a, perechii a Vf-a este foarte dificilrll rli l!.r'r'rr(,ilr,t, l i l{i i, tlo o afingere la nivelul nuclear sau radicula,r a' net'r-ului\ t (llrl lrlri si rtlab.. f9;$). I{u$chiul drept intern de partea nelezai':i scr'.rrr1rrrrIii rrolrrlL), iri schimb ml;chiul dfopt exterl de partea ]cziunii rnilrrr! i ionlli lzi' i irr r.tu'sril Inisci ilor dc late,ralil,ate. In aceastl' formi'l sintl, 'zrrlr' l i lrlr,lc rk,srrr,trrlentc ale bandeletelor longituclinalc posterioale {ile ltr{.r'rirrl porl' i lr rr1 rnilciit ' i lor dc }ateralitate la nucleul tr'bducens de aceea';ilrirr' lr '). (l)rvllg(,r11ll, srr llrotlrroc rrormal, NistagmusLrl orizontal aprlre de;r i r r ' l r , r r o l r r ts i , lcz iurr i i l : t ool i i t t l c :Lre ?r jveqte in af l r i i
l)i l i,f('r1,ii^r'(,rr intlc celr tlouli forrne se facc pf ii ' l lruliza' compr,tr'tlri irrrrrrrr'IriIor' ( irlr, itr:ti{)llrlrzii, in seng orizorLtal. Astl.el, in forma antu ioiir;ltrlr r,1rl rrl r,r lc|rr il(f l)lutea leziunii funcliolleazi normirl, in tirup oe clrcptulrrlr'r'|| rlr' |rrr' l0rl oltttsli cste I)al'alizat pentru miqcarea conjugatil, de l:r,te-lrli lrrlr. s1rlr. l)lltetu lcziunii, insL fulc{,ioneazi, norirral in convergeltit 'Irr lirrrrrr pos l t,r' ir ia i ' i i, rtmhii drtpli jntcrni :ru o arti 'r-itate normalil, a1,itrrr lirrrlrrrl rrrir;r'r' i l i i rkr l.r Lclt.tl it,:tte, r:it
"ri i11 timpul corn-ergen1,oi. N rnai
r l r ' r , l ) l r l ( ' \ l { ,1 ' r r rLr pr t r '1t , i r loziuni i cstc pat 'a l izal pcrt t l r 'u. mi;carea t l ' l r t te-r ' : r l i l i r i r ' . l f r r l r r l r l ror ict ' io i l t ' i i 1xrrr1,o I i t l i ' l i r t 'c t t ( ' ia, i i r , t l t l l ta l i r l iz i l , ptr4l l i t t z is iI t 1r | t t ' t ' l t i i r t \ l i r t t t t t t l i t i l t r i l t l t ' l l r ' l I t l t l s f i t t t t t l t t t ' t ' l l t ' i ) i l ' i l l f i f i t . (kr l l r r t r l 1 i
' 'o l r r l r , ( l l l i l l t r r r t r r t rL l l r l , : t , l t r r l t l r t t t l , ' t t t r i t t r r l r tg i r ' , r 's l r ' l l l i r i logir , sf i t ' r '1 i r t I l r l
5u
tll
il1I
1r ' t ' t r r . t t i i dc , ,o1lrr Into1t l ,6 i r ' r l l l l r t l r l l r l l ' i i tL ' : r lx l r l r ' ( ' i l " ' (1 i t r t t lxrs lct ior t ' t i )
1 i t l r , ,o l l t , i r l l r to l l l t rg ic i t t 1 r ' t ' t t t t r , I r ' : t t r i t l t l r l t l t l .utr l i t l " (1 i l t t t l t t t l l r i r l l t l ' i l ) 'l)iaqnostic etiologio: lt) 'rr'/rto;-rl ' in pliici eslr' (1:l ' l lzil ti(rll ' tttrti lt 'trtrvtrtll 'ri
l of lalmoplegiilor inicrttttclt,iu r, ttlti- sau bilater:lltr; lr) lczitttriltr virs( rll i lt(tse iau irL considerare in tjotttoxtul clinic (Ifa ingtorr si cttlab., l1)61i; \!rllHll;i l loyt, 1969; Cogan, 19?0; tr'dtzsch, 19?1 ; Gonyoa' 11f74)
CJ Oltalmoplegiile internucleare pot si apari' de ambth piirli,.trsr.tciirtrlu-se qi o oaiecare asinergie a globilor oculari, precum ,1i pitt'rr' l izii rtlrrprir.irii veiticaie, 1l sus, ale globilor ocdari (prin extcnsia lozitttti ltrl lrott.iinc in paltct'| inferioarS, a rnezencefalului (Cogan gi colab., 11)5() -- r'iirt,l'ir L ' . i iot lecht el , lC6j) .
2,/r.6. Paraliziile oculogire suprarruclearc
2.4.6.1, Sumat d,e iJ'ata semioloylice . L'ezi.ltlile suptanuclt'ilt t rrrttttafecteazij, mecanismele miqclrilor conjugate se traaluc sentiologic ltt itt :
a ) Dim,imtarea *atr abolirea mi;cdrilor conju'gate oolunl,arc s(r (lir ril'(t'ierizcazi, prin paralizii de tatera,litate, de ve*icalitate sau dc collv('l'gll lI r'i'.ln funcfid de iopografia leziunii, bolnavul nu poate sI'-;i dirijcze gkrbiioclllari ia comandi intr-o anumit[ clil'eclie. De asemenea, drurii rt[rrtt('itt'pacientilor este atraBri spre un obiect cale nu se afld, in fata krt',.lti. trtt 1ipot deplasa ochii pentru a-l privi. Eristl $i o crestere ll ,,tonicii;i ' l ' i i" ttlttrlchilor antagoniqti, care duc Ia o devialie a globilor ocul&ri de l)rrl(rir, ol)rr$ .\r apal fenomenc rliplopice
b ) Itttensifi,aareo, Dlec&nismelor refletelor de .f italic st' pttxltttrrr ;ttittpielclerea conti'olului inhibitor. ln mod normal, iirlrtt *,r itl l i l sLtlr colrtrolul r-oinfei qi ochii pot fi miqcali de la un obiect ia a[1,uI tltpii, rLrlitr(ri.!n p.r' 'rl iziile supranu-cl"are, bolnavul lu poate sri-li tr2rnslix\r or,lti i tlr 'pe un obiect pe altul Ia comand5, insd poate uuniti i [u obiotrl; orttrr sorni;ci. in direcl.ia paraliziei. De asemenea, se pot e!'iden tjtl uicllrsji Lrill lrrfr'rolrnalo la stirnLrlarea labirinticii. Pie}derea rnisciil ' i lor volll l l l, iIrrr irl('globilcr ocula,ri, cu lespectarea trtulor mi;cirilor ooulal'o r{rflo\(', $(\riurnegte pseudo-oftalnnplegie. Paratiziilc m\ciLrilor dc ltttttrlitrtlt ', rrtrpistr:.rer -conrergiltei, indicii o leziune corticdld' sar pe c(idl. tnrl,ittol'tt 11ult,inainte ca acestea si, a,tingi centrii subcorticali. In untlc cazttti, i lt rrrt'tr'contloltl voluntar se pi€rde, reflexele de fixalic pot dovdii t t t ' i t I I t i I t I r I I ' ,prir-irea se,,ancoreazi" de un obiect, lncit o mi;cart ultcriorl'ri l Il l l lxrirlr'l i fir.urtri decit tiupi, ce se elimili irnpulsrlti le lctirticno (itrcltitlt,t lrt rrt,ttacoperirea ochilor). :Lceste situa'!ii ar1 fost dcnul]Iil;r' ,,a'l!1t,1:it o()ttl '!ritttolorie'1 (Goldstein li Cogan' 1965).
t ) Intensi.ficutea rcll(.relor proprioaeptiu cillo l)or'11{ls(' rlrr Irt. lrrlrititrl 'si de la rnurschii gitului epa'e atunoi cincl leziunt'lr sc:rllr-t' tlcilsul)li l l l l l(lf i lt)rpontini ai sistemului l 'estibulal. Astfel, tle piklir la lttr clz li lcrtt'tr ttrilt 'rit i l lvoluntrro itL sus sau spre dreapta sint irrrfosiJ]il{', lLrltrii insi ('rt,l)l l l ('sl,r'
br s'r (oborit sau illtori sl)rt! sl,inga, otrlrii str r.ott' it.zri sttlr tttt tttt$lti rr{ttlin srrs i1i slr'(f {lrolrpt,it, ct':t1xli i lt Il lo(l aul,ornfl1 sii srr t t ' i r t I ' r I I t t ' t I i i, ltt lrozil i lrI r r t ' r r t ' izot l l ; f i i . I ls l , t ' . lcnonentt l , ,oohi lot i l t Tt i tyt t t ; i ' " . t t t | t l i l t l thr<' i l , r r r t ' t ' l l0xt ' l t rLrrLrilirtl icr', dlr,cil, l l l iri{ i lrl i l ' crr,pllltl i r^s14' lrt'tts<rii, ;i rlt, crli;t 't ' i t t r p t t l s t t t i l r 'l r lopl iogrrp{, ivr , t lc l t t , t t i lc l t t l I I l I I f j ( I I i I ( | | . ' t l l t t l t i j ' r l l r r , r i , t t t i ; t : l t t t ' i t , t ' i t l r t t l t t t
t l l ; , r r r ru i k ' t t t i i , .
lr
l')11
r t t ' r tnt4l t t t l ) t l t t i l t ) t . .x I l t , t l i t / i r r rJr l i | l . r :
,, ,,,:;,1,,,,1'lll"-i1:';1"','i,"'j1i:.'i,ii,'iiill;lli,il,l,l,i;-;,,l,,i," llil,li,;i,i,,,1,,:iii,;,,'l,iil;r l . r r rrrrrr ' r ' : rz i , r .z i r rrr . r ' r r ' : r r r ' r ' l i . r r rolr , , i i t l " " , ' ; , r" r ' , , i i l ] , , , , , , , " ,u ' r iscr i r i lo ': i ' : l i ' i , ' ; , ' , ; : i l l ;); ; : ; i , l ' , ; ; l : ] ' i l i .-:1i l , i ; : ; , ,r.ziunei, ",,r i ,""" l l , i i , . ; . i i i r . . . i ,r i l i" l i
,,,,1,,,,,,,,i,. ,i,,.;i.,,,;i,;;,;''il;';ili"Ji ;|?1iil11:# T,;:i:i:". sint pii'r"1.te,,,.
tt ) t,t ix:iir.itc da .u,tmd,rire sint l,estate sofi"iti lJ laci"ntuhi si1 jirezer r r l ' l ) | ( .1, | l r t0 se tn isct j , d i ;r, ,r , , , , , .r , i r , , , l . i r l , , i ; , ; . , i l i l | " : ; : l l : i^tu:!" i" r i ta, la aproxirnativ 60 t,r l i rr,r;ri ir,,.,, 1,,i"i,,,-ioai.i'T1il::"ffi.'i:-Jii:tfiil?"1i?llff:lif;,yui*or'i
, ) ' l 'rxttt!. ntet:u.n,is.mului,d.e l.ixuJie: piLcierhul csio sol;i,;tat ",;.
pri-\ i.:, r'rr rlr'(' l)1i rJl- fat. cramirxtoruiui, i lmp in care .ro A.airu;o,rrL uir ,i i ' iul, , l , r r ' . t ; r l , ( , r i l i , r ' i ' , . iml tu lu i v izual (# i ; r :ar i t :a ," i i " i i , _" i i ) , ' i_,s* dc lL i , l * i l ) i ) .t r r r , , r t r r l . t rur l , st : l t roduce o rniscare -a
pr iv i l i i ip l r st in ln lu i r ,e: j l j r , ! .L i \ , .r 11 r'rr.r!' ' rr.r'srr:i rnisciiri s.gereazii o t,,ri*" ","u'li
t"ri"""ur,i cr-iiLr. ;rrir_r( rrr'|r '|",
(' '!*1r' rrc re'einrui occipital oi "i""riit
i, riir" i rre rir,,:*:., .. . " ,
., ' t \t,4t, tt( t ttttt 'p) gen,rri.., examinatolul cr'le borr[r \'rLrui si_i rlr,rnr-
ii, I ',, ,'i,;.; 'rrr,
('.rr. (e rni..:j5. lerN ir fatra ochitor ip,:" .,io,i,,;", ,ia"iiiiii
,, ,t ) ' l 'r-'xlurau farei l.ente ( tl"stctgnustrltti ttptoltittetic. Utl ect:ul tiriutcat| ' t ) t ' / t \ l ' r t icaie de curo. i d i ler i tc este ' r i icat
in I l ta pacrel t , r r l r , i . r .r' i" 'r{rr
.str soricil,at sii tiui,p'ir-irea u't "ruJ'"u"..t,,ir' i
pe ceni,.lr er,-r11-, , r l r r i , i i ' r t ) i r r salp ngesl j , est i miscat- l ;^ i l#; , i ; ; j t r .u direci , i i . ln, . , r r r i i t r l { ) t . l r l l l ( j apar i : n istagmu-"ul optokinet ic. - - '
..,.! )
. ,. ,, . .,
, , , , ,., , , ttirttt0tnusul.ui,_;c11t!Uuia,r rotator srLr\
^ tlistq(nt| ).tl lu it t t t t , t t t . : r t ' l t . t , ( l i r1(_ i rn l rot , la l ] tr) r, , irrr ,,.lr,rraliziti ; ,"nu"u,-#iiii:,:?".,?,::t;,",i,",,x"::,r11:ij:;;;illi;\ , , , l r r , r t r ' s i r r t , J)r i_. .1rate, leziu,rc l t r . t
" i " - r i i . , , i ia- ' ,1; ; ; ; ; , "
arc, tui r .eUr-' l1 i I
r l , t ihrr t l r (ncrvul r , ,est i lu l ur _nuclcut _, . r t , , f r , l ,n i iu i Deitet ,si"iilI lltllli,li ;li,lLl];,Il;?:ii:;lJ,Jl;L';';,1'f,1i,'"_,ii;1;tl":l,";:lfll:rrrr, rrrr.rl 'rl, (J(,llsltl lrl nucleilur nervilor, .oculoin"t""i- aral
'r._,i..,. '.,i\, .1rl)rlr1 ( sI{l i lrlrft. ln_prezenfa paraUril". iril21i"r"lJ ali 'prs,irii l lri,r:rale, I r r ,r ' , r | | i I I ( . r| j l:rrt,rr ulechii protluce numai rniqciil i tenie. afe ochiuhii.
:'. t.( i.:.1. l, uihl tu e rI e di a Elttostic toltograJia .,si etir.tpat ogenic
,,,,, ,., !,:,'i;,,i ,,1 ,,,',;::'i',:i;li,{:i:,:,:,,;"x!;i:1,i.:,1:,^1i,,r"'1;,*;T:l:.fiH:T,,;"_,:. l ' r . r l r ' t ' l t , r l r r r l t <,r^tr l t . i lo i OLtt t lo.,,,,ir,ri ',,rrr,r'.1,;; ;ilii d;illli"ftlrliii'iTlift:J.,,*"TT;l'Ii ii"i,.li,?i];r , r r r l , r r l i r i I r ,orr t i r l i r l j r r a;r tbt lc t ,
I r1 l, i i, : ; i I I ; r;, 1 ;1, ll i :li ilu i #]r liix nsft ,,;li [mlri#"1*,uffi il t ' r r r j l i ' r ' r ) l i l r i i lo: ls i i . l r r i l l r i r l l r , , l r r r r , : r l . iz , i i l r , pr ,J l i l i i l l r r r rhtst . f [ ( ] lozi l , l r i inI l l l l i l lu l l l l r , l r r , t r l r , i t r l r i r . r l l rr , r rNr( ' r r ( . r . .
: r l l i I t t l t i l t l t t l l i ' tL ' r ' i t r i ' l r l prot l t lsLr r lq l , z iLt l j
| ) I ' , t t ' l l i . : i i l ( nt is:rr r i l t t . | , , , t | i t | | | , | t | , , t i . , , t t l r r l r . ( r i4t l ) , , )4.1t1t t , l i . t , ; l l t , ). ,
I , : r l I r I j z r r I r , r r r i , r , I r r , r I r . r l r i r . l t r l r . t , t r l i l l r l r . , . , , r r , l , r r r i r r i I r I J r r | : i i | | i I i I : I I r , . L I r r i r ,( ' , t r , l r ,o l . i l . , r t r r r l l l , lo l r r l r r l o l r r l r l , r , l r l r ,1rr , , r l t , , : r ; ,1:r l f i , , . i , r , , i , , , , i , i
l l t )
( I t ) I | ( I ( ) l | | i I ( ' | | I sc l t t r t t l t t l r r r r r l . t r r l L, l r l r i l r l ( ' r l l . l l lg l l l i i ; l g l r r l t i l r l t rx, t t l r r t tin ( l i rc l l i l l o l i r ts i i l l t r r l iz i r . r ; r r r r r l rL.
l )ccr ls l r1 ja l ibrelol or , r r loui l r ' pr , t r i t t t tn i ;cr i i t ' i l r , ( (n l , j r lgrr l ( ' I l t , i ' r ' r ' : t l l i l : rI r i le l !eduncular infer ior ' f i lx l r r l , i l r st tpur i r t t ) a l r : t tn to l i ; tqtol ' t 'a l t l ; i t r : l r rbil irc:r, diagnosticului topogralic al It- 'zitrnilor'. Astlcl, i Irtrclnpcrc:l I i lr l ' '1,,r 'deasupra incruciqiri i induce pitlalizia milcil i i latcralo slfc ?l11crl ' ( i l)rrf i,.
I : i { / . 11. Lt . iu l r i ie c. i i lar aculol t tc:.l : N.Eon .artnrl :rdliocnl:rrat.r; -B
: Ne!rc! mezo.cialnr hcDicrrltrrnrr ;C: \ . r {on neT..elalni x l . . ! lonr. l . r , ] r i i .onr:n; 7 - ' I ' .h l iz ic l i . r i rerni a .c l lon
'l.rt ll:i .\tdn : I - Pi.rli2ie n!(l.arr .onjlgali | ., - I-rerialic conjrrgai' lrnr leTirx '
)pNte'di.il 4 _- Dc;irlie tunjlgat: lrin itTnD' crnisJ'r('
in 1, i r r r1r cc i r i l lc lu1telca' 1ot srb t lccusal ie catrzetz l j , p l r l l iz i r i l r t i t t i l i i l r r l l t . r l '
c i1rr , r tct ,ou5i l t l r t '1r ' .I t r f t t t tc l i r r t l t , l r t t t t l iz l t l t ' i t l t ,z i t r t r i i 1 i r l r r pt i t t tkr t ' t , r t ' l t l lot s]r ' t t r r l t t t t t r ' ' t
vrr i rsr . r l r r vt ' r , i I r r ' i1 l t I r r : st ' t l t ' r t ' ; ' i t l l r t i l i l t t t r i t l . t 's i r t r ! t 'o l t t t t t ' I ror i l l t ' ( l i l . i l : i . il lg. I l ) .
. : r ) . , { i r r r l . r , r r i t r l l t ' t ' t i l l t r t t l r ' t , i r t ( tnt i l l I r i r $ i ? l . I t ,n lat . ) r , r r l r , l r r . . r l r tn r l0I ' r r r i l ' . r ' : i i lu l o l r r lo; i l r ' rL. i rsulrr , i r , l r rn lc js j l l i i ( tn l i lL,x l t r r r ivr , l i r r ,psulrr , r ) .l i , , r r r : r r r i l i . r l i i 1rr i r r l , r ' -o l r r r r i r , l iz i r , r lc l l r lc l l l i late a ] ) f iv i r i i , r j l l ( [ { fv io i ( ] r \ g lo-l , r l , ' r , , r 'u l : r . r ' i , r r r r ror . i q i i i r l l l ) l lu i , s l ) r ' ( , t r )ar tea leziuni i (bol l raytr l i ; i pr iv i tqteI i 'zrrr . : r ) , l :L r . :u ' r .s( . r rsoci l lz i - r , ( ) pat ,? l l iz io faciai5 t le t ip central , i o hemi_lrlcgir '.rtc l) it l l ,(fr ollnsir lczinnii. L,eziuli le cauzale sint hemoragii le, infalrc-t r . l r . i . i l r r r rurr i l r cmisfcr iee.
. Nlrrriii'stiir.ilo inverse, ilitative, pleced aleviatii conjrgate alo globilor,,, rrlr l i (rrrruor,i si alc capului) sprc lartea oprrsil (confotm legii lui pr6vost
I ' l l
t l ( l l ) l lZ\ ' ) .
It\ '{inrln,nul Fot,il le m ijlocitt, (protuberanlial superi,or ) cste realizat(1, 1,,,:rl, ir i i lrlelor ocnlogire dup5, incruciDare $i astfel globii oculari sint
S xl . rot t tu l f l ( rgr t tnt t l - ( l rNl t t t t ( l i l l t l l t ) l l l l l l 'supct ' i (n ' t l l - l t 'g l t t l ' t r l t t l t t i l tot t
t, in) culrirrdtr, in conljexl,ul sorrtirrl irgir ', tttt sirLrj 'rotn lrovil lo ttri j locil l ' lrt ' t rt lr '
l,;'i;;;;;it ;;;ililii ';tti c,'i,'l,t,il 's'ipsilatoral f i hotrliliipo.sl'r'zi' gl'5rrli
de parlea olusl leziunii.- ' ' " , ' is ; , ,a i r , r r1 fst iTl l In. fPr io i (ptol l t l ) r t ta! ia l i t l l . ' . i t t t l cr l r gr ' t t l t ; r l
O" l " r iooi , i " .a i lo l oculogir i -ub inciucjsarp i i s t malr i lc ' \ l I pt i t r p;r l i r l r / r : '
i r i i : i . i i i r r t " pn,1oa leziuni i , cu alevjerer- coniugat i r a globi lur o( : r l l i r r i n l )11'
i ' r ,1"^ i ' - i i ,g i SioO,omuf Tor l i l lc jnfel io l s. lo i r , . rsocia.$i , . r r urr s i I ( l r ' , ' t ' l
f i f ; i i j t . r -"d i jn j" t I i l in ' "nua si lu i r i i s is lemelo' t le asoci{r l io : r l r ' . i r l r . t l '
ii'iiiiiii"X#"i, oil"iiriir" p"tl"e sint aclesea bilalerale, iirs:i i'og^ltr' irtt
risnunsulile li -irnpulsruili' rostibulale silt pierilute'' *"-.'i"o*firiifn
i"cdmpt"te ale privirii de latiralitate- pot irnbrlca, lirirrt
nistrE "tii,r,i i
orizorlh, c"."i i-pn" cintl globii oculrri silrt itttlrtrlrlrrii
ln diieclia paraliziei.
!) I'iraliaiile migcdrilor conjugo'te tle tertic:ttlilate (sintlttittrttl I'itt
"u'?Jrlunlt" comisulii albe posterioare, alc nucllilor lui jll'rlischtrwil s' h
. i Cr ia l s i a le iubstrn(ei cenuEi i pcr iapedu( ' l i r l ( d in regl l l l l { 'a Ll l r t r ' l r r r r r . i
;;"r;l ';t.;;;i aoietlo"i p.ino tibrele ocirlomor'o'i i bupran ucloa'r' r l itt rt trr I rr l. '
i i ir: 'r i i l i i lTj. ' i ; l o pu'i- l i , i" ryivir i i vcrl icalp' L;lt iur! i (ar\ ' :r ' si '- ' "inr i -aor"r io ' (craniai t pror l 'uc paral iz ia pr- iv i l i i i .n- 'us, iar r ' r ' l ( ' ( : tx rr ' l
mai posterioare (cautlal) realizeazi parallzla prwrr]r rn Jos'
fn cazul in care pa'ralizia migcirilol, conirgate de vertiur'l i lrt '1't ' rt '
"*o"irn'* purlotizia miqcAritor orizontale, teziuiica se gdseqte irr lta'ttthrl.lrt
r " i ' " i i ' iur" i5- "" t io" io" i i
d in regiuner 1ep12l i 1J.5ol l i q i Srr l l i ' l l r t i l
Si ; " i ,b l ; ; i ; i . i paial iz i i l , ' c le vei t ical i tate nrr apar in leziuni lc ' i r t ; : t t l : t t 'r-"
"oli*fifo" sup'eriori, ci ntmai in leziunile care a'fecteazi' zotlil l)r{'l"r
i.rx ibt}t;.rttlt li colabl, tooz; Pasik qi colab '
1966; B€nder l1)(i1r)
Sindromul . Parinaud se mani{e)t; prin imposibilitalcl oxtrltrlrrrtt
ro l r"Ar i io l de t i t l icare; i1 sau dr. cobor i r ( ' a globi lot ' ocuJar i ' -h l r port l r ' l r
"";,Jf.ia" ,n"iiiA-.ti."' ilrigcare de verticali{ate' lntr-o paralizio itttrtttt-
i , i " t i . i ' i i i r i i - "e l
t " r i i t : "c l , "nr , afcctarca pr i r i r i i in s i t ' ' ' r tpui r r ' . | r i t i " i i
i ; i lb; ] ; ; ; ; ; ! ; i to t i .p ce numai in jos apare foartc tat l ' i r ' t rk ' t r i r
ilr_?irir,", il--ll.s L asociizi rdesea cu absenla rcaclici l)ulilxl.(i lrr l1r
;;t-. ;i; miclriazS, relativ2i li tu menlinelea ree-c{ici dtr (lollv('l'g('rr1rr '
Daci,'*;';ierd; si iniqcarea de privire in jos, rparc ln plus tlisprtt' i{ ' irl It ' '"
modirii qi a oonvergenlei.ReEiuncr precol ic( l la l ' l nsle f l ' : . r l ' lc aplorpr. do uumJrlo\ l l l l l l l ( l { ' i r f r l
" " , lotrrJ i -Gi 'ctm rn s i , ca alal . - ' . . indlomul Pat inaur[ { { ' ' r t ( r t ' i i rz i i I r r
;;;;;;-;i;. o;;"}ii a rrilu', in special a llruscbitLlui lidicrilrx' itl l)l(r()tr l" l
i 'ncrioare ii tleficite in )ol,il itatcp. lupilei, a1e rl. 'omodal tr Sr (x)ltvtf'gr'rrl.r '
A'r:oli;"ll-a' rr"t*lrl.i p""".hii a I\''-i -ebt{i excepl i()tlir'Li .In krzitrnilt' il"
;;; ';;l j id- ;i;cdrile t1e urmirile pot ti pristri 't^e, in tirtrli.l,t ' trtiq|r'i.r' i l '
i . , i . " i ; " i " t o in i t t ' ' " Di I lopia 1 'o ' r t ' ' I i 1r 'oz ' t ' t i t i r r Parrr l iz i i l rL 'v.r '1" t
t i i r i " , - ,st , i t , ' , r tarea opl or l ' i rLei ic,-r sat t vest ibt t la l r ' t t tu i t t r l t t r ' ' t l i r l i tqt t l ' t
lerl,ical.Sintct iz incl4l lp jgt l in l i t r . r ' : l1Ltr . i , I l { ' ILdcr ' ( ] { )U|r) iL l i l l l i ( j i i i l | | , iu ' l l ' l lx I i I
, , r is , , , i : l lo i ,4e lqr l . icul i tato s i r . , t91, ls i 'c i i t , t t t tn l snt i I r r l t i t t t t t l l r , r l i t t t t t l t t i ' l ' l ' t r i t t r ' l ' '
t ; i i ; i i , , ; " ; i , , t ; i r lor i i : a,) t l i i r r i r r r t le i t s:r t t l t i t ' t t lc t t ' i t r ' ( 'gt , r r r l r t i l t t tp i l l t t ' l r t
i ; ; ; ; ; i ; i , ; ; i ' i ; ; r 'otr* t r tgr : t i l , i r ; b) sp: t r i t r r s i t t t ' i r ' t ' r t l iz ia
(1r)rr \ ' ( ' r 'gt ' r r { ' ( ' i ; | ) ( '
v i t l i r r l l r l t , i r r iqoir i lo l n is l , r rgrrr i , ' r ' , i t t r , l t ts i t , t l is l r tAt t t l ls l ! r l r l l r t l ' I I I f1 I I I I I I | ) | | | 1
I l!1, . Sl lltoulnele Lui FoDiItre:/ . l .L ' r ! l l l i r rh l r l i l . / r . I r l&l ! ,u i \ , r r lonlnor i i (oculosnc) j r . - r i l r recol t icodrdurel l rdrn, l . ! .h l ) j i , -SLr| | ,J"nl
' r l r , )vr l t . port jh(xr t* ; Z _ Sirr t rdmrt lL j i Fovi l )c p.{nrne-
rhLl i , t r I r ryn{; , t - : i r ' r , t ' ' I r t
t ! i l tv i l . l ) rnr lu.rnl i r t infc. ior ,
r l , " r i l r { , i - lorr i l s l ) t . r , l ) r l r ' l ( , i l , . l l ) l i t r1 l r ,z i r tn i i . I ) r rnr l iz i l , l : t r i t t , i i i , r ,stc r lc l i l l oq11 r , l r , l, r r . i ( ' l t l ' l i i , i t r r ; r r ' r . r r r r l 0tr I r r , I r r i ; I I r , ; I i I r , r l r ' l r r r r ' l r . r r r r 1r r rs l l r 'z i r r r r i i ( l ro l i r r r vrr l i ; il , t rvol l r , t l r , l r l l r ( ,1r , ; r r t l r r l iz l r l , r r ) .
0: lr i : l
r | | r Inr i r l .F i r r i i r r i f l . vr l I r l r . . ( l r i i . (1r ' iz( ' l ( ' r t ' I l ( , { . i f . r i r , | t { r r r r ]n)( i (h l (1(r l l l l { . ( ' ,: r r ( , t i . l i , s l t t r^r l . rg i l . r ( t . , . i r r \ . r r , l , . i r . s i (1. r , , t . i l i l , , t r r l l i , r r . , , , . r r l r i r r r t r rSt i i r r ( , i ,Ar ' fh l" " r ' iz . r i r r l 1r ' rx l r rsr ' ( l r 'sr i r r l r l i r r rc.s iv i 1 l r , ,v.rr i { , i r l r r r l .z i r r r i i r i l iac(r} l ,ocr i i l r r l r .or . l i ro t r t r r , l t rar t pr ' t r l l r r r r rJ;r , i i r i lc coir . iugat c i. l,) ) (rlst)ilatliru firls1ri, irr- lr;rrril,ia uror urisrr:il i (x,llrlrc r,lipidc $il r ; r . l i . ( . , r t is l i lg, l ' i rk 'snt t nr i , r r . l , r r i .c ,
- in special or izc, . ia l t . , t l l r . q i v-ort ical 'e
srrrr . r r r l i r l , r , i i , i r 'et l iat inairr l r , r le a f ixa un obiect (u ' te l de, , t remor dolrrr'lrxrrrr"'). ,\r,cste. miqciri pot fi acompaniate de tlemor il capului.()lrr.(,k)lriir rr fos1, descrisrli,.in dir-e'se cncefalite, ii inel prod'si, de i6ziunirrL,olivtri bulbar.e;i a,le nucleilor ditla{i din cei.ebcl (Jicnder, 1969i.
l, ') ,l l i.oclouiile ritmice ole globitor oculari pot upiire:l in leziuni alerr t l l , l i r I i r r r : t t r l i r r .cerebel . r r le ruclctr lu i ro iu. o l i \ -e i ' l r r r l l ra le s i7 sau aler'r'r'rrr1r.lr,r' lr r lrunorrrbroolir-ure. Se manifesti, prin contraclii riimice alellnlrilol or,trlali ('u o flecvenld, de 50"-90 pe lfinut, clrora'Ii *" o*o"i*rii,rrr rr.r.lrrqi ri1,rn, tnioclonii ale.palalului mdale, ale f01ei, Iinlbii, faringeluijlr, 'r.rrr'r(' lri, rl irLl'r' lgn*rlui si chi:rr ale membrelor. Dc 'rrrrilte'
'ri ' miocl6niile
rl|,Iri| 'r '.rrrrllr' i silr1, $e'de diferenl,iat de nistag'mus, i.si. o elaJizi, clinicir r r : r r l r l l r r l l i r rc al l l r i , c i i nu er ist i , fa.z[ le l t i_(i ) ;lqilatiu alobilor oculuri, (,,ocular bobb:ng',) se craracterizeazii p|in
rrrrlr'rrli irrvolrrrrtrrr.c sincrone ale ochilor 1n ios,-cu reyenirea, imetliati inlrrrzi{io rrOr.rnrlii. A fost- d.escrisi, in leziuni ii isiructi\-c intinse alc protu_lr.r:rrr(r.i (Jrishcr, 19e4). ln leziuni ce,rebeloase s-au d.e"qclis mi6ciiri ini-oltn-lrrrr. si Ir.IrrlrrlIrr,u r.i ni$ciiri oriznntale ale globilor. ocdari, cu apa{iti:r inr , r ( , l | | | i , i l r l l r r iDul l i r r i r i i ur [ r i obiect .
:i.1.7. I'roblcnre de diagnostie etiolo.{tie in palalogia sistemelor0rtr l0| [ { r I0t i i
. ' l 'r 't,r.r,rt'rr irr lcristl tt ,prinriltalelor rouze ale olal no,plegi,ilor prezinti,rrrr rL'osr,bil irrlr,r,trs pr,actic, cr rltale procerld.m la u" sintczit, etiopaiogenich(rlrrpri .,\r'slrri si r.olali., 19?? ;i Popor.iciu si Fa,scu, lgg0). -
..:!..1,.7..1. l)oli. .inJec!base ;i in.feclios-ulet gtce acute si srlbttcltte:rr) | | r r r r I ' I i r I i I I r 'r-i.ritice pr.imitir.e (t-pidernicrii, z,,siiriani, ubici, prin arbo_'r'rrsrrr.i
.1..). b) )lncefalite 'ir'o1ico
necundare (rariceld, vari'olii, rrijeoli,,|rr.rl irl i l i rlrirl 'rnictr, n)onontl'.leozri infectioas:'i, gripi elc.). c) Encetaliterli. I ' 'r 'srr.l inl*(ii i lor generalo Ifebr'i, l itoidri, scar.lafini, lrise
'conYulsivd,riir,;rIirrltrrii, ltrtrrt ttrurnii, richetis jr'ze, malar.ie ttc.) al) Nc.11ingite acpte saurrrrlrirrrrrlr.(r'cningococic5,_.}ncumococici, t uber'cuJoasii,, s#itis rr]o.niogo-r;rs.rrLr' rri..) tr) J.)oliradic,loneuopa,Lii (polirad.iculoirer.-ritd, Guillar-n-lli 'r.(t1 r,{li,i{ 'tk)z(: prrnneoplazice etc.). f) Nevrite interstil ir}lc secunda,rerrrrrrr irrlr'<rl,i i rl0 r'ccini"lato (sirr zitc,_o-tite, ostei1,e, abcese etc.). g) Nevritcrlir..ltrslrl .u',r' h,li . inlcc{,i.lrso .(tlifteria, botril ismul, tetriniiiul, s.a.)l r ) Nr*r ' i l . i rnr ' ro,k*c, i . . ( l t .s lv l r .cr inale: asa-ziscle , ,p,r 'a i iz i i rccurenic, i a l6
r ' t I l l (Jt ctal l l i I t 01c.) .
:!.4.' i . i l . l t i l i ,tdaholiut: i l) {)l i ( ir irextirlc (}ri ' deli ici l, ( lc i i irrrl inri ': r . i r l r r i r ,o| ' i r r i r ' , l rc i r l r rsr , , r ' l r i t . rc.) , | ) i r r ,br ,1; z i r l i l r i r ( . g) , { r r r . r r r i ' . r l ) l?ol l i i r . ic l
)1.1.7. i i . I t t l r . t : . i r ru l i i r ' ,uturt t r . . r r , ) l lo1ir l i r , r , (p l r r r r r l r ; . r r . ) . l r ) Firr ln l r l r l l| ' t g i l t r I r , ( t t totrrr i t l t l0 ( | l r r ' l l | | r , l I l ls l , l t , r r ( , r , r r r .g l r t ro I0sf0t . i l ' i r s l | i r ot , i i - i l Io( , t ( , t txt( ,1r , . ) . r ' ) \ l . . , r l r r r r r . r l l 1\ l . r l i . l t r r r , r r l r r : rsr . ( | r I r I , ) r i | | I | , i I , I , , ( | i I , i I : I I i . I , , l r . r r r ' , l r i l i
( l t i
. r r r l r r , i r r I t r I l i | 'o t ' i t l t r l t tot t t t t t t t l l t t , , , ' , t r l i rzr ' , i t ' l t l i t t t i l l i t l i l ' r r o l ' l t ) ' r ' ) I ) t l l r t t ' t t t t t l t '
I r l l l l l l l l ' i i ln \Zl l .
' ' '1 ' i ' . .1.1 ' t ' ' ' iu t t i l . I | ! ( l t ] , t t l ' : | | | I t t | ' , l r ( ! (1 ihrnt . , l ' , t1t i i r , . ' t ' . r I t t ' i r l r 's l r t t r I r .
l r qt tc l t i r r r r lc l r r i t l . i l t ) t lntn ' r is t t t r ' . ' l \ ' ' l r r i io r ' ' ' ! ' i r r r r . t c i t -u 'nr r : i "wel t utTol ' i r l i tw'
, , t t t , t , l i t r , , i r l i r u, t ) tor lu( ' o s i t t r l t l t r t r t l ' t logir ' ' ' l i l i ' l
i l i i t r | ' r r t r r { i " rh ' D"z i I i r t
t , r ' 1, t , . l l i r ' . i r t r , l l i j ix ; ( i 'grr l t ' i Nlrr t t t r l . t96l l ; ( i ' r 'c t r a\1.(a) l r r l r '1 l l r t ' l ; r l ls | . r r l
. , i,i, ' l '., lrrtri, l.9t.r, 197?) : ctkt untirioare leze:r'zil t 'o!'i ltot'vii octtLrtttttl.ri
, , , , ,1, , ,sr , I ' t i t , , t t iu.r l super io,ui i l l , pcrethi i a l t t -a) ,s i t l l tnt t t l t ' t t I i ' I t I t t t i t I I t l t
t r r ; ' , ' r r r l r r r r I t r i ) ; tde rni i toai i lezeai5, la fet to! ' i nervi i , oul l lu l r Lok)r l t l ) t1\r l l r r l'1,, i i ',, 'ri, it,Jtil i rormu:i ale trigerncndui ; uieltisrnt'lc ptttteri'oaro loztt"tr' ir '
r r r r , l r i r r i l r , n( ' r ' \ 'u l oculomotor ; r teru (VI) $ i r re l 'vul t r igeruetL i r I l ( ) l r r l i l t l l ' r . '
,,,,,;;;;i,;-'_,; _i rrri sindrom claude Bernard llolner ([t'ziurLet ,1rrit,$lo;tt"Zl\r
,,,a,,' i i,",'*i,*",t' i, 'rrn). Anet:rism,ele aarotid'i 'ene s'upt'aclinoitlieut pttl lt 'zrt ttt
,,,,,,i ir,,lal tt, ', t 'tLl oculomotor comtltt. Att'eurismele de urterd tio nt'lt tI it:Qrt'lt1
,',,,,ti,,:;,,,,r:A s1' 11rL manitesta atlcsea- cloar plin plozii ' pllptilt ' l l i i ' lrlr'ftirtl i ir r r t r r l i t l r ' i . . ' lnr t r isnte[ ,e nrterei bazi lur t poi prot l tce j r l r : r l iz i i txr t t t l t i t r r t ' l ' r "
, t . , , , , , i , " . i , i1u, , r r l l l - . r , . , i ^
f I - . r , - ia" d. hrr l l t oLi t t l t s inr l r t , t t t I ' r t r i t t : t r t r l
' ' i;;;;,:,;, '; i; ' ',t,u-r'iri,talirr". ',Lt A n.ite ie tt.iJeritc etiutuqii' t 't 't 'r"ntt' lt
t t , l , r l r r 's i t l t t r ln i (L l tPrt tu^. t ) t ' is l e r( to l ido'( t tDcrt toust
l!.1.?,5. '1't '{trunttt itnle ctalt it,cttctful ice : t1 -F\'mtrrri clrrtritr lto it l t ' l trtzt 't
, , , , , , i , i i r , i * i l * r , i r le orbi te i . b) Coniuzi i cerebral t ' . I )c pi l t l t ' r , in. n)nl l lz i r r '
, , ; ,'l;;:;ii iiffiil;il pi l"* iniit"i paralizii izolat'e^ *lt' ltet'rx'hii rt \/ l rt ',rrt tt l t l l t l izi i multiplc l)a,l ' tt i l ' lc (le oculomotoli ' ln coli ' ttzi lt (x' l '1rl)rl l l t l
, . , , 1." , , , " i , : r l , , i ' i ,1, : , l ' , , i ; ; i ' l c t rob' l l , pot I i in l r '11' \11( i . ( i rL grrrrk r l i l i ' r i l " )
, " , ' , , i ' t l i i
. , , 'ut , , i , , , , ' r , i ' i t r I t : r . t t t r i l . c* i t r i t 'n. r1c et : r ' j r t r i j lo. i t t l t t t l r ' t t t t . t t
i.,; ; 'r',;;;i;;1i,,";,;;';r.ir,t,:
iit oi vt, ,l-n' urteo..i trururri irl(' pc.'(1hii u v I rr, 1 l, l l i 'r l ttrcll 'al posttlr lumal.it. d-) nlecrnirtrru hit lrr, ' t l inarnico' erl( ' l tr 4l
r ' ' . , ' ,u, , ,a i ; r , " . i " pcdl , ' t a le. t ' ) l ln( o{ulopi l i i l 'o" t t l ' r u lnal ic{ ' 1t ' r ' l l l t t r t i vr t t i : t l t '
,,,,;,i;;;;'iiii ii" 'int,ilizi; p, r'ite'ic't', duclcrire, srrrltr'- $i ilrt(t'rIu(rl(rrr'r1')
' ' . ,1.7.6. .PrtrcseL( enpttt lsite itttracruniene plothrc rtl l l ' l t ' lrnoplr'gii l ir '
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l ' r { ;1, . \ l l l r ' l r l r ] s i I ) r ' I r I ' I r r r r I r r I l ' l t , I , \ . l l l i , l111i1l) . l r i ' r r l r r | r ' i l r lozrr l r : r l | l , l r r r r l l r.1, l , r l l I i rzr t r t | i r r t t l I r r r l i r l : r11rr . r , r - r r l i l r i r l t t l r r r ( ) l ( ) r ' : t l t r t , t I r I r I I ' Iot : l l r i l t ( ' i l l
t r r r r r r l l i l t r t l i t t l l l l ( ' l i l i l i i l i t l ; r r r r l r , r r r ' . r r |solr tg j I t t t ' : r ( ' \ i ( l r ' l l l i i t i l ) l , t t l l r t t t r t t ' '
' , ' , l r r r : r l r r r i t tsct t l r r l i i (1,r . \ | , l l l l ; { ; ; I i r t l r l r '1s s i l l t r t r r lo l l 1t , l l l l ; l r )t ' ) l l i . : lnt l iu ut io l r t i , t r N/r ; i r l?/ l )or l l ( ' l l r ( 'z( ' t l1; l l l i ( 'o l r l ( ' \ l l l l r r i r l l
, l r r , " l l r ' l r r r l l i o l i t t t i l t t t r ' : t t l r r r ' : t t i l t t t g- l tb i lot t t t ' t t l l r t i , r ' l r i r r t . l i l r l r tz i i l r r r l
1 ' , l , r r r l : r l r i l r t i t ' t r t l i ( l l r t r i r r t r s i l l t t t t ts , l1)6?). L i ln i l : l r r t r t t t r r r l i l i l r i i i i oct t l r t t t ',
' r , l r lz i t t i r ( . \ ! rhr1. i i i l ro l i i s i r l i r r t ( rst l l to l iv t r r t l i r l i l i i 1r t r I I r I l t r r I t l i
,1, | | rJrr l i ( , .t t ) l ! i t ) '11(, l ia. cct t t . t 'o t r t t cI ou rd (n)to1' u l ) t t l t r i i ) st ' r ' r t l r t i ' i t t iz l r tzrr r ' l r r r r '
l , r r r r r r l i r r l t t roplogi t 'er tcrni , laci ts iu iopat ic; i t lc1ic i1, r t r t lot r t l I I I t I t I I ) I I | ( | | ., r r , , , r ' i r , l r i : r r ' ( , l l i l t i l )c( , to pscudr:hipt ' r ' t lof ice 1. l i l t t1n, l l l i?, 1 l )? l r l . ( ) r ' l rz ( l '
r . r i l ' r i \ l l r | r tss0 (1070) xu notat s inr i l i l u( l in( ' l t i t ( ' ( 's1r ' i r t l t ' t ' l i t l t r r r L l t , t t , t
r , , l r : r { , ( r l l r ' : i r l r 'scct t t lcr t t i r a 1l ' inei ct4r i l l i r i i ( l ,ees s i l , i \ { ' ts( ' lq( ' , l1){ ; : l )
l : ) o l lu l l t ( rPlul iq t ' t r r t { r t t t t tu lorp ntrsct t l t t t i i t lc q l i t r t r lut t i r t t t " t t l r l r r
' t t , t , , r rJt ia l r ' r t l i rs l t lcscr is i t l ( r ' l i \ tz (1966), Zi t t lz s i \ r ' l l iq | r ' i l l | r ; , ) ,l r , ' :L , i \1,)st , r ' (11) i t ) ) s i t l t r l ) i t i t : t i t to r i to l r r l t . (11) i l i ) . . \ .o| i r rz i i r l l r r l r r ! r
l , l , r i , ( i i , r i I r ' I l i { , . r l is la. , ic s i r i ( l l i f i f l lo lof l lor i t t t l t l t t tot lc l : t l l t t t l t t t t r r t ' t
, , , r r r r r l r r r t r r r r rscrr l l t f i r [ r ' gJi t ,ogr. t i .t ' ) .1 l i<ni l t r r : t r lu.r t i s t . ( ' i in ' i t (1 (^r ' iz0azi i pr iu ert . r l i l l t l t t l i i ' ; i o | ' I I r I t r l r1r I l I I t ' ,
r , , r , \ is l ( '1r i l l scrrLrtr , lor t le l t i pcr '1 i lo i t l is l l r ( l , j \ r ( ' ls( ' (19(, l l l ( ; : i ) .r l 1 ' l l i t4t t r l iu ot : l t lur i l i t ' totr t . i ' i t , t i , s t r t ' i l t ' r t ,1r ' t iz t ' l tz i t l t t i t r r^rr I I i I r I r r I I ' . r
,11 , rLrr l ) l { 's i r , l r tog-r ' { rs iv i i r ' \ t ( . r l l i ( l ) ru( l t tnr t l , I1}{ t8; I i t is t ' t r l t l lu,r i I r ' l : r l '1 ' r t ' r l1 \ r r l r r | i l l i lo i t l j lur i , a l r tcsl0r ' o l l l t l tnr i l tJ |q i i I to l l l t ' I i t I | ' t t r , , t L , I t ,
' I I t
r r r I i r ( I i r , ( , i L I ) 1 I I r ' 1 | (J( . l l jnr l r , l1)( i f ) ) .
l l l ' l ( ) . l lo l to l l (a i i . l t r t 'or t i tc ytn4rtx i t t r l in t t t i r r t l r t t i t
\ l r ts l r ' t r i r t gr i rn is J)oir i f t lo l r t t l l t r ' tL pl r izr ' i p i t lpcl t r r r l i : i oI l r t I r r ro1' I , ' I r 'L\ \ r l r l r s i l l ( ) \ '1 , I { }0$). l ) ( , i ls t , l l r (J l ( , i l , l i lz i t r i r r i ' t t ts t t l t ' to l t l l . i t ' i t t t i r l lc t r t l t
" r . r r r r , r i l l r t l t t toulcgi l t csl r ' r l )J{) i r l )c ( ,oI tstr tn l i (S()" , , ( l i i r ( , l lzr l t i l i : r r l l r ,t ' t , , , l l l?1)) , l rctrnlurotr l i " r s i t . r ' l rn;r i i l t lcst ' l t t t r t t ( fN(1( io l lcr lz i l r t l r t l t t t i t t i r l t r t t r ' : t, , r r i r lo l : r r r t i ( jo l i | ( .st{ , r ' l lz j ( r j . Slr i l l j l i r | r r , r l i l rut iosl i ( ' t t l t t i I l ( ' t t ) i i rs l r ' l l i i l j t l l r \ r r l
, l r r i l I io 1r ' i t r l t r . [ tn i t t is t t rut ' t l . l t r l ro l t l t t t t t i r t ( l t ' t ts i I t t r ) , t ' i t t t l oI I I t I t t t r I1I I r ' I ' t : r
t , , , , l r r r ' ( l i t , I i r r 1 l } i t t r t t l t t r i t t is l l ru l ' tL, ( I - I I I | ) i l 1 r r I l r I t ' i I I i i , r I t t l r i i | r t r | o l l : r l r r t ' r
t , l , r ; r : r . r r , ( , ( ' t )1. l l r ' : lz i i , ( leslr t l r l l r r lxrr ' rurr l i r r l i sc c l l ' r '1 t t t t tz i l r l l r r l r l r l i l. r UI i l ( . l t t r ( l ( , l , r 's l l ] l ( l t 1( ' r ts i lor r t t t r t Iosl 0r I i I j t ' i t i r r t ) .
: l - i . l l . I ' rohl t , r r re r l iaryrrosl i l t i r r prr lo loqirr l rn l r i lar i i
' .1. : .1. l l t , r l i . l i r i i r i I t ' s l t r l i t r t l t ' pt t l t i l r , i
I ' . . r t r t t t l r t t I s i r r l rc i r l prrpi lc l r ) f ( ' J l t ( ' ( f l r t l t l t t t i t t l t z i l , ' i sr t t t l r r 1r l l r r l r r r i lr , l r i r : t l r t t r tor I r ' t ' ; t I i | , ( ' i l t r 's i i l l i t t t t t lcz l r l i t t r r l r ' l : ts i t t t r r - : l t i . i i t r . r ' ' r ' { : r ' t l r l r r
| , , ' | | r , i l | | r I r | i ( , r , | r i . | ) r t r r r . t r r i t t I r i l r . r t r t r , i ; r t I ; t i l r ' I t { ) f I r | ; r | { ' l r I r ) I t t t l r t l t i l l r to( i r ' l : r l r r, rL.r ! . r r | l l r r ' : j | l r | | l ( l ] r ' r i , r ' l r o l r i r ' r ,1r ' : r l r to l r i r t ln ' ) r i i I l r r r l t l l r l ' t r i lL l , ,1) l r ' r ' l r ', ,1, ; r : r I l : r l l ' l I ' t t l r r l , ' l I t r o I r r r : r l r . s i t r | : r r l , . r r r . r r | | r '1 ( l ! l r i r l { ' , t tsr t t r l r ' l r l r t . r t l r ' l t t t '
, , , t r r r i ; r r : r r : r l t r r i r t t r ' l | | r . rLr jo:r . I | i : r r r r , I t ' , I r . l r r r l r i l : r r r ' l r , l 1L t , l rL L ' i r l , l
1.r r r t r r i lor l r ' 1rr t ; r r I r r r I l l r I i l r . ( ( l : r i , , i i . l l r r l r . , l l l l i l i ) .
\ l r r r r r r r , , : r l r r r I i l { ' l | l r ' r ' .1r , i l r ' lcr r r r t r r l r r l i r l : r r ' r ' r r lo, r l r r r t t t t r rLt l t t t , r l ,
1,r , , ' r r , t , l ' r ' l r l t r r r lc t l r ' l r r r r r , l t r l l ( ) r r ' l r r r I r , r r rorrrr l t t i ; r t r " t t , t t r ' , r l r ', , l r r l r l r r r r l r l r t r l r r . r l i t r r r r l r ; i r r rpr : r i r , r 1r : r l r r i t r rgr : r l t l r r l r ' l r r l : r , , r ' r r , 1:r l : l. r , , i r , r r r l r r r t r t l r r r t l I l r t r
. i ' . / , , r . ; ' . . l i t . r t t , l . i t , t t t l r .ut . l t r r l t t l r l , , t l t r l i . l , . i l . sn.hsl .*) t l . i r r r l , i l ; r , l r r i r r str . r t l,o| | I I r | r r . | | \ : | | o l i , r l prrni l r i l r I r r l r , r r r l r . r r r l r r l r i l i r ,orr r lxrrroir l , i r , s is l , r r r r r r r l r r i vr ,Arr ,l : t l i t (s i t t r ; r r r t i . s i l l l l ln l r , i ' r l , i r t r r . ; r l r . r . . r ' r . : r1Irr , { . i r r r ,h.z i r r r t r . : r r , ; r r r . , , l , r ,u l r l r r: r r r l l | t i t t l : r ( l r . t I : i r i l I ( . : l I | | | | , | | | . | | , | . . A. . l l i . l , s I I L { | | I I | ( r , l r . r . r r l i r r r . rg i | r . ; i r . r , ln; |Jr . r r ( r r r ] r .str t i tzrctr l l roduc |orr l t ; r ( l { i t r l )u l ) i lc i , in t imp u) Sl t l )s l jAl | i ,e l t , l r l i "i r l i r r . r ' { i lc r i i , r i rn l r r ,L i"nmirrrr . l , i r . r , o i i i l r r i ; i . I )e cele mai rnul to ol i , I I i rorruI | i i I I r
:1 l i l ' j ' l l : : ; r lo pupi lc lor .s l r rL I r ' , , ,hr"( , t ic do lcziuni r lc l :
. i rs i l | r l , | ' l i , , I l l r r l ,. ' r , r , r ' .Z l l l lu r tp SlmDal, tCLt lUi .
, ,.,\) ,\rii,s/arrlr l" cu)e ,,Jecteaad actiritatea pard,simp( ix(i si se folosoFtc
.1 D rr)r ' r r i i , r1, . r .ar?rfTrenlru dingnus[ icu] d i lcreni i l l a l aDoLnal i i lot ,d, , mi l , intoIrrr I i l : r l i . . i r r l parasimpaf icom imol. ice Si ptrasimpai icol i t icc. l r in l tc cr . lo't)tt)u\ntputLu)ntmctrcp emmtim |
^) physoswrnhLa (ezeina) O,Zi % Uo_rlrrlr' lrr rrrr ochi normal o contrac_ti;-madmai; a pupiGlor ;$ f Aolir$iio.r,'lllil I ",, i)r.oduce r.r zrctiule similari, ezerineif ins5 Ae 'ittensitate -mli
lf l l ' 'rl Ir:) rtttttcotl_na sollttie 2,5 7o.nu produce nici o modificare ia o pupil),ror ' r | | i r t : r . t l r ( rzI I iD care inervr- t i , r .pf l rasimpat ie l oste ixtrerul td, m sihi ic,,rslriclr)t' i rlevin mai sonsibili _$! astfcl hetacolinn 2,5 o/o -va'proriucor, , r r r . r l i , r i , . l r lp i l r r . r i 1 r l l Ceg maj lo lo i i td .s/rs lonld p, t rusintpi t icot . i i ica esier l t ut t t t t , l t t t t h ldrobromi"d 5o/o. ln r imp de 40_60 minute de l t insl i l rLre: ] ,I r | ) | , | : | | | r , | , I I | { ' i . cr pupili normalii se dilrlr] la maximum. DacJ inervabia,: , r r . t , : r l r | i r ' . i r . i r r l rerupt i r r l i la l r r r r . r esfe tn ic i sal t i )b; :eat i .
, f f ;1t111.11( ' "_r lstanlelpe4rpaleclpd:doct iDi tatp(ts i / , .?d/ icdsicaresefojoscf lc
. ] , , ] l : i i , l i tb aol i re,^cer mri ur i l izar i e, . te coco;na 4o7o. Insi i larea de parru
lr, ., l 'r 'r
(i r. r ' '(.r ' i
i i i n sr cul con juDctivrl produce, in motl normal, d ilai:r,rr.a|,tt1rrlrr"ri. ' irr sa2u1 itr cnre inerratia sifopati;n'este intrerupte in afarn,.ir' l.r'rl l l i ..lr'\os corrtt'ri l, acest fenome.'nu apare. Dacd, exisi$ o activitato;.r:rr'.rrirrrprri,i.i. ( 11'suuti, ef,cctul dilatator .aI
-cocainei este slab. Se poaiu
t.t tt 't ..t..ltt ')rtt.lIl gangliutt,ltri stelol cU 5 rnl rle procain:t hictl"oolorici l ol..r t r | 'oD{tr( | | l ro l r t r l ( . , l ) l tp i l r r devino miOt iCd di t cauza aCt iur i i parasimp;_l r r ' r r l r r l
l.,l lll rlurlo,[.oq.i( tt.tilizd,rii probelctr colirelor este urmltoarea ; a) Dd,od,lt t.t lt t ltr t :tlt' .ttt ith i.atiLrii, se ta testa in primul lincl cu metacolin i, 2,i t/o. Api_lr{r:r pr;rilrr ( r ' lsir.ic1-iei demonstreazL o leziune parasimpatici:" Liisai)rriirr', r n\:rtlltt puprlare ]trage atentia asupra unei Stiri de excltatiOrLrrrrIrrrIi.i i, r,r*. |.rN{r ti confirmatl printr-rin-bkrcai aI ga'gliouului iiefiirrlrrl,r:, :r.r.,t 1,11,('r{rler api-(ind ,co-nsirici ia pupilei)'; ni \icA pupUa isiir / , ' , ' . / , , , , . .sr . . \ 1 ' ,s l j r rL.pr imul r ind cu homaLropixd ioo. ln c lzr t in car, ll ) r r l ' r l : r r l r .v | | r ' .1 i , : r11" mrdr i r t ic i , rvem dc,r f rce cu o s lare d.c crc i l l l r i l i t r tol,;l l:l l l
,l ' jri:.:: :l:icu1i, iar rtaci se md:e$te pu1i1, le aflaim in fa,1a ui;;ir(,,rrr, r'r ir trlrunulur simpatic. Du1ri-trecerea efectrlui homatropinei,'pulenlrrr'{ r r.r (lo{liritril,. Darli pupila se dilati in mod oviclentr probibil li-ziuacar, r r r r I r r r I i r r iii, sc ir,i'lir, in caclrul S.N.C., iar dac[, acest fenomen nu se Droduco,l.zrrrrr.rr s. grist.rjl{' irr:r,ftta S.N.C., I* nivel'l f.ibrelor ple- sau posl;ganglio-t r r r l r , (N1r:r l r t i r r r , l t l t i f ) ) .
" : . ) . .1. , \ . , : j . , l t i : rx:ur i t ( iuHt , l i t l t , t , y tTi lard)- ' ln rnod rxrr . r rn, l , pupi l r . lo
*r , ' l r l ( ' r (x. ' r r \ i i r r r i i l i r r r r ' 1 i I0rrc l i r r r r .nzi l r rg l r l l r st i rnt l i . l laci l prr l i lcJr , i r rAl i t f r ' ( l { f r t , f r : l l t i . r s i l r l i l lg l t , l , , t r . lxr i t lnr l r t l l t i t l r r q t t t t , i :pt1xt , i t , , r f4 / 1.r , r i , i ; r r r l : r r i l ,r t r r , r . I ; r I i I r r I l i r i r l ) i r r ( ' ur l i r r r I r r l t , r , l l r , r r , lor . 1rrr1r i l r r r , r , , i tvotn o / lx i :or , / ) f / / r r . / i r i ( ,1
'l i'.
l r ' , , . ( ) r l i f l l r r r r t i i r l r r i t t t l r l l , ' l l ' r r r r r r i t t l rc r I i I t I t t t I I I r ' I I I l l lot r lot t i i l t t t l t i lc
1, , , t , 1 i lorrs i r l l i l r ' l ' i r , t ' r r , I izr , , i , , ; ' . r r r r i1)rr( l i ( i i s l l t l i t ' . ' , I , t l ' i r l r r r : r i o rrs l l i l
i l , r r r , l i : r I i i : t I r r str l t , t lot ' l t l t to l ta l t r i r l r r r r l r r t l t r r t r l t r t r r ( i t ' i s l r r t r l i l l t l r i l i i , i t t l r l r t t r i r r I
t , ' , , , , r i r r i i , t : t l t l t rv i r tc Et l t t t t t i l i r r : t I t r I t ( ) l t tL izrx: t - r l ' ic s1l l1 j ( i i l ro i l i ( r I i I i t ' r t t l t t r r l t
t l , \ , l t : . i tnt( i t t , t t i l t t t t : r r t l , t i , . l i r i r i lu l i t t i i , , l ie pureLiad' , t ' t t ; t ' r i i t [ t ' l '1 t ' : lz l ' i rct t l t t t l
1 ' l l1,r1, , r ,0trs l , t i01t i r q i c l i , ikr Nl l l | ' l l f { ' l ( ' l l t r ' ( 'paraslnl} : l '1 ' lcor l l lL l l l l l l r r l r l f l ( ' r ) r r r
i ,1, , . ,1, , , , , ,1, , s inrp:r1, ic i r , . I ) ( , ts( : l r I ( r lca, anizocor ia poal 'c s i ' l l l ' : l l i i ' : i l l t l r r i r l r '
i , , ' ' , , , , , r , , i i , r i i i i r t rL inhibi ! , i i a, ctr i t ru lu i co'str ictor, co.s{ j ( ru l ' i ' r ' l t 'z i t t t r i l . t '
, , r r , , r . r r r r roL,rr [ r r . ArLizucor i : j calo sc accentueazi , in t imlul d iJrLt i i r i i l r t t l r i l . ' ir l , r l l r r l r i t ' r ' i l r l odusi , de l tz iu l i a le s i rnpat icului ' in t i l r lp rx ( ' t ' i l . { r r l ( '
, ' , , , , , . 1, , t , i r r , l r i r l contracl ie i este consecinla lezir i i parasi l ) r l ) r ' l i ( ' l r l r r i "
: ' ,t.t i .,t. -/,I idriaza (creFterea dium'etrultt i l tttTti lo'r pesle 4'. 5 tttttt.)
r ' ,,.rt, lr rrrt, i lni lt j , si in conditi i nolrnale. Astfel, pupila trstc nlai (l i l ' l l1 i l lrr
i , ' ' , , '
, , ' I : r l r i t l ' r r l i , Ia m opi , l l ' : r r lo lescenr i '
l l l ' . i t r t t i u l r c i i lur t ' l t l i t r
l l i(t.t ' i .a,f;(t Qrtaur(i, ici i se nall i lestri prin faptul cti l tupilrt ' lrr oclr itt l
,,r l ' { Hl(f irrk'sca' Inai mare decil, ]a ochiul s;nil ' tos Acela6i f l]rrolt lotr Ntr
'ui,t,,, i ,, i , ' l i irr rrhiul ambiiopic. l l :rmautoza bilateral[ ' , apart rt ttt i th' i:rzi i
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r i l r l r r l r . , lxrrr l r r l l r l l . l t ( ' l t t i t to: t l l l { ' ) . l } l l l l i t i l r r t t i l l r l l r I I i I I I I I ' r ) ; r | ! L I l .
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or l r r ;x"r ' r r ( i i lor : t { r i ( ( ) . l t t l r l r l r , t r l t t t r tptr l i i l r l l l r t ,nt t ' t inr l t r r l i t t : l r r l r ' : r '
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l l l l , i tot i t t l t t tn l t t l , , r : t , , t l , t . ) t l ) t t i t ) tu. t .| ) t t t r rz] t | r r : r l r ' l r p l . , r r l r r Lr r l r , r l r ! l l ,L l j . l t ! : l r r . r , l l i l r f r t u l t l i t l t r t l t l . ( . , .1r .
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.1.) . l 'ural. i.t i i 'pztpilure &sacial.e cu trulburdri de uerlere, L.l ulrriu.(, :r,rrtt)r ' l(.zirrri carc afecteaz5, atit f ibrele pupilare, cit qi f i]. l icle opti$f, l)(!I|:| |(|r.L.rrI lor comun (intre retini,, r i i zona d.inaintc:I coryibr g;nicri l;t, i, \ l ,r 'r i, lrr)do fibrele pupiiat:e se alespart cle cele optice) i
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lr) I 'rrroza, pupilarl ambliopic:i apare in cazurile i]t care leziunilrrr. l irrr, i srrrr ,kr'.r ' . lui optic slnt irrcompletc. Rc:r,ctia luli lar:i la I 'ntirrl.. i . l .. l : ' i 5i p.rrlurigit. i, a't it cea dircctri. cit 6i cea coirsensriald. ln lcziruri lrrunrl;ri l rrl( ' , (x)l l l ,r incfi ia, consensuali oblinuti, prin si; imu1::r,rea ochirrlrrir irrrrl,s . ir l. rr 'r, i nrla.c rlocit r. ir,spunsul dircct la lurninii. pareza pupil . i i ,i r | | | | ) | i ( | | ' ; r ' i i rr i irs1, d.solisi i iu nc-r'r itele rctrobulbarc, leuropatii le dlabd;ir*,r r r r r r r l r l i r r l r i l r I l r l r r rg i r , l ' r_
ll i t. ir l( 'zi l 'r.rt . i i ikrr a,l irro.tc se g!'tseftc Ia nivelul chiasrnoi uptirr.. : r r r
I r : r r r r I i I ' I . I ' r ' r ) r r r r ( ' r ' , r ' r . l l t r - ro lc pupi lare s lnt p icrdnte nunlai I i ! s l i r ) l II r r r ' r I r . r r r i r , ' I i r r r ' | ' r r ' , ' r r ' I ' ' . i , i lcosl ,o cdrrut i i , lYcm o heni : lnopsie i rs{)oi l r t i irtr , 'r l ttt l i i i l tttpiltr l h urt.. iurt oltsice (rtrxti-, ia hcmialopsicir, :t_ l l t i 1,Vlltrrr ' l , l | , r ' :,r i r r r r i I r r ccrrl l lr. lo trlo
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r l r r , , , r r ; I . r r I I r r I r I I i ) . l ) is l , l l l j lof l , rcaCl, ie i pupi lUc pol t t ; r ,u 1,( , ( l . r ) l ,ot : ) l ) l ,o l r i l l i r ,, r l ) i r l ' i ' r . i l t r . r r i l , r r l ; i i v iz iuLlc, , \ I iozi . r , (ou r t i ,spuns foar.1,r , : s l l r l r l l r , l i 'n ' r i . rI r , r t i , r i l r iz t ) (x l l i i t s j l l l , l i ( f l t lno c l in ico oi t r0 : tcornpani l lz i i i t l t lo l r , l tc i t r r , l t l i r r l r i lr r , ' r , l r i . r l , : r l : r , l r r r i r r : r . r r ,pupi l l lo11 ut1gcl1j l rsol ia l , i i -q i grr f l .c l , i i lnrrr i l l t 1r t r1r i l1|rr . ,i i , t t l r , ' t t t r l lnt t l l l t r lur l " t t t t i t rs,{ . ;1. ? i - . -100i)1, r I i ' r . i rzrrr . i l . i l , i s i l . i l i , rt t , t r . r i r t r s l r r . r . i r r l l r r l rcs s i ; r r r ' : r l iz ic gtrrrc l l l i In ig1lqsi1, ;1. ' l r r s l , r r , r l i iL, i r rc il ' r ' ' r l , r ,
r ' ' . l l r \ , l r l . l : r l r r r r r i r r : r l r r r r r l ,o l i krrr l 5 i i r r I Iorrr1I | r , I . l ) r r r , , l l r r l r l r i r r r r r l l l r r r i ,l r : r ' : r l r / r i r rz, , l : r l : i : r 11. l l r \ l l l l t i l i l lQrr) l r l0r 0sl , | l r i l l t l , r r r ; t l i i . l . l r r r r r l | l | r , i r . , , ; rzr t t i, l l t , i r l | l . t i | t | | A|r l t ' l l I i r I I r r , r ' I I I r I r r r I r r i I I r I r , r . I r | . i r r t r | r ,s l r i l , r I r { i i , i r r r t r r i j | r i l l | | tu.l , r r r r or , l r i r t l : r l r . r i : r l r r r r o l , ( r r ) ( f l r r i l i r l ) l l t f i r l i lcr l , l l l r r r r r i r i : i , i r r ; r t r | , i I i r I , | | | |s I I I
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, , , r r ' l i t i i pelologice c: , r , ccl pupi lo-constr ictor Ia lunfni l . - t \ tnbulo s i t t l r r l ro l i l ., r r l .z i t r l r i l t : c i i lor comule f izuale $i pupi lare, insl pot t i i r ] t t r ' { r rJrr l r ' ( l i l r ' r ' r lI l ,.ziurLilc de trunchi cor,cbr: .
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l ' , , l l l r ' ( lonr i r ia rc&t iv i tatea p1t]r i lar : i i (semntt l ln i ) Iarcus ( i t rnr ) . l t : t r t,, lrrrl sl ir i i tos este stimulat qi cdii lalt este it,oop(x'i1, pttl i lrt, r ir ' tttrtIo:r: i:r, ,,orLI,r 'r, ir i,r i nolinal. DacA se i lumineazi, oohiul zrfocl,rt1,;i ccli i l :r l l , r 'r lr,, , ,1,r ' r i l i , a l l i { rc nrmai o rer,ct ie minimal i l , , 11tr ]L i i , t i de o (1i l l l i1 l r '1r st l tpt i t rzrr,, r, r ' . Airr.sl semrl a fost doscris in neuitele t 'ctrobu.l, lrur?.
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lnttl l IJri*:r '!totL itn:r:rsu.l, ) a fos1, t iesorisii i l I olt(xfl l ir l i ir l , (,1)i([( ' ttr i( jai rt i i ttr ' r r r r r l isr ) t|r (i l t,] i io]l{r clt intelesat'o1l ol 'bitci.
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; l r i ( l ( ,s( . r ' is ln i . l iyru,r i t lc t r t ] r t i0 Ttr t , l t i lu.r t i totr . i .o i t : r t ) ( t t t r , ro{ io i t t l t tr r r i l r r , l r r r r r i r r i r (s i ' t t t l rot t t l l l tsNTt ln, t , - P' i t t r ) ; l r ) r r t tcar{ io l t r l i lz i l l i r l r r ,
, , , r , r ' ! r ' r l r (s indrtutr l Nur,n.gtr ' ) q i t r ) int i tz i t lc l t , sr t , t t i thr l i t t l t t l i r r ,L i t , i I r i ( r r, l I t r l l r l ! r ) i r r i , c i i , ry i l r r , r ,ot tvr , r ' i ; l l1, i i ( r int l r t twtt , l , l . t t i , ; l r l , i r : su, t . t , t r l l r t i l l r i l li , , r ,1. i1r . qr : r lc r l i colc l lc ! l , iptrr i rkr pt t l r i lc 1,otr i r , t : r t 'p l t 'z i t t l ' i i nuirr l , i l r, , ' l , r r rs i I r r I I r r r r ' : ' i l i , i t r t r l r , t t t ru l r t t t Lr l t i , r r l isDtt l iut j l r r pt t I i l l t r ' r j t t l t l t t r t ir r : ,1. r i r r l l r i r r r l i l r ' , I ic i r r r1r I l t t t t r ' , l ic r , i ( ' lJ lu ' l l i .
, \ in l t , , , t t t t l lu i l t l i r : (sr t r . t r l l t r i l l t i t . l . / , l r i ls ) r ' t r I r l i r r r I r r , ; r r l i t t ; , ; r t , r ts;r t 'o l , t t lr l i prr l r i l ; i lorr i l i r , 1 i t I i t r r i t r t t r r t l r r , s i r t t i r , l ' r r l i l ( : r t r , l l r r r r , l r r r ' ( , r l rx ' ln ' t t r l i t r l i l i ( , .l ' r r I r l : r l r r r r i r . : r r l i t t l t i l t l t r r t t t t t l Ar l i l c i r lc t t t rx l r , t r t l r l i l l t , l l r l : i , , r t , | l t t ' r ' I t l tv t ' t t l ,r r r r r I r : I r ' r ' r r I {s( t " i , r l i r r | r rzt l | i ) . l ic l r f ( i r r , 1ru I i l l r t ' i i l : t l t t r t i r r : i t l i t | r l : j l j i rxrrr l r , t t
't't
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';rrr '. r ' i l t tstt l lrt 'r 'yrt, it,, \ ' ir lrsul herlles zostor $.[. l)rl l izi i I l l , ir lrr lxri l tr r i r l r r i t ,c ; i i r r pr i l i l ld icukrt ieyf i to l r Gui l la in- I l ln ' r i , p lcct t tn I i i r \ ' :u i r r l r ' l lr r , r r i r r r lo l r t r l , l l l i to. l lLr l lc t l i rLtrr , pr l la l iz i i le faci l lc l ) { ) r i l l (n i , . ' . ; rsrr z i ' , r ' , , r rt r , I i r r" ' s i r r l i r i r . ' l r l ih i t i r ]11'( l t ior tse, i i t l fe lornt , t iu l ( lo i l ( fvro( l { r ( i l i ' t r r l l r ll r ( r r t [ 1 's i ( , , rL ' j ia1i1, cel ur i r i ar lcse:t , o r Ie l ry i t i i , fnciaLi , insol i l , l i r l ( . (n l i . rur li i , r ' r .1 ( ' rvul l : i i t r lpet l [ot [1 1r l1 J l r r l lopo. Tnl to cu,zur i , l ) r I l r l iz i i r I i r ( f r r l r l
, r i l r l l r r t t l lur i ot i i t lor ' $ j , r 'cs l lcr , l i t ' , Lnml i r l ts to i (L i1o.
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l. l i .7. Sirrlronul lui Xloobius este o rar5, afectiutrt, {.(rlgenit{ i i i i 1l(,, l r r r lor l ic i r r r , : i r rcplecizat i l , care asoci t . ,z i i , o !a l . l l l 'z ip l tLrx la i tn i - sau l ) i l : rl . r ' r r l : r . crr l l r la i iz i i oculo:notor i i ( indcosebi de abi lucens).
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, l ' :ur t t .u l l s i s i rLr I ru l . . . \ r 'ur . l l l i { , I ) ( , r tsr ; . ; . . t i I i , , , , , , . i t , . <.pi l iz l r , r^ 11,r t , ,1, . r ( . r l . l r i tJ() i r , ,z i . I I iLI I r , I . r I I r i i , : , ) ; ,11, (1 i , , , " r , , ,1 i 1, \ .* , , , , i s i r . . i r r l r . . l l r i .3,l ' r ,1, l1, i ; ) . l , r r , l r i r r r l r i r r l r ' . ' r . i l . I I r r r r1I I I ' I r , I r , s i t l i , r . r , t r l ' i r , ' l r r l I l l l r , r r ,l r r l ' , , : r . , r rz i i l r ' : r r r l , ' i ' r r . r ,s i srrr l I r i t r r i . r , r rLf . i , i f , ,u, , r" i f , , , i , , , . , , , , f , , , , r r l l . t ( . t , i r ll , r1{ . t t l t l l r t r t i r r i r r l i r l f l r i lxr l r l , r rz i I i r r j r r Iu l l : r : . j Ol l l lz .
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l, lrirlri ,/orlrr, parorislice cle t:ertij (apirute cle piitl ir in crdlul urrrrr:rtt lrrri|r', s|u al lrnor su{erinl e valcutrire) cara 1,1€brie djfc}0n1 irrl,rr rlr,r , , . , r i r i r . i , l t , ; , r i ( r . , . . i . cr : I r ro. sn rr t i l izeazi in l l rct icf l nr .uI 'o logi , . , . i , , t { ,L'r ,:l Lr ||.||r|r'||It\ tlr sindru)n mhtiiriforrn (pentru care u'ii ni:ti rrtil iz.rrzr'1,r l , r r r r l r r r i l i r . r . r r r , ' r t_de , ,boal i pseudo- l ldnidreD n.n.) , car,e incJudc p:rr .oI r', {r,. \ i lt i., ( l (ltl)nt bnrsc, dar mai benigne, dc inti"nsitate gi dc chrlrrlri
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r r r \o l r t l i r l r ' , sr . r ' l i rc(uctz i in rrrod s i rmrl ta l cLe ci i t r ,e l r rnbi i g lobi ocLr l l r r . i ,r1 rr l r l i l l r i , l r r i rc i i1 l , s i r r l i lepuiz i rb i lc. Fiecarc osci lat ie r i t i i r ic j i . se i , r r r r r
l , r ' , r l r r r r r I r . r 's i r tc l t , I r l ru: i secust, e letrrcnl ate de seni opts $j dc 1, j l1,z: i, lL l r r l r i : r r r r r l r r l r i r [ i ; i l r l1, l lerr t i r . Secuslr , lcnl , i l este c le or ig i t ie t , ts l ibrr l , r r . . rr l r ' : r r l r r l r . l r i l l )u l iu,(u rcst iLrulat l i f , i , tot |nsului rnuscular, . l l t r lnsi , s l r . r r r , r rryrrr l | , ,1, . ( ' t . \ ' : . r t ' l r i i rLf t , l . "s i dupl i aceasta n() or ' ient iu l iu; t r .a i i i r , i i , r r r
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t t . . . : r t r i t r . i .s . l ) ( , 1tr( ln( ,1r( ,1r , i t r , l r r r i I s l ' i sr , l l r r lc izt ,z. i t t l r . r t : t i l .u l t r , t t , is l r r . i rnt: . t I I t t t . t i \ | t , l r r } l r l | ' r?r t I iz i r l r t i qtur l t . Asl l i ' l , l r is i r rgrr tUNl l l i r ) l t1( , I i l | r .qnul , t t l l ,,_r l r ( l r r l t : r | : r t r . r l {1 t l l l I ' r t l r t r , r l | r ' r r [ r r l0 piui . t r sr . (1r tSt; i nr1t i r l , , ; l i r t rTr.r l r l i t l/ / , f l r ' i r . , l l . , r l ' , r r . r ' : r l r i l i r r l , r ' iv i | r . r r t l i r . r ' r ' l i i r r I l r i i i , : r l0 qrur l t r l I I l , t i t * lr r r l r r t t t iorr l r ' l rozi l i i l r . l r l i r i r , i i , r r r l i r . r r r r l , i l , i r r l r r t , r r . r , i l : i i r r l r . l r , t l r ! l i i l , r )zr l r rr , l r r . r r r r . r r l r . l r r r r i r . i i "
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. t . r ) . l ' r t ' l t t i tn l i ' . t r l i r [ (u lu, i I i i t r i t t t l ) l )on1j( , r , ( ] t l l iza, i t i ( , i lzrr l l i r l i l r r i ,\ i i ] | r ) r . i , , r , , r l r
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1,,'.ll] li, lll:ll',,i ,.r,. 111 ]rutgl si,-qi rectiriie cventu;ta 'd;i:irrir:
l, t;r,,,r,.1,,r.! ir)'.oIr, |lrfir, itc,'i isti!, Irrol)- esto de interlret:r,re djfici]i, ciici cil, i:.j i,r. ,1r , , : rz: i ; r , l i l , r ' r r l loct i r . i t i l t i le r-est ib . ' lo_spin; le, c i t s i 1re 'celc t ,c 'c]r , l " r r r .t j , . . . t l r . . : j ; t ' ,1, . , r . ic i r i s i l -z i .u," iCS-l l . - "
' " " r" 'lt ) I\rt tu nersu.lr,[ dn stetr, u lui Babinshi_W eit (saw reaeliu, locs.tn;.1.,, r it
' tr t ', lti i .r' n r:lt,i,1i ). _ lin suLriect nor mal .pii,stleazl tini& alrea,tti in r.r,rrirr,l,.' r irr,r {lrl rrrrrls dus-intots (cn ochii inchisi). Se admitc o tolori|i l I rl," , l ' ' r , r ,1, , . . l ) . tn1,s;1i1, i . I 'o lnrrul CU sindjorn \ .pst iLrul ; ; , : , , , f , . . ;1. , ,' I | ' ' , , I
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' l r r r : r l , r r r r i r l : r { r : r r r ;urrr i pr :ovocat esie dc'25-25 s""u"a". o cr i rn i l i i :y , r . ru' r ' | : r r . r . . : r . , r r r r r I r r r rsclr f iaui \ ld: :mu5lr lu; int l i r . iohipo-sruoir , r - i . r i r : r ,, , r r r , t , t : r r ) r l r r l r r - i .
, r l , , .o l , i r "o i l^ozional ; . O prr , luneire^r ui , t3Enl : , , ,1. i ,r ' r . , , l l r : r . . . r r l , urr f ( , r ' t r . t r r r lens [1, in i ]a o r , . r i tahiJ j c;dere), j l l { l ic i o, : i t , , . r ., . r r I r r , l r i l i l r r I r r l r r , l r i l in l , ic i r , .
. . . , , r r ) . ! , ' , , , : , i , ' t , , l , iLul l r r ( t ! . ; ! tagn;c() r ,atut i t ,e. ln.u 'srr l :L.c"roi i . , . , , , .l ' I | r : | | ' | | t l r ' , r . \ , . t l i r l , l l mtnUcslJ o c lcslcr . ( , a t i r r rpu)ui dn la lcnt . i t i , ,, . ' l ' r , . : r I i r r r l r r l r r i r l , . Ior l r l io nis l tgmicd, c( . rc pnat i uninc, , c.rr i r l r : i , " . l lr l r ' ,1 , l r . l . i r i , r , r i 1( i r \ .L l rur ' .nc s i_colab., 19j6, lCGr). 1u
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i r ] i . i l ] . , l j l , , : . : "" ," . t , resupnno f ie o boa.t i , I {enidre bi larcratr i , f ic rrr '1, , l | t , 1 r t r . , . l l , . r , l , . l , l . l r r l , . , r t i a rrr icrr l i , r i - \ lp\-a Ux.. .l , l r : r r r r i r r . i r r lc vnst ibul l re intelrcr i t ice al .at l i o l i1tr lcxci tabi l ! t l tc l r r l r iI l |r. l ,r( i
,. l ir 1,r|0ba 0rlrlr icir,, j irr ,uleo|i chiar prezen!a'Inui f irr ri istn,q.rrrrr,,, r r ' I , r r { i : rL i , | l : r
. r r r i . , . r i r iL. l l , l i tc r le , , : ,p l lu i . pr"num ". : r un, . r rL j rcr . r , t r .| l " , . ' | | , i r r r | i r r i . l ' , r :L; , l r r i r rClr iu lu i , le prr l , . r lop11roi ls5; , . , insol i t r - r s i r l t .r i r r , t r i l i t : r t r . s i r r , .s igrrr , , rnf i i r t i lnpul mersului . r i
" i r . l i " l i - . " ' " ' "
' t ' " '( r , t : r t , r { l j . r ' r l l i i r afccl i r t rL i i , h ipoaclz ia s i zeornote. l0 lur icul l ro rr ,r ' r . ' , , r2.r . { . r r r i t I Lr i r I Lomctr ic i i : t1r i l tge.qi f rccventeic aCnte, i l l l prolx, l r .r r , r t r r r t : r l r . i r r r l ic i i o net i , h ipoexci t i ,b i l i t : r te.l i ",\ i t r l.r o u u [,. ht i, .. C og an,, prin'siuil i tur]inea sa cochlro_r_estibulrr l i i ,.r ' r ' i l)r{.2(,rt,r), , . lbt 'rnii. p:rrt icular:ri de verti j Mdniirc, irr crlr,e r'rzrh rL.
: :.1 I ,ri:il
, ll t in,.ri, in,i61,i1,, de fotofobiq dureli ocutarc, irrcr,l'oqn r.r,,a,
'.:.1], 1l , l',,,'lll]'ll ' irsr[,^ zA,nnote auricnlare, grefuri s1i Yiirsiiiur.i, 1ic 'prr,r,
' rr' rLrl|r'tr ur jt)i-rrind si o cheraiitir, intersti!ialfi ncsilililticai, iSt(;ii:tl,l l ) ' , : i ; \ t i ! ,x fNcl t . I i )?8).7-, I t t l i l_r' l t wltI i.t ' . iJorwr., cnrat;l,efizate pri ' tr_o mrre srmili lu(l i,r j . ':r l,, , jr ' \r.r ' tr!: rrr:rse rl i lL lrr,r,r, lu l l . jnidre, se datot,.sc ltt\or ceulc Lrnultt sar.t t t t t t t l t . , \s l le l , r lc i i , lc(Nl ,e rnxnj fesl i r i vcr l ig i t tot ist s i rL i , rL, rnul l ,c olrprr | r r" is l jcr ' , r '10 nu au_ l tu i i i r r l inci tar l ,ea cr izel lur d i rL bui l l l r , .N[ i r r r i r ) r r r , I ) r ri I r i r ' I r . ' r r ( | i rJ l r is t lu ln l lsul , Lrr l l [ r r i r t i ]c t lc ccl i i l i ] r r :u ry i l ani f fs l i r ihr vogol : t l , iv I
r i r t l i ) r l l l ' r r r i r l i rc. . r . ' , \sr , r r , ' r r i ' r , rnu,rr i lbstr i r i inrr ' i r ) r i r i r r r r r . s. i r r , i r r r ,s.t.t l ., ' i tr l,, tttr lt:,,,t i rrr.ntit,:r, i tr |tt l ,4,t\t l . t,tLbl ,, i \ l t,ou) ,el,t) rrdirslir;r,, i tr tttroltr. , , i . ! , ' , . , , ! I , . l . \ |w'1l | | l l ' | ' | ' , \ | l t l l ,1 ' ' l t ' l | ' ' |11l t . r r l r t t t t t1 i i l t t t l t t ' l t 'dt r t4| 'dr i | l | : l ! l ' | , . l , ( | | | | I l ' | . | || l i r \ \ l t r ( , t .1, , i | l t i r t , , l l ) t i ! ) ; l i , i r t ( f r , l { } r i : .1 ; l \ l i l i , fcsr i r t , l l )?S).
. l l - I r r l i . j t l t , . t l r ut .ur t t i lo j ;dx ( t t l tn l th i t , i t t l ih, l t , loni t t ) . Nlrr lp l : r l r i r . i r r .I t I r ' l r , I r r r t l r , t r . r l : r lot t . ,k. l r r , t r t ror . t r t r . r l i l t r r l ( \1 l , r , l t 1 l l ( . I , r r , , ' . , , r .1t r l l t r t ) l ' r . l
I t ) . t
, | l t , I { I r I I I I I r I I I , I r | :L | | 1 \ ' l I I i ( ' i | | i | . (1 l t i t r i | l l r , r t i ( i i r t : r ' r . t i l ' l r r t r t r t , i t t i l ' i r r t t I r tLt t I r , ' r ' I t ' '
, , , r , l r r l tkr | l t t l to l t , l r ro l l t tq i i l l t ' t rzt ' t t i r r i ) , I i t r t l t tot r l l l ( l \ l t r i l l l t ( ' f r l l l l t { ' I l l r ! '
; , r , r r l r r . I r ,z i r r r r i r l .g. i t . r . l r l i ' r . l r l . I i l t , ' r ' l . r ' r ( i rv( , i ls . vr .s i i l r t t l r r t . s i I t I t ' r ' r ' I t t I . I , t ': r ,q l iornr.r , . l )c i iqr t v l r l , i . i i t l d iu i r r l i ix icrr i i l t l l , i l i t ' i i r rcLt la r ' ( ' r rs l i l l l r . r ' ' l
' r r : r i I i l r ic c\cnplu.Slrr : i ot t t ic i ia l l ro(hlce ( j ( lo rn2t i f r { l ( ' \ - r ' l l1(r vt ' t1 i . lc t lo rr t i ' l i t r r ' ( ' " i r ' : r '
1,r i r r l , 'z i t t t t i le labir l int ico, i l lo nrolei lor ' | i : r l r : t i i l r r t ' r ' r ' r :1 i l t t r l r t t r " \ r ' r ' ' r l r '
' r r r i l i ,s l i l i l t t r t ig; inolse s jnt dooscbj l ; r l t ' i r l l , t lnst ' [ l t I r l l t i t r l l i t r 1 r r r i I r I i l i
I l iZ i i0) . i r tsot j t r : r |cnl i l ] ' j t l l l } )111' i j r i ( | ( ' } } } lJ 's ' ( l | , ' l l js i l l I l l l l l | ] | } l ' IZ i ' ' I l j l I
' , r , , r ' i , r , , t i l l t , 'g i r : i1() l ' ( t lc o l ) i ( 'c i b i . iatrelal ) , g lcrr ' { : l s i vr)rr i r i r t t ( ' t r i ( " l : t . r t t . sr '
t , , , : r lc : rsr){ , i i ! i i r : , r1 i1: , .1 i s i t jn i t i1 l r r { 'chi . i l 'u lbu. i I ' i l . r1r t , r ' l t i l i } r . r r i r i t l l t r r . t r
I ( ) 1rs( , l l r i soi izr i t ia i f lo r-cr1, i j lxr l , ptTs, ist : r n l l i r i iu l t ; i i Vr l ' l ! r r" I ) r r { r ' l r l i l
t , , l l r l (1, i l i i , i1 i i lezjrr i r i lor s i u . ' t r i lxrrr i , ' t . i r i l - . t ' t i1t i l i r , . ,s*. tx i l r ' i l r t l i i r t l t t . t i , r
I ' r , r : r i lc s is l ,er l lL l iz l t t 'c l , r iLsl l t ls t r i i lo l ' la probt lc \ ' ( s l , jh l l l i l l t ' l r t ' l t ' t r ' ' t r r l ' ' ', , l , r rU f i r , l t ipo- -<l t i i tLcrr t i i : r i r i l i i : t t t l . t 1n'ol l r , i i r ( le l ( ] r i { r i
-s i to l i r l { ' r i ( ' , lJ I r r ' r r r r l
, , r r l r l l r l ; iz l l r i ' i l l l r iue(t() f { l l tu l i fouis l i , l l ln( l l i ra l i l ' r l ( l l l i r r l l 'z i t l l r i : r i i l ( r ' l r1r ' r r l t "
, r l s i i rcr i j i I t t , i , ) . I iq, tu.nt i t in,o . . . i nt : r t t i t i i to i r I ( ,01n, i12i{ r i t l 1rr t r l i l r . r , { i r , . r r1rrr I r l r r l, , , i r l ,1rrr ' , i r ior l t t t , i tLr l l rc l r t i t . t r p l i l r l i i i1- 'o i l lLtz i i , t lo.pt ' r i r r '1.r1ic t t l crrr l t ' lLr ' l r t ', , , , i i i r r t r ' , i l l i l r ,sr ,s(rr , i1r !" i i ) , r i ' lczsaziL r i l , l j r i t r t r t l 1{ ' )$1 I ) ( , r ' r r { 's i r ' , ,1 r l r . ,
r ' r . , ' , , { i i i l t l t l t : L l r ru ' t . l tonl t r r l ro l t r l r ' , l1}( i l ) ) '' ( l l t i . t t i , , )u t . ' -a:rar l j l r l r i i i i r ' l r i l t t i l ( l i l r i l (111 ; t r tp l t l t t t i t : i t t lL ' 1I i r I t I t tc i t I I I r t t
r , r ' . icrrrr i i l t ' r i i r i l .q:ni l r l i I t ' l r ' l i t r rLvel l ' l . , l i l iLni l losl i i r , j 1:1 '1 ' l ' i l j11111rt : r ' l r t t r l r t l r "
r o i i l i ' t l r gf l ' t , r l l i , 1 ' l - i r ) r i i i ,1 i r i , h i l ro l t ,nzir ' ; i z i l r tnoir l I t I I t i t I t t I I t I I ' , 1 l I I t t r r i : l
, , , r . , , , , , : iz t ' , , i r , ' , r i icv l i .z i l . . i . i . l : l l r i l r ' r . : l s l i l r i i i l r r i l i . l t r sr , l l i rn l t , i t t i t t 1 r I I i t ' r I I r r I r '
, r l r i ( r r ( i l r r : l ; i tL i l t i . l lz i i l i l i l { l ( lo( l i l l ( '1 l I r i r ; i l t f i t ' r ' r - l ' r 's i l t t l t "
l t ) " o lost , { t 'o ' t .L i } i , l t l ( ' : i l i \ l1 l s i l r r } i i t i t r t t t l r |sf i l r r r l l t t ' I I I r t r I t r ' ' i t r ' I r1 r t ' r
, r ' l iq i t t r la.srr l t l r in i r l ( ) ( l t ' i l l11 ' . r1,r ; I ' t r i r j r I i ] r ' r t i l l t r ' n ' rz i t i r r r r l r ' ( 1 : r l ' l r l l l i '
t t , , i i i in r l r : r :csr, th^ 1, ip t rx 'n i i . | l i l i , ' i ' i r l , : r rs ' r ( i l r - ; j 'Lr ' ' r ' ' r l l l ' r ' s i I t i I to| t r I t ' r r '
Nf . t " i l r :n i . f r :* l i ' , t i t t t t r l i r l inr :o. : te i t r r ' t t t le l t i l i .gtnt t 'Lt ' l t :r ) I l i [ tar l t : r t : ' i t , t ta( t ( j i t l i t : !d ] l lu(hr(1o l i l ut t i i l to l t t r l l i r r t t r t l i i i t , r r t r r l '
,1, , t i i , i J l rb i r ; l i i l l r r i r I ,Sl i lnr l r r r ' , in:r t r j loglai . l - . r i l l 1rr '1, i , j ( ' , I r t I I 1 I I i l i r ' : r i r ' l : r
, . i : r ; i cr- lc i ts i l t c l l l r t t l t l i i i i i i ;sol , i r , r ' q i tkr r i r rs i l l t l l r t t r l i , l l t ln( ' ! ' i ( \ ' r r t l i r l
, ' r r l l i l i r cot ls ic l t ' t ' i i , ,1elsr ' 'or l r ' i ' ' ' Sr l r o ' i r r : ' r r r ' ' ' ( ' : r { Lt l t i l r t r t ' r ' r l i i r r l r i l i l ' r r l r '
, r i i l r r r l l i | i , t , t r l t i l ro l r r r z j0 r l , ' r r ' r ' , r .Jr l r" l , i l l r1" l : l j i f i ( ' l l . " - l ( l l r l { i l { r l l l l l , r l l l l i l r l \
r !L( . r 'onr! t l l l I ) l l ls l l l ,I t ) . I I : r '1t , t i t t t t ' i r u ra t t i ( r ia l ' ( i (Lc l ls l l ) t1 '1 lo1l l ) ( r r r ic ( l ( ' ( 'L l r l i i l l t ' r ' r t r r ( i i l : t l r r
, , , 1 i l r r , , i r r '111'111'111 Si i tor ' : r 1)( , l r i ru l r l l t r r $0 s j l 'ucl tz i i ' -s i l t t l t l l l t t Lt 'L ' \ ' i '1"( ' l i l l l \ : ( r
,1, , ,1, , r r r r , , l l r r r tspi t ' lL i r i i , r :3rr l t t t i ' v i ls i l ' t l l i ) l i . r r t tL i r l ' r l i l t '
t , \ "4, /a, : t i t t i i t ( r t tdu:r iJt t ' (hrr l t r .s. l l i i i I t I i t i i I ' I I r I q i 1t I t t ' I t1 i I r t i r I i . t r r ' ) l r ' 1r" l
, , , , . ,1 i ' , i r , ' l r i l r . r r ,x. i i l l t i l i l l r i ' r " l l tJr i r i r l l r i . i l t l t t t t t r r t r i l i r i r l i i t i r , ' t ' t i ig i t t ' l tsr ''
i \ I t r t l , l io l t t l , t t . l , at t l t t t t t [ . \ i t r \Jt i lxr t s i l t l l l t l l i ' r l t ' iz t ' v<' t l i r l t t r r r : r ' . l ' i 11'11
,, , , . , r 1, i , i t , nr | t ,s, cv0lr t i r r r I i t r l r lU'el t r l 0t t vaJrt l i l t . l t ipt : r : I l i r r | r r r i r . r ' . l l r : l r ' r ' ] l r \
, , rzrr t i . c l r r i , t ' r t t t is l i lg l t t { } l t t ' i l l l l l l , - |o l t l ' r r t lv i t lcr t l i l t o l t i l t rnt l ' l l l ' l i r i l r t io l r l l r r
, , r r l ic i i I t i I r r I t ' t I t I i i , t l t r t r l t i r , t ' i s i t r t l l t i r r i i '
t ) l t r t tTutxt t to j i l i r 1 i i t t s i i t r r l t ' r 'a r l l 8 l I tNtt to. l i l . i t t . .1t( l t to| t t t ( : t t l t t t l
' , , i r l t r i i t t l .sr i r t t , , , , i i i l i ' *1 i i l i
' r ' t l i i - l i t t I r : t t I I ' , i t rs, I i i r r t l t r i t 's l l r l r i l i l r r i r r l l r r ) t l ' . i i l : r -
t l i r r r i i t t t l t l i , l r r l l r r l l i i l i r L ' r ' r ' I t i I i I I l t t , l r i l r t i l i l to i i r l l i t ' r ' , ( r ( ' l i I11! ' , l ) l l r ( ' r i l ( 'z l l l r l
r r ( , l r t l r t { . , l t t ln ' l l l t f f ! r i l t l l f i t l l ( r ( r r t lx tp l r l : r l r ' ( l ' r r lNrvi t r i r t 1 i r ro l l l l l , l l l?t i I
l \ l r l , ' r ,g(1 ' , t1) is l ) - l i l i l . r . i , t i ( , ' ( l l l i l - i ) r ,<, l r r l r ' ; rz:r . r ' r r , r1r . . r ' i l r , r l r . l r , . : r l . t i . r r
1, , , i ' , ,u i , t , ' , r ,11, , r ' r l r ipct l , , r r . r l r r l r i l i l r r i r . t r .s l , i l r r t l : r l r i , r ' r ' tosirrr i l : r I r ' i I I r t I r I I i I i ,
1. , r , ; ' , : r ' i i r i i t , i , , , t , , ' l t , ' r ' , ' rcr l r l r t r lo r | i ' r ' I : tL i r I r t l i ( i r l l r f ' l ) ( l l , t l i l t t r i tz t t t i ' r ' l l . r r
1, . , , r , r IL,JIrr , , ' I I r , ' r r r r : r , Jrorr l r , : r r . i r l r r l l r r r , . r . l r iPcl lo l l l r l l r l l l i l r l r l l i l l t l r '
rt!
t0$
s). N e,fritele_. cronica (trtritr rkrzrxrhililrrele hidro-clcctrolitico ou rc.pc[.cnsiulti cFl Dra lichidelor orralolilnfl,ioo qi prin hemoragiilo labirirrtice)lxltrri rlrrl,trllrine crize vertiginoase, urroori de tip rndnidriforrn.
lt) llt,iirile. alergice .prodttc, adesea $i leziuni ale urechii intcrno, cUrtislrtrol,ii labirirrtice qi m:r,nifesti,ri vertiginoase (Williams, 1056, oilntrL' 1!likr;oscu, 1978).
ll) It'orme particulara d,e aertij labirintic. Este bine cunoscut faptul olir rrlirltl, do procescle patologice amintite anterior, mai existl o selie tlorrorrrlifii specia,le, caro favodzeaz5, aparilia ulor crize vertiginoase I
t\') l'ertijul _f,&roMstic d,in ,,rdul d,e ma,re1' se traduce printr-o simpto.r r rrl okrgio complex5,, dominatii, tle vertij cu alur5, paroxisticd qi tle feno onerlrrrrovcgctative
" (grea!i,, . vd,rsd,turi,- paloare, lipotimii, midriazii eto.).
Yr,r.1;i.jrr1 eorrstii, in senzalii de instabilitate, sau d.e riisturnare (rotatiollorrsr ' r ' t t . ivc tangajului produs pe marea rgi laLi . . Apar j t ia cr izelor ' r lolrrll,i,j rlirr ri,ul de mare a fost cxplicatii prin fenomene hidrodirramico dorlr'lrlrrsrutr lrruta,Li a lichidului eldolimfiltic, aare tuctiolteazi, asupra ftl)fl.nrt,rrlrri otolitic. Yertijul din riul t1c mare se insole;te qi de hipotonsiur0rr.r'lrrlirr,li, grelruli, vtirsiituri, hipersalivahie,._diaree gi transpirafii rcci 6lrir, oJricoi oodeazil, dupii, inceiarea excita!ii lox de cilLtorie.
b) ll utij,al. d,!,n ,,rd,u] de at:ionl'apare ca ;i riiul rle mare, la acoloir,rlllrrl,r,grlii rlo indivizi $ensibili, traducindu-se prin vertij pr,roxistic sill.glrlr,sir,tr lriooill,i; (,tl itlte semne vestibulare. In cazul zborului cu ayionul mai DotJrrll 'rrt,rr urrrroli scnza&ii bru$te de vertij, insolite de durere :r,uriculu,t rl,irrl,r,rr|ri ryi rlLr srr|tl itato uni- sau bilateralS,, prin rl,ero-otit5, la indivizii currr i r r l l l l r i r r I In i l i t1,( ' ra l ( l? iquet qi Piquet, 1965, c i tat i de Stoica, 19?B).
. I'J.. ,4tkt. .lo'tna d.e.. Dertij ,.labirintic:. vertijul de ascensor, vert,ijrrl
I ) ' l 'u lhur i t r i l .ul) il\t,lburrfu ih naurot)ollnl l,lM olinntolar,ioc po0 irrrlrlir:t ln ooutontt{rrlitrif 1i r rult r ilosl,r'1,r.i vtrr'l igirrorr,xr,r, lrrsrr(il,rr t.[o rrrullo ori rLt zgornol,rl rrrrti1111.ori r[rr zgurrurl,o rr,rrriou.Lrr.c 5i rkl i,ul[rulrit ' i do oclti l i lrrrr, (11, l lnnitro iL ltrror Iti pot'c.soitrtbiliti l fll ir lr i l i t t l ictr (ovitlcn!itt bile l: l prrrlr ir, ur lolioii,).
rlrllrrrrinnl; rlo unornaliilc rle retraclie (astigmatism, hipcrmetropie, mioflorrl,c,), vcrl,i.iul onlcl)t,i:rl, vertiiul inotitor.ilor. Ultimele slni, in roalitui o.ol,c,), vcrl,i.iul onlcl)1,i:rl, vertijul inol ' , r l ru.r , r r r l , i . ic .
lil. ,,1,'ttlsol,o wrtija't sint amefeli in infelesul cei mai trannl glluy i t t l , t t l t t i :
rr,) f ir, l ttr: loI rnt l iut t ' t l i i lo
b) l ' l lst*rr rp i lo l ts io I
o) llrlsolo vcrtijo ds origine psihici, (indeosebi din std,rile fobice):
_voltije de. origine c:i,rdio-vasculari, (boala Arla,ln-Stokotr,sinuzale, aritmiile, tahicardiile, stenozclo aortict, eic.):vr*tije din unele sti,ri prodrornalc ale anumitor crizo d0
r[)..1)r.r,l,solo vertij_e do carzd, oculnrl din tllburii,rile do rofraofie,grulrrJizii u,lo rnuqchilor' oculari, la, indivizii cale poartl lontiloprrrrzrl l,orlru viciului ds rcfrlc{,ie q,a.) ;
c) I'u,lstrkr vortijo dupii hiperventilalie ;f) tu,lsrrle vorti;ic prin tulburriri de statici, (a,st,ilzo-a,bnz ice -
ttr l,ulbtrrll,rilc tlo <:oordonaro de natur5, cersboloa,sii):
in unoloncC0l0l.
ln tftboa,
g) faholo vortijo (lin st5,rilo hipoglicemico {i din hipomeflocbivitatolsino crrrotidifl,nli, (l'opovioiu tii colab,, 1.978; Popoviciu gi Pasou, 1081).
2.8,i,2, Munfeak\riIt oarl,'i 11iru'a'x rtmolo rotrolahrinlin| ) B\nl:' pro(luse (lc(thoot[, (prlntr-un prooott do norritifi
[06
ila orillina wstibulatlt (d,in tind,roq,sufsrin|ia ugfvIlrrl yostibul&r, rl0stlu do notuolr&tlo), .lio ilrlI root{,
miopiorlitrrl o,
l r t r i rurrur ' l ( l t l i t t 1u'oot ' l io t [o vt lc i t t i lhr lo: t , t t t t t l r t r rg i t l t t i , c i t r l t l r i t r t r ( r l ' ( i . ) , l l ' ( r1t i r r ( \ i l , J l ( ' t 'v l r lu i vcx(, ibt . t lar l iorr l l , r i ry i t lot i t t r t r i t 'ca, t lo , ,s i t t t l t t l l r t ro l , ro l : t l t i t ' i t t l i t r t ' .
I 'ur liaul ar il,d!,i stmiologice:V tti jul aestibulatr ( denumit Si. rel'rolaltirinti.c J oste tnai lttl{itt ittl ltts,
rrrri puliri zgomotos fi rnai putin calactclistio drxrit crrl laltirittfic. I'ort1r'rrrsii, si, aib5 un caracter pa,roxistic, de 1;ip rndni<)l ifolmr oll (!\lc('t 'Jrilri lrlr,rilcririlc capului. I)urata accstui vcltij vestibultlr (qi a sitrpl,otttclot rrsrr,rirrlc) cste variabilX, in functiet de natula fa'cl,orulrti et'ittlttglic, crtt tlrr
'rlricci antrcneazi, o hipoexcitabili l,ato sau chittr o irtcxciiabili l lt lrr vcsli
' , r . l r r t i l t le par lor lqzal i .
J! osib ili.t d,!i 7t al, ol og ie e :A ) N etritela aestibularc infaJioctse (lues secundar $i ttrl,iar, IrrtloI,irIiLii
, lridcmicii,, herpes zostcr, febr5. tifoidri, tifos cx:urtomal,ic, In(rtilrgililolt#rospinali microbian[, meuingiljc virotice, mcniugitc tultt'tcttiortsr',
ripii, difterie, malarie, rujeoli, brucelozli etc.), I)etalicm rloltr cil 'r,r'rr ;
^) Neurita ustibulard si.filiticd' (satt neurolabirinl,itu l'uetiad' ), I'tl, nni
,r li in ultimii ani, cste produs:i prin mecanismc dc rrre jugo-virsoull l ' i lf irrr stadiile secundare $i tor'l iruc ale bolii Si oste car:lctorizatti pritr vt,r' l,i i l,1,, lrlare Yiolen{5,, crr eri&ccrblri la miEci'r' i le oapului, olr hipo:l( uzic f i ', l lq,rrriluri in urechi. Pe lingil l ista-gmus qi rlcvialia bralclor, se ovi(l(,lr l ir z.ri, ' l t ipoe: c i tabi l i t a l c vcsl ib lar i .
I:) Meningoneurifut oestibulard, u,rliditd' sc pro{luce llr l l)roxil}nli\l, -10 zile cle la a,par:itia pa.rot,itl itei cpidcmictt, asociinrltt 'sr'rn,\rli ri (ltcziune concomitenl,i, a facialului, e\'cntual si :r' itltor' lrcr.vi cll|rri{rtli.
' trr,nifestirils vestibuJaa'e, uncori bruta.le, sin1, doclinn$al,e lrirt lczirttti rrrrvlil, co, rneningeale, precum Di plin r:dtlm consccut,iv tlot'cgliiri lol cirrrrrlrrloliilrrriferice intraiabilintice. Se realizcazzi astifel utl sintlronr tlirl coclrlco
' r'sl,ibular, care debuteazil prin acufeno, hipoa'cuzic gi rna ifost,il i \,('sli-lrrrlnre, Ilipoacuzia poate li uni- sau bilateralii, de tip percelll ie, cu ovolu{,i,.lrrlrirli i,, uneori pini la sulditate (uneori definitivl, all;oori t 'oversibili, orlrrli(.r vindecarea infecliei urliene). Scmnele vesl,ibulare se tr:ltluc pritt ulizcr rutiginoase (uneori foarte violente), nistag lxs, tulburri,ri rlo cchilibru 6ihipoexcitabiliiate vestibulard.
c) N earita cockleo-aestibul0ii zonatoasd, (hcrpes zostcr) csto [oir,r1,('r':r,rii ln forma acutii, veltijuJ apa,re brusc, ltr crize, od a,1,[ cu il,1)l,t'it,ir,rrr[ptiei, in contextul scmiologic al unui Findrom vestibular aru)()]rioH,rrrr duratii de 3*8 zile. Se poate asocia o hipoacuzie do pcrccpl,io, rldrli{cir,,,r'olutiv5,r pinii la suralitate totali, $i definitivS. Unoori, instr, sinrlronrrrlvrlstibular este foalttl discret, cu ame.feli moderate, pc prinl plan sil,utudrr-scrllt]o simptomc ale herpcsului zost'er cefalic'
dJ Sdndromul l,ui, V ogt- I{oy unagi, vorosimil dc originr: virol,icri, tsrr-r, ilr,z6, I ncvritl'i, oochlco-vostibularli, (cu sualitate qi crizc verl,igiJlol,so),uvoit[ l)ilatoreltr, vitiligo' rrloleoio 5i polioztr.
a\ Sind,romuL l,u,t Il arada, fourtc ril,r, tot tle la,tuni virol;icl, ol[.rrt,Bomlun[tot cu I)t'$ft{loltl,ul, rntxliittd ilt plus qi dt)t{li l l irr: (lo r(11,i}rI.
I\ Ilteninllo-net.nt-hrtrcnlrnalt, .lr'ritl l l (l(! l 'rt 't:vtrttl.o irr rrnck' f[ri, sntr.rrrltr0 TLin Slnthom ooohloo-vrtt' l, i l)l l l ltr, ct'l ttttt ' i tttlt 'uoll, ttxttcirtl ou lczhrrrirlrlltinlo do rrorvi ofttolortl El ou Sotnllo tlc polirmlictt lotrcvlil[ 1,tloroa, orrsinrlrrirrr liolridiuu do lln Oullll,ln'ltu'r'r{.
107
,r{. ri,,,r,,,. i,,,2:, ,ri,, i, i.* ,; , i,, i l l i l l ,,, l,,, i; i l: i l; i l, i l ' l , i;,]] l i; l l,, l l, l);. j,,; i1ii,,,,;l i ) , \ t ,ut . t \ ) ( l i i l r r ( : t l i l
;.li.r'r l' rir;ii';illi'lrt*i,ll,,i*-r:, tilf,"li''j. rxr iirllriri''iiri., ,.,,,,:, , t ' , ;,.,,;;;,;, i ,,.: ' , iq,: i l i l : ],,]: l i l . ,I l l ,^u;;.;1,' ' ' :1,, ,n,,,r,.r:,, ,. (r,,, , , , ,1, , i , , , "1i ,1", ,0 ' ' r ' : t ' , : , ' i i , : i : d in unhrtoidi t r t r t t r unohi n. , , , t , ( t t , i ) , t , , \ , t , t lz,:rri,, rrr, r,,rj^:, i*p"t d"*,1.i.11;::li:"[Jill iit;l :,;illi:l;,;l,n:l.:ll: ,,;,',:i'l","t"""lli,rti;_r,i1i,".9*tbul;Lr ,si ce,r,er,er,j'. ,r"',1'i"i,itin ,iiiri;,l,\; ; ; ; irt ii;, d; 1;*:*i*|j{{,|"",iti:i,Li;ttr1 iii:,l ili* i "'i,gi, ., iii, i,,,;;;rr r,;rl',l,lll', Jil#3;[*i #"r#hfif:f i:.#'tl#!'{i11ifu f ii-{ r r""""i;'i'li;i;;l;i:l';llfj:,ili*",precizate larse'ri;: ci,rai.lliiii,f illi,ii:llt;;,;;*;lll;;;,irij#t#l,i#il""ii'l_;il","#1,ffi #":ft ;,,'lil',lii, l;i, llllllruj'*i ;,f;#4;:.,*ri"''# *t'i.ifr.lllJ pie'os,,.oar iz,,,,,r,,i,, ii,,,i,jii'";,;,:;;i;.'r;;';i',lfr'H;,ii:,";li.iti::.1ll,1.iJj"::-'iogic:1,,r
,ii.y:.'yy1';,i '!',,f i;iii,lil',11,,'ff:;:{f;iii',,ii*i,i u;i !lil,l,!:,0{;,,,"u', ,,ebtibt,t.,,,,,( I t lDt()r ' i , l l r t ) ( , ( ,s. , rL|glrngj ,a i ;1. ,,r. : rr r.,..). r,,,,r,.,,,",,,,,Jtf l'lii]j.,ii' {;j}ffi,.'i[1;i$?,#1ilili. j r l r \ r t i , r l { )1, I or l i l>rr la i . i .
, ,,, ,"i,i,'l,i"ii,'i",fii, lllfiif,ril,li ii,:i:,iili:{L:,,!",,i{,'!,,,ii,j,i,i)1,1;1ui,,, ,,,: l:,;,;,1'l:,',,',li,l', ll;,,:i'i;1,,?:';,f 3i,.1yt,.1111i,r,, i;;;;"-;;i
-,Li','*.. iuror zir,, ,i
, i, lr ir i, r, rr i ; ii t1t;hfr *ifr:iitilfl,'iiffi;l :r i "ir i;r r ;, ; rll;l;;l , li:l,i;l;l;:",,,;nllfl1ijf,illiiili;ll,..,iili"'J'l,il'1i?;ll,T; j'i1,"Jii;l,1ll; ';:l;, , ,1ll,l:.iil,l,lii,::,;i'j;i:,:li;iJlli,i;i,;;i,,i,lli,'i,;ii,l,iiiillil,li,,i,,T;;t,j,i:;1,,,1i l l l;11';ll;;,'r,:'",,1;lt;ilil,ilifl,r,iv,,srir,rri,rr1. 1i;i;;i;'.;i;;ii; o(,,1,,,,rr,o,,r,\i j ,,1: ,,.. {,\.. ,iroii,i, ,,,iiil..'l;-iiil;l;i,:':lJi,,i:,il;il;lillll:;,;l;j;llll;
,lt;;;t:r ii;;,:il,,iii,,llil,l,l,llil:li:,i,lilil,,lil,:t;i:,'lll;,:;i;,,tl,l,il;i,,tijlii'l;"1i;iil,il: l l f r l l t t r ' r r r r l l r l r r l r r r r r r i s i4r l t r r r , i t , t . , t l ibt t l ( t , t . i r . , , r , , , , r , i ; , i . '
,,,,,r11),,1i,,'ljli;;,'l;l;1';;ll,,lllllt',1'l',;j,ll;iiiljlili;,ilt;,,ii;ll,",Jt,lll;;1,;';ill,,i;;,liijl r r l l r r l r \ l r ( i r l 1r . i r r I r r ' , r I r r . I r ' i r r r r I ' r I r r r r . r r I : r I r r l i
' r , r r i r t r i i r r . f , , , : , . , i i j i r r l i r r r l . , r r r ' l
l0 l t
r l r t l t t t lu r l r , ot i , : i t t r r otrr t i l l t l i i s t r r tzr t ' l i l l t I t ' I i ' t t t t I I t I t I I i , prr l r1t ' l i i ' l i l ts l l t ; ; r ' r r 'i l r " . r r . is l , i i , r r r l r r t t t t r r is t t lgtnus Ioi l l to v io lc l r t , .
,,, Drrcii itL sintlromui- vestibular lierift-T io itrt' ihrirrL rlislilrglrrrrsrtl r'r' i
r,rrrrla,i -si/ sau lotator, in sindromrd vestibulirl de ollgilitl .ctrirltl i i ' ttisLrg,rrs.] isi,c atlesea ,,schimbltor de sens" (a'dici, bate in m:ri r'ulttr tl it 'rrrl ' i i)ri. i:, Irlus, aparc nlstagmusul Yertical, care nu so intilncfjlo IrirIiotiIt ' i i i itrr llr i iele perifericc.
i, irr sindrom'l vesl,ibular central, directia cilderii corptllLti [it ' lrr.lririi{,}rrl)its rlr cste influentlti de schimbirile de pozi!,ie trlo (r:l ' luLli
r ?"n aceste sirrrlroiuile centra'lo se pot remarca nodilicr-lti I t i I I t' I t ' I ' i r I i It:r, ;,i ',1iek. instrumentale ltic hipoexcitabili iate, fio hipere\oitllbili l 'rt lt ') '
' ' i i 'r trcmplt in scleroz:r' in pl5'ti, in ca;re aproape con'strt'tti so itti ' i lrrrrll l,, lr ipr:rc-r:citabilitate lt toa'te probele.
1ti Ne dentteazii, doar nturile crize aerliginoase cu grea!'ir si vr'1'l 'ri i ' l 'ttti '( ' irr(' l iot li Incori intitnito qi in unete vertije centralet. ca de pild'-l ' irr ritr<llolr-r:iele vasoulare bu.lbo-pnntine (Wa1lenberg, Geli, R:rynond 1k'r'jlrrrlr (:t,-.tan-Chenais ), in scleroza in plxci (uneori)r in lrnolc cllfi)ftl l i l(r (lt!
tIrirLr,ii i cerebral, in sii ' ingnbulbie si in nneLe ttrmori de fosit' posttrt tttlt 'trr,r,lrri i l l{,s aturci'cind" in contextul 'serniologic apare q:i o hiport'cuzitr (p|irrlr.ziril i ,isociale ak-. tncleilor cochleari), situaJ,ii carc poi pf{:}te' lt[ (jr]1rl:lrzii, ri . rdroamele vcstib'da,re periferice.
i, in sindroanele veslibular:e centrale reactiile nistilgnrki{) ,,itt rl 'rttr'
l , r r i ' , i : 's int ra ie (Oarvthornc qi co1ab., 1969; l i iser, 1952) ' - {st le l , i t t t r r tztr lr,1,",' l irrii tuturor nucleilor r;l)stibulari, nistagmrlsnl baie in trtrti ttrtti lr ',l irl l:rii. c1a,r krziulea ueciom:inanti a rluia djntre :rccqNi mrclci lrtrrrr crr'
', ', ' ' i l-ititirgi"iisul st' pretlomine intr-o anuniti, t ' l i}eo!,ie' hi silrrrr{'irr rtr
, r'r, i,ste :r{e"ctat ln singrr nutdtlll vestibultlr, pui,cm intiltti l l l i l l islirsrrrrrrl
,,,r Ir)rnlil p'.r;'". Astfef lezitnea lucleLrlui lui ]leit'ers 1tt'ottircu ttrt ttirl 'rtt1rru.r o|izontelr ia.l o lcziune bulbo-ponl,inl d€teu]lil l: i 11ll Il lslirll lrrrr I
\ (.i i ir:11 st.x predominant, reriical, Cintl lezirurilc irilotesc'il zi cott t is ttlrt' pr t;; I t'
I i(,i r ir-, se p-ot ittti lt-ti dii.erso tipuri de nistagmus, t1:rt prcilttrtrir Lr"t' lol't|1rrr I rirlrnltul vortical.
;) E:{isten{,a, leziunilor t*,ltibol^t" oerltralc osl,t' lti 'st:Llri fi Irlirr1'',,ti lr,1;1 risiagmusului p,:ldulai, c:l.lc nn sil itLtiltrttl ie tricirlrlltl l i i it lczirr,) 11, j i (r l i fol icc.
) l t '0t 'me eti{) 'pa,logex.ice t le manifcsNd"ri t :et l i l t i t totse ae]tLrtt l0:
/) I 'arot isnt:h rerl ' igi t toasa t le ori ,git t t : lxn n't t l i t : t i ' l ' t t 'Li i r . t l ' cr:rt l t t .r l
t tr tr ; i .r l ; ic constl iu -ssrl"rat ir . t dc t l t-rsigutatr i i t , in tr i t : ; t i i r t i ' t t r l l ' t r i . ,r .r ' l i l r
, r t r l ' l lu l r r i . { ) r l t r i t ra l i , i t r r l r l i l , l { , t i r vol t i j r t lLt i nr t i r l i i ' t ' i l i r t r t L l l r t t t t t t r t l i r r
, , , r : i ' . r in l i lsr l scrtz l l r i i l r . l t l i r r : t l l r l i i ' . ' r i t ic iotr t i i ( ' ' \ t r ru.r i ; i ( )1; i ' r ' r (1 l l ' l l ) ' r ' : l l
l l i r l l i { - lo t : i t :u. t [ ' ) t o, t iur t t ! r t r . . i t tn l i t t sr : pol i l r l i l l t i tn i l t r i l l r ' ; t ' i t i \ ' r ] l i ' i i l i r ro i r ' r r '
r ' r , ) l Lr (1 l t {x) l i f r i l l r , vt t l i , i t r ) , t l l t t i r r l . i t$t lL l t i i r t r -o l l r t tz: t l i . l l t r i t t 's iqt t t r t l r l l r
r r r r rLcts, l ts . r i i t i i i r t t . r ' l l i l r ' ' , 1t ' I I I I ; t i : i i ' i i l t t l t l r r ,
i l i f l ' r ) . l l i i ' ' i
i r r l ) r r r ' ' l i . i r l l
' , , r , , , t i r ' , t : r ' t 'ot i i t t l i l t t i t t r l t r l l ' i l l t r i r l i rqr t l t ls { l t ' ! ' r ) f i l i r "
: ! ) l / r : r l i i t t l | ) | | t t ) t i | | i i | | t ] l t " t t i i r ; ldt t , dt r t t i r l int l r t ' r l r r / r t t i i Vlr ' l i . i t l l
I ' r , r r i r l i . t r i , l t r i i t i l i r t t r r . r ' i l l , ' l r l i i r ' t1 ' r ' l l ( ) I ) l i l i ! r I j r ' ( ' r r r l l l , i i i t r r l i l ' r ' ts t ' l r r
, , r , ' , i , , , t t r r , r i ( . i l r i i r t I i ( , i i ' I , I r i l . i | r t i i , l r , t i t ' l r " t l l ' l r t o l r l t l r i l : t t r r i t i I0t t t t i I r ' t r I I t .
l r : r i i j r r l r rur t l l l t t t l l l l r i rL i , r ' i l r , l t t t l r l l l t l i . l L l r r i : l i r r r r l r r l i { i i l l t t t r : t tc l t l r r t t r ' ,
r r i l r l t ; l r ' r t i i r rz i l r l i t t r r r t t r l l l l : r l )Lt i i l i l r l ( r ' i l { l ' / : l l l l l ( l \ l l l l l l l l l r t l i I I ) | | ( I ( ) | | | | I ' t ' I I I '1, , : r i , r , . , , l t r , r l , l | l i , l r t r t r l l t t i i , r l l l l , l l r l l , r l l l r r ) l r ' l i r l l l l l l l f l l r l r l t l l r ' ; r l1 i l l t l r r
, . r r , i r l r r r r , r , r I r I I ' r I ,
' I rL t r l ! r '1, . r \ r ' t l l , { '1. r ' r r l r .1 ' r r r r l t l , t r i r ' r r r0 l : r r '1, ' r ' i : r l | r ' l
,,1&,1
t{)11
l r . l r ' . . l ' r ,z iLur. . ( l ' '1r 'v i . i r r r , , i . . l r r t r . , l l t ; l t , l l )??, J l ) l {0; }1r1xrvi . i r r r i l , i r ,s.rr ,
'8t l"
:i) )t sir' inltltbulbia )ll i l, l| i l!,81,!iIi j(r \ or,l,ig,irorso sc plitrsoirrzi! trrll rn.!1rr irri,r' sirrrpl,'rnclo initialc, pulirr<l ,,pii,rtlt, Jic'in crize foail,o vi' l*nlr, iri.rr r,i,lL(,ulr llur ufoalc, aproapc ioldcartrra accentuate la schirlbiirilrr dtt ,dr r r ' : [ I , ( .1]pl l rur $r asoclat( . cu ju lbul i r i de ec] i l ibrr .
I ) I )t lt ttconert arfte tulbu{rile vestibu,lare apar in pesi;e 90}i, rlirr,rrzrrri, r rrilnilrlstindu-se sub forrua unor crize vertiginoasg cu ahuri'rntt-rril l i l irlrrril, i!.speciai in cursul.py.seulilor evojhtive -ale sclerozei ruultiplc,, .1:"r ' , r r r r r . l , r i , .L iar ca s jmplo.nle. in i l ia lo. Cr izejc v io lenic. br .u1rt , . , s j ; , i r rLrr , .\ | , r r , , t r l l I I S I I | ' .Stc. DUit lora[ , de ojJ jcei o l izot ta l ; i schimbi l r r1 ' r lo.oUs,r I i | | | r I r r . r ) | |s i 1( , . t1( . ,1 stu |otalor. inso{ i1 dc l u lbur i r i dc ocbi l jbrrr . Ur:cot , j ,rlrrl.r,itr' i rruci par.eze cie ooulomotor citern, putern constata un 'istagrirnir ljrior.iit,l t rtoltriculat,
,, ,f.) ,l ,..ltgc. oetu|lelc sp_itao-eerebeloase pierra_Xlarte, L]t, boale lxti,I t u\t! t, rh .:t ,1.n di.', rstlc Jut'ne de altoJii cerebeloctsr puD apjrca accc,.^ Teiti_. ' ' r ) : r , \ { ' t | .c lor l - tntc. c l t duraLc dc la { . i tora minutc I in i la c i tcr i . i , z i l t . ,ir,rioqlriLlo olt ttaxie ccrebeloasii, D-i cu nistagmus, cao", -,1" obicei, eiito oril, , t r l : -1, l , ib.{r . r ' , r i i i lcnt , pctbis i jnd s i inr ie g, izelc icr t is iuoo- i . p,ot
" t , ,, i | l ' , r ' r { { . , .1 Io i r tu] l i s i t r l rornl{ l , le, .dar de mu_l ic ot . i i l ra la J hi l rer |xci fabi l i_lrLl(1, l)ll,i ld fi:u.niza ohiar unple indicat. cle diagnostic prec6ae la adtli,i ilrr('r i r ir'( 'sirn],tiomai,ici din familia rerfiectivi (Fh cox'si L"i*tl
-igil;i.
. ti ) .4l cr:tiurtite aentriculului at ly_tca qglio'arne'qi .[i"t*i *ri.l.*iir.r rlc vcrl,r'icul IV, glioame de trunchi cerebral,,alte tumorl buibo-pontiitcjiilr r rrri( ) (i'iiri tr,pt'oape totdea.una de tulburi,ri cle echilibru, nirtagmu s d'izont,o:: r t ; r , lot
,< i \ ' , r l i ( , i r l , \ ' i . ts i iLul i , semne Cn!.pbcloase, divcrse i*Lnnc de t l i r r_rrLi,' rr.,)rrlr, ,.(r(.||] f 'ol,rlar, ]si n]alifegtet,i vertiginoaSe il] c,lize, tle obiceirL (,|i i,r|,lI|L{) si acccnl,uate de sclimbiriJe de p6zilie ale capului. Se I;rrittr'\ i(l('rtiii, hir,u- st:,' i'excitabiritate vestibulird t'" p""t "r.'i".i"""i"ilt,ir",r r l u rrcol i Jr iJxtacrtz ie.
I'rrr.rrritrlr ax1;ansive vel.Tiene qi rle ventric'l al lv-lea p'ezi'tii celrruri lqflr;r,1, irr contcxtul clinic 6i iindrom,ut lui Bruns, arr" ""osti
,tin'1. ' 1] l l : : l : : l . i ; .1 i . y, l1 -!r , t . . , ,posrurat",.r- iolcLrtf insorir dc cri fatcc qi vir.Jtult ,I r r :L l ' i r . r ' r l r , . t i r , j ( .h lml) j i r ' lc do pozi i ic Ale capuIUi. Bolna. i , ,u l i ; i mt.nt i r r r l, : r .1,rr l r r rr , , t r i t 1 i I r r r isc{ oda{I cr i coipul 1in
. , , -60""* " . , l i l " i i - . . i i " i
i " i . , , l t " i_r r , r , l r , ) .
7 ) N ut,rnnita testibulard (Dr1 $ Hallpi,le, 1962 ; Cawthorne $i colftb.,l l r t ;1, ; l \ I i I ' | . , r ' r i ( . I | , ISZg) cupr inde B forme t l in ice :, ..,::!,.\'::::,,,:!ta uas,t[bulurd p^ro1triu.-.zi.sd este o afecl,iuno benignl, cri inoi"
lji. ".t I L l ,
iii!l]9 i$ulte (30 -5qde_ ani), care interescaid neuronifvestibular.i,::l: :l.ilill' 1ll;lll.! $r i.cr-qenr4,. Debureazi, brusc prin crize vertiginoaso crirr ('||s|| t"lr,rr. Irrogrcslvir in citcva ore sau zile, ciup' carc disparc.-Nu luting0r r i . i r x I r r, I r'i, irl,onsitatea crizelor Mdniire, dar qr6bek
".*tii;6;; (ir..i;;T;l'l,N ( l) .virltrnli*zii,
'n sindrom veslribur'ar cu-rripoexcitibitiitate de lar1,*rrt l i rrrllr,l,tl.
_ . l,)- -ryr'i 'r"a,r'i la rertigittoasd, satt tsr.rli jul rpidentic (Cirxthurne 5i r.,rlrr,lr.,l l l l ;1, ; Nir . ls , . r r ; i . r r l rLb. , c i l . t ( i r i r r lVi l , r ; ,1scu, ' lC?g) l t , joro t . , ,s, . , i r r l , i r ' i , i ir ';rin.rl irrrir'{i 's .rr rulrru'irri r', 'spi.ati,r.i i i i l i",i "',i;,Ji"r:itrto$ti.?!
t(, Fi .', r | | | | r r ' r r I r | ( ' r r r t r r ( r ' r I r ' r ' f r | I i l i . r ' . T ' ru ' t . r ' i f ic o i r r fcr ' { , ic v i r , t ic , i r , l i l r i l l ( r s, i : " i rri rlrr lrlrri.i '1'rzrr, li.hirrilnli, rim{ooita'ri,,- aqa ir,,it ' i n"t-.i.,"i.rr',,at ;i rr,i rrrl ' r t r I r r r r . r rcr . l :uI i I r . ( l ) r r rn l , T\rnovi l iu .5 i ru i l r l l . , I { rCf ; l l i fur ' t i i r ,sr ,u ry i r ,o l l l r . ,l r r { l i r ) . ' l ! r , l r t . r l r ' r i r i ( ( ' ) .hr i ' r r r r r :urr i i i ' r * l i . r i t l . i r ; l i ' , i , , in, , , - ! i , i : ru l l r , r ; . i r .n i t r r r i ,
I t0
,L'('l i! l( '{,, ir,i\ir(,11i(:, Bljxlc sltl}li l lu il:i, rii, tlo cokr rnlli rtttl{;tl ttf i, sotrttttr do lltt 'cllttrrru rlclvilor octtlomotori, ott rliplolritr.
c) B'inrlromut Ttseutlontti tt i i,ri,.lorn. (aI .lui .!'iytlty ), tlr'ii td'ittlttgitrr,r..tz*tii. se c*ractdrizc:lzrr, t,r' irr inanitcit;rri ver"liginoasc irrst*lrl 'r ' rru'irl,i l,r,, :m,i nrrtin brul,al decib-in boala Mdn.idre.
S 1 VeitlSul paroai'sti'c epiteptia,. tr'orna cea mxi pctent:r' do vtrrli.i
lraroxlsiic epil'epnii este repr6zedtat:a de criaa tampo,ali' psihoselttoritt'l .ii
" , t , .er :a i ie l le ineleal , i 3 i - rostogol i re (Arseni i i colab" 1978; Grsl ' :ut t l '
r : r ; r r F6Jovic iu r i colab., 1976 i Stoica' 1978; Popovic iu \s i Pascu' l ( l i i { ) 'ii,,'r '.
-vd"iijo1 .lueptic {,oato il apgl {ie .sponran (in cazul cxisl'r'tr1r'i
urrrt j octr cll eploEetr treoseuit de adtivl, fie in mod rellex, sub itrllttctt(rt.i, 'nr
"""it*ii i 'o.siibulrtu, care realizeaza cxacerbrrea paroxislicl :r
l'ocaru-lui.V erri.iwl' enitepl,r'c (epiteBsi'a lrestibutogatud' ) poate fi cliferen{'iat tlo rrllo
tor ruc , li l icc 'de 'vertij - cu ' aluri paroxistici, (Sloica 1969' 1978 ; . S:t'gt't '
, i . u i rb. , f 'g lO; Gastaut, I973; fopovic iu i i colab" 1976.; . Pr inciPrulc l ' r
' i:tite;ir de diattiostic diterpn!itl, sint : a) alterarca cunotIin{er i o) 1l'Fr'r'rlrrr'rcrLi iu lu i ( I ie- inde pendent, f ie al termndcu al te s iu lptomc cl i t icc ( lo ( ' l ' r
i,';"'";;d;rH,-tie ci si buli, in cadrul unei crize epileptice convulsiv.., i
' 'ul* g'*o.triizat"l : it couslabarea anolralii lor EEG pr'rorist ilr ',r'pi
lclrtice cu* loealizars ieinporalS,. Traseele EIQ po! prezent'a' dt':Lll'lr'l'iol'rue iritative cu sediu temporal qi in perioaclele intercritice'
9. Exi.std, insX gi oerlije tenporale ne.eltileptice (in tumori, .altct'tit"l.r'rLum*iiJme de lob ternpor6,I), caie apar in crize cu durati mai ltlttgii'
rlrr rliteori sint aproape lerminente qi-au ulele-caractere clinioc pit'rl'itrtt'
t,r,rle. Astfel, bolnaivii idcedrci, senzalii .le ghalie, alorid.ica,re sau dc loltot il'r''
rlu rle proiectie in diferitele pianuri ale spaliu1ui' inso.lite sau nu (L(! irrrllrr,,no lCiostaut, 19?3; Popoviciu qi colab., 19?6; Popoviciu $i Pascu' l1)$o;
| 9E1).
2.f). .PROBLtsMI] DE DIAGNOSTIC IN PATOINGIA NIIRVULUIGLOSOFARINGIAN
2.9.1. Invcstigaria semiologiei a nervului glosofaringian ilnlrlicri' :
a\ Entrnenwl fwnc! i.ei motorii.: Se celcetcazti' motilitatca ptrrcLt'ltti
r,,,tt.r1io" al tr,rinfetui, tlcglutilia pentru Folitle' cYcntuala plczettfi a'.r rnuLtlui coltiuci tl lui Ycrncf.
It\ Itrnu'menul fitnalict sanzitiar, &nalizind scn$ibilittte:r' ltorr:ltrlttit ,onl . rr iLr t l f l r i r rg, l r r i ; i i r , t l r j iLrr l lnr igd: l l icnc'
t:,\ lil,t;urnr:rt'rt'L .[tr'na!iei, ttr:n:nrialo constii, irr investig&ii1l' .glsl'ulrti.lttt,,,i,nu.'i li rsii'.i,
'.r,r'il ,r, lim5ii (tltt , s,iu(rio l'u.i,, lrttltr,sobi 1o r:litrinl't)'
i \ l ' : \ t unul . Iunol i r i u l tetdir i r ( ' ( , t rHl , i - t i r l l t l t rct ' i t ' t r ' : t nr t t ' t ' ! i r r i l ) l t ro i ' j t l t \,1 l r i Io , r : r , r r h i I r . r r r r . r i . l i ' ' i lu l ivr t r ' ;1) q i r r r r . l l r .xt t l r r i s i t l iv$r l r r { 'K{ ' i l i t l l l r gr tBl , l ! l , rvr .
{\\ lt){.tuLu t,t,t'[ n,llttrlu turingirvte.
l l I
! . l f . i ! . Novrrr l l l iu glosol t t r i t r l ; i r r r r r i . l l i : rg l l rs i ' icrr l .st sIr th i lc , ,s l ,o pr^ r ' r is-1(, l r f1[ u l lot ' l ) r l r ' l , iot l l l l r i t l i l i r i t t l t t t r , l i r ' ( l ( ' { 'c lc / r r l J t ' ] ' t t t ( cLl ture:
l) Nnrrutgia glosoJu'in11i att ii lt t'i.ttl,i,tirii satr, Ttrint.ard (est'rl'ilr'lii iltI r,r'rn irr.rlogia riecbi teime,n care f'olluie abandonat) afecteazd ill go]ll'rtr,llrrrlrrrvii peste 40 tte ani. putind insi Bli apar5' ;i la tineri.
t)('l)nlnl bolii cste de cele mai mdte ori brutal, iu llini, siililtal'orrllrrrrrlir. lntre prima crizd' durcroas5, si -urmi,to-al:ea
pot trece cittvllr:itrlirrritri sau cifcva 1uni, perioacli, va'riintl mult de la caz la caz. Criztilrrrnnilorr(f rlevin din ce in ce mai flecvente.
l)llr'rror debuterzd brusc, violent, la baza limbii sau intr-o zonii' dittl,,irr rrnristhlia tii. Locnl durerii maximale se afli ' in regiu:rea farirgiarl i i ilrrigrrrrli "inelr-ati, rle nervnl glosofaringian' I)nrexea qi zonele "s:i e tloilrrrli.r'o sint sl,rict localiza;te uDilatelal (Arsenl fi Oprescu. 1979; Dcptui$| 1l{;8). I,l ' i{rl(son (1963, citat de Arseni $i Oprescu' 1979).a stahilit klcalizalerrrlrrr,' i i i irr lrd. ,o1u?, in funclie de {or:ma clinici: a) in forma tlctsir:d': l ir 'lrrzrr lirrrbii, in regiunea arnigda,liani, cu iraclieri^ spre.timpan' ruri"lj l l lrrrrrrrrli lrrrlrt 6i lggiunca submarilar5:t:J ln.forma fat'.i,ngianii: in regiuncit'rrliirl(l,rliirnrj, '" r) \tt fonnu ti.mpanicii satt' oti.cd: in rcgiunc'a awicrrlari' pro-lurr(li l, s:ru nr condlictul lutlitiv exte.rn ; d) in marile ytatotisme il ' 'trcreu'rr,,rrl,r' ir ';rrlin sj .in zotre m:ri i ltinsc, respectiY rlai inferioaro fa'tli i ' t1e ccltli,.lrrlrrlc ttrai ils (Arseni li Oprescr, 19?9)' Bolnavii '"1i( hel'eaz5' dlrroreil,.rr j ' i i irl tk'oseLtit i le violeirtS, '5i de ahoce, lscmuilrl-o cu o ,,lolitlr:i i clo|rrli l,". .^rtrr soc devtlic" etc. In rare sit a;li i, durerea estc apreciatii ca o,, riz,,ii,. ,[,, 'rl ist'onfot t (BoJrm qi Strang, 1962 ; -Bues, -
196ts, ,cit'a;li dtr
'\r'rr,rii i l i ()l)r{rsctl, l9?9). Durata unei orize csie la debttul bolii de 20*il0
',',,,rrr,i,l, rlrlr-se nrilol1,t odat5, cu cvolntia bolii. lncetarca cltrerli cst'tr
lrrl, rrlrl. i lrr l:t 'tLft,i i ort si d ebul,ul ci, intel'] 'aleJe intelpl}loxist-ice fii lcl asitri-
1rIrrrrrirIitur. I't ' l ioliktle libcrtl intru crizele du]eloasc r-al'iez5, de la uI boln:wirr rrll,rrl, rhr lrr, cil,oi,rt Itrirutte 1tini, 1a citevil orc s:l* Lliteva, zilc. Roala!o:Il(), , i , r l r r i i t r l , t tsct t t ' i r l t t l t roast l q i remisiuni var iabi le oa dur: i te (ca; t l l t t l ':I|l||,1r, t)r,r;r lrr' I -i atLi). Clizclo apaT tlc cele m:ri multe ori ziull. cltt,1,'t,, ' i,, ' it irrs:i si tton,Dtc:t jn fazole alvinsa,te 2llo bolii De asentenea, clizt'ltt;r, lr.,i, r1r'ul)r iit slh't,, care se relct,i la intervale de tjmp valinbil'
filrthi.liIrtr ilittrtttotl'i,r:t,t.ltti' corect "d.e neTralgie glosofaringianri presrlpinl0rrrrrLrlir', ':r lrolr Lri r.tj ltLi in timpul unei crizor anlliza facl,orilor caxe determjlli l 'rrlrrrli{irr rlizci qi locatrizarei zonelor declartqatoa,r'e (,,trigger zones") (Ar-
r , : r r i s i { } l r lcsct t , 19?9;Popovic iu qi Pascu.r 1981) '
Illrriirirol), pacieirtului in timpul crizelor- permite ollscrvarea crisptiriiIr,tr,i. rr, r rt rr' l:it i i iuloluntarc a miinii ta nivelul zonei inferioare t[ lti lei fi,rllr. l:r,r'illr.,, sa,u sDre urcche, intrerupexea masticaliei etc' Fenomcrl:lor I '
, , , , r r , , , t , , r i i i : . i . r r t l ' l r r ' . " i se pot manif t 's tn pt in inroSirr ' : r homifotr ' i f i pr i t rrrscirciuncrr grrt' i i tlc partca- dulolii. In tirnpul crizci -
tlurerorlsc bohrnvjiF,l,irr. (l(! rrbicei, olisltrti, cu fncit:s imobil ,si a'plccfl1i inainl;or pclltl 'u lllrr, i l i lrr srrrrlg,r'cr snlivei. ln alte (iazrlrir bolnavul iqi montinc callul a'llooattrrr,rri rrr :r rrrli i.r:r, nrtts.ttl l lttra h 1;r'r'txrcrvicalli, sn,rt il i aptrtd, 01 mina' urochon
i t . r ' , ,grrntr l , lur l i t l l rgtr , i l l l 1 i /s l r t t r ' : r t t l t l t t l l l l l ( l i1: iv r ' \1 ' \ r l ) '
Atrtlizit, frtol,ot'i lot'tln,trr Irr'cipil,i! ttprtt' i{ ' irr cliz|lot rcfirozinlir' o (ll lpilr
i t rxr t ' l , t t , r r ( i t rL cnlsrr l orr t r r t i t t t i l i i t t t t t l i l r r r ln l tv ( i l t l l r 'v t i l lg i { r g lono l i l t ' t ' i t tg i i tnt ' [ .l ) r , , r r l r r l i l i r r iorr l i l t t t t
' ' , , , t "" , , t t t lot t l r l t l i t t t l | ! r l l l lnql t t t rn ' t l t ' iz t r lot ' , l t t HJrt ' t r i : t ' l t l
i i , r t i i , l , '1,1" Dr ' , ' , t r , r l , l , r : t t l 1t t " ' r r i t t r f i i , . ; ' i , t t r t l r t l r r , rLrgl t t l i f i r r i , r ' r is l ' i i ' r i i : r l { i I r ro lot ' i, t r r , , I r ' , ' , ip i l , t r tprr t r ( i r r cr iz, ' l , r l : r r i i t r r r : t i ' t t l i ,Hl ' r i i t l t t l , t t l , l t lsrrr t ' r r t t I l r t l ' t t l l t : rsr t l t t i ,
r l , .s,.hirtr .r ,r . ,r srr ' i r . r ' i . .carr ' :r , i l , l l ." i , , ; , . ! ; , ' ' i1., i : i l l ," ; , i ;1.] , ' ; . ' ."" ' r ' i . rrrrt l i r t ' t t r tvrt t t
' '" f"l"."ir',llrJ",i]:i:$ri*:"t:i*l,,iiii;li:;li':ltti;,,i;;1,i,;,r'i,,(',rliii,,l;l:rll#i::*'l#::;l#y#til'itli;*r"*l!tri:,irii:;iir,t lflf, ilrrt::;rx;li ulr, irri'r :o *:i :tiriril;i, lil jtr liri:; i ; i ; ; ; i ; ; ra l r"nduclrr l : ' ld i t ; i 'c t t ' r ' r ' - ' i rcsiuncr mtt- ' r
[:4tkly;l *:l :; ir *nl'';: ;l:: i*lxmil' lo: :'jl'I| i:;' l''I 'II I : Ii, , i l i L.
" tn;oi t i o ' or"n olr t ' ingologicc '-"' s-,,n rles'is caz*i *'t;n#: r:i",.#*r:":il,i:!i:il liii$ *i:iilli::
:ili,:t',tlii*1"'!i?Fi:Li t"*yil".:ji,."""',f ;iltrui ji, d{ 1.}i;r j[i:i]] li , i il?il"].i*tT;-ti*[:ii".:i!H1':rgil'; p"p"'i.". ;i e;o]]1" 1e?8 r rrrrrrrr i. rr
" 'S:ll*:ii);*,""r1,-q,e:Ld,";';?,,:?;.i ll;1i,T;"#!'::ffij'l;,.'"""""''1,irl,cr motrorii salr gusia Ye'
;*tlti'{,,j;{,;:i;,^r,.|,0;'il,i,ll;,i,',!l:;i,!:Ililid"iljiili,ll;i ];lj*T*{ft'"'?l#::tii';tll*'.i:ilr:!"i:l{'rinl;i"' dc'l rr s :'
l',, rl;ji::l;l -: :il" :.' ll';:::'; ill ; ; lll lll'jil: l;;; jlr ; I ill;l, , r r ,b i i . i urpcr, i . . .1, , , ru ' ,1, ." ; i ; i . ; ' ; , ; - ! : '
^ l l : i l l , ' t r r r r t r r i i r ' r r l i r r ' ' r " " r ' '
;*:*l**i'lr-i*rli 1r iiri,i i1iil'In*?im J-$Sr:;l i*;lii;i, (?":,*iT xlT*i$:1;'":"'"""1';;liti:iliii'li;;ii; \sl,lq:";lrihi{",,$ff lff :{ii?fr'{h-itffTfriihi#hiili'"H::*;:*$#,*u!'*;d'i-1*
ilII
/
-'nii'fifiTJ,:iij'lyli:'iil,',*':*,:'';,'',1"{fiiJ'i'; ltiLi':iil;tii,:lit"ir,il,irt sind'r om,ttl nel"D'u|Il't LarN1
", "i 1r.#:i ;iiin;i j g i "irf ; g ili q*iTl::d iilliilil,;, i,,iri ii::r',,lnl,l l, l'flllil'ii il ll l,.)/'li,{t,ill,i],:fi*il,,r* iifr ,t:frin tlll,rk ' rk 'g l r r l , i { , i l ' s l r l ivc i 1 i l r l t i t t t
;i::[tl,llil"' llil;i: lll,; lll:l;',;;1 ";;i lll;l l'll],':iii lniil" ",'ri',flllJi, i , . " i t t , ' , f i t ' , , ' , , , t1111"1:""rr i ' r r l r r { r l r l : r ' - l t t f r l i r r ; i l r l l lF(1
-r f l i l r ' r r ' l le l '1
t f r ,v*r .X r ' ' ' I r i ' ' r r , ,
I \ , , l t ' t , r 'I I:t,16
, , i i | I t IJ l i i , ' r l ) t l l , r , l t o i l i r !v: t l t i l l l , r , . Hl t t ( l t . r I r I luI I ,s l , ( ! ( 1 ( ) I t I t ) I ( , I , i t , l , rLt u l , t r i_ i r r c l t i t r -1( ' : t ,Nir ' . l r s:u( i i |n l .o v ior( f r , r ' , rsrr r , r i r r r i r r r i , ( lu t l$ur int i r o novr ' t l rg iL\ g l ( ]solr ! -1, , . i t f l l , l l i \ i , IoNl l t 'oI iv, t r r r l i r : { i r r r r r , t : r r ig i r r , l i . bo s, : rnu dc t l iagnost, io cst0r lr || , 'r '(.. r,. .l)r'r.,vor.iitr-r, in_ punclul ll lrirrgrrlrri superior, adicd, intre ci}nu] car1,i-r:tjr rr' Lrn ( 1.[ fr osul l]roi.l. lloba rlccisivd este alcoolizarea n€rvului, cr,r,ol'l||rl|rr rltl lerca,. Uneori se constal,ti asocierea sindromului laringritrirrpcliur' ou sindromul cle ganglion sfenopalatin.
I I ) Neuralgia glosofuringianii secund,ard (simptomatici)
. .. ):.1.1..:l*l g]os.ofaringir,ni, s^eoundari, se d.eosebegte ctini,c d,e aea, primari,t ' r ' t r in : rL( ,a l 'c te elemnnte: &) fond drrreros cont inuu, pe cale se supropul l' Ii.i,r:r,rlr. r.[rrrcroasc- pr,ro\isbice: Lr) tlurolqa, nrr at idqi
- intcnsit ateb, dctci, | | | | . r , ' \ l : l lg l l l pnmrf l r : c) dulerca so . local izeazi i aproaDc torclpauna i t r,:.,,
1'11 lj^,pro.,ly-dc- al. g-ibul i. crr iradieri r,uricutare si frr:r,ndibul*r.e; rt.1, , ' , . ' , l r \ t :Lt , i l t ipo- calr tnrstozi : l lo j i i . amigdal ienc- s i a rngiuni i far lngie 'n, . :r') r'ris1;i 5i semne de afectare lsociatd ii trunchi.tui - dotor ar neryuru irllosofrrli irgian; f) se a,sociaza qi semne din partea altor nervi cranicnirr\ ( r,rrrlr; g) sc constati, extindelea ariei durcrolse peste limitele anato-
" , ,. j,;1l ,l l:.1I"]!i
glooof*r ingia o ; h ) evotur ia cs[e progrfsivi, cu agrav:]r(,rr,. | ' \.r rl,t.r.r' '":l i r':lpld:i r simplomat ologioi, fdri rcmisiuni.l | l , . r r r r t iL unor lorrnp l l . ip ice. s i incompletc l j , dcb t , s i rnptoma{ ologirr ,t , , t r : r l r i ' i g losOlal ingipnC recundar.r ' eSLe dc cele mai *r ,Lt" OI j SuJiCir . l l i ir r | , i r ' l : rc l ( '1 lst , lCu. l \ l UI f e tot me r lp nevralgie glOSOfa r . ingiani1 S{.Cundrui .prri irrsi rlcbuta cu tablou cJinic rle ncvraigie 1l;im;r;. i;i" aceste motiv(!11r rrl)11'r.i tz.'t cii orice ,er'ralgic glosofaria-ngidnJ, irebuic consirlerati, rlol l r r , , ' ' ( 1. ' r l l 1
. r ln lynr lar ; , r i n,rmzr i drrpi efectuCrea in\ .obI jo: ] I . i i lor paracl in i t , , .r ' | | ) | , t ' r ' r . : t Ulnr l ( .zUl l .bc r teqaf i \ o o vom cOnSidr.r* pr . jmi t , iv ; ,('ttu,xclc acle mai ft ccvenJe aie rrcwalgiei gloso{aririgiene secun{larlr
.. ',::.1 .:.."\ .t"".':t:!j ':"^:lJ !7lilt i lP t./r bazei.cto rtiulai liuai alei ,;1";" -pi';";
.i, 't l l..(. ' i l, lr ' ,{,Un..r'rnolrflngc); b) tr&umdlismele craniene i c\ arahnoid,itele cen:-r)ttrt: () t(,tt,crce 7unrcti: meningioame, neurinoanie : e\ anel)tisme ulr\|rr,r'rrIirIr,i (jl,lrunc i t) i,nfec,tii locaie, indeosebi amigda,iie;e etc.
I II ) N eualgiu glosofaringiand, ,,Junc!,ionald,, (simpatalgia),\r,r':r,stii, llormd, d.e ne\Tc,lgie glosofaringiani, se caracterizeazd, mirrr I rr!.r r cr r ritt,totjer cle arsur:i, 1.1 b:r,za limbii si in regiulea trUgq"ii*ei' ai,r,ir,rlr{.r,{' rll}ro trompa lui Eustachio, spre ur-echea foedie, oar Dl spre altozr rr.r ( ir'o depii,qesc teritoriul nervuluiglosofaringian. Std,rea dd dii;;i;;i;:t, lr.ltrLvilrl r[r.viuo mai prosnant:L in-1ifrp-u] clegtilt,i l iei-.. in Soi;'.
-ti l idi;l ' l r r : r . r i i :urr i r r rprcsin unui"corp s i r { in. 'Din ,1; ; ; ; ; ; ; c,cesl , i n:}c i { !nt . iIr| 'r 'rrrrrir sl,lLsnlt' trltr-oglenc r,U LUSC. rn ineerCxrile lor de a Climila l.co"nritrri,r'riirr)'..fi.,za!ia do arsur.X se-.asociazi O"-rii"ti" *i
"" ;;;ilriili""1il'1.'1,'j:.l,,i.ll,lli._u-tii,,care nu po_f fi.obiectivate ra un er"-ui
"du"t al gusi";;i:|,r! | r,irt r! ctzrrlrtc se noteinzl ,li rut conte_xt newotic, care Joac6 un rolirtrl)orlrltul; in intrerincrm clur.erlor.
i,l.9.ll.-Puralizia rrorvului glosoftringianI,,l,l'rrtizi|, nurvului uk,*"1:11_iilti,l.r= so
-m.r,nifesti1 l)rir: disfagio ponNrui t l i trtc[1,o i lo]ir lo ; tr: lft l l iziru rnr0i,,,,,",;*,,1';;ii,;h,,1:ii',,;iiiiiiliiiilllli';Iill,iil'ilJ'lfffi;,yilliiilll,fl!,lfiii$fllllit l i l rb i l ,
;lt t.l
. l ) ' l 'u t t , t t , , , t i l " d, fu l lu l i t i , 1t t t l i t : ' l i t l ' r " ' t r : ' l i l r t i r ' . \ r ' r r r r r r r l t | l r r r ' r r
r r r r I r , , t l i t t t l . l ' : r ' t :u l jz i : i , rnrr . ' t i i i r r l r r i l t i t t r ' l t i r ' l ' r t '111" t i r r l r r l | ; r ' t i t t I ' ' I t I i l r l l r ' t l iL ' ' : l
' l , ' t ' , lrt l5ar' lra ;ri dcsfi iquralicl" ' plimrLirti f i trrl i rt l-t lrrelrri i{ ici 1rt 'tt l l tt rrolir l i ' l l t '
, ,f ' , i i i i i , a"id,,t.toasi poato'antr'"n1, l l l i l , iurr(l{ r( 'rt ruli.trt ltt lr ltt l ' i tr Lt't i ttc'r"
r,, , l*r"t iezi 'nilor b-i laterale at nt'n t,hri glostrlu.i n gi lrr, l ,tt l lrtrtri ' ' i lrr rl.
,1. . : . l r r l i t i . s in l qr l re. S-a sr 'mnal: l l . {L l ' asf l l ! { 'nc1, u lnot [ i l i ' i t ' t r ' : t ' l i t r t l ' t t t l t t r
' , i i i i ' i i ' i " , , io- . l i i i " r tn* aspeclului l : r ' t inqolui 1r ' r ' i cul io t lc t t 'zot t :utr l r r \ '
B)Parut iz iat t i .usel t ' iu lu icot ls l t t r : torsuper ioralJar i t tgt tht ' i ' i lo l ; r ' r ' t t t in:r, r , . r ' r iJ 'c, ia l . r t l , - " a i : r , r ing' tu i ] rLt l t l iz&1 , s i ' r ' 1 'a l iorL sJni l l . r r r ' r r f i l ' r l l i r r
' r . 'us (sci l in l ] coI t jU, i l , i ]u i \ /c] ' rc lJ) . A.nn\1. ( ln l l I i l ) | l , l .c | \ { . I IJ: ' { ' ' . | | | | | { ' i IZ ' I
r r , r , r , tount ia {onomclor . 'o" s l ] l l , ra ' ' 5 i Ja ort i te lea hr in3' l r : i . r I l r l r : l i l r '1 '
r "i,J'-ii"ii
aiw*e repeiie p"in ji l iotic:, comlrnsatorio,, ccl'r.l,l l i rrrrrsrlri
f,ri,i irgi.ti. Rett-exui faiingiain de partea paralizatrir cslc cljrtti lttt:ti ' siutt it,lxrli l.
A) Tulburririle de scttsibilitate li senzoriale se cal1i(rleiiz{ilz'i prrrr
t,ipociiezie sau anesl,czie pe fri,r inge ;i pc Jre19c3 lonftlir'rt 't i :r l itrrlrii, r'tt
l r i f r s l f l aSuc; io 1 'cnrt t l atner, in 5l 'a l ' l { \ ' l ! lu l I i r r r l l i ' l
Pa,ralizii]c unilater'alc sau bilat(j] 'ale izol:lte alc nttvltlui glosolru|itrll i lttt
,,irrt' exceptioaale, ele in'riininc]x se rnai {r't 'cvcnt inpletttri ('tr lrrrr':l l izii rrl('
rrclvilor invccinai;i.
2.10. PR0BL,EI|u Du IIIAGN0STIC iN patoltttit,q NliRVlll ',tl l
PNI'UilOGAS1'RIC
2.10.1. Invcstigelia serniologici a ltrvului vag (X) i[r}litrii ':
A) Dsanterutl futtclie.i ntotorii somalirt: constil in exattritlnt tl l tttol'tl i
r ,ti i vxJuilraiatufrli 6i i la:'ingelui, prcturn 5i a deglut'i l ioi (pcrrl rrr lir ' lrirlt ') '
Enanzeit'I sinlia : vilul palatr:Iui se elamineazii' aprcciitldtt i pozi(iru
r,t,,i,"i. '"u.ttu"a si sirnetri*, r' i iulti, prccum ;i evcltu: a 11N1slio 1i clcttl 'ttrt '
llo iriqc[r' inrl'oluntare velo-palaiile.Daamenul d'inantic: r'om {ace aprecit'1i *supla trrolil i l ' l i l i i ir:ult', trr'rl ' ir
r(J.Ltru care se cere bolna,vului sir, promrnl;c allurrito lroc:rlr' (tt:r' ' '. 'I(' ' ' ') 'i i."^A"t"t*lU,
"i l icrnn, vi' luluir l[etr' ntin]irrildu,-sc l'c li l] ir)' ltr(tli it 'rrii '
tri leziuni unilaterale se remarci u asiuret.ie a *i' luTi, ttt .ttlr't irt ' l l ' ri:t ' tl i
,fi,"iu"*, i-pr"u"I cu ltctjar <1e plrtta sllrritoasi'. ln.1ill)lul (rxllttril lr ' i 'r ' i
" ' , , t i t l t ; t i i , s ' r . r t lnat t ' i l . tc t ' , 'n l t t l t t la iLsimcl t ic i Lr 'z i t t t t i lc I I i I : r ' i . ' t I t I r ' r lc l t ' r '
i,iiiil'li iiirri"*" ,i nirr"tui ln ambelc prr'1i, accsta liind inr'r''alil sil' rrrc()lI [Ta0tre.
Dt.QlUt i ! tA i ;e r . lamirr t r r ,z l i r l r l rd l ro l l tar t t l t t i s i t l ) ( 11, , { ' l l - i j l i j i ' r r t : l t r l i l i t i . r '
, t , . ,ont , . " lu i r .z i r rn i u r r i l *1, , r ' ru l ' . r i r , ( r l 'Nl . i r l i . r ' r . l l t t I r t t . : r , I ic l t i t l r ' l r r t ' t ro l r iLs
r , l /
, i , r r i r i i r u.11, ' .n,r , l . t l l t 1t :u l t r ' , ' , t l l ( l r ' r ' l iL l r \ iLt l t ' : r ' t l tnt i l ' l1 l
{ l ( ' l t lN(" l1 l l { 'z l
, , i i i t , iJr i lat *r , ,nt , r , l iohidrdo l ) i i1t .u)r( l , r t r r r ; r r I i r r l l i i r - t r :uh|r . . {1 l r i l r , ( l in ruI l l l l
, i , , r , i " r i f , r*
i , , i i r r , , , l l , t . ,s l i l , . t i , , i t , r r l r lcgirr i i { i . i l i t . l r j r l . l r r ' . [ ) { r i ts . r l ( ' ' ( r l , l r l
r l t t ' i l , i r , l , ,g i , r t , i i i t ' i , t t t '1 ' r ' r r ' l ' r ' l ! t r r r r l t : r ' 'Jrr l ) i ' i r l ( ' i i . l l r ' l i l rgt ' l t t t r t t st t l i t l ic i i t l r r
i, 'u, 'niir, ir,?r r,,, i ' r,: ir, l irr l i lrr r,rr,1xr.i, r.rr 1.ziur,r, ' I r r I : r, I r. ' r ' ,. r, I i L ixnr 1nih,l,cl1tl i l tL
trr , tvtr l t i v l lg (s i , r r l l i l l l , , t t t i i t t r i r r i l t t i Ar l r t t r r" , r l .s . t i r t l r r 'Ltr l ' t t l i , . i l ' i t ' l ' t l r r
l 'o l rovioi t t | t i | ! r , l | r r , l { ls l ) .
-dli
I I li'
tf
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, i I t I I l t
. t ' i t t4t l t t i i , l r l , r j1 l , l r r r rLt l t , i t1 l l l l 1ol1r. l , i i i j i t f l l t . l r , l , l l l t lt l ) r , l l . ; r i , r r l l | | r | l r | i l ru r i ,s l r i t , ; r i { | t . r r , . r r r r , , l r . r r t l r r i ( [o l , l ls( , . l \ , 1fu Jr | r , r , izrr | r , : r, : ' ] : l l l : ] : : i , l : : ] , r i r r , r r r .
Lrr i r ru i r r , r r r r . r , i : , , , r t ic i i r r . r ln o, \ iurron l l , r . i lg i r t , r r i , , . i i rl i l , : ,1 'z i r , r i '
l r r i l r . i ' t , ) r . l t ( , ) t i ' . i {1, , r , r l . l r ( ) i ( l ; i i i ro l . i ter t . id, l1ur,r , nur i1 i l . i r , r . r . i' i , . | ' r r : r l r ( . : r i ' , . , . r igut i t r . .u l r r r i l r r l ; r r , : r1, i , i ; ; 1 l ] t im!,uj r6rbir i i , l r i r . r . rL.r . r . : r| , ' . , r , | | , I I , | . . r t l i . l l r . . , , ,nsfal | l ! r lu_se si t r r j l , r r . : : r . i de respirrr t i , , . l , ; r r : r l iz j i l r . , l r .i Ir irIIr(|L()| i pr.oduc modifici,t i accir.t lrte Oe tona,tic' lpiir l, ln ldorrir,), r.rrI r r i r | | | r ' r l r r ( r lr ln lrali i . Palarizii le dt'rbd.ctc' i realizcazi, ' r:r. ir{ cont},i1,, dise,,i.t{ lI
, ,1: : , ' l1 l
, , , , . , . , , , j , i . . I ] : ]u. i , rporr io le t l rbrLr i i r : i i . .p i"" i " r i i / in s1,," . i : r l : r t , ,
j , , l ] l ] i i , . l l ; i u.r ' r r . i l ,o-eo.._i i -str idor. . Tn parxl iz i i le rotr lo ur i i l : r lorat , , , \ . , r ( . , . : l
' rr,. r'r,l [[ir, vox1r1a, Iiri. mociificirri.er.idente de rcspiralie ;i cu refltrrrl'i 1". i rs(' r)irsi,r'irt. prraiiziite totare b nteraG
-p"o&oJ ind,iiri"iLri sevcrc :lrlil 'rii ' i rkr 1bira1lie pir:i 1a afo'ie, rips:u rctteiirtiri
'ir" iii." qr dispnec .rri l r ' r ( i ( )1 , in i l i a, les i r inspiraf ic.
., . l | ). l l ,,n1,1,,ryt f.tr nc!-iei 'se*zit ite
sornatice ce.ceteazti sensibil i tat t,: r,' , : | | . r r , r . l r r r , ( . t lL l r I mu(,o! .F;u, . ac|csiLr i lo erpto: . l r . i . c l in i , . , , : z, ,n;r; , , , . , . ' , , ' , , ' , ' , : l , l l ,
, ' : : . l l ,T l : ! : .1 p(,r .err . :e , ,o:rcr ior at con, l i rcrLr l r r i r r i t i r i r crrcr : r r ,i'1.,;1, ,li ' ' ',
rIr'rrrcr sulcljoari a pilierului r.rill]Jui palatului, frringclt.,
| , | | I . . , , t t , r t . t t t t f , tn, . t ; , ; i . {1, t t \ ,1. |n l ) i u1,rnr, i f l r . l r . i l , . l r r l r r i r t loLr i r .
j , , , , ] , . , ' , , , , . .1, l , , ,* ' , '1r . l , l tsr ' r t r : s i r r r l ror In i l ( . - \o (o, .u lor , : r r r l iac. s i l ror r , r .o
, , , ' . , , l . ' . .1, ' ! , " t - ; ' .1
. l t tn, ! i i tor u.ege' , : ' ; , . ragnte (1,1trasi4pn; ise). ln Ieziut t i
, ' , ' . j , , , , , , ' , , l ' l l ' ' : 1
. ]1 i . . , i rcneol , , r . . i . * ize. , ie r r1; '6gp 1". , l j . l : ,g i . , r r h i , . : i r r l i , . .i ' { , ' . " l r r"rr{" l r r rur izrr . r l t ( " t i l la l i '1 , . pa* i l iz ia acut} , b ihter;h l netyrr l r r i, , . ;
, , ; : , .1: . ] , l l , ]^
o: i - inco_r lp i l . i l , i : - { . r , . i . jur , , . Ior r j , l .on iu, : r r l . , . :z i . i
,,1,.,,::i l ';",1;'l;ll ' ', ' ".. .;;,,,' ' ',.1,""',lt',lil,..lii:l;l:|,': ;:"i,:1,:,;,, ill,rr'rrr lr(.it l i islrrr;rsrrrilor cll],diot-rlscrim: qi cercbral (popor.,icin gi criiair.,l l r r i ; ( I ( | | I I I I , i { I , I l }? l j ) .
I. l i).:1, l\ rrvralqia vagdi
, Nr.rr,:rl., i irr I 'r|;rrl l i s0 crt,ract i,r, izeirzi prin parosismc algice c:\ir i iplrr, r 1, r , r , r r r r t .J, . r l i , l r i l r r r r j , . r lnL l lLr l : i , r . . ,g. i , r " f " . i r
f t , l , r rn, , , ,0 t r rn( n l i l . i l, , r : , r ' ' r , , r : r ' . , . i l , i . r ' rn: t .u / { - r ^ l : I 'odd. l0t ,x. c i i i L i t lc popovic iu i i
l , , l l l l . i l i : ] . , . l l l l l l : :1j ' ,1"., exattr i a nerrr lgi i ior l i lgt le esrc t l i f i<, i l i ,' " ' ,,r ' r,: rr,r (. :rtri lstLDno:clc pe care le lealizeazi, ramulile periferico l lr i:r 'r, i rri
'r( 'r 'v Irr ] 'unitri lc altor ner..vr
. cr.. l] r i,: l i i ( irt(kroucbi cu iervLrl gloso_|.r , r | , I I I I r I I I1- r i l t i i l l^r ;J l lo din ' i i r [ : i . . in i l r
cct , r_ ic l - le (Ur_L].) f i c* s is icnLrr lrrrrl,rri ir. trr ir(x,st s1.irs intrri . in diqoirtie si
"irritg' i,; i a,; i". in LtoritrL r{m1,r.t. i it ' t t tt ' tttrt r rl,r '1r irf{) si un irnrorr:rlt conriingcnt d" f it i t i i i tr
", l"" ' l i1r.s'-i r r r ' i r r , r r r t r .
| ) l) i.:r:t l t.:: irt, ttnn,u,ti. i tttr,t, irulure u nenulu.i, ldq rr, l iosl rlcsrt. isi, r lrr\ r . r ' r r r l , ( . i i , r r l , , i [ ( ' I I . ! . r ] { . , ) i l l r , 11)1, , } ) f i constt i i . , r t r_, i ' , t i , r i , * , , lor : r l izr t i i i r r,,,,1i11j,,,,1,j,,1,f,,, i . , , ,, ' , , ' \ . r,\ i i(,r.n, jr iroi i1,r. i 'uncuri do
"n"i, r,, i i i , i i , . , i" i sertltol i i r. i
' , ' ' ' , , . ' . ' | ' i \ | . t t . t '1t | t1 i t t , l l | ' | ' l ' l | ' l l | i , | | | , t ' '1 l , | l i ti r l | r ,1I l r l r ( \ r ' l | | :1, i - i ( f r . i i | ' l t r r l0r ' izr , ; rZi i 1t t , i ] | l r , | l , i { ; i t r r r r r0r , l I r ror iSrrrrr ( l t , i f l l tSt)( t t r r l ; r r1 l r ' r ' l r r l ;1rrr , rLrr l , l r i r , : r l iz l l r . i i r . r . r , t l i r t r r r . l r ' l l r I i r rg i , , , i i i
" i , , , r i , , i | , | l i , , l , ( , f i l , t , r !
t* ' r , t11, i i r , / r l . . i l l r t . r , l r , r . l i ' r r . i r | ) r , , l r r r r r l r i l l i i r r l . r . r , i i i r r r , i i l t ' ; l i l r l r t r . l ) r r ' r , r ih^r t t r l , i I i , r ' I I r r r i r ; r I r , r rL,r r r l , r . r r l . r l r . , l r r l i l i i r , , i r i , , r ,1 ' , 1, , , , , , I i r , . I i , , , , l i r r r l r r , r . r l r ,
l l r l
1' l t t t L i r r , t t t r r r l r l l l r l i t t r r . t r l i r t r ' - l r . I r i I rL ' IoIr , r , I r | :L l ) t t r , r r . t r r r r : r r , i r t r ; i l r l r . I r , . r i r ll t l r r I l l o zrrr : r r l i r r l r r r r l r r , i i l l r l t r l l i l r r i r l ; i o:rrr l l t ro i r l , lor r r r c:ur. r r , r 'v l ll r r l r l t i r r r r ; r r r | r . r ' ior , s l t . i i l l l l l . { " I I r t I I r I ) I , i i r I I I I i r , I I i r I i l r | | r I ( , , r .z i ! iq. l t i l . r \ r , r , : r r l : rf ( r t . i l / r ' pol i l r r . l ' r i r l i lu i 0 , ,1| ig. ; i | t ' z0tr( , " , i i i i l l |s l { ,z i i t lo | l r i r i srr l r I r r r r rr l l t r i i r r r . I ) iutrrc i t l )1) l t . l { . I i ( l l \ r l ; t l t i i t l i i s i r r r l rg| i t r l t l , i i 1) l , i t r o| i r r | i r . i l : r ( i ,r r l i iL, j r l i i r r zortr , g i t t r l r i i ( t r isr ' , io l l r i r , r . , ( i i j ( : i t1,) . L i r r r r r r l l , i l ro l l r i l i , r l r r l l r . r . : rr r r ' ln ct tacl , t , t ' r 'e lat i r . pctrrrurI t i i , r ;L. t rs l rcclbi I i p i l f l ) \ i i l i (x. . ' i r r i i r r r l r r r li ' r ' iz i . Io l r r t i l r lor . i i t r r i l r r r .er .orrs l i r . i l i l rL i l t iJ i i , lxr l r l l r . r r l r l , l tLr l , i r r l l r r j l , r , r r i l i r r r rrUl , L Urcor i apiL| e l t iso t lc ( l ( 1. t1s{ l dt i l t io i l r j i l , i r i s l t t i t r [0 r ' i0 l r ' r r lo, r . r l r I r , r 't r r r l l tk ' t lccr tJt i l ( I i isr : i ' , 1.91i2). I )ur . r ' l ' i ta thn t ' i tz i z i lc r l r r r i l r l i i r r r i r i . r " r r rr r r i r t l i l r r ingologic nr:L tv i rk ' i r l j l rz i sonure uir i tc l i r .c. _\ l i t t l i , r l r r r , r ' r ' i l l c r, : l | r . :e l ' l loYl i t lg ic apai ' in: . lur ingi l r : i rc. . r te s i tu c l r r r r ic t , ( rJ0 r l l r l r r r . l r l r i l r r r l .' ' t t i l l | ' i), dtp.i rnl i,7r{r;/ecloz,i i r. ln irr lLn;.rrl urror I 'r lft/:tr (gt,ipr' i cl ir)- lt i :r" l ro: l l t i i l poz. i t i t 'se l t i tz . l tzr ' i , l r r ( t i l r ' : i t terul( ] durci . j i . r l r t I r , t ' r I i { r t r I i r r r , I r r . . i | 'r l r r t i i l r d i"ql tnr i ! in accstei l i t r r l r I ]a l :nestczir i locl tL ' l r l i , , r . i r r l r r i i r r r i r ( l i : r r r
l l l [ ' I ' l ' - ] I .
f . 10,3. Paralizia nervutrui i lner{mo{Jatstri( i
. l ' ru 'e l iz i l r ic ] , t - ldui ] } lcurnogasi . r ic sr , r r r i l l i fe"r l , i r I t ' i ' l 1.111]) i t r i t i t i t r ) l ( ) r ' | | ,{.r!zrl ir-n si t '{,gola1tir1'. l)unli: irt tttt i l .airrqlit, r lr.urc Ja, iu^rrti i l l t |rrl izi l ' v|1{'
I ' r l r r t i l r iL (hcrniv i i l t izut , l i i l ;ototr . l i i r ,1 l i t l ' r r , , { i i r r l i . p i r l t r l , , \ i r r i iorr , i r ) . \ , r r . , , r rr l r ' \ i l r l n i lzoi)at , i ) : i i i l l tu l l tur ' : i l i ' i r r rXcghL1 i t i rL l i r . lh i r l ,Jor. , r ,Lr l rd l r i :ur , r r l r r r ' 1r , ., r r r . St 'cr i t rstat i i o i remiar l : i0zir ' i l r . i lu l l r i l ) i l l |1 ui l l t i rL i r | j i r r , l i I I I r , IL| . r I , I
1r ; l re l i lor a l ic l ' ior i s i l tostr"r ' i r l i , t ) t1,c luJl r i l t j iu l t i l i l i i i j ' . , i l r l r l r l r . rl : r I i t rgcluj . I l r l i l , i . u l r rcLopl la l iJ l { 's lo ( i ;n l i r l t iL l s i l r t a i r0 l iL l l r . I l r , t r ' r r l I r : r l . r r .i , ' : i i t t t l !e bi . l t ! t ; 'uI t 1t : 'cxLt t t t l : t ] i rLt ; i i l i i . i l r t r l i t r rL. .g i r t l i l i r J i t l r i r i r l r r r . l r r l l r r r ' : r r rL I l i ) l r i i i !1r r l d i i i lo l r i { ) r tLr : r l i r t i r . . l l ' r i l l lL; ' r l t i lc \ i '11 l l l i \ ' ( ' , l i r r l r r r r r r l , ;l ' l r i i r ' t ' i t l i r i r , 1|( ' t t ' | l t r i - , ' ; t1] { '0 | ; l - i i i t i r } : L| : I I } | I I i i ] . i | l i , i t i . i l r lo, , i i I t , r l r r r . r | r l , ,. i l r i l l . l l r i ) . r i I ' i ts . l ) i r t l ot j i crr l r ior i Io1t i r ,11ic, r ic r ro l r : ln i r r r r i l l r ' ( l , i r , i l i r l l , . l l, , l r l .
; l . l{}./.r" l!oain hri i loska:n { hipelroikrcli l l l nt t ir sitrourrolir l ir rrl i l irri r | i i i r1clr 'e lzai in Jrr i l f iLt l I i : r i l l t r . i r r nt : ,n. i . l rs l i ! t i s i t r t , ,p, t l , , . r i r r ' : r | r , r ' l r ,Uirr t l r l ! i t ra1; i t logla Jt t i ] i lurr i -L t lo t ror t l I r ,s i r i r r r , l r s i r t r rsrr l f i r . i r ] ( , i , ( l i i r i r r . l , r ' l
r r l { l i r " i r lual iz:L t l t i i t rnLr ' ( ( ] i r ' f t r r . i i l ; i .11;pol ic i r r , l l r i : l i (1) l , l r l i t r l t ) ' , . . i ;I \ )pr , \ , i ( l i l : s i PrurLl , 11)E1):
. l ) Ti f )uL rauul ( rnrdic; iLt l t , i l i fur 'J so ( l l , r ' i r i l l u izoi lz i l l i l i r r l rp;rr , i l i r , r r r l l rTr r l t , l rut t r l 0rr t r t1 l l r ] : r i r , i s i r ) l r r i r r i r tJ, l r , r ' l i t ' i i i i t lotr I t I t r r i , i i I r I r ' { , r ) r ( | i i t r . r r . r , t r | r ' l r0 ir r r r ' t11, l r i t l i l r t r io i r r . r t l l1 iut . , c l l { [ i l t . t ] i i vrr l j l r i r i l i r ( l - , l f r , ,1 ' f ) . l i i I i r l l r . r r r r r, t inr , r ' l r l r t iu i i r l l r t t l i r i , , r . t io lz i i ,1 i l i t r i r t r l l r r t rn;rJ sr l , r ' r l l l r i l l i i l , r ' . . , \ l ' .ot) i l ir r r tut , r ic t t ( r t vrrLorr , t r l t l i ( l r tuonl ,o l l : l i r i l t t t lLthni i r is l r ' r t l l r . l t r , r r r l r r , r r i r i i l i i 1r1r.r ' r lr ,x, . , l .o l i , l ro1rr , rc ( 1 i r I i I j I ) i r I I r i I ) i I r l : i , t . l c i i rot , i t i t l ; , r l l { , i sc i r r r , l r i r l r . i r r I ' r l l r .
i : ) ' f i ; l t t . i t t t : , i t , t | t , I t t r r ; r t i ' r , r , i rs i r i i l r r r l l i i i l i l r , i r i ; r r , iors i l r r i r r r l r . r ' , : r1, . ,r r t I r r I r , . r t t I l t t I , r l r h l i ( I j1I i r , r ' { I i r . , i lL l r j . i l l , t l r rJr i i , r , , ' r r i l l i r r l r i l r r s i r rorrrr .o l , i r l i t r r r : r -\ r t r l l t t r r r t t i l i ' : l l r ' i t i t l t t l i t r l i t r l ' I t t r , I r I : r Io t I r r l r l i 'o t r i r i i . i l rs i r l i r l l , r ' r r r r , r r i i r . r l ,r , l l r r i , r i l r r l l r r 1r l l r r ) r r I r i I l i r l r , r t r l l l r r r l i t r l i .
t l ) ' l ' i1 tu l , t , r t t l t , r l s t , r . t ; r l l , . r i l r , r rztr I t i r r r I i r r I r r r r r r r l r ' : r t l : i l i i r l . r l r r r r
. r l i r . r r '1: i . 1 r i r ' I r I r . r ' r ' i | , l , r ) l t t i i l t l r r i I | | I I i l r r r | | i r r ' 1 )1l l r ) l r { )1, . i r l l i r i r l i r t r , , : r r r r r ' ( r , l i , i , r t ll rur ' : r r i r l r t t r . r l l tL ' , , , i r l t i r t lot tvt t l l i i r l l l i l r r 'pr i r ,p l i r . . r \ r ' r . r i l r ' l l lnrr . l ( ,: r rn i , i r r l l t r r , t r l r l r , r l r r r i r . r r r . r ' r , : r l r ' r r r r t r r r r r l r r r crr ' , , I r r I i : r r , .
1t ' l
i l l I i l r i ( ] .
@tr\,
@
! ,rr , 1,. [0lJt, i lMtt t) td l ] l l ( ;N(]s1,t( i lN t,A,tut,o(i lA Nt,RVUt.,Ul sPlNAt,(A00l iSl) l l ; l ' l , j l f l , l j l l l lA A XI- l )
't I l'l;,1"\'::,::l^"*:, j"_iiglgsr:r, a nermrui spi,ral impr icri :
tro(x1$il,i l, l l 'rrlro(rsl,outit tlo urgolrt' it,. ltr etlzttt' i lo an dabltl.rlrrrc strirkrr', dispnoe qi tlisfonii pinir, ltl a'fottit '. Iltl l l lcxttl, i iur irrurit suu chiar abolit.
lonl,-pt ogrettt ' ,( lo l;uso osl 0
,;,,t.1,"j:"^T"lFl1in . serniotogici n rrrrr,ttui spirrat impti,.,i :' ' | J I' i|amctlut clnuc nentmL rannna internd, i nurvrtrii-i l)i,,at est,t,trt cu cel practicat p&tru compolenta motorie a nervului r)leumo-
D ) f'aralizia neraultti sphtal et'tern' so lllrt,l l ifcsLil prin ssnlno (lrllgrrrtr*' mr6ohiului sternocleldomastoidian ryi tlrpez do llcocil,lsi pil,l l,o.
I'ara,lizia unilaterald, a muschiului, sternoaleidomastoidtal, so ruanilirulf[irr primul rind prin qtergerea retiefului musculat a'tit in repaus, cit.qi lrt"tirnpul miqcd,rilor de inclinare qi flectare a capului do parten lozitttrii.l)e asemenea, muqchiul prezintii o hipotonie marcatl qi atunci clnd lx:lllllvul intoarce capul de partea sinitoas5, qi examinatorul se oputut ,l,cottt( irrriqcd,ri. Uaeori sd poatelvidenlia Di o ahofie de gtadc diforitc a' nrttqchirt -lLri" Ilin cauza actriunii sternocteidomastoiclianului de partea.oprrsir,l"ozitrn ii.,oapul poate si fie'ugor inclinat ci,tre partea sinS,toasf,' Paralizia unilntclrr,lii,lu, inuiciriului sternbcleidomastoiilian nu impieteazd, prea mltlt miqrrfil iln,,apului din ca.uza intelvenliei celorlalli mugchi ai gitului. In clzttl lt:r rtr'liziei bilaterale, capul se afii, in u$o&r[ extensie, iar bolnavul oxtrcttl,tl, t:t.tgroutate flexia capului.
Parali.aia muqchiului trupez re,alizeazia urmS,torul tnblou cliltir: : rr,)rrrrrlrul rle partoa lezati este coborit qi proiectat inainte I b) mugincir ir,tr h'Iiuaril a portiunii superioare a trapezului este qtearsd, ; c) spD0iul suJrrlt ohl -vicrrlar. eite hdincit, iar r:lavicula apare mai bine reliofatd, $i paro proi{joltll iritl lai te; tl) coborirea scapulei ; e) clevierea in afarir, a marginii- spittrllo ir,on,uplaiului; f) diticultatea efectud,rii miqcirii de abduclio 6i .tlo t' it l icl,r'r'a briilulni; g) imposibilitatea de ridicare ,,in coa,te" dirl. pozil,irl l l l l l lnl,;h) rlificultatea efcctuirii miqci,rilor din articulalia nm:iruluil i) 1l,r't 'gctlrt,r:,l ieiului qi hipotonia muqchiuln) trapez; i) a,trofia, tnu;ohittltti l,rrtlcz
llurulizia sittgulatd' a neraului spiual este raril. lJfl, :l l lrtto rlo ttlrltrrrii. rrlrrerLnd, cu paralizia ultimilor nervi bulbui (in spccial ctt port'rlti lo tt,I X-a ii a X-a) (vezi in continuare), ' loluli, procese care se gd'sesc tn i n nli a l,ttt lrof)iere a foram,enu,Ltri magnuln ;if sau' u, regiuttii, cetuicule $tt,lcriottrr(lr)carc osteomielibice, pahimeningita specific5, qi nespocificft) pttt prtttlttco
lrrlalizii nnilaterzlle sa'it lti laterale de nerv spinal, Adesorl, oparul'i i lo tn
itqiunea cerui,aald lnaltd (ca, tle pildi', sec{iunea spinalului in tortiut'1i*)silrt rosponsabile tle proclucerea paraliziilor nervultli sltittttl ' Ane,tritmttl
^rterei rcrlebraLe calo se dezvolii) i l canalul slritltl l superior pott,e t:otttlrrimtl
norvtrl spinal qi poate si plovoace o paraliz,ie trrrilatoral.i ' (l jor'loohl;ttl ' 10(|6)'
l;li:liil "" cel practicat p&tru compolenta motorie ;;""Jrir,iiilll"Sli
Ftg, 77 a, "Astr'€{te lch€,rnatice ale examenulu.dlalrjngoscopic:
;;:lllili#; li'iriii:i;l'1 ii';"':i:l'';'?'i;ll*,i,,5x*TiffiJJ':i iil:i::ilI:1.11.3. lraralizia nervului spinal
ir;,i,i*ii,:q-$*ll#":$|liii,:,yli::,*imiti;$::t{^*Ti*:ir I lrl,or nii). C drcirLoltlul liroidi
,,iil,i*i+*!#_*ii#_',E,5,1,:*ri:;t'*r{jrft,:ffi jniti j ! :j:i' i i:, "i,###,:fll{f trtr'",::* !.i,il;:'Jt ;i:r r t r v ; w::;v;r:;i;i';li,:',\"Yf *'f ::'u1":*$,,i:il,#:::fi 'ffi "'#,fi ):;*'J'1T:Hai.iir,rr rrc rroui\, nri
-oi'co*ilJi'ir'rfiL),',"o!!,lJ1f?t1,fl.1 utrvului .""*"nt
illl,l-llHl-""lHlglinn:Ysx$itni"';''i;;i";;;;ilifr:'J#il.i|#i:1 i r.z r, i p s ir a rc*ri " ;;;; i; -;.f.il-
ii #, i;:i: ?:#,,Ir#; *:,Ttlir. 'orur.rrl; pr[tluCe YoCe stlirlet
lll,ll;iylii,-',l,,. *" 1i"""?, iii,*l"ll;i,li:r".i,",1;,,f,1,J#lH":T;iil,f,H,,,:$itI'a.ralitia bi.IateraLii de nt
ri:,iliii11fii,n,lilii!:y;;,*f i"#t{{i,TEH"{,#l1,;b*nuiindeeir,ri,',,,,ii,ii'"i,i,n,i"i:;;;';^;:;ii:,:'tr::^;i",iltfgT"fi ,:lyitd:'-l",Pml:
I lj8
9.12. PROBLI]MD DF] DIAGNOSTIC IN PATOIOGIA NDRVUI/UI HIPOOLOS
9.1L1. lnvostigutria somiolofliolt n norvrrlrri hipolllos (XtI) lmXrllod:
I ) ( )hsurva,t,irr 1,ozi1;ici ."i a nn;rootului limbii in sbore tls rolf&ult rrlngi tut t .
