CEREBROSPINAL LIQUID [liquor cerebrospinalis; lat. cerebrum brain + (medulla) of spinalis spinal cord; synonym: spinno
brain liquid, liquor] — the fluid biological medium of an organism circulating in ventricles of a brain, likvoroprovodyashchy ways, subarachnoid (subarachnoid) space of a head and spinal cord.
C. carries out in c. N of page for - shchitno-trophic functions. It protects a head and spinal cord from mechanical influences, provides maintenance of constant intracranial pressure (see) and relative constancy of osmotic pressure (see) in tissues of a brain; takes part in metabolism of a brain, performing transport function in a metabolism between tissues of a brain and blood, in processes of neurohumoral and neuroendocrinal regulation, ensuring maintenance of a water and electrolytic homeostasis (see the Water salt metabolism). C. participates in development of compensatory and protective mechanisms at patol. conditions of c. N of page, accumulating antibodies, antibacterial and other agents. The system of a likvoroobrashcheniye is closely connected with system of cerebral circulation. It is caused by hl. obr. that blood supply of the vascular textures which are carrying out products of C., it is provided with branches of brain arteries of carotid and verte-brobazilyarny systems. Vascular system of c. the N of page plays a role of the blood-cerebrospinal fluid barrier interfering penetration of nek-ry substances from blood in tissue of a brain (see. Barrier functions, Blood-brain barrier).
About existence of C. Hippocrates, Herophilos and Erazistrat knew already. F. Marangdi for the first time formulated idea of circulation of C., described a structure of ventricles and vascular textures of a brain. Its works laid the foundation for intensive studying of C. at the end of 19 century. A big contribution to development of the doctrine about C. (likvorologiya) were brought by domestic and foreign researchers: A. V. Favors
cue, V. K. Horoshko, L. M. Pussep, G. Quincke, M. Nonna, F. Apelt, Lange (Page F. A. Lange), V. Kafka, Ayer (J. Century of Ayer), etc. Significant progress of a likvorologiya for the last decades is connected with M. A. Baron, D. A. Shamburov, A. P. Friedman, Schmidt's works (R. M of Schmidt), etc.
C. it is concluded generally in side, third and fourth ventricles of a brain (see Ventricles of a brain), a silviyevy water supply system, tanks of a brain (see) and in a subarachnoid space of a head and spinal cord (see). Process of a likvoroobrashcheniye in c. the N of page includes three fundamental units: products (education), tsir-
kulyation and outflow of C. Products of bulk of C. it is carried out by vascular textures (see) ventricles of a brain by active secretion by ferruterous cells. Second mechanism of formation of C. dialysis of blood through walls of blood vessels and an ependyma of cerebral cavities is, to-rye function as the dialyzing membranes. Exchange of ions between a blood plasma and C. occurs by active membrane transport. In products of C., in addition to structural elements of cerebral cavities, the vascular network of a brain and its covers, and also cells of brain fabric (neurons and a glia) take part. However in normal, physiological, conditions extra-ventrikulyarnaya (out of cerebral cavities) products of cerebrospinal liquid are very insignificant.
Circulation of C. occurs constantly; from side cerebral cavities through Monroe opening it comes to the third ventricle, and then through silviyev a water supply system — to the fourth ventricle. From the fourth ventricle through Lushki and Marangdi's openings the most part of C. passes into tanks of the basis of a brain (the cerebellar and brain, covering tanks of the bridge, the intercrural tank, the tank of an optic chiasm, etc.), reaches a silviyevy (side) furrow and rises in a subarachnoid space of a konveksitalny surface of cerebral hemispheres (a so-called branch track of circulation of C.). In a crust, time it is established that there is also other way of circulation of C.: from the cerebellar and brain tank in tanks of a worm of a cerebellum (see), via the covering tank in a subarachnoid space of medial departments of cerebral hemispheres (a central route of circulation). Smaller part C. from the cerebellar and brain tank goes down caudally in a subarachnoid space of a spinal cord, reaching the final tank (fig. 1). Opinions on circulation of C. in a subarachnoid space of a spinal cord are contradictory; the point of view about existence of current of C. willows the cranial direction it is divided not by all researchers so far. Circulation of C. it is connected with existence of gradients of hydrostatic pressure in a face-voronosnykh ways and receptacles, to-rye changes of venous pressure and position of a body, and also other factors are created owing to a pulsation of intracranial arteries.
