SPASMS — involuntary reductions of cross-striped or unstriated muscles, various on intensity, duration and prevalence, having pristupoobrazny character. Pages represent one of versions hyperkinesias (see).
Classify by the nature of muscular contraction of S. on clonic and tonic. Clonic S. are characterized by short-term reductions and relaxations of separate groups of muscles, quickly following one after another that leads to the stereotypic bystry movements having various amplitude. Tonic S. represent longer (to the 3rd, sometimes and more min.) reductions of muscles, as a result to-rykh «hardening» of a trunk and extremities in various forced poses is created. The variety of S. which are found in a wedge, practice does not keep within a framework of this classification. Many forms C. of the mixed character are had: at dominance in muscular contraction of a tonic component C. define as toniko-clonic, and at the expressed clonic component consider them as kloniko-tonic.
Clonic S. usually arise at superexcitation of cells of a cerebral cortex, especially its motor department. Their somatotopiche-sky distribution on muscles and groups of muscles according to an arrangement of the motive cortical centers in a front central crinkle is characteristic of this type C. So, e.g., having begun with face muscles, clonic S. take consistently muscles of fingers, hands, forearms, a shoulder, legs (so-called cortical epilepsy). Tonic S. arise, as a rule, at superexcitation of subcrustal structures of a brain.
Depending on S.'s prevalence subdivide into the localized in one muscle or group of muscles and generalized, fascinating many muscles. Generalized S. can be a final stage of a convulsive paroxysm of any type.
Pages are caused by various exogenous and endogenous reasons. Pages of a different etiology are not identical in a form, frequency of attacks, their current, features a postattack-nogo of the period, to a combination to others a wedge, symptoms and data of laboratory researches. At the same time identical in a form C. can arise at various diseases of a nervous system which are followed by functional, structural, metabolic and liquorodynamic frustration — meningitis, encephalitis, abscesses, parasitic diseases and tumors of a brain, aneurisms of brain vessels, a craniocereberal injury, intracerebral, subarachnoidal and subdural bleedings, vascular spasms, ischemic strokes, etc. At this S. happen both generalized, and local, in the latter case quite often pointing to primary localization patol. center. Pages often are an early symptom of hereditary and degenerative diseases of a nervous system: a leukodystrophy (see), etc., the senile dementias proceeding with demyelination of a nervous system, progressing — Alzheimer's disease (see. Alzheimer disease ), diseases of Peak (see. Peak disease ), etc.; choreas of Gentington (see. Gentington chorea ); the torsion dystonia (see), a double athetosis. S.'s attacks beginning local myoclonias, further generalizuyushchiyesya and passing into the general convulsive attack, are observed at a myoclonus epilepsy (see). Attacks of the localized S. are more characteristic of a tuberous sclerosis, an entsefalotrigeminalny angiomatosis (see. Fakomatoza ).
The somatopathies leading to disturbances of cerebral circulation and a hypoxia of tissue of brain can be also followed by S. Neredko S. development observe at heart diseases and pathology of the main vessels, diseases of blood (leukoses, disturbances of coagulant system of blood, hemorrhagic vasculites), collagenic diseases (a system lupus erythematosus, a nodular periarteritis, rheumatism). The pages caused by disturbance of metabolism in tissue of a brain and connected with endogenous intoxication develop at a hypoglycemic coma, a hepatic coma (see). At these conditions of S. usually have generalized toniko-clonic character. Pages at an eclampsia (see) pregnant women are symmetric and cover face muscles, trunks, extremities, can be followed by a short-term loss of consciousness. In cases when at an eclampsia there are acute frustration of cerebral circulation, also big convulsive attacks sometimes develop. Chaotic, asymmetrical reductions of separate muscles or muscle fibers (muscular fibrillations) are characteristic of an uremic coma (see). Sometimes these S. pass convulsive attacks into generalized kloniko-toniche-skiye. Pages at burn shock (see) usually have tonic or toniko-clonic character and, as a rule, develop at patients with the deep burns occupying from 5 to 40% of a body surface.
Can lead various exogenous intoxications to S.'s development (see Intoxication). So, e.g., the poisoning with carbon monoxide which is followed by coma can cause tonic S. like a cerebrate rigidity, a lockjaw; the drunkenness can be shown by generalized convulsive attacks, to-rye a thicket arise in a debut of a tremens. Also S. at tetanus concern to this group (see).
