infectii neurochirurgicale nespecifice
TRANSCRIPT
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Dr. Minodora StoiceanuClinica Neurochirurgie II
Spitalul Universitar de Urgenta Bucuresti
INFECTII NEUROCHIRURGICALE
NESPECIFICE
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INFECTII NEUROCHIRURGICALE NESPECIFICE
• Abcesul cerebral
• Empiemul subdural
• Abcesul extradural cranian
• Abcesul epidural spinal
• Abcese medulare
• Tromboflebitele supurate intracraniene
• Sindromul meningeal in neurochirurgie
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ABCESUL CEREBRAL
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DEFINITIE
• Colectie purulenta focala, localizata in parenchimul cerebral
• Proces expansiv intracranian septic
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FRECVENTA• Incidenta scazuta 0,1 – 1%
• Predomina la copii si tineri intre 20 si 40 de ani (incidenta mai mare a infectiilor otomastoidiene)
• Foarte rar dupa 60 de ani
• Apar la sexul masculin
• Mai ales la cei cu abcese metastatice, posttraumatice
• In emisferul stang
• La imunodeprimati
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ETIOPATOGENIE
APAR PRIN CUMULAREA A 3 CONDITII:
• Sursa de infectie
• Calea de propagare
• O regiune de tesut cerebral devitalizata (ischemica)
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ETIOPATOGENIE
TIPURI DE ABCESE CEREBRALE:
• Adiacente – de vecinatate
• Metastatice
• Posttraumatice
• Criptogenetice, de cauza necunoscuta
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ABCESE CEREBRALE ADIACENTE• Cele mai frecvente
• Sursa de infectie: otite, mastoidite, sinuzite, infectii dentare, osteomielita locala, flebita vaselor emisare, meningita purulenta
• Cale de propagare: prin continuitate sau de la un focar de osteita sau tromboflebita, mai rar din canalul auditiv intern
• Localizare: in functie de sursa de infectie
› Lobul temporal sau cerebel: otita medie, mastoidita
› Lobul frontal, temporal: sinuzita
› Lob frontal: infectii dentare
› Lob frontal, cerebel: meningita
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ABCESE CEREBRALE METASTATICE - INFECTII LA DISTANTA DE EXTREMITATEA CEFALICA
• Sursa de infectie: supuratii pulmonare, endocardite bacteriene, cardiopatii congenitale cianogene, infectii digestive si genito-urinare
• Calea de propagare: hematogena
• Localizarea cerebrala: multipla, la jonctiunea dintre substanta alba si cenusie
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ABCESELE CEREBRALE POSTTRAUMATICE - INOCULARE DIRECTA
• Sursa de infectie: plagi cranio-duro-cerebrale, fistule LCR postraumatice, postoperator
• Cale de propagare: directa
• Apar imediat, rar tardiv dupa traumatism, pe o cicatrice cerebrala sau in jurul unui corp strain: eschila osoasa, glont
• Localizare: de obicei adiacenta traumatismului
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NECUNOSCUTA - ABCESE CRIPTOGENETICE
• Cale de propagare: hematogena
• Localizare cerebrala multipla
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AGENTI PATOGENI• abcesele otogene au flora mixta de obicei:
• Streptococi aerobi si anaerobi
• Bacteroides
• Enterobacteriacee
• patogeni mai rar identificati:
• Stafilococ in abcesele posttraumatice sau postoperatorii
• Fungi la pacientii imunodeprimati: Candida albicans, Nocardia asteroides, Aspergillius, Mycobacterium, Toxoplasma gondii (SIDA)
• la sugari: germeni Gram -
• culturi sterile in pana la 25 % din cazuri
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MORFOPATOLOGIE – 4 STADII:
• 1. Encefalita presupurativa - zilele 1-3
• ramolisment venos septic (mai rar arterial)
• centru necrotic inconjurat de infiltrat inflamator
• slab delimitat
• 2. Encefalita supurativa (abces necolectat) - zilele 4-9
• focare purulente neconfluente
• fibroblaste, retea de fibre de reticulina
• edem perilezional
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MORFOPATOLOGIE – 4 STADII:
• 3. Abces colectat (confluent) - zilele 10-13
• focarele purulente conflueaza
• colectie purulenta inconjurata de infiltrat inflamator
• 4. Abces incapsulat - capsula apare intre saptamanile 3-8
• centru necroticopurulent inconjurat de o capsula colagenica
• 3 straturi ale capsulei:
• intern - granulos
• intermediar - colagen
• extern - vase de neoformatie
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MORFOPATOLOGIE
• localizare: peretele periventricular este mai subtire datorita vascularizatiei deficitare
