What is hydrocephalus of the brain in adults? Hydrocephalus in children: only the facts Pathogenetic factors of the syndrome

Hydrocephalic syndrome (HS) is a pathological condition caused by hypersecretion, malabsorption and discirculation of cerebrospinal fluid. As a result of such changes, cerebrospinal fluid accumulates in the ventricles of the brain and between its membranes. This leads to increased pressure in the venous sinuses, epidural and subarachnoid spaces. The stretched ventricles of the brain become inflamed, and the head circumference increases. More often this condition develops in infants, less often in adolescents and adults.

The cause of hydrocephalic syndrome in infants is perinatal damage to the central nervous system caused by hypoxia, infection, and birth injuries. The syndrome has an ICD-10 code G91 and the name “Hydrocephalus”. In modern neonatology it is called cerebrovascular distension syndrome. This is a fairly rare disease, the diagnosis and treatment of which is carried out by pediatric neurologists and pediatricians. Children's appetite worsens, tremors and convulsions occur in the upper extremities, they lag behind their peers in psychophysical and speech development.

Depending on the age of the patients, GS of newborns, GS of children and GS of adults are distinguished. HS occurs predominantly in newborns suffering from perinatal encephalopathy. With absence timely treatment the syndrome progresses and transforms into an organic brain disease - hydrocephalus.

Etiology

All etiopathogenetic factors of HS are divided into two large groups– congenital and acquired.

Congenital causes of hydrocephalic syndrome include:

• Perinatal hypoxia,
• Intrauterine intoxication with alcohol or medications,
• cerebral ischemia,
• Birth head injuries
• Hemorrhage into the subarachnoid space,
• Intrauterine infection of viral or bacterial etiology,
• Congenital toxoplasmosis,
• Congenital malformations of the brain.

Among the acquired reasons:

Idiopathic syndrome develops in cases where it is impossible to identify its cause.

There are risk factors that contribute to the development of pathology in newborns:

• toxicosis in a pregnant woman - preeclampsia, eclampsia,
• arterial hypertension in the expectant mother,
• drinking alcohol during pregnancy,
• childbirth up to 36 weeks,
• delayed birth - after 42 weeks,
• long stay of the fetus in the womb without water,
• multiple pregnancy,
• chronic maternal pathologies - diabetes mellitus, hypo- or hyperthyroidism, collagenosis,
• mother's age is more than 40 years,
• hereditary predisposition.

Liquor is actively produced by the choroid plexus of the ventricles of the brain, ependyma and meninges. Passive production of cerebrospinal fluid occurs as a result of changes in osmotic pressure and the movement of ions outside the vascular bed.

Liquor is absorbed by the cells of the arachnoid membrane, the vascular elements of the membranes of the brain and spinal cord, ependyma, parenchyma, and connective tissue fibers running along the cranial and spinal nerves.

Mechanisms providing liquor flow:

1. hydrostatic pressure drop,
2. the process of secretion of cerebrospinal fluid,
3. movement of ependymal villi,
4. cerebral pulsation.

The pathogenesis of hydrocephalic syndrome is based on the processes of obstruction and obstruction of the cerebrospinal fluid pathways with impaired reabsorption of cerebrospinal fluid.

Pathogenetic factors of the syndrome:

• Overproduction of cerebrospinal fluid in the brain,
• Accumulation of cerebrospinal fluid,
• Enlargement of the ventricles of the brain
• Penetration of cerebrospinal fluid into the medulla,
• Scar formation in brain tissue.

The amount of cerebrospinal fluid in the skull changes when the balance between its production and absorption is disturbed. The accumulation of cerebrospinal fluid in the ventricles of the brain occurs due to the formation of obstacles to its normal outflow. If left untreated, death can occur.

Symptoms

Clinical signs of hydrocephalus syndrome differ in newborns, older children and adults. The symptoms of the disease depend on the individual sensitivity of the body to changes in cerebrospinal fluid pressure and the general condition of the patients.

In children

Affected children are born in serious condition and have a low Apgar score. Acute development of the syndrome in infants is manifested by restlessness, crying, vomiting and confusion. A sick child does not take the breast well, screams and moans for no reason. In patients, the volume of the head quickly increases, the venous vessels on the head expand, the sutures of the skull diverge, the fontanel tenses, muscle tone decreases, innate reflexes weaken, tremors and convulsions appear, horizontal nystagmus, convergent strabismus is observed, and regurgitation is possible in a fountain. The gradual onset is characterized by a delay in the child’s psychophysical development.

Experts note a monthly increase in head circumference of 1-2 cm. The head of newborns takes on a specific shape - with an overhanging occiput or large frontal bumps. Enlargement and deformation of a child's head can be seen with the naked eye. When examining the fundus of the eye, swelling of the optic disc is detected. Reaction decreases eyeballs to the stimulus, which sooner or later leads to complete blindness. Blood vessels are visible through the overstretched scalp. The bones of the deformed skull become thinner. Newborns experience incoordination of movements. Sick children cannot sit, crawl or hold their head up. Their psycho-emotional development is inhibited.

If left untreated, the syndrome is complicated by atrophy of brain tissue. In patients, the functions of the musculoskeletal system are first impaired, and then the visual analyzer and the thyroid gland. Gradually, sick children begin to lag behind their peers in development, and they develop mental disorders of varying severity.

In adults

In adults, a sudden dull and aching sensation occurs headache in the area of ​​the temples and forehead, tinnitus, paroxysmal dizziness, temporary disorientation in space, vomiting in the morning, limb cramps, gait disturbance. They sleep restlessly, often shudder in their sleep, are overly excited or lethargic, apathetic. Violations of the emotional-volitional sphere range from emotional instability, neurasthenia, causeless euphoria to complete indifference and apathy. In some cases, episodic psychoses with hallucinatory or delusional syndrome are observed. With a sharp increase in intracranial pressure, aggressive behavior is possible. The head becomes large due to chronic hypertension. Full-blooded blood vessels are clearly visible on it - the venous pattern is enhanced.

Pain in the neck, nausea, diplopia, a feeling of pressure on the eyes, blurred vision, loss of visual fields, and urinary incontinence may occur. Patients find it difficult to raise their eyes and lower their heads. Their skin turns pale, weakness and lethargy, lethargy, absent-mindedness, drowsiness, hypertonicity of the leg muscles, and squint occur. The thinking process slows down, memory and attention are impaired, and an inadequate reaction to bright light and loud sound occurs. Possible confusion of consciousness up to the development of a coma.

During hydrocephalic syndrome, two options are possible:

• a favorable outcome of the pathology, which was based only on functional disorders - complete disappearance of symptoms within a year or their gradual regression,
• unfavorable outcome - increased symptoms and the formation of a picture of organic brain damage with the development of hydrocephalus.

Complications of HS in children:

1. epilepsy,
2. violation of general development,
3. delayed psychophysical development,
4. loss of hearing and vision,
5. coma,
6. paralysis,
7. difficulty moving,
8. urinary and fecal incontinence,
9. brain atrophy,
10. dementia,
11. weakness of the muscles of the arms and legs,
12. thermoregulation disorder,
13. violation of fat and carbohydrate metabolism,
14. death.

If treatment is started in a timely manner, severe consequences do not develop, and the prognosis of the syndrome is considered quite favorable. In the absence of medical care, disturbances occur in all vital systems of the body. The child ceases to see, hear and understand normally. In sick children, hydrocephalus develops by the age of one year. In case of exacerbation of the disease, the risk of death is high.

The body’s powerful compensatory capabilities make it possible to achieve stabilization of the process by 2 years. Complete recovery without consequences is observed in 30% of cases.

Diagnostics

To make a correct diagnosis, specialists only need to examine the child and listen to the parents’ complaints. The symptoms of the pathology are so typical that they cannot be confirmed by the results of additional techniques. Newborns and infants have their head circumference measured and their reflexes checked regularly. Deviation of anthropometric data from age norms is an important sign of the formation of hydrocephalus.

Specialists examine the brain to determine the degree and form of the disease. For this purpose the following is carried out:

• radiography,
• electroencephalography,
• echoencephalography,
• rheoencephalography,
• neurosonography,
• tomography,
• dopplerography of cerebral vessels,
• ophthalmoscopy, determination of visual acuity, perimetry,
• PCR diagnostics to determine the type of infection that caused the syndrome.

severe hydrocephalus on MRI

Doctors evaluate the vessels of the fundus for the presence of spasm, congestion, and edema. Lumbar puncture allows you to take cerebrospinal fluid and study it cellular composition and measure the pressure. In patients with hydrocephalus syndrome, cerebrospinal fluid leaks quickly and contains red blood cells and macrophages.

More detailed information can be obtained using nuclear magnetic resonance. This method provides a clear image of brain structures and accurately identifies existing abnormalities.

Treatment

Treatment of hydrocephalic syndrome is carried out in a neurological hospital by specialists in the field of neurology, neurosurgery, ophthalmology and psychiatry.

Drug therapy consists of prescribing the following groups of drugs:

1. Diuretics that facilitate the removal of fluid from the body and increase the amount of urine excreted - Furosemide, Diacarb, Veroshpiron;
2. Drugs that improve brain trophism and have metabolic, neuroprotective, antihypoxic and microcirculatory effects - “Cortexin”, “Actovegin”, “Curantil”;
3. Nootropic drugs - neurometabolic stimulants that have a specific effect on higher mental functions of the brain - Piracetam, Phezam, Vinpocetine;
4. Drugs that dilate blood vessels and improve cerebral circulation - “Cinnarizine”, “Drotaverine”;
5. Anticoagulants and antiplatelet agents that thin the blood and prevent the formation of blood clots - Ecotrin, Warfarin, Clexane;
6. Venotonics that improve the condition of the vascular wall of capillaries and reduce their permeability - “Detralex”, “Phlebodia”;
7. Sedative drugs that have anxiolytic, anticonvulsant, muscle relaxant effects - “Diazepam”, “Relanium”, “Seduxen”;
8. Multivitamin complexes.

This standard treatment regimen is supplemented with other medications depending on the etiology. If the cause of the syndrome is an infectious disease, antibiotics and antiviral drugs are prescribed. If there is a tumor in the brain, treatment is carried out with cytostatics - Methotrexate, Cyclosporine. After the acute effects have subsided, they resort to non-drug interventions: patients are prescribed a course of physiotherapy, including general massage and physical therapy. These procedures are performed only by specially trained doctors who have experience working with sick children. Patients are offered speech therapy and correctional classes, assistance from a speech pathologist, psychologist, and psychotherapist. They are prohibited from strenuous physical activity, watching TV, computer games, loud music.

Spinal puncture has a therapeutic effect in case of acute deterioration of the patient's condition. Surgical treatment is carried out to correct congenital anomalies of the cerebrospinal fluid system and restore the outflow of cerebrospinal fluid from the cranial cavity. If the cause of the syndrome is a neoplasm, it is removed surgically. Surgery is also indicated for TBI. According to indications, intracranial hematomas are removed, abscesses are opened, and adhesions in arachnoiditis are dissected.

If the cause of the syndrome is unknown, shunting and drainage operations are performed:

Prevention and prognosis

1. prepare for pregnancy planning,
2. carry out the prevention of neuroinfectious diseases,
3. avoid conflicts, stress and psycho-emotional disorders,
4. do not overwork, get proper rest,
5. promptly treat infectious and inflammatory diseases,
6. to refuse from bad habits,
7. Healthy food.

The prognosis of HS is ambiguous. It depends on the cause of the disease, the timeliness and adequacy of therapy, the age and condition of the patient. Children with the syndrome may have disabilities, but the level of impairment may remain mild. In infants, the prognosis of the pathology is most favorable, since their transient increases in blood pressure and cerebrospinal fluid stabilize with age.

Hydrocephalic syndrome is a serious prerequisite for the development of severe consequences in patients. A late detected disease without properly prescribed treatment leads to complications and even death.

Video: about hydrocephalic syndrome in children

Sylvian water pipeline:

• anomaly
• congenital obstruction
• stenosis

In Russia International classification of diseases of the 10th revision (ICD-10) was adopted as a single normative document for recording morbidity, reasons for the population’s visits to medical institutions of all departments, and causes of death.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170

The release of a new revision (ICD-11) is planned by WHO in 2017-2018.

With changes and additions from WHO.

Processing and translation of changes © mkb-10.com

Congenital hydrocephalus

Includes: hydrocephalus of the newborn

Excluded:

• Arnold-Chiari syndrome (Q07.0)
• hydrocephalus:
  • acquired NOS (G91.-)
  • acquired in newborn (P91.7)
  • caused by congenital toxoplasmosis (P37.1)
  • in combination with spina bifida (Q05.0-Q05.4)

Congenital defect of the aqueduct of Sylvius

Sylvian water pipeline:

• anomaly
• congenital obstruction
• stenosis

Hydrocephalus

Hydrocephalus: A Brief Description

Hydrocephalus (dropsy of the brain) - excessive accumulation of cerebrospinal fluid in the ventricles of the brain and intrathecal spaces; manifested by symptoms of increased ICP. It occurs due to an imbalance between the formation and absorption of cerebrospinal fluid: less is absorbed than is formed. The cause may be an obstructive process in the ventricles or in the subarachnoid space, less often - true hyperproduction of cerebrospinal fluid (with villous plexus papilloma) Characterized by excessive accumulation of cerebrospinal fluid in the ventricles of the brain or subarachnoid space with their expansion In newborns, it leads to an increase in the size of the skull and brain atrophy (decreased metabolism in adjacent areas of the brain).

Classification

Non-communicating (obstructive) hydrocephalus is caused by a process that causes blockage of the ventricular system Acquired hydrocephalus Tumors of the IV ventricle (medulloblastoma, ependymoma - all ventricles are dilated) and the aqueduct of Sylvius (glioma of the midbrain tegmentum - the lateral and III ventricles are dilated, but the size of the IV ventricle is not changed) Fibrosis of the arachnoid membrane due to meningitis or intraventricular hemorrhage Congenital hydrocephalus Stenosis of the aqueduct of Sylvius in the presence of a septum and true narrowing (#307000, Xq28, L1 cell adhesion molecule gene L1CAM, À). Congenital stenosis is characterized by a small size of the posterior cranial fossa. Dandy–Walker syndrome is congenital atresia of the foramina of Magendie and Luschka. Characterized by cystic dilatation of the IV ventricle and cerebellar hypoplasia Aneurysms of the vein of Galen (v. cerebri magna - Galeni) and other vascular malformations Benign intracranial cysts (arachnoid and ependymal) X-linked hydrocephalus is a rare form of congenital hydrocephalus in men.

