Hypoxic-ischemic genesis of perinatal pathology of the central nervous system. Perinatal damage to the central nervous system in a child: diagnosis, treatment and consequences

Hypoxic damage to the central nervous system in newborns is a circulatory disorder in the brain, as a result of which the brain does not receive the required amount of blood, and therefore experiences a deficiency of oxygen and nutrients.

Hypoxia may have:

• perinatal origin associated with pregnancy and the birth process;
• postnatal etiology that arose after the birth of the child.

Among the causes of damage to the central nervous system, hypoxia is in first place. In such cases, experts talk about hypoxic-ischemic damage to the central nervous system in newborns.

Acute and chronic diseases mothers, work in hazardous industries ( chemical substances, various radiations), bad habits of parents (smoking, alcoholism, drug addiction). Also bad influence the child developing in the womb is affected by severe toxicosis, infection and pathology of the placenta.

During childbirth, the baby experiences significant stress on the body. A child has to endure especially serious trials if birth process occurs with pathology: premature or rapid labor, labor weakness, early loss of amniotic fluid, large fetus, etc.

Degrees of cerebral ischemia

There are three degrees of hypoxic damage:

1. Hypoxic damage to the central nervous system of the 1st degree. It's pretty mild degree characterized by excessive excitement or depression in the first week of the baby’s life.
2. Hypoxic damage to the central nervous system of the 2nd degree. In case of defeat moderate severity there are more a long period disorders, characterized by seizures.
3. Hypoxic damage to the central nervous system of the 3rd degree. In severe cases, the child stays in a hospital where intensive therapy is carried out, since there is a real threat to the health and life of the baby.

As a result of hypoxia, innate reflexes can be impaired, and functional disorders of the central nervous system, heart, lungs, kidneys and liver are possible. Subsequently, a delay in physical and mental development, sleep disorders. The pathology can result in torticollis, scoliosis, flat feet, enuresis, and epilepsy. The recently common attention deficit hyperactivity disorder is also the result of neonatal ischemia.

In this regard, women are recommended to register with a doctor at early stages pregnancy, undergo timely screening examinations, conduct healthy image life at the stage of preparation for pregnancy and during pregnancy. For effective treatment cerebral ischemia should be diagnosed in the first months of the baby’s life.

An expectant mother is always very worried about the health of her baby. On forums on the Internet, a topic related to disorders of intrauterine (perinatal) development is often discussed. For the most part, they are afraid of pathologies of the central nervous system. And this is not at all in vain, since damage to the central nervous system of a newborn can lead to serious and severe complications, even disability.

The body of a baby is very different from that of an adult. The process of brain formation is not complete, it is still very vulnerable, differentiation of the hemispheres continues.

At risk:

• premature or, on the contrary, born later than expected;
• infants with extremely low weight (less than 2800 g);
• with pathology of body structure;
• when there is a Rh conflict with mom.

Damage to the central nervous system in newborns: main factors:

• hypoxia or oxygen starvation of the brain. It is not always a consequence of unsuccessful childbirth; sometimes the pathology develops even during the period of gestation. For example, infectious diseases that the mother suffered during pregnancy, smoking, working in hazardous work, nervous stress, previous abortions. The consequence of this is that the woman’s blood circulation is impaired, which means that the child experiences a deficiency of nutrients, including oxygen. Hypoxia develops, from which the fetal central nervous system suffers;
• birth injuries. Coming into the world is a difficult process and it does not always go smoothly. Sometimes doctors need to intervene seriously to allow new life to emerge. Prolonged intrauterine hypoxia, severe asphyxia, obstetric manipulations, and operations in approximately 10% of cases lead to damage to the baby’s tissues and organs during childbirth. The photo clearly shows how, in especially severe cases, obstetricians literally pull out the child;
• dysmetabolic disorders (improper metabolism). The reasons here are the same as for hypoxia: smoking, drinking alcohol, drugs, illness of the expectant mother, her taking potent medications;
• Infectious diseases suffered by a pregnant woman have an extremely serious impact on the health of the newborn. First of all, herpes and rubella. Viral agents and microorganisms also negatively affect intrauterine development;

Periods of the course of central nervous system pathologies in newborns

Acute period

Immediately after the baby is born, doctors begin to take the necessary measures:

• the baby is placed in rehabilitation, where the child lies in an incubator. Doctors fully restore the functions of the heart, kidneys and lungs, normalize blood pressure;
• remove convulsive conditions;
• relieve cerebral edema.

The first thirty days of life are decisive, when dead cells can be replaced by new, healthy ones. Most often, the symptoms stop after the manipulations, and the baby is transferred from intensive care. Next, drug antiviral and anti-inflammatory therapy is carried out to eliminate the causes of the lesion.

Recovery period

Paradoxically, this time is sometimes more difficult for parents than the acute phase due to the fact that at the first stage it was not bright severe symptoms. The period lasts from the second month of life and ends when the baby turns six months old. At this time, the following behavioral characteristics are noted:

• the child does not show emotion, there are no smiles, the usual “humming” or baby talk;
• lack of interest in the surrounding world;
• does not respond to toys;
• quiet cry.

Only his parents can notice such manifestations in the behavior of the baby. They must show the child to a pediatrician for diagnosis and treatment. Late recovery period, which continues until the age of one, also deserves the close attention of parents.

In cases where the acute phase passed with severe symptoms, manifestations of disturbances in the functioning of the central nervous system may disappear by the second month. This is not a sign of final recovery, but shows that Taken measures gave their results and the baby’s body begins to recover, so it is important not to stop the therapy started.

