Formation of the bridge of the cerebellar angle on the left. Pontocerebellar angle. Syndrome of the lower surface of the frontal lobe

CEREBELLULAR BRIDGE ANGLE (angulus cerebellopontinus) - the space where the bridge (pons varolii), the medulla oblongata and the cerebellum are closed. M. y. open anteriorly, towards the base of the skull, in the region of the posterior cranial fossa (Fig. 1). From the ventral side of M. at. covered with an arachnoid membrane, the edge does not go deep into it, but is located superficially, as a result of which a receptacle for cerebrospinal fluid is formed in this area - the lateral cistern of the bridge (cisterna pontis lat.), often identified in the literature with M. at. in the broad sense of the word. In this case, under M. at. they understand a narrow space resembling a flattened irregular pyramid in shape, bounded in front and on the side by the posterior surface of the pyramid of the temporal bone, from the inside by the junction of the pons, medulla oblongata and cerebellum, which make up the top of the cerebellopontine region, from behind by the surface of the cerebellar hemisphere, and from above by the cerebellum. In the area of ​​M. at. (Fig. 2) the roots of the V-XI pairs of cranial nerves, the anterior inferior cerebellar and labyrinth arteries, and numerous cerebellar veins flowing into the superior petrosal sinus are located, among which the vein of the flocculus is distinguished by constancy.

Pathology

In M. at. patol, processes of both the inflammatory, and tumoral nature develop.

Arachnoiditis M. at. usually develop after infection, in the acute stage there is pleocytosis in the cerebrospinal fluid, in the chronic stage - cerebrospinal fluid is normal, there are no changes in the internal auditory canal on radiographs, bilateral hearing loss is detected with audiometry, and vestibular excitability often increases (symptom of cochleovestibular scissors); often dizzy. Arachnoiditis (see) often leads to the formation of arachnoid cysts, to-rye cause symptoms of an inflammatory and compression nature.

From M.'s new growths at. the most common neuromas of the auditory (vedimentary-cochlear, T.) nerve (see Vesti-cochlear nerve), less often meningiomas, cholesteatoma, and tumors of the cerebellum or brainstem, spreading to M. at. These tumors are manifested initially by focal symptoms, which are caused by damage to the part of the brain or nerve that is the source of tumor growth (auditory nerve, brain stem), and then, as the neoplasm grows, symptoms of damage to neighboring brain formations and cerebral symptoms develop (headache, hypertensive changes on craniograms, congestion in the fundus). The latter are associated with secondary occlusion of the CSF pathways at the level of the posterior cranial fossa (see Occlusive syndrome).

Neurinomas give the expressed symptomatology of defeat of an acoustical nerve, edges quite often appears long before all other symptoms. The disease usually begins with local symptoms - a slow and gradual hearing loss in one ear according to the neurosensory type. The wedge, a picture at neurinomas is in the beginning characterized by defeat of cranial nerves in a cerebellopontine corner. In the future, stem and cerebellar disorders join, more pronounced on the side of the tumor. All symptoms have a clear lateralization. The phenomena of increased intracranial pressure develop relatively late. There are 3 stages in the development of neuromas:

1. Early stage - the tumor is small (1.5-2 cm). In this period, only cranial nerves are affected in M. at .: vestibulocochlear, trigeminal, facial, glossopharyngeal (on the side of the tumor, hearing, vestibular irritability, taste in the anterior 2/3 of the tongue decrease or fall out, slight violations of the function of the trigeminal and facial nerves are noted ). Hearing loss begins with high frequencies, the intelligibility of perceived speech suffers more; sound in Weber's experience (see Weber's experience) does not lateralize, despite unilateral deafness. There are no stem and hypertensive symptoms. In almost half of the patients on radiographs, the internal auditory canal is enlarged, in almost all patients the protein content in the cerebrospinal fluid is increased. Some of these tumors are clearly visible on computed axial tomography. At this stage, diagnosis is difficult. The most effective operation (the tumor is completely removed). Facial nerve function is often preserved.

2. A stage of the expressed wedge, symptoms - size of a tumor apprx. 4-4.5 cm in diameter. The tumor affects the brain stem, cerebellum, and often causes hypertension. Multiple spontaneous nystagmus is revealed (toward the tumor it is larger, tonic, and in the healthy direction it appears already with a direct look), optokinetic nystagmus is disturbed (see), ataxia appears on the side of the tumor, the trigeminal and facial nerves are more often affected. The clinical picture of the disease at this stage in most patients is clearly expressed. The tumor can be completely removed in most cases. After surgery, paralysis of the facial nerve often develops.

3. In the advanced stage, swallowing disorders, damage to the cranial nerves and the brain stem on the healthy side, severe hypertensive-hydrocephalic phenomena join.

Meningiomas and cholesteatoma M. at. in symptoms, they are similar to acoustic neuromas, but signs of damage appear later and may not be so pronounced. With cholesteatomas in the cerebrospinal fluid, the content of cellular elements is increased with a normal protein content.

The diagnosis patol, the processes localized in M. at., is based on data of a clinical picture and rentgenol, research methods - craniography (see) and X-ray contrast researches of liquor and vascular systems of a brain (see. Vertebral angiography).

A thorough tomographic examination of the skull, in particular the pyramids of the temporal bones (see Tomography), the use of pneumoencephalography (see) and cisternography (see Encephalography) make it possible in most cases to detect even relatively small tumors of M. at. Computed tomography has a high diagnostic efficiency (see Computed tomography), with the help of a cut it is possible to detect volumetric formations of M. at. dia, up to 1.5-2 cm (Fig. 3).

Craniographic diagnosis of tumors M. at. is based on local changes in the bones of the skull, due to the direct influence of the tumor, and remote changes due to displacement of the brain structures and bone compression, impaired outflow of cerebrospinal fluid and displacement of its reservoirs, compression and displacement of vessels in the posterior cranial fossa.