Communicating (non-obstructive) hydrocephalus occurs when there is an obstruction in the cerebrospinal fluid circulation pathways distal to the exit from the fourth ventricle and at the level of pachion granulations Acquired Inflammation of the arachnoid membrane during meningitis and as a result of intraventricular hemorrhage (most often with birth trauma and in premature infants) Vein thrombosis, stenosis of the dura mater sinuses membrane Trauma accompanied by subarachnoid hemorrhage, followed by inflammation of the arachnoid membrane Normotensive hydrocephalus Congenital Inflammation of the arachnoid membrane - intrauterine infection Encephalocele Agyria - developmental anomaly: absence of cortical convolutions cerebral hemispheres brain; the cranial cavity is filled with cerebrospinal fluid.

According to the predominant accumulation of cerebrospinal fluid Internal (ventricular) hydrocephalus - hydrocephalus, characterized by the accumulation of cerebrospinal fluid mainly in the ventricles of the brain External hydrocephalus - hydrocephalus with accumulation of cerebrospinal fluid predominantly in the subarachnoid space or (less often) in the subdural space in the presence of communication between the subarachnoid and subdural spaces General hydrocephalus - hydrocephalus with accumulation of cerebrospinal fluid both in the ventricles and in the subarachnoid space.

Hydrocephalus: Signs, Symptoms

Clinical picture

Hydrocephalus: Diagnosis

Research methods

Differential diagnosis

Hydrocephalus: Treatment Methods

Treatment

Types of operations Shunting cerebrospinal fluid into the body cavity Creating a communication between the ventricular system and the subarachnoid space

Conservative treatment

Complications

Forecast

ICD-10 G91 Hydrocephalus O33. 6 Fetal hydrocephalus leading to disproportion requiring maternal medical care Q03 Congenital hydrocephalus

Application. Normotensive hydrocephalus develops in adult patients with insufficient absorption of cerebrospinal fluid by pachion granulations, which allows the pressure to remain within physiological limits. It occurs as a result of subarachnoid hemorrhage or meningitis, sometimes appearing after several years.

Types of hydrocephalus

Hydrocephalus (ICD code 10 G91) is a disease of the central nervous system, which is accompanied by the accumulation of excess cerebrospinal fluid in the ventricles or spaces between the membranes of the brain. The disease does not always manifest itself with symptoms of increased intracranial pressure. At the Yusupov Hospital, doctors use innovative methods for diagnosing hydrocephalus using modern devices from leading companies in Europe, the USA and Japan. Neurologists prescribe individual treatment depending on the cause, type and severity of hydrocephalus.

All complex cases of the disease are discussed at a meeting of the expert council with the participation of candidates and doctors of medical sciences, neurologists highest category, who are leading experts in the field of diseases of the central nervous system. Patients requiring surgical treatment are consulted by neurosurgeons. Surgical interventions are performed in partner clinics. The staff of the neurology clinic is highly professional and attentive to the wishes of patients.

Causes of hydrocephalus

Hydrocephalus can be congenital or acquired. Congenital hydrocephalus debuts in childhood. Acquired hydrocephalus occurs under the influence of various provoking factors.

Depending on the mechanism of development of the disease, there are 3 main forms of hydrocephalus:

• occlusive hydrocephalus (ICD 10 code - G91.8);
• communicating (open, disresorptive) hydrocephalus (code G91.0);
• hypersecretory hydrocephalus (code G91.8 - other types of hydrocephalus).

Disruption of the flow of cerebrospinal fluid in occlusive (closed, non-communicating) hydrocephalus occurs due to the closure (occlusion) of the cerebrospinal fluid pathways by a blood clot, a voluminous neoplasm, or an adhesive process that develops after inflammation. If the blockage occurs at the level of the ventricular system (Aqueduct of Sylvius, foramen of Monroe, foramina of Magendie and Luschka), proximal occlusive hydrocephalus occurs. If the block in the path of cerebrospinal fluid flow is at the level of the basal cisterns, a distal form of occlusive hydrocephalus develops. Communicating (open, disresorptive) hydrocephalus occurs when the processes of reabsorption of cerebrospinal fluid are disrupted, due to damage to the structures involved in the resorption of cerebrospinal fluid into the venous bed (Pachionian granulations, arachnoid villi, cells, venous sinuses). Hypersecretory hydrocephalus develops due to excess production of cerebrospinal fluid.

Based on the rate of progression of the disease, there are 3 forms of the disease:

• acute hydrocephalus, when no more than 3 days pass from the first symptoms of the disease to severe decompensation.
• subacute progressive hydrocephalus, developing within a month from the onset of the disease;
• chronic hydrocephalus, which develops within a period of 3 weeks to 6 months.

Depending on the level of cerebrospinal fluid pressure, hydrocephalus is divided into the following groups: hypertensive, normotensive, hypotensive. In hypertensive hydrocephalus, intracranial pressure is increased, in the case of hypotensive hydrocephalus, it is decreased. Normal pressure hydrocephalus (ICD code 10 – G91.2) is accompanied by normal values ​​of cerebrospinal fluid pressure.

Hydrocephalus can develop after traumatic brain injury and various diseases. Hydrocephalus is formed due to the following diseases of the central nervous system:

• brain tumors localized in the brain stem or ventricles;
• acute cerebrovascular accidents;
• subarachnoid and intraventricular hemorrhages;
• encephalopathy of various origins (chronic hypoxic conditions, alcohol intoxication).

Elderly people often develop replacement hydrocephalus. Its cause is atrophy of brain tissue. When the volume of the brain decreases, the vacated space is filled with cerebrospinal fluid. Background diseases that provoke the development of hydrocephalus are arterial hypertension and diabetes mellitus. In case of thrombosis of cerebral vessels, the outflow of cerebrospinal fluid is blocked and hydrocephalus occurs. Intracranial pressure increases and hydrocephalus develops with instability of the cervical spine.

In the neurology clinic of the Yusupov Hospital, the priority is the diagnosis and treatment of acute and chronic hydrocephalus in non-traumatic subarachnoid hemorrhages due to disruption of arteriovenous connections and rupture of arterial vascular aneurysms, post-traumatic hydrocephalus.

Symptoms and diagnosis of hydrocephalus

Acutely developed occlusive hydrocephalus is manifested by symptoms of increased intracranial pressure:

• headache;
• nausea and vomiting;
• drowsiness;
• congestion of the optic discs;
• symptoms of axial displacement of the brain.

Headache is most pronounced upon awakening in the morning due to an additional increase in intracranial pressure during sleep. This is facilitated by the expansion of cerebral vessels due to the accumulation of carbon dioxide, which is accompanied by blood flow, stretching dura shell brain in the area of ​​the base of the skull and the walls of blood vessels. Nausea and vomiting worsen and sometimes lead to a decrease in headaches. The most dangerous sign of increased intracranial pressure is drowsiness. It appears on the eve of a sharp and rapid deterioration of neurological symptoms.

With increased pressure in the subarachnoid space, congestion of the optic discs develops. Manifestations of dislocation syndrome are rapid depression of the patient’s consciousness to a deep coma, oculomotor disorders, and forced head position. When the medulla oblongata is compressed, breathing and cardiac activity are inhibited.

The main signs of chronic dysresorptive hydrocephalus are a triad of symptoms: dementia, paresis of both lower extremities and impaired walking, urinary incontinence. The first symptoms appear 3 weeks after a traumatic brain injury, hemorrhage, or meningitis. Initially, the sleep cycle is disrupted - patients become drowsy during the day with disturbances in night sleep. Over time, their overall activity level drops sharply. Patients become spontaneous, lacking initiative, and inert. Short-term memory is impaired, patients lose the ability to remember numbers. In the later stages of the disease, intelligence is impaired, patients cannot take care of themselves, they answer questions asked inadequately, in monosyllables with long pauses.

Walking impairment is manifested by apraxia. The patient can freely pretend to walk or ride a bicycle in a lying position, but in an upright position this ability is immediately lost. A person walks uncertainly, with his legs spread wide apart, and his gait becomes shuffling. In the later stages of hydrocephalus, paresis of the lower extremities develops. The most late and variable symptom is urinary incontinence.

Neurologists at the Yusupov Hospital diagnose occlusive hydrocephalus using computed tomography and magnetic resonance imaging. In chronic dysresorptive hydrocephalus, tomograms reveal a symmetrical expansion of the ventricular system with a balloon-like enlargement of the anterior horns, the subarachnoid fissures are not visualized, and there is a diffuse bilateral change in the white matter of the cerebral hemispheres in the form of a decrease in its density, most often around the lateral ventricles. Computed tomography also makes it possible to clarify the presence and extent of concomitant ischemic brain damage in patients with subarachnoid hemorrhages.

Patients undergo a lumbar puncture and at least 40 ml of cerebrospinal fluid are removed. She is sent to the laboratory for research. Improvement in patients' condition after the procedure is a good predictor of the patient's recovery after surgery.

Treatment of hydrocephalus

With an advanced clinical picture of the disease conservative treatment ineffective. Patients at the Yusupov Hospital are consulted by a neurosurgeon to decide on immediate neurosurgical intervention. In case of hemorrhage and thrombosis, the operation consists of applying external ventricular drains followed by the introduction of streptokinase into the ventricular cavity - a drug that dissolves blood clots and thereby ensures normal outflow of cerebrospinal fluid.

If the symptoms of chronic hydrocephalus do not progress in patients, they are prescribed diuretics - diacarb, mannitol, furosemide or lasix. To prevent hypokalemia, patients take asparkam. When the symptoms of occlusive hydrocephalus increase, neurosurgeons perform shunt operations. Timely surgical intervention for hydrocephalus allows for the recovery of all patients. Currently, neurosurgeons prefer to perform endoscopic operations for hydrocephalus.

If you have signs of occlusive hydrocephalus, call the Yusupov Hospital. Neurologists take an individual approach to choosing a treatment method.

Hydrocephalus in children

Protocol code:a

Duration of treatment: 13 days

ICD codes: G91.0 Communicating hydrocephalus

Q 0.03 Congenital, acquired

P 37.1 Caused by congenital toxaplasmosis

G91.1 Obstructive hydrocephalus

G91.2 Normal pressure hydrocephalus

G91.3 Post-traumatic hydrocephalus, unspecified

G 91.8 Other types of hydrocephalus

G 91.9 Hydrocephalus, unspecified

Definition: Hydrocephalus (dropsy of the brain) is a disease characterized by excessive accumulation of cerebrospinal fluid in the ventricles and intrathecal spaces of the brain, accompanied by their expansion due to impaired circulation and absorption of cerebrospinal fluid. Hydrocephalus is a secondary disease and develops against the background of the current pathological process or represents its residual effects.

By time of occurrence:

According to the clinical course:

1. occlusion at the foramen of Monroe;

2. at the Sylvian aqueduct;

3. at the Magendie and Luschka holes.

When the ventricular system of the subarachnoid spaces expands:

1. unfavorable factors in the prenatal period and at birth;

2. postnatal factors (inflammatory process);

3. intrauterine infections;

4. stenosis of the Sylvian aqueduct;

5. hereditary factor;

6. traumatic brain injury;

7. brain tumors;

9. brain infections.

Indications for hospitalization:

1. clarification of the cause and type of hydrocephalus;

2. no effect outpatient treatment(decompensation).

3. progressive increase in head size;

4. presence of neurological symptoms;

5. clarification of the etiology and type of hydrocephalus;

6. determination of the type of therapy (conservative, surgical).

7. The required scope of examination before planned hospitalization:

1. General blood test;

2. General urine analysis;

3. Ultrasound of the brain;

4. Computed tomography of the brain;

5. Nuclear magnetic resonance imaging of the brain;

6. Examination of the fundus;

7. Consultation with a neurosurgeon.

1. pathological increase in head size;

3. divergence of cranial sutures (Makoven’s symptom);

4. pronounced venous network on the head;

5. thinning of the skin veins;

7. high-pitched “brain” scream;

8. increased intracranial pressure;

9. focal symptoms;

10. paroxysmal headache, vomiting at the height of the headache;

11. congestive nipples optic nerves + vision pathology;

12. general excitement with tremor of the hands;

13. “pseudo-Graefe” symptom;

14. phenomenon of the “setting sun”;

15. disturbance of motor and reflex spheres (delayed psychomotor development);

List of main diagnostic measures:

1. General blood test;

2. General urine analysis;

3. Consultation with a neurologist.

List of additional diagnostic measures:

1. Ultrasound of the brain;

2. Computed tomography of the brain;

3. Nuclear magnetic resonance imaging of the brain;

4. Examination of the fundus;

5. Consultation with a neurosurgeon.

The choice of treatment method depends on the presence of activity of the primary pathological process that led to the development of hydrocephalus.

1. In the presence of inflammation, antibiotic therapy is indicated: amoxocillin + clavulonic acid suspension 156.0/5.0, table. 375 mg.

2. In the presence of specific inflammation (toxoplasmosis) - chloridine, sulfadimizine (tablet 0.5 x 3 times) 3 courses for 5 days with a break of 1 week.

Conservative treatment: for acute progression - mannitol IV drop 15% or 2-5 solution at the rate of 1.5 g of dry matter per 1 kg of body weight. Furosemide is prescribed to infants intramuscularly or intravenously (0.7 mg/kg body weight). Its effect is enhanced by simultaneous administration of a 15% or 255 solution of magnesium sulfate (0.2 g/kg body weight) intramuscularly or intravenously. Treatment for chronic dropsy (usually a communicating form) is aimed at inhibiting the secretion of cerebrospinal fluid.

3. Drugs that improve cerebral circulation - encephabol 100 mg in a table.

4. Dehydration - acetazolamide, doses are selected individually, on average 1-2 tablets/day x 2-3 times a day according to the scheme 3 days +, 2 days -, with potassium preparations. In general, for children under 1 year of age based on mg/kg body weight per day, for children 2 years of age the dose is reduced to 50 mg/kg.

List of essential medications:

1. Amoxocillin + clavulonic acid tablet 625 mg; solution for injection 600 mg in a bottle;

2. *Mannitol solution 10%, 20% 100 ml, 500 ml in a bottle;

3. *Furosemide 40 mg tablet; 20 mg/2 ml amp.;

4. *Acetazolamide 250 mg tablet.

List of additional medications:

1. Chloridine 50 mg tablet;

2. Sulfadimizine 50 mg tablet;

3. *Magnesium sulfate 25% 20 ml amp.

