Sindromul Mediastinal -Curs 2013

7/29/2019 Sindromul Mediastinal -Curs 2013

1/83

SINDROMUL MEDIASTINAL

Dr. Anca Mihailescu


2/83

Cuprins

Delimitarea mediastinului si acompartimentelor sale

Semnele si simptomele SM Explorarea functionala si paraclinica a SM

Patologie mediastinala


3/83

MEDIASTIN- DELIMITARE

Inferior diafragm

Superior apertura toracica superioara

Lateral

pleure Anterior stern

Posterior - coloana vertebrala


4/83


5/83

MEDIASTIN - CONTINUT

Cord

Ao, AP, VCS, VCI

Vase limfatice, ggl

Trahee, bronhii principale

Esofag

Nervii vagi, laringei recurenti, frenici, ic, lanturilesimpatice

Timus

Tesut conjunctiv

Ty, Pty ectopice


6/83

SINDROM

SINDROM = semne + simptome careapar adesea impreuna in diferite boli

cu etiologii diferite- tumorale

- vasculare

- infectioase

- inflamatorii

- de dezvoltare

- traumatice


7/83

Mediastinul superior

Trahee

Esofag superior

Timus

Arc aortic

N X N frenici


8/83

Mediastinul anterosuperior

Tesut gras

Ganglioni limfatici

Tiroida ectopica Timus


9/83

Mediastinul mijlociu

Cord

Aorta ascendenta

VCS, VCI, vvbrahiocefalice

Vase pulmonare

N frenici Ganglioni


10/83

Mediastinul posterior

Esofag

Canal toracic

Vv azygos,hemiazygos

Aorta descendenta

Nn vagi, intercostali


11/83

SIMPTOME

Dispnee, tuse, disfonie

Durere

Disfagie, sughit, varsatura

Sincopa

Cefalee, ameteli, somnolenta, tulburaride vedere


12/83

DISPNEE

Compresie extrinseca a traheei

Obstructie bronsica

Iritatia n X Pareza de CV stg

Limitarea miscarilor resp durere

Pareza de frenic Tamponada pericardica

Revarsat lichidian pleural


13/83

TUSEA

Chintoasa

Latratoare compresii traheobronsice

Bitonala pareza laringeu recurent

Afona distructii de CV

Surda Hemoptoica staza, T br, ruptura de Ao


14/83

DISFONIA

>2-3 sapt semnal

Sdr Ortner

- fonastenie

- afonie

- raguseala - diplofonie


15/83

DUREREA TORACICA

Nespecifica

Nevralgica frenica

- ic

- cervicobrahiala

Terebranta

osteita sternala

Pseudoanginoasa


16/83

SIMPTOME DIGESTIVE

Disfagia compresie, obstructie,inflamatie

Sughit- iritatie frenica

Varsatura - +vag, afectiuni esofagiene


17/83

SEMNE MAJORE

Cianoza

Edem

Circulatie colaterala

Sb mica, Sp mare


18/83


19/83


20/83


21/83


22/83


23/83


24/83


25/83

SEMNE (I, P)

Anizocorie, sdr Claude Bernard Horner

Retractii - mediastinita retractila, atelectazie

Bombari anevrism Ao

Adenopatii, splenomegalie Puncte Valleix

Emfizem sc

Anizosfigmie


26/83

SEMNE (P, A)

Matitate interscapulovertebral- sternala superioara

- rotunjita deasupra cordului- baza toracelui

- segmentara

Obstructie localizata/ abolirea MV

SS parasternal stg

S Hamman


27/83

Rg pulmonara (f,p)

Masa mediastinala vs sdr mediastinal

Largirea mediastinului

Rx :Pulsatilitate

Rata cresterii masei mediastinale


28/83

CT

De rutina in SM

Dg cert de anevrism Ao, lipomatoza

mediastinala, grasime pericardica Localizare, extindere, invazie, circulatia

colaterala

Semne indirecte de malignitate (invazie, meta)

Ghidaj


29/83

RMN

Afectare nervoasa, vasculara

Leziuni apropiate de apertura

superioara

Invazie diafragmatica

CI la substanta de contrast (alergie, IR)


30/83

ECO

Chist vs solid

Ghidaj biopsie

Copii

Leziuni E/periE (ecoendoscopie)


31/83

ESOFAGOGRAFIA SI EDS

Afectiuni intrinseci E (diverticuli, cesofagian)

Compresie extrinseca


32/83

SCINTIGRAFIE

I 131, I 123 Tiroida

Ga 67- limfom

I-metilbenzilguanina

feocromocitom

Selenometionina PTy

Tc pertechnetat chiste neuroenterice(mucoasa gastrica)


33/83


34/83

INVESTIGATII INVAZIVE

Bronhoscopie spalare (BAL), periaj, biopsie

Toracotomie

VATS biopsie pleurala/ pulmonara

Mediastinoscopie (suprasternal) nu Ap Ao-pulm, paratraheali stg

Mediastinotomie parasternal

Biopsia medulara Biopsia excizionala


35/83

MANIFESTARI ASOCIATE

Hipoglicemie mezoteliom, teratom,fibrosarcom

Sdr Cushing

Hipercalcemie T Pty

Simptome neurologice T neurogene

Miastenia gravis - timom


36/83

EPIDEMIOLOGIE

Adulti frecvent AS

Copii frecvent P

Simptome ~ malignitate

Leziuni maligne mai frecvente la copii

Lf in crestere


37/83

PATOLOGIE MEDIASTINALA

Acuta/ cronica

Tumorala/netumorala (hernii, chiste,infectioasa, inflamatorie, traumatica)