Sometimes S. arise at the patients having neurosises with a hyperexcitability of a nervous system. However S. defined as hysterical, always demand a special complex research since they at the heart of S. treated as functional, often lie is hidden the proceeding organic lesions of a nervous system.
Perinatal asphyxia, intracraneal patrimonial hemorrhages, malformations of a brain, neuroinfection, metabolic disturbances (acidosis, a hypocalcemia, an alkalosis, a hypoglycemia, a hyponatremia, a hyperbilirubinemia, deficit of B6 vitamin) can be S.'s reasons in the period of a neonatality. Pages at newborns often are the first a wedge. display of hereditary diseases — neurolipidoses (see Lipidoses), an entsefa-lotrigeminalny angiomatosis (see), a tuberous sclerosis (see), family acidosis (see), etc. S.'s reason at chest age as well as in the period of a neonatality, there can be organic lesions of a nervous system, neuroinfection, malformations of a brain. Pages are observed almost at a half of patients with cerebral palsy (see. Children's paralyzes). Page at hereditary diseases, such as phenyl ketonuria (see), dekarboksilazny insufficiency (see), a leukodystrophy (see), fakomatoza (see), arise at chest age in combination with the expressed delay of psychomotor development more often and much more rare are the first symptom of a disease. Pages can accompany preventive inoculations (a postvaccinal convulsive syndrome).
Also inborn heart disease can be the cause of development of S. in children of early age. Weight of convulsive attacks and their frequency depend on the nature of damage of heart, expressiveness of the general hemodynamic frustration. At children of advanced age the convulsive attacks caused by disturbances of a cordial rhythm can be noted.
At the children who had the closed craniocereberal injury S. caused by a chronic intracranial hematoma and also the traumatic epilepsy which is characterized by a progreduated current with gradual formation of epileptoidny changes of the personality can be observed (see Epilepsy).
Pathogeny spasms it is difficult. Due to various mechanisms of development of convulsive paroxysms distinguish convulsive reaction, a convulsive syndrome and an epileptic disease (see. Epilepsy ).
Convulsive reaction arises in response to the irritations, extraordinary for this organism, caused by an infection, intoxication, overfatigue, stay in the stuffy room (a condition of a hypoxia), etc. Convulsive reaction can develop at any healthy person, however easier it arises at the increased convulsive readiness. Degree of convulsive readiness is variable and undergoes individual changes depending on circadian rhythms, under the influence of internal and exogenous causes. Level of convulsive readiness also depends on degree of a maturity of a nervous system, age and its genetic features. At children's age of S. arise by 4 — 5 times more often than at adults. Unfinished differentiation of a brain of the child and, as a result of it, physiological hyper synchronization of «work» of cells cause frequent emergence of convulsive attacks at children under the influence of insignificant exogenous or endogenous influences. Example of convulsive reaction are gi-pertermichesky S., to-rye most often observe at children to three-year age, in the period of the increased convulsive readiness. Than the person is more senior, especially strong influence is capable to cause S. Primer of convulsive reaction in adults S. at insulin shock, poisonings with tetraethyllead, carbon monoxide gas are, at a massive drunkenness, etc.
Incidence of paroxysms is characteristic of convulsive reaction (see).