Parents of sick children should:

• monitor the temperature in the baby’s room to avoid hypothermia or overheating;
• to not allow loud sounds, including from TV or radio;
• keep visits from friends and relatives to a minimum so as not to infect the baby with any infection;
• If possible, do not neglect breastfeeding;
• talk to the baby, play. Use massage mats, books, developmental complexes. But everything must be done in moderation so as not to overload the baby’s weakened nervous system.

Outcome of the disease

If the child was born in a modern clinic or maternity hospital, then in case of pathologies, doctors immediately begin his treatment and rehabilitation. When measures are taken in a timely manner, the chances of a favorable outcome increase.

By the end of the first twelve months of life, it becomes clear exactly how the disease affected the child’s health. It is important to understand that there will still be some developmental delays: the baby will begin to sit, walk and talk later than his peers. If you try not to let the disease progress, then with a mild degree of damage it is almost always possible to avoid serious complications.

Only those processes that have entered an advanced stage become irreversible. Modern medications are ways to fully or partially restore the functioning of the central nervous system in case of severe damage. With the help of drugs, the nutrition of nerve cells is improved, blood circulation is normalized, muscle tone decreases or increases.

Rehabilitation period

Here drug therapy fades into the background. Recovery methods used:

• massage;
• special gymnastics;
• physiotherapy: electropheresis, acupuncture, use of a magnetic field;
• heat therapy;
• music therapy;
• swimming, water exercises;
• Educational psychologists work with the baby.

Classification of CNS pathologies in newborns

Hypoxic lesions

It is estimated that 10% of infants suffer from some degree of oxygen deprivation. Modern medicine is not able to influence the formation of hypoxia and structural damage to the brain, because no drugs can bring dead nerve cells back to life. Treatment today is focused on the consequences.

Hypoxia can begin in utero due to disturbances in blood flow in the placenta and uterus, thrombosis, pathologies of child development, bad habits, which the mother could not refuse. During childbirth, a lack of oxygen is caused by excessive bleeding, entanglement of the baby's neck with the umbilical cord, bradycardia and hypotension, and injuries (in particular the use of forceps).

After birth, oxygen starvation is provoked by improper functioning of the lungs, respiratory arrest, heart defects, hypotension, and blood clotting disorders.

Hypoxic injuries are:

• mild degree. Experts call it hypoxic-ischemic injury. Doesn't last long. As a rule, it does not affect later life, since the brain recovers on its own;
• expressed. In this case, asphyxia may begin, when oxygen stops flowing, organic damage to the central nervous system occurs in children, which leaves a mark forever, including disability.

Traumatic lesions

After the release of amniotic fluid, the child experiences uneven pressure, as a result of which blood circulation is disrupted and the brain is injured. Factors contributing to this:

• big sizes infant (macrosomia);
• breech presentation;
• postmaturity or prematurity;
• oligohydramnios;
• developmental abnormalities;
• turn on the leg obstetric forceps and other techniques that doctors use for successful delivery.

They lead to intracranial injury, when hemorrhage occurs, convulsions begin, and breathing becomes difficult. There are known cases of hemorrhagic infarction and coma. If the spinal cord is affected, motor function suffers.

Dysmetabolic disorders

Metabolism changes due to:

• intoxication (mother took drugs, strong drugs, smoked, drank alcohol);
• kernicterus;
• oversupply certain substances in the blood: calcium, potassium, magnesium or sodium.

Depending on the cause of dysmetabolic changes, they manifest themselves as: convulsions, hypertension, tachycardia, hypotension, depression, rapid breathing, muscle spasms, intracranial hypertension, apnea.

CNS lesions in infectious diseases

The list of ailments that cause complications in the unborn child includes: rubella, syphilis, herpes, cytomegalovirus, toxoplasmosis. After birth, the baby himself can become infected with candidiasis, pseudomonas infection, staphylococcus, sepsis, streptococcus. The diseases cause hydrocephalus, increased intracranial pressure, and meningeal syndrome.

Diagnostic measures

Damage to the central nervous system of a child occurs in 50% of cases, and most of it occurs during premature birth.

Signs (vary depending on the degree of damage):

• excessive anxiety, nervous excitability;
• trembling in the limbs and chin;
• regurgitation is likely;
• reflexes are reduced or, on the contrary, strengthened. For example, a child does not breastfeed well;
• muscle tone is increased or decreased, absent physical activity;
• the skin has a blue tint;
• high intracranial pressure;
• the baby is slowly gaining weight;
• rapid pulse;
• bradycardia;
• thermoregulation disorders;
• respiratory arrest;
• diarrhea or vice versa constipation;
• cyanosis.

In case of organic lesions of the central nervous system, urgent cardiopulmonary resuscitation is required to save the newborn. Doctors determine PPCNS in the first minutes after birth, and when symptoms appear, neonatologists prescribe examinations.

1. Ultrasound of the brain through an open fontanel. The procedure is simple in nature and can be carried out even if the baby is in intensive care and connected to life support devices. The disadvantage of this method is that the results are greatly influenced by the child’s condition: whether he is sleeping or awake, crying or not. It is also easy to mistake a place with a different echogenicity for the onset of pathology.
2. EEG – electroencephalography. The activity and degree of activity of the brain is determined through electrical potentials. Most often, it is carried out while the child is sleeping; in this state, the method is most informative, since there is no muscle tension.
3. ENMG – electroneuromoiography. With the help of the procedure, it is possible to see violations actually before the birth of the child, when he is still in the womb. The degree of motor activity is assessed, since muscles work differently in healthy children and children with developmental disorders.
4. Video monitoring – allows you to dynamically monitor motor activity.
5. Positron emission tomography determines how metabolism occurs in the brain and shows blood flow.
6. MRI - displays any disturbances in the functioning of the central organ of the nervous system, allows you to determine the location of swelling and its signs. The procedure is considered one of the most informative.
7. Dopplerography - displays blood circulation in the vessels of the head.
8. Laboratory tests: urine and blood tests. Some CNS lesions, such as hyperklemia, do not produce pronounced symptoms.

