THROMBOSIS of VESSELS of the BRAIN (Greek thrombos a piece, a clot - j--osis) — process of formation of blood clots in brain arteries, brain veins and sine of a firm meninx.
Thrombosis of brain arteries develops in most cases at persons of mature and advanced age, is more rare — at persons of young age; it is the frequent reason of an ischemic stroke (a heart attack of a brain).
As characteristic «somatic background» for thrombosis of brain arteries serves the expressed atherosclerosis (see) with defeat of vessels of heart, brain, extremities, an eyeground, the phenomena of heart failure. Quite often atherosclerosis is combined with arterial hypertension, however the leading disease patients to thrombosis of brain arteries usually have an atherosclerosis. Thrombosis of brain arteries occurs at patients with heart diseases (see), both inborn, and acquired (sometimes in a stage of a decompensation), at vasculites (see), in particular rheumatic, syphilitic or like an obliterating thromboangitis (see the Thromboangitis obliterating), etc., at nek-ry inf. diseases.
Wedge, a picture of thrombosis of brain arteries it is identical a wedge, a picture of an ischemic stroke (see the Stroke). Convincing a wedge, the criteria allowing to differentiate the ischemic stroke caused by thrombosis and the ischemic stroke arising in the absence of thrombosis (a so-called не-тромботический an ischemic stroke), it is not established. Thrombosis of ek-strakranialny departments of the main arteries of the head (sleepy, vertebrata) can proceed asymptomatically or be followed by passing disturbances of cerebral circulation. It happens in cases of bystry development of full-fledged collateral circulation when essential deficit of blood supply of a brain is not created. Thrombosis of intracranial arteries is almost always followed by a clinical picture of a heart attack of a brain.
Harbingers of thrombosis of brain arteries quite often are passing disturbances of cerebral circulation — the so-called tranzi-even ischemic attacks, to-rye are characterized by emergence unstable focal nevrol. symptoms. Usually they are a consequence of short-term deficit of blood supply of a brain in that area where the heart attack develops later (see). Sometimes just before a heart attack of a brain the tranzitorny ischemic attacks become frequent; in such cases they make enndry a prodromal stage of an ischemic stroke. At the same time the stupid headache, signs of the general somatic discomfort can be noted.
Thrombosis of brain arteries can arise at any time, however more often it develops in a dream or right after a dream. Gradual increase focal nevrol is characteristic. symptoms for several hours, sometimes even
2 — 3 days; apoplekti-formny development of symptoms is less often noted. The prevalence focal nevrol is in most cases observed. symptoms over all-brain; the last quite often are not expressed at all. Localization of focal symptoms of a heart attack of a brain depends on in what pool of blood supply there is a struck vessel, from a condition of a collateral krovoobrashche-stub (see the Stroke, Cerebral circulation).
At the thrombosis of intracerebral arteries leading to heart attacks in cerebral hemispheres paresis and paralyzes of extremities on the party, protivopoloyashy to the center of defeat (see Paralyses, paresis) in combination with the central paresis of facial and hypoglossal nerves, disturbance of sensitivity, defects of fields of vision — a hemianopsia are especially often observed (see). At an arrangement of the centers of defeat in a cerebral hemisphere there can be alalias — aphasia (see), a dysarthtia (see), and also disturbances of other highest cortical functions. Paresis of a look of so-called polusharny type is often noted (eyes of the patient are turned towards the struck hemisphere). On the party patol. the center it is quite often observed blefarospazzh (see).
At fibrinferments of arteries of vertebralno-basilar system with development of an ischemic heart attack in the field of a brainstem often there are oculomotor frustration, a nystagmus (see), dizziness, disturbances of a statics and coordination, a dysarthtia (see), a dysphagy (see), disorders of the vital functions; quite often patients complain of a headache, is preferential in cervicooccipital area. Sometimes there are alternating syndromes (see), features to-rykh depend on the level of defeat of a brainstem. At fibrinferments in pools of the back brain arteries bringing to distsirku-lyatsy in back departments of big hemispheres photopsias can appear (see), vision disorders, sometimes on both eyes, are more often in the form of a hemianopsia (see); symptoms of damage of a thalamus (see) with characteristic disturbances of sensitivity, a peculiar tonic installation of a brush like «thalamic arm», ho-reoatetozny hyperkinesias (see).
