Síndromes Meningeas e Hipertensão Intracraniana_Aula 4

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SÍNDROMES MENÍNGEAS E HIPERTENSÃO INTRACRANIANA 1
Síndromes meníngeas e
hipertensão intracraniana
Aula do professor Addison · 18 de setembro de 2026
Transcrição revisada, organizada em texto corrido e complementada com Bates | Propedêutica
Médica (13ª ed.).
Nota editorial: o conteúdo falado foi reconstituído a partir de uma transcrição automática com trechos
incompreensíveis. As falas paralelas foram retiradas; as explicações complementares e as correções de conduta
seguem as referências ao final. Esta versão é um texto didático revisado, não uma transcrição literal.
Síndrome meníngea: conceito e manifestações
A síndrome meníngea reúne manifestações decorrentes da irritação das meninges e do espaço
subaracnóideo. É uma descrição clínica, não um diagnóstico etiológico. Pode surgir em meningites
infecciosas, hemorragia subaracnóidea e outras condições inflamatórias ou infiltrativas, inclusive
neoplasias que acometem as leptomeninges. A apresentação depende da causa, da idade, do estado
imune e da evolução do quadro. A meningite é um processo inflamatório das meninges; por isso, não
se deve usar “síndrome meníngea” como sinônimo de meningite bacteriana. [1, 2]
Cefaleia, febre, rigidez de nuca, fotofobia, náuseas ou vômitos são pistas clínicas importantes.
Alteração do estado mental, convulsões e déficit neurológico focal aumentam a gravidade da
suspeita. A cefaleia súbita, de intensidade máxima em segundos ou minutos, sugere hemorragia
subaracnóidea e exige avaliação imediata. O vômito pode ocorrer sem náusea prévia em situações
de hipertensão intracraniana, mas a expressão “vômito em jato” não confirma um diagnóstico por si
só. A ausência de febre ou da tríade clássica não afasta meningite, especialmente em idosos ou
pessoas imunossuprimidas. [1–3]
Pesquisa dos sinais de irritação meníngea
Para pesquisar rigidez de nuca, primeiro considere a possibilidade de trauma ou lesão cervical. Com
o paciente deitado em decúbito dorsal e sem suspeita de instabilidade cervical, sustente a cabeça e
flexione delicadamente o pescoço em direção ao tórax. A resistência à flexão, acompanhada de
desconforto, pode indicar irritação meníngea. Dor ou limitação cervical por doenças
musculoesqueléticas também pode interferir no exame; por isso, o achado deve ser interpretado
com a história e os demais sinais. [1]
O sinal de Brudzinski é pesquisado durante a flexão passiva do pescoço: a flexão involuntária dos
quadris e dos joelhos constitui resposta positiva. No sinal de Kernig, flexionam-se inicialmente o
quadril e o joelho do paciente deitado e, em seguida, estende-se lentamente o joelho. Dor ou
resistência aumentada à extensão sugere irritação meníngea. Esses sinais têm sensibilidade
limitada: resultados negativos não excluem meningite. Também podem estar ausentes em idosos,
crianças pequenas e pessoas que receberam analgesia. [1]
É importante distinguir Kernig de Lasègue. No teste de elevação da perna estendida, ou Lasègue, o
examinador eleva o membro inferior mantendo o joelho estendido; a reprodução de dor irradiada
compatível com trajeto radicular sugere irritação de raiz lombossacra. Já em Kernig a coxa e o joelho
SÍNDROMES MENÍNGEAS E HIPERTENSÃO INTRACRANIANA 2
estão inicialmente flexionados, e o movimento testado é a extensão do joelho. Uma dor isolada na
face posterior da coxa, por encurtamento muscular, não equivale a um sinal meníngeo positivo. [1]
Hipertensão intracraniana: mecanismo e reconhecimento
O crânio contém parênquima encefálico, sangue e líquido cerebrospinal. Como o espaço
intracraniano tem pouca capacidade de expansão, o aumento de um desses componentes pode ser
compensado apenas até certo ponto; esgotada a compensação, a pressão intracraniana sobe.
