ARACHNOIDITIS (arachnoiditis; Greek arachne a spider, a web + eidos a look + - itis; synonym: arachnomeningitis, leptomeningitis externa, chronic fibroziruyushchy pia-arachnitis, the delimited adhesive meningopatiya) — the special kind of serous meningitis, at Krom inflammatory process strikes preferential arachnoid (arachnoidal) membrane of a head or spinal cord (arachnoidea) and in much smaller degree soft. The term «arachnoiditis» was for the first time applied by A. T. Tarasenkov (1845). Detailed description cerebral And. Beningkhaus gave (Böninghaus, 1897), calling it «outside serous meningitis» (meningitis serosa externa).
- 1 An etiology
- 2 Pathological anatomy and pathogeny
- 3 Clinical picture, forecast
- 4 The diagnosis
- 5 Treatment
Most often meet infectious and infectious and toxic And., connected with flu, quinsies, typhus, pneumonia, tuberculosis, sepsis, toxoplasmosis, rheumatism, a brucellosis, syphilis, parotitis, infectious diseases of ENT organs. And. often develop after injuries of a skull and backbone (including closed). More rare And. are connected with endocrine and exchange disturbances. To precisely establish an etiology And. not always it is possible.
Many diseases of c. the N of page and a backbone can become complicated And., especially often tumors, encephalitis, myelosyringosis, epilepsy, osteomyelitis of bones of a skull, spondylitis, etc., and reactive And. sometimes develops far from primary pathological center in a brain.
Pathological anatomy and pathogeny
Arachnoid membrane at And. becomes reinforced, dense and gets grayish-white coloring. Between it and a soft cover commissures are formed. The same commissures quite often arise between web and firm covers. Commissural process leads to formation of arachnoidal cysts (fig. 1) containing likvoropodobny liquid. If the cyst exists long, its walls gradually become more and more thick and dense, and it turns into tumorous education. Liquid of a cyst can become xanthochromatic and contain a large amount of protein. The firm meninx in the field of pathological process is strained, edematous, thickened, rich with vessels, loses the gloss. And. often conducts to occlusion of likvorny ways and a secondary brain edema. Spinal And. can cause blockade of a subarachnoid space of the vertebral channel.
At microscopic examination in an arachnoid membrane fibrosis (fig. 2) of various degree (a thickening, coarsening of argyrophil fibers, their collagenization), a hyperplasia of an endothelium of a cover, infiltration by its lymphoid elements (fig. 3), proliferation of fibroblasts is found; in an arachnoid membrane vessels from firm and vascular covers burgeon. In a soft cover — a hyperemia, a new growth of vessels, inflammatory infiltration, and in the subsequent — also fibrosis. In adjacent sites of a brain find the secondary changes caused by pressure of the shell cysts and commissures, frustration likvoro-and blood circulations and also direct transition of inflammatory process to substance of a brain. Quite often hard proceeding And. are complicated by periventrikulita and an ependymitis.
And. in one cases arises under the influence of impact on covers of the activator, in others — its toxins. At injuries the main role is played by frustration krovo-and a likvoroobrashcheniya in covers and a subarachnoid space. Dynamic frustration krovo-and likvoroobrashcheniye, hypostasis of adjacent sites of brain fabric and covers explain the remissions and deteriorations characterizing clinic And.
Pathomorphologic changes — from slight fibrosis of an arachnoid membrane before formation of big cysts, numerous rough shvart in which all covers participate and necroses in substance of a brain — do clear various weight of separate cases and extremely unequal availability of their therapy.
Clinical picture, forecast
And. divide on adhesive (hyperplastic), cystous and slipchivokistozny, limited and diffusion, one-focal and multifocal. Distinguish And. cerebral (And. cerebralis) and spinal (A. spinalis).
And. can proceed with defeat of covers of konveksitalny (convex) or basal surfaces of a brain.
Localization of inflammatory process — the main factor defining features of a symptomatology and a current of separate forms A.
On a current And. are divided on acute, subacute and chronic, by a pathogeny — on primary and secondary.
A cerebral arachnoiditis
For cerebral And. general and brain and focal symptoms are characteristic.
