2. Meningeal syndrome
Inflammation of the meninges (meningitis) or
irritation of meninges with extravasated blood
(subarachnoidal hemorrhage), rarery due to
exogenous intoxication, meningeal
carcinomatosis ets leads to meningeal
syndrome; which includes general and
meningeal symptoms.
3. Thus, meningeal complex of symptoms
with subjective (nausea, vomiting,
sharp headache, dizziness, high
temperature) and objective symptoms
(rigidity of neck muscles, positive
symptoms of Kernig, upper, medial
and lower symptoms of Brudzinsky) is
common as for meningism.
4. Meningeal signs
Meningeal syndrome - is irritation and inflammation of meningea, displayed in general
and muscle-tonic symptoms:
1. Rigidity of neck(neck stiffness, Nuchal rigidity) muscles-impossibility or difficulty
during passive attempt to bend head of a patient and touch chest with chin.
2. Kernig symptom- inability to extend patient's leg knee after bending in knee
and pelvic joints.
3. Upper symptom of Brudzinsky - simultaneous bending of legs during attempt
to bend neck of a patient.
4. Medial symptom of Brudzinsky - bending of legs during pressing on hypogastrium
of a patient.
5. Lower symptom of Bruzinsky - simultaneous bending of one leg during passive
flexing of another one in knee and pelvic joints.
6. Mendel symptom - pain during pressing on meatus.
5.
6.
7.
8. Meningeal syndrome includes general and
envelope symptoms, which is divided on 3
groups depending on pathophysiologic
mechanisms:
1 group: symptoms of hyperesthesia - general
or sensor organs - hyperacusia,
hyperalgesia, hyperosmia.
2 group: reactive pain phenomenons - pain
during palpation of N. trigeminus exit spot
projection; pain during palpation of spots of
exit of N. occipitals (symptom of Kerer);
symptom of Mendel.
3 group: muscular tonic strains or contractures
- rigidity of neck muscles, symptoms of
Kernig and Brudzinsky, symptom of Gordon
(reflector extension of foot big finger during
shrinking of shank muscle), symptom of
Lessaje (hanging) for children.
9. Different meningites and meningism
• General for different meningites is presence of
meningeal syndrome with headache, vomiting,
stiffness of muscles, Kernig and Brudzinsky
symptoms and cerebrospinal fluid (CSF) changes
are typical for inflammation of meningea. General
symptoms of brain reaction on infection are also
usually observed – loss of consciousness, cramps
and hyperthermia. In case of meningism presence
of some meningeal signs (more often neck
stiffness) and absence of inflammatory changes in
CSF are observed.
10.
11. Lumbal puncture
• Lumbar puncture (LP), also known as a spinal tap, is a medical
procedure in which a needle is inserted into the spinal canal, most
commonly to collect cerebrospinal fluid (CSF) for diagnostic testing.
The main reason for a lumbar puncture is to help diagnose diseases
of the central nervous system, including the brain and spine.
Examples of these conditions include meningitis and subarachnoid
hemorrhage. It may also be used therapeutically in some conditions.
Increased intracranial pressure (pressure in the skull) is a
contraindication, due to risk of brain matter being compressed and
pushed toward the spine. Sometimes, lumbar puncture cannot be
performed safely (for example due to a severe bleeding tendency). It
is regarded as a safe procedure, but post-dural-puncture headache is
a common side effect.
• The procedure is typically performed under local anesthesia using a
sterile technique. A hypodermic needle is used to access the
subarachnoid space and fluid collected. Fluid may be sent for
biochemical, microbiological, and cytological analysis. Using
ultrasound to landmark may increase success.[1] Lumbar puncture
(LP),
12.
13. Infection Appearance[44] WBCs / mm3[24] Protein (g/l)[24] Glucose[24]
Normal Clear <5 0.15 to 0.45
> 2/3 of blood
glucose
Bacterial
Yellowish,
turbid
> 1,000
(mostly PMNs)
> 1 Low
Viral Clear
< 200
(mostly lympho
cytes)
Mild increase
Normal or
mildly low
Tuberculosis
Yellowish and
viscous
Modest
increase
Markedly
Increased
Decreased
Fungal
Yellowish and
viscous
< 50 (mostly
lymphocytes)
Initially normal
than increased
Normal or
mildly low
14.
