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FACTS AND DELUSIONS OF PERINATAL NEUROLOGY
The main goal was achieved, many parents (and doctors) had a certain clarity in perinatal neurology, many kids had "saved" from hospitalization, unnecessary examinations and pills. Many doctors and massage therapists "scope of work" significantly decreased. It seems that everything has long been understood, unfortunately, the article has absolutely not lost its relevance, so I am writing again and again. September 2012
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Key words: perinatal encephalopathy (PEP) or perinatal damage of the central nervous system (PP CNS), hypertensive-hydrocephalic syndrome (GHS); Gref’s symptom, the symptom of the “setting sun”; dilatation of the ventricles of the brain, interhemispheric fissure and subarachnoid spaces, lentikuostriarnaya vasculopathy (angiopathy), mineralized (mineralizing) vasculopathy (angiopathy), pseudocysts on neurosonography (NSG), muscular dystonia (SMD), syndrome of hyperactive disorder and ventricular syndrome.
According to the perinatal neurologists of the leading medical centers of the country, so far, no less 80-90%! children of the first year of life come in the direction of a pediatrician or a neurologist from the district clinic for a consultation about nonexistent diagnosis – perinatal encephalopathy (PEP):
The diagnosis of “perinatal encephalopathy” (PEP or perinatal damage of the central nervous system (PP of the CNS), in the old days was very common in pediatric neurology and extremely convenient: he described almost any real or imaginary dysfunction (and even structure) of the brain in the perinatal period of life of the child (from about 7 months of intrauterine development of the child and up to 1 month of life after childbirth) arising from the pathology of cerebral blood flow and oxygen deficiency. Later, bringing to life "continuity of neurological diagnosis", perinatal encephalopathy (PEP) necessarily transformed smoothly into two other favorite neurological diagnoses: MMD (minimal brain dysfunction) and IRR (vegetative-vascular dystonia).
The diagnosis of “perinatal encephalopathy” (PEP) is usually based on one or several sets of any signs (syndromes) of a likely disorder of the nervous system, for example, hypertension-hydrocephalic syndrome (HGS), muscular dystonia syndrome (SMD), hyper-stimulation syndrome.
After a thorough clinical examination, sometimes in combination with additional studies, the percentage of reliable diagnoses of perinatal brain damage (hypoxic, traumatic, toxico-metabolic, infectious, etc.) quickly decreases to 3-4% – more than 20 times! The saddest thing in these figures is not only a certain unwillingness of individual doctors to use the knowledge of modern neurology and conscientious delusion, but also clearly visible, psychological (and not only) comfort of such overdiagnosis.
Hypertension-hydrocephalic syndrome (HGS): increased intracranial pressure (ICP) and hydrocephalus
As before, the diagnosis " hypertensive – hydrocephalic syndrome" (GGS) or "intracranial hypertension" (increased intracranial pressure ( ICP) ),
one of the most commonly used and “favorite” medical terms in pediatric neurologists and pediatricians, which can explain almost everything! and at any age parents complaints. This is extremely comfortable for the doctor!
For example, a child often cries and shudders, does not sleep well, erupts a lot, eats poorly and gains little weight, widens his eyes, walks on his toes, his hands and chins tremble, there are convulsions and there is a lag of psycho-speech and motor development: – hypertensive-hydrocephalic syndrome (HGS) or increased intracranial pressure. ” True, a very useful and convenient diagnosis?
Quite often, “heavy artillery” is used as the main argument for parents – data from instrumental research methods with mysterious scientific graphs and figures. Strict scientific medical terms look mysterious and impressive, forcing the uninitiated to be even more respectful of medical conclusions.
Methods can be used very different, or completely outdated and uninformative / echoencephalography ( ECHO-EG ) and rheoencephalography ( Reg ) /, or surveys “not from that opera” ( EEG ), or incorrect, in isolation from the clinical manifestations, the subjective interpretation of the normal variants in neurosonography or tomography. Especially in recent times it has become an actual subjective interpretation, dopplerographic indicators of cerebral circulation in NSG. "Yes, the child has an increased rate of venous blood flow, and the resistance index is lowered by as much as 0.12! This is the surest sign of hypertensive-hydrocephalic syndrome!" – confidently say worried parents. "Look at the screen! That same – the left lateral ventricle increased in 2 months by 2 mm, and the right, even by 2.5! This is a very bad, serious problem, we will treat!" – comes from the neurosonography office, and both parents slowly slide along the wall.
