BRAIN

From Big Medical Encyclopedia

BRAIN (encephalon) — front department (central body) of c. the N of page of vertebrata, including the person regulating relationship of an organism with the environment, managing behavioural reactions and functions of an organism. It is located in a head cavity and consists from final, or big, a brain (telencephalon) and a brain trunk (truncus cerebri). In a brain trunk distinguish a diencephalon (diencephklon) including an epithalamus (a nadbugorye, epithalamus), a metathalamus (a zabu-gorye, metathalamus), a thalamus (a visual hillock, thalamus), a hypothalamus (a hypothalamus, hypothalamus); a mesencephalon (mesencephalon) including legs of a brain (pedunculi cerebri) and a plate of a roof, or chetverokholmy (lamina tecti); a metencephal (metencephalon) presented by the bridge (pons) and a cerebellum (cerebellum); myelencephalon (myelencephalon). Back and the myelencephalon is combined under the name of a rhombencephalon (rhombencephalon), the upper part to-rogo is made by a cerebellum and a top and bottom brain sail (velum medullare sup. et inf.).

COMPARATIVE ANATOMY

Phylogenesis

Fig. 1. Brain of some vertebrates (dorsal view): 1 — Cyclostoma (cycloostomy); II \cartilaginous fish (selakhiya); III \bony fish (carp); IV \amphibian (frog); V \reptile (lizard); VI \--------bird (pigeon); VII \mammal; 1 — an end brain; 1a — an olfactory bulb; 16 — other part of an end brain; 2 — a diencephalon; 3 — a mesencephalon; 4 — a cerebellum; 5 — a myelencephalon; 5a — a front share; 56 — lobus vagalis. On Kulenbeka.

Invertebrates. At worms, mollusks and arthropods of the greatest development reaches the most front department of c. the N of page presented nadglotochny and subpharyngeal by nodes. At mollusks and arthropods, and especially at insects, the nadglotochny node is highly differentiated, consists of a number of departments (primary, secondary and tertiary brain), and each department includes a number of more or less isolated accumulations of cells. Front department of c. the N of page of the highest invertebrates has the most complex structure in comparison with other its departments; according to it more difficult functions are inherent in it.

Vertebrata. Of m is most simply constructed at acranial. E.g., at a lancelet of c. by N of page it is located epikhordalno. Its forefront G. makes m where the gleam of the central channel is slightly wider, than in the tail (spinal cord). Of m of a lancelet receives afferent signals only from two nerves — olfactory and terminal.

At Cyclostoma Of m goes beyond a chord and accurately is divided into the main departments (fig. 1, I). In particular, there is a rhombencephalon, from to-rogo at the highest vertebrata stand apart oblong and a metencephal. Since Cyclostoma, back departments of a trunk of G. of m dominate over lobbies therefore upper plates of a rhombencephalon disperse in the parties, forming a rhomboid pole. Its formation is caused by emergence of the bronchial (branchiate) device and development of the structures managing it: sensitive and visceromotor fibers of back roots of a rhombencephalon and their kernels. Here near kernels and the descending ways of the VIII pair of cranial nerves the central representative office of lateral system, or bodies of a sideline is located. Appearing for the first time at Cyclostoma and being reduced at land vertebrata, the lateral system provides assessment of speed and the direction of movement of a body of water — a basis of orientation and coordination of movements. Nearby the kernel of a spinal way of a trifacial and a single way (a kernel of the IX—X couples) relating to viscerosensory area, and several knutra — visceromotor area with motive kernels V, VII, IX and X nerves lie. The motive kernel of a tire along with small cells contains very big cells (Müller's cell) which axons, giving on the course of a collateral to all segments, reach the most caudal part of a spinal cord innervating a tail — principal organ of the movement of Cyclostoma. The cerebellum is presented by the cross plate consisting of a molecular layer and a layer of grains, between to-rymi large cells — pear-shaped neurocytes (Purkinye's cell) are located. Mesencephalon of the small sizes, its upper wall it is formed by a vascular texture. The division of a diencephalon on an epithalamus, a slight thalamus and a hypothalamus is planned. The last controls the visceromotor centers of a rhombencephalon through system of efferent fibers. The end brain of the small sizes, consists of a lobby — bulbar and back — lobar parts. Cellular masses is located only periventrikulyarno, represents primary (a bulbar part) and secondary (a lobar part) the olfactory centers. Effector ways, hl. obr. from a lobar part, there are to a hypothalamus and to nuci, habenulae (a kernel of a bridle).

At cartilaginous fishes (fig. 1, II) in well developed akustiko-lateral zone of a rhombencephalon localized representation of lateral system. A cerebellum — the folded voluminous education considerably blocking from above a mesencephalon. Lateralno a cerebellum adjoins area of preddverno-lateral kernels of a trunk, forming auricular shares in the place of an excess. The mesencephalon is developed better, than at Cyclostoma, the well-marked roof perceives visual fibers and fibers of the general sensitivity. Kernels of lateral system stand apart. In a diencephalon the thalamus and very strongly a hypothalamus, especially its bottom is rather poorly developed. The end brain is more, than at Cyclostoma, also has more complex structure. Voluminous olfactory bulbs disperse in the parties, the cavity of a ventricle is surrounded with the periventrikulyarny cellular masses forming a basal kernel (the corresponding corpus striatum of mammals), dorsolateralno from it — an epibazalny kernel, and inside and up — an upper bazimedialny kernel (there corresponds septum pellucidum — a transparent partition of mammals). From a basal kernel the so-called olfactory bark displaced to the basis of an end brain [a paleocortex, or ancient bark — stood apart see. Very tectonics of a cerebral cortex (hemicerebrums) ].

At bony fishes, especially at cyprinid and somovy, the rhombencephalon is organized rather difficult that is connected with high development of the flavoring analyzer. Representations of the flavoring fibers arriving from an oral cavity form voluminous lobi vagales (fig. 1, III, 56), and the front share located between them (fig. 1, III, 5a) receives fibers from the skin flavoring kidneys widespread on all body. In a motor kernel of a tire at bony fishes so-called enormous cells (Mautner's cell) lie. Fibers from primary predoor kernels, kernels of lateral system, kernels of a trifacial, from a cerebellum and front a dvukholmiya approach their dendrites. Neurites of these cells reach the most caudal departments of a spinal cord and, giving throughout a collateral, carry out coordination of motility. The cerebellum forms a characteristic ectropion in a cavity of a ventricle of a mesencephalon (valvula cerebelli). The mesencephalon is constructed more difficult, than at cartilaginous fishes: front dvukholmy it is already clearly differentiated on three main layers. Bigger development reaches back dvukholmy. In the field of a diencephalon the thalamus is rather poorly expressed, it is strong — an epithalamus and especially a hypothalamus. The lateral cranked body, adjacent to a thalamus, at some types is divided into plates. The end brain is developed, its upper wall formed by a simple epithelial plate thin, side very much massivna. The rudiments of bark G. of m arising at cartilaginous fishes at bony fishes are absent.

In a rhombencephalon amphibians (fig. 1, IV) in the field of kernels of the VIII couple for the first time in phylogenesis along with predoor arise also actually acoustical, or cochlear, fibers (a dorsal kernel), coming from snails (cochlea). Srednemozgovy ways of trifacials are strongly developed. The cerebellum, unlike a cerebellum of fishes, is developed poorly, especially at tailless amphibians, at having a tail auricular shares as the lateral system disappearing at tailless amphibians is kept are rather well-marked. The mesencephalon represents not only visual (lobus opticus), but also the general correlation center as perceives not only visual, but also vestibular fibers, and also fibers of the general sensitivity. It is well-marked dvukholmy. From formations of a diencephalon it is better than others the thalamus is developed that is connected with increase in a role of skin reception. Efferent fibers of a thalamus go to a dorsolateral wall of an end brain and for the first time in phylogenesis represent though very poorly developed system of a talamopallialny projection. At amphibians, as well as at reptiles, birds and mammals, the end brain almost completely consists of hemispheres. Basal part of an end brain is formed by the basal kernel passing knaruzh into the lateral field of a raincoat further there is a dorsal field of a raincoat, and the medial wall is occupied by the medial field of a raincoat (primordium hippocampi, a rudiment of old bark). In all these formations are isolated more dense internal (adjacent to a cavity of a ventricle) and more loosened peripheral layer, however a true cortical plate it is not differentiated yet.

At reptiles (fig. 1, V) goes a further differentiation of acoustical and predoor kernels. At the level of a motive kernel of a trifacial there is the main kernel. At all reptiles the worm of a cerebellum is developed better, than hemispheres that is connected with disappearance of lateral system and with big development of spinnomozzhechkovy bonds. On average a brain from scattered cells of a motive kernel of a tire the red kernel is for the first time consolidated, upper cerebellar legs approach Krom (pedunculi cerebellares sup.). The acoustical kernels connected with secondary ways of system VIII of couple and with back dvukholmiy that corresponds to emergence in reptiles of the hearing aid are well developed. In comparison with other departments of a diencephalon the thalamus already clearly divided into the main kernels is strongly developed. The fibers connecting them to bark make the new system of talamokortikalny and kortiko-thalamic projections (pedunculus dorsalis) which is completely absent at fishes while the ventral system of a diencephalon (pedunculus ventralis) connecting a hypothalamus and a mesencephalon with basal bark belongs to old systems of a diencephalon. In an end brain of reptiles along with ancient bark (paleocortex) for the first time there is a well-marked old bark (archicortex). Old bark occupies medial, dorsal and dorsolateral surfaces of hemispheres and consists of macrocellular and small-celled parts. The lateral wall of a hemisphere on a small extent is formed by lateral bark — a homolog of new bark of mammals. Ancient bark, including an olfactory hillock, diagonal area, periamigdalyarny area and a partition, creates the basis of a brain and comes on a bazimedialny surface. Only in a paleocortex isolation of a cortical plate is hardly planned. Feature of periventrikulyarny kernels of reptiles is existence of the ventricle of the so-called gipopallialny hillock covered on the periphery with the condensed gipopallialny cellular plate, and in the center occupied with the central kernel (striatum dorsale) pressing deeply in a cavity, a cut is connected with the basal kernel (striatum ventrale) located ventrally. Functionally end brain of reptiles more than at amphibians, loses value only of «rhinencephalon» and gains value of the general correlation center.

In a rhombencephalon birds (fig. 1, VI) are well developed kernels of an acoustical nerve and the system of predoor kernels is very difficult presented. In the first floor of a myelencephalon for the first time there is an olive. The cerebellum is strongly developed. The mesencephalon is covered in front with hemispheres of an end brain, and behind — a cerebellum owing to what front hillocks are pushed aside in the parties and in the ventral direction. Back hillocks are absent; the kernels concerning system of an acoustical nerve are submersed deep into and blocked by a roof. The red kernel is developed much better, than at reptiles. In a diencephalon olfactory bonds are considerably reduced. But talamopallialny bonds are strongly developed, and kernels of a thalamus are developed and differentiated much better, than at reptiles. In an end brain the central nodes occupying almost all mass of hemispheres prevail. The central kernel as well as at reptiles forming a big ledge in a cavity of a ventricle is especially big. Bark is developed poorly. Ancient bark occupies only the small field, directly adjacent to a small olfactory bulb. Primordium hippocampi is expressed clearly, however there is no accurately isolated cortical plate in the field of old bark, and new bark is absent completely.

Further development of a great brain went on two opposite ways: at birds — in the direction of dominance of the central nodes, and at mammals — domination of bark. Functionally it was expressed at birds in bigger development of the inherited forms of behavior, and at mammals — individual adaptation.

In a myelencephalon mammals (fig. 1, VII) happens further development of an olive. It phylogenetic new departments send fibers to new formations of a cerebellum — to hemispheres (neocerebellum). There through kernels of the bridge and average cerebellar legs fibers come from new bark of hemicerebrums. There is a pyramidal way which is directly connecting bark of a great brain with spinal motoriums. The volume of a medial loop and bulbar kernels of the ascending ways of back cords increases. On average a brain there pass pyramidal and cortical and bridge ways, there is substantia nigra (at the lowest mammals it is hardly planned and deprived of a pigment), the sizes of a red kernel increase. The medial cranked body is formed. It is well-marked back dvukholmy; front dvukholmy — the highest visual center of the lowest vertebrata — substantially loses this role; major importance gets the lateral cranked body transferring visual impulses to occipital area of bark of a great brain. The diencephalon of mammals increases at the expense of a thalamus, growth of the sizes and complication of a structure to-rogo correspond to extension of contacts with bark and a striate body (neostriatum). In evolution of an end brain of mammals growth of new bark is leading. At the person in comparison with monkeys the specific weight of such areas as the lower parietal area, many fields a frontal and temporal lobe, transitional temporal and occipital area, i.e. those formations which are connected with the second alarm system strongly increases.

Important feature of a great brain of mammals is development of furrows, at subordinate vertebrata only planned in the field of old and ancient bark. Thanks to growth of furrows the volume of bark without increase in capacity of a skull increases (see. Furrows and crinkles of a cerebral cortex ).

At all mammals, except single-pass and ascigerous, arises corpus collosum (see) — the commissure connecting new bark of both hemispheres. Subordinate vertebrata have only commissures of ancient and old bark.

Classical researches of Herrick (Page J. Herrick), A. A. Zavarzina, E. K. Seppa and A. I. Karamyan (1970) data allow to formulate ideas of staging of formation morfofiziol. G.'s features of m in phylogenesis. The first stage is characterized by development of spinobulbarny level of integration (acranial and cyclostomous). Formation powerful cerebellar tektalnoy systems at cartilaginous and bony fishes — the second stage of development of G. of m. At the third stage amphibians and reptiles have a dientsefalotelentsefalny level of integration and, at last, at mammals neotserebello-neotalamo-neocortical mechanisms gain development. This fourth stage leads to formation of a complex system of associative fields in a thalamus and bark of a great brain at the person.

Ontogenesis

Fig. 2. The scheme of cross section through a brain fillet (a) and a brain tube (b) of a triton: 1 — a brain fillet; 2 — a chord; 3 — an ectoderm; 4 — a mesoderm; 5 — an entoderm; 6 — a digestive tube; 7 — a brain tube. Across Gertvigu.

Process of ontogenesis of G. of m repeats the main stages of phylogenesis. At the person, as well as at all vertebrata, formation of a nervous system begins with emboly, or invagination, outside germinal leaf (see) and educations so-called nervous, or brain, tubes (fig. 2).

Fig. 3. Brain of a three-months germ (right half, from within): 1 — pallium; 2 — thalamus; 3 — epithalamus; 4 — metathalamus; 5 — lamina tecti; 6 — pedunculus cerebri; 7 — cerebellum; 8 — fossa rhomboidea; 9 — medulla oblongata; 10 — medulla spinalis; 11 — pons; 12 — pars mamillaris hypothalami; 13 — hypophysis; 14 — chiasma opticum; 15 — pars optica hypothalami; 16 — rhinencephalon; 17 — corpus striatum. At the left below scheme of development of brain bubbles: and — telencephalon; — diencephalon; in — mesencephalon; — isthmus rhombencephali; d — metencephalon; e — myelencephalon. On Shpaltegoltsa.

In process of a nervous system at the person the brain tube is differentiated in longitudinal, or verkhnenizhny, the direction on upper (front) and lower (back) departments. The lower part is differentiated in a spinal cord. Upper forms the so-called brain bubbles arising owing to the uneven growth of separate parts of its wall. In the beginning there are three such bubbles: neoncephalon (prosencephalon), mesencephalon (mesencephalon) and rhombencephalon (rhombencephalon). Further on both sides of a neoncephalon symmetrically forward and in the parties two more bubbles, forming an end brain (telencephalon) are stuck out, and the tail of a neoncephalon which remained undivided creates a diencephalon (diencephalon). The rhombencephalon gives rise to back (metencephalon), an oblong (myelencephalon) brain and an isthmus (isthmus) — fig. 3.

In further development G.'s configuration of m changes and becomes complicated. From an end brain there are hemicerebrums — a cerebral cortex with the subject white matter and basal kernels. The thalamus, an epithalamus, a metathalamus and a hypothalamus are formed of a diencephalon. The mesencephalon creates legs of a brain and a roof of a mesencephalon (chetverokholmy), and back — the bridge of a brain (varoliyev) and a cerebellum. From an isthmus of a rhombencephalon the upper cerebellar leg, an upper sail and a triangle of a loop develop. The lower (back) part of a brain tube which is not divided into brain bubbles forms a spinal cord. According to division the brain tube is subdivided into departments and her cavity: in the thickness of an end brain there are pair lateral ventricles, in a diencephalon — the third ventricle, on average a brain — a water supply system of a brain (silviyev a water supply system), and in a rhombencephalon — the fourth ventricle.

At the same time brain tube is differentiated also in transverse direction. Its back (dorsal) and front (ventral) walls lag behind in growth from side, divided by a boundary furrow into the main and upper plates. The main plate corresponds primary somatomotor, and upper — to primary somatosensory centers. In the field of the most boundary furrow visceromotor and viscerosensory plates the containing kernels, the innervating interiors, vessels, skin and its appendages lie. The boundary furrow, as well as a motor plate, reaches only front departments of a diencephalon. Therefore, all end brain is formed at the expense of primary touch plate. Contact with the environment — one of determinal factors of post-natal ontogenesis of G. of m of the person. In particular, at newborn monkeys bark G. of m on thickness makes 80% definitivny (finally created), and at the person by the time of the birth reaches only 20%.

Under the influence of environmental factors snowballing of bark G. of m of the person occurs within the first five years of post-natal life (I. N. Bogolepova, 1975).

ANATOMY

Fig. 1. Sagittal section of a brain: 1 — lobus frontalis; 2 — gyrus cinguli; 3 — corpus callosum; 4 — septum pellucidum; 5 — fornix; 6 — commissura ant.; 7 — chiasma opticum; 8 — hypophysis; 9 — lobus temporalis; 10 — pons; 11 — medulla oblongata; 12 — cerebellum; 13 — ventriculus quartus; 14 — lobus occipitalis; 15 — lobus parietalis; 16 — lamina tecti; 17 — corpus pineale; 18 — aqueductus cerebri; 19 — thalamus; 20 — regio subthalamica.
Fig. 4. Trunk of a brain (from above): 1 — thalamus; 2 — corpus pineale; 3 — lamina tecti; 4 — n. trochlearis; 5 — n. trigeminus; 6 — velum medullare sup.; 7 — pedunculus cerebelli sup.; 8 — pedunculus cerebelli medius; 9 — n. facialis et n. vestibulocochlearis; 10 — fossa rhomboidea; 11 — n. glossopharyngeus; 12 — n. vagus; 13 — n. accessorius; 14 — medulla oblongata; 15 — pedunculus cerebelli inf.; 16 — pedunculus cerebri.
Fig. 9. The scheme of an arrangement of kernels and cranial nerves in a trunk part of a brain: 1 — aqueductus cerebri; 2 — n. trochlearis; 3 — nucleus motorius n. trigemini; 4 — genu n. facialis et nucleus n. abducentis; 5 — ventriculus quartus; 6 — nucleus n. hypoglossi; 7 — tractus spinalis n. trigemini; 8 — nucleus n. accessorii; 9 and 13 — n. hypoglossus; 10 — n. accessorius; 11 — n. vagus; 12 — nucleus ambiguus; 14 — n. glossopharyngeus; 15 — nucleus salivatorius inf.; 16 — n. acusticus; 17 — n. facialis; 18 — n. abducens; 19 — nucleus n. facialis; 20 — pons; 21 — n. trigeminus; 22 — pedunculus cerebri; 23 — n. oculomotorius; 24 — nucleus ruber; 25 — nucleus n. oculomotorii.

The form G. of m is close to a shape of a skull. The average weight of G. of m of the adult man of 1375, the woman — 1275, individual variations — 900 — 2000 g. G.'s weight of m is more, than at the person, only at an elephant (4000 g) and a whale (2800). The relation of weight of G. of m to body weight at the person considerably exceeds that at animals.

In G. the m can distinguish a trunk and big, or final, a brain. To a trunk (truncus cerebri) G. of m (tsvetn. fig. 1 and 4) carry a myelencephalon (see), the bridge of a brain (see), cerebellum (see), mesencephalon (see), a plate of a roof, or chetverokholmy (see), and legs of a brain, and also a diencephalon (see). The trunk generally keeps the general with a spinal cord (see) the plan of a structure — the side mass of a brain tube is divided into the main plate (the motor centers) and into an upper plate (a touch zone). Between touch and motor zones are located visceromotor and viscerosensory area, concerning an innervation of interiors, vessels, a trophicity of skin, mucous membranes etc. To a configuration of a trunk there corresponds the shape of the central cavity — ventricles of a brain (see).

In the majority of kernels of a trunk of G. of m (tsvetn. fig. 9) originate or come to an end cranial nerves (see), except for an olfactory nerve (n. olfactorius) and a spinal portion of an eleventh cranial nerve (item accessorius). In addition to kernels of cranial nerves, in G.'s trunk of m also other large anatomic educations lie: olive kernels (nuclei olivares), reticular formation (see), own kernels of the bridge (nuclei pontis), red kernels (nuclei rubri), gray layer of upper hillocks (stratum griseum colliculi sup.) and kernels of the lower hillocks (nuclei colliculi inf.), thalamus (see), under the Crimea kernels are located hypothalamus (see).

Fibers of a trunk of G. of m divide on endogenous and exogenous. Exogenous fibers come from a spinal cord, from big hemispheres or from nodes of cranial nerves. Some exogenous fibers switch in a trunk to new neurons which neurites are endogenous fibers. The last go to a spinal cord, to hemicerebrums, connect among themselves various formations of the bridge, leave as a part of efferent cranial nerves (see. Motoriums, ways ; Visual centers, ways ; Conduction paths ; Acoustical centers, ways ).

Fig. 2. Brain (sideways): 1 — lobus frontalis; 2 — lobus temporalis; 3 — medulla oblongata; 4 — cerebellum; 5 — lobus occipitalis; 6 — lobus parietalis; 7 — sulcus lateralis; 8 — sulcus centralis.
Fig. 3. Brain, dorsal view: 1 — lobi fron-tales; 2 — lobi parietales; 3 — lobi occipitales; 4 — fissura longitudinalis cerebri.
Fig. 5. Basis of a brain: 1 — lobi frontales; 2 — tractus olfactorius; 3 — n. opticus; 4 — lobus temporalis; 5 — n. oculomotorius; 6 — n. trochlearis; 7 — pons; 8 — n. trigeminus; 9 — n. abducens; 10 — n. facialis et n. vestibulocochlearis; 11 — n. glossopharyngeus; 12 — n. vagus; 13 — n. accessorius; 14 — cerebellum; 15 — lobi occipitales; 16 — pyramides; 17 — n. hypoglossi; 18 — corpus mamillare; 19 — tuber cinereum et infundibulum; 20 — chiasma opticum.


The great brain (cerebrum), or end brain (telencephalon), is divided by a longitudinal furrow (fissura longitudinalis cerebri) into two hemispheres (hemispheria) — right and left, connected by means of a corpus collosum (see), the arch and front commissure (commissura ant.) (tsvetn. fig. 2,3 and 5).

In size the great brain exceeds all other departments of G. of m combined; from above it completely covers a trunk, including a cerebellum.

Average length of a parencephalon is 170 mm, width of both hemispheres of 140 mm, height is 125 mm.

On each hemisphere it is accepted to distinguish three surfaces: upper lateral (facies superolateralis cerebri), medial (facies medialis cerebri) and lower (facies inf. cerebri), and also three poles: frontal (polus frontalis), occipital (polus occipitalis) and temporal (polus temporalis). Three surfaces are accurately differentiated at a front pole, and at back borders between the lower and internal surfaces are erased. The Verkhnelateralny surface convex in all directions also corresponds to bones of a skull. The plane medial surface, corresponds to a medial surface of other hemisphere, from a cut is above separated by a crescent shoot of a firm meninx (falx cerebri). The lower surface lies on a base of skull, in front departments adjoins to it, and in back — with mashed a cerebellum (tentorium cerebelli) which separates it from a cerebellum (tsvetn. fig. 2, 3 and 5). Besides, on a lower surface of hemispheres distinguish some more anatomic educations. In particular, all surfaces of hemicerebrums are covered with a raincoat (pallium) formed by gray matter — (see Furrows and crinkles of a cerebral cortex), between to-rymi crinkles (gyri) are a cerebral cortex (see), the cut-up large number of furrows. On a lower surface of a frontal lobe (in sulcus olfactorius) the olfactory path (tractus olfactorius) lies, the front increased part to-rogo forms an olfactory bulb (bulbus olfactorius), and expanded back — an olfactory triangle (trigonum olfactorium). On an inner edge of the last there passes stria olfactoria medialis, and on outside — stria olfactoria lat. Striae olfactoriae limit in front the front made a hole substance (substantia perforata ant.) with a set of the openings serving for passing of vessels of a brain to subcrustal educations. Further kzad the basis of a brain create temporal shares and lying on the centerline of formation of a brainstem between them (tsvetn. fig. 5).

Between front departments of a corpus collosum (corpus callosum) and columns of the arch (columnae fornicis) there is a space closed by a transparent partition (septum pellucidum), edges divides front horns of side ventricles (see. Septal area ). The space between two plates of a transparent partition is called a cavity of the septum pellucidum (cavum septi pellucidi).

Fig. 4. Frontal section of a brain at the level of front commissure: 1 — ventriculus lateralis; 2 — caput nuclei caudati; 3 — capsula interna; 4 — nucleus lentiformis; 5 — chiasma opticum; 6 — hypophysis; 7 — gyrus parahippocampalis; 8 — commissura anterior; 9 — claustrum; 10 — capsula int.; 11 — columna fornicis; i 2 — cavum septi pellucidi; 13 — corpus callosum.
Fig. 5. Frontal section of a brain at the level of the third ventricle: 1 — capsula interna; 2 — nucleus lentiformis; 3 — capsula externa; 4 — claustrum; 5 — nucleus ruber; 6 — tractus opticus; 7 — nucleus subthalamicus; 8 — gyrus parahippocampalis; 9 — pes hippocampi; 10 — ventriculus tertius; 11 — insula; 12 thalamus; 13 — cauda nuclei caudati; 14 — corpus fornicis; 15 — corpus callosum.
Fig. 6. A horizontal section of a brain at the level of basal kernels: 1 — cornu anterius; 2 — caput nuclei caudati; 3 — capsula interna (crus anterius); 4 — putamen; 5 — nucll. anteriores thalami; 6 — nucleus lateralis thalami; 7 — capsula interna (crus posterius); 8 — nucleus medialis thalami; 9 — cornu posterius; 10 — splenium corporis callosi; 11 — cauda nuclei caudati; 12 — claustrum; 13 — insula; 14 — genu capsulae internae; 15 — septum pellucidum.

In the thickness of a hemisphere the cavity of a side ventricle lies (ventriculus lat.), covered by an ependyma and containing cerebrospinal liquid (see Ventricles of a brain), and also subcrustal, or basal kernels (see), and white matter. The kernel (nucleus caudatus) having a tail, a lenticular kernel (nucleus lentiformis), an amygdaloid nucleus (corpus amygdaloideum) and a fencing (claustrum) belong to basal kernels (fig. 4 — 6).

White matter of hemispheres is formed by the nerve fibrils connecting bark of one crinkle with bark of other crinkles of the and opposite hemisphere and also with underlying educations. Topographical in white matter distinguish four parts which are unsharply delimited from each other: 1) white matter in crinkles between furrows; 2) area of white matter in outside parts of a hemisphere — the semi-oval center (centrum semiovale); 3) the radiate crown formed lucheobrazno by the dispersing fibers entering the internal capsule and leaving it; 4) central white matter of a corpus collosum, internal capsule (capsula interna) and long associative fibers.

Nerve fibrils of white matter divide on associative, komissuralny and projective. Associative fibers connect bark of the same hemisphere. Komissuralny, or commissural, connect not only symmetric points, but also the bark belonging to different shares of opposite hemispheres. The majority of komissuralny fibers goes as a part of a corpus collosum, except for fibers from front departments of a temporal share which pass in front commissure and a commissure of the fornix. Projective fibers connect bark of hemicerebrums with underlying educations, and through them with the periphery. These fibers divide on centripetal (ascending, corticipetal, afferent) and centrifugal (descending, corticofugal, efferent). Almost all projective fibers, except for belonging to the olfactory analyzer, pass through the internal capsule. In the internal capsule distinguish 5 parts: front leg of the internal capsule (crus ant. capsulae internae), bend (genu capsulae internae), back leg of the internal capsule (crus post, capsulae internae), zachechevitseyaderny part (pars retrolentiformis capsulae internae) and podchechevitseyaderny part (pars sublentiformis capsulae internae). To each of these departments there correspond certain ways. Through a front leg there are cortical and bridge fibers, through a knee — fibers from bark to motive kernels of cranial nerves; through a back leg — afferent and efferent fibers sensomotor) the analyzer, and also the fibers connecting bark with a thalamus; through a zachechevitseyaderny part there pass fibers of the visual analyzer (see), and through podchechevitseyaderny — acoustic analyzer (see).

Blood supply of a brain

Fig. 6. Great brain (from above): 1 — venae frontales; 2 — lacunae laterales; 3 — falling of veins of a brain into sinus sagittalis sup.; 4 — sinus sagittalis sup.; 5 — venae cerebri superiores.
Fig. 7. Scheme of arteries of the basis of a brain: 1 — a. communicans ant.; 2 — a. cerebri ant.; 3 — a. cerebri media; 4 — a. carotis int.; 5 — a. communicans post.; 6 — a. cerebelli inf. ant.; 7 — a. vertebralis; 8 — a. cerebelli inf. post.; 9 — a. spinalis ant.; 10 — a. spinalis post.; 11 — a. basilaris; 12 — a. labyrinthi; 13 — a. cerebri post.; 14 — a. chorioidea ant.
Fig. 8. Great brain (from below): 1 — a. carotis int.; 2 — a. cerebri ant.; 3 — a. communicans ant.; 4 — a. communicans post.; 5 — a. cerebri post.; 6 — a. basilaris; 7 — v. basilaris; 8 — v. cerebri magna; 9 — a. cerebri med.

Veins G. of m are presented by the internal carotid and vertebral arteries, their branches bringing blood, both superficial and deep veins, on the Crimea blood flows hl. obr. in sine of a firm cover of G. of m (tsvetn. fig. 6 — 8).

Arteries. Each internal carotid artery (a. carotis interna) on the basis of a brain breaks up to front and average brain arteries (aa. cerebri ant. et media). The right and left front brain arteries are anastomosed by a short front connecting artery, very changeable on diameter (a. communicans ant.).

Vertebral arteries (aa. vertebrales) on the basis of a brain trunk combine in a basilar artery (a. basilaris), edges, having passed a nek-swarm distance, breaks up to two back brain arteries (aa. cerebri post.). Each back brain artery is tied with an internal carotid artery through a back connecting artery (a. communicans post.). Educated thus vascular ring (tsvetn. fig. 7) carries the name of an arterial (villiziyev) circle of a great brain (circulus arteriosus cerebri).

Hemicerebrums krovosnabzhat pair front, average and back brain arteries. Trunks and their branches are located on G.'s surface of m in a subarachnoid space (tsvetn. fig. 6 and 8). Branches of the same artery and a branch of various arteries widely anastomose among themselves (fig. 7 and 8). Especially a lot of large anastomosis is concentrated in zones of collateral blood supply. To norm thanks to system of an anastomosis in all arteries of a surface of G. of m approximately identical Intra arterial pressure would be supported. At obstruction of one of arteries blood comes to its pool on an anastomosis.

Fig. 7. The scheme of distribution of branches of front and back brain arteries on a medial surface of a hemisphere and their anastamosing among themselves (zones of collateral circulation are shaded): 1 — r. orbitalis; 2 — 6 — rr. frontales; 7 — 9 — rr. parietales; 10 — a. cerebri post.; 11 — a. cerebri ant.

The front brain artery (fig. 7) gives cortical branches (rr. corticales): orbital (of Orbitales), frontal and polar, front, average and back frontal branches (rr. frontales) and parietal branches (rr. parietales), paracentral, postcentral arteries, a branch to a precuneus and a corpus collosum. The front brain artery supplies medial departments of orbital crinkles, direct, zone, upper frontal crinkles, a paracentral segment, a part of a precuneus, a part of an average frontal crinkle, upper parts before - and postcentral crinkles and a verkhneperedny part of an upper parietal segment, and also white matter, giving the central branches (rr. centrales). Besides, branches of this artery feed an olfactory path, a final plate, a knee and about 4/@ corpus collosum, a transparent partition, legs and an upper part of the arch, a part of a precomissure.

Fig. 8. The scheme of distribution of branches of an average brain artery to the surfaces of a brain and their anastamosing with branches of front and back brain arteries (zones of collateral circulation are shaded): 1 — r. orbitalis; 2 — 4 — rr. frontales; 5 — 7 — rr. parietales; 8 — 11 — rr. temporales.

The average brain artery (fig. 8) on a surface of a hemisphere gives cortical branches: orbital (rr. Orbitales), frontal (rr. frontales) — the precentral, central and postcentral arteries, parietal (rr. parietales), back, average and front temporal (rr. temporales) and an artery to a temporal pole. The average brain artery supplies the lower and average frontal crinkles, the lower 2/3 central crinkles, lower parietal and a part of an upper parietal segment, a middle part of an outer surface of an occipital share, upper, average and adjacent department of the lower temporal crinkle, a lateral half of an orbital surface of a frontal lobe and a lower surface of a temporal pole. This artery gives also branches to an island.

The back brain artery (fig. 7) on a surface of hemispheres gives cortical branches: temporal (rr. temporales) — olfactory, cross and median and basal, occipital (rr. occipitales) — a lingual, shporny and parietooccipital branch (r. parietooccipitalis), supplies all crinkles of a lower surface of a hemisphere, except for the small site of a temporal pole, a shporny and parietooccipital furrow, marrow of a wedge and an adjacent part of a precuneus, upper, lower and back edges of an occipital share, a part of an upper parietal segment from the lower temporal crinkle. This artery also supplies the most part of a hypothalamus, area of a leg of a brain, a hippocampus and a back quarter of a corpus collosum.

Fig. 9. Scheme of distribution of sources of blood supply of separate parts of a kernel having a tail, shell and pale sphere (at the left) and vascular textures of side and third ventricles (on the right): 1 — caput nuclei caudati; 2 and 16 — rr. striati; 3 — a. cerebri anterior; 4 — a. cerebri media; 5 — ventriculus tertius; 6 — plexus chorioideus ventriculi tertii; 7 and 12 — a. chorioidea anterior; 8 — plexus chorioideus ventriculi lateralis; 9 — a. cerebri posterior; 10 and 11 — rr. chorioidei posteriores; 13 — cauda nuclei caudati; 14 — corpus nuclei caudati; 15 — globus pallidus; 17 — putamen.

In blood supply of vascular textures of ventricles of G. of m, participate: front fleecy artery (. chorioidea ant.) — a branch of an internal carotid artery (see) and back fleecy branches (rr. chorioidei post.) — from a back brain artery. The front fleecy artery supplies the bottom and glomus of a vascular texture of a side ventricle. Outside and internal back fleecy arteries — branches of a back brain artery. The first supplies glomus and forefront of a vascular texture of a side ventricle, and the second feeds a vascular texture of the third ventricle (fig. 9).

Basal kernels (a kernel having a tail, a shell, a pale sphere and parts of the internal capsule, adjacent to them) are supplied with striatal branches of front and average brain arteries (rr. striati; fig. 9). The feeding subcrustal kernels and the internal capsule of a branch depart from a front brain artery to a front connecting artery and is in rare instances closer to a beak of a corpus collosum. The quantity and size striatal branches of a front brain artery vary, them can be to eight. O. Geybner (1872) for the first time described the most constant large striatal branch of a front brain artery more often departing at the level of a front connecting artery and turning back to the front made a hole substance. Striatal branches of a front brain artery supply a head of a kernel having a tail, front departments of a shell, pale sphere and the internal capsule.

The branches of an average brain artery supplying subcrustal nodes and the internal capsule describe as striatal branches (rr. striati) of an average brain artery also divide into internal and outside groups. These arteries depart from an average brain artery throughout 2 — 3 cm before division of its trunk into arteries of hemispheres of G. of m. They supply a body of a kernel having a tail (sometimes and an upper part of its head), the most part of a shell, a pale sphere and the site of the internal capsule from the parts of a kernel having a tail supplied by these arteries to a lenticular kernel.

The third source of blood supply of basal kernels — branches of a front fleecy artery, edge departs from an internal carotid artery immediately of a kzada of the place of an otkhozhdeniye of an average brain artery more often. It gives back striatal arteries to the front made a hole space; in subarachnoid space they anastomose with branches of an average brain artery. Back striatal branches supply internal and average parts of a pale sphere and an adjacent back leg, zachechevitseyaderny and podchechevitseyaderny parts of the internal capsule (fig. 9).

The front fleecy artery gives branches to a visual tract, often supplies nearby parts of legs of a brain, gives branches to a pole of a temporal share, to a hook of a parahippocampal crinkle. This artery feeds also amygdaloid nucleus, the outside, turned to the internal capsule part of kernels of a hypothalamus, zona incerta and black substance. On the surface of an outside cranked body of its branch anastomose with back fleecy branches from a back brain artery. From educated thus vascular network short arteries get into a lateral cranked body. The front fleecy artery changeably and in various volume supplies a tail of a kernel having a tail, upper and lateral parts of a thalamus with the adjacent site of the internal capsule.

