From Big Medical Encyclopedia

PACHYMENINGITIS (pachymeningitis; grech, pachys thick, dense + meninx, meningos a cover + - itis) — an inflammation of a firm cover of a head and spinal cord. Inflammatory process of a firm cover of a brain is called a cerebral pachymeningitis, and a firm cover of a spinal cord — a spinal pachymeningitis. Depending on what layers of a cover are struck, distinguish the outside, internal and intra shell Item. On the nature of inflammatory process distinguish serous, hemorrhagic and purulent P., on a current — the acute and chronic Item.

Pathoanatomical changes at serous P. are characterized by a loosening, hypostasis and a sharp plethora of a firm cover of a head and spinal cord.

Fig. 1. Microdrug of a firm meninx at a hemorrhagic pachymeningitis: in the thickness of a cover are visible hemorrhage (1) and various size of a cavity (2) regarding which the endothelial vystilka is visible; coloring hematoxylin-eosine; X 200.
Fig. 2. Microdrug of a firm meninx at a hemorrhagic pachymeningitis: proliferation of fibroblasts (it is specified by shooters) in a zone of hemorrhage; coloring hematoxylin-eosine; x 200.
Fig. 3. Microdrug of a firm meninx with the capsule of a hematoma at a hemorrhagic pachymeningitis: proliferation of fibroblasts (1), accumulation of macrophages (2) and lymphoid elements (3); coloring by toluidine blue; X 200.
Fig. 4. Macrodrug of a firm meninx at a hemorrhagic pachymeningitis: hemorrhages of different prescription with treatment of a firm meninx fresh (red color) and changed (brown color) blood.

At hemorrhagic internal P. in patol, process is involved a firm cover of a brain, is more often than a verkhnelateralny surface a frontal and temporal lobe of a cerebral hemisphere, sometimes both hemispheres of a cerebellum, areas of the Turkish saddle are more rare. In a firm cover of a spinal cord hemorrhagic internal P. meets extremely seldom. At this form there is a hemorrhagic treatment or stratification of a firm cover of a brain owing to a rupture of walls or phlebitis of brain veins in a zone of their falling into sine of a firm meninx. Macroscopically struck cover has a motley appearance due to alternation of the brownish-brown old centers and accumulation of blood in the cavities which are formed as a result of repeated hemorrhages (tsvetn. fig. 4). Further contents of cavities completely become colourless and so-called hygromas of a firm cover of a brain are formed. Microscopically at hemorrhagic P. the centers of hemorrhages of different prescription and a cavity, an inner surface are found to-rykh it is covered by an endothelium (fig. 1). The organization of hemorrhagic masses (see. the Organization in pathology ) happens by growing into them of granulyatsionny fabric to formation of thin-walled vessels (fig. 2). In granulyatsionny fabric accumulations of gemolizirovanny blood, and adjournment of hemosiderin come to light; in the forming fibrous capsule proliferation of macrophages (fig. 3) is noted. The capsule can be an infiltrirovana lymphoid and plasmocytes. Hemorrhagic P.'s feature is slow development of processes of the organization and insufficiently expressed coagulation of the streamed blood owing to the small content in it of fibrin or impurity of cerebrospinal liquid. In the central departments of cavities processes of the organization can quicker develop that is followed in some cases by adjournment of salts of calcium or ossification of a firm cover of a brain.

At purulent P. the firm cover of a head and spinal cord is full-blooded, purulent or fibrinoznognoyny exudate is located on an outer surface of a cover or in a subdural space, gradually being exposed to the organization and an otgranicheniye commissures; at the same time extra-or subdural abscesses are formed. Microscopically in a firm cover of a head and spinal cord perivascular infiltrates from segmentoyaderny leukocytes and granulyatsionny fabric of different degree of a maturity are found. During the subsiding of process fibrosis of a cover develops.

At hron. The item develops fibrosis of a firm cover of a head and spinal cord and there is its union to surrounding fabrics. Distribution of process on an extent of a firm cover of a spinal cord promotes formation of a muftoobrazny thickening with the subsequent prelum of roots of spinal nerves and their atrophy. At tuberculosis, syphilis, an actinomycosis and others hron, infections the hyperplastic Item meets hron. The firm cover of a spinal cord at the same time is thickened due to treatment by gelatinous exudate, has yellowish-gray color, can be spliced with surrounding fabrics. Microscopically specific granulomas are found, at syphilis gummous defeats prevail.

The cerebral pachymeningitis

is Distinguished by several forms cerebral P.: serous cerebral P., hemorrhagic internal and intra dural P., outside and internal purulent cerebral Item.

The serous cerebral pachymeningitis can arise at systemic infections, intoxications, allergic reactions. It proceeds, as a rule, asymptomatically and therefore it is practically not diagnosed.

