Cerebral edema

Pathological phenomenon

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Brain edema refers to the pathological phenomenon that increases the water content in the brain and leads to the increase of brain volume Brain tissue Response to various pathogenic factors. Can be sent Intracranial hypertension , injured brain tissue, clinically common in Nervous system diseases , such as Craniocerebral trauma ， Intracranial infection （ encephalitis ， meningitis Etc.), Cerebrovascular disease , intracranial space occupying Sexual diseases (e.g tumour ）， Epilepsy And systemic diseases such as Toxic dysentery , Heavy pneumonia 。

Foreign name: cerebral edema
Common location: Brain tissue
Common causes: Brain injury, intracranial space occupying lesion, intracranial inflammation, cerebrovascular disease, cerebral hypoxia, etc

infectivity: nothing
genetic: nothing

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pathogeny

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one craniocerebral injury : All kinds of brain injuries, which directly or indirectly cause brain contusion and laceration, can cause brain edema, accompanied by intracranial hematoma, and can also cause brain edema if local brain tissue is compressed. Depressed fracture of skull , compression on the brain tissue, or direct injury caused by the fracture penetrating into the brain tissue, and brain edema occurs at the affected part, Knock injury Air wave Impact the chest, or the chest is directly squeezed, so that Superior vena cava The pressure rises sharply and spreads to the brain, impacting the brain tissue, causing extensive capillaries in the brain tissue Diffuse Spot hemorrhage, increased capillary permeability, often diffuse brain edema Diffuse axonal injury , can be secondary to severe diffuse brain edema.

Cerebral edema

two Intracranial space occupying lesion : The tumor compresses or blocks the surrounding brain tissue Venous reflux , increased venous pressure, intracranial Congestion , cerebrospinal fluid Circulator Absorption disorders, and tumor organisms Toxic effect The brain tissue around the tumor will be affected, the blood-brain barrier will be damaged or destroyed, the permeability of blood vessel wall will be increased, and local brain edema will occur. Cerebral Primary Malignant tumor The complicated brain edema is particularly significant, lung cancer ， Choriocarcinoma Waiting Brain metastasis No matter it is single or multiple, there is serious brain edema around the focus.

three Intracranial inflammation : encephalitis, meningitis, ventriculitis brain abscess and septicemia It causes diffuse intracranial inflammation, often secondary to varying degrees of brain edema, which is similar to Pathogenic microorganism And the range of involvement.

four Cerebrovascular disease : Thrombosis or embolism of internal carotid artery or cerebral artery, Cerebral fat embolism , reducing or interrupting the blood flow of the artery, causing an acute attack in the blood supply area of the artery Cerebral insufficiency And cerebral infarction , while secondary limitations or Universality Brain edema, Cerebral aneurysm or Arteriovenous malformation Rupture bleeding, subarachnoid hemorrhage Intraventricular hemorrhage At the same time, cerebral vasospasm occurred, which was secondary to brain edema.

five Cerebral hypoxia Status epilepticus ， Thoracic trauma . Due to different reasons dyspnea Or suffocation Cardiac arrest , long time hypotension , shock Altitude hypoxia 、 carbon monoxide poisoning And other pulmonary origin encephalopathy , make the brain in hypoxia state with brain edema;

six Exogenous or endogenous poisoning : General poisoning caused by lead poisoning or other reasons is often accompanied by diffuse brain edema.

seven Brain metabolic disorder : Brain edema is caused by various reasons, such as systemic or localized brain metabolic disorder.

eight Brain radiation damage : including electromagnetic damage such as microwave infrared 、 X-ray ， Gamma ray ， Beta ray 、 Fast neutron Etc.

Pathogenesis

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The pathogenesis of brain edema is very complex, and there are many related factors, such as blood brain barrier Microcirculatory disorders Cerebral ischemia and hypoxia, intracerebral Free radical Increase, Thromboxane A2 And prostacyclin, Neurotransmitter And neuropeptide Class changes. nerve cell Calcium overload Can affect the occurrence and development of brain edema.

one Dysfunction of blood-brain barrier The blood-brain barrier has the greatest effect on brain edema. The blood-brain barrier is the barrier between the capillary cavity of the brain and the brain parenchyma vascular endothelial cell 、 basement membrane and Astrocyte It is composed of vascular lamella. Blood cerebrospinal fluid barrier Mainly Choroid plexus Epithelium and endothelial cells Blocking between Small band There is also a barrier between cerebrospinal fluid and brain parenchyma Pia mater Gliomas Membrane composition. So the relationship between brain and blood Substance exchange It must pass through this blood brain barrier. Water can freely pass through the blood brain barrier and the blood cerebrospinal fluid barrier, and the ability of electrolytes to pass through the blood brain barrier and the blood cerebrospinal fluid barrier is related to their Liposolubility Relevant, fat soluble substances are easy to pass, but glucose Can also pass. In case of brain injury, brain tumor and inflammation, the blood-brain barrier will be destroyed, causing plasma Macromolecular substances It can penetrate into the brain cell space from the vascular lumen. Therefore, it is considered that the damage of the function and structure of the blood-brain barrier is the pathological basis of vascular brain edema.

