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Abcesele cerebrale : etiologie, diagnostic si optiuni terapeutice

Antoniu Brinzeu. Abcesele cerebrale : etiologie, diagnostic si optiuni terapeutice. Program cofinantat din Fondul Social European prin Programul Operational Sectorial Dezvoltarea Resurselor Umane 2007-2013 INVESTESTE IN OAMENI!.

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Abcesele cerebrale : etiologie, diagnostic si optiuni terapeutice

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  1. Antoniu Brinzeu Abcesele cerebrale:etiologie,diagnostic si optiuni terapeutice Program cofinantat din Fondul Social European prin Programul Operational Sectorial Dezvoltarea Resurselor Umane 2007-2013 INVESTESTE IN OAMENI! Continutulacestui material nu reprezinta in mod obligatoriupozitiaoficiala a UniuniiEuropenesau a GuvernuluiRomaniei

  2. Definitie Abcesul cerebral este o colectie intracerebrala de puroi. • Tesut cerebral inflamat, necrozat • Capsula de celuleglialesifibroblasti • Edemperilezional Imagine SCJUT The Merck manual - 2011

  3. Definitie 2007 Quinones-Hinojosa A

  4. Definitie 2007 In jurulabcesului se evidentiaza: • o zona de edem • Micsorareaventricolului lateral • Deplasarealinieimediane HIC! The Merck manual - 2011 Quinones-Hinojosa A

  5. Etiologie Bacterii : • Stafilococi – traumatism, endocarditebaceriene, neurochirurgie • Entrobaceriaceae – infectiiotice • Anaerobi – Bacteroides, Streptococianaerobi – celmai des • Flora mixta : aerobisianaerobi • Fungi, protozoare Mecanisme de propagare : • Plagicraniocerebrale – traumatisme, operatiineurochirurgicale • Transmiteredirecta de la o infectie a capului – osteomielita, mastoidita, sinusita • Calehematogena : drogurii.v.endocarditabacteriana The Merck manual - 2011

  6. Abceseleasociatesinusitelorparanazale : localizate de obicei in lobul frontal – Streptococcus Milleri - posibil, cu saufaraanaerobi Abceseleasociateotitelorsimastoiditelorcronice : flora bacterianamixtaaerobasianaeroba Stafilococcusaureusposibil MRSA din abceseleposttraumaticesaupostoperatorii ( uneoriculturapura) Abcessecundaruneiinfectiirespiratoriicronice - abcespulmonar - Streptococcus Millerii+ anaerobi + altipatogenirespiratori Rar: M. tuberculosis, Listeria monocitogenes,Toxoplasmagondii, Nocardia,Criptococcus, Aspergillusfumigatus Antimicrobial Chemotherapy - Fifth edition 2008 – D. Greenwood, R. Finch,P .Davey, M.Wilcox

  7. Etiologie Determinari la distantapornind de la : • Abcese – pulmonare • Osteomielita • Tumorisupurate • Infectiipelviene • Malformatiicongenitalecardiace cu suntdreapta – stanga • Valvulopatii cu endocarditabacteriana La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  8. Etiologie Frecventa in crestere in ultimiiani : • Pacientiimunodeprimati • Sex masculin – maifrecvent • Varstapeste 40 de ani • O frecventamai mare a abceselorfungice, parazitaresauprinbacteriioportuniste Crestere relativa a frecventei prin : Diagnostic imagistic eficient – neuroradiologie ! La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  9. Brain abscesses in the county hospital Timisoara Since 01.01.2000 until 31.12.2005 29 brain abscesses 2 steps : 2000- 2002 – antibiotherapy was not standardised 2003 – 2005 : protocol for the antibiotherapy and surgery Empiric therapy III rd generation cephalosporine+ cultures Vancomicine Metronidazole

  10. Etiologie Profilaxia infectiilor perioperatorii in neurochirurgie Infectiilepostoperatorii: un loc special • Germeni – frecventstafilococi MSSA • Posibilsigrav - germeninosocomiali Infectiileposttraumatice– 10 – 20 % din totalulabceselorcerebrale La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  11. Etiologie Abcesecerebraleposttraumatice Factori de risc: • Corpistrainiintracranieni : plagipenetrante • Fragmenteosoasepatrunseprinplagilecranio - cerebrale • Plagipenetrantecranio – cerebraleprinintepare • Plagiimpuscate – prinarme de foc • Fistule LCR traumatice La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  12. Diagnostic Clinic: simptomatologie, istoric, patologie subiacenta ( ORL, cardiaca - valvulara, traumatisme, interventii NCH ) Imagistic : CT, RMN Microbiologic : identificarea germenilor, testarea sensibilitatii lor Punctia lombara : inutila, riscanta ( angajare) → contraindicata The Merck manual - 2011