Tumores, hematomas, edema cerebral e alterações da circulação do líquido cerebrospinal são
exemplos de causas. A pressão de perfusão cerebral resulta da diferença entre a pressão arterial
média e a pressão intracraniana (PPC = PAM − PIC). Quando a PIC aumenta muito, a perfusão
cerebral pode cair, com risco de isquemia e herniação. [1]
A suspeita clínica pode reunir cefaleia progressiva, piora com tosse, esforço ou decúbito, vômitos,
alteração do nível de consciência, diplopia e achados focais. O exame deve verificar sinais vitais,
estado mental, pupilas, motricidade, pares cranianos e fundo de olho quando possível. Papiledema
corresponde ao edema do disco óptico relacionado à elevação da pressão intracraniana; o
borramento de suas margens é um achado fundoscópico importante. Sua ausência, sobretudo em
quadros agudos, não exclui hipertensão intracraniana. Diplopia horizontal com limitação da abdução
pode ocorrer por paresia do VI nervo craniano, um possível sinal de aumento da pressão
intracraniana que não define, isoladamente, o local da lesão. [1]
A tríade de Cushing combina hipertensão arterial, bradicardia e irregularidade respiratória. Trata-se
de um sinal tardio de comprometimento neurológico grave: a elevação da PIC reduz a perfusão
encefálica, desencadeia resposta pressora, e a elevação da pressão arterial pode produzir
bradicardia reflexa; a evolução com disfunção do tronco encefálico altera o padrão respiratório. Não
se deve aguardar a tríade completa para reconhecer uma emergência. [1]
Hidrocefalia de pressão normal: distinção clínica
Na aula, a hidrocefalia de pressão normal foi citada para mostrar a importância de reunir sintomas
que parecem independentes. Sua apresentação típica inclui alteração da marcha, comprometimento
cognitivo e sintomas urinários, sobretudo urgência ou incontinência. A alteração da marcha
frequentemente é a manifestação mais evidente; a avaliação clínica e a neuroimagem ajudam a
reconhecer ventriculomegalia e selecionar a investigação apropriada. A designação “pressão
normal” não significa ausência de doença nem corresponde automaticamente ao quadro agudo de
hipertensão intracraniana descrito acima. A presença da tríade clínica também exige diagnóstico
diferencial com outras causas de alterações da marcha, cognição e continência. [1]
SÍNDROMES MENÍNGEAS E HIPERTENSÃO INTRACRANIANA 3
Punção lombar e neuroimagem na suspeita de meningite
A análise do líquido cerebrospinal é central para esclarecer a etiologia de uma meningite, mas a
decisão de fazer punção lombar exige avaliação clínica. A transcrição sugere tomografia antes de
toda punção; esse ponto precisa ser corrigido. As recomendações atuais não indicam neuroimagem
de rotina para todas as pessoas com suspeita de meningite. Ela deve preceder a punção em
situações selecionadas que sugiram risco de lesão expansiva ou herniação, como novos déficits
focais, convulsões com sinais preocupantes, resposta pupilar anormal ou rebaixamento importante
ou progressivo da consciência, conforme o protocolo clínico. Também é preciso considerar
contraindicações à punção, como instabilidade, infecção no local, distúrbios relevantes de
coagulação ou sinais de hipertensão intracraniana com risco de herniação. [2, 3]
O fundo de olho e o exame neurológico ajudam a identificar sinais de alerta; uma tomografia sem
achados de massa não torna a punção automaticamente segura quando a avaliação clínica continua
preocupante. Se a punção ou a neuroimagem atrasar, a coleta de hemoculturas quando viável e o
tratamento empírico de uma possível meningite bacteriana devem seguir a urgência das diretrizes,
sem aguardar o exame de imagem. A conduta concreta depende de idade, apresentação e
protocolos do serviço. [2, 3]
Leitura inicial da tomografia de crânio