Criteria for transfer to the next stage of treatment:

/ books / Handbook for formulating a clinical diagnosis of diseases of the nervous system (Shtok, Levin, 2006)

Chapter 15. Trauma to the central and peripheral nervous system

accompanied by the formation of subarachnoid cysts or obliteration of the subarachnoid space, progressive myelopathy - myelomalacia, local or diffuse atrophy of the spinal cord, cystic degeneration or syringomyelic syndrome. The degree of spinal cord conduction disturbance (complete, partial) should also be indicated.

4.4. Consequences of cranial and spinal cord injuries

and peripheral nerves

Consequences of skull injury

OFD. Same as in ICD-10

nerves, classified

Consequences of nerve injury

OFD. Same as in ICD-10

PRFD. Post-traumatic neuro

Consequences of injuries, class

pathia of the right axillary

certified in ru

laceration due to a sharp cut wound

brikah S44 -, S54 -, S64 -,

right shoulder girdle. Consisting

postoperative wound revision,

nerve suturing, weakness and hypo

trophy, deltoid hypoesthesia

muscles, pain syndrome

Consequences of nerve injury

OFD. Same as in ICD-10

Consequences of injuries, class

classified into rubrics

kah S74-S84 -, S94 -

Chapter 16 Other diseases of the spinal cord

Damage to the spinal cord occurs in diseases of various origins. Based on etiology, the following groups of spinal cord diseases can be distinguished:

1. Vascular diseases of the spinal cord (see Chapter 1).

1.1. Ischemic spinal strokes (spinal cord infarction: thrombotic, embolic, arterial, venous).

1.3. Arteriovenous malformations of the spinal cord.

1.4. Aseptic intraspinal phlebitis (thrombophlebitis).

1.5. Spinal subarachnoid hemorrhages.

1.6. Chronic vascular myelopathy.

2. Degenerative diseases of the spinal cord (see Chapter 6).

2.1. Hereditary myelopathies (familial spastic paraplegia).

2.2. Spinal amyotrophy.

2.3. Spinal cord damage in amyotrophic lateral sclerosis.

3. Spinal cord injury (see Chapter 15).

4. Inflammatory diseases (myelitis).

4.1. Infectious myelitis (see Chapter 2).

4.1.1. Acute viral myelitis.

4.1.2. Myelitis (meningomyelitis, spinal abscesses) caused by bacterial, fungal, parasitic pathogens.

4.2. Non-infectious myelitis (see Chapter 3).

4.2.1. Acute transverse myelitis (idiopathic, post-infectious, post-vaccination).

4.2.2. Subacute necrotizing myelitis.

4.2.3. Myelitis in sarcoidosis, diffuse connective tissue diseases and vasculitis.

4.2.4. Paraneoplastic myelitis.

4.2.5. Damage to the spinal cord in multiple sclerosis.

5. Spinal cord tumors (see Chapter 14).

6. Compression lesions of the spinal cord.

6.1. For spondylosis or disc herniation (see Chapter 19).

6.2. For craniovertebral anomalies (see Chapter 22).

6.3. With spinal arachnoiditis.

6.4. For epidural abscess (see Chapter 2).

7. Dysmetabolic diseases of the spinal cord.

7.1. Funicular myelosis.

8. Anomalies in the development of the spinal cord (see Chapter 22).

8.2. Other developmental anomalies.

9. Myelopathies caused by intoxications and physical influences.

9.1. Radiation myelopathy.

9.2. Toxic myelopathies.

In some cases, even after a thorough examination of the patient, the etiology of spinal cord damage remains unclear (myelopathy of unknown origin).

In each of the options, the headings related to such diseases should be looked for in the corresponding chapters of the reference book. However, ICD-10 has a section on Other Spinal Cord Disorders (G95), and its categories can be used to code diseases not included in other chapters.

diagnosis (ODF) and examples

Spinal cord compression

OFD - see note

Note. The cause of spinal cord compression can be: metastatic tumor, lymphoma, myeloma, epidural abscess and subdural empyema, tuberculous spondylitis, epidural hematoma, displaced spinal fracture, hernia intervertebral disc, spondylosis, spondylolisthesis in the cervical or thoracic regions, subluxation in the atlantoaxial joint (for example, in rheumatoid arthritis), primary tumors of the spinal cord, arteriovenous malformations. These diseases are coded in the appropriate sections. This subcategory is used mainly for statistical recording of unspecified cases of spinal cord compression.

G95.8 Other specified diseases OFD - see note

spinal cord

Note. The rubric codes drug, toxic, radiation myelopathy, as well as myelopathy with lathyrism. Lathyrism is a chronic intoxication that develops with prolonged consumption of seeds of the legume family, which contain toxins that primarily affect the anterior and lateral columns of the thoracic and lumbar spinal cord.

Spinal cord disease

OFD. Myelopathy of unknown origin

Note. When formulating a detailed diagnosis, one should indicate the type of course (subacute, chronic, progressive, stationary, undulating), phase (progression, stabilization, regression), the affected part of the spinal cord, leading clinical syndromes

Chapter 16. Other diseases of the spinal cord

G99.2* Myelopathy due to OPD - see note

nias classified in other headings

Note. This subheading codes damage to the spinal cord due to compression of the anterior spinal and vertebral arteries (M4- 7.0+), HIV infection (vacuolar myelopathy) (B23.8+), disc herniation (M50.0+, M51.0+) and spondylosis (M47.- +), malignant neoplasms (COO-D48+), spinal cord compression, vitamin B 12 deficiency (E53.8+). Traumatic spinal cord injuries are coded under different headings (S14.0, S24.0, S34.0). When formulating a diagnosis, the affected section(s) of the spinal cord, the degree of transverse lesion (complete, partial), the degree of impairment of motor, sensory and pelvic functions are indicated.

Chapter 17 Hydrocephalus and intracranial: hypertension

2. Intracranial hypertension and cerebral edema

Hydrocephalus is a condition characterized by the accumulation of CSF in the cranial cavity. As a rule, hydrocephalus is accompanied by dilatation of the cerebral ventricles and intracranial hypertension. The diagnosis of hydrocephalus is established using CT or MRI of the brain.

There are non-communicating (obstructive) hydrocephalus, which develops as a result of blockade of the outflow tracts of CSF at the level of the ventricles, and communicating (non-obstructive) hydrocephalus, which develops as a result of impaired absorption of CSF in the subarachnoid space (due to damage to the soft meninges as a result of infection, hemorrhage, trauma), less often - due to hyperproduction of CSF by a tumor of the villous

Chapter 17. Hydrocephalus and intracranial hypertension

plexuses or due to decreased fluidity of CSF due to increased viscosity. A variant of communicating hydrocephalus is the so-called normal pressure hydrocephalus, in which dilatation of the ventricles occurs in the absence of a significant increase in intracranial pressure. Compensated hydrocephalus should be distinguished from normal pressure hydrocephalus, in which the process of active accumulation of CSF in the cranial cavity is stopped and, therefore, the clinical status and neuroimaging data remain stable.

The cause of enlargement of the ventricles may also be atrophy (reduction in the volume of brain tissue) caused by a degenerative process (“hydrocephalus ex vacuo”); in this case, the enlargement of the ventricles of the brain is accompanied by an expansion of the subarachnoid spaces along the convexital surface of the brain, interhemispheric and lateral fissures. This condition is not accompanied by active accumulation of CSF in the cranial cavity and is not true hydrocephalus (pseudohydrocephalus).

Hydrocephalus can be internal (accumulation of CSF in the ventricles of the brain) or external (accumulation of CSF in the subarachnoid space), symmetrical or asymmetrical.

In ICD-10, acquired hydrocephalus is coded in categories G91 and G94*, congenital hydrocephalus is coded in category Q03.

Proposed general wording

diagnosis (ODF) and examples

detailed formulation of the diagnosis

Excludes: congenital hydrocephalus (Q03.-), caused by congenital

daytime toxoplasmosis (P37.1)

OFD. Same as in ICD-10

hydrocephalus remains unclear (idiopathic communicating

OFD. Same as in ICD-10

A guide to formulating a diagnosis of diseases of the nervous system

Note. Obstructive hydrocephalus can be caused by a tumor or other space-occupying process (posterior cranial fossa, less commonly supratentorial with tentorial herniation), intraventricular hematoma, intracerebral abscess, ventriculitis or ependymitis, granulomatous inflammation, arachnoid cyst and other diseases (add., table .) - This subcategory should be used when the disease causing hydrocephalus is not coded in another category

OFD. Normotensive hydrocephalus

PRFD. Idiopathic normoten

positive hydrocephalus with severe frontal dysbasia, moderate cognitive impairment of the subcortical-frontal type, neurogenic urinary disorders such as urinary incontinence

Note. Normal pressure hydrocephalus (NPH) is a variant of communicating hydrocephalus associated with impaired absorption of CSF over the convexital surface of the brain. May be a consequence of fibrosis and fusion of the meninges resulting from subarachnoid hemorrhage, meningitis or traumatic brain injury, but in a significant number of cases the cause remains unknown (idiopathic IGT). Clinically, IGT is characterized by a triad of signs [gait disorders of the frontal dysbasia type (gait apraxia), subcortical (subcortical-frontal) type dementia, neurogenic urination disorders], the obligate of which are walking disorders. Signs of parkinsonism or pyramidal insufficiency are also possible (invigorated tendon reflexes and moderate spasticity in the legs, bilateral Babinski reflex). The diagnosis is confirmed by CT or MRI, liquorodynamic test (extraction of 30 ml of CSF should cause a significant improvement in motor functions within 24 hours). When formulating a detailed diagnosis, you should indicate the course (rapidly progressive, slowly progressive, stationary) or the degree of compensation after bypass surgery (complete, partial)

G91.3 Post-traumatic hydro Code for statistical accounting is not

unspecified cephalia specified cases of post-traumatic hydrocephalus

Other types of hydrocephalus OPD. Same as in ICD-10

Hydrocephalus

General information

Hydrocephalus (dropsy of the brain) - excessive accumulation of cerebrospinal fluid in the ventricles of the brain and intrathecal spaces; manifested by symptoms of increased ICP:

• It occurs due to an imbalance between the formation and absorption of cerebrospinal fluid: less is absorbed than is formed. The cause may be an obstructive process in the ventricles or in the subarachnoid space, less often - true hyperproduction of cerebrospinal fluid (with villous plexus papilloma)
• Characterized by excessive accumulation of cerebrospinal fluid in the ventricles of the brain or subarachnoid space with their expansion
• In newborns, it leads to an increase in the size of the skull and brain atrophy (decreased metabolism in adjacent areas of the brain).

By the presence of communication between the cavities of the ventricles of the brain and the subarachnoid space.

• Non-communicating (obstructive) hydrocephalus is caused by a process that causes blockage of the ventricular system:
  • Acquired hydrocephalus:
    • Tumors of the IV ventricle (medulloblastoma, ependymoma - all ventricles are dilated) and the aqueduct of Sylvius (midbrain tegmental glioma - the lateral and III ventricles are dilated, but the size of the IV ventricle is not changed)
    • Fibrosis of the arachnoid membrane due to meningitis or intraventricular hemorrhage
  • Congenital hydrocephalus:
    • Stenosis of the Sylvian aqueduct in the presence of a septum and true narrowing (#307000, Xq28, L1 cell adhesion molecule gene L1CAM, À). Congenital stenosis is characterized by a small size of the posterior cranial fossa
    • Dandy–Walker syndrome is a congenital atresia of the foramina of Magendie and Luschka. Characterized by cystic dilatation of the fourth ventricle and cerebellar hypoplasia
    • Aneurysms of the vein of Galen (v. cerebri magna - Galeni) and other vascular malformations
    • Benign intracranial cysts (arachnoid and ependymal)
    • X-linked hydrocephalus is a rare form of congenital hydrocephalus in men.

• Communicating (non-obstructive) hydrocephalus occurs when there is an obstruction in the cerebrospinal fluid circulation pathways distal to the exit from the fourth ventricle and at the level of pachyonic granulations:
  • Purchased:
    • Inflammation of the arachnoid membrane during meningitis and as a result of intraventricular hemorrhage (most often during birth trauma and in premature infants)
    • Vein thrombosis, dural sinus stenosis
    • Trauma accompanied by subarachnoid hemorrhage, followed by inflammation of the arachnoid membrane
    • Hydrocephalus, normotensive
  • Congenital:
    • Inflammation of the arachnoid membrane - intrauterine infection
    • Encephalocele
    • Agyria is a developmental anomaly: absence of convolutions of the cerebral cortex; the cranial cavity is filled with cerebrospinal fluid.

Separately, functional hydrocephalus is distinguished, which develops as a result of excessive formation of cerebrospinal fluid with villous plexus papilloma. This tumor may also itself obstruct the ventricular system, causing obstructive hydrocephalus. Small hemorrhages from it cause obstruction of the subarachnoid space (after removal of the tumor, hydrocephalus may persist).

Based on the predominant accumulation of cerebrospinal fluid:

• Internal (ventricular) hydrocephalus - hydrocephalus, characterized by the accumulation of cerebrospinal fluid mainly in the ventricles of the brain
• External hydrocephalus - hydrocephalus with accumulation of cerebrospinal fluid predominantly in the subarachnoid space or (less often) in the subdural space in the presence of communication between the subarachnoid and subdural spaces
• General hydrocephalus - hydrocephalus with accumulation of cerebrospinal fluid both in the ventricles and in the subarachnoid space.

Symptoms of hydrocephalus

Clinical picture of hydrocephalus:

• At the initial manifestations of the disease, the child becomes restless, followed by low mobility and poor appetite.
• Progressive increase in head circumference (up to 60 cm or more), thinning of the skin, enlargement of the veins of the scalp
• Divergence of cranial sutures, tension, enlargement and bulging of the fontanelles, lack of their pulsation
• Symptoms of intracranial hypertension due to the compliance of the skull in newborns and young children are not clearly expressed
• With a significant increase in ICP - a symptom of the setting sun (the child’s eyes look down, the lower part of the iris is covered, a wide strip of sclera is visible from above; upward gaze paresis)
• "Cracked pot" sound when percussing the skull
• Swelling of the optic discs, subsequent decrease in visual acuity due to atrophy
• Damage to the motor sphere: increased reflexes from the lower extremities, later - paresis
• Developmental indicators lag behind normal; in advanced cases, mental retardation is inevitable
• The disease, which occurs after 17–18 years, is not accompanied by an increase in head size; signs of intracranial hypertension come to the fore.