Cerebral edema

two Cerebral microcirculatory disorder Whether the cerebral blood flow and microcirculation are normal or not is extremely important to maintain the normal physiological operation of the brain. The cerebral blood flow is affected by the systemic blood pressure, and changes with the Pressure difference It varies. Cerebrovascular It has internal and central regulation function cerebral blood flow Keep stable within a certain range. When brain injury, brain tumor, inflammation and other diseases occur, cerebral vessels spasm or paralysis, microcirculation dysfunction, and their venous pressure increases, Cerebral hyperemia , Brain hypoxia, leading to brain Metabolic disorder Brain edema. Therefore, brain microcirculation disorder is an important factor in the occurrence of brain edema.

three Brain cell metabolic disorder Nerve cells in the brain are the structural and functional units of the nervous system, including Soma And protuberance. The fine structure of brain cells maintains the normal metabolism and function of brain cells. During brain cell metabolism, glucose metabolism Is the most important aspect. Normal Aerobic metabolism When the brain is hypoxic, glucose metabolism in cell metabolism changes to anaerobic mode, which is decomposed into lactic acid 、 pyruvic acid Wait, also Release energy 。 But because ATP It is only 5% of normal aerobic metabolism. The function of cells and cell membranes is damaged, Sodium pump 、 Calcium pump The plasma pump is out of order, and the excess Sodium ion The chloride ion enters from the outside of the cell and binds to the inside of the cell sodium chloride And increase the osmotic pressure in cells. Water enters the cell from the outside to maintain the balance of osmotic pressure inside and outside the cell and form intracellular edema. But inside the cell Acids The production of TNF also increases the permeability of cell membrane and aggravates cell edema.

four Free radical : Free radicals in brain tissue, oxygen free radicals are a kind of Chemical activity Oxygen containing group of, mainly composed of superoxide anion And oxyhydrogen radicals. When brain injury occurs, oxygen free radicals increase in the brain, cerebral hemorrhage , Brain Ischemia reperfusion The free radicals also increase in a large amount. The free radicals damage the cell membrane system, damage the blood-brain barrier, and cause brain edema.

Cerebral edema

five Calcium overload of nerve cells In recent years, some studies suggest that the change of calcium overload in nerve cell membrane, and calcium overload in nerve cells is an important antecedent factor causing brain edema. Calcium is an important factor in maintaining the normal function of nerve cells Central nervous system Cells information transfer Synthesis and release of neurotransmitters and nerve cells Axoplast The function of blood brain barrier plays an extremely important role. cell membrane calcium channel If it is opened abnormally, extracellular calcium ions will enter into the cells, and intracellular calcium overload will occur Injurious effect 。 The adverse effects of calcium overload are wide: it can be activated ATPase 、 protease 、 phospholipase , make ATP, cell protein 、 lipid Catabolism Increase Cytoskeleton system and Membrane system , affect the Quick reaction Gene expression and regulation, affecting cells DNA , causing serious damage to cells. It can also make Cerebral vasospasm And brain Hair cell Vascular permeability Change occurs. Therefore, calcium channel opening and neuronal calcium overload have been regarded as one of the key links to cause brain edema.

six Intracranial venous pressure rise and others.

clinical manifestation

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Multiple population

People with brain tissue damage caused by intracranial or systemic diseases.

Symptoms

Cerebral edema

Brain edema is a secondary pathological process caused by intracranial diseases and systemic diseases. At the same time, brain edema often causes or aggravates the increase of intracranial pressure, so the clinical manifestations often overlap with the symptoms of the primary disease and aggravate it.

one
Symptoms of brain damage : Localized brain edema mostly occurs around the local brain contusion, laceration, brain tumor and other space occupying lesions and vascular diseases. The common symptoms are the aggravation of epilepsy and paralysis, or motor aphasia caused by the expansion of water quality and the spread of language and motor center. After brain injury, if the symptoms gradually worsen, more attention should be paid to brain edema. Diffuse brain edema may continue to expand to whole brain or diffuse brain edema at the beginning, such as diffuse axonal injury, because local brain edema cannot be controlled.
two
Symptoms of intracranial hypertension : The symptoms are headache, vomiting, restlessness, lethargy and even coma. Fundus examination showed papilledema. Early compensatory symptoms such as changes in vital signs, slow pulse and respiration, and elevated blood pressure may lead to brain hernia if brain edema and intracranial hypertension continue to deteriorate.
three
Other symptoms : Brain edema affects the frontal lobe, temporal lobe, and anterior thalamus, which can cause mental disorder, and in severe cases, unconsciousness and coma. Increased intracranial pressure can also cause mental symptoms. Sometimes the body temperature increases moderately, and brain edema affects the hypothalamus, which can cause damage to the hypothalamus.

