The term "alternating syndromes" refers to pathological conditions in which there is damage to the cranial nerves and impaired sensory function. Diseases of this type adversely affect the quality of human life. They are divided into several types, which differ from each other in the clinical picture. In the treatment of alternating syndromes, modern techniques are used that help alleviate the patient's condition.
Alternating syndromes are neurological disorders involving unilateral cranial nerve damage.
Pathological conditions, which are called alternating syndromes, appear when one half of the spinal cord or brain is affected. They are also diagnosed in people with unilateral combined lesions of brain tissues and sensory organs. Pathology can be caused by impaired blood circulation and the development of tumor-like neoplasms.
There is a whole classification of alternating syndromes. It is important to be able to distinguish diseases from each other, since the selection of adequate treatment depends on this.
Clinical picture by type
Painful conditions are divided into separate groups depending on the localization of the lesion. They have their own code in the international classification of diseases ICD-10.
bulbar
Pathology is characterized by damage to the cranial nerves, as a result of which their activity is disrupted. The disease also affects the nuclei located in the medulla oblongata.
Bulbar syndromes are in the ICD-10 code G12.2.
| Syndrome | Description |
| Jackson Syndrome | The disease is diagnosed in patients who have a half lesion of the medulla oblongata in the region of the lower section. In parallel, paralysis of the hypoglossal nerve and a significant weakening of the limbs develop. Due to the disease, the tongue begins to deviate towards the affected nerve or nucleus at the time of protrusion. During the contraction of the left-sided lingual-chin muscle, the tongue is directed to the right side and pushed forward. With damage to the right-sided muscle, the direction changes in the opposite direction. |
| Avellis syndrome | Paralysis of the palatopharyngeal type actively progresses with damage to the glossopharyngeal, hypoglossal, or vagus nerve. Pathological processes occur in the pyramidal pathway. In a patient with such a diagnosis, paralysis of the pharynx and soft palate is observed from the side of the location of the focus. |
| Schmidt syndrome | The pathological process is characterized by a combination of damage to the fibers and nuclei of the vagus, glossopharyngeal and accessory nerves. The pyramidal path also suffers. The disease manifests itself in the form of paralysis of the soft palate, vocal cord, part of the tongue and pharynx. The trapezius muscle, or rather its upper part, is greatly weakened. |
| Wallenberg-Zakharchenko syndrome | Pathology is also called dorsolateral medullary syndrome. It is diagnosed in people with damage to the nuclei of the glossopharyngeal, trigeminal and vagus nerves. Due to the disease, the lower cerebellar peduncles, the pyramidal pathway and sympathetic fibers lose their function. On the side on which the lesion is present, one can notice signs of paralysis of the vocal cord, soft palate and pharynx. The patient loses temperature and pain sensitivity on half of his face. On the opposite side, there may be an incorrect perception of temperature and loss of pain. |
| Babinski-Najotte syndrome | Pathology manifests itself in humans with a combination of damage to the sympathetic fibers, the inferior cerebellar peduncle, the medial loop and the pyramidal pathway. It is joined by dysfunction of the spinothalamic tract and the olive-cerebellar pathway. The disease can be recognized by cerebellar disorders and the development of Horner's syndrome. |
Pathological processes tend to progress and aggravate the patient's condition.
Pontine
Diseases are characterized by damage to the brain bridge. Specialists identify a number of syndromes that differ in this symptom.
Pontine syndromes are presented in the ICD-10 under the code G37.
| Syndrome | Description |
| Alternating Miylard-Gübler Syndrome | The disease is also called medial bridge syndrome. It is caused by damage to the fibers or nuclei of the pyramidal tract, also in the seventh pair. Pathology gives itself out as characteristic symptoms, including an asymmetric face, the absence of folds in the frontal and nasolabial zones, weak facial muscles and a racket symptom. Incomplete closure of the eye, which is caused by paralysis of its muscles, is not excluded. When the patient tries to close his eyes, the whites of the eyes run up to the top. On the opposite side, signs of hemiplegia and hemiparesis are diagnosed. |
| Fauville syndrome | Lateral bridge syndrome develops due to damage to the roots of the facial and abducens nerves. They are joined by the pyramidal tract and the medial loop. Doctors recognize the pathology by paralysis of gaze to the side and the abducens nerve. In some cases, weakening of the facial nerve is diagnosed. On the opposite side, the development of hemiplegia or the central form of hemiparesis is observed. |
| Raymond-Sestan syndrome | The disease state is characterized by damage to the middle cerebellar peduncle, the pyramidal pathway and the longitudinal bundle. Pathology affects the medial loop. The disease is recognized by severe gaze paralysis in the direction where the lesion is present. |
| Brissot syndrome | The syndrome manifests itself in case of irritation of the nucleus of the facial nerve. The defeat is accompanied by dysfunction of the pyramidal pathway. The disease is characterized by the appearance of facial hemispasms, which are present exclusively on the side of the lesion. |
| Gasperini syndrome | The syndrome develops against the background of damage to the pons. The disease is accompanied by dysfunction of the facial, auditory, trigeminal and abducens nerves. These signs can be seen on the side of the lesion. |
Pontine syndromes occur in people of different age groups.
Peduncular
Pathological conditions that develop against the background of damage to the brain stem are called pendular. Pathologies of this type have their own clinical symptoms, as well as stem syndromes.