  13. Diagnostic Simptomatologiainitialadifera in functie de forma de boala: Complicatiauneisuferint ORL saustomatologice • durerelocalizatasicefalee • semneneurologice de focar • alterareastarii de constienta • tesutulinflamator se necrozeaza, se constituie o colectiepurulenta • edemperilezional • trombozevenoase • hipertensiuneintracraniana • zone de ischemiecerebrala Imagine SCJUT La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  14. Diagnostic Semnele de focar (apar la 50 – 80% din cazuri) sunt: • Tulburarivizuale • Afazie • Ataxie • Nistagmus • Hemipareze Crizecomitiale la 50% din pacienti. Febradoar la 50% din cazuri. Semnelemeningealedoar la 20 % din cazuri. La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  15. Diagnostic Cerebrita : este o inflmatie a unei regiuni a creierului, de cauza de obicei infectioasa. Netratata eficient evolueaza spre un abces cerebral ( este stadiul incipient al acesuia ?)! Tratamentul este cel al abcesului cerebral. IMPORTANT : diagnosticul imagistic este dificil . Necesita examinare RMN in modul DWI ! AJNR – 2003 GA Tung, JM Rogg Case Report - Diffusion Weighted Imaging of Cerebriris

  16. Caz clinic - 2011 M 18 ani • Otomastoidita : tratata, operata ORL • Abcessecerebrale multiple • Edem cerebral • HIC • Coma Imagine SCJUT

  17. Diagnostic Sinusita Otomastoidita Abces dentar frecvent Coci gram pozitivi Stafilococi Pneumococi Streptococi Posibil : anaerobi gram + Gram negativi

  18. Diagnostic In cazultraumatismelorsi al interventiilorneurochirurgicale: • Istoriculeste relevant • Simptomatologiacorelata cu localizareasiextensiainteventieisau a traumatismului

  19. Diagnostic Imagistica – rol hotaritor CT RMN Ambele cu substanta de contrast ! Diagnostic diferential cu : Metastaze cerebrale Hematoame Infarcte cerebrale Uneori necesita RMN Alte neuroinfectii : empiem subdural, ventriculita, meningita

  20. Diagnostic Hemoculturile obligatorii ! Cand sunt pozitive sunt foarte utile ! Cele negative nu sunt relevante! Antimicrobial Chemotherapy - Fifth edition 2008 – D. Greenwood, R. Finch,P .Davey, M.Wilcox

  21. Tratament Antibioterapia : Ceftriaxona 2g i.v. la 12 ore sau Cefotaxim 2g i.v. la 4 ore durata peste 4 saptamani ( 4-8 sptamani ) Exista riscul de infectie cu: Bacteroides fragilis - necesita metronidazol : doza de incarcare 15 mg /kg urmata de 7,5 mg /kg / 6 0re Staphylococcus aureus meticilinorezistent ( MRSA) respectiv nafcilinorezistent - vancomicina: 1g /12 ore The Merck manual - 2011

  22. Tratament Corticosteroizii : Dexametazona 10 mg i.v. prima doza, urmata de 4 mg/6 ore i.v. timp de 3-4 zile. Anticonvulsivantele ± in scop profilactic The Merck manual - 2011

