Alcoholic encephalopathies (Greek enkephalos — a brain and pathos — suffering, a disease) — one of groups of the metalkogolny psychoses developing at hron. alcoholism. The combination of mental disorders to the system somatic and neurologic disturbances which are quite often dominating in a clinical picture is characteristic of them. Depending on sharpness of a disease mental disorders are defined or preferential heavy deliriums and conditions of devocalization, or various pictures of an organic psychosyndrome, various on depth (see. Psychoorganic syndrome ).
- 1 The historical sketch
- 2 Classification
- 3 A clinical picture
- 4 Pathological anatomy
- 5 Diagnosis and differential diagnosis
- 6 Forecast
- 7 Treatment
- 8 Prevention
- 9 Bibliography
The historical sketch
the Beginning of the description of a clinical picture of this group of psychoses belongs to the last quarter of 19 century It was noted that at patients hron. alcoholism (see. alcoholism ), in addition to delirium tremens, crazy states and hallucinosis, there can be psychoses which general feature is development various on depth and structure of dementias which are followed by massive somatic and neurologic frustration. In most cases these diseases came to an end letalno. As separate forms were described: diffusion encephalopathy [A. Gayet, 1875], an upper acute polioencephalitis [Vernike (To. Wernicke), 1881], alcoholic paralysis, polyneuritic psychosis (S. S. Korsakov, 1887, 1889), central degeneration of a corpus collosum [Markiafava, Binyami (E. Marchiafava, A. Bignami), 1903], alcoholic pseudoparalysis [P. Chotzen, 1906; Krepelin (E. Kraepelin), 1912], cerebellar atrophy [J. Lhermitte, 1934], laminar cortical sclerosis [F. Morel, 1939], central necrosis of the bridge [Adam, Victor, Mankoll (R. Adams, M. of Victor, E. Mancall), 1959].
A number of these forms, first of all upper acute polioencephalitis, Bender and Shilder (L. Bender, P. Schilder, 1933) suggested to designate the term «alcoholic encephalopathy». In the subsequent it began to be used not only as a synonym of the picture of a disease described by Vernike, but also as the generalizing definition of other forms. In the first years 20 century Elkholts (Elsholz, 1900) and Bongeffer (To. Bonhoeffer, 1901) suggested about existence of psychopathological and nosological dependences between the forms described by Gayet — Vernike, on the one hand, and korsakovsky psychosis — with another. Nearly half a century later about possible nosological unity between these forms many French psychiatrists [A. Pallasse, came 1952 to a conclusion; Girard, Devik, Gard (P. Girard, M. Devic, A. Garde), 1953, 1956; Anken (M. Enkin), 1957; Tommasi (M. Tommasi), 1957; R. Pluvinage, 1965], some English and Swiss psychiatrists [Adam and Victor, 1953; R. Wyss, I960] and Soviet researchers (A. P. Demichev, I. I. Lukomsky, 1968, 1970; G. I. Laricheva, 1969).
The clinical picture described by Gayet and Vernike testifies, according to some of them, to sharpness and big weight of pathological process; korsakovsky psychosis (see below) has rather sluggish and less malignant current. Very often mental disorders beginning the symptoms characteristic of Gayet's form — Vernike, in the subsequent are replaced by a picture of korsakovsky psychosis. Allocation of the concept «Gayet's syndrome — Vernike — Korsakova» [Gamper, Anken, Anzhelerg (R. Аngelergues), 1958] was result of these observations. Some psychiatrists (Anken, A. P. Demichev) define And. aa. as «Gayet's disease — Vernike — Korsakova».
This, gaining the increasing recognition, the point of view is resisted by views, according to the Crimea korsakovsky psychosis of alcoholic genesis is special not only in clinical, but also in the nosological relation a disease and shall not mix up with And. aa. like Gayet — Vernike (S. G. Zhislin, 1965; I. V. Strelchuk, 1970). Plyuvinazh considers all described forms A. aa. nosologically one disease.
Clinical generalizations in the doctrine about And. aa. were confirmed by researches of pathomorphologists, studying of late symptomatic psychoses and works of experimental character. The facts received at the same time promoted also understanding of a pathogeny And. aa. (see below).