The convulsive syndrome develops, as a rule, at actively current patol. processes in a nervous system. In its emergence major importance has the acquired reduction of the threshold of convulsive readiness of a brain, at the same time the role of exogenous factors in S.'s development is slightly lower. Repeatability of paroxysms is characteristic of a convulsive syndrome. Convulsive readiness is physiologically characterized by all signs of a dominant and represents the extreme extent of the central excitement which is going beyond norm. Its pathophysiological sign — the change of electric activity of bark and subcrustal educations consisting in synchronization and hyper synchronization of a theta rythm, existence of paroxysms of convulsive potentials in structures of limbic system (see), delay of synchronized rhythmics in a mesodiencephalic reticular formation (see), intralami-narny kernels of a thalamus, a kernel having a tail and in a cerebral cortex (epileptiform activity). At the same time both the background and caused activity of separate neurons changes. Early and clear changes of biopotentials register in the hippocampus having high excitability, abundance of bilateral ties that provides big inflow to it afferent impulses. With a low convulsive threshold carry to structures also an almond and structures of a medial thalamus (see). Development against the background of convulsive readiness of a convulsive paroxysm requires additional inflow of afferent impulses to the center of a hyperexcitability (primary center) owing to what the pathological dominant forms. S.'s paroxysm can arise at irritation of any department of c. N of page, on condition of increase in excitability of structures of a brain out of the center and, first of all, increase in excitability of a cerebral cortex. In pilot electrophysiologic studies it is shown that at irritation of a cerebral cortex evoked potentials at height of a convulsive state are registered not only in projective zones, but also in other its areas. The irritation, a cut causes emergence of a usual complex of evoked potential in a normal animal, after introduction of a subliminal convulsive dose of camphor leads to emergence of the group categories turning into generalized epileptiform activity, and further and to development of spasms. At the same time excitability of motor bark increases by 3 — 4 times in comparison with norm. Extent of synchronization of biopotentials reflects expressiveness and space distribution of convulsive readiness in different structures of a brain. The shift of a wave range towards low-amplitude synchronized fluctuations on EEG is observed long before emergence of a convulsive paroxysm and can indicate its future character (local, the general). Spread of activation comes from the center of a superactivity not only on the surface of a cerebral cortex, but considerably on reticular structures of a trunk. At a convulsive syndrome the long irritation of limited sites of a cerebral cortex leads to gradual education in subcrustal departments of the independent centers of arousing congestive character, to-rye can show the activity and after the termination of irritation of bark, irrespective of primary center. The center of excitement in subcrustal structures, in turn, causes generalized excitement of a cerebral cortex (so-called returnable generalization of excitement). The important role in generalization of excitement belongs to rostral department of a reticular formation — to a mesencephalon and a hippocampus. Change of a functional condition of a mesodiencephalic reticular formation sharply affects the level of convulsive activity. In a crust, time it is shown that the weak irritation of reticular structures promotes formation of the congestive center of excitement in a hippocampus and facilitates creation of convulsive readiness and S. Otmecheno's appearance that the strong irritation oppresses paroxysmal activity of a hippocampus and leads to considerable decrease in convulsive readiness. It is established also that the high functional tone of a cerebral cortex leads to decrease in convulsive readiness, and the main role in this process belongs to frontal departments of cerebral hemispheres. At intracellular recording of activity of neurons in the pathological convulsive center considerable changes of membrane potential (towards its depolarization) and increase in synaptic activation are established. Depolyariza-tsionny shifts arise in a catfish - the dentritic sites of neuron having a postsynaptic membrane. They are result of summation of excessively strengthened depots-lyarizatsionnykh of postsynaptic potentials. Pages of various origin exert considerable impact on metabolism of cellular protein, causing strengthening of its disintegration at simultaneous oppression of synthesis. At the same time decrease in content of RNA in tissues of a brain, damage of mitochondrions, disturbance of processes of oxidizing phosphorylation is noted (see).
Page at epilepsies (see) arise against the background of hereditarily the caused increase in convulsive readiness of a brain more often. S.'s attacks at the same time usually arise without any noticeable provocative factors.
In many cases, especially at early children's age, differentiation of epilepsy, a convulsive syndrome and convulsive reaction presents difficulties since borders of these states are conditional. So, e.g., convulsive reaction at children can sometimes be early display of epilepsy, and the convulsive syndrome under the influence of long influence of an exogenous factor and for the second time the arising disturbances of metabolism of a brain and cerebral circulation can be transformed to epilepsy.
In a wedge, practice along with pathogenetic classification of convulsive states S. subdivide depending on features of muscular contraction (clonic and tonic), their frequencies, on disturbance of biochemical constants of an organism, level of defeat of a nervous system, prevalence (local, generalized).
Depending on the frequency of emergence of S. divide on incidental and constant. The last, in turn, characterize as periodic (serial) and the convulsive status.
The pages resulting from biochemical disturbances subdivide on gipokaltsiyemichesky (see. Tetany ), hypoglycemic, giperbilirubinemichesky, piridok-sin-dependent, gipomagneziyemichesky (see. Spasmophilia ), etc.