All-brain symptoms at fibrinferment of brain arteries are expressed unsharply or are absent. Loss of consciousness at most of patients does not happen, easy devocalization, the increased drowsiness, various degree of disorientation is more often observed. Perhaps acute development of a korsakovsky syndrome (see). More rough disorder of consciousness is noted only at extensive heart attacks in the cerebral hemispheres proceeding with wet brain (see Hypostasis and swelling of a brain) and a secondary trunk syndrome, and also at the accruing thrombosis in large vessels vertebralno-oh-zilyarnoy systems.
Vegetative disturbances at the ischemic stroke connected with thrombosis are expressed more weakly, than at a hematencephalon. The face of the patient usually pale, sometimes with a cyanochroic shade, the ABP more often normal or lowered, is more rare — raised, pulse is speeded quite often up, the lowered filling.
In blood of patients with thrombosis of brain arteries, especially in the first days of a disease, essential changes usually it is not observed. Indicators of hemocoagulation sometimes testify to the increased coagulability of blood (see Koagulogram-m). Cerebrospinal liquid also is, as a rule, not changed.
The cerebral angiography (see) in cases of thrombosis of brain arteries gives information only on existence of occlusion of a brain vessel at this or that level. However the last can be caused both by thrombosis, and an atherosclerotic plaque or an obliteration of a vessel. The computer tomography of a brain (see the Tomography computer) is informative for diagnosis of a heart attack of a brain since 2 — the 3rd day after a stroke, however the data obtained with its help cannot be used for the solution of a question of existence or absence of thrombosis of brain arteries.
The differential diagnosis is carried out with a tumor of a brain (see the Brain, tumors), a hematencephalon (see the Stroke), sometimes (at the remittiruyushchy course of thrombosis) — with multiple sclerosis (see).
Treatment is directed to improvement of a cerebral and general hemodynamics and to the prevention of complications (see the Stroke). At the same time method of the choice is thrombolytic and anticoagulating therapy.
The forecast at fibrinferment of brain arteries depends on its localization, extensiveness of the heart attack of a brain, a condition of the general hemodynamics caused by it. The forecast at, is better for fibrinferment of ekstrakranialny departments of the main arteries of the head, than at fibrinferment of intracranial arteries.
Thrombosis and thrombophlebitis of brain
veins. The vein thrombosis of a brain can arise without the previous inflammation of their walls (phlebothrombosis) or against the background of an inflammation (thrombophlebitis), however their differentiation on a wedge, to signs is complicated since the phlebothrombosis often is an initial phase of thrombophlebitis. It is preferable to use the term «thrombophlebitis» at the inflammatory genesis of a disease which is not raising doubts.
The wedge, a picture of thrombosis of superficial brain veins is characterized usually by a combination nevrol. symptoms with the general signs of inflammatory and infectious process. Morfol. the substrate causing at fibrinferment of superficial veins of a brain emergence nevrol. symptoms, are the hemorrhagic heart attacks developing both in gray and in white matter of a brain, intracerebral and subarachnoidal bleedings, ischemia and wet brain, etc. The disease almost always begins with a headache, edges quite often is followed by nausea and vomiting. Consciousness is quite often broken (sometimes with psychomotor excitement) and on this background there are focal brain symptoms. Motive frustration are more often shown mono - or a hemiparesis (see Paralyses, paresis); spasms (see) have the general or focal character, in nek-ry cases the epileptic status develops. Aphasia is quite often observed, is more rare — disorders of sensitivity, a hemianopsia. Characteristic of thromboses of brain veins consider variability nevrol. manifestations in the acute period of a disease (disappearance of one symptoms and emergence of others, variability of degree of their expressiveness) and less rough rate of development of focal symptomatology, than it happens at fibrinferments of arteries.
The diagnosis of thrombosis of superficial brain veins is difficult. Diagnostic value has simultaneous development in the patient along with cerebral symptomatology of thrombophlebitis of extremities, a basin (is more rare than internals), existence of developments of stagnation on an eyeground, considerable disturbances of coagulant system of blood (see) at malignant new growths, in the postoperative period, at severe craniocereberal injuries, etc.