At various And. aa., in particular at Gayet's forms — Vernike and korsakovsky psychosis, pathoanatomical changes are similar, often indistinguishable and have identical localization — most often are surprised average and a diencephalon [W. Spielmeyer, 1904]. At the same time it is not about inflammatory as considered Vernike in due time, and about degenerative [Shpilmeyer, Gamper, Shpatts (N. of Spatz), P.E. Snesarev] process, most likely toxic character what S. S. Korsakov for the first time pointed to. He noted similarity of the psychosis described by it to mental disorders at beriberi and a pellagra.
During the studying of late symptomatic psychoses [Tiliman, 1934; Neybyurger (To. Neuburger), 1936; M 3. Kaplinsky, 1938, 1940; A. V. Snezhnevsky, 1940] similarity of mental and somatoneurologic disorders, and also pathoanatomical changes to those which met also at is established And. aa.
Comparison of both groups of diseases allowed A. V. Snezhnevsky to suggest (1941) that emergence as late symptomatic psychoses, and alcoholic psychoses (see) with a clinical picture A. aa., the described Vernika, it is impossible without development of the system somatic frustration which is shown damage of a liver went. - kish. a path and vegetative and endocrine disturbances against the background of physical aging or a cachexia. Somatic and mental disorders, according to A. V. Snezhnevsky, have causal dependence on avitaminosis.
Value of oryzamin in a pathogeny And. aa. it was shown by Alexander (L. Alexander, 1938, 1940). He noted similarity of pathoanatomical changes at Gayet's syndrome — Vernike of various etiology (a scurvy, alcoholism, pernicious anemia, sepsis, the melancholy accompanied with a cachexia) with observed in an experiment at avitaminosis of B1 at pigeons. It in the subsequent was confirmed by positive takes of an intensive care vitamins of the B1 group of alcoholics with Gayet's syndrome — Vernike [Justin Besançon, Klotts, Villar, Plyuvinazh (Justin-Besancon, Klotz, Villaret, Phivinage), 1948: Phillips Victor, Adam (G. Phillips, M. Victor, R. Adams), 1952].
Standard classification A.E. no. Anken and A. P. Demichev allocate acute, subacute and chronic And. aa. Diseases like Gayet — Vernike concern to the first two; chronic And. aa. correspond to korsakovsky psychosis. Plyuvinazh allocates subacute and chronic And. aa. It carries Gayet's type to the first — Vernike, diseases with a degeneration of a corpus collosum — Markiafava's type — Binyami, a laminar cortical sclerosis of Morel and the central necrosis of the bridge; to chronic — korsakovsky psychosis, an alcoholic pseudoparalysis and a cerebellar atrophy of Lermitt.
Such division And. aa. rather conditionally. Especially it belongs to definition «subacute». Is clinically justified to speak about acute and chronic And. aa. Such division allows to define better therapeutic tactics, cover a right choice in the acute, most often meeting cases gives the chance to keep life to the patient.
In clinical practice the forms relating or close to those that Gayet and Vernike were described (acute most often meet And. aa.); much more rare — korsakovsky psychosis and an alcoholic pseudoparalysis: (chronic And. aa.). All other forms, except for alcoholic encephalopathy of Markiafava — Binyami arising at the use of some grades of wines and described by preferential Italian and French psychiatrists are casuistic.
A clinical picture
the Indispensable background for development of all forms A. aa. the alcoholism is. Duration of an alcohol abuse at And. aa. from 6 — 7 to 20 years and more fluctuate. Occasionally, first of all at women, And. aa. can develop in 3 — 4 regular alcoholism. And. aa. arise usually at the end of the second and in the third stage hron. alcoholism with the long, proceeding weeks and months consumption of alcohol. Often And. aa. precedes for years the lasting daily alcoholism. Along with vodka patients hron. alcoholism use various substitutes, is more rare — fortified wines. Hungover symptoms both physical, and mental at them are expressed and long; quite often in a hangover there are epileptic seizures. In 30 — 50% of cases in the anamnesis of patients alcoholic psychoses are noted (see) in the form of gipnagogichesky, abortal, professional, is more rare — usual delirious states. Gallyutsinoza or crazy pictures are rare. The expressed changes of the personality, decrease in working capacity with this or that loss of an art are continuous; mental and social degradation is sometimes observed.