Disease hazard

Brain edema increases the intracranial pressure, which can aggravate brain edema. When it develops to a certain extent, it can make the brain Histogenesis Functional and structural damage. If it cannot be diagnosed and treated in time, brain edema will worsen, or it will develop from localization to diffusion, which will cause serious damage to the brain, and form irreversible secondary pathological changes brain death 。 This outcome is caused by the widespread damage of brain tissue and severe damage of brain stem secondary to brain hernia.

Check diagnosis

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The examination and diagnosis of brain edema can be prompted from the following aspects:

one
According to the clinical manifestation and process of the disease : Brain edema is often secondary to the primary disease. If the clinical symptoms become significantly worse in a short period of time, local brain edema should be considered. Patients in the cleavage quickly develop severe symptoms of increased intracranial pressure, coma, and most of them are extensive or global brain edema. If there is diuretic effect after dehydration treatment, and the condition also improves, it also indicates that there is brain edema.
two
Intracranial pressure monitoring Intracranial pressure monitoring can display and record the dynamic changes of intracranial pressure, such as the increase of intracranial pressure. The analysis of intracranial pressure curve combined with clinical process can indicate the development and regression of brain edema.
three
CT or MRI : The most reliable diagnostic method to directly prompt brain edema during CT or MRI scanning. The signs shown in CT images are around the focus or white matter area, low-density areas in different areas. On T1 or T2 weighted MRI images, the edema area is high signal, which is more accurate than CT scanning results.

treatment

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The treatment principle of brain edema is to remove the cause of disease and adopt comprehensive brain edema treatment, both of which complement each other.

surgical treatment

Timely removing the cause of brain edema is the fundamental treatment. Contusion and laceration of brain Invasive, necrotic and liquefied brain tissue and Subarachnoid hemorrhage , clear intracranial hematoma , remove the Bone slice And restoring depressions fracture , relieve the stimulation and compression on brain tissue, brain tumor Excision, Non Traumatic Intracerebral hematoma After clearing the cause, the brain edema gradually subsided.

Other therapies

The important measures to prevent and cure brain edema when improving cerebral hypoxia should first keep the respiratory tract unobstructed. If hypoxemia and hypercapnia occur, auxiliary respiration and controlled ventilation should be used. It is common in clinical practice for patients with brain injury to remain in coma, so tracheotomy should be carried out immediately and oxygen should be given fully. After the cerebral hypoxia is relieved, the condition will be improved. If the hypoxia is not relieved in time, the treatment will be difficult to play a role.

Brain edema and treatment of intracranial hypertension

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Dehydration treatment, according to the condition, choose dehydration drugs, commonly 20% mannitol, furosemide. It can be supplemented with concentrated serum albumin to achieve good dehydration and hypotension effect.
two
Obstructive hydrocephalus leads to hydrocephaledema. Continue to drain the lateral ventricle to reduce the amount of cerebrospinal fluid, so as to achieve the purpose of decompression and removal of brain edema.
three
There is a lack of consensus on the use of hormones and other drugs for brain cell damage, and the use of large doses of hormones. Free radical scavengers have certain therapeutic effects.
four
It can promote cerebral blood flow perfusion, improve microcirculation, and reduce the permeability of blood-brain barrier. Calcium channel antagonists such as nimodipine can be used.

The function of promoting and improving brain metabolism Nimodipine, as a calcium ion blocker, has the effect of protecting cell membrane and preventing calcium ions from entering the cell. CDP choline is an important coenzyme in the process of lecithin biosynthesis in the brain, while lecithin is an important component of nerve cell membrane, and drugs such as cerebrolysin, piracetam, and duxil have the effect of promoting cell redox, Increase cell energy and accelerate the repair of brain cell function.

prognosis

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Brain edema belongs to secondary Pathological process , systemic diseases such as severe heart and brain vascular disease 、 Respiratory diseases 、 hepatopathy Shock and poisoning Metabolic disease Waiting for the body internal environment Changes occur, causing cerebral ischemia and hypoxia, brain microcirculation and brain cell metabolism disorders, cocoa can cause brain edema. So it has universality Meaning. stay neurosurgery In terms of encephalopathy, such as brain injury, intracranial space occupying lesions, inflammation Cerebral vascular disease 、 Cerebral parasitosis , Brain Congenital disease Often secondary edema, secondary edema, often related to the process of intracranial disease and prognosis , which is more significant. In the field of neurosurgery, if we can better understand the mechanism of brain edema and prevent and treat brain edema, we can achieve better results in the treatment of intracranial diseases.^[1]

Disease control information

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In 1905, Reichardt observed and compared the differences between brain edema and brain swelling on cut brain tissue samples^[2] 。 In the 1960s, Klatzo proposed Angiogenic cerebral edema and Cytotoxicity Two Concepts of Brain Edema^[3] 。 Fishiman first proposed interstitial brain edema^[4] 。

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