Topical diagnosis of thrombosis of separate superficial veins of a brain is very difficult. Arising at this pathology a wedge, syndromes were described by nek-ry researchers on the basis of the verified cases of limited vein thromboses. The number of similar descriptions is small, partly this results from the fact that the isolated thrombosis of one of veins is observed extremely seldom. According to the existing descriptions, thrombosis of frontal veins is followed by a hemiplegia (hemiparesis), motor aphasia, spasms of a hand and face muscles on the party opposite to localization of defeat, the general spasms. Similar nevrol. the symptomatology is noted at fibrinferment of the central and paracentral brain veins. Thrombosis of parietal veins, except symptoms of disturbance in the motive sphere, can be followed by anesthesia (see) on an opposite half of a body. At fibrinferment of parietotemporal veins similar symptoms in combination with a hemianopsia are observed, and at a vein thrombosis of a dominant hemisphere also aphasia, an alexia, an acalculia are noted (s'm. Aphasia). Thrombosis of temporal veins can lead to development of touch aphasia, spasms of extremities, sometimes — to a hemiparesis and a hemianopsia on the party opposite to the center of defeat.
THROMBOSIS of VESSELS of the BRAIN 303
Due to the existence of an extensive anastomosis between superficial brain veins the described syndromes are observed changeably.
For a wedge, pictures of a deep vein thrombosis of a brain and a big brain vein (Galen's vein) serious condition of patients is characteristic; they usually are in coma (see Côme), Krom is preceded sometimes by a phase of a hypersomnia (see the Dream, frustration) or an akinetic mutism (see the Speech, frustration). Repeated vomiting, the expressed meningeal phenomena is observed. As a rule, there are signs of defeat of trunk and subcrustal structures: oculomotor disturbances, paresis of extremities, muscular rigidity, choreiform hyperkinesias, spasms, hyperthermia, disorder of breath.
Klien, diagnosis is complicated. For diagnosis development of a picture of severe damage of a brain against the background of thrombophlebitis of extremities, detection of other inflammatory centers in an organism, napr, in a puerperal period, after abortion matters, at otitises and an inflammation of adnexal bosoms of a nose, inf. diseases.
In differential diagnosis between thrombosis of brain arteries and veins it is necessary to consider that thrombosis of brain arteries usually develops against the background of atherosclerosis, arterial hypertension. Thrombosis of brain veins develops against the background of inflammatory, inf more often. process, differs in most cases in slower development nevrol. symptoms, quite often is followed by emergence of congestive nipples of optic nerves and other symptoms of intracranial hypertensia (see. Intracranial pressure), and also spasms.
Treatment of thrombosis of brain veins shall be directed first of all to fight with inf. process and a thrombogenesis, and also on normalization of a brain blood-groove and intracranial pressure. Appoint antibiotics of a broad spectrum of activity, sometimes in combination with streptocides, antihistaminic drugs. It is necessary to treat use of anticoagulants with care in view of frequent hemorrhagic complications of thrombosis of brain veins. Their use is proved at the accompanying thrombophlebitis of ekstrakranialny localization and development of a thromboembolism of pulmonary arteries (see the Thromboembolism of pulmonary arteries). For the purpose of cerebral decompression appoint dehydrating agents, however their use is not recommended at dehydration of an organism and a pachemia. Purpose of the means reducing permeability of a vascular wall is reasonable (a routine, ascorbic to - you); at spasms anticonvulsant therapy is shown.
The forecast at fibrinferment of brain veins, according to most of researchers, is more favorable, than at fibrinferment of brain arteries. It is caused by hl. obr. extensiveness of network of the venous anastomosis interfering development heavy morfol. changes in a brain. At a septicaemia, meningitis, fibrinferment of sine of a firm meninx, the expressed wet brain with the shift of a brain trunk the forecast worsens. The forecast at a deep vein thrombosis of a brain is much worse, than at fibrinferment of superficial veins.
Thrombosis of sine of a firm meninx. The wedge, symptoms of thrombosis of sine (see the Meninx) subdivide into the general (infectious), local distsirkulyatorny and various neurologic.
