Lesions and pseudolesions of the cranial vault: Differential diagnosis and illustrated overview of pathological conditions manifested by focal lesions of the cranial vault. Intracranial pressure and radiography

After a detailed examination of the patient’s neurological status, a neurologist analyzes the identified signs and syndromes, as well as the sequence of their development in order to determine topical and pathogenetic diagnoses. If there is an assumption about the neoplastic nature of the process, intracranial vascular malformation, or the presence of a clear clinical picture of intracranial hypertension, the patient must undergo additional research in a neurological or neurosurgical hospital. Neurosurgical departments are part of all regional, regional and republican hospitals, as well as a number of large city multidisciplinary hospitals and university clinics. In case of acute head and spinal trauma, victims are often immediately hospitalized in a neurotraumatology department, which has neurosurgeons on staff. It is always necessary to conduct a neurosurgical examination of patients with increasing cerebral symptoms (persistent headache, especially at night and in the morning, with nausea, vomiting, bradycardia, slowing of associative thought processes - the patient’s mental load, etc.), since it is known that in the brain In the brain there are significant zones, when destroyed, there are no conductive or focal symptoms(for example, the right temporal lobe in right-handed people, the base of the frontal lobes, etc.). Additional studies of neurological patients are aimed at assessing the condition of both the brain structures themselves and the liquor-conducting systems, brain vessels, and the bone cases that protect the brain (skull, spine). These bone tissues can be involved in a pathological process that spreads to them directly from the nervous system (germination or compression by a tumor), or are affected in parallel (tumor metastases, angiomatosis, brain abscesses and periostitis, spondylitis, etc.). Naturally, a large group of neurosurgical patients

In patients with injuries of the skull and spine, these bone structures are primarily affected.

Almost any medical institution in our country, starting with regional ones, has X-ray facilities, so you should start with radiography.

RADIOGRAPHY

To assess the condition of the bone sheaths of the brain and spinal cord, X-rays of the skull (craniography) and spine (spondylography) are performed.

Photographs of the skull are taken in two projections - frontal and lateral. In a direct projection (frontal, frontal), posteroanterior (the patient's forehead is adjacent to the cassette, the X-ray beam is directed along a plane passing through the upper edges of the external auditory canals and the lower edges of the orbits) or anteroposterior (the patient lies on his back with the back of his head to the cassette) images are taken. When taking a lateral (profile) photograph, it is taken from the right or left. The scope and nature of this research, as a rule, depends on the tasks assigned.

When assessing survey craniograms, attention is paid to the configuration and size of the skull, bone structure, condition of the sutures, the nature of the vascular pattern, its severity, the presence of intracranial calcifications, the condition and size of the sella turcica, signs of increased intracranial pressure, traumatic and congenital deformities, damage to the bones of the skull, and also its anomalies (Fig. 3-1).

Dimensions and configuration of the skull

When studying the size of the skull, the presence of micro or hypercephaly, its shape, deformation, and the order of suture healing are revealed. Thus, with early overgrowth of the coronal suture, the skull increases in height: the frontal bone rises upward, the anterior cranial fossa shortens, and the sella turcica descends downwards (acrocephaly). Premature closure of the sagittal suture leads to an increase in the skull in diameter (brachycephaly), and untimely closure of other sutures enlarges the skull in the sagittal plane (dolichocephaly).

Rice. 3-1. Craniograms are normal. A- lateral projection: 1 - coronal suture; 2 - lamb-shaped seam; 3 - internal occipital protrusion; 4 - external occipital protrusion; 5 - posterior cranial fossa; 6 - cells of the mastoid process; 7 - mastoid process; 8 - external auditory canal; 9 - main part of the occipital bone; 10 - sella turcica; 11 - sphenoid sinus; 12 - posterior wall of the maxillary sinus; 13 - hard palate; 14 - anterior wall of the maxillary sinus; 15 - anterior cranial fossa; 16 - frontal sinus. b- direct projection: 1 - sagittal suture; 2 - coronal suture; 3 - frontal sinus; 4 - sinus of the main bone; 5 - optic nerve channel; 6 - superior orbital fissure; 7 - orbital part of the frontal bone; 8 - pyramid; 9 - infraorbital margin; 10 - maxillary sinus; 11 - coronoid process of the lower jaw; 12 - zygomatic bone; 13 - mastoid process; 14 - cells of the mastoid process; 15 - supraorbital edge

Structure of the skull bones

The thickness of the bones of the cranial vault normally reaches 5-8 mm in an adult. The asymmetry of their changes is of diagnostic significance. Widespread thinning of the bones of the cranial vault, as a rule, occurs with a long-term increase in intracranial pressure, which is often combined with areas of compaction and thinning (“finger” impressions). Local thinning of bones is more often found with brain tumors when they grow into or compress the bones. General thickening of the bones of the cranial vault with expansion of the frontal and sphenoid sinuses, as well as an increase in the supra-

brow arches and occipital protuberance are detected with a hormonally active adenoma. Often, with hemiatrophy of the brain, thickening of the bones of only one half of the skull occurs. Most often, local thickening of the skull bones, sometimes very significant, is caused by meningioma. In case of myeloma (Rustitsky-Kahler), due to focal destruction of bones by the tumor, through holes are formed, which on craniograms look like multiple round, clearly contoured foci (as if “knocked out with a punch”) measuring 1-3 cm in diameter. With Paget's disease, as a result of structural restructuring of the bone beams, areas of clearing and compaction appear in the bones of the cranial vault, which gives a picture reminiscent of a “curly head”.

Condition of seams

There are temporal (squamous), coronal (coronal), lambdoid, sagittal, parieto-mastoid, parieto-occipital and frontal sutures. The sagittal suture heals by the age of 14-16, the coronal suture by the age of 30, and the lambdoid suture even later. When intracranial pressure increases, especially if it exists for a long time, suture dehiscence is noted.

Vascular pattern

Almost always, vascular grooves are visible on craniograms - linear clearings formed by the branches of the middle meningeal artery (up to 2 mm wide). Often, photographs of the skull reveal channels of diploic veins several centimeters long (Fig. 3-2). Often in the parietal, less often the frontal bones, the bone beds of Pachyon granulations are determined parasagittally - Pachyon fossae (rounded enlightenments up to 0.5 cm in diameter). In the frontal, parietal, occipital bones and mastoid processes there are venous graduates - emissaries.

With meningiomas, long-term venous stagnation, internal hydrocephalus expansion occurs, additional formation of vascular grooves and emissary graduates occurs. Sometimes contouring of the grooves of the intracranial sinuses is observed. Also often with meningiomas, craniograms reveal hyperostoses of the internal plate of the bones of the calvarium (Fig. 3-3).

Rice. 3-2. Lateral craniogram of the skull. Enlarged diploic channels are visible (a sign of venous-cerebrospinal fluid intracranial hypertension)

Rice. 3-3. Hyperostosis of the skull bones. Lateral craniogram

Intracranial calcifications

Calcification of the pineal gland in healthy people occurs in 50-70%. The shadow of calcification is located along the midline (displacement of no more than 2 mm is allowed) and 5 cm above the horizontal, running from the lower edge of the orbit to the external auditory

ear canal, as well as 1 cm behind the “ear vertical” - a line passing through the ear canal perpendicular to the indicated horizontal (Fig. 3-4).

Rice. 3-4. Normal position of the calcified pineal gland (shown by an arrow): a - lateral craniogram; b - direct craniogram

Calcifications of the choroid plexuses, dura mater, falciform process and cerebellar tentorium are considered physiological. Pathological calcifications include deposits of lime and cholesterol in tumors (craniopharyngiomas, meningiomas, oligodendrogliomas, etc.). In older people, calcified walls of the internal carotid arteries are often detected at the site of their passage through the cavernous sinus. Relatively often cysticerci, echinococcal blisters, tuberculomas, brain abscesses, and post-traumatic subdural hematomas are calcified. Multiple round or stringy calcareous inclusions occur in tuberous sclerosis (Bourneville's disease). In Sturge-Weber disease, the outer layers of the cerebral cortex are predominantly calcified. On craniograms, shadows are visible that resemble “twisted beds”, repeating the contours of grooves and convolutions.

Shape and size of the sella turcica

The sella turcica normally reaches 8-15 mm in the anteroposterior direction, and 6-13 mm in the vertical direction. It is believed that the configuration of the saddle often follows the shape of the cranial vault. Big diagnostic value give changes to the back of the saddle, while paying attention to its thinning, deviation anteriorly or posteriorly.

With an intrascidal tumor, primary changes develop on the side of the sella turcica. They are represented by osteoporosis of the anterior wedge-shaped processes, an increase in the size of the sella turcica, deepening and double-contour of its bottom. The latter is a very characteristic symptom for pituitary adenomas and is clearly visible on the lateral craniogram.

Signs of increased intracranial pressure

Increased intracranial pressure, especially long-term, is often diagnosed on craniograms. With closed hydrocephalus, due to an increase in intraventricular pressure, the gyri of the brain exert increased pressure on the bones of the cranial vault, which causes the appearance of small areas of local osteoporosis. These manifestations of osteoporosis on craniograms are called “finger” impressions (Fig. 3-5).

Long-term intracranial hypertension also leads to thinning of the skull bones, poor relief, and deepening of the cranial fossae. With closed hydrocephalus, changes occur on the side of the sella turcica due to excessive intra-

Rice. 3-5. Finger impressions are a sign of osteoporosis of the skull bones and a long-term increase in intracranial pressure. Dehiscence of cranial sutures. Lateral craniogram

cranial pressure, - secondary changes. As a rule, they are represented by a widening of the entrance to the sella turcica, thinning of its back and a decrease in its height, which is characteristic of osteoporosis (Fig. 3-6). These changes also include osteoporosis of the inner crest of the squama of the occipital bone and the posterior semicircle of the foramen magnum (Babchin’s symptom).

With open hydrocephalus, the vascular pattern disappears, and there are no digital impressions on the bones. In childhood, divergence of the cranial sutures is observed.

Anomalies of skull development

The most common is craniostenosis - early fusion of cranial sutures. Depending on the sequence of premature overgrowth of individual sutures or several of them, bone growth is delayed in the direction perpendicular to the overgrown suture, and various forms of the skull are created. Other anomalies of the development of the skull include platybasia - flattening of the base of the skull: with it, the angle between the continuation of the platform of the main bone and the Blumenbach slope increases and becomes more than 140°; and basilar impression - with it the area around the foramen magnum protrudes along with the upper cervical vertebrae into the cranial cavity. Craniography reveals

Rice. 3-6. Osteoporosis of the dorsum sella. Lateral craniogram

congenital cranial hernias (meningocele, meningoencephalocele) by the presence of bone defects with dense sclerotic edges.

Fractures of the skull bones

There are the following types of fractures of the bones of the cranial vault: linear, bayonet-shaped, stellate, ring, comminuted, depressed, perforated. The characteristic radiological signs of a fracture of flat bones are considered to be a triad: gaping of the lumen, clarity of the edges, a zigzag course of the fracture line and bifurcation of this line: one line is from the outer periosteum of the skull bone, the other is from the inner plate (symptom of “split thread”). To identify a fracture of the skull bones, photographs are taken in frontal and lateral projections. If a fracture of the bones of the skull base is suspected, axial and semi-axial radiographs (anterior and posterior) are additionally taken. Local pathology is best identified by targeted photographs of areas of bones suspected of fracture.

