Rus Articles Journal

Hydrocephaly: not to miss time!

the Increased intra cranial pressure - the diagnosis which is known by almost all young parents as it is exposed in our country widely and often - are groundless, without carrying out necessary researches. Actually at the heart of this pathology - a serious illness, one of which - hydrocephaly.

Hydrocephaly (brain dropsy) is A little anatomy and physiology

(from gr.“ the hydra“ - water, “tsefalon“ - the head) is the state which is followed by increase in volume of ventricles of a brain. In a brain of the person there are several cavities which are reported with each other filled with a likvor (cerebrospinal fluid). These cavities are called ventricles. The ventricular system consists of two lateral ventricles which connect to a slit-like third ventricle (the III ventricle) which, in turn, via the thin channel (Silviyev a water supply system) connects to the fourth ventricle (the IV ventricle). Likvor is developed in vascular textures of ventricles and freely moves from lateral to the IV ventricle, and from it - to subweb space of a head and spinal cord (subweb (subarakhnoidalny) space the space between a brain and a firm brain cover is called) where it washes an external surface of a brain. In the same place there is its return absorption to the blood course. Likvor is a transparent, colourless liquid, by the form very similar to water, contains insignificant quantity of cages, protein and salts. At the baby the quantity of a likvor makes about 50 ml, at the teenager and the adult - to 120 - 150 ml. Likvor is constantly developed and soaked up, in days is produced by vascular textures of a brain to 500 ml of cerebrospinal fluid.

Any violation in system of a likvoroproduktion, likvorotsirkulyation and absorption of a likvor conducts

to its excess congestion in brain cavities that is called hydrocephaly, or brain dropsy.

Types of hydrocephaly

When on the way of cerebrospinal fluid from lateral ventricles to an exit from the IV ventricle there is an obstacle and the likvor cannot freely get to subweb space, hydrocephaly is called not reported (closed, okklyuzionny). In other cases hydrocephaly carries the name reported (open). Hydrocephaly is primary (as the main disease) and secondary , i.e. complication of other diseases (tumors, malformations of the central nervous system (CNS) and vessels of a brain, etc.) . Classifications of hydrocephaly exists much, but these are the main and are used most often.

Violation of circulation and absorption of cerebrospinal fluid leads

of Display of hydrocephaly to its excess accumulation and increase of intra cranial pressure. It is differently shown at kids till 2 years and at more senior children.

the Main symptom of development of dropsy of a brain in children till 2 years is the accelerated growth of a circle of the head. Skull seams at kids did not grow yet, and the size of the head increases because skull bones are moved apart from within by the growing brain. In the same way the balloon when we inflate it increases in volume. There is a schedule of growth of a circle of the head. It is necessary to measure it everyone one - two months, it is done by the local pediatrician during routine inspections. If the head of the child grows quicker than normal indicators, then it is a disturbing symptom; it most often demonstrates development of hydrocephaly when the accelerated growth of the head happens at the expense of a surplus of cerebrospinal fluid in brain ventricles. Often it happens the first symptom of a disease. Besides the accelerated growth of the head of children it is possible to reveal increased in sizes and a vybukhayushchy big fontanel which has to be closed approximately by 1 year, but at hydrocephaly it can be open to 2 and even till 3 years. Bones of a skull become thinner, the forehead becomes disproportionately increased and acting. On a forehead and on a face the venous network appears. In more started cases can be looked down down (a symptom Gref). The tone of muscles of legs raises. Convulsive attacks can be observed.

the Child begins to lag behind in rates of psychomotor development. He does not hold a head in time, does not sit, does not get up, does not play. The sick child sluggish, apathetic, times is nemotivirovanno whining. Perhaps, the kid feels a headache: it can grab a head.

the Majority of symptoms of increase of intra cranial pressure only the skilled pediatrician, the neuropathologist or the neurosurgeon can distinguish

, but parents can measure growth rates of the head and check according to special schedules. Anyway, the accelerated growth of a circle of a head of the child, and also unclear lag of rates of its development has to be the cause for serious inspection of the kid at the neuropathologist or the neurosurgeon for a hydrocephaly exception.