  23. Tratament • Punctiastereotactica cu caracter evacuator ( si diagnostic bacteriologic) • Evacuareachirurgicala • Pentruabceseleunicesi cu diametru >2cm ( 2,5 cm dupaunii ) Evacuareaestejustificatadaca : • Dimeniunilesuntmari • Existaefect de masa • Hipertensiuneintracraniana The Merck manual - 2011 La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  24. Empiemul subdural 15 – 23 % din infectiile intracraniene Mortalitate ̴ 10 % Complica evacuarea unui hematom subdural – mai ales la etilici Alte cauze : TCC cu fracturi de bolta, sinusite, otite, mastoidite Clinic: • Semneleboliideclansatoare: ORL ( sinusita, otita, mastoidita), hematom subdural evacuat, fractura de bolta • Convulsiigeneralizate ( frecvent ) • Alterareastarii de constienta • Coma • HIC La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  25. Empiemul subdural Este o urgenta neurochirurgicala ! Evacuare prin : gaura de trepan si aspiratie sau craniectomie larga Antibioterapie masiva : bacili gram + si gram negativi, coci gram +, anaerobi La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  26. Ventriculita • Drenajeventriculareexternesau interne • Catetere de monitorizare a PIC Frecventa infectiilor este variabila : pana la 33 % pentru shunturi si sub 2 % pentru ventriculostomii La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  27. Ventriculita Factorifavorizanti : • Infectiilecutanate • Patologiasubiacenta : hemoragiaventriculara, hemoragiacerebralaasociata, PIC > 20 mm Hg siirigareacateteruluisuntfactori de risc care favorizeazainfectia • Experientachirugului • Tipul de shunt : celventriculo- peritoneal maifrecventdecatcelatrio - ventricular La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  28. Ventriculita Caile de contaminare Germenii : Stapphyococcus aureus sau epidermidis – de obicei Caleacutanata – plagaoperatorie Calea intraabdominala – intraperitoneala - ascendenta pe calea cateterului Germenii : gram negativi Calea hematogena – de la un focar infectios cronic – abces dentar, infectie urinara Germenii : Streptococcus viridans , respectiv Escherichia colli La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  29. Ventriculita Debut - cateva saptamani Disfunctia cateterului NU este semn de infectie ! Simptomatologie Febra + simptomatologie abdominala Greata, varsaturi, durere abdominala, semne de subocluzie ….. Tablou de peritonita ! Laborator: Hiperleucocitoza Hiperalbuminorahie Hipoglicorahie Cultura LCR ! Hemoculturi La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  30. Ventriculita Tratament • Antibioterapie sistemica i.v. • Inlaturarea suntului - unii autori o recomanda de la inceput – cresc sansele antibioterapiei ! • ± drenaj extern Antibiotic : • De prima intentie - antistafilococic • Dupacultura LCR sauHemocultura Studiul puterii bactericide a LCR : permite evaluarea eficacitatii tratamentului antibiotic ! La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  31. Profilaxia infectiilor postoperatorii ale SNC Evaluareariscului de infectiepostoperatorie a SNC Factorilegati de tipul de interventie - clasificareaAltemeier Clasa I: chirurgiacurata, programata, riscintre 0,5 – 5 % ex. • drenaj intern al LCR, • implant de dispozitive pt. tratamentulspasticitatii Clasa II: chirurgiacurata, contaminata, risc 5 – 10 % ex. • Hipofizectomiapecaletransethmoidala in care abordarea se face pecalenasala, • Chirurgiafistulelor LCR in etajul anterior al craniului – rinoliquoree • Chirurgiafoseiposterioarepecaletranslabirinticasau trans mastoidiana • Drenaj extern LCR • Chirurgia TCC inchise in primele 6 ore La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  32. Profilaxia infectiilor postoperatorii ale SNC Clasa III :chirurgia TCC - chirurgiecotaminata,riscinfectios 10–30 % • traumatism deschis cu plagacranianaoperata in primele 4ore sau • traumatism inchisoperatdupa 6 ore Clasa IV: chirurgia “murdara” – infectata – risculeste de peste 30 % • TCC deschis – plagacranio – cerebralaoperatadupa 4 ore • Chirurgiainfectioasapropriuzisa : abcescerebral,empiem subdural La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  33. Profilaxia infectiilor postoperatorii ale SNC Factorilegati de pacient : • Scorul ASA > II • GCS la internare < 10 • Interventiinchmairecente de o luna • Patologiatumorala – risccrescut de infectie • Antibioterapie in antecedentelerecente ( < 10 zile) • Focare de infectieexistente la distanta de loculinterventiei – depistare, tratament ! La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  34. Profilaxia infectiilor postoperatorii ale SNC Profilaxia se bazeazape: • Tratamentulfocarelorinfectioaseexistente la distanta • Pregatireacutanata a campului operator • Radereategumentuluiscalpuluifavorizezainfectia – se recomandaradereadoarpetraiectulplagiioperatorii • Inchidereabreselordurei mater prinsuturaprecoce – breseposttraumaticesaupostoperatorii • Antibioprofilaxieperioperatorie *Antibioprofilaxia in fistulele LCR posttraumatice in etajul anterior( rinoliquoree ) sau la nivelulstanciitemporalului ( otoliquoree ) nu s-a dovediteficienta La reanimation neurochirurgicale - Bruder , Ravussin, Bissonette - 2009

  35. Profilaxia infectiilor postoperatorii ale SNC

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