Symptoms of meningeal syndrome

Typical objective signs of meningeal syndrome, ie, irritation of the meninges - symptoms of Brudzinsky, Kernig, rigidity of the neck muscles, revealed in the patient regardless of the cause that caused them.

Rigidity of the neck muscles is revealed in the patient lying on his back. With passive bending of the head, a marked strain of the musculature of the neck, occipital muscles, prevents the chin from bringing to the chest. Rigidity of the neck muscles is often combined with rigidity of the muscles of the extensors of the back and extremities. False rigidity may be in patients with spondylarthrosis, spondylosis of the cervical spine, with constitutional features of the skeleton. Rigidity of neck muscles may also be absent in children younger than 6 months. With special care, it is necessary to investigate the rigidity of the neck muscles in patients with acute craniocervical injury.

The symptom of Kernig is the impossibility of completely unbending the leg in the knee joint, bent at the 90 ° angle in the hip and knee joint. In a patient with acute brain damage, the Kernig symptom may be less pronounced on the side of the paresis. Passive leg extension in the knee joint can be difficult with diffuse muscular rigidity and joint pathology. A distinctive feature of Kernig's symptom is the appearance of severe muscular rigidity (muscle contracture), which does not allow full extension.

When assessing the rigidity of the neck muscles, it is possible to involuntarily pull up the legs, flex them in the knee and hip joints, which is regarded as a positive upper symptom of Brudzinsky. If, in the study of the Kernig symptom, bending at the knee joint of the opposite leg is observed, this is the lower symptom of Brudzinsky. The flexion of the legs in the knee joints and their pulling to the trunk with pressure on the symphysis area of the bones is regarded as a positive average symptom of Brudzinsky.

Children have an important symptom of irritation of the meninges - "pose of a dumb dog" - staying in the positions lying on their side with the head thrown back and bent at the knee joints, legs pressed to the abdomen. In infants, a symptom of the hanging of Lesage is also revealed: the infant, raised above the armpits, pulls the legs to the stomach and fixes them in this position.

Meningeal symptoms are combined with intense headache, photo and phonophobia, nausea, repeated vomiting, cutaneous hyperesthesia. The value of these signs for diagnosis of stimulation of the meninges in the absence of other meningeal symptoms is ambiguous, although in certain situations they outstrip the appearance of meningeal symptoms, arising in the early stages of the disease. The correct interpretation of the nature and severity of cephalalgia, cutaneous hyperesthesia, taking into account the general clinical picture (the presence of signs of inflammation, suffered head trauma, etc.) allows you to suspect involvement in the pathological process of the meninges and choose the correct tactics of patient management.

As the disease progresses, as a rule, there is a clinical picture of the unfolded meningeal syndrome. There is oppression of consciousness of this deafness, drowsiness to deep sopor and coma. When the brain substance is damaged, a focal neurological deficit develops.

The overwhelming majority of patients with meningitis have inflammatory and toxic manifestations of the disease: fever, hyperhidrosis, changes in the leukocyte blood count. Sensitivity of isolated meningeal symptoms in revealing the lesion of the membranes is relatively low, a much more significant combination of such signs as rigidity of the neck muscles, symptoms of Kernig and Brudzinsky, fever, headache (worse with coughing, straining), and mental disturbances. Interpretation of the results of the study of meningeal symptoms requires mandatory consideration of anamnestic data, clinical picture of the disease, paraclinical studies. In this regard, it should be noted the need for lumbar puncture in some patients with a clinical picture of the inflammatory disease, but with the absence of meningeal symptoms.

It should be borne in mind that with moderate inflammation in the cerebrospinal fluid, the severity of meningeal symptoms may be minimal or absent altogether, increasing with severe meningitis (> 1000 cells per 1 μl CSF).

The acute development of meningeal syndrome against a background of physical or emotional stress, during active wakefulness, accompanied by a sudden intense headache (can occur as a stroke, sensation of spilled on the back of the head or back of boiling water) may indicate a spontaneous subarachnoid hemorrhage. Extensive hemorrhage can be accompanied by depression of consciousness from deafness to deep coma, the development of single epileptic or serial seizures. Simultaneous emergence of focal neurological deficit is typical for parenchymal-subarachnoid hemorrhage. Meningeal syndrome in combination with: confusion or depression of consciousness occurs with acute hypertensive encephalopathy. Focal neurological deficit is not typical for this condition. Indications for recent head trauma, neck, traces of trauma on the head in combination with meningeal symptoms, oppression of consciousness with a high probability indicate traumatic subarachnoid hemorrhage.

Meningeal syndrome can occur with extensive lesions of the brain and its membranes (tumors, hematoma, abscess, parasites). In this situation, both direct stimulation of the meninges by the neoplasm as well as the effect caused by a significant increase in intracranial pressure are possible. Sometimes there is a toxic effect on the shell. The overwhelming majority of patients have a focal neurological deficit. Its severity and character depend on the location and size of the pathological focus. These conditions are also characterized by an increase in cerebrospinal fluid pressure, which is revealed during the lumbar puncture. It is possible that the protein content in the cerebrospinal fluid is increased, as a rule, in the absence of inflammatory changes.

Dissemination of malignant neoplasm on the membranes of the brain (carcinomatosis) can cause the onset of a slowly growing meningeal syndrome. In addition, these patients are diagnosed with focal neurologic symptoms, including cranial nerve damage. In some cases, neurological disorders outstrip other manifestations of the oncological process, even associated with the localization of the primary focus.

Infections accompanied by intoxication can also cause the development of meningeal syndrome (influenza, salmonella). Of great importance for establishing the correct diagnosis in this situation is the careful observation of the patient with an assessment of the dynamics of his condition, often requiring lumbar puncture to exclude the true damage to the meninges (secondary meningitis).

Pseudotumor (pseudotumor cerebri) is a rare syndrome characterized by increasing intracranial hypertension, edema of the optic nerve disk, oculomotor disorders (in particular, afferent nerve damage).

Radiation encephalopathy can develop in patients who underwent radiation therapy for cerebral neoplasms. For this condition, a combination of manifestations characteristic of the underlying disease (brain tumor) and the effects of radiation exposure (focal or multifocal symptoms, epileptiform seizures, and meningeal symptoms) that occur immediately after the course of the therapy is typical for this condition.

If the excretion of fluid from the body is violated (for example, adrenal insufficiency, hypoosmolarity of blood, hyponatremia), it is possible to develop hyperhydration - water intoxication. Moderately pronounced meningeal syndrome is combined with krampi, asthenic disorders, possibly with ascites, hydrothorax.

Pseudo-meningeal syndrome arises from reasons that make it difficult or impossible to move in the cervical spine, knee joints, thereby simulating the presence of meningeal symptoms (stiff neck muscles, Kernig symptom). Most often it is caused by increased muscle tone (Parkinsonism), paratonism (resistance to extrapyramidal lesions) or orthopedic pathology (spondylarthrosis and spondylosis, including severe pain syndrome).

[1], [2], [3], [4], [5], [6]