hemorragia_cerebral_espontanea

Hemorragia cerebral espontánea

La hemorragia cerebral espontánea es una colección hemática dentro del parénquima cerebral en ausencia de traumatismo o intervención quirúrgica previa.

Representa el 10-15% de todos los ictus, y según su localización puede ser intraparenquimatosa o intraventricular.

Es la 3ª causa de muerte y se estima la duplicación de su incidencia en el año 2050.

Se presenta con doble de frecuencia que la hemorragia subaracnoidea y tiene peor pronóstico que esta.

A partir de los 55 años de edad, la frecuencia es doble por cada década que pasa.

Se produce con mayor frecuencia en personas de raza negra y japoneses.

En cuanto al sexo, no se observan diferencias significativas entre ellos.

Más frecuente por la mañana y en invierno.

La clínica va a depender de la localización , del tamaño, del edema acompañante y la presencia de hidrocefalia entre otros.

Característicamente se produce un intenso dolor de cabeza, vómitos y alteración en el nivel de conciencia.

Puede presentarse como una parálisis de la mitad del cuerpo, disminución de la apertura y desviación de los ojos hacia el lado del cerebro donde se produjo la hemorragia y dificultad para hablar. También puede manifestarse con una alteración para mover los ojos y disminución en la sensibilidad.

Uno de cada 4 pacientes va a presentar un deterioro clínico en las próximas 24 horas sobre todo en alcoholismo, hematoma irregular,nivel de conciencia bajo y niveles bajos de fibrinógeno.Antecedentes de isquemia cerebral,enfermedad hepática,niveles altos de glucosa,y tensión arterial por encima de 200 mm Hg.

La fiebre y el crecimiento del hematoma son predictores independientes de mal pronóstico.

Se necesitan investigaciones futuras para estudiar los mecanismos de este fenómeno y analizar si los protocolos iniciales de modulación de la temperatura se asocia con mejores resultados (Rincon y col., 2012).

Solo un 20 % podrán realizar una vida independiente 6 meses después.

El 50 % fallecen en el primer mes.

Los volúmenes de >60 cm3 tienen una mortalidad del 90 %

Escalas pronósticas

El pronóstico final de los pacientes, no depende de una variable aislada, sino de la conjunción de varias; por ello se han intentado crear escalas pronósticas que las agrupen.

En la actualidad han surgido escalas breves, simples y con alta sensibilidad como la “ICH score” creada por Hemphill.

Enlace http://www.mdcalc.com/intracerebral-hemorrhage-ich-score/

No esta clara la estrategia a seguir.

Estudios mal diseñados.

Deben de agruparse en Localización, tamaño, GCS.

No agrupar sistemáticamente todos los tipos de intervención quirúrgica.

Hasta el momento, ninguna intervención en particular es claramente superior.

Una revisión de los estudios aleatorios disponibles, sin embargo indica que las opciones menos invasivas puedan mostrar resultados mejores.

Esto puede ser en particular verdadero en pacientes jóvenes con signos de deterioro neurológico reciente.

Reducir el volumen de hematoma permanece como pilar básico.

Las futuras investigaciones e intervenciones van indudablemente en esta dirección.

Este interés en identificar mecanismos bioquímicos refleja el aumento reciente de publicaciones de investigación de mecanismos celulares y moleculares

Mientras tanto, la responsabilidad permanece sobre el clínico para hacer el juicio terapéutico lo mejor posible.

Rincon, Fred, Patrick Lyden, and Stephan A Mayer. 2012. “Relationship Between Temperature, Hematoma Growth, and Functional Outcome After Intracerebral Hemorrhage.” Neurocritical Care (September 22). doi:10.1007/s12028-012-9779-9. http://www.ncbi.nlm.nih.gov/pubmed/23001769.

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La hemorragia cerebral espontánea, es el sangrado no traumático en el parénquima cerebral.

Es el segundo subtipo más común de accidente cerebrovascular, con 5,3 millones de casos y más de 3 millones de muertes en todo el mundo en 2010.

En el 2001, la incidencia anual era de 20-30 por 1.000.000 personas

Según su localización puede ser intraparenquimatosa o intraventricular (HV).

Hipertensión arterial

Hemorragia cerebral por malformación arteriovenosa cerebral.

Aneurismas (saculares. micóticos)

MAV.

Fístula arteriovenosa

Angioma venoso

Cavernoma

Telangiectasia

Enfermedades hematológicas

Afibrinogenemia

Déficit de factor de von Willebrand

Púrpura trombótica trombocitopénica idiopática

Leucemia

Síndrome de hiperviscosidad

Mieloma múltiple

Coagulación intravascular diseminada

Trombopenias primarias o secundarias a fármacos

Angiopatía cerebral amiloidea

Vasculitis multisistémica aislada del sistema nervioso central

Síndrome de Moyamoya

Trombosis venosa central

Tumores: primarios y metastásicos

Enfermedades infecciosas

Tuberculosis

Brucelosis

Leptospirosis

Micosis

Simpaticomiméticos

Anfetaminas (anfetamina. metanfetamina)

Cocaína

Crack

Norefedrina. efedrina. fenciclidina Fibrinolíticos

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