The hemorrhagic internal and intra dural pachymeningitis can arise at an injury, atherosclerosis, dekompensirovanny heart diseases, diseases of blood, increase in intracranial pressure, inf. diseases, etc. Small hemorrhages in a firm meninx proceed, as a rule, asymptomatically. At extensive hemorrhages the headache which arose in the acute period gradually extends to all head, is followed by vomiting, sometimes a loss of consciousness. Decrease in memory, apathy, sometimes, on the contrary — psychomotor excitement, nonsense is often observed. Focal nevrol, manifestations depend on localization of hemorrhage. The symptoms caused by running off of the streamed blood on a subdural space and also wet brain and neuro dynamic shifts can join them. Poorly expressed Meningeal symptoms come to light. In nek-ry cases congestive nipples of optic nerves with retinal apoplexies or an optic neuritis are found. At a spinal puncture cerebrospinal liquid follows under supertension, in it increase in protein content, a small pleocytosis, an easy xanthochromia is sometimes noted.

The differential diagnosis is carried out with a cerebral stroke (see. Stroke , Cerebral circulation ), subarachnoidal hemorrhage (see. the Subshell hemorrhages ), meningitis (see).

Treatment in most cases operational. During operation delete a hematoma and prrizvodit bandaging of the damaged vessel. In mild cases the conservative treatment directed first of all to a basic disease is recommended, apply symptomatic and dehydrating agents.

The forecast at timely treatment, as a rule, favorable.

The outside purulent cerebral pachymeningitis develops at penetration into a head cavity of contagiums from a middle ear, napr, at purulent average otitis, subordinate clauses (okolonosovy, T.) bosoms of a nose at purulent sinusitis, and also from the suppurated wounds, an anthrax, furuncles of the head and other areas of a body. From gene outside purulent cerebral P. develops more often in a back cranial pole, is more rare in an average and front cranial pole. At otogenic and rhinogenic P. contagiums get into a head cavity contact, hematogenous in the ways, and also on perineural spaces; from the remote suppurative focuses — a hematogenous and lymphogenous way. In an initial stage of P. involution of process can be observed, but sometimes as a result of P. extradural abscess is formed. Outside purulent P. can be complicated by subdural or intratserebralny abscess or purulent meningitis. Transition of inflammatory process to walls of sine and veins of a firm cover of a brain leads to sinusitis and phlebitis with the subsequent thrombosis (see).

Outside purulent cerebral P. and extradural abscess sometimes proceed asymptomatically. In the majority of cases in a wedge, a picture the localized headache and local morbidity at percussion of a skull according to localization of process are noted. At P. and extradural abscess in an average cranial pole the most severe headache is localized in temporal area; morbidity at percussion of a scaly part of a temporal bone comes to light. Aphasia, paresis of extremities, epileptiform attacks are sometimes noted. Inflammatory process at a top of a pyramid of a temporal bone causes on the party damages the severe pains in frontal, temporal areas and an eyeglobe, a hyperesthesia of skin in a zone of an innervation of an optic nerve which are combined with paralysis of the taking-away nerve (see. Gradenigo syndrome ). In a back cranial pole are most characteristic morbidity at percussion of an occipital bone of abscess, restriction of movements and forced position of the head. Defeat of a trifacial at P. can be combined with injury of facial and preddverno-cochlear nerves and be followed by a nystagmus and a rotatory vertigo. The eyeground at P. and extradural abscess is usually not changed. At a spinal puncture build-up of pressure of cerebrospinal liquid, a nek-swarm increase in it in protein and a small pleocytosis is noted.

Outside purulent cerebral P.'s diagnosis is difficult in connection with small expressiveness nevrol, symptoms. At otogenic outside purulent P. important diagnostic value can have increase purulent separated from an ear. The X-ray analysis of a temporal bone and adnexal bosoms of a nose can give Nek-ry help in diagnosis; it is reasonable to use ekhoentsefalografiya (see) and pneumoencephalography (see), and also a computer tomography of the head (see. Tomography computer ).

The differential diagnosis is carried out with a tumor and abscess of a brain (see. Brain ), a cerebral arachnoiditis (see. Arachnoiditis ).

Treatment in most cases operational with simultaneous introduction of high doses of antibiotics and streptocides. An operative measure consists in carrying out an osteoplastic or resection craniotrypesis according to localization of extradural abscess, emptying of its contents and excision of walls of abscess. After that into the operational area enter polyvinyl drainage tubes for the purpose of topical administration of antiseptic solutions, antibiotics. Through the same tubes there is an outflow of wound separated. Treatment of a basic disease is at the same time carried out.

The forecast at timely v treatment favorable.

