HYDROCEPHALY (hydrocephalus; grech, hydor water + kephale head; synonym edema of a brain) — the state which is characterized by excess accumulation of cerebrospinal liquid in cerebral cavities and the subshell spaces. Is a consequence of various diseases or brain injuries and its covers.
gained the Greatest distribution to the USSR the classification offered by A. A. Arendt in 1948. In it G. is considered depending on time of emergence, a current, etiol, factors, localization and the nature of dysfunction of the likvorny device.
On time of emergence distinguish the inborn and acquired G., on a current — acute and chronic.
On localization allocate outside and internal. At outside G. there is excess accumulation of cerebrospinal liquid preferential in subarachnoid spaces, at internal — in ventricles of a brain. Internal and outside G.'s combination — so-called the general is quite often observed.
On the nature of dysfunction of the likvorny device it is accepted to distinguish the open (reported) and closed (occlusal) G. Otkrytuyu G. in turn subdivide on hyper secretory, at a cut secretion of cerebrospinal liquid is considerably increased, and arezorbtivny, characterized by disturbance of its absorption. At occlusal G. there is a disturbance at various levels of outflow of cerebrospinal liquid from ventricles in subarachnoid spaces as a result of commissural process, cysts, tumors etc. The mixed forms G. when occlusion of likvorny ways is combined with disturbance of a resorption or secretion of cerebrospinal liquid meet.
The etiology and a pathogeny
can give Various damages of a brain and its covers by. Most often it is observed after infectious diseases (purulent epidemic cerebrospinal meningitis, secondary meningitis and meningoentsefalita) and craniocereberal injuries. Besides, G. can arise at difficulty of outflow of blood from a head cavity (pathology of venous system, fibrinferments of sine, a prelum hems and commissures of the taking-away veins), at tumors, and also at hypertensia, diseases of kidneys and parasitic damages of a brain. Sometimes G. results from anomaly of development of a head and spinal cord (an underdevelopment of a brain, brain and spinal hernias etc.).
The above-mentioned reasons can lead to disturbance of secretion, absorption or circulation of cerebrospinal liquid with the subsequent development of G.
Morfol. changes in a brain and covers at G. depend as on the basic disease which led to G., and on duration of the increased intracranial pressure. As a rule, expansion of cavities of ventricles, especially side, due to increase in amount of cerebrospinal liquid (fig. 1) in them is observed. Side ventricles are expanded symmetrically as at the open, and closed G. with occlusion of interventricular foramens of a water supply system of a brain and apertures of the IV ventricle (fig. 2 — 4).
Asymmetric expansion of ventricles is most often observed at obstruction of one interventricular foramen or on the party of an injury. The progressing increase in ventricles leads to an atrophy of brain fabric, flattening of crinkles and smoothing of furrows of a brain. Early pyramidal ways are surprised. First of all white matter, a corpus collosum and the arch is exposed to change. Change of gray matter is observed at G. as a result of an injury and in hard cases of. At inborn G. the structure of bark can be broken. An atrophy of nervous tissue at G., according to U. Penfild and Elvidzha (A. Elwidge, 1932), B. N. Klosovsky (1949), V. P. Purine (1968), results from a prelum of capillaries of a brain owing to intracranial hypertensia. The expressed astrocytic reaction in white matter at G. is a bad predictive sign. Except changes from tissue of a brain, at G. note the expressed changes and from vascular textures, an ependyma of ventricles and its covers. The atrophy of vascular textures with fibrous regeneration of their connective tissue basis and death of an epithelium is observed. At G. after infectious diseases reveal signs of a granulematozny ependimatit (see. Horioependimatit ). A meninx is sharply thickened, mutna, are edematous. Note their fibrosis, an union of hl. obr. in the field of basal tanks of the basis of a brain, a big occipital opening and apertures of the IV ventricle. In covers reveal inflammatory infiltrates. At traumatic G. in a brain find signs of the former hemorrhages, hems in places of necroses of brain fabric, commissure in the field of outflow tracts of cerebrospinal liquid etc. In vessels of a brain at G. find symptoms of arteriosclerosis with a hyalinosis of vessels.
The clinical picture
the Clinical picture G. is diverse.
Distinguish 2 stages of a disease: progressing and stabilized. The progressing stage in a phase of acute progressing has symptoms of the diseases which led to G. V to a phase hron, there is no progressing of these symptoms any more.