The main source of blood supply of a thalamus — the central branches (rr. centrales) back brain artery, and also branch of a front fleecy artery, average brain and back connecting arteries.

Chetverokholmiye (plate of a roof) is hit blood on two special arteries: front and back, and also from back fleecy branches. A front artery — a branch of a back brain artery; it gives branches also to legs of a brain and a medial cranked body. A back artery — a branch of an upper cerebellar artery.

Three steam rooms and one unpaired artery supplying a cerebellum depart from basilar and vertebral arteries is an upper lobby, the lower lobby, lower back cerebellar arteries and sometimes one unpaired — the lower average artery. Upper cerebellar artery (. cerebelli sup.) — branch of basilar, seldom back brain artery. Without reaching a cerebellum, this artery supplies a leg of a brain, takes part in food of upper hillocks and a part of a kernel of a third cranial nerve. Front lower cerebellar artery (. cerebelli inf.) — the branch of a basilar artery — supplies back and side departments of the bridge, roots VI, VII and VIII cranial nerves. Back lower cerebellar artery (. cerebelli inf. post.) can depart from a vertebral or basilar artery, then four secondary branches break up to two, three and even, supplying roots IX and X cranial nerves, posterolateral departments of a myelencephalon, the anteroinferior surface of the bridge, vascular textures of the fourth ventricle. On the surface of a cerebellum of an artery anastomose among themselves, forming uniform arterial network (see the Cerebellum).

Blood supply of a myelencephalon is provided by a front spinal artery (a. spinalis ant.), branches of vertebral arteries, basilar artery and back lower cerebellar artery. The type of blood supply of a myelencephalon is similar to that of the bridge; the myelencephalon is hit blood on median and circular arteries though the course of these vessels less correct, than in the bridge. Median arteries branches basilar, vertebrata and a front spinal artery partially reach a bottom of the fourth ventricle, supply a pyramidal way, a medial loop, predorsalny and back longitudinal bunches, a kernel of a hypoglossal nerve. Among short circular arteries of a myelencephalon distinguish an artery of a lateral pole — a branch of a basilar artery. Four or five branches of this artery together with branches of a cerebellar artery go in posterolateral departments of a myelencephalon, krovosnabzhy olives, gelatinous substance, a spinal way of a trifacial, kernel of the glossopalatine and wandering nerves, and also kernels of an eighth cranial nerve.

Fig. 10. The scheme of distribution of veins on outside and medial surfaces of hemicerebrums: 1 — v. anas - tomotica sup.; 2 — vv. cerebri superiores; 3 — v. anastomotica inf.; 4 — v. cerebri media; 5 — an anastomosis between branches of frontal veins and branches of an average brain vein; 6 — v. cerebri magna; 7 — v. occipitalis; 8 — v. basalis. According to Bailey.
Fig. 11. Scheme of venous sine of a firm meninx: 1 — sinus sagittalis superior; 2 — v. cerebri magna; 3 — sinus sagittalis inferior; 4 — v. anastomotica superior; 5 — y. cerebri interna; S — v. basalis; 7 — sinus intercavemosus; S — sinus cavernosus; 9 — plexus pterygoideus; 10 — plexus basilaris; 11 — sinus petrosus inferior; 12 — sinus petrosus superior; 13 — v. facialis; 14 — v. jugularis interna; 15 — v. jugularis externa; 16 — sinus transversus; 17 — sinus occipitalis; 18 — confluens sinuum; 19 — v. anastomotica inferior; 20 — sinus rectus. According to Schenk.

Veins. Distinguish superficial (fig. 10, a) and intracerebral veins of G. of m. Carry to venous system of a brain also sine of a firm meninx. From G.'s hemispheres of m blood is collected by superficial veins. On the surface of a brain they fall into larger trunks. Blood from vascular textures side and the third ventricles and from the most part of subcrustal educations comes to a big brain vein, or Galen's vein (v. cerebri magna; tsvetn. fig. 8). Superficial veins of big hemispheres divide into upper brain veins (vv. cerebri sup.), system of a superficial average brain vein (v. cerebri media superficialis) and lower brain veins (vv. cerebri inf.). Carry to the upper brain (ascending) veins: frontal veins, veins before - and postcentral crinkles and a vein of parietooccipital area. The superficial average brain vein collects blood from adjacent sites by a frontal, parietal temporal lobe, and also an island, falls into upper stony (sinus petrosus) or cavernous (sinus cavernosus) sine. The lower brain {descending) veins include group of temporal and occipital veins: front and back temporal and the lower occipital. All of them fall into cross (sinus transversus) or an upper stony sine. To veins on a verkhnelateralny surface of hemispheres of G. of m mostly there correspond veins of a medial surface (fig. 10, b). Upon transition of a convex surface of a hemisphere to medial both veins adjoin and fall into a sine separate trunks or previously merge in one. A venous blood from a medial surface of a hemisphere flows in an upper sagittal sine (fig. 11), and in an opposite direction — in a basal vein (v. basalis) where veins of front departments of a zone crinkle, a wedge and back departments of a zone crinkle fall. The basal vein falls into a big brain vein. Feature of superficial brain veins is a large number of the anastomosis of various diameter connecting branches of various veins among themselves. A large anastomosis by the sizes does not concede to the main venous trunks. Such is the lower anastomotic vein, or Labbe's vein (v. anastomotica inf.), connecting an average superficial brain vein to a cross sine, and an upper anastomotic vein, or Trolar's vein (v. anastomotica sup.), between an average superficial brain vein, a vein of the central furrow and an upper sagittal sine (tsvetn. fig. 8).

From a thalamus and subcrustal kernels blood comes to talamostriarny veins (vv. thalamostriata. Connecting to veins of a transparent partition (vv. septi pellucidi), a hippocampus, the subependimalny white matter surrounding ventricles and vascular textures (v. chorioidea), these veins form internal veins of a brain (vv. cerebri internae). They merge in a big brain vein (v. cerebri magna) falling into a direct sine (fig. 11). Veins of a corpus collosum, upper average vein of a cerebellum, basal vein and internal occipital vein fall into the same vein. Veins of a cerebellum are extremely changeable, the quantity varies them from 6 to 22. All of them widely anastomose the veins collecting blood from an upper surface of a cerebellum, from side surfaces of legs of a brain and a roof of a mesencephalon, the bridge, and also from a lower surface of a cerebellum, combine in the veins of a scrap falling into an upper stony sine (see. Meninx ).

On brain veins blood flows in the brain sine located in a firm meninx. Like brain veins sine are very variable. Absorbent vessels are not found m in G.

See also Cerebral circulation , Vascular textures .

The radioanatomy

For its studying is used a X-ray analysis of bones of the arch and a base of skull (see. Kraniografiya ), vessels (see. Cerebral angiography ), systems of ventricles and subarachnoid space (see. Ventrikulografiya , Encephalography ).

At a non-contrast kraniografichesky research carry out a X-ray analysis of a skull in the main axial projections (direct and side), estimate structure and thickness of bones, existence and the nature of manual impressions, x-ray density of bone educations, character of seams and a condition of edges of bones of a skull, the provision of physiologically calciphied educations — an epiphysis of a brain (strobiloid gland), some vascular textures, sites of a sickle (see. Skull ). The vascular system on kraniogramma does not find rather full display, it is possible to find only vascular furrows of arteries of a meninx, impressions of venous sine, the diploichesky venous courses.

Apply different types of a cerebral angiography to a research of vessels of G. of m. As G.'s blood supply in m is carried out by various vascular systems, for contrasting of vessels of each hemisphere and vertebrobazilyarny system conduct a purposeful angiographic research (see. Carotid angiography , Vertebralnaya angiography ). The fullest display of vessels of G. of m is received at a bilateral carotid and vertebralny angiography in standard mutually perpendicular (side and direct) projections, and if necessary — in slanting, axial, etc. At a serial cerebral angiography depending on duration of a research and frequency of shots it is possible to receive the image of arteries, capillaries, veins and sine of a firm meninx. On time of passing of a contrast agent judge the speed of a blood-groove.

Fig. 12. Right-hand carotid angiogram of vessels of a brain: an arrangement of the main branches of an internal carotid artery in side and direct projections: 1 — a siphon of an internal carotid artery; 2 — a nadklinovidny part it; 3 — an orbital artery; 4 — a front brain artery and its branches; 5 — branches of an average brain artery; 6 — branches of an outside carotid artery; 7 — cervical department of an internal carotid artery; 8 — a front fleecy artery.

Administration of contrast medium in the general carotid artery gives on angiograms the image of branches of outside and internal carotid arteries on the party of introduction (fig. 12). The main branches of an internal carotid artery are normal located rather typically. At a carotid angiography the siphon and nadklinovidny department of an internal carotid artery, orbital, front and average brain arteries, a front fleecy artery, in certain cases back connecting and back brain arteries is usually filled. At the isolated contrasting of an outside carotid artery on angiograms branches of average meningeal, superficial temporal and occipital arteries are visible.

Fig. 13. Left-side vertebralny angiogram of vessels of a brain: an arrangement of branches of a vertebral artery in a head cavity in side and direct projections; 1 — cervical department of a vertebral artery; 2 — a basilar artery; 3 — back brain arteries; 4 — upper cerebellar arteries; 5 — back lower cerebellar arteries; 6 — a back connecting artery.

The unilateral vertebralny angiography gives the image of a basilar artery and its main branches — both back brain, upper and back lower cerebellar arteries (fig. 13) and smaller branches filled changeably.

Determination of shift of the main vessels and their branches from a normal arrangement for what use various kraniometrichesky measurements is the most important for detection of pathology (their relation to the median plane, definition of correctness of an arrangement of «an angiographic silviyevy point», a terminal corner of a deep average brain vein, a bend of a basal vein, or Rosenthal's vein, etc.).

The system of ventricles and the subshell spaces of G. of m consists of the internal tanks which are reported among themselves: ventricles and subarachnoid (subarachnoidal) space and subarachnoid tanks. There are several various methods of contrasting of this system. For improvement of visibility of various departments of system after contrasting use various laying of the head of the patient — standard and additional in horizontal and vertical position (sitting). As contrast agents use air, oxygen and other gases, heavy oil contrast agents (pantopak, mayodit, duroliopak) and their emulsions with cerebrospinal liquid, and also the water-soluble triyodisty substances (konry, Dimer-H, etc.) which are quickly brought out of an organism kidneys, unlike oil, for a long time remaining in cerebral cavities and subarachnoid space.

Fig. 14. Pneumoencephalograms of ventricles of a brain (and — the back roentgenogram — a picture of front horns of side ventricles; — the front roentgenogram — a picture of back horns of side ventricles; in — the side roentgenogram — a type of ventricular system in a side projection): 1 — bodies of side ventricles; 2 — a transparent partition; 3 — front horns of side ventricles; 4 — the third ventricle; 5 — the fourth ventricle; 6 — subarachnoidal cracks of a surface of a brain; 7 — back horns of side ventricles; 8 — the lower horns of side ventricles; 9 — the tank of the bridge and the intercrural tank; 10 — spinal subarachnoid space of a spinal cord; 11 — the cerebellar and brain tank.
Fig. 15. Roentgenograms of ventricles of a brain with an emulsion of a mayodil in a direct back projection (a) and side in situation on spin up the person and facedown (in): 1 — side ventricles; 2 — back department of the third ventricle; 3 — the lower horns of side ventricles; 4 — front horns of side ventricles; 5 — back horns of side ventricles; 6 — a water supply system of a brain; 7 — the fourth ventricle; 8 — subarachnoid space of a spinal cord; 9 — front department of the third ventricle.

On roentgenograms of ventricular system and subarachnoid space during the use as a contrast agent of air apply four typical standard projections to obtaining the image: back — position of the patient on spin, the central bunch of radiation is inclined in the kraniokaudalny direction by 15 — 25 degrees (a picture of front horns of side ventricles), a lobby — a forward stroke of the central bunch of radiation, two side (fig. 14). The picture of the third and fourth ventricles and water supply system of a brain requires introduction of large amounts of air and use of laying, difficult for the patient, that increases danger of a research. Therefore for obtaining their images use heavy oil or water-soluble contrast mediums more often that considerably improves the image, reduces number of pictures, reduces reaction of the patient and beam loading. Heavy contrast agents, even at position of the patient on spin, at free passability flow down in the fourth ventricle, the big occipital tank and subarachnoid space of cervical department of a spinal cord, and during the narrowing or obstruction — stop and show the level of occlusion of ways, circulation of cerebrospinal liquid, the shift and deformation of ventricles, defects of filling from implementation of a tumor. Especially well cerebral cavities the emulsion of a mayodil (fig. 15) contrasts.

For obtaining the image of subarachnoid tanks of the basis of a brain use a tsisternografiya with introduction of a small amount of air (8 — 12 ml) without deflation of cerebrospinal liquid. The picture of tanks of a back cranial pole is made at the bent position of the head of the patient, and a picture of tanks of area of the Turkish saddle — at unbent. Apply to improvement of visibility of tanks tomography (see).

Front departments of side ventricles have the characteristic appearance reminding a figure of a butterfly (fig. 14, a), back — a figure of the flying bird (fig. 14, b), side — the irregular peculiar shape with the clear image of all departments of side, third and fourth ventricles, and also tanks of the basis of a brain and subarachnoid space of its verkhnelateralny surface (fig. 14, c). Apply pictures in the special provisions providing the highest arrangement of the interesting department at use of air and lower at use of heavy contrast agents to identification of separate parts of ventricular system.

At interpretation entsefalo-and ventrikulogramm consider the sizes of ventricles, their deformation, shift of rather median plane and in the perednezadny direction, defects of filling and change of a form of subarachnoid space, not filling of separate tanks of the basis of a brain, a prelum and shift with their tumor, an obliteration, excessive expansion etc.

See also Kraniotserebralnaya topography , Meninx , Vascular textures .

The PHYSIOLOGY

G.'s Physiology of m studies specific mechanisms of activity and the general principles of its organization.

At vertebrate animals, including the person, G. of m defines interaction of all organism with the environment, managing complete behavioural acts and their vegetative providing.

A factor of fight for existence, demanding the greatest possible speed and adequacy of behavioural reactions, resulted in need of the accounting of distantny information on the environment. As a result appeared acoustical, visual and olfactory receptors (see) and, respectively, structure back, an average and a neoncephalon — central offices of the signals arriving from distantny sense bodys. Further development of G. of m went on the way of improvement of the central mechanisms motor, visual, acoustical, olfactory and contact analyzers and their interrelations. At the same time one of philosophy of the organization of all complex systems — the principle of hierarchy was realized. In relation to G. of m the principle of hierarchy is that phylogenetic younger departments of G. of m exercise control of higher order, becoming as if regulators of regulators, supplementing, but not substituting for itself phylogenetic more ancient levels of management. As a result possibilities of a complete organism as in sense of thinner differentiated assessment of each irritant each analyzer, and in sense of more adequate perception of an overall picture of the world on the basis of a spatio-temporal complex of all irritants available to the analysis extend. Correlation of results of activity of many is the cornerstone of adequate perception of reality analyzers (see). The highest form of expression of the hierarchical principle is process of corticalization of functions (see. Cerebral cortex ).

The principle of integrity is integrally combined with the principle of hierarchy. Coordinating reactions of an organism, G. of m under natural conditions functions together with all nervous system (see) as a unit. Of m receives an afferent impulsation, carries out its analysis and synthesis and as a result creates the flow of efferent impulses defining the most adequate activity of all set of peripheral bodies. So, the principles of integrity of, m dialectically turn into the principle of systemacity.

Fig. 16. Scheme of functional system of formation of the behavioural act: change of indicators of a homeostasis depending on fluctuation of intensity of metabolism creates the signal of change of internal environment defining the dominating motivation (requirement). The dominating motivation, influencing memory, selects from it information on ways and methods of satisfaction of this motivation in the past. The Obstanovochny afferentation characterizes a specific situation and allows to choose specific necessary and sufficient conditions of satisfaction of the dominating motivation from memory. The starting afferentation is a direct signal to performance of action. As a result of afferent synthesis the decision to action in turn creating a set of the efferent vozbuzhdeniye defining somatic and vegetative components of behavior and the device of assessment of results of action is made. Copies of efferent teams arrive to an acceptor of results of action with correction about a condition of the motor sphere. Efferent vozbuzhdeniye are resulted by the action directed to achievement of result. Parameters of result are estimated by an acceptor of results of action and if they correspond to the plan, then are fixed in memory. The result of action leads to changes of metabolism, and, thus, the circle becomes isolated.

The principle of systemacity formulated by P. K. Anokhin in 1935, and afterwards in details developed by it and its school assumes that any behavioural reaction synthesis of diverse signals of an afferentation of a condition of surrounding and internal environment of an organism is the cornerstone, of motivational incentives (see. Motivations ), in many respects determined by a metabolism, data of specific and individual experience (see. Memory ). After afferent synthesis (see) the decision to action is made and the specific goal of reaction is set, there are efferent signals creating this behavioural act and acceptor of results of action (see). The flow of efferent impulses defining somatic and vegetative components of behavioural reaction goes to peripheral bodies and provides their coordinate participation in complete activity. The behavior always in a varying degree changes relationship of an organism with the environment and characteristics of internal environment biol, an object. Parameters of these changes, i.e. the data about biol., and for the person and socially important results of the behavioural act, are perceived by receptors and in the form of the return afferentation (see below) m to an acceptor of result of action come to G. It is possible to speak, therefore, about a ring, on Krom during all life of an organism there is a circulation of messages, providing continuous information communication: the center — the periphery — Wednesday — the periphery — the center. Thus, functional systems of behavior form and function for achievement of net useful result which is a backbone factor (fig. 16).

The possibility of achievement of reasonable result is the cornerstone in various ways of the principle of plasticity providing G.'s reliability of m. Plasticity is understood as functional variability of nerve centers (see. Plasticity of physiological functions ), especially clearly shown in the course of compensations of the broken functions G. of m or a peripheral nervous system, napr, after removal of a cerebellum, enucleation of an eye, etc.

On the principles of hierarchy, integrity, systemacity and plasticity all work of G. of m is based: are carried out instinctive reflexes (see), including and difficult (see. Instinct ), are implemented conditioned reflexes (see). The same principles are the cornerstone of representations, concepts, thoughts, and also inherent only in the person of ability to generalizations in a verbal form of the phenomena and patterns of the world. It is the conscious mental activity of the person connected with function of the highest departments of G. of m and first of all bark of big hemispheres.

Final knowledge of all laws of work of G. of m of the person and the highest animals — business of the future, however a number of the main mechanisms of its work it is already known.

Irradiation of excitement. Come to c. N of page afferent impulses extend first of all in the ways, specific to this touch modality of irritation (see. Visual centers, ways ; Acoustical centers, ways ; Tactile analyzer ) also switch in projective kernels of an average and a diencephalon. E.g., for somatovistseralny sensitivity the switching kernel is the back lower (ventral) kernel of a thalamus. Axons of neurons of this kernel reach touch zones of bark where there is the highest in limits of this analyzer the analysis of afferent information. Participates in processing of each afferent parcel much more cortical neurons, than thalamic. Therefore, excitement of one neuron of a thalamic projective kernel activates a set of nervous cells of bark of big hemispheres, i.e. talamokortikalny projections have the extensive nature (R. A. Durinyan). Spread of activation out of borders of areas of specific touch projections is called irradiation. Morfol, substrate of irradiation are the numerous branchings of axons of nervous cells which are coming to an end with synapses and a chain of internuncial neurons combining many centers. At the level of a mesencephalon collaterals depart from fibers of specific touch ways, on the Crimea excitement irradiates on reticular formation (see) and nonspecific kernels thalamus (see) and hypothalamus (see). Here excitement gets biol, the modality, i.e. is defined biol, sense (a signal of pain, food, an indifferent signal, etc.) of each afferent incentive (light, sound, tactile, etc.). It is established that a reticular formation as well as other subcrustal educations, napr, the hypothalamus, an amygdaloid nucleus, etc., renders the ascending activating generalized influence on a cerebral cortex. After processing at the level of the cortical end of the analyzer impulses can irradiate as it is horizontal on inter-and to intrakortikalny ways, and vertically on corticofugal ways to nonspecific structures of a brain trunk. From here through nonspecific kernels of a diencephalon excitement irradiates again, but already on all bark and has, therefore, generalized character. This mechanism is described by V. N. Shelikhov (1958) and called returnable generalization. For a long time impulses can reverb, i.e. circulate on the closed neural chains both in separate structures of G. of m, and between several structures, napr, kortiko-thalamic reverberation. The phenomenon of reverberation can be the cornerstone of short-term memories (see). In an experiment the easiest to observe irradiation of excitement at long action of strong irritants. In this case there are reactions not adequate for this irritant, and also the mental disturbance disorder, emergence of spasms etc. is sometimes possible. At action of irritants of «usual» intensity these phenomena, as we know, are not observed, on the contrary, coordinate reflex activity is implemented. Restriction of irradiation of excitement due to the central braking is the reason for that. However and in normal conditions irradiation always exists, moreover, it is absolutely necessary for implementation of any behavioural act. Irradiation allows impulses different touch y biol, modalities to come to any efferent way.

Central braking. In 1862. And. M. Sechenov for the first time showed that the chemical or electric irritation of visual hillocks of G. of m of a frog leads to braking of reflex activity of a spinal cord. Further existence braking (see) it was confirmed by many researchers, and mechanisms of the central braking are in detail studied by Ch. Cher a ringtone, I. P. Pavlov, X. Megun.

Fig. 17. Scheme of presynaptic braking: exciting synapses 1 — 4 carry out excitement from exciting nerve fibril (VV) on neuron (N). At excitement of brake nerve fibril (TV) through the brake synapses (BS) transfer of excitement on neuron from synapses of I and 4 while synapses 2 and 3 carry out excitement on neuron in the regular way is slowed down.
Fig. 18. Scheme of returnable and lateral braking: the impulse of neuron (1) through, a collateral of his axon (2) and exciting synapses (3) activates brake; neuron (4). On an axon of an inhibitory neuron excitement takes place to brake synapses (5) on neuron (1) and the neuron which is nearby (6); returnable braking of neuron (1) and lateral braking of the next neuron results. The system of an inhibitory neuron is designated in black color, shooters specify the direction of spread of activation.
Fig. 11. The scheme of relationship of exciting and inhibitory neurons on the example of bark of a cerebellum (And). Excitement comes to bark of a cerebellum in two ways: on climbing (1) and to mossy (2) fibers. Excitement of the climbing fiber activates a pear-shaped neurocyte (3). Impulses from mossy fibers excite cells of a granular layer (4) which axons, branching in a molecular layer, form the parallel fibers (5) exciting dendrites of pear-shaped, korzinchaty (6) and star-shaped (7) neurocytes. The horizontal spindle-shaped neurocytes activated by impulses from mossy and parallel fibers (Golgi's cell — 8) are capable to brake cells of a granular layer. Star-shaped and korzinchaty neurocytes slow down activity of pear-shaped neurons, neurocytes. Axons of pear-shaped neurocytes — the only efferent fibers, coming from bark of a cerebellum which brake activity of cells of intra cerebellar kernels (9). Shooters specified the direction of the movement of impulses.

Neyrofiziol. J. Ekkls's researches, P. G. Kostiuk, etc. it is established that braking in G. in m is caused by activity of inhibitory neurons. On elektrofiziol, to characteristics work of inhibitory neurons practically does not differ from activity of «exciting» nervous cells: on their axons usual nervous impulses — action potentials extend according to all laws of spread of activation. Neurochemical inhibitory neurons are characterized by what at excitement their axonal bombways allocate special brake mediator (see), napr, piperidic to - that, glycine, taurine etc. Axonal bombways of inhibitory neurons synoptic terminate or on an axon a hillock and dendrites of nervous cells, or on axonal terminalyakh of other neurons. In the first case speak about postsynaptic, and in the second — about presynaptic braking (fig. 17). Electrophysiologically postsynaptic braking is expressed by brake postsynaptic potentials (TPSP) of hyperpolarization of a postsynaptic membrane. Distinguish returnable and lateral braking (fig. 18). At returnable braking of TPSP develops in that neuron, aksonny collaterals to-rogo excited the braking neuron. At lateral — TPSP arises in the neurons, next to it. Presynaptic braking develops at permanent depolarization of presynaptic axonal bombways. Morfol, substrate of presynaptic braking are akso-axonal synapses, and a possible mediator — piperidic to - that. Presynaptic braking blocks an impulsation on approaches to a postsynaptic membrane. With its help, in particular, it is possible, having slowed down the bombways which are hyper polarizing this neuron to remove postsynaptic braking. The braking cells can test as pre-, and postsynaptic braking. E.g., pear-shaped neurocytes (Purkinye's cell) of bark of a cerebellum braking activity of cells of kernels of a cerebellum and a lateral predoor kernel (Deyters) can be in turn slowed down by korzinchaty neurocytes (tsvetn. fig. 11). Perhaps, dlinnoaksonny star-shaped neurocytes (Golgi's cells like II) and star-shaped neurocytes of a cerebellum brake activity of gigantopiramidalny neurocytes of bark of big hemispheres.

Both types of braking are widely presented in, m. Mechanisms of irradiation of excitement and central braking, more precisely the thinnest interactions between these basic processes, are the base of integrative activity of a brain.

Fig. 19. Scheme of convergence and occlusion: the strong irritation of an afferent fiber And excites neurons 1 — 5, and fibers B — neurons 4 — 8 while at the weak isolated irritation of fibers A or B neurons are not excited. In this regard neurons 4 and 5 receive afferentation) from fibers both D, and B therefore at simultaneous weak irritation of both fibers they will be excited (the mechanism of convergence). At strong simultaneous irritation of fibers A and B peripheral reaction will be less as the neurons 4 and 5 which are already completely excited by one fiber, for example And, will not be able adequately to answer additional excitement of fiber B (a phenomenon of occlusion).

Convergence of impulses. Really agree on each neuron of G. of m, or converge, many exciting (depolarizing) and brake (hyper polarizing) synapses. Spatio-temporal ratios of their activity define finally digit characteristics of neuron. For the first time the mechanism of convergence in 1911 described Ch. Sherrington; it showed that the impulses arriving on various afferent ways can reach the same internuncial and efferent neurons. Convergence allows, e.g., gigantopiramidalny neurocytes of motor bark to receive and process signals of various touch modalities. Such type of convergence Jung (R. Jung, 1962) called multitouch. It is proved that on one neuron can converge motivational excitement various biol, modalities (multibiological convergence). Also the facts touch biol are determined. and efferent touch biol. convergences. Convergence is the cornerstone of phenomena of spatial summation and occlusion. The phenomenon of summation, or the central simplification (it is open I. M. Sechenov in 1863), is expressed in strengthening of the reflex answer at increase in frequency of irritation of an esodic nerve — temporary summation or at increase in number of the excited afferent fibers — spatial summation. The phenomenon of summation is caused by that, as exciting, and brake postsynaptic potentials have rather big duration (10 microseconds and more), and the postsynaptic membrane is capable to carry out algebraic summation of their instantaneous values. The phenomenon of occlusion (obstruction) consists that the effect of joint irritation of two esodic nerves is less than the arithmetic sum of the effects arising at their irritation separately (fig. 19). Or a pessimal condition of membranes of efferent neurons owing to summation of exciting postsynaptic potentials, or the phenomenon of lateral braking can be the cause of occlusion (see. Bioelectric potential , Excitement , Braking ).

The mechanism of the general final way, open H, Sherringtony, is that to the same efferent way there can be impulses of various modalities. E.g., the food, sexual, approximate and research or defensive motivation, a light, sound, tactile irritant, etc. can be the cause of purposeful behavior. The reason is that to several afferent analyzers (visual, acoustical and t) there corresponds one efferent — motive. Number of efferent neurons, to the Crimea converge impulses from receptive zones G. of m, it is many times less, than afferent. Therefore the net result is defined by from what zones and what impulses will be able to reach an efferent way. Thus, any behavioural reaction is result of fight of afferent signals for the general final way. On the nature of interaction at a stage of this fight it is accepted to subdivide reflexes into allirovanny — mutually strengthening each other and antagonistic — each other braking.

Feedback mechanism. For the first time representations about feed-back (see) are formulated by Ch. Bell (1811). The big contribution to studying of a functional role of feed-backs was made by I. M. Sechenov, Ch. Sherrington, N. A. Bernstein, Winer (N. Wiener, 1958). Unlike a feedforward between an exit of one element and an entrance of another, a feed-back becomes isolated between an exit and an entrance of the same element or system. The feed-back increasing influence of entrance influence for the weekend parameters is called positive, and reducing — negative. In the first case a feed-back strengthens and fixes the reflex act, napr, at an unconditional reinforcement of a conditioned reflex; in the second — at different types of punishment, leads to easing or a full vytormazhivaniye of reactions. The role of a negative feed-back in regulation of constancy of internal environment of an organism is big. Information transferred to G. by m through feedback channels on a deviation from a normal amount of any parameter of internal environment (fig. 16) is an incentive for return of a constant to norm (see. Homeostasis ). In an organism both forms of a feed-back function that is a basis of accuracy and selectivity of the created reflex acts. P. K. Anokhin (1935) in detail investigated one of forms of a feed-back — the return afferentation) (fig. 16).

The mechanism of a dominant was for the first time opened by A. A. Ukhtomsky (1923) as the principle regulating relationship between nerve centers. The dominant (see) is expressed in emergence of the center of the excitement changing and subordinating to itself activity of other nerve centers. Opening of the mechanism of a dominant showed relativity of classical representations of R. Descartes that this reaction is caused only by this irritation (see the Reflex). Only the simplest reflexes it is possible to lay in the tough scheme an incentive — the answer whereas more difficult reactions are defined also by a functional condition of nerve centers. The dominant condition of the center is characterized by hypererethism, firmness of excitement, ability to a summation of stimuli and inertness of excitement. The dominant center can form under the influence of reflex, humoral and hormonal factors, and also as a result of direct irritation of the center in an experiment (A. A. Ukhtomsky, 1911). K. V. Sudakov's researches showed that the dominant center arises owing to the motivation existing at present (see). The activity directed to satisfaction of motivation changes and as if includes other reflex reactions, i.e. becomes dominating. E.g., during the act of defecation or swallowing of bending of a front extremity in response to irritation electric current of a certain point of motor bark does not occur. Instead the dominating activity accelerates or amplifies. Obviously, the mechanism touch biol is the cornerstone of a dominant. convergences, namely, against the background of biologically specific activation influences, earlier subthreshold for this neuron, become threshold. The dominating activity is always followed by more or less expressed braking of all other reactions which are not connected with satisfaction the existing motivation. Therefore various irritations in the absence of a dominant leading to certain reactions against the background of a dominant of such reactions do not cause; instead the dominating activity amplifies. Told does not belong to action of very strong irritants causing, e.g., painful motivation. In this case new, stronger motivation creates the new dominant center which defines all further behavior.

The phenomenon of induction opened by I. M. Sechenov and in detail investigated by Ch. Sherrington characterizes changes of a functional condition of nerve centers after the end of action of irritants. Often after cancellation of a brake irritant there is a condition of a hyperexcitability of the center called by positive successive induction. After excitement decrease in excitability, or negative successive induction develops. The inductive relations are possible also between various nerve centers, napr, excitement of one center leads to decrease or increase in excitability of another. In the first case speak about negative, and in the second — about positive simultaneous (simultaneous) induction. In G.'s activity the m repeatedly met the induction relations I. P. Pavlov during the studying of conditioned reflexes. It allocated and described the phenomena of successive cortical positive and negative induction.

The considered general principles and mechanisms of work of G. of m are a basis of various forms of brain activity.

Functional linkages between various departments of a brain. All departments of G. of m are directly or indirectly connected among themselves though fiziol, the importance of these bonds is not equivalent. Of m is bilaterally connected with lying below (at the person) or caudally (at animals) department of c. N of page — a spinal cord. 12 pairs of cranial nerves (see), the innervating sense bodys, skin, muscles, mucous membranes of the head and a neck, and also some internals depart from G. of m. Traditionally consider that IV, VI, XI and XII couples contain only efferent fibers, I, II and VIII couples — only afferent, and other nerves — mixed. However A.S. Dogel's works, R. Granita, etc. established availability of efferent fibers in nerves I, II and VIII couples. The spinal cord and 12 pairs of cranial nerves provide G. of m with bilateral ties with all parts of an organism, and through them and with the environment.

Fig. 10. The scheme of functional linkages between various departments of a brain. The reticular formation of a brain trunk (1) activates bark of big hemispheres (red shooters). The synchronizing bulbar system (2) brakes (a white arrow) activity of a reticular formation. Nonspecific kernels of a visual hillock (3) brake (green shooters) bark of big hemispheres, and exert the activating impact (a pink arrow) on a reticular formation. The hypothalamus (4) activates (yellow shooters) bark of big hemispheres, and exerts the difficult regulating (phasic) impacts on trunk structures, the shown excitement and braking (brown shooters). The limbic system (5) brakes bark of big hemispheres (blue shooters). Bark of big hemispheres (6) .izmenyat activity of a reticular formation of a brain trunk, rendering on it the difficult regulating (phasic) influences (lilac shooters).

Forms the tail of a trunk of G. of m myelencephalon (see) where are located vasomotor center (see) and respiratory center (see). There pass all descending and ascending ways connecting G. by m with a spinal cord. In a myelencephalon it is partially located reticular formation (see), having a huge number of the ascending bonds and a set of descending. By means of the last the reticular formation exerts the facilitating and brake impacts on reflex activity of a spinal cord. The initial opinion that the descending influences have only the diffusion facilitating or brake character is disproved; it is proved that the reticular formation can make also the local impacts having reciprocal character i.e. to activate one reflex acts and to brake others. Through straight lines and the mediated bonds (e.g., through kernels of a thalamus, a hypothalamus etc.) the reticular formation is capable to activate bark of hemicerebrums that behavioural can be shown by awakening, vigilance, and electrophysiologic — a desynchronization test of EEG. G.'s bark of m in turn through the descending corticofugal bonds modulates activity of a reticular formation, managing its tone. Neurons of a reticular formation are very sensitive to various biologically active agents. Thanks to extensive bonds practically with all departments of G. of m the reticular formation is the major integrative education (tsvetn. fig. 10).

It is closely connected with a reticular formation cerebellum (see). Tactile proprioceptive, interoceptive, acoustic, visual and other afferent pathways approach bark of a cerebellum. Efferent bonds reach a spinal cord, trunk structures, bark of hemicerebrums. For a spinal cord a cerebellum — the important nadsegmentarny center participating in coordination of movements (see). Through a reticular formation the cerebellum is capable to influence bark of hemicerebrums: the irritation of a worm of a cerebellum causes bilateral desynchronization of a rhythm of bioelectric activity of bark, and stimulation of hemispheres of a cerebellum is followed by desynchronization of EEG in a contralateral hemisphere of G. of U. The irritation of a cerebellum leads to emergence in various departments of bark of hemispheres of the evoked potentials (see the Potential caused) which are implemented through multiple cerebellar and cortical projective bonds. L. A. Orbeli (1938) established that the cerebellum renders Stabilizing, i.e. adaptation, influence on many vegetative functions. There is a basis to believe that at the level of a cerebellum coordination of the somatovegetativny reactions providing functionally full act of movement in space (is carried out see. Autonomic nervous system ).

Borders on rostral departments of a reticular formation thalamus (see) which combines a large number (to 150) anatomically the distinguished kernels. Physiologically they can be divided on specific (switching touch and not touch), associative and nonspecific. Carry group of the lateral kernels united in a ventrobazalny complex to specific. Through its lateral part as via a peculiar synoptic relay, pass tactile, kinaesthetic signals from a contralateral part of a body, and also temperature and painful impulses to bark. A medial part of a ventrobazalny complex switches flavoring offerers. Carry also medial cranked body to specific kernels of a thalamus — the relay of acoustical impulses and an outside cranked body — similar education for visual information. All specific touch kernels have the topical organization. Through specific kernels all information (except for olfactory) about internal environment of an organism and the environment surrounding it comes to projective zones of bark. In particular, through front kernels signals from a hypothalamus, basal kernels, a cerebellum pass etc. Specific often carry to group also the associative kernels sending neurites to II and the I layer of associative areas of bark. Carry a pillow to associative kernels, dorsomedial and lateral kernels. Function of associative kernels is finally not found out. Nonspecific kernels (reticular and intralaminarny) are an intermediate link between the ascending systems of a trunk of of m and new bark, limbic structures and basal kernels. Morfol, substrate of this function — powerful intra-and the ekstratalamichesky bonds consisting of multineyronalny ways. Nonspecific kernels of a thalamus of a polisensorna have also no accurate topical organization of efferent. At electric irritation of nonspecific kernels the experimental animal fills up, in parallel in bark of big hemispheres there is a so-called reaction of involvement — spindle-shaped fluctuations on EEG.

The areas of bark of hemicerebrums receiving an afferent impulsation from kernels of a thalamus give to them the efferent fibers rendering hl. obr. brake influences.

