Brain hypostasis — promptly developing accumulation of liquid in cerebral fabrics without rendering adequate medical care leading to death. Makes a basis of a clinical picture gradually or quickly accruing deterioration in a condition of the patient and the deepening of disorders of consciousness which is followed by meningealny signs and a muscular atoniya. Confirm the diagnosis given to brain MPT or KT. Additional inspection is carried out for search of the reason of hypostasis. Therapy begins with dehydration and maintenance of metabolism of cerebral fabrics, is combined with treatment of a causal disease and purpose of symptomatic medicines. According to indications perhaps urgent (decompressive trepanation, a ventrikulostomiya) or delayed (removal of volume education, shunting) surgical treatment.
Swelling of a brain was described in 1865 by N. I. Pirogov. Today it became clear that hypostasis of a brain is not independent nosological unit, and represents again developing pathological process arising as a complication of a number of diseases. It should be noted that swelled any other body tissues — rather often found phenomenon which is not relating to urgentny states at all. In case of a brain, hypostasis is a zhizneugrozhayushchy state as, being in the closed skull space, cerebral fabrics have no opportunity to increase in volume and are squeezed. Owing to a brain hypostasis polietiologichnost, in the practice both experts in the field of neurology and neurosurgery, and traumatologists, a neonatology, oncologists, toxicologists face it.
Brain hypostasis reasons
Most often hypostasis of a brain develops when traumatizing or organic defeat of its fabrics. Treat such states: heavy ChMT (a brain bruise, a skull basis change, an intracerebral hematoma, a subduralny hematoma, diffusion aksonalny damage, brain operations), an extensive ischemic stroke, a hemorrhagic stroke, subarakhnoidalny hemorrhage and hemorrhage in ventricles, primary tumors of a brain (a medulloblastom, a gemangioblastom, an astrotsitoma, a glioma, etc.) and its metastatic defeat. Hypostasis of cerebral fabrics is possible as a complication of infectious diseases (encephalitis, meningitis) and purulent processes of a brain (a subduralny empiyema).
Along with intra cranial factors the anasarka which arose owing to heart failure, allergic reactions (Quincke, anaphylactic shock), sharp infections (toxoplasmosis, scarlet fever, swine flu, measles, parotitis), endogenous intoxications (swelled at the heavy course of diabetes, OPN, a liver failure), poisonings with various poisons and some medicines can lead to hypostasis of a brain.
In some cases hypostasis of a brain is observed at alcoholism that it is connected with sharply increased vascular permeability. At newborns hypostasis of a brain is caused by heavy toxicosis a pregnant, intra cranial patrimonial trauma, obvitiy an umbilical cord, long childbirth. The so-called "mountain" hypostasis of a brain which is result of too sharp ascent without necessary acclimatization occurs among fans of mountain sport.
Pathogenesis of hypostasis of a brain
As the main link in development of cerebral hypostasis microcirculator violations act. Originally they, as a rule, arise in the field of the center of defeat of brain fabric (the site of ischemia, an inflammation, a trauma, hemorrhage, a tumor). Local perifokalny hypostasis of a brain develops. In cases of severe damage of a brain, not performing timely treatment or lack of due effect of the last, there is a disorder of vascular regulation leading to total expansion of cerebral vessels and rise in intra vascular hydrostatic pressure. As a result a liquid part of blood propotevat through walls of vessels and impregnates cerebral fabric. Generalized hypostasis of a brain and its swelling develops.
In the process described above key components are vascular, circulator and fabric. As a vascular component the increased permeability of walls of brain vessels, circulator — arterial hypertension and expansion of vessels which lead to repeated increase in pressure in cerebral capillaries acts. Fabric the factor consists in tendency of tissues of brain at insufficiency of blood supply to accumulate liquid.
In limited space of a cranium of 80-85% of volume from 5 to 15% — on tserebrospinalny liquid (likvor) are the share of cerebral fabrics, about 6% are occupied by blood. At the adult normal intra cranial pressure in horizontal position varies within 3-15 mm of mercury. During sneezing or cough it for a while rises to 50 mm of mercury., what does not cause disorders of functioning of TsNS. Hypostasis of a brain is followed by quickly accruing increase in intra cranial pressure due to increase in volume of cerebral fabrics. There is a sdavleniye of vessels that aggravates microcirculator violations and ischemia of brain cages. Owing to metabolic violations, first of all a hypoxia, there is a mass death of neurons.
Besides, sharp intra cranial hypertensia can lead to dislocation of underlying cerebral structures and infringement of a trunk of a brain in a big occipital opening. Malfunction of the respiratory, cardiovascular and thermoregulatory centers which are in a trunk is the reason of many lethal outcomes.
Due to the features of pathogenesis hypostasis of a brain is subdivided into 4 types: vazogenny, cytotoxic, osmotic and interstitsialny. The most often found type is vazogenny hypostasis of a brain which cornerstone increase in permeability of a hematoencephalic barrier is. In pathogenesis the main role is played by transition of liquid from vessels in white brain substance. Vazogenny hypostasis arises perifokalno in a zone of a tumor, abscess, ischemia, surgery, etc.