CORESPINAL FLUID STUDY

The brain and spinal cord are covered by three membranes: dura (dura mater) arachnoid (arachnoidea) and vascular (pia mater). The hard shell consists of two layers: outer and inner. The outer leaf lines the inner surface of the bones of the skull and spine and acts as periosteum. Between the layers of the dura mater there are three vascular networks: the external and internal capillary and the middle arteriovenous. In some places in the cranial cavity, the layers of the shell do not grow together and form sinuses (sinuses), through which venous blood flows from the brain. In the spinal canal, these sinuses are filled with fatty tissue and a network of venous vessels. The arachnoid and pia mater above the grooves and fissures of the brain do not have a dense fusion with each other and form subarachnoid spaces - cisterns. The largest of them are: the greater occipital cistern of the brain (in the posterior cranial fossa) and the pontine, interpeduncular, and chiasmal cisterns (at the base of the brain). In the lower parts of the spinal canal, the final (terminal) tank is distinguished.

CSF circulates in the subarachnoid space. This space communicates with the ventricles of the brain through the paired foramina of Luschka, located in the outer (lateral) parts of the IV ventricle, and through the unpaired Magendie with the subarachnoid space of the spinal cord. CSF flows through the Luschka foramina into the subarachnoid space of the posterior cranial fossa, then partially into the subarachnoid space of the spinal cord, but most of it flows through the tentorial foramen (pachyonic hole) onto the convex (convexital) and basal surface of the cerebral hemispheres. Here it is absorbed by pachion granulations into the sinuses and large veins of the brain.

Continuous forward movements of the CSF help remove waste products. Its total amount in a healthy adult is in the range from 100 to 150 ml. During the day it is updated from 5 to 10 times.

CSF - component complex, reliable system of protection and nutrition of the brain. The latter includes the walls of capillaries, the membranes of the brain, the stroma of the choroid plexuses, some elements of glia and cell walls. This system forms the blood-brain barrier. CSF protects brain tissue from injury, regulates the osmotic balance of nerve elements, transports nutrients, serves as an intermediary in the removal of metabolic products and as a site for the accumulation of antibodies, and has lytic and bactericidal properties.

For examination, CSF can be obtained by lumbar, suboccipital or ventricular puncture.

Lumbar puncture

The first lumbar puncture was performed in 1789 by Quincke. It is most often performed with the patient lying on his side with the lower limbs maximally bent and adducted to the abdomen. At the same time, the distance between the spinous processes increases. The spinal cord in an adult ends at the level of the upper edge of the L 2 vertebra; below this level is the lumbar terminal cistern, in which only the spinal roots pass. In children, the spinal cord ends one vertebra below - at the upper edge of the L 3 vertebra. In this regard, the child can be punctured in the interspinous spaces L in -L IV, L V -Lv and L V -S I. An adult can be punctured in L II -L JII, L JII -L JV, L JV -L V , S 1 - gprome-

creepy. The interspinous spaces are counted from a line drawn through the crests of the iliac bones. Above this line is the spinous process of the L vertebra, and below it is the L V (Fig. 3.7).

Rice. 3-7. Lumbar puncture in the interspinous space of the vertebrae L IV -L V

The puncture is performed after treating the skin of a surgical field measuring 15x20 cm, located in the lumbar region. The field is treated with an antiseptic solution (iodonate, alcohol, iodine, etc.) from top to bottom. First, local anesthesia is performed: with a thin needle, 2-3 ml of a 0.5% novocaine solution is injected intradermally and subcutaneously, down to the bone, while preventing the needle from penetrating and introducing the solution into the subarachnoid space. After such anesthesia, a puncture of the intrathecal space is performed using a special needle 0.5-1 mm thick and 9-12 cm long, the end of which is beveled at an angle of 45°. The needle lumen is closed with a well-fitted and easily sliding mandrel, the diameter of which exactly matches the needle lumen. On the outside, the mandrin has a head (cap), by which it can be easily removed and inserted into the needle again (Fig. 3.8, see color insert). The puncture needle is directed strictly in the sagittal plane and slightly upward, according to the imbricated location of the spinous processes. The needle, having passed the skin and subcutaneous tissue, penetrates through the dense interspinous and yellow ligaments, then through the loose epidural tissue and dura mater. At the moment of passing the latter, a feeling of “failure” often arises. After this sensation, the needle is moved another 1-2 mm, the mandrel is removed from it, and the cerebrospinal fluid begins to flow out.

Puncture should be carried out painlessly, the movements of the doctor’s hands should be smooth, without sudden changes in the direction of the needle deeply inserted into the interspinous space, since this can break off part of the needle at the point of its pressure on the edge of the spinous process. If, when inserting a needle, it rests on the bone structure, then you should remove the needle to the subcutaneous layer and, slightly changing the direction, immerse it again in the spinal canal or, as a last resort, make a new puncture in the adjacent interspinous space.

Sometimes, at the moment the needle penetrates the subarachnoid space, the patient suddenly feels a sharp shooting pain radiating to the leg. This means that the needle touches the root of the horse's tail. It is necessary to slightly pull the needle back and slightly change its position so that the patient stops feeling pain.

By removing the mandrin from the needle, we get the first drops cerebrospinal fluid, which may be slightly stained with travel blood (since in the epidural space the needle passes through the venous intravertebral plexus). The following drops of clear CSF are collected into a sterile tube for laboratory testing. If it continues to flow with an admixture of blood and the clinical picture of the disease does not suggest a subarachnoid hemorrhage, then a second puncture can be quickly performed in the superior interspinous space. In this case, the CSF usually flows without blood. However, if the leakage of bloody cerebrospinal fluid continues, it is necessary to carry out an urgent test with white filter paper, on which 1-2 drops of cerebrospinal fluid flowing from the needle are placed. You should insert a mandrin into the needle and observe for several tens of seconds how a drop of CSF spreads across white filter paper. You can see two options. First, in the center of the spot there are red blood cells in small fragments, and a colorless transparent rim of diffused liquid appears around the circle; With this option, we conclude that the blood in the cerebrospinal fluid is traveling. The second option is that the entire drop placed on the paper blurs pink. This indicates that blood was in the CSF for a long time, hemolysis of red blood cells occurred, i.e. The patient has subarachnoid hemorrhage. In both cases, 2-3 ml of CSF is taken and in the laboratory, after centrifugation, it is confirmed microscopically which red blood cells have precipitated - fresh (with travel blood) or leached

(with subarachnoid hemorrhage). If the doctor does not have white filter paper on hand, a drop of blood can be placed on a white cotton cloth (sheet). The result is evaluated the same way.

WITH diagnostic purpose 2-3 ml of CSF is extracted, which is enough to conduct basic studies of its composition.

CSF pressure is measured using a membrane-type manometer or a water manometer. A water pressure gauge is a graduated glass tube with a lumen cross-section of no more than 1 mm, bent at a right angle in the lower section. A short soft tube with a cannula is placed on the short end of the tube. The cannula is used to connect to the puncture needle. The height of the cerebrospinal fluid pressure in the subarachnoid space of the spinal cord is assessed by the level of the CSF column in the manometer. Normal cerebrospinal fluid pressure in the supine position ranges from 100-180 mm of water. Art. Pressure above 200 mm water column. indicates CSF hypertension, and below 100 mmH2O. - for hypotension. In the patient's sitting position, a cerebrospinal fluid pressure of 250-300 mmH2O is considered normal.

CSF is taken for research or removed for therapeutic purposes after measuring the pressure level and performing liquorodynamic tests. The amount of CSF required for the study is usually 2 ml. After the lumbar puncture, the patient is transported to the ward on a gurney. For 1-2 days he must remain in bed, and for the first 1.5-2 hours lie on his stomach or side.

Liquorodynamic tests

Liquorodynamic tests are carried out to study the patency of the subarachnoid space of the spinal cord in cases where compression of the spinal cord and subarachnoid space is suspected by a tumor, hematoma, displaced vertebra, hernia intervertebral disc, bone fragments, cysts, foreign bodies, etc. Tests are performed after a lumbar puncture. The liquorodynamic tests used are listed below.

Queckenstedt's test. Compression of the jugular veins in the neck for 10 s with preserved patency of the subarachnoid space leads to a rapid increase in cerebrospinal fluid pressure, on average to the level of 400-500 mm water column, after the compression stops - to a rapid decrease to the original figures.

The increase in liquor pressure during this test is explained by an increase in venous pressure in response to compression of the veins of the neck, which

causes intracranial hypertension. With good patency of the cerebrospinal fluid spaces, cessation of compression of the veins quickly normalizes venous and cerebrospinal fluid pressure.

Stukey's test. Pressure on the anterior abdominal wall until the sensation of pulsation of the abdominal aorta and spine during patency of the subarachnoid space is accompanied by a rapid increase in cerebrospinal fluid pressure to 250-300 mm H2O. and its rapid decline to the original figures. With this test, compression of the inferior vena cava increases intra-abdominal pressure, which entails an increase in venous intravertebral and intracranial pressure.

Poussep's test. Tilt of the head forward with the chin brought to the anterior surface of the chest for 10 s with preserved patency of the subarachnoid space causes an increase in cerebrospinal fluid pressure to 300-400 mm water column. and its rapid decline to the original figures. The mechanism for increasing cerebrospinal fluid pressure is the same as with the Queckenstedt test.

Fluctuations in CSF pressure are recorded on a graph. If, during the Queckenstedt and Pussep tests, the cerebrospinal fluid pressure increased, but did not decrease to normal after the tests were stopped, then a complete or partial blockage of the cerebrospinal fluid tract in the spinal canal is diagnosed. In this case, normal fluctuations in cerebrospinal fluid pressure are characteristic only of the Stukey test.

During lumbar puncture, the following complications may occur: injury to the epidural veins, injury to the spinal root, development of inflammation (meningitis), implantation of a piece of epidermis (with a poorly fitted mandrel, when there is a gap between the bevel of the mandrel and the wall of the needle) into the subarachnoid space with subsequent development through 1-9 years of tumor (epidermoid, cholesteatoma).

Prevention of these complications is simple: careful adherence to asepsis and antisepsis, precise implementation of the puncture technique, strictly perpendicular insertion of the needle to the line of the spinous processes, and the mandatory use of a well-fitted mandrel when inserting the needle.

Cerebrospinal fluid examination

The study of CSF in the diagnosis of neurological pathology is important. Since CSF is a medium that washes the entire brain and spinal cord with membranes and vessels, the development of nervous system diseases

the system is often accompanied by changes in its physicochemical composition, as well as the appearance in it of decay products, bacteria, viruses, blood cells, etc. In the lumbar cerebrospinal fluid, the amount of protein is examined, which is normally 0.3 g/l, cells - 0-2x10 9. The amount of sugar in the liquor is 2 times less than in the blood. With a tumor of the brain or spinal cord, the amount of protein in the CSF increases, but the number of cells remains normal, which is called protein-cell dissociation. In case of malignant tumors, especially the meninges, atypical (tumor) cells are found in the cerebrospinal fluid. With inflammatory damage to the brain, spinal cord and meninges, the number of cells in it increases tens of hundreds of times (pleocytosis), and the protein concentration remains close to normal. This is called cell-protein dissociation.

CONTRAST METHODS OF X-RAY STUDY

Pneumoencephalography

In 1918, Dandy was the first in the practice of neurosurgery to use the injection of air into the ventricles of the brain to diagnose intracranial pathology. He called this method ventriculography. A year later, in 1919, he proposed a method that made it possible to fill the subarachnoid spaces and ventricles of the brain with air through a needle inserted subarachnoidally into the lumbar cistern. This method is called pneumoencephalography. If during ventriculography the ventricular system is filled with air from above, then during pneumoencephalography air is introduced into the ventricular system from below, through the subarachnoid space. In this regard, with pneumoencephalography, the results of contrasting the subarachnoid space of the brain and spinal cord will be much more informative than with ventriculography.