For bigger reliability rentgenol. signs of a tumor produce the following paired craniograms of the sick and healthy sides on the same film under identical shooting conditions: transverse radiographs of the temporal bones according to Stenvers; direct radiographs with the projection of the pyramids into the orbits; posterior semi-axial radiographs to detect destruction of the posterior surface of the pyramid. Stenvers images are of primary importance, giving an idea of ​​the size of the internal auditory meatus on the side of the tumor, the state of its upper and lower walls, the deep ampullar part, the relationship of the tumor bone defect to the cochlear capsule and the vertical semicircular canal of the labyrinth (Fig. 4, i, b ). Sometimes pictures with a projection of the pyramids into the eye sockets are more informative.

According to craniography, it is sometimes possible to differentiate various tumors of M. at. So, meningiomas rarely cause an expansion of the internal auditory canal, more often destruction of the top of the pyramid and its surfaces with uneven outlines, calcareous inclusions are often observed along the periphery of the tumor (Fig. 5); with cholesteatomas, there is a sharp expansion of the internal auditory canal with the destruction of the anterior surface of the pyramid and linear arcuate calcareous marks with smooth outlines of the adjacent bones.

On vertebral angiograms with acoustic neuromas, the vascular network of the tumor is rarely contrasted, and therefore the symptoms of vascular displacement (secondary signs) are of primary importance. With caudal spread of the tumor, the basilar artery is pressed against the clivus (Blumenbach's clivus) and its lateral displacement in the opposite direction. With tumor growth in the oral direction, the basilar artery is displaced posteriorly from the clivus and in the opposite direction.

The superior posterior cerebellar arteries on the side of the tumor are displaced superiorly and medially. The inferior cerebellar artery on the side of the tumor is usually displaced downward. In meningiomas, the tumor vasculature is often visible.

Pneumocisternography and pneumoencephalography can reveal different rentgenol, signs: lack of filling of the lateral cistern of the bridge due to its closure by a tumor; detection of a tumor in the form of a defect in the filling of the lateral cistern of the bridge; displacement of the IV ventricle, aqueduct of the brain (Sylvian aqueduct) in the opposite direction and compression of the lateral eversion of the IV ventricle by a tumor. With oral spread of the tumor, the cerebral aqueduct and IV ventricle are displaced posteriorly. Positive ventriculography (see) with Mayodil's emulsion at M.'s tumors at. reveals the displacement of the aqueduct of the brain and IV ventricle in the opposite direction with defects in the filling of the lateral eversion of the IV ventricle. With oral spread of the tumor, these formations arcuately displaced backwards and upwards. Such symptoms can be detected both with IV ventricular occlusion and in the absence of cerebrospinal fluid patency disorders, which is important for the early diagnosis of tumors. The severity of the symptoms described above depends more on the direction of tumor growth than on its nature.

Operations in the field of M. at. undertake concerning the diseases connected with defeat of the nerves passing in M. at. (Ménière's disease, trigeminal and glossopharyngeal neuralgia); arachnoiditis M. at. and its tumors (acoustic neuromas, meningiomas, cholesteatoma, etc.).

During operations, unilateral accesses are used. The accesses proposed by W. Dandy and A. W. Adson (Fig. 6, a, b) are the most widely used.

When accessing Dandy, a parabolic incision of soft tissues is made.

Dissect the skin, subcutaneous tissue, aponeurosis and muscles covering the occipital bone on the side of the operation. The skin incision is made at the midline, at the point of intersection of the midline with the lower nuchal line (linea nuchae inf.). From this point, the incision is made in the direction of the lesion and, rising in an arcuate manner, reaches the junction of the upper nuchal line (linea nuchae sup.) with the lambdoid suture.

Then the incision line descends downward along the bulge of the mastoid process, almost to its apex.

Bleeding is stopped by diathermocoagulation (see). Educated so. the flap is separated from the bone and retracted downward. If there is bleeding from the emissary veins of the bone, it is stopped by rubbing in wax.

Then, a burr hole is made in the exposed surface of the occipital bone and expanded with nippers to the desired size.

At the midline, the burr hole does not reach the external occipital crest, outwardly it reaches the mastoid process, from above it reaches the superior nuchal line or the lower edge of the transverse sinus. From below, the edge of the trepanation window ends approximately at the level of the upper edge of the large occipital foramen, which corresponds to the place of thickening of the occipital scales. The dura mater is dissected with a cruciform incision. During operations on the nerves that take place in M. at., after opening this shell, a good access to its formations is created, for which the hemisphere of the cerebellum is lifted upward and somewhat medially with a careful movement.

The cerebellopontine angle is exposed after the outflow of cerebrospinal fluid from the lateral cistern of the pons.

At M.'s tumors at. often, to create a good access, one has to resort to resection of the lateral part of the cerebellar hemisphere. For this purpose, the cerebellar cortex is coagulated and, after its dissection and white matter aspiration, the desired area of ​​the cerebellum is removed.

With Adson access, a linear skin incision is made approximately in the middle between the midline of the occiput and the mastoid process (Fig. 6a). At the top, the incision starts from a point located 2-3 cm above the upper nuchal line, and then lowered vertically down to the level of the atlas arch. The skin and underlying soft tissues are gradually dissected down to the bone. Bleeding is systematically stopped by coagulation, due to which the operation, as a rule, is almost bloodless. Muscles are separated from the bone with a raspator and a coagulation knife and parted to the sides by automatically self-retaining retractors. Then a cut hole is made. If, when biting the bone towards the mastoid opening and damaging the emissary vein passing through this hole, venous bleeding appears from the emissary, it should be covered with wax in order to prevent air embolism. The dura mater of the brain is dissected as described in the Dandy access, and further manipulations are carried out. Some neurosurgeons, in addition to the described trepanation of the occipital bone, additionally bite the edge of the occipital bone and the arch of the atlas on the corresponding side. This is usually done when removing large tumors (neurinomas, meningiomas) of the cerebellopontine angle.