Cytotoxic hypostasis of a brain is result of dysfunction of glial cages and violations in an osmoregulyation of membranes of neurons. Develops mainly in gray brain substance. Can act as its reasons: intoxications (including poisoning with cyanides and carbon monoxide), ischemic stroke, hypoxia, viral infections.
Osmotic hypostasis of a brain arises at increase in osmolarity of cerebral fabrics without violation of work of a hematoencephalic barrier. Arises at a gipervolemiya, a polidipsiya, drowning, metabolic encephalopathies, an inadequate hemodialysis. Interstitsialny hypostasis develops around cerebral ventricles at a propotevaniye through their walls of a liquid part of a likvor.
Brain hypostasis symptoms
The leading symptom of hypostasis of a brain is disorder of consciousness which can vary from an easy sopor to a coma. Increase of depth of violation of consciousness demonstrates progressing of hypostasis. It is possible that the consciousness loss different from a usual faint the duration will be a debut of clinical manifestations. Often progressing of hypostasis is followed by spasms which through a short period are replaced by a muscular atoniya. At survey obolochechny symptoms, characteristic of meningitis, come to light.
In cases when hypostasis of a brain arises against the background of the chronic or gradually developing sharp cerebral pathology, consciousness of patients in an initial stage can be kept. Then as the main complaint the intensive headache with nausea and vomiting acts, motive violations, visual frustration, a diskoordination of movements, a dizartriya, a hallucinatory syndrome are possible.
The terrible signs testifying to a brain trunk sdavleniye are: paradoxical breath (deep breaths along with superficial, variability of temporary intervals between breaths), sharp arterial hypotonia, instability of pulse, a hyperthermia over 40 °C. Existence of the dispersing squint and "floating" eyeballs speaks about dissociation of subcrustal structures from a cerebral cortex.
Diagnosis of hypostasis of a brain
The progressing deterioration in a condition of the patient and the increase of violation of consciousness which are followed by meningealny symptoms allows to suspect brain hypostasis to the neurologist. Confirmation of the diagnosis is possible by means of brain KT or MPT. Carrying out a diagnostic lyumbalny puncture is dangerous by dislocation of cerebral structures with a sdavleniye of a brain trunk in a big occipital opening. Collecting anamnestichesky data, assessment of the neurologic status, clinical and biochemical blood test, the analysis of results of the neurovisualizing research — allow to make the conclusion concerning the brain hypostasis reason.
As hypostasis of a brain is the ugrentny state demanding emergency medical service, its primary diagnostics has to occupy a minimum of time and be carried out in stationary conditions against the background of medical actions. Depending on a situation it is carried out in the conditions of intensive care unit or intensive care unit.
Treatment of hypostasis of a brain
Act as the priority directions in therapy of hypostasis of a brain: dehydration, improvement of cerebral metabolism, elimination of the prime cause of hypostasis and treatment of the accompanying symptoms. Dehydrational therapy aims at removal of excess of liquid from cerebral fabrics. It is carried out by intravenous infusions of a mannitol or other osmotic diuretics with the subsequent purpose of loopback diuretics (a torasemid, furosemide). Additional introduction of 25% of solution of magnesium of sulfate and 40% of solution of glucose exponentiates effect of diuretics and supplies cerebral neurons with nutrients. Application of a L-lysine of an estsinat which has ability to remove liquid is possible, though is not diuretic medicine.
For the purpose of improvement of cerebral metabolism oxygenotherapy (if necessary — IVL), a local hypothermia of the head, introduction of metabolites is carried out (a meksidola, a korteksina, a tsitikolina). Apply glucocorticosteroids (Prednisolonum, a hydrocortisone) to strengthening of a vascular wall and stabilization of cellular membranes.
Depending on a brain hypostasis etiology include dezintoksikatsionny actions, antibiotic treatment, removal of tumors, the elimination of hematomas and sites of a traumatic razmozzheniye of a brain shunting operations in its complex treatment (ventrikuloperitonealny drainage, a ventrikulotsisternostomiya, etc.). Etiotropny surgical treatment is carried out, as a rule, only against the background of stabilization of a condition of the patient.
Symptomatic therapy is directed to knocking over of separate displays of a disease, is performed by purpose of antivomitives, antikonvulsant, the anesthetizing medicines, etc. According to indications in an urgentny order for the purpose of reduction of intra cranial pressure by the neurosurgeon decompressive cranial trepanation, external ventrikulyarny drainage, endoscopic removal of a hematoma can be carried out.
Forecast of hypostasis of a brain
In an initial stage hypostasis of a brain represents reversible process, in process of progressing it leads to irreversible changes of brain structures — death of neurons and destruction of myelin fibers. Bystry development of the specified violations causes that completely it is possible to liquidate hypostasis from 100% restoration of brain functions only at its toxic genesis at the young and healthy patients in time brought to specialized office. Independent regression of symptoms is observed only at mountain hypostasis of a brain if timely transportation of the patient from height at which it developed was successful.
However in most cases at the survived patients the residual phenomena of the postponed brain hypostasis are observed. They can vary considerably from hardly noticeable to people around of symptoms (a headache, the increased intra cranial pressure, absent-mindedness, forgetfulness, sleep disorders, a depression) before the expressed invalidiziruyushchy disorders of cognitive and motive functions, the mental sphere.