The internal purulent cerebral pachymeningitis meets seldom. It arises most often as a complication of purulent sinusitis, is less often observed in the form of otogenic and metastatic subdural abscesses. The item is localized by the most part on a verkhnelateralny surface of cerebral hemispheres. The combination of subdural abscess with extradural or thrombosis of sine of a firm meninx is possible. Sometimes disease is complicated by a purulent pia-arachnitis.

For a wedge, pictures the fever, a headache, sometimes vomiting, Meningeal symptoms, drowsiness, apathy, sometimes nonsense, the expressed leukocytosis, shift of a blood count to the left, the accelerated ROE are characteristic temperature increase to 38 — 40 °. In some cases the congestive optic papilla comes to light. Spasms, a monoparesis (or a monoplegia), aphasia are quite often observed. At a spinal puncture cerebrospinal liquid follows under supertension, the amount of protein in it is increased, the quantity of cells can be normal, but the moderate pleocytosis is in most cases noted.

The diagnosis is based hl. obr. on a wedge, a picture, a research of an eyeground, cerebrospinal liquid, degree of manifestation of meningeal symptoms and data of an ekhoentsefalografiya. The differential diagnosis, as well as at outside purulent cerebral P., is carried out with a tumor and abscess of a brain.

Treatment, as a rule, conservative is also directed to a basic disease using anti-inflammatory and dehydrating agents. In the presence of subdural abscess operational treatment is carried out, as well as at extradural abscess.

The forecast at timely treatment, as a rule, favorable.

The spinal pachymeningitis

Spinal P. meets more often than cerebral. Outside spinal P. is in most cases observed, at Krom inflammatory process usually begins in an epidural fatty tissue and then extends to a periblast of a firm cover of a spinal cord (see. Meninx ). Often outside spinal P. is called epidurity. Outside spinal P. on a current can be acute and chronic, and on the nature of process serous, purulent and chronic hyperplastic. Serous spinal P. (serous epidurit) quite often proceeds latentno and asymptomatically.

The purulent spinal pachymeningitis (purulent epidurit) usually develops for the second time as a complication of the purulent processes which are localized as near an epidural space (osteomyelitis of a backbone, juxtaspinal abscess, a back mediastinitis, etc.) and: at considerable distance from it (purulent tonsillitis, a pyelitis, a furunculosis, a felon, etc.). Purulent spinal P. can be also at sepsis. Contagiums get to an epidural space in the contact, hematogenous, and lymphogenous way. The purulent inflammation of epidural cellulose can be limited in the form of epidural abscess throughout three-four vertebrae or diffusion. Purulent process is localized more often on average and lower chest departments of a backbone. At the same time the spinal cord and its soft cover usually are not involved in inflammatory process, but they are exposed to a prelum epidural abscess, to influence of toxins. Besides, defeat them can result both from disturbance krovo-and lymphokineses. Only in the few, the most malignant, cases contagiums can get into a subarachnoid space and cause meningitis, a myelitis.

Purulent spinal P. begins sharply, less often subacutely, is followed by weakness, an indisposition, a headache, lack of appetite, gektichesky fever, changes of blood of septic character (a high leukocytosis, shift of a blood count to the left, the accelerated ROE). On this background appear nevrol. the disturbances caused by hl. obr. a prelum of a spinal cord, its covers and roots of spinal nerves epidural purulent process, the inflamed and edematous firm cover of a spinal cord: radicular pains, paresthesias, symptoms of a tension of roots, paresis and paralyzes of extremities, most often in the form of the central lower paraplegia, disorder of sensitivity of conduction character, pelvic disturbances. * Along with it also radicular symptoms of loss are quite often observed: absence or slackness of nek-ry tendon jerks, hypesthesia, hypotonia and atrophy of separate groups of muscles. Increase nevrol, disturbances happens quickly enough; in acute cases already in 2 — 3 days after emergence of radicular pains the central paresis (paralyzes), pelvic disturbances, etc. are found.

The differential diagnosis is carried out with acute myelitis (see), spondylitis (see), abscess and tumor spinal cord (see). It is especially important to otdifferentsirovat the purulent spinal pachymeningitis demanding urgent operational treatment from an acute myelitis, to-ry treat only conservatively. At an acute myelitis in an onset of the illness there is no pronounced radicular syndrome, there is no morbidity at percussion on acanthas of vertebrae and Meningeal symptoms are expressed poorly, there is no build-up of pressure of cerebrospinal liquid, quicker, than at purulent spinal P., paresis, paralyzes, conduction disorders of sensitivity, pelvic disturbances, decubituses develop. The spinal puncture at purulent spinal P. in connection with danger of a drift of an infection in a subarachnoid space is made carefully in the zone remote from abscess. At the same time the needle with mandrin is entered into an epidural space in the beginning, and then if after removal of mandrin from a needle pus does not appear, she together with mandrin is led to a subarachnoid space. At purulent spinal P. in cerebrospinal liquid the xanthochromia, the increased protein content, sometimes a moderate pleocytosis are noted; Liquorodynamic tests (see), as a rule, reveal a face-vorny the block, to-ry is confirmed by means of pnevmomiyelografiya.