The main flow of efferent impulses comes to a hypothalamus from other departments limbic system (see) and a reticular formation (see). At irritation of the wandering and celiac nerves within a hypothalamus there are bioelectric reactions. Representations of visceral and somatic sensitivity are closely blocked here. Morphologically in hypothalamus (see) distinguish St. 30 couples of kernels, by the anatomic principle combined in 4 groups. Physiologically in a hypothalamus «centers» of thirst, food and saturation are revealed; its participation in mechanisms of a dream and wakefulness, in regulation of endocrine and vegetative functions is proved. The physical, i.e. facilitating and brake influence of some of its kernels on a reticular formation is proved (tsvetn. fig. 10) and reflexes of a spinal cord. All functions of a hypothalamus are under control of bark of hemicerebrums, especially temporal, limbic and sensory-motor areas. Neurons of a hypothalamus are highly sensitive to biologically active agents, and a part of neurons selectively reacts to some one substance, others are sensitive to many chemical connections.

Thanks to all these features, and also existence of broad bonds with most departments of G. of m and endocrine system the hypothalamus takes the central place in implementation of somatovegetativny coordination that provides maintenance homeostasis (see). Almost receive afferent fibers from all departments of G. of m basal kernels (see). E.g., in a kernel having a tail leads irritation of exteroceptors of various sites of bark, a visual hillock and other structures to emergence of evoked potentials. Unlike neurons of a fencing, nervous cells of a shell and a pale sphere do not answer pain stimulation, being under constant control of other formations of a striate body. Basal kernels give fibers to various structures of G. of m E.g., stimulation of a kernel having a tail is capable to cause changes of bioelectric activity in front departments of bark.

Changes of behavior of animals at irritations or destructions of basal kernels are very various — a disorientation, the periods of an unmotivated physical activity, strengthening or weakening of a tremor, an aphagia, an adipsia, reduction of the threshold of excitement to touch irritations, etc. Though it is difficult to establish accurate correlation of behavioural reactions with the corresponding bioelectric phenomena, it is clear that basal kernels participate in processes higher nervous activity (see).

Ancient and old bark G. of m are presented by formations of a paleocortex and a very cortex. Interstitial bark as a part of prepaleokortikalny and prearkhikortikalny zones separates it from new bark — a neocortex. Until recently the very paleocortex was connected only with olfactory function. On the basis morfol, given to Peypa (J. W. Papez, 1937) formulated a hypothesis of existence of a ring of the visceral brain including and a very paleocortex. P. Mac Lane (1952) experimentally confirmed Peyps's assumptions and entered idea of limbic system (see), all-in formations of a very-paleocortex: amigdaloidny area, limbic bark, hypothalamus, some kernels of a thalamus, Gudden and Bekhterev's srednemozgovy reticular kernels. Peyps's ring — Mac-Lane is capable to carry out reverberation of excitement.

From formations of a very paleocortex the largest sizes have hippocampus (see) and amigdaloidny area (see). For a hippocampus specific forms of bioelectric activity are revealed. In particular, at impact on an animal of the new incentive causing oriyentirovochnoissledovatelsky reaction (see) in a phase of a REM sleep (see), at the irritation of a reticular formation causing reaction of awakening in the course of self-stimulation of zones of a positive emotional reinforcement in a hippocampus there is correct, very regular theta rythm with a frequency of 4 — 7 fluctuations in 1 sec. The theta rythm is generated by dendrites of pyramidal neurons of a hippocampus in response to the impulses arriving on fibers of the arch. Besides, it is possible to observe a desynchronization test (e.g., at defensive reaction) and bystry rhythms. A hippocampus — the oriented bedded structure therefore it is convenient for a research of genesis of the slow bioelectric activity which is the cornerstone of EEG. The fact of receipt in a hippocampus of impulses of various touch modality is proved by means of the equipment of evoked potentials and microelectrode registration. Stimulation of any afferent system leads to emergence of evoked potentials on all surface of a hippocampus; besides, apprx. 60% of its neurons of a polisensorna. The irritation of a hippocampus leads to approximate and research reaction, or to the movements, it is possible in combination with hallucinations, or to fear reaction. All these reactions are complete, with adequate vegetative providing. Very quickly electric irritation leads to emergence of epileptic activity. Final fracture of a hippocampus is difficult for the anatomic reasons; however its extensive bilateral damages complicate development of conditioned reflexes. Many authors consider that in a hippocampus mechanisms of memory are localized.

In amigdaloidny area various touch projections are presented diffuzno, her irritation causes various behavioural reactions. In parallel blood circulation, breath, activity of a digestive tract changes. It is not excluded that these manifestations are caused by close bilateral ties with a hypothalamus and a reticular formation. Removal of amigdaloidny area leads to depletion of emotional reactions in combination with emergence of hyper sexual behavior.

Thus, the very paleocortex takes part in alternation of a dream and wakefulness, the organization of emotional states, regulation of vegetative and endocrine functions of an organism, formation of special forms of behavior, napr, approximate and research reaction.

Historically it developed fiziol, division of a new cerebral cortex into areas of touch projections, motor bark and mute zones. The irritation of skin, sense bodys and esodic nerves leads to emergence in zones of touch projections of bioelectric primary answers (see. caused ), and stimulation by electric current of these cortical areas is followed by elementary feelings by the principle «a point in a point» (e.g., the irritation of area of bark where there is primary response to stimulation of skin of a shin, causes a feeling of passing of electric current, pricking or numbness in the same area). In a somatosensory zone of bark of a kernel of analyzers skin (field 2 and 3) and partly proprioceptive (field 1) sensitivity are organized by the somatotopichesky principle. The principle of the topical organization in general is characteristic of touch zones. So, in acoustical bark (fields 41 and partially 42) there is a tonotopichesky representation: defeat of front departments breaks perceptions of low sounds, and back — high. For all types of sensitivity existence of secondary cortical touch areas, and for some and tertiary is established. In Mauntkasl's works (V. Century of Mountcastle, 1957) the possibility of the vertical organization of neurons of bark in «columns» — elementary units of the cortical analysis of irritants is shown. All cortical ends of touch analyzers have the mosaic nature (I. P. Pavlov) that in many respects defines integrative abilities of bark G. of m. Told fairly and for a motor analyzer (the back field 4 and the front field 6). Part of its neurons of a polisensorn (answers irritation of all touch modalities), others — monosensorna, i.e. react only to stimulation of this receptor field. There are also neurons with non-constant receptive fields. Besides, more than a half of all fibers of a pyramidal way originates from the pyramidal neurocytes localized not in motor, and in other areas G. of m. Secondary motor fields are located on a medial surface of hemispheres and in a paracentral segment, and tertiary — in a tire and back departments of an island. Efferent influences of motor bark reach kernels extrapyramidal system (see), other zones of bark, kernel having a tail, reticular formation of a mesencephalon. All touch zones have powerful projections to specific kernels of a thalamus through which to these areas of bark afferent impulses arrive. There are also efferent bonds of primary touch zones of bark with peripheral offerers. Ways of acoustical bark to spiral (kortiyeva) body, visual — to a retina, etc. are tracked.

The irritation of mute zones of bark in most cases is not followed some accurate immediate nevrol, shifts. There are bases to believe what so happens because of high complexity of these educations and small adequacy of modern techniques. Nevertheless some material about their possible function is saved up.

In frontal department of bark fibers of a verkhnemedialny complex of a hypothalamus and front kernels of a thalamus where Hypothalamic ways switch terminate. From frontal department of bark impulses can extend to dorsomedial, intralaminarny and reticular kernels of a thalamus, a striate body, a preoptichesky zone, entorialny and presubikulyarny bark, limbic system, a subthalamic kernel, a hypothalamus, a red kernel, the central gray matter of a mesencephalon, a reticular formation of a brain trunk. There are bases to believe that efferent bonds with the ascending activating complexes participate in regulation of a tone of all of c. N of page. Removal of frontal bark destroys purposeful behavior, results in the apathy and drowsiness alternating with the periods of not purposeful physical activity. Are closely connected with bark of a temporal share ancient and old bark. In the dominating hemisphere on la 21 and 37 are connected with function of the speech, there is an overlapping of zones of acoustical and visual analyzers, in a subdominant hemisphere this area is connected with formation of a body scheme. By data At. Penfild and with sotr. (from 1950 to 1959), the electric irritation of bark of a temporal share can lead to sudden emergence of similar to hallucinations of bright and detailed memoirs, and also strong emotions, is more often than fear. Klyuver and Byyusi (H. Kluver, to R. S. Vis, 1937) described after bilateral removal of bark of a temporal share at animals the syndrome consisting in disturbance of memory, visual orientation, hyper sexuality, a hyperphagia and loss of aggression.

Parietal and parietooccipital bark receive afferent signals from associative and specific kernels of a thalamus and from cortical touch areas. Efferent bonds of parietal bark extend to a pale sphere, a lateral kernel of a thalamus, a subthalamic kernel, a kernel having a tail, a shell, a hypothalamus.

Damage of parietal bark leads to disturbance of complex analitikosintetichesky processes of century of N of.

Regulation of somatic and vegetative functions. Numerous attempts of a research of functions of mute cortical zones, and also requests of modern clinic changed ideas of localization of functions in G. to m. Persistent fight between the lokalizatsionizm presenting to G. m as if the scrappy state, consisting of dwarfish sovereign principalities each of which solves the problems — from control of movements to social «I» [O. Vogt and Vogt (S. of Vogt), 1951], and the ekvipotentsializm considering G. of m as undifferentiated whole, all parts to-rogo are equivalent in respect of implementation of mental functions [Leshli (To. Lashley), 1958], lost relevance. Ideas of system and dynamic localization of functions (see the Cerebral cortex) in G. of m gain ground.

Relying on the principles of hierarchy and systemacity, these representations allow inclusion of each structure of G. of m or its part in various functional systems of behavior. Therefore disturbance of the same function can be observed at different localizations of defeat of G. of m. On the other hand, disturbance of activity of this or that structure can lead to disorders of several various functions (A. R. Luriya, from 1962 to 1967).

The central regulation of functions of an organism is possible only if G. the m obtains rather complete information from the periphery, is capable to process it and has an opportunity to transfer efferent impulses («teams») to executive bodies. There is also humoral way of impact on executive bodies. As, as a rule, both mechanisms in parallel work, it is possible to speak about neurohumoral regulation (see) somatic and vegetative functions. A bright example of neurohumoral regulation is regulation of activity of a respiratory center (see).

At the heart of regulation of somatic and vegetative functions the hierarchical principle therefore safety of all departments of G. of m in the presence of rather strict and at the same time flexible subordination of the lowest levels of c is necessary for its full implementation lies. N of page the highest. The lowest levels have the known autonomy therefore at the animals deprived of all departments of c. N of page, except a spinal cord, the known extent of regulation of a number of functions, napr, motive is possible.

A special form of regulation of somatic and vegetative functions is the uslovnoreflektorny regulation based on development at animal conditioned reflexes (see). This form of regulation is possible only in the presence of unimpaired (sometimes only partially damaged) bark of hemispheres. Providing as bystry adaptation of an organism to environmental conditions, and adequate vegetative regulation of behavioural activity of an organism as whole, uslovnoreflektorny regulation is the most plastic.

The brain and behavior

Different forms of behavior of animals and the person can be divided into two basic groups — inborn and acquired as a result of individual experience. Simple inborn forms of behavior at the highest vertebrata hl manage. obr. subcrustal educations, and also very paleocortex. The most difficult instinctive reflexes, or instincts (SI.), at the highest mammals form with the participation of a neocortex: after its destruction or shutdown the complete adaptive nature of reaction is lost though its separate elements can proceed without change. Individually acquired behavior at animals always has the uslovnoreflektorny nature though it can be shown in different forms (figurative behavior — I. S. Beritashvili, 1961; extrapolation reflexes — JI. V. Krushinsky, 1960; complex-reflex behavior — K. M. Bykov and And, D. Slonim, 1960).

Short circuit of temporary communication — the central mechanism of a conditioned reflex — becomes to special properties G. of m, possible thanks to a nek-eye: abilities to the analysis and synthesis of irritants, to formation of emotions, memory, regulation of level of wakefulness, etc. which combine in system for achievement of net useful result As each of these properties has more or less specific structural organization at various levels of c. the N of page, temporary communication is always functional merging of many structures of G. of m on the basis of multilateral interaction.

Primary analysis of all irritants begins already in receptors, however in full this function is implemented in G. by m. Existence of inborn mechanisms of the analysis of separate signs of irritants of all touch modalities is proved (visual, acoustical, etc.) at the different levels G. of m E.g., in visual bark the neurons reacting to separate elements of a form, to the direction of the movement of a visual incentive in somatosensory area are found strictly specific neurons reacting only to skin irritations are allocated. There are cells which are selectively reacting to pain and temperature stimulations, and also the neurons activated at the movements depending on the angle of bending of an extremity in a joint. Thin neyronalny differentiation is found as well in cortical representation of internals.

The Uslovnoreflektorny analysis of signals — multi-stage, complex process. It begins with «allocation» of unit characters, most likely on the basis of inborn mechanisms. From unit characters in the course of training form difficult on the basis of which there is «an identification of an image in general». Thus, the complete image is created as a result of synthesis of separate elements to which the nervous system «spread out» a difficult incentive in the course of the analysis. The Uslovnoreflektorny analysis of irritants happens hl. obr. at the level of new bark, however some signs of a conditioned excitator are analyzed at the level of intermediate and a mesencephalon.

Normal functioning of G. of m is supported by the flow of an afferent impulsation regulated by a reticular formation of a trunk. The last is in turn subordinated to corticofugal influences of a neocortex. Besides, existence in a neocortex of the neurons similar to neurons of a reticular formation allows to assume that regulation of level of wakefulness happens with the participation of a neoncephalon. Therefore, all process of regulation of level of tonic excitement of G. of m, is implemented by corticosubcortical mechanisms.

It is established that the reticular formation renders not only diffusion activating, but also selective influence on various areas of bark of hemicerebrums and participates in formation biol, specificity of reaction. The electric irritation of certain sites of a reticular formation of a trunk exerts not same impact on food and defensive conditioned reflexes.

The emotions (see) which are shown in the form of a complex specific motive (fear, rage, the attack, etc.) and vegetative participate in the organization of various forms of behavior of animals and the person as the most important adaptive function of a brain (change of breath, heart rate, blood pressure, etc.) the reactions reflecting the states accompanied with positive or negative subjective experiences. Fiziol., psikhol, and morfol, researches allowed to reveal several areas G. of the m connected with an affective behavior. These areas lie hl. obr. in limbic system. An important stage in studying of the central mechanisms of emotions is discovery of effect of self-stimulation (see).

Any adequate behavior is impossible without memories (see). Distinguish the inborn (genetically caused) memory, edges defines instinctive forms of behavior, and individually created memory — the most important mechanism of the organization of the acquired forms of activity. Individual memory can be short-term and long-term, the Short-term memory

we hold traces of irritations within several seconds or minutes. The nature of a short-term memory is connected with reverberation of excitement in the closed neural circles, and long-term — with molecular and submolecular changes of protein in the activated postsynaptic structures. Probably, with participation RNA (see) there is an active protein facilitating transfer of excitement here. It is not excluded that a short-term memory — the phase of education long-term, however a number of researchers does not see between them any communication. Individual memory is defined at the highest mammals by activity of bark of hemispheres: after a decortication ability of formation of the behavioural reactions demanding participation of both short-term, and long-term memory completely disappears. Sharp disturbance of a short-term memory at children with the injured hippocampus is revealed, communication of short-term and long-term memory with activity of associative fields of frontal and parietal departments of bark is shown. In associative bark the system of neurons with the increased properties of fixing of traces uslovnoreflektorno of the developed reactions is found in cats; the possibility of regulation of duration of preservation of these traces from a hippocampus is shown.

Alarm systems are inherent to the person (see) two types — the first, inherent and an animal, and the second — verbal, specifically human. A number of essential features of activity of the second alarm system in its interaction with the first is revealed. Thanks to new methods of a research G. of m of the person also some specific patterns neyrofiziol, providing century of N of of the person are found. Became available objective fiziol, to studying and various subjective experiences (emotions) of the person. It defined emergence on a joint of neurophysiology, neurology and psychology of the new industry — a neuropsychology (see). Applying a complex method neyrofiziol, studying of a brain of the person at emotsiogenny and psikhol, tests in combination with local electric impacts on the flowing and set emotional and mental activity, neuropsychologists investigate the structurally functional organization of mentality. N. P. Bekhtereva allocates five main directions neyropsikhol. researches: 1) the analysis of the general changes in G. of m in implementation process of mental activity; 2) a research of the zones which are most closely connected with mental functions; 3) identification of degree of importance and role of various zones such; 4) establishment neyrofiziol. entities of the changes developing in the course of mental activity; 5) search of objective signs of interaction of the explored areas in the course of mental activity. The materials received during the development of these directions confirm ideas of unity of mechanisms of all types of activity of G. of m, including and mental activity, of system and dynamic localization of functions in G. to m and put a number of new problems which solution is of considerable interest for a wedge. Medicine.

See also Analyzers , Self-control of physiological functions , Centers of a nervous system .

BIOCHEMISTRY

the Foundation for a systematic research of chemical structure of G. of m was laid in the second half of 19 century by J. L. W. Thudichum and A. Ya. Danilevsky. Continued a research A. V. Palladiya.

Of m approximately for 75% consists of water, 25% make proteins (see), lipids (see), carbohydrates (see), nucleic acids (see) and products of their exchange, inorganic matters (tab. 1), and proteins and amino acids make apprx. 40%, lipids — 50% of dry weight of G. of m.

Table 1. CHEMICAL COMPOSITION of GRAY AND WHITE MATTER of the BRAIN of VERTEBRATA (in %)


Proteins Of m by criteria of molecular weight, speed of updating, physical. - to chemical properties more geterogenna, than proteins of other fabrics. Fractionation of proteins G. of m represents big complexity, practically ways for allocation of fractions, characteristic on proteinaceous structure, are not found. Remove different amounts of proteins from gray and white matter; the first is richer with soluble proteins, the second — proteins of the rest. With the help the disk electrophoresis in polyacrylamide gel the soluble proteins making apprx. 20% of fabric proteins manages to be divided into 16 and more fractions, but also it is probably not a limit. In fabrics G. of m simple proteins — albumine, globulins, protamins, histones etc. meet; a significant amount of complex proteins — nucleoproteids, lipoproteids and proteolipids, metalloproteins (e.g., tserebrokuprein), the glycoproteins and phosphoproteins incorporating fosforilserin and being one of the most active protein fractions contains. Also such proteins as neurokeratin, collagen, elastin are found; the proteins characteristic only of nervous tissue are found: the acid protein S-100 which is preferential concentrated in glial cells (astrocytes and probably an oligodendrogliya), the acid proteins 14-3-2 and 14-3-3 localized generally in neurons, an acid glycoprotein of 10 V, tubulin in axons and some other. Immunochemical five proteins specific only to G. of m are secreted. Function of these proteins is unknown. From trailer nerve terminations (synaptosomes) aktomiozinopodobny protein — neyrostenin is secreted.

Proteins G. of m are exposed to continuous synthesis and disintegration. The period of their half-decay averages 1 — 16 days, for the majority of proteins — apprx. 4 days. Biosynthesis of proteins in G. is carried out by m the same as y in other fabrics. Speed of updating of proteins decreases among: bark of big hemispheres — a thalamus — a mesencephalon — a myelencephalon — white matter of hemicerebrums. Phylogenetic younger, and on function and structure more complex departments of G. of m differ in more high speed of updating of proteins and nucleinic to - t. Hydrolysis of proteins in G. m carry out intracellular acid and neutral proteinases; the first are concentrated in lysosomes, the second — in cytoplasm, microsomes and a myelin. The formed polypeptides are affected further various ekzopeptidaz, among them amine and carboxypeptidases, arylamidases and dipeptidases.

Free amino acids G. of m are a source for protein synthesis and biologically active compounds. They participate in regulation of a metabolic homeostasis, are a part of the ionic environment and serve as substrates for oxidizing phosphorylation. Amino acids come to a brain from a blood-groove, between tissue of a brain and a blood plasma high concentration gradients of a number of amino acids are supported that is active process and demands energy consumptions. At the person in G. the m contains free amino acids almost in 8 times more, than in a blood plasma. The m consumes amino acids selectively. In comparison with plasma contains in it much more glutaminic to - you, on a nek-eye to data and asparaginic to - you, slightly more threonine less leucine, from a leucine, valine, a lysine and arginine. Besides, in G. the m found glycine, alanine, serine, proline, methionine, tyrosine, phenylalanine, a histidine, taurine and tsistation. The maintenance of N-atsetilasparaginovoy and f-amino-maslyanoyk-t is high. Content of free amino acids averages 40 — 43 mg on 100 g of a brain counting on the general amino nitrogen. Synthesis of a carbon skeleton of replaceable amino acids is carried out generally at the expense of glucose.

For G.'s functioning m the system glutaminic has paramount importance to - that is a glutamine, contains edges to 80% of all free alpha amino nitrogen of a brain of mammals (see. Glutamin , Glutamic acid ). This system performs protective function, connecting the ammonia which is formed in various reactions and protecting brain fabric from its toxic influences.

In tissues of a brain processes of interamination, especially with participation glutaminic and alpha and keto-glutaric to - t, oxidations, transmethylations, resulphonating of amino acids intensively proceed. Reaction decarboxylation of a number of amino acids is important for specific neuromediator functions G. of m. So, decarboxylation glutaminic to - you, 3,4 dioxyphenylalanine, 5 oxytryptophane and a histidine lead to education according to piperidic to - you are (GAMK), dopamine, serotonin and a histamine.

The main free peptide G. of m is glutathione (see) which makes apprx. 1/3 all nonprotein nitrogens. Its function — maintenance of metabolic important sulphhydryl (SH-) groups in various connections in got into condition, and also transport of amino acids and disintegration of peroxides. In insignificant quantity meet gomokarnozin (gamma aminobutyryl - L - a histidine) and gomoanserin (gamma aminobutyryl - L - a methylhistidine).

Of m contains a large number of lipids, in it all systems of biosynthesis and disintegration of lipids are presented. The quantity of lipids significantly increases in the course of myelination. The lipids found as a part of nervous tissue are classified as follows: phospholipids (or phosphatides), glycolipids, sterols, neutral fats (triglycerides) and lipids forming lipoproteidny complexes with proteins. Phosphorus lipids (phospholipids) — the most numerous group. In gray matter G. of m they make St. 60%, and in white — St. 40% of all lipids. Phosphoglycerides, letsitina, phosphatidylethanolamines, phosphatidylserines and plasmalogens are a part of phospholipids; the kephalin B combining fosfoinozitida; sphingomyelins. filo-and an otnogeneza in detail investigated distribution of phospholipids in various sites G. of m at different stages to E. M. Krepa with sotr.

The glycocerebrosides, galaktotserebrozida, sulfatides which are ethers a chamois to - you both galaktotserebrozid, and gangliosides belong to glycolipids (see). The last represent the glycosphingolipids containing sialine to - you. Quantity of gangliosides in gray matter approximately in 10 times more, than in white. They are a part of plasma membranes of neurocytes of synaptosomes and a number of subcellular organellas. Are suggested about participation of gangliosides in a mediator - receptor interaction and release of mediators.

Sterols are presented to m to G. cholesterol (see) which in G. the m, unlike other bodies, is almost only in a stand-at-ease. Its contents intensively increases during myelination.

In very insignificant quantity in G. m are found prostaglandins (see), the Crimea is attributed an important role in modulation of action of a number of mediators.

Neurocytes and a glia contain DNA and RNA. The amount of DNA in a kernel of a cell is almost constant, and number of kernels in unit volume of a cerebral cortex in direct ratio to the content of DNA. E.g., contains in kernels of neurocytes of bark G. of m of the person 7,1×10 - 12 of DNA. Practically all DNA is concentrated in a kernel of cells though a small amount it is found in mitochondrions and plasma membranes. Distinctions in the content of DNA between gray and white matter, just as between various areas G. of m, are rather small. The exception makes a cerebellum, in Krom the content of DNA at different types of mammals is nearly 6 times higher, than in bark of hemispheres. In all cellular elements G. of m all main representatives of the RNA group are found. They are found in a kernel, cyto - and a sinaptoplazma. Content of RNA is proportional to the size of cells.

Among nucleotides according to contents adeninova nucleotides are on the first place. ADF makes 1/5 — 1/10 from the content of ATP. Guaninovy nucleotides contain in much smaller quantity, than adipic nucleotides. The uridinovy and cytidine nucleotides and their derivatives which are taking part in synthesis of uglevodsoderzhashchy connections and also cyclic adenosine-3', 5' - monophosphate and cyclic guanine riboside-3', 5' - monophosphate are found in fabrics G. of m; these substances play an important role in regulation of functions of a cell. The tsAMF level increases under the influence of mediators, prostaglandins, adenosine, at the same time the protein kinases stimulating phosphorylation of separate proteins and enzymes are activated.

The main carbohydrates Of m — glucose (to 50 mg of %) and a glycogen (40 — 150 mg of %). Glycogen (see) find in neurocytes and a glia in all structures of a brain. Of m has a small reserve of carbohydrates which depends on deliveries by its circulatory bed. Treat number of the acid mucopolysaccharides found in G. m hyaluronic to - that, hondroitinsulfata And, In and With, and the first prevails in white, and the last — in gray matter. Speed of exchange of acid mucopolysaccharides in G. is much lower than m, than in other fabrics. A part of acid mucopolysaccharides is in the state connected with proteins. Are suggested that they can serve as ion exchangers.

Of m differs in high metabolic activity. He utilizes 20% of the oxygen absorbed by an organism at rest though G.'s weight of m makes apprx. 2% of body weight. The main source of energy — glucose (see). More than 90% of the utilized glucose are exposed to glycolysis. Many glycolytic enzymes G. of m have higher activity, than in a liver.

The Pentozofosfatny way of disintegration of glucose is of great importance for the developing brain when significant amounts of NADF-N2 are necessary for synthesis of the lipids demanded for myelination of fibers. In tissues of a brain enzymes of synthesis and disintegration of a glycogen are found. Unlike other bodies, in G. of m carbon of glucose joins in amino acids more intensively.

In energy balance of G. of m mitochondrions in which by oxidizing phosphorylation ATP is formed have paramount value. On structure OVER - and flavinzavisimy dehydrogenases, tsitokhrom, negeminovy iron, coenzyme Q10 and to substrates of oxidation (amber, apple, alpha and keto-glutaric, glutaminic to - you, etc.) G.'s mitochondrions of m do not differ from those in other bodies. Of m possesses all enzymes and intermediate compounds of a cycle Tricarboxylic to - t — the main source of ATP which, as well as in other bodies, is split by the corresponding ATP-ases on ADF and phosphate with allocation of energy. In G.'s microsomes of m, unlike some other bodies, there is no P450 cytochrome participating in processes of a hydroxylation. Processes of a gluconeogenesis in G. of m are not found.

Considerable part mineral substances Of m make sodium, potassium, calcium, magnesium and chlorides. The amount of mineral anions in white matter are less (25 — 51 mmol/kg), than in gray (31 — 62 mmol/kg). Deficit of mineral anions in relation to cations in general is characteristic of a brain. It is filled at the expense of organic anions — amino acids, proteins, lipids, acid mucopolysaccharides. Content of iron, copper, manganese, zinc and lithium in G. of m is insignificant.

M play a special role in G.'s activity chemical transmitters of nervous impulses — mediators (see). In G. m carry acetylcholine, dopamine, noradrenaline, serotonin to number of the most probable mediators, glutaminic and asparaginic to - you, GAMK and glycine. One of the most studied G.'s mediators of m is acetylcholine (see) having the exciting, and also braking effect. GAMK, glycine and taurine belong to brake mediators amino acids. A product of exchange of GAMK — gamma and hydroxy-butyric to - that suppresses brain activity, increases the content of dopamine, blocking its release. Except a gomokarnozin and a gomoanserin, in G. the m found other derivative GAMK — guanidinomaslyany to - that, etc. Their role is not clear.

Glutaminic and asparaginic to - you are exciting mediators, especially in cortical departments of hemispheres and a cerebellum though they play a part and in subcrustal educations. Catecholamines mediators are presented to G. to m by dopamine and noradrenaline, the most often observed effect of which is braking of nervous activity though in a hypothalamus and a myelencephalon there is a small amount of the neurons which are excited under the influence of noradrenaline. The serotonin (5-oksitriptamin) rendering both brake, and exciting action belongs to indolamine mediators of G. of m. Also the histamine, adenosine, the substance P which is polypeptide and some other substances are among possible mediators of G. of m. In fabrics G. of m all enzymes of biosynthesis and disintegration of mediators are presented. Each mediator in a neurocyte is in several various on exchange activity chemically and spatially the separated funds — pools or kompartment. Allocate a pool of a mediator in a body of a neurocyte and in nerve termination (synapse). In a synapse the mediator is at least in two pools — in a stand-at-ease and the metabolically stable, connected with high-molecular compounds pool. Under the influence of nervous impulse in a synaptic gap the quantum of a mediator of a free pool contacting a receptor on a postsynaptic membrane and defiant a number of reactions which consequence depolarization or hyperpolarization of a membrane is is allocated. The mediator quickly disappears from a synaptic gap or due to splitting by the corresponding enzymes, or capture by the glial cells surrounding a synaptic gap or by the return capture (reutilization) a presynaptic part of a synapse.

One of urgent problems of biochemistry of G. of m is studying of mechanisms a mediator - receptor interactions. On modern representations, receptors are built in a postsynaptic membrane and represent difficult proteinaceous and glycolipidic complexes. Quite successful researches of various types of receptors are conducted. In particular, serve as receptors for catecholamines (the beta and adrenergic receptors which are lipoproteins. This receptor is localized in a membrane and closely tied with enzyme adenylatecyclase, but the center of binding for catecholamines is other than an active center of enzyme.

Various substances and subcellular organellas synthesized in a body of a neurocyte can be transported to trailer nerve terminations by means of an axoplasmatic current, in Krom distinguish bystry and slow components. The possibility of retrograde transport of substances from the peripheral terminations to a body of a neurocyte is proved. Specialized structures — neurofilaments and mikrotubula which part special protein tubulin is take part in axonal transport.

Big complexity is represented by researches of various functional conditions of G. of m. During the studying, e.g., of all hemicerebrum all mass of a brain is at the same time analyzed. As a result of change in the departments of a brain which are in one state smooth out opposite directed changes in other departments which are in other functional state. So, at the increased activity of a brain catabolic processes amplify: the maintenance of a lactate, pyruvate, NH increases 3 , the consumption of glucose, ATP and creatine phosphate increases. In the course of a narcotic dream the speed of metabolism decreases. At development of braking (conditioned inhibition, a dream) anabolic processes prevail (see. Metabolism and energy ). Many questions concerning biochemistry of separate functional conditions of G. of m demand further researches. So, e.g., data rather biochemical, bases of learning and memory are contradictory. Obviously, these difficult functions in which implementation not one population of neurons participates cannot be reduced to changes only of separate proteins, nucleinic to - t etc. Also the problem of neuroglial relationship is insufficiently developed.

Development of a brain is followed by change of its chemical structure and metabolism, strengthening of formation of proteins, DNA, RNA, lipids, a number of amino acids, mediators and other substances. Activity of enzymes of glycolysis, Na+, K+, Mg2+ of dependent ATP-ases, adenylatecyclases, etc. increases. The questions concerning biochemistry of a brain during the aging are less studied.

Exchange processes — material and power substrate of ensuring functions G. of m therefore at disturbance of his metabolism develop patol, states. In particular, because of genetically caused lack of beta glucosidase, a beta galactosidase, a geksozaminidaza and sulphatase develop according to a disease to Gosha, Fabri, Teja — the Saxophone and metachromatic the leukodystrophy which is characterized by accumulation of glycolipids of hl. obr. in cytosom.

At Nimanna — Peak of a disease (see) a large number collects sphingomyelins (see); at an extensive sclerosis their concentration in a myelin falls, the quantity ethanolamine-plasmalogen and the main proteins decreases that is caused by activation of acid protease. Deficit phenylalanine-4-hydro-xymanholes (KF 1. 14. 3. 1) leads to a phenyl-pyruvic oligophrenia (see Fenilketonuriya); at the same time collects fenilpiruvat, the content of serotonin, GAMK, glutamine, cholesterol, cerebrosides and lipoproteids goes down. In the absence of argininosuktsinatarginin-lyase (KF 4. 3. 2.1) in G. the m breaks process of myelination, the amount of argininesuccinate increases in blood and in urine. Deficit of L - serine-dehydratase (a tsistationinsintetaza; KF 4. 2. 1. 13) causes sharp decrease or disappearance of a tsistationin from G. of m and homocystinuria (see). Disturbances of exchange and other amino acids (histidinemia, Cystinuria, gipervalinemiya, tsistationinuriya etc.) which are followed by disturbance of structure and G.'s activity of m are described. Low activity of alcohol dehydrogenase (KF 1.1.1. 1 and 1. 1. 1. 2) the m increases in G. at hron, alcoholism, membrane permeability is in parallel broken, absorption by a brain of glucose and oxygen falls. In experiments on animals at a drunkenness the maintenance of a glycogen, pyroracemic, milk to - t, coenzyme A and ADF, activity of beloksinteziruyushchy system etc. goes down. However on animals it is not possible to reproduce a full complex of symptoms of alcoholic poisoning and therefore experimental results cannot be transferred to a human body entirely.

Intensively investigate metabolism and chemical structure of G. of m at emergence and development of various mental disorders, and also under the influence of neuroactive agents and long starvation. It is established that hormones, vitamins, various mineral substances participate in maintenance of normal metabolism and chemical structure of G. of m; good nutrition is of great importance. As a rule, at disturbances of metabolism and G.'s structure of m certain changes can be observed in cerebrospinal liquid and in blood.

The PATHOLOGICAL ANATOMY

Pathological anatomy of G. of m includes as the general histopathology of nervous and glial tissue, and the private patomorfologiya considering structural changes of G. of m at various diseases.

The morphology and a pathogeny patol, processes in G. of m — body with heterogeneous structure of cells, the complex organization of blood supply and a likvorodinamika — has a number of features. Unequal sensitivity different in structure and chemism of separate neurons or groups them to various influences, regional features of blood supply, variety of reaction of a glia, nerve fibrils and mesenchymal elements explain topography and polymorphism of changes of a brain at various patol, processes.

The most important feature of G. of m is that it very quickly reacts to a number of influences by development of the local or extending to all body hypostasis. As G. of m is in the closed space of a head cavity, even small increase in its volume in connection with hypostasis can lead to a vklineniye of a trunk incompatible with life in a big occipital opening (see. Swelled also swelling of a brain ).

Pathoanatomical research G. of m there begin with macroscopic survey, the description of a configuration of shares, furrows and crinkles, establishments of the fact of total or its partial swelling, transparency or a turbidity of a soft meninx, existence of its unions with blood vessels and cranial nerves. The krovenapolneniye of vessels of G. of m, change of arteries and veins, and also ventricles of a brain water supply system and the ependyma covering them are important. For diagnosis of a row hron, diseases the total or focal atrophy of, m has essential value that can find expression in reduction of its weight or focal retractions of these or those formations. Sharp consolidation of a consistence of separate crinkles is characteristic of some diseases. Change of a configuration of G. of m is possible at some inborn malformations.

Microscopic examination of G. of m is conducted using various neyrogistol. methods, including cytochemical and electronic and microscopic. With their help it is possible to reveal characteristic of various patol, processes of change of neurons, a glia, nerve fibrils and G.'s vessels of m

Patol, changes of neurons divide on nonspecific, arising under the influence of the most various factors, specific — most often developing at defined patol, processes, and the changes caused by disturbance of development of neurons.

Defeat of neuron usually has reversible character until the kernel underwent it heavy changes. Furnacing of nervous cells is not special type of their defeat, and a final stage of many patol, processes. The calcinated cells often meet in hems, about abscesses, organized heart attacks. Acute swelling of neurons meets at various diseases. It is characterized by swelling of a body of a cell and all its shoots, spraying and disappearance of basphilic substance, increase in volume of a kernel and kernels. Acute swelling is reversible if it is not combined with heavier changes. Primary irritation of basphilic substance (Nissl) in the form of axonal reaction, retrograde degeneration — the reversible change of neuron caused by a break of his axon. Characteristic signs: a chromatolysis, especially central departments of cytoplasm, shift of a kernel on the periphery, its ectopia, rounding of contours of a cell. Process proceeds with increase in number of mitochondrions, disintegration and the subsequent recovery of a complex of Golgi. During the wrinkling of nervous cells their form becomes extended, outlines angular, a kernel hyperchromic, a nuclear membrane reinforced, an apical dendrite shtoporoobrazno gyrose, granules of ribonucleotides are pulled together, tanks of a cytoplasmic reticulum are expanded, substance of a kernel is condensed, cytoplasm and a karyoplasm lose water. These changes meet more often at is long flowing patol. processes. The atrophy of a nervous cell is expressed in reduction of the sizes of her body and shoots, decrease in amount of basphilic substance, sometimes accumulation of a significant amount of lipofuscin. The Transneyronalny (transsinaptichesky) degeneration — change of neuron at afferent denervation — has the termination or reduction of inflow of afferent impulses in a basis. Characteristic signs: reduction of the sizes of a cell due to decrease in amount of basphilic substance, the volume of a kernel does not change.

Among irreversible damages of neurons distinguish several forms.