Outflow of C. in the basic (30 — 40%) occurs through arachnoidal (iakhionova) granulations (vorsina)
of Fig. 1. The diagrammatic representation of ways of circulation of cerebrospinal liquid (on a frontal section of a skull and the spinal channel): cerebrospinal liquid from side ventricles comes to the third ventricle, and then through silviyev a water supply system — to the fourth ventricle; from the fourth ventricle cerebrospinal liquid passes into tanks of the basis of a brain and rises in a subarachnoid space of a brain; a small part of cerebrospinal liquid goes down caudally in a subarachnoid space of a spinal cord (the direction of the movement of cerebrospinal liquid is specified by shooters); 1 — cerebral hemispheres; 2 — a side ventricle; 3 — an intra ventricular vascular texture; 4 — the III ventricle; 5 — silviyev a water supply system; 6 — it is mashed a cerebellum; 7 — roots of spinal nerves; 8 — the final tank; 9 — a subarachnoid space of a spinal cord; 10 — a spinal cord; 11 — the IV ventricle; 12 — a cerebellum; 13 — a subarachnoid space of a brain; 14 — arachnoidal (pakhionova) granulations; 15 — an upper longitudinal sine; 16 — a firm meninx of a head and spinal cord.
in the upper longitudinal sine which is a part of venous system of a brain. Arachnoidal granulations represent shoots of an arachnoid membrane, to-rye penetrate a firm meninx and are located directly in venous sine (see the Meninx). Main mechanism of outflow of C. from subarachnoidal (subarachnoid) space through an arachnoid membrane and its derivatives (arachnoidal granulations) in venous system the difference in the hydrostatic pressure of C is. and venous blood. Pressure of C. normal exceeds venous pressure in an upper longitudinal sine on 15 — 50 mm w.g. About 10% of C. flows through a vascular texture of cerebral cavities, from 5 to 30% — in limf, system through perineural spaces of craniocereberal and spinal nerves. Besides, there are N other outflow tracts of C., napr, from subarachnoidal in a subdural space, and then in vascular network of a firm meninx or from intercellular spaces of a brain in vascular system of a brain. Nek-roye number of C. it rezorbirutsya by an ependyma of cerebral cavities and vascular textures.
Total amount circulating C. at the adult normal makes 90 — 200 ml, on average apprx. 140 ml. Updating C. there are about 4 — 8 times a day. Considerable fluctuations of speed of updating C. depend on a daily diet, a water relationships, fluctuations of activity fiziol. processes in an organism, fiziol. loads of c. N of page, etc.
Structure and properties of cerebrospinal liquid. C., received at a spinal puncture (see) — so-called lumbar liquor — it is normal transparent, colourless, has constant ud. weight — 1,006 — 1,007; ud. weight of C. from ventricles of a brain (ventrikulyarny liquor) —
1,002 — 1,004. Viscosity of C. normal fluctuates from 1,01 to 1,06 spz. C. has alkalescent reaction — pH 7,4 — 7,6. Long-term storage of C. out of an organism at a room tekhmperatura leads to gradual increase it pH. Temperature of C. in a subarachnoid space of a spinal cord — 37 — 37,5 °; surface intention — 70 — 71 dynes! cm; a freezing point — 0,52 — 0.6 °; conductivity —
1,31 - 10-2 — 1,38-10 of "2 ohms '1 • cm' 1; a refraktometrichesky index — 1,33502 — 1,33510; gas structure (in about. %): 02 — 1,02 —
1,66, C02 — 45 — 64; alkaline re
zerv — 49 — 54 about. %.
Chemical structure of C. it is similar to composition of blood serum: 89 — 90% are made by water; the solid residue (10 — 11%) contains the organic and inorganic matters which are taking part in metabolism of a brain. The organic matters which are contained in C., are presented by proteins (see), amino acids (see), carbohydrates (see), urea (see), glycoproteins (see) and lipoproteids (see); inorganic matters — electrolytes, inorganic phosphorus (see), microelements (see). Structure of C. it is normal presented in the table.
Protein normal C. it is presented by albumine (see) and various fractions of globulins (see). Contents in C is established.
more than 30 various protein fractions. Proteinaceous structure of C. differs from proteinaceous composition of blood serum in existence of two additional fractions: predalbumino-
howl (H-fraction) and the T-fraction which is located between fractions r-and ^-globulins.......... The prealbuminous fraction in ventrikulyarny liquor makes 13 — 20%, in C., contained in the big tank —
7 — 13%, in lumbar liquor —
4 — 7% of crude protein. Sometimes betrayed buminovy fraction in C. it is not possible to find since it can mask albumine or at very large amount of protein in C. in general to be absent. Diagnostic value has proteinaceous coefficient of Kafka (the attitude of amount of globulins towards amount of albumine), to-ry from 0,2 to 0,3 normal fluctuates.
In comparison with a blood plasma in C. higher content of chlorides, magnesium is noted, yo glucose, potassium, calcium, phosphorus, urea contains less.
The maximum quantity of sugar contains in ventrikulyarny C., the smallest — in C. subarachnoid space of a spinal cord. 90% of sugar are made by glucose, 10% — a dextrose. Concentration of sugar in C. depends on its concentration in blood.
Quantity of cells (cytosis) in C. normal does not exceed 3 — 4 in 1 mkl, these are lymphocytes (see), cells an arakhno-idendoteliya (see the Meninx), ependymas of ventricles of a brain (see the Ependyma), polyblasts (free macrophages).
Pressure of C. in the spinal canal at position of the patient lying on one side normal makes 100 — 180 mm w.g., in a sitting position it raises to 250 — 300 mm w.g. In the cerebellar and brain (big) tank of a brain pressure is slightly lower than it, and in ventricles of a brain makes only 10 — 20 mm w.g. Children have pressure of C. below, than at adults.
