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Wschodnioeuropejskie Czasopismo Naukowe (East European Scientific Journal) #4(44), 2019 61
Shoyunusov Sarvar Ikramovich 3rd year student of medical faculty, Tashkent Pediatric Medical Institute. Tashkent city.
Scientific adviser: Karataeva Lola Abdullaevna Assistant Ph.D. Department of Pathological Anatomy. Tashkent Pediatric Medical Institute. Tashkent city.
ASPECTS OF THE VIOLATION OF THE CEREBROSPINAL FLUID SPACE OF THE CRANIAL
CAVITY
The article includes the data of literary analysis on aspects of the cerebrospinal fluid space, which are important for physicians.
Key words: violation, injury, aspects, external environment.
The urgency of the problem of nasal liquor currently growing steadily. This is due to the fact that neurosurgeons began to more widely and radically remove craniobasal neoplasms, craniocerebral injuries became more frequent in modern technological society, and the percentage of iatrogenic injuries increased.
According to M. Bernal-Sprekelsen, the discharge of cerebrospinal fluid from the nose develops in 2.6% of cases of patients with TBI, and the CSF fistula is located most often in the frontal area.
According to Landeiro et al. traumatic nasal liq-uorrhea accounts for up to 70% of cases, O.A. El-Banhawy quotes the same figure. According to the observations of W. Hosemann et al. in 94% of patients with nasal liquorrhea, the latter has a traumatic genesis.
In the case of anterior craniobasal and frontal basal injuries, the paranasal sinuses suffer; with lateral crani-obasal and laterobasal pyramids of the temporal bones and the middle ear cavity. The nature of the fracture depends on the applied force, its direction, the characteristics of the structure of the skull; each type of deformity of the skull corresponds to a characteristic fracture of its base. Displaced bone fragments can also damage the meninges.
The analysis of the literature also showed that the meninges prolapse into the bone defect resulting from the injury, preventing it from clotting, and can lead to the formation of a hernia in the fracture site, consisting of the hard and arachnoidal meninges and the medulla.
With a partial tamponade of the site of damage to the dura mater or tissue interposition, liquorrhea can appear after lysis of a blood clot or damaged brain tissue, as well as a result of regression of brain edema and increased liquor pressure during stress, coughing, sneezing, etc. The cause of liquorrhea can be transferred meningitis after injury, as a result of which the connective tissue scars formed in the third week in the area of the bone defect undergo lysis.
Early rhinolikvoreya stops spontaneously during the first week in 85% of patients.
Nasal liquorrhea is a serious disease characterized by the communication of the cerebrospinal fluid spaces of the cranial cavity with the external environment, caused by the violation of the integrity of the natural anatomical barriers separating the cranial cavity from the nasal cavity and paranasal sinuses, and the expiration of cerebrospinal fluid from the nasal cavity.
The authors noted that the fistula, through which the cerebrospinal fluid space of the cranial cavity communicates with the external environment is the entrance gate for infection, so nasal liquorrhea is often accompanied by severe intracranial complications: recurrent secondary purulent meningitis, less often brain abscess and cerebellum, which even can be fatal.
According to M.L. Durand et al, 1993, up to 20% of purulent meningitis are caused by infection of the cranial cavity through the cerebrospinal fluid fistula. Mortality in such cases ranges from 25 to 50%.
Natural anatomical barriers demarcating the cerebral fluid from the nasal cavity and paranasal sinuses are: the cytoplasmic plate, the cerebral walls of the paranasal sinuses, as well as the dura mater densely adhered to the above-mentioned bone structures.
Liquorous circulation includes 3 units — production, circulation and resorption of the cerebrospinal fluid. Under physiological conditions, cerebrospinal fluid is produced mainly in the choroid plexus of the ventricles of the brain with an average speed of 840 ml per day, 35 ml per hour.
The circulation is carried out initially within the III, lateral and IV channels, and then the CSF enters the subarachnoid space of the brain and spinal cord. The total volume of liquor is on average 140 ml.
The outflow of the cerebrospinal fluid occurs mainly in the superior sagittal sinus, from there through the system of other sinuses of the dura mater - into the internal jugular veins and then through the system of veins into the right atrium. The time for complete replacement of liquor is 5-7 hours.
One of the leading reasons for the development of nasal liquorrhea is a craniocerebral injury (TBI). According to A.C. Lopatin and D.N. Kapitanov, nasal liquorrhea due to TBI in approximately 80-90% of cases. According to A. A. Potapov, liquorrhea occurs in 2-3% of observations among all patients with head injuries and in 5-11% of patients with fractures of the base of the skull. . The author also believes that in children, especially up to two years, liquorrhea occurs much less frequently, the ratio is 10: 1. This is due to the greater elasticity of the bones constituting the base of the skull in children, as well as the underdevelopment of the frontal and sphenoid sinuses.
62 Wschodnioeuropejskie Czasopismo Naukowe (East European Scientific Journal) #4(44), 2019 SMI
Persistent flow is observed with insufficient comparison of bone tissue (displaced fracture), impaired regeneration along the edges of the TMT defect in combination with fluctuations of the liquor pressure.