I) Inrplorarso mol,illtillli Umbll, solloitlndu.ss bolnavdul rl1, oroouto,r outo mtgodrllo podblle on t I mbn.
' l r0
tl , ' , l , l \ ' t i | l l r | r ' l l i r r | , l i ( . I I i | ( | | I r r r r l r r r . 1r . r r l I r r st t | . l , r , i l l ( l ( . r t , l l l r l l ' l i i l r , t . r r r r i .
Hi | l r l ) i l i l l0t i t l r ' .
. / / , / OIrs l l r " l r , { i l r ; r r . t 'z t ' r r l , r , i r l r , l t r< r t l l r r l i j i l i c . \ 'eniul l , l r l l { } r . u l t i r . r r , l
r l | ! . ) I I l l I l t ( , -
:1. l:1.:!. l laralizia nervului hipoglos
.l 1 1'o.rulizia u,nil alerald, tuiertru,lui iti.ytoglas; realizeazi\ o dtr:irtit.I r r ' 1r : r . i . i r -s i in i toasi i a, v i r lu lu i I i rnbi i , , in s inu, , . Daci boln[r . r r ] cf( . t . t { r { . i rz:r
Ir ',r lIrrzirr I irnii i i , wir.lul i l(,csteiit est.j { let' iat spre par.trr boil}rtvi i. [) l, i lrr( ttturrir lt[ isd]iulrd -Eenioglos
de p:rr' lea opus:i ]eZiunii. I]c :rse:lt,, i ,orr,l:r l.r l .* '( l ' i l l ] al l i rbii fot]I l leazit o curbiL Lu corca\-itateit, spl,e i lr it,1,(. irr : irrl loirf i. -\t:casti i deriabie esto produsri i jr in actinneil mrifohinhti r{i i{)., ' l() ir *) ;(l ; r (,!(,:1tuea z:i in t i inlpul cfor.tLrri lor de t ducc i itnba cic 1[r,r.1rrrri r r l t r r r r i l .L int lxrestc{ t t rof ia l ( i t iet ladt ,*par 'n l iz i r l l iLqiprezint i ip l i l ' i . ,J i , ib i l .
;r. rrrlrr ' :r lr ir i l jrnbii. 11 hernij inba rrlettal i: se poi remarc,a,.Jasci::r. lu!,, i. itnt\t tt[/t) t: irr coridi{, i i1i: in cr.r 'o ieziir le:r sc:rl l l i lr, nivelul ntc]trdii ne}i. l i iuilr1r,r,: los. l)f i l ir i tt i t ia {.rroli irI a i lctonelronik;t,.
1t ) N'rrroli::irl itil.atert;ld, a er,nri.ui ]ti,ito1lios praiar:e tuil.lirlrj iirrrr-lr,rrri l , r 'r ' Ive al(.. t|r{rl l l i t i , i i i j irntri i . Acessta-nu pca.ig fi .r:ri;catr), r-i lnir"oi 'r i l , rrr ;rl i i i , rt ici inirrrNr-rl 6i nir: i in aftrr.a gnl,i i . Atr.ofia i idrbii este bilrt( ' .r:r l:r, r l. r,r, l. ' . t i rr t l l ,{: o' i ca rnuitipJe l i e\.ialette flscictlati i *tusrt ir lr.,\p tr si lrt tr:t'ii,ri, t!e mostica.rtie, deqlt,:ti!,;e lsi tle pranut$*re ro con s ou.jtt:lttr.
. . l l i l l(1il:r!11.1 rrt(,t afectat, !n gcnelal, tL, er:erlelrsi afcc.tiuni sa Sipeieij j l i l(,I l',. \ sj -\ l, !l'r cr,r.rnt.o.tismele craniot:erebrc(l.e cit frac1,lrti rie itazli pot-1,:t,Dtlncr,t:tt ' t\t t t!.1(\:)t it ()(! 3i 't1.gukt]"ri $, nen:ui'ui hiitogios. Attetsrit i,nttl qlte;:ai 1),,1{h;(lt,r,rt l ' r 'r ' :t l izlr rr 1:rr:rl izic nli lat, jr1r.l i . a nerr-ulai hipoglos. lez;unile reqit.tn.i i
t.t ) t i t l t l t ' ;ttq[te pot aft 'cta re.rvi.rl ]r ipoglios in poltiunea sa extracnrria Il j ,.lrr ;rr,.,r.1r, r,orrtl i i ir ' rr: 1,t ' i trrlc si sitnpatitul l.reri iclrrr l, id,lrn si l lsist: im tra rrtrirrlr lrtr r, l j l i i , soltprl l dia pal,l izie ir11jl:tpri. l i . p" 11.,tr-uh.Li lt i l jOgios ;i r in_rI|rrrr ( ' lr nl<, J lerI rartl-Tfutrtrl de a,ceeasi paute (Taverneri f.-Oel;. '
: i ir i t.tr;r,Lrrlhia l)otte lcsla s1i lrodtor: o henia_trofie a l in):i i , rrr.r,r,. r l i l . I r I r ' : r r r r r r l lsor i r l r i cu l .u lbur i i r i l le r t , t is ib i i i tate i : r regi tnea' t l ' ig.Dr, , r rLr l I i -
, ,.\t l(tt)1tt lrrtt:.yui.aL anti-tt iro.ficd (q.L4.) st si,nd,roamele tle tt-.[,.A. 1xtl,r lr ' lrrrlrr ,,rr , i . l tzitr. 'ro dc i ipoglos, da,r de obicei se asociazil \si sentno {lo
l.zirriLc rr cr,lollu,lt i rcl:vi irulbari, preonnr [i simptome piramitlale.lr' irr,uil.rt Ltnrtor*l,c fi it'ur.*t1{ttice ale g6,u,rii, cont'l,il.iene anlerioare ttrl,.s,tv
rrr ':rzrr rrrl.r irrrir lrcrvului hipoglos (sinclroilul lui oollet). rreziuni trmorrlor,i I.rrrrrrr:rI i.r ' rrl. glj,ruii c' lr l i l i .ne qi ale gd,r;ri i ruptc postc.xioare rea[iz{)lr,zi,:,t,r l |o)ttul. ..tr.t l i l .o-qnu,ri i ru,pl. i pottefiaurd, al lui S,icu,ri l, aslpra ci,ruia, l.orrr
'r,vr,rri rnrri l ; i |zirr, r l ind vom {ll lorda, ; i sindrou,m.ele bulbare ct lntofestl,olt
r r r . r 'v r r l r r i I t i l togkrs.lu l,rr ttr l i i l .e lt . l?b,[e].ot otrrl i{ '(. l t superi,()are fto lot obsor,va, l) l lr l i l izi i
r lc n l ' r 'v l l i l )0gl( |s.l ' r r r t l . i : i i l r l int l r i i dt ot ' i t i t t r ' t , tn l , t ,u, ld, p l i r r l r rz i r r r r i i r lo f i tsc i (x l l t l l l t i q. . r r i_
r 'u l : r ' l r I sr i r rso{r ,st : r tc rr l , r 'o l i i u l ,u f i l ) r ' i l l t i i i r r r r rscrr l l l ,nr . I rczirrr r i ls I i l l r , i , r ,1 l l1:r l . I r r gr l i r r r r I r r I r r i r r r r | | i r r r r r r r l . I r r l r , r ' l r r* l r r r '1 ' . t l in r . t indt t r t t ru[ ?*ut& tn,Lb(,r l i sorr , t r i l ' r . ,1 l i r . l i r r i r , l r r , i r r | , t r I I r r r | r i I i l ' r r I r r r { ior t I t I i r i r r rJr . l l t : t r r l r r , i t r l r , r , r .s l t r r l [ t | ts l i -r ' : r ( i : r , r l l j , l l l i ( i t r 6 i r r l l i l r r l : r l l r r r r rv i r r l , r , lor ' .
| :t0
: .1; i . l , I t t ) IJLEltuD| l l ] IAGNUS,I I0 iN|,4 ' t r t t , r l r i t , t l ,^ l i^1, IZl l | , ( ) | tMt l | ,1.1| ' | . | , :AI.,E NIIRVIL0R 0ltAN ll ' lN I ll l l l ' ltAlil
3.i3.1. Atoeliuai extranelraxialo crt itloctirri mlllti i] lc tlc ttorvilor
0r:rnie i bulbari.
ilTi'lli#,{l,",,;ir;#*ht,ilHiTffi ;i1'*:1i4i*?,'rfi :li
"-.iili,Hiitimixa ::::uiir'lr uul'l {iif'.'i'l::'r;l ;i ir 1;'rl:;:";i,"q.;,,;,;r;#:;;l,l;*;*f {li$ffi iti',illl*,il,,i;,lilll,,il;l;":il:r #*:',lillf l**;i,l'll-"*4i!tiT"i$i$:ltil,*t^li;lllr;;:illi:,:j;jtiti:tiJ11lJtfi1":ii'iii1H!!:HTi::,:,,:.,j
o1,T,,.", "i,,,r 'u,.'',,'
$Hil$jiti#fi'iffi ',1,*:ril"s:ru;;r!**ii111ffi ,
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r r 'br" ' r rer ' '
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produs cie obieei cle o icziunc r-r qirrr-lrorrrrlrri i l lcr,ior, (llcrifolrn) al vagului $i a nervului JripogJos (Llotri:r: si,',Lrlr., l l)(il) ; Pr.rpoviciu si Fascu, iOSf y. in, simptcrniatotSgia sindrornrJuiI r, r', rl.rrr, rrr rui scr,nitlt'se adaugS ,i p"*iiri"-d- ii-rrfil,-ii'actorii it;utoiril, l : , r r i . ,_r i , , : : , r i L 1nlr . , [ou, l , r 'ndrurnr, , t ] r { c.d(.nlc.t, ) ,\ i ttr l*nnit.[ l .Lti Collet-R,card cst,. proihu de ieziuni c't,c alfr]f, i t i i , i i , tr ' r,,.,,|r*i l i tr.r lr loltc for:na,l iunile car.c tr-cc pri l {or.arlcnul jtgular (l: l l inr
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t. j l ' t t)(tr( rtst:u.Lan e ::tncvristne i1c arto.ei carotide sit 'ate sub bazll, r i.r ir l*i1 .r{r\ I i ' 'c ale artcrci.r 'ertebr.ale ;i bazilarc, I lebite ;i trombofle_, 1r. r l r ' . r r r r l i j r rg l l r r , ro, tunol i gJont icc j r igrr la le l i r i qx,c ia l j .
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t ' ) , \ i t r l r l t t . t t t i ' l t * l r t t l iu.r 'dro-T.tarol id ian aL h l , i l laref se Oat, : lotel l -. ' : : I I . r . r r r r . ' ' , t , I r .u, . rJr . 1, i r r ; . l i i i i a l , " t r l l in, l r , r pat t ,u 1e,.r .chi de l r . r r i cr . , rr ' r ' r r ( ' , , r r . i |1 ' t | ' l l l j ' r , , { \ { r , , t r ( ( ("ol i r r .Si , ,A|r l / l . l l r tn S: l tdfonr { I : l | l r l ( .| ' , ' : r t r t , ' r ' t . , r r . \ ' { l j t l , i , .U (} J j inJl iz jo I rCj l l iJ .
. l, 'rrt lor.i. i r l ' i t ! loti( i. si lr l re|'r lcz,etrtr1i dc afecti lrni lclci,rl izatc in sp".r, l i I, l t f l t r ,yrr l t
i r ] i1rr . r i r i / i l r r r t , t l ropar, , l id i rn i r ) I raru n:r i is t r rL, ; L) iunlor l ( l j ;u, i l .t r , l r , r t ' l ) ( , l rJt . i t . lc r i l r r r r r l iqrrr , , tu l r ror- i t l r , \ l l l r l j j l . r r , t rz; i l | l l , )st( , l , jo i l , ro, i i l r r t r . r r_r ; I r t l : I r t ) | , r r r i l r r i r1rrr I i i , I rorr l l r l lorhl i i r r , t r l , icrr l r rzr , , r ro iht l i I i r r r l , r r f i i r j , r l r ., ,Jrr l l i r rcrr l r l : rz i r , i1; r , ) prol lsc in l l l r t r : r lo i , i i I r , r r lc ( 1 r i r I . r I 1 i r I i 1 r , , r t l rc l r , i . :u, i r rI ' l r ' l r ( . r ( | ,1( i l ' , r . l ( f . . ) .
, , , ) , \ i t t r l t t ' t t t t t I l t t i ' l ' , r1t , t t ( l l r r t Jr : r | l r l iz i t t r l loso l l t t . i t rg i t r r r i 1 { . ) t r . r i r . , l { r . i l f
' ' i r "zrrrr ' ' | | i | | | r I i | |J | | ' l l r r ' r ' ! r IUl . r ' i r r t t l r | t , r t r t i l t r i r r l t . r r t t t : t i L I r r r t r r r r r r I I r I r ,11
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r i t t r l I r t t to r1 i t r : r l t t l r i i l r lx) l l l r , r r l r I r ' r I i ' r t r I r i t t I ' i ; i | | ! i I i ( ) I I I I I I I i 1,1 r i l i r I r r r ( l I ' l l , l ,l1) .1| i ; l i is l t , 1 l ) i iL l ; l l rpor ic i t t r . t l ' : t , ; r r t t . , l t ) i j l ) [ i s{ ' r r r r r l l t r l l t iz t ' r tz i i 1t t ' i t tl r t t ' r l l i , , , i r t , s i i t i tot i l t I t r , I r t i I i t r r I r r i , prnt) iz ic i l )$ i l r l i ; ( f r i t l i i i l , ( r r l t '7 i i v i t . i l l r t ( ( ' l li l r l r i , r r r i t , v i i lu lu i palz[ tu lu i q i r r I r r I i r rgcl l t i ) l i ( , \ -cr ] t .u i l l l ) i ' i r l l ] r r l r r l jz i ( ' r rs( , ( r i : r l r lI r t t t t ;chi lor sternocloi t lo l i r i rs r i t l ian s i t r ; lpt :2. Uttoor i Iu1 l i r r l i l , l l t , { i r titcrvii simpatici celvicali, o1t sindrom Cltrtdc l iol 'nrlr(l lkrl ' tt i ' t ( l iory I I,tro la l t . , 1.969).
t r 'actot i i et ic loyl i .cr i s int : : ' . ) I raumal ic i , in speci : t ' l , L l rL i r r , l r t l q i l , t t l r t r ;h) Fat:tori, ttt.tno"rali pi c,t inpresi,t i (turnori ale glaridttor ptLlrrl i t lr ' , 1f i ' i lrrt lozr',lrctastaze l,:.,cele, adencpatii, l lmfosarcorrno s.a.) ; c) l: 'utlori i i l l lrtutrrl0tr(par{}i i( l i te) : i ircese, celir l i te q.a.).
3) , \ ix t l r r ;mrl , de hemibazt i (s i t tdNtnLul [ t t i Galr : in, s i tu lntntul l r r i ( i t r t ]'Lain
;i { ioci.n sau sindromul lui Bertololt i 'G arain ).'1'ablott ' l ' semiolagic este constitutt t l in po'ral, i l l i l :rt11i;rlr: t l t ' tr lt i I
{ 'ra}i icni, in {olmele l ipicc qi completc fi intl aiccl,:rte tttrtttr c|l i ' I l1 l 'r 'r ' ' r ' lrttLc nenri cr:lnleni <le o p:trte, da.t cu clemsil i-c s(xnioloil iot) l l .o tLrirrt l, I rr| i:r1; i le, in funcl ic c le sediLrtr in i l ; ia l e l leziuni i . i l fo l tnt ' lo int 'otr t l t l t ' l r r r l t ' r t t rrlrotn t1o i i i :nihazri. ttt l i i ncrvi cr:i ir icni 'q1ni, cruli: i1,i (f1'{ ' i l l rrrrl i l .rt i t 'rt l . rinti ftecyentil), i : lr nlt lr ior afect*rorl l]ervilol ci ' lnicl] i sc {rtrro l i l ' t l i t t rrlr 'r intcro-postfl ' ;or, f ie ri in srns }ostoio-alltotjoi ', oll plirxlet' i 'r l i ir i l ir l l , i l ir ' 'rrcrviit) l; c1':1ni{,ni rl in fosa oerebralai mij locic, f ie I ult i l tt lol i j l l lr l( l lr lt l , lr l(1r r : r i 'T i crarLioni ( IJ lomorrt i s i cr)1: tb. , 195i ,c i ta1 ide. I logcrf i i i 'o l r rJ, . , l l l l ;1rr 'ir i l i te situt,ir i i , i to l lot : l io!: ita l i unul sa'.1 l i l lr i : i l l i l l l l i n(l lvi rt it l l i{f l I i { i, ' i) ir l lr ir,;,ontloittterali, (Arsol]i 1i col:r.b." 19?3; I loiler ir i c(trlJ-), 11){i1i)
l iult ir ;remc, itr tvolttf i i l si ldrotttt ' lol Gr;lcirt tL'-t srr sl)rrr,rl( 'rr 'romni: dc lt i tcltonsiun{r intracrtl l t iat}l i , cero iw|1rc ndosea1,xl '(! iv' { r, \IItr l,r] 'r '{ lcruihri pi1:iht', r::u'o aIl i ie m:i t. lci;rtrnc. l l s i11{1ro tl lncit) 1r'rt l r ltr lt.rrtri"lr::r i rm sc i lcrrla'azii, l lel lt le t ls ltzi iute lt, tr i i tt lr i lot ' senzitri|rr sr'rrzrrIi ir l{ r
r r rotori i i l tr ' :r i ier-r"i lxialr.i 'u:lo: t i et,olttgtt-: i tt i s i iztl toa ,t ictor Cor{:i.11 de h(ntib,L.i i.
: : . ) '1 ' t .mori le: t t r tnor i o l l ] 'N s i l { l t }z\-o1tal i r r i r rs i i ; i l r , lzr i , ' t r i t t i t r l t t l I
Lr i ) I ror i c i i l l l r I ]ct d i ] gr lccl | i ' t l in: i i l ' l lc t r i inai , j { rs s; lL l r l l { '^ t l r , r t l r i I r ' i l i r r , 'volb: l de tumol i l inola,r i t rg ic l r : c l to i t l l t lo: tzf i , b l l : r l l t r l r l t r i t t l t i i . ( l r ' lc t r r : rLl l tccventc $i i rb t r r l t lof i l0 a, t t r ic :u l l l t ' , l l i ' lz i t lc . r i l lL l r : r l ( r s i r t l t ' l r t t i t r l r ' l r r i ( i r t r l ' ". r ,b i cpi lc l io:rmc alc : j1)af j i lo i ' bazalo posl t ' r ior t lc i t i r l lc r i i lLtut t t i l t r r ' , r t t i ro:r t r r ' 'i iml lsart l r l l t r lo : l lo l inolar ingt l l l i , l l i t r ' ( i i r tv l l i l ( r lLzi ' otr l i t i t t l l t t i l r r l iv . t r l ':ofrr f l l lne), 1r scut i t 1 i tumori le 1; t i tn i l i l t : l l l i r t t lsc lot l l lL,zci ; i l t l r ' l I I I I i I i I : , t ' I r r
{ l i l r rosarcoat lc, s l lcoimc qi osl ,cosl lco: t t txr ) ' } I r l i r i l rcsint L l i l t to l i i t r l t t t t r t l ' 'lni I i tr.\taclri(), ir, lr: }nlalului s:t, l alo glandclol sll ivlt l t, ({lrtr;1'rri i l ttrr ; i rrolrrl, ,1 l ) l i5; , \ r 's t t r i ; i r lo l l t 'b. l9?4), l l l i " r tLrr l ; i t t t r r tot i l t t r r i t r I l ts l i l t ' i t I ' r rkr l r r rzr '
r l l l t r i l r i , r , i t l t i tu i . l r l i r l l l r : r ,a lc r l i t r c iu (r i t t txt tno l l l i i l ) ) l l l i ' s l l t l 1 t t t I r t t t I r t i t t r ' .i i i t r t i t l l l r rotr , tcoi l ' i l lo, I , i ' ( ' ( r t t l t t . l i r l in l r l to l ,Lt t tx l r i l l l0 l l l lo l l l l l t t t t t t t l t t t ' , : r l r r
r l ) i r , I i l l ,u l t t i l5tr i r id r , i r t igest iv ( , \ l ;cni 1 i cohlb. , l1)74; j i r - rgcr '1 i t ,o l r r l t . , l l l t ; l t ;; { i r , ) in 1i [ . r r r t t ln i r ' r ' , l l ]51 ; { l la l l l ; i i ro l r lb. ' 10{ iL) .
\1 l ;s l r tntgt i l l l tc l l t t l , t l t t l ,c t ' t r t i t t t t s i r t t l t t l i l l t t t l t1o l t t r r t t i l t l lz l t : l l l t t t t ' t ' l
,1 '1, i r l i ' r t t l r i r l t ' , t r t t ' tL i t tg i t t l t t t t r , , t ' t I t r I t I I I ' t t t t I i l l { r . j ( ) r I { 1 l , i I I I I j i s l i r t l t I ot ' l r ip i l ' l r l r ' ,
r r r r r r I IoI l l r r r . l r rzrr l r , , i , t t t r tot i t l lot t t i t r t , , l r l l ts l t t rxr i lo: t t t t l r , t t t i i ' IoI I r r r I ' t t t t l l l i l r l r ' ,
' I l I r , r ' r r r i t r r ' i , r ' i i t r l r , r : r l : t l r r i l tor l t l l . i r r { . i r . ( l iog( ' l 1 i crr l r t l r ' , l l l l i l l ; \ r r i l ' ! r l I
, o l , r l r . , l l l i j i l l ) i 1) .l t ) ' l ' t tu l 1t ! l i :1t t l . l r r : t i r i \ ! l t l t r l r l tzrr l t t l t t t i t t l t t i '
t : t ; r
,11)u' l t ry l r r l i t t r r i t ' r r : : t t t . | , r t r : l t r nt t r l t , t nu l l r . l r i r xr l i ( I I I I I i r | | | I i ( ( I t r i I I ; r r r r u. ,l l l , '1, , r ' l l l l r l I I i ,ogr ' t ; i r .o l r r l r . , l l t i ; i r l ; . r r . t t i r tur ' i t t f . t " r t r , t r t : r ' r tnt \ t t ( ,1( 4 i l t t ' t , i, ' . t t l i t l t i l l t t nt ( l ( is ' ' r ' . 1 lJ5: l ; . \ t . f i r ' l i , r l r r i lb.r 11.)7,1),
r l t ( l ix l i t t t ro:r l t t in l iL jp l r , ( , rL lo( . l l iz l t ( , bazal i l , \ rsclr i s j f ( t l l i ) . , l1, i , l ;l j , , , r | { , r l l ) . . t | | r i9. / .
ct I i rr l i r tr , l I lel t , rzr:z, i ' i lc lr : rnLLlt iplc t l r , nclvi cr.anieni 1i l tol , tru.ditu. i , i l r l tr r i r r , r r iv i lot i i rc, zr l i rator"se, c l i l ter ice i .a.) , care pot f i nneol ' i ( io l r r1 l ) i -t . r l I l i l l { ' -
l l ' . isl,rr roit lrnorLte fornto partic[ia.r 'e dr: poli la'Jicu]orcn.ite t.rir i i iglor l , t r l r ( l r r i lLr i r r - i3rule, cn al :ect i l , Iea bi laternl i i (u leor, i predaminal l t r t l i -l . l , r ' : r l : r1rr r r l l i r | r0]ot IJ?l1, tu- }etool i i ( ie rrei l i et 'aniel i s i a oc L1l0t l lo l r ' , r i jo i , ,, r r , I i r l r r . i : r I i r r r r l l rur l i r l l -c i toJogic: i . ru genne I , l l IG cle ] { 'z iu l rc t rcr . , , ,_. , ln1r ' ' r r t . l l i [ : , s i I r r r r r -o l u l ie far-o|r .b i l : ] , ( I r i s ler . l9 i6; Ke1,z s i l : {o lderror" 111i6;\ l r r r . , r l , 1 i I l r r l r i l 's , 1 l | f i5; l lavt , 196?; l lopor ic iu t i Pxsr. i r " i !1, !1) . Fir i l t ru,r , , , i / : l r t f r i r l r f ( )p l l r i t i : i lutnr l r l i r , ,s inal l ' { } tnul lu i I r ishtr : , r , { I ietz ; i f { { ,1! l ! t ier ' ,l ! , { ; ) .
l/ / I r lolr. t i tulrtrt t( l l( u,nqhi p ctri <,,terth el ot I l{}t i lrtt.rni jn uttt!t ' . ' : ttt l, r t i r , l t , r l i , s i lcz i r rn i ?r le pcref l r i lo l I I . X, i i - \ I
( rareol i , r i a le hipoglo; I i l i i i ) ,rr rlr, 'r r. lr i |r ir l t,niori (nlcnir']1^io:)rner tur] oli c}it lermrli( lc. glio:rrt i ._ere-I , i ,r r . lr lrrrrrrrgioiln)(r arl,{rbol(}tse: t l lrrri]r"i :r, lc pilr l i i Lltelale i i !entrir,; lnluir l 1r : r t : r lc i r , i r r r rurr i r i r . r ! : ionlus jugLi l t r , turnot, i mettr t t r t lce, t lent . inoir . i t ;e i i le' | , , r r r I : r l i r r I r ' i r r r r r r I r r i , r 'agr: Iu i , : i spinalului 1. , \ .1, &] . . i | * i ( j id i . i? r / i is l icr : 1 i . , : lc-t ) t : tnt i t l t ln int) t i ; ( de ( i ' i ( rC . t : ( ,ebru d p ' i . l tat i l , r r t i (Alajolani le qi r : ' ; i r t l i , .r ' r l : r : l i , r , t l r ; i r :o lu l r . , 1! i69:1rsel l i ; i r ' i ih l l . ,19i . i ;Polrot ' ic iL is iPascr, l$31).
l"l;1.)- t[{ 'cttunl inlranelraxialtr cu loziu}i lr}ult iF}c dc nerri eratrirni.
| ) , ' i i trtI*ttrttrIt rIts{ti | | |!t 'a tLt: ttu,ttclt i ccrebrctl,
\1, \ i t t , l t , r r ntr l r lut lb( i . t '
/ ) ' \ i t t , Int t t r t l ]nt t ln!ui i .q1L ( l i l r r i ] o i t , ,U, i l lentoul . t i Scho{. i l ) , tu+' . , t t t I t , , , r t r t I tnit ).t l ;t ' t t ul ltt i Dlj ir it.t, :t i ,tt l ,ro'ttt.t[ i tr ltfuLitrr a[ !ui, ]Le|/tokl-I ' , tt l lrr l l t,: lr ' t i ttt xrrtr. h utt i;t lr:t1itr, oltr:t,nir ittferioard) .qlr tt t iduae selri,, logict,r rlr , l r rrrjrrrrlzi i i trrr I iell iJr lcl i l . ie a oI)1r'ri l i l teta][ jn1'eriotr.t! (r 'esi.x,t. l intli . r r , | | r i , t i rL i l ( ' l r , i l l ) i ( i io l l t l l i i l l i tatr ! i r lc i Lul l lare, i . r isc l f i t i i r l ]neor. i : i i ' lc or ' r r i r r l l r " . iL. , .1 r I i . r ( ) ( , j I I 1 i { . r ie t ip tahrf fu (pl in lezi i r lea }relgi ic i i i r i l ie i l )r ; r r f r l r r I r r l iz i r r i r r r i l r r tc l l t l i a, l i tnbi ; ,ou : r l i . ) f io s i cu fasr: i t ,ub. t i r , a i , , , , t i , r i t i
l ' . , r r r r i i , , ' ; r l r r r r r iLr I rL i i r i t l r ip i igk)r l r lu i (p; i r i icz innca f i l l ,e lor r .ar l icui i l . ' , , a lo:r , , t l r , i r r t , r r i | r . l r r l 1r ; r ' i l i r , : r -hrr ]Jta| i t l i r :g i l tnea i - i rL lbar i para rr i t r I i : r l i i ) .I rL l r r l r r l r l i t l iy , t : t t , i t u i r r i lL l t l t r s i ix l tot t r , ] - . t j t i l tz j l tner l at t r l l ' l r t zonc j r r l r ' t ,o-l r r r r , ' , r ' r i l l l r r l r lcc io 1i 1_lrrrr l iz ie l r ib, t t r la l : i i i pelc lh i i I I t r ipr in l r . l l tz i r rr r r r i r r ' loI r r I l , r ' l | s l r i t [ t I ( : l ] l i i ( r ' io: i l 'c) .
' ' I t : ; r t l t t ) t t tu l l i t i l r i ' l l . i : : (s i l i (h.oi t l l t I nuol0t i lL l i l inr ] - , ig1111) i . , ! rs l ir l r , l r ' r l r ' ; - , i r r r r r r izol l r i : : i l t r r rc lctr l t r i l rn l r igrrr i ( I ] i , X). t r , l ldur i r selr ;n]r , : t j r ,l r r r t r l r l r r l t r . r r r iprr l r r l iz i l l ' r r r i r rgo la,r i r r go-r . r , Iopa l : i t i r r ;1 . i ) r t l l l l l ( ) r t i . so,r o ' , l r i t r i r t r , r l r rz i r r t t r , l r i r r tu i r l lJ i s i : i f i t !c ia.ul i i l l t i n[) i r ]otrr l l rn i ( , f l i l l l r l r rI r ' i r t r t I l l ' l f l rz l r l , r r l r i | r t l i l t r t tczl j s i / r l l . r r ( ) hrr i i i i ] r i l r r r t ,s l r ,z jo 1t . r ' r r r ( ) l : i l , ' i l i I r ' i
t r r tLI l r r | r r I r ' r ' r r l r i , t r , i r l iz i r r r l s i r t r lntztr l l t r . i l ) t t i , l l l 'o l . l t l r i t t ( l ,ot l r s i l , i r ' t r r . ,l l ) t i ) ) . i r r l r rzr t l i l t j r r ( , l , r t f : r i rsoi . i ; r r l l r i f , ' t r lLrr l r . t r r l r r . lo l t - r , t l l in l r ' l i t , l l { , , r, , , r l , t t l t t i r l r l i l i r r t r r ) , t ' r t t l i r t lz . ; t r i r , , i r , , r t t r t l i r i ) l i l i r r t t ' i . l l t t ru i l i , , t : l t
| 1 l ' \ r ' r ' , I ' l t i l r )
I :14
l ' , ) Ei t t l tot t r t l l t i St l tntr l l 1 tut l tot tu i t \ t l t ) :11) int t l ) r r t r r l r t i r t t l r lc lczt
t t t r i i t t i tc l r r t t l t t i 1 ' ; lgrv s l t i t t l t l r r l : l l i l l ( l r ' l t l l l i s l r i l l i l l l l ( ( ' t 'sol , s l t t l l t l i l r t ' r r l t r t
l r l l i l r t l r r lc l t ,k, t t t t r iot t l t i i v : r ,1o rr l r i t t ; tL Err l r t i r t l tg i t ' s t l t r l t t l t l l t r t ' iz t ' l tz ; i l I l l l l l l ( )
I t t : r r r ipr t r . l r l iz ic VOl i l l ' , l i r i , i l l i r , l r r , i , r 'z i l t , r ' \ 'ocale, '
s t { , r l lo( i l ( ' j ( l . ln,s lo j ( l i i r l r l t l l l i
' . i r i, t laoezului.
4 )-ELnrltontrI lui Jotl;: 'rttt ' ( '{ inthomul vag'o- s})in{} -] i ip{ )sl( 's
i( ' ) irrlr 'r l
l ret t { l ; paral iz ie uni lateral i i a rer\r i lor ctanioni IX, - \ , \ I ( t i t t t r t t r r r
. l ir lrLi ) ,si \II, le cal'c se poatc asocia o helniparez'i t()l l lr i l l ir l( l l ir irr
tL in i l [e i r r ' ' i Alr journirrc, ]935, c ta i ' de Loeb $i ] Ie"Ye], l l ) { i - } ; I t I t ( I ( ' ( ' I I I ' I ' I ,
19 6i ) .-{rn aruintit an1,eriol ' cir sin(lroan}tlB lui -{r-el1is, Srhurirl l i i i ' lrr( ' l is('rr
l r , i r r t , cel t l la i adeset j de or ig ine l }e l i iet icr l " i I l | ]col i r i .c ' r t ' i i l i l r t r ' ( ' i r l r r r l i ] .
cl€ l.ezultinil dinir.o-leziune l]| ]}el]-i l( ' r.enpo.ti\ i h lr;r t. lul g]i||I] ' i i | ' l | |) l( l
DoBteri{}lte san al sr:rl iuhli rctlunti l i&ll l lr r ' l1L'le (ir l 'r l l i i lr r ' l i l '(r s' i l l l I) l (}
i luso printr_o ati 'gire br lb:_' ' i i , elc rezulti i dir l6i,ni ir: i ir:r.,srt rtu.l,tttt
l }Jedsebi iu,noruitl, intrlr, SaI etitrabull-l i tr e , i i nttrtrtt i rrl l( 'ol i ( l i tr l |zirrlr i
i ,usct are,8:lre realizeaz:L l ie sLrferintc pnr nulleartl, f ie srl l i ' l i l i l t l tr l l l Irrlrrrrr)
pirr nllcl6,rl ' ,1, ci l i aie altor folrrr.L{iri l , i t i irr r ' 'ertl ' zt,)l}c, ' frel
oc (r\ l) l i t 'rr '' ,rsocie'e:r, si t ie alie sinptone. rlupil ' 'xl ir l l .rr ltnri lt l i t-:rr tc' iot'( l ' i i ;rrrt1;lrr ':
rgOi, !os"" ; i cohb., 1969: trir-rpor-:ir it si colttr" 1llE0; I 'oltrrl i l irr ' ipaser i , lgsi) . fn aceste 'n l f ime (r i tz1l1i n[ se mui lor tc lo l i r i t j t 's i t r { l r r ) i r r r r l
t)rue. ,,cla!icoil ,\voll i .q, Scbmidt sau Jtif l isoir ' ci rie fallt ( le lr l irutl '( l rrl( '
, ' . t io,, l ' i io,ttu".n,, 1"l lscli lalc bulbrre asindlom rctr., olir-lt i \1-it l lctt lrttr ' .
r;espectiv sin(lr{lrr interoli ' l l ) (I 'opovicirL si |trsdl, 19El; Jlrltttt i . i tt ' t.o lab. , 1f180 ) .
: i i 8 it i .t i t ontr1 lrttt i 'cl ' ctl tttttbultri. o' intlrorttrl l istrt ' i i [tullnrr Iultttr l"
sittt",rc,niu,l, ' : 'et] 'o-()1.i1:qr (uL l.u,i D, jt, i ' t ' I ' sit ' l tuttttr l l tr ' [ 11-'1[lt ' ttbt:r '11 xrrrr *rtr
, i i 'ornt,t i l arlcrd (:?rebelodse Ttotl, ir inlr:rioar' ' i i ' c:rttr tetizr::rzi s.rir i. l ' :r i '
llil rurlltoaleLe :'"" - .!.)r ' ,tc,,r,,,Fi Parl ', t:J lezitnea : e) IJemianestczie (sau ltt lnti l t i lrol
1;ezit) fa't iali^ cel rnaj ldesea disoc,iatr: (terrno-algezic[ ) ; i Jocalizrtl i i rrrrl|rr
"" f r i l i i i " . l tot" , , l c f ta lmict ih i ; bt ' Iu l l r r r r i r i r l ' four l io .1 i
t lc r l r rg l t r l i { i r '
{ i ,tr.,t i . ' , i .*,tgtti1) 6i ptrraiizia cotzii .r-ocll lc ; t1 Siitdrotrrrt l Ultruil 'r l i( 'r 'rrrtr ' . l
l i i r r t . r " , l ,a i r i t " r iu i re l l coloanei s i tn l , r l i rc r l ) Si t t ,L ' . r rL ve. l i l r t r l r r r ' . ( l i r r i r r r r r
L, , r i . i i , i o- l , : i t i l i ln nasc, gret , , , r . i q i i . ' - , i . . r r tLr i i . . t r i r t r : rnr t t t ' , ; i . r11r ' sr t r t t t r r t ' t t r t l i
l tu ln l 'e: e) l i imis in i i r i j rn 6161s11sLrs. t r l I , I { r i i I I I I I 1 I i I I I I : t l l t I r Ltr t l t l l t t t l i t t l i ' t ior"
- ' f , ) t Ttu,r lea oPi,sd: I t i l )o^ ' tczi" r l isr" ' i : r1r ' ' t l r l r r ! r ' t l l r .z j ( ' i ' { ( r l r r r : I
r r r l t ' rca respi t , l , i r r t l fn l l (nu tot t lcrLt t l r r l . ' i l i111rr1 i ' , r I r ' t ' r I :L1I ' ' ' r r i l i r ' i t ' t r r r r l "
' : r . i i , . l , l , . t i j r tat ' t r ( l r i l l )2 r : ' ,balr . l l iU;r .' i j ,s te l " r i r ,otrnt s i i iecnl to : l ,c i r r i , r r l , r r , / / t l , , . l ru i t , t i , , i t , t l roDtt t l t r i l t i
l l : ol[cttbt"t ' ! l (-,.ozi Popoviciu Fi ] 'r. ' ir l t l ' I l lSll :' l "orntu t t l t r ; t i r : r i ,1 i1r icr i ' r l l l t 1 ' l l l l i i l t { )st r lcrr ' r is i t t lc f \ i r l l1 ' r r l r l ' t l i r r l$ l l
"I r , l l l r i r t i i , l r t i t i s11s.
i i i tu l rot t t t t l t 1 l 'uL[ t ,n l t t ' r1 ' t l i ]1 i" ' i t " " ' l ' l ' t ' ' t t t r . l r r tx l t :
( r l ) I ( t r r l i l
, r r , , l , r j r , l t ,z i l r r r , ' r I r l i ( , lc1l1l i l r r r r l i iJ l ' t r . i i r l . r f i i . t l l l i l ( l i i ,1r i t r . I i t I I t I t t i t ' r r l ,
1, , , , t1, , t i l , t ' { r l l l iz i l l ( i l l l l s i rn l tom' i ' ' 1 i1r ' \ rc} ] is l11r1 \ I rL i , l r t11r ' I ' ' tLt | i r t ! I t t l ( l l l t t
l , , , i , i t , . ia, i t , , , t , , " i . l i t , i ' r ' , nrr . lL i i 11. l i l r r r l r r r i s j r , i r r l i t t .s f , i t11 I r r r ( i l ) r r ( r r r
l r , : , l r l i , r r r i t l iz i l l r l l l r r l ts t r l lLrr t l t r r ts i l l ( l l t ) r r l l l ( ' l r l t l ' l i l r l t r ' i t t I ' ( ) t t t1t I I ' I . t I I { I ' ) f r i | | ( i | ( | | t | | | Il r i t l r ,s l , l r r r t l l tc t t r r is , t ' r t l1r l r t l ts l r ' t l i t l t 'o l l i r t t t i l t l t t rs lczi t " t t t t t i l r t l l ( ) r t l( l i | r t l { \ i i t ' l l l i l l ( l l lot t t r r t , t t r i ' i : i ( r l l l t ) ( r l ( f l |z i t t t to l t t t t t t ' l l , t t l t t i l t t t l l r i l l t t t t '
r r r sr . l t i r r r l r t r r , I I i t | l l , l r r t r ; i l t r r r l r t ; r r , t r t t l i r r r l tot t t r t ' r i i l r tL l r t t l i ) l l l l r r i | | I ( ' I I I | | i I I
r l : r r l l l l r r ' . t i r r i , r r , l t i l i r r r l r r r t t t t l l l t t t l l ; r l r t t t r I ' i Nrr"r ' r ' l l ' ' ( ' f l i r " l l l ; r ( ' r ' r ' l l
T{ i l1r ' r , t r I ( | r I ( r I I r i i , ( , i t l l , i i , v i t , r l r t , l r l . r r l t ' l lz i l l t r ( ' i l , l l , l ' l , ( t t ' ( ' i l i ts t ' l , r ' i I l t t t ' t t l l l r l r , l l t t l -i r r r l r r i , r i r r , r ' . t t 1 l ' t r tkr t t t i t r r r ' t r1rr r i i t t t i , I r r r l - i i ' I i , iu lJclnl l ( f lo l ' ( lo.$f l lor i t l l i i l l r lL i
l r r , i r .* i l i i , r r , l r r r i l r r i l r r i ( t r igr , r r r r i r t r r l I i r l r r i r r i r ( lc obicui iudomll l ] v l lgo- i ip in l l l t l lr . : r lo Io l l I l ,o l )u1; in &1, ins; cor 'Dtt l t , l i r lotrrL s i n lLclei i vest ibul l , r i s int l :o{ l , r1]{ \rrrir.r 'r,srr,l, i , r[c irndc rezdlti i r in ;rt:t,tr ' ;. i ttdt om vestihulo-cclebelos, ctl m&r(!
r , . r I . i i . r r r r r r i - i ,s inorgic, hcmiatrnio ! i l&lcropulnic de lar tca lcziutr i i l
r L i rz!)r I l r ( , i , l l )07 ; "BodechtPl ,
l96i) ; (e; l indroamole bulbare nuclc: t ' t t '
iz,, l lrk' (Avcll is, Schinidt si Jackson), care in mod exceptional lezrl lt ir ';i;'"i;f ;, :'k'*;;;' *r itl*iire o"itnlirau ; (r) sin{l,roame },iind pe prirnr ' l : r , r r I . r r lbrrr ' : r r i r l . , scncibi l i la l " (Saradi iSvi l i ' i SIr , ! - , \ t -cvcl idze. 1960) ;l r r l r , . r r r i : r , r r , , . l r .z i ( .a lLerni l ' rmo r lgnzi( ' i r , pc fa l i I i pc hornicolpul opus;r.rr lrlrrriri,ttt'slczic termo-:]lgezlca! contrulaieral:i, ; cu tulburriri dc sensibi-lrirr,lr { r'r'tmr-it lgczicS, hilatel'ale pc faJi, iar pe cxti'cmititi doar tle pa'rtctt',,trrrrii ' lozitrnii i 1g1 Sinoro:r,me \Tallenberg ii,ri, tull:urili^ dil pa'rtea cor'-,.rkrl r,,rr,rt,lc (I1liJu, 196i, ciir-r,t cle Popoviiiu qi Pascu, 19$0) ; (h) Cazut'i, r r I r r l l , i t l l l r i i l t ' s , nsibi l i t r r , t , b i larerah l lc fo i r ' i , pre"uul ' i ' 'azt i r i cu tu lb l l -r':u i sr,trzil,i l 'c bilate-ra1c, dar lucitlizate tloar perioral, inciusiv pe 1imb5, ctt: r . : r r lz i r . tSr l r , l t i i cul{r ,b. ' i9G;, .
' t,,,riit srnttolc,ltice de sindrom lTattenbtt'g mai' entiinser. cu interesa're fit ) , r r l i r r i , ( l${ ' l } ) 19i?; Schol j t g i cohb., 1965), care. ast c iazS,. q i sufer intr li,rr, l,.i lor' 'r 'r ' l lnicni VI li VII $i chiar alectarea fasciculuiui piramidal (clt1r'rrilrr,rozi'1, controlal,cr:t'lii), sau forme in care coexisti' qi trulburdri vaso-r,r,rl,oi ii (ctr orractci' :tltein) fi l lgii hcmif:lciale'- &sociate- tneori cu algiilr,,rrrir,rrr';rrl ' it1c corti,ralat€rale (lsch, 19;7). S-t relat-at sinlrcm'tt' l sub-bulbal,l t t i ( );alrli i (crL llpocstezie faciaii, siadrom cerebolos qi Claude Bernard --ll.r'rr.rl rl. rr,r,r:r:a'i -palte, hemi:lnestezio clisociati qi eveltuaL hemipa-rezri
1 r i lr r r r r ir I rr ii i rtlrtrrilaieralS,, dar ldri atingerea ncrrilor , I-XI)' lchol'lt.i r',rlrr,lr. (l1ili5) qi l?0poriiciu 1i colab. (1980) au
-rclatat,. qi sindroamr!
\\ rr' l lr.rrlx,rlu irrslil i l;c si de sintL'om Pa,rinatd' 52111 {le paralizia perechilt-rt'I l l r . r r , ' i l \ ) i i t t ts{r . i , Ic l ' in l "z i :Lne; i aar l . rc i |crc l 'o l .Jt l ' {c supe'r ioar( ' )s, ' , i , i , . . , , , i . , . - i i r l l l r r r t r r r i asocjr '1e r izualc de r ip uc'" ip i ta) . cr t hAm!anopsir ' ,r .r' i lrlr coli irLlii satL alcxic (Ilcyer si col*b., 1956 ; tr' irchor
-$i colab'' 1961)'
li ) flitrl.roirtu,L Lui lJabinstii_Jageoltc sau' sind nmll hemibulbttlu'i' rut , t , , , t . \ iu, l r , t , ,u l c lqsi" , l I 'L; B' ;h inRt: i - \ -ageattc sr 'arac
t e l i zeazi t -, . l l i , ' f , ' , , i ' ru i r , t t " rn i f tnr . ' r : i s" , l l bcmiplegic nohtralatctal i ' p l in l l ( ' l l r i
' r r r . . . l , .zrr ' Ic l r , r , r - iu lg"zic l i p, ' benr icot i :u l ronlralale[a1- \s i pe. l le l ru lafa ] l )n l '
Lhr,rr l , r , I r I i | I t l isrncl t i r ' , I l ,s jnergie. l l l teropu- ls ie ( ipsi laterx]c) , -pr l 'n
somlr i r
t ' l t ' i l :u ' ' t i u l r ( ( , r ' j p l in Lerrr ipar l l iz ie l 'e lopalaLuft . . tu lbur ' ; r r de ocglur l l r t '
. r r l . r , t t I r i tc i i J l r iu l ' : l l iL l iz i l - l , iphl l*1 ' ' Ia l i , o corzlr vocalc '
7 | sittrlrotntr'l lui C estan - Chenatls este asemd'n5'tor cu sindrorlltllt , ' , t i , , r , i t , * i . i N, ignnrt , ' , i r r labloul c l in ic asoci ind totdPauna (pe , l in ' { i t r,' i,,rrr,.rrilkr r,cestui sindrom) qi semne datorite tnei - leziuni * nuc.toulll l
r rt|l)i*I , l0rlpoctrY cu o par:]i;ie. ipsilatera15, a I'[]ului palatului \i 8' corzii
,\ ) Uirul,t otnt+I, lLutJleLtIL[i ltt'i Dei'tart se caractelizea zil' prin crizo vcrlri'
s i " , , ' i "1. . r , i i " r" ' i r i , i * i i 1, t , ' ' , i r , i "n i t lc 1ar l ,c:r lcz iuni i ) , n is l t ' [ inrus or izot t l * [
i,i i i ', i i ' i ',5i ",' it i?,tlt $i/iau rotatjor)' l iur:um 5i plin devielea braiTelor sPro
l t t l , ( ' l l l ( fz l l l l l l l .
l \) i l in tht r u nt,tt l e Pottt itrcI ) f i i txlrtn ,tt l ht,; "i l l . i t.t(t)d,-(i l .bld. r.r 'rr l izt, i lzri,, solrriologic, o lxurtl izltt
r r l i r r , I r i , ' I r i r t i f l t i l i i , i l rs iLulr ' r ' r l l i , inso{ ' i l , i i ' , rkr o l l icc i , (10 l )n ' l 'cz i l ' l l { l l l p l ! l ' l ! l lz l l r
l ! ( l
t t tu i l r l r i r r l t r i d l t ,p l r rx l ' r r l t t , i l l l r l i l r lopir ' ; l i s l , t l tb ist t t ro l rv( '1 'g( ' l r l r , l ) t 'c( l l l l r 11lrlo o Itorttipltrczii s:lu Ltotttil lt,gir, r.ottl,t ltl lttcril l?l.
l!) lli,nilrotnul, I'or:iLIc irt,lrtior sau sindromul Itr,i llot:i.llrt-llillurrl-'( irLbl,a: se ca,racterizeazS, prirr prlldizia rniqcSrilor ooniugatc itltr ttt ' lt i lot'i l lr 'o palirea leziunii (,,paralizie conjugatii direct5,"), plin paralizitt, lrcr vikir'(.I ' lLnicrri YI qi YII, iar cind leziunea depLqeqte zo ele dosi:tlo alo l,lrl lfi i 'rrpilrc qi o hemiparezh contralaterali. Se poate asocia ,si o hemialr('Nl('zi(rrlternii facio-colporald (facial5 ipsilaterali, fi corlorall, disocial il lr 'tl iro-rulgozicl, de partea opusi,).
3 ) Bi,ndlomul lui. Grenet satt ,,paralizia sen.zit'it:ri" tnutt,ci;ltir consf iirLirtl,l-o a,restezio faci:lll ipsilaterald, (de obicei termo-al61ezicii, tlirl tttrt'ot i:i globali,), ;i i l intr-o anestezie pe h.ernicorpul controlateral.,{t[r'st'rt, slrusociazl o paralizie ipsilateral5, a rnuschi]or mastioatori ;i ttn hcntisitith otttr'orebelos ipsilateral.
4) Bi,ndromul lui Raymand, - C estan (sau' tiptttl str'perior al sitdro'ttului lui tr'or:illb ) t'ealizeazia, semiologic, o paralizio a miqci,rilol corlitl$Ltt"rr,lo ochilor spre partca, leziunii, alterarea sensibilitiii,lii supelficittlc r1i lrtrr-i unale, semne cerebcloase (ataxie, asinergie, dismetrie) $i milcr:,l j (lo 1 ilr.,rtrbric" (atetozice sau balistice) la rnembrelc contralatoralc.
i ) Bi,ntlromul lui Gelli esl,e asem:inXtor cu sindromul lui i\l illr,rrl -( lubier [i cu sindron]ul hLi Raymond -Cestarl, dar reaTizeaziu 1ri' 1t'itrtlrlan o leziune importa,nti' a perechii \rlII, cu snrditate ;i cll r','rt isii,plcc1111 Ui cn lateropulsii de acceaqi parte cu leziune?) Ia cnrc se iuso('iir,z:il)l,r'ftlizia motor-ocrllarrr1ni extern qi paralizie faciali. In cazuli]c cu lt'zitttt,rirnportanti, a nucleilor cochleo-rrestibulari' se impune diagnosl,iclll. (lili"lcnlial ct rln proces tle unghi ponto-cerebelos.
6 ) Si,nd,ronul lui Pierre Mari,e-I'oi'n saw ,,hetni'pa'reza cerebchxr:tir"u lni,' Marie ,s'i Toir (,,sindromul latera|') inminunchcazS,, $cmi('|)git' 'lulburii,ri de echiliblu ipsilaterale, cu clismetrie, tlisilergie $i dindill(l(x'ollrinezle, rsi, exceplional, semno piranridale conl,t alateralc.
7 ) Sind,rom,ul ntioclonic al trunclzittlwi cerebral &l lui Gu'illain, llol.llrtt'I,i ilertrand, (1933) Bau sindromul posterior aI calotei (Sohotl
'l l,6?) se cara,ctcrizeezi, lrin aparitia unor mioclonii velopalato-fal'ingi0ll(' 'rrtlcsca limitate tloar Ia nivclul vilului palatului (',nistftgmus a1 r':"r"hrhli"),r[lr susceptibile si, se ext'ind[ !i po mufc]rii felei qi/sari ai lncrnlx'nlllisr perior fschott, 196?; Popoviciu qi colab., 1.973' 1980; Popovitirr 6iI ' r lscu, 1981).
$ ) Sindronnr,l, lui Gasperirti, cupriticle nn con1,cx1; ,semiologic lrtlrNl ilrrjt riintr-un cleficit al neriilor danielli' V' VI qi \rII rle o 1:altc, rriitx'iit'tr rr hemianestezic contraleter'&l:t tcrmici, si durcroasii ('I'roncorti si l\'lottl,rt-t r : t l i , 1960).
!) O.ltalm,oplagiile i,nlertt'1t'clettre ,li lost c).prlsc dc noi llnl,cliot lir
1rrr,l;ologia sistemclol oolrlor)lotorji.
O) Sirulntu.trn'Lc pe tl,nn<ttlure (nte;c tr,el tr,lice,) :I ) iJ'intltou,u,l. ltti lfr:Jxr, si.ndrunnt[' Ttr u,nr:u'lctt' pr.',r'rr'nttt],'iatt, utrtlt'r'1,
' i n rl,to trtr.t,l, d,( ?itJiat pttl,tr,naufttr (srr,tr, htrniTrlallia (Ll,(t'i1.i1' sILpo'iorLrii' ) At\
' r r , t ' i l ,c t ( f f iz( ' r r ,z i r , l r l i t rh ' "o prr t i t l iz i r , i t I r ' r t t ' l t i i 1[ I l [ - l t i l )s i l l t l ,or i l l i i , l i l c l l ro no:r . tooi l r ,z i1, o l tor t t i ; t i t , t 'ozi i , st t , t t l t t ' t t t i l t l lg i r r ( ' { ) l l l r t th l l , { r t : t l i i , . . l 'a , t : t l iz i r l , pct t ' r ' l l i il l I r ,stxr l ,o i l l l i i l i r ,n pl t , r ' { i r r , l i i 1 i r , i t cs l , r r ptor l t t t i i i , l r t i tL l lz i t t t t l i t , l i I r t ' r 'kr l t I t t I i t I r t -l i r , r r , , r , lc r rur t ,o l rx l t r l r r , tu l t t i lont t r l , i t r { t ' r t i l l lu l l t t r pt ' i t r l t i r , iot ' t t l t t t t 'z t ' t t t ' t ' f r l l i r ' .
A| :t 'i
, \ r ' r r l l l r , r i laI i / , r i r r r r r l r l l r / r r ' l r r . l r r r r r , r l r l r r r 'n l iu l t { r , s iut lnntu. l \ l tht t 'trnrl itntltt l i tr. l t '11tnrtt lu.l I ) | t I | | | t t ' t | | t t t . r ' tt prtt l l l izit: 1,o1;it l i i i t l)cr(r(:hiir l r r l l l r l i i r l r , l ic i l nr{r i ,o l i l l r r tctrr I r l r ' Ior ' I I i ' l , i r f t r t i r oplrs?i .
ro lnni i I i /sr ,u rrrrr l isrro 1r l ( i r rot , ico (Aqgin, t r , ,s i Vrr iu, , 11) l - r l3; l . )01xrvioiu, l { ) ( i l i Il 'rtyrviciu f i -^Dgiil,r, 19ii8; Aflgilur li cola,b., 1975 I l 'opovi0itt i1icol t l t . , 1980).
II) Afecliun,ile inJec,lioase s'i imunoalergice d,e tntnah,i cercbral (polfur\t-cirfitlitels de tip inferior sau superior, rombcncefalitele, sclorozr rnull,i-yrli"l, qi afecliunile demielinizante inmdito) produc variate tablouri srrnio-logice, cu configuraiii variabile, complexe, de lcziune a norvilol orlrriolri,rle cele mai mult€ ori nesistcmatizate.
III) Bolikt eredoilegeneratinte .:i d,egenerative implioS, do ascnrcll{ll,k'ziuni ale nen'ilor cra,nieni.
A) S-a conturat incleosebi entitatea clinici denumitS, paral,izie lt .lr.r,rd, Ttrogresirti (P. B. P) a adultului, care realweazd, r'tn contexi Bemiologiocrr:ifectarea ilegernerativi, a neuronilor motori din trunchiul cerobl'l|,l, lrl|Jpecial ai ultilnii{)r neryi emnieni (do Ia perechea a Y-a la perechea a XfI-rr,)..,\celsii, P.B.I' I'eprezintd, doar un $inahom in cadrul unor variato lxrlir)curologice. In tonrte raro cazuri, P.B.P apare in mod singular, oil oon-sfituind cle cele rnai multe ori o modalitate cle debut a acestei sufcrinlorroulologice. ln cadrul P.B.P: unii autori inclual qi aspectele serniologioodin scleroza lateral5. amiotroficd, (Norris gi Kurland, 1969).
Contexl set t r io luoieCele mai multc ;azuri tlebuteazd, cu tulbuldri de vorbirc (clificu ll')l,t, i
de fohalie, in special cu rinolalie), Apoi se asociazS, dificultd,l,i in doglui,i-{ia lichiclelor lsi a solidelor, atrofii faciomasticatorii, faseiculalii po linrbil,;i pe muqchii rnaseteri qi tulburi,ri ile masticalie. Iieflexul faringin,n rlis-p:lr'e la multe cazuri in plimele faze ale bolii (Bonduelle, 1965 ; (iirhoqi Kovarik, 1970). In alte cazuri, imediat clupi elebut, s-au inst;aluh 1,ulburiri de respiratie, uneori gr&yo (Black gi llyatt, 19?1 ; Castaigrx) {icolab., 1971). Completa paralizie a mu$culaturii masticaliei duce la dl,r lorr rr r,rnandibulei, iar afectarea orbiculaluldi buzelor pelmito scurgerea salivei rlirrgura intredeschisai,' Asocierea aproape constant5, a tulburlrilor dc doglu-tilie duee la acumularea salivei, alind impresia unei hipersalivalii.
Palatul noale devine imobil qi aton, pemitincl regurgitarea fluirlokrr:pe nas. TulburXrile de deglutilie sint frecvente, ceea ce face necesartr irrl,ro-rlucerea unei sonde nazogastrice. Bolul alimentar sau lichiilele Du pot fil'c!,inute de citre buze, iar gura nu poate fi suficient de bine inchisX,. ltol-rravul este, de asemenea, in imposibilitatea de a impinge cu limba alinlon-tcle in fariDge, motiv pentru care t^z^ reflcxS, a rleglutiliei nu poato {irleclanFatd. Bolaavii se ineaci uqor cu alimentele.
I)iza,rtria este frecyenti, $i evolueazi, rapid pinii lzu anar[rie. Ao|ulsoapir, prin nas in timpul fonaliei, iar corziie vocalo sint in pozilie &nol'-rnali,. Dificultii,!,ile iniliale in vorbire sint procluse de hipomobilitatoa limbii,Ll ca,r'e se atiaugii, paralizia pa,latului moalo. Bolnavii n[ pot pro]rur|,lr,rolect lingualelc, tirnblul vocii captrt5, o tona,litatc nazalX t;i dispa,ro rnorht-h,tiu, vocii. l,ipsrr, clo inchiiloro contpletl zr, glolci, palalizia, mrrsorrlai,rr riibuzclor', cit;i i,ulbLr t' i it ' iLr alo tosl)irr11,io cornplotanzii tftbloul serrriuloiliorr , l tu lbrrr t r r i lot ' t lo vot ' l r i t r : in I . r , l ! .11.
Atrof i i lo t t luscrr l r r lo t i r r l ' p lozrrnto rJ i v iz ib i tc. l r i r r rb;r , osl ,o I l t rsor l , ,i r r robi l i l , ry i l l , rof ic i t , . l lo i r r r r r r r r r r r r r r , i r rcr l , r l in pr i rnolo [ r r ,zo l r lo l ro l i i , $ i r r t rnrrrrr l t rr r l ro l i l t , t t t r t ryol t i l r t t tn: t ,ur l , r , , t i , l r lc l i l 'o t t ' r , l i r r l ' r L l oxr l r t totr t t l s l , r r , l . io 4i lu * l , r lngo-
l ) t t) tl I r ,
l ix is i i i s i , , l i r lse s int lurat t to \ \ r 'b l r ' " , l t l i r r a lcvl ism local izat le i i l turr '
'rrlol irlr' i, irrl,olrri, in r.eciniit:ltcil lulor'(]i c€rre,b]ale posterioare' p(r al't{tti l.orrrrrrrir.irrrl,i, pirsterioari,, care complimi in rnod dlect nervul IlIr pli '-r rrrrr si lrir.iotttl poduncular (Ileadorvs, 1951).
:! ) Nirult'oamele trucleu,Itr,i ropu (sau, sindroanzele ltedu,ncu'ln'e dorsule )1rr rl, I i r rs I fol sistetnatizate (Loeb si lfeyer, 1965 ; Bodechtel 1965 ; Popoviciu; , r r lo l r r l r . . l9S0; Popol . ic iu qi Pascu, 1980) :
qj ,\ ind rot.ntele i.nferi.oare ule rLttaleului royw:ttt Ni'nrlronrul l 'u,i, Claude-Laye?j ("'(u silldromul lui Xothnagel ) se
r ,r r':rr'1 rrlizrrrirz,-r priritr-o paralizie pzrrlialii ft oculomotorului comun cleprrr'lr.rr lrrzirrrrii ;i lrrin tulbrrr:ir' i extrapiramidale ;i cerebeloase de partear ' l r l l i :1.
It1 flitulronul hti .Ilenad,il;t, asemSnltor cu plecedentult se manifest[1r'ir lrrrlrrlizirr otrulotnotolulti comun de partea leziunii qi prin hemiparezi,.i rrri, ' i i l i inrl)lrlntare (de tip coreic, parkinsoniene qi intenlionale, aclesear ' l r i r r l r r r i r r . lorr i i ; i tu ior i t rn i i ) de partea opusal .
l ',| sinr|rorttt:I.t s1.t?erio{Lre ale nlr,clewlui roptt ::t1 Sittdronul lai CltiraE-7'oir-[icolercu se caractedzeazd, prin hipel'
( irrcz ii rl ir.r,r'st,, rigiditate extrapiramiclal5,, herniataxie, disdiaclocochine-zir', prlr.r.rrrn si priu hemiparezir, toate 1l hemicorpul contralateral leziuniirrr, l i.rlrri r',r1u {la care se poaie asocia fi o leziune discr€ti pir"amitlald, $irr;.orrr',, lullrr ri}i dc sensibilitate, respectirr ult sind]om talamic, care sin1,l r r r . r r l izrr lc r lc nsernenca i lc partea opusi , .
It1 triurltrtrn,ul ltti Niaolesctt, este asemiinai,tor cu precedentulr dn',rlrlorilri lrplrrlui tri leziunea est€ situati, inapoia nucleului rogu, poate firli 'r ' lrrlrr i,r i i lrv.rrsrr ! iu' hLi Wclnekinli ;i, ca atarc, se produc milciil i invoL[n'l : r t r ' l r i l l r I l l t r l r . .
il I in rlr'rr.ttt.do lctltnultQle cu]rrind mai multe grupe de sintlroamtr( l , r rc l r i i . \ l11 r ' r ' , l l ) ( i i r I lJopovic in t i co1ab.] 19?2' 1973, 1976' 1980; Popt l -t i l i r r i : i l ' r rsr l t , 1980) :
t) ' \ inrl 'rrtnrLtl f lr lerai cefebela{1se sllperioare se calacierizctzX, selnio-lrrl lrr ' . lr l irr rri;rr,ritr cctcbclorlsfl homolatcraH, $i prin hipo- sau anesteziorlrrrr.rrrl ir, lr.r 'rrxr-a,lgezicil (sau un"eori pentlu toate s,eqsib i l i teli le )t| 'r ' | | I lrI lrrI(,r ' l l i t . Sc poate rsocizt lrt l sindrom Claucle Bernard-Ifsrner iDsi-lrr lr l ir l , o pirlr l l izie a, percchii a IY-.r, contralaterall, datoritd incmcild,t ' i ilr lrrr, lr i lr i icl icLLlni qil uneori, chi&r o hi?oacuzie sau surditate (clatoti l;r ' il r .z i r r r r l i r ro l i r r r r l r r lu i in ler ior) .
lt) N iniromul,tU norinau'i l tr:ri luce o leziune 1a nivelul eolicululuirirr1rl l irrt ' , rtspecti l ' r regiuuii a.nterioare a tuberculi lor quadrigemeni l1irrr, nrrrrri lcsi.rj, pli l palaliZi:,t milciuilor (le ridicnre qi/sau de coborire Il l(rrrr ' lr iLrr', rrrlt,scii ts,rt i ialt ' cu o par:l l izit do colYclgenli,t cu o midriaz5, ptl ltt-lr i icri ; i orr t l u,bolite rl reflexelor ?tpilare.
oJ Sirulroutul lui l{esxenbau,tl realil'earn un cont€\t clinic constil,ui1,rl irrlr ' .r irr siurl lorn .|. 'al iuilud, Ll crtrc so asociazi[ ' ; 1)isl itgmug disjunotiv'rrrirx,hrrri i oc rt kr- t ol,r 'a,clo ti i , l tt lbnli l l i pupil i lrt ,,si paleze izolote (lo ntlr.viI I I ; i I V. 1,)strr rut sittt lurrri de suft 'r inll i i l substrr"n{ci cenufii porirp()duot,rl l(!
r i i rr, IrrrrrtIr,Ir,Ici Iorrgit,url it l t, lo ltosl,ct irt i l to, ptitr protr'.te oalutir:tt ztlt ' ,:t,t Ltrt ' tt lor'p l r r l t r l r r i lxx l t ' t ior"rr ' t prrr l ic t t l i r l t l i t r ' , t t r , t r t l r t r t iLr , i , t r t t r t r r lo i t ls t t l i lx{ l iorr l l l l t l ii r , t l r r r r r r r r r i i I r r r ' , r r r r r r p l i i r ytr t r ' * r iu, l t t l i rurs l q i , r ' i t l t l i t ' t t ' , x t r I r I I l tsr t t ' i l t , I t i1x ' t -
l : l t l| -0, 11
l : ! t )
Tl , r t r l i t t f i lor ' , r .s i l r lc r r r r r l ic or i r , l l l r . f . l lo l r rorr lc i t lor l l rs lo i r l j l l l r r l ; i l , r ' l r l l r rzrr ll ; r . r t l lo l i lz l i , t t t i r i i i rz i r r i r r r , r r r ' ' r r r l r . t r r l l { ic i l ro l i i . [ . ] r r t rot i l ]a l l t l iz i i l , q i l l1,roI i r r ,: tcr ,s l ,ot ' t t r r r fc l r i l ru ponrLi l l ro l r l rv i lo l s i ; i l i r l ico c l rpul t l tc i t cu ajul ,o l l l lrrri irri lor'.. l lrrscit-rulir l i i lcrrpa,t prr I irrr bi, }r tulseteri $i urr0or.i i i pe musculatu-| r I l luI l (11t .
S l,r rlescris tulburili ale motilitiiiii esofagiene li gastlointostinal(j{lirrrrlucllc, t965; Boutiin qi colab., 1971), precum qi tulburlri cardiacoi trlr Iiovrlscrrlare. Tulbut'ilile respiratorii pot fi cauzate de pareze al(l
rrrrrsorrlirlurii lt:spiral,orii, de para,lizii ale corzilor vocale [i chiar de crizolcslrilrrlolii centrale (Carala$ li colab., 1966).
l)(lgcneratea ciiiior corticobulbir,re, relativ rar intilnitii in P.B.P purir,,;rrlrrugr'i t ' lcrncnte semiologicc de paralizie pseudobulbad. l,.,eziunile centli-Lrl vr'11r,tliivi duc frec\.ent la tulburdri circulatorii gi respiratorii foartcul i tv{ ' '
iladrc nozologiee1) Paralizia bu,lbard, progresiril crotui.cd la adolescenli qi la adul{i
;xrirl,o rp[rea fie ca, Jorntd sptoratlicdr lie ca Jormd, eredo-familiald. (Colmant,ll)?it ; Malkland qi DaIy, 1972). Diagnosticul cle P.B.l' puld poate f ist.rrlrilil; numai pdn examenul anatomopatologic, care va erolude leziunil{,pilir,rnidale, P.B.P apflrut5, in ailolescenld, a {ost consider.ttii ite Marklanr Ili I ralv (19?2) ca o form5, particuiar5, a bolii Kugelberg-Welander.
:!) Grw)ul sclermelor lateral.e amiotrofiod (S.I'.A.) cuprindo 3 tipurilrt itrrripalo, in ca.rc P.B.P apale fie la debut, fie in cursul eyolutioi (Hiranor i rur lub. , 1967 ; Brot ly f i cota;b. , 1971).
.r,\ !l'i1tul sporudic al B.L,A. cuprinale cortextul clinic de P.IJ.P in cel1ru {,irr li i o/o din cazuri (Nishigaki, 1970 ; L972; }Iii l ler-Jensen Fi Be1'nhardt,ll)7;t). I,'r(.{,v€rr1,a P.B.P in eadrul ac€stor forrne sporadice de S.L.A. es1;orrrri rrrarrr la biirbatj decit la lemei (Girke qi Kovarik, 1970; Rai qi Jolly,l1)?1 ; .Nishigakir 1972). S-a raportat o creqtere in ultimii ani a, frecv€n1eiirnnoi bulbare fa!d, de forma spinal-d, a S.L.A., indeosebi in jurul qi pestcvhslolc rlc 50 ile ani (Dazzi gi colal:. 1969; Campbell, 1965; Saha-r l l l r r t r , 1969).
lr) f ipul ,rd,e Guamt' reprezint;, o asociere intro S.I-,.A,, parkinso-rrisrrr 1i rlcrncnfi,. Tipul ,,de Guam"'prezinti mai frecvent sernne bulbaro11i riyrrrsl irril irle <lrcit forna sporadicfi de S.L.A. Tipul ,,de Guamrt are o evo-hr(irr rrrri k'n1t1 decit celela]te formc (Ilirano qi colab., 196?).
l, 'ol'rn(r dt) S.L.A. asemdn[toare cu cele ,,de.Guam"se intilnesc, se pare,r1i irr l,)rrropl. Nu s-a putut insi preciza nici un factor ereditar, nici sub-Ir':rIrrl irrfcclios plintr-un virus lent (Gibbs qi Gajctusek, 1972), deqi soprrrrr cii uilt, multe ozuli cu sindrom de S.L,.A. realmente virotice (Popoviciu:r I ' r r r r :u, 1.980).
It,rlalil tl i ltre complexul parkinsotrism-demenli, si S.fl.A. s-a veli-litrrl lrr l5-2io,( din cazuri (Brady ;i eo1ab., 1971 ), f:r,pl. ronfirmat 5i do:r l l i i ( ( l r r l r l ; r ; s i cola,b. , 1966; Bonduel lc s i mlalr . , 196E; l l la, i t 6 i cohb.,l t? l t ) .
c,) ' l ' iytrl tril,i lar tle iS.7,...| ., r.lesttl rlrr lar', plczirrli i u l rarrsrnisjrrrro:r,ulosorrlll dourinlmtl, ia,r scrnnole bulbalo sint tnai frecvenl,() ((1as1;lr,igrrrrr i col i r l r . , l1)70 I . l l i l r r , t ro ; i r :o l t rb. , J067; I l r rg l r t rs [ i Jol ] r ]m{! , 11170).
il) I\tuli: itr, hnllttrni, lttolyninti, tl itt, uytr,-tisrkt ,,t |.nt,l.i i rttu.xr,ttlurt
l : l { l
t ) t l lnt l i t r t t t rstulur i rp i t tu l i in. lut l i l i i ( lnxr. l r r . l t r . i l l t r r l .n iq I lo. l lur tnt), t t t lc l t ' t tn i l t is t t t gct t r , l ic ( t r l r i t r l r rs rrrrosiv i r r r i ,osurrur l ) s(r l )o i r l , r ' i r r iur l i r l r ,l lz i r r r r i l r t r l l l l l t 'o ( l ) t ' r r ,chtnlLrr l i I l l ln l i { f r , 1001 I M rrrncrr l ,hrr , l r r r ' , ,s i Vrrstr , l l : r ,l l l i0) . r \ ( 'o! l i col) i i , inci i r lo Lr r l ls t r r lc , l r \ )z i rL l ; i t l , r r lbrrr i ' r , r ' i r lc xrrpl 1 i r l r ,r l lg l r r l i ( ic , a l r ur l f i lc ics i r r t rx l t lcs iv, rntrx l ibul i l csto c i izrr l i i , l i r r r l l r l r , l lo l i l r r,r trrflcxclc lmllta,r'e dirnimtll,c. Oclo rnai rnu]bc cazuli rlccrrlcrrzii irr lrrirrrul:rrr rle v ia!,ii,. ltr forrrLcle rua,i l lcniglc, cu supnrvie!uiro pirrir, irr rrrloicsr,r'rri 'r , I rr lbuliirilc bulbalc pol, fi intilnil,e pin5, lzr, douii, tlcitni (li rr olz u li ( Nl u l ln lr colrr ,b. , 1969; I l r iu l f i l t rnofy, 1{}71).
ltl Atrotia nyuscu,lu,rd, tpinulii juaenild ( boala l{,u11r:lltu q ll:tlrrnthr)l otntctelizeazd, prir) |l,ttofii spiuale proximale pseuilomioprbicc r,ii l lr. rrrr
,1,,1(.nninism gonetic autosornal recesiv (Srrith qi Patel, .l.t)65 I l, 'rrrlkrrrrr ,o l lb. , 1969 ; Namb* f i colah., 1969). ExistL $i cazui s lor ' , r ( l i ( l ( , . l r r l r l i
,rrrrir,Ileryilol(franieni (inclusiv bulbari) a putut fi demonsl,r'ltI, lrl :.i1,'i;,rlrrr crrzrri {,\{eadows qi colab., 1969; Narnba li co}ab., 190{,r.
a) Atrofia musculard, spinald, lo,rd,iM (boala Yulpian- llcll hrr lr l l,) ;rlr.zitrlr' i, un dcterrnitism genetic de tip autosomal tlomina[1., dlt,r sirrl ,si rrrrrllo, r,zrrri sporadice (Cazzator 1969; tr'rieil SiDmery, 1971 l Zellrvcgrrr';i ('olrrb.,llr72). Doar puline cazuri plezinti ,,si lczinni bulbare (Dyck iJi I r I | | r I I ) ' ' r
' | , ,l lrl;,q; Bobowick $i Broaly, 19?3).
,1) P,B.P in alte boli degenerati,t:e. Dintre atecliunilc degerr.rirl ir',,|lr (riue poate Si apar5, P.B.P, amintim:
tu) Hi.potentitnea orlostalic.d, (sindromul Shy-Drager') s(r 0r|r,olr,r Iz|rtzii in plimul rind plin lipsa transpiraliei, rnanifesti,f i sirrrrPrrk,, pir.r',l lrr.l l controlului sfiloterelor', sindrom palkinsonian, atrrrir.,ri sr.rrrrr,.l r r r l l l r l t ' .
l t ) Sir t l rot t t r l Ri ley-Day este plot lus de o ( ' legcl lerarc rr l i r l r r r r r ( i r , rt , l iculare a bulbrrlti, cu inl eresaLea qi a newilor bull:ar'i (Ilrtrurislcr', I l)i l ).
c) P.B.P asociatd, ou surd,itate $i. cu abo.fie opticd. ^
losL rlr.ro is:i rlr.rrrli mulfi autori, f6rd, a se putoa contur.a un sindrom apaltc (il'r'ilk'l 1icolllr., {?0; Boudin qi co1ab., 1971 ; Serr.atrice fi Gastaut, .11)7il).
tf) P.B.P asociaid, corcei cronit:e Ilurttittgtol cste litrli (lrnrli rjrV rr in, 19?3).
o) P.B.P asoci,atd, sindromului Bteele-Richardson-Olsaewsk i u, lirsl, r'r.-rrr:rrr,l1ii chiar tiin articolul pfinceps al acestol autori (1964) li (l()lrfi lnrrlri,,1, ' l . | . hrrn:rnn si colab. (1969) ; i Constant in id is $i colab., (Jt)?{}) . Astn. l ,1',' l irrgii selrlele cuntrsrute t1e acestui sindlom, au fost des(rriso llr lorr rlr.r , | | r l t l ' r .uzlr | i . i tu lburdr i t le t lcglul i { i , . .
' iJ P.B.P d,sociatd. nL afectareo, altor sisterne; nucleii nrlzt'rrcr,lrli l it I iorrr I r r t . I I t . r i colab., 19?0l , ta lamusul (Van Bogaert Si oolrr l , . , [Xi f i ) , (1, t ( ,r" ' l r l ( \ ' : r r r JJogaer ' t ; icolab., J965; tsrbwnel l q i cotat i . , tOfO;.
!) I'.tj.P a*ociald bolilor paraneoplazice ale siste.ilu.lu,i turtttr. l '.1\.1,rtr tottltl itul umri sintlom tlc sclelozii lateriLlil i, amiol,lrli it,i i rrirlrrr,,oltrrzr,,rr losl tlrsctiir in cillcinoa,mo blonhopulnronarc ;i allr, 1itrl r.i rlt, ti l,r, 'r 'rr rn l igtrr , ( l l l r r i r r q i coLlb. , 1{}( i5; ( io l l ine qi S'rxr lst ,1 , i i )0?; Nor.r . i r r 1 ir"ol l l r . . l lXi9).
l l \ , \ i r i qt ,hr l l t iu .s i sr . / r ' lota l t r l r t ( l u, t t t iu l to, / i r r r r pol r r . l r l izrr , l ( ,z iunirrrrr l l i l r l r . . r 'orrr I I i r r r r I r ' , r rL ' t r l l t ikr l , r , r r r r r i r . r r i l r r i l l r l r r i 1 i porr l , i l i , ICtr lorrr lx[ l i r r r l r l ( . r { .1 i l t l ( t i iur , r ' , l l t , ' : i ) r . r ' i i r r l r r tzr , r r { l r r r r r r r i i . l i I r r I r , r r I r r r lo l I r l l r l il t r ' l : r l r io glosrr l : r l i t rgo l r r r . r r r i i r . r ' , r ,orr I r I i r I : r l l r r l t r r . i : r l i r r ;1r l i l i ror i : r l r . l t rn, l , .t r r r . t r I r . IoI | | | i . r I r I I i I t I ' ( ' , t { | l r ( . t . l i i r ' r | r r . l i r I i t l : i r r r r r r r r"r I i r r l t r r r |oz i l i : r l r .z i r r r r i i
.dl : t l
]:fllpTlglo Si 4€riforico a per:eohilol IX, T, XI qt XtI gi rii1, ilcrimind,rn tnsu;ilr:tlrl uorros (rosp€ctiy lniduva cor-vioaH qi bulbul), ocle tloud, cauzo mdiI|('ovonro Illnd Bcleroza laterah a,miotrofici (inclusiv sindroamele de SIA)qi niringobulbia. In. aceste-situalii se nai impune G*; sd; fa,cd, un aUglj:i':lig $il.or9r1ial gi fald de com-prosiunile p-iimetor segrnenrc cewicale -9i{uo.r)ulDurur, cal.e artrg-neaz6 adesea tulburxri paretjee Ei atrofiee Elos<i-r uur)gol|,rlngee (boala I:9tt inalta, .tumori ale giurii oceipitale, iumorillrl ltmedu laro tnalte, glioze mie)o-bulbare, pachimeningiti hip'ertrofiedcet l jcalc inal te E.a.) .
, -, t') lnyJqlo1ati.a .lui-fVprnickr, afecliure desrul de l,ar.i, cauzal d" de o
tloliciant[,_ de thiamina, (de obicei ]a alcoolicii eronici), asociazA, o oftalfii{i.I,.lr:qio .(ldeyai I otalS ), o ala.:i ic si demenfi, progrcsi.r.d (Vicl,or qi colab. ,J 071 ; Iilank gi colab., 1975).
' tJ
i ' l i r , l ., . .1-r ' , , r ,
O PNOBLEME DE DIAGNOSTICO. Iw paRauzu
3,1 EXPLORAREA SEMIOLOGICA A DEFICITNLOR MOTONII
_ E:plorarea seiniologic5, a tleficitelor motoxii (p&rezo gl I&-nrljzii sc faoe prin :
7,) Examina,re:| a,teutd a m,otititd,lii actiue (s a voluntare) ca,ro ropro-zint:i ansamblul tle'nrlgc[ri pe czre un individ Ie oiecutd, in motl vohtntnr,incepinal de la nivelul celulelor giganto-piramidal'o ale lui Setz dln cor.l,oxul prerolandic qi pin5, Ia nivelul muschilor striali, care Blnt axocutorlldilecli qi nemijlocilj iri miqcirii. Se procedeazS, tottleauna Ia ca:atninurt,not,ili,td,lii actit;a segmentara, adicd, invitind pacientul sd, execute tn nurdsistomatic toate miqeirile fiziologice, alin toato ar"ticulagiile, obsol'vlntlu,ro{1u atontio amplitudinea, rapiditatea qi precizia executdrii lor.
2) Tottleauna acest examen se comptleteaad, au: a) aag oraraa,fotlainnnculare segmgnlure}. b) probele speciak pentru depietarua pareaalot(lrobele lui Band, llingazzini; .Gr4sset, Vasilescu, Ba,rr6 -Iiohuror);u\ enarnenul, staliunii ortostatice (bipeda, uniperld, pe virfuri qi po c{,lciio);rl) euam,enul mersul,ui, al saltulwi, unipeil pi al Jugii; e\ eaptlorarea molilildliiytutiaa (a tonusulbi muscular) ; t) enplorarea motil,itdlii. dutomata i g) erti-d,enlierea et;enlualelor mifcdli, si,ncinetioe; h) eoid,enlderea a:anhtalelorni.ycrlr I inrclunlarc,
3 ) Semnele asoaiate sint deosebit ale importante pentul. diagn.oatlaul,lopogralia al paraliziilor: a) atrofia muscularf, importantit $i progrosivd,ilno{itX de modificfui de excitabilitate electriod, inrlicd ils obicoi o lsziunor! Trouronulni motor periferic i b) nmdificdrile refloxelor ostoo-teud inoos6,$uta,nats, a,rticuliro Ei dccelaroa roflexolor patologice phamida,ls il do,,olihoraro" (sinoinezii, rofloxo ds trip16, retrac{ie otc,) contribuio ln, treD,rt ,l,oa diagnosticului diferqnliial lntrs o leziuno do neuron motor coutl el8o,u poriforio,
4 ) lluantenul, elcol,rio olaaia, emmenul, fr,M,Q,, paameai, oto aai.rfl(rrdo Ei alte euplordri newotiaiologioe (lsu protiodso inrlicnlli d0 dia,tsnortlolittp gra{lo : lozlnno po ncruontrl r. otor' fi0ntru,l na,u por,lforlo nl lo 0o nlvol,lsliun6 muBcIlor[,, tttlbrrrnr,o funol lonul{, ol,(,,,).
"=:ii; i!;l ;liiiirilial*;iiiigliii ii::i:i :
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1!iE4;jiiti,:iiliiilliiEliiiiEiii*itiiiii1;r!:;:,,
=iEiiiiilsiiiiliiiii:iiiE,E:giiigiilriii;i iii;i:ii?;Eiiii;iiEiiiffl E= ;i3 iiiii=i:i,t iiEiiirliiaiii?aiiiiEii;i s
'ii i1!i ;;i :,
- i;::i::1:;:;!+iiiFi:ii! = t :;: i'=,i= ii:+=,
its
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iii iii' giiiiiiiai i ia ri ; ; ii :
j'u {::
: i := i ti ;a?Etl::E! ! : i;6i ; 3 i{
ig E; IElEgE:E:i;i::* g=F;isigsi':;vi=sF i: iiEflit;;:*;.,;€ ;i.iEEEi;i€Ei3;i=iili;?rii€i;i,iir;";::'=:':?liti I i:;ii: =
E s fi;:i its34 E!E.;3e E l l F o oE
E Er iEi iE" o ' . i E: 's j - : :
r s 3 iEeiriiE= !: i ;E!i ,=? Ei5! i;g; [ai irr ; : ! i f :5 i ?i r$t
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== =a=
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T) ) I t toot ' t t 1 ' ,1 'pr t . t1si . t t t i t t . l , r ,u nt t t , nt . l , rL l t l r t i cotobr l lhr I ) r ' i t l i l ' i \ ' { r s i t , t t
r r r r l r rs l i r l , i r r r , I rot t l t l o l l tne (str l r r l r r l l r , l , r ' ' l l i r l t t ta l , intraparenchimltos), i t l tcoso|'r. rr. l r I lr hr, Lrr bct Ouloame, pat itzit ozt: i l l1,r ' i t,cri l,niene,
:lJ It n.r:cfulitele, enceJalomielitele, boli ilemi,elinizan a (scleroze mulii-plir, lc rrcoencefa,l ite $. a.)
1) linceJaloptLtiti inJantile!;l !l\r , ,lnatistne crani,o-cerebru,le
:1.,3.1.L2. Eemiplegi.a spinald este ipsilaterali,, intereseazi' numairrrr.rrrIrlo|o, iar'leziunea medularS, este situa't5, cleasupra intumescenlei.'r'r'iolt,lo. l)c cele mai multe ori hemiplegia spinal5, este asociati, cu semne
r,lirrilo r1o hemisecliune medulal5,: sindrorn Bro'n'n'S6quard. Nu se con-rrl rr Lri rrir:i urr semn de paralizie supra-medulari,, nici paralizie faciald,r nici:rlirzir, nioi dizartrie. Ilemiplegia se instaleazi, f6rf, ictus $i fd,rd nici o:rll.r'rrrr a, stirii de constienli,. Se recunosc cu u$urin![ e]ementele senzi-Livrr lhr sindromului Brown-S6quartl : abolhea sensibilitSrilor profunderlc prrltul hemiplegic[' gi hemianestezie termo-algezicS, ale partea opusr,.Nrr rrrrri pot fi utile in stabilirea cliagnosticului de hemiplegie spinal5, ($irrrr plirr lcziune emisfedcd,) tulburirile sfincteriene care de obicei nu lipsesc,plrrorrrn qi prezenl,a unor mici atrofii radiculare ale muqchilor scapulari qi:rlrr I nllrozului.
flrrrniplegia spinalf pouta Ji' reut'izatd' de ::r) 'l'rrurnatisme. b) Mielite (virotice, luetice). c) SclerozS, multipld,. tl)liilirrgrrnielie. e) Tumori, care de multe ori realizeazi" de fapt o tetraplegiexpirrrr,lir,, tllr cu pretlominanli pe un hemicorp. f) Discopatie cervicald,(lirrr'l,o ra,r). g) Sinilromul lui Mills, tle etiologie necunoscuti incS, (probabil;rlirr rlrgcrrerescen!5, progresivd,, e1ectiv5,, a fasciculului piramiclal) so tra-rlrrur priutr-o monoplegie inferioari (crurali,), care se extinde lent gi larrrrrrnbml superior, reallzind o hemiplegie spinalS, f5,r5, tulburS,ri de sensil r i l i l , i r ,1,o.
:1.i1.1.2. Paraplegia poale fi realizati atit de leziuni ale neuronrrluirrol,or' rxrrrlrftl, cit qi de afecliuni a1e ncuronului motor periteric. Oa atare,rlirr rrrol,ivo tlirlactice, in acest capitol vom aborda pe scurt pamplegiilolrlirr lrziurri r1o neuronului motor central (cortico-spinal), care pot fi re:l-lrzirl,o rrl numai Ir nivel spinal (indeosebi), dar gi Ia orice nivel al lreYrn-rrrlrri, rlrcr"r, sint interesate fibrele piramitlalo (ad.esea cu realizarea del,.lr',r,plrrgii). Nr: vom permite ca in continuare s5, abordi,m separat problo-rrrr,lr rkr rlitguostic topografic qi etiopatogedc ale paraplegiilor in sensullrrr';1 rrl rlrrl ' itri l.iei (atit piramidale, cit qi periferice).
l) I't,ntp[egl,u spinald,. Forma cetu mai caractelistici este realizatiirlrr iririrllornul de sectiune ttansvers'i,, care intruneqte o para'plegie currlrrrrrr, trilrr,rnirlir,Ie, insolit5, tle anestezie pentru toate modurile ale sensi-lril i i,.rlo, plroLrm Si de tulbuli,ri vegetative qi trolice, cu neti, l imitale snb-lrrziorrrL'r,. Nivcltl leziunii me:lulare se poate preciz2r, prin aprecierea modi-l' iciil iIrl rrrllorolor qi l nivclttltri trrlbtrdrilor rle sensibilitate ;i, in rnrtrlolrligirl,orirr, plitt crrrrnonul l./.0.1i. tl i prin rndiogr:r,fi i io $implo Ii prinl r r r l ,or l r r r lo rurni ; t r r ,sI , .
' | ' i r , I r l r r r l ikr r lo l r r r r rp logio spi l t r r , l i i (s imiLt , t 'o srxt{ iuni i t t ' r lnsvot 'so) 1tol , l l il r r r r l izrr , l , r r r l t ' crr l6 tnr , i vrr l i i t t ; r t l l t 'oot tsc: tu l tn l t t ' r rs i t t t t i In(nlulr l ro, tn i r r l i l ,c , l ro l ir l r r r l i r r l i t r izrr t t l r r , l ro l i r lcgct tot ' ; t '1 ivr , 1. t t , .
t : l
! ) J. 'uxt ,1t l , r 'u i t t l r i t l i t t r i l ro i t l r r l i p l r r t l t ts i i pt ' i r r st l l t t i . t t { r r vI t i ' r t I t t I i t t t ' (ot ' I t tz i r at ' io lo lor p l l lat t t t t t l i l l t tc r tL ' s is l l t t t t t l t t i v t r t t t l r l r l - l t l tz i l i t t ) , i ) t r ) (1( 's(r l l t 'o lo lmativo care comprimL pittirit 'ttl porttin, boli tlernit,linizrtn lr' ;. rt.
' 3l Purapleeia paraunl'rald este reznlt.r,l,ul lc'ziutii lot' I t i I I t ' I I r t I t I r ' : ' l llobuftui paiacintrdl (meningioame parasagita'le, tromlrolkrhilri tlt ' sittrtrlonEituclinal, sindroame bilaterale ale suferinlii a altelelot (j('l! fl)I'iI l(| itI| | ('r'ioar'6 etc.). Este important de relinut faptul cd' dcficitul trtolrtt' lrtrt lr' l ' iprecetlat sau inso-tit de crize jaksonielle loca izate Ia nrt'rrtlt(' l| itti irt iorltr',lrecum $i de tulburf,,ri sfincteriene.' 4l Parapteqto- prin leatuni nt'ultiple. In atelo- $i al'ttl i{)s('l i 'r!tzrr txrt('-brali,,'multiflel"e hlune de clezintegrare ischemicS, pot a,fecta, t'tt ltrtrciirltrtrrfibrele corticoslinale ale membrelor inferioare la nivelul cmisli'rrrltl cllrrbrale (centrii dvaii, capsuia interrri,) sau in trunchiul. ccrobtrl, Irrlt'lizlttrlparaplegii sau tetraplegii (cu predominenll pl raplegiei). Pfi n t ttrrtrrt'r t ist t ttriimil-arJse realizeazfi p:r,raplegi1le prin ]eziuni multiple din sclororll llr plii('i'din unele encefalo-mielite, din boala lui Little q. a.
3.3.1.3. Probleme d,e diagnostic topogralic Si eliop&Iogenia lin sindnnnr loparaplegice,
In diagnosticlt'l sind,romuhti parapleg'ic este necesar sL so I),rtrrrrlgr'iin mod logic $i succesiY urlf,5.toarele etape (Riser' 1952 ; -$ollcirrrr '
l l){i?;Bodechtel;1965) : a) diagnosticul tlifercn.tial intre o paraplegi(' rii {r.,11rr1,'rldoparaplegie"; b) diagnosticul de tip al paraplegiei (piramidalil ; tlrr ttlttron motoi peiiferic; pedcadon:lla' poliradiculoncvriticd, . polittrrv.t'il i|l ;rnusculilri) ;-c) tliagnoslicul dc nivel irr crzul paraplegiei pillrttirlrrlrr (rpirtald qi topografia acesteia; cerebralal) ; d) tliagnosticul etiopttl rtgcl t it"
1l Pseu,il.oparaplegiile Yor fi eliminato in plima et:tpii it tl irrgttoslilrtlu i :
:l) Pseutloparaplegiiie prin artrite acute sau clonicc qi tr)lirr rrll lorr\protLuc false dAficite rnotorii plin anchilozd,;i prin imobilizrlr'(' ir 'rr l 'r tlAr|ri '{rtumatismul poliarticular acut, poliartdta cronicil c\-olutil i) ul)t)||(|iIiIit:r rrclli lopoieiici,, artroglipoza congenitalil, rnultipif,, coxNrNlt)z"lt' f. :t );
b) Psetttoparaplegiile pril afec.tiuni carc clolucllzri cu rttitti l.ti lrrrlorrii, cu ltaxie gi/sau cu tulburiri t1e echilibm (ata;ie 1'rrl-rclit ' i i, silttltttrrtrtt 'r{ uluirnelnice, erodoataxii spilo-cerebe}oase' sindrollntl 1,cs(ilrrll;rrrr, rirrrllorrme cerebeloase, al,axia frontal[ a lui l]rrrns) ;
. tr) Pseudoparaplegiile plin tulburili psihice : t,pirtrrplr'g..irr " rsllt ' i lrr Ir | | i rZr ) . : t l )aZta.
2) E'Lt'rdroam,ele paraplegice Q(ul,e sutt, Jrnrte rultitl, t 'uslilrril l ritl. ti 'r rrrrrioalcle probleme diagnoslice :
t ) Miet i tete ( t ransl 'c*er in spccial , dr t l q i colc t l is t ' t t t i l t i t ic s i r t t r l i l t rzr ' )r i lo l , ico sau bacter icne, antrcnc: iz i l i l nt t i t l t l t l tmal ic, bt t t l r t l , o i l l i r t r ' l , i r l r r 'lrlogio, ctL scrnne piramidaic irlso{,itc.si r.ltr t 'ulblrrir,r' i tlc stllrsilril i lrrlrr u"ii slirrrri, 'r ' i, 't,", t,u sau JarL seinnc prt'tttttnitolii gcntt'i i lt, 5i/srttt ltttttologicr'.
h),41.ial,o-railitttl1el1tpv'iN1i1t(r'cttpttrlit 'rtt.icln-1talirrull,ictrIo.ntt'riltlr.t)1wlrlel , r r l i l ( ,111, r l r l l d0 obi t ' t ' i nt ' r 'ot t t ' I i I t t i I i t t ( i i t 'vr t z i l t ' , pt t l i t t t l l | l r l iz i l l r i r t , l
Pl |g i i sr t t t l ,et ' t ' l t ,p l0gi i ( : r , r l t 's0lr ( ' t t | , r 'o l t t ( i0 r tst I t t r l I l t i r l ) i { ( ' l l l t t r ' l { ' t l t ' l | ,z l t t t t I
i , l r , r t l l r r r r lu i t r t i l l ,ot l grr , l i l i r r . ic r . , i l r 1r loIorrr . r r l r r r r r r I r r i +r ' r rz i i i r (scrrr l r r ' l r . r ' : r r l i r , r rI r r t t l r , r ' i | , icrr) l t t int t r l tz{ I r r { f r r l l l l l t ' t t t l r I t t | : t t r ' ,
A
t31l
c) l \ l i t r r l , i r t t . [nt t t t , t i l t l r l ' r l t r . r r l r r r r t t r i ( i r r l l r i t r rp lcgi i , l r l )o i i l r r ' \ { ' l l l l ' i ( r tlo l , r ' r r , I l r rg i i r (1 l l r r i t , r ' i Lt t I I r r r t r r , t t l r \ rzr l r l i r r t ro l ,ot i i , t t r l l ico 1i vt , iJrr l , i t l iv t t ,r r r l r , l rnr r r r cvol tLt ica,st :ot t t l r rn l r i l j i r , t r r r l r . r i i r , r 'c l i1 i i Inclv i l ( ) r 'c l l t l l i ( ' i . iJ{) l lL l l ( t1f,lrr lrrzirrno trcylaxiu,Li (irrrltrosolri irr,rrrrLclc pilarnidale) Iipscsc. .\Ioclil i i i iri lorrr 1,.( l.l i. sirrl, cl,r'actcrisi,ico.
tl) l'olk nieli,ta, &cut{i e ltri. II ei.ne- Metlin intli, totdeauna in cliscu{iolrr rtlr copil s:l,rt Ia nn indilid ti[5r, mai ales dacai, s-an conse]l]11:r,t sclnno,1rllrrrorri1,olii infec{ioase (febr5, manifest5,ri digesljiye $i/sau respiratot'ii'rl l,clrrrlrr, str:i,r' i i goneralc), algii poriferice, ce{alee, ytlsi,turi, radiculalgii,.r lgii rrrrcl,h:, fa lialgii, semne meningeale (subiective gi/sau obiective).| 'rr lrr lrlr{iir, loate ti dintr-odati' masivd,, hipoton:i (,,paraliz izr, de dimilea-irr') rlcsclisi de West), cu reflexe abolite, sau se poate instala doar o mono-lr l,'{ic, cventual paralizii parcelare. De ̂ obicei fenomenele generale qi menin-u( rl(i l)r'ecod partrliziile cu 3-5 zile. In unele situalii, pierdelea blutali,,rllrrrrrrl,icii,, a fortei musculare este impoftanti, qi ertins5,, atingind mu;chiirr.rlurilor', i:r,i trunchiului, ai membtelot, cu extensie chiar la nivelul mugchi-lol irrrrlvrll,i de pericarionii bulbopontini. Atlofia rnuscularS, este precocosi irr rrortantd,.
q N euromielitn optiad, ( oftalmoneuromielita, boala l,u,i Deuic) deba-I rrrr,z ji, r lo obicei brutal, de multe ori paraplegia precedind semnele de nevritiopl,irii, (Dri,ginescu qi colab., 1962, 1963).
l') Ilxistd gi cazuri ile scler oad, in pliici acutrit , care realizenzd paraplegii(rrrrr hrtrrlplegii) dramatice, flasce sau spasmoalice, cu senrne plramidaloirnl)r)rl'lntc. Sint frecvente puseele de paraplegie acnti, in cursul evolulieirrrrci scloloze in p15ci. Puseele evolutive de mielit5 in cursul unei gclerozorrrrrll,iple pot sd, se declanqeze cu o ,,tragici brutalitate" (R5-":.fgP",
g) A.lte encefalornielite pot realiza in contextul clinic malifest5,ri para-;rlrgico brutale, I& care se asociazd qi semne suplaspiuale.
\) Spond,ilita tuberculoasd (boala lui Pott) trebuie suspicionatii tot-rLrr,rrur, in liulrr unei paraplegii acute la un adolescent (indeosebi) sau Ia unrrrlull,. l)itgrrosticul este u$urat prin prezenla conira,ctudi dureroase ;i it,rlru'olii colornci, dar mai ales pdn evidenlierea ghibozitS,lii qi a altor semnorlrr plri,lrrrryilo vertebrald,.
i) llr,nrtnu,I primi,tits rah,id,ian al ltti Ewing poate realiza o pa'raplegiolrrrl,rr,lj1, Lr, copii qi Lr, atlolescenli. Djagnosticul se verificS, prin imaginilolrrr l ioglrr,[icr: plulifocale, in geocle, pludver"tebrale qi costale.
.iI JLl,l,c tumori primiti,De se,u securl.dare i,ntrarahid'iane, intra- sau extrn.rlrrlrr,lo pot plorluce paraplegii acute gau cu ingtalare rapicl5,, precedatorrrlrnrrir rlo o sourtl periorLdfl tle rahialgie qi ciaudicalie spinal5,.
lil l[t,n.in,go-mteli.ta sifiliti,aii a,eutti intfi, astS,zi prea puiit in discufio.l) Il telom,ataciile (rumolismen'tul, total, transaars li ranxolisrnentul
ttpintl rnl,rtrior) pot realiza fie paraplegii, lie tetraplegii dramatice (Lazot'I l r r l r . l l )?2).
ill 8 intlroanzele paraplegice ou insl,alare lant-progresiud, :t) f*:lerozn rnultipld, (S.l\[.) realizeazS, cel mai frecvent un ast)tnenolr,
I'ir,lrlou sorrriologic, cu par:lparezd,-paraplegie spastic5, piramitlali evolu-l,ivil, (url rn:r,i rl(losoi) ou puserrri). Iformele ou evolul,io lont progresivir,, liiirrl,lrrrrlorrrj cu s{)rrrno mici r1i inoorto h mombrolo Buporioa,ro qi. fi,rll rr,lto scttrnonrrlrlrl-npirrirlo rlo sclorrrzi, rnull,iplii l irl ioii, rlosigLrr, lrloblclno tlo rliul4rruslinr l i l i r r r r r r l , i r r , l cr t t r t io l i l ,o lo orotr ico, or t cotrrplosi t t t t i lo tnrdt t l i . t t 'o rr i ou i !nr l l r lo i .
140
r l i l , i , l r r s1t i t r r , l r . , l l r r o l r i r r , i , i t tn i i , r r l t t t t t t ' l t t r l l l r l i ,c l , i t , lc ; r , r . l , i t . j r r lo l srr l rcr , iotrrot tcvlrrr i l t l r r l r , t r . l r i r l i l t tz iut t t l r ' t t r ' i t r iL l l i tnc. l r
- l .z i r r r r i i , r , r r n, , i r r r r r , 1 r i r i r r r r i r I I r I r rl l r , t r l l t l , r r r r t r ' r r r l t r r , lc , r ,u sr , tnt to rrsooi i t i ' t r c l t t ' l t t ' l r r r tso, vcsl ibr t l r t lo s. i r , . , r , r r .ur i \nr ,cr tn l ia l potr l t t r i . l iuglnost icu1 S.. \ I . I t r1otr t t r r { ' i i l r r r r r l t rsc t lo i r rv i ,s l , igrr , { , i i1, r , l . r ,t r r r l i r }e1, ice qi imunoe le ctrofole t ico scl jce, I [ i l | r l r , i l i l l |s r l j r r 1, . ( j .1, ] . r r r l r r0rr lqrrrner l te in plus pentru diagnost ict l , l , S. I I . , i lsr , c l t l r r cr{o ru ' t . r r i i l : r ,;lstii,zi socotiti, ca o JJoaU, autoimuni rle aut9ag1gsi11l0 (l 'clrrlro li ,lolvirr,ll):14 ; Ila.bat, 1957 ; Liirventhll l i colah , 1960 ilrlrlsrlen 1i c'lu ir., I 15tt ;I )nmii, qi cotab., 190-1, 1965 ; Schapira qi Palki 1961 ; Vari Su rrrlr,, ' I l lri? ;l3r*us qi colab., 19i2, 19?9; Cojocaru l i c ," ,Ja\ ,19?8; 'Pop6vic iu ry i t , r r r . r r ,l$80; Kright, 197?; Colby qi colab.' 1977).
b) Neuromiellta opticd' ( oJtftl montielila, boala lui, Dpuic) poir,t;o , y()r f io evolulie subacut-cronicii, x11 ..tlebut ?xlil l lrrletic - paraplirgic, rl.5i iirrn:ljoritatea situalii ior debuteazd, acu'l saLr sr-ibacut (Driig-nncscrr 1i coi:rlr.,1962. 1963).
cJ Mielita .cro ,icii, .lueticd -(Er.b), p.oru1'1egin spas t,-ttl icd, r:rt:d,oti.l i l i.
l icd" u, lui XIarJun gi sin(lronr,ul tui GuiLlain ti Thion {asocioto rlc s,.irrrr,,de encefaliti, cil tabes qi.cu mieiiti l Erb), frqiysnls altddatir, sirl .r lr.rrrr.te rar intil.nite astizi in practic,r,. neurologici,. Nu tr.ebuio i,Ohrqi rri lrrrLiti.m, iar prezenta sgmlului hii ArgyU-fi6bsrtson, a hipclcil,oz.i, rrl r ipefr lbum inozei q i po^zi t iv i ratea -react i i lor B.W. s i 5 benzoi r ' , r1r i r l r r . l r r , ,
' . l r r i l ic i d iagnosl icut . Tn plus. in pataplegia rpasmodici c1or l . -s i t i l i t . i . r ,rr. lui Marian apar gi : keratiti,, tulburd,ri psihise importante (ca11,c1;r'r'irr,1r qi,1, ' t ip demenf ia l l ; i , adeser. convuls i i .
J) Compresiunile medwlare de diver:e naturi (tumoralo sa,u ilrflrr.nr!r.-colii, primiiive sau metastatice, subdurale, extracluraLe sau intramoriu lllr.o)|eailiz.eaad,, in funclie,.de livelul acestora, _plraplegii sau tetrrrpkrgii. l,)rirr'1, , rn j ' i mul le pobibi l i t i l i de reaLiz l re a del ls i [11[1 6e6o, ' -
- O compresiune realizatS, brusc sau tapid se poate manitosl,rr, rrr.irr{r'-o paraplegie flascfi, ulterior, in decurs dd citevi s[pt5,mini, 0voiirlrrrl$pro o paraplegie spasticS, senzitivomotorie. Se intelege c5, tle obic.i
' I'rrzr1,
ou dureri railiculo-funiculare intr-nn^terit'olil limitat, bine prociz^,1, (rrristu bilateral) precedd, instalmea aleficitului motor cu citeia sil,,l,i,ririrri,Irrni, sau chiar ani, fenomen cu male valoar'e diagnostici.
- Alteori paraplegia esto lent-progreSiva, de la incerrut sDrrrt icil.,lrr de mu lte ori precedald, cu mult timp inahte de fenumene tlo clnurlicrrllri$pinal5, oel mai adesea fir5, clureri.
- Alteori evolutia lent-progresivl nu esls precedati, de fonorncrtrr rlorrl:urdicalie spinali, in scbimb pot apxrea 1y15iop11i sfinctoriene plnooor..
- Dvolulia cea mai tipicS, este unndtoaroa: mai intii faztr, rodlc'.LrrL ilureroas5,, apoj perioadi, de clauclica,lie, apoi sindrom Brown-sdqnrrlrlr..i, iLr shriit, paraplegie spa8tici,, inso!itd 5i rle tulburiri tlc scusibiiit.lt.o(r ' r r rc t le mulLe or i Pot l iPsi) .
Compresi,uni,Ie rneilulara ceruicala superioare prorluc rnono- s^,ll h.rrrl.plegie, urma,to r1e tetraplegie spasticS,, cu tulburd,ri de se.sibilit;,6 ,rrl I lvet.
C ompresi:,unila -
aeraicd'la inletrioare rea5zeazir, o paraplegio fiptrsl,l.ftBubju,cent5, insol:itir, do hrlbul[,r' i pftreto-atrofico tlc tip *idlcriin,r'
' i rr.rrr.
Irrelo supoliotttrr (Llr- D')'Oomptroaiunila nvdulara dmtalo ttti,,Lthaa,zi'i, 1r'oooc. 4ollioit. rnol,'rlt
( t l r r ,1,0r i l i l lngrrstr ' r l i i t I I t t t ; t , I t t I t t i t t t | t l t t l r l t ) , (1 l t n l rn l i f i i , l l ' i Hi r r lo rof loxolor. ( j I t l l .
I
,fl
l{tl
| | i r lo r l | ) | | ( ) | | r i | | i ! | ( . ( r r r r t , i rk rrr t r r l ' r Io l { r ' | | l t i r i i , l0tr l t ' r r sr , r l i r r l l |z i r r t r i i ) . Axl l r r l , t l t 'p ik l l l , i t r l ro l r l r to i l i l r t t ik) L l t t ivrr l r r l l ) t r , l r rz, t r l lcxolo crr1l t , t l t , l ,o l r lx lotrr i t t t tL lrrrrprrtiolrtc r'ai,lnhl i ncr:r, 1trozonl,o, rliu rll l(l\(ll(i outanato lrbd{)rninlllc rni,ilooiirii itrlirl iorrro sint abolite. fu stititrtlr, irt compresiunile sub Du, r'cflt-rdo:r,|rrIlrrrirrIrlrr so mcnlin pii,strate. In cazul unei compresiuni sub l), r1i tlea-ri rr l, r'1, Hoglrrorrtului Dro se poate evidenlia semnul lui Beevor (€itr1, de Arsoni,,i lolrrlr., l1)?7) : la ritl icarea capului $1 a trunchiului, ombiJicul se depla-rrorrzir, irr sLuir datoritd, laptului cd, porliunea superioard, a muqchiului ilreptrrlrrlorrrinal primeqte impulsuri motorii, in vreme ce porliunea inferiotr,r':ir . i r l c l r i r l l l l iz i t l , i , .
( lr nn?resiu,ni,le med,ulare lombare suptaioare realizea,zn paraparezer|r' I i;r lrilurnidal, cu Bpasticitate (neobligatorii) qi cu unele indicalii de nivel.i\ltli.l, iu complesiunile I-.,1-L,2, reflexul cutanat abdominal inledol' estoprrrlrrl, ia,r'rtflexul rotulian (cu inchiclere la ltr-ln) este eriagerrlt. Inlorrrplr.sirrttile Ll :rivelul Lu- la, a,tlt reflexul cutanat abdominal infeliorr.rl r1i lr,llcxul ll,nal sint prezente, in schinb reflexul rotulia,n este alrolit.(iirrrl cornplesiunca lornbali se oxtinde spro coada cle cal, tulliurflile dorrrolil i lrrlr, inftr'acii, un caractel flasc, cu fenortene de neuron rnotor pcri-I r ' l r ( , -
liut prcsi,unile m,ed,llla,re s&ar ,te realizeaz5, paralizii fd,r',i, sprnne pira-rrrirlrrlr,, itr schimb cu nete fenomene raaliculare. Astfel, complesinnile larrir r.lul opiconului (L,b-S?) se manifestd aalesea doar printr'o paraliziellrscii in tcritoliul sciaticului popliteu interrr, iar compresiunile conuluir r rlr I rrlir r' (S, - Su) se recunosc pdn a,bolirea reflexolor anale, prin tulburdrilerlrr st'rrsibilitate perianale (in qea) qi pril marile tullurd,ri sfincteriene, :rbiarrrri lirzirL pul,ind si, apali, ma.nifestS'rile paraparetice.
(lonpresiu,nile la nioelul cozii de cal realizeazS" paraplegie iloar inlrrzrrl sirrrllotttnlui total al cozii i1e cal (r5,cl5,cini1e Lr-Su), insolite totdea-rrrrr, rlrr lulh uri,li de sensibilitate extinse r:e dermatomerele restectiTe si derrrrrli l,rrlhulll i stincteriene. in schirnb, s]nclroarnele t1c comliesiune nar-r r rrr li l,rrlbu lll i stincteriene. in schirnb, tle compresiune par-
rotolii si senzitir.e in{irr,li rr cozii dc cirl se caracterizeaz:'i prin ttlbur'dni motolii qi senzitir.e inl l r , l i r r (x,Zl l ( le Oitt SO CalaCleltzeaz:], prln l : t l - toUlan m0lolrr Sr Senzltr l ' l .e lnIrrrciic rlrr li1ul supe.rior (L.-Ln), mijlociu (Lu-Sr) sau inferior (Sr-Su)r|r' rrirriIr'orrr de corili l tle cal, timul (cel inferior) intlr'unin.l $1 telburdri, timul (cel inferior) intrr'unin.l $1 telburdrirL l i r r r . lc t i r . t rc i rnportante.
I'rrtrxr'lt erpansiae intramed,ulare, indcosebi cer"r''icale (glioamo,1rlrrrIiIrrrrrrrrrrr, i nbclculoame) reakzeafld, tablouri semiologice cu totulprr r'l icrrlrr,rrr, r,rrrt i.rebuie cu grij5, diferenliate cle S.I-.,.A. sau de alte sil-,lrrr:rrrrrr rlo S.1,.4., precurn 1i de siringomielie. Astfel, aceste:n se manift:stii1r r irr lr' l l lrlrlcgii ploglesive cu semne piramidale (mai exprimate 1a mernblei.orrrli 'r ' iorrrrr ou sllrsticitate), cu aljlofii musculale de 1,ip Aran-I)ucherrner,lrr lrrrr, firr rlsociazili, tulburi,ri de sensibilitate suspendate (irritirrl) sau sub-Ir,ziorrrlir rlo l;ip siringomielic, cu clisocialie termoalgezici. Pot s* lpa,rlrli rlru'r,r' i corrlorrirle, plecum qi dureri de tip radicular la metrblt' le supoli.,rrrlr, l ir rlr,ro sc asociaai qi fenomene yegeiati\.e (va,somotorii gi sudollrlc)rrrr1rolIrrtrItr. Irnnginca rnielografic[, descrisl inci, cle Sicard Si l{i],guc1rilu(lltJt!, cilrr,fi do ll,iscr', 1952), tlesemnind aspcctul in fus almldrvei dilattt,o,riu Hculllol'orr slrbslartlei radio-oplce po pi,rtilc laterale, snb fon:n:l lr rlorrii,rtrIrirrrc lirriir,rtr lirstrinlrto, vino sii confiune tliagrxrstictl tlr trrruoli, irri,r' it.r r r . t l r l : r I i i .
a) I irirtl lom. i tl ' i.a, rrslrr ttl it,tiv lr;iot'tlc t'ccrr ttoscrr t,, ptin ilsocicrrlr, l:r, rrlrI r r l r lor l r l r r l ) r , r1r l ) l , r t 'z i i (srur l r r l , l t l r r , t r rz i l ) p i r r r , r r r i r l r rJr l , i r rso{, i l r lc l r r lnr l i l i
t42
r l l ' s( l l rs i l r i l i l l r l r , , r r r r I | r , t r r l l t l , r , ( i r r i ( i r r l ) , . l r r r st t l r l t 'z iot t i t l r l | . l i ; r s i t ' i l tgrr t t l i r ' l i r ' ,i l l I tot . t ) I . ( f t ,0|( ,s i r r l t t , i l t t l l r r r r i t i i , r r r l i r t t r , i r r l tsc l r t t I t t I , i I I t t I I , r ' , pt ' r ' t l r l t t I i t t l t t t l r 'l r r r r iv t i l i r l t r r i i r r i l . r 'q i l r1 r l .961r, l ' r , l r l r t r r1t , r l r l1r , l , t , i t , i r t r , l i .zr . i , i l . i t r l I t ' r tt i i l r r s i I a1,r0l i iLrr , t lc { iD , \ r 'ur) ,1)ur, l ( ' r r r r r ' . Nlrx l i l ic i r l ik , 1, . ( l . l l . s i t t l : t l t -r . r r l r . i : ru lu i i r r i tnp,rr t : r t r i t ' (cvel t t t ta l r l iscr t i i t l t ipcl t r l l t t t t t t i t tozi) ' l ' r t l t t ' ; i '
,.rist.r, siririgomi,.li i iu evoiufib rnili r1pirll i, .. 5l.crrj l idrirlirtrr qi t'tt i lttrtgirtirl,, l iniorlolin,,Lerrzi perime4ul*re't cr,r, i ' tumor.ilc iltra,rcrlulirtr,, siittt{ii, r r r . : r r tc d ia gnosl icul -d ev i lc fu:rr l e di [ i l i l .
I Deqe tr eresccntek sp i no-cerebektase (boaln luiL'riodteich litx'tlo tlrr't ' itt,, r,L,iloasi a lui 2ie*e
-Marie) corlrrporl;it, minime olorncult: ltirrtrl i.tr ' itrt 'rrrirll le. ne Drim Dlan situindu-se sernnelc cerebeloasc 1i tle col'(loill l(r Int$'
i,.r'irart'.- lf nlusi caractelul ereclo-familial tra $eazd, tlia'grrosliortl'
xt Paraiteqia spa'slicd' fatnili&Ld' a lui Btrr'iirnpell-Lorrairi', 1xr litrgri'rrila,iiegia li"ait iAaia cu contl'actur5r asociazd, in contextul glrtrLiologitr
.i semnE cefubeloase (uneori discrete), pe ling5, un caracter eredo-tilrtti l irt ' l '
hl Arahnoiditele sqiinale compresiae (diJuze sau local.e.);i -art'lmo'n
itttitele iealizeazd,4e obidei paraptegii (sau tetraplegii) insolite rle lttrr'tttt,tttr{ltrrcroase cu apari.tie tardivi f tle semne intinse, etajate ryi atlosca, tlistrttlrll,nte (hipoest"ezii ' neregulate, atingeri radiculare tlezordontrl'c, itllnrt'lt'"liiiruronsta,ntie ale Ir.C.R,. (in funclie de efectuarea punciiilor etajat., .tl.5ltt0rr,i ncrequlat $au Dar-t-ial, cu lentoaxe de intoarcere la presiullerl' i lt i l irrli itl ' l"cljul"fiintl mai iet in pozilie aqezati decit in pozilie culcati' srtl i l lv{rr$)'j \ l i r . loerat ia ( .ste caraclei js l ic , (Arseni $ i colab. t9?3) '
i) Mielopatii.le subct cute Fi aronice t:ascwlare pot realiza palilpirt(^'r'- rlrr||rrrrlallegii le-nt-lrogresive, al cdror iliagnostic este extrem tlo tlifitril 1i',,,1r.,si,r,.-se face plrin"eliminarea altor cauzer diagnosticul lor prtNris pttiitttlttso stnbili cloarlrin arteriografii selective. Se qtie cd ischemiilr t crlrrlrrr!pot fi realizate prin leziuni Yasculare primare gi prin compLt'sit.ttti vrtrt tt.]rrrt in cadrul inor afec.tiuni ale m[duvei $i ale rneningdor ((irrrrritt r,tiIirxr(lot, L966, citali cle I-,azor"thes, 1972; Lazorthes, 1972)' Atotrt- ryi rur'l 'ttr iosclo.oza vaielor lpinale este mult mai rar5, decit arterioscl:tttzit v:trr'1tr'ct'r'cblule (Jellinger, 196? ; Lazorthes, 1972).
i) Selerosa tlateram afi,iotro.7icd' (BLA) este u$ol'l le rtlcttnoscttl ' 1tt' itr,r.zr]nt'zl atrotiilor musculare tipice, indeosebi dista,le la mern5lrrlc sttlt.t ii, 'rrt (cu sindrom Aran-Duchenne), cu fasciculalii )' l i c-u somk) pitrltttirlrtlrrlrr iorite membrele (mai exprimate totuqi la membrelo infolioa't'c).
k) B inal.rcamele de scleroBd' lateralii am'iolroficd pol, li lea'iiztt'1t: tlrr lirrt'tlrrrrrrrlt,e irlectiuni: compresiuni cer"vica,le tle tliverse naturi, pa,chirlr('rrirr!{ilt '.r'r'r'vic: c liipertroficd luetice, arahnoidite., encefalomielil,c fortno .irrrlrr',
' r ' r ' r l ' r r r in ln i spinale (a:a-zisc
' ,cen1r 'opt ' l i ter jce" ) . L l l runl iLListr lo v. t l t ' l r t "
i r r , . , I r r | . . I . , . inr . l r ( ) q.r . (Arscni ! i colrb. , 1973; l ) ragi lncsct t { i r { ' l r r l t . , l l } l i : i ,r1xi3, t 965).
l\ Stndroatne'p&roplegi( ;i lelrupleglte ltol sii aprlrii ' i l l Itl l lnttlttrlxo.r l i , , , t i r r r r i ; r l r ' l l ' urol ; l l lu i In, i tut ' l rc l i fcr ic. { 'aro vul l i r rLrurr l l r I r ' i t t s t t I r . r t l t i l ' 'l r r l r r r r r r : r tut . - i c l le .c di l t ' tou{ i r rzr i l t ior , i l l conlr , r lu l t l i tL i r ' , r l " 1 l ; r ' t ' : r ' I l |g i i l 'r r r I r . t , r ' : r r r lcui i leDi luni thr le:grol iotr t i0 l i l ,asnl t i lcLr l , i isa,usubor l )n i ( i i l , ( [ i (1rr) l r l t ' i i )r r r r r i , , t l . r j l i , i -Lr i i 'hr l lu,r t - M'r r ; i . , , l rn iot , rot i i l0 r lp in i l lo plr) ! { r 'o i ; ivrr , pol i t t t rv l ' i i 'o l t r($ i 1 l l , ( ! 1t( ' l i lg l t r r r t r l r , t i i ) , l lu l i r . i r ' r l ior t lot tovl i l , t r lu. . , \ ln i l l l ,o[ , l I l l l l , (11' io l ( ! , ( l r , f i
, i t , , , , r r r . , t i , r ' i i . , I 1 i ' r t i r , l izrr l r ' \ i dt l td, i l t nt t r , t t r t t t la ' rc {r l is1 ' r 'o l ' i i l t t t l t tot t l i r r l r l t t r 'p l r r rs ivr , , r r t i0zi l r , , p0l i r r r iozi l r . ) , r r t . t ' l t l r , l r i { r ' t r ro l ) r r r r r t i r l r t ryot ' t l r r t I i l tgr t r ts l i11l l l ,I t r oo t t ( r , r i t t I i i t ' t t t i t t l t l | j i l , '
I
l . l : i
i | . i l . i l . I ' l l r r l iz i i p l i r r lozirrr r i r r lo rrrrr lorrrr l t r i nrol i t l ' pr l i for i (1
;i.;1.:!.1. Oorakt!;ii rttorfo-ttt tt,cliortrr,lt si se'nioloqice An lezilln' a lt(uro-n u l.rt i tttol orperileric.
l) fic 5t,ie cil, indiferent de setliul lezi:lrlii, si,nd,romul d,e neui'on moloryrri.li'rit: irrrplicii o serie de caractere generale : a) deficit motol' proportio'rrrrl crr rrni1,i,!,i lc motorii lezatc i b) hipotonie musculari' I c) retlexe osteo-l(,rrlirorlsc diminnate Bau abolite; d) contraclie idiomusculari pi,strata
lrrrrii la rrr gr:rd al atlofiei musculare; atrofie muscllard precoce li irupor'l:rrrl,ii, irr crrzurile in care este compromisi, integritatea neurollului motor;r,) plczorr{,r, fasciculaliilor (indeosebi in leziunile pericarionale) ; l) i'eacliilerlrr r lrgruorrscon!,ir, electrici,; g) modificlri EMG caracteristice de tip neu-f0 l fc l t .
3) ]tr-'ris&l insii' o serie de particularitii,li ale distribuliei paraliziilortrrlrr rrlrrrll i i lor' qi ale activit5lii electrice musculare, precum $i ale unor sim-
;rlrrrrrrr rrsrxria'te, ca're p€rmit il i.ferenlieri. ale toltograJiei. lezionale: a) la nivllrrl lrcrirrrrrionului motor I b) la uivelul ridS,cinilor anterioare I cr) la nive-lrrl pl,rrrlLril tl) la irivelul nervului peliferic.
lf) I'onlrr aprecieraa topografiei ieziuniior nsulonului nlot'or perifericrrrlc ut,ifii, olrnoaDt€rea pri.ncipalelor ac!'inni molot'ii segmcnlo,re ;i coretpon-t nla. i erl)etie' rad,iculo-med,ulare ,ti, perifc,riaa (a. tabelele nr. I' II, III Si,Iio. l[i, 19, 20,21t @up}" Iiiser, 1952 qi Chusid, 1970 - cu moalific5,rilor ro l rn{ r t lJ .
TABEL NT. I
lligeirile capdui
l I ig l . i r i l { r r rn 'ml, |1 ' lo l st lp( . r lonro
' lAl l l . l . Nr. i l
ip inosulr I
alr lu i r r r r , ,ndulrr i r r f .
, l t ) r , , \ , . r l l li ) r r l r i : r l
i r r i i (1( ' i r , r \ |
{ ( l i l l l :L l
hoir l r l r ir iLr lNnr l l | i
Dlepli antcrioliSternocleido-rnosloidieni
Pr'ni i ner\. i ar.nieni
n. spinal I- ramura n ( lolr: lccrv;cali
l , l \ l ( rs i lI i l l ) l r l I l
I | | f l i l l r r rculr l . { ' r r l l i
Splenius(lomplexul nrareDrcpti posterioriMici i obl ici
Scalcni'I'rtlpcz
Splenius
l{xrele rlen' {rrcipilxlMarele n.n' occipitalPrimul ner' \ 'eervica]Marelc rLcrv
Pdmii 6 n{rr i ccrv i r r l iSpinal - l - Fl imi i d, , i i r . f , r ' \ ' icaliMalc lc l rerv occipiLtr l
SDinal l- C,
l \ l r rc lo nt ' r ! { . i I iLr l
Ntr l rdr f rcrv rk ( i lJ l l r lM{rr ! lo t r ( . rv (x ( ip i t l l
I t0 lo l i j rcr t l )1rhr i(sr ' fcdrr : r l , t r t )
Slcrnoclc ido-rr : rstoidial r s l lng( l rnrUr l rxul DrI | r ( )s l lugSt) l f l rhrs ( l11 l ) tMnr'oh (lr'll.
txrr l l ' l l (n r l r ' r I ) t
Per, XI -Fcr"-c"or--c,
cr , ( :xor -- 0N
cr;.C,Per. XI. crao+c, -ct
Cr-C"Ct-C'q-c"cr-c,
C,- CoPcr. XI -l-cr-c,
I
t ,
I l id icarcarrmimlui
'1'raprz
Dintat mare
3
"--* I3r*C, C..Spjnnl I r r i r r i i
(cI . \ i | r l iNcNul
. r r l l r { ( l i
Circunrf l ( \ il l id icareabratuhri
Ileltoid C" Co
3 Coborireaumir hr i
I tomboidIL'tghiularPectoral ,nic
ca cscn c"cl- cs
Nervul l0 l l rhoNen'lll llDi.jhiLrNervul pe{ Lor l
,1 Rotalia bratu-l i l i inaiDte $i
inrpci
J)orsahrl mitreSubscapularrl
cl cuca ot
Nervrt l rnxr(hriNer.Jul suIs.: t l l
Rotatia bratu-lui in ahri
SupraspinosSubspinosRotund rnic
Cr cu0r CuCn- Ct
Nervul s l rpf)spiNer lu l sr lspi t l (CircuDrflc\
-Cdrtucliabrafului
Dorsollil marel lotund marePeotolaiul ma].eSLrbscapularnl
c, cuca-cscl-csC,-Cu
NeNul dorsalr l rNetvr l l rotLrndul\ Ia i Inul l i ncr\ ' l
c l i ] r p lc) ' r r l i )
Abducliabralului
Del lo idSup!aspinos
cs-ceC" Cu
CircumUexNcrlr l sul scl
fi Flexia4nlebratrului
BicepsBrahiai anleriorLtrng supjnator
ce -crce crc6-c?
\ I r rscnlo ' ( ut i r r r Il lusct lo rLrt r r r t l
rygrlI iadir l
Mcdian
crbi!1li ladial
n adi:rl
I tacl ia l
CubiLr ltr{cdiaIl
ilubit:rl
l lcdiarr
( t r1) i t j ] l
N{c(t ixr l
( l r r l r l l : r l
ExteDsiaantebratului
Tl.iceps Co C"
to l '1e\ ia nr i i r i i Pahrafii(mare qi rnic)Cubital arrLerior
Ct* Ce
1l
t t
t : t
r i t
Ilxtensiar:liinii
F l0xia poi icelui(pr ima f i a(loua falangd)
l lcx ia indext lu i$ i a mcdiusul [ i(Dr ima falangA)lr lcxi r { l t langclor
. ! , ! . t -i l ( ) , ia dcgctclol' l [ i 5(pr i rnr f t lnnl i i )( rL ( louu tN l t l
' r l . { i )
( r ' I r ' i r ll r l r tVr i )
ScurtLung
il cxor'
Prinrul ;i al doilearadial extcrnExtensoflrldegetcl orCubi f{ postcr ior
I t l ter{) ln,s i palmxr i
fi doIS.rli
F lcxor comun(sl |per l , f i pr0f . )
L lLcrosl , t i p: t l r r r r i
f i dorsr ' l i
r , | l t , r r l r ( i r l
Cu -' Ce
co- 0u
,9L9,o? 1)1C' D'
cr l)1
c? -, T)1
l - 'i
(? r)r
j , ' , , , ,] , ' , , , ,
t44 l4 i r
Corllnuarc cqbcl lI
2l
l t l
l lJpollcelui
Abdrctta(lcgctclor
Alrductia
A l , ( lucl lu
TABEL NT. IIL
MlgeiTile membroloi lqlodoare
l lo[nlr ( f rco[pid
l , f lor l l l
I lx l orBl[rl){ lccrlui
l lx lcrrs ldl r lUrrr lor 4rl{ :grd.c (primnhlu rgl l)( r ( loro $i alrchr ftrlanEtr)
Lung f i scurtoxtensot
Extcnsor comunPlopriu al indexu-lui qi a1 auricula-ruluiIntcrosogiLombuicali
tl
oo-o!
Cu-C"
Ct Dt
' / -liadial I
/
Radial I
Cubital ICubital '
A{l( lrr(Lin Fi| ,Pr)r l l larhgcl.olor
InterosofiPalmari
c"- DrC"-Dt
CubitalCubital
dductia Opozant ce D. Median
Adduclorulpolicclui
cr-Dr Cubital
Interosoti dorsali
Abductotuldegetului 5
cr- Dt
cr- Dr
Cubital
Cubital
pollceluiScuftul abducloral policelui
ce- Dt Cubital + Median
(l( l l rcl ln Adductorii L"- Ln :urator, musculo-cutanatinterll, Bciatic mare.
col lpHcl
Fesierul mic iimijlociu
Lo-L fesier superior
totof laI i t l rnLru a
(roIptcr
AbductoriFesiexi miilocii
L,- SLn- St
fesier superio!fesier superior
' Inth(flr l l {ObturatorPdtlatul cruralCroitor
L^_L.Ls-L4Lo-L"
ObtumtoxObturatorNervul musculo-cutandt extern
(li)rpsci Psoas iliac Lr-Ln NerYul crural + ramuricolaterale ale Plexului lamba!
'jxl (!n$ln Marele fesier scia!ici
0xlug0r bol
Drept ilternIlicep$ cluxalSomlte$dlrrossomllllenrbrtnosPoplltcu0rol lor
L^-LoLo- SnI-o- srI 'o- SrLr- srLr- L*
sciatic mareSciatic mqreSclatlc maleSclallc poplibou intdMuiculo-cutaDot cltorn
r40 t4r
o I z I
cf l r r I li ixtcn\iA QnAdJicep$ulcrulal
L'n-l't
Flexiapioiorqlui
Gambier antelio?(Si rotaliaineuntlu)Peronier anterior($i rotatia ln afardlExtensor aldegetelor (tn mod
L4-r"6
Lu- st
Lu- S.
popl i leu
' f ibianul antcrior
Sciatic poplitcu cxtcrD fllanrenol
10 Extensiapiciorului
Gemeni si solea!Gambier postedor(qi rotatiainiunttu)Ltng peronierlatelal(9i rotattain alard)
Ln- s,
Ln* S"
Lu- S'
Sciatic popliteu inlerD
Tibial posterior
Sciatic poplitcr exLot.n
n Rotatiapicioruluiinduntru
Ganbier anteriorExtensor propri[al d€etului mare
Lr*Lu.Sciatic poplitcu cxLerDTi}ial antealor
Sciatic poplitcu intern
Musculo-cutanat
Iibial anterlor
Tibial posterior
Nervii planlui cx[(,nltdrn
Iibisl posterior
n. plantar internn.. plantar htorn
Sciatic popllLcLr exlcrn
vl
plant{r inlorn il
Planl inlclnplantar int(r:t
plant0r lntcfn
I _.1 Rotal ia,picioruluiin alar{
Iixtensor comunal degetelorJ-ung peronierlater4Peronier anlerior
L._ S.
Ls- Sr
Ls- Ql iJ Irlexia
halrlcehiPrimalalangd
- Celelaltefalange
Lungul flexorpropriuLornbricali tiinteroso9iLrngul fle)rorproprmScurt llexorproplrlrAdductor propriu
La- Sr
Ln- S.
Ll- Sr
Ln- St
L"_ S.
IJ Extensiahalrcelui
I-ombricali qiinteroso$i (pt.ultihele doidfalange)Extensor propriuPedios
Lu- Sr
t5
t0
Fl exiacelorlaltedegete
- Pdmafalange
- A douafalange
Loinbricalt $iint€r06oqiFlexor comunScurt flexorplahtarFlexot comun
Ln- SrLl- St
Lr* frllxtensia
celorlnltedcgcte
Extensor comunPedios (ln afaladegetulul 5)I"omhlcall tilnterosoil (pcntrul[hnd( doulfslun{c)
Lo -'- Sr Dlautmilntqr:1 l l
(:o|l,llllalo trnbol
cxl0ID
B{qrh lcte d ia I is,flex ar,'.carpira0talts,Pqlflchs lcnilus
Apponens pallitis.
Abdua.f.or pallicisbrevts
flexat pollicisDrevls
,Abduclor Po icis
sibiifiisFlexar ccryi
Abdrc.bt digili.flixor djgiljquinti bretlts
-Ttiaeps
- Exlensor corPrrodidlis lonqus
Exlensor coai'tudiolis brcvis'fxlensor cffpi ulnorisExiensot digikrun
Abductar potliaislon1u5
Abdwlot Pollicisbrcvts
Atubus ntdits
Gluleus noxinug
Gto ailis
PercueustonquSfibiql,is
Ex lensordigilorunlongus
&
2a
SFt r
ciis €* .8
F,t, 20. Muqchii superf lcial i si membrLrlui superior (drept) '
SenilendinosusEiceps fenorisVoslus blerolis
Sen inenhronosu,s
Anloiot Fastetilr
Irl0. lr, Mur4hlt rtrpol'llsldl al mdmltlulrrt Inlopl0r (droDt)'
. i - , i .1! . ) ! . l ' ro l t l r utr dr l . i t r1t t ,* l r t l r t1t , t t1rul i r l i t l io l .oqir i t t l t r r . t , r . l , i : i i l r pr i t rI , i r t t t i r r . l t | t I t | t | ) |1. t | | t t , i t t t r l r t t 1n t i l r t r l
l \ l . , i t t t i l " p r i r r t t ' iunulr :l) I 'olirnn.irli lr a,nlui.ourd, &u,u,l,(i, (lM,l,(, l,ut IIein,c- llh:tliri). l)rliciltrl
rroiol sc irrsiirLulzii bl'utal in decut's dc citeva oro sau zilc, rle obicei dupii o1r,,r iorrrli i l irlrl i l i, (lo nrulte ori inso{,iti, cle fenornene digesl,ive, I'espilatoliii. r rlr. rr,rrrrrr nrorringe&le), dar uncori Ei in plini, sfnS,tate (,,pam1iziile der I r r r r r r r r . r r, { i r ' I ) . Sc lcalizeazd, tablouri I'ariallile, cu paralizii limitate, parcc-l:n(1, riur, rIirrLllotlir-L foalte oxtinse, tuteoli cu caractexe ascendento (sin-
'lr,rrr l,rrt(ly). 'I 'otdeauna reflexele osteo-tendinoase sht abolite in zonele1r:rlrrIii icrr, l l)i l,r' rapi{l attlfi i musculanc Di hipotonii remarcabile.
l,ipslsc 1,rrl brrli i l i lc de sens jbilitatt-,.')) I'r tl irtm,itl,i.tn, o,nteri,oud, cronicd se caracterizeazS, plin deficite motorii
lrr rrllolii lnuscrrla,r'c (rle rnulte ori rii cr fascicldalii), cu instalare fi evolutiel{'rrl plrrgrrrgivi,, orr loc ,lizare bilaterali, !i simetricd sau cvasisimetric[.l\l:r jr ) r'ii lrljol, lrcos1iol ,r sint degeneraLive (rareori cu caractero er€do-familiale),c,rk, rrrri rrnrltc ii inrl dc fapt forme atipice de S.L.A. (Ratlu, 1978 ; Trilletrli |olrrlr., I070), iar unele cazuri putind reprezenta forne subacut-croDicerlrr prrlirruriolile vilotiice (Drd,gi,nescu qi colab., 1962) sau sechelelo unei1roIiorrrir,IiIu a,nterioat'e acute (Ileine-Modirr), in care atrofiile musculalerrr rlrlir.i irlc rlotolii, dupi mai muui ani de la stinger.ea procesului acu[,rtrlcp ;li, so extirrclil {i si se accentucze ptogresiv. Drpi, Radu (1978){l \ rirl rlrrlrr, cir, ontil itli distincte a atrofiei nusculare progresiyo Aran-Duchetr-rrr., r.rr, rlc lal)ir fi {l pa,raliziej bulbare proglesive Duchenne este indoiel-r r( ir,, rt'l,i.ii1oil leplezentind mai probabil forme atipice ale altor afecliunirr'lr, rrrrrIr'orrrrIrli lnoitor (S.Ir.A., sindroame r1e S.L,.A. el,c.). Cr€dem, deci,r':r lrrlnurLrrl rlc ,,lrolionrieliLiil anter.ioar.i, cronici], devine incorect in etapa,:rIlrrr,li i rr, orrrLo;Lin{elo| noastre, pentt.u cazut'ile c1l otio)ogie neprecizati"Iritrrl lrlrlirl ir,bil si $e nlil izeze telmenii dc ,,sindron tle S.L.A. atipicttrrr,rr rlrr ,,sirullo])r I )(r'icalion:t l anterior oronic de etiologie nepleciza;bii, 'r.' l ' i lrrrl lrl rilr,i IrccvorLt intilnit este siuchomul amiott.ofic Aran-Dlchenne,rrr crr,r'r, rloiir,i lrrl rroi,or qi atrofia rnuscular5, incepe la triye.lul rniinilor,rr.:rlizrrrrl, Ir' irr rr,i,r'olil, oi)ritentolor tenari, |i hipotenarii [i :r, interoso-,rl,,r', ,,rrririt, sirrrirr,ti i i ') ;i ,,rrrila in ghear5", dupi cale progresiunea atrofieil:r rrrrclrrl rr,rLi oll|ir,l,t1or, tg lrzaa,z\,,m ta t1e lredicator.,, $i ,,mina Si anto-lrrrr,l rrl rrr'Irrrlrrl,icJ'. -,\t l '{rfia ss poate exti de qi Ia nivelul nusculatur ii bra,-I r rlrr i |i r' lr i it I lrl rIl so[]intura lizomelici a memltrelor Supelioare.
ii:ur (lrF(,r'ir.i rji cazut'i de ,,poliomlelitrd cronich" in ctre atrolia debu-1,.rrz,: lrr nilrrlrrl utl$ct atut'i i proximaie ar membrelor superioare, realizind:r,r 1,i., lc prorrrlolrriopa,tice (Yulpian). tr'ormole de ,,poliomielitl donicS',r r rlr.lrrrt, l ir rrrcrrrlrlele itlforjoat'e (pe glupele tnuscxlare peroniene) sintl l l r l l l t r r ' .
'l .l nirlrol'i il.t: s1ti.tt.u.le progresior (aniotro{ia progresivi, in{a,ntilii,\\r'rrlrrr;1 llollrrulrur, arr)io{irofia spinalti jnvenilii, pseudomiopaticS, Wohl-lrrll, l i r rgirllrolg-Welanrier) pot fi recunoscute [i diagnosiricate prin car.:rc-| ,'r'r r I lr rl lorr ol ic olc(lo-1atrilial, prin masivitatea sji bilater.alita,t€a atrofiilorI t I r I r L r | | | I r I r ' ( | , irrirrl(,il,c ;i de al1,c sernne de afecijare degenera,ti\.:'i a moton€uro-rrilol rpirrrli : rr,r'olltrxil, osi.cotondinoasri, modifioXtilc ll.M.G. de tip lteur.o-11r.rr r r r i r , Io1rrr I i r . , l ipst strrrrntr lot t r i r ' lnr idalo [ i a, lu lbnr i r i lor d€ sensibi l i la i tc,gr l l r . r r r r r 1 i l ) t ' i l o\ 'o l l l { i l l (n, l }1n1, ictr l i ' i j ( . l lNdl , l9?8, t971}) .
, i ) IJrry lu. ( t t j r , i t , i ro. l i ( ) l . i ( l l t t t , t ' .n | . J/o ' i I srx i r rz j i , i r r corr lor l l r l f ( . I l r ioloyJi l rorr t l l r l l l t rz i r r t r t l r , r r0rr l r I r r i | r I t r r roI o l i ; r r , r , i l i I l i r r i i r I j I l l r r r iv i r l r r l | r t ' r ' i t . l r ,
i0
r iot t r t , l ( t t t t i i t t t r l totr t r l t ' , , I ) ( ) | i ( t I I I i { | I i I I ' i 1 ' I t t t I t r t ioI t I i i t lot t i t ' i t ) , r ' i I i1 i I ' to l t r t l l r r t 'prr t i l i r t i r , , l r r r r lut t t ; i sot t t t t t l t l t l t jot ' t I t I i t ' t t t I l )osl(n i { r l l l t f . l i r l l l l t l t , l t t ( ' i l l ' l l l r l l ' ft j r 'ur lo. I l r , r r r i I i l r , I , r l r :Lr t tLc: t 'z i r i t l c0pi l l i , l i t l s t t l l l i t , \ ' i l 's l { r .1, i t l0 l ( ' , l , r i t l r l ' i , to l i irl is[alc localizi,to 1:l rnomblclt inlerioare, cuplinzir([ ittl,i i ttttlst'tl lrtltt|rt ' 1rr'rrrrrior'[, apoi pe cea gambier'; post,erioarr",!, la il lccpul ou (lolioil lrr()lt)r lrrrplc:r, irnporta,rlt, menlinind mu1t5, vreme sta,liunca fi rnol'sul (c,,trr ilttrii rlrr lrrjlrcep[t poate lua un aspect stepat). Apoir 1en1j -progr osivr ll,Ilriolr'( ]l i i l rrro\tinde in mod simetric qi la treimea inferioarii a co[],J)s()lor' Iolll izirr(lfrl,rofia caracteri,sticd, ,,in picior ale coco,i' (sau ,,in cizmii iltaJl,il,") lilrozi{ie de mrus-equir a picioarelor, cu consecutiY€le tulbut'i it i rlo tttol il i lnte, insolile li do tulblrrd,ri i le sensibilitate ectromelice (strbi()(li ivo fiiobiectivo). Xlernbrele superioare si]]t afectate mai tirziu, do l'egtllii ilri(,ilrl{n atlofie tle tip Aran-Duchenne, extinsi, ulterior pini in lr'eimca ttti.ilotrirt?r antebratelor (atrofie ,,tn rnan$eie"). Existi qi form€ de tl'ecclo irrlr'(rboala Chaicot-Marie $i eredo-ataxia cerebeloas;, (boa1a lui Fritxh'tr irrlt),situatii in caro se asociazd si tulburiri de sensibilitate profundX, cu irl,l \jl'{prin"leziur ea fibrelor radicuiare lungi din coraloanele posterioare) li, ov(rlr't,ual cifo-scolioz5,, picior scobit cu d€gete in ciocan, precum !i mioi fi lirrdive semne cerebeloaso.
4) Itt siringr.tmiel'ia se constat5, lrecvent semne motorii poricariorl:rl(t,cu sindrom Aran-l)uchenne. Amiotrofia, cel mai adesea simet'ricii, int{no'{ea,zd, membrolo suporioare cu fasciculalii' excoptional de rar apil,r'irrrl lrr,lrlembrele inferioare. Prezenta tulburd,rilor de sensibilitato di$o(lirLt(1:iirigomielic, suspondate, a imporbantolor tulburbri trofice, a sindrolrrlrllri}iramirlal asociat, procum $i €Yolulia foarte lentd, ne sugereazri (li:rglxtHliicul.
5\ Iurnori,le intramed'ulare ti traumutismele aortebro-mcdulu,rtt (:tr'hnnal,omi,eli,e) pot genera siDdroame motorii pericarionaler asociirl,c (1ll rt,ll(\$ernne comisurale, indeosebi cu tulbur5,ri de sensibilitato de tilt si|ittgrtrnielic, de obicei inil,ial suspondater apoi sublezionale (cu niYol (l{,5(!rr$ibilitate ).
ll\ Leziunila rdd,ic'LLlare .mteriodre prezintr, o serie de particllllll if i,li.I)istribulia topografici' segmentarS, a deficitului motor $i a celol'Lrliro sorr rrri Icolelate a1e sindr'omuhi do neuron motor periteric este identici' ctt |trit' tlittIcziunile perica,riorului, dar fasciculaliile musculare sini exceplirtLrtl rlrrfur intilnite.
Pe de alti, pafte, vocinltatsa ridS,cinilor posterioare facilil,oltzil' rlsoriorea frecventi tL unui silfdron do protoneuron de tip radicnl'l't,'
1) Comprosiunile raaliculare (tumori, arahnoidile, hornii (lisrlrrl{r lirli,o &fectimi vertebrale compresive, tumori vertebrale primitiYo s2l,tl s(xlllrrrf irrt, boala lui Fott .s.a.) teallzetuz[' cele mai Yaliate sindroamo tolx)gtrrli( 1r(rorvicale, dorsale, lombare, sacrate) mai mult sau mai pulin o\l,irrsr!.llrrrliticilrils de reflexe (osteotendi:roasor cutanater a,rticull,re' pilolrrol(,l i i,rrvsntual m[coase) $i apreci€rea tulbu.rAriior de sensibilitate i],so(,iirl,(t l,r\rlclrnatomerele respectivo tranqea,zl localizarea $i extonsia, loziunil(]I'.
2) RadicxLli,tela (respect'ia ma'rlingo-rdd'i,culi,re1c ) virc1,ieo' ltotitrtt sttlrrlo llto ctiologii pot fi unilalrorlllo (n&i mult sritt ]nfti l)ulin oKliins(r) $rr'rll)i lr,l,(n il,lo.
Jl) I'olirtdia.tl.on,(,,1n ild( lt\tl t 'ollizl irttblortri i;r{,t tltlcgitltr (trtiti tiw tlorrt1r l r , r ' l lp l0gico ) , | )o l ' ic i l ,o lo rr lo l ( t i i i t ,J I l , t ' i t t l l t t t l ,cr i ' t t l l t l lo l ' l l I l )11) l t l i ( ] l l i to l l l l l { l. . l : r , r '1 r l9 tL{ ! l t t ( , l r r r i l lot ' ; r r r t i l i r r i t (ot t l t , t t r l l t rx io t ls l rot t l ,ot l t l i t l t i t ,s i i , t l t t l t i ; t r t
louir ! i { i l , l t l r , i ,otr i r r t r t l ts f [ | t t i i 11i I r r i r , l t0 l i i ) t1 i ( lo [ t1)1ol t r \ l l t l t t t s t t t tz i l , i t ' r r t t
ll l , l
r l l r l l i l r t ( i r ! : r l , i l , p i r iLnt i r l l t , l i i , r ' i l , 11i l r r I , r .orrrrr I i r r i i , . X ' la i r l i f io i i po:r ,k l l i r r I roor. ir l i r t r l rosl , i r : r r l i t r s i l r r r r , ! , i i l r r i r r r . r r l r r r I r , I j | i i r . | ,1 rr l l ' ) r ' i i l l t r . r l r r t ) r in i l , l l l r , iu l i .c i lt r r r , t r r I r l r r IoI , l r t r r r l r rc i r t i l t r t t l l r l r lorr t l i l ic I )s( i l t ( l { )nt io}{ , i t i ( r . . l ) tbu1,tr l bnrscrrrrr Ir,Ir,l,iy lnrrs(1, yirsiN, do .r,pl,r' i l i{) (l|, or.ioe vlrstS,), a,l)olirea ]rtlct{ol(r',rlrrrrkrrrrlirultso (rlroli cn pistrrr,rea r.ellexelor idiomusculare), lipsa atr:o-lii lrrr rrrrrsrrrrlu,r'o in si,adiul de debut si mai ales n.otlificXrile lichidienc, cetrrrr.i rrrlosoil (xr disociatie albumino-citologicX, vin sE, para,feze cliagnosticulr I r r 1 ro I i lr r r I icr rlone.vriti. Gtrillain,Baud.
I) ilind,roamele coai,i d,e aal rbaltzeazi, tablouri multiradicuJare par"li-lrrlrrrrr, rr,rlcsc:l, cu paraplegle, 4A$cd,, hilg-tp[6r ?ISflexiE[ $L s11 at{oJii-rnrs-ortkllo. 'l'rrlburzirile de sensibiljta.tg pella4aler. in ga.Si tqlb.gr'rilc sfinete-lr,ro irnlx)rtitnte ttimiln diagnosticut Oe potiomiitith; tifrsa tulbur{rilor., l ( . , . r r l i l ) i l i ra.h. ucl lorrrel icd Gubiect ivc $i obicct ive) el i rnf ia i 'd l ;gnbi l iar i lr l r . l lz i r r r r r . rnct lu la: i i .
Jt)'isl,i\ trei til)uri de shdroa,rne cu coadr, de cal :n,1\8intlrom.utV6ffi.\ol aoai,i. ite cal realiwnzd, oteritabild; p,ar-aplegie,pet!
Irrli*i,, 1ltr,scd,, arafloxigd,r.i1lierosird ioate $rrlelo rnusctlale.alo rnembrelor-rr|rriolr'o (cu integritatea psoasului il iac) 5icu masjve tulburdri sfino_
l i i r t l t 1 i l r r r t t t i i r l is t l l l r c l t r t t l ro l ' I o i t l iz l t , t t l t s i t t t l t r t t t t t l r r t o:r l l i t lo r , l r l ' l )o pik l l t t
r,itrtl irtr boltrr,v rr, rrouzrr,L lrit0vit sri,l ltit,tnini soi ,hr,lgii lu brrsottli i,, tl;tt i1i rrtti l l r r l iar i l ,osl iaulr I r 'o i ] i 1xrr inoi [ lo, ] rooulr l I i t - l t t i t t l l r t t l i i l i s l i t t r l I r t ' icr t r ' , i t ttlrolrlenl,ul ilt cirr.e au sui'vcnit Ei lorlo ]onolo lilteliotr ;i l,tLlb tt t i i l i ltt tl0 srrtrl ilri l i[a1,c in ;a, trebuie categoric sii inbi],ndorti ' lm rlirigrtosticul tlo lotttlttrscilticri ban:rH,,,si ilii xe gindirn la o compresiuno in cozii (10 (,i '
b) In cattr,L rtrvi euolulii suba,oute sau cron.ica lan't-progrtsiuo rrogittrlitttirr prirrtul rind la o campresiuna a cozii de cal, in spocial prin tutrroli srtlxlttl e primitive (neurinoame indeosebi; limfosarcoame ;.rr.) sittt ttlol,rr'"si:ltice (subdurale sau extradutale), alte tumori extrrldttlrrlc, borula, IIotl 'elcirr, alahnoidite chistice pseudotumorale, sau la comptositttti rlrr rrli 'r '1,rrrinrir. inclusiv rertebrale (boala Pott, metastaze !s.tr.)
ll l) Lezi'unile plemLrale te^lizeaz\ silldroame de neutott tttrtlttt ;rt'r ' i 'li)r'ic cu topoglafie palticulari', uqor de recunoscutr pri]1 ertenBla, (x)lrl'rlrl,ului semiololic in teritoriul plexului respectiv (cervical, brahia,l, lortrh;rr,siloritt,). la caie in rnorl obliga-turiu se asociaz; tulburi,ri dc seusibilil;alrr irita'ofice in respectir[l teritoriu tle inervalie plexurali.
Arnintim pe icuri colt.stela,ti0, sanxiologicd' 9'i problem'ele {k dr(llttorlior:liologic Ln sindladmela pleaulare :
1.) Sind,rotnul d'e plen cemiu'l impiici : alteratea mi$clrilor tic IL'xirr,roirrlie qi inclinalie lateral5 a capului qi a gitului' la cate sc pol, asttt:i:r'i,ulburi,r:i reSpiratorii prin paralizia diafragrnului, prtcum $i trtll.trrtrlri tlr',n'nsibilitato in teritoriile ratliculare Cs -Cn.
E*te reahzat de multiple afecliutti I tr'aumatice (rlt colonnli tltvira,Lr. inalte), tumorale, inficlior-r,se, malformrtive {r-r'zi Arseli ,si rrolllr.,l l ) i i t i ." "'1;1' g i nd.ronut daltlel,iru.bdpoate fi reatizat lie tle leziuni t'rr,rlicrrl , r ' , 1 i 'u- [ r , ) , l ic , le ' t r"z. iuni-ale t -mnehiur i ]or l t r im1 re (s l l ln ' l ioI ' , t r t i . j l rxtr t.;r i,Ui..r:iur), Iie rlr' leziuiri rte trinchill itor sccundul t -(suporiorr irrf(rri(rrq,i ptxt|r' ior), fie '.rle ptexului insuqi. Ca ataie, se pot rlistitrge patnt, I)trrittttlt '
' ' "''".i]{rifl,i,o,rutde.mialiiri-tiitiio pterutr+i braltial st cirruct.rrz{trLllrl irrtr-n paralizie c-o4qd9-t[;-exf6d"-ta intreg membml superior rb$lxr(rl,iv,|rr anestezie gtroba}i iL teril'oriul intregului plex'
b\ sintlr<.nnul sipelioi,rte plea btakial ( By'.9fu94.?q-Hrb ), itr citlrr ltrzittrLr.:r intereseazd, rirli icinile Cr-Q, respectiv teritoriul nervilor l-nruo$lrl, , l t i r . l r&l l i a l r i ic l lc in i i erpe.gle! med!4nuly i . se rrracter izcazr ' i p l i r l i l t \ l i l ' r ll l r r ruL. i atrof in r tnr r r , .b i lor l le l t o id, /b icrpsr/ b lahial ln le l iordtutg r t t ; r r t r i rlor';i nui pulin a muqchilor dorsal mare, pectora tnarc, diltflrl tttrt'tl i i irr,1,nir(l maie. Rellexele bicipital gi stiloretli4l sint rrbolite. Tulbltli-rI i l ', tlt '
" , . r rs ib i l i tate " inf p|ezcntr ' - [ r 'derma-ioFier?tr ' ( . , r rcsprtozi lL{)atr ' ( ( r . - (" ! ) .
r'1 sindrcmrt injer.ior, da plex broh;Ltl ( 4t,lrupLv'lM#t;rldJ , itt crrtr'. , .z iuncrL in lerc lcazr. i ' . , ' lAcini Ie Co-D,, respcct iv le l i l r r | iu l t rctVi lot , l i :ubi l r t ll i par l i : r , l a lsncr l iauutui , sc ca t act-er izeazr l p l iu r l r ' l i i , i l - l loJgl i i l t lut . fuulrrrr r
"Lilol rniinii ti ri gruputui intern el antobrat/ului' tulbutriri rlo srrtrsibililrrlir pt tL:rrniilttrneroli cot'cspurrzir,toa,rc (Cr-D1), llt, trlltc sc itstxriltzri (ittlcz i r r r loa r iu l iorr [ur i i ' ) r t tL s int l t 'om Ol:urt lc Berna,rr l - I Iotnct , i i t t t r ' l l l r r t ll:rrlriCo-prrrntlt;ot' tsl,o rr,lxrl.it.
r l \ ,^- int l ronrt l t t r i . j l , r iu i r 1 ' l t . t : ht th i ' r l . ( Hc.mt, t lc l i t r { ' : r t r ' l { / r i t r t r r ' . r r r ll , .11.s( ; r r i i u i t l r i l i t r : t O' t r ' .p l r ' l iv t ' ' l i l ' , l i t l l ( ' i l ( l r r l r l l l " \ l l l l l i ; i r t l f ru l i : r l r t l r r r .i r . , ' r ! r ' : r i , l r l iz t . i rz: ' , Pl i r i r l r , l ic i l , t t t r t tot '1 i l t ' l t i r l iu t t , l r r t t4rr l t i l l l t / t l ' i t ropx,r ' i 'x t r , r r
I ' rr t ' j tuul.lt) N [rulrontr isutrter'ior \ql, cozi,i,Lle ca,l.
prrlriir,l sint abolite ixl cqle achilicne qi medio-plantare sint pishate.r t x indronuL f f i r ior ' (sauat 1 ol razi i dr aul ( Io - J" , ) . In legr i latea
rrrrr;r'hilrir a,nt€riori ai coapsei collrastcazi ru imlortaiita -.pariUzie -arrr:r.iclor rrrusculare po$teti0-4re, inclusiv a mugchilor fesieli ,;i gambieri.l'iciolul cstc balant, ou tieticit de flexie-extensie, intilnim nD impo*antrlolicil, rlu flcxie a garnLrei qi mari tulburd,ri de se)rsibilitate perianale,1rrlrrrrrr si pe fala posterioard gi externS, a coapsei gi a gambei. Reflexulr')l rli lr fi rnedio-pubian sint p5,sirate, in schimb roflexele achilieno qirrrrrrlio.planta,ro sint abolite, lt]ulbgrlrile sllgleriene r i,irin pe primul plan.l i , . f l l rcL. r r r r r lc (cxlern $i interr l -s int abol i ie. Pot . ' i apalr i s i es 'care.I'r'olrr.k, rlo elongalie pentru sciatic pot si, fie pozitivc. Teoretic ai.Ti1r,' rlril:r r/i/i,r'r nlilttt irtrc leBiunile corrului Fi ale ep,iconului meduldr.fald,lr tt ittuilr,, '^-iIL]e rtrl.Inc[ Lhermitte (1919, citat de Riser, 1952) precizaserrrr,lr, rrli l,rrli i rlo tliagrnstic diferenlial: in leziunile conului qi epiconului,l rll l i lr s'irrl n)li ])ulin vii gi mai pu-tin persistente in membrele inferioare,r \ r,nr iiorrnll lrri Babinski, asistd,m la o simetrie a tulbur'[rilor cle scnsibi-lrlrrirr;i rle rtotil itate, la mari tulburlri sfincteriene si genito-ur.inare,I'r', 'r rrrrr fi lrr o paralizie atroficl importantS, si a, muqc]rilor anieriori ai
Sc irrrprrrnc ;i tl,iagnosti,cu,l tliferenlial fa\d, de afec!,iunile prostatice, inrrllrrlcrr, lrolrravii simlind pasajul urinii prin canalul uretral, precum qil:tlti, rlc, ltti.tr,tti ontinpe al,e pleuului, lonzbo-sawat (ca de pilcli, in invaziileIrrrrrolrrlir rrlc micului bazin), care pot simula un sinalrom de coatlS, de cal.
lrr frr[a unui sindrom ele coadd, de cal se rialic5, foarte malte problemerlt rl.it r ttt.o;sl,ic tl,iologic :
t,) .Ln, cltzttl rlnei, i.nstald,ri rapid,e, aaute sau subaautre, ne gindim inlrlirrrrrl rlrrrl ln o borlll I?o1;1; joa,sii (lombarir,), la o rneningorrdiculil,i, infoc-(iorr,sii rr, r'ozii rlo cill, l l, o prr'i,lrtr6iro vorl,clll l l i i pliu tunrot'i l 1r'irnilir.i i rarrrrr , r ,nrrr l r r t i i , r r , r ro lo; t t t0 i vtu ' t ,o l r t ' t t lo lotnl t i t , t r ' . l r t r r l i t t t l i rut ' l t t r r r lotr t ; r i ,ozi ' i ; rcrr l i .
t5: l
i
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i
j t 0il
ili',,'li,lliiil:,jil ''i,1";;;lil;l,; 'l ,;r,,litt'r, r0r'ror rr rui 1 r'ir,iDitill ryi .. rr I uu,uri r i
l ';rLa,liz,irr do lrhrx llrlrLiil l r.nla. 2r.r,r/usri rlc tliatrtrr: ,tl it,!,inni: ,, tl 'laniu,ni l,r& ryjeliq? Irr, rrivr.lil colorrngi/cerricrr,t,, inierioartr li,dior-r{ir,l(, Nl lxrljr)rrre, sa,u la nivclufclu,viculei, a/riL,xilei si l-[ zonelor sujpia_ siirulrllrrr.ilrrllrr; frlcturi ale claviculei, ldxaiii scapulo_humerale. clotrEai.ii1,,,.1,,:]i l,l, l'..],, ,1 ; lrir
(.t uIi,a te rtr viculei, .luxa.l.ii scapu lu.h u mcl1l lc. cl,irrga r iil , f . i l l ' , f l . l l l l , , l i Sl qlf plerului ,(ureori ctr iar..r .u snrulsprea I ' i i t t ic initorl ;
, r , r r l ) r l s l | l l l | t i l \ l ta. ca de pt ldA la pur ldtor i i de ( , i I ic . jn l ( } rvent, i i chinr i ,|,,rrrl)rr'sl|rlrL,l|f i l,\rla, ca _de pil.ld, ia purthtorii de cirje, intewenfii chimr,-l : r , . r ( , ,1)r . : r r ' r ' t , ' ' ts- l Icgluur do mai SUS; t raumal isme obstclr icaje, cu L.z i r rne:r! f : : ) , ' ] ,1 ' . ' . , , ' : :n l r r , rn r Impl l t .nr l ler i i (consecut ive xnui bazin s i r imt, r rneil)r'r'?r'hrirlrrrtel{'ctuo-irNc, unei eompresiuni exercitate tle manevrele obiitetri_, :rrr., l)r' lr,\l l ptcxului intre claviculd, Di prima coast5, elongafiei sau smul_l l r r i i I ' ju l i r . i r r i lor ' ) e lc.
,b\ . I , ' \ ' .y i l , t sa.* r ( : I icul i t r , ( f ts lp?t ; , rudiaut, ,pnt i i ) t ' intec! i ( )1sr. . . . "4oxi .c
l , r ' : rsr . t1r1 r . t : tprr , ( . , pur l \ ac. tnt ln., . 1) Su.feriu,!e
-uertebrale tlc ditserse naturi : hpondilite (indeosebi morbulr.rr r.(rr r.('r'vrcar) ; ,tumori Yertebr.ale, i.tr_ara,hidiene ;i extrarahidiene;l r r r r . l r r l i ; i r l is iocl l i i vertelrr 'ah. ; /herrr i i de t l isc cervicule. _
. . . , ' . r t . l ' : ' r r ! ! : i cosl t )nertpbrolc
^si .a lc deJi leu. tu i sralar i r r r6oastr i cen. ical i i ,: . | | Inrrr | l r { , Ni . r tcnlce, rcal izalo indeosebi pr in t r ibcnrof ja nru^chirr l r r i scr jr r . r : r . r r l ( ' l lot , crre lxgrslcaz{ , .def i ieul scalenic ' , (sapt iu l r l i l t re cei doiif l,l i, l l ' i l,,l : ',, Ei pnnra coa-slii) rqi care iD acesl mod r.omprimi, ple.rul br.;r_rrrr sr irr'1(,llt suDctaviculard, (Arseni qi Oprescu, 196?; Ionescu,* popovicinrr i culalr . . .1.921 ; Riser, 19b2).
. ,.1 rl'lrmori ale, virtulyi p.1r$g-n?T. i Sinilromul paneoast_Tobias, incru,. ,lr.
Insii p,aralizia plexuliri biafiial, inti]ninr dureri qi un siDaliornI t i | | t { r . lJ I t t } : l ro_l iorner.
:l) I,'arlrliziile d,e ple* lom,bar .(traumatiee, tumola,le, infecfioasc etc)-rr ' r i ' r r '1r ' r iz i ' | i lz i l p. i r def ic i le motor i i cu atruf i i a le coapsei g i pr in durei i, . r r i I I i I r ' IL| | I r { . }n lct ' i lo l i i le nervi lo l ,abdominogeni la l i , - fernurocut:r ,nat , . i, { t , l i l { } { , t u t .Nl .
. ,ll I'ut li,ritle_d.1 tt(lt sstat realizeand, rin context semiologic in care
I | | ' . (. I r | | | I r | | it 1'll 'uii rilc din parlea, ner"vului scial ic, la ca-rc se c,sociazi I tro_tr t r .sr .n. , r l r r r r . r ' i pet . inel le s i lu lburdr i sf jnct er iene (pl in afectare: i sf inc.I r ' t l l r r i l t rut l r rx l ;e ln ) .
.. l:tl l.:,
: i,,:
,, : i ,t , lterr ur periJeriri pdt. fi izolate (nevrite, neuropatii),iriroi.rrr., r)Irlt rltc (mlllUnevi.ite) sau extinse, bilatemle gi simetrice-(poli_rrr , r l i l r ' , lxr l i r reulopat i i ) .
| ) I\ruli:i i le i:olnle flte npt rilor pcri.tpt.;(.i :l) I'uru,lizia ,ner.uului circumJler se traduct lrintr- n tleficit motor alrrr r . . r ' l r i l r r i r l | l l r r i r l , . "cr , ( , r ,crccazd di f icul ta lea,5i11r. , i . i . i p;oicc[ ie i i r ra in le
I r r r ' : r l r t ! t { 's- l , r { . t tv. i r tnent iner i i acestuia la ur izonl t j i . At l ,ot ia mu)r,hiul i| | r.|| |,.|| I r,r'r'r 'rzi] r r|l_rrginea rle ,,umi,r in epoletr) sau de ,,umir tfi iat cle secur.tr,,!r | | r . | | . | | | | t | | : I o relilxue a articula-tiei scapulo_umerale. paralizia muqchiu-Irrr l.l,r111rl rrrir,.,impietcazii ltri;oarea de rolalie ertem5 a bralului. l iulbu_I ir r r.: I r tr' $('r rNil)il i1 Ltc sr. distrihuie intr-o ,,zonir, de r:lcheti,)' pe'fala rxternl,i r l l f ) r i t l r ln ' ( . l , iU, 22)-
,......,1r.::.",,,,r: ,i,:., ' l,rt.t1iri u,ni tts ti,nt ni.ti.. fractuli ;i rlislor::iri ale cu,pului: l l l , , , l l ; ,1, t ' t i rgr 1r 'urunrr1ir , , (p l jn N,rmc nl l )o $irn de for_) ; com])rcsi f t i lN,rr \ ' . r , r l ' ' ; ' r r t r ' ( l ) r r , l i ,s i {n l '1, , , i r t cut ,snl sornntr lu i , s i l r r i l r cur l ru l i r r r .s l r ,_, | | l r t ; .1| . | | | I i r | | 1, . r r r . , r r ro l l r l i i 1( l r i r l r ( ( l11 0xir l r l r r r l t | ' l ror t ) , r , r r r l0. t0xict , ( t l i i rl r ' l l | r . t I r ' { . ) . i t t l r . ( t io i tst , , " r , t l ) l r , t , l tDt | r .
{ - l t .
l i r r l
) ) L 'dr ' t . i . r i t . t nr t ru, l t t , i . . :ar . l :+( t t , l r t nt l ( . . t l , sr ' l l r t t l t l t , t ' l l r i t t t lo l i t r i l , t t to lor ,rrl tnrrrychilor' lr icops, lrrrr[ri lr l iul l,oriof osi cot rtt,olrra,lt i i t ' I , r 'ospccliv (1lr I): lI( 'zl,I l t tx ic i l r rLelrr i r lu lu i (supl in i t iL do hrngul supi l l r r tor ' ) ; ; i r r , r ' i r l ic l i ' r ' i i t t t t t i t t t l t t i ,irso{,itr"r de o hipol,rofic;i hipotonie a rluiiohilor lo.j i i ir,nt t ' ,r ' iorrrca, lrt 'rr l ' t l l tr i.1l 'rrlburriri le do strnsibil i tate sint mici (vezi f ig. 22).
h'uctori etiologici mai imporlanJi r pligi pl 'hl at'mc albt, srttt t lo l ixr IIt i lcl,uli ale hurnerusului I anevrisme ale alteroi Axilttt 'e I r:ottrptr'sitt l t i(1u'oi'csiorrale san in cursul somnului) ; nor.lile (fotrrtc rtlr).
Muschiul dellaid
,qomufl culanate
Nervul circumflex
Muschtul ratuhd mtc
NervuI musculoaianat
Muschiui biceps
Circumflex
Ramuri cu.onleale antebralului
/ r r . . r . \ " f \ i i c i icur l rUc\ \ i " . ' rs, u1ocr, l l l : r l ,
1r, rz i(it: in a,bduclior:rr lr'l t olie rl eririnonqi prr rn rrs<rrr l l r l ; r r t ' r rr r t r I r , I r t i r , { r r I r r i ( ,1 i11. i l : ' i a) . l , r r l r ,x l t t l r lc i t t r l t i r l t , t r ' : t pt t t t tr r r r lu i ( r r , l l r t i I ' i l lor r i ' l ' r ,s l , t t l , , , l : i .u. l ! i l l , ) pol i r , r . l r . 1 i r lcgr ' l t t l r r t ' i l i i l ,ot r l t t xrr
lr li rr cnbitalul :rnterior, lungul supinator qi fasciculele cubitale ale flox rtrtr lt I ii,ornrrrr plofund). Iilexia falangelor distale a,le {legetolor_?r[-4.{t'or li.ttt.ijkrr,irr r,sl.o imposibiki. l l\carea de opozilie u, policelrri trLt st.poal,c trlt,oltttt 'I i irrrl inlocdilS, prirrtr'-o rniScalc rG n[duZlli.ai fi,]iclri. Sl lealizclzl l
d, policohli po ltnlali l lan r:u oolela'lto <lttgcir',t( r ,mlna, r i i t t t ia4r i") , r t I t o l i t , t , t t t t so lx)11( ' ( f x I i l l l l i r
brcnhial
| fi[
l l.r' l.rrzii, irn { I(,gd,ul ln i j lot,iLr s. i ' lrrrl urrzii, doa,r, ptrr,f,inl, rorlizind ohiar rrrr:rH;rr.r' l,.tlrr. ,,gr.{ii. medianl,l '. J,:r, ,,pr:oba, bucleil, (a tui Pitres qi ,I.estut)(.1i1.. .:!:i c)r lllangeta irrdexului Du poxte si, se u,propie de cea a'policelui,rrr;l l i. l irrcll; trici nu poal,e sL string5.1n obiect inlre ]olice si extremitatei,cr.lrrr'l:rllo rfrrgcte. l,a proba. ,,{g!!ilgr_-!_nsnrciqate,' (.fig. ZJ (t,), lTd,exalrir rrrrrlirrsrrl rlmin intinse ,,in sdg---e-at$1'. Un alt test eonsta in'iinposibili-(n
i , ^
l r , l !1. , ,LL,r iL : l r r ru, i ) l j r - Pa.al iz j r !
Fig ' 23' i
ilu,rll,il'ir ii";l;;,ll;fijlir,.il*:tf,',.:}"!!!iliiri'Jll'''::'ill.i5'Jll"L"'r;#:tl'Ll,i'ji1::l*ill;tin.\ , t.\t..!, r . r ",,ri,i.,,,k ,,,, , ,.,,.,,.,;"','i,ii.;,Jf;-J'.ii"ll 1"il :i.::. :',"jJ'"', ;:"J^fr,I ll"f..l;"nr. I . . | , .d,- ;g 'dtA'r . j . ' t )p ' t ra: ,?. \1r l ) j?*t" i ro.r :_,an":J l mei i ianuluj .
lrrllrr llrxici rrltimci falange a rlegetului ariltitor', astfel ineit, atutci cindr'|rrir ,.rl(! rrrjozirlai. cu fala pa]marii pe masd,, boLnlr-ulgg pq_?!9_-lg-ZCil!grr:rr,rr rjl l urrghfu degetului aeitnlotl Unelo mis(.ii ri coEi.h,
" srtrcrur,j i{.,,
.rlr, polir,r.lrri 1i rr,le celorlalte degete sint imposibile sa,u incoinplete (indeo_ri'.1)r Itriri( j lIiI(r rlo prehensiune qi t1e prindcre ir, obieclelor). Nir trebuie sriIi l,ir||r |i i rle rnulto ori apal dureri cauzalgice, r]rbotite t1s tulbur,:iri vaso_rrrrrlolii ;i l rrrli icc, limitate ldhlvehil inAe.iiitui,.i aimerl jusului, in specialr l I l ) . r l | i l r r r i r l in- t ( l r . net-vUI l t i mer l ia l } .
. 'l'u I tru t i}'i}:. tlp- S-eg51bili.tpl-c sc consl,ati dolr l)c ur.l i,-,ritoriu par{ialr r l z , r r r r ' i r l r . i t r l lvrr l ic l r , Iu ' r r r r l r r i mrt l i r . r ( . [ i , t . : ' . j ,^ i .
, I 'rin.ciptli i.lurhti ttidouit,i t a,\ lcziluni lrautta.ltce h rrivolrrl br,:r[,ului(Dlr t i i r l ) r ' i t ) r t t r t r , i r l l r r r s l r r r r l r r l i r r . , I , , t [ l , l ! rHi l l l r i , L,z iurr i pr i r r solu{, i i i r r , j r , , r I I I rL|l , j r t ; r \ r ,n i ) r l r r r r i r r . l r r l l r l i l i i lo l r r l r r r ) ; l ' ) r r r ,v l i l r , i t r l ( , r , l i , r . rA(, ; r . i r ) r , r i i1p11, i i
Ih0
l r rx ico ( t i r t l ' , r t i izo|r lc l r ntvt ' lu l t t t t r l i : r t t t t l r r i ; ; r l ) l 'z i - t t r r r ' : r . t t t t ' t l j : r t t t t l t t i r t t
* i " . i " " - t i f . fnr ,""JcarDia8cslccrr lc let ist i t i r , i r r tablot t l r l i t l i r ' l t lot lotr t i t r i t r r l
* l* i i iuoe.e io".o in t6i , i ior iu l ncr.rului lnudj :r ,D, i r rbu{ i t { ' r l r . r rrrr l io rr l i q i r l , -. i , : l ; " i t ; - ; ; i " , i i . i dc at lo l i i muscularc in ter i lot iu l t l is la l (sulrr : : r t l r i r r t r l : ' l
totali a nervului cubitl,l so (11rt r t('
Ialangi a degetelor seicuhru de minh ,,in gllfA cu'biLrId" : ltrittt 'rin exlensie, iar |e i i l r l t r ' r lot t i I rL lat tgc i t r
iiu"i"l-r""".ie atitudide fiind mai exprimatn h ultimele rlouri, r1.g.lr' ;frl U"e"iJ mi" se menfine in --qbd,i;ie,
iar slaLiile. jnicro$o'so ,.ritrl
,i""ri,i". inift'ebi primul spal iii inierosos (''a qqu"a' t,+bachc'ii xllirt(r*i.a,t-
" l"i S-i.rrd).'b" asnninnea crrrirent& hipofcnari cste i4rlrliziti ir I
. i ' io f " r i r "
i l . ot . t i 'a lc, iorso 1le niveluT !or:1iui l i i infor ioarc r t : r ' t l1r ' l t r r r t t t l t r i
;l;;;ii;J;i ';.iinii), 'd'.r,torit5, cru!5,rii fleror'lui c.o1u1 prof.ntl ;i .ttlri
' r f . l r i , -nt" . io i f
^ l i i l tn la o pozi{ ie a nr i in i j cu ul l imele d( 'u i i logcl( r r l
t[\;; Ji P;i" piralizia intelosoiilor se compromil tnilciiti lc rl ' ' ubrlrrr'l ir '
"i-0" ",Oi*i* ite degetclor ; e) beficilul Ino-tor inrcres"r'zi 1i tlcx irr' rtl l i
t " fot aore i "g. ie, ddeosebi a degPtului mic ' precunL.) i udduc! i r r p ' r l i "
lu i (bolnavul c6mpenseazd, par[ ia l aceast i tu lburaru pt i t r miqc: l r t ' : t t l t ' r t l t ' t
r i i i " . .* i l t . i ; .p" i i r nemrl medianl ; t ) Paral iz ia muqchiulLr i ct th iLrr l r rn l . t i ' r r
; ; ; i ' ; ; ; , ; ; . [ un t lc f ic i t r l adduc! ie i ! i d l lexic i rn i iLr i i igr Testul l t t i [ r r ' r t r r . t r l
;;i;;ifi;t !;irtiria ailtluctoniiui policelui, in sensul,c5' bolna'vul tttt izlrtt
i;-t";6;i;; cu mina un ziar siu o hirt' ie intre policele intitrs .6i irttl.r
i;l';i;;i;;;; rla face doar prin flectxlea ultimei fala'ng-e a polictrhr i- rti
;rl;-;;;;l l i; policelui, rcalizeia prin ucrvul median) l-h';, Test'ul tlt: ,,r' i i*i i r ' , r , " ' i , deEetelof i atunci c ind r-ni in i le s int apl icale una pcstc i t ' l l i ) l ' r ' r r rti,tele lor pa*Imaro .qi cu degetele_ _i.n abduel.ic e:trem6' de par,ll i
P:";:':i,"ie .". .iia"tiirre ina14"
"fi" o r) istanli rnult, mri micd' intre tlegol'tr iri{ir'
,i" o"tLo *X"Xl.asX I ii trlina fiind a6ez-atd, cu fala lrLnara pe rnas[''. rrriticiegeiglui m-j iar txrl, t lr'
l
iutmrrii"t" ri" Oegetului-midiint'ebOIitA f f ;cu mina.plasat'i cu Ia1* ltrtl .;;;;;; rrr.rsd, bo"6a u'ul tru poat'e sd zgiric"masa cq d.9gc-tul.l4jq (scrrr'rrl
iri 'piir"rt
; r.r Tulburi,rlle. d! se=qlbj-titaLQ sint localiTate 4" ilSY*,f 'l:':'I ti"*g*xil],*:'*g*r**gttl'*tm*'"'11"'#f x'i#A#il ii ;' ;t;
i , i ; , . ; : ; ; "^."^- ;"" ; Xi a. ' .^" ; i , , ' r 'qraat,er carrzalpic: m) Tulbur i r i lo vul 'u-riU,,eo,i se asociazd Ii dur'cri cu-caiacter cauzalgic; m)-Tr-rlb-u rlriltl '-t 'ut'tt '
; r r , . r ror i i s i t rof ice se int i lncsc at lobea in le l i tor iu l nerfulul (delonnt l l l i r l r '
;;";hiii";; o*c,i"ioi."a pielii, cianozd, pielo lucioasS' qi subliatfi, txlt'tttr.'
ovdntual chiar ulceralii a,Ie degetulqi mic).
r l is{ i r rgo 1; t ,1tu va' t ' i r t i i l , i :l \ , ) ) ln ptrrn, l . iz i . r r h ld i i u t t t " t r t t l t r i x t in[ (pural i : i r r ' , , , l tnhir t l i r " tnyt t t
,ur . t i r , " i t ru , r , t i i lurd , r ' tnht i l . t drrx i t ' i I l i r t ' r , l9 l : ' ) "
ru) ' ; \ t r i r l r ' r t { ' t t l r r l t i r t "
I ' r incipot i i faalor i e l in logir i : a) Leziuni I rcunaI l ( la.nivclnl coi t t l r r r
r , , , , r ,o"" t t i r i huninrusrtni 1-di raI , ; 'p lngi a le ncrvului l& nirelul i t l r lc l ' r i l
i , i i , , t i " i " f
rn i iu i i (adesea "
o.1io41'so-; i l iz iunea : l rLelei cubi t 'a l ' ' ;1 cont l r t r '
i i i i i i i ,1" 1t 'nut i to. nervo: l ,sc-tr ' rm ina Ie pc osul p is i lo lm (par ' r l iz i i r ' , (
i r ' l i -
l j lor"'l: b iU '?bm ntii '.{.sto,]:it 'tciia1" g;'dle d'eJileutui soalenic rco:tstii ' trot ti
( , : r l l i ; l r i ] ) ( 'J l rof ia rnuschjului snl lcn an[er io l , cu ingu" l : r t 'ea-, ,deJi lot t l t t - i
r i r . r r , I r . r r i i . i ) 1 , ' ; r )aol i le rul t i la le i t tTec! ioase pot ap, lc l r i r r / l r l ( s, / lc l t i l ' / l i ' l r r i '
l i i ( ' i ' l i i ( l ivct 'se v i roze, tnalur ie 9. a.:,:,),1?araLizia neruth,i tatl ' ial se carrlcterizcaail' 1tt' inlr-rt sct'itr tlo strttttt"
lrrrlrrgirirrrr,,ni.r,, i ' l irrC1io rltr srrTi*l lt:tiutti,i, itt l\1111,{itr tlt ' ('rl,l 'o s{! lr' l '
1t,?
cutanat a!
ro lo l ' ( fx l ' ( , r I r . l1) l i l ( ) l ' ( logoi( ' l r ) l i n) ' I ( rst , l l l , , r ' i ls l i l ' iX l ' i i ( logcl t r lor ' " (a, l lu i l r ' Iot t lo l l l )l l cfcctuarrrl tniqoil,rii dc cxl,ensic qi indeplrtarc (r'i isl' iraro) a-tltrgtrkrlrr,rlc nrrter Dirralizati' nu sr: observi tcndoanelo olil,tlnsorilor' (Ji11 25 b);,,1 destul ,,itringerii miinii (al lui tr'roment) de asemonea alatir, cL (l(r l)rrll i .a lc ral iz i t i r , nu se evid"nl iazd nic i tendoanele cxlonror i lor , n i r i I ) r ' ( t t ' t r r lnent-a radialului extern #ig. 25 c) ; p) Testul prehensiunii uttot ttlritrt'llmici plasate pe un plan orizontal (a1 lui Pitres). Bolnavul nu pttitl'tr sir'a,pucd obiecte-, intrucit pe de o parte este imposibilS ridicalon, miinii si rr'n i jmelor fa lange ale dcgetelor, pe dc al tb par lc I Ie- \ iunoir" ( l (g ' ' i t ' l ( , r ' { "i lce t t i f ic i l s i cu for( i rcr lusd, nu i lator i t i paral iz ie i l lcxor i lot , r ' i r l r t lo l i t : ,irpl'ului ci, ace$tia nu-qi pot exereita funclia de flexie decit dacii rnirtit sr,':r,fii in cxtensie. In schiir.rb, flcxorii vor funcliona foarte bine tlaczi so t itlit'r'rrnina de ciltre examinator, sau daci, se plaseazi mina in ii,titutlittcir '.rlclusirciune" (Pitres) ; r) fulburd,rdej.e.-.sen-s,ib,-.ilitate se rer:narc5, po 1r'r'il'lliu-I cutanat al nervului, dal mai ales la nivelul pr!4ulUi. gpaliu inlrtrrrtsttxtlorsalsi ruaialcs la nivelul ta bt cherei anal orAice ff;g' 2d d). Este rf irlizrt lit l r lezi . in i tJau mgt ice t i .n. t t i ld (pi in luxal i i a le umirului . f tact t t l i i t t i r ' l l r ' : r l 'brrrr ierrrsuiuj ef . ' . ) , sau ol te prcrcsP ar i lo 'e ( tutnot i l .
cubitql
FlexoruL profund'ol degetelor
Gheoracubitald
Abductcr po{icelui Abductor
Opozant
|^,,,*,*Interasosi dorsaliInterosast palmari
Lambticali iIl, IV
/ i./. 3./, NrNul cubitnl: ramuri nervoqse, distdbulia Dusculali fi crtanoti. Crilacubitald.
ferloriulcutand
-Fig. 2r. Nelvul Edial :
r - r!ri. ,,itr Eit de lebede"; ! - Sequl ,,rasfitnni dertrelot" lF/otuettJ t , - Senntrl ,,std!8erii mlt,il" (l".ott.i,) lrrrrl.a nJrili;tl ntr se obsenl tenddN'F eteDsonlor it m.i proeminmla tadialtrhi crternj d-T.ilornrl .ulirrr
"
l,\ Iurnlizitr, rad,iata tt,Lilf,cil (aBa-zisd ,.brahialf inferioafti," a, rt'ttlorilol rilr.ici - Riser, 1952) e;ie cea niai frecvenl ir lormri de paralizirr r:rrli:r,l ir, .si rezrrlli i, din leziunea nervului in partea mijlocie a.brail,ului, l it ' ttivr'ltrl,"'rrn {,nlui rlc torsiunc a} liuq,ro usului, Apare in cazuli de {rntlturi aJo htttr tcltrsrrlui snu in diverse trnumalisntc humcra'le, la purttl,1,olii <lo oit',i i ' lu, lrtrlivlqi irr rrilcrrlrstlnfc rle coutprcsiurtc a' ttetvttltti (cltl$ica',,p nly$io tltlg ttltttttttotrxr) dtxcuisi, rlc l)il,tts satt ,,pa,I'alizi:t, rlo rlutnilitfi")' Itt ttt:trrtsiil ' fot'tttit ,s l ,9 pls ib i l f i uxIr1l l i i t , i r r t I 'gIr t ' r r , { ' t t I t t i , i t r I ' t t tc i l ' 1t ' i t t t r l rst t l cnlg ot t t tBtr l 'v i l ,1 ' St 'r r r t rs l l l l iorr ic i l r r r r t r r . | t ' t | | | , r I t i r , | | i | | | ' i t t t l l t ' i r t t ' ( l l t l l t , r r r l iz i r t i r r l r r ' l I ) , i r r r ' lLrr i l
',': lt )
il l I l i ! |
Itltsrr rrolzii Irrrrgrrlrri srrpirurlor'. l l ' irtell (citrr,t tkr li isor, 1952) r lirrrui cir, olicoprrlrrlizic lirrli l l i i, ealr: rcspcotl lungul supina,tor' (in al'r.r,ra unoi leziunijolrso,,rrlr lri[rrrrrll '1,i , rrcrvului) se dato]€qte unei pnlalizii radiculo-rnodulxre,rrur,i lxrlirrcvrite satutnirrc sau unei isterii.
i.,) I'oral.izia radiaki antebrctltiald tnaltd, este roalizal,X, ale trautnrtrisme,rl,. lr( lrll i infccfioqi qi toxici (indeosebi de satrmism). Respectd, lungulrrlririrlor' qi permite r.idicalea pumnului, intmcit lezirmea atinge nervulrtrlr rrrrr:ichii epicondilieni.
i',t) ).'arulizia radialti antebraltiald, joasii este intllniti, indeosebi inrr.rrrrriismc (de pild:fi, in fracturile radiusului) qi in nevrite. Intereseazi,rll:rt lrrrnrrrilc radiale ale policelui (scurtul qi lungul extensor, lurrgul abduc-I()r') si (lxirensot'ul ptopriu al indexului, cu tulburS,rile motorii Si atrofiiler',,trsrrtrrtivc. Tulburiirile rle sensibilitate sint limitate la o mic5, zon[ Iar'ivolrrl bir,zei dorsale a policelui ,si a primului spaliu interosos.
li) I?aralizi.tt, nerLr ui obtu,ra.tor se recunoaqte prin constatarea unuirlclicit; rnotor 1)l adducliei coapsei
-i a] rotariei exteme a -acest€i,a, cu atro-
lr,r loirlsrri fi plinbr-o an€stezie pe fa{a internS a coapsei. In timpul mersu-lrti lrolrrrvrrl prezintii o deplasare in a,fard, a gambei qi a piciorului. Este1rt rrrIusri prirr traurla,tisme qi la fcmei, in tra."-ali,w prelnngit, prit:' compresi-Lttrorr, oxclcitatii, tle capul fetal in timpul traversiirii bazinului.
i'jo irnpune si recunoaqtem sindl'omrLl ltti HowshiTt-Rombarg,, realizat1r'itr cornpresiunea ner/ului prin hernie obturatorie. ln acesta, pe primlrlrrn sc l,flir, o durele care imdiazi, pe marginea intem5, a coapsei, atinginclr'r rrirnuru de iltensitate la nivelul senunchiului.
i) Puraliziu nerralu,i crural (cu cele patr'u llnuri telminale ale se,le :,,r'i vrrl musculocutarat exterr, nerl'ul musculocrta,n,.t intern, nerl'nl, \ r(llioepsului qi ne vul safen intern) se manilesti prin; a) Imposibili-Irlcir fbxioi coapsci pe bazil; b) Deficitul ertensiei gambei pe coapsi I, r 'i'rrlbuliili rie staliune qi de mers prin irnposibilitatea, ertensiei $erun-r lrirtlrri- Aceste tulburi,r'i de staliune qi de mers silt mai mari irt para,lizin,Irr,rrcrrIIrli i, inalti,. situa{ie in care bolnavul est€ oltigat si-$i ,,trag[" ]x?tn-lrrrrl irrfeliol in1,r'e doui, cirji. In schimb, in palalizir, troncularir .jo:*1,lrolrrrvrrl p(,rile merge, dar cu contlil ia s[-Di mellini, genunchiul ,,hlor,,it"Ir ('\t|rrsilr. l)acli se prorluce flexia, gamba se derobeazS,; d) Urcntul sci,r' i-1,,r crt,r: irrrlxrsibil siu {oarte dificil; e) Bolrrayul nu poa-te s{, se rneniin.S,rrr ,,pozi(irr 1x'r'ino':; f) Reflexul rotulian este abolit; g) In lrtostaliune sellrrllvii o lxrz:i(ie cle ,jgenu recurvatum"; h) Atrofia telei antt'rionre a coap-rli ; i) 1l\rrrllrnul rotuli:rn este flaso, depresibil; j) Tulburi,ri de sensibilitate1,r. lrr(t rr r r ltto-intelri :r coapsei si pc fala internd, a genlbei.