Methods of a research. In the most widespread way of receiving C. for a research the spinal puncture is (see). Receiving C. by a suboktsipi-taljny puncture (see) or ventriculopunctures (see) perhaps only in specialized neurosurgical hospitals, on proved a wedge, to indications. At punctures of C. for organoleptic, chemical, cytologic, bacteriological, immunological and other types of a research collect in sterile test tubes. Complex of researches C. at each patient is defined by need of specification of the estimated diagnosis and the control of efficiency which are carried out to lay down. actions.
In a wedge, practice determination of pressure, color and transparency of C is obligatory. (before centrifuging), quality and quantitative standard of impurity of blood, intensity of yellowing (xanthochromia), protein content, number of cells (cytosis) and their qualitative structure (tsitolikvorogramm).
First investigation phase of C. measurement of its pressure is, a cut make during a puncture of this or that its receptacle. Tonometry is performed the water manometer of Ayer or the electromanometer, transitional cannulas to-rykh attach to an aspirating needle. During a puncture it is also possible to take electrothermometers temperature to C. (rakhiter-mometriya). The great value for nosological and topical diagnoses has comparison of the data obtained as a result of a research C., taken from its various receptacles. The size of pressure gives an idea of a condition of products and outflow of C., and also passability of ways of its circulation. At a spinal puncture make liquorodynamic tests (see) for detection of passability of a subarachnoid space within the spinal channel.
For visualization of subarachnoid spaces, determination of level and character of the block of ways of circulation of C. (a tumor, commissural process, etc.) apply X-ray-radio-gramophones. methods of a research: a miyelo-grafiya (see), a kraniografiya (see) with introduction to ventricles of a brain of radiopaque substances, a computer tomography (see the Tomography computer), a radionuclide tsisternografiya. The radionuclide tsisternografiya is based on spatio-temporal distribution of radio pharmaceuticals (see) after their introduction to the final tank of a spinal cord at a spinal puncture. Registration of distribution of radiopharmaceutical is made on the gamma camera in various projections through 1; 3; 6 and 24 hours after introduction. The method allows to reveal disturbances of circulation of C., process of its resorption and outflow at various patol. processes (fig. 2).
At a macroscopic research C. define its color, transparency, availability of impurity of blood, etc. Impurity of blood can change color C., causing a xanthochromia. An indicator of intensity of a xanthochromia is the size of contents in C. bilirubin (see), to-ruyu define as biochemical methods, using qualitative test with Ehrlich's diazoreactant, me-
year of quantitative definition on Wang - den - to Berg (see. In An - den - Berg reaction) or on Endrashika (see Endrashik — Klegkhorna — Grofa a method), and by means of a spektrofoto-metriya (see).
At microscopic examination of C. define quantity and character of the cells which are contained in it (tsitol. research). Determination of quantity of cells (cytosis) is made in a cytometer of Fuchs — Rosenthal (see cytometers), volume the cut is equal 3,2 mkl. The quantity of cells in 1 mkl makes approximately V3 of total quantity of the cells found in a cytometer. For tsitol. researches C. centrifuge, then from a deposit prepare smears and paint them by Romanovsky's method (see Romanovsky — Gimza a method). Tsitol. the research allows to count quantity of these or those cells, sometimes to reveal atypical tumor cells, i.e. to make a cytoface-vorogrammu.
Special bacterial. researches C. make at suspicion on an inflammation of a meninx of any etiology. A main objective of a research is allocation and identification of the activator, the definition of its sensitivity to antibiotics proving purposeful antibacterial therapy. For bacterial. researches the C can be used., received at spinal, suboktsipitalny or veins -
Fig. 2. Gamma topograms of likvorny ways of a head and spinal cord (front direct projection): normal (7); at occlusion of likvorny ways a tumor in the field of a silviyev of a water supply system (//); at open hydrocephaly of the inflammatory nature (111); in 1 hour (A), in 3 hours (B), in 6 hours (V) and in 24 hours (G) after administration of radio pharmaceutical drug (RFP) in a subarachnoid space of a spinal cord. IA — РФП fills a subarachnoid space of a cervical part of a spinal cord (1), a silviyeva of the tank (2), a mezhpolusharny crack (3); 1B — the same structures are visualized, the maintenance of RFP increased; 1B — RFP disappears from a subarachnoid space of a cervical part of a spinal cord; 1G — the subarachnoid space of a brain is filled. ON — • RFP is in a subarachnoid space of a cervical part of a spinal cord (i), but does not fill the likvorny ways located above; IIB — are visualized the same structures; IIB — РФП fills side tanks of a varoliyev of the bridge (4) \11G — RFP in a subarachnoid space of a brain is absent, remains only in a subarachnoid space of cervical department of a spinal cord. 111A — RFP is thrown in side wentrods of a brain (5), fills expanded side tanks (2), a subarachnoid space of a spinal cord (I); 111B — the same structures are filled, activity of RFP decreased; The II IB — are visualized the same structures; 1PG — РФП fills a subarachnoid space of a brain and expanded ventricles of a brain.
trikulyarny punctures. C. it is normal sterile therefore allocation from it any microorganism is considered as a positive take bacterial. researches. The probability of detection of microflora increases at crops of C. on mediums prior to antibacterial therapy.