Diagnosis of hydrocephalus

Research methods:

• X-ray of the skull: dehiscence of the sutures of the skull, deepening of the finger-like impressions, thinning of the bones (with prolonged hypertension), intracranial calcifications (as a result of congenital infections). Small sizes of the posterior cranial fossa suggest stenosis of the Sylvian aqueduct, large sizes suggest Dandy–Walker syndrome
• Ultrasound (neurosonography) indicates the degree of ventricular dilatation, intraventricular hemorrhage
• CT helps to determine the size of the ventricles, the location of obstruction of the cerebrospinal fluid pathways, and allows to identify associated anomalies
• MRI is the most informative and is indicated when hydrocephalus is combined with tumors, vascular malformations, and multi-chamber ventricles
• Angiography helps identify vascular abnormalities
• If a congenital infection is suspected, serological tests are performed for rubella, herpes, CMV, Toxoplasma gondii and Treponema pallidum viruses.

Differential diagnosis:

• Congenital macrocrania (normal head growth rate and family history of macrocrania)
• Enlargement of the head with rickets (overgrowth of bone tissue of the skull and skeletal changes typical for rickets)
• Volumetric intracranial formations (subdural hematomas, tumors).

Types of operations:

• Removal of the cause of obstruction of the cerebrospinal fluid pathways (brain tumor, arachnoid adhesions)
• • Indication: progressive communicating hydrocephalus
  • Methods: ventriculoperitoneal shunting (the most common); ventriculoatrial, ventriculopleural and lumboperitoneal shunting, ventriculoureteroanastomosis, ventriculocholecystostomy - less popular due to the more frequent occurrence of complications
• • Indication: non-communicating hydrocephalus
  • Methods: ventriculocisternostomy according to Torkildsen, ventriculostomy of the third ventricle.

Conservative treatment:

• There is no drug for adequate treatment of hydrocephalus. As additional therapy, acetazolamide is used (reduces the formation of cerebrospinal fluid) and furosemide - to reduce ICP
• Intraventricular hemorrhages are treated with medication ( symptomatic therapy), since in this case the dilation of the ventricles is transient.

Complications often arise after shunt operations: shunt dysfunction, purulent complications (peritonitis, ventriculitis).

• G91 Hydrocephalus
• G94* Other brain lesions in diseases classified elsewhere
• Q03 Congenital hydrocephalus
• Q05 Spina bifida [incomplete closure of the spinal canal]

Treatment of hydrocephalus

Treatment is predominantly surgical.

Types of operations:

• Removal of the cause of obstruction of the cerebrospinal fluid pathways (brain tumor, arachnoid adhesions)
• Bypass of cerebrospinal fluid into the body cavity:
  • Indication: progressive communicating hydrocephalus
  • Methods: ventriculoperitoneal shunting (the most common); ventriculoatrial, ventriculopleural and lumboperitoneal shunting, ventriculoureteroanastomosis, ventriculocholecystostomy - less popular due to the more frequent occurrence of complications
• Creation of communication between the ventricular system and the subarachnoid space:
  • Indication: non-communicating hydrocephalus
  • Methods: ventriculocisternostomy according to Torkildsen, ventriculostomy of the third ventricle.

Conservative treatment:

• There is no drug for adequate treatment of hydrocephalus. As additional therapy, acetazolamide is used (reduces the formation of cerebrospinal fluid) and furosemide - to reduce ICP
• Intraventricular hemorrhages are treated with medication (symptomatic therapy), since the dilation of the ventricles is transient.

Complications of hydrocephalus

often occur after shunt operations: shunt dysfunction, purulent complications (peritonitis, ventriculitis).

The prognosis for hydrocephalus in newborns is unfavorable.

• G91 Hydrocephalus
• G94* Other brain lesions in diseases classified elsewhere
• O33.6 Fetal hydrocephalus resulting in disproportion requiring maternal medical attention
• Q03 Congenital hydrocephalus
• Q05 Spina bifida [incomplete closure of the spinal canal]

Application. Normotensive hydrocephalus develops in adult patients with insufficient absorption of cerebrospinal fluid by pachion granulations, which allows the pressure to remain within physiological limits. It occurs as a result of subarachnoid hemorrhage or meningitis, sometimes appearing after several years. Clinical picture: classic triad of symptoms - dementia, gait disturbances, urinary incontinence; no signs of damage to sensory, motor or cerebellar functions. Diagnostics: radiography of the skull (increased pattern of digital impressions on the cranial vault, porosity of the “sella turcica”); CT/MRI and ventriculography: sharply enlarged cerebral ventricles in combination with relatively unexpressed atrophy of the cerebral cortex; over time (in the absence of adequate treatment), overstretching of nerve fibers leads to progressive thinning of the white matter of the brain. Surgical treatment is ventriculoperitoneal shunting. The prognosis is relatively favorable (the operation brings a visible effect). Results are best if the method is applied within the first 6 months after the onset of symptoms. Synonyms: aresorptive hydrocephalus, hidden hydrocephalus, Hakim–Adams syndrome. ICD-10:

• G91.2 Normal pressure hydrocephalus.

Hydrocephalus

Hydrocephalus is a condition characterized by the accumulation of CSF in the cranial cavity. As a rule, hydrocephalus is accompanied by dilatation of the cerebral ventricles and intracranial hypertension. The diagnosis of hydrocephalus is made using CT or MRI of the brain.

Non-communicating (obstructive) hydrocephalus is classified as

developing as a result of blockade of the outflow tract of CSF at the level of the ventricles, and communicating (non-obstructive) hydrocephalus, developing as a result of impaired absorption of CSF in the subarachnoid space (due to damage to the soft meninges as a result of infection, hemorrhage, trauma), less often - due to overproduction of CSF by a villous tumor

plexus or due to decreased fluidity of CSF due to increased viscosity. A variant of communicating hydrocephalus is the so-called normal pressure hydrocephalus, in which dilatation of the ventricles occurs in the absence of a significant increase in intracranial pressure. Compensated hydrocephalus should be distinguished from normal pressure hydrocephalus, in which the process of active accumulation of CSF in the cranial cavity is stopped and, therefore, the clinical status and neuroimaging data remain stable.

The cause of enlargement of the ventricles may also be atrophy (reduction in the volume of brain tissue) caused by a degenerative process (“hydrocephalus ex huasio”); in this case, the enlargement of the ventricles of the brain is accompanied by an expansion of the subarachnoid spaces along the convexital surface of the brain, interhemispheric and lateral fissures. This condition is not accompanied by active accumulation of CSF in the cranial cavity and is not true hydrocephalus (pseudohydrocephalus).

Hydrocephalus can be internal (collection of CSF in the ventricles of the brain) or external (accumulation of CSF in the subarachnoid space), symmetrical or asymmetrical.

In ICD-10, acquired hydrocephalus is coded in categories 091 and 094*, congenital hydrocephalus is coded in category p03.

Included: acquired hydrocephalus

Excludes: congenital hydrocephalus (003.-), caused by congenital toxoplasmosis (P37.1)

1 |___________ 2____________ |_______________ 3________________

Note. Obstructive hydrocephalus can be caused by a tumor or other space-occupying process (posterior cranial fossa, less commonly supratentorial with tentorial herniation), intraventricular hematoma, intracerebral abscess, ventriculitis or ependymitis, granulomatous inflammation, arachnoid cyst and other diseases (adj., table) - This subcategory should be used in the case when the disease that caused hydrocephalus is not coded in another category

091.2 Hydrocephalus of normal OFD.

PRFD. Idiopathic normotensive hydrocephalus with severe frontal dysbasia, moderate cognitive impairment of the subcortical-frontal type, neurogenic urinary disorders such as urinary incontinence

Note. Normal pressure hydrocephalus (NPH) is a variant of communicating hydrocephalus associated with impaired absorption of CSF over the convexital surface of the brain. May be a consequence of fibrosis and fusion of the meninges resulting from subarachnoid hemorrhage, meningitis or traumatic brain injury, but in a significant number of cases the cause remains unknown (idiopathic IGT). Clinically, IGT is characterized by a triad of signs [gait disorders of the frontal dysbasia type (gait apraxia), subcortical (subcortical-frontal) type dementia, neurogenic urination disorders], the obligate of which are walking disorders. Signs of parkinsonism or pyramidal insufficiency are also possible (invigorated tendon reflexes and moderate spasticity in the legs, bilateral Babinski reflex). The diagnosis is confirmed by CT or MRI, liquorodynamic test (extraction of 30 ml of CSF should cause a significant improvement in motor functions within 24 hours). When formulating a detailed diagnosis, you should indicate the course (rapidly progressive, slowly progressive, stationary) or the degree of compensation after bypass surgery (complete, partial)

091.3 Post-traumatic hydro- Code for statistical recording of non-

unspecified cephaly specified cases of post-traumatic

091.8 Other types of hydrocephalus OFD. Same as in ICD-10

Hydrocephalus is a disease that occurs as a result of excessive production and excessive accumulation of cerebrospinal fluid in the intrathecal spaces and/or ventricles of the brain (in the sub-arachnoid or subdural space), leading to thinning (atrophy) of the medulla and divergence of the skull bones.

ICD-10 provides the following codes for various types of hydrocephalus: G91 (G91.0 - communicating hydrocephalus, G91.1 - obstructive hydrocephalus, G91.2 - normal pressure hydrocephalus, G91.3 - post-traumatic hydrocephalus unspecified, G91.8 - other types hydrocephalus, G91.9 - hydrocephalus unspecified).

Classification of hydrocephalus

There are several options for classifying hydrocephalus. First of all, a distinction is made between congenital and acquired hydrocephalus.

Congenital hydrocephalus is present at the time of birth of the child and is the result of inflammatory diseases of the central nervous system (CNS), malformations of the brain, as well as intracranial (birth) trauma, hemorrhages in the brain.

Acquired hydrocephalus develops after birth due to etiologically and pathogenetically diverse pathologies (neuroinfections, tumor processes, vascular diseases, traumatic brain injuries, etc.).

The disease can be active or passive. In the first case, there is an increase in intracranial pressure in the presence of dilatation of the ventricles and subarachnoid spaces. With passive hydrocephalus, it is assumed that the described changes are observed in the absence of intracranial hypertension.

There are open and closed forms of hydrocephalus. Open (communicating) hydrocephalus is diagnosed in the absence of disturbances in the connection of the ventricular system of the brain with the subarachnoid space, and closed (occlusive or non-communicating) - when this communication is disrupted.

External and internal forms of hydrocephalus are determined by the localization of the accumulation of cerebrospinal fluid (CSF); External hydrocephalus is an accumulation of CSF in the intrathecal spaces of the brain, internal hydrocephalus is an accumulation of CSF in the ventricles of the brain.

Pathogenetic classification of hydrocephalus: 1) hypersecretory forms (excessive formation of CSF); 2) aresorptive forms (impaired CSF absorption processes); 3) occlusive forms (the presence of an obstacle to the movement of CSF from the source of its formation to the areas of its resorption).

Depending on the existing level of occlusion of the cerebrospinal fluid pathways, five variants of hydrocephalus are considered: 1) occlusion of one or both foramina of Monroe; 2) blockade of the cavity of the third ventricle; 3) stenosis or occlusion of the Sylvian aqueduct; 4) occlusion or non-opening of the openings of the fourth ventricle; 5) violation of the patency of the subarachnoid spaces.

Depending on the achieved level of control over intracranial hypertension, it is customary to distinguish between compensated, subcompensated or decompensated hydrocephalus.

A separate variant of the disease is normal pressure hydrocephalus (“symptomatic”). With it, there is initially an increase in intracranial pressure (a consequence of excessive accumulation of CSF in the ventricles of the brain) - with or without ventriculomegaly, which gradually decreases, but remains moderately elevated (150-200 mmH2O). There are two types of normal pressure hydrocephalus - idiopathic (cause unknown) and secondary (consequence of subarachnoid hemorrhage, trauma, tumor and/or infection of the central nervous system, complication of neurosurgical intervention, etc.).

S. Oi (2010) proposed a “multi-category classification of hydrocephalus”, reflecting modern ideas about this disease (table).

Etiology and pathogenesis of hydrocephalus

The most important etiological factor of hydrocephalus is intra- and perinatal pathology of the central nervous system. Pregnancy pathology and oxygen starvation of cerebral tissue are considered as etiological causes of congenital hydrocephalus; intrapartum factors leading to hypoxic-ischemic and/or traumatic brain damage; gestational immaturity of brain structures most susceptible to the described damage.

The development of hydrocephalus is caused by inflammatory diseases of the brain and its membranes, as well as intrauterine and neuroinfections, congenital malformations of the central nervous system, vascular pathology, tumors of the brain and spinal cord, traumatic injuries (including intracranial birth injuries), genetic factors, etc.

Cases of hydrocephalus associated with cerebral dysgenesis, brucellosis, mumps and other infections, diffuse villous hyperplasia of the choroidal plexus, vascular anomalies, intracranial hemorrhages, etc. have been described.

Post-traumatic hydrocephalus (progressive excess accumulation of CSF in the cerebrospinal fluid spaces and brain matter due to traumatic brain injury) is caused by impaired circulation and resorption of CSF.

According to C. Schrander-Stumple and J. P. Fryns (1998), hereditary X-linked (congenital) hydrocephalus occurs in 4% of all registered cases of the disease (according to other data in 5-15% of observations), up to 40% of cases of hydrocephalus are etiogenetically caused. Hydrocephalus occurs in Dandy-Walker syndrome, Arnold-Chiari syndrome, etc. At least 43 mutations/loci associated with hereditary forms of hydrocephalus (in humans and laboratory animals) have been described; Under experimental conditions, 9 genes associated with this cerebral pathology were discovered, but in humans there is only one.

The progression of hydrocephalus is accompanied by structural and morphological changes in the brain of varying severity: 1) thinning of the cortex and white matter (up to its complete elimination); 2) atrophy of the choroid plexus; 3) atrophy/subatrophy of the basal ganglia, brainstem, cerebellum; 4) severe disorders of capillary blood flow; 5) thickening and/or fusion of the meninges; 6) excessive growth (hypertrophy) of glial tissue. In severe cases, the formation of hydroanencephaly is possible, when there is only ependyma and a thin layer of the pia mater.

The most intensively functioning and highly vascularized periventricular region suffers the most from hypoxia. The consequence of atrophy of the periventricular white matter of the brain is passive expansion of the ventricular system with the formation of ventriculomegaly.