• medicatie: antibioticele si corticosteroizii intarzie formarea capsulei
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MORFOPATOLOGIE
• Abcese multiple
• Abcese multiloculate
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TABLOU CLINIC
• Triada Bergman:1. sd. infectios
2. sd. HIC
3. sd. neurologic
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1. SINDROM INFECTIOS
• local: tumefactia regiunii retroauriculare, durere spontana si la palpare, otoree,
• general: febra, frisoane, alterarea starii generale,
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2. SINDROM DE HIPERTENSIUNE INTRACRANIANA:
• cefalee
• greturi, varsaturi
• edem papilar
• sindrom meningian
• hernia de uncus hipocampal - complicatie majora cu risc vital
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3. SINDROMUL NEUROLOGIC DE LOCALIZARE
• Modificari de camp vizual: cvadranopsie, hemianopsie homonima
• Pareza de nerv oculomotor comun: anizocorie cu midriaza ipsilaterala, ptoza palpebrala, strabism divergent. Semn de gravitate - iminenta de hernie uncala
• Tulburari de limbaj - afazie Wernicke - in emisferul dominant
• Crize partiale complexe - epilepsie de lob temporal
• Tulburari de echilibru, vertij
• Alterarea starii de constienta: stare confuzionala, agitatie psihomotorie, obnubilare, somnolenta, coma
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EVOLUTIE CLINICA• Forme evolutive:
• evolutie acuta
• evolutie subacuta
• evolutie cronica
• Debutul simptomatologiei:
• intre 2 si 3 saptamani
• istoric de supuratie otomastoidiana
• febra - la copii
• semne de hipertensiune intracraniana: cefalee, varsaturi
• crize comitiale
• alterarea progresiva a starii de constienta
• insidios
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EVOLUTIE CLINICA
• Agravare, complicatii:• efractie in ventriculul lateral - ventriculita
• efractie in spatiul subarahnoidian - meningita purulenta
• angajare de uncus hipocampic
• tromboza septica a sinusului transvers
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INVESTIGATII PARACLINICE• Analize de laborator
• Sindrom inflamator biologic
• LCR: PUNCTIA LOMBARA NU ESTE RECOMANDATA
• Serologie HIV
• Bacteriologie• Cultura din materialul bioptic
• Hemocultura
• Culturi din secretiile otomastoidiene
• Identificarea agentului patogen prin amlificarea si secventializarea ARN ribozomal
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IMAGISTICA• CT cerebral
• faza de encefalita presupurativa: arie hipodensa imprecis delimitata, fara priza de contrast
• faza de encefalita supurativa: hipodensitate centrala cu priza periferica imprecis delimitata; edem perilezional
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IMAGISTICA• CT cerebral
• faza de abces colectat: hipodensitate centrala inconjurata de margine hiperdensa postcontrast bine delimitata
• faza de abces incapsulat: centru hipodens, capsula groasa, spontan hiperdensa mult accentuata cu contrast
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IMAGISTICA• CT cerebral
• edemul perilezional, abcesele multiple sau multiloculate, efectul de masa
• leziunile distructive ale stancii temporalului, corpi straini, solutii de continuitate osoasa
• Scintigrafia cerebrala cu leucocite marcate cu Indiu-111
• SPECT cu Thalium-201
• Angiografia cerebrala
• Radiografii de craniu, stanci temporale, SAF
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IMAGISTICA• RM cerebral
• fazele de encefalita: hiposemnal T1, hipersemnal T2
• fazele de abces colectat:
• centrul: hipoT1, hiperT2
• capsula: hiperT1, priza de contrsat
• edemul perilezional: hipoT1, hiperT2
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DIAGNOSTIC DIFERENTIAL• Procese expansive intracraniene
• tumori: glioame (GBM), metastaze, limfoame (priza periferica de contrast)
• hematoame spontane, posttraumatice
• ramolisment postoperator
• parazitoze
• Supuratii intracraniene• abces epidural
• empiem subdural
• meningita purulenta
• Altele:• AVC ischemice
• encefalita herpetica
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TRATAMENT
• Antibioterapie• unic tratament pentru abcesele unice sau multiple de
maxim 2,5 cm diametru, localizari profunde, sub 2 saptamani de la debutul bolii
• tratament prelungit - 6-8 saptamani
• sensibilitatea in vitro poate diferi de cea in vivo: hipoxie locala, pH acid, permeabilitatea barierei hemato-encefalice
• urmarire prin CT sau RM seriat
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TRATAMENT• Antibioterapie