On the level of defeat of a nervous system conditionally allocate: clonic spasms of cortical genesis; constant arrhythmic clonic spasms in certain groups of muscles (kozhevnikovsky epilepsy); tonic or clonic spasms in the extremities opposite to the center at jacksonian epilepsy (see); trunk S. — oculogyric spasms, gormetoniya (see), myoclonias of a soft palate, language, etc.
S.'s localization is various, quite often observe S. of face muscles: a front hemispasm — unilateral tonic S. of mimic face muscles with the advent of wrinkles on a forehead, procrastination of a corner of a mouth of a knaruzha and up, with tension of a hypodermic muscle of a neck on the party of a spasm; a front paraspasm — periodically repeating tonic symmetric S. of face muscles; the spasm usually begins with reduction of circular muscles of an eye, then reduction of a circular muscle of a mouth, muscles of cheeks, a chin, neck, language joins, sometimes these spasms are combined with drive ches Kimi S. of muscles of a mouth, a neck and quite often are followed by pain; a nictitating spasm (see) — the tonic S. of circular muscles of eyes which is shown a painful zazhmurivaniye the clonic S. leading to a frequent blinking are less often observed; a platizmalny spasm — the tonic tension of a superficial muscle of a neck; The Page can sometimes extend to muscles of a chin and a circular muscle of a mouth; Page of a look (see the Look paralysis, a spasm) — the tonic S. of oculomotor muscles which is shown involuntary hardening of eyes in the provision of extreme assignment of eyeglobes (in the parties, up, down); nodding S. — the clonic S. of grudinoklyuchichno-mastoidal muscles which is characterized by the bystry rhythmical nodding movements of the head of small amplitude; alternate reduction of muscles can lead to rotary motions of the head (so-called rotatorny S.); The Page of a diaphragm has clonic character more often and is shown by a hiccups (a loud bystry breath with a characteristic sound). Clonic and klo-niko-tonic S. of the muscles participating in the speech act, and respiratory muscles lead to stutter (see). Tonic S. of masseters (see the Lockjaw) lead to a dense smykaniye of jaws, at Krom of the patient cannot sometimes eat and speak. Local tonic S. can arise in sural, sartorial, belly, intercostal and other muscles and be followed by sharp pain (krampa); at a palpation consolidation of muscles is defined. Characteristic tonic S. of muscles of a brush («obstetrical hand»), face muscles, observe stop («horse foot») at a spasmophilia (see), tetanies (see). The localized static S., or saltatorny spasm of Gover-sa, is shown by bystry rhythmical jumpings owing to clonic reduction of muscles of legs. In a start of motion, made with loading, the in-tentsionny spasm of Ryulf can develop (see Ryuljf an intentsionny spasm), at a cut there is a clonic reduction of muscles in the extremity making the movement, then S. extends also to other groups of muscles. The local tonic spasm of muscles of fingers and a brush is observed sometimes during the long letter (see. Writer's cramp) or at playing musical instruments. The page of muscles of big and index fingers — daktilospazm — is observed at tailors, typists, telegraph operators, milkmaids, saddlers, shoemakers, hairdressers. KS., connected with steady professional stress, carry also a nictitating spasm at watchmakers, a spasm of muscles of legs at ballerinas.
Generalized tonic S. can proceed as a gormeto-niya (see) — periodic tonic S.' kinds of a trunk and the extremities arising at extensive cerebral defeats. During gormetonichesky S. the backbone is slightly unbent, hands are extended, are in the provision of pronation, legs are unbent. Generalized tonic S.' kind is also the cerebrate rigidity (see).
Generalized clonic S. are sometimes shown by frequent rhythmical starts of a trunk and trembling of extremities (earlier carried the name of convulsions). Clonic S.' kind — myoclonias are characterized by asynchronous chaotic, «fulminant» reductions of various muscles. Myoclonias can be generalized and local.
The Toniko-klonichesky sodorog which are followed by loss of consciousness are classified clinically as a big convulsive attack (paroxysm). The structure of a convulsive attack can be combined various tonic and clonic S. Struktura of convulsive attacks at newborns, babies and children of more advanced age has specific features. Convulsive paroxysms at newborns are shown by fulminant, generalized tonic and clonic S., to-rye easy to take for the usual movements of the newborn: a blinking, a zazhmurivaniye a century, assignment of eyes in the parties, twitchings of eyeglobes, smacking, suction, the movements by hands reminding swimming or rowing, the movements by legs reminding driving the bicycle, tonic contraction of separate groups of muscles of extremities. Unlike physiological movements, S. are usually combined with vasculomotor and other vegetative frustration and are followed by specific changes on EEG (see Elektroentsefalografiya). Tonic S. with sudden extension of all extremities or bending of hands and leg extention are characteristic of premature newborns, at full-term such paroxysms often testify to hemorrhage in cerebral cavities.