Na tomografia, deve-se examinar a posição da linha média, o aspecto das cisternas da base, os
sulcos corticais, o tamanho dos ventrículos e a presença de assimetrias. Desvio da linha média,
apagamento das cisternas ou dos sulcos e deformação do sistema ventricular podem sugerir efeito
de massa ou edema. Os ventrículos podem estar comprimidos em alguns processos expansivos e
dilatados quando há hidrocefalia; a interpretação depende do contexto. Sinais de herniação
representam urgência neurológica. [1]
A escala de densidadeda tomografia também orienta a leitura: o osso e, em geral, o sangue
intracraniano agudo aparecem relativamente hiperdensos; o líquido cerebrospinal costuma ser
hipodenso. Edema e infarto isquêmico podem produzir áreas hipodensas, mas alterações muito
precoces da isquemia podem ser discretas ou ausentes. Assim, uma tomografia inicialmente sem
lesão evidente não exclui um AVC isquêmico precoce. A análise radiológica formal e a evolução
clínica permanecem essenciais. [1]
SÍNDROMES MENÍNGEAS E HIPERTENSÃO INTRACRANIANA 4
Escala de Coma de Glasgow e avaliação das pupilas
O nível de consciência deve ser descrito por observação seriada. A escala de Coma de Glasgow soma
três respostas: abertura ocular (E, de 1 a 4 pontos), resposta verbal (V, de 1 a 5) e resposta motora
(M, de 1 a 6). O total usual varia de 3 a 15; não existe Glasgow zero. É preferível registrar
componentes e total, por exemplo E3 V4 M6 = 13, pois a mesma soma pode resultar de
combinações clinicamente diferentes. Se algum componente não puder ser testado, como a resposta
verbal de uma pessoa intubada, registre “não testável” e o motivo; não atribua automaticamente a
pontuação mínima a uma resposta impossível de examinar. [1]
Na abertura ocular, 4 significa abertura espontânea; 3, ao chamado; 2, à pressão; e 1, nenhuma. Na
resposta verbal, 5 corresponde a pessoa orientada; 4, confusa; 3, palavras isoladas; 2, sons
incompreensíveis; e 1, nenhuma resposta. Na resposta motora, 6 indica obediência a comandos; 5,
localização do estímulo; 4, retirada ou flexão normal; 3, flexão anormal; 2, extensão anormal; e 1,
nenhuma resposta. O estímulo, quando necessário, deve ser padronizado e interrompido assim que a
resposta puder ser identificada. Flexão anormal e extensão anormal são achados distintos e têm
pontuações diferentes. [1]
Tamanho, simetria e reatividade pupilar são informações neurológicas adicionais fundamentais. Na
extensão denominada GCS-P, subtrai-se da soma Glasgow o número de pupilas sem resposta à luz:
zero, uma ou duas. A escala de Glasgow convencional continua sendo E + V + M; a avaliação pupilar
não é um quarto componente obrigatório de sua soma. A interpretação de Glasgow ≤ 8 deve motivar
avaliação imediata da capacidade de proteger a via aérea, junto com a ventilação, os reflexos, a
evolução clínica e a causa do rebaixamento, sem substituir o julgamento clínico por um número
isolado. [1]
Referências
[1] BICKLEY, Lynn S.; SZILAGYI, Peter G.; HOFFMAN, Richard M. Bates | Propedêutica Médica. 13. ed. Rio de Janeiro:
Guanabara Koogan, 2022. Especialmente os capítulos de olhos e sistema nervoso, exame de cefaleia e pesquisa de
sinais de irritação meníngea. Livro fornecido com a aula.
[2] WORLD HEALTH ORGANIZATION. WHO guidelines on meningitis diagnosis, treatment and care. Genebra: WHO,
2025. Disponível em: https://www.who.int/publications/i/item/9789240108042. Acesso em: 19 set. 2026.
[3] NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. Meningitis (bacterial) and meningococcal disease:
recognition, diagnosis and management. NICE guideline NG240, 2024. Disponível em:
https://www.nice.org.uk/guidance/ng240/chapter/recommendations. Acesso em: 19 set. 2026.
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