Research of chemical structure of C. carry out by means of methods qualitative and quantification, specific to separate substances.
Amount of protein in C. determine by a photoelectrocolorimetric method (see Photometry), to-ry is the most exact. The method is based on property of protein to cause opacification of C. at addition to it sulphosalicylic to - you, at the same time intensity of opacification is proportional to amount of protein in C. also is defined by a fotometrirovaniye. Definition of structure of protein fractions (protea-nogramma), the maintenance of glycoproteins and lipoproteids carry out as by paper electrophoresis after a preliminary condensation of C. or method of an electrophoresis on agar gel (see the Electrophoresis) without its preliminary condensation. The methods of qualitative test of approximate content of globulins applied earlier in C. (Pandi's reaction, Stolnikov's way, reaction to Nonna — Apelta, sublimate reaction of Veykhbrodt), Kafka's method for definition of a ratio of protein fractions in a crust, time in a wedge, practice are used seldom. Almost colloid reactions of Takat — the Macaw are not applied because of their not specificity (see. Coagulative tests) and mastic reaction, so-called triptofanovy reaction and Levinson's reaction applied in diagnosis of tubercular meningitis. For diagnosis of nek-ry diseases of a nervous system, especially neurosyphilis, sometimes put the colloid reaction of Lange based on change of a degree of dispersion of solution of colloid gold at its mixing with patholologically changed C. The last leads to change of purple-red color of solution of colloid gold. C. part consistently in 10 test tubes 0,45% with solution of sodium chloride, receiving cultivations in 10; 20; 40; 80 etc. time. Add to each test tube on 2,5 ml 1% of solution of chloric gold. Results of reaction fix next day. During the mixing with normal C. color of solution of colloid gold does not change, and during the mixing with patholologically changed C. its color changes and on a bottom of test tubes the deposit drops out. Discoloration in each test tube designate tsif
Rami: 0 — color is not changed; 1 —
red-violet; 2 — violet;
3 — red-blue; 4 — blue and blue-violet; 5 — light blue and blue; 6 — a colorless liquid. Results of reaction express as a number of figures or as a curve. Considerable decolouration of solution in the first test tubes (weak cultivation) is characteristic of parenchymatous and degenerative processes in a nervous system, and especially of a general paralysis (a so-called paralytic curve). Decolouration in test tubes with big cultivation of C. (especially in
6 — the 8th) it is characteristic of inflammatory processes of a meninx (a meningitichesky curve). There are also various transition types of reaction of Lange. In a crust, time this reaction is used seldom in connection with broad implementation in a wedge, practice modern biochemical and immunol. methods of a research C.
For definition of a sugar content in C. apply any of the methods accepted for definition of sugar in blood (e.g., a hexokinase method).
Concentration of electrolytes in C. determine by method of flame photometry (see). During the definition of microelements apply the neutron and activation analysis of C. (see. The activation analysis), baked-trofotometrii a method of atomic absorbing (e.g., determination of content of magnesium). By a radio immuno-logical method (see) reveal contents in C. hormones of a hypophysis, bark of adrenal glands, etc. The same method is used for determination of content of lactoferrin, a lysozyme and r2-microglobulin. Adrenal hormones can be defined in C. and method of a flyuorimetriya (see).
Methods of a serological research C. include statement of an agglutination test (see), precipitations (see), etc. They aim at diagnosis of syphilis of a nervous system (see Syphilis), parasitic diseases of c. N of page, a brucellosis (see), etc. At suspicion on a virus etiology of defeat of c. N of page will see off virusol. researches C. The fermental and immune method and a method of radial diffusion according to Mancini (see Immunodiffusion) allow to establish existence in C. immunoglobulins. Immunoglobulins C. investigate for the purpose of studying patol. the autoimmune reactions of a brain playing an important role in a pathogeny of nek-ry diseases of c. N of page.
Changes of cerebrospinal liquid at pathology (likvoro-diagnosis). At various patol. processes in c. N of page are possible changes of pressure of C., its properties and structure, to-rye develop in certain likvorologichesky syndromes.
Change of pressure of C. can be manifestation of many patol. the processes causing disturbances of its products and (or) a resorption, circulation and (or) outflow. Build-up of pressure of C. (likvorny hypertensia) it is observed at certain stages of development of hydrocephaly (see), at tumors of a brain (see) and a spinal cord (see), abscesses of a head and spinal cord, meningitis (see), encephalitis (see), a craniocereberal injury (see), hypostasis and swelling of a brain (see), parasitic cysts in c. N of page, etc.