The low strength of the cribriform plate, the close contact of the arachnoid membrane and the bone with perforation by its olfactory fibers make this area the most susceptible to the occurrence of post-traumatic liquor fistulas. Fractures that pass through the frontal lobe — the sphenoid sinus or ethmoid cells are the most common cause of the dural fistula and the source of rhinolikorrhea. It is also possible nasal liquorrhea through the openings of the ethmoid bone in the absence of bone damage due to traumatic separation of the olfactory nerve fibers.
According to the authors of the literature, another important cause of nasal liquorrhea today is neurosur-gical interventions. This is due to the fact that at present, neurosurgeons more widely and radically remove tumors of the craniobasal region, penetrating into the cavity of the paranasal sinuses. On the other hand, in practice and in the literature there are cases of nasal liquorrhea associated with manipulations in the nasal cavity. They arise as a result of intranasal operations for polyps of the nasal cavity, dissections of the cells of the ethmoid labyrinth, transnasal removal of pituitary tumors, craniotomy in the region of the frontal sinuses, manipulations on the meningocele mistaken for poly-posal vegetation of the nasal cavity.
Iatrogenic nasal liquorrhea develops when anatomical structures are damaged, which are risk zones: the roof of the ethmoid labyrinth, the lateral part of the sieve plate, the bony wall between the sphenoid sinus and the posterior lattice cells.
A separate group consists of spontaneous nasal liquorrhea. The cause of the development of spontaneous nasal liquor can be the pathological process of inflammatory, degenerative, neoplastic and disembrioge-netic genesis of the brain and cranial bones. According to D.O. Spontaneous nasal liquorrhea is observed in 40% of cases among all patients with skull base disem-bryogenesis.
According to the observations of N.V. Tarasovaya et al., Spontaneous nasal liquorrhea occurs more often in women with clinically confirmed osteoporosis with a decrease in female sex hormones in the period of pre-and menopause.
The congenital defects of the diembriogenetic nature include dehiscentations of the base of the skull. They are observed most often in the areas of the seams of the cranial bones. According to B.V. Shevrygin, one of the most frequent localization of such a fistula is the lateral wall of the sphenoid sinus.
The authors also found that the tumor process is most often the cause of spontaneous nasal liquorrhea.
According to neurosurgeons, in some cases, spontaneous nasal liquorrhea is a pathognomonic symptom of a brain tumor.
The tumor process can directly destroy the integrity of the skull base and dura mater cusp and lead to the formation of cerebrospinal fluid fistulas. This is particularly true for tumors of the epididymis, which destroy the bottom of the Turkish saddle and grow in the direction of the sphenoid sinus. Tumors of other localization, breaking up, lead to the development of extensive defects of the base of the skull. The development of a tumor in the cranial cavity may result in a nasal liquor indirectly: tumor tissue grows and overlaps the natural lymph outflow pathways, which leads to the development of intracranial hypertension. In such cases, nasal liquorrhea is compensatory decompression, which prolongs the life of the patient.
I.A. Yashan cites the case of the occurrence of nasal liquor from the osteoma of the ethmoid labyrinth.
Osteoporosis should be attributed to degenerative processes leading to the formation of cerebrospinal fluid fistulas. Bone tissue is a dynamic system. In it, throughout the whole life of a person, the processes of destruction of the old bone tissue and the formation of a new one occur, which constitutes the cycle of bone tissue remodeling. An age-related decrease in the intensity of this process causes physiological atrophy of the bone tissue. The rate of bone mass loss depends on age and gender. For women after 35, it is 0.75-2.5% per year, and up to 3-4% after menopause. Osteoporosis is the most common metabolic disease of the skeleton, characterized by a progressive decrease in bone mass in the bone volume, including the bone walls of the ethmoid labyrinth and the sphenoid sinus.
Thus, summing up the literary analysis, we can note the value of studying this problem in medicine.
Literature.
1. Rybak, A.A. Congenital intranasal cerebral hernia / A.A. Rybak, T.V. Matveeva // Russian Rhinology. - 2002. - №3. - p. 358-37.
2. Piskunov, GZ Clinical Rhinology / G.Z. Piskunov, S.Z. Squeaky - M .: Medical Information Agency, 2006. - 526 p.
3. Potapov, A.A. Post-traumatic basal liquorrhea / A.A. Pota-pov // Medical newspaper. - 2002. - №81. -pp. 3-5.
4. Martin D. Surgical management of anterior cranial fluid fracture with cerebrospinal fluid fistulae: a single institution experience / M. Scholsem, F. Scholtes, F. Collignon // Neurosurgery. - 2008. - vol. 62 (2). - p. 463-469.
5. Yoo, H.-M. Detection of CSF Leak in Spinal CSF Leak Syndrome Using MR Myelography: Correlation with Radioisotope Cisternography / H.-M. Yoo, S.J. Kim // Am. J. Neuroradiol. - 2008. - vol. 29 (4). -P. 649 - 654.