Ir'ul tt'i, tt'itlogici: a) Atecliuni vertebra,le Di ale cozii rle cirl (traumatice,Irurrolrrlo 1.t.); b) Turnori pelviene; c) Compr€siuni de alte naturi (prinrl(.r'lrl g|il,vi{l, in cursul unor inter"venlii chhurgicale, cind coapsele sint
rrr rrlxlrrclir rnirximi, sau irr cazul purti,rli unor banclaje herniare compre-,,rvr,) ; rl) Abccsc ale muqchiului psoas iiiac; e) Intervenlii clirurgicale peruilrrl lrilzirrl f) Irractud aJe bazilului qi ale porliunii superioale a femuru-lrii ; g) .s! tnevro de rerlucere a luxaliei coxofemalale I h) Anevlisme a1orrr lrloi lemulille I i) 'I'tr,untatisme directe ale nervului (de obicel cu cointe-r r.sirlcil, corrcouritontl qi a ri,r'terei lcmurale) ; j) nevrito ,si neuopatii (dia-I r r . l ic i i , yrr t i l inr t r ic [ , toxic l ) .
it) I 'rr,r' l l izirr, rrtrlvrrlrri l ir:siol srrllorior (rc:rlizati (lc frr],ctnrri irlo l)Mirnllui,r lc i r r r r ro l i r l l r l igrro i t , l r r l l r lz i r r r r l r r i , r l r r l r i rurr t i i t is l rc l ) r in NI 'nIr ! tkr i ix , s i t , t t l r ,ur torr l l r t . , t l r r corrrgrt t . r ' r i t t r r i r r r r r r r i l i r l l ' r l t r i . i r l lu l {o l l l in crrut t l I l r l i r , t i i , s l t t t r l r t l l r r ' -
l0t l
lc l t ; i , . 1rrr1r1r{ , ior l r l r lc t r r ,vr , i lc ior icc l r r r r t i t r l i ro{ iorrso) so t , r rcr t r ro l t ,q i l l r l r l i r r :r') l) inlirrLriLlrir for'{,ci rlo tbttrrr:liu .r, cr.riLltsei cvirlerr(,ilr,Lii, rulr,i tr,lt,s irr l;i irrIrrl, . l t l . i l t r i i 1 i : r l t r r , . r ' . , r rJrr i p ' i r r i r r , . I i r r I r r ' , , , r lxz in rr l r r i r i r : p;rr . l r . : r , r { } ' r : i . , : r t l . , . i, t tu l bulrruvrr l .1. spf i j i ' i pe mcmlr.rr l inf . t i r . , r t l lcctrr l ; I ' l . r l iz lu [ r i l r r t . r r r . ; r l . rro llil(luce priu meriiul legi,nat ,,de ra!:i':.
. t t t l 'oral i ; ' i t t t .e i , ,u l ' r i j ,s i ty in ler iu ' (pr io. fue loL. i et i , r lugi l i i r l r . l t i r , i , . r r, r ' r r .Xl) l t t i r p i , t t i t l tZ l : t p l , , r . ( , !Lcnl i ) S(,rocUnOtstu pr in LU,nLi i t0 l l . t , ( . lc J i . | | l l r;r.rir.rirte,rlc_paralizj nrufchiului Jesier rnare: i,) Iicttrrc{,i1, j.krxolilol, ' . ) rpsAi: b) Dimi l -uurr ' l fur le i de a\- t r 'nsic a corpsei pc Lt tz in jq IL i r I i r , ; r r . , . : r, l r t r .pozi l i r ' lcz indi , oste di l ic i l f , ; d) ln ortosbar is i r uoiorn:r prczirr l i r , , l r i1rr . r .LIr,lrrzi,.lo-rnhrrrri (?entm,r, componsa, $i a egaliza contraili l l,rri,u,goriislir,,1, I,r1;\ouror coaps-el) ; c) ijcolioz.i cu concavitatea spre pat.to|, siirriil,o;r,rii ;l) Lu{.r'sul-$i mti s,les rucatr . scirilor se face cu dificlultaie; g) Itr rkrcrrbil,i crrl;r'al, dacl se lixeazL baziul bolnavutui, acesta nu-rsi ]oatc r.irlirrrr,q|rnb:l de pe planrt1 patului; h) la contraclia fesei, so remircii o itsirn(!1,ri01lO COtlUl.aCUe,
. ,]0!PgratjZltlg s.ctatice _prezintii,, in funclie d.e topograJin ltziurrii, rrrrir rLllt+j I 'artant(' semioloEice :
, ..,,_!0tl _P"qr-ol.i r.ia railiculard, to.:l!' trqnoatqlrd' Lnutrli, testa realizrltii plirrr , r r rnce rudacinj lor , gr ,u a neryuir i i s , . iaLic i ] ! bazin, la ie5irol d in l r iz i r r.,l|r.rn. r.rerrnct lg4rlrq superioaTi a.go]apgql Se recrtnoagte prirt r r r . r I r : i I r r r . r r I' 'ttt( t!t::lu9togtr.. carc .rezulbS rlin asociorea palatiziei sci*ticrrltri prr|tirr, r r.Klefir, r_t ,scrr,tlcului poplilieu intern;i a ramurilor musculare al0-l;r,irrr, rllttur ncr\-'lut mar.e sciatic la nirelul m.sculaturii posterioar.c it ooitrl)rior :
',']:llt]iri" tu$1o1 myryh1t91_ garrrb--ei "qr.. ai +iciorutrii, realizincl un ;ii,ri,,,.
:,..,,,-,]],,1. f,_ corrplct rmobil; b ) rUersd,eEte,.Etepatn ridicarea pc vi|l. tlrir.irr. , . , . ' , ' ] l
, , : . l r l i '1. ' b la! .1-yoe?.p: v jdur i t ipc ci ic i ic este imposib[J I r . ) t r , r t i r : rv l, )u l ) r) : r r ' rgr : f t ) r ' r r rr iz ia n.rrot ic i _ a .muqculalur i i poster ioaro lL uD , l l r0 j' ' ,rrr1 rrr r. l.', i*rposibilitatea frexiei gambei (test semiologiic ae tararizi ., rl,,i'iiri ) ;,.r r\ lrofiile muscdare interesor;z; ]r_q-Eq4gt _"lSlrscriatuxfi"-_postoriol,rd, ri' ',r,t'r.x i ,.i Inrisclrlalur', gjmbei : tt firlB'ufir-ife de scnBibilirat,. s(, r.\t.rll.l,',,,11'll tl, rrrl-elnl rntregului picior_(cu gxceptia pirlii interrrc rt, |lrrrlr'i| .,, nri, le. ' ler f ir, lertle ),, precum si pe fala laterald, a gamboi I t) J)c ci, lrr rrrr,rl , l l l l , : : l l ' l - " lE111" sciaI ice si , , ' t pn n rolc .s impJome si-so si l r r i - . rz j r t , , . I , r . i r l r ll , r : r r l l l | l . ] t r t , lZtUI] l le IJd,culaf( . Ci t , s i in cel , . t t "ont1uhro. g) Sr: l r | ' l : r .urc i :r lrllrtri,ri vasornotorii Fi -Uaf]gs _(crleme g,rnhiero qi atc piiorulii, tript,r,l, ('r,rLlozir,. plnntare, "rnbritticXii ale pl:lii ';i
^f" "iigLiifuii".rlce'.,1ii pi,r,,
l i r r r l s .d, . ) .iu; fuiltt:ittc ,,|oni ttttit.C_7og.re ] sint rnuit mai fi,eaveirtc, lrt(,11ri{rrl, r'\ rr ,rcrr-L1jrc t'ru in trcimer mijlocie a coapsei fie sub ni]Iehtl tle crrrorgt,lltiir lrrtirurilor dcstiniite la muschii regiulii ]ostcriouc lr, crrq)sri. 0rr, rr,j,rrri,,rlr'ri.trtrlrl srrrnhl-i po co..psr este in pi,rte cdnservat:i, i,r,r plrii l izil o$tc(liH(lr"rr')' rir sr riirL ril i irL u'.tt:xfrrl cli ' ic predomini fie semnele pa.r1lil,i*r rrr,
. ] ' . , , ; .1: l l l l l iJ l l l , l * , l ,cru. i ie ccle de sciai iopopl i teu int( . rn. r l r r ro i i t r i l : rpt r r t r r r' , r rur tn( 'n l r i t l l t i r l i l r t rnorvs{, i : r t ic i i l r i :oJr. t rct . to i_ lst . , icst i | | : t lo l , r . r : r , lur l ' , r l ]I r l l l l t l i ln l l , l l t i i l l ( r s i r | t r lo i i r , L0rLni1r, in i l ; rscic l ] le dis l ; i l rc l t .
lt).,\ l)t,r.u,licitt aointiaiWTwfiitc.Ii-iitam) 1s,i ,, ,..t,t.,,1,i tiltirtl, ttost,,iorI t t t r t t ' , t , t l t ) t t , ) t . r . , l l t J t1, : r l izr l lz i i , : t r ) I ra,r , l r l iz ia, '1,1. \ { ) t i l t } r 1 i l rddi tct . t , l l ' r| ' r ( : | | r | I | | I I I , ( , \ r r l { . | l l , i l I | | l I i r . .u | | t { ( , l t i l { ) t . I todl . r , l . i r r t i j t r i ga. f r . r r . i ( l l r . r ( } r . r. t t ; r r . t l ie i ; ' l i . . r pr1 ' l r , r / , i . ; ! . r r r r . r i . , , , r1, . : r r . . g, , , r i | , i , . , , 1, , , , , f , r i , , i f ,L i i r t r r l r r r i , l
r r r | | . r r ' | | | | r | | , , r | r l t i r . | l i r I i " : r r l ) t r . i0 l lUt , 1, crc(rp{, i l l [ r , r l i r rst t l t t i ( I r t I i I t t r r IOt, i i. r u, \ ( | l l t r I r . ;1r ' I i I r . l l r , r , r r r r , ; r l r r l r r r io l i j ) i l r ) i t ' r ( ' r r r r r | r . inIr l , I r r ' r I r t r r , r , r r I r r r r
1
I l{r I
poil,i,(! star p.c vh'firl ?ioiorrlti, (,irto r)ll ?o?t.t(r 1i plrlsat nici hr addlc,licr-nici"rrr lol,rr,{,irr iltu ni, qi nu poatc sd-fii fle,cteze degetele: e) },iolta plantard esl;trlrtl lrrrsili i; d1.1\lcrsrrl csle dilicil, de alurd tal'$3ld ; ,') Atrofia.i+telesea,zal' 'girrrrr.rr. pl:lnla}i, rnargieiJe piciorului $i moletul gainbier; f1 'Tcndoqgll,.,lrilirln .,s1,o depresibil ; g) Eellexelc achilian fi medioplantar 'frint abolite ;lr) { l1q117xlgi- gi dureritre de, tip-rne-v.riiicf ' sint destul ile frecvente; i) Une-,rli xr, rtrriir.r'ci $i $tergerea lgheibulul retromaleolar ;i picior ,,in gheeri,",
cu t legote , , in c iocan": j ) Tesiul lu i Fromunt:in staliunea intr-un picior, tendonul lui Achileri.mine flasc, depresibil, iar gemenii nu se con-tractfl tle parted paralizatd';- k) Testui ,,picio-rului balant') : bolnavtl, plasat in decubit ven-tral, este solicitat s5, llecteze energic gamba pecoapsi- Ie partea bolnavS, piciorul rimine ba-lant: l1)l TulburSrile de sensibilitate obiectivS,sin1, rjecelate pe ta1, plaiitard, * piciomlui({ iq. 26); m} So pot eviden! id i i [u lbur;r i vaso-
ni ricrii ' qi trofici (edem aI piciorului, ,rlter.aliiale pielii !i ale unghiilor. ulcere l,rofice nalca-
,i;i='--\',',)\ neenen maleolato qi/sau digito-pl&ntarc).
--'-\:iv 'r}a]} Patdlizia neraul'wi c.ialia poplilea entern'
ttervut. dknhr este reaizatd in. special prin leziune ln nivelui' tatirat .qgDdui leralgd]Li qi interescazi celqgsg m.rl.!-ch]
/ ,J. ; , ; . t i . r i tor iu l cuL.Luat cI anter ior ia i gamboi. tabloul sel i r io lugic consf indr ' , ; r r , l r r is , i l l icpnpl i t ( r in lcrr . d in: a) Pic iorc izul , halanL, iu va"rus-equtn ct l
primele falange in {lexiune I b)' Impo:ibilitatealLrxiei dolsale a piciorulu{i a falangelor ptoximale ale degetelor I diticulta-l,,rL tbtluctiei piciorului; c) Imposibilitatea de a ,.bate gldsum" cu prcrorulrrli'ctrt ; rl) tlina botnafirt se spii;inL pe un singui picioi, tentloanele exten'
sorilor deget?lor, ale peronierilor li tibialului an'terior sint bine proerfinente cle partca s5,]r[toasi
'i l schimb siol $te"rse de partea paralizatS, (prob:'sral,iuoii uxipede a lui }'roment) : c) Ia proba-. n,-pingelii inapbi. qe cunslald, at'elali fenurnen de Iipsriile ividentiere a acestor tendoane I f )Mers stepat ;q1 f mposibifit 'atea de sta(iulc .pe cdlcii ; b) Er len'i:tplir'rei fahngel it I)iscrete tulburi ri senzilive,p''oartea la t'elald, a gambei 5i pe dosul piciorultrij.Sig. ZZ.), seclelorii, r asomolorii gi trofice; jr ' l lr '-l ie ie le ichi l iene Ei mediopl ln lare s int coneetval ' ' .
-Factor i i e l io la l ic i rn leziuni le norur lu l sr ' iu l i rpot acliona, ia nivel radicuhr (In-Su) sau Ia livtltroncular' : a) tr'actorii vertobmli sint cei mai trer:'venli (hernii diseale; morb Pott; tumori -primi-tive. sau metastatice ; traumal,isrne ; in ultimclrsitualii, paralizia sciaticS, poate a#5rea in cadrulunui sinalrom de coadd, tle cal) ; b)' Traurnatismolo
,, Si rtiverss afecliuni a,Ie bazinului: Iuxalii coxo'DislfibUtie sm:,,,v j Sl drverso aleclrunr ale D&zrutrrur: ruxir,lrr uur(r'-'-"'-' i :tcnnrrale ; o$teo-artriti, s&cro-iliDol i frrottlri a,l(l
1,4f .11: . ,11; ' l l l l i l f . l ' l l l l l ' . " .1 l r r rz inrrhi ; l r rnror i r l lo l r i tz int t ln i i { : ( , r t r l ) t ' r 'Nirrrr il l rrr'r'\rrrrrrr r\r'rrru( Di'l)rrrlrr ,,..,,rcilnlrJ rlrt 0rt,l l .l '()i;lr,1 sllrt rlo ll ir '<,r,ps I tl ivl)r'sr.
I16'J l r l ; l
' f , r : { i r r r r i , r r r , l i r l . l r r l i l i r r , . r r . iu l l ; , r r r : r l . r | i i r l i t r r r r i r . r r l l r : rz i r r ; c) l , t , : t .utnkl , iHtn(.r l r l r { r l ( ' | : r l ' r ' tvr l r i ' r ' i r r r i . l ; r r r ivr .ht l r r r : . r ' i i . r ' r r l r i l r r r . i s . i i r r i i . ( . , .L [ r .s. i , r . r r r r
1.l frr{:t 1rosl,'r io:rtr'r, ..ir -currpsrri (lezirrlri prirr rlnrre ir,ll lc srnt jrritr lr,l,lrrrr rlr,l'r ; , €lolrg.i ii'
- dupri i'iectrr,r'e accidentlalir, in trnuchiul sciiflic ir, rnr.r.
srrr)stu,nlc nrr jrtlcamenl uase , algog! penicitinii sau alte solnf,ii r:u rrr,{,i_tttur destrucliyS a nervului) ; {} Nevrite virotice ; tN Noulopatii l,oxii:lrsuu toxicoalerEice.
_. _,..}:r,;,11 sciit.ic poptittu i ntern_poate fi lezat prin traumatisnt c f, n x:eittrtur,l1,t)pIdec, l.rltcturi lle oaselor gambei, prin tra rme directe (cu anlc ulirt, srrrr' r , ' r (x.r s, t r .oor i pr ia lcvr i le ( lo: ice sau infcct iof ,sc).
. M-rrlril scialtc popliteu rfrtet'r est.e lezat de obicei in tlitrrIn:ll,i$ll( j l ir,'1Y, , ' ] l
! "pr- tq l peroneului , in rnumiJo condi l j i prof{ ,s io l r i t le (h rr ln(1i t , , r i, ; : r r r s l . l . ) -u ml . t qhemuit i .pc ! inc Ia pr,r-atrrJ strdzi lor . I r prrr .bct l l I i r j . r_) ,:1, ' . j ' " , , ' *n! l i rn nerr i lc ( rusicr . . v i ro i i ro elc.) . Trcbuie rel inut I r r ,p l r i l r , : rrr rvtl
,scra,lic p_opliteu ertcrn por"ie fi lezat qi ilr rrod izolai; chiln. irr rrli,r,r r r r r l r lc l ruDcl t iu lu i sci l r i ic r l t u aJo plerului srcmr.
..,.,!),-fI:r-l!,1::r,/ite|. reprezinti, constelalii clinice in care serniologir. sr,, ' - . ' ) l : , t , par '2t lz 5aL l )a r ' ,zrr r lo nrai mul lor . nerr i per i fcr ic i ( r r r r r , , r l i : . i, l i rnrcnl) . rptrute l ic s imrr l run. f i , . s i tccr.s iv, drr c o r l iq l } ibul i { ' l r r l , . , , . : r.xp.icioasii, qi nesistematizati, p.ezenfa r,nui trbk u semiologic 'rl. rrrrrllil l i . : i ]1. . i : . .ys. : l :32i . ( in hrnfuic dc n.odut de instalurc pi de cv"olu( ic; r r r . r , r , ,,t.t:t,t l:1' lrostbtttt,{j.l i etiopolsgpn;., : J) llult;npwitp rirolice (prin vii.rrsrrr iL.l.::.,., ',,,, rr\s1ckre, . tlerpes zoster, rareori prin arborrirusurir, Z) Mlt(tint,t t ' i t ' t t .? l :ct , (pusivaccinr lc. po" l sero terapice ; r lorgi i medicrrr | l , . r ,1, , , , . ,. . , : i . r . . " ) l I otogp o:p .St bott o [otmu a ( pol ineuromioz j i e, IUpUS cl i l r . r r r : r t r r . ,- r ' l f ' r 'o(rr . l rn jo. i )o.rrartor i l i nodoa-. i r . " l l . l4 r t l t i pLtr i te ( n ul I i i eu ro po I i i ) l tx;y. '
t ; tbt t iae t r i iabel icr . ; ,n cvolul . i i l Lrnor pol f i r i i ; careuqiaic; pr . i r r r . r : i r rgh,l f l ' f l | r , . ) . . , r - t t t t r l t c( ,u lo l i ; ptxtnectpluziae ( ta.rc1.t'),1'rltlrrrittle
.si p ol i nearopatL r.la (metabolice, torrce, onr.olll,irtr,. . . , . i I i , t l { . ' ,za dol tct lo tuuscrrh|e dc ertc ls ie letrrplegic l sau r t r I i I r , 1r I r | I r .lrlt'gie,r'i,, totdelula cu localizale p-rerlornlnant .ct"om'effi, insolitc rto iripo] o tr 1' ,.. t ,a trofii .nir r,scuiale," de are{le:ie osteo-tendinoasii, prccurn si rlrr l,rrll r l l l : r r r r lp s{ .n ' rb i l i ta lc srLLr ier . l i i : i s i , rb ioct iv. i . cu ra_facl?r. d l . i r \ r . l r r , r r . : r ,r r i l : , r l r . r l , s i r r ic t l ic , ; i eclromel i ( . . , \bscola or i "arui scim Jn h,z i r r r r r , p i l r r r i
,lrlr, {btr r-, coldi}ie esentiali in stabilirea diagnosticului. Maselr irLrrs,,lI r '1 ' . ,p l ' r l r . rpo lu lL leatrna stnt duLr.rulse l l prosiunc, iar e longul . i : l r r r . r .v i l r r r .t , , ' l i l l l ]g i c. l , ' a dc-scl , . i I Lsuporta h i l i . t ' , , l i fpyy;6.1. ' .1 pol inr iu.optt i i l r , r r r r' , ' r r r1 iorLa., dc r . -grr ld. n ic i mudi l ic i r i : r lc L.C.H,. , n j l i t ,u ibru, i l i s f i r r r . lc l i r . r r , . .| , r ' ' , i ' , 'e l . I ; r delrrr l pa|r l iz i i lo jnc(? i i predominl la c l l renr iL i i l . i , r l r r r . 1r ' , r .: ; t sr" \ l r rdt . t j ( o lDi I l i ( . i : : s im,- t r ic l i , > i put s i rpal jzezr.r . [ i i : i r r t i . , t , r , l t 1, l ,g i , ,' ( ' l . r l i r . . r , l ; lu l t i r . ipa r . i r i r re l r is i r . a musculatur i i g i tu lu i , I I lunchiuiui l i, . r t ,
r t t t r . ' l l i ; r r ' r ' . r l iu l j lgrrrului . Pulal iz i i le s in i t t tJearLn: l in.u1. i l ,e r l l r r r r r . i il lr lrotr)lru rrlu\(. l l la,rc si cu irnportante al,rofi i rnuscula,re, dilr ri i0irxll, l ;t i , lr,1rr,,1. ttrrtsivt. c:r in lcziunile ti ir.cte ale pcricar.i.nului moio. rt in .oiut,,(,|.'rrrf i ' i ir i ir,r 'c ( l rr rl ir r rr r ir I i1 i si ulle silnlroa,ri ie pe.icarionll lc). f ieflexr,ltr ,rr,r,.l i l l r l l l r ( ) : r t ( . F| l r l ( l { . t r .g l i i r I i t r r i t r r t I r I r : str t r : r l t r r l i te, r i l r I l , r , l l , r r , l t , t1 l l l . j lL l r ., I r l ( l ' . r I | l l ( .or i i r r l : r l t r : strr t r l , , l . r r I i r I t i t r t I r u I i . . Nl i f r , e, l lBt j , t t i l . I t r i r I j r : I t [ , r t r rr r t l lsc l r l l l t t , . .Nor l i l ic i l i l r t l r l cx( , i l ,1 l ) i l i1, . t , l1 sh,rr l r . is i . i , r r r l l izo1,zi , t , r la l t { , i i r l r ,t l t 'gr"r * t . r i . r ' r r { i i l i r . i r r I r r I r ' , r ' r r r r i r t ' i l r r { , i r r pr t r r r r r r i r r : r r r r , rxrr l r t rnrr l i r r i r , , r r r rt t tv l ' l r l ig l t ' f i iL ' l ' ) 'M'( I . l r I l r r t r r , r ' r t t t t1rk ' | ' r t . | , r r r t r l rnpLr l r r , r r r i r r , i i r rzrr l r r l r r1( j r )prr1(!r1\l t to ln) t ro i ] r sr . r rz l l i I i l 4 i t l i i t r r l r r lo l ' r l r . l r r , l r r l r { , i l pt ,or i r r r r r l t i r i r r l in l t lh l l )01 l t i
zr ( l l l ,o I ) t r r l io lso lxrrr i r l l l s l r r , l r i l i r r r r r r l i r rgrrost icului de krz iune troncular i l ,lr.rpr.cliv polil lotroulari, (poli nortrrrpll icii).
Nr lilcbuio sL uiti,m ci, polincvritcle qi polineuropatiile realizaazhr lulrrrr)Nill: forme semiologice (mixte, motorii, senzitive, pseuilomiopatice,psrrurlot,ulretioe, acrodinice, hiperalgice, parestezice, predominant trofice,prtrrlornitralt vasomotorii q.a.), care ne pot sugera posibilitS,tile etiopato-r1r'rrilo (Iiiscr, 1952; IIareq si Nisipeanu, 1976; Mareq $i Stamatoinrl l t t is ; l ' ( ' r rL lofunda, I976 : fo{ letea, 1067;.
l) l. prezcnld unui sindram poline,ari.tric (polineuropalic) cu ilrstalarert trli. .ti. str.bacutii ne gintlim ln primul rinal la urmetoatele posi,bi.li.td,li eti,o-l)trl.t)u(tn(e:
r\ Polinetu'o1tatii, toni.ce {profesionale, med,iaatnentoase, crilninale,s t t i r i il u,yv, eti.l ice ).
- l?olincuropatia etilicd, est€ de obicei mixt5,, dar cu predominanlaLrrllrrrliililor senziti'r'e (sublective si obiective), apare la un ei;ilic inveteratrrrrrrurli fiind pledorninant parestezic[ qi dureroash. De obicci este lelt-lrrrrglrisivti. Para iziile mari sint exceplionale, 'Iulburiirile trofice ryivosrl rri,ir-e sint precoce. Se poate insoli de fenomene de nevritS, opticil $irlrr rnrrllrr ori, do tulbuli,ri psihice care realize zh forrn psihotici subacut[rr, lrri ](ursakov (contuzie mintald,, a,mnezie, confabulalie). Se poate realizar1i lorrna pseurlotabeticri) cn algii fulgurante, tulbur5,ri de sensibilitate1rrrrl rrnd:i [i ataxie.
* Polineuropatia d,iabetic:d, cu instalare subacut5, este rarii. De obiceirc rr:n,lizcir,zii forma cronici,.
. Polinatroltatio, arsenicalii eeutd,-sub&cutd, este cle obicei profcsio-rrrrli, rlstlizi mult mai rar medicameltoasi'. Apare la murLcitorii care lucroazirrrr lrriricle arsenifere, in industria pieliriei, in industria unol vopsele, aol,r'iivulilol raticide 6i a unor insecticitle, in industria chimicd, (hidrogenrrlsorrilt, acid arsenios, axseniali). Totdeauna apar iiemne gastmintesti-rrillu grave, precum qi ali;e simptome neurologice (convulsii, sinthom hole-lilirlrrr rr,rseuical), tulburi,ri cutanate qi ale fanerelor (stria transversa,ldr, lrri .Nloes la nivelul unghiilor). TabIouI polineuropatic este mixt, dar culrrrrr lon rinrln!'a tulburi,rilor senzitive ;i trofice.
. PoLineuroytul,ia sutrurnind, aautd-subdc'utii este tle asemenea deose-lril, rlr glrvrii, predomininrl in tabloal clinlc tulbudrile psihice (confuzierrrirri,r,lit rgii;atd, sau torpoare), tulburiri cardiace) hepatice qi renale,plrrcrrrr 6i tulburd,ri tligestive (clureri, virs5,turi, constipalie) ,1i hemato-lrrgirr (crr seinne de podirie). Se poatc realiza, Di un tablou de encefalopatiepsilrolricir, de tip Korsakov. Polineuxopatia poate debnta asimetric (perrolvrl ndial, in dreapta) qi este predominant motorie, cu atrol:ii musctt-lrrrrr li lpido.
' .\'oLineuropatia mercuiiald, acutii-sttbacutd' este tle obicei acciclcntalai.rrrr,rr volrrrlbar-suicidard,, la cei care lucreazS, in pr€zenta toxicului: disti-lirlcrr, rnorcnrului, fabricarea lSmpilor de incanalescenli, qi a ampulelor'lrr,rliokrgico cu trompe cle metcur, industria termometrelorr a barometrelolri rr rnilnornotlelot cu metclr, fabricarea sirulilor de metcut, azotat derrrurr',ur', olorulX, qi cianurd' de mercurt intlustria farmaceuticd, (calomel,oiirr[rl'l <[o m.ercur, sublimat). Totdeauna(l igosl;ivo (sto ntite me,rcurial5, cu gingivildlizolrul girgiva,l), somr:olo gonet'ale Fi renale.
lblirlrrrrrlu,t;il l, os1,o J)r'orloninr[rt rrotori€, Dutin(l (lobullt t)l ' in lritltlotrrurrr io l rg i<l t lo t rnt l l , i t tot t ro l t l f i r r (nrr l i r r l , r t t t t nct t lo- t r l t l , i t t t i t '1 , l t ' i l t l i l l ropl i l ' t r t t
l0{
sint prezente tulbur[riloulcerativ5 Si hilersalivalie,
r ' \ l ( , t ' l t ) f i r t r i ) { i l ) ( l t t .Nr.rrr l r is l , l r r i r lo srrrrurc t lo ot tcrr l l t , l r 4 l t 1, i r t , l l r r (xt t . i l l l( ( . r r st l l r t l ( ! r l r . r ' r l l r r r l0 l ts0 l l r i Jr t , i r r r ; r l l l r r ) ,. . Alty.1nl,,inr;u,ro1xr,li i lotr:it 'o aat,l,r:-su,lta.at,l,c (11'itt iuriliri, lrl i,lol,lrr.trz'rl, srrlIr';i rlc rarJr'n, trioltoclozilfostat, tclanclorel;nn) s,, 'r . , , < , I r r , , , 1, , ,t.r ', '/rf('n1,ul rlc aparif_ir, (la rmrlcitori oale lucreaz:'1, ou loxi(,.1. rrrsp.r,l,ivr,)ri plin asoeierea .fi de paralizii do nervj cranieni (oculrrnolor,ii oplir.i,rrtolrleo-vestibulari), tulbur.iri psihicc gi / sau semne hen url,olog iiu r., .- P.olineuropat.i_a tulicd.fste rard. P.ealizeazh o for.nii rlixl,ri (r,rr 1rr,r,, l ' ' r rL i r r l ln i , . r tu lburr i r i lo l senzi t ive) qiseasociazr icusimDtonrcr,rr ' : ro l , r r r , is l , i r r r r :
:r lopccie, .altera{h uxghiiior (cu strii le lui Mees), convulsii, Bi}rrl)l,ornc o\ l,t,rI;i i 'rri.irhle (tremuriluri, miscX'i coreice), sirnptome psihicc (rlirrlrrzi'.rrll , r I l l l0s1;]ce).
lt) P. olineuropatii i,nfecliouse. Cele mai obifnuite sint :' '-PolttrcDritu cltltrricd intereseazi, in special nervii crluielrj (rrrr 1Ir|rrliz,i;r r-r'rlului palatului, tulbur5ri tie deglutitie qi de fonai ic, rrnrxrli 'r1i r,l
l.qllruri-ri l '. 'sp_lratorir, adesea qi cu paralizia rle acomodalic rr ;n,ivili i lrr,rlisianli,)r iar la nivelul membrolor afecteazi, indeosebi tmnclriul,ilt, rrrr,r,,l l i,lor inferioare, realizind o formS senzitivo-motorie disocial ii (crr rrlr.rlorr r i rrlnJ;a tulburirilor de sensibilitate profundd,).
* Polinearitu, brucelozicd (rari ia noi) se in,coteqte fi (le sortrnrl t r, irrr3'rrle qi de a,lte sinptome (heprrticc s.a.).
-- Polin.e,:ritele secundere ttnor beli infeclioase qt ltt,.tl.. sild liu,rr ri rr,r ( , t t l r rq. i6 noni , 1Jl l bol i i d" \az:r t fe l r r r i t i lo i t l i , l i l l i , , . \ | l r r lcr r : ,1 i , , . , l izr , r l| , 'r ir r, laludism).
- Tjolintt*,itet ltoi,ulinicri deb.teazi, aproape totclen'ua (1ll (lislirl,,ir.,Ir,'( i ' i i i l lne& gurii, laralizia \-iluhi lalatului, tarlburiri rle vcrlt,r,rr 1i,i irit , ,ur l iz i l t acomotlat ie i ; i midr iazi) , ot ta lmoplegi i extr jnsccj h i l r l l l l r r | r , ,l:r lrr'{r s{) 1rol, lsocia tleficiie:r,le memll.elol cu p}edol}l'nit1t 1ij l izorrrr.li l ir.lrr', 'r 'rrrr 1i tulbru{ri gfincteriene (constipalie si retenlie rtrina:,ii).
t. '\ J'o[. 1e1 'af]alii Ttostraccbtale li :postseroterutpice . Sinl I' irfr,(|osi,rrrrrr,itrorrl)i0ii, lostselodiitelicd s.a.) qi-de obicei nri sc ilsL:rlttrzi irlrrlrrl, rrrrr i)r,lllcsa procesului a,lergic r.ilccinal sau postserotcrapic.
:!) JIL fn'eeen!& unui sindront ptlincrritic (polbeuropu l,i() (u .irtskt,lrttrl, nl Uoqr$iui se pun in cliscutic toatc cauzeic posibil,. lxl (,lt.o (tt,i , tl l"r tlno|inl succint:
r) ,Pt,/ tnett ite.le infecli.oase intri pulirr in (liscu(ie (polincvlilrr l,prrrrrurr. ' \ , .n l l l r l . pol inelr ' i r : r luot icu).
,.. 1) Potine-uropat.ii.It to.rice (satur.ll iD,;, ulscnic:ll i, rlt(ll1lI,i i l l i, 1;tli(!i l
, , t t l l r r ' ,1r 'bon1{f i , .h l l ic5, rntdic l rnentoasi t ) s{r lccLrrroso i r t lorr lor ' l , r r l pr .ol ' l { r l l l r l , ClJnt{ , { r .unlcXlnl {o l l tc l r )T n( ' t i l l i ,L( . . v iscCrl l , . . gr . r . r ' r t l , , , r l r . l : r l r r , r ,I t l . t t t ) 6 i solr io logic ucurologic (rL sr , 1 'cr ' [ r i r serr l r rc l r ' e i r l l rc i , . r is l icrr i l iv t l r i l lo,1rol i r ror l . ropat i i toxice) ( , \ Iarc5 s i t r t lmir , to iu, 1968; gof lotou, l t l ( i?; l l i r l r , ,t t , | : .1 ; lJr>dcclr lo l . 196i) .
. . r ' ) P-ol , i ,n cw"opal , i i tc r . l iabel i . t :e i r . rd ln ic suspic iotrN,tc lo l r lprrrpr i r l l r r r r r r l i r rl r r ' l , i ( . [ {1, ;11'1, r l ia lx, lar l sr) ( l ( rso(, lxr l , i i , r lorrr , c i i r r l t lpr i l .${rnut( , i {1 r l ( , pol i t r r . r r |ol r t l icr r , r t t r ' ( 's1o scnzi t ivo- lnolrr l io (crr prrx lorr i i r l r r r { r i sr , r t r i l i r : i , r r r r r . r r t , rr ' l t i r t ' psorrr l . l r r l l t . l ic i i ) , l | i r r r r r r ' I r r is t r r n i l r i t , r r r l i , l , i ts . r r l r r r , ( l r r , l r , r ioprr l i r , )t l l l r l ' r r r r l r r lo l i r ' . l l r r r , r r l i r r r tur l izr ' tv , i i o lo l r r r i l r i r r l i r r r r l l r r i i , s l r r r r r r l r t l r i i r r l i l ,r l r . l f , gr . r ' . f i lJ"Ui lor |H( l r , t l , i l . ( i r l r r l t isrrr , l l t i i : r ) , ( , t r , r r l i r rErr r r r r r r : r l r , rr r r r r r r ' l r i i r r I r r I r r r ' I r r l r . ' r r " r r l rs, i l i . ' r l i ' r tx I i i grrrrrhr, i , r r r l r r l l r r r r , j r l i r l r , r r r r r r , r( l t r l r : r l r 'F l : r r t l r ' r r l r r l r r r . i r r l r r r '1. l l t t r , r r t igtr t r , r l iz t , r tz l l Iot . l t r , l r8r , luol l l rJ l l , l , t , ,
100
i\ I'ot.trt,eurttltuliiltt r:ttrtn,!iu,[,tt sini; urttLt' rr-tiri [t"cvctrl'o doci[ so ol'tx[('lt'I i irrrl ioulizittt tle tliverse ntcc{,iutLi ttigcsl ive, rirrlhbsurbliYo, dc.anacidi-i , ,1, f , . j , , - r r . i " " ; i de al l i - factoi i ( l -nulusiv al(ool ismul .s i . r r l te luLice) ' : t lctitttnjrt'tti l carenlc de sil,amine tlh grupul B qi d'' aniil^fr'l it ($oIlclea,l l | l i / i l \ l r r ro i 1 i Siarnarciu, 1968: Popovic iu ; i col : t l - r ' . 198[, '
r ' t l ' , , l inturonat i i le dismetabol ice. fn Iata unor t l1bloul t ctrorce oe porr-
rr,',r r',,ilL'tii croni&, neolucidate prin ilvesi,ig:r'liile curontc, trebuie si' ne
t',',ri'i, li fu acesd gnrp de polfoeuropatii clismetabolicu ;i si' praciicim
irr ! r ' . l i l r r l i i s i in acest sens. mai a, les la ln i l lvrz l t L lner l :
- Ilolineurupatia porflricd sc poate rccunoa$te prin sirnptomatologia|r|r, rrolvo:r.sli (cLr -tlblo-uri" tle multinevrite,, uneoti l1lononerrito radiale', .v,r l r r i i , r l .nt 'e puhncuropat i i ) , v is{ 'crald, (s i r }dr . ,mul abt lominal l , culatraf i '
1,rr , . , , , : i , ,p i , i r , , i i : ipersen. ib i l i tare la tumina, cu pcle pigmentare cafcui i, l r ' l i I r l l ' tn i i , lc to ' ' , ' rc{pcct iv cu lcziuni cuLan'1tc "vaccini fon oe") . g l r le
t,rl,,,r'',ltrr (sinitromul uiinar'; preze$a, respectiv cleqterea uroporfirineiolqi rr coproporfirinelor).'
-^ l'rlttirunlropatii,le d,isgtobulittemice sint' ra,re' Amintim polileuropa-t i i l , r ' i r r l so lof iot i ln i in rer iculozele pa raprotei ncmice (mec roglobu l i .n r ' -
, ' r " ' tV, , t , i " ' , * inOt ; i l - ,oalr lu i Kahlcr) . in une)e lumor!-sarL in t l isc l ioglobu-I i r ro,r i , ' ( l l t ichorr r i cohb., 1959; Faqon ; i Sctrwrr tz. 1963; $of lct 'ea, 1967;t ' , , i , . 'v ic i i i i i . , ,Lrb. , 1968). Cootexiul c l in!c dc sr l te l int t i lcrvoas5 (pol i -
,,..,i,,,p,il,i,. 1ent-progrcsivi,l, osoasi, (aspectelc de leziuni multiplo oso-as.e,,i,,,'i"l,ii
"""t".Liale'si in iasole late),
-hematologice, cr alterarea sti'rii
1r,""'irrl,r'll tti p"*ruot^ hipergamrnaglob Lll ineruicf (cu.spectr'u1 caracteris-ili,;i ;,i;;,r'i;rrt"J; aft"osti""i ae 'eticuloza
paraproteinemicii' 1n schiml,,,tl,it'r1;a, cepricioasd', 6t instalr,rea sau agra,valen trbloului clinic (cu
-mrlti-r r , r ' r ' i t , ' tn igr lutc .1 i pol ineurop r l ie t le oi j icei ar imeLricd) in pcr io l t lc le leci
i,t,, ','.riii"si
la"ritiiica""a ciioglobulinelor ne o.ienteazi' spre '
tliscrio-
*""'Titli},ii;rr, trntiite din, colallenoze sint ulor de incadrat nozologic
,t,,,,,i ,,,srx,.tivlr, iulecenoz,i, (periii"terita norloai5,, lnpusul edtemir'tost der-rrnlurrr . r r i r r rn iozi la, l . "oLiueuroh io" i ta, sclerodermiar boal t r BehqeL t 'a ) se
"',,',i ti*i,iu cu simft6matologia tipici. Eristir insii'. crzuri-care pot .delut&
,.i r.r.'lllir r^rrltiir vreine cu simptoine neryoase pc.ite.ice.. Sint totrqi citeYr'i 'r ' it,,r' i i olir'ntltive: - Evohitia progresiva qi c:rpricioasi' I - Prezen-ta
lr,rrrrrr,lot gr,rtelalc (asienie, stiri {elril"e, algii rrlticrrlareqi rnusculare etc') Ii,,,l,l,,iti i [i" ,,rnultinevrite" capricioase 'fi,-rio polineulopatii asimetrice ;
i\toilil'icrili 'ide obicei vascuiare) a1e I'.0. ; : Hipelten$iune :lrterialil'(irr plr irlrteritn lodoasS,) ; - Semne de arteriopatie periferici' ;i, de.ce1errni' rrrrrlte ori qi cerebrilL; Sderin iu, lrLlscubri, (d€ tip Eiozitic) pe
tr l r r r r t r l r r tL i in t lermr,mpol i euloiniozi le) ; -Nl od i I i ' " i r i rk ' V'S Fl ' , . a le
i ; . ' ; i , ,1, '1: A3l 'o * i waaler iRo"e, p 'ecum qi r lc testelor de dispruteir 'emie t i,,ii', ii"i,r"Gt".torezei ; - Prez6n{,a rnod.ilici.rilor cutanate (in dermato-rrri,rzil;o, in sclerodermie qi in lupusul en'itematos).
l,lxtltni itrile E.M.G. qi moditic5rile histopatologice mirscnlare, vas-r ' I l r11' , iL lc f ibrelot uetvuase Si a le ] .esutului ( l t I nrn-cpidr ' r ' rn i ' ( in )r iupr i i t '
' ' , i ; ; ; i i l , ; ' , ; , t , ; ; i . i ,
"" . " , t "u in. obl igntor i l in uc ' ' r tc s i l r : i '1 i i ) -pol { i - r r r i l ( '
|r.rrrtt'rr rlia,grLostio (Dulnn, qi colab., 1960 ar b I Dtma tst (otaD '
tvttd ;l(ft,lrtr6,rr, .L9$l ).
: : l l , , , l int t t t , , l , r . l i i t { ' pard rcpl( t t i ( : f 'c ln l i l r r t ' ic t r t t r ' tL i l l le nt l l ' )c l )u io
, , , r , | ,Trr ,1, , . t , . , r , , , i i t , t . i t t i r i . r , , l r , t rLr ' ' nt ' t t to1tgi . t ' l ' r (x l r lsr ! l ) l i t l r : t t t t t l t l t 's i t t l t r '
r l i r t r0 l , i r t ,x i , r . t j i l r r , l , i i r l r r r , i i l l t I rot '0st t l t tc i , l t l : tz l r ' (1 t t r r t r r t i l t r i t r l i l iv t r , r t t r ' l ' i t -
l0( i
t t l r rz,r , t r . r ' I l I r r r r I r ' ; r i /srrrr r , r ' r ' r ' I r l I i I r , , I r r i r , I r r I r r I r r , , i r r l i ) l l l r { i i | r , r I r r t r r r i l r , , , lxrrr , l i rI lu lgkl t t ; , r t . ) , l 'o l i l r r r r r r r r l ) i t l i i l t l ) iL l iut{ , ( ' l ) l lLzictr so t ( { l los(1 r ' r ' l r r t iv l$or ' ,l t t i t t l th l r r r l l r r t r r i r l ; ( r l r r l crr t rot t i , l r t r lor n i r l r r r l , i ' t , scr tz i t i r , i ) , i r r l l r l r lorrlr,rl rlo ,,irrrplt'gnalo" ttcttcrtrli treoplazicl, cu cvolu!,io prtrgrr.sivir.
lt) I ', l itturuyuliilr tlcgru.cruti,rc. Aoi so inculrt'azir ir5rr,-zisir ,,1r,/ilr,tt it,i" hip, r(n,.1;,.,i tamitiali ,.r c,./piliti?; (buofu ly; D(jlrin, sutt,tx\ .tr r lu l t t r ( t i ( t ;pt i l , l t ;dp s i tour j t t r r ) . SiLr b4l i dcgr.rr | r ' : r t iv | r i l ' , \ ' , t r r l i r . l ' r l1r Irrgt csi-i 'r ' i , in care atrofiile musculare cLr debut distal iti i ing ilr rrlo(l In)A11,.sir', in tlectls de ciliva ani, toate cele patlu rncrnbre (rlul x,slxrclii r.orr;rstk', bra,lcle, ct'nl,urile qi fa!a). Se inso(esc de mari tulbulriri rlr scrrsilrilrlrt,lc do tip ectlomelic, cu caracl,ere rlisociate (cu nlaforili i hiporrslr.zir',ltini )r anestezie profuntl[) si eu mar'e atarie. Cel rnai ii i lescri lrr, rli ' lrrrl,rrllr'rl i i, b,rlnrrvii acuz; si clureri fulgurante. Un simptonr pirlrierr0l 0rrir,({'.rt'. l)crlnitu rli:lgnosticul fftti r}e ,,tabesul arniotroJic',) il corrs1,i1,uir, lrrgr,,rli it i le foarte ugor palpabile, strlr folni, de ,,mitrinii, r] ]r, 1r'ul0hill l i l lr(.r'\-orse, crlc) itr intregime pot fi hipcrtrofiate. Sint prtztnlr'lrrlr.sr,rr 1il.rs.ir'uhlii musculare, c-are s6 qtie cd,
"sint, cu tolul excepiionrrlr. ir rr.lr,,i
1ra t,iile pe.riferice-D) Poliracliculortr:rri,tele realizeazi sindroa;me senzitir,o-rrr o1 ri r,i i lrilrr
lrtale . Di. sirnetriee, cu diBtributie atit pluriradiculall,, cit si (rl,rr)tl(' l icir,rlo obicei foarte extinse, putintl gelera tablouri paraplegice sur rrriri rllut abi1 .tetraplegice, cu axeflexie osteo-tendinoasi,, cu nrlrt:lti Iripolorrirrtrrtsctrlari, qi cu atrofii precoce gi lapide. Sindromll ile profouelrrrrr sr,rrz,il iv (cu tulbur[ri globale de sensibilita;be) ptezintii aLe asclnclr{,1 ilt,tt ,rrlistt'ibulie poliractricula,ri, clt qi ectr,omclicl. Cel m:ri iulesea sc li:(lclr,lzil;i trlvii cranjeni (perechiie III, Itrr, VI, Y motor, VII, fX, X, -\t ;i I I I ).i l l,rrli l ir.r' i,rile lichitliene, cel rr..u i ailesea cu disociatie albumin*r.ilol rgir.ii,r ir r'i palafeze diagnosticul tle poliratliculoncvr,itir t.irrillain-Ila ll'r.
I PROBLEME DE DIACNOSTTC+. Itr TULSURARILE TONUSULUI MUSCULAR
4.1. HIPOTONIILO MUSCULARI'
4.1.1. Hipotoniile t/anzitorii, paroxisticc se caracterizeazf,,ptin bruschcfca cle aparilie qi prin tlurafa scur.t5, (citeva secunde sau| | l l I l [e) :
L) Atacli cala,pLectia consti intr-o pierdele brusc5, drarnatici,, aiorrrrsulrri muscnlat qi a motilitd,lii voluntare qi printr-o pritbusire ,,pos-irrr:rlii') ca,re cortrasteaz5 - de obicei - ct perfecta csnseryare a conqti-r.rr{,t,i (.Devic qi colab., 1967; Popoviciu qi colab., 1978.; Rechtschaffen qil)crnrrnt, :1.967). De fapt, atacurile catapiectice apar in mocl ercepliona,lizolrlr', t'lc nsociindu-se, dc reg'Lrli, cu atacrrile narcoleptice (Yoss $i Da1y,lll{iO; Popovioiu qi colab., 1978). Uneori accesul ca;taplectic poate fi pre-.rrr|rl, rlo scmne premonitorii (senzalie dc oboseal5,, de ci1,lduri sau iler.r,rrrI,r'ic|ir, ctc.). Inhibi!;ia tonusuhi postunl poa,te plezenta intensiti.{,irr|Jirrli i l lr, ric ll o hhibilie total5,, cu clclere (mar.ile acccso cataplectico),lrrrrrr lrr o rlirnirrua.rc tonicX localizati, la ta telitolin rnuscular (crizek,r.:r I rL lrl00l iIrl pirrlia,le).
t) l[r.uilc urcese cataplectics su,u atacuriie crtaplectice severe (Dal.r"1i Y oss, 1l)?it ; Corfariu gi Popo.'-iciu, 19?3, 19?4 ; Popoviciu ryi colab.,ll)i l{; Irolx)r.i(fiu, 1,979) sint tipice ca rnalifestare: in rnod b|rsc, mancti-lrrrlrr lu)rolti, gura se intretlesohirle, pleoapele se inchid, capul se ilclirri,pr' lrir'1i1,, urcmbrele superiod,re cacl c1e-a, lungul corpllui, obiectele cacl diltrrrrirrii, gcrrLrnchii se indoaie rsi bolnavul sc pri,buqeryte. PrS"buqirea este,rllr'i. r'rrpirlii, (La,r' nu instanNanee, brutali, ca in epilepsie, ci progresivi,Irrpl lritll'inl penl,ru sttubilirea diagnosticulli. Fe de alti parte, bolnayul:lrisl;i rrrrrlt,ient la at'acul siu de ,,pr5,bus,iret'caiaplectieii, d:rr r5mine de.lrilci corrrplct irnobil fi afon, ca intr-o staro tle ,,cLuarizare" si inccarcil'lrrrlr.rir.rr o sorztl.,ie de neliniqte, de anxi€tate. Uneori sepoate lcln:rlca : rniozti'trl lrr lrisrrr riivclgout, mici tresi,rlri mioclonioo li, cxc0!f,i{)na1, rehxir,r' jrrf irrr iclirnr, Sint 1i cazuli, la care inhibilia motiiiti,{' i i Dn etite totu',li i}bso-Irrl,r' i. prrl,inrlLr-sr: rr,rulr,lcir,, in culsul clizoi, rll ioi rni6ciiri lolutttlt 'r:, l it iti l;rtlrrl r r r r r r ' lo i , r , r ' i | , r r l i i , pr?lrrrn 1i orLrocir lc posj l ' j l i l r l t i p i r r t i r r l ( r ( le l l ' t ic , l t l rut(r 1r ,r r t r , r ' r ' t tv in lo, r l r , o l r icrr i tur i t r i ;c l ig i l r ih, . [n l i r r r l r t t l t ' t izc i s l i r t t t ts l l t l i i : l t i l to 'I r t t i r *rr t t r , r ' r r l izr t l r i . r t l to l i t r r t t to1| l r r t 'k t t r t t loo l l t t r l i l to i tsr ' , r t l ro l i t t . ' l l t r ' l ' l t r -
l f i l l
iUU;ilg;ilt*11l * l*i iii,--:[-l,li'* i;lr)litiri,riiij*+*#*t*ms[t*ffiw*t*rr'*f i#jt!!i?:,T""{$*,il:'lf"{'t*:"tkl'k#ffit'ii,",ff r{]niililif ii*{i-T*l,l-'*:*"*}T*l$i.*"-tlu?-"+l.a j'ml*:*+lrlr;tE?C";g:yj*ti1d;Jd#1,fi B'lrH":it'il:l:$;'iilf,lt',",!llr{ff'::"t:t'tilt:?{f ;'!'!t"-'ie
("rarvate" - Devic $i col'rl)' rrxi?;
lli3;*r"'ffi iil,:i,fi.:*:b:: ii":Hi-""3il* *:.ql#fr il iiill,:ii*xli**l##ir,r,,",n'lii]*iiiii.!3?i3d':i"il#i3i,iuri*ir,iu,r,i,llif "f *lff "###f*j:":,fiif **,'-ffiiiffi t','"inrui,s,,,,,iii:tiff i,"",H#Ti*"T*,H[r..{"3-;1"+$tiA;i*r#:lt"*m[liiiliii;l*F1;?''1i'hiJt',:3'ff lf,'(t:ii" "-,'::ff;l'l; ;Aj"ilf *T,lil,l jl,fl],
:::fi.li:!i6,:#:;t#f,:! f::;:: "!i ;,;,1/;:,;'"Ti,f i'*tf 3; *1 ";fl , :;il il
ltrrffi d,$gl;ftt*l{r,i. i?;j:f##i"+hlfl*1[,.*firt1;;[****L:riliiiJ::i:l.i:T,1,,.J,:",:tl'llli li ; ;i;
B) Boata Lai, lJnrerrillrt
ll'tl*'#'r;ilt*#illG:!:i'i"":iK:?i'1"1'":TJ:3J3*,TiJHillillllllni,l.f,i:{'1j.ffi T1,iii:'{Jpjjt_*i,';#,:lx''f l,""lr;}ir;;i:il;,:,:,.:;,:,iiyi;fiiil!;,f,l:jiii,':,!ij,:;',,;\j.:ffil;$ill'l,f,ift*.lifd.#ifiliitlrii{iiit'fi',1-:l'itl11ll,;;lx,l,iJ,fi:iL,:":l"tl,:il*il,:*,i,lilliilili:liij
iiilfril;li:t i,r,ir[ iliiillilililifriil;i: il,llin;f l*-iruil ( |0
r'rl,ir, rrxir.nrtllri, lrrlrtavul lrlozirrt,i i l,m'rrspiratii ;i poliulie' '1'ottleilutrarrrrrsrrrrlrr,Llrli| oslo tluretoasi| ryi in tirnpul crizei se cYidenliaz'i hipokaliemia'in sr,hirrrlr, itr palalizia perioclicd, familiali hiperkaliemicd (boala lui Garn-i , , i , , , , , , r " t . , ,o ' , r dc obicei i l r lc . . , s i 10 aui (90% din crzur i ; , se dcclan-
r , : 'z i ' I ' r ' r r , , r , , iud, os, b i z iua, mai alcs pe nemiD.cate. duph inani{ ie qi dupd',',1,,r'r rri rritrsculare intense, paraliziile predominind pe mu$chii cranieli 'trr I irrrtrrrL r,r:izci se constat[ d cre;ter" lr$oarii a ionului de K+ (crr rnetlie.ite
' , ' , ' l ; , , ' i r . t i izr , poal" f i p iovocrfapr in adtrLinist ' tarca de I 3 g de CLK
r , r "igrir rtt rliiglostic. iare insi, trebuie efectuat cu pruden!d')'
lt\ (lri'.rr de dt,m atlacl: se mlrrifesti printr-o pierdere brusci a tonu-. rrlrri rrr';i utir[, tu,riti i ,le pribuqirea, bolnavului. l)ebutul este bruscr f[r6,.', '1'.. ' 1,r,.,,,.",sr:rle, r-Lltr se pro{luco de obicei in timpui rotaliei sau exten-r,.i ,,.irrrrlrri r,i rtu se insulrq1e de pierdelea cuno$tintei' Auzul, vederea qi
, r,rlril i ir rLttiLl lerltrtlte. i 'riza cle drop al,tnck este un simptom al insu-til icrrli,j r,irculltl,orii vertebro'bazilare Coriariu, 1971 ; Kubaia qi Mil-lrlirrrr. l1){il; l lopoviciu si co1ab., 1968; 19?6, 1980)' Diagnosticul tliteren-
',' I ,,rr , r,zr,lt ' epileptice akinetice (amiotonic-llkinetice) se imptne tot-
, l , . r , r l ' , r . i r , n ic i r l r r crz nu se evi t lcnt iazi modif icdr i - t lEG dc t ip epi lepl ic.nt,,,fiti,,i iri le li l lG ale atacului de dlop uttack nu pot fi suryrinse, din
I , r r , i r r i r i rnpl i v iz ib iJ ic i ! i i epal i r ie i cr izei , r la i c\rmeaul 9lFG esl" necesarti , , t , r r , r t nu.r l , evident ia oar"cate anom:l i i c lcctrograI lce ca'racier is l icerrrsrrli l it 'rLi.ti r-ertebro-bilzitare (PopoYiciu si colab', 1968r 1976r 19?8t| 1)r'i()1,
l'l lr)ristii' ft,rine dc cptlepsie in care dominf pierderile tonusului de
,,,,tit,rril in, " (cpilepsiile ,,siatice" ale lui ll,amsav -Elunt, crizele de petit
1,,,,t ,,,,,i,rtonici-akinetice, crizeie epileptice temporale amiotonic-akine-ri,.,, (itstaut 1i colab., 1969; [iastau-b qi Broughton,. 1972;. Gastaut'l : r7; , : I ' , ' r ) , )v ic iu i i cola b. , i 9707. Con t er t u l s"m io logic ne or ienteaz; ' de obicei. , i , , i , r ' r r i . l , . . . lnr ct izoi , r ' t t dt t ra l i scuut i , pr in asocier, 'a foar le f recvenLdlr, pllt LLr l,ir,r'iliri conltiinfei, de obicei cle tipul ulei obnubi]iiri sau absenle',, '*iii i'ir,,' colf uzionale
-pdstaccesuale, a amneziei accesului si, mai ales,
rrrrorrrrrli i lr IIEG qi pohgralice din aceste crize'Gt I ' t ruLiz i i le dP sont l (paral iz i i le hipnagogice, cataplexi i le hipoe'
, , , ' ' r ( r . i i r l r ct l t .o le l i i le c le , ,aclormirc" s i r 'u de ' , l , rezhe")
s i t r t ' in real i tate,
ii,.il .*,. ,r,', rr,t,'rrii musculari, prin inhibilie musculari generatS, cie structu-,iil,, .,,,nll,,ni,ofalice ale sistemului somnului REM, apirind de obicei la
irolrrrrvii tttlurleptici (Daly qi Yoss, 19?4; Yoss Ei D3'ly' -1-q59;
Eis^hikawa. i , , , r , ,n- . lCoir : - Pompeian6, fOOZ; Nan'no ; i colab. ' I970; Cor{ar iu 9ii ' , , . , , ' i , ' i i r . f974. 19751 Popovic iu t i colab., 1978) ' Trebuie d i ferent iate c le,,,'i,r,, r,,.'o" tte cpilepsie rnolfelcd, prin inYestigalii EEG qi poligrafice, in,,,,,,rlizi,l,r tLe sodn iecxisthcl anomalii EEG, in alarX de contextul poli-
r:r"r,lir,, cir,tt: arlti c5, paralizia de sonl, fie in forma sa izolatd" fie la narco-
icrrl rci^ implicri aplrilia inhibiliei musculare caractedsticai somnului R'EM'
1ul ti,'gil ,ri, fulcl tle ielativS, stare de veghe (Nan'no qi colab., 1970; Cor-
frr,r' irr 6i lbpoviciu' 19?4' 19?5).
1.t.2. IliPotoniilc durabilo :
It) II iytokniil,a lqnarllisate sint raro:
L M.iul,uniu, (rtri]lrtnkt') mn!/ ni.lald' a ltti Oppcnh r,itn $o lll l ' i lno$l'ol r r , r ' r rDi i . r r lo l r i r r , t r t i l | t , , t t l : r l l1 I ' i i t t t l [ l t l t , r l , t r oxl l r i t t r l i i , , t l i t ' t l t , t f , t l t ' is l , i t l i l ' , gr t t r r r r r l l i -
I ?{ l
r . ; r l r i , 1r l l r r r i I i r i r I r r i isr{ i , r , i l l r r r iv , r l r ' , r r r . l r i l r l r . ; r r r rp)o (s in1; r r rs i r , - r r r l r r i l i i , , r ,oprrr lc l r r r rc i r tc i ' l i iset . 1952).
:!- l:t.lt'r i n lcl.c aerebeloase nta;ine ( atrofi,i,le cerebelo(s(: ).;i. Iltt(.|c tl.is{rofii musculat e progresire.4..' l 's,besitL (forma amiotonicd,).B,l J{ipotoni.ile nzo,i mulN sall mdi gtulitr, locali,zate (tle 1,ip lrrtrri;rl,gir,,
lrrla,piegie, l,etraplegic sau doar la citeva se,gmente ale corpulrri) rrlrrrr.irr, r r r r r i l r : , r , ' l t . s ; lual ; ; pulologice :
1. ,ln- najoxii;atea cazurilor, hipotonia se instaleaai, brasc 6i esl,c llrrliziil,ri tle Le.zitttti ale aroalui refler toni.gen, respectiv ile leziutii ntrtlultn.,.,i pti,Jerice. Aceste tulburili tonice prin atingerea arcului rcfltir lorric'Ir.rnentar sint totdezruna iinnitate si segmentare, dispuse dup5 o topoglrrtrr.L rrliculaRi sau tlonculari,. Se constati, qi coexistenla trrlburdrilor srinzilit'r,,t otice qi paralitice iar leflexele osteo-tendinoase sint abolite (semtr li rir li l
:rrportant). Ilipotonia este cu atit mai importanti,, cu cit lcziun(fl, rr, lojrlrirri bnrscl. De pildi, sectiunile miiduvei tealizeaz:a cea mai masivij lllr, i(nte rausculalri, ct topografie paraplegici sau tetraplegicd,,
a. [,eaiunile merlulare antrerreazl simultan hipotonie pin[ ll lllon iltttusoulari qi paralizii (de tip paraplegic, tetraplegic sau mai rar mouoll(lfli().
:l\t'&,rlrnatism?.[e medt are (cu secliuni complete sau incomplctq t,vcrrI r rii I prin comolii medulare ) qi lrcnzatamielia realizeazd, paralizii hipoi,orr ir,,,rrrr atonice imccli:rte, de tip para sau tetraplogic. Adesea debuteiuii ;rr.irril o fazii de +oc, insoliti l rle un raasiv deficit motor ni atonie crr rr,i '|,.,,,.' rslco-fendinoase !i critanate abolite, cu incoltinen{.I sfincl,cr,iu rr ii ri r rrr r rr rt'i tulbur'dri de sensibilitate. Aceast[ atonie musculari in ]eziurr ikr r rir.r I rrlrr'c masiye persistf pini, cind se instaleazd, ienomencle de aul,orl rr,i,isr rrrrrrlulirL, cu respcctivele simptome de elibera,re, cu sincinezii globrrlr.. lrr, rrlsrrl compresiunilol medulalc br.utale de diverso origini, sa,u irr lrrzrrlriror'frpctiuni spinalc incornplete, se observS, adeseori acelagi dcfirril, rrrolrrr,,rlrr trr hipotonie mai pulin marcat[, qi mai pulin clurabili,.
Lc;iunile medulara a.arle nelraxnn(rttce tealtzezzd acelaiii sirrrllorrrI'rl l l l it ic cu lripotonie. Itste vorba de m,ielitete aar,te transoerff $i rlrr 2,,/r,,ttitl ikt acndd,, in care palalizia hipotonici, qi aretlexicril tlotniiri 1:ilrlorrl' iirric:! 0u topografie tetra- sau paraplegici,.
ln ytoliam,it:l i lele subasute sau tw instalare prr.rgresi,t:i i, pc prirrrrrl |lrrrrr r srl,ueazi, paralizia atroficii, hipotonia {iind ins[ nolipsil,il.
!, In compresiuttiie ntetlulare progresioe (prin i,umoli tle rlivei'so rr:rirrli,rltcrxe, pachimeningitii,, arahnoitlitn q.a.) hipolonia^cstc rilrtxl' i irrl,i lnil,ir,rlrr obicei constatindu-se contrlcturi musculari. ln scliimb irr tir,irrrotrtirrlie qi in tumorile intramedulare, leziunea, pericrliona,lrl poatr: llrirr,rrrr rrci, de la inceput hipotonie muscularl.
3. I'eziunile progresil)e spinala posterioare pri,n leziun i ale atnlaqntlrn.lt,tsllrioare (ale fasciculelor lui (ioll qi Burdach) sa.u pr'in leBiuni r(r(li(ut(rtloxtarioare realizcazd, de tsorn(lnoa, lripol,onii plin inl,elfln:treil u,tt'ttlrri rrrlh'rlr)nl{r Olementiu.
a. il ipnl tt,<)ostor rodidllo 'm i(lite poltlffiaor,r.r estc rr,prtzlrr l,rr,l rlrrlrrbrl, nlti nkrs i rr ril,rrt{;ii lo cu irnpoltrr rrt rr tull;ulr1l:i r[o stqr si]r il i l, i!1,{r lr rol lrlriri,.
b, H i.rul;uq,nt d,t' r t Jihrr lu,rrgi (dt. .nr(loun( Ttuslrtiourt,) ?v:u.lththr,r ' r ' { r intnl l l ( ' i io lu l (x)ut , ( fx l , r r . r r r io logir i r r t : l r rc pc 1rt ' i r r r r r l p l l rn so t r , l [ ' i , l r r l l r r rl i l i lo r l r r ptol) t i ( )nr{{r l ) ( i { r , r r r ; r r r , l l r . l i l oslr 'o l , r t r r l i lo: l , . l l i , r icrr l r iprr lorr i r . r r r r r r rl r r f r r . r i i . Adctr , l r , r .s l , r , vol l r : r t l t 'n i i tou. t t 'd( t t r lu t ) t i i t t tuhint l l i , l t r l r r r r . i r r( ,or i r , \ lu l c l i r r ic : r1 l r r '4 i r , r r r r r r , 1r i l I r r r r i r | I r l r r . f . { r ' g i r r r l i t r r , i r r : r r . r .n l r . r r r l r r l r l i r ,
t7 l
\t s irr,rLl'ou,nte l,e n'au,ronn'ent,i,.xt, lit' sindroamele tle salerozd, com'bind'td caren-
liolri, lrr, rrtrolo d'egeneresce ;!'a sp i nrt- cer,ebeloase (indeosebi eredo-ataxia sauirorrJrr, hLi I'rieaheich) (majoritatea rlegenerescenlelor spilo-cerebeloaso,irrrlrrscbi eele de tipul Piene-]farie evoluind, de fapt' cu spasticitato
lrilrrrrrirlnld,). Rareori existS, scleroze in p15,-ci care teallzeazS" folTa pseudo-.i.rIr{'l,it,ri,, cr marcati tulburare de sensibilitate profri:nld, cu hipotonie $ilrirr,rrr.Il,i.,rie osteo-tendinoas5,, in cate qi semnele cerebeloase apar cevarrrr i l i tz iu.
.1. t,a: tu'nil,e periJeriae ale orat'Iui refLen c\7 hipotonie consecutivi',rrrrrl, irrl,ilrrite in iumbroase afectiuni |
^) Polirad,i'culo-nevdte ; b\ Poli-
ttt t,ri:r'. ni tt oltttc ur o putii i l 'e diuerse origini, (ve capitolul precedent) ;, ) V,,,,r ift, ' si neu,ropatil. (tlaumatice' torice' metabolice $.a.) ; d) Leziuni, , l t p l , . t t t1 i l t , i l l r t , rL i l l , lotnbar ' o:rcraL).
l. Alealiunile rlasculttre, ca c1o pi1t15 in distro{ii1e ilusculare plogte-; ir,. (rrL ri.rzulilu in c.ne se irxtaleazi atlofii importante, degi :rrcul retlexr . i lc r l l ra, t , t ) ,
0. It;:tutlilc ftttmaliuttllor cu acliune Jaci'Li.latoare osupta dtaxt'lui't t llt ,t) Lt)tLioen ( prin intemediul sistemului rei;iculat facilitator tlescentlent),siirr,r(ii iricLr,rJhipotonia musculard se datoreqte preva,Ienle i acliunii for-rrr : r t i r r r r i lot inhibiror i i etescendente :
t\ I'eziunile aerebeloo'se (infec-tioase, traumatice, degenerative, atrofi-ilr coictreloase cu tliversele lol forrne clinice) se pot insoli de hipotonierrrrrscrrlat'd (uni1aterald, sau bilaterali, erentual crr predominantd'
'le o
p: lu), care se poaLe evidcnlia, pe linga-ptobele clasice de e:.plorare ai ' r , , r i t i iz i l i i pasive, q i pr in al lc probe senr io lcgice: proba pasiv i tdt i i a ' lu iA rrrlr'6 Tioriias (dd rS,sucire pasivS, a tmnchiuiui bolnavului, remarcindu-serrrisciililo rnai ample ale bia-tului de paltea hemisindromului cerebelos) ;prolrrr, ,,r'ezistenlei" a tui llolrnes-Ste,ivar"t ; proba reflexelor pateiare
"'o"ttlll^rl;r*,*or, neostriate (coreile tle diverse tipuri qi etiologii, acute qi
crrrnicol sindroa,rnele atetozice) asooiazS, hiperkinezia caracteristicS, qilrip,rl,uttia rle iltensitS,li variabile.
c) Llnale sind,roatna aesti'bulave se pot insoli de o discret5 hipotonierrrrr*r , r r l r r l l i insi lateral i leziuni i '
d\ It l&lunite neuron'ilor tnotori'centrali, hipotonia muscularS, poatoHri ti(' irrl,ihriti i, numai in situafiile in care sindromul piramidal s-a insbalatlrlrrsc. dlr si il accsle cazrrri hipotonia dureazi doar timp de citeva sdp-trirrririi. in cale asist[m la o hemiplegio flascS, (sindromul piramidal defici-i:r,r:rl iui Barr6), dupd, care se instaleazS, hipertonia piramiilald, c&racteris'l,irrr'i. Nlonfioni'ni ru:rele parali.ai'i fl'a,ece centrale pseud'opariJwical
-inso"litgsi rlrr u,1,xrlii muscula,re, adesea cu distribulie pseuclora,tliculari (dar fd'riii. | ). ,r,,,tlo*usculard), rea,lizate d.e unele tumori fronto'parietale (menin-giorr,rno, glioame) sau de suferinle vasculare.
4.2, HIPERTONIILE MUSOULARE
4,2,1. Iliporl.orriilo plroxistioo sint roprezentata la diversa crize de(ont,'tu,hffd, cliro inturosor.tzii, Iitr orrt'pul ln int.regilne, Iio auumito scgmontooor.Dori 0 ii:ola,to ti u, oi"!l 'ol'durlll,i ir lrr Iunofio i]o rnocllnigmul contnlcburii 'rtxl,0 <1() t l00Ltttt lr.}-ttt i tttt l ,o, t{l l , l l ( l( l i) l(1.
l't !,
4.1!,1.1 . I l ipul,ott i,i l.u pu.rotittl,itl rtutt,r'ttul,izttl,t:|) lr'onnt:lt Lort,i,r d,r: qtik4tsic q(n,ar lizal,ii (glarl rn:r,l }r,irntr,r. grrrrrrr,ll ' l i
zirlr itl,u $ootrtr(lirl gonot' ,l iza,1;) sint rcl ,tiy nryor rlo rxtnrroscrrt, prilr lrrrslr,,n.rlrrrt* bruscil rr, corr;Liorrl,ei, prirr carrlr,torul oonvulsioi i,oni(x), l)rilt {lut,t[l,nsorrrtii (minuto), prin tulburf,li lo respiratorii, vit sor]ro1;ol'i i rlo a,rxrrrrprrrrirrrnonl;, plin ernisia dc urin.i in crizi,, prirr mulscaroa lirnbii, prin prrrzrrtl(,rr,rlo ottioei a miclrirlzei qi prin surprinderoa moclificririlor lrllr)(l (Ar.sorri [i, " l rb. ,
1978 ; Popovic iu . ,q i colab., 1970).lr\ Marca crizd piliatici poate sd, realizeze o corLtrrrcitrr,il, grrrrrrr.rr,li
zt,bii, da,r, spre deosebire de criza tonicd, epilepticS,, ar.e o dulttii tnli lrrrrgrr ,rru se insoleqte de apnee, nici tle emisie de urinI qi do mursclrrlr, l irrrlr ri,rtioi de sernne EEG, apare intr-un context psihic revehtor., il lr.sirrr;rl,rrrlr,l,ologia critic5, este ,,neulomimetic5' t, adicil, are o topogr:r,tir: cN,r.o rrrlrr.sj{)ir {ru colespunde structulilor anatomice reale, ci ,,itleii,, 1o otlr lrolrrr,vul o are dcspre ,,organizarea" Ba corporald,, creintlu-se zr,sblirl o Irr,lsrr,.,schem5, corporald,'J (Enitescu gi Popoviciu, 19?8).
c) Tetani (si sind,roamele spasmoJil.ice) pot s5, realizezo (x)trl r.rrrl u llspasmoclice ale extremitd,lilor (cu spasm carpo-pedal, minil rlo rrurrrro4ii cu planti, excavati,, cu inclestarea pumnului), a1o trunchiului (orr rrl,trrr.ciri ale torsului), ale muqchilor felei (cu,,ris sartlonic,)), spnsrrLtr orrrrkrrrrotolii, ale limbii, a1e laringelui qi chiar crizc tonice gcnei.r,liia,0o rkr lrll r.t,pscudoepileptici, (Riser, 1952; Figi,rd,qan qi Popoviciu, 19?8). I'rr,zr,rr(,rrsrrrrrnclor lui Chwostek, Trousseau gi Erb, lipsa pierder.ii cunosl,iuf(\i, :lrl,(,,.rl{lontele, modi{lcd,rile EEG qi EI}IG (1a proba g:lroului), motlil i ici' lr ' i lrr c:rllcrrrici qi/sau als magneziemiei, clarificd, dlagnosticul (f ir,glriiqrr,n ;i l.,opovir i r r , 1978).
) Crizele tronice de Josii posterioarii au fost ilescrisc inilial rlc .lrrr' l isorr(ll{?1, oitnt de Arseni qi colab., 1978) sub termenii cle ,,cercbollilr. l i lrr",, , l , r l r r rnrs_l ike seizurest ' $au , ,cr ize postedoare, t . Apar mai: l los Lr, r ' r rp i rrr rr l:r adulli tineri, in special in tumorile mecliane cle fosri, lrosloliorilrr(1rrl, po un Taterial de 1040 caauri de tumori cle fos[ posteriorr,i.i, pulrti,.r,irlr, Arscni gi co1ab., 1974). Aceqti bolnavi prezintii de obicci ;i |i 'rrorrrr,rr,"rlo Iripcrl,ensiune intracraniani,, insolit5, adesea si de o r.cclo:lro l i1(\l'(,i lr:r lrrhisului, precum qi d.e pozitsia ,,ceremonioasi," a tnpultri.
. ln mod brusc, de reguld, in urma unei migciri bru;tu a ca4trrll i, colprrl se plaseazd intr-o contractqd, tonic5, in extonsie, in opistotorrris, irr,r.rllpul este.aruncat_inaloi, eu ochii deplasali in sus, mcmbrclo liinrl Jrlrisrr,tr,irr li lexie qi pronalie. Uneori se asociaz^ $i trismus qi incontinorrl,rl sf irrlltrrrir,nir,.
^R,espiralia devin-e foarte neregulatH, qi supcr.ficialtr, stnt (lr! i,ill
t l lrovne-Stokes, apare bratlicardie, pulsul este fil iform, bolnrr,- lI I ' j irrrl rlorri.rr rroori obnubilat . Criza dtreazra do obicei clteva minute, putind I'i nro r,l,rr,lil,.t)rr!ir, .crizd, cefaleea $i vd,rsS,turile se intensificS,. S-au deicris qi lonnrr pn.rl|ak) da $tza tonioe, caracterizato doar printr-o contracturfl ;la,rrrx inl,irrrl,l rxrfci, sau a membrelor qi a oefei, dar nu lipsesc aproa,po nioiodrt,l,it, i'trllrrr|itrile r'<lspiratorii, paloarea qi cefaleea. S-nu descris ii crizo tolrim 0rr prrrrlrrnrirrrrn(;ir, unilatcrali, cu asloct rlo torsiuno a,xirll5, (Va,n Boglorl;;i Mur'l,irr,ll l '..11"t, oilrrti d.o Arseni 6i oolrr,b., 19711). Mrr,ioritatolr, ir,coslior orlzo l,lrrirr.rirtI rryola,torlro pontr,u. trrmorilo rlo frrstl postoriotli ' i, (inrloosolri vollrlt,lr\)rii ;rorrl,r'u nngt.jfi,rilo l;errrpor.llc, t5i r.lrtrrlo l,sl,l i l l do rlrizo in ctr,to so H1ill1,1rlr.it r r r r r | | ; iotr l , r t t r . r t 1;r ' r r l lu io r I I r r r l r I r r r I r11;o 0u 0r ' iz0kr rrpi lopi i r r r r i t ) l l i r { r ( l i , iHr,r ' , l0 l t l l ,At lotr i q i r l r l r r , l r , , l l l? l t1 Al 'Horr i 1 i l 'opnvi l i r r , l { )Bt)) , t l { ! l r r t , { ! , r to I I i l ( , I r I r \ I | | \ I | ,j f po;r l ,o l r r l i l t t i o f i {ut to l t r fn, r .o l t r r , t l l , r i , I , r r t r i t , i l , i t rx l r t i l , iL r l t r r r i l l r rozi i , 1 i r l r '
t i / ]
r r i r l ' i i lx i i . l ) l r ' , i r r . l r , l l r r l r ' l r r r l , r r r i ' izrr r .1r i I r '1r I r . i r , s. p|0r l i ic0 o rr l ) l r ( , ( , ,, l r rp i r . r ' i r r r . t r . ,p i r ' : r { i i l l s , . - r r , r : r . r l l , r t r r r r r , rJ r l ls l r r l r l r . r . r , j {u l ; r l , I , r ,Olurrd(, i ,,{r'r' l()lrrir'slr, (1lr t(}frd (li i(i ' iL(i do criz,, tonici a hri Jaaksun. -tn schirltr,
.rr.r.il. r'r' izr. lunice tlc_Iosii, posterioari, cu rluratii de aBerncnea Bcurtii,, nu
. , . r r r r l r . . r . t tc.obi t .e i t le pierdorea d, . cuno[t lntr ] s i ecl rnai tdesex disparrrr ; rozi l ic de decubi t dorsal (drs.r i l i cohb., 19?8). Arseni (1050) a einisi.,r'ir v.'Lricu1ari, confomo sireiir aceste crizc se produc printr-rin rueca.-rrrsrr rr'1icula,i, ceea, ce erpliri qi_fuptul de cc lrcesie crize-pot si, apani inIrrrIr: pr,ocosele patologice care iriti perelii r'e1}triculari.
t,) 0.izele h,tptertonice d,in letartos tlcbtteazi, prin trismus gi ris salilonic., l l l r i r r . : r r ' , . coul tactura se gencrr l izctrz i , cum plet ixd u sc eu rer lua rea cefei ,, r r r l ivr . rsr . in l lexiur i i a le t r rnchiului ( i r :a inte. inapoi ; i Jat , . t ,a l ) , c l r reduareJrr rrrr..cl_rilor, tlrepli abdominalj si a muSchilor pectrxali, plecum si clr contrac_irrli alt rnembrelor. Aceste hipcrtonii t€tanice sint pielungitg persistenie,rtrrrl'roaso, fiind eracerbate prin paroxisme tonice vioientii initise ae c"*ijl:r I i i scnzoliirlo si psihice (zgomote, lumin5, emotii etc.).
t 1 .7 t . t u rb.o r e apar conrracLur i bnrsl o I r r ingo-tar jngu-d iaf r .aema I i r "e,, t ( . , , . , .h i r d, . r io lente. . insol i rp de cr i "e de apnec $i t tc blo 'caj l r r in; ia; ; i t i Il.rrlrr,tivtde
-de deglutilie a;ntreneazi, desciirrca.ri tonico-cloni"ce ale*buzelor.
:rl. rrur;chilor faciali qi ale constrictotilor faringieni. Ca gi in crizele-clirit'.l, rrr)s, acoste conlnacturi tonice rabice sint, in moil caracte'istic, declan_,rr lrr ii .xacerbate Ia cel mai mic zgomot sau Ia eea mai micii rniscai'e aol,iv6rrr.rr ll i lsivii,
,{1it crizele tonice <Iil tetanos, cit qi celc rabice, sp iusolego dc oxago_'rr.r.ir
tti let_telor idiom, sctrla,re, ostcotendinoase Si mai rles i unor rofleie,lc llrrnchi cerebral (nazo-palpebnl, mtscter.in, Chwostek).
t) In intonica!,ia cu stricwtnd (sau, tn su.pradotarea terapeuticd) poate:rlriirtir ti sttire de contracturi . d e., tip tctatic, cu t,rrucorb[-l.i p""6rliti"e,: ' , i , . , ' : r r , l lorrr ind crr convtr l ; i i c lunice_
'f .i!.1 .2. II ipertoniile paroristice localizatet) Crizcle epilepslice localizate (tonice sau tonico_clonice) tle tio iack_
rr'rirrr ((,u f.i1 fii,rd lierderea de cunoqtir-LlL, cu sau fi,r6 der-iatia'cilj u_,lrrl.rr rr r.rrpului $i a ochilor') se recunosc prin durala lor scurta, uneoriipie_lr.rlirrrl o crizii generalizatl, precum [i pri]r contextul clinico-EEG. '
b) 'I't:tun ia ;i, spasm,oJilia se poi manifesta printr-o crizd, de contr"ac_lrrli i. l irrr.iti it i la un segrnent corpoml. Oontextul clinic gi EMG o" pr..i-zr.:rz:i rlirrgnosticul.
() (hitete ocwlogire posl,encelalil,ice realtaeazd Im context semioloEicrrryol rlo roounoscut: {ixalea brusci,, penrbilA, coercitivd, a globilor oculi,rirrr nrr H, itxoliid de, deflexiunea capului. MuIt mai rar se reaU;eazi un spasmhipr.r,torric latelal (cu sa} flri devialia conjugatd, a capului),
""*p'*iioIrr fpilrirn ou coborirea globilor oculari. Une6ri in cursui crize'i oolifogi""rl, lrollu r.err)in]'&r, midriazd, sau miozd,, iar alteori bolnavul poate meniileirr cursrrl crizoi o a,titudine statuiticatd, rigid6, a intregutui c6rp. Niciodatitr Hrl (xrnst,rtd, :r,ltelarea sttrrii de conqtirn{d, in timpul crizei -(element derllrrgrrost,iu dilorcul,ial fa{,ii, de, unr.lc crize opiloltice cir devi:r,6ia conjugaid a;lLrlrilr. oculari itr-ilus, ou [ti1; mlli t ult, cu cit s,l| 'rr d escris crizc o-cu"logi|o,lo ltnprrtl, tlx r icct- ttl rn ic,, rlrtlti"l trnt'o lo Iixrnzii in tlcvia!,io sursllnvor.gcll,:1,
ll,isrrr', l{}Ii2)^ (lrizu 'trulogi.i"r,
i lr., lrr g.rrtiHtl, rlrrrl,l,i l Iutrgl (ri. lr, ti it.ovrrr r r r r r r r 1 , r r ; r i r r i i , l l r c i t t r t ' l r orr ' ) , l l r t l i ru l I i r t r t cor i r r rp l i rn i r , t r ' l volrr r r t l r r , , t l i r r . l l r r
olt i t l t ' i t t t r 6tr l t t t t t l i l ; t t t t | ' t t t t t r t io gi la, i r l t r t i t t is l , r i l lo l r l r r l l l t l l l r . i t , lo r lo : t1,ro1r i l r i i ,r l l tu Ncr ruol : r , r r r i t r j i , .
, .r l) I l lr lu,nnptsrtt..nl. si sltttsrnu,l .faaio,t, ltn,i<t l ir l icl i, irrr.Jrorl, lrrrl(r I)|.6I)Ir\|r||,r. lu rl irugrroslic, pul,irul l i explorirl urrol rnllnil 'estl ir i spasticrr p'riprr.rrl izi.Irt,ciu,L'i,, a unnl rnrr,nifesi,Lri extrapirarnidil le, s.m lunc!,iotur,lc, irrdrisiv gri l, ii r h( i { ) .
. a) Crampa scriitorilor se caracterizeazti, plintr-o contr'tt'otuI'ii 1[rsa,grrlii,,,,(,ora,1;ivi,, a murschilor miinii (uneori [i ai antob]'atului), cu otisplu orr, irr liipr,r.'l 'kr.r ie a.degetelor, care apare in co!ciil i i binc rteteuninate ;i rih,l iv ir lor rtlir.r,,respectiv in mornentele in care boLnavul incepe si, sctic. ()r'runj)1, rsl,rr r lrrlr,lol,sri ,5i se extinde adesea qi la mugchii brafului, ai umintlrri ryi rr,i gilrrlrr r.Do aele mai multe ori este vorba de crampe ,,funcfionalo,, irrrrlrisiorrrl,,(Lr, drctilografe,- la_funclionari, la pianiqti, la violoniqti oto.), irr llrrriti,rrl i i l i distonice declanqate qi/sau exacerbate de o fobie a stir,isulrri r-i:rrr :rprlctici,rli profesiunii lii de o fatigabilitate excesiv5. Unrxllj insii csl,o vollrr,rlo o diskinezie eltrapiramidali,, sugeratii, incii de Il,iser (19f2) qi vrr,it.icr tl,clectromiograflc de Aqgian gi Popovi.iu ( 1980). Astfel, se pructirli, cx i r,l rrl trr Il ) l IG simxl tan at iL pe rgoni i t i . c i t , l i po i ] ,ntagoni l t i fprrr t , r r , , i r r r . r .v;r( . r , . rr 'e, ' iptocc") . In crampr, ncrrol icS,, la accaslA plobl ' r : r , , i r I r . r ' v r , 1 i c i l r . r . rlrtoce)t .se tlepisteazS, o funclionalitate normlh, ln sclsul i:i l l, txrrr l,r.:rr.(irrrgoni,lti lor se constat[ decontraclia antlgoniptilor. fn schirnb, rlrrrii r.i i,,vor'lla de o ditq.kinezie extrapiramiclali,, Ia contracl,ia rgorriFi,iiol sr, r,r,rrl.r'tct[ .$i rnu$chii antagoni;ti, adici. apare o activitnte EM(i ;i 1xr l,r,rrsr,rrlrrrrr;ohiului antagonist, inregistratd in mod simultan cu cont,r.l,c 1, ir r, rlrr rr,.1r'rr,soul EMG.al muqchlului agonist..Credem cd, aceastii, prob;i lrlozirri;r,'olrrkrilre semiologicS, pen!ry diagnosticul diferenliat intldcrarnpirlo rrrrvloI irrr si ccle extrapiramidale ,si pentru olientarea tratamentnhii.
l)..I.n -m,iotonii,
(boala Lui Steinert €i boala lui Tltomsen) ln o\ir,rrr\rl,rrr;rr'r' l icial ne-ar putea duce in eroa,te, sugerindu-se in mod irr<rorrrcl, r,rir.rilr vorba de o lripertonie. De fapt,.dupii, cums-a precizai, irr uli,irrrir :rrri,.,irr ciiLda aparenlelor qi contrar definiliei clasice, miotonir.r, nu cshr o lrrllrrrrrr'o de relaxare, ci o contractie prelungiti, determinatri do irclivil,rrl,r,rr,I r.ir x'lcetricS" interactiv[,_ suslinut[ a sarcolemei" (Radu, 19?ll). l)i:rgrrorrIicrrl este relatiy u$or de stabilit, gratie ulm5,toarelor elomcn{,o :
Caracterul eredo-familial atit al miotouiei congenittlo hipori,r.ol.ico(lxrrla lui Thomsen), cit qi. aI distrofioi miotonice, (bo;la lui Si;oirror.i);
- Prezenla hipertroiiei maselor musculare irL boa,la lui ll,horrrxoir ur:r rll;rofijLor musculare in troala lui Steinert;
-.Prezenf,a fenomenului miotonic, care se gtio cri nu ptozint:L torrru,ririu lotrsitate in toato grupelo musculare. Astfel, sc poate lo-rnl,r,cir r, lrr.rrrlrrrrrirrlnll a fenomenului miotonic la musculatura <listll i i a lnorrrlrr,il,,r_'1,,rriol,oni:l, conge_nitald,. (Thomson). fenomenul mioto ic aprlro gorrot,:[l izlr,l,,rr vrome cc in distrofia miotonicir, Steinert este mai limitat, alleirlirrrl r|rrr,r"c i l ivr , .muqchi sau grupe muscuhre (mugchi i pol iceht i , rnuqrchi i l i r r r l r i i ,r rr rrqrhii flexori ai rlegetolor,'mu;ch i i orb!culali ui ploo.r,pol rr.ryi odu krrrrol,or.ii).lrr lrrr |rlmiol;onia congonitalii t, Iui. rlult'nl; rrrg lerrr)luernrl rniol,rtrrio porrl,r,rrrlclcsil ln rnorl oxclusiv nruqchii faoiali (li lri lu, l-9?8) ;
-- or )rrBi,rIli l 'ol, Ii l 0xir,rrr{)nIl lr)l\l (l rr, srr,lvoi rrriokrni0rr r i i r , r . r r, r r I , r , r . i r r I r r r r r( r r t r l r r t ' lu l i l , p i l r r ' i , l r r , ! l ) s) , corrr l , i l ,u i l i , t l i r r pot , r r r r{ , i l r , l r r l r lxr i , i l , ivs qr!r{ , r , r l , r { r r; I r r ' r l l r ' l ' i r r r r r lp l i i r r r l i r ro qi i r r l r r r r rvrrrr{r ' i , r r , i r r r r r inr l r r xrr rDoi i r r r r ' r r i , r . r r , r fH(x,n{ l ( ' l ( ' l t l , ;
. . . l ' t ' .zr fa l i r , r . r i r r r I r , r r r r r I r r i r , r r r l r r r . r ' i t i t r r l i l l . r r l i r r , r r r i , i , r r i . i r , lJ i , r r i r r r r l . i .
l Tft
, l . I . l l . l l i ; lor lorr i i lc ptrrrrrr r r r^rr lo (srrbtrrr lc s i r , ronica)
'l-:!.:1.1. I I .i i lt.l 't oniil,e ruh,itl iute (rtthitotaiile) clu,yproase .sc pot intiLnii r r r r r r rotoir ,se Ntcct i iuni :
t) ilinrlrotnul mentnge&l, realizat de meningite qi de hemola,giilo sub-iurlrrr)irli( 'no implici, in tabloul semiologic o hipeltonie dureroa,s5,, ertinsiiirli'${,ir lir i,u{,i muqchii cen'icali postedori qi ra;hidieni dorso-1i:mbari, inso-Liiri (l(l rlxloarea neiii, a cefei, de pozilia cancterisl,icd, in ,,cocory de puqci',1i pozil,ivil,ater bingcunoscutelor manevre Kcrnig f , Kernig trI, Lasdgue ,l l r r r r lz i t rs l i i I , Rrudzinski I I ry. a.
lt) tlii,ttdromu,l pseud.o-nz,eningeu,l, al f6ei posterioara trebuic dilerenbiatrlc sinilrrrilmelc meninge,ale propiiu-zise. Acest sindrom pseud o-lr cningealcslr, rr.rrlJzat de procese localizate in fosa postelioari,, dal' qi de altc proieser.)i l):ll)sivc supratentodale, ca,re produc fenomene de angaja,re a cercbc-trrlrri, r',.spor.tiv r lobului temporal. Se poate astfel evidenlia, o ledoarerlrur.r',rrsi rahitli.tuii celvico-dorsalS cu Bemnul lui Kernig prezeut, cu olrozilio rleflectati| a capului, cu membrele inferioare in flexie, cu atitudinelr ,,(xxiol de puqci'". l)ar aceastS, hiper-tonie dureroasi, a cefei qi a rahisl-Irri porrl,e prezenta exacerbiri qi remisiuni, fiind va,riabili in iritensitate, ia,lrrrrrrrlirr lornbard, (periculoasi in aceste situalii) poate s5, tie urmat5, de olr.rrlrrrlrsot:nli a, algiilor occipito-cernicale $i a semnelor meninge:lle. Unr.rrrrrrr,n lrtont ,i sistenatic al fundului de ochi este susceptibil sd, previn6,i l g( 'rrrcl loln el 'ol l .
r:) Ilt"pertonia rahi.dialxd, dureroatii,ipolatd,, interesind doi.rr unii musch irri cofiri ;i trapezul, imprimind o atitudine vicioasX (cu torticolis) loato fiirrli lrril i i in cutsul unor leaia ni, endoaraniene qi ' intra-rahidiene ce|Dicale.iir.ril rlc;te irita,lici nervilor spinali Si cervicali. In contextul serniologiclitrsirsit, (lzri,:i tle sinclroamele preceilente) contlacl,ura rahiiliand, krmbJrS,1i'rr nrunblclor inferioare,de ase-menea nu Be evidenliazi, semnnl. lui Kernigr'r , ', l,Lrl1r. scrrrne lr|ningeale. 1n plus, contractura mt$chilol cefci rnlni-i,,;l:r L1r.turr1eii. De obicej capul este plasat intr-o atitudine cle anteflexie,ll;pr.r'1 iv rlc antellexie Si u$oari, rota-fie laterali (in tor"ticolis). In plus,lr6llrrrvrrl rnen-tine capul intr-o ,,imobilitate ceremonioasi" (Yan Boo;rcri- r I l : r r t i r r , l t r28, c j lar . i de Rise.r ' . 1952). AcesI c i . t r rc ler de lur t icol is . ,pcr ' .l r : r r r , r r t . n l ; r1 i , ' , f i rat , puf in schimbi ior" ' i dunetos i l d i iercul i rz i ' i . . ior-t,i{u)lislll Fprsmodic (vezi ln continuale, ca,p' 0: Probleme de dilg'nosl,icirr rrr,rrr iul.rlia, lniiqod,rilox involuntare). Aceasl,S atitudine vicion,sX a capuluirr'prlzirt,ii, lrn somn precoc€, care apare in tumorile subtentoriale, al.e foseirrlslr rliolr lc, intl eosebi ale ventriculului al fY-Iea qi mult mai ral in st:rtliiler,rcr|,icr,I,. rrle trrmorilol rle unghi ponto-cerobelos qi ale emisferelor *grobe-1,,.rs,.. Acr'lsth pozilie vicioasi, de ,to$icolis ceten:onios" trebuie dif,ercn-li:rl,r rl, ' Dozitii le licioase ale capulul consccttivo unor leziuni ale colo*ueiirrrit,.,,s,.[i prin morb .Pott cervica,i $i prin traumatisme ccrvirnle). trIxist;,si riltrtti i in oare unele tumori ale {osei posterioarer migrate spre rlr,hi;u}(,.r vir.rrl t)r' jrr gaura occipii,alS, unele neoformalii extra- sau intre,dnrlle1r.t,vigrrlr,- ilaltc si mai rlr o hernie cliscal5, po1, tlcl,errnina nn tortioolisl)rnrr,nrnl;, lnsolit, t1e tt ledoa,ro dureroasi a mu;chiltir ceiei, a traputuluiiri rr rrrnii,nrlui.' l 'r 'ebttic, rleci, sti rglinem faptul ci, majorilulea caztrrilrt 'i lrr lor'1icolis nn sinl, tlc origine rounaticii, b&nalii,. lTueori rahiatgia lipstq.te,Irr rlrrr v rrl arflrzlnd (lor[r o crtttrllee tliftrzi"t,, j l lobilizrtl 'ott acostiol' b(]lnilvi tr'{d)ui0, i i I i r , I i i , ( r r1 i i , f r r l r t t t l l i i , I t ' r t t l t r r r ( i t , i l r l l l l ( i i { ; o l t t i l t r t tvt ' i i , l t t r r l r I r t t ; i t l i i ' lxr l r l ; r riL l l l \ l i t , o r , t l t l r . t ,b lurr l r t ' r ts l i i l t , i i j t t t l t r i t t t t t lu i r l t ' l t i l l t r l l , t , t rs i t t t tc i t r t l i r ( j r i l l i l l r i ,
lT l r
o l l izrr lorrr l rL, o ; r i r r tur l l i r , i , t rururt i , t , l t r t t o t t r l t t i r , l t r l r i l r r ( l i i r t t , l l l l , l ' ;, \ t r r . t t i r i r , ,o l r l r . . l1 l i , l ) .
, \ r , t , l rs l , j i r r , r lo: t r t r l t cc l i r i so l lo l t lo IuIrrr1rLr | , I r , , r l r r l r i i cr t r r l l l i I t . l l l l i r (:ur1{r io l ,0u o t r l ls i t , i ( ,ont l lo1,nI ' i ' i , l t , i t r l t t l lJ i (x) lo i r l tcr l ) l ( r r tnt s i t t t ruzl t ,lonjcc t lescl iso t lc JacksotL qi i le Arscni .s i tur l t t l t . ' l ' t r r l l t t io ; i r t r r { ' i t t t ' t t t t ' i r .nurlc irnportanlii plactioii prezinli ttlplul cti turbilizrllor, cruprtltri cslo tl ttt.|orrs[ qi ci, se inso-teSte foarte frooYont d.o paloiil '(], q1('1ilr|j. IMI||il| i iIr Irtri'tiginoase qi rnociifie5ri carclio-vasculale qi iespir:l'1,ot'ii.
d) Contraeturitt 'ni- sau bi,laterale,localizate, u'le col.outtti.1i. Jntt,stulqlu t ilt:erticale, tkrrsale ;i d,orso-lombare pot fi intilnite in cele mrti tl ivr:tsr' :tl lr '1uni ale coloanei (spondiloze, spondilite, puseuri de rertntal isttt t 't itLrr|rtrrIhr:rnii dc disc, tumori vertebrale), dar si in alte proccse (aLrccsc trrr i, c lt rr I rrlito do diver"se etiologii, arahnoidite, meningoradiculit c lo<rtlizrrlr, , 'r.:r.,\u trebuie si uitim nici inqeli,torul ,,lumbago primifiv llrrlrrtrrqrh.gir 'rlesclis de Sicard (citat de liiser, L952) c semu dedebut (fazi, t r r t I i r r r r I r r r ' : ' rrir cvolulia unor tumori extradulale satr subdurale, in snre insii sitttlt0ttrrr]uranometric qi cito-chimic lichidia,n de blocaj rahidia,n sint rr1 iltr 1r.tr { r rl:r'an$area diag:rosticului.
4,2.2,2. Hfutertoni.il,e { t:onlraclurile ) d,e origi.ne ce,ntraLri (ernrrr.li:.trl,tuzt. toc,alizate)
a) trIfuiertonia (contractura) piramidald prezintd, p:llticul;r,riiil {iLr lrirr,(lnnoEcute: predominanld ectromelic5,; caracter electiv sau (1r'irsir' l(\ ' lr\(1troponderenl,i pe flexod $i pronatod la meinbrele supeljoar'(', r.rp(,rl r\1rc ertensori la membrele inferioare) ; atitudinea caxactcristicii a, lnrr r lr rr,l, ,rintcresate (de tip Wcmicke Mann), consecutivi acestoi contl' i|,(,1,rrIi r,l, ',l i1'e; prezenla sincineziilor (globale, de imitalie ;i de conjuga!,io) I crrlrrlIcrtl de cedate ,,continu5," qi elastici la probele de mobilizrlrt prrrrivllopograiia extinsS, hemiplegici,, para,plegici', tetraplogici' sau monopk',;1icrrplczenla altot semne pirarnid.aie.
Caracterele propdi ale hipertoniei (contracturii) pilanlidillc lrr p('frrrit aprecierea topogratiei leziunii qi ca, at'are, un aieosellit itLtu(.s lt)lt)ttt'tl/ic ]rrezintd, semnele asociate ,,de etaj" (spina1e, de tnnchi cctclrlrrl, rtrrlicrLle, subcorbicale), care trebuie clutate cu grij6.
lt) Eiptertonia (conlracturo) entrapiram'id,alii (paLr:oslriutil din sinrlr,tttu.l, lt ' i,ytntoni.co-hipakinettc sau porhi,nsotzim d) prezinl,ri, ])[ri,i{]uLr'r' i l,r(il,l ) l t t ( jcunosoute:
De obicei este generalizal,i,, Ia toli muqchii pet'ifot'ici, tl lt,r' itrlorr'rrorrai indeosobi musculatiura axo-rizomelici n staticii [i :l echili ltlrrlrri (r rr rr;r,hii cetei, ai g'utierelor vortebmle qi :r,i centulilor scapulnl'it, 1i prrlvirrrrii l.!,(' mult'e ori se poabe lealiza un homip*rkinsonisr .
- Este globalir', adic5, intereseazi, in rnisurii, sensibil ogill i i it,1i l, glrrlrr rl, 'l lr,xorii, cit Si pe celo cxtonsorii, rlvind toiufi o uDolrl plulorttitlr'rr{rr 1r,'
rr\ ( .) f t ..* trlsl,e ceroa,sX" nla,sticir.- Ditrimrt'r,rzii i ir cnrsrrl .\otnu ului"* Ocderzl in s ( . ; r , r l t r r loa, l iz i r r r l scrrr t i r r l l i Neglo (rr , l t r r ( i i r l i r r { r r , l r . ) .
I i \ ( l l r ( ) r r ) ( ' r r r r I r r r ( , i i r l i t r { l t , l r r g1; 1111,1r11{,111r iv i r , , ov i r lor I ' i i r r r l r t s0 t ) r i r , i l , r r l f irnrr t j r r <t t t l t r r l r . i i rc l , r r i t i i uur)r ' l r iu lovr ' ( ! t lc t r t i r iu i l i n l l ivr , t ' - , t r r l t t , l ,hr t : t r i r l l i rI r r ' I , r r r r r I rLt r I r r t t r t ' r t t l r t r , ( l r , r r r t r t r l I t t i Noic l ) .
I ' r t r l )1, , , ( | ( | | | | r l | | I I l r i ' t r r l t r i l , ' r 'ot t t l t tL r v i r l i r r t { i l tz l r rcrrr t r l r l t r l l r , l r r l r r , tior t i r i ln l r r r rDrr l t r r , I r i t r r I t l r t i i r r . r , l l r l l l r r r , r . r r r l r ' I i l r l i i r r l , t t t t r , i c i r r r l l r r r l r r lvul
t't't
r{r rnolll ino l)n |lt] }ioior', cin([ $e lirlicii, $uu oilrLl tn{.rge, respcctiv atruDcir r r r l i { i i r . l i r ) i ' r , ' . " r 'Dul i r r : - r iote.
- Jl,ellloxcle <le posturd, sint exagerate.' Uitracterele contracturii imprimd, bolnavilor o serie de aspecte
prr,r'l;iculare cle posturS, qi de migcare : atiiudine statuificatd, qi,,in sein deirrl,robure", mers rigial $i_cu alur5, tle ,,fug5, dupi centrul rle groutate,,,
- Diminueazl la aclministrarea de scopolamini qi de substanle doLip r[tropill ic.
-- Llipeltonia parkinsoniani, antreneazX disparilia unor sincineziironlule gi se insoleqte de o serig de sincinezii paradoxale, ca cte pild5,:lioxiunca precoce, anticipath a lungului supinator la inilierea flexiuniirr rr t;obla,{ului.
. :. l)up5, teLanizarea" faradicii, decontraclia musculari, se prorluce mailctri; rkrcit ln mugchiul normal, iar cronaxiile tind sii, se egalizeze.
- In cursul ,,kineziilor paradoxale', hipertonia dimlnui| in mod net.-. I{ipertonia pa,tkinsoniand se insofeqte qi de diminuare& auioma-
lisnrrrlol rnotorii, plecum gi de bradikinezie.1r) Sii nn gitnm combinaliile tariabile de h,ipertonie ectrapi,ramiilald,
ti p irn,rn [d,ald. dtn sind,romul pseud,obulbar, combinalii1e d"e conlrq,ctul.d, si,lr'.:tltusrne dill d,egeneresaenlele lt epato-Ienfiar,lare (boala, Iui Wilson gi pseurlo-;rrllrrrzn lui Westpha;I-Striimpell) qi tlin d,istonia lenticulard, progresi,oii aI u,i, % inhen-Oppenliedz (spasmul ale torsiutre qi variani;ele acesttia),' rlistorz,iiladt, u|ittttline ilin sindroamele extr.lpiramiclale cornplexc, din sindroamele' lcrr l ' r . r 'ubr i r"e. d in disronia musculolum deformaus q.a.
tl) Rigitlitutea ile deaerebrare, prin leziuni ale sistemelor reticulaterJlsrrcrxlonte din ca]ota mezencefalici este caracteristici,. Este vorba ds or,orrlrlacturi, foarte puternic;, a membrelor, a, capului qi a ceiei, care esterrrir.jola1,ii, sau diminuati, prin schirnb)i,rile de pozilie ale capului (fenome-rrrrl Lui l\Iagnus qi De Klejn). Crizele de rigiditate prin decerebrare rea-lizi,l,zi, t> hiperextensie a capului $i a coloanei, extensia membrelor infe-liol,r'e, in vLeme ce pozilia membrelor superioare este variabil5, (in flexie,rlir,r' rnti ales in extensie). Se insoleqte de reflexe tonice cervicale si labirin-licc. Il,igiditi.tite prin decerebrare pot fi reatizate cle procese rliferile (tumo-|rrlrr, irrfocilioase, vasculare, tra;Lrmatice) care iDtereseazd, incleosebi calotar r rczcr rccfirlicii, sau structudle vecine (epifiza, tuberculii quadrigemeni).
rr) Arseni (1950) :i, d.escris crise untriculare au a,spect de rigidi,tatedwtLrelnald, in tumori cerebrale cu variate localizS,ri:
-- '{umori rio fosi, posterioa,ri, (50/6, respectiv ulterior 90/6).- 'I'umori ventriculare (23%, respectiy r;Jtarior 271): turnori de
glllrlir, pineali, turnori d.o yentricul al Ilf-lea, tumori de ventricul latoralorr rlivorse localiz[ri.
- Tumori supratentoriale asociate cu angejd,ri do Iob temporal.ln gloamele frontale profulrde, care prind peretele ventricular,ln tumori sau hemoragii extinse pe scoarla cerebra15,, situato bila-
h,,r'rr,l (henatoame cronice subtirrale bilaterale, tumori parieto-occipitalel r i l r r i , r r l c) .
I)rrpir, Arseni (1950) $i Arseni qi colab. (1978) cxizele ventriculare nurrn r!$poot tipic de rigiditate decerebratd,, intrucit membrele superioare sintrlo colo rnl,i rnrrlto oli in hipedlcxie qi nu in hiperextensie. Pe de alt5, pa,rte,rlcrsl,o clizc vor )l;r' i0u liu'o itpitl bnlsc, la sohimbnfc:r, d.e pozi!ie, petrtrn ctr, sril t r lczrr i r rur l i r i l co l ro l r r r r ,vt t l se crr lc i i . l ) in obsct vn{, i i lc ptczcnl , r r , te r lo Arsorr i( l l l l t ( l ) i i i Alsr , r r i 1 i colr I l ] . ( l l ]? l t ) r r , i i rsrr c i i , i ,orr1, t r r r r izolr i r lo hiprrr l , r r r r i r r prrx l lss
lTr l
r l r , i , t r r tot r l r . r r r l r r r r i r ' l x l i { l r r l ( f l " vr ' | | | | i I I | | r t I r i t t l i r l r ' t r i i | r ' , i l r l l i l , t r ' t t I r l t ' vr t t rr ' l ; r l l i r lo l ) r , i " r ' i t l r r i r r r ; ru ' r l ,otr t , r ' l r I i i t r r l ptrrr l t isc r l l i t ' i l r r ( i r r l l t ' t t '1( ' l l t t lc l r i tL,rr l r r t , r l i t t crr t rzrr pt t l t t t l r i t l i i I r t l t i t l l rx l i r l t r r r i r l t l i t t l i t r t l r t t i s t r l t i t t t l r i i t i i l toztl r , i l r t l t t t l t . t i . Aocslc r , t izc s i t r l , t l r r l i r , [ r { ' r r l izrr r '1t i l r ' ; r i i ( ' r l . . t ] ' I i ( I | | I i r I I r ) ' ( \ r ' i l ( ' r r ti loLrb. , l { }7 i i ) .
l ) r rp i i , Arstui ; i ur l r r l l . ( t { )Tl : i ) r l iagrrosi ic i t l t l t r l t t t t t r t t r ' i \ t ' t t I t i l t t I r r t r I
l r r r r r l r r r l . l l l i l i pc hlz l pr t :zen!oi l l t t tx f i t r cr jzo ( lo l ] i lnr t l , r , l t ic , i t t r r l i l , , r ' r r l i r r r ' , ,Itrtttot'[:r se taoe rlupit cclehlte sitrrptotntt t lrrt l l tt 'rt;tt lc (l(r iol](tgll i I i ir l) l!rIr ' i l ll r , i I rUrro|rr l , t l r r l l r t ,urn urm(,r !z i :
( lr izclc prot' luse t1e tumolile tltr l iosi, posLt:r ' iolri i l tttplir,rr r1i gtrrr, 'irr l lrrrri l i caldio-r'espiratori i (brattior,rt l ic, puls net'cgultlt ctr vrtt irt{ i i trrpirl,, r r i l r r r ,crrsualeclela 60 120/min.respiur, l , ieneteguhtr i ( let ip( ' l rYrr( 'Slrr l i l r .
ln l i , l r 'o sau cianozi) , precurn qi i tnport lntc matr i l i rst l i l i ( l f l r i l ) ( ' r l r ' l l i i l r l r "rrl lurrranianfi ;i fenonene cerebeloase.
- f izele plotluse de l 'urloli lc f iuntale ca,rc i l fc(icrizi i pt'rr ' lrr lt ' t t ' tt l tt, Lrlrr sint deseori asociate cu;rierderi alo cunosti lrtci 1i ctt ltt l lrtt l i i t i prrrlr i lc do l. ip frontal.
Crizele de vtnl,r ' ioul al III ' Ie:t, se insolcse de l i ' t tt i ttrcrrt lt iJxrlrt, lrttrtr.r 'rl rlc crize convr sive cu pierderea cunoittintei.
Cr izele c lc yentr icul la l ,eral ss inso{csc de i r l lspir ' : r ( i i , t t t i r l t i r t r : ri pirrost'ezii in rflcmble.
'i ) Contr&ctur'ile psihogene :; ' l indromul, catalit ic (al lui, Kaltlbaun, lt K'rappdin ) Htr t 'rt lrtt ' l t 'r ' tzt:tz r
lrlirrl,r.o imobilitate prelungiti, cu durate do ore sau tlc zilo rt l r r r l t r r r t t t l t t t .( ' :uc pirstreazd, o atitudinc catapleai,icX ,.qi tegativisti i . l ' t ' t irtr l i t ' , :r,r 'rrir lrrr1:rro orltatonici poate fi inlocLrit l de sl, i l i de agil lt{ io, trtt i t t t I t t r ls i r t t r t ,t:r;1r'r 'sivitete. i, ipsa sennelor neluologice obicctivo, pt(x,tlrtr \ ' i t rtIrt lIctttItrrrrr, i. ional qi pasager elirnilS ul gindron extra,Iit iull i( l l l I siur rt l lrt irtt l ,
' rrlii olg:rnicd, a, sistemului nervcs.
(lontTactx$a (hiperlonia) pil iat ' icd, se i irrpurie oi} t l l l (r])i[r ' lr(]fr l, tt ttr lt tttL, r'rr t crt semiologjc crrncieristic cu ccloraturS, nevroticil.
,1.2.2.3. Contt&atur' i l .e re.fLere, locale pot sit apari ' i tr allt i lr ' , rt,t l ttr irr ' ., l ir l lsu adec.tiuli viscerale, precrim ;i in unelo sittt: lrtttrxr t,rt ' ttzlt, lgic,' t j i i l,rf ir ziBul sindrom extenso-progre siv a,l lui Sic:r,rrl ; i l lrurr!. ( lrtt l{.r ltt l, ' l irr i(1 r.ste I eYela,t0r'.
fl
6. pnosr,Eurg D0 DIAGT,{osrrc IN ATAXIi
5.1. pR0EtEt{}N DE tttiT0l]Ol0clti SEMIOL0L}I0I
Ptntru aprecierea serniologicii, ;i topograficii, a unei ataxii, r',1)rrn o serio de con{lil i, i, lnetodoLogice d,e enatnen:
/, lu:iinfe de toate rrebnitl apleciati, sterel r,l e conltiot{i,. Sc ;tie eii,))rr{rl{lr1irl, htntc:lrca proceselol psihice, obnub.ilarea qi dezorientaleR nu
l)r.r' i|| i l (j Trlni ccorrlonare a rtriscririlor., ci,cirril astfcl, t|tleser, rlell1tc inI or.(.i{'tlrit, cxi).ottr a probelor cle ccortlonl-r,rc.
i.l. l_)€'ticitele motorii pril tcziuni a,ie neuLonului motor periferic saurir Irrrioiculeloi.piramidale poi co litiona rt) mcls ezitant, rlificil, 1cnt,1r rlirr lrrrlonios, precuur qi ,,falsd," incoorrlona,r,e a rnisci,rilol pril tl icctiu,ear r ris|r'l| i lLrr lctive sr:gmentare.
.'i. I'Iisciirilc involuntare pot parr.zita rlano.vrele de coorilonrre..1. Ilrtcizi:r, unei misci,ri poatc Ii, r.Le ascr:renca, pertrLrbati, printr-o
rrrlr,rr'(rrrtri, tnlbura,re de tonus muscula,r, regltr,rea tonic:i a atitudinii si arrrisr.ri ' i i l ' i inll unul rliatre factorii edenliali ai coortlollrii. Atil hipoto;iilerrrrrrr,rrLtrrrr cit ;i corLtra,ctLrlile (pirarnidale qi extr:.Lpilarnitlale) pot sd per-Irr|lrr. r'recutalca perfeeti. a unol migcilt.i, creincl impresia _ clacii, nu sin_l.r.rrr r l,r'tr{;i cd, este vorba qi rier r: tulburlre cle coordonare
l. inlinte de a trpreci:r, o tulburale do coordonaro tirebuie s:i eliminilmri i ( | ( vctrtullt:r, astazo-abazie (func{ion:r,lir, sau orgl,nici), plecurn gi unirrrir ri st'rniologic z1 unui sindrom psenilobdbar.
/i, ,\tr,xi:1, tr.ebuio totdea rma si, fie diferenliati de o apraxie (indeosobirrI|IrIrr|itr)r cu (ii lt,c se coltuldri adcscl l2t, rn etianten supedicial.
i. itr s1i'sii, i ' l: l!:r u'eri lrlrtrii sc i'rptlne 'n
examen sistcrn,t,i.rl , ( . | l l r I r l ) r 'o( j i ( , rorr 1; ipt t lu i r lc i t f t r s jc ( l ) r , i ) r l iu l t l [ t1 i t , i : r , le ser]s i l t i l i t l i { i i pt ,op| io-.o1l l , ivr . , Dr, i r r l fz i t r r r i t . , .Lrrr l r . l , r rsr^ srrr i i r ,s l , i l l . . l t r | l ) , l l topog| l f io i l l i r r ,x io i11( i i r r r r { i l i ' i i , r l r r r r . r ' r r l iz l r t r i i l r ru l : r I r r r . i i rgr | l nrc l r rb l t t ) , r l r : l l r r l r t l r r i . , i : r , i r r { r , r r -r r i i l r l r i : l r r . , r . i (s l , r r l , rcr , r l i r r t r r r i r l i ; l r l , r r l r i , r . i l : t l l I r I r I I I i i ( r r i i , I r ) ,
lJ l l r
i r .J. l ' l io l r ! , l , l i \ l l , i l r l , l l r lA{ iN{)s ' l ' l ( l l , l ' l ' l l } l 'A ' l ' l ) ( i l ' lNl( i s l ' l \ ) l ' { ) ( i l lAI l ( l
i r r p l r r , , l , i r l l r t t t t t to logic i i t l l r tgtrosl i l r t l l t t t t t r i l t l , i t r i i s l r l t l tzrr : tzr i l r r l t r l l l r r i l lr r " r ' . r t r rc| , r ' I t t i l t to1tr i t t l t l lcs l r lc l iv l i i r r I I r t t l l ' i l i t l t r t r r rot t lot t l t t t ' , r ' i l i p" t r r
r , lc r l r r l I r rot t t I l l t I r i r r t r t t t t1; s i I t ' r r t t t t t ' r l t t l t r l i t l ic .
i i . ! .1. Al , r t { i p l i r r lu l l r r r r i i r i dr , sotrs ih i l i l l t r r p lopr i rN'r 'p l iv i i i r l \ r ' l i r l, . r i r r r r i 1 l1 l i l i , r ' icrr sr t t t txr t t l ; t r t l t cr t t r i t t t t ' t t ' r ' t t : tz i , l i l ikr strr ls i l r i l i l i i { i i 1I t I r I t t t r t I r ', ) r r r i l i r f I l lo, [ i i t (1 00t '0 l l t t r t l i tc{ 's l i ( ) ] l t l lb l l l i l i prr tp l i lx l l rpf iVrr . r \ t r t ' r ts i : i r r i r r ' '
iur , I l i t r l l r i i r , l r lor t tegrr idcl t :pr t ; l i i r i l t ' ; i r r , r l tu|ogl l t i ' i t ' r ' l t t ' i r t l r i l i i (ut ' t t l l r t l tzrr l r r .I r , lr, 1)l l i{r i, i lrt r l l lrtnil ind la mctn}lnrl,: inferiolt lc) ' !o
l ir lr l;r 'rt;rri sl rt i t tt t r. rr , ' r ' r r r l , l0f iv i l i l i ikr lnotor i i . [n 0lr t t l i lc t l isr , r 'e l ( ] , prohclr ln i i f r t t t l i l ' t { ' r r I r l r r
, , i l r l tot l rxt l i t i t :ust ' l ; i l i . l !s tc i rnpr) t t l rn1,( l r t ro l , ; in t r ' i , tn i l t r l l t t l cs l t ' t " r ' r ' r "1",r l . r i i rc i i t le l i r incl 'putnl i )costei i l : d i rcol j Ige i ] r l l l i i i i i r i { l r r l l , ' r ' ; r l r i i r r r r r i r l ' l I
,J ! l r l r lUl r l r i ) t tarv l l r i t ' tspctc ' r , i r .e, ou impr)1i i l ]11o r lcvi l { , i i i r r r i i t 'otr t ' l r r sr , r r r r t r r ' r ' r ' r li i l r r l i i : r - rk: i rc l l l l r [ t , ] ,Lo intr- tu l sot ls s i l lL in :11f i l ] . l i t t t ' l r ' t t r t ' r t l , i I I I I t , ) I I I I I | |
,.rrri lr l irgic {ri,t,. ' laplu1 ci ve{1ereii, corcstelrzin tlLlbrrl l i i ' i lo t le crxr|riottrttrr Drirrl]| 1rr', rp; ior':cepf is f i cir, ocluzia, oohilall ' le agr|lvl::t 'zi i l) itt rtct 'r l ' l trolir,rr ',r lrr lrt i Hornberg cste pozitivi l ir l i l toalo plrtbole rlo rr. l,rt ' 'r irr (rri i l 'rrr
, ' r . r r r r rchi , p l i ln l - )arei i c i l lo i i r i lu i pc crel lst l ! t iL l ic i , ?rol) i l , corci l lu i , l ) to l , I i ! l r l r rl i r i r , . i r , ) o i luzi . l ochi i r , r r rn l i re l te cvjdent (r t r l t :o l i chiat t rot ts i r l t , t r t l r i l ) I r t l l r r r,,!( rl0 c,-{rt,: i0u&tit.
i ic rn: l j i tsociazi ' c le obicei l i b i lotonic mlrsoulrr iu s i , r l t r t t t t r l l " ' t i ,rr iL.l ier clsi;eo tefr[i iuoe,si,, fenourene ci-!.r 'c sit i i i ( lc i]sotl l{)rt(i ir cttttsrrtt itt l(. rrl, '
, jri i t irii ciiilot selsibilitirtii pt'oftrntle.i lsto important t le relinut c[ l ipsesc amr)toli lo 1i tt isl 'rtgrttttstri. trrl
, o, iliit':r, e$te Iloln][1i.
:j.2.!.j" ;\t.t+tLitr, ilLsolitti d,e drelleaie osteotend'inortld litiioij t I t r t r ; r I , ' , , r , I ,rrr r lr lcme cli;rgnosf ice ;
t. Poli.r ir r"it i , le {. 1.talineurol.tati i fu. Si: insolcsc 1i rltr irrirrrsl,r 'zi i, r l l i 'rr l,rrr ': i l t t i tr stn$ibil i ttte oblcctive cu disl,ri l)rt i. io p1li{lorl l i l} i l i l i i t r t I 1 t r t t r t r ' I i t ' I t
r r i i i ' ) .up(r ' l io i i t lc , c i1, l i p iotul l l1o), t le i i lc f ler ie osl ic() 1,ol ] ( l i l r r ) r r$ i l , r lc r l l l i, , i ir. rrrotori i ( i[ l i icterist ' ioe, ova'l]tua] isi de aii l{}1ii. []tttr lrt ' i t i l l tsivi lrt l 'rrrr I 'rt ll ,Ir i ir i lol i ' i e scnsibil i t i ],to profund:i ; i i l i tLlr,x ici Irr:rl izr,rtzri, ,,pscrt{lo I ' ir l}rlrrrlpr,l i lr l ic". .Durerile la presiunea fira$elol lt l l lscullu() i i i l i l lrrcsit lt tolt, 1,l l tr rrl lr I r l, i l ,,r ' rrervoase sin1, consttl l to. .A1bc somnc (l i[ ctt)l,()\t ' l l l s(rrl) iologir' $rlrir l i l(' li';rftru. stabiliroa diagnosticultli e1;ioktgio.
!: Po!,i,rt i l ' icutonet)ri,tale lrrtruncso irr trrl) loll l sottt irt logitr, 1rl lttt l ;:r, . I r . r r r , . I i i ; { i I t I gxI.lIse atr]l,oriol, pozitj ivital,e& scmne]rl rlt i ckrrrgrr,{, io trr,rt irrr l i r,r 'rr
; i r r inr l |otnrr l l ic i r id i , r , r r p l ;ognotuonic polL{tr t j t i t rdr{)mlr l ( } l l i l l i r i r ] - l l : r ' r ' r ' r ' )
l i l t , r l t l .i l . ;J in,thonuJ meduLu'r t lt Jibtt luugi (d, d)nl t,tt: po:tlcrio4l'1r) srr trrrt:trr
Itt tr,t::tzi\, rxtrlttsiv pI' i l t l ,uIbuli lr i t ic sttrsriLil i trrtc pt'tr luttrl i i (()lI$1,i1I I I ' i t '
(rrl
r r r r l rot t1tr l i l , i i , l ,1xic (prrr l l r l t r t in l l t t l , l ' i , s t lu {)x( tur j i l i i l i t , t r t t t t rbr l ' l l r i t r l i r t ' i r r l r , t r ' ) t r r. l r r r r t r ' l ' l t rx i i r oslr00-kr l t t l i rurasi i , . l , i I$of , ( , r l r t t r r I i l0 l l t I ) rc$i t l i l ( f r , t t t l t t^ ioIot t r t t t t i r ' t tl r r | r . ; i : r , L| t t t toI t i t t t i Iot l r ( : l v i ) i tsr ' ' l r l ' ( ' ( t l l l l l i1 i l : t , Lr l0trgl l { i l t ' t i i r I I ' i r I i t r iLt t
i ) ' l \ t , lntr . l , r ) : l l iz( l i rz i i ' col t t t : t ' i l t r r lc t t l ' i , r r l t l t t t t r l r r r i r r l i r t i l r ( i i , l l r r l r I t r I r r I t t t r '
116l l r1; i9 l t , t r r , ( j l l t r r . r l l : l l t l t \ i r i r ( i l l : t , t t l l l t ' r i t t t i i r : t t : r l l r r ' i t l t t t l t l r t l t ' l t t i ' r t t r l t t " t t
i l r . r r r r r r r l lu i i \ lgrr l l t i ,o|rr r | I i rot I ) r l l l r f ( r l l l t l l i l i ! r ' l l l ' l l i l l t t t p l |zt ' t t l l r t ' r r r ' { t | t
r r r , r r i r r11r.r , lpr ' ( ' r l r ( r ' . l r l o l r i l l i i l l i l l i l i i r l ( r rzr i r i l I , ' I t t t ' : I l t : t l t ' t t l l r t r '1 i t r ' ; t i l ,
t I
' I r I r ' r ' \ i f I r ' i ' q i l i r | r r rc l t , t r r r l , r r r l r r l l r i r i r r . (J l izr ' l t r v isccl l lc s i r r i , r l t r rnul tu ol i u l i l r rrrr | ! | \, r ' I I i t ( , , | | .( ' lt0rrLrrr rliagllosl,itr.
h) Ato,r'ti.le _aauta priri l,,ziurri^ alc co.rluune]or posterio..rrc (rnklliLe,' t r r l ) t1.s iuni merlula: 'e, cpidur i f l , ) s int mrc.
, ) .4. l . tp. le: ;uni aLe Jihrelor l r ragi so por iu l i ln i in:\ tndrolnuI ncuroonemic sc poi ] le rFcuouagle pr in : arbi l ie Eastr icf .: r r r . r r r i r . l r ipercromi, scmn{, de c, t r r luane postel io l re, *ref lexie o-r i ; ; ; : ;_rlirrorrsle lil oare ins5, se adaugd, qi semne de cordoan6 Uterate lsimpioinep ilrr r nitl:l lc).
. - Nind,romul nauroachilic.. hipocloftirlde qi achilie, semne de cor-(l,i'x.. postcrioare, de obicei cu sellne mai pulin impurl,ante tle co*loan.l i r i , ' r ' i r l r ' . d:rr L[e ]nul le ol i g i r .u scmnc dp pot ionrror iu i i " .I loala Iu i Fr iedreiah. intrunc. le rrn minrrnr.bi , re s imptornc pcrt i_(,ulirr,(!; caracter ere.1o-familial, .fenomene- cordonale posteri6aro (itaxie
Lrlbctif omi,, tulburiri de sensibilitate profurrdd, hipotoinic, a,reflexie osteo_Lendimas5,), semne de leziune a f:mciculelor spino:cerebeioase qi eventualrr corebelului.(cu ataxie cerebeloasi, tulburiri de echiiibru, adia,docotrri-j l i l i l:]Jii^ll l I:, tremor inlentional, t ul bu r:t ti de vorb ire), sem ne pira,m idale.u||rrnran trotlce (c llo- scoliozd,, picior scobil- cu deg..fe In cioca:r;, uncori, i j r l r r i ' , l lot i i dc t ip Aran-Ducbcnne sau C.ha lcot l : \ [ l r l ie.
Itrred,o-ataaia cerebeloasd,- a lui pierre Mq,rie asociazd pe prim plnnsr,rnrro,cereboloase qi pira,midale, simptomcie cortlonale posterioare {iindrIU ( l tscrete.
.. ... .,-
,!o:!!trSia lantiliald Btrilm?elt L(rr&,in. prezintii, exceplional dcI i|| .ir stn]pto_me coldonale posterioare, sitir:r,lie in care *taxia este mixtii( , ' r , . lx '1, ' cof t jona15 ) ,^.dJ r pe plar i securrdrr ' [u1i i r le pr i , . rp legia piramid:rLt .
, I)lsl,azia.0rcJlettcd aongrnitald Ruusq_ Lirg "alrlnoa"zi
un sind|our,,lr]l l l i r,posrerlor. (cu ^li,tltxilr
,1i rrefle-ri{] ostco-tendinoasii,), apXmt in'.,)l,i i;rr're ((tr,ollrcel) s intintc de pube]'ti ite. Oaltcte|ul e,redofa,rdlial, evo_lrt{,ii!
^ai benigni, si asocierea uneor.i de niotrofic sitaeazf, ace,,st''atoc-
(rntc clr o formd, de trecere int,r,c boeirr lui Fricrlreich si boaia Oharcot,l\! r r t ' ir^.
tt.:!.1.2. Hemiataniile rru, tulbu.r.dr i de se sibil itale Ttn,jundd, d,ar ur,rqfktn. ost,eo-te,nd,inoo.se eonseraate ridicii urrlilolrele proilcine ile'rliagnos-l i l iop' 'gr ' . r I i . s i e l iup.r iog. ,n ic: '
.l. 4taria pariclald esle. produoi prin leziuui vascull,re, tumorale, trau-rtril,lr(,,(r rlc..:rle eircrtmcolufiei pa::ietalc asr-,endente slu :r pnriec[iiior pe:rr ' . ' : rq l i i r i i i i r r r r r ' . ( i 'n l ( \Lul semiologic inr I rurei tc lu lbr l r ; f i d-e scn- ib i l i ta lerrr i r l r ' ( r lu r ctr prcr lomina nl i -L profu nr lu r , h, .mi: , t l x ie, nstereognUzie, dar derrr l l r , of l Fr-al tc s jmptorno de local izrr ' . l ,ar jctald, {c l . izr . j { rckdoniene scnzi_r rvt, rilllr ol il' sr[zrttvomotorii, apt&xie, hemiasom* tognozie, hemianopsie).
l. Ag*ig talamind, (din -sindrornul
talamic al .lui Ddj6rine-Roussy)rrlllr. continlat€r'al leziunii (de obicei vasculare sau tumolale) nucleif;,lrrlunllcl luterah, insotindu-sc de hetnianestczie p}ofrurdd importrnt; fipr.r',ristr,nti,
_rle algii de tip hipel'palic (.,overrea ctiorr" .- EIcrrI-;i Eobnei)ir t|o ruttcIln coreo-3.col,ozl0o.
S..l.Alnniile pedunaulo-pontu-bulbare. r)ivel'sc procese patologice (l,umorill i lrnrrrHri\jnt:c, tlctnot.t.glt) lucitliziLh) iit ctlola truuCbinlUi cercbral pottrrr,lizll,.dilr(lr()ir.lrlrr iLlt0r'nrrr itr cotrt,,rtul {)ilr'orir, dr intilrr,'sc ryi trrl lruril.rid.od.nBlrDlr t i r t ( ' prr , l l | | r ( l i l crr r r" l i r r i r , . Ar:orrLrr i l i rx l r0rutrc i I l l { ' ln0 pot , r r i t r rp) icerr , l l l ; r r ,1 ' l r r i i propr i (n1r, l l t ivo, c i l q i r l r r l i l r crrrrrholos, l , l ( t l ro l , i lnt : t , i )hrr t i ) l ) r ) -
t82
; .1nr, l io o*1r, ; l r l t I ic t t I t r ' t : r r v l \ r l r l r t r t t l t t , t t t i i t l t l r i i t nrr t rz i l iv i i oHit ! i l l l ' t l l t ' i r l i l l J [ ,I rorrr i r t l , r r r i r l r r r . t r r l r r ' | t r ts l i , t 's lo t l i t r rc i ' i i ( t l t r t t l t ' r ' r t , '1 i p l t t l , t r t r t l l t 'z i t l t t t r i t ' qt i r r t t l t rz ir r r iLr l r rLvi lot r r t l r t r i t r t t i ) , or oxcrp( i l s i t r r r r i i ikr l t lo l l rz i t t t t i ; t t ' , t l t t t t t r t t l l t t r ' , l t rr r i r r ' lu l r r r rc l r r t r l t t i ro1tL, srr , t t r l t t l t i i , i tur l t tc i ; r t t ' t ta, l t t i Wtr l ' I t t rk i t th.
5.it.P. Ataxia voltibulard cslo t'cz nl l,rt,ttt it ' Iozirrnilol nclvtrltti, rrlrr tLr'i i lot'rt rrlo ttuclcilol vesl,il)ttla,ri Ii $o (,rl,r'rt c t olizcrlzi-"t plitt t,Lrlburrili t.lc rLir{,ittttrri i i r lo rncls, cu osci l&t i i ry i ou t lcv i t , t t in lcchqi scrrsr i l l i l , inh) ' i l l i l l ) r r i f i l ' l llrr,lolrrl, irL l 'Lrncltic r[e trivchtl, rlc tilrul ;i tlo rrrtsivitrltea' lezinttij. r'\ ' io rtsrxrirr.zrirr sorllu lionrberg pozitiv (olcmont impoltant (le dilglloslic)t l)tl l(lttrrr ii irrislrry4rnus $i ame.teli. Este ul,il de lctinul, lrytu1 c:i sensibilitiitt(]a, pt'ol]l'irtcrrplivtr, reflcxclo osteo-tendinoase, probelc de r:oordonarc qi volbit'trrr, ttittl'rrorntlllc. Ata,xia vosiibularii, nu uroclific5, mi$ci,rilo izolttc alo tnctttlrtr' lrrt ryi,rir, ;r,1;N,r'or spre doosebire de bolnavii cerebeloqi, in sindloatnclc vtrsl,iltttlrrt'r,rrrr sc constati, tulburd,ri scgmentare de coordonalc.
5.9.3, Ataxifl cerebeloasi se recunoaqte uqor, o1,r, :rpiitittl l l it lroltrrtt i,rrrrr rLu ptezintl nici tulburi,ri obiecti\-e dr: scnsibili l,rr,to, ttici sitttltl,otttovrs l,ibulare.
5.2.3.1, Sumar de d,ata senziologiceSindromutr oarebelos la om se cari,cterizeazh prin trei gt'upo ttrtli rlrr
f lt ptomg :l!., Ata*ia asrabalaasd' se traduce plin urmltoarele sorrrilo:L Dismetuia consti, intr-o dimensionare grcqitii, n, uriqc:irilot', lxrltrrr,
vrrl neliind capabil s5, ajungi, la linti, in sensul ci firi o depflqolto (ltipttrrrrotrie), fie se opreqte inaintea lintei (hipometrie). Ilsl,e itnpot tilnl, tlr,, ptlr,izrr,t cL bolnavul nu eziti, la polnilea niigci,rii, crt tttitxioul pclilirt'ic, rut,rtol posed5,, cu toat; tlismetria qi tremurdtura inten.tionalii, tlirect,iu, gcttr^r'rtlrr'rr, rrriqcii,rii, Dismetria se examineazii, prin umttoarele plobe :
a) Proba i,ndice-nas. I-.,a solicitarea de a-gi duce indexul lrr, vit l'lrlrlrsului, bolnavul so oprEte inailte de !int6,, sau trece dincolo tlo ott,, izbirrdu-qi degetele de obraz, de frunte sau de ochi. Direclia genclalit itti!inln,:r, rniqcirii nu este alteratd,, iar ocluziunea ochilor nu influonleazfi, trrlbrr-nrlea,
b) Proba sti,ol,ad s D. a, g6,tul/ui' slrlolBd. Cerebolo$ul nu izbutoiito sii,-ttiirrt;r'oduci tlegetul in ori.ficiul unoi sticlor sau uu e in stare sX, apuco glttrlsl,iolei. el dmerind al6turi,
ci Probd, iniliaa-inilioa. Bolnavul cr oshii inchiqir nu esto ca,pabil Brt, {irr,plopio in mod corect Yirfurilo celor doud dcgete inilicatoa,ro.' 11 frobo Linidlor paral.ele. Se traseaz6 dou6, linii Yorticalor bolrtilvttl
l'iind solicitat st tragi o linio orizonta,lfi, lntro aoo$toa, Oerobolosul nu r4olxnllre opri exact la nivelul liniei vortioale tlin droapta' oi o alop6qo[t,o' iilr,rlr{r ODrcgto inailtoa, oi.-
a) 'Proba
prekenaiunii (eatt poharului), IJa solicitaroa do a apuctt }ltltrr,rrrl, po de o p rte cerebolosul tlop5gogte sau nu ajungo pahar'[l' po (lo olltl,p:r,r'to minil tui so deschide mai mul[ docit ests nocos&r.
l.) Proba p notului. Solioitlnd bolua,vul s[ faol un purtot rlu ol'oiorlul'rxurbolosul tl oxecutS, diticit, frloiltlu-I tlin mai multo liniir introt{,i1t1,o slthforrnil unoi gtolo.
g) Pruba lotisului', Sot'i*ul oolobolosului orl,o tlifttt 'trt, tlt 'n tttrlttnttl,,l it,ololo Iiinrl rnlt' i, ttutogulilltt, itrttgtrltr.
lB3
, , , , , t t . ! . . t . . " : . , , , , , . ' : : . : i l , i , i t t t t lun, l t , i l r r r lcrrrbjL r lor .srr l , r i r iscrr . r ,c i i u( f , r p l l l l { f , i l i j l! r r r r r l f r ' .1( l l r l l r ( l r r t l ( , [ r r rs rr . laCo CU dCpl; i l r :a Sl t i t OLl r i i r t , i le* iA t : i i , : t t i l ] t r ir : ' lrirr rl, 'r ' i ri i.r'rl rniqcliri de
,i e.resaie, 'boi"""oi p"ot" olroge genuntrriur"tt i 'nrtu 7tr'ir,bd'r'i,i cdrcti.*ru,i pe creasta tibiei.-ra eri,rurarca ti. rnis-,. {':r |. ' l ltco <_ru uu CiLractel,feStonat, cU oSCilatii., !. l rl iutloc.ohi,neaia ( Disctiadocokinezig) 'con$,j,
in tncapacrtilto.irl. rr .r.r,rri.ir.t ' ifcL.i altel:lratiye-succ.sive. S6 e:rploreazi,.u aJuiorul urxnat_i l t r 11l9t ' l l robc :t) .l?roha nnrioneteloy. Bolna''i cste solicitati s.i, facii, titi$cxri :iltrer_rrrr\'(, (1.9 pr.onalie-supimlie
_rlc irnlebralelor,, prin :rtixgel,e& altel.nal,rviirr t,or| soi cI pe mele, apoi cu dosrrl rniinrior. De p'artea bo.frraYd, rniqcl,ltlr, si,, rcrrriiu irrtr-un r.itm mai lenf, mali glloi, inteie.dinil o sc o pa,orii,, r,a,,,,' , ,
i]i.,.;:jilr-" i,n":ilca mjsciiulor succlsive, sau notnavil-gre|e;te rniqclrc:r "
, it i 'h)aa JkrtutllL ;i entensiunii clegetelor zr.dla'd. Se constati rrceasi,rrtrr'zr,rr. sru gJrc6ir,e a miqci,rii de partla bollavi,.r ) 1'r^br. baterii tobei ca" .d,e.1tetele. Bolnavul os1,e solicit&t si loyeascilr)rririr (iu {iegetele aubelor miini, const:r,tinA"_su ac""rr.i-luburr,.e Lo-r*iiii
Itl)l,1.lo procedente,
, .rl) })r.aba Jleriunii dorsale gi Ttlantare ct, p icioarelot. lJolnaml yl irr_r . rzr i ' , r - l l | l . \J g loci miscar, .x l l tnt . tDbrul r lc p i t t .u l , ,z i f r i r i r .,,. .rrLnerata constt in imposibili i;atea de a, coordona artiunea tlifc_r il /'l{n . glupi trusculare in vede-rea executi.rii ";"ir;,ii;j;
cornplexc. Ast,|{ 1, rIril(r}ilo ('rnrplerc..se tlesconpun in cornponentele 1or clemeul,iue.,,. ,,'.'..!,_':,.:":::,:o:y:"!:::::!, sr)&te (proha asinergigi sratioe a tui Babinski).|,, |lr{r(| nr)r.tnal, rasl,urntret pe spale compolti, flexiunea asociat[,, conco_rrrrl.rrl,r'1r a trunchiul.ui;i a mimbi.elor infei,ioare rlin genunohi. Cerebetosrit(lrlfrxlurl)une miqcarea qi la accasti, probi lipseqte tt&iunea ga,mbelor d ir:: 'r 'rrrrrrclri, incit cerebelosul cade pe spatc.
,.1,)-,['rabo fk.rtunii gaml.,ei pe -ioapsZ
gi a ao*psei pe bazm, \probli" cnl_irr tir,:r) sr. erecu15, in decrrbit. rlorsal. ielebel6sul -rlescompune aceastirrriqrr,:rro, irr sensul cd, intr-un prim timp va 1iace it"r,lo"".ni "ou1rrni,
tirlicil_l,il. ii 1',,1y,.!^,:lt.de pe planul fatutrri 6ihou" i" uf a-rir", ii*p rr.,:{rea,sii fle,\ | l | | | ( ' l i g,at] ' t bet.
. , , . ' , ' , ! ' : ' . : ! ' : o. : l , l ! ! 'L ' - n;c igrutui pe sasva {rJ in f ' rz i t i . ot lustrr i ' i ) . s{ '
' r , | ' : r : , r i r i ( .ctct eosiut i tpUxeto a lx i t ( . t i i . i i , in Scn.u I Cr i i l l p | i rnu l I . imn facerrr . r r r r . r ' r r {ar i r l |5cr pe l l rz l r l cu nrcml j ru l inf | r . ior t ,xt in i q i ib ie in r l c io j ler"i I i ) r : l ( , i r ' \ runca girmhci pe cotT]J i ' i .rl1. I\.olxr, ind,ice-nas. Li a_ceasid, miD&r,re so observi, cri ce'ebelosullrr.r' irr l,i i. :r}ducfia braf'lui $i abia, apoi fiexiune:i n"i"t
"o1lrtni $i dii;;;;r r r l r . r u lu i I l l na,s.
. ') ,L'r'tha mrrsulu,.i- Iipsind coordonar,*r intro acl,ilnea srrmrttanii, :rI i.:,,11.,i11.
tlitn(,lt)utu1 $i .1 membrelor irifcrionre, in timpul mersului,r':,. Nr\ rit(.{. c* i 'Jzil, (,e sustcntajie lniritd,,_ trunchill l l]nlne in urm' fali,l( rrr1'rrl)r'c, incit, bolnavul poate chiar criit"a p" sl,ate.-- -
./. I)il1,oli1ii tuiburii,rilor de ccordonare .^"o pot irLteresa, si mu;chiil , ' l r i r l , r r i , t , t rb i rea asle r l tc la i i (sacadarI sarr exnloziv i j .
, ' . ' l ' t t t ,utd. lato i tpn! io ul . i . .Po:r lo l I i r rea izol t - r ,1, r : r r r r rSUr.r : I la CU { l iS_
r i ' , | l r ' . t , . i l f l r . t t l lc l I : l l dt . : t t l i l i i ,s i tn;r i l r r r r l r l i lJr i l l ( ,o in fCrcBt_u ou, lUClCi lOr' l irrl 'rrli. lr)ii i:rr li irr.titl $, 1 intorri i(, 'rl ltr, lrr,rii;rrr- cri. irl,xc ul crrrsur .xrcu-lr r
' i i rrrrr ri r rr is.ii .i.ryi J ipsoryl o irr
'r4irr r*r. s.irbs.r i.ri lrr, i i i.tip u tr rl ,,n,,i n, ism,irll,r l r r ' r r r r i r r l . ' l i r , sr i r l i r ' r r r r r r i ; .1)r ' i i ; r i s . r ' r ' i r r . r i ( i r rzr i , r , 'a, i r t [ i . r . r r r Drrrrr . i i rpr l i11l-
r r i i r , I l | ! ,1 r , I r I r r r r I I t l r I l i l l izolrr l i i . l i r , r r l t , i l t l i i I r l r l is iD,, l l . i ; r . , | , r | , r r I I I | , i i | | r | I I
t . l
r r i r ' r r I rorr : r I r r , ( l r t r l l r l ,u i r ' , r r l r , : r l l l . t l t t t , : t l l r r j i l t t l t t i , ( r r l1 ' l l r j \ ' l r l r ' l l l r l l t l l l r l ', , , r .11rr l r r ( , r , r r i l . t | i l i r r l r r l t t t r t | l i r r lot i l r r l i t ' ( l i l r r r r r r l r l t | i 1 i i l t0ul l l r r ) .
l l . f i i t t t . l t l . t t t r t . t t :ut l u l u t ' t 's l , i l t 'n ht ' r r . Atrcsl ,< ' i t , : l l t r t t t l l t i r t t i l l l ( r ! | I I I \ | I | | | I I I I
l , , r r l i "s l , t in i l t . r l i l l t l c t r r t r l r r r l 1 i l r l l l t l l t l , t tL vcsl , i l l l t l l t , t -! . t l s ! ,u, | ' iq, oot t i l i , i , i t t l ' r 'o i t rs i 'abi l i ta, i ; t l , c ln ' t l r t t t l r r r l t l t ik ' t l r ( ' t l l l t r r ' r ' r ' i t r l l i l
r r , r r i i vel ' l , ic l f t l . [ io l l t l tv t t ! t tsci l0 l tz i i t t l l t l l l r r s l ' t ts t t t j l t r t r t t l ' t l t t rc l t i t r l , l t t l l r l
, ,1, l i1"; i , l i si i ,-$i l )r i i , r 'oru;ol" l bi tzi i , t I t t sLtstcl l l ,al i iu. OsciLrt,( ' i i l t r l t t l L; oLlpt i t t t Irr st t ' r ' I t '
rrrr l :r , i , t ' l t , ccf: l l ic i , .:!. l lcrsuL cstc ebriosr ezita,nt qi t itubant. lJolltr vj i lul Pr)l l) i isl rrr lt 'rr i i
, rrrrl{ri, in trinlul rnelsului, ci deviazti i i a,ubinza do s ustol l l j i l l , i{r l lr irtr lrr '
I r , r ' r l r : rn l , t t l i te lo s ' lu retropuls ia. I roba rnetsulr t i i t t s l t ra. r i t t r i t r i r l r
1r , i r r l lo i 'u1 vtrst ibular, Ioats ?la relal i i p: l to1,gicc, bolr t r tvt t l t l . t ' i i t t r l r r '
r, ri rottstanl de partea leziunii cerebeloase'ii. lr eftijlrl ,,:i nlStugmusuL L.r, un cerebelOS intliCii lcziLLttcrt, t u r t I t . r i I t t r r I 0 I
, r 'r*lrrlo-vcstibuli i le.4. Proba tlet:ieri ' i bra,telor. Br*lele tlevia,zil dc- partcil l trzitttr i i rrrrlr ' lr '
l ,) irri ' , sl,u i1e partca emislerului cerc,belos ccl mai lczlt.4t.. 't'ulbu,itiri care se ea:plicd, ?rin alter&red a,JerenleLor yropt"irtLttplirt :
l .Hipotoni* 'm' tLscul&/ i i .Secaracter izeazi ipr in l lascidi i ' r t ' l ; t ' r t t t t r ts | t t, lru i i . l l icLtm ;i prirr aroplitudincr exirgerat[ a miqci'r i lol pllsivr" l io ' ', l ' ,r{" '2,-i, prin uir, i i , tr,erele plol:c: ' ,t '). I 'a mobiLizuTect pasbii u tttttt l ' t ' t t l ttt
:.,t 1,, 'r iot', "!e ati lge cu uqurinli, umii 'rul cu articulaf ia rtt l lo-.rlt lr irrtrri I lrt
t,ru ltra.xiurLile prri iTe a10 membr'lui inlerior, se polltc atingc f.srt .tt . i t l .r
rl. i ,r l f lexiLLi*it coapsei pe bazln se facc c* mtlt:-"t ' rrqllr i1ri i l ' ! '1i t l t ' rttrr ' lr
, l irr* oxagcrl, i i i t ) it intei,sia mtitt i i Sc lacc,ostc l i lnit. l izi, l ,r1i. i i (1rt , l, '
, ' i , , , l t lTrbo p, . . t " iL: i ldt , i i u lu i l3ara,ng.Impl i rnarca utrct t t t i l t r i l l i : r l i l r r r ' '
r ' , l t , r isrrr i r t . , 1t L,rr th j t r lu i la un colebi l los in s l l ! i i r r i t r l t r r ' f i t r r t l : t r l ' l ' r
r r r , r i , r l t r p iLr :1. t i t l rohar ' : i excursi i r ru i ample i t lo t r rcrut lx ' t t1ui st t l t t l i , t r l r r r
i i rrl:r!, i i i ir i l irr I l o -hrtlneril l ia ; e) Probu rcziutuqei' ,tt Iui l loltnts '\ l t tr"rtt
l l ,; lrr i"; i i l cstr: iolici l 'at sil frrci-l f lexjunea :mtebrallrrlui pc btrr(. lrt . L r"
1,, ',1,'r,t. lu itron ienl Ltl in c:r,re dtitn dl 'utlul r":utebtLi'1tit lLlir .t i t l 'rLlttttt 'i , r ( l i , r '1,rr t l { r l i i r iu i r i i I l l r t l ' i p icpt tL l orL mir l r l ( r l l i ' t I i t ' i r r t l t i l t r l l i t r l r r l "
, , i , ; . t l r i : :1 i i : ! i [ r11] : , t l l11or i t i i l i l ie i - intr i i r i i 1a t inrp in 1 'ut t r ' ! io r t ' r r r r l r r r l r t r ! r
l r . rL lbLt t : r . r 'e c rL{- ' . I }o i i l1 i i i uux c l t t1e t l iscronomcl;r ' )c) ( ' \ t t t l t r ' r ' l ' l tot t t r r ) r '\ ! ' t r r l t ( t ' t 'e. f l?,r / ' l r , r p i t t tTt tLarr .1)ccl l t tq i t i i l t tc l l t r t t l t t i i r r l t t l i r t t t l i t t t t t i ro l t r : r t
, , : r l i 1tu r i r i rs iL, 1r t ; g i t l t lbole at i . ' i '11, t l *Lt : r r r r i i i i r r t t n ' l l t " - r t , l , t r l i : t t t 1r , t , , l r r
lL.r i i ' i o s i ' t i t , t i l ln i lc i i l i iuei ln4l lo 1i i t t r tu ' l r t l i l i t i r l t t t r r t i t t r I t | | i I r I tL ' I r r
1 ,r Ll, ' 1;: ' ,: ' i :cir i.:,,r lttr-i i I !) Praba tisl,n,t ' t,r ici t 'onift ( l)] i t l l t i tttsrrtr ri lr"rr
' , ' , , ; . jc i rc i ' t l r i r l t r . r , r ' t t iL. i i 's i f i t l io( j r l i l )c l ( i bt ' r t11lr i ; i i r i l l t r r t1) t l r r ts l ' r t l r t t t r ' r l '
, , ,1, 1, , , , r , * l i ; r , j r i t is i r r l i r iz i { i r r ) l . iz() t l i r r l i . l ) t r p l r t i , t : i r l t 'z i t t t t i i r r . t r ' I r r ' | . ' r r , ,
, r t i r l l 'orrrs l l t t i r : l i i , r fs{r l ' i t l i ( j i t l ia is l is t l tx ' i l t r t ' l t l t tLt i t i tL ' \ t r r r i t l l r r l l t l l r r t t t r t l t I
r l l r ipr , i t r r i r l , r ' ia s i t l isc l r t l totr l t l , r ' i i r , pt i t t . i I t1r ' l i l t ' I t 1 'ar t l i " i i l l I l i r r r r L, , . r ' , , i t i ; i , i lor , ( , i I i j i l i i ln) toni i I t i r t isou] i l l i .
: : . '1. 'u, l , l ru;rr i t i , inu'pru. t i t tcr t l t r t ,z i l ' i i l t t t r r ) l ' l { ) l l l i lv t l l t r t r ' t t { i r t t r l r r I t t t l r t ' l 't l r ( . r . r / i t t , . i r r 1r t , t r r . , i ,1 i r t r rc, , , ,11i- ioI I l l ' r ,1 c i t ot l r i i t t r t , l t i ,s i . I i i r l j<: i t r r r l t r l r r r ' lLr l r / l l
. ,1r , , r s. l i . i l , i i ; r r l r ' i t ' l ' t r l s l i l j I i * l r : r ' l i l t r 1,r , . Ni t ' t r r l r t t t l l r i t l t t : tv t t t t t , i r t r ,
, , r , i l r pozi i i r i r t i ( i r r l r i , c i r , i i r rLrrr , l ; r r r r i r r iyr , l r t t r t i r i r I i l l r I ; l r1 l l , r l t t r r t t t l l r t r r '
' , , , , , , , ,1, , , , r ' i r i i r r r i , l r r r r t izrr t r l l t l l t , i { r l i r i l l i t r t l r o l t t : t t ' t t l t t i r l r t : ' i I r l t l l r r . r l "
i , . l ; r l ; r i f , I r r . r r r ,Lr t l i l t r l i l l i t t t r ' . l i r '1 ' l t t l l lL l " ' l t t r rv l t t t r ' t t l l r t t t l t t i r l i l r r r r r : r r t r
, i l ' r , , t t t r st , l i , ' t l t t i ) . l t r t t r l i t r ' t t i t t r r r l i4rur i l i t (Lt ' t t t t l l r r ) l i t r r r ' '
I I ' i i r l r t l l t t t t , l t i , t t l l r ' , l l r l r t t t l t t r r r ' ' , r lLr I : r I l r I r ' l i l ' I l i ; i , ' r I l r ' r r ' r ' l r ' \ { ' ' L l l r
| ' t ' l r t r r t r r l t r t r ; , I l t r i ( , ( . r l t l i t l ,o l l i l t l | . , I I I . | | | I t I I I I I I I i I l l r t l l l r t i l l : r l l i l i l ( i ' i '
j l l l I
l.srrlrri. str .'k'rrrrcrrzli, gi unr,.i rrislllrro ..rnpltr,. Irr scrri'rrr 1 r,ctrtutiit tr r,a.rl|upi'rrrrrirlirl i l,nu.stc infhren!,i[t?i; ia'' p.'leia, pilanrida,lti, se accentueazil.It. tlrilelc auebeloase. Unii bolnlvi-pr ezinidu crize tle opistotonus, crrlrilx)roxl,ousio a msmblelor. Aceste c'ize- se aseamd,ni, cu i,lgiaitatJi Aer lr,r,r'rrrbranrr oblinutir, la animale prin secliune mezcnceiatiEA d;;;;pi:;
r r r rc l l l l t i i lo6u,.t- Li1..2. Prlbleme etirpatogenicp, 4n sind,romul cerebelos.1. I I r ( ) r t lpcprphel4oscr ia. t rpptezenlafeinapJ'oximaf iv60o/odiLrcazur i
il: .clj:11,1,,; ^ll.1llt ,.1. r0lo fiild hemargiobla sioame. cnisrufi, abcese lir ' ( , t ,agt*ze. (A'sr , -n i c i colab.._1974). - \e or ieol i .m spre di lguost icrr l c ic tu-
r l lo l i l , C(. ln0r. lOi isa alLlDct c io( i ln. .ooierLUl c l in ic, pe l tn.qr i semnelC r ,er f lbe_Iorlno, irprlt f i simptome tle hipertelsiune intrasraif:l,n[,, oi,re este insil r.aria_D ir..cit- trrjnsrrilre_ $r tnoment- de aparilie, in funolie tle rapiditatea tlez-l.:,1]l:.ii]1119.li ]-l de peltlr.bd,rile pe care.te.tletermiin. r,a c6pii ne gtndimru l r r r r ru l I ixr l l t urr mcduloblastom, crr .e do mul ie or. i t le"buteaid nr in' r . l . l ' . { ' . vhrsalur. i (de ubir .e i ! ,aJinale. f i rA greate s i fare efor iur ia in i , , i .lcl, bolna,vului), tulburlri de echilibm qi ata;i& indsului (sindromul &re-I'r'l)N vclrr an), staz:i papila-r5, precoce, creryterea dimensiunilor cutiei cra-rt|(.nr'. r'll .te.h r$cenl|t suturilor pe ladiografia erania,n[ simpld,, ,rzgornotrlr,,
'rrli, spar1,5t, la cioc5,nirea craliului ;i adesea atitucline ,,cireinonioasf,tr r r ' : rp.rrhr i . i r r g i tu l r r i r precum si . , l ize lonicc t , ,cor.ebcl laL, f i ts ; ' j .
n l i t rn tumori lc cu local jzare emisfer ic i ig l ioame: jndeosebi ls t ro_.ilrtrrrrr',;,.tuberc.lo_ante; hemangioblastomul ietino_cerebelos sau boalatru r trlr Hrppel,lmtlau f .a.), cit-$i in cele vermiene, Bimptomelc din lartearr.r viloi cmDieni, precum. si cele din partea marilor cdi senzitivo-r.riotoriir r ( l ls( . t |1, . . l l r lchj tnL, . in lumot j le uug.hirr lu i ponto_cerebelos ap:r t r r re_
'r)r,c s{,rnnc cochleovestibrrlnrc {per. YIIII, precufo si dc afectare a irereihi_l , r r ' \ ' - . j VI I , serrruele celcbcloase apir iu, i inai t i rz iu.
ll. ,4.f ecti.tmile inf njioate ale - cerebelului :
,1) .in, erotulm enr,eJalitelor de diverse origini, primitive siu secund ,re,irc'l() $a,u ct'onice, apar adesea.simptome cerebeio-ase. Dxisti *nele situaliirr (1llrc, loc:tllzalea- pro_ces3lui infectios se face cu pre<lileclie i" c"rcb"t,rr rr.t'si. cazu.i tabloul clinic fiind dominat sau fiiirl constit*it excxus#rlr rr11 11i1;1111'11 g1'rebelos. Pentru aceste cazuri se folosegte adesea l,errncnLtlrlc urtbeli.ld,.
t'elt'br.litelr. -sint
rle, fapL nemarite arule in.feclioase, eel rnai udeseal) t ' | l r r r ) r r ' ( { lar , f t seeundare}, rouni le al t idalr , s b lormcnul (1, . ?.atar i i:r..rrr(." irr(, lnl r-_,eyden.( ljecourt, 1922). Se pot intilni in cele ma,i variatcirrl or'ti i {{r lrrd 1 iloir Ii i ., d ifr t.rie, ru.ico]-d , sr.&rla iini. variohi. g;.ipi, pn.r,,,noj",r l rzr . I l r . t ] r . . \ 3t ! l -cel l . tusc convuls iv5. d i r"erqenevrar i lp" i ro l ice_cu:urbu-viltrsrrli rltr pildil, encefalitX epidemici) ;.a.
:! . AhceselE carebetdase sint relativ frocvente, ma,i ales in cazul abceselorr.rrli l lctrlr' (otogene gi rilogene) care rlau in 34% alin caauri abcese cerebe-r',irHr, rn oele oJogene {Arseni si colab., I9Z4) Fi mai pulin in cazul abceselo:rnl(.rlnliltlcc. l)eDulul subacut, cu sernne generale hfeetioase, cu discretlirrrlrrrrn d-e hipertensiune intracraniand, lf debut, dar cir aglavareit, pro_gt'r'sir,ii, lr,tlcsoa ryi cu semne mcnilgiene nc sugereazii, djagnosticul.
ii. 'l\tbereulonu,l cu, Iooali:ure enre.lalicd, aDalc mlri ales la conii si lrrr r rLrh * ' r ' r r ( i . , lo. i r . l iz i r
'orr . .dr . 1.r . r . r l ih 'c1ir . l i jnr l r rx.mrr i iu c, i r , . t ,e l ; i in- t f i i i , , . i , i , i i.r'r ' i!rr.irr (A.s.li i ry.i .rlrlr., 1074). ll 'rrhcrrculoa.m.lo cerebcl0aFc r'(,aliz(,ll lzr'lrr r.rrr' ('rrzr.ir. sinrrTonr d$ hipr.fl0nFiuno intrtucrnnirmii, slndrorn do fr r,rrl )oH | ( ! r i { r r r i r , i r r l ) i l rz, r l i r r cuzrr I i r l : r l r r r rnrr i i r r r i ! f^ r l i , , r , r rzrrr i Fir rdrrrrrr
180
I r , r r r l r | [ rH, i t t t l l fot t t t l l . t t t l r ' t r r I t i t I I r r t I r ' I i r , I i r ' ; l i t t t t l 'o l i ; l i t t r l t r r t t t t l0 l l l lg l l i l l ( l l l l l lr l t r r l r t ' los ' ( , \ t ' r i r^ t t i 1 i r ro l r t l t , I1)? '1) ( l t ' t r r r t r t r t 'x l ' t r t l l l t lht l t l l ' ( ' l l l t l l t l i i tgr l r t$ l r (
. r l . l ' i r I t , r i l c i r , i r r l rcr lu lorr , r i r r rk, , r i r r ! r r , r r l izrr , r r r t , r , t r ' l r t lo i rs i i t t t t r l r r lot t t t i t t i r l r '
, r l r i r : r i i r r t r t l r ! . { r , t r t t l i l lo, l , i l , l l gt j l l t r l ( l i lz i i t l r r l t t ' l i i t t tpkl l lLt t t l is t l t r ' l ' ( ) (s l ' l l | t r st t l t
, ' r , r r l ; r , r rs l l t r i r i . . i sr ' i i i lcr t i t t gtr ' t t l l r i r ' , r :e l l r l t ' r ' ) .
l ' . . lJol i teclem' ia l ' in izunLa( i , t t t l r tost t 's t t l ,ateu'mnl 'L iSt l i ) t r r l t r t rz i t t i r i r r I t r t rrirrrrihr (, lro lczeazir, ccl rrui tt 'o0yorlL cetcbclul. Irrt intl ivizi i l , i lL(\f j ' l l l(12(' lrt ' irrrrrri siutltorrt ccrebolos ()u oYolutie lentir, qi ml,i Dls$ ou pu$r)uli i1i tottt isi
' i i i i r i,t i , i i , l ;otrle:r,una suspiciunoa unci leuconovruiitcr lII iLi rrltts t lrt.rt ' rt ' '
'rxx,iu'z,i i , si simptomele ,, i iramidale Si veslj ibula'rc" I!xisti i i ttsri, ' l i t l trtt '
i , ,,,,t,, j iorr'"".1c'scleroz,i inultipH, in cnre sernnolc coriireloa,so l){tL (r, l l$l, i
I u i rrruliril yl'ttno singllrele manifnstd,ri ciinice .
\1. Afeclittttile rasctdare a[e cerebelul,ui
l. l lenmagio cerebeloasd' nu este chial asa de r:*r' ir, cl l lr l slt ( ' lr 'zl l l '
, ir rt.urizentin{i: de fapt 10-13% din totalul hemomgiilor ptirlrrtr '(! irrlt ir
,,.n biale tltpl, uneJe sllt istici (McKissock,;i colab., 1960; (iorn'vil lo) l{ l] ' ; l l ;
\ l i l ,diell 1i, i.ngrist, 1942). Ce]e mai multe hcmoragii ccrc'}{ ' ' lorlsc tlr l |rrrl
olrsorvttte ttc P"opoviciu qi collb. (1980) in zona de vasculaliztl{ ir I tt ' lr l ' t ' t 'r ' t
. , r ' r . l r lo lse t nLero-supel to l r ( .
Sr Do&t.r recunoaste tlulft debutul brusc, cu grcluri fi viirsil'tttt'i lrr
r , , .s lc 90V din (azur i , l€ caic se lsoci lzS, o t r iadi ' catactcr isf ic l r : : t tnr t t 'i , . ' . . t c ioas"r i *" tn, pr"r l i r i , pr iYir i i ipsihteralc ; i p:rral iz ic faci l r l { . 1x ' t ' i f r ',i,,ii."ifltt .,.1 .otrir', rgf+), dup,i car-e se instale?zi. ttilburilri rtxpilnlot'ir'
"'rrsl'ind in speci iri riiplr:r'1ie peti'rtlicri (llc
- -tci ssrrclt ri irolll'l) ' tl)(illl
r , l , ' , r l r icni , oumi l t lp id i i f tomai ) . i Rogpl . l$?5).
$o nut t l istinge 5 tipuri ale instahre , sil l lptomrl Lologirl i i tr It l trIot'IrI ' . i IIr '
, , r, ' l ,r l , i ise (rlup.r- Schobl gi colnb., 1965 ; ! ' isher ,si colab , l{){i i I I l t lxtv.tt ' ttt '
l ' , 'rrtrcilntla ;i -Pascu,
19801 : a) Tipul ,rtumotal", cara'otcrizrtt ltt i tt xtttt l t
t,,rrr. t,c.ebelbrso cu'ticbuf lcrit s.i. piogresir', rtsocilte cu l irttrtttrt ' tr. r lr '
ir i txri t orlsiulre intracraniand. b) Tiput rrrmingian", - c,.rri l ,utol izirl ' l tt i tt rt lr 'r
r i l irr, rrcuil, ]trul, i l1ir, a unnii,tuarelDr sirnptomt : cr, 'f: l lec, vllt ' tsi ' !trttt i , st 'ttrttt '
rr,.rri lge:rle. fclornene confuzionale, slnptome ccre'helotlsc sll 'Ll olf l l ' l)r ' lrr-
, , , r i t , r in.s i 1. . ( .1 i . srugbinolcnt . c) Tipul iu aspoct dc s inel t r tm t l t ' 1t ' t t t r r ' l t i
, , . t : , ' t t t * f , ' io- t t i * r t - ,1 , i tat . r 'u comi, prufrrndi ' l ) t ip i l t ' r r r i r r l ic{" l i r t l r i t rshr
r,i i ,r1,<.r'a,1, hipol,olic $i tuiburil i motoii i mlri (c-rrL, rnrrsch(rl lzi l, tullrrt ' i i t ' i l '
. r ' t rdrol tase' ; i rneni l ig iene). E\ ist [ l i f ' tmrt , ' l r t l t t t i r t r t t r l i " ( r l .srr ' is i l ' r l "
t ' lr,,t ias ;i l iogerr', 1925 ;i ' I( innier' \f i lson,-It l5i)),-ctt , i .u' l.r ' t ' i t ' lrttt irt l ' t :r
, orusticLriei si i.u b rnotrle rapidtr,). ( l) Tiprrl cu debut mai puf in gr!r\ ' ' t 'r l
' , r ' l r i . r lnsi{ . l t r int i l , q l r '2Li i , v i rs i l l l l i ' ccfulco v io lctr t i i , l ; t ' r t t t ' ' r tst t l ' i r rz l
rl lr, i i ,,t l ,Lrl iru: r-tI i tt. con;ti, l1')i. er) {ipul ln care dupd' o saurtn 1{tl ioll( lrrrlo rnm[," bolnarrul igi revino, '^cuzind in conlinuatc rltttct ' i i tt I ' t 'gittttt 'rr
, . , ,gr i rLI i , g l r ] tu l i " i v i , r 's i t . r r r ' i l t t t iu i u les l i r schirnlr i l i l " r l r . . l tozi l ic r r l { r ' : t l r r l
r ' r r r ' . i rumr' ic l i ' r iu l ' r r tc. Obi t r '1 iv t r i ' t t t u l t rg i r ' , sr 'p(r i r l , ( ' . { ' \ ' i ' l ( ' t l t i i r l l t r l l i$ l r r i l
,rrr, ,,r, iz. '. i ,1 (car,c tlrr,ci i, esi,r unil:.toral, inrIi.r i sulirt l Iozil lnii) f i t l l l lrr ' lrr l
, l |rrl l i tr cor?b0l0s fuOrnOIatOral. I)o lrtrt lto rlt i stt pttlttc OVjdtrlIt i l l , i1i rt. Itrtr r r r r r t r r l i i l0r lotr , I ( , rLtcoal i i , , t l r ic I r l I i rn l i r r l r l t , t tg[ , i : t t r l t i t r l l l ig( l l l lo lof( ' { r l l l l r ( ' lo l l f i r '
:!. I: l tmalnnnrL cerlbAljA ?rrrr0df (,,spo l, ltr rt i tr rkrn ttttt i t '(! i l , vo{' l l( ' , r l l
, r r r ' ,^r '1r t Atr . ic t t i 1 i colrb. , l t )?1) cst( t ( losl l r l r lo t ' r t t ( r t l t t t t r i t t t r t l i t l i l i ' i , '
' l i r ' , r r t I t ' i l ( ' t l r ' l tot t t r l l ,o i l t l t ( ' i t t t ' l l l '1 t r t t ' r ' t t t l l i t t l r t l '0 i t l r t r l t l i t l t r t t r ' ) i i ( ' l r l r i l l i
r l i grLrrs l , i r r r r l ) t i l | { lo l ) l t l l t l br , t t l r r l ( i r r l r l r r t r , l t , i t t ;Lt l r . ) r r t t utr f i t l t ' t ' ot ' r , i I i lu l r l ,
v i r r ; ; I , t ur , i , v i , r . l i j , r ' i [dcro l i l , r : r1, gr i t r t r l t , r , . {hr n l l l tof l , i t t ( l l , r l r r ' r r ( ' i r l . i t l r r ' r l i r r l
I rl7
(lrrrri ^('ci(l.lr1'
(irL lirrlrr.r. irrtrtrN sil* rrupi, oiteva zile (in formere subacut.e). ir* lrr,lrrrzr'i, r, sindrorn neo- sa! paleo- cerebelos,'in fi;;1ri; ;;"I"'*iljr i r r ' | i r I r ( r I r i r r ' | ' r r r r r I r r i (Arseni 5i co ru b. . r g;4 r . s ' . po, t . '^*-cra sLaza oaD ar: i --ir,rrllorrrul do irilal,ie meningeali,. prr.cum si ;-"; pir"*;;;i;ili--:;1;| . , | | i r r . ( . r ' , I r r I f r so.rnD'. de tnt | rc l t i cercbral (Arscni 1 i coluh., i9Z4). Exjst i c i
l:ll,'i:l; .'l,.llr::'n,^"_r',:,:,11 "rf" e\irut run.in'e rapi.t. indnoseiri-;;iJ ";;'rJ;"',:r|||l i irirr(,rul' cercbeloase ] _ gaJ? OcCipitali,. Alteori bolnavul igi"revine,t l l r : l ' ) r ' r r .Urn:r loasi i in i l i : r l r . f r r i a pfezetrLl , Scmsc pret m,rr i cercbeloase.
' " r , r ' r ( . , ( l , rp i i r . i rcva zi le .A apar i i iemne de nip". i "nJi , rne
' in; ; ; ; ;^" ; ; . i
rrltlii:iffi T":rrt,il",f H:",1,f,i",":;ff :i*:F:lt-,""""Xi:?li" jt",*]f;r',r\'(tir'.rr u.ui hemal,om cerebelos. ri" ;;l; ;;i;;lti-"Jrr insl e'olufia('iri r.rr- p.og'r'si'ii,.aspectul crinic fiind asemi,ndtor cu cer al unei neo-| ( , r ' l l l l i I I ( ,c l ' ( ' r 'e luJia ( . . lOf in: t l lSCU.lut U m,Jral ; ! r r ) .
:1. Eindtoamele iscltemice cerebeloase. Infarctele cerebeloase izolate.lrrrl', sint in general destul de rare, intmcr. se qtie cir,
"i..rfi,tir"."f"i"ilil:r .r.rqbelului ests relativ bogati. Astfel, ocluzia'a,r"berei cerel:eloase antero_::l,il.l:ll::,..,"1i" 3,s.imqromalied,r inrrucft infarcrele cerebeloa,"se produser , r r r ' r ' r r , r r ' rut ,cestal l l11erp <int .mi, . i s i d ispr,rst te (popovic iu, pendefuncl : r ,
,i...]'].1..]1.: ,11101:-it :9bl-lr, ocluzia arrerei cexcb;rolLse anrero_supL,_"r;rr(!
pfufluce, pe- linga, leziuni cerebel0ase la niyelul nucleukri dint-at.il,J:,i,fil]:.Ji,l:y"I"t J.9l"tt"ooit ponto-meze.ncefa,lice (popoviciu si cod,t.jr:'nrJ. rfdure sa nu_ urtam t:,ptur ci, reziuni burbare cu simne cei,ebeloase,rrrri,rr'\r, (.tl mar Rdesea numero&Se sinalroame ischemice ale trunchiului'i'r'r1'll.NI (sildromul arterei cerebe_loase postero-inferioare c* r,',iantele s:rlez, . i , ' , " l l l ' . ' : ' l ' ]
l r l i r 'e ' ran-|-b, 'nais, s ind| .orrrul tu i srbin. t r i ' . r ' rg,nrtc, - rndl 'onrI t] . i i l : ,1) . ] " ' : "u l . .s1rn. d judromut t r r i p i , . r r r , I lar ie.Foir hrr . .h<,miprr . , .z,r, , r " - r , , . lo; , { ,1 . - \ 'ezi cJp. l ) , int f t r - i r In l re lgd j l igJl i . i , . . rc l . ;o!ulr i i e" t , .. , \ r r r r - ,Ulr { r , l , r tm u e cot .cbelo.rs| l ' jscuic Lt io l t "uo(bi l tJ bazi l : r , . sc nLr i' rrrr's. r'irn.rismentere cerebel0ase bilaterale trin trombozcre vertebrcr,l,rrzilirr(. (l)oloyiciu, -pende{untla si l?ascu., fOSO; Scotif fO6T a,, b).
ll.,:LtroJii.le cerebeloase/. \r' sirrdim la o otro.fie aercbploosd seaundord, s[n$)lomalicd. t] nr(./ ' r r l . r . l l r l l lurrc. iLnr l rum cclebelos, carc s_a jnsl : t la l la un-bolnar t i care nLtr I r ' 1 r is I ii r r r,. rrl1. iiictul. et,iologic, dari la,care eviilenlieia in antecerlente unr:r ' l | t | - t . tocTlos. roxlc. l raumat ic. r , lScular, ctc. , po. ib i t gencft tor cI corr_
: : , ) : i l ] I i l l l l ] "1?i-L(. c.r .ouotos s i , l : r i . i_Lrc. pr in jnvpst igdl i iJo r . for . tur fo 1lncn.r.rr'.( { rirl(rgtallc, tomogralie arial{ computexizati,l s_a eviilenliat ;-trofi:}l l l r ' l r l l u l u i .
:!. ' ltroJiile cerebeloose pritniLile :
.. ,,,.,::.).,,1,!.,f .!il: -!t!:!il*yt ered.o famitiate ne sint sugerate ite intervenlia,
' \ r r { , . r r r , i r , i r . nnot l?clor i . gtnef ic i . As el . se surpr in. le caraclrrul crer io.r i | | r | | r i | | , ( l r ,Dt .ut i ] r 'c loc j0 cnpi ldr io Sau In- adolescent i . cvolut ia bol i i er fe|l'trl Ploglcsir'5,, iar in conteitul semirrlogie o,pal n*irf,rl.t si alte elernente,
:.:l:.:ll f:::l-1,1:".,lglli respTtil-e:- . pcta^la tui. frri,ed.rei,ck tmphcli' qi l;zi""i1.,]'-1'l ,jl:,111 l?)r"froarc $i tulbur5,ri trofice. _ Hredn_ataoi.a .&pinacirebeloa,aAt t l l t . t r t t r t 'e JA41L.d i tsoe i rz iL f i . {Crnnr, p iUnt idale J i , cv{.nLur. l , i lemeul( . l rnr i , ,_l r , l r ( ( . ( tn l r ) ( r i l f iL lur ( hu|r , r , l . . I ) is inergia oerebeloasi i , mioeloniad u, l r t il.knnwy Hu,nt rk'.ltrttrlzii clt tlizc rlo r:$ik,psio ia,l .sindromul cerobclor,ill:,'::,'1:i, .,1". l":,1r
rlt,ir rrt,, s,, :riirxriirzi, qi oi rriioclonii t,"liizlt,, la urulrhiir . r . r f r . r l r { r rr)rr 'k)r ' r r -rr1x'r ' i r r i r ' r . , I r ' , ' r ' r r r rr 1 i .u ( l r . i r . r ' i r , r i r . r rr int . r ' r r rrr . i r : r r il | l1,]{r-f .r lvi f . . t f .rolta otr l ,od(Vtl t t l tnxd, u l t t i eoft]on_tIt l i t tr ,$ r lr i r t t l r .rrz, i
r80
r l r r r r i i , vh ' t r t r t , r l ( l i l { ) t l t r l r r r i , i I r r . i , I r I I I r I r r | 0 l i r r i r s0 f l t t ' r l t l l t t t iz | r tz i i l t t i t r l t r l l r l r l l r f ' '
s i r r , l rorn txr t t rbclr tx ct t ovol t t { io l r logt ts iv l l , I i i r l '1 ' scrt t l t t r t l t r l ( 'z i l l l l l i r : r l l r r l
l l t t t01'ul i t tct voi l N{r .lt) Atro! iiLa aerebrioase (u detsruLin'ilm aonge'n'ila'l sittt; .ltryrt rlt ' rt\ 'rrtrtl
,,rr1,, lriin pr6zen!a, unui funpo*ant sindrom oelebelos rr:rr'nilt 'slrrl i lr l)ril lrt l ' '
L,,,i hup[tna-steie, suferinti, cere1,eloas:1 fiinrl evidenl; lcg,'1i. rlL' ittl 'trt 't 'It{iIr
' , i i , i i n i in"a pzr, lotoeic su.ueniL in t inrpul v ie l i i in l rar t l . r ' i t r r ' { : r r l ( i r I t r r r r r r r it,.s1ll ' 'c <liscdbriopiazic[. I)iversele entitSll clinicc se, Iot lptctrirt' lttr.ltrtzrtrrrlcnsit:iti i su{eri-ntei celebeloase gi a semnelol de indica.!'ic lczionrtli i ' ltt.p.'