All-brain symptoms cerebral And.: headache, vomiting, dizziness, change of an eyeground, epileptic seizures, change of cerebrospinal liquid. A headache — the most frequent and usually early symptom cerebral And. In most cases it has character of the constant headache which pristupoobrazno is becoming aggravated, amplifies from the physical tension, mental work, disorders, from cold, overheating, accidental infections and other factors. Position of the head sometimes exerts impact on intensity of a headache. Vomiting comes usually at height of an attack of headache. Dizziness takes the third place on frequency. Changes of an eyeground are found in most of patients. Most often find more or less expressed congestive optic papilla, neuritis, even more rare a simple atrophy is much more rare. The general epileptic seizures are observed infrequently. Meningeal symptoms are a little expressed or at all are absent.
Focal neurologic symptoms are various depending on localization of process.
Damage of cherepnomozgovy nerves — an everyday occurrence at cerebral And. various localization, but more often and stronger they suffer at basilar from A. Obychno several nerves are surprised at the same time.
At a puncture cerebrospinal liquid follows mostly under supertension, it is colourless, the amount of protein in it is normal or lowered, seldom increased, the cytosis is usually not increased. The pleocytosis within 3 — 10 is stated approximately at 1/3 all patients, higher than 10 — at single patients.
At many patients essential shifts from the autonomic nervous system are stated. «Neurotic» complaints are frequent.
And. a brain begins sharply and subacutely soon after the postponed infection, an injury, strong overcooling or influence of other vrednost capable to call A. No it can begin and is absolutely imperceptible for the patient, through various terms after influence of an etiological factor. Disease severity is extremely not identical. Acute And. can end with recovery. Acute And. quite often proceeds with a subfebrile temperature. The morphology of blood and ROE mostly do not change. Often acute And. accepts hron, a current. At hron. And. temperature is usually normal. It is characteristic for And. a current with remissions and aggravations. Severe forms cerebral cystous and adhesive And. give a picture of a tumor of a brain and can end letalno, especially at localization of process in a back cranial pole.
The leptomeningeal cerebral fibrosis can proceed without occlusion of likvorny ways. It is most various on the clinical manifestations and is especially difficult for diagnosis. The persistent headaches which pristupoobrazno are becoming aggravated quite often are followed by vomiting or nausea. Dizziness, decrease in working capacity. In the anamnesis — the postponed infection or an injury of the head. Hron, remittiruyushchy current. Scattered neurologic symptoms. On an eyeground there are no changes or there is only an easy smazannost of nipples of optic nerves. Kraniografiya quite often reveals symptoms of cerebral hypertensia without destructive changes in bones of a skull. Pressure of cerebrospinal liquid is unsharply increased, content of protein in it is not changed or slightly increased, a small pleocytosis. The lumbar puncture often gives relief.
Konveksitalny arachnoiditis of area of the central furrow (rolandovy). The epileptic jacksonian seizures of motor or touch character, hemiparesis of various expressiveness, headaches reminding migraine. Symptoms of cerebral hypertensia usually do not happen. At extensive diffusion And. a convex surface of hemispheres a brain edema can develop, and then the symptoms of the increased intracranial pressure unusual konveksitalny act And. At an electroencephalography — diffusion changes of biocurrents of a brain.
Treat basilar arachnoidites And. optokhiazmalny, And. back cranial pole, And. mosto-cerebellar corner.
At optokhiazmalny And. process threatens the patient with a blindness. Visual acuity of one or both eyes decreases. The hemianopsia, quite often bitemporal is observed; the atrophy of an optic nerve, is more rare developments of stagnation on an eyeground, an anosmia. In certain cases motor nerves of eyes suffer. The headache is localized most often in a forehead, a bridge of the nose, orbits.
Arachnoiditis of a back cranial pole — rather frequent and very severe form cerebral And. The clinical picture reminds a tumor of a cerebellum, but symptoms accrue much quicker here. The all-brain phenomena sharply prevail over focal. Often significantly VI, VII, VIII pairs of cranial nerves suffer. Developments of stagnation in an eyeground. Inflammatory process quite often causes fusion of a median opening of the IV ventricle (Marangdi) and a side opening of the IV ventricle (Lushki), occlusion of likvorny ways, an internal brain edema with expansion of all ventricles and a brain (silviyev) water supply system. Pain is localized in occipital area, irradiates in a neck, an upper part of a back. Headaches pristupoobrazno become aggravated, often are followed by vomiting.