One only "scientific and strict" entry in the NSG description – ". Changes in the structure of periventricular tissues are also revealed: on both sides of the projection of the parenchyma of the subcortical nuclei, linear hyperechoic structures (thickened walls of the vessels) are visualized. Conclusion: Easy expansion of the outer liquor spaces. Pseudocyst of the right vascular plexus. Lentikulostriar vasculopathy (angiopathy). mineralized (mineralizing) angiopathy (vasculopathy). echoprismus SEC (subependymal cyst) on the left, in CATV (caudothalamic tenderloin) SEC" – can easily and thoroughly poison the life of any family, especially "anxious violet" moms. Unhappy mothers of such children unwittingly, with the filing of doctors (or voluntarily, feeding on their own anxiety and fears), pick up the flag of “intracranial hypertension,” begin to actively "to treat" hypertensive-hydrocephalic syndrome (HGS) and for a long time get into the surveillance system of perinatal encephalopathy.
In fact, intracranial hypertension is a very serious, and quite rare, neurological and neurosurgical pathology. It accompanies severe neuroinfections and brain injuries, hydrocephalus, impaired cerebral circulation, brain tumors, etc.
Hospitalization is obligatory and urgent!
Intracranial hypertension (if it really is) can be easily noticed by attentive parents: it is characterized by persistent or paroxysmal headaches (usually in the morning), nausea and vomiting, not associated with food. The child, almost always sluggish and sad, constantly naughty, crying, refuses to eat, he always wants to lie down and cuddle up to his mother. The baby is really, really, bad; any attentive mother will notice this immediately
A very serious symptom can be strabismus or pupil difference, and, of course, impaired consciousness. In infants, the bulging and stress of the fontanel, the divergence of the seams between the bones of the skull, as well as the rapid, excessive increase in head circumference are very suspicious.
Without a doubt, in such cases, the child must, as soon as possible, show the experts. Usually, one clinical examination is enough to exclude or, conversely, pre-diagnose this pathology. Sometimes it requires additional methods of examination (examination of the fundus of the eye, neurosonography, as well as magnetic resonance imaging or computed tomography of the brain (MRI and CTG).
Of course, the expansion of the hemispheric fissure, ventricles of the brain, subarachnoid and other spaces of the cerebrospinal system in the images of neurosonography (NSG) or tomograms of the brain (computed tomography of the brain or magnetic resonance imaging) cannot serve as unambiguous evidence of intracranial hypertension. The same applies to isolated from clinical manifestations, cerebral blood flow disorders detected during transcranial Doppler of the brain vessels, and already, especially to the “finger impressions” on the roentgenogram of the skull.
In addition, there is no direct and reliable connection between intracranial hypertension and translucent vessels on the face and scalp, tiptoeing, shaking hands and chin, hyper-arousal, developmental disorders, poor academic performance, nasal bleeding, ticks, stuttering, bad behavior and
That’s why if your baby is diagnosed "perinatal encephalopathy (PEP) or perinatal damage of the central nervous system (PP CNS), intracranial hypertension or hypertension-hydrocephalic syndrome (HGS)" , on the basis of “staring out” the peephole (not to be confused with the true symptom of Grefe, the symptom of the “setting sun”!) and walking on tiptoe, then you should not go crazy beforehand. In fact, these reactions may be characteristic of very excitable young children. They are very emotional about everything that surrounds them and what is happening. Sensitive parents can easily notice such a relationship.
Thus, upon receipt of a non-existent diagnosis "perinatal encephalopathy (PEP) or perinatal damage to the central nervous system (PP CNS) and hypertensive-hydrocephalic syndrome " Before you panic and start actively stuffing unnecessary pills into your child, it’s best to quickly get a second expert opinion and contact a neurologist with modern knowledge of perinatal neurology. It was then, you can finally make sure of the absence of serious problems in the baby.
Start treatment for this unspecified "serious" pathology on the recommendations of a single doctor on the basis of the above “arguments” is absolutely unwise, in addition, such unreasonable treatment may not be safe at all. Any medications "removing intracranial hypertension"appointed unreasonably at that age can be harmful! Side effects are very diverse: starting with a mild allergic rash, ending with serious problems in the work of internal organs. Only diuretic drugs, unnecessarily prescribed for a long time, only adversely affect the growing organism, causing metabolic disorders.
But! There is another, equally important aspect of the problem that must be considered in this situation. Sometimes medications are really necessary, and improperly refusing them, on the basis of only my mother’s own conviction (and more often papa!) Of medical harm, can lead to serious unpleasantness. In addition, if there is indeed a serious progressive increase in intracranial pressure and the development of hydrocephalus, often incorrect medical therapy for intracranial hypertension entails a loss of an opportunity for surgery (bypass surgery) and the development of severe irreversible effects for the child: hydrocephalus, impaired development, blindness deafness and others.