"i'rii":r ' '-
iptazia congenitald, toiald'; - herniaplazia cere-beloaslt' i. . (tl'ln
li,r, n,eocerebelitasd' a lui.:Vogt i - attlaiia arhi- gi, Ttaleoceretlloasd l)ilrgtr, 'l irrtl osto facilitat de pneuinoencefaloglafie, pe rrtliografiikl I 'A itt pozift'
.r,zirrrli, evitlenliindu-s6 spaliul subtentor'1al rrursiv l;lgit, rtct.rl tl itt itrr.rlr'irrrr. t'ealizlnr1 irno"eunii cu ce1 tlin ventriculii la;terali tttt its,tN:i rrrt'trr.l.ristic de X. in fozilia cu capul adirnat, aelul Se ac'rnul.^zr'i ltrrlr.i i\ ' rl
li'sir posl,el:ioar"l, desemnind gradul tle ap-Iazie."ti; Atrofi,ile cerobeloasa cu- apari'lie tard'iud sint' {:'\plesiir rrrr{'t'l)ri)('t "
,' lriotmfice,' degenetativc, cu irrjtere,sa,ro cereboloasil r:leci:ii'i - l)ivtrtsllr'r rr,r' i*rrte de atrStii cerebeioase taraLive se pot incli ' idurr.lizlt 6cstttl rt. rli l ir,i l.
rr,, l iaza virstei la care debuieazii, gi a extensiei topogralico rt lt 'zitttti l. 'r, u'rrrbeloase.
ANrofia o:Li,ao-ponto-earebeloasd, a lui Ddjdrina^ Tftomns tiratrr itt itrrrrlr i'stei cl"e 50 rie -ani, realizinrl rlrr ll]Lr,r'o siirdrom cerellelox, t'll trvrtl.tr(ir'
l)rr,gfesirr6 (in cale predomin[ tu1bur5,rile de mers, ataria' 1i 1 f(nl] tl rii'l I l,l rli , rt;rii i l iona,td,;, la cire pe parcrus se avrciaz5 _,1i stttttittr ttxltitlri l ittttitlrtl ' ,
1,,r'cuil qi iialeze oculbrnotorii.si rrle mi;clrilor cottjrigli,l 't ' rtl ir glolrtl"t, r ' l l l i t l l .
--- Atrofia cerebeloasd, ta,rd'i,td cu prellorninanld' -@rticnlii
u' Lu'i I'ittr'It (,ie-Ioifr:At04nrani,e apare mai tirzi' decit celelalte iti:t'fii .r.'t't'Irtr1'I r .
r,lrrrrii virsta d; 60-65 dd ani), are evolu-tie mai leniil, iar itt trtttrl 'r 'rlttl
' r' i iulosic oretiomin[ in mod net (sau sint crclllsiYli) iit ' lrtlr( l(
1',,Ir:oceiebel6ase: tulburitri irnportante de s1,aliune ;i tlc tttt 'ts, lttl ltrt 'rri tutburd,ri de vorbire.'
AtroJia olitso-rubro-aercbelousd' a lui Lejonne'[ifunn'tlid it1l:llo ttt
.;rrrrrl virsiei"cle 50 de ani, are evolulie lentri 9i s. uitlir{jt(.r' iztritzrj, itt 'ritttttl
' irrrl prin importanll ati,xie a memb.-,'lor',. uu r!:tl i tulbr'ir'r ' i itrl 'rrrr(ir' '
,,,,1,, {i o'oziijonale,' la c:lre se asociazil, gi mioolonii (lLtrooti ' it 'tttitrir)
vr'1"
lr,rLr,1inei falingolar:ingienc, diafragmltice ti ale globibl o('l l lrtl ' i '' ' Atrofia' cerebeToatd d'ifuzd tr twi llr6utoa :l 'priro lnai (l{rvt('rrr(' (l('( rl, ,,l,,lrr,ltc (intie 40 si f'0 lnj ), are o evolu{ie mai rnpid; qi rc*liz.i,z}; lttr tr lrt ir y
. r r r , l totn ccrolrc los compl ' ' l ' l i r lh i , pslco- 1i lcuc' ' r ' L ie l ' r ' i - l r i l : r l ' ' l r l l ' l r r ' r r '
r,r' rrsrtciazi, Si semne extlapillmirlalo (itrcJusir' (lurrt -rll l)l lc(')'
lt. Atunii,te carabeloase troaica sa irrl,i ltcsc in iltoricl(,i* trl,i l it l it, (rt,tlttl itri r,runici,) itr intoxica,liilo pt'ofesiori:r,1e crorLicc crt plgrnb '1i ttltlttttr, ptr'trtlttt
,i i, ' ,l,tlsul tlatarncnl,elor -cronictl eu tloze rntli tlo hitll l(oitlt ' (i lr sllrvrirrlt '
l r , r robru'bi1,*1, pr i rn i t lont , 5. ,u.li. sinilrowtcta acrubeLouga trawnatkle sitrl; ttqol llo tccuttosott1, I ittittrl
r i r . i r r r r i t do f i tot l r r r t l t r , t , r t r r t l l , l , ie, cr l l r l l ) r ' r r l l t (xr ( ' r , l l l Z i i , l l r ' l r lo l t tg i i i l l t t t l t t ' t t t i t. lo lutc oot.ol , , r t lousr, , ( l t r r l ,oxl , t i l sr , r r r i . l , rg i r ' ( 'nt ' r vrr t i r l t i l t l t t l l r t , l tz l i t , t l ; t l r ' ,
t t t I t t l tof io t l t t l r t t r t l l iz t t t t r l 1 i t ' : i l ,ot t l i r t , l r rz i t t t t i lot ' l l i l lu l l l l l ' i (x"
ll, Ataoitr, Ialtupinoht'z iod' Jonili 'd' ( honkt' ht'i I 'r.nti+ lltt) (xrrrsl' i i ' rl itl: rxur. i r , r r ,n, t t t r t t i s i t r r l t ' i l t r r t t , t ' t , | , , ' i , ,x l t t ntol t r l i t ' l t r r rgt t rs i t t t , l t t l t t t l l ' l t ' l t t t tg i t ' r '
180
l"i',i,;lliJ,ijii,.u':tili,oo"_T$'f;,lt alo losuDrerrolor. ttin jurul _trasusu.rui sirn(. .rrt(,sorulu
'cr.csiv*] *t olo"-*;*ti"11?rlter -famiiial (cu tiansmisi
:::tl:l'lt:f '"^iffi fi l#xtrall,#ffi t;:"#3"T'fi li{.i:#-Hffi*iij ijiHil F::::;,,"i,!" t"*i tix'3;Hyt3:l#ff; :"3lidl3i#5#ftiii:.ilillii;i; Affi'#-1"Xt'#ignetizare"
a lui Dennv'nrowq; dnexae ae
;J[Iiugsl$',1ffi1"a,i'fl r{iti'qT#{f i:',"i.}}"x'ffiry**ili|I';r 1);)t i srsor qi cora).r.,, r;r;, F.ff"'fi
"ul,Ti;lh,t?3t;,.Fradis ei Botezi
F PROBLEME DE DIAONOsrlc lt't spl'ttot,,otitltO. MIscARILoR INVoLUNTARE
6.1. HIPERKINEZIILE
Sint migcx;ri involunta,re, rrariabils ca aopect sorniologic'r,rr, topogufie qi- ca eti6patogenie' Majoritatea aoestora sint tle orlgittt'oxtrapira,rnitlalS,.
6,1.1. Hi.nerkinezii bruqte ;i clonioo, fir[ dcplasdri sesmenl'ar'('.' xtlltr.u deplasiri iegmonlare dd obieci limilatc'
l. Mioctoni'ila sint eontra,clii rrusculare involu-ntat'e, (li)r colllli(lllr'r,.u*ia, J" iil clonie, arirmicc 5i uneori rsincrone, alteo'i sittcrottr' 1i nlttr.rria"."ii-iiri" lr un'lascicul :nuscula. sru numai la un rnurochi (c.vt'ttl ttttli,fri*t
"" mai mulLc grupe muscutare). Sint asemlni'toare cu 0{)n1trt(tlllr'
ino..ri-u ptoOrie di e^xcitegiite electticc galva .no-tarariice' fntctt*itnlt'triii"ii"" mt"'J""ii este foarte'variatril; tle 1a individ _la intlivitl
'i tlo .lrt'
iiir'^ia i" rr"ri;. u"ele sint discrete, cle micii, amplit.dine, f[r]l 'ir'i,rrrr
fr,lil,, ,lellasare a segmenielor corpolale lespeativcl pntinclu'sc oottiittttlrt r'tti;,-;i;;i;tiii; *ui-cutu"e. Altele; dimpotiivi, sint tttlgertrtoarc, :trn1tlt";i;;"r,;;r.i-;;r;lor"
-o,lu.nt) s'egmcniet' corpornle respectivo $trtr ('lrirrl
iiifii:*,ii "J"p.
-eiirix i rnin6to# ritmiec, sfereolipc, conrinut' (ttrirr'll"
ii 'ril"te;; 9i mioctoiii mai a,tnple, care pot prod uco (lorctl'?o!:'j t'lottit'r'musculare mai intense."
il;d cum ne fune dreptrr,te au remalcat Ga$ttuut fi colab "
(l97J)',*,naaoiii d'J,ffiucro"i"" a 'reprezentat multd, vreme o. sut's[ dtt t'rt:r l'ttzit'ii ,i"'!ir"tt*iirli. i"t*.oot ad ,,*ioelonio" trobuie s{ fie utilizat ltt st'ttvttlnf.
"*tii.l""ii-"ioei., udi"n s[, iniptice orice contraclic musoularf involtttt'
i'iiiii,"r'."i"ti,'"J-;o* I ot"tilit lictr, Muskens (1928' cit{tt <lo Gastnut 4ir:olab., 19?4; qi do Popoviciu 5i oolab.' 19?0).
Contraotia'sourtd iivoluntai{, poato afecta, unul sart mni mulli rnu6chitri,, no'ptoauclna-nici o mlgcoro (ttoflnsare), otunci olntl ttcli()neftz[ !(r lnn'l'
i,hi mlioi,lle producind o rnirlcaro.'
ln luuctio ritt tliatribulia lor splJio-tetnpwald, pot' Il dlsiinro doutlu,"roi'orfiiirioiu {a iiiitoiti W"orotir'ote t n)- mipolittii Jragnrenlafe, nlunel;il{
"ft,ift;ti;Jnoron ll nrjinotrlo vrriat'o'p&r!! nlo irtttroulntu'li coqro'
rnlg i b) at{oolond{ nncluo nrnr blla,tor|l.1o, rrlnerono il rlltlFttl(lo, 6n.f0 nl0olloutn
ill
. l l : : : i ] ,1 l "
r r i r i r l r . l . l r . I ,g iu,r . r i , \ l i t rs{ j q i ohirr , r . i r r t t .cgrr l 0or! . Accsto r l ( , l t i - i ,i r l r r l I r , ( i , r r r ' ( ' r f ) r l r i g, . rLr ' r ' : r l izrr l , ( ) l rcbuio s i l , f ic r t is t inse ic in iocloni , i l ,e un. i_tttttt.It\ ' lu4 ltutl l t l t I ( iLr'\) r ' irni]I lOCalizate ln o jUrnir,t*te at cor?UlUi, SaU hiur s{ ' l l r i I ( r } t to;por l l .
.lll::;f,l"ll]:.. "-:11f9! fi impi,r!fte fi in: 3) mioctonii sporadiee, aticit,
I ] ., ll':.ili_,ll'-r.Tlljj^u*,, nesisrematizat5 I b) mioctonii ,,pseuttoriknice,, ,, , ,1. n. p|urt t r r t tu, rn lFtTir l l . rnpi mul i iaU mai pul i r r f ixe.l)i\,pxLnct tle ,ed,ere cldnic, ruiocloniile pot f-i ciasificate tn umi,toarel€
,11-{i, .(ll: ;l^ _.i.il ].1!o,:,.Gr.h,lt, ii r.otub... r"or.r ;.popovicru ;i colatr., Jgz2,: . . . , r . , ) ,
, , , , l
, : lo ' l l tcP ( t t t .ufne l ! .h ipnict ) t bJ potologiae. car€ poI f i , la r lnr lu lt.t. '!,. i -. ttttn?rotlt' org.unt?e.ncppilepltcc, care pol, fi dc divcrsi etiopatogenii :rl|r.r,r r,rirsrj (encr.Ill itc), to)iice, degenerative, metabolice etc. 1 *_
m-ioc1o-rrr olganicc epileptice.L) ,l[ ioclon iile orllani@ lnepileptricepot fi intilnite in nlmeroase afecliuni :
, !. .I!?r,y,ij,e. di,,t enaeJtlikr epiLlem;ct, (fort,o tt,iortonicd sau, atgo-,,,,, '.,,,..,.,,,u,,ru ) lt lttL ultp tt,ptyo V[t? eunlrope Srnr l,irpidc. rifmice, Unebri
' r , i rL| | . r to rmpte (nu-d{ 'p laser i segrnentare). Apur r le obicei in coDl.cstul. . ' : l . l : , . i i r : l l - r l : i ! , tchra. radicrr tatgi i . pare- l iz i i ouula! .c. b ip( , rsomnie (srrr1. , , .1: : l ] , " ' , ] , i : : lor ,n. !9 menirgeale. s l i i i I i - c.ontu:z ive. chiar cu evolugie s l re, , r r r r r ' . . r t . r rLn{t t f t cr i a l te mc.ni lesl i r i r i er t ra pira midal , . lparkinsonieno.. . l | r * l r i )snr do Iol i i t rLo) ,s i cernbeJoasc,
(.lorcaa electriad, a tu,i Dubiu i cste o formii, pari,ic'iari, de nevraxitii,' r i ' r l , t r rn ic i . crr r r r locloni i ampJc. brusle s i r lp i t l "e.
, i l:: 1r,,,,:,*J1!i.tc,te-25!ygzonte sub,:Utp 1r,eSS7 qi;n tpucoenaclat.ite.t : \ t t "^. / tntpst t tnr , , / .1Ll_Js/r leLtpvanBogaer. t , rn ior , loni i lesinlmrai tcr i__,r , { . . I j , r r^nr i . . unoolrr to i rLur i br l is t ie l ) im- l l r r ra i or l inre (r"bir , r hemig, ,n, ._
I I ' l l ] , - ' : g i l ! l , , i l i . rn l" , , insoi i r . r , r ruoor i ; i de urrc i ipcr i inozi i l ip isnrt .] ' .11, j . , , ' , , r run. t utur . r a le nrembi elo-r . . spasme , le rursiuu,. , bcrui f r l ionr,r l | r .n.rrr ( t r r l l |c) . Aprt Lr ( .Opi i \ i lu t { lo le\Cent j , lL l r_uu |Otrre: l r . l in in Crr. .1 ' { . r ' r r , . i ' p l ' ,grCSrvi l s ldr i i .geUerl le. : r r lesca oA fcbr j . ( ,u , l { .nteol ich,
l , ' . , . , : i . : . l l ' , . ' , i , - , , I l , : i : : . I pI , 'p l i r .e. l1y,r1x_1;. esrc s, ibacurr. rnor l : r t i . r lupi t .I i i r i r , . ' ! r r Lr |o{ :1, . l t l r l l ) . } l j r icrrueckpr(1974r s i_[ 'opot i r . ;Lr - , i , . , ,1Jb. ( tg i6]
, , i , r r i , r r r i i l i .
1t1i1, t - !51, : l t t in pESS prr .zrnra o . : , , . in i tn, . r r , in, , , r" t t i t , , r , .nr , iat^r. I.r {r,. ir11r'.rrr1r,(lonll ree.pileptice ;i epilepl,ice: a) tarea reactivitate iar | | r ,Ur . : i \ | lz t I . \ o- lc-0zoftalr ; b) dur i l ta ln: l ' i lung,r) aJ, ."el SecirSelC nt iOclo_r" r ' r r | l t U'rr j , t . ' tc u cont.ra, . l , i ( . lonicJ rez;durLi l i t l " h jperkin, ,z i i vrr | j r r_lri|, (rczi rii l i i sus -, inrlecscbi cnreice)1c) lcpetiqil peiotlic:i a rnioclo_rrilrl t,u itrt;crr:llt ' rLesi,ul cle regul.,lte (intre 1_'1b ,""ioAa; d) plezenla1,,,rrt,h'\(,Lor'lttr(+ ale hri R:lrleimecker, c:l 'e de cel.e mai *.ii i" Jrii"so,t"sc' I , r ' | ' , t r i i ] r ' . . . ' . , i r , l .c3 ; i nr iocl6ni i lc o rernrrc:Li t i pel iocl ic i r . , r , . .
, . , . , . \ t , t ! t t t ! t t .L pt , t l t t ) t , ( repr 'ozloia, n l 'ormJ. ol igo, j i rnploniut ic i de errccfa_| | , r r , l ) t l . t l l ' l .a s: | t ( { , , : l rJ. nt tLUit . in ctrre ml,c loni i le dir f ragln* i ic{ ,
' ' . I | r . r i . , l : -L ; r t l r , , ,1. . srrgl l ; t c l t drrr2lg 4a zi l . SNu caDi. : tn i l i .L I 'ott l)Diu([ottusul tt,ult i,plen (al
. lui t lr i,etlreiclr, aparo la adu11;i si, crr lrrrl,clizr,lrz,i pril nioclonii sinctxice, frccvente '(1,12 pe s), lotali_r . , l ' l . t r l . , . l t . i Uirp ' -2, dcl tu i r l , h j4o!5 ; i cv ldr iceps. Se rcc, ,J l t l ic i lzr l i r
' r , ) l |1 lLt r l l r | : l l ( 1. , L l . r j j Su lu]rr i , Sirr t de,rbiCt. i lOr int , r . f iobS,. (n i , \ i . r r_' r r c) , I ' l , l ( ' r ) r , i r r , i r i i t . i r t r i l iL psi lurpat i .
,. W)
,)l i ,tr lrtniiIc cli l t1tt, itu ltoi I i in{,i lrri lc itt ntnna,r.tasl Jot tttt: t l ,r:L:lrr.,.
1 l I l l l ( t ' ( l t l l ) l ) l l t ) tJt) t :
l . , ' l lut t t1, :1" , r t i rx: l r t t t i t t t r
( . t . '1t . i r t pt i i r . r ' r r , i l , f fur t , i t t r , r , r tn i r t ' ) r* t ' r r , r , i r r , r r : , r , i -1,r ' i l r ; i [ ( l l l l l ] l I r r '1 r l r , t r . r l i r | r r r , l i t r i r . l r r i t r S,r t , t t r i | r r I r I I I . r r I i r r r r r l t l l , i1r r r r i01I tot t r r : .
| 9: l
(1 l l to l )o l , l t t r l t t i ic l , t l iv t , tHl usl t t rc lc, t l t r l t i i i t t l ,ot ts i l r r l r r r t , t1 i t . t i l i t t t l r r t t ' : t l tc t rs l t t t r t( ( l i r ,s{ ; r r r r l , , l l l l i lJ , l l l l ; l l ; ( l r t r l ,a, t r l , , ,s i I } I r t t tg l t iot t , l l )71JI I ' r tpovirr i t t 6 i ool t l r . ,l l )?( i ; i l l t$sir) . r t i , ,s i colrb. , J {Xi t } ) : l t ) Miockrtr i i t t rLt l ivo s i t , t l gtr l tot ' r r l . izr t l t ' , n i t tclrxrt,, [l i lafirt'rrk', rlo obicoi silttol,rioo, ltlttxrli itrsii, itsittttrl 'rico 5i itt lrltsrtttl i i(rrli,errrind d.olao crizri la alttr,, tle o p:irto srtu rtltl lttrrnioot'1xrt'l l i1). Artslcrr,it r l;clcsoilzii, cu plcczfidero rllusculat ra axo-tizornolicil l i i lnu;clrii l lrrrioli 'yrlrxlrrcind o bruscii flexie a capuhli qi o proicc{ic irulint,tt it, lr,(,l l bt',,l,rt it 't1r'liorr:c, mult mai rar fiind intercsate $i membl'ele itdcrioilrtl (r.rtt ciitlctr').lr) llioolonii parcelare, localizate la rnici srrgnrcnto oor?orfrlor sitll clt irtr t ttt t tr r ilrr, r.numitc fascicule musculare (fil,ri tleplasi,ri segneDtir,ro).
Aceste rnioclonii insolesc o pierdere de cunoiitinl,il, (ltbsoltl,i i,), :lrrrlrr'k'iilri)rnene (rniocloniilc qi a'bsenla) filntl cxtrem de scultc ca rltltrt,lit (ilrr lrr'ril,cv:l zecirni dc seculdi, pini, la citeva secunde) $i pot sil, sur'\rirrir, firr Blxrlllrrtt, fie dnp5, unele stimuliri senzcriale insolite (,rrcacljtr s(tllzo"ololtirii"rr, hri l lusirens). Un alt element semiologic impoll,ant, csto trplcz(rrlLrrl, (l(lrIcscii,rcarea electroencefa;1ogra{icd, generalizati,, bilil,t{rrN,lir, Hi,)cr()111, fi
pEf t f MAL l \4IACLO NtC
! ' f0. ,8, ARp(,( l t Ml( i dc Pfl t t Mlr l r l r ioclonlc l copl lul l l "NI" 4 nnl. srob$(frvl l dcsoi lr(r ' l r i r lo Jxt l lvlr lur lul ldo bi l i t tor lr lo,6lt lctol lcf Si , l l l l t0l t i r l r l
(drt l I l ' . r /nxrl . l r $l coLrb, ' 1070).
r i trrrd,t i0i i , , r lo utxlrr t ' rxrt ' t r [ :r , tr l ,rr trrrgf l l , ivo t lo l0 o/rrrrt l . , izol l l to nl l t t t t t ' l t t t t ' l , t t t l t r
rrt t i r , rklui l , utI( lo lcn1,(\ t t l rgt l ivrr, clr , t ' rr l t t r t I t l t t t , I t t I t I t t I l {) t ' tu! l i r( \ i l ,zi i dottt l t t t t
l r i r r :hr outn,c ' l ; t r r i r l , lco: Jtol lv l t f r r r l lo 4l pol iv l l t - t t t r t l r r lo ( / ig ' l4 ' l / . l l l ' r ruvl t r [ ' r tr r l r rs l ,ot ' l to l iv i t ' I t tnt l r r r r l l , r r vrr , r ' i r tJt l l r l , t l r r l r r , l t r r l l l ' l l l r r , l t r r l iv i r l 1 i r l r r L l ct lz i l
c5 -r5
l(lN
t r t ct tzr i ( r l r . , i3 ^r ' i r l i , . ,
r l t , I t , , /nr , i , . , r l r r { i ( , , / r j ( , (1. , sr l l r l r r l0 r . iscc.) ( l \ r l rovir , iurrr lo l , r l r . , l1)?l i ) .
, l l t r r . l r . t r i .u i sr . ru i r r logr l i t r ) j )or tant cBte lcptezenlrat 11o ( lesceirc i r , t ,ct de
l)r i r r r r r : rh. | | I I r i \ r . I i I I I | ' ; r l r rp lu !o .Ul IG, potel l i l l le oare t ra( i l . t c s i tcus. ie mi '_I l,, l ' , , ' , rrlr 'u(it l i tr.:r lc lrrrlr i I 'ecrutan1,1i, I 'eslectiy, f iecale ,,vlrf ' , t1c pt,l, l l , l{,1 i ir
,r lrr)if( 'stt i pr,intr.o d.,soaircare ntuscnlri i lr ioclonic5'iTassilu,i ' ; i
t r l r r r r . , I l l ( i1 | ) .
, ' .. ( ' t i ,:, l" cpileTt.ire tiotlonice qenerrl izate biktter(Il.e ntttsire (1|mgoclonic
/, /./ i ,\ ' lr l . l , ' frnil irrlogilr, rrrrlu' i lor anglo-saxoni) pot sil apa,*.i i tt tty.,t[rtc*reler tt lt lrr! i cl in iut t lt i le.plicr::
,;r ) in l,ncl,. t 'r ' lr i r lp ,!. i lepsie.ltetit zral (rclatate antcrio].) in o:,.r,e
:r ' , r r i ' ' ' , , ( . t { ' tu
srnl 9, , , r*r ' r rJ iz:r to, l l tpt Cale jUSt i f iCl i r . letrrni i lc : . r , t le, ,mio_r ' l r r t r i i t l l rs j t 'c)) .
ir) irr :rrullc t l in cazurilc lc tpil.c:psii t:atrLtlsi,tL 11rrLnd,-ntu[. 1tr-iuvtt,! , l t , ' t , r ! ; | t . | , 1, , t , i . t . , . , . |ot , . i , , JrOt s i . j r l ) . . | r . i r r spr, , . '1,1 I t , r1, . [1;1 1;y f i iz , i , i r , ; r iu l , lr : r /1 r t ( , r r , ( . , r ru,rr ' l , r t i t rusi .e, de.obicei in f le,r i r : , Ast fe l , t iupi [ i l rsdaut, s il r r l r l r . ( l l t7 '1) o t t 'e i r r rc r l i r r bohrar i i r . r1 ct izr . tL, j l iuLr c lunice pl tz int i l s i nr i i i_' l . t r i r t r r ' rs i r r . I ' i l ; , tor . , l , i t r , . r r r t , . r lu l , r , izr . l ' r . r . , ! r l \ ' l \ i \ r . f , , , , , . " ' . ] , r i , i , " .'1. , , r / , , i r l l | i . t i i l (19: ,7r . ( , i lat i , l . Cr. t i r .utSi colulr . . l ! ]71 j , t r ,nsi . l : , t r , , ,1] t . lI I I i | \ ' | , ) I I I I I . | | h l l : r l , t . t1, . t rst \ ts -c i : r t t r l i l iz : r t lo n| l I i l l d{ . . . i t r l l , | t l , i \ . . , p; l i tr||,r l ') l)., 1nl trrioclonii l i ] care apftr f i. c] uni. fc1lotl lrn rpilcpti ic (109, din. rz.rr ' i l , f io p'ecotiri
.(50.0/o din c:rzuri), f ie 'rmeazi,
(3?f/o), I-ie siit ( i; lco_rr l { , l t1o ol t 0r izele tonico-clonrce.
,.) I i ., i ;. i i i , qi clzuri de cpilepsii manifesl,: lte prin cri:e et:clusi.u ntio-, '/,,rrr,1 . ;1;.,,;1,,1".. irr sleciLl in adolescen_ti _(dar. untori si in mica copil ir. ie),l r , r i
' , rrrir,(l,rnii1c m.rsire se produc rle obicei 1a treziic .si t iot t, i l ici l i t- ltel r . , l ' , l r l i . i ' l r . t1 ' . . r oclr j lu i . . I ic t ln depr ivr lor d. o:rml. t , r r rn i i Lr , ,1n rv i , mio.,lorri iT,. (". jr.r ' l is") p,rt f i pr ur.oc:l,tc de stirnularerr, lurninoa,sl intirrmitcnt.),i l i r r '1, f , r r r l ,s i cql f . i l ,
: -19i2 ; G,rstaut ; i cotab., 19?4; Arseni ; i colrrb. , 1O?8),
r'rr Ir rI l,,, i lrtt, lent:r, l , lC rlzele S-o1arc, de lumina de tCleYizOr, rle ,,Urmriri lr1 ,",\ izI rl. 'L (J.'rerr i irg epilelsy,') s1u do stimuli irten,tionaii lpiiml.r:rrear.rprrl i ..:r rrri ir i i i in f irf:r, u,.hilur, stimula,rea luminoesti sl,r6boscopii i, i . Foi,o-ir, rrri lr i l i i l t , ieir ir,ccsl,Or desc:i 'ciri este bine cuiLoscttri (Gastaui si 'colab.,t : ) ; t . ; \ r r . ' . r , i . r . j cuhJr. . 10;b; Naquet s i Weklruin, 19?2). Aceste mioclo_
" , r.rt
,t 'rt,r l.r ' :r le ' i sirlctr. jce, uneorl l i lr i tate cloar ]a rtru.cchii periol,bitui,rr pr rlpr.lr,;r l i , da. rte'bicei sint difrue, debutintl pe rnrrschii axr,r_r:izome]icir1r rrlrrri crl, inzinrlu se qi pe tnu;chii periterici. l l ioclonii le masirre pot lveill11!,\ '( 'r l4r r '- i i l i lbi io (rle obicci 1-n/s1 si aprr rn ,,elisu.tde mioclonice)'l r r r l r i r ' , r l l r ( lo 2-I0 s, dar un,rJr i s i rn , ,sfr t i is mior lbnic, .cu Cnlrr , t i t1etrrirrr1r. .. Ul |hi:rt r l '- o|e, putinit cuirnina.intr-o crizii Ee]reri i l iz?1ti tonic<t_,1, ' r , r ' . r . l r r r r izr ' ' , nt iu. lOni , '^ , U, l l l : r l i r / r , i I . rLgr. pol . , i i1 l , r i . r . i r : , , " , , . i ; i:r1,, rlr i l i i . i lc vigilcnfi, insolrite fi r le tulbncr-r,ri r-lgetrtir.v. l) iJgnosticuli. i 11r'r ' {,r ' iz. epil.ptice cit mioclDnii masive este con{irmat ,*i p.ir i i t*,esli-rlrrl i i lr, lr lt l( i, cu,ro c\-i{1 efri; iazl pclir. irf u;:i-Inde (s:r,u ungo'i r,!rf-ur[le sitrrlrrrl i , l lcsoilr ' l ir i (1o undo lentr, eelelalizetc, it i l ,,tr-rrall., si.rrtrrrn. ; il r i t r r l l t i l .c .
l l l i , t l ,Ui t r : tcr .s lot ' i r t , jz ," r I ) i i ) ( I I ( ) I I j ( j ( | r l i , i rn l t l izr t . t l j i tasi \ ' ( r eS1r, r . l t r . i t r l r i l i ,l r r r l i r r r l s i i , r r l ln i i r r tncqful . i t r , t ,nr 'q l l t . lotc t , t , . , l i rndogutr : s i 4n utcr ] i l t t l t t t l i it t t i rx l tu i . t t r ' t t . t r l t t ! i . . r ' . r ry ' r , r i ( r r r i . r . l r r r rx 'Di1r l is i r r , l l r rgrr 's iv i I r r r r r i l i r r l i i l l , r rl r , r r l r r l r r i l l r rvr i l i< ' l r l I r I I I I I I I ) r ) t 1 l ; r l is i t r i , rg i r r c. I . I r r , I , I r I I l i t r r i . r , I ' r r i . i i : r l t t il i r t r r r . r r l l lurr l ) .
t ! ) ,1
titlt l
lt
t l t l ' l ' i l t l r t t t l t i l r l , , t t i r r r l t t ' r \ l r t . t i r r r . l r tnr i l i r r l , r ( lx t t l r l r r i l t r l l ,n : r r t tI t ,u l t r l r t i l tnt , r r i , l t l l , t tur l lx t r r t ) i l r . l , l | l l ( '11,( , I r r r j ts l { , ; l r , i r r r . I r | I r r . ( r ' r ' r r I l l r r r r i l i . r l ,l r l r ' ! t r r . r i l r l i t r l l i r r r i r r c l r rs i r , i i : r . I i l r ' l rs i r ' . r r r i r r l jorr i r , r i r l r . r r rur l i i , crr r r i r l i r r r r ll r t t t i t t : r l . l ln:r l r l r l r r r lc i r r l r r r l l ) l l l l t r r i (c l i i l l i r r l r l r , v i rs l i i ( r r r I i r r r , r r r Io:r I r ., l t r r r , r r , , " i i , . r i )1 i l r l l o r l r r l l t l . i r , r l i r ! I { l l l . l i ( iu o rrrcr l i r . r l r . ; t rsr . t r r r i (Vrr . t r l l r . . i, ( , I r i r ' I I I I l r , | | , l1)7.1 ) . I l i l r t , l i t r , t 'Ol o l rz i i r r r r I l t i r rL l lo I i tzr ' : p| i r r r r I l tzr i ( ' f l l r | ( ' r . ] t, r r .Drr , . r ls i i l l l t r , l l i l i .p l , ic f gorrr ' r ' r t l izr t , i r . . l t r l i tzr t r r . t l r r r t r t , srr l I l : t r rg i i , 1 i r r r ior ' l , rr t t | , r ' r1 l t , s i l l j ip i l l l r ioo, lLsirr tc l l isc, l ls i r tgt l tLq, t ' rupir lc; i v l l r . i i l l ) i l ( j ( i r r i i r r rpr t t r l , t rs i i r t i r , ) . r \ccstc rniocl i tn i i po1, I i1 l , t I ' f i l r , lc s i r , r r gutrrr , i l l iz : r l r . Slr l i i l r . t l r ,
, I r ' r ' I i l r t I r r t r ior ,krrr i i l l ' s int l rpr \ rzontr l , lc r [c rnrr5olLi i nnrt ' r i lor '1 i l r i r r l ,nr l r r tlL,r ' I i I i I i ' I i ( ) I I I { , . l )colr icrei , r losi t i l r 'c i i , r ' i lcr l ioclotr i t tnt tsoirrsolcstr l r ' ; t i r , t r l , ' t , r r, t t t tor l i r r { r ' i s i s i r r l i lmpl i l icrr l ( r a lc nl is( f i r f i l ( r inten{ iorLlr lc. l ) i r r in l l r r r lr l t :p u i r i r { ) r r ) t ) . -ht c1rs1l uvglu1,, io i l . ro l i i sg l r ,s ist i i , to l r ls l , r lp l t r o r lcrrrr , r r { r
' r ' r ' l ) r1\qr ' ( ,s iYr i , . i t r f i iz1I rkt l l r i l , f i l ,Sin 1,cnui l l : l l po1. tp i i |c : l l i s0t t | l l i r r . r l | r rp i t : r
r r r t r l r r l l r i r r rLcor i s i tu lbuvir i cerrebelolr ,sc,r'1 ))i:t i trcrytirL tn' telotsri mi.oclonicii (o, LuI l l tnr,su.y ,l/rrri l) rr. lrrrrr 1,,
r , r r t , , r rs l ;c pr i rL crr)bextul serniologio c i t lg l ,s0ci : rz i r , i rnpr) t l i l l ( f l | t i i ) r ' lo | l i li , u i r r (xJl l , r [ : rn) i t t l t ,n l iotrrLlr r , ) , cr ize o]) i l t 'p i i icLf corrr .u ls i r . i r gcrr . l i r l izr l r ,1 ,i,rf i rr lr i{)cLoiricc inlsive) ; i ln sinr.lrom atolcbolos crr cr.olrrl io ploglr.rrir;rl l l i r i r , r ' t r r ! i1({ ,1, t t ) i .1) . In rni l iot i ta l ,c i t c, tz l t r i lor , S.L, . I . i r i r l r rcr , i r r r 1 r r r r I r r r r I , ,r I r ' . r , r r i ' r ' r r t i rrior:lonice fi descriroirl i l l i l( l t1o poliv' i l fut i- r l l( l{r rlrr i l 1"' r ' irr l r r l r ' r r i s i : r r r tc do 1i l i sccnndc ( I i nr lcr .mecl icr , , 19?4 I l l l ,s i r r r r l i ; i lo l r r l , ,l l r r ' l ) .
t i fn t n t+:.fakryt ctt iu, 'nioclottici i cu, lt i .1t xr,r iL'rn. ic (It.1l.L.l l .) (funlr lrt tl l , ' i7 irrl i lni irr (le lr,selnener] rnioclonii, i i{ losoa rnlt,si\.1-, ("irt l,ssivo rrrr ',,, l ,rrrr j i r l is'r). r\ i l t, lcl, 11r orzul.i le in caro sp:.ts]I lole int0r,esolr,zli ] ' l lLl,oil {"t itr l rrr.
l r r I r t : i r , ! r ' i r t t i , so rc l l izerzi l i tspcctul do ln ioclolr i i mr)s i r . . t l , 0rr lkrr i r r orrprr l r t t1, , 1r p l , i r r .L { ' lexi t nrerr l i 'c lor snprr io i t lc ; i cu l i lc-x in nrcrr ib lc lo l i r r l i , r ' i , r : r l r . ,r , . 1 r1111'111-5, . , i r r l r rsrrnlrht : i t i tudinoa , ,1[ t ,u1ui in LrNot] ' , (x l ] ] l ] i l r l , i l i r , r l, , t t r I i i r I r r t l r l unrLi b l ie i : r r ,g ' ) ( t iasl , r ,ut ; i col : lb. , 19i i - l ) . lhoi , spi l ,srui . lo i r l ,r 'rr 'r,, i i { lr)i l ,r ' rnuscuLltur': l Lr'utchiului ; i a l l idircirt i i rrrornl)i 'clor', f l( ' r ' ,,r l lj : rz i1 rprrsnt i l l i l r i ] - l izomoj i { t , c&r 'e i l ,1, ,sr . . r s! r I i1t l ' f l r1 i : rzr i ' , r t gr t ' r t r l i r l r r r r r . r l r . l , '
, r iz l t rL i r ; i r lo lL icrr r iusiye (r ' rnI 'oclonic jerks") . ( lo l n l l i I i r rcr ,crr l 1 i r r r r i r . rLrr l1,rr . l i ( , L i } de spasrn (pi l tcgt to l r iorLic pcn1,r1r l )o i r l i l l r r i \ \ rcsl ) ( \s i { l f , l ) i r , r r l lI ' . ' , i , ' (T1)() /o din c i iz l r i t lupr i ,Jcovons si i ]orvcr ' , l l )?4, r i t i l r ) / , r l r rp i i I 'op rr i
, r r r , i iur l r l ; . r 1 l i7( j ) , i i t r re const i i i r r l . r ' l l l l s l ) i lsrr) r I r i I ) ( | I r ) r I i ( I (J ' l r \ o( lorr( 't , r l . / l ) r ' l isu, soul t , fu lgcr i i |n, ' , gotor i [ l iz l [1, , ru I Io: . i r , g i i r r l r r i , r r . l l t r t r r ' l r i ll r t r . i r r t t r t r t l r t ' t r lo l i t t let ' io: t tor in yr t rnt , ctr l l l i t . l tkr s i r r1, l t l t t t r r , l r i r r i r r r r l , r r r r r rr r r l r l l ' , r j i r t t l t [g r l t r t i r . i r , s i t l6t t t t tn i t ' r . l r , r l r r s l l rsrr t , ,S: t l r r . t t r t " s lu , ) I I I r | | { r r ] , r ' , It r t1, l " , i t t lnrc i l l r ,nslrnblul pozi l , io l r l i , l s{r i l r r r i l l l i i cu salutrr lor icrr l r r l , , f { r r l r r r r r r" .
\ l r r t t i i i r r , r ,ccsirot l t t l t r i losl , l i l ' i l i l sLrgr l r ( i r r l r t ' i i i ru l i r , r r r l r r r i t r l i i ) , t r . i r r ti l u l r l )s i l ionrol ior ic ; r i i rs l tcclul I i l t ) ( i c l , r ' i i t l ,e l is i , io ( , , l r ipsir l i lnr i r r" r i ; r r r, , r l i r l i l t r i r lurr f i tn l , jot ' i " - ( i i l r l ls s i coiu1.r . , l l )54; ( iaslrrrr r l , 1 i l t r , t r rotrr l ,l1 l , ) i j ) 1 l i l ) i r l i l ,z i , i l l rn{)r l ( l i l i ' r l iagt t l )s l , i (1r t l .
l l . t l l iot i lu i i l t foprrrz in l r i , o yrr , t io l r r r l ,o r lo rni0olort i i , ( , l r t l lur I r 1r ; r , r ' l r r l r ll r r r l r l t ; r r t r r i r r logi t r , i l sorrsrr l c i s i r r l r ' j l l r r i r r r r , 1 r , r r r r I r r I r r , r ' r ' , r , i t r r t t r t r r ' , r l t t t , r , l r r1, ., r r I ' ' ; 1 r I 1 1 I I i | , 1 1 r I i 1 1 , r r ,q.r l i i , , s1,r , r ' r ro l , i ; )1. l r l \ r iv( f l r l : r r r l r ,s1,rrr , r , t rs l l r l i l i . r ' i i i i r l , r l r rl |1r r ' : i r , | | l l , l l I . i l r ' r j l0 r i l l0 l ) ostr i l r r { i i , / r r r i r r , r l r r ' , i r r g, . r r r . r ' t r , l , r ' i i t r t i t r
' , , ' , r r r
r l r r I i I r r , , r ' l r r . i l r r r l t l r t , , ; t . ts i r r l i t t t l r r r , l t rLr , i : r ' l r ' : l r , r l i i r r lLt t : t t t l $r)r l l l l l l( l r r |a r , r , i r l . t i | r r l r l r . , l l l l i f l ; Srr l t l ' r ' t i r ' , l1){ i i ; l ' r r1r rVi i r i t t 1 i r ro l r t , l r . , 11, i i l ) . Ar ' ( , r l ' \r r r i , r r ' l r i r l i l i I r r r i l r ' ( t r r i r r l i I r r t i r ) i t r l , r r t ' r r t l rz r t l r r o l r i r r r r i i i l t l ) r l l r t t r . t t l r r t r . t r , l r l , i r
Lr
l115
r ' ( , r l r l rH(. 5 i p 'ef i ' r 'crr( i : rk, : r r r r r rychi i rJ lu lu i p:r l : r lu lu i ( , .n ist i )Srr rur , . ' , l \ i i l l r_Irr i ) . , l i I ; r l ingt ' lu i , h.r ing(. lu i , a ip lan;cului 6ucal , a i t imUi i 1cu misl i r i i r l lc t rrrrrl,r'rlrt pr.ricclic - retractie), ai gl.oirilor oculari (cu ,,nistagmus', ocularl)r.rrtltrLr, girstor sau retractor)r_ ridicdtorii pleoapelor, rliafragrnul (cusrrglr i0, r r ru. . r .h i i inrercosbal i , muicbi i g i tu lu i s i ;usct i i i d i i lat i r i rncmbrclorj . l | l ] r . r ' i rnrrc (cu- mi ic i r i a le degelelor qi cu _migelr i a l temante r io l r ronal ie-rrrpirrir,{ie). Cele rnai frecvente
-sint_ miocloniilo (mioritmiile) or'ofa,rin!1o-
lrlingi()nc, precun fi cele oculo-relo-faringo-laringo-cliafragmatice, careFirl l)ilaterale,. cu un I'tm de 12,0-180/minut pi care
"sint revel"atoare peltru
a.[u,;!,i,wni ale_triunghiului oliao-dentorubria (&uillaln si Mollaret, 19Bb; Bon_(luollo, 1968i Gastau-t, 1968; 4lajouanine qi colab., 19b6; popoviciu qicolt,b., 1973) prin leziuni yasculare, ercefatitice, tumorale siu tiaumatici... Ill. .Miokinlile. s.au Jascicu,l.aliile musculare sint contraclii muscularel,rii( i(:l i l irre. dc,mici arnplitudine. eare nu produc deplasiri SegmeotaJe,rrrur.se-obserni, Bub-pieLe, _sub forma ulor contraclii-clonice, ieritmicejlrrlritte, fulgerltoars ale fibrelor musculare izolato li caro so succed la inter.ivrllo
^lirccvente qi neregulate. Aceste fasciculatii' apar uneori pe teritorii
rrruffi11s1, alteori pe grupo musculare intinse, chiai gc nelrallzaie. Sint netrrurrrntuate de frig, de_ohoseal5,,_cle percutia muqchiior,-de excita{ia electrieiryi do arlministrarea de ad.renalin5. Nu sint irifluenlite nici do' somn, nieirlo srupolaminl.
. V ulo-araa semiologicd, a miokimii,Im (fasciculaliilor muscalare) esterluoscllitS,, reprozentintl un sernn precoce, revolator- pentru o sensibilitaterluorma S, a fibrei musculare la mediatorul chimic (aclienalini,), consecutivi,rrrxri rlc_rervii,ri (feromenul lui plnngnl prin.leziuni, subacut-croniee gteri -oru.ionala (sclerozd, lateral* a,miotroficf ; poliomielite subacuts qi croiice;r.nr.cl lopoliomiclito lirotice subacute 9i cronico - Dr[Elnoscu si Otteanu.M56 ; gi1ing66i6l ie).. So igpune multd atenlie in sindioamelo de pseuclo-nr.lcrozl lateralS, amiotroficd (Barrd gi Roger, cila!i do Eiser, 1952) prinIrrsirrni corticale (tumori parieto-fron-tale, a,rahnoidito etc.), ln care so poater1)illiza o. monoplegio sau o . paraplegio corticald, phamidald,, inso!^iffi qirlo ltrofii musculare cu fasciculalir, dar. prez-enfa in coltextui semiologi"err, r.r' iz,' lor jacktoniene odenteazi de obicei diagnosticul.
_ Astfcl cls faaciculaiii muscul.are se mai pot intitni qi itj c(ffeea jibtitorfl, lu,i Moroan, care esljo o newaxiti, acuti Ei caro &soeiazi b 6ntoxtulnorrriologio; f2,g6io1l2,!ii, mioc_l.onii, tuiburiri neurovegetative rlo tipul aero-rlirrioi, t,rrlburd,ri trofice qi sudoralo qi eveutual tulburari do somn,
. .fr'usc.iculalii_ musculare. izoJate la nivelul mugchilcr felei pot fi obser-v rr,l;c in sptasmul facial peri.feri.c paslp6ral,iti.c.
". INncep!,ional,d,a ra,r. pot ti intilnito Jasciculafiilo musculare ln potira-
rliut.l.on.earitre qi in unele p olin etri,te inJeclioase fi tasi.cs.
, J,l..ri,std, uneori-fasciculalrii izolate_la basedowieni, la i:rdivizii surmena_ti5i rrntxrri dupd, o obosealS, musculard, intensfl la indivizii normali {miokimiilel r r i { ' r r r t 'ho1).
{i,1.!. ll{igctrri involuntare alternatile, regulate, rilmiec ;i stereotipo
. .' l 'rr ut or_ul.r'a1lr ozi ntir, o-m;$care involuutar; rapidi, sf orcolipit, rIc irtcn-si l i r lc v iL l i r r i l i , prcr lo Lininr l la nivclui c-xtremit i r l i lor . Sc impune i l i lcrcn_I i(rr(rir, lrrrnll,toil,rcktt' ,formo semiologice fi, pa,l,ogenice :
.1. lltrentlLrdlura ila posturiL. (a,ry1,-zisi1, ,,do lcp&us" -- lolmon vechi,tlrv:0trrx.llrttrzriltrr') 0sl.o t.ltrtltl t,or.iHl i(ir'1, lxtnt,t.u sirxlrotrrtrl rrxlrlrfrjt,tr,rnirllri
'| t0
I r t1t l I Iotr i r ro l r i lxrJr i r r r , l , ic ( ; l l r r l i i r rsorr i l r , l r ) r l r r r l ivcrsrr r r l , ioplr logrrr i i (poslorrcr ,l r r l i l ic , r r i r I 'urrr I I r l ' , posl , lntrrrrur l ic , strrr i l r r l ,c . ) . Alr i r , r 'o l t r r r r I ' r r ( i r I r , r ' r , I l , l l rorl r r rz i ( i i ( i t t r t l t ts iv i r r l rozi{ i l t t i r : t t r l t i t us), cslc t i l t r r i t r i r r r lo I r r r r1r I iLtr t I i t r r r r t tor I ( , t rL l , i 'h,r l l I t r ' r l . r , r r ( i i , r r r i r : i i , (J l { ) osci l r , { i i /sr ,c.) , r 'o i , r 'ornt ' l i t : i ; i l l r t , r l r logr.s l , r r r r l i , ( i r r r i l i l ,r r r r r r r r r i lc : r t r ( , i t t t r i ; dc l rutni i rar ,c n l tarr i lot . , t lo, , f l r , r , r r r , , i r , l r i l r r | . lor ' , r l r r l l r , l r r r r r: r lo l rc i crr r logel ,c lc c i .c.) , d i l r i t r r ro lut i , s lnrc l isplrc i r rcrr lstr l . r r r iqr , l ' i , r . i l r r t . l rq l ivr , ,l irrlrursilicii la cmof,ii qi tl isparc in somrr. l)c rnlll i,o ori irrlrrrrrsclzi, rri
, rlrcrrril ir,t;o:r, ccfalici (rniscIli ,,tlc afinna,r'cr) sau ,,rlo rrcgrr,{irr,)).:!. ' l 'te n.ulr\I,ula intenlionalii, (d,e a<:! tn,nt) ap:rrc il sirxlrorrlrl rrr,rr,lx,krrr
irr lirrrpnl nisclit.i lor acl,irjer, :r,oceritnirllu-sc'progrusiv otlairi rrrr rlczlollrrr,r,lrrrir.r' i i l i i (ovcrrtual tlori,r lrr, slh.qitul rniqcirii). Ilstu rnai arnlli ' l dtcil, lrr,rltrr.rrlrlr Jlrr')r insonitr,n[, rrereg'ulatd,, rlisparc complet in reparrs qi Irr rrrt,rr{irrorr.irrrrrr.i 1rostuli. Se insr:feste de alto sernne corebclolse.
:i.. Tr.enlurdlura optoz,l]ion alii este tot o trcmn.rii,turir ilc rr,o[irrrrc, rupilrrrl lu sfirqitul uriqcririlor activc, da.r' esbe constiluitl r)in osciLl(ii l irrrr.lrrrrIrl,lr, (iir niste,,biit{i,, dea,rip:i, ca?e tind sii indeplidrczo rrrflu[)nll lr,nprxrtivlrlrr obicci supcrior) dc lintii (de unde tennenul tlc ,,oyrozi {iortali ' i," nrru rlt,,irc1iu1ro antagonistL"). Este ca,racteristiczi pentm sintlroa,lrokr rlcrrt,orrrlr.t ' itro dc, diverse etiopatogenii qi pentru degenerescctll elo helll l,o 0o|rrlrlrrl ' (l ioala lui \lrilson qi pseutlosclroza lui Wcstphal-stli impt,ll), rrsor,iI r r I u sc a,f)roape l,otdeauna si do miqciri de tip coreic qi de spa srirc v iololr 1,r,.
,1.. il 'r.emurd,ttuile permanlnte 86 obscrri,;tit in rdpaus,-cil, 6i ll (irtrprrtr r rl r r {i rcrii r:nor postuii qi constau ln oscil{ii neregulatd ale ilegrt'ck.rr ( u lrooli',r :rlr. lruzelot) de mici rmplituclinc. Pot fi : .fi:-iolcrg ir.r (tle iltosr,:rl,i 11i rl,,lt4t), (moli1)e (simultnil boal* lui B:r,sedow)," lt i pc rii r,itliene, \rt tt,ilittrtrtt.rlrrrric, ln intor'icalii le en mereur, cu nicotin[, cu coteinti. Nu so lrrsol,onc(lf, $('funo extrapiramidale, eu exeeplia ccTor senile.
;,. Trcntoru,l isltric ,si al sirnulan!,ilor trebuie diferonliat do vtrirurl,okrIrrt.r\trlnte do 1,remu$,tufti. Acost tremor nu are car.actelo rituri<,o qi rlu.rvrlilx', eri dimpotriv{,: apare intemitsnt, apare in prezenla epr:otu,trxllor',lrrl o 1l1yq1la, neregrrlat, heterotipie, Iiinit variabil tlela un morncnt; lrr, oll,u l-\lrirlc_fio ln, repaus, fie in miqoare, are caracter net circurnstau I,ilr,l, l'iilrl
rlr.pcrrrlent de_ sil,ualii le emotionale qi/sau levenrlicativo (Soflo1,(rt,, J1r0?).r . l r . r r r t l tc or i sc. insofesto qi de t icrrr ; i , t lc spasmt: ; i rkr cur i lors iu l r i ' l l izrr . r r . ' .p;r l r r r loxulc, c lownieno (Riser, 1952). -
. {i.l.i}. Il iperkinezii bru;te, il iseonl,irmc, rapide, dc ounrolrr rdorrir, tlozorrkrrrrlrr (ncrilmicel
1. . Ii;cd,rila coreice sint rniqciiri involunta,re gencmlizrd,r: (dc ohicr,i).,,rr pr rrrrlominanld, la, fa,t5 ryi la rnrrnrblcle supcrioarc, bruql,tr, dworrlr.rll lo,rIrfir,(,, i l,$irne1;r'tioo $i asincr,ono, schirubintlu-se noirrccl;:r,1, do lir, l lrr gl' ltprrrrrslulll l l l altul. Sinl; va,r'iabilc dc la un monrcnt lir, altul, so inl,rrrsilicir,lrr r.rrro ( ii, l ir, eforl,uri 6i ln cfcclirilrtu, rrnor acNiun i rnrr $cul:llc icllmcl,or, ncrrrirrl(,nfional) 1rlra,zi1,ind rniqcir,r.ilo vohrntalr', ca,rtr dcvin asl,lrrl i lra,tlrxrvll,r,.i ir. rrluLrrcl,z ii, pinr'i, lrr rlispari{,io irr loptus doplin lr pl,i, i l l lrr routn rli lprr,t'.I r r r .o l i s i r r ! l inr i t r r , l ,o Ia, r rn l t t : rn i r ror l t ( l rcrni tnroi) , i r l r , do } ik l i r , l t r r . r i r r r l iorr ,r r r r ' l r . l l r l l r . r t t i r . r r q i . j t tx t t r l l t . l : t r r t i t r ' .
Nf i t t , r i r i f r r r ,or l ioo ,vr , in l thuso )n:q) (lol'rrrrt rt.tu,li i ( tl 'utl.t,thtr,ttt), tr:[ttr rtpltr lit rtrlrii,rlrr ollirrci in1,ro fi lfl
r r t r i , l ' i i t r r l r l r r i l o l i nrrr , l l rocvrr t r l l l , l t r , 1 i r l , i lo. lCrcr,pl , iorrrr l ro ln l l l turnl ,o 11 vl r , l r | ' tr r r l r r l l i l . \ l r r r r r i i l r r r r r r l ru l , r r l r l r r r i l lo l i r l r r r r r t l , ixrr l r , lo.
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, ,...,,'i1...".'.': ' : "..":I I | | | | I | | I I I t i I r i r l l l ) t r l t i r l l . \ ' tnt .ut . t l11, l11, l rJ. . . . r r t . .cct t t r r l t t f : i r tLrOi j i , l r t . r . r . r . t r r r l i r . t , -r(x1r*(,s(r*(lrr so i* .,rrlcxt,I scmiologic al rospectir-ei onc, t.rii in "i ,i
""m]rrllor' (l(r irLloctic gencr:ll[.c) (lort:eo, itronicii a lu,i Eu,.ntington aplre la vir.sti adultti, fiild eredi_lrrli si l 'arnili i l l iJ. cu transmisie. dom;n:lnb,i. Atingc ir mocl'egal ambele
;1,) i . : , , , . i '_ . : " ,11! ] i , . l r 'nr-pl i |gresi ld. b iperkinrzi i io s i r t rnr i emptc, mri, rz i r r r ' . r r : t t . r ,cvl rn i t r tcnto deci l in cureea S.rderrbam, tnr . r . .u l i i ind ntrr i.,rrrrrrricrAt";i mai ,,dansant',. Eruluetzr-r, ;i cii tlnrnrr,ii i f"o.t_pi,,,gr_esii;i i.
...,,1),.., 'r.,-,,r:: ::!rild rp,rre 1lr, indivizi in r'ir.st[, pe tondul suferiniei va.sculare' r r r ' : r l r : . c l e fo , t ( , o , a.oolrnd Ll_se ( ,U f t ,omo r uooj l , | . .em n D i l l rn i r i l lO_r. l t ra_l)iri l,rll idille ;i dc lacunarisin celebrel (inctusiv cLr nerrrrrcile ,rr"ol.igic-psiI r ic i i ) .
., ) (',tttik ?)'on,ice s;mptomd,tice pot ap[re:t in t raurrrJt isrnole clajtio-(.or\.t,t ' irlc sr rr unele clcctalopatii toxice (indeosei:i cLr oxid de ca|botr).ri t.lt slula,rc.
, . . . i ) { ' , t t , " , t r l ln ptcr l r 'upol i i le in lunl i l " r , ,prr . r iUl I r l , ty u l t q indrum
:l l . r i t r l l | | l , :9rr fe\ l qcminlogic c l r j l | rpor l . rntr . ; r , rn,rL, p i r . . . rmidaI, . r . \ l , . ,p i |ami-, l r l { ' . l )sr , ) rcc ( tc l , i rd. t r .c minL- l l r i l ,e\pnl , r i s i r .u c i iz , , opi lepr i6. . . Du obiccir.sli.rrrrbatle D-
-hcmicule c, mi;c5rile coreice liind asciat; artesea, cu misciiri: | l ( . ] r , l tcr . , toal lz inr t o Coreo_eletOZj. 7) . rytre ' r hpnipleqir i Iur est , ' o bomicor{ 'o crr . : lp l l i , rudlu.cbi inl r ' t t l l r l ( .g l lp infrni i lc . . i uneor i i r horr t ip legi i iu sascrr l . r ie. Sr. i r r . , r foslo dcolricti qi de rnigci,ri atetozice.
h.) I{ernicarei,le d,in, leaiunile mezencefaliae (sindroanrcLe de ,n,uclezt,) ttlt r-tll ln.i.oarp snt infertoarc), talatnice ;i ju,nlatalamiu sint tle obicei\;r\('t.rre lr se .ecunosc in contextul semiologic de suferinli
'rclcncet:rlicd,xrr rr ti i lamicX.
.. i) .(.lareeu istpric{i rp:r_t r, Ia copii t1e vilsl,ri scoltrr,X, t1r. obicsi il nici( ||r1.r.'.rlrrr..rTrtrritLcoliTe, prin ,,contamin:lle', psihogenit, do Ia un caz cu col,ee\ r,r'rtirhrlt, Irin,rmitatic- Slilcirrile coreica au calacl,erc to:r,tlalc, apar ir1|r1'r'rrf:rJ sp ecllr 1o.Ijlor, srut mai a.mple qi rnai d:lnsanle;i so evirlcnliazri qi; r | | ( ' I ' ie lnenle Dt ihoqen e.
. . . l ; . t . l . . , t f loc;r ; i ,wnlu,r ta l r : i l iseunt i luc, inul to, rapide, dlr rnut t mnil i | | r i l i t l f . i InHi r tcrool ipe ({ l ! . r . r . , 19-, . , :
, ,/ . Tiaurtle .silt ;nisc,rli inyoluni;are intelmitenie (discontinte), c,Les-lrl ,1,.,,-r,,lrlorrr1rN, corrtplere,. brn;tc, repet:.te, rapide ,,li tle clr:rcicr clonic,Ir.r.rr Lpc. -\cestc acio sillt inoportrlne gl absurdc, ailerea :.ealizind ,,ges_lrti incomplt:tre'r, tloar schifate. Sint loarte cliferite ca morlalil,ate tle"ex_
Jtt itrt rtr. (clipit, jucrnntlrr, blelerospasm, grirn:rse, tuse, rtisucirea gituluisr,r,r , ' LPului, rniccili :rlp_membrelor). Acela;i tic po:r,tg si'r, fie lepetat timp,lr..lrrrri_r'lu_ rr,ni, ri,minind absolut sterectip, pinii 'cind pozrtc sti tl isp:lli i,.r'rl irrrl locul altuin. Ticurile ccrleazii in sorirl !i, la incep'ut, pot fi influonl1r,l,{i rl(l critro voin.fri. Sc exagereazii Ia emobii.
llorr,l,rr. tk.tttri,ktr (a l,ui Gtlles d,e lu Ilourette) so polNe l'esunoi]lbc plil ll t1.z ' ' r r l i r { l r . i i (uI i rnLr l i i I I , ' , gorrer i t l iza1'0, cn pt 'or lorni l r rur ! r i la, n ivclul 1c{,0i.1r , ; - l r l r l lut , i r ,N(,( ' i i | , t , ' . s i Ulr [ , r i lbtr l i - r , r ' i psi l r ice s i 1,uIbLLlr ' i , r ' i {10 vol . l ) i r ' { ) ( ( ]o l ) r { , -l r t ' l ic . i c i roIrr , I i I r ) . l )obrr t r : r r ,z i i in copi l , ; i r i i l , t lc r r l r icc i crr t icLu. i i r , r , r i i r lo, i r i t r i , s i rr , r l i t t r l l r lourts i t ' , po rnir ,sur.r t , lutorrnl , r t i , r ' i i ; i i r r Lr t ) I I t t r . r i l i Ior , psi ! to1lr i , i r r , . Nrrt io { ,otr I r I , I r I r ' i , t r ic i r r r r l l \ rntr r l r , sr t t0r i t r i , i l l r r r .v0lr ,s i , o lgr l , l l i ( : i i .
' l l
: ' . l l rnt i ln l is t t t t l ( t i r t t l runt t l ' ' r t l t t r l t t i
l t t i I ' t11: t ) l r ' l r l lz i l r l i r o l r l l t r ' l '
l r r r r ' , ' r , l | | r | l . r ' r i , I r I i r l : t , t l i sr u t t t l i r t t l r i , I I I t t I I | ' t I I I | |1| I t t r t 1 t I i I t t t I i t t r ' , l l l ( l t r i i l l l, , r , r r r r r rcrrr I r r r ' I r ' r I r ,o ; l t i l r .s i t t i r l i r r locrt l r ' l r t i t t t l r '1t l i ts l t t i l r l t t , i l r '1 i r r l l l t ' l
t r l r ' . r r t ( r t r l l l t t r , : rzr i s i i , r 1t , ' t t t l t t l t t t r r l t t t t l t , i t l t I I t I t t t ' I r i t I I t I i . St ' l to l t l t l t ro l t r t ', r r t r r r r r . r i t i ( ( ) t ! , i r ' ( ' t l t t r l l l ( ' .
l ) i lu l i : tntul , r i I l r ' I i t t t I , ' r ' tc t io l r t r r r i l i rL l i i ( t r r r i i ) r t ' t r t t ' r t t r l l t izr ' : rz: t l r t t t tr , , , , r r r i I r r , t r r i I r r i I i i ' ( ( ' i r l ) l t t l \ i t t j t t t t t tx l s i t t tot t i r r t l l l t t r t l t r r l r l l l r i t ( ' i l t t t r r i l r r t '
1, , ' r1, . , l r l r , i r t r t r l i l i r i r t l l o cvol t t { io lc i t i ptol l t t rs iv i , .
{ i . t . i i . | | i I r ' r ' l i i r rczi i l r . r t l r ' , I i t i t t ' r r l i l t ' lc t c lot t i t '
1. . l l t l , t : r l r ' l r lcz i t t l i r t l tJ l r ' t l i i t tcz ic t l i ' r t i t t t ' r ' i r t t l t i lc t r l i r l l r , i l t t t i ' , i r l i ' i t, , , r , r , : i , r , r r t l r l , i | t ' iz i t t t l r r srr i r ) ' j l l In i fc i i f i i l IV{} l l t ] l l r l l l ' t t t t t I t t I I t t t I t r , l t | r ' r l , r t r t tr r . r r r l . r i : r r r c l l l r rs i t ' r ' l r t t t i t ' r l t t l i r r i t t tn i l i i lJ i l t l r r l l r s l tctr i r t l I r t t lcgr ' l r ' l l r r r i i
| | l ! , r , ( l ( ' r r t r r 1 r I i I r r r I i t r r r tnot lct ' l t iL Si l t t ' rn i l t l i t i i , t ' l l l ' i t t r t t l r l t r ' , \ ' ( ' l ' r l r l r ' l r l i l r l ' ,| , r ' | l | | l r I i l | r i ( l ( 'g( ,1| lo l s i rn i in i i : t l i l t r t l i l l i l l l l ( 's{ ' r ] ' l r jzr l t t ' , r ' t t r l t ' t t i t r ' l r t t l . r r
r , ' r r r r ( l l l r j u r lcgt ' ic lot ' , t i tLt l t t t t t t l i t t l l t r r , ic ' t ' i t i r l r t l l l t l i t t t ' r l r r t ts i r ' , 111"1r ' l r ' l r '
' ' r lLrLr l r r i r . i t r t r tot l i r t t l r 'pct t t let t l , i t t t ' i lc i lc , t ler t iv t l t t l t ' t t t r r t l I i r ( l ' i r lc l r ' l l r l l r l l ,
, r r r r r r r l l . r l t r l l is( ' r i r i v i r t ' i i ) l ) i l1r l tot t l r ' t t f icr , t l lc t l in l r t r cL' , t l t ' l t i1t I t I r l . ' t r r l i r 'r r r r l . l l t ' r i r r l i r l { i r l i . l , i r I i t i l r t rn i r l l ' i r l l r rs i t r l ' l l t t { i l l t t t i t i s i l ' l t r r t l i l t t ' ' t l r t l tz t t r
, l r r ; r i . r r r iscr i l i r le i r r t ic l r r i t l l r tc l t lcgr i t , lo i l i r lc t l i l ' i . i r t i t l r v i l l l l l t t i l t i l iot t t l t r t, r , l r l r r r . i r r iut t lnr , r ' i r r t l s l t l r j t t a1rt i i , $ l t t r l t t l r i i fc l r : i ; i r i l i t t t t tot l ( ( , r r , l : r r r l ,
r r r r r r r r t i , r ' t . l r l iz j r r t l r t rn i i r r i t , i i t l iv t : tsr fxpt ' ( .s iv i rougt i t t i i ts t , l t ' (x ' l ( ' t t l i l i | . i l l ( l i r l r 'I r r r i r { .1)r ' ( 'v i rz t t r , i ln ' t t t t t i i th i i Si tu l i r i leal izol lz i r is t r l r i l i i t t r t { i l t t r l t l t r
, , , , 1, .p l r r i r , . i t r t ' rnstr l r i r i ; i r i i r i lor , h ipt i l l i i r t lz i l t ' r t l r r lozi t ' i i l ) i l l i r r r l , i rzr lr r r .Lr I i I l r I l ' l r l rc1iv l j : r , i t t t t lc t ' i t te i rnt iccvl t l i , .
\ i " l f )z l l ) { l r i ( ' l i t tn. i lu. l r t t l . i s t t ; r t l t i l r t . ler t t I r i , lu ' r t I i : :u. l r i . s i \ t t t l t l t t t t t l t t ! l t t
r t t t r | r r t i i t r r r t ' i l t l i i t r t t i t l t t r t t t : l t t i l t rst i I i s t ' t r t i r I logi0l ' , i t t t l l ' , rst ' l r i t l i t t r r | t t r r, I r r r ; r i l i r r r r i r l r i l i i .
rr) l tdo::rt , dubti i ' (st. : , tu.s )u Q,t t t to'a, l l l* al ht i l t o! l l . ) t ' r ' l t 'v i r lc rr lr t l l i ' r
,1, , ( i rnr ' ( 'ong(f l i t r l , i , , sr t l r este col lstroinla, nt l t l l t r r t t r t r f l l l i l t r i t l t r l r t t t t t t ' i r ' , r ; r t
I r r r r iur r l lnol sechclo ( lo e1I( ief : l lopl l l ' ic inf l t t r l i l i i ' ( i l r t l r , l ls t l r i l ) l i l l l l r l ) . \ r l
' r r : r l l i I r rc l r i t i r reout la l i ) . l l l rcol i c.qic i tsoci l r l r ' i l t t o r l i l t ! ' i1 i r , I r i I ' I t t t t i r I I r | : r t l r '
t r l r r r l l ro l i i lu i l , i t i . lc , r 'u lu l l ) r ' : i r i l ls i l l i ( ' ( r f i 1 l ( l ( rs{ ' i t {1 l r 1 ' r ' iz( ' (x, t l \ l l l r iv{ ' .
l t ) l loalu. l 'u i l l r l l l r l r i lut f l t l I : * i btul t . l t r i l 'o t l r i r t l r r l i ' r ' ( i t t t r i I ' t l r l lr l , ; . r r r r . t ' r r l i rc iatni l i r r lc (crr i r tst 'c i r t { r t ' r t l t t ' i l t l r td i i } r i I r I1r ' t r t Io I ) r l l i ( l r r l r r $ i : r ( ' r ) t
l , r r l r r i l r r i l , l l l 's) . , \ l ) l r t lnpr i r t t t ; i t r t ' t ' i l t t t l I t l t r i t i t t t l r t t t ( l i r t t t t i t Vtrgi) r r r r t t t r
, , l , , l r r t l l i ( ) ro l r l r r l r r i J l r t l l t , tvotr lct t -Sl) l l l7) , i t l l l ' l l t r 'o l l l r ' \ l N( ' l r l i r , ln l ' t ., r t r . r r ; ro| i l tz i : l t i lx ' t i r t t t i0 qrr t rctr t l iznl i i t ' \1 l t l l ) i l i l l l l i ( l l l l i l , t 'ot |o t l r i0zrtl , l . r1r , r ' r r l i i , ( i t r r , l r r r i r ' l i r tntrrrc l t i i i i ' ( r , i ) , l i r l l l t r l i i l i t l t ' t ' t t l l r i t r ' ( t l i r l r rg i r ' " l t i r t l i ) 'l ' | l r , ' o( 'uL| l l ] r . r i t t t i ts l i t , i t l t t l i i , r r l t ( | i i r r o l t f i t ' i , l ! ' l i l ) i1 i i l ) iu l l l ( ' l l l r l r r r . t l i
r r r , r r { r r ; r rugrtr iv l ' i r1 i t . r i l r rs ( i r r c i l lvr t l t r t t i i l l i r t t t t i r i l t l r r r r l i l i l i r l t t i \ o;11
, rr r l i i i l r r i r r r i i t t Iot t t l t , . iuvct t i l i i , r t , l t t i l l r t lk ' t rot t l ( ' l I i i l ) l t lz) .
, 1 , l t tLt , l i r r pol i r l r , lu l l t i tn i i I I t | ) t in 'u i t ' i i t r . l t r i t r r t t Ikt l r t r t l cs lc o rr l to l t l,1,1, r r , ' t r r l i r , i I l l i r i l i i r l i i ( t r t t i i ) , r ' r r t t t tsol i i tz i i : I t i1tct I r t t t i t r r ' r i t r t l t i t ' r t t t t i t l r t l : r
r , , r r l r ' l r r r l l r r I t t r " t t t I r I t I l , i t t l i ' t ior t l ' ( ' s i l t t t t r l t ! r ' r i t t t t l ' t ls(x ' l l ( l ( ' l l { i i ) , l l i | ( ' l l \ l l r |z r l
, r r r r l r i l l ' , ( , r ) l t t I l r ' \ r , ( ; t l r ' lotr i , l r i l r r ( r ' r r r l i , s ; l t t t t t t l ' t l0 i t t ts i t t t t r ' , I t r ' t t t i I r : r I i , t r t )
r l ) l iu l t / t i ( t t r t l ; l r l r l , l r l i r t l ( l t r , l i r tnt t ' . l i r l r t l t r t l . i l l t t r t t r t i l t int t l t t t l t t l t t l t t t t
, I ta l ; t l r l ) ( l i l ' t l t . l t t t l i . l i t t t t t i i t t lxr , t t l i ) i t l r t t t t ' l r t I , { i I l ' ' r ) , I I | , ' t l r ' v i tn i i r r r r r . l
l r r , ' r r , , I r r t r r l { I r ' | { | | t I i I l l r I i t l r , o t t t l r ' l : t I r1r : r I i l l i t r r I r i l t t cvolr t l i r , lc t r l l i ( ( l r t I, l r r r . l r i l r r l r r l r . , | ! ) r ' i I , r ' i i r r ( i ( | ( , l ) t l i i , l r r t l i i i t l 1 i l ' r r . j r r l , l l ) i l ) t t t t ' t r r l t i r i l t t l r r r t r l r tl r r r \ lz l r r . i t r , r . : \ r i r r r r r rz; i t t t l r t l r l r r t t l r t l t t t r r r ! r ;1 i r r : l i t l l r t t l ' i i t ' r { l r ' \ ' r ' ( l (^r l , ( t r l l
l t )
l ] l1i : : . i : l i l l ; ,1' i : ,1l lu]1,1,1t, ' , J,r.()Ar'csivi i , rrr iuctoui i , at irr i i r . , t l izrr lLUo qi rtr . rrrrr r ,lll',,]ll,llt',
, ' ir.t otoz rcc fi 0r'izo corr\,1r lsiyo. llvolu lia osre rrpidii ( | _ 4 rrr ri) spr.ir
. t ') Ilncr,lalqtotid corsccutiDd, pritrobtastozei .fetate (i.terut ntralear)tUut. tnt,t.ntp((ttntt,tqk dc Joet0/r _Eh intrutre:te de fo:lrtc multe ori in tablouli(\rrU,)i glc col.co.atel,ozi, bilateraLi,.
- geoer.alizabJ,, ,sociatd cu spasm de
].::lll:lll,:l Llt::':ll. ."".]lapiramidalni ar,axie cnier"ioaJ? l,erraparezi,{ ( , rvt srr o l , r t ( .pt lco f t det iCib in ic lpCtual .
.,.",,{] 1,t}..1:1. dltrt{ m.al poate face.parte. qi_ tlin cortegiul simpromatic,:l li:i11 iJ"i/#'f# ;#i'fi,1 ifi ll$T5lll,lil:l*,Ll"",^fi i;Hf $,.1"",*f l,li;(listnnin lcnticulard,, corcea iui-Ilnntington ; .r"ao-oi"iI, cerebeloasb.
11 ),Ilamiatetoza esto rezdtatul unor leziuui localizate, care gener€azajiil ].lli?l .ggt"togic cu hemipa,rezi,, silriro.ln t aramic qi'nip"rk'inezie der r p
.i) l r.riuzr(. (Bjl.u. coreo-atel ozic). La copii tablouI a parr. dupL tr?umaf igme,, i )srrLlr( ,J lo gr dupa cUcr. t i l l i re
. ( ru jeol icd. .scar lauinoasj , . L.ulreol ic i . dupJ,l rrst'. oonvulsivi,, .diftericd 5.a.), La ,aury;.,',Je JUi""i-u*i"'to"*ucutivd tra;u_lii;l'':ft]'$' iitti3i,T"Lo"""'
accidenbelor vasculare cerebrale ryi exceplio-
(',!. I)IS?ONIILE (SINDEOAMELE DISTONICE SAU DISTONIII,,E KINETICESPASMODICE _ RISER. 1952)
,'lirrt mirycxri involuntare cu caiacter tonic c:!re teurizcazia o atitudinepllti':Il;tr]i, cnrc se mrn!ine un timp rrariabi] (citeva *""aro,l" *uo mlnutet.l,r'rrr ilrpcl r,irnra mal mult sAu mai pulin durabild, pe care o induc. SpaSmriilll"j:,.::--!]lli lll,.!ll, !o Tgp:t1 in frod_srereotip, f1;arie lrlcvent qi -adesea| | ( . o Ur i l lut i t suOrotr i rot t in to l cursr i l s t , l r i i de l ,ogl( , ( l lnpol . i " i in sontn).. \ r ' r . , - t r r r l . isroni i ,k iuci icc pot s j l ie.rnaj mult s,u-urr i 'pr : . i ; ; r ' ; " , : ; i ; ; ; i ;i\ir,l l /ix?/,3nt.. lJe obrcer se insolesc,1i de hipe.r.bonii e.rl,rapiramidilc, precumrii rf rr- liipolliinezii, Aceste distoaii hirletice tealizeazl o'a"phr*"u'*'"g;""_l . : ' ] i . l l : , I i .
{ lnrur i t i i unei contrrcLi i spasmodit ,e lorens" a $nrp, , lo. . , , iuscu-r jUl ' r l r . ( ! r ' r - f i ;11(r ,conl . r tct ie-crrrccstcprogresiv i . re[r , r i1.dur; l ) . f - . ( ,aractcrulr(!l)r.r,rr,lr/ itt mlfcar rnroluntars realizate so datorreryle unor varialii nein_rotnlr: rlc tonrrs mrsclhr', bmsc_diminuat _si apoi din nor i:msc exagerftt.n {x,stc rtcplasi,ti tr)nioe a,normale sint ritmate qi oarecurn stereotipe Iartrxrlrr,ri bolnav, putind ant.rena cu yreme& deformalii scoliotice qi aiiicu_Lrtrr. Nu slnt $on,sibile la preparatrele cle tip atropinic.
(i.2.1. Distoniile kineticc localizatc
. . L Torticolisul spasmod,ic prozinti urmitoarele c&ractelo semiologice :llu Bptsm musoular tonic antrencazii, o lonti, rotalie qi laclina{ie vicioasd,1r, ol,pului, ou o contraciio a muqchilor stemocleidomastoitiian qi ttapez(ovonl;ua,l. qi. o_ piolosrrlui gitr ui do acooaqi parte, .rareori qi r murichilolitrvocinrlri ,i glbulrri). uuor:r'i rxruLrac{ia, tonicrn a color doi n.rry.hi ino'rrrr,t,i{lo (pinull oiri,o billtorluki,, il,r: cu,prl to flccto',zil 1,oni(r spro u.u.fI (rol.rrrcolini.
20{t
\r'rrrrll 'ri, rrorrl,rlclir lotrft,i i ltrlrrlzi' l, l l l,rrnl rlrtprl o trcrrr'1il, yrtu'irrirrll l, (notrrnrlr,),, r r ! t t l l i t r i r , i r r r l xr t r r 'v i r r r l i r r lxrz i l , i r r , r rorrr l r l i \ , r l t r . i r r rcr l i r r , l , lo l r t .or l t t r , r r t tn rr l i ,, l r r r l t t ] , ( f i l r r " l l r .prrr i r .ct . r , l rz i i , l r r lxrz i ( , i r r , v i0 io l r ,s: i , * i I11l l t r t ' l l i r l r rprrrhr, r l t r r r t r r l i ,r l r , r ' r r i i , o sol i r r r lc osci [ i r , { i i Iotrkr , i r rcgl l lc , c i l rc ] lo l , l ' i rn i r i lc r l r r r , f r1111,1 1u,1t t , ,r r r l r r i , c l l t , r ,on;( i r . r r { , s i ! l r lut , s(} o l lut l t l l r , r l t r l tL lsalc l t , o l rprr l t r i , l t l i l r goHl,rr lr r r r l r rgorr i r l r l r r cort l \ ic , rn i l i r lcgrt l l i i , s j r r rJxr l ic r loci l , o l ic : tco ( l . i , iBrr , l l ) f ! :l l r l l r l l t , l f ) i r i ) , c i1, t r , t . t l t $of l r r l i r t [ , 1$( i7) . J3olr , l l i lp l l r t r lo obir , r ' i l lu l r l l l ( i l irrr.r'|Iltoh)r lrrrrgltrsiv. lr:i, trn it(lolosoorrt tto Vorn gi di irt f itnLrl rltrrl l lr, ,r, rrr', 'f;rli lri oltidcrrrioi, sitn l[ o seclttrli i, postcr rccfa,li{,i.i i, rnlt,i i lkrs rllroii, gixirrrI irll lr $culno rlin selirr, exl rrlpirl,rrridlli i qi dacr'l plr:zini;ii, gi r:r.izc rrcrrlogirr,r r,vrrrtur'r,l - pareza c,onvcrgenfci globilol ocula,ri.
f,)st,rr rlu o dcosebil,i i, irnptntln!ii, practicr-l tl i l en!i?r'm ,i :l l itului,ltrrtttttotlit (tlc ori.gi.nc e ra,piramlduld,) d.t: aLte J'orma dc turl,ir;olix, r.lnpfi, rrrrr lrrrrrti:r,z:i: a,\ l.lorlicoli,sttl con.geni,t&l csto perrnnncnt, irrstl{il rrtr0rlr,ir rlr. rrsimctlii trl.nnio-fa,ciale. Acest torticolis congcriital loltro I' i i:ol,vrrlrli l
ttn',t nmllatrnatii crutt,icne, ocr:ipitale, ratebrnle sau, nru,trcu,fuxt (rlrr olriru,i,,r irfcrr{iabile ratliologic) ; b) I'orticol,isnl simptomatic cste rnnstxrrrl,iv rrrror,,'r izr. loc,ir'le : tnimitd, localli (roumaticit, virol,icd, atc.\, red,i(rtLilii uroi.aqllrultniot'it,s1ton.d,i,l,itd,, arahnoirli,td, ceroi.t:aki, ln acesto situ:t,l.,i i, tol.t,iooliHulr,rrlr, irrsolit tlc durcli in muqchii contractati, dlrreri cilre dc ,.rbir.ci sinl, r.r,rr, , r'b, I rr slu dcclanqatc tle tuse, de stri,nut qi de migcilrile oapul ui ryi:llc gi t,r r lr I i Irl I'rri!,ii.le aici.oase ale atpztlui tleterminate tle l,umoli ale losci postoliorr,rri'. r rl '. L.ziuui vetfehrc,lo (dc^pildii, un morb Pott cervic:r,I, o ftaciurii, ru,rvi, rrl:i, ry ]11'111ip rLscalii etc.). jn aceste situnlii, de obicei tottiicoli$ul crl.o Iirrrlrtl lr.r ic.irnintc, cu inclinarea, .laterali, a capulli), tlacl nu drrfil it iv, ccl prr( irrlrrrrp rlc. srlpt5.mini, firl exaccrbilri tonico, filr 'L manilit 'stririle spu,strrixliloI rrr lr,rr ii i l icc ;i rapid intcrmite;nte, o& in cazul vcriljabilullti torticolis slrrrnrrr,xlir... Si!u, elrerrtual, :ttitudinea vicioasii a capului (.'s1c par.oxisl,irr' l, 'rlrrl,lrrlr';rzii, citcva, orc, so ilsoleqte rle ce{alee brrifall;i tlc vir,r,srituri (ciizr,hr'li' ,.r I r rgxjiir€r') ; rl) It'alsul torticolis spasmodia ad,re insole,ltc, 3u11, axtr(J s(u .tl.t r l .t i net:ralgii a _m.arelu.i nera occiptital al lui, Arnold,, se rccunorulo rr4r rr,,,lr(' ir I,incrtr sea,ma de ]ocalizarea durerii qi de scmnelo dc a<rornpir,rrirr,rr ri,rr l,l,l ituur 1i ntliologice) de lezirrne rrtliculrr,r' i i ('r-('o (rr11r'rrze, rlirtrt,lcif irLl,r,ilrr|rr.lizrr1c, ]riperostoze, deform:r,]ii ale lNrlui -
olos ctc.) ; ri) ,I,ttt,l,itnliyLtl,,rrrric (r'echiul torl,icoiis mental al ]ui Rrissaurl qi }krigr', ci1;rL,{,i dc liirrrr',l lrl,2) $o_ r ccunoaqte uqor, plin car.acterul atipic (pozifionu,l), l l l in irrkrrrsi"lrrlr.,rr, ltrll luri,rii (majoratii r1e enrclii), pr.in callcl,enrl inttrlrrril,trrrl, (iru'{il l,r (l(! rjt,luo{1, anxioasi,) qi prin depista,r'ca faoliot'i lol psilrogtrni ctruzu,li.
!. Spas,nul ntonoplagi,c (Jiiscr, J 952) ('Iorrnt'n incorcct,, l l.l l. ,l\.rnr(\nulrrrri oorcet ar fi ,,Spasm rle 1;orsiurrc lrr,aobil,lt,). Actstn ilt.r", irr 1yrrrr,r,rl,| , ti r(1lirlo similir,r"c cu tor.tiurlisul spasrnorlic, da,r'otr loonlizilr.o ll l urr rrrrrrrrltrrrrrrr1r.r'irIr'. Dsto vor,ba, do 0 nriqcnrc de lorsiunc ircestui rntirnlrrrr itr .irrlrrlrrrrrlrri sIu, dc pronrl,tic ;i i lo supinl,tio {orltl,: 'r, l lt,rrrnativitr, r:u, urr Icl rlrr,,rrluliu(r') i l lttnrrrr,tivii. Oorrira,o(,irr, spirsmfiljci[ esle lehljiv lcntil, qi plogrr,.rrvir, r,!t '(tori cOvtr, rnili r:tpidii (d1Ir niciodnl,li, 0u r:il l i lctc|ul d0 brusr;hoh,lotr,icil), l lstfrl incil pozi!,ia lnorrnlll ir, estc nlrrrtinul.il oitcvt, sturtrndo Jrlru'll r r . r ' i tovl , r t r inrr l r , , p l in l , r -o , ,h ipcr.1,onio r lo l ro i t i ,u l t ) , , ' ( l t iscr , l { } I?) , Al l r inrrlrrrlrntl srrllrrr,iol r.r,sprcLiv rtvinrr Ll loc, llr.irr trlitrx ll t(yr rrrrstrrrlrrl,trril.
' r r l l ' l r ,Ht, i , r looorr t l rur{ io l i i r r r l t lo rrsrrrncrr t , r r , l t rn l , [ ( in ! . - I i n lcrrrrr l r r ) , r l ru r1tr ,6r i ,r rrrrorr rlltrl,t '[, it t1r'ttcil lr rh.o l,in tp xrl v irrr, l l rr lrou Hpll l{|l], t,l,lr r1\l)iJl,l i r,()l11,fl,(]t,i l lu.; t t t t r t ' t l t t t thr . (1ru I i l t t t r t tzt t l l , ( ] r l i ( ro l imt lu i t t l t r r .xtrrrx lh, , , { t , l r r i l )u l t t r r r r r l lor t r t , lo.
201
l i t rv iz i i l i ; $ l ) . l r i t t t t r l l t r ( r l t t r ( ] r t ' i l , r11.r ' i lupir | i t , l , iv , ( io( ] ro i l i \ ' , i rur i l r r i<, i v0irr l r r , rr i { , i l , r ,st , l l t i r , t r io i rn i4cl i l i l r r i r r lc tL{, iorr* le s:ru aut,ornatc, t r ic i rn lnovrr : lo i loolrlirr^ ll spllsrrrului (irrclusiv r.[on3a1,ii] ltclivi r.,:in p rsirir'r, rr, nrcrnbrului re$-1rofiliv) rru llot suprirna spastnr:lt,. T)oll sornnul le abol,5te.
. r\ccst slastn brahial ap:r,re in sti,ri postencefalitice (de obicei), in sufe-lil{o \/tl,sculare, tra[maiice eti],
{i.i l.2. 1}istoniile kilotice gencrnlizatc sau cxlinse
.. 1.. lJpasmul de [,rrt;une. (tlisbutia, lord,otit:ti a, l.u.i. Ziehen *i Opytt:nhcim ;tl,i:tlotr irt l.entit:ulard, progresird, ) prezinl,il douii elt'melte somioloEice : dis-r , '0 i ; . r i lur i iun(,1 ( l la. . l i . r . 19. .3._ci t r t de Soi l , . ler . lC6ir . . \ . r fp l . i i , l rnz; i i r .ri{. ropll,us. iI1 decrLbil,, :rceqti bolnar i lrrr aplorrp., n(,rlDali (cu er-c,,p{iacorriil,atrilii :\lNor eyentmle semne- t1e encefalopir,tic : herniparezri, nins-cirir,rrlcu'ltr,lozice q.a.).,1n momentul in o:l,r e $o lidirii, !l in pet, t-rLrnttriirl iniepeLii sr,irrilbozo in lordozii, crpul se re-rroflectcazit,, iar eOoi, ollatil cn o:recir-lrr\,| primilDl'pa;i, ap*re (sll] se er.rcelbei-Lzi) u I lrurrrro r:le i,onus pos-irrr'rl, o:u'c intereseaz5, atit trunchiul, cit si rnemblcti:. l lolnavul se rii icd,lxr vill irl pioioarelor printr-o e\t,,nsit' a mombrrlor iD{criotre, a,poi trunchiullslt inr:ulbnt in rnod ploglesiv intr-o ptternicfi lordozil qi rot:1i,. lxt€r:nlr,lirrrlr in ou,r'e capul sc plaseaz:i ir]tr,o pozil,ie da tolticolis.sau dc rctrocolis,irrl rncLnbrelc janpcrioarc se r'risuctrsc irr pr.onalio sau in supilai:ic. Acest6riprrsrrrc cetleazii, tot I'cla1,ir; lent- si apoi din troLl l'caplr, in mod alternativ,rrrrliziiul o lernarc.rbild, variabilitlte postuf.lliir cu rtltudini bizar.e, contor-siorrrrtor incit :icest ilspeot grotcsc a,l bolnavului :l fort fo:lrlc llasticrorrl)lrirl (Lc citre li iser (1.959) .-u ,jIraocoon inlirnt ui li,,,j,tu rL. (.ritrc \\iurmer(r'i lrr1 rlc_liiser) cu-rn ,,clorvn mrcirbr.u'). Dil lrricinr lrcestor sla$mer mis-r,ii l i lc voluntare silt inadccyat: si, apllrent, rrecc{)r{1on!,te, -iar
rnelsulcslrr r.rtlem do.cliticil. l)e f:lpi, se prodtic i. ':tl ialii toni{ro (in scns de hiper-s rrr ilt, hilxrlolie) la un grup muscular fa$ii tle alt Lrl iji dintf-un monrentirr rr,ll l l (l ie siruultan, lie alterultir.; inert s-l qi sug?r,rt (,.i lt accastjl []oa1{,lrl rr yrn'ba rlc o ,,dismetric a r',plr turilol f i :i !r ju.tifi lor tonice,' (Riser,l1r ' l ) .
r lr, i j i in caznl boh:Ivilor pr,rkins;rieni st p:)t r€ir jtfol, ;i l:r, aoe91,ilrrrlrrr,r' i, kinezii pr,ra.lox:lle. De obicli rn,rschii fetei si :r,i l irnbii nu sfntirrlolr,r ii i, 11.lr s-::r,u rlescL.is cazuri eil ccintefe3,lret aceJNorl, roxlizinLlu-se :r ' rL \ l l i i r r r r l i r , . l , t l ' lu"ar i de vor ' l | l r 'e . i l io rn yr1 i . . ,11. ,
l)in,. puttct.d,e "leilre eti,op{rtog6??,ic, sepot rlistinge mai nrulte tormedoirl)itrslrt (lo t{)rsluno :
r) I)istonia cle l,ortiltne agu-zisd, ,,id,ictpr.tlicd", ialentificati do unii cu,,rl,isl.rtrt it.r, ,masr:u,lorum.
-tleforrnans)) , ,elte in realitate o boali, clegenerativii,,l l losirrril rne'labolicd, (Wooten qi co1ab., 19?3), de obicei cu c,.t t 'a-cter eredo-l rrrril i rl, c'r,r'c ap.tre ir copiH,rie s.r,u in adolescentil (Eldridge, 19?0 ; Marsrlenrri l lrr,r'r' ison 1974) si cirro poate fi recunoscutti, pr.in evolutir sa ptogresiy-uctttt'. r,l izrt tit .
. il l)isknin de tol"r.iule sitnptomaticri est{l mult n-rai frecvent5 qi aparorfrrlri, srrrr in crrrsul svoluliei rl.nor {LJc.a!,i,toLi a.la stru,cf,urilor entrapiramiilala-rl.(! (livolslr tntt,uti: . A ncc.falitri t:p,irl,enicti (cel mai arlesea) ; - Alte e nctfn,li l,rrl - Il nrrrfrr,Io p tr,l, i i, toni.oa (crr oxirl d0 cl,rbotr de pikli) i - I)e11c.netrcs-)nb lutltolo hnl i.r:t.r,l.rt rc (hou,lu, Lu,i lYil,son;i boa,kt Iu,i, lV e t I, p htr,l,- Striint,p r . )
In r t , t t r r t ,1t l , l ' r i i r , l i , l ) sotni tu t rs l t . r , l l i t . r , t t r i r I r l lc ( iuolrrs iu s l ) i t$ lno { j . l , r i [o l ( ] l . is t i t lol r lo i r r ( , r r i , r r . i i l i , r ' i ur)r ' ( fo . I l ;01,r)z i ( ) t \ , r {Lr t r i l r \ ( lo l i ; l ; l . r , r ' l i i t isrr l i r , r r ) , | , r r I I I r r r . i l , r .
. r l l t r r l l i r I r r r I r r , r r r r I I r r i r , r r I r t r l t t i , Hr,rr r r r l r l l r r r l i , r ' i r r { i r l t r ' | r r I i l i i , i r r r . l r r l l t r i l i r r r u,rl i l l r r r , l r r , r ' r i i , r r l ; , l r r ' l r r , , t t t l ' lu: r t r . r r l r r r t , ' l r r i " , l l l r r l r . r ' r ' r r l r . r , r r l , r I l r rsrrr i l r l r ,, r rz l r '1r i l r .1r( i r , , . r ' l r ' , I
l , ) t t r t . l i t l r t l t r t l i i i t t . l i r t r l i l t \ l t r i t r l t i l r r r i r , t tcorrrr I r r I i i , I r r r r r r r r r r i i r r r r r r , r r l r r l r . i r i, , r l r ' . I r I r r1rr I r I i r r r r r r r s i ctrcr , [ I r I i I l r r r r r r ic l t t ,o l t i l i t i r . r , l r . ) ;
l l l ! i t ' t l idtqt , t t t t i i r , r ( i r ( , r l11'r l is lorr i l r r l I l r r i s i r r r | ( . i r r l r i , i r r r r r r r ' l r ,g i r r l r r , r | l r, r l , r , ,Lr . t r I r i r , ( ) l l r i i l ( . \ i r l l r , , r ' l l0t ' i r ; t t r isc i i t i ( ro l t ' r ) . l r l { , lozi( . r , r r r l t r r i r , . r i r . r r I r r ,1,rr : r r r r i t l l l r c i t . ) .
2. l lnr lc r t i t : t t t l t i I t l , ' l i t r r l , is ] , iu r l . i t ' r l t ) l t l r t )a l r pol r , r l i l izrr l rs l r l l l l r i , ,r rLrrr l r r lo l , I i t r rLt I r i t t l I r i ; i l t r r r r - r t t l t ic lo i ' , r rorr t p l i i l r r { r r r , r t u i l l r , t i i , ( , r t r . l r l I , l t i r . . l. r r r I i t i t l t t t ' i r i l r ( '11) i l l r r .s i s i i ( t ' | ,ze i r r t l r tcsi l r , ( i i t r0 [1] i i tn i l ) [ l t1 i t I I I | | r | ( | i r i | ( | | | | I
( l l iots i l l r r ( ' . , \s l t l r l , arr luntr i l isrnclc 0ircrrrncr ls ivc (s i r rorr i r lc ; , , ( , t iz( ,1r , ( , l r ll , l ' l i ( , ( ' r 'o l r t rJ l i i r '1 , . r , r iz t ' l t r f l ) ikrpl ico t i l r runcrr |s ivtr") ( rot is l , i tU i l r . ( ) r t lt , ' i r ' { ' ( ' l f ( ' i lc l t l i r r i , c l r t lc pol t t r r ut t r i r t l i c t i rnpkr i r i r , r , l r rL l r i lut t l t t r ocolr t r i p l, : r l r , l ro l r tavrr l lc f l t rc 1n j lu i r l s i i . r r . l )c lscmonot, I ' r is l , l i l rbslrr{r ,q i l r r l r r i i r
r r r izr : lorr l ro l i rkr i l c lue gi l l l i : r pol , i ,c 1 i in lo l t r i l , i c t r o I i l rc l lorr i t r r r r i l r r l lr r r l r r ( ( l r rs l l r r r l ; i col l r l t . , . l1174), on]0 i r l i t : i L i r r l rsDerrt t lc s l l isrrr r l r , lo l r i l t r r . .I t r : ' I r rosLir : r t l rc 1r 'atr f r l rz: i t t ;0r ' i l l f i lvOrt t t , t i t r r rc i c l iz t . r , l r i lcpt i t . t , ,1 i r r r r r rr r r r l r r l is l i ingzi i t , : r l r t ] t i larnidalcr pr in a, l t r ra c l , i l ic : i , t lu l r r i , r r l i r i r l l l r lur , l r r ,,||II r ' i |1{IiL sti i ,t i i dc r:rxirl icrrt i si ruiolr}ir l i i le l,11tr (i lrr-rl.rtorrlc.
i i.ft CONVULSIiLE
(i . i l . l . Aspcete sc.rniologiot ' . S1r 'e r l t r isdbi l t ' r lc a l tc rni i r , i r l j i rnolrrrr l r r l r , ,,,rrrvrrlsiikl so pl\izitrtii s lt formi-t, tlc acatBe. ll lo llol 1li y(uutrlt:;rrlt,, tl\t; . r r r r l i r lotal i latc rnust:ul ; l l ,urn, cor l iotal i i f i insol indu-su ct : l r i r r r i l r r l r . r r . r r l ., ' p icrr lcre tutal i srrr rc l : t f , iv t i : r , s i iu i i de const i i t l t t i , s i r r r , r I i r r r1roIr i r r i ,7,,rr'l irl l:, silul!ii in caro intercseazil un gmp rn iir:rtln,r. ttrtri irrtrll itrrI rrrlrrl r 1r l in 0xir i l t s .
l. (lon,mtts i i lc tonir:o sittl re,prczenl.iltc tie conlrrrc{,ii rrrrrst,lltrr, prt.lrrrri,rlr', (r1lr'o atrtron(l:lzat, o stiu\) p[,ro)iisl.ioii ])0 t)ll n(, 1i'i,, tl lrI r' lrIirl lr.ri,r.ril , r l r i , r l r : i ig i r l i ta l ,e, crr t0 antLent ' : rz, : i urr scgrnt ' r r l ( . , , r ' l ) { r l i l l , srrrr , i l i r r r l ro l r i I r r ,r r r l r t , l rgtr , lnuscul , t t i l i i t0tpol : r l l i , JJrcrnplul r . r ' l r r r : r i r l r rorrs l , r ' r r , l iv c i l r , l ; rzr i, l ' ' r 'o l t la(1ur i , lotr ic l gonu'al iznl iu rr , t l i i lepsic i g l l lnr l rnrr l turrrvr t ls i r , l r r r i r , r r, lorricr', itr (iu(', luzilulrll st'c11s;olol si hipt'r1,rxriLr, rt't,l izcilzir, (x)rrvlllsirr lprrir,irr r r l l r r r ic s l , r ] i r r cx1t,r ' rs iu, i r rso1i t : i r1 i r lc o pic l r le l t r lo laLi , r r s l i i t , i i ( l ( f . r l ! l ri t r ( , i .
! . ( lut t :u l .s i i l t c lot i r l s in l rn i6rr i r i i t rvoluni , l lu r l is t ,orrrrrrrr r , , $ l r , l { \ ll r . l , r ' , i l r rp l ( ' r ro1t , l i1 i r . r . , r r l r , l , l t . r11 r ' r ' iz t t . l ( ) l ) l i t r i lp, t i ( i i t l r r* t r . r r r i ; . i i l , i l r r , r rq l r , ,. '1. . i { ' r , } i rkr . rn i l r i g.u p.nr rrs<rrr l r r ' , r 'Lr . r lur i l l , r i scrnl . i i (ztx, i r l . srr . r r i r r l r , r r r i r r r r i , , l ,{ r l iNl) l l r i ( , i i r , r ' r rp i t i r i 1 i r ,orrr l l lc l l i , i r t l t ,sol t t r l l ) r ,o l ) i l l f i l lo (chirr l . r r g.rr . r , r r l iz : . | r ' ) l i ( lc ( , r ' l r r r r I r i r r r r r l lo rr I i oI | srrs l lorrr l l t r ' r ' l r s l i i I i i t l r , t ' ig i l I r r { , i , , l i , r , , r r r r , , r r[ [ l ! ) t l i l l l l l ro l i l t r t i r l t ' t r l i f ic i t f ( , i1, [ i i ) t o l ( )g i r I t I t , c l ! r r i l r t r i l r ,s l l r t ,c t l r r 0 l r ic | tr '1r ik 'p l , ic i i .
r \ r 'c i i i r I r r t r r l ' r l i r r rnrrr j i , ( l r r r r i r , i r , q i ( r l l l i { r i i ) In)1. $ i i r r r l r r , i r r r r r r r , r r r i l lo l r , r r rL,I r rh l : tu.r i . . t t r :ut i t loqi l r ' ; l t ) ( l r . l r . t lorr i i l i r l r r r r , r lo turrrvr I I i i i l sr , l , ( , r r l l ( ,1,r . t lnfr . r r l iz inr l fo l r r r ' l ' r r i .o . l r r r i . i . i r , r , l r i l r '1rs i . i gr , r ( ' r r r l izr i l r , , l lz l r , lorr i l i i , ( r r r r r i| ' ' r r ' l i i ) l ) r ! ' ( . ' l i r r r l |orrVrr I r r i i | r r . ' l0 l i ( ' r ' ; [ r ) (1rrrr t r r l . . i iL, l ( ] , , i r ' , r r . l r r r i ( , r t l r i l f i i1
:10J
,{{r g'(r'.rul , i. lr,t.irr, I ' l,r.rl itrl,(ft,vul li ln'., lrrlrlizitrrl sl,ur.cd, dtt ril,tt rpi.lrnl,i,1{)rior} ohr)i(:; .) (r.ru rkr'i, rirrrn. p'r Jil cxistti ir.irtii, i.*iir[,,r''i,,irii,t'rri.ir nr,' t'r.r.* .[oni.L ,,, t,pit,,,siol 'gr.aii
i il;i; ;iC;il dou[, fon'o potnr), srr pr.rxlucii bilatcral-siuroirioo (,epiGpsia to"l"o'_"io"i"i generalizati,),ri.ur. ruril,tr:ral. (epilepsia tonico_itcinici ir"*igu"Lri;tey," sau numii;:',fl i:llii' i i.i l&"'"t#,#?ljlli".",ln,1"b u t' roc'r,'ioci r i sa,' Ibcr r,i : r,J rmi,
(i,iJ.2. l,roblcme de diagnostic etiopatogenie gi topografir:
.I. ln fal;a- rlnei crize conrrrlsive.se pune in primul rind importantaJrroblcml a sl,abilirii dacX este
"o+? g" d".ir;
"pii.pli"; sau, dimpotrivE,{frc{, este rrorba de o cridd, conaalsiud, neepiLelttiid,, 'care poate s, survind,
:,1")11."-i]"3::rj,.:j::]l:!1"t" (pgloyier3 ni ",irnr,.,' r riio. 'rsrsr : 11 crizd,;::::l:,ii3-X,:fi'Jifilj".'*lffffHi3,.f,,J.,F,;:,A{:l{;.'\f"n,:J:;Xf:;,,;tt(iriLc urenl'ica. s). c on,)itsiite ah cnceJo.ropiii h$itlt-plitita. 6) centoutsiilei i n. k,r e n ; o, gra ui tli ad. T ) C o tt a u l s iile, rt i n' i n t or tta ! i o ;t tian ; n icd. Z1 C o o ii tx i i l t d in tu. tbur, i i Ip pnr loar in" l r ,ctrnie. p i*uJbni iop, , , f i . iOi** ; .u. j .ll\ Unele conrulsi,i febrile.
.. .l)itgnosticul se orienteazi. uneori relativ ulor itt contextul semnelor.liri.. ;i de h,borator, alteori imlrlicind i"""stigalii Aeoi.",lit dc aminun-(il,o 6i.,atente. Astfet, Gastaut.(19?3)._$i eop""t"i" "1i "rtrU. ffSZ6i;" pl"_
lrrrs d illercnllie.ea clintre ,,atac.l ckr.epilbpsie.'' lresp"ctiv A"?""r,ulsie tonico_,lll,ll'lll[) !i t,gpilupsia propriu-zisi,, ,, '"uri"l,i,ra'- ads i'ouiir" u",_"o puor,"of|rzr'tlr ctre sc repoti! dc o aiurd, mai mult sau mai pulh cronici {i carerr'zrrlti-r, rlin..dcsci,rcar€a hiporsincrcni, a unci populr,'tii';urotrrle. O crizi,,rrPilo|tic:i" ,Iic[', precum l-r crizele convu]sive accidentale ("o a" priJerrrrckr conyulsii febrile, crizele de.ecl;rmpsie p"o"pui"lif "r,i"tu
tolice,rrrcl,tbolico $_.a.) nu constituie o veritabili'epil"pri.,.';;p; cum nu consti-1 rr jo o voritabilii epilepsie nici rcpetalea mai-muit s;u ;;i pugin frecveni.d,ir lnror crizo conyulsiye in crtrsul.unci afecliuni acute (eniefilopatia ure-rrri.i, rlin boola lui tsright, encefalitele acuti). CrirJ" .irii.pt,"e veritabile:rrr, tlrxri, un c&racter iterativ, crnnic, ele repetinclu_se lat anumite intervale(r)rrr,i i!(jl lrte sau mai lungi).
.. I flngem atjenlia indeosebi asup ra oo,nawlsi,iloy kiltoglicemtca din hiperin-strlin.i:tnt.uL t u_ncftonal gi clin kiptirinsulinismul orginl, (i"oo sru ca,r-(r|r,)nt irJt celulelol belra pancreatice), Caro tle obicei se confuncli cu epilep-rrirr,. l,)xist[ insii, citeva elemento care ne pot orienta asupra ulei conmlsiil i;xrqli..rnice: a) precesiunea crizei piin unele simptime revel&toare:1rrIn,r'c, tchicardie, tremurd,turl, hidriazb,, patiitalii, anxietateIl)).if r ist,(ilL!,a unor simptome interorilice,_ca : so-noterrali,,"concentrare ilificili,,itrrilrlrr'rru, ir,1;entiei, a mernoriei qi a inlelegerii unor nogiuni abstracte, st[riil:li:,1,.1,,1.:
qi de dezoricntare, aprtie, brirtipsihie, irclerenfi, sti,ri de ag!I i l I , l i \ ( l l i l { l ( 'SlVrtate.
ll. ,\tumar de d,ata etiopl,togenice 4n, uieele conaulsirse epileptice
... A .. ()r.i.zele epilepN,ice conuu,l,s.ira la sugari.llajorita,tcLl crizelor convulsiyoitrlrrrrli lrr 'sirrl; i.r'(itrr r.r. pi*r'r1e.o rt' cunoqtinfir, itr,u cro obnubir.,rc. Nu tre.rrIr'1 srL lil ' irr]rr r}iu|ir{,rr, rreos.llir,i i cu oalo copilul mio pr.zitrLit 0 cr,izit, r.lo
204
r,pl l r ,pHi l l i r , t r l ' l rnt l t t t ic l lc lor pr t l l rgr , t r i l . Vott t I 'ozt t t r t i l r l r ,uztLr otgrr , t r i r : r t : r r l6rr l r I l r \ lv( ! l l , ( \ r t ln ot iztr lot ' opi lopl , icrr l i l t t t tgrr , t ' i :
I ) l l l tnt,nqo. trn,ar'.lulo1xtl,iu, l,m,ut ,l,ittd, (pt'irr frr,ctori itrlrtIlrrrrl;rr,li olrnl,o.Itrlrrli) r'gl,o c:urzlr ooir rnlli 1t'rrrvontit l lr rrcolsh'1, virnt'fi,, I 'txlto sl'[ fio orlrrr,rlr, rr *irrr.;rlii, tr,4fi.r,ir ( hi,lnnit) n,aon otu,Lil sittt tlo h,nnontgi,i ottrclru,lt utu,I l t ' ( ,hn.oidick0,I t tovocir tu l l r i t r :o i rcul l ln"ut looort lot t t t r t , t t i tnotrul l i i r loculr lor torrrIriIir111|, lt ' l,vr.r,liu prolurrgit, munopot'o ll lutalo do tlcga,ju,r'o foIirL'[, rr,lrli,,rt,, rlr forctrps, vitlext,t' it,c{,io, cxpulzii lrtltorioilso (prczotrlt,l,i i virrirrlrHr.,rltrrlrxrii, iror'{,io utcrint'r,), opora,{ii crzilricne (prin soltimbtilo ltlrrscil rlo pro,rtrrr,), ltj l iziIr'o tlo ocitocicc, b]oo:llcit, cr'ti lol rcsplriltot'i i uJo frlt,ulrri lrl irrrrrpilir(iu tlo lichid arnniotio, rlpl,urii, tlc pla,ccnt':i1, q.a.
)! ) .Mani,nllitre ,s,i encefa,lita .lcDrile : mtningito acutu ba,ctrrt'iotro nrrpl,L.r,,r.r rllI rr,I i1,o n,cnto bactcricne, viroticc, richettsiono, lucticc ntc.
ii ) I I em,u,toama subd,urale (fotrtc frccvente lil sugar, pinr), lt 60'/, rlrrlrr'i,\rir('ui [i colrb.), angioame (28o/s dupl Arseni 6i colab., 1071).
.l ) Putapitoza (cisticercoztl,, hidatidozd), do ascrncnul l 'oir,r' l,o l 'rrrcvcrrl,olrr rtrrglr' (Arsoni .1i cola,b., 19?4).
t),Llleence,faloptali,iTtri,nJactoriprenatrali(careaunoliouirtitrprrr.iorr,tll{l|z\ ()f i i i.r' i i ombrionarc 5i fctale) : a) Anomalii congerlital.a (iuolrrsiv il,lroDtlli i.,rl 'rrr()zonLiu,lo), carc produc disembliophziilc {ct:r,Io: mlrlfOl'l l l l l{,i i r : r ': r, r r i r , r r r r(rrr'r,('rfitl ic, oxiccfdie, turicefalie, scafocefill ie, piatiblrzir., irrrplr,rirrrr,,lrrnil:rli i). b) Malfortna!,ii cerebrale (microgirie, polenco{alic, tnlll irlrrlr,(ir,.\r'rrrrlrf ( l ltirrli). c) Anoma,lii occi,Tttto-ceraicale, <1) Mu,Ifor,nru]ii rtutturtltn'
(i,l lAi()rriLliozir, _ cerebro-trigeminali,, boir,la, lui Lind.a,u d,0.). ti) AJit,l,iu.tt i' ltrnrtlrLhol,.ice.feXale 1i tel&urfumoza (prin factoli gcntrtici) : la.*txtd i ntJiilt,,{rrIr')tirI fonilpirul'icii, sinrlromul lui ILutnup din por.Itirr,lrclll,l iot'l, sol,rrrzir,l : r r r r i l i r r l i i d i iuzi i ctc.) ; l ipot l is t rof i i lc sau sl ingol ip i t i ozdo ( i r l io( i i r , I r r rn i I i r r I I r ,, r r r l r r r l r r l ic ; i a lu i Tu,y-Sacrhs; boala lu i Niernl ln-Piok I g i r , r ,goi l i r r r r r r r l ; l r r r r r l r rllrl (liurolrol el,c,). f) Atte, aJeeliuni, metubolica eraLlil&re: ftrli lrrriotrrrr,irr.,lr,rrrrrrr.isiilrnliir,, zlcidernia hiperfolicii, piridoxin-tlepcrulcn{,il nou-rriiscul,rrlrri,r,l Niutlto&me gcnetiae au tulburd,ri ale formulei, cromozomi,o,Le.' rirljrrrrrrrrllrri lt l inoftltcr, silrrlromul lui Patau (trizomiu l) s:tu ttizolni:! l i, lb),rt|||(||{|rIruI lui Erlwards ('l,rizornia E sa tlizorni:r, f 6-l.fJ), itl i0{,irr, rrrorr60-f,,l(lir (il izorni:r, 27),h) Infec!,ii materne (lat.srltoli or,rrptivo lr,lt. rrrrrrrrri, rrrrilrr,rlr,, rr,ltir boli infocfiol,so). i) Afec!,i.uni. paratitara uLl rnunari ( rxoplrr,xrrrozrr),11 I,)rtrr,[t lopta,l,ii p,rin aplenli tizi,ci asu,pra norzci.' tr,trunrr,t,isrrur I I I I r .l r I r I r j r r r I I I rrl{\ lrl luurli gosl,ilntc, iradioli cu rulit{ii Iioontgt:n. k) '1'ttl ltu,rdri. nu:hr,hl,irtttlt lunttr(\ oa;'o pot prod[co oncelirllopll,i i irrla,nl,ilo (tli lr,hoi,, l irtrrl,oxir,ozi),t' lt.). L) It) tt ctfu,lopuli.i prin aJenl,iu'ni ambrionare 6i,fttuk ltrit irloorn1rrr,LiIri-f rlrri,rr rlrr f, rc t,rrr' -Zfli, ou ic1,<t'rruckrilr. n) ALli faaktr,i u,ntennktll (vllirrirr r ltrrlrr li lri lrrxrf ioo otc.). rr) l 'rcrnd,tur,;l,atp..
f / i r l ro l . l l i l ,scul ; vrr , l r t rhr t i s i i Icctr t ro l r i l orn oonruls, i i l t otr . , t r tt r t r * in,L r t t i t r . . t ,b. i I ep i .Le p l ioe , dr l r or l ro lutool i pol , l i lsrr , o plo-' l r rp, rz i ( i r r t r l ik l r l , i r r i :
l-,\pttt lu,l, ltoltttl,u,Lrti de pl,ti.n,s (,,sp/rsl}r,c tht sLnolol,lt:r,l lrri Itrrlrr,tl riil , r ' rvr ' ; , l ' r , r r r Hi l l io t l t o l ig ino l l f i rc l ; iv-orrrof ionl l i , o i t , o t .o i rc( io r l r r l l l r r r r i l x t r i tr l r , r r r r r r i , , . l l | r rsc srr r l (x i l r t ,n, ! t i i lz i l s1t rsrrrr i l r l r , l r l i t rs, i t r H|r , r , l r r l r r l l t . r i i t t l l i , r tpolt t t l to l ro l , t r 1r I ' r r f t t tuIr , , ot t i rg i i ; l ( ic , gtr l r i l , j r i r l i r r p i l ig l r r r t r i i s1 1vi , r i l , r r l i i l i l ,r l rau r l r r l r ipr l l t r r l t ' , _ l r t r rxpi l t ( i i r l i t t crr i t t co r t r r t i 1t t 'o l r tngi lo, cI i r lo( lxr J, t , t lI t r t r r l r ' , r ' r r r t r . i t t l ' i t t t r , l , x l i | l r , l rL ol t l t I Nl) i tst t t r r l gLl l r r i , r l0 t t t l r l r r r l r r r , iv l l , t r r l r , t ' | .I t t l t t l r t r t ' l t t t | t , i rHl is i ( , i c l t ( ' l r r l r rz i i , l ) i ( \ r ' r l ( r r r r r l r r , , l I r r r \ r l l l t [ r1 ry l r rorrvrr l t i i . l t t t l t r '1,r , t l r ,yrr , r r r i r r l r , , l r r l l l l r t ' i r r l r , r i ln l t r , t t l l , l i t l , r ly t r t t t , r [ r ' t izr ,hr | r , r l r . V l , i . r l t lh. .
:10 $
l r l l r r { l : r , ia.rr ' l ) r r i r l : r r ) r r ' r i l t l , i l i r ' l : l * { l { r ' r i l r . l r )sr . r r r i r r l r . l l . l r r I i r r l , , : . i l r r, r r r r r r . r r r r i r i I r r l r l l , l ( l r r r r sc 1r l ; r ,gc rrrrorr l r l i j r r i r . i t , l r i r r r i r rLrr t l i l i r l r i l r i r r l iz i i .,
; . ( t r : t r t t r . ls i i l , h i ln. t t . r t t t i t r , (1clr ' i l r : , l r iprr l r i i . t :1 ic.) r . i r . [ ic i i , l ' .obl , r r r ., I l r r , : r l r r r l r . r l i r rarr ,s i i r ' ( l , t , r r r r r i r , l iuch1hal , t9 i . j , ; pc4ruI ' i r iu qi colair . , l f )?t i ;| ' , l I ) r ) \ i ( . i . I I si l ' i isr,rrr 1(tT9), {hrpit . l lnr vo'r r.eilea i ir coirt irL.*are: t j Uneleirrl
'r ' , i I r r r i 'r I t r r . ' tr ' ' lsi. i
'olLzi'rrlh ,,: ir,cidenl_ale', gcnerate 11e'l iL:b'i i1l r t \ l l r . lo s i l1, r lc l tpt , ,s inrul ;e co1r.uls i1.c ' ' l lsu-r , rqr le s21 clrc l io iahj l] r i l r i r i i
' r ' l l t : r . sr . r ) r t l i r r . tu l ie l i r r . i ; , ,1 \ lh.h, } , t rz i t i un .Jpotcl l l i r t l f 'e\ , ( ) lu_
i i r r 'p ik,pt i r , ; r l ) , \ l tc le s int e l , i le l , ) i i rL l iL i i l i i r . rn i r t , fenl : i t0 s i i ; r l r I : r r , , , res_1r.r, i i Ir 'Jr (,1)i lrt)1t(i0 hil lctl.ct ' l l icc, rl l ' l carc silt e\ it{ter}l i l , i ,e s:l ,,pl,ccipiiate",i, r l i i . i l . I ir)r. i l t ' intruLlc'te; tr) Alte colmlsii {ebrilc pot sir, intr 't, irr c.n-l, r l ir l r, l irr i. . l u.,r ' r lcningitc, oncefarite sau mcuingi). c:cliLlite inf:rrrt i lc,l ) ( ) r l l i r r i l i ' i r 'o i t l t t ' lL:1, c l in i l i i . s i l l l i {1, ptL,{ .urr s j p\-r t i i1. i i t , pci t p leciz i , r ,, . : . , I i ' r , , : r r ' , r l ' : r : . , ,1,
' . r t ' .g{ ! t i i 1, . \ ,Jnr i , rcrr l r , r .i). 3 pu,t;ttt.of i[iu lin sugal se rnarrift st:i rmr'lt urai t,rcvc}rN tlecit ]r;, a,J ult
lrrirr r,riz. t,.rr 'alsi 'e crL pie'dc'c 11o rnnoqtirif i i . Di:rqnostic*l cste dr:osr-l r i l r l . r i i l i t , i l , cu r t i l m:r i l u11 . . ,1
' i l in r ' . r r j ru j i rL lc l i i l t l ' . l i i lor c i . !o rorbarL. r l r r rsnroi i l i i
- t rcurogeno (Popor lc i t q i col tb. , 1C76, Ig ig; I i ig i l , [$rn s i
l \ r l ro ' i { . iu, t97E i l l r i icu l i Polenr.u, 1:r i3) i j i r l r \ i s , , r . r ru i } r r i l l i r* 's te i i,.r lr ' lrozil ir ' , r rr:rn i{rsl i i .r ' i lc EE(l .rnt :rrrrlr iguc i. i r lpl,rrtrnl,(,.
l l . lr i:t le tpi[r:p!lce rt)tt t t.r l t i l :t L(L rro?il.
. l . (ri::t[t epi\eptiu i.nso!ite de Jcbrd si de samne tlo lt i ,perLet:sirtne intrc_
t ttttt i ,tt i i r:tt, i tt;;tu,lctre aurti i |a,tL sltboclit( i. ne orienteazi ini]eOsciri spre rrnni-I r r r r t r , l I af t '<: f iuni :
tt) i l [::rt ingite qoLte_])xu,1t[ent,. i l |onturtrL] clitr ic crir, l i si un sindromrr,,rir{ 'r, i l l asocid,, iar l:r, r:rhicerrtezir, se o}r{i l t urr J,CH tri lbure sall puru-lr.ri1, irr cirlo st t l icien'!, iazi gc,mcnii rluz:Lli,.prin cli irrlr,. 'url Sacterioiogic.l i r r r r r l l r . r . r r . r . r . '1, , ,1 in prr ' l , r rg i la .e insLr l , .v. s i r l , . r r l lo r .omlr l i l r , l i i r ,oulr l lu_. ' r , r ' r l ' u l l l t r i r ' t t r . t . \ ' t . r . : | t r r / , ' t r . . .n l !Upnrc pi | r rnr i , l . r l r , , r lL l ; , : r . i d! .vr, l l { t1r i11( ' . ) .
lt) .i l leninltite rirot[ ce ctt lir '.h i,] ,.1a r' (rnt,lingila Lu.liruriL, nrcningita poli-, r r r r i.I i i it,i i , tncDillgitelo cr rilrrs C.rs:rclie si EL,II(); corioirteniriuita,lrrrrlrx'ilrr'ri i ' rrr rrirus Armstrong I mctingitcle dia bolile eu
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I r i r r : r l l r . r i . l l r t r | | . | I r r l ' rg i r r . r l r . I rn, i r l iZ:1t l . . r l : r I i r r Dir l r . , t r I : r j , I r i t , r t , , : , r . t rzr i_I i l0r 'ur t l | t l r ' l . r rz i i o , , r l l l rntrrczir r l . srr l r . l r lJo ' , i : l | t r r , l r l t rLr l . i i t t ic sr l r ,otrrplrrl r ' ; rzrr r r rp i r l l r r r , r ' l : r ) t , r , , oIrrr t I I r i I rLr t r I r lgtcsi l i i .s i t t l l r r sr , t r r r r t r r l r , I r i I r l l ic i r l . r ir r r r r , i r r I r ' r r l r ' : r r r i : r r r r i ( i t rc l r t r i t , l l : rz i i Plrpi l l l l i )_
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: ' l ' t i ,1, , y i l , l t l i t , i t r t ' l i l , r l , : i r ' r tnt t r l , h i1t , t l , t l r t tnt ' i t t I ) t I I t I t ) t | ' t t t I tr r i t I r I l : r i r r r | r ' I t r l | t t I r l ' l tu t ' t i r t t t l t t , r l , ; l r l l l r l . l , ) t l t t l t t r t t i , t t l t t t lr ' i r r i t l r ' : r t l t t io t , . t to: t r , . ( \ t ru t t i ; r i r ro l r l r . , l l ) t ' . ) t : r ' l l l t nt t l , t t t t t t t i t t l t t r ' r r ,
I t ' r l t y t i t t t t r t r ( t r t t t l l t r r t i r rL l r . l i r ro l ) i i r l l r l l r r t r l r t l { i \ t tc t r i r , r r r ' , ' l r r l 'l1 l ,
' ) ; { l ) l l i , l tu:r ' l i l i i r l * l r t t l i t t l x i i : l t r t r t , r t l t l in ' .
) . ( i t i ) " l t ' r ' r t | | t . I t | ) | i t . I t in tnn, l t ' , t t l t t . l t tn r t t xt t I r r i t l t t t t r l t t r t l r ' r ' r t r r r ' l r t l t r
' t ' ,n i t t i (c.u i i r i i l r l r i l r r r l r l i r , i lc r t t r r lo l i i , ot t I r r t t r i l ls l i i , r ' i { r \ l ' r ' i r l r i r ' t r r r i r l , r I r r r ' r lr , i r | r i r r r t r r r r i tL l . t l i ) t ( f o i i ( f r rh! i lz i i , r | t \ t 1J t t tL . l , t , l t ) l t , t , l i I r ' t , , t t i , " r i t . l , t t t l t l ' r
1,rrrr l r t r lo i ' i i r rs. l l t t ' i i l r t r tct i r r r ' ( r 'cz i c l iz , r l t , <rpi lc l r l i l r r t r t l tv l t ls ivr ' l r , t t t ' i Lt t l
l . l l r i : t l t s tntu[ ,s i r r ' 4t tu 'nt l i : . : r t l r t i ( r lotnl iat l t str ) t t t t i l , i t r l t tnt , ' t tt ' l . ; , t t t i r t [o4i l st ibar, t r l ( r : t , tc r tsr t t ' i i tzr i , t ' r ' iz l r r ] t i l ( r l l f i t ' t r , t t t . t r t i l l r I ; r l i l r r I r ' r ' l . rr , l i i ' r ' , ( l ( 'gJrr l l i r tc 1r '0gt ts i t , i i r , l ' l ln{11: i i l l ) r i i t1,L ' l t r l i ; t l t l r ' ) l l ( f o! i1 ' l l , r r I r l r l r ', ' t t )1 .1t ! l i l t i : : t thtr t : t . t t t i (p,r tu,rLt ' r , l i r l l i l , i s ! ) lc t1r, , ,ur1i sulr , rct t i i . s t , r t l l r t , , , , t r , ,I r lL i . r r i r l t r 'ozl t i r t r1 srr i t . t l t lL) . r \ : i l )1)r l t l l l c lcot , r ' tX ' t i0 i r l ' i t loqir t I i<: ct l l r t r 'pI t t r r l I r ' r, , , r r r1r l l rckrL l t t i l i l t l t r r r ro l l l t ostc tc l -o l t lot .
. , . ( l t i : r ' l r ur t t t : t r .Lsi t : r , hr . lut iz, soLi l r r , r r : t ' i t l ig i t r t I l i , i l r l r r I ) I ( |L| , I t r I ' r l ( ( l r ,' ' r r , , . i i r : l ) l i i ' i rh i r lc in l r i i , l ln l iyo l t l i , r iu ' t t i t tLo-ct t ru ' l r l i i r ' lo l r r r , l r r l r r r r , r ;l , r ' l i rLrrni i l is l ) i i r r i : ln i r^ni , ; r ) . \ t i thnoi t l i ic ct , r ' t ' I r t ' r t I t r I r l ) { l i l r l t i r ' r ' r ' r ' , l r " lt1, , , r t , ' l r f , . ' l r t ) i i , i , ix)s[ , l i r i f l l i l t l l i l i i i . s( ]ut l l l i l i t ro t t t t i tL l t t t l t t t t l t f isr t l . { ' i r r r i ' ,
r ' r ,1 ' , l i . i i r n i r l l f i ' i r srLrr r tn i t i tz i t t o l t " ) ; o) , , \ t tg i i r l lnoI i ) I r ) I t r r l I r r Io1r,r , I i i i r r l , r r rr l , , l r t l i l t t ts l r t r r r l r t t i .
/ i . f r r r col) i i l iLr t f , r i ) l r i r^ s i i t l i l , i i l l t t \ i { t r ( t r i ; ( l ,c conrt t , ls i t t t l t t r t , r i t , t l r
1t ' t i . '11;1 i1161" (r l r rp i ' i r ' 'accini t i i lcrrr t i ipol iot t r ic l i t i t t : , r t t i , i i i i i r ' , ' 1 i ; r r r l i ' l r l i , , r r , ,1
4, . ( i ; [ : t I t e1.r i [ep' l , iot conrt t l * i . r . t Lct" ruLt t , l , l .1) t l tu l r t i r t t t r , i r 'p i l r '1r ' r i i l r r r , l r l l
1 ' , in i r i ' l l t ' r i1 iu: l f i i r [c1r. l l i r t l , t ( , \ tsoiLi i i i c l l r r l r . , l1)7$). {1r ' lc t t t t r I l , r ' r ' t r l r 'r r i i , , , r ' ! i l ( , t lc t+r ' in i ; r i i t r t iz ,c c i r iLci i t ioc l r l r t tLt t l t s i tL l i l , r l l r l r r I i | l | | | Ic r ' , , r r r , ,, , , l r r ' . r l r ' , }n;c i ,scio l r l r . r i is ivc inL'r ' i i , , r i i l t t iotrc s i i t r l i r r , l i i l r . .
L t l r iy l t c1t i . ! rp l i r , : l t ) t , t ' t . { ) t . t lot ice so t t ' l ! ' t i , l : r ct izr ' l r , c r ' , l , , r r l, , r r , r r ro l l r :nt i ln pi '1, L l l l t t ' i t , t t tLrr l l isr t t ( i f r l i l i i ) - ( ic ] l ' l ) l l l l i t i r l i l i r | r ' i r i r l , " r r r ri ,1, . r l l t s i , i r i rL, t [u ] ) f l11fu , , ( i rnol{)g, I l1)r , ' r l l rc i r ' l r i l r '1rs i i 1r , r ' r l l r ' , r i r r ' r , i r , ,t r , l r r i r r i iu lcpl in ik ' tn l i r ' . rLt i l lc colv l i { i i ( r lLrpi i \ rs i l r i r i ( , ) l r1, . , l1r , i i )r ) l i , r l r \ ry11l s i i , nu l i i r r .Lr t , c l izo opi l { rp l , ic l r ln l l r1 ' f i { } i r , r 'o l t , r ,urrrr l i r r r ru l r r i ; l r ) l l r
' r r r c i is ic o l r , l1, i i lozi r io o( j r ' ( t ) t ' r t l f i c l l i lo l t l , r rgr ! t i i | ) | r I t r r r r I r r i r , i i r l i i , t t r l l . r r r ' l r rr r | | l ] t1) i l r ' t { t r l ) l t l f i iv in l l l , ( t l r t l r i r l l t lLtr t t r t t l lLr ts0t t l ' , t t t , t i t , l r 's r r r i r r r r , r i ! r ' . r r t | ll r l lo l ( l { r l ) ) i ) ( i ( 's i ; i p l r , f i r vrr , l i t l i t , 1 t r r t i r t t { i r , I i I , r r I r r r t , i t t tcr l i r r l r i r r l t r i , i , t r r r r r r r i r r r r r ;
, ) : i r l r t r r r is t , r o l i , l i ' l { , i l rur c l l iLryr l ,ogrt t i i r l t o l r l i t r r -grrrr . r ' . r ,1, s i l I r ' r r r r r , ( r r r L , r r , ,, , l r . r ' , rzr i , i t .zDi ;ctr t io, l r i l t lg l iot ' r t t i r r ) ; ( l ) ' I r ' , r , l l i ! r l l , isr t r t t l sr i , l i l , | r l r r i r r ' r , l r r l ,
, l , l r : r l r t t t i t : l ) { ' l ) lut c l , c l r 'o i t t I l t rz i r tur i l r ,ot 'o l r r ' , t I sr i I i r r r '1t i l r , I lo;1 rr .
I r r I l r l r , , l l r r I r [ i l i rc i r r t l r r r r l r r l 1t , r r r t r r r r i io ; i c t iz l r l r r r l r i l r . l l l ic r . r r i , . l , r : r r l r .r : r I t r l r i l , r lo l t r f i l r ry i l ru i r t t t io l t i t t r i l r , r r i { i t , . t r i l t i . I ) l t l ) r i \ r ' l r , r r r ; t r ' , , l . r l ri l r r ' . i1, r l iz l l ( , r i r r r ,p i lc l rs i r r posl l , t i r , t t t r r r l ic i i pol l i : r r ) l t t t r r l i r t l t ( r ' r r r .1. r r r r 'r , Lr t t t , l l t r r i l ( ' \ ' l l sr ' f l l i r srr t t t t i r r t t lo t l t t l l i i , r t l l r r , l ; , r lo olr ic | i r r r . r . r i r ' : r l r r r r , ll , r r ' . r l r ' ; l r ) l t ' t t n l t (x, l ' r t , l ) tu t ) t : t ' )J : r l t t r r l c r , s l l l )s i , r ' i r i , l l r fL l ( ' r r i l l i l , r . r l , r lt r | | r r i r i |11 rr oorr i , r tz io stLt t r t r i , r l t t i 1r ( l r , i t r l ) ( ! 's iLIhlr t rot | , io:r , I r r , l i i r r , . r r r ' l r r l , ,, , r 'p i r l r r i r r sr , r r l l lLr i i 's ( f \ l ) r , i r i i \ .Lrr t l ( | t r ' , r r : r I ,utr t i t r I t r r1r ; r t r . r r r r I r i r r r , r IoL, l r r . r r r rl , r r r r i i r l r l r r , r l t r t r , . I i l rur l ; . \ r i , r l r . r t izr . r .1r i | r '1r I i iu, s i t r l , r r r r r r . r , 1 r , r r I r r | , . ,l r r r l ; r , ) l t l . i t . i , t l t , : r l r t , l cr i r r l l r l r ' . r l l l r r1r | i l r r I i i I r . r ' r1r . r t r r iy , l r r ,L l l r . l rr r r r l r r ' . : i r r ' r r r r i , r r r r r l sr t l r l r r r ' r l r r r , r i , r l r 1rLr l r t , ' | r i t t r r r1rrr , r l r r r" l i r r l t r r l r r l r . r r .l r l r l , r ' I r r ' r i r r l r I , . l .1r l l r . I r t ' , . r11' , r l ) r l r I r l t r r r ; r , r I r t r ' I t t I r tL l r t r l { , l r r r r r l r r r r r, l r r . , 1 , r , I r t r r z r i , , . r r t 1 r t , ' r t r t I Lr t l r l r r ' . r l . r ( r r r r r r ' . r r ' ) r ' I r ' I I r ' r r ' r ' r . : I I i r I r , | t r IL i r , r
' l { l ' /
irrI't 'rr'.olclrrirli i I i) I ')pilr'1r:tt lt,:r t rt tr ttt,.r,i.tti. tu.rtll it i i (<:tr rrprr,r'i(ir Lr, (i lrrrri,| : , Nni r l r r l i i ' i r r r r r r r r r , l isnr) r , r r r r . r ' r ' r r l izrr , l i " r , rkr c ica,1,r . iccu, i rgr inuo-sr,r l l r ra{ i i ,rltr l l.Lrrrrzlr, rli lrrzrl, l i rriu r':r. i l,r rrr.lo conLplicl{ii taltlivc (rbr.str, r r ' , .1,r ' : rh. . r . l r is lUl i . l . l , | i r , \ l . r , . r r r s i { , , ,1 i r t , . ( [ t17,{) , m jor i i .atel a, .cslor ( , r izur.rrr l r l r . I . i1r l l i t l r ' l t i r l ( .1! t , , / . , | i t r i . rz l i / , dupi l .ure ur.meazd cr izclu l ,ocaJe,i,u (1v('tr1,uli,l?i generalizarc (lfio/o rlin botnavi) qi alte tipuri de crize.
- 2.^.(lr'izale. c,pitep,liaa An meningite g^i encefalite, foarte frecvente l$ copii,
' . ' . i r r l i l r r r . ; r . . i .h aduUi. eLiologi l infccf jorsr i p lasindu se pr inrrc or im-elcrr i . i r ' : ruz(. i rupL,r tanlo ale rnani fcsl l i r i lor : cpi lcpl ico (Gudrn-urLr lsson. tC6C-r r t : r t . r l r . , { r ' rnni 1 i cotab.,1C78;. ?n cazul cr izeloi er , i leDl ice sur\ .cni tp rLl r -unlorrlcxt irifeclios acut sau subacut, v:l trebui sA ni ginaim h: a) Meningitesrrpural,ol b) Meningite virotice (vezi anterior) ; c) Encefalite'de divErst:rrrrl,nri (viloticc plimitivc sau secuudare) I at) Meningitd, triberculoasi,lr,) .Abces ccrebral.
lrr oadrul rnanifestii,rilor epileptiec postmeningoencefalitice clomin[,tlizclc con-vllsive generalizate, :liit iu pelioada acutl u, bo1ii, cit mai alesirr cr^rr, 1,a,r'divf. Trebuie sd, nu uitlrn faptul cL ulele accese pot si, survini,rlrrpiL, luni sau ani de la sting_erea procesului infeclios (Arieni;i cotab.,l1)73; I'opoyiciu ryi colab., 1076).
. ij. Orizele epileptice ca simptome de ilehut sau I,n cursul et:oluliei proce-sr'.lrr ,r,t:pamsire intracraniene. ,sinl deosebit .de frecventc, putintt ijungol i r r l . l : r 50 o/u din rolalul cour-uls i i lur- l r a,dul t (Arseni s i r .u l r tb. . l97S). Art i ; | ,, . r izr . l r . r1J)ept i r .e d. in pel ioarJa de t lebut a proceselor erplnsire intr lcrajrrir,lr (22o/o) reprezinti un prelios gimltornde alarmii,, cu-tleosebiti, valoarcl , r , r r l jzrr to:rre. de focar, put ind udpsea int l ic l q i natrrra procesului e\ptnsiv.rr |ursnl rjyolutlcr proceselor oxpansive intracraniene (360/o) reprezinti(l{r lrrulto ori coirsccinla fenomenelor de hipeitensiune intracraniand,,pirt'zirulLr-si rraloalea precisS, localizatorie (Arseni qi colab., 19?8). Cei(r mair'pilcptogene tumori cerebrale sint cele situatc in vecinitatea zonelor mo-iolii .si scnzitive ale cor"terului, in specia,l astrocitoamele, oligodeldrogli-r 'ir r )r{rl{', rncningioamele si glioblastoamele,
l. lrizele epileptice prorlase d,e uJecli,unile aasculure neurochintrqicalalrrr lrlrxlu{l irl ungioarnele cerebrale suprateutoriale, in aneurisntele :.rterei|rrtrrl itltt irtternc si alc rarnurilor acesteia, \n boalo Bturge-Weber .si tfuai, rarI tt. ltt ttt tr,[otn, ul prinr,&r i.ntraparellckintdtos (netmuma,l,ic ).
5. (irixtle e.pileptice nn pt"ocesela inflatnatorii, tt eurochirurgicale se in.til-rrcsc irr : l) Tuberculoamo cerebru,le (fcrarte frecvent - 850/o dn cazuri dupd,\r'rcrii rli rrolab., 19?8); lt) Abcese cerebrale I c) Ifai rar in araltnctid,ila wio-rhir*utt,l,icd, qi in go'mele sifil,itice.
(i. (lri.zele e,pileptice in Tsarazitozele cerebrale: a) Cisticercoza cerebrald,l1l')1, tl, sirnptome de debtit, fie focale, {ie generalizate, dupd, Arseni ryilr rf r r I r., t.f )78) 1 ls) H iilatid,oza cerebrald.
7. Ortzele epilaptrice t:ascalure ss intilnesc indeosebi la adultii mai lnvilsli qi la biitrini, fi ind realizato de: a) Ramolistnentala Tsseu otuntorale 1It\ INnlr.fal.upa,ti.a hiputcnsid ; c) Unele hemoragii cet'ebrale. Debutul icti-lirr.r)r si oonlioxtul clinic sint rcvolttoale pentru accste manifestirir .1r i lcpl , icc.
,\. Ori::i.r api.l.e;plito in, bolikt rlrttontnlite $h1t m.ult miri lrur:tJ I)itinuqit, t:r'rrhttkn,vi rtt,ior:ltntirii i b) It)pik'psin mior:l,onicd,proTTt*irnl, n,Iu,i
it 0tJ
l tpnrt idt l Lutr t l l 'urq Lt . l l , r t ; c) l iur l t l t i l , , r r l , i t : tou (r ' r r r r .or i )1 r l ) , l i ,ar l , rI t r i l l t l l r t ntrr l t u, \1,( l : ; ( , ) l iorr l r r l r r i ( r r r , r r lz l i . l r l . l r r t ,or l .
! ) . ( t r i r '1. r l t i l t p l i t r : i t t i t t l . . t i .u! i i l r t t t , t t t . r t , s. l | , t t r | | | | I t , t I t - / \ l ' l r l . i . r l. r t r I l t ' jo l r r I i i r r r r r r t l i t i r r loxicrr( i i po1 si i l r l l t r i r cr iz l r . r r r r r u l r i r . r , , 1xr ( , i r r ,urn.rrr l . r ' i t r r r lo I 'orrs i r lor , i i r l t r r1t1, r , r r r . i I r r I r i I r r t , I i l r , ; rs i i , r , i r l . l r r , , , r , . r Iyrr I r . i i r r r . r . rr l , r r l r t lo ' ) : t t , ) i t t , in ln l ; iu! , i ih e, t : t r t t t te (r , l i l i l i i , r r r r 1r)rrrrr f l , r ,11 i l l r ; r ,n, ( .u rr , r r i, r r l r lo c l r l lx l l r ou sul fu l l i drr oul iotr , r , t r lx , l l l i r loLr j . crr s l l i l r r i r r r , r . r t r i r r l r l r l r ,, l t l i l trt l -4.n att.[\r.t, ln,l l ,scori s.a,.) ; Ir) in irk*iur!, i i l t tniortlttr.,(urr,lr ir,. r,rr.r.l:r lrrl lr l ic poltali, cncofirlopa,l i(f lr it t(r r '(,;[1 ici ) .
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?.1 RIICOX{ANDARI MIiTODO],OIiICI] DI' SF]MIOLOGIE
7.1,1,,{ltnliza {nlhirrli.i lor snbieslive do sansibilitate,r. l,t(,c piiltl,r LLn interoSl,rtoriu ltonl,, cu,o pLecizt rzii prczenla rli,Lrcrilcr,;i, '.rrur lr, ir,ltoL senzl],ii :rnolm r,l^, topogr'a{i.i irrestor'.t, J\L)cicretr cu alteir{rrzr sirbi('ritirre, oiarul de ap-rrii ie, c:u'aotcre,le drlrcrii etc.
L Sint .sittutlii..1tt. cuye du,rerile ;i,fsau, pareste:iile constitLtie si,nlyut u,l'tt t . sU b ierlit al bclii, st u, s imptornuL senzitir: i lol.t,i:tu,tut, Lllb:rri.rilc obie;tivefii,,(l ririirirne silu lirsinil) crr, rLr; pillri rrr cefrl,i, ir ariErr:rrr:, in unele n:vrite, i l rLr l i r r t r l i t : ( {orn* stnzi t iv i r i p,rJ i rnvlJtc i et i l icc l , i iL uncle r , l r l i l r lone,vt i I r ' .
?. I, lr isti i sitttt l i i in ctre ,lntpt,le si sa prr, 't,slt: ir le Dneei| alte seny.etrr rrtrlrt l i .ae. si, clcci, au t.:r, ior,.r ' t, ,[,, si, ptonl s, mnQl : .,t 1 rLrtleri lo mu:;cularerii ru 1icrrlrr '.. ir pe|ioada i. le inr.-ir,zie prcp],ratit ic:i a poiiol.ricl itci ir, ir iLrrio:lrerrrrrir_; . lr) -l lgi i le
premonitori i cclvicale s.lu dorsrie i l hern r,tornieli i ;r ) . lLr lu i i l r r inrrol io i . , t i . ldeclcbut luneipar l l iz i i facialo;r i ) e lg ia i r r ' rugurald, arrlri lrrl lx's zostcr I e) drlrei. i l i . clhiJicle c.r pr.edoninr nti l noctirrnd, iniri l i l is l rrr '( l1ilu; f) duieri le lJ Lirlr l-rre di,r r,, jrnpl|simrilu medulare..
; j. l f r ir l i ,. si ltutl i i in cwe urrrtlr c;t ea, pri i inpari(1jqt:L lor,, tarita_hilt . l l tturc rl. in.ice nle u,nor afer:l iu ni I i ,1 forrn r, , le.ici, a crmplesiunilor rneilu_I rlr. ;, lr ). l"r 'n r t lgiui. a .mrof _poliner-rito qi polineurop:tt i i ; c) forrn,l algo_I l I r | | { | ( | | | | ( . : | ; l nr .vrJ\ t r - l cpt : l r . tntpp,
L 'L.'ul.bn rd,tile de sensibilitete subiectiud, pot sd, aibti o ,rnure uLlo&ret t lt x'.n lt)4..rt u, nnor
-a.fec!,itm,i .neurologice (Guiblrt ; i Guibert, 1g?4) ; : i) Terino_
rrrrrlqczi:t, srlmnalati de ci ',tre -boin.,w
poinihe eyoc:lrea unci ,siringctnieli irrrrrr rr rrLti sindrorn siritgornielic; b) l l ,el. ltarei1 rlc ciitre boln:,lv-* uneiirrcrr;r,rri l i l , i r lc lecunolstere a ohiccteltrl cu l iuturul pipiitului, rre face srirrr. qrrrrl irn 1i 1:r, o agnozie t:}cti l : i , plr)Irie luui sinr1r'orn p rriet:l i ; c) Rela_liu(.:r ulr, 'r 'r l treti (cuntlnut-, dar cu execcrbli i i in p.r.rorisrne itt loce hemi| ')r ' |),,I iLIr., L.\ir{cl.rtu rlc prl}uti i, precurn qi cu 0 coior:lturi i afectiyl clezil,grt, ' lr i l i i) srrsctci.uzii donri p0siit i i i tr i l i : - l) r lur.i lr.e tzl: lrnicii oLt c..lractorIr. i;xrr'1rr I ic I - o IcziLLuc r, f irsciriLllului sli ir ' t. 'hrl ic (ltunci cintl sc colstrr,t i i8i o l,0u1l{)rr, lrrrl i t0zi(r.
5. ( lq.r t t , l .u 'd: ' l t l r r t l . r : i i lot ( r l is t ,s l t ,z i i i r r i ) t r t r j r r r i r ,s i i l io l r i r ru 1l , t ,c iz r , i ,o,j tccsi( ' [ I i i t t r l t t l r r l r r , i r , r i r r l i i l r r l r r i l r l iv i srr ! l r i i l i ' ; , i l ; r r rs;)r ' r l r : , , rn i (c,r , l i , ,I r t l t r i r r i i I r r l i , sr , r rztr ! i i r lo l t r l r l s t r t r r lc loru ' r ,1r . , , \ r l r "strr r rJr- r l r r , r , r ,< i l r , r i t r r t i rc
: i I I )
l ro l t r r t i r ; r r i r t r l r , l r 'gy ' r , i t t rp iotrr l r l i l i , t i i r , , , \ r l1, l , t r t t r l ( r l r , r l t r r r t i t r r l , l r , ; .1 l r r r r r. rLr tot ( r ' r r I r r , l r r r t r r l iz i r r t t t r t r i t r t , ' t r t l r t t t , I l t t ' i r r : r l i r ' r ' r r t l r r r t i l ' i ) r ( 'Dzir l r r ' l ' . l |1 ]l l i r i t r r . l l r r I I i . i ( ' t | | r . t l ( ' r l ( r ' r , l r t r i r . l r i t t r . 1r t r . r , izrr1 i r r i lo ' i r l ; r , r t ' l 's i lz i , . r l lorr t , , , , .. l r l r ,s l ( ' l i I r t ( { r iz i t t t ' r t , l t r , r 's i l r i i r . t i l { r t i r l ot t r , t t l r ' : rzrr t l i r tgnosl i l t t l . l \ t r : t l r t r l ttprr l t r t . l t r ! i t r t r i l t n l t r i lot l t t ' r i . l t t i r i , i t r l r ' : . i r t t r i l r t t t r t l t t l l r l r i lo i l l ' l ' iL( l ( . r l r , r lr t tut ' t t ) : . ! \ i l t r r | r 's l r ' l t t l i t t r t l t t r i l l0 l togi i r i i r i l ) r r l l ,s l |z i i l | l i i l r t l t r t ' r t ; l I r , r r r , r I r, r i r i . i t t r r l r t t t i t lc l l r l i lc t t i , tu l logi t , r , , l t i r t r .s l t ,z i i l r ,pul r rp l l r r . i r t , i t r l t r t l t r t lnt
t t l ' t ' i t t t t l r r lor i . t l t t r i . l l r [ut (s1rr ; l tc t r rsct tLr l r ' , i tot i r l r r t ra l i i :L olr l i l r ' r ' r r r r l : r, l r ' . ) . l ) t ( \ 'unI ; i i t t d i t ' r ' t ' i l t le rr . l t t : i i t tu i l ( o l t t tot( lot i ) t l t / / r , ( ' i r r l r ' l i pu:rr l r, lcrrrr t r r i l l r r r l t r . , I l t r t 's1t 'z i i " \ ' isc( , t l l l { r ( lcrr t iorr i t r r ; r r r r l r ' iu. l r . l . ) r : lu { ' , / r , ll , , l ' t t l i i . l \ t l l ' r , r t l ,o c i tzLt i i , lxr l r i r tv i i ect tz i l s(nrzi l l i i { l1r l t r r i ' { iutrc i r ; l r ( l r . l r 'r r l i ;u( , ls l r l ) l l r i i fe l i l . t ' lot s( 'g in(r l l1( f i r lc l r r l ru l r r i r l igts l i r ' , pr l I r l r r l r r i r r r; , r rzrr{ i l t r lo r ip l i r r r l t . in inr i i r : tc,
( i . ( )anrtLrr t l . r : { ixr? ' i i r r in l a( lcscir r ' ( 'v( ' l l I ( ) l i i lxrrr l t t t s l r r l r i l i t r ' : r r l i r r i , , r r r r il i ' r t l r r i r r f i - ' r l i r r r r i i . I l tu 'ereu, ( ,orrs1: i lu i ( ) o sr : i tz i t l io l r r , t t i l r i l r i , t r r ' l r l r r r r r l r r . l r ri r r :uulr . : r iL t turr , r ' i i , t rc l lu ie 1o1( leauol l s i i pt tN, iz i t t t : r l r . r ' i r r r l r r r r ' l r r , l r r : r r r r lr l r r t l t ik ' r local iz iuca lo l prccis l i , r iur ' r icnirc i r lot ( t rot t I i t r t l t t , 1u,r ' ior l i r ' , , r r r r, ' , , r l juut t c l t er a iccr l ) i j , f i ) , dut 'et t t , t iz t i r t r ' ( luf( , r i ) i rs( ' r l r ' : rz r lc r l r r r r ' r i l r r . r ro, t i l r ' , i r tcnsi t l tea, t i rn l l r r l dc alr [1 i1 i r ' , t ' r r t ' l t , r , l t , t t t l r<,r tzrr l i i ]ot r l r r rcrrr : r , . r ' ,, l r rc i s i r r t srLr r in i r ]so1, j to dt i fcrrr l l r r t ro iur i lo l i i s inr l r ,gr t i r , l i rc s i r r r r l r r l r rr r l ls lo l l , 1 ie lu l de instnl : r lc z l l dulc l i lor ' ( l r r r1, s l ru ) l t r tsr , r '1r ' . ) . l l r r l r ' t i l r . r , ,, l : rs i i icr i aciralrnr:ntc in t re i l r i l )u l i l ] r i l , . io l 'o ( . , \ rsor i s i ( )1,11'sr . r r , l1r{ i i ;t l t r l ' lou, 19?2; Wri l ton, . [ t ]75) : t lut 'c l t : : t sul) l i ) r ' l r r ' i i lc i I r { ,c l l l I I r l r i , r l r r r , r r ' , rr r l r l i ) r ' r l [ t le iusrt l i [ i dr len]a . ,J( lur 'o l 'o) ' l i lopt i r r z isr i ( , , r r l l r i r rq 1r:r in"1.i { ' p{)1i : l ( l i iugu,: dul( i lc l , pul .q l r i , i l i r , durcrrr t i t r :xr( i t i ( l { f g l { ' l l l r , r i r r r r . r ' r ' r r r r l ,lor ruai (lc clampai ,,qi durcrell l irneinilnli.
7. ln lapol t ou rc( ,st i 1 l i l t i l r l tc l l i t lc r t t r t i s t ts, dt t t , ' t i l , ' xr ' l t t l r l i . l t t t l t , rt|: nrrralgii, t l tteyi rdrl itu.Lar4 dlt| 'rf i . ()t ' t l t)|a.l(. j dutt 't i lqldtit i t ' t :\t tt l l l, l ttttr i r:entrale ,<,i t lu.reri. [ i ftrt 'ult. [.-I l] loo l l]rLr{o ot'.u1ti tr ' , l t lnrr strrr rlrrttr,,r
l ) t t " r :a algin, estc dlrrerei l cn loc: iz i l l ' ( 'ptr i l l i l r t t ' i t t l t t t t t t i nct r . N.t r r lr : i r l )o i r r t i i nurnele ncrvului in tot ' i t i l r i t r l t , t i l t t i r t l tp i t t r ' ; t t r rvut lg i : r i t i i l , r r r rr r : r l i , r tevl i t lg i i l sc i r t ic i i c tc. [ , rueoI ' i t tcv i r t lg i r t t , r t t ts l i l ' t t i t , t t t t i r , t t l s i t r tp lotr tr l ( s l1 for i l i t i i , : r l ncr ' \ . r i lu i rospocl , i \ r . I lu t ' r i ic r l t l t ' t t t t i t l t l i t lc o l lz i t t t rc rr t rctr r tl r r i l r r l i fc l ic , c i r le unt)r t i uu l l r i . rn 'nr i r l r ' i , r i i l l l t ' r i t t tp lot t r ' , O vrr l i l l r r ic r lct rcvl i r lg ic o oolst iLuio c i tuzalgir i , i t t c l r l t 's t ' t tz l t l i r t t l t t t t ' t t r i t i l t r ' f i i ( ' r '$ i l l r ( i l : r ,
' r t l r I r inr i , ( . lo alsur i ! , ct l t r l , i rur i , i r tsLtpLrr1: t l r i l i i , t ' l t l t t t i t t t l t t r ; r ' l r r r r ; r I icrr{ i r r t r t I r 'r1 ' r l i , r rot iv pdl tn l calr arrcsl i l lo l r t r tv i i ; i i t tvr ' l t 'sc t i t i i t r i l l i t r t ' i tpr , t t r l r . r , rr i ' r i ) N, jurrgirr( l s l i , a, ibr i , , , r i t i i r r i t l l spi i l i lor t r tsr i " ; l r r r r r r t r I i I j l r l i Ic r r l l i t l l r r r , ,l to l l r t l l i r ig i l t r r l l r r r t ' r i t ' i i r r r l jc t ' l t l r , I l t t l ' t t lor ' , ; i i t r l l r r l t i ' I i t r tsot t t r r lot i i . ( ' r t t tz i r l
;1 i r r str r l l r , lor t ,sto I r rz i i | i i f i l l tc l r i t r . r 'gr '1 l r1. i t t ' i l l ( r l i ( ' lYi l ( t l ; t | t ' i l i ' t i ( i f i i r l ) r t l I r l ', , l r i | r . i 1xr 1r ' t ' i lot iu l ] | ( l l ' \ 'Ul l l i l l rc( l i i l l r r ' . l t l : t l l t t ' l t , t t l t t i s | i i t l i r r l r r r l r l i l | r rr r r Lt ' t 'n.
l t ) I )ur t t i . l t r rudir t t lqrr ' t t t t t t t i tz i l l t i l t t t i t t l t I t ' t t I t I t1r t t t t t ' tc I r r I : , l t ; t i t i r r r lr l ' ' i t l I I rg l r r | rn l t t r 'Lt t , i l l r l i r n iv( ' l l r l i t I I | | { ' | | i r | | I I i l t t i t t t l f i t t i t r . l | t r r t t t | r ' t tI r r l i i " . Srr lv i r r srr l l l i rurr i t lc s i inr '1 i ( r t t i sr i t t r l r ' l t t lgrr t ' i t l t t r i i , l r toPrgrt l i l r l t r rr , l | r r l r t t r l i t t l l r l s ; l t 'o r l is l i r l . St t t t i t t l t t l t 's | l t i t t l r l iz t r t l t t tc t t l i ls l ' , t l l t t l to l l l t , tlo l i i r lo c l t ( ' \ i rqr l l ) i i r i l l t toxis l i t ' r ' , I l r t r l i l t r l l lg i iL ' l t r t " , l t t ' r ' t ' l r t ' l tz i i l l t l t t l t r ' ,r l l r ' i r l l srrr r ' l i r r ' l t r t ' i I iz i l r . , l r ' i r l i t r r l i t r l l t r l t t l r t ' t t r '1 l r ' t ' i i l )11'r i i l l t r i i l r ( l l l tn{ t l
l r t i r l r i ( l i r . i l i i l r .z:r l r . . l ) t t t l t i l l t : t r l i t ' t t l r t l l l t t t t l l r t l r i t ' r ' i l l t l r i rz l i i t t l l I t t r t r r ( r tr , r , r r i l i l r r ( i i :1r t r l r , r r , r t st t l r : t l t t l r ' l t . l r , t r i r I r i r r i t r i IoI t r t I t i I I i I ' t t r ' , i l i l l l t r i l l lzr \ ( l i ' \ r ' r Ir r r r l r r l r . : l r t t r t r r t i t r r l r I t t I r t I t , r r t r t I t t r r r t r I i I r ' , r t t r r l l r t t l l t t i l l r l l , l t l t t t r i t l r , t l i r t r : r ' l r ' .
l l l l
( ) r r r r r r r (, i r r r r I r .nprvriu,lfi rrrrrt,i l i l rlrr'r',i l ir lrrlgrn.rlrrkr tlbotico: ?toestoa ap,rt sul)lirrrrrri, rlrr .r.izo rlo silg.ll lrrri s:r,rr Irrlgr,r'Lltrr.i tl. int.usitate foarte-miro.int,tli itttl Jtf tt 'rt,itxll;0kr stirr,lri0rrlrri, rLr obicoi lu :,mbele membre inferioa,ic.uli nlrrs in.f impul uoplii-ryi nrxxrlinrl la tratl,mentele antinevralgice obiqlrrrriirr. Asrrsto rlureri au lu, bilzr-r, mouingoradiculita postorioarf iudtic'd.
(l)lnlt,esiuneh rldiculari dir, doui tipuri distincte de durori: durererlc tip novrulgic qi durere de tip mialgic (Alexaniler qi peritz).
| )urcloa de tip ner.ralgic e o durere vic, ascutit*, pltrunzdtoare. mani-li.l:tl it |rt o tln,rn| 1sx1's eleclric5, $i este asociaLi-cU larestezii. tunnicd,turinrr,rli irrrl .rapid pe inLrclgl dislribu{ie a rddi,einii (tle ̂ la
umir in jos, in totrruuulx'ul superior, pini la tlegete). Ea este maximi la periferie, bine 1ocalizrrl;ir, rlistal, iar proximal e r1ifuz5,. Durerea do tip ner,T:rlgic ctilrintle de lairrcrlut lotrnembrul sau se poate manifesta nrimai in reglunea- proximalX,collorirLrl ulterior.
[ ) t t rerel c lp t ip ncvralgic are doud aspecto pr incipale.--
^o.senzatie slrpel{iciali de inlepi,tur5, cir acul in zona perifericd,
.r'rrrr so intinde proxim-al. Atlesea ea este precedat* de amorleal5 -qi furni(,r'il,uli ; ca este produsi, de compresiunea iibrelor rddd,ciirii rloisale crlrl isi l ibu{,ie superficiall ;
- o t.lurere situati, profund, constrictiv5 si limitatd,, c&re so accen-Lrrtu,z:'i, ln mlqcd,ri. Este asociatX, lrecvent cu o redoare lroiurdi localizatd,rlc r ricci 1a, git, umi,r, bra! I rnreori durerea se intincle pe o regiunc mairrl,ro i ol estc provocatii, de compresiulea fibrelor rldi,cinii dorsalle ce iner-vcrr,zir, lolmaliunile profunCe: muEchi, fascie, pcrigst, capsule articulare.
'l\rritoriul durerii radicutare esto mult mni intins decit distribrrliar krlrrlri,otnului, deoarece clurerea iradiazd, qi in muqchii inervali de r[cl],-cinil lr,ftrcta,t:i.
irr extremitatea supcrioari a membrrrlui dispozi{ia fibrelor nervoasocsi,o mLrlt schimbat5,, ilatolitii aranjamentului comllicat al muqchitor,rlirL ou,rrr, c-alzii, nu e.xistd, o suprapu:rere topografici, exicti, intre distiibuliasltp(n lioia]ti gi profund5 a fibrelor rddS,cinii dorsale.
.ltrxlrinderea durerii in arii ce depi,qesc dermatonmele clasice ar fi tlato_.r'ilri, qi intcresii,rii fibrelor simpatice din rddicind,, yom putea observa ast-li.l rlurrrli tle tip sterno-cerwico-faeiaL (datorite compresiutii la nivelul C").fi liipul costo axilo-brahial (datorite, compresiu:rii la nivelul Cr).
(hi(x) compresiute pe o rXili,cini cerwicalii, inferioarA, poate ila dureriil rcgiunoa_ pectoraiS, fl_ vom av_ea- simptome dc pseudo,angind, pectorali,,i l r i rz ( ' i durcrea este Iocal izald in stLnga.
.. l)urcrca precordial5, poate fi dat5, de hernia cliscului Cu-C, I acestrlisrt cornprim5, ridi,cina care formeazi, nerwul toracic anterior' 'medial(t l, 1i 'l\) sl],u ner-yul toracic antero-l:,teral (Cu qi C") ; Ice$tiJ, inet"vei],2i, marelo4i rrricLrl peetoral gi astfel bolnr,vul poate rvca o clurete localizati Dre-l l r t , l i r t r : .
l)lrrore:i de tip mialgie este caracterizat; printr-o senzrlie profundi,,corri,inuii., nepl5cuti,, perforr,nt5, puternicii. E.r, este bine looaliziltd, intr_ozorrlr, rlirr trlirrtea proxirnali,, sc letlecti, in.,regiune:l sclpularir, qi br.r! (C6) ;,irr urniir', in rogiuto,r, scir,pulo-pcctorrild,, n,xilarii, br:rl!, antebr.lt,, iat:r, iirdriiii,(( )r) ; itr t;nlpoz, sc,.lpulrii,, dolLoid, blll;, cot (Us) ; cri se ;lsuciu,zli uu rcrlo:uoIt rrrsr:ttlrr,t '1i,.
l) Lu'or'oi,I rnitlgicil rlotrrirrir, rrrltrslon Libloul clirric ryi cil trsl,. rlo obiooi. l ) t i l r l r , l r i l . t . r i l i .$ l : : r nr { i r l ' r r ) l r$ i . .
' r 0 i
l ) r t ' r r ror t , r l l l , i1t r r r i t lg io rrs l ,o r l l r , l ; r r l i l ,L rrrrc i s l i , t ' i r lo l r i l r r r loxrr i l , i r l r i l i l r r , l r rl r ,ut 'o rnl lxct t l l r , t i i , i t r rut t ;c l r i , n l r t r , ro [ r lor l r r i t i , pr in cortrprrrs i r t r to i r , r . I r l l r r i r r i ivr , t r l f r r lo. l ) i l l l r , tnrr l r r l r i , i r r rprr lsr t r i lo s i r r i ; oorrr l r rsrr r l r l r l r i lxr l ; pr . i r r n i , r lLr . i r r r r ,,lrrlrrll ir, crtro$llrrnzir,torr,r'o, I)rrrcftlr, trsl,o sl,rio t, Ioolr,lizlt,l ' l, irr rrtrrgoltii irrrrr.v r,(,i rlr,rirlrioilrilo vorrbrtln oxcil,rrl(f qi uir osl,0 abolil,i i ciIrl. r.tlrl ir,r:irrrr, tlors:llrI rrorrlr; rr r rrzii I.orr,lo osl,o aucgl;oziir,l,i i, sllu sgotionilti i,.
l i idii,oinile vontr':r,kl sinl cornpusn din {ll ltr groa,so oo l,rausrnil, irrrlrrrl.,rli lo r[ot]oilrc Lr, muschi i1i din fibro rnl,i subtiri oaro pol pftrrlrlco o nl,rr,r'rrrrrlrrlir.i in fasoiculelc lnuscuLtr(r, I)urr:rilo obscty:tttr rtnoori lrr crrrltrrr^nirrrrr,rr ri,tltrcinii ventrale uu $lnt inso!its do corrtrrrc!ii nrusnrrlirrrr, ,1,'rirr,.,, ', l( ' i irnt, provoc[tc de exr:itarea fi]rrolor radiouhro vontrilkr lino.
lrr regiuncr ccrvicalL, o hernie rle disc intru,fora,rninn,lil Doll,lo rrrrrrrritrr'orlrroo o comprosiune selectivi, a r5d:li,cinii rrontrtllo, tri,siirl lrl,rlr1, irrrr,,1,'r':rli mai rnu[t s,lu mri pu{in intaotii. Acclstii, ovont lrl.t,]i l i l l,(\ Irr{xlu.r\' ' rlrr'{.r'c do tip nrielgic. ln astfel de cazuri nr'. cxisl;ii sullnrprrrroirr irrl,r'r,, ',rrr (lo distribuire a durerii ;i dermatom. Daci, ]rct'niu, rlo rlisc rrorrl1r r,irrrIIrrrrlxrlo rridi,cini, cxistd, o combinatio ale durcre dc tip millgio ii i rrovr.rr,tgic.llrrtrrnrt intereseazii o arie mai ma,rs decit cea I unui rlorurrrl;ont; rlorrr' lrr,rlr,;lrrlar distribulia durcrii corespunde dennatomului.
Nl lncvrele pentru proclucerea durcrilor snu acccntnrlrcrl krl sirrl lrrlkrlrrrzi{ii l le capului, glttlui qi bralclor, cum ar fi: intoarcorot or,yrrrlrri sprrrI'r,r' l,r' it, rleafectatdq intoarccroa capnlui spre pr,rten afecta,l,i i rii pli0rr,rr.l,pr,sirrrrii pe veltex; hiperextensia coloanei ccrvic:r,lo I floxirl coloirirrri r.r,r'r rlrrlo I cornpresiunea exercil;a,t5, asupra gitului I prx'cuilirr, rr,lro l ' izrr lor. Hpirrr'rso siru percu,tia paravcrtebralS la nivclul leziunii I i lpliur,rrrr, prrrsilrrii, l r i , , i l r l r pe t runchiur i le plerului brahial (durclo; t s,rLr 'p rrrrs l ,czi ikr r i r r l1rr.r'roptrlo in aril tlerm;tom ui rospect,iv sl,u pc itl i lorl,gtt, tr,r' io) I I r, I r I i r r r r , r .r . r It,r!'sirurii po mu;chinl scalcn, Atit in leziunilo rrulicrrliLu!r oil ;i irr crlr, rr,lrrl , l r ' \u lu i , -s int i lurcr i pe t runc.hiur i le plexuhr i su,rr prr rnrrr ic l r i r r l scrr l r , r r,rrrlctior'. In leziunile plexului cif&ctelistic esto llptul oii sirn lrl,orr rrrlrr llrrl,r r r l r r r rs i l icate de miqci i r i le qi pozi l i i le umd,rnlui l i br t lu lu i . l ) r r , r 'q i i r r l lz i r r r r iL,r r r li{r Llli lre mi$cii,ti le membrnlui afectat ryi in speciill tr,l.o bltl rrlu i (rl rr rrr r,r rr 1rl rr,rrrrl so imbracii sau se pia,ptF,n5,) decia,lqenzi, rlur.olil purrtr.rr l,orsl rrr,ri,ivI'rr.iotL1,Lt1 ili l imiteazii, accste tipuri de ni;ctrri, frr,pb ci,rir so rlirl,or'rr;rlirr rrrrrri,prsr.rr _al muqchilor scapulo-umerali, qi nu trrlc{iunii po t,r'rr rrclr irr i.i lrr 1rk,,.ttltri. Mi;clrilo urnlrului nu au nici o influcufil, ruuplrllrrrz i(,irri l i irl i,rirrilor.\r'r,rrsl:r, cxplici, tle ce unii pncienli pot sri nri;to tl.ourbl,rrl i l ltxrl,rr,l,, crr lolrl,rr
, l r r ' ' . r ' i l r ' rn i , r i po curo )e atr . t |pI ic l t , rc l r t r ' , . r "uLiurr i i po blrulrr l : r l i ,c l . . r t . , r r . r . r . r r l . rtrtrrrl iu a,bducfio ryi supinaJ,io cu capul intors corrtr:r,lit*r'Dl (s.nrurrllui i,rlxf grrol:r gil,) (icclan;o,tzri clureri itr nemllrul suporiol. rcsprxil;ir.
I r rtensificare:l durerii so oblino prin tuso qi striinut, tkxrilurco lrr ptrr.' I r{i(| o clostoro brrrsc}, a pr,csiunii intr.*ab{lomina,lo qi intriltoltc i.o. .Atr.ir,rl,rr,ru' pont,r:.oxplica- plin f,r,p[ul or), s0 pfoduco o sl,r,zii, vonoiwtr fur vlsolo opi.rlrll l(! Di, r.tsttol, $0 comprilnij, $itoul tlural qi rir,d.tioirr ikr ; oorlplruirr rroir,:r.t,rrr,sl,l! so polfo rtlor yr:_rill is I I ' i l,ejn,lu-so rnioluscopio qi so vir, vtdol cttrr r r l r r . t In ic lo#r, t r r t . r i sO i r t l j . rs l ,o:r ,zr i .
l\plioa,roa plr)$ilrnii po prtrrlolo ntill lgioo rlor:la,ni1cazil, tl l lorj Irrrnr|r^(.1()nll)r'()sill lol, riuli0lrli iri i provoitlriX hipor.rr,lgrrz ia rnrrgultilor', frr,pl, orr,rrr lrto., t l t loo l t t t t t t t t t l l ( , t t r i r l lg l txr t t t 'u l l l )1, zonolr) ( l0oLr l IBlr , l t l l r , r r r l l ,Lr r l r r r t r i i j . . l ' t t t r< i l ,o l | lt r r i l l lg i r :o r Iu lotr l r ,Ho ni t r l , loo.r , l iz r , l ,o l i t , r r . iyolrr l r l r i lo r l r , r r r r r l i l r r l r ruvoi lno rrrrr i .l i r t ' i r "1 ,111,r* B , l l l tnt l i t f (u,z i i , i ' r r , l . lu i r [ . l ) t t t r r t t lu r+r 1,rr r r r l ' loolr t , l , r1, Hi ( fN1i1x:1, ' l l l t ,gl t t r t r i r t H(tgt l to l l l , l r , t i1, i t t l , r r r r rn l l , l , ; r lu 1, t ' i roo r l r r1 l i1, i r r l ' i I i , r , r r . ( , I i lor , r i l l cr t r rov,rrrr i "
'fiimrii^,; ,;i,f[
i r r r ' r , l r r r r p l i r t sr c( , iot t i r r r . l r l i i r l i r ( r r i lo l t lotsrrLr. Vi t t t l tx ' l r ( , l r ( l t t l r t l i i l ) l ' i t t i t r l j ll l r r ( i ik ' l rx,rr ,kr r .u I rot ,ocir i t r i r r r r prr t l r . l r ' t l t t t t ' t r l lx t r t l t r t l r t l i i ' r ' i i l t t t t t r io l i r r l t t l r r -r , i r i i r l i ' i i l l sLt tst , lo I t i t t t i t t t , r r lc r . r l i l r t { i r , i . t l t r i i r tu iot i ( l t l l i rn) r r r r l r r i i . r ,1 r ' ispirsrrc lo rrrrrscLr lu lc lor l r l iz l r l t , r ' r . .1)r ' r 'z i l l i i sur$l d l l r 'ot j i , ! j i i rcdoi t t 'e i l r t l l$or-lru r,, rlorlurr{ur c\irJtii i o de s(fii1('it tc t,rtutintui tle poterrl,i i l l din princlt'1e, ilttro-I r ) rsr ' ru l r iOlLl l l l ' ( r ,
t.) I)urqile r:rnlatLale sinl (.trrter]nirat'e de leztrta cordortllclor laieraleilJ l l)os1 ('1 ioa,r'o t],lc m:iduvei spiri,rii, in special ale f:rsciculelot' spino-tala-rrrilr,. Sin1, duleli surde, neplecise, lepal'tjzate pe un teritioriu r1ale fi sintrlr.olritci irrso{ite de tulburlri do sensibilit:rtc obiectiv:i cn l'el.}artizal'e }eltir l l| lni(orp srlu cu nive-l la un anumit segment.
rl) f)ut:orca n,eni,n,gi,alii $e rraractclizeazii plin dureri oel:alice difuzer rr rrrrloiilc tle ceafi, qi oste deti, in turnorile cerehelo:lrie ;i hemor:lgiile's u ira lrllrnoid jt:ne I durerea mr:ningittlL sil,uati, spinal trste datoritS, tunorilorrrrrrlulillo 1i hclniilor de disc ;i se calarterizea,zin priti coiltrootar'ea pilrirvcr{;Lrbrtrlir, asoc:iatl"l cu dureri pe ma,i multe segmente.
L:) D,urerile Lalamice apar in leziunile cturc adecteazf grupele nuclearelirlr,r'alc ale 1,alamnsului. I)ulerile se localize*zl pe hcrnicorpul opus tala-rrrrrsrrlrri lt:zat,, rrai ales pe fat-i, l i pe rnernbml superior, au o accentuatalrrrrtli ltto aiecl,ivS, nepH,cutd, qi se insolesc de lulburi'ri tle sensibilitateoIirrrlivil,, rnti a]es proprioceptivi,. Aceste dtrcri apar indcosebi irr ll:zinnilevirroulare ale talamusulli;i anurne in afecliunile din teritoliul altereilr,rr liculo-optice I leziunile vascularc tlin tcritoriul artet elor talamo-gt*1icu-lrrir'i, si talamo-pedol'tltii dau aStere la tulbul'5ri de sensibilil;ate obieciiYl'cu l.opografie caracteristici, da,r nu genereaz:i durerei'l talamicl propriu-zisii, slu goneleazi1 doar dureri tle mai mici, intensitate.
.l)urelel t:llamici poate fi conl,inuX cu exacerbiri, sau po:r,te survenitliscorrl,inuu. Soarte acleseori ap:Lri!ia durerii sau exacerbarca ci est'e rleter-rrrirl ii, de survenirea unor excitalii liziologice, liminale sau unoori chiarsrrlrliminal.e. Astlel, drircrile pot si aprrl l l rlpliczr,rel upei reci pe o1lraz,irr lirnpul picptinatului, a survenirii ultui culent tle acr reoe I lrlteorir t)rrritirr dril'erii cste determinrtd' de excitan!,i senzoriali (mirosuri deza'gitrllrile, zgomote sau lumini putelnice) sau chiar a unol factori t'rrolio-irlrli. -,\cca,sti, integlare in durere a excitaliilor senzitiYo senzoriale saui,*il,i,r', ,r I'ost denluurili, tle citre lead ovel'reaction (stprarcacfie). lnilgi I ruli cu tlurerile talamice, mli trehuic emitrtite noi-iunile de hiperal-gizitr 1i .lriporla,tie. Il/teral.gezin, se traduce printlo sensibilitate dureroasi,r.r r,rsi vi, plintr-o scidere a pragului durerii, astfei, incit uir stimul ile inten-sillt(, r r({l-rrreroa sir, poduce^tlui'ere . Hiperpatia este tot o hiperalgezie, inr.rrrrr ilsir, tlurerea are o tonalitate afectiYd' nepli.'cutd fi, palalel, e\ist6,I,rrllrrrliirj. da sensibilitate obiectivi, in sensul unei hipoestezii mai rrult;.rr,rr rrrni pu(in accentuate. Iliperpatia apare foarte adeseori in cadml sin-, l r r r r r r r r lu i la lcnr io, a l ; tur i t le duret 'ea spontrni '
11 I)urerile [isceralc. in eazurile de lezare a dilerselor organe intcrnelrohraruii ecuzi, rloui, categolii de senzalii nepli,cute : pe de o parte dluerilel:uu,|rr ilc sufclinla nt'rnijlc citi, a forrna{iilor recept'oare de Ia nivelui orga-rrrrlni rtsDectjv, iar p.' dc alti, parte, d'ureri, proiect te (re.ferite) la riivelullcgurrrcrrt^r,lor'. As1{e[ bolnavii cn anginI pectomlS, acnzi' dureli in rogiuneall r'ocor'd iir,lir, qii pe fr,tl intorYrd, tu brllnlu.i sting, srferinzii de ficai; acuzztrilrrr', 'r ' i irr rrrrrilt iLl rlrcl' l, bolnavii cu ol'jzc tenalc 2louzil, dtlef i ploicctato inrogi {)a, itrghitro"sctirtn,L'l, oljc. A&\$1.(} t'oritorii pon'rt:1 Yrulncl(f
' lo ,zonel0
Irr i I latul t ' .
1I4
I r r pt ' r r r , l lnr , t t r . r t t 'o l r tg l t r i l , c l , l i t t t t t t ' , l l t , t l t t t t r r i r ' i r i t rct l t l l r s i l ) l i i l l l i ln i t l \r | l1rr r r r r r r i i l r , f r \ t l i t r ( l (u l . t i ] ( t l r t l td i r t ' , t ' . t t r t ( r t t t t l r l : t t t i t t r l t t t ' t r t i v i r r l r , t t l ' l r i t t t ' t ' t l lt t i rcr t r l r ig i t ,s l t ic i i , i t rsf i r l r l l r r l r r l t lo 1i i t tso{ i l r r r l t t l t 's t ' r l t l t r v i i t 's l ' l l t t ' i l tot s is l ' r ' t r l r ' ,r l r r r ' , . r r l , t igot i r , 1t)r i l ' l l l r t . t lg I t I i t t t t r I t I I t I i r r . A. t rs l t r l t i t l t r t l t t t t ' i tz i i t r i l t ' \ ' i t , r r t t '
. r l r ! r l ( ' i : r z ik: , cpuiz i r t t l 1tc l to l t t i t ,v . Ntt t ' t r lc i lzr ' i , l l t , l t ' t ' i t l t i i l o l r iqt t t t i l r i ' r t, r r l i I i r r1r , lo: grr .s l l i i r ' . I t t l t i , , t , , ( ' t ' iz I l ' r l ' g i l l l l i ( r ' l i t l r t l i | ' r ' i | t t t l t i t ' t l t t ' rst ' - ' l t
, r l t r , . t t . :e t : i icaral .e: ( t ' i la . l ( t r in l l i e; i cso.fur ingi lnt ' ( r l tasntt ' t l l t t t ' t t t i ts l . l t t
l r r l i t r { r s i csoi t lg, ct t icni l la dcglut i l i ( \ ) ' o i l ( t l^ t iatkur ' (str t tz, t t ( i i - t l r ' l t r r r '( i r r r r r ; r l rLr t r ror$i i n test iculului) , t t r iza r : l i tor i i l iorp (st : r rz l l i i i t t i { i r l l VrI I t t ; I IoIr I r r ' ,, , : r r l r i r l t rnr i fonni i , l reptat in t lurcr i v io lcnto), ar ize ur inut t ( r l t t t l t ' i t t t
r ' .zir ' . i i1i rLle tri l), crizc hringiene (foalte pertculottso prilt lrpl,rt l lr i prrl, l r r r ' , ' l rL : r ,s i ix i t ' ) . ln toatc lcesto cr izc, nt ss ale1l ist€azi ' l l r tz iuni l r lo l t t i i t r t ' ;1r trrrrlrri l l tr ivolLrl c[ruia se resirnte durerca
7,1.2. Analiz:r tulbur{r"i lor obitotivc ale tl iversolor slrrrifuil i l ir l i . l)rrrr r r i r r i r , rcn acestot ' categor i i t le scnsibi l i tato poato scoft t ( t iu ovi t l l t t { r i t l i l l t i l lrr l)( '(,fo piltologico Di anurno : in unclo irnpftrjrtri ir i sti pl 'o{l l l(1rr (, r\\ lr l. lr 'r ' lr l 'r\,, no r r s i lr i l i t i ,!, i i , sbilro nurniti i hiperestazia l altoori i l l) i tr(f tr t l i t t t i t r t t r t t , ' : r ' '
rrl ' :rl i l ; i i i i rcco1ttivo, care sc nutle$1c hi,podtniet c:l l( l l)orl lr(r l l l l t l 'Alf lt l lr i l lrL
IrirrlrIr,r 'oil Cap:r,cit i{, i i recoptivc' sta,re numili i . an€sra3iP. II i l)r)(f$11',i lr, r irrt
rrrrcslr,zia pot intclesa 7;e itr)t l i aroncttlu,re, raditttt, lu.ra r, ' ,t t1 ttor't ' ttptt)1:tt lt4!tt|t t ) t t ) t t (utnante mad,ula,re. t r jLe lot intoi 'cs i t i ;o: t tc rnol l t t t ' i lo t l r r srr t ts j l r i l i l l t l r l '
, ,rrrl rrri 'birn rle hiTtoestezie sau' anest'ezie gl.oha,ld, s',t ' tt lrttt i tt l t ' t ' t 'srt ' rttttttrtrr r r r r r r r r i to categ0Li i i le sensihi l i t ; ,1 i i , celel : r1t0 f i inr l i i r l i ro{rr , <, i r r r l IoI l r i r r r r l , .
h i l tor ' : r t , .z ie sau al let te! ie t l ' isoaiold ' Existr i t loul i f t r l t t t ' i t lc i l 's{ ' l r l ( ' t r { ' r r t l r r r l, r r r ( i i :
1. . DisociaJia s i r i t t gom iel icd. , in c i l t 'c br t l t r lv t t l l t ic t r l r r r r r t ts i l t i l i l r t i t ' r t
i , , r r r r l , rL lgozic i i , scnsibi l i t l r te:r , tact i l i i ; i s tnsibi l i l r r icrr l r t o l ' r r l r t l i i I i i t r t i i t r l r r , r '1r , .\ 1rrr tt ir i s lr izgo i it. ielir: 1i \rL sintlronm,e lc sirtrtJlont irt l irrtr .r i st 't lrt lot| i1lr. [ 'zti t tt
lr lr lr ' loL tormo:r,lgezice :l lc fascioulului spitto-l,t l l tt,ttt i t l , l l t, tt iyt, ltt l tttcttt l ir : i l i i t l in comisi i ra ocnt l l ie : inter io:r i i l , sa,u 1a' n ivol t t l I r ls t r i t ' t t l t l l t t i r l r i l toI r r l r r r r r ic poster ior .
:!. I; isocit1,l ia l,abel,icd,, \ lL care bolnavul lr iet'r ltr strrtsibil i t i t l tr it ' Itttt l tttttIttr i s.r^ibil i tatci, tacl, i ld, opicrit icl i, sensibil i t l tcrt l,ot ttto-lrlgrrz i. i l , ,1i t 'rrrt, l i t.lr l l r rt L rl 'r,paticit f i in,.1 irLtirctc. Apare in. trabr:s sit ' tt i t sindrottttt ' l t ' 1t:st 'tr lr ltt,r ' l ir ' ,; si eite dctermirutri t lc iezirc'.r, coll lolln0l()l [)()sit 'r ioirrl ' .
?.2. pltoBlljMl,l DU DIAGNOSTI0 T0P0(ittArl0 li l I,l1'11)l,AT(xl lrNl( j.
SINDIiOAMIJ SIINZITtVII lI0PO(iRAII(JII
(ii i, ih seusib ilitri{ilol pot ll i lczn,1,o in ttticaro ltrtttcl; rtl lrtl icr'1'ttltti hrr,I r r i r r t l r r ,st tc l r ra, lhoro s i r l r r r : r r r ro (1l in ico r l i l i r r . i tc , lcga,t0 t i i l rvr i , r l {J krrrrr l izrrlr' lr, lr,ziuttii. ' l lullturiirikr tlo sr.rlrsibilitaLo pot, sti ooulxr o jtttttrl,l,:rl 'o ir' {1r,tIrl 'I r r i . r r r r rnorrrbr ' t r s i t r t nurnrui utrc lo t0r . i to l i i l r , l<r utrui rncrnbru, l ) r r r r ,Hr. l | t r , t t r , t tr,lri rrrrt irrlo'osil (lolt' ltnolo lrlo(lul' i (lo $(rllsil)il i l; irto. Iatil, rltxli, (fi l 't,pttllt 'ttl ir, I.ullturdrilor xr:nzilirc ;i lu,lifulat' lor, t'cslttrtrtiv notlttl lor rlo $t'l l lrlrl 't.,t r , r l , D|c0iz i t ;1( ' ( [ i l r l lL,z i l t l l i i . ' l ' i t t i t t t l soanta ( lo iux)Ft0 t l t t t ts i t lot ' tut t t r , l t t t l ' l ' l, r . l r i [ : ' I r r t t t t t t t l I r r : t t r ' l r g i t t r . l r r t i t t t t r r
' rct tz l l ivr ' :
A. Sir t t l t 'ontnolo glr t tz l l iv l ! p lu ' i l { - r i t t t .l . S indrxr,rnttlt, l ,t 'uuot[u,ut ( rttortotttrtt ' i l irr) . l ,r 'zitttr i l t ' l l(! l 'vi lol ' l)(\t ' l l l \ '
r io i r l r , lo l r r r inr ' i Lrr Ibrr l i , t ' i t l t 'ntr t t r i l r i l i l l r l ,o, . l1,11, str 1t t t1 l i t r r i l . r t l r r , t t t r t . l t i l l ,x l , t '1 ' r l
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iril'll;l##iry##Jiff {{id':,,!fr if#','tr'fi "f.',Hf iff "+'"onc'1a'le,r,,ri"iiuriouio..r,rtr*r;*lf h,S,t'#xil*"?iJ#"fffjffi '-Jft lilifi1;$i;;,,1l;ti;f ;i;lji{{ryi"J.i",1ff ,xill,',6ldiffi ;rt;i.,r,iiili,".rri,'iiii;;,l,ilivil;l,ll),ffl'i,"fili,iiJ,1:iii;fff?sfifi.l] llllll*j;fl0
rrrur i r Ict t I r r t1( l r t ) l ( l t l r l ) ic( , , r l i r t l ro l l l l r , lu i I l r ,srr i r r r ' . I locl i Srr l t l l r r r r r i t . t r r r r r l i t r l r ' ; r l l i ,r l i r r pol f i r i i 1 i r l i r r r r r r r r l t r i r rhrx ic l r , l , i i cu sr t l i ' t rnr i r l r r r oxir l r lc c l r , r ' l rorr q i l l r r .I r i l tn ic l .
lr, t\in;lxtltttl rarl,iottl,arsi7tol,i,tnilitttlrtt ' irrrrtiirtrrrrcltoit,zr't, tIrrloli cu rl i ll , r ' r l r t r ( i i t l , t l icuhlro, p i t , fo$tozi i s i tuLbrr l r i l i r l .o sursi l l i l i l , i r t ,o obirrc l , i r . i , , l ) t .c(r l r r tr r l r r l l r r r l i i l ia lorc l lexclol in t t r : ' i l ,o l iu l r t r l i r ,c i r r ikx ' i r r tor i :sr to. l , )s lo crr , r ' i r , r l r ,r ul icli, t Ii sl;r:ib n1,iil net tndioulilril, dot'rnltornoricii, lr, 1;ulbur.ii,r' i lo l rlrr su rrilr il r l r l r ' , r . l rc t ,s l ;o t lo obicei gkl l t l l i , . l )cbutrL[ r lurcr i lor s i l l1 srrrr lnr lo l t r . ior . j r r l r .r r r ,o l i r , t r l ,u: lzr i t l ingnosCicrr l . ^{ccsl r r cstc blrr t , i r , l i i t 1,r : rLurnlr l , isrrr o, i r r r r l r , r r rr rll i l itriiccl;ii qi proglcsiv in tumoli. Adcseori lcziuncrt int cttrscitzii rrt r r, i rr l l l lr r r r l r ' ic i r i i , o inr l voi 'b im de pol i r : ld icul i te, sau i r rbcroscl ,z i i , l r , l i l , r ' i i r l i i r r i r r i l r ,rrlrirli{flc, cil, 1i norvii periferici, cind vorLrirrr de pol,irnilit:u,lorrrt,ti lt. lnrrlr.sl,r sitrurl!i i, semnole motorii sirrt irrrporbd,nto, cu pu'il l iz ii l lrxro pr,r.rl 'r 'r ' ir '1 . ,l.ccs1,c poliratliculonevrite sint dc obioci irrliccfiorlsu vilrrlirr|.rr prr1, luil un clt'a,ctcl asccndent. Alteori se lealizclzii ruortirrgorrrir,lo po lir';rr I ir.r rlolcyrito.