The arachnoiditis of a mosto-cerebellar corner is usually shown before everything by damage of the VIII nerve, a flaccid paralysis of a facial nerve or neuralgia (neuritis) of a trifacial. Symptoms of suffering of all these three nerves can be shown at the same time. Later the cerebellar symptoms and bilateral pyramidal signs which are mostly unsharply expressed join. And. a mosto-cerebellar corner it is quite often connected with infectious process in an ear.
Just as cerebral, spinal And. can be adhesive, cystous, adhesive and cystous, diffusion or limited, one-focal or scattered.
At a diffusion spinal arachnoiditis the clinical picture very much of a polimorfn also develops of the radicular and conduction symptoms connected with damage of a spinal cord, its covers and roots at various levels. The disease of the most part has the progressing character: motive, sensitive and pelvic frustration gradually accrue. Cerebrospinal liquid is changed as belkovokletochny dissociation, but protein content is increased unsharply. More or less considerable remissions under the influence of treatment or the spontaneous, concerning all manifestations diseases or only some can be observed.
The limited leptomeningeal fibrosis can exist many years, without causing any clinical symptoms, but it often gives the radicular phenomena, causing a clinical picture of persistent radiculitis (the sciatica, intercostal neuralgia, kaudit, etc.). Are quite often observed radicular and spinal And., in which clinical picture the combination of the radicular phenomena and a prelum of substance of a brain is noted.
The cystous spinal arachnoiditis clinically reminds a tumor of a spinal cord. Intensive radicular pains and paresthesias, having appeared on one side of a body, quickly enough come over to other side. They are followed by conduction motor disturbances and sensitivity, disturbance of activity of pelvic bodies. Gradually the compression spinal syndrome obliged by the origin to a psevdotumor forms.
The arachnoiditis at children makes about 3 — 4% of diseases of a nervous system. And. develops as a complication at flu, pneumonia, children's infections, in many cases — at inflammatory diseases of adnexal bosoms of a nose, otitis. There is also primary virus A. Inogda meets traumatic And. The neurologic symptomatology is defined by preferential localization of inflammatory process. At children at konveksitalny And. quite often (more often than adults) have focal convulsive attacks which can accept generalized character; in some cases paresis of a facial nerve on the central type, asymmetry of tendon jerks, hypesthesias are found.
Often meets basilar And., proceeding with damage of cherepnomozgovy nerves, symptoms of intracranial hypertensia, an incoordination, at some patients — with endocrine frustration.
Spinal And. occurs at children seldom.
In diagnosis cerebral And. neurologic symptoms, development and disease, a condition of cerebrospinal liquid, its pressure, data of a pneumoencephalography have major importance (especially defects of filling of a subarachnoid space with air).
General diagnosis cerebral And. it has to be added with the instruction on the nature of process, its localization and an etiology (if it is known), on existence or lack of occlusion of likvorny ways. Diagnosis cerebral And. demands comprehensive and detailed inspection of the patient, a cut shall include by all means check of sight, an eyeground, hearing, arterial pressure in dynamics, kraniografiya (see). In all not clear cases patients are subject to dispensary observation or stationary inspection. Many patients recover, then the diagnosis And. remove. In certain cases it is necessary to speak about the residual phenomena after postponed cerebral And.
Differential diagnosis cerebral And. it is necessary to carry out: with a tumor of a brain, multiple sclerosis, cerebral atherosclerosis, hron, diseases of ENT organs, cervical osteochondrosis, migraine, a neurasthenia, an adynamy postinfectious or posttraumatic. The differential diagnosis with a tumor of a brain since the last demands perhaps earlier recognition is especially responsible. In some cases cerebral And. can accompany a tumor.
Differential diagnosis spinal And. with a tumor it is very difficult, in many cases it before operation is impossible. It is necessary to consider a number of the moments capable to a nek-swarm of degree to specify true nature of suffering. Frustration of pelvic bodies are usually expressed less intensively, than at a tumor. The radicular phenomena are more scattered, interested there can be many roots, and it is not always the roots located in the neighbourhood with each other. The compression syndrome to Nonna — Fruena (a xanthochromia, proteinaceous and cellular dissociation, high pressure of cerebrospinal liquid at the beginning of a lumbar puncture) is expressed not so accurately. Kvekkenshtedt's test (see. Cerebrospinal liquid) does not cause strengthening of current of liquid. In cerebrospinal liquid the pleocytosis can be found, degree to-rogo fluctuates at the lumbar punctures made during the different periods of a disease.