Diseases are presented in the ICD-10 under the code F06.
| Syndrome | Description |
| Weber syndrome | The disease is diagnosed in people with damage to the nuclei of the third pair of the oculomotor nerve. The pyramidal path is also exposed to pathology. On the side of the lesion, symptoms are observed that give out Weber's syndrome. The disease is indicated by diplopia, divergent strabismus, problems with accommodation and ptosis. Patients notice mydriasis, central type of hemiparesis and paresis of the facial muscles. |
| Claude syndrome | Another name for the disease is lower red nucleus syndrome. It manifests itself due to damage to the nucleus of the oculomotor nerve, the red nucleus and the cerebellar pedicle. On the side where the lesion was diagnosed, ptosis, mydriasis, and divergent strabismus are present. On the opposite side, doctors observe rubral hyperkinesia and intentional tremor. |
| Benedict syndrome | The pathological process develops with damage to the nuclei of the oculomotor nerve, red-nuclear-dentate fibers and the red nucleus. In some cases, patients are diagnosed with dysfunction of the medial loop. On the side of the lesion, divergent strabismus, ptosis and mydriasis are observed. On the other side, doctors diagnose hemiparesis, hemiataxia, and trembling of one eyelid. |
| Parino syndrome | The development of pathology contributes to the defeat of the tire and cover of the midbrain. The disease disrupts the center of vertical eye movement and the upper section of the longitudinal beam. This term refers to paralysis of upward gaze. A person has bilateral partial ptosis, nystagmus, and no response to light. |
| Notnagel syndrome | The pathological process develops due to damage to the lateral loop, the nuclei of the oculomotor nerves, the cerebellar pedicle, the red nucleus and the pyramidal pathway. On the side of the location of the lesion, divergent strabismus, ptosis and mydriasis are observed. On the back you can see hemiplegia, hyperkinesia and weakening of the facial muscles. |
Correctly determine these conditions allow modern diagnostic methods.
Central hemiparesis of the extremities
With the disease, the sensitivity of some parts of the body is lost
Central hemiparesis is a disease in which higher subcortical functions are impaired. As a result of this, a person loses sensation in a certain part of his body.
The disease is listed in the ICD-10 under the code G81.
This group of alternating syndromes includes pathological conditions that are characterized by a generalized description of changes observed on the opposite side, regardless of the location of the lesion.
On the opposite side, in patients with this diagnosis, spastic hypertonicity, the development of pathological reflexes, and the expansion of reflex zones are observed. Doctors also diagnose imitative, coordinating movements and painful synkinesis with central hemiparesis of the extremities. Among the clinical manifestations of the disease are the protective shortening reflex and the Remak reflex.
Diagnostics
If you suspect the development of symptoms that are characteristic of alternating syndromes, you need to seek help from a neurologist. He diagnoses the brain stem and other parts of it, assesses the patient's condition and puts forward his assumptions regarding the diagnosis.
Neurological syndrome, which is studied in neurology, requires a detailed study. The patient must undergo a thorough diagnosis, which will reveal the true cause of the disease state.
A neurologist can make a presumptive diagnosis after examining the patient. During the diagnosis, the specialist will identify the characteristic features for a particular syndrome of the alternating type.
To determine the exact cause of the disease, additional research methods are required:
- Magnetic resonance imaging of the brain (MRI). The study provides information on the location of inflammatory foci, tumors and hematomas. Also, with its help, it is possible to achieve visualization of the stroke area and compressed stem structures.
- Transcranial dopplerography of cerebral vessels (TCDG). One of the most informative diagnostic methods. With its help, a violation of cerebral blood flow is studied. The doctor detects the presence of local vasospasm and thromboembolism.
- Doppler ultrasonography of extracranial vessels (USDG). The method is used to examine the occlusion of the vertebral and carotid arteries.
- Analysis of cerebrospinal fluid. Diagnosis requires a lumbar puncture. It becomes necessary if there is a suspicion of the development of an infectious process and inflammatory changes in the cerebrospinal fluid.
Complex diagnostics makes it possible to determine the presence of pathological processes in the human body that affect the development of the alternating syndrome.
Surgical intervention is required in case of violations of the blood supply to the brain.
Treatment is aimed at stopping the underlying disease and its symptoms. It may include conservative and operative techniques. Rehabilitation procedures are also prescribed, which can improve the patient's condition.
Conservative therapy
Patients with alternating syndrome are shown drug therapy. The patient is prescribed a course of drugs that perform the following tasks:
- Decreased blood pressure.
- Relief of soft tissue edema.
- Normalization of metabolism in the brain.
The choice of therapy directly depends on the etiology of the disease. For example, in ischemic stroke, vascular and thrombolytic therapy is indicated. With infectious lesions of the body, one cannot do without an antiviral, antimycotic and antibacterial course of drugs.
Surgical treatment
Not always conservative methods of treatment help to improve the current state of the patient with alternating syndrome. If drug therapy fails, then he is prescribed neurosurgical treatment. Such methods are required for the following pathologies:
- Volumetric neoplasms in the area of lesions.
- Violation of the blood supply to the brain.
- hemorrhagic stroke.
According to the indications, patients are prescribed the formation of an extra-intracranial anastomosis, cupping of the tumor-like body, carotid endarterectomy or reconstruction of the vertebral artery.
Rehabilitation
Physiotherapist will help you choose exercises to restore health
After the main treatment, under the supervision of a rehabilitologist, the patient proceeds to rehabilitation. The exercise therapy doctor and masseur are involved in the process.
Rehabilitation methods of therapy are aimed at preventing complications and increasing the range of movements that must be performed by a person with alternating syndrome.
The development of pathology can have a different outcome. It all depends on the type of syndrome and its severity. In most cases, diseases lead to disability.
Alternating syndromes(Latin alternans - alternating; alternating paralysis, cross paralysis) - symptom complexes characterized by a combination of cranial nerve damage on the side of the focus with conduction disturbances of movement and sensitivity on the opposite side. Occur when one half of the brain stem, spinal cord is damaged, as well as with unilateral combined damage to the structures of the brain and sensory organs. Various AS can be caused by a violation of cerebral circulation, a tumor, a traumatic brain injury, etc. A gradual increase in symptoms is possible even without impaired consciousness, with the spread of edema or the progression of the process itself.