The term «kariotsitoliz» designate blanching of a kernel and cytoplasm with gradual transformation of neuron into «cell shadow». Reduction, wrinkling and a hyperchromatosis of a kernel, a chromatolysis and vacuolation of cytoplasm are characteristic of the «heavy» change which is quickly leading to death of cells (across Nissl). Ischemic, or necrotic, change — a coagulative necrosis of neuron. Reduction and a hyperchromatosis of a kernel, a chromatolysis and angular contours of cytoplasm, its eosinophilia are characteristic of it. Homogenizing, or anoxic, change is close to ischemic, process of coagulation also is its cornerstone. Characteristic signs: homogeneous opalescence of cytoplasm, a kernel in the form of mulberry berry, sometimes vacuoles in cytoplasm. Most often pear-shaped neurocytes of a cerebellum, neurons of a gear kernel and the lower olive kernels are exposed to this change. Edematous, or gidropichesky, change of neuron accompanies wet brain and is characterized by a chromatolysis and increase in volume of cytoplasm, increase in the sizes and indistinct contours of a kernel, a cut often perishes because of fusion of a nuclear membrane.

Death of neurons often accompanies process neyronofagiya (cm) — implementation in a nervous cell of leukocytes or gliotsit and its absorption by them. It is necessary to distinguish a psevdoneyronofagiya from a neyronofagiya (a pronounced satellitosis with participation of the gliotsit which are not implemented into neuron).

The changes of the synoptic device of neurons revealed, e.g., by method Ramón-and-Kakhalya also divide on reversible (coarsening, increase in the sizes, hyper impregnation) and irreversible (a separation of presynaptic; fibrils and disintegration of synoptic structures). Synapses show exclusively high sensitivity to various influences (see. Synapse ).

Pathological changes of separate types of a glia are very various. The division which is found at some authors patol, changes of a glia on «progressive» and «regressive» is inexpedient, t, to. these concepts at treatment obshchepatol, processes are unacceptable, It is more correct to characterize reactions of a glia, using such terms as «hyperplasia», «hypertrophy», «wrinkling», «disintegration» etc., and in need of detailing of the description of process to use the terms accepted in neuromorphology designating characteristic changes of this or that type of a glia, napr, «клазматодендроз» (disintegration of shoots of astrocytes), «mast cells of Nissl», «a drainage glia», «a rhabdoid glia», «Alzheimer's glia», «an amoeboid glia», etc. (see. Neuroglia ), Formation of difficult glial complexes — nonspecific response of a neuroglia to various influences, Usually complexes consist of glial macrophages, oligodendroglyocites, lymphocytes, polinuklear. A kind of glial complexes — gliozno-plasmatic growths — represent accumulations of gliotsit and plasmocytes. Hron, and subacute damages of G. of m of a different etiology can cause proliferative reaction of astrocytes with formation of a large number gliofibrill. In this case speak about fibrous gdioza among which distinguish isomorphic (the arranged growth of the gliotsit producing fibers and replacing the died neurons with saving the general plan of a structure of this or that area), anizomorfny (a chaotic interlacing of glial fibers with full disturbance of very tectonics of the struck department of a brain). Besides, allocate a spotty, subcortical gliosis, etc. Methods Veygerta, Ramón-and-Kakhalya, Snesareva, Holzer, Glis, etc. reveal a macroglia and astrocytes. Oligodendrogliya and a microglia (a mesoglia, according to Robertson) have probably other gistogenetichesky origin and therefore it is elective come to light by other methods. A picture of more or less widespread destruction of shoots of astrocytes — klazmatodendroz which represents quickly developing reaction on various harm and is found by a zolotosulemovy method Ramón-and-Kakhalya.

The amoeboid glia — peculiar degenerative forms of astrocytes — well comes to light by Snesarev and Alzheimer's methods.

Proliferation of a microglia is characteristic of acute inflammatory processes, and also of reaction to these or those destructive changes. At wet brain and other disturbances of a likvorotsirkulyation the interfastsikulyarny oligodendrogliya forms numerous tyazh of drainage cells of Snesarev. At vital observations in the conditions of culture of fabric ability of oligodendrocytes to a rhythmic pulsation and other forms of mobility is proved.

Patol, certain patterns of the general character are inherent to changes of nerve fibrils of white matter of a brain. Pathology of pulpy nerve fibril consists of changes of at least two of its basic elements — the axial cylinder and a myelin cover. Regardless of the reason of a break of fiber in its part, peripheral in relation to the place of a break, the complex of changes designated as vallerovsky regeneration develops (see Valera regeneration). Similar changes of the axial cylinder and myelin cover develop also at primary (system, diffusion) defeats of white matter, napr, at an amyotrophic side sclerosis, avitaminosis, intoxications, malignant tumors of various localization etc. At multiple sclerosis disintegration of axial cylinders arises infrequently, but destruction of a myelin takes place stages of vallerovsky regeneration. Methods of identification of myelin covers of Veygert, Brand, Kulchitsky, Shpilmeyer, Avtsyn, etc. allow to distinguish the process of demyelination accompanying bacterial, protozoan and neuroviral infections, and also genetic, circulator, autoimmune or metabolic frustration. Impregnation of nerve fibrils phosphatomolybdic silver by Avtsyn's method allows to reveal pathology of the thinnest myelinized fibers, napr, cortical tangential and radial that has basic value at patomorfol. to diagnosis of senile psychoses, syphilitic defeats, the phenomena of demyelination at encephalitis, after vascular necroses of nervous tissue, at some avitaminosis. A part of demyelinating processes has a difficult origin as a number of pathogenic factors takes part in formation of the centers of demyelination.

The stated features of reactions of neurons, glias, fibers and the synoptic device on pathogenic influences it is necessary to consider at identification patomorfol, G.'s changes m with the basic concepts of the general pathology of the person. In particular, the term «dystrophy» seldom designate the changes of elements of substance of a brain corresponding to this process. More often dystrophy call accumulation lipofuscin (see) in neurons (lipidic and pigmental dystrophy), obesity of nervous cells (fatty dystrophy), and also changes of nervous cells and a glia at tezaurismoza (sphingomyelinoses, glycogenoses, etc.). Some authors allocate dystrophic encephalopathies, carrying to them anoxic, alimentary and dystrophic forms of encephalopathies, or speak about the dystrophic nature of changes of a glia. The group of hereditary diseases of a nervous system of which the diffusion disintegration of a myelin with destruction of axons caused by disturbances of lipidic exchange is characteristic is called a watering can dystrophies.

Separate elements of substance of a brain (neurons and their groups, glial cells, vessels) and even the whole areas can be exposed to a necrosis (see). Carry to necrotic changes of neurons kariotsitoliz. In the course of a necrosis the superficial membrane of cells collapses, mitochondrions bulk up and are condensed, granules of ribonucleoproteins completely disappear, occurs reksis kernels. In a concluding phase of death of a cell the large role is played by hydrolytic enzymes of lysosomes. The necrosis of certain areas G. of m can be incomplete and full. At an incomplete necrosis only nervous cells, its outcome in case of weak reaction of gliotsit — «the centers of devastation» either an isomorphic or anizomorfny gliosis perish at proliferation of a fiber-forming glia. Full necrosis — death of all elements of substance G. of m. The site of a full necrosis undergoes certain changes, On border of the site, and is frequent and in him the remained vessels come out polymorphonuclear leukocytes, there is a hyperplasia and a hypertrophy of all three types of a glia, formation of granular spheres, emergence of again formed vessels, and also formation of glial, argyrophil and collagenic fibers. As a result of these processes the nekrotizirovanny site is delimited from safe departments of G. of m and replaced with a gliomezodermalny hem, the sizes to-rogo, as a rule, less than the sizes of the struck area. Other frequent option of an outcome of a necrosis of site G. of m — formation of the sacculated cyst or abscess of a brain.

Disturbances of blood circulation in G. of m happen the general and local character, the General hyperemia, is frequent with cyanosis of bark, is characteristic of acute insufficiency of a right ventricle of heart, a pulmonary heart, heart diseases, sometimes arises at arterial hypertension, disturbances of venous outflow. G.'s anemia of m is possible at anemias of various genesis, a cardiac standstill, a collapse. The plethora of certain areas G, m happens at focal disturbances of cerebral circulation (see. Stroke ), inflammatory processes, poisonings, tumors etc. Ischemia of certain sites could * the hectare arises at reduction and the termination of a blood-groove in arteries at fibrinferment, a thrombovasculitis, atherosclerosis, an embolism, a vasculitis, a hyalinosis of walls of arteries of a brain with reduction of their gleam at an idiopathic hypertensia, a prelum of arteries tumors and opukholepodobny educations, etc. Ischemia leads to death of separate neurons or groups of them (an incomplete necrosis) or to development of heart attacks of a brain (a full necrosis).

Character and weight of changes (as a rule, nonspecific) neurons, a glia, nerve fibrils, vessels and other structural elements depends on size, a plant louse of a telnost and localization of disturbance of cerebral circulation, and also on a condition of all organism. For patangioarkhitektonichesky researches use injection ways, methods of impregnation of blood vessels, elective identification of a krovenapolneniye of intracerebral veins and capillaries by means of magenta acid, and also the benzidine method.

The inflammation in G. of m proceeds with development of alteration, proliferation, phagocytosis. Alterativny changes can take neurons, a neuroglia, white matter, vessels. The hyperplasia and a hypertrophy of all types of a glia, infiltration by leukocytes, plasmocytes, histiocytic elements of substance of a brain and walls of vessels is characteristic of proliferative processes. Phagocytosis is expressed in a neyronofagiya, a gliofagiya, capture of decomposition products by granular spheres, glial macrophages (see). The inflammation is followed by all nonspecific changes of neurons, including ischemic, formation in gliotsita of inclusions, disintegration of white matter, hypostasis, a necrosis, hemorrhages and other disturbances of blood circulation. Different types of inflammatory diseases of G. of m (see. Arachnoiditis , Meningitis , Encephalitis ) differ from each other in cellular composition of infiltrates, localization of inflammatory process, degree of prevalence of destructive changes and reparative processes, outcomes (the centers of devastation, an isomorphic or anizomorfny gliosis of a gliomezodermalny hem, abscess, fibrosis, unions of an arachnoid membrane, hydrocephaly etc.). Special forms of an inflammation develop at tuberculosis, syphilis, fungal and parasitic diseases of G. of m. Among tubercular defeats tubercular meningitis, miliary tuberculosis of a soft meninx and solitary tuberculosis of a brain have the greatest value.

The most part of the abscesses (apprx. 60%) found on section has an otogenic origin — is connected with spread of an infection on continuation. At metastatic abscesses the infectious agent gets to G. of m with a blood flow. It most often happens at a septic endocarditis, suppurative and ichorous processes in lungs, hron, the bronchiectasias which are especially complicated by an inflammation of peribronchial veins. Plurality is characteristic of metastatic abscesses; some of them, being located, as a rule, on border of white and gray matter of bark, can have the microscopic sizes. In the center of abscesses without special work it is possible to find the mycotic (infected) embolus. Due to the reduction of number of cases of a septic endocarditis and successful treatment by antibiotics of suppurative processes in lungs metastatic abscess of G. of m became quite rare pathoanatomical find.

Abscesses are put into the capsule which thickness of walls depends on duration patol, process, properties of the activator and reactivity of an organism.

Acute tubercular meningitis (see) represents an encephalomeningitis and it is characterized by a seroznofibrinozny inflammation of a soft meninx with preferential defeat of the basis of a brain. In rare instances, especially at senile age, tubercular meningitis can be only serous, in others — impurity of fibrin is so considerable that all cover on the basis and in the depth of furrows of a convex surface of G. of m has a gelatinous appearance and light yellow (with a subtle greenish shade) color. In these cases there is a need of the differential diagnosis between serous meningitis and acute serous and purulent meningitis that bacterial, and patogistol is easily carried out with the help. researches.

As a part of infiltrate of covers hl are found. obr. lymphocytes, large Meningeal macrophages and it is frequent (in fresh cases) neutrophils. In uncured cases considerable proliferation of an internal cover of an artery and arterioles, damage of their elastic membranes, a fibrinoid degeneration, and also a fibrinoid necrosis of vascular walls, including necroses of a mussel is observed. In walls of the struck vessels quite often find accumulations of tubercular sticks. At the subacute course of tubercular meningitis in covers the proliferative phenomena prevail. Involvement in patol, can lead process of walls of veins to pan-phlebitis, formation of blood clots and hemorrhages.

Patomorfol, the diagnosis of tubercular meningitis is simple. Student invisible character of exudate in the field of the cerebellar and brain tank, visual decussation, side poles of a great brain, and also around the brain bridge and a myelencephalon is very typical. The expressed brain swelling with a vklinivaniye of almonds of a cerebellum is important for the macroscopic diagnosis of tubercular meningitis, a cut can arise at any stage of a current patol, process and to be a cause of death. Meningitis is often combined with miliary tuberculosis of covers, at Krom prosovidny, and sometimes and larger hillocks are located on the basis of a brain, on the covers covering a cerebellum and also in the depth of furrows of a brain raincoat. However miliary tuberculosis of a soft meninx can proceed also without any symptoms of exudative tubercular meningitis. Epithelial, colossal and lymphoid cells, and also a zone of the central caseous necrosis are characteristic of specific tubercular hillocks.

Defeat of brain fabric at tubercular meningitis is closely connected with the rough inflammatory process which is played in covers. Inflammatory infiltrates on the subarachnoid spaces surrounding vessels get into gray matter of bark. White matter usually does not suffer. The encephalitic component comes down to formation of granulomas, diffusion proliferation of a microglia, inflammatory infiltration around subependimalny vessels.

The special form of tubercular meningitis, at Krom, as a rule, observes a combination of a local rash of miliary hillocks (or solitary tubercles) and not extending productive inflammation, so-called limited tubercular meningitis is. Localization of this process on the convex surface of a brain often gives focal symptomatology. Solitary tubercles — rather frequent form of tuberculosis of G. of m connected with hematogenous dissimination (see. Tuberculoma ).

G.'s syphilis of m can develop in various stages of a syphilitic infection. At primary syphilis (see) cerebral defeats, as a rule, do not arise. At secondary syphilis development of an acute encephalomeningitis with lymphocytic infiltrates and formation of small histiocytic (microglial) small knots is possible. Meningovaskulyarny defeats with formation of the gummas which are quite often involving in patol are characteristic of tertiary syphilis. process the vessels passing through subarachnoid space — arteries. The resulting panarteritis like Geybner can lead to sharp deformation of large vascular trunks, destruction of their elastic membranes and formation of syphilitic aneurisms. In patogistol. the relation the geybnerovsky panarteritis is characterized by powerful limfoplazmotsitarny infiltrates, the considerable proliferation of subintimalny elements conducting to full or almost full obliteration of a vascular gleam. Around the struck vessel there is a powerful network of argyrophil fibers. In its loops lymphoid and plasmatic elements and a small amount of multi-core colossal cells are located. Approximately same patogistol. the picture is characteristic of a gummous pia-arachnitis which can strike both the basal surface of a brain, and a convex surface of hemispheres. Quite often gummas of a meninx merge among themselves, forming considerable conglomerates.

Treat so-called parenchymatous forms of neurosyphilis general paralysis (see) and back tabes (see).

The general paralysis represents the chronic encephalomeningitis arising, as a rule, through a long time after infection. In typical cases opacification and a thickening of a soft meninx is macroscopically expressed, there are symptoms of considerable outside and moderate internal hydrocephaly, decrease in average weight of a brain by 100 — 150 g, granularity of an ependyma of the fourth ventricle is noted. The focal atrophy of crinkles is expressed to a thicket in frontal poles and in basal departments frontal, and sometimes and temporal bark. Perhaps moderate wrinkling of subcrustal nodes, in particular kernels having a tail and thalamuses.

Despite a characteristic gross appearance, owing to spontaneous and therapeutic caused pathomorphism (see) the macroscopic diagnosis of a general paralysis and other forms of parenchymatous neurosyphilis it is almost impossible. Microscopic identification of widespread degenerative changes of a nervous parenchyma in combination with perivascular infiltrates from lymphocytes and plasmocytes, unsharply expressed pia-arachnitis and diffusion proliferation micro and macroglias is necessary. Degenerative changes are not limited to cellular devastation of gray matter of brain bark, but extended to conduction paths of white matter and basal a ganglion. This degeneration is not a consequence of defeat of vessels.

An important diagnostic character — detection of the pale treponemas which are freely lying in nervous tissue, and sometimes creating considerable accumulations [F. Jahnel, V. K. Beletsky].

Other form of a general paralysis — a focal general paralysis (Lissauer's form). The spontaneous stationary general paralysis and combination of a general paralysis with meningovaskulyarny or gummous syphilis of a brain deserve mentioning.

A special form of late neurosyphilis is the endarteritis of small vessels of bark for the first time described by Nissl and Alzheimer (F. Nissl, A. Alzheimer; 1903, 1904). This form of a neyrolyues traditionally concerns to group of a vascular, i.e. so-called mesenchymal neyrolyues. It is more correct to consider, however, it transitional between a mesenchymal and parenchymatous neyrolyues. Patogistol. the research reveals an insignificant thickening of a soft meninx, a characteristic thickening of small arteries with a partial or full obliteration of a gleam, formation of vascular konvolyut in bark, considerable proliferation of a macroglia, degenerative changes of cortical neurons.

In spite of the fact that at a syphilitic endarteritis of small vessels of bark extremely scanty lymphoid infiltrates can be occasionally found, it is necessary to agree with Nissl and Alzheimer's opinion who carried this form of a neyrolyues to noninflammatory. A. Jakob suggested to call this process not arteritis, and arteriozy, assuming its toxic nature. At this form of a neyrolyues not only brain bark is mentioned; the centers of defeat can be found also in other departments of G. of m, in particular in striopallidal system and a hypothalamus. With immunobiol, the points of view neyrolyues Nisslya — Alzheimer is characterized by the lowered reactivity that is proved by almost total absence of reaction of immunocompetent cells in c. N of page. In rare instances at this form in walls of brain vessels, and also in cortical substance it is possible to find treponemas.

Patol, anatomy of tumors of G. of m is based on their morphogenetic diagnosis. The largest group is made by tumors of a neuroectodermal origin. Gliomas of various look among which the astrocytoma, a multiformny glioblastoma, a medulloblastoma, a neurinoma quite often occur concern to them, is more rare — an oligodendroglioma, an ependymoma. At gistol, a research the so-called bifraktsionny tumors consisting of two types of gliomas can come to light (e.g., an astrocytoma and an oligodendroglioma etc.).

The second basic group — the tumors which are arising from a meninx and walls of blood vessels, i.e. having a mesodermal origin (e.g., an arakhnoendotelioma, the Meningioma, an angioretikulema, etc.). Degree patol, impacts of tumors of G. of m on other its departments, and also a role of tumors of G. of m in visceral pathology it is necessary to connect with their localization, in particular proximity to the highest vegetative centers.

Detailed data on morphology of tumors of G. of m — see in separate articles (e.g., Astrocytoma , Glioblastoma , Cranyopharyngioma , Medulloblastoma etc.).

Kompensatorno - adaptive processes in G. m also have the features. Regeneration in G. is very limited to m that aggravates weight of any patol, process. Nervous cells and their axons do not regenerate. At damage even of considerable sites of cytoplasm of neurons the recovery processes which are expressed in formation of the membranes surrounding sites of damage, intracellular digestion of these sites with phagosomas and normalization of ultrastructure of various organellas develop in them. Reparative processes are imperfect, happen to participation of a glia and mesenchymal elements, at extensive full necroses come to an end with formation of a hem, a cyst or abscess of a brain. Adaptive and compensatory processes in G. are carried out by m not so much at the expense of structural how many due to functional changes. Morfol, correlates of these processes demand further studying.

METHODS of the RESEARCH

In nevrol, clinic apply various methods of researches G. of m (see. Inspection of the patient ). From experimental physiology the methods providing a direct tool research G. of m began to get into medical practice. The quantity and quality of the atraumatic tool methods approved by experimental neurophysiology steadily grows.

In group a wedge, methods enter: collecting the anamnesis, the general survey of the patient, a research of movements, tendon, periosteal, cutaneous reflexes, reflexes from mucous membranes (see. Reflex ) and their changes, sensitivity and ev frustration, coordination, vegetative and trophic sphere, the highest mental functions.

Big help in diagnosis of diseases of G. of m is given by tool methods, napr, spinal puncture (see) and suboktsipitalny puncture (see) with the subsequent research of cerebrospinal liquid (see).

For diagnosis of tumors and opukholepodobny diseases, and also for definition of damages to result of a craniocereberal injury use rentgenol, methods. The simplest and available of this group is the method of a kraniografiya (see. Kraniografiya , Skull ). Introduction to the subshell spaces or ventricles of contrast agents or air allows to carry out an encephalography (see) and a ventrikulografiya (see). Layer-by-layer pictures receive by means of a tomography. For detection of vascular disorders use a carotid angiography (see), a vertebralny angiography (see). A modern diagnostic method of volume processes in a head cavity by means of ultrasound is ekhoentsefalografiya (see), and also tracer techniques of a research.

The radio isotope gamma encephalography is based on ability of a number of radioactive connections to collect in fabric of tumors, abscesses, the centers of hemorrhages, etc. From the moment of introduction of a method by Moore (G. E. Moore, 1948) is offered a set of indicators. The best connections, marked — pertekhnetat appeared the short-lived radioisotopes radiating gamma quanta of low energy, e.g. 99Tc (Eγ = 150 kev T physical = 6 hours). Radioactive material is entered intravenously in a dose by from 5 to 10 mkkyur on 1 kg of weight for 1 — 3 hour to radiometry.

For registration of distribution of a radioactive label use a method gamma topografirovaniya with receiving stsintigramm in front and back straight lines, right and left side and parietal projections (see. Radio isotope diagnostic units ).

Fig. 20. Stsintigramma is normal of a skull of the person (and — a front straight line; — left side projections): 1 — area of hemicerebrums; 2 — diploichesky veins of cranial bones, a firm meninx, superficial brain vessels; 3 — area of sialadens; 4 — a mucous membrane of an oral cavity and a nose; 5 — a sinus drain.
Fig. 21. To Stsintigramma of a skull of the patient with a tumor (it is specified by shooters) front departments of a corpus collosum: and — front straight line; — left side projections.

On a normal stsintigramma (fig. 20) the image of soft tissues and bones front and a neurocranium, mucous membranes of an oral and nasal cavity, and also the sialadens accumulating isotope in a significant amount is accurately visible. The brain is presented by area with the smallest level of radioactivity. In the presence of an intracranial volume new growth on a stsintitramma the center of the increased radioactivity appears, to outlines to-rogo it is possible to judge localization, the sizes and prevalence patol. process (fig. 21). Diagnostic efficiency of a technique depends on the sizes and gistol, the nature of a new growth. Large meningiomas are diagnosed in 90% of cases, glioblastoma and tumors of the metastatic nature — in 80%. Cranyopharyngiomas, tumors of a hypophysis, Epi dermoids come to light no more than in 10% of cases. By method of radio isotope diagnosis abscesses, the contusional centers, capsules of cysts, subdural hematomas, arteriovenous aneurisms etc. come to light. The radio isotope gamma encephalography does not allow to make the final conclusion about character and the nature patol, process. Any new growths to dia, less than 2 cm by means of this method do not come to light.

During neurosurgical operations apply a beta and radiometric diagnostic method to simplification of search of tumors, comparing the radioactivity of not changed G.'s departments of m to the radioactivity of the tumors which are selectively accumulating radioactive phosphorus. Isotope 32P in the form of disubstituted sodium phosphate (Na 2 H 32 PO 4 ) enter intravenously for 1 — 24 hour before operation in number of 3 — 5 mkkyur on 1 kg of body weight. After carrying out an osteoplastic craniotrypesis and opening of a firm meninx carry out by the needle SBM-11 beta counter radiometry of muscles of the head. Then, sparing functionally important sites, the counter is entered into fabric G. of m in the place of a projection of a tumor. Beta and radiometric search of a tumor is carried out under control of sound indication, after each centimeter of immersion measuring radioactivity.

According to radiometry it is possible to give preliminary estimate to degree of a zlokachestvennost of a new growth. Radioactivity of a benign glial tumor is equal or the radioactivity of muscles, and radioactivity malignant, including and metastatic is lower, is, as a rule, higher than tumors.

Methods of a research of cerebral circulation. Tracer techniques: a research of a regional brain blood-groove by means of easily diffusing inert gas 133 Xe entered into an internal carotid artery, intravenously or it is inhalation; definition of time of a brain blood-groove by means of introduction of not diffusing indicator (a seralbumin, marked 131 I).

For the same purposes use also other methods, napr, a method of Ket — Schmidt, polyarografiya (see), methods with administration of dye and assessment of results on the basis of Stewart's principle — Hamiltona, definition of a blood-groove electromagnetic termisterny or ultrasonic flowmeters, and also by data termografiya (see) and serial angiography (see). Judge a condition of cerebral circulation also with the help rheoencephalography (see).

Methods of a physiological research

Main methods: Electrophysiologic methods of irritation, switching off, measurement of a brain blood-groove and cash oxygen G. of m.

Among elektrofiziol, methods gained the greatest distribution electroencephalography (see) — a technique of registration of total electric activity of G. of m through covers of a skull. Its version are techniques of registration of bioelectric activity directly from various structures of G. of m by means of electrodes, napr, from bark — an elektrokortikografiya, from a visual hillock — the elektrotalamografiya etc. found for Elektroentsefalografiya owing to the simplicity and availability broad application in psychology, neurology, neurosurgery, psychiatry, anesthesiology etc. The analysis of superslow bioelectric activity is possible with the help nepolyariziruyushchikhsya electrodes and amplifiers of a direct current. The technique of representation of total bioelectric activity developed by I. N. Livanov (1972) in the form of the images which are developing on the screen of an oscilloscope from 50 and more shining points which brightness is modulated by the instant size EMF of a brain in the respective areas received the name of an entsefaloskopiya. She allows to observe and to quantitatively estimate dynamics of biopotentials at the same time in many zones G. of m therefore it is used for studying of patterns of integrative activity of G. of m at diagnosis of a number of diseases.

A technique of evoked potentials (see. caused ) consists in registration of electric reactions of different departments of G. of m in response to single irritations of receptors, nerves or the central structures. Evoked potentials classify by criteria of stage of latency, configuration, duration, topography, sensitivity to chemical substances. The technique of evoked potentials allows to investigate zones of touch representations, their patterns fiziol. and neurochemical, the organizations, the nature of bonds between various departments of G. of m and also to judge their functional state.

The technique of a neyronografiya offered I. Dyusser de Varennom is applied to identification of feedforwards between various areas G. of m. A basis fiziol, neyronografiya is property of the strychnine which is locally applied on a brain to cause rhythmic epileptiform categories. According to a hypothesis of the author, these categories are capable to extend on axons before the first synoptic switching. By means of a neyronografiya intrakortikalny and corticosubcortical functional linkages and interaction of brain structures are studied.

Inside - and extracellular bioelectric activity of separate neurons apply the Microelectrode method of a research to the analysis. By means of microelectrodes are studied fiziol, properties of nervous cells and their ensembles, mechanisms of synoptic transfer of excitement from a cell on a cell (J. Ekkls, P. G. Kostiuk). This technique found broad application in studying of the principles of coding in a nervous system and researches of the neyronalny organization of simple and irregular shapes of behavioural acts.

Methods of stimulation include various ways of direct irritation of various structures of G. of m direct and impulse electric current of different force and frequency, chemical substances and other incentives. For a research of emotional zones G. of m the technique of self-stimulation [J. Olds, 1965] which is that the experimental animal the actions itself starts the stimulator irritating him a brain was widely used. By quantity of irritations in unit of time it is possible to judge degree of «gratefulness» or «trouble» of stimulation of this zone G. of m.

Techniques of switching off cover a number of the ways allowing to eliminate temporarily or constantly activity of any area G. of m. Temporary switching off reach by means of cooling, anode polarization or use pharmakol, the substances suppressing activity of nervous cells. Lean's depression extending after application of potassium chloride which is in detail investigated by J. Bures can be an example. Constant switching off is carried out by surgical methods. Many fiziol, it is convenient to solve problems on the sites of c isolated in the operational way. N of page, napr, on completely neyronalno to the isolated bark (M. M. Hananashvili, 1971).

In fiziol, the experiment and more and more persistently gets into a wedge, neurophysiology modern computer facilities, methods of cybernetics, specialized analyzers and universal COMPUTERS are widely used.

PATHOLOGY

the Symptomatology

At various patol, G.'s processes of m there can be subjective and objective symptoms caused by localization, character, the course of process, a reference state of G. of m, the somatic status and other factors. On origins objective symptoms divide on general and brain, an obol ochechny (Meningeal), focal (local) and symptoms on a distance.

Disturbances of functions G. of m are the cornerstone of the mental diseases which are expressed in disorders of mental processes and emergence of the corresponding symptomatology — disorders of consciousness, developing of hallucinations, nonsense, psychoorganic syndromes, decrease in intelligence, etc.

All-brain symptoms reflect the general reaction of G. of m to pathogenic influence and can be display of hypostasis, intoxication, etc. Various extents of disturbance of consciousness (devocalization, a sopor, a coma) are characteristic, epileptiform syndrome (see), headache, dizziness, nausea, vomiting. At increase in intracranial pressure are most characteristic: a headache, vomiting, developments of stagnation on an eyeground, sometimes the Meningeal syndrome, bradycardia.

One of private symptoms of a disease of G. of m — headache (see). The detailed analysis of character, the localization, degree of intensity, the factors provoking or reducing a headache, changes of pain during a disease, a combination to other symptoms in the course of overseeing by the patient — a necessary condition for the correct assessment its wedge, values. The headache can arise at diseases of internals, exogenous and endogenous intoxications, need of an exception of the specified diseases from here. Assessment of intensity of a headache depends on a condition of consciousness of the patient. So, at alcoholic intoxication, a soporous condition of the complaint to a headache quite often are absent.

Sleep disorders (dyssomnia) — an important early symptom of functional or organic lesions of G. of m, and also somatopathies and intoxication. Show complaints to sleeplessness more often, is more rare — on drowsiness or perversions of a form of a dream — drowsiness in the afternoon, sleeplessness at night. In the analysis of a dyssomnia it is necessary to consider features of backfilling, depth of a dream, duration, character of dreams, value judgment of sufficiency of a dream. It must be kept in mind that in the period of a dream some can come to light patol, states, napr, an epileptic seizure.

Disturbances of memory, attention, increased fatigue can be early manifestation asthenic syndrome (see), atherosclerosis of cerebral vessels or any other patol, process in G. of m.

Quite often signs of irritation of various departments of a vestibular analyzer come to light (see Dizziness), to-rogo various patol, processes — disturbances of blood circulation, inflammatory diseases, tumors, etc. can be the cause.

With dizziness and a headache it is often combined nausea (see), vomiting — the symptoms accompanying increase in intracranial pressure, irritation of kernels of a trunk, reticular formation, vestibular analyzer.

Vomiting (see) — the important objective symptom of diseases of G. of m, a thicket arises at increase in intracranial pressure (a hematencephalon, a craniocereberal injury, tumors of a brain, wet brain) and also as manifestation of local irritation of the emetic center in a trunk (at tumors of the fourth ventricle, hyperexcitability of kernels of a vestibular nerve, disturbance of a blood-groove in vertebralno-basilar system and other processes).

The analysis of provocative factors is necessary for time of their emergence for definition of primary or secondary origin of nausea and vomiting, within a day, to dependence on position of a body, the head, a combination to other signs of defeat of G. of m, and also a state cardiovascular (bradycardia, tachycardia) and digestive systems.

Syncopal states (see. Syncope ) — the short-term loss of consciousness arising against the background of falling of the ABP and disturbances of a postural tone. Faints can arise as manifestation of acute insufficiency of cerebral circulation (see) at healthy people at strong mental and somatic influences (a fright, an injection of medicines, a sudden rising after long stay in a bed). Faints can accompany diseases of cardiovascular system (an atrioventricular block, acute coronary insufficiency, an attack of a Bouveret's disease, etc.), hron, diseases of lungs, a thromboembolism of a pulmonary trunk and its branches etc. The syncope can be the first and only manifestation epilepsies (see). For clarification of the reasons of a faint it is necessary to carry out the careful analysis of the anamnesis (existence of faints at relatives, the slight craniocereberal injury postponed in the childhood, rheumatism, abortal displays of epilepsy). Somatic inspection, the careful analysis nevrol, the status, an electroencephalography (using methods of functional activation), functional methods of a research of a condition of cardiovascular system (an ECG, reografiya, etc.) allow to specify pathogenetic essence, diagnostic and predictive value of a faint and to define methods of treatment.

Short-term disturbances of consciousness which patients subjectively note as «stop»: instant feelings of unreality of the world around, sudden not recognition of earlier familiar situation or, on the contrary, emergence of feeling already seen (a syndrome of deja vu) can be quite long time the only display of epilepsy (see). Various hallucinations (see) — olfactory, acoustical, flavoring, visual (elementary and difficult), distortions of perception of own body can be also only subjective manifestation of the local epileptic category in the respective areas G. of m. Helps objectification of complaints of the patient electroencephalography (see), as a rule, allowing to reveal epileptic activity.

The passing frustration in the form of the flickering patches of light, zigzags which sometimes are observed in the corresponding half of fields of vision continuing within several minutes (sometimes more than 1 hour) with the subsequent or simultaneous development of a headache — manifestation of a vasomotor spasm of brain vessels at migraine (see. Migraine , Hemicrany ).

Quite frequent symptom is hiccups (see) — can arise owing to defeat of a reticular formation of a myelencephalon (at disturbances of blood circulation in vertebral and basilar arteries, encephalitis, tumors, intracranial hematomas). Development in the patient of a hiccups against the background of the accruing disorders of consciousness (devocalization, a sopor) always demands the emergency exception of the intracranial volume process which is followed by the phenomena of dislocation of G. of m. Disappearance of a hiccups against the background of further deepening of disturbances of consciousness (development of coma) predictively is adverse. The hiccups can be the only symptom of trunk encephalitis or microfocal hemorrhage in G.'s trunk of m.

The shell symptoms (symptoms of irritation of a meninx) are shown by a stiff neck, Kernig's signs, the Brudzinsky, malar symptom of Bekhterev, being often supplemented with morbidity of eyeglobes at their extreme assignment, a headache, nausea and vomiting. Most often the Meningeal syndrome arises at meningitis (see), under an obol ochechny hemorrhages, a hemorrhagic and ischemic stroke (see), at G.'s tumors of m, and also at a craniocereberal injury (see). Tumors in the field of a back cranial pole can give the dissociated Meningeal syndrome: absence or weak expressiveness of a Kernig's sign at the expressed stiff neck (see. Meningism ). The meningeal syndrome can develop after a spinal puncture, in these cases it usually disappears within 2 — 3 days.

Focal symptoms — a consequence of local defeat of structures of m. According to the struck area G. of m it is accepted to allocate symptoms of damage of cranial nerves (see), G.'s trunk of m (see the Myelencephalon, the Mesencephalon), a diencephalon (see), basal kernels (see), the internal capsule and a cerebral cortex (see). Distinguish focal symptoms of loss — result of destruction of this or that department of a brain (e.g., paralysis of extremities on the opposite side at the patient with a hematencephalon) and symptoms of irritation — the investigation of an irritation of these or those structures. Sometimes symptoms of irritation are transformed to symptoms of loss. E.g., the limited clonic spasms in a hand caused by a prelum a tumor of area of a front central crinkle are replaced by the accruing spastic paresis of a hand. The return dynamics is less often possible: e.g., at the patient who had a stroke, symptoms of loss (paresis, paralysis) are supplemented with postinsultny focal epilepsy — manifestation of irritation of cortical structures the organized cyst or the forming hem.

Focal defeat (hemorrhage in substance of a brain, a cyst after the had stroke, a tumor, etc.) it is not necessary to consider as absolutely isolated as each area G. of m is in the closest structurally functional relationship with other departments of the and opposite hemisphere. Therefore each focal defeat usually breaks functions G. of m owing to a transneyronalny degeneration, reparative processes around the center, the autoimmune processes which are quite often accompanying hron, focal defeats. Instability of primary symptoms of irritation of bark — the centers of epileptic activity is very quite often noted: through a nek-swarm time can arise the mirror center in other hemisphere that is clinically shown by change of «formula» of an epileptic seizure.

The concept «syndrome of defeat» of this or that area cannot be identified with the concept «function of the respective site G. of m». E.g., the alexia at defeat of the 39th field of Brodmann is not the proof that this area — «the center of reading».

Symptoms on a distance arise more often at volume processes in a head cavity when, e.g., at tumors of a pole of a temporal share in conditions of the expressed intracranial hypertensia of a gippokampov the crinkle puts in an opening of cerebellar is mashed and squeezes upper parts of a brainstem. At the same time symptoms of focal defeat of a temporal share can be moderately expressed, and into the forefront defeat of a third cranial nerve acts.

At defeats oblong and a mesencephalon, the Bridge function of cranial nerves (the III—XII couples), as a rule, suffers. Alternating syndromes, bulbar paralyzes which need to be distinguished from pseudobulbar paralysis are characteristic.