Generalized clonic S. — alternate reductions of separate groups of the muscles migrating from one part of a body to another are quite often observed at the full-term newborns.
The myoclonic type C. at newborns is characterized by single or multiple twitchings of upper or lower extremities with a tendency to their bending. These attacks usually are followed by vskrikivaniye, decolourization of skin.
After the period of a neonatality the motive component of a convulsive attack becomes more expressed. The general tonic attacks — the so-called infantile spasms which are characterized by bilateral symmetric reduction of muscles are more characteristic of babies. Fleksorny spasms carry also the name of propulsive attacks or «salaamovy attacks». During a paroxysm there is a sudden bending of a neck, trunk, hands, to-rye are bent and led to a body (or, on the contrary, are taken away). Ex-tensor spasms (retropulsiv-ny attacks) are shown by sharp extension of the head and trunk, assignment of hands. Carry also partial, fragmentary forms C. to infantile spasms — nods, starts, bending and extension of hands and legs. All forms of infantile spasms can be combined among themselves, their distinctive feature is tendency to seriality. S.'s duration can be from a fraction of a second to several seconds. A series of attacks lasts from several seconds to 20 min. and more. Per day the number of paroxysms fluctuates from single to several honeycombs and even thousands. Pages arise most often before backfilling or after awakening. Infantile S. can be followed by shout, a grimace of a smile, the scared look, rolling of eyes, trembling a century, pallor or face reddening, a temporary cessation of breathing. At frequent serial attacks children are slowed down, the loss of consciousness is sometimes observed. After three-year age infantile spasms meet seldom.
Big convulsive attacks at children of early age have abortal character more often; in structure of an attack the tonic component prevails. Attacks can be followed by rise in temperature, vomiting, abdominal pains and other vegetative symptoms.
Postvaccinal S. arise in several hours after an inoculation or on 1 — the 3rd day and only in isolated cases in later terms. Page usually local or small propulsive. After vaccination against S.'s measles can be observed during rise in temperature on 6 — the 7th day and have character of single toniko-clonic attacks.
Febrile S. arise against the background of the diseases proceeding with high temperature (see. Hyper thermal syndrome). Frequency of febrile spasms at children reaches 8 — 10%. Pages can have generalized character with dominance in structure of an attack of a tonic component, or to be focal. In 50% of cases febrile S. at a hyperthermia can repeat. In cases of developing of repeated febrile attacks and emergence of attacks out of a condition of a hyperthermia, the risk of development of epilepsy considerably increases further.
At children with a hyperexcitability of a nervous system aged from 7 — 8 months up to 2 years respiratory affective Pages are observed. Such S.' emergence is provoked by a fright, severe pain, anger. During shout there comes breath holding on a breath (an inspiratory apnoea), cyanosis develops, the head is thrown back back, pupils extend, for several seconds consciousness is lost. Owing to the developing hypoxia there can be a generalized convulsive attack. The village can warn switching of attention of the child at the time of shout. Approximately at 50% of children with affective and respiratory S. emotional and behavioural disturbances are observed.