• Antibioterapie tintita pe baza culturilor si antibiogramei
• Antibioterapie empirica
• Oto-mastoidite, sinuzite, supuratii pulmonare: Cefalosporine de generatia a III-a + Metronidazol
• Posttraumatism sau postoperator: Ab antistafilococice (Vancomicina, Nafcilina) + Cefalosporina de generatia III
• Endocardita bacteriana: Ampicilina + Gentamicina
• Infectii abdomino-pelvine: Cefalosporine de generatia III
• Cloramfenicol + Metronidazol
• Meropenem - alternativa la cefalosporinele de generatia a III-a
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TRATAMENT• Tratamentul chirurgical
• Drenaj
• Punctie-aspiratie ghidata stereotactic
• minim invaziva
• valoare diagnostica: culturi si biopsie
• abcese uniloculate in zone profunde sau elocvente
• pacienti tarati, stare generala grava (anestezie locala)
• punctie ghidata prin neuronavigatie, CT sau RM intraoperator (fara cadru de stereotaxie)
• risc de recidiva
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TRATAMENT
• Tratamentul chirurgical• Excizia abcesului prin craniotomie
• abcese multiloculate, corpi straini, abcese fungice
• excizia capsulei - scade riscul de recidiva
• craniectomie decompresiva
• tratamentul fistulei LCR
• Dezavantaje: mortalitate si morbiditate crescuta, sechele neurologice, cicatrice corticala epileptogena, insamantarea subarahoidiana sau a plagii operatorii
• Antibioterapie obligatorie 6-8 saptamani postoperator
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TRATAMENT• Terapii complementare:
• Oxigenoterapia hiperbara
• Cura focarului septic otomastoidian, sinusal, etc
• Tratament depletiv cerebral
• Manitol, Furosemid
• Corticsteroizii - rol controversat: reduc edemul dar prelungesc evolutia
• Tratament anticomitial
• Sustinerea functiilor vitale, tratament simptomatic
• Urmarirea eficacitatii tratamentului prin CT sau RM seriat • initial la 1-2 sapt, apoi la 2-4 sapt
• ameliorarea clinica devanseaza ameliorarea aspectului imagistic
• se urmaresc: dimensiunea, edemul perilezional, disparitia prizei de contrast si a efectului de masa
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PROGNOSTIC• Ameliorarea neta a prognosticului in ultimele
decenii: diagnostic precoce, urmarire imagistica, antibiotice performante, tehnici chirurgicale minim invazive
• Mortalitate: 10% mai mare la copii
• Sechele: 50 % - deficite neurologice focale (hemipareza - 35%), sechele neuropsihice
• Epilepsie: 30-50%
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PROGNOSTIC• Recidiva
• 5-10%
• mai crescuta in cazul tratamentului conservator sau al metodelor minim invazive
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EMPIEMUL SUBDURAL
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DEFINITIE
• Colectie purulenta focala, localizata intre dura mater si arahnoida
• uni sau bilaterala
• La suprafata emisferului cerebral sau interemisferic, bazal, in fosa posterioara
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ETIOPATOGENIE
• Vezi abcesul cerebral
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TABLOU CLINIC
• Debut brusc
• Sd. Meningian!
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EVOLUTIE CLINICA
• Supraacuta
• Acuta
• Subacuta
• Cronica
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INVESTIGATII PARACLINICE
• Vezi abcesul cerebral
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DIAGNOSTIC DIFERENTIAL
• Meningoencefalita
• Tromboflebitele cerebrale sau ale sinusurilor durale
• Abcesul cerebral si extradural
• Alte colectii inlocuitoare de spatiu subdurale
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TRATAMENT
• Medical
• Chirurgical
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ABCESUL EXTRADURAL
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DEFINITIE
• Colectie purulenta dezvoltata in spatiul epidural, intre dura si tablia interna a calotei craniene
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FRECVENTA
• Rare
• Mai ales la sexul masculin
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ETIOPATOGENIE
• Adiacente
• Postraumatice
• Metastatice – foarte rare
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TABLOU CLINIC
• Necaracteristic
• Mare urgenta neurochirurgicala!!!
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TRATAMENT
• mixt
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ABCESUL EPIDURAL SPINAL SI ABCESUL
MEDULAR• Sd. infectios
• Sd. de compresiune radiculara
• Sd. de compresiune medulara