M superior/anterior/ mijlociu/ posterior

/difuz

Frecventa/rara


38/83

AFECTIUNI MEDIASTINALE

frecvente rare

Anterosuperior TimomLimfomT germinale

Leziuni vasculareT mezenchimale

T endocrine

Mijlociu Chiste bronhogeneT limfoide

Chiste pericardice

Chiste gastro

Posterior T neurogene Leziuni vasculareT mezenchimale

Leziuni limfoide

Hernie Bochdalek


39/83

PNEUMOMEDIASTIN

Durere in inspir, dispnee, disfonie

Crepitatii sc

Context clinic

posttraumatic/ barotrauma/ruptura esofagiana


40/83

MEDIASTINITA ACUTA

Perforatie esofagiana Sdr. Boerhaave

- prognostic prost

- durere brusca, febra- Rx - pneumomediastin, hidroptx- tranzit baritat- TCTrat: chirurgical+Ab

Post sternotomie (in I sapt, < 1%, Mo 15%) Perforatia traheobronsica Prin contiguitate


41/83

Esofagograma cu gastrografin Sdr.Boerhaave


42/83

MEDIASTINITA CRONICA SIFIBROZA MEDIASTINALA

Sdr de VCS

Peric constrictiva

Obstructie de AP Obstructie

traheobronsica

Evolutie lenta

CT, Rx, angiografie

Culturi -

Histoplasmoza

Mycobacterii

Candida Iradiere

Metisergida

B autoimune


43/83

PATOLOGIE TUMORALA

Ap metastatice si din Lf cea maifrecventa cauza de masa mediast

Mediastin A si M 70% simptomatici (local/ general)

LH LMNH


44/83

GUSA PLONJANTA

10% din masele mediastinale

20% M

Simptome apar si in formele B

Rx, CT +/- scinti


45/83

MEDIASTIN ANTEROSUPERIOR

T timica , HT timica

Teratom (B, M), seminom

Limfom


46/83

TUMORI TIMICE

B/M

Mediastin AS

Cea mai frecventa T mediast primara

Decada 5-6, B=F, unilat Sdr paraneo

- miastenia gravis

- hipoglobulinemie

- aplazie eritrocitara

HT timica decade 1-2

Asociaza miastenia gravis, HTy, ICSR, acromegalie


47/83

TUMORI GERMINATIVE

Seminom voluminos, ant, stg, HCG

Teratom benign fete, voluminos, resturi

ectodemice

Teratom malign meta, creste repede


48/83


49/83

MEDIASTIN MIJLOCIU

Adenopatii - LH, neo bronsic, sin

- infectii (tbc)

- sarcoidoza Chist pericardic

Chist bronhogen

Anevrism Ao Hernia Morgagni


50/83

SARCOIDOZA

B granulomatoasa necazeoasa

Ap simetrice hilare/ mediastinale

Asimpt/simpt: astenie, tuse, dispnee,eritem nodos, uveita

Dg: biopsie cutanata/ ggl

Evolutie stationara/ remisie/progresiva


51/83

HERNIA MORGAGNI

3 M: medial, mature, minuscule

Femeie, obeza, de virsta medie

Mal formarea septului transvers

dr>stg

+/- defecte pericardice

Dispnee, tuse, simpt dig sup nespec

Complicatii: incarcerare


52/83

MEDIASTIN POSTERIOR

T neurogene (schwanom, neurofibrom,feocromocitom)

Anevrism Ao desc Diverticuli E (Zenker, epifrenici, interbronsici)

Carcinom esofagian

Hernii (de alunecare, paraesofagiana, Bogdaleck) Hematopoeza extramedulara

Pseudochist pancreatic


53/83


54/83

ANEVRISM DE AORTA

Crosa SVCS + pusatii si expansiunesuprasternala

Crosa si Ao asc comprima laringeulrecurent + osteita sternala

Ao desc disfagie + nevralgie ic + osteitavertebrala


55/83

HERNIA HIATALA

Cea mai frecventa

Nivel hidroaeric posterior de cord, de

obicei pe stg.


56/83

HERNIA BOGDALECK

- 3B : baby, back (posterolateral), big

- stg>dr

- Lipsa de inchidere a faldului pleuroperitoneal


57/83

SINDROMUL DE VCS

Dispnee, cefalee, obstructie nazala, tulburare deconstienta, coma

Edem, cianoza, circulatie colaterala, stridor, edem

papilar

Compresie

Invazie

Tromboza


58/83

SINDROMUL DE VCS

C pulmonar, LH, meta

Fibroza mediastinala

Anevrism de Ao

Histoplasmoza, TBC, lues T benigne

Tromboza (cateter venos central, pacemaker)

CT sediul/ mec obstructiei RMN vizualizeaza direct fluxul sangvin

Venografie circulatia colaterala


59/83

Venografie - sdr VCS


60/83

Anatomia VCS si a venelormediastinului


61/83

SINDROM MEDIASTINAL

Dispnee

Durere toracica

Disfagie Disfonie

Edem in pelerina

Cianoza in pelerina

Circulatie colaterala


62/83


63/83

Timom


64/83

LIMFOM


65/83


66/83


67/83

pneumomediastin


68/83

HH


69/83


70/83


71/83


72/83

ti


73/83

timom

timom


74/83

timom

Rest timic


75/83

Rest timic

pneumomediastin


76/83

pneumomediastin


77/83

Meta melanom


78/83

Meta melanom


79/83

Fibroza de iradiere


80/83

limfom

G l j t


81/83

Gusa plonjanta


82/83

T neurogena


83/83

Anevrism de aorta descendenta

Date post:	03-Apr-2018
Category:	Documents
Upload:	stefania-iulia-popescu
View:	379 times
Download:	5 times

Sindromul Mediastinal -Curs 2013

Documents