Pressure decrease of C. (likvorny hypotension) arises at the states which are followed by dehydration of an organism including as a result of action of high doses of osmotic diuretics and saluretics. This effect is the cornerstone of the dehydrational therapy (see) used at sharp increase in intracranial pressure. Likvorny hypotension can develop at administration of drugs, the C reducing products. vascular textures of ventricles of a brain (e.g., Diacarbum), at a cachexia, an adynamy, an ependimatita (see Horioependimatit), decrease in arterial and venous pressure in vessels of a brain, after brain operations, an open cherepnomozgovy injury, etc. Falloff of pressure of C., developing sometimes during a spinal puncture because of disturbance of outflow of C. from a head cavity at the block of a subarachnoid space owing to the inflammatory processes which are followed by development of commissures, existence of tumors, parasitic cysts, hypostasis and swelling of a brain can lead to dislocation and infringement of a brainstem (see Dislocation of a brain). Cause of infringement of circulation of C. there can be a local volume process in c. the N of page who is mechanically limiting normal current of C. (tumor, aneurism of vessels, abscess, parasitic cysts, etc.), diffusion or local defeat of a meninx of various etiology. Acceleration or delay of circulation and resorption of C. is the main manifestation open internal (ventricular), outside (excess content of liquid in subarachnoid spaces of a brain) or the combined (general) hydrocephaly (see). Character and extent of disturbance of circulation and resorption of C. have big a wedge, value since on the basis of data on their disturbance specify indications to operational treatment of hydrocephaly — to the shunting operations on the likvorny ways.
Diagnostically important likvoro-logical symptoms are changes of transparency and color C. Decrease in transparency (opacification) can be caused by impurity of blood, increase in quantity of cells (pleocytosis) and increase in amount of protein (hyper pro-teinorakhiyey). Film formation on the surface taken by C. it is caused by presence at C. fibrin or fibrinogen that is characteristic of tubercular meningitis (see Meningitis; T uberkulez extra-pulmonary, meninx and central nervous system).
Impurity of blood can change color C. from yellowish to dark red. Impurity of «traveling blood» at punctures of subarachnoid spaces usually decreases in process of the expiration of C. in a test tube; unlike it, impurity of blood in C. owing to subarachnoidal hemorrhages of various etiology (a hemorrhagic xanthochromia) remains in all its portions taken for a research. The smallest quantity of erythrocytes, a cut it is possible to determine visually by discoloration of C., makes 500 — 700 in 1 mkl. After a gekh\gorragichesky stroke, a severe craniocereberal injury the blood which streamed in a subarachnoid space and painted C. in red color, disappears from C. to 10 — to the 20th day of a disease. At a moderately severe craniocereberal injury it disappears within 5 — 10 days. The erythrocytes which got to C., gradually collapse, the hemoglobin which is released at the same time under the influence of enzymes of endothelial system of a meninx turns into bilirubin, presence to-rogo and gives C. yellow color (xanthochromia). Degree of manifestation of a xanthochromia depends on massiveness and prescription of hemorrhage; usually it accrues on 2 — the 3rd days. Decrease and disappearance of a hemorrhagic xanthochromia depend on the speed of clarification of C., from the erythrocytes weighed in it, from time of a rassasyvaniye of clots in likvoronosny ways and subarachnoid spaces back and a brain.
The xanthochromia accompanying tumors of c. N of page (a congestive xanthochromia), it is caused by disturbance of permeability of vessels, stagnation of blood in vessels of a brain and receipt of the blood plasma painted in yellow color in C. Such xanthochromia is stable on intensity, is usually combined with a giperproteinorakhiya and meets more often at well vasku-lyarizirovanny tumors, new growths which are located in close proximity to the cerebral cavities and subarachnoid spaces containing C.
Contents in C. crude protein or its various fractions can change at various diseases of c. N of page. Increase in protein content in C. (giperproteinora-hiya) or decrease (gipoproteino-rakhiya) are important differential diagnostic characters. Gipoproteinorakhiya meets at the diseases which are followed by hyperproduction of C., napr, at hydrocephaly. The most frequent symptom at diseases of c. the N of page is a giperproteinora-hiya. At subarachnoidal hemorrhage of various etiology (a craniocereberal injury, a stroke, a rupture of aneurism of vessels of a brain, a tumor of a brain) it is caused by impurity of the blood which came to C. at hemorrhage or owing to increase in permeability of a wall of vessels. At hemorrhagic strokes protein content in C. can reach 1,5 — 2 °/00 (! Л). The maximum increase in its quantity to 8 — 9 °/00 (g/l) is observed at break of blood in ventricles of a brain. At ischemic heart attacks of a brain the giperproteinora-hiya meets less often, is preferential at a cortical or periven-trikulyarny arrangement of the center of an ischemic heart attack of a brain, and does not exceed 1%0 (g/l) in an acute stage. At tumors of a brain the giperproteinorakhiya is caused by stagnation of blood in veins of a skull and a brain and (or) penetration into C. products of protein metabolism and disintegration of the tumor. Malignant tumors of c. N of page, in to-rykh can develop the centers of a necrosis, a cyst, hemorrhage more often than benign tumors, cause a giperproteinorakhiya. Besides, existence and expressiveness hyper pro-teinorakhii depend on localization of a tumor: at tumors cortical
the shell and periventrikulyarno-go arrangements protein content in C. above, than at the tumors located in the depth of cerebral hemispheres.
