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Short anatomical data.

Three membrane membrane the brain and spinal cord: dura mater (dura mater, or
panchymeninx), arachnoid, or vascular sheath (arachnoidea) and pia (pia mater or
leptomeninx). Dura mater and pia mater wrap nerves as they exit from the cranial
cavity or spinal canal.

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
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.

To reveal the syndrome of irritation of the meninges (meningeal syndrome), examine

the tone of certain muscle groups, which reflexively increases in pathological
processes in membranes.
Tonus cervical muscles investigated by passive tilt the head forward and bring the
subject's chin to the chest, The inability of the passive motion in full volume due to the
increase in muscle tone is regarded as the stiffness of the cervical muscles.

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 is usually obtained by lumbar injection, or lumbar puncture - the

introduction of a special needle into the space between the spinous processes of lower
lumbar vertebrae (L or L) in the position of a patient lying on their sides. After outflow
of cerebrospinal fluid begins, measure its pressure by manometer and collect it in
sterile test tube at a few (5-8) ounces of liquid for microscope (the definition of cells),
biochemical (protein, glucose, etc.) and bacteriological study. Before sending to the
laboratory study carried out a visual assessment of cerebrospinal liquid (color,
transparency). Normally, cerebrospinal fluid is colorless and transparent; its pressure is
on average 90 to 150 mm of water. art. (6-11 mm Hg. art. in a horizontal position),
protein content - 25-40 mg/100 ml, number of cells - 1-5 in 1 micro liter (usually
lymphocytes), glucose - half than of blood (2,5 -3.9 mmol /l).

To identify the blockade of subarachnoid space in the spinal canal, liquor-dynamic

samples can be used during lumbar puncture. Kvekkenshtedt Test: short (5-10s)
pressure on the jugular vein causes an increase in liquor pressure by 2-3 times (due to
increased venous pressure leading to increased intracranial pressure), and stopping of
pressing leads to a rapid return of pressure of original liquor. Stukeya Test: pressure on
the anterior abdominal wall causes an increase in liquor pressure is about 1,5 times,
and cessation of pressing leads to rapid normalization of liquor pressure. If spinal
subarachnoid space is blocked, increased liquor pressure is not observed or it is
expressed insignificantly during Kvekenshtedt and Stukeya test.
In various neurological diseases, changes occur in the cerebrospinal fluid, so the
lumbar puncture has a wide range of indications. Currently, however, lumbar puncture
is used less often with the introduction of X-ray computed and magnetic resonance
imaging, which allows diagnosis in many cases without a lumbar puncture. In stroke,
traumatic brain injury and many other diseases, lumbar puncture is applied in cases
when there is no possibility of CT or MRI.

It is important to study cerebrospinal fluid to diagnose subarachnoid hemorrhage.

Absolute indication for lumbar puncture is when infectious disease of the nervous
system, such as meningitis is suspected. Lumbar puncture is contraindicated in
patients with inflammatory processes in the place to puncture. If you suspect a lengthy
process (brain tumor, intracranial hematoma), lumbar puncture is dangerous because
of the possibility of displacement and herniation of the brain structures, so it is only
possible in the absence of signs of venous congestion of the optic disk using
ophthalmoscopy. In some cases, cerebrospinal fluid is extracted through suboccipital

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.

Meningeal syndrome. Increased intracranial pressure (hypertensive

syndrome). Hydrocephalus
The syndrome of irritation of the meninges, or meningeal syndrome include stiffness in
the muscles of the neck, positive Kernig and Brudzinski symptoms, Bechterev
symptom. An important feature of irritation meninges are headache and general
hyperesthesia: a painful reaction to any external stimuli (bright light, loud noise,
touching the skin). In severe cases there may be a peculiar posture the patient: lie on
side, head thrown back, hips pressed against her abdomen, legs to the hips.

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.

Hydrocephalus, which is well revealed by X-ray computed or magnetic resonance

imaging of the head may not be accompanied by a significant increase in intracranial
pressure (normotensive hydrocephalus). It happens when it bypass the acute
pathological process that caused the hypertensive hydrocephalus (traumatic birth,
meningitis, subarachnoid hemorrhage, tumor), or in cases where the ventricles and/or
subarachnoid space passively increased due to atrophy of the brain (hydrocephalus
exvasio). In these cases, it is possible that variety of neurological disorders is caused
by atrophic process.

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.

Meningeal syndrome is more often caused by meningitis, brain injury or hemorrhage in

the subarachnoid space. Suspicion of meningeal syndrome requires immediate
hospitalization of the patient.

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.

Congenital infantile hydrocephalus often is caused by a brain haemorrhage (premature

infants), meningitis in the fetus or the newborn or congenital malformations of the
brain, such as atresia or stenosis of the aqueduct. Acquired hypertensive
hydrocephalus is caused by major process in the posterior cranial fossa (tumor,
hemorrhage, or abscess) , subarachnoid hemorrhage or other diseases, leading to the
blockade of the circulation of cerebrospinal fluid. Normotensive hydrocephalus is
caused by the migrated meningitis or subarachnoid hemorrhage, in which impaired
resorption of cerebrospinal fluid through villi (Pacchionian bodies) is filled with blood
degradation products. In various degenerative processes (Alzheimer's disease,
dementia with Lewy bodies, etc.) there is hydrocephalus ex vasio.

The treatment of hydrocephalus is aimed at the reasons if possible. If there is no

occlusion within the ventricular system, a temporary therapeutic effect maybe
provided by lumbar puncture with removal of a small amount of cerebrospinal fluid.
Long-term effect is achieved with the imposition of a shunt between the ventricular
system or subarachnoid space and, for example, the abdominal cavity (respectively
ventriculoperitoneal and lyumboperitoneal bypass).

Meningeal and hypertensive syndromes

Syndrome Major manifestations

Acute development of a severe headache, stiff/rigid muscles of
the neck, symptom of Kernig, symptoms Brudzinskogo
Headache, nausea, vomiting, visual disturbances, impaired
consciousness, increased liquor pressure above 200 mm of water