Bulbar alternating syndromes
- Avellis syndrome(Palatopharyngeal paralysis) develops with damage to the nuclei of the glossopharyngeal and vagus nerves and the pyramidal tract. It is characterized from the side of the focus by paralysis of the soft palate and pharynx, from the opposite side - by hemiparesis and hemihypesthesia. (in the diagram - A)
- Jackson Syndrome(medial medullary syndrome, Dejerine's syndrome) occurs when the nucleus of the hypoglossal nerve and the fibers of the pyramidal pathway are damaged. It is characterized by a paralytic lesion of half of the tongue from the side of the focus (the tongue "looks" at the focus) and central hemiplegia or hemiparesis of the extremities on the healthy side. (in the diagram - B)
- Babinski-Najotte syndrome occurs with a combination of lesions of the inferior cerebellar peduncle, olivocerebellar tract, sympathetic fibers, pyramidal, spinothalamic tracts and medial loop. It is characterized on the part of the focus by the development of cerebellar disorders, Horner's syndrome, on the opposite side - hemiparesis, loss of sensitivity (In the diagram - A).
- Schmidt syndrome characterized by a combined lesion of the motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves and the pyramidal pathway. Manifested from the focus of paralysis of the soft palate, pharynx, vocal cord, half of the tongue, sternocleidomastoid and upper trapezius muscle, on the opposite side - hemiparesis and hemihypesthesia. (In the diagram - B).
Wallenberg-Zakharchenko syndrome(dorsolateral medullary syndrome) occurs when the motor nuclei of the vagus, trigeminal and glossopharyngeal nerves, sympathetic fibers, the lower cerebellar pedicle, the spinothalamic tract, and sometimes the pyramidal tract are affected. On the side of the focus, paralysis of the soft palate, pharynx, vocal cord, Horner's syndrome, cerebellar ataxia, nystagmus, loss of pain and temperature sensitivity of half of the face are noted; on the opposite side - loss of pain and temperature sensitivity on the trunk and limbs. Occurs when the posterior inferior cerebellar artery is damaged. Several options have been described in the literature.
Pontine alternating syndromes
- Raymond-Sestan syndrome noted with damage to the posterior longitudinal bundle, middle cerebellar peduncle, medial loop, pyramidal pathway. It is characterized by gaze paralysis towards the focus, on the opposite side - hemihypesthesia, sometimes hemiparesis. (On the diagram - A)
- Miylard-Gubler syndrome(medial bridge syndrome) occurs when the nucleus or root of the facial nerve and the pyramidal tract are damaged. Manifested from the focus of facial paralysis, on the opposite side - hemiparesis. (On the diagram - B)
Brissot-Sicard syndrome occurs when the nucleus of the facial nerve is irritated and the pyramidal tract is damaged. It is characterized by facial hemispasm on the side of the focus and hemiparesis on the opposite side (In the diagram - A).
Fauville syndrome(lateral bridge syndrome) is observed with a combined lesion of the nuclei (roots) of the abducens and facial nerves, the medial loop, the pyramidal pathway. It is characterized from the side of the focus by paralysis of the abducens nerve and gaze paralysis towards the focus, sometimes by paralysis of the facial nerve; on the opposite side - hemiparesis and hemihypesthesia (In the diagram - B).
Peduncular alternating syndromes
- Benedict syndrome(upper syndrome of the red core) occurs when the nuclei of the oculomotor nerve, the red nucleus, red-nuclear-dentate fibers, and sometimes the medial loop are damaged. On the side of the focus, ptosis, divergent strabismus, mydriasis occur, on the opposite side - hemiataxia, eyelid trembling, hemiparesis without Babinski's symptom (In the diagram - B).
- Foix's syndrome occurs when the anterior sections of the red nucleus and fibers of the medial loop are damaged without involvement of the oculomotor nerve in the process. In the syndrome, there is choreoathetosis, intentional tremor, a disorder of sensitivity according to the gemitype on the side opposite from the focus. (in the diagram - A)
- Weber syndrome(ventral mesencephalic syndrome) is observed with damage to the nucleus (root) of the oculomotor nerve and fibers of the pyramidal pathway. Ptosis, mydriasis, divergent strabismus are noted on the side of the lesion, and hemiparesis is seen on the opposite side. (On the diagram - B)
- Claude syndrome(dorsal mesencephalic syndrome, lower red nucleus syndrome) occurs when the nucleus of the oculomotor nerve, the superior cerebellar peduncle, and the red nucleus are damaged. It is characterized on the side of the lesion by ptosis, divergent strabismus, mydriasis, on the opposite side - hemiparesis, hemiataxy or hemiasynergy. (On the diagram - A)
Notnagel syndrome occurs with a combined lesion of the nuclei of the oculomotor nerves, the superior cerebellar peduncle, the lateral loop, the red nucleus, the pyramidal pathway. On the side of the focus, ptosis, divergent strabismus, mydriasis are noted, on the opposite side - choreoathetoid hyperkinesis, hemiplegia, paralysis of the muscles of the face and tongue.
Alternating syndromes associated with damage to several parts of the brain stem.
Glick syndrome due to damage to the optic, trigeminal, facial, vagus nerves and pyramidal pathway. On the side of the lesion - peripheral paralysis (paresis) of facial muscles with their spasm, pain in the supraorbital region, decreased vision or amaurosis, difficulty swallowing, on the opposite side - central hemiplegia or hemiparesis.
Cross hemianesthesia observed with damage to the nucleus of the spinal tract of the trigeminal nerve at the level of the bridge or medulla oblongata and fibers of the spinothalamic tract. On the side of the lesion - a disorder of surface sensitivity on the face according to the segmental type, on the opposite side - a violation of surface sensitivity on the trunk and limbs.
Extracerebral alternating syndromes.