The well-known CT scan for newborns is rarely used. In the moment x-ray examination the baby must be motionless, he has to be given anesthesia. That's why similar method applied after several years. On the monitor, the specialist sees the patient’s brain, any disorders and neoplasms.

Consequences of central nervous system damage

The main question that torments parents after diagnosis of damage to the central nervous system in newborns is the consequences. Here the doctors' reviews agree: it all depends on the degree of deviation. After all, a child’s body can recover and adapt so quickly that after a year, with a mild degree of damage from the disease, only memories remain.

The neurologist makes a prognosis after the first month of life. It could be:

• complete recovery without complications;
• slight impairment of brain function: hyperactivity (attacks of aggression, difficulty concentrating), attention disorder, school maladjustment, developmental delay, asthenia;
• neuropathic reactions;
• the child is weather dependent, sleeps poorly, his mood often changes (manifestations of cerebrasthenic syndrome);
• autonomic-visceral dysfunction syndrome;
• the most terrible consequences are epilepsy, cerebral palsy and hydrocephalus.

Parents of the baby must strictly adhere to all the instructions of the neurologist, regularly carry out the required examinations, and not neglect any medicines and methods to help your baby recover.

Perinatal damage to the central nervous system is a pathology that includes a group of different conditions that, under the influence negative factors have a detrimental effect on the spinal cord or brain of the newborn.

To date, there is no clear terminology describing PPCNSL in newborns. Until the 1990s, they used the classification proposed by Yu. Ya. Yakunin, where terms were used that were not entirely appropriate from the point of view of modern medicine.

Thus, the term (literally meaning “brain weakness”) indicated persistent, almost irreversible changes in the nervous system. But many perinatal disorders are reversible. At the initial stage of life, the brain has enormous compensatory capabilities and is able to fully recover even with pathology medium degree gravity.

And the term “cerebrovascular accident” was associated by neurologists with strokes and did not have clear signs. Over time, they began to call him ". A separate conversation about hypertensive-hydrocephalic syndrome. Intracranial hypertension is often diagnosed, while measuring cerebrospinal fluid pressure is quite difficult, and the diagnosis is often made on the basis of symptoms that are quite common for infants in the first weeks of life: trembling of the chin, increased excitability, shuddering, shallow sleep, restlessness and crying. As a result, children unjustifiably take serious drugs from an early age.

However, perinatal lesions exist and cannot be ignored. Severe pathology is really dangerous for the baby’s life. According to some estimates, the diagnosis of PPCNSL is made in 5 to 55% of newborns. This difference is explained by the inclusion here of mild forms of disorders in this period. This is mainly a problem for premature babies, since body weight at birth directly affects the formation and functioning of the nervous system.

The diagnosis is relevant only for babies in the first year of life (that is why it is called “perinatal”; the word indicates the time close to birth). When the baby reaches 12 months, a different diagnosis is made, based on the totality of existing symptoms.

How the disease develops

There are three phases (periods) of perinatal damage:

• acute - from birth or from the prenatal period to the 1st month of life;
• restorative; it is divided into early (2-3 months) and late (4-12 months, in premature infants up to 24 months);
• outcome of the disease.

Each interval has its own clinical picture and manifests itself in the form of certain syndromes. The severity of the disease is determined by how pronounced they are. Let's consider their features.

Acute period

1. Hypertensive-hydrocephalic syndrome. Cerebrospinal fluid accumulates in the ventricles of the brain due to disruption of its outflow - thus increasing intracranial pressure. Parents or doctors may notice a rapid increase in head circumference, as well as protrusion of the fontanel. Frequent regurgitation, more like vomiting, eye nystagmus, and poor shallow sleep indirectly indicate the development of hydrocephalus.
2. Convulsive syndrome. Rarely occurs in the form of twitching of the arms, legs and head, and occasional shuddering.
3. Vegetative-visceral syndrome. Manifests itself as a marbled skin tone (since the tone peripheral vessels impaired), problems with the gastrointestinal tract and cardiovascular system.
4. Apathy syndrome. The vital reflexes of sucking and swallowing are weakened, and motor activity is reduced along with decreased tone muscles.
5. Increased neuro-reflex excitability. Characterized by muscular dystonia: tone can be either increased or decreased; reflexes fade longer than usual, children's chin trembles, especially when crying, which occurs every now and then for no apparent reason. The baby sleeps superficially. The syndrome accompanies mild degree severity of the disease.
6. Comatose syndrome. It occurs as a result of severe depression of the central nervous system and indicates the difficult situation of the newborn. An infant who has fallen into a coma is placed in intensive care in an unconscious state, since there are no signs of coordinating brain activity.

Muscle weakness is a warning sign

Recovery period

The early recovery period is deceptive, because it seems that neurological disorders become less pronounced, muscle tone returns to normal, and reflexes are restored. But over time, the clinical picture worsens again. It should be noted that such a situation arises only when moderate and severe CNS damage has been diagnosed in newborns.