Now a few words about the least “adored” hydrocephalus and hydrocephalic syndrome. In fact, we are talking about a progressive increase in intracranial and intracerebral spaces filled with cerebrospinal fluid (CSF) due to the existing! at that moment intracranial hypertension. At the same time, neurosonograms (NSG) or tomograms reveal changes in the course of time of the ventricles of the brain, interhemispheric fissure and other departments of the cerebrospinal fluid system. It all depends on the severity and dynamics of the symptoms, and most importantly, on the correct assessment of the interrelationships of increasing intracerebral spaces and other changes in the nervous system. This can be easily determined by a qualified neurologist. True hydrocephalus, which really requires treatment, as well as intracranial hypertension, is relatively rare. Such children must be observed by neurologists and neurosurgeons of specialized medical centers.
Unfortunately, in ordinary life, such an erroneous “diagnosis” occurs in almost every fourth to fifth infant. It turns out that quite often some doctors incorrectly call hydrocephalus (hydrocephalic syndrome) a stable (usually insignificant) increase in the ventricles and other cerebrospinal cerebrospinal fluid spaces. By external signs and complaints, this does not manifest itself, and does not require treatment. Moreover, if a child suspects hydrocephalus on the basis of a “large” head, translucent vessels on the face and scalp and
Sometimes during neurosonography, an ultrasound doctor finds in the brain pseudocysts – but this is no reason to panic! Pseudocysts call single round tiny formations (cavities) containing CSF and located in typical brain regions. The reasons for their occurrence, as a rule, are not known for certain; they usually disappear by 8-12 months. of life. It is important to know that the existence of such cysts in most children is not a risk factor for further neuropsychic development and does not require treatment. Nevertheless, although quite rarely, cysts are formed at the site of subependymal hemorrhages, or are associated with perinatal cerebral ischemia or intrauterine infection. The number, size, structure and location of the cyst give specialists very important information, taking into account which, on the basis of the clinical examination, the final conclusions are formed.
Description NSG – this is not a diagnosis or a reason for treatment!
Most often, NSG data provide indirect and uncertain results, and are taken into account only in conjunction with the results of the clinical examination.
Once again I must remind of another extreme: in difficult cases, sometimes there is a clear underestimation on the part of parents (less often – and doctors), problems that a child has, which leads to a complete rejection of the necessary dynamic observation and examination, with the result that the correct diagnosis is made late, and treatment does not lead to the desired result.
Therefore, in case of suspected increased intracranial pressure and hydrocephalus, the diagnosis should be carried out at the highest professional level.
What is muscle tone and why are doctors and parents so fond of it?
Look at your child’s medical record: is there no such diagnosis as “muscular dystonia”, “hypertension” and “hypotension”? – probably, you just did not go with your baby up to the year to the clinic to a neurologist. This, of course, is a joke. However, the diagnosis of “muscular dystonia” is not at least (or even more often) than hydrocephalic syndrome and increased intracranial pressure.
Changes in muscle tone can be, depending on the severity, as a variant of the norm (most often), as well as a serious neurological problem (this is much less common).
Briefly about the external signs of changes in muscle tone.
Muscle hypotonia characterized by a decrease in resistance to passive movements and an increase in their volume. Spontaneous and voluntary motor activity may be limited, muscle probing is somewhat reminiscent of “jelly or very soft dough.” Pronounced hypotension can significantly affect the rate of motor development (for details, see the chapter on movement disorders in children of the first year of life).
Muscular dystonia characterized by a state where muscular hypotonia alternates with hypertension, as well as a variant of disharmony and asymmetry of muscle tension in individual muscle groups (for example, in the arms more than in the legs, to the right more than on the left and
At rest, these children with passive movements may experience certain muscular hypotension. When trying to actively perform any movement, with emotional reactions, when the body changes in space, muscle tone increases sharply, pathological tonic reflexes become pronounced. Often, such violations further lead to incorrect formation of motor skills and orthopedic problems (for example, torticollis, scoliosis).
Muscle hypertension is characterized by an increase in resistance to passive movements and a restriction of spontaneous and voluntary motor activity. Severe muscle hypertension can also significantly affect the rate of motor development.
Disturbance of muscle tone (muscle tension at rest) can be limited to one limb or one muscle group (obstetric paresis of the arm, traumatic paresis of the leg) – and this is the most visible and very disturbing symptom, forcing parents to immediately contact a neurologist.
To notice the difference between physiological changes and pathological symptoms in one consultation is sometimes quite difficult even for a competent doctor. The fact is that the change in muscle tone is not only associated with neurological disorders, but also strongly depends on the specific age period and other features of the child’s condition (agitated, crying, hungry, drowsy, cold and
But even if functional disorders of muscle tone are confirmed, there is nothing to worry about. A good neurologist, most likely, will prescribe a massage and physical therapy classes (exercises on large balls are very effective). Drugs are prescribed extremely rarely, usually with a pronounced spastic muscle hypertension.