An alcoholism, against the background of to-rogo develop And. aa., often is followed by somatic frustration. As a rule, meets hron. gastritis, is more rare coloenterites and a peptic ulcer. Clear clinical signs of damage of a liver are rather infrequent. However number of authors [Katshell (V. Cutshall), 1965; Hey, Bernard, Brice (N. Eu, P. Bernard, S. Brisset), 1967; A. P. Demichev] notes that honor in all lethal cases at And. aa. on section find fatty regeneration of a liver and cirrhosis is more rare than it.
Prodromal stage. Most often to the beginning of manifest manifestations acute and chronic And. aa. the prodromal stage lasting from several weeks or months about one year and more precedes. It is usually shorter at acute and is more long at chronic And. aa. The shortest (2 — 3 weeks) the prodromal stage happens at very heavy, «superacute» And. aa., often coming to an end in death. Quite often its beginning falls on spring and first summer months (G. I. Larichev).
The main mental disorder in a prodromal stage is the adynamy, usually with dominance of an adynamia. Falling of appetite can reach to anorexias (see). To food, protein-rich and fats, disgust appears. Often, especially in the morning, there are nausea and vomiting. Complaints to heartburn, an eructation, abdominal pains, ponosa which are replaced by locks are frequent. Physical exhaustion accrues.
Disturbances of a night dream — difficulty of backfilling, the superficial superficial dream accompanied with dreadful dreams with frequent awakenings, an early prosypaniye are constant. The perversion of a cycle of a dream — wakefulness meets: drowsiness in the afternoon and sleeplessness at night. More often at night there are conditions of a fever or heat accompanied with perspiration, heartbeat, feelings of shortage of air, pains in heart. In various parts of a body, especially in extremities, feelings of numbness, a cold snap, tightening, weight, an ache or pain appear. In gastrocnemius muscles, in fingers of hands and legs there are spasms. Legs seem heavy and held down. The movements lose former ease, confidence, accuracy. There are difficulties at manipulations with small objects. Deterioration in movements can be followed by dizzinesses, an intentsionny tremor, a hypomyotonia. There can be a dysarthtia, various on degree of manifestation. Complaints to headaches, weight and noise in the head amplifying at the movement are frequent. Quite often sight worsens. There are phenomena of a hyperesthesia and a hyperpathia.
During a prodromal stage patients continue to take alcoholic drinks though by this time alcohol often does not reduce as earlier, intensity of hungover frustration. At the end of a prodromal stage disgust for alcohol can appear.
Occasionally prodromal stage can be practically absent, and psychosis develops against the background of a hangover and acute infectious or a somatopathy.
Manifest psychosis — the following stage of development of a disease. Its emergence is most often connected with influence of accessory factors among which first place is won by various intercurrent diseases. In some cases psychosis is preceded by single or multiple epileptiform attacks. The clinical picture in this stage of a disease depends on a form A. aa.
Acute alcoholic encephalopathy (Gayet's type — Vernike). Men aged from 30 up to 50 years get sick preferential. Most often the disease develops in 35 — 45 years; cases, arisen in 20 — 29 years are described (V. P. Dyagileva, 1971).
Data on frequency acute And. aa. are contradictory. According to one data, at hron. alcoholism this form A. aa. — one of the most rare (I. V. Strelchuk, 1970); on others — rather often meeting: e.g., Riggs and Bouls (N. of Riggs, R. Boles, 1944) gave 42 observations, Vardner and Lennox (N. of Wardner, V. of Lennox, 1947) — 52, Mallamudi Skillikorn (N. Mallamud, S. A. Skillicorn), 1956; A. P. Demichev — on 70 observations.
On weight and duration acute And. aa. can be conditionally subdivided into three subtypes: 1) actually acute And. aa.; 2) mitigirovanny form and 3) «superacute» form.
1) First subtype of acute alcoholic encephalopathy. Mental disorders at the beginning of manifest psychosis are most often characterized by various delirious states — not developed deliriums (see. Alcoholic psychoses ); usual delirium, professional and mussitans deliriums; much less often the shizofrenopodobny symptomatology meets. Severity of mental disturbances is, as a rule, directly proportional to weight of neurologic and somatic frustration.
The symptomatology of not developed and usual delirium at the beginning of manifest psychosis is observed most often. At not developed deliriums visual hallucinations and illusions are poor, sketchy, uniform and static. In their contents it is often impossible to reveal some certain delpriozny situation; if it is also available, then is fragmentary, contents it is ordinary or connected with an art of the patient. Not plentiful verbal and tactile hallucinations can be observed. Affective frustration are monotonous, poor, deprived of shades and tension; they are shown most often by alarm or alarming and timid mood.