With post-traumatic hydrocephalus, pathological processes in the brain are morphologically characterized by dilation of the ventricular system, periventricular edema and obliteration of the subarachnoid fissures. Obliteration of the cerebrospinal fluid flow pathways is determined by the following pathogenetic factors: subarachnoid hemorrhage, intracranial hematomas, focal and/or diffuse brain damage, cicatricial adhesions and atrophic processes (including after extensive craniotomy and resection trepanations), meningoencephalitis and ventriculitis. The time frame for the development of post-traumatic hydrocephalus (normotensive, hypertensive or occlusive) usually varies from 1 month to 1 year.

Clinical syndromology of hydrocephalus

The main symptoms of hydrocephalus (congenital and acquired) are determined by two groups of factors: 1) the causes of the disease; 2) directly hydrocephalic syndrome.

The first group mainly includes focal manifestations (usually in the form of spastic paresis of the ascending type in the lower and/or upper extremities). The severity of group 2 symptoms depends on the form, stage and degree of progression of hydrocephalus. In the congenital form of the disease, signs of hydrocephalus may be present both at birth and appear later - by the age of 3-6 months.

More often, the first sign of the disease is a disproportionately rapid increase in head circumference. To assess it in children, special tables (centile) are used.

In children of the first year of life, there may be a predominance of the “cerebral” parts of the skull over the “facial” (as a result - a forced position with the head thrown back), increased venous pattern and congestion of the saphenous veins of the head, tension of the greater and other fontanelles, divergence of the skull bones, Graefe’s symptom . These symptoms are accompanied by a lag in psychomotor development (of varying severity), and less often in physical development. Atrophy of the optic nerve nipples - severe complication untreated or treatment-resistant progressive hydrocephalus.

Cephalgic syndrome is more typical of acquired hydrocephalus in children over 1 year of age (when the fontanelles and cranial sutures are already closed).

Clinical manifestations of post-traumatic hydrocephalus are characterized by neurological and mental disorders caused by primary brain injury. In part, they are a reflection not so much of hydrocephalus itself, but rather a consequence of a traumatic brain injury (TBI) or premorbid pathology.

A. P. Konovalov et al. (1999) distinguish three variants of post-traumatic hydrocephalus: 1) against the background of resolved or mild residual symptoms of severe TBI, with dominance in the clinic of any specific symptom complex; 2) against the background of slowly resolving severe symptoms of severe TBI with the addition of intellectual-mnestic and ataxic syndromes; 3) against the background of a vegetative state (which prevents exit from it). Hypertensive and occlusive post-traumatic hydrocephalus (excluding normotensive hydrocephalus) is characterized by headache, vomiting, and dizziness. All patients exhibit psychopathological symptoms (intellectual-mnestic disorders, euphoria or lethargy, aspontaneity, akinetic mutism, etc.); as well as gait disturbances and ataxia (with a characteristic “sticking of the feet to the floor”), dysfunction of the pelvic organs.

With normal pressure hydrocephalus, there are usually no classic symptoms characteristic of congenital or acquired hydrocephalus, but since ventriculomegaly has a negative effect on adjacent areas of cortical tissue, the disease has its own characteristics (classic triad: gait disturbances, urinary incontinence, decreased intelligence of varying degrees of severity).

Diagnostics and examination methods

Establishing a diagnosis of hydrocephalus (in addition to physical data) is based on neuroimaging data (neurosonography - with an open fontanel, computed tomography and magnetic resonance imaging of the brain - CT and MRI), which are considered in conjunction with the symptoms of the disease described above. These neuroimaging methods have replaced the previously used skull radiography. It is resorted to only in rare cases; Survey radiography of the skull allows one to indirectly judge secondary changes in the bones of the skull (in the absence of CT and MRI).

It is especially important to monitor the adequate functioning of shunts installed during neurosurgical intervention. At the slightest suspicion of shunt failure, the patient should be referred to a neurosurgeon.

Isotope cisternography with introduction radioactive isotope(during a lumbar puncture) and subsequent observation of the removal of CSF from the brain allows us to establish the diagnosis of normal pressure hydrocephalus.

Diaphanoscopy (transillumination of the skull) has now been practically abandoned. Lumbar puncture - traditional method studies to assess blood pressure and analyze the CSF. Increased echo pulsation up to 70-80% during ultrasound examination is not a brain diagnostic sign hydrocephalus.

The study of auditory evoked potentials often reveals their disturbances, which indicates a special sensitivity of the brain stem to intracranial hypertension.

An ophthalmological examination of the fundus allows one to identify changes characteristic of hydrocephalus (congestion in the fundus, atrophic processes, signs of inflammation, as well as hemorrhage, changes in the tone and caliber of blood vessels, etc.), which makes it possible to assess the course of the pathological process.

If a congenital infection (intrauterine infection) is suspected, serological and virological studies are justified.

Abroad, a method of non-invasive monitoring of intracranial pressure through the large fontanel in children of the first year of life, based on the principle of applanation, is used. The measurement is made using a special device (fontanometer), and the study itself is called “phonogram” or “fontanometry”.

Differential diagnosis

Hydrocephalus is differentiated from the following main pathological conditions: subdural intracranial hemorrhage, megalencephaly (primary), hydroanencephaly, meningitis, brain tumors, familial (constitutional) macrocephaly, vitamin D-deficient rickets, rickets of premature infants, etc.

Less common are other types of pathology from which it is necessary to differentiate hydrocephalus: achondroplasia, Soto syndrome (cerebral gigantism), numerous so-called “neurocutaneous” syndromes, a group of leukodystrophies (Alexander’s disease, Canavan’s disease, globoid and methochromatic forms of leukodystrophies), gangliosidosis, mucopolysaccharidosis (Tay’s disease -Sachs and Sandhoff), urine disease with the smell of maple syrup, etc.

Treatment

Therapeutic measures for progressive hydrocephalus are divided into surgical and therapeutic (drug and non-drug).

If there are signs of an ongoing inflammatory process in the central nervous system, children are prescribed appropriate therapy (antibacterial agents, specific drugs, as well as glucocorticosteroids and human intravenous immunoglobulins - according to indications).

Progressive forms of hydrocephalus (occlusive), as a more serious variant of the pathology, require timely neurosurgical intervention (shunt surgery). The purpose of surgery is to create an adequate outflow of CSF using special shunts (drainage systems made of synthetic materials). There are shunts that divert CSF from the ventricles of the brain to various loci of the body (ventriculoperitoneal, lumboperitoneal, ventriculoatrial). Thus, some shunts transport excess accumulation of cerebrospinal fluid into the peritoneal cavity, others - into the right ventricle of the heart. Ventriculoperitoneal shunting is the main method of neurosurgical treatment of hydrocephalus in the Russian Federation and abroad.

There is a method of surgical treatment called “endoscopic third ventriculostomy” (perforation of the lower part of the third ventricle of the brain to eliminate the blockage of CSF flow and increase its outflow); another name for the method is “endoscopic ventriculocisternostomy of the bottom of the third ventricle.” The purpose of the described operation is to create pathways for the outflow of CSF from the third ventricle into the cisterns of the brain, through which the resorption of cerebrospinal fluid occurs.

Other types of endoscopic treatment of hydrocephalus in various clinical situations are aqueductoplasty, ventriculocystocysternostomy, septostomy, endoscopic removal of an intraventricular tumor, as well as endoscopic installation of a shunt system.

Among the neurosurgical procedures in infants, ventricular puncture (removal of CSF from the ventricles of the brain through the fontanelle) can be used. This external drainage procedure is used extremely rarely, as it can be accompanied by a large number of complications (infection, etc.).

There are isolated reports of the use of intradural spinal endoscopy in the treatment of hydrocephalus and associated conditions in children.

At acute occurrence intracranial hypertension use drugs that have a diuretic effect. These include: furosemide (intramuscular) - sometimes in combination with a solution of magnesium sulfate, glycerol (per os), mannitol (intravenous drip).

If long-term treatment of hydrocephalus is necessary, acetazolamide (Diacarb) is first prescribed, a diuretic from the group of carbonic anhydrase inhibitors (an enzyme that catalyzes the reversible reaction of carbon dioxide hydration and subsequent dissociation of carbonic acid). The action of acetazolamide is associated with the suppression of carbonic anhydrase in the plexuses of the ventricles of the brain and with a decrease in CSF production (hypolyquor effect). The side effects of acetazolamide (acidosis and shortness of breath) are systematically corrected by the administration of sodium bicarbonate (0.5 g 3 times a day).

Patients with hydrocephalus under the age of 3 years need to be prescribed vitamin D and calcium supplements. In addition to calcium, subsidies of potassium and magnesium preparations (Asparkam, Panangin) are absolutely necessary among mineral substances during acetazolamide therapy.

Symptomatic treatment for hydrocephalus is determined by individual indications and usually includes: massage, physical therapy, various types of physiotherapy, biofeedback method, as well as stimulating therapy (nootropic, metabolic, vascular drugs, etc.), etc. Anticonvulsants for children with hydrocephalus prescribed if there are appropriate indications (symptomatic epilepsy, etc.).

Neurodietological measures should be aimed at maintaining nutritional status, adequate fluid intake, supplementation of vitamins and minerals, and, if necessary, nutritional support (clinical nutrition: enteral and/or parenteral).

Prevention

Since in a significant number of cases hydrocephalus can be established even in the period intrauterine development, sonographic examination of the fetus is recommended (starting from the 17th week of gestation). In some cases, MRI examination is indicated, although P. Peruzzi et al. (2010) indicate that it does not have significant diagnostic advantages compared to ultrasound methods.

In order to prevent hydrocephalus in children, timely detection and treatment of intrauterine infections in their mothers is necessary. Needs implementation in to the fullest prevention of childhood injuries and neuroinfections. To prevent myelomeningocele, preventive intake of folic acid supplements is indicated.

Forecast

Hydrocephalus is a cerebral pathology associated with significant neurological deficits, potential disability and decreased quality of life. There is a risk of irreversible changes in the nervous system and a decrease in intelligence (even mental retardation).

With congenital and acquired hydrocephalus, the prognosis is determined by the early onset and adequacy of treatment (pharmacological or neurosurgical).

A serious complication of hydrocephalus can be epilepsy, induced both by hydrocephalus itself (structural and morphological changes in brain structures) and by the installation of a drainage shunt.

According to M. Mataro et al. (2001), the average IQ values ​​in patients with hydrocephalus are reduced in a number of verbal and nonverbal functions. Among patients receiving adequate therapy, in 40-65% of cases, normal indicators intelligent functions.

Literature

1. Kliegman R. M., Stanton B. F., St Geme III J. W. et al., eds. Nelson textbook of pediatrics. 20 th ed. Philadelphia. Elsevier. 2016. 3474.
2. Shamansurov Sh. Sh., Studenikin V. M. Hydrocephalus, congenital and acquired. Ch. 11. In the book: Neurology of early childhood. Tashkent: O’Qituvchi, 2010. 156-164.
3. Studenikin V. M., Shamansurov Sh. Sh. Hydrocephalus is congenital. Ch. 9. In the book: Neonatal neurology. M.: Medforum, 2014. 120-135.
4. Studenikin V. M., Shelkovsky V. I., Kuzenkova L. M. Hydrocephalus and hydrocephalic syndrome in children // Doctor.ru. 2006; 5:2-5.
5. Oi S. A proposal on “Multi-categorical Hydrocephalus Classification”: McHc. Critical review in 72,576 patterns of hydrocephalus // J. Hydrocephalus. 2010; 2 (2): 1-21.
6. Oi S. Hydrocephalus research update: controversies in definition and classification of hydrocephalus // Neurol. Med. Chir. (Tokyo). 2010; 50: 859-869.
7. Kandasamy J., Jenkinson M. D., Mallucci C. L. Contemporary management and recent advances in pediatric hydrocephalus // BMJ. 2011; 343:d4191.
8. Schrander-Stumple C., Fryns J.P. Congenital hydrocephalus. Nosology and guidelines for clinical approach and genetic counseling // Eur. J. Pediatr. 1998; 157 (5): 355-362.
9. Peruzzi P., Corbitt R. J., Raffel C. Magnetic resonance imaging versus ultrasonography for the in utero evaluation of central nervous system anomalies // J. Neurosurg. Pediatr. 2010; 6 (4): 340-345.
10. Mataro M., Junque C., Poca M. A. et al. Neuropsychological findings in congenital and acquired childhood hydrocephalus // Neuropsychol. Rev. 2001; 11 (4): 169-178.

V. M. Studenikin, Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Economics

LLC NPSMC "Dream Clinic", Moscow

Hydrocephalus in children: just the facts / V. M. Studenikin

For citation: Attending physician No. 4/2018; Issue page numbers: 66-69

Tags: cephalalgia, brain, cerebrospinal fluid, intracranial hypertension

The essence of the problem is that the child has enlarged ventricles (where cerebrospinal fluid is formed). Depending on how enlarged they are and the symptoms observed, intracranial pressure is often increased (you need to periodically go to the ophthalmologist and look at the fundus). It is impossible to reduce the ventricles with any drugs; sometimes children “grow out” of this disease - the ducts expand and everything returns to normal. I studied this topic closely, because my son had this diagnosis. The most important question is this: the standards for the size of the ventricle were developed a long time ago, when ultrasound of the head was not so common, etc. And children now are often accelerated. My son at 5.5 months was 72 cm. What organs should he have (including a heart) as a child at an age corresponding to his height or corresponding to his age? If the child has no symptoms other than the ultrasound findings (whims and food preferences may be due to something else), then don’t bother.

I am afraid that if this is really hydrocephalus, then it will not be completely cured, thank God, such a diagnosis is very rarely confirmed, and is usually determined during pregnancy. Normal development of a child - interested in toys and the world around him (climbing everywhere), begins to walk and talk on time, and the fact that he eats little - as far as I know, the amount of food consumed corresponds to the child’s mobility and his temperament. I really hope that everything will be fine for you

My son is 14, has internal hydrocephalus, and periodically suffers from headaches and his head gets wet. Treatment is only in a hospital, we are treated every 3 months, on a CT scan without dynamics, we have been receiving treatment for 3 years, we are being monitored by a neurologist and we are still far from being diagnosed.

We have the same problem, although the child is still 10 months old, but the doctors all say that the whims are due to teething. He eats little - this is an individual issue, maybe it just seems so to you. And we also categorically refuse to eat meat; we have to add ground meat to the porridge. But regarding intracranial pressure, have you often noticed that a child throws his head back? They explained to us that this is a sign of a headache. The blood pressure rises accordingly; by the way, we haven’t been prescribed any medications since we were five months old. Yes, I forgot about the massage when they did the massage, the Baby felt noticeably better.