It is quite logical that a child who has suffered this pathology, will develop with a delay. He will be able to hold his head up, sit and walk later than his peers. Later, the first smile and interest in the world around you will appear. All delays in motor and mental development should prompt parents to once again show their baby to a neurologist, although children with such a diagnosis are already registered with him.

Also, if intensive drug therapy is used during the acute period, then in the recovery phase the emphasis is on physiotherapy, massage courses, and psychocorrection.

Outcome of the disease

The results of the therapy are closer to one year old. With a favorable prognosis, the following consequences may persist:

• delayed development of speech skills, motor and mental state;
• hyperactivity and attention deficit - the child cannot concentrate on the subject being studied for a long time, has difficulty remembering new things, and is inclined to show aggression and impulsiveness;
• cerebroasthenic syndrome (expressed in feelings of anxiety, shallow sleep, manifestations of hysteria, weather dependence).

Severe disease leads to the development of:

• epilepsy;
• cerebral palsy;
• hydrocephalus.

Cerebral palsy is a consequence severe defeat CNS

In numbers, the options for the development of the outcome of the disease can be expressed as follows: 30% - complete recovery, 40% - functional disorders, about 30% are organic disorders, in in rare cases death comes.

Causes

Speaking about the causes of depression of the nervous system, we can distinguish 4 main factors contributing to the development of the disease:

Our habits affect the future of our children

1. Acute hypoxia. Oxygen starvation can begin during fetal development due to chronic maternal diseases (diabetes mellitus, nephropathy), fetoplacental insufficiency or infection. The development of hypoxia is quite possible during labor, if it is rapid or prolonged, the fetus is not in a cephalic position, placental abruption has occurred, etc.
2. Traumatization. Occurs during delivery due to unprofessional actions of personnel or due to other circumstances (narrow pelvis, large head size, entanglement of the umbilical cord, breech presentation).
3. Toxic-metabolic damage. It develops if the baby’s body has a metabolic disorder or the mother consumed toxic products (drugs, nicotine, some medications, alcohol) during pregnancy.
4. Viral or bacterial infection.

Severity

• Easy. Muscle tone is moderately increased or decreased. Strabismus, Graefe's symptom, slight reflex excitability. The chin is trembling. Signs of depression may alternate with excitement.
• Average. Suppression of reflexes, rare seizures, restless behavior, disorders of the cardiac system, gastrointestinal tract and kidney function. Symptoms of depression prevail over symptoms of excitement.
• Heavy. Respiratory and cardiac dysfunction, low Apgar score, condition requires resuscitation measures.

Diagnostics

A neurologist can send the child for a consultation with an ophthalmologist and additional examinations. What are their advantages and disadvantages?

Neurosonography

An accessible, safe and widely practiced method for studying the structures of the cranium using ultrasound. The procedure is performed with a special apparatus through an open fontanel. The study can be done on very premature babies in the intensive care unit, even if they are connected to artificial ventilation.

Neurosonography allows you to see the degree of filling of the ventricles of the brain and suggest for what reasons it is suffering. brain activity. The downside of the study is that any area with altered echogenicity can be mistaken for pathology. Also, the accuracy of the study is influenced by the condition of the baby (is it calm or crying) and even how the sensors are attached.

Computed tomography and MRI

It happens that neurosonography did not reveal severe pathologies, but symptoms of central nervous system depression are evident. Then a study using magnetic resonance or computed tomography is prescribed. This method is more informative; it allows you to “look” into the most remote corners of the brain and evaluate its smallest structures.

MRI - a modern diagnostic method

An important rule: the child should not move during the examination. Therefore, before the procedure, he may be given special medications.

EEG and Dopplerography

Electroencephalography helps to see bioelectrical brain activity and evaluate vascular pulsation. But the brain is immature in the perinatal period, and the study needs to be carried out more than once, comparing indicators. Using Doppler ultrasound, blood flow in the vessels is assessed.

Treatment

The task of the medical staff is to establish the fact of violations of the central nervous system as soon as possible and begin treatment in the maternity hospital. Let us recall that the first month of life is the most decisive, when it is possible for nerve cells to mature and fully replace those lost after oxygen starvation.

PPCNSL in the acute period is treated in the intensive care unit. The baby is placed in a special incubator and all efforts are directed towards maintaining the heart, kidneys and lungs, eliminating seizures and cerebral edema. IN this period treatment with medications that improve cerebral circulation, normalizing the outflow of cerebrospinal fluid. At the same time, doctors take a responsible approach to choosing the dosage of medications, especially when it comes to premature babies with small birth weights. There is 24-hour monitoring by neonatologists. A neurologist may be invited for a consultation directly to the intensive care unit.

When the condition returns to normal, the baby is transferred to the neonatal pathology department or to neurological department For further treatment. Reflexes gradually return to normal, the work of the heart muscle and gastrointestinal tract is stabilized, and ventilation of the lungs improves. The choice of therapeutic drugs is aimed at eliminating existing syndromes.

Recovery period

Rehabilitation measures during the recovery period include a course of massage, electrophoresis, and therapeutic exercises. Swimming is very beneficial. On the one hand, it relaxes muscle tone, on the other, it strengthens the muscle corset. Massage elements will differ depending on the type of movement disorder. For hypertension, a relaxing massage is indicated. And for muscle hypotension, massages are designed to relax the limbs and activate the muscles of the back, abdomen, arms and legs.

Warm baths have a beneficial effect on the nervous system. And if you add a decoction of motherwort or pine needles to the water, you get a balneoprocedure with sedative effect. Healing effect heat is used in treatment with paraffin and ozokerite, applying applications to the affected areas.