Chemotherapy and radiation therapy, combined with surgery, are identical to those for other brain tumors - see Brain, tumors.

Bibliography: Egorov B.G. Neurinoma of the VIII nerve, p. 80, M., 1949; 3 l about t-n and to E. I. and Sklyut I. A. Acoustic neuromas, Minsk, 1970; To about p y-l ov M. B. Fundamentals of X-ray diagnostics of diseases of the brain, p. 211, M., 1968; Fundamentals of practical neurosurgery, ed. A. L. Polenova and I. S. Bab-china, p. 233 and others, L., 1954; Adson A. W. A straight lateral incision for unilateral suboccipital craniotomy, Surg. Gynec. Obstet., v. 72, p. 99, 1941; G u s h i n g H. Acoustic neuromas, Laryngoscope, v. 31, p. 209, 1921; D a n d y W. E. Removal of cerebellopontile (acoustic) tumors through a unilateral approach, Arch. Surg., v. 29, p. 337, 1934; Kleinhirnbriickenwinkel-Tu-moren, Diagnostik und Therapie, hrsg. v. D. Plester u. a., B., 1978; P ertui set B. Les neurinomes de l'acoustique developpes dans 1'angle ponto-cerebelleux, P., 1970; T a v e r a s J. M. a. W o o d E. H. Diagnostic neuroradiology, Baltimore, 1964. I. S. Blagoveshchenskaya (otoneurologist),

E. I. Zlotnik (neurosurgery), 3. N. Polyanker (rents), V. V. Turygin (anat.).

All the nerves of the bridge (5-8) and the cerebellum were involved. All symptoms are on the side of the focus. The reasons:

Acoustic neuroma - adhesive process of cerebellar-bridge angle

Acoustic neuromas are more common, followed by meningiomas and cholesteatoma. Neurinomas grow from the shell of the vestibular branch of the VIII nerve, ^ ^ but its lesion is detected here only during otoneurological examination; dizziness is rare. Usually the first symptom is hearing loss accompanied by noise. The trigeminal nerve root (decrease in the corneal reflex, pain, paresthesia in the face) and the vrisberg nerve (taste disorder in the anterior 2/3 of the tongue) are early involved in the process.

In half of the cases, the participation of the facial nerve was noted (pronounced damage is rare), as well as the abducent. As the tumor grows. 5y revealed cerebellar, stem (nystagmus) and cerebral symptoms. Bilateral neuromas of the VIII nerve are found in neurofibromatosis ^ Recklinghausen (see). An important diagnostic value is the radiographically determined expansion of the internal auditory canal.

pyramids of the temporal bone. With meningiomas, cerebral symptoms appear faster than with neurinomas. Cholesteatoma occurs as a result of chronic otitis media. With them, unlike neuromas, the VIII nerve suffers little. 3 x - Tumors of the IV ventricle. Ependymomas are more common, choroid papillomas are less common. Intracranial hypertension appears early, headaches are paroxysmal in nature, often accompanied by vomiting and dizziness, impaired cardiovascular activity, and breathing. Frequent cerebellar disorders (primarily walking disorders). Typically forced position of the head. Of the cranial nerves, the VI and VIII are more likely to suffer than the other 4, less often the V, VII, IX, X nerves. Focal symptoms include bouts of hiccups, respiratory and cardiovascular disorders. There are also attacks of tonic convulsions of the muscles of the trunk and limbs.

Trunk tumors are rare. Among the intracerebral, there are astrocytomas, spongioblastoma multiforme, among the extracerebral meningiomas.

2. Damage to the nervous system in AIDS. Clinical manifestations.

Etiology and pathogenesis. HIV infection is a disease caused by the human immunodeficiency virus. This virus belongs to non-oncogenic human retroviruses, the so-called lentiviruses (slow viruses), the main point of application of the cat is the immune system. Viruses have a long incubation period and are capable of persistence in the body. When they enter the body, the helper population of T-lymphocytes suffers first of all. In addition, they have a clear tropism for certain groups of cells - macrophages, monocytes, hieroglia cells, which causes chronic demyelinating damage to the nerve of the system. Activation of the endogenous - opportunistic flora (herpes virus, yeast-like fungi) and sensitivity to exogenous microbes (mycobacteria, cryptococci, cytomegaloviruses, toxoplasma, etc.) causing secondary damage to various organ systems.

Clinic and diagnostics. Neurological disorders were noted in 1/3 of cases of the disease and usually correspond to III (stage of secondary diseases - cerebral form) and IV (terminal stage - specific damage to the central nervous system) stages. In rare cases, during the period of infection, acute viral meningoencephalitis may develop, manifested by epileptic seizures and impaired consciousness up to coma. The cerebrospinal fluid showed lymphocytic pleocytosis. The most common syndromes of late damage to the nervous system include the AIDS-dementia complex, sensory polyneuropathy, or a combination of both. The cause of the AIDS-dementia complex is brain damage in the form of multifocal giant cell encephalitis and progressive diffuse leukoencephalopathy. In the initial stage of the disease, the patient complains of drowsiness, impaired concentration, and memory disorders. Then, a slight increase in muscle tone, sucking and grasping reflexes, adiadochokinesis, apathy, indifference to one's condition, bradykinesia, and tremor join. In the advanced stage of the disease, against the background of severe dementia, mutism, epileptic seizures, paraplegia, ataxia, and dysfunction of the pelvic organs occur. In the cerebrospinal fluid, a slight pleocytosis is detected. Computed and magnetic resonance imaging revealed atrophy of the cerebral cortex and expansion of the ventricles.