Damages of a cerebellum are shown by disorders of gait, intentsionny trembling, a nystagmus, adiadokhokinezy, a dismetriya, alalias, a hypomyotonia, an asynergia, change of postural reflexes, an ataxy. The break of bonds between gear and red kernels can lead to hyperkinesias.

The disorders of sensitivity (see) which are especially expressed in distal departments of extremities are characteristic of defeat of a visual hillock. Disturbances of sustavnomyshechny feeling are shown by a sensitive ataxy, so-called thalamic pains and a gemigiperpatiya on the contralateral party are characteristic. The increased efficiency, violent laughter and crying is quite often observed, the atetoidny movements can appear.

During the involvement in patol, process of a hypothalamus arises the Hypothalamic (diencephalic) syndrome. Symptoms of defeat of basal kernels come down to changes of a tone of muscles, a physical activity (see. Amyostatic symptom complex , Hyperkinesias , Parkinsonism , Extrapyramidal system ).

Defeat of the internal capsule is characterized «by a syndrome three those»: hemiplegia, hemianaesthesia and hemianopsia. The centers in the semi-oval center give the symptomatology close on character to the phenomena of defeat of the internal capsule having, however, more limited character. Bilateral defeats lead to pseudobulbar and bilateral pyramidal frustration (see. Pyramidal system ). Defeats of a corpus collosum (see) are followed by disturbances of mentality, apraxia.

Damages of a cerebral cortex are shown by disturbances of a gnozis, praksis and speech functions: agnosia, apraxia, aphasia (see). Symptoms of loss of function of a front central crinkle are paralyzes and paresis, and irritations — „attacks of cortical jacksonian epilepsy (see). Disorders of sensitivity are characteristic of defeat in area of a back central crinkle.

For a syndrome of damage of frontal lobes, except all-brain symptoms (lack of an initiative, apathy, euphoria, disturbance of preferential abstract thinking, inability to acquire new, stereotype of behavior and statements, the disinhibition of inclinations, carelessness and lack of criticism) characteristic the wedge, a picture depends on localization of defeat. Difficult motor and psychomotor avtomatizm arise at defeats of premotorny bark, disturbances around a frontal pole lead to affective and strong-willed changes (see. Apathetic syndrome ). Left-side defeats are shown preferential by alalias, as motor aphasia, disturbances of a gnozis and praksis (see. Agnosia , Apraxia , Aphasia ).

Disorders of sensitivity are expressed at defeats of a parietal lobe, one of frustration is the astereognosis.

Defeats of a temporal share are shown by a hemianopsia, an ataxy, dizziness, olfactory, flavoring and auditory hallucinations; a frequent symptom are epileptiform attacks. At defeat of the left hemisphere touch aphasia can be observed.

Defeats of an occipital share are followed by preferential visual disturbances in the form of a hemianopsia (see. Hemianopsia , Visual centers, ways ) and visual agnosia. Visual are possible hallucinations (see).

Malformations

Malformations m win first place (apprx. 25%) among all inborn uglinesses diagnosed during the openings of corpses of newborns (E. B. Krasovsky, 1964; Yu. V. Gulkevich, etc., 1975).

Pathogeny malformations the m is various. At externally full development m are possible biochemical, defects, napr, a delay of synthesis of the main mediators (see). The delay of approach of a so-called mediator stage of development of a nervous system involves disturbances of a further differentiation of mezhneyronalny bonds and can lead to considerable losses of functions. Thus, at external wellbeing in a structure of m the in-depth study can reveal defects of metabolism and ultrastructure that, on modern views, it is also necessary to consider malformations.

Are the cornerstone of a pathogeny of malformations of G. of m mutagen and teratogens. At genetically caused diseases (see. Down disease , Fenilketonuriya ) there are delays of a histogenesis of a brain, groups of neurons drop out, forming as if gaps in a kolonkoobrazny structure of a cerebral cortex, the quantity of bast layers decreases, there are dedifferentiation neurons and glial elements, the asinapsiya is possible. Than earlier the organism faces teratogenic influence, especially heavy uglinesses of G. of m can arise. Under the influence of adverse environmental factors many newborns have these or those changes of a nervous system, but only regarding cases they have resistant character and do not disappear in process of growth. More often the most vulnerable suffer phylogenetic young departments of G. of m. G. of m is especially sensitive to infectious influences and air hunger. The heaviest changes are caused by flu, a rubella, Toxoplasmosis, listeriosis, cytomegalies and other diseases transferred mothers in the first months of pregnancy. It is experimentally proved that the anoxia and a hypoxia slow down development of a brain of a fruit. The phenomena of oxygen insufficiency can be caused by intoxications of alcoholic or any other nature, diseases in pregnant women, especially diseases cardiovascular (the inborn and acquired heart diseases) and respiratory (bronchial asthma, hron, pneumonia) systems.

The medicines used during pregnancy can become teratogens. A placenta of a pronitsayem for quinine, nicotine, opium, morphine, chloroform, Chlorali hydras, a papaverine etc. The quinine applied for the purpose of the termination of pregnancy causes micro and hydrocephaly, antibiotics — a growth inhibition of bones of a skull, deafness. Endocrine factors have significant effect. Among the children born by mothers suffering from a diabetes mellitus and a hypothyroidism, inborn uglinesses meet more often than among children from healthy mothers.

Developing of many malformations of G. of m can be connected also with ionizing radiation. Most often find hydrocephaly, a nanocephalia, a microgyria, a pakhigiriya, lack of a corpus collosum. Some immune mechanisms of a pathogeny of inborn uglinesses are installed. In an experiment considerable increase of defects of development of G. of m in fruits of animals, immunizirovanny is noted by the corresponding antigens. It is established that the high probability of the birth of children with malformations of G. of m is observed at mothers with the first blood group.

Experimental reproduction of malformations of G. of m are possible at patol, impacts on a maternal organism in the critical periods of an embryogenesis established by P. G. Svetlov. It is shown that the separate nitrozoamina entered to rats into the first half of pregnancy (during a domediatorny stage of development of a nervous system of embryos), make on them teratogenic impact. The same chemical connections entered to females into later durations of gestation (during a mediator stage of development of a nervous system of fruits), induce at posterity of a tumor of G. of m Besides, malformations of G. of m arise during the crossing of animals, heterozygous on translocations with the animals having a normal Karyotype (V. S. Baranov and L. L. Udalova, 1975), and also in some other the experiments pursuing the aim of a perversion of ancestral features (see. Medical genetics ).

Birth rate of children with malformations of G. of m sets tasks of their timely prevention. Purposeful studying of malformations of G. of m is manufactured in the USSR. Methods of inspection of pregnant women in medicogenetic consultations are developed (see).

Married couples with the adverse anamnesis (genetic diseases, microanomalies, and during pregnancy infectious and viral diseases, professional harm, spontaneous abortions) are inspected cytogenetically (a dermatoglyphics, a sex chromatin, karyotyping), biochemical with use of paper, thin-layer, ion-exchange chromatography of amino acids, proteins, carbohydrates, lipids, etc. Methods of pre-natal diagnosis are developed and implemented into practice: amniocentesis, contrast amniografiya etc. New methodical recommendations on morfol, diagnosis of inborn malformations, first of all are implemented by c. N of page. At corpses of fruits and newborns intracranial fixing of G. of m with the subsequent careful research by its various methods is made.

The group of inborn malformations of G. of the m which are combined with various defects of a skull is called kranioskhiza. Carry an acephalia, an anencephalia, a hemicephalia, an ekzezzefaliya and G.'s hernias of m to them.

Acephalia — G.'s absence of m, a calvaria and a facial skeleton — it is connected with an underdevelopment of front department of a neurotubule and structures, adjacent to it, it is often combined with defects of a spinal cord, bones, an aplasia or a hypoplasia of internals.

Fig. 22. An anencephalia in combination with extensive defect of a skullcap, a wolf mouth and a labium leporium.
Fig. 23. An anencephalia — a Cyclops: the eye hollow is located on the centerline from above, a nose aplazirovan.

Anencephalia. At an anencephalia (fig. 22) there are no big hemispheres and a skullcap at an underdevelopment of a brainstem. The anencephalia meets in the form of the isolated defect and in combination with other uglinesses. Acephalus and anentsefala, as a rule, are born the dead, die less often in several days after the birth. Pathomorphologically it is possible to reveal only separate groups of neurons and gliotsit among proliferirovanny richly vaskulyarizirovanny connecting fabric. The Teratogenetic Terminatsionny Period (TTP), i.e. time of calling of inborn defects of a brain a certain teratogen (see. Teratogenesis ), makes for an anencephalia of 3 — 8 weeks.

According to WHO data (1971), the highest frequency of an anencephalia — to 5 on 1000 childbirth. In the cities of Northern Ireland, in France, England, the USA — 3 on 1000, in the African, South American countries and in Japan — 1 for 1000. There are messages on seasonal and year fluctuations of frequency of an anencephalia. At the WHO researches conducted in Alexandria and Bombay the increased prevalence of an anencephalia in kinship marriages is established.

The anencephalia occurs at girls a little more often than at boys.

Fig. 24. Hemicephalia.

Hemicephalia — a partial underdevelopment of G. of m, at Krom the brainstem is kept, subcrustal nodes and parts of shares of hemispheres, adjacent to a trunk, are developed not completely, deformed and underdeveloped a roof of a mesencephalon and a cerebellum, disturbance of a differentiation of ganglionic cells is expressed. The skullcap usually is absent, in most cases there is no integument (fig. 24) also.

In some cases the anencephalia and a hemicephalia are combined with a cyclopia or a cyclocephalia — ugliness of development of the person, an eye. The only eye hollow is located on the centerline (fig. 23). The eyeglobe is absent or is reduced, sometimes doubled; the century is not present or they are underdeveloped. Nose aplazirovan. The skull is reduced in volume, the most part it is made by an average cranial pole. The reduced front cranial pole is not divided, and the optic nerve passes through a solitary foramen. The trellised nasal bone, a part of an upper jaw and a wedge-shaped bone, the lower nasal sink, and also the corresponding cranial nerves are absent or gipoplazirovana. Microscopically in a retina sometimes it is possible to find sockets and proliferata, same, as at to a retinoblastoma (see). The child is impractical.

Tserebrotsefaliya — option of a cyclopia (two merged orbits and the rudimentary nose located below eye-sockets). This anomaly not always is deadly. Other form of a cyclopia — cyclops hypognathus, differs in anomaly of the bottom of the person and lack of a hobotkoobrazny nose.

Exencephaly. There are no bones of a calvaria, is frequent in combination with a pakhigiriya — an excessive thickening of separate crinkles.

Partial defects of development. Porencephalia — development of the cavities in tissue of a brain extending from subarachnoid spaces to cavities of ventricles. The porencephalia (see) is caused by an inborn delay of the myelination leading to disturbance of formation of cellular layers of bark, proliferation of a glia and growth of cicatricial connecting fabric. Forecast adverse.

Hydroencephalitis — an atrophy of big parencephalons in combination with hydrocephaly; gives similar a wedge, and a pathoanatomical picture with hydrocephaly. Nevrol, symptomatology in the first days of life can be hardly noticeable. However already by the end of the first week of life symptoms of intracranial hypertensia accrue, paresis, paralyzes are shown. Big hemispheres of G. of m have an appearance of the thin-walled bubbles filled with liquid, substance of a brain no more than several millimeters thick, in white matter heterotopic nervous cells are defined. TTP for this pathology — 2 months of prenatal life.

The forecast is adverse, children perish at early age.

At agenesias can be absent or be reduced frontal, parietal, temporal and in rare instances occipital shares, a corpus collosum, a cerebellum and a trunk. E.g., an arinentsefaliya — a full or partial underdevelopment of a rhinencephalon, a prozentsefaliya — incomplete division of G. of m. If big hemispheres are not divided absolutely, then speak about a goloprozentsefaliya; this defect can be combined with a cyclopia that is, on modern representations, ugliness of autosomal and recessive character. As a rule, these anomalies are combined with multiple defects of development of a brain and skull, a nanocephalia, hydrocephaly, clinically shown by a rough delay of mental and physical development, an incoordination, paresis, paralyzes, convulsive attacks. The underdevelopment of separate educations of G. of m is quite often combined with pathology of a spinal cord. Agenesias often meet in the form of Kiari and Walker's syndromes.

The forecast at G.'s agenesias of m is serious: the lethal outcome comes on the first or second decade of life.

In combination with G.'s agenesia of m, and sometimes and independently there are defects of development of cranial nerves. More often others in clinic are observed by paralyzes of the VII couple (Möbius's syndrome) and the VI couples (a syndrome Gref). Simultaneous damages of several cranial nerves, in particular VII and VI, VII and III, III and V, and also parallel dysplasia of internals are possible. Sometimes because of an insufficient differentiation inside - and internuclear bonds there are synkineses, napr, a phenomenon of the Hun (pripodnimany centuries at the movement of a mandible). Malformations of cranial nerves do not pose a threat for life. The forecast is, as a rule, favorable.

Pakhigiriya — the wide big crinkles which are combined with insufficiently differentiated nervous cells. In comparison with norm the quantity of brain furrows is reduced. Furrows are usually small, and sometimes are absent. In these cases separate gyruses are not separated from each other. White matter of a brain is often underdeveloped. At microscopic examination — a heterotopy, disturbance of distribution of blood vessels.

Agiriya — total absence of crinkles. Often defect is combined with a porencephalia.

Makrogiriya — the moderate reduction of number of furrows which sometimes is combined with increase in volume of G. of m of Makrogiriya big wide crinkles and insufficiently differentiated cells of gray matter are inherent.

Microgyria — reduction of volume and increase in number of crinkles. Macroscopically at a microgyria of a crinkle thin, narrow, microscopically in molecular and subcrustal layers ganglionic cells of embryonal character are found.

Clinically the malformation of crinkles is shown by weak-mindedness, spastic paresis, paralyzes, spasms. The forecast is rather favorable: these anomalies do not pose a threat for life.

At accretion of twins by the area of a skull defects of bark and subjects of structures of G. of m with formation of the general circulating system of cerebrospinal liquid are possible that it is fraught with danger of death of children at operation of division.

Hydrocephaly. In 1 case on 2000 childbirth, according to Yu. V. Gulkevich, etc. (1975), meets hydrocephaly (see), edges can arise owing to teratogenic impact of a number of substances on an embryo or genetic defect.

It is necessary to distinguish a hydroencephalitis from an inborn edema of a brain and true macrocephalia (see).

See also Craniospinal anomalies .

Hernias of a brain — protrusions of covers and substance G, m through defect of bones of a skull.

According to B. A. Schwartz, G.'s hernias of m can be met in 1 case on 4 — 5 thousand, and statistically A. F. Zvereva — on 8 thousand newborns. Lobbies make 84,7% of all cases of hernias of G. of m, back — 10,6%, basal and sagittal — 4,7%.

The etiology and a pathogeny of hernias of G. of m are found insufficiently out. The existing theories connect them with defects of development of a bone or nervous system. Usually G.'s hernias of m are covered with the changed skin which is sharply thinned rubtsovo.

Depending on contents of a hernial bag distinguish several main forms: to a meningocele, entsefalotsel, entsefalotsistotsel and latent form. A meningocele — hernia of a meninx, i.e. their loss through defect in a skull with formation of the hernial protrusion filled with cerebrospinal liquid. The wall of a meningocele consists of the changed web and soft meninx covered with skin. The firm meninx does not take part in formation of this hernia of G. of m, and is attached to edges of defect of a bone from a skull. Marrow also does not participate in herniation. Entsefalotsele — in addition to covers and cerebrospinal liquid, contents of hernia is the changed brain fabric. Entsefalotsistotsele — except covers and tissue of a brain, is involved in hernial protrusion a part of an expanded cerebral cavity. Some authors in addition mark out the latent form with existence of defect of bones of a skull without ectopia of brain fabric and the chipped-off craniocereberal hernia which is not reported with a head cavity.

At gistol, a research of contents of a hernial bag find a thickening and fibrosis of a soft and web meninx, a sharp atrophy and regeneration of brain fabric. Often G.'s hernias of m are accompanied by other malformations: nanocephalia, hydrocephaly, underdevelopment of a corpus collosum, transparent partition, asymmetric development of a brain etc. Hernial protrusion can have various form and size. At the message with a head cavity through a big opening it quite often pulses. At a palpation in protrusion liquid, dense inclusions is defined. With age hernial protrusion can increase in sizes, especially it is characteristic of the hernias which are localized in occipital area.

Bone defect is always located on the centerline. Depending on localization distinguish front, back, or occipital, basal and sagittal hernias of a calvaria.

At front hernias the internal ring of the bone hernial channel is located in the field of a blind opening. On localization of an outside ring distinguish nasofrontal, nosoreshetchaty and nosoglaznichny hernias. Outside openings can be 2 — 3 that leads to emergence of the bilateral mixed hernias (N. D. Vitebsky).

Front hernias of G. of m disfigure a face and deform a facial skeleton — eye-sockets, a nose. The wrong wide arrangement of eyes because of what solid vision is absent is characteristic or it is broken, and the flattened wide nose bridge. At nosoglaznichny brain hernias, as a rule, there is a deformation and impassability of the lacrimonasal channel, often there occurs development of a dacryocystitis, conjunctivitis. At lobbies and especially at basal hernias nasal breath is complicated, the speech muffled, with a nasal shade.

Basal craniocereberal hernias are located in a cavity of a nasopharynx or a nose, by the form remind a polyp; defect of a bone is localized at the bottom of a lobby or an average cranial pole, the hernial bag bends a nasal partition.

Back hernias of G. of m divide on top and bottom, depending on an arrangement of bone defect — above or below an occipital hillock.

Nevrol, symptoms at G.'s hernias of m are defined by character and localization, in some cases can be absent, especially at newborns. At more advanced age there are complaints to headaches, dizziness, mental retardation, damage of cranial nerves, most often I, II, III, VI, VII, VIII and XII couples, asymmetry of tendon jerks, patol, reflexes is found. Paresis of extremities, choreic twitchings, epileptic seizures — focal and the general are possible. At the lower back hernias coordination frustration in extremities, disturbances of a statics and gait, the fixed position of the head quite often come to light.

Fig. 25. The patient with nasofrontal brain hernia.
Fig. 26. The patient with occipital brain hernia.
Fig. 27. The roentgenogram of a skull of the girl of 8 years with inborn nasofrontal hernia (a front semi-axial projection): roundish bone defect in the field of a bridge of the nose with dense edges — a bone hernial opening (1), flattening of medial walls of eye-sockets; lack of a frontal sinus; the soft shadow of hernia (2) closes nizhnemedialny department of the right eye-socket.
Fig. 28. The roentgenogram of a skull of the child with inborn occipital brain hernia (a back semi-axial projection): rounded shape bone defect — a hernial opening (it is specified by an arrow) in scales of an occipital bone on the centerline.

Data of the anamnesis, outer inspection, palpation and nevrol, inspections allow to make the diagnosis of hernia of G. of m. At nasofrontal hernias (fig. 25) in front department of a bottom of a front cranial pole in the field of a bridge of the nose it is possible to find a bone ring with the dense edges (fig. 27) which are often acting in the form of a visor. The tomography is necessary for detection of basal and nosoreshetchaty hernias. At back hernias of G. of m bone defect is located in an occipital bone (fig. 26 and 28) near a big occipital opening and often is connected with it. By means of a pneumoencephalography resolve an issue of a form of hernia and of its message with subarachnoid space and cerebral cavities. The pneumoencephalography is of great importance for assessment of the accompanying cerebral pathology limiting indications to operation. Lobbies and back brain hernias it is necessary to differentiate with dermoids, lipomas, angiomas, hematomas and nek-ry tumors of bones of a skull, and hernia of a base of skull — with polyps. Big help in diagnosis is given by a puncture of protrusion.

Treatment of hernias of G. of m only surgical. The question of character and terms of an operative measure is solved individually, however in order to avoid secondary complications it is necessary to operate children as soon as possible. At front hernias ekstrakranialny and intracranial operations are possible. Delete with Ekstrakranialno a hernial bag and make plastics of an outside or internal opening of the bone channel without opening of a head cavity. The Ekstrakranialny method is shown generally at small defects of a bone or at a full otgranicheniye of hernial protrusion from likvorny spaces. During the closing only of an outside opening often there is recurrence of hernias, the Liquorrhea. Therefore most of surgeons recommends to close an internal opening of the bone channel, minority — all bone channel with use of ekstrakranialny approach. A lack of ekstrakranialny operations — danger of infection of a wound in view of proximity of a nasal cavity and okolonosovy bosoms.

Fig. 29. The scheme of intracranial extradural plastics of bone defect at front brain hernia: 1 — skin; 2 — a transplant; 3 — edges of bone defect; 4 — brain hernia; 5 — the taken-in defect of a firm meninx.

The intracranial method allows to pressurize reliably a head cavity and to make plastics in the most aseptic conditions. It is shown at the hernias which are reported with a head cavity through extensive defects of a bone. Operation is made in two stages: the first — intracranial extradural or subdural plastics of defect of a bone; the second — 1 — 6 month later — excision of hernia (fig. 29).

Fig. 30. The scheme of different types of osteoplastic trepanations at front brain hernias: 1 — according to Herzen; 2 — across Ternovsky; 3 — across Svyatukhin; 4 and 5 — according to Egorov and Shishkina; 6 — according to Zverev. Light circles designated trepanation openings, by solid lines — connections of openings, dashed lines — a leg of a bone rag (fig., 1, 4 and 5); the bone rag at some types of trepanations is taken (fig., 2,3 and 6).

The intracranial plastics of an internal opening of the bone channel at front hernias was for the first time carried out by 3. I. Geymanovich in 1919 it is also described by it in 1928. In 1923 P. A. Herzen suggested to close bone defect a periosteal and bone rag from a frontal hillock. Herzen's operation underwent a number of modifications which came down to various methods of opening of a skull (fig. 30), closing of an internal opening of the bone channel, plastics of defect of a firm meninx under frontal lobes. If it is not possible to take in this defect, then make plastics water-proof penopolivinilformaly, the aponeurosis of a temporal muscle, a muscular and fascial rag taken in areas of the hip operated or a lamellar umbilical cord of a fruit of the person.

The issue of a technique of operation is resolved depending on age and the general condition of the child, a form, the size of hernia and defect of a bone, and also accompanying patol processes. At occipital hernias operation is made in one step. For plastics of bone defect use a periosteum or bone and cartilaginous transplants, and also plasts.

Children with G.'s hernias of m are in most cases viable, however without the surgical help most of patients perishes from secondary purulent complications. Most of children after operation physically and intellectually develops normally.

Damages

G.'s Damages by m can be followed by fractures of bones of a skull and meet without disturbances of its anatomic integrity (see. Contusion of a brain , Craniocereberal injury , Electric trauma ).

Diseases

divide G.'s Diseases of m on primary and secondary. Primary strike originally G. m whereas secondary are complications of pathology of other bodies and systems of an organism. On the nature of process of a disease of G. of m subdivide on allergic, demyelinating, chronically progressing and hereditary and degenerative, vascular, infectious, parasitic and opukholepodobny. Carry to G.'s diseases of m also epilepsy (see), mental diseases (see), functional diseases of a nervous system, neurosises (see).

Disorders of functions G. of m accompany neuroendocrinal disturbances, such as an addisonova a disease, an adrenogenital syndrome, a hyper aldosteronism, Itsenko's disease — Cushing, an acromegalia, Derkum's disease, an adiposagenital syndrome, a pituitary cachexia, a thyrotoxicosis, a myxedema, a tetany, a menopausal syndrome, a diabetes mellitus.

Against the background of pregnancy the chorea of pregnant women, disturbances of cerebral circulation can develop and eclampsia (see).

Defeats of a nervous system can arise at a medicinal allergy and at the toxic effect of drugs, napr, antibiotics, antitubercular drugs, neural activity stimulators, sedative substances, etc.

G. the m is surprised at poisonings with toxicants (aniline, antifreeze, carbon monoxide, etc.), and also at food toxicoinfections.

Infectious and allergic diseases of a brain hl are presented. obr. neurocollagenoses, first of all rheumatism (see). Allocate vascular and meningoentsefalitichesky forms of a neurorhematism (V. V. Mikheyev). The vascular form, a cut is the cornerstone a rheumatic vasculitis, can lead to development of a stroke, most often ischemic, hemorrhagic strokes and subarachnoidal hemorrhages meet less often. Dystrophic process in G.'s vessels of m leads to inflammatory changes of brain fabric. Depending on area of preferential defeat there is this or that a wedge, symptomatology. E.g., the hysterical chorea (see) develops at disturbance of functions of subcrustal educations. The place, the second for frequency, at rheumatic encephalitis is taken by the Hypothalamic syndrome (see). Neurosis-like states are possible. Heavier, than at a neurorhematism, disturbances of blood circulation are observed at a system kras sing to a lupus (see), the active angiitis with leukocytic infiltration and fibrinoid destruction of a vascular wall is the cornerstone of them. At a nodular periarteritis vascular frustration, wet brain, sometimes hemorrhagic encephalitis are also expressed.

Demyelinating diseases represent combined group of diseases which cornerstone the general infectious and allergic pathogenetic mechanisms and similar morfol, changes (are see. Demyelinating diseases ). The long incubation interval, the progressing current, dominance of degenerative changes over inflammatory is characteristic of these diseases. Patomorfol, substrate of demyelinating diseases — disintegration of myelin covers of pulpy fibers with substitution of the centers of disintegration by a neuroglia. From this group of diseases most often meets multiple sclerosis (see), postvaccinal encephalitis, parainfectious encephalitis, panencephalites.

Chronically progressing and hereditary and degenerative diseases include various nosological forms which are combined by steadily progressing current. The etiology of these diseases is studied insufficiently, however in some cases their genetic nature is established (see. Medical genetics ). In particular, the chorea of Gentington is inherited on dominant type, at hepatocerebral dystrophy (see) genetic defect causes insufficiency of functions of a liver with disturbance of exchange of proteins and copper. There are instructions on hereditary character of separate forms of a cerebellar ataxy, in particular Mari's ataxy (see. Ataxy ), myoclonus epilepsy (see). Carry an olivopontotserebellyarny degeneration to the same group, etc.

Vascular diseases of a brain are a cause of death, the third on frequency, after a myocardial infarction, tumors.

Stroke (see), both hemorrhagic, and ischemic, arises more often against the background of an idiopathic hypertensia (see) and atherosclerosis of arteries of G. of m. The main reason for the subshell or subarachnoidal hemorrhages is aneurism of vessels of a brain (see).

Also rheumatism and other collagenic diseases, intoxications, an injury, syphilis, meningitis, encephalitis, heart failure can be the cause of disturbances of cerebral circulation, clotting disease (see). The apoplektiformny syndrome is possible at myocardial infarction (see).

Insufficiency brain blood circulations.) it is accepted to subdivide on acute and chronic.

Allocate also passing disturbances of cerebral circulation: sharply arising disorder of functions G. of m, a cut is shown by the focal, all-brain or mixed symptomatology remaining no more days.

Infectious diseases m and its covers initially can strike G., being in this case independent nosological forms. Secondary defeats of G. of m can complicate practically all infectious diseases and local inflammatory processes.

Among infectious diseases of G. of m on the first place on frequency costs meningitis (see) — an inflammatory disease of a meninx. Usually understand preferential defeat of a soft meninx as this term. The inflammation of a firm meninx is called a pachymeningitis (see), and preferential defeat of an arachnoid membrane — arachnoiditis (see). Meningitis classifies on etiol, to a sign; e.g., spotted fever, pneumococcal, syphilitic, staphylococcal, streptococcal, tubercular; the meningitis caused by an intestinal and pyocyanic stick, leptospiry, Pfeyffer's stick — Afanasyeva, Armstrong and Lilly's viruses, the cook Saky, ECHO, etc. On a current distinguish acute, subacute and chronic, and on the nature of changes of cerebrospinal liquid — serous and purulent.

G.'s inflammation of m — encephalitis (see) on a current can be acute, subacute and chronic. On an etiology primary — virus (epidemic, tick-borne, mosquito) and encephalitis secondary, napr distinguish encephalitis, at the general infectious diseases (pneumonia, dysentery, measles, smallpox, chicken pox, a hay fever, scarlet fever, a tularemia etc.). Often at the same time there are phenomena characteristic both for meningitis, and for encephalitis. In these cases speak about meningoentsefalita. Meningoentsefalita can be primary (e.g., an acute seasonal dvukhvolnovy encephalomeningitis) and secondary (e.g., at epidemic parotitis).

Wedge, picture of such infectious neurotropic diseases, as rage (see), tetanus (see) and poliomyelitis (see), it is in many respects caused by G.'s defeat in m.

Abscess of a brain — the accumulation of pus in substance of m delimited by the capsule. Formation of abscess is permanently connected with penetration of the infectious agent into marrow from any suppurative focus in an organism or from the environment.

On mechanisms and ways of development G.'s abscesses of m can be subdivided into the infections arising from suppurative focuses in the neighbourhood by distribution on continuation of per continuitatem, metastatic hematogenous and traumatic. Abscesses of the first group are more often otogenic. Less often abscesses at suppurative focuses in soft tissues of the head meet rhinogenic, orbitogenny, osteomiyelitichesky, in a mouth and a throat. Metastatic abscesses of G. of m meet by 2 — 3 times less than abscesses of the first group. The most frequent reasons of their emergence: the malignant endocarditis, purulent processes in lungs, a bronchietasia, is more rare — abscesses in other bodies, osteomyelitis of tubular bones, phlegmon etc. Despite prevalence of suppurative processes in various bodies and fabrics, metastatic abscesses of a brain are rather rare. By data I. Ya. Razdolsky, among all abscesses of G. of m they make about 25%. The quantity of traumatic abscesses of G. of m is defined by the frequency of wounds of the head. Therefore in wartime they dominate. During the Great Patriotic War traumatic abscesses accompanied 12,2% of all getting wounds of a skull; 80 — 85% of abscesses developed after missile wounds. Due to the sharp increase in transport traumatism of a close attention abscesses after fractures of bones of a skull of lobnonosoglaznichny area deserve.

Fig. 31. A horizontal section of a brain with abscesses in a frontal lobe (are specified by shooters).

From pus of not traumatic abscesses sow staphylococcus, streptococci and pneumococci more often. The myceflora of otogenic abscesses often consists of two and more species of bacteria; in metastatic abscesses flora is more often monomicrobic. Flora of traumatic abscesses of G. of m depends on age of abscess: the more time passed from the moment of wound, the it is less than pathogenic anaerobe bacterias, hemolitic streptococci, and, on the contrary, the more often emit colibacillus and especially staphylococcus. Kapsuloobrazovaniye and the wedge, a current substantially depend on structure of flora. Especially powerful capsule forms at staphylococcal infection. M can be localized G.'s abscesses in any departments. Otogenic abscesses generally are located in a temporal share or in hemispheres of a cerebellum. Metastatic abscesses usually arise in frontal (fig. 31), a parietal or occipital lobe; traumatic abscesses are localized in the place of traumatic defeat on the course of the wound channel and in the field of an arrangement of the foreign bodys which got into a brain, first of all bone fragments. Abscesses more often happen single, but quite often happen multiple, especially hematogenous and traumatic.

G.'s abscesses of m generally at people of young and middle age develop, often occur at children. Both traumatic, and not traumatic abscesses meet at men more often.

Wedge, a picture includes obshcheintoksikatsionny, all-brain and focal symptoms. The distinction of combinations of these groups of signs and their expressiveness determined by the volume and the nature of abscess of G. of m, extent of perifocal reactions and formation of the capsule, features of the activator, a condition of an organism in general results in variety of types a wedge, courses of a disease.

In clinic of abscess of G. of m staging of formation can be reflected it is purulent - focal process, however the accurate sequence of phases of development comes to light not always. Rather frequent option wedge, currents: slowly, the indisposition gradually accruing, the headache, nausea and vomiting join Krom. On such background appears or if earlier there was G.'s injury of m, the focal symptomatology accrues. The second option of a current is characterized by the acute beginning — emergence of signs of the increased intracranial pressure. Further the light periods with the periods of a sharp aggravation of symptoms at increase of focal symptomatology alternate. Quite often the wedge, a picture of not traumatic abscesses of G. of m or early abscesses of a traumatic origin proceeds as focal purulent encephalitis. Frequent the first symptom of abscesses of G. of m, especially traumatic, developing of focal or general convulsive attacks which throughout sometimes considerable time remain the only symptom is. Further all-brain and focal symptoms join. At elderly people abscesses can sometimes be shown as a brain stroke.

Carry to obshcheintoksikatsionny symptoms of abscesses of G. of m: an indisposition, small appetite, the increasing pallor, temperature increase. In blood in an acute stage the leukocytosis comes to light, and at a sluggish current — the accelerated ROE; at patients with especially heavy picture of a disease the monocytopenia and a lymphopenia, reduction of quantity of eosinophils can come to light.

The most frequent symptom of late abscesses of G. of m — the headache which mostly have constant character, sometimes with attacks of a sharp aggravation. Vomiting — rather constant symptom of abscess of G. in m and the most part arises at height of an attack of headaches; quite often it is preceded by nausea. Only single vomiting at the beginning of a disease is sometimes noted. A frequent sign of increase in intracranial pressure at G.'s abscesses of m is the revealed constant or the bradycardia arising only during a hypertensive attack.

Existence or lack of congestive changes of an eyeground to a large extent depends on rate of increase of intracranial hypertensia. Stagnation usually arises at rather bystry and substantial increase of intracranial pressure. Stagnation is absent or at very rough increase of the phenomena when changes on an eyeground do not manage to develop, or, on the contrary, at slow, gradual when compensatory mechanisms for a long time prevent its development. Hypertensive changes in bones of a skull reveal, as a rule, only at not traumatic abscesses (see. Hypertensive syndrome ). The research of cerebrospinal liquid in assessment a wedge, conditions of patients with G.'s abscesses of m has a certain value. So, at corticosubcortical or their paraventrikulyarny localization in it the amount of protein quite often with a lymphocytic pleocytosis and a small amount of neutrophils often increases. Increase in cells in cerebrospinal liquid is usually combined with emergence of meningeal symptoms and is a symptom of the menacing opening of abscess. At traumatic abscesses, especially early, in the field of wound defect of a skull tension and protrusion of a brain appears; its pulsation decreases or disappears. Sometimes at patients with G.'s abscesses of m in the field of a post-wound and postoperative hem fistula comes to light, from to-rogo pus is emitted. Sometimes it so is not enough that about purulent fistula it is possible to judge only by existence of a constant crust on a part of a hem.

At most of patients before emergence of focal and all-brain symptoms disturbances of mentality come to light. Originally there are preferential neurotic frustration: irritability and capriciousness, affective lability and tearfulness, general weakness and increased fatigue, indisposition and loss of appetite.

In a stage of the developed picture of a disease mental changes gain looking alike of a darkness which are characteristic of G.'s tumors of m. Drowsiness and an oglushennost increase, perception and comprehension of the events is complicated around, the attention and ability to concentrate is weakened, the speech, motility and all mental processes are slowed down and complicated, apathy and depression prevail, memory, in particular storing and a reproduction of materials necessary at present is reduced.

At a progreduated current of a basic disease the oglushennost accrues to a soporous state, there are acute psychotic episodes of exogenous type (delirious conditions, conditions of amental confusion, twilight states) and the epileptic excitement accompanied with usually epileptic seizures. Numerous change of apathetic states or conditions of the dulled consciousness by acute psychotic episodes is characteristic of G.'s abscess of m.

Rather exceptional cases of a disease proceeding with catatonic and shizofrenopodobny frustration in which genesis constitutional factors play an essential role are described.

At a sluggish current long depressive and hypochiondrial syndromes, vyaloadinamichesky depressions, conditions of apathy, an adynamy or irritable weakness which at an aggravation of a basic disease can be replaced by progreduated development of an oglushennost or acute psychotic episodes are possible.

At break of abscess in cerebral cavities there are acute mental disturbances with confusion, sharp psychomotor excitement, soporous or coma, high temperature and the meningeal phenomena. On their background, as a rule, quickly there comes the lethal outcome. At multiple abscesses acute mental disorders — a condition of amental confusion, epileptic excitement, development of an anamnestic disorientation or bystry increase of an oglushennost also prevail. Localization defines character of focal symptomatology. In dynamics of a disease focal symptoms can change. The originality of dynamics of focal symptoms at development of late traumatic abscesses is that in a wedge, a picture process of compensation of the functions lost as a result of wound is combined with progressing a wedge, the phenomena caused by formation of abscess. Secondary focal symptoms — result of shift of a brain join the primary and focal symptomatology caused by immediate effect on adjacent fabric at increase in intracranial pressure (see Dislocation of a brain). Some mental disorders are connected with localization of process; e.g., at abscesses of frontal lobes moriapodobny excitement or vyaloapatichesky aspontanny states often meets.

Fig. 32. Angiogram of a brain, venous phase; vascular network (it is specified by an arrow) capsules of abscess of the right frontal lobe.