Children with the inborn or developed at early age G. are slow-moving, lag behind in physical. development. Their obesity is observed, and in an end-stage — sharp weight loss. The shape of the head — it spherical is most characteristic, it is increased in sizes, the big hanging forehead, deeply located orbits, the half-closed eyes, the bulged ears (fig. 5). Integuments of the head are thinned; plentifully developed venous network appears through. Fontanels are increased, eminate and are strained, bones are thinned, discrepancy of seams between bones of a skull is noted. At percussion of a skull characteristic «noise of the burst pot» is listened; in cases of closing of fontanels and the begun smykaniye of bones of a skull — a sound with a bandbox shade.
Neurologic disturbances at G. of a polimorfna [A. A. Arendt, 1948; D. D. Matson, 1953].
Damages of any cranial nerve, various motive frustration, various forms of epileptic seizures can be observed. Symptoms of these defeats meet in various combinations and can be expressed in different degree. Their variety is caused by the fact that it is possible as various localization and prevalence of the process which caused G. and various extent of damage of a brain and its covers. However most often at G. defeats from optic nerves, a vestibular mechanism and the motive sphere are observed.
Decrease in visual acuity, sometimes to a total blindness, change of fields of vision, congestive nipples of optic nerves or their atrophy are a consequence of hypertensia and a direct prelum of a hiazma and visual pathways an expanded III ventricle. Congestive nipples more often happen at occlusal.
Damage of a vestibular mechanism at G., by data A. A. Arendta, is observed in 93% of cases. Children of advanced age complain of attacks of dizziness and a sonitus or the head. At inspection find a spontaneous krupnorazmashisty nystagmus, disturbance of a caloric and rotary nystagmus at experimental tests.
From the motive sphere pyramidal and cerebellar frustration are most often shown, subcrustal are more rare. Paralyzes, paresis of extremities (the lower parapareses are more often), disturbances of a tone, change of reflexes, ataxias, statics, gait, the horeopodobny and atetoidny movements of extremities, spastic contractures can take place. Cerebellar disturbances are characteristic of occlusion of likvorny ways at the level of a back cranial pole. Children of early age have an arrest of development of motility, i.e. ability to hold the head, to stand and go.
At defeat of diencephalic departments of a brain standard metabolism goes down, it is broken water, carbohydrate and a lipometabolism, and also thermal control, a dream, bulimia, the increased perspiration, and sometimes a mramornost and a xeroderma is observed. In a pathogeny of these frustration simultaneous dysfunction of all vegetative centers owing to long intra ventricular hypertensia is of great importance. At a prelum of a hypophysis and infundibulyarny area symptoms of dysfunction of endocrine organs are shown.
Mental disorders at G. are very different. It is conditionally possible to allocate two basic groups: conditions of intellectual insufficiency and disturbance of the personality. The first group combines many forms — from an easy, reversible delay of mental development to an oligophrenia with different degree of mental retardation up to a deep deficiency of intellect and an idiocy (see. Oligophrenias ). At children superficial intellectual defect (moronity) is more often observed. Heavy G. is followed, as a rule, and deep mental retardation. However there is no accurate parallelism between degree of manifestation of G. and depth of intellectual defect. The oligophrenia at G. is characterized by an atipichnost. Other Simeon (1958) and G. E. Sukhareva (1965) observed at patients selectively good development of mechanical memory and separate abilities (to the account, ear for music etc.). The developed mechanical memory, especially acoustical, quite often causes rather rich vocabulary. At the same time in the speech stamps prevail, statements have a shade of empty reasoning at insufficient understanding of many words and expressions; at good memory on numbers and easy performance of separate calculating operations patients are not able to solve the simple problems demanding logical thinking. In some cases at patients the normal intelligence is observed.
Disturbances of the personality, in particular emotional and strong-willed properties of character, meet more often than intellectual insufficiency. Dominance of slightly raised (euphoric) shade of mood, sometimes with tendency to flat humour, bystry transition from euphoria to apathy or the suppressed mood, weakness of motives, passivity, a divergence are the most typical. At G. at children quite often note a lack of children's vivacity and a spontaneity, poorly expressed aspiration to contact, lack of the expressed attachments. At so-called latent G. instability of mood, affective excitability, tendency to dysphorias, asthenic and neurosis-like disturbances are observed. Under the influence of situational influences or during the strengthening of intracranial hypertensia there can be episodes of excitement with malignancy and an agressive behavior.
