Prolapsus, protrusio cerebri

Prolapsus, protrusio cerebri (loss, swelling of the brain) is the protrusion of the brain substance in the wound through a defect of the meninges and the bones of the skull.
Vneocherednoy the location of the brain can occur when open (often firearm) wounds to the skull and brain or after operations on the brain. Under the influence of edema - swelling of the brain disorders blood and liquorrhea or as a result of infectious complications is increased intracranial pressure or increased the volume of the brain, which leads to swelling of the brain through a defect skull bones in the wound. Many authors consider the terms "prolapsus cerebri" and "protrusio cerebri" synonyms, identifying concepts about loss and swelling of the brain and the main attention is paid to the state ipatevskoy area of the brain and causes swelling. Therefore I propose to distinguish between benign loss of brain", coming under the influence of his edema - swelling (see Edema and swelling of the brain), and "malignant", depending on infectious process. Other scholars, the term "prolapsus cerebri" called the swelling of the brain occurred immediately after the injury (primary) or in the next few days after her (early); the term " protrusio cerebri" - later protrusion (bulging) of the brain associated with the development of infection.
Loss of the brain. The primary loss of brain occurs most often at gunshot wounds. The sudden increase in intracranial pressure, coming as a result of hydrodynamic action offensive projectile or acute swelling of the brain, causes adjacent to the bone defect part of the brain is pushed out. Sometimes the fallen part of the brain is completely destroyed and later rejected; the deeper the departments of the fallen plot maintain communication with the brain.
Fallen brain looks like unaltered brain chemistry is whitish-pink, sometimes it is saturated with blood, and when events congestion - bluish-gray in color.
When gunshot craniocerebral injury in the first hours after the injury can occur as a loss, and the expiration of the destroyed particles brain (fluxus cerebri). The amount of loss depends on the size of the defect bones and shells, and the reasons for the sharp increase in intracranial pressure. Phenomena meningoencephalitis have not yet been observed, as the infection is appended at a later date. Sharp growth of the volume (swelling) of the brain may be observed in patients on the operating table, during of manipulations on the base of the brain (in infundibular area, in the zone III or IV heart), when trying to make resection of the affected frontal lobe and other
What if this irritation reflexogenic zones (N. N. Burdenko) accompanied by the disturbance of cerebral circulation, leading to increase of the volume of the brain due to its edema - swelling. In these cases, the swelling of the brain through a defect in the skull bones become threatening complications, as along with increasing the eyes of prolobbiroval are violated veins from the edges of the bone defect, the breaking of the brain, bleeding, exclusion of some areas fell brain matter and the growth of new ones.
The early loss of the brain is usually observed after 2-4 days after injury or surgery. The reasons it is local or General cerebral edema, intracranial hemorrhage, offset various parts of the brain, circulation failure of the liquor and other Drop-down area of the brain is always organically connected with the deep parts of the brain and in the reduction of swelling may be a reverse development.
The brain in the early loss is an oval or mushroom shape of land protruding unaltered brain matter. Its dimensions are rarely reach more than 4-5 cm in diameter. Together with the surface layers of the brain to the side of the defect skull bones shifted and deeper divisions of the brain substance together with lateral ventricle.
Dimensions fallen brain changes together with the development of traumatic and postoperative swelling of the brain. By the end of the first week after the injury stops the growth of brain edema, and by the end of the second he starts to suffer a reverse development. At the same time dimensions fallen parts of the brain first stabilize and then start to decrease.
If dropped, the brain is not exposed to infection, it keeps plotnosenow consistency, transmits a pulse that is covered by granulations and gradually drawn into the cranial cavity, saving largely functional properties of the brain substance. Such favorable for early drop brain has given grounds to call his benign (N. N. Burdenko), aseptic or stagnant.
Treatment of primary and early loss of brain should be aimed at preserving the viability prolobium the brain, reducing the swelling of the brain and the prevention of possible infectious complications.
Wounded with the primary loss of brain needs special care delivered in hospitals neurosurgical: preferable their evacuation by air (helicopter); a thorough protection fallen brain from any damages (wounds impose sterile dressing, dropped the brain is surrounded by cotton-gauze "donut hole"). At dressing in any case not allowed to cut wystawy section of the brain, as this can cause bleeding, additional infection of the brain tissue, and the risk of persistent neurological deficiency (hemiplegia, aphasia, and so on).
The primary loss of brain although it difficult surgical treatment of craniocerebral wound, however, is not a contraindication to it. In these cases, we have to dissect the wound edges of the skin of the head, to expand defect in the skull and Dura mater, carefully remove from the wound channel in the brain, bone fragments, blood clots and brain detritus available metal fragments or the bullet, and wash the wound channel weak antiseptic solutions. Spread during the great Patriotic war the technique of self-emptying wound channel through artificial increase of intracranial pressure (when coughing or natureway patient, or squeeze his jugular veins) not applicable at loss of the brain.
After processing the wounds in the drop-down section of the brain dressings with vaseline oil or ointment containing antibiotics, protect him from possible trauma cotton-gauze "donut hole" and conducted patient energetic dehydrating therapy (hypertonic glucose, sodium chloride, magnesium sulfate, unloading lumbar puncture, appoint novoryt, Mercosul, limit drinking, and so on).
If on the operating table is acute swelling of the brain immediately to stop operation, stop the bleeding and apply very massive dehydration (to the above tools, it is recommended to add an intravenous infusion of urea - wrogue - at the rate of 1 g dry urea per 1 kg of patient's weight). This treatment it is advisable to combine with the use ganglioplegia funds.