At hron. inflammatory processes in c. N of page (pia-arachnites, me-ningoentsefalita, periventriku-lyarny encephalitis, optokhiazmal-ny arachnoidites) of various etiology amount of protein in C. more often remains normal, however in the period of an aggravation of inflammatory process it can increase to 1 — 2 °/00 (! л). The hyper pro-
teinorakhiya is characteristic of an initial stage of formation of abscess of a brain during the involvement in perifocal inflammatory process of a meninx and structures of ventricles of a brain.
Amount of protein in C. it is almost always raised at cysticercosis of c. N of page (see Cysticercosis), followed by chronically proceeding pia-arachnitis — to 0,5 — 2 °/oo (! л). However at localization of cysts of a cysticercus in a back cranial pole (it is preferential in the fourth ventricle) it can not exceed the upper bound of norm.
At nek-ry diseases of c. N of page the normal content of crude protein in C. it can be combined with change of a ratio of globulins and albumine (proteinaceous coefficient of Kafka). Selective increase and - globulins in. observe at meningitis, encephalitis, a craniocereberal injury; r-globulins — at malignant tumors of a brain, atherosclerosis (see), Parkinson's diseases (see. Trembling paralysis); ^-globulins — — at multiple sclerosis (see), a severe craniocereberal injury, syphilis of a nervous system, a subacute sclerosing panencephalitis of Van-Bogart (see the Leukoencephalitis), a hemorrhagic stroke (see). At multiple sclerosis, besides, specific oligoklo-nalny fractions
of immunoglobulin G come to light, to-rye there are no C in normal. At the block of likvorny system in C., containing a large amount of protein, there is almost always no prealbuminous fraction.
Benign tumors of c. N of page can cause minor change of a ratio of protein fractions of C. towards increase in amount of albumine.
The differential and diagnostic value of colloid reactions with C. (e.g., see above) in a crust, time it is considered Lange's reactions insignificant. It is connected with the fact that results of colloid reactions depend not on character patol. process, and from protein content in C. (the more the giperproteinorakhiya is expressed, the dispersion in a colloid system is broken stronger), from change of proteinaceous coefficient, impurity of blood to C., etc. E.g., impurity of blood, at a cut in C. more than 2000 — 2500 erythrocytes in 1 mkl contain, cause the changes of reaction of Lange inherent to degenerative and inflammatory or inflammatory processes in c. N of page. At chronic inflammatory processes in c. the N of the page which are not followed by a giperproteinorakhiya Lange's reaction is more often (in 88% of cases) does not change.
Many patol. processes in c. N of page, especially inflammatory and leading to irritation of a meninx, cause increase in quantity of cells in C. (pleocytosis) and change normal tsitolikvorogram-we. Cellular structure of C., received from different departments of a subarachnoid space or from cerebral cavities as well as the quantity of cells, allows to judge localization patol. process in the central nervous system and about its character. The reactive condition of the fabrics limiting a face-vornoye space causes a lymphoid pleocytosis. Inflammatory processes, especially purulent meningitis (see), are followed by a neutrophylic pleocytosis. In the first day after subarachnoidal hemorrhage in C. find erythrocytes, neutrophils, lymphocytes, monocytes, eosinophils in the ratios corresponding to a blood count. In the next days the pleocytosis increases, the quantity of neutrophils (they make 80 — 90%) increases, there are polyblasts and the macrophages taking active part in normalization of structure of C. At the favorable course of process by the end of the 2nd week after hemorrhage the pleocytosis decreases and gains lymphoid character (there can be a small amount of the changed neutrophils). Prisubarakhnoidalny hemorrhages of various etiology the size of a pleocytosis not always corresponds to the size of a giperproteino-rakhiya. Increase in protein content (albumine and globulins) at a moderate pleocytosis or a normal cytosis is called proteinaceous and cellular dissociation. Sharply expressed proteinaceous and cellular dissociation with a xanthochromia is observed at stagnation of C., especially at the block of a subarachnoid space of a spinal cord (a tumor of a spinal cord, a limited arachnoiditis, etc.). The return ratio — normal protein content in C. at a pleocytosis of various degree is called cellular and proteinaceous dissociation; abouton it is observed in early stages of neurosyphilis, epidemic encephalitis, at aseptic meningitis, etc.
