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The outer layer of the dura mater adheres to the bone and periosteum the inner layer
is the actual mater. Between the layers of dura mater are meningeal arteries supplying
the bones of the skull. In certain parts of the inner layer of the dura mater is far behind
from the outer one, forming the epidural (or rather intradural) space, within it; the
venous sinuses of the skull, the spinal canal (loose connective tissue) and venous
plexus.
Arachnoidea consists of an outer cellular membrane and the inner layer of connective
tissue, which is attached to a network of thin trabeculae, resembling a web, therefore
its name. Arachnoidea is fixed to the dura mater with the villi, or pacchionian
granulations. Arachnoid protects the brain against the penetration of various
pathogenic agents.
Pia mater consists of a thin layer containing cells lining the entire surface of the brain
and spinal cord, with the exception of the ventricles. It is fixed to the brain
ectoderamal membrane, which accompanies all entering to the brain and exit from it
are blood vessels.
Subarachnoid space (the space between the pia and the arachnoid) is filled with
circulating cerebrospinal fluid (CSF). Areas where the subarachnoid space expands
considerably, called cisterns. In a large cistern, located between medulla oblongata
and cerebellar tonsils, goes through Majendie foramen, cerebrospinal fluid is formed in
the ventricles of the brain. Subarachnoid space extends to the coccyx and from level
L1or L2 of vertebra, which ends in the spinal cord is a hollow sac (terminal cystern),
which roots of cauda equina pass until it exits from the spinal canal.
The system consists of two ventricles pair of lateral ventricle, III and IV ventricle. Each
lateral ventricle is divided into anterior horn, body (middle part), dorsal and ventral
horns. The lateral ventricles are connected to III through the interventricular foramen
(foramen Monroe). III and IV ventricles are connected by running water. The entire
ventricular system of the brain is associated with subarachnoid space through location
in the IV ventricle paired foramen of Lyushka and Majendie. Ventricles of the brain are
vascular or villiferous plexus (plexus choroideus), which are most pronounced in the
lateral ventricles.
Cerebrospinal fluid is produced by choroid plexus of the ventricles, mainly lateral one.
Endothelium of the capillaries, basement membrane and epithelium of the plexus form
blood-brain barrier that protects the brain against the penetration of pathogenic
agents. Cerebrospinal fluid is distributed to the brain via ventricular system and enters
through Lyushka and Magendie foramen in the subarachnoid space, and which
circulates around the brain and spinal cord.
Cerebrospinal fluid acts as a liquid buffer that protects the brain from mechanical
injury of the head. In addition, it serves as a kind of "canalization" in which the
products of metabolism of the brain (CO3, salt of lactic acid, NH2, hydrogen ions) pass
into the bloodstream, and moves dissolved substances within the brain and spinal
cord. Cerebrospinal fluid is colorless and transparent water; its pressure is on average
90 to 150 mm of water (6-11 mm Hg. Art.) contains protein - 25-40 mg/100 ml, number
of cells - 1-5 in 1 microliter. Resorption (suction) of cerebrospinal fluid is through villi
(Pacchionian bodies) in the venous sinuses of the skull. Every day ventricles produces
about 400-500 ml of CSF and in subarachnoid space is always about 130-150 ml of
cerebrospinal fluid.
Methods of Investigation.
Test of Kernig symptom: lying on one’s back, ask subject to bent leg to the hip and
knee joints at right angles, then unbend the knee; inability to fully straighten the leg at
the knee because of the tonic muscle tension is regarded as a positive Kernig
symptom. To study rigidity of the neck muscles, may involuntary flexion of the legs in
the hip and knee joints (upper Brudzinski symptom), the study of symptom Kernig -
involuntary flexion of the other leg in the hip and knee joints (lower symptom
Brudzinskiy). Pressure on the area of the pubic symphysis may due to involuntary
flexion of both legs in the hip and knee joints (medium symptom Brudzinski). Tapping
on the zygomatic bone can increase and cause a headache on this pain side of a
patients face (symptom Bechterev).