Sensory popineuropathy syndrome is manifested by pain, paresthesias in the arms and legs of the type of "gloves" and "socks", in combination with a decrease or loss of knee reflexes, flaccid paresis and autonomic "disturbances. Multiple mononeuropathies (lesions of the trigeminal and facial nerves) may occur at different stages of the disease , as well as muscle damage in the form of polymyositis and myopathy.: Treatment. There is currently no pathogenetic treatment. Zidovudine (200 mg 6 times a day) is used, as well as symptomatic therapy. 3. Osteochondrosis g.o..P.

Osteocondritis of the spine- this is a degenerative process that develops in the intervertebral disc and the vertebrae adjacent to it, which together is called the vertebral motion of the PDS segment.

Disk functions; Depreciation, Fixation, Provision of movement. OHP - a dystrophic lesion or change, which begins with the nucleus pulposus, spreads to the fibrosis ring and then to other elements of the PDS and often forms a conflict with adjacent neurovascular diseases . Theorim arose OCP: involutional, hormone, vessel, genetic, infectious, mechanical, abnormal, etc. According to etiology Zab-e muptifakotrialnoe. There are 2 main factors: decompensation in trophic systems and local overloads of PDS. Pathogenesis. Stages: Chondrosis is a process only in the disk. Osteochondrosis is a process in the disc and in the bone. Periods: 1 the period of intradiscal displacement of the pulpous tissue. Shrinkage of the nucleus pulposus, the appearance of cracks in the inner section of the annulus fibrosis.

2P-od of PDS instability. The nucleus pulposus was completely cracked. ZP-od forming hernia. 4P-od disc fibrosis and total changes in other structures.

Fibrosis - immobilization by a scar.

Clinic OHP is determined by the level of damage. First of all, these are vertebral syndromes. There are following manifestations: pain in the affected area (local pain during act and pass movements, limitation of movements, vertebral deformity (scoliosis, smoothness of lordosis / kyphosis), tension of the paravertebral muscles, soreness of protruding str- p, spinous processes), cervical backache, cervicalgia, thoracalgia, lumbar backache (lumbago), lumbalgia (subacute aching pain in the lower back), sacralgia, coccygapgia.

Extrovert syndromes are also distinguished, they develop as follows: post-afferent impulse from the affected PDS along the synovertebra nerve, spreading through the posterior horns to the anterior and lateral horns of the corresponding spin segment of the brain. At the same time, in some b-x forms myso-tonic, in others vasomotor, in others - neurodystrophic,

Flow OHP can. hron (there are no complete remissions), recurrent (series of exacerbations and remissions), hron-recurrent (the appearance of a new syndrome or increased clinical manifestations against the background of a slowly ongoing obstruction). Each exacerbation has 3 stages: progression, stationary, regression.

Vertebral Syndrome - pain in the affected area of ​​the vertebrae 1 .Local pain with active and passive movements. 2.0 movement restrictions.

Z. Vertebral deformity (scoliosis, smoothness of lordosis, kyphosis, asymmetry of the transverse processes).

4. Tension of the paravertebral muscles. b. Soreness of protruding structures affected by PDS Extravertebral syndrome- presence of symptoms at a distance. radicular syndrome:

Root compression can be caused by disc herniation, overgrowth of bone, hypertrophy of the yellow ligament, cicatricial adhesive changes in the epidural fiber; - deficient stage: hyporeflexia, malnutrition, muscle hypotension, hypo- and anesthesia in the zone of the corresponding dermatome; - irritative stage: reflexes are normal or animated, hyperesthesia. Diag. Clinic + X-ray signs:

Local change in the configuration of the vertebra (flattening of the physiological lordosis, the appearance of kyphosis, scoliosis) - a decrease in the height of the disc

The image of the marginal bone growths of "osteophytes" ("whiskers") - subchondral osteosclerosis

Pathological mobility (spondylopisthesis) - displacement of the bodies of adjacent vertebrae. As well as MRI, KG, ultrasound.

Treatment: exhausted and adequate information about the disease b-mu; high-quality, adequate, timely anesthesia; orthopedic regimen in the acute period. First-line analgesics are NSAIDs:

Non-selective COX-1 and -2 inhibitors: ibuprofen, diclofenac, naproxen, indomethacin, piroxicam, lornoxicam, ketoprofen, ketorolac

Highly selective COX-1 ing-ry: low doses of acetylsalicylic acid

Select ing-ry COX-2: nimesulide, meloxicam

Highly selective COX-2: coxibs.

They must be combined with 1 table. Omeprazole (for the stomach)

Muscle relaxants are used: baclofen, tizanidine, topperisone.

Chondroprotectors: stimulate the production of the main components of cartilage in chondrocytes + help slow down the degeneration of cartilage tissue and restore its structure.

Fixation of the neck with the pom of the Shants collar. Manual therapy, massage, IgloReflT, physiotherapy. With chronic pain syndrome - antidepressants.

At home: rubbing, ointments, applications, herbs, can massage, self-massage, needle applicators, reflexology with pepper plaster, metal and magnetic therapy.

Surgical treatment Absolute indication: acute compression of the joint venture of the brain and cauda equina roots, relative indication: severity and persistence of the root. syndromes in the absence of the effect of adequate conservative therapy carried out for more than 3-4 months. four .Pseudobulbar syndrome. Research technique in pseudobulbar syndrome.