Hyperactivity syndrome (syndrome of increased neuro-reflex excitability)
Frequent crying and whims about and without, emotional instability and hypersensitivity to external stimuli, disturbed sleep and appetite, abundant frequent regurgitation, restlessness and flinching, trembling of the chin and handles (and
All motor, sensitive and emotional reactions to external stimuli in a hyper-excitable child occur intensely and abruptly, and can also fade away just as quickly. Having mastered these or other motor skills, children continuously move, change poses, constantly stretch to some objects and capture them. Usually, children show a keen interest in their surroundings, but increased emotional lability often makes it difficult for them to contact others. They have a fine mental organization, they are very impressionable, experiential and easily vulnerable! They fall asleep extremely badly, only with their mother, they constantly wake up, cry in their sleep. Many of them have a prolonged fear reaction to communication with unfamiliar adults with active protest reactions. Usually, hyper-excitability syndrome is combined with increased mental exhaustion and fatigue.
The presence of such manifestations in a child is only a reason for referring to a neurologist, but in no case is there any reason for parental panic, and even more so, medical treatment.
Constant hyper-excitability in the causal relation is not very specific and most often can be observed in children with temperament peculiarities (for example, the so-called choleric type of response).
Much less often, hyper-irritability can be associated and explained by the perinatal pathology of the central nervous system. In addition, if a child’s behavior suddenly suddenly and for a long time was disturbed with little to no apparent reason, he developed hyper-excitability, the likelihood of an adaptation disorder (adaptation to external environmental conditions) due to stress cannot be ruled out. And the sooner the specialists look at the child, the easier and faster it is to cope with the problem.
And, finally, most often, transient hyper-excitability is associated with pediatric problems (rickets, digestive disorders and intestinal colic, hernia, teething, etc.). Parents! Find a competent pediatrician!
There are two extremes in the tactics of monitoring such children. Or “explanation” of hyper-excitability with the help of “intracranial hypertension” in combination with intensive drug therapy, and even the use of drugs with severe side effects (diacarb, phenobarbital, etc.). At the same time the need for treatment "surely" justified by the prospect of development in the child in the future MMD (minimal brain dysfunction) and the IRR (vegetative-vascular dystonia). Or vice versa, the complete disregard of this problem ("wait by itself will pass"), which may eventually lead to the formation of persistent neurotic disorders (fears, tics, stuttering, anxiety disorders, obsessions, sleep disorders) in a child and his family members, and will require long-term psychological correction. Of course, it is logical to assume that an adequate approach is somewhere in between.
Separately, I wanted to draw the attention of parents to convulsions – One of the few disorders of the nervous system that really deserves close attention and serious treatment. Epileptic seizures are not common in infancy, but sometimes they are difficult, insidious and disguised, and almost always, immediate medical therapy is needed.
Such attacks can be hidden behind any stereotyped and repetitive episodes in the child’s behavior. Strange winches, nods of the head, involuntary eye movements, “fading”, “pinching”, “limping”, "falling asleep", especially with the sight stopped and the lack of reaction to external stimuli, should alert the parents and make them turn to the specialists. Otherwise, a late diagnosis and untimely prescribed drug therapy significantly reduce the chances of treatment success.
All the circumstances of the episode of convulsions must be accurately and fully memorized and, if possible, recorded on video, for further detailed narration in a consultation. Attention! The doctor will ask these questions! If the convulsions last for a long time or recur – you need a call “03” and an urgent consultation with a doctor.
At an early age, the child’s condition is extremely changeable, so minimal deviations in development and other disorders of the nervous system can sometimes be detected only during long-term dynamic monitoring of the baby, with repeated consultations. To this end, specific dates for scheduled consultations of a pediatric neurologist in the first year of life are determined: usually at 1, 3, 6 and 12 months. It is during these periods that most severe diseases of the nervous system of children in the first year of life (hydrocephalus, epilepsy, cerebral palsy, metabolic disorders, etc.) can be detected. Thus, the identification of a specific neurological pathology in the early stages of development allows you to start complex therapy on time and achieve the maximum possible result.
And in conclusion, I would like to remind parents: be sympathetic and attentive to your kids! First of all, it is your actively-meaningful interest in the life of children that is the basis of their future well-being. Do not try to cure them of “suspected diseases”, but if you are worried and worried about something, find an opportunity to get independent advice from a qualified specialist.
Details are here:
Read also about other mysterious letters of the city of the old neurology: MMD (minimal brain dysfunction) and the IRR (vegetative-vascular dystonia).