Dynamics of a pleocytosis in many cases forms a basis of the correct diagnosis and assessment of efficiency of treatment. At the patients who underwent an operation on c. the N of page, at a smooth current of the postoperative period a pleocytosis on 2 — makes the 3rd days 30 — 100 cells in 1 mkl\in cyto-likvorogramme lymphocytes make 1 — 5%, neutrophils — 92 — 98%, polyblasts — to 2%, single macrophages meet. Further decrease in a pleocytosis is noted, to-ry gains lymphoid character. On 10 — the 12th day after operation the pleocytosis decreases to 5 — 12 cells in 1 mkl; in likvoro-gram lymphocytes begin to prevail, still single neutrophils meet lizirovanny kernels, single macrophages, 1 — 2 polyblast. At emergence of complications of inflammatory character a pleocytosis in C. again sharply increases, calculation of cells in the camera it becomes frequent impossible. Lymphocytes in a tsitolikvorogramma make 0,5 — 1%, and neutrophils — 98 — 99%. Even during the performing antiinflammatory therapy the pleocytosis in 5 — 7 days remains at the level of several thousand cells. V Ts. it is often possible to find vnekletoch-but also intracellularly located microorganisms. At the favorable result of inflammatory process the pleocytosis decreases, gains lymphoid character; normalization of C. there is during 40 — 45 days
Hron. inflammatory processes (arachnoidites of not parasitic etiology, hron. periventrikulyarny encephalitis, etc.) in most cases (apprx. 90%) do not cause change of amount of protein in C. and pleocytosis. The pleocytosis appears at an aggravation of process, a thicket in combination with moderate hyper-proteinorakhiyey or normal protein content (cellular and proteinaceous dissociation).
The pleocytosis of various degree is often observed at abscesses of a brain (apprx. 70% of observations). Its size depends on localization of process; so, at a periventrikulyarny or corticosubcortical arrangement of abscess the pleocytosis makes 35 — 140 cells in 1 mkl. The break of abscess in cerebral cavities or subarachnoid spaces is followed by more expressed neutrophylic pleocytosis.
At malignant tumors of c. N of page cellular structure of C. differs in variety, a cut it is caused by various combinations of cells of both a fabric, and hematogenous origin. At localization of a tumor near covers of a brain in C. the pleocytosis and a giperproteinorakhiya, and also cells of a tumor is defined. In ventrikulyarny C. cells of a tumor meet by
5 — 7 times more often than in C. subarachnoid space of a spinal cord.
Cysticercosis of a brain is characterized by a lymphoid pleocytosis and existence in C. eosinophils. Main diagnostic likvorologichesky characters of cysticercosis of c. N of page are a lymphoid pleocytosis with a large number of polyblasts (free macrophages) and positive reaction of binding complement (see) with tsistitserkovy antigen. At an echinococcosis (see) c. N of page structure of C. often remains normal.
The exception is made by cases of localization of an echinococcal bubble in ventricles of a brain, at to-rykh the giperproteinorakhiya and a moderate pleocytosis is observed. At a toxoplasmosis (see), inborn or acquired, quite often proceeding with symptoms of encephalomyelitis (see), an ependimatit or poorly expressed pia-arachnitis (see Meningitis), in C. are often noted a xanthochromia, a giperproteinorakhiya, the sugar content is lowered. Pressure of C. it is raised, the pleocytosis mixed from 70 to 700 cells in 1 mkl.
Diagnostically the research of a sugar content in C is important. Decrease in content of glucose in C. (gipoglikorakhiya) — a symptom of meningitis, especially tubercular, acute purulent and carcinomatous meningitis. Reduction of level of glucose at this pathology is caused by glycoclastic activity of microbes, tumor cells and, perhaps, leukocytes. Very low content of glucose in C. note at insulin shock and a hyper dysinsulinism (see). Moderate increase in glucose in C. (hyperglycorrhachia) is observed at nek-ry types of acute encephalitis, napr, at the Japanese encephalitis
of type B. At a diabetes mellitus (see a diabetes mellitus) amount of glucose in C. raises in parallel with increase in amount of glucose in a blood plasma. Products of metabolism of glucose (acetone and acetoacetic to - that) appear in C. only at a diabetic coma (see), tubercular meningitis (see), the epileptic status (see Epilepsy), uraemias (see), alcoholic deliriums (see. Alcoholic psychoses), starvation (see).
In a crust, time the great value is attached to a research of electrolytic structure of C., especially at resuscitation actions, since degree of manifestation of hypostasis and swelling of a brain after a craniocereberal injury or operation on c. the N of page often correlates with increase in concentration of sodium and decrease in potassium concentration and calcium in C. Dehydrational therapy at this pathology shall be carried out under control of electrolytic structure, pH and osmolarity of C.
Increase in amount of chlorides in C. note at increase in its pH, naira, at degenerative and dystrophic diseases of c. N of page; substantial increase of their contents happens at insufficiency of secretory function of kidneys. Decrease in level of chlorides of C. it is characteristic of meningitis, especially tubercular origin, patol. processes in c. N of the page which are followed by a giperproteinorakhiya and an alkalosis (see).
Research of contents in C. pi ro grape and milk to - the t gives the chance to judge a condition of energy balance of a brain. Content of lactic acid (see) in C. at patients with the intracerebral bleedings, a severe craniocereberal injury which are followed by metabolic disturbances, spasms increases in 1V2 — 2 of time. More substantial increase of their contents at this pathology is extremely adverse predictive sign.
Thanks to use of modern methods of a research as a part of C. presence of hormones of a hypophysis, a hypothalamus, the nek-ry hormones cosecreted by peripheral closed glands (e.g., insulin, cortisol, etc.), enkephalins, endorphines is established (see Opiates endogenous). Content of hormones in C. changes depending on biol. circadian rhythms of an organism (see. Biological rhythms), physical activity, at stressful conditions, reception of liquid, nek-ry medicines (e.g., Parlodelum), disturbances of circulation of C. Changes of content of hormones of a hypophysis in C. have diagnostic and predictive value at hormonal and active tumors of a hypophysis, cranyopharyngiomas, nek-ry gipotalamo-pituitary diseases, patol. the processes which are localized in the field of the Turkish saddle.