5. S'i,ndrom,ul, d,e ,,ganglionitii" so caliloterizoluir, plin srrrrurrr rlrr lr,z irtrr: rrrclusivii a ganglionului spinal ;i a li i,t1.[oirrii posl,olioir,r'o (srurzil ivo;plitr ltectarea ,,pri.r' i legiatd,)' de c5,trc virusul hcrpcsului zos1,trr, crr rr,l ' irril irlr l rcuroectoderrnicil,. In localizarea clasicri, sintlrornul sorrziliy :rrrr rrl.rll)ogr'r.t 'fie radicular5, manitestintlu-so printr'-o nevralgio rlo t,ip ,,irrl,r,r'rrr,ii.rrl" unilatelald,, violenti, continuX, da,r cu exirccllti iri pilrrrrisliru', rrrrlrrt:url,ere ale constticlie, de impuns5,tulir, 1i rlo arsurii, l i l cu,r.o $o ilr1r,(1irzl,:rlrtoupc obligiltoriu o enLplie critema,to-veziculaL':i r-rrr irrxrrl;i hrlrrrglrrl ' ir..
lrr practicii, asist:in la varilte loca,liziil i: culvicir,lo, colvico Irlir,r' lrr;rlr,, l rrrilcn,le (,,intercosta1e"), lornbo-inghintlc, krmbollornrLlir,Lr, ri:1,(,1'{) ii{r1lri,rlicr'. .Sr-r, mr uitLrn tormele craniene, cu lcziurtoil nctvilor. rrlitrIicrri, V, Vll\ | I l r is , YI I I , IX, q i X.
li. S intlrom,u.I tle Ju,n iur,litd, tt,l, hti Bicartl. 1i l, 'ot'trsl,in'(,slo rxrrrlr{' itrlrr,lr,zitttti i l i,tl itcinii in por!iunea sa erittr-Incn ilgcu,lii, Lr, livclul l,r' ir,rrtli i it l l, lrirnii t1e conjugare (JtU. 29)
rr) )n s in i l rom.u,L de i r i tu l ie funiculaf i , Lulbur i i r ikr s in l , ; r r r l l r . r rz i l ivr ,r1i ri. 1utrluc prin dureli vii, a,soci:rtc Filrr lu cLt o blLlrt{i, rlc lr i lrocsllz io, rIrrrr'r i lc l i i t l l cxacetbate t le mi;cr i r i le oolounei 1 i t l r i i rn,s i r r r r r , l , prr l l l cr ' l i ' l r l r r l i r .; ' i, irsoci.rz:"r, ;i trtitutli l i antllgico ou conl ra,cl rrt' lt, trrr rirolr ilor' 1lr,r' lrvc ll r.lr l ir lr .
1t) ln sbtdromttl tla aompruiutta ,f vniatt lut'ri, s(tunrkf rlr lrl,itrrlr.tt. rroiol i r^ s i t t t pc pr i rnul p lan, iat cclo t lc a l t rc l ; r r ,nr s i r t rz i l iv i so l l iu l r rc pl i t r ; r lg i i,;i lrl irr hipoestezii in benzi (uulicLrln,rc).
Il. Sindroarnclo srqrzitivo ccnl rulo
1 . llin,tlrtnmole sanli,l,i1)e .nulu.Inra
L Sinilrornt,Ll sacli,u,n'ii.l,otala ( com.plcte) u nddlu,no i rhl,cnuinri, rrJlr,r' ifirr,r r t rc i i tnrstozi i g lo l ln lo subiocl ; ivo qi oLr icct i l .c r lor lcsulr tu l lcz i r r t r i i ( l ; r r l l r r r .t r r to t l r r sct ts ib i l i t r r , { ;o , ,otr n ivol") , i t tsot i t r i ( lo l ) i r , r ' i t l } lcgio srr , r r kr l , t ' r r l lk ,g i r ' ,I t r l l r tLt iLt i i r l r t t r . l l r r r . r 'Lr t , l , r r l l lurr i t i v(Hot, i I t , ivo gi l , t t l ' ico. N ivrr l r r l lu lhu t r ] , t ikr t 'r lrr sr,nsilt i l i lrr,l,r, rl opirrlo rlo rri volu I lrrzirrrr ii urtxl u lu,ru, ry i rlokrrrrr irru,r'ou I r'rri,lrui,: r t r iv l l t r l r t i l , r r l l r r r l r \ , r i lor r l r r sotrs i l r i l i l , r r . l , r , , u,r 'o dr,oxolr i i r i i , v i l lonrr i t r n l , r r ,b j l lt r , r r , r l i : rgrror l i l r r l r t i lo l l i r . r l f t ,z i r r t r i i .
i ! . Sindronn, l r l t h lnt i r r l iun.r tu, r r r iu l r r l r ' i grr , r r r i ldr l r r r r r l l lnnon Nrtquuxl ,l r i l r r r , l r r xotni l r i l i l , rL l i i ; r to l ' r r ruIrr f i i t r t I r l i l r , r :1,r ' 6 i 11,11. 1ql1r lorrni l r l l i l r l , l . l l l r , t ' t ro.
qtt
1r l [ (z i ( , f l ' i i r ) ( l i t r ( r 'urr i [ r r ic , ] r t , r r r isocl iLr crr r r r i r l r rvtr i v i t gencra - pe i i lg i il r r r r r l iz i ; r , r r rcrrr I r l r r I r r i j r r l i , r ' io l s l iu l r , rnt ,nrbLelol de accea,f i pal te cu lcziui ter ,i r l r r r i r r r ii r I r r v c i . o rlisuci:l!itr fa,bcticri horloLll,ct,alii leziutii qri o disotinlier ir irrlorrrir, l ior"l toll,r ' t latelali leziutri i . Astfelr o lcziune in legiuner ri. ir.ali( irr|rrr.rrl i i) [ Irorn iuri ir]ur'. ei sti lrgi r.* g;cnela i (] tnonoplcgie crula]i i Jting?:?trr( 'r 'r l( 'rt. ir, sctrsjbil i i . i , l , i i plofulde conDtiente in membrul infcricr sting sipir.rrlorr.rr slrrsibii i l ,r i i , i i tenrro-algtzice in partea ch.eapt5, cu nivel pi*i Ia,
l '? . : r . Sindroamcle senzi l i \c pcl i fo l icc.
rrtqrrrnrlul ln({luli lr. lezl,t. frrteresalea concomitenti i a r"i,cld"cinii spilaletl 1 |r 'r ' l ir,. Lr nir | lul si t)e p rrtoa leziunii, prorluce o balld5 de airt*tezie"1, ' l I l . r r l ' . i r i l ' l . r zur, t ' i dr l r re- tezir , I ro[rrndr i st ing: , ,
, i. Sinrlroqne.Ie tle disotialie & sctlstbil i td,l i lor :t) t\ irtr lrrtuu.l de cortloone p <;sle,t, io&r'e (GII,L gi l]urdach ) sau sindyum,al
rlr . l i l t tt lungi. oI l.u,i Uijdri.ttt. Tttlhuririfu su,biectiLe constau in: plrcstezii., i rrrri rrL's s(,l l l lc lcccse de tlurt:ri fulgulanter (fulgeritoale), cu scrliu l irrrrrr r:u' irrlr i l . I)1\) \ 'ociireiri. l t1 ex:rCc:,barea :rcCSiola prirl anl,efieria i:eprLlUirr. l ir l l( 'r{, lzi o l1,ingtr,( ' ccrl ici l l i i , in sperial plin conrl:resinrir .: ln ir l inr'1,'1.' i 'r i i ir l 1tl: ir i. X'tttbtn ci.rI ic obiecti l)e teil izeazii o disocia,tie ta]:etici. a rcn-
rr i l r i l i i r r ( i i , l r i l l ter ' r l i r s:ul t rn i l r t r ' l : r i i (dt : : rceear i parto cu l tz iu l t r r l .I ' t,t, i l t i l i t t i !t r:I i .olrLrtite I 1-lbt's, sirrrlrolrnc ]t ituro-anemice sau altr] ntia-
l,rzl lrrrricir ' lurc (clr rrtn1. i lo1e, {r 'goncratl le etc.), scleroze oornbi rtr, })olir lr,*r ' l |r,r ' , i l ivc (bollu, lui l lr iOrL.eich), r 'r ' t:ntr:n,l ft irrnt do cor' i lon lcstc|ior. , , 1, ' r r rz, . i i r r p l : i r . i ,
l t) i l int{xtntu,l. dr ttntitturr"r, r:r 'nusit poslctioatd (sut rcl.roeTtt'niintur )t l r t l iz l r rz i t , o t l isol i r r { ic s i l i r rgorrr i r l i r , i i , l , r r l rno- i r r r : r luczir , r i (Sr l ru l tzc ; i i l i r r l rk ' r ' ) ,r t r l r i ts l l i r t l r r srr t r r . i l r i l i i r i l i i l r r . r . l i l r ' 1 i r r , r , r , lc i prrr l t r ru l r , , ' l ' r r l l r r r r i r . i lc r r r . r rz i -l iy , , r r t t o IoIrol l I t I i r l l i l ( l ic l l l l l l r t r r ; l r r t t r l l r l i i , i t r l rcrr i : i pt t l i tk ' l t i r r t t l r t i r r r l t r rI t t r . l r r t , l ) r r l i i i t r I i t r r I r ' r ' l r r l rz i r r r r i i , ( r r I I r r t l l ' i I i l r r s i r r l I t r ] l j l ( ) l i l i l i r t l , ' (1, r tu( , i, . i r l , ) r { l t I r i I rLIr . r r r l r , .
: r l l l
| 'osi I r i I i I r r { i r , l i r r l rg i t ' r ' : s i t i t r ; l r r r t i r ' l i l t , I tc t t t r t { t t t t t i t r I i r t , I t 'z i t t t t i l t ' t l t t l torrrr , r lLr l r r r ,L l l iotrrrr l r r l r r . , l r r l to l i i t r I t i r t t r l r I r r | r r t r . t l r , t l i tc t 'sc t t r t l t t t i , l t i r l t tI l l l ( l r '_
, .1 \ inr l tonrt t I t (n)ut l l . i loxl . ( , t ' iot t r . r t l izr , i rz i o 1(, ln l r r l l i t lg( 'z i t ' t t t loprr
1ir : r l r , , t r t l i r , l t l , r t i , i t r sr ,gnl , t t ( ' r 'k t cr t l l ro l i t l r t col ' r ,s l t t t t t l l i l t l l t t t ' l I l i { f lo l l : { r f ( l r ' l ', l r i r , r , ' , r ' t r p i i r l ut , r l " r t s | i rs i l r i l i l i i i i ptof tnr t l r r ; i l , r ro i i l r ' ( r lc f i t lc i i ; r r t i t i t t ;1 'r r r r r ' l i , j , r l r r l r lc r rccci ty i l i '1c l l l lcz i r t l tcr t . Str i r t t i l t t 's l r , i r t r l t 'o l r ' l t i I l l lnt l l l l1,rr r r i , l i , ' .
IL Si arIntunu'lt srn.-iI i ' ta o,lt ' I,t ttrtrrh itt, l rt i ((n'bn|1.t , i r t t ' l r : l ) lb t t ' t i i , prr tubrnr,n! i t le in. , far iourt i t t tc t tstazi i t . r i i i l t r r r r t t r ' r ) r t l i l r r { r rt r r r r r . l r iL l r r i r . r j nrr , r l l l t 'o lo l r f t12r i i rcrucir l t r tc:r l { ) r ' . ia,r c i i i lc strrs i l r i l i i i i { i i l i ' { r ' rr r , : i , r l , r l r ' i t r I r ' r t t , i1 lntr . l ) { ) i l ( ic(rLL, i t t . { ts lo lcZi i ln i l .o l g{ ' i l ( f l ' i l Ni t t t l l ' t i t t l t t s t t t
t l i t , r t l t i t t r ; l i r l l l t t l l i l i t lc i icnsi l ) i l i l l r loglol l i r , l i i ,a l t l t ' ic i t I t ' i t t t ' t ' I I r j i l r r t t l l r t tl r , , r ,L l ! r ' l r ) i bci l t i l r r t tstczic rr or t t l t l ntel l r l i , ( t t i lo ix los( ' ( ) l i i l l l ' I r l t ; r i l l l ', r , , , , i r l s i t i t tg lorni( '1 i0. Aceirst i r , tu l l r r l t t 'e al t t , r ' r l " t ; i r l i rocirr l i t l t ' r l t t r i l r i l t. r l r ' yrr ic inr : i r ,ost th i in s intL 'omul lu i \Yal l r tn l rctg, l l l t t i l l r r l r i t t r l i i Nrr ; : ' r ' r r l l , 'r r i l r r i ( lcstrrn-( lh{ l l l i i r ( \ 'cz i c i )p, 1) .
t . , : i r r t t i lc 'prr iubctut t ! i t t le su,1t t : t ioatc 1 'L pcr l t r t t . tu lar t t l r t t t l t t l l r l t t r l l i r l t t. ,1r \ ( ' ( ,o i l h i i . i l .c . r ' | , le alo f r , {c i , l t r r t rc}r i . t i l t t i ; i rnt ' rn l r f t r lo i .
l l lc;ittrt iIt bu, tu,re intrt 'oli t:nrr:, r iel,ot'rrt i I Lrrtc l lrrolri lci l t l i t l r r I r I i I r ' t I t t r ' ; I, r r i , r ' r ' i s l i in l le l t t t tc l io iu 'er pt l in1;r i lcz: l r :o l . t f lscr ict t ILrht i 1t i t ' t t t t r i I I i I I i i i : t t t l t t r tl r r r l r , |oglos (r : i l le genot 'oaz: i o homiple!{ ic cr) l t i . f i t l i i t our l ; -1, ; , i l r l r t r r l iz i r r l r t
l r ' ' r t i r l rout i l inr i r i i ipsi l l t t ta, lo) sc lczl i iz i t ; i pr l t rg l i r r r t , l r r i l l t r i l i r r r ! i r r r l r ; r ,, r . i i r I i . t ( lnr f ( r t l ,z t i 0 l t t rnt i [ncs1 r ]2 i0 ool l l . l i l l iLt( ,1 ' rL l i i l ] l ' t l l l l i s t ' r t ; r i l r i l i l r t i | ' r r
l , r , r l i r r r r i r i ( t1mi o r l isr . rc i r l ! ' i i r r lc i : ip ln l ro l i t : ) r ' tL l t 's ; r t r i ' i r t r t r t ' sr ' l | . i l , i I i i : r t i II t ( r ' , .
l l l . SinirotLt l t t l t lukinicr : i t t l t t t lo logtu, ' t r t r t r t i t t i . ' s i t t l I I I I I I | { ' I i ) i I i . t , l l l i l l l l, l l l r i t t t icst l is t l i c l l l t ( ]sui iLc in r i l t in:el l deccl t i i , . l t l i l t l i 'o l t t t t i . i l i r t r r l l t t t r r
I rz l iL. r l t t . I '1t le i lo i l i lh ln ic i l i i t con0! iu l l i l { } r ' l l ( rcstorr l , I ) l ( r I l l l l l r , l l ) r ' l r r i orr \
' , , r r r r , , , t r l l r tc lo l r t l or ' Iof t rnct io l l . t ] o, a ct- ' lot ( ' \ l ) ( r l i l l l ( ' t r l i r l ( 's i t l r ' l r r t l r r l r r '1r , 'r r r r . t r i (Si tgtr ' , 1960; f , i izot lhcs, 1.967 I L l r t r r r r r i l {1r , l l ) . ) i , l l lJ i l i I | , I rct t t r i I I r '
. r ' l r r '1krs, 19l i t ; A, iu r i . rgrLtrr t l , L1) l i { i ' c i l l < l t r l l ] rg| l ' , l l l ( ;0; | ' r t I toI i I i t t ,
l1 l , i t i l )o l ) ( i t . i ! i i r r , i i 0rrLlrb. , 1 l i i " i0) . l 'o l l l t l t i t l leJl 'gt ' r , t . l r ' i t t ' t rs l r t l i t t r ' l r t r r r l t t r 0t t r
, , r , ' l l t r r i i i r l ro l$t l i , ( l 'opovir i t t , l { )7{)) (1, ' iq. i t l ) ) .
I . s i iu l ronnl l r . r l t r , t r t i t t g l .o l ,u l c lnsi t ' lq on, t l t 'scr is t l r r l ) ( i , i ( i l ' i t r ( ' s i l i , t t r r t 'f r f l ls l r ( { t i t l t t l l l l i i . l { t i l t ( l l ( ) s j l l l l ) lo l t t ( l : i \ ) I ] ( t iat t f t t l ( ' ! i ( t l r l ) ( l l t t t t r l ) t ! r t l
l , i r t t t i i . t , t t o l t i ( \o lu l i r i t l i t f t t l ( i r l lsot ' i i r lc ( r ru l i t t< lctr t l l t . t l t l l I r i ' l l l l l l l r ( ' l l i i l r l
l r l r r t , : r ptolut t t l i i ) . l , ) r is l i i , s i l r r r r { i i i rL t r i l r t i ' t t l ) t t t l i t ' i l ' t l t s( ' t ts i l r i l i l r r l r ' r r l r i I r
t r r l r 1,ol i t r t l t l i ic l t i rs l tcol t ' t l t r l lc t tz i ps( ' l l { lo l i l ( l i ( l l l l l l l ' ( ! i ' l r l l l i t l i ( ' l l l l i t l l l r l l ( ' l lI r r , i . r r r l is l t i l r r t { i r r i : rx l i r r | i i sr t t r l t r l r i l r i l i ) , (1r [ i r r l ) ( ' l r i i i r l ! { ' t l ( 'z i i l r^1rrrr( i r r l l r l r '
] l r r r l . | | r , (x) i l i ( i i l i i , i t t i ts t ' t t tot t t i t $ i l l l r l l i i , ( l j i lg l losl i t ' r r l l l i l i ' r?tr( i l l i t t i t r ' l t | . t r r i, r r r ' r t ( ,z i i l i r r l l t l t i t ' r ' i q i l tc t r t i l t t t t 's l t 'z i : t t 'ot1i t ' t t l l i t l t rv i t t r ' l i l t t l r r r l i l i l i l I
I t1 t l t t t t i l r r r t r : i i t , r ,y i r l r r l l r . . . | i r i i (s i t t t l t l t t t t l ( ' i l l ( ' l l l i l r { l l l l I r l l i l l t I l t ' l l r ' l l l l r l l '
, r r1rrr , r ' i r rz i i l r r t t t t ( i t t r , l , l r l r t i l t la is ( l l l lz i l l l l f i t l l t l i t l t t t ts t t l t r i , r ' i r r t r ' ; l i t t t t i r
r r r r r , , , i t t r r i r r r r , t r r ; r , l l r . i in l ( ' t l t r ' ) ; c) l l t ' t t i r r l , t r ' , r i t ur t t l . t t l t l r t t l t i t ' t l t ' t t | ' i t t ' I r ' t I '
r r i r l r . ( r ' r , t t . l r r , l l r rn( , , i l i r ' t t , r i i t l r r l I t i t t l t l l l t i t t r ' r r l r to l ) t ' i ( t l t ' ( ' l ' l r1 i t ' i ) t l l ) l \ / / t lxr
t r t t l t r ' l , , rxt t l t l t t l r t r , / r t l ; i r . ( i I I I I r ' ( | l \ I ' I t i I t t t t r t t t r i1t t t ' i i i t I | | I I I ( i | , t | | | I I i ) i
r ' l l l r t t , t i { / / r , r ' . r i I r ' i | , t ' r | | i { ' | ( ' lp | r ' i r t l r ' ( t |z i l l t l l i , jo l ) t l t ' ; t l t t l t ' i t o l t t t l t t i ;
l l ' l ' , t l t tnInr, : i r ' ( I r l r r r I r . t r I t t I t t t t l t r r l r ' l rx ' t t l i l r , l t zrr l t t t c r t r i l l r l i i , ; t r ' l t t ' l r t ic t t tpt t l
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I r r r l r r i r r ' )1 g) Asr.*otnu: i t (1r . i l r ru l l r r r ' i i . i l r . r ' l t 'sr : r rs ib i l i t . le, r r ,dcoscbi r r r r r"l r r t r r l r r ) ; l r ) J. l ipr . ' rput i r IuLunic. i (s i lu, ,s lptrTcacl i r . la lamicr i , ' , cn"espr i r r io.lrr' l,.rrrr,rLrrlui o ,,ovcr-rcactiou,' l l tufllcrd), carc constd, in fendmenul.rr'irrs .ii .r'icr. c-,ir:i1rnt, chiar. sublirninat, ,Lph;at de partea bolnavi sarr(lr\ p.r,r' l(,a $rruir,ljoasii nneori, plecum $i alli excitanti (de ordin senzorial,
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LECENDA
6r nucleilor Gr nrcleilor 6r huclei lor t6a nucleilor
CL:N. Cq'p gedcuto,laEral
CM;Ncory genbulol
OM: N.l)f,Rp-
+N. furdfasci:ul.3U : N. Sutndib
VL (W j:N. Veitr. ld. CL: N. Cehtral
l-D: N- lateral
Jriq. Jr, Nucleii talamrisului $i concxiunile acestora (poporiciu, 1979, sehem$({'rnbinnLi dupd sislematizareatf,nucleit";"?;.r,n n" Wa tct, Sager, Le Gx)s
i : l l ' . iJ l i , i l psihlu) sc, , i r r t ( .grcazi" i r . r durcr, . . -A,.1f t . t . r t , ,p i l i l i i , o c\( . i t t l i ( .I i r ( . l i l i i , d l l r ( . r l ) t f i qrrr lcr ' rn ir . i 1 in stx.c i l l i r igrr l srru at t 'u l r i . r :e), ' ( , l r i r r s imDLl.I t I i t tgr . t ' r r . ru nic l i i , l ) i l l ) i { , l . i tn l , l r i r :1r1r i rrr l1 l ctc. . r l " r , larrs, . rr .z i r i l * Xa,r , , , , l i i r inr. \ ' l t { ) ( |ut ' f l r r t r ) l tH(, .vtr , .c
-( . i l l . i lc t { , t ( lo i l r ' \ lD, i " i d i r : l t l r t ,oklr i l t r l i t , l j r_
r , \ l r ( , l l l ( l r ! ( l ( ,Zir f i t1.r) l ) l l . . i i1 t l l i i . { l I r r . l t )1, i i s i r r l . r r .s i r r r l i l i t r r r r [1. t l r r r i l )Ul( . t , i r .r t r . ( .1t . l n l ( r ( l no i t l ( l l , | r l r r lgr ,z i r . ) . I t r . s l r l r . r , i l . l r t r r r i r r : t . I r r r I r . I . I r i r I . i , r r r r r . l t .
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r r r i r r rHrr l i ( i tu l lorolr i r lozugrr , r rJr ikr) , ct t to! i iL ' , r rv l r iL l l r { , i i t t ' r t t t tL ic i ( t t l t i r ' t ' t t t t l I r 'r r r l l rx l i i ) 11i r rst i ( , i r , t , i ikr v iHorr t : r ,Lr Jrol , r l r r l r r , t t t , t l t t t t l i l i r i t , r ' l , t r v i i t Io ; t t t t I ' t ' r t ,l ro l t r r t ,vr '1, . Ani , fo l , t t l tu l d i r r l ro lna,v i i lu i I l t r r r r l (<r i t r r t '1, t l r r Sr!g( ' t ! . l { l { i ( l ) r ' r ' i lr l r .orrr l r i i r lo af lxrNi l t r lc rnt :z i l i i , , l t tc i { , , , t t t r l l t r tor t , sI r t 'z is l r t I t , i t t t t t tu i t l r t 1,r t t ' i l irrr,ttzrll i lkrr do par'1;ort, sll bolnilvii,", i i l l rtlt lrtoirrnl, rrl ltri Ilrrrt,tl it,l ' it 'ttttt, t 't ' l, , l r l ' r t t ro i r : int l o in l , i t cotul , o srrr tz l t { i r : gt 'o iLzt t i r l i t v t r r t l t t ' t l i r t l l t t ' t ' t r t t , I loIr t l t t ' i '1 ' ' ,' l 'r 'o|ll i l, i i],ceastii, leritl inl,ir, tlo t t 'tr:t,c! iOtllt oxoosiv ltt 0ticu 0x0itit(io s0tteil i r l , sr inzor i t r l l sa,u psi l r icr ' i I r '1r l ,z in1i i , fenoruct tu l r lo supt ' r r rcr tc{ i r ' l r t l t rr rr irr' i, (,,ovct-teaction"-IJe:r,d ) sa,u d o ltiylpatirt" A ccsto lonottttttto st' t 'r ltl it i ilrl irr lrlptul (Sager, 1960) cil, in nuclcii latorali convttg c-roil,l l l ' i i rrfi1, tlittrrrr.rlirrl itrtern (prin intermediul nuclcului dolso-mtx.lian), rril, i i i tl itt tttr'tl ittlr.rl 'r,r'rr, a,tit prin nucleii tjalanici de releu pc cit' i le divcrsclol ilf('r 'olrlr\ H|tlzil ' ivrr, cit 6iprin nucleii talnmici nespecifici, in lela{'ie cu fotttta,tiit, t 'trlitrttlrrlri, rcspectiv chiar stalii pe sisternul reticulat asccntlcnt (v(lzi lig. ii l)).I lqr,rl 1i f161p"* (citat'i de Sager, 1960), incercind sL e xplicc tlut'ot't 'tr hilx't 'rrrrl,it.,l i, talamicX. au ar5tat cd, lezarea fibrelor cortico-tll latnicu rt,t t 'I iItt 'trt, 'r ' lrtlelo senzitive talamice de snb in{luenla colt' ical5 inltibitolitr 6i rlo tttrrrrrrt'rr('r,g1,i nouloni senzitiYi ar prezenta o ,,supraleact,icr' ln olitto r'rcilrt,ttl,llrirr,r subliminal. Dup5, alli auttli (citali do Sagor, 1960), rlivcrsohr 2rolr"vIr'. ion,a,le (tasoalare, tumorala, i,nflamatorii, cticatriciale elc', ) an cxcil,rt, txrltt lt'lt'rrr,rrzibivc talamice qiar produce durelea. Incerclrile clo inl,olrotrrrtt rt tl lttt 'l i lol talamice au dus Ia il ispute incd' incomplet elucidato. S-rltr rr' lt ' i lttti lrui,fol talamugului, in afard de rolul si,u ds re]eur qi unelo prtnibilit 'rl,{,i tlrr rt
' r'nlrjbui Ia elaborarea senzaliilor tlate tle stimulii nociccpt,ivi tlo l ip pt'trlolxr,tic (Mori.n, 1955; Ilead, Ilolmes, 1912r cita!,i do Sagor, I9(il))' lrltot'rrrill,e (1936) a ard,tat c5, alterarca nucleilor laterali exalttl, lronalil.rr'l,r,rt, rt'li't'livil, & senzatiilor, intruclt aceastS altelnre ,,Buprimil, un l[n:]ljj. trl,or, lrlllill,nr selectiv aI sonsibilitd,lii gsnsrale", a cd,rui func!'ie csto tlo tt, ttllri trtttt||rrrrcntele dureroago gi protopatice ale acestei sensibilit[] ' i. l)uror('r\' l ihltl
" $onzatie, esto fd,r6 indoialS rezultal,ul uneri funclii coltionlo, lnl,ntt'il,
rlorlr la nivelul scoarfei excitatia se transform5, in senza'l,io.Desigur, dnrorile rlin sindromul talamic ritlioit, plolllornrl rtivtrlttltti
lrrlrnlior al integririi senzaliei dureroase, iar o ,,soluJic irtrprrr;abill' qi rltrttlrr problemei nu existd qi mdte tlin concepliilo mai vochi 6i mtli trtotlottttrlrrr,zrr,to pe interpretd,ri $i fapte totuqi obiective, difur\' tlo lit lrutol ltl n,ttl,ot"'(Alnoni qi Operscu, 196?). Scoarta cerelrralii, rcprozint;ii lt,pll.rlll,ul sttporiotrlc porceplie a clurerii, Dar qi talamusului Ii levirrc, dcsigul rttt rrtl lttl lt lt 'itrrportant, atit do releu pe cd,ile senzitive (inclusiv dunt'o?r,H{i)' <:il, qi llrrli l l,ru seloctiv, precnm gi de a ,,moclttla" qi do n contribui ln, ttlttlxrrlut'trtt ltrrivolul scoar'fei a unor senzc,trii parl,icularc * tlupil, cttttt trll l i l lt(l l l l l lrrttotior'- prin convcrgonla, ln nucklii latera,li n' unei lnulti[utlitti tltr ttLr'tr,tr!o extcto -,proprio-gi visooroocptivo ;i prin I'oltrl,i ik) ittrtrst,rtr tttttrloi t 'ttl i ltnal,ia, rel,icnlarit' qi cu sc.oa,rfa ccrclbrt i*l (Sllgcr, l.$60 1,\rscrti qti ()l)r('H('lt '
f lf(i? ; IloDovioiu, 19?9) ; i) Mrri pot apiirtr:l rnirscrirti (,or(o'at(totit:t ', \ '1\t't\ Itl
tlr.norlrl sitrf tl iscrcl,tt i i i lot:a'liz11,e la nivrdu) rniinii (prin ltrzitrnrrll I ' i lrrtrlot'lrrlit,ttto'8trirto, r'os1:txrtiv t trucltttlrti trot ti,t r l-ttttttl i ltt t l,l Itri Lu,r-s); j) ,,J\llrrrr,lir,l iunir{r," rrsLc cu't' it ttt ol' int,irfi , ltt sttttsttl t,i 't, drrgrdcltr sin1, tltrrl i volrll,tr tltt trtl l t orrr i6oi l , r ' i lo l totozi<xt(utStt"z isr , lot f i t ,ut l i t t i t lo, , t l t 'gcl , t r i t tg l t t r l r t lot 'pr innr i4rrdl l l lrt,l,ol,rrzitrr) i k) ll 'rt,l,hurllriIrt ntnlotittkt Hitlt rtl)roz(flltnlrr lltr: lt 'trttltittrt'oltttitthk 'nt l i l l tont ,oni 'ntd ( l l ' i t t l r rz l t t t t r , ; r cor]1t t I t t i gct t ic t t l r t ' l t rx l r ' r t t ut t t l ) l i l l I ' r { r t l l l ) l , r l rr rn1;c in, l t l t t r1t . r , l r t . r t lc I prx l r r r iqtrrr , l i r r r t | ,z i r r r t r , l r r I r r i lo l i r t l r r r r t ' l i< 'n l r r , l t t t 'c l l , t , i ,
zrl
, ! l { r . ) l l i t l t t t l t i h i l ) t t l t t l i r l t t ) t t . i toNIt iNd Jt i l )o. t } ( t t . ( | / ) , !?}? ic ( f t , i l t l .z i r r r r r , l tr r r t l r r t r l l l rsol i l r l i t . crr l i t I l r r r . r ' I I r , I t t I ) .
:. ' . t\ i ttr, ltrrrtttt l t. l ttnticr ltrtt l iuIt,. rt) [)a,tc ir nilt ut rro-clinice (a1e lui |hor,rrrr l l r ' , l1)1.r , l1) j i l i , l , ) { \ . l t i i rs i l lc Iu i l l i r r , i tescu f i Nicul tsc ,1925, c i ta l i r lc)ir l l( 'r , I j){io j i ' . j ( . I ) L i j . 1. ( | I , , 19;i{i, ci1,al de S:tg01,, 1960 ; ?opor.iciu si coial}.,l1r' i l ' . l lr$1)) , lu (loilLurri i lrut crist{tnlt ttr\ot s i,trt lT ao,rla lalamice at luibu,rd,ritl, :;t n:;iltil.ilrrl,t, itrsd .lrirri dureri, prin lezrrea, exclusivii :r, nucleilor ventralil )o: l | { ' t i ( | I i .
Ir) S rrLr rlcrrrris Jitrntc heniotgice pltre ^le
sindromului tr"lamic (L,hor.rr l l ( ' , I l ) i l j i ; ( l rLrr : i r r , 19l i i , c i ta, t r1e Sa,gor, 1960; Foerstcr , 1926 I Sager,l1) l i ( l ) l l i i r r l t ,z i r rn i uLc nuclei lor 1atcf t r1 i .
,1. f i i l l( lr '{) iulolo [ulln[r:p ruscrthu, sint tot I ind,rotune pu,yli&le, Tez,l i,, i ,r l l l) i ir l plotlsc vilscniale loca,l izate hr teritor.iul ut:ruia di-tr cei cinci pedi-r r l i r r r lc l i : r l i t lcr .cr . iq i inc. . i in 1925 dc l lo i r , I l i l iemand si Niculesut: : i , r tcrc lcLrli lr l){} i( 'r i(,rri i l |1, si tall irno pe}folate (r 'amlrl i alc : l l terei cerebralc pos-i( r 'rorr('), |1,1()1.,r l{_' lrt irulo- opticx (r ' l ]}rtri i a, rrterei siir. ienc), arteri:I, iubero-Irrl irrrricri, (r ' lunuli a itrtcrci romunicante posterioare) .,si artcra coroidi, rrr rrrrl l l ionli i (r:rnnu,ii a artt:rei silr-ienc)" Cele mai i inportaute qi mai frec-\, ' lr lr. ! i lr lr l) itrre ti l l : l lnice \. i l ,scu1:lt,c sinl cdle trei rarietd,l i { lescrise de lher-rrrr l l r . r . i r i r r r i u l { rs dc Si tger s i colab. (vezi Sager ' , 1960) :
t) ; i l( l)\Dtu,l Lle. obliterare e, patl ic,tLlu,l lLi l(.1& xo-qenicll lat (carc irigi,|)otl irrtroii l l l tcrl| l i i si l]oiitelio:ir;1, indeoselti nurle1rl yentral postcr'o-lal,e-rir l). f i1' r lrnr{,t{ri izr,rrzl plin tulbur.i ir i t ' lc sensibil i iato obicctivi, la mernbrelttt:t i i 'rplirrlLl,c Ir rncmbrul in{orior), f i ir i i afeciar:ea sensibit it i , l i i felei.I )tttr.tcr'. rJ,rr. i1 e-risti i , se tl l i pc 1rltn secnndar $i este pulin explimatd,. Setrrr,r loi, i lrzi o herlialropsic homonimd,.
l) irrsttosrl ir,r l l i ]rr imll ici i t i i i i icult i i l i atunci cind apar $i alte simptome,ttt :r lrrlrr cr,loi scnzitirt : r ir irt i i t l .r lamici, miqor,ri coroo-atretozice, tulburi,.r,|r.I)( 'I().I) j( 'si irrrrnilrtolts!e hurnitnim,i laleralti (cal.e insj, eslc de originerot l i r ' : r l ;1, r l r '1rr ' r r r lo l l i i dc lczi t t rca col t ical i : r , in. te l i l ,or iu l a l tcrei col .cbralotro r l r . r io iu i , r l i l ( ' r r ( ' prr l r i re r i i 1 ler i icuhl ta lamo-genic i r lat) .
I i i t innr'\. r ltur' l ttt t ' t 'rolo11ic, sil ldxomnl talarnic gIobu,l (cn de altfel qirrrrrJtrr:rrrrIIrr lI i .trniirtr p,l i . i i ' t lo) cstc re:r1iza,t Ll.e !x)c6p, t:uscti lare (ramolis-t trf l r r i ItItrr 'rr. l11ii), It ' ottt!1i(:e, l i t la)'e,le (indeosebi glioir,me), t legeneratiue
t tu I lu t t t t r t , t i i (o1,( t ' . f i l l i te) .l\\ \ l i t l t i tt) lt l t l r l.e oit l i terorc o, pddic'ul 'uLai tu,l ma-perJor&t (c'r,re i l igd,,
lr,. lrrr,tr i r, ltr. l()rir i.n{,irLri exti:ttalanlicr], nucleul se.nilunar :r, l lui lt ' Iechsig).'- lr. c trrclclizlri i l i i l l in iullrur': i l i de sersibil i tate obiectiY:i ]a nivelul felei,rr i< i lrr rrrr,rrrl i lrr l slrl)ct ' ior' r j i : ibsente 14, merrrbrul inferior, L:l fe1 durerea,rl:r lr r.ris1ii, r<c silur::Lzli 1u, rrir-e1u1 fc;lei i1i er-entlal al mcmblului superior
r | i, l , l)rrl in r\pfinrir,t i ;. Se pot asor:i i i un homisin{lrom cerebelos, mifcd,r' il irrr,rrrrlr, lozire 5i ,,min5, i: l larri icit,". Prcciziim c:i din date lurnizate dcI ' r , r ! | | ' , r ( , r r (11){ i6, 19?6) 6i rb I?opovic in Di colab., (1980) s inr l ro lnul de obl i -lr,r 'rrl l rLl lrrrrl iculului 1r:l larlo-per'1oi'a1 poato fi rnnll rn:i i gl ' :t l , tnai boga,l,t r r . r r r r l i r r r r l , i t i i r t rc i t , i r r l r l ) ropj t . rc iL l in ic i rnet l ianc, f iecale dint le artc lcI t tlr l j i tr,r Ir( 'r ' l i) l lL{r ro iLnp,n't.tr irL rlouii r ' :rmnli, ci l}r sc diri jeazil bilatcrrl, i i r igrr s l l rLr , l r r l ikr l l l tnuo-srr l rL l r l rD.] jcc s j rnel l ico- Tn l tcest fe l , l r l ,etole pcr l i l r r l r r l r r i l l l r r r r ro pi . t ' l io l l r t i l iq i l r i rn l . t r l i : t r .g iutLi i l i rncef l l l ice, ludi fcrerr t t l i t tr ' : r t t l ) r r ' j ( f p l r rv rrr . I 'orrr l rct on ( l ! ) { i ( i , 11)?0) ; i l>opovic in 1i colr t l l . (1!} l i0) , t t , l tl ! l<.r i l r r l l r , l crJ i l i | r r { i r r { i ( | ( r r ' | ' l I r r | ( ) I i } i I i r ( | t t1t I t r got t r t i t , l ,c dr t o) lst t ' t t t t l i i t t t t t t r i r tr l t t r l t l ' r | r ' l l r . j lJ l r '11, r ' r . i r l izr , i rz i i l l r r i l ) r ' { f i l l i l ; t l t t t l i l , r l r r , , f l tL l t r t r r" , ( r t t t t i ' i i l t r
1r iotr t r r IoIo;1ir , ;1trrrr1, t l i . Icz i r t t t r , t l i t ' t t r , t ' l r r l i l i t l r i l l r l r r t ' l r l i i ( i t r< ' l t ts iv t r t t r r t t t t t i l ) .
: l l : t
r ) i t in l t , , t t t t t l t l t r l l i l | t r r t r r r l t r r l i I t r lu l I i l r , t t l t r t t l , t 0 l t l t t ( r ' l r r r ' l l l j i I
, r 1u'r ' i r r l r r r r |1, ' i i l : r l I t ' r r l i ) r r r r t ' r t t r r t r l t ' t iz | r tz i t ; t t i t t 1r t 'zr ' t t { r t l ) ( ' t r r ' l l r l l ) l r l r i r
, l r r r , i r i i ( r t t lor l ( ' ( l i r l i r ( ' l r ' l l ' l ( ' l t i l l l t ; r l r l i l r ' ) , I r t ' r t l iz : t l l t t r r r r i t l t t t l l I l r t t t l r r t l r t t t l
r r r t . ' r . iDr '1 (1 posi l r i l i l i i ! i r l I i t ' l r r i i , . r r . ; i l r r r r r | t I l r tUl st t l t r . t iot s i l : t l r i . l t , : r r t t r r l
i , , r r r r I i I r r i r , , i , l i , , . l i I r , r ,gclr l i r , i ' i r lcr | r ' i r i i . ' l ' r r l l i i r r r i l r , ( } l r i r . r , l iv | r l I r r , " t t ' r i l r i l r
i r i r ' l i1rr1.1q1' , s l t t t s i t t l nt i t t i t t r r ' . St ' l rstrr , i r tz i s i o l l t ' t t t i l t l r t ' r 'z l i cot l i t ' t l ' l l l r r l : t
l r r r r , r : , , i r l r r i i ' r l i l l i i i j i t l ( ' | l )s l l l ( ' i i l r l ( l ' l i l ' \ ' { ' ( r r l r ( ' ) .
\ ' . r ! i t t r l tnt t t t t1 r i is l t i t r l i | i , ,h i l t , , l , t l ' r t t i t r " ' t t I ' t i t . i t r i | |
' r i t t : t i l l t t i ' ) t t t t t t i t t t
r l l t l l , r ' i l : r { i 11t , l ' r l r . i i t i t t s i t ' r r l r r i ' . r 11}sl l ) : r l ' : r r l r l r r r l r i ' r i i r r i r ' . ' r r r l " ' r ' ' l ' '
r , i r r i ' l t ' t ' t ' t l i t t gr t tpt t l t l l i ( l l ( ' l { ) r ' t t r s i i i i l t r t i o| i l ' i t ' i i l r ' ; t1rr t l i t l l r l i l ' r ' r Ior ' r l l r r 'i , r r r r r ' ( r ' l t r r r t r l i a lo i ,o l t r }nrL, i 1, ' )J. , l i l l11 ) r i i i i , : , i t l l i i t , r l . t t r t t l r l r t l t t t t t , r r
: l , t r l t i ( ) t t tck ' s i t t l cr t t r l l l l t lxc ;1 i ( 1 '1r l i l ' r l : l r , t r r i l r i l - l i . I I ' I | | | : I I : I i ( ' t : I I I i " l l i r r r l : r r l
, r , ' l 1 ' ( ' l ( l ) ( r l l )s t , r tn 1,r ' t l l a ' tct l l ] , ht t t l i i t t r t i l ls i t r t t t i lotr i t t l ; ' I 'ot t I I I r I : r I l . t r | : t l t t ' t t t
, r r , r icz ic cotLl t i l l t i tc l i l l i i p l o i lornin:- i r ) l Uoi l l l l { l i , 1 i i ts l t ' r loqt t ' rzt t "
l ) t ' i r t1 i l r , [ 'oJxt t ' ic iu; i co1e1r. (1$( i9) t r r l l t l lc i t : r t1 r ' i i i t t l t t t r i l t r ' l r t t t i l, r r l , , r ' l ) i : l ] , in i t l . r le, t ' \ 1r i lp in l l l i { l r l1. , {x ' l \ ' l ) { ' lo ' rL( ' , ; r ' r tz i l iv t ' ' i v iTrrrr l ' r t | '' r , .1r ' i i i I l 'g iut le: t h ipot l lLalr i " r , , ' r r l r . , i r ; r i l : , l i r i ' r . l ' ' I r I I I r r l l i r l LrrrrrrLl
r r . r lc t t t t t l i l t ' l t , cor ' f l l t i l l i l t t lc l l Lr i s i l t r l t , ' t t l , s l , r i r ' . , . l t t t l t r t t l l ( l ( r ' i r r I r i l l l l
r l , l r l . tn t i t , i i " .
r, . '\ iniJrontu.l, san[li,L, rcrti.(:sl l ltrielo['/ ) l ,cz iuni lo par iet i l lc pot t letct ln inr t 111) i l l i l i l i l l l io l l t t l l t t t t t i t i t l t ' t t
r l t i l i i t t l t r tnnplerr i , culu s in l , t r r l l lu l ' i t r ikr r lc r r l l r i ' t t t i1 t ' r r t 1 I r r t : t I I t . : t ' l ' " ' t, , r r , ' , r i . r , l l t r - ; loenozi l , t l ot ' t t r0 l ] cx i : i ( iml l i ls i ] l i l i l r l l | l r t l r ' l t t t t t t t ro rr l ' ' l r t t t
1, r t i . i , r i : t ' v i iu i l lS I c i f r . lcr l i tc i i l lc s l l t l ( l ( 's" l l . l . l t : ts t l . r l " ' " r t t t r t t r r t l 't , , l lur l l t ) t , l l tdo l :ur l i t l r t t l t t i , cr t r l j l l i { ) l ' t l l l t r t l t i I ' r t ' j l i t r t l i r r ' l i l ) r '1r ' l t r l l t
i , r i l ( l l i \ l iet , le c l l ' t t i tLtc: osct t t ; i r ( ' i lcr i ln\n) ln i i l l r ! { ' i t l r r t ; i t l r r l : r i r r l ' r ' l1r l r t l l
t1 ' . \ . ) j i 1 ' ro i ruca ani ,ct ' io lu ' r i r ' c i t c ' , t t l r -o lu( i l t t t i lc t l ) , - l '1, r l l r i r r { ' ( '
l l l l l r r r r"rr '
. , , , r rs i i r i l i l , l i ( i i pc jn l l t i t t i tca olusi l l l cor ln l l l l i , I t t r i i I t t ' I ' r ' t t I t I I r I i t r ' ' I t . t r r I I t '
I nr , i i l l { 's po incinhi u l supcf ior . l l lL lJJmri i r t ' l t 1tr t r r l r " i i u lo l r r r l r i , i r r l " r ' r r r r r ' l
i , ,LL ! { r1r( lLr i i lc r le sensibi l i t l l te, s ' i t l 1. to i t l t , l l t t r l r r t t t i t r r t r l . i r l l r l i r r ( ' r r i l i l ' i l r i r r l
1r r l t t t t r l i r . Ani 'st t t ; l i i l t ' g l<tbakr; i nr : ls ivtr r t ic t t t t l i i t t l l l t i i . ] t t t t t l l l r r l t r r " ' t l r r r
l r r r r . i t r i i t t t i 'o t i l 'o i t t l lo st ts l l tc to l l l r 1; i t i : t l is t r t - , \ ! r '1) l t ' l l i ' : r l t t t t 's l tzr i r l l r l r t l '
I | | l r rs i \ { , i ) i } l l lp i l ( , t ro l ) i (x1{ i \ - r lOl t I i r r i . : lz t l t r l i . :z i r r r | ( prrr i r . l : r l : r i t r t t t t t t t i t , : t r t r t t t
, r , r ' r r t r r r r i i i t t t t t t l - t t1 1l : . t t iet i t l s i ncorts l , l t t l t t l t t ' i t l 1 l r ' , i r t r r r l l t i t r t l t l i r t l | | | t | | i I I I I I | | '
l , i ; i r r r r i i .
t i t tcot ' i l t t l l r t t l 'a t ' t t , t l l t r str t t s i I r i l i 1 i r 1 r I l t l l ' lLc st l l l t i r t t l t l t r r i I I { | | I | | I I I I I I i . ' r l
r l r t l r r t i i t ' r t l t l t 's l t is t l t ' V, ' lg l r r i i l ) r i . i { r ' i r r l ' , r I r ' t ' r ' I i t t t I t t i i r ' l r i l t r l r t ' t r t r t l ' t
l r l . r t i i I r . l l i lc ( 'p i ( ' l ' i1 i r ' { } s i r r s i i l ls i } r i l i l i t i j pfol ' l l l r ( i ( ' r ' r r l l r l I ( ' r r l ( ' , r ' r r I ' i l I r r r ' l
r r r l r r l r t i l r t r r l i l I I I ' t t io; t t I i t ' ' r t t 'c l t t i i r r t t t lo-r t l i j ,z i ( r f i r l t l l t t i t ' i l r r r t l ' r t ' t l r r l t
r r r r l r i i ' r i t t vq ' r ' i t i rb i | i I t l isol i r r l i , r ' t i l i , i1 l l r r l r l l ic
| | l , ' t r r l t r t ' ( r r i i t I I l r ' ( i t r i l r l t ' l s i ( l t t i l tcr{ , l l l i l ) : l i r l r is l : r l I lsr lpI r r l r r r r r l r r I .
t t t r t t , t t i l ) t r l t t t i l i l i ' r l< 's i t t t l t l t t t r l l r t i s l t tz i l i t ' t ) i i i ( f l l l r r ) ; t l . i t rx ' ' r ' r ' r r r '1r ' r ' r l
. i ' r r , r i I r i I i I r ' i I i I , r r ' ; t t i r I t t t I t i r ' , i t t r l i l , r | l r i i r s i l l r { t t l i r i r t l i ( l t ' l i t r i l l ' t sr ' r f r r r l . r r l : r r I
r r r Sirrr l r r l r r i \ i l t | i l lot (p i r l r . l i |z i t r r r l I ) | l i i , t l l ( , I I ' l ' l ! ( . l r l i , . ! l l r I I I I ( ' I I | | ( : r l r r , l
l , i . l ' r iar , i ) , r t ; t t ' t ' r ' t '1r I i l . i , r I t t t l ' I t I t i i . r r r r t { l { r ' i r l i t i r t j ( ' I r ' I ' r ' I I ' I r I r ' ( r l r i l r ' i ' t t r ' t r t
t l r r I i I I r I i |o l I t IoIr ' r ' t t I i t r ' ( r . . t r ' , t1, r i , 1r ' t r r1 ' ' t r1I t t i . l r l r I r r ' i l l l l ' ) ; I ) l r l l '
t t l r r i t t r ( t t l t t i l , r r ! i , r ' r i i , l i r r r r l i l , r ' ( r r l t ,1r , ' ; l t tozirr t , i r r r I i I I I i I I I | 1 | I | | | | ;
( | ) r | | I i | . I I , ' r i r I r ' t r I r I i l ' I r r t t t I t t t I t l I l | t r l , t l ' t t l I ' t l l r l r "L t r t I i t t i r ( t I t t I ' ' r ' ' I t z t l r ) '
' | ' I t I i , r r t I r t i I , . i l f r ' t | . " ILI | |LI i i i . r ' l r l \ r lL l , l . r I l : r r t t l l : r ' i I1I I I | ' | | i ' l l ( .
ill
tr
iii,,iiiii,i;;1,,ril;Li'll,iiili-#l**[qt*[,#;#i'fl"'ii];.i;r;;"';i:Iii;itijlil'i'li#,:lii", rrc.seusib'itateselocalizeaza po mini, sau,,'',,.., '"1. 111;*,lll.. jr: lbi:u_r t ul]:uririte Au s""silriiitat" ,i-oiaor,ht" d" tot-, (, i,,,, , ' ,ru,rrr, ri. lL(lrr(r Icz.lroa conccrnitenti, a fi,ontalei assendeate in
il;iiiiliili. rr,rlir,ccrrto ;i rrc l,l,rofii oror"oraro-*"*itn.iJiJ.i^o"."rlre de-Sii"
gg,lii$11;!li',1$lll;itt,* ;x"Jilill?1,"#"*'jtl:,'"'i",ij""'*'.*t'11:lil lilli'Ji;J ltii:i?:1TrJ.........,fi";:ilr1,'1,';*i*",'S"iliflili,":"i;*rroduto aproa.; I I tn, li'l " :;;, ;lt*lui il,1,lj: ,t,1*riil"*,y*::[;9l;:ll_itffi:ff fiiiiriliffi !jri,"*lf #i*:i?rdffi ,rrurmnay,*,i:i:s"*1,r,^,,.,,,
)r,rT',t rnr rile subiectiw de 'ensiiitita4
din sinalromul parietal con-
.,,,,,,il,,0'Ji'''Jifil',i*.."13"'*1ff**n'J".ll;;H: a,morferi, carc pot prera ra
r,,,,il,i{!i.':,i'if#tll#?ll;,'i j?Htli,"i*Hi'"r,"jT;;c?},^pi"si'ci,,,,,^,,?,.,1liii,iil#':f::ifj'iij?,1,fi.*1,"* llj*,llgf;y,i:r obiccte, care
:r;r:,rl,i jfl i:::ii,;T'fiiLi;,tf l3'fiit"il:;I?f ,*li;l[tx,T"llJH3.:*;l:l:ititlii:; '(;il',l:"jlili',J",;;Bli: i.:,fi'J;i;"1.#ll"T?;"jji"il,lJ,:*.i*:'ii:ii";11"-iliilililli'hllli"'Tl?#ii.,i?i,,fffil_X"-1m;;sticui,rircrin-
.lJ [)c o tenld, t:aloare d,i,s,,ttitttt,, h,,,,:.ttiz'r..o de obicei'JLi'jJ:,:]#:;i;iji,i{x.f,jj";,"ir,,tr",,lf;,::f.r,' ztt {s' trz':rlii rre artLor(crl'ti' ri,,illlf,i'l:,,];"il|ll,l;l,U:lliifi,,i:T,*
illi;:, i:lll:,; !!ii'Iiiil","iil,ii,r"eori cL ir r imp'r,oir rr., .:displriri.,,. a, meor_,, ' irf l . rr 'sUn()rly. Bu-perlor sau itfefior, a miinii, slu doar rr, unor dcrelet^
ijt:ililil.tiili::; i,T,:l:;r.,1;';#i;;j;."H"ilffif'J."JilJ,.HX?"",1""'Js,;i;,,r! {} r1r'rzl't, nlororlc dc 1jp R rav&is-Jackson.
. !) I,la o ce d, raloara d,ia gnodicd silt ;i ,remzele serniologice asociate
lli!li,!i:d;f; ff i'i'l,',v!,##l?f f f,i,{ti#t"l1.HT,Lr,i:*;n"x*{4*-xil:l:l't.:Yf::,i:.3- Temb,rur Burorior, indeosebi la muDchii mici ai miinii, rale-olr r(,illzuld un srndrum um6r_mind,), insoliti do tulbur{,ri vasornotorii
Il,fflil;JilfrlT,::li,;,"i:;i,i;'):z!"n,ii:;,yii,.l*:ll',li*rlli*,yl iif l l l : : . i t i . l ' , , : ' . r l n( .nzr l ry propr iocopt iv) ; d) Tu ru.rdt i oest ibut i re.1r.arr , , suirf i'i'l-ir'iil,iil r,lli)|;,!)tiiillffi'iflffiK'ff,(#d:fiiHil,iilli'f i,,ll;l,i;i;il;xl , i t tg i (vrrz i g lp. l0) ; g) , t , tL l .bniar i l izr i , r l r , ( l r r .mirr , r r i r l rs i , , l r , r rnotr i rnr l , t , , , r r -
224
IrrLrLrr l r r I i i , r l r r o l r iooi i r cvl t l r r r t t l , i l r l i ' , r ' i r r r ' ) ; l t ) A' i r {hr)rrr t l lu i ' l t r l , t t t t1 il l , r l , inxl , : i ( l t r r t r r i r rsot t t r t logt toz i r , , i r t t r tzol l t t t tz i r ' , 5 i i t t tozrr t l i lL l i r t ' i r r ) I i ) A' i r r r l t r r r i r r r l
l r t l i t t ' t i l ,uL \n, ' l tgt l ( rz io t l ig i l , l t l i l ' ( i t rct t l t r to i l r t 'k ' i t , t l t r l l , I ( tc l l l lor l !J l ' r r ' t l i \ l r ,r l , , r r r r r r r i q i t l t r l t , t l i l i t t t t r { , i l c t r lo c i t tc i t lsgtr i t r , t t t t r ' l t r i t t t l l l t r r t '1, t l t t l l l tc l r r I l , t t lI r r : r l l r ( lc or i t . t t l , r l lo t l roal t t ' l r -s l , i lga I l tcalct t l ie l r tgt iu{ i t r l l t r t i l r t t l , , r , l t rs i1tgrrr ' r r , l r r i I l l lyor ' - ( i ross ( i r r spocirr ' l l l t l t r t l t t cxtx l t t l i i t , l l t i t t i t l t t$t l t t t t r t l l : t l l l r r \ i, , , r r . l l r ref i i ) ; - j ) Al tc sernnc l ,oqtogxlJ icc cort icnle, pt i l t osl , t t r l * i r t , l lz i t t t t i lor"l,r I o r'rniri,iurlile vocine .
:)) lir cailrnl sinih'ornului pu,riotal sa pot itlanti'.li.ca ur nt,iil,tut t, I t tinrlr ',rr rtttr topograJica :
r1 il i idront'ul senzitia parietal global, clasic, lvl lrti, ).)(i6rint xi. l/lytr,. r'r,o[noaqte prin tulburxrilc de sonsibilitate suhiocl,ilL rii obitrol,ivr'i ' tr' lrttrlo ttterior, Exceplion asoci;r,zi\: antiotrofic, hctnitll lollsio qi rtlrtzirtl r r r I r ,z iuni le st ingi) .
ll Sintlromul, de girus puietal su'peric'r (a'riile \tu, 5b ) t'tl.r'lizo'tnti, rt.rll.r'.rrc rnai pulin marcatS, a tuturor sensibiliti,i i lort 1o ltt:trticorltttl rrottlrrrlrloral, cu test&urarea rapirli, a sensibititi i,fi lor ttlcl,i lo, toltlticii;i tlttt 'r '.r,r.rri, tl lr cu rnenlinerea indelungatd' a abolirii sol rsil,ri l i Lii ' l, i krr 1It'rIIttIItII '
c) Bindromu,l lui Anton' 1i Bn'binski (vezi :ltrtcriot ) cslo Ittrt,l iz t,l, ltrittlr',riritri mri ertinse, cate implicii, : puietala, anteriolt' i i, ltt ' itttrt uri ri, rlottrr,r rr, rrrnvolulie pr,rietali,, girusul suprarnillgirral qi u p.r,tlc r[itr pliort, trttrltrl-
tl) Sind.romul, lui, Gerstmann estc produs priu luzirtni (1il,l ' lr irt l(\r(' i{(firzii,lrrrr.!i 't le trecere.lintre circumvolulia parietalii inlloliollir, ,,s i cit'ctttrtvoltt\ ' , , " \ ' i l , i t ' l la mi j locie c l in pir tea sf ingi .
t) Sindromul parietol p08terior al lui. An'drd Th,ottt'tt'tt ${) l1!olllrt)rl,'1l'(\1rr irr ; henianestezie predominanti, pentru tact 1i portt,r'tt i lrttsi lti l i l,rrlr rrr'1 r r r r l r L r ril i ' i, I br':rdihinezie qi disrnatrie, apraxie idoltolicI orxril,rt' ltt vrrtltrtl i i.
l) Eittdromul' Ttarietal p ro.f wfl' al' lui tr'oir (prin lozitrnc slirrgii) itttlttttt,rrrzrtrrrrrrrit,otul conteit semiotogic: tulburS,ri souzit it 'o bill l,rll 'rrlo, il l irttlntirrrltrtrri l les simlul pozifii lor, apraxio ideomotorie bili ltotrtlit Il lt i lzitt tttrrrlrrritl,i l( ,1, , t ip mixt) ; hemiplegie r l ro-r ,ptr i .
?.3. PROBLEMII] D!] DIAGNOSTIC DIIIOI,,()(iI0IN DIVF]RSE SINDROAMII AI,GIOiI
7.3.1. Cefalalgiilc (Colnlcilr)
\\ Cefalalgiilc acule trc srrgcrcazri,, evitlcnt, o co,ttzd nrt,lli,, lxr or,r'o rlInrrrrr in considolarc qi o invostigilrrr in Iunc{,ic de lootlizl,r'ol cofllt 'oi 6i rlor orrllri,r.LI clinic in c;u'o apu,to (Arsturi qi Oproscrr, 1007; llrrrris ryi Wrrlll ',I lrl '1, (rit,trfi dc Arsoni 6i Oprosorr ; I]otrovi0iu rii .l.,rrscu, .19?0) :
I ) hr t:t'fo,lal gi,it(t la t,l,ir(,l( : it) 7n regiu,nao .fronto-l,arttpora,[ii .' s irr u z i h]l r r r rL i r l i r , s i l ,u otrnoidrr , l r l , lcrr i i , l g l l r r rurrrr l i l i l l ' i su,u i l i r locic l i l , i i ; l r r r r ' ;x 's l l i1J, , r r i r r i r , l I r r , r ' tot i t i r , s i r , r r i r r ' lc l ioprr i io ( t ,crrr1xn' t1I) r lo r l ivrrrso t r l ,1;rr I i ( I r r rk,o8rr I t Il , r orr , r r r l t r i i i r r y i t i r l i )1 i r rxrr l ic i r r t r l r i , r i r t t r l l r1,rr t i r r crrrol , i r l i r r t r i l , I Lt ' r r ,ut t r r r , l int t tr l . f r l i r l l i l r l In r t l l i t t t t t r t tu 'u i1t i l , t . t l . / r , , ' t r rv l l lg i r r ocoipi l , l , l i i , -Al t to l t l I l t rz i t t t t il i ' t \ ic i r , lo str ;xr t ' io l , l t ( | r ' r r r r t r r i r , I i r r r r , t r r l t r r i r , l , icr , , r l rot ' r r io r l i rcrr l i r , , t r t r ru r . t l i lc t t , t ' "I l r rz i r )1 l l r r f r r r r r l t r l r iprr t l r , r rNirrrrrr r r , r ' l , r r r i l l i l ; ( ! \ ' ( !n l ,u[ l r ' i , r r r t , r r i r rg i t , i l , ( r t r vn { i t r r rt r , , r r t t i r 11i t l r , r rotr l i , t l t t l r r l i r r i r r ) ; | l l , ,Xirr orur i1r i I r r I i1 r , io l In l l r l t r r l r , l r t t l , t t , t t t t t t i
l ! - rL l l
t th
l r ' r t r ' r l lg i i , -s l r l ) r r i r l : r t . i r l i t , l rc ( l l r , bolrr lv i i h ip.r ' tcnsiv i , r r t , te l iosckl l r r i ic i q il : r , i r r r l iv iz i i ln t , i l ,Nl , i i , \ -
, l/ lrr u.lekrl.yiil(1 gtnuali::a.le : a) Protc.sc i.nlt,ucraniene acute (ltenn "I rr rr(! ; ll{rmo}'ugii iltr,:rcerebtrlc - in c*re cefaleea, se instaleaai, deosebitrlr, lrlrrl;tlr plcccrlind coma - srru extracer.el:rale I turnori cerebrale cu evo.lrr{ir, rr,rirrrpi,omiltici Bau cu alte sin4rtome pini in moment}l declalqJ,rilrrrl:rkrr:i, plin creqtere bruscit a tensiunii iniracraniene; procese infla'ma.l.' lri i, l l)ccsc celcblllc. nreningite, rneningoencefalite ; irdrnboze ale sinu-, r l l r l l r r ' r 'on(,rse . - i r le \ 'onclor cerebralc) ; l ->) In. fer t i i qenprale sud t . ,cr t l l(sc vrr, ctiutil contextul clilic infecfi_os.1 i c) Altc inJbatii; ineningite, arterito,f lrrlritq, 1,..r'rarUebite cerebrale I .d.1 .Traunotismc
'craniene 1 71
'n6n Ai
lt i.lr( t lt.ttsiunp afieri^ali. I f) .Int oaica!,ii, (cu monoxid de ci,rbon, ititri{i,r r i l r ' : r { i q.r . ) : g) S'r f / . i i r l f r iscrrale acutc sou acul izate (care t r t ,brr je, ; r r t r iol , r l r l l i i l rnr r . ind nr1 ge poatc c lucida utr met,anisrn cerebral) .
ll) .C^efalalgiile perioilice (Amcli qi Opreecu, t|)6?; Botez qi gerbi,.rtcsr:rr,,.1965 I Br"uetman, 19{4 ; Kudrow, 19?4 ; popoviciu Di pascil, 19?9) ;
, l . l , l ! ig11l .o( in.s i tual . i i lc inmr.ealgi i lepre2iul iuncaractcrhernicrrnic,lrrrlsrrtil, inso{it $i de alte simptome, indeosebi oculare). Vom reveni rnail i |z i r r iu l r -un subcrpi to l seDarat.
- ,2 ) , .l[ a(ormo! iit.e -r-asculore
cerbrolc (angioamc. anevlisme,; se potir"oli dc crize cefalalgice pscudomigroroase (dar aproape totdeauna'rlo:rcr.r'rrsr pat'te) sau nemigrenoase, putindu-se insoli in ulele accese algiooi.r rle rrllc simptome (crize epileptiee, hemipa,reze, tulburXri vizlale, fdno.rrrr.rrc :rt:tzice, eventual de paralizii periotticc de nervi oculomotori_ca dollrl'lir, in rlnevl ismcle de aater i, comunicanti, posterioard si in cele de a.rteri[Ir'r'| 'hrrLi posteIioari).
.. .3) le,Jal.algia p.arocisticd, peliod,icd, tn tam,wile cerebrale este rar{,,tipul ct'l mai obi;ntit fiind de ceialee progresivii, cu orar. matinal, sa.u do',.l:ll(.e c()ntinuii cu exacerbi.ri paroxistice (Arseni qi Opreseu, 196?). ABt-h'1, cefrllccfl, prroxisticl pcriodicri este car&eteristic5, pcntru fazele rie detrirt;rk, lurrrolilor dc vcntrictli laterali qi de ventricul al treilea, tiind declan-r;r.rlii rlc _rnoditici,rile de pozilie ale capului, de trecerea in ortostatism, do, ' fot l ; idc s l r inul (Arseni s iOprescu, l967) s i oste in, lo l . i t i $ i do al [c ,onrrror, . t t to l , 'g ict . (obnubi l_5,r i paSagere :r le vedcr i i , tu lbur i r i d in pa,r le:L Ltn rrrr.r'v l cl' i|,nt(.nl sI endoerrno),
! ) Aefalceu Ttaronisticd, d,in, hipertensiunea urteri.ald, poate fi tlifuzll,*rrr locirlizrtL (fronto-tcmpora,15 sau in rertex de obicei), api,rincl brusc,rl{, rjr' lo ruil,i multc ori sple rliminea,ti. Se poate realiza qi o formi psettlo-rrrigrrirou,sf. Examenul funduiui de ochi arati modificd,ri nete vnsc:rlarolrprrslrrc ilrteriale, edem sau clia,r hemoragii).
5) ( ofaleaa paronisticd, d,i.n hipatensiunile arteriale tecuntlu,re oltoru.ltrlir.t ti.(fcocrornocitom, aterosclerozS, sistemici, qi cerebrali,, ecla:npsit,irloricu,lii profcsionale , suferinle renale) trebuie corect gi la timp identifi:cul,ir, irr contextul clinic qi prin investigalii corespunzitoare.
6) Cefaleea parorisli.cii, di,n encefaloputi& hi?a.tensh)d, se inso[r:qto,si rlc all,c rnanitcstd,ri cerebralc consecutive etlemului cerobral acu1, rlirrircoa,sl;i'i, oncefa,lopatio.
7 ) Uttul.eaa parotisl,icri din hi,ytoNensiuneu o,rteriald, (t:sen{il.1ir, snurrrcrrrrrlirl i l, tl ivorgilor frlotori) rto csto sugclalll prin survenilca accstt.iir, Iiolrt ltururlolr, irr dinosllt,t;innt (,,cclilr,klr rlo pot nil" - I )iirt rrcsctr,1)rxIotllIu, l1];8),I i r ' , r l i t r tpoh' i t , r l , l r t , l , t r r11'11' ,1 i t t ot l6nt l l , is t r r ( l t i lxr l t ' l ts i t r t r r t r r , 6t ' i1s1:r l i r , : i ) ,
it"\(l
t r r r l r l | r r I r t r r l r r r , [ r r l r r , , l t Hrr l rcrr t r t l t r t t t i l rz i l , q i t l r r l rur l r t i t t t t r , , v i . j i i l , t r I . i i t t t t t | r r lL l ,i r r r , , l , l r , ; r r r l l r i l r r l , i i ; i r r t r r I r i l i 'n I i l i l r t r ,s i t tco; t : r l t Hl t t t s i l tcol l t l t , ,
' ) t 'r lr lu't, 1 t r t, t t t . t : i :t I i r : i r. d,in. r.nr h su.lrt ' i .ttI.rr !rrt. ltttottrr.t r: 1i lt l ir l irrt rrr,. l . , , r ' r1r r r r r r rzr i r lc cr i r l t r t ' l l r t t : l l , t r l i l io i i , r r , f t t t l r t t tct t r : lo l l r t t l i i 1t t t I t t tot t i t , t t r xt t t tl , r , l1 r , r . ' l r . l r t rz. l i .
1t 1 t ' , l ,r lurr, prt,t 'o,t isl. it i i r l, in, rLirvt'sd,r stt loitx!0 tl i .gtsl, i.ru ir lt ir l lr i t l r 'orll , , l r l , r r r rp l ,orr l l l ic i r l l t . r r ,sIr t st t l i r l in lc,
| 1 t ' t l ir lr ' i lr pu,rori , i t:t: urrr su,r'pin pa ut. Iond dc ot.fu,lot ttn.l, i .nutt, t ir lt<' L,r l | | | , , ' r , , r r i l ( .srrspioirrrr i , crr lo t r t l r i i I l rp0t l , l t , t t te, ( ] | ,1 ' ( ! i r t lpur l t l l i ls l r l i r l r ! l l lgr , l l t l ! ,I l t r , I ln l t : t l l ) iu1) lc:
i ) ' l 'rrrun'i l t: cercbrule (tlo obioci sc irtsof,eso 6i rlo rr, l l ,o sittt l t lotttr ').' ) ln t ro l t t . l i t r , h ipertensiu,ni . i in l racruniene t l i t t i t t tg io i l t t r t r Hi t l l r r l r r r
r t l I r ' | , t , r ' ( \ | ) | I I I ( | .
' | ) ln ralu'l iu, tratt matis malor cranio-cerebrale,, clrtt l po fttttt l tt l ctrl 'rt, lrrrripr ' l l r urr i r ( ico so l lor luco o ccfalalgic Daroxis l , icr i ' t lv i r lonl , ; i , r rx is l , l ' i t r r l ir 1r t t , I , r r r r I r r r . r r l i i lnrui helnatorn intra,palenchintatos t ( i l11, (Arsotr i f i ( ) l l ro l ( ' l r tl r r r , , r , r i r r l r r r r r r r i l t l tc compl icatr i i coleblalo.
I ) l)11N111ev7,., angaji i,r i lor (a nnurilor i la, 1n't:t; ' i , 'unr: ) itt l ,ttrttoli trtrlrrl , r r l ' . , I r r r r r r r r | ,o i l r r r r r , abccse, chistur i parazi tDro f ,a. ( l (x ' l i i l l , ,o i tzt '1 t r t izo v i , tl r , l l , r l r , r ' r , l r r lcrr , (1rrre s int inso{, i to qi do fonomcnc dc str f t r r i t t ( , i t ' i t , | ' t t t t t t r I t i t t I t t i
' ' r , 1, ' . r l , r lo i rcgl i l i tate pupi lar i , orrent iual q i do I 'o. t loxo ( lo i l l ) t t ( r , r r ( \ ( ! { r r r f i
p l l r ' l l . ' \ ) : r lotni ;c i l r ipendularealeglobi loroculrr i )dol , l t l l ) l l t t i t ' i t 'oxl t i t r t 'l r ' r , r | ,1, . r r r r l t l or i ( lo comi nroAresivr i .
,) tt,.ft l t i Ttls onistice ?e Jondul unor caJulu,l l l i i trrnl. itr.tr 'rt pol rt ltr 'rtrrrt ' 1lItt l t ' t:t 'r lot,ttt.t: su,Itdurale cronice, \n lTfela procese tlc JoYti, potslt ' t ' io(t ri ( i l t r '1ii l l tt,
l l l l , l l l , Lr( ' ( lof l | , loca Be exacerbeazd, la miosctrr i lo cal tu l t t i ) ' i t t t r i tkrr t t (ht to i t l i l r, ' ,r,1,,, ' /r (1rosll,r 'nr ma1,ico, postmeningocncefalit ico)r ltt .r ldri/r ' l trt:r l tr i l i t ' t 't '1,t1' tttttt t irr . lenonenelc d,e kiperterniune aenousd, (\tt lr l ir( l l , i l l lr i trrttt l i tt,t 'rrrl l , | , | , | | | r ' | | i i i | ( , I r sau in compresiuni pe venelo jugularo) $.t1,.
t ' ) l t l tt ' i l ,& tentporald' (Boala lui Tlorton) ponta ow)ll l l l , t ' t t trollr, lrrl
| |,r ' , r,rl ir lrf. No oricntim in ciiagnostic t lupri tabloul clitt i t l 1 r I t t ' | , i t I t t I t t t 'ir,r, l r l,,r ' trrrlsrrl, i l i l ui- sau bilateralir, Iocaliza,tl i , Irrtrd,t)- 1'oll I I x rl ' i [ ], (\t ir( 'rrtl r r r l , , l l o l i r r '1,rr l i , de apleci , r i ie capului $ i c lo ol inosl , : l [ ' is t r r ry i i l rxr t l i lo. t l t ti r r r l ' , , r ' t r { r i pulsnl , i l i a, a;r t€relor tempolale Stt l t t r l ' f ic i t t l r r 1 i r l r r t t t t t l loot i 5 ir l r , ' r l t r r l i . r r r r r r r rnc ccrcbralo ; i c l t iar colona,r ' iono) (Wol l l , l lx i ; l ) .
, ) (tt lal( 'uL d,in atero- t i arterioscleroza tertbrt 'Li lt,1tit,t ' t l t l tt l t l t icrri i tr, ,1,r ' l l l l . , r l i r l r t i l to ale acestor afect iuni , dardo multo or i f i lnsl , r t t l i i lo; t t r r lo l r r ,r l r , r l ' , l r r r l r rorrr : Istcnic ale aterosclorozoi ccrobra' lo ( l 'opovirr i t t 1 i r r r t l r t l r . ,f r f r , r ' l ' r r l r r rv i r . i r r q i Pascu, 1977, 1979).
lt I t ' t ' l t t l(.t( i. i le continue progresit c ne srgotoivil urttri l l ,ort,rtdrr lt l 'rrr ' l i t l tt i :
| ) ' l t t ot i aertbraLe in primul r\T\(1, 2\ I latnabattac (itt l ,rrlctrlrrltt 'rt l lrrtt, t r l r r l r i r r r l ) , r lo obicol soci indu-t io 1i r r , ,o s imptuntu r lu sr t l l * ' in l ' i i , t rot t t l r t ; l l t l ,t l r , l r , r \ : r l r \ s l , i , r ' i i < lc v ig i lonl l g i sctuno olr i r r t ivo l l t ' t t t l ) l ( rg io()) . i l )
- . f t r r r r r |ndrn||,,ttt,rItt i i rtnhn t (rr,Lccsti, t iqrnbtrl lebitc ct:rolrt:r, lt ' , 1;tuttrlxtI lol ri l ,rr t loalrrr , ' ir1(,nros, l,rrrutlxrfklbil;r j, t lo sintts IIttortl, bt'ottt lxrl l lol l i tr ' i , r lo rltttttt, r ' r1,r l r r l , r r r r . r r i r rg i l ,o, rnoningootrct t l l r l i t ;o) , f i r l tn i l i i t , t lo$ot l , i r t t l r t t t l ; t lxb sot t t io l r tg i t rI r | , I r t , ' |
| ' i i i ( i 1i irrfrrol, ios rnvoli l l ;or'. , l l II i l tr i,an t itt,nrut i n,lruontnitr 'ttr\ ' $(\ l)t) l l i t\. l r ,1, , l I r l ( r r r r , l ' r r , l r ro oorr l , i r r t t i l l l r r rg lcxivr ' t . l i ) { ) r r f r r , l r , i tx t t t t , i t t t to l }11)glo ' { iv l r l ) l l l , t ! t l l
f l f l r f t r r l r l t in. fu, ! i i , 17n,ur, l i , [ t 'hr i l t (hr l r t r r r , t ' t t ; t l , ivrr , f r r l r l r l l i fo i r | r \ ' I ' i Ion ol t t t t 'l r ' r r r l l f r t l l r l I r ' i ( , , , t t r r t tot t t t l l l t r tz i l , i t t l ' rx t{ , iot t t t i ] , gt ' i l i i ) , i l l t r r l r t r $tr I t , f t t l t r i r l i t t l ,r r l r r t l r L i r l r r r l i ,qf i6H l ! , , l r1 i l , l i r r r l l l r l r r l r r l , r r i r r { r , r r l r (1! i l , r r t t l ) l I f l i t , cr l l t l txr l l t l
x27
i r+r . , r t l , t i r t rnt ' 1 i /srr t t r l t fc t r t t { i t , l ) r , t l i l ic i l i a lc s l i l i i r le cLt t ts{ : i in1,r i 6 i pr ' rbcl t tr l r . I : r l rot l r lot t 'c \ 'c latoi- t r ( , .
l')) (lt'[ulutqii co'ntinue curstante sau cM sicotrst{r?rr, (eYentual cu €\{r-.r'r' lri iri px,r'irxlice) apar in foarte numetoase afeclliurri I L) Leti/ulli oso(ise,,trr. tttrtirttlt'tn aie cotoonei. ceraicale su?erioare (fn acestia cefaleea cstc,rr'r' i lri io-rrrrcrrli, so cxacerbcaz;l la schimbirile de pozitie ale capulti $i seirrro(cslo i,,i ilc :lrnedeli.) Ilste vorba de: unco-iliscartroze cen'icale, rrrt-rlfor-rrrir{ii rrlo .iorrc{iunii occipito-cervjcale, rniozite etc. 2) Insuficienle circu-I r lari i rart:ltrale (earotidione qi/sau vertebro-bazilare), 3) Arah'noidit e corc'/rla1r: (lxrsi,frilumatice, postmeningoencefalitice). 4\ Ce.Jalalflii de tensittnet'(lrsilrogrrrc). Aci se irrcirrlreazi, gi unele cefalei prin coirtnctura Dlrscula-lru ii r:ryLLlui ;i a gitului (,,mtscle tension headache"). 5) Diverse o.f€(]i1ttlisislrntirtt (ancmii, le,ucemii, afecliuni a1e sistemului r€ticuloendotelial).ri) (lt.lirlcur, bolnarilor cardiaci fi di'n alte stiiri' hiponice (insu{icicnlc catdio'lr,spirrtolii cronice). 7) Cefaleea posttrarmatici, (postcontuzionali
' post'
t , ' | | | ' , ( i ( ) i r r r I i ) . 8t Ctfqlpeo, boltat'i lor hiperlensi r. 9) CaJaleen aroniri a
,ti,thriiril,tr. '10; ln'direrse suferinlo hipatice., dttohenibiliare fi t 'ettale,Il) i4 prstuf i,l,iila de d.iaerse origitti, (endocrine, neurogenc, in diverse sufet'inlcrli;1r'slivr: ,s.a,.) pot prezenta in contextul clinic cefalei persistente, zdesea,|rr rrrirr:cl'bii,ri paroxistice, asocia;te cu parestezii peliorale qi iir membret(rr sDirHr[ cmpo-pedal [i uneori cu manifest5,ri conrulsive. ].2) II i;pogli'(r'rii(r se manifestd, prin cefalei cronice) de obicei cu exacerbS,rir insolite qirl(f sr)rnr rolcntii,, sti,ri de obnubilare, transpiratii $i uneori cdze conY lsiv€.lii) '\i, nu uititrm cefalalgiile din aJealiunil e octtlarc (ghucom' tulburiri.itolcllirc{'io, iridociclite, cheratitc Di alte boli inflamatodi ocularc), din gfec.-.lirrtti. na:ale, rnastoidtene si. sinttaqle (tralrmal,ice, tumnu e prin infecliirlrr frrcrr,r' kroale 5s.a.) qi dit:r ir'fecliunile mauilo-dentare (infeclii de focar, perios'i ittr, l,umori q.t.). f +) Cefti,lalgii.le hot'monale (1* femei cu disfurclii oYat i"r,rrc, cu mcl,ritc eronice, in proclimaxr in climax etc').
lt) Ceful,algii,le c\nl,inue regr$i1i), (Ars€ni $i Oprescu' 1967)-sint t'epro"zr,rri'rrio ile: lj Cefaleile din encefalopatia posttrm.malicd'' 2) Cefale;iie ltlh iprrltn.si.ttii tralali . 3) CeJaleea Stsihogenti (hr lemisie). 4) Alte a.;feeliuni {venlrr:ri sus) in curs de vindecare.
7.11.3. nl igrcnele
Nligrtrrt l,r'ebuie diferen{iati, de restul cefalalgiilor 7}ritL utrs.at$el'.exrlt: xrtirtiologtco paz"ticu.lare, in sensul unei cefalalgii periodicer predonti"rr:nrl; srrrr o)iclusiv unilaterall, pulsatilXr insolit5, tle obicei de tcttomcrttt,rrrrlu rr (l'otopsii, hemianopsii, oltalmoplegii), de tulburiri velietiltivo(itrr'(rfi, vr'i rsil,tui'i). De multe ori migrena are o incidenfi, familirtiri. Littrrll i.k.rr'rlrrl i lyoai)o decisiy de tliagnostic cste reprezcntal, {le r!.l l ' i1irl,rlriirrrril i irr l i lolestenli (pind, la virsta dc 1A-25 tlc ani), astfcl incil ullriirrrlrrirrr rrriglenos apd,rut tlup5, tirsta t1e 2,5-30 de ani sugcreazir ll ltLirlr.glrrbiu o lcziunc organic:i intracllniani,, cri de pikli, un tune\-r'ism' rtll:rrrgiorrr, o turuolil ctc. (Arselli qi Oplcscu, 1967; I)iamond, 1974; Iilbolnr; i I ) r . I i i r rc Ol ivrrr ius, t07l) .
I ' tohk.rr tc tk ' r . t ioprt lo l le t r i r r
l, l l l i l ltutrt' dttitlt uilrtnu ttnnmrii ',ti rttigttttrr' ,,tin r I i r I t ' r ' /t i t t r ' ' (,,itt
, , ( l | izrr i t t I i i t r { t t i I r r ' ) , , , f l t tHl t ' t . l t t r i t , t l t t , t r l t r r ' ) ) i r i t r l , t r ' l i t i iv r t ; r , t ( l ( r l ( \ r l l r ) r , 1r 1 l l l ,
,.'',,,,||
l , r r r r ; r t r ; r l t r ( : r , r ' r ' lot l . t r , i s l , : t r l i i (p l l r ' r . [ r l r r lg i r ' , r , r ' I r r I r r I i i i r r r l i por i lcr ' l r r I r l ; i t , ' ), r r r r r r r l r | r r i r r gr . r t r ' r ' ; r l r r l lc l r to l r l | t r r r r r , I io | t l r Iot | , t r i | r . r lo l r .z i t r t r r ' ' r t i j r r r i , , r
, , r , l r t , r l . r .
l l r i i r l ; r , i t r* i I l r . i i i l r r r t i r l r t r r igtr . l t ; i , t r t t t i t t t l t t r t t , r l t tpr ' i t t t r i i r r t r l r r t i (At . t l t r i| | ) l ' t l ' r , , | | , l t l { i i ; l ) i I l | l ' ' | | {1, l1}?.1 ; l , ] l i l )orr ! i l ) " l i ' inr , ( ) l ivrr | i t rs, l l l i ' I ;
I l l r r , ' , r r , l l , i ) f ; ) , l ru l ( ( l 1I t l l r r t t l . i i i t t s i , r t l r i l i lc l r , r l i r rgt tosi i r t t l r r i , r r r , r roHi i i ru l ,,
' r l , r r r ' , i r rvcsl , igrr{ i i i l l ' . r r l ' ' ( i r ( , l r rs iv lu l r , t iogrr l icr ' , | ) t I r " t r I r | ( ) ( ' r | ( | I ' i | | , , | 1 r ' r Il l , , I r ' l r , ( , i l rx ' r ( fc l l r l r ig l l r l ' i l r ' ) , i t r l t l l i l i t t sprt l r . l l l r t l r loulrr i t r r ig l r . r ro i i t r r . l r , r r l r r' , l l r , , l f f , l ' \ t 'u lu t i4t t l t t t t , r , l t t t i , , i :
' ,11 iqrr 'nrr ( t . st 'nu i ) t t t tu ' r t lor l i t r t dt iu: [ iu ( t tJr t l r r t t l ( l . i l ) t t t i | t t t | t ' t | | r t l1, , , t l '1,4t( , t l l r : i t , l t rn i tnol t t i t t * i t r l t s i t t t l t l t l t t obIr t : l , i t r t r l tnt loqirr ' ) t i r l r r ' ; rr r r r I Iu i r r r . l ( ' r 'vc l l t t t l i i i l i :
t l l l i r t t t ,u i i tu i labi ld, i t r s i l r r r r l i i l i r i t t r . :urr s i t r r I l ,orr r r ' l r r r r r . r r r r l r rg i r , lr l r l r l l : r l r , 1r . r ! , r r i l , rx l i l l t ' r , crr cr iz l i , l r lg ic i r , s l , r r i r r ror l i I r I , r | r rp l ' i c l iz i i , r r r r r r i r . r l ,u lr l r r , . r l ) iu( r , r t t rcclr t i i i con( i r i r t t ( lo i icr i r l ' ( ) t l r t i l '1 , i r r t i lvr ,s l igrr f i i lc cotrrplr . l r rr r , , l r r ! r r r rg io; l l r l i r r r r r , t rbur l i ) t r r r ovi t ler t ! i r rzr ' i t r i t t t i r r otgrrr i r . ,
I t1 l ' : i r t t r lant i . r l r tnt t l iu r t n.giot t ,nt ,eLc t :ereLru, l t , i r ) r ' l r t \ r st ' l r l t r ' l r r u{ l r t ' r ) l ! r i l i i r .r l , , r r , r r r r I r r r r r i i r r r r r ' t r t , 1x ' rs is l r i , ; i r lupi i r t ispar i ( i r rc l l r la, lu ic i , sr1 l ) l r1, i r$(r ' r . r :J i
' r r , r '1rr I r .1r I i l r ' , i r r t l r r , i t rvcsl igr t l , i i lc I i t t l io logi t 'c s i t t t tg iogtr l i r r r scr l ' 'p ix l t " r rz i ,r r r r l i , , r r r . r i t i t , r , I tSott l l l t ' i i .
| | l ' :r tt l .otJtiqt'()tq, t l i tt, rt,tt,ttrt i.stttt lr <:crtbrall: totrpot lr ' i o iu,t ' irr rl, ' r. lr.r r r l , r . rn i ( , l r )g i rut t l i fc te l r ( i l lc 1 l ! i t t l t : Iu igt t ' t r l ptrrpt i r r 'z isI ( \ t ' r r r ' t r i i1tl t , r , , ( n, l l ) { i7 i / \ r 's( in i ; i colr . lh. , 1974) : - Vi ls l r r , r r l r i i r r I r i r r | , I r I j i , i t r r . : r z rr l, ,nr \ | . | | r l , lor ' psrrr u. lorr I igr t : r r otr sc (30-.10 r lu rrrr i ) . l )Ur ' : r l r r pr , r r is l r , r r { r ' r' r r ' | | r .1, ' f r r r . r r t r rkrgicc, 0 i r tc nU rot t r lotx le i rz i i , iDLrr l i l l l ; r l t r l t ; i I r ' iz l r , ru ' l t r l r r l , i i | ' i ,, I r r r r r r r r r l l ( . r l f i /s l l r i l icotr)plot . Pt ' r^zt ' t r i , ; r ' r , Ino( l i l io i i t i I r l s l l l i i r l r r lorr l l ii , r r l . r , r r l r r l r l i t t ic l , t l iu i l r revl is lnrr l l ) r t rp l ,o. l ) r r 'zctr{ , i r , r r ror I i l i r ' . r l i |ot '| | r I | | ' I I r . r l i | ( . ( r lc i l i noYizul l iz i t re l r ]nni 11rrev| istr t 1xr ungirrgr ' : r l i i r ,n l r r pr t l r i l r l
Ltt t ; " j , r l i r r t rzrui , r lupi l , Arseui ry i Oprcscn, l ! )07).- l , )v i r lcrr l i r , r ' i . r r r r r r r r r
i iurguirolcnl , in ca.z LrI anevl isnrelor f igur l l tc s lLrr r Ip l r . f i r r r l i l r rzr,. ' rl, I irr i irr sp|!ii lc subarrlhnoid iont'.i l l iqn 'nr , of l ,u I noplcyl t t t i i rsociazi i , o rx: [ l l i r lg i r r r r r igrrrrrorrr i l , ; i o
' l l r r l111,r ; r l ' ; ' r , , r l rs i l r r , l ,ot 'a l i l . ( ) f t [ l tnoplcgi l l rpf i , t '0 r lo t l l r i r r r r i i r r s l , r r r l i r r l ru. l : r I r r | ; .1 i r ' ,I r l r l l l
' r t1 ' ( l { r lu, i t ts t l l i l ten t lL l tcr i i q i Iatrn}r ' i l r ! | l l l z iL ' . l ' l t ' r r l iz i i l , , , ' , , r r
1, , ' r , '1, ' r r r l r r r l , I i pr t , r ' { i l t lc (perccl tca, t JI [ - l t , ) s l r t r lo l ; tLr (prr t r ' r , l r i l , l l l , l \ / l i\ l l , . , L. , i r r l ( 'c t t f tc l , i l t 'e l l pru ' t , i l t , l , i , l r t totvtr l r r i l t igotrrr t r , So f i ' rurrr I r l r r l , i r , r ri , r r r r , r r r l r l r , r l igr t r r i i , of l , l l r ruplcgic i i , s i l r ' i i l l r i l i ' t r rzrrrv l r 1 r lorrr ' l r r l r rzrrrr l , ,| | r , r r , | l r r i r r Drt l , t t l ,cv idrrr t { i l r 0 lczirDro ot 'g l t , t t ic l i , i t r l r r r f i l , r . r i l l l i | | | I | | | | r r | , I r t i r, r . r r r r r l r . n i ,1tno o, l l . t t . l . tn o pl t ,11irn l r rodt t t t r lo ut t . t t : r i : ;ut ( r l r r r r r l l l i i , r ' : r tu l i r l r ir , , inr r r r l l i r \ ' { ' r ' r )oNr r lc l r l r r l i , tur t r r r r r r io l t t r l i l )oslc l io l ln j , j r l r r l r t l , r , r ' r i lor t l ' r ' : r l i lt . ' l I ' r r r l r l l l l : r t r t lc r r t l r ' t i , r , r ' t l r , l r l1t l i i ) sr i r lo ( / / f l t . , l i r ! i r t t t i . r th i l r r t t t rot
I r ) l l , r l i t r tp l rq i i l t i l , l t t ' t ' rxt : t t l i t r l , , r lc I r t l t i , l rscrtr lotrr ig l r r t r r r l t t r r l t r lr r r r r l r l , , . r r , , r ' i l r l r i r l ) : l l i t t . l ' i t l t l r r , t t r r r l . idr t ctrrr t t ton,rr i ( t r r rcvt i i r r r r r r l t l r . I r l r , t i ir r r , r l l r l , r r r . i r , i { t r r r t r l l ( , l to l r i t \ 'c |s{ l rZi , s i t r t rsrr l ( l \ ' ( ' l { 'N), Hr, j t r i l l r r l | t rzrrl ' r r , r , r l l . r l r r ( , l l |g io i r | r , r { i l l r I I r ' Iu, l l t | r ' r r i | } t i l t I i ( ' f l l l l i , l : t , r . l | r r r i r : r r r . r l rztr, , r l l r l r r r r r ' (1rrrr i , I l r r ror ' l r i l , i l r r r ) , l r iprrcsl lz io i t r l r l i lot i r r l Lt igr , r r r r . r r r r l r r r l r r rr t r , r , , l ) r | r . r ' i r r r t r t : r , o l l : r I t r r i r r l ' i ) q i t t t r r i t r l l t r s i t rctrr t t t , l I r r l r r r l l r r l l l l r l l I l l lr , l r r r l r l l | l ln, , r | l r i l , r r oorr l r t i . . r \ t l | r ' i r4gt ' l t l i l r r iz r r r r I iz | t r z l i | . is l t r l l r .
l i r t , l r r i t r r i , ; i t r . l l r ' r t . l ' l t r lntpl t t l i i 1tr ' r i r r l icr i r t : r l i l t ' t ( r , , . l l lu lgr t 1 ' , r r ' ,, , / r , , r t r i r I r r , \ ' I t r i r r r r . I r r r l r r l t t l l t ' l r l o t r r t t t r t r ' : t t r I I t l r r r t l r . t i r r i r t r r , I r ' r ' r ' l r r i j t , / / , r /
r. ttltltlii, tl,tLt'rn)(LNc ( t utr t:Llf reourehlid,I, ihrr tttmi1runoatri ln ptuc0s0irrlIrrrril ixrIii i l lo sirursului cilvcr.nos stiu alo olbitoi. '
O 0 rrrlr[o}krgio rlrrroroasii cu.. caract()] recu}elli,i:r,l (in care algia, nurr ri , , . rr'il'( l{}r' I Lr:mic.alic,. ci prezi,-Itii, o localizare ret.oorbitari sau i"n tori-l{ i I r rf l { rr t,rltr'r(i) rLpa, e $i in ldfiaft,erita cdroti.tl,i&nd, i.ntramternoasd, (descriSiir l ' . I l lu, i i , ' r r l r r ,Jr . , . 1-00t. c i t : t , l id0Arsctr i q i Oprescu. 1962). tn tatr loul semi_r ' r , , ,4t( .sr j l )L, [ us,Jciu[ st scmne de lcziune a oerfului opt ic.
.,1.1.3. Sindroamcle pseudomigrenoase (sindroarne migrenoase simpto.nrr l r (x l ) :
1. IIem,aragiil,e subarahnoidiene din_ mafforna!iita ,t)aso,u,larc (aneuris"tttr:, rr,ttliname ) pot genera cefalci pseudomigrenoi,se cu caracter recuren_( i i r l . . r rsur r l r ' r l i lgnosl icet pr in debuful brutal-al cefalcei , pr i t r semnele semi_(lr,):jrr',.rtc uoompal ament oare persisti, mai multi rreme, prin constatareiurrnrri L.C.ll,. sanguinolent $i prjo evidentierel malformitliei.
:!. lllutnortle de uentriatli laterali se poi manifesta prin 'crize cefalalgico
lrllir.rrlioc, deolanqate de schimbArile de pozilie ale 6apului, cu d;bu; Sirlrr'.it lrrpi,l..ldrA frze precise pre- 9i posteefrr,lalgice cain migrenr clasicd,r:'| t|r .(jv'rturt:I, ultenoari], apar semne de hipertensiune intracranian[(;\ r solri qi Oprescu, 1967).
ii. Tt.r,m,orile de aentri,clr,l .III -pot g.exera Ia clebut crize pseudomigre.
rr.rr,s. irr,sofite do fenomene vizuale similare cu c(-le diD faza frotlromal"L arrrigrtuei. l)al aceste crize sint declanqlte si, r.especliv suprinrite la schim.lriir i l ',
-rl.t. prrzi;ie r,le capulli, ia r evolu f ia t ra nseaiii d iagno\ticul , pu
-isu.*in"r:.li l i i.siodr.omului rle hiperuensiunc intrlcranianii ip:rr qi semne neuro-l,rgi,', obioclirre erolul,ivo (sindrom parinautl, sindrod Arllylt_Robertson,l)rllz{) ooulale, semne tliencefalice etc).
, ,1.. ll 'ttmorile occipita-le pot.genera la debui crize pseudomigrcnoase cuItx'rrlizrtt,'. fr.onto-orbitari,, asociate cu manifestd,ri vizfale tranzitorii (foto"l,fir. nrnlrilrtopsl tru,pziforii),. dar p€ parcurs apare sintlromul rle hiporten.sr"" r I r Ll,,ct'i).lant, iar hemiatopsia Be contureazd, din ce in ce mai stabilfr r. ct|,titcteL progrcsiy.
5. .Pseutktmigrena bazilard, reprezinti o formil de ischemie tranzitorioin lr'r'il,orilrl vertebro-bazilar (inclusiv in teritoriul uneia sau a ambelorrrllr.rr,rrrlrrbrale p_osterioare), oaractgrizatd, prin tulburiri vizuaie (cu sco.l,'rrrr. s.i.rrl,illnte hemianopsiee, ilceloqarea vederii li/sau halucinalii'etemsn.l.:rlr..;. crfrrlrrr. pulsatili i. (cu localizare iudeoscbi postcrioard. in regiunor,olcilrirrrli i), rr r;r,ni festi,ri vcrLig-inoase. felomene ccrebe]oase, zgomotd auri-llrl.lr', rliziLrlrie, parestezii bilaterale atit la membrele suireiioare, cit rtrllr rrr,rrrlrrr.lc inferioare si la fa!d, (peribucale $i linEuale) si -chiar
alte*,rca,r l r ' r r i i . r l r . r ' ig i lentd (obnubi la,re, .b ipersomie). Sc p6t asocia: n istagmus , i ilr.rr.rlizii rrculomotorji trenzitorii, Acest contcxl, scmiologic trebuieiu grij 'dr.l.i.lrlttliut a mi,grena bazilard (Binkerstaff, 1961 ; popovi*ciu qi colab., 1".9gd ;l l rJrr . - r . r r . i furn, 1977). pe care de al t fe l uni i o coni ist l , s i sJ ne or icntozr ir r r 1 ' r i r r r r r l r . int l spre o afeal iune organica in ter i l ,or iut ' uertebro-bazi lar :
,. .t) lnsuJicien!,ir, . c.irculatorie aertebro-bazilard, alercscleroticd, (forrnolocl i r r i r . i ) 1r ' i rnzi tor i i q i in icrm i tcnlo)., ..lt) Mu1,Jormnlii uasuilare (anenrisme, angiodtna) ln teritoriul veltcbl.o"l ) i rz I i l t f .
rl I't'oluse l,nlocui,l,oure il,c spnli.u r.tl,c fowi ?ostarioare,S'- i t ' l )u ' , rk. . i , i r rvr , r l . ig,r . { , i i l t t . . r r t ,o 4i tJ( , tn l } l .x i ! (o l : r r r rorrr , , lLrrhrr ' l ' -
, { l r " : l r l l l r l {10 rX' l l t , : r , r i l l rLI .o v iz| l :L l i l , , c i r r r l t v izt | l r l I | ' r l t r r r i t r I r , i I r r r l i l ( )g icrr
2:t{l
t r , r r rc i r l r , t r l r r s1x' i , i l r l r r l l r r r , r r r rorrrrrr ' l r r logl l r l i r r f l l r r : ( iorr l r i l i , r ' r ,sPlc l iv l l r r l l i, r r I , r ; i t r t I i r ' , r r l , i l iz i t r t l r l r , l r i { ( , t r | ( , | | ( | l r , i t tc i t I r r t t ( r , I r t t iur l io logirrrr sprrr : i r r l . pr , t r l t ' t tl r r , r ; rosl ,ot io l t , t i i , l l t t ' lc t iogt t r f i r r vr ' , r l r r ) l l r l i ' i , ; sr : i t r l , igtrr l i r , l lonrogtrr l i r , : r r i r r l1L, r , r r r ; r r r h ' r ' iz11 l i , r , | t 'c l , t tx, t rcr . l i t l rg l i r f ic q.1, . ) .
t lJ l l t, l , lutntt ! i i . uIt . losti t:urln'u.lr ltttsltt i ttrtrt yi t l t ; ionlirnti i. rrrtnio, , / i r r ! r r ' ( inr I r ( .$ i r t t ro brrz i l i r t i , p l r r l ibuzi i r , s i r r r l |orrr I i l ippl ' l l t \ , i l q.rr . ) .
| | | | | | ' ' | | i .n( : l ;c | ' l 'u . l t t . t ' t t ,ut t t i 'u. | i l . ! i l t 'n ' i ' t t t '11t t t t i t l : t l t l t :u| . t t l ' t ' , t t t ' t l . | . t l t l l l | i l l' ' , r t r t t t t l . lbr tnat i , to r i i r l r lc i srr t tsprrct , [ c l i l ,c l i i lc srrgrr l t r lo r l r r l l i rLclrr l r r , l ll l l r l ; l ) , in( lcosel) i aplrr i f , i i r str l r v i ls l l t r lc l l5 r lo i r r r i r ; i nrvtr ls i l r i l i l , : r , l r , r r lo l r r l l ,, r rLrrrr l r ionr{r l rL object ivc l l r scrrr l . i , vr t ' r r : t r r l r rp i i , 1 l ( ices, s{ ! lx) l t l r r $ l , r r l r i l i r l l l
1,rr" l ic l l r l t . r l igr ' , r r i b:rz i l ; r l r i .lrr sl ir 'qi lr, rt ir i t leJruic avut irr vtrlclr ftrplu). cii \ i u,n.rlt aritr lt ipruli
, , t t t t t r 1xt1, s i tnulrr o migleni , l lazi l i t t i i (s lu ot icu rr l i i , fotrni r r l i r r i r . i i r l r ,t r r r l l r ' r r i i ) .Oartat t r , s-asipropus ( l 'opcscu qikr ln, . t9?7) ploht, r l i r rgrrrr l i r l, r f l r r r ;xr t r t ic i i , cu solul io t lg glucozi i 20-30% (20 -00 nr l ) , r r rnr i r r x i l r r i r ( i iL 'rrr ,,:rrrr ptorhce disprlri l ia manifcstridlor nenlopsihiur, rrl pul(f l, oli.r ' i rrrri,rLl (l i ' ( 'onfiunLrc a originii hipogliccrLicc l urror clizl rrr igrlrro:r rr '.
7.11.4. l lgii lc orcipito-ccrvicalc
Alyii lo .oeoipilo-eervieale ricl ici, urmi,toarolo ploltk,rrro r lrr rl irrgr rorl to| | r l l l l t l r )gol i l ( j i
n ) 'I\ruumo,lisme aertebrale tau ,rterlel)ro-marlrr,lrrrr. ' l 'rr,l lrrio rrrrtl itrr r r l , . r ' r . I r r , l l t , r r l (Arscni q i Oprescu, 196?; Als ln l i q i oolrrb. , l1)?: t ) r ' iL r l r rl l , r ' , . r I l tuurat ismele vet tebro-rnglul ln u eotvicukr i r rcutrr l r i , o r l rvrsr , l r r l i r ,l r r , r r r l : r lc 1 i c i i t rebr ie c i iu iate cu gl i j r i , i rn i r l ia[ r l r rp i l l l r r l r r l r l i r r r r , r r , r r rri, ' l l rlc k'zirnre u,tit ver"tebmld,, cit si mtiduleril,. Silrl sil,rrrrt,i i irr oilro grr[r,r'rrr(rr,rrrlrIrrIrrli i esto oligosimptomaticit snu inexisl;ontri, in schirrrlr rrrrxlil ' i lnlrlrrr l t l r . l r t ; r lo haumatlce s int import lntr : , snic l in l ,a l i r l icrr l l r r1 l , t ru l r r r l r r r l t t Ntr, ' l t t r r r , l r t iu t lurcr i cr l rv icale sau celv ico-brah i i r lc , lnt lc, ,st ' l r i r l iskxlr l i i l r , r r , t 'lr,lrr:rlr, si i lrcturile-disloca{ii rletenninii simlroiuno lr li(j ltlrur', i l r.rr'r\l , , l r r r r l r r l l rcnzi) , l lg i i puternice in ceaf i i , , cu i l i rd io l i s l t r t r r tg i r r t to l r r r ,c ip i ,l r r l . r r i sprr um5,r , insol i te de contr ' . . rct lu a rnlscrr l r r , t , r r r i i r r r r r r r r ! ' 4 i r l r r l i r r r i -lr'r '.r uifjr-riiIi lor coloarrei ver"tebrale cor.vioalc. lr)sto irrlxrr'1,rr l, xl, srr ptr,r,i.r l lzr . r l r r r i i , s i r r t sau nrL; i s i t tptone asocial .o ( lo l r r f r , r i r r ( i i , r r r r l l t r l r r l l '1 .
lt ) Il isaryatiile Lefi&)ral.e cerait.:ala '|;trttrltte rlut0r'i ou (jirt1tr11(,ro (li l i,rr\rt{ l , r l ' r r l rn( j i io de st td i r l a l ter i r i i d iscalc. -Asl , f tJ, i r r l ivrr , I ( i I r l I ; r i r , r r I . r l ,
' l r ' . , r l i r t l i r ionl i i , t l iscnl i i dur:eroasi i , t ' * .Do Sdze) dl t l r l r r i l , r 's l r r r lo l r l I r ' r r l i ,l l t r t t l r r l i r l i r r rn scgrncnt vct t r ' .br i l , l , oa, l i j rx l da1;ol i1, i , i r , i l , r r { ic i I | , r . I | | i I I I r 1 i i | | | |r r , r \ r r r i ( l r l i r r r l iscul a l tc lat , I ) r r r .e lca, sc t l tzvol t? i r luobicci I l t l , prrrgr, , . r i r rl i r t r r r ) r ' l r rz" ' i l p l t lcrr t i i ovi{ lcr1; i1, . l )oar uncol i l r , lg i r r , r lohulc l rzr ' i , l l l rsr : , l rprrrr , r r l ,r I r ' r ' I r r r r r I r I r ' i r lo rrn 1] l l r ,utut l , igrn tn i r t i tn, r lc ( ) tn i ;o l l r0 l l t t tsoi , g l r r t ( l t \ ( rxtr) I t t ( , f t ll , t l r t l1 r i r r r r rozci l l i l .J)ut t r r , r loslc l rur iv io lcrr l , l i r l i r r r i t rc l r l l r , r :u( ,c l tz i i t ,oxr\ l l l , t i il r t r r r ' l r t r r iqr i l i l rkt cof t r inrc i , ia l pr , r r : r r { , ia looul l j i r r ,ct , l r l ; r r t , i rzr l i t lg i i r , . l t r r r r 't l l r , r lur : r ( . { l i ts l , l ' i l t rz i l , cvol t r r razi i , r lo ol l icc i i t r l r t tsclr i q i r ru srr i t rHo{r , lc r l r ,r r r , t t t t t r , r , l i t r ico ( i t t r r l : r l r ' i , r lo s l t rs i l r i l i l r r l , r ' i r , JoctrLi) t i i n iu i r lc srr l t r r r l l r I i , r I rg i l r ,l r l l i r l r lo o 0v0tr l , r r i r l I r ' lg i t l i i : r1,0 l t colxr , r r0 i 0r i t v ic, l t lo,
I t r I i rz i r , l r , r lourr , ( r l t r , ,b l r l l l . j t l sr ,grrrorr l , l t r i I ' r r ' r l is l l r l r r r l , i t rJ ' , Al t r t r i 4 lI l l | l1. I r , [ , l l l {17) ( l lnr t r , r lovi t r r r r r r r t i v i0 lorr l , r I , , l r r r t i 0r i l i r rsr ] , i t r r r ,Ai t t r r r , i r | r , t .l l r , i r l r i rJ i xrr i t t l t r r lcql . r r l i t l l lotr l , t r r r . l r r l | r1 l | , r i i l r l l t r lUir . i i , l r r . t '1 l r1r r , i r l r rr , r r r . t l l i l i r rL,gi t .o r l iNI t r r l t r rz l r ' r , 4 i / r . r r t r l t t l 'o r l i l r ' t r t l t0zir ' r , .
ilil I
l:ll lirll::lii'tl'1i,,,,i;i1,l,lliil:,1,,1,1.1,,,l_il,li,,1llilili)l:l illi,,l,:l;..;"ijiii,ll,,lliit t , l r , l ) i r , r ( 'z i i l ( ' t l r r ; r l 'g i r r) , - r . lo l ;1. , , . . ,1, , , j , , , , , t t " or i . , , i i i , r t , r t r i rc Urusc, i 1or l rr , t , r t ril ll,,ti ilt,:,I li;i ,;ll:::;ll,; it ;;i;l:i,;11.,;i,HJ tt,*li;*"li'iii.lt:i'iJill
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.(r,'1r,,'r'11",1 |rrILlu]|li si 1)l::,sa,rea rrrci greutiti i" mina p:Icieillul i,I rl l l l. l.rll ttt. fiul,,r ruf l)[tr.uiic a,langit) se agravelzd,. c) gemnx;t lui Als,nt' t | ' t t ,x t ; , , r . rv l l t . l l : r l i t r ._czuf cu rrrr i r r i le l r l rsr ie le jor pc gr.n t r r , l . l' r ,.r.1),ut
.rn lrii,rilr 'a-t oxl,ensic $i r.plectL; dc p:,rtel ilurerorii, cste soliciLrt,r ,r lrlrrr.lr.zc ir rr'.r,oc1c in inspiralie for!,atii. Aceastil mr,ncvr,i decl,"tscrrz.r,I , i r i , . . r , l r r ' i . i r r r r r , tLbr.ul s 'psr ior dureros s i o dimin'r 'e a ar.pl ; tu,1i i , ; i1, , r t',tltrt.tl) l l,rtrr rrt lvi I lalsteo,tl, : 'Irlc,liunclr, iu jos in axtl membrulrri srrp,,)ri)r', r'u ;irlrrl rrr ori0nsic fi cu c,t,pul lotttt cloirt;t,alrltci,ltl, exuccl,bt,ilzii. j i i l
r l , ' I r r r . rc.r i t L i l l . ( r tc i t .I t r l . r r . r l l i i r r ' r ' (L0iJ; l ) u, $frr , r r i , l i t t , . i } r .h i r , l r r i Ai l r rorr-O.f l .v I , r r l r . l r
I t rzt l t t : r , l r : l i ' lo r l i r r l , r r l srbirru{, i i t ro i . int l i , u i i , r I i lc i lc c j i i r r r i r r lcr l r r i r . ,1.1, . , , , , ,r | | . I r I r | 1 ) i I i r j I I I r lLr s i r r . l lor I lc l l i , , r jc vu I r , r l l r i t i s i i t , l i r r r i r r i i r r r i r r , t r l i r l r i r r l lu l i lo,r ' l l r l r . , , l r , r r r i : r r r j r " r ' i r r l r . t r . r r . r , l r , l r r , r r , l r , ( i r rc l r r r iv r i i ; . r l r ip, l i i l r . , ; r 1 r , , I r , I i I i I , , I r . ,
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Ii t I t , r ( r ' l r r r l r r i t t l r ' l t i l i f l i . l lo l t to rr l t ,gr ,1:r l ivrr ( | r i1r | r , r , r r r i r r l1111rr l i i , crr Dir lc rrr1i11,rr l i , ' r ' l r i r r l r ' , oVr.nl l l i r l c l l (1 i ln( ,2 i , ( j r t ( r { lc ln l l i , , i ( j ; t \ i l , nt i in i i s i s l l t1 l , 1 i1 l r1,gl l l1 lr r . r r r l r l r r . r i r r '1xrI ior) s i { ' r r r l ico ort , i t lsc (1,( 'g l rurctr t rur t r , t r r r tsotr lar( i r r i r l r \l : r t t r r l r ' lot) .
ir lr(,r tnlriiLscrn(ruoll l,ablou olinic trebuie si, ne Eindim cri silr,l l lrrrrrll r r rz;r l ; i i " l ro l l r f l i gerr(r l i t . r lc l i r r r r le nt l l . i Jnctctr i ct iopa, loget l i ( ; \ rsol i 1 i( ) t ) ' , . r ( , , l1t{ i7 i . , lohns(m._i i Sp.r , ld ing, t9?4; $o el ,ea, - tg6-?) : a) I , r ,z i r r r i iIr'rrrrrrrrrii< rr (rrLri rrlcs), il{1a,rn:rtorii sau toxice alc nenlilur periferir,l si rr|.,lrlr'...rrlui1 Ir)..l)r.oct'so r:on4rlesiv-e rcgjonale sau locale cu readlii conjulciir oi.i.rl ' ir:. i i lrr..s. crr,r.. inglobeazi, nervd Si vasele; c) Iractnri c'rl.
. I r r i r . l l r r lc ; . { l ) . l ( lc f i )?:r1i i (boaln, I [odgkin, tuberculozi i ) I e) -4feul l r r r r i: r l { r l r ) r } I l l I i l ) l ( , t t l ' i [ l .l)rrpi.A.r'serrirli Otr)r.rscu (1962) cauzalgi,r, pfczitti, trei grade : gri,,{l,tl I
rrrr r.r zirlsirr Lrcrrli; g|ldul tl_Il-le:t, uru ca;rzalgia region'ab (ciirl {tri,,rrrrrrr.l. ..p.irul i,1r,cg rncmbrul .respcctiv); gradul al Ilf_lea sa.u csatz,rl, i i r r , r l i l r rz i i ( . i , r l l . ' , r 'cnele s l : ext indpeo jurni , tatc r le corp qipot chiar.srrlrl r('. ri rl. 1,'hil opusi,, cu tendinfii de gencralizar't ). cr6tleri cii aci.srrrr.lrrril i.rrrr'_rliu.ti pr.cfioase indicl{ii de diagnosl,ic in cazu.ile cu srirpror..,lt.Lrr',ir, p.li 'L'rfir,, ,,ba,slard[,), cu topogiafie nesislienatizati ;i l ierrrrir,,r rr |{ I,iIr'I iI r'(|Il rrr ror tclrrrerri pcrima],i c:r, ,,siurlr'orn f izioprtic" (al lui ]Je,-hir,rlr il r , , r ' | , r r l ] - . i . . - i r r r l r ' , ' r r r ( . \ t ( . r )sop|ogr,rr iv ' , ( r r l lu i t , r116;.
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'c girir,l i lrr t,,
rrrrr,r'r' isrrrr rrlo lrlolelor invecinatc (ale arterei subclavicularri sal rrL,1rlrIirrrrI.LIIrrJ. }Lrlrnonur'), h tumori sau. infl?malij rlediasl,inale, l*, pkurilrrr r r r r r . I i r r r. I i r r r r, I r r s[rr rli i l l i 'rrgmatico, li l pcricartlite sau ]t un abces'subliirl |rgt | l l I t ( 1.
| )'.lr '(\it si1 locirliz.azri, l:r, Jtezrl gitul*i, i l}a,poiil mJrgiDii sternrrlrri,1r'r'rrrrrI qi Lr brr'z,.' tol.Icc]rri (cu.proieclie lnteliou,ri), fi inr[ i"nsolit:i arltsr',r,,1, . r r ry l l r i { s i r lo i oni i , rospiratorre.
( ir)rri(.\hrl slmit ogic se complcteazi, cu prezoniia umtiiioarf lorI ) tt ) t ( I | | | t t | (t't )( | 8 (t |e1)d&toen pentl? adeastri neVralgie :
, :r) | 'r 'r 'rirrrrr.;r puu.lului Jrenic,- situa,ti intre cele doui. inserlii iufcli.rrrr,'1, . r r r rL:r ' I r i r I I r r i s t ' . tuoch. i ( Io l lastoidiJn.
f)) I)r{)Hiun{tr, irt primele spalii intercostala, imediat in afara rnargirriir l , , r ' r r : r lc r ts1tc01, ivc.
, ) ,,\lri islrlol,. in punctul- d.iaJragma,tic, situat la incl'uciqat,ca tlirrlri,1rr , l r r ;1 i l r . r r , l i t r ic i parastelnale cu coasf,a ia X-a.
r11..\;r:isrr,r'rr:r pa regtunea tle inscr!ie trJracici a diLtJtagnului (1xtnr:t 1,,t r t t r ,ur t , t t , r t t ,1, l [us4 ) p lo, tuco, r l , . aSpln{,neJ, r l r r rc| i . "
. !" It 'routt.artl in,- descrisil. d_e cli lr ir ' icrri i m:ti vlchi, sr: traducc prirrir orlr ' ; ir ' 1,.:t l izir, l; i i , h, nivclnl virhrlni cturl irc, suir { 'r 'rnri t i ie irr!ep:ituri, irrs,rl i lrr,
r l r , . r r r r r i . t r r1, . , i lp i l in{ l Dr) r r t r fond ncvrtr t i . c . l losl ; r ,p l t t icJ i r rspcci l l l r l i r l r r r ,I r ' i r rzrr i . 'p i . l ls(1, c l l ro iu ' dr , , i l r rn i l t l r , t l i l t r r r rs i . g.rst , r i i : i i , , l [ l r r rgr is i , r . i0 s i , /s i r rr r l t rx 'o l i r ' (Sol l r r ior t , l {Xi?). Algi i lc l r r .nrxrrrr l i lcrr r r r , r i pot r ip i r r , r r , s i l r r l ro i r i ; r , r , i r. r r l r . l r : r l . i l r r r s l t l0rr t l l [ t , r f r r l i r ' , I '1! ] l l t l j i i r r . r r | t r r l srr i t , i r r i i . Nrt l r , , , l r I i r ,r ' r r r r I r r r r r I I r I r l crr r l r t t t r t i l r l i l t j i | l ( ) i | l i t . r r crr r t i r t ' r : r l i j i r r , i | | l r . r ' t ! r l i l l l i l .
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, i t t t t r t t t t * i c i teva detal i i lupograJica ($o{ l r ' l ' : r ' .111(; i ) : i r ) l r |zrrr t r r" '
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t , . , r , t r ' : l t l r r ' l t t t i |or i l l r l r ' l r ' ' i t t ' l | ' i t ' t t t t l t i l l \ ( ( l l l i " t l c l t l t t r l i t r l l t l t t ; t t t l t t t I r r
ut ' )
ilillii); i,, lilll;'H,,,lllli'1i,1,,1;lllr,il"i3lllli,,l,li1l;liil' ri1:11,,r,, c,,,,{,,,,,,,,lll;' i,iiii;$iii.t"'i p'u'aaii"' (ecrrinococozil) I ;;;i;;:i;,1,i''";:fi:i,l:i"illil,Nl
,,,.,.',:1,,";,,;';):;:\!',*,!'!"r{{!^Yt'tat'e se ridicia umitoarere snspiciurii: -r, 1 r,i r r' r'i .o ,. . a'rlriiiiiif ;; ; ;;fi ;"-ff Hi:l, *T,i?Htr ;r,?1tl_"ilt,l f^;lill,li{:i,"f i.ii,ii',,tr*f 'T;T"T"?,:,;ll*l*f;d"Xf i;"il;t;*'iliil;
f ff rlrHrlifdru:i jiilm*ri,::*:fl#ilfndi;*ltJ":jffi d;i[iii\. itlt., - ? ̂ ;;"f '::r{:,:" ::^l:XW::;AXi;:j:iilX,1,,ff -tr;"il;
/t. 1)'Lst:oltatia uytebrald, !::.i_!lti. !tyuc,a.!d/,. destul dc rarr! in accsl;o;t t : ii il;,1:;l'sJik+'!,il"ir!.H"i:,il:tli:":.,1f ;{;ffi tii*; .,l**lil
il,ill'i [Tr1?;,t,1iff'ri;t?fl"1"::l,.gl9t1 .;' ep"iiti ri,."t.i*.irsi0)"li;
lit['ti[i:q1.nt*iltfli*h';,'t*:ffi ,r*''ryrmirgiii cxcr,si-r. u"; n;"J;;;;"1,11"r11',ilu",'S';i:Ln"':tT:"ffiii:tl1i:ln
iilif ,*lffi #i"itr$i,lfii:ffi"1*i-1"'.*lftt;ll::"'*''T.*'Tillr'irrri.urr'o 5i aoar in'nere;;1,',11fi*ih"Hlillol"ooti.,$.T*",tin'itffi1;ll*l
il*ijr jgijil"Hl;"t1T,ff .l?f ""ffi f*1?#t$Tlt'".m$jf:l'.,"4p*il:rr po{izci spinolso rcspcctive.
!tl1:l!'J$tiiiJ'il9$:i',f ,1i1"'-:i,'.Hl'6"'*'H;Tff l'fl1h1X1,,**;T1it,r,)l)rr lui tindbcrg :. dacd-.n d99gl9y4 o""iT.' a" lo_i;L i";itG-;J";.lll ill ;:Jr',I'lTi t#i3'Hi*,ff ii?.f-:JfTl;f. :g:,*:t*J:'l,il lliilLtt r rrot ir, l ir,).
i, Allliile rarTiculare din l:e:p:! zoster,(aona a,oster ). Zona zostcr A0|lrrlizol,ztr csl mai frecvcnt .pc - segmenteld t""g1i;:;;a;.
I i ri'll:iiif$ t'i#ei:,,:'*T,*ilitfttidr*#T3stT;fili*'"#:i,,li( il, rl r(lroil, r'c(liculad, esterli.:,r;u*Fi*o**q*iFjt'ir#3iTh".:,,"riffi f,rj,'ilffiz r I,, 1 r, rrir,., L r citevrr, .sIptr-,min i ),. crup{ ir rE, i.i, t"..A p"'.f ..(i:rrr1 so siliuottzri qi dUrorilc ra,;1,s i i, r J ) nrcriie, r"rr.;,i;i;tti:.h^liti[t ff J,iiy*]f#,--.lf:r r r s l r r , r l i r r l posternpt iv.
Itifi.rrltri{,i t 'Nrsobit. .o rlirgrrosl,iu i.rr.l ir' lrirrinr l ' $il, ',.(ii l(i irr (1lLro
i:ililX'il,lli'',:lJii:l,i:i:ll,'* ?ill,,iilfl;"ll'il;'l;l:,;,);;,,ll"Jii:,',',i,Tili,Iil;*iililjl:r l r r l r r r r r l rotHir lon{; i r , l inr lo l r r r rgr r , t , r i , : r luor. r , . io l { ,116 :r l r : i i iJ , , ' , j , , , , , , l .1r .gr . , f i l
t 'r idioulurr,, oit,Io nu so asocilt 'zitr ctr t lLtr t l l trtt l t ' t t l tt i tcttt iol0girro l '( 'v(' lrt loitr{ '
lrcntm altii, rfcctiune netrologrca'
,,*",1,i*fl$lf,'#1"*K;:tn:{:{H,{i;lqt:'}f i*:1J$it$.'liii,ii{ili;;;^g;*Gi;tli; marira remeie),
H:t}Tjij**."-#}rli',],,'irc" ii" si,iiiL,,,lif",ft;ti#llT",,'itt.1;il; "^"\AE;;',;; fiprinrr ur pr'r,t.s 'i'rr',,r,iiri,ri'r,,
)i**fu1ilti:ilix*:!i3'i; :'""ihr"'.'""'",T.", .l;f:',);1,;';:xltt):" \ t ') '
,".",,;.il'{;'ffi ;$:iq{:#:r#jtj'";?x1ltru;niil;liuji, lf i,lliil:il;il ilr ;i"';:l.'tll*fi :i' *i:{*":rl*lil;,illii"r:" "''' L :' 1 i "
-u,,3,,,Ti'#',{;'*iT,',*iJ'J,:'xifliild*S:iji:!i:'l'liil'x'l'l:'li'Ll.,l"il"'l"l'rlim:r*#$t*trl';:r +mtgf*ru;ll liliiiil riliri riri,lh-i#i"'Tf ll1'f t1l1ii-1{}ffi+[:T;f i$?i1*lf ll]i;-l,l:;:,:l;llr:na Dselor, insolinch-sc ;i dclcnbo'sacrate.
,. '.t,X:li{l.i-$lf1;1'"J-:'fi',l-'f#il,ll;i 'x;)lil'i'f,;'''lli:il"l:1"'i'"li:l'r'l:ilii;;i::t#'J#[i'i-* l' .*;;l!lf;jlt'': hil$ri rli lli,''l ii:ii li ri, i ri*i;;;*i;;il-;i*IulPliciiointe.resie1jllrl''ll,'+l:;)Jil,",,,, *,,*,,,,,,,,,,,,,,ll,ii3:??,i*1*'J'$":?"?'-1,i;ir;;.m'"iiqei]i,,'.11'11j11;i:iiili, il;,ll:l;ll';rl*ijrT'l"xll;:**ig lTJ;"ff:"jf; llt; fJ""fiill il,'i"'lil"'i".'* i" r'i' '.'sigmoicllr"n etc.).
7.3.9. Sinitroanele algiee alc mcrnltrului ittioriot'
I
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ii, :[- ;,1'[t*ili ; i r;- rr *;ril,i 'l il| xf irm] rliiuri 1 "iri rr,iiii,;i:lil);"'pi;i*1,,,11i't,]i'l
l'u''i;]lil"'l:i:'il''l'lil;"ill"'llll';l'"i;l'l'li;iiliiritijilii,li;i;iill. ;i;;i;,:ilr:l;i:.illr,ri'l';lll;;r;i; li,iiiiiliilliiriiit'l;ii;ljiriiil
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1,, 1, , i r r *r l r i . r l r i t , r l i r , l r . l r r l . ' r . , , r . i i 1 i r . l : r i r r 1 r r I I I I r r r . I r r : r r . : r : I r f : r ' I l ) { r iJ i , l r l i r r . l i ir r l | t z i ( , | | i t r ' t r i r , l t tk , l . l i r r r . i r r r l i r , i i , 0 i t ,z i I t l ( r l i l l t iv( . lUl l , ] , St-
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, l r i , \ . r l l r . i t ) , , l r l , r . rur , r , i p l in i l iver: ie le mancfr l ,o r te elolgal ic: i i ra,n, ,.r r I i l | L:rsr',t ir,. (r,rr|r. lrrl |1r. l i pozitiyir unil i l telir l, contrrr, la,teiai _ Sernrrrrl, | l l ; , \ ' l r l , '11. , \ n
'Lrbi l r r l r , r ' l l ) ) r r l | ]n-e] . -? ln i Bonnei , mlncvrt l t i Charn1() l . ,, r r r | | | { ' \ ' r 'r | , . I i I i .l'i6r'i, lr}itltevra lui Nlf{ziger, mane.!,li,i lui \i!'asselman'lr,l l i l ir ir{ixi l ( lr ltnr. cletali i , yeziAiseni si Oll,escn) 1g0?; Arscrri
r . r , , r r , , l l . l {108: [ ' , rpor. ic i r r : i r "o lab., l lTU/.
, ) I\rctt;!rt, tt i tu,t l i .niLor atdalg ir.,e (inclusiv a ci{ozoi loml::u,c rnti i, li i l r , , r ' r 'spir l . i l a , ,spr i te lu i drept") .
. r l ) I)rt:r.n.lu, tulbtniir i lor rle tonut mtscttlnr.; hipoionic fcsiorl, a co.lp,, i r, i l gr,rrr)rei, f leoum li :r, trri, lonnhi ahil iu; in sc,trimtr, coritractuii i ,; ' :L l r rvt l l r l l la l l i .
. ' ,), l)t t .-.t ttl r t
-.p, t rett.zi ilu ,_.czro pot irnplioa, rtlele scrnnilica!ii localizrr,
, ' r - ' I \ r ' \ ' , r , r r l ( r l ) rcq, . l l . 196;) . lSUel, I )arcst , ,z i i l ( . , . r |o i t , : r r i iazi iu halu, , r ., , l r " . r , , l t , r ' i r i ( i r i isaalJ Lr uivclul d isr .u lu i Lo _L.;
' r r , , .stezi i l t . c . r i radirrr .
,,. r.r ' irr... Llterl l i ,-a ph'tei, pc tiosul picioiulni" qi/suu po ' lt imele
dcgcl,t,. , r r r r r i l i , i o l r l rn i r . l i ! o iypl l l r l i ic i t l r r i t ._-Sr.
.l ) L'ft:){:nld Lulbtn iirilor obiec.liue d.e sensibilitatc ne polte, de ilsemenolr,'1"'j,,l, ,.ll.t].1,' irrlice{ii ropugrafice: .:rstfel, irr hernirj rliscalir, l,n_ I-.,u sri)' ).rr1' rrr,.,.L.rl U nlpoe\tczre.le la!r, aotorolitterd,Li a gnnbei, pe alosut pici{)r r t r r . . t r t r rz: i l t r l r rcelrr i , lu hcrui : r d iserr l , i . l .s _S,.6ipucstczi . r st . ef lh, cr l ,] ' , " , ' . , . , " 1:rry l ;11py.,1, i grmbPi. p+ i r rnr : i la iea Lt ' ter , r . [ i , r pt t l l re i f i r dosur, | | | | , , . , , I I I I I I r r l , r .ecl n j i po ul t i rneL, r ieg, . lc .
1) Pn:r ntt )nalif icir ol' d,e re.flene. Reflcxul ahili*n este diminurrlr.rr ,rtrrrtrt irr Jrfril i l rle alisc li*Sr_. Uleori refloxul cutanat, pla,ntar po?],h\Ir rr.lrrli l, sirrr..i lp:irc chiar semnul 1ui ]3abinski, ca manifeiljaie supn;iozio.r r l:i (rl rr,lolilii tulbirrririkrr vesouhre l,sc ji te comprcsiunii raii^icul&r,.).
h ). I'r(;:(n,t{t tu,lb*riirilot de btet itata po:tie avs:i certe yalori looa,lizit,.',,r rr. \:i i;[ol, <le.pild[, p:rrezx ilerorilor :tp-r,re iri ]relni:l discului Lr._S,,' , . ' t : . ' . ' . , r r I r . r . r , r l i1 i , mu:"hi lor ld_0J d\DLl t rs l r r t l h,r , lue. : lu i . n.r*n=o.
-&_,u,l , r , i r r ' r , r , r ' i l sc l l o{ tcn{oI Jt , t , , j .Lelor nc p ) . [ to rugur,r l rer ,n i , l r I is ;u l r r rL, | , , , .
. f r r l r , . r ' r r i i lu , l i . : - r , lo p. iu coinprci iunr piur i r . rd icul i r ' i , se pcato rec, l izr ,
, i ' r . I r , r l ) r . t . . r l lnLl , cu p-r , fJ l lz ie. dL. nerv sci t [ ic popl i teu er icrn, dc nor.r,i, r.,lr,i l)r)plitou intern s:)u cl:i, ' oinrL.'m (henidifah;m) cte coadii, do orr,l,i) I 'tt '.:(,njd tulbu,rd.rilor sl i,tt cterien e ne poalc intlica hernii media,rr.,1rr tr rr':r,ur(NIi:rirre, c&rc comprimi $i I' i i, laicinile s:lcrute infet,ioare.
I' n I t l,t, me tlc d,itr,g nost ic et iop d0 g enia 6n. Iotnb osci atalg i,i :,r ) li,olruirrtim cir, mrre:l rn ljoritatc rt rombalgiilor, a lornboscirllrrr,l .
; l i l ; ' l , ] : r l , r r )1, . )cr ' t r r ' r r l . , i i iL, , r . t l r . , t , , .s0i t , l i r r crz,r l . i ) "srrr t i , l , or i ,q inc rert"t4\ t t , , t t tst l t t t ( \ . t ( ' i [ ) \ rLry pL.trr i I lsor l , r 'ozr" t Si hofni i r l isc l le (r \ rsoni . ; i fa,rur l r ,
l i f : l l ,L) j , r ' i s i . ( )pr*{ ju, l1) i iT l Alstni s i .Nirniot t :su rr , 1.9( i r t i r \ tscni ry i col lh. ,l 1J ' / l ; ( ) l ) l ' r i i I i 's ' , l t , { ; l l ; I ' .p 'v i . i r r s i r , r r t , l r . r l t . i i ! ; l \ , i ) r )v i ( , i * l i i l i r , , f , ,I r ) i i ; ) .
/ , ) ; I i t l r l r r r t r r l l l t t : , t i IoIr I r , r t t t t t l t , ; j i : t t r , t t t t t t t rv l l t t ' r r : t t ' r t l t l t t r ' t tz t t t tl ' , r , r ra.r lc r l i r t r I t t r r r r r r r . l r lg i r ro ( srx: i r r l , r r r lc r r | l f t r t : t t t t t t t l l r r r r t r l t r r t t : r l l i '
i l l l l , r l r ( ' r , r l r . \ l r r l I l i t I i f ) 1t0l ' s i i i r i l r l i , , ; : i a l l t t l io l r t t l i i . ( ' t t I I I | | t | i ] | | I I I I l : r l l l | l ll r ; , r r r r l r t r r ro l i ( t r r r t t t i r roI t t r t r r , colcslcr t lo l r t r t r ' r1.r t . ) sr t t t pt i t t : t I r t I r t t r , t r I r I r ' ,, , , ' , l , r r l l r r i l l r l l , ( l t lcol i tu l r (1( ' i ls l i i , l t tc i t l izr t t r r ) , l t l t t t l t t l t l is t t t t r v l r I l I r I r r | r ' ,,
' , , , l r , r i t l r t l ic t t l r t t r ' , s l i r l r t r l iLr l is iczis, n l l i t t t l i l r r t l r r t l ivctnc t t r t l r t t t l l r '
I t , , r l r i lo i , i r ts i , sr i r t l ' ic l r , t r t r I ic t t | l t ' t r ' i ; t tor l t ts i l t t i r r i rs i ' l r l ( l tor r r r t t lz t cr t l t rl , l l , r . r l r r i r l t r l ru l lo r i l i l lcz i r r i i i 6 i tut s i t t t l t r t r t t t lc tur t r l i i r l r r r ' : r I r r r ' ' i r r r , t r | : r I ,
, r r r l r . r l r r t r l t l , r r l l l r t i r t i s t t tz i l , ivr t - r r l r iot i i .
. ) , \ r i t r l i l r t , 1t I r t t t l t r i i cs l ' t ' t ' r ' r t l iz t t l r ' i ( l t ( l iv(r 'so J] t (xx 's( ' s l l t l : r l ( rLr r r r r , r l l| , I L (Lnr\ i (c, lutr tot ' i i r lc s l ic t t t l t t i , r t l t l t 'srr l l t t 'sr t t l t l t t ' ( ' j I ' l r l r r ) t i l , r r , , l . r l r r ' ,, , , , l . r r r r rc rr l l l i r rc s i rntx i i r l r ; . r . ) . I )o r t r t t l lc ot ' i r t lL i i l r ' , r ' io lctr l r ' , r r r r r l l r r l r, , ,1, r r I r Io1. i r r r I r r scsj i lc s inr l lo:ruto i r lg ico rnl i cr l i t ts t , i t t l r . r i lo l i r r l 1r l , , r r l t t r
, l ) , \ t i t ! ! i t1L l rot tLt i t rd, c l t ' ; i t ' rLt ' i , 1t ' tbt t i r r lo i r t l i r tvrr l r i i r r vcr l l r r ' . l l r
r " , l r t t lv t i l . io i i , ( i t r t loscl l . i v i t t r l ic i ) , st l , t . l lx) l l i ( f I i l tor l t r r i r r lc r r l t r t r r r r ' r
' r i r r l r i sc j t l io ( t ior t l inont) , t lc t i { : t t t t r r t i t l t t vct , i r r j i l l r l r r (orr lcotrr . o r l l , r, , ' r r r1, r l t tn i c l t lus osos vic ios^ ol t lo ( I ( ) I I I I ) t i I I I i i l tc l Y r l l ) (1!( ' l r { r r r l ( l r ' \ : r r l
, , \ i | | ( . l r ) r ' r rc|r ' r t l r r i sc i r i t ic . I r l r "col tst , i , r t l l . i t t r i s i l , t r t { i r r ( r : t t i i ) , r l r r r l ' t r l , 't ' 1, r r r r c l i r iosl , : t l isrr l l i l crp:r , r i I I or '&)sl i r1 istr t , c i t t t l s t ' t ' t t t t r l r t l : t r ; i 1rr ' , r r , r r { : r
, , , ' , . r l r r l i lot l l t ib sul)cut l lmlc, c i t 1 i sul l I i r t t tu l t l t t r ' i l t t t t r l l i l t t t l t t t . t , r r : , '
' I ' i r r r l l r r rp l i f r 'Lt s: t r t Ia nivelul c i l ,puhr i p( t lotx) l r l t r i ( l jo l l t '1r ' r r , l l l t i ,1.
' ' . \ t t ' t lq i f t c] ' t { ra ld:, , I \ r ' t ta lg i t t cruruld t l t t or ' ig i t t t t ' . ' r f . ( tb) t t l i , t l i : :u l , r ' . , \ r r l ' l l l ' r t r , : r i r r r l
, ' , , l r , r r i i r l iscr t lo I i i , L1- L2, sc pt(x l t t t1, ( lo olr i tc i t l t l r : r , t t t r r ' lot l , r l r r t , r r
r l , , r r l r : r , r r r r i t 'at l ie l i in lcgiuncrr : l l t l ,c l io l t l i i rs i st t l l t t ' i , r r r t r r r t ru l t l r : r l r . l r r , r r r t l, , r l r , r ' r r i i i r ( l iscului ls- I - ru, r lu ler i l t t i t i l t l i l i l , r r i t t 11'9- i l l t t t ' i r : l r t l l r \ ) r r r t t r r r ' l
' " ,1, r r . :u i i i r co: l lsei , de-n lungul not 'vt t l t i i s t , i i r t t i t t l 'c t ' t t , pt lct t t r t , i i r r ; r r r r l
' ' , , r r r ' I r i r r I r r i . Sr: constr , t i i , ; i o hiporr :stozic i l t l ,cr i r t i t t l t t t t t l rL l t t l r t r . l i , ' l r r ' r
, ,1 r i r , . r r l i r ) {1 l l t losel l ooapsi t d l l rc lo i rs i ' r , f l txr t r t l , i r 1 l r l r r ,z i t t .
l r r r )nt( f \ tu1 scmiologic se nlai lo i r tsrxr i : t : t I i t t I i t t t t : t I ( ' i I l i r r l l i r l l r ) lLrr ' , r
' l l , r r l r r i t o lu l i : l t r , nncle def ic i to t lut to l i i ( I i t t t i I ' r t t t r r t cr l l t t r r i l i i l i r r r r l r ' r l r , ,, ' r1, . r 1 i l r I lcx ie i corrpsci pe N,b( l { ) l l l r { l ) , l t l t r l t t t t t ; i I I i I r ( | I t l ' l i I t t r r r r i . l { ' l r r r l
t , , ' , r . r l r i r r l ts ,Sir tdrornul t lecrur i l l r t lg i i r l ) { ) l t l ( ' l i l l r r 'o l i l r i l r t lc t r t l , i r r l r r : r { l l, , ' , r1 11r gi l rd i rn l io l* o rnts iv i l hort t i r l t l isc lu l i i t r t t r r l i r t t r i i , l i r ' l r t o rr l l . r r t l , ,
r r r r , r . thrhl l lL i (spont l i l i t i , t t tmt l t i i , vct l r r l t r . l l , i ) srrr t i r t i r r r r : r l t i r l i r r t r : r ( t r , t t
, , , ' , ' r r r , r ' r r l ls tct t l ;om, rr i rhnoidi t i i { i ( r . ) .
l , ] ; \ t :ontl .Qitt t i t t l . t( I ld prin al, to t ;r t , t t ' : t : ( tu,ntori . , ul tr t tsr: t t t 4l lr l , t ' , t t : t
t , nt t t l . l t t t in) ts l ,c t lo ol l i lo i t I t t i I l t i r : r ' r r I r ' i , q i t lo t t t t t l l . r r ot i l r r Jr : r l ; , : r t , r ,
l , I r i l r | l i r l i i l t t r r i t t t t t l i t , s t r ] t t ) i t t0 l )ot lx l l ) l ) ( ) t t 'q i t t t t t t t t t r l l l l l l ( r l l r : t i { r r i i l l t t r r | ,
t r Ni . r , r : r lq i r r s{) l l )o l t l iz0lr ,z i ' t , pr l f , l l . r , t r , r r l ,0r ' r r - i t r l ,Ott t r i , t t c{) l l t : r r . i r r t r ?, , l r | l
. r r r , I r i r r l t t i , i t ru l i i tu l s i t tc f r r l . , l r l t , t t l l r t r t - i t t l r r l t r i : r ' i i l r i r r i . Al t tur t l tc IoIr | , I r I t I r : r ,
, r ' , , r r ,z, i l r ip rr i ' l lLrr i l t . r l r l i r r r ' i , 1 i l r ip r l t r l i t , cvI l l i r r l ) : i l t l r l i .
' '1 , \ t t t i lq i ( t t r r |u lu i r l t l t t t r r lo l s( ' I l ( t l t r ( r l l l l ( ' t t ; ' t ; r r i t l t l t t t ' r ' t i l , , ' t r
i ' r r l ' l r ' l : r { : r , i l l l l t ) i : t r r r t l r l r l i r i i l t 1 : r ' t t t t t t r I r i t I I t t i , l l r r , l r l r r r ' ; r ' r r ' | , ,
I r , . . r : r , t t t r t1rr I r i IoI : t I t r I r t r r Io l t . l l ) r t lo t ( ' r r l izr I l r i i r r ' I t i l t I lz t t t t t i r l i r r l r l , (1, 1, ,
L l , 1, . , ) , l i r l r l i l r l r t t l , r t i l r t r r t l r r i l t t : t t t i t r t t r r l t t l l r : rz i t r ( t lzr , t t t r r t t t , l t t
r , r r : r l l . r . r r ' l r t r ' ; r l t r ) -
, ,1 L
i . \ ' r t r , r l l t i r r I t 'utrr to t t r l r r t r r l t r ( t t r r ' r , t l t t i r t l t t t t t t l t i i t I lu i l i r lh ) u\r ' , r r r r , r : r r i , r r lot pt i t t lot , r l izr t t t r t i l t t t l t i i ptr l : t , l : t : t t t lc toct l t r l r ) l t , r t ( ' ( r i tpr l l l ,, r o l r r ru, i r r r r i I r r I r ' t r r I l i , i t r so! i l l i , l r1t I r l r tPrr I r t I t I l r t t t I t I t , l l t : r t I t i1t l r '1rr t I io l t ( r1r l i i r l t l r lr r r l r l r r r r r : r r r r r l i s l t tzr t l i i r t lgr l ) i t l i ' : i l i ( 'z i (x) t lc t l r r l t i , i t r l l i t l r t 'xc i l , l l t t l i l t r l t ' t t l t r .. , r r r r i r r r r l i ) . Sr i r r r r r r i l i i t l t ' i , r t t t iur t i l t r , t : rLsl i i , tntr t ; t lEi t ) I l l t r ( fs lozi( i i so lxr l r l r ,, r , r , , r r r : i I r r n rrqlqi r r , t t t ) t ) t . t . lu i l l i : i t i Lo' ( r ' IL l '&l (o i t lo pfovi l lo dir l l [oect l l i I i i r l : l, r r r : r I : , r i ruc rrrr { t r r iool , Io l t . i l t ' i rpropi l lL ct t fotnr ro oul tur i l tu l i t t t l r i l t t l, . rzrrr ; r i r r r r r l . r ( , l r iu l l )sr) i [s) , s i fu i [ f i ( ] in c l rc so:rsocir . tz i l , o dul 'cre po 1r1r lr r r lc l i r r r r i r :1, cot |sr , i , i t t r t t l i r l , sul l l t fc l l t l t lcntut i l l i i .
t , ' r t t l ' , r i t l io l , t ! l ic i : l ) $pon( l iL)zc lourbi i t t - ' , c l iscop*t i i ; b) Spott t l i l i l r , ;. ) ' l ' r r r r r r i r i r , ' r ' l r ,bt . l t l f s i l rL i r l l t i i r r ih i t l icno (oarc t r rebuie c i iutate tot t lc i t t t r r i r
rrr l Lz rlo 1xr',r isi i 'rr l i i , l i i lgt ' lyiuli i t luleri lor) ; t1) ArLhnoidite sphtrl(!; i ,)I i r r r I i r . r r I i I r r , fr lr rrri)nono|l i[ ' i ' , r ' i |otici l I f) Procese inlhntntori i si iu tunl{)] ir lr!, l r r r r r r i r r r l l r r rz i r r : i1) I ' ;o i i i ' . ; h) CompresiLrnea, I re l rLrh.Li de cX,tre r t l ' r r l r r l, . r ' r \ t r l .
:"- Nindrorn,rLL;ohJ-picior replczinti i ' corespontlartul slnclromului utttri ' t:rrirLrr rlr lrr, trrirnLrrtt l supolior', f i ind gencrat (foflctea, 1967) tlc faol')r ' i
! rr! ir{ t. ior(,ir ir ir, r,snpri\ l iutulni ganglionar prevei'tebral s:lu asullra pl(,rI i l ,)r ' \ '( l ,folir 1,iv() trl)(l omino-peh'iene (afec{iuni alc por!:iunilor telmittrrlr,
. ' i . . lrrl irr lrri r l igcslrir ' , rtocl; iuni uter'o-anexitle qi .t,-ezicale, procese infl i l l trrri,rri i , i rrrl i 'r ' trrl, i lr lo l lcrito|elle Di rctropcritolrealc, psoi' lo .,q.4.), precul)l t i lr ir. lczirrrri lrr,ri iculrut (sponil i lutloze, spincli l i te ry.a.). Se poate recunorrtlr '
l ,r ir lr o rlrrrolc lsooiirt i, cu. rn:rni{est;d l.egetatiYe de tip simpatllgic t1t(rr l l r r r l i i l i v . rsrr ' r t r r to l i i . Durerea sc local izcazi , in arf iculnl ia qoldului , r ' r r rr, r ' lrrrrlr sr, l ir rui;cir,ri le mai ampl€ ale acestei articnit[ l i ir iar episodic i lrr, lrrr, l rrltc zortcli: i .nt'ecinate (r'egiuDet inghinald,, lontbilrd,, fesieri i,, Irr ' lrrrrrl.r 'o irrlolni ir, coirpsoi), Irecrlm li dista] (in regiunile tibio-ta,rsialt i i , r1tlrr.r ' t" rrrr(rrhlr '; irL,nii,). l lobil iztre:i actiYil, Si pasiYri a membrului inforiol,. , 'r i ! r lr (. ir zi i { ir! r(.r '{)ir ') i l l l rcplusu1 o am0lioreazit) de;i de rnul0e ori se irsinl ri.| ! r ' . i r r r { r r l ) r i l i l r t r t r i i l . i lc nocturne.
,\ lr lorr,pr' l ,oi,rhrrnurt s9 cr.it lerrl iazir, m{liologic motlif iciri osljeoco]lrlf.r i i r. ir l(, (.(, loirrir i vi lr l i{rbrale {orso-lonlblre, mcciit ici,r i ale arl, iculalici t 'r 'r,,t l r r r r r l r r l r 1 i i r r r r tut i ( )s icoloroze t l lso-rnetatarsiene ($of letetr l -96?).
l i . Sitrl,rr,nrul ctnaltr,hri tursiutt, iKeck, 1969, citrr,t ds Dofletea' 11)li?). rlr., olrrrrrrrr, r)tnologul sinalromului cnrpian tle la membrul supu'jot 'l , l r lr ' .r l 'rrolrrl, r lrr ir itrtr ia nervului t ibial posterior in canalul lLri l l , iclrrrl 'rr:rrr rlrrl I, ibio ir$ir-i lgirl.o-cirlcelrcan). Se $tie cii, in acest canal osteo-fi l)rrlIr;,, 'r,,. ' ,,,, ' r|(r|r.Lrl t ibial posterior qi r-aselc cil i toresc intr-o teaci f ibrorrHrl,rrr r.r, irrr irrl,crr, i;ocii sinovirle a tendon',rlui m[lchidui I leror proprirt rt llr r lrrr.r. lrri. irr l, i icsl, ci lnrl, ncrrul t ibial poiterior sc bifurci, inceidoi rxrt 'r 'r
1,1 ,rrl.r lr, r 'rr rlr,stinil l io notorie In lnulchii pia,trtari qi senzitiYl la plttt i ' i i
i irrrrI lorrrrrI rr, l;1io csLe fi ivorizat de traum:}trisme locale (lractnri lnit lrr,rl ir r l, rrr l r. i 'r1 ) (l )rr lrr:, j i i , ontorsc, di ',-ofse intcn'eri l i i chirurgicale) ;si do piciorrrl 1rl r l, r i i r ir, c,rr '. iol,ctizc:trzii prin furtl icrituri, infcpS'trLli, a'mof$eli 1i dttltrr i,
' r , . , r ' r r , l i , , ( l { i r r !sul i ' r , 1rr , n ivcluL o. I t t . t lLLl i r i t : t ts i i t l , in } l l )n l i i i l i in dcgolr , ,
: r1, , , : ' r crr i l r , l i l l i ; i 1ro l r t , ! l i t r l ,oL' t r i t l i , g l ,ur l ) { r i .
\1,r ; i i l r r 1 i 1rr , t ' r l l 'u i i I l s1r Nr01, i r l t { i l l l ) tz i - t i t r t r l lor i ' r i , l is tn; i i t t l i tn l t t t l l t t r r lqrr l r r i r i , r l r , r r t t t l lc r t t i , t t r t t l r i l i . I i t t l r i i l iL l l t I I r r l i I t I I : i , l r i l torrr l l r r l r i i l ) l r l ' l l l i l ' t ( r l i lr l r ' r ' , . I , . r | , . I i r r i | . \ r r | ) r ' i i i t t l , ' r ' , r r i i t l l l ' r t l i i s i r t l rL l t tc i ' t i i r l r "1r1 r ' lor ' . l ) i r11rnr j t , l l r , t l r r l , r ; l l i i r l ' i l ' t 1r ' i i r I i ( r t l t l ' i { t t r r l l r t t i i r r l l1! ' r , r | 1 ' r r r 11 f r r l
: ' t l
, , L l r r r11{, l r r l : r l r l1r ' l l r , r , , l t l r r ( I t r ( I I i I I I i L | | i I l l i l l l ( \ r l { , l l ) i l l i : l I I i t I r I t I r t r t t t I t t t l t l l l r
1,rr , l r " ; l i (1 l r r | , rcLt l i l r ' ' , . i , i l l r r t l l r l r , l t i t l i l t t t l t t t ' l l t t t t t i i t ' t ' I tot t t I t I | I r I r t r ' , t r " I r ' t 1tr ,
' , , , i r , l l i lcr i , r r lo lsrr l r r [or ' l : r l r i , r r 1 r i < r i r t t t t I t t i .
7. i l 'L t t ta!4i t t Tl t tntat i (ho(, l lu i ' l lor l r tu ) s i^cl l t : t r r i l ' t izcr tv,r l l ) l r l r r l l l r ' r ' t l
1" . l izrr l i , l t iL ivclul t r r l icLi l r l i ; i i lof l t t i r t i t l r r t tsol i t l i t l t t f i r , l to ( t l r r r l rct i : r l l l ' l l l
| | \ i i i i i t t s i ) i t1 i i lo di ! { i l . t r lo i t t lc t r t r t t r t l rL ls i t l t t t ' , t r t t i l i t r l i t r l i rptr ' r t t l t t l r l r ' ;1 '
I l , ' r s i ( r i i l f s .p] 'c c i \ , lo i i l i F l ) l { r l ' r l1 '1r 1){)stc l io i i l l ' i l l ur l r r r l r ( ' r , { t l i r l r r r r r l r : r r r l
' r i , , l , . r f is tn s i i r r t inprr l r t t t - r tst t l t t i , l t ' t t lo l io l ' i t , t t r i t t to l l l t ; t ts r r i l r r . , i r l r r : r lc t ' r r, r r r i r l i lot i ' ($ ' ; I let :e l , 19{ i7 ; L idvlo ; i I luca, l ! ] i iO, 0i l r r t i t lo [ r r l h l t r r , l l t l i r l
l , r l : r i | ) Iosfo un*i nerrort s i tuf l t po rnul d i t t r lc i i lo i l I ( : lYi l ) l i r l l l ' : r I i . l , r r ' r r r ( l, , r '1.r , i tc lv i l1r | t i ig i ta l i p l . rnt l | i . l )ozvol t l l t 'cr ] l l ( lv l r ) l i l l l l l l i t '$ l I l : r t r r t rzrr l ; r
1, r r . r r i r i . i i in l la l r r r tor i i locl t le (osoirso l i net . l ( , i l t i t i ) , ( l i r ( ' I t I I I I ) I ( ' r ' i i I I I I i r l r t r l r : i lr , . , j r rc i ' r , l f i ' r ,mi :Lt l i , r1e osteof i te, dc roi lcf i i } { ) f iosl ' i l l l ' t l ivrr lsrr , t t r : r i r r l r ' : r l r r '
t , r r r ' i . ' l \ :e l . rLt ie 11i{crcn! iat i i de l l te aleoi , i r r rL i t t r lo l t r l l ior ' : t r t t r l : t l r r t r r r l l1rr r l , '
, l r r , r 'so or ' ig i l i , osloocondr i tc 4.1( l oDpotclol l l l l r l i , i l l i j i ( ' l r ( f , t t I ( | : | | I I I i i | | I iLr '
' r l , , r r , i - r , (cr i ctentuala t lepistare t lc to l l i Eu1'osi l r l r t r l r r t i l .
11. Si t td ' 'antal ,p ic ioarelor nel in i . : l i te" ( , , l i ts l ' [ tsx l t11t sr l t t r l rot t t " l " 'u l t, t l . iboDrt l96f /estc le lat iYuDort lo t*" , t1n1511111' l t t i t i r t l t r t t i ( i r r , t lc l r : r t r ' r l l r ' t l r l, , l r r l ' f t ' i i t r t te l rbrc lo infel io luc ( in giunJ)o i i i col t l r i l r ' , l r i l r t l r ' t r t l r 11t I t r r t . '
r , r , , .1, i r I xcptni l , in: t . i a les noi lptea, in c iL l t . l t t r i i l l r t l t l l t l i , r ' r l 1r t l t I r r I r ' t l I r rt , r r l , i . r \cestc p:r t 'or isme a. lgo-p; l rcstozioc (101,(r l ' l l l i l l i l ) ( ' l )o l l r r r r r ' : r r ' \ r ' ( ' r t l i, , r r , , ' : i | i : l ls l l t , r r rb ic lor , t1e t , r t te t lo l iv i i t r l t l t tot t t t l . IJ t t I l l . t r t I r t l t r r r l r r ' r ' l : r r r lI , r i r i i l losi , ic cste negrt i r i l : i tca c-{ l l r lor l t l l r l i o l t i t ' t r l iv t t t ' t t IoIrr ;1 i r ' ( l ' l l ' l r " t r r 'r ' r i1) ; sDf lstca qi cohl : . , i90L).
I t , (1uu:alei i }ot f i i l l t , i ln i te qi l i l t t t t I t r t I I t r ' 1 I I i t t I l t i r I : r t r ' , t t t l . t t l " r r t t l, , , , r r i l r t i sc i : r t ic , cu oaractc l 'c le i l rn i l t i l o i in l ( ' l io l .
11. \ , i ) , { tet i le t l 'bet ice $ rocurtosc Ic l i l l , iv l l for , l tL i l t t I t t t t I r | . I t t . I ' ' ; r t r '
i r , r i r ) Al : r r . in saive i le dLrrcr i l l f [ l ter l t t l tLt l l s l l l l t i ' t r ( r r t t r l t t r ' , t l l t l i r r1r ' r ' r
' r r r r l f ) , cu i l ] te j . ] 'a le l ibere I 'ar iahi le i l ) ) I r l l I I t I ' I l I I ) I ( ' I I ' i t t lc t io: t t "
; r r l | r r ' ' r
' r r r l i r r r ; i ' r , pc t in iec| :1c scir i t icutui ; c) Atr t ] r t , t I t . i : I r I t l t t | 1. '1 t t t I t I r I ' r ' i I I I I I r t I r t t | ,r , , r , l r r t lGci t c leclan,sato de sl , imul i pfol) l io( jo l , l ' iv i ( t l i r l t , r i t lo rrr l t i t r t l t r r t t l ., ' , l , , r r o logiec, ccuR ce r tneol i pol l ic i [d l l (xr l t t t r t r r r r t r ' ) ; r l ) A;r : t t r r l l l t r r l r r l ' r ', r l , r , r l t t l iv , c i t g i iu t : r .bcst f , , f ixr L1r" I t l ) St l l rsocirr 'z i i , r r t t : r l lc l . r ' t t t t t r ' l r r l " '
i , , r . ; l ) Se ] io l asocia $i Cu l l , I tc cr iz{) i t lg l l ( ] L l t l t t r l i t ' t r ( r ' i ; i I ' t ' I I ' I r r , r t r I I t r I : r r ' I r r, r l r I t i ' ) .
B.PROBLEME DE DIAGNOSTIC iN TULI}URANIUITftOFICE DE ORIGINE NBRVOASA
8.1. TULBURARI TROFICE ALE PIELII, ALN FANERELOR$I ALE TESU?UBII-/OR MOI
l. Pielpa usruld, sol2oaso, slriard prin fisuri, r.calizind uneori aspcctul:tr' l)rr.t', .,(te crap" sau 1{e gopirld" poate fi intihite in sirixgomielio glln slI|(| l 'oilmete strtnqomteltce.
'?. Pielea_rece, nAkdd,.sub!.ia-ld, uneori pitald,, lividd, cle aspect I,amo-lil, rr. prrrrlc observl i n,poliomielite, mielite;i altc atecfiuni medulare, daLrI | r r .or ' t sr rn ncl ] l rp l0gr l je vasculrre {Arseni , i .8o1ez. 19Zl) .
' '1. I'rr.zcnla tle Jlirtens, de eruplii butoase 1i d,6 aspcite sclerodermiooIn,rLl,c I t -r'cvelatoare pentru siringomielie $i alte atectiuni medulare.
. ,4. .l\ ' lot'maled,^,:I Irfl!]i l it.otpd.unghiilor, precum ;i eJilarca degetelor ssrr l r l r r ' . jc l rccvcnf iu r l ivr . rsclc alec{, iuni a le nerv i lor 'pei . i te l ic i , p iecurn glIrr ${ilu'ozrr in pltici.
^ 5.^,lIipcrtroJia. .n i,inilor,. mergind pini, la aspectul d.e ckeirotnegati,o
r l \ l , l l l l l l { . :r l lo ln SlTrngOmtelte-l;. ltcq me lple reci, cianozale se intihese in compresiun iie med ularo.
rl:rr' ,.i irr hcrrriplcgiile vasculare, in'polinevritr,, pol ir:adiculonevrit c gi iriull,rr nouropatii.
7. Arpootul do membru rogu, dureros, se intllne$ts in sindromul eri-Ilorrroliulgio, i:r,r d ogetul alb, ischemic este u$ol de recunoscut in faza aga-zilri ,,Hiltooplltr local[t, din sindromul Raynaud.
'\'. ' l 'rofalemul crozio (sinouime : boala lui Meige i distrotia edcmaloa-u:'l I rrrirrrltrrurrl. localVat; edemul ,,reumatismal,- cionic al lui Desrnos I.rlrnr'l H.gr'cntar aI lui Debove; pseudo-elefantiaza neuro_artritici, a luil\,lrrl,hirrrr I lr{)rrlu, luiMilroy) repre,.lintg, o v&rietate de e.dem crorlie aib, Aur,rr{lr)l(,r',-ou lclxurtil io segmentari, avind _cel mai adesea_ sediul la inemll, i {,to rl lct ior,l o, uni- sau bilateral. Nu are * se pare _ nici o specificitato,Ilrrr,t,u lli congcnital, ererlitar gi 16afl.jal1 dar ddmulto ori inso^,teqte bolilor\rorlo-{logonot&tivo, unelo boli do colagen, apd,rind chiar in rcuinatismnlclorrio crr poliartrit5.
, 0; lldcmul .rozat ^aI ,fclcir..ul obrajilor, al gitrrlrri. al spnt(.lui ,"i al iolol, r 'HI | . r r . i l , | l In l ( r r . l i l l i i { rL iL l rnoor i f i r lo pigrn.rr l . r r { . i i t r i t lc l ( ) l r g i t ,ct lz i i )
ho I r l . i l r ( , !1.( , i r r pDik iL x k,r ' rn l l l Drnir rz iL l l ( l r i r l r l t lu i I 'o l rgorr- ,1:r r ro l r i .1,-
24t
10. Ihhnl rh dirr : r t t t t l ipu,r i 1 i h)pol l t ' J i i lo l ' I i i t r i ' i l r r i l r r i t t 1ol i r t r , v r i l , r , ,1,r ' l r l r r , r l iouLrrrrvt i lc , pol inot t t r tpt t l i i , colagotroztr , i l t t l t tcc l l t ' l r t - t t t io l t t l ' r t l l iot ll , ' r r . r , r ' i te ( i rusir , -z i rstr l , ,s indlorn neurr t -cdelr ta l ,us t l } i r lot l r i t l " l t l l r t i l ) r 'pt6\l,rrrrr), in unolo cornpresiuni mielo-radicukr're , in silingontiol itr, itr Itrittti lrlcI' r r I,, r Irr rliverse origini (Arseni si Botcz, 1971), in sintl lrttrttt I l trt t it ' l, ir ' l (,,1r itrrr',! | r'oriLl,or,siitt din sindromnl parieta,l) $.a.
IL Ar:len aarnek cuta'no,tet mai rnult slu rnai pitl,itr pigtttctrll lrr, rlrr
'rrrrliriri clifeli.itl (de la un bob de linte pinii la o circlg:i), rril,ttitlo itt tttorlr.tr,rt' irr in jl i lul gurii $i al na$ului (dar gi in alte zono 1;ogrlrtl(' l l lrrr{r) r{il l l,
',r',,fi[toare peni]u sclcroza tuberoasi' a lui BournoYillo,l2- N tutfiibrctnato!(r lui Becltlinghausen, se po&to t'trcttltttrtrslrr ltt ' itt
1,r,.zr.rrlu, de tLunori multiplu pedicula,te cle tip ,,rnollLtsr.lultttlt ; t r r r t r I t t I t t t t t ' 'lrrrrrr rrepediculate), de consistenli moale, pigmcntate (brttttc srt,tt grt'l lrltto),, r!, {rol mai arlesei) coexist5, cu pete ligmentare br'[nc- oirlol I i i 1i ott I 'tttttorirr lollni de qiraguri de mi,td,nii rotuujite sau fuziformtr, tl ispusrt lrtr I 'trt,irrrr1,,1,. lroryilor leriferici.
13. Ang ialnul cutrd,urt pktn hernifacial, adesca voltttnittos, sil 'rrrti, i lr,l,r|rrrLiul trigernenului, este revelator qi nc obligir, sli oil,u li inr :lltgirttttrt' ltrzrt,,,rr i.r.l 1rlo-trige.rninali, a iui Sturge-Weber-Krabbo.
14. Preaen,ta de ytete pi'gmenta,te (tle culoarea cafolci olt Lr4rl,o) itrrlivrrllo. 'rrrr 1L;rps11ls, ilsolite tle novi pigmentari $i pilofii po zonoltt ttt 'rtctt rrlttlrtr,rrrr:rl), Ll un copil sau la un adolescent, ne cvocii o rncli[tl(tzii l lotlr(t olll!r-rrrr lri, rnir,i ales tlaci ln contextul clinic existl ;i crize olilopl,ico 6i/srt,tl ttrrttrttrr,lu l)n)ces exparsir intracranian,
tti. f um{'faclii le cutanqte noLlulare la nivolttl trtornlrtrtlor, tl l l,ttr:rrtrltl i,r ,rl :rlrdonelulii, insolite de crcqterea in volutn ir, $irli lot' siltt tttrrtrrrltr
' r rl ir.o pentlu adipoza durero&sd, din sind,ronzu,l Lu,i I)trouttt,16. Pana,riliu,l ana,lgezi,a, earactorizat pt'ittr-o l,trllrttlrt,ttt I ' lrrl ' irrtl ' tu
r r|lu|ilol unuia sau mai multor degete (merginrl pinii lrl N,lIl l)l l l ' l l 'r{n[ ll l l ' irrrr,i l:rhngo)r in absenla durerilor spontane sau pl'ovo(ill,or tlrt 't ' tltt rltrtroltt 'r"rr rlo tulburii,ri de sensibilitate tle tip siringotniolio, ovcttlrtttt ' l tr tttttl i,rrilr'{)m amiotlofie de tip Aran-I)uchenne qi:r, uuol sctttlto pinltltitlttlrr, ltrrI rr r r,' si'r ne orienteze spre diagnosticul de siringorn iclio stl,t I tlo nitttl tttttt Hilitt -l.,rrrriclic tle alti naturl,
l7- Panari,!iul anulgt:zic, insolit de faoics .ltxtttin, tltt lulbtrt'fl l i pigttrr,ttI rr rrr, r lc leproame cutanate, ile hiper"trofilr, nLtlnilifornri, tl trot v ilttt ', t lo tt,ltttnl,rrri,, 1.oo"ot, " (eu protlominanli, tormoillalgczicii, ittifirtl, n4roi gkrbrt,hl'),
'1" ,r r{}ficxie, do loziunea mucoasei pituitare, no orionl,oil,zil npro (l it,l{ttu$l,i(!u I,l,r hpril, obliginalu-ne sA, ci,ut5,m bacilul lui l{ansou ln tttttounul trt,ztt,l ryir,Lr pnlcbic5,m reaolia lui Midsutla,
18, Ulcarwl perforant (mal perforant ) ylunl'ur attt tlttbrri, innirlior ryirrrrlo!rr'. Inilial aparo o zon6 tle hiporkeratozl, apoi so dozvrtli,i l,t Htl(nos[v'
' l l irl,cni {i apoi o ulceratrio rotunjitti sau oYalrrtr '
cu tondilr{,i1, tlo Ild ittclrot,,rr rrrrr,r'gini ploeminentg, cu fundul acopolit tlo o sorozitrto giiJltttitt tltlttrrrr,rrrrrr irroloni;ri. Ulooralia gi togrrmoltelo din jur sint indoloro, Siu[ $l[ul!'[,ri irr crllo ulcoraii&, clozvolCindu-so in profunzimo, atingo orliiottlnl,ll lt lr1i rrrrrl. Ilvolufia, osbo torpidtr, cu oioD1;tizflti otomoro. Ulor:r'Lrl pulfrtt'rltrl,rr. rrr',r rl$ obicoi ln Labos, so locolizoDzfl, fio t.l itlonnoan, fio [a, nivoluI rlrtlott'lrr(,rrrr rrrrrtirl;i lr$o- tir,ltngiono t ll l ltrooltri, fio lrlnisolul tlrtpttltti <xtlttl tlrt tl lr . r r ro i lc , r rnol ' l r ,ht , r 's i tn qisol lo i t lo i tsoci : ! t i t t ( l ivor$o : !Tl ; l 'o l ) t l l i i l , t lht t l , lcrr , l t t ' t r ',rrrrr 11i ort lozirrtri rt,lt 'DIi0u 1i rtrtbrrrttil,ioo r
| ' r t . t : r r I r i . i r r i r r r . r ' r r l r ' , i r r r l i l r lxr l , i r r I . ; r ' i ' i , Dtr . r ' r r r r l i i l r r r t l , i ) I ) i IL i i I ( | r l r { . r ' .I t r l l r l i r l l r f r l i l s i t l l r l t r r t t l I l l , r i t i l i l t l 1 l l1 i ' l , l tgv.otr i t r r l s l l t I I ( , I i I r I I i I i I I I( r l ror ' : r ( l i ( , ) l r l l r r i l l rut ' r r , r r - l l l r r .L i t ) ro ({ i r r i lxrr . { , ; i ( i r r i )xr l i ; , . l ! }?4),
I ! t . l iJ( ! ' t . . t . !1, pr t . lonrnt , .u, l c, l1 l t i , t r l r t i i , t t l r t x i t l nru. t , i la, iu l t t i , t i t , l t , , r ,/ , i ) r ' r . r l , .
' l l t l l , D' l i r , i l r ' . , {p l [ l r t ' . l r icr , i r r r 1rr l , r ,s, r ] r r s i i ' Sir ing' t l t i . I l
I r t t l l r t r .: '(). l l inft sttctt. lttLii u ltt i J[a ncsat, so irrt i l trcst]e in siringorri ir, l ir r
rr rr ' ( irr] l(11{'r ' iz(l irzl i ' p|itt1r| urL tlt lrrn ir l rtt i irr i i ; i l l r lcgeiclor, 0ir10 apinl r]rrl l . l r : , I r i . l . r r I i i r r rL rkr , l r ic . i ur) lut ' r c l rnr htc i . l i l i . U'c i r i insi , p ie lea'p.r t . l ir r r r : r l : r . ru$) i l f r i i _f i s( , l l iurroi ls i . Unghi i lu t iut r r t ruf icu qi r i^eform:l fu, i , r lr l . r ' . l . l r r 1rr i l , I i r l . l i , ' r r r rL1,o s i pr i iL ostco:ut lo lJr t i i lc coc\ ' j5tcnte ale i ' I r r r"r ';,.Lrr', 1r' ir.st,., l iz.kr si pfiu resot bli i lc schelctice, prin frectlrri lc sl,,) 'l : r r r r . , 1r . i r r r i I . , . r ' :LI i r | , , : r l ( , r rc i i pr in panir i l i i le l ,n g;z]ce i rsocirLtc. , l I r r i r r r r .' , t t r i t l l r ' ,1, ' , . l r i r ' i ILt l s{ lct t l ( . r ,1"-
:; t. l l i tur, irt,ttttk:it l , l ,tt i Lhetlt itte (t l in sinrlromul t l, lamic al lui l_ri i, jr iI irro l irrrrsrt.) so cilt i tci:cr.izclztrr .pf intt.un aspect cii inotic al trri inii, cLr ir irr_I.:r .rrIrI irr,I i i , ;r i lcce, cn unghii le recur.bate, f isulatc si sfi l ,r inicio:lsc] lrr, rrtrr r. rrriocirtzir, lt i [ulinosCUte]e pozil i i denir.elate aIe rlcgettlor, car,! i i l ,: r r r r r r r r lc r lo r l isc i i r i t t t :Lozice r lo l lexie, extensic gi abr luci ic.
r'1. l,)sortt cle si lrtutili:eazti i:r, livelul legiunilor in care ccmprcsirrf{ r, {r '1Ul,rrl iLr}l '(si ir l lpLicit, ischcrlri l ; cs1,e urrl i pronunt].r,t ir,, arl ici i Li niv0lrl r,rr.r 'rrlui, ,.1 zri 'cltr.clrloinct.Lrc fialfefclor itrtcr..e l le c,.r.Lpselor. ln lrrzir, l..r l. lrrrl, r.sr:rLr' ir, r 'nccfrc ia nivelul picli i , care intl-o zonri l irnitatir, capitir, ,, r lr,r|r. r 'rrsi,., r lrrlr i r,t|r: l i1lnlo nesroza tisulari i, sub forma unci lLlcet.r r , . r I r I , r ' I i ' r , i | | r I l l r )$esi I p ic lcr" , lcsutul ce]ulat sul ]cutanat Di mu$cl t i i ,;rrrl irrrl rr. jrrrrqr pitri i ir l , os. I)c rnulte oli se supi,a,infecteazl. Aceste eior,rr,r | , . r Icr , r I I r iL rc iu l . i l t rcsc in: a)_ par.aplegi i de c l i - r 'ersc natur i s i o l . ig i r r i ;l , r r l r r , r : , f t z i r r r , i r r r . . r l r r l . r .c; cr L"nr ip lcgi i ; d) pol incv. i tc, pol i r .ur i icul , i r r , .\ r ' r r ' . ; . , ) ( t t \ , . r 's t , l , , , l l , rnI t , , I r l i i ; l ) l , r , bolnlv i i comrto{ i ; g) Id, bul r r \ i l' ,1, r ' . r1 i . , . r .1 r i i r , ; . . , ' . . i r r r r i , r l r , rpc, l ic .n.rurr .untr . r t izrr i , 'supi i } i uoci :urr l j iI r I r ' r | ! | | | / , . I r
' i , , r r ' . r . , , 1rrrrroI i , , . , r r . l rL. t lc , l )0 hCmiCOr!UlCoulL,Ala[crr l (Jrr , , r r i
: t l lo l lz . l1) i I
I:T.,. TULBURARI TR(T.IOE OST}'OABTICULABE
. 1, 1.,'nr,cl,ut.il,c spontane indolora srttyit fie insidios si fd,rri o ctuzii irlr.r-r', rrlri, Iirr rlrrpr'i,.urr tr':urrnrliism rninim. Indolcnla aoestor friacturi gcncrlr,,. r utr'|' nnlsuinla ; a,) iliind igncratc de bolnav qi rlo medic, cintl anilr,,-r, rzrr, rr I,rrllrull,ro funolriolta,Li moderatd,, riscd, sii nu fie ti 'atate. b) Anl;r,on, rzr, l 'rrr!o (,ltl)ul.iri osoiirtc, cu deforrnS,ri scheletice, dezxyi.ri, incrlr.h'i,r,r,,jr', ri", IIirrL)rii iIi, i 'ounlro (lc pgcudo:utroze $i do cr,lLlsuli viciol.tsr, Irr{!_, rrrrr r,r rurrrrlrrr'sitrrri ti.qulirrc si ncrvoaso (inclnsiv mc(lulare !i/sr1u lri.l l lrftr,I i r , t r1: tz l l l r ' : r0 lut . i l i [ Vortebr i l lc) .
, , . \ , r . r . l r r f l i , r ' t r r i s lx,rr tnu inr lo loro t reLruie s l : i , nc sugcreze: a) l f i l l rcsrr l l
l ' ) l l r r r r r ' " ' r r r i r ' l i r . f r r ,cr ; rs1,r i r r l t , i rn i l I l fecf , i r r r r i , , f f i lL l t ru, i lo vur l ;cblr l l t r s l r r i ,: . , l | r r . ' r r r r r r r i r r r r l r r r lo r l r . loIrni l , r ' i lo coloru;rc i ( i r r r l rosLrbi r l0 oi i i rsco l i r ' rz l t , 1r | i r . r is .I ( ' r r l l J
l l . ' \ r l t 'o i r l i iL, r t ro 0r ' i r l l r l$ nrM)i l i i i l l r ) t ) r l ) r r r l i , r I s0t io r l l f t4) t t r l t t r
l , r t t t tu l t r , r . ' i r ) l l r r l )u l rL l l , i l r ! r ' r ' r l r r r r c l i r r i r r , l i r r l , l r l r i r r I r r lo l r l r . , rurr r r r r r lo
: I , I I I
l , , r ' , . ; i i i r l , t r r t I r i tzr i r l0 olr iotr i i t t t lx t l I t l lo l i r r r i l r r l r '1 l r1 l ) i t t l r t t r r r r l r l t r ' . r l ' t "
, , t , r r t , , i , l , , t iu s i l l l r ' : r l i lc l ( l iz ; l l { p l i t l i I | | I ' ' I I I : I I | 1 r ' l ' t t t l r l r i l t i I ' i r { i i r r ' r ' r : r r r l
. i , ; ,1. ; r ; .J; ; ' ; ; " i i i , . t "
or . t io l - r iPtr l r r r l ic . , ' i l ' i i r r t r ' l i r ' ' t .s l r . r ' l i i : ' l t l t i ' t r
l r "
r - \ ' |J . Ci t f i CStntCt i \ ' ( ' r Ccl 'ml i : t t l t ' ' r ' r r i ' l { . t t l t r r" l l l r l . i l r l l l r r ( l r ' I r r ' l
, , , , . i 'u ' ln pro" i , f """ain. t ) , t lugcnic, su p.r l , ' ( ' i r r ' r 11. ' l . i r r r l ) ' ' r ' i r t r l .1," , t
, ir ' ,.,1,ir"1""""drif"r '"ng"t"tit i 'simi. ' t ici ,t l ir i ztrr.. ' ' . rrr1 |IrrI tI i ' i t t I I ' t t r r.t I tI 'I r1 ; r.rlc si leziunile tiolice osteo-articulare'
tr)e multe od afiropatia loatc constitui semnr.l - itr i i ' irr l
ir l rrrrl r :r l ' r I
; . , r r r ioEia". lndeose-bi a l tabr-ului 5 i r l s i l ing,rrnir ' l i " i . Srr l ) : r r ' ' r l : r ' l " ' I
i , , i ; t l t "u ?t i i lnar i" i poatn r \cr t o t l (oqcbi t i v l l ( r r r r ' r ' t l i r ' : r r"r '1 r ' : r ' r r r " r '. ,f ,]"-i-o i.trorr"i ic locil izat,1 Ia nivclul membrului slrl.r ' t)t ' l), i t l(: lr r\ \,
,
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; ; * ; i ; 'u i l i "g"- i " i i " ' in vrctnr: cc 1rLrupat i i l ' r . r r t ' t t r l r ' t r l t t t r r r l ' r r " '
, ' , , : i ' ; i ; ; l ; ; "
inoi tset i pcutru l tbos, r l r t ' t tncot i s i p ' t r1r ' t t t r t r r r ' "1 ' ' r r ' ', l i r l r :1 ic[ , .
, " . l t iosnosl ict , l v [ ,1, ia: { t ) In ?"r i 'ad' ' l ( dr t r ls i t r l r l l r t i . r ' l r r ' ' l r
. . ' . I i ie tu; id ioS, Si lut( ie in care r t t roprt iJ Sc ( l r"{cr ' | r ' f i r . { r r rx:r / r , r r r , r r r , r
l . r . . - l lontaneslu a l lnoi d is loci i i i l r l icul l lc ' l l t ' { : t l l r r r r r : l t l l r ' : r ' I ' r r r r : ' r '
' l ' . J ' i *" i " t i ; ; ; ; i ; " ; sau-oi i l 'e un . fo l l : r t l i ( ' r r l i t . r" . t t ) t t r vtr l ' - t " ' t , '' r ' , , cousl l t i : lspccl l l l pscui lo- I I "gtn. ,nos l I l l l l r l r l l i r \ r { ' l ' i r l r l r ' r r I r r r ' r r r r ' r ' .
,,,1,,,,n, r 'osie. atlese'4, cchii lotici ') qi-prczenita dtr vettt i ( l i l ir lrr(t! r lt l lrt ' rrrr
' , , , ' .
' f t : l icr i l . t i l este caldi l s i desf insi dc o colccl i t ] s( ' | r t ) l r ( t r r r r l r r ' r r ' r t : r l
' , : : ; ' ; ; - ' l - ' " imnor, ' r r t i mbdcrat i i ' r ' ) i t r 1"t i " t '1" r ' t r r l i " r ' : " r r t t ' l " t t -
: , , i i a. . f . "Lrerr?i t ' in i l : r d ispar i I i ' ' cr lctr t t t l =r ' t i s( ' i r r l r r" i ' r ' r r r r r r ' r r r ( r '
,L, t , , t ' ; r " l iA" l i upo." o i r ipcrt lof ie : r ' p i r ' l i l t r l r r r r ' i ' : r : r r ' l i ' t t l : t { i | t r r r i r r ' : l r r '
' , r r ' . r , l oso:So. S'pr l l - 'crz i i cr lcm'nlr ' ( ' r l l l ) r ' r l ' l ' r l l " l " i r l " l l l r r r r ' r '
, i , : . '1: . r j , , t i iL i t te i i i ' in i lc ; i r i to r i lmin i r l f i 'L r l |s l t t l r l . ' i r t t t l r I r ' i t r r r l " l " t '
t r | , . . f ' t tc t tL i :c, . tea, c i i te Yar i : rh i l i r i l r {u ' r ' ' l i ' r l ' l r r r ' r l r r ' r r tzrr l r i : i r r l . l r r | "
, , r i i . lezirui i s isternulni nen'os i )N obict i sr i r l : r l l r ' l r l t r t l r r r : r lorr ' r ' l r ' ' r r l l
' i , . , ; ; , ' " i " * f t i i iu i , g i tuhr i , nui l i i ; i t rmi i t rL ln i ( l ' r t r r | t r t l r t t . t l t I I I I '
I t I I I I ) ; : t l i
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f lZ iorutr i l ; i r le colpsci ( l r t ' r l r r r l ' . t t r l i r r l i r r . t )
' . - l r t :ou,r t l i t t ' l i t ' s i t i tqoulpl i r " l l i r rg i I ' Icr ' I I i . ' r r ' r r r l r r r r l : r r l ' r ' r r " r '
. . , : i ; ; . . i , ' " "1: ; i l ' ; ; .d, . i , ; " i , . r ' l . i : i r r l i ( .1t , r r i . ; , l r t l r t i r r t r i r r r t . r r ' i ' , r I . l r i . l
:r r r riL1lui,' : . " i , , l i ,ovut i i led,Lt t ta l tcsi l tcrcscrzi lot l l ) l t ' r l i l ( ' ( | i l I r l l i r r r l r r l i i l r ' r t t t
t t t l r r t t
I , i ; ; i1") , r r t i ' t r lath gemrtrchiulr i i ( , , r t t r i | r ' l t ' .q | t t t t t t t . l , r i l r r lx { t r" l t 1 ' t t
; , . .1 . ] r t - ; i i ; l i l , r ! ia pic ior :u lu i ( , ,p i i : i t , r rL l r . r r l r i r . " r r . l I r r r { ' I r I r r . r ' r ,1 . r l r i r i ) ,
r r , , r , ; r i lc in c. t r r lezlunct o '" 1 ' l l l r ; r r l l i . ' l l l r r : r ( ( i r ' i l ' t r l - i ( : I I I I ' ' | | ' I ' I I I I '
, . i fu l , i i " t r lcr l iu- lur i i r t r r ' : r i r '111i1
111;r1i r . . i r . t ' : r ' r ' l ' ' r r l r " r ' l r r ' r '
, L, j , ] , ; ; l ' i ; ; i l *neo-cuboir l i r , r r i ; i ) rur l i r . | ILr l i , i i r ' i . . , l : r r ] i : r r i r ( r r . ,L , : , r r ;
, , r , r i l l ; r - r : r i , i l r , ta lso-rnet i tL l r r r i l I n l i ' ( r , ' i fc f i ' ' r l1!r" l l izr ' 2 r I l l l l l i l \ l l r r r r l r r ( l r '
r ' , , , . , . , . r l i i Ia, n i r .e lu l halucclrr i ; i s , ' r t r .o lnsi , { l { ( r l } l { ' r ' r . r l r \ l l l r ,
r l l ( ( r l r '
r r r , '
1 l | r l l r l i r l l l iar) ; h) ar i ropi l t i l r ' ( r ) \ r , j i ' l r l i l t i r l i ( 's l ( l i l l ] ( r ' r ' l l ) l r r l i l r l i r r ' r l r r l r r ' '
t ,1, I ' i l i l l trofir l cl r,ololl l to, ci rltr t ' ip lr ' i ' trr l i i tr) '
j . : t t t l r rn l l l tL l s l l l lo l io l , i t l l i ' l t tPr i i l ( r i ' r t l t r r l ' i t r t l s i l l t ' l ( r l r l i { l i r l i " l l r l ' i i r 'LI
r ' , l , r r lc ( lcg(r t (11)r .r l t i , , i t i l , l , t t i t l t r i t t t l r , t l I ' t r1 : l l l ) t r i l l l l l ) r ) l l i ' l r l ) l ! ) t l l l ' r ' i l ( l ( ' r1{ ' r l l r l r l r r r ! l l l r '
: r rLt , t r l r { i i i t r r r , r r , l , r1 i l , , , l t r t r ' t0r t l iz i t t t l l ' r l r | r l t t l l t t t l i r t ' t l t r r l t r l i r r r t l l t t t l ' i ' t ' t
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i l l l ,
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(i?:"-,:nff ,ffi,"fffi :ilxr;, ! #is&*x?"'T;I,rr:?:i rll,",!'r',:,'i::"iil,#':*,":i?'r"ji:"$;iji-!ti",,.i.11'?li_gfi.li',lll:| | l i r r . iL l l u i l rL ' r . r 'cr t r .b|al osoS bete|ugen. inegal (mai iUr(l!r,f{\ :r,|l I tt)ltcit zii O inflexiUne
ii1ili11rm*'[#**q:T:lr1x*i{tiilil',;'liliilfl1il,:ir;l'ilii'il:li"il*t"ff"lil',*-l:iiffil1,t" ae o'surii-
'i :.,I:;il;:i:. i; ftli:t :,;t::!:r!:i:n;:;;ir !!#{,2,}rf};g7rr.,"",t , t . t I t t t tAi bpi u, t , t [colp i rnfrcn0az; al , l ropaI i j le ]a Il iorrrr,, lrr.ir r ut.rrri,torii factor.
ili:ti,il'i;illitli,,lllrlr"ii,ft '*$:".1if&lii;ffi1r#:'d,1iTli#"":;r"tr' rir r'r ) ; r, ) ficrer'2,r,,,,",,?liJ'iili$i"l#:;#i* l'fi ii/i:|{illiiliillil;l :llllli,lt,Sil#-;1$'i'
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"".,"t."ji",ton'3ii.-i.t rffjlJ.::i*l'oi cLio"iif ptii
. .l,niunilt n,ritl;utrci lotnbo,s,cclraie ,"tr"no"ra u,:i"ii"ii ate nerlbr.o-
ii i i :l I ,j;':i,,i i 1,;i''i}:ltt'iij::t1iiffl:!131',"1i"i,,3;iif,i,*iffffi irx,f,i,r.i 1,\,li(1(!; c1 sirirqomreiif::lil#l ltffiitllJSilrr",#?:g,*:i;i'l,rir;1i,,il;;";l ';,1,1'i''i' ilffiilir":i"'li"':"'i"i .ii.ilff;'fff;1#ifi3 ';l:ill'i
2. latziun,ih sistamului. nerun pat,[!tr i.t lxrt *ntrenrl rrltrtprr,tii rlis_l r r l l I
,,,,,,,i1 ,nilillll,ll'lll,l1;i'lli'lil: ,lli;.li?li,,i,llii i,i,llll;,ll1lll,1l,:'li,l,,illl;lll'ill,l:260
lric", compiu:ubil cu col nl.tlbosului' Ma'i t ' lt s{) pr'('(l l lt1(r n't' ltrrlti l l irt l ' i lrio'
t,rr' i iruir, $i ccu 11, gcn[ncl]lulul'
,,,,i]r*;'l*.l:#";;;ffii.Ll,HlT.,l3ili?il"h ryit:nli I'er Ii'' o$ L(\') p' ) rr )z ( !'