At pubertal age under the influence of infections, physical and mental injuries developing of incidental and periodic psychoses with disturbances of consciousness, the unstable crazy ideas and hallucinations is possible.
At G.'s progressing slackness, apathy increases, decrease in intelligence is observed; cerebral decompression is followed by increase in activity and increase in intelligence.
In the clinical picture G. which arose at children at more advanced age, as a rule, into the forefront symptoms of increase in intracranial pressure (a headache, nausea, vomiting, congestive nipples of optic nerves) act.
Acute occlusion of likvorny ways with G. is followed by sharp headaches, vomiting and bradycardia. At height of an attack there can be a loss of consciousness, disorder of breath with the advent of trunk tonic spasms.
Of adults has no same current and a certain clinical picture. Into the forefront the syndrome of increase in intracranial pressure acts (see. Hypertensive syndrome). Changes in bones of a skull are expressed in much smaller degree, than at children. The neurologic symptomatology is very different. E. F. Lobkova allocates several syndromes of preferential damage of a brain: a syndrome from a mesencephalon, a back cranial pole, optokhiazmalny area, big cerebral hemispheres, diencephalic area.
For G.'s identification, in addition to complex the wedge, inspections, use a number of additional methods by which it is possible to define a form, a stage and G.'s etiology, level of occlusion and degree of manifestation of. Broad use in a wedge, practice was found oscillography (see), tonometriya of a fontanel, transillumination of a skull, ekhoentsefalografiya (see) and a research with use of radioisotopes (see. Radio isotope diagnosis). In G.'s diagnosis methods of inspection, and also the methods directed to studying of a condition of likvorny system have the greatest value various rentgenol.
Kraniografiya (see) G. allows not only to make the diagnosis, but also to define its form. At the reported G. which developed at early children's age, a shape of a skull of a sharoobrazn. Bones of a calvaria are thinned, the relief of an internal bone plate is maleficiated (fig. 6). Flattening of cranial poles with deepening of a front cranial pole, discrepancy of seams of a skull and not fusion of fontanels is noted. The entrance to the Turkish saddle is expanded. The expressed manual impressions in bones of a calvaria, discrepancy of seams (fig. 7), expansion of diploichesky veins, impressions on a bone from a cross sine and existence of expanded emissariums are characteristic of occlusal G. At occlusion at the level of a back cranial pole the deviation of a dorsum sellae of a kpereda, its thinning and narrowing of an entrance to the Turkish saddle is quite often observed. At occlusion in the field of a water supply system of a brain the bottom of the Turkish saddle is deepened, its back is rejected kzad. During the closing of one of interventricular foramens the skull has the asymmetric form.
X-ray contrast methods of a research are applied to specification of an etiology and a form G., degree of its expressiveness, and also to determination of level of occlusion. Researches are conducted with use of gas or iodide drugs (mayodit, konry, etc.).
The pneumoencephalography with removal of cerebrospinal liquid is applied at the stabilized open G. to determination of size and a form of ventricles, a condition of subarachnoid spaces (see. Encephalography ). At G. with increase in intracranial pressure the pneumoencephalography with removal of cerebrospinal liquid is contraindicated. In these cases apply a pneumoencephalography without removal of cerebrospinal liquid to definition of a form G. and level of occlusion and with introduction small (15 — 20 cm 3 ) amounts of air. Passing of gas to side ventricles is observed at an open Form. The delay of gas at the level of the mozzhechkovomozgovy tank testifies to occlusion in the field of an average aperture of the IV ventricle. Lack of gas in the III ventricle at its existence in IV indicates occlusion in the field of a water supply system of a brain. And the delay of air in one of side ventricles is observed at occlusion of an interventricular foramen.
Ventrikulografiya (cm.) it is shown at the expressed intracranial hypertensia and trunk symptoms and also when it is supposed that G. is caused by a tumor. She allows to judge a form and size of all departments of ventricles, and also the level and character of occlusion. On ventrikulogramma at open G. symmetric expansion of all departments of system of ventricles is observed. A contrast agent at open G. passes freely in a subarachnoid space of a spinal cord. At occlusion of a water supply system of a brain expansion III of a ventricle (fig. 8) is especially expressed, gryzhevidny protrusion and omission of its zadnenizhny departments is noted. Damage of upper or lower parts of the IV ventricle with difficulty of outflow of cerebrospinal liquid leads to expansion of all overlying departments of system of ventricles. At impassability of one of interventricular foramens the contrast agent entered into one of side ventricles (at an integrity of a transparent partition), does not pass into another. At occlusion of likvorny ways a contrast agent is late on site obstacles.