Central. Developed with damage to the corticonuclear pathways 9,10 and 12 pairs of c.n. and manifested (with bilateral damage): dysarthria, dysphonia, dysphagia and pathological pseudobulbar reflexes (oral automatism - Proboscis reflex. ankylosing spondylitis oral reflex- Light tapping with a hammer on the upper lip of the patient or on his finger, laid across the lips, causes involuntary protrusion of the lips; Sucking reflex. Oppenheim sucking reflex- Stroke irritation of the lips leads to the appearance of sucking movements; Wurp-Toulouse reflex. wurpa lip reflex- Involuntary stretching of the lips, reminiscent of a sucking movement, arising in response to dashed irritation of the upper lip or its percussion; Oppenheim oral reflex- Line irritation of the lips, except sucking reflex, causes chewing, and sometimes swallowing movements; Nasolabial reflex. Astvatsaturov nasolabial reflex - Tapping with a hammer on the back or tip of the nose causes contraction of the circular muscle of the mouth and protrusion of the lips; Palmar-chin reflex. Marinescu-Radovic reflex- Caused by streak irritation of the skin of the palm in the thenar area. At the same time, a contraction of the chin muscle occurs on the same side. Normally caused in children under 4 years of age; enough.), violent crying and laughter

The human brain has a complex structure. The cerebellopontine angle is located at the junction of three areas: the pons, the medulla oblongata, and the cerebellum. Often it is here that tumor growths appear, which have a negative effect on blood vessels, the movement of cerebrospinal fluid and nerve endings. This is due to the compression of these elements. As a result, the bloodstream does not supply enough oxygen to the brain. The cerebrospinal fluid does not have the opportunity to leave, accumulates, aggravating the situation.

Diseases of the cerebellopontine angle

Damage to a part of the brain occurs under the influence of neoplasms. A tumor of the cerebellopontine angle is not one of them that occupies a certain position. In this case, damage occurs in any structure located at the site of manifestation of the pathology. The disease is classified into types that are subject to various therapeutic measures.

Types of cerebellopontine angle tumors

Medical statistics note an important fact. It consists in the fact that in ten percent of a hundred formations in the brain are located in a place called the cerebellopontine angle.

Types of tumors associated with a site lesion:

• neuroma of the vestibulocochlear nerve;
• meningioma;
• cholesteatoma.

The first disease accounts for 95 percent of all formations of the cerebellopontine angle. The detected tumor is benign and does not become a source of damage to other organs. Patients of working age are at risk. Often neurinoma is found in women. Today, doctors prefer to remove the tumor by surgery, while performing unilateral or bilateral removal.

Doctors often diagnose "cerebellar pontine angle syndrome". It should be noted that it is a consequence of another disease called neuroma.

Symptoms

It is not always possible to detect a tumor in the brain in time, since there are not enough good reasons for a full examination. The clinical picture is weak, there are no sharp jumps associated with a deterioration in well-being. The patient does not pay attention to the noise in the ear for a long time. This phenomenon is called cochleovestibular syndrome.

Gradually, the symptoms of the disease become more intense. As a rule, it is manifested by the appearance of deafness, the facial nerve is immobilized. Only after that a full examination is carried out, and the patient is immediately sent to the operating table to remove the tumor.

It is noted that this stage becomes the first bell about a developing disease that requires attention.

Clinical picture of the signs of the disease

The manifestations of pathology are as follows:

1. Headache.
2. The reflex responsible for closing the upper and lower eyelids is disrupted if you try to touch the cornea or conjunctiva with a tissue. This means that the patient needs a complete and in-depth examination.
3. Phenomena present in the cerebellum. They also have several varieties, including general cerebellar ataxia, unilateral hemiataxia. The patient has disturbances in gait, the tone of the muscular apparatus decreases. There are complaints of dizziness.
4. Hands and feet fail, paralysis sets in.

When a lesion of the cerebellopontine angle is diagnosed in a patient, the following signs of the disease are added to the indicated symptoms:

1. With a neuroma, disturbances will be felt in only one ear.
2. The defeat in the auditory area in the first periods of the disease is manifested by noise or whistling in the inner ear.
3. Gradually, the state of the organ becomes worse, deafness sets in. The only sound that the patient can still hear is only high tones.

The position of the neuroma in the brain indicates a future source of negative influence. This means that if the right side of the cerebellopontine angle is affected, the organs located, respectively, similarly to the left hemisphere, will suffer.

Additional symptoms

Also, the disease can manifest itself as follows:

1. In the back of the head, patients feel pain, localized where the tumor is located.
2. The facial nerve is not sensitive to external stimuli.
3. If the auditory canal is damaged, the patient develops profuse salivation. The patient does not smell, the sense of smell also disappears.

An increase in the neoplasm leads to the fact that the nerves of the cerebellopontine angle are pinched and then additional clinical signs develop:

• the voice becomes quieter or disappears;
• when talking, the timbre can change;
• swallowing function is impaired.

When the cerebellum is compressed by a tumor, the following symptoms appear:

• arms and legs are weak and move with difficulty;
• it seems that the patient is in slow motion, so he moves;
• the tips of the hands begin to tremble;
• when trying to get something, the patient misses;
• eyeballs move spontaneously.

Carrying out diagnostics

The examination helps to identify the source of the ailment and prescribe adequate treatment. Also, the diagnosis is designed to exclude other diseases with similar symptoms, as in a lesion of the cerebellar angle.

Diagnosis occurs with the use of medical equipment:

• CT scan;
• x-ray;
• magnetic resonance imaging;
• angiography.

Treatment

The success of therapeutic measures depends on the period of detection of the disease. Accordingly, the earlier a lesion of the cerebellopontine angle was detected, the greater the chances of restoring the patient's normal state of health and the performance of the damaged organs.

Today there are two types of treatment:

1. Conservative. It is used if the tumor formation has a low growth rate.
2. Surgical. Surgery is used if the formation is rapidly increasing in size. Additional means are chemotherapy and radiation therapy.

In this case, surgery is used as a last resort, when other methods have not yielded results. This is due to the fact that in the place of the cerebellopontine angle there are many important areas, damage to which will lead to the patient's disability or death.

Neurinoma is a benign tumor of the cerebellopontine node. However, there are also malignant manifestations of the neoplasm. The tumor has other names - neurofibroma, schwannoma. A tumor grows from the cells of the sheaths of nerve endings. The mechanism of development of neuroma is poorly understood. It is believed that the pathology occurs due to a malfunction of the immune system. Another risk factor is hereditary predisposition. Symptoms of neuroma are manifested by increasing hearing loss and tinnitus over several months or years. In other cases, the function of the cranial nerves may be impaired.