The diagnosis of convulsive states provides, first of all, clarification of an origin of S., i.e. diagnosis of a basic disease. For this purpose all patient who had at least a single convulsive paroxysm conduct the comprehensive clinical examination including electrophysiologic, X-ray, biochemical, cytologic inspections. The important place belongs to the anamnesis on the basis of which find out premorbidal features of the patient, factors promoting emergence at it of S., character of a convulsive syndrome, S.'s presence and their analogs and others nevrol. disturbances at relatives of the patient. Specification of nature of the basic pathological process, objectification of existence of convulsive activity of a brain is helped by an electroencephalography (see). On EEG at S. paroxysmal categories of high amplitude, with the pointed form of waves and peaks, arising separately or in a combination to a trace slow wave are registered. The form of a paroxysm on EEG to a certain extent depends on character of convulsive attacks. So, irregular high-voltage fluctuations, single and multiple peaks and acute waves are characteristic of infantile spasms in EEG. The symmetric amplifying complexes of slow waves are more typical for big attacks. For detection of the hidden convulsive readiness carry out «activation of EEG», applying a hyperventilation, rhythmic light and sound irritations. At a convulsive syndrome, unlike epilepsy, elektroentsefalo-graphic changes in the mezhpri-stupny period can be non-constant that has great diagnostic value. At early children's age identification on EEG of the signs reflecting convulsive readiness of a brain is complicated in connection with instability and an illegibility of a picture of biopotentials owing to immaturity of the central nervous system. Therefore in this period the main role in diagnosis is assigned careful a wedge, to inspection of the patient.
S.'s treatment should be carried out in parallel with treatment of a basic disease. The choice of anticonvulsants (see) is made proceeding from a condition of the patient, structure of convulsive attacks. At purpose of drugs consider age of the patient, his weight, time of emergence of attacks (night, day).
Treatment is begun with small doses of pharmaceuticals, gradually increasing them to a minimal effective dose. The main anticonvulsant is phenobarbital. At generalized convulsive attacks the hexamidine, dipheninum, benzonal, Chloraconum can be also applied. At frequent attacks apply a combination of these means to tranquilizers (diazepam, chlordiazepoxide, thioridazine, etc.), borax, caffeine, a papaverine, extract of a belladonna, a gluconate of calcium, etc. At focal cortical attacks, and also clonic generalized spasms benzonal or its combinations with other anticonvulsants is recommended. At small propulsive attacks apply Suxilepum, Pyknolepsinum, nitrazepam (Radedormum), diazepam (Seduxenum), etc. Good anticonvulsant effect at these forms of paroxysms hormonal drugs (AKTG, a hydrocortisone, Prednisolonum, dexamethasone) have. S.'s treatment should be carried out it is long: after total disappearance of attacks anticonvulsant treatment is continued by not less than two years. At cancellation of pharmaceuticals it is important to consider indicators of EEG. Unjustified breaks in treatment as sharp cancellation of anticonvulsants can lead to development of the epileptic status are inadmissible. It is not recommended to reduce a dose of pharmaceuticals in the period of somatic or infectious diseases. At S.'s treatment along with anticonvulsants it is necessary to appoint periodically dehydrational therapy (see) — Diacarbum, glitserol, magnesium sulfate, lasixum. At prolonged use of anticonvulsants the close check behind the general condition of the patient and carrying out EEG is necessary.
Pages at newborns are the indication for the emergency medical actions since they can quickly lead to wet brain and oppression of the vital functions of an organism. Because S. at newborns are most often caused by disbolism their stopping before examination etiol. a factor it is necessary to begin with introduction parenterally 10 — 20% of solution of glucose, 10% of solution of a gluconate of calcium, 25% of solution of magnesium of sulfate before the termination of Page. If introduction of metabolites does not give desirable effect, enter anticonvulsants — diazepam, 2,5% solution of aminazine or its combination with solution of Pipolphenum and 0,5% solution of novocaine. After removal of spasms pass to a maintenance therapy with phenobarbital and take all necessary measures for statement of the etiological diagnosis. At febrile spasms in the acute period along with antipyretics it is necessary to appoint anticonvulsant and dehydrating agents according to the body weight and age of the child. The question of expediency of purpose of anticonvulsants after the first febrile attack for the purpose of the prevention of repeated attacks and transformation of febrile spasms in epilepsy shall be solved individually depending on age of the child, his premorbidal state, character and duration of a convulsive attack, changes on EEG. At emergence at the child of the second convulsive attack which is not connected with a hyperthermia he should be treated it is long as patient with epilepsy.
The forecast depends on the reasons which caused spasms, age of the patient, character of attacks and efficiency of treatment. The pages arising against the background of organic lesion of a nervous system usually tend to a progreduated current. They become polymorphic, become frequent and always make heavier a current of a basic disease. The forecast is adverse at frequent generalized, long focal attacks and the convulsive status. Early the begun differentiated treatment, successful selection of equivalent ratios of pharmaceuticals leads to long remissions and improves the forecast.
See also Spasm .
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