And besides neurologists, you turned to somewhere else. I can’t say for sure, but it seems like there are certain types of massage... Try it, maybe it will help.)))

Congenital hydrocephalus (Q03)

Excluded:

• hydrocephalus:
  • acquired NOS (G91.-)

Sylvian water pipeline:

• anomaly
• congenital obstruction
• stenosis

In Russia, the International Classification of Diseases, 10th revision (ICD-10) has been adopted as a single normative document for recording morbidity, reasons for the population's visits to medical institutions of all departments, and causes of death.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170

The release of a new revision (ICD-11) is planned by WHO in 2017-2018.

With changes and additions from WHO.

Processing and translation of changes © mkb-10.com

Types of hydrocephalus

Hydrocephalus (ICD code 10 G91) is a disease of the central nervous system, which is accompanied by the accumulation of excess cerebrospinal fluid in the ventricles or spaces between the membranes of the brain. The disease does not always manifest itself with symptoms of increased intracranial pressure. At the Yusupov Hospital, doctors use innovative methods for diagnosing hydrocephalus using modern devices from leading companies in Europe, the USA and Japan. Neurologists prescribe individual treatment depending on the cause, type and severity of hydrocephalus.

All complex cases of the disease are discussed at a meeting of the expert council with the participation of candidates and doctors of medical sciences, neurologists of the highest category, who are leading experts in the field of diseases of the central nervous system. Patients requiring surgical treatment are consulted by neurosurgeons. Surgical interventions are performed in partner clinics. The staff of the neurology clinic is highly professional and attentive to the wishes of patients.

Causes of hydrocephalus

Hydrocephalus can be congenital or acquired. Congenital hydrocephalus debuts in childhood. Acquired hydrocephalus occurs under the influence of various provoking factors.

Depending on the mechanism of development of the disease, there are 3 main forms of hydrocephalus:

• occlusive hydrocephalus (ICD 10 code - G91.8);
• communicating (open, disresorptive) hydrocephalus (code G91.0);
• hypersecretory hydrocephalus (code G91.8 - other types of hydrocephalus).

Disruption of the flow of cerebrospinal fluid in occlusive (closed, non-communicating) hydrocephalus occurs due to the closure (occlusion) of the cerebrospinal fluid pathways by a blood clot, a voluminous neoplasm, or an adhesive process that develops after inflammation. If the blockage occurs at the level of the ventricular system (Aqueduct of Sylvius, foramen of Monroe, foramina of Magendie and Luschka), proximal occlusive hydrocephalus occurs. If the block in the path of cerebrospinal fluid flow is at the level of the basal cisterns, a distal form of occlusive hydrocephalus develops. Communicating (open, disresorptive) hydrocephalus occurs when the processes of reabsorption of cerebrospinal fluid are disrupted, due to damage to the structures involved in the resorption of cerebrospinal fluid into the venous bed (Pachionian granulations, arachnoid villi, cells, venous sinuses). Hypersecretory hydrocephalus develops due to excess production of cerebrospinal fluid.

Based on the rate of progression of the disease, there are 3 forms of the disease:

• acute hydrocephalus, when no more than 3 days pass from the first symptoms of the disease to severe decompensation.
• subacute progressive hydrocephalus, developing within a month from the onset of the disease;
• chronic hydrocephalus, which develops within a period of 3 weeks to 6 months.

Depending on the level of cerebrospinal fluid pressure, hydrocephalus is divided into the following groups: hypertensive, normotensive, hypotensive. In hypertensive hydrocephalus, intracranial pressure is increased, in the case of hypotensive hydrocephalus, it is decreased. Normal pressure hydrocephalus (ICD code 10 – G91.2) is accompanied by normal values ​​of cerebrospinal fluid pressure.

Hydrocephalus can develop after traumatic brain injury and various diseases. Hydrocephalus is formed due to the following diseases of the central nervous system:

• brain tumors localized in the brain stem or ventricles;
• acute cerebrovascular accidents;
• subarachnoid and intraventricular hemorrhages;
• encephalopathy of various origins (chronic hypoxic conditions, alcohol intoxication).

Elderly people often develop replacement hydrocephalus. Its cause is atrophy of brain tissue. When the volume of the brain decreases, the vacated space is filled with cerebrospinal fluid. Background diseases that provoke the development of hydrocephalus are arterial hypertension and diabetes mellitus. In case of thrombosis of cerebral vessels, the outflow of cerebrospinal fluid is blocked and hydrocephalus occurs. Intracranial pressure increases and hydrocephalus develops with instability of the cervical spine.

In the neurology clinic of the Yusupov Hospital, the priority is the diagnosis and treatment of acute and chronic hydrocephalus in non-traumatic subarachnoid hemorrhages due to disruption of arteriovenous connections and rupture of arterial vascular aneurysms, post-traumatic hydrocephalus.

Symptoms and diagnosis of hydrocephalus

Acutely developed occlusive hydrocephalus is manifested by symptoms of increased intracranial pressure:

• headache;
• nausea and vomiting;
• drowsiness;
• congestion of the optic discs;
• symptoms of axial displacement of the brain.

Headache is most pronounced upon awakening in the morning due to an additional increase in intracranial pressure during sleep. This is facilitated by the expansion of cerebral vessels due to the accumulation of carbon dioxide, which is accompanied by blood flow, stretching of the dura mater of the brain in the area of ​​the base of the skull and the walls of blood vessels. Nausea and vomiting worsen and sometimes lead to a decrease in headaches. The most dangerous sign of increased intracranial pressure is drowsiness. It appears on the eve of a sharp and rapid deterioration of neurological symptoms.

With increased pressure in the subarachnoid space, congestion of the optic discs develops. Manifestations of dislocation syndrome are rapid depression of the patient’s consciousness to a deep coma, oculomotor disorders, and forced head position. When the medulla oblongata is compressed, breathing and cardiac activity are inhibited.

The main signs of chronic dysresorptive hydrocephalus are a triad of symptoms: dementia, paresis of both lower extremities and impaired walking, urinary incontinence. The first symptoms appear 3 weeks after a traumatic brain injury, hemorrhage, or meningitis. Initially, the sleep cycle is disrupted - patients become drowsy during the day with disturbances in night sleep. Over time, their overall activity level drops sharply. Patients become spontaneous, lacking initiative, and inert. Short-term memory is impaired, patients lose the ability to remember numbers. In the later stages of the disease, intelligence is impaired, patients cannot take care of themselves, they answer questions asked inadequately, in monosyllables with long pauses.

Walking impairment is manifested by apraxia. The patient can freely pretend to walk or ride a bicycle in a lying position, but in an upright position this ability is immediately lost. A person walks uncertainly, with his legs spread wide apart, and his gait becomes shuffling. In the later stages of hydrocephalus, paresis of the lower extremities develops. The most late and variable symptom is urinary incontinence.

Neurologists at the Yusupov Hospital diagnose occlusive hydrocephalus using computed tomography and magnetic resonance imaging. In chronic dysresorptive hydrocephalus, tomograms reveal a symmetrical expansion of the ventricular system with a balloon-like enlargement of the anterior horns, the subarachnoid fissures are not visualized, and there is a diffuse bilateral change in the white matter of the cerebral hemispheres in the form of a decrease in its density, most often around the lateral ventricles. Computed tomography also makes it possible to clarify the presence and extent of concomitant ischemic brain damage in patients with subarachnoid hemorrhages.

Patients undergo a lumbar puncture and at least 40 ml of cerebrospinal fluid are removed. She is sent to the laboratory for research. Improvement in patients' condition after the procedure is a good predictor of the patient's recovery after surgery.

Treatment of hydrocephalus

With an advanced clinical picture of the disease, conservative treatment is ineffective. Patients at the Yusupov Hospital are consulted by a neurosurgeon to decide on immediate neurosurgical intervention. In case of hemorrhage and thrombosis, the operation consists of applying external ventricular drains followed by the introduction of streptokinase into the ventricular cavity - a drug that dissolves blood clots and thereby ensures normal outflow of cerebrospinal fluid.

If the symptoms of chronic hydrocephalus do not progress in patients, they are prescribed diuretics - diacarb, mannitol, furosemide or lasix. To prevent hypokalemia, patients take asparkam. When the symptoms of occlusive hydrocephalus increase, neurosurgeons perform shunt operations. Timely surgical intervention for hydrocephalus allows for the recovery of all patients. Currently, neurosurgeons prefer to perform endoscopic operations for hydrocephalus.

If you have signs of occlusive hydrocephalus, call the Yusupov Hospital. Neurologists take an individual approach to choosing a treatment method.

Benign intracranial hypertension - description, symptoms (signs), diagnosis, treatment.

Short description

Benign intracranial hypertension (BIH) is a heterogeneous group of conditions characterized by elevated ICP without evidence of an intracranial lesion, hydrocephalus, infection (eg, meningitis), or hypertensive encephalopathy. ADHD is a diagnosis of exclusion.

Epidemiology In men it is observed 2–8 times more often, in children - equally often in both sexes. Obesity is observed in 11–90% of cases, more often in women. The frequency among obese women of childbearing age is 19/37% of cases are registered in children, 90% of whom are aged 5–15 years, very rarely younger than 2 years. Peak development of the disease is 20–30 years.

Symptoms (signs)

Clinical picture Symptoms Headache (94% of cases), more severe in the morning Dizziness (32%) Nausea (32%) Changes in visual acuity (48%) Diplopia, more often in adults, usually due to paresis of the abducens nerve (29%) Neurological disorders usually limited visual system Papilledema (sometimes unilateral) (100%) Damage to the abducens nerve in 20% of cases Enlargement of the blind spot (66%) and concentric narrowing of the visual fields (blindness is rare) Visual field defect (9%) The initial form may be accompanied only by occipital enlargement - frontal head circumference, often goes away on its own and usually requires only observation without specific treatment Absence of disorders of consciousness, despite high ICP Concomitant pathology Prescription or withdrawal of glucocorticosteroids Hyper-/hypovitaminosis A Use of other drugs: tetracycline, nitrofurantoin, isotretinoin Dural sinus thrombosis SLE Menstrual irregularities Anemia (especially iron deficiency).

Diagnostics

Diagnostic criteria CSF pressure above 200 mm water column. Composition of the cerebrospinal fluid: decreased protein content (less than 20 mg%) Symptoms and signs associated only with increased ICP: papilledema, headache, absence of focal symptoms (acceptable exception - abducens nerve palsy) MRI/CT - without pathology. Acceptable exceptions: Slit-like shape of the ventricles of the brain; Increased size of the ventricles of the brain; Large accumulations of cerebrospinal fluid above the brain in the initial form of ADHD.

Research methods MRI/CT with and without contrast Lumbar puncture: measurement of cerebrospinal fluid pressure, analysis of cerebrospinal fluid at least for the protein content of CBC, electrolytes, PT Examinations to exclude sarcoidosis or SLE.

Differential diagnosis CNS lesions: tumor, brain abscess, subdural hematoma Infectious diseases: encephalitis, meningitis (especially basal or caused by granulomatous infections) Inflammatory diseases: sarcoidosis, SLE Metabolic disorders: lead poisoning Vascular pathology: occlusion (dural sinus thrombosis) or partial obstruction, Behcet's syndrome Meningeal carcinomatosis.

Treatment

Diet tactics No. 10, 10a. Restrict fluid and salt intake Repeat a thorough ophthalmological examination, including ophthalmoscopy and visual field testing with assessment of the size of the blind spot Observation for at least 2 years with repeated MRI/CT to exclude a brain tumor Discontinuation of drugs that can cause ADHD Weight loss body Careful outpatient monitoring of patients with asymptomatic ADHD with periodic assessment visual functions. Therapy is indicated only in unstable conditions.

Drug therapy - diuretics Furosemide at an initial dose of 160 mg/day in adults; the dose is selected depending on the severity of symptoms and visual impairment(but not from cerebrospinal fluid pressure); if ineffective, the dose can be increased to 320 mg/day Acetazolamide 125–250 mg orally every 8–12 hours If ineffective, dexamethasone 12 mg/day is additionally recommended, but the possibility of weight gain should be taken into account.

Surgical treatment is carried out only in patients resistant to drug therapy or with threatening vision loss Repeated lumbar punctures until remission is achieved (25% after the first lumbar puncture) Lumbar shunting: lumboperitoneal or lumbopleural Other methods of shunting (especially in cases where arachnoiditis prevents access to lumbar arachnoid space): ventriculoperitoneal shunt or cisterna magna shunt Fenestration of the optic nerve sheath.

Course and prognosis In most cases - remission by 6-15 weeks (relapse rate - 9-43%) Visual disorders develop in 4-12% of patients. Loss of vision is possible without previous headache and papilledema.

Synonym. Idiopathic intracranial hypertension

ICD-10 G93.2 Benign intracranial hypertension G97.2 Intracranial hypertension after ventricular bypass surgery

Application. Hypertension-hydrocephalic syndrome is caused by an increase in cerebrospinal fluid pressure in patients with hydrocephalus of various origins. It manifests itself as headache, vomiting (often in the morning), dizziness, meningeal symptoms, stupor, and congestion in the fundus. Craniograms reveal deepening of the digital impressions, widening of the entrance to the sella turcica, and an intensification of the pattern of diploic veins.

Congenital hydrocephalus

Includes: hydrocephalus of the newborn

Excluded:

• Arnold-Chiari syndrome (Q07.0)
• hydrocephalus:
  • acquired NOS (G91.-)
  • acquired in newborn (P91.7)
  • caused by congenital toxoplasmosis (P37.1)
  • in combination with spina bifida (Q05.0-Q05.4)

Congenital defect of the aqueduct of Sylvius

Sylvian water pipeline:

• anomaly
• congenital obstruction
• stenosis

Hydrocephalus

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)

Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan

general information

Short description

Expert Commission on Health Development Issues

Hydrocephalus is dilation of the cerebral ventricles and enlargement of the subarachnoid space as a result of increased CSF pressure, accompanied by various signs and symptoms.

Protocol name: Hydrocephalus

Abbreviations used in the protocol:

Date of development of the protocol: 2014.

Protocol users: pediatrician, pediatric neurologist, doctor general practice, ambulance and emergency medical services doctors, paramedics.