Treatment of primary and early loss of brain should include rare conducted very carefully bandaging using bandages with fish oil or ointment with antibiotics. The latter should not have epileptic properties (dangerous application on the brain penicillin); preferably ointment to cook with antibiotics local action (kanamycin, monomitinom, norfolkline or oleandomitina).
With the development of brain edema may increase the drop-down section of the brain and impaired bone-shell-hole; therefore, careful observation of the wound. If the drop-down brain becomes cyanotic shade, stops pulsating and loss grows, you should think about the infringement and should take rapid expansion of bone and shell rings.
The application of preventive antibiotics along with the vigorous dehydration necessarily.
Wounded in the skull in treatment in the hospital or hospital shall not be appointed to evacuate to the elimination of prolapse of the brain.


Bulging of the brain. The reasons for the late bulging of the brain, i.e., protrusion, is intracranial infectious complications encephalitis, abscess of the brain and other Relatively more favorable course observed in the protrusions of the brain, depending on the focal encephalitis, as the latter often can not be cured. Over the protrusions, developing in the diffuse encephalitis or abscess of the brain, it is extremely difficult, especially if it is combined with liquor fistula. Encephalitis can develop in traumatic brain injury in early loss of brain, when the drop-down plot with; in such cases they say about "continued protrusions of the brain."
More often bulging brain appears for the first time, that is without loss in connection with developing in the wound infection in the absence of a primary treatment of craniocerebral wound, her untimely and nomadically (the later stages of the operation, leaving in wound channel bone fragments, blood clots, residues headdress and others). The swelling of the brain contributes to inflammatory edema, resulting in increased intracranial pressure. Indirect cause protrusions of the brain may be an early evacuation of the wounded after the operation, as this creates favourable conditions for the spread of infection in the brain matter, and the intrathecal space.
The course and outcome of the loss of brain injured in the skull largely depend on the timeliness of treatment: it is important to avoid the transition limited encephalitis in diffuse, time to recognize and eliminate the abscess of the brain, if he was the cause of development protrusions of the brain.
Bulging of the brain with limited encephalitis usually develops gradually. The General condition of the wounded in the skull significantly worsens, headaches, nausea, sometimes vomiting, drowsiness, lost appetite, increasing focal symptoms of nervous system, accelerates ROHE, increases neutrophilia.
Characteristic changes in the wound brain substance ceases to pulsate, enhanced by a purulent discharge, granulation become stagnant, appears and increases in size protrusion of the brain. Wibehouse brain chemistry is usually mushroom shape, covered with festering tinged with dark foci of necrosis, at the base stored granulation. Infringement visualsage area of the brain bone, shell ring can cause seizures and strengthening of necrotic processes in it, that threatens the transition of limited encephalitis in diffuse, causes the death of brain injury and resistance focal neurological symptoms.
Bulging of the brain in the diffuse encephalitis is characterized by severe clinical picture: high feverish, stunned wounded in the skull with a progressive progressive cachexia, General tremor, lethargy appear and quickly increases in sizes bulging of the brain. The latter has a loose consistency, areas of necrosis, often bleeds. On the surface visualsage area of the brain rifts that divide it into several parts, some parts are rejected with purulent discharge. After some time, a new mass visualsage brain. A shift towards protrusion of the lateral ventricle of the brain, combined with pervasive in depth encephalitides process leading to ventricular perforation and persistent liquor svesu. Earlier this pronounced signs of infection (fever, rapid ROHE and others) with the advent of liquori considerably reduced, however, in 2-3 days upon the spread of secondary infection through the gaping fistula in the ventricular system on basal areas of the brain are manifested even more.
When such protrusion wibehouse brain resembles the decayed cauliflower, covered with purulent or putrid detachable (in case of accession of anaerobic encephalitis), or blood clots (at the expense of the vessels of the brain). Such a bulging of the brain called "malignant" (N. N. Burdenko and others).
Treatment for bulging brain when encephalitis should be aimed primarily at the elimination of the inflammatory process in the medulla. In these cases, along with dehydrating and restorative therapy is conducted vigorous treatment with antibiotics, intramuscularly, intravenously endolumbalno and topically on the wound (see Traumatic brain injury). In some cases good effect has the introduction of antibiotics in the carotid artery.
Great importance is the protection of visualsage area of the brain from injury, secondary infection, drying. When protrusions of the brain with infringement shows the expansion in size trepanation open and defect Dura. When liquor fistula good result gives ultraviolet irradiation visualsage area of the brain. Thin sterilized sheet of polyethylene able, as the case close babuhski part of the brain and surrounding skin that helps stop liquori. This technique should be combined with the "handling" the lumbar punctures.
At the cleansing of the brain from necrotic masses effective headbands with the tools that stimulates regenerative processes (ointment dressing, ultraviolet radiation).
Bulging of the brain in abscesses depends on increased intracranial pressure. Such patients are all signs of abscess of the brain (see brain abscess). Along with lethargy and oglushennosti they have headaches, vomiting, aetiology, typical changes in blood (accelerated ROHE and neutrophilia at relatively low leukocytosis) and gradually increasing the swelling of the brain. Wibehouse brain chemistry is often cyanothece-grey, not pulsates slowly increases in size until infringement in his trepanation hole. In the latter cases begin necrosis and bleeding and protrusion acquires a "malignant course".
The treatment should be aimed at elimination of brain abscess. Once the abscess liquidated, protrusion tends to reduce and reverse development. Sometimes the injury visualsage part of the brain during manipulation, aimed at the elimination of brain abscess, leads to generalization process, hence the need for vigorous measures to combat infection.
The best method, prevent the development of malignant protrusions of the brain is early, gentle and radical primary treatment of craniocerebral wound, and then assign dehydrating and antibiotics; required bed rest not less than for three weeks.