,, ̂ ii"t*r,:;mg:lilllli,f,? $fffsg"'#:';"ili:;.{iJii?ill;i;,lil'il;;i'll':,"i,"{i{rqJi:uii"iul**lisf J'l*-""':tH;*tililiil--]illiilf i:lllilJ3,lltlJff 3ff r"#x"i*r#hf*r;'[,,"fl"$$l:lJ:liiir*ilft:li:'lTl;&f,T#;ii''l'd;"""n"'"'iTftT.,t'l,iltr,f iit$^i,*r,r,.,,,,,,l,li;i;iil:ii"f#ltll+fi,1itrT1"#""i1{5giT3#fr *TltcL,,r)nr,,rriv rrticulare I tl) In ulelo tt, r' i-- t:i lburiri osteo-artlcuare'
,,,,,,,1,1|;nf,'11.i:"'i:il1'Jtisl--.Tl'lii:x?'#r't"Jiu, i"ll|,"'11),'liilii*l',ilii'iil'i[$*ru;* *-*rr*+ln+i"{lf,"iit,*iii*iii*[liir',1 ,'^,{,';"d;.Tt+ni"":* T":tJi['i?it iliitilil,,,lllll,l:li"il]t,i,lli;:"1t"*H"'Ll,T:i";l'?,liJ!;t!*;,'-,"';.l;'iiill'il"iliii#l;lllllii'l;l'\,1,,.ti"*;""llli:ii''";[*.:1"*?ftli'T];ll'';i ,li1,,,1';';;,'',r;';; i',"u',tl,rlri,'o {1,"a..-"tice, toxice q' a')'
lV. Aeropatiile ulce ro-mutilante
1' Din lttmct d'a uetlua a'{ ' ini 'a se eatact'e;rizoilzir ' p|in tlrttr i ' i tuttrrlt i ttt l t
I r l t l lg :
1,,,..:1"*r*'g'uffiL"xiu5i;#if'x'T:i*Jl,i'ini'lliil;':iii'lii^l'Ililii]i':;;; ;;#;i;;;;;.1i." p"t'=':*ru;l*,tfT#iill'ii ;Jil'ilil,li,illl:'''"'l l i Inut i lSnte. se pot tsocia modlLlc i l r l ate uugrrLtr( ' r + ' Lt
il,il1{:$"{#-:-#"i?t*tli'',""'ffi il.Hy,;lfi :illlfiil';'h-ll[llr ,xt , l rnsiv iafalangelorrametatarsieni lor 'apoi 's i 'LtN'r$t t l l l i 'o l l ( l t ' ( r i t l ' ( r t t ' tt,, tiu , a unor importante detormaJ'ii'
,lly"#"ru;:rme;{!;;:lffi 1!:!r!$[ldi'i':rlrlxi"ilJ]i;ji$ a"#:;lf l,:tillt''l,,lll,"T,"l',t,,'',Ti,';::1tlill'ili'lilllil"il'lr,,, iiurln,'io1,,t'o .st. rtrur! *ll,,t;'-l;,ll;nl,liliii[i,,llll'l]i';11;lll,,l'1,,1'iiilllJlqi l r t , rn i in i , t r t t ur ic i t t t l l r t t r i t tl iz :1,1(J 0c l , l \ l l l r | ! l l ( l i t "
!n l
) ' . I ) tp p1111a,1 t l t n\ l t \ t ) r l ioyt t r . l .orT, t r i r , ( , l t lc y i , r . l ) i r , r l r r t r , l i . , r t i r r r r i r lgslrr l r loLji;;,'ij ', i,liil:i;l"l;;t,i;:i';,:,l,ili;'i; Xi, f;lilll,iill;,;,,1,1*l:llllll ;ji:iil'ilillll;,: r l , r r : r r l r rc i r r i lo l r , r r l r i r l icrrrr q i l l i r r r r r ,v ikrr . 1 i . r .Ui i ; , i i . " " " " ' "
't ) rt tt)r),ti. ur.txt ntur'i/rttttri .fan ttialii a rui, ,l!dren.r{L (sa. rir,ul.-rr ' ' : l r :r rrr l i . rrr:r . i t ' rr ' rr i i r . i , rui I) . i r .v-rJrr* 'ni , i"r ," i i l i , , , , i i , ,r , i i rog,.,*; , il,,l'] ';ll;ll:;,];liil"ili':iJ:ll"Tl,ililliii,nc riitl*som'i'ri1, ",, ,p,iiii* i*trel;--;l{r
,,,,,!:/,,,t,:,:,i,:i:!,:,,:i!,:,','"ril"il,l:u',i1,),1^,it sporattit:ri, neereduard, o ltti Bt;tr:au,
; l - l, : ; l;l';lli,,n rl * t#;uJ[$*i:*it,l ml:xrkit;1;i#l l r l i r ' , c \ l )u l rc l . i l i t l t l r ig.
t, ) ..lcropoliu, ulctro-muti.lan tii din ttiahet :tlrre riircori, d;tpi. i0 t}rl I ,
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o" aoo,ialir. vegeirr,trvc),i;,;;;l; ,'x'1i:ilil.,)lil,,J#ilh*'t"T$:l;i, ilil"" a"-p*i"t.'n-sc,-p,,riii
lliiiri,ii:rlltxlf ifj;h"*i*"*:H"#ff.1#xn$'#:tl;lrjlrilii;lii.li,lJ':
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s.J. I'ULBUttAlil TR0IiICL. MUSCULARII.
Il.i l. I. l,r.irr.i,i i .c corrrli l i l i i scr'iol' lricir i ' *uri*troiii. i. r_c.er.e.i ti, irisi r r r r r . i i r r r ' : r r I i r i ' i i r r .z, losic. , recise a . in, , i at" io i .n i i i , so i i r1,or, o s i r , i { , { l r llrr r r.rpii rlrr rrorlluiirr' i sriinioir_.gicii, ,t,rf,rl "r"r
-irrni"ez,i ""l ' f l l i r r l i r l r r r . r rL . l r . r r r r r ru i r r , i i r r l ' . i r . r rc. ; i , , r - ' , i i : , , i , r 1 i , , , i l r i r r | .
, i . ] , Al , ' , ' , , j , . r r ' , r 1.01t0,1; ' r r f i r i . t . r , r r r :1. . . : r ) uni l . , t0r . r i l , i ; b j br i : | terai , , , r r . , r
lil,l' I 'iillil;1"'l,:illl,;li,l'iliill;,,;l,li:' ' '.'n s,rr lrrrrxir,rir'iitr)r'cnriz 'ri' srrr
i l . , \ l l r r l iz t r ctrr ' : l ( t i i r r ' | lot , I r r r r i I r i t I r I i r I i i t r cr , 1 l r i t . r ,1 l0 c() nsi i t0 l r l . l ( t l t . i | i ir I r ' ; r l l r i I r i I I i , r . l r r r l i l i i , r l r r l i i r , l r . . ) .
, '1, i i l r t r l i r r l , r ' r r , t r I l r r t ( i l i s i r r l r I r ' rurrr I r . r r r r I i ( , i n) l r r i l l i t , t l r ( i l r t . , , r1, , r , , , r , r ir l i l t l | l , | . | t r ' \ . i , I l t r r l r , l r r t l r . r I , r r r r , . r I I , r r r i . r I I I r , t r j , , i . I r , t l l t r i , ,1, , , , , , , , , , , . r . ) .
').tt"l
5, ( ' : i l l l i l l ( ' i l l ' i i r r l t ' t r l I i |o l i l t i l r ' : r I I r I t ' i | r r I I r ( i i | ' r | t t t t I I t I I I I t t ' ' '
( i . \ ' l , t ' i l ' i l l l t l r ' l t ' r . l r r t t l l l r t l l i t ' i i t ' r ' | ' l l ' r r ' I r r t ' i r l i r r t t l I ls t l t t I l l t ' . . : l t l r t l l r l r l l l l . t . t ' t t . ' '
, r r r l is l to l i i l r r t t t t tsrr t t l r t t t ' l t t r tgt ts ivr ' ( l ) l l l ' ) , r ' r l rqrr t l t l r r i t t r l i r l l r r l i i l r r r r r r t r i t t
i ' , . " t , t i , , i , i , t i , * ' , r l l r t t lz l t l t i i . i i r s i tu l r l i l t r t " l r l t l t i l ts t t l t t i r r t " pt t 'z l r t r ( r ' r ' r r r l ( l i ) : ! r
, Lrrrr i r r r r i l l r t i t t i t t i r ioI t r I I i i I t I I lot l t t ) ! i ( '1){) 'Z. V.r i l i t r l t rcrr , r . l1 'xc1rr . .s l r i i t lc t t l l i t t . l isr ' : l l . l l l l l l l t r i t r r r t t r i . ' l t " l r r l '
, r , t ic t t t t r l t tg icc, r l lo l i l t l s l l t t l l t t t l l ; r I i I i t i r L t t I t 1 t I i t r I t r t t io i IoI i i Ic t | | I I11I j ' i | | I
1,r ,s1l t lc n i t t l l i i . r '1 'orrrc i r l l ) l l l ' .
l l ' ( lntrrr lu l t l i t -orsr : l t t l sr : r rs i l r i l i l i l i , cr t rc l l i i l 1 i r t l i l t r r f i r r t r t r ' l " r l r
l r ( ' l i i l lcurogcn(: ( radicr t l l rc, 1xr l i r t l r . t ' i l iot ' , pol i i r t t l i t ' t tLr t t | t t t l r ( ' { ' l r r ' r r r r r
l r r r c ctc,) ,$. Ckutrr t l , cx istcnlei posibi lo t t ' t l r t rcr i lot , t ' : t t t r pol l i l t lcz. ' t t l r r l ' rLr
rrrrclc amiotlo{i i n"t,.og"itc -.1i,
lrrl i t l ts, in tnirtzil 'o;i ' i t t t t t i t l r ' : r r r r r r r l r r r l L l
r,, nenroloEice,10. n8tarca t l ivcrselor at i t l t t l i l t i pa t t ic t r l i t t ' t ' , t t r tc l i t l 'or t t l l ) ( ' t l l ! r l r r r r r r"
lr,f i i l(: l i l icgcner sat pcntru unt' le :rttt iotlofi i l lctl l 'og'(rl(r (i l s(' \ t '( l( ' i l r lr r ' ')rr
i r r r r l t te) .' ' ' " . i i . , yer i t icalel l or . ig i r i i i l l r icgele s l rU tr i l r l rgr . l r r . , r r s i : r r i i . ' to l r r l r r r ' . r
, ' 1 ' t , ,gt tost ' l "utu i pr in i lect lot l i ' jgnost ic t ' i p l in . l r ' ' i t r r r r r r r tg l r t l i r r ( l ' ) \ l ( l r
' 1I. Ufcctuarea, in unele cttzul i, l l birlpsit l i rmrsctl l lr l ,tr t rrrctrlt rri rt .r: '
, r r.rr nlui histopiltologic.
13. ] l feclruarca, unt lc estc cazul , : r unei anclrei t ' gt ' r i l l i . r ' ; i r l i t l t r l r
r'.r orrliotipului }rllnavului.
t4. Efectuaretl t1e tletelntini 'r ' i biochinrir* l l lo rrtrrit l i t lrr i si .tr":rlttrttt ' r
i,r i,, strig;,Sl l lr ir i i) ' 1 cxzilnclol rnusclrl i l to (fosloct't 'rt l i tt l l irr lzrr' IIrcIi..rI i Irt
, r ' , ' j j " ; ; l : . t . ) , , r l l , luhzelor, a t ransani t t r rztr lot , l t r l i f t ' t t i I r r i r l r rzt i r ' l r ' '
8.3,2. I 'robleme do diagloslic stmiologie |i lopollr 'rrl i t '
. r , .J.2. t . .4 t t ;o l rL, f i i I r uc-nruraf , g i t t 'I . .4 i rc l i ih nr in".defrc l" dr ut i l i : 'nte (ul t "J i i l r r l t tuul i l i nt") : r1 ' : ' t r t r t t t t t t '
' ' , , ' , t r l i i in ' l i i ' lna"Iurgate ( indeosebi in apar,1 '1c gi}srr lo) , i l t t r t t tst t l : t l | r ' { t t t t t t
r,,i i'ii;"iii""t "r",
i,,ti"rit"1iito" url:irlhri, a1c i:orrpsci fi rtl r:J ' t t r t I t I ' I r i t t I r t r ', r r r r r i secl iuni t le tcnt loane, 'p l in unelc t t r r t t t t t l t i is t r t r ' r r r r l ' r ' r r l r r |o l . l r ' - l ' l r l t
' , ' i , , , , i , ' ; l , i "
' t i iour 1, . 'p lu l 6b nrr sp ( ' r 'nsl i r l i r t i r i t t t r ' '
t r r t t t l i r r r ' : : r r t l ' \ l ( i
,1, ' lz iur te l t neurorruluf motor. per i ie l ' i ( r ' i l l t ' t l i l tgt losl i | r r l ( i i l r / ' r l I l r ' 1 l or
, t , st , rb i t l t , in cazul a l , rof i i lor : ' - l ' i r t r rp i 11"p111111i ; '111r ' . i t t r ; t t r t l l t t t l r ' ( r " t t i t t t
, r " , ,oI a,* : i "u i q i coloana') , s l i nr ru ' h 's ' - r t r r t r t r* ' ' l ' r ( r . r l " r l r ' l i ' r ' l r r l ' t l '
' r t i i izrrre, o i s i t , cx1i lo} i r In 1i evol lur l . l l t 'z iLt t t t l t i t r I r I t t I I r t I I r r i : r l r l r ' \ r r l r r r l r r ' l
l r i r r l .: / . .4mit t l rof i i l .e , ,nu-tr i l i r :nale ' y i l l Is t t t i lu l t t ' l ic t t pol l i r r r l r l r r r l .
r r l in cursir l srr l r lnpi t pcr ioadc do l ipsi drr I t I i I t tc t t I , I I I i r " , - r ' t t t ' l t t l r ' ' t ' r ' . t
, , , r r l i ' l l l iment l ro r ' r :s l t ic^t i t . i s i r r r dczr: i , l t i l i l r t ' r t l t r , t 'v l ' t t l t l l t l t l t i l t t r '1t t r . r t t l '
r , ' , r r l , r lcanor i tx ico(pl i r r r t 's t l ic l i i t ,g lohrr l isr t t t c l l ' r l1 i l ' r i r lc r r l ) ( r r l i t l r r r r ( ' r r lLrr '
l r ) lhr t l i ' l l j : t t 'c i ctr t t t i t ,c , i r r1or" , 'Otr t i i r r l l i t t t ig i t r t l ' r 1t ' r l t l t : t r r r l t t l r l r '1r ' r l r r '. , r r l ' i l ro ln l l i i r t t rLcl ic i to t lc r t l rsr t t l r l i r r I
( ) i l t t r t t tst t l t t r tot l tJ i ' i l l i t t t r i t ' t r t t t i | i l t l l l i i l ' t t l iz l l l i l { ' : l l l l } ( l ( l l l r / ' I i i r ' r \ ' r ', r , l , r ' i i i f tot t i<u' , l t t l t t r t t i I t l l t l i lSt t r ' ( i r I r I r ' '
I I r ' I I i v is l lut lL l r ' ) , r 'o l r tgct t ' rzr" I l t t ' t ' 'l r i r l i r lc s is l l t t t ;
r l ) l , r r l r , r lLr . r r i i l t t , l i rctr l ' r l l t i { : r r r r i t roz. , ( i r r r rp l l i r l r l i r t l i t r rp l l l l i ' {
, r t , t ) .
' , l l t i
T, , . . . . ' . :L, i ] : ' , I .
r r l r . r r t , . s i l r r , r , { i i , r r r l i r r I r r r l . i r r , ( r r l r i l r i r r r r z is ( j i r f r , \ i l ) rs l , r r r l i l .uzi ,' . i p. l r . r r r ' r : r | ' l t , . l r r . | l l r . t f i l l , .sr t l r r l r t i l r , r l ipr ts. I )0 rrrr t lht ( ) t . i ,so l rs0(] i i tz i ,0t t t | l ti ] l l )1, , i . ]
, : . . : l i "J l l . . r r r . r l , , lx . r ' '1 { i i r . r r r I i l ) r r t ,0r ' r r i {1 i , r r , t l r l l r i r u, . ichi p luvnu,cir ,,t, irrlrr , 'r ,, l ' .rrr.t l.t I r 1;1151'1'1'Sir,l, Clt0 pcrsisli i citovlr, st{I, ' i l .,. i ieflcxclorr l lr)i lrr l irolsri sirri, ctirrsclvai:cr nr]_
-rxisti l la,scicrihlif
-rnusculrre spou,l i r l r . i r i lu prr)v( '0 iL( ,0, i r t , r ' t :x i l tncl tu l IG este nofrna, l . '
. , . , . , . ' ) . . t . " : , : . , r r , l : , r . . t . t i t i r i t , , t r jc f )L,r t , , l .ecunoir : te pI in rr . lu l i r s i cu cpisor._l{ r ' :11r ' ( ' r ,srvr . ( l r . r t r r \ r , , j r1tc, . l i l ic i . pt . inprcdorninanpa,h r , idacin.r , m. inbrc -
]] l,,j ' l, j. i l]:: ':.; trrlr.,rgrosi rc cvidenti dupi, intreruperea toxicului, pr\)-, rrr' f r l)r' irr I n.g:utrv rt irl.ri!_c\umenului clinic neurologic qi cle cele mai milt0, 'f i,i ,;i i,, '.,1" ' ', '*' 'S
,r I I l, )f l,.uti (cu exceptia polineuropatiilor etil ice deja cou_
.. .ll. '1 ..4nioln[ii[c tlin tm.ele ,.i.nto r.icalii endogette. De piirll, amiotrofitrtt.rrrr,ri sltrvilL. irL oursitl insuficicrLlrci renr,le cronice, ar6 o pieclominantir,pt,rr i.rrLrrlii, so l,sooiazii :ldcsea cu.crainpe musculare, iar invesilgitffi" "li#ilrrlr,r'ir.rlrr, *''uLi. Dilicull,lli cliagnos--tice intirnpiirnin Ooar -in'silualiiio
r r rr|:rIj ir.i i lrolirrouropa,tiei ulcmlce.
.,,.l.,t .1,!,,i,! ':, 'Jiu,.rlin b:,r.ata lui llac Ard"Ie-scttmirl-peorsol, poate crea:, . ' l l
r ' , . l ) r ! , ' ,1| l l r ' . r t l lguost ice c.u amiotrof i i ic miogene. Do frpi , e i lc o amio-I '1 ' r , ( , , | l . r \ ' t tvr t urrui t [of ic i t cougeni ta l a l fosfor i ] rzci f ruscul , r r , . , car, ,rrr l,' r'r.ril.{r Lrilnsfo|ntjrrcJ glicogenrilui in acid lactic. Ii,eprezinta o boali,l.llllll l.]l,l,,l ,l.l,rr,rlrir, (cx transmisie autosomalL_recesivA), tegate Si ale, "J| ' i r l rXl l l r l t . : r t r . . .SS pol fe r( ,cunoir :Lc pr in crr . r ,ctent l eret l i iar , pr in apar i -, : , I I | , r , , I I ) I | : | |L. r r r ar lo lcsccnt i . pr in amiotrol ia r izomcl icd, inso1, iU, i i d,rr- | | | r .U,Ir l : r l r . \ r { t ( . .cn|npo. p| in aprr i l ia de sidr i episor l icc de conbractur il l , ' i : : . , : .1: , ' j ] : . . , j : . "1
dc c lor tur i p i urrnrtc de.miogtobinrrr ic f fanziror ic (revo-rllrguo\t rn), prin cs?mcnul ncurologic ncg-r,tiv (in afara
t , r r ' . ' , . | | l ( . r : | l r l , l l .o l t ( . i d iscrelc r izouel ice t l - t J0% dincrzur i , ) j ipr inoramenul
' . ; l ] .1:, I I ,
l ' : l l r : . ,11 p'obci de ischemic r ' , i i " ' , i i ; ; ; ; ;e-p' ind la sitcnl iuirrl ttrr',.ir :rotr.yrlrtli i-bioelect|ice, paralel cu instalare:l coftracturii cluic_,"Lr{L (riir , ,/s' tiorvlanrl $i gglg!., 1965, citali de Radu, 197g; Sr,ior,1r Sli.lrrri, 1.0?5, r:il,Lli de Raa1d, 19?g).'. i . . l ! t i t ' t t , , l i ; t r de or ig ine eu.r louind se pot inr i in i io:
.t .rt .l tlt ittlt 'ttfia,h iperti roid,ianii are- o pred.lominanld, proximali, (ce1 m:r,i. r i r ' . , , r l ) r \ r \ . r ,1 l t , . r t i r , rn:r l rar sc.r puloh umcral i ; , sc asoci . r ,z i i adcscl t cu fas., r , 'ur . ' l | | 1, . t , . r r , . t Sr.m io logjc
-der.uh nl ) . dar cxrmenul c l in ic neurologioi lr r' ri.{r,r I v, lrr. ox&msnul llMG evidentiazi, semne minore d.e tip neurog6n.
.. ,..,.,), l,:.::.,,,r::! t, prIn hip,ercortic-lsrru. (indeosebi ilin sinch.omut ti,i Cusn'i"gt, r , , r ' t l | r i r r l r tcs, . i r rn3SCJl i i , dC obCZitate.
, ;t luir t'f i i pdltnr op&uz;cili,_ sc itsetmilrd cu miop-rtia 11rogresiviir . , l t r r \ , , i r t l r \ r .vI t r . . \prr | L, femci introi0si G0 dc ani , p ieclominn Ia rhdi i -r rr:r rr,.rllrl lot. (irxloosebi la rne-mbrele ilferioare) gi id asociazi, cu hipo"l,rrrrr. rrrrr.rrLrr.i-r,. I)i.lr nu existi frlscicula,lii, r,eilexele osteo_tenilinoi,sorrrl .r)rr,r'virl(!, rru sc evidenliazii, alte serin6 neurologice, iar examenulll\l (i rrr rtllvi, rrrrxlifiq"lr.i irirportanl,e.
,\.:t.:!. ':. i l nioh.ol i.i le miouerl,e
I i lo l ' , crr ptrr l r r t t r i l t lu l t i l , I ) loxi l l l l r l i ' i , l r l i t rg i t t t l t t t l l i r t lcs t ' t ' t t l t l t i lc ' t l r r r t t t t l t l t l t t t
i i , , . , i , , i , , i i ; , , i , , , , , , , i t , i . Su rrrr r r i t , i r r r i r r . , i . r i , : r . r . : r ' r i 1, , r r l iz , r t . r ' - l . t : r l : t l r r l : r
' , , ' , 'u i : r f - r .nr .p. i ip l l i rch"nnn ; i c l t " tut t r r ' r r l . c ' ' t r l r r t i l ' r t , r l r r r ' ' r r ' r ' \ r5 l : r
I ' i r j : i . rY. a ' i - i^r . ' i ro, n i r l u i r r , ; r r r r r ler ' . fuLrurr lu i curr . r ' i , r r r ' r r r : r l r i l ' l i . l r , '
i " , , lor in, ' l ' ; i
6,""s ' r rdr forntr Iu i L\ l t l loni) ; i cel ' .o.rr l : r ! i ' r ' : r r r1 I t r ' l { ' r i " l
t, ' i i""-"^ttl""ite,t' i ' i i2gnosticc (Ratlt, 19?E; Guibert ;i (lrril)('r' lI |1l' i|)'
oi De nlulte oli ' a'miotrofia plorimr J contrlstr':rz:i t tt tt Iti lrrrtl toli|
, ,1" ; rn; ' ; * ; ; ; i ;L i r rn ' : i i " t ie) r r a l t6r mu- 'chi : gxrt t [ ' i t | i { t r r : r i i r ls t ' l r i " l '
i ; ; ' h ' ; i ; ' i l . j ; ,
i " r i " i , l : 'd) consisrenla lnuqcrrhrr-r t t t t r ' ' t . r r r r r r l r l r r ' : ' i r
,i;;i l ' l;-;;;i a"rjrotg,rii de zonc fibroa,se ;i i], urr'r' ,srurl.lri 'r 'r ' l 'rrlrr .
, 'r nefie,'ul idiomuscular este totdealro'l abolit pr:ccorir". lrr t i i r'\( t 'pt rr' 'i i P;il;;i l id;io.-uJii ost"o-a'rr'iculare prog|osivo, irtvrtJ irlrttrlt ' (itt r;r|r'r'r I
i i,-f";; nocnlm" de Boulugne) ; g) iJleltror ti,r g , rsi ir. l .rlr. rrl i .r,rrl;rl|
;i;l i.,liiTJ;1" :',-,l",\lil"Jl' i:il",llilijljl; r,''::illil illi"lilllii,"'li':j;r;ill ;i ' i gt , i ' i i . " " i -U, l i 'C
otr te un t las. 'u t ip ic tn iou.rr ; r l .gt r r l : r t " r r l t . l . t t ( t "i , i , " ?"- i i r l i " t " i r " tor ie, a c5ror <lurata qi lnrpl i t r r r l i r r .s i r r l , r r . i l r rso 1r rrrr
rtt i asDccl, polifazic cu componenie scultt I r ldlorrlt ' lrt '{ l t ' {trrfot' l l ttt l t l lr ' lot '
;,;it#-iLtdl;liratu"t"it; iraseu DMG dcirscbit tlc-bogirl; itr l irttlrttl tr.tt
r.a"1iei -iirlmite,
care gencreazi' virfuri neidentilicabiltr ; i) '\spcrrl rlcsi ttl
rle tiaracteristic, in geniral, ln biopsia .muscularii ' : rrll 'r 'r 'rr'{i i lrrli irlr" tlrri
1,ersate, segmentare,'ct inegaliti 't i i le tibrc'lor muscttlittt ' (tIrtt tttItIr' ' lt i;x t'
i.oiice lalr-nt.ntice), c' coelistenlii in acel:rqi ftrscictrl, r' ' Ij lrtrr t.ir'rtIr|.Irr'r'
_i ii" i ri"'r"r"i", cii intittralio grisorsl rnli mull $iru rlr.ri 1l(il irrrp,r'lrrrr
i,r. ' i. i ' i-"r' i.t:i"ii i
si p,'."o"L h'lperllazie a tesutulrri irrt'clrl ' i{irrl, rlrt.t lrttrt
' ; , " i i " ; , i ' ; ld in l la l iarot ' i " ; j t -Doz: ' r r ' t , r s i rngt t i t t : i . ; t . t ' r tz i t t r r 'h ' t r r r r r ' i t r l r r '
,,lr,ie.-al-irrrrd, "Gierea
impoitan a valuril,,r' rrkl,,trrz,.i sr,r'ir,r" rr r,rr'rrlrrr
iiiii-lliqt";'i;iiioti"iia"og"i."rui, in schinrh o sci,ttt'rr. ir v,rl.,r'i|.,r' rlili'rr,ri i ; ; i ; l"r"i ( in unele forme,-clt de'pilt}-r ' Jorma llrtch.rtttt ') I l i) IIt.IrI itIItrI:r
;:;;;;;";di""G&otx (a"" nu eJtc prtogn,_,rLronici'i pt'.ir.' l)Nll" lrrrl,rrr,li i;""";;16- qid aite-amiotrof ii rnioge?Le qi.neurogcnt ; 1 l ), 1'i lrs|Kr r l tr t ..t t L'
-""" t r"c i l ' f t n,r lparc;m) l ipsesc i rampt ' le t r r l lsc l l l r r l l ' ; t t ) \ t t a" r ' r ' l r ' l r l l
' : , i .1 i""ror i i - r iar ' t " t , ' spoir ta n" stu pnrvocul ' ' ; l ' i1 ,s ' s" r t l lc ic t r t t t . . t t t t t t i '
iU;;'i;;^ ";;;pil
to"itelot foarte dvoluatc, utLtl* srt ',1'
rrlt ' l i rtrllrrrr' ' '
, rieotentliloirsd si apar retraclii musculotctxlinortstr) ; o) l '(l lf rr$l(\ rrr'rtrrl
; iJ i "a l ; ; ; Ei l ta i i ' ronr" a l i l ,udini par l icrr l : r r t r . i r r . : r r t r . r ' is t . i . . r . : I r i I r . r | , ' r , I , rz.r
, : ' i o i i l i ' i1 f ""
i , , r inLl ' oI f r , f o*onului ' r i ta l i : r ' . r l r ' r i r ' -pr" ' ( i t r i . t t r t : t l l r t r ' l r '
,;,i ,1;;i;"i;iopai:ic cu mindci' l i jrrt:i, ctt rl.schirlct' ':r rrrrril irlail rr lir rrlr'
i , , , : i t i fo" f , r . " ia, . :u 'buza , le . , t lp i r ' ' ' . c iL rrs l r I r '1 l : t t rsv( ' r 's" i t t " l r t t r t l r lc H ' t t r : r ', , ; ' , ' ' ; ; " ; ; ; i ; r l I l : ; r in t . . l tn in l : tc iu scal ' r t l ' r l r rLrLt ' t : t l i r t l r t r l r ' r t r r l ' r r r r \
l)6j6r'ine) ,,q.4.
E.3.2.2.2 I)istrtfi ite ntiolott' ice ('niottttt i i le )' S-tr '11'io cir' :rli l lrrirll 'rrrrrrr
, , , , u; ; ; ; ; l ; - i , ' ;
. ' i t r luL " i rc i , t
sc pL's ' ' ,z i ; i . i iprr l . l ' . r . . ' f tnt l iY l r r r ' r l ' t l t r t
; i l i , , ; ' , , *" i i^" f , i * i " l j , ' ' i i is t rot i r , ' i jo!r ' icL
(srrrr b, ' iLr , , lu i . Sl . i t r . r ' l ) , t l i r t l t ' l t : r
, , , i , i , in i , l i i intani i l r ' i , (congol i ta l r r , ) , c i t f i 1 ' r t l ' r r ' r t r iu l r r l r i i r ' . rx)rrA( ' r r i l r [ (J)r ' i r l i l
l i i i V ' r r l iu l .* l r r : r 'g) , pr txt i i r t r 1 i r r , , i r r r ' r r r i , i l , , i r i i le, t ' r . ' t .z i t t l : i r r r r l i l : i { i t ' l t t t t t t t
{{ ' I to i ; io(r ( l is l , in(11( ' i l l t ( l i l l { ) tn io l ' r r t t i l t r r r l t t tz i t t t i t ' t l l r i t t t t t t l l i l t lp lot t t 1 i t t t l r r
l r r r r r l i r ' ( l i l r r l r l , l l )?f i )I t r i l r rp l ; , i ,o l t l t l l t t r l 's l t r : r l i r r r ( i t r t t i s i t t l t r l t t i t 'o l ' t r l izr I I ' t t i t t l t t i l t t r i ; t r t l l t t t t t
rnot t tct t t t l r t t i , , l , ,n i t , t r l t l t r t t 'pt tz i t t i i i ' r t l t t l l r t t l r t t t ' I r t r r r ' I i r r I r I r I i I I ' I I t ' I ' i t j | | | i | | | | r l
/ l i l , t r ' i I r r t ts.rr l t , r ' r ' , i , l r i . r ' l i t ' l r l i r r r l i r r i r ' ; r t i t r l t t r r l t t t r t l r t : l r ro l l r r : r l ( l l I ' | 1 ' I I I t I I l i I |
' t
, , '1. , . . i , t ' 1, l ) is t r :4 i i t , t rnrsculore pyognsiac ( l lNt . l ,1 r l t , obicci nul lUr" . r { r r t t , r l - { r } , r l lcr . . l ) l . i l l I l |1rr i r t o i , { . lu c; , : tCl , ( , t . ( j :
, : r ) l ' . r l i r . l ( ' r ' A, ! r . l , i t r . r r { lo, t i t r r r i l i l l ( r r l roor i l i inr l spotar l ice) ;l i r l l , r , ! .o i r ' , l r , v i rs l , r . lo rnir : i ; i r rvol t r i io l r tn i ,L, r l t r l i l r .oxol l lb j i
r r r l r ; r , ) . , \ l , r 'o i i . r , s i t l r r l ic i l r r l r r r , r l ,o l s i r r i ; , i r r r r r t i ru l rn l . jo l i l t r , i , r r
l l lr4
ct'e0il,zii
lt) Do-progto-
l [ ( r i rzu'
.Jl
' . l l ' l l
: r ( I | ( ' r ' I r I | ' i r ( I { i . i r r r l ( i l r iUlr i s l . i r r i , . r . r r l iz i r r r l r r r r . l i l r r r r i ' | , , r r i ' i i , . Asl , I t l ,r l r t , ) r l I r i ' { i i r rur f ( r l i r i i ( ,s l ,c lo l l i i , s i prr l r r r rg i l i , r l r r l i r r r lo lor , i i , r rcggsiLirrr i| , . r ' l r , r ' i \ 'o l n l i l t r l r . r r t r l r i l . lcol ts i i i , lnrorrr l l io l l t lccot t l t i r ,cI ie i pot t , t ,e sut ,vgt t il l l. ,rt)rl. Al/r),talr,r, (lltl)ri o c( ) l] 1]t,t[o1,i0. v oh r rrtrLrii, sir[ (lo o trtit niitir, Ttronncatd,:rrli lrr rl.rr.pii r) (i{)ll l ir(i1io iru.lusii,_: lic_.prinl;r.o ac!iruro rncornicii '(percuf,irir r r , l ' r ' ' l , i ; r . r ' r r r i r r r . r I I , . i t ( . r r ) r ' r . . i r l i rn bi j . srrr l l lurrgulrr i $upi l r r tor) , i ic pt , i l l -I r , , ; ' i111111 111. r . l , r . l r i r . . r . l i { . r r ( , rn( , r ru l nr iutonic pui lc f i torr . ic l ]et cvidcu_t i r r l r . r r ocrrz i l r r l i ;0 i t i lot t lo plehonsiune.
I. lirtrr.llt, Lui, Sleiu.t'rl (,niottnia atroficd, sau. clislrrf ia rni,otonicd, ) st| |a | | r | , , : | - i ( r ' r ' l r r I i I r r . , , r r , l )o l_,rz, l UrmiIurului conluxt Sp-miOlugi f :
t 1 I'rt.cttlrt ,ttnl,tr,t.l it lar, sub acest aspect boal& lui Sfeinert fiindl i f . l i l l , l \ r l r l , t r ' . r I I I , . ' . t i r r r r r . , l i r r r |est grup CtrC re| t l izoazi , r l ro l i i muSCul$TC.,\r.rsllrr,.<,.1 t rqrogr.ir fitr, sinti faciaL 5i diitele la, membre, atilginel trmdto-rr,i .rrrrr;chi.: rrrrri;drii 1cfei, rcalizind un facies inexpresiv, atoir, de aspect..ll irrrulrirrli lr. '), cu lipsa cutclor fruntii, cu deficit;I ol6icdarilor ociilor. i i r l
, l I lz , r ' l r ) r ' : r ' i r i i r ' : t toI i i p leorpclor_:uper ioare (cu plozir pJtpebr.nl i , ) ;
r . - ( t ) l r l l l i t 3{ I r ( .J lont (cu cvldcnta alrol ic) i s lernoclc idornastuidi_,r | ' r { t l { : r { , . ) , . r r , . . r cu { . \ ' i ( l { .nt : i . r l l .o[ ie) ; musc] i i ,ntcb|r tu l r r i 5 i e i rn i in i i ;r r r r r . , l r i i r l i . i i r l i I , i r tLel br{ l , rT in io l io l rc {mult mai ta ld iv} .
l,) .1' t' t: ( tl I u, ! ttt rttnenultti m,iotonio relatat anterior.t ) o)illi: cu Q(|t?lic(i, c\ anurnite caractere particulare:
I trrrlsririsio c[r'e urrnclzli o moda]itate clomidanti,, srrb aces, aspec[liirrrl o llrrr{irurc rlotr:nninat:i de o gen5, ploiotropr, autosomalf clominait[,r'|| |)I.rI(,I|II||ti i rurrnplcti, s&u_i]pruitpe completi, ifarii sri sr,rti peste genelalii i. . r ' , r r . , r ' , . \ : r r i i rb i l i l r l t ' dc crp|r ,s iv i i l te (Crughe-y l i Mwienr[onoulos.l : r r ; r , i 1. . ' r , . ,s. I :1. ,7 c i ta l i r le nrrdu, tgTd); apxre Oin ce in cc 6ai dc-r t., rrr,.i i irrrl 'r 'rcrr, rrs.l('rtr clinice dince in ce mai graye dc-a lungul genera_1|l1,,'r (l( ,rll](.Jr' (l(.nL rrilc ,):rntepozitiert SAU ,,anti0ipAigio, qi ,"rprOlreSie,,,.,1icr lir.r,, lru,l; ( 'rrugli(J' ,si lWyri:rnthopoulos, .1966,' cit;!i" -de -n,adu,r:rrs); rt(.| ' 1r'irz:-r rle olricei in arlolescen![ si inainte de 30 rle ani.
.rl1 l\t ':tnlo iJc tttlburd,.ri tndocrine; - alopecie precoce, ptogresivtr r r r l , Lrrr I r r r r r l r t l : ( , I ) i rc i f ier . i cr . is iu l in icne generaloire do catnra6ld <i t ,l r p \ , r;l l s:l r r t,. 1i1r JrJeisubut l * atrofie l,esticulari,, cu sci,derea activifi,_r.rlr r, )r,,, tr( r'r ir u : r z, rosllcrntie ,si cu scdllerea eliminlrii de 1?_cetosteroizi I
l:, 1( ir, i, It'r'cvcn!:rl, a enol'cei, a aTorturilor iterr,ltiYe saU ft StedlitS,iii;r rr rlrrlr,n.:r r:Llolilor oestrogonilor ' si a pregnantlioluiui.
<'\ )lorl,i.Jittiri ItrtrI{}: Prezen\a tlescSlcdrilor bioelectrice musculrut.or ' , r r ' ;LI l l , r ' i . r l i i r r r o i l l .o loal izeazd,, , rafa, le le, , , , ,avorselot , sau,,sayele" mioto_rr ' ( ( l r ' r r l l r r r lc t t l i i , vozi l iadu, 19?8).
". Iirnlt, l.tt,i I'hontsen clasicd replezintd, ula diltrs formele clinicorrl, rrri,lrrri.i .rilgc'iti e qi so diferenliaz5, de boala lui steinerb prin urrnii-l , ' r , L ' . I i , r i r r r , . r ' , . : . : r rApJr i l i3 rnul I mri mrJ I b) Exir tcnla rue- i b ipnrt lo-Irr l r 1 I 1 I .1 , , 1
' ; 1 , , , , r'rirl'i cirrilor membrelor supcrioare qi in{crioale, a geflsnik)f
rr :r rrolr.rrlrllrl i; o) Iieacfie miotonic[ mai marcr],tit, Ia nivclul membrelor,,rlrr.r' rrrrloli prrtiml intcresa intreg ansamblul muscu]aturii, cl) AbsculliIrrIIrrrr;r.r' iIol lnrlrxl' ine I e) lrognostic .mai bun, felti1i1,ate,. speranli rior rrtrr ri crrprrcil.;11c tkr rmrncl putin alicctatc, sirnpiomltologie de obiccirrlrr{iorrrui (ll l,rlrr, .11)78 I Caughcv qi nlyri.:r,nthopoulos, 1906, citnli ttol i r r r I r r , l l )?f i ) .
,i. I ' t ' l lt iolil i l t.on,trn.il,ald (hoal,a, Lrr,i l. 'qtt lNtl,tnbu.rl ), nrultii yt,crrurl r r r r I r r r r r I r r I i r r r r l rorr l i r l r r i ' l ' l rorrscr rr 1ro:r ,1c f i to l , t r6 i r l i l i r r r , r r ( i r r , l l ' i , r lo l ro l r , l i l l t t i' | ' I I r | | r r r r r ̂ t I l r t i r r r r r ro lo r l r , r ' l lo lcr l t t l t r l r r r l i i ,s i r r l r i i r l t 's l r l r r l i r r iorr I r r r r r r I r r i nr io l ,o-
l l i r ( i
rri,, (r!.*kr,r, *)'i.' ri,1ll1,lll],il,["i,ll.il;]11,,:i;,;;;lil''i;i,,i'iill;'{:;l'i:il:'li'll;ll;
|iil#{;j;4i#:"1{H"i"*:1,;irtv:{rli*ii*ri;ilr;;;r'rri:itr*,#,F,"?H',:g::'*".Te;:"x"*;;t"lr'***:.i1i;::li:';l';l li",illii*i,iilll*#*$nllt*s+:t$u""ttll{y#'i{i*ilrrn,ir,lirili,l;r:rr,',r'mer1ul trapart al t*nr",]Tl'j.".1{'_!1['"ti,.f;"'.ltlii,il,l,, ,rirrr,.rri,.r ;,illlili"rixffnJ:"T,:?;,u,n",ii,ila in deglutilie, rlupii, co'sLr,r' rtrr irrgr'.t:r{:r.i'i'' "#
";;;;l*i" *4, d.rr "n".'1L*1?.',1;?11"1?iii"TlT,lil, l{ : } l i l l l il l Jl ii i,
i rli,'lil"ii",i,ll$i* "Hf-#lXit$Jil'*ililE# #'tgdllt*"t' ll$l L: Il l lj#ii #*""qf T+?,l3""i'ii,gT:?Tg# #t;; j*j*;,iitill, l, i llli ti ir l ;. r l', aroplitudinii potenf ialelori ' i ;o;" 'n i" t ""-ql i in io i i " t t " 1972, c i lat i dc I l rdrr , 1178)
4. N eurorniatoniil la s-au itleniiticat qi conl' 'rat i ' .lf i.rii ir 'tri 1i .ttltt irrrl
i,rei entiti,li cliliee :
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i , , i , ' f , r ' , , t " i f , , , , t ' ! l l l l l$r l l l l , r t i i r l i i t r r l ' i , i t ts l : r l r t l r ' i ' l l l l ' " l | i l r l t i r ' ' : r ' I r : t ' t r I t t i t t r I t t :u '
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( ' tzr i ' , i r r r I i ' i I r r , | , r r rurrr l i r r r r i r r l i l r ' r ' l . l r r ' , rs.r I r r , r . , r r . i ' i r r , i r . r r r rzrr i i l r r . i . ,Ar,r l r r ,r I i o iUI l lUt h\ l r l r l i i I i i r r r r r r r ,otrrus( i t r l l l r , ( , .
, \ . ,1. t1.?. . i . I ' r l in i t r i l r , l r , r . j r l ic i l r l t , crr l t r r r l r i l r r r l lo ol i r l i l ic ikr prol t lcurrrt lc t l i r rgtrosl ic , ! i r r i r l l srranlr r lc l l r , I ) l t t l ( j i c l (1 gl . l t l )c l ,z i l , r , g. n l -L ( lo r t , tcci iurr it r t t t . r ' t l : ' r i . i r l . l r l r ; l l r . ' l : i l r t i r r r i l i r , . . r . r r , r sr . r r r i , , l , rg i r , ,1, , ( ,1, i , . , . i put i ,n, , r f l i , , : i ilopog":ri i tr ot' l rrriLi trt lcsol, r ' izorrrclicti, pscutlorirJopal,icti, t lc ruturri infla,,
lll.]1:ll.il;1 rlr.s,.rrcr':rl iv:i ;i/s:tu .autoirnurili, nesupuihl,c, ctL er.olugie :rcutr'i,l | ' ' : r r . r r i r ' i rU r '11lrr( ' : r { r t l . rnul l . ' t , l icu i l r lcr l .s i r r .c:r - - i i r t ( , - r , rur . i lor t i ] ' lar i r [ ( !
, . r | | ln rr l . : ' | r j r l , . . r r | i r l : r r . i r r i l , r t s i i r , l r r rochirrr i l , r t , nprruaso . i c l r i i , r . : iL l to l\ I r r ' {11 ( I } | | I | r i r r i c hb., I ,Jt i3, 1965' PopeSou qi R: i , t lu, 19ig; I ropor- ic iu qilo l r r l r . , l1)Ti ] . .1.1)?5)-
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L,( | I I r | | r I . t , ' ' , r I ( ' I ; I { i I r Nlontli{lii tle Neulologie ($rFN) (\-ezi popescrl ,"i
"naiu,Il,7,s) Nirli
'*rrl.i trxohrsi' viLotice, ar<a.-curir s_a crezut (priir virus Coxsn,lr' l i ir, rlirr glrrpnl. I3), de obicei fiind r,-orlba rle rnecanisme iirtoimune puse in
.1rrr,.rrn|o|i (l{r di\'{,tsc infeclii Yirale-(Ohou qi colab., 19?0, citali tlc liopesoLlri l.i.rrlu,.19?8; J)un12 ;i colab., 1963, 1965) rlar ile mfite t i.i rtc picesolrcii rrtrr,llr,r' if ictrttr.
rL) l)olin.iozilele acuf,e s.i subrrctLtc se pot reclnoaqtc prin debutul] : ,1.1. i : l l l l
lo l l l t i \ brucr ' ) . , .u .sc np y rpi t? rnt i ,Wzt i , " . i "Urr . , . " ia i , . , , ,l l | r ' fn l - vrr t ' j i r l l t t t \ . t t tsr t t t .u 'p t t t .utLt l ru lp.
. lI iu,l.oi.i.k: sinlj acuzate la nivclul brale1or qi gambelor, inso!,ite doLr.t.iltr' l l i l
i,tntt ,1i
(rattlpr ,mt6(ulc,ra, apoi.5i de parize'interesirrif s"g;e"t"ii,
l)r1,\||r,rirri.,:l lr._t[rnrl)reJor, ial uneoli qi rnusculat0ra faringelui sia rrd,hr-r|| l),rrrUtrul, uuscnllrtur't cste. sensilti l i i, la presiune ;i fermi, (indura,tl)lr l)rll) ur. I,ioilexele osteo,tendinoase sint insd, de obicei no"mri",
"o e*Jr, 1r{ir li 'r 'r r.lLr. rl ' ' pulir':rrlic uloneuroiliozite, il l care se constat[ si'moiiifi-
' |l 'r {,. L.Lt1.\{,, p]e(,nrr}.si trLlbnriri de sensibilitate dc tip pclincvritic; r : r . r . r . l ) ( '1 | | r r l r { . l to l l ' , r t iL i r ' ( l ) rur ] , , ry i colab., 1963, 196b; popovic iu qi colab.,l . r i i i f . l l r ; . ; , ) . , \ i t r t 1, l , , t t , . r lu lsqi t r , , t t04, t t i t .s te prezenl i lu i1r |or i rnal i r 40o1,rrrr r i rz | r ( t , ' . r . { ( ' . i ( | t ie. 1974. c i f r l i dp pup{-sr .u ; i Ri , lu, t9;g, , i i i r i r iL l ' l r '1, . l r l l r l . r { l ! . : { . i t l t { r ' . r . i o l j i c \ ( . ln l loa"e. po.k i judI l rn i i , , ot lcmt .u l r_l t t l : r t r : ,1r . l l ' , ( . : r l i r . r t , . r r r : r i : r l , ,s p4, hr1i . pcr io lb i t r r i p, ,g i l , pe utnr.r i , p, , tur , : l, ' . , t l ' . t : , r I : | ( I | | I | ( . melr l l r l .F lUt,) .
, sl l,r' l ,:t. ', 'tt. ' i:t_ sittrplonte uiscepule de cardiopatie (tahica,rdie, subticui_\,.l.rri.r rr.rli.i.1f, blu,,rtlior-entricrlar.),. adenopatii, splenontegaiie, ulcera_
ut t t , t*{)" t t t . - t I tdt . . .a. . pt( ,cunl \L o! l t i ( t l t , t ; ; lof [ ; .ltl I)ol.ii i.azitele rzozice contllrerzlr in motl prl,grcsi\. 1,al.ilouri pseud0-
r , r r ' ,1, . r r r , , . ' . r , . t r l , . t .2,( ' . r i : I r . r i , ' t ro i i i l r ior imaln. pfer.x111 .1 cU sinrprLmn t l r .r r l r | | r I i I s | ' . r | | i | , . r I r | ( , totrnr, - : i colal : . . l9 i t ; J,opor in i r r .c i nohb.. ! gtJ, lgT;) ,,, ' ,, ,,. ",. irf(lr-lirzai cpisorlic trtialgii, precum- si_Jenomene cutanate ia ;i i i ir l l ' t t r t r ' ,4r , r l i r r r i , rz i1.Jr . aCrr le. io0, ,ntenc r l^ t ip HarnrLrt l , r r r . ,n i [e"1; i r1 . ,1.1, ,1Itlr' (ttl lr,rrsrrlri ltr, l ivelul artir.uletii lor.scapul",-uiner.ale 1i a1e miinilor.) ;itlrr{ r'ri{\ | | l r r I i l i l[ t i l ri visceralo. (rniocrirtlite, lncunonii
' tra,nzitorii q.i.j.,1,}-lr,.irrr1r,r'laxt
(l( re { ilxt laptul cil a.miotrofiile rizornelice sirnetiit,i 'r,rr \ ',1ttr' ,, ' rlr. r-r'rr1r.tr,1n.i .-i rl( r'ctrn,clii, creeazri (lc ccle mai multe ori t.rr.,, ol'|r ,lr. lrIul rlirlrolii lrl lJruscltltlte l)rogro$ive liacio_scrapulo_hrrrnorir ltr. i r r , r r r , r ' r i r i i . l . ,1.L ' i -1,)rr l r .11( ' ( l tothstoi l l s i ( t r r i . lson, 1f)?1, c, i t r r i i r le I>npcs. '. , r , l i , i l |1U.. . l l lTs. i _ lJ rru. : r ' i r .o l rL l r . . I9t i : ' i , l ! ) r i i : Nrrr i r r , l t16 l : l , , r | ' , r r i , , i r r r ; i, r , l : r l r - . l1,7i l , I t ,7J)r . I ' . .1 ' t i r . s; i l i t r r , r l r r , i . r l , . r rs, . l r i l r l r . r , l , . r r l i . pr : r r i t . r r l r I r rr l r r l r i l i r r r r r l i : rgrror l i r r gr '1 ' ; i l , r lc l ) I , .
l l i t l
l l t l tc t t l l l i { i t I r r r tnr . I t i I t r t l r r t l l t l . {nol l ic t r r , cTlr . r rz i i , 1111 1111,11q 1,11111i11r, r r r l i t rHr, ,, , r , l . r l tar , r rz i r l r t l r lotnir l r . r , lcr , l r r lotrr i r ,kr lxr l i t i l l iorr lorcrr lorrr iozi l l i , ( : l t l r l r t )l l l
' ' I r ' | | r ' I I ( t r toIot i i i r t t1rot I , i r r r I r ' ( r r r r p l r , r lorrr i r r r r I r ( . i i l izorrrr , l i r . r i ) , { l t lu l l ruf iurr l , , r r r r l ' r l i l r r l r r r l r , l ip [o l i l i r r l i ruLrtrr . r ' r ' i l , i r , , r , r r i r r r I ror ' I . r r r r I r , r r r rx l i l ic i i l i r l r ,r , l l , . , , ( r l r .uJr i r r r . i r I i t r r i t r r r I r i r r srrrr I r , l ro l i l r . ) , r l l r r ' ; i crr tx isk ' r r { , r r r l ( 'sctrr{ 'p i r ; lt r r r , l r l r , r l r , l r r l l r r l i i r i l r r r l l r r r l r ' 1 i , cr . | , r r r r , i : r r l t 'srr i r r 5 i r l r r I r r I I I r I l r i , r ' i r l r r l , i l r r r r i r r r il , r , r l rur ( | ' r ) | ) ( | \ . i r , i r r ,5 i r ro l l r l r . , l97i t , l l )? i i ) .
I r t l t tqto:r l i t t r l pol iut io; i l . t l rn l r { \ i l , , iu l , . l , , i . t t . t t ts l i .y1u! i i l t putot l iu i l r , , t . t r t ,1r , ,1 t r t l r t i r r r l r r r r t r r l i lo l r t t r l r r r r rx l i l i r i , r ' i : l r ) ( l r r r l l r r r r l r V.S. l l . , r r r l r , porr l r , l rl r r ' , l r l r r l r , lc t rcorr i lozir , r t r l l ru l l ) l i l ic ; l l ) Olrql t r r r l r r i t , r ' l r , lo l l l l r r : r ' r r . l r ,
' t , , t t t t t l t 's . l , t l , i t r r : : r , i ( l l ipcscrr s i l l i r l r r , :11)78); c) [ I rx l i f ic i , r i i r l r , l r ,s lc lor ' , \ i i l , t Ir \ \ , r l r , r ' l i r rsr ' ( i t r r ,orrshirr i , r r ) I r l ) i \ t rx l i f ic t i l i l \ : lut l t i t t rur l r / / r r r r / r / , , r 'u
,r , l r r ' i r r r l l r r 3; i r r g iut lu l , -g lo l ru l i r r r i l r r , (Wl l l l r r r r q i Ar l i r , r r rs, l l l i r i { ; l ! r l r r r
' r , r r r r l r r l r r l r . , f1)?: , i , t9?5) I c) Iurpol l ; rL: t r i .o tnor. l i , l . i r : i r i . i tnunu, l t r l to. lor , l i r ' ,,
' , l , l ( r ' r , i r l ( i ( l s i I ( i [ I ( . t 'opovi l iu qi rxr l l ] r . , 197; i , l { )?5) ; l l , l lu l i . l i r ,ut l t
I l l1, l r t l I i r r . r ' r l i l l ,o l t r r r , pul in<l sLrrpl in i lc r r l r r r i , lo l l r , l t , r . l r . t r r r , l l r ' ( r l r r l r ir l r r r l r . i t r ; i Ni l lzbuch, 1969; l l ,ar lu, .1.078; L,olrovi t r iu 1i colrr l r . , l l ) ' r ' i i ,
| t r , ' r ; r r r I r r t t { i l r Iu d0 f ibr i la! ic, suryenirr i l i <xrrrrPL, l i , r ' t r l l t , r r r l f r r r r I r |l r r , 11,r 'o l r r r l r i l o i I c\pl 'cs io:r , unci pol ineuropr i t i i - , ,d.y i lg- l ) l ( .1( ") t polr , r rl r r l , l r i r l r I i r ,z i r r r com1l loxc sul lvnl ta, to, Or l , l o i l ] l ] l i l conI | i r t , { i l l , t ,oIrrrr I . I I | I r I
| . t r \ i i i i l i t r rpet i t ive (potcn! ia le cu f r (x jvol1, i i , r ,Pi( l i i l0 : \0/ | j ,, ' , , , , l , r l r : s{ , i tnLr l r t re l mecatr ic i j , a rnuqchiului s i l ,u dr i lnr) l ) i l iz i r t r r r r . l r .c l r r r, l r l r r l ) r l ) i i I 'opcscu qi I iadu (19?8) tocml i acestc f i r rsrrr^ l , )N' l ( l , , l r r ; r r ' l r ,' , 1, , r r r r ' " ( , r l I i lotef izcnzi pol imiozi te le.
' '1 , l l uli, l ici i,r i le histop atolog tce din biopsir.t, l tttsrul.rr,rir, rr(lu( ,,r 'r.r lrr r , r r r l ' r i lc is iv t le pol imiozi t l , puni f t l ln evi t ion( i i ( l l r r r r l r s i r , { , l , r l r . , l1}( ; ;1,l ' r r ' , l ' r , l r { rs( ,u 1i l l ,adu, 1978; Popovichr s i col i r l t . , l l ,1 iJ, l t )7 i i ) : i r r l r ll , r l , r r l l r l l iL lot i i l imfo-plasrnoci ta le ; i monoci ta le rrrrrscrr l l r r ' , . r , i p, . r r r : r ;L, r r| ! ' , r ir 'r lc t it 'r 'csconte :r, le t ibrelor mlrsoulitre, cu lrol, ivi lt i t i r|gi.trr 'r ' ir l !\ r, ;
| , '{,r lr)zit festtului nocrozat; - f ibrozii inlclsti {, irr l i i .
' l 'o l iut io: : i tc le ( t lermutop ol in iozi te le ) ,dt r :srrol l r i ' ) ( r l i r r i l ru l t . r I t, l r l r r \ \ l , 'N r .czi ?opescr s i I iadu, 19?l i ) s i r r l ; nnl l r , r .o i r f i r f i , r i pnl ; . r ,111'1.1qrt ' r I r , , r I r r r i . r r r l i f icul t i r , f i d i*gnosl , ice. Cu, : i t r r , r0, i r r I ,Orr ic I , l l r lorr l i l r r r l r r I r r r r l , r rl r r , l r r r r , rz i i icr ,cronioe trebuio s i l , se s lu 'pr in( l i i hru, lq, r l r , hr : i i . . r r ) Nlr l rur i r loz:rrrr , r l , r ' i r ; l r ) I rupusul er . i tematos r l iscnr in i r ,L I c) I I t l i I r , r ' I r ' I , i I r r r r r r r lorr ; r r ;, l r l ' , r l . r r ' l r i i i i loumat ic i ) , ; e) Sint ln l r r r . r l Sjdglcrr I l ) I l r l i r r r iozi l , r r , l r r l r r r r ,u,l l l , l i l ) i i rgn()st icul se stnbi lc; tc t lo i l l t lupi i , p l i r ( i i iu l l l r innt t i r l t t l . r r l , , r1"r1,r ' l t r t t r r ' : a) hnunoeloctroloreza ; b) . l ) ivc lso i t l to i l tv( ,s l , igr( i i i r r r r r r r r r l r r, ' r r , , r l l r lLt t t in i i , r i leDM(1 ; t l ) 13iopsi i lo inusot l l t ro; t r ) (1 l . r ' r r r r i I i l i I r r r I r , l r i r r lo, r r . r l r , , l , r r1 i r I 1 i ) - Invest igaf i i ladiologioc, oncologicc r i . i l . ( l ,orr l , r ' r r r l r , l r r l ll r r r l r . r r r . i l i i ,o lLr l la: I?opcscu , l i } iadu, 1{)78, I {6hni tn, l1)${) . )
\ '1.::.; i . I ILi,tt 'oJ i i la n,eu,rogene
\.;i.: !,,:1. 1, ( l rr,ft.t (Ltr( s( ttt, ioLot1 ir:( glenuutt' :/ ) l ) is l , t i lnt( io i l g{r l tct i r l <r t t pt ' ru lor t i t l r , r ( i i , t l is1,rr l i r , , l t r r io i loI i i I r r I ' r rnr l
l r l r r r r t l : r i r , t l r l l , 1 i loclr l iz i rkr , I i r r I I i I I r I I ' r ' r r I r r (s i r r r r r l l ico l l r , r r l rg i r r r t l l i r r r r ) .i ' , | l l t r , l r : r r r r io| , t r r f i i n{ l l r ( }g l l lo rrrr i r , r r r l i r r { ,L r l r r t rx,r , r rn i r r r r r r .. i , / So i rsolcsrr r l r : i r ) I I i1roLorr i r r r r r r r rcrr l l r l t ' i , r r l r , i r r r l l l , r : lu l l t i p l l i t l
r r r rpot l ;ut l , i l , i l r r t c i r f t r r l r r l t r t r l l r .o l i r r t t r . t , l l l l r rz l i , i r t ; l r t ; r l r , l ( ru l j l l l ( l l l l l r i r lI to l r l i ; l r ) l l r l r l ic t t l l r t i i r r rdr , l l i r t r ' , <urtr , t i r r l r : : r l rc l r . r ' i l l i l i r i r r r l l rur , l r i lx ' r r l r r t
?il l l
f r ,nr( ' lo Hl) i l l l lo Hul) t (1 l l lo f i crol l i (xf . l l l rsciorr l l r , t i i lo s i r r l ; r l r rost f i i t t lo strgrrs l , iv t rl l , r r l l t t r t t ; t locls r lo t lc t rot ' \ ' l , t t r r ( l l ' l t l )sr l t ( , tn lot . nt t cxclur lo c l l r lotLrful nou-lr41r'rr rrriclolll l ic :rl nrniotrotici, nta,i l,lcs cil (lo pot {i rnascato dc fcsul,urilor r I r | ) | : r I r r I ii ( r ) irrrlcostdli cind ili rlu origin{t& In fasciculclo lnusculare profuntlo(lirrrlrr, l l l?lt). 'I 'rchuic sii mai;tim ci fasciculalii lc, de rcguld,, ploced amio.lloliir. c) Iltrlkrx idio-rmrsculal conservat; rI) lieflexe osteo-tendinoase colnrri irrloiJcl, dinjnuato sa,u abolite; e) Tulburili vasomotodi $i sudo-lrrlo rlcstrrl rlo frccventc I f) Existii, in unele cazuri semne neurologice aso.riiri(', rjil,r'c pulmit diagnosticul topografic: tulburi,ri de reflexe qi/sau dosi'rsilrilil,lto, cventual alte semne spinale.
4 . INl.tatrodiagnotticul cle rutind, incumb5, o sede de aspecte reyelatoaro :t) I)t:n.cn:urca completd, .' irexcitabilitate galvanici, qi faradici a ner-
vrrlrri I incxcitabilital,o a mu$chiului la curen_tii ile excitalie scurt;,; len-lrrr,r'ca, ,si miiriren pragului contmcliilor la curentul galvanic i scidercilplrrgrrlrri rcobazic a1 muqchiului; galvanotonus muscular pa.tologic I creq-l0l ' (r l r cron:l 'x l l lor,
b) Deneruareo, incompletd,.' conservarea excitabilit;lii galvanice qilrrlrrrlicc u, nelvilor, contracliile avind ins5, o amplitudine scflzut5 ; la nivo-Irrl rrnrqchilor se remalcd o oarecare excitabilitate a unor fibre musculatolrr crrtcntul faradic, dar cu r5,spulsuri heterogene la curentul galvalic, insctrsrrl cir, uriele fibre au o contractie 1ent5, la prag mai sclzut, iar allete auo corrl,nrc!,ic destul de vie la ul pmg mai ridicat.
5. ,Eleatromiogra ia araLd o sd,rS.cire sau o absen!5, a potenliale1or dorlrillrlo motorie, in general aceste potenliale conservindu-Si morfologinrrolrrrll'l. Iieapari.tia acestor poterlia,le reprezintS, indicalii precoce, adesor(.lrirr' l)r'(!clil i ice, de reinervare.
;r) I )11t1cy1)o,ys(r cotngtleld, se caractedzeazE prin: - Existenla uncirrotivil,i,{,i spontane perrnanente a fibrei musculare, cu prezenla de potenfi-l,lr tlo fiblila!;ie tle scurt5, durati, de slabd, ampliturline qi de frecven!tr.jorr,si-r,, rlir,t' rrrlal,iv sl,abilii, ; - Absenla oricS,rui potenlial de unitate moto-ric crr rxllziir, conl;ra,c{,iei voluntare.
)t\ I)cnart)eree, par,tiald, se caracteizeaz\ prin : - Prezenta in repausrlr. plit,rr{i:rle tle fib4lalie sau cle fasciculalie qi atlesea de potenliale ilol ilirlr. Ir'rtoti!', - In timpul contmcllei voluntare, se inregistreazl oriiliicilrr :r, poton!,iatrelor de unitate ;rrotorie, care pot prezenta uneori chiarr r r r r 1 r I i I r r r I i r r i cvasinormale. In cazuri extreme, un efort deosebit poate de-r,lir rrllr, l,r' irsr:ul simplu
(i. .l)i.opsin musc't d,rd, ofer5, de obicei imagini histopatologice net difr:-lr,rrlirrl,o l'rt,t ii dc amiotrofia miogend,: a) Existenla de Ieziuni in insultr,srrtr itr pliioi, care corespund atingerii fibrelor unei aceleiaqi unit5li moto-lii, i vr'orno ce fibrele unii,5,lilor motorii nelezate prezinti aspecte nonnrlc Ilr) lti lrrrrlo iozate sint atrofiate qi inlocuite de lesut fibros sau adipos.
,\.:l.!.:1.:a. AmiotroJiile mielopaticel. (:u,ntdere sam,iologice gen,erale: 1) Amiotrofia este de obicei bilal,o-
lrrlri, rlrrl rrl cste toldeauna simetrici,. 2) Amiotrofia debuteazi, cel rnairrrllscl rlisl,tr,l, tll,t cxamonul electric nc irrdicii totus,i o leziunc mai tlifuzil,Jl) l,)volrr(irr, os1;o tlc obicoi progresiv ascondcntl. 4) Irasciculalii le sint dorlgrrlii lrlt,zrrrttr, dar ele cel ntai adcscll tlcpiiricrsc zoncle musculart ilt,ro-li:rt,c. 4) li,ofloxolo os1,co-1;ondino:lso sinl; abolitc (eventull rlirrrinut1o) lrr; roI iorrr i r r I i I ,oIc l t , t r l ;c t ionro 6i ln s inr ' l ro l rmclo , , r 'cc i r r t r ) t , t lar . ,s i l t dc r i rgt t l i lr ,xrrgrr l l lc ' in f l l ,A (pl in r i rx l r r rnrul p i r r r , ln i r la, l aso0i l1,) , t i ) Trr gr , r r l l r l t r r roxix l i t r r l l r r r t l r i sulr i r rc l ; iyc ulr t r o l r i r ,c l , iyo r lc sonlr i l r i l i l t r l r , , r l l r r " r , r is l r r t r t , l r ,
ll(,0
t r r" i r l i ' i ,x i l r { i i l , . r ' ' ' r { r : t i t lg, . r j | r f r l r . l i l s i r , i r rg0trr i r , l i (1 r ,s l l r r 1 , \ ( . I i I I i ) i | | I , l , . . , . l t , r lI ' t r r rAolr l l r ' l r r ' r . I I l t t r r t I r r t I t i r ' I i t l Nrt t t t t t t s i t r r l t r r r r r lorr isrr l l r l r l r , r r l l l ' i r ' l i r i l r r r l i r , :i , r , r , r ' r r ' l r , - { ; ) l r gr ' r r ( . t . j l l , r r s i r r l , i I r r1ro| I , I r r r I r r i . l l r r r l i i l i s l i r r | lcr , i | r r r , .
I l . .,1 tt iol.xtl i i l t ttt i t, lapulict rl, t,r,ol,r.t l ir: rnlidi,1.. ,,1ttt. id rolt i.tr, t l i .tt, bau[u, Lui, . l I t: irrt+ f,It:r l irt, (paliottt it l i lrt. rnttt. i t)tu,tl
' , r l , t ! ) . .n. r , : ' r t . l r . r iz . l rz i p. i r r : i t , ) JrLsl , ,hrr : ra l r i t l i , j b) _Al , i r rg.rrr , r i t i i r \ i r i rr , r r ' | r ' r ror ' r r r Is ' , r l i l l r r a l i r r ,1 l ,0 I 1r) .1. :0ca, l iz l r i r Lr l t igrr l l r , lo, t r r , l r r r r i : r r l r . r r r ! r ,r 'rtrtolI ir0, irr grriru': l l lrt ' ixln'.rir r it nt0 l i l rn.|rbrtl ir irrl irr iorr,rrr ( i r r r I r , r r r l r , I r r1, , ! ' r ' t t lxr l ( ] rTru,alc, ; i ,pclonict 'c) , i l r l la rnottr l i ru 'kr sI l )ct , i { r i , ( l
; i r r ;1r , f l1, , ,1, ,r , t t r , , Ul i r / r r LrrrrrTrr l r l lh i l r , l r , l 11) ; \ rn io l , l ,of i i t , sc l lsoci iz i j , t , r r ; prrr | l r l i , , i r
l l , , : , . , i ,s l j r , l j 'c l i r r r r ' lc r r rp i rL i . Lr , t r r l i t 11'r ' r r . l iz i r r , . . r l r , r I i r r r i r r r . : I 1 i r
. , r r l r r r\L I l ' - l l l l ) r '1r) l l r . lo i t . r l ( . i l lpor. l : tn iJ ; l r lxr l i r , , , l r , t , ( . l l { . \ r . l r t , r , t , l r . r ,i , r r . r l r r r . l l ,No i . c) Nu Be constat i fasciculal i i , tu lLrurr i , r , i srrnzi l ivc olr i r . r . t i r r , ,I r r I l . , r r r ' I i l i i l l i rn, ic l i ( r rc ( t l :ar 1n, ,ot t , 1;recI in i rc) ; i r r ic i 1,rr lbrn, i i , r , i prr i l r i l r r ir r r , ( r ' t r . l l l : t Ul l , . , , r i .Si 1 prczcnlc; i : _] t ipr . r t r . r r r r i r . . r , , . l . : rh:r : ,sr . t r I . i r r l , r . r .' r r . r , . r j , . | | . r ' i r l r ' .
^r th i t lXi i , . r ix lg j i . rcaci . ie In( :n j l rgr . r" l i l : r , r i r . l r111, ,1,1111,, ,t r I r . r ' I t l r I . l , i .n LCR {pl i . i , )c i tozi . apoi_ rs i h iprr ,* l l rurrr i r rozi r r ro i l r . r r r t l ; ;
1'r l ir.rr,.{, irr, dc <legcnerescenfzi pc mlschii cor;spunzii l,ol, i l .zirrrri i .,r,rrrrl ir i. r ,1, r ior ' . r : i i rs l r i l ' . rz i l rp id. ; h; pot , i 1px1,.- | , s i r l t , . l r r l l r r r | i r . i l l r , t i { , r . r , . i' , l : r . l i r r : : i ) I i ind vorba r lc u r fcr .q june l i ro l ic i , , r . l rc t )n, i l t r r r . (1, . r r r l t ; ,
, 'rr l,, j /. i l*i rnai extinsc (poliocncefalomielitr i) po{ sil ,, ira.i, 5i si,rI l.rrr., | | r ' ( | I | | I ( | ( ) -
' .). A nt,ioNroJin miel.opaticd d,in hentatomielic.. l) So rttnl,il,rrirr r,lrpirl,t,r,r r'()rril,riorea leziunilor cIeate prin hemolagiil, iriI.ir,rrrrrrIrIIIrr.ii ; lr,) l i)*tril , ; ' . r l : i . r l r . , ,un. { lc tor .et io iogic generator dc } ior .n i r , . l ,orrr i r r l io (1nur i r r r r i I i l r r ;I r l , r r , r r r l " ( , c1roFi , ,T"t ,
"q; sau la_ chesonier i I a,rxrnr i r l io v l rscrr lu. i i r , l r , . ) iI J t.i*ir.iL tiipcctul ate liip Alan-Duchenno Unililtot..l ga,. I r i I i r | , r I r .t r , I lrltrrr
lr' ! rr ( irzal leziunilor cervi-cale cu cea mai bogal,r.i, vir,srrrrlrr,r,izrrl,ir,, r'r,l , ' r r l 'osl , ( , r ' i l t i i , in cazul leziuni lor segmeDtclor 1," :S, ; ( l ) $o:r ,so| i r iz i i r r r r :1,rr,rr r,lir.i.. f l it,sc5,, cu abolirea_mpid5, a i.eflexclor osico-ti,irrl i i r,rr,x., {1rr l,*1r.r(.rlr r l l ) r . i i r i .s()nzi t ive c le t ip t l isociat s i r ingornic l i . , crr r l is l r ,z i l , i r r i r r r r r r i r r r . r i r . r i ,rr i, Ir,rrrliLl,t-r, I .o) ln cazul unci hematoini.li i rrrr ilrrl,.r.ir, h,, $. lr,s,rrii lzii, rl.
l r : r r lcrr lozirrni i , un s indrom Rrorvn-SCclunrr l ; f ) l r r r r r r r .hr l . i r r r r l r r lo l r r , r r r r r , l ,o.rrrr , r l i r r Nc insta, lcaz[ sublezional un s indrt i r r ; l r , r , l r1 l l rg ic, l r r r r r r ip logi i r Hrr , r rr l , r r rph's i ( , h inceput. fJasc, a,poi spl ,st ic I g) $r srr lpr i r r r l r r ror i i I ' i i , i i r , i r r , l , ,| | r i : , ,s ;u lgl t l lo letr t r ta tnccput, a!oi xantoolr)rnic, ct t pt t l ,orrr i r , l l r i ;x , r t r l l rur.rrrrr.,:r, ,.j i r nod erc,t i:i, crcrstere a clcrlcntclor c.lnlirt: (u,1,il l irrrlir.i i,zii, r,i l."r r ro l i r r r rc l txrz i l , ) .
l ' , . . . lu. iut t , t l i i . le- l i t tormcta joasr olo ncuru. ; i t t i tp idrui t nIr l ln, t t t t t r , ,t , , t ' t r l t , r . , r l i t t rny ' r ln l ' , 'nt i , l i l i r Vt in ul l r u i rusLtt i r inL, i l r r o l r i l r . i , r . r r Io, . : r I i . , r r r , , ,r r , r r r r r . l i l i . ( r r r : r i r ' . r r i l r . l iP, \ r ' l r ,n- l )uclLrrrrrr . ) . r r t i r rs{ lu i l r t . r r l r r I i r l i . , i rs l r , i i r r r l r r r , rl , r r r r r r l r l ' i r r i l ; rnrrLOt f lascrr ccl r r r l i l r r l r .st l r , ru 1r) | l . , i_trrLI i ; r I r r , i , r r , ; l I rg i r , i i , Hi ,r r l . ' r r r t1.rsr1 ; i pt iu contrrxhr l i t r l i ' r . ] , i r rs, r . r : l l r l l r , i r r , rkrs i r r , Iu l r | i l , prcfrrrrr 1 l I r . rr r r ' r I i l ' i . i i l i | r r rkr 1 ip in l l i l r r r i r , l ,or r l i r r 1, . (1.11,. or ' l r r l r i r f i l r .s.rr r ix is l i i , n i r r r , i r r r r , rr l r . | r .z i r r r ro I ' r rct l i l l i r . i r , .
I I I " rl tttiolrolii lt ntitlolurlIttr t:u. r rrol.tr!i1 [r:rtUl,
. . , \ , . l ' \ t r t r t . t l l : . , ,1t t t t ' t l ' d. t t t t io l ro, l i i . r t t , i r lopt l i r , ru uol t t l i r r l r , l r l i t ( { i I i l r r , l . t r. r l i r r i l r r ' t l , l l ) i ' l ) :
, ,1. , . lnt i l l t " l i , r_r l . in lnt l i lu id i l t tu l t t i lur l l , r . r . r1 i1r l . i l r r l r lp l r \ r ( f ( .11q1H16rl , , l t r l r l t , r rJrr I r l l l l ( i r r | , r r r r t , t r , r r r i t , t l r , l : r l r l r r l | i i , t i r t t t , r . r r I i r t r r , r , l i r r r , t t r r l I r r r t r i l i i r , l .
{ il, i{ulvilo l)t.ofol'( i l (,i l I lu, arlul{,ii rrlr,scrrlirri (irr1,r,, g5 ,li ,lI rlrt n,ni), o arrtio_1t'rtf itt, (r:tt tlofirriI n1t;1,e1) Ar.o lir, rlgbrr.l, 1 t opog4tio' [ista lir, la inclnbrglglrrlx.r'irr:rrrr (:r,nriolrulic tip Atan-Duohonuo) qi ii i i, ovotuoazii, lent,_progresiv,|lr l l,lrnr\I)rally Ur.tntl,uitrciL succcsiune ]ezionalii,: rnu;chii erninen(oiIrrrrr,rrr ii i. hipotrrnir,rc. (nina sirniani) ; mu;chii interusoli qi iombricali{ r | | i l l : r .$( . l t ( : l i . l i r ' i ) ; f lcxor i i drg€tclor. tmina de prcdioalol . ) ; esDensor i irlrrgr.lr.lor' (r.a,ro tlansformi, mina de predicator in r-ninii ale ,,marionetX,D) Irrrrrsllrii brt{,ului (,,brrr,f,ul ineft $i btlnnt',); muqchii l imbii (mai tirziri).l\l ir,i lrr'fi rrrult rnai tarrliv arniotrofia atinge qi mu;chii rnembnilui inferior,,tnurs-cbii srlqrulari, murychii abdominali. Aini6troti'a se inso!e;te totdeauuarlo luscieula,i;i i ovidcnter incd, din perioada de Cebut.. _ lroziu.ni aualoago pot cointeresa .si nucleii motot'i ai trunchiului cere-Irllr,l, _ r'o:rlizind. polioenceialita superibarii cronicd, (ct oitalmoplcgie nu-, l"l,ri .1lrogrcsir-i.), rcspectiy polioencefalita inferioari, eronicX^ (plraliziaI t t t l l r r r , t i i p logrusjr . i ) .
. . .). ,IniotroJia.din ,,atruJia m,usculard progresiud, spinald, su,bacatd. a1,.r1ll:lr,Zu"rt 7i Alajounninc', /, descrisX, ;i Ce Stl,te Driglincscu $i Olteanu( ll)l-t,";), so instaleazd, destul de rapid la e,rtremitilile tiisiale ale rnembrclortittprlioaro, sal eventual ale membrelor inferloar:c, evoluinrl relativ rapiilr'ii l!1)gr'()siv, ducind la un sfirqit letal prin grav sindrorn bulbar terminal,il rlttlrrs_dc citeva luni pind, la u.n an. S-ar pi,rea (Drigincscu qi Olteanu,l_lrlir'j ; fJuhova, 1951, citatr, de DrlgLnescu $i Olted,nu, 1915) ci,-estl} rorbarlo o vorita,bilX poliomielitS, (ence{b,lopolioririelitX) pur5, viralil.
:1. .Am,iotnJin sltinald, iu,fantild, (boala lui Werdnig, EofJ nztnn ) te-prrzirrli i,, in realitate, una din cele mai fJecr'onte boli genetice'ate copilului(ittt ' irltrn{,ir, dc 1]a 20 000 de na;teri, dup5, Kriiger fi-Franke, 19?4, citalirh I t r r , r lu, 1978).
r,l ' l ' ipuL ,racuf' malign (Radu, 19?8) prezint5 urmittoarele caractere:- I,l'rNlitl,1,u rricesivii nclegati de sox; - At.ingcrea ambelor sexe i -
l)ol)lri; l i)rrr,[o prcrnoe (uneoii fetal, dar iri generallntre 3-6 iuni - md,xitrtrrrr I a,rr)1 -.Alioctarea musculaturii oste generalizatii, qi deosebit tlcr,rrvcrii, I *-llt oarirotcr imlorl,ant al amiotrofiilor din boala lui llierdnig-Ilolltrrir,rrtr t:stc cointcresaiea, ,:i a musculatur.ii par,avertebrale, care cair-./.ril./.;i {.i lrl,.r'r.:1, in fa!i, a copilului in pozi{ie qeziridS,, intr-o atitudilc, , I r iuI t i r , i I r r r : - t ' ' ( l l , r r ,du, 1978); - Evoiul ia este rapidd (3*4 ani maximum);r\ l,i|lgrrrrril trLrrsculaturii rospiratOrii determin,i, clispnee permanenti ;it cu;ril{,{;io rliafra,gmaticS,, p}eoum Si infeclii intercru'ente i - Aretlexia astcl,olrt li ;i gonoralizat;, ; - Eipotonia este masiv*, generalizatX, sirnetricit,(r'tt rurltloplcgie, hipcrlaxitate muscuto-ligameniar[, realizind- ,,p5,purya,rlrr rit '1ri, dozarticulatS,') - Guibert qi Guibert, L974); - Iievelatoarolx)lrl nr rla,$i! a, hipotonie sinti Si abdomenui bombat Si faciesul inexpresiv,ll lr gflr' it, tlrst:hisd, (Rariu, 1978); - Paralizia flasci, este generalizatx,,tli lttz.ii,, rilrLotriotr, rlar mai exprimatS, Ia nivelul mu$chilor gitului, ai trun"trltiultti ryi ai ri 'tdiicinilor; - Iiareori se constat5, fasciculalii; - Progresivnrt ilfuc1,oa,zi:r, $i mu$chii limbii, masticatorii, muschii felei, ai faringelu i,irt,t '1,ir,nliv ,ri tnugchii distali ai membrolor I * Se adaugS, cifoscoliozd,, picinlir vr,t'.o([uiD 5i urroorl palaplogio in flexic; - Rcaclia de degcncresccnfii,rtrlo nrrxivit; DII(i ontc alo tip naurogon (pericarional clc reguli,) ; * Nrroxixtll, ttrlflrriiri do sursibilitato, sornno pira,midalc, trrlburh,ri psihico(t'itt 'rxrt' i oligolirrrrio) (llronkol, 19?il, cit&t do lia,alu, 10?t/.
lt) l l ' ipu,l. ,,ltlttiy'nf irrclrrrlrr clrrn o l;nrirno (lin oil,zuri qi so rrilra,ll,orizoir,zil,ltl irr (lirr,rlrr, 1.1)7t11 (iarrrstxrlp, Ili07) : -- I )rodorn in&rrlitr lrr, trrolnl)l 'olo
!0t
r r r I l r roIr | ' r r ; I , ) r 'oIrr( , i r r r r , l : r l i l r r r l r , i l r r r r r i l , rn l r i l r r r rg i ( ; r l r r , f i , l i r l r r lo l rs l r , r r t r l ) ,, l , r r r l i r ' ry i i r r l .s1, . l r , . . l l r f i I l ) r . l r r r l r l r rDi , r , i r , r r i , l r , t l . I l t r r ; Nlrrs.rr l r r l i r r r r ,I r r . i r r l r i l r lc n l l , i l ) l t ( i l t l r f r r r , l i r l , i , .
l . . l t t t io l ro. l i t , spirr t Id. ynryr 's lLt i . jnwuiId l txrrr lot t t i , t l t t r l ic l l ( lx t r r l t lu il l ' , l t l l11yl l ' , '11rt7lb1' t4- l l ' r l tu l r t ' / - ' - l ) ( .1) l l l i l / . i r i r r l r r l r i l i r . i i . s l r r r i r r l r r lo l r , l, , r r l r r , ( i0 ' ) { , r l i r r c i rz, t r r i t r , r ' i r r r l ur t c1r '1,s lgr i l i r r r i l i t r l ( r ' r r 1r ' l r , r rsrrr is i r r r . r . r , r . r r i r i iI r i I r r I I r ) | | | | r I i i , ) , I r rs l r r l I i i tu l s0r lo i j l .0 c l rzr t r . i s l lot ' i l , r l i ( r r (Nt ) l ) l t f i i ( , t ) l i l l ] . , l t ] i 0 il . r r l , r r ,11oslr i ; i lo l tb. , l { )?0 - , - r i l , l i i i ic I i l ,drr , l l } i l t ) I l , ) r ' r r l r r ( i r r l r r l r rl , r r l l r l 'grrrr i i r , l i , r r r r0r ' i r r r 1r t r rg i l ro l io l ldo r lo i i l , l l l r i l iz i r , r . r r I r \ r r r i , l l , r r l ' i r r ,' l , . r ( ' l . l ) . r '0\ i r r r r r , l i i , , r l r r I i r r i ror i r r ru,stral , i i r to t r r I i l tozi l , l l i c I | ) ( . I r t I I | i r , . , i | ,, l , o l r i r , r , i l t r lcrnl t lc lc j l { (n. ioaro, : l l tur , i t r r l o l t .ost l , { , i r r ru l r , ; r r r r r , r . i , rur ;l i r l l r r r lc { ) : \ l r ! ( ,1{r t ) ( l i r r r ) i tso l indcosc}r i rotul ierxr l r : ) s i l i i r , l lo l i lc l } t . ( l l r ) ( , r ;l r r , i r . r r l r r { i i l r r $ i 1, inc{} t rs l ,a] l te i - - l ) ia,gnosl , icul r l i lcrrrr( i | l I r r { r i , r l r r o I r .M.I ' ur I i r r r r pc ba,zi l c-r tmerlr lu i I l l lG, carc i t t boala, hr i Wolr l l l r , r ' l - l i r rgr , l l r l r '1.1.\\,,11q11111'1' lr l i , l iL srrrirrc t lo tip rrcurogen pclic:lr iclrLl, l.
. ' . t l lrolirt rnusau.Lard, slt itruli i sau.pulo-petnnitd (boult ltr i. I)t r ' , i t lr tt l ;ttr,' t t ) t i t ; t t t l t i tnui , recent sub r tu, tnel , ie brte[a lu i Ntut l , , htrxtr) $o ] )o i l l r r , ( ,1ror r lo l r l i t r tOpograf ia amiolrul i i lur , r 'ar .o s i r1, t ,urr1, , l l r r r i r r r . r , l i t r iLr, r r l , r r l r r r r r ( r ' rspoct iv tacio-sc:r ,pulare) qi i r r musrul l l l , r r t i t I r r r I .or I io l l i , Srr p l r r r r
, r r oz.olo.,. l ic it,pr,r,r ' | inc boli i lui \\ 'ohllarl-Kugclbcl,g-Wrllrirrlrrr., r.rr, o r.:rl ir 'rrrl i l. r r r r l r l r iu, (1 ladu, 1978). Si i , nu se conlundo i r rst l cu hlrrr l , scrpl lo l r r , r , r r r r i, t , r r r | ) . l \1. [ ) .
l l . l , 'otutc le , ,usacial ,et l de amiotroJi i m, ic lopel ic( ru erolu! i t / r i r l 1( i r t rl ' , r i , i ( l r r i l r r r r '1,r 19?4) c lpr inr lo sel ie desindr 'ot , t r r ( l i r r r r io l , l r l icrrrrr ioIr l l r l i r , r r. rrl ir lr r.rr it l tc sirrelroame sau conste)a,!, i i sinrl l o rrlr, l, ir,tr :
l . , \ indxtr tmel,e d,a B.L.A. I iadu (19?8, l { )? l ) ) , i i pr l l rz:r srrgor l i ihrr .r l lo l r ru io l i , t ' t ,comant l i l ut i l izarea terrncm ui r l t r , ,s i r r r l r ,orrr r lo H,1, . , \ . , , 'l , rn c i r ro i ( l dcf inef tc , ,cornplexql s imptomat io corrs l , i l , r r i l , ( l i l l t , l t io l t . l r l i lr l r , i : r l r ' , I i r ,sci crLla! , i i $ i semne piramidalc, t l in cauzir , v i l r i t r l tL( i i c i l r . r r r r r r l r r r r1, 1, , r ' in ( ' r r r { ) ace:rst i i s i r tptomatologie se int i lno; to, i r r I r o ] i r | r t r i i r r l l r j r r r r r l l, , r r t r r r r i prr( , in t ip ic[ ; aceastS, v i ]detato t le c i rctrrrrs l r r r r {o l i t , r r r r r , l t l iz l l t ,u t r
l l . r o l iPrr l f i l ,A rn recluroa,r ; te in nic i un ( : i tz un rnrrrr i lor ' ( ,o l | | | l | l ( l i l t l r l l ! ,1,r l I r r , r l ( | r 'o rdi( ) iogic) ' .
I r r r r r lourt t rddt i lc noaistrc da plact ic i t , I rctr t r rkrgic i , Iorrr r t l i l izrr , r ' I r , l il r , r r l r , r r r l r t r r io logic i l a r .ar iantc lor prtzorr1,al ,o r lc l l l r . l r r ( l l )?H, l l )?|) , r , l lr r r , r , l i l i r , i i l ikr 5 i complct [ r i le ] roastro :
. : r , ) [ , 'ornu, J l en craLizr . t ld, , a lasidi , a S.- i I , . ,4. I ) i19rrosl icrr l r r r r r l r , L i l , , r lol , , l i r l i r l l r ' r r i i (o1r,r ' r lor .c l ractr l t t sutr io logiLi() : - l l r i i r l t i , l i t l i j , r , rntr l l t , r , r , r , r , r l r rl , r r r r l i r r l ( r loci f l ' i , r 5 uu dctc l rn i r r isrrr gt^1c1, ic) ; . - .Al i t rgrr lo i r , l r r r r r r r ,h. i l ir t r r l r r 'k ' ;1 '11, , r lar ctr prct l otnirran{ i i l l r r r i tnr scxrr l t r r i lscul i r r . l r ) ! r l r l r l \ r ' r \ l ll r " t r r , l i r i r l l i r r l . t r lc 20 t lc i l l i , In,r . i1, i r ia, i l lc t lc l !0 ( lo t r , l j f i r l r r l l ' i , ?{) r l r , r r r i i "
I r r . r r l r |o: i r r r i r ( iv 30){ , r l in t . i r ,zrrr i sulv inrr i r ( rc 4(} ; i { i0 ( lo l l , i ' | i ( , t. ' l . \ ( l i ' r ( , r r r '0 rrrol ,0 l t ,on(Irr , l s i . r r1, r l0 obir . r , i l t r r pr i l r r l r l i r r r I , l l t , r r l i , , , r , r rz i i, r r r r r r r I r ,o l i i ( l { l 1, i l ) , \ r , i l t r - l ) l l ( , l l i r r t rcr r , r r ( f r l ( ! l t$ io I ) rogtr t i iv t i , l i r l r i r r rn l t l , t , r r , t . r rr ,1ror I r r I r ' i r r r l ; i l } r ( l r r r l l rc lo j t r l i ' r i0 i r lo, Mi l i r i l t ' r lo l l t t l , r r r iar i , L l t r l r t ry, l r r rl r r r l , r r r l r i r r i r lor ' , l r i r ,c!s, lx , l l r i r r l l r r r I ,o l io l r l tot ' iscrr ,pr t l i l r i , l i I \ ) i | . ( I | | r r | | | ' i l r ir . r r I r . I r r ' ; r , ( r r I L r i ( lx , ) ( , i r r 'o i r rs l i i l i l i r r r l r r i r r r r r lsrr l cvolrr{ ic i ) I Al ix l , r l r r r l r l r rl ' , / r r r r l r r l , i r l is l lc l i i , ; i r r r l r i l r r l r l i l i i , 1 i r r r r r r t l r l r i ! r l crr l l i r ru l i , l ) ( rc l , ( , fn l i , t l l t lr l r r lur , l i , r 'orrr l r r ) iz i I l lo i r r , r r r r r , i l i tz iu t i l \ l t l l l r , l , ( \ i t ,z i l { i | | I | | i t ( , I | | i | 1 , r I | , I I l r t r l l r r t t , r l , l
l i r r r l ( i l r , r , r l r r l r ' l r r1, I ' r , r r r l r i r r r r i , r . i r , I i r l pr . .g|r ,n iv i i , , i r r r , r i . r tu l r i l r r ro l i l r l l t r
20ll
! l i lu l i j - I , ' rwr; iotr la,( , i ikr s i r r1, . prrrzrr l i r . 1rr l ,dqlu1l I - . , l . r r lbrLr i i ,L, i lo sf inc-fr . l ' i r r t r l l i t r l l i tu. , i i r . l ' ( l i \ ' (1 ; i r l isr . r ' , : i , ' t
.u,,r) It'orn.ut, Duilorri, rnalignill, Ii .a.pig evolntiyii, &fcctcazil inil,iaI $irrlrsiv rrrrrscula,l,uril irrorvati5, cle nucleii motori bulbopontini. Tiebui'orni{i:rl..rli l i.r't ' l! i:r1,1 de ? polioencefaliti i infcrioar:i $i, dineirlrelcs, cle o| | l t r ) r ' i i ( to 1r. l t r le l t l c( j lcDlut , l .
. .t.;) I, 'orntu Ttst udultol I n curi,tri,cii tle SLA (form6 lui patrihios ) pr(,do_r| | I i r t r r , t ' 'x t l 'c tntnin. I ' sn caractor jzerzS, pr iu al- ingerea de obicei a gr.rrpc-i , r l r r r r I i r . [ | | I r , I ( . jur . rvr lc dc sciat icu] p-opl i teu nyLorn, c le sci l I icrr l po.-pt i icurrlrtr'tr, sir,u :I amhelor, ,insotindu-se. de crampe _musculare in repa-uJ qi hrrr),'s fr {le all ')l irea reflexului achilian, eventual si a celui rotullan.
.lt) ll'ipul j uaenil de BLA .ear semlalat) apaie snb 30 de ani fi reali-r,,orrzii,. cu 1trcc,;rde,re amiotro{ii proxirnale pseuclomiopaticc scapulo'_hume-r.r1'lr.;i/,sau pclvi-lombarq sau-formc scapulo-peronieie iNclsoni5i prensky,l l |7: . ( . i l ( i t le.Rut lu, 1978; Cioran. ICZ9). r .arc por
" , :ca di t icul t iDi d ia i :
r ' | : i r , r , r ' , 1 l&nsf l r te tnsa pr in prezen{a [asi . iculat i i lot , ) a l r lse,atol E-\ IG,;rro( l t ( , l l t to l Dlopstc^ sr a ovoluI lot .
Q. llormu Jarnil,iald, d,e BLA lpare inlr-o proportie tle 1?o/o din totalul,r' ir,zurikn dc SLA (Haberlanalt, 1964), atectincl de fapt, tn paii,Iel, celulelet'r'r.rrr Irri, antcrior, tracturile posterioare, spino-ccrebeloasi ,si piiamidale,{tr''.r
-rrrptrcin(.1 li unelc semne ce;rebeloase, de corclon posterior qipiramidald( li l,rlu, 19?8 ; Kurlancl ;i Mulder, 195b; iTaberlandt; 1964 ; Cibr'an, 19riij.
d\ n'orma d,e SLA d,in cotnplerul Gtmm, ( SLA - parkinsonism *dtvtt:ttlti ) rru ridici, probleme riiagnostice la noi in 1ari, cleiit in misura it{r,rr lrrti),stjii, formd, are etiologie virotici, (virus leni) li in cazul unor sin-r l ' r . r : r r r r r r r l r . -Sl ,A.rnt i ln i [e 5i . la noi in lar i i iu ia l r loul senr io logic i ]LI cfrror.aJ)ot sir :rpilrit fr altc simptorne oarecum asemxnd,toare cu cele din ,,comple-r.rl, ( lrrir,rn') (fenomene ext_rapiramidnle) tulburd,r.i psihice qi altel6') qi 6aro, i . r r I l l r . l in ' .xdrrbi lc nozologic. dar care,probabi l - rcprozint i forme . ,s im_, '
| ( ' r r r r I i i , : r . ' ' (yilot,ir,c Nnu_degeneratit.e) (popoviciu ,Xi l?ascn, 19?9i. S_a
{ r'r|$Ii11ir,1; crr, plcvrr,lon{:r, SLA este de 100 de ori mai marc in insulele Guamrri l rlu,, rlrlci[ in oricc altir, regiune a lumii (Iieed qi colab.,1966), o frecvenl,i,rrrr.lri5rrrrit rlc t'arc intilnindu-se si in F,itipine si in Nour, Griinee. Ilirario:r i . r ' Lr l r . ( l l , t j7) a l r r r jLt l c i , r le f r l '1, . . , "ornpl i ,xul Crm,rn ' . t lcbrr loazi l l\ rIir|r..||rirI l l l(.r'u Fr lt,lc o cyolufie mai leriti, semnele piramiilale precedintll r r r cr ' lo l r r r l l l i l r r .
, ,..\\..lIlt\l i& ]nusculard, progresitd, Aran-.Duchenne, prccum fi Tsoralizin4trllurrl.TtrytqresiM, DucltctLne se p_are cd, nu reprezintii 6ntit;!i aiisiincte, cir,ii,, rrrrr,,jolil,a-tctr, acestora, in realitate roprezintd, forme al,ipice dc S.L.A.( l lur l r r , 1971J).
' t t ,utr ,uLa ult .plue u,e Dr_1t (_(Ir inuu, -ryi6;Utofan, 19/U) OSte tmpor.taniHll,,lio locrrrLoscutc in plactica rreurblogici: - foima mo:roparetici, (curlrrlrrrl,. lr rurtrl.din membre, de obicei dlstat; ; - forma pariplegici, (iot
l) hbrm.aLa atipice d,e B-t-4 (Raclu, 1978 ; Cioran, 19?9) este important
r l r r l r r r l , l r runr l d in membre, c le obicei forma ptraplegice (tot( ' l | ( l0 l r { , (cu rlolrrr{, rlisl;nl, cvcntual intii la un singur
'membru infirior); a foima
; rlc rr l rrr r iopa,l,ioil (rolatati, $i a,nterior) I - forma cu debut brusc; _ forma|I| l Nrlt(.Il:r1,ii mu$culare la rlebut; - forma miaSteniformi, dC debUt,( i t lctr rr,ll irri(,i iu ull;orioari de fasciculatii Ei dc amiotrofii; - founa cu tulburtiriptilrir,o l{, dobut (confuzionalc, dr:melr!,i incipielti) ; - forrna cu somnoux l,rl l l i l iuuit. lulo.
inc ip ic l t i i )1 - forma cu sonlno
2.. It'tn.oortyti,i da amiol,ro.fii, neuro{lcn.a (<n i,ablout'i t r S.T:.A.) pot sir,Jr l)il,r' ir, ln sonilil,:r,l,o, irr ncoplir,zii rnrligrru ryi irr rnickrp:r,tii lo isrdrcrrrigo ili l,tlrr,lTrJ) .
l(i ' l
:1. Ni t l te( nt , rNi tn l l t ) t l l i ( r ' r l r t \ .1, . .4. i . r r r ry l io rr i i , r r l r r r r l t lu l r r r r l l r rr l r ' , ( r r r r r i r r r l t r lo logi |0 ; r01, to i l l iz t , l r ,s | r r r r l , r r s i r r t l lotr t l t1, i r r0 r lo i . { l rA, l l t , r I r .or .r , , r r r r r l r r l ,crrr r , l i l i l r j , c$l , r r rkrosr r j l , r l r r i r t r1xlr ,1 l t , r r l , i , l lotr i , r r t r l in,grrot l , ic 11it I i , I r r | | | r . r r L ; l r ) Nrrvr l , r i l , i r , o l l i r lorrr icrLl b) Sindroi l r r rc lo r lo l { l ,A r l i r r ; r l r r r r r r r, , Lr I r r r i I I i I r r I r r ; r r , i r r r r l lxrv i t r rsrr l i ( l h. i ig i l l tcsou [ i ( ) l l , ( ] [ l I r , I t l l - , ; i )11lgl l, r ' , r ' r r .L i ( , ( ) l , r l ' . , l l ) ( i9r l l ) { ; : }1.1)rurr t ; i colab., . l9( i0, l9( ; ; t , l { t ( i r ' ' ) ; r ) l l t r r . r r| , r | , , r r r r l I i I r ' I r r r l i r r r r r rc lc I i , l r re t r l r r l i l , ive I d) L 'o) iornic l i [a l r r t r r r io i r l i i , xrr l r r r r . r r l i r
' r r r , r 'orr i r . i i I c) ,4norrr i rJ i ikr jotrcf i r rn i i occi l i to-c(x 'v io i i lo 6i l r lo I r r l r i r r r l r r r, r | \ r { ; r l ( l , ( 1, , I l ) { l ' r r r lor i lo col ' ! ' ic i l l t i r ra, l tc; g) ) ) i lchirnorr i t rg i l , r r , r . r , r ' r i l l l r ll r rp, r l l r r l i r . i i ( l r r r l i l i r , ; r i r lo aJlo ct io logi i ) ; h) Alahnoidi tc lo <urr . r ' i r . I r I r r r1 i r l r rl , ' | | |osic l ' io i t ] i , 1 i ) , \miol lo: l ' i l r ] in scloroz-a in pLic i ( l inrrr i r , i r , r r r ioIr .oI i I I r ,r l , i l \1. : r , l r r i l , r , . i . r r r r r , ( i i t ,a l , do ( iu iber '1, $ i Guibcrt , l9?4).Olrrrrr i i r r r r r r l r r r r r ,zr i ,l r r , r r r r r r ; i tnr c- \N, ln( in t rcul ,o lof l io atcnt st t rpr . i l i l cy{ l l l1, i1r , i r r prrrr ' r r l r ,l , r , , r r r r r 11i l r l r :zcn( l r , u, l1.ol setnrt i l (cercbeloase, t ,est jbul i t o, r l rv l i l i i opl i l l r ,r , l l . l r r r l l l r , r ' i , r rvrrntul l r loar cu paloale papi la l i i , t t , rn lxni l l i t ; r l i ror , i r r , { r r r, . r r r r r l l l is l i l r ' i , I i l loa,c! i r cu bonzol coloidal ctc.)1 i ) Sir . i t ruor rr i r r l i r r , 11i l i r rr l torrrrrc l r r s i l i r rgor l ic l icc pot rcal iza tablour. i dc S. l r , "A, , r l l r , t ' rnr : r l r , l r l r r r t,,r, rr rrr:ulrrlogic ltoatc stuprinde cycltualclo scrnne :lsooii l l ,rr rrrvrrl l l lotrrrr1, I r r r r r l i r r ( i I r , . scnzi l i r i i s i r ingomicl ic i I tu lbul i r , r ' i lasonrol ,o l . i i ; i t r r r l icrr\ . . ' r l t l l l1 ' l | l l ' ) .
,\., 1. :!..1. il. 'Lm iotr of i tla r ad,ic ulon err itice
.1 . ( lqvn11[py4 semiologice genetale:1) Survin ln or. icrr l i l 's1, i1, . ! ) A rr , r r rr ' , , r r , , r ' : r l , urr r lcbut t l is ta l , mai ales la sxt lcmi l i l1,r l t , r r l , l r r l r r r r lor i l l i ' r ' i r r i r r . r ,i t l ' , r l , l i l r i la, t t* : r , lc s i s imetr ice ( in pol i radiculonol l i l ,u; i ; roI i l I r r I i r r t r | r r r r r r r I r r rt , . r l r ) r ;Lrr r t ,s i r r re l , t ' ice, t lar q i uni la, teralc, chia, t ' l rc i r l iz l r lc . , l ) l , r . r 'z i r r l i t o, l r r r r lopogl l r , f ic l i t d icular '5, sau troncnl&t, i , , ct t txccp( i l r , pol i r r i r r r r r rp l r l i rLrr, ) l i ( l i rNo(csc rk l tu lbur l r i senz, i t ivc subiect ive $i / s l r , r r o l r i r ,c l i l r r ( , l t l l i . r ' r r ] l
|, 'Irrri1r'||irr radicularii, troncularX, l]rultinovriticir, $i]u l)0liltovrili(,i i. ) it,Ir r r , r1 i ' l i r r lc (L i ln inualea sau ab0l i roa ref lexr: lor osl t r r - t ,crrr l i r rotulrr . i ) Nlrrr, l r r , r r , , i i , o crolui io favorrr ,b i l i , , regresivS, cu cxccpl j r ]x) l j l { rvt . i l r ' lur ' ( [ ' r l rr r , r r toIr i rL i i Ior ' ) gelet icc tami l ia lc cronico. .9) So a,soci l ,zf l o l i , l ) , r l r r l r , ; i r r l i r ,, l . r r r r . ; i l ip i r . i r . ! . | ) I lareor i s0 insolesc de fascicuLt( , i i . l0) Aplorr , ; r r r I r r I , r I r r r r r r r r r r ,, | ' , 1 r r ; r I r' i r r r scrrsibilit*tca la, prcsiunoa rnil,solor' trnrscrrlarrr ;i lr, Ir.rlrrrIrirtlrIuI,rL, r ' ror ,s( , , 11) i l lu lbur: i r i lc sf inctc l icnc r lc ol . l icei l ipsosc (crr ( ! ) i rx!pt i i [ ]1 i r lr I l , r r r r r r r rLr l radicnlare lombo-sact,a1n, inclusiv i r , lc oozi i ( lo t f l l l ) . l :J) , l , r r l l r r rr , r r r l r , v l rsorrrol , r l r i i , $ocrotr l I . i i q i t lof icc s in l ; f t ( ! ( rvcni , r ) i i i i l t lx) t . l , tut l ( f .
l i. .l t ' ioNfoJ ii.lc ru,tl,icttla,rc so pot rcounon$to prirr rrrrrril,lo:r,r.rrLr r11s1q,'l , r ' , , sctr io logico: J.) : \ rn iotrof : i l , cs l ,o 1lrc( loco qi r rkrc1, iv i i , , l l , ingir)( l r l r , . l r . l r i lI ' r r t i r l rz i r , { i . ! ) I r ipsos( j c{) [ t ] :aol i i l ( ] la,scicul l r rc q, i l ibr i l r r , r r r . l t ) Air iHl i r r r l r r ,lnr ' r l , / r r i l r l l l , t i r l iz i i f l : tscc l l l t r gntpolor. l lusa la l ( ) ( inclr , : l l r r r l i r t r rx lxrc l i r r r l lr',rrIrrcirri), cllro irnllrnril, o loDoJ{r'l l i() spociu,lii ,,r,rldicLrLllri,", rIrr,I,or.iIi i, l irlr-l r r l r r i l i i , l i r l r r r r r l f t l i i .o i t r i r , ( l i t , r ' i lnnl l i l i r rn i l i r r ru l { , i r r r t rqrr l r i ; , i cr l , I i r r ' r r , r , r rr r r r t r l l r i cs l , r r inrrr t 'a, l ; r lo rnl , i ln l r l t { r r r j r l i i ,o i t r j . 4) I r lkrxolrr ( ,$ ln lo. in} I t l i l t t l tHr l, r r , r r l ; r r l t i r ( | i l r r i t I r r i l 1 , ( ) s l lu i )o l i to pcrrrr i i ; t l iagrrosl , i t , r r l t lo Lrcrr l izrr , r . l r r ,
i r l r r r l i l l i i nrr l i r r t l i r r r r , f r ) f i r r srrr ' I r ' i r r r l r r o l t i l rocxr, i l l rb i l i l i l lo gi l lvrrrr i l i l r1rI r r , t r r r I icr ' l , . l i ) I l l r r ,zrr l r r , l rc l , r ' i r i i , , r i r [ r ' i l r ] i i r , i r r i |o| 'poslrr l io i r r r r , l ,u l l r r r r j l , r i l r r r l rr t r , t r t t i I r i I i 1 r r , I r r t ' iNl i t r t r l r , t i i , o l i r l l , Jrosi l r i l i l i { i i r r p l tu r l r lor . t r , l iz t r ro: l t ) ' l ' l t l lnt .t ' r t t i l r r sr t rz i l , ivo s l l l ) i { r r l i \ { r r ' ( ' l , l izc l lz i i { , t izc l ( ! r l ( ! r i t r l i r t r l i g i i , r , r r , r ' r t ,o l r , r ' l l r r r , loI l i t t t , i r t l r r t r ( r t , i t | r 'h lot ' i t , r I r t ' j r t i . r i r ( ' r , l l I r t ' r ' r r Iot ' t l t r o, i l l r \ Iot { r r r , r , l r , l$ r ' t r , t t rr r t r l f r , t r l l lz f i o l t l r l t r t ' r , l l r r l tpr , t i i i t , l t t r t t i t t t r i i l , { ' l t r l i l l t t r , , t r , | r l t . t t l l t t t lU l r r
a0$
, r i r r l , r ' i l , r ' i1,( l i i , i1 i I i lor l rz i r , l , (1, r l r r r l l r ; r r , l r ,z i i , r l r r r r r r i l t r f r r ptoior ' { i r r i r r loI i l ,0r ' iu ll r r l r r t r r l l r l r r r t 's l ,ot r i i r l ic i r r i . l , ls l , t r I r rcvorr i . i l , l r i l i l lo la, l i l , r t lca, r lc lntr i rxr t l r r \ rrr rIrrll l ikrr', I\ ' l irncvttlrr rlo oklrrga,{,it: l lc ll i,rLicirrikrr rkrcliltr;ca,zi iJitru (fxit-crtlrrrrzr'i rr,lgiilo ; b) 'Urtlbtttir,t ' i lo do scnsibili l*tc obicctivir, s(, 0&l'aotolizoilzr"t,plirr lrilrrxrsl,ozii, l,lLcslczii, unoori 1)rin hipercstczii, cu ilspect global fiprrrlrotfiotril l, (lo ilsorncnca ou topografie speciali in bcnzi ra,diculilr'c.'i ) ,\ pr'orr,lxr t{)tdoaunr, gi.sim trtoclificilri ale ICIi : fic de tip in{eclios lu merrirrgo-r'u,rliorrli l,olc virale, luetice sau prin alte infeclii, fic tle tipul disocia-( iihrl lllrtuniuo-r,itologico in compresiunlle radicularc.
(1. AtniotroJiila d,in ntonon,eurite (9i mononeuropatii de ilba'se c.,rigini )(rltrpil (.1u,ibert Si, Quibut, 1974):
l, |u,racl,(/rc generale :r,) A riotrotia reprezintai un semn constant, alar precocitatefl, $i
irrrlxrr'la,ntra acest€ia variaz5, tn func,tie dr natura leziunii I este precocor;i inrportuntii in sindroamele tle secliune $i de fuitalie; tardivii $i discretlrrr sirrrllotrrul de compresiune.
lr) Arrtiotrotia se insole$te de: parez6, sau paralizie flascS, cu topo.IlrrIi,r Iloncularil ncti; diminuarea $au abolirea reflexelor osteo-tendi.rrorrsc iri toil,oriul jneryat de nervul respecti-r; tulbur5ri de sensibilitatoiiulrirri,ivo 5i obicctivc cu topografie periferici,, do asemenea de intensitatovrrlirr,lril i i, irr luncfie de natura leziunii I tulburi,ri trofice cutanate qi vaso-rrroiolii irnportante in sindromul de iritalie; L,CII, este normal.
r) I)rucrilc pot fi foarte vii, spontane ira,u proyocate d.e citlorrrirlr.irli, rrrrroli ou hiperestezie cutanati, $i durere la presiunea maselolr r r r I sr,r l Iirrrr 11i l, trunchiurilor nenroase.
rl) ltollcxolc locale sint abolite.o) ll,ogr'oiiiunea, qi vindecarea sint posibile, cu restaurare muscularii.l. lllor)tL(l,a scntiol.oclice di.feren!'iate tn J unclie d,e natllro leziunii:it,) lli.tulnn,t.r,l. tfu secliune aompletd: - Amiotrofia este precoce, pro-
glr.sivii, i1i lirir,t'h: cxplimati, pe tnuqchii paraliz^\i ) - Asist[m la o paraliziorurrrr;r|rrLr'i, crr hipo- sir,tr atonio; -lieflexele osteo-tendinoase sint abolite;
li,rrl ' lrrrrrl irl io-rnuscular este. de asemenea, abolit I - Nu sint tulbur5,ririr,rrz il ir l l lrrrlrioctivo, nici alureri Ia presiunea maselor musculare , i a trun-r'lrirrli|rl rroLv()rs{i slrb niyelul seclidnii; - Se constati, a,nesiiezie superf!r,irr lir gbbr li, I - 'I'ulbur'5,ri1e vasomotorii sint putin exprimate ; - Solrr rul,rr,l,i, I ). Ii. l)iasivl.
It) Sinrlrom,ul, tle iritalia: - Amiotrofia este de asemenea precoce,.r'rrprirlri I Asistim do:lr la o parezi,, cu conservarea tonusului muscular;
lirrllrrxrrlo ostco-tendinoase $i cutanate sint diminuate, rareori abolito;llr,l[rr rrl irl io-mnscular poate fi exagerat I - Se constatii impon;ante
lrr l l r r r l l i l i r r r rz i l , ivc subicct ive: durer i v i i , Bpontane, exacerbate de fr ig,rlrr pllrirlrrlr rrLasclor muscularo ;i cle migchrile de elongalie; - Adesearrrtlrlirrrlrrrr lriporcstozie cutanat'), I * Se remarci, tulburiri trofice impor-l rur l r : tkr p i r r l i i , ostcoart ic l lare qi a le Janerelor.
11 r\inlxntuL da compresittne: * Amiotrofitu estc tardivri $i maiprr{ i r r i r r l r r r rs i , ; - | ) r r , r ' i l l iz i l , poal ,o i i c( , r l rp lo l , i l , t l * r to lusul rnuscular ostotr,litl,iv ('r)llr.rolv|,t, 1 '-.l l,ofkrxclo ostft)-1,(irxlirIor,so qi cttltt tLill.o sint clirrLi-r r r , lo r i r ,u l , lxr l i to I - L io l ' lc . r - r r I i r l io- t t t t tsct t lar c$l i (J (1t) t Is( t t v i rL; - ' l ] r t l l r r r -t i i l i lo solrz i l , ivo str l r icc l , ivo s i l r l , r ' r t , t ' i t r ,b ikr I Asis l i r , t t r l r t t t l t ipt t t t rs l 'ozi t r yrr , r ' i tb iL i ,( r r i l i r r r l r r , l r i r r r r r rs l , r rz i r r ) l i l ) r t i r i r l i l r f , , i r , , I i l r i i , i ' r r lJrrr l i i l j t lo sot ts i l r i l i l , l r , l . l l r l r r -
l0$
l r t t r l i i ; - - I \ l t t6r ' l r i i ry i n.r \ i i t , i jnr r r r r rx i l r i l i l l l pr tHirrrurI Ntt so r . r r r rx l r r l r l ,l r r l l r r r l i r l i l ro l i t ,o t rv i r l t r r r l , r , -
r l l N. lndt tnt ,uL t l t ! , , t . t , l t l t rut . ( . r t ,1t Hulv i lo I io $l)ol t l , i l ,n, l . io r l r r ; r i1, i r r l r r rvr . r r ( iotr r i r 1 r r r 1 r | , i r , 1 l , , r . l r l l r r . l t l iz i r r r l r r . srr I r , i r r : Al l r l i l , i l t r lo r l i r rot , i Hjrorr l , l r r r r r i r . r r , i l i
: , , l l , f ; 1, . : l ] l l . l , l l t r l r t t r l r r i , . i tk . r i r r l r . r ' i l l . r rv i r r . r t l i . l r l i r r 1 r r r , r i i r r r r t . r r . Hir r t l , r . r . { . r t l r l| | | | | | ( r I | I r r ' | | ( , I ] | r r t \ r , : rsr I r l r . i tsulr l , i ( l t .z i r t t r i i , i f t r r l i i r r r l tpf l . lxr l i l i . r i r r 1r_r,rrr t i r r l| | r | | , | | . | | | r | | | i r l lUl ' l lc l l ; - 7,r t i r , t l { ' l l r r r . lLczir , l i , . r . t .U. i r j - l { r , l rprr i r l r . , [ : t , r . r . ,
r , r ' r ' r ' r in ' r ' i r r ' ( i r
s.rrs i l r i l i l , i i l i i sa 1, , r : r i r t u ' rn i i toa,r 'u l r , orr i i r r . , i . , , r r , ,1, , ;1 i , . i t i' | | r | | r | | | r r r r | . i [ [ | r ' ( r r r I I | ( I i r , l l ) r r i ( j ( , i [ I , r r ,0t i l i i ; i ] l l dtrrutr t ry i , i r r I i r r r r l , r , r , l l r , rr ' r r , : r ; | ( | l t l lSl t l l t l t rh( . I tu. r . ( t i l l ) in.( i i _ Rt l iofUr i l0 t tutsct t l i t r l r r r t r r l r l r
r r r r" 1r I i r r ( ' r ' ( 'srr l f (1 , i r r 1,"() lurrr afrnasir i rnuscurr t r :1 -- . l t i ,1ci l r . i l r vorrrrrrrr r l ,, l , \ | t r , i l r rnor l 1) t . ( )grrrx iv,r l i l rcoinccma, i tunl lo;-- 'Snpt l i l r r , , , , , 11l( , l l l l r , r , j r f ( , i r ,1r r r r r r r r r , l I ik I t . t rk:r l t i t , i .
l ) . . lut . iu l r , 'J . i i l , , l i t pr , l I r t t Dt. ; l t ( f t*pel iD l t t ) l int t r , )Utt i i ) ::u . \ r r r i r ' ( r ' ' ' l i ik snrt t r i l i r l l l l t . i t r , r r i , ra i 1, i1 i l : r r . r . r . r r I r r : r I r , l r r r l r r t r r , ( r .' ' | , | , r , I r , r ' i i r t i l i l ' : r_t i )sr '1. , i , . i ) ; bt \ r r r iutr , , f i i l r i " j l1 l , I r i | 1 1 | r . r : r I r . , s i r r r r . r l i l r . 1 i l r .
" r ' r ,1 rJ. , { 'u- ( l rFl i l l ' l r t re r l is t l l i , f i i l l _topogr,a, f io r ix l icul tL l , i i , s i r , r r | . r . ( | | r r I I I i I r . i | ;t I l i r l lL 'xol . r is l tur - t . r i l i roa,s. .s in1; .
aboi i t i i ; d) N. s. . r 's t i r t i i l r r r . i i , r r r l i i j, t i i . r r , ;oci i lz i i t :u tu lbul i i l i senzi t ivo r luf icot iyo f i o l ) i {yr1, i \ ,o t l i r l : rhr , ' r , r il r r l l r I f r i t i vr l ;orrrotol i i , scc] .cto] . i i s i t ruf ict ; I ) . l t . I ) . (s lo l r t ' r rzrrrr i , i lo l r l r , l rr r r , . , . I U l , r |osl i r I i , .d isrr l i ; g) S, . i tsot ' i i r r I ; i r lLo b,r l r r , . 1| ' r r | | r r r | I i I i l | r , t r , , , , ,
| ' r r i r r { ' . . l r l l l l l l r , loglco e1'1.) , in funcl ic de natr t ra, pol i r r t r r r |o; I r I i r r i ( l ( ' r r . r r ,I t r l . r ' { io i t ; r1, prrr losional [ , carelLt ia l i , , t l isrnetabol ic i , i r , r r io i r r r r I r r i i , r , r l l r r ;1,_
Il. . l tr. iol.roJ i i. le di,n Ttolin europatii le uonict . l i tnti l i t lr1. . . l t t t . Idro. f ia r ] i t t pol tneur i tu ( tcrnen. i .nr :ur t r : | . I pn, l r t r r l t i l : l r r l i ly l 111,,
l , ' t l t , t ) i I l tn\ l i ! te l i i h. [pertroJ. icd, a lu i Di j i r ine_got,Lt : t ut ,z i r t , t i , l r r r r lorrrr , I r, . r r i r ( l ( '11r sctniologice i a) I )ebute; Iz i i in copi l i r , t , ic Hir , r r i r r l | , r lo l r r r , r , r r t i r I rr , ' r , lu l t r r t r r l r l r ) lor infer ioa,re I b) prei lomir i i r , l t t r i r , r r l r t l r r r l r i r rsol i I r r . , r r lt " t r r t r i . r ' ik l r '1 i - : t l r r ruqchi lo. p lantar i , anl , r . t i int l lnor.$ Hl{ i l ) i t , l , Pr. i , l . r r r , . l r r l, r , r , ' t r ' tc nI ( locan f l cu gr i fa degotclor I c) . l ,ozon,zi i r r [ r i l r r r ( i r r r r r r r l r , l r r iI , , , , I , I i | | r ' i r r , i g i lmbei ( iu fLzcle in i l , iak)) l i : t , i (1)1t l )soi I r l ) ( l r rp l i l r r l l l r r r r l r rr r r r r r r ' l r i j r r r0rrr l r r : l lc lot supcr io: l l : , t ,oal iz ind () lu i r i r i l , r r r l i0 r lo l ip , , \ r , r r r rl r r , l r lnr{r i r ) I Ix lxrpl ; ional so oxl , i l ldc f i l l t l luf(1hi i l i , { r r i ; l ) l i r . i r l r r , r , l r ir r r r t , r ' ' l r i i t ' i ' i , r l : i r r i t r i lor r lcrrr l l t 'c l0r 1 i l r , i tmnchi t t ln i I g) . l l . lkrx.rrr , r l r r ' l r , r r r l rr ' r ' r . r r i r r l , u l r , l i1, . th) ( l r r i tcx l r r l s. r . i , rugi . i r rp l i t . i r q i r r r l l r r r r , r r ' i ! r , r r r r r rLrr :' l r r r , r ' r ( : l r lcsr , t r , i 'u lgulanlr) , h i1r9- s l , r r rurc i i t t iz ic t up(rr , l ic i i r l j l g l r l r r l i r , r r r1ror. .t , r r l , , l t r l l r r r t ' i t l i ( [o $( l l ts i l ) i l i l l t t ( , lnol)r i ( ]ccl) l i \ ,c , l lc l i r ) r i l lo i l r i ! r l r , r r1;rrrr , ;r l l i t r t . l . r ' is l i (xr s i r r l , l ip.r l r ' , i i i l . r r . r , r , i l t i t , r . l l l r1r , i , f i .x1r l . r l r ( ip. i r r ; , t r l l r r . r , , , ,, , , , 1, , ' I r i I roI i roI i i l l r r t i l r r l I i l ) ( l t . ( . ( , i ) t t l - ( , srr l r luruut, l tnol , (x)1,( lo i1 l ( ! i t r r l r r r i r l r , ,t , ; r r l r r l r l , j ) l t . l ) . r ' I r r t , I l i r , i ' i , r ,s lo i r r r l tor i r r l l i i , , so\ .c l i i , ; l i ) I lvolrr( i r r , r , r r l r rl ' . r l i r , I , ( | r ' I I I i t , i I r ( | o hnrgl i , i r r r l l l i lv i t r l , r r i l t r .
' . ' , . , lnt i t l t r l l i t . l in lnt lq lu i ( tht .x.ol l , Iut i r , l ,oolh. . i l ) l r i , l ) l l r , lz i , l lr r r l r t Iu ' ic f , i l | l iu i | { I I ) | r I i i ( ' ( | I | ( i i , r , r r l r r [ l i l r , r l r rs| l r , i r r l r r r l t ) -g0 i l r r i ( r | | r r ,or , i r , l r i I It r r i r r r l lv l r , t r ro, I l r . l I l l r r i ) , l r r i t , i l ln. l r l t r r l l l i i0 r l r r l r t r i , l t l i t rp l inr l r r r r r l l , | rl , r , \ r , ( l l t l l i I tot , t r , t r l , xcrrr l t r r I r t i l t r I i r r ) , t l r t l r i i o r t r r r r I I r I i 1 I r I r r r l r r 1 t I t . I t n I r r r r r i r rl , r , r , ' l ! 'ar rL, l i l r r Iorrr i r r I r , r r I . l r j r i r r l i r t I | r i i r i l l , i t t r$t iBirrrr i h, i , l i r r r r ( l u i r , , r i i l
:( t '/
( l ( \ I ' i l ) r r r ( r i l i iv , { l I l ) i i ( iu l I r io f i r l r r , ' r i l l ( l l rz i i f i i i r f l r { r sIror l l i0( ! ; l ) ) , , \ r r i { , lnr) l i i !I l r r rz i r r l i ' i , o rr l l i i 1,o1xrgr. l l io r l is l i r l i , i r r i lcrr t r l i r l s i r r rct l ic i i , ; r , ) I )cbrL. [orz i r , la,r r r r r r r r I r r r r l t r i r r l i r r io l t r i l , lcz i r r t l i r r i t le l r ,urr l r t l l r , t . ior . s i t r rctrr l r re lc sulcr . io i l r .o;rl) l)rrli l i lrrl rriol,ol uvoluclr,zit, in ltat':r,lcl fi propol,liorlal cu aniol,rofiu;.) l,lr isl,i i, o slrc.o$iullo oronologicii, de dispozific topograficil a mriotrolioi,rlrrlrii r, 'rrr u notzii: l,:l nrelnbrcle inferioarc: pcronierii, cxtensorii degc-lirlor', glrr,rnbiurul a,ntclior, muqchii moletului, apoi, mai tliscret qi tardiv,cvrr,rll itrpsul (mai ales vastul in1,er.n), ceea cr: realizeazi, amiotrofia .,irr.irrli irrli,)'a lLri Clarcot, cu ,,picior de coco;', sau in ,,labe dc barzX". l.,arrrcrrrlrlclo supcrioare (dupX aploximativ 2-b ani rle evolutie) amiotrofiarr,1,i1rs1) suri{lcsiy: muqchii mici ai miinii (intcrosogii, apoi muqchii tenarienili lrilx',1,orrl,rieni), rcaliziml amioirofia aie tip Aran,Duchcnne, iar m&i tir_zirr, rnrrschii a,nljcbtalr ui (extcnsorii, apoi flexorii). pronatorii si scurtulrrr1rirrlIoI' sint pu1,in afectali (sau de]oc) ; f) Amiotrofia respccti, urmitoriirrrrrs< lri : atlrluctorii coapselot', mugchii centurii peiviene, lungul supina-lor,.rrrrrschii brafului, muqchii centur.ii scapulare, muqchii trunchiului,rri giirrlui qi ai fel,ei; g) Amiotlofia se insotefte cle fascicula,tii (lu totrlea-rrrrrr ) si rkt crampe musculare in perioada c,le debut, tle tulbru.ilri senzitive,rri,il srrbicct.ivc (parcstezii: uneori dureri), cit qi obiective (tulblrdri tlesirrrsibjlilu,l,o tactilf fi proprioceptivX cu localiza.re distali, ectromelicd) Ilr) 1l'rrJburir;r'ile yasomotorii sint importante (eritrocitozi,, rd.cirea extremi-1,ri(iLrl etc.) ; i) Reflexele osteo tend.inoitse, indcosebi cel achilian, sint(lirr)irll i l l,e sau abolite; i) ,Iotdeauna se constatl Ii.D. de jntensitator rrr,irrlril i, rilar progresivS, si trasee EMG iie tip neurogen troncular;f ) l,lvollrl ja cste lcnt:i.
I,'. ,Lmict|rotiilc multiner:ritice: 1) Apar in teritoriile mai multor nervi(jorrli'cla,{,i, rxtea co confer:i o configuralic asimetricl;i asincronii, care 1o(lil i lrtrr{,iNzii nol, de polinevrite qi rie polineuropatii. 2) ln general, estol,li'r:1rrl, irrl,ii ln nerv, apoi, la intervale de ziie -sd,ptimini sint cointeresali||l(i r,rvi. i l) Tulbud,rile de sensibilitate sublectivr, apar mai intii, mani-lr'rrl irr(1. s. prin algoparestezii, iar mai tirziu apar $i tulbu'd,ri obiective,r u lrr l)lsc po tu'itoriile de ilervali6 multinewiticd afectate. 4) Amiotro-Iiilr sr ov ir[or!i:r,zi,, in general, mai tirziu fatii, de d.eticite]e motorii.li) Vrl{)llrot, scmiologicil a semnelol de leziune multinewiticd, constd, ilouclli lt.o,t, sprc urmS,toalele afecliuni: a) Colagenozd,: periatrita nodoas[(borrLr lrri t(iissmaul-Meier), lupusul critematos diseminit q.a.) ; b) Diabetz,rrlr:rll l ;. rr) frrkrxicatii (cu sulfamide, barbiturice, oxid de carbon) ;r l ) li r li r L r s isttrm (boala lui Rue,rger, boala lui Besnier-Boeck- Schaumann,l r , r r l , r l r r i \V;r l rk.rrs l l i j rn) ; r , ) Lcpr i .
,\. : J. :!. J. L. A ntialrof iile d.a origi,ne centrulri
|. Alroliilc la hemipleui.i mai l)ech,i au fost relatate incii, do Marinescu( ll ' i lt,ri) 5i rk: rl{i lr,rrkrr.i cllLsiui (cil,a{i de Arscni qi Jlotez, lg7j), So intolcgo{rii l)t(,2{rll l l Irrrrnil,1.gioi, 0u (xnltrtLcturii, qi ilnobil izr',ro, trrt lro 1I,.rntil,oI t i i , i r , r ' r , r i i r r r r l i r rgrroxl i<rrr l . l i i rn i r ru rknr. s i i - i ptoizt i rn ul io logi l r .
: l { i t t
' ' . l l rot i i l r : r t t r t : t t :u lut t r l i t t l t ' . , i t rn i l t I t t 'Nl t t t t t l r ( l ( ' (p l t t ' i t r l l r l r r ) i l l l Hl lHlr i l r t l '
, , , , , r r , ' , i , , * ' t i ( i i , ' , r l r i
r r l r , l l r i r , l r r l ro l ' I i t t t r r" ' t i t t r r l ' r r t l : t t t1.rr .1 i prr l ' s i i ' l t t t l r t l t t r t t
, , , , , i , r , ' 1 , r r ' , ' t i r | , , r ' I r I t i r , I r I I t t I r ( I \ ' i r I i l l I i r i l l { rh( l lHolr ' l l l l i l ; ( l l i l 'c l rkrvr l1) ] i l '
, r l , r l r r l i r Al lctr i 6 i l i r l , r '2, l t l? l ) 1 i i r r .srr i t rs ' r l ' l rs ' . ' i ( i t r r r r r l r l l t l t t l t t lor : t ' l )r l , r r | r r r r r r ' l , )NI( l ( [ | l (k l | l { ' rv i l , l { ) Ei r t ' , I t t " r l i l i ( ' i t ' i r l t i l t | . l r ' l i r - r ' ( l i r l r rz tJ i ( ] r i l r r r r
t r r r r r , l1 l { i l l c i l , r r I i t lo Als( ] l r i r i i l ]o l , r '2, l l l? l ) Nlrr i t t t r t l l , Al i l ( r r r i f i lk t ln 'z
i , , , , i t , , l t l r l i i ' l ' r r l , r i l i , l l l t 'o l l i i lo t r t r l l , t t t r r i l l t rcvclr t t ' ; i t t t : r i r r t r r t i srr t t l t r ; r ' t t i l l t t
i , l , ' , ' , ' r , ' r , , ' i i i , i t t lo r tkr r r t t t i r l t t t t t l r t i t l t 'op1, ' ArsoLi ; i In i t r rz ( l l l? l ) : t ' t r r r ' t r r l r t ' l
, , | | , , , l t r ' , l i i l , ' t l t r t t r ig i t t r r t l t r rL l t l t l l i i rL l r ' :L i r r r l isr ' l l l ' i r ' . ( t r ) l l : i . l l t { r ( ] l l l l i i l t l l t t I t l l l ' ( l
1. , f r | r , l r r r l i l i r t ioo t t t l i i i r r t lxr t ' l l t t r l , | : i r t l r l t . r r l i i lo l l l i l l l { rz i l l l r i l ' l l l r lor l r l r \ r i r t '
t r , , , , , .1,r i r r r l r i l lss ( [o ] i1)s i l , (x) l r t l r lu l r t i l , t r r l io t lo or ig i l ro t r t t t ( t ' l t l i ( l r , , , r r r r t r l r t tl r r r I r ' r , I i r r ) ) r L i r r g i t ' t lsuI postcorr t l l r I1, in l rcrnc ctr , iu < ' r lz ' t l l , r r r I t ' . i r I I i I I i1 i i r r l r r r
i , , r , " l , i i i ' t r t ' r r r i l i t t 'g i i tc i rnsrt t rhr . ' , i 's lo ' ' r ' r l ' i i '
i t t t lc 's. l r i r [ ( o l i l rHi i ' r l ( \ r t l ' r
l , r r ' , , : r , r r r rur l r t ' r r l t r i pual i l , ic $ i at lof i i l t .
9. PROBLEME DE DIAGNOSTIC IN AGNoZII
0.1. AGNOZIILE TACTILE (astereognoziile)
Constau intr-un deficit de recunoaqtere a obiectelor cua,irr1,,r'rrl .pipiii,ului de c.),tre un subiect (cu ochii lnchili) ate cd,rui sensi-l)ilil,il,ti olducrtale sint intacte.r\ccstcl, apar in leziu,nile yasculare
_(homoragii, ramolismente, hema_l(,rnrc), lntrrorale,- traumaticc. etc., -ale_
lobului larietal qi ate g'lrusuiuirrrr;l.rrrnu,r'gin:r1 (aria tactognozici a, lui lhermittd: cimlurie Z qi iO firoa_r r r t l r r ) .
.. .!l.l,l. I)iagnosticnl tle agnozic taetiti !i al iliverselor sale formor.lirrico so fl.].l l i lg!!" printr-o irpJorare-semioiugicii riguroasd,: a) Se stu_rli:rzi sursihil i l, i l1;ile. ck)mcntare (superficiale _;i.-profuiile) ; b) Si;"pi;_r ' , ' , : r t . l h i lu4. , t , , : i , r , i r r l i r . r i . . idf l r l i l icarcr mf l lpr ie i d in r .are eslo fo l rnr l obieibul{ l | | . , | | r iU( ' , r t r . l r t ( ,sr t r r t stU rcziSfoni . le led S:ru rugos ct l . , . ; JCmn, f ier ,I r r r ' l i r . , r i r r l i i . s t i | l ' i or . . ) . \ i mor. tog ozi t t { fo l .m,L $i d iminsjuni lo oUi.cLi f r i i I.) r\r. r'r1rfor.cu,zi tttpognoz.ia (se
-face- o excit;tie cutanati, Si iridit-idili
I.rrlrrrir' *i i irrrlico sediul cu ind€xul); d) Se'exploreaze disc ,mlniii iluclil i.: a) i ' 'rr;.111i1.i1; bolnar.ul sX, facfl detmnirea etictd a obieatuizt; prtieitljrr t|rorl (,( ) tl)iu.|,l;iv, cu ambele miini.
!1.1,!. l,r.olrlcrro de diagnostie clinic:
..... !1,,,,1t/,'!,i,i i l! t!u!.j,l,e prin^o:e i a,) Agnozia,d.eintensitatel, (ah,i,Iognozia ) :' t . r I r | | | | | r : I ( r | ( ' r ' t ( , rncntare s in l intaclc f i to lu$i sutr iectul
" r1e i i icalabi lr , r ' r r r , r ' ' r r . r r r r , : I I r ' in 1ra)puro nrr fcr i r d in cat ,C eslo for"ma t Obie; td:t t t t t tnt ' . t " , , ' t t t , lcnsi t t te ' , (a nor logno: ia 1 : dcsi 1111 6,"1a,; l rdbwir i obiecjlivrr rl. s.rrsilril i l:rlo, subiectul este incapabil sL rccunoasc?i form:l qi ii i_rrrr , r r r i r r r r i f r r o l r iocl ,n l u i ( ! , ig. 32 ) .
:J ) .Agnoti.itt: t.uctile sectmdare .(asinbotia tactili )- In aces[e c&zull,rIrli
'rin'log.ozi* qi )rilog'ozia sin[ inl,aclc, bo]nav.l nu.ccu.oaqto obiec-
Irrl. l,)' l,rr . Irrll lrl lrrr do rtrcrrnoa6tcrc a semnitioalrici sirnlxrlic. a, obirrrt,uhri(vt't,i .1 i11. :ll! ).
2?t)
l \1 ls l t ru4nor i l , l t .h io hrrnr l i i ( r l t 'Hcl l r i i t lo ( l r i lc l t l r ry, l { }5 i1, r r i l , t t ' | , r l t rI l r r r r r l l r . r ' , l l l??) rrrr rx l r i i t r i t t r1rot t i I t i I i1I t I r ' I I t t t r t t rot t t t t t i t , ,s t l r to i t , t t l r i t ' t t l ' t r l t t t
, , I r l I r r r r I r , " f r r ! j I r '1, i { r r t t ( j l l o l lv i l , i l lo i ! l ) l l ( l i l l i [ .
l) . l trt,: i i(, t.u,tl. i l , i i , srt i l lEo((iH1'o ttt lcot' i ctt u,1tnt':r ia nti itr i i irtfrtrlr l plit ll r , r r r r r r r . i r rur t l l t lu i r l t los (( l t rsr l r rv in( t 8 i Krpl lur , l0( i2) '
A III
/ i ,/. .rr. ' touograria lcziunilor care ".;Jroii,: lr iYt"rttt"
tacli l0 ((lrrl,h lt isfr ' lrr l '11.
' , , , , f , . r r \$rpr.dlrai r i is ;P. : t l icdclrb2t;Pa:Pf ictr laas.o.dcol l t j , 'U ' l r ' / i rnx ' i '1r '1 r"r t r ' r ", ,1 ' ' l r ' i l i l ;Lr1
\ rn i l l , i l . . lLdmJtJlesl izsigcrdindo!, lnor ie.or l i ( r lJr i l ' r r ! lnr l l ; -1 l l ' l r l r ';' L ."i, L r.!,oN',;/i"e, Brncrin,r Jjno/ic p(ri
f:'&:il':"1#.,i','jl.' .4rlr - rczirno r,rdkr; .rrr '- rn/r""'
l ,) ., lsl(rmgnazia bilateralti poal,c fi roN,lizlt l i i l tt i tt l ,t tt l t 'zittttrr :t .trrttrt , r , r lcnr l r r ' : t lc st ingi .
t i) l l ulostercoagn ozia (Ilalpern, 1945, citat tto I(t lr itr(l l{n', l l l?7)(l(rtrrl lr ii ' r l i r l r l l l c i r bolnavul s imte obiectul , pe care-I l l r i r t r l t l i l l t t t i t t i t , t r t t t i r r r r r t , ',1, , r ' r I i t r rcnl i tate.
9.2. AGNOZIILU VIZUAI,I,]
( l r rshlu in pierderca posibi l i t i l , t i i t lc r t tct t r t r t i t l i t r l t t i l ( ) l ) i l l t i ln\ lot r ' l li r ; r r l r r l r r l vct lcr i i , t le; i l lo l r ravrr l nt t i t r t t t t i t l i o rnul i I icr t t ' t r r rv i t l t r t r l ' j i t l r ' ! lz i l ivr t -rr 'rzolir l i ,, ir lr l iacull,If i to sa,lo mirl,a,lo sitt l; contlcrv:lt,tr ' I\rt, f i r lr, tttrt i ttttt l lrtl r l r r | i :
l . A1;rrozia vizunl"r U)ntru obittcttt txrt 'esputl(lo (xr(i i l , i ,t ' i i l)$ilr itrri rr lrril \ l r r r r r ' l i . l i r . to l rnt lc gravlr , r tcol l i bol t t r t ,v i r r l t loct t l l { ) f i ( , t t io i t t t t o l r i t r r r l , t t ic i
' , | ) r ' r ' l 1 r l | | | i i , , l i l i t i r i l t t ' propt i t l r l l I igt t r i , , I ' t ' t rzot t i ,at t : i t , t t l l t t i o l r i t r t r l l r t t t t r r l ,
I r r r r t l l r r , r l is l i l t t l , i t ' , i l l l Nnl ln ' ( ! l t ( l i lz t i , t lo l t t t tn i t ' t l l l , o l t i r r l l ; t t l t l i , l l lo t r i i r t t i (1 i l , t ' l l ( f l i '11\pr i l l r l r r pot t ,o l , r r1 i s i l { io t lostr istr , St t l r i txr l t t l f ixol lz i t o l ) i (x1i ' l l l r I ) t ( 'z i l l l t t ' r lr r r r r r r i r ' : i srrr ' ; r r i r rFl i I i l t l t rst ' l r , corc r t , t t lot iz l t { i i t , t lo l t I i l i , i t tgtr , t l t r I l , 1t t t , l l t t t , o l r I r r 'i r r l , r , r . r ' l r , to i l , t t l , t r l , ro l lz i i , t l r r t r t l t t t i t t l l s l t , t ' ,x l tc l ' l i . l lo( l l l l t r ) : l , i j l ( t fo i l , l l l l l l i o l ) i ( , t ' ll r r l r . r r r r r l i , i r rg l r r t t i r r l , i i t l i t , r ' i i i t , r ' t ,s l i t t 'x l t r l t i l t tz l l i " i t t t l t rot t t r l ' i , c t t l t l l r r l t r ry i t , l l ' r rl r r i r l i l , r r r r , i r l iL i l i l , cr t l i l , , r i t t t l r r t l " r lo t t l t i r r r r l ' t r t rs l ' t t t t t l t , i t t l i [ t ' t ' .
r \ l l r ror i r t 1r t ' t t l ' t ' t t o l r i t r r l r r i i i r r r r r ; l i r r i l igr t t r r ' l iv t ' , Htr t tst t t ' i l tz l i , r l t r t t l l l t , r t ir , r r r lurr , r i r , rorrs l , r t to l iv i t , r l i r l r , r i r , l l r : r l i t r l i i , ' r l i r t ' t r , l t , t t l i t r x lur , l i r r l r i , t t r t t l i l ' i r r t1, t l
'.','ll
rhr l i1q11y vizutr l ; i r lc r r r r r l l ,o I l ic l t r ) r l i i ( l ( l l t ) l l , r I I r1r I r r l i I i i , I i |or , i r r I r , I r r r : t r r I r I r ,1 l i I r . i r r r l lcr , l l ) ' /7) .
l f r l ) \ ! t ) (11)71) i [ ( ]cs(1l is utno:: i .n, t iz t r .u l i i uptr t : t '1t l i . r : i i . , i r r r . t r t : r . l tprr l il r r l . r r r l . r l isc l i r r r i r l r lc a, obi t : r l ' r r l r r i r :s1o pist i l i i l , i i , dai ' cc l , t lc rcr :u lo l r i ic lor.rl. lrrllru|rr,1i. irr lrlto citzrrl ' i, s0 tnarrifes'tr:i o,falid, t.r:t:tt ttoalf,r:rc a abiic'rtlu',.r'r'rr ..r |r' la,|rrrr,zi. lrulnlrvul ilvinrl o olrecarc irLrudire dc liolmii cu obiffhtir q ii|,lri l (1tlt ' lrg^noziir, optir::i a lui r.on n'Iayendorf). S&u, ctaci obiectrd al.rl rr'(ittr1r)scrrl,, rirunelo s[u este ulteriol' aplicat ;i la a,ll,e obiccte, fo:r.t,torlil i 'r ' i lt (,,i i r loxicai;io pt,in obiect),). Ei po1 si, nu rnai rocunoasci r.rjci, r l . r i l r . . ( , t4t , , , : i t . t . t t , t , t l t l i rn ) . Stu di feroxl , , le dr. r .u lor . i . i r r l 1 ic, ,ceI , r r l r , ,l : , t : i : r l r . l , | I l ' . i r , i r l ( .n l i l icX (o,s in,bol ip t ronul iL.4 ) .
. l,l\ i$l,r"r, \\i o, ccail,(da corti.cctld penl,nt culori, calacterizat5 prin frptullri l,r lrl o crrlor,ilo sint virzute cenu$iu. Existil ,li o hem,iagttrnie yteittru,'rrlr,rri ((llonning ;i colaLr., 1966, cit:tl i de l{reindlcr, l9??J.
. 9. lguozia pcnlru. imagirri poa1,e s5, existe in mod izolat. ,lstfel,Irolrr:r,r rrl recnnoafte obicctele co:rcrcte, dar nu recnnoaqte aceleaqi obiectrilrllzlrrllri,c_in irnagini. Aceasti formi, de agtlozie se poal,e in\rcstiga pr{)zr,rrlirrl. ]rolnarru-lyi imgsini- harsruate cu linii sau im;gini la tabfrtofoolrr,i rrrliciiintlu-1 sii, ls identriflce.
il. ,trgnozia vizuali asocialivi sc ca,racte.rize zi, plin imposibilit&telt,rlo il .lf[]ri, tlo :l descrie li/ sau a indica utilizarea nnui obiect perceput,r izurL,l, in schimb cu conserla.rear posibitit;,-tii de a clesena obieciul qiritl:r I irlcrri;ifior, prin alte ,,canalo". Diferen(a dintro agnozia vizuali, apercep-li\ ir, iri t(':t u,socia ivrj, consl,i in faptul ci, in aceastia din ur.inii, p e,r cep_t"ialrr|rrrr.i. si 1l co-nformn:tici sint nomlale (Rro.$'n, 19?2; Nreindlei, tO-t?)...\r';rrrizirr, r.izu:rli, asoci:rtiv5, ar fi ut.t fel de ,,asimbolie,, r.jzualii.
.1. ,tlynozia viru:rli spaliali cuprinde o bog;.tie c1e manifestiri:rr) .l r1ttrt;i4, t:izu.aki rle locnlizare lcnoitater, pcntru spl.lqiu) const[ in incapaci-lrrir.rr. rlc l, sosiz:l rclatii lc sp.lfiale intre obiettc, de a le localiza -'mai:rll ir irr Irofr.rlzirne -, de a aptceia distantele calc seDarx. obiectcle intlrr ' l r " r i o l r i r . r , l t lo la l i l de obserr-ator. Dlcd, t le excnptu, su sot ic i t ; bohavul' . r , , r : ' r r ' l r ' z l r l i j lo ' u l r rnei l in i i drgptc. c l r r grn. i .
l ' ) .ltlttrrirt, tl itu,uld stet eoscopdcd, foalte lari, constE in inposibilitate*r lc:r I i r i t urosimea ul t i o l : icct t r id imensionat.
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r . r 'or i r r r . , - : r r r . l r . i r rcr . r l : r l , l r , { . i { . t1. ; l d isr l r111qlsa1, lst le l incrt aceiLa exccul i ir r r . r , . r l r { t ( ' : r } r r r ( . lu( , b i l , r ,_ srrr h i ; r r . rd im r .nr iuna I o ( f i i l . , . r a t i un atact icIr ' r ' r1, .H,, i i r I l , ( ' { ' r1.1 'c los). .U i i bolnavi cu s indrom Bal int i l i apr i t rd l igara.. rir I irlr-rrlrrl r.c(\tcin, ci la rnijlocul ei, sau manevreazn eulitu.l in failurle{rr.t)l lr ' t{ i rtc l ')(.Ll[ in c{u'e trebui si taie o bucatx cle caine (Kr€indler,t | )??).
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, , r l r r I rnmir ,^:e l , i l . rdo drra.r reprczentarea ( imagioca) I izual i i ar , | ) r 'a | | . I r , | . I ' r ' c lLd rn crc i l r tea COrl ical l , se pierde comple1211p61,s 61j6,6irlrzirlic si _p(,I'ceptje vizualai. Cecitatea ?.sihic.i se insole,ste, de obicei,rr rlc ir.ltc rrlcmentc agnozice .r-izulle (aleiie, acromatognbzie), ae Ue_ll: r r r r '1r . i . . . . i r l . lprar i r . (LrDntrucl i \ i .
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, Stttt tt.i.l itrt!i.rr, t9.lo-lyof!a( n ogae:i_ilor . r.i":unle. Agnoziile yizuale au car;rrlrrl.rrl lr,zirrrLi u,le klbrrlrri rccipitll sting la drepiaci, c[ci leziuni alor,r,izrrr.ii .r,irlr.arino si alc. regiunii_ paracalcarine stingi (cuprinzina intreg( rrr(l.rrrl) pr,rluc :r,grrozii bilatcrale. Adesea este volba rle l6ziuni simetricl:rl. rrrrrlril.r l '1ri occipitali (fig. t,3 1. T,hermitte a subdivizat aceast5 zo;Lirr rlorrri rrgirrni : una clestinatil formelor qi culorilor (aria 19) Si alta. mairr,rrI,'r ' i,rrrli i, rlcst,jnilhii cleserului, l itelalor, cifrelor. Tulburi,rile'dg 61i.r6rr,.1:r;'rr,ziilr. slr;rlia,l.) sint rlatorite unor lezi'ni profunde :rle pir_iii superioaro,r irrir'r'rrrl l,lr, u,r'ioi par':l{jalcarjrrc 1: r,r' i.r, 18), e{ingind si mlirile fascjcule dc:rrrocirr i i r r . ' l ' l l l )u l iu ' i le memol io i ton,rgl l f icc depin, l insi , de obicei , do
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l r t r r ; rot i r l l . t l j ( !nt fnt t i r r r l l lotrrr , prr , r lotrr i t r i t , r r l , opl i r ro ofr i r , r ' l i t l t r ( l l t .s1, t1| l " . l ll l , r r r l t l t l l r " i i , r tgr tozi i l l o l l ico 11r 'otrrr , I r ' i r . r r i r i r r i gr , r r r r i r lc r l r r lcz i r r r r i l l i l l r l r , r ' l r l lr l , l , r l r i lor ' l l r l ic i : r l i ( i r r r , luzirrr l 1 i g i l rnrr l r r r l r r . l r r rur , r 'g i r r : r , l ; i p l r l l r^ : r , pol l r , r r, , . r r . r : r , lo l r t t l t r i Plr l i r l t r l sr t l t t ' t ior ' ) l r r r rct t t r t q i l r l r r ctr lc i t lo l r r lot l r , 5 i l r l r t i r r, r r , r r r r r roIrr( i i o l r , i l t i l ,aJrr ; i akr . jorrc{ i r rn i i crr a, t loul { ' i r r l l lnrv{ , l l t t , i r , 1( . r r ln,r . r l . r l l i ' .c l , r . l t 5 i Arrgolc lgucs ( l00l t ) l lu 1urrr . izr l l r , i i lcz iurr i r r l r , r r r r r i r i l l l l r
)
t t , t i r . (hrrspr)ndc lc topograt lec alexgn{)z i i lor \ izui le :
, , r , , , , r L) . ar ia r( : ! , !$LlJ i l i ' d, Lai l ihr .a aler ie i, . ' i . r . l : , . . l "
' . , ^ l i \ , ' , . i r . ' -, ,
' r r f r ( r r ia l8 s1n . . i i l l . icdlornd) j l f l
, , , I . .Lr i r 19, ! (st)or l rL, i l iL 1! n1!c mislr i r le l f r' ' ' ,r :i de ii t.grm. lormrlor ii a .d..il.r!,
, l r r 1r i r ' .prot luo indeoscbi agnozi i pentru i rnagini I igrr l r r I r r1 prr , iLr , l ) r t l i I r17r\ r . . r, r ' rroz i i sl l l l ialc unilateralc,, in vleme cc l eziutrikr cr rrjsl i,rt i sl r r r j l r l ir.r {,r r.r j/ , l, ,r pli'r,ii,tkrrtl a,gnozie pentlu culoli.
e.3. A(iNOZIILE lut)tTtvt,)
( lrr prirrd urrnii,toarele formc clilicc ;l . l lurdi t tcu, psihic i i l , luLt t sau rr . r l tu* i r r t rur l i l i . i . r , r tut1t I r . l r r . l t r l r r r r r r r l
; ' , r ' r r '1rrr zgoi t tot t io, poi t , tc. rOrrr l r i t t i r i r t l , t ,nsi l i l i l , , l t r ts l . , r , l r , r . i l r , prr l r l r . l , r I t r l rzrr1r;r( i r r l r r l l t t 'cstc. incapl lb i l s i l r l l l i r l r r , , r , i t r l r , l r r l l r , I r l . r r I l r r i r . | r ( r r , i r r . r r r r r r r r r r r l r r r
l , ' r '
( l r l r l1,o ( i l . rv in lc s i '1, lc id ' r r l i l i . r ' . l r r . l l , ' r r r l l r , r . i r r ' l i r ' ' r r r r I l i r . r r r . : r t r ' ; r r r . r , l,1, : f l r r i r , ( i r ) l l sor \ . i i , t r . l t rskl i r r r l ror '1, : t r r t ( lo l , { i r i r r l l l r I i r r l I i i l ro l r i r r r , r r l ( .u : r ! . , r . , , r r r .I ' r . r l l t s l l l t r t ,o l rct 'cc1lo t lc r r r t t l lo ol i r r l r i l r i l l r ror , l r i l . r , r r t l r . r , r l r iur t r , l r . l r .I lyorrrolr ' , lotrur i f . i t . ) s i l i i l tgtrozi t t , l ) ( ,n l t .u l j l l l lc io rrc\r , r . l l r , l r r r r r t l r , l r .i , r r r ) l r in l i ( 'u surdi l , rLtc i t t ( r . l ) l t , l r i .
: : . . Su. l i t r i l i lo ls i l r i r , r . .sp*r . ia l iznto. ' : r i ) Ntxl i l t r l t t r / . r ra l r i . . i r r r , r r l r r r , . rl r r i . r r r l * i r , r l i l i ' t r r r r l i i r , rk l r* ' i i r r r r l r i r r r r l ' r r : r l r . r ' r r r l isr : r r r { i r r r r i . l i r r r r ' r , r . l r , ;l t t , \ ,1di l ( l ra snt , r rgno; iu t t t t l rx l i , , , r i r r r , : r I r . r r . i I : r I r . . r r l . i r i r l r . r r l t l t ( . r r . l ' t r . t r r l- r , r r f r r , ( . r r i t r r : r . i r r r r r ) ( i . r ' , r rs i r l . r ' l i r ' : r r r l i r r r r r i i r l r , l r l : rz i r , ) ; r ) l i r t l i ru l r t r xau,ut t r r t i r r t ' i l t t t i t i i : i t t r r : t 1 r i r , r . i I I r I r . I I r l r , l r r l , . r i iz i r l i i r r r r t l t r r r r . i l l l r i r . l r r r , i r r r lz r l i r l r , ,
r l r l t r l r ( ( \ 1 r r , t r . r , 1 r ( r : r , lorr : r , l l i r . r r l r . i t r l l r r ' l i r .
it'10
i l. Srrnlil.rrl.ol vrtthrrlir sirrr rllrr)li l r,orl)ll it Il lt.ri, .L'rlr,(x) ltt,rl,o rlirrr t l i rz i r t , \ { r r r t t t ioko ( t t t t r l t v l t l i r l i rs<,r ' is l i - y( iz i Olp. 10).
l,rlzirntilo g(l lr (fl itl,oar'(i rlc irgrrozii u,LLrlil,ivc sint colticr,lc, cu loc:r,lizlu(rirr 1ror'{irrrrrrrl, lxrst,rrlioa,r'i l a plirnoi cilcurnvolutii tcmporale qi a cclci de:r rlorrr, r,ir\rlltrr\'olu1,ii lorr)poralc a cmisferei doninu,nto (Nielsen, 1962),rlcri rrrrii slrsl,in cai loziunilo gcncratoare de agnozii auditive sint bilateralo
-F i9, 31. Topografia lcziunilor care antreneaztrcgnoTi3 audi iv ; :
,.lI: pljcile de tr€c.r€ tcmporo-nrsulare ald circunvoluliel,). iemporale tnnsvcls. a luj Heschl (zoDa slJdtllii corricale
aldio-senzoriale) ;,,itI:zona urn.zi.i;,4?7I-zona suditeJlivcrbale (drpi ltsa/, 1052).
$.1. AGNOZIIL]I IMAGINILOR CORPORALE. TULBURARILEINMGINII (SCHEMED CORPORALE
Irrlr,sincil, sau schema corporal[ este o noliune foarte complexi,, carolrrzrrlii, rlin iltegrarea multlplelor mesaje senzitiYo-senzoriale $i carerurrrsl,ii in pel'ct:perca fi reprezentarea exacti', in fiecarc moment, a exis-Irrrr{,ci ,,eului') rrosl,m corporal in ansamblu qi pe segmente. Integrarealul,rrlo:: cxciLu,liilor senzitive supedicialet profunde $i Yisceraler a1e celorr izrrrlc, lrlbirinlico etc., permite in permanen!5 r,conqtiinla') eului nostrur,or'pollrl in ftnsamblu, precum ,si volumulr pozi-tia exacti, in spaliu $i(lr,r | | | ro r ror r [a diyerse]or segmente corporale.
f ,)\ isl,ir, urm5,toarele ti,puri de agnozii. ale im gi,nii (schemei, ) corporale :
l. Asornatognozia constr, intr-o nerecunoa$tere sau o ignoranli, din1r:r,r'l,r'ir, subitxrtului (in lipsa altor hllburdri psihice) a imaginii propriuluiHli, l t (x)t l) :
I I rntinsomutognozrla (sintlromul lui Alton qi Babinski) apare 1a bol-rrr,vii crr lrt:rrriplogie sting5,, manifestindu-se la nivelul acest'ui hemicorpIi rrr lrrlrrcl,clizoilz[ prin citeva si,nrytome card,aterfut;iae : a) Nerecunoaqterearrirr|r'rrrrrLir.ii, 1ro rlo o parte a tulburXrii morbido, a paraliziei (anozognoai'e )trrrrgirrrl l i i, r,r' i,e pirralizat I b) nerecunoafterea hemicorpului stilg sau allrll i H(lg)rl(!nl, rl hemicorpului (asomatognozie propriu-zisd, ) r' c) uneoliirslo vorlrl tlo o cornpletii indifcren!5 fa!5, de acest' hemico4r, pe care iligrrrrlr' i,, c[ li irrrl o ,,p:n'tc inuti]ir, a corpului)' (u"nozoLliaJorie ); d) alteorilrolrrrr,vii i6i r'(xill lro$(, rrotttlltelo, dal lo polcoll dota\sate dc cotp, sau defot-l r r r l , r r ( : l lurrgi l ,o s l ,u rna, i scrrr '1c) I o) i t t unolo cr tzt t r i o i perccJl r loLt t i , ht t tn icor-
l r r r r i s l , i r rg i ( i l r rz i r r , t t r r t t i i r , l l , t t t i lur t , t t t i r t t t l r tu sulxr t i r ) t ) , s i t t t l t t r t top t t t i ryt i l r in;xrrr l , r r r r r i t r r r r r r t r r I l t r r |o I 'o l t r ry i i t t to l l i l r r ( i l t r : t i i l ; i r t rs tz i r r lJ ; l ) r r r i r i t i t t ' i t r
!'t t;
, l ' , r l l r r : t l t - i r t . ' lot . l t l iz i r , t t ' : t r l r , r ' i r , l t r r l r r r l t r : t t i t t l t l t t l t ' i t s i i t t i t lo; t r l l i , l t l l i t t t t t -
l i r l ' r rorz i l , i \ 'o rr ; r l i ( ' r r , l r , | l r ' , ; [ t , t l | r r l r l ' l t r rvr i ,
l r rp; i l f tcr l l t i r ' l i l j ( l l ) l i l ) ) , l tgt tozir t l tcr t l t l t l r r r t r t ip lcgirr t lot t t1Ir t l I i i t l r r t t r ' i
, r 1" , i l r l i l i ' r ' i l ,o: l r ) l l t rozogttozi l t vot l r r t ' l i i ( t tcgrt t t r l t , vc l l r t r l i i , r r ' I tc I I t i1r I I ' I1 i l t ) ,,
' r ' , r l r r , lo lc; l ,o l ) r 'cz( l r l t i t lc I t l t I t t I r i t t I t i i i l i i l t t rs l t rz i t ' t r ( r l r r r r r i ; r r r ' i l i ) i l t 1rr t t l t - : r '
1, r r . | , , r r l l i '1 l t ) : t t t t tzogurtz i l t l r l i t r l t t [ ) r t t r i , r i ( l ( ! ( ( ) l r t l ]o l l lu l l ( ' t )1, t ' r t l r t i t t t
r r r r r r l l r l r i , p l i r r l r ' -o l , t t l l ru l t t r r l t l , r ' t r ! ic i 1rr , ( ' i i r l t l j t t t r t i l ,a, i . ( i l l , ( rot l ) r ) t i t l i r l t r r t i ll i l r .
| , i t i l r t l (1( ' t 'o lou:n, u. l , t t l t t r t t ius ontn.kt t t t to: i r : i s t t i t ' l ' l i , i l r ct t t is i t r t i t ' t l t t l r l t l r rr , r , r l i r r l ,ot l l l , r ' i r l ; t l , g i l t ts t t l I ) i l r i ( l r t l i t l io l ' io l ' , g i l t ts t l l i i l l l ) l l l , l r r i l l i i i r t i r l ) .l l , r , , r ror t t r r ; l , r )g l lozir t i lp l t t i r t lo ol . r icc i i rL st ld i t l l i loul l t l t t t t t r i I t t I t t t i I I I r ' I 1 t t ,r r ' 1,rr"r ' lc z i lu r l r r ; l i i ic1,ns ; i s t i . t rso! , i :1te $i ( lc r l l t o l t l l ) ( i l l l ' ( r gr i [ ( l ( l r r ( ' ( ] l l i r i , ' i r l
r , l , r l i u ol icrLl l r , tc. L l lcor i l lccst , s i l t (honl arc t t t rvol t r ! , in t t t l l i l t t t lg i i . i \ t r r rz,r 'r1" rrr lr(l l l l l l l lrtrtuiplcgic sc iri, i lntrl l 'c .trrrovtrtrl l l l lol l rrt 'v i i t l tt t r t l t t i l t t l l r t t l r t t t,1, , r r r i l r i l i l ' t to (sulror l ic ia l i i i1 i profundi , ) , t leci t l t l i t r l t t r t l t r t , t t t k i t t t 's l r rz i r ' : t ', , r , l , r r t i rnr r i r l intpol t l ln l , ' i i i , ,orglniztrol" s l r i l ( i t t l r r i t l t I I ; t t t t i t | . l ) t t l t r t ,
' r r r r r r r r io l i ( I l ru lcna,n, 1925, c i l , : l I de Klc inr l lcr ' , [1)??1 Nir : ls t r t t , l l l l i ' - l ) , t t rr , , ,1, ( i r ,zrui lo dc : lgt lozic : r , r juca uD rol imlor '1 i i l , IL1; ; i l t l l rz i t t t t r r i r t l i t r r t t r ' : t ,, ,,, rrlr i. l ,oo*Iizaro:r, lt lziunil in crrrisfcrl rh ca1ll i i , ( l l ;rr,-zisii
' , I I r i t I r r t I r ' ' )
t , r , l r r r t r0 ; i oxistc l !a ulror spcoi i i l iz i r r i d in orr t is f t l r i r , i l l ' ( r l l l ) l i i , i l l i t t l t ,gt l t l t r t,r,,,r ' I r lr l(tso vizuospzr,fiale.
: , ' , Sirrdronrul lu i Gcrs{martn ; i SeLi l t lcr se oir t i tc l , t r l ' iz t r r tz i i ; r t i t t t l t t t t i t , ' r t
' l ,r r ' lr o[{)rn{)ntc: ?,) O afqzie-dgtrozi€ toa]'t( l slt i l tr ia l i i ' , t I I ' t t t t t t t i i i t, ,, l ttt j ir.t, r , ' i , '1 : bolrravul nu poatc dis l , ln l ie, a l ' i t i i l t ' r i i ( l ( l t r r r r r r i t I i I r ' t i I r ' I r ' r l l i ' r '1"
, l , r , r r i r r i lot 'sr i , lc f icolo:r , lcr l i i t r i iobscrYrutol l t l l l i ( t t t t t t t t t t t r t i t r t t ocl t i t t t r l l t t , r t ,, l r r r l t i r t t f i ot1 ochi i deschis i ) t l t ) . l )c:or i . tnr ln t ' ( . ut tY)t t t l i i t l t r t t l ) l t t x l t t t t l t lr r r r r l r r r : r , lc sr i t l is t ingir partca drcipt i l a colPl l l t l i t l t r r l ' : r s l i t rgr i , t i i \ r t l t r \ r r r r i : r ) . ;, t l r , r l l t t l i .c ( l ipsir de est imarc a v i l , ]or i i c i l t o lor ' , i t t r por i l r i l i l r r l r r r t , r l r r r r , r r l : r l , r l rr r r r l r l rnr t [ t : oalcu] f i t lc a, rezolva o problol l t l i ' r l rLtxr t t t r r 1 i , , I tcI I Ict t I r l IL; ' I ti r . r l r r" , i r r serNul c[ boln*r 'u l ignorS, serrrni l iot i , { i l t lotr t t l r t i ot , t t l t l t l r lo l t l t "r,r rl lx'r 'rrf i i lo matomal;icc) ; d)- AgraJia, itar f i ir ir, 1 , t t I I I t t t ' i t ' t 'r r rr I i r I r I r I r . i t t I t t rr r r t , r ' ror ' . Aceast l agrai ie se prczintd, m2] i rnu11, t : l r o l l l r t l t ,x i t r ( 'otrrr l l l l l ' l rv i l
1 ' , r r l r r r i i tere Si cuvinte,l , r ' : : i t t , t t ,ea intcrcseazi l , p5r l , i lo an1;ol io: l , l 'o f i l ) i lz l I l { r l t ' l t t g i t t tst t l t t i t . t t ; t t r l
r r r , r , r ' : ' i r I1 l l i l l omis{erci st ingi , prcol l ln , ) i T,ol l i l l lo l , t t r t r r t r t l t l i t r i i I t l r ' l r i r l l r, , , r ' i l r i l r r , l (c i rnpur i le 39, 40 ls i l -9 l l rodt t t i t t t t t ) .
:1. [ l l totopoaqnozia so ca,raotor izo{r ,z i l , ] ) l i l I t l t rzt t l i t r r t f i t ' t t ' l t ' I t t I I I ior ' I t t I t t tr r r t r r .p0t l ; ou Corpir l s i tu f i pr in i r r tposibi l i t l t l , r l t t , t l t t t t r t , l ' i i ' l r r t I i t ' r ' t I I { . I r r t t r r l r rr { . , r r r ju ln) [ i osto g(] tnr ta l ; i r , ( io l ( iz iuni pal ' ic l i i r lo ( t l r l o l r i r r r r i I r i I ; t I r , t I r I r ' )
l . | ) is i rsorrrr to 1; nozi i l t t t 'c l t t tz in l , i r , i , t t l l r t l r i i l i c t t t t t l t l t ,x t , r i i v l r t i l r ' l r i l r t ,r ' , r r r : r , f i i Ixr , I ' l , ic tL l l r , r r i do sohirrr l i r , t ( i iL (x) t 'p l t l l l i i t r l t r rg ,s i l t , srrgt t t r r t t l t , l r t t l l : r l r ' ,r r r , . l ) l ' ivosl ,o lor t t ra, , l t t t rg i l tx l r t , , gI 'ot t l , l t l ;c i t , vol t t t t t t t l , l ls lxrc i , t l l .
l-r, | | el tt l t lsoopiit ( I t i t I r r r r i r t : r I i r t s;ttt vizittttt 'rt spctrtt lttr l ' t , | | | I | | | ' i I ' | | | | i . IrLrr r ' :u i r , r l ,of izol ,z i i , Pt ' i t r fctrorrrot t r t l t r t ' r r r i i lot ' : Utr i l t t l r i r t ' i , , i r t ( f i t ,?, , \ 'o l l r1 i r l ) r i l t l t t ll r t r r r i r [ l t , r r , l t t i o i t t r lg i t t r r l l r t i i t ts t r l i , l ) t t r l ) l ' i l t l $ i i ' t t , , r l t t l r l t t " . l r ) \ i f l t r l t l \l r l r . r ' r r , r ' r r l l r r l , r1oi . l l , l r i l i \norrol g l i , l i r r t i t r , ,Ntt i l , t l r r l ) t ' r t r i i t t l l t l r r ) ' t lo l \ l t t t t l t i , l , utl l r , , l lot ' l l !1 ' t l r r J\r l t t , t t1t i t , t l r t , t t l , . Vrt l , r t ' t t t l t , l r t l tugl lu l i r : i : l r rz i t t t t i l t : t t ' i t r l ' r t ot ' t I i I r i | , I t , I r tr r l t t r ;1 i .
)'t ' l
. . l i
. MelrrhrlJr, hurrontll :. t.\ ,l lrurltul .lurthnld ul tultutolil,r rr.pr.,.zirrr.r.l
l r ' . r t . t .pt l : t ik ' ( . i I l . l l . I 'L | | | I | \ . | | | I I r r r1r t r i r r , I l r , r r r r t r r l l r . r t l t r i 1x. , r l r , , i r r r I r r r l r i I . r r . r l l ,- \ l i ' r . l ,nt l r .s l r . I , ( : I r ' | , | ) I I i , r , i r , l i , r i0rrrr , r r r , . l r l , <.u rrr , , i , fo lOgia . i i r l i r r r . r rs i r r r r i l r ,i r lu,rr ' , i r . r lxr : r tc t r l )c l . ( : rT.r l t t ctr i .uI i r r t l mi ; r , iu, i suprrse voinlei ; i l r t . l r .se: l r .strrl ( ' f l r , l l r f f . f { f ln l r ' r ts; . l t ) l l [ rnLreb,foh- lomA lu ur i r r tputu! i s int i rxct ,pr iur l r | , .rn l , / . l |u . i t , t i : . l rk:yuI i lot , a lo } id ic iu i lor nervoase, gangt,eur. ct( . . , r :urL, r .l ) r ' r | | l i r I ( , t touiLl t r l r l r t l tbru, not an^l l ,cnr, in rnod jn- icrnt i terr l . p. , r r .ot i r rrrrrrri. rrrr.rrrlrlu lirntonli suprtiul sau fLrzionat membrailui Daralizat. .DIcm_rr*. I : r .1r)r ' i l r ,L (x is l i l ; i la buloar i i cu secl iune complel i iau l l t i Inziurro:r nr i r tuvr. l s l ) I | t i rn l , Tlrccum Fi in lcziuni ta lamice t pal , ic ta le ( i r . , ,p i , , .
, 7. ' l 'ulbrrrririft. paroristice ale somatognoziei reprezilLi fonne parli-
I . i I l . , - l , : ,
, | , . r rLr i r ' r r r . i , .p i lep1icr . , in cursul cdiora boLr:-rrvrr l r r i icglc , , iu i lar .a,rrrl.,r('sl{. fl,-r t4)scDto un henieorp, d, qi-a pierdulr rn membru siiu ull::'fl:t,..trt._,,.t. -1",'Tbru.
Alteod inceaici, jluzia ieplasirii corlnlni, tlctapi,rii: i l l l l i l l l : : ' , ,b1y.. l l ,L1zjr urrui , .mernbru fautomi. i . u , ,u, i , ' rcrrrbnr sirf la-l r r l l r l r : r . r ' , .au l l i r i , . { le o ha- lucinat ie hoauloicopic i . in fa(a rrnor aialo' ii']].'.,.1:,"_l .Fau tliie\te o haiucina,lie heautosco;iricir,, in tn1, .,rro" *irrolli
,l:l]:1i.ll.: srndrm lir o epiiepsie fosali, pariettld, (tumoraiii,, l/a,$crlarti,,sil r ra,{,ii rro gildimI r ' l i ,rrrrur,t ieii ctc.).
va,s crlilrli,,
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Dxist i l dourY grt tp i l iLnporta,ut t r t lo 1t t I I t t t t ' I i t i t l t ' t r t t l r t l r ' :l . ' l ' r r lbt t r i i , r i a lo cr t is iuni i q i : r , r t icrLl i , t i i cuvir t l t , l t t t ' ( l t l r ) I I I ( ! ( I l I | | I I t I | | | | | I
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l i i r i , r r I inni fos l , i i l i pnl ,o logioe {r i l , t 'o pol ' r t l i t tgrr I io s l , l l l ' l l t r l ' t ' t tv i I t I r ' Iot ,
; , r r r r l r r l l lut ' iu ' i fona,tor i i ] ) ro?I ' iu-z iso ( t lu rrut is i t t t ro ; i t l r t p l r r t t t t t t l r t t r , r t ,lorrr : r r rc lo l 5 i n s i labelor) , f io al t t ror t ia, , l i l , r r t t t l , r lo l l i l ' t t l f i r ' , t { l r ) r t f l t ' t or ' l t t l i t .f ' r ' r r l l r 1r) i l t io accstoa s0 toztr l 'v i l , t t t t t tur t lu l grr t tcnl l tV ' t l i * r t t l r i i , l t t l tu l t ' t t lr r ro l r r , i r r l , t '1" i , lo i t t ' to r t tu l tc tn lbrrr i i r i :
l . ' l ' r r I bt t r i r r i lc t lo t tn is iunt t s i ( l ( t l ) ronutt l i t r t t t t ( ) t l | | | | | | ' | | | t ( ' t t l ) l r r r lr r r r r r r r 1 r r r r r rkr gnrpo r lo l ) l t , r l i l i fs f i i I ' i ( r i l l i (x) :
l . l ) ix lu l . i t , r r r r rs l , l i i r r i r r rposi l r i l i l l , lc l r , r lo l r l r t t r t r r r t l l t i r , t r t t t r t i l r , ; t t r r , lnr , r r r , 'or ,LIr i t r r r , l , i i r lo i i t r t l r1, t r ( t lot t i i l lc , l i t ,b i t t ' lc , gt t l t t t l l t r i1. l t . ) . t \ t r t i t t l i r r t t lorr tl r l r r r l r lor t t l r r l t t r l is l l t , l i r r ;
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; r r r r r r r r r r ( r r , r 'c , t t i r , I ptot t tnr( i t , r r , l r , r l l l i r t ' l , t to i t l i l , ru i . i t t t t r l r , lot r l , 1, , H, z, r i , , i , ( )
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l r l r I l rn l l { , i l t ' { \ i l r l r l r r r l ' t r r r i r ,s i r , l t , t i t t t t r r l r l lo l n, z, t l , . j . Atx)r l , Ni i j l r l I l iHrt l ro i l l t tl l I r r r r lur r l r ' r , i r , tzr , r l i \ r l , r , lo ( l t t l r r t t r l i i i r t i t r t I r l i t , t r I l t , r ' , ' r r , r l i t r ( i lot , t i r , t t t t t l i r t t r r t t ,11l r I r r r ; r r r r , i ( i l r , t t r i r r i l i r t t , l r r t i l , t ! , j t l l l ! , l i r l l , l r lo; i r t r io) ry i r l r r c l t ' t tz t r l t r r r l t ' t t l , t t I r
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I t ) l ) is Iu l i i l t : k t iqh: st ' r la l ,or tsc r lc obicci r lu i r . r l t , l i rc lc I l , r I i i { { ) I r I i ( , ( Lrr l r ' l i r rzr ' lor ' (c l . l r r tz i t , ( lo io l ) tu c) .
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"rlrrl l r l ! r r : r1 i ix) l r r r l l l r r ;o s i bulbo-pcnt iue; f ) Palal iz i i a lc rmrlc l i i lor fo l r l tot i;rrrrr l,.,. ir lr,r ct t 'r i lrt lr, l i l a loli; iunii inferioare a celor doli, ci lcunr-olui, j iI rorr l rL l , . . r r | r r r r lonl ;c (opercul i i ro l : lndic i ) ; g) Leziuni a le fasci . ekr | g, , r i i -r r l i r l , l ( i | | ( | r ' r ) iL lnrr p set t loblLbare),
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, , , ' ; , ' r l r t i t t t l l l .
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t t r l l , t r t r r t i l t ot i i t t 2si , l t i r ' , l t r l t t l r t l r c i r t r t t l t r t i t t r r is l : r ' i i r r r i i f i r r t t t ' i \ l r t t i . ' : l r l t t r t t t t
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r l , ' r iL l r t t i r ' , gco;.1t ' : r l i l r ' l r ' . , r i r l i r r l r to l i ' l i r t ' l r t t r i l l l t I I I I I i I I I | | | I t I i l t i I I ( ' | ' I | | I I I I l r
| | r i | , I i ! i I | | { i | | ' l r t t i t r l r ' l | t l t t r t l i '
: I t /
. l l . l , l t r : i r r , l rorol i r corrsr : j i r i r r l r rs i r r iJ i t l r tc l r lu t , - rp l i rnar,c vor.bi l , r i i , ,,4,r ' r r l l s l l l l s t , r . is i i . l . io l r r : tv i i i l l r4eg cr.el_ce l i se spune, jar nu pt i t , cvocal::illl, lll ,:,'l:l ll'ill,'rL1r'rr crpriinlre, cu al1,c cuvinti ci s'" oru, in ii"posiiriii_] . , '1. 1t : .1] . . : ) , : , - , r l l .
ru rnl . r , i , i i fon;r tur i . rn i . .nar i le corenpLUzrj loald fcni lu:r . s( , , . \ l ' tUnir t r r \ 'utbr l ' ' O.r l i i . . inrr r . r r r r ru; , .L i i mi in i i , pentrU a Sc Cipr imlrrr vor lriro scrisi. Afazia, rnotolie cuprinde 2 forme- principale: i,faziarrrol,olur prlrpriu-zis?i, (alemia) qi agrafia.
.1.. Ll.,fcntkt {.a;fazia motorie propriu,_zisii, (mu,tria lui ptene Marie )lrrrrsl,ii,. il imposibiiitatea dc exlximare oralii. Este produsi, ae feriri"i af,"..r)11111'_i. ,,irnaginilor.t) yorbir.if:lrtioul:lte, localizat' in piciorul trontateir , t . t ,
, i ; r . . r I i r r . t i l r { l r .nnl ru I lu i Bluca;. r ,u roI in eLaborared- m isci l i lor mus_{ r , ' r ' l , ) r r i r l , r f t rn l l rnpul !orbir i i : r . r t iculr ln. Spr" dcosebire de muLism,i rrll ul irro(lurnrle colo lutr inasi\.e, boltayiiflot pronunla ci.te,un cuvint,'rr
o,\i1.,l)ii (ta-ta,_ti-ti, rnil-ma, da,._nu etc.). 6i fa; efo"iui, urrror_,e p"'trur r r r r l r . i . : r r rL.dr 'zola{ i ; i i 'a .c ih i l i r l io- r .anza nerou. i tc i Lentt l ivc i - lur de.r r i , ) l r ' r . lo lu-rocl tdoiol g l .s lU. l i la |g i . ln lULmele mai Ufuaro, boi t raVi ipo0r ' \ l r l l l r l ;b
' ' l lor : l . 'U\rUlp
"aU I IAZe Sr-Ut1o. \dcset Ci SpUt: . ,s l iU, daf 'nU
ll:il.^. ,ll:l.9iflii1 rlroruntii, substa,ntivele. Alreori t"t"'avii uiiiizui"x p""il], i:']il::-I. tjl loc d_e ,,qutri" sptn :.,,[sta este cn care se taie',). Deieorir" , l l r i r \ .ut r { r nasl rcrz i nr i l r r i , .a.crpros. i \ . i r , indic ind pr in moi l i i ic , r i a le fc le iuLr.r plin gesluri, ooea ce estc incapabil si, cxprim6 prin grai. Exprimarcar u loirrrlrri (lurniratul, denllrir.ea zilelor tlii si,pfdmin? sau a lunilorrrrrrrlui, cintatul, recitarea ulei poezii etc.) este inai line conseryata.. , . i r r r f : rz i : r
^rnotor. ie }Julorn int i ln i urmi iorrele grupc dc tu lbur. i r i( \ r i r . t , ' ; l | r I l rn. (Jmtlredaoe l i J)urrnd, j939; l lo la l - l i Lhct , rn j e. .1963).;t) il'tr,lburdri artrice. Dez,integrarea foneticd,. fntensitatea tulburiirilor{t(l (,\l)i ll1il,rc..(:inartlia, duprii, unii autori) este variabili,, de ta sr"Lpresiunea
:l,l.,,flli:.].1:1ll.l,i p0sibiLif ititor de,crprirnare, pinilla tulilurii,ri -tA;;;1;;r . \ l4r , l |o l1 iJ ( in( , la osle nocc_' l , t , i r t t i l iz l rcr dc lcste spenialn. Din 'pr tnofr.lr v1'11911- lorLcticr
'orbi.ea estc net tletorrnnti. r-i"earizarea va-torilo'
',1 :1.]' l:: ' l l l l cirrc\e, rompLrre limba,jul necesiti, o
"oor,loo^l" Ierfectii, a, ll lrrUl lr.Llre[[, a tensirmii corzilor vocale, gi a ,,forrnuleloi, rnotoriilrrrr'. r'r' l r-li lringiene' caro sint proprii, adec.iiatle tietli irl i i-ton"m. s,presi-rir (,, si/ riiL. deteriorarea foncmeloi crpr.inrl: elizi.ni, asimiliiri (ex.';;i il ] ,11" ' j
, l l l , ' r i i . Fnni i i rur i - . pr i , { rc l rn luc, lc, .eslc l ctc.) . orrbrr i r i i i l i 11,c i .i i l l l ' l l l : " l ' l l " ' l '11 ' i '9t , t , mel:1rozo (bel . r i lou iu iuc dc [ r ibelour. npc| | inzo( |) || , r, rr r I I r.ir i rL lu( de tliblioteci,). Se mai prodrlc unelo modific5,ri f6netice,r rr : rr lr zir,lizl,r.cil unor vocale dcschise,_ diiiongarea unor r,-ocale, asurziredr'r'|)r' {'r)rso:rlre sonorc' o red,clie g10bal[ a varia.fii lor mel0dice aie vorbirii,r r r,,Lt:r,lizir,r.. a, accL'ntului tonic asupra fieci'ei silabe enuntate etc., merEitldlirrii lrr rlislorsiuni fonetice complexe. A):i,joualirre qi .,;trlr. i ig3g,
-i?.6tirrrr r.rrrril, i.i[l ic aceste tulburi,ri an:rtrice qi foneiice *.,b in";;;;i d;. . ; r r r r l r r ' r r r r l , ' , r lozinlcgr l re font . l ic i . ' . _!nsi" l i r id 1i arupra apra. : ie i buco_r:rr ' r i | l r . , i t r l r r t , r r rnt lJZtrcf l ar .oSt0t , I td l lut , - r i a ie eSpreSiei o i .a le.