Diagnosis is based first of all on the accounting of dynamics a wedge, the phenomena, existence is purulent - focal processes in an organism or the getting craniocereberal wound. At not traumatic abscesses X-ray inspection often allows to reveal symptoms of intracranial hypertensia, and at traumatic — to judge the size, an arrangement and a condition of edges of wound defect, existence, character and a depth of foreign bodys. Sometimes it is possible to reveal moving of a foreign body to cavities, accumulation of gas or calcification of the capsule. Shift in the party opposite to abscess fiziol is possible. calcifications of strobiloid gland and limy inclusions in a crescent shoot. A special role in diagnosis is played by the cerebral angiography (see) allowing to reveal the shift of vessels, existence of the avascular site, uniform contrasting of a zone of a vascular frame of abscess in a capillary and early venous phase (fig. 32), the general and regional delay of a blood-groove. A pneumoencephalography without removal of cerebrospinal liquid (see. Encephalography ), a ventrikulografiya with air and positive contrast mediums (see. Ventrikulografiya ) on character of shift and defect of filling of ways of circulation of cerebrospinal liquid allow to judge an arrangement of abscess. Unconditional confirmation of the diagnosis is the puncture of abscess, extraction from a cavity of pus and the subsequent abstsessografiya (see), allowing to define precisely localization, the sizes and a form of abscess.

Are important for diagnosis an ekhoentsefalografiya (see) and an electroencephalography (see), especially in dynamics, and also the radiological research revealing accumulation of isotope in the capsule of abscess.

Fig. 33. Abscesses of a brain with the eumorphic capsule (remote it is total).

Preservation of life by the patient without operative measure is almost impossible. In a wedge, practice three methods of treatment are applied. The most radical and effective is total removal of abscess with the capsule. However this method is applicable only at rather created capsule (fig. 33), resectable localization and the corresponding condition of the patient. The method of opening and drainage of a cavity is applied in cases when total removal is impossible: at badly created capsule, at an arrangement in hardly accessible area, at the condition of the patient excluding a possibility of more radical intervention, napr at generalization of an infection. By quite often puncture method of patients prepare for radical operation.

At serious condition of the patient and the expressed picture of the accompanying encephalomeningitis it is reasonable to surgical intervention to premise intensive antiinflammatory treatment. However if within several days of noticeable improvement does not come, then further waiting is inadmissible and it is necessary to resort to a puncture or opening of an abscess cavity.

In the postoperative period carry out antiinflammatory and dehydrational therapy (see) since the accruing hypostasis and dislocation of a brain, development of purulent meningitis is the main reason for death.

The lethality at surgical treatment depends on the sizes, depth of an arrangement and a stage of formation of abscess of G. of m, expressiveness of the accompanying inflammatory changes, intensity of perifocal hypostasis and brain swelling and, of course, correctness of the choice of a method of operational treatment. About a half of the patients who successfully transferred operational treatment keeps working capacity.

Prevention of abscesses of G. of m consists in timeliness and correctness of treatment of primary purulent processes, and at craniocereberal wounds — in full value of roughing-out of a craniocereberal wound (see. Craniocereberal injury).

Infectious granulomas of G. of m. development of the centers of a specific inflammation of G. of m is result. Granulomas of tubercular and syphilitic genesis meet more often.

Tuberculoma. G.'s tuberculoma of m represents quite frequent form of defeat of a nervous system at tuberculosis, meeting, according to various authors, in 0,87 — 8,8% of diseases of tuberculosis and in 12,2% of tubercular defeats of c. N of page. Among the verified intracranial new growths there are tuberculomas (see) are found in 3,8%. Occur at children of a tuberculoma of G. of m by 7 — 10 times more often than at adults.

G.'s tuberculoma of m is connected with hematogenous spread of an infection from primary tuberculous focus. The most frequent source of an infection — affected with tuberculosis easy and peribronchial limf, nodes, is more rare the centers in bones. Formation of a solitary tubercle happens due to merge of miliary hillocks which quantity in the created tuberculoma can be from 3 — 5 to 20 — 40 and more.

Multiple tuberculomas make 35% of all solitary tubercles and meet at children more often. Macroscopically G.'s tuberculoma of m consists of tumorous nodes of yellowish-gray coloring, a dense consistence. Its size depends on a stage of development. At early stages it usually small, on late — large; average to dia. 0,5 — 1 cm. Microscopically in the issued tuberculoma it is possible to allocate three zones which are indistinctly delimited from each other: central, formed by the centers of a caseous necrosis, a belt of granulyatsionny fabric and a zone of a perifocal inflammation. Tuberculomas can be exposed to calcification. In the absence of calcification there is a caseous softening. It can lead to purulent disintegration and transformation of a tuberculoma into tubercular abscess. In certain cases G.'s tuberculomas of m can be a source hron, a pia-arachnitis and or acute tubercular meningitis.

The disease usually begins with a prodromal stage, duration to-rogo widely varies, averaging 1 — 2 month. The first wedge, manifestations: general weakness, slackness, astenisation, disorders of behavior, block, tearfulness, irritability. The beginning of a disease can be acute (rough increase of symptomatology) and subacute with the long asymptomatic period and slow progressing of separate displays of a disease. Initial manifestations depend on localization. At supratentorial tuberculomas the beginning is shown by focal symptoms of irritation in the form of convulsive attacks and hallucinations. At subtentorial localization the beginning differs in early all-brain symptoms: headache, dizziness, vomiting, and also congestive nipples of optic nerves. At children in connection with blocking of ways of circulation of cerebrospinal liquid symptoms of hydrocephaly can be shown at early stages of a disease.

Character of focal symptoms depends on localization. At localization of process in frontal area there are disturbances of memory, attention, behavior. Localization in the central crinkles and near them leads to sensitive and motive frustration and epileptiform attacks. Early symptoms of defeat of subcrustal nodes are disturbances of a muscle tone, the violent movements. Extrapyramidal symptoms arise at late stages of a disease. Tuberculomas of hypothalamic area are followed by endocrine and exchange frustration at unsharply expressed symptoms of intracranial hypertensia. Localization in the area a chetverokholmiya and legs of a brain gives alternating syndromes, an ataxy, bilateral defeats of third cranial nerves, paralysis of a look. Cerebellar symptoms, in particular disturbance of balance, at tuberculomas of a leg of a brain (area of a red kernel) meet seldom and are not specific to this localization. An early symptom of tuberculomas of the bridge of a brain and an upper part of a myelencephalon — paresis of the taking-away and facial nerves. Further there are paresis or paralyzes of the lower extremities on the opposite side (alternating syndromes of Miyyar — Gyublera and Fovill). In process of growth of tuberculomas in the caudal direction bulbar symptoms join. The static and locomotory ataxy, disorders of coordination tests, vestibular disturbances are inherent to tuberculomas of a cerebellum.

Current of tuberculomas usually chronic. Remissions are more often observed at subtentorial localization.

The diagnosis is made on the basis of the anamnesis (existence of tuberculosis, drift, remissions), and also data of clinic, a X-ray analysis, electroencephalography, ekhoentsefalografiya. The differential diagnosis should be carried out with tumors of a brain, gummas, neuroinfections.

Treatment is surgical, before an operative measure apply dehydrating therapy, massive doses of streptomycin, PASK, Tubazidum. In the postoperative period continue specific antitubercular and fortifying treatment.

The forecast is serious: in far come cases of change from a nervous system are irreversible.

Gumma — inflammatory education at tertiary syphilis (see). Develops, as a rule, in a firm meninx, but further passes to soft. Gummas happen isolated (in isolated cases) and multiple. Are localized on the basis or a convex surface, is more rare in substance G. of m. The sizes of gummas vary over a wide range — from several millimeters to several centimeters. Big gummas meet seldom since their growth stimulates the fibrosis detaining further development. Color and a consistence of gummas differ at different stages of development. In the beginning solitary gummas have an appearance of grayish-red small knots of a soft consistence. The central part is presented by kleeobrazny weight, peripheral consists of the granulyatsionny fabric constructed of polymorphic lymphoid, plasmatic and epithelial cells of irregular shape with a small amount of colossal cells. In vessels inflammatory and infiltrative changes are visible (endo-and a perivasculitis, gummous arteritis and phlebitis). Further the gumma can undergo disintegration.

Fluidifying of a gumma and disturbance of food cause a softening of surrounding brain fabric and a further atrophy. Regenerative processes lead to growth of connective tissue elements, promote calcification and formation of dense cicatricial fabric. The gumma becomes dense and gains white color.

The clinic of a gumma of G. of m has much in common with the growing tumor. Intracranial hypertensia causes all-brain symptoms. Focal signs depend on localization. At an arrangement of a gumma on the basis of G. of m there are symptoms of damage of cranial nerves, and at localization on a convex surface of hemicerebrums — attacks of focal epilepsy. Mental disorders are defined by the size and localization of a gumma. At multiple defeat the picture of dementia can develop. At the big gummas causing increase in intracranial pressure, mental changes remind disturbances at G.'s tumors of m (various degrees of stupefaction, psychoorganic syndromes).

The diagnosis is made on the basis of the anamnesis, a wedge, yielded and results of laboratory researches (positive Wassermann reaction in blood and cerebrospinal liquid, a syphilitic tooth on curve reaction of Lange, supertension of cerebrospinal liquid, proteinaceous and cellular dissociation, sometimes with a small pleocytosis of lymphocytic character).

At a X-ray analysis expansion of an entrance to the Turkish saddle, increase in manual impressions comes to light. The differential diagnosis should be carried out with tumors, tuberculomas, arachnoidites (I eat.). The main criteria — the anamnesis and serol, reactions. Carry sometimes out trial treatment by iodide drugs — biyokhinoly — in combination with a penicillin therapy. Lack of accurate therapeutic effect during 3 — 4 weeks testifies against a gumma. Trial therapy is carried out carefully (in order to avoid bystry disintegration of a gumma), since small doses with gradation on big.

Treatment specific — antisyphilitic. Lack of effect of conservative therapy, the progressing intracranial hypertensia, deterioration in the general condition of the patient serve as the indication to an operative measure.

The forecast is serious. The disease can end letalno.

Parasitic diseases. Cysticercosis of a brain is caused by larvae of a pork tapeworm (Taenia solium). Meets in 74,5 — 82% of cases at cysticercosis (see), making 1 — 1,3% among all volume intracranial processes. In patomorfol, a picture in an initial stage of a disease widespread vascular disorders with the phenomena of a staz, thrombosing, perivascular hemorrhages dominate. In late stages into the forefront the phenomena of a productive inflammation in marrow and covers act.

Fig. 34. A horizontal section of a brain with multiple cysticercosis (it is specified by shooters).

Allocate four main forms of a disease: cysticercosis of big hemispheres, ventricular system, the basis of a brain and the mixed form. Usually defeat happens multiple (fig. 34). The periods of an aggravation are replaced by remissions that is connected with a development cycle of a parasite and aggravations of aseptic inflammatory process.

Multifocal epileptic seizures, polymorphic and labile mental disturbances are characteristic of cysticercosis of big hemispheres of G. of m. Focal symptoms of loss are usually softly expressed, mnogofokalna, often bilateral. The phenomena of irritation of a meninx in the form of a headache and meningeal symptoms are natural. At cysticercosis of ventricular system the fourth ventricle most often is surprised. A wedge, manifestations are connected with disturbances of a likvorotsirkulyation and irritation of formations of a rhomboid pole. Forced position of the head, brunsovsky attacks, and at late stages of a disease — an occlusal syndrome are characteristic (see). Cysticercosis of the basis of G. of m is clinically shown by a syndrome of a basal pia-arachnitis, temporal epileptic seizures, development of an optokhiazmalny arachnoiditis (see), defeat II, III, IV, V, VI pairs of cranial nerves. At fusion of outflow tracts of cerebrospinal liquid at the level of a back cranial pole in a wedge, a picture the occlusal syndrome can dominate. At the mixed form of cysticercosis the specified symptom complexes are combined in various combinations.

Diagnosis is based on complex assessment of a number of characteristic signs: the remittiruyushchy course of a disease, polymorphism and dynamism nevrol, symptoms, in a cut dominate the expressed symptoms of irritation of covers of G. of m, the fluctuating lymphoid and neutrophylic cytosis in cerebrospinal liquid, sometimes with existence of eosinophils, positive RSK of blood and cerebrospinal liquid with tsistitserkozny antigen (Bobrov's reaction — Vozna), existence of calcifications in hypodermic cellulose and various bodies, existence in Calais of eggs of a pork soliter, anamnestic instructions on a disease of a tape worm.

Conservative specific treatment does not exist; symptomatic therapy includes anticonvulsant, sedative, antiallergenic and dehydrational means. Operational treatment comes down to removal of parasites, separation of the shell unions, recovery of ways of circulation of cerebrospinal liquid. At defeat of ventricular system operation is urgentny.

The forecast at G.'s cysticercosis of m is defined by plurality of defeat, localization of parasites and extent of reactive changes in a meninx.

Fig. 35. A frontal section of a brain with a multiple echinococcosis (it is specified by shooters).

Echinococcosis of a brain is caused by larvae of an echinococcus (Echinococcus granulosus). Meets in 0,22 — 1,9% at an echinococcosis (see). The single-chamber echinococcus of G. of m represents spherical shape a cyst of whitish color, to dia. 0,1 — 15 cm, the volume of its contents can reach 700 ml. The wall of a cyst consists of an outside chitinous cover, from within covered by a germinal layer; the last is a source of development of affiliated bubbles and a scolex which growth happens towards a cavity of a cyst. The Echinococcus alveolaris in G. of m (fig. 35) represents a conglomerate of the small sizes (from wheat grain to dia. 5 — 7 mm) of the bubbles united in a uniform node intermediate connecting fabric. Growth of an Echinococcus alveolaris happens due to formation of affiliated bubbles out of a cavity of primary cysts in the direction to the periphery. At a single-chamber echinococcus around a cyst the reactive zone, the most outside departments a cut is usually well differentiated are presented by rather narrow belt of a glial hyperplasia and hypostasis. At an Echinococcus alveolaris the reactive and inflammatory phenomena in surrounding fabrics are sharply expressed and have the nature of perifocal encephalitis with a belt of a softening of marrow around an echinococcal node up to 1,5 cm wide. The course of a disease remittiruyushchy owing to periodic aggravations of perifocal inflammatory process, fluctuations of volume of a cyst and dynamic disturbances of blood circulation.

The clinic consists of the accruing symptoms of increase in intracranial pressure more often, at a single single-chamber echinococcus focal symptoms can not come to light a long time. At localization in motive and speech zones the first symptoms of a disease — focal epileptic seizures are more often. Symptoms of loss develop gradually at later stages of a disease. At frequent localization of a single-chamber echinococcus in cerebral cavities in a wedge, a picture into the forefront symptoms of disturbance of circulation of cerebrospinal liquid act. The Echinococcus alveolaris in most cases happens metastatic, multiple. Its clinic has much in common with single-chamber, but, unlike the last, epileptic manifestations, sometimes jaundice, exhaustion of patients as a result of primary damage of a liver are rather more often observed. At sub - and an epidural arrangement of an echinococcus atrophic changes in bones with their local thinning are characteristic that at a palpation of a skull is followed by feeling of «a crunch of parchment». In certain cases the course of a disease is complicated by a rupture of an echinococcal cyst with receipt of its contents in subarachnoid space and cerebral cavities. Sometimes the cyst of an echinococcus is abscessed and breaks in the subshell spaces, causing a symptom complex of an encephalomeningitis and a ventrikulit.

At diagnosis consider the remittiruyushchy course of a disease, the fluctuating character of focal symptoms and symptoms of shell and radicular irritation, existence of ring-shaped intracranial calcifications and local atrophic changes in bones of a skull, positive reaction of Kasoni, the Echinococcosis of other bodies, jaundice, the general exhaustion.

Treatment only surgical. The main method is total removal of a parasite. Puncture methods (repeated suction of contents of a cyst and washing by its parazitotsidny liquids — usually 1% solution of formalin) are counted on death of a parasite with the subsequent his organization. This method is auxiliary and is used as a temporary measure at accidental detection of an echinococcal cyst during a diagnostic ventriculopuncture when there are no conditions for immediate intracranial operation. At a multiple echinococcosis of G. of m decompressive operation can be made for reduction of intracranial hypertensia.

The forecast is defined by plurality of defeat, localization of parasites, reactive changes in a meninx. Usually it is worse at a multichamber echinococcosis. During total surgical removal of single parasites there occurs recovery.

Fig. 36. The bubble of a tsenur removed from a brain: on an inner surface white spots — a scolex (are specified by shooters).
Fig. 37. The basis of a brain with racemose bubbles of a tsenur in its covers.

Coenurosis brain is caused by a larval form of tape helminth — a tapeworm of a mozgovik (see the Coenurosis). Tsenur G. of m represents the thin-walled bubble filled with liquid. The wall consists of a periblast (cuticle) and internal (germinal), from to-rogo the scolex turned in a cavity of a bubble (fig. 36) develops. In marrow and cerebral cavities single large bubbles, in the subshell spaces — racemose accumulations of small bubbles (fig. 37) usually meet. Around a parasite there is always a zone hron, a reactive inflammation, in ventricles — a picture of a productive ependimatit, in covers of the basis of a brain — the phenomena rough hron, a pia-arachnitis, is frequent with fusion of outflow tracts of cerebrospinal liquid.

The clinical picture of a coenurosis of G. of m consists of the general and focal brain symptoms connected with localization of a parasite, inflammatory changes in marrow and covers, and also the general toksiko-allergic reactions of an organism.

Diagnosis is very difficult. Long headaches and congestive nipples of optic nerves at the persons who are living in areas of sheep breeding and having close contact with dogs at increase in protein content and a pleocytosis in cerebrospinal liquid, in the presence of the phenomena of the closed edema of a brain, «spottiness» at a tsisternografiya with mayodily in basal subshell spaces allow to assume a cerebral coenurosis.

Treatment only surgical: removal of parasitic cysts, separation of the shell unions and recovery of outflow tracts of cerebrospinal liquid.

The forecast is defined by plurality of defeat, localization of parasites and extent of reactive changes in a meninx.

Schistosomatosis brain causes a shistosom — a parasite from flat worms (see. Shistosomatoza ). According to WHO data (1959), on the globe was ill the general schistosomatosis apprx. 150 million people. Frequency of defeat of G. of m a schistosomatosis among other defeats makes 2,3 — 4,3%.

The direct way of defeat when the parasite gets into G. of m through a venous blood stream is possible and lays eggs in brain veins, and indirect, embolic, a way, at Krom of egg get to brain vessels through a system blood stream. The main pathogenetic mechanisms consist in reaction of marrow to mechanical and toxic action of a parasite with edematization and local necroses. Macroscopically patomorfol, the picture is characteristic of parasitic abscess of a brain and is similar to a tuberculoma and a gumma.

The clinic and a current depend on intensity of defeat and degree of reactivity of an organism. Allocate four main forms: acute cerebral, hron, G.'s defeat m with focal granulematozny or diffusion embolic process, symptomatic psychosis and the system portal encephalopathy similar to encephalopathy at laennekovsky cirrhosis. Incubation interval of 3 — 12 weeks. The prodromal stage is shown by fever, dyspepsia, cough, allergic reactions (skin rash, a Quincke's disease). The main brain symptom — epileptic seizures.

Diagnosis is based on indications on stay in the endemic area, existence of the prodromal phenomena, detection in Calais of eggs of a shistosoma, a considerable leukocytosis and big percent of eosinophils in peripheral blood, characteristic changes of a mucous membrane of a large intestine (the thickening of a mucous membrane of direct and sigmoid guts, inflammatory infiltrates, ulcers and papillomas defined at a rektoromanoskopiya), positive RSK with the antigen prepared from a liver of the infected mollusks.

Treatment is carried out by drugs of antimony. Specific conservative therapy should be begun as soon as possible. Surgical intervention is undertaken in the cases proceeding with rough focal symptoms, focal epileptic seizures and high intracranial hypertensia. Operation consists in enucleating in the stupid way of parasitic granulomas.

The forecast at early recognition and timely begun specific treatment favorable.

Paragonimiasis brain is caused by a pulmonary trematode. Meets in 30 — 60% of all cases paragonimiasis (see) and at most of patients arises against the background of damage of lungs or after it. It is possible that eggs of a parasite get to G. of m from lungs in the hematogenous way, or young parasites migrate from a chest cavity on perineural and perivascular ways. In a pathogeny the important place is taken by vasculites with obstruction of brain vessels eggs of a parasite and the subsequent development of ischemic strokes. Patomorfologiya consists of the phenomena hron, an arachnoiditis, parasitic granulomas and the encapsulated abscesses.

A wedge, manifestations depend on a variety patomorfol, changes, localization of defeat, its plurality. They are similar about a wedge, a picture of other parasitic diseases of G. of m (e.g., cysticercosis), however symptoms of loss (paresis, paralyzes) at a paragonimiasis are usually expressed more sharply. During a disease distinguish two stages — acute, duration from several weeks to several months, and chronic, lasting many years.

Diagnosis is difficult since symptoms are often atypical and imitate many other diseases. The main criteria of the diagnosis — the instruction on residence in the endemic area, detection of eggs of a trematode in a phlegm, excrements less often in cerebrospinal liquid, calcifications on kraniogramma and uneven blackouts in lungs on roentgenograms, positive RSK of blood with antigen from a pulmonary fluke.

Conservative specific therapy is carried out by emetine, prontosil, chloroquine, hlorokhinemetiny, bitionoly (emetine and bitionol enter into a carotid artery). Surgical treatment is shown in cases of existence of the limited centers of irritation or loss. The purpose of an operative measure — removal of limited abscesses and cerebral decompression.

The forecast depends on massiveness of parasitic damage of a brain.

Trichinosis brain causes round Trichinella spiralis helminth (see. Trichinosis ). Patomorfol, a picture consists of the phenomena of not purulent encephalomeningitis, granulematozny small knots in substance G. of m and rough vascular changes with perivascular infiltration, proliferation of an endothelium, a thrombogenesis in small vessels.

The clinical symptomatology very of a polimorfn has also no peculiar features. It consists of headaches, mental disturbances, sometimes focal symptoms of irritation or loss. Symptoms of increase in intracranial pressure usually are absent.

The diagnosis proves accession nevrol, symptoms to a picture of the general trichinosis.

Specific means for conservative treatment do not exist. With success use corticosteroids (a cortisone, AKTG, Prednisolonum). Due to the diffusion of defeat and lack of increase in intracranial pressure surgical treatment is not shown.

The forecast is defined by plurality of defeat, extent of reactive changes of brain fabric and covers.

Amebiasis brain is caused by the elementary Entamoeba histolytika (see. Amebiasis ). Frequency of defeat of G. of m at an intestinal amebiasis reaches 8,1%. Pathomorphologically G.'s amebiasis of m in an acute stage represents a picture of a purulent encephalomeningitis with focal abscessing; in late stages there can be abscesses with the eumorphic thick capsule.

Clinical manifestations: symptoms of irritation of covers, increase in intracranial pressure, existence of focal symptoms and a pleocytosis of cerebrospinal liquid against the background of the elevated temperature, anorexia, diarrhea, falling of weight.

Treatment in the presence of accurate local symptoms and symptoms of intracranial hypertensia surgical — abscess is deleted entirely together with the capsule by the accepted technique.

The forecast during total removal of abscess favorable.

Tumors

Classification

classify G.'s Tumours of m:

1) on localization; 2) on gistol, to type; 3) on degree of a zlokachestvennost.

Classification of tumors by localization is given in the International classification of diseases of WHO.

The clinic uses various specially made classification schemes. Usually divide G.'s tumors of m into intracerebral (intratserebralny) and extra brain (ekstratserebralny); carry to the last tumors of a meninx, roots of cranial nerves, a cranyopharyngioma, the majority of the tumors growing into a head cavity from his bones and adnexal cavities. But to the place of emergence distinguish primary tumors and secondary (metastasises from other bodies and the tumors growing into a head cavity).

Classification on gistol, to type and degree of a zlokachestvennost of tumors in process of neurooncology changed. Division according to external symptoms of a tumor (fleshiness, sliminess, etc.) existed before opening of a cell. The foundation of division of tumors by the histologic nature was laid by R. Virkhov who opened a glia and separated gliomas from sarcomas of a brain. Division of tumors according to belonging of their cells to this or that direction and a stage of maturing of nervous tissue in an embryogenesis (dizembriogenetichesky, or dizontogenetichesky, classification) arose because of the theory of Kongeym assuming that tumors come from the embryonic cells which lingered on this or that stage of the development. Bailey's classifications — Cushing (P. Bailey, H. W. Gushing, 1926), Ostertaga (B. Ostertag, 1941), L. I. Smirnova belong to dizembriogenetichesky (1940, 1951). Division of tumors according to a histogenesis (gistol, the nature) cells from which there was a tumor, and in separate gistogenetichesky groups — on degree of a cataplasia, or dedifferentiation, a zlokachestvennost (gistobiol. classification), is based on idea of development of the majority of tumors of G. of m of cells of mature fabric, but not from embryonal rudiments. Refer J. W. Kernohan's classifications to this group et al. (1949), Ringerttsa (N. Ringertz, 1950), Henshena (F. Henschen, from 1951 to 1955), B. S. Hominsky (from 1954 to 1969), Tsyulkh (To. Ziilch, 1971). In the majority of classifications primary division of tumors according to belonging of their cells to derivatives of this or that germinal leaf is used (e.g., neuroectodermal tumors, mesodermal etc.).

International gistol, classification of tumors of G. of m is just developed. Bailey's classifications — Cushing, L. I. Smirnov, J. W. Kernohan, Ringertts, Tsyulkh, B. S. Hominsky are most widespread.

Table scheme 2. CLASSIFICATION of NEUROECTODERMAL TUMOURS (according to Bailey and Cushing, 1926). Note: in small print names of cells, more in large print — names of tumors are provided.

Bailey and Cushing according to the dizembriogenetichesky concept in systematization and the name of neuroectodermal tumors followed modern to them the scheme of transformation of a multipotentny embryonic cell — a medullary epithelium — in separate types of cells of mature nervous tissue: the neuron, an oligodendroglyocite, an astrocyte, an ependimarny epithelium, an epithelium of a horioidny texture, pineotsit. Names of tumors repeat generally names of cells from which the tumor came (tab. 2). E.g., from bipolar spongioblasts, unipolar spongioblasts, astroblasts, astrocytes there are respectively a multiformny spongioblastoma, a unipolar spongioblastoma, an astroblastoma, an astrocytoma. Ranks of tumors beginning with a medulloepithelioma were allocated with such way: choroidal (horioidny papilloma); pineal (a pinealoma — a pinealoma); ependimny (a neuroepithelioma — a multiformny spongioblastoma — a unipolar spongioblastoma — an astroblastoma — an astrocytoma fibrillar and protoplasmatic); ganglionic and cellular (a neuroblastoma — a ganglioneuroma); oligodendroglialny (a medulloblastoma — an oligodendroglioma). It was supposed that the zlokachestvennost of a tumor strictly is defined by the place taken by it in a long line — from the highest at the beginning of a row to the lowest in its end. Despite an inaccuracy of the dizembriogenetichesky concept, Bailey's classification — Cushing in the main truly reflected real grouping of tumors of G. of m on their histogenesis and a zlokachestvennost. It is explained by the fact that cells of some neuroectodermal tumors really sometimes find lines morfol. looking alike embryonal. However the reason of similarity not in identity, and in insufficient differentiation as those, and other cells. Distribution of classification of Bailey — Cushing was promoted by the description accompanying it a wedge. - morfol, types of tumors of G. of m, based on existence of bonds between gistol, the nature of a tumor, its localization, the nature of growth, growth rate and a wedge, manifestations. In the subsequent Bailey and Cushing changed a little and simplified the classification. So, the term «multiformny spongioblastoma» was replaced with the term «multiformny glioblastoma», the terms «ependymoma» and «ependymoblastoma» are integrated under one name «ependymoma».


Ostertag tried to connect in the classification selectivity of places of damage of a brain by a tumor with complex processes of formation of c. N of page in ontogenesis.

L. I. Smirnov's classification (1940, 1951) is characterized by the aspiration to develop the dizembriogenetichesky principle, to emphasize existence of transitional forms between benign and malignant tumors, more stoutly to present variety gistol, options of tumors and their bonds. Being guided in one cases by a community of a histogenesis, in others — a community of localization or a pathogeny, L. I. Smirnov allocates the following tumors: I. Neuroectodermal. II. Meningososudistye. III. Bidermalnye. IV. Pituitary. V. Heterotypical. VI. System. VII. Metastatic. VIII. The tumors growing into a head cavity or invasive (tab. 3).

Table 3. CLASSIFICATION of TUMOURS of the BRAIN (according to L. I. Smirnov, 1940, 1951)


I. Neuroectodermal tumors come from derivatives of a neuroectoderm. Structure and names of the tumors included in JI. I. Smirnov in group of neuroectodermal tumors, almost completely repeat ranks of similar group of classification of Bailey — Cushing (an astrocytoma — a polar spongioblastoma and an astroblastoma — a spongioblastichesky medulloblastoma etc.; tab. 2). Unlike Bailey's classifications — Cushing: 1) preliminary division of tumors is entered on: a) homotypic — mature and immature, constructed of the cells more or less close to mature and immature cells of nervous tissue in its ontogenesis; b) heteras otipichesky — unripe, constructed of kataplazirovanny elements; homotypic tumors are in most cases benign or poluzlokachestvenna, heterotypical — zlokachestvenna; 2) is accepted that in cells of a medulloblastoma it is possible to find initial signs of a differentiation in the direction of specialization of cells of the developing nervous tissue; 3) existence of malignizirovanny astrocytomas (a dedifferentiation astrocytoma) is approved; 4) options of a multiformny spongioblastoma and «primary cancer of a brain» are entered into the nomenclature gistol; 5) two new groups of tumors are allocated: a) bifraktsionny, constructed of two types of the cells relating to two different branches of differentiation of cells of nervous tissue, napr from tumoral oligodendroglyocites and tumoral astrocytes (oligoastrotsitom); b) the bidermalny, containing tumor cells, from which one neuroectodermal nature, others other, usually mezenkhimny, the nature (e.g., the tumor containing tumor cells of a multiformny glioblastoma and an angioretikulosarkoma); malignant options of such tumors sometimes call gliosarkomy (R. Virkhov used the term «gliosarkom» in other value, namely «a malignant glioma»).

II. Meningososudisty tumors are constructed of cellular elements of a meninx, brain vessels. Extending the dizembriogenetichesky principle of classification and to this group of tumors, L. I. Smirnov, according to the scheme of an embryogenesis of a meninx offered by P.E. Snesarev (1939), divides it into two subgroups (tab. 3): 1) the tumors concerning embryonal stages of a meninx: a) the gistogenetichesk connected with a boundary perimedullary membrane and a pialny intima (sarcoma of a pialny intima, nodal meningeal sarcoma); b) the gistogenetichesk connected with a perimedullary mesenchyma (adventitious sarcoma, an angioretikulosarkoma, an angioretikulema); the tumors concerning elements of covers after their splitting: an arakhnoidendotelioma (meningioma) in various gistol, options, vascular tumors, tumors from a mesoderm; primary melanoma and a melanosarcoma of a meninx which is not specified in the table are also among meningososudisty tumors.

III. Bidermalny tumors.

IV. Pituitary tumors. Adenomas of a hypophysis and a cranyopharyngioma — a tumor of a pituitary pocket (Ratke's pocket) are carried to them.

V. Heterotypical tumors are constructed of the fabrics which normal are not found in this body (epidermoid, a lipoma in head cavities, exceptional cases of primary neuroectodermal tumors of a meninx, napr, an astrocytoma, an ependymoma in pelvic bones, etc.). Arise because of ektopiya.

VI. System tumors are initially multiple; a considerable part of cells of any fabric system is exposed to oncogenic transformation (to a schwannian glia, an arakhnoidendoteliya, etc.). Are that, e.g., multiple nevrinomatoz (a disease of Recklinghausen), a multiple angioreticulomatosis (Lindau's disease), multiple arakhnoid endoteliomatoz.

VII. Metastatic tumors. Metastasises of cancer, especially often bronchogenic and a breast cancer prevail.

VIII. The tumors growing into a head cavity (invasive). Usually it is primary and secondary tumors of bones of a skull and its adnexal cavities.

Tsyulkh (1956), without accepting unconditionally dizembriogenetichesky concept of an origin of tumors of G. of m, keeps, however, for neuroectodermal tumors Bailey and Cushing's some terms (a spongioblastoma, a medulloblastoma) not to increase number of synonyms. Gistol, options are allocated where it is essential to clinic or gistol, diagnoses. The possibility of semi-malignant and malignant options of an oligodendroglioma, an ependymoma, horioidny papilloma is not provided. Tsyulkh divides all tumors of a brain into four families: A. Neuroepithelial (neuroectodermal) tumors. B. Mesodermal tumors. B. Ectodermal tumors. G. The tumors arising because of malformations (tab. 4).

Table 4. CLASSIFICATION of TUMOURS of the BRAIN (Tsyulkh, 1956)



A. Neuroepithelial tumors (are presented by 10 subspecies): 1) medulloblastoma; 2) spongioblastoma; 3) oligodendroglioma; 4) astrocytoma; 5) glioblastoma; 6) ependymoma; 7) pleksus-papilloma; 8) pinealoma; 9) neurinoma; 10) gangliocytoma.

According to likeness of a histogenesis these 10 subspecies combine in 4 main groups: I. Medulloblastomas. II. Gliomas. III. Paragliomas. IV. Gangliocytomas.

I. Medulloblastomas. The group includes a medulloblastoma of a cerebellum, a pinus (pinealoma), a sympathetic nervous system (sympathoblastoma). Not differentiation of cells, similarity gistol, structures, a zlokachestvennost, young age of patients combines these tumors.

II. Gliomas — the tumors coming from glial cells (astrocytes and oligodendroglyocites) are opposed to paragliomas.

Enter into group of gliomas: 1) a polar spongioblastoma (according to Tsyulkh, gistol, and topographical option of an astrocytoma); it is allocated under the special name with the purpose to emphasize the slow growth distinguishing it, and in a cerebellum and the clearness of borders with surrounding normal fabric; 2) oligodendroglioma; 3) astrocytoma; along with several gistol, options the malignant astrocytoma is allocated; 4) a glioblastoma (the options presented in the table gistol, structures for clinic do not matter).

III. Paragliomas — the tumors arising from the cells relating to derivatives of a paraglia. The term is entered by Ortega (R. Hortega, 1932) who suggested to distinguish two lines of development of a normal medullary epithelium — one in the direction of a glia, another — paraglias. Tsyulkh carries to paragliomas: 1) ependymoma; 2) pleksus-papilloma; 3) pinealoma; 4) neurinoma.

IV. Gangliocytomas — tumors of a ganglionic and cellular row. Three local options differing on biol, to features are allocated: 1) gangliocytomas of a great brain, myelencephalon and spinal cord; 2) gangliocytomas of a cerebellum; 3) gangliocytomas of a sympathetic nervous system. The malignant ganglionic and cellular tumor of a sympathetic nervous system (sympathoblastoma) is carried to medulloblastomas.

B. Mesodermal tumors: 1) A meningioma (corresponds to an arakhnoidendotelioma, according to L. I. To Smirnov), it is presented by three gistol, options, distinctions between to-rymi have no essential value; 2) fibroma (in a brain meets seldom); 3) sarcomas, are included into their number two types of diffusion sarcomas: a) the sarcomatosis of covers which is characterized by widespread defeat of a soft meninx; b) the sarcomatosis of vessels differing in preferential distribution on periadventitsialny spaces of intracerebral vessels — so-called, periadventitsialny sarcoma; two types of limited (nodal) sarcomas: c) sarcoma of an arachnoid membrane of a cerebellum — meets very seldom, d) sarcoma of vessels — monstrokletochny sarcoma; e) fibrosarcoma of a firm meninx; e) primary diffusion melanomatosis (in literature idea of the neuroectodermal, but not mesodermal nature of primary melanomatosis of covers and vessels of a brain dominates). Carry to mesodermal tumors also a chondroma, a lipoma, an osteoma and chords to ohm.

B. Ectodermal tumors include a cranyopharyngioma, adenomas of a hypophysis, a «tsilindromatozny» epithelioma.

G. Tumors because of malformations are presented by epidermoida, dermoids, teratomas.

D. Malformations of vessels and vascular tumors include angiomas and aneurisms.

In 1939 there were experimental proofs that the majority of tumors of a nervous system arises not from the cells which lingered on stages of embryonic development, and by an anaplaziya, dedifferentiation of cells of mature fabric or from its cambial elements. It found reflection in a number of new classifications of neuroectodermal tumors.

So, Kernokhen et al., believing that an astrocytoma, the astroblastoma, a multiformny glioblastoma represent the anaplaziya differing on degree options of an astrocytoma, all these tumors were called an astrocytoma, estimating degree of a zlokachestvennost in four gradation and designating it in figure. By the same principle tumors of ependimny, oligodendroglialny and ganglionic and cellular ranks were classified and called. On tab. 5 new classification, a ratio of its nomenclature with former — dizembriogenetichesky is presented. So, e.g., the astrocytoma, an astroblastoma, a multiformny glioblastoma are called as an astrocytoma of I, II, III, IV degrees of a zlokachestvennost. Is not present in the new nomenclature of an analog of a polar spongioblastoma and Bailey and Cushing's neuroepithelioma since existence of these two tumors as independent types is denied. The medulloepithelioma is carried to malignant ependymomas. The term «medulloblastoma» remains as the origin of a tumor from embryonic cells is very probable and its high-quality homologs are not available.