At children 2 years are more senior than

seams of a skull grow, and increase of intra cranial pressure is shown in a different way. The classical picture is headaches with nausea and vomiting (is more often at night or in the morning), changes at an eye bottom (so-called hypostasis of a disk of an optic nerve which can be revealed by the oculist). Headaches, especially with nausea and vomiting, are symptoms which demand inspection from the neuropathologist or the neurosurgeon. They can be caused by hydrocephaly, a brain tumor, brain malformations. Pediatricians often forget about it, and children long time also are aimlessly treated concerning gastritis, pancreatitis, dyskinesia of bilious ways, poisonings and zheludochno - intestinal infections and so forth, and to the neuropathologist and the neurosurgeon get with delay in a serious condition. It is necessary to insist on carrying out consultation of the neurologist and inspection in case of unclear headaches, regular episodes of nausea and vomiting, decrease in sight, and in some cases it will allow to make the right diagnosis on early terms and to save the child`s life.

Other symptoms of hydrocephaly are various

and depend on the reason which caused it. It can be epileptic spasms, sight violation, increase of a tone in legs, pelvic frustration (an incontience or a delay of urine), endocrine violations (lag in growth or giantism, premature sexual development, a hypothyroidism - decrease in production of hormones of a thyroid gland, obesity), decrease in progress at school and so forth

of the Reason of hydrocephaly at children

of the Reason of hydrocephaly are very diverse and substantially depend on age of the child.

  1. Hydrocephaly at a fruit. Modern types of prenatal diagnostics (for example, ultrasonic research - ultrasonography) allow to reveal hydrocephaly at yet not been born baby. In most cases various malformations of the central nervous system (CNS) are its reason. In 20% dropsy is connected with pre-natal infections (a cytomegalic inclusion disease, herpes, toxoplasmosis). Planning pregnancy parents have to pass researches on these infections which often proceed is hidden and to treat them. It will allow to avoid many problems with health of the kid. In rare instances hydrocephaly is caused by genetic disorders.
  2. Hydrocephaly of newborns. Most often (to 80%) dropsy at newborns is caused by malformations of a head and spinal cord and consequences of pre-natal infections. Approximately in 20% hydrocephaly is a consequence of a patrimonial trauma, especially at premature babies which is followed by intracerebral or intra ventricular hemorrhage and the joined meningitis (an inflammation of brain covers) that leads to violation of absorption of a likvor. Extremely seldom at this age tumors and vascular malformations of a brain which can also become the reason of development of dropsy come to light.
  3. Hydrocephaly at kids and children of advanced age (of 1 - 2 years is also more senior). There is a lot of reasons of development of hydrocephaly in such children. Tumors of a head and spinal cord concern to them; consequences of the postponed meningitis, encephalitis (a brain substance inflammation), various infectious diseases (for example, tuberculosis); malformations of a brain and vessels of a brain; consequences of hemorrhages; consequences cherepno - a brain trauma; genetic disorders. Sometimes the reason of hydrocephaly does not manage to be established.

As make to
the diagnosis?

Diagnosis of hydrocephaly is based on a clinical picture, survey of an eye bottom, and also additional methods of research, such as neyrosonografiya (NSG) ultrasonic research of a brain (at babies till 2 years), the computer tomography (CT) or magnitno - a resonant tomography (MRT) of a brain. The pediatrician, the neuropathologist or the neurosurgeon can make primary diagnosis neonatolog.

the Most widespread operation is ventrikulo - peritonealny shunting (VPSh).
Neyrosonografiya`s

is an effective method of diagnostics of a condition of substance of a brain and ventricular system at children till 1,5 - 2, the big fontanel and others “ultrasonic windows“ - skull sites on which bones very thin (for example, a temporal bone) and pass ultrasound was not closed yet. It allows to reveal expansion of ventricular system, intra cranial volume educations (tumors, hematomas, cysts), some malformations of a brain. However it is necessary to remember that NSG - a method not absolutely exact. The image of a brain turns out with considerably smaller permission (less accurate), than at KT and MPT.

to

At detection of any pathology of a brain needs carrying out KT or MPT. Without them it is impossible to make the exact diagnosis, to establish the hydrocephaly reason and the more so to carry out treatment. The equipment this expensive is also still installed not in all hospitals. In this case parents have to insist on carrying out KT or MPT in other centers or execute them independently on a commercial basis. It is necessary to consider that the clinic which undertakes treatment of children with hydrocephaly is obliged to have this equipment. Otherwise it is possible to recommend to parents to choose another, more equipped hospital, at least and in other city.