To a bowl thrombosis sigmoid (sinus thrombosis) and cross sine meets, usually it is a complication of purulent otitis (see) or a mastoiditis (see). The septic syndrome is in most cases sharply expressed (fervescence with big differences, a fever, an earthy or yellowish shade of face skin, a dryish fur, increase in a spleen), the leukocytosis, the accelerated ROE, in nek-ry cases — anemia is observed (see Sepsis). The hypostasis of soft tissues in the field of a mastoid which is followed by pains during the chewing and turn of the head in the healthy party is characteristic (the head is usually inclined in the sick party); with a pressure upon a back surface of a mastoid morbidity (Grizinger's sign) is noted. Early nevrol. a symptom is the headache on the party of defeat, the depression, in other cases — excitement, a delirium, the meningeal phenomena is sometimes noted. Emergence of focal symptoms — paresis of extremities on the party opposite to the center of defeat, a hemianopsia, aphasia is more often caused by spread of thrombosis on superficial veins konveksital-ache the surfaces of a brain or difficulty of blood circulation in them. Signs of increase in intracranial pressure and development of congestive nipples (see) optic nerves are sometimes noted. Cerebrospinal liquid (see) can be not changed, sometimes in it the increased protein content and a small pleocytosis is noted. More expressed inflammatory changes in cerebrospinal liquid appear at a complication of septic thrombosis of sine meningitis (see).
If thrombosis of a sigmoid sine extends to a jugular vein, then its swelling and morbidity appears. At the same time symptoms of defeat glossopalatine, wandering and additional craniocereberal are noted (cranial, T.) nerves, patients have a difficulty of swallowing, the voice becomes hoarse (because of paresis of muscles of a throat), sensitivity in a throat goes down, flavoring sensitivity on a back third of language decreases, paresis grudino - clavicular and mastoidal and trapezoid muscles develops (a syndrome to Verna).
Thrombosis of a cavernous sine often is a consequence of the septic state complicating purulent processes in a face, an eye-socket, an ear and adnexal bosoms of a nose, arises at a hypertension and atherosclerosis less often. Symptoms inf. process are usually sharply expressed: the high temperature of a body with a fever and perspiration, a neutrophylic leukocytosis accelerated by ROE, sometimes anemia and increase in a spleen. Clearly signs of disturbance of venous outflow are expressed: hypostasis of fabrics around an eye-socket, the accruing exophthalmos (see), swelled a century and conjunctivas, developments of stagnation approximatelynumber day, sometimes with development of an atrophy of optic nerves (see. An optic nerve), secondary glaucoma (see). Most of patients has an outside ophthalmoplegia (see) owing to defeat of the oculomotor, block and taking-away cranial nerves, the ptosis (see) an upper eyelid, disturbance of reactions of pupils, opacification of a cornea is observed (see); owing to defeat of an upper branch of a trifacial there are pains in an eye-socket, in an eyeglobe and area of a forehead, disorder of sensitivity in a zone of an innervation of a supraorbital nerve (see the Trifacial). In nek-ry cases not all nerves passing in a wall of a cavernous vessel are surprised.
Thrombosis of a cavernous sine can be bilateral; in these cases the disease proceeds especially hard, and process can extend also to adjacent sine. In a wedge, practice cases of thrombosis of a cavernous sine also meet the subacute course of a disease.