Motive excitement is expressed in in the same way repeated actions on limited space — often within a bed. There can periodically be short-term conditions of an obezdvizhennost with a muscle tension. Patients it is uniform cry out the separate words including and said by people around, muffledly muttered. The speech contact with them is most often impossible. The speech and motive incoherence dominating in the described picture pulls together this delirious state with an amentia (see. Amental syndrome ). Similarity increases in process of weighting of delirious frustration and emergence of the symptoms characteristic of professional and especially mussitans delirium.
In more exceptional cases when manifest psychosis begins a usual delirium, quickly there is its transformation in a professional or mussitans delirium.
At shizofrenopodobny frustration at the beginning of manifest psychosis there are alarming or depressive and crazy states, acute sensual delirium which are combined with verbal hallucinations. However and in these cases soon at night the delirium joins.
At all options of the beginning of manifest psychosis several days later the clinical picture changes. Most often the so-called pseudo-encephalitic syndrome meets: in the afternoon devocalization of consciousness develops, initial manifestation to-rogo is the somnolence passing at further weighting into a sopor. Much less often in the afternoon there are conditions of an apathetic stupor which are replaced at an aggravation of symptoms by devocalization. At night in both cases there are still symptoms of a professional or mussitans delirium. At further weighting of process coma develops; at it delirious frustration disappear at night.
Neurologic frustration are various and changeable throughout short intervals of time. Symptoms of damage of the autonomic nervous system are observed. Patients are physically exhausted, look is more senior than the years. At one person bloated, at others — grease. Skin and mucous membranes are pale, scleras of a subikterichna. Language twitches, crimson color, nipples from edges are maleficiated. The hyperthermia is constant, and is frequent and is long. The hypothermia is occasionally noted. One patients have from the very beginning a dry skin and shelled. At others, on the contrary, the sweating which is especially expressed at night and at an elevated temperature is at first noted plentiful, in the form of drops of dew. Strong perspiration can be observed also at the lowered temperature. At patients temperature usually fluctuates from 37 to 38 °; its level in 40 — 41 ° predictively is adverse. Extremities are edematous. The extensive necrotic decubituses which are taking and subject to fabric are easily formed. Disturbances of a cordial rhythm in the form of tachycardia and arrhythmia are constant. Arterial pressure at the beginning of psychosis can be a little increased, but in process of weighting of a mental state the hypotonia which is followed by often kollaptoidny states begins to prevail. In blood the leukocytosis, usually to 20000 is observed. Breath is speeded up to 30 — 40 and more in 1 min. The liver can be increased and painful. The frequent, liquid chair is quite often noted.
Fibrillar twitchings of muscles of lips and other face muscles are often noted. Difficult are constant hyperkinesias (see) in which often alternate trembling, twitching, the horeoformny, atetoidny, myoclonic and ballistic movements. There can be attacks of the torsion spasm (see. the Torsion dystonia ). Intensity and prevalence of hyperkinesias as well as a form of their manifestation, are various. Also disturbances of a muscle tone in the form of hyper - or hypotonias are also changeable. The muscular hypertension can arise sharp attacks, and its intensity is so considerable that allows to speak about a cerebrate rigidity. The so-called oppositional muscular hypertension — increase of resistance in vigorous attempts to change position of extremities of the patient is characteristic. At their lung and smooth bending the muscular hypertension can not arise. The hypertension of muscles in the lower extremities quite often is followed by hypotonia of muscles of upper extremities and vice versa.
Symptoms of oral automatism — a hobotkovy reflex, the sucking and giving smacking kiss movements, spontaneous protrusion of lips and grasp reflexes are constant. It is always observed ataxy (see).
The earliest and constant eye symptom, according to Vardner, Lennox and Demichev, is the nystagmus — more often krupnorazmashisty horizontal. Adam and Victor note that all oculomotor disturbances can be limited to a nystagmus. Along with a nystagmus (in some cases with a rotational component) also other eye symptoms — a ptosis, doubling, a strabismus, reduction of fields of vision, a stone look, pupillary frustration — the so-called symptom of Gudden reminding Argayll Robertson's syndrome (at Gudden's symptom the miosis, an anisocoria, weakening of a photoharmose up to its total disappearance, disturbance of convergence are defined) are noted. Set of all listed eye symptoms usually is observed at height, and sometimes in the terminal period of a disease.