Radiodiagnosis of an arachnoiditis
Radiological identification And. perhaps when owing to inflammatory process there are commissures between web and vascular covers (adhesive And.), the breaking circulation of cerebrospinal fluid, and local expansion of web space (cystous And.). Recognition and differential diagnosis of Ampere-second tumoral process requires comprehensive examination of the patient and comparison of results of kliniko-neurologic and radiological researches.
Cerebral And. it can be diagnosed at a contrast research of a brain — a pneumo-encephalography (see. Encephalography ).
On kraniogramma of change, as a rule, are absent. At And. the convex surface of a brain according to localization and prevalence of unions of an arachnoid membrane on pneumoencephalograms reveal lack of air in subarachnoidal cracks or uneven filling with air of the expanded and deformed subarachnoid spaces. At And. the bases of a brain depending on location of commissures on pneumoencephalograms in tanks of the basis there can be no air or, on the contrary, tanks can be overflowed with air and are deformed. And. a back cranial hole along with an obliteration of subarachnoidal tanks sometimes causes occlusal hydrocephaly that determine on pneumoencephalograms by increase in cavities of ventricles of a brain.
Spinal And. according to roentgenograms of a backbone it is impossible to distinguish. Make a contrast research of a spinal cord for its identification (see Miyelografiya). At adhesive And. a contrast agent lingers on the sites corresponding to the level of defeat. On miyelogramma it is displayed in the form of accumulations of a contrast agent, shaped drops, strokes, spots with accurate and often twisting outlines. When commissures call the full block for passing of a contrast agent, to distinguish on miyelogramma spinal And. from a tumor very difficult.
Contrast X-ray inspections of a head and spinal cord are important at the choice of a method of surgical treatment And. and for assessment of results of operation.
Treatment cerebral And. can be conservative and surgical. Diffusion hyperplastic And. without occlusion of likvorny ways, without the considerable hypertensive phenomena and epileptic seizures it is necessary to treat conservatively, and cystous or adhesive and cystous Ampere-second shall be subjected by a clinical picture of a tumor of a brain to surgical treatment. Therapy at cerebral And. shall be individualized, complex, systematic and systematic. Pathomorphologic essence of process such is that it is not necessary to expect easy success. Conservative therapy includes disinfecting, anti-inflammatory, resorptional, dehydrating agents. At And., connected with the infectious center in ENT organs or bones of a skull, simultaneous treatment (conservative or surgical) and this disease is necessary. Cerebral And. without occlusion of likvorny ways and rough focal symptoms therapies quite often well give in.
The yodionogalvanization according to Bourguignon, collar massage, mustard plasters is applied to calves, on a nape, a collar zone also warmly on the head (if the patient well transfers it). At severe headaches — analgesic means. It is impossible to appoint drugs. In many cases And. there is useful a subarachnoidal administration of air. The deep roentgenotherapy reduces pains, weakens inflammatory process and reduces secretion of cerebrospinal liquid. Surgical intervention often yields good results. Drug treatment needs to be carried out also after operation.
Treatment spinal cystous And. by conservative methods usually inefficiently, and an operative measure yields good results. Adhesive And. are subject to conservative treatment (medicines, as at cerebral And., physical therapy, mud resorts, subarachnoidal administrations of air; in many cases good results are brought by a deep roentgenotherapy).
Surgical treatment of an arachnoiditis
the Main objective of operations at And. removal or separation of the shell unions, hems, the cysts pressing on brain fabric or causing disturbances of circulation of cerebrospinal liquid is.
Indications to operation
the Indication to operation at And. a konveksitalny surface of big cerebral hemispheres the frequent focal epileptic seizures which are not eliminated by medicamentous therapy, especially at cystous forms A are. Usually big prevalence of defeat of covers and brain fabric at And. demands establishment of exact localization of the center.
The indication to operation at And. a back cranial pole existence of occlusion of likvorny ways with the accruing gipertenzionno-gidrotsefalny phenomena and focal symptoms of defeat of a mosto-cerebellar corner, a cerebellum, a brainstem is.