..lr) lrr .urlrul turb,rEr or de articrrare are afaziciror motori se situeaziitt i i.\ltt(.': (4l.iitc (Alajouanine ;i colab., 1939, 1964; Iloriad_Krohn, tS+Z :I i, )r r,z, | :r(iz). Ao(,rtrt,l touic,. ritmul, tonalitatea,, timbrul si intensitated,r , r ' : r l iz , . r rzrr . r r r | ' lor l i : r , .s i ru. l , rozo( l in rorbir i i . I ) . jn pro.oai , oe ; t , teteE var iat i iLc1r ' | l l | r . ] r i i i t t { . r t t t . l i , l ( lDto l , r t lAlr- t . : j do r i tm, cai ,o cOnfOri j t .Orbir i i t l iVCrSe
].1.,.,:1ll!,..../.1'f',,*t1, I)r1,2(,rlrc oslo grosolan altoratir, irL afaziilc motorii, inciti l l . rs ' ' r . ' , ' . 1r , ( ( r , l r l l , ( i ls( , , . .u l ,u l lx l l t r tvr t l r r i , fo in, t . at lesoi t , vor l l i r t i ; l f i inr l ' tynis i ,( ' t I l t i I r i ( . | { , ] , r I I I I I lL( ' ( '0 | 1, ( l ( ' l i r r r brL s l lL i r r i i .
:.| t
r ' . ) f l t t ,pr t : i i t t t t t r t . l int l t t j t t l r t t . t \ l r t t t l i I i r t . . I | \ | | | I ) | | r ' I | | r I r I lo:r r r r : r , i i t r l ror 'i i r l t l 'L l r , un(, f l r , l i t ,z i r r i r rorul j r i r r l l o l r r r l r l r { , ic l r , r t r l r r rx i r r i o l r r , lc . l r l r l r l r l r i l r ,r c l l r i l l l i 1xtn, lc l i i - - r l r rp i i , c l ln j t , ln l l r r r i r r l , i l , - 1,ul i r , l supl i t r r i r , l , i , s l r , r r l r , r l r r t ii i l ( itcva lottc,rno: stolcol,il l i i lo r.'ct lti l lc. So inlrelcgc ptin stttrol,iltirt n'rlnlto t e ductie a limbajului I'olbit, l ir, o e-rpresie s1,oreo1,ipir crr slrr ir'1,r'i i sr,,rrrrr il irltic lingl'istici, ca un fel dc .Loit-motir., pe caro Jacksor) il colIrIrIr,r'Ir, r'rrtttL teflen de org5. Aceasti, expresie stereotipX poato fi corrsl,il,rril,i i, rlirrlrrrorne, tlin cuvinte sat dintr,un fragment de frazir. Io }itr(llrrsul r.orlrllri l iri i, afazicul i$i poate recuper& unele formule &utomalrizitt,(), r,rr,r.rr pol,rlot'eni, in mod pasager, noi sterootipil. Se intilnerytc lroovenl; irr lrrrrrlr,lornncle intra.er.ebrale (temporale; Arseni, 1980).
d\ Agramutismul se manifestl prin imposibilitatea rlo I rrli l izrr lrrr'rrttrile (modurile de a$ezaTe a cuyinbclo{ in Im,zi,), cuyinl,cl0 rlri logiil,rrll i,rr rotilurile qi formele grama,tic e ale verbelor. In cltlrnl lt,gnt,rnir(i,rnllu!irll i i lnim sirnltomnl denumit ,,stihr,[ neorilor", carc consl ir i l rrli l izrr,rr,rrlirtlrnlui la ilfinitiv, procurn qi simptom[l ,rstilul teLqr&Jid ), r,it,rc r.orrslriirr omisiunea ile cuvinte (in special de legi,turii) rlin frazir,.
c) ParaJo;iilr, j arou n a;f a,zi,ik:, tl isinteniile. Oa ;i in a{a,zirr, sorrzolil l:i,rll i it i lziir nrotorie sc pol, intihrj celcmai lariate tipuri tle pm.tlitti i ,,ti;jtnlrtttrr/,r:i;. lsupra, r.irola nu mai insistiim. La acestea so Ldlrrgii rrrrrli lrr rlorint.;xit, (d,isinlari.i le ), care constau in aceea c5, irnbiutr,r't.: r, :rr':r,rr.|rrr, rrl l lzelDr comportir, confuzii. Disintaniile, numito qi lrt i l,-l{l i l rrll,isr rr lr rl.,rlslarnatisme impresive') se diferenliazi, de aglam;ltisrno l)r'ir l,(,(\.r, r'r,rlrrc tleosebire de agramatismul adevdrat sau exprcsil ', irr r,lrrrr cslr, r'rrllrrrl(r riti l. izarea unui limbaj simplificat, in disintaxii cslo volllr rlrr o ;rir,r'rlr,r'r'rr r-i:tlorii elenentelor gramaticii si ale sintaxei, cr,l 'o rlrrlr, lrr, rrli l izrrlr,;r, l,,r'rrfoorentii, la conluzii in orrlonan_ta cuvintelor'.
l) $i in afazia motorie se intilnesc p erseue t'i i.r i l.( fi inlt).1 itulii lt ' lttttt 'u 11) |1, ,
g) Unii descriu in afazia motorie o anosognozia u. ult:.ir.trlrri, r'tltrtinst*, in aceea cd,, cle multe ori, ca,racterul patologic al l)r'rr(l (,ti iIrr r r,r' lIr,lr'lrtl este perceput de bolnavi, car€ so comporti, ca qi cLrrrr :r| vorlri rro|rrrrl.Accgti afazici anosognozici sint intr-o staro do oxcilrr,!io p),ilro rrrolorrr,,iin cruberanlX, qi logoree.
Pentru enamenul a.faziei, m<tlorii se ulil izc:lzir, o lrr,r'gii grr,rrrii ,l, t,i iLi:1r) Teste care apreciazi i b i lanlu1 posibi l i t i i f i lor l r l i r , r r l i lkr l i i : i r r l i i r r r r , r r , r l r ra se expr im& l iber asupra diverselor subieoi ,o; sol i | i i r r , r 'orr , , ; , r .1, ; ' r , I r , l r r ,li)l}eme, cuvinte qi fraze din lis1,e intocrnite de nr-ri irr lfl, l i 'I, in( rl, lr,lupr indd, cele mai diverse var iet [ , ! i q i ansarnblul i < lc l i rnrrrrrrr , i l r r r , rv i r r lof i de f raze. b) Teste care apreciazS, , ,va,1or i le" solr i r , r r l i r . r r ; i g l i r r r r i r l r l r r l r ' ., \s t fa ' l , se vor studia s istemat ic : - l )osibi l i l i , t i lcalcov{x ' i t l r ) r r l r r f r r r i r r l r r lor ' ;
: l tomal i iLe Yalor i lor fonenr i , e eipr i rnr l , r ( r lc fo}rrrr i I i : r lo I | lv i r r l r , lor ' ,i t i l t rcuir i dc cuvinte) ; - natura l ingvis l i . l i l i l cnviulolrr r crr I r I r r l l I I I r r i r , l1rl)sl'nte (substantive, a,rller'be, olvinl,c rlc lcgii,1,rrlri,) ; r r | , I r r i r , r ' r . r r, rlrri r l i tmal ie : l l imb: l jLr lu i oxpl inr i r t l - s l l lJ fosi l . l r r i lo sarr l lo l i lo i r r r l l r r . l , r r l r r ,.*rrrrrfiicnl ii, rL I razolol,.
lnc: i r , . l l r i l l : r lg0r '1 i , l i r r l is()rr (c i l r r { , i r lo ' l ' issot , l1) i ; ( i ) r r r r 1r |o l r r r r i r . i r l i r r r -l l t , j t t l sr i I ic s i t t t l i l r , l i r r I t t t rc( , i l r l r r corr l r r r { , r r l s i l r r i r r I r r lor , ( , r r l r I ry i l r , l i r r , l i l , r r l l l r , ll i t r | i1^ i t r t r r r r l f t r t , r , r r l r r r r l0 l l r r r l i r r r r , l i l l : r : r i r . i so rr l i l iz ; r ' l tz i i i r r s lur l i r r l r icrrr i r r l , 'r l ic : - l i t r r l r r r , j r t l r i l l l \1 l t t l r r r r lorr l r { iz t r l ( , ,g i r l : r I i t r r r i " ) ; l i r l r r r t r | r r | r r t l ll r t t l i i , ' { r , , r lo l r r tct t l i r ' , r l r r l r t r , , : rcr . r '1r i I r r r ' , r , r r l l tz I l i l r r l r ; r . i r r l r r r l i r , l i l lporr l r r . r ri l l ' l r l ) i r l '1. r ' t t i l t t l r ic l i r , lxrr ' lo lut l r \ ( l r r r r r i l i r . , l r r r r l i ' l iurrr ' . r . i r l i r l i r l r , r '1r . , ) , r ' r r , r , ,
: l l i l ,
l r r r : r l r , r l r r r r i u l r i o l r l t t ( ' l i l rct l . l t l r . i l l r l r ,Lr , t r , r r lu\ i l l lc l r l t i i r l l l o lg i l l r r , r r l ( ' i r1r ' : rz l i I l i r r r l r l r , j r r l l r r i r r p l r r lxr , ,<olr I I I r I r . ' ' ( r ! i l l i t i l ( ' l r [c{ , l i \ r ' .
' f \ l r l r . r r r r r ; l ,orr , *r loJ t . r r tut inr t l t ) i t t : \ 'orbi lc: t Hp()nt in l i i s i r l - i r i , i l r , l r r 'r orr lo|rrr i |s lc l0t ( lo rni t i s l ls , ( l i l l col l \ ( r 's l l , , l . i l l , ( r r lonl i ! ; I )s ul i l j | i , r i
o l r i l r l r ' lo l s l , rL rr , int lg iu ikr t ' l l lezcul i t to l l rwr iurrLt t lu i ; L loscr ic le;-u t lo t l i l t llrolrr:r,r i lr, rn{ri $(iori) lLriLlc siuLl l igut inl,o })o u}r tabl{)lr I .- l?or-esti lt i t, r lr,.rrl l l lrrr: icrrl, N rrl{ j i isiolioar'o (are i-a iost e-\}rrsi i - C'onstrutca tlt i .r 'rtzrrr. (loli i , l |oi sjt,rr rl l :r i lmrlte c[\. inte inpuse ; - Solicit ir l i t lc lcperrl l e ri,,r r r ( .1( fJ ( i l r \ i r r1,c ; i 1r 'azc.
'!. i lgru.l irr (x)rsti l , lr io o a,11;. forDri. t1e afazie r-notorie, caic eor;siir i lIr lrrrrlrrlr.r, lrosibil i t ir.t, i lol unui indiyid dtl : l se cxprima c[ rjutoml sti ' isu]ri.I, lrr, rc rlrrlurc\tc ur)ol loziuni la nivehil centrului ,, imaginiior" graiirt l l{ 'r orlri l i i , lolrrl izat, i ir piciorul circumvoluliei fuontale, a doutl din cnisfcr':r,r l | l ] i t .
,\glll ir csle trra,i greu de :lprcci:lt la bolnalii afazici, dcoarece ii{aziilrrlrr rllclrt,lci sc irrso{:esc 1i de htlmillegii dlcpte. In aceste cazuri, se l'ecul'sili l i l lr prrlrc speailllc de exarni ale a, scrisului, prin folosirea de litele con{trri ir r rrr I c s i plin solicitarea bolna.r.ului dc a, sclie cu rlina stingii. Se poill o,orrsi:rirr cli, bolnar.ii tru pot sct'ic nici spont:r,r:l, nici dicta1,, nici copilll.l,r (,(' i r.lnr'(! jzlrrrteso totuqi sir scrie, se consiali, ?oralJrafie, jMgonajrlzie li.l)t r!:rt\.t'&re (fonrirircno ascm[niitoare cu cclo descrise anterior).
I'toltel.c ttti l izttte in so'tsttl sponlan, tltctat pi aopiat sint foarte variairrrii .onsl,ltr irr : - Scrici'ea de lilcre, cuvinte fi propozilii (eventriir,l, irrlrr.zrrli lc ll lrrver in consNruirea de cuvinte tlin litere con{ectionatq s,rlru lisrr po (ii lr ' loarrrc), - Denumirea prin seris a unor obieci,e care s€ pr'clrrrli i lrolrrrir.rrlui. - Solioitarea de a rd,spunde in scris Ia intrebi,ri puso,rlrr r rlcsnio in sclis anumite scene, de a povosti (in seris) scurte istol'iat:ir(',rl0 lr rurrrrll lct:r, ou anumite cuyilte o serie de ftaze scrise, in care lipJos{:rrrrrlrriic crrvinto. Se apreciaz[ astfel defectele de evocare scrisi ale c .i11
ir,lor' (\ri ur:r,rlrrle rlcslJora)) deformarea, cuvintelorr tulburirile ortogfifi( orIlrrrrrlrIir,lrIrr si dr sin trl,-.i:i, etc., despre care anr amintit.
l',. tl.lt:iu ntirtd, (totalii satl tle tip Broca, ) constd in a,socielea r:eliti l l | r : r l i r | r ) r ' r , l i r r i t 'c dcscr isc: Scr izor ia l [ [ i motol ie. In contextu] c l in i r : lxr l; r l r , r Iorrr i r r : r , r i r r r l r lonrcle celei senzbr ia le, s:m ale celei motol i i .
l l. tl l lt.lo) ta il iniae de aJuzie. S-zru ]rlai desclis o sei:ie de :fulrrrt rlr,: r l r r ,T i r r , r r r r i r r r r r l l s tLrr luaj pr l i in binc in r . l i r - i t ' lu al izai e , , \ i acccpiNte ca elr t i i l i l ir l r r l i r r l i r :
l" l l t: i tr t,nncsticii (t1tlsr:r: is:i inil jnl de Pitres qi de Wilsol): ronf t i ir r r r r r r I rorrr I r i I i I l I t r r t t lc a prrrr iun!r , , ( lc a eloca anumitc onl inte, mi l i i l l { ' lr r r r I r rLrrr I r r r ' I r ' , l ro l r r ryrLl i r . t i tur$ul I orbir i i d isrursi lc l r t i l iz in i l 'nul t , ' , i l{ | | r | | i ) | r t i I r I r i s i 1rc: i f r lze (cu inr l icalca ut i l i t i i l r i i obiectelor) f i Er ' , r iur ' lr ' ' . 1 r I i , : r I r r r ' . l l fr lo rin f(d r' lc i,nll l t l lro clt l.t i l i , a alenllnri l ' i i) cu rncrrfirrcrr.rr,r r l r r I I l l r r I i i , r r l r .pcl i , r ' i i 1 i r r , in1;c lcgcl i i \ 'o l l ) i l i i . [ I l l11i ( l i r ] t ro : r ,cel i i bclrr \ i, l r r r r i r r r I r l l r r i r r , r lc orr tutr t r i r i is i , r ' i r1r i s lur l r i l l l ( r i . lJ( i ovi t lcrr l i r tzI la, I :o l r r '1, 'r r r , r c l l ro vot l l r l r t r t lc t lcrr t t t r r i t r r a, o l t i r r t r lot . l lvo<, lut l t , r ' tn, in i t t ln i r i r , t i r r r ,r r r r r r r , l ro l i l r i l i i , r l ru ' i , i r , r l r r r r r t r l c l lc l r , j t r l l r , l , r l r c\r i l i r i l l ,or ' . l ) r ' r ) l r r r ) l i l r lL l ix l
l r l i r r r r r i l l t l r i i , r t r r r r v i r I i r r I r t i , r l rLr r l r t r ' i i i r . r t r I r lorr_rrrr I iL o srr i l l i r l t r l i i i i r r i r ' ,pt t r r l t r r r . : t t r t r r . r ' ,11;rr ' ; lo r i i r ' t t r , i t r i t t l t r rs l r r . r r l i i . I t t t t t r r . l r ' lot t t t t t l r r r ' r ,ztr ', r r , r t r l l i i , : r ( r r t r r r , r i r tct l r r r l i i r l t t1tr i r t t r i i r t t lo l i ) l ro l r : t t r l ru l r , r r l r ' , t . r L lr r r r r r r i r r l , r r ' l , l j r ' , i r r . r l r . l i r r l l lc o, ' l t r , r i , r l , ' , r l r i l r '1r ' l r l : r r , r f r r r l ) . r r r r l , , i l r l r t
: , l l r )
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r ' , , l : i r , r l r | r r i t r r l l r . t r r r l , ' r ' : t r l i t , l1)r{)) i l i t i l r r i l l l ' grrr t t { ' { } t t ( t I t , t i i I r I I i r I t t t I t , t t I t | r ' :
' r ' r r l i l t t r t | l t i t r t l r , L i i l r r l l r r l t t : t i l t r r r t | r r t t I t I t t i i I t I l l l l t l i : l l l . i | r ' l l \ : l r l L l
, , 1 t , , i l r . { r ru, i l r . { ; . : r .t ' J , ,1f i i i r l r r r , r ' l i I t t l l t t i i t l t ' l t l l tz i t r l r r r t t t i 's l i r r i i ' ( ls l { r l l ( ' t f ( f i r i t t t ' i t t r r t t t t l " l r1 ' lo l
, , ' r r l ,orr l I v,r t l r i i t t l i r t t l r l t , s l r i i t t i l )o ( '? l lo l t ' i l l \ i i , l l l o. i - jo ( ' l ( r ( f l lz l l : l r i l l r ' l
, i ! . r t t t r l i r t l r t t t l rz i i ( t l r l t l t t t l i l v i r t l l ; i t lor t t t r t t i r ' t l i t r t , t rcs] t r i l i t t t t t r ' r l r r : t l r tzt ' )
, L ' , i i r l | r i l t , t ' l r l ts i i i lu lLt t t t l t , t t r 1. , i l t t r t lo i r l iot ' i l , t r r l r l { ' l r l , { i i l ( r l r l i r r l | r r r r '1"
L , r r l I l r r r r i r , r i0rr t l l t , l iz : l r r r ,s i i r r s l l t l ( i l l l t l t l I i l r l l l l t l l t l t i l l ls l l l l lnr t r ! l l l r l r l r rL l
t , , , r r 1r t i t t i r t l i t r l t l r l t l i lc t r s is l t r t rL t l t l s t l t t t l t : t , l iz lurrr l ' i i , t ' i i t t t t t r r r l t r r ' t t r t : r l
, , , , , r ' r . , rp l i l i i l r , o l t iut t t t l t t i t t t t t tvort i i i t r iagi t ic : t ' l t t i s i t t t l ro l ic i i , rcr l r : r l : r
, r r r r ' r i l r i i ,1r 'o iut i i , c l i l tc t l l ts i i ' :L l i tz io lu l l l lo; i l i ( ' i ) (1 l l l l ( t i r ' l l l l l i r r i r r l l )
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, r r r , i t l t l i t tn i l ta l ic to- tempolo occi l ) i l ' i ! l ( l d i t t i ' i t t is lct l t ( I ( | | | I | | | | I | | | I I
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, , , , .1: i t rq l l t r l {0 l i r t tn l l ] : i t iorr : i ]eA,1), (1 l1IO 1l , I (1( i1. i t r r , I r t l t r , t i l r , , I t I t t t t i I t ; t i t r r r
l , r r f r r t r r , i1,roi l t tz iune t l i i acclst i votbi le s i t t ' r t t r i i ' , i I t I t r | l t t ; I I I i , l r l t r r : r r l "
. r l r j r l { , r ,r t1'oini l i r iz:r, te r l i l r i i conl imll , cL1 i ' ( t i l , i r ' i , I r I t t I t t t I r I t t ! I t rr l r :r ' rr ' rr l i l
. , r i r , . l f r t t tc l , i r t , uuDin:r , t iYr i ( , ' reprezorr t r , i , iv i r ) ) ) r t t 'ot b i t i i , ( l ( r l r r r r r r : r l r r
' r , , i LLrI i r r , (1111i6, ( i i1,at , do [ ] ] ro lmi1, t ,o $i l ] i i r ( ) l l r ls l r { i , l lJ / { ; ) , ( . r r l l r l
i , r l i i r ' i r I i ( ) t i i " l , r 'Lt i cu] ' i l l i , i l ) t i l - l l l , t u In i t , obi t ) ( i I ; i l t0t t l t t l r t rJ l ( f l t l t 'z | . t ! | l l I r ' i r ' ,, r 1, L ' r ' i r , j l l Lru '" ' intele eol csl l lmzir , to rc. L l totr t t i i , l r r f i l ) ( ! r ' ' ) r r ' r r r r i l l l l ' { ; )
r : 1 t i i t 'Lr lL inr [ r ' i lc r le l jm]ai d in:r ' j i t 'z i l t ' l r ' t r t t t r rz i r r i ' r r l l nt l r { r ' . r ' t l i r l .
, , '1, ' l i r iotr l r i inLclc l t tual i i , n is i c i t o t ,Lt lbt t r l i , t r l , )gr l l ) ( ' l1r l r i " : r r r r r ' r r r ' r r r r '
, , i t t lb l t i i l rc a , r1111.[1i [ r i lor v iznaic" ( , , i tp l t t r r t t { is l r t r i l r \ I l r r l l r r ] '
, , i , r l r r i l l cu un dol io i l i a,L m0lrLt l f io i \ 'o l i ) t lo. / \ l l l t i i l r : t t t t t t lz tct t t t r l ' l t : '
, lL l r r t ' s t t t isul t t i uni t i i i / i lor l iu* l is l i t r t l , (1 i i r ' { ! r ' r 'zr l l l i i r l r t r l r ' ' r . . t r '1 i t ' '. r , lo | j l0r 's.r lnalr t ioogi( l int t ' ,o i {1,orgoto i t 11I I I11I |111 Irrr t r r r I i |o | l | | r , r r , , i r l i ,
' i , r ' " ( l , l r { rn i i , t r : q i l )6rouesni ' L9i t l ) . I ) r l l t i i : r ( ' r ' i r i r l r r r l r t t r ' l ( ' r r r r r r l r, l r ' r r r l ) t ) la lc st ' i l lg i l rnt lcneazi i o t l is i r r t rc l i r r t r r t t l i l r r l r i , r : r r ' ' \ r r l r r r"r
. ' | | ) r r r l j r t ctLl ia, l u} lnt lc Dxlezice l lo c i rv i l l i ( : l r ) r ' . i ) : r t : t l , r ' : r r l : r : t l r t ; t '
l r , r c i l l r r lupir , | ,1! i : lu i ,or i - - a l i ) l l l $ l i l l ( i i l ' s(r ' l r ( ' l i r r ' : i ; r r l r r | ' r r r l ' r ' r r
, , ' l , 1ro t . r tkr t . lo rcgresi turc ( l l icrrc - i \L l r io I l l r i r I l i t l i t t r l l l r i , r r l ' r : r ' l t, | , rL i l t t l l l l ; i i , :u r ;p lezet lL i \ t t l i l t ' ln i , t l t r l t l r tz i t r t t t r r iot i r r . r r r t t t r l r ' : r l r t r " t l
i , l . 1, ' r l r r r r l r i , r l l t Or ig jnt , i ,c tn l tOl lu l i , , l t r i t t I t rz i t t t t t r i t t l ror l t r t r r l r t I ' r r r '1r ' r ro; r . l
, , , r : r l r . i l r , l t e l r .
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' l tot t t l t l l t t i ( l t r t 's l , t n l l t t t t ( t i t r l r rz i r l t t r r l t l t t tc l r t l ' t ' t r t l t ' r t . o( t l l )L l r r lL, . , t r , r rsr t i r i l t ,z i , r l r l t l t : t t l i t , l t ,u l r t l i t ' , t tq l t t tz i t r r l i r l i i l r l : i ; r l t t l l ' r r ' r r r r l i
t r ' , , r 'potr l i i ( t I i I i r r I r I t , r i ( i t l r r i t i t r t t l , i l i l r t tc t l i r ' : t1r1rr , i l I r t t l r r l
l / / / r / i . t i ' i r lc o f r t t t r t i i , l ) i r l l i ( ' l l l l l l i i r l r , r t l r tz l r ' . r ' l l l l t , ( l r ' l i ' i l l i r l r l r r r, . r r , ,o l r t , l l r l r , l i l t t i l r t r l i t r i l , r r ' l r l r lz i ( f r r l r r . l lc l : r l r l . r r l r l r ) : r , l r r ' l { r ( l i r l r r i ' r r r r
t r , r r r t r l . t r t t t t ; r i t t t tqtr t t l l l l : l ' i r l l l l l l l l t r t r t l r i 1 r t t 1. i t t r r r l r I i r r r : r l r l r ' : t t r t t t r I, i IL r , ' ( ' l r (L i t l i t t t r r ' i | l r ' t t t r , t . ; r ' l t l ( ' l l r , r t l l : t i t r l i l i l l l l l i I11 | | I I I \ I | | I I i I | ', r l r r r l r l r t j i i r r , r i r r l iS), i : r r ' , l r r l l r r l l t t t i i t to l r ' lot ' t t r t tz i r ' ; t l r ' : r r ' l l lor . r1t . ' l
' , , I r l , : r p l r l i i ' t l r l r r ' . \ t r t l l t i : r I r ' , ' I I | | r ) | I . ( I i t l t t t t i l t ) t l t11 r / r t r t r ' , r r t ' r t t
' l , r t t t , r : , , t t | t i t r l , r . l : r t r r r r l t r l t : t t t i t l t l t ) t t t t / ; ) / r r r , . i I | I I t | | I : | | i I | r r r1r , I
, r | , , r r | , r | r i r r1r ' : t r l | i r r r ' ( ' I I I l ( | | | . I I r ( ' i l r ' l | t l r l l l?. I ( l r l : r l t t t r , r l l r ) r r r r l , l ' . Lr
1 l r r r l l l r , l l r l r l r l r r . l r l r <1, : l l r ' , l r l ro: l , l r ' l r t r r l r : r ; t r l r l l t i r l t l t t t . ' r ' : r l t ,| , t t . t . t ' t , ' t r , I | | | I ) ,
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l i t , .n ' i rcsp|cr i I r . . Cornpr, . t rcni iu; ;Y;r r , r l r i l r . , . , i : t r qcl iqul o l lc norm2l. C6pi , . i ,e j" i l r i l i . I ' r r l1c o,cc, , le nrr lctcrc a.* i i c , i r l i f i,,,,rii, 1,,,,r"liii,-j;;;;#;i;j; i',,;i,;,X. t'X;yllrf?"*i,,1.":1,X.:, :l',l,ll:plns este qi eridcu.l,li,ll;:i;,,*",::l; *"i'",iuo ""1,'* u,.iil;f; i;ffir|,:'!"T;""|i;'""i:');crr lo l i lor (vczi f i r tntpr ior) .
l r , , l r r r r i r r l r ' ( | l i r t ptor, , r ro or ' l t tz i to i r l r l r . t , r i i l r t ' l , r . t i r r l t l r tozi i , , i t r l r t i l t i l r , l , ', , r lL l r1r , , , r r , t I t r t l rL i r . r ' , I i l i r rc, r r l r ' . , r r l ru pt i t r r , t r r l r r l i i i t r ru l i r r . l , i r r t r i l r r c i r l r l r r r , . , 1.t l l , l , r ' r r , r r ro l isrrr t r t r l r t l s i l l i l t , r r srrpr. t l ic i i l l poslr l ior ' p l r r r l t tm l t l l r ,z i r . r l r , l r l r\ \ ' r r r i l , ( ' . l l i r , t t to l is t t ( , t r l I l prr t i , , i r r l l r , t t r l r r to- l r l i t r i r , r r t l l ' i r I r r i , r , t t r r i r r I r , : r l r rzrr ,\ \ , r r r r . l ,c r , t r I r Ict Iutr t i t r r t r t I r t , sr t t r l i t i l , i i t crbl l lc (1 lu t ' i r , t o srr l r r l r r r rgr ' i l totr t i ; r r , r l rur , I r , , r r t r r t t i t t t i i , cot t l lo la l r ' t r t l i i , l t l t l lx i t r i t i t ro- t rutol io; i l t t l l r t t l i i l i r I r , r r ' l r l t r r r, , , r ; , , , r , r r I i i ) . l t , r r r r ro l isrr tcrr l r r l l l r r ' l i l l l l r l r . ic toyr l ic i r , r r r i r ,b l i s( l ( , l r r | 1 | ( ' I r , r . i r ' r ,7 |, ' , r , , , , r l , r ;1 io l l i r r i , r r lbrr l i r . r i r r lo l i rnbi l iu l r r i sc l is ( : lg^r ' r r l ' ic ; i l loxirr ) . \ l r r l r . l r rr , r , , , r l r i r r r r r r r ( , s i l l i t r t r sul l i , r ' i i r . i l l 1t t ' r i t l r r rur t r f i lz i i r , t i r ix l i " l 1, ip l l loclr , i l r , r ' r r r r r , r ' , ,1, '| , r | | | , I I I r r r | ( ! r l i ; s i lVi t r , t i p lo l tuLd si , ing r lcLcl tn i t r i r ln fo l l r t z i i I nt i r i l l i , r t r r r ' l r r r r lr r l r , r r r i l r l r rg i r . l l , iu l ro l is l r l ( ] l r t u l i r r tc l i to l iu l r : l t rLrr l i l r l i l r r l ,cr io l lo rr , lc sr l i r r , r r , ' il r r , , i l r r . ' i ' r r l z io t t t01rot ie. tu,rrLol is i r rot t tLLl in l ,or i tot ' i t t l i r t i , ( ' ro i ( ' i f r ' ( , l r r r l ( r
I t . , l , r |o i l , | { j rsr i i tLsofc;1,o t le u, f | l .z i0 \ \ i t l 'n ioko crt 1 l t ' r , r Iorrr i r r r r l r ! I r , : r l , r i , r i .l l , r r r : r l r r r r r r r l in ' la 'aptrcnchirnatos rLi tu ibur i i r i dc vol l l i r ' ( , , , I r rur \ ' r ' r r l r l l , r ' r 'ol t l , r , , r r l l l l i lc l { l ' l lntsc r , l } tc ar:Lcsca pune , , i : r l , rcbi t i " r l i r t , i l ro l rurr r r l r r r rr t , 1r t r l r i t ,
' ' . ( la,tnc i.nlcLr!ioasc Fi torice (mcningii, i l cotcbro-sli irrrl.; i , r r r r r , r . I r r I i I r . ,r ' i l r l rL, r r lxrr iJc cot 'obnr, lc, intoxical i i cLt opiu, ou bol l l t , t l ot r r r i r , , or i r l r l r r l r r r lxrrr
.) ' l ' u ntot i cerebrale ale lobului.ternporal. ; i alc regiu r Lii lxr,r ' icLo-lr.rrrp.r'rrrrr , rtrlrrlrr stingi. Caractrfrul afaziei oste c:i, ca cvoluo:lzir, lont lrtogrr'.rrr,r ! | l ' , , r I r ( l i r l ' l r tearzi i brusc, c ind in tutnnr i i , sc l laco utr Ih is1; s i r , t r l rorr , r ' r r ,gr i , .
|. ' l 'nun&lbma cr ankt -c er ebr ale.., i t atroJiite corticale din dcmclfcle prcsonilo (bou,lr lrri i \ lzlrr. irrrt),
, r l r r . r l l r r l izc l ,z- i , t le obicei L-r , inceput o afazic anrmrsI ic i l , . Arrrs l : r , sr , r r ro,rrr , r r r l i l t ior cu a, l te t [ lbur i l , r i c le t ip af lz ic, cu al t . t i s i t t t l r l r r t t t r r r l r r r r l r . t i t r l r i ,r 'r,, lrr;r, lr i ; i cl l,ulburii l i de tip derncnlial.
f){,sigrlr, I,n d,iagnosticul, topograJic pi eNiol,oJlia lc ir irri i , ,t i lulhtlt l tt l ttr,ru"lt4it:1: asr.tciate: a) I lemianopsia lateral[ hotrrorrirrri,, r l lu,r 'r, lr,/rrl(.1,I r l r , ' r ' r r lxr t ' r r , r l ia l i i lc opt ics in substanla aibi i par ieto-tortrpol i l l i r , I l r ) l t r r r , t 'r i l i , rrt l)1orll( i parietalc, tcrnporale ,si/ sau occipil,alo l)l 'r 'z.i lr l, i ], rrrr irrl,,r '(1rrlr rr L, lrrl, irr sta,bil i lea exa,cti, a t,opografiei; (t Acrrlo l jn,, a,grroziir, r l i 'z t.rr,rrl r r r r ' . r r l r r r i l l r1;a-st ingt q i tu lbur i l r i le bi laterale r lo sort t i r , l ,ogt tozio (rrgrr ,z i r r, l r1.r i ; r l r r , t r t tutopoagrxrzie $.a.) cocr ist t i atunoi o i l t ( l lcz i l r rc:r , l t i t rgrr l r l r l iuI r r l r i r r j i l l i t r tcf t postcr 'o- i t fcr ioru ' i l a lobr.r lu i par io la l ; r l ) Apl ' tx i r r , (xrrr$l r 'ur ll \ r , r r lcolnotol ic f i nneol i ideator ie sc i lsocia,z:"r , in lczirnr i lo piu ' i i , l r l r , rur l,
'1,1,11,1 rr) l lot t t ip lcgia (cu satr f t i r i i tu lbur i l r i r l t : scnsi l r i l i l ,a, l r r ) r , l r r f r i l| ' r r r r l ( i l l , l {0r ' io*r 'e, inso} int [ l f r tz i ih l ro lo l ' i i , r ]ar r l r r l r tu l l ,o ol i 1 i : r , l r r ,zt t l r rt r r ' . l , ' r i l l t iar ' , i i colc sol lzol i , r , lo (1r l jn cxl ,cnsia lozirrniLl r ror ' l , i r ,o srr l r r r r t l . r
' r r l , t ; l ) | ' ( r t '1,rr l l t i r , r ih l t l lx ioc, dc cr)ctr l r i i sort i | ,1,ogl rozir , r r r I r r r r r r r r r , . I r ' , . r r , z r r ,I | | | I '
, , | ( i L I r 1 i t , urgi t tn i i Din icto- tct t Ipul i c i tL c l lbr l : r , t r r i l l l r l i r i l i i l i lot ' r ' r , l r r t 'r r l r r l i l i r t 'c t r { i ru1,c. , \ r l i i r rgrr , l ,o { , r r l l r r t l i j , r i lo l i rJ 'u,z i rc, r i lu f l i r rc i r ,z i ; i r r r i r i rnrr l l ,r r1 ' r . , r1: i l , i l r r got l r t ' ; t lo tLr ct t i r r l r r l tL i q i r i r l ic l i , l l r t rb lcrr l r , I ' I tp( | r ' | , I I r i I r I | ' r l ' i r / i l i, | | , r . ' r l ,z i i r , s i r r r r ,pr i lx i l t , ( , \ l * . iourt , r ino s i rn l i lb, , I l ) ( i '1 I | | i t r I r t r ' I r t t r , I r r r r , t ,t r r / l )_
1",1,i'f ft {i-,*if il:Tg:,J:ffi :i{:##:{,*,i:i'^$i::tJSlli*:;tji"Ji,tl"r:rifl i:iiir".,*,iJi1g,ff ,ilt;*n;t*xxrtilltrJ:*lll"xnl;itnlf ffirrTi#:il$l?tl*i'"4lTbtiilrifi l'l;,*?r{{,1$l:l'i;Lir:;:.:rrin;tti*ix;#::;;i;#:f*#riirif"'f};,ktrJplil;;ll'1")i';'ii"lo!Iit"l1.T;"iff3jl'* "on*1"" ^"in'ro']"" iii"io"i"ill ii ;;6b,;
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varoare de locarizare la niverur 4i'tpi onpnr,,,.,i n,i ,r,,.gr,,iii,, i;ffiii;#li,f*"]tf,rS{il1;"?"1',,";,f";'i"il*li:.fi[1,iir',,lli"lil,l,1ll"lI,l*,**I"T."1,".ii,1*:gL*;g*#J*,",,"",:*i"j1ilt,,,,,,,,111;';";,,li,J;illiiii'il''ii lil},,lii'ii,tix'#ili;"il:il,ff1:_imporra,,i,oi l $ l l l r l i l l r r r r1, I .oIr ic i s i t l rcr l
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11. pBoBl,EME D0 DrAcNosrrc iN ApRAXrr
1.11. DUFINITII
Pnntlu cxecutarea unor acte mai cornplexe, nu este suliciun0c r ,'ri r,ri,r' i l,r olcrn:nLato si {il nor'nale tloar c} for!:a $i cooidonare. ci sc iut-
;rrrrr , ,r r, oir s:r, so desfir,loare qi inlir-o &numiti, forinS, si succegiuno. ExecLrfit,r,rr,,rrrLii, l, iniSc-"urilor, a geslrurilor, ittr-o formi qi succesiuno adecval,itrxrrrrllrlrri, crrrrstil,uie aLLpra.ritT, iat aprania este o tulburare a gesiualil jfl,i ltr,rrr, oorrstir, in irnposibilibl,taa, pcntru un subiect caro nu este nici paralizlr,trtrriri rr,l,rr,ctio, nici coroic, nici doment, t1e:1, efoctuft corect gesturile. Cu 4,11,(t\.|\ i\1,\',, nproixitt, csl,o incapl,cit:ttea de a orecuta mitrc5,ri ailecvate unrtluoo1r, rlr;i lrolnavul nu prezintl parozi, tulburii,ri de sensibilitate, ataxio,r rr i,r,r r li i rr voI ttnta,l'o uou tnlburilri psihice.
Srr sl,irr oii roalizrlrcl unei acliuni voluntare in vederea indoplinirilrrrrrri st,rp lrlrr,vrt su rlestiiqonrii in mcd grailai;, la trei nivelo succcgivo(f(r,,irrrf lrr', l1)77; Zl,urvill, 1960) : Primul esre nitselul clnceptwul, \L atrL\i r r r l i r i , l r r l i1 i pr :opunr i i - l i s t t tb i le l to un aoumit scop al acl iuni i motor l lr , , l r r r r l r r rc, i1 i r r l r r l ro lcn,zr i o schi l i i , , o schem;i ani ic ipatoare a actului . Alr lr r r 1,. r l i l,rr n i atl.ul, ,[or nzul,iiri i lrinatice a actului) a gestului, in caro indivit] ul
Irr',r,, ',1,'r,zri lr rlcrloerr,r'ou,, din cadrul stosul[i innozic al foimule]or kinotiotrirrr. Lll,c, rr, rr,cokrT lirnnLrlo cntir sint colo ma,l aalccyate realiz'irii ac{,iunii,r r , r l , r i r r l r r i 1r , , r1rr t , r . A1 i ; r r ; i loa csto ni ,uelal i ,neruw!, i ,e i n otor i , i , ccntr i l lu 6llItl if|r' ir!r (f |l inllrLr'{Ji, in joc * sistolnclor rnotorii piramitl ',l lc, extra,pir'&mi"rlrlr, rrr'r'clrrllr,so si spitlrlo), ilalo conourii l l l rolll izlurol ac!iunii vrtluntllt 'o,l r rcsl , r r l i l r t , I ' r ' r l r i r l roztr l t ; i ' t , doci , r I i t i rn l l i r r , l l r l i t , l r ,c l , i v i t i r , f i lo r : oolor l , t ' r r lI r r r , ' l , r l r r t r r t , io rrr t , I r r l ) t " l r t izr l l , l r ) t I i r ' i N| lJ, I , r l rs I r t r r r I r f , r rL l l i$tru, t l t t p t l t lgt . l l t r t i ! t t t
r , r i r l r l rs locrr , r ' r , in l r iLtr f , , l ln rz i r t , ; ]osl ,u l l i ,J ' t ' , r1 l t ' r rz i l l , i , o tot t t ; t r i t l r t l t l iu t l r t t t "
t r . l r i l r l l i r t rprr t l r r t t l i i .
i , l t I
l l . r . l ' : \ A l \ l l ' lNl l l ' Al ' l iA\ l l l ' l r l i
\ , ' , l i r ' s(r l l t t ' r " I t l l t j t l l t t t t t l t t r l t t i i l r r l t ' tc lo l ptr t l r t ' :
| { l l i :Lci i l i i r t l r l t r tz i l i r r ' ( l ' r r f ( r l l t l i r t t l l l i r r i t ' t r I I t ' t t i1r t t I i I l i r l r r r r ) t i r r r r l r r ) : r r ' )
r , r , , " , t t r t t l t r r t t ' , i l i t ' t . ( l t )nI( : l t l t .Lt( t : i1n' I i l l l r l i r l ; i tLrrscl l i t l t r t r r l t ' ool t i l r t t ' t i ' r i t l t t
r l r r ' r ' r t t i i , $rr t t l l l ' r l t t r l t , l i r r l l r i i , l l t lx i iL ; i i r r r l ' t l t ts i l l t l i [ot i ic l t t t i i t rgt t tot l l . l t l t '
t r , ' r , r | , r . l ' t , s I t i t t t t j t i ' l l 1t r t t t t r t t t l i l i , t ' , t " ' t ' l ' t ' t ' l t t l r l . t t i incl- t l t t l t r r l i r l t l I r r g i i t r l I i . r ' lo
r f , ' , r r , r . r t , , ' t , , t i , , , ' r ' t , l t i v i l l ' r r l p i i r ior r r l t r i " t i 'c ' i l t \ r t t ' i1r : i i r t i r ! r t l t t ' : i l i t ' t t l t r t t t t t t ' t '
1, , , ' , ' , , r , ) : st l l ihLl l r grrs l t t l t l I l l , l I I ( r1I in11rro, int l t tLr i ' l l t r ra ' . c l ' t r ' ' I i l \ I ' ( I I I l ' i r I ( \
,1, ,1 ' , , , , ,1, ' , r l ' t l r i t l sr l i t l l r i t l i r r r i l ' l r ' ( ; ioI rN rrr i l r ; r i r t i in l r tnt i l ' i t t r : r l rst t t i l t l i , , t :
p, ,1, , ' t , t , , : r sr : l r i t l r ior i , t l t r l t , b:r to t t t r ctLi , t l l r t ' pt i t t t lc o l i r l l 'so ' l ' r l ( j r l ' ] i l l l l i l '
l l , l , '1r , l r '1, ( l r l l , s l l l ) i l lN' soncl i t \ ) t .k l t ' s i t sr l i l rp ina, t lo l t ' , . l t r i tLt la ' t l t r i r l r t t i '
, f , , ' , ' , , , , , t ' , , i , , r r r i i r r r i r t ig i r ,ctc. ;d) in i ; t ' i i r i ' in l ra"zi l i ' :c t" t ' t t l t t r t t r 'Ttel l ts i r t t l r ' l r . t t
*n, , t t l t , , t t r t l i i : s l i , l tL l t i l t l i i l i tar , gostul d(r 2 l t \p l i l l l ( l i ) ' i ) \ ( r (11l i l l ' l ' ( ' i | ; l r ' f l l l l l r l l
l r r r ' , r r r r r r l r r l t t i , i I ' gostuhl i de l l r l io cu nl in&, !s in '
I l l iscr i l i l r i t t rz i l i le (ctno i t r i l l l ic l ' lnanip[ ]ar(xt ' r l r r o l r i t r t l t r ) : r l ( r / l ) f : i '
r , , r r , , , l | r l r11i f i t ' toa, l inccL{ i i l rL,r t lu l r r i la cravr ' t i ' , s t l ' ing{) ] ( rN l i t t l ' t t l t t i ' l rpt t l t
,1,.,, , ,,,,,, i r, l t i l lr i t, tpr.indcrcr, t i l ]ci l igir,ri, incuirr, l,nl tt; i i , I t i r r ; r | ' I i t r I r ' | ' t t | ,
1r ,1, ' r r , : r ic lc l i r t t t t l rL i , ar t tnci l r t t l n ingi i , punt l rc l l ocl lc l r l t iLr t ptr t r i r { ' { l r r t l
r l r i , t , r , : r r t r i i cLl ohciar pl lnerci l unei h i r t i i in pl ic ; i l i ; r i t r r r t l t t i r r l ' r "
, t . l ' r ' i r r i r r ( 'ot ls l . I t ro l i \ i l : descuul d in nlcntot ic, l 'o l t i l t ' t t t t t r i l i l ' t t t t I ' r ' t r
ir, rr r, , , { r)rrs{r' lrt l l , ir l nnoi t iguli din ohibrituri o1'(r '
l l , l r \ ( l r 'of ic]) i t d0 l rnpolLaut ca toate acestc prolxr t lo grrs l t t : t l i l t t l " r ' t t
, r l l r r . r ' l r i l t l '
( rcs}ect iv intranzi t ive $i tmnzi t ' iv( i ) sr ' i I i r r i r rs l l l r r i t r r r ror l
l r , l , l r l r i r i r , ; r r r ; r r t , * t t i t
penttu nr in: l drcn'ptd, c i t q i pcrr i r r r t r t ' r t ' t t i ' i t t l l : i l ' ) r r l r r
r l , , r r r l r l ' i r i r l tpor '1. t lnt s i , ne : Is jgul ;m cL bolrr l lv t t l t to i l t { r r l r '4o' i t t l r ' r r r . i l '
r r r r , ' l ,Lr \ i ( ' i r in- t i r t a,rc laqi t in lp i ; i af : lz ic i l )o &s( ' l t l ( r t l r . i l ' , l t t r r t t i t r l t i l l t t t i t l
1, , ' , t ,1, ,1, l rctr l t l t : t , nu gr ' ( lg i , a,sr l l t l l , pt t lzel i { , t l i t t t lot t l r r . t ic i l l r t t r r t lo l i i r t i ' i t r r t t l '
i , , , , , , , , , , t ' , * i i , l I u l t r ] r ' i .u lbru l l j t l t : cor i ' l rn l l t rnt t r t l , t l t r a ' ( r t r { i r r 1 i t l r r i t r i l i r r l r r r r '
1,r , ,1 rr : r l lot l r , l i ro! ' iuui n(r ut 'o-Dsihi( l ( l '1 i r t l . ( ' a ' r r (1t l i 'o i l l l l r l l r r srr t t r t r i l r ' r r ' l ' r t
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r , , r , , , . , , r r : ' i l inr l r r ;1 i r r r i r r : t , i r r i l { i l , iJ l , l r , t lc l r i l r l i l , t l i t< ' i i ' sol i t ' i l i i r r r l to l t r r r r t r lI i , ( Ur i r i l i i r r r l l i l t r i ts t r l , o l t [ t t r ' t t ; r 's l0 s i t ' t ( ( | l io ] l t r r t t l i t r : r , , r I
r , i , l r r r l l r l r r i r l r , l \ ' l t l iz t l n l i i ( l l iot i t t t l rccr l l t i l , f ( ) t ( ' ( ' i \ l i f . ; tot t l r t , t r , r r t r r lr , ' , r . r ' r ' . Sprc r lcoscLi j r t dc i , t l t r lx ieul i t l t ' r t ,1t- t t ' , t ' i l t r r s( \ l l r l l r r r r r ; r l
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r r r r r , r l , r r r r so 1xt l , s( t I i do Nt i lo l r lx | ] ) i l l I i ) , s( ' l i l r ( l tL i l l | l ' \ t i t t t l t t I t t r r l | . r| , | , ILr l ro l t t l r l iz i t { l ,c1 l ( lo l l t t lcLc , ,1r i t ' iot l r t ' l1c pi l ior ' " , t r t t 1, , r1 l , ' r rr , r r r t ' ' , r r l l i ( . io r l , t r r t Io i i tLci l fa, cotoct , t t t t l . ) l [ l io l r | l I l )o l ( l ' , r . r ' r lr , r r , |
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' . l r t t t t t .
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| \ur : r ' r i r r t t t t l t t l t i l t t l i r , ; i s i r r i t l r t rx i l i t tot ' r i t l t l t i t r r l r r i l i l l is t . l t r ,, 1 , , , r r r r r r l r r l l l l l l i i , : r ,c l i ls1, i i , l t ,p l i r r i r sr 1to: t ,1o l i t t t i l r t . t i t i iu l : l t t l t I t ' ; t r t t I r t t t t , t r I1, , , ' r r l r r l l r , r ' \ r 'nr l ) l r t ,ntr l r ioclul t r t r r : t l r t t lc i t s i - ; i l l l l l lz l t i l t t t t l t , r i t t t l i r t r l l r ,, l , r ,1, , nr l l l r , i i , srr<r,ot i i r r r rcrr , r 'otr I t r r r r ( , i i |ot r ' ;1o t i r t t o lgrr t t i r t l i t , i i t t t , r l , '
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l , i L | , , r I r | | r l r ' r l j r .s ln l s i i r r , ; r |sr Jro urt l r t t lot t . NI i ; r ' l i t ' i lc r l l lo l r l i r l i , l ] l l r l l i rr ' | ,1, r l , , l : r , l r . , r ' l r , i r i r r r ' lc ro l t r t r l r r , t t r . ( ' i t t t r : t , r t t ' r 's lc i l r r t t t t r r t l r ' :11' t : r , \ r i . 11| l, , l , r r r r r . r l . r , l ru i r t , r ' r l l r r r t t l r r i t r r r r lot l r l i l t r r l t t l r r t l r l .
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1"'l r.r::lLi1,i [:].uL'rrr,'rl iL, drl,l izbutrse si"r, inghitii, lnrnoJrenex. l]ac:i, bol'*vil, r r r1, : l l I r ] : : - t | l l r l : , l toL , . \ r jpUl u i r - , , . iLC Or,al iU..
. . , ) .1; ' l ' i ' ] i ) - : ' : ' i :9 l t 'nu pot f i cxe' utulr ' la-urt l in, po1 I i i r r r lcpl iu i t r r r r rl | | , | | r \ : , : \ . i : t rn mod i tutolrru, l . I )c IO: , te rnUlLe or i apr*sir bUCuf*r , i ;L l l, ' , r r . . r r i , r , . r r , , r , ' , , , \ l * i rn l , [urnJ, t iC, I ,SOCi: ] ,1 in a[rrz i : l mO1'o.e Si a l r r i l r r ( ) { . i r , .r ' r r r , r {" / . ra ' r r r r ' , ' r : ' r r r" l r inr ' , f ior , r i i a e ' i r . i pr+ceutrare (Dcr lv-s i Lber,rr i r . r . , , .r : ' r ' . , ; \ r :1. .1,) ' iut l tn{r : l LUe.nt1, lc, 1960: K'oind. lcr . , tg l l ; Ar.seni ; i IJ . l , rz,,ll)l)!,,
ltt0{)). P..tru rr, sr: prod*cc accaiti, apraxie, trebJie si, exiite rlrrrrl,r' lrrli rul,! rr r,cgnrnen ilterio]tii a, ariei preccntrale gi a iloua lezirrtrrr|Ir)rrr t,lr lr) iurrlu.r)t cmrst,lrj sau in ernisfeta opusi, (Arscni, 1959. lg7g).
, l;, ,\l)raKi' l.ru'chiul'i se. caracterizeazir, prin dificulti,l i le bolnavulrri' l { . . r , . , . l lc : t , rn pr1 . do a q" r , i r l ica ct in piur, t lc , , a j - lo io*."n s i de a ur i r lr l ) ) r , r , ' \ iu r : r ,p ' r r . l ic J5o(. i iu l , i unnor i i i c , t iemnc dc lprar ic a ' rncmbr, l t , , r , .lrlsl,,1 rrsir, toarte g_rer de rlitelenliat dc nra\ia t""ncnii f"i ryi Ae asincigi"..\ p.rltr irL krziuni dc rlivcrse ulturi (_intlcosebi tunori) lr,ie brrpof"i-rii* jlr u I l,,l lt;i lk), prccum gi il bo.r,l:t lui pick (la nge , 1930, cita,t A"' X"oiriai,,i iI l ) ; ; i .
. . , . : l t lJ | : t l l r r r{ | l lu i (d{,n.r isa dc cersrrnann qi Schi tdcr, t926, c i t . , r , l . rl]1, l),ij,,,ll1l.r: l11/ / )" s,e. c,r q ctcrizcazir, prin piuderr.* ini[,iariici ;i I ilrtl' r | | r i r . r | l . t | l . r . i t t t t . A$1lel . in t impul tncrsului p i r ioarele se inciur. iSolz l ,, r , , | | , . , \ l l l , .Tg c| | l ,J i l rn ic i . pr . v i r fur i lo pic iOarelor, bat , nasul Oe toc t l r ir ' | | ) ! , ; r , , / r , . ] . * t , r r r l , , .pr rnr l grcrr p ic ioarelc t lc pe sol , iar l runchiul i imin,r . i r rr r ' r r , : . . , . \ i t , r \ : r . i l1ru i l , l ) r i r \ iu
'u mursul . , i u,pat,e ln Ieziuni l in i loosebi tumorl l r r )
:111 ' , , ' , ]1, , ,1 111,rrkI ,p r t lon1;r t , car, ' i rnp- l ic ; $ i .p l l r tca arr l er ioar i . a corprr l r r i,.rrr, ., i i. , '(:r1...r'rrll in ttenlie -$i disc€rnii,mint in iclentific,area acestei fbr'rrrr ' . | | " , r " : r I r ' i r \ , l r { :n1 rLt . l ' urr l i cou[unda ld, cu l ipsa de in i l iat iv l 1 i dn, torrrr , rp,.trlrrl, .rr rr,1;lr,xiN trunchiului a lui'Brun.q sau-cu fenornind d";,;;g,ni;i;-
l ; ] . ,1 , ' . l , . l l l . r l . ' t j ' i r . ,ra,or:r, i ion) al.mcmbrelor interioar" fal i Ae iol, cl i i ru,.r , . r , r r , , : r r , , r 's t r : r r fe p.rctroOtalc (Kleinr l_ l f l , , 1977; popovir . iu qi 'Aggir l r r ,t r ) r i ; \ t , ,y{ . r . p i t t r r r runl 1900, c i ta i i a" XrcinUier, ' fOi?;" .
ll. \pr.rrxia rlr imbrieare (descrisi, de Ildeaen) se caracterizeazil pr.irrr r r rprrrr l r i l i l , r r , l r t , lxr lnar.ului dc,a.se imbr5oa,. de-a se A"rn" i .o, Oe a qi i rg i iI r . r , \ . r l : r s i ; i | r r1.rrr i l , . r le la panlol i , dc a maDipula, i l r mod adecvat div|r , lo l r rl l l i , ,
, ' , ' ' r ' iL( ' . ' r . ' r l r r ( i l ,Lr1, spontan, c i t q i la coma,nr l i ) . Se asocirr ,zr-L r : t1r ' r , , , r " ' t , l ' , . LJ ' | |1I I I i | | r I i t rcapta.s l , ingJ,J cu tu lbur i r . i v izr tor urrs l rucl ivo t i /. , r , , r lu r l l )ut . :u.r : r . t , : s, . t l0mci corporalo 5i a l to t r t lbur i i r i grruzir ,c ( lc- l i , j : r r i r r ll r r r r r r is ' r r ( i r l r r i sr i .g. t ,c.) , evont-ual q i un rrurnir ln i ip i r , " r r , r rxr ' i rn i st i r rg i t r
l r l r r r . lozirur i prrr . ic t l lo, lospcot i r ptr ioto_ocoipi l ; t lo r l lopto ( l lCclon 4i, \ j r t l i r r ,urrrr l r ' : r , l l )51),
l ) . ,1;rrrrx i : r , .s i rn pl l ,o l . i r : i i " ( , ,s i r r rp:r , l , ic i l , r ) - lc l luol lo(r , rc( j1, , r r . r r , ) rn l , r rI t t t l l l i l r t ic r r t r s i t r l lorrr t r t l t , i corrr I lc l , r , t r , l , r t ,srroi i t ,z l i o t r , I l l r , l i r r l r , r r I o r r r I r f r r l r r t .
; t0{)
l r r ' r , I I r , t r I i | | i t r ' ( r , , r i , r l t r r r l I l l r i , , l ; t l : r / l r r r l r ' l ip l i t o| l t . i \ t r ' : t l l ' i i ' Iot t l t r i ' l r l r t l r, . r l i r r l ' , r t l r t l r r i | r ' ; lo tor t l iz l t l l t r l r r lozi t t t t i l l l r r t ' t l t l t t l l t t i t ' l l l r t r ( i l t r l | r r l r ' l r t
, ' , , , , l r tzt i lc l t , t ' l 'o to i t r r r t t r l t t t l l r r I I I t I t r t i t t I t , t r I ; i i t t I t t t t tot i l ' r I t ' t t t t l ' r r t r l t I r l r l r ' )
i i ' . ' l ru rr( l r i l ( l [ l ) l r t r t , I1) l i : ] ) .
l l l - l l r r t r i : l : t t t t t lz i t : i (at l t t t tz ia voet l i i s l t t t : tvolal ia l t t i l l r r t tsehrrrr) r ' ; t l ' r
' r , , ' rr :r . i ' i i ,
t i . i l , l l t l t ,xir l t . tr loolt irLtr i . ; ic, i , lol l l l iz l t l , i 1xr t t t t t ; . l t i i l l rr i t t l ' ; rr l t tr
11.4. I)IA(iNOSTI0 l{fruLOGIC
lrr lr lruclir, i i ,, :tpli lxi i le api:l,t de celc mil, i l lul lto tlt i i tr l t: ' iurtr t ' .tt(tt l ttt ', , t , , Lr l i isc i t t , tu ict t i r l lmol isnelr tu, hetnorrr ,g i i , Lctrulortr tLr ' ) \ i i t t . l . t rnt" t t l '
, , i , r , r / r .srrrrrai i r t l i l r tescinal ' to. l i i te(Uebralc l t r tsct t i lL ( l t tn l4 l t r i l l hr int t t, t ' t,1, ), it\ I {d,Itrnat' i 's ne ar&nio-urebw,Ia l '1.,.
1 6) I 'RO|JLEIVIE DE DI{G],I0STJC ilVtuli luRnnrr.t:LLt. DE coN$TTENTA (ctrNo$Til\TA)
, , r r . r , t r r ' i r , : i r r ) l l l l , f l l l l r ' l l r r l l ' t t r ' r l ' r " r ' l i l r ' r t ' l r l i t ' l | | I I t | '
i I I I t i I ' I i | | | | | | I I t I I I i I i l r ' { l r t l l
L ' , , ' , ' , '
, l , t l , t t t t r r ' l l i pt t t t l r r r r ' t r r ' l i : r r r I roI : r ' I i i ( l i l ( i l l l t i l '
l r r I t , . : r t , i tL i l , i l r , l r i , t r r t t t t r t , l t ' r : r '1 I r ! \ or ! { ' t rvr t l t t l ' ' i r r r t r l r r i l r l t r l r i ' ' r l r r ' l " r l i i i f i "
' ' , , , ' , . l , , i , ' ' i l i , , i ' , i i l i , r r 'b i i , r ' i l , , r ' t l r : i r t ' lot t t r t l ' r ic i l ' r r i ' t r i tLr l r tso . l ) t r l t i i ' t l i t t t l : t ' t : t r r t ' L l r r
, , , r , , , i , , i t i , t r ' ro: tLr l i r rs l r r I io r ' " ' r is iv i i ' p l l r l ; i l l r t l i to1'rr ' l ' i i r r i r 'q l i lvrr ' r r l ' r i ' i l ) r ' r r
" ' " ' , ' , , , , , , r . , , t ' r r 'ocsLoi t lo l i tL i f i i s i l Lr f ,u lutL t l i l r p l t 'L*tr t ' l l i i - r 'otr l r r i r l r r ( r l r r r l r r l' ; ' i ; , l i - ; ; , , i ' ; ' ; ;n l") i* - , l i i i ' ' r t " t : tn"nul '1 ' ' ,p ' r rnrrv ig i l i ' ' ' ts l 'otr t t l r r t t r r r l r "
r , , r l | , ) lo{ i (1, In) l , intol t (10 co]ui i propl iu-z i ' l -L ' ; i tL ' r l rL" ' t rotr t i i ' I r . ;1t l r r . "
, , i , ; i ; i - - ; ,1 , i i , , i : i rL, , u, , - .c l t ' in ' t t r - ' ;c I : r ' i ; i 1 ' r ' r t r t t 'Lr i . r t r ' r i . " l l l ] ]1.*" ' " r r r i r ' r l r r r r r r l
: | ; ,,i:1.';llll ,i,ii'illllll,u'l"i';";ll.1,,Xin"."s'',iil l; ,J"l:li'J;:l''",' i llll", ; ] : ;J i , , , ; . ' ; " ;
' ; i : "T; ; r r r i , , r i ' t , i , . l )e rr 'sut i i1 i , , r ' , : t . . '1" r"rr . r r r r r l ' t r "
; , , ' , , i , i i i
. i , ,1 r ie t 'u i lur : r , r i v" ;c iat ivc, n i t i r l r ln ' r r l i l i . i ' t i r r . t tLt t r r ' ' r
. ,l ',:,",t",r";,rrrl, "" "i '*iriJ"or,,
i icurologlc tlir,i r'r. 'rzirrrr.
rlrr .rtrr l,\r',1
l ' , , , r , r , ,ont c1e com5, i rs i arc or i$ i re l i .n cuvirr l t t l . .gt t r ' r ' ; t r " l i t t t t t r r" ' ' " r t ' ,
, ; t i ' ; , ; i l - ;- t""0. '1"p'r ' r 'ot ' is i"t t l l i ' : : . : : l - . l ' , l l l :1.rt ' r Ir l t l ' r t ' r ' (rrr i i r l ' i ' rr
' t , . r l r r l i |o i l s t i l r i i de conl t ,e i l i ' Es:Le o c lctrse,bir t i i l l t ro. io l t r l I ' t r r tTrr t | r l r I '
L r ' , I r l i r o{)n Lr,c l l cu madiul t . i i ' t i - Oo" t" lunct ' i i v i rsol ; r l l i r t t t r r t l t t t r r [ . ' l r r r ' . '
' , , ' , , , " i " f , r r i ic i
l i co-1, unAe exlst i i ' o leziunc rr ' Sl t 'A ' \ r l i r r l l r r r r i l r r '
, i;i,i;6f ;;1;.'co** 6siu-o stare prtologicr-r'' prr <'irttl s,rrrrrrrl .irlr' "r r . l iz ioLogic i , .
NL1.2, Problcms rte diagnostic in s{irrile tolnlloilt(l
; ' -1.2.1. As7e?te Y niotogiac
' ' , r r tn ic l ) loz;nl i , o s l t r ' : p ' l ' to loqic i i , rn *r ' r : r t : r ' l r ' r ' iz ' r ' r " ! r r r r l t i '
, , ,1 "" ,n i ln i* a con,.r icuic i cu 4ispar i , . i r i , . .n i t r r 11 , l t r . t ! t l . r ' l : r ' l . r r r r '
l t , , i , , , ' , t ' . . i ror , t l "cval ' , : r reacl i i lor la s l i lnul i i ' l i t t l t r t r t " : t ' { \ l r l r r r ' r r ' '
i , i l , ; : i " t i " i " " . " lcd; i . cu supr imnrcr ' (s i r ' r r . l i t r r i l r r r l l : t ) t r r ' r l t l r i r ( r r
, , , lLr r l r r l ) . ou mo{l t rcalr u, i " iut ' i to i ' lo t l ivotscl t " i t t t tc{ t i v t rqr ' l l r l rvr" r t l r '
,,, ' , , r,,,, i ' , in" hidro-etectlolit ico qi umor:l lo'
| :.1.2.1.1. ' l ' t t lb a'area ite t:ons't ienli i ' cottsti l ' t t io sittt l t l 'rrtrttr l l t t t r r I I t ' t t t ' ' t r
,,, ,,, ' l t^t
it i t"* diagnosticului dc cotrri i '
, I i ) ' .tL'rt. lsl alt lele d"e inst(l lare n std'ri i d'e aotnii 1xt| ' I i rulrl i lrt ir ' trrlr ' l :r l 'rrr '
r , ,nr ' I t l l i lgnosi l " ,^ t ro"" 'o '^ i i i tx I t locol t l tna' i t r t i t l lorr t i I I I ) I ' i | | | I I | : | ' I I I l ' r r r r '
l i ' ,
l r i , i t i l i ic cbnqr; i .* t1"; la tn int l iv i t l in r t 'p l t . t t l r i r r r ' r ' r r r r r l ' r r r r l r . r r ' r r l
, , ; , . ; . , r i . ; ; i - t ;o; i { icni 'vasc,ul1,r : r rcrg6r1l ; i r r ru l t r^r l r i l i r , r ' r r t r I r ' r ' ( , \ ) r ( \ \ l , r r , r r r r !
, . , , , . , , ; r i , i i ; , ; : " i i ; ; i . : . i r , r - , ,nu *n. t crnnio-oir lobnr l i r r r rrr l , r , r , r , r l r r rr t , .L) : , t , r ' , , t , r : ,1 ' | ,
1q, 1ro: t ' lo t i l tq{) t in o l tornot l l 'g i t l s l t ' t t t t l t l t t l t t t i l lotr l ( r rx i ' r l r ' t l t t t : t l r r i r l t l l ' l f i l ' l r ' r ' l r
r r l , r l t r | r l l ) . ( ) l t t t i l tnnozl t , , ,pt t t l i t * i0r l l l i ' " I t t t l l r t l t ' l ' t l i t t t l i r r r l l r r rvrr t r l ' t r : t l r t ' r ' ' r r r r r r
, , , . , ' , , , r i i l i : i , r ' , r , r ia, , r , , - , r i , l r i iJ , , , r .Lr l t r r ' i i , rhr . r r , r ' l i ' r r ,_ l r 'orrrrr ' i i , r l . r ' , l i l , . , , ' , r r ( r I
' ; ' . ; ' ' ' i ; , ; i , ; , i , i I i r r r r , ' l ' r '1" 1 i ' r ' l i ' r srr ' i ' r t t ' r r i r r i i ) ' ( l i i t i i t 'or t ' t t t t , r : r ' t r r l r i r l : r l " t l "
, ' . , i , , , |J" ' , , , ' i , , i , i t , , i ; t , t ' i t t n ' i " i t l r tDt 'o l t i r r t r r r t ' J r t t l l t l t ' t t t l t t i l r ( r r ' : r ' r r r { l r { r r r r I r ' r r r r '
l , r , r r t , t t l r ' r l i t l : l ' t t t l t l t l ' l ) l l ' i ' i 1 l ' ' A t t l r r l r r l l r l t t l l ' l t r l i l t i t r t l l l l t ' t t lo r i l 'o t r r l r ' t t i " r r r ' 1" ' l
, , , , , , , ' l , t ' , i ; , ' ; t r t
t r t t t t t i i I I t t i t I r I I t ' t I i ' r l t t t i t l ' tLr o l 'ot t t l i l r t i r r r j l l l ) l i l r l . ' i r r ( l ' r l r ""
, i , , r : , , i , , , i i t t l r r t t l i i , r c l t ' r ' r . r l r r t t t r t t r t l r t t r r I i ' l t l r . r i t t , I t I t ' t r ' : t ' t r r Io l r r i r r r r r r l r " r"r '
, r ' r , , l r r l l t , l , t r l t l r , i l , l l t l ) t l t l r l l r r l I r l t ' t t ' t ' r ' ;1 i i t l ' l r r l t t l t l r ' ' l l l ' f t l i l l i l t l r i r l l ' t t ' r t t l r t r r
, ; ; , , , ; , , ; ' , ; ; . ( ' , , . r , , , 'L ' p i"r ' " r l : r l ' r l " "" l r r ' l r r i
( ' r l i r r t r r ; r ' l r i r i ( r r l r l r r r r t ' r ' r r r r r r l l I r r r
It
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It1 I. I. PRINCIPIILE M]ITODOIOGICE SEIIIOLOGICI,1)B DIAL.INOSTIC IITIOTOGIC SI TOPOGRAI,'IC
12.I.1, Prceiziri de {tr.meqi Qi alc Droblerxati*i. in:r,r.t,rrl.rr,lril,rrl- vorir abtirtla succilt problcrnctc de diienosfic doan itt std,ri.te t:attrrlr.,a*r qi.in.alte su,sp€nd.d.I'i de con$tienli, de scurtj, tlurati, ca dt, }illiiirr rr lurrifcstilrile silcepale.
I ) i r r runo51 iu15 sa l r cunr i ien t i Se 1n lo legc posibi l i fatca c le a f i i . r l - r . r r . r t ,r t r l : r , : r ,v( . i r i s i ru a l tu crrrro; l i r r l i i de cer&, de a s i i in ruor] iust de obi( . , . i , ,1, .' - i l r . r r , r | l r r .nole inconjur l toal .e 1dc rcal i ta tea inconjuldtbarcl . J pir . r r l , ..rrr,rsl,ir4,ir, inseamnii it, nu Dti de sine (Dicfionarul lirnbii romf ne tnc,il"r,,,,,r1, l '7) .
il'rrlburdlile care survin in sfera cunoqtintei constau nu in rnoriijir,rlrrrl,r rli loril,c gr':r,rL., cum.se.s1une, li inrl vorba-numai dcspre pr,czen{rr rrir,l: r , I | { | | l l lL {1r ni l rU L,onsl l tute cUma.
Oorna csto un sindrom care, prin definilie, Se traduce prin abolirrr[lrrlrr,Li, rr, conrytion{ci * element constant;i dorninani * asociatii, frecl,t,rrt,r:' :r,lhr'ii,r.i alc luncliilor
^ve,getativo, tulburi,ri biochimice ryi, evcntuill .rrirrrrrrrrrr r.urr)lr)gico de diferite grade, dup6 intinrlerea laterali, a bziurrilr rr Llrrrrr:IrirtI urrebral.
, l ) r r lu lu du f iz iopatolugic, ncuropaiuJogie qi c l in icX au dus la cot , . l r , , i r li : , : . r ) , ' r r ro u s lant de cunol l ln l t i , cs le expresia unei L.z iuni sau lcr tu| l r i | | ,1r r.r r l lrr ri,rn'a f-orma,liulii roJiculare ascondcnte de pe linia median-d, din tr.rlr r",lrrrrl lcr.rrbral. Porturbi,rile legetati-ve, care insolesc fi.ecr.cnt $tal,orl (ll' 'r,rrir, f{) {lirl,oroBc implic5rii stlucl,urilor vegetative din trunchiul ccnrlrrrrl:r,lr,r.irrlc.rIr accoali leziunc, prin intindcro:l ei laterali,, caro dtlpitfr,ltl.(,:r'r' i i l. :r'r irrlr ryi_pcriariialo *le formaf,iurii roticularc. Nuriai o.xporirr,irri:r,r, r',rrri p,rut,o [i dctcrmilati, printr-o l.ziurLo purii fu SIiAA rtin 1,r,rrrrr.lri,Irr r lirrifir, lrzirrui puro .il trunclri sc irrtilncsc r;ir,r'; ccl rna,i iL,4os11, 1rz,irrr1'rr,r , l . r l i luzi i , crr f l inzind,,s i < l t r r ic l r r r l . l )oci i r r corr i , o.x is l i i dc I r r l r t o Lrzir r r r r ,, , l r r r r r . l r i l lsooia, l ;5 cu l rz i r r r i i r l rx r l <rr . i r r r r r l r r i , s l rL l , l r , r r l ,or i r . : l i . lnr { l . i r ( . r ' r ir , t r r l . i t r lozi t t t t i s t t lD' i t l , r ! r lor i l rL l , f t t i t r l , r . t i | i1, l r l ,o: l I l r r t r r , I r i r r I r r i . r r r ' r ' I r l l r I . l r r; r ' r i r r r ' r r f r I r , zr t | i I r | r r l ) i r ' l r i l r i i r r ' ; r , r r i r r l l r r r r ] i , i , i r l0 rrorrrr ' l , i i r r ( r ' i , (o l r r r t r l r i l ; r , r , ,r 'otr l t tz i r ' , r rorrrrr l r l ' t r t , i ' i , ) 5 i r r t r I r : r ' i i ; i l r i l i i { , r ) r r i i ; I i r I r r , r I i I r , : | , , , . , , , , .ur , , , r r r l r , r r r ; l r l : r ,I r ; . i r r r r i l r : l l lut lcrr io l i ; l l r l r , r r r I r r I r , r . r r r i r r I r i , r . r , lLrr , l r r l l i r r r i r . r . i l t ! l t t i r ) l lL l r . ( ( l l
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" ' r r , l i , r l r r | | ILrr j I r r , I I : l t , l i t r t l r r r ; to1, l r lc<lrr , ; t r r r t l t t t o t ,ot t t r i r '1r i I r , I t i ic l i . I ' r t , t , ' r t t I, '11 r . : r rLr r ' , r l r lcz i r r l i r , o rrrr t r t t r i I i t ' l r , ( , i r r l l r rc i l ic i i , I l r t l t t l ; i s t r i t t l i l t t r , ; i l t r r : r , rt '1, , I ur l t r r r r ro l l lg i r r , r r r r t r r I l l l l t i i , i t t r ,ot t l t , c( i l i r r i i ; i t t r t t ro l i i t t r l r t t t r t , l r r t ) r t i t t, r , , ( r i r , lozl ! t rc st tg l lc l tz i i , t lc o l t i r , r t i o cr t t t t i , i lL c l t , to rrx ls l r ' i ( , s l ' i r ,z l r ' \ ( ' t r ) : r i : l
, 1, , r t r r l l r i i t : i i r r I r r r r l i i i lc tcspir t , { rn i i ( r ,ot t tc l t ipr t t 'crul t t t i t 'c) . ( l t l l r t l t , t t r l r t lzrr l ; r, , , , ' r , , (c i r rs i r ) l t 'p i r l i i t tc 1tot t1, t r ot iorr l ' s l ) l ' ( ) o t r t tn i j , l , r r j r i ' r , or i t ' : t t l rotrrr l : r '
r L i l , , , , : r , i r lc t i l r r , l i , tcgrrrrrurtc ln ' (c\ 'o l r i ,ur t l Ei prozct t l r t , t lc , , ; (c lu lc" r : r r' ! l , ' r r rc ol i r r r r lorz, i ' i . s l i rc o tot t r i i , hel t : t t icr i , . l l . ipor 'p igt i t l t r { ,1r , ( ' i l t 1trr t t t r t r l t t l ,
I | ' , r r r ( r ) rn{} lo l r tc por l i l i r rdr t , l - r t l t u,1,cI t i , , i i i , s l l t ' t r t t t l t l t t r i ' pt i t t i t r s t r I i . i . r r i r r, , t ' , r , r r r l r r . [ ' r ' r 'zcrLir l , rutui hcrpcs pot l l ,c f i LLLi l r i , i tL t l i t lqt tor l i l t t l t t t r , r, , ' , ' r ' r l . ' r ' r ' r t l r r r r spirr t lo s l t t r a l t tnoi pnoutr tor t i i . I ' t l1, t r ; i ih l l { i ( ) | i I r t I I i i | |
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' , . ' l r r ' r r l t ' rL to l l t , r l iu,bct ' ic t i $ i pontru cot t r l i , t lo i I I r ' i i ) I I I I i ( | , i t t r , r ' l r r r r r l r, , ' l , r r . r i i i l r r t ,bt t r i r l tu lc pot f i rcr .c l i l tot lc pct t l t ' t t cot t l l I I ipo, l l i , r ' t r t r , : , ,l , , , r , , ) r r r ! r l i i r intor icai , i i lo cu iDSe{1{, ia i i ( l ( } , t t t t l , i t t t t l i t t t rs i t r t r t ,z i r r r r r : i l r l t r l l r t' , , l , , r r r r r i l i l l i lo,
l ' , i r l r r , cci t inrozclor, a, cseor ia l i i lo l I i i l , 1rn{)r p l iu i I ' r t p i r i , r rL, r ' '' , ' r , r r i l r r r r r r i r , i ic : l s im 1l{)stcr i l , io i l la, L in t l r i l r lb ic, l ) r tz( ' r1r t ( | ( I r ' I r I r ' | ( | | r , '. , , , : r , . : r i l ) r i ) r ) coui i "L t r rcrnicr i , ccl lmpt ic i i , f i u l t { r ( } r ' i s l t t i r t t t t r r l , ' t r r , ' , t , '
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, l r r r t r r c t t i t tgo -en cef i l l i t l i , abces cel 'cbr i tL s:r . t t l , t t t t r t l ro l l r ' l r i l r r r , r ' , 1 ' r ' : r l r r tI ,1r r r r l r , l t i lxr l ter t rd la *pr i rut i r , pe parct t lsul t t t t r r i r ' , t t t t l r r t l l r r r ' / i r r i r l ' r , I
' , , , r i ( l r ! ls , i l r t rucl i r intcrv inc in conl icr tu l t iLt t l lo l t r r t t tc: r t l )n l r l , , | , . ,, , r r . r l i r i i , , i rL stat [s cpi lcpt ic, tumori ccl :brrr lc lu l t t rgrr ' . i r i l i , i t t lorr , r ( r ,I ' , I ' l r | i ( i i i i l r , t ropirr ic i ctc.) .
l , r r rpct ' l ura, prezintr i perturbl i r i s t t t t t t t i I i t l l t i t 'o l t t l t r r i l i i l r t r l r r t i , , ' r r r r rr , , , t , r ' r ) luni lc -- in cornelc do graalc lo l i i j i ' l , r l r r r r i i l r ( r l '7 l l l i ( , r r l r ' ; r t r t t t
r , r , l , r ) l )11,r lc i l , infer ioar i , l t ,p l l ) i j i i ; i i r t bt t l l r . l l r i i r l i i , r l r r l r , l1r t l i r , o l r i l r , ' r1, , ' ,1, , , . r r p l i l tou", cu. caractor progl ts i \ ' . i \s l lc l , t r l t tLt t t t t i i t r lo z i l r r cr i r r l . r ',1, ,1, , r1( . r r r jo rnot lcrat i i , ( i l ju l do i ]8 ' ) ; i t r r I I r f i t r r r i i , r t '1t t t i i t r I t l t t r i i l , r : r t ,1, ,
' l , | l r { l i r l l v j r rc 0 noui c lc l tctc (0u o( ' l r l " ) soi 'ur ; l ! t l r t t t r l , z i l , r ; l r , ] : r , : r t , l : r ; . rr , , | 1, , i r r p l r r tour ' ) , pentru c i r , st t l l r i l i i l r s i , st : I i t l i<r , , , i l t z i t t : t r t t r r r r r l , , : r r ,
' 1, , . . l l r p l i l i ( )u) ' (Alsoni 1072) 5i rLql , s i sc rol t t l l , t t Pi t t i i l :u rr l r t r l t t t l l r t t ; t l ,, l iu\ i r (1 r i l t i l lc l i ,c l tn io r io 11" s iLt t l l l l i t i1ul1"
: l l ta.r t l t t l , t6- l t i t f t lor ; i crut l io 'nat t r : t t l t t t : t ) l l , t l t t r r t I toI I t r I r t r I t I i 1r , r ; r l "t , r r r l r r ,grrosl i t t t l , t ' r^ t t< l sc ct t t ts l l l l i l t , i , r r r l l l i i ( t l i l t t i l i ,s t lo : t l l r to l l r l r r r . ,t l , ' r ) . r lc r r r l r lot t i i , s l l t r t l t t t t r . t ' r ' ( r f ( t ( ic ( r t r t r t : t , I I i : r , I r r , I ic i i ) , l r , l r r l l r r '1 ' : r l r ,, ' , r l r r ' l r r r l , i r i ) $ u l r t t t r t t t i r t t l t ' l ( t ' r r r t r l r , t t l r , t r r i , r ; i )1 l t ) l inr i i l t t t t | r r 11' 1,o;r l r '
, 'Lr , l r , r r r r ' , r r t t r 'Lr I t r t r l t l l t r r l i t i t t oI i l r , t ' r ' r r i r i i l l l l l l { r l r r t ' t t t t t t l I t I t , t I t t I t t t r ' , , , )t ; ' r , r t i r r . l t ro l tnt t l ' i , r l t t i l t h i ixst t t r t , t t l i i r t t t t t t I t t t ' i t , r t t l r r r ic l t i t t r 'orrr : r r l r , r l ) l i , I
, , ' I i , r 'orrrrr : r r r i r | , I ; , . i r ' r ' , r l r r l r i i r r r l r l r ic r ' r r t t t r , l r J l l r tv{r , ( 'Lt t t l l l l r ' r r r { ; r l r t r l l ' . r t . ,| | : lnt i l i t t prr i t r l i , i i . t l r l t l t ( 'hr t l t t r t , \ r / / , r r r l r l r l l l ' r i l l r r I r ; l r r i r r t l , t t r r l L l r t r li , , I i , r l l l ) t , ) . ' l l ( ) t l t r l i l t : , t ' t t r t t r I t | , , r ' i I I r I r ' r r < rr t r r r r | , r t ) " t t t t t r t , i r l r ' r r l r r , t r l ; r . r
r i ' ; . , l , l r l r r r t r , , t : i r ' r ' t , I r r ' r r | ; I j , r r t t r : t t r ' , t t t t r ' : t l t r ' t l l r i ' l l r i l l r ' \ l r ' l l t l l r ) l l r l r l r ' 1 . ;i ' . : l t t t r r l t , r r l t | i1t l ) t t , l . r i , t , l r ! : r r ' r r r r r r l t r r l r t r l i . l l l r r l l l l l : r l r r r r r l lo l r ' ' , r ' , , ;
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i I I n,utnarat, lipu,Lui raspirator' (ijoiaoic lrr, blrba'li qi abdominal la femei)rtrlicii, rr ulrvilirto rrraxirnil a comeii g) Bradiaard,ia este caracteristici,rrrrlirl irr{,rltr bulba,ro in ca,drul sindlori,melor de hipertensiuno iDtracranian[plirr lrorrror:rgie celcbralX, hematoame intracranieno, tumoni si abcesecf |ob|r,lrr ntrningite , ineningo-encefalite. IIai apare ln comsle din nixe-rlr,rrr qi in rxrle pril hipopituitarisrn ; h\ Ta,hieard,ia apare in multe come,irrrlrroscbi il cele infeclioase, in comele in care apar complicatii pulmonare ii1 NotntLc|a d,a l.e:iune aaloul,ard, ca,rd,iacd, ne olienteaz;, spre o embolie cere-irlrr,lir, ; j) ,lritnii.le card,ince Fi, alte mod,if icd,ri card,iace ie pot sugera meca-rrisnrc oxtraccrebra,lo ale unci come (embolie, infarct, iusuficientd circula-lrrlic lrermodinarnicS, etc.) ; k) Eipertensi,unea d,rterid,ld, cu intXrirea zgomo-lrrtui a1 doilea la nivelul orificiului aortic $i cu hiportlofia ventricululuisl inq ne poate orienta sprc o hemolagie cerebralS,, encefalopatie hiperten-r'ir.ii sau urcrnie; l) Eitrtotensiunea atteri&ld, Ia debut poate sugcra o insu-ricrrLil saptatenali,, o comX cliabeticS,, o com5, prin tleshiilratarc, o com5,l.oxiu"r,, sau rnctabolicii, (prin oxitl de carbon, barbiturice, alcool, suferinlelLop*ticc, boala lui Addison), o com5, hemoiiina:nicii prin hemoragie masiyS,r;rlrr prin infatct mioca,rdic etc.
4. -A.paratul iligesti.ts, Vd,rsd,turile sint n€caracteri$tice, putintl st:rprlrii, in nuureroase come de origine neuroiogicr, toxici sa,u metabolic5,.Ilepatosplenon egaiia ne poate sugera o comd, hepatici,, leucemic5, mala-rir:L, in boli de colagen sau a,1te atecl;iuni d.e sistem.
Dagluti,li.a este perturbati, in leziuni caudale ale trunchiului cerebraltirrrlinl nucleilor :rervilor IX*XI) qi este un elemcnt de prim ordin inrrprrrcicrea grtulului de profunzime a comoi. Deglutilia are aloi timpi.'l'iurpul I (lzr,bial) : bolnavuiui inconrstiont i se apropie o liugurili, cu apdrlo )ruzor el intinde buzele, o suge gi o inghiie normal sau nu intintle buze]o
- iltunci vom spune c5, timpul I (labial) este prezent sau abolit. Timpul)rrbi:rl are o reprezentale cort,ical5, qi una la limita superioard a trunchiuluilur:olrral. Timpul II (degiutifia propriu-zisd,) zicem c5, este bun atuncirrirrrl tirnpul labial este absent (pacientul nu intinele buzele sH, sug5, aprd,),rlrr,r'cind, introducinal apa intro dinli, eI o inghite bine. Timpul II al tlo-tlrri'i{,ioi csto intirziat atunci cind o introd.uccm in guri,, paoientul linorr,pl, irr gurii, rn timp gi apoi o inghite, Leziunea eslo Ia nivelul nervilorcrrr,nioni IX I inl,roducem a,pii, in gura holnavului, pacientul trine a,pa, carslrolboloseqte, dar nu o inghlte, are un refler c1o tuse, o parte tlin ap[irrllri in ci,ile rospiratorii $i se ineacS. Spunem c5, timpul II al d.oglutijieiosl,r a,bsent, cu sau f[IH, reflex de tuse. Ireziunea este la niyelu] nueleilorrror'r, ilot cranieni X-XI.
I udoral,io este semnificativi, numai in cazurile f5,r5, hipertensiune.lioziurrol, csto in ium;,tatea in{erioard, a bulbului.
'lluto tulburirile vegotative (afari ile deglntilie) au valoare daodnirrl, lrrl,1;o in ansamblu (tabeiul IV); izolat, elo nu au y&loare.
I 2. 1.2. 1.3, Y al,oarea d,atelor efro, menului neurol,og ic
1.. Il;ri.ttcn;la harniplegioi, l,robrLie vcrilical,i, din capul locului. Consta-l,ir,r'oir, r nci ho,n iplogii irrstalir,to bLusc sugottnzii -a,ploilpc totrlcauna unrlr.rcirlr:rtl; ylrii0rtljr,r mrobral $ll,I l ln(x)ri {] r,11.q?}jilro. Itr sohirnb, su]prirriloron)rrrrrr i l rorniplogi i i r r i ; r ' -o cotr t r t i t r . l ; r r , l l l , r i in t r ror I lotr l t1u porr ,1;o $ugoni ] Fi u, l1;c 'Jrosi l r i l i l , r " r , l , i r r i i , r loqir l r r (1;ut t t r r r , r 'o i t r r , l r r !b00$ oot 'u l l t '1tr1, hr t t t t r t , l i0rn Nlr lx l | rnr l ,
;10 0
' I r rnpeIatUIa
I lodlf ic{} l lo lulrr ' l l l lot r ' ' l t ( l r th$ lr t f l r t)orl ( :r t l roi lr l lozlunlk}rtl llr{lic lll opclatorii
' lAlJr ' ] ,1Jl . Nl l . rv
cer(llrirrkr r ltollrrosllo
Indi fu l iLt , l , l ,L r , , r r
te lot lu l l L,
ahicardiebmdi-
Sci idcrca pr0l . t r r r l1 i ,l ' l l lsul
arterialdImpollant?i atunci clnd ccielalte
agravare
c0lot l r l l l , '
curbe orarti coul l l r l
bradi-
I t0$pi l l11ia
(iullos,tii4a
Adinci, rapidi,spuml
pe Ltrzc
l1olenld
l) fg l rLLi t ia Tulbuleri greve indeglutitie
IIemillegieIipilepsieSimptome de hernjelemporali
A((f r r l l r r r f r , r r I ' r r ' i l r .s i r r l n r I r I r ' l , r f r ,r t r .o l ( ,gr fL!
Inrportantcnl nr
rrroningitS, tuberculoas[', parazitozd, cerebrald,, mai ra1' cncolil,lil't'I, ltsrrtttl,r'hrrnorald,) :
a) ln comele superficiale, deficitele motorii silt uryor do I'0orllrorrrrl'rrr,1,it prin probele motilitS,lii active gi pasive, cit $i prin inogtll if ir,l,r,rr' rl,rroactie a membrelor la Dracticarea stimul5,rilor dur'otoitsa.
'b) ln comeie profu,udo Be ror practica o serie de pr'obo : . lrlf ul;(tnlt[rrrcmbrelor paralizate, care cad mai rapid pe planul Jxll,tthti lrr ttttt,tttrvrl|r(lc ddicare qi d€ Hsare brusc5,; -,,semnul piciorului totilr In nlh,rfi)'nllrri Bogolepov (citat de Yoiculeseu qi Stoica, 1907) : - trrl:tt;irt, prt,tl iri i,r r rir,ximI, ln afar5, a membrelor evidenliazl' lipsa do lovolliro itr lozi{irlirridial5, a mernbrului paralizat, plin hipotonia rotatorilol intrrtrti I . lrtlz.rr{,a parezei faciale dc tip centlal (eviden{,i:r,bilir, 1rit.i ft1cs t}lt ttrritzjlt t,x ltt"l r r , { i i lur ' , pr in , ,semnul pi l r ' i " sau zt l , ,p inztr i do cut i tb iot t I l l l p l r t l r r r l r , r l r ,rrpir,t i l lo pe globii oculati, lxJ rtli l lgirroi! rrrl,r'ortrarrtl i l lttla't i i srltt 1rr lltt trlltlttll:rlirrlrrhri, rn lipsl grittr:rsti tlo 1r*rl,tl it, prr,ra lizlll rl ') I - ltntzrtttl:t, t t t I i I r r I r ' I ' t r, I tlr r l l t , r r r r r rhr i l t r i l t iu l r i t r t l i i ; - t l i t t t i t t t t i r t t ' l t ' t i l t , t t l l lxr l in l i l t t l r i l l '1 , r ' , r i l l i '1 , I t ' t r^ lh,r l lot ' c t t1, i r , t t i r ,1,r . r i t , lx l r t r r i r r i ikr t ; i i I r i r i t r t r l ; t ' i i t , rc l l t rxrr lot ' r )$t , ( r ( t hr l l ( luroirr l t t .
it" I 'rn( l,t.t uttilu.l 'ttt 't l<L,, 1111v,i 1'rrl ' lrt 't 'd( trNr).u(rt't '{l ltuHpilU{ roJlox) rtrrttr l r r l r l r r rcrr f r . l r ) r l l !1 i i , ( , l r , , l ' i l j l t r ' l | r , ; i ) : r , l r r i i t t i i , r r ' l ; r i t I l t t t I r t i , l t l gt l t ' i i , l r t tz l lor
i i l l ' i
r i : t ' l l i t t t l r i r ' pt t ,ztr t t ( i t , t t t t i I iutrr l r l I i t i r l i is l l lnsl l l r r i Iorr ic l l l u i r r ior , r r I r r i i l l ] r r ih rr l l ( l . l r ls l . i r r l l r r r r l ro l r r ; r , r , rb l r r rb i l i l l srr ,Lr corrLi l l ,os i roato iugcra o loznl lx)IrtrrIr.rrl,rr,li i, trrrri,r,rrl[1.r.r.r,I/u. LIrr gr(]spiug rotlox bil;1,el'tt,l .]ru il,t,c Ialoa,t,olrrr.rlizrr,lolio, lLrcsLu srrgctiltl o su:til inli, dc lrunclri cet,ebr,il.
, :';. .4 ho[.it.'ctl re!l.et;ektr . o1teoleniliuoase sc poal,e constata in diabr:trrr lrcrrLor.ilgiiic subiuahnoidiole, irr unelc mcningil,c blcilare, in situali:i,1r,{l\isL{)lrl,ci urror polincvrite (polineuropa,tij) inteitiorsr', etihde, cliabeticc,r:o.lirgritrozicc, lxccurn fi in hts. hr stntli i ar arisr,tl alc'coneloi, abolirealolIrxr,lul ost (]o-tondinoaso nu prezinti somnificalie patologici, (ce1 multprrrgr rr rsl,icii).
. L L'rczerrla sem,.nelctr de rigitlitate prin decerebrare pi a cel,rtr de ri,oiditateprin lcc,o.rlir:are (y. a.)poato fi constata,tii irr rnulte corne (vasculare,'toxice,rrlri rr,l,rolicc, tunoralc, cncefa,litice) qi pot indica sediul le ziunii (Jouvet,I l)0{)) |ii scnrrifica,Iiilc prognostice.
5. [trezo]]t& temnelor meningeale intr-o comX, instalatir, ictiform noirrrlicir, in prirnul rinrl o hemorlgie subtrahnoialiax,i,, dar si o hemoragio,r'(,rcl)r'o-rnellingoc s:l,u o inundalie ventriculard,. jDtr-o coni, fcbrild,, sem-rrr:lc nctir4leale sint lerela,toare puntm o meningil,i (urrui lles) sau pentrurnr lbces ccrcbral. Recloarea cefei (cl atte s,,rnn6 merringeale
'absen?e sau
rLrr,r' schi!,:r,te) se poate intilni in proceselc expansile intralcraniene (tumori,tlrctrscr Lernatoame) cu fenomene de angajare.
6. _Prezerrla unr_ rnipcdri au,tomatico-rejlere ch co;r&ctar stereolip, o":d-tLu. 1,,if,cle_miFcltri caqfologice (readocerea cuverturii ori cle citc ori desc-ofeiimIrolrull'ul1 miscd,ri do apucare qi de frecare a organelor geriitale, a na;ului,lnr r'r,ltc rni,sciri ges1,ua1e storcotipe) se intilnesc irrrloosebi in comele mai, ,u l , , r ' t i , . i l lo din i r r tccl i i , in[o: ic-r ,1 i i , i i unclc mo n iugo-cnccf l l i re.'/. 1't nurdturi ole e.ttrenitd!ilot tu a*p.(t ttc ,,biitdi de oripi', (,,Jtap-pinl lrrmoi" 1 apr in cornr.le hepat ice.
8. Mod,iJicd,rile puptil.are. .Pnpileie se prozinti miotice in intoxicalia, r r o;r inrr .c. in.conLa uro-nr ice; i in unclc l , .z iuni protu bcra,nt ia l r l (benloragio1,,,rrl.ini., l rornbozii. bazilar'ri, t unrorj puni inc). pupilele midrirLtice sugerca*zi,,r rrrr,'rrc:trtre al,roplmcA stu o comd, gravd, vascularS, O midriazx unilate-rrrlrt (ipsilai;er-ali,
-lezirnii) sc intilncqte iu heruatoame epiclurale, Nubd.uralo
r,;ru ir r tr;lcercbr ale, in tumori cerebrale cu anga,jare a tonutui temporalryi irr anovlisrnele de arterd, cerebralil mijlocie sau postrrioard (asociaid culrt,ozii pllpebralil),
9. Pre:renld. anai oftalmoplegit (ptozh, strabism gi rnidriazd,) asociatd,('r.ri.crrnc rnenrngrale ne sugereazl o meningitd, s&u o hemoragie subarah_ruritlia,nd prorlusi^ prin rupturi de anevrfum. O oftalmopl6gie masivd,ilrl,r'-rnr corrtext infcclios ne poate indr.uma sprc o tromboflibi[i, de sinus, i ivr . r ' r ' , r . socieroa, of tn lmoplcgic i cu bcmnc piramiclalc. caro real izeazd,r l r ' . r r ipL'gio:r lLernf i , , nc sugfroazi i , u leziune r le tn lnr :h i ocrcbral ( tunror i ,i,rrr.r'Irr,Ii1,o, tt ombozll dc afieri, bazilar[ s.a.).
tU. n,flr.ru| Iolo.n?,otar -poi\I " ti abolir, in conrele protundc, in unelo
|'' ro irr ciLr.(f srj &Nociazi afcctarea motorocularnlui coinun qi/ Sau nervulol)1 ic, pr'ocunl qi in comele vascularo prin a, jeriti lueticA.
, ,I1.. .l)euialia conjugatd a globiior oculari constituio un semn importantrll lt.zirrnn.el,ir focar. _I)eria_!ia,. eonjugati, a globilor oculari spre-partoaoprrsi, Ircmiplegioi indicil o lezirLnc eniisfcricil 1l_,olnavul ,,iqi privegf,e lezi-rtrirr,", conf{rrrn.Icgii Jui IlrCv,'sh f i L:r,nilouz.y). Ilcvii,l i l,
*spre'partoa
h.rrriplugitii, inilicir, i lo obicr,i . l(,zitnlc nlr,i j i,risr'i, in lrLrnchiiLl <drcbt.li,l(ri r rr l l rnr ltovil lo [t11,r r lrrrr,lr,rrl,irII i nlor:ior),
: i { ) t l
l : ! , Nln:rr l ) t ! l t l t t l p l : r l l r r r r , : r . r r r r r l l rp lc l l r r r r r i l i r , l r t i i : l )11,(x ' . r r , \ l , l t , l i l tvr | | t r r ( 1 I i r , I r i i r , I t , l r ! r l r l )o l l r l l l i r r r , r ' r ' I r I ; I I I I , r , r rcr ' l l t l i i , r j l rsot t r lo i r r l ror . l r l i i , r ' r r l r , l t r , -
io l r i r l ' i l r I I i I ) r ' r ' I r . r r r i r I i , r . I r l r . I r r Io1rrr , I r .ccl l l r r r ! t io i , l rotrol l t ,g ic srr l l r r , l l l r r r r r rI t r r , t r i i .
13. Alrof iu opLioii utli lolet &l,ri, la, un bolnav couli)los porrl,c sr'i rro irrIlrrrrrs gp16 o hcmor.agit subarahnoidianir prin anelrisnL lupl, (rli lcii rirrl,ri scrrLle mcniageale), sple o tronbozii, de alterri carotirl"L (rllrci, r,sl,r ri rrlr(:rriplegic contralaterali) s&u spre un sindrorn l.ostel .Kcrrrrcrlr' l i l irrr r r r rn l i bazr l i i { lo c la j rnter io) .
14. Motli.;f icitrile reJlernlui cornean, pot, si, ofcre inrlict,li i rlo prrrlrrrrzirrrrrr, rortteir iat uneori prezinli, ,si t-aloare localizatorie. Asl,fcl, tbolilclr, rrrrilrr,it 'raiin ne sugcle:lzil o leziunc pontind,, iar o abolirc ll i lftLcl.itl i l (rrrrrrrlrliorlrr,i r t iu gradul de profunzime al comei) ne sugelea,zl o lcziunrr r rx l i r rs i i r r rtlttl chiLrl cerebrul. Prezenla rutlexului corrrcu-pteligoir_liu,n (ur, ,si :r rr,llor,r',.l lcxe arhaice) lre poato intliel o suferinl,i f trun]chiului ircrtir,rrt, ,lrr,r.lr'rflLilte oli nu are valoa,re ]ocalizatorie (reflexo clc clibor.lr.c).
1i. Abolirea reJlerelor Jaringi,an ,si 1)elo-p&latin, rr:prczilti ' i, irrrIir:rr,Ior,i1,. l)rol[nziur(' i.i, comei, dlr uncori qi semnc cle srLfclilfi i brrll)lr,r' iI rr:r||
i,rtcuilobulbin'ir,.
12.1.2,2. Clinica sintl,ro mu,lui comatos
Olinic, siridromul comatos,ue uriniitoarele co[1pouc]11,o :1. Abolirea, total[, a stS,rii du cuno;tinld (cou;iienfn;. fir corrrii, rrrr rrrr
' otte vorbi de eristen_ta altor tipuri do porturbiiri ale $1rii,rii d.o crrrrollnrlrr,.a lr)ua $9 poa,te agrava, ducind. la exitus, san so poate a,tnclioll, I I r r, r r i r r r r I r r Irrr'ozertinal in a,ccst caz simptome de trezire.
! . Tulbur: l r i vuj jetat ivc..J. -L tL.DUraIl OCUm,IC.4. Tulbur5ri neurologice,
12,L2.;i, Gradarea Si clasiJicurea comeilor
llator-itir, clracterului evolutiy al leziunilor, c:r, fi Ltlti l i l, i i,(i i lx\fi,l li)r' lri lor y&sornotorii existi o variabilitate a aspeoteloi r,linioo rii rlc i1t",,,,r,,, sl,riutl cl$siiici]rc rru cste posibili practic. nst:e ins[ }osil)ilL (; grrrlrrrrr lt '.r' ',turzimii comci $i aceasta este indispensabil si fie reaLizl,tir, d irr rlooo* i I,ri, I iclinice qi practice, adicfl ds rS,spuns la tratamcnt
'i (lc apr'c(Jiol,o pr.r,;jr'r,t
I rc,l,.
,G,raclul rls profunzime a comei nu poate fi cert stabili l, rlrrril, 1;11f i1,rrivelnl gi intindsrea leziunii majore din trunchiul oerobrtl, (lol,orrtitxrtrlrrpri criterii clinice Si paraclinico.
Dup5, acest criteriu al lcziunii clominante, noi am propu$ siiitorlrl izrr,r'ea in 5 grado de comi,, cu urm5,tora,le caractorc (tabcltrl V) :
Grailul I. Bolnavul este inconltient, functiiis vogota,tivo sinl; ln linritrrrrorinalc sau_,uqor modifricatc, toli timpii ds aleglutitio slnl; plczorrli, rlorri{rrrruc& Iel'lexolc rlo apirr,r.o $i autom&to plozonto. _tictloxrrl rkr rr,[11,r'rr,r,'lrlo prozcnt, boln*yul so apillri la, cxcitalii lo oxtorocoplivo (srr :r,l)iI,r"d, rlrr orrLrLsoi i , ) . . I l ,of lorc lo rr ,u l ,urnl l l ;o s i r r l ; p l r rzonto, bolr l lvul so api l r i i , h oxoi l , r r , l , i r l l1r t 'opr iorotxr l r t , ivr , ( r l r rcrr rn i r l l l l l ,o i t .U (Li . ! r j i i r i l r lo l l ro, so: lcopor, i ' l crr o l r i i l , r r l r r ,r l r r ,o i i i i o i r l ,o l l ig) . l , r t ; r i lo lo hi l t i norrnl ln $l l r t f r ) t . ru i r l i . i l t t i ru i , r , r r l r r l luxIr l l l l t r ( r l , i ) r r l i t r t i t r t t r r , l s : t ,u nlrul i l , . I r r r , l r to l r . l r l I r r . ic l i , voi l , i l r t t l l r . j i , so rrotr . t l i l l i i ,
-1
: ( ) t l
F,Jr!
I
E
t l { )
+
:5
<5
z
z
4
'a
6,1
r , (11'v i r , t r l l r r t r i r , r i |otr , j r r I I I I I ; r t r ; , . I r l r r l r r r ' , , r ' r r l t r I i i i I tL, l ) lLr l ( l l l , i l ' iq l l l i i " l , l rz i t t t t t t l t '
, t . i r r scuttr r r r t l t r l I i r t l l l r l l I l l , r l l t l l l l l l l l l l i ( ic lobr i l l '
( l r l , r l t t l L l , l i t r l t i i lv t t l o i l r r i t t t rot t i l f ic t r t , f t tuo] ' i i l t : vog(! l l t ' t ' ivo l l l rx l (1 l I I l '
, ' , , , " ' ' : r l , ' i , i , , i i i 'y , t ' i i i t . t r i , , t l l , l r l t rg lrr f i l ic i r - :stc abul i t , '1 ' fJ: ' ) ,1 '1"
r l t t r t t r l t t t t t i r 'i , ,,, ,", iLst', 'r 'vrrt i., r,olt i t lo ,r, ir ir,r;,r, it iT 'boiitt ' ' I.r ir ' I lobii vt:sli l i tt l i t ' t i l ' t 'rtIrt i. l t '
, . , l i i o dovi | lc ler i t cor l . iugr l l , i r , a globi lor ocula ' r ' i spr ' ( j ] ) r r l l i i l l l rgrrr i r '
1,,,., l | lci} este lnedin-pontini.rttqd,ul LII. Bolnalul este inconqtient, exist': i- gravo lnn'trl l l) i l ' l ' i . i ! l(!
, , l f ,o u"u" iur j 'e, i i l r tu l f nf J"grr i i t i , . i , lorcabol i l . t i r r r l r r t l I l i t r l i tz i r r ' l '' , ,1
, , . ' '1,, j , , i . i , ; ; i ; ; ; i f f i i " i r tr i t , ' . i* pr 'ba rt ' jurr lrr ' r i ' ' r t l ' t t i ' : r t t"r, r'rr,iri ' i, u (Ii ' l1'role a glrbilor oculari, frecvent . discorrjtt git'1 i ' srt'tt lt 'ttstttrl 'u
,l, r i l l i i oclii lor'. Hipertcrmle qi i"tt"iooo "t"riali '
oscilarLl'i ', ou 1(\lr(li lrlri '
l r . r , l tut ' r ' . Lezi t rncl cbl ,c in par lca' in[r ' t ioat i c p nl l l '
{ i rud,u.I I{. Bolnar-ui este inconqticnt, 1'otll areactit', liuno! ii.ltt t tt4tt"
' ,rlr,, i i i i i i"te gr:ay pertltrbate' kr, limiirr, curnl"atil ' ' i l itrr'.ti i cu stll)Il l 'vr{rll lrrtrir"
,r, .r,,t lr. ' ia-alii i i i,, 'reilexul ae iuse p"c,ent,*intirziat 's.au abolil; ' Nli ' lt irr'zo
i .' ', ';,,i l"il;;,l"'r;i;;;;;t-$i;ii i-o;pi"r'l i,bolit"' rit 't l"t"ltr ttottlo trtrrrt' lt
, r,.. r )r{llo-l.tr,i ibulare sint *froiii".'ff*t"iAita,te muscula'ii, ' i
.r t 'trttrirr
', i, i,"''ii,',l" l.i;;;.-i";il; ;s!" io pattea quperioar[ a' bulbultri'
t irrttlLrl | (eoma tlepir,qitd,) ' Bcrlnav total inconglicnt, crr circullr'{'irr' t1i
r , r , , r ' :LI ; r r r l l i l ic ;a l sustrnule- 'p i in metor lc de rcsus,ci tut ' " l " z i t t t r f r r ' . r " ' l t t
r r , r . r t . r t r r sc!rnenl0le bulbarc in ier ioare. Sindrotntr l ct ] l { \ l ) l l l l t l r \ ( ' r ' r r r r r r r
. r , r r , : r l lc i i creielului" .l l lr,; i ic. tail loul t le comd' depnqiti ' - a,,& cuin t ' l i)sl (lo$otr$ trr '
r ' . t i r , , i lu, t le i l i i t . Godon, in 1959-- bupr incte t rc i o i t ' logor i i ( l ( r s i t r r l ' l t ) r r r r r :
,r) ,\br:lirca totalii a tuncl,iilor vielii do relal'ic'
l,) ,\bo1irea, marilor f unc!,ii vegcttltive '(,) llEG cu traseu izoelectric persistent'
l l iD(rl,onia cor]leei cu lipsa cle transparenld' a ei tlonot?1' ttton'r1'ttu' t 'rt 'tt '
t, , ';:i l;"".i.i;i i i. i."i*'."t""e denoti, cd, Ieziunet , cttlt ' itts l 'rrrilrrtirtl
t r t, l, r rit,nuhti tli:f zona bulbo-medularS''
I :l . I .2 .4. Probtame d'e d'id,gn\stic etiololia
N . Oont epibpticd. Ctiz:r, cpilepticri, grant-l mal $'r il l\olr1iln) l:i:l,],1:,,1:l,t, t,.r,, .t{, .r prolunhi, tulburar,. a, ('on$titulci, cftr"o itnrrrrt, i '
rir,sll,I);l(ll, ',,;;,l l; i:i:, r r l" o t iro idtt'a- si poetaccosuate. tn r nocl brusc, sau r lu 1ti' r' i '
i,i;ii',f;iiit#';i";'iiJA;ffi"'ili*-ffin;v;ryft, aop'i ""u ttrrittrit'zr'l' Itittt'
.,;lll,'il;li**lr;h";:;*;,tl*t';*'*rr*qLll;t'":*lilT,f ,lill;lll::l il 'lili;i.i"p#ffi;;il. b;A;"r,-'" , lost asistrtir ari rfi't't'. rrrrrrlir",L L nr r o o sorioasa
"o^tnr.ro'r, i .si o catarmxlzi ', caro rto l i i ' t trut'ttq[tr ' . l) ltt
t l t
, ,,l,,ii','i''it,ir^i^;,ffi;;;;";;i;t-l",uiu-'ii ."u,ltntor' intru(iii) lr Hlirfil'rrl;,,, ;' ';'i,,,ri;; i;;lu"uuf iiii"itt,t incirnrytiont, aroactiv la- sf irnnlt'i 'rila .rl'itt't
,rrrr',,, r'rt ttrsltit'rt,llia, sbcrtorolsir,, S,t poi rtrtnnrca' in cLrlllul it'll:i l::::ilit'11:l] ', , , ' , . , . r r ' , .1r l i r r r l r i i , r ( ' r ' r r ' { i : rJ l i I l i \
' I ' r i " t n l ) l l l t ) r r l ls i t , l l t l r rsr ' : t ls l l t , t l { l l l l l ( r l ( ! l l l i r t l r ' l i ' l
, , , , r ' ,1 l . i r , t r , r l t r , l i io t l , r r i t t ' , r , r r*1, i r"r [ ' i ' i p 'o l r rz: ' t ' , . r 'v ' t t r l ' t t ru l t r l t t l ( rz i l l l r i . l l l l r l l l l l l l 'r r r l r r r r r r t r l , ' t i 'zc i . t , ' l r t t t , , l , ' , t , ' , ' i t ' i '1" ' t t t i i t t :u l i , r i t l l t 'x t ' l t ' r ' t l l l t t t : I l r t I I I I r I r t t r r i t t t t I t '
' l i , , l i , , i l , ' , , , r r , : ' , , i , , , ; i ; , , ; , ; ; ; i
' l ' l , i , i i ; t ' : i r i i ' r ln ' r ' " ' i ' " , i ' t t t t t t r t t l t t r r r t ' t t t t r l i t ' t .pr ' r r l ' t t t r r l
, i , '1, ' r ' , i t i , r , , , ,v, , t r l , t t r t l , , l , ' , r l r i l i i ' i l ' * r r ro l 'o l i i r i 'z i i l r t r r ' l ' r (p l t l i l l iz i r r ' l t t i ' l ' l t l t l ; '
1, , r '1,r I , ' I , r ,1I i r I | i r r , i i ( r ! l l l i l , f , \ i l , r f l r \o i t r t t t l l i l t t r I . r l : t ' r ' l ' ivo l i r ' l r t t r t i t t i i ' , t | l l r r r r r l r t t t l t l ' t t t t
: l | l
l r . t r r l i r r r r : r ,so: l l rsctr l , . , l l \ . r r r l i r r ( l r , l i r , r . r . l r r i . i r r r r r .s l rorr l . : r t r r i i t , s l : .
ii'ii,iiii;.iil,l,:"{ijl rlli,iilll #iit,ilr',";ii'l} r*li*ulr,rliiliili|ll;iliilj;ii:l':i"1;".11'.lhl1!"flijll ili.h$,J:;s,:i,;,.;:'.1.*,,','i.' siriqrro'r,,Itrrrrol ' i irrsii, ooirla doviuo Ir .,,,, .,..ii pi criv ;;i;;;ii;"li'i',:li;'i1i*it i[in1til:,Hit*: lj}*limi i ' l i ,;;: i l ,; l j : i l l i ;;,: l l ,; i i l i f l '"1cir'
&trrc se-itnpunn' p'i ir investigatii riri?i
;l;lj;i;:ii',lilji;i,iiiii,[i]""i: 'li'"il'l.ili'i;.T,J?f,$'Tl":l:iilill"lli,,,, 1,., i 1ui 1 1,,",'cu,iilr, fi i ffi ililrt":?H_?t, *"""iL:,t$1ii;i,* hip ertcn; i*i,i,
llig':f *MJll]'l',:#i:::i"x b""'"r*ir" il+ill#'i:'" ('1 ,.11ff,,:,"';Iln'iltliii;i#,;,xxfti#fltii,"-1il,!:"xi.':',*':l"lfl lli."*o*i6t)tiebuiolilti,I1uiilj,l,j;t 'l-n:*:,#.1*:-.*lxkill#";*i**ir'llili''""1'f"'u*#;i J;ll, l;;;; ;;;;;';';ruu;;"1;; i]",*if ?ffili"L'i""{1i:iii3'Tli:fir; r f#'?it,r,',il;1,5'; j1T*,'?#*1.,.fi ;x*5:i-i;"*+i"rJ::i$il.iffi*m;J"l't{l;
2. Oonxele d,in accid,entela aasaalnre cerebra\e
;rllr:iitiHif# jiti:ffi1"*']?:*:",*Iii*ilffi '!1:':i,""#*ilil::l tit i,l:.*!t:::,,_,.n"i hemiplef#lJi/ J;''J:,?li":iflli"i:.,,1ff?;*lf,;j,tr,,i !] l lir:.,i:lt{*jijrlJ fifi 1i.:.,1'#1"i3;i,*",""'sf,f i ji tl ffi1""i"f;Tli iirr v..rl.r.. cii,,,pari1,iD unei corne h un.tind,r
"" po^t"
"".1"0" porinifit"ioii
iti ;;il,iitiitfil*Ji"v,lliih*11,1?"ilfiliiti*t"Ji i""i:tt*il.i*,*"i#il: :iiiiiil', :{rl,"i iu r,:liliiuis:t ":3f r"w,,n*i,li, ?*:d:;*Htix,"ti;ili,riiiil:ii, iii"".lil; iT'lili;i,T.i,J,'i1f,.',",r1',Hi"d" ifT,.fj,li1.:"iTi,T'1,#l;llii,il,i"i,?#i*:l1l*,?gH'Hhffi1"j_".i"11"i;*ii.lr's;r"il;;;l i lcrrlrlltl l i i cotoJ.rralo lrin me
iiii,iil'i"lX"iiil,lili,t:l?Y*#.&?#,1#;"it#-"r*:#!;'#..ru'i1,' H, ri' . f r,,,,, r r rr, (Li- r t; Jiff stt.l?3f #til9,',ffi"*|t,1i#5,i#:filj'liir l r r l r r r r , . i r ' l . i t ' , r . r ' r . r r , . , i " , .1 ' : .u, ] l l , l unui hcrnalom posttraumit ic etc. .1.
, ,,,,r,lii,,itll,*;llili;,li,l'fil,)iLl"i'xlii J";iffi""""_T,l,xl'3""T imporLalrr ,'i
--iir*l*|lx'ffi "i,h3ilii3xlihi3*11?J#j''il;3,{i${ .1 r ' ' 'nr i . ' t l i t r , (1v. l l t l r :L l ( lo l [ r . ctr _Eo. ' to l0n! i1, , c ' t t fuzic s l t t t obnrt l> i l i ' .u, * l r r rrr l l ' r r ' i r r"r . l r r . r ,z i [
- i r r . . r r r i r , , in rr . .u.s t ru , i tova u, , , uoir 'ar" . i tavl t , z i r rr , r rr t ,
r l ' ( ' t ' l l l ( l_r ' l l , / . l l l l , l , r t l t t t i { i t tut l r , l iuc i t {0 l to l r r io t : t t i t r , l r t l t , l l l lo pt .ogt t rs iv l ' i , , i l r Dr l r r r
iJ t2 ffroti 'J r , t t l r r ' .
r ,Lr I r r . , r I r I r r r r t I t , 0 x i lk l t r ( t r i l t r r r l r r , r r r i r l ,o rr I i t r I . r ' t r , r . r ' r ' t , l r t i r l l r t i t t t i i , i t ' t t t r I ' I I t , t t t t r i tL i t ' ,r , ' . , , , . i t . .Ltr , , t t i , I t , t r ' ' I L l t t r , t t i t t t ' t t l t r r l ' , \ r ' l t l r t t i t i i (xr l l l l ) . , l l l? l ) $t l l l l l ', , , , , ; , , , ' , i i , , i i r r r r r r l r r ' :Ltrr . Hrr r l l . i r r r . i i , l l r r r r r r r l r r , ' ,zrr . i ( t r r r r r I t i r t t ' I t , i j i I t l r r t r t , t . t t t t t t
rL : r r r rzt l i , ) s i tn l l { ,0t l t l t i ,o l r tg i l t , i ( l t i i , t i r r : i , ( i t rst t t tL i t r ' l t l iv t ' ts | t l r r [ i t r i l t r t t r r t t t t r l r r
r1',',, r.i coirrir,) lioato fi rti:i l iz.lr,l,i ' (1.(, (, t,Ltru(,i!l (! .trt .5r'l l lt ' (1tt' itt lttrttt 'rrt';1it' " ' t " ' i r r rnoral i r ' ! i
c t lo ln, pr i rL l ' r rg l j i ' r i l le unor tutnor i l t t . r ' t t l t l { ' i r r l . t l r r t t l i i '
,,rr,r li '! rlr r oirient tlai;, prin mlt, staze cereLrrnlo cu r-rvolLtfio IlrPitli 'r ' 1i rrtti , ' , ' . l ,o1ont i t l edemaio=s ; i bcmolagic int t l t t tmr ' r ' l l ; '
r " i jdent intna unei hemiplegi i la un boln:rv colnf t loJ (srr ' l l or l r ' \ t ' l r r t i r 'r . r r , . , i ;nro tom5) reprezint i - in-general un bot; , r i lor atgutt t r . t t l . i t r f r r t , , : t t r ' ; r ', , ] , . , , ' i ident o aicuia" cercbral i TotuSi, in unelc s ixuf l ' t i i ' i r r ( ' r l ' r ' ( r l ( r r ' : r ' t r l lI r i, rrr,r,l vascular s-a constituit la ttistan!5, fa!5, de cd'jlo nrultli i l)inrlt I i( lrr|1'r,,."' ifttcgia poato lipsi, dar putem constaia allie semne neurolog i.. l 't(\21\lr(r!
l,rl,rit,tr,l-L a unor- semno neurologice (indeosebi pirlq'1i{alg)' jttsl'rrlitirr
., ' .,, :iLitent sau in tloi t,impi, suger-eazd, mai multe posibiliti (i : I t ' ' t t t r r t : t ; i i r r
, u r i t t ( lat ie vcutr iculard ' , - procis ocluziv bazi lar , hcmatolrr ( l r ' 1r ' t l l r r ' l r l, , r , : , r .L l . h ' " .atom emisJei ic cercbral (ct t marc cdcm l i i sau i r l )grr" i i t I t \ t l ( )l ' ,1, , , , , r |oral , cu c,r l renarea in sufer in l1 ; i a enr istmului opt ts) ' l ' r ' r 'z ' t r { r r ', r r ' , r l r , ,mipl"gi i inr"omplote la un paciont cate cvolu-cnzd. splo ( ' { r l r r i i l l { l r t : r
' , , , L ic i r inea unui Drbces expansiv : hcmatom subdural , htr l t t r t ' lotr t i t t l t ' t '
,, ',r,,),,1.
tumoale cirebraiS. (Lrseni qi colab., 1974 ; Yoicultstltt ryi Nloit'rt ' '
| | r ( ; ; ) .i 'r ': lctica neurologicS, ne mai invali' ci, tol'deauna, i 'aitrtt: tlrr rt' rt ' l ittttrt'
rlr,r.l|,rsticljl l de accid"ent vascul:lr cerebral (hemor:agit, Fr,lt i l l,rt,t: isrrlttrttrir'),. r , ' , l , l i t : l1o| i r l rd, c l imini ,m, pr in cxatnini t i t l r 'n lo i ' l i r r i ( ' ' r ; i | | i t l r r ' ' l i r r i " ' :1, , , ' t r r r r , i lc le l raumat ice cxlraduml $i subdulat ( iL( 'uL i t i s l l l ) l l ' ( ' l l l ) ' l l r l r r r r l r r ( ', , " , t , . , lo, r ' rcningi tc le f i mcn i l lgoce{aUl r ' l { r l1u i l rs l i t l i t lc r r r ; l i r l i l i t t t r ' l t r { t "
l I r r , , ' rn i l , encr ' [a lopal i r , h ipertcnsiv i s i crr l lLru ( l ) ] l { ' l ' l r | i r '
lt i|r,grrt,s|icul de mcefaloptt,tie hi.pcftensinii osi,e ]'ol:L1,iV tttltlt. tlrr ir|,l l l l iIt|,
r, , ,r i. nl toarelor eleircnie ; a) n6 afl6,r in falil urui crt'z' rrtt I t' t t 1 ' t t t I t r t I I ' t t | ' r r
i,,,,,,1,,r,si..e {fie cu hipertensiune a'terialii, a.sa-zisir' cstrnl'irrli i ', l irr tir" tttt
, t , i r . r : l rcfr .Se;Amaial6s, i r rcadr"ulunui feocromoci totrs i l , l l r r , r r l r l l i l r r l r ' l r , r r l
, , , ' , ' , , ,unla-rnoal , in cadrul unei coarctal i i r l l i -1 l rL l tor l i ( , r r l t t l r ' i t t t t ' t r t t r ,, , . l r r r i , ts i i 'sau al unui Satu'r isrn), cu masir-r ' t r ]1 ' t ! l r . t ts i . t r l l l i r ; i t r t t i t t t ' r r l '
t r r l i ' l i rodi f ic [ r i a le I l .O. (pini la maro edcrn prr , l iLt t ) 1. b) Oott t i t t t t t t ' r t l "
'r,,rr lrr.ofunr15,, cste de obiceli tranzitorio I c) O'trta, trs1,t: tltr tttttl lrr rtl ' i ;rlttt tt
lr,,r,l i iui "oo""i*ii
I i l) Cefaleea este intensii; e) Se 1lr-tt' asotriit ' 1i :rll 'tt rtrtttttrr
,i,i r,,,,,.," (uriu importantul etlem cerobra,l) ; f) J)c .bicci I r t t t I t r l r t , I r I I r I t I t I t 't, ,,,,l,,,ir"iaid, este
'lrccetlatS, rle fenor*ene protlrottti.t ltt (trtrlrlltrtr ittlrrtttti l,
r rr'r, 'r rr nii, episoacle-de confuzic qi obnubilare)'ilamoriaia subayahnoid,iand, de obic.i nu crccuzi, r I i I i r , r r | | , i i, t i r l irr,ifrr,
'r, i, ,,. ,,, inilr"iiot *amiologic li ind cel mai adcsea re't' l i l1,ot' : s.rttttrr ttt.ttitt*rrtrlrr
'rrrrr,tiri,ntc" cefalee inf,erLsit, tu vii,rsl,t ' ltri, rrrotliticili :r'Lr ' lr ' 'O (itrrlxrrlirttl ', ,1, 1 i f ,d^o.*gi i ret i r r i , n, ' ) , rn ic i tu lbrrr l r i d{ ! oonl t i in l i , ( t | | I I I I | / | ' , , ,
I
. r . , r t , , t ; ; . l )^ . ih,rnrO1OTic, Sd| | l r ru l r ' l ) ( : i , t : l r , .or i cr t tn i ) , r ' lutrr t lo ( ' ( '1, , l t r i r r l r r r l l l r '
, , i : i . t , iu,r j t ipS"*" . p lgzon!; ,n ' lcz iuui lor de norvi crani{ tn i ' ' i
r t l l i ' t t t ' t r t ' r r t t i t t r t l r r
r*,i,,,,,, 6.o l ioalizaro 'o
p.1; srrn.r.i:r, topogtali l t, qi latttrt trrlt l l i) lrtrrrl ' i . i \rr 'r{
, ' r r l r r t , , t i ,s l t t t tLzi , t t t i t t ' t t i l t r I l t t t t tot ' l l ,g i t r ' pI ' i l t I ' l l1 l tu l i i ' '
l r i t i r r r r t l i t i t l i : tgt t r r ; ,1 i l r : ptr l l t r l t t I I i t t I 1 r i t t I l , i t t ' i i i r t : r ' { i r r ' i rPl ' t ' i ( i l i t t t r r ' t
| r | | r r { | | | I t ) i i l , i [ , : r l l t r l ' t ' l l t t t z i l r r t l t l : r ' r I r ' I r t t I t t | : r t ' ( ' i ( | I I I I l l l l l l l l l : l r ' t : l r r Hl l l l l l l l l
, " , ,u, f , , i i , u i ' i f i f i r r l i l rurrr* I iLrr i r .orr , r ' r ' i l t r t t t t l l , r t t t t r r r t t 'o l t r i r l r t t i l t l o t ' t r t ' i t l i ' t t ,
, " L l , , , , , r , r , t i , , i , l i r r l i r , o l r l t l r . , | i l$ io r . r , , r t r l r t0. t t t t , , t t i t tgrr t ' , { i t l l r l i t tn l ' l t l l t ' t t r l t t t t t t t l
;i,l 8r3
ll
I r I r | | , I . | | r , I I I I r I I i i I I { r ( t l j l , r l t l ) l t , ( , i i l l t i , ) \ is lc l l l r . i r r i r ;1 l l l i , r r ru l l l i t 1. , l l : I i i r l l rI t t t : t t t IL i t t t i ' t t i I1) i ( t ( fo l l l i l r l r i r ( r r r | . r l r r r i r i i r r Jr . r r r i r t r t l i i , r l i r r l s i l t ,z i r t t i l . isr , l r .r r r ic. r ' r ' r . I r l r r , |o) ( i \ r 'sor i 5 i . . , l , r l . r t ) . - , l t ,?1; V, , ic, r r i , , ,s, , i i 1 i Sl , r lc i r , , f - f i t iZ;l ' : r r . r , r . 5 i r r rLr l r - , J, l . t7t i , r , i l r r , l i j dg J j61r6r. . i1 i r r ; i 6 lab. , J l i f i r i1.
. t ' ttt.qitttxttt 'ut ttt. l tt.t ntiq[ , ln,trc. henro.a,i.d, eerthruli i ; i in.ivctul urehro.tl r r l r r , r ' r r l isr ' l r . r r r i . ) r 's l . r r . c.ro rni l i nrur l , . i * i or1;rr : rn t rc ' r r i r i r r i i , i ; ' , , ; i . ] ] ; i ; ;r r I r rrrr . i I . r ' i i i . ' r r r rr ia. t , ra,rLz*r l ' i i .q i f ,s i : r ,u i , tcr ' r ' i te, ia, aio" i pr,r , i l ISugr i lcesl ,crrlrrcirrl iri i J )i u'i r,fc:t zi' i diaqnosi,icul.
, .. l,lris1,ji,, 101rr5i (). scrie rlo clerncltc rlifercllialc (nraiotltatea stal:il itcrrlrir, rt(i rnirl,o'ii .l:rsici) i 't:.e :r,t:Icul aloploctic'heinJ'a.gic;i ce. isoheruirr, , l l ] ; l ' ; l l i l i : : l l i . r . l i , r r l r1, : i -
\ - r r icrr losnrr q i -S'oiru. i r ro i l r , . , , , , . - i {oJcb.,r : ' rD. r f , , , r ' t i i l t t r l , , , , r ,pr) \ Ic iu ) i ccl" l r . , IgsO) :
, , . . . . , ,1. , . i l
rX, ' : ln,r t l l " apr, ' r . i rz i , i . , , .omti ) 'o l id( i r iLclr , l : r r i i , ,d.c, r i r lcc) ,j i i , ; l i . , , . i
, . , ' l l ] l j , . ' j : l r . l i l1 ' . prot iundi i f i .sm,vi _r rn:oi , i r i s i r i , i rnp, . , r ; rn1, .
' r r , f : r r r Yr, i r l iu l t \ 'p) i .s lc rc! . ( . l i1Jfo3l ,u indeosobi peutru bnmoragir , nerc_
] l : . 1 : l l , : : . l , l l l . i , . rrrcnr. innt.a.srr ir . i i . te conrrieni,r, ' i rr-"-.on," \upcl iciat i t ,ji,r'illill;ri lil' i;li;;;lj';,:,31j"3i,.i1,;liin,8i,"",.l l';l'.J;?;l:)iu';J,'1"':,".1;rrr,lrorrric. ?rczenta nnei irnr:ortante obnubit.iri, *;;iu;t"",, o hemiplcgici.r,rrr.rrplctir, ne sugereazi, riai tlegral-li, u" h;;;;;; intracerobral,t) Ih.utatitatea, t)rusctlettea instat,iirii iiifi"iiiiti,* r,rootitii nraltii,\.r'r'rrr. {.irr,.ictcl.isticii _p.ntrr homoragic, s_a iio\_edit a Ii rlneoli ulr eleir:eni:||rl 'r:rtr,r,, trul, J:l lel de bTusc, de lirutal, putinilu_sc instala qi ntr etac is-
i 1:.:' ]i.l,l.|i:"ii llltnea,,o hr,moragie-se loiate irsra,ra, uncolr icrirorm, da,rr : r r i r I l j r ) l l t , i l t r dn colrs l t i .u lJ, sr t t , .h i t l , in r ut l ]cnl .
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' ] . . ] ' . . : l l l " r ' : r l 'zrr t ' r { t r ' i r l t i :uz:r i i l r , r r i t , ; , r ' r , r ' I i r l , ' r 'ur , , r r" , ,1 rrr ' i l , . r l r1,
. l \ l r l , l i ( . r ' l | \ i t l r ) : . t1. :L I r , , , ; r , I i , . , 1 , , , . ; , . .l t ) l l t ut t t l t )nnt l i t t l t r r tot t l t t t t l
_ srr f r r l l l r r r l r r r i l i , i r i t i , r l r r r r , :1rr l r i , , . . , i r i r r rr l r r i r . r r . r r r l l r . i l i r r r l r i , r , r r i r r I l l r r r I I r I r r , r , r I r , r : l , i , i , j , , , , i i " i , ,1, , j , , r , . , , r . , , , , , , t ,
l l l l r r ' : r | r | | | | r r I r ) | l I I r I r I r i , r ' r r r r r t r i l , l : t j , l . i | | : r l r ; l l . ; i i ]L , t i r r r 1 r i r , r r r r , I , , : r l r , I r r r . I . L, .
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, l r t r , l l t t .ogt , r rs i r i t , l l r , r ' : r l r , i i i r i l ! r r 'L i t , , : t , r l t t l i i , r ' t l l r t l t s l r 1r I i i r r r i r r i . ( t L l , l l ! r r l i f
, , r t r i l i r . r r r . r r r l .zr i r . i . r r l ;yr . , r . r r , r ' r l r t r rqt 'cs iv r i r r l t l t r is l i r t ' t l t l i i t t t 'ot t t r i - i ' r ' l t r t t l l ' r
, , ' r r , r l , rg icc
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i : r r ; r
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' I j i t i t t t 1r l t - l r t t r I '
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, , , l , r r l r r l ic t , a[ccSc' ccrebrald . tc.) se instaleazi t lont-pr.gt , 's i \ ' ' r ' : r r r ' ( r r L
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t
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, rnt t i l r t sc i r ' ' t : i , lo l , i l , l 'u :c ( t l ( r r l l \ ' l l l i l l s l ' 'o l l l l r '
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, ' , ' r l , l , rg ioo i r t i , r -un.ct t r t1 ' t lx t t lc r t rgr t l t l ' f t ' l t r i l , r ' t l rnor l i l i l l i l j t l r r i ip i t t l l ; t t r t r t l " tr r r LI l l l .
l i . ( lo rtr : l t t r l i .s n d ubo[ice
, t . ) (1, t t t t , t , l t 'Ltr t r l l i r t tnt , i t t i s t r j t ts i i l l t r l lz i r l r r r t l t i t 'c i t l t t l t i ' t r r t l l ) l ror l l r r r l
' l r , , r ' l r l rs, l | ' r " t i , i i i r t , , r ' i , , r r ' r ' ' r l r ' I | : r t r r r ' . " l l r l " ' l t r tspi t : r l t t I ' t " l t t '
t '
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) t ' , , t t r , r i t l i t t l t r l i , " i r l r r r r l r lc l r r r l l l r . r '11 1rr l ' / i l I I r I r r I r t I | : r ( r '
: r ' i r t r r r t I r t r r l
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, ' r ! \ r , r l i t ( l r f r ' { t l i l t t i | | i r | | | | I I I iLI , I l , l r ; I I | ( I ( | I I i r , I I , : I f i i t t r t \ ( , : i r l r , t ( , i l 0r( . ( l i ( r : t , l i r f i l t l i t l i t ll r r l r ( , , r ' lo l l ur i pr , r , l r l rg ih l , r r rcrr i rur l l | , I , r | , r , i ( , i i l , u l i . i i r r l .c( , l i j i r r i r . r . ( , r l r { . r r l , r ) .i ic i r r l l r r l l r rz i r , i r r r r r r r r l l t l r ) t . l ls i \ , (sorrrrurLlrr l l i , r l ls l r r l r lq l l i r t i , r r lxr i 1 l r r r i i j ,prctr r l r r . l , i r l r r . l r r r r l lo l r ruc (ol lost l l l i l , r l t t lot ' i l t l t r lo l r r i t l l lo, ; t t ror .ur i ic , g lo{ur,r ,r : r , r ' I r r r I r r I i , ( ! r l i t , l ( : { f , i l , ln. . l ,c l i , zg() luot( i N, i l l i i iu l i l r 'o, : r }at i0, s0Irztr , i , i t i r t i r i . l r , ,l ) { ) | t | l ) .
l irr r rIrt,i,oIr,r'rI sirrl, tl i l i;clo r.r-lbrtrrlrllui gonctrll, p(. irrpli,t.l.Itc, ]lcurol(\li l; , i r l . I r I I r ' r , i i , lo} r ' l ls l tcct t l tshi , l | l t lut i t t , t , tnrr i - tLtui , cu tegurn(x] i . l r \.i i*r I.. I '(l(l i Ii ciurLotict:.1 - gl.bii ocul.L,ri h.iytrtori la p:ll1:lrc I - itratii lrrrr,,(llJ Irl,irrriri), crr iuspiralie pr.'ihngiti, apoi pauz{ tt-upi, bare cxpii;l(,itr,{,ilr) irrlurli) rilrrtlr,i i, rlr.o:r,ltir p:r,trzr'r rn:],i lunE:t, (r,espirll ic ascnri,niit, o i l,r'rr (r.rrr {l{r i,ip li.i issnnrrl) ; ,-- in haloni, se pcrCepc lniroslrl de acetoni,;lrilrolr'lrsiurur l,t{ct il,l i j,, l)uls slab si r.rWidl - hipotrrrnic, i _ nalcati; lrilrrrl.rri* rrL'srrrrlrr,r,i,; hipo- sau arefletiu 'ostco-ien(Linoas[,
I * nidriazii :,
, ' r . r r , ' r l r : r ' , ,1 inu|r t i r . d j r l 'ot i r . i r nu n) ic i hemortqi i h l ' .O.; _ pt .nz, . l r l : i,,lLrrrrzr.i si rr, r.oll)il{rr (etnnici in urin5,1 - gliccrnia rnult cresenti,i rezcr.r;rr,: r , l r r r r , l i r r i i sc i izut l i .
t ) Ct)ntq tlre ricd Nste relativ usor de rccunoscut : _ antececlcnl,rrrr|lloprrlice l - arproalc totd{ aun:t r.str. Irr.:cet1rr,1,ii tlc Drotltoarne ca,r0rrrrrlurrrrrrlrcezii : oboseal5, cefalee, anorciie, glealri, v:.irs[turi, diarr:o,(liri l)rcr', n).iodozopsii (,,,rnuqte z}uritoara,,), eclipse vi2uate (pini, la amlrrr',,r...1,r'rrrrz,ltririi), rnioclonii,,si tresiriri fnscicll:lre mlscuhre, ufteorl ortli rrlsii I - l 'ri l lonii, lu.c rriros a.mouitcll; respirrr,{i:r, r:s1,e de in[lte ori rlr,lrlr (rirr1'11s Stokes; - bolnar-ul Ostc palirl, hilotelmic, cu pleoapol(lr,rlrrrrr,l i ir,lc fi lrozinlii, sughit; - pulsul este f,,irtc binc bi,ttti Ourll.rr.irrrrrrr, rr,r,tclia,li l este cr.cscut5, - cordul estc rnirii,, cu zgomote dlllr.i lr lrlrrii i.uli pcuicardiacc i * la examenul nelrologic'sc cons1,atrX, semlr{,rrr.rrrrgitrlri, rniozir,. hiperr.eflexic osteo-ten(1inoasii,, i lneori seinne pitatrri,lrL, ii c x I rr lpi r:lrnidillc (inclusiv flapping tremorj ; - la exaucail F.().,r, r.irirslrrl;iL: ncur.orci,irriti l albnminurici, cu nLorlificiri evidente vas(ilri;rr', ', r.rr irr.srrrll l l,rr ,,i l stca,,',. cu cdern sau s,lazX papilar[ cl hemoragii I,. r,orrrir l i i oliguri(i, :r,lbruninurio, azotemie ma,siv6, acicLozJ,
tl ) ('ort.tt, .ttotrnir:ti sc irst&lcazit tr€pta,ij I,r, un bolnav carc a prezentu,t,, rr;r:rlrrii *rlrirl,ltc (pri1r a{ociiuni gas.iiro-intcsitinale salr vi.r,situricentra,l.)r, i , :i,r',, rnr t)it,r:i[1,11 rles]ridratat. Se,rllne1e proclrornrllo Sint asemxni,toitr\\.rr r.r'1. riirr (,o riL ltr01)t.icil, ca fi,tar.e diaglosticul difcrenlial va Ltrre scanlr,lr, ( rl,:\ir r,lcirrcnl.c t.cr.olatoare: , bolnav tleshidratat; * TA scizLrtrl;
r,rrrlrirr,zii i l)l.ozon1:n :lzotemiei, a alcalozel qi a cloiopeniei., ) i l,ttttrr, tr:itr,ny|ioi este u,sol. de recunosou.t: - ilsoleqtc o toxicozi
' r ' r r r r l r r ' : i r l i r r : r , r lorut imni i l_r te: i , sa,rc in i i san in crrsul nastar i i i _ prczir l l , i ,'r:r | | r, ;rl i i Ii 1r|,ll i orlr!,lc I ovelatoare (r:elaiee, v5rsi,tori, cdlme , ilbuilimrr ir,,l r l r r . r i , . r r . i r r r r r ' , o l ig i l l i t r p in:" l la arul ie) I - - coma debtteazf, 'cu miocloni i ,lrrrr rr i r r I r i r r I r . r r i I I I .,ir.,,.lsii l,onico,clonice (:rdesca subiriIante) qi chirrr;r , r l r l . r r r r , Ior . : r lo crr lc l r r i r , lo (parcze, mftni iest i i r i a lazice etc.)"
| ) ( itttrttt. lu ltrrLirii ut ridicir lroblemc cliagnostice dir,ci, _tiflom Sca,rI| ,r l . r r . r r r r r i . r r r . I r r . l . r r rcrr i ( : : - - antooet lctr te ] ropat i l - ro thcp: i , t i te gr: i l \ 'e 1i{)x io{rrr l r r r | r ' r ' i ror l rc, r i r tzc, nct i l t l i tsrrL l iep: t l ic) , e l t rn lu i l et i l ism cloniol
rrrr r i l r .s l i i l i l r r , r r r l tut t l t , l t ror ta,r , r . r . r r ln l rc l t inslcsjr l l ; r , t l l r l r r , ,N, l )at iorx,Ni( \n i ( rr r r : r . r r r l r t ,sui i l r i ( ,y i rs i l , l r i ,n l { ' i , ' i , r , is r . , , i i r r ;1 i1,rr{ i , . ,s. r r r r r , , l , , r r ( , r . i ,progrosiVi I , ,r ' l r i r r r : r '1. r 'orr l r rz ' iorr i r lo, s l , i i l i r l r r r rq i r ' r r r i i r . I l lsc ict t l r r l i i s i sprr ,srnc rr l l rsr i r r r t r l r ,r r r r , ,o l r r ' , r r rvr ls i i r l r l i l r o;r i l r r ! l i r , ; , \ rpr .c l , r r l I r r I I r r r r t , r r I r r i r : l i i r r l r r l r r | r r l ,o l , :| 1 r 1 , I 1 1 1 1 1 r I I I r ' r i i .orr . i r r r t . , l i \ r ' l l , i . l ( t . t { , r , . r . r r I r ' | : r r , l r r r l r i 1, . , i , f l i i r i r lo l r r , r r ro l . l rg i i
: t I t
I r r r 'qrr : r1, 1 l l r , l l l l t t r t l 1 ' r ' ' r r r l r l r r l r I I r ' r t l l r l ' t t t l r l t ' t r r ' l ' t r l r ' l r t r r l t : '
, l , r t r ' : r l : r , 1,* ,1111 l r l r1r l t l l r ' , r t l r " r l r r ' l r r 1r r IoIr t l I ' I I I t r ' ; i ' r ' r ' r ) r1r l l : r l : l r r r l
r r r , l tor t t t t r , t t t t I I t I I i I t I , 1, , t I r r I r , , r I ' l " r r rLrr ' r l r l r ' r ' t l l r l { l t r t r r t r r r r l : l r ' l r i l r r l I l l r l '
, , , ' r r , , ' r l t l t l , i i l t l r l i r l l 1, t ' i l l l l " l r r l r l r ' l r r l l l r r l . l ) r ) r l l l l l i l l
i r r t l ) ( r7. l l lo l l i r l '
i , r r l r i l i ( l { ' l ip t lor ' , ' , , r r l r ' l ' r r r ' , r l r ' l ; r i r l r i l l i l r s l r i i r l ) ' . r r \ ( l l l l l r r l i l l : \ l ( '
t ' , , r r r l l l r i ip l t l i , ' i i r rc t t r I I : r t r ' : r i ' I r 1r t ' rgr l r i t ' . i t l c i t r l i r l i r r l i i iSlr t r ' lor ' l '
' r , l ; ( i I lo i l , , i l l i i?; l i ( , r ' l ( r r r , l ! ' ( ; r i I i l r r l i r l r ' | ' t i1)r tv i t ' i t t ' l l l i f i ) ' r r r | r ' I t t r r l
, r r l r t l t 'sc gr i t l l t l r i , , l t i l t r : tsotrrrr t " t l l t t i tL ' l l r i t r ' i J l r l l r r r l l l ) t r ) l l l l . l l l l l I r l
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, , i b, i , , r i , i i i e iceful .oput i , t l t r 1t ' : t l " ' l t t t t lu l t lx t tu l t - t ' t . t ' ,n l : i t ) t r ' ; r t tz i t t l "
, , , , ' : i ' i , , i , ra i j t i , , , t r . i ,u c l t i , , torrr i i l r tprL ' i i ' ' ' r " 11'r i r r l rcIuLrr ' l r r r r i j r t r t t r r r r lot t r , , r r ' l '
; i , ; , . , , i ; , i i l t i i lu i ,o i l i " i . r ,19?d),c, l l ,e lnrnl t rLur- ,herzio_sirrr l r rorrrr lo l r f ' r ,, , ' '1 , , i i , , , i taLr ioul htpal ic qi neuiopsihic t ' \p l l s in cadl l r l t ( i l ) r ( r i l t r 'pr t l t r '| , r ro so aclar lg i l 'J in s ladiul precornntos; i subr 'otnalos' t l l l l r ( r l r r ( ' l t ' \ l r ' l
i ,; ' ;,i;; ,apffii 'at"pr., a rrriirrilor', elcnLuiib ,' l l. l l l i ls ti ' ' root)) (Slr.r' l,r' l '' .1;r : i j i l ieJ, 19i iT : c i i , i t ,1 i t le T'r rpuvjc i rL, 19i l {1 I ropxrr- i i ' i r t , l ! )?! i ; i i i r
' " ; . i i i i ; r i . ' i "EI I I 'd iagr iost icul" ' ' : " r ' rL i leqtc l ip l in l r ru l r t r lc t I t ' I I t I t . t I t I I I t| , L I ) r . r ' r luronient ie) .
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, , , , , r ' r r , cr i ter i i t lc d iagnoi t ic in c i teva come to) ' icc mai t l t :s j r r l j l t r i l r " :
,r ) Cotn,r, alroolicci oste precodat'; de citeYa serrne dc rtltrottlisttt rr' 'trl
, r ' , f , ' , i , i ' r : , .L,1rtz ic, r l iznr i l ie, u l r \ i ' ' \ i l r i ' l l l i i ' r lupJ {-rr11' s( ' I r r ' " t l r r { l
, , ' i . ' , i i i , t .1ni , . i i ' on. i t r r rcr i lo lot ' tn idr i rzS. laLicardi( 5 i l r ' ' I i t : r ' { i t ' l ' t .
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,i,,t, tr:i i iri, i ipotensiune, cianozir, r' lcirea cxtr emitr'i l i lor ' '$i o ( {'rrr'r
,,,,,i,,,*fii-"ii-Oiula'ri1ia tlltutil rellcxelol, cLl respira.lie CI(r).r(i fi lr)li( 'r(, , Ll
,,,,,r rrlsii f,.rr"o"i) si'clria" cu tenourene de rigitlitalc de tlt(crthlrrrr' (rrcDr
,t, l,roundstic gtli- ). Coma dureazi pini' la 20 de orc'
It ) Ooma mc'titicd, se instaleazi| brusc (chiar 1& ('i i;tlYr'r' tltirrrrl '. rlrrlril
,,,, ,.,,ri,r, ,i,,uufiil it i metilio)' realizfutl ulmXtoalc'le sill lptt)rnc : Irtr i. r I rrl
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, , r7 l l t t .' ' ' i l i C,r ,no barbi lur icd, . in c:r 'zu ' i rD' l l lc sr ' Ical iz. i r l ; r r lo l l ' r r t r r i i r r i l r r r r r l
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i , r nr ls iy i t t r r i t l r i iz i r ) , d is l } l l l ' i l ia 1 '0f i ( ' r t ' lor I ' t t t r l tnotot l i ( l ( r ( t I I | \ I I I I ( ' | | \ i I
r , r ' r r i t i l l t t l i , ro|orr t i t l ' t t t i t r l i t i { ) r i l r , i i I r r i t rs l : r l i l r ( '11' ( 'o l I Ic j ' i j t f r ) l ' l ( ' ( l r \ ( : r r" i l
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r ) ( |or t t r r lJ t i t t t t l t i t t tNt ' ( i r r r l l l rs l l r i r l t t | i i ' t r tor ' l i t r i l ) t l i ' l r t t l t l t r r r l r t r t t l t "l , , r ' , ' ,1, , l r t r r i i ' l l r i r ' , I l r t ' t t l l , , i t t r r r i i t i t t rot i t i i l t t l r r r l l t t t i r i i t l t i .zr t l l ' r t I r l ' '
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, , : r r , , r r l r r r rg l i l l i ' r r r r r r
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r r ' l l { r l r ' ! j t r l t t t l t r ' t l ( f , I ' I I | ' | | | : I i t ' I t t I ' , i r : r l l i r ' , i r l r r r i r l r ' t ' t r i t t r l t ' r ' i r l l r t l r r r l r r
t . ,1, , , r i l , , t r l l 11i l t t r t r , ' l r , , . I l r r r l : r l l l r " : r l l r l i t l r l l i l I l i Io l r r r r r : r ' l l r l l i l t ' r l l l l l
t r , I I i I I I I | { ' | | r I i I l t : r l r ' l i l r l t . l l r f \ t . l t f l r f l l ro l l i t ( , l r i l ; r r loztr r l t . { ) , l0 t l ( l r ( , t .of)
, r l l . l lJ r i (nr() l l rn i r i r r . i l t l t r , l r i l l r ) i rc l l ! l iu( . ( f I I r I ) I L r , i ( . i r , .. l ) t l t ) t t t t l )nt) t l tutul io l l (4 i (? 'sc l ts( , lu l ) i in l i i r r l i r r i i r r l r , r . i ( . l l ro l r i r , l l in
11 ) (1rnt t uxrt i t t , i t , r i . .s l ( ) l l r " . r ) ( l iL l i , r l . 's i r r r . in | . r , io i i ( l i i ( r , i r .x ic l l r , r ( \' i r : r ' r r l . l i . . r^ i l r . r r r ,1r ' i . s i . rL rra,rrroir rar i i . obicat , i l i i r , , .0 i rs i , i par.r ' ' i l r r r r ,r r . i r r r r r l r l r r , ( i . . r l . . .s . l * l lo po1, I i r .vr l lu| r : r ' r . ( ( l : l ' l i i r . r ,h i i , i , l r r l ) . , . l l )66): r r r i ' l_lrr,lrrrir',...trrirl.irr,zii, i,*lr i.a,rrl i.,. (,r' i ic'r .,1 fc!oi, h,anipirrr,!i i, h\re.icnsirr ir,,: r r l . r . r ' i r r I i i , l r i I r r . t . r . r i r i . . I )oslul i la . r ,p i r1 se insialc lz i , cu ' .a, a io0iat in . ' :I , : r1, , . ' r - , . I ' r r l i l , ' | l l . . l i ] i lor ' l . lpslr i r l l i t .ncrcglr lu l : i . t r . l t " spirur i i r .eci , s l r r , r . , .| | r ' I t : l l ) . r . 1, , 'z j t t , t t i l r t r . r ,sr .111g;r r . . ln l_2 g I 'or ot , , l * : u.2u ur j t { } Arrr r r r I r r r in is lL l r , t ,o l ) i [ rcn1,oi 'a] i , .
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i . t ) ' , r , t . t l l l I t , r ,n1 , ,1a' ' 1oni .o_r. lunino, : r lcosnj , , r .on, u l"s i ' r ,l , | | r r r l t r r l l : . i j t rn r . i r r inr . lnr >UbinL|ant. O( l t t : - r CU anrOlJndtt .oa Sl l i I i i( orrrloils{r. l,l, r.loze mai nra,ri dc.hidr:lzide, coma, sd instalcazd rapirt,rrrrrrl i l i i rkr hipol,onsiule, tulburir.i respilatorii (cu impoltanl,i, bipdlsr,, r('tro J)rt)ltf ioii) f i de hipertcrmie. pupilele slni m:irlrjatice.
t ( t , . i l , : : ! : t
i t , s , , t . ia i tg! i ,o, ta m:I i rar j . put inJ i i ancir leulr l i \ r .u l rut i r l l l' . . . r t ' :u a. r i r ur ' rnr r { l tn i r is l t i t i ! t leaspir in j in doze rnrr . i l l , .u l_, i i t lcshidrrr , r r r ( l. t ' , l i . . r r t i r . , . s i tu: t ' i i ,n l ro permit . r^umui l |ot . t l i , . i lc t i luf . Jnrur ina, i : r , .1 ' . ., r i i, l i r rriri j.L ll in (Vui,.ulcscu_ ql Stoica, 196? i GaL tier $i colab.;196(;) :I r , r r r ) | | r ( , r | ( , rlc e-rcitafie nellroasii, ct tremur[turi, anxietate; agitali6 psjlrirrrr.lolirr, sliri l\alu cinator,delir-a,nte. qi (uneori) conrulsii. Apioape titrt,,rrrrlt ,., ' irfx)(,iir,zai ;i t,ulburi,ri digcsti'e (grof,uri, r i ir B:rturi, -colici
abdorrrir,:rl( ) r{i . t|ir,rispirn{ii abunrlenic. ,ficspirttij lc sin1, ll,mlle qi irnbracii rrrr:r rlrll i rlo lip l{iissnriurl. Faza rlc excrtil ic lrccc it 'torpoare si colrii,,lr':rl,t., irri!iu,ir-r fi itrrl inloc*itl de acidozd,. l]e cele rnai'i lutte bri- ajr,,,:I ' i ||{||rri 'r)() lr (x11 (n'tugipirre la nivelul tegumcntelor ;i ar rmrcoaselor (carilr,I r . r ' rs l r r , r r t r1rs1l i i tL l ;or icA! i i ) .
. .. i 1 ,t . 'r,,, ' t:.t;. ',
,, '.:,:., !.,, '.).i. aryo noJus:Io t;.i , d iizopr ,,pilfl uoro Iost:) t _ l)1,1,;r , t r i , , l r t l ' t t 1 ) t , , - l i r l . . . . l '1 . ) l ' l ) ; . h|r i l . , .1 i l tc l ra fosh { _ U"e f t ' ; ociumct i lp j r l , '
l : : , ] , , i ] l :1, . , ( )ut- . \ ; . t1 i r . t i_rparar i t rofcni l fosfat_paraoion;c1iet i t l ia,r , r r ,, r r r1 ' r r ' r t r . r r tost ,Jt I ' l r1.rr , th ion. EhatoxI met i l t r imebi lpropani tuorofosl i l r , li " , r , r I r ; r l r r r . l r t ruLrr i r i .e luxir ianfosfe, t . _ Tabun). Ne pnat6 atrage aterr{ , i r r|, ,:r:r, 1r'r'r,rl l,[. l.)tolesir)na] (aparilia, la rnuncitori a.lricoli care milui0l|
ii\r'rrr'rtr' l irfrr r.ctr rlramenl, de proteNtie), fie inciden{a lor accidrrrr .r:', t:r
't.t\ tl i i,it11. itl l colrnunal lructe sau logun]e stlopito cu {tccsi,ttrlr l:rrl., ;i i ' l .rtL{} .u utilizai ace$ti pi'odu$i pent'ru dcparazitarea loollirr1r,l,r. l l, i i( '. rr.rrl:tt..rc simplomal,ololia geneiat5 tlc iiaciivarea coli.osr,,:,/i | ,i (t,.r,i ' lsc(rlwlt, tlclllrlulare excesivir, de acetitcolini, cu fenomrirlrri t r . l r l , r , r rN1. ' , r ' i ' ic : t r iozi i ; h iper, i t l l \ . f t l ie; r la l ' ioreeI hipersut lo* l ( , i . ;
' r { , i " ; l l l , , i - , . r . r , . l in l r 'orr . ic : r ; L,ronl lucnnSlr i . l . , . ; r r isprr , . r , r , tnt l l i t ,ur . r i r i r j: , r ' . r . r l , r , r l l l , . r t r .edem l)ulmonar acut; brar l icar.r l io; h iDotcngiuyl6l 111,.Lr.r t : . : \ : r . , , I r | : , I I r I i r , I r .n l in i : r l r , lornirnlo. d i r r r er , : r r r i , , r i r r i r i j r r r l r , , r . i r | rsr . .I . , t t r ,otr r lorr l
, l rptrr ' : t r ,nxiohl ,c, : rg i l r r , t i r , _ 1rsi l191l t , , j , , t , i . , l t ,cml i r . t i tu i i , 1:r ,sr , i' i I r : r r | | , l | | r ] j {1 l r | ) r I r r turn ' l ,c t10 r , r , r r r ILsi i , .11I1r i |nr ' , s, . j r rs l l l l r , z i l coln: l , , ( , i r , r ! \| ,o:r I r . r ' i r r I r r I r , l r r i l r l , i r r l t l iurc l r r l0 ! { ) r t l o i r r t lc I i r , i l lor ic i l l i t r pr in prr , r , i t , l ir ' r . r , ' l r i , ' r r i ' r i r r" I i r , r r r r r . r r . l r l r i l r r , I . l r r . r r { i i l iL ( l ( ,zo rr i . , i r l . a i , r , r l i i ' i i r , r rs l iI r r r ,Lrrr r ' l l ' r r r l 'Jr l t ' r r l r l r rs r lc r l i l rUrrrrs i i r . .
l , ) ( l r t t t r r l t r in ot i r l t l l utr lntu ct i r I4I I I r . : r , r r r r I r pt , lyx l l l ! j l i , r l r r 11l . r t l16tr l r . r i i r . \ r r r r , . l r r . i r . i r rg i l t r l i r , . ( t . t r r i r l . i r r r , l r . r l . r l . I r i ; r r , r I r r r r r r i , , , r l . .
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L' I r I r i | | | l t r )?: i | : I r l l . l i l r . , j1, r 1, , l r t r 1, , .n l lu i r i r I r , r , r , I r , t r r ; L i r r r t r l l r or ir , l i |or i r l r i i , lcr I , r r r r , : r . r { l , I lL l , r r r . r r r r , I r r r ior ' r i r r r r l i , r . r l , , l r I r r r I t r r r r r r l l lL l r l l r t t iL ' i t l i '1 ' l ( r i , r r ' I ' r , ' , r | | r r ,L ' r , 1r r l r r l . r l r ' f j , l l . l . r r , l l r ( i ' r ' ) r ' r r l .
' t : r . l r , r ' i r r l i . r i : r r I i i r r l r r r r r r l r r . , r . r l r , I r l , . l r : r , t 1rr ' l l i i r r r l r r r r l : r , r , r r l . r . : r , l r .r " r r ' . r iL \ r i ' r r r I r ' r ' I r i . i r iLrr : r r l . r r r , ' , r l , l : r r r r i r r r l i l j r l s i i , r r i [ r r r ] i i o (r l , : r r . r"
[ ) ( l t t t r r , L l i t t i t t lot t , i . t r r l i r t r t r , t t r l , r i , . i r lcbiLl .o i r ,z i i 1n] t , ( l { j l ru i t1 l , r , r r i r r l , r . r r r lt r l l r r r . i . i r l ig.r ; l ive (col i r i r r I r r I . r r r i r r r I r ' , v i i .s i1.r . i , t1 i ln,ac, c) t i l l . i t , l . r . r , r r l r i r l ; .\1rrr 11,11i1,1 ' : r : r ' i t ,crrr cui i l , i t l . r , i r l ' i r rz l i , i , l lh i*Lr i l i r : . s i t t "o ( l r ) ._r . i l r r t i i , r . i r
,1, lrr ' . r .uur-rr l"r i i r sttre d0 r,oLl l)s, ( ]orr ir ai l odcri .r pulmonar.,
l; j. l.i i. Problenre rie diagnostic i.,r tuanilestjirile silrcopalrr si rrllclrrllrririrri de constiuri.rt de scrlrli Jut,niir
ll.l.:).1. DeJini.li.i,. P rtti::t\ri tle tet'yaeni
i i i r r " ! i , i , io l r : ' , l r rLc Jrr iu l , , r p ier .derr : br r r ; : r . i : - i dt , st .u l r r i { l r , r . : r l i t : r' ' , ' . r i l l . , . i . iu:ot i t i s lu ul r : t tnrni l t ,st i r i tonru:r i1( , , l r r r . r . r . r l . r l . : i : l r r r r r li lt ' rlrilttolnLr preaccesuale, in determinisnll ci,reia intclyirru U tr,rror, ir.,, r!' l)urJL gensralizati[, ?roil-.rsii,- l:r l i ldrLl r.i tic o oplilc r:onrplr,{ii, rrru: ,r,rrpe cornplel,i, a ci}culatici sii 'salL :r respir,afici (Oollurirr, |);1i;
. r ,1rrr . l s i \ igrruloU\. lU;1. 1 \ l : r . i inv, IgLi l ) .i'l{r ltic c:i piertlerite d,e uLno\\tin\d ile saurtti durafti sitri, rnlr,i r,l,,ri i/,,.,r rt..::ri tteurololliati, in _centrul acestot manifestlri situindu-se lr,.a.li.l,r r,1,r
l, 1rlirr., rli l. pot./i intilnite foarte fr.or:ent $i in diyersa]'<r tu,lbu.rii,i tl. t,ri4t tt,, ,t:it .ll urd, cu crxplesio neurriloglticii, ca de pikli) sincoTtele d.e divlr,str r rrr I r r i r. ri,l isilri, carc iusE trsbnie tol,dcarua difererLliu,iir de .fu,lselc tittr.t,1t,: :l r l ' r l i t . i i srL ' s i rnplc , , leqinur i , , (Fai i . re, J.9?2). - l l rcbuic
aco*irr , i i i , r ' r : r r . , ,rr rlrrrl,art!:ir, ,ti sincopelor tagale cane,,nc conduc la o ncurologio 1rlr.itl l ir,.r
l,rrll icrrlari".l, ct sau f[.r5, reflexe rascrltio r-aso-vagfl,Je snu vagir vrr,11:u1,,,, i rrli i. lurminologia arrglo-saxoni., c*rc fac tli l i lcest secior hibir.rl, rrrr ,i i.rr' i,1, r r i i1,rc in1rr . cardiologic. l i ncurologicr ' (Faivre, 19?2). Asl , ic l , r l r r r . i i l r l , r
, r l , i " (1, . I ' i l , r .s i nce f ibr 'u lor . te lnt i r r r lu l lo rugulrr i ( iu l r :u| t r r l r l ig, . ; , t r r. i rl ( )r' i i- ti l,r.inge , rle pildi) sc r.olbpDbe Jcsplc rcJi.ru aayt,uagu,l.c ( llatll i.ts ) ,r ' l : r r - i r i l l r _rrr l dr .c l&nfr lu l dr , s inropc pl , . r" i t l in \ isu, c:r { l , i I iL l : i r l i r r
' l i ' , l l l4 i ru d| | r t l tc ad' . ro, cSfe to| l r : r t lv r rJ l l ls DaSo.tdqnlr . l r r 1, , : r r , ,.r' i ' i i1. (razul'i cstc I-orba de intcrIcn!,ia ulot tcflexc ri:[l{o_{].1,r{r1.1{,:t,t.r,i '/
rrr rl. clcctc cardio-inhibitorii. ln accstc c{r,zul,i, corclxl rilsprrrrrl. lrr, lri lrr,r'r rr.rri.Iio lio prin tulblrii l i silro z],[ricu]iare, fic jolcriotialtr (1r.irr {,r.rrrrl,rrlJ"r( (ior)ul atlio-vcutliculrr). Ii ielderile dc crrnogtinf,ir, vagal(J ),1(! irrlr',r,lrr,,, r r l to pt1ohrgie dc grani( i i nouro-ca,rd io,vn scu1." l r5) ' ( . I r , i l ivrr) , I t ) i : j l .I r slir'5ii. sc insistii in Lrltitrrii fttri asupll i4o-rruntit(\lor ,,sincopir rrrir I,r,,,r | )r rlr,l l i grial:., 1954), ttro poi I't colscr,ittlrlr, r rnr,i itr ull or rr,fco{iLtrri s jrl rr ll,;r, r rrr , . r l l ( , \ ' ILI i ( ' IL l i t , l ( ) .
l : ! .1. :1. ' ! , \ t ut ' l ( lu pi tn l r r i t l t ' t .ut j ( , i t t i . t i t dr ruu:, i nrurologir : i l ,
| ' i | | I ( | r I I ' { ' I t , r I r r cu rr n l , i r r ( l r lo l : r l : i l i ruIrrr1I l r i : ' i i r t r p t i<,11, r l isol t t ( , i l l r l r rLrr , l r \ : r ,r t r ( t i 1ts i l r i . . ( l i i : i l r , r r { r r , i r r r , r r r , . , r r ' ) , : r , r i r , ( i i r l r r r . r , l r r , ( , i r r ( l r r r t r , ( i i srrrrz ' t . i r rt r t r r l . t i i ) 1 i 11, f i r , ( r i r r r ; i r , l : r i i r r . i r ' : r r r i i , 1rrr I r r r . r r : I I . r . i r r , l r r r r . i ; r l ) . l r r r r . | | r r l , I i r i i
l r r l r l l r l r .o l r r l r , r r r : r i n l r l l r , r r r r r r r prr{rrr r .orrr l r l r l r . : r | , r , r , r1r l i r r r ( r r i , r . r r r l r ,
: t : f I
lri lrl iL ltr ct'i;ck psihoulol,orti, ryi hr alrd s/dri lnsotito do tlivrrr.so rrr:r n il 't:st,r1,r'lturt rzot'io-rt to1,ot'i i qi vrgrtativo.
tfrlrrlrrric Bfi a,\'(xlr in vcdere aci doud, gru,pe de pierd,eri ile cunoftinlt\rlt sou,rl.tl, dura&[ (;\ruold, 197?; Popr,iviciu gi Pascu, 19?9).
1t.1.3.2.1. Crisele d,e epilopie, care comport5 o disolulie scurt[, ttt.orrii i,iolferi, dar cu hiperacl,ivitato sau activitate normal5 sau cvasi.rrrrlrrrrr,Ii i, trrototic $i vegctativii, pot fi: a) Crize generalitate, respectivll rrl,r'orLnrl'llicc (Crantl Mnl, Pctit Mal) ib) Crize parliulo, fie cu ,,somiologiur r lrr rr ur nia,r'ir,!' (rnotorii, senzitive, senzoriale), dar fd,r5 alterarea cnnqtienfol,lirr rru ,,stirrriologi.o elaborati)', ca de pildi, c]'izele temporale, crizele insularo,rlizclrr psihomotorii cu moalific5,ri ale congtienlei ctc. Diagnosticul pozitivll cljzckrr cpiloptice se bazeazi, pe o bun; anamnezd, gi observalie 61inic ,;ru rlirl,ulo ltltG (standard qi mai ales prin actil'5,ri) qi pe datele complo.rrrrrrr1,rr,r'c (a,rtcriografice, pneumoenccfalografice, gama-cncefalografice eti.) tr,) (irfuctc de peXit m,ql ahinetic (saa amiotonic-akinetiee) nu trebuie confun-tlrlc t:t.r, ututut'ile co,ts,plectice ilin ncolepsie, in care disolulia tonudululrrrurculil,r' la lrembrele inferioare, eventual generalizati,, se proaiuco doolrilci rlupii o cmol,ie , firi, nici o tulburare anigilenlci qi ffrf motlificnrll,)lt(i ((bltariu, 1971 ; Corfariu gi Popoviciu, 1971; PasBouant, Popovioiuryi r.rrlrr,h., 1968; Popoviciu gi colab., 1-97A, 1972, 19?8). Derutante slntclizclo cltaplccl,ico inso{ito $i de oareca}e tulburd,ri de vigllenlX (Corfariuqi I'opoviciu, 1971 ;Popoviciu si colab., 19?2, 19?8). ln sfirgit, crizolo rlu1xr1,ib rnirl akinctic nu pot fi confundate cu accesele de kiryersomnie ulou an:o[t:TrLicilor, ale cSror manifestid clinico-EEG qi poligrafice slntIlrr,rrryirrLi,o (Popoviciu qi colab., L972, 7978). ln sfirgit, la oamenii mai hl ilrl,ir, (inrleosebi dupl 50 do ani), care de altfol rareori pot prezenta crizorltr pctit rrLal alcinotic (Arnoulcl, 1972; Popoviciu si co1ab., 19?6, L9?8ilblxrviciu ryi Pascu, 19?9), o c5,dere brutal5, in genunchi (prin alerobamot(!rrr l)rolo1 infcrioare), fd,ri, pierdere de cuno$tinld,, fXr5, sau cu veltij, tto
rrvrru"i, rr cr'f,pd de ,,rlt"o7t-attacktl, caLe cel mai adesea este declanqatd cle tor'.rrirrnrrrr, gil;rrlrri qi rotalia capului, care antreneazS, o obliterare tranzitorior, l,t lor'( ji vcltr',brale qi, in consecil!5," o ischemie acutl a sistemelor rei;iou.Lrlo rlirL lrutrchiul ccrr:bral (Arnould, 19?2; Aqgian, 1968; A$gian qi Po.lrov icirr, l ${i9 1 A;gian qi colab., 1969 ; Popoviciu qi colab., 1967, J-969, 19?Ertll?t)). Atn'N,gc r atentria asupra faptului cd, fenomene de insuficien!5 vol"i,rrln'o brr,zilillii, cu crize do ,,drop-attack" qi cu obnubild,ri pasagero d0rrorr5l,ion{,ir, }retabile la confuzii cu crizo de tipul absenlelor epileptico potrnrnvrrrri 1i l& indivizi tinori, purtdtori de unco'discartrozi, cervicald, Irll (h'imla psi,hornotorii prin leziuni tomporale, limbioe (Alnould, 19?3 II t r l rovic iu f i colab., 1976,19?8; Sager qicolab.,1970), sau alo t r iunghiulullxilrorrurl,or (Dimitriu, 1972) sint lesne tle rccunoscut din punct tle voclotoof il io ,,ri l l l iG. Acestoa nu trebuie conJund,ale cu ,,ictusul, omneziol,, sar}Irll)rozintr, o staro confuzional5, do mai multo ore, cu alezorienta,ro tompolo.Hptlitlll, dal in cato $taroa do vigilerth, qi funcliilo sonzot'io-motorii Blntpul,irr altorato (Arnould, 1072; Iiisor, it962; Popoviciu qi },asou, 10?0),Acusl, islru'r aurnozio, duptr, cnro br:Lravul mauifcstb o arrutozio o fonornsno.klr a'ooorJr.ru,lo, $o (ll,l,oloflto umri irrsulioiorilo cir,oulalrorii, cu o consooutiv[ttt I brt li r,ro Itt t tol,ior ttt ltL tottt Jxrrtr,l[.
I)ia(ln,o ,iott'/" d,lfot0,ttl,Jdl ln lrrrlrrl 1rrNi1, tr olirrrirro ttllt rnrr. ni.ltttl,l l.t ' in t u,ro-psi.h i.u,l.riat,, fl irt n r. nl nt tlt ' ttturrl, r pilrlttiti l, l i uti 0 u, tnt,porlll0 1,(t ikr,l)il.d rlittol.u,l,i( tr ntuylir'nlr' i :
l. Oritcl( ),mearopal,iorrt) .. n) (lriut ntnLnld. So plodu ou trr cir.(il l lrr fl1,rr l l(\rprrc i t lo,s i ou t rn, ,sor) l ) r r1, i l i l t r , r " ) (Alrrorr ld, 1972; J?opovic iu r l i colr l l r . ,l l)713), obsol'vindu-so irr rnrrtlicirlr, ,,rIIr,r.rIrl 'III)i, 't, qcolarr'!, sau socia,l)t (oxl)ol.l,izr'i). Sirnularca, esto grosolruril, rlrl rrra,i adesea vizibil ,,volunta,ri,tt, l ir,l ' i,lrtl ltnt'i i,ri vasomotorii (in slxtcia,l la fa!ir,), firi rnitlriazi, Id,rI tulbrrr'fit iIl i l l()toliene, fLrX somns piramitl:r,lo eta. b) Cripele pitiatice pot rca,lizl, fi(!lrsorrdo-come letargice, dar cu absenla tulburXrilor nourovogetnl,ivu, r'rr, 'r cos do tezistenfi ia tentativele de ,,trezire, t $i cu ,,impresiott dc vigilol rl il ,l ir! crize pseutlo-convulsiyo, dar care nu comportd, nici citlole br,rrll lf i,rrici apnee, nici clonii, nici stortor, nici hebetudine postoiticl. So nlr,ilrrrte nota ur tremor palpebral qi circumstante emolionale docla,nqa,rr lo,r\ Criza afeatiad, banald,, .omare a unui $oc emotiv, poate comporlrL llltol{r'.lolnente care pot preto la erori tliagnostice : stupoare, hebetuclino, il,gi1 rliopsihomotorie dezordonatS, rlar totul clerulindu-se pe un registru do torr,rnil,rji {1o anxietate.
2. Criaele m,atebol,ice: a) Criaele kigtogl,icenice se manifost?t do obicrlrlupi un efort, la un inttlrval mai lung clupX, alimentalie $i sint pr.o(1(xllrl,(lrhr tlanspiralii $i ale o sonzatie de foame bruscd qi violentd,, Dsrulilroil lrlporlte fi similard cu cea a crizelor epileptice, chiar cu prezenla do furrr|lrrr1riltrrridale. Efectuarea unoi glicemii trangeazd diagnosticul. b) Oritt'lrtxpnsmofilice, Experienia ciinicS a diverqilor autori (Arnoulal, J.0?2) rii lruiu,strS, din ultimii ani (tr'Xg5ri,gan gi colab., 1971 ; Popoviciu qi r:olirlr.,ltJ70, 1.972, 19?8) aratd, cH, acests erize spasmofilice $int alostul (lo I'l,rvrt il,rbile crize ,,tetanice" prin tulburare primiiivi, a rnctabolisrrrrrlrri.rrlcic. De multe ori este vorba cle crize de agitaiie anxioasd, cu pal;ril,rr,l,i i,rrr irnpresia de ,,moarte iminentE tt, cu tendinie lipotimico llsol,il,rr rlorrr,nzalii de rd,cile gi clo furnicituri, dured $i amorleli in oxtrornit,i,fi riil;r rrivelul buzelor, precum $i de contracturt in membre. Amintirlr oil, nrrrrlrr{ r'izo spasrnolilice pot imbri,ca aspecte ale crize pitiatico, iar alt,olo pol,lrrru :r,specte clinico aproape tipice de ,,absenfett, sau chiar do qnvrrlsiilonico sau tonico-clonice epileptice. I)oar prezenla spasmului clt.rlll1,,rrlu,l inainte, in timpul criZei iau postcritid precrirr, ryi aspocl,{rlo .ltiri( I(r k'scd,rci,rilc d.e unde lento asculite hipersincrone gi/ sau clo undo lorrl,rrrrirrrrsoidale induse cle hiperpnee; absenla modificd,rilor do tilr opilolrl,iolrr, st;imularea foto-carclidzolicS, qi la activS,rile cu Mdgimido) 'puf t,r,it,,irr'rlirgnosticul in fa,r'oarea spasmofilioi, oventual diagnosticul do slxr,rrrurf ilirr:rvrcilr,t5. c-u epilepsie (I'A,gArE $an $i colab., 1971 ; Popoviciu fi c(,lub.,l r )?0, 1972, 1978),
.12.1.3.2.2. Iotusurile de saurtd, duratd, Al[,turi do ictusul apolloot,io,,r,lr r{,r'ui rnanifcstd,ri pot 1ii ile lungi tluratf,,, so pot obsorva la unii vtscu,lrriJ i{}li lr$uri $curto, atkrsoa rtpotatc, caro survin do multo ofi cu oqlzillrrrroi ilohinrbii,ri rlo pozi{io in spaliu, dor unoori chiar Iu ropaus (Arrroull,l l l72 i.l lopovicirr ryi.I.)ascrr, 1{)71}). So paro citr ln &oocto cinzuri ogl,o vot'lu doo l,n lbuto,to d0 iriga,llg oorobmlfi,, produ*Itr prin hiloto:nsiurri t,ol tivo, rot{";xrrl,iv pt'in it tufioianl,o uilrIrrIrr,|rolii rrlr.obrtlo ty[nzito]'i i Ii/ snrr int;olrniln)r]1r(l(rIr,1,1 rlo l,rorrrlxrzo lx!rlir o l)r! slnl,orrrrr'l oaroti(li0,n). lfupil, n<ttrtll io t.l,rr,rrrrrii r r l tonl ln( l (or t ( l l t r r !1, ( lo ol l r ! \ ,1, noctr t rdo 1r l r r11, ln oi l ,ovn rrr l r r l l , r r ) r l l , ln l t r
i r r t t j i , t l r ' o l r i r l t r i t t r tc l r . r r t i r , i l i t . r turr t t I r t I t . r r I r r I " icr , : 1r1q:1r51,1,7i1, J, iu.( , / . ( , l l l1r iu.r , ,r l r : r r r r r r l r r l , r t l l r t r r : i f i l t f l lz i (Nl { )1,o
I ! .1.3. i2. ; i . XI u i . f st i i r i l c s i &pqt( ,
. l : : , . ; .3.1! . :J.1. l ) t I in i . ! . i?- , { rn i rL.Lt : i r , r r r t i ) , $ i ) tcoP(, r . t l r r lz i r r l i i o l ) i ( j r i l r , r l rIr..rir-ii, 1(rrlior':n ii, a crrrxrqtintci, do dlu'atli scuilit, pl'(l.o(lri i srrLi rrrr rl,,r.r|lrl i ln|lrto l)t'(i ir]c(10stL|.1r, (,i.l,tIz:.tti i (lo (} tl,nori0 crtrtb|alii .qi iti l lrsocrili,lri rlr,olricr,i i lo rrrorlil ir:ir,ri orgllnioc ccrcbralc (Oorfar.iu, t g?g ; Wrlvnc, l tlti l ),Sirr.r1rr,l. sn u;1, intrluh.a, iu.r';rnprrl accosclol rli it lnc riccpiioplicc ((irr,lrr,r,irr,llri lr l l l?il). tia$taut [i (iastatt (1956) au a,{irilat loati;c sugcst,ir. r,i sirrlulr,lr', r'rr,ro llu ayut totrlcllunl soarta ,,p:irinli.lor silraci)i in cor,l,cilirrl,r irrr Ir'.Ir,r rrrrIrIr. pa,r'it.risl,icc, r.e1xczintil in re:ll it:tte- cauza cea ma,i fl,covrilrlr!;r lrioltlr'ri lrrl rlo c u n0,5l;in!:_"r, lure, s:tu :tsocille cu convrLlsii tonicc;i t,i ir*rr';i lar rrrrr'rriftrsfii| i tlcbuirr in rirod cltegodc difclcnliate in p]'irurl r.i},11 rlr,r r izr lc c l r i lc l ; t icc,
l: './..1.i1.,i.2. Ula:tiJictititr BilLupelor sint Ioarl,e clifcritc rle 1a rlor,I : r : r . r r . l ' r ' . l l r i t , l (1U.50) r- i l i gel ; i i .otab. r lg.- , .1 I re l r . ter ,z i c iuci etuzo rr . r . .1, , r . , .,:rprrl' i lr. s)r, lrr,otluci sirLcope: iulbtrrriri rle cir.culalie perifericri, aliec{irrrrir,:rIrIr:rr'| ', r.r'|tLZLr Iorlu.i!t{'ri i, rfertiuni ccrobra,]e qi boli psihice $i, ca, [11r,,;lrr llrol)us rurniitoruca cla.sificare : l) 'Iulb".trdri ale cirau,laliei ltcri.fn.il :;t sir{:i,l)N, 'r' l.r,so_-tlepreso:lre (raso-\.agalii) i b) sincopa din }Lipoterrsi Lr rrorr,rrr'lrrsl,rrlicii. ,2) Af(,cliuni cardiace: a) tultluriiri de ri[m cartlia,c lin spcr.il lrrrrrlrrrrrrrrl ,,\ tl lm Stolics) ; b) sincopa, din biperreflectivitatel ,sino,ll,r.r,lirl irrrrii; rr) sincopa prin aitc tulbuliri ; rellex6 vaso-vagale, r,efltxe g.lrrrrrlrrlirrrlo vrulir,lc, rcflexe oculo-ra,ga,le. l) Sincope prin iawze respiritorii::r 1 . .., i r r , - r r 1 r : r, rlt ' 1L ipr.r'reril iJri,l ic ; b) Silrop:r, la trse. 4) Sincopa tlin tlif rit.r,ttlhurtiri ffrrl.trqle (sinc,,1ri psih.icl). fi)- Alte lrpari; sinc,opa do tiri(,l irn I r I l l , ( ] .
, Wlyrro .(11)61) lr,. propls cea mai complet5, clasilicare a sincol)(ll(l!.,r l r . . , i r ' r ' i i i l r r , ] r i l i r , p l in l i i rsr r lc prociz i t rne ry i 11e exact i tatc a unor i to i i r r r r i r
,\ " NirrooTrr_. pri n isch,amie aet"ebrald, gener&Lie&Nd :l. l 'rin scdil,r.na rezistenlei peri,ferice:
^) Atiire: - sinropa r':rs,r
r;r;1rlii, sircopl, simtsrlui cmotk'li*i,n, -- sincopa de liper-.l enl il lt ir,,sirrlo;lr, plirr rci' lexe ccrcbralo (sincopr 1a tuse), - sincopa, prin lollr,rr,
rrrllrr r:rlrli lrr) (siritnpn din stalrozn qi insuficienla aorticit), , sin()l)irlrt irt tollrrro (,nlorrlLt'c (ilfl:t 'r.ct ;i anginir, pectora,lir,), - sincopa pliu rolll(,\rtprrlrrrorlr,rrr (sincop:r, 11 1,use, sirrr:opa din onlLiolia pulmonari,. sincopa rJirrIrrlrr,r' lcrrsiurron plihnonafit, sincop:l prin pulerei! in joc a nnor iefltrxorrrll,ir-r'), lr) I)usiae: - li ipotcn$iune o.r'tostaticil (in convalescclli i, j lrr.irrlr.:r,r'{i i l:r rrritdo rlrogLrliI postsitnpalie{itortrie), - hipoterrsiurLc ortosjll icrll l 'rricii (irliopr'r,tirrii, slu secnndarii unot: lloli nel.voasc).
l. I 'rirr, scrirlt:rtn tlebitrt,l,tr,i cardi.dc: 1) stoyt card,itc (srruurprr, .r.rni,rr:rgrr,li i (r,lrrlioinlrihii;oric), sinoolr, s;imrsulrri rrmotirli inr, silcopt rlirrrrlrtctrl Atfrt,trr-Slol<<rs1 1;1 prin descrafl.rrfi tnlu.tn-hci\d,ii rrardilrrt (sitrrrozjlrroll,ici, irrltloL tniocitrdic, a,nginir, pecl,rtll l l ir, lrl i l, lnic caldia,ci,) jrrsrtiirriorr(jir r r r r ' I i t , : ' i ; i s l ,orozr ' r , mih:r , l l ) .
i l " I ' r in. tnu, . tu ( t , l , r f tcot \ I i l t i ( : i r , ) l r ipr . r . l i l rs i rntu l rLr)rnonl t r . i i I l r ) s i t r l r '1rrr ,l : r . l l$( , r ; r . ) l l . i r r r r ra,rrovl l r , Vlr , lsrr l t , r r .
l l . NI t tcr t l t t 1tr in. iwhrrnr. i t u. t thnt ,h i , Iur t l i : t l i i :l . l lo l i tur .srulq. t t r t r t r lu ' l l t : l r , ) l r , l , , r 'o r i i : r l i l l iosclcrrrzt i ; l r ) i ront l tor , ; i .
: t : f . l
,11rr i r l r l lL r l , , I r i | , r , r r , r r I r | , I ' ! lr t t i l r t loI I r I i rLIr ( r crr l r t r r r i .
, r r l r r l : r t ( . r ' l l r l l , r ' t i r : r t t i lorrr l r , ri r r l i r r l t r l l i : r i l 1 r r r 1 i : r I t i1r , , r i r . t r l i t : r ;tL l i ro t i t r r t l l r { l r ; l l , i l , . r , l l r l i r r r r
1' , . t \ i t tut l t t ' 1tr in, nrr , | : i t ' ,1 i i t t l t t t l ,o: i l iq, i i t t l r l t t i :l ) . l \ t ' in hipor, i t : r ) r r r r ) , r ( i i1 i i r . lc :L l i i1 i id iur , I l r ) i r r i ro l i r ' ( ' rq( n i i : r l ( l
, l l r f i i r ( r { ' . 2) l ) t ' i r t , h. i ,1totrr .1 ' t r i r ( r i ;L io l rc l t i rL l i i i ; t , r ' i cr{ , i l l t1u:1. l l ) I ' r i t t l t i l t ' r, , r i r t r i r ( i r r r :orr t l i f i i t lc ls l i r i r , , i r r z) :orr t i r t1-r : l j i l lc) . 11) 1 ' r ' i r i I t i 1 t r , r 1 I i , r ' t t t i , .: ' ) I ' r in tu. Iburd,r ' i de nulr i i i r .