Indications for pneumoencephalography and ventriculography:

Carrying out differential diagnosis between volumetric, vascular diseases and the consequences of past inflammatory and traumatic processes in the brain;

Clarification of the localization of the intracranial pathological process, its prevalence, volume and severity;

Restoration of liquorodynamics in patients with cicatricial adhesions of the brain of inflammatory and traumatic origin, as well as in epilepsy (therapeutic purpose).

Absolute contraindications for lumbar puncture and pneumoencephalography:

Dislocation syndrome detected in the patient being examined;

The presence of congestive optic discs;

The presence or suggestion of localization of a space-occupying process in the posterior cranial fossa or temporal lobe.

Pneumoencephalography is performed in a sitting position on an x-ray table (Fig. 3-9). Depending on which parts of the ventricular system and subarachnoid spaces want to be filled first, the patient’s head is given a certain position. If it is necessary to examine the basal cisterns of the brain, then the head is bent upward as much as possible; if the cisterns of the posterior cranial fossa, IV ventricle and Sylvian aqueduct are needed, the head is bent downwards as much as possible, and if they want to direct air directly into the ventricular system, then the head is slightly bent downwards (10-15 °). To conduct the study, the patient undergoes a regular lumbar puncture and with a twenty-milliliter syringe, air is injected in portions of 8-10 cm 3 through a needle into the subarachnoid space. Typically, the amount of introduced air ranges from 50 to 150 cm 3 and depends on the nature of the pathological process and the patient’s response to the study.

There are several methods for performing pneumoencephalography. One involves carrying it out without removing the spinal cord.

Rice. 3-9. Pneumoencephalography. Air or oxygen is introduced into the subarachnoid space through the upper needle, and cerebrospinal fluid is released through the lower needle.

howling fluid, the second - simultaneous introduction of air and removal of cerebrospinal fluid, for which the subarachnoid space is punctured with two needles (usually between L m -L and L IV -I _v). The third technique involves step-by-step, alternating, portioned introduction of air and removal of cerebrospinal fluid. After each portion of air, craniography is done in one or two projections. This technique is called directed delayed pneumoencephalography and allows you to examine the subarachnoid spaces and various parts of the ventricular system purposefully and with greater safety.

Pneumoencephalography without removal of cerebrospinal fluid is used for tumors of the posterior cranial fossa, for occlusive hydrocephalus, as well as for supratentorial tumors in cases of risk of dislocation.

For therapeutic purposes, pneumoencephalography is performed for focal epilepsy caused by a cicatricial adhesive process. If it is unclear whether Jacksonian epilepsy is a consequence of meningeal adhesions or a brain tumor, then pneumoencephalography can be decisive diagnostic method research, and in the absence of indications for surgery for meningeal adhesions - at the same time as a therapeutic measure.

For better orientation when reading pneumoencephalograms, it is necessary to clearly understand the structure of the ventricular system of the brain (Fig. 3-10).

Ventriculography

Indications for ventriculography are: the need to determine whether there is an intracranial pathological process that causes compression and displacement of the brain (tumor, abscess, granulomas, occlusive hydrocephalus of various etiologies), or whether there are atrophic phenomena that are not accompanied by anatomical changes in the cerebrospinal fluid system; the need for precise localization of the volumetric process, especially inside the ventricles, or the level of occlusion.

Ventriculography is done in cases where pneumomyelography does not lead to filling of the ventricular system or it is contraindicated. It is not performed if the patient’s general condition is severe due to brain dislocation.

Rice. 3 -10. Ventricular system of the brain (cast): 1- anterior horn of the left lateral ventricle; 2 - Monroe hole; 3 - left lateral ventricle; 4 - III ventricle; 5 - posterior horn of the left lateral ventricle; 6 - inversion over the pineal gland; 7 - inversion under the pineal gland; 8 - Sylvian aqueduct; 9 - lower horn of the left lateral ventricle; 10 - IV ventricle; 11 - Magendie hole; 12 - Luschka hole (left); 13 - pituitary funnel

Ventriculography begins with the placement of a burr hole on one side of the skull or one on each side.

For puncture of the anterior horns, the patient's head is on the back of the head, for puncture of the posterior horns - on the side. The anterior horns of the ventricles are punctured at Kocher's point, and the posterior horns at Dandy's point. Kocher's points are located 2 cm anterior to the coronal suture and 2 cm outward from the sagittal suture (or at the level of the line passing through the pupil) (Fig. 3-11). Dandy's points (Fig. 3-12) are located 4 cm anterior to the external tuberosity of the occipital bone and 2 cm lateral to the sagittal suture (or on a line passing through the pupil). The application of burr holes is made under local anesthesia or general anesthesia from a vertical incision of soft tissue on the scalp 3 cm long. The dura mater is dissected crosswise. The pia mater is coagulated at the apex of the gyrus, if possible, in the avascular zone. For puncture of the ventricle, a blunt-ended plastic cerebral cannula must be used,

Rice. 3-11. Location of Kocher's point: 1 - anterior horns of the lateral ventricles; 2 - lower horn of the lateral ventricle; 3 - posterior horns of the lateral ventricles

which significantly reduces the risk of damage to cerebral vessels.

The most convenient is ventriculography through both posterior horns of the lateral ventricles. If one of the posterior horns is sharply compressed, then a puncture of the anterior horn of the ventricle is performed on this side, and a puncture of the posterior horn is performed on the opposite side. Sometimes there are indications for puncture of both anterior horns of the lateral ventricles. For example, if a craniopharyngioma is suspected, since in this case quite often it is possible to get into the tumor cyst, which bulges into the cavity of the ventricles. The amount of air introduced into the lateral ventricles varies depending on the nature of the pathological process: 30-50 ml of air for supratentorial tumors compressing the ventricular system (Fig. 3-13), and from 100 to 150 ml for occlusive hydrocephalus with a sharp expansion of the ventricular system.

When puncturing the anterior horn, the end of the cannula is directed to a point 0.5 cm anterior to the external auditory canal, trying to position the cannula perpendicular to the surface of the brain (Fig. 3-14).

When puncturing the posterior horn, the end of the cannula is directed to the upper outer edge of the orbit.

The depth of insertion of the cannula should not exceed 4-5 cm. After inserting the cannula, air is injected through it into the ventricles in an amount of 20 to 80 cm 3.

At the end of the air administration, radiographs are taken. Anterior-posterior projection: the patient lies face up; the central ray is directed through the frontal bone above the brow ridges to

Rice. 3-12. Location of Dandy point: 1 - lateral ventricles

Rice. 3-13. Pneumoventriculography. Distribution of air in the lateral ventricles when they are deformed by a tumor of the right frontal lobe of the brain: 1 - contours of the tumor; 2 - air in the lateral ventricle; 3 - cerebrospinal fluid level

Rice. 3-14. Puncture of the lateral ventricles of the brain: 1 - anterior horn; 2 - posterior horn; 3 - III ventricle; 4 - lateral ventricle

avoid projection of the frontal sinuses onto the ventricles of the brain. At the same time, the ventricular system normally has a shape resembling a butterfly. The outlines of the anterior horns and, less clearly, the bodies of the lateral ventricles are visible. The shadow of the third ventricle is located along the midline. This image best reveals the nature of the displacement of the anterior horns of the lateral ventricles.

Along with air, positive contrasts (Conray-400*, Dimer-X*, etc.) are used to contrast the ventricles. Currently, water-soluble omnipaque *, which does not cause irritation of the meninges and cortex, has become widespread

brain Dissolving in the cerebrospinal fluid, it does not change intracranial pressure and has excellent penetrating ability and contrast.

In the presence of subarachnoid cysts or porencephaly, pneumograms can show limited expansion of the subarachnoid spaces or cavities in the brain substance, communicating with the ventricular system. In places of fusion between the membranes, pneumograms reveal large areas of absence of gas over the convex (convexital) surfaces of the hemispheres.

Myelography

Introduction of radiocontrast agents into the subarachnoid space of the spinal cord, followed by X-ray examination. Myelography is performed with positive contrast. Depending on the method of contrast administration, myelography can be ascending or descending.

Descending myelography is done after puncture of the subarachnoid space from a suboccipital puncture (Fig. 3-15).

Rice. 3-15. Suboccipital puncture: 1, 2 - initial needle positions; 3 - needle position in the tank

Suboccipital puncture is used to diagnose volumetric processes in the spinal cord (descending myelography), to detect deformation of the dural sac and spinal cord in cases of vertebral fracture-dislocations. This puncture is performed in a sitting position. The head is bent forward as much as possible, which allows you to increase the distance between the arch of the atlas and the posterior edge of the foramen magnum. For puncture, find the midline from the occipital protuberance to the spinous process of the C 2nd vertebra. The end of the needle is inserted strictly perpendicular to lower section occipital bone. The needle is inserted in stages. Each stage is preceded by a preliminary administration of novocaine. After the needle touches the bone, it is slightly withdrawn, the end is directed lower and forward to the bone. This continues until they fall into the gap between the lower edge of the occipital bone and the arch of the 1st vertebra. The needle is advanced another 2-3 mm forward, the atlantooccipital membrane is pierced, which is accompanied by a feeling of overcoming resistance. The mandrel is removed from the needle, after which the cerebrospinal fluid begins to flow out. Omnipaque* is administered and spondylograms are performed.

Ascending myelography is performed after a lumbar puncture. Contrasting the subarachnoid space with air or positive contrast is performed after preliminary removal of 5-10 ml of cerebrospinal fluid. Gas is administered in small portions (5-10 cm3). The volume of injected gas depends on the level of location of the pathological process, but usually should not exceed 40-80 cm 3. The amount of positive contrast used (omnipaque*) is 10-25 ml. By giving the patient different positions by tilting the X-ray table, gas and contrast are achieved in the desired direction.

Myelography with great reliability allows us to identify the level of complete or partial block of the subarachnoid space. In case of complete block, it is important to determine the shape of the stopped contrast agent. Thus, with an intramedullary tumor, when the thickened spinal cord has a spindle-shaped shape, the contrast agent in its lower part has the shape of jagged stripes. With an extramedullary tumor, the stopped contrast has the shape of a column, cap, dome or cone, with the base facing downwards. In the case of extradural tumors, the lower part of the contrast agent hangs down in the form of a “tassel”.

In case of herniated intervertebral discs, filling defects are revealed in the contrast agent at their level (Fig. 3-16, 3-17).

For spinal cicatricial adhesive processes (so-called arachnoiditis) and vascular malformations, the contrast is presented on

Rice. 3-16. Myelogram of the lumbosacral region with a herniated intervertebral disc L IV -L V, which causes circular compression of the dural sac at this level (shown by arrows). Direct projection

Rice. 3-17. Lateral spondylogram of the lumbosacral region with a defect in contrast filling in the dural sac at the level of its compression by disc herniation L 5 -S 1 (indicated by the arrow)

myelograms in the form of individual drops of various sizes, often scattered over a considerable distance, or in the form of winding stripes of clearing (like a “serpentine ribbon”) - these are dilated veins on the surface of the spinal cord.

Angiography

Injection of a contrast agent into the vessels of the brain followed by radiography of the skull (cerebral angiography). The first contrasting of cerebral vessels was performed in 1927.

Portuguese neurologist E. Moniz. In Russia, angiography was first performed in 1929.

Indications for cerebral angiography: diagnosis of space-occupying formations of the brain with identification of their blood supply, pathology of cerebral vessels, intracranial hematomas. Contraindications for performing angiography include the terminal condition of the patient and hypersensitivity to iodine drugs.