As a rule, the hyperpathia which is quite often extremely sharply expressed is observed; the polyneurites which are combined with the easy paretic phenomena. At a hyperreflexia Babinsky and Rossolimo's symptoms can be noted; quite often fan-shaped discrepancy of fingers of feet meets. From meningeal symptoms muscle tension of a nape most often meets.
The eyeground is usually normal. At a lumbar puncture in a prone position build-up of pressure of cerebrospinal fluid — can be noted a nek-swarm up to 200 — 400 mm w.g., more rare above. In cerebrospinal fluid the amount of protein to 0,5 — 0,80/00 at a normal cytosis can be increased. At a pneumoencephalography find the phenomena of hydrocephaly of various degree, in particular expansion of side ventricles.
In 3 — 10 days after development of manifest psychosis mental and vegetative disorders can undergo a considerable reduction. These «light intervals» proceed from one to several days. Repeated deteriorations which can be a little are usually less heavy and less long, than previous.
The most precursory symptom of recovery is normalization of a dream: in the beginning only in the second half, and further and during the whole night there comes the deep sleep proceeding and in the afternoon. Women during this period can have symptoms of konfabulyatorny confusion testimonial of a possibility of the subsequent development of a korsakovsky syndrome.
The described condition of patients can last 3 — 6 weeks and more.
2) The second subtype of acute alcoholic encephalopathy — mitigirovanny forms. At one patients manifest frustration are defined by somnolence in the afternoon and not heavy delirious symptomatology at night. At other patients it is noted having made lenno-dysphoric mood and various hypochiondrial complaints. Somatoneurologic frustration are insignificant.
3) The third subtype — a «superacute» form of alcoholic encephalopathy. Mental disorders at this form are shown from the very beginning by a professional or mussitans delirium and are followed by massive neurologic and somatic symptomatology. Sharp temperature increase to 40 — 41 ° is characteristic. The manifest stage proceeds immediately. In one or several days at patients coma develops. These cases most often come to an end with death on 2 — the 5th day of a disease.
Forecast acute And. aa. in many respects depends on weight of a state, term and tactics of therapeutic influence. Frequent outcome actually acute And. aa. (The I subtype) and a mitigirovanny form (the II subtype) development of an organic psychosyndrome of various depth and structure, including and development of korsakovsky psychosis is. When after the postponed attack acute And. aa. the alcohol abuse proceeds, there can be repeated psychoses with a picture of a delirium, acute or chronic And. aa. If patients do not die at the same time, then on a minovaniya of psychosis at them the organic psychosyndrome up to emergence of the expressed weak-mindedness accrues.
The lethal outcome is possible at actually acute (the I subtype) and «superacute» (the III subtype) And. aa. If in the latter case death can come in the first few days, then in the first it most often comes by the end of the second week, is frequent in connection with accession of intercurrent diseases, first of all pneumonia.
Chronic alcoholic encephalopathies
carry To them: 1) korsakovsky psychosis and 2) alcoholic pseudoparalysis.
Korsakovsky psychosis (alcoholic paralysis, polyneuritic psychosis) often occurs at women (S. S. Korsakov, Krepelin, M. O. Gurevich and M. Ya. Sereysky, 1946; I. V. Strelchuk), and, on a nek-eye to data, more often than at men [Hottsen, Marchand and Courtois (L. Marchand, A. Courtois), 1934]. In the last two-three decades considerable reduction of number of cases of this disease is noted (A. N. Molokhov and Yu. E. Rakhalsky, 1959; I. V. Strelchuk).
Usually korsakovsky psychosis develops in 40 — 50 years, however is observed also in 50 — 60 years or at persons at the age of about 30 years.
Most often korsakovsky psychosis develops after structurally difficult alcoholic psychoses (see), first of all those in which clinical picture the delirium and verbal hallucinosis dominates. Much more rare, generally at elderly patients, the disease develops gradually. Quite often in the anamnesis of patients with korsakovsky psychosis it is possible to reveal a tremens at which involution arose tranzptorny, lasting several days or weeks, korsakovsky syndrome (see).