Angiography (see) use for judgment of G.'s degree and differential diagnosis. On angiograms at G. the arc-shaped expansion of vessels of a brain without noticeable change of their topography is observed, at tumors usually there is a shift and deformation of brain vessels.
Research of a condition of likvorny system. At the progressing G. pressure of cerebrospinal liquid in ventricles and a subarachnoid space of a spinal cord always above normal. A big difference in figures of intra ventricular and spinal pressure, and also dominance of pressure in ventricles give the grounds to suspect occlusal. At the difference which is reported to G. in figures of pressure can not be or she is not great. At the figure of pressure stabilized G. can be in normal limits.
At hron. The amount of protein in the cerebrospinal liquid received from cerebral cavities decreases from 0,1 to 0,03 °/00.
At occlusal hydrocephaly amount of protein in the cerebrospinal liquid received from lumbar department, usually above than in the liquid received from ventricles. At the difference which is reported to G. in number of protein in the cerebrospinal liquid received from different departments no. Increase in amount of protein and cellular elements is characteristic of the current inflammatory process in a brain and its covers (see. Cerebrospinal liquid). For establishment of the opened or closed form G. use liquorodynamic tests (see).
G.'s Treatment can be conservative and surgical. It is directed to decrease and stabilization of intracranial pressure. At conservative treatment fortifying therapy, salty pine needle baths with the subsequent wrapping of the child are shown, febrifugal drugs, the dehydrational, desensibilizing and antiinflammatory therapy taking into account G. Inogd's etiology the good effect is rendered by a roentgenotherapy.
Treatment of mental disorders generally matches the specified conservative therapy of. For treatment of the expressed affective and strong-willed frustration, and also incidental psychoses various psychotropic drugs are used.
In the absence of effect of conservative therapy surgical treatment is recommended. Absolute contraindications to operation are: the stabilized G.'s stage, an acute phase of the progressing G., and also G. which is followed by a blindness, rough nevrol, and mental disturbances, existence of bacteremia.
For G.'s treatment more than hundred various operations are offered. However most of them has only historical interest. Operations can be divided on palliative and radical.
Palliative operations. Spinal puncture (see) — diagnostic and to lay down. intervention, is for the first time described by G. Quincke in 1891. It is shown at treatment
of the puncture [Dolyotti (1933) and Geymanovich (1939) operation] opened for G. Ventrikulyarnye. At the closed G. if it is impossible to make radical operation as the temporary measure is applied by punctures of ventricles with removal of 50 — 100 ml of liquid (see. Ventriculopuncture ). At sharply come occlusion the puncture often is the only way of rescue of the patient. A. Dolyotti suggested to make a puncture of a front horn of a side ventricle through an upper roof of an eye-socket from an eye hollow, creating outflow of liquid in retrobulbar cellulose. 3. I. Geymanovich recommended to use temporal area for punctures. These operations are shown only at children of early age.
The long drainage of side ventricles on Arendta is shown at sharply come occlusal crisis when weight of a state does not allow to make radical operation: enter a drainage tube from silicone rubber into a front horn of a side ventricle (is more often than right), to-ruyu connect to system of a long drainage.
Decompressive trepanations can give only temporary positive effect at G.
Radical operations divide into four types: universal and operations at hyper secretory, occlusal and arezorbtivny Forms.
Universal operations are applied at any Form. For removal of liquid outside and internal drainages are offered. Outside drainages use very seldom as a temporary measure since they can be complicated by purulent meningitis. Internal drainages found broad application. There is a large number of operations at which outflow of cerebrospinal liquid in a hypodermic fatty tissue of the head is created, an eye and infratemporal area, an epidural space, a pleural and abdominal cavity, veins, the right auricle, an uric and gall bladder, chest limf, a channel, In a crust, time only two were widely adopted: ventrikuloaurikulyarny shunting and ventrikuloperitonealny shunting.