Development of the disease

In women, neurinoma of the pons of the cerebellar angle is detected more often. There is also a correlation between the growth of neoplasms from hormones and exposure to radiation. The growth of cerebellar neuroma leads to its compression, compression of the 5th and 7th cranial nerves, the bridge, the group of nerves of the medulla oblongata and spinal cord.

The growth rate of the neoplasm has a different intensity in patients. Most often, a neuroma of the brain grows slowly at a rate of 2 to 10 mm per year. In some patients, pathology may not manifest itself until the moment when the tumor grows to a significant size. Cranial neuroma is surrounded by a capsule, is not able to grow into adjacent tissues, and can form cysts.

Clinical picture of neuroma of the brain

Symptoms depend on the location and extent of the neoplasm. Patients complain of whistling or tinnitus. Gradually, the noise is replaced by partial deafness. The patient may have difficulty hearing high pitched sounds.

If a neurinoma of the right cerebellopontine angle develops, the patient complains of a hearing disorder on the right side. Accordingly, with a neoplasm on the left, hearing loss occurs on the left side. After partial deafness in one ear, complete deafness develops.

Patients with neurinoma develop periodic and involuntary movements of the eyeballs (nystagmus). Other symptoms include:

• occipital pain on the side of the tumor;
• loss of sensation of the facial nerve.

If the tumor develops in the region of the internal auditory canal, the patient develops a violation of salivation, a partial loss of taste and sensitivity in the nasal cavity on the side of the tumor. If the tumor grows and affects the vagus nerve, the following symptoms appear:

• weakening of the vocal cords;
• changing the modification of the sound during a conversation;
• swallowing disorder.

With compression of the cerebellum, the patient develops characteristic symptoms:

• weakening of the tone of the muscles of the arms and legs;
• slow movements;
• inability to perform rapidly alternating movements;
• tremor with purposeful movements;
• miss;
• spontaneous movement of the eyeball on the side of the lesion.

With large sizes, neuromas can develop. Patients complain of severe headaches in the morning, which are accompanied by vomiting. Usually this symptom appears several years after the onset of the formation of a neuroma.

Diagnosis and treatment of neuroma

When diagnosing, cholesteotoma, Meniere's disease, neuritis of the auditory nerve, arachnoiditis, and vascular pathologies are excluded from the patient. In addition, an aneurysm of the vertebral arteries, tuberculous or syphilitic, is excluded.

For diagnostics use:

• computer diagnostics;
• x-ray examination;
• angiography.

Since the tumor grows slowly and may regress in some cases, patients are offered conservative treatment. To eliminate cerebral edema, it is indicated

With a small size of the neoplasm, its microsurgical removal is indicated. In this case, patients may retain hearing and nerve function. Rehabilitation after removal of small neurinomas up to 2 cm is much faster. With the total removal of a large neuroma, postoperative complications can occur - paresis and paralysis of the facial nerve. With partial removal of a neuroma, radiation therapy is considered.

Complications after the operation are possible:

• temperature rise;
• convulsions, nausea;
• loss of sensation in certain parts of the body;
• dyspnea;
• headache;
• tachycardia.

When pathological symptoms appear, a second diagnosis is carried out in order to correct treatment and further observation.

Alternative methods of treatment of neuroma

Folk remedies for the treatment of neurinoma include the use of tinctures and decoctions, dieting.

Important! Any even harmless prescription of traditional medicine should be discussed with a doctor.

Traditional medicine recipes:

1. Horse chestnut tincture. 50 g of flowers are poured into 0.5 liters of vodka, insisted for 10 days, squeezed. Apply 10 drops 3 times a day. The tincture is diluted with water. The course of treatment is 2 weeks. After a break of 7 days, the course is repeated.
2. Sophora japonica tincture. 50 g of raw material is poured with 0.5 alcohol, insisted for 40 days, filtered, squeezed. Take a tincture of 10 ml every day. The tincture is diluted with water. The course of admission is 40 days. If necessary, the course is repeated after a two-week break.

The following fruits and vegetables have antioxidant effects:

• beet;
• blueberry;
• grape;
• blackberry;
• garlic;
• broccoli;
• cherry;
• a pineapple;
• green tea.

Dangerous foods include fatty meat and dairy foods, smoked meats, sugar, flour products, and canned goods. Proper nutrition helps cells recover, improves the patient's well-being, protects against inflammatory processes, and improves metabolism.

In conclusion, it is worth noting that in the event of tinnitus, deafness, you should consult a doctor and undergo a comprehensive examination. Due to the timely detection and removal of neurinoma, the patient increases the chance to preserve hearing and cranial nerve function.

Novosibirsk State Medical University

Department of Neurosurgery of the Faculty of Medicine

Disease history

FULL NAME. patient: K****, age 44

Diagnosis at admission: Volumetric formation of the MMA (bridge-cerebellar angle) on the right

Clinical diagnosis: Volumetric formation of MMU on the right. Symptomatic neuralgia 1, 2 branches of the trigeminal nerve on the right

Novosibirsk 2011

1. Passport part

history neuralgic tumor cerebellopontine

Full name: K****

Age: 44

Gender: male

Profession: Manager

Family status:

Time of admission to the clinic: 05.05.11

On admission condition: satisfactory

Hospitalization indications: plan

Complaints on admission

The patient complained of periodic facial pains of a shooting nature in the frontal region, as well as in the middle zone of the face on the right, arising during the morning toilet, when going outside, after or during prolonged work at the computer.

Complaints at the time of curation

The patient complains of dizziness, the right eye does not close, which leads to dryness and pain, as well as the lack of hearing in the right ear.

