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Paulo Roberto Silveira
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Qui, 19 de Novembro de 2009 21:22
Escrito por Paulo Roberto Silveira

O QUE SÃO CRISES EPILETICAS GENERALIZADAS

As crises  epiléticas generalizadas podem manifestar-se sob forma convulsiva e não convulsiva.    Dentre as crises generalizadas convulsivas destacam-se, em primeiro plano, as crises tônico-clônicas, também denominadas “grande mal”. Tais crises, puderam ser minuciosamente analisadas mediante filmagem. Iniciam-se por algumas rápidas mioclonias que duram alguns segundos e se acompanham de um grito característico, a partir do qual a consciência torna-se completamente abolida, caindo o paciente ao solo, ocorrendo, às vezes, fraturas e contusões. Aparece, então, um espasmo tônico, com duração de 10 a 20 segundos, interessa a toda a musculatura esquelética e que determina uma série de atitudes características, segundo a seqüência de músculos acometidos.

De maneira geral, ocorre uma curta fase de flexão, seguida de uma longa fase em extensão, ambas se caracterizando por uma rigidez muscular completa. Segue-se a fase tônica vibratória, constituída por episódios de descontração muscular completa, interrompendo ritmicamente a contração tônica. Os intervalos de descontração  vão se espaçando e os movimentos clônicos vão desaparecendo. Desde o início da crise, inúmeras manifestações vegetativas podem ser observadas, tais como elevação da pressão arterial e a freqüência  cardíaca, bem como aumento da pressão intravesical, porém sem emissão de urina, nesta fase inicial, devido à contração simultânea dos esfíncteres. Observam-se ainda midríase, congestão cutânea com sudação e piloereção e, por fim, uma  hipersecreção glandular, principalmente salivar e tráqueo-brônquica. Terminada a fase clônica, surge uma nova fase tônica, com duração de 20 a 4 segundos, durante a qual pode novamente ocorrer trismo, como na primeira, com mordedura de língua. Verifica-se, em seguida, relaxamento esfincteriano, com emissão de urina e começam a regredir os fenômenos vegetativos. Normaliza-se a PA, desaparecem a taquicardia e a midríase e o coma vai se superficializando, retornando o indivíduo gradativamente à consciência. Ao final da crise, o paciente queixa, às vezes, de cefaléia intensa (apresentando uma amnésia lacunar total) ou cai em sono profundo. A duração da crise varia de 5 a 15 segundos, sem incluir o eventual sono pós-crise.

A crise tônica, antes denominada crise tetanóide ou crise tônica postural, ocorre com maior freqüência na infância, embora possa ser descrita em outras idades. Caracteriza-se por contração tônica completa não vibrató

ria cuja duração varia de alguns segundos a 1 minuto. Por ter início abrupto que acomete de maneira mais intensa, classifica-se em três variedades:  crise tônica axial, crise tônica axo-rizomélica e crise tônica global. Geralmente, ocorre uma perda de consciência apenas momentânea, porém há referências a casos em que surge estado confusional de curta duração após a crise, durante o qual se verificam automatismos.

A crise clônica é menos conhecida ainda que a crise tônica, aparecendo exclusivamente na primeira infância. Inicialmente, ocorre uma perda da consciência, com amiotonia, havendo, às vezes, breve espasmo tônico, antecedendo a queda. Iniciam-se então mioclonias  que variam em relação à freqüência, amplitude e topografia. Praticamente não há fenômenos vegetetativos, com exceção das crises mais longas, quando pode perdurar um estado comatoso ou confusional.

No curso de encefalopatias, de evolução subaguda ou crônica, eventualmente surgem mioclonias em tudo semelhantes às do pequeno mal, só se diferenciando deste por uma duração mais longa, maior reatividade aos estímulos sensoriais e por uma tendência a se repetir de maneira periódica.

Ainda mais específicos que as mioclonias são os denominados espasmos infantis. Ocorrem em lactentes que apresentam uma encefalopatia com hipsarritmia e se caracterizam por um espasmo tônico muito breve que predomina sobre os músculos flexores, repetindo-se ritimicamente a intervalos de 2 a 10 segundos. Recebem também a denominação de espasmo de reverência.

De formas generalizadas não convulsivas, destacam-se, em primeiro plano, as ausências típicas ou pequeno mal. Caracterizam-se por uma  “suspensão das funções psíquicas, com abolição da consciência e da memória”. Tais crises podem iniciar-se e terminar de maneira súbita e tem uma duração variável em geral de 5 a 15 segundos, chegando , eventualmente, a durar vários minutos. Durante este período, o paciente permanece parado, com o olhar vago e fixo, retomando seu gesto ou sua frase ao final da crise, como se nada houvesse acontecido, e sem se recordar do que ocorreu.

Em outros casos, não chega a haver abolição da consciência e pode persistir uma atividade automática que, freqüentemente, é confundida com os automatismos da epilepsia psicomotora temporal. As ausências se acompanham, às vezes, de fenômenos vegetativos (salivação, midríase, sudorese, rubor seguido de palidez etc.) e não apresentam aura. Pode ainda ocorrer uma queda súbita, como se houvesse um interferência sobre os mecanismos e manutenção do tônus postural. Em alguns casos, surgem movimentos mioclônicos nos membros superiores bilaterais e simétricos, bem como repentina flexão da cabeça ou do corpo, ou então os abalos mioclônicos se apresentam nas pálpebras (piscar rápido e sucessivo) ou em toda a face ou na musculatura cuticular do pescoço, observando-se também desvios dos globos oculares para cima. O EEG do pequeno mal é bem característico,  constituindo-se em um ritmo da ponta-onda, com freqüência de 3 c/seg.

Ao contrário das crianças acometidas de outras formas de epilepsia, especialmente daquelas do lobo temporal, no pequeno mal não há distúrbios de conduta e de ajustamento a elas costumam ser normais tanto física quanto intelectualmente.

Outras crises, freqüentemente  na infância e excepcionais nos adultos, são as denominadas crises atonicas. Caracterizam-se por uma perda súbita do tônus muscular e o paciente cai ao solo, recuperando-se imediatamente e retornando à sua atividade. Alguns casos sem perda de consciência.

Fato que deve ser colocado em evidência é que, tanto no grande mal como no pequeno mal, também chamadas epilepsias centrecefálicas, não existe aura, isto é, a perda da consciência é inicial e abrupta, não aparecendo os sintomas prévios que, em geral, indicam o caracter focal das crises. Dentre as auras, a mais freqüente é a aura epigástrica.

Estas auras tem grande valor diagnóstico para se precisar a topografia funcional  das descargas. São encontradas nas epilepsias focais ou parciais que, ao contrário das generalizadas, constituem grupo essencialmente complexo. Dependem da descarga de um setor específico e, do ponto de vista clínico, podem abarcar uma grande variedade de fenômenos (motores sensitivos, sensoriais, vegetativos e psíquicos).

 

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O(A) escritor(a) Paulo Roberto Silveira escreve para o Canto do Escritor desde Seg, 26 de Outubro de 2009.

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