Brain vessels are contrasted using urografin*, urotrast*, verografin*, omnipaque* and other drugs. The contrast agent is injected into the vessels of the brain through the common, internal carotid arteries (carotid angiography) (Fig. 3-18, 3-19), vertebral (vertebral angiography) or subclavian arteries (subclavian angiography). These angiographies are usually performed by puncture. IN recent years angiography using the Seldinger method through the femoral artery (catheterization method) is often used. With the latter method, total cerebral panangiography can be performed. In this case, the catheter is installed in the aortic arch and 60-70 ml of contrast agent is injected. This allows you to simultaneously fill the carotid and vertebral arteries with contrast. Contrast is injected into the artery using an automatic syringe or manually.

Rice. 3-18. Instruments for cerebral angiography: 1 - puncture needles; 2 - transition hose; 3 - syringe for administering contrast; 4 - vascular catheter

Rice. 3-19. Carotid angiography through the right carotid artery in the neck

Carotid angiography through the right carotid artery in the neck.

Arterial puncture is performed using a closed percutaneous method. The patient is placed on the X-ray table, the head is tilted back slightly, the surgical field is treated with antiseptics, and local anesthesia is administered with a 0.5-1% solution of novocaine (10-30 ml). If necessary, this manipulation is performed under intravenous or intubation anesthesia.

Using the index and middle fingers of the left hand, the trunk of the common carotid artery is felt at the level of the lower edge of the thyroid cartilage, corresponding to the carotid triangle and the tubercle of Chassaignac lying at its bottom. Borders of the triangle: lateral - m. sternocleidom astoideus, medial - m. omohyoideus, top - m. digastricus. When feeling the trunk of the artery with your fingers, slightly move the anterior edge of the sternocleidomastoid muscle laterally. Puncture of the artery is performed with special needles with various additional devices that facilitate angiography. Use a needle about 10 cm long with a clearance of 1-1.5 mm and a cut at an angle of at least 45° with a mandrel inserted into it. The skin is punctured over the artery pulsating under the fingers, then the mandrel is removed. Having felt the pulsating wall of the vessel with the end of the needle, they pierce the wall of the artery with a confident movement, trying not to damage its second wall. A stream of scarlet blood serves as proof that the needle has entered the lumen of the vessel. In the absence of blood, the needle is very slowly withdrawn back until a stream of blood appears from the needle, which will indicate that its end has entered the vascular bed.

After the needle enters the lumen of the vessel, the needle (catheter) is inserted along the vessel, fixed to the skin of the neck (with a bandage) and an adapter with contrast from an automatic syringe is connected. Contrast is introduced, after which a series of photographs are taken in two projections. In the first 2-3 s of injection, an image of the arterial phase of blood flow is obtained (Fig. 3-20, 3-21), in the next 2-3 s - the capillary phase and in the remaining 3-4 s - the venous phase of filling the cerebral vessels.

If carotid angiography does not provide sufficient filling of the cerebral vessels of the parietal-occipital region or there is a suspicion of pathology of the vessels of the posterior cranial fossa, vertebral angiography is performed.

Rice. 3-20. Normal arrangement of blood vessels during carotid angiography (arterial phase). Lateral projection: 1 - internal carotid artery; 2 - siphon of the internal carotid artery; 3 - anterior cerebral artery; 4 - middle cerebral artery; 5 - posterior cerebral artery; 6 - orbital artery; 7 - frontopolar artery; 8 - pericallosal artery; 9 - callosal-marginal artery

Rice. 3-21. Normal arrangement of blood vessels during carotid angiography (arterial phase). Anteroposterior projection:

1 - internal carotid artery;

2 - siphon of the internal carotid artery; 3 - anterior cerebral artery; 4 - middle cerebral artery; 5 - ophthalmic artery

The vertebral artery is usually punctured on the anterior surface of the neck at the level of the transverse processes of the III-V cervical vertebrae medially from the carotid artery. The guideline for searching for an artery in this area is the anterior tubercles of the transverse processes, medial to which this artery is located. Puncture of the vertebral artery can also be performed in the suboccipital region, where this artery bends around the lateral mass of the atlas and passes between its posterior arch and the squama of the occipital bone. For angiography of the vertebral artery, puncture can also be used. subclavian artery. When introducing a contrast agent, the peripheral part of the subclavian artery is pressed below the origin of the vertebral artery, and then the contrast is directed precisely into this artery (Fig. 3-22, 3-23).

To perform angiography, you need special X-ray equipment capable of producing a series of short-exposure images that allow you to capture images of different phases of the passage of the contrast agent through the intracranial vessels.

When analyzing cerebral angiograms, attention is paid to the presence of deformation, dislocation of cerebral vessels, the presence of an avascular zone and the level of obstruction (occlusion, stenosis)

Rice. 3-22. Vertebral angiogram is normal. Lateral projection: a - schematic representation of the arteries; b - vertebral angiogram; 1 - vertebral artery; 2 - main artery; 3 - superior cerebellar artery; 4 - posterior cerebral artery; 5 - inferior posterior cerebellar artery; 6 - occipital internal artery

Rice. 3-23. Vertebral angiogram is normal. Direct projection: a - schematic representation of the arteries; b - vertebral angiogram; 1 - vertebral artery; 2 - main artery; 3 - superior cerebellar artery; 4 - posterior cerebral artery; 5 - inferior posterior cerebellar artery; 6 - occipital internal artery

main vessels. Arterial, AVM and carotid-cavernous anastomoses are identified.

When performing an angiographic examination, the following complications may develop: suppuration of the wound channel with repeated bleeding from the puncture site of the artery (a complication, fortunately, rare), development of stenosis, occlusion, embolism, spasm of cerebral vessels, hematomas in the soft tissues around the punctured artery, allergic reactions, extravascular administration of contrast. To prevent the above-mentioned complications, the following conditions must be observed: angiography must be performed by a specially trained surgeon, careful adherence to the rules of asepsis and antisepsis is necessary, when using the percutaneous puncture technique, it is necessary to insert a needle or catheter through the vessel, before the study it is advisable to prescribe vasodilator drugs to the patient for 1-2 days (papaverine, vinpocetine) to prevent the development of spasm, and if it occurs, the drug should be injected into the carotid artery. A contrast sensitivity test is required. After removing the catheter or needle

from the vessel, it is necessary to press the puncture site for 15-20 minutes, followed by applying a load (200-300 g) to this site for 2 hours. Further observation of the puncture site is extremely necessary for timely diagnosis of a growing hematoma of the soft tissues of the neck. If necessary - symptoms of displacement or compression of the trachea - the trachea is intubated, a tracheostomy is applied, and the hematoma is opened.

ELECTROPHYSIOLOGICAL METHODS OF RESEARCH

EEG is a method that allows you to study the functional state of the brain by recording its bioelectrical activity. Biocurrents are recorded using metal or carbon electrodes of various designs with a contact surface of 1 cm 2. Electrodes are applied at bilateral symmetrical points of the head according to existing international schemes, or in accordance with the objectives of the study. During surgery, so-called surface needle electrodes are used. Needle electrodes are placed according to a specific pattern according to the objectives of the study. Registration of biopotentials is carried out by multichannel electroencephalographs.

The electroencephalograph has an input device with a switch, amplifiers, a power supply, an ink-writing device, and a calibrator that allows you to determine the magnitude and polarity of potentials. The electrodes are connected to the commutator. The presence of several channels in the electroencephalograph makes it possible to record electrical activity simultaneously from several areas of the brain (Fig. 3-24). In recent years, computer processing of brain biopotentials (mapped EEG) has been introduced into practice. In pathological processes and changes functional state In humans, normal EEG parameters change in a certain way. These changes can be either only quantitative in nature, or expressed in the appearance on the EEG of new, abnormal, pathological forms of potential oscillations, such as sharp waves, peaks, “sharp - slow waves” complexes, “peak waves” and others.

EEG is used to diagnose epilepsy, focal brain lesions due to tumors, vascular and inflammatory pro-

Rice. 3-24. Electroencephalograms. Indicators of electrical activity of the brain: 1 - α-rhythm; 2 - β-rhythm; 3 - δ-rhythm; 4 - ν-rhythm; 5 - peaks; 6 - sharp waves; 7 - peak wave; 8 - sharp wave - slow wave; 9 - paroxysm of δ waves; 10 - paroxysm of sharp waves

cessah. EEG data makes it possible to establish the side of the lesion, the localization of the pathological focus, distinguish a diffuse pathological process from a focal one, superficial from a deep one, and state brain death.

ULTRASONIC

RESEARCH METHODS

Echoencephaloscopy is an ultrasound examination of the brain. This method uses the properties of ultrasound to be reflected at the boundary of two media with different acoustic resistance. Given the direction of the beam and the position of the reflecting point, the location of the structures being studied can be determined. The structures of the head that reflect ultrasound include the soft covers and bones of the skull, the meninges, the boundaries of the brain matter - cerebrospinal fluid, the choroid plexuses, the midline structures of the brain: the walls of the third ventricle, the pineal gland, transparent partition. The signal from the middle structures exceeds all others in amplitude (Fig. 3-25). In pathology, ultrasound-reflecting structures can be tumors, abscesses, hematomas, cysts and other formations. Echoencephaloscopy allows in 80-90% of cases to determine the amount of displacement from the midline of medially located brain structures, which allows us to conclude that there are space-occupying formations in the cranial cavity

Rice. 3-25. Echoencephaloscopy: a - zones where ultrasonic sensors are located: I - anterior; II - average; III - rear; 1 - transparent partition; 2 - lateral ventricle; 3 - III ventricle; 4 - pineal body; 5 - posterior horn of the lateral ventricle; 6 - IV ventricle; 7 - external auditory canal; b - main elements of the echoencephalogram; c - scheme for calculating the displacement of M-echo: NK - initial complex; LS - lateral signals; M - middle ear; KK - final complex

(tumor, hematoma, abscess), as well as identify signs of internal hydrocephalus and intracranial hypertension.

A sensor placed in the temporal region (above the ear) generates ultrasound and receives its reflection. Sounds reflected in the form of electrical voltage fluctuations are recorded on an oscilloscope in the form of peaks rising above the isoline (echo-

signals). The most constant echo signals normally are: the initial complex, M-echo, lateral echo signals and the final complex.

The initial and final complexes are a series of echo signals from the soft tissues of the head, bones of the skull, meninges and superficial structures of the brain adjacent and opposite to the probe.

M-echo - the signal reflected from the midline structures of the brain (septum transparent, third ventricle, interhemispheric fissure, pineal gland) is characterized by the greatest constancy. Its normal permissible deviation from the midline is 0.57 mm.

Lateral echo signals are signals reflected from brain structures located in the trajectory of the ultrasound beam at any part of it.

The Doppler ultrasound method is based on the Doppler effect, which consists of reducing the frequency of ultrasound reflected from a moving medium, including moving red blood cells. Doppler ultrasound allows percutaneous measurements of the linear velocity of blood flow and its direction in vessels - the extracranial sections of the carotid and vertebral arteries and their intracranial branches. It determines the degree of damage to the carotid arteries, the level of stenosis, narrowing of the vessel by 25%, 50%, etc., blockage of the common, internal carotid artery both in the neck and in its intracranial area. The method allows you to monitor blood flow in the carotid arteries before and after reconstructive vascular surgery.

A modern ultrasound Doppler ultrasound device (Transcranial Doppler sonografi - TCD) Ultramark 9 (USA), Translink 9900 (Israel) determines the speed of blood flow in the intracranial arteries, detects their spasm in case of closed craniocerebral injuries and subarachnoid hemorrhage in case of rupture of a saccular aneurysm, monitors the dynamics of this spasm and determines the degree of influence on it of various medications(2% solution of papaverine intravenously or nimodipine intraarterially).