Classification of neuroectodermal tumors of Ringertts (1950) is similarly constructed, edges differs only in three-sedate gradation of a zlokachestvennost instead of four-sedate.

In B. S. Hominsky's (tab. 6) classification neuroectodermal tumors are presented in the form of ranks * from which everyone includes tumors of one origin, but * various degree of a cataplasia (anaplaziya). Three degrees of a cataplasia differ that is reflected In; the name of tumors (e.g., an astrocytoma — an astrocytoma atipichesky, or dedifferentiated, a glioblastoma). For tumors in which development the role of a dizembriogenez is represented rather reasonable (ganglionic and cellular tumors, some cases of pinealomas) the same division into three headings according to degree of immaturity remains. The list gistol, options of types of tumors is not introduced in classification since in most cases these options have only descriptive value.

By the principle and the nomenclature Henshen's classification is close to B. S. Hominsky's classification.

In 1971 Tsyulkh offered new option of classification of tumors of G. of m (tab. 7). In this option only 15 types of tumors, at the expense of an exception of versions are left; the nomenclature gistol is unified. options (isomorphic, nonisomorphic, polymorphic, amitotichesky, oligomitotichesky, polymitotic); division of tumors according to degree of a zlokachestvennost (four gradation) is entered; the wedge, observations which showed that some tumors which were considered as high-quality meet also in malignant option are considered (e.g., a spongioblastoma). In table 8 the tumors entering classification are grouped in degree of a zlokachestvennost. For an illustration of predictive value gistol, estimates of degree of a zlokachestvennost are given data on life expectancy of patients after perhaps fuller oncotomy.

In the given classifications the tendency to their gradual simplification as a result of failure from the dizembriogenetichesky principle of classification, from allocation insignificant gistol, options and owing to elimination of a part of synonyms is obvious. The aspiration to reflect in classification essential to practice gistobiol amplifies. properties of a tumor.


Table 5. CLASSIFICATION of NEUROECTODERMAL. TUMOURS (on Kernokhena et al., 1949)



Table 6. CLASSIFICATION of NEUROECTODERMAL TUMOURS (according to B. S. Hominsky, 1962)


Table 7. CLASSIFICATION of TUMOURS of the BRAIN AND THEIR ZLOKACHESTVENNOSTI'S ASSESSMENT (across Tsyulkh, 1971)


Table 8. The PREDICTIVE CHARACTERISTIC of TUMOURS of the BRAIN DEPENDING ON THEIR LOCALIZATION AND ZLOKACHESTVENNOSTI'S DEGREE (across Tsyulkh, 1971)



The tumors which are seldom included in classifications. There are types of tumors of G. of m mentioned only in separate classifications. The following is among such tumors.

A microglioma — the tumor coming from a microglia. It is for the first time described and entered into classification under the name «mesoglioma», «mesogliolastoma» (malignant option) by V. K. Beletsky (1933, 1936), A. P. Avtsyny (1936). The term «mesoglioma» comes from the term «mesoglia», the used Ortega for a microglia assuming its mezenkhimny origin. Some authors carried not only a microglia, but also an oligodendrogliya to a mesoglia.

«Monstrokletochny sarcoma» (Tsyulkh, 1971) — one of options of limited (nodal) sarcomas of a brain. It is histologically characterized by giantism of cells and a ganglioidny type of cellular kernels. Sometimes mistakenly is accepted to a multiformny glioblastoma or a ganglionic and cellular tumor.

The Tsilindromatozny epithelioma (Tsyulkh, 1971) — the rare tumor which is found in the field of a node of a trifacial (a gasserov of a node) and at the bottom of a front cranial pole. Histologically has a structure of «tsilindroma». Comes, obviously, from an epithelium of adnexal nasal cavities and an acoustical (eustachian) pipe from where grows into a head cavity. Also the malignant, metastasizing tsilindromatozny epitheliomas are described.

«Primary cancer of a brain» — the little-used term for designation of group of the malignant tumors developing in head cavities from an epithelium neuroectodermal (horioidkartsinoma), ectodermal (cancer of an adenohypophysis), teratoid (usually in the field of a pinus) the nature. In L. I. Smirnov's nomenclature the term is used only for the name of exclusively rare vnutrizheludoch-kovy high-malignant tumors, unlike a horioidkartsinoma, by almost undifferentiated, possessing growth expressed destruiruyushchiya.

A cyst of a brain — the pathological cavity in a brain containing liquid or more dense masses. Not all patol, the educations answering to this definition call a cyst of a brain (e.g., abscess of a brain, an intracerebral hematoma). Intracerebral and extra brain (subarachnoidal) distinguish cysts of a brain. On a pathogeny of a cyst of a brain can be divided on: a) parasitic (e.g., single-chamber echinococcus); b) dizembriogenetichesky (a colloid cyst of the third ventricle, epidermoid, being retentsionny cysts, and the cysts which are formed in sites of an underdevelopment of a brain); c) distsirkulyatorny (form on site the centers of an encephalomalacia after thromboses and embolisms of brain vessels, on site hematomas); d) traumatic (remain on site the traumatic necroses which are not replaced with a hem); e) tumoral (there are owing to dystrophy, kollikvation of tumoral fabric or transudation of liquid from defectively constructed vessels of a tumor).

Extra brain (subarachnoidal) cysts are formed on the soil or defects of a bookmark and development of a brain, or owing to the disturbance of circulation of liquid in a subarachnoid space caused by a productive inflammation of a soft meninx. The structure of a wall and character of contents of a cyst of a brain depend on its nature. A wedge, displays of a cyst of G. of m are caused most often by changes of its volume and in certain cases toxic action of its contents on surrounding fabrics.

Frequency of separate types of tumors

the Frequency of separate types of tumors according to the offered classification by JI. To I. Smirnov it is presented in table 9, across Tsyulkh — in table 10.

Table 9. FREQUENCY of VARIOUS TUMOURS of the BRAIN (according to aggregated data of L. I. Smirnov. 1951)



Table 10. FREQUENCY of SEPARATE TYPES of TUMOURS of the BRAIN (according to Tsyulkh, 1956)


Note: the table contains incomplete data in comparison with Tsyulkh's original.


Types of growth

Fig. 38. Microdrug of the bifraktsionny tumor (constructed of two types of cells) a brain (ependimoastrotsitom): 1 — ependimarny structures, 2 — proliferating astrocytes. Impregnation according to Ramone-and-Kakhalyu.
Fig. 39. Microdrug of a polar spongioblastoma of a brain. The Puchkovy arrangement of cells with oval kernels. Shooters specified colossal cells.

Among G.'s tumors of m is growing expansive, infiltrative and combining infiltrative growth with expansive.

Expansive preferential extra brain tumors (an arakhnoidendotelioma, a neurinoma of roots of cranial nerves) grow. The majority of intracerebral tumors grows infiltrative (gliomas, medulloblastomas, sarcomas) that, as a rule, makes impossible their radical removal.

Infiltrative growth svoystven not only to malignant gliomas (glioblastoma), but also slowly growing histologically to high-quality options of an astrocytoma, an oligodendroglioma. Tissue of a brain in the invaded zone its cells of a high-quality glioma can long keep the structure and function.

Fig. 40. A frontal section of a brain with the ependymoblastoma of the fourth ventricle which is carrying out his cavity (it is specified by an arrow).
Fig. 41. Microdrug of an ependymoblastoma. «Mosaicity» of a structure of tumoral fabric is expressed. On the right below — an element of a tumor with characteristic neuroepithelial structure — cells are located in the form of a paling.

Infiltrative growth of malignant gliomas and other malignant tumors of G. of m is at the same time and the destruiruyushchy growth which is quickly leading infiltrirovanny tissue of a brain to death. Infiltration of fabric cells of a glioma in some cases is result probably not only advances of tumor cells, but also the continuing diffusion or multicentral blastomatous transformation of cells of a local glia outside already created by it by the central part of the tumoral center.

A combination expansive and infiltrative growth the ependymoma, a pinealoma, infiltriruyushchy find tissue of a brain in the place of their initial growth. Sometimes the microscopic amount of immersion of groups of tumor cells in adjacent tissue of a brain it is possible to find on a surface arakhnoidendoteliy. In some cases the glioma on some sites pushes aside more, than infiltrirut, substance of a brain.

Primary tumors of G. of m are usually presented in the form of a single node, but can be and diffusion, initially multiple (multicentral), for the second time multiple (metastasizing within a head cavity).

Diffusion tumors of G. of m occur among gliomas. It is possible to distinguish: 1) exceptional cases of astrocytomas, oligodendrogliomas, glioblasty, not forming a node, and diffuzno infiltriruyushchy fabric on a big extent (a diffusion astrocytoma, a diffusion oligodendroglioma, a diffusion glioblastoma); 2) very seldom meeting so-called diffusion glioblastoz (spongioblastoz, central diffusion shvanpoz) it is characterized by diffusion infiltration of preferential brain trunk the extended spongioblastopodobny glial cells of not specified nature. The unsuccessful synonym «central diffusion shvannoz» was offered on the basis of some lines of morphological similarity of tumor cells to schwannian cells (lemmocytes).

More often gliomas are initially multiple. They are characterized by existence of several tumoral nodes which arose independently one from another and are not connected with each other. Nodes are quite often surrounded with a zone of a diffusion glial hyperplasia or a diffusion gliomatosis. Sometimes zones merge together, occupying extensive territories of a hemisphere; in these cases distinguishing between diffusion and initially multiple glioma often is conditional. Both types of gliomas quite often combine under the general name «diffusion glioma». Also the neurinoma, an arakhnoidendotelioma, an angioretikulema can be initially multiple.

Some types of tumors are given in fig. 38 — 53 and tsvetn. fig. 12-21.

Innidiation

Fig. 12 — 15. Astrocytoma of a brain. Fig. 12 and 14 — the cuts of a brain passing through a tumor (it is specified by shooters). Fig. 13 and 15 — the microscopic pictures corresponding to them. Fig. 13. Microscopic structure plasmatic (and and b) and fibrillar astrocyte: and — gentle netting is expressed; — large star-shaped cells (coloring across Kakhal); in — bunches of glial fibers (coloring on Goltsera). Fig. 15. Microscopic structure of a dedifferentiation astrocytoma: and — the site with multinucleate colossal cells (1) and proliferating veins (2); — astroblastic structure (it is specified by shooters) around a blood vessel; in — tumoral spongioblasts (are specified by shooters).
Fig. 16. The neurinoma of a mostomozzhechkovy corner deforming a brainstem and a hemisphere of a cerebellum (it is specified by an arrow).
Fig. 17. Microscopic structure of a neurinoma: and and — vortex, in — palisade structures.
Fig. 18. Sagittal section of a cerebellum, a myelencephalon and the bridge (the arrow specified a medulloblastoma).
Fig. 19. Microscopic structure of a medulloblastoma: and — characteristic psevdorozetochny (are specified by shooters) and kolonarny (are specified by two shooters) structures; — the cells of a tumor having looking alike primitive neuroblasts; in — the cells of a tumor having similarity to spongioblasts.
Fig. 20. Frontal section of a brain: the arrow specified a glioblastoma. Necroses and hemorrhages in fabric of a tumor are expressed.
Fig. 21. Microscopic structure of a glioblastoma: and — polymorphism, abundance of multinucleate colossal cells is expressed (are specified by shooters); in the right bottom corner of drug — the center of a necrosis surrounded with a paling from the extended cells; the site of the drug «and» in bigger increase, shooters specified colossal cells; in — growth of blood vessels (1) and connecting fabric (2) in a tumor.

Distinguish innidiation ekstrakranialny and intracranial.

G.'s tumors of m practically do not metastasize Ekstrakranialno (out of limits of a head cavity). Reliable cases of such innidiation represent an exclusive rarity.

Ekstrakranialny metastasises malignant arakhnoidendoteliy, sarcomas, glioblasty, oligodendrogliomas in lungs, limf, nodes, kidneys are described; are observed at the operated patients.

G.'s tumors of m usually metastasize Intrakranialno (within a head cavity) by transfer of tumor cells on ways of circulation of cerebrospinal liquid with formation of implantation metastasises in a subarachnoid space of a head and spinal cord and on walls of ventricles. Especially often metastasize on these ways of a medulloblastoma, pinealomas, glioblastoma are more rare. In rare instances high-quality gliomas, an ependymoma, horioidny papilloma can give implantation metastasises and histologically.

Fig. 42. A frontal cerebellotomy with the ependymoblastoma of the fourth ventricle which is carrying out his cavity (it is specified by an arrow).

Occasionally describe cases when primary malignant tumor of G. of m gives metastasises in substance of a brain (intracerebral metastasises in the narrow sense of the word). Ways of such innidiation are not clear.

Clinical picture and topical diagnosis

Fig. 43. Microdrug of an ependymoblastoma. Sites of a chaotic arrangement of cells with hyperchromic kernels.
Fig. 44. A sagittal section of a brain with the pinealoma squeezing area a chetverokholmiya (it is specified by an arrow).

Allocate the following stages of development a wedge, displays of tumors of G. of m: compensated, subcompensated (flickering symptoms), dekompensirovanny (manifest symptoms and a terminal state). The leading role in consecutive change of phases is played by growth rate of a tumor, its localization, intensity of escaping of a tumor of products of metabolism and reactivity of an organism of the patient.

Proceeding from pathogenetic premises, at opu-hlyakh G. m subdivide a wedge, symptoms on local and all-brain. The symptoms resulting from irritation or destruction of brain fabric the tumor growing or replacing it, are called primary local (focal), and the signs of focal defeat which are not corresponding to an arrangement of a tumor of G. of m, but caused by its development designate as secondary local symptoms. Symptoms «in the neighbourhood» reflect dysfunction of the educations which are in close proximity to primary center, especially at the nodal encapsulated G.'s tumors of the m which are pushing aside brain fabric in the radial directions. If it is about shifts and deformations of a brain at considerable distance from a volume patol, the center, usually around difference of intracranial pressure, then it is accepted to call the arising symptoms secondary symptoms «on a distance». As a rule, it is symptom complexes (syndromes) of defeat of a certain site of a brainstem, for to-rymi in the world literature the name of dislocation was approved. In an origin of any group of symptoms the huge role is played by disgemichesky factors. There is no accurate side between this or that category a wedge, symptoms.

Transfer of all-brain symptoms of tumors of G. of m comes down to the description of a picture of a hypertensive syndrome (see) or an occlusal syndrome since all-brain symptoms of other genesis dominate seldom.

Fig. 45. Microdrug of a pinealoma. The tumor consists of large ferruterous (1) and small limfotsitopodobny cells (2).
Fig. 46. Microdrug of a neuroepithelioma. Characteristic rozetochny structures (are specified by shooters).

Obshchemozgovye symptoms

Fig. 47. Microdrug of a horioidpapilloma. The tumor consists of the fibers (1) (in the drawing in cross-section) covered with a cylindrical epithelium (2).

The brightest and constant all-brain symptom is headache (see). At G.'s tumors of m it meets in 84% of cases (I. Ya. Razdolsky, 1954). Not less than at a half of patients is the first signal of a disease. The headache has usually arching character, prevails in the mornings, after a dream, at a ducking, tension of a prelum abdominale, etc. that correlates with dynamics of intracranial pressure. The heavy feeling in the head, the general discomfort, faintness can precede pain; in the course of a disease the headache becomes a constant. Pristupoobrazny character remains at occlusal paroxysms (see. Occlusal syndrome ).

Frequent satellites of a headache — nausea and vomiting — have the same dynamics of development. Vomiting meets at G.'s tumors of m in 68% of cases.

At 78% of patients congestive nipples of optic nerves come to light (see. Congestive nipple ). Passing a stage of a venous hyperemia easy for puffiness, developments of stagnation can reach stages of plentiful hemorrhages. Degree of manifestation of developments of stagnation can sometimes not correspond to the size of intracranial hypertensia. Eventually the postcongestive atrophy of an optic disk develops.

Fig. 48. Microdrug of a ganglioastrocytoma. Large tumor ganglionic cells (1) among astrocytes (2) and small chyliform elements (3).
Fig. 49. A frontal section of a brain with parasagittal arakhnoidendoteliomy (it is specified by an arrow).
Fig. 50. A sagittal section of a brain with arakhnoidendoteliomy the bases of a brain (it is specified by an arrow).

Mental disorders are expressed in 50 — 80% of all cases of tumors of G. of m and develop, as a rule, after neurologic though can sometimes precede of Development of mental disorders depends on age of the patient: they occur at children extremely seldom, and at elderly people — is frequent. The nature of a tumor, its size, localization, growth rate is of great importance. E.g., at meningiomas and other benign tumors of G. of m mental disturbances meet seldom. In most cases mental disorders represent all-brain reaction to tumoral process. Carry conditions of the broken consciousness and manifestation of psychoorganic syndromes to this group (see).

Disturbances of consciousness are expressed in devocalization of various degree. The attention and concentration are reduced, perception and comprehension of the events is complicated around, all mental processes are slowed down. Patients speak slowly, hardly look for words, perseverirut; storing and a reproduction of the necessary materials of memory weakens, orientation, especially chronological is broken. Patients are quickly exhausted, cease to react to surrounding and fall into a semi-drowsy state.

In process of increase of intracranial pressure the oglushennost passes into a sopor, and then into the coma which is usually preceding a lethal outcome. Sudden transitions of an oglushennost to unconsciousness or development on its background of acute psychotic episodes (delirious, amental, twilight states) are possible. Sometimes, especially at elderly patients, independently, against the background of the dulled consciousness signs of a psychoorganic syndrome or dementia, most often anamnestic) (korsakovopodobny) type develop. Disturbances of memory and orientation accrue, up to development of an anamnestic disorientation, the attention is broken, the volume of perceptions is narrowed, the clearness of representations and concepts, level of judgments and other types of cerebration is reduced. The initial increased affective lability turns into the accruing affective obtusion; in process of decrease in criticism apathy, indifference, carelessness arise and increase.

A number of mental disturbances depends on localization of a tumor. Refer to them pristupoobrazno arising hallucinatory (flavoring, olfactory, visual and acoustical) the frustration at tumors of a temporal share which are quite often accompanied with epileptic seizures — a symptom of an ankyroid crinkle. At tumors of frontal lobes decrease in mental activity, the aspontannost reaching degree of an akinetically-abulichesky syndrome with affective obtusion and anamnestic disturbances, or moriapodobny (pseudoparalytic), conditions of disinhibition at orbital localization is expressed. At tumors of deep departments of G. of m conditions of reduced reactivity and an initiative, and also a peculiar importunity are described (akayriya). At tumors of the third ventricle often develops Korsakovsky syndrome (see). Vyaloapaticheskiye, depressively painted states it is possible to observe at tumors of a diencephalon. Dysphoric and ecstatic conditions, epileptic changes of the personality and thinking are observed at the tumors proceeding with various epileptic seizures. Depressive and maniacal states are described at deep tumors. Hallucinatory paranoid (schizoformous) psychoses meet seldom, hl. obr. at patients with premorbidal deviations and hereditary burdeness by mental diseases.

Local symptoms make a basis of topical diagnosis (see) also allow to reveal localization of tumors of G. of m.

The clinic of tumors of frontal lobes consists of several groups of symptoms. Motive frustration act in the form of counterlateral mono - or a hemiparesis (paralysis), corresponding change of a muscle tone, emergence of pyramidal reflexes, epileptic seizures of jacksonian, peredneadversivny or generalized type with the focal beginning. At defeat of a dominant hemisphere motor aphasia develops. Localization of a tumor in polar, medial and basal departments of a frontal lobe causes specific psikhopatol, the phenomena.

The accruing disturbance of memory generally as interfering braking is followed by confabulations. There are frustration of the emotional and strong-willed sphere, and into the forefront the aspontannost acts. Gradually the intelligence decreases, the criticism is broken, there is wrong a behavior. Emotions are impoverished: prevail euphoria, the complacency is frequent in combination with affective explosions. To an aspontannost the syndrome of dynamic apraxia is close to the phenomena of motive and speech inertness and perseverations.

At tumors of a frontal lobe pseudo-cerebellar symptoms can be observed (see. Frontal syndrome).

For tumors of a parietal lobe leaders are counterlateral disorders of sensitivity: a hypesthesia or anesthesia on all half of a body or on a part it, paresthesia, touch epiekvivalenta or auras before attacks. Defeat of back departments of a parietal lobe leads to more difficult touch, touch and space and visual and space disturbances: astereognosis, constructive apraxia, alexia, acalculia, autotopagnosia, afferent paresis of opposite extremities, preferential hands.

At tumors of a temporal share of a dominant hemicerebrum touch aphasia is most characteristic, in a cut as the main components allocate disturbances of phonemic hearing and disorder of storing of a consecutive number of speech information.

Consider that at defeat of a subdominant hemisphere perception of nonverbal sounds — music, specific murmurs of the forest, the city etc. similarly suffers. Refer the subjective and objective visceral and vegetative frustration permanent to focal symptoms of tumors of medial departments of temporal shares psikhopatol, changes, generally towards a depression, disturbance of high-quality perception of taste and a smell, polymorphic epileptic seizures. At an irritation of cortical zones of acoustical, olfactory, flavoring analyzers there are corresponding hallucinations or aura before an epileptic seizure. Also counterlateral gomonimny quadrant or full hemianopsia (is possible at the back deep centers), vestibular paroxysmal disturbances.

At tumors of an occipital share depending on massiveness of defeat on the opposite side the full or partial hemianopsia (see), napr, quadrant, with preservation of macular sites of fields of vision develops. Symptoms of irritation are or primitive (fathoms, photopsias), or «difficult «picture» visual hallucinations which can act as aura of an epileptic seizure. Disturbances of separate components of a visual gnozis are possible at defeat of adjacent sites an occipital, temporal and parietal lobe.

During the involvement of a subdominant hemisphere recognition of objects or their details is broken, i.e. the specific parties of a gnozis suffer; agnosia on faces develops. At defeat of a dominant hemisphere of the patient cannot estimate sense of what was seen in a picture though well distinguishes details; visual agnosia on abstract symbolical images develops (letters, figures, etc.); from here alexia, acalculia, agraphia. Visual and space logical bonds are broken. Often there is anamnestic aphasia.

The tumors located superficially, napr, the meningiomas sprouting bark of a glioma, etc. clinically, as a rule, begin with primary and focal, but not with hypertensive symptoms. At them it is incommensurable more often, than at deep new growths, there are epileptic seizures with a focal component. Only superficial tumors can give somatotopichesk the isolated dysfunction, napr, paresis of a leg, paresthesia of a half of the face, an astereognosis without disturbance of sensitivity or other monosymptom. Sometimes there is a local shell headache; there can be other local signs (protrusion of a bone, etc.).

At tumors of deep localization (in most cases gliomas) the disease is more often demonstrated by a hypertensive syndrome; local symptoms of a tumor are more widespread — a hemiparesis, a hemianopsia etc.; quite often full syndrome of the internal capsule. At defeat of subcrustal nodes Extrapyramidal changes of a tone, trembling or a hyperkinesia, oligo-and a bradykinesia are interwoven into a wedge, a picture. Epileptic seizures — generalized or characteristic of defeat of medial departments of a temporal share. At new growths of a corpus collosum bystry disintegration of the mental sphere (on «frontal» type), disturbance of bimanual reciprocal coordination is possible.

Primary tumors of a diencephalon (including the third ventricle) make only 4 — 5% of intracranial tumors, an average and a rhombencephalon — apprx. 3%. Generally it is gliomas. Secondary defeat of various departments of a trunk is much more often observed. It can come in the corresponding stage at any localization of a new growth.

The syndrome of defeat of a diencephalon includes generally symptoms of disturbance of regulation of a metabolism, a vascular and vegetative innervation, a muscle tone; they can be shown both sharply, and torpidno. At primary tumors of a thalamus the phenomena of intracranial hypertensia owing to occlusion of the third ventricle and half conduction (before everything sensitive) disturbances dominate. Frustration in the emotional and strong-willed sphere (defeat of corticothalamic and cortical and hypothalamic ways) to stages of a decompensation develop into disturbances of consciousness.

Srednemozgova the syndrome consists of the following main components: disturbance of reaction of pupils to light, paralysis of a look in the vertical direction, disorder of convergence, symptoms gomolateralny (in relation to a tumor) pyramidal insufficiency, bilateral patol, reflexes, specific mezentsefalny muscular and tonic frustration — a Kernig's sign, a stiff neck, braking of reflexes on the lower extremities, dissociation of a tone on an axis of a body; in an end-stage — the phenomena of a cerebrate rigidity, ex-tensor tonic spasms, disturbance of consciousness, dominance of disorders of breath in comparison with disorder of cardiovascular function. The syndrome is supplemented by signs of defeat of surrounding educations and adjacent systems.

Fig. 51. Microdrug of an arakhnoidendotelioma with meningoteliomatozny (1), concentric structures (2) and psammomatozny little bodies in a tumor (3).
Fig. 52. Microdrug of an arakhnoidendotelioma fibroblastichesky structures (it is specified by shooters).
Fig. 53. Microdrug of a sarkomatozny arakhnoideidotelioma. Accumulation of cells with hyperchromic and polymorphic kernels (are specified by shooters).

The syndrome of damage of a medulla develops usually violently and quickly reaches a stage of a decompensation, in time a cut fluctuations of the ABP, pernicious vomiting, cyanosis observe bradycardia; the apnoea can come at safe consciousness. In earlier, reversible, stages the symptomatology is poor and unstable: pains in occipital area, the fixed position of the head, paresthesia of an innervation of trigeminal and upper cervical nerves; hyperemia of covers of an upper body. There is a dysarthtia, a hiccups, incidental vomiting. Detection of secondary symptoms from the side of the bridge of a brain — a spontaneous horizontal nystagmus, paresis of the taking-away nerves, and also cerebellar symptoms allows to expect approach of dislocation in the field of an occipital opening.

Primary intra trunk tumors differ in slower progressing of symptomatology, formation of classical alternating syndromes (see) and late accession of a hypertensive syndrome.

The diagnosis

the Diagnosis of a tumor of G. of m is made on the basis of the analysis a wedge., elektrofiziol., rentgenol., radio-gramophones, data and research of cerebrospinal liquid.;

Fig. 54. The roentgenogram of a skull of the patient with a calciphied meningioma (it is specified by an arrow) parietal area (symptoms of intracranial hypertensia in bones of a calvaria and the Turkish saddle are not expressed).

Primary (straight line) rentgenol, a symptom of tumors of G. of m — limy inclusions in the fabric of a tumor. In 80 — 85% of cases cranyopharyngiomas (see), in 50% of cases — dermoids of area of the Turkish saddle obyzvestvlyatsya (see the Hypophysis). Quite often calciphied inclusions are observed at extra brain tumors (meningiomas, psammomas), meet. completely calciphied (fig. 54) meningiomas. Less often limy inclusions arise at intracerebral; glial tumors, hl. obr. high-quality (see Oligodendrogliomas). It is quite often possible to find calciphied inclusions in dermoids and teratomas (see) a great brain, organized intracranial hematomas, tuberkuloma, the encephalitic centers etc.

Secondary (indirect) kraniografichesky symptoms of tumors of G. of m and other volume educations it is possible to divide the local changes in bones of a skull connected with growth of new growths kraniografichesky signs of dislocation of brain structures into the general signs of ginertenzivno-gidrotsefalny changes in a skull.

Fig. 55. The roentgenogram of a skull of the patient with an intracerebral tumor (the general symptoms of intracranial hypertensia are expressed): seams (1) are expanded, the drawing of manual impressions (2) is slightly strengthened, the Turkish saddle is deepened (3).

The general signs hypertensive gidrotsefalnykh changes of bones of a skull are most important. Development in G. the m patol, the processes increasing its volume, as a rule, leads to increase in intracranial pressure (see. Hypertensive syndrome ). Radiological intracranial hypertensia is shown by thinning of bones, education or strengthening of manual impressions, a sparseness of bone walls of the Turkish saddle, expansion of seams and porosity of their edges (fig. 55). At children in connection with incompleteness of growth, formation and blood supply of bones of a skull gidrotsefalny changes over hypertensive and compression prevail: the sizes of a skull increase, bones become thinner, the shape of a skull comes nearer to spherical or ellipsoidal, seams of a skull extend, disperse, prints of manual impressions amplify, furrows of vessels and venous sine go deep. Secondary changes of the Turkish saddle — porosity and thinning of its walls, especially backs, sometimes its total disappearance, being the main kraniografichesky symptom of intracranial hypertensia at adults, at children are expressed poorly.

At adults on roentgenograms traces of compression impacts of tumors of G. of m on bones of a base of skull, napr, deepenings of cranial poles, especially a bottom of a front cranial pole are often visible. Only at the expressed intracranial hypertensia at adults it is possible to observe sharp strengthening of prints of manual impressions. Discrepancy of cranial seams can be observed only at young age before the end of the period fiziol. ossification.

Fig. 56. Roentgenograms of a skull of the patient with a meningioma of the left parietal area (and — side and — a straight line of a projection): the hyperostosis (1) of an internal bone plate of the left parietal bone to which converge the strengthened furrows of a venous sine (2) and an average meningeal artery (3) comes to light.

The local changes of a skull connected with growth of tumors meet not in all cases and are various at tumors of different morphological structure. Local changes at extra brain tumors are most demonstrative — meningiomas (see) at which there are hyperostoses which are located or on an internal bone plate, or the layers of a bone taking everything and considerably eminating knaruzh. At some forms of hyperostoses it is difficult for Kraniograficheski to distinguish a meningioma from other tumors of bones of a calvaria, especially osteosarcomas, for a cut the needle or column structure of a hyperostosis is characteristic. Hyperostoses are often observed at a konveksitalny arrangement of meningiomas, at meningiomas of wings of a wedge-shaped bone. In certain cases at meningiomas instead of a hyperostosis it is possible to find the single or multiple centers of destruction of bones in a zone of initial growth of a tumor. As manifestation of the strengthened growth of a bone at meningiomas of a hillock of the Turkish saddle and the sphenoidal platform, along with consolidation of a bone, it is possible to observe a giperpnevmatization of a wedge-shaped bosom with protrusion in a head cavity of above-mentioned bone educations. In addition, local signs at meningiomas include strengthening of the furrows of the hypertrophied meningeal arteries which are feeding a tumor and usually converging to area of a hyperostosis (fig. 56). and also the strengthened development, expansion of the diploichesky veins which are taking away blood from a tumor (hyperostosis) to venous sine, deepening of furrows of these sine, formation of additional emissarny veins (graduates).

Fig. 57. Roentgenograms of a skull of the girl of 7 years with an astrocytoma of the left frontal lobe of a brain (and — a straight line; — side projections): in bones of a skull symptoms of intracranial hypertensia are moderately expressed; seams are slightly expanded (1); the site of thinning and protrusion (2) frontal bones at the left with the delimited upper edge comes to light, the drawing of manual impressions is strengthened (3).

Local bone changes at intracerebral tumors are characterized by focal thinning of a bone from an internal bone plate, an atrophy of a diploichesky layer, rapprochement of internal and outside bone plates. Further quite often thinned site of a bone eminates knaruzh (fig. 57). Similar local changes of bones of a skull meet hl. obr. at children's and young age at the benign glial, superficially located tumors which quite often have cystous composed or connected with cerebral cavities. At intra ventricular tumors with occlusion of one of interventricular (monroyevy) foramens at children on the party of a tumor the volume of a half of a skull with thinning and protrusion of bones — half of the arch and the basis can increase. At adult similar local changes of bones of a skull, as a rule, it is not observed.

It should be noted that the above described local changes are observed at children's and young age not only at G.'s tumors of m. They are characteristic of the sacculated accumulations of liquid in the subshell spaces of a brain (hron, the sacculated subdural hematomas, subdural gidroma, sometimes porencephalic cysts), and also can accompany also other not tumoral volume educations. After an oncotomy or other new growth the above described local bone changes and deformations of a skull usually are not normalized.

Kraniografichesky signs of shift — dislocation of brain structures have considerable diagnostic value. Shifts of a calciphied epiphysis of a brain (pinus) aside, opposite to an arrangement of a tumor concern to them. Shift of calciphied strobiloid gland — the most important and precursory kraniografichesky symptom of a tumor or other volume education — can be found before emergence of the general hypertensive and local changes of bones of a skull. The calciphied vascular textures normal symmetrized from the centerline and an epiphysis of a brain at an arrangement of a tumor in back departments of parencephalons can be displaced as lateralno, and in the perednezadny direction. In the party, opposite to volume education, also sites of calcification in a crescent shoot are displaced.

Data of a kraniografichesky research are supplemented and specified by means of a tomography (see), ekhoentsefalografiya (see), methods of radio isotope diagnosis (see), a vertebralny angiography (see), a carotid angiography (see), etc.

The differential diagnosis of a tumor of G. of m is difficult. Any volume pathological processes can simulate a tumor: abscesses, infectious granulomas, hematomas of various genesis, parasitic cysts etc. The differential diagnosis is carried out with the diseases giving all-brain symptoms (hron, encephalitis, an arachnoiditis, occlusal hydrocephaly) and focal symptoms (limited encephalitis, disturbances of cerebral circulation, multiple sclerosis, etc.). Hemorrhagic strokes can be under certain conditions taken for hemorrhage in a tumor and vice versa.

Treatment

Conservative therapy has especially auxiliary character. The main place borrow the dehydrating agents lowering intracranial pressure: lasixum, furosemide, Uregitum, etc. Persistent headaches demand purpose of analgetics. In the presence of epileptic seizures or their equivalents apply anticonvulsant treatment. According to indications apply fortifying, the hypnotic drugs desensibilizing the cardiovascular means, drugs normalizing vegetative reactions. Disturbances of mentality, and also secondary asthenoneurotic reactions stop neuroplegic means, tranquilizers, antidepressants. In a stage of a decompensation, in addition to, listed, apply all necessary symptomatic methods of an intensive care. Contraindicated biostimulating and physiotherapeutic treatment. Method of radical treatment is the surgical oncotomy.

Radiation therapy is applied more often after operations less often as an independent method of treatment. The indication to it is existence of malignant neuroectodermal tumors and malignant extra brain tumors like sarcoma or an angioretikulosarkoma. Radiation therapy is carried out after removal of metastasises of malignant new growths to G. by m and at some tumors of a hypophysis. One of the main conditions of purpose of radiation therapy is knowledge of histology of a tumor. At tumors in mezentsefalny and diencephalic areas such verification is not always possible, and dynamics a wedge, pictures can form the basis for carrying out radiation. Individual approach to radiation therapy of benign radio sensitive tumors is necessary (ependymomas, angioretikuly).

At treatment of malignant tumors of G. of m the focal dose makes 6000rad. Small fractionation of a dose on 200 is standard I am glad 5 weekly that determines duration of a course of radiation in 6 weeks. Children up to 5 years receive 2/3 doses of the adult (100 — 150 I am glad daily). Radiation is begun with a dose 50 — 100rad, Klin, control, dehydration, vitamin therapy are carried out throughout all course of radiation.

Use of sources of high energy allowed to irradiate a tumor for one course of radiation with such dose, edges are rendered by the best therapeutic effect, than fractional, at multicourse radiation.

Fig. 58. Distribution of isodoses (black lines) at radiation of a hypophysis on gamma and therapeutic installation with a source 60Co activity 3 300 - curie from two fields: 1 — in the horizontal plane; 2 — in the sagittal plane; 3 — in the frontal plane.

For formation of necessary dozny distribution, i.e. the corresponding gradient of a dose between a tumor and healthy fabric, and for decrease in the general beam loading use multifield radiation (fig. 58). The philosophy of radiation therapy — a high dose in the center of radiation and the maximum shchazheniye of healthy fabric — is even more stoutly incarnate in a method of radiation by mobile well kollirovanny bunch. At this method load of the struck brain fabric comes down to doses, much more smaller, than tolerant. Critical structures at G.'s radiation m are eyes and G.'s trunk of m, especially a myelencephalon.

Fig. 59. The scheme of an arrangement of the planes of rotation at radiation of tumors of a brain of various localizations (are specified by a dotted line): 1 — the plane passing through a tumor of a big cerebral hemisphere; 2 — the plane of rotation used at radiation of area of a back cranial pole; 3 — the plane used at radiation of median new growths.

For radiation of new growths of area of the Turkish saddle the technique of mobile radiation with use of an angle of swing 240 ° is optimum at the field of 4x4 cm with the additional lead collimator allowing to reduce beam load of eyes and a trunk of a brain by 4 times. The plane of rotation passes at an angle to the frontal plane (fig. 59) therefore the patient shall lead a chin to a breast as much as possible. Position of the patient is similar and at treatment of tumors of area of a back cranial pole; the angle of rotation opened towards a back cranial pole, 120 — 240 °, fields of radiation not less than 6x6 or 8X8 cm. Distribution of a dose at rotation in sector 240 ° and the field 6x6 hardly practically repeats a shape of a cerebellum, and 30% of the dozny field are covered by all cerebellum.

For radiation of new growths of big hemispheres the field 6 X 6 and 8 X 8 cm is optimum. If the tumor lies not more deeply than 4 — 5 cm from the surface of a skull, then circular rotation is reasonable. In this case the center is covered by 100 — 90% of the dozny field, and eyes and trunk structures receive a dose, much more smaller, than tolerant. At glubinno the growing tumors located klinovidno apply rotation in sector 180 — 240 °.

