Ventriculitis (ependymitis) is an inflammation of the cerebral ventricle, a formidable complication of penetrating craniocerebral injuries, intracranial surgical interventions and infectious processes. Clinically manifested by febrile fever, headache, vomiting, tachycardia, convulsions, depression of consciousness to a coma. It is diagnosed using computed tomography, lumbar puncture, cerebrospinal fluid analysis. Conservative therapy is carried out with antibiotics, diuretics, corticosteroids, anticonvulsants. In case of inefficiency, ventricular drainage, washing of the pathways of the cerebrospinal fluid outflow is carried out.
ICD 10
G04.9 Encephalitis, myelitis or encephalomyelitis, unspecified
General information
Ventriculitis in Latin means “inflammation of the ventricle of the brain.” There are four ventricles in the brain. The two lateral ones are arranged symmetrically, one in each hemisphere, the third and fourth occupy the middle position. Cerebrospinal fluid circulates in the ventricles. The ventricular cavities are lined with an epithelial membrane — the ependyma. Since inflammatory processes occur precisely in the ependymus, in neurology the term ventriculitis has a synonymous name — “ependymitis”.
Causes
The disease has an infectious etiology. During the newborn period, it is observed due to intrauterine infection, in the structure of neonatal sepsis. In the future , the causes of infection of the ventricles are:
- Open traumatic brain injury. Fractures of the skull in the area of the arch or base, accompanied by damage to the cerebral tissues in the periventricular region, the formation of cerebrospinal fistulas are the pathways for infectious agents. Getting into the ventricular space, microorganisms cause inflammation.
- Penetrating wound of the skull. Gunshot wounds penetrating into the cranial cavity, wounds with cold weapons, household items are accompanied by infection of brain tissues. The infection gets from a contaminated wounding tool or through the wound canal.
- Abscess of the brain of the pericentricular localization. Infection occurs when an abscess breaks through with the outpouring of its contents into the ventricular cavity or periventricular space. The bacteria in the pus provoke the development of ependymitis.
- Encephalitis. Diffuse infectious and inflammatory processes occurring in encephalitis spread to the ventricular area. The penetration of infection into the ventricular cavity causes ventriculitis.
- Purulent meningitis. The subarachnoid space adjacent to the cerebral membranes is filled with cerebrospinal fluid and, along with the ventricles, is part of the unified cerebrospinal fluid system of the brain. Pyogenic microorganisms are able to penetrate the liquor pathways, spread through them into the cerebral ventricles, causing their inflammation with the development of meningoventriculitis.
- Neurosurgical interventions. Violation of the rules of asepsis during operations in the ventricular area leads to iatrogenic infection of the ependyma. The infection penetrates into the ventricles through insufficiently sterile instruments: a needle for ventricular puncture, an external ventricular drainage system, etc.
The risk group for the development of ependymitis includes persons with penetrating head wounds, open TBI, patients after neurosurgical manipulations in the area of cerebral ventricles, newborns who have suffered an intrauterine infection, suffering from neonatal sepsis.
Pathogenesis
The cavities of the cerebral ventricles are the least immunologically protected areas of the human body. Local immunity is weak. The presence of a blood-brain barrier causes difficult entry into the ventricles of protective immune factors and injected antimicrobial pharmaceuticals. Under the current conditions, intraventricular penetration of microorganisms is accompanied by their reproduction, development in the walls and cavity of the ventricle. Infection triggers a local inflammatory reaction. The walls, ependyma of the ventricles swell, thicken, are covered with purulent layers. The production and absorption of cerebrospinal fluid is disrupted, hydrocephalus occurs — excessive filling with cerebrospinal fluid. As a result, intracranial hypertension develops. The pus flakes contained in the liquor can cause occlusion of the interventricular opening of Monroe, causing the appearance of acute occlusive hydrocephalus.
Classification
Ventriculitis is classified according to etiopathogenetic characteristics depending on the path of infection. Accordingly, there are:
- Primary ventriculitis — associated with direct infection of ventricular structures. Occurs with injuries, wounds, surgical interventions.
- Secondary ventriculitis is caused by the penetration of microorganisms from an existing infectious focus. The secondary form develops as a complication of meningitis, cerebral abscess, encephalitis.
Symptoms
The development of ependymitis in injuries and wounds is accompanied by a sharp deterioration in the general condition of the victim, an increase in body temperature to 40 degrees. A similar pattern accompanies the breakthrough of an abscess that had a stable course before. During the period of retained consciousness, patients complain of intense headache, repeated vomiting without relief is noted. Characterized by severe tachycardia (heart rate more than 130 beats), pallor or hyperemia of the face, respiratory failure. Meningeal syndrome is pronounced.