The wedge, a picture of thrombosis of an upper sagittal sine varies depending on an etiology, rate of development patol. process, its localization within a sine (tsvetn. the tab., Art. 304, fig. 7), and also from extent of involvement in process falling into it veins. Especially hard septic thrombosis proceeds, to-ry is followed expressed inf. syndrome (fever, characteristic changes in blood, etc.) * Distsir-kulyatorny symptoms clearly are expressed. At fibrinferment of an upper sagittal sine on all its extent overflow and crimpiness of veins a century, a root of a nose, temporal, frontal, parietal areas is observed and hypostasis of fabrics in these areas, often there are nasal bleedings, morbidity at percussion on the centerline of the head is noted. Nevrol. the syndrome consists of symptoms of increase in intracranial pressure (a headache, vomiting, congestive nipples of optic nerves); during the involvement in process of superficial veins of a brain the partial convulsive attacks which are quite often beginning with myotonia of foot are observed. Focal neurologic symptoms (the lower paraplegia with an incontience of urine, a hemiplegia, a tetraplegia), and also various extent of disturbance of consciousness can be observed up to a sopor and a coma, meningeal symptoms (see Meningitis, a meningeal syndrome). At septic thrombosis inflammatory changes in cerebrospinal liquid, pressure it are found it is, as a rule, raised. Thrombosis of front department of an upper sagittal sine can proceed asymptomatically. Thrombosis of back department of a sine proceeds heavier that is caused by involvement in process of superficial veins. On the course of thrombosis of an upper sagittal sine allocate apoplektiformny (fulminant), intermittent (spasmodic), slowly developing (latent or oligosymptomatic) forms.
Thrombosis of an upper stony sine is followed by pains or paresthesias on the course of all three branches of a trifacial, sensitivity on a half of the face can be reduced; paresis of masseters of the struck party is sometimes noted.
Thrombosis of the lower stony sine is shown by paresis of the taking-away nerve (see. The taking-away nerve) on the party of defeat, and sometimes the combined damage of the trigeminal and taking-away nerves at otitis (see Gradenigo a syndrome).
At diagnosis of thromboses of sine of a firm meninx crucial importance has existence in a wedge, a picture of signs of the general or local (especially in the head) the inflammatory process which is combined with local distsirku-lyatorny disturbances in a face, an eye-socket, a pilar part of the head and nevrol. symptoms (all-brain, the shell, focal). From the special methods of a research specifying the diagnosis the cerebral angiography (however its data at this pathology are not always rather informative), a cerebral flebografiya and a sinusografiya can be used.
Lech. actions at all localizations of thrombosis of sine shall be directed to sanitation of primary center of an infection, to fight against a thrombogenesis, inflammatory process in sine and to elimination of the disturbances of a brain blood-groove and circulation of cerebrospinal liquid arising at the same time.
At fibrinferment and a purulent inflammation of a sigmoid sine an urgent operative measure is shown, a cut make in the field of primary center (at a mastoiditis — on a mastoid) and in the field of a sine (its opening, removal of blood clot). At the fibrinferments complicated by abscess of a brain (is more often in a cerebellum and a temporal share), make emptying of an abscess cavity, appoint antibiotics (see) a broad spectrum of activity, sometimes in combination with streptocides (see. Sulfanamide drugs).
Before introduction to a wedge, practice of antibiotics septic thrombosis of a cavernous vessel in most cases came to an end letalno. Use of antibiotics and anticoagulants lowered a lethality at this pathology almost twice. Considerable more effective method of treatment of septic thromboses of a cavernous sine which significantly reduced the frequency of lethal outcomes was the long continuous intrakarotidny infusion of medicines applied in a crust, time, to-rye are brought directly to the center of an inflammation before receiving resistant a wedge, effect. It is the most reasonable to enter a catheter for intrakarotidny infusion into peripheral branches of an outside carotid artery (superficial temporal or occipital), leading him to the general carotid artery to the IV—VI level of cervical vertebrae. Enter isotonic solution of sodium chloride, 0,5% solution of novocaine, heparin, fibrinolysin, one of antibiotics of a broad spectrum of activity (Benzylium-penicillin sodium salt, Kanamycinum, levomycetinum succinate soluble, Morphocyclinum, tseporin). Infusion is performed with constant speed by 16 — 22 drops in 1 min., is continuous within 4 — 28 days (on average 8 — 14 days). After the termination of infusion it is necessary to appoint anticoagulants of indirect action. Long intrakarotidny infusion of medicines at septic fibrinferments of a cavernous sine shall be combined with the standard methods of treatment of patients with septic diseases (see Sepsis), especially intensive complex care is necessary in the cases complicated by septic damage of lungs.
At treatment of thrombosis of a cavernous sine it is important to open timely the abscesses located in a face, an eye-socket, an oral cavity, adnexal bosoms of a nose, etc. The forecast at fibrinferment of sine and especially septic thrombosis of sine of a firm meninx is always serious.
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