15. PATHOLOGICAL STATES
I. Cell -protein dissociation (increasing of cell count with normal or slightly
elevated
protein amount) is typical for inflammatory diseases of nervous system.
High cytosis is typical for meningitis of different origin, moderate – for
arachnoiditis,
encephalitis, neurosyphilis. Lymphocytic reaction is typical for serous
meningitis, neutrophil – for purulent. Neutrophils in CSF are arising in CSF
with presence of blood (unsuccessful lumbar puncture, subarachnoidal
bleeding),
sometimes – in another inflammatory diseases of nervous system
(arachnoiditis,
brain abscess).
II. Protein - cell dissociation (increasing of protein amount with normal cell
count)
is typical for brain tumors: than closer latter to liquor reservoirs than higher
protein amount. Protein amount also increased in cases of blood presence in
CSF (unsuccessful lumbar puncture, subarachnoidal bleeding).
16.
17. Intracranial hypertension syndrome
• Intracranial hypertension syndrome is
characterized by an elevated intracranial
pressure, papilledema, and headache with
occasional abducens nerve paresis, absence of
a space-occupying lesion or ventricular
enlargement, and normal cerebrospinal fluid
chemical and hematological constituents.
18. Intracranial pressure (ICP)
• Intracranial pressure (ICP) is the pressure exerted by fluids such
as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is
measured in millimeters of mercury (mmHg) and, at rest, is normally 7–
15 mmHg for a supine adult.[1] The body has various mechanisms by which
it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in
normal adults through shifts in production and absorption of CSF.
• Changes in ICP are attributed to volume changes in one or more of the
constituents contained in the cranium. CSF pressure has been shown to be
influenced by abrupt changes in intrathoracic pressure during coughing
(intra-abdominal pressure), the valsalva maneuver, and communication
with the vasculature (venous and arterial systems).
• Intracranial hypertension (IH), also called increased ICP (IICP) or raised
ICP, is elevation of the pressure in the cranium. ICP is normally 7–15 mm
Hg; at 20–25 mm Hg, the upper limit of normal, treatment to reduce ICP
may be needed.[2]
19. Signs and symptoms Intracranial
pressure (ICP)
• In general, symptoms and signs that suggest a rise in ICP
include headache, vomiting without nausea, ocular palsies, altered level of
consciousness, back pain and papilledema. If papilledema is protracted, it
may lead to visual disturbances, optic atrophy, and eventually blindness.
The headache is classically a morning headache which may wake them
from sleep. The brain is relatively poorly supplied by oxygen as a result of
mild hypoventilation during the sleeping hours and also cerebral edema
may worsen during the night due to the lying position. The headache is
worse on coughing, sneezing or bending and progressively worsens over
time. There may also be personality or behavioral changes.
• In addition to the above, if mass effect is present with resulting
displacement of brain tissue, additional signs may include pupillary
dilatation, abducens palsies, and the Cushing's triad. Cushing's triad
involves an increased systolic blood pressure, a widened pulse
pressure, bradycardia, and an abnormal respiratory pattern.[3] In children,
a low heart rate is especially suggestive of high ICP.
20.
21. Signs and symptoms Intracranial
pressure (ICP)
• Irregular respirations occur when injury to parts of the
brain interfere with the respiratory drive. Biot's respiration,
in which breathing is rapid for a period and then absent for
a period, occurs because of injury to the cerebral
hemispheres or diencephalon.[4] Hyperventilation can
occur when the brain stem or tegmentum is damaged.[4]
• As a rule, patients with normal blood pressure retain
normal alertness with ICP of 25–40 mmHg (unless tissue
shifts at the same time). Only when ICP exceeds 40–50
mmHg does CPP and cerebral perfusion decrease to a level
that results in loss of consciousness. Any further elevations
will lead to brain infarction and brain death.