The method identifies paths collateral circulation when using compression tests of the common carotid and branches of the external carotid arteries accessible to compression.

An ultrasound, computerized, 30-channel Doppler system allows one to obtain qualitative and quantitative data on intracranial blood flow, which is very important in the surgery of cerebral aneurysms.

Ultrasonographic examination of various organs of the human body or B-mode examination allows you to obtain a two-dimensional ultrasound image on the monitor screen, in which you can read the contours and structure of the object being studied, see pathological objects, establish a clear topography and measure them. The difficulty of examining the head is associated with the high reflectivity of ultrasound from the bones of the cranial vault. For most diagnostic ultrasound frequencies, at which the structure of the brain is clearly visible, bone is impenetrable. That is why, until recently, ultrasonographic studies in neurological and neurosurgical practice were carried out only through “ultrasonic windows” (fontanelles, trepanation defect, foramen magnum). The improvement of ultrasound devices and sensors, as well as the development of special methodological techniques for examining the head, has made it possible to obtain a good image of brain structures during transosseous examination.

The ultrasonography method can be used as a screening study for diagnosing organic diseases of the central nervous system at the preclinical or early clinical stages of the disease. Transcranial ultrasonography is indispensable in urgent neurology and neurosurgery, especially in those medical institutions, where there is no CT or MRI. There are mobile ultrasound machines that can be used by emergency doctors and emergency care, neurologists and neurosurgeons of the air ambulance. Ultrasonographic diagnosis of brain damage is indispensable in the practice of a disaster medicine doctor, a ship's doctor, and a doctor at polar stations.

Ultrasonography techniques of the skull and brain are divided into two groups: standard and special. The standard ones include ultrasonography of the baby's head and transcranial ultrasonography. Specialty techniques include burr hole ultrasonography, burr hole ultrasonography, cranial dehiscence and other ultrasound windows, water balloon ultrasonography (water bolus), contrast-enhanced ultrasonography, intraoperative ultrasonography, and pansonography.

Transcranial ultrasonography is carried out from 5 main scanning points: a) temporal - 2 cm above the external auditory canal (on one and the other side of the head); b) upper occipital - 1-2 cm below the occipital protuberance and 2-3 cm lateral to the midline (on one and the other side of the head); c) inferior occipital - in the middle

her line 2-3 cm below the occipital protuberance. Most often, temporal scanning is used with a 2-3.5 MHz sector sensor.

The method can be used in neurotraumatology. With its help, it is possible to diagnose acute and chronic intrathecal, intracerebral hematomas, brain contusions, edema and dislocation of the brain, linear and depressed fractures of the calvarial bones. In case of vascular diseases of the brain, it is possible to recognize hemorrhagic and ischemic strokes and intraventricular hemorrhages. Ultrasonographic diagnosis of developmental defects (congenital arachnoid cysts, hydrocephalus) and brain tumors is effective.

Ultrasonographic syndrome of epidural hematoma includes the presence of a zone of altered echogenicity located in the area adjacent to the bones of the calvarium and shaped like a biconvex or plano-convex lens. Along the internal border of the hematoma, the acoustic phenomenon of “border enhancement” is detected in the form of a hyperechoic strip, the brightness of which increases as the hematoma becomes liquid. Indirect signs of epidural hematoma include the phenomena of cerebral edema, compression of the brain and its dislocation.

In acute subdural hematomas, essentially the same ultrasonographic signs are revealed as in acute epidural hematomas. However, a zone of altered density is characteristic - crescent-shaped or plano-convex. The ultrasonographic image of chronic subdural hematomas differs from acute ones only in anechoicity and a clearer “borderline enhancement” reflex.

Ultrasonographic symptoms of intraventricular hemorrhages with transcranial ultrasonography are as follows: a) the presence in the ventricular cavity, in addition to the choroid plexuses, of an additional hyperechoic zone; b) deformation of the choroid plexus pattern; c) ventriculomegaly; d) nonanechoic ventricle; e) disappearance of the ependymal pattern behind the intraventricular blood clot (Fig. 3-26, 3-27).

Transcranial ultrasonography is quite informative in the diagnosis of brain tumors. Figure 3-28 shows the capabilities of transcranial ultrasonography in diagnosing a tumor of the subcortical structures of the right hemisphere.

Comparison of tumor images on transcranial ultrasonogram and MRI shows the identity of its size, the possibility

Rice. 3-26. Ultrasonographic image of a subdural hematoma (indicated by arrow)

Rice. 3-27. Ultrasonographic signs of intraventricular hemorrhage (examination through the temporal bone): a - CT transverse projection; b - sonography (indicated by arrow)

Rice. 3-28. Brain tumor (tumor of the corpus callosum). Indicated by arrow

determine the depth of the tumor from the bone, the degree of dislocation of the midline structures, and the increase in the size of the opposite lateral ventricle using a transcranial ultrasonogram. All this data is necessary for the neurosurgeon to resolve tactical issues.

TOMOGRAPHIC STUDY

Computed tomography

CT was developed by the English physicist Housefield and was first used clinically in 1972. This method allows one to obtain clear images of sections of the brain and intracranial pathological processes in a non-invasive manner (Fig. 3-29). The basis of this study is the unequal absorption of X-rays by normal and pathological formations in the cranial cavity, depending on tissue density. Scanning

Rice. 3-29. Computer tomogram of the brain. Cystic tumor of the left frontal, temporal and parietal lobes

the device (X-ray source and recording head) moves around the head, stops after 1-3° and records the received data. The picture of one horizontal slice is made up of an estimate of approximately 25,000 points, which the computer counts and converts into a photograph. Typically 3 to 5 layers are scanned. Recently, it has become possible to produce a larger number of layers.

The resulting picture resembles a photograph of brain sections taken parallel to the base of the skull. Along with this, a high-power computer allows you to reconstruct the horizontal picture into the frontal or sagittal plane in order to be able to examine the slice in all three planes. In the sections you can see subarachnoid spaces filled with cerebrospinal fluid, ventricular systems, gray and white matter. The introduction of an iodide contrast agent (Magnevist*, Ultravist*) allows one to obtain more detailed information regarding the nature of the volumetric process.

In vascular diseases, CT makes it possible to reliably distinguish hemorrhage from cerebral infarction. The hemorrhagic focus has a high density and is visualized as a white area, and the ischemic focus, which has a lower density than the surrounding tissue, is visualized as a dark area. Hemorrhagic foci can be detected already in the first hours, and ischemic foci - only by the end of the first day from the onset of thrombosis. After 2 days - 1 week, hemorrhagic areas are difficult to identify, and areas of cerebral ischemia are more clearly identified. The potential of CT is especially great in diagnosing brain tumors and brain metastases. An area of ​​cerebral edema is visible around the tumor and especially metastases. Displacement and compression of the ventricular system, as well as the brain stem, are clearly visible. The method allows you to determine the increase in tumor size over time.

Brain abscesses on tomograms are visible in the form of round formations with uniformly reduced density, around which a narrow strip of tissue of higher density is detected (abscess capsule).

Magnetic resonance imaging

In 1982, the clinic was the first to use a tomographic device operating without X-rays, based on nuclear magnetic resonance. The new device provides images

similar to CT scans. Theoretical developments of this device were first carried out in St. Petersburg by V.I. Ivanov. Recently, the term “magnetic resonance imaging” has begun to be used more often, thereby emphasizing the lack of use of ionizing radiation in this method.

The operating principle of this tomograph is as follows. Some types of atomic nuclei rotate around their axis (the nucleus of a hydrogen atom, consisting of one proton). When the proton rotates, currents arise that create a magnetic field. The axes of these fields are located randomly, which interferes with their detection. Under the influence of an external magnetic field, most of the axes are ordered, since high-frequency pulses, selected depending on the type of atomic nucleus, move the axes from their original position. This state, however, quickly fades away, the magnetic axes return to their original position. In this case, the phenomenon of nuclear magnetic resonance is observed; its high-frequency pulses can be detected and recorded. After very complex transformations of the magnetic field using electronic computational (EC) methods using nuclear magnetic resonance pulses characterizing the distribution of protons, it is possible to image the brain matter layer by layer and study it (Fig. 3-30, see color insert).

Image contrast is determined by a number of signal parameters that depend on paramagnetic interactions in tissues. They are expressed by a physical quantity - relaxation time. It is understood as the transition of protons from a high energy level to a lower one. The energy received by protons from radio frequency radiation during relaxation is transferred to their environment, and the process itself is called spin-lattice relaxation (T 1). It characterizes the average time a proton remains in an excited state. T 2 - spin relaxation. This is an indicator of the speed of loss of synchronicity of proton precession in matter. The relaxation times of protons primarily determine the contrast of tissue images. The signal amplitude is also influenced by the concentration of hydrogen nuclei (proton density) in the flow of biological fluids.

The dependence of the signal intensity on relaxation times is largely determined by the technique of excitation of the proton spin system. To do this, use classic combinations of radio frequency pulses, called pulse sequences: “saturation-recovery” (SR); "spin echo"

(SE); "inversion-recovery" (IR); "double echo" (DE). By changing the pulse sequence or changing its parameters: repetition time (TR) - the interval between the combination of pulses; pulse echo delay time (TE); time of application of the inverting pulse (T 1) - you can strengthen or weaken the influence of T 1 or T 2 proton relaxation time on the tissue image contrast.

Positron emission tomography

PET allows you to assess the functional state of the brain and identify the degree of its impairment. Studying the functional state of the brain is important for many neurological diseases that require both surgical and drug treatment. This method allows you to evaluate the effectiveness of the treatment and predict the course of the disease. The essence of the PET method is a highly efficient method for tracking extremely low concentrations of ultra-short-lived radionuclides that mark physiologically significant compounds whose metabolism needs to be studied. The PET method is based on the use of the instability property of nuclei of ultrashort-lived radionuclides, in which the number of protons exceeds the number of neutrons. When the nucleus transitions to a stable state, it emits a positron, the free path of which ends in a collision with an electron and their annihilation. Annihilation is accompanied by the release of two oppositely directed photons with an energy of 511 keV, which can be detected using a detector system. If two oppositely installed detectors simultaneously register a signal, it can be argued that the annihilation point is located on the line connecting the detectors. The arrangement of detectors in the form of a ring around the object under study makes it possible to register all annihilation events in this plane. Connecting detectors to an electronic computer system using special reconstruction programs makes it possible to obtain an image of an object. Many elements that have positrons emitting ultrashort-lived radionuclides (11 C, 13 N, 18 F) take an active part in most biological processes in humans. A radiopharmaceutical labeled with a positron-emitting radionuclide may be a metabolic substrate or one

of biologically vital molecules. This technology for the distribution and metabolism of a radiopharmaceutical in tissues, the bloodstream and the interstitial space allows non-invasive and quantitative mapping of cerebral blood flow, oxygen consumption, protein synthesis rate, glucose consumption, blood volume in the brain, oxygen extraction fraction, neuroreceptor and neurotransmitter systems (Fig. 3-31, see color insert). Because PET has relatively low spatial resolution and limited anatomical information, it must be combined with imaging modalities such as CT or MRI. Due to the fact that the half-life of ultra-short-living radionuclides ranges from 2 to 110 minutes, their use for diagnostics requires the creation of a complex including a cyclotron, technological lines for the production of ultra-short-living radionuclides, a radiochemical laboratory for the production of radiopharmaceuticals and a PET camera.

Evaluation of craniograms in patients with neuroendocrine syndromes.