Use of modern biochemical methods of a research C. allowed to establish quantitative contents in it separate lipid fractions — cholesterol (see) and its ethers, free fatty acids (see), kephalin, lecithin (see Letsitina), sphingomyelin (see), cerebrosides (see), sulfatides (see), gangliosides (see), lipoproteids (see). Also activity of many enzymes (see) which are contained in C is defined. — kreatinfosfoki-naza, lactate dehydrogenases, gluta-minshchavelevo-acetum transaminase, adenylatecyclase, zymohexase, an isolemon dehydrogenase, to a beta glitch of a ronidaza, amylase, etc. However diagnostic value of quantitative changes of these indicators is so far poorly studied.
Changes of cerebrospinal liquid at mental get sick and - I x. Research C. at patients with schizophrenia in most cases does not reveal aberrations, however at the schizophrenia proceeding with a syndrome of a febrile catatonia (see Schizophrenia), protein content in C can raise or go down.; sometimes the sugar content at its normal concentration in blood raises. Giperprotei-norakhiya most often does not involve change of proteinaceous coefficient. At schizophrenia change of separate fractions of gamma-globulins and nek-ry immunoglobulins, neuropeptids, biogenic amines is noted. There are experimental data about toxicity of C. patients with schizophrenia concerning various biol. objects. At patients with maniac-depressive psychosis (see) changes of C. usually does not come to light.
At patients with the epilepsy (see) which is not followed by increase in permeability of a blood-brain barrier, structure of C. usually normal. However at frequent epileptic seizures disturbance of proteinaceous and power exchanges of a brain with the subsequent disturbance of enzymatic activity and electrolytic structure of C can develop. When epileptic seizures are a consequence of organic lesions of a nervous system (an effect of disturbance of cerebral circulation or a craniocereberal injury, a tumor of a brain, an encephalomeningitis, etc.), changes tsitol. and biochemical structures of C. are defined by character of a basic disease. Structure of C. at an epileptic syndrome can change in connection with increase in permeability of a blood-cerebrospinal fluid barrier, disturbance of a likvorodinamika (see above), cerebral circulation, increase in intracranial pressure, localization patol. process near likvoronosny spaces, biol. and morfol. features of a new growth of c. N of page, etc. Variety of the reasons which are the cornerstone of changes of structure of C. at patients with epileptic seizures of various etiology (an epileptic syndrome), defines also variety of combinations patofiziol. liquor of logical syndromes (see above).
At an oligophrenia (see) in C. aberrations, as a rule, do not come to light. However at the weak-mindedness which is combined with hydrocephaly (see) the gipoproteinora-hiya with relative increase in globulinovy fractions and increase in concentration of calcium is observed. At a Down syndrome (see Down a disease) in C. positive Wassermann reaction is sometimes observed (see Wasserman reaction).
At the mental disorders caused by the cerebral atherosclerosis, an idiopathic hypertensia acquired by weak-mindedness senile and presenile processes, a general paralysis, syphilis of a brain, inf. diseases (scarlet fever, a typhoid, a typhus, a brucellosis), intoxications (alcoholic, at poisonings with various poisons), often note change of structure of C. Tsitol. and biochemical picture C. is defined, first of all, character of a basic disease, one of symptoms to-rogo are mental disorders. Moderately expressed lymphoid pleocytosis is characteristic of psychoses at scarlet fever (see), a typhoid (see) and at a meningoentsefalitichesky form of a brucellosis (see), is more rare at a general paralysis and syphilis of a brain. Along with a pleocytosis also protein content in C usually increases. For psychosis at a sapropyra, psychoses of vascular genesis, a tremens, the acquired weak-mindedness (see), senile or presenile processes (see. Before senile psychoses) proteinaceous and cellular dissociation is indicative. At the acquired weak-mindedness, neurosis and presenile tardas, epilepsy (see), atherosclerosis (see), exogenous psychoses (see. Symptomatic psychoses) in C. increase in a sugar content is noted. At hron. alcoholism in C. can appear acetone and atseto acetic to - that, to increase its pH and content of phosphorus in it. Increase in content of cholesterol in C. it is characteristic, e.g., of the acquired weak-mindedness, neurosis and presenile tardas. Considerable increase of amount of potassium and calcium in C. note in the period of the remote effects at the patients who had the gunshot getting craniocereberal wounds at which the clinical picture of this period is characterized by a heavy psychoneurological syndrome (see. Craniocereberal injury).
the MAIN BIOCHEMICAL INDICATORS of CEREBROSPINAL LIQUID is NORMAL
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TSERKOPITEKOVY HEMORRHAGIC FEVER
185 E. P. Yurishchev; G.F. Dobrovolsky (fiziol.), V. F. Imshenetskaya (mikr.), E. Ya. Scherbakova (I am glad.).