Generalized clonic or tonic-clonic convulsive seizures occur against the background of motor arousal. Epileptic paroxysms are accompanied by an increasing disorder of consciousness. There is a progressive lethargy of the patient, lethargy, turning into drowsiness (sopor). A coma is gradually developing. Exhaustion of the patient can lead to a drop in temperature to subfebrile figures, a decrease in the severity of the meningeal symptom complex.
Ventriculitis due to intrauterine infection in newborns occurs within the framework of serous inflammation without a specific clinical picture. It is detected only during ultrasound examination. Ependymitis on the background of neonatal sepsis has no pathognomonic symptoms, aggravates the serious condition of the child.
Complications
Inflammation of the ventricles is accompanied by the release of pus into the cerebrospinal fluid, as a result, the viscosity of the latter increases, which complicates its outflow. The situation worsens sharply when the pathways of the cerebrospinal fluid flow are blocked by flakes of pus. The increasing intracranial pressure leads to compression of the cerebral substance, provokes cerebral edema. The spread of inflammation to the IV ventricle, the expansion of its cavity due to hydrocephalus cause compression of the adjacent structures of the brainstem — the bridge and the medulla oblongata, where the vital centers are located. Compression of the trunk causes cardiac and respiratory disorders with a risk of death.
Diagnostics
Ventriculitis has no specific symptoms, its clinic fits into the framework of severe TBI, intracranial hemorrhage, purulent meningitis. Therefore, diagnosis requires a thorough analysis of the anamnesis of the disease, additional research. The diagnostic algorithm includes:
- Collecting anamnesis. Special attention is paid to the prescription and nature of the injury, indications for the performed neurosurgical treatment. With secondary ependymitis, information about previous symptoms, the presence of an established diagnosis of encephalitis, brain abscess is important.
- Neurological examination. Allows the neurologist to identify signs of intracranial hypertension, meningeal symptoms, to establish the degree of impaired consciousness. Concomitant focal neurological deficit helps to determine the localization of intracerebral lesions, the location of the abscess.
- CT of the brain. It reveals hydrocephalus, increased density of cerebrospinal fluid, swelling of periventricular tissues. The detected changes are nonspecific in nature, evaluated in conjunction with the clinical picture, the results of the analysis of the cerebrospinal fluid. It is definitely possible to talk about the presence of ventriculitis according to CT data when visualizing a foreign body in the ventricle, a breakthrough of a cerebral abscess, a post-traumatic cerebrospinal fistula.
- Lumbar puncture. It is performed with the measurement of cerebrospinal fluid pressure, conducting cerebrospinal fluid dynamic tests aimed at detecting occlusion of the cerebrospinal tract. Examination of the cerebrospinal fluid determines the presence of pus, microorganisms, inflammatory changes, allows to exclude hemorrhage, to establish the type of pathogen.
Posttraumatic ventriculitis is differentiated from the concomitant injury of hemorrhage in the ventricles. Both processes have the same CT signs. The study of the cerebrospinal fluid, which does not detect the presence of blood elements, allows to exclude hemorrhage.
Treatment
Conservative therapy is carried out according to the principles of treatment of purulent meningitis. Insufficient effectiveness of conservative measures serves as an indication for the use of neurosurgical techniques: ventricular drainage, washing of the cerebrospinal fluid system.
Conservative treatment:
- Antibiotic therapy. Gentamicin, its analogues, a combination with ampicillin is used. Intrathecal administration of drugs directly into the liquor space is possible.
- Dehydration. It is necessary to reduce cerebral edema. It is carried out with the help of diuretics (furosemide, mannitol), glucocorticosteroids (prednisolone).
- Symptomatic therapy. With psychomotor agitation, tranquilizers are indicated, with convulsions — anticonvulsants, with hypovolemia, severe intoxication — careful infusion therapy.
Neurosurgical treatment:
External ventricular drainage. It is carried out through the milling holes in the skull. It is combined with washing the ventricular cavity with an antibacterial solution. An inflow-outflow drainage system with constant antibacterial drip washing of the ventricle is preferred.
Flushing of the cerebrospinal tract is indicated in cases resistant to other therapy. It is made with the help of lumbar and ventricular drains. To prevent obturation of narrow areas of the cerebrospinal fluid system with pus flakes, the procedure is performed from the bottom up, the fluid is supplied through a lumbar drainage.
Prognosis and prevention
Ventriculitis always has a serious prognosis. According to various sources, the mortality rate reaches 35-50%. Timely diagnosis, massive antibiotic therapy, drainage increase the chances of survival. Surviving patients need long-term rehabilitation therapy. The best prevention is the prevention of head injuries and wounds, prevention and timely treatment of primary intracranial foci of infection (meningitis, abscess, encephalitis), compliance with all rules of asepsis and antiseptics when performing neurosurgical manipulations, operations.