Treatment of hydrocephaly

the Endoscopic ventrikulostomiya allows to avoid implantation of a foreign matter.

in case of statement of the diagnosis “hydrocephaly“ (any reason) the child has to be examined by the neurosurgeon. Most often children with hydrocephaly are treated surgically, and the neurosurgeon defines indications and contraindications to operation. Supervision of children with hydrocephaly only by the neuropathologist or the pediatrician of indifference of the neurosurgeon is a mistake and sometimes leads to an unreasonable delay of surgical intervention.

to Parents hardly is given the decision on need to execute operation. However long increase of intra cranial pressure causes a delay of psychomotor development which not always manages to be compensated after unreasonably postponed surgical intervention. It is also necessary to note that unreasonably big head of the child having dropsy even after operation will not become the former sizes any more - it will be possible to stop its further growth only. In a literal sense, it will be difficult for child to carry it on shoulders, besides, further it will cause many cosmetic problems. Parents of children with hydrocephaly have to know that even if the neuropathologist does not direct them to the neurosurgeon, they have to show an initiative and to organize this consultation.

the Purpose of operation is that the likvor is taken away from brain ventricles in other cavities of an organism. The most widespread operation is ventrikulo - peritonealny shunting (VPSh). On system of silicone catheters the likvor from a lateral ventricle of a brain flows in an abdominal cavity where it is soaked up between intestines loops. The quantity of the following likvor is regulated by the special valve. Catheters are carried out under skin and outside are not visible. Annually in the world more than 200 thousand such operations are carried out. The shunting systems saved millions of children`s lives.

Less often the likvor is allocated for

in the right auricle (ventrikulo - atrialny shunting), in the big occipital tank (operation on Torkildsen) or the spinal channel at the level of a waist connects a catheter to an abdominal cavity (lyumbo - peritonealny shunting).

With development of modern endoscopic equipment (the endoscope is entered into cavities of a body of the person through small cuts, allows to examine them, to carry out manipulations) the possibility of treatment of patients without installation of the shunting system appeared. By means of the endoscope in the depth of a brain the roundabout way for outflow of a likvor is created. This very effective operation (it carries the name an endoscopic ventrikulostomiya), which allows to avoid implantation of a foreign matter what the shunting system is and by that to prevent many complications. Unfortunately, it is possible to help this operation only to limited number of patients (about 10% of all number of patients) with some forms of okklyuzionny hydrocephaly. In other cases it is necessary to put the shunting system as improvement from endoscopic operation will not be.

Successfully executed operation stops progressing of a disease. The most part of children has an opportunity to return to normal life, on an equal basis with healthy peers attends kindergarten, school.

In certain cases patients with hydrocephaly are not operated with

, and are under supervision and during more or less long period accept Diakarb (the preparation reducing production of cerebrospinal fluid). It becomes when there are no obvious signs of progressing of a disease and increase of intra cranial pressure. Observation is made under strict control of the neuropathologist or neurosurgeon with frequent surveys, measurements of a circle of the head of the child, repeated NSG or KT - researches.

Myths about the increased intra cranial pressure

the Diagnosis “the increased intra cranial pressure“, “intra cranial hypertensia (VChG)“ or “gipertenzionno - the gidrotsefalny syndrome“ as it was already told, is exposed often and in certain cases - is groundless. How increase of the intra cranial pressure (VChG) is shown? As it was already noted, at kids till 2 years such manifestations are, first of all, the accelerated growth of a circle of the head, vybukhayushchiya and the increased big fontanel, possible disorders of the movement of eyes, a delay of psychomotor development. Most often all these frustration are shown in a complex. At children 2 years are more senior these are headaches with nausea and vomiting, more often in the mornings, changes at an eye bottom (come to light at survey of the ophthalmologist). Certainly, the clinical picture can be various, but without above-mentioned symptoms the diagnosis “the increased intra cranial pressure“ is doubtful.