Irina TERESCHENKO
Professor, Head of the Department of Internal Diseases, Faculty of Preventive Medicine.
Elena SANDAKOVA
Associate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine. Perm State Medical Academy

Any neuroendocrine pathology that has chronic course, is accompanied by changes in liquorodynamics and intracranial hemodynamics, which are reflected on craniograms. In this case, it does not matter significantly what is affected primarily: the hypothalamic-pituitary system or the peripheral endocrine glands. The craniography method can be classified as routine, however, it provides rich information about liquorodynamics, intracranial hemodynamics (both arterial and venous), osteosynthesis disorders due to hormonal imbalance, suffered intracranial inflammatory processes. It is important that the method is accessible and does not require complex equipment. As a rule, radiographs are taken in frontal and lateral projections, using a scattering grating, with focal length, equal to 1 m. The most informative are photographs taken in a lateral projection. In chronic endocrinopathies, it is often necessary to study the dynamics of craniographic changes. To do this, it is important to observe the condition - not to change the position of the head during repeated photographs. Considering that bone changes are a slow process, it is not recommended to take repeated images frequently. Thus, if a pituitary adenoma is suspected, a control X-ray examination after 6 months is permissible; in other cases it is carried out no more than once a year.

The analysis of craniograms should begin with an assessment of the shape and size of the skull, the structure of the bones of the vault, the condition of the sutures, then check for signs of intracranial hypertension, symptoms of vascular disorders, both arterial and venous, and assess the pneumatization of the sinuses. Next, it is important to characterize the size, shape and features of the sella turcica, including identifying signs of increased pressure in it.

Shapes and sizes of the skull

The most common are normocephalic, brachycephalic, dolichocephalic and irregular shape skulls The extreme version of the brachycephalic form is called the “tower skull”. Changes in the shape of the skull suggest that the nature of neuroendocrine pathology is congenital or acquired in the early stages of ontogenesis. A “tower skull” may indicate a genetic disorder. For example, it occurs in Shereshevsky-Turner syndrome and Klinefelter syndrome. The brachycephalic form is often identified in individuals with congenital hypothyroidism. Normally, the sagittal size of the skull ranges from 20 to 22 cm.

Evaluation of the calvarial bones

It is necessary to determine the thickness of the bones of the cranial vault. It is measured on a plain radiograph in lateral projection. The measurement is taken between the outer and inner plates of the bones. Normally, the thickness of the bones of the cranial vault ranges from 4 to 10 mm. Thinning of the bones of the cranial vault, especially due to the spongy layer, may be a sign of hormonal deficiency, both congenital and acquired, for example, with pituitary dwarfism, Klinefelter's syndrome, Sheehan's syndrome, eunuchoidism, etc. In these cases we are talking about bone tissue atrophy, i.e. about a decrease in bone volume, and not about osteoporosis, in which bone loss occurs without a change in volume. With severe intracranial hypertension, atrophy of the bones of the cranial vault can be local. Thickening of the bones of the calvarium occurs with hypersecretion of growth hormone (acromegaly).

Signs of endocraniosis

The term “endocraniosis” refers to hyperostosis and all types of calcification of the vault and base of the skull, the dura mater in various parts of the cranial cavity, as well as the choroid plexuses of the lateral ventricles of the brain and the pineal gland. The nature of endocraniosis has not been sufficiently studied. Endocraniosis is a nonspecific polyetiological syndrome that occurs as a result of neuroendocrine-immune disorders that accompany various pathological processes. Detection of calcifications in brain tissue helps to judge the localization of the pathological focus, its shape, size, and character. It is believed that the development of endocraniosis may be due to:

Impaired local blood circulation in the brain, in particular changes in hemodynamics in the dura mater;
- reaction of the dura mater to inflammation paranasal sinuses, nasopharyngitis, meningitis, etc.;
- dyshormonal disorders, in particular dysfunction of the hypothalamic-pituitary system, as well as pathology of peripheral endocrine glands(adrenal glands, thyroid gland, gonads, parathyroid glands);
- violations calcium metabolism;
- brain tumors;
- head injuries;
- iatrogenic effects (radiation, hormone therapy), etc.

Endocraniosis can have different localization and manifest itself:

Hyperostosis of the internal plate of the frontal bone, which occurs most often;
- hyperostosis of the inner plate of the parietal bones (isolated or in combination with the frontal);
- calcification in the area of ​​the sella turcica: diaphragm, retrosphenoid ligaments (whiplash symptom);
- thickening of the diploic layer of the bones of the cranial vault;
- calcification of the falciform process of the meningeal membrane, which, as a rule, indicates previous inflammation;
- post-traumatic and post-inflammatory calcifications, which can have different localizations;
- early sclerosis (isolated or combined) of the coronary, occipital, lambdoid sutures;
- calcification of the choroid plexuses of the lateral ventricles of the brain (Far syndrome or so-called Pachion granulations).

Craniopharyngiomas calcify in 80-90 percent. cases; areas of calcification are located mainly above the sella turcica, less often - in the cavity of the sella turcica or under it in the lumen of the sinus of the main bone; sometimes the tumor capsule may also become partially calcified.

In most cases, frontal hyperostosis is associated with the fact that osteoplastic processes occur in the dura mater. Classic version frontal hyperostosis occurs in Morgagni-Morel-Stewart syndrome, characterized by hypomenstrual syndrome, infertility, abdominal obesity, severe hirsutism and severe headaches. When identifying frontal hyperostosis, you should pay attention to the state of carbohydrate metabolism: these patients are at risk for diabetes mellitus.

Craniostenosis

Craniostenosis is a premature fusion of the sutures of the skull, which is completed before the end of brain development. In this case, the growth of the skull bones is delayed in the direction of the preserved sutures. Premature closure of cranial sutures in childhood always leads to deformation of the skull and causes changes in its internal relief as a result of increased intracranial pressure. If fusion of the sutures occurs after 7-10 years, then the deformation of the skull is not very pronounced and clinical manifestations are scarce. In this regard, a distinction is made between compensated and decompensated clinical forms Craniostenosis. Craniography is crucial in making a diagnosis. Radiologically, craniostenosis is characterized by deformation of the skull and the absence of any suture. In addition, an increase in the pattern of digital impressions, thinning of the bones of the cranial vault, and an increase in the vascular pattern appear. There may be deepening and shortening of the cranial fossae, thinning of the back of the sella turcica and its beak-shaped deformation with anterior deviation. For the diagnosis of craniostenosis, it is not the thinning of the vault that matters, but the disproportion of its minimum and maximum thickness in adjacent areas.

Evaluation of the sella turcica

The sella turcica is a depression in the middle part of the upper surface of the body of the main bone, limited in front and behind by bony protrusions. The sella turcica is the bony bed of the pituitary gland and is called the pituitary fossa. The anterior protrusion is called the tubercle sella, the posterior one is called the dorsum sella. The sella turcica has a bottom, walls and, in the upper part, posterior and anterior wedge-shaped processes. The bottom prolapses into the sinus of the main bone. In front, the sella turcica is closely adjacent to the optic chiasm - hiasma opticum. The difference between the sizes of the pituitary gland and the bone bed does not exceed 1 mm. Therefore, based on changes in the sella turcica, one can to a certain extent judge the condition of the pituitary gland.

The evaluation of the sella turcica should begin by examining its shape and size. For this purpose, the sagittal and vertical dimensions, as well as the entrance to the sella turcica, are measured. The sagittal dimension is measured between the two most distant points of the anterior and rear walls saddle and in adults is 9 - 15 mm. The vertical size is measured along the perpendicular, restored from the deepest point of the bottom to the intersphenoidal line, which corresponds to the position of the connective tissue diaphragm of the sella. The pituitary gland stalk passes through its opening, connecting it to the hypothalamus. Normal vertical size is 7-12 mm. The entrance to the sella turcica is the distance between the middle and posterior sphenoid processes.

The shape of the sella turcica has age characteristics: juvenile sella turcica has a rounded shape; the index sagittal size/vertical size is equal to one. For an adult, the most characteristic is the oval shape of the sella turcica, in which the sagittal size is 2-3 mm larger than the vertical one (the normal dimensions of the sella turcica are given in the appendix). The shape of the sella turcica is highly variable. There are oval, round, flat-oval, vertical-oval, and irregular configurations.

An increase in the size of the sella turcica is observed with macroadenomas of the pituitary gland, the “empty sella turcica” syndrome, as well as with hyperplasia of the adenohypophysis in postmenopause or in patients with long-term untreated insufficiency of the peripheral endocrine glands (after castration, with primary hypothyroidism, hypocortisolism, hypogonadism). Changing the shape and size of the sella turcica makes it possible to determine the preferential direction of growth of the pituitary adenoma. The tumor can grow anteriorly towards the chiasm, and then it is necessary urgent solution question about surgical intervention. The tumor can prolapse into the cavity of the sphenoidal sinus, which is usually accompanied by painful cephalgia, or grow towards the back of the sella turcica, often destroying it. As the tumor grows upward, the entrance to the pituitary fossa expands; clinically, this is often manifested by obesity and other hypothalamic disorders.

With small intrasellar adenomas and microadenomas of the pituitary gland, the dimensions of the sella turcica may not change, but the pressure in the cavity of the sella turcica increases, which is characterized by the following symptoms: osteoporosis of the back, its posterior deviation, doubling or multi-contour of the fundus, a symptom of “pseudo-fissure” of the fundus or back, “undermining” sphenoid processes of the main bone, calcification of the retrosphenoid ligament (whiplash symptom). Similar changes are observed with pituitary hyperplasia of any origin. It is important to remember that pituitary hyperplasia and adenomas have become a fairly common iatrogenic disease in recent years, which is associated with the widespread and not always justified use of hormonal drugs, in particular contraceptives. Foci of calcification may occur in the cavity of the sella turcica, which most often indicates the presence of craniopharyngioma. Signs of dorsal atrophy are a decrease in its thickness to 1 mm or less, lack of differentiation of the posterior wedge-shaped processes, sharpening or absence of their apices.

When the sella turcica is enlarged, a craniogram cannot make a differential diagnosis between a pituitary adenoma and the “empty sella turcica” syndrome, which is fundamentally important, since treatment tactics are different. In this situation, it is necessary to refer patients for computed tomography and magnetic resonance imaging if there are no clear clinical symptoms indicating an adenoma (for example, no acromegaly, etc.). Empty sella syndrome can be congenital or acquired.

IN clinical practice The “lesser sella” syndrome is common. The small sella turcica should be regarded as a marker of endocrine dysfunction that arose before puberty. It is typical for patients with pubertal-adolescent dyspituitarism (hypothalamic pubertal syndrome). In women with menstrual dysfunction central genesis it occurs in 66 percent. cases. Based on the presence of this syndrome, Shien's syndrome can be predicted. The “small sella” syndrome refers to a decrease in the volume of the pituitary fossa. In this case, a decrease in one or both of its dimensions may be observed: sagittal less than 9.5 mm, vertical less than 8 mm. This always creates an increase in pressure in the cavity of the sella turcica, which affects the function of the pituitary gland. This manifests itself especially often during periods of endocrine changes (pubertation, menopause, pregnancy), when physiologically the volume of the pituitary gland increases 3-5 times. With a small sella turcica, constant or periodic ischemia of the pituitary gland occurs. Therefore, women with a small sella turcica have a much higher risk of developing Sheen's syndrome. The formation of the small sella turcica is caused not so much by congenital reasons as by a violation of osteogenesis: the fusion of all 14 points of ossification of the main bone normally ends by 13-14 years. Premature synostosis resulting from hormonal disorders, is one of the causes of this pathology. In this case, there is a discrepancy between the size of the pituitary gland and the bone bed. Accelerated synostosis occurs with premature or accelerated puberty, osteogenesis imperfecta against the background of congenital hypothyroidism, and can be provoked by taking anabolic steroid hormones during the prepubertal period.