Alternating syndrome at the level of the spinal cord - Brown-Séquard syndrome- a combination of clinical symptoms that develop with damage to half the diameter of the spinal cord. On the side of the lesion, there are spastic paralysis, conduction disturbances of deep (muscle-articular sense, vibrational sensitivity, pressure, weight, kinesthesia) and complex (two-dimensional, discriminatory, sense of localization) sensitivity, sometimes ataxia. At the level of the affected segment, radicular pain and hyperesthesia, the appearance of a narrow zone of analgesia and termanesthesia are possible. On the opposite side of the body, there is a decrease or loss of pain and temperature sensitivity, and the upper level of these disorders is determined several segments below the level of spinal cord injury.
With damage at the level of the cervical or lumbar thickening of the spinal cord, peripheral paresis or paralysis of the muscles innervated on the affected anterior horns of the spinal cord develops (damage to the peripheral motor neuron).
Brown-Sequard syndrome occurs with syringomyelia, spinal cord tumors, hematomyelia, ischemic disorders of the spinal circulation, injury, spinal cord contusion, epidural hematoma, epiduritis, multiple sclerosis, etc.
A true half spinal cord lesion is rare. Most often, only part of half of the spinal cord is affected - a partial variant in which some of its constituent signs are absent. In the development of different clinical variants, the localization of the pathological process in the spinal cord (intra- or extramedullary), its nature and features of the course, different sensitivity of the afferent and efferent conductors of the spinal cord to compression and hypoxia, individual characteristics of spinal cord vascularization, etc. play a role.
The syndrome has a topical diagnostic value. Localization of the lesion in the spinal cord is determined by the level of violations of surface sensitivity.
Asphygmohemiplegic syndrome(syndrome of the brachiocephalic arterial trunk) is noted with unilateral irritation of the nucleus of the facial nerve, vasomotor centers of the brain stem, damage to the motor zone of the cerebral cortex. On the side of the lesion - a spasm of facial muscles, on the opposite side - central hemiplegia or hemiparesis. There is no pulsation of the common carotid artery on the side of the lesion.
Vertigohemiplegic syndrome due to unilateral damage to the vestibular apparatus and motor zone of the cerebral cortex due to circulatory disorders in the system of the subclavian and carotid arteries with impaired circulation in the basins of the labyrinth (vertebrobasilar basin) and middle cerebral arteries. On the side of the lesion - tinnitus, horizontal nystagmus in the same direction; on the opposite side - central hemiplegia or hemiparesis.
Optic-hemiplegic syndrome occurs with unilateral damage to the retina, optic nerve, motor zone of the cerebral cortex due to circulatory disorders in the system of the internal carotid artery (in the basin of the ophthalmic and middle cerebral arteries). On the side of the lesion - amaurosis, on the opposite side - central hemiplegia or hemiparesis.
The brain stem, which includes the midbrain, pons, and medulla oblongata, contains long ascending sensory and descending motor pathways, as well as nuclei of the cranial nerves.
Due to the fact that the motor cortical-spinal (pyramidal) path crosses below the brain stem, and the sensitive spinal-thalamic path crosses even in the spinal cord, a unilateral lesion of these paths at the level of the brain stem leads to the occurrence of central muscle paresis and loss of sensitivity on the opposite away from the hearth to the side. Foci in the brain stem are also characterized by damage to the nuclei (or nuclei) of the cranial nerves, with the appearance of symptoms of their defeat on the side of the pathological process. Therefore, a unilateral lesion in the brain stem is characterized by the occurrence of cross syndromes: symptoms of damage to the core of the cranial nerve on the side of the focus and central hemiparesis or hemiplegia, as well as conductive sensory disorders on the opposite side. Such syndromes are called alternating. The combination of symptoms of damage to the cranial nerve nucleus and pathways is of great importance for making a topical diagnosis, since it indicates damage not to the cranial nerve, but to its nucleus or fibers within the brainstem. Knowing the topography of the nuclei of the cranial nerves, it is possible to determine the localization of the pathological process in the brain stem.
Depending on the localization of the pathological focus, alternating syndromes are divided into pedunculated (damage to the midbrain), bridge (pathology in the bridge) and bulbar (damage to the medulla oblongata). So, with pathology in the brain stem, Weber and Benedict syndromes occur, with damage to the bridge - Miylard-Gubler and Fauville syndromes. These syndromes are described above.
With damage to the medulla oblongata, alternating syndromes of Jackson, Avellis, Schmidt, Wallenberg-Zakharchenko are most often observed.
Jackson syndrome is characterized by a combination of signs of peripheral nuclear palsy of the muscles of the tongue on the side of the focus and hemiparesis or hemiplegia on the opposite side.
With Avellis syndrome, on the side of the pathological focus, symptoms of damage to the glossopharyngeal and vagus nerves are revealed, and on the opposite side, hemiparesis or hemiplegia of the extremities.
As a result of Schmidt's syndrome (lesion of the medulla oblongata at the level of nuclei IX, X, XI pairs), paralysis of the vocal cord, soft palate, trapezius and sternocleidomastoid muscles on the side of the lesion and hemiparesis of opposite limbs are noted.
With ischemic stroke in the basin of the posterior inferior cerebellar artery, an alternating Wallenberg-Zakharchenko syndrome occurs. On the side of the focus, paralysis of the soft palate and vocal cord is detected (double motor nucleus is affected), segmental dissociated disorder of pain and temperature sensitivity on the face (the descending root of the V pair or the nucleus of the spinal cord is affected), Bernard-Horner syndrome (pathology of descending sympathetic fibers going to ciliospinal center), cerebellar disorders (the spinal-cerebellar path is affected), and on the opposite side - a conductive disturbance of pain and temperature sensitivity as a result of damage to the spinal-thalamic path.
In addition to these syndromes, other alternating syndromes are also observed in clinical practice, in the symptoms of which there may be signs of damage to the nuclei of cranial nerves and other structures of the brain stem. They occur in violation of cerebral circulation, inflammatory or tumor processes in the brain stem and are of great topical and diagnostic value.