Anamnesis morbi

I felt sick in February 2011, when for the first time there were pains of a shooting nature in the frontal region on the right. The patient consulted a neurologist and conservative therapy was prescribed. The patient took Finlepsin 200 mg 1-2 tons per day to relieve pain attacks. In April, the pain began to appear in the middle region of the face. The patient was referred for (MRI) Magnetic resonance imaging of the brain with contrast, filed by which there is a picture of volumetric formation of MMA on the right. External replacement hydrocephalus. A consultation with a neurosurgeon was recommended for subsequent hospitalization for the purpose of diagnostic examination and surgical treatment.

Anamnesis vitae

Hepatitis, typhoid fever, malaria, cholera, tuberculosis, venereal diseases denies. Allergic history is not burdened. Has been suffering from psoriasis since the age of 18.

The present state of the patient

General inspection

Patient's condition: moderate

Consciousness: clear

Patient position: passive

Build: correct, no deformities

Skin: flesh-colored, dry, clean, without rashes, no hemorrhages.

Gait: -

Lymph nodes: not enlarged

7. Respiratory system

Nose of the correct form. No visible deformation. Palpation of the larynx is painless. The chest is of the correct form, symmetrical. There are no deformations. The type of breathing is mixed, the respiratory rate is 18 rpm. Palpation did not reveal any painful areas. The chest is moderately elastic. Auscultatory-vesicular breathing, no additional respiratory sounds. Bronchophony on both sides is preserved.

The cardiovascular system

There are no visible pathological pulsations of blood vessels on the neck. The area of ​​the heart is not changed. The apex beat is localized in the 5th left intercostal space 1 cm medially from the left mid-clavicular line of a positive nature. Cardiac impulse and other pathological pulsations are not determined. Heart sounds are normal. There are no additional tones, bifurcation, pathological rhythms. Noises are not auscultated, the rhythm is correct, the heart rate is -68v/min. BP on the right and left arm 130/80 mm Hg. pulsation of the carotid, radial, popliteal arteries and arteries of the body of the foot is determined.

Digestive system

Appetite returned to normal. The chair was restored - 1 time per day, a moderate amount. There are no blood impurities in the feces. The tongue is moist, without plaque, the mucous membranes of the oral cavity are pink, moist, hemorrhages and ulcers are not detected. The abdomen is of the correct shape, symmetrical, participates in the act of breathing. There is no free fluid in the abdominal cavity. On palpation, the abdomen is soft and painless. Symptom of Shchetkin-Blumberg, Sitkovsky, Rovsing are negative. A moderate noise of peristalsis is heard over the entire surface of the abdomen. The noise of friction of the peritoneum is absent.

Pulsations in the area of ​​the liver were not detected. The edge of the liver is sharp, painless on palpation. The surface of the liver is smooth. The gallbladder is not palpable. There are no protrusions in the region of the left hypochondrium. The pancreas is not palpable.

Urinary system

No deformities were found in the lumbar region. The kidneys are not palpated. Symptoms of tingling of the lumbar region are negative. Urination is painless.

Endocrine system

There are no complaints about thirst, hunger, constant feeling of heat, sweating, chills, convulsions.

The thyroid gland is not enlarged. Secondary sexual characteristics correspond to sex.

Neurological status

cranial nerves

pair - olfactory nerve (n.olfaktorius) sensitive, the place of exit from the brain is the olfactory bulb.

The sense of smell is roughly preserved on both sides.

pair - optic nerve (n.opticus) sensitive, the place of exit from the brain is the optic chiasm.

Vision is tentatively preserved, there is no loss of visual fields. The color perception is preserved.

a pair - the oculomotor nerve (n.oculomotorius) is motor, the place of exit from the brain is in front of the bridge, on the medial edge of the brain stem.

pair - trochlear nerve (n.trochlearis) motor, the place of exit from the brain - dorsally, behind the quadrigemina, goes around the leg of the brain.

pair - abducent nerve (n.abducens) - motor, the place of exit from the brain is the posterior edge of the bridge, in the groove between the bridge and the pyramid.

palpebral fissures are asymmetric D=S, eyeballs are mobile, movements are in full, synchronous. Paresis of the gaze is not observed. There is no diplopia. Pupils of medium size D=S, rounded, reaction to light is direct and friendly. Accommodation in normal convergence is not disturbed.

pair - trigeminal nerve (n.trigeminus) mixed, place of exit from the brain, anterior edge of the Varalian bridge, later. - movements of the lower jaw are not limited. There is no tension in the masticatory muscles. Trophy is not broken. On palpation at the exit points of 1-2 branches, slight soreness was noted. The sensitivity of the facial skin is preserved.

a pair - the facial nerve (n.facialis) is mixed, the place of exit from the brain is on the posterior edge of the bridge, in front and laterally from the olive.

facial asymmetry is not observed, slight smoothing of the nasolabial fold on the right. The taste is not affected.

pair - vestibulocochlearis nerve (n.vestibulocochlearis) sensitive, the place of exit from the brain is the posterior edge of the bridge, laterally from the olive.

there are no complaints about ringing and noise in the ears. Hearing acuity on the left is not reduced, on the right, hearing acuity is whispering next to the right ear). There is no dizziness at rest or on movement. Nystagmus is not noted. There are no complaints of nausea and vomiting.

pair - glossopharyngeal nerve (n.glossopharyngeus) mixed, the place of exit from the brain in the posterolateral groove of the medulla oblongata, behind the olive.

pair - vagus nerve (n.vagus) mixed, the place of exit from the brain below the glossopharyngeal nerve, in the posterolateral groove.

swallowing is not difficult. Phonation and articulation are not changed. Salivation is moderately increased. The taste is preserved. The voice is loud and clear.

pair - accessory nerve (n.accessorius) motor, the place of exit from the brain, the upper roots are behind the vagus nerve, the lower roots are between the anterior and posterior roots of the cervical nerves.

the head is located in the midline, raising the shoulders is not difficult. The strength, tension and trophism of the sternocleidomastoid muscle is not reduced. There is no wryneck.

pair - hypoglossal nerve (n.hypoglossus) motor, the place of exit from the brain between the pyramidal and olive.

the tongue is located in the mouth, and when protruding in the midline. Atrophy and fibrillar twitching of muscles and tongue are absent. Physartria is not noted. The symptom of oral automatism is absent.

motor sphere

When examining muscle atrophy, true muscle hypertrophy, no pseudohypertrophy. There are no fibrillar and fascicular twitches in the muscles. Passive movements in the upper and lower extremities in full. The volume of active movements in both limbs is full. There are no paresis or paralysis. Barre test is negative. Walking is not difficult. The strength of the muscles in the distal and proximal sections on the right and left - 5 points. Muscle tone is not changed.

