Edema of the brain after tumor removal
Swelling and swelling of the brain - an increase in the volume of the brain as a result of a kind of violation of water-salt metabolism.
Etiology, pathogenesis, pathological anatomy. Developing with various diseases,swelling of the brain is variable in terms of its morphological and biochemical indicators, as well as its clinical and thanatological significance. In this case, often swelling of the brain is combined with his swelling. The difference in the pathogenesis of swelling and cerebral edema, according to popular belief, is that when the brain swells, there is a binding of water with colloids of the brain due to an increase in their hydrophilicity, whereas in brain edema the penetration of the vascular walls and the accumulation of fluid in the tissue gaps occur. Nevertheless, the pathogenetic proximity of these phenomena is so pronounced that a clear demarcation of them is not always possible.
"Swelling", or "turgescence," the brain described N. I. Pirogov as early as 1865. This problem has acquired special interest at the present time in connection with the development of neurosurgery. Most often, swelling of the brain in combination with edema is observed in focal processes in the brain (tumor, abscess, infectious granuloma, etc.), as well as brain trauma; in children, edema and swelling of the brain are noted for various toxicoses of infectious origin, and in newborns for birth trauma.
Swelling and swelling of the brain are especially pronounced in white matter near the lesion and gradually decrease with distance from the lesion.
Macroscopically this is expressed in a significantan increase in the size of the white matter in the circumference of the focus, which leads to an increase in the volume of the corresponding hemisphere (Figure 1), whereas the cortex of the brain appears even narrowed. The consistency of the swollen areas of the brain is dense, the surface of the incision is dry. If the swelling of the brain is accompanied by swelling, the surface of the cut appears to be more moist, and when the swelling prevails, the brain becomes flabby and an abundant edematous fluid drains from the surface of the incision. Histologically, swelling of myelin sheaths is uniform, or with the formation of bulbous swellings along the nerve fibers (Figure 2), as well as peculiar changes in neuroglia. In the pathogenesis of swelling and edema of the brain, an important role is played, apparently, by vasomotor-trophic disturbances (NN Burdenko, AI Arutyunov, BN Klosovsky and others).
Swelling and swelling of the brain (along withfocal processes that increase the volume of intracranial contents) lead to an increase in intracranial pressure and can cause death, especially if the process has spread to the brain stem and caused a disruption in the functions of vital centers.
Swelling and swelling of the brain is a reversible process. After removal of the pathological focus, it can regress; However, if this process drags on for a long time, the destruction and melting of a significant part of the myelin fibers begins. Thus, we can distinguish between two stages of water-salt metabolism in the brain: the first - with reversible changes and the second - destructive (BS Khominsky).
A special form of cerebral swelling, whichoccasionally observed in general infections, intoxications and mental illnesses, is characterized not by an increase in the water content, but, on the contrary, by an increase in the dry residue, which is due to the violation of non-aqueous and protein metabolism.
Fig. 1. Swelling and swelling of the cerebral hemisphere in tumors (glioblastoma).
Fig. 2. Brain swelling: balloon-shaped swelling (1) of myelin fibers (staining with hematoxylin Kulchitsky, x 360).
Clinical picture. Clinically differentiate swelling from swellingthe brain is difficult. These disorders can develop after traumatic brain injury, brain tumors, abscesses, encephalitis, during or after surgery on the brain, with vascular and other brain diseases, as well as with various diseases not associated with primary brain damage. Swelling and swelling of the brain most often occur in the white matter of the brain or in individual parts of the brain. The spread of these disorders to the brain stem cells often leads to the death of patients. Regardless of the nature of the process, swelling and swelling of the brain can develop from the first day after the disease, brain trauma or surgery on it, reaching a maximum on the 5th-6th day, gradually regressing to 10-15th day. Sharp swelling and edema of the brain most often develop in patients with malignant tumors and brain abscesses.
Depending on the location of the process in the brain,the nature of the disease and the severity of the craniocerebral trauma, the clinical picture of swelling and edema may be different. In some cases, against the background of the underlying disease, weakness, drowsiness, headache, vomiting, and stagnant nipples on the fundus are developing. Focal symptoms (paresis, paralysis, etc.) are identified or intensified. Then follows the regress of symptoms, except for the symptoms associated with a brain tumor or trauma of the very substance of the brain. In other cases, as the swelling and swelling of the brain and the involvement of the brain stem in this process can develop convulsive attacks, lethargy, drowsiness, down to a coma, oculomotor disorders, extinguish reflexes, pathological reflexes develop, cardiovascular disorders develop, disturbances of breathing and thermoregulation, often leading patients to death.
Treatment. Fighting increased intracranial pressureis conducted by intravenous injection of hypertonic solutions that promote the excretion of edematous fluid from the brain tissue (5-10 ml of 10-15% sodium chloride solution and 40-50 ml of 40% glucose solution). Favorable effect is given by intramuscular injection of 10 ml of 25% solution of magnesium sulphate. In the absence of kidney damage, intramuscular injections of 1 ml of novurite can be given within 2-3 days or 0.5-1 ml of merkuzala every other day. Assign hypothiazide in tablets to 0,025 g 1-2 times a day. Lumbar punctures are also shown in the supine position: small portions of liquid are slowly extracted with extreme caution in case of suspected brain tumor or occlusive hydrocephalus. In these cases it is better to resort to unloading puncture of the lateral ventricle or to establish a long drainage in it.
Edema and swelling of the brain reach the greatestdevelopment on the 3-5th day after trauma or brain surgery, and this gap in time should be used for medical and preventive activities. Intramuscular administration of ganglionic blockers is also recommended for 2-3 days (5% pentamine or 2% hexonium per 1 ml 2-3 times a day) under the control of the blood pressure level.
In severe cases, if the patient does not have a lesionkidney and liver, and the content of residual nitrogen in the blood does not exceed the normal level, the most effective way to combat swelling and swelling of the brain is intravenous drip (at a speed of 40-60 drops per minute) 30% urea solution in 10% sucrose solution from calculation of 1 g / kg. In the absence of effect 3 hours after the infusion, it is necessary to discuss the question of indications for decompressive or unloading operations or revision of the wound after the operation. Since after the introduction of urea during or after surgery, sometimes the bleeding of tissues increases, it is prophylactically necessary to re-enter small doses of vicasol, calcium chloride. During the first 24 hours after the application of urea, it is necessary to observe the water balance of patients and to regulate it by intravenous drip infusion of 500-800 ml of isotonic glucose solution, Ringer's solution with addition of 200 mg of ascorbic acid and 100 mg of vitamin B1.
In the clinic, a new powerfuldehydrating agent - mannitol (20-25% solution at the rate of 1 g / kg with the introduction of the entire amount of solution for 10-15 minutes). This drug is superior to urea, low toxicity and can be used in patients with kidney disease.