THRONIBOSIS AND EMBOLISM OF THE CEREBRAL VESSELS Occlusion of the arteries in the brain is far more rare in the child than in the adult because of the absence of arteriosclerosis, which is an important etiologic factor in later life. In hereditary syphilis arterial occlusion may result directly from the vascular disease. In childhood primary thrombosis of the brain vessels is rare as compared with sinus thrombosis, as the latter develops in the form of marantie sinus throm bosis under conditions such as exhausting disease, lowering of the blood pressure and the like,. which in the adult usually produce thrombosis of the cerebral arteries. Sometimes occlusion of the cerebral vessels occurs secondarily from extension of a sinus thrombosis. Embolism of the cerebral vessels is more frequent and is always clue to some in flammatory disease within the vascular apparatus. The aeutc infecti ous diseases, such as diphtheria, scarlet fever, pneumonia and even measles (Baginsky), may he followed by cerebral embolism, the cere bral occurring as a late complication of the primary trouble. After rheumatic endocarditis occlusion of the cerebral arteries is rare. Poison ing and burns are also mentioned among the causes of cerebral embolism in the child.
The pathologic findings vary with the interval that has elapsed between embolism and death. In recent eases luemorrhages or acute hternorrhagic inflammation, so-called "red" softening, is found. This is followed by "yellow" softening, due to changes in the blood-pigment and the breaking down of tissue. If the site of the embolism is not well supplied with blood, the area of softening is white in color, so-called "white" softening. The final result of this encephalomalacia is ab sorption, scar formation, cyst or sclerosis. liven in the later stages the relation to the blood vessels is easily recognized.
It follows from the above description that the dividing line between infectious embolic encephalomalacia and primary encephalitis cannot always be sharply drawn pathologically, particularly in the later stages of the disease. As a matter of faet, the only difference between the two conditions lies in the size and number of the embolic plugs that are carried to the brain.
The characteristic feature of cerebral embolism is the sudden oc currence of grave brain symptoms. The disease is usually ushered in by convulsions; this is followed by a stage of coma, cluring whieh local paralytic and irritative symptoms are often recognized. Sometimes the disease is preceded by general cerebral symptoms, headache, rest lessness, vomiting and hebetude. An accurate diagnosi.s cannot be made until foeal symptoms make their appearance, the most important of which are hemiplegia, aphasia and sensory paralysis. As the initial symptoms subside, the localizing signs become more distinct and afford some clue to the identity of the occluded artery (see diagram under brain tumor). A knowledge of the parts of the brain which are supplied by the various cerebral arteries, as shown in the following table, will aid in localizing the lesion: Embolism of the artery of the fissure of Sylvius, which is followed by the appearance of hemiplegic symptoms, is the most common fortn. If a small end artery- is occluded, marked symptoms of paralysis may be wanting.
When arterial embolism involves a large area of the brain or affects a vital portion, it may prove rapidly fatal. The child does not regain consciousness after the initial eoma; profound collapse and increasing heart weakness develop. More frequently; the course of the disease is favorable; the initial symptoms gradually subside and a palsy results which presents the picture of cerebral infantile paralysis. In such a case the occurrence of brain embolism can only- be inferred from the history.
Diagnosis.—The presence of a cause and the history of sudden onset are essential. But since in childhood various cerebral affections begin with convulsions, the distinction from a circumscribed menin gitis, a cerebral litemorrhage or an encephalitis !nay at first present great difficulties and in some cases may be impossible.
Treatment of the acute attack consists in the main in supporting the heart, and mitigating the severity of the cerebral symptoms (see treatment of encephalitis). In old cases the treatment is the same as that of cerebral infantile paralysis.