Hydrocephaloid

HYDROCEPHALOID, a syndrome described by Marshall Hall, characterized clinically by spasms of the extremities and general convulsions, rigidity of the neck, depression of the anterior fontanelle, strabismus, etc.; anatomically by edema of the meninges and transudation into the cerebral ventricles; it depends on disorders of circulation in the brain; it is observed in small children, after large losses of fluid, and possibly under the influence of toxic substances circulating in the blood.

HYDKOOEF

When injected into the lateral ventricle, with free communication, it appears in the punctate after 3-8 minutes, and 30-60% of it is excreted in the urine within 2 hours. Significant delay indicates closed hydrocephalus. With intralumbar injection, excretion in the urine normally begins after 5-10 minutes and ends after 2 hours. Significant delay indicates impaired absorption. If a 10% solution of sodium iodide injected into the ventricle is not found in the lumbar canal after a short time, there is complete closure of the ventricles. If normal excretion of iodine in the urine does not occur or is delayed for more than an hour with free communication of the ventricles with the lumbar canal proven by encephalography, then insufficient absorption by the brain surface or complete absence of absorption should be considered. With free filling of the third ventricle with air, the obstruction can only lie below, and most often in the aqueduct of Sylvius. If the fourth ventricle is clearly visible, then the foramina of Magendie and Luschka are closed. Free communication between the ventricles and the lumbar canal and an increase in the amount of air on the surface of the brain with normal excretion of iodine injected into the ventricle, proving normal absorption of fluid, indicates hydrocephalus vacuo. Slight pressure of lumbar fluid and rapid stoppage of outflow with other symptoms of hydrocephalus or a significant difference in the composition of fluid obtained by puncture of the ventricle and lumbar canal indicate closed hydrocephalus. Course, treatment and prognosis. The onset of the disease can be observed at any age, but most often occurs in the first years of life. Children with congenital hydrocephalus often die after birth or in the first months, only a few reach older age. Usually children die from complications (bedsores, nutritional disorders, intercurrent diseases) or surgical interventions, rarely directly from fluid pressure. Often children appear healthy, and only gradually does the skull enlarge. In other cases, the skull enlarges after some acute illness, most often after meningitis, pneumonia, inflammation of the middle ear. To determine skull enlargement, regular measurements of the skull must be made. In small children, an increase in volume of 1-1.5 cm per week is observed. Recovery is possible only in very mild cases. Arrests in the development of the disease can occur at any stage, but improvements and arrests cannot be taken as cessation of the disease, as new deteriorations with fatal outcome are not uncommon. Sometimes complete disappearance of all symptoms occurs, but often nerve atrophy remains. Therapy. There is no etiological therapy. Treatment aims to establish normal intracranial pressure and prevent further enlargement of the skull. Stationary hydrocephaluses are not subject to treatment. In some cases, healing occurs without any external cause, in others - spontaneous or traumatic rupture of fluid outward, mainly through the nose, sometimes through the orbit, eye. Of internal agents, diuretics, laxatives and diaphoretics have been unsuccessfully used, aiming to remove as much fluid as possible from the body and thereby enhance absorption of the fluid present in the ventricles. Furthermore, diversion to the skull has been recommended. All these means, however, give no results. The administration of thyroid gland preparations is also recommended, which, according to Frazer, by affecting the epithelium of the choroid plexus supposedly reduce the secretion of cerebrospinal fluid. In cases of syphilitic origin, specific treatment with salvarsan and mercury is necessary. The latter has sometimes proved useful in non-syphilitic cases. There are indications that compression of the skull, for example by means of circularly arranged adhesive tape strips around the skull, after previous puncture, in infants sometimes gives some favorable results, but with forced attempts it can lead to skull rupture. More effective is surgical treatment, aiming to reduce the amount of fluid. The simplest method is lumbar puncture, which is performed every 4-6 weeks with the release of a small amount of fluid (20-50 cubic cm). Such treatment can be carried out for months and even years. It is applied, however, only with free communication between the ventricles and the lumbar canal. In the absence of communication, ventricular puncture is resorted to, especially easily accessible with open sutures and fontanelles, but in adults this operation is also performed quite easily. In these cases, too much fluid should not be released: when the fontanelles sink, the release must be stopped immediately. With too rapid release, a fatal outcome can occur. In general, the success of these punctures is very insignificant, as the fluid soon accumulates again. Recently, many authors have proposed operative methods to create conditions allowing constant outflow of fluid into the lymph or circulatory system. Relatively safer is the method of puncturing the corpus callosum (so-called Balkenstich) by Anton and Bramann; This puncture establishes communication between the ventricles and the subarachnoid spaces of the hemispheres. It is especially applicable in closed hydrocephalus. With significant damage to the absorption pathways in the area of the hemispheres, the suboccipital puncture by Anton and Schmiden may prove useful, removal of the occipital dura mater, thereby establishing outflow from the cisterna magna into the subcutaneous and intramuscular connective tissue of the occiput. Mikulicz and Henle introduced a gold tube into the lateral ventricle and from there into the subarachnoid space or under the galea. Quincke makes a subcutaneous incision of the dura mater. Rau used a freely transplanted piece of human saphenous vein or a hardened dog artery from formalin to obtain direct communication between the lateral ventricles and subcutaneous tissue or between them and blood vessels (sinus longitudinalis, vena jugularis or facialis communis). Heile and Gillavry recommend establishing outflow of fluid into the abdominal cavity, Heile and Frazer into the pleura. Heile created an anastomosis between the ureters and the spinal dura mater, Sokolovsky and Irger - connection of the ventricles with the subcutaneous layer on the face (glo-toulus adiposus Bichati). (See also Brain surgery.) The value of the mentioned operative methods, however, is far from clear, and the indications for them have not been developed. While some consider it possible to admit them only as indicatio vitalis and in the most severe cases, others exclude severe cases and admit these methods as palliative or therapeutic means in other cases. In cases of healing with various defects, it is necessary to strive to improve the mobility of the extremities by means of baths, massage, gymnastics. Severe degrees of feeble-mindedness require appropriate medico-pedagogical intervention.