The clinical picture of korsakovsky psychosis develops, as well as at acute And. aa., from mental, neurologic and somatic disturbances. The first are defined by a triad of symptoms: amnesia, disorientation and confabulations. Amnestpchesky frustration are shown by full or partial disturbance of memory of current events — fixating amnesia (see); memory on the events preceding a disease — retrograde amnesia lasting from several weeks about many years suffers in a varying degree.
Confabulations (false memoirs) arise at inquiries of patients more often, but is not spontaneous and are shown in stories about the events which allegedly just happened to them which usually have the contents the facts of ordinary life or a situation connected with professional activity. Occasionally confabulations in the form of difficult and fantastic stories about incidents and adventures meet. Specially asked questions quite often possible to send konfabulyatorny statements of patients to a certain party that testifies to their increased suggestibility.
Often multiple confabulations, in particular fantastic, meet at insignificant dysmnesias; they can be poor and uniform at massive dysmnesias. In close connection with fixating amnesia and confabulations there is an amnestpchesky disorientation or, on the contrary, false orientation of patients in the place, time and surrounding persons. Slackness, passivity, decrease in motives, increased fatigue is noted. The mimicry and motility are grown poor and slowed down. Slackness and apathy can be replaced by the periods of irritation or alarming concern with hypochiondrial fears (see. Hypochiondrial syndrome ). The listed mental changes are expressed at elderly patients more considerably. Persons of young and middle age are usually more live, more mobile, to a large extent show interest to surrounding including to various occupations. At them usually in bigger volume former skills and knowledge — remain up to difficult. The background of mood can be with a shade of euphoria.
The known consciousness of a disease, in particular concerning dysmnesias, is noted at all patients. It is confirmed not only by their complaints, but also the frequent aspiration to hide various, though very primitive receptions the dysmnesias which are available for them.
Neurologic frustration are shown usually in the form of neuritis of the extremities accompanied with this or that degree of an atrophy of muscles, disturbances of sensitivity, easing and even absence (is more rare increase) tendon jerks.
Parallelism between severity of mental and neurologic disorders often is absent: heavy mental disorders at an easy polyneuritis can be observed and vice versa. The phenomena of neuritis and muscular atrophies pass quicker, than mental disorders.
Forecast. The disease at treatment, and sometimes and without it flows usually regrediyentno, especially at. persons at young and middle age. At women more often than at men, considerable improvements (A. A. Butenko and S. A. Sukhanov) are noted.
The alcoholic pseudoparalysis
Develops preferential at men after 40 — 50 years. Mental and neurologic disorders remind general paralysis (see). Falloff of level of judgments, lack of criticism to themselves and surrounding, euphoria accompanied often with the ideas or nonsense of greatness is characteristic of mental disorders. Dysmnesias of this or that degree are constant. From neurologic symptoms are noted: a tremor of fingers, language, mimic muscles, the pupillary frustration close to those that meet at Argayll Robertson's syndrome (difference consists in existence of weakness of convergence), a dysarthtia, changes of tendon jerks, attacks.
Forecast. The alcoholic pseudoparalysis proceeds doubly. At involution of a heavy or long tremens and acute And. aa. it flows regrediyentno. In other cases when it develops gradually, against the background of the expressed alcoholic deterioration and in some cases is complicated by the accompanying organic diseases — it proceeds progrediyentno. Can be such associated diseases: the craniocereberal injuries postponed in the past, developing at the same time vascular (including and syphilitic genesis) process, atrophic processes mitigirovanno proceeding, in particular a disease of Peak (see. Peak disease ).
An etiology and a pathogeny
the Leader in a pathogeny And. aa. disturbance of exchange processes and first of all vitamin balance, developing at hron is. alcoholism. Especially is important In 1 - hypovitaminosis. Consumption of alcohol increases the need of an organism for polyneuramin 1 — the thiamin which is carrying out in an organism a role of coenzyme at different types of decarboxylation. Preferential carbohydrate food, damage of a liver and disturbance of processes of absorption of thiamin in intestines aggravate In 1 - hypovitaminosis. Insufficiency of B1 vitamin leads to sharp disturbance of carbohydrate metabolism, especially in a brain, for to-rogo carbohydrates are the major energy resource.