Classification

Diagnostics

Additional diagnostic examinations performed on an outpatient basis:

The minimum list of examinations that must be carried out when referring for planned hospitalization:

Basic (mandatory) diagnostic examinations carried out at the hospital level:

Additional diagnostic examinations carried out at the hospital level:

Diagnostic measures carried out at the stage of emergency care:

List of additional diagnostic measures

Hydrocephalus syndrome

Hydrocephalic syndrome is an increase in the volume of cerebrospinal fluid in the ventricles of the brain as a result of malabsorption or excessive secretion.

The syndrome can be classified in various ways, but all forms are considered a disorder of liquor fluid dynamics.

ICD-10 code

Epidemiology

There is some evidence that the incidence of hydrocephalic syndrome in children has decreased significantly in many developed countries.

One Swedish study conducted over a ten year period found the prevalence of congenital hydrocephalus to be 0.82 per 1000 live births.

Causes of hydrocephalic syndrome

The causes of hydrocephalic syndrome can be congenital or acquired.

Congenital obstructive hydrocephalic syndrome

• Bickers-Adams syndrome (stenosis of the Sylvian aqueduct, characterized by severe learning difficulties and deformity of the thumb).
• Dandy-Walker malformation (atresia of the foramina of Magendie and Luschka).
• Arnold-Chiari malformation types 1 and 2.
• Underdevelopment of the foramen of Monroe.
• Aneurysms of the veins of Galen.
• Congenital toxoplasmosis.

Acquired obstructive hydrocephalic syndrome

• Acquired aqueductal stenosis (after infection or bleeding).
• Supratentorial tumors causing tentorial hernias.
• Intraventricular hematoma.
• intraventricular tumors, tumors of the pineal gland and posterior cranial fossa, such as ependymoma, astrocytomas, choroid papillomas, craniopharyngiomas, pituitary adenoma, hypothalamic or optic nerve gliomas, hamartoma, metastatic tumors.

Acquired hydrocephalus syndrome in infants and children

• Tumor lesions (in 20% of all cases, for example, medulloblastoma, astrocytomas).
• Intraventricular hemorrhage (eg, prematurity, head trauma, or rupture of a vascular malformation).
• Infections - meningitis, cysticercosis.
• Increased venous pressure in the sinuses (may be associated with achondroplasia, craniostenosis, venous thrombosis).
• Iatrogenic causes - hypervitaminosis A.
• Idiopathic.

Other causes of hydrocephalic syndrome in adults

• Idiopathic (one third of cases).
• Iatrogenic - surgical operations in the posterior cranial fossa.
• All causes of hydrocephalus described in infants and children.

Signs and treatment of hypertension syndrome in children

Hypertension syndrome is a dangerous disease that can manifest itself in children, regardless of their gender and age.

If the disease occurs in a newborn child, we are talking about a congenital form; in older children, hypertension syndrome is acquired.

This pathology is considered a symptom of dangerous diseases, so a child who has been diagnosed with this disease should be under constant medical supervision.

However, this diagnosis is often erroneous; in particular, sometimes hypertension syndrome is diagnosed in children with too large size heads, although these facts are in no way connected with each other.

Intracranial pressure may also increase during periods of intense crying or excessive physical activity. This is considered a variant of the norm; in this case we are not talking about pathology.

Read about the symptoms and treatment of hydrocephalic syndrome in children here.

General information

The cranium has a constant volume, but the volume of its contents may vary.

And if any formations (benign or malignant) appear in the brain area, excess fluid accumulates, hemorrhages appear, and intracranial pressure increases. This phenomenon is commonly called hypertension syndrome.

The disease can develop rapidly or be sluggish. The first option involves a rapid increase in symptoms; as a result of this condition, the substance of the brain is destroyed, the child may fall into a coma.

In the indolent form of the disease, the pressure inside the skull gradually increases, this causes significant discomfort to the child, constant headaches significantly worsen the quality of life of the little patient.

Causes

Hypertension syndrome can occur in children of different ages. Depending on the age, the causes of the disease vary.

The clinical picture of hypertension syndrome in newborns and older children may be different, however, the signs of the disease are always pronounced.

1. The child constantly refuses the mother's breast.
2. Moodiness, frequent crying for no reason.
3. During sleep or at rest, a quiet, drawn-out groan is heard as you exhale.
4. Hypotonicity of muscle tissue.
5. Decreased swallowing reflex.
6. Convulsions (do not occur in all cases).
7. Trembling of limbs.
8. Severe strabismus.
9. Copious regurgitation, often turning into vomiting.
10. Violation of the structure of the eye (appearance of a white stripe between the pupil and the upper eyelid, hiding the iris of the eye by the lower eyelid, swelling of the eyeball).
11. Tension of the fontanel, divergence of the skull bones.
12. Gradual excessive increase in head size (by 1 cm or more per month).

1. Severe headaches that occur mainly in the morning (painful sensations are localized in the temples and forehead).
2. Nausea, vomiting.
3. Pressing sensation in the eye area.
4. Sharp pain that occurs when changing the position of the head (turning, tilting).
5. Dizziness, disturbances in the functioning of the vestibular apparatus.
6. Pallor of the skin.
7. General weakness, drowsiness.
8. Muscle pain.
9. Increased sensitivity to bright lights and loud sounds.
10. Increased tone of the muscles of the limbs, as a result of which the child’s gait changes (he moves mainly on his toes).
11. Impaired concentration, memory, decreased intellectual abilities.

Possible complications

The brain is a very sensitive organ; any changes lead to disruptions in its functioning.

With hypertension syndrome, the brain is in a compressed state, which leads to very adverse consequences, in particular, to atrophy of organ tissue.

As a result, the child’s intellectual development decreases and the process of nervous regulation of activity is disrupted. internal organs, which, in turn, leads to a loss of their functionality.

In advanced cases, when large brain stems are compressed, a coma and death may occur.

Diagnostics

To identify pathology, it is not enough just visual inspection and interviewing the patient, so the child must undergo a detailed examination, including:

• X-ray of the skull;
• EchoCG;
• rheoencephalogram;
• angiography;
• puncture and examination of accumulated cerebrospinal fluid.

Treatment options

Treatment of the disease can be conservative (using medications) or surgical.

The second option is prescribed only as a last resort, in severe cases of the disease, when there is a risk of developing serious complications, or when drug treatment is ineffective.

Conservative

In addition to taking medications prescribed by the doctor, the child must follow a special diet and lifestyle.

In particular, it is necessary to reduce fluid intake as much as possible (while avoiding dehydration of the body), and also eliminate foods that contribute to fluid retention in the body (for example, salty, smoked, pickled foods, strong tea and coffee).

Excessive physical activity is contraindicated. As additional treatment, massage and acupuncture are prescribed to help relieve pain. It is necessary to take medications, such as:

1. Diuretics (Furosemide). The action of the drug is to remove accumulated cerebrospinal fluid from the brain area. The drug must be used only as prescribed by a doctor and in the dosage indicated by him, as side effects may occur.
2. Drugs to normalize the activity of the nervous system (Glycine) are necessary to reduce the load on the brain and restore the function of producing vital enzymes.

Most often, the child is prescribed to take Glycine or its analogues. Positive properties The benefits of the drug are that it has a safe effect on the body and no side effects. However, the drug has a sedative effect, which must be taken into account when taking it.

Painkillers and anti-inflammatory drugs (Nimesil), which help relieve intense pain.

Drugs that lower blood pressure. Prescribed if the cause of the development of hypertension syndrome is a sharp increase in blood pressure.

Surgery

In some cases, when the disease is severe and there is a risk of complications, the child needs surgical intervention.

This treatment method is necessary if the cause of the development of the disease is tumor formation.

In this case, the child undergoes craniotomy followed by removal of the tumor or foreign body. If excess fluid accumulates, a brain puncture is performed, or artificial holes are created in the vertebrae through which cerebrospinal fluid is drained.

Forecast

As a rule, the disease has a favorable prognosis and the child can be cured, however, the sooner therapy is prescribed, the better.

It is known that the disease is easier to treat in young children (infants), therefore, when the first warning signs are detected, it is necessary to show the child to a doctor.

Prevention measures

It is necessary to take care of preventing such a dangerous disease as hypertension syndrome at the stage of pregnancy planning. In particular, the expectant mother must undergo examination, identify and treat all her chronic diseases.

During the period of bearing a child, a woman must take care of her health, protect herself from viruses and infections, and follow all the instructions of the doctor monitoring the pregnancy.

Hypertension syndrome is a pathology associated with increased intracranial pressure.

This disease is very dangerous for children’s health, occurs due to a wide variety of reasons and can lead to the development dangerous consequences, up to the death of the child.

The pathology has a characteristic clinical picture, a set of pronounced signs, upon detection of which it is necessary to urgently show the child to a doctor.

Treatment should be started as early as possible, since the prognosis for recovery depends on the timeliness of therapy.

About hypertensive-hydrocephalic syndrome in infants in this video:

CHILD NEUROLOGY, PSYCHOLOGY AND PSYCHIATRY

FACTS AND MISCONCEPTIONS OF PERINATAL NEUROLOGY

although they are much closer. and therefore, “seven neurologists have a child without a diagnosis. "

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Key words: perinatal encephalopathy (PEP) or perinatal damage to the central nervous system (PP CNS), hypertensive-hydrocephalic syndrome (HHS); Graefe's symptom, the "setting sun" symptom; dilatation of the ventricles of the brain, interhemispheric fissure and subarachnoid spaces, lenticulostriate vasculopathy (angiopathy), mineralized (mineralizing) vasculopathy (angiopathy), pseudocysts on neurosonography (NSG), muscular dystonia syndrome (MSD), hyperexcitability syndrome, neonatal convulsions.

Despite free access to any scientific information, and so far more than 90%! Children of the first year of life come for consultation to specialized neurological centers about a non-existent diagnosis - perinatal encephalopathy (PEP). Child neurology is a relatively new field, but is already going through difficult times. At the moment, many doctors practicing in the field of infant neurology, as well as parents of infants with any changes in the nervous system and mental sphere, find themselves “between two fires.” On the one hand, the position of the school of “Soviet child neurology” is still strong - excessive diagnosis and incorrect assessment of functional and physiological changes in the nervous system of a child of the first year of life, combined with long-outdated recommendations intensive treatment a variety of medications. On the other hand, there is often an obvious underestimation of existing psychoneurological symptoms, inability strategic planning, ignorance of the possibilities of modern neurocorrection (orthopedics, ophthalmology, neuropsychology, speech therapy, defectology, etc.), therapeutic nihilism and fear of the practical application of modern methods of neurorehabilitation and drug therapy; and, as a result, lost time, unused internal reserves and the development of neuropsychic disorders in preschool, school and adolescence. At the same time, unfortunately, a certain “formality-automaticity” and “cost-effectiveness” of modern medical technologies lead, at a minimum, to the development of psychological problems in the child and his family members. The concept of “norm” in neurology at the end of the 20th century was sharply narrowed, but is now intensively and, not always justifiably, expanding. The truth is somewhere in the middle.

According to leading perinatal neurologists medical centers countries, so far, at least 80-90%! Children in their first year of life are referred by a pediatrician or neurologist from a district clinic for a consultation about a non-existent diagnosis - perinatal encephalopathy (PEP):

The diagnosis of “perinatal encephalopathy” (PEP or perinatal lesion of the central nervous system (PP CNS), in the old days was very common in pediatric neurology and extremely convenient: it described almost any, real or imaginary, dysfunction (and even structure) of the brain in the perinatal period of a child's life (from approximately 7 months of intrauterine development of the child until 1 month of life after birth), arising as a result of pathology of cerebral blood flow and oxygen deficiency.Later, bringing to life the “continuity of neurological diagnostics,” perinatal encephalopathy (PEP) necessarily smoothly transformed into two other favorite neurological diagnoses: MMD (minimal cerebral dysfunction) and VSD (vegetative-vascular dystonia).

The diagnosis of “perinatal encephalopathy” (PEP) was usually based on one or more sets of any signs (syndromes) of a probable nervous system disorder, for example, hypertensive-hydrocephalic syndrome (HHS), muscular dystonia syndrome (MDS), hyperexcitability syndrome.

After a thorough clinical examination, sometimes in combination with additional studies, the percentage of reliable diagnoses of perinatal brain damage (hypoxic, traumatic, toxic-metabolic, infectious, etc.) quickly decreases to 3-4% - this is more than 20 times! The most bleak thing about these figures is not only the certain reluctance of individual doctors to use the knowledge of modern neurology and conscientious delusion, but also the clearly visible psychological (and not only) comfort of such overdiagnosis.

Hypertension-hydrocephalic syndrome (HHS): increased intracranial pressure (ICP) and hydrocephalus

As before, the diagnosis is “hypertensive-hydrocephalic syndrome” (HHS) or “intracranial hypertension” (increased intracranial pressure (ICP)),

one of the most commonly used and “favorite” medical terms among pediatric neurologists and pediatricians, which can explain almost everything! and at any age, complaints from parents. This is extremely comfortable for a doctor!

For example, a child often cries and shudders, sleeps poorly, spits up a lot, eats poorly and gains little weight, eyes widen, walks on tiptoes, his arms and chin tremble, there are convulsions and there is a lag in psycho-speech and motor development: “only he is to blame - hypertensive-hydrocephalic syndrome (HHS) or increased intracranial pressure.” Isn’t it a very useful and convenient diagnosis?

Quite often, “heavy artillery” is used as the main argument for parents - data instrumental methods research with mysterious scientific graphs and figures. Rigorous scientific medical terms look mysterious and impressive, forcing the uninitiated to treat medical conclusions with even greater respect.

The methods can be used in a variety of ways, either completely outdated and uninformative / echoencephalography (ECHO-EG) and rheoencephalography (REG) /, or examinations “from the wrong opera” (EEG), or incorrect, in isolation from clinical manifestations, subjective interpretation of normal variants with neurosonography or tomography. Especially recently, the subjective interpretation of Dopplerographic indicators of cerebral circulation in NSG has become relevant. “Yes, the child’s venous blood flow rate is increased, and the resistance index is reduced by as much as 0.12! This is the surest sign of hypertensive-hydrocephalic syndrome!” - confidently declare to worried parents. “Look at the screen! Look, the left lateral ventricle has increased by 2 mm in 2 months, and the right one, even by 2.5! This is very bad, a serious problem, we will treat it!” - comes from the neurosonography room, and both parents slowly slide down the wall.