At optokhiazmalny And. the main indication to operation is the progressing falling of visual acuity or narrowing of fields of vision.
Operations at spinal And. are shown in the presence of a compression of a spinal cord, and also at the accruing motive, sensitive disturbances and radicular pains connected with limited adhesive process or with formation of cysts.
Surgical interventions at And. are shown at inefficiency of conservative therapy in hron, or a residual stage of inflammatory process.
Technology of operation
At And. a konveksitalny surface of big hemispheres perform osteoplastic trepanation according to localization of the center of defeat. At cystous And. empty cysts and excise their walls. At limited hems, commissures between an arachnoidal cover and bark make entsefalolizis. In some cases resort to subpialny suction of bark in a zone of the epileptogenic center. Localization of the center and its sizes are specified during operation with the help of an elektrokortikografiya.
At optokhiazmalny And. open with frontal access the hiazmalny tank, separate in the stupid way the changed arachnoidal cover, excise commissures, cysts around optic nerves and a hiazma.
At And. a back cranial pole with a syndrome of occlusion of likvorny ways operation is directed to recovery of outflow of cerebrospinal liquid. At a cystous form empty cysts and excise their walls. At a cystous form A. in the field of the big tank excise the changed arachnoidal membrane forming a back wall of the tank and separate the arachnoidal unions in its side departments interfering outflow of cerebrospinal liquid on basal tanks. At an adhesive form A. areas of the big tank for recovery of outflow of cerebrospinal liquid of commissure need to be destroyed not only in the field of a median opening of the IV ventricle (Marangdi), but also on a side surface of a myelencephalon and in the place of transition of the big tank to a subarachnoid space of a spinal cord.
The possibility of removal of hems and unions is defined by their expressiveness and localization. The section of a worm of a cerebellum for the purpose of recovery of outflow of cerebrospinal liquid from the IV ventricle is shown: at a dense spayaniye of the lower worm and a vascular tire with a myelencephalon and a caudal part of a rhomboid pole; at impossibility of separation of commissures between almonds of a cerebellum and a medulla, especially at the expressed bulbar disturbances; in the presence of rough changes of vessels in the field of the big tank and a median opening of the IV ventricle.
The section of a worm of a cerebellum (operation of the Dandy) is made on the centerline in a middle part of a worm. At occlusion in caudal departments of the IV ventricle cut upper parts of a worm of a cerebellum. For the purpose of prevention of secondary fusion of an opening in a dissect worm the resection of the lower worm and a medial part of almonds of a cerebellum is offered. In certain cases occlusion can be caused by inflammatory obturation of a brain (silviyev) water supply system. In such cases bougieurage of a water supply system is shown only after specification by contrast methods of a research and at the small extent of occlusion is made by semifixed probes without considerable effort. Usually at impassability of a brain water supply system operation of a ventrikulotsisternostomiya (Torkildsen's operation) is most reasonable.
At expressiveness of cicatricial and commissural changes in area of the big tank of a back cranial pole in some cases operation of perforation of a final plate, a nadkhiazmalny ventrikulotsisternostomiya or one of options of operation of a section of a corpus collosum for creation of outflow of cerebrospinal liquid from cerebral cavities can be recommended in the subsequent.
At And. a mosto-cerebellar corner depending on its form make emptying of a cyst with removal of its wall, separation of commissures, a neurolysis.
A main objective of operation at spinal And. recovery of passability in a subarachnoid space, elimination of a compression of a spinal cord and roots is (meningomiyeloradikulolizis). Laminectomy (see) shall provide access to the changed sites of covers and a brain. After opening of a dural bag make amotio of an arachnoid membrane. Then the last is made an incision along a spinal cord and carefully otslaivat from it and from roots. Rough commissures exsect provided that in them there are no vessels. The section of an arachnoid membrane is made up and from top to bottom before emergence of cerebrospinal fluid in a subarachnoid space.
In the postoperative period at And. the most frequent complication is the outbreak of the dozing infection even in hron, stages of process. The aggravation can lead to meningitis, encephalitis, a myelitis, a liquorrhea, repeated occlusion.
Prevention of an aggravation and formation of repeated unions is most sparing technology of separation of hems and commissures, the prevention of flowing of blood in subarachnoid spaces, unloading lumbar punctures for the purpose of removal of the changed cerebrospinal liquid and protorhenium of its ways. Is especially important to - and postoperative treatment of the patient with antibiotics and other types of antiinflammatory therapy.