At And. aa. also insufficiency of a pyridoxine (rat anti-acrodynia factor) is observed that aggravates dysfunctions of c. the N of page also went. - kish. a path at patients And. aa. A vitamin deficiency In 1 and P leads to increase in permeability of capillaries and hemodynamic disturbances in a brain.
The nature of disturbances of exchange processes emphasizes that role of «an intermediate link, intermediate poisons» in development of symptomatic and alcoholic psychoses, in due time took away-ruyu to them Bongeffer and Bostr (To. Bonhoeffer, 1912; A. Bostroem, 1921). Alcoholic psychoses and among them first of all And. aa. cannot be carried to the diseases depending on direct effect of alcohol though its etiological value is undoubted. And. aa. develop on the foyer of the disturbances of exchange caused by alcohol and can be treated as metalkogolny psychoses.
At acute And. aa. hypostasis is noted, brain swelling, sometimes with the shift of its various departments is more rare.
As at acute, and chronic And. aa. the main morphological change in a brain is the hemorrhagic syndrome of Gayet — Vernike, i.e. defeat of vascular system of certain sites of a brain. Hemorrhages in a brainstem are visible approximately not always. At microscopic examination the microhemorrhagic syndrome (Anken) comes to light. Most often — in 84 — 95,7% of cases — vessels of papillary bodies are surprised, is slightly more rare — in 73 — 77% — kernels of podbu-mountain area, in 70 — 80% of cases — around walls of the III ventricle, on average a brain, is preferential under an ependyma, in the central gray matter and around a water supply system of a brain (Malamud and Skillikorn, Riggs and Bouls, Anken). Less often hemorrhages in a visual hillock, white matter of a cerebellum and a corpus collosum (Anzhelerg) meet. Hemorrhages (fig.), as a rule, bilateral and symmetric (Penchev, 1970). In the absence of hemorrhages in the specified departments of a brain, especially in papillary bodies, the brown pigmentation and proliferation of an endothelium of capillaries strengthening an angioarchitecture is noted. It is followed by growth of argyrophil fibers.
Actually a parenchyma of a brain at And. aa. suffers for the second time. Changes of neurons at acute And. aa. can be followed by acute swelling and a lysis of basphilic substance (Nissl) of various degree of manifestation. These changes occupy various departments of a brain, not only area of hemorrhages. The hyperchromatosis and a smorshchennost of neurons, and also their losses around vessels are preferential observed in a brain at patients chronic And. aa. In the analysis of other changes (accumulation of lipofuscin in neurons, the phenomena of an atrophy) it is necessary to consider age of the dead.
In a neuroglia growth of fibrous astrocytes in places of distribution of hemorrhagic changes is most characteristic. Oligodendrogliya reacts to wet brain. Changes of a microglia were not noted.
Demyelinating processes in nerve fibrils have non-constant character and are found more often in the field of spread of hemorrhages. Korsakovsky psychosis often is followed by a polyneuritis.
According to P.E. Snesarev (1950), A. aa. can be carried to hemorrhagic encephalopathies. It characterizes a disease as «hemorrhagic entsefaloz», emphasizing absence in a brain of inflammatory changes. Shaltenbrand (G. Schaltenbrand, 1951) noted similarity of a pathomorphologic picture A. aa. with observed at a purpura, in particular skorbutichesky. Penchev (1970) process at And. aa. characterizes as «dizorichesky encephalopathy» and emphasizes its secondary, mediated character connected with a vitamin and liver failure.
Defeat not only gray matter, but also other departments of a brain caused failure from the former name «Vernike's polyencephalitis».
Diagnosis and differential diagnosis
Precipitancy and kaleidoscopical variability of a clinical picture A. aa., especially their acute forms, emergence of the most life-threatening sick frustration (wet brain, acute cardiovascular insufficiency) demand bystry therapeutic intervention and, therefore, the early differential diagnosis. The last is very difficult. Inspection is complicated by very frequent existence at patients of devocalization of consciousness. For the correct assessment and a differentiation of observed frustration very important along with survey of patients it is possible to collect the anamnesis quicker. At its collecting it is necessary to establish: 1) time of the beginning of alcoholism — in the heaviest, often fulminant, coming to an end with the death of the patient cases its beginning, as a rule, falls for the youthful period; 2) signs testimonial of development hron. alcoholism, especially its third stage; 3) character of alcoholic beverages (use of substitutes, fortified wines); 4) a picture of the psychoses arising in the past, first of all deliriums and features of the last; 5) existence of attacks; 6) the characteristic of the period which was directly preceding the beginning of psychosis.