Ventrikuloaurikulyarny shunting — constant removal of liquid from a side cerebral cavity in the right auricle (fig. 9), is carried out by means of drainage system with Shpitts's valve — Holtera or Pudentsa — Heyera. Preference is given to Pudents's system — Heyera, at a cut the valve is located on the cordial end of a catheter. The valve interferes with throwing of blood in a drainage tube and ventricles of a brain.
Operation can be recommended for treatment of any Form. Most often it is used at children of chest age.
Ventrikuloperitonealny shunting — removal of liquid from a side ventricle in an abdominal cavity (fig. 9). Operation is shown generally for G.'s treatment at children of early age. Use drainage system with the valve which is located on the end of the catheter entered into an abdominal cavity.
W. Kausch in 1910 took away cerebrospinal liquid from a ventricle in an abdominal cavity by means of a rubber tube. Scott (M. of Scott, 1955) offered a polyvinyl tube for this purpose, on the belly end the cut was located a small barabanchik, from to-rogo cerebrospinal liquid was allocated only with a certain pressure.
One of universal methods of treatment of hydrocephaly is Kyuttner's operation — Venglovsky. G. Kyuttner suggested to open a cavity of a front horn of a side ventricle and to create outflow of cerebrospinal liquid from a ventricle in subdural, epidural spaces and hypodermic cellulose of a skull. In the subsequent along with opening it entered the condensed artery sheathed by two yazykoobrazny rags found from a firm meninx into a cavity of a ventricle. R. I. Venglovsky as a drainage applied a rag from a firm meninx together with the vessel feeding it curtailed in the form of a tubule (fig. 11). Though the author executed operation in 1907, he made the first messages only in 1913 and 1917 S. L. Kolyubakin (1923) replaced a tubule from a firm meninx with the rag found in the form of a letter «T». And V. N. Rozanov (1926) suggested to sew up the firm meninx which is previously split on H at this operation. N. Burdenko.
M. P. Sokolovsky and Yu. M. Irger (1925 and 1928) offered drainage of the lower horn of a side ventricle by means of the «plait» found from a fatty lump of Bish. Gildebrand (O. of Hildebrand, 1923) created outflow of liquid from a ventricle in a cavity of an eye-socket by formation of the channel in an upper wall of an orbit.
Operations at a hyper secretory form of hydrocephaly are directed to reduction of secretion of cerebrospinal liquid and consist a choroidal texture of side ventricles at a distance (Gildebrand, 1904; U. Dandy, 1918). In 1922. U. The dandy offered coagulation of a choroidal texture by means of specially designed device. In the subsequent coagulation of vascular textures at G. by means of ventrikuloskop was made Patnem (T. J. Putnam, 1936), Skarff (J. Scarff, 1936), V. N. Semenov and A. I. Burkhanov (1970).
Operations at occlusal forms of hydrocephaly are directed or to elimination of an obstacle and recovery of a normal anatomic way of circulation of cerebrospinal liquid, or to creation of new channels for outflow of liquid from system of ventricles. At occlusion of lower parts of the IV ventricle and area of the mozzhechkovomozgovy tank carry out operations on a back cranial pole. For the first time At. The dandy in 1921 suggested to separate arachnoidal unions in the field of median and lateral apertures of the IV ventricle at their occlusion. If at the same time it was not possible to reach free outflow of liquid from a ventricle, he recommended a section of a worm of a cerebellum. At commissural process in an upper part of the IV ventricle and in the field of a water supply system of a brain At. The dandy made drainage of a water supply system of a brain, and Fraser (J. Fraser, 1923) — its bougieurage. These operations in a crust, time use only when the water supply system of a brain is closed by the film eminating in the IV ventricle.
Holds a specific place offered by Fraser and Dott (N. M of Dott) in 1922 — 1923 operation of windowing of cerebellar is mashed, the altered and added H. N. Burdenko (1937) and I. M. Grigorovsky (1931, 1936). At this intervention in a cerebellar namet defect therefore the message between a subarachnoid space of a great brain and area of a back cranial pole is formed is created.