Treatment of patients with purulent spinal P. is directed to a basic disease, at the same time apply high doses of antibiotics and streptocides. In the presence of epidural abscess operational treatment is shown (after a laminectomy at appropriate level delete purulent contents of abscess, excise its walls and in the subsequent drain a wound).

The forecast at purulent spinal P. serious. It depends not only on weight of purulent process, timeliness of the begun treatment, but also on character and a current of a basic disease.

The chronic hyperplastic pachymeningitis (chronic hyperplastic epidurit) can arise owing to the postponed spine injury, hron, his diseases of inflammatory and dystrophic character, napr, osteochondrosis, a spondylosis, and also an actinomycosis, a brucellosis, tuberculosis, syphilis, etc.

The disease begins mostly subacutely. There are severe radicular pains, pains in a backbone sometimes reminding a lumbago and which are followed by a muscle tension of a back. The movements in a backbone are limited because of pains. The initial stage is often followed by remission, later cover pains renew, there are paresthesias, hypesthesias of radicular character, the phenomena of a spastic lower paraparesis (more rare than tetraparesis) and conduction disorders of sensitivity accrue. Especially strongly the muscular and joint feeling suffers. Broun-Sekar's syndrome is sometimes observed (see. Broun-Sekara syndrome ) or only its separate symptoms. In cerebrospinal liquid usually find the expressed belkovokletochny dissociation or a syndrome to Nonna — Fruena (see. Cerebrospinal liquid ). Nevrol. symptoms accrue gradually, more rare, having reached a certain degree, are stabilized with small fluctuations of expressiveness; symptoms of damage of a brain at the same time are absent. The general condition of the patient in most cases remains satisfactory.

The diagnosis hron, hyperplastic P. presents great difficulties. It it is necessary to distinguish hl. obr. from a tumor of a spinal cord and arachnoiditis (see). The contrast epidurografiya, pnevmomiyelografiya, spondilografiya and research of cerebrospinal liquid are of great importance for specification of the diagnosis.

Treatment, as a rule, operational. During operation delete granulyatsionny growths and excise considerable fibrous thickenings of a firm cover of a spinal cord. Before operation appoint antibiotics. In the postoperative period apply anti-inflammatory, resorptional pharmaceuticals, and also physical therapy, massage, LFK; hold rehabilitation events. At moderately severe limited hyperplastic P. quite often recovery occurs after performing conservative treatment. At discogenic lumbosacral hyperplastic P. introductions to area of the center of defeat of mix of solution of novocaine, cyanocobalamine (B12 vitamin), a lidaza and Prednisolonum are effective epidural.

The forecast at timely treatment is more often favorable.

Separate forms of chronic hyperplastic P. are the cervical hypertrophic syphilitic and tubercular spinal Item.

The cervical hypertrophic syphilitic pachymeningitis is described in 1873 by Zh. Sharko and A. Joffroy. Meets seldom, develops slowly (for 1,5 — 2 years). During a disease distinguish three stages: a stage of irritation of roots of spinal nerves, in time a cut pains in a nape, a neck and hands are observed; the stage which is characterized by radicular symptoms of loss (sluggish paresis of hands with an atrophy of muscles of a belt of upper extremities and muscles of a brush, a hypesthesia in the Soup region — Tlij); the stage of a prelum of a spinal cord which is followed in nek-ry cases by a pleocytosis in cerebrospinal liquid.

Data of the anamnesis, positive Wassermann reaction in cerebrospinal liquid and other symptoms of syphilitic defeat of c are important for establishment of the diagnosis. N of page.

Treatment specific conservative in combination with antiinflammatory both use and balneoterapiya.

The forecast is more often favorable.

The tubercular spinal pachymeningitis in most cases develops as a complication of a tubercular spondylitis. Nevrol, manifestations correspond to localization of inflammatory process.

The X-ray analysis of a backbone, roentgenoscopy of bodies of a thorax, statement of reactions of the Tuberculine test and to Mant are important for establishment of the diagnosis.

Treatment specific antitubercular (Tubazidum, Ftivazidum, streptomycin, PASK) in combination with other means and methods applied at treatment of other forms hron, hyperplastic P.

See also Meningitis .

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X. G. Hodos; Yu. A. Zozulya (neyrokhir.), M. A. Sapozhnikova (stalemate. An.).