There is only one “scientifically rigorous” entry in the description of the NSG - “. Changes in the structure of the periventricular tissues are also revealed: linear hyperechoic structures (thickened vascular walls) are visualized on both sides in the projection of the parenchyma of the subcortical nuclei. Conclusion: Slight expansion of external liquor spaces. Pseudocyst of the right choroid plexus. Lenticulostriate vasculopathy (angiopathy). mineralized (mineralizing) angiopathy (vasculopathy). echo signs of SEC (subependymal cyst) on the left, in the CTV (caudothalamic notch) SEC” - can easily and completely poison the life of any family, especially the “alarming purple” mother. Unhappy mothers of such children unwittingly, at the suggestion of doctors (or voluntarily, feeding on their own anxiety and fears), pick up the flag of “intracranial hypertension”, begin to actively “treat” hypertensive-hydrocephalic syndrome (HHS) and for a long time end up in the monitoring system for perinatal encephalopathy.

In fact, intracranial hypertension is a very serious, and quite rare, neurological and neurosurgical pathology. It accompanies severe neuroinfections and brain injuries, hydrocephalus, cerebrovascular accidents, brain tumors, etc.

Hospitalization is mandatory and urgent!

Intracranial hypertension (if it really exists) is not difficult for attentive parents to notice: it is characterized by constant or paroxysmal headaches (usually in the morning), nausea and vomiting not associated with food. The child is almost always lethargic and sad, is constantly capricious, cries, refuses to eat, he always wants to lie down and cuddle with his mother. The baby is really, truly feeling bad; any attentive mother will immediately notice this

A very serious symptom can be strabismus or difference in pupils, and, of course, disturbances of consciousness. In infants, bulging and tension of the fontanel, divergence of the sutures between the bones of the skull, as well as rapid, excessive growth of head circumference are very suspicious.

Without a doubt, in such cases the child must be shown to specialists as soon as possible. Usually, one clinical examination is enough to exclude or, conversely, pre-diagnose this pathology. Sometimes additional research methods are required (fundus examination, neurosonography, as well as magnetic resonance imaging or computed tomography of the brain (MRI and CTG).

Of course, expansion of the interhemispheric fissure, cerebral ventricles, subarachnoid and other spaces of the cerebrospinal fluid system on neurosonography (NSG) images or brain tomograms (brain computed tomography or magnetic resonance imaging) cannot serve as unambiguous evidence of intracranial hypertension. The same applies to cerebral blood flow disorders isolated from clinical manifestations, identified by transcranial Dopplerography of cerebral vessels, and even more so to “finger impressions” on a skull x-ray.

In addition, there is no direct and reliable connection between intracranial hypertension and translucent vessels on the face and scalp, walking on tiptoes, trembling hands and chin, hyperexcitability, developmental disorders, poor academic performance, nosebleeds, tics, stuttering, bad behavior, etc. d. and so on.

That’s why, if your baby has been diagnosed with “perinatal encephalopathy (PEP) or perinatal damage to the central nervous system (PP CNS), intracranial hypertension or hypertensive-hydrocephalic syndrome (HHS)”, based on the “bulging” eyes (not to be confused with the true Graefe symptom , a symptom of the “setting sun”!) and walking on tiptoe, then you shouldn’t go crazy in advance. In fact, these reactions may be characteristic of easily excitable young children. They react very emotionally to everything that surrounds them and what happens. Sensitive parents will easily be able to notice such a relationship.

Thus, when receiving a non-existent diagnosis of “perinatal encephalopathy (PEP) or perinatal damage to the central nervous system (PP CNS) and hypertensive-hydrocephalic syndrome”, before panicking and starting to actively push unnecessary pills into the baby, it is best to quickly get a second expert opinion, and contact a neurologist with modern knowledge in the field of perinatal neurology. It is then that you can finally verify the absence serious problems at the baby's.

It is absolutely unreasonable to begin treatment for this unspecified “serious” pathology on the recommendations of one doctor based on the above “arguments”; in addition, such unfounded treatment may not be safe at all. Any medications that “relieve intracranial hypertension” prescribed without reason at this age can be harmful! Side effects are very diverse: from a mild allergic rash to serious problems in the functioning of internal organs. Diuretic drugs alone, unjustifiably prescribed for a long time, have an extremely adverse effect on the growing body, causing metabolic disorders.

But! There is another, no less important aspect of the problem that must be taken into account in this situation. Sometimes medications are really necessary, and wrongful refusal from them, based only on the mother’s (and more often the father’s!) own conviction that medications are harmful, can lead to serious troubles. In addition, if there really is a serious progressive increase in intracranial pressure and the development of hydrocephalus, then often incorrect drug therapy for intracranial hypertension entails the loss of a favorable moment for surgical intervention (shunt surgery) and the development of severe irreversible consequences for the child: hydrocephalus, developmental disorders, blindness , deafness, etc.

Now a few words about the equally “adored” hydrocephalus and hydrocephalic syndrome. In fact, we are talking about a progressive increase in intracranial and intracerebral spaces filled with cerebrospinal fluid (CSF) due to the existing! at that moment of intracranial hypertension. In this case, neurosonograms (NSG) or tomograms reveal dilations of the ventricles of the brain, interhemispheric fissure and other parts of the cerebrospinal fluid system that change over time. Everything depends on the severity and dynamics of the symptoms, and most importantly, on the correct assessment of the relationships between the increase in intracerebral spaces and other changes in the nervous system. This can be easily determined by a qualified neurologist. True hydrocephalus, which does require treatment, like intracranial hypertension, is relatively rare. Such children must be observed by neurologists and neurosurgeons at specialized medical centers.

Unfortunately, in ordinary life such an erroneous “diagnosis” occurs in almost every fourth or fifth baby. It turns out that some doctors often incorrectly call a stable (usually slight) increase in the ventricles and other cerebrospinal fluid spaces of the brain hydrocephalus (hydrocephalic syndrome). This does not manifest itself in any way through external signs or complaints and does not require treatment. Moreover, if the child is suspected of having hydrocephalus based on a “large” head, translucent vessels on the face and scalp, etc. - this should not cause panic among parents. The large size of the head in this case plays practically no role. However, the dynamics of head circumference growth is very important (how many centimeters are added over a certain period of time. In addition, you need to know that among modern children it is not uncommon to have so-called “tadpoles” whose heads are relatively large for their age (macrocephaly). B In most of these cases, babies with large heads show signs of rickets, less often - macrocephaly, caused by the family constitution. For example, a father or mother, or maybe a grandfather has a large head, in a word, it is a family matter and does not require treatment.

Sometimes, when performing neurosonography, an ultrasound doctor finds pseudocysts in the brain - but this is not a reason to panic at all! Pseudocysts are single round tiny formations (cavities) containing cerebrospinal fluid and located in typical areas of the brain. The reasons for their appearance, as a rule, are not reliably known; they usually disappear by 8-12 months. life. It is important to know that the existence of such cysts in most children is not a risk factor for further neuropsychic development and does not require treatment. However, although quite rare, cysts form at the site of subependymal hemorrhages, or are associated with perinatal cerebral ischemia or intrauterine infection. The number, size, structure and location of cysts give specialists very important information, taking into account which, based on a clinical examination, final conclusions are formed.

Description of NSG is not a diagnosis and not a reason for treatment!

Most often, NSG data provide indirect and uncertain results, and are taken into account only in conjunction with the results of a clinical examination.

Once again I must remind you of the other extreme: in difficult cases Sometimes there is a clear underestimation on the part of parents (less often, doctors) of the child’s problems, which leads to a complete refusal of the necessary dynamic observation and examination, as a result of which the correct diagnosis is made late, and treatment does not lead to the desired result.

Therefore, if increased intracranial pressure and hydrocephalus are suspected, diagnosis should be carried out at the highest professional level.

What is muscle tone and why do doctors and parents “love” it so much?

Look at your child’s medical record: is there no such diagnosis as “muscular dystonia”, “hypertension” and “hypotension”? - you probably just didn’t go with your baby to the neurologist’s clinic until he was a year old. This is, of course, a joke. However, the diagnosis of “muscular dystonia” is no less common (and perhaps more common) than hydrocephalic syndrome and increased intracranial pressure.

Changes in muscle tone can be, depending on the severity, either a variant of the norm (most often) or a serious neurological problem (this is much less common).

Briefly about external signs of changes in muscle tone.

Muscular hypotonia is characterized by a decrease in resistance to passive movements and an increase in their volume. Spontaneous and voluntary motor activity may be limited; palpation of the muscles is somewhat reminiscent of “jelly or very soft dough.” Severe muscle hypotonia can significantly affect the rate of motor development (for more details, see the chapter on movement disorders in children of the first year of life).

Muscular dystonia is characterized by a condition where muscle hypotonia alternates with hypertension, as well as a variant of disharmony and asymmetry of muscle tension in individual muscle groups (for example, more in the arms than in the legs, more on the right than on the left, etc.)

At rest, these children may experience some muscle hypotonia during passive movements. When trying to actively perform any movement, during emotional reactions, when the body changes in space, muscle tone increases sharply, pathological tonic reflexes become pronounced. Often, such disorders subsequently lead to improper development of motor skills and orthopedic problems (for example, torticollis, scoliosis).

Muscular hypertension is characterized by increased resistance to passive movements and limitation of spontaneous and voluntary motor activity. Severe muscle hypertension can also significantly affect the rate of motor development.

Violation of muscle tone (muscle tension at rest) can be limited to one limb or one muscle group (obstetric paresis of the arm, traumatic paresis of the leg) - and this is the most noticeable and very alarming sign, forcing parents to immediately consult a neurologist.

It is sometimes quite difficult for even a competent doctor to notice the difference between physiological changes and pathological symptoms in one consultation. The fact is that changes in muscle tone are not only associated with neurological disorders, but also strongly depend on the specific age period and other characteristics of the child’s condition (excited, crying, hungry, drowsy, cold, etc.). Thus, the presence of individual deviations in the characteristics of muscle tone does not always cause concern and require any treatment.

But even if functional disorders of muscle tone are confirmed, there is nothing to worry about. A good neurologist will most likely prescribe massage and physical therapy (exercises on large balls are very effective). Medicines are prescribed extremely rarely, usually for severe muscle hypertension of a spastic nature.

Hyperexcitability syndrome (syndrome of increased neuro-reflex excitability)

Frequent crying and whims with or without cause, emotional instability and increased sensitivity to external stimuli, sleep and appetite disturbances, excessive frequent regurgitation, motor restlessness and shuddering, trembling of the chin and arms (etc.), often combined with poor growth weight and bowel dysfunction - do you recognize such a child?

All motor, sensitive and emotional reactions to external stimuli in a hyperexcitable child arise intensely and abruptly, and can fade away just as quickly. Having mastered certain motor skills, children constantly move, change positions, constantly reach for and grab objects. Children usually show a keen interest in their surroundings, but increased emotional lability often makes it difficult for them to communicate with others. They have a subtle mental organization, they are very impressionable, emotional and easily vulnerable! They fall asleep extremely poorly, only with their mother, they constantly wake up and cry in their sleep. Many of them have a long-term reaction of fear when communicating with unfamiliar adults with active reactions of protest. Typically, hyperexcitability syndrome is combined with increased mental exhaustion and fatigue.

The presence of such manifestations in a child is just a reason to contact a neurologist, but in no case is it a reason for parental panic, much less drug treatment.

Constant hyperexcitability is not causally specific and can most often be observed in children with temperamental characteristics (for example, the so-called choleric type of reaction).

Much less frequently, hyperexcitability can be associated and explained by perinatal pathology of the central nervous system. In addition, if a child’s behavior is suddenly disrupted unexpectedly and for a long time for virtually no apparent reason, and he or she develops hyperexcitability, the possibility of developing an adaptation disorder reaction (adaptation to external environmental conditions) due to stress cannot be ruled out. And the sooner the child is examined by specialists, the easier and faster it is possible to cope with the problem.

And, finally, most often, transient hyperexcitability is associated with pediatric problems (rickets, digestive disorders and intestinal colic, hernia, teething, etc.). Parents! Find a competent pediatrician!

There are two extremes in the tactics of monitoring such children. Or an “explanation” of hyperexcitability using “intracranial hypertension” in combination with intensive drug therapy, and even the use of drugs with pronounced side effects (diacarb, phenobarbital, etc.). At the same time, the need for treatment is “confidently” justified by the prospect of the child developing MMD (minimal cerebral dysfunction) and VSD (vegetative-vascular dystonia) in the future. Or, on the contrary, complete neglect of this problem (“just wait, it will go away on its own”), which can ultimately lead to the formation of persistent neurotic disorders (fears, tics, stuttering, anxiety disorders, obsessions, sleep disorders) in the child and his family members, and will require long-term psychological correction. Of course, it is logical to assume that an adequate approach lies somewhere in between.

Separately, I would like to draw the attention of parents to seizures - one of the few disorders of the nervous system that really deserves close attention and serious treatment. Epileptic seizures do not occur often in infancy, but they are sometimes severe, insidious and disguised, and almost always require immediate drug therapy.

Such attacks can be hidden behind any stereotypical and repetitive episodes in the child’s behavior. Incomprehensible shudders, head nods, involuntary eye movements, “freezing”, “squeezing”, “going limp”, “falling asleep”, especially with a fixed gaze and lack of reaction to external stimuli, should alert parents and force them to contact specialists. Otherwise, a late diagnosis and untimely prescribed drug therapy significantly reduce the chances of treatment success.

All circumstances of the seizure episode must be accurately and completely remembered and, if possible, recorded on video for further detailed description at the consultation. Attention! The doctor will definitely ask these questions! If convulsions last a long time or are repeated, call “03” and urgently consult a doctor.

IN early age the child’s condition is extremely changeable, so minimal developmental deviations and other disorders of the nervous system can sometimes be detected only during long-term dynamic monitoring of the baby, with repeated consultations. For this purpose, specific dates for planned consultations with a pediatric neurologist in the first year of life have been determined: usually at 1, 3, 6 and 12 months. It is during these periods that most serious diseases of the nervous system of children in the first year of life can be detected (hydrocephalus, epilepsy, cerebral palsy, metabolic disorders, etc.). Thus, identifying a specific neurological pathology in the early stages of development makes it possible to begin complex therapy on time and achieve the maximum possible result.

And in conclusion, I would like to remind parents: be sympathetic and attentive to your kids! First of all, it is your active and meaningful interest in the lives of children that is the basis for their future well-being. Do not try to cure them of “supposed illnesses,” but if something worries and worries you, find the opportunity to get independent advice from a qualified specialist.