U. Sincopc pr in t l is ju.nt f i i rc) t t t 'c i r :1) I i ' r 1, i t ' 7, ' ' i r ' . ' l ) S i t tnt l t r r . : i i r t t r : : r t l t t i
" r , ' l i r l . iq,n ( . farna centrald,) .3 '1 In ist t i r ' . I ) { , t l t t t : : , ' , ,1 i 'ut . . : , ) ln l t t t t t t i, , t t l l i t l ,a.
l '1{roiz[m cii rrra.iorit l,tea crcr.ttft l i i irt i l t}r de la irrrrrrt: lc l l si lt rrrrr r r l rcr i t lb i lc s incope, c i . le fa l t reprczint i i tLt lLr tLr i i l i l lc i .orrs l icrr(r , i r i , ,, l r , r r : r ' : t , i . i pr i r I r l^ | l i .J t , i . l , .
|:!. l .3.2.3,:). I i .tt1ttont nt.olog ie clixiari
tnainte de a aborda, clj.rcrselg entit i i l i cl inice, al,r ' tgolr ir,r,(lrrlt rrrpr:r,, rttt l tt.ont,clol ' { lenarole, camune \\i, a 4inpreju.rdri lor in cllLo so {I( '(,I i IIIr i l ir?.rI r 'I r ( 'o pa,
r\ntl iza i ir lprejuri l i lor carc i lu dLrs la inltalarea piclt lt 'r ' i i i lr lrrrrorj i irrl;r, ir r lc o deossll it[ inipoltari l, i i , in s1,a,l; i i irca dingno-qliori lr i i ((]or' l irrr,I l) , I , 19?8 ). Tlebuie si, so l i i i i l so:l ina de sohimbi.i ' i lc dc pozil lc rr lc l. r tr ul r i , r lc e. , .entuala deciau$are la tuse, t i ic l iunc, fe l t r l . r ,oLrr l r l r :s i r r r r i l r r l l roi , r ' \ iclrle, la einoiti i , sl, ir i i de "lrisi i si rie lerrsitrre elc. .r\ l ictr:rIrrL1rl,, lrr 'r 'r,,r r r lo r e bolnar.uhi s int t ic inare \ -a loaro: t tecl i iur i le c i l r r l i l i l r , I ) l lnr l r i r ( . ., r lor l i ler unele sr l fer in!e ne. ' , rxologicc (s i r ingomiel ie, l t i t ts i , l r ' . ) . , \ r1, . , . r ,l, i( r '( lcrca cunoqtin!ci esto prccedati gi,/ slu urm:r1,ir, ( lo lrr{,r,r r. i r r I r | ) | | , r I r ., t ) r | insincopale ' ' (GasLaut, i9 j0) . Oor lar i i l (111' i . tJ .19?8, \ r i ( . lo | l l t i i r t i l ' , r t , ,
r i l i tL (19?1) a,Lr insista'. Rsup]'* i l t lou i, gt'rps do sirnpl.omo; u,) sirrr;rlorrrr, lr,l , r l ir{rcesualc, care rnoori se poi lnall i tegto fi lr ir, si i, { ie xr'mt1{) (lr) 1rir,IrIr.r,,r, r r r rost i le i , put ind del i 0oDst i tu i un , ,echivalcnt) ' a l s incol)ol0r ' ; l r ) r r I r . r ' r i r r lt 'r 'r, ln:iu-zis ; c) siinptomrrlc !ostaccesltlo.
S imptomele f)rcacces1Ld,le pr€,lneig cu aproxinutir ' 5. j l{) rlrr rrrlrrrrrlr,r r r r l r r la lca picrdcr i i de cuno{ i in i :5, rnan i losl inr iu 'se pinlr -o s1,rr , r ' r r r l r . r l *,orr l i rL ' t , t ransl i la l i i ieoi , inccfoqarr :1, Teder i ; , amclcl i , gr i ' l r r l i , prr lorrr , , ,r , r rzr t , t ie de pr i rbni i t 'e. - i lccste s i inptornc preacoosui lo , , r l r , l r rct l izrrrr ' " | t l ' l/ r l ' ; i i , { i : r , de pi l< i i t i r i s incopa 1a nirr l ; i t :nc. Ln schimb in cuzrr l r i r r l r ,1, , i r l r r rrrrlr lt 'c1.ul it-Liocartl ic sau dirr angirra pcotolaJl, pr: l ingii ir,r 'r l i io sirrrplrrrrr.p lcr r , r . r :cs t ta lo obi$nui te, pot zpare: durcr i p lccoLr i i i l lc i r r lors, ' , I l i l i i r l r ,r r,rrrt,c q.l l., pc l i lgi l semnelc sti lr i i r lc qoc.
,4 ccasul propriu,-zis tle pia,rtlere da at,nofttnl{:t cstc sourl (i { i{) si r.rrrrlr '),Lr ( 'utsu1 oi" t ru ia so lcrnl lc i i i l i i i r r , l o f l l lsc i t l i t l l l , t , r l t iscrr l r r r i i 1 i l r r r l r r r l r . ,, l r ! ( l i t ( , i1, a,ccrr :srr l sc J)r 'u lnngar l lc , sc l )o l t . lc insl , r t , l t o r ,or t l l t ro i r r t , i l r r r r i l r r ,, r r ' t r r t l i i , t t i tcot ' i ( lc ( , i i ( jv i l < 'otrr t r ls i i ( ,1{) l t i { . r ' . ( , r t r l r r t . i t l r ' i , l1e 1,1 l ( l r r r r . r r r r r l r , .I r { ' l ts t l l l l lzr , i 1,r l i<t , l l r r lcrrr l rs i r , i r r l l t , o l t ; t r r t , i r , i l r r l r i i l rLrrr , l l r s l i r 'q i l t r l : r r t . . il , r r , i t r l t t ls t r l Jrzr : i l lorr i l l r l i l r r r r l r r l r ,csr l r l i r r r^ l l r i l t r i i : r r l r . r i l r r r l l r r l r i , r . il r , t lotrr : ts i i , $ i ( l t 'nrnl I r t r r 1 r I i I t r r I i t r r ' . Alr , l l r . r r r i r I r i l i rs I i i I i Iorr icor ' Iorr i l r ' | r , ,1
r . r i t t t i {o rr l l iz i i r l r , r '1r i l r , ; r r , 1qt : r t r r l r r r r l .f i i r t t l t l rutrr l r ' l t t t t l r r t , r ' , ' t r r r r l t ' . l l r r I r i r ' l r r r iz t r , r r : r r . r ' i t , , i r l r , ; r i r '1r I l r , , , : r r r r l , r . .
I r t t l r r i , l r r l t l t , t ' t l 1r l r . , . i t r | | , , r r r l i r l r r r i l r , r l r i r l ' r ' , r r r l r r , r i r ' . r l r r l r r i : r r , r ' i r ilovi t r r . r 'otr t l l r ' l , t l ; r l l r l r , r r r l r , , r , r , l r r r r r l , I r r I r r r : I r I r r , , l : r , l r r r t r l r l r r . , r l r t r l r r l
. l i r
(ur i t r l t r r r l ro i r i r : r , i r r l l r r , | r ) . , \ r . r , | ior t i r r r l r l , , r r ( ' t : r , r l r ro i . ic l | } i f r r l r . f i , r l r r t i r r r I lorrrr io l r r r l r r , l ro l l r . r i l i r '1 i r '1r i I r , I r I i l I i , l ) l i l ( i l t i . i l l l l lo l l r . r r r . l i i , r , l r , ; i Jr l i r r ( , t ) l l ( , \ l l ll t r r 1 r 1 r r r r r : r 1 r r . r l i t r r t i l i i I r r r t t I ]oI t t r , .
l . | i r t t l ) t l t : , , , , 'U. . ,u, t , ' . l . i . , 1r ' r r . i r rz i i , ( ( i i l i l r . rL l i . r r r r lz , l l t i t i ) i . i , l r r r .1, .1q1,;;Lrr . r r1rrr I r , r ' r l . . r ' i rJ i r r i i r lu l l i r I i oslo aki r l )1{)) i i rnr} l iv I l lo s i r r r r rpo, r l . . r rr r I i . * I r r I is I i . i r l , l l i i ( i i l , l r l ) r 'o( ] { rJr t i ( lo l0% do a, l :or( , i l , ' r i r . 'u ' r l io-v i ,scrr l r r , r r rI rL l r ' l i l t r . r ' iq i r r . r r s i t t lurp. l0r ' , l locir , i r i iuUl s i ] tcopolol , ( i iu,di i l f i l osl , ( , l . l ,r l . r r r r r r ' r r i ' r ' l r r i i , I i i r r r l r , r 'b l r , { lo o f i r l l )n} l , r 'o hem-'dinamioi i c le grrv i l r r , r .. i r l r . r r l i i r r r . i l r l i i l i . : r r , )_ l io- ' p,rrz i r cnlr l iLcr i r , r ,^ ' inr l c l 1 i crnsccint i . ' i rn.r I i : r I r r ,, r , I r ' i . r ' . r , i ' r ' r r I I r , I r I | i i r ; b) l ic o t t r lbrr | ruo de r i t rn, ut t r i l r tc l r l r l la, t rn gl l r l r l r ,i r r , I i . r r ' i I r r I r r . l r r l i l i ' i l , I r ) f ie r i s impl i l l r ' ibr ' . ; i r :c : l c lcbi t rdni , c:r , ro D{) , r l t ,r1 ( rnr)rr t r ' r r r r r i rnrr l lo l roc:1rr isr 'nc. r ' rogrnsNicr l l rccstol s incopc {r : l , r i l i r r . r ,l r l r , IoIr I r , r r , r r r r r I g l t r r ' , oxist int l l isct i l r rLr t r ' ! ; i i srLl t i te.
r," l inrtt lrtIa. rl. in t:u.rsuI r:tt t l ioplti i lorrr) lrr .r./aro:c {{0rl i&i sinoop:t :u.q ciu'it otoro prtognoixoDice: sull irrrr
LI I ( | ( i | | i I r i r i r r orr i .s[ l i t f0r '1,ur i lor , es1;c to la l l i i , i luret l td 1:Z min te s i l i lsr , r t r .,, ' ..r 'rr l
. i i l , ,.1,i l t1rl ifrrr.rnr', r le\i prczerrl:r, a,oestiola, nu elimini i i i lglroi t, irr rrl
( t ; r l ' , r ' r r t , r ' i r 1r1 l l l i l ) . ( i r l t 1: l \ .a i 'd in, pt 'ecrr tn Di ]Jammarst0n lCi ta l i r t , ,( lr l l ' ,{ 'r l{r ' ' ' lz, l9?ti) N,u r.r ' l l ta,l, e:isloD{a rlrror tulJ:urH,ri premoniiori i, r.rr,r.,,l ' , .r 'rrri i . lrr.rlr lr,r 'rrlui sit-f i , rprcgiitea$o['r {10 multe ori iXclerea: clisltrrr,rrIr ori lr,sir i i , plo,siruro i,olr-ucicil, senzir,f ie hit l lJir, t le ,,glmbe de vat5,,, ovr.rrlrrrrl o. r r.r ' i l , l , lr i lr"r. it izi i, r1e lngor'. St. r(ltt i tr,. i l ,, pibuqire {r, T.A., pti ls f i l il , ,r 'rr. (,11.'s(' i l , irn pci,r.tptibil). a,sur.zi 'eil zgomotelor cardiace, arleiea s.l lrr,r
.1,_,1i, , r I i r r r i r r r r r,t r 'r, s Ln {i i\ lr iu i l ia tt i l{hri sistolic. Dupi, Trendgre (cilrrl,,1, { : i r , ' , r r l . r ' r r r t r . l i r ;?t . s i r r . .u l ) : l t l " ofoi , - r r l r i r ru io :b% din"slenozr, t , .: ,r. i ir r ' , r 'rr r. is. dc t.o:lr|c subil. i si r.r, p.oEnostic ulter.iur reZervat (mour,l,rr r r r r r r , r l i l i r r r l r r r r r ls do: ' -4 ani dupi t p l ima sincop;) .
lt) Itt, ttti.t ot"tttr.l le,u trotnboz& u,u,riculo,rd, (afec{iune rari,), tuiburilr illr. 1r'rrlrr. r,cl rrl, i r i lr 'sou, r,u ocazii: l schitnll l i l i lor de pozi!: ie : crti, digpnoi(,i l ,
, r r i r )z i l , ( l r l l t l l l i s i ct .crr{ ,ual s int :opir , ., ) lrr h i1t.r 't lerLs iunea 7tulm,onari1,, pierderiie de cuno;tinli sinl 1ruli lI c l r r . r l r ( ( l i lgcrr l i t r . r r l ,z , 1.972), I i ind l l lorer late- de cl isplcc qi const i i , , i i , ,
l ,,r:,r, r (1,irri i , lrr,, l l*ntrri, d u.e'e l lrrginrrir,sri l. ln cadr-ul hip'ertensiur r i lr rr.l r r r l r r l r r r : r r . , rrrr. lot. spcci:l l- i) o',rr1u, hipcltcrrsiunea puhnondrX primil, ivir,r r r . r r | r ' I i r r rur I r r r Iu s int mai t lcrvel tc. l i r srhinr l r , h ipcrtensiuni le -securr t l ,u, , ,r r . r ' r , | | | ! I i r ) I ) i I I i i dr l r iudi te srnl congcni t r l l . &r dt s incolc t loar in 2/o r l i r r, i l l r i r f i i r l , i r Sr, .1) l ' . . , i u l r lc Gi l ln.nluanlz, lC72).-
rl\. ltt i tt*rt lioientu. coronq,ri(Lr1.d, t)ot Bit so producii si,ii,ri sincopalc, rlrr,r.l r r r r r r r l l r r r r r r i , ; t , t r isrn. . 1rr i ' larcf l r l t r t iocardic, poa,tc sulreni , in faza a,r t r r l , i1,lr ltrrtrt r lr I lrrr.,vgrrl;r o sinCgpli, : l t lCSea, mOltit]r i" l l l t ,I, Aoeeaisi l,radu1r,,r,ri, l r r r r ' : i r ; i r r .o l r r l : ' i , 1x[1l , t l l i i 1r |or lusi i , de c l l r tze di l0] ' i i ie: 1,ulbtrr .nL,e dc l i l , r r r ,r ' , . l l r , r r : r t i r r l r srrrr r . r lu1rs. l i0 cunoi lqto, tb pi ldr i , gt , i t v i t ,at ,c i t , 1,ul l tut . i i , r , i l , r i(1, ' I i lnr ( l i r ) i r r I t t r r l , i rL s lc l i l l in blocrui lo l l t , r ' io-venl ; I , i ( t r l :Lfo. I )unrr . t ] l t ,: | | r | | I I t I j i , i I I t t r t t I t t t r t I 1 t t I d cttltt rr ' ,r it,t, i i l{ j ftr)Z(ri I)olt1,o l)fovotj lI o sincol)it, ro1lcXil,.I r r i r r r i r r I i r . i r r r r I l r , r ,o i r l r ln. i lnr i ' t , r ' r 'or t i i r i l ic cr t r r , l r r i i r , , l lngoru I s i t r r , ,o l t i t l r ) . l ) l| | I i I I | | I r \ | | t I I I ! l r i t t l , r t t t t r tst , t r lo l t t , r ' i t l t r t r l r ' lo;rrr l r i l , r ' r l i r t I I r | r I io1rI t I i i I r I is t ' l l { r r r r i | r , .
l l" |; i tt, ln' lt t l i l turlt"tt l l ,tt, lhuriit i lrt r le ri. l ,n utnlit,r:r \ r r rc i l r r r r r r r r r r i r r l l i r I r ' r r I , r r r rnrrJr l l i r . r ' r r l r r l r lo i : r l l i r r r l r r I l i r r r r I : r , r , l r r r r r , l r iLt t t t t I r ' I t ' t I I r r r r t r l t r t t t t Ar l l l t t t r t l { lo l i t rs. I ' t i t r r . r l i t r r l r ' r r ' , r r r ' I ro i I I r ' r r r r r r I t i r Io l r r r ' { , l r I i
, l l r i
l l t t t t i t to l r tg ic; , r t r , i t t r l , ' r i i r , r l r l , r ,1, i i l , i r L l l , r r ) r r l i r l l : t i l r t t l r r r l i l r r r ( ( l i l t1r ' t rJ, r ' ; r I lz , l l t t : l ) .
I ' i i t t t r t t1r t ' I1| t l i t t s i t t r l rotrr t l \ r l r r r r r ;1 i , r l \ ' r r I ( r l ) l ( rz i r r l i i ; l , l '11, ( l i l r l ( ) l r r l r r l, r rzt t t i lot s l r t r l i lL lo r lo \ \ r t r r r ' ( l l ( ; l l , r i t ) r : , i l i , { l i l l s t r t l i r { , i i i t , l t t i ( l r r t I r r r i r( l1 l ; lJ) . , r \ l ) r t r t lc o l ) i ( ' i ' i r l r l l r r r \ r r ' r l : r r l r l l0 ( l ( j l l t t i , t l l i l i l t l i 's i l r ' l r r ' i t j r i t l i I tL:rrr lccct lcr i to c{ . !Tdi t t f t ) f i : l I I I r , r t r r L I ( , | | | ( i . i l l l i , l l torr l c l iu ic r l t l j r t ,z l i i t t I t t t t r ' { t r 'r l r f 1, ipu1 t le asis lo l ie, 1rr I r t t t t t r i i r l r r p r t r '1, ic i r l aa i l i i l i le r t 'pcrcr l t r i r t rL i i : rst t l ' t : t, ir r,Lrl:r,! ici ocrobralo. lJl l{ri i s1.ol)ul cludiac tluieazi ci{ cr;l l stttttLtltrr ltprtttr, lorrr o st&te dc sli l ,biciuno, itLso!it, i l , do pftlo:lrc) alneloli, ;r i tLll lrrrl i l i , t lr '
rrrrlcre. :\sislolia r1e pesle .10 secnnde produce piet t lcr'cl l c1n1(rlt i l t l( ' i , . (1ll
, irr,rtozir, turgescenla i 'enelor jugulale, I i"rirea qi suler{icj l l izir r ' rt, r ' l 'slr irrll i(f i (pin:l l i . npneir) 1i convulsil tonico-olonice (tr1-a1'ne, 11)0 i I ( 'olIrt ' t i tt ,r l r i l i ) .
ln cadrul 1tll-rlriu'ilol dc lii,m, ''je descritl:
1) I 'ulbtu i 'r i le (le co duc(re, ca'ie sini celc rrrt l i Jritrc cunoscttttr trtttzr'rI0 sincopelor :
^) Blocltl etri.o- t)etLtri (rLlar . De obicei, pic,rdelea i le cuirorl l i l t{ i i t 'r l t '
'r lNrtrt l lnir, qi imprevizibil ir,. ' \Itr l l , r lrai r: l l
' oa estc dccl:rn;atir, in-tirtLlttt l tttrrrr
,, i irrt, ca, Oe pilrt i, mictiune:t slrn defccalia. Sc-;tie cir, daci' blr.tctt l ' \
\ ', , , r r r f let se i t iagnost ichcazf rr .ur ' ( i i3. j ; ; ) , l , locul i le
-prtr r isI i r r t r t i r l i r : r
l,rrbleme di{ici le t1e diagnostic. PiFrllt 'rcir, ( le L L1lrof 't ' in1ii ' diu blt.rctrri l tr ' \ \
/ t
i ' i t . 3?. lnrcgistrare po) igr . r l ic i h bolnavul S. I . ,61 dc ^[ j
Di4 ' \ i r r t , , l , : l(s indrorn Adams-Stoker) . ' l
IosL internal in 19i0 cn dg. Stxtus c l ) i lopt i t r rs 'pcnhLr l rec\cnlc . r izc dc I icrdcrc a c l1nol l in l l i , lnsol i te dc mtt lLc or i d( icon\ar ls i i iunjc! r ionicc. I I c i in ica
^vcnrologic i r Tg. I iuret exancr[r l Ul i ( ;
i r tcrcr i t ic a lost Deg. l t i1 ' . E-\anrcn]r l pc, l igrai ic a eYidenf iaL un ]) ]oc nl l i r l 'vcnLr icular pe ECG, cu uD l i ln l vrr iaLi l ( in l ro 22 $i 18 bir l i l i pc rrr i ' r ) ,cu Duncroasc xsistol i i , iutrc 1i-3i s. Pe f igur; t se vede aprt i l ia pc l i l l ( ;de undc lente bi latelalc, s i rcronc t i s i rnet l ice ( I rcdomirxnte dc dcr i t r r l i i l r 'arr ler ioarc), dupi carc, odat:r cu i lsLxlarca &sistol ie i f i p i t rdcrcx crrrr( ' )tilllei, trascul se aptatizcazir, Aprdlia primei conLreclii c:1rdittco fuco rii-tr t rpar '5 l lnclc le din barrdx de1ta. CuuofLi l r l l l rcnparc Lrcptet , odLI l . i ( r r r
r { r iuarca act i . i i t i t r i i cardirce $i rc\ .cnirca l . i no nal N rcLiv i l i i l i i f l r ( : l r i r ' ( 'corcbrale. lntreaga Pcr ioadd dc 1a instnl : t rea asistol i ( i Pini I r ror(rrr i rcrrcunoft in l f i l )o lnxvului a dtrat 3B si :cLr[dt . Sl i j r : r l .a i r ld icr"r r ( { t r i r ( i : r lc l i 'v i l i r l i i cxtat i {c0 (drrptr Cor ldr t l r , 1! '17, Cot l iu i t t } i l )opor i | i r r , 1071 f i
l , . , lat , i r i r r t i cakl) . , 1t t i3) .
| r r r l r r r0 l r ,5 l ,0 l , t r l i r r { . { ' r r , r i i r r r ' ( ( l ih1r ' r r l r t ' l r , t r i ,z , l { f?!) : l io o l I t ' l lz i i , vot t l , r ' i r ' l l l1L|r i( ' i l ; r / , ( l i r ) r , r r ,zrr I i ) , I i r . o l i l r | i l r r l io l r r r I I t i t r t t I i t t i i (9{ t r ) i , ) ' l i r t o I r t I r t I i | I t I r I io, ' r . l ,nr t t r i .
l t \ l l loru. l . x i t t r t q l t i , r l , t r rLt l l t r r r . i t t t t t l t , t ' l l l t t r ' , r ' r lc t t l t t l , l r r t t t l t ' t t t l r ' ; t l l i ', l i t r i r :1r ' i t r r r , , r ' l r ' ; r , r r t r i t r r l ' l , , r , r r ' r : r t < l r r r " i r o r l i r ' t r l l l i r ' l r r r l r ' I r ' r ' I r 'o l I r ' t r I i , r I1r i r , l r i .
( ) l loo'1.& t i i t * , ' t t i . s( ' r ' ' . , r ' l r . r i ' i / , ' rz i r , r r . i , r L I I r . | ' | | r r , r ) ( l r , r : r l r r , . l r t ,5 i l l ' l t rn,v,r t , l t r r , i : r l i l r r r i i
. r ' r ' r r r I r I r ' I r . 1 ' r ' i r r r r l r l i l r r l i , , i , tu. i l l l i r l i l ; , i , , r r r r , . i l r i : r , , l ic l r r r l l i
" \ t l r ' t t t { \ Pt l t l t ! t t i i l )Nl t l t t l i \ ' . , { r . r ,s i0 1r! t , r . t , i l r r . t r l , : t , l i r r l r , l i t t t t r t , i l t t t l t t ,r r l l r r , l 1r ' l l r ' r r l . r r . l l - r r i r r . r [a ' i r r . t ' r r r . r lL i r r { i r , , c i t ' . l r i r r i r , i r r apr: l i r , r r r , r r r* t r i r , t l r r, . i | , I r I , I ( ' I I I I I I ) I r I rL ' ) c l t rctrrrs is l ,o l jc (p l i r r p1r,r ,11r) i r r , ) , s l i i r . rsr . : r i t p1i1 t l i i i r ruf t ,n i ll r ' r i r ; rcrr l i r r ' l t r l r . . r . : r i r t s l r r r 0 t r l l r I i 1 , , .
!, ! l \tr, l, lnu i i,r i lp de ?raitabil i,t l t ' . . I,r jrri lc ltcslclr, tr it,rrl, ioniun fi ibli l l ,! lntr t r l l i r r r l l l l i , r l r c iuei corrsccl iu!r i i t r rcr l i l t l estu olr i l e l t ,
'c i t ,cul t l ;or io. i )o
l] l1]l.il , :]:] I :,iil,,lru.it,^ i',,1,il, ice pot.sil se insot,ensci, rt9 t,i,,"ac"i ,t,, .*;,rliir,iii,i\rr!)r)cirt srrti .i,l 'r ' irr l rrhicrrr'<iii lo supra-ventriculil i 'e (J3oriver"b, Firruiu,,:1. ' , i ]1. ' l
, i ] : l
, , , i
, l , , l r r r ' r | l r , \ '1 ' ' l ' r ro I )o l . . r i i su rr l , ,o{o0,s. i dr '1r i r . r 'dr . r i rh: c urro;r i r r [ .11,. \ r r r ) l ) ( ' r ( ! s l I r ' iu ' r ' r t i t l c r ' r l l r . SUp"A I onlr , i r .u]rr |e l l lotrvCrcl . Fi t tL l i r t , ,h ibr il r{i.,a,r:ri.ulll.ri l l lr,xistitiL I irr ulltirna va.ictu,1e, 'sincopa pbato surl'r'ri
lr, ,slir;itLrl, rtrustrlui,,pr.iri pa,Llzir, auriculari, post_tifirifdliej. SiiiL,rrr/ , r'rLr lr(.llcUl()rNc, i;r stlLirnb, tahicardiile vontricula'c, prin riscurlloile vontriculalc, prinlo l r l r losol t i l ,o,
'l' uI [ou.[, sincultul poale irnbri,ca urrniitoarcle configurafii :ru) lr pr:r'turbiililc hcrnodinarrrice cu tlurati, Ae l-iO setunde, tulllu.r, .i'.rr l.1,t',iit tr. osle de obicci .tsinriitii tle hotnav, perioacia fiirrdst, t t r t i t . ( io l ntul i - holns,r . ' r r l resinrto n ( fa la.rd; . t^
-x.1r-^- , .
rri, - l l)u l iulDtl rlo l lclnodin&nice cu druati, de b _10llrl i l cirrrrr l l l , tx,i i t trn osle de obicei losinll; j t i i de bolnav,pt lrr sl rrr l,ir,. UeJ t rr-ult, holt rar-nl resim be o stare r;ag5, r1e ,,rb,u,,-sau o efemot{r
Ilin(liu|olcs, in contcxtul clinic al tuturori r r ic l l , c l ize conv rdsi i .e,
,\rl,1il tlc accrirltirite in repctilie corstituic
s"rr,zrr,(it^ rle ",,vitl
i.tv'ior", cr_i,re-i pemrit evitare"a cXa6i.ii in cazul in cftr,(l, l r ) l , |1rrcrL Lcnlodir i tn l i ( . i l I l iude Si se prciungeaSCH.
. , b) Lr. pcllutbirile hernodinamice ae 1O-ZO -seeunde,
manitestlrilo; , r | l I , l r r i r t l t r l r . l rsr . , l ,u lnurut [ | r 'Czerr l ind O paloAr, . b.ruiat i a fetei , VOrt i l .I 'r r\ r 11. ir,i rsr.rr t.r' i. opr rfc .r \ oJ lJirii $i I ac r iv iln lj i mo tori i, d u pir cari: inai viOtjir i j r t tr l l i i lol ,rv t tatc:t .
c) ll i 1't.t lrtrl,rir' iJo snls dcpiqcs,. 20 de secunde. piol'dct,ea rle cuxoqtiritN,r.rilr. r.'si\ ri, (.u rboli.r' i l rcllexr.rlui corneln dupd, iO O" ,-"*A".-fl-,i.,r,i i iI r r ' i : r . i l^ l i l dr ' i i l r , .u l ju se s i r ucazi jn l re t ,c i 3 f r inute.. r.l) Itr ,,ineuptle cu dur'lltI de pestc B*4 minute, leziunile cerobralo
sirr l i r r r r . c ls ih i lo-
,rstaren de rdu
. .ll. .{iar',r7,1/, ,oJ tla. Einaopa uaso-uagald, re.f\efi, po:tte Ii tlofi-uittt
I ) r l l t ' l , l ' l ' ( roro uc cutrol t lu{a scu_rte, cu sau f5r i convuls i i , sccundar,rlrfr Iriurz,! (1il,ldl&ue s&t unei prd,buqiri tensionale reflexe (W;ber, 1g?2).I trr.l;rDl,, *crstr: sirx.ope, cele mai frecvcnte qi mai benigner'sint pluriotiri-r(,lirr'r'! (|i lI r o:l.Lo alr ull ctcmcnl cumun : tercnul pe t ar.e surrin aceite nranl"]1..1.1:ll:.lr:f i:t
o .labilita,te imporr aniI a sisl,crnuiui ncrwos wegctativ. Aprwr', r,'tr1t r lrrnlr, l& 40. dc a,ni $i sint mult mai fr ccve.nte la femei decit- lOrr : l ,u, i r . l r_ l ) rn t , ) tctut .srn( 'o lo lor studiatc de CnIf l r iu s i popovic in ( Ig78),l . ( r ' r l r ' t r ) r ' ln{ , l l l l t l . i l t tzAt un ptocc {nj de 93, l o/o, In antocedcnl ,e le : r ,costr j ir ) r ) I l i r \ r Iu , . ru sc| | l t r l ' lutz i i de obicci bo. l i orgal l i r .e, c i , rJt . r ,egul i , Simptotno: l l l l , i , j l l , " l , t r r lbur i i r i vcgo.tar ivcJ tutburtrr ipsihico t le ort l i rL dicct i " ta 'peiuo...'rrrir{.r or.otive' instahire 9i labiio vegetatir,'. uneoli in antecedefrto soHr''rrr lr' irzi, fi l lcIt( sirrnc artcrialil,. ca fncl;ori declanSatori so somnalo&rll(( lr)r' l: ' i, f i ,l,opovicill, lg?J; Co'f ,r' in, 1.0?g) : frioa, sii,rilo de crnotir,iiai"of i l d l : r l . , t i t l . i l , lo, . s l r 'cssrtr i lo, sul , ; I l i I l l |1ni t l i i l , i l rsol l l | l i i lo, aorul t lo l t tUt,r \ \ r i l , ( t ( ' : l , tcrxr t , n( t t l r in i r t l l ,a.ron, ( l ( , in, i t 'c l i i i . t . , l l )1 i l rccqi ; i faclol i i loclanJt:trrrr'zr\, rrttrlt mai uf(n'rl.,osrrl sirr.rrprr,l riur,,i, bulna,vrri so ntlll in ol,r]ostrol,iHm.llttpil, rrbiryrtuilrrlrr rrlr,l i l i 'nlr"r,r,i Jllr':rircrrsrrrr,l0, ntrnollzij, sr,url,ru p ior,rl ririr
' ciO
rr rt rroEl,irrt,i 'I,,
:|tfi
a,cesnol slnoope so }ot
, . \ t r ,x i t r , r ,* t r rbru, l t '1, , .* t , r r r , [1. r , r r , r r i ' , r r l , t . r 's l . i l i t r t , , I t r , 1r ' '1, . f i . r r r t , l izrr i i tl l l r r l t l iUi t t t t t l l ,o r t torut , t r lx t r I t r t1,) . l i l r , i , ' t I l r r l r , r r { iaJ 0s1r i r .o lxrrzotr i t r , l , , l r r ! l ! ' f ,( l i l . i r ' ) tn ' i ' r l r rp) i ( l i r ,x l , r r r r l ' r , r i . r r l r l r . ( r r i ( ; ) , { lo o on rdio- i r r l r i l r i I io. ( ]c lu l : r , l i i ,.rr,ztt,r' i.ritrl, in .trr,1ror'1, r' ' ' ,r l r i l x r l r . r r r i r r o tt' i lrrzit,orio llt,itr v|,xorli[a,1,1t,{,io;x.r ' i l . r ic i r , ru*Lir l , (n i r r . 'p i , r , r r r r r r l r rp l r .s i l . i l , ) .sau cu o i l l i ib i t io rospir , : . r ,1, ' i , i t ,1] . , ' : r l '
l , lpnec Nru cl l i : l , r : r1rrrr . r ' ) , ( i l ls l r r , r rL qi cola.b. (1956) au a,r . i j l i l i ; ix i$1, t r l r l ,u,rtnrrr I,)rme \.aso-rtol, t '( '$ i r 1' 1trr.. i l sincopei, al5turi de fot:na cauli,_ilhili i-lottc puli ;i dc fonnr,lo rrri_r.1o.-l)o faptl aqa cum arn r.emarcal, $i rr{)j (( lrrl : r r iu s i?opovic iu t9- / l ; ( :ur f i ' i . , . t928), acei l i f tc tot . i bc pot ai ' t : i l t , l r r . r l ,l )c bunA.drepfate. Webcr (1972) : t t i rmd, cL, pare i luzor i r r 6J, sc t l i f r r r , , . r r1 i , .z, .,[iversc iipuri de sil_ cope (r' '.utfalc, vaso-depr?sire, vago-vagr,lc slu vin,]r,r.,,vagrre. rcsluiitorLi. vaSo-vagale cu bradica,rdie primitivi). Do l|,r.r,r,:r\\-obe1 i1972; susline cd,.este pr:oferabil ca. toate acesie $incope sit $o rrri{lrpez: llp nxm e1e de. ,,s;ncope taso-aagale,,, cu atit mai mu1t, cu <:il, rist,,pt'obabil c5, se asociazX sau succed o cardioinhibil,ie yagali 6i o r,ir,sotlepresie simpa_tic5, qi cL do
-fapt aceste diferite m'ecanisine pol, ir,von, rr
origine comund, depinzind..de un reflcs care pune in joc Ir. Tl,. pontobulbrtS. care. conline centrii respirarori qi circulatori qi in special c:urli,r.rnoderatori Bi vaso-deDresori.
Starea sincopal i propr iu-z isd ( in mod impropr iu denumit{ dtr Wr. jx.r(L572). .rtazd, ictald,") esre dc obicei precetlati, dd o fazd, prutlromtlrl (irlpropr'iu dcnumitd dc Weber ,,{azd pre.ictald.',;.
, ^1 . Faza prodromald, ( pre-accesuald,; pre-ictald, dupd Weber ), cu rltl.Lt.rr.
dc. zU-J0 Becunde, se manitcstd, prin impresic de ,,rd,u gcneral", t,rrurrsIilafii, am6{,911, zgomote. auriculare, alteraJii ale peiceptici vizLraio, lri1,i,r.s_ialoree, senzafii i ie ,rvid ce.falic", parestezii in extremitl1i, palou,i,,,. nrtrr,(tunpotrivi, roleata, t-egumentelor, uneori dureri opigastric6 iitrrr rl,,l,irrit,.,grelud $i exceplional vi,rsS,turi lOorfariu, 19?1 ;'Weber, 1g?2).
2. Atacal sincoptal (,,Jaea ictald,ii d,upd, Weber ) corespllodo piorrlrrr,irIropliu-zjse a-_cunogtiafej. cat.e esl,c completS, $i urmattr dc cd.clrrol I'rrlnrrl, 'st'e .inscsizabil, zgomotelo ca.rdiace stnt siabe'sau ab$ente, dar nr,rpiru,Lirrdc obicei este conseryat5,. Reluarea congtien{ei esto rapidi, drrrrur,,r,'t.,rii i i i ia sincopei fiinrl sub 10 secuncle, iar treiirea iiinii totain, fd,rt, oburrLrlhl'.plelungit5,. secundari, amnezia fiincl limitati, doar la durata pierdorii urrrpjielpi. Sinco.lete-cole mai grave, aproximativ o.trsime din-cazud, so 1xrt,Insolr de manfesttri conyulgiye : spasme tonico ln opistol,onuB, oxcotrt,hr.lpl r: 9*p-"9!!oto^nq, r1rm?F sau prccectate uneori do ctonii girrr"ruririii",(CorIariu, | 97.1.; Cortariu gi Popoviciu, 19?1 i Weber, 19ZZ). A"cobto nnutirosra{r convursrvo se,lnsolesc totdeauna do o rnarcat[ midri&zd,, u[.(,r'ide trtstaf,'mus.. hrpJrsatlvatie, emisio de urind gi mugcarca limbii, rin ltrxrr,rrsmr expucabrre dlrrcuitaFile do diagnostic crL epilopsia (fig. Bg). tn htorllr.ianto_rioaro (Corfariu qi Popowiciu, 19?1; Corlariu, fOZ"A; Ijopovioiir ficolab., 1976, 19?8) am oxpus pe larg criteri.i,te d,e diagnostic, po o.iro rlrlrr,r.le Tom lezuma :
a) Examenul clinio este negativ, iar traseele XEG (standarrl ryi plirrnctivS,ri) din fazolo intorcritico sint _ normalo (Cir,lcii,ianu $i Stoio,,, '.lli{tfi ;Oorfariu, 1971 ; Corfn,r,iu ,si P,opoviciu, 19?1 ; Gastaut, tO6f; flnsirr,rrti qi.olab., 1956 ; It&illofl, 1000 ; Slioica 0i Bro$toanu, lgit9). Doart V.rcolhrl,1,ir(1960) a gfl'sii la 30'1, rlirr lr'lnrlvii cu sincop., anolnalii lr.r!(1 r',rro.rr,1,.si Itu l-0% {,n"{,rnrIlii rrlrr.l,r'i.u rro ilslxrcrt cornifin,l, inrl.osobi l,l sLrbi.'l,ii .rr$irl(Dpe vll,Bo-vlulllo,
3:)tl
. l l t tc l r i t r r l r , i r r L i t r r I r r l l i r rcolroi s i r r r l r lo srr r , r t l r rg rrrrdo lont( ! , I ) i I i I I i I I . i | , I ( It i i i Bi I l ( , r " r , I I i r , xrr l r | l r , r o l1, l r , l , r r , ( l ( ! i I lu l . i ' i , s i r r r tsoir l l r , l l i , , (1 l t o I r r !ov(! l )1, i1, i l0 i t . . l r , / r r( ( | r r f rU' i ] t ] . l l )71. ; ( l ( i r la l ' i r l ry i l , ,1r ,v ic ' i r r , u)?t l Wt,brrr , l t )?J). l r r s i r r r r , l r l. r r r I r r ls i I r ' i , l r r r l i rut . i lo ( l r ) rn( lo lcrr to s i r r1, rnai Jr i r rg i 6 i s i i r l i r r t rurrrpio r lo i rnrr i l r r r r { ' i r r I l r r . l ' r ' i rL l Ip lo '1 lo o0rnplr . t , ( , : r r l1. c(u{.NI,uur[o s l ] l r ,s] l l l r l l r i lo i r ic . , , t <rcsl ,l i l . l { i r r l r r rc l rz ' i i ' r r i lc la, sccundo qi cstc urrrr : r , t dc lc i r l l l r , r ' i { i r l r r } ( | j ' lo l i { ' l11o,.rr|. o Il,rrr rIlzii, lrr0grosir', pinii h rcculrc}a}t,ll urrr-ri r.i irri rronrrrrl, l\rstir1r ' i i i ( r l l t cx is l ; i , i l rxrrna, l i i l lDG.
(.lrr,sl,rr,rr1; . (I950) . a . doscris sirtolpi], nrrcturnir, a hiperl.agotorjicilor Sirr.r,r,r,iLirI.it, i l i l ir|crr'(;iorii a,ocstcia de- opile+sia rnodei;i,. Aiestr: sincolNr
\r,,o \ ir,gir,l(, sirrl l:lyoriz:11,c in oursul nopl.ii, de ridicarea in tirto,.talij inI.ri rlc rrrrvoiir, rlo ir,.rLriru, la vagotorricii constitnlionali irL faza ch hipor,-
'rr,g.i.rrirr rr'ot,ulnr"l. Asocierca acestor diterili factori (staliunc l,ertic:Lli,
rrr lril i ' l lr, ln srrbicci, prcalabil culcat $i cu tonus vascuiar r:eclus, afer,r,nlor irrrrrr':rJrr ctrrl;r' ipcl,cr J)rovalen1,[ nocturlX a reactiviti,l i i vagald) oxpljcll. 'r 'rr,vil:rlorr il,cosl,ol sirrcope qi asocierea freclenti a nr a,iifeBtSrilor coiyul_riVrr Iirlifi1, u.ol)lonM, tliagnosticului diferenlial cn epilepsia rnorfoici-r,,' l 'oIrr1i, lrr.ozon{,:r, tloar a tnei contmclii tonic6 in opistAtoius (pl.cccdlr1,rj,rrrr uIrIrt' i rkrlr r10 1*2 sccuso muscnlare gcnel;lizate, ilar'-Iiciorl:r,1ri,irrrrolil i i, rlo o 1'rr,z[ c]onicii ritmicii propriu-zisi), precesiunea cidorii ;i rr,;riclrlolii .orlLory1,inloi dc c5,tle o stare de riiu gencral cu gre!.uri, paltii lr.o, , i t r ' : r , r rs l r i r ' : r1 i r r r ! l rund, nl i ! , a- l lscot I r ncmoolor EEG de epi lppsi ; . 1,r .ecur,r s i1rroIrII..rlo rxri npro$iunc .a globilor oc[lftTi pozitivi,, etimind, Olignosticrilrlrr rrpilrrpsio lnorleicd, qi obiectiveazi, hipeivagotodia (Gastaut, ' i9I0).
. l)orli.s-1, orczu-t tri sincop-a yaso-vagald, reprezint[ u ri,spnns teusio_r.lrrIr'rriror }r {).lt,l{r()sirne psihici,, cercctiri ale rioastre (Corfariu $i l,opor.icirr,l!r?.ll ; ( iorInlitr, I97-8) au arltat c5, existir, o irnportanti participarti cardiolrrrlril i i l,oirnl .(1i11. 38), carc oste capabila prin ea ilsh,-;i sb, declanriezc orr r r,rr io cottll ' i,|,i l"t.
. l'onl,ru rlocllnqarea unei sincope, respeoi;iv pentru leprodueerea irtlrIr()r'ltl,rt: ..1, nroocsllhli sinco_pal, se.utilizeazi, conprcsiunea oculari, compr\)_rrirrrrur, rJilrusulr.ri cr,roljidian qi rnanevra Valsalva f Corfariir. l9?t.I lr78 ; ( lrrl 'ariu Si Popoviciu:,- 19?1.; Gastaut, 1950 ; Gasta,rit qi cola,ti., f ObO i( lirrrlrr.ri, 6i ̂ (h,$1,lr,ut,
1_956; YercclJctto, 1960 j \ycber, 19 Z2)..Oompresiun{t;olrrlir,rii trr fu,rxr tirnp de 10-15 secunrle, etecbuindu-se concomitent o inro-llirrl,nrlr ;xrligrtfici, (EEG, ECG, pneunfograrnd,, eventual $i pletismogra.nrii,). l\,llrnovla, o$to pozitiyi dac}, aceasta antreneazl, nauli cardi;,rr?.irlrr 5.,I l:lu rnai nultI _ririrea, . ftec\.enlei cardiace cu c6t pulilr 50o/o;rrrrrrilcll;flri 1r'o.siucopale (prc-ictale), sventual chiar o siircopn 1vb)i
, lirzlrltoto poziti.l'e cI valoare _diagnosticr, au ob{,iDut Gastaut (1950)i1 (.il, 1,rnr'1,4i colab. (19-lir6), Vcrcellctto (19ti0), Corfariu (1971, 19?S) fil Irr' l 'rrli l ;ri l 'oqovicin (1971). r,s, uncle djn cazurilc noastre, pe lingi nlrrd-(rrlrr obiqrlril,o do opriro cardiac5 (la 4? 0/o din cazuri) am obsbr-vat giblorurirrrrrrr rr,l rirrkr ,,ltr lanltt, l i l intervale iie 2-3 secunde. La cazurile obsorvtlo'l(' lrri. (( lorj:)l ' iu,- 19?1, 1978; (,trrJariu qi Popoviciu, 19i.t) nu arn putul;1'rrrrrr irr.rrvidonftr prin acuastL. probii riispunsuri ,,corrrphtetr itrU(i, <nrlrl l.trri rlo.rrnilo kl-nt o scpu,r0.bi rlr: 1x.r'itr.r,tlLr tk' tl, ]rrrlsjr. t,luutr.ici-r,, i l,Dil, iflnttI r ' . r r i [ t ( , i ! l Vorcol l t :1,10 .11{}60), e i r lo i r } r . i ts1rrrrrsrrr i t )1,)( i , , i r r t iorr i1r l0. l r , ) t( f r r t lot t t ' i r lo ut t r lo. lont t i , . l r i l l l l ,o l l l le, s i r rcr t r r r ' , s i r i ru i rJru. , r i , r l l ru ' | ,s i rLrrsoir l r r , l i i ) .1r . . . I rp1r, ( lat l , iu l ' t6 i or l i tb. ( l l ]5( i ) l tu lu ' i , t i r , l . i i , r ' r l r r ts i i t u lxr l , r ' rx,rrc. l r r , l .g ' r i -l i r r t ' I , onlo r l t r i , r rntr i t l r , l l i , r lc r l r r l r r , l , l l :ml i r i1,ol , i : rur l l loc rr l r r r l i l lo t i r ro. l l i r i i r l
J30
i i i
"t
plt r i l l : r , ( i scrrrrr( l r lu rrror l r l l r i l l . r ' r r r r r r r r l l l l r ) (1, r r l r ,x is lar l i r r r l r txrs l , r r 6 Hr.r . r r r l l r rl t rot l t tcc l t t t l ! r r t t ' i r lo t t t t r lo l r l r r , r , r r r l r ' l l : r , gclrct : l l iz- i r i ,c , ia, t ' r t t t s lo l r c l r , : ' r l i r t , t rctr o r l r r t '1r , l ; i l , r lo 1rc$lo l i l r i l r r r r l { ' [ l r , i r . s i i , r r , l l l l l i ( loscl- [ r ( r i r i ( lo ul l { l1r h,ul ,obi l l r , l , r rn l l r I i i l | l (11r ' i ( , r ) r r r I r , l r . r l r r l r l r l I l iz i l r r ' : l t I ' i lsort l r r i ( (1{) n(x) ln i l o l l l , t l l lol lrtult i l iura, clinir:ri, 6i cl o (.ol nrrrl, io irr opistotonuS, proccdil l, i , { l i f I : lcJorti i gcnti l l l izate). Nirriorlrr,t i i , nu ti4)l, l 'e insi o fazl convulsi\ ' l i , clr)r)i(,r ' [l) l olrl i [-zisai,. Castlf irL;ri c01 lr. (.1050) au mai demonstrat cir, Ja, trioi rrrr
p teE LI4 o c a L.t pRE s tJ t,t E 0.ur,1,ii-'--'']-;;:"--*
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.lrig. .r3. Proba comprcsi(i octl]arn ln cursul unei lnregistreri poljgralico Irbolnavul P.D., 23 de ani . Dg. s incopi vasovagal i . Rohavul s-a i ik ' r ) ru llcntru pieldcri dc ctnoqlinl:i de scurti durat:i, declanFate in special d(lcrnol i i t i de eDervir j , lnsol i tc uneor i f i de convuls i i Lonico-clonic. , I i i ' r ( lsuspcct!t cle epil clJsie. 'foate iDreejstrir.jle EEO intercdLice eu iost nci{aLi\'( .Proba comprcsiei oculare evidenliazd, dupi 6 secunde de la inceperea nlArl(yr ei, o nrodilicare a ri[mnlui cardiac(de ]a 84 bltli pc ninu t 1ai0 b:itnii tnin L),nulncroase bjocrrr i s inoatr ia le cu durale de 2-3 secunde in , ,s | i tc" , I r i t . inod if icarua 'f .l\. si a activitilii EEG. TesLele de cornpresie siDo'carolidi r)iigi maDcua Valsalva a fosi negati.ic (dupi Corfcriu, 1W7, Cotlilriu tii
PopoDicir l , 1977 ;1 PopoDici& si cnlab., 7978),
ca,z de sincopl vaso-vagal5,, actiyarea c&rdiazolic5, lru pro(luco li(,i lrllit de reactivitatc epilepticS,, dar c5 aceast[ ac1]ivare de multc ori l)t o\,r)it,('iisitrcopa, in cantit;,li rnici ale substant5 injectati,.
Masajul regiunii sino-carotialiene poate antrena o pr5,bulir'(i loltii(llra15, in cazul unor sincope yaso-depresoare (Corfariu, 19?1., 1978; Cio}lrrlirr1i Popoviciu, 1971 ; Weber, 1972).
In sfirgit, in sincopele prin inhibilie respiratorie poate fi rrl,ilii ptrrrl,r'rrrliagnostic proba lui Yalsalva (dup5, o inEpiralie profuldii, so plrlciicir,rrrr efort expirator cu glota inchis5,, ceea ce produ ce un blocaj tl Irrl o:r,rr.,'r ' i ivonoase, prin hiperpresiun€ toracici). AceastS, prob[, practiclltlt qi rlr loi(Corfariu, 19?1, 1978 I Corfariu qi Popoviciu, 1971) a ploduH Lr rrrrr.l,rsincope vaso-vagale o reaclie cu totul particularS. Antfr:1, h slir;i l,rrlprobei, s-a produs intii o reacrie bratlicardicS, de lungi, durntr:r. irll lrr, j l l isocunde de Ia terminarea manelrei s-au produs blocuri sirxr"rl1,r'i lhr ,,r rr|l,rr],". Accstu roaclii au fost interpretatc de noi drept consccirr!o trl(! lurormI'lcxe exagcl':ltri dc tip va,go-r, agal (13 ozol <1-J aris ch) cu tcJ)()t'(l ltsil l ir r ,srrpra norhr lu l r r i s i rxr-a, l , r ' i r l (Oorfar i r , 1971, 1978).
Ilu,clori,,i tl.irfut11it,i, tti :titttoptil.or' tttso-ota,guLr sir11, rrrrrrrrl 'o;i ((I()r'lrIIiI|,1071, . l07l l I ( rot l t t i r r t i i I 'o1rol ic i t r , l ( )?.1 I Wrlx r , l1 l? l - r ) :
l . l l i t to l t r t , tnul i t ' r t , : l t i t r i , , s l i i r i tkr i r t t to| , i t i t i I I r , , ct l ' t ' t i i l i r s l l l l+rrr l i( l lv t ' t 's(1,
: l . i l
. . . . ' , ' , "1] l ] i i " .h ipt t l r r lu ' t r '11 t r i l l , r r I r r r r r l ' t ' . t t l , i i , l r st t t : r t ' r i i1 i l r r , r r r4r i i i r r l , i r r r l r r r lI I r t I i r I r | | | r ' I I I | | ! rLI i I r . , r rur . ln r l i r r i , rc l , r .c i tLrr t i i r t t ,o l tc l ' i iur l r ,o i r l t t t r r l t r , i ,o otr r ,o l r t i t l 1.H||t| l I I I | ) r , | | r \ I I I r I ( r . . S|) rrlt, i so ]uN,loil,zi, sitrrxiJi0 l i l i trr l ivjzi r: ltt,tr s l,: I l , io oil,zi,[r l | r rc rrrr . l l l r r r rg;r '1.r i , r r iu l i - r ,1rc l i i r rchisc, srrplrr , - i t rc i lJz i to, gr t l t ,s t ' i r r rpul i r i l i r r ,. ,
. i . ,\ Ltt 'ol),tt t,tt t luH)t.c u1l:lrt in caznl tnrol dur.rl i viscer.tkt (t:olfui lro-I ' : r l r i . r ' s : t | | r . I | | . I I ( ' . , c t izr . atrgiuuu,sr.) s iLr t nu t i r t i ( , r , .
1.. S;; roplh tl, i . n cu,rsul efitr)lordri lor inslru.rcntu[,e al)i]r i ldoosol,i iu.lr.|rrl rrrrr)r stirrrnlir,ri in teritoliul r. i lgului (risofagn. iu1,u, ganrrus,,,,-l r i i ckr . ) -
' ' - Si tcup, l r , t r lost t t l i r aplr . in tursul urrur lUrrgi s l rL l ionar i i r r p i r , i6111q1,r : r . ' r l : r r i r l i i . l r r r ' : r r l i r r 1rrr , t . i l ( .Dnvir lesccnla dup: i r ru i lc rnrr , t , l t l i i . Urr j i i r r . lur i: r r r sr s[ l ( , )pcto l I l r . t , l ( , t r t te ({ or l&r i . 1971. t tTE ; Web(.r , 1972). t l ._ i i r r: r . , r .s l . r . : r i r r t r r lv inc l i r l iSL.n, . { i t . \ 'cZicala. Sir_r, : t rpol , , or tostaLicc ; i cot , . l ; r ,r | | r ' l | | | l )o vr)r ' t r l r l l r , t r . r lc noi Scpart t 1r |z i in |onl inua:, t ) .
ll.. 8 i,runl(.Lc i.atrogene : dupil ingerarea, unor rnedicamente sr.rlr lllr r r r lsrr l tnrot iu jec{ i i .
i. il irr,cop ele tlupii r:on su,,m, d,e alrtxtls. ,\ i ttttt l tcle d,upo. ttuu in cursul tt t,t,r r Iurturi I izice.
. lt,. Sitropclc pri.n
.h;11t tse s;biLitutt^ t sinusulti i rorti idiatt au I,t,, l .rrl,r irt
'r{rirrse itf cad].ul sincopelor vaso-'agale? crezi'du_se c;, intervirro
rr lrilr.r'r.:terl,u,h,iJilate r...r,g,,1i.. Da_r_ tle_ lapt eld constituie o entitate apariir,j i l ; l l . l , ]1, , ! , ,1(w", :s. f , { :5: : , I9 iJ3. ; } l i r rv ie i t t r ' . ru5i ; Corrar iu, t9, i , i ezs;| , t t r iu l . i r | 1)povic i . 197.1 ) : : t , ) r ipul vagal sau c:rrdio_inhibi lor ; l ) ) I iprr il,r,rrsio-tloplcsor' I c) tiptrl cer:ebral.-
(':r, :Ll,il,r'u r-or' 1i expuse pe larg intr_un subcapitol separat.l1l. It ' luxtrl, lar[ngiott. esLe.o formi de sincap[-gal"s r,pare la indivizi((!vi!. rr&i r.i 'sli l ici (50 de ani), pnrti,tori ai uior afecgiuni respiratorii
' r'{)ri, r', Irr .rr.. r' iLcurnstanfele de aparilie sint chintele de fuse. b fornril,n| l |J , i r . t ' ' lus0l | l l t ] r rngtan cSte , ,LuSea obnubi lantai , , . ., | | ". Si.ncopel,e post-traumati,ce. Se confuncli, arle sea cu epilspsia posFI t ' l r , t t rrul l , ic l ' i , -
l).. f:ii,runpele 1tr_in alte d,i,oerse cause : subalimentalie, dupX insomniiur,rr sLir,r.i rlrr obosealil ctc.
, .l1l...Nin!\1,? tle ^lt,ipu
aentriLalia este mai rareori intilniti,. Aparo indoo-. . ' . \ r , r t r ! t , ' r I | t , r InLrc z0 -40 r le ani , .cu-tulburhr i Iuncl , ionale gai t l ,o_intcsl , i -.: .r,/ ir,lr .i mlb-.r,.:,sculare. tractorii d6clanganfi sint'totcleadna de naturr"r,; , , , i , l r i . r i , : r . r r l l r . r int l_o s imptomalologie preacceiualL mai lunga (3* l rn i_|lrr,(.),,r' irr':tl 'I.(:t 'rza,l,i prin^palfi1,a1ii, sl,arc de rd,u, transpiratii ieci, senzatiir I | , , , ,1)rrr I r r , , cong0sl , l& lc lc i , usctc iunea gur i i , incetogarca, veder i i , furni-. ir.r.'r 'r l| *'rr)rtotr in exlr€mititi, prccum !i respira(ii frecvcnte. Aecosrrlrlo.lrirrrkl.o ru cuno$tintei este de scurtd, duiath iZO secl, in ti-prl U"oiiil r , r l . r r ; r ' r r l r . . r r r i i r t ' r isc i to cd,-vedc, dar cd, nu poatc r lspr i l rde. Aceste mani-r ' . . : r . f r . . I l l r , l , l .or luso prrrr htpervenl i l l t ia pulmonard (wayne, l96t) .
. lY."Nitr,rropa Ia truse esta ugor.de diagnoslicat,. Aparo tle obicei tlupitrr l r r l r r l r . : l i -4{ i i lc ln i . la btrrbal i i carr : lquferJ. r je di i ,crsc afecl iuni I r r r i r .l r , rpulnlr . )n: t r r . . , t1 ' r r icr . (bron; i to cr .onice, crnf izcm lrulmonar, a,$tn) $. i . . ) , dorrr l ( , r ' t s t
' ' l . t . t ' l tn:Ltorr , Ac{,eJUl sI I lcopft l sc pl ,o( l l tcu i r t l i t t tpul t t tsci , l I
l : i l ' : l f , , .1:( , : i r r r l i l , rn ' r r t - r lo pr)z i I i r l , . col .Plr l l i , i i r s i r r rprorr . rc lc l ) t ,esr l , , r l l ) : r , lotr | , .x. , r ( ' . r r r ' tz : t . r r t . ' ; l l r l i r l r t r r , : r .z i i , . lnt . r r . l l0, \o. l ' r ( lo 1- : l_; l r r r i r r r r [o r i i ' r r r t( r inHo(r ' ' i l , ( r r lo co, 'vrr ls i i l ,oniu]-( [ r ) l l i ( :o, r ro l r r r r , r r t r r r ,vtur i r r t r r r - ; i l r r ,p i t r r ' f ; , r , r i
r r ' r l . r r r r . i ' r r . i r r l , l ' I r r r l ' i r r r t r I i i , r ro rurrrhrzio l ' l t do i l r r r r razir ' , r i l ls i r r io r i rgrrr I
: l:l:l
f i r l ( f s( f t t t t t0r l t r ts l t t , r ' ru ' r t t t t t l t ' { l ) , , l r r ' r ' r r i r r l i r r l r , l l l l )5 I ( l r t t l i r l i t t , l1)?l t ) . ( lot-
l r r , r ' i r r ( l l )Ttr) 6 i ( ior l i r l i r r f j r I 'o l r rvr r r t ( l l l i l ) , r t t t t ' t i t lon( i i l l , l : r arr t ' ; l i l ro l t t i lv io l r iporscrLsi l r i l i l , i r l ,o i t , r i r r l tHulni l r t toI i t I i i t t t ( .1: i11. 3!) ) .
l ) in obsclva, l i i l r r l r r r r i l l r ( ( I r r r ' l rL, t i t r , l1)78; Llor: I : l r iu qi l \ r l l t lv i t r i t t , l9?l)(vtrzi 5i 1Jg. 139), rt icsrr cri, irr sitrlolrt, lr l tuse pilrtricipii hr miuc rn[sttrl ii ' i1 , , ' rserrs i i i l i ta iea s i r r rsr l r r i l r r l r r t , i r I i r r , r r , ( , t1 impbrtal t r i lspuns t ' l rd io i t r l t i
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irig. 39. Inregistrare poligrafic! tn titnpul compresiei siDusului carotidiaDdr:ept. le bolnavul L-'\., 47 de ani De mai multi ani prezinte rare c ze(2-3 pe an) de picrdelc a cuDoqtiniei, declansate de tuse (de obicel),dar ti de rls. Esie mare fumdtor $i are o brcnqilti cronicd. Proba (k:compresie a globilor oculari a fost negativd. Se poate lemarca laptul ctrla compresia siriusului carotidian drept apare o pronunlatd bradicnr-die (cu 16 bitii/min lali de valoarea initiall). Concohitent s a produso scidere a T.A. de ]a 150/80 la 85/40 mmHg, cu revenire la valorilcinitiale dupi 22 secuntle, L:r manevra Valsalva, scdd€rea tensional{{usese si mai mare (ta 10 seculde dupi lnceperea acesieia), iar dupfitrsu1314s n4nqvrei, s-a evidentiat o rcaclie hipertonic{, cu cre$tefl alc'1.A. pini le 170/B0. Ileicsc o hiperscnsibilitatc a sinusului carotidiandc Lip crrdioinhibi Lor $i t ensi odepresor fi o reactie hipertensiv{ exagcral I(lup[ tcminarea manevrei Valsalvs (dupi Corfdair.l, i971' Corturiu
Fi I 'opauiciLl, 19'17 6i Popooiciu $i doldr., 1978).
lrit.ol qi tensioclepresor. D€a11,1e.1, se pare c; acosto zone b&r)rls('l lsjl )ilt ':rr pul,ea sd, fie influentate qi de hipertensiunea artorialfi protltlsil, tlttpirrr,ocesul de tuse (ca tlealtfel qi dup[ incetarea manevrei ValsaJva, itt oltst'tvrll,iile noastre) ,.si al conduce implicit la instalarea unui bloc sitlortlt itt'lsrnL la o pd,bu$ilc a tcnsiunii arteriale, cu ro1 in cleclanqarcrr, sitrloltti.
\t. Sincopu ortosttLticii este socotiiX' de cei mai rul!'i (Dod.irlol;' I lli'll ;( i i lgenklantz, 19?2 i Hrs, 1972 ; Weber, 1972) tlrept o sinoollt, vlg;Il?l,.l,h reprezinti 5,5 o/" din totalul sincopclor studiate de Wayno (l 91j l) {i1,3% din sincopele studi:r,tc de Coliariu (19?8) Si Clortaliu ryi.l 'opovitritt( l$?1). Apare cle obicoi la' inclivizi treculi de 40 de ani. Forma ,rprliti lg('r'I '"rr, u,ccstei sinoopo sc tlulnrt;oirzX, dupir, o pcrl'ioadl lungi, tlo ot'l,o'!1,1!f iNtIt(1,) i r rhno qi oola, l ) . , 1f) .17, r ' i l : r , \ ; i do Corfr , r i r t q i Popovi l i r r , J97l) ' l t ' r r l r r r r r 'r r r r r r ic i l , ( [ ! r rgol , l1) f i0) ; r i fo l r r r r r ' r l i t r h ipotot ts i t tnof l posl ]u l rL l i r i6 i v l ' l i r lcrrz i l ,s i r r r ptr t ruu!r logi : r , , J l i l l r i r r r l r t ! r i l l r r t t l r t l l j , l t , c t t t t5t iot t { , t l i , i r r t t t t t t t t t t t t 1 , t t I I t t r t r tu ' i ir l i r r c l i r rosi l t , l ; isrrr l t r ot 'Lol t i ' r r I i r r t r t , t t t r r i t i dt lJ) iL o scl l r l l " r ' pr l l ' io: t ' r l l l ' l ) l ' ( ' l t { ' ( r ( rNl Ir r l r ' i crr l r t , l r i rn,rr l i t r , r r l rz l ( r r r r l r i 1 ' ' i11 . i i lmo{tr l i . I ' i t r r lotrr i l t l t t t r t t t to{1 i t t1f i , lnI t rso{r ,1 l r r t l r r ror i r I t lorr t r r l r r r r lorr i r . r r r . lotr i lo, l fotrr l t l lot t i r ' f i i t , l t i t r t t l r r , l ro l t t t t ,v i ir l i : r l r | l i | i , r r , r I t I inot t i t , t r t , t t i t I t t1 i r r t r r i r ' I t r ' i Hl t , l l l t t l , r ! l i ( ' i . l '1 t t , t t r l r .gt ' t iN Li t t |o l t t t
: t : t : t
oflosl,iIl,irio lrr sirrrlrornrtl Shy-l)nlgtrr', bol,[il rlogurroltr,l,ivir, ln r:rt'o po lingil,lripol,orrsirrrrou, or'krstalicii, sc cunslal,ii, urrhidrozil, impotcn!,i srxuali,,1roI;Ihittl iu rrxrl,urnii,, abolirea roflexclol pupilare, simptomo cxtrftpirtuni'rlir,lrr ryi rr,bs0 !l crc$torii orijostatice a catecolaminolor.
lrtrrvis (1904) a descris un sindrom de hipotonsiuno ortrc,staticil, {||,rIIi-liirlii, i,ir,r'r, loplozinti, o boali degenerativd, cu transmisie er'odilarIJ.
SINUSULUI CARA|IqAN DREPf
ECG
( ' l r l { 'Hc l , lu i f l : ' i . iorr l l i , r r r r lo l t r r r1rol i r r , r r I i r r r l r r r l l t r r rs l r r r r iu l r , r . r rs l , r . i Hirr loprr , p l i r ri tc l , i tLtr i r , r l l r l io i r r l r i l r i lo l i r .
l i l l , Ntncopokt l t ' i t t , t tu. t : . r r r i , r fu ( l )or l inot , 1972) s int l r lor l r rsrr pr , i r rrni[ i rnu]to aloolj iulri (, i l ,r1li lr irr, rrcrrlologicc sau vag:lIc, prti irrrlrt-so ;rlrrt izlrou lnaro dilicultato rlr,rtzlr, crurtii a, acestora,
PNEUMA COMPRFSIUI,IEA SINUSULUI €AROIIDIAN DREPT
itir, d?. Inrcgistrare poligraficd 1a bolnavuM.L., 53 de arli. l)g. sillcof,la nliclirne, La compresia sinuslllri carotidian clrepl s€ produce lrrrbloc sinoalr'ial de 5 sec., insolit de o senzalie de letin iDinenl. Lr clir(ttarea unei manevre Vals€r1va a prezentat - spte sfi$itul acesleix - 0intonsi reactic tensionald, insoliti de extrasistole ti bradicardic (dul)ir{ :arfariu, 19'11, Corfaria; i Papariciu,1971 , i PapaDictv $i co1or., 197t1).
, 1. Cauza nzi,rte cardiace (cte pilcld, stenozi aortici, qi bloc a,tr.io-vr,rrll icurar palotiis0rc).
2.Oau'ze miute tago-cartlidc€. Este vorba de piltl ir, do irri,rrlvr,rr{irunnui factor vagal in docklnqarea de sincope la bolnavi purtr'ltoli rlo lrlor.al rio-ventricular comolet .
3. C nztze miute niuro-card,iace: a) Epilepsie pi s,indlctm ,A.tltuns Sl,tl,t:r.Se ''stio ci sincopa Adams-Stokes, fiind f-oarte aclesca txrrrltrlsivrr,rrli i,poate fi confundati cu o criz5, de epilepsie, iar Dorlinot (19?2) l tlr,rr,r,irrun caz de comilialitate interpretat ca un sindrom Adams-Slokcs, rlir,l,oli l ir,unor tblburS.ri de ritm car:diac apirlte dupl episoadele talricirrrlito rlirrcach'ul manifestirilor sale epilepticc si la care o ttrra,lic anl,it,orl i (irrli :rdus la suprimarea acestor mo{lificif i.-Tot Doclinot (19?2) t,clrrlt ':rzi r|r,uucazrrri care prezentau concomitent cele doui afecfiuni (epikrpsirr 6i sirrrll0rrrAcb,r'rs-Stokes). Totugi, Doclinot se intreabi,
.pe buirri rir.tr1rLir|,rr, r,rr 11i
nai, dac5, aceasti, manifestare eliloptic5, nu reprezintii in rclrli l l lo rtrr,lrr' lrr,anorial a unui sindrom Adams-Stokes. lt) Sincope d,e rril in trt.l ' ':ulru.tt,5i, si nilrotn A.dams-Slokes, Tot Dodinot (19?2) relateazj,i cir,zrrr,i l ir, r.irrr,ltlocurile paroxistice Adams-Stoh€s pot agraya urele tullnltti l i virii lrrlrrrr,<rcrcl;r'ale la bolnavi cu insu{icienfe fie vcrtebro-bazilar o, 1io oIro|,irlir,rrr,,lrodncindu-so sincolo t1o etioJogie rnixt:i, do aceoa, l)tolnuto rngtrrrizirr,r,ir,t tnot cortsnl l ra,{ i i r rorr lo- t r l r l io logico la bolnavi i calc plczintr i l r i r r t r l r r r , i r lo( l l r i f ) ) t l l i t t ( i t ' i i r t o l t t I i t l i t l , r r ,
O sor. io r l r r i r r r lor , i ( l l r r r r , l | t7 l l ; { i r ) l ( l l l r ) ' ( ! t , i1 i icor ' , l { }?0; , \ lorrrrrr l 11lcol i r , l t . , l l lT l ; l io l r r r r 11i r , l l : r l r , , l l )? l y i l r l { i i ) ; r l l ) t , ( } l r l l l l osor io r l r r r r l lor r f r rt t , t l t ror t t t , . l \ r t r r ' ! i r i t t r r lu l t lu i t i t t twul t r i t . i r r t r l i . r t i l i ! i i l ) iar l t t ' ( pt in ntr l r t l tt l t , , t ! t t l ' ) ' t 'n l , t ! ! u l ' r r , l r l tut t i t l , , l i t ' , r t t t i luI t t .
COMPRESIUNE.4.^\.-/2\
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FM. -4.4. Plus 66lmin. Pius 51/min.
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Ii0. lr, Inrcgistiare I)oli$afici tn timpul compresiei sinusului caro-lidiu drept lli bolnavul A. I., 3? de ani, alg. crizc sincopale orto_statice. Boln4Yul prezinli erizc sincopdc tnatinale la trccerca dinciino- ln ortostatism. TA. ln clinostatism era de 120/?0 nmHg'irr in orl,ostatism de 90/60 nmHg. Comprcsia globilor oculari a{ost negalivi . ln schiarb, ( jomprtsi.r sinusului caroLidian drept sevoalc ci produce o scidere a tmului caldiac cll 12 ]ritdtlmiDut, crro cliscretl scitlere a T.A. (de l^ 1201'15 la 11/75)' Manevla Yalselvaa proalus o masivi scidero tctlsionali dc la 120/75 la 75145 mmHg((rupi alorlariu, tn t,
""Il:i"i:.qisP|apa'icilt' 1s71 ei -PopoDictu $i
ItrrlriL, Oorfariu (19?8) qi Corfariu qi Popoviciu (1971)' multe sincopr'r,r'{,rslrrlico siut, rle fapt, consecinla unor hiperreflectivitS,fi sino-carotltl i 'r r ' 1.1i4. l r ) ) .
\1, SirLcopa de micliune este destul tle raril, (3,3 0/6 in statistica ltti\\ r yrrr, .1lil0L i].13oloin statistica lui Corfariu, 1978). Se intilneqte indeos0lrilrr, lri i l lrl,{,i, dupii, yirsta de 40 de anir alo obicei ilupd, coasum de alottttlirr s,,rrlrr, plcmfrgiitoare a'cces Ini. Dup'i un timp variabil de somn, bol-rrrr,r rrl rr.spr,<.l,iv se scoali, Qi imediat dupi, micliuno se produce o sculir'1,;rir,r'rlr,r'o ilo curio$tinlE, de 1-2 minute. l)oar uncori se pot semnala simlt'li,nrr' | '
r()il,c0esuale (amelelir gleluri, amo{eli in mernbre), dc obicsi actrsl tttt,l ipxirrrl (Oor'l 'ariu, 1978). Criza sincopal[ dlrea,zi, 1-2 tninute, ra'tottti|rirro(.irrrlrr so (lo conyulsii tonice sau tonico-clonice, iar postaccesutl holrrir,vrrl :ltuzr"r, ailtonie, amclrelir cefaloo ,5i o stare do te&lni'r. Waync (l9tll)rr, lrrcrr,rll lr,t at:casth, tolm',i in cadrul acceselot sinoopalo llrin hipotonsiullooll,osl,irl,ioL, irl ()asta,ut (1950) :r, pla$ft1j sin(iopa tlo micliulo irt otdrttlsirrcolrolor vrs()-virErllor li irrd fnvorizrltt ' i, do orto,gtatisfirr Inl,r-o ftzit, tlrtIrilrrrlvir,guLorrio rrocl,ut'nir, l ir, indivizi vtl,gotr)ll i{ ' i. In doclanqarcil ittrosl,oin i r ro l ro i r r l ,o l r i r ro 11i l t ipol ,onsir t t ts i t : t t '1, t t t i r t l r i , tc l lox[ , prodttsL pl i l ] gol i rou,vrrei , , i i r r l i r l r ro. ( l r r ' I r r , r ' i r r ( l f ]? l t ) q i Oor[r t t ' i r t i1 i l 'o lxrv ic i t t (11)71)ut ovir l t t t r ( i r l l ,l r r , r r , r ' r r r i l ' i l ro l r r i r , r ' i q i r ' l r i ; ro l rotrs i l r i l i l t r , lo I r , s i t r t tst t l t t i t r t t , t r t l i r l i l t ' t t (J ig. a| ) ,
: r : t4
lr' i
ilI
L:.
I
PNEUMO
JlqtuW
V-Vff l . Nirr l r ,2r i r ' l t r i t l . h iy tn l l t ( l i t . i l r r l l t i t to unl , i t l i t . r l i .l l i r rv i l i l l r . ( l l )5 1, l { )J)7) rr i r is l , r ' t t l r l izrr l s i r r rp lo l r r l r r i ) i t ) ( , t r , ( , l lcct iv i t r i { i i
r r r r , ' ( ' r t r 'o l i t l i r r t t t i r t I I I I t ) i i | ( ) l r ! ' 1 | I ( r gt t t l r t , rkr i r r l ) } l r | i r i (c rr (o l t l l ) l l '1 i i t , i l ( l r ] i , i t r r r , { ' r! i ) r l i r I i s i l l rpr iYi i . i r r , l1)72) I
/. ' l \ t l l \t,r 'r it i l t, l(,t. l \)us(j :t l l ' l t trttttLtttt l t prod,rotnak sirrlr int,otrsl itrrl c (l irxl rrrcsl clr, r.rjr l: ' iy
r ' r r r r r , l r l t ,zr , r r l t r lc r l i 'o s1: i , r ' t ' d( ' t .urx i r j l :11c, cu ( .o s1t i0 l i ( , 1r , t r 'acjr . i r . : r . lg i il I r r ' ( , i | | ( | j I I ( . 1 | , (li$lll{,(i sj sonzlltio de sufoc:}t.e.
l)) ,4t u't lt l xi?r(,r1lrrl ,,pNt'e do obic{}i dup:' l, \- irs1,i} dc 30 :lni, r le l) l l , l i \ .l i l lr l l t, sr'\rrl l l lrscrrl in, dlpli cum I'ezulti l i r l in obsetr.ati ikr rorrslr,c(( tr l l l i l , l l)71 i []ot' l l l iu $i l lopoviciu, 1972). Acegti bohra,vi sint t lr rrtrirci:rl l loririr, lo;i f i hipi{ 'tLlrsiyi. Arlf, '1, NlthtrLsnu (citr,t d'r Wa)rrc, t l i i lJ ir,:rr:rlrrl ( i ' i 1t, l)r 'o)(itntit iv 0lreimo djn bolnavii cu afcctjuni oor(,ni.r, l i(:r !1. .\L rri: r r j : i r r i i lx( ' t ' , l i r l i : r r r r i I ipc|ren. i l , i l i , I l ' te s i ] ro,ctr , ] f i r l janr j . l r r r r . , r i . , t , , , t ,lrrrrrc ir i ovidtrnfti, dirrel.sc ft)rmaliulri ganglionare latolo-ce.rvisale si pli i ir,r l lrrrlo localo. Sinooli i propriu-zisi, se declanqeazii do obicei lrr rr.,r. i . i lr io ir ir r r1i orrur,l ologio plesifrcopali, apil ind in coldit i i in oare clc).1c i i, lr-r I r r rrlt, (l c l:r, n ivolul gil,uhri (comptesiuni in di\rorse circumstantc, iltl I)i!_r'(11,(,irr,r r iisl rt| lrt.(,a oa,plrlrli la b5.r]:.it'.r,, miqoi,ri bruste ale ca,pului (rto.). _\1rcp-\trlr i ir( ol)l, l (, i i lo rlc sourti, duati (10 -60 secunde) ,i poatc ti irrs<if i1 rlc lori-r ulri i . lolricrr'cloni0(', cale pot imita pcr.tect o criz;, epileptioi. i l t, la,pt,rrrrr, ioli irrIr,Ir ltolnavilol no$tri au iost fuldrull}.ati cu dia,Enosticul , lr. criz0, l ' r l ' t , l i , (1 (( urJ:U. i r r ; i lopot jc iu, 19i2).
. t ) .i:l in?lonrclc ?ostacceslt( e se c&ractcl.izeazii printr,o $til.ro clr'o.pus.r'rI lrt i i { l(t (, i i ot'a nitrrl e, printr-o Senzalie de anxietato $i de mal.i_,ft l. i i ista,}tic/r,u rlulir lr ' i { lc cit cva ole, pini la, citeva zile (tr{invieil le, 1$,1?), tulbluiir irlI r'rr,ri r,01,cl', nc}r,ozi1a,tc, somnolenti, prelungiti,, st;ri de depr.esie, i(l(rir l r r l i t i t t r io t r lc ,
( lllrrhr ir,(|r:t,so po1, Irozcnla manifestdri tle tip nal,colefl ic (_\Iayollr ;i( 'hr,N.iogr'( 's, cila{,i d0 Minvieil lc, 1957). Turne.r: f i I/ealu}onth (19,1S) u,urllir(.r'ir.i lsi :r,lr'r,ctui ou criderta elpului, ca in accesole al{r petit Ijral rle lillprlrrrl, lr l ic. S-au rnai descris 6i echivalerrle verliginoasr, i lccese cn tnll lu-lifl i ltl lliri o {lo r.c(]cr'o ulri- Br]u bi1ate.1.a1e. Weiss iii Bzr,lier. (1983) gi \.f.r,risr+ijr lolrrlr. (11|110, ojtali de Cor{a,riu qi Bopoviciu, 19?:,) au individurii izl llirrufl(J o('r'oblir,lo rr,L(.j hiperleflectiYithlii sino-caroXidiele, Dnnifesta,l,olrl irr cl izo rlrr ollrubilalc, tulburiri de volbire, atacuri irntste de sl. ibiriuuo,, . r l l r i , l ) | l ] , j l j : r l r . l r r t r r r"rr lu i musc lur ' , r 'p l l lodnso I ' r . i t ! , int l , l& cunrpr i . . . i r r ( 'r r ; i r r rn l l r r i c i lJ ( ) ' l , id i : l l1.
:!. .ll.t( lrltrniltstdrri : Il.anifestiirilc ca,r'dhce ci)nstau in tulbur.irIi ilr.rr i i r r r r . : r r r l i : r r . . . i l r r iur i [ i ' i i i l i lngirro; tsr ' .
''1. (trilrtiil,r ila d,iagnos'tia t c hiperreflet:tir:itd!ii, s i. tlocq.roti(l,ie,ira sr. lrol,| r r r l | i r l ls l , f ( f l :
t) I ! intt,tu slrr,rt, l t. l ,( da tl,eil.unSQ,re: O rni;t ltr,t l fusoir, l l cit,pului (i l11ttrsf lr irrrlI i trrrlrrlr i l lr.poi slutt lN,1,eraJ{i,) itt rttettcil,zl i, o ci,rlolc ort picldeltlt, r jonii l i ierIloi.,\ l i IoIi lrrl l iu|t i,r ' i ]o su(lced ulxri c( ] l] r])r0 Ftiutr i (.( ' t\, ioa,le (gult.r '1rrr,rr, si l irrs,i| |, i Ir. i ir|r, ir, r 'rr r[ irri. l irL tl lr])ul bi,t lb j(r ' i tuhr.i, r lu,Lr[i i l ,ul ] ir lor:r ' l ]( j olot.lr it l)tot,r l r r l i r c lo.) $r l r ( lu}L rr l r r i r r l i t lc t r rso ( I io i r r dcrtLbi i , ( lor .s iu l , I io i r r 1r , rz i ( i lot lrrslrr, l ici i) ; l t) Utt tLt:tu,tt, l . i . l t. l)ot' l ttn.:|. tskt t: i .t:slrt (Jt olrl<roi Icsl,o l ' . '0 t lr, tr,rri)t , i l t tcz l t t ( i r l r l t r t r tst ict t rzrr i r i i /s l t , t t t r , I r i I ) ( r r I | ' I r t i i I I | | i i l l r lc l j l r lo; c) ( . l i r r r l , rs l , r rr r r t l I r t l r r int l i r " i r t i t t tu i I . int t " i . , , ln lor i i , l t t1 ' t ) t i : : t t l i , F i l i r l , ro l l r lz( , l t l i l , t i ( l rJ i r \ . i l i rl r i l i l r ' i { i r , r r r r r l i t r r , l r r , l r r l r i l i l i i l i \ r , iTel l l i \ ' ( . i i r r r I \ i { ,1 i i l , i r rovlrr l i r ' r r \ | i r r I r , . i | | r r ,l l l l ' i ; ( t r t l r r r i l , l ! l? l ) ; r l ) Nlrr i l l r , r .N(\ l , r ' t l ru l , l i r r lv j r l r r r r { i i , ( ' inrz, ' r ) r !1,Lrr i , , r r
: t : t { i
i t t t t 'g i t l t t r r l t , s i t to rr l t to l i t l i l t , t t l t : : t I | ' t r ' ' I ' I r I r r ' 1rr ' r i r r rJI tL i l r " . . { .11) l l i lx lz i i { l r f ( r i l l { I
t r t l i , i r t r t tot i t , r , tv i I l t , l r , r t l t t r , t t t t ' r ' : i r " l i r l r " t l r ' ( i \ l i r l l i l i l l r ' , l { } i " i i ( l r r l l r l l i l l
i ' i i " i , l i , i , l , , r . t$t : t ; , . ) Sirr{ r ' i t r r t r , ; r r , r ' i r I r r t r I . I r : $ i ' r f . l ) t l . lo otr . r r rz i r t i t t l t ' t, , , , i i i i ; ; , , ' , i i l l t l - l : * i * , r , . i ' r r r . , .1rrrrr , . : , r , r r r r l r i . r l : r r ' r , . , . - r i t . , i { " r i ;1.11 r l , . r , . r r r l
r r t i t l t ' c j t r r l so i t | lc l i t l ' I t l t \ r ' l r l i t t ' l ' r ' : r i l r iz : r ' t l ' i t ' s l l l l t : l l l r l r '
t l ' s ernn'ele obier:ltt;t ' tr lt l t i1" rn l lrLlir i la!i i si ' tr ' ' "urot idic'tt 'r ' I ' lrci lrrr.rt
,, i ,n-"*rl i iOiaoi se prttct ici i pr i ir crrirrplo'irnca digitrl i r "unei
cal(11 ido lrL',,if"riil-
r,ii.li.iliei, ' 'rmi'iril.
sr._ utinic ..i poljgr:lliu ('1r,1.ri. oN,r'(liruu'"r,irrsirirale. respiniorii Si cerebl'ale. Itroitaxea sino-ca'ro1 itl i rl ri g1r 1r.rt' l I
,, ,itl.o'ri '""li i-
iolicita,rea ixdiyidrhi de a-1i llsiurna cllpul i]rlrl).i. i i i"
, ', ,J. "tt"ii*
si comlr'csiunca carotidci ll imitiYe' car€ are dfirl)t lrl lrrir'r'( 'j , , , f r - r ia
-ar i lor ld ier i ' rnr t i nr l l t l salr mai pul in colnplc l j r I ' l i ' t r '1t t ' ' ; '
r l| l 'zt's-Rueft, 1953), care antlt'nellzi - rc:i 'c!ii .prin Lipott'tsiuno:l, ('rr(losr
rrr tz- iL l i 1]ror lxci . Prohl i t rvot . : ] r lc h ipcrt lnsiLure endosin-uzdi- t ' i r ' l r r r t l r ', , I r i :
* o- ' - - " . . "u i 0, ' t ' rsr . ' (Nt invi . j l lc . I9L7)sau p i r r pr ' rba lu iY: t l ' i r ' l t ; '
,,,,f;i*#i",'0,,),2ufii$Jl:t"$ $'Jfii:1"Jt i"%"*{ri; fi J:,{:Ti:{,1:"','[,iii.t 'olfariu. 19?8) :
1\' ] I i.pul aag*L tatt c{ 'dto'1'nllibilor ' fnci' ]a <lel:utul excitilrii' rlsifliirtr
l.L o;tu;e';'e;;' i"iui, upoi chiar la o oprile cardiaci timp de 10 stttttttk'';ll,i,i;;; i"
""t:i"" ,"^r,ia la frecrcnla i'o'mali' lllectrocardiogra'Ir. it'r'it'llt
,.iL'bradicaltl ia s€ datdrefte urui b16caj sino-atrial sru. atrio-vtll1.r'i(iull r
r\ tlopinizarca pr€alabilX sau ld inistraJca de adrtrrlini' prevu]f rr{r'nl('
rulbrirnri. Ar iitra in ioc u:r rnocanism bulbar (nfinvieille, 195?)'
b\ fitrut lttnsio-d,epresor consl,S, intr-o hipotensiune altoriitlil irKl(l
r,rm"irtri 'Oe t "ud.i"utjdi",
t:l,rc s-ar d*tot'a unei va'sodilatafii g(trcrirl('-
i"-"it. -o"itn*tl',
i c€d€azii, ta adrenalidi li o. sht inflrenlate d(*r1r'.1)itrrl
ifriin i";lfc, t95?l Corfari[ [i ?opovicili, 19?2). Ar inira in joo iirl rrrl
uiecanism bnlbal (Minf ieille' 1957).c\ Iivut c€??rr&l cor($Iulde tablourilor de hipelTefleci'ivil it'i l sitttt
, : ' rut id ian' I (are nu | .c i lso!r 's f de rprct ' in l - r i )c mod i f ic5-r ' j cat t l i r t t r ' : i sr t t r
, , r t . ioooi . . . i carc nu . i l t in{ luenlaf ddo atropi l r i sa, t t dr- adrr ' tur ' l i t r ' r ' ' l r r t
, l , i , rcrvarca i ino-crr . t i t l jani l I i jnr . l e{ icrce (Minviei l lc , 19571. -A.r ' r t i l i I . t t r t i .
r,rfebrali, n fosi individu€rlizati' inci de lTeiss $i Raker (1933), rlltrti tltr
t1'flris. UaDrs si Weiss (193T, cita1i de Corfariu $i Popoviciu' l1)?!), trrttro
,,, ".i
iof'Jti rLou)i treiini .1in caiu,r.ile 4e hiperreflectivitatc situr.r,rrtrrl irl ir,ni, realizeazi' aceaJttd, forlllri, tleqi ll i lvicille (19i7) Fi Corl lirl {11)il)llr ai.[tat cE,, de fapt, este Tot.ba cle ccle mai multc uri r.lc folrru, rrrirlrr-
,\ liji autori ilaSeurl, in cadrul formel'r cerebrale Sindroanl(trf tl.r' lt ilrt'tr,,l iectivitatei, a cirot simptomatologie esto nervoasi, j,4ifrtrrtttl ('rt '( ' ir ' l ir r rutr i icst . i t i lo obi( c l i \ e de Laz*.
Mjnvieille (195?) a individralizat mai multc Jomt' ;
a,) U'anneLe cet ebraLe Pxrr(i (rara) ̂ se caracterizoazil pr,in rr'trrtrsc tlc rlittti
t|rtalc a s15rii tlc cort:lticnl,ii, piolderoa, totLusriitti lLlsoulinl', l lJtlrl(( li lLzl_L,rrot. au'icu lar'(', .hiu' r,tirrvulsii d0 ti, ()pjl(rllLio, $0.l',iri i i alrf sli,ltitrittttrr,t i ] ibrLl i r , r i do yt 'drr t i r , i l ( l ( 's{ ' i t , l t ( j (1(rs( ' rk ' l l l i t ts t tctr lot ' iv l r '1 , t l iurr 1ro1' I i t r '1r t ', t i isc * i f1, l r , l )1.( ,s i ' r ' r , , r i r r r rsrr t r r i ( , i i r1) i i ( l i tur , I ) l i l l . l l i IXrt ' ' t t { r \ $ i } r r i r r r l t r . l .prrrr l ls ' I l i r t r r l t , t , l l r tg i t r r , , t l l , t l r r I ' r l t l : i l ) t i l r r l l l l t t i t r ihLl i l t l r l r ' . l l ' ( l i l i l l i ( t ' l l l l i (1
i l \ l i r rv i r r i l | , , l l )b ' l ) , I l r l i t t t | l r l l t | ts l r ' t r r r rx sr \ | r ' l ' I i t ' \ ' i ' I | | t I I i | | ' | ( I r l t l r ' ( l l r r
i ' l l , ) ( i r l r r t i I r r l r i l r , | ) i io (Nirrr i | i l l r , , l l l l r ' i ) , i r r I l ru t rot t l t r r l o l i r t l t t tDlr tg i r ' , t r tor l t
l ro i r t i r r | ' v i rN( lo l l t ' l l l r l { ' l t t ' ,
. . / I tu r-d-rr
: t : l i
, l t t I l t l r i , r r r r t r l i l t r , r l , t , t , n. l txr l ; i , r r , l i l t t r . l ,u i ( t t . t ,d i r t . s, , l . t ts i r t r t r l , l t t , t l ,I J) : . r l l l i r I r . l ' r .Z;r r l l r t , . l ' r l . r l i t r r r . , . : , , . , r , , i i r r r l l l i i , t , { l , t i . r , r l r r r . , r r r - I i , . I I t . | ( , .1
: , t I i , r ' i r r l i r r \ ' l . i i r . , ,1,r i r , . : r r . r , r r l r r l r r i . i f r r l t r r i r . : i r i l . r . , . " ; r i r : . r , , r , i i . l r r l . i l l i , r| | l1, . , r | . l r z i | r ' : r l r . . i t r i r r l r r i , . : r r , r t i r l i l r t r 1dr.rL, . r t : r r , , . l r ; , r r . , t , .2 i , . : i ) . r t , r . . r l l r l r i r\ l i r i i " r l r , , ( l | , : , t ) ' r i rL ' i iurL ' - su1trosiv i i l r , iupl l s i i r .0{)1)( !101 slrn).{ j l r r1)1 i r l i ( ' r ( \ ,I ) l r l r r ' ' . ' \ l . t1 i t , I r ' : rg . i l ' , t r l . COtl i i i i i r t t l i r , Si pt , i i t . l i lX,r , l ] , t r , : I f ' r , t r i l r , f i r r r r i l , r lr t 'grr l r r l i r . . r r r r l . l r l . r l i r i r r f l r rx ' r ' ikr uo. i i repl , i \a o ' ( i r t i . ' l l^ , r ' ig i ru,r i s i r r r , , rI|( i 1
' | . , I
) ( , i r I L i I i I | ( I irr rr,rrtrlirfi l imp sir r.zlste l:l i lchcmirr, t\dati;ir, {i itrl (,r.r r r l l r l l l r r .
,.1.. )l,trli.l i,<irilr Il l iri it hiperref Lecth|tutea si.,o_carctlidiartii. Jt)l.t,l,,' i r* *rir,rrg"'.1('l, r 1r'ltti*lir,r in pelioadelo interditice sint cel mai [rlrrrur,rrlrrrrir,L, lrll i lrv,if i i lc,, tUtT l Cor1a,riu, 19?1 ; Corfariu qi Fopoviciu, 1{t?:,}).l ] l l l ,
, , , l l , , l l ut l , i r l r r l ,s i icupel0r, , sau la excl tarea sinisuluf(pr in corrr [ r , i i,'llill:' l.1,cil-!,1,.,1'xl,ulii,, pr.irr rnasaj,.sau prin stirndarc m6canicl, il.trrr,l '. l, i lrrlR., tr) ugrliu([iDr,li1, asupra axului carotidian, rcaliza,lE prin rii,sl,Lrirur,r r ' :L , : r j l l t t ' t
' l r - rput) , r , . .spdct iv p. in var iat i i lc dc presiunc cnt l r rs i . r rzrLlrr
; r r r r r .or : r l , ' , :Lt i0 i r r l r ipor ' , ' r rs iu{ru lcomprcJiu;e subsin-uzal i , ) , c i l , s i i r r l r ipr . r .t(.r.rirrr,' (iiu,luiii j de luse, prubl lui yalsalva), se pot obfin6 o seiie tlc iirrli(.rl,l lr l,r1 {r(,:r,i0, cit}.e r,u tost sistemat,__zate de n[invieille (19bT) in J tilturi:rr') I 'r ' irrrLrl i ip ; uu ,r)ri,r'J nici o modifioare EEG. Doai. sistemul crir.rri.\ , : r . , . ' i i '
' . i l ( . 'n lcrcsi i , . l ; b) AJ t lo i lea t ip: arnp. l i l ,udinea r i f lnur i lor I i l r
ol | | l l | l l r r . : lz jL l i . i ! t i t { tc0ut | | [ r txCiLal in i g i Sc nOrmal jzCazL la st . i rq i tu l pI t | ix . l ,L'rrrrrrr,'rrl Jiirrrl bihte-ral ,qi, sincron d,] tiina ae fapt idlentic 'cu rirr,.{iil,irr" .lr'rr'(1 \ rzr:urc sftu dc irlta natulir,. Irodiiic.irile cardiace sau tcnsi0rr[|.1,1,r ! . |
' r i , , r . i , i r i ' i r ,c{- . l t ip de r . i ispuns EEG ; c} Al t re i lna t ip: r r rodi f ic i . r , i I r
r ' . r ' , t , s ' r t t r ' m&i plu 'utr f r , tc, l , raducindu_sc pr in rdr i i i a le t r i ls . r rLrr .r r i r l r t , , r l i i ro l : r t r . , .1.952; . t I inviei l lc , 1957). Ast fe l , l imp de ci teva scclul l l rl r : r . ; , ' . r l r r | l : ' r : r r r r rd i l jc i . r ,poi scadr. ampl i tur l inea, iar
-drLpi 5_10 gccrr l r r l r r
: r ' r ' r ' r iJr . r l r ' i i .ur , l l ' \ 'o l l r r le ( to t0 c i ' r i /scc s i undc r tate, mai cvi t lerr t ,o rrrrl r ; l i r t r r i l ' , I ' t t r t r i rL l . . l r i fu. l r . ru l r . . d: l r cu o ur.olru, prcdominanln de prr , r , f . i , ru. , r l t . . t ' r r ' \ ( , r1. ; [1 , / \ , . . . i l , , r r r lu ]ente Sint la inCcpUt din bAnda l ,c l ,a1 rr . | | r r lir1r.r'itt.so fi rr)rl,i tn[1], odat5 cu crcDterea amplitudinii. realizinil 'rrrirl.rlrrlirr rlrr I,r'rrri, sirrrrs,idal5,. Oda,tri cu- e,pa.ili l u-ndclor lente, bolnavut i4llrrr,r'rl. r',,11ir..1f,,, putind _l)l,eze'ta s,i _citeva convulsii. Unrielc 1e.1,. lrit,r ' | r ' r '$rr l i r l ( ,_ - l ( ) s ' ' { 'nd' ' , t lar ' uneoxi chiar 1-2 minute. ccl mai arrrrrsarr, r . r : { ; r , , ' r ' r .Lr , { io ct . ' r ' lugi t iu intre r i , r i rea t taseelor EEG qi br : ld ioa r . r l l r r ,'r 'rr1r.r'Lrr 1lrr,rrzu, tl:r,r diacii nu depiqe;te 6 secuntle, lr,rr,oeul EEG nu srrlirriil ir,rir,tri, rlL]. du,cii a,julgc ia 10-1b secuntle, apar modificii,ri EE(i, crxru.rr .r'r' i i ' rulrrl u'rroxi.i ccrcbralo *,uzate dc abseuJa sistolei ventricirluftr,r l , l i : r r , l r i r r . r . r r csr, s inguta t ,auzr i , lMinr l . i l lo, j9 j7) , jntruci t cor.r . r , t r l l i: r l , l t t i . l , l t rg, , l . i i r , r ' l r rb. (19j4) a ' r rqtrrrr t t i , rnocl i f jc i r i -E-DG in : l l rar , r r1rr ,,,r'rr';r.r lJnr.rlr(,ilnrll l ;:r,l l hilrotcnsiuni ar.teriale. Aceste constati,r,i altrnf,$' \r.ltr,l lt,ir, lot. lbLlrro urlollra lti. purc, aliluri d0 formo intricate, irr rr lrr.r,;r,l|,rrtlu, irrllrrr'r{:"r, r',,r't,bta,li, diro.ctd, la, 1i.r,r,tOrii cardi:r,rr sau 1jonsiorrrr,l.' I r 'o l r t l " i r r l l , i r rvudrr t : l r ,ptulc i r ,p_o.I l l )Gnuscpuui levic leni j , mani lcxl , i , f l,,1,,.1,r'ir ', ' clilr.Ii,it.. irr lirtrlrrrl p.ob.ktr dc .xcii:r,1li. sirLo-oar6tidiarrii (.Nllrr,r r ' . r l l r ' . , l^ l ) f i .7 i | ! ' ) | . I i , i i r | , lU7l , l .9Zl i i L ior lar iu ry i l :bpovic iu, 19?2). i l l l lori r | , , | r ( r ( ' | | r t l , r ' r , t r i r ' i i r i I r : r ' I r i r l i i r pr i r l l r !0 pi0r ' rLrr .0 rLl eotrr i l , icrr l , i i , cr t rn i rycr ' l , r ' lr l r r I ' i I l l l r r l ,o| . l r , l , isrrurLrr 'q i orr c i l , t rv l l c lo l r i i , r r t r sc i r r r r rg is l , r r1r ,z i r , r l r lg i l , i t r r r lnl . r r l . r r i r r r . . I l , i , r ' r l . i i , . r i r I ' i r ' | i - r r r r r I . (Cor. fa,r i r r ry i l t r l ,ovic i r r , I1)?2), l ) r r r r lt t , t r , t t , l l , l r , l r , lxrrrr( l i , r r Icrr I r ,o-rr I i I r i r r i i , r 's i r r 1,ol l t , l r l i l i r r . i l r i i , r l r r i t , l rstrrr l i t , r l i r r | r r l , i l tt r l r l 1 i r l r , , , l i l l l t r . l r " i r l r r i r , r r l r r 1;rrrrr I ro l r I I r , .
*rsi11i.rtih,**;lx|rl: i;li, I'jiili :r';'trll*[rtf; ;] ri;iriliiiffii;)'ffi i;-i,p"l#ii;t$tru**l,:";lf t"';iy:;t,ltiil'li'f,Lllr;.liiit;lvi l i t i i s ino-carol , id iene ( l01 .o ' t ' i
'p io* i i " ' *u t lu t l ' pt" ' io iu l t r i t r l ' r ' i r r ' l i r ) '
i i 'b i l r ; t " *"pr inde o'rJ.r ' i rc p"o- i* iox a act iv. j ta i i i c lccl r i r " r l r . t r t r t l i r '1"
l,i}lrf \T:f".li::'tJ-ru"""t*ti?;','""*"#iJff :'.i'lJ't't;lii;lill'iilii,$11i;,**-;;*it*[:41"*6]t":1l3"Tlill'"',1'1ffi ,;il"r"''t'ffli11uf#k*t44"-#.:*ili'lt"'*g_si::!"ii#li;i"i,,lli;t*m' "*llx",*ril;ll ;lT$H"{:ii#"T .ti*a'lik so pio,,r, ce .
*;*flX.*:\s{.l*$*f*1yi*tl*:"*d"""}ffi *l"*fl1*"#*i}lti1i;*?;,:"tntmm*t*iif u-.*::,igm*1;)f "il?xtl;'de-hipcrr.rr.r
-",,*gm'ttif it*,T:".ii#,","'*##i*i-*l?H#4il1:"i:::t;':l;lll;il
,,I';iffi;l;r*t""on5ria"""i'iii"$""\1]#i:lllrsriJii:3i!,?lH"1l,;iill''ii,1::r:?T,ff :,ff *1ii:ifii.g1*,.t11i""t*','f;:gffi il*iil,l;ll;lT:rj:i:rdf#"r"*rT{#:ni#"*;#"J,t'eii"*};','f i#tltril;,:li:' I ;:;llt"i:l'.i;l ;'ru;:l m Ji,ri;:iirilllti,i*lt#"lii,''i: ll ll il;;iililikn""l'Jl*" j,l*,.ff ;?"*:pl*"-tf;:li,ll:""l,nl*'i,'il:ll;l':il,',1al ciirnii;i i etc').
;d:::*il'i"i*lii:ilkij?{,*r jl:,k#::L,$ffi *:fi,lliil;fiil,i{1, lr **llunHitr J;*ft ':l"""th
h- t ji :; :iit I ; ; ll; ;ill;'irii"i""1 .ir""rr"A ;;"tt;p'ii"i;;il. Si*ptoro'atotrgia post:}ccosua,lii |o rrH I ii
''tr-o icurtii, stare crcluscrit'I,.$:.ii1$"".:i;''ff1',i:1,%:t-ilL[llili,,l';l
dulatii pind, la 24 de ore)' eonitt'
"" delir (Passouant gi Minvieille, 1954)'
se relateazs, faptui cr uneori*i:Si;i"tt?l,t'J:ff?r-li#iH:Il :il]'lliil lil:f'"iL:f ,ii:rHitff i'.:titgp"ryt41*itrf kilil[il,lif t*lIt i;i ii,li:ln,lrl lilll l' ;i i iiiilli,*lii':ffi t; i; iifl }liiii i,1: ilii]l*!:,,lii;,jllilr,i;,i'ill"llilll,, ,ilil;;,;ill,li ll,,,llilil:;;,l,,li,ij,,lli,ijt,llll;;;ii,,i.i: i, , , ;lilllili:i,l;ll i: lfl
,;l;ii;,1;lt,,i,i,li;1.;l,l:ill111'll,l,'ll,i'l,l;,:1;iilliii;lti: r30:J;I l
,"I
\ r r I L i I | i r I r . , I I i i ( ! . At l l i r l r lo s i r r rgr lorrrc t r , r t ; t l i r r1, f i I r ,1t t t r r l1s9 I) l i1 { ,1! t r l )1.( . t i ;111,! lr , i t tustr l r r i r ' : r r r r l , i r l i l t , r r ( \ l r iss ,1 i l l t l l i ( l r , I l l i l j l ) .
l ) i l l . l ) l l r (11, r [ { r ! {x]0ro l iz i r i l i l , l ;01t lg i r r , s in( l ro l r t t r l ( lo l l i l ) ( i r t ] \ ( l i l l r l ) i l i1r ! i , r rrr, l l i .rr r rs lI i .r,rr,r0t,ir l i lr,rr so pou,to l,ratluco l io pritrtr,-un r0lIrr <lo tip c1t,r '( l i l |-rrrlr i lr i l ,or' ( l ig. ,12), f ic pr,irrl,r.-rrn rcl: lcx tdnsi o(lcpl'osol'. i tr unrikr crr,zrrr. irrl lslt r lorrir, l ir lnrrt rlc r rlt,n i l 'os1,a,ro nutindll-se inti ' ica,
t ' | .1. : ; - :J, l . t " l l t l r l t r l r l t t l t , , l t , t l ' t l "4t t t l1t i1 i t l pr t l i r t r t l i t i inr l i t tpr" : t
I i I t t , l , uc(Je:t!o1 5I I Ir : t t 1trr Ir
.D Ul l i i , c t t t t r i l l t l i l l iL l : r l : r l . r ' l l l ' l l r r l ' t rzt t l l ' l c lL l l l l ( rq is l l ' i l i l ( r l r )11)( l f i
IX) l igfaf ioo t l ) l l i i1, i1, io | \ i l , t t l i l r i r , r ' i 1r : r r : r r . I t t t i t {1 i l l ( [ i$P( 'x l ' iu l ) l l ( pol11' l t l ( l l i l ]g l l t )s
i i . r i l t ,ut i i i r '1 i t I i I . t r : t r1 i : r I : r l s i t r . ,1 ' I . r ' '-
. \ ' . - i , , r "q i i t ,Ai ik t : t . t , st t tdt i r t ; ; l t t t t i t : t \ nu r l l r ' l i r l r ' "1 ' i * t i i I I t ' ' ! t I ; r ' I i i
(Gast*ut, 1t)"56 i Oilcf ia,ulL qi 51oic.t , , lut j ; ; (ort ' r ' r ' i r t , 19?1, 1978; (. lol l i r ' r ' r l l
. iFrno" ia iu, lC7:. j i . l )or t Vot" t l lc t to (1960/ 3 gasi l l r ' 3uo/o t l j l r cr tzt t . t t
,i"o"rloiii nroilcr,rte'Si lu 10o/o din 10O de bolna'i cu sincolo, itld',str1i tl.
tip 1-aso-ragal), anomalii EllG de tip epiieptic'
tri, I'nregistrd'tile potigrdfice pot furniza- clate pre!io:l's() lu rltlrrr'L (ltr
,tia,g";sti;, 'iar
ryi ref'erit6ar; la -Inecanismele carc concurS' h instit'irlt rrrr'
sll]oopol,i. In.reaistrarea accesttlui, oste posibili, foatte rat, dar clnd se lx'irl'(l
Ir-r,ce. ie tlifdrentiazX, in motl net aCc€sul slncopal de accesul cpilolf i(r'
2. lt .faBele intercri'xi,cet p1'rl,cticarle& clirerselor nrcto'lo de testalr rr
roncdr rofiexogelre (test€le d; compresie a glollilur oculari, de corltpt(!$i(l,r" ti"iu.if"i caiotitiih,n, netoda Vtlsa'l"rr') pot surplinde po poligli)'rtiir'
liincrrettcxiritatea zonelot reflcxogencr evetrtuill chiar s5' l€ptodtr('ii' irt
iaborator acoesul sincoPal.a,\ Test ta'eT refletului aculo-card,iao se fir,ce prin crjmpresil gkrbilrrr'
1,culi.lii, ur rnirin{lu:se p0 poligrami, actiYitatoa ECG' re,spira!ia' 'I'r\- 9i. l't:t''
""ot i,lpC. L.tf"t,Verceilefto 1iOO0), testind roflexul oculo^-cardiac, i], ol)l'irrrr I
'lo'iz ,iin 33 cte cazuri cu si[cope' stopuri ca,rdia,ce de 2 -9 s' cu
"lil'r]rtlrr$li'n O lncomptet" (unde lente dihterale, sincrone $i $imotrice), iar lt!.rrlli
l- t oi"r"i toi" ""i
li3 studiali;, stopuri cardiace cu ,,ri'spuns EEG cotttltLrl')l
'rrui"uii cic u*de Ieutc cripate tle pcriuldc de -dePrr:sie
eloct't"gr':r' l ir ':r)i l r ;u i t Lf iOr ut i l iz ind i retoda. cornplesic i g lobi lor ocrr lmi Lr ' l ( ) r l . '
irof"ot:i. J, obtinut sc l:rea ritmului ctr'rrliac ctL mai lrr[lL de l0 lril l i i P''
"' i""i i i, io*t" cazurilc, pauze pc ECC cu dun'ta dc 2-3
-s (Ii 'ri rrisprrtr'r
llnei U 18 cazuri, pauzi pe ECG uai m*ri de 6 s (cu.ulde lcnto lti la'l 'r '
"nt". !io"r"o" Si sim-otricc lre EEG) la 4 cazuri, sljoluri caraliaco ntli tttrt,ti
,l,r iii s (cu undo foerte lente bilaterale, sillclone $i simetricct ul'lna'l.! -(l(r"uolu,tirrr,i"o traseului $i de instalalea piorderii de conqticnttr') la' lllli li
i16lna,r-i.- -i.,a bolnavii obserYa,ti ele loi (Corfariu, 1971' 1978; Corlariu usi lhlto-
t ic lu. ' igfZ. l9?3) s-a obt inul ' pr in testul dc cotnpresio a globihrr r rcr t l iLt i ,
, reacr-ie di oprirc cafdiaci la 47 o/o di[fie bolnavi, cu alur.ir tlrr lrlrr.rrri
^ri.ro-otiiat" cu d.ura,to tle 2-3 s. I.ta unelo cqzuri ann evidotrtil'li bl)lrrtrt
"i;; ;;;i;i; -iu
iant", la intervale do 2-3 s. ln cazuistica noastl i'i' Iru rlrrr,,f,*"."oi, it""*,'sul 'accstei probe, clenivcliri tcnsiolalo 9i nici IJrlttttrsttt' i
-.,ro,noi'i"; uuG cu pierddea c6nqticnfei, ca in relat5'rilc lui Vt't crrlhrl trr
ii.s-ooi- iteatttoi. Gasfaut (1956), Corfaiiu (19?1' 1978) gi Cortariu 6i l'r.r-
i , . r t : i . i " i rszz, isza) au c,picciat c i ' , . t :xpresia) ' EEG csto doloI 'mi l r rL{ iL r l t '
1 i , , ,* i* ^ i i r ,ot t i .
Asi tut ur i b l , rc s i r r , - : -u l r ia l cu t l l t IaLA st lb 6 $, t r r r l r l ix l i l i { i i
ia'r.r,scul EEG. in schitnb o rlsisl,olio ruai rnato do 6 sr prodlrco lr{1 l'r ' ir 'r ' iorrli i iJC lr,rt"u.i rlo *rtrlo 1,IrIILII.rLrIItir, gotroralizal;0, cilro oLos. i1 ilrttltl itt-ttl it 'ti i r i l , ,err .s r l .o, i i , t rvr l t i r r r r t I t t t I t r , lJ t t n1' , ' t l ludi l t l t l t r , dur i l l ; i r ' t l t l 12--1 ' l t t l r r r r r
, i i , r , i r l r r , r : i t r uo l t ) lC(.1 r loscr i l r r : i l r r l r r r r r r rkr kr t r l ,o l t i [ : r , l ,or t lo, $ i r r ( j l r t l ro l ; i i s i t t t i r l , t i r ro,
' , r ' r r r ' , l1,r t t l i r l r , l t l l r l , i t l t , t l ! i t I ' t ' i l , ; Iot t I t I t , I I t r I t I i I i I I i t t ' t I ( ! i ! l ( r i l to t l t ' t r l t l t l r l r t l l l t t r t t l I t t r t I
, , f i r r i , , i , r*1, , , ,1*t , t , , , l r to l ' { l r ' t l , r l r r r r t l t r l ; l . i t t l r ' i , . l l t t l l r l : l l l t t ' l \ l t l i l l ( l lu i i r ' l l l t t l l r i i t r
COMPRES/UNEA SINUSULIJI CAROTIDIAN SII NG
Fffi---\ /1 nn f \AnnAAr ^
. . , .^ A ^ \F.uGv v !4 vvv v\ /vw- ' \ /vvv vvl /va i{X!4^,4^,\^.&-^^.^.4ae@
FM-V/\@Va{Url^t*r^r,r. "."".,,
{*:S***@"Y-:-'":,;:*'PD.-TO " l
?t1*\t'$^^&4!t'{ry&+@
./.it. :{.9. I cflistmrc lolisralici (compresiunea sinusului earoLiCian dupi|ilx'ryDce) Ii bolnr\,ut C.ll., 48 dc ani. Dg, cr.izc sincopate p n hipclreflec-li\'il.ntc sinocar.otjdian:I. Pentlu cr.izcle de pierdorc a euno$tintrei, deti IirAcollvuisii lo i(!)-clonicc ti lir;r njci o simptonratologie preacces[a]d, a lostr.lidrctr)t:1 drelt epileptjci. lll clinica noastri loate invesligaljilc clinice\ i t , r r , l i l l ice t inr l . iv UEG . i I 'F:b) crr fo. t ncgrt ivc. Compirestun, a gt t , -l r j lor oculr l i a iost l regat iv i . In schinj tJ pt l lgura ie r edc cum_conlprcsruncasir rsului curolidiAn sting (dupi hiperpnee) produce rrn bloc siu;atrial cu( l r r rNl i r dc I srcnnde, Insol i t dc un bufcu de unde lente bi laterale, s incrol leii ni )rilrict, llodiliciri similflre s-au produs 9i prin comptesiunea sinusrluir i ro l id i ln drcpl . l lancrra Valshh:a a lost . Dcgat iYi (dupd L'ortor iu, 1971,
(hr lar iu$i ?opoDiciu, tg?l s i polor i . iu $i colab.,TgjB),
.-. l\. r9inccrpzle- din net:ralgia ltlosof uringianti. Ri1cy i1g42, citat rlo\Vr!,yn0, .11)01) ;i ()oltu[olla (1OiT, citai de Coriariu, 19i8) au d'escris lsO-r. i l r i r l r r . r r ' : r r .&lSi i g luso tar ingir . lc ( .u s incopc pr. in b ipersousibj l j r . i , t . , , r r ,H| l l rs | | tut { : t .1. . r1.1( l l i ! . Ac' s l .c loTmc ,plr f iculare dc s incope intr t t t r , ,u, , ;r rr,r'r'rr,lgi..gl',solnringianL in accesc duicr'oase sfir;itc prin aciese sincoprr,Lr,Irilrr,r'rr.rrsilril i lrr,t,c sino-r:aro lidil,iti, 6i prezen!a unui h.ig-qer zone, a i,i ir.,,ri r r ' : r , ( i r . i r r r l r r r . r r . r , iz l r , s incopl l i . Dur.r i lc a l r i in rcnnse uiolente cu dr, , r r , l l ,{ l ( . : j ( t . . l t l , -s, I i i rLr l r . r r ,ntorr i r , t r r la.baza l in ib i i , in amigdal i , q i in unghi t r lr r r r r r r l i l r r r lot ' , i r r r . intro cr ize dc obicer i bolnavul nu: lcuZ[ nic i 'un s impl:ot ' ,lrir is |,i i I r) L rii lxrl nlrl i car,. acuzil dureri pcrrnanente, peste care se snpt.it l)lrrlpr o.,-,ilruc lr,lgiilr Yiolt:trtc, I' io_spontano, fie tlec]an;a,le de deglntilid;i/ 'srr,rrrl^ i ' i l,rr'.rr, z,rr.l 'r ' i lrcLyatn rlc glosofaringian, rle.rnulte orioontimirii. sir l i l r i l r r I r ' i r r r rp l r , r ' i l , ia, s incolc i q i insoi ; i1,e sf l ,u nu de convuls i i i , rn ico_. lo l i , , , ,i-l i rr |
- s i 1, r r lr, I i i i l r,rrro sineop:l su declanqoazir rruml,i la ,,nevralgia rl: inulri.
!,irrr" (i ' ir i. ' si rr,lub., lt)5? I I?:ii l lu,s, 1lltio), d l d. muli;c o.i sincopclr pr1; fir l r r .Lrrrsrr l , . 1 i l . in corIqutsiurL. : l s inut l r r lu i c i r , r .ot i r l i l r r ( | . ' l , i l l r r ,s, Jg00), i r r rpr fr l i r t11r11, 'q,1, , , , r r r l ' r l i t . t , t r r r rntoi ts i i , l l , s i r t t rsu]rr i so pot i t r l , r 'cr tuxt nocosolc s j r r r r rl r r l r r , r l i r , r ' r r r r ry i c l izc lo ncvl l rJgicc. l r r r r ru l lo s i t r ra,( i i , t r r r t i ro l ,o ln i i l , l l l r l ,a. l . l t , -r r i lu l ' i , i r , r ro lvulrr i i { losr l in i l rg i l , l t 1rolr lo i r r . l , r . t ' , tuprr r r , ( i l , r r t , izc l . l i lg icr , , r , i l , y ir t , l l r t t i l i r t , l t ,s in l , r r lc i r . l r , t r l i r r , r , r r 5 i l , s i r r r ro l rc i l i l cot l ; t r , r ,s i l t rcr t s i r l lsutr l , . r r r r r t r .r l t : l | l .
: l l l )
./141
l j l ' j ; j ' , ,1: . , l : l l l i , i ' , . r f l , . , l , r ' ' r . r l rLt i r i r , r ' r . r r1 l r r , b i i l i r i l r r crrr , r l r r lu i , r l lpr i , t , i r , r r r ; r r . t l i r r . t . r r lr r j r l j r i r ' r l l I r , r r ( .N| r r r r r l r ' l r r l r . r t l r ' . t l . r , r r l l r r , l iz l r , i r , , r , ru.c i ty l t , l r s i , ssrr , r l i i , ' . i r r l r r rp l i .I t l r l i t t , , l : l r : r l r j r l l l r r r r I j I r r , r ' i , , I r , r | , . r 1, . r r r : r r i r r r r r r r . : i0 r l r . r . ' . I l r t l , l t | tut 'c sc r . r , i I .
si lr, lolr,zi i, 1,r ' ' . ,r0rrl Ir)l!( i r lr i brr,zii lr)r ' lrxLI. lr i.,,.,nrL,.i l ., r,t,,rsir,.,, l ,pa,r,r{, i ir, rrrrrl. lr l.lctrl '0 s-rr, I, 'orlus dr|r"r'_? -l0 $(1(,utulc, iru pi,";.t,,",ro ii i ir rulsiil l,,i s-1, irrs1,rr,t1r;rlrrpii, . .sistoli. va'i*bili i fintre 12 qi fS s;, i 'frurc{,ic t1i ptirt,ic,I*il i i,1ii.oilollrrtorti alo fiecilrrri bolnav.
b) Oonlpr*il,jrea sirtttst.Llui cttrotitl ion, dnpii cutrL un pl,eorzil,ti :t nto,iot,,,r lrrirrllln tcstmrr:l re ,ctiviirilii lcr,sl,,i irnpoitante zonc ieflexog"ui., lirtli. i islrLrrrrn.ile 'lrl i lrrt.e
rt,Jupra, activititl,i i ti,rdiacc, a;f-.1. Ui a't.ai.irlriir ' , r i r r . t r r l t i . t { . ( , i lz l l r ' i 5{ . poL olrLin(. lnrogisLr i jT j pol ig|af ic, .u lo urrUr. , . r , izosirr , - r ,1r ; r . l r ' . lnr : r i \ \ ' , . isr : i lJ lk, , r r lb3l / &u !rr . ( . izat i . i r , l l ' . . luoo r . l l r , r , . . ju, j i r iz j ir { ' ) r r i r t t ! I r ) t [ , le; . i l t { ,1] s inusul i carof id iAn tru prodUce nic i Ut l lJs l $rr,rrrrtrnal, iu,r'ltr, rostul inclivizilor, rcrj[str, cornpres'iune i,'tluce o braclici|rlitrr r r ' , ' r l ( . r r t i i 1sub.0 bdthi / ; r r i r r I11i l i d! r .a lorr . - r in i l i r la) 5 i o scnrJero u ,1, . . \ ,: r , l l , | l r r I l : i - la l i i ' l { , l i r loJ rea jn i l i r l i .
Irr schimb, la bolnavii cu hippr.r,,flt.ctir-jtat c siro-coro bicliani, mns*iul):,:ii. y]]l!]^"!l"l:"1 r,r-.,stei regiuni anl,reneazi o serie de noditic5ri, rliqrt[i r I | r r lUxr( : tz l r , 1_\ t r .o\ j ( ' i l le. 1957; Corfar iu. 1971. 19?g; t ur f r r iu ; i 'J- , ,prr-rr ' r r , 1972,. t913i . 1) f i , . nurnr l i r r ru, l i r jc i l i ECri , f i r i i mudi f ic l r i , t - .Ei ; :1,.) .1..r-'ortrlrult'r ttl(jc, ins{Jl ite dc apatilia de unde iente din bancla thet,.r:hiur delt:r,, po toate deriyatiite, carc c'oincid cliu punet d;;;ii;;i;i,lr rr
.[, iordu] or, cu Di,l blnlei tinrp c1e 10 -30 s, clar cu pirsistenla modificiriior.lrjirl(i t"l LLe 1ir(.n 1-2 minute. Rezulli5 ci, Ia bolnavii c. hiperreflcctivi-lrr,i,t' r, i rru -e:.ro1idiitnJ,, comp.esiunea sinusului carotidian deteiminX, itilco-i . i ( l ) r r r , ' id. l ic i t i ca.dioiuhibi tor i i \ i nrai pul in
'csodep.rcsor i i cu scir lor( . ib
1. , - r rs i r r r r i i i i r ior i r l ( . . , 1rr oxper ionr l .nua,strA, 'b lu{ .u l s in6-air ia l O"ntan.ai ' , i
ir,v|l1, rtLrr';tt, ' ]-i.tru bile (itrtre 2^ qi 15 s) Di a fost faTorizat de hipcrpueoir,|r'tr.,labilii'. Modificirite pEG sirit crependente nu nrmai de duratii, *isisto-litri, rli lr '; i de uncle reactivitii l i indir,' iduale, in sensul ci, la unii bohaviirrr apii,rut unde lente biiaterale, sinerone Ei'simetrice (mai exprimatc tx)rh.r ' i . r ' i r . l i iL.&nter ioar( ' ) dupa o asi" io l ie do 8 s, in schimb Ia al ! , i i ; io t i ; I i Ir f l l ( . r , r : r . . t . lU r lc l2-14 s ( fobdcauna dupd hiperpnee).
( . j ' | r l , r iu (1971,.1978) f t .demorstrat ce dcncrvarex, ipr io inf i l r r r r { i r r ,i r . r r ( . i1.{ . , , 'c i ) a s iuusului r .a.or id ian a coudus la suspendarei . mudit ic i r r i ' r .p.ligltlic. ltr, compresiunea sinusului carotidian, in-clusiv cu o desincrlni.zrrro olocl,roencefalograf icd ipsilaterald,,
,;:) Maneura Yalsaloo paate induce modificd,ri ale dinamieii circul*ttirjil)r l cr'o$tolea _presiunii intratoracice, cu aparilia de uncle lente r,hctrt.r|rlt,rr, yxr
-traseelo pHG ;! ghiar cu decianqarea ile accese sincopale (Clkfi,
i : r r r r r s i Sr6i11r, 1963; Sbcrpey-Sbater, t953). ( or far iu 1lgi . l , j i?xt * jt . r l ; r l j r r f i Popoyic iu (1C72, lgZJ), pracr ic inr l manerraValsair a la Uohiavi, I snl , r l ,n ul . fosfal ice. ]a-miel iunc Si la 1, l lse, au ob[, . inut pe pol i l i ra lnr . [t r r r r r l i l i . i l i drr L ip
"r tO n'oOibi lo[ , cu instalr , rea unor b]ocui i s ino-atr i l r l r ,
rt{. Hrultr-rr thrrati, (B -4 s), .lar {H,r[, modifici,ri EEG concomitente. .l,rr,r,lrrl{r (,irizul i, colcrtilLrl nostru a r€nrarcat ue$terea T.A. cu 60_g0 n}m}lgIrrl'ir, drr r.rlloaloli,- injtiali. Sciiclerile T.A. in cursul manevlei valsalvriilr\xlrru fi roac!;iikr hipertensive ap5,rut s dupX sfirqitul acestei manov:rr,nr\' ir,lr rJrro('r"rl irkxxl cii aooasl,il nrrl,ncvrii ar putea infhrcnla zonele rrfhiro.gr,rrr l r r r r r rsrrnsi l r ik : , c&r 'o, i r r c i r ,z dc l ig l lscnsi l r i l i ta lc, pot lcaclktna, i rukxr-r i ( l r l , r ' r r r l , r ' - r ' r r i l iv i i r l to
crrrr l io inhibi l ,o l io (Cor lar ' iu, J. f )2J. , 19?,$; Oor1l l I iuIr l l f l ) ( f ! io i , L!72, l ! ' l :J) .
i t , l : l
1 :1. I . ; i , : ! . , " i . n. I 'x l t l l t t r 'dt r l r t r4t l* t t l l i . l t , t t t t ! . ia l . , i t t s i , t ru l t l
. l . )Npi . l , t1t : : . iu. r ' tp ' .z i r r l i i , r r , I r , ( ( t r I I r ( ) : | , r , r r , , : r , r ' . s i lcopoLl s. lxr t . , , f r r r r r l l l: r r l lsea. l : )str 'c t r r io;1rr , l l r r l l r r r l i r r i r r .s lo:J00 ( t ( r bolnai . i invci i , iga! ; i r l r r r ro i ,,, l t ruTcllc lurmd rto i i l ] l .,)J)r't ( l.oitr i l , lr 'o)i irMtiv 5o/o au {ost indlrrrrrat,i crrr l r r ,g) lost lcuI corent. t lc . s jur .upi , rest-ul a l l fust d j l } ,Sno.1ica,1 i : l , r f lbrr la1or.? l r l, l j \ ' r ' r rc le.sorr ic j i pol i r . ) i l ine, drcpt cpi l r .p l jc j , ceet ic cul jnor( l i ; i , . r r r r r i , , l , ., ' l ,surla!l a1e lui.Gastaut qi Broughton (19?Z) si ale lui \-v-ayne (11)(i l).{,) r,n:unnrzi, prrp.,tl, .sau o relatare inexactX a sirnptonr:ll,irlogiiri. i rn pal let Dolnavului $ i /Sau A apar{ indtor i lor , poate l r r , l iL h u { , r r r iLI0, l r !gn, ,s] rcX, srnco]Jcte pot f j Conlundalc indeosebi cu accoselr . , .1 j l r ,1r t i | '1rrkinetice sau a,niotonicu, dar (in cazul coexistentci convulsiilor- toirioo-,l,lnice) qi cu clizole upileptice grand mal. Existi-totusi ulele elclncrri,rri,rtr(r pot fi utilc in oricntS.rile di:r,g-nosticuhri dc sincopit. (Gastaut, 195(iit 'orfariur. 10?1, 1978 I Corfarit ;i
-Popor-iciu, 19?2 ; Fopoviciu ;i 'cohtr. jlll?ti) : chiar lu sincopa con.i-ulsivi,, faza tonicii Si jaza ?Ionicii Jint, rrnrlt,
rrLli scurte si irrai t stonp:lte, iar dup5, epuizarea lor nu se ingtalcazi, currlr,l , ' j lcr ' r t rcJ. cale este (r l ra( t :cr io l ic i acce\rr lu i i ic cpi l , .p. ic. l , rcsigur. , i r r | r .q i ; .' r i r i lc EE(i . sf : lnt la.r . t l . dr I rna, i a les pr i , r act i r j t i , p lec m qi i i l , r .g i r i r , , r . r : i1, ,l l , l r { ra l r .o ( ln ' , luSr\ , u lc. iarcc toDelo.r re l iexogcne) ulucidr.azi d i i r . ; r r , ,s l i_lrLl in marca maioritaiie a cazurilor.
. 2. Accesele de hipersotnnie cu apari{ie brutali, qi de s,rurti, tlulll,ii, sr,,lot confunda uneori cu crizel{r bincopale. lnrleoscbi narcolupsia cu 1,.1it,,*lii,1 umplet5,, .re,specl,iv cu ataclri cataplectice, cu hajucinatii'hipn*gog,ir,rr ryi, r r l r rc l iz i i de sonrn p|ei na.rr j la, croi i a lo diagnost ic. Lrar, , rc" isul , l t , . . , , r , , i ,r r i r rcol t l l jc l I { ' o dul ' t r t i rnr , i lu_ngd, c l rcurrr , , tanlo du apar i1 i , . Di crr , , t , , r , , ..lilice qi poligraficc. (inclusiv_ de-orgalizare a iomnuliri;, calc l,rarrqoir,ri,rli:rgriosticul (Pop-oviciu-li colab., 16?2, 19?E). Mai Oifii i l Oo rlif0lr.rr{irr,t,r ,i i u uneori accesul calaTtlectir,, al,unci cind sun ine izolat. Acest ilccls r,lrl:rl , lcr '1rc 5c. ct l 'acIet izc; tzd pr i -n l l o p.r i r bu\ i le a boj : rar t lu i . c[L o I r , I r i , . , . i I j I j ,r . prerdcl ' r Drul t tealonuSutuimuscul t r . inclusiv l )osluraj . logt t r i r l r r r r r r r l i, , r ' i
.de. factor i atc( l [v-eJnot io_nal i . lnsd, spre dcosdbirc t ]e aecisul s i r r r r , ; r r r l ,| l r runpul &taculul catap]ccLiu COnql ieUla CSte pr\TlC,1d, C.( ,a cu ( , ( , l r I t . t , i i ., , , r r \a l id semn de di lgnosf ic di fercnl ia l . Dcalr fo l , i f fegis l r i r l j lc pul igr . : r I i , . , ." loct t rate dc: :unrc-rogi ccrceta tor i (El ishikarva ; i cotabi , 190g; Co|f i r l i ,s i .l 'opov_i .c iu, I973; Popovic iu 9i colab., tC72, l t i ;g $i a l l i i ) au dcrr , , l r t r r ;1,( ' i r praougrea totuSu. lur muSculu,r .S, .Ju{cc in decurs de ci l Iv i r , s | r . r r r r r l r . ,t i ind : rdesea inso{ i l r i de ur jF.ar ' i oculare , .a in sonr l lu l RE,\ I , I i r i r r rur l j t i , , r r l irupor ianl ,e ale al ior pararnorr i pol igraf i r . i , sprc doosebjre t l r . r .J. iz:r , s i r r r , , r|rLtal rn carc p_e^ inregrstrtr.ea p9]lg1afi9d apar modificdri IIOG, ,kr lll.A.,Jrlccum qi modific5ri ale activitil i i EDG (untle lente ditr ut jr, ,", ,,,,,,i. r r r rp lc) , concomitcr i t cu pierderca cuno; l ;n1{, i lCol faI iu, JC?i, l t }7r t 1 r ' r r r . .i . ' r ' ju l i Po"povic iu, 1972, t973).
Cit rlespre parali ziil.e de wmn, &c(]stea au caractcre r:linice qi poliglli l.irro,'u,l ' lcteristice, care lranqcl,zii diagnosticul (Oorfuiu, 19?t, .iO?Z ; .l ,opo_r iciu qi colab,, 1072, 19?8).
3. Crizek: iic cirtlcra tlin ou.rsu.l q.ltutu,l,u.i, ]l l htii:n, itrs.{,ii,. r.'r. 'r,i si tl.1,r , . t r ! : i r ln l lUxr[1 i l i . r , sr ' I r , l r l i l r ,urrosl , i t , r r , , , r r r r \ i r t r i t i f i , i r r r ' rorr l r i r l , r r l I , r r l l r r rr r l r l " l \ ( r ' l r I l t to:r . : r ' , . r ; r r l r l r l i r r . q i l r l ; r l r I l . i t , r r l l r I i t r r l i l r r r ' : r . r , , , . ,1oI r . r . izr . .
. .4. ( i , r i ; t l t
! r r . | . rc1t . t r t l r t 1, , I | i I1I | i I | |o| I | ( | r I i1,( j p( ' r r l , r , r r i r rs rr I r r . i r I r r I , l I c i r . r I I l lu
rolrc \ r ' r ' l l l r i ' l r l / j l r , t i r r , r r : r l r r r r I r ' r ' j ; , r , r r ,zr j r p l i r r i lo l r r l , l r t , r r l i r , l , I i i r . i i , t r i t r r1r Iorrrrrl r t ' i i i r , ( t ( f { r$t [ [ l i ] ( r | \ ' ( | t | | , I I 'LI r lo:rr , Prrrr l | I t , ' | l l { .Nl i , i t l ' r , I , i ; i i111r;111I. ; , r l r r t ) l r i | r , i l
,illll343
I | | I | ( | i I i i ] I i , I i I I i I r : lx lz i l , io l l l r r r l l t , l t t t l t t i , l r r t l t l l t ,v t t I l r tcz.rr t r i t t t t l o l r l r t l . t l : i t Lt '
t ; ' I ] I : I I : I t
l l i t r n i t t l t lotr ' r t , l , r l t r t tst t l t r i l l rus( l l l l i l r r I i i t l t I pt ' r ' l i r l l l ' (Nl l t ' i l ' i t ' l l1 ' I t l l ( r l ' l l l r l l l l l l
] , r r , . , , ' i , , i . u, ' i , r . r i t . " ,ur_r,1.
$ i vor l r i lcu, r i i i , ru i rL i r r i t t rcrr l l ,o l l , l ,o (Slrxr l r r r , r r ; i t r l r t ' l t . t
r1rr ; r i , i , lu, t r Ni iU( 'vor ' , j .9U5; I 'opovic i r t 1 i colr t ' l r ' , l1)( i1 l I Wi l l i r r ' t r ts 1i ( i t r t
r , , t l , ,L . i i r r ; : : : 'Oor) ' r , r i r i , l t ,? i , t9?u). l l -odi ik:r i l i I t r l ' l l ' l ( i r t t t t r rot i tLrs l ; t t l t lo
,",l l ' . ,- i i* 'u.. i" l,tt- ir,s,i i iclcri1,1, vortcllrobazilrrt ir i l '1it 'r rrlui rlhrs Ll ru1'rrI itt
. , ' i " i ' i i ' i i i " , ' l i " t io. ' ino, iu i r i r i t r . i r rn in i (Prr , r r t i r : iLt ; i c , ' ) r r ' l r ' , l l lG0T l l r r . ' r ' l
, , , ' i i , r , i f i ' " i " , t f . f " - l . r l ,e l r ro- l razi l r r ' , apa, 'p i t t r r r :g is l t r r t i lo l ' l l ' l ( ; : t t l iv i i j i ( l
; ; : " ; ; : ; ' i . ' l t ; ' - iegir in i lo rr ,Lcr ioi t r ' ( ' , - t l ( , l lp Ft l i l ) . \ i l i l I l lA, ! t , " l l l l l l ] ] ; i l1
. r ( ( ,Lr l ) . . l t i tU) ' c i r r : c{ 'put , cunl l l l rd i l , c l l urrdt .Lr l ' l l l i (1 in c Ldlul i l l : r ( l l l l l l l. ; " , ; ; ; ; i l , I , t r
- i io i . " t , , t i lo : r ,par i1 i , : a. l acts lur g. i r ' lo{ l " r I r .ute .stc r l i l t ' t i l '
, r , t , . rzul 's inuupci acesfe anoD];r l i i l : l . l ( l lpJl lnt t i l r l l r iu rr tg l i i l . l r ' ( '& : l i ) l r l r r r l l
cnrdirr,r,, respo;tiv ilupri prir,trugirea T' d.,I A TULBURARI PSIHOOROANICE (TULIIUIIARIIE'. DE CONSTIINTA CU SUBSTRAT OIIGANI(;)
I. Con;tiin!g este forma cea mai inalti, de teflectare subicctir.i, a lumii obiectiye (Dic{ionar enciclopeilic vo1. 1' 1962). Ea cuprirrrLrcunoa;terea propriului eu qi a mecliului ambiant. Este facultatea rlc rr,gintli;i a determina raporturile cu re:r,litatca inconjuritoare pe baza rtflt'rrtd,rii realiti,tii obiective in gindire (Diclionaml limbii rom6,ne, trl.ii,ttr:r,Acadcrniei R.P.R, 1958 qi Diclionarul explical,iv al limbii romiino trtli{,iruJ9?5). Starea de congtiinll este sttlrea ,,cle a-qi da seama clo tntirlitt 1ir1e sine ilsu;i" (Cobb, 1958).
2. Tdburdrile de conqtiinld, sint de "d-o;1i ca.tggorii: tulburirli tlrrconqtiin!5, firi, srhstrai eyldent de leziune anatomo-patologicil' (;xrrr,toavea tulbur5ri enzimatice, biochimice) cum se intilnesc in patologirt psihiatrici, care nu aparlin probiemelor noastre de neutochitulgio, irrr':ttttuiburiri psihice date de Ieziuni evitlente anatomoptttologice. Aoortsirt, rt,losr nunr i t i i lu lburere poihuorganicJ, care ue preocupi .
3. ln ce priveqte substratul ana,tomic a1 conqtiinlei, 1a tcaliztllcrt r,iiau p&fte toate structurile cerebrale, unele fiind de bazi, cuttt tiitrl : cuttexu1, nucleii bazali qi trunchiul cerobral, Conqtiinla reprezint5, ult pr'o( (\Hcomplex anatomic, fiziologic $i psihic.
1r. Tulbur5,rile psihoorganice sint de diferite gracle, in lnnol,irr rlrrsediul leziunii.
5. Orice leziune circumsclisi sau difuzii, a creierului poatc dol,ot'trtirur,tulburiri psihoorganice. Tulburii,rile de conqtiin!5, datoritri hrziurriLu'cerebrale pot fi grupate in tulburd'ri rle conqtiin!5,specifice localizir,t'ii, liiirrrlrlate de leziuni circumscdse, incit in clinicX aceste tulburlri siul, iirkrsil,rrca simptome pentru iliagnosticul tle localizaro (moria, ,,antriebsnulttgr '1",sindromul Gertsmann, agnozia spalialE etc.) qi tulburii,ri psihicc gk-rbllo,oind leziunea este intinsi,, tabloul clinic fiind totu;i specific in rrpor'l, orrloziu nile etajelor encofalnlui intcrcsato.
I)csif{ur aftsto luzirrrri difuzo, pe lingit, cri, dau tulburlr,r' i psihico rrrr<,:llaotcl clinio ll irrr, rlrrf init,, poi, itrclurkr li.SIi-4.4, alc ciinri tulbulr1ri vol rlrr,o corrrporurrr l , r '1, i r r p l r r r r p l i r r t r r r r l i f ic t t r r i l lu lbul i , r ' i i do cunr l l iouf i l , l ) i t r u,r , r rs iorrr0t , iv0, : l ,Pnrrr ,Prr 1o(, i r r , r t lot ' i i t r r urrcrr i i1 r l roI i , t r t l l l t r t ' i r , to r l0 c0n,;1, i0nl i r , t r r ' i r r0trrllrrrrirtrr trrrvt'rt,xinli[ trjrrrlnrl tlr'$lrr(l trir, ci1, olt,rt lol,it,l i i rirxl lozirttr,:r, r,rt
34t '
T
it t l , r r r t rc l t i t t l otr t r rbt i l l ( t rotrr i i ) ,s i r r i i r rNlr t pt t t ' t i l l l l i ' , t l l l t r i , I tz i t l t t t t l t , t r t ' r t s i l t t l t , f i ir l r r l rsrrpl l , tnozottco{ i l lu l t t i l i t ,s l [o l i t tc i f i t tg l t t l l l t ' sot t t t r t t l t r l l ( i i , ' ( ' ' r l r l l l / i ' , i l , i l iIrr,{irr 1rr l,rrIbulrit ' i lo lrrlr{ialr dc cot16tiicrL{,ii.
Arlrsl; pundr do votlcro nu trste coloctr dtxlattrctl 1,ullrur'i lt i lo slts-l)l(tl-liorrrlo sirrt lulllulril i t1o conql,iin!:i I osi,o a'dovai'rat cit itt utrttltr <litztlt ' i(rioln rr()lonirir) cxistir,6i o cornpontlnti' rninirnii do tulburl,trl tltl cott;i ' iclt{,i i,,Irrrr'|,ici1rir,r'ul, rn:r,jolir, fi intl insi, tulburarca de conry1;iinlrri,
Arrrsto sintlroarnc sint foarte elocvente in lcziunilc traurnatioe cr'ruii(l(|r('olirlicc grirvc or,rc sc Iemit. Cind bolnavul iesc din comL, leziuuilc siltl,irr cnrislirrele cerebrale pinii in regiunea mezotlienccf alici''
I )u,<fr, loziunea din intreg creierul este pini, ileasupra capi,tului rostralrrl Llrrnchiului corobral per;iapetluctal duce la instalarea unui muti$urlkirrrrtic sau h, sindromul de d.ezaterentarc.
I)l,cii leziunca r5,nline cantonati, in emisferele cerebrs,Ie pini l:r zonarrrczorIienccfalioS, apare,,staroa yegetativ5,".
I)rcL lcziunile de intensitate variati, sinii cantonate in emisferolor,r'r'ollale, inclusiv nucleii bazali dau sindromul cliencefalic.
G, I)acii, Icziunea este in totalitatea, cortexului' in general provoacilo rl'ru'e tle agitalie, cu iusomnie, confuzie agitat5, sau anxioasS,r pdn fa,ptu Ilri, iul,rca,ga activitate rdmine sub controlul nucleilor bazali Di al trunchiultti,lolollral,
;\dcseori, in diferite afecliuni, procese infeclioase' procese itrlocuitoarorlo spu,fiu, traumatisme cranio-cerebrale etc., leziunile inte,reseazd, toal,tJcclr t,roi ctaje ale encefalului - cortex, nuclei bazali, tr"unchi cerebral -1ap{; rarrr du"ce la realizarea unor sindro'ame combina,tA lsiniiromui apalic),l)rrcori, intr-un sindrom pot fi implicate tliferite etaje separat (hiperkinezior,r r Iogorcc, rigiditate decerebrati,).
I),r1,orii,i, legii biologice, structurile anatomice cit qi funcliile cerebraloloh rrrir,i noi sii-t lezato p{i}Aqle Si cel mai uqor (cortoxul qi vorbirea); lrr,,rrz rkr t'cYcnire (tlc la trunchi spre cortex) ele iqi revin ultimele, persistin(lirrcii, rrrr 1,imp dupf revenirea integralS a celorlalte funclii (surdomutitattl'rirrllornul vogelativ prefrontal tiescris tie Ttinnis).
ItiNliitrr r][r,i ios aceste sindroatne
Sindrotmclc generate de lcziuni Ia iliverso niveluri ale creierului
/1. l,czi[ni situats in partea supc-ri{)r,r'ir, a trunchiului cerebral
ll. l/{!z.iuni siLtla'hc in nuclcii bazali
t1. lfutismul akinetic'12. Sindromul de dczafectare[3. Starea yegetativi persistent?t
lIJ.l. SINDIIOAMII I)A1'I{ I)I' I,,IIZII]NII.,TI DIN PARTIJA SUPIIRIOAITTA TIIUNCIIIULU CEREBRAL
f#fjd js?i','"',g;l#,i,|Uq*'ih"""?,1,,:'^1';"""Jiotuilarr'icu',r'rii";llil"';#l?'"1""J"?Iit:#;,t*$it*f":ihrl'tffi it$li;+j+1:;-*e*aH##tH*.;q",XT r,',',flt Jl,iiijill"{*l" g:*#ri"*i}!"'','ffi:ffi;iq'*w:lii,It'"t'T"'*vniyll:l1lt*tirtlxktti+"#h,$#,{i$if'jirl.;iri:l;llH*l"{ifl yil,}*:_Tf*}:rd:F:diiFirmliir#:r*r,r1.""":uiiiffst$i :ffi:*i"",Tffi iJ"tii*#l'?*1",1?J**T]]H',1n","'*1J,1'1;,,i1,'l,l
Ilutismul akinetic se cr
ff H:lli;;ffi*#'1#x"""t"ff ri?"J l'"*"-ii:{{J:t:*i13ft';';;133 ;'; ii 1 ;,;'i;"!l"q.'":t.rH*idih*r,"r'*l'Xil f;-i',f i*{i;"##"";;r;;:f#1,"jt#*fitl*i:,":j:t"tTttr}i:liliiit3l;llJ#d"f#rr:f :d{i{Fii}-lilih'tii-i""""";;J'::*:nl,ltlttliH"txt'.'ji.T#iiil",iljtril?i:'.*,? 'iJill;iif!it?,1!![i:l'i"llJill:rr"ffi+e$*t}"m;at{[1,'ft firi'{ft f *;1f*{ilfr;;grig+;:;;f4';:{'fl };;if iiji'}:b'dr'"arii.i#i]1,ir,';i,ril-t1ff H,:t{il:#if,iir**irH"Jid,rhit'd;{"5rnqt:ll,,ffi,l iri"l*ioiii* i r1 lr Lr{11*r[t'iil1i1,fl1'trd].,'Till,,,1jJilili'.liillll,ll,lll:l'llliii:tl,,"ii,,ll,f,:l,i;llllli,ll i;liik,w:ilii:li;$*li*llTli;
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l r r rz i t t t l i r l i l t t r0Nit t r l toa,rrrrr r l t l ,o r lo Iozi t r r r ritt t ' l lr i i l l ,o cl, lr,. io.
J l . l i ig i r l i l , r r , l , r r r r , r l r r r r r , r r r [ r lu, l , i r ,l f . I l i lxr lk i r l tz ic ol I rgotrrrr
{1. Loziurri sil,uir1,o in coltex
dup5, leziuni cerebraleSindromul dienccfalicSindrornul KorsakorvSindromul Kliiver-J3ucyR,igiditatm clc decorticalcSurdo rutita,tcaSiridrorrrul vcgctativ prcfnrrrl tl(Tatnnis)A1;ita!irAr r rttozin l)o$1,1,t'lulrrtl,i(rirSintlror rttr l rt,prr,lio
I it ; :
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: t4 ( l. )1,
Fr j i r r l l l l iHl l r l l l l to l , ( l r r f i l ' i l l l l ) t ' ( ls i l r ( l ( r i l l (x) l l i j l i { r l11i l ' s i l ' l l i l ( r ( l (1 l l r ( r l r ( ' i ' , rkr ; t i lxr l r r r t 'v i ii i r r l , pct l r t l ' 'cr t t t i l l , iot t f i . I ' i r r r l t r i t r ror t ,s l l l ' , i r r t t t i l i l ' ; i rkr a ' l l i i (Ort , i t r rs qi t ro l .l l ) .1 l ; l l l { i ! ; Skrr1l ,01,y, 1f}( is; $dn) i ' i , i i i ( r )1. . l l ) ( i5 I f r lyat t r l - l l t t t r r t ,T, t l Il i issirl l..i rrol., l1)(i{)) (,slo cit oxislit, vit,rir[1,ii do lit, thitxrzirt ir(lov it,r' ir l,ir, (clriirr
1r:rlrrlizic itr sottsul or(lirlr,r al otrvinliului) ;i rmrtisn (sart tloilt l,Ionitr) IItriir Lrrlbrrlanr olalil tle corr;li inlii, (sau doar u$oa'r'i i, hipolsolnnio situ obnLbi-lrr rr,) pi rri, la, o sirnpli'l apatie generalizati, cu reactivitat'c bun:i h exoita,lrl i.{ l(ilrx;liri lc rroa,slrfa iln mai ari-rtat c5,, de ceic mai multo ori, dupai, o 1u ir,lrrlrr,lrrl ' qi I{cmpcr qi liomanul (196?), XIA (in folma clasici rlesclisil, rltrt lr,ilrrs si trol. t.i+t) rcprezintil un sindrom tle ocluzic a al'terei bazilare inpor( i r t t t i r sa rni j loci l .s l ,u joasi . la care unoor i se pot asociz ' tu lbur i l i r t "i,orr1iiin1,L (prin" leziunea ialoi,ei pontine qi/ sau .mezencefb,lice, atinginrls RA A).
Sindrornul de dezelerenlare (sindromul'oloked'in")
Af octarea ci,ilor cortico-spinale qi cortico-bulbare printr-un mmolis-rrtorl; localizat in piciorul piotuberanlei (I{emper qi Romanul, 1967),rlncind la tetraplegfu qi afonie, determind, o stlrtdo imobilitate com-pletfrr, lrolrulvului Eiin;apicitatea iui de a se exprima I'erbnl sau gestual. Ta-hlrrrl ciinic p6ate sugera o stare de mutism akinetic. Spre tleosebire dtrrrll,irlul sindi'om, car-acterizat pritr tulburi,ri mari in sfera- p€rceptq?lr,rirr sirllrornul de dezelerentare perceplia nu este altera,ta, bolnavii fiintlrrt iorL{,a,1,i tsmporo-spatial, putind face calculor a$a cum a ar5,tat-o (]onouni',.,,1,,,1 , j11
"i irin iiteim;diul cotlirii miqclrilor ]or oeulare.
Sttrea vcgclalivd persistentl dupi leziuni eercbmle. Jannett (1972)rlcsrrlit: sindroinul tle ftaro vegetativX, persistent5 in motlul urm5,tor :
I)upii o perioadS, tle comi profuldS' de" reguli, cu-ItaJiate grade doIi,spunsirri eftensoare (rigitlitate prin decerebrare sau prin decortlcare)r.cuo rlrrratii do o snptimini, sau mai mult' supravieluitorii i!-cep. s5, deschiditochii la, inceptt -numai ca o reaclie la stirnuli rlureroqi. Ulterior bolnavu Irrrorrl,ine periodic ochii deschisi, chiar in absenla oricirui stimul qi pa,re arrlrrr:'ili ci privirea, dar firX:r, fi atent, apoi recade intr-un somn apalen-1'.\rr poir,l c ii insrl r:orbr de un real ril,m lcghe - somn. fn perioadcle drr:L| | i | t I I r I i 'L st l te r le tcghe nu exis l i ldspuns de apdtare pt in ocluzie palpc-l r i r rL i l :L:rnrcui t r ta lc. in unele cazur i i : . i ; ,1d mi lcdl ' i sponlane alc globi lo l 'olrrlrr,ri, tl ind impre$a ce bolnivul urrnire$ro cu privjrea un obiecl c:rt ttsr, ,1,'pllscrt'zr-r' in-cirnpul si,u vizual, dar nu se poate afirma cA este vorb{[,1, . r ' i i r r r r r : l t lu aleul ie. In al le c i rzur i a1lar chiar ln j [cEr i cert
-cooralonah!t. r r l r .csr,r r r t r lu de sci lp ibt le sau de adueetu a mi in i i spre locul de oxcibatt trr,,r' i,rr.1rl ivii. Cx toate ci, cxcitarea nociceptivS, poate d€termina fie Yi$cArirlr,, n r r r,il,i<lr,{,ic fic trismus sau grimase, bolnavul nu emite nici un ele}u-orl,vclbrll irrt,cligibil, ci cel rnult'- sunetb artic-ulate' Starca de constiinf il'liirrrirxr rloci frofuncl alteri],1jI, bolnalul ri,mine inapt de. orice comunicall)trrrr illr nioi ri leaclie aalaptivil, la mediu, nu este leceptiv la nici un lltxlirrirnnill,iv. J)in punct dd vedere legetat'iv, funcliite sint conserYate, du'rslirrrrrli i nocicepLivi puternioi pot inducc rcacl,ii vogotative auortnalo-, lttrpocirrl t 'cspilafrrrii. Strlrca vogetzllivf potrl,c pol'sisi2r,lim1l loarlje inclclutt"g1,1, 6i, ovr',irtuu,l, so po&l,o 1lcurr2utdrtiza a,lil, l,irnp tlit; bolnavrtl stlpl'2l\' iolrt'r{rft,r),
' l ' t ' r t ,soclo I , ) l i ( i a,rr t t l i [ l , iL1' , i t l t ' l t r - t t r i l t t t ' t l lx l i t tsr ' 1 i gt : t ,vtr l t rz i t t l t i I t t t t ltot l ' ic t lo, t t l l 1, l ' i lsol l 1-r l l11, s l r , t i iz . r , l r ,c l , t i r ' , l i r t rp t l t r t t t l t i t r t t t l l t r s i r l r i i i t r r i t t i
(t4lr
( l t ' i r r 'Lr1.1r . ,1. . l l t i l ) . l r r I i r ,z. i l r ' r l i l r r , r l . . i ( l ' I i i , r l t i r r r r r l l . s iPl i i r r r r r r ir i t t t t . l t t t r i I i r , l r r r l r I rv i i c srr ; ) I r tv io( , r r i r .o , , r ' r ,g r , I , r r , l i r l ' i t t l , r ' i tsor,Lr l r r r l r r , r , i i i l r r t r r r l0I t r t t l t : s t tp l inrr l l l r , l r s l r , r r r , l r i l r r r r r r l i l r r r : r l l l r , r r r r r r r I I r I i I i I . i I I r i I r r i r rsr i , l i r s l i r r r r r l i it izr l r , l i , a,rrr l i l iv i s i l r r nooiccl l l , rvr ,
. ' lopogr ' : r , t ia 1i in l inrktr i t r r , Ltz i r rn i lo l nu l l r r prr l r r l , l icrr r r r r l i { r r r l i r rcsirr l r i l i l lr l t ro l : l t ivelo put ino la,zur i st ld ia l ,c. Au his i , r l t ,s t r l isc c l tarrr i cu rrr l i r r roI.zittIr i neocolticale. So cilea,zii cazuri crr lozirrri i t,rt..nsit ' ir srrlr..r. i i . ir lr,,r l lrr cu crulat'oa structuri lor. trunchiului cetr:lt l l l si inr,crs rrr lr,:r inrrir lc lrunchi sau cu r:xtinse zone isr.hcrrtice tut i i i ,Lile s;r,u srrlxurr,l, i t.rr, lr,.
13.2. SINDROAME DATE DE LEZIUNI IN NUCLEII BAZALI
Sindromul diencefalic
Se earacterizeazX prin tulburS,r'i rle constiintf cle intensit:r,l,o r.:rlirrl,ji,ci.n'e consl,au intr-o sta,re de apai,ie, lolpoare, obnubilaro, soIIll(t (,1{i' i,' i l Ipoirre- Rcspirr( ia e\ te de ! ip Cheyne-stbkes cau t 'espirr l i r , . r r I i t r r r .* , , r iI r1'ttrgulat,", rnllerullt uncorr de pauze scurte, pupile mici, rtrilr,tivrr ll l, lUr nrr;.lellexul cilio-spjntl este conservat, miqci,rile reflexe rlo gl0lriloI{r'uralr ln plan orlzontal slnt con$ervate, insi, uneori rnotilitate r,r:lltrriir xrular5 rrerticall este.IimitatS sau abo]it;, (comprimarea rcgiulii l)t.ol,(r,fale) ; existS, reflex oculocefalogir (in lezidnile'de ironticrtii rIitrrr|r,IrrIor r rczen cefal ici), deriere ronjugatd, a capului qi ochilor, ten0rnt,lrrrI rlrr, . r .nr dc prpu$i , ' . r inool i der i t , re Ient i t i porsistent i a glolr i l r r l rx,ul : r l r .So noteazi, semne de suferinta, pir*midal5 ditatcrali, (I3::r,blnslti hilrr,l('r.rr,l ).Ibt fi evidenliate o rci,istenjii, ̂ muscularii,
tle l,ip paiitor,fu .\i rrrr r,,ll,Ji,1, . f tpucare for tatA.; iD abscnla unui det ic i t rnoloi r i .eqtc lnor l i i i { , r i I i p,r t I il,ihter:!le. Pot erista diskinezii. Tulburi,rile vegetative sint abscrrtr,.
._ Sttpoar_ea. **" *oilnoi&1" reprezinti, u p,ig_rdere .par(,iall a t,ir$l,l rlsit' i lor la solicil,5rile mediului inconjurilor, ii i starea -tle colt$liitrli i r)Hlrtrrtectati, r.r a,i rnult sau mai pulin. precurn d,ratii, denumjlile iu;_rirr,rrt,iorirte. pacientul prezinti o stare de somnolenli, mai mat,e sa,u rnti rrrir.ir,e l r r l r ' . ) ic a ln sau . .h lat , . uncor i . cpontan (dupn gl ,a( lu l s l r r l r r l j i ) r r . l | r .z ' r l ' . l urbe: lo, ( lA r i ispulrsur i ader.r at . compl" ie, lncornpl , . t r i d in l t iur l i \ r . ,(,,,r'e ce a}e ne\-orc, mill]rnci, singur sau rlacd, i se di, sL rniirrirr<:o I rlr.rrrrrl | r ' r ro i l . loule t l r 'sr . l r idc ochi i , str (eara Si .$ i fa( , i ncccsi l i { i le, r r r r r . r r I i r r r i ; r . : r ,r . r r l l ( . Sponlrn. cbtrr pot te urubla; [u lcqi i le v i [ l t , lc r j l t Lr l r r r r , . Sr.r , l r t l r , . t , .rizprtzi, printr-o. mai iltensi, cr.g;t-glq a plairurilor s€lzoriale, cilrt arrr rlrr,plr|rrrrt: o recepl,ie intilziai,i, qi inadecYatd, o lentoal,e si o tllfi<:trl1,|lt rr rlr,si i . - t t r i r i i 1rror. .esalot tsociat i re, Bolnrr u l c. t r . lp l l i r , r , i i t r r r t r r l r . r , r r i r r l i rzrc l r .l : r i t r l r r ,b i r i . pr ' in rr i .punsur i vagi . apluxirnr i i r , , , i r ro i r rp l , . t r . 1 i , r l r , , , , ,1r .r,rrai rnulte ori, l ipsite de sens. -lltpori (,s1e ,\ornn;leut, tlr'zurirrnill,;i corrItz,. Evocaro:, ar'nczi(ii so efc(.tucazir, rli i i,.i l, rr't,rrri l i irrrl irtrlrrisilrilri.l l r ' l r r r r ,vnl cstc. . l I ; r11i1ts ih iu ; i . ln i td ik inet ic, sc or. i i r r r l ,c l ,zL i l i f io i l s i i r r r , ' r r r 1r I r , | ,t r { l } t ( i l l . i . l i ' r i i r r l i r ' r r r r r I i i
' r r l i s i i r t r .s:r . lc r l r .sIr . r , l r ' , l r ' i t r *r P, . r , . , , r : r r r i .l , r t int , i la,{ , i i r r r i t i lc ;x, l r r l i r ! i l l l t i i r l r , l r f i r . , l ro l r l rvrr l i r , r , r l i . t r r i .zcrr la, r iur i r r r l l l l r
l , r ' ( \ r iz i . r i i t ' i i r l i I : r ' | r ' . I l . lh ' r r t l r l r . r . l i l r i t l : r r r r rLr . r r i i r {*r , .s i r ' , r l loxrt l .o|rr . i r r r; r i t t l l t tcz,r ' t t t r , . l i r l r r r rvrr j l r r l r r r i r , l r r I r I i r r I r r r r | , I r , , i l l l r , l i t r , l , i , r , l l I r r r r r : ( iorrr , i r ,z i i ,r l r , . . r tb i r r r r i t tot t r t r r , l , l . l lu;Jgat i ) ; t r \s ls rr l l r iy t r , ls l r l i , (11 ( ,ogl i r , Vigi l r \ , l l r , r r r r . r rr r l i l iz : l l , t l . i l r t i r r r . i i I ' r , r r r r r . r ,z i . l ) r r , r , t r , p l r . i t , t r l r r l
' l t \ , r l , l r , l r \ 4 i t r r r
' i l lDrtrrr l r , l t r ,
,{ilit4rl
l , \ l l i I ' i l I i i l ( l l l , l . l : . j , i I l (x) l l t l i t l t lqt . l l t I t t l l , i l t l ' r I l t r . i i t ' i i l l l r t t t t l l t t t . i I r . l i t t I i t t r . r r r . l ' r , t r |1. ', .1r . r t r l . t ( l . .1:r11' r" ' l l i l lz i \ . ' . s i t l t l ( l ' s i l l | r t r l l l . . '
l l t t t t i i { r l l t l t t l t l t l sr tnt t t r l let t l l - l ; l t t l r r r l r ' l l l r ' r ' r l r ' l r l ' r l l l l l l l l l i gr l l ( l i r :
Jr i i t i , , , l , ' , ' r l r ' { l : r ' l r r l l , * t , i t ' ' r t ' i ' l l l r t t rz i" ' : r t t : t r I . t I r t ' t I r ' s . r r r r r ' l " r r l : i '
, ,1,rr , , f , i i , i ' : , . , r , i , , 1, , ' ip, , , ' t r ' . , , s lc t lat i r , t1c t ro i t r tcrosl t rc l p l r r ' l i r rJ i i r r ' t r l f (11( ' i l1rr
l , r r ,z,r t l i : sotr t t t t t l l l r r l , r t i ' "1,c tnotLcr ' : r ' t i l , r ) iscotr l i l r t t i , Prr ' ( i " l t1r l ( lN( lo i l I ( r : i ' ( l i l r
,,i i ',,i i i, ,,irr,l qi {ra'ticlpir, pulin la oxciiat,ii lu tlitr tt.rcrlittl itto.ttjulitlut.St:rr . r . : r r l | t t , , r . ; rOni , . i , . Fol l l ( . dCf in i r ' : ' , i t t lo l r i dtZol i |J i l i i ro Icnt l t t ' ror1t : t
i i , , i , i . , . , , , . i , , r i " " , r
t , ' : r , , t i l i i , ' , '2 i , .s i r ' . r sr i r l . r r ' r r ' l .nust t l l l i uf . r ' l i ' r , , l i i . iut . r r ' l
i i ' , i i i i ir l*l ir i," lt,. i" sc,[t6.c:l i l i f i lr,t ir l i , ir ' l i l t lctt i ir i ; i ruptiof. Stalcr t ltr
i,f, i , i l i" ,r"*in intro craqierri :t, prrlgul i lur srnzorjir le oLr r) dirrinuaic ir '
rr,rsilr i l i t , ir, l i lol rlc leccDtrie (care s6 rdalizeazi i lu oarecare groutabe ' l i .ctri,,i,,"i'ri.'I,rr Aiiitotiiii tn*rti"t in"' preculn ;i cu dirnintarcr stplelei ;i r.r'.'""''.1'i;1;ll.ilj;'hi
!i'trLl lr oste o somnolerrti' ,''ai a":'certrltit'i,' bolnav'l, r , ' , , , i l in, , l r , i tu1. =i , r" t "5tn l rst iLnul i ' r 'orbr ' . i+ t tuci)r i r r { 'c l 'u ' ( 'cLl L in(1}r i
i r . r r r r r r r , .voic; l , 'z i t t t r i lp s in i l r i la leralc jn nuolc l t Uazl l t '.s t ' i i ru, i tnn . t " g i : ;uO,, t ITI (obnubi la lct cslc r) nonrnnl{ 'n l i . p loturtdi '
: r r r r r r : i , r r r . ' t :onl in ' l i I pacieotr t l Jbia r isfundc l2 1 1ni la1 i i f i rn l lebur l ' l : l leor l
. , i , i l " i . . t . r i " ; ; ; ; i - , r ; l t 'z ! t tncr e ' l ie in nt tc lc i i brzr l i 1 i i r t b ipotalrmut
; , ' , ; , i ; i ' l ' ;c . l ; r ; ; r 'c" t l r lu i crc icr"ului ; t | i rn ' b i r r l c t r" l r r r l cs ie i t tdt t t t '
Strtloarea sc intilneqte in' im,umatismelc crl'trio -oel cblale glave'-.iin
r', "
t"ii,r '"ot"'J" ,ne.ri.*r& fi"tix irr comil) sau in foruele {rarc se al11elio-; : , ; ; i , i " , l in. . , i io
"o,n;1. in cn 'e[ : r l i t ' . ' i pro 'es": \P:rnsi ' ' r t ' in ' t r ' t : 'n i r :ne
, r"" , , , , t . iJ io. t l i r* t " : ) i i in cole cc cumrvirni inr l i rc( ' t d ioncefr l r t l '
I'rosnosticul este ill fimctic tlc e|olu{ic : daci sc amoiiorc:lzi,' prog-
'',',tr'i,,iti-,r*i"'t .i" I dacii sttpoirel se tgral-cll'z[ ;i trcte in comil' prognos-
I i ( , r l l { . l tc er '3\ .' ''(i;;fJ*".,=1c o .'frrc psihicir, clati dc o leziune a cmisfclc'lor corcbralc
',, ,,;iil;;;;;t;; parrtial[, ii insularit, n diencefalului; {rLnctiile ri'i;a'lc sint
I ' rur( ' . t ) t t r ionlrr l t ,uar" "h ' l t " i i , rL i t "
i "s i i r ' ' l r t - i lc 'oelPrr l ( ' r 'e t ico.c l r i
, , , , f :u ' - . i ' , f i ' i "p i to.ur i innLlc 'v: l . l ' ; uueql i ost t r 'h i r l prr l iu t ic l in i ' { i l '
:1. , { i l , l ,1t .
Itolvcin inclutle torpozrrea' stll lJ{rlrr' 't -]i oblu]rihre:r i[tr-ur] singnr
r^r',",,u', ,,io""!olaie a cinrytiinlef"'(,,1'loucliirg of r'olscciousuess" )'
Sindrornul Korsakol"
| ' ; \ | | .1|onI i | ' ' Ier . i in i r ' . " - la loIogi . . ib incrIof in i t : r . l 'cz ' ' ] . ' ' r ' ld in:rq, . ! { ' iotc},1,, ,ririiiL..tffiii neurologice'dc tii polinerritic cu manitostilri psihicc' in
clr'r tltttrtitlit, &mnezia antcrogradJ, confabulalin' "'i
dt'zorientarca'
lJrrrl iul lcziunilor dominantc este mezencefalo-dicncetaUc'
lrr cliolottic, factoml dominant esto toxioo-metabolict iu: marea
,, , ,u l , , l l i r , , t " ' , ' r ' -7"r .Lrr j lor ' Al t . t 'onr l i t , i i ot in logico st t rv i t r , int t o rr t iutr l i l l t t :
i i,, l,i i l,,ri ri rt"i-tl,r riaturi, turno'al;i (tt*roL i tle uutJei brz2r1i, rnetastazc'
t.r l,,,r,rrikra,rno), infectrioasil,, l'asculatit' slu t'r'atn af ic;"
si t t t l r t r t t t t t l Kl i i lcr- lNtt t ' r
Sirrr l l0rrrrr l l i l i i \ / ( ' f i lu( ' ) . l t1}r t , , t t r t l , i : r l r l : r l i i s .ur l l t ' 'z iL l t t i t l i r i {nt t t ' i r t r
I r i I l t ,1 ' r ' t r t I t r r l t ' t t t l t l t I ' l l l t l ,1 i l i t rcrr ' ' t i l l r I i r r ' (g i l r tsr t l l t i1 ' rx ' r r t r r l ' t t '
l t l l ( l l i l ' { 'o i l r l l l
l r t i Artr t r t r i t r , r r t i r t l i lcr t t l l r ' t r r igt l l l l i l l r t ) ; i l \ r ( { l t ( } 1 r t ' l l t t t l r l t l r ' : r ' : t l i i l i i t l r ' cot t -
:lti0
sl i i t r l i r , r ' t r ( \ r r , i t \ r ' l l r r l r r r i . , . or . r l , , l r r r r l r r r l t r . r r r .zrr ; l r l r r l l r , r l l t r , I r I i r r i , , r .or i t r ,o l r i l r ' l r l i r r l l r r l ) r t l \ rzrrr l , , , i , r r l , , r , r r . r r : r l . r ; r r ' r ' l r l l r r t r r l r . r 'oIrr1roI . I I r r r I r ' I r | ,, ' t r ro( i r t t t i t I | r l i t l r , r ' , , r r r1ror l i l r r ' l l r r ' \u: t l
l : t . ; i . s i t f r i l ) t ioAi \ ' , t l l \ ' l ' t , t I r t i l , l iz tUNt ( j ( ) t t ' i , l ( tA l , t , l
l l igiditallt prin docorl icarc
Eindrornll r'1c rlecorl,icare ale u}tuitoalele ea,r.l:ld,t'r'is1ir.i :-- r' igi{litate in elterrsie :,r c:}pillui li trnnclliului, i le jti l,rrrrsilrrlrr rrro-
( l r ' t ' l l i l ;
postrrX, a, membrelor tuperioare cu contraetulii in fle_rirrrrr :r irrl rrl or sr€inentelol cu pt'cdominanlii a celor dista,le ;
- Iostuli a, rnembrelor infe.lioaye cu conlracturi, in cxlorrsir,, r'ol:r,l i,,,irrl elnii gi l1cxie planta,t:i.
, . fi,rotnencle. de rigitlitlte sint rrrai p[!in sau tleloc inl]uorrt;rll! rl0l [ | | r lJ t noch,-pl j r i qau r le a] t 1 i ,1.
- rellexul llagnus-rle l{leijn poate fi pns in e.r'irlerr {r'r I- semne de piramidalitate bilatemli,.- alterarea accentuat5 a stfrii de conqtiinti, dar nu r:onli |rrrrr rLr,
rrrli lnesle in rigiclitatea prin dccttebt *re, ;i :r,socialii, cu pcrt,ulbiil i vr.rill l| ive ma.i pulin ample sau in unele cazuri chiar absenle .
Snrdomulilatea
- nfai. pulin _{reclent ini,ilniti, dup[ tlaumal,isme grtlve, rtir,r, lr)jr lr\rrpirrrca,-chiar qi dup:i.cele u$oarre: bolna,Tul qi-a rcvenit iornlilt,i, rlrr,i,r,r,,,
1r,r'risli" o itlutitnte timp de 1-2 slpti,mini, fXfX, alte sirrrpLonrr,rrrruloI'gicp_p:rn tai61.c. A{-c|LSlii rnanifestarc este clator.iti procesrihti rlrr irrlrilri l i.s t Lpralimintrrii a zorLelor celor r:rai noi apifltte pe scari, onl,o- gi filogr.rr rrl irir r.,t ouforln legilor biotrogice care au demonstrat ci, structurito :r,rrriorrrir,i, ,rI t tnc{ i i le lor revin cu ai i t mai tardi l ' , cu c i t s int de : rchiz i1 i , , ; r r r i r r , , . , . r r l r r
-rinrlromul vegetativ profrontal (Tiinnis)
. ln partca supclioari, a ariei premotorii existri, o zolir \, (,11.( 1t i I I r \ : r r utrtl de a, legla teasiunea ar1,t,r.iull-u ;i pulsul. Sindlonrrl irr)llt,ir ur trr,z:r rtrlr r , . t . r . l r i l j lo:r bclr t , r r r lu i , lupR di fcr ' i icpnc,. iu l i lo , i r ru i : , l i .s l t . in j t r : l , t r . r r l, r ' r l l r , ) ro le l t lu lc: ptc i r . t r l ,u l Oste to]nplct r t rstabj l i t norrulk lg i0 1i prr i l r r r ,{llr })ersisti. ui}c1t: tnllturS.ri cardio-vasculalo. l-,a,cicntul I:rr,c ri lri;rrrl.i*irrrr,,r '1rrr ia, l t i , s i o ta l i ica,rdie aturrc i t i ' i [ is i sr . ] i r r rL i , lozi f i i r r l i r r i l r r , , r r l r i i r r r( )1 1{)s1. : r l is ln. , l ( iesto tu lb l l i . l i s i r r l r .L i i l r ' l r r i r l r . r l r i r i r r t r r lc l ) t .o l i r r , r l r . r r rr i r r b i l i rc l ( io l l l l t , lcs( . ( ' l t l ( ] i .
lUi l l i r r
\g i1 l r , ( , i l l r r i r r r ; r l r r r l i r ior . l : l i i i , r , r r r r r : r r r i l i .s l l i l i l r j l t . r , t i l . r , r , r i l r r Hotrr , r , l r l i rr l r r r r l rz i t t t r r l r l r l r t r . l . r , , r r I ' I r , r r r I r t r r r , t r . l r r ' : i , l .
; i l ' I
IA rnnoziikr posttrnutnll,irttl
(jotrsf il;ttic urtttl tl inl,rc oelo rnai cornuno fcnornone alc ctcoltlor ttitu-rrlrlictr rurrr'lrril le - iltit lt:cento cit si tardive --- indifotcnt de inl,onsitltcitI r';r,rt rnlll,isrntt Itri.
Amuttzia posxlraurnaticii propriu.zisd
\rnrurzia posttlaumatic; propriu-zlsi (APT) este tlefinit5, ca perioadario r,rnnezic dun5, revcnirea bolnavului la un anumit nir-el tle conDtiin-ti',clrirlr inoil, perturbati, sau la un nivel normal, in care persisti, nurnairkrlli0ilul amnezic.
I)ulatja amn0zici }osttraumatice este in diroct raport cu graYitatcaIrrziunilor traumatice cerebrale .:i exist[' o relatie directii intre durataru,rrurczici posl,iraumatice',ql virsta bolnalrului traumatizat.
,\prrocierea amnoziilor posttraumatice nu se 1loate. face {leriit rotros-
lxxrtiv, rlupii ce bolnavul gi-a redobintlit un suficient nivel de_ conftien!5.' Exisbii, pertulbarea memoriei recente' chiat in condilii de completii,
rorr,bilitare aparentd, a nivelului de congtien!5,, Si nu a1€ legfturi, nici c_uglrr,v ils,tea, I6ziunilor core.br&ler nici cu virsta ori cu leziunile celebraleploorcisbente. Nt ar exista dificultS,li in reamintirea vechilor engrameinrrcsticc. Bolnavul este in md,sur5, si,-qi rezolve problemele vielii cle fiecareiri, (lal este invalitlat in achizilia unor cunostinle noi.
S[Jrs1;ratul moriologic, lezionaI, al amneziilor posttraumatice parosi, f ic in arilie hipoca,mpice ale lobilor temporali'
Amnezia retfogradi (AR) este detiniti, ca imposibilitatea de a reme'rrrola, ta,pti] sau idei din perioatla imediat precedenti tmumatismuiu'i'( k)rldiliia-cste c:] in momentul traumatismnlui oreieful sii, fi fost &lelt qiirr conrlitii functionale norma.le.
I)o regul5, AIl, cste tle foa,rte scrrrti' ahratil (tle ciieva -secunale, citeva
rrLirrrLi,c, mai lar dc citeva ore). l)urata AR este in prirnul rinil in laportr:rr u,ruploatea ii ou grayitatea leziunilor serebraltl traumatice.
llxistii, cazuri ile AR <le foarte lungi durati, - citeva' luni sau chiarci{,ilu, ir,rri. In aoeste cazuri sint implicate pert[rblri gral-e qi ieziuni intinseir sl,r'uctulilo rinencefalice (Russell' 1976).
1 3.4. SINDROAIIF] DATE DE I,8ZIUNI.:.DIFUZ!]
Sirrrlromul apalic
Hinrlrornul clinic poate cxista in forma complet5, sau ir, forme parli*le,ircornpkrtc, ctrnosoute sub denmiroa de sintlroams,rdispalice".
Sindromul complet, in perioada de stare, ere urmltoarele compo-norrto ((lcrBtonbrilndt, 190? ) :
rr') r\ltiora,roa sttrnii de ritttrqtiini';i, estc intt'-o oaroo:lle milstlril asemi-rrii,l,olr,irr ctt crla tlin mtrtisrnul zr,kiletic. JJohllvLtl rnott{,itre oohii deschitsi,rllr lru rrnntr,rc6to ott ptivirel, rtu ,r,to rcfl(rxlll do clipirc ltr u,m(rlinhrotrrrr rut roJlo-r pll,lpoht'r,i. Ntt ntr ttbsorvii ' ttitti o lrra,c{;io cnlo{ionlll i l tl iforrtrt-(' irr,l11, oi rrrtrrtu,i tttrt' lo Ptlutt{lttotttoiion n,lor rrilto sint, ttttslxrcifirrtr, {lo lltl l ' l lri l,
JI'I '
vcgrr i l r I iv i i . Nt t l r ix l r i nr ' r r l l r l r r l r r l l t t , r ' ( i r r l r r r r rcr l i r r l iurr l r i iut l , , l r r r r ror lI tcct ' r ' t t l , r ' r is l i i o ; r l t l t t r l l r l r , r r , r ' r l r r r r r l r t r r . iorrr t r - vogi t r , , r , r r f , r ,ur l t r pr , r io i l r l r ,t l t t t cgl tc ( l l . l otr ' ) l r l l l l r r r r r r l r t r l r r r rg i l r l t io l r r lc ( l ( ! sornr, r l i l l l r r r l l ro l t r i tvrr llx la r l i l , t r rz i l p l in r l i l r r r t l i r ror . i rur1rI , i r , i .
b) I lonomottolo l )oHlur i l l ( ! , r . i r r r r corrs l .aLl i r r 1tozi1i l , i r r Ucxio l r r r r r r r r r I r . r ,Ior'. :\colt,sl,lt, so poakf lrr.r,orrlrrr llr, sclritnbtlet, pl,sir.l. ' i, rle lozil,io a t,rr.pllrrrrii cste mai marcatii J,r rn(llnblrdo superi{)are. l 'r 'ttlchirrl csl {} in uf olll,ir,extensie. In timp apal a,rrkilozc, ret,rac!,ii tendinoase ;i t:hirrl osiliclri.
c) Fenomenele motolii prilnitivo stei ool,ipe-lurormakr.!'onomene veEetativeIlenomene oculo-motorii existi constant.Simptome pira'rnitlale. O tetraparezi, spastici),, in rnorl rrorrsllrrl,.Simptomele extrapiramiriale de tip parkinsonian sinl; frtrcvrrl t,i,.Tulburd,ri sfinctodene (incontinenld, total5 sau de vezicri rtrtlorri).
13,5. SINI]trIOAME DATE DI' LEZIUNI SITUATR IN VARIATE }.]1'A.III
Existl sindroame neurologice care pot fi date de leziuni irr to:r,l,o cl,u,irrlrrencefalului, uncori intr-unul (codical, subcortical, trunchi) sll,t.t rlot|iietaje. Astfel, existi, :
Sintlromril dc logoreo eu hiperkindzie (Arseni-Diniilii,)Urmiirind comportamentul bolnavilor cu dif erite afec{iuli uorr r,orlr i
rurgicale, am <lbservat c5, in afala sindromului de mritism akinetic, siir.r.r.lbolnaviior se poato marrifesta si in sens opus, imbricind. a,spcct,rrl rlrr lrrgoroo cu hipelkinezie Eau o gamd de aspecte variate, interrnorliarrr irrlrrraceste extreme (logo1ee fhrd, hiperkineziE, hiperkinezie f,rtr logortrr,, hiprrlkinezie cu mutism). In tabelul Y sint indicate leziunile Si sind.r.orrnrl r,or,,,H.punzd,tor in cazul ceior 13 bolnari studiali.
ln genclal, Ieziunile au fost de tip compresiv-cl istructiv, ,1i rrrr rlt, l,ipiritativ.
Considerfm cd, sindromul de logor'ee su hipcrkinezio esto un sin(lr(rrlantagonist accluia de mutism akinetic. Ambele sindroalro il4)ilr (.r, r)consecintrri a unor leziuni distructive (contuzie, hcrnoragie, r'nnnolii{rll{!l |1,,comptesiune cerebrall) Di numai exceplional poate fi vorba do o ovclll ln h,excitafie. Muti$rlul a,kinetic are la bazi, o leziune netlr, si1,uri1,r'1, lil irigolrrlformaliunii reticularo activatoare aseendente (SIiAA). $indrorrrrrl rl{,logoree qi hiperkinezie se produce, in contrast cu precetlantrrl, lrr clz rlrrleza.re a sistemului roticular inhibitor ascenitent (SIIIA).
Leziunile gdsite in cazurile noalitl'e (punte, partca lostralil l lnlnr,hitrlui ccrebral, hipotalamus, partea a,nterioa,ril qi intcrnii, a lolnlrri t rrnrgror.rrl$i cortexul cerebral) marchr:azL cl,lea SRIA, a ciirei lcza,ro at plotht(ur u,ru.r1,sindrom,
Simptouratologia., corcbr':r,lir, plozcnl,l1,L, ca,ro ostc ll,it tle d ivtrrxr\,, rrrrpoa,to fi ()xpli(llr,l;ir, dtxrit plin irrl ticrlruil loziontlfl ooutxrrnil,unl,r' l {i in pltr-j)orl,i i v:l,Ll,hil) ir, q.lol rl0rrL Nisl,r!rno r(i,i(j l l l l l ir(! i l,r{(,{r (lo l{! :r,r11:rg()trlHl,rrinhibitor t1i u,(11,iv 1,r,r',
ln <:,t,lt, ,,t, Privrr6l,r ltotr ti lt i1x,t' l< itrozirr, rlo ir,lrrr,ilri i ul,r'1r orr leziutrt*r,,$- i l l ' l ) l t l , r tb ( ,x l ) l i ( , r ! l ) r i f l r r r I r r r i I r r l r , r r , t r r r r r i l r rz i t t r t i i l x lx lurrrrr lUi t r r l ic t t l t r r inhil l i l , ( l l r r l l l l ( l l ' l lh t i r , r r r l l r r l lpr i l l l r l r rnr , l , r ' i l r , r i l r l i l (1|rrnl r l r ' I r ' r ,Firr r ro I r , r r r1ror. : r | ,
JUJ
?r l lur f (x l l r l ) r ' in l i r l , t ' t t t rc l t iu l otrrr l r t i l l r I r r ,1t dol t t r l i t l i i p l in l roz(r l l l , i l , gr tspi t tg-rr . l ' l r r r r r lu i t l t t Drrr t t r : t insi l t l t t r : t l i i .
irr cunclu)ic, tablloul urrui bolnav cu logorec ryi hipcrl<inezi.o ciittrrrlrr riitorul : pacicntul prezinti, o dolinfi sau un irnpuls irezistibil ;i aproalxrrorrl,irrnrr spi'e acfiune, miqcare ,si vorbire cu : a) logoreer. cre$terca fluxuhLiirtcrr,liv (tahipsihic) $i a si$temi ui itleativ (tahifemie)' cind leziunile corl,i-, rr lrr rr u sint prea mati ; b) latenli, hiperroactiYfi (hiperprosexic) Di reflexrl,, oli,'ntlre prornpt; c) latcn!5, foarte micd in ri,spuusuri I d) incircare:r,frxrt,ivi, atiocvatS, aitualiilor e) hipermnezie, cu exagerare, el'oci,rilor7 carorlrv irL trrrnultuoase, intempestivo qi rapido ; f) sim! cxitic ascul,it ; g) coe-rr,nl,r iii ].rttrfunzimea gindirii pot fi pistrate' dar de cele mai multe orir-1r1, rk,tri iorate, fapt Cate depinde de leziunea cerebraH, $i tie fenomenulrlr, hipcrtensiune intracrania,nl, in cazul proceselor e{pansil'e; hipermle-zi,, (cu r.xagcraroa cvocS,r'i1or, care deYin tnmultuoascr intempestive qir'.r,lriil,.), cxagelareil atcnliei, u reflexului de orienl;are, logoreea, mobilitate,.rrrr,.r',r,tri, s iini, critic ascu-tit, somn foarte pulin (2--3 nre din 24)r jud.ecatd;ri lr iunamcnt- nortn:tle sau deteriorate dupX gratlul ;i localizarea leziuni.i{ ir) t tr l )raLc,
l l iridital€a nrin dt'ccrebrarcSintLomtl de rigirlitate prin dccerebrare, sub dileritele sale Yarianto
r,i irr rliiirritclc ettpe posttraurnatic,€r survino cu o incidentl relativ mare,r ' : r ' r ' i i r r r l int t 'e t1 l roximal i r J00'o d;n cazur i in sPr ia, noasrr ; ; i a proa pr-r.t0,1, (tin oazuriin atte serii (Bricolo qi coi' ' 19?7), Deoarece un sindromrlo'r irriditate prin decerebrare poate surloni imediat post-impact sau in,,llsrr[ unui sindrom de agravare, incidenla cstc in furrclir; nu numai deLrcrlliz.area si,gravitatea leziunilor, oi. qi de promptitudinea qi eficienlarrliruclrL misuii tera,peutice' -A.cest€a sint, in ordinea priorit5,lii, antihipo-ri,.r,, rr, rrt ieclenraioase qi chilurgicale in cazurile in care se reveleazd, unrrro(i(ls cxDansiY intracrania,n.' Sinrli'omul clinic. Sindroruul de rigiditate prin decerebrare poate s;J:r,rrr,r'rr, Iio sub forrna $a completXr tipic;, rsprezenl,ind prototipul sinchomu-lui" Iio slrb lorma dittritclor varianto clinice. Frecventr sindlolnul de dece-l,lililnr cste asociat cu alterXri ale stS,rii de con;tienli, ,si cu semno ncurolo-tioo, irr lunctio dc intindorea leziunilor clil tlunchiul corellralr precum $iil, ' lrziutrilc lerebrale coexistonLe. '
!)xistil si o l/ariantii, f{iii, abolire total5, a stS,rii de conqtiin}L, care soolrsrrrvi't, erceptional de rar qi in literaturi, exist5, citate url numir restrinsrlr. r' ir,z.rrri {uairn., tgi2; .Ralsev qi Downie, 1966 ; Arseni s.iOprescu' 1966).SrrrrrioLrgic. in ace.te cazuri r:igiditatea, decereb.ratii apare l]umai industr<lo si irrrrili nociceptivi, niciodatS, sponta,I}; tabloul clinic este mai atenuatriirl urrL Ii rccunoscutc toatc €lementele. Ca nivel de conqtiinli, acesta solr.zrrirrii I.r, nusibilitate& do a mcn!,!rLe ochii deschigir de a negn sau de acorrtirnu c6va prin rniqcXri ale c:Lpului, do a reacliona lont $i.mai multr:r,rr rruri nul;in corrrplet la un ordin Yerbalt in unele ca,zuri de a incerca sIrrrr,rrrrlbti cuva inill,eh'{ibil sau de a incerca sii, rd,spundl grafic' de aso-irurrr,,rr, inill,elilibil. Triseelo E:ltrG efectuate ln unele dintre &cesto cazuriru,rr uorrIjlnrlt i l itgrrosticul.
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( l i t r t r i l (1. 1, , ( i { } t t r r ! (h l ) . ( l - t ' { ) l i t r ' I ' r r t t ! ' l l )72' 6 ' 1:} : l - l4( l '
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