Pneumatization assessment

By the age of 9-10 years, the sinus of the main bone is partially pneumatized; by the age of 16 - half or two-thirds; by the age of 24, the sinus of the main bone should be completely pneumatized. The lack of pneumatization may be due to hypofunction of the anterior pituitary gland. Frontal sinuses may be of normal size, hypoplastic, or completely absent. Impaired pneumatization of the sinuses may reflect certain changes in the endocrine system. Reduced pneumatization of the sinuses occurs with hypofunction of the anterior lobe of the pituitary gland, hyperfunction of the thyroid gland, as well as with inflammatory diseases of the sinuses. Hyperpneumatization of the sinuses can be a manifestation of neuroendocrine pathology, acromegaly, and hypofunction of the thyroid gland. Hyperpneumatization and excessive development of mastoid cells are also signs of endocrinopathy.

Signs of intracranial hypertension

Radiologically, intracranial hypertension manifests itself:

Strengthening the internal relief of the cranial bones and their thinning;
- changes in the sella turcica (expansion, osteoporosis, straightening of the back, and later its destruction);
- expansion of cranial sutures and cranial foramina;
- changes in the shape of the skull (ball shape) and the location of the cranial fossae;
- secondary hemodynamic changes due to impaired venous outflow (expansion of the channels of diploic veins and venous outlets);
- strengthening of the grooves of the meningeal vessels;
- an increase in the fronto-orbital angle of more than 90.

The severity of these changes depends on age and the rate of increase in intracranial pressure. Strengthening the internal relief of the skull, or the so-called finger impressions, are imprints of the cerebral convolutions and grooves of the cerebral hemispheres on the cerebral surface of the bones of the cranial vault. Finger impressions can be throughout the entire arch, but are predominantly found in the anterior section, and at the base of the skull only in the area of ​​the anterior and middle cranial fossa. They never occur in the posterior cranial fossa, since the cerebellum is located here. At the age of 10-15 years, digital impressions are visible in the frontal, temporal and very rarely in the parietal and occipital bones. After 20 years of age, they are normally absent or very faintly visible in the frontal bone of the cranial vault. Long-term intracranial hypertension can cause smoothing of the previously pronounced intracranial relief of the skull bones. In the case of compensated intracranial hypertension, lime deposits may be observed in the form of a strip along the coronal suture.

Vascular pattern of the skull

It is composed of clearings of various shapes and sizes, as if outlined by a thin plate. The craniogram identifies only those vessels that have a bone bed in the cranial bones. These can be grooves located endocranially, grooves in the meninges, channels running in the spongy substance of the cranial bones (diploe). One of the signs of hemodynamic disturbances in the cranial cavity is the expansion of the channels of the diploic veins. Normally, they may be absent or detected only in the area of ​​the parietal tuberosities. Their contours are unclear, bay-shaped. Signs of expansion of diploic canals are an increase in their lumen by more than 4-6 mm and clarity of contours. When venous outflow from the cranial cavity is difficult, the dilated diploic canals spread beyond the parietal tubercles, their walls are straightened.

Features of craniograms in some neuroendocrine diseases and syndromes

Acromegaly

On the radiograph, the dimensions of the skull are increased, the bones of the vault are thickened and sclerotic, and the relief of the outer surface is enhanced. The frontal bone becomes especially thick. This is manifested by an increase in size and roughness of the occipital protrusion, superciliary arches and zygomatic bones. Sometimes there is an increase in the vascular pattern of the cranial vault. The pituitary fossa of the sella turcica is enlarged. With acromegaly, a macroadenoma usually develops. However, it should be taken into account that with somatotropinoma microadenoma also occurs. Pneumatization of the paranasal sinuses and mastoid processes is significantly increased. The sphenoid sinus is flattened. Lower jaw significantly increased, interdental spaces expanded; prognathism is often pronounced. The saddle-cranial index increases.

Itsenko-Cushing's disease. The sella turcica often retains its juvenile (round) shape. Usually there is a basophilic pituitary adenoma that does not reach large sizes. There is an expansion of the entrance to the sella turcica. One of the indirect signs of basophilic pituitary adenoma is local osteoporosis of the dorsum sella. Areas of the dura mater in the area of ​​the sella turcica are often subject to calcification. The saddle-cranial index is within normal limits, but may increase. Severe osteoporosis of the calvarial bones may be detected.

X-ray signs prolactinomas. Prolactinoma is often a microadenoma and may not cause destruction of the sella turcica. Therefore, in an appropriate clinic, it is necessary to conduct a computer or magnetic resonance imaging of the pituitary gland. Hyperprolactinemia always causes intracranial hypertension, and liquor hypertension itself can cause hyperprolactinemia.

Sheen's disease. The X-ray picture is characterized by thinning of the bones of the cranial vault, osteoporosis, caused primarily by a deficiency of sex hormones.

Morgagni-Morel-Stewart syndrome ("frontal hyperostosis syndrome", "neuroendocrine craniopathy", "metabolic craniopathy") is characterized by a triad of symptoms: abdominal obesity(main symptom), hirsutism, menstrual irregularities and reproductive function. The disease is often accompanied by hypertension, diabetes, painful cephalgia, weakness, mental changes including dementia and other symptoms. Radiologically, the syndrome is manifested by thickening of the inner plate of the frontal and sometimes parietal bones. In these areas of the roof of the skull, nodular, rough thickenings of bones are visible. These changes have received various names: “candle drops”, “stalactite-shaped thickenings”, “geographic map”, etc. Sometimes diffuse thickening of the skull bones and calcification of the dura mater in various parts of the cranial cavity are noted. Along the external occipital eminence, growths of the “spur” type are noted. Craniograms often reveal a violation of pneumatization of the paranasal sinuses. Sometimes an increase in the sagittal size of the pituitary fossa is found, but the increase does not progress further.

Pathological menopause syndrome. Craniograms in most patients reveal various signs of endocraniosis, as well as symptoms of intracranial hypertension (thinning of the bones of the cranial vault, increased pneumatization of the paranasal sinuses, mastoid processes, etc.). Moreover, the severity of clinical manifestations of pathological menopause correlates with the severity of radiological symptoms.

Fahr syndrome (symmetrical calcification of the vessels of the basal ganglia of the brain of a non-atherosclerotic nature). This syndrome occurs in various pathological conditions, the most common of which are congenital hypothyroidism or hypoparathyroidism. Clinically symmetrical intracranial calcifications are accompanied by headaches, speech impairment, epileptiform seizures, gradually progressive dementia, pyramidal signs

Pubertal-adolescent dyspituitarism (hypothalamic pubertal syndrome). The accelerated process of puberty leads to the formation of small sella syndrome in such patients. There is a tendency to increase the sagittal and decrease the vertical size of the sella turcica, which takes on the appearance of a horizontal oval even in 11-year-old patients. In many cases, signs of increased pressure in the cavity of the sella turcica appear: thinning of the quadrangular plate, pseudocrack of the dorsum sella, calcification of the retrosphenoid ligament. Disruption of the ossification process affects the condition of the sutures of the skull: compaction of the coronal suture is formed, and in some cases coronary craniostenosis develops. The shape of the skull changes: it acquires an irregular or dolichocephalic shape. An obligate symptom is intracranial hypertension. In patients who have had a history of neuroinfection or traumatic brain injury, phenomena of endocraniosis are observed (internal frontal hyperostosis, calcification of the dura mater in different parts). Strengthening the channels of diploic veins indicates difficulty in venous outflow from the cranial cavity in this disease. The severity of radiological changes depends on the duration of the pathological process in the hypothalamic-pituitary system.

"Empty sella" syndrome. This is a polyetiological syndrome, the main cause of which is congenital or acquired inferiority of the sella diaphragm. This syndrome is characterized by expansion of the subarachnoid space into the pituitary fossa. The sella turcica increases in size. It should be emphasized that the presence of radiological data indicating enlargement and destruction of the sella turcica does not necessarily indicate a pituitary tumor. The most reliable methods for diagnosing an “empty sella turcica” are its computer or magnetic resonance imaging.

CONCLUSION

Despite the introduction of new advanced examination methods, such as computed tomography and magnetic resonance imaging, craniography remains a classic diagnostic technique. It is accessible, facilitates the correct interpretation of clinical data, and helps in the differential diagnosis of neuroendocrine syndromes.

APPLICATION

DIMENSIONS OF THE SELLA IN PRACTICALLY HEALTHY PEOPLE

Age, years

Sagittal size of the sella turcica (mm)

Vertical Saddle Size(mm)

Maximum

Minimum

Maximum

Minimum

X-ray examination with meningiomas, as shown by craniography and angiography, reveals large changes in vascular system and demonstrates not only a number of features in the blood supply to meningiomas, important for differentiation from other types of tumors, but also reveals a number of secondary compensatory changes in the blood supply system of the brain and skull, which develop intensively in meningiomas.
X-ray studies of the blood supply to meningiomas not only reveal much about the vascularization of extracerebral tumors, but also expand our understanding of the blood supply to the brain in general. It makes it possible to accumulate a number of facts and expand, using meningiomas as a model, our understanding of the mechanisms of a very special, still little studied area of ​​venous circulation in the physiology of the skull.

With meningiomas, ordinary radiographs of the skull in a large number of cases show an increase in the pattern of vessels in the bone, indicating by the direction of their course the place of development of meningiomas. This is especially evident when tumors are located in a convexital location. At the same time, taking into account the usual location of the grooves of the arterial meningeal vessels on the bone and the main paths of the venous outflow from the skull, it is possible to easily distinguish the afferent arterial paths from the venous ones on craniograms (Fig. 206).

Rice. 206. Craniographic display of highly developed vessels in the bones of the skull in convexital meningioma. The grooves of the meningeal argeria (a.t.t.) are visible. supplying blood to the tumor, and diploic efferent veins (v. d.), going to the superior petrosal sinus.

In the afferent arterial tract, there is a sharp strengthening of that branch of the meningeal artery that supplies the area of ​​the membranes where meningioma develops. Strengthening of the arterial meningeal branch is reflected by a corresponding deepening of the groove on the inner plate of the bone so much that the branch of the meningeal artery, usually not visible on the radiograph, becomes clearly visible, and noticeable and normally appears as a powerful, sharply hypertrophied trunk in comparison with other branches of the meningeal artery of the same order ( Fig. 207). With the development of meningioma in the anterior part of the fornix, the frontal branches of the anterior branches of the middle meningeal artery become clearly visible; when localized in the frontoparietal region, the anterior branch of the middle meningeal artery hypertrophies; with meningioma of the posterior parietal region, the posterior branch of the middle meningeal artery hypertrophies. With the development of meningioma in the occipital part, the occipital branch of the posterior branch of the middle meningeal artery hypertrophies (Fig. 208), usually either not visible on radiographs or barely visible.

On a regular radiograph, an increase in the venous network is also noted, but the network visible on the craniogram is located mainly in the bone - this is a network of diploic venous ducts. Moreover, if in the arterial network only the strengthening of preformed branches is visible, then this cannot be said about the veins, so sometimes this network of diploic venous passages is so powerfully developed. Radiographs clearly prove that usually short, sharply tortuous, with an unevenly rapidly narrowing lumen, non-smooth bulging and non-parallel walls, diploic venous blood vessels are reconstructed under the influence of changed conditions of their function in meningiomas. Due to the new conditions of blood flow - a greater mass of outflowing blood, greater pressure on the walls of the diploic tract of this blood and a determined direction of outflow - the bulging walls of the diploic tracts are smoothed out, their walls become parallel, the tracts are straightened and lengthened. The changed function leads to the transformation of the diploic blood container - the blood depot - into a formed venous vessel (see Fig. 198, 206, 207).