Tendon and periosteal reflexes of the upper extremities

carpo-radial (С5-С6)

biceps (C5-C6)

triceps muscle (C6-C7)

Vivid, symmetrical (D=S), zones not expanded.

top (th7-th9)

middle (th8-th10)

Lower (th11-th12)

Lively, symmetrical(D=S)

lower limbs

knee (l2-l4)

akhilov (l5-s2)

plantar (l5-s2)

anal (s5)

Lively, symmetrical, zones are not expanded.

Pathological reflexes are not called.

Clonuses of the foot, patella, hand on the right and left are absent.

sensitive sphere

Superficial sensitivity t (tactile, pain) is not changed (temperature sensitivity was not tested). Deep sensitivity (muscle-articular feeling) is preserved.

Difficult sensitivity, stereognosis - normal.

Pain on palpation of painful points of the occipital nerve, brachial plexus, paravertebral points was not detected.

Pain along the course of the intercostal nerves was not detected. Tension symptoms are negative.

There is no anti-pain installation of the trunk and limbs. No paresthesia was found.

Coordinating sphere

Performs coordinating tests of the finger-nose and heel-knee satisfactorily with the right and left limbs.

In the pose of Romberg Ustoychev.

There are no signs of tremor. Test for adiadochokinesis is negative.

autonomic nervous system

Skin of normal color. Trophic skin disorders are not determined. There are no edema. When checking local and reflex dermagraphism, no pathology was detected. Male pattern hair. Nails of the correct form. Diseases in the area of ​​the solar plexus were not revealed.

pelvic organs

There is no urinary retention or defecation. Controls the functions of the pelvic organs. There are also no imperative urges to urinate and defecate.

meningeal symptoms

There is no stiff neck. Kernig's sign is negative on both sides. Brudzinsky's symptoms (upper, middle, lower) are negative on both sides. Bechterew's symptom is negative.

Study of speech functions

Comprehension of oral and written speech is not impaired. Spontaneous speech is possible.

Paraphasia, perseveration in speech is not observed.

The phrases are grammatically correct. The naming of objects is not violated.

The patient correctly understands complex, multilink and attributive constructions. Words are spoken clearly and distinctly.

Psychic realm

Gnosis research: recognizes and names objects correctly. Recognition of objects by their characteristic sounds is preserved. Recognition of objects by touch is not impaired. Correctly identifies and differentiates parts of his body. Feels pain. Smells, taste irritants distinguishes, differentiates.

Praxis research: purposeful and programmed actions are preserved. Actions with real objects, imitation of work with imaginary objects are preserved. Familiar gestures are saved.

In the study, he is completely oriented in place, in time and in his own personality. Contact. Sleep is not disturbed. The behavior is calm. Memory, intelligence corresponds to age.

Survey plan

Expected to do:

.Clinical blood test

.Blood chemistry

.Clinical analysis of urine

ECG

.brain MRI

Data of laboratory, instrumental research methods

Clinical blood test 05/06/2011

Erythrocytes 4.9*10^12/l

Hemoglobin 155g/l

Color index 0.96

Leukocytes 6.3*10^9/l

Eosinophils 2.0%

Band 2.0%

Segmented 74.0%

Lymphocytes 19.0%

Monocytes 3.0%

ESR 231.0mm/h

Blood chemistry:

Total protein 71g/l

Urea 6.4mmol/l

Glucose 5.8 mmol/l

Total bilirubin 14.6 µmol/l

ALT 25.0 units/l

AST 19.0 U/L

Clinical urinalysis:

Color - straw yellow

Oud. weight - 1024

Reaction - sour

Protein - norms

Epithelium squamous - 1-3 in p / sp

Leukocytes - 1-2 in p / sp

Salt - oxalates ++

The rhythm is sinus, correct. Heart rate - 62 bpm.

There are no signs of hypertrophy.

MRI of the brain:

Conclusion: MRI picture of a volumetric formation of the right MMU (neurinoma is most likely). External substitute. hydrocephalus. Rhinosinusopathy.

Preoperative epicrisis

Patient Kim Oleg Suinovich, 44 years old, has been in the Department of Neurosurgery since 05.05.2011.

Diagnosis: Volumetric formation of the right cerebellopontine angle (neurinoma 2 gradation). Peripheral paresis 7 on the right. Neuralgia of 1-2 branches of the trigeminal nerve.

The diagnosis was confirmed by MRI of the brain, clinical and neurological data.

Blood group A(2) Rh(+) pos.

The operation is scheduled for 10.10.2011

Operation

Operation: Microsurgical removal of the tumor of the right cerebellopontine angle (neurinoma) through the retrosymoid approach.

Patient position: sitting

Rigid fixation of the head with the Meyfield brace

Anesthesia endotracheal, trephine Codman

Magnification Microscope Omni Pentero

Paramedial oblique incision of soft tissues in the cervical-occipital region on the right. Automatic trepanation of the PCF paramedian to the right from the retrosigmoid approach, the size of the defect in the occipital bone is 4*5 cm.

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