At occlusion in the field of a water supply system of a brain, the III ventricle, upper parts of the IV ventricle the ventrikulotsisternostomiya is shown — the operation offered by A. Torkildsen in 1937 — 1939 at a cut by means of a drainage tube is created the message between a back horn of a side ventricle and the cerebellar and brain tank (fig. 12, 3). At occlusion of two interventricular foramens bilateral operation is recommended. Count and Hembi (Page J. Graf, W. Century of Hamby, 1957) recommended to carry out a drainage tube through the section in a cerebellar namet made kpered from a cross sine. At the same time the tube was located under a firm meninx. For removal of cerebrospinal liquid from a cavity of the III ventricle the greatest distribution was gained by operation of nadkhiazmalny perforation of a final plate (fig. 12,1), edges are represented by option of operation of Stukey — Skarffa (V. of Stookey, J. Scarff, 1936). At operation the message between system of ventricles and a subarachnoid space of a great brain, and via the intercrural tank — with a subarachnoid space of a back cranial pole is created. These operations are shown at occlusion of a water supply system of a brain, the IV ventricle and the cerebellar and brain tank.
The occlusions which were widely applied earlier at a high level a porencephalia (creation of an artificial opening in a wall of a front horn of a side ventricle), a puncture of a corpus collosum, a ventrikulosubduralny anastomosis are almost not used. A puncture of a corpus collosum — the operation offered by Anton and Bramann (G. Anton, F. G. Bramann) in 1908. Outflow of liquid in subarachnoidal and subdural spaces comes from a side ventricle through a puncture in a corpus collosum (fig. 13).
H. N. Burdenko recommended a section of a corpus collosum throughout 1,5 — 2 cm, A. Yu. Sozon-Yaroshevich offered a puncture of a corpus collosum on border of an average and back third it.
The Ventrikulosubduralny anastomosis consists in removal of cerebrospinal liquid of a front horn of a side ventricle through a drainage tube in a subdural space of front departments of big hemispheres (fig. 12,2). Arezorbtivny
hydrocephaly operations. Most operation of lyumbo-peritoneal removal of cerebrospinal liquid was widely adopted, at a cut liquid from a subarachnoid space of a spinal cord at the L3-4 level by means of a tube is drained in an abdominal cavity.
The Omentoduralny anastomosis across Burdenko — to Bakulev (fig. 10) — the operation directed to removal of cerebrospinal liquid from a subarachnoid space in an abdominal cavity. For this purpose from an epiploon excise a rag length apprx. 15 cm, the basis to-rogo has well kept blood supply.
After a laminectomy at the L2-3 level the rag of an epiploon is placed in a subarachnoid space.
The ureteric drainage (ureteroduroanastomosis) was offered Gaila (V. by Heile) in 1925. After removal of one kidney and a laminectomy of L2-3 the renal pelvis is sewed in defect of a firm and arachnoidal meninx. Thus, there is an outflow of cerebrospinal liquid from a subarachnoid space of a spinal cord through an ureter in a bladder. Matson (D. D. Matson, 1953) suggested to connect an ureter (after removal of a kidney) with a tube, to-ruyu sewed in a terminal ventricle.
At the operation offered by Anton and A. Schmieden in 1917, cerebrospinal liquid from the cerebellar and brain tank is taken away in muscles and intermuscular cellulose by means of windowing of an atlanto-occipital membrane.
Operative measures at G. of inflammatory or traumatic genesis can lead to an absolute recovery; at G. caused by inoperable benign tumors, operation prolongs life to patients quite often more than for 5 years. At children at early age the most effective operations are the ventrikuloatriostomiya and a ventrikuloperitoneostomiya. After them at 50 — 70% of patients good results are observed.
After these operations sometimes there are an impassability of drainage system, infectious complications, a vykhozhdeniye of a drainage tube from a cardial cavity or an abdominal cavity. At a ventrikuloatriostomiya fibrinferments and thromboembolisms are possible.
At patients of advanced age with occlusion of caudal departments of the IV ventricle the best results after operations are observed after a section of a worm of a cerebellum, and at a high level of occlusion — after Torkildsen's operation and removal of cerebrospinal liquid from a cavity of the III ventricle. Good results after Torkildsen's operation are observed at 50 — 84% of patients, and after removal of cerebrospinal liquid from a cavity of the III ventricle at 46 — 90%.
G.'s Development, especially inborn, at any stage can stop, but the absolute recovery almost is never observed. Most of children from the inborn or arisen at early children's age G. without treatment perishes. Optimum G. at children of advanced age proceeds. Results of surgical treatment depend on timely carrying out operation, extent of damage of a brain a basic disease, and also on the most careful accounting of indications and contraindications to this or that type of operation.
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V. I. Rostotskaya; V. V. Kovalyov (psikhiat.).