Because of jumps of a clinical picture throughout short intervals of time frequent surveys of patients and dynamic observation, especially in the first two weeks after development of manifest psychosis as at this stage at acute are obligatory And. aa. develop connected with displays of actually alcoholic encephalopathy life-threatening sick frustration.
Differential diagnosis And. aa., first of all acute as extreme states defines therapeutic tactics and, as a result, an outcome of a disease.
Wrong diagnoses are, as a rule, made at acute And. aa., is more rare — at an alcoholic pseudoparalysis.
At all subtypes acute And. aa. first of all their differentiation with deliriums, various on a clinical picture, is necessary.
Special suspicion on existence acute And. aa. shall cause the heavy deliriums in particular accompanied with professional nonsense, neurologic frustration, elevated temperature, falling or differences of arterial pressure. In these cases it is better to choose before statement of the final diagnosis tactics of treatment acute And. aa.
The second place in the differential diagnosis is taken by tumors of a brain. In these cases the anamnesis (existence hron. alcoholism) can play a crucial role.
Acute And. aa. differentiate with schizophrenia, organic or acute symptomatic psychosis. And in these cases anamnestic data have paramount value.
At a differentiation of an alcoholic pseudoparalysis it is necessary to consider that vascular, traumatic and atrophic processes which define the forecast of a disease can be combined with usual alcoholism and give pictures, similar to an alcoholic pseudoparalysis.
Forecast And. aa. in many respects is defined by a clinical picture and disease. Private forecasts of various forms acute and chronic And. aa. are stated above (see. Clinical picture).
The forecast concerning life of patients And. aa., first of all acute, was until recently adverse; not less than a half of patients died. At introduction of modern methods of treatment (see below) number of deaths it was sharply reduced, and number enough full vyzdorovleniye, first of all at acute And. aa., considerably increased. It allowed Berzherona and Ania (M. to Bergeron, M. Hanus) to carry acute And. aa. to group of so-called reversible dementias. However considerable number of patients And. aa., their especially chronic forms, loses forever (partially or completely) working capacity.
Therapy And. aa. shall be complex within several weeks, month or more. First of all obligatory daily use of high doses of the vitamins entered intramusculary is shown: In 1 — from 500 to 1500 mg; In 6 — from 800 to 1000 mg; With — to 1000 mg; RR — 300 — 500 — 1000 mg. Injections do three times a day. Treatment is carried out continuously. At detection of noticeable signs of an organic psychosyndrome it is desirable to carry out repeated courses of treatment by polyneuramins the same or reduced doses in 1 — 2 month after the first course.
Along with the beginning of vitamin therapy the treatment similar to that is surely applied, a cut carry out at a heavy tremens (see. Alcoholic psychoses ).
Demichev A. P. About a recurrent form of alcoholic encephalopathy of Gayet — Vernike, in book: Alcoholism and toxicomanias, under the editorship of D. D. Fedotov, page 107, M., 1968; Dyagileva V. P. To clinic of mental and neurologic disorders at an acute form of alcoholic encephalopathy of Gayet — Vernike, in book: Vopr. wedge, and sovr. ter. mental diseases, under the editorship of V. M. Banshchikov and O. V. Kondrashkova, page 381, M., 1971; Zhislin S. G. Sketches of clinical psychiatry, M., 1965; Korsakov S. S. About alcoholic paralysis, M., 1887, bibliogr.; it, Chosen works, M., 1954, bibliogr.; Snesarev P. E. Theoretical fundamentals of pathological anatomy of mental diseases, page 317, M., 1950; Strelchuk I. V. Intoksikatsionnye psychoses, M., 1970, bibliogr.; Angelergues R. Le syndrome mental de Korsakow, P., 1958, bibliogr.; Enkin M. Étude anatomoclinique des encéphalopathies carentielles d'origine éthylique, Lyon, 1957, bibliogr.; Girard P. F., Deyic M. et Garde A. L'encéphalopathie de Gayet — Wernicke des alcooliques, Rev. neurol., t. 94, p. 493, 1956; Pluvinage R. Les encéphalopathies alcooliques subaiguës, Vie Méd., t. 46, p. 1663, 1965.
N. G. Shumsky.