Hydrocephalus in adults ("dropsy of the brain") is a pathological condition characterized by excessive accumulation of cerebrospinal fluid (cerebrospinal fluid) in cerebrospinal fluid spaces. Hydrocephalus may be an independent nosological unit, or it may be a consequence of a variety of brain diseases. It requires compulsory qualified treatment, since the prolonged existence of the disease can lead to disability and even death.
The disease in children is significantly different from the manifestations of the disease in the adult population due to the fact that in the child's body the brain is only being formed. In this article, we will examine the causes, symptoms and treatment of brain hydrocephalus in adults.
- 2Types of hydrocephalus
Each person in the brain has special spaces containing a special liquid - the cerebrospinal fluid. Inside the brain itself is the system of the ventricles of the brain communicating with each other, outside the brain is a subarachnoid space with brain cisterns. Liquor performs very important functions: it protects the brain from shocks, shocks and infectious agents (the latter due to the antibodies contained therein), nourishes the head the brain, is involved in the regulation of blood circulation in the enclosed space of the brain and skull, provides homeostasis due to optimal intracranial pressure.
The volume of liquor in an adult is 120-150 ml, several times a day it is updated. The production of cerebrospinal fluid occurs in the vascular plexuses of the ventricles of the brain. From the lateral ventricles of the brain (containing approximately 25 ml), the cerebrospinal fluid enters the third ventricle through the Monroe's opening, the volume of which is 5 ml. From the third ventricle, the cerebrospinal fluid moves into the fourth (also contains 5 ml) through the Sylvia aqueduct (brain drainage). At the bottom of the fourth ventricle there are holes: the median unpaired Magendi and two lateral Lyushka. Through these holes, the cerebrospinal fluid enters the subarachnoid space of the brain (located between the soft and spider webs of the brain). On the basal surface of the brain, the subarachnoid space expands, forming several cisterns: cavities filled with liquor. From the tanks, the liquor enters the outer (convective) surface of the brain, as if "washing" it from all sides.
Absorption (resorption) of cerebrospinal fluid occurs in the venous system of the brain through arachnoid cells and villi. A cluster of villi around venous sinuses is called pachyon granulation. Part of the liquor is absorbed into the lymphatic system at the level of the nerves.
Thus, the cerebrospinal fluid produced in the vascular plexuses within the brain, is washed on all sides and then absorbed into the venous system, this process is continuous. So the circulation is normal, the amount of fluid produced per day equals absorbed. If at any stage there are "problems" - either with products or with absorption, then there is hydrocephalus.
The causes of hydrocephalus can be:
- infectious diseases of the brain and its membranes - meningitis, encephalitis, ventriculitis;
- a brain tumor of a trunk or near-barrel localization, as well as of the ventricles of the brain);
- cardiovascular pathology of the brain, including subarachnoid and intraventricular hemorrhages due to rupture of aneurysms, arteriovenous malformations;
- encephalopathy (alcoholic, toxic, etc.);
- brain trauma and post-traumatic conditions;
- malformations of the nervous system (for example, Dandy-Walker syndrome, stenosis of the Sylvian aqueduct).
Types of hydrocephalus
Hydrocephalus can be congenital and acquired. Congenital, as a rule, manifests itself in childhood.
Depending on the mechanism of development, there are:
- closed (occlusive, non-communicating) hydrocephalus - when the cause is the disturbance of the CSF current due to the overlap (block) of the liquor-conducting pathways. More often the normal current of cerebrospinal fluid is prevented by a blood clot (due to intraventricular hemorrhage), part of a tumor or a spike;
- open (communicating, disrezorbtivnuyu) hydrocephalus - the basis is a violation of absorption in the venous system the brain at the level of arachnoid villi, cells, pachyon granulations, venous sinuses;
- hypersecretory hydrocephalus - with excessive production of cerebrospinal fluid by the plexus of the ventricles;
- external (mixed, ex vacuo) hydrocephalus - when the content of cerebrospinal fluid is increased in both the ventricles of the brain and in the subarachnoid space. In recent years, this form has ceased to be attributed to hydrocephalus, since the reason for an increase in the content of CSF consists of in the atrophy of the brain tissue and the reduction of the brain itself, and not in violation of the circulation of the cerebrospinal fluid.
Depending on the level of intracranial pressure, hydrocephalus may be:
- hypertensive - with increased pressure of cerebrospinal fluid;
- normotensive - at normal pressure;
- hypotensive - with reduced pressure of the cerebrospinal fluid.
By the time of emergence:
- acute hydrocephalus - the period of development of the process is up to 3 days;
- subacute progredient - develops within a month (some authors consider the term at 21 days);
- chronic - from 3 weeks to 6 months and above.
The clinical picture depends on the period of formation of hydrocephalus and the level of pressure of cerebrospinal fluid, the mechanism of development.
In acute and subacute occlusal hydrocephalus, a person complains of a headache, more pronounced in morning hours (especially after sleep), accompanied by nausea and sometimes vomiting, bringing relief. There is a feeling of pressure on the eyeballs from the inside, there is a burning sensation, "sand" in the eyes, the pain is bursting. Possible injection of vessels sclera.
As the pressure of the CSF increases, drowsiness joins, which is a poor prognostic sign, since it indicates an increase in symptoms and threatens to lose consciousness.
Possible deterioration of vision, a sense of "fog" before your eyes. On the eyeground, stagnant discs of optic nerves are revealed.