Cerebrospinal fluid changes in various neurological diseases, and therefore its study is
of great diagnostic value. In intracranial (submembranous, intracerebral) hemorrhages,
cerebrospinal fluid may become bloody; red blood cells and later developed xanthosis
(yellow color) appears as a result of the degradation of hemoglobin from red blood
cells disintegrated. In inflammatory diseases (encephalitis, meningitis), CSF shows
pleocytosis (increase in the number of cells). Significant neutrophil pleocytosis (up to 1
thousand cells in 1mkl and more) are common in bacterial infection, if mainly
lymphocytic - for viral, tubercular, and other infectious diseases. Increase protein
content in cerebrospinal fluid significantly or prominent pleocytosis (protein-cell
dissociation) occurs in tumors of the brain and spinal cord, carcinomatosis of
membrane, some inflammatory diseases.
Increased cerebrospinal fluid pressure at above 200 mm of water art. (14 mm Hg. Art.)
is regarded as increased intracranial pressure, or intracranial hypertension. It may be
asymptomatic with a gradual increase up to 20-30 mm Hg. art., in higher or a rapid
increase in intracranial pressure, arise symptoms: headache, nausea, vomiting,
oculomotor disorders (often defect of n. abducens), transient visual disturbances and
the stagnation/congestion of the optic disk. The headache often is caused by
stimulation of the meninges, nausea and vomiting - the excitation of the vagus nerve,
visual disturbances - compression of the oculomotor nerve and venous stagnation in
the fundus. In rapid and significant increase of intracranial pressure, blood supply to
the brain decreases and possible impairment of consciousness up to coma. Intracranial
hypertension can cause penetration - displacement of brain substance from one
intracranial compartment to another, for example cerebellar tonsils to foramen
magnum, which is associated with high risk of death of the patient.
Dropsy of the brain, or hydrocephalus, often develops because of obstacles the
circulation of cerebrospinal fluid in any point between the main place of its formation
in the lateral ventricles and subarachnoid space of the base of the brain. Because the
obstacles, circulating cerebrospinal fluid accumulates in the ventricles, extending
them, squeezing adjacently to the ventricles tissue and slightly widening the brain.
Such hydrocephalus is manifested by symptoms of increased intracranial pressure
(hypertensive hydrocephalus) in infants or young children (up to 2 years), who
fontanelle and cranial suture are not completely closed, which increases the size of the
head. Acute appearance of hypertensive hydrocephalus (eg, due to subarachnoid
hemorrhage, or bleeding in the cerebellum, leads to the blockade of the ways of
circulation of cerebrospinal fluid) leads to impairment of consciousness.
After the lumbar puncture, intracranial hypotension may develop due to continued
expiration of cerebrospinal fluid. When sitting or standing, increased intracranial
hypotension in a few minutes is manifested by headache, combined with the pain and
stiffness of the neck and sometimes nausea and vomiting. These symptoms usually go
away within a few days.
Causes of meningeal and hypertensive syndromes, treatment principles.
The intracranial pressure increases due to increased intracranial contents (brain tumor,
hemorrhage, extensive injury or cerebral infarction and other diseases), increased
venous pressure (superior sagittal sinus thrombosis, or obstruction of superior vena
cava), prevention of flow or absorption of cerebrospinal fluid (swelling, meningitis or
subarachnoid hemorrhage), increased cerebrospinal fluid (choroid plexus papilloma).
To reduce the swelling of the brain that causes intracranial hypertension, mannitol is
usually used (for 0,25-1 g / kg / per every 6 h) or glycerol (250 ml 10% solution w /
every 6 h) or dexazon (but 50-100 mg/s w/w or w/m), in critical situations -
hyperventilation and neurosurgical intervention. In some cases, surgical removal of the
pathological formation (intracranial hematoma, or tumor) or decompression for
cerebral edema is the only chance to reduce intracranial pressure and save the life of
the patient.