Such symptoms as sleep disorder and behavior, a hyperactivity, deficiency of attention, addictions, bad progress, a hyper tone in legs, “marble“ drawing of skin, including on the head, nasal bleedings, trembling of a chin, walking on tiptoe, in itself do not testify to the increased intra cranial pressure. And all - some neuropathologists expose the diagnosis of VChG on the basis of these complaints. Neyrosonografiya, having become the huge benefit for pediatrics and neurology, brought the essential contribution in excess and false diagnostics “gipertenzionno - a gidrotsefalny syndrome“. NSG gives the chance to quickly receive the image of substance of a brain, to measure the sizes of ventricles. However for specification of the diagnosis as we already spoke, carrying out KT and MPT is obligatory.

What is a tomography?

the Computer Tomography (CT) is the x-ray method of research allowing to receive images of internals and bones of the person in a look poperechnkh cuts. At KT X-raythe vsky tube rotates around the patient`s body, making a set of pictures, and then the computer summarizes the obtained data and builds the ready image. Magnitno - the resonant tomography (MRT) also allows to receive cuts of internals of the person, however thanks to other physical principle. The patient is located in a pipe with a strong magnetic field, the special electromagnetic signal is given, and then on the basis of the reflected signals the computer builds the image. At MRT it is possible to receive the image in all three planes (cross, longitudinal and direct). X-ray radiation at the same time is not used therefore pregnant women can carry out MRT. MRT is “the gold standard“ in diagnosis of hydrocephaly, she allows to estimate the sizes of ventricular system, structure of substance of a brain, to reveal tumors and malformations of a head and spinal cord, and in certain cases even to see and describe circulation of a likvor. KT is simpler and fast, but less sensitive way of inspection. It can be recommended for primary establishment of the diagnosis and dynamic supervision.
Parents often ask

what techniques allow to measure intra cranial pressure. Direct measurement of intra cranial pressure is possible by installation of the special sensor in a skull cavity. It becomes in large clinics according to special indications (for example, at heavy cherepno - a brain trauma). It is rather objectively possible to judge intra cranial pressure at a lyumbalny puncture - introduction of a needle to a cavity of the spinal channel at the lumbar level. All other methods of research give only indirect information and are valuable only at their complex assessment.

the Rheoencephalography (REG) and an echo - an encephalography (An echo - EG or the Echo - ES) for diagnosis of intra cranial hypertensia are useless

: they do not give objective information, and their use is profanation.

(survey of an eye bottom by the ophthalmologist, data of NSG together with pictures of KT or MPT) can be spoken to

Only on the basis of careful comparison of clinical data with results of additional researches in increase of intra cranial pressure and to find its reason. The diagnosis of VChG demands urgent and most often neurosurgical treatment as it threatens health and the patient`s life. To observe the child with intra cranial hypertensia, without having shown him to the neurosurgeon, - it is all the same that to suspect appendicitis or a sharp myocardial infarction and to suggest to come in a week.

Excess diagnostics of the increased intra cranial pressure leads

to a stress at parents and to unreasonable purpose of a large number of drugs to the child. The only preparation which in out-patient conditions can reduce intra cranial pressure is Diakarb. He is appointed very widely. Such preparations as Kavinton, Cinnarizine, Sermion, nicotinic acid, Nootropil, Piracetam, Pantogam, Entsefabol, Pikamilon, herbs, vitamins, homeopathic remedies, are very popular, but do not influence intra cranial pressure in any way. In any case, there is no research which objectively would confirm their efficiency at VChG. The drugs appointed without indications cannot bring advantage, and they have side effects. Besides, it is essential load of a pocket of parents.

the Right to make the diagnosis and to appoint treatment is only at the doctor who saw the patient. However the problem of hyper diagnostics of a syndrome of the increased intra cranial pressure exists and requires attention and vigilance from parents.