If the patient does not seek medical help on time, the continued increase in the content of the cerebrospinal fluid and intracranial pressure will lead to the development of a dislocation syndrome - a life-threatening condition. It manifests itself by the rapid suppression of consciousness right up to the coma, the upward gaze, the diverging strabismus, the oppression of the reflexes. These symptoms are typical for the compression of the midbrain. When there is compression of the medulla oblongata, symptoms of swallowing disorders appear, the voice changes (until unconscious), and then heart activity and respiration are inhibited, which leads to the death of the patient.
Chronic hydrocephalus often communicates with normal or slightly elevated intracranial pressure. It develops gradually, in months after the causative factor. At first, the cyclicity of sleep is disturbed, either insomnia or drowsiness appears. Memory worsens, lethargy, fast fatigue. General asthenia is typical. As the disease progresses, mnestic (cognitive) disorders are aggravated until dementia in neglected cases. Patients can not independently service themselves and behave inadequately.
The second typical symptom of chronic hydrocephalus is a violation of walking. At first the gait changes - it becomes slower, unstable. Then uncertainty is attached when standing, difficulty in starting movement. In the supine or sitting position, the patient can simulate walking, riding a bicycle, but in an upright position this ability is instantly lost. The gait becomes "magnetic" - the patient is glued to the floor, but, moving from the place, makes small shuffling steps on widely spaced legs, staggers on the spot. These changes are called "apraxia walk." Increases muscle tone, in neglected cases, decreases muscle strength, and there are paresis in the legs. Balance disorders also tend to progress, up to the inability to stand or sit alone.
Often patients with chronic hydrocephalus complain of frequent urination, especially at night. Gradually, the imperative urges to urinate, requiring immediate evacuation, and then incontinence at all.
The main role in establishing the diagnosis belongs to computed tomography (CT) and magnetic resonance imaging (MRI). These methods allow to determine the shape and size of the ventricles, subarachnoid space, brain cisterns.
Radiography of cisterns of the base of the brain allows to evaluate the direction of the CSF current and to specify the type of hydrocephalus.
It is possible to carry out a test diagnostic lumbar puncture with the removal of 30-50 ml of CSF, which is accompanied by a temporary improvement in the condition. This is due to the restoration of blood supply to the ischemic brain tissue against the background of a decrease in intracranial pressure. This serves as a favorable prognostic sign when predicting surgical treatment of hydrocephalus. It should be noted that in acute hydrocephalus, lumbar puncture is contraindicated because of the high risk of brainstem damage and the development of a dislocation syndrome.
The initial stages of hydrocephalus can be treated medically. For this, the following drugs are used:
- to reduce intracranial pressure and eliminate excess fluid (provided that the outflow of CSF is preserved) - diacarb (acetazolamide), mannitol and mannitol in combination with furosemide or lasix. Obligatory with such treatment is the correction of the level of potassium in the body, for this use asparks (panangin);
- To improve the supply of brain tissue, Cavinton (vinpocetine), actovegin (solcoseryl), gliatilin, choline, cortexin, cerebrolysin, Semax, memoplant, etc. are shown.
Clinically deployed hydrocephalus is subject to surgical treatment, medicamental methods improve the condition for a short while.
Acute hydrocephalus, as a life threatening condition, requires urgent neurosurgical treatment. It consists in trepanation of the skull and the imposition of external drains, which provide the outflow of excess fluid. This is called external ventricular drainage. In addition, the introduction of drugs that dilute blood clots (as intraventricular hemorrhage is one of the most frequent causes of acute hydrocephalus) is possible through the drainage system.
Chronic hydrocephalus requires carrying out liquor-shunting operations. This type of surgical treatment is the withdrawal of excess cerebrospinal fluid into the natural cavities of the human body through a complex system of catheters and valves (abdominal cavity, pelvic cavity, atria, etc.): ventriculoperitoneal, ventriculoatrial, cysteritoneal bypass. In the body cavities there is an unobstructed absorption of excess CSF. These operations are rather traumatic, however, with a competent execution they allow to achieve recovery of patients, their labor and social rehabilitation.
To date, the less traumatic neuroendoscopic technique has become the first among the invasive methods of treatment. It is more often performed abroad due to the high cost of the operation itself. This method is called this: endoscopic ventriculocisternostomy of the bottom of the third ventricle. The operation lasts only 20 minutes. With this method of treatment, a surgical instrument with a neuroendoscope (camera) at the end is inserted into the ventricles of the brain. The camera allows you to demonstrate the image with a projector and accurately monitor all manipulations. At the bottom of the third ventricle, an additional opening is created that connects to the cisterns of the base of the brain, thus eliminating the cause of hydrocephalus. Thus, as it were, the physiological liquor is restored between the ventricles and cisterns.
Hydrocephalus is a dangerous disease, ignoring the symptoms of which is fraught with a disability or even a threat to life. The fact is that the changes that occur in the brain as a result of the long existence of hydrocephalus are irreversible.
Untimely treatment can turn into a tragedy for a person: loss of ability to work and social significance. Mental disorders, movement problems, urination disorders, decreased vision, hearing, epileptic seizures - this is the list of possible consequences of hydrocephalus, if not timely start its treatment. Therefore, with the slightest suspicion of hydrocephalus, you should seek qualified medical help.
TVC, the program "Doctors" on the theme "Hydrocephalus"
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