Consideration of the accumulated material concerning changes in diploic venous tracts in meningiomas proves that the direction of these venous tracts, despite the great apparent diversity, can be reduced to certain groups in accordance with the main directions of venous outflow in the skull (M. B. Kopylov, 1948).

New form the vessel corresponds to its new function, and the change in the shape of the walls with their expansion and smoothing indicates new increased pressures on the vessel wall. The magnitude of these pressures is insignificant, but sufficient, however, for nervous perception and launching complex process trophic changes associated with bone remodeling still await new measurement methods.
The directions of the venous channels are also subject to hemodynamics in the skull, i.e., mainly to hydrodynamics. Venous blood flows downwards along the spherical surface of the skull in connection with the position of certain parts of it in a particular position of the head. Therefore, the direction of the diploic vessels to some extent repeats the direction of the veins of the membranes and goes either radially, to the venomous sinuses, or deviates, repeating the directions of these sinuses (Fig. 209, 207). Long-term, sometimes multi-year, growth of meningiomas allows one to see the development of diploic vessels in dynamics. We observed cases of significant changes in the lumen and direction of the diploic vessel over periods of 2 to 6-7 years (Fig. 210, 207).

Physicians Northwestern University / United States / found that young adults from 18 to 30 years with low levels of physical activity 2-3 times more often develop early diabetes. Thus, the passive way of life as a young man creates the conditions for a serious diagnosis, and body mass index at age 20-25 years determines the likelihood of rapid development of diabetes, according to physiotherapists. Doctors stress the importance of not only regular physical activity from an early age, but also maintaining a healthy weight through a balanced diet.

Other adverse events in patients treated with Avandia, are consistent with those in the list of instructions for the medical use of the drug and included fractures, which are often recorded in the group of Avandia and mainly consisted of fractures of the shoulder, forearm, wrist , leg bones, foot bones, predominantly y zhenschin.U patients treated with Avandia, also produced the following results for the pre-defined secondary evaluation criteria (secondary endpoints): * Lower mortality from any cause (136 deaths or 6.1% compared to 157 deaths, or 7% in control, hazard ratio 0.86, 95% CI 0.68-1.08).* Lower mortality for cardiovascular causes (60 cases or 2.7% against 71 cases or 3.2%, hazard ratio 0.84 for 95% CI 0.59-1.18). Among these cases, there were more deaths due to heart failure (10 vs. 2), but less - due to myocardial infarction (7 vs. 10) and in connection with stroke (0 vs. 5). * Less than the sum of all major cardiovascular events including cardiovascular death, myocardial infarction and stroke (so-called �MACE�) (154 cases or 6.9% compared to 165 cases or 7.4%, hazard ratio 0.93 for 95% CI 0.74 -1.15). * More cases of myocardial infarction (64 cases in 2,220 patients, or 2.9% versus 56 cases in 2,227 patients, or 2.5%, hazard ratio 1.14, 95% CI 0.80-1.63). * Fewer strokes (46 cases or 2.1% compared to 63 cases or 2.8%, hazard ratio 0.72, 95% CI 0.49-1.06)

For those who know German.

gekennzeichnet durch Schwankungen des systolischen Drucks von 140 bis 159 mm Hg, der diastolische Blutdruck - 90 bis 99 mm Hg Die Krankheit, die bisher Ursachen sind nicht klar, was zur Niederlage von allen Einrichtungen und Teilnehmer an der Studie innerhalb von vier Wochen taglich erhielten eine Kapsel mit einem Placebo (inaktive Substanz), dann - innerhalb von 8 Wochen - taglich eine Kapsel mit den Tomaten-Extrakt. Am Ende der Patienten wieder ein Vier-Wochen-Kurs von Kapseln mit Placebo werden.

Bisher konnten die Wissenschaftler nicht ziehen diese Schlussfolgerung aus der Tatsache, dass sie nur selten gelungen, die Vogel fur eine langere Zeit zu beobachten. Selbst die Tauben nicht halten Vogel in ihrem eigenen mehr als 5 Jahren. Ein markantes Beispiel fur einen langen Aufenthalt unter menschlicher Aufsicht ist ein 19-jahriger Taube namens Opie, lebt in den Mauern des Instituts fur Okologie, Evolution und Diversitat der Universitat Frankfurt, wo seit uber 35 Jahren der Beobachtung dieser Art von Vogeln in der Gefang enschaft.

The term craniography is translated from Greek as “image of the skull.” This is a relatively outdated method of instrumental research, which still does not lose some relevance today.

In modern practical medicine Craniography is increasingly being replaced by more expensive techniques instrumental diagnostics, which include computed tomography and magnetic resonance imaging.

The essence of the research methodology

Craniography is an X-ray instrumental study in which an X-ray image of the skull is taken, usually in 2 projections. A special feature of the study is the absence of contrasting the structures of the head with special compounds, so in the image the doctor can clearly see only changes bone base. A targeted X-ray can also be performed to study local changes in the bone structures of the skull, in particular the area of ​​the sella (base of the skull), inner ear, and orbits.

Indications for use

Despite the widespread use of other more modern methods of instrumental visualization of the skull, craniography remains relevant for the diagnosis of some pathological changes which include:

Also, in case of volumetric processes of brain tissue (tumors, intracranial hemorrhages, cerebral stroke), subject to the presence of pathological calcification of the pineal gland, its displacement is determined on the radiograph, which serves as an indirect sign of pathology and requires further in-depth examination of the person.

Contraindications for carrying out

Craniography is contraindicated during pregnancy at any stage of its course, as well as in childhood. The exception is situations in which this technique is the only diagnostic method. Then the doctor decides on conducting craniography on an individual basis. Contraindications to this instrumental research technique are due to the fact that x-ray radiation has a negative effect on the organs and tissues of the developing fetus, as well as children.

Craniography can be performed in any medical institution equipped with an X-ray diagnostic room. Most often this study It is carried out in trauma centers if there is a suspicion of a head injury with a violation of the integrity of the skull bones.

After collecting anamnesis, it is necessary to conduct a detailed neurological examination of the patient.

First of all, you need to pay attention to the patient’s appearance. In some cases, muscle atrophy, winged shoulder blades, duck gait with myopathy, large skull sizes with hydrocephalus, acromegaly with diseases of the pituitary gland, dysraphic status, scars from burns, trophic disorders with syringomyelia, multiple tumors with Recklinghausen's disease can help in diagnostics.

The expert neuropathologist has the following tasks: 1) identify signs of organic damage to the nervous system; 2) establish the nature and severity of dysfunction; 3) determine the localization of damage to the central or peripheral nervous system and determine whether the process is local (for example, with a brain tumor) or diffuse, diffuse (for example, with encephalitis, multiple sclerosis); 4) find out whether there are symptoms of only focal damage to the central nervous system or whether they are combined with general cerebral and meningeal symptoms; 5) determine the presence of autonomic disorders, neurotic reactions and psychopathological disorders; 6) determine the sequence of development of symptoms; 7) assess the nature of the course of the disease - progressive, regressive, remitting or in the form of persistent residual effects, etc.; 8) establish the combination and relationship of neurological symptoms with dysfunction of internal organs.

An expert often has to determine the ability to work in patients with unclear and complex diseases. Difficulties in solving clinical and expert issues can be explained by the following reasons: 1) low severity of neurological symptoms; 2) a discrepancy between detectable symptoms and functional capabilities: for example, severe adynamia in the absence of other motor dysfunctions or, on the contrary, the presence pyramidal symptoms in the absence of movement disorders (in the residual period of diseases of the nervous system, during remission, etc.); 3) the difficulty of identifying paroxysmal conditions (diencephalic crises, paroxysmal paralysis, attacks of cataplexy, epileptic seizures, vestibular paroxysms, etc.), which reduce the patient’s ability to work; 4) insufficient ability or inability to objectively identify symptoms, especially with pain of central and peripheral origin, which usually sharply reduces ability to work; 5) the uniqueness of the “experience” of his illness and the individual characteristics of the patient’s personality with different neurotic reactions and psychopathological manifestations, sometimes with an inadequate attitude in the form of underestimation or overestimation of one’s condition; 6) atypical development and course of the nervous system disease; 7) the complexity of the complex of diseases and trauma suffered in the past and the current combination of neuropsychic, somatic and other diseases; 8) the age of the patient, which often leaves a unique imprint on the course of the disease of the nervous system (for example, the course of vascular diseases progresses with age); 9) underestimation of the ability for good restitution and compensation of impaired functions; 10) incomplete examination and incorrect application of research methods.

To clarify the nature and severity of dysfunctions of the nervous system, it is often necessary, in addition to careful neurological examination, the use of special research methods: electroencephalography, electromyography, radiography, arterial oscillography, capillaroscopy, electrodiagnostics and chronaxy, psychological research; analysis of cerebrospinal fluid, metabolism, blood biochemistry, etc. For the timely recognition of thromboembolic conditions, determining the functions of the blood coagulation system is of great importance. For this purpose, a coagulogram is studied. Of particular importance are such coagulogram indicators as the number of platelets, plasma tolerance to heparin, the amount of fibrinogen and prothrombin, and fibrinolytic activity of plasma. The complex of these indicators gives a correct idea of ​​the state of the blood coagulation system. Determination of the activity of the rheumatic process is helped by the study of blood proteins by electrophoresis, mucopolysaccharides, glycoproteins, etc.

For hypertension and atherosclerosis, the determination of blood catecholamines is important.

Through X-ray examination, the morphological and functional diagnosis is clarified. In this case, a complex of clinical and radiological data is important. X-ray examination is especially important when assessing the ability to work of diseases of the brain and its membranes, in particular in the consequences of traumatic brain injury. Even such a question as the size of the skull defect cannot be resolved without radiography. Sometimes the very fact of the presence of such a defect is established only by radiography. Of even greater importance for the examination of work ability is the identification of metal foreign bodies and bone fragments located intracranial. Clarification of these questions influences the establishment of an indefinite third disability group (severe anatomical defect). When patients complain of persistent headaches, especially in combination with anamnestic data on multiple fragmentation extracranial wounds or contusions, X-rays of the skull are taken in order not to miss the presence of intracranial foreign bodies, the possibility of which may penetrate into the cranial cavity is sometimes not noticeable to patients.

X-rays of the skull sometimes reveal changes associated with impaired cerebrospinal fluid dynamics. In these cases, radiographs as a result of hypertensive effects on the bones of the skull show thinning of the bones of the vault, increased finger-like impressions, stretching or thickening of the sutures and changes in the sella turcica (deepening of the bottom of the fossa, decalcification - thinning of the back of the sella or its straightening and tilting anteriorly), strengthening of the vascular pattern grooves, especially the grooves of the venous sinuses. The more severe and lengthy the process, the more pronounced the effects of hypertension are. With craniostenosis, the suture pattern is leveled and against this background, increased finger-like impressions and hypertensive changes in the sella turcica are detected. If intracranial venous circulation is disrupted, X-rays of the skull show an increased vascular pattern. Important has the detection of osteophytes in the area of ​​uncovertebral joints on radiographs of the cervical spine, since the pathology of the cervical vertebrae can lead to stenosis of the vertebral artery with transient neurological disorders. By compressing the atheromatically altered and sometimes healthy vertebral artery and irritating its periarterial plexus, osteophytes can cause temporary or permanent disturbances in the blood supply to the brain. One of the most characteristic manifestations of stenosis of the carotid and vertebral arteries in the neck is transient disorders of cerebral circulation. In the presence of osteophytes, such phenomena can occur when turning and tilting the head, extending and flexing the neck, since this compresses the vertebral arteries and the blood flow in them decreases, and this causes the corresponding clinical picture.