Apply an oksibaroradioterapiya and intrakarotidny introduction of galogenozameshchenny analogs of thymidine to increase in radio sensitivity, e.g. 5-bromine-2-dezoksiuridina.

The forecast

Depending on gistobiol. features and localization of a tumor life expectancy — from several months to 30 years (e.g., at a neurinoma of the VIII nerve). Cases of self-healing do not happen. After the surgical and combined treatment of tumors of a shell and vascular row, neurinoma, adenomas of a hypophysis there can occur recovery (full or with residual dysfunction) or long remission. At intratserebralny gliomas operation gives only short-term effect.

PHILOSOPHY of SURGICAL INTERVENTIONS AT DISEASES of the BRAIN

Indications for operation on G. to m serve existence of volume process in a head cavity, disturbance of circulation of cerebrospinal liquid in ventricles and a subarachnoid space owing to inflammatory process or occlusion of likvorny ways, existence of the vascular pathology which is followed by hemorrhages or leading to disturbance of blood circulation at a stenosis and fibrinferment of vessels, krovosnabzhayushchy a brain. Indications for an operative measure arise also at the cherepnomozgovy injury complicated by injury of bones of a skull, hematomas, the centers of a contusional softening at a persistent pain syndrome, epilepsy, the violent movements, etc.

Contraindication for operations there can be a localization patol, process in inoperable zones (e.g., tumors of subcrustal nodes, a trunk etc.), multiple metastasises, weight of a condition of the patient, prevalence of process, existence of general diseases and so forth. Are even more differentiated depending on features of a disease of the indication and a contraindication for operations at such diseases as epilepsy (see), hyperkinesias (see), effects of inflammatory processes in a brain and its covers.

Operations of m can be divided into G. on diagnostic and medical.

To to diagnostic operations carry a suboktsipitalny puncture (see) and a ventriculopuncture (see), contrast researches of ways of circulation of cerebrospinal liquid (see Ventrikulografiya, the Encephalography) and vascular pools of G. of m (see. Cerebral angiography ).

Due to the ample diagnostic opportunities of modern neurosurgical clinic the punctures of a brain applied earlier with the diagnostic purpose are practically not used.

Depending on the nature of treatment neurosurgical interventions can be radical and palliative.

Refer removals of a benign extra brain tumor, abscess, a hematoma, removal to radical operations patol, the center within a share of a brain (lobectomy), cliping arterial and excision of arteriovenous aneurism etc.

The interventions directed to elimination of intracranial hypertensia at a nonresectable tumor (a so-called internal decompression, or decompressive trepanation) carry to palliative. Cerebral decompressions reach by means of the interventions normalizing outflow of cerebrospinal liquid from cerebral cavities. It is necessary to emphasize relativity of division of operations on radical and palliative. Operations, palliative at one diseases, at other pathology of G. of m are radical. E.g., creation of a bypass outflow tract of cerebrospinal liquid from a side ventricle in the cerebellar and brain tank (Torkildsen's operation) at the nonresectable tumor blocking circulation of liquid between ventricles is palliative, and at the occlusal hydrocephaly caused by inborn ugliness or effects of inflammatory process can be referred to radical surgical interventions.

Depending on a method distinguish the open brain operations, stereotaxic operations and operations which are carried out by an angiotaksichesky method.

The majority of modern neurosurgical operations is included into the first group. They are made at the most various diseases of G. of m: tumors, traumatic and vascular defeats, hematomas, abscesses, etc. The exposure of these or those areas of a brain is carried out by means of osteoplastic or resection trepanation (see the Craniotrypesis). At osteoplastic trepanation cut a bone rag which after operation is stacked on the former place and recover integrity of a skull. At resection trepanation the site of a bone struck as a result of an injury or a tumor is deleted. By resection trepanation carry out also operations on a back cranial pole as the bone plastics in this area is technically difficult, and the powerful layer of cervical muscles, despite bone defect, reliably protects a brain from possible damages.

Some operations, napr, a puncture of abscess, emptying of a hematoma, a leucotomy, it is possible to carry out through frezevy openings. Except trepanation of bones of a calvaria, at a number of operations apply also other accesses: e.g., approach to a hypophysis by a resection of walls of a wedge-shaped bosom, or an exposure of a front surface of a trunk of G. of m by a resection of a part of a slope of the Turkish saddle with approach through an oral cavity.

Good access — the key to success of intracranial operation therefore the sizes and the place of trepanation shall provide a wide exposure of the relevant structures. During the approach to basal educations, napr, to an arterial circle of a great brain, to area of visual decussation, it is very important to make trepanation most low.

Reduction of volume of G. of m by means of dehydrating agents — a necessary condition of good access to deeply located areas. In many cases the shift and G.'s assignment the m is facilitated thanks to removal of cerebrospinal liquid (a spinal puncture, drainage of ventricles or opening and emptying at the beginning of operation of likvorny tanks of subarachnoid space).

Easy vulnerability of substance G. of m and abundance of the vessels feeding it define some essential features of the neurosurgical equipment. Accidentally not to damage G. of m and to protect it from drying, all naked surface is closed the wadded strips moistened fiziol, solution. Necessary removals of G. of m make special flexible pallets. For long keeping of a brain in a certain situation use the special retractors fixed to bones of a skull. The hemostasis is carried out coagulation or cliping of the bleeding vessels special clip-on earrings. Parenchymatous bleeding is stopped tampons with hydrogen peroxide, an absorbable gelatin sponge or a gauze. To a stop of bleeding from veins and sine of a firm meninx apply a muscular tamponade, plastics a rag of a firm meninx, a podshivaniye of a firm meninx to a periosteum along edge of bone defect and so forth.

Closing of a wound — an important stage of any open operation on G. of m. In all cases where it is possible, it is desirable to recover integrity of a firm meninx and bones of a calvaria. The firm meninx is sewn up with a continuous or knotty suture. If operation is accompanied by removal of its site (e.g., at the shell tumors), it is possible to close the formed defect, having resorted to stratification of a firm meninx or having used an aponeurotic rag, a wide fascia of a hip, a tinned cadaveric meninx.

The bone rag is fixed periosteal, and in case of need — and bone seams. Defects of a bone can be closed bone auto-allotransplant (autogomotransplantaty), quickly hardening plastic and other materials. The pneumatic bosoms opened during operation cover with wax or close a rag of an aponeurosis, edges to-rogo hem to a firm meninx. In these cases topical and general administration of antibiotics is obligatory. Under a bone rag of blood and exudate apply rubber drainages and special vacuum venting to the prevention of accumulation.

Performance of open operations on G. the m demands special equipment (see. Neurosurgical tools ). Special value has illumination of a surgery field. As at operations, especially on basal departments of G. of m, the surgery field happens deep and narrow, it is necessary that the direction of light and an axis of sight matched. Frontal bulbs with the directed beam of light are most convenient.

At operations on G. m widely apply vacuum venting to removal of cerebrospinal liquid, blood, tissue of a brain and soft tumors.

In addition to monopolar electrothermic coagulation at neurosurgical operations with success use the bipolar dot diathermy (or microcoagulation) allowing to coagulate small vessels even near the vital trunk structures without being afraid of their damage (see Diathermocoagulation).

Many operations, napr, at vascular defeats of G. of m, neurinoma of the VIII nerve, basal meningiomas etc., make with use of an operative microscope (see) and special microsurgical tools (see. Microsurgery ).

Micropreparation under direct vision ensures safety of the small perforating arteries, krovosnabzhayushchy subcrustal departments. The microsurgical equipment allows to make reconstructive operations on vessels of a brain, to delete some benign tumors in earlier unavailable areas.

For control of a condition of the patient, delimitation of touch, motor and other zones, and also for studying of functions G. of m of the person during operations use difficult modern neyrofiziol, methods, and operations plan and carry out as exact Kliniko-fiziol. experiment.

Functional neurosurgery. The big group of operations on G. in m is combined by the concept «functional neurosurgery». This group can include the operations applied at treatment of persistent pain syndromes, the surgical interventions eliminating hyperkinesias and normalizing a muscle tone at a number of diseases (parkinsonism, a choreoathetosis, hepatocerebral dystrophy, etc.). epilepsy and some mental diseases operations (persuasive states, patol, aggression). The purpose of these operations — to break off functional patol, chains by destruction of certain links of conduction paths and «relay» subcrustal kernels. In most cases such surgical interventions carry out by a stereotaxic method (see. Stereotaxic neurosurgery). Craniocereberal

injury operations. At a craniocereberal injury surgical intervention is shown at injuries of bones of a skull with a prelum of a brain or implementation in it of splinters, at intracranial bleedings with formation of hematomas (extradural, subdural and intracerebral), at the big contusional centers causing hypostasis and G.'s prelum of m. Need for surgical intervention can be caused also by effects of a craniocereberal injury: formation of likvorny fistulas, abscessing of a brain wound, osteomyelitis of a bone rag and so forth. Surgical tactics, volume and the nature of operation are dictated by specific features of each case (see. Craniocereberal injury).

Surgical treatment of defeats of vessels of a brain. It is shown at aneurisms of vessels of G. of m — one of the main reasons of life-threatening recurrent intracranial hemorrhages. Along with open intracranial operations for switching off patol i of vascular educations with success use an angiotaksichesky method (see Aneurism of vessels of a brain).

Surgical treatment is applied at hemorrhagic strokes; it is especially successful at the lateral hematencephalons which are followed by formation of big hematomas in white matter G. of m (see. Stroke ).

At the ischemic strokes caused by okklyuziruyushchy defeats of vessels, krovosnabzhayushchy

G. in m the reconstructive operations recovering passability of an artery (an intimektomiya, prosthetics of an okklyuzirovanny segment or creation of a bypass anastomosis) are possible. More often such operations undertake at occlusion of the general sleepy and internal sleepy arteries, is more rare at disturbance of a blood-groove on vertebral and subclavial arteries.

Operations at inflammatory damages of a brain. Some effects of inflammatory defeats of G. of m demand surgical treatment, napr, abscess, tuberculomas, gummas.

Need of operation arises at the inflammatory defeat of covers of a brain which is followed by disturbance of outflow of cerebrospinal liquid and hydrocephaly (see). At occlusion median and lateral apertures of the fourth ventricle (Marangdi and Lushki's openings) it is possible to achieve recovery of circulation of cerebrospinal liquid, having separated a surgical way of an union in the field of a back cranial pole. At inflammatory occlusion of a water supply system of a brain good to lay down. the effect gives a neostomy between a side ventricle and the cerebellar and brain tank (Torkildsen's operation) or perforation of a final plate. In certain conditions removal of cerebrospinal liquid from cerebral cavities in the right auricle is shown. At last, at arezorbtivny hydrocephaly, in addition to a ventrikuloatriostomiya, it is possible to resort to removal of cerebrospinal liquid from subarachnoid space of a spinal cord in an abdominal cavity.

Surgical indications can arise at local arachnoidites (especially at cystous forms), napr, at the optokhiazmalny arachnoiditis which is followed by falloff of sight, an arachnoiditis of a mostomozzhechkovy corner, the konveksitalny cystous arachnoiditis which is the reason of focal epilepsy, etc. (see the Arachnoiditis, surgical treatment).

Operations at parasitic defeats. At the parasitic damages of a brain proceeding as volume educations (e.g., an echinococcus) or as widespread defeat of covers of G. of m with disturbance of dynamics of cerebrospinal liquid (e.g., cysticercosis) or as a combination of that and another, surgical interventions are similar to those which are applied at abscesses and limited tumors or are used for normalization of circulation of cerebrospinal liquid at productive processes of covers of G. of m.

Tumors operations. Irrespective of gistol, the nature of a tumor inevitably lead to irreversible injury of a brain; being located in the closed head cavity, they in process of growth squeeze tissue of a brain more and more. Therefore the fact of existence of a tumor of G. of m is the indication for an operative measure. The purpose of operation — a radical oncotomy in those cases where it is possible (e.g., benign limited tumors — meningiomas, angioretikuly, neurinoma, etc.), and a partial oncotomy (intracerebral glial tumors, the shell tumors, on a big extent the striking bones of a skull growing into venous sine of a firm meninx, etc.), reduction of a prelum of a brain and decrease in the increased intracranial pressure (decompressive trepanation at tumors of a brainstem, removal of cerebrospinal liquid from side cerebral cavities at their occlusion a tumor, etc.).

Contraindications for surgical treatment arise at widespread deep tumors, multiple metastatic tumors, extreme exhaustion of patients, etc.

Extra brain tumors, first of all the tumors growing from covers of a brain which vast majority can be removed considerably are optimum from the surgical point of view. The shell tumors (meningiomas) considerably differ in size, localization, the relation to the vital departments of a brain and vascularization. In this regard on the volume and complexity the corresponding operations sharply differ. It is necessary to carry their rich vascularization, rather frequent growing into sine of a brain and damage of an adjacent bone to features of the shell tumors defining specifics of surgical intervention. Therefore during surgical removal of the shell tumors such moments as surgical access, artificial arterial hypotension, a technique of preparation of the vessels connected with a tumor have special value. Operations at the located meningiomas difficult available basally (meningiomas of a hillock of the Turkish saddle, wings of the main bone, etc.) which often acquire large arteries, krovosnabzhayushchy a brain are especially difficult, and squeeze the vital trunk departments. Technology of operations at tumors of a hypophysis, cranyopharyngiomas, neurinoma of the VIII nerve is specific (see the Hypophysis, the Mostomozzhechkovy corner).

Treatment of intracerebral tumors most of which part is made by glial tumors — one of the most complex problems of modern neurosurgery. Lack of a clear boundary and distribution to deep departments is characteristic of them, up to walls of side ventricles therefore the vast majority of intracerebral tumors considerably not udalima. The exception is made by astrocytomas of a cerebellum which excision can lead to long remission or even to almost absolute recovery. At nodal forms the tumor can be removed considerably within the perifocal zone surrounding it. The volume of operation is defined by the nature of a tumor (degree of a zlokachestvennost, nodal or infiltrative growth) and its position of rather functionally important structures of G. of m. At localization of tumors in functionally rather less important zones (a tumor frontal and temporal shares of a subdominant hemisphere) the resection of a share of G. of m affected with a tumor is admissible (see the Lobectomy).

At localization of a tumor in motive, speech and other functionally important zones, at distribution to underlying structures perhaps only partial removal. Apply trial punctures of a brain which allow to define the change of density of tissue of brain corresponding to a tumor to specification of borders of an intracerebral tumor, to find the cysts which are contained in tumors. With the same purpose the radio isotope research allowing to distinguish in some cases a tumor from surrounding substance of a brain as they differently accumulate some radioisotopes, and some other researches is used.

Primary limited tumors of ventricles (a horioidpapilloma, a meningioma) can be considerably removed. If the oncotomy is impossible, carrying out palliative operations with removal of cerebrospinal liquid from okklyuzirovanny ventricles is reasonable.

Features of neurosurgery of children's age. A number of diseases of G. of the m demanding surgical intervention meets preferential at children's age. First of all it is necessary to carry various malformations to them (hernias of a brain, etc.). At children's age neuroectodermal tumors prevail, and are especially frequent is median the located G.'s tumors of m. Considerably more often than at adults, cranyopharyngiomas meet. Tumors of a meningososudisty row at children are rather rare. Many diseases (tumors, inflammatory processes, etc.) lead to development of hydrocephaly, treatment a cut at children's age represents an independent task (see Hydrocephaly). For removal of the phenomena of acute occlusion of ways of circulation of cerebrospinal liquid at children often resort to repeated ventriculopunctures or installation of system of a long drainage in side cerebral cavities. After removal of the child from serious condition radical operation can be undertaken.

The principles of surgical interventions at children the same, as at adults, though anatomic features of children's age (thin elastic bones, existence of fontanels, etc.) introduce certain amendments in performance of these or those surgical receptions.

Preoperative preparation and anesthesia at brain operations. A number of the features causing anesteziol is inherent in neurosurgical operations. tactics. In particular, subject to intervention is plentifully vaskulyarizirovanny G. of m. The surgery field is located near upper respiratory tracts. Reaction on patol, process or an operational injury is hypostasis, swelling of a brain — increase in extent of hydration of all G. of m or its part with development of intracranial hypertensia (see Hypostasis and swelling of a brain). Patol, process and surgery break a blood-brain barrier (see). All this introduces certain specifics in preoperative preparation, maintaining an anesthesia and a conclusion from a narcotic state.

In the course of preoperative preparation carry out hemodilution (see) for the prevention of possible deficit of volume of the circulating blood. Cerebral decompressions reach introduction of saluretics and osmotic diuretics. The prevention of hormonal insufficiency and normalization of functions of a blood-brain barrier are carried out the glucocorticoid hormones and drugs reducing vascular permeability.

The majority of neurosurgical interventions carry out under multicomponent anesthesia (the combined anesthesia).

The introduction anesthesia is carried out intravenous administration of hexenal or thiopental-sodium, Droperidolum and fentanyl; at children — inhalation of nitrous oxide with Ftorotanum. Intubate a trachea against the background of the artificial mioplegiya caused by introduction of the depolarizing muscular relaxants (suktsinilkholin). Right after the beginning of a mioplegiya in order to avoid the hypercapnia which is sharply increasing intracranial pressure include artificial ventilation of the lungs (see. Artificial respiration, artificial ventilation of the lungs).

The main method of maintenance of an anesthesia (see) — artificial ventilation of the lungs on a semiopen circuit by means of narcotic devices or medical ventilators mix of nitrous oxide with oxygen (3: 1 or 2:1) and small concentration of strong inexplosive narcotic substances (Ftorotanum or Penthranum); the anesthesia is not deeper than III1 of a stage. Widely use a combination of an anesthesia nitrous oxide with a neyroleptanalgeziya (see). The anesthesia is supplemented with a local infiltration anesthesia of 0,25% solution of novocaine with adrenaline (1:1000). At operations on G.'s vessels of m, during removal of plentifully krovosnabzhayemy tumors use the managed hypotonia. It is not necessary to reduce systolic the ABP lower than 60 mm of mercury. and more than for 1,5 hours. For ensuring approach to basal departments it is necessary to reduce G.'s volume of m that is reached use of Mannitolum, urea, lasixum, deflation of cerebrospinal liquid by means of the ventrikulyarny or lumbar puncture moderated by a hyperventilation (pCO2 is not lower than 25 mm of mercury.). The best results are yielded by complex use of these methods. The artificial hypothermia (see the Hypothermia artificial) is applied seldom, by hl. obr. in need of the termination of a blood-groove on the main vessels for the term of more than 4 min.

After operation it is necessary to wake quickly the patient to provide early neurologic diagnosis.

Except the stated general principles, it is necessary to consider certain specifics anesteziol, actions at interventions on various departments of G. of m E.g., at hypophysis operations, during removal of meningiomas of a hillock of the Turkish saddle, cranyopharyngiomas and gliomas of an optic nerve include a hydrocortisone in preparation — 100 — 150 mg a day or other glucocorticoid hormones (Prednisolonum, dexamethasone) in equivalent doses. At a subfrontal oncotomy good access is provided with use of osmotic diuretics in combination with a moderate hyperventilation. After operation continue treatment by glucocorticoid hormones within 5 — 7 days.

During removal high-quality, usually plentifully vaskulyarizirovanny, tumors of hemispheres of G. of m of blood loss) reduce by means of artificial hypotonia (see. Hypotonia artificial ) in combination with sublime position of the head (Fowler's position). Blood loss is immediately filled. For the prevention of deficit of volume of the circulating blood use presurgical hemodilution Polyglucinum, to Gelatinolums. At malignant tumors enter glucocorticoid hormones for the purpose of normalization of functions of a blood-brain barrier and reduction of perifocal hypostasis.

Fig. 60. The «improved» sitting position recommended at operative measures in the field of a back cranial pole.

Operations at tumors of a mostomozzhechkovy corner and the fourth ventricle make in position of the patient on one side or sitting that provides the best access, but is accompanied by danger of developing of a cardiovascular collapse and air embolism. These complications warn use of the «improved» situation (fig. 60), elimination of deficit of volume of the circulating blood and carrying out artificial ventilation of the lungs under positive and zero or polozhitelnopolozhitelny pressure. The pressor reactions and bradycardia arising during removal of tumors of a mostomozzhechkovy corner are eliminated with administration of alpha adrenoblockers (Tropaphenum, phentolamine) and atropine. Depressory reactions during removal of tumors of a bottom of the fourth ventricle force to refuse continuation of intervention. After operation of patients it is necessary to transport in a sitting position, to provide the maximum rest, to avoid jumps of situation; on call there have to be tools for production ventriculopunctures (see).

Operations on G.'s vessels of m make with use of the managed hypotonia under the combined anesthesia with Ftorotanum or Penthranum. The last is more preferable since allows to raise the ABP if necessary. Endovazalny occlusions patol. vascular educations carry out under local anesthesia.

Stereotaxic operations make under local anesthesia (see. Stereotaxic neurosurgery ). The neyroleptanalgeziya can also apply) or an anesthesia nitrous oxide with Ftorotanum.

At diagnostic testings use premedication ataraktichesky drugs (Seduxenum) and local anesthesia. At children and at behavior disorders at adults use an intravenous anesthesia Epontolum (Sombrevinum), hydroxybutyrate of sodium, etc. or a gas anesthesia nitrous oxide with Ftorotanum.



Bibliography

Anatomy — The atlas of a great brain of the person and animals, under the editorship of S. A. Sarkisov and I. N. Filimonov, M., 1937; Blumenau L. V. - the Brain of the person, L. — M, 1925; Bryusova S. S. Angiography of a brain, M., 1951; And B. K N-dtse. Arterial system of a brain of the person and animals, p.1 — 2, M., 1947 — 1948; Grinstein A. M. Ways and centers of a nervous system, M., 1946; Zavarzin A. A. Sketches on evolutionary histology of a nervous system, M., 1941; To ares yan A. I. Functional evolution of a brain of vertebrata, L., 1970; Klosovsky B. N. Blood circulation in a brain, M., 1951; M of An and N and A. A. Ultrastructural bases of activity of a brain, L., 1976; The Multivolume guide to neurology, under the editorship of N. I. Grashchenkov, t. 1, book 1, M., 1959; Sepp E. K. History of development of a nervous system of vertebrata from acranial to the person, M., 1949; Sh and d e of J. and Ford D. Fundamentals of neurology, the lane with English, M., 1976; Sh in and l of e in V. N., R. M. and Mingazov I. V. Reyd-ler. Stages of formation of the autonomic nervous system in connection with emergence of its main mediators in an embryogenesis, Arkh. annate., gistol, and embriol., t.63, No. 8, page 48, 1972, bibliogr.; Clara M. Das Nervensystem des Menschen, Lpz., 1959, Bibliogr.; Crosby E. Page, H a m p h r e at T. a. L an u e r E. W. Correlative anatomy of the nervous system, N. Y., 1962; Herrick C. J. An introduction to neurology, Philadelphia — L., 1927; His W. Die Entwicklung des menschlichen Gehirns, Lpz., 1904; Kaplan H. A. a. Ford D. H. The brain vascular system, N. Y., 1966; Kappers C. U. A., Huber G. C. a. Crosby E. C. The comparative anatomy of the nervous system of vertebrates, including man, v. 1—2, N. Y., 1936; Kety S. S. The cerebral circulation, Handbook of physiology, sect. 1 — Neurophysiology, ed. by J. Field, v. 3, p. 1751, Washington, 1960; Nall M. L. a. Ferguson F. C. Physiology of the circulation of the brain, an annotated bibliography 1938 — 1952, Washington, 1956; B.M.'s Patten. Carlson of B.M. Foundations of embryology, N. Y., 1974; RansonS. W. The anatomy of the nervous system, Philadelphia — L., 1947; Villiger E. Gehirn und Ruckenmark, Basel, 1946, Bibliogr.; Walker A. E. a. F an e t h W. H. Vascular system, in book: Progr. neurol. psychiat., Ann. Rev., v. 9, p. 367, N. Y., 1954, bibliogr.

Physiology — Anokhin P. K. Biology and neurophysiology of a conditioned reflex, M., 1968, bibliogr.; B of e r and t about in I. S. General physiology of muscular and nervous systems, t. 2, M. — L., 1948; about N e, About physiological mechanisms of behavior of the highest vertebrate animals, Izv. Academy of Sciences of the USSR, it is gray. biol., Nt 2, page 137, 1957; Bekhterev V. M. Bases of the doctrine about functions of a brain, century 1 — 7, SPb., 1903 — 1907; K. M. Bulls and Slonim A. D. Researches of complex-reflex activity of animals and the person under natural conditions, M. — L., 1960, bibliogr.; Delgado of X. M. R. Mozg and consciousness, the lane with English, M., 1971, bibliogr.; Ivanitsky A. M. Brain mechanisms of assessment of signals, M., 1976, bibliogr.; Konorsky Yu. Integrative activity of a brain, the lane with English, M., 1970; Musyashchikovas. Page ichernigov-with to and y V. N. Cortical and subcortical representation of visceral systems, L., 1973, bibliogr.; M e at N G. Bodrstvuyushchy a brain, the lane with English, M., 1965, bibliogr.; The general and private physiology of a nervous system, under the editorship of P. G. Co-styuka, L., 1969; About r e of l and L. A. Lectures on physiology of a nervous system, M. — L., 1938, bibliogr.; Pavlov I. P. Complete works, t. 3, book 1 — 2, M. — L., 1951; G. I. O Poles principles of the neural organization of a brain, M., 1965; Sechenov I. M. Reflexes of a brain, M., 1952; Ukhtomsky A. A. Collected works, t. 1 — 6, L., 1950 — 1954; Physiology of higher nervous activity, under the editorship of E. A. Asratyan, p.1 — 2, M., 1970 — 1971; X and N and N and sh in fi - whether M. M. Neyronalno-izolirovannaya bark, L., 1971, bibliogr.; Sh e r r and N of tone of H. Integrative activity of a nervous system, the lane with English, L., 1969; E to l with D. Physiology of synapses, the lane with English, M., 1966; it, Brake ways of the central nervous system, the lane with English, M., 1971; E sh and U. R. Konstruktion of a brain, the Origin of adaptive behavior, the lane with English, M., 1964; Gellhorn E. The physiological foundations of neurology and psychiatry, p. 333, L., 1953.

Biochemistry — Biochemistry and function of a nervous system, under the editorship of E. M. Krepsa, L., 1967; Questions of biochemistry of a brain, under the editorship of G. of X. Bunyatyana, century 1 — 9, Yerevan, 1964 — 1974; Gayevskayam. S. Biokhimiya of a brain during the dying and revival of an organism, M., 1963, bibliogr.; Galo-yan A. A. Some problems of biochemistry of hypothalamic regulation, Yerevan, 1965, bibliogr.; Geynisman 30. Ya. Structural and metabolitichesky manifestations of function of neuron, M., 1974, bibliogr.; Danilevsky A. Ya. Phosphorous proteins of a brain, in book: Fiziol, Saturday., under the editorship of A. Danilevsky, t. 2, Kharkiv, 1891; Ivanenko E. F. Biochemistry of a brain at an anesthesia, L., 1972, bibliogr.; Crêpe of E. M. Phospholipids of cellular membranes of a nervous system in development of fauna, L., 1967, bibliogr.; To at r-with to and y M. D. and B and to sh e e in N. S. Biochemical bases of the mechanism of effect of serotonin, Kiev, 1974, bibliogr.; Pas of l-l and d and A. V. N, B of e of l and to Ya. V. and Polyakova H. M. Proteins of a brain and their exchange, Kiev, 1972, bibliogr.; Pevzner L. 3. Functional biochemistry of a neuroglia, L., 1972, bibliogr.; P and are of e in and 3. D. Biokhimiya of the developing brain, M., 1972, bibliogr.; Polenov A. L. Hypothalamic neurosecretion, L., 1968, bibliogr.; Sytinsky I. A. Piperidic acid in activity of a nervous system, L., 1972, bibliogr.; Hachatryan G. S. Biochemistry of a brain under normal physiological conditions, Geksozomono-fosfatny the shunt in a brain, Yerevan, 1967, bibliogr.; Basic neurochemistry, ed. by R. W. Albers and. lake, Boston, 1972; Biochemistry of brain and behavior, ed. by R. E. Bowman a. S. P. Datta, N. Y., 1970; Brain dysfunction in metabolic disorders, ed. by F. Plum, N. Y., 1974; Handbook of neurochemistry, ed. by A. Lajtha, v. 1—7, N. Y. — L., 1969 — 1972; Me I 1 w an i n H. Chemical exploration of the brain, Amsterdam a. o., 1963; Nachmansohn D. Chemical and molecular basis of nerve activity, N. Y. — L., 1959, bibliogr.; Thu-dichumJ.L. W. Die Chemische Konsti-tution des Gehirns des Menschen und der Tiere, Tubingen, 1901; WollemannM. Biochemistry of brain tumors, Budapest * 1974.

Pathological anatomy — A histopathology of the central nervous system, the Atlas of microphotos, under the editorship of A. P. Avtsyn, M., 1969, bibliogr.; D and-vydovsky I. V. General pathology of the person, page 368, M., 1969; And about t and nanosecond to and y Yu. M. Normal and pathological morphology of neuron, L., 1965, bibliogr.; Zurabashvili A. D. Synapses and reversible changes of nervous cells, M., 1958, bibliogr.; Manya N and A. A. Ultrastructural changes of N Reparative processes in the central nervous system at various influences, page 60, L., 1971; The Multivolume guide to neurology, under the editorship of S. N. Da-videnkov, t. 5, page 11, M., 1961; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 2, page 369, M., 1962; Sarkisov S.A. and Bogolepov N. N. Submicroscopy of a brain, M., 1967, bibliogr.; Smirnov L. I. To the gistogenetichesky characteristic of tumors of a meninx, Vopr, neyrokhir., No. 3, page 2G, JNs 5, page 3, 1940, No. 2, page 3, 1941; it, the Histopathology of a nervous system, the Management on nevrol, under the editorship of N. I. Grashchenkov, etc., t. 2, century 1, M. — L., 1941, bibliogr.; it e, the Histogenesis, histology and a toiografiya of tumors of a brain, p.1 — 2, M., 1951 — 1959; Snesarev P. E. Theoretical bases of a pathological anatsmiya of mental diseases, M., 1950; H a g e of H. Die fei-nere Cytologie und Cytopathologie des Ner-vensystems, S. 71, Stuttgart, 1964; Hand-buch der speziellen pathologischen Anatomie und Histologie, hrsg. v. O. Lubarsch u a, Bd 13, T. 1, S. 101, B. u. a., 1957; Kornyey St. Histopathologie und klinische Symptomatologie der anoxisch-vasalen Hirnschadigungen, Budapest, 1955, Bibliogr.; Russell D. S. a. R u-binstein L. J. Pathology of tumors of the nervous system, L., 1971; Spiel-m e y, e r W. Histopathologie des Nerven-systems, Bd 1, B., 1922; Ziilch K. J. Die Hirne^chwulste in biologischer und morphologischer Darstellung, Lpz., 1956, Bibliogr.; o of N of e, Atlas of the histology of brain tumors, B. — N. Y., 1971, bibliogr.

Pathology — Badalyan L. O. Children's neurology, M., 1975; B of l and the Tax Code about in S. M. and Smirnov N. A. Shifts and deformations of a brain, Morphology and clinic, L., 1967, bibliogr.; Bogolepov N. K. Semiotics and diagnosis of nervous diseases, M., 1973; Boldyrev A. I. Epileptic syndromes, M., 1976, bibliogr.; In and N and r-skayae. N and Pulatova. M. Dizartriya and her topiko-diagnostic value in clinic of focal defeats of a moeg, Tashkent, 1973, bibliogr.; In I - territorial H. M. Znacheniye of focal lesion of a brain in clinic and a pathogeny of mental disorders, M., 1964, bibliogr.; Galperin M. D. An angiography in diagnosis of tumors and vascular diseases of a brain, L., 1962, bibliogr.; r and nshteyna. M and Popova N. A. Vegetative syndromes, M., 1971; To about to E. P. Visual agnosias, Syndromes of disorders of the highest visual functions at hemilesions temporal and occipital and temenno occipital area of a brain, L., 1967, bibliogr.; Kopylov M. B. Bases of radiodiagnosis of diseases of a brain, M., 1968, bibliogr.; Kornyansky G. P., Vasin N. Ya. and Epstein P. V. Parasitic diseases of the central nervous system, M., 1968; Korovina. M. Paroxysmal disorders of consciousness, L., 1973; To about r with L.O's t. Tumors of parietal shares of a brain (clinic and diagnosis), M., 1964, bibliogr.; Krasovsky E. B. Uglinesses of the central nervous system, M., 1964; Petelin L. S., Kasatkin Yu.N. of S. M inosikov. Radio isotope diagnosis of diseases of a brain, M., 1976, bibliogr.; A. V triumphs. Topical diagnosis of diseases of a nervous system, L., 1974; F and y-zullin M. of X. Radiodiagnosis of tumors of a brain, Kazan, 1967; Tsuker M. B. Clinical neuropathology of children's age, M., 1972; Sh and and with H. Evoked potentials of a brain are normal also of pathology, the lane with English, M., 1975, bibliogr.; Sheliya R. N. Tumors of ventricular system of a brain, L., 1973; Shmaryan A. S. Moegovy pathology and psychiatry, t. 1, M., 1949; Schmidt E. V., Lunev D. K. and Vereshchagin N. V. Vascular diseases of a head and spinal cord, M., 1976; Arseni C. u Oprescu I. Traumatologia eranio-cerebreala, Bucure§ti, 1972, bibliogr.; Bailey P. Intracranial tumors, Springfield, 1948, bibliogr.; Carey M, E., Chou S. N. a. F r e n with h L. A. Experience with brain abscesses, J. Neurosurg., v. 36, p. 1, 1972, bibliogr.; Constante J. - P. et Sch lienger M. Indications de la radiother^pie dans les tumeurs intra-craniennes et intrarachidiennes de 1’adulte (Tumeurs de l’hypophyse of except£es), P., 1975; Cushing H. Intrakranielle Tumo-ren, B., 1935; Goldhahn G. Psycho-pathologie der Tumoren des Grosshirns, Lpz., 1970; J a n z e n R. Neurologisehe Diagnostik, Therapie und Prognostik, Stuttgart, 1975; Klinische Neuroradiologie, hrsg. v. K. Decker, Stuttgart, 1960; T a-veras J. M. a. Wood E. H. Diagnostic neuroradiology, Baltimore, 1964, bibliogr.

Surgical treatment — Abrakov L. V. Fundamentals of stereotaxic neurosurgery, L., 1975, bibliogr.; B of joint stock company and y L. and L and. Wet brain, the lane with English, M., 1969; Vasin N. Ya. Surgical treatment of tumors of a temporal share of a brain, M., 1976, bibliogr.; Herzen P. A. About operations for front brain hernia, the Collection of works prope-devtich. hir. wedge. 1st Mosk. un-that, century 3, page 5, M., 1926; Zverev A. F. Inborn cherepnomozgovy hernias and their surgical treatment, M., 1967, bibliogr.; Zlotnik E. A hemostasis and the managed arterial hypotonia in brain surgery, Minsk, 1965; Kandelye. And. and D. V. Kriokhirurgiya's Atlas, M., 1974; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 3, book 1 — 2, M., 1968, t. 4, M., 1963; Fundamentals of neurosurgery of children's age, under the editorship of A. A. Arendta and S. I. Nersesyants, M., 1968; Fundamentals of practical neurosurgery, under the editorship of A. L. Polenov and And. C. Women ranks, L., 1954, bibliogr.; With N and of ra pe in V. of Page 0-radiometry in surgery of tumors of big cerebral hemispheres, Vopr, neyrokhir., KV 1, page 12, 1972, bibliogr.; Surgery of the central nervous system, under the editorship of V. M. Ugryumov, p.1 — 2, L., 1969; Since about with k e r E. F. a. o. Technitium brain scanning in the diagnosis and management of brain abscess, Amer. J. Med., y. 56, p. 192, 1974; DandyW. Himchirurgie, Lpz., 1938; Handbuch der Neurochirurgie, hrsg. v. H. Olivecrona u. W. Tonnis, Bd 1—7, B., 1954 — 1974; K e m p e L. G. Operative neurosurgery, v. 1, B., 1968; Suwanwela Ch., Sukabote With h. a. Suwanwela N. Fron toethmoi dal encephalomeningocele, Surgery, v. 69, p. 617, 1971; Tandon P. N. Meningoencephalocoeles, Acta neurol. scand., v. 46, p. 369, 1970.


B. H. Klosovsky, E. P. Kononova, And. H. Filimonov (An.), B. H. Chernihiv, H. F. Suvorov, B. H. Uranium, M. M. Hananashvili (physical.), G. H. Bunyatyan (biochemical), A. P. Avtsyn, A. N. Koltover, B. A. Morgunov (stalemate. An.), A. M. Lokshina, F. M. Lyass, 3. I. Polyanker, V. S. Snigirev (mt. issl., I am glad., rents.), L. G. Yerokhina (symptomatology), L. O. Badalyan, V. N. Shvalev (malformations), V. I. Rostotskaya (hernias), A. P. Romodanov (diseases), N. Ya. Vasin (parasitic diseases), V. V. Arkhangelsky (classification of tumors), E. Ya. Shternberg (psikhiat.), N. A. Smirnov (PMC.), A. N. Konovalov (neyrokhir.), And. 3. Manevich (anest.).

Яндекс.Метрика