Alternating syndromes (cross syndromes) is a dysfunction of the cranial nerves on the side of the lesion in combination with central paralysis of the extremities or a conduction disorder of sensitivity on the opposite side of the body. Alternating syndromes occur with brain damage (with vascular pathology, tumors, inflammatory processes).
Depending on the localization of the lesion, the following types of alternating syndromes are possible. Paralysis of the oculomotor nerve on the side of the lesion and on the opposite side with damage to the brain stem (Weber's syndrome). Paralysis of the oculomotor nerve on the side of the lesion, and cerebellar symptoms on the opposite side when the base of the brain stem is affected (Claude's syndrome). Paralysis of the oculomotor nerve on the side of the lesion, intentional and choreoathetoid movements in the limbs of the opposite side with damage to the medial-dorsal part of the midbrain.
Peripheral paralysis of the facial nerve on the side of the lesion and spastic hemiplegia or hemiparesis on the opposite side (Millar-Gubler syndrome) or peripheral paralysis of the facial and efferent nerves on the side of the lesion and hemiplegia on the opposite side (Fauville syndrome); both syndromes - with damage to the bridge (varoli). The defeat of the glossopharyngeal and vagus nerves, causing paralysis of the soft, vocal cords, disorder, etc. on the side of the lesion and hemiplegia on the opposite side with damage to the lateral part of the medulla oblongata (Avellis syndrome). Peripheral paralysis on the side of the lesion and hemiplegia on the opposite side with damage to the medulla oblongata (Jackson's syndrome). on the side of the lesion and hemiplegia on the opposite side with blockage by an embolus or thrombus of the internal carotid (optic-hemiplegic syndrome); the absence of a pulse on the radial and brachial arteries on the left and hemiplegia or hemianesthesia on the right with damage to the arch (Bogolepov's aortic-subclavian-carotid syndrome).
Treatment of the underlying disease and symptoms of brain damage: breathing disorders, swallowing, heart activity. During the recovery period, vitamins and other activating methods are used.
Alternating syndromes (Latin alternare - to alternate, alternate) are symptom complexes characterized by impaired function of the cranial nerves on the side of the lesion and central paralysis or paresis of the limbs or conduction disorders of sensitivity on the opposite side.
Alternating syndromes occur when the brainstem is damaged: the medulla oblongata (Fig. 1, 1, 2), the pons (Fig. 1,3,4) or the brain stem (Fig. 1, 5, c), as well as when the hemispheres of the brain are affected. brain as a result of circulatory disorders in the system of carotid arteries. More precisely, the localization of the process in the trunk is determined by the presence of a lesion of the cranial nerves: paresis or paralysis occurs on the side of the focus as a result of damage to the nuclei and roots, i.e., according to the peripheral type, and is accompanied by muscle atrophy, a degeneration reaction in the study of electrical excitability. Hemiplegia or hemiparesis develops as a result of damage to the cortico-spinal (pyramidal) tract in the vicinity of the affected cranial nerves. Hemianesthesia of the extremities opposite to the focus is a consequence of damage to the conductors of sensitivity, going through the middle loop and the spinothalamic pathway. Hemiplegia or hemiparesis appear on the opposite side of the focus because the pyramidal path, as well as sensitive conductors, cross below the lesions in the trunk.
Alternating syndromes are divided according to the localization of the lesion in the brain stem into: a) bulbar (with damage to the medulla oblongata), b) pontine (with damage to the bridge), c) peduncular (with damage to the brain stem), d) extracerebral.
Bulbar alternating syndromes. Jackson syndrome is characterized by peripheral hypoglossal nerve palsy on the side of the lesion and hemiplegia or hemiparesis on the opposite side. Occurs with thrombosis a. spinalis ant. or its branches. Avellis syndrome is characterized by damage to the IX and X nerves, paralysis of the soft palate and vocal cord on the side of the focus and hemiplegia on the opposite side. There are swallowing disorders (getting liquid food into the nose, choking when eating), dysarthria and dysphonia. The syndrome occurs when the branches of the artery of the lateral fossa of the medulla oblongata are damaged.
Babinski-Najotte syndrome consists of cerebellar symptoms in the form of hemiataxy, hemiasynergy, lateropulsion (as a result of damage to the lower cerebellar peduncle, olivocerebellar fibers), miosis or Horner's syndrome on the side of the focus and hemiplegia and hemianesthesia on opposite limbs. The syndrome occurs when the vertebral artery is damaged (artery of the lateral fossa, inferior posterior cerebellar artery).
Rice. 1. Schematic representation of the most typical localization of lesions in the brain stem, causing the appearance of alternating syndromes: 1 - Jackson's syndrome; 2 - Zakharchenko-Wallenberg syndrome; 3 - Millar-Gubler syndrome; 4 - Fauville's syndrome; 5 - Weber's syndrome; 6 - Benedict's syndrome.
Schmidt syndrome consists of paralysis of the vocal cords, soft palate, trapezius and sternocleidomastoid muscles on the affected side (IX, X and XI nerves), as well as hemiparesis of opposite limbs.
Zakharchenko-Wallenberg syndrome characterized by paralysis of the soft palate and vocal cord (vagus nerve damage), anesthesia of the pharynx and larynx, sensory disorder on the face (trigeminal nerve lesion), Horner's syndrome, hemiataxia on the side of the focus with damage to the cerebellar tract, respiratory distress (with an extensive focus in the medulla oblongata) in combination with hemiplegia, analgesia and termanesthesia on the opposite side. The syndrome occurs when thrombosis of the posterior inferior cerebellar artery.
Pontine alternating syndromes. Millar-Gübler Syndrome consists of peripheral facial paralysis on the side of the focus and spastic hemiplegia on the opposite side. Fauville syndrome it is expressed by paralysis of the facial and abducens nerves (in combination with gaze paralysis) on the side of the focus and hemiplegia, and sometimes hemianesthesia (damage to the middle loop) of the opposite limbs. The syndrome sometimes develops as a result of thrombosis of the main artery. Raymond-Sestan syndrome manifests itself in the form of paralysis of the combined movements of the eyeballs on the side of the lesion, ataxia and choreoathetoid movements, hemianesthesia and hemiparesis on the opposite side.