The specified complications after operations on an occasion And. cause frequent adverse results of interventions, especially at And. back cranial pole. According to L. A. Koreysha, improvement after operation on an occasion And. it was observed at 57,9% of patients. At 15,9% of patients the state remained without changes, at 14,7% worsened, 11,5% of patients died. The acute prolapse of a cerebellum and hypostasis of a trunk served in O. A. Laponogov's observations as a cause of death of 11 of 104 operated patients. By data K. Ya. Oglezneva, good results at And. a back cranial pole after operation were observed in 70%, at mortality to 20% and a recurrence in 10% of observations. I. M. Irger specifies that operations at optokhiazmalny And. give improvement of sight in 24 — 37% of cases and often stop progressing of process.
Bibliography: Burdenko H. H., Egorov B. G. and Skorodumova A. V. About surgical treatment of an optokhiazmatiche-sky arachnoiditis, Vopr. neyrokhir., t. 4, No. 5, page 23, 1940; Linchenko H. M. Chronic periventrikulyarny encephalitis and arachnoidites, M., 1961, bibliogr.; Madzhidov H. M. Klinika and diagnosis of a chronic fibroziruyushchy pia-arachnitis — an arachnoiditis — a back cranial pole, Tashkent, 1969, bibliogr.; it, the Chronic fibroziruyushchy pia-arachnitis — an arachnoiditis — a back cranial pole, Tashkent, 1968, bibliogr.; Margulies M. S. Infectious diseases of a nervous system, the Management on nevrol., under the editorship of N. I. Grashchenkov, t. 5, century 2, page 544, M. — D., 1940, bibliogr.; D. S footer. Diseases of a nervous system at children, page 105, M., 1965; Hodos X. G. Cerebral arachnoidites, Works of the 1st In sulfurs of wasps. congress neuropath, and psikhiat., t. 1, page 57, M., 1963; Duker M. B. Infectious diseases of a nervous system at children, page 61, M., 1963; Schwartz A. M. Clinic of basilar arachnoidites, Tomsk, 1961, bibliogr.; Handbuch der inneren Medizin, hrsg. v. G. Bergmann u. a., Bd 5, T. 3, S. 249, B. u. a., 1953; Wünsch er W. Über die sogenannte Arachnitis, Psychiat. Neurol, med. Psychol. (Lpz.), Bd 9, S. 331, 1960, Bibliogr.
Radiodiagnosis of A. — Esinovskaya G. N. Short guide to a neuroradiology, page 164, L., 1973; Neurox-ray inspections in diagnosis of a konveksitalny arachnoiditis, under the editorship of S. P. Vorobyov, L., 1972; To οπή l about in M. B. Bases of radiodiagnosis of diseases of a brain, page 473, M., 1968, bibliogr.
Surgical treatment And. — Bondarchuk A. V. Principles of surgical treatment of an arachnoiditis of a back cranial hole, Trudy Vseros. nauch. - prakt. konf. neyrokhir., page 171, L., 1956; Irger I. M. Neurosurgery, page 206, M., 1971; Koreysha L. A. Principles of surgical treatment of effects of an inflammation of a brain and its covers, Dokl. Vsesoyuz. konf. to it-rokhir., page 417, M., 1960; Laponogov O. A. To a question of surgical treatment of inflammatory occlusions in a back cranial hole, Vopr. neyrokhir., No. 3, page 35, 1959, bibliogr.; Ogleznev K. Ya. Surgical treatment of arachnoidites of a back cranial pole at children, in book: Probl. sovr. neyrokhir., under the editorship of B. G. Egorov, t. 4, page 242, M., 1962, bibliogr.; Fundamentals of preventive neurosurgery, under the editorship of A. L. Polenov and I. S. Babchin, page 418, JI., 1954; Sokolova O. N. imalyarevsky A. A. About surgical treatment of a family form of an optokhiazmalny arachnoiditis, Vopr. neyrokhir., No. 3, page 28, 1969, bibliogr.; Surgery of the central nervous system, under the editorship of V. M. Ugryumov, the p. 2, page 153, D., 1969.
X. G. Hodos; Yu. G. Elashov (rents.), O. A. Laponogov (hir.).