Doctors strongly recommend trying to maintain lactation during this difficult time. Why? Yes, because milk contains everything necessary to protect the baby from infections and allows him to quickly strengthen his immune system. Milk and maternal affection help reduce stress and improve emotional state. When a newborn is admitted to the intensive care unit, he is fed by bottle or tube. To conserve milk, express regularly. Attach your baby to your breast as soon as possible.

A child who has suffered perinatal damage to the central nervous system must be protected from loud sounds, overheating or excessive cooling, and sources of infection (allow only healthy relatives and friends into the house). In general, he should be as comfortable as possible adapting to environment. For psychocorrection, music therapy and tactile stimulation are used; parents are taught to interact with the baby and evaluate his reactions. All actions are aimed at maximizing the child’s quality of life and his social adaptation.

• All types of traumatic brain injury
• Traumatic meningeal hematomas
• Traumatic intracerebral hematomas
• Fractures of the bones of the vault and base of the skull
• Spinal cord injuries
• Consequences of severe traumatic brain and spinal injuries

Traumatic brain injury - mechanical damage skull and intracranial formations - brain, blood vessels, cranial nerves, meninges.

The frequency of traumatic brain injury and the severity of its consequences make the problem of great importance. social significance. Traumatic brain injury is predominantly suffered by the most active and socially and occupationally important contingent of the population - people under 50 years of age. This also determines large economic losses due to high mortality, frequent disability of victims, as well as temporary loss of ability to work.

Main causes of traumatic brain injury- road traffic accidents, falls, industrial, sports and domestic injuries.

Brain damage may result from:
1) focal damage, usually causing contusion (contusion) of the cortical parts of the brain or intracranial hematoma;
2) diffuse axonal damage involving the deep parts of the white matter.

Symptoms of Traumatic Brain Injury:

Depending on whether the injury preserves the integrity of the skin of the skull and its tightness or whether they are broken, craniocerebral injuries are divided into closed and open.

Closed traumatic brain injuries traditionally divided into concussion, contusion and compression; Conventionally, these also include a fracture of the base of the skull and cracks of the vault while the skin is intact.

TO open traumatic brain injury include fractures of the bones of the cranial vault, accompanied by injury to the adjacent soft tissues, fractures of the base of the skull, accompanied by bleeding or liquorrhea (from the nose or ear), as well as wounds of the soft tissues of the head with damage to the aponeurosis. When intact, solid meninges an open craniocerebral injury is classified as non-penetrating, and if its integrity is violated, it is classified as penetrating.

Traumatic brain injury Based on severity, they are divided into 3 stages: light, medium and heavy. Mild traumatic brain injury includes concussion and mild brain contusions; to moderate severity - moderate brain contusions; to severe - severe brain contusions, diffuse axonal damage and compression of the brain.

Based on the nature of brain damage, they are divided into focal(arising mainly due to shock-anti-shock biomechanics of head injury), diffuse(occurring mainly due to acceleration-deceleration trauma) and its combined injuries.

Traumatic brain injury may be isolated(no extracranial injuries); combined(at the same time there are damage to the bones of the skeleton and/or internal organs), combined(simultaneously influence different kinds energy - mechanical, thermal, radiation, chemical, etc.).

According to the characteristics of the occurrence of traumatic brain injury, there may be primary(when the effect of mechanical energy is not due to any immediately preceding cerebral disturbances) and secondary(when the impact of mechanical energy is caused by an immediately preceding cerebral catastrophe that causes the patient to fall, for example during an epileptic seizure or stroke).

Traumatic brain injury can be sustained for the first time or repeatedly, i.e. be first or second, third, etc.

During a traumatic brain injury there are: acute, intermediate, remote periods. Their temporal and syndromological characteristics are determined primarily clinical form traumatic brain injury, its nature, type, age, premorbid and individual characteristics of the victim, as well as the quality of treatment.

A concussion is characterized by a triad of symptoms: loss of consciousness, nausea or vomiting, retrograde amnesia. There are no focal neurological symptoms.

Brain contusion diagnosed in cases where general cerebral symptoms are supplemented by signs of focal brain damage. Diagnostic boundaries between concussion and brain contusion and slight bruise brain are very unstable, and in similar situation The most appropriate term is “commotion-concussion syndrome” indicating the degree of its severity. A brain contusion can occur both at the site of injury and on the opposite side due to the counter-impact mechanism. The duration of loss of consciousness during a concussion is in most cases from several to tens of minutes.

Mild brain contusion. Characterized by loss of consciousness up to 1 hour after injury, complaints of headache, nausea, and vomiting. In the neurological status, rhythmic twitching of the eyes is noted when looking to the sides (nystagmus), meningeal signs, asymmetry of reflexes. X-rays may reveal fractures of the cranial vault. There is an admixture of blood in the cerebrospinal fluid (subarachnoid hemorrhage).

Moderate brain contusion. Consciousness turns off for several hours. There is a marked loss of memory (amnesia) for the events preceding the injury, the injury itself, and the events after it. Complaints of headache, repeated vomiting. Short-term disturbances in breathing, heart rate, blood pressure. There may be mental disorders. Meningeal signs are noted. Focal symptoms manifest themselves in the form of uneven pupil size, speech impairment, weakness in the limbs, etc. Craniography often reveals fractures of the vault and base of the skull. Lumbar puncture revealed significant subarachnoid hemorrhage.

Severe brain contusion. Characterized by prolonged loss of consciousness (lasting up to 1-2 weeks). Gross violations of vital signs are detected important functions(changes in heart rate, blood pressure, breathing rate and rhythm, temperature). The neurological status shows signs of damage to the brain stem - floating movements of the eyeballs, swallowing disorders, changes in muscle tone, etc. Weakness in the arms and legs, up to paralysis, as well as convulsive seizures may be detected. A severe bruise is usually accompanied by fractures of the vault and base of the skull and intracranial hemorrhages.

Brain compression implies the development of a traumatic hematoma, often epidermal or subdural. Their timely diagnosis presupposes two unequal situations. With a simpler one, there is a “light period”: the patient who has regained consciousness after some time begins to “load” again, becoming apathetic, lethargic, and then stuporous. It is much more difficult to recognize a hematoma in a patient in a coma, when the severity of the condition can be explained, for example, by a bruise of brain tissue. The formation of traumatic intracranial hematomas as their volume increases is usually complicated by the development of a tentorial hernia - protrusion of the brain compressed by the hematoma into the foramen of the cerebellar tentorium, through which the brain stem passes. Its progressive compression at this level is manifested by a lesion oculomotor nerve(ptosis, mydriasis, strabismus) and contralateral hemiplegia.

Fracture of the base of the skull inevitably accompanied by brain contusion of varying degrees, characterized by the penetration of blood from the cranial cavity into the nasopharynx, into the periorbital tissues and under the conjunctiva, into the cavity of the middle ear (during otoscopy, a cyanotic color of the eardrum or its rupture is detected).

Bleeding from the nose and ears may be due to local trauma, so it is not a specific sign of a basal skull fracture. Equally, the “symptom of glasses” is also often the result of a purely local facial injury. It is pathognomonic, although not necessary, to leak cerebrospinal fluid from the nose (rhinorrhea) and ears (otorrhea). Confirmation of the leakage of cerebrospinal fluid from the nose is the “teapot symptom” - a clear increase in rhinorrhea when the head is tilted forward, as well as the detection of glucose and protein in the nasal discharge, according to their content in the cerebrospinal fluid. Pyramid fracture temporal bone may be accompanied by paralysis of the facial and cochleovestibular nerves. In some cases, facial paralysis occurs only a few days after the injury.

Along with acute hematomas, a skull injury can also be complicated by a chronically increasing accumulation of blood above the brain. Usually in such cases there is a subdural hematoma. As a rule, such patients - often elderly people with impaired memory, who also suffer from alcoholism - are admitted to the hospital already in the stage of decompensation with compression of the brain stem. A skull injury that occurred many months ago is usually not severe, and the patient is amnesic.

Treatment of Traumatic Brain Injury:

The main goal of treatment for traumatic brain injury is to minimize secondary brain damage, since primary damage cannot be treated.

Emergency care at the prehospital stage for traumatic brain injury
The outcome of a traumatic brain injury largely depends on the early assistance provided to the victim. The neurological status is assessed at this stage. Hypotension and hypoxia associated with traumatic brain injury occur in 50% of cases; hypotension accompanies systemic damage and may be due to hemorrhagic complications and a decrease in vascular tone with damage to the brain stem; hypoxia occurs with hemopneumothorax or obstruction respiratory tract(usually the top ones). The causes of obstruction may be a coma and retraction of the tongue, the entry of blood and aspiration into the airways.

Therapeutic measures aimed at eliminating hypotension and hypoxia. Any patient with a traumatic brain injury should be considered as a patient with full stomach, since there is a risk of aspiration of gastric contents into the tracheobronchial tree. Trained personnel at the scene should perform tracheal intubation, which reduces mortality in severe traumatic brain injury, and begin intravenous fluid resuscitation. Indications for tracheal intubation: upper airway obstruction, loss of upper airway protective reflexes (GCS)< 8 баллов), неспособность пациента обеспечить дренирование дыхательных путей, необходимость механической поддержки дыхания (тахипноэ >30 per minute). Some authors highlight indications such as hypoxia (PaO2< 70 мм рт. ст.; SjО2 < 94%), гиперкапния (РаСО2 >45 mmHg Art.).

Spinal cord injury occurs in 10% of road traffic accidents. To avoid injury to the cervical spine, intubation with the head in a neutral position is recommended. Intubation is facilitated by the administration of succinylcholine (1 mg/kg) and lidocaine (1.5 mg/kg IV). During the procedure, the method of traction of the head by the mastoid processes along vertical axis body (manual in line traction), which prevents hyperextension and movement of the spine in the cervical region, while the Selick maneuver is used to prevent aspiration and vomiting (pressure on thyroid cartilage). During transportation, inhalation of 100% humidified oxygen is carried out, and, if necessary, auxiliary ventilation is provided. The victim's neck should be immobilized with a rigid collar. The victim is placed on a special board, to which they are tied with belts, which prevents the movement of the spine during transportation. The board for immobilization must be radio-opaque, which allows the necessary studies to be carried out without shifting the victim.
At the scene of the incident, correction of hypovolemic shock begins with intravenous infusion of various solutions; after catheterization of the peripheral vein, 500-1000 ml of isotonic solution, or 50-100 ml of 10% NaCl solution, or 250-500 ml of colloidal solution are injected in a stream. The use of a hypertonic NaCl solution does not cause an increase in intracranial pressure. At the prehospital stage, the volume of intravenous infusion is limited to avoid pulmonary edema, increased bleeding and increased intracranial pressure with a sharp rise in blood pressure. At the prehospital stage, mannitol is not used. According to numerous double-blind randomized studies, dexamethasone and methylprednisolone, prescribed in the early stages of traumatic brain injury in appropriate doses, do not improve clinical outcome.

Inpatient treatment of traumatic brain injury
Activities aimed at supporting breathing and circulation continue. The neurological status according to the GCS, the size and reaction of the pupils to light, sensitivity and motor function extremities, and other systemic injuries are assessed. The efforts of specialists should be aimed at prompt diagnosis and surgical removal of brain compression.

Intracranial hematomas are diagnosed in 40% of cases of traumatic brain injury. Early surgical decompression is an imperative treatment option. With significant intracranial hemorrhage detected by CT examination, delay in surgical intervention within the first four hours increases mortality to 90%. Clinical indications before surgery – the classic triad: impaired consciousness, anisocoria and hemiparesis. However, the absence of these symptoms does not exclude hematoma. Diagnostic value has a decrease in GCS score during repeated neurological examination. Great chance the presence of a hematoma is observed in elderly patients, alcoholics, with injuries received from a fall, fracture of the skull bones (especially in the areas where meningeal vessels and venous sinuses pass).

At this stage one of most important tasks– surgical reduction of intracranial pressure using decompression craniotomy. Bias midline structures brain is a more reliable indicator for surgical intervention than the size of the hematoma. According to Ropper, midline displacement of 8 mm is associated with coma; by 6 mm – with deep stunning. The operation is indicated for displacement of the midline structures by more than 5 mm, an increase in intracranial pressure of more than 25 mm Hg. Art.; decrease in CPP by 45 mm Hg. Art. also serves as an indication for decompression craniotomy.

For the purpose of preoperative assessment of a patient with traumatic brain injury, attention should be paid to the following points:
– airway patency (cervical spine);
– breathing (ventilation and oxygenation);
– state of the cardiovascular system;
– collateral damage;
– neurological status (GCS);
– chronic diseases;
– circumstances of the injury (time of injury, duration of unconsciousness, intake of alcohol or medications on the eve of the injury).

In order to prevent hernial protrusion and strangulation of areas of the brain with increased intracranial pressure, therapy aimed at reducing intracranial pressure is carried out before providing neurosurgical assistance. Typically, to avoid increased intracranial pressure, mannitol is used at a dose of 0.25-1 g/kg body weight quickly intravenously in a drip over 15-20 minutes. The peak decrease in intracranial pressure is observed 10-20 minutes after administration of the drug. A number of studies support the effectiveness of low doses of mannitol (0.25 g/kg) under the control of intracranial pressure, especially in cases where repeated administration is required. In some hospitals, they are used to reduce intracranial pressure in patients with traumatic brain injury. hypertonic solution NaCl, which significantly reduces the production of cerebrospinal fluid (CSF). When using it, a decrease in the volume of brain tissue and the volume of blood supply to the brain is observed to a lesser extent, and the effect of reducing intracranial pressure is less long-lasting than when using mannitol. Bolus administration of concentrated 7.5% and 10% NaCl solutions (up to 6-8 ml/kg) effectively reduces intracranial pressure and causes less risk of sodium retention in the body than drip administration of large volumes (equivalent in the amount of sodium) of moderately hypertensive drugs 2-3 % solutions. A 23.4% NaCl solution has been successfully used for mannitol-refractory increases in intracranial pressure. As a rule, the administration of NaCl is combined with the simultaneous administration of furosemide (2 ml of 1% furosemide is added to 200 ml of 10% NaCl).

Anesthetic management for traumatic brain injury
Before administering anesthesia, remember the basic principles of optimal anesthesia for traumatic brain injury.
1. Ensuring optimal brain perfusion.
2. Prevention of cerebral ischemia.
3. Avoidance of drugs that increase intracranial pressure.
4. Quick awakening of the patient after surgery.

Due to the fact that there is a high risk of aspiration of gastric contents, to prevent aspiration it is necessary to use crash induction - induction into anesthesia quick sequence(rapid seguence induction) and the Selic technique. Crash induction includes:
– preoxygenation with 100% oxygen for 3-5 minutes (with preserved spontaneous breathing);

– induction of anesthesia – narcotic analgesic (5 mcg/kg fentanyl), intravenous anesthetic (5-6 mg/kg sodium thiopental or 2 mg/kg propofol). Doses of anesthetics depend on the depth of the disturbance of consciousness and the state of hemodynamics. The more pronounced the disorders of consciousness and hemodynamics, the lower the doses used. In patients with unstable hemodynamics, preference should be given to etomidate (0.2-0.3 mg/kg). Sodium thiopental and propofol are not indicated in patients with hypovolemia;

– precurarization with Ardoin (10% of the calculated dose) 5 minutes before the administration of a muscle relaxant with a rapid onset of action (ditilin). The increase in intracranial pressure caused by ditilin, short-term, single administration of this drug does not affect the outcome. In patients with limb paresis (not earlier than one day after a traumatic brain injury), ditilin-induced hyperkalemia may occur; in such cases, a relaxant of a non-depolarizing type should be used;

– Selic maneuver (pressure on the thyroid cartilage);

– tracheal intubation (laryngoscopy lasting less than 15 seconds). Positioning the patient on the operating table with the head end elevated by 30 degrees improves the venous outflow of blood from the brain.

The issue of ventilation support during anesthesia is very problematic. It should be said that hyperventilation has long become a routine method of treating patients with traumatic brain injury due to the fact that it causes vasoconstriction of the arterioles of the brain and pia mater. It helps reduce cerebral blood flow and volume, as well as intracranial pressure.

Known disadvantages of the method are hypoperfusion/ischemia (in pre-existing conditions of hypoperfusion) and inhibition of oxygen delivery due to a leftward shift in the oxyhemoglobin dissociation curve. When comparing patients who underwent hyperventilation with a decrease in PaCO2 to 24 mm Hg. Art., with the control group, where PaCO2 was reduced to 35 mm Hg. Art., a significant difference was revealed in favor of normoventilation, if we consider the clinical outcome 3-6 months after the injury. It has been proven that hyperventilation can have beneficial effect in patients with increased cerebral blood flow, especially in young patients with predominant symptoms of cerebral edema with intact brainstem function. The intracerebral pressure-lowering effect of hyperventilation in patients with reduced cerebral blood flow (late phase of traumatic brain injury, acute phase in the elderly) is, if not completely absent, then very limited. Moreover, in such situations, hyperventilation may have a detrimental effect and cause further local deterioration of cerebral blood flow, which may fall below the ischemic threshold. It is usually recommended to continue mechanical ventilation in the postoperative period, since maximum brain swelling occurs 12-72 hours after injury.

The most optimal method of anesthetic support in patients with traumatic brain injury should be considered an infusion of sodium thiopental at a rate of 4-5 mg/kg/hour. This method is especially appropriate for patients with severe traumatic brain injury and coma.

In patients with mild traumatic brain injury, low doses of isoflurane or desflurane may be given to maintain anesthesia. One should only remember the need for moderate hyperventilation when using these inhalational anesthetics. Isoflurane and desflurane at a concentration of 1-1.5 MAC (minimum alveolar concentration - the alveolar concentration of an inhalational anesthetic that prevents involuntary movements of the limbs in 50% of patients in response to a standardized stimulus (for example, a skin incision) and does not cause a noticeable increase in intracranial pressure. Enflurane and desflurane, when used over a long period of time, may interfere with the reabsorption of cerebrospinal fluid.

Nitrous oxide increases cerebral blood flow and the amount of air in the cranial cavity, so its use in pure form in such operations is limited, although a number of clinics use N2O in combination with sodium thiopental infusion. This makes it possible to reduce the rate of infusion of the latter and, thus, ensure rapid awakening of the patient. When working with N2O in this category of patients, ventilation should be carried out in the mode of moderate hyperventilation (PaCO2 = 32 mm Hg) and turned off before closing the dura mater.

To maintain myoplegia, a muscle relaxant with an antidepolarizing effect is used (vecuronium is preferred, but Arduan is widely used). Opioids are administered during surgery for pain relief. It has been established that fentanyl and sufentanil can increase intracranial pressure in traumatic brain injury. Maintaining blood pressure at a sufficient level when using opioids prevents an increase in intracranial pressure.

An important point during the operation, before and after it is infusion therapy, which in patients with cerebral edema is somewhat different from that accepted in general anesthesiology and intensive care, although the general principles remain the same. Infusion therapy should ensure not only hemodynamic stability, but also adequate CPP, prevent an increase in venous pressure in the cranial cavity, maintain a stable blood plasma osmolarity within 300-310 mOsm/kg H2O and prevent the development of both hyperglycemia and hypoglycemia. Brain perfusion pressure should be maintained at 80-90 mm Hg. Art.

During operations for the removal of acute epidural and subdural hematomas, especially with rapid decompression, there is a significant decrease in blood pressure, which can be aggravated by initial hypovolemia and bleeding. With systemic injuries, patients are often hypovolemic, and doctors' efforts should be aimed at normalizing the volume of blood volume. Hypovolemia may be masked by hypoxia, a sympathetic activation in response to increased intracranial pressure. To correct initial hypovolemia, an isotonic NaCl solution is transfused until blood pressure, heart rate and diuresis are normalized. The hematocrit should be maintained at a level of at least 30% to avoid cerebral ischemia. Isotonic solution NaCl is the main and in most cases the only drug for patients with pathology of the cranial cavity. At the same time, it is important to remember that hypervolemia can increase cerebral edema and contribute to increased intracranial pressure.

The anesthesiologist should strive to awaken the patient early after surgical intervention, allowing for early neurological examination. The presence of consciousness in the postoperative period greatly facilitates monitoring of the patient and allows for earlier detection of the development of complications. Consciousness is the best criterion for assessing the patient's condition in the early postoperative period, but early awakening of the patient should not be an end in itself. If the patient's condition allows, extubation is performed at the end of the operation. Along with stable hemodynamics, normal body temperature and adequate breathing, restoration of the patient’s consciousness is a mandatory criterion for early extubation. If an increase in cerebral edema and an increase in intracranial pressure are expected and it is intended to use hyperventilation to reduce it, there should be no rush to extubate.

The outcome of a traumatic brain injury can be assessed no earlier than 6 months after the injury. According to the Traumatik Coma Data Bank, of patients admitted to hospitals with severe traumatic brain injury, 67% survive (excluding gunshot head injuries). Of this group of patients, only 7% show good recovery upon discharge from hospital. Thus, almost all patients with severe traumatic brain injury have various neurological disorders.

Prognosis for traumatic brain injury. With a concussion, the vast majority of patients make a full recovery. The outcome of brain contusion and open skull injuries depends on the severity of the brain injury. In most cases, survivors retain some residual cerebral symptoms. Timely removal of the hematoma saves patients' lives; In many similar cases no significant residual symptoms remain. With severe brain damage, mortality can reach 40-50%.