Peduncular alternating syndromes. Weber's syndrome is characterized by paralysis of the oculomotor nerve on the side of the lesion and hemiplegia with paresis of the muscles of the face and tongue (lesion of the corticonuclear tract) on the opposite side. The syndrome develops during processes on the basis of the brain stem. Benedict's syndrome consists of paralysis of the oculomotor nerve on the side of the lesion and choreoathetosis and inteptional trembling of opposite limbs (lesion of the red nucleus and dentator-rubral tract). The syndrome occurs when the focus is localized in the medial-dorsal part of the midbrain (the pyramidal pathway remains unaffected). Notnagel's syndrome includes a triad of symptoms: cerebellar ataxia, oculomotor nerve palsy, hearing loss (unilateral or bilateral deafness of central origin). Sometimes hyperkinesis (choreiform or athetoid), paresis or paralysis of the extremities, central paralysis of the VII and XII nerves can be observed. The syndrome is caused by a lesion of the midbrain tegmentum.
Alternating syndromes, characteristic of the intrastem process, can also occur with compression of the brain stem. So, Weber's syndrome develops not only with pathological processes (hemorrhage, intrastem tumor) in the midbrain, but also with compression of the brain stem. Compression, dislocation syndrome of compression of the brain stem, which occurs in the presence of a tumor of the temporal lobe or pituitary region, can be manifested by damage to the oculomotor nerve (mydriasis, ptosis, divergent strabismus, etc.) on the side of compression and hemiplegia on the opposite side.
Sometimes alternating syndromes are manifested mainly by a cross sensitivity disorder (Fig. 2, 1, 2). So, with thrombosis of the inferior posterior cerebellar artery and the artery of the lateral fossa, an alternating sensitive Raymond syndrome can develop, manifested by anesthesia of the face (damage to the descending root of the trigeminal nerve and its nucleus) on the side of the focus and hemianesthesia on the opposite side (damage to the middle loop and spinothalamic path). Alternating syndromes can also manifest themselves in the form of cross hemiplegia, which is characterized by paralysis of the arm on one side and the leg on the opposite side. Such alternating syndromes occur with a focus in the region of the intersection of the pyramidal tracts, with thrombosis of the spinobulbar arterioles.
Rice. 2. Scheme of hemianesthesia: 1 - dissociated hemianesthesia with sensory disturbance on both halves of the face (more on the side of the focus) with softening in the area of vascularization of the posterior inferior cerebellar artery; 2 - hemianesthesia with a dissociated disorder of pain and temperature sensitivity (according to the syringomyelitic type) with a limited focus of softening in the bay area.
Extracerebral alternating syndromes. Optic-hemiplegic syndrome (alternating hemiplegia in combination with dysfunction of the optic nerve) occurs when an embolus or thrombus blocks the intracranial segment of the internal carotid artery, is it characterized by blindness as a result of blockage of the ophthalmic artery? departing from the internal carotid artery, and hemiplegia or hemiparesis of the extremities opposite to the focus due to softening of the medulla in the area of vascularization of the middle cerebral artery. Vertigohemiplegic syndrome with discirculation in the subclavian artery system (N.K. Bogolepov) is characterized by dizziness and noise in the ear as a result of discirculation in the auditory artery on the side of the focus, and on the opposite side - hemiparesis or hemiplegia due to circulatory disorders in the branches of the carotid artery. Asphygmo-hemiplegic syndrome (N. K. Bogolepov) occurs reflexively in the pathology of the extracerebral carotid artery (brachiocephalic trunk syndrome). At the same time, on the side of occlusion of the brachiocephalic trunk and the subclavian and carotid arteries, there is no pulse on the carotid and radial arteries, arterial pressure is reduced and spasm of the facial muscles is observed, and on the opposite side - hemiplegia or hemiparesis.
Studying the symptoms of damage to the cranial nerves in alternating syndromes makes it possible to determine the localization and border of the focus, i.e., to establish a topical diagnosis. The study of the dynamics of symptoms allows you to determine the nature of the pathological process. So, with ischemic softening of the brain stem as a result of thrombosis of the branches of the vertebral arteries, the main or posterior cerebral artery, the alternating syndrome develops gradually, without loss of consciousness, and the boundaries of the focus correspond to the zone of impaired vascularization. Hemiplegia or hemiparesis are spastic. In case of hemorrhage into the trunk, the alternating syndrome may be atypical, since the boundaries of the focus do not correspond to the vascularization zone and increase due to edema and reactive phenomena around the hemorrhage. In acute foci in the pons, the alternating syndrome is usually combined with respiratory distress, vomiting, disruption of the heart and vascular tone, hemiplegia - with muscle hypotension as a result of diaschism.
Isolation of alternating syndromes helps the clinician in making a differential diagnosis, for which the complex of all symptoms matters. With alternating syndromes caused by damage to the main vessels, surgical treatment is indicated (thrombinthymectomy, vascular plasty, etc.).
The brain stem includes
1. midbrain- located between the diencephalon and the bridge and includes
but. Roof of the midbrain and handles of the superior and inferior colliculi- the formation of two pairs of mounds located on the roof plate and dividing by a transverse groove into upper and lower. The pineal gland lies between the superior colliculi, and the anterior surface of the cerebellum extends above the inferior ones. In the thickness of the mounds lies an accumulation of gray matter, in the cells of which several systems of pathways end and arise. Part of the fibers of the optic tract terminates in the cells of the superior colliculus, the fibers from which go to the tire of the legs of the brain to the paired accessory nuclei of the oculomotor nerve. The fibers of the auditory pathway approach the inferior colliculus.
From the cells of the gray matter of the roof of the midbrain, the tectospinal tract begins, which is a conductor of impulses to the cells of the anterior horns of the spinal cord of the cervical segments, which innervate the muscles of the neck and upper shoulder girdle, which provide head turns. Fibers of the visual and auditory pathways approach the nuclei of the roof of the midbrain, and there are connections with the striatum. The operculospinal tract coordinates reflex orienting movements in response to unexpected visual or auditory stimuli. Each hillock in the lateral direction passes into a white roller, forming the handles of the upper and lower hillocks. The handle of the superior colliculus, passing between the pillow of the thalamus and the medial geniculate body, approaches the external geniculate body, and the handle of the inferior colliculus goes to the medial geniculate body.
Defeat syndrome: cerebellar ataxia, damage to the oculomotor nerve (gaze paresis up, down, divergent strabismus, mydriasis, etc.), hearing disorder (one or two-sided deafness), choreoathetoid hyperkinesis.
B. Legs of the brain- located on the lower surface of the brain, they distinguish between the base of the brain stem and the tire. Between the base and the tire is a pigment-rich black substance. Above the tire lies a plate of the roof, from which the upper cerebellar peduncle and the lower one go to the cerebellum. The nuclei of the oculomotor, trochlear nerves and the red nucleus are located in the tegmentum of the brain stem. The pyramidal, fronto-pontine, and temporal-pontine pathways pass through the base of the brain stem. Pyramidal occupies the middle 2/3 of the base. The frontal-bridge path passes medially to the pyramidal one, and the temporal-bridge path passes laterally.
in. Posterior perforated substance
The cavity of the midbrain is the aqueduct of the brain, which connects the cavities of the III and IV ventricles.
2. hindbrain:
but. Bridge- located on the slope of the base of the skull, it distinguishes between the anterior and posterior parts. The anterior surface of the bridge faces the base of the skull, the upper one takes part in the formation of the anterior sections of the bottom of the rhomboid fossa. Along the midline of the anterior surface of the bridge, there is a longitudinally running basilar sulcus, in which the basilar artery lies. On both sides of the basilar sulcus, pyramidal elevations protrude, in the thickness of which pyramidal pathways pass. In the lateral part of the bridge are the right and left middle cerebellar peduncles, which connect the bridge to the cerebellum. The trigeminal nerve enters the anterior surface of the bridge, at the point of origin of the right and left cerebellar peduncles. Closer to the posterior edge of the pons, in the cerebellopontine angle, the facial nerve exits and the vestibulocochlear nerve enters, and between them there is a thin stem of the intermediate nerve.
In the thickness of the anterior part of the bridge there are more nerve fibers than in the back. The latter contains more clusters of nerve cells. In front of the bridge, there are superficial and deep fibers that make up the system of transverse fibers of the bridge, which, crossing along the midline, pass through the cerebellar peduncles to the bridge, connecting them to each other. Between the transverse bundles are longitudinal bundles belonging to the system of pyramidal pathways. In the thickness of the anterior part of the bridge, the own nuclei of the bridge lie, in the cells of which the fibers of the cortical-bridge pathways terminate and the fibers of the cerebellopontine pathway leading to the cortex of the opposite hemisphere of the cerebellum originate.
b. Medulla- the front surface is located on the slope of the skull, occupying its lower section to the foramen magnum. The upper border between the bridge and the medulla oblongata is the transverse groove, the lower border corresponds to the exit point of the superior radicular thread of the 1st cervical nerve or the lower level of the pyramidal decussation. On the anterior surface of the medulla oblongata passes the anterior median fissure, which is a continuation of the fissure of the same name in the spinal cord. On each side of the anterior median fissure is a cone-shaped roller - the pyramid of the medulla oblongata. The fibers of the pyramids by means of 4-5 bundles in the caudal section partially cross each other, forming a cross of the pyramids. After crossing, these fibers go in the lateral funiculi of the spinal cord in the form of a lateral cortical-spinal tract. The remaining, smaller, part of the bundles, without entering the decussation, passes in the anterior cords of the spinal cord, making up the anterior cortical-spinal tract. Outside of the pyramid of the medulla oblongata is an elevation - the olive, which separates the anterior lateral groove from the pyramid. From the depths of the latter, 6-10 roots of the hypoglossal nerve come out. The posterior surface of the medulla oblongata takes part in the formation of the posterior sections of the bottom of the rhomboid fossa. The posterior median sulcus runs along the middle of the posterior surface of the medulla oblongata, and outward from it is the posterior lateral sulcus, which limit the thin and wedge-shaped bundles, which are a continuation of the posterior cord of the spinal cord. The thin bundle passes at the top into a thickening - the tubercle of the thin nucleus, and the wedge-shaped bundle - into the tubercle of the sphenoid nucleus. The thickenings contain thin and wedge-shaped nuclei. In the cells of these nuclei, the fibers of the thin and wedge-shaped bundles of the posterior cords of the spinal cord terminate. From the depths of the posterior lateral sulcus, 4-5 roots of the glossopharyngeal, 12-16 of the vagus and 3-6 cranial roots of the accessory nerve emerge on the surface of the medulla oblongata. At the upper end of the posterior lateral sulcus, the fibers of the thin and wedge-shaped bundles form a semicircular thickening - the rope body (lower cerebellar peduncle). The right and left lower cerebellar peduncles limit the rhomboid fossa. Each lower cerebellar peduncle contains fibers of the pathways.
3. IVventricle. It communicates above through the cerebral aqueduct with the cavity of the III ventricle, below with the central canal of the spinal cord, through the median aperture of the IV ventricle and two lateral ones with the cerebellar-cerebral cistern and with the subarachnoid space of the brain and spinal cord. Anteriorly, the IV ventricle is surrounded by the pons and medulla oblongata, and posteriorly and laterally by the cerebellum. The roof of the IV ventricle is formed by the superior and inferior medullary sails. The bottom of the IV ventricle forms a rhomboid fossa. A median sulcus runs along the length of the fossa, which divides the rhomboid fossa into two identical triangles (right and left). The top of each of them is directed to the lateral pocket. A short diagonal passes between both lateral pockets and divides the rhomboid fossa into two triangles of unequal size (upper and lower). In the posterior part of the upper triangle there is a facial tubercle formed by the inner knee of the facial nerve. In the lateral corner of the rhomboid fossa is the auditory tubercle, in which the cochlear nuclei of the vestibulocochlear nerve lie. From the auditory tubercle in the transverse direction, the cerebral strips of the IV ventricle pass. In the region of the rhomboid fossa, the nuclei of the cranial nerves lie symmetrically. The motor nuclei lie more medially in relation to the sensory nuclei. Between them are the vegetative nuclei and the reticular formation. In the caudal part of the rhomboid fossa is the triangle of the hypoglossal nerve. Medial and somewhat lower from it there is a small dark brown area (triangle of the vagus nerve), where the nuclei of the glossopharyngeal and vagus nerves lie. In the same section of the rhomboid fossa in the reticular formation, the respiratory, vasomotor and vomiting centers are located.
4. cerebellum- a department of the nervous system involved in automatic coordination of movements, regulation of balance, accuracy and proportionality ("correctness") of movements and muscle tone. In addition, it is one of the highest centers of the autonomic (autonomous) nervous system. It is located in the posterior cranial fossa above the medulla oblongata and the bridge, under the cerebellar tenon. The two hemispheres and the middle part located between them is the worm. The cerebellar vermis provides static (standing), and the hemispheres - dynamic (movements in the limbs, walking) coordination. Somatotopically, in the cerebellar vermis, the muscles of the trunk are represented, and in the hemispheres, the muscles of the limbs. The surface of the cerebellum is covered with a layer of gray matter that makes up its cortex, which is covered with narrow convolutions and grooves that divide the cerebellum into a number of lobes. The white matter of the cerebellum is composed of various kinds of nerve fibers, ascending and descending, which form three pairs of cerebellar peduncles: lower, middle and upper. The inferior cerebellar peduncles connect the cerebellum to the medulla oblongata. In their composition, the posterior spinal-cerebellar path goes to the cerebellum. The axons of the cells of the posterior horn enter the posterior part of the lateral funiculus of their side, rise to the medulla oblongata, and reach the cortex of the vermis along the inferior cerebellar peduncle. Nerve fibers from the nuclei of the vestibular root also pass here, which end in the core of the tent. As part of the lower cerebellar peduncles, from the nucleus of the tent to the lateral vestibular nucleus, and from it to the anterior horns of the spinal cord goes the vestibulo-spinal path. The middle cerebellar peduncles connect the cerebellum to the pons. They contain nerve fibers from the nuclei of the bridge to the cortex of the opposite hemisphere of the cerebellum. The superior cerebellar peduncles connect it to the midbrain at the level of the roof of the midbrain. They include nerve fibers both to the cerebellum and from the dentate nucleus to the roof of the midbrain. These fibers, after crossing, end in the red nuclei, from where the red nuclear-spinal path begins. Thus, in the lower and middle cerebellar peduncles, mainly the afferent pathways of the cerebellum pass, and in the upper ones, the efferent ones.
The cerebellum has four paired nuclei located in the thickness of its cerebral body. Three of them - serrated, corky and spherical - are located in the white matter of the hemispheres, and the fourth - the core of the tent - in the white matter of the worm.
Alternating syndromes occur with a unilateral lesion of the brain stem, consist in damage to the cranial nerves on the side of the focus with the simultaneous appearance of paresis (paralysis), sensitivity disorders (according to the conduction type) or coordination on the opposite side.
A) with damage to the legs of the brain:
1. Weber's alternating palsy - peripheral paralysis of the oculomotor nerve on the side of the lesion and spastic hemiplegia on the opposite
2. Benedict's alternating palsy - peripheral paralysis of the oculomotor nerve on the side of the lesion, hemiataxia and intentional tremor on the opposite
3. Claude's alternating syndrome - peripheral paralysis of the oculomotor nerve on the side of the lesion, extrapyramidal hyperkinesis and cerebellar symptoms on the opposite
B) with the defeat of the bridge:
1. Fauville's alternating paralysis - peripheral paralysis of the facial and abducens nerves (or gaze paresis to the side) on the side of the lesion and spastic hemiplegia on the opposite
2. Alternating palsy Miyard - Gubler - peripheral paralysis
Facial nerve on the side of the lesion and spastic hemiplegia on the opposite
3. alternating Brissot-Sicara syndrome - spasm of the facial muscles (irritation of the nucleus of the facial nerve) on the side of the lesion and hemiplegia on the opposite
4. Raymond-Sestan alternating paralysis - gaze paralysis towards the focus, ataxia, choreoathetoid hyperkinesis on the side of the lesion, and on the opposite side - hemiplegia and sensitivity disorders.
C) with damage to the medulla oblongata:
1. Avellis syndrome - peripheral paralysis of the glossopharyngeal, vagus and hypoglossal nerves on the side of the lesion and spastic hemiplegia on the opposite
2. Jackson syndrome - peripheral paralysis of the hypoglossal nerve on the side of the lesion and spastic hemiplegia on the opposite
3. Schmidt's syndrome - peripheral paralysis of the hyoid, accessory, vagus, glossopharyngeal nerves on the affected side and spastic hemiplegia on the opposite
4. Wallenberg-Zakharchenko syndrome occurs when the posterior inferior cerebellar artery is blocked and is characterized by a combined lesion of the IX, X nerves, the nucleus of the descending root of the V pair, the vestibular nuclei, the sympathetic tract, the inferior cerebellar